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108 Cards in this Set
- Front
- Back
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How much fluid does the kidney filter in one day?
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187 L/day
GFR 130 ml/min or 7800 ml/day |
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What is reabsorbed in the descending loop of Henle?
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Water
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What is reabsorbed at the ascending loop of Henle?
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Sodium
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What are the functions of the kidney/renal system?
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Filtration
Reabsorption Excretion Control constituents of body fluid Regulates fluid balance and blood volume (EPO) Electrolyte and pH balance |
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What is the % of Na, amino acids & glucose that is reabsorbed in the peritubular capillary network?
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80% of Na
100% of amino acids 100% of glucose |
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What is the MOA of ACE inhibitors?
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Prevents the conversion of ATI to ATII
(Cause the efferent arterioles to dilate, which lowers the resistance to outflow and lowers glomerular pressure causing a decrease in GFR & an increase in Cr & K. This helps slow the progression of chronic kidney disease) |
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Describe the normal characteristics of urine...
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Clear/amber, 95% water
Contains metabolic waste, few/no plasma proteins, no blood or glucose SG: 1.010-1.025 pH: 4.6-4.8 Should be negative for: glucose, ketones, blood protein, bili, & nitrates for bacteria |
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If there is injury to the nephron what lab result/study will be abnormal?
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UA: There will be excessive protein in the urine
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How much protein must be in the urine to consider it "microalbuminuria"?
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30-300 mg/24 hours
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What is considered overt proteinuria or macroalbuminuria?
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Over 300 mg/24 hours
(Dipstick +1) |
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How much renal function does one need to lose before Cr & BUN begin to increase?
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40%
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How often should you check a UA in diabetics and hypertensives?
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Yearly
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Why would a UA be positive for blood, but negative for RBCs?
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Dye on the dipstick will turn positive with peroxidase from Hgb, additionally myoglobin has perioxidase activity.
(Urinary myoglobin can also show up from rhabdomyolysis in the absence of blood) |
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If a UA has a large amount of epithelial cells what does that mean?
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It was contaminated
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What is normal GFR?
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120-130 ml/min
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What is BUN?
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Urea is a byproduct of protein metabolism, it is excreted entirely by the kidneys. It is helpful as a ratio with Cr. Normal ratio is 10:1
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What is Cr?
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Cr is filtered by the kidneys, but not reabsorbed in the tubule...therefore it is an indirect measure of GFR.
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What is normal Cr?
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0.6-1.3 mg/dL
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What can causes an elevated BUN:Cr ratio? (ie. 15:1, BUN is elevated)
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CHF
Bleeding Dehydration GI bleed (Need a greater loss of renal function to increase BUN) |
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What can cause a low BUN:Cr ratio?
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Liver disease
Low protein diets Chronic dialysis |
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When is a CT without contrast beneficial?
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To assess...
The size of the kidneys Size of the collecting systems Visualize anatomical obstructions (ie. stones) |
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When would you do a CT with contrast?
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To ID perinephritic stranding & inflammation
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What is a renal US used to assess?
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Kidney size (< 9 cm - irreversible kidney disease)
Characteristics of mass lesions Post-void residual of the bladder Good when you cannot use CT (pregnancy) |
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What is the scan of choice when diagnosing renal artery stenosis?
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MRI
(Also good to ID renal cysts, if a pt cannot have contrast and is good for staging renal cell ca) |
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What are the clinical manifestations of nephrotic syndrome?
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Massive proteinuria (> 3.5 gm/day)
Hypoalbuminemia (pee it all out) Edema Hyperlipidemia |
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What are some disease nephrotic syndrome is secondary to in adults?
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DM, SLE, Hodkin's, non-Hodkin's, Hep B & C, HIV
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What are risk factors for nephrotic syndrome?
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Renal insufficiency at dx
> 50 yo HTN |
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What are signs & symptoms of nephotic syndrome?
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Salt & water retention
Dyspnea Pleural effusion Ascites Staph/strep infections |
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What lab results will you see with nephrotic syndrome?
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Low ions, hormones & drug levels
Hypoalbuminemia Thromboembolic disorders Increase synthesis of lipoproteins |
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What is the spidemiology of minimal change nephrotic syndrome (MCNS)
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"Nil lesion, lipoid nephrosis"
85-90% kids with nephritic syndrome have MCNS Sudden Onset between 2-8 yrs M=F |
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What causes MCNS in adults?
