Bb Renal

Front 1

When can you see rhabdomyolysis

Back 1

1. hypothermia,
2. drug toxicity,
3. prolonged immobilization,
4. crush injury

Front 2

What is the cause of renal failure in rhabdomyolysis?

Back 2

tubular damage resulting from filtered myoglobin usually associated with hypovolemia

Front 3

What are the urinary findings of rhabdo?

Back 3

urine blood on dipstick with absence of RBCs in sediment
-due to myoglobinuria causing false positive reading

Front 4

What is the treatment of rhabdo?

Back 4

1. fluid resuscitation,
2. mannitol,
3. urine alkalinization

Front 5

What is reabsorbed in the proximal convoluted tubule and loop of henle?

Back 5

1. Na
2. K
3. bicarb
4. Cl
5. protein
6. water

Front 6

Where is glucose reabsorbed in the kidney? When does spilling of glucose into the urine occur?

Back 6

proximal convoluted tubule
-when plasma glucose is >180 mg/dl

Front 7

What is the effect of ADH and where does it act?

Back 7

reabsorption of water and concentration of urine
-distal convoluted tubules and collecting ducts

Front 8

What factors decrease RBF and predispose to oliguria?

Back 8

1. anesthetic effects,
2. SNS,
3. ADH,
4. renin-angiotensin-aldosterone system

Front 9

Over what MAP is RBF autoregulated?

Back 9

60-160 mmHg

Front 10

How does the renin-angiotensin-aldosterone system work?

Back 10

1. decreased renal perfusion pressure and decreased delivery of Na to distal convoluted tubule result in the release of renin from the juxtaglomerular apparatus
2. renin acts on alpha globulin in plasma to form angiotensin I,
3. angiotensin I goes to the lungs and is split by lungs to form angiotensin II,
4. angiotensin II goes to the adrenal cortex and causes secretion of aldosterone
5. aldosterone leads to HTN, hypokalemia, metabolic alkalosis due to increasing the Na and water reabsorption and H+ and K+ excretion in the distal convoluted tubule

Front 11

What are laboratory tests of tubular fxn?

Back 11

1. SG 1.003-1.030,
2. osmol 40-1400 mosm/L,
3. Na 130-260 mEq/L

Front 12

What is normal creatinine clearance?

Back 12

110-150 cc/min

Front 13

What are urine Osm in prerenal and renal failure?

Back 13

prerenal >400
renal 250-300

Front 14

What is the Urine/Plasma osm in prerenal and renal failure?

Back 14

prerenal >1.8,
renal <1.1

Front 15

What is specific gravity? When is specific gravity not useful?

Back 15

It is a measure of urine concentrating ability
-in the setting of glusocuria or diuretics

Front 16

What Specific gravity is indicative of volume depletion?

Back 16

>1.025

Front 17

What do fatty casts in the urine indicate?

Back 17

nephrotic syndrome

Front 18

What does RBCs in the urine indicate?

Back 18

trauma,
tumor,
infection

Front 19

What does proteinuria indicate?

Back 19

parenchymal disease

Front 20

What can alter serum BUN?

Back 20

1. increased protein intake,
2. GI bleeding,
3. dehydration,
4. the capacity of the liver to form urea from amino acids,
5. rate of incorporation of amino acids into tissue protein,
6. rate of release of amino acids from tissue protein(sepsis, trauma)

Front 21

How do you calculate creatinine clearance and what are normal values?

Back 21

CrCl = Urine Cr x Vol / Plasma Cr;
U = concentration of creatinine in the urine (after 24 hr collection),
V=urine volume,
P=concentration of creatinine in plasma;

nml 85-125ml/min in women,
95-145ml/min in men

Front 22

what is the overall effect of activation of the renin-angiotensin-aldosterone system?

Back 22

renovascular htn

Front 23

What happens with stimulation/stretching of atrial stretch receptors?