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Only 15-20% of adult with nephritic syndrome, causes include...
NSAIDs Hodkin's |
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How do you treat MCNS?
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Steroids for as long as 16 weeks
If steroids don't work: Alkylating agents |
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What is the MC cause of nephritic syndrome in adults?
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Focal glomerulosclerosis: Scarring of part of the glomerulus, causing it to be dysfunctional and lets protein out
Only 10-15% of nephritic syndrome in kids |
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If you were to biopsy a patient who you suspected to have focal glomeruloscleritis what would you expect to find?
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Sclerotic lesion on biopsy
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How do you treat focal glomerulosclerosis?
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1/3 respond to steroids
Secondary causes not responsive to immunosuppresives If resistant: Control BP & proteinuria with ACE inh |
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When does membranous glomerulopathy peak & what are some secondary causes?
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5th decade
Underlying malignancy SLE Hep B |
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If you biopsy someone with membranous glomerulopathy what would you find?
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Glomerular BM thickening, glomerular deposits of IgG & complement
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How do you treat membranous glomerulopathy?
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Steroids alone may not help
Cytotoxic therapy: Cyclophosphamide |
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How will pts with membranous glomerulopathy progress? (Remember rule of thirds)
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1/3 will have spontaneous remission
1/3 will have stable disease, but continuous proteinuria 1/3 will go into renal failure in 5-10 yrs |
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What are the 5 patterns of glomerulonephritis?
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Asymptomatic
Nephritic syndrome (acute GN) Rapidly progressive GN Nephrotic syndrome Chronic GN |
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What is the treatment of asymptomaitc GN?
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No definitive tx
Corticosteroids & cytotoxic agents to reduce inflammation ACE inh to control BP and slow progression to ESRD |
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When does nephritic syndrome (acute GN) occur?
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After bacterial infection (strep)
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Who is nephritic syndrome (acute GN) most common in?
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Kids 2-10 years old
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How do you treat nephritic syndrome (acute GN)?
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Symptomatic
Treat fluid overload HTN (diuretics)/antihypertensive agents |
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What is the treatment for rapidly progressive GN?
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Corticosteroids
Cyclophosphamide Plasma exchange |
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What are the two MC causes of chronic renal disease in the US?
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DM
HTN |
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What are the stages of renal disease?
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1. Diminished renal reserve: GFR 50% of normal, BUN/Cr normal, kidney vulnerable to insult
2. Renal insufficiency: GFR 25-50% of normal, effects become visible (HTN, anemia), BUN/Cr rise as GFR declines 3.Renal failure: GFR < 20% (<15 ml/min), SrCr 6-8, dialysis or transplant 4. ESRD: GFR < 5%, atrophy/fibrosis of tubules, kindey mass reduced, dialysis or transplant |
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What are common causes of progression of progression to ESRD (from chronic renal disease)
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Diabetic kidney disease (MC)
HTN Glomerulonephritis, polycystic kidney disease, interstital nephritis, obstruction, HIV... |
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What is the MC acute concern with chronic renal failure pts?
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Volume overload & hyperkalemia
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What is azotemia?
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Accumulation of nitrogenous waste-BUN & Cr!
Early sign of RF: Increased BUN BUN dialyzes off more easily than Cr |
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What is the most important electrolyte abn in renal failure?
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Potassium! 90% of K is excreted via the kidneys
CHECK EKG! Most pts HYPERkalemic, will see peaked T waves Low K diet |
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Does kidney failure cause metabolic acidosis or alkalosis?
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Metabolic acidosis: Decreased elimination of H+ ions, poor regeneration of bicarb & low pH due to low bicarb
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What should dialysis patients take to prevent excessive phosphate?
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Phoslo-binds to excess phosphate
Pts also take EPO |
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What happens to calcium during CRF?
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Inverse to phosphate, so as phos increases calcuim decreases causing PTH levels to rise
Secondary hyperparathyroidism can occur Also Vit D synthesis is impaired and therefore intestinal absoprtion of Ca is impaired |
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What is the most profound blood disorder associated with CRF?
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Chronic anemia
Hgb < 10 Hct < 30 Occurs when GFR is < 40 |
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How do you treat chronic anemia associated with CRF?
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Recombinant EPO
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What are common COD(s) in pts with ESRD?
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HTN
CAD Pericarditis |
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How do you treat GI symptoms of chronic renal disease?
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Low protein diet
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What causes peripheral neuropathy in CRF?
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Uremic toxins demyelinate & atrophy nerve fibers (stocking glove peripheral neuropathy)
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What are skin manifestations associated with CRF?
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Pale skin
Pruritis (uremic itching) Thin/brittle nails Caution-skin breakdown with LE |
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Does insulin need to be increased or decreased in a pt with DM & CRF?
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Decreased
Also caution with NSAIDs, may also need to adjust abxs |
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When a pt has renal disease, when do you refer to nephrology?
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Cr > 4
Increased Cr & no risk factors Uncontrolled HTN |
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How do you control/tx CRF?
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BP: ACE inh
Control DM NSAIDs Stop smoking! Tx UTIs aggressively Diet: Protein restriction, Na/water restriction 2 gm Na/day 1-2 L fluid/day K restriction when GFR is < 10-20 ESRD: K 60-70 mEq/day Phos: Keep below 4.6 & dietary restriction to 800-1000 mg/day Mg: No Mg laxatives or antacids |
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When do you do non-emergent dialysis?
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DM: GFR <= 15 ml/min or Cr of 6 mg/dL
Non-diabetics: GFR < 10 or Cr of 8 mg/dL |
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What are the 3 means of vascular access necessary for hemodialysis?
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1. AV fistula: Vein anastomosis to an artery, diabetic poor candidates for this (takes 2-3 months to develop)
2. Graft: PTFE, teflon material anastamosed to a native vein & artery (can use in 1 week) 3. Catheters: Shiley, Tessio, Permacaths |
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If during dialysis a pt has cramping or chest pain what do you do?
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They are too dry, give fluid back to pt
Caution: Don't overload CRF pt will go into CHF |
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What is the treatment of choice for ESRD?
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Kidney transplant
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What is the criteria for acute renal failure?
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Abrupt (within 48 hrs) there is an increase in
~ Cr >= 0.3 mg/dL or ~ >= 50% or ~ Oliguria < 0.5 kg/hr for more than 6 hours |
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Define oliguria & anuria...
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Oliguria: < 500 ml/day
Anuria: < 50 ml/day |
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What is the MC way to acquire ARF? (ICU, hospital or community)
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ICU 6-23%
Hosp 2-5% Community 1-5% |
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What are the three classifications of ARF?
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1. Prerenal azotemia: Hypoperfusion -> shock (MC among hospitalized pts)
2. Intrinsic azotemia: Disease that directly affects the renal parenchyma 3. Postrenal azotemia: Disease associated with renal obstruction |
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What is the MC etiology of prerenal failure?
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Absolute decrease in effective blood volume (hypovolemic)
Hemorrhage, skin/GI/renal losses, fluid pooling |
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What is diagnostic for prerenal failure?
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Fractional excretion of Na < 1%
NOT diagnostic in elderly, those who have received diuretics, pre-existing renal disease, acute GN, vasculitis, radiocontrast induced RF, cirrhosis |
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How do you treat prerenal failure?
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IV crystalloids (NS/LR)
Use colloids or blood is Hgb is low (albumin, dextran) May give pressors once tank is loaded Tx underlying cause |
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List the blood vessels as they enter and leave the kidney...
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Vascular, glomerular, interstitial, tubular
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What are clinical signs of intrinsic renal failure (ARF)?
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Casts, blood, protein in urine
Decreased output ~Oliguric phase: Oliguria, anuria ~Diuretic phase: Improving urine volume ~Recovery phase: Recovery to near baseline |
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What is the MC cause of intrinsic renal disease?
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Acute tubular necrosis (75%)
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If you have RBC casts/dysmorphic RBCs where is the pathology?
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Glomerular disease
(Nephritic syndrome) |
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If you have WBC casts where is the pathology?
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Interstitium
(Pyelo, acute interstitial nephritis) |
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If you see eosinophils where is the pathology?