Back 23

-decreases sympathetic outflow and causes release of ANP
-ANP causes systemic vasodilation, decreased sodium reabsorption, and inhibition of renin and aldosterone release

Front 24

What is the response of the atrial stretch receptors with contraction of the atria?

Back 24

stimulate release of ADH with increased water retention

Front 25

What happens to GFR at MAPs <50?

Back 25

decreases rapidly

Front 26

How do volatile anesthetics effect the kidney?

Back 26

1. decrease RBF and GFR and thus UOP,
2. disrupt autoregulaion so that RBF becomes pressure dependent,
3. ADH increases

Front 27

By how much does SCh increase serum [K]?

Back 27

1 mEq/L

Front 28

Should you use SCh in renal failure patients?

Back 28

yes as long as their [K]<5.5,
-beneficial in renal patients due to its metabolism

Front 29

What are the effects of adrenergic stimulation on the kidney?

Back 29

release of renin

Front 30

What can increase levels of ADH?

Back 30

1. positive pressure ventilation,
2. fluid loss,
3. volatile anesthetics

Front 31

How much of the nephron has to be lost before signs of chronic renal failure develop?

Back 31

> 60%

Front 32

What are manifestations of chronic renal failure?

Back 32

1. infection (increased risk, major cause of death),
2. hyperglycemia (resistance to insulin),
3. hyperparathyroidism (inability to excrete PO4 leads to increase parathyroid hormone levels which produces osteodystrophy),
4. Acidosis (can have difficulty excreting H+),
5. Electrolytes (increased Mag, Cl, K, decreased Na, Ca),
6. coagulopathy (platelet dysfxn),
7. anemia,
8. cardiac failure
9. htn - activation of RAAS

Front 33

When should you consider spinal in a patient with renal failure?

Back 33

after coags are check,
-they can have abn in PT and PTT, also platelet dysfxn

Front 34

How is vecuronium affected by renal failure?

Back 34

It is an acceptable choice
-25% excreted in urine,
-elimination is mainly biliary,
-duration of drug is somewhat prolonged

Front 35

How is rocuronium affected by renal failure?

Back 35

-eliminated primarily by the liver and kidney
-renal excretion may account for 30% of elimination,
-may lead to longer duration of action

Front 36

How is metocurine affected by renal failure?

Back 36

primarily excreted by the kidneys (50-60%),
-increased duration

Front 37

How is reversal of neuromuscular blockade affected by renal failure?

Back 37

neostigmine is excreted renally,
-in the presence of severe renal dysfunction
(CrCl 10-50ml/min) the dose should be reduced by 50%,
-if CrCl <10ml/min (ESRD) the dose should be reduced by 75%

Front 38

What inhaled anesthetic is the least metabolized and a good choice in patients with renal failure?

Back 38

desflurane

Front 39

What should you do in a renal transplant patient with low urine output in the recovery room?

Back 39

evaluate renal blood flow with a renal scan;
-if ischemic period before reimplantation is >2 hrs a peroid of oliguria followed by diuresis is frequent

Front 40

When should dialysis be done, in a patient that is on dialysis, before surgery?

Back 40

6-24 hours prior to surgery

Front 41

What is the main complication if dialysis is done too close to surgery? Too remote from surgery?

Back 41

-volume depletion
-electrolyte disturbances

Front 42

What cardiac complication can occur after release of the renal vascular clamp during renal transplantation?

Back 42

Vfib and is most commonly due to hyperkalemia

Front 43

Which are the loop diuretics? What are uses?

Back 43

1. Furosemide
2. Ethacrynic acid
-treatment of increased ICP (alterations in BBB do not affect the ability of lasix to decrease ICP),
-heart failure
-pulmonary edema

Front 44

What part of the kidneys are affected by thiazides?

Back 44

cortical portion of the ascending loop of henle
-they inhibit Na and Cl reabsorption

Front 45

How does spironolactone work?

Back 45

competing with aldosterone in the renal tubule (in the absence of aldosterone, spironolactone has no significant renal effect)
-leads to hyperkalemia

Front 46

How does acetazolamide work?

Back 46

inhibits the reabsorption of bicarb and prevents the secretion of H+
-can lead to hypokalemic acidosis

Front 47

What are types of osmotic diuretics and how do they work in the kidney?

Back 47

1. urea,
2. mannitol;
-mannitol is freely filtered at the glomerulus and not reabsorbed,
-free water follows mannitol,
-urea greater than 60% is reabsorbed

Front 48

What is the dose, onset, and duration of mannitol?

Back 48

dose 0.5-1 g/kg,
onset 10-15min,
lasts for 2hrs

Front 49

What can happen with a rapid rate of infusion of mannitol?

Back 49

may cause vasodilation of vascular smooth muscle which can increase cerebral blood volume and ICP while decreasing SBP
-(dependant on dose and rate of administration)

Front 50

How does urea affect ICP?

Back 50

crosses the BBB and is associated with rebound increased ICP

Front 51

What are vasopressin antagonists?

Back 51

1. alcohol,
2. demeclocycline,
3. lithium

Front 52

How does triamterene-amiloride work?

Back 52

increases excretion of Na, Cl, and bicarb at the distal convoluted tubule,
-independent of aldosterone

Front 53

What is rhabdomyolysis?

Back 53

Necrosis or breakdown of skeletal muscle with release of the protein myoglobin
-characterized by massive acute elevations of muscle proteins, that peak quickly and usually resolve within days after the inciting injury has been id'd and removed

Front 54

What is the functional unit of the kidney?

Back 54

nephron - made up of the glomerulus and renal tubule

Front 55

What is the glomerulus?

Back 55

a capillary tuft intimately associated with Bowman's capsule

Front 56

What forms the renal tubule?

Back 56

1. Bowman's capsule
2. proximal convoluted tubule
3. loop of henle - medullary
4. loop of henle - cortical
5. distal convoluted tubule

Front 57

What forms the collecting ducts?

Back 57

Several distal convuluted tubules

Front 58

Label the following picture

Back 58

a

Front 59

How much of CO goes to the kidneys?

Back 59

20%

Front 60

What are renal lab tests of renal function related to GFR?

Back 60

1. BUN 10-20 mg/100cc
2. Cr 0.7-1.5 mg/100cc
3. CrCl 110-150 cc/min

Front 61

What are the effects of aldosterone?

Back 61

1. htn
2. hypokalemia
3. metabolic acidosis

Front 62

If UOP falls, what tests can be used to determine whether the problem is renal or prerenal?

Back 62

1. Urine Na
2. FENa
3. Urine osm
4. Urine/plasma osm
5. BUN/Cr ratio

Front 63

What is the following in prerenal vs renal causes of decreased UOP?
Urine Na
FENa
Urine osm
Urine/plasma osm
BUN/Cr ratio

Back 63

-Urine Na: pre <20-30, ren >40
-FENa: pre <1%, ren >3%
-Urine osm: pre >400, ren 250-300
-Urine/plasma osm: pre >1.8, ren <1.1
-BUN/Cr ratio: pre >20, ren <20

Front 64

What does ketones in the urine indicate?

Back 64

DKA
Starvation

Front 65

What are problems seen as a result of renal failure?

Back 65

1. Anemia - cardiac failure
2. acidosis
3. coagulopathies
4. electrolyte problems
5. infection
6. htn
7. hyperglycemia
8. hyperparathyroidism

Front 66

What is felt to be a more accurate indicator of GFR, BUN or Cr?

Back 66

Cr bc is is freely filtered and secreted, but not reabsorbed unlike BUN

Front 67

What is one of the most powerful vasoconstrictors known?

Back 67

angiotensin II

Front 68

Which is felt more strongly postoperatively, ADH or aldosterone influence?

Back 68

ADH influence which is the reason hyponatremia develops

Front 69

What are common causes of chronic renal failure?