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Interstitium
(Allergic interstitial nephritis) |
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If granular casts are present where is the pathology?
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Tubule
(Acute tubular necrosis) |
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If hyaline casts are present where is the pathology?
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Pre or post renal
(Pre/post renal failure) |
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Will urine Na be high or low in renal/intrinsic ATN?
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High (>40)
Will be low in pre-renal disease (<20) |
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Will BUN:Cr ratio be high or low in pre-renal disease?
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High (20:1)
Will be low in renal/intrinsic ATN (<20:1) |
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What is the MC cause of post-renal failure (obstructive nephropathy)?
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Prostatic hypertrophy
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In ARF, do you tx bicarb if it is > 16 mEq/L
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Nope (mild acidosis)
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Is EPO an acute option for ARF related anemia?
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Nope, transfuse pt if actively bleeding or sxs referable to anemia
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What is the MC COD in ARF?
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Infection/sepsis
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What is the goal urine output in a pt with ARF?
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> 0.5 ml/kg/hr
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What is the most important route by which bacteria reaches the kidney?
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Ascending infeciton
(Most all UTIs from ascending infection) |
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What male population(s) are susceptible to UTIs?
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Those with outflow obstruction & men who get STDs
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What is the common pathogen of UTIs
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E. coli & other gram negative rods (proteus, klebsiella, enterobacter, pseudomonas)
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How do you tx acute interstitial nephritis?
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Abx: Quinolones, third gen cephalosporins
"Rules of 2's" ~2 T#3 ~2 gm ceftriaxone ~Temp reduced by 2 degrees ~Can tolerate 2 glasses of water |
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What is renal papillary necrosis?
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Ischemic necrosis of tip of papillae or regions of renal medulla that becomes stuck in the ureter
Causes include analgesic abuse, infectious pyelo, DM, obstruction, sickle cell |
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What drugs cause acute drug induced interstitial nephritis?
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Methicillin, ampicillin, cephalosporins
NSAIDs Sulfonamides Diuretics Usually 2 weeks after exposure! |
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How do you tx acute drug induced interstitial nephritis?
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Stop med
May need dialysis High dose steroids |
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What causes chronic tubulointerstitial nephritis?
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Prolonged mechanical obstruction (stones, chronic pyelo, prostate, cervical ca)
Obstructive uropathy Tylenol ASA |
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What morphology will one see with chronic tubulointerstitial nephritis?
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Scarring of the kidney from the renal calyx to the surface of the kidney
Kidneys will be small & contracted on renal US (hydronephrosis & renal scarring) |
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How do you tx chronic tubulointerstitial nephritis?
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ID cause
Small, scarred kidneys: Dialysis Obstruction: remove Analgesic nephropathy: Stop med |
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What lab abnormalities will you see in hereditary polycystic kidney disease?
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Hematuria
Proteinuria Nephrolitiasis Flank/abd pain HTN US may show 3-5 cysts |
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How do you tx polycystic kidney disease?
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No know medical treatment
Aggressive tx of HTN Low protein diet Watch cysts Kidney transplant |
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List the layers of the glomerulus?
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1. Capillary endothelium: Inner most, freely permeable except for RBCs & platelets. Fenestrated & lines glomerular capillaries
2. BM: Controls permeability, boundary between blood and urine 3. Podocytes: Epithelium, supports BM, important in filters protein (between pedicles) 4. Mesangium: Mechanical support to glomerular capillaries & maintenance of filtration of membrane |
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What are the characteristics of diabetic nephropathy?
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Persistent macroalbuminuria (>300)
Decline in GFR Elevated arterial BP |
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In which populations is diabetic nephropathy MC in?
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AA & Native Americans
(M>F) 40% of pts with T1 or T2 develop this! |
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How often should a T1 diabetic have a UA performed?
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Yearly after you have had DM for 5 years
T2: Yearly |
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How do you tx diabetic nephropathy?
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Glucose control
BP control: ACE/ARB Diet Cholesterol control Don't smoke Avoid NSAIDs |
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What is the MC cause of ESRD requiring renal replacement therapy?
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DM
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When do diabetics get dialysis?
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GFR <= 15 or Cr > 6
(Everyone else GFR <=10) |