Back 69

1. pyelonephritis
2. acute glomerulonephritis
3. interstitial nephritis
4. htn

Front 70

Renal failure occurs when there are only ___% of functional nephrons.

Back 70

5-10%

Front 71

What is the cause of anemia in renal failure?

Back 71

1. decreased erythropoietin pruduction by the kidney
2. uremic toxins which depress bone marrow function

Front 72

What Hg level is well tolerated by pts with CRF? Why?

Back 72

Hg of 5-7
-Due to compensatory mechanisms:
1. right shift of oxy-Hb dissociation curve due to inc intracellular 2,3-DPG
2. increased CO

Front 73

Should you use Atracurium in renal failure?

Back 73

Yes, it is an excellent choice bc of Hoffman elimination and ester hydrolysis
-does not depend upon hepatic metabolism or renal excretion
-<10% is excreated unchanged by the renal and biliary routes

Front 74

Should you use Cisatracurium in renal failure?

Back 74

Yes, it is independent of renal or liver function

Front 75

What does severe anemia do to the blood:gas partition coefficient? What is the result?

Back 75

Decreases it by 25%
-leads to increased speed of induction and faster awakening

Front 76

How do the loop diuretics work?

Back 76

inhibit Na and Cl reabsorption primarily in the medullary portion of the ascending loop of Henle

Front 77

What are the side effects of loop diuretics?

Back 77

Hypokalemia which increases the potential for dig toxicity and potentiates nondepolarizing agents

Front 78

What are the K sparing diuretics which act independently of aldosterone?

Back 78

1. amiloride
2. triamterene

Front 79

What is the function of carbonic anhydrase?

Back 79

It is an enzyme which converts CO2 + water -> bicarb + H+
-bicarb is reabsorbed
-H+ is secreted which is accompanied by reabsorption of Na and water

Front 80

What is the overall effect of acetazolamide?

Back 80

1. increased diuresis of a more alkaline urine
2. metabolic acidosis - hyperchloremic hypokalemic

Front 81

When is mannitol contraindicated?

Back 81

If the BBB has been disrupted - may enter the brain and bring fluid with it increasing ICP

Front 82

Where do the following drugs act in the kidney?
Furosemide and other loop diuretics
thiazides
triamterene-amiloride
vasopressin antagonists

Back 82

-Furosemide and other loop diuretics - medullary portion of ascending loop of henle
-thiazides - cortical portion of ascending loop of henle
-triamterene-amiloride - distal convoluted tubule

Front 83

Is Thiopental an acceptable induction agent in CRF?

Back 83

Yes, but it should be administered slowly to avoid hypotension

Front 84

Should the induction dose of Thiopental be changed in CRF?

Back 84

Yes, bc thiopental is 85% bound to plasma proteins and in uremia, with decreased protein amounts, there is less binding to albumin and other plasma proteins and thiopental is therefore availavle at receptor sites in greater amounts

Front 85

Is thiopental a weak acid or weak base? How does this affect CRF?

Back 85

It is a weak acid so the acidosis of renal failure results in more unionized, nonbound, and active drug - another reason for administering less

Front 86

What is the pressor of choice in a pt with sepsis and oliguria?

Back 86

Dopamine - has a unique ability to increase myocardial contractility, renal blood flow, and GFR
-Doses: 1-30 mcg/kg/min
1-2 - renal dose
2-10 - beta
>10 alpha

Front 87

What is the MC coagulation defect in the setting of renal failure? What is the cause?

Back 87

decreased platelet adhesiveness
-not completely known, but the accumulation of metabolic acids may interfere with factor VIII activity and subsequent platelet aggregation

Front 88

Plasma Cr < ___ does not generally alter platelet function.

Back 88

< 6 mg/dl

Front 89

What is considered mild, mod, and severe dehydration based off % of body weight?

Back 89

mild - mod = 3-6%
severe = 10%