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141 Cards in this Set
- Front
- Back
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What product builds up when the Kidneys begin to fail?
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Uremia
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What does uremia actually mean?
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Urine in the blood
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What is the number one cause of metabolic acidosis?
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Renal Failure
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If your patient is in renal failure, what must be done with his or her drug dosing?
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It must be reduced because pretty much every drug is excreted by the kidneys and toxic levels can be reached with even normal adult dosing
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What hormones do the kidneys secrete to regulate their own blood flow?
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Prostaglandins and bradykinin
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What can the secretion of erythropoietin from the kidneys cause?
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Over production can cause anemia
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Renin, prostaglandins and bradykinin are hormones that when secreted by the kidneys participate in what function?
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Systemic and renal hemodynamic regulation
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During fasting, what do the kidneys do to help regulate the bodies nutrient supply?
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Catabolize peptide hormones and synthesis of glucose (glyconeogenesis) when fasting
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What waste products are excreted by the kidneys?
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Urea, creatinine and uric acid.
As well as drugs |
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What is the clinical measure of a healthy nephron?
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Glomerular filtration
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What is the plasma clearance rate?
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The rate at which a substance is cleared from plasma per minute time.
Cleared meaning leaving in urine |
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What effect does reabsorption have on the plasma clearance rate?
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It slows it down
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What function of the nephron can increase the plasma clearance rate?
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The rate of secretion of the substance
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What are the indirect ways of assessing GFR?
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Blood analysis of concentration of various substances
Urine analysis of the same substances. |
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What is the equation for clearance rate (ml/min)?
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([Urine] for sub X Urine flow rate) (quantity/ml urine) (ml/min) / ( [plasma] of substance
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What are nephrologist still looking to find to help truly determine plasma clearance rate?
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An endogenous substance that can show the exact measurement of GFR
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What substance is the closest to determining the plasma clearance rate?
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Creatinine
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Is creatinine cleared faster or slower than the actual GFR? Why?
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Faster because it undergoes a little secretion
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What are the requirements that must be met by a substance to give a true representation of the GRF?
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1. the Substance would have to be freely filtered
2. Its concentration must be stable 3. Cannot undergo reabsorption or secretion 4. Cannot be something tubular cells metabolize 5. Cannot be a substance that can affect GFR, ie vasoconstriction or dilator |
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Why is inulin not ideal as a determinant of GFR?
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It meets all the requirements of the Holy grail but it must be given to the patent continuously on IV drip while monitoring Is and Os. Very inconvenient.
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What is the normal value for creatinine in the body?
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0.7.1.2 mg/dl
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If GFR declines, what happens to PCr?
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It goes up. inversely proportional
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Along with serum creatinine levels, what other value is compensatory hypertrophy a limitation for?
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GFR in general
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What is compensatory hypertrophy?
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A mechanism by a kidney in chronic failure where it increases the size of its nephrons and the rate of filtration to stabilize GFR.
So although GFR appears normal, it does not correlate to healthy nephron mass. (the nephrons become overworked) |
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Why do variations in creatinine production act as a limitation to its use for GFR values?
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Diet, muscle mass, or recent meals can vary the values of creatinine with no direct relationship to GFR. Therefore someone with high creatinine levels may not have decreased kidney function
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What is creatinine secretion? When is it seen?
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Increased secretion from proximal tubular in early early renal disease.
It is a compensatory mechanism that would make creatinine plasma levels appear normal because they are hyperfiltered out of the system. |
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If BUN levels have gone up, what 2 things does it represent?
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GFR has gone down and water retention has gone up.
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What is specific gravity of urine? what is it an indicator for?
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Measurement of the osmolarity of urine. Compares the density of a fluid compared to distilled water.
Can tell you the state of ADH in the body. As ADH rises, the osmolarity of urine goes up |
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Other than the renal system, can creatinine be excreted from the system in other ways? how?
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Yes, by bacteria in the GI tract as a result of advanced kidney disease
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Why is Plasma Cycstatin C not a reliable indicator of GFR?
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It cannot be used in large populations such as CHF, DM, COPD and it gets metabolized as it travels down the tubules.
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What does basic urine indicate for?
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Possible Urinary tract obstructions or common in chronic renal failure
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WHy was plasma C thought to be a good indicator for GFR?
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it is filtered at the glomerulus and not reabsorbed. but it is metabolized by the tubules.
produced by all nucleated cells, its rate of production is relatively constant and not affected by gender, age, or muscle mass |
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What is BUN?
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the concentration of urea nitrogen in the blood
Has been thought to be an indicator for GFR? |
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As GFR goes down, BUN goes ___?
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up
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How do creatinine and BUN levels differ in terms of rising water reabsorption levels?
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Both values will go up but BUN will go up to a greater extent
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What does basic urine indicate for?
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Possible Urinary tract obstructions or common in chronic renal failure
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What are CASTS?
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small sheets of epitherlial cells that are actually renal tubule cells.
When someon has consumed something nephrotoxic, it can cause necrosis of the cells and they get sloughed off into the urine |
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What is the number one cause of disorders of Renal function?
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Aging!
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How much of the nephron mass is a RESERVE?
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50%
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How much nephron loss is needed to see real problems?
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75%
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What 4 classes of disorders/abnormalities cause renal dysfunction?
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Congenital disorders
infectious disorders Obstructive disorders Glomerular abnormalities |
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Which renal failure is reversible?
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Acute
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What % decrease do the kidneys undergo with aging alone? What lab value will this relate to?
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30%
will see a progressive increase in creatinine levels |
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With aging and decrease kidney mass, what must be monitored by the nurse in terms of drugs?
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The patient will have decrease metabolite excretion and thus will need a lower dose for most medications
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Why can aging put a person at risk for acidosis?
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Decreased excretion of H+ from the body
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Because aging patients have decreased urine concentration capabilities, this puts them at risk for ____
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dehydration
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Why are elderly patients at higher risk for hyperglycemia?
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Because their kidneys will hold onto more glucose before it starts showing in the urine. The threshold has changed due to decreased kidney function
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Why are elderly patients often incontinent?
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The autonomic innervation to their bladder has declined. They also have weaker urinary muscles that decide when you will urinate. They have changes in the structure of the urethra that decreases schincter tone. Also makes starting urination difficult
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What happens to elderly patients urine production during sleep?
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It goes up
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What is a major cause of urinary obstruction in men?>
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Prostatic hypertrophy
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What is considered a functional obstruciton of the bladder?
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When bladder tone or innervation to the bladder is reduced.
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What can occur if an obstruction Is not fixed?
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Can have dilation of the urinary tract above the obstruction or of the kidney itself and eventual pernanent damage. Can also get urinary stasis and infection
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What is polycystic kidney?
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Fluid filled cysts in the paenchyme of the kidney
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What is an obsructive uropathy?
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When there is a functional or anatomical obstruction to the kidneys and causes subsequent damage.
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What does the severity of a uropathy depend on?>
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The location of the obstruction. The higher the obstruction the more problems.
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What are the most common causes of urinary obstructions?
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Kidney stones
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What are the other names for kidney stones?
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Renal calculi, nephrolithiasis
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where do kidney stones almost always originate>?
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in the calyces (the point at which the renal pyramids dreain into the renal calyces)
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what are kidney stones?
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solid masses composed of a collection of tiny crystals formed from the super concentration of stone forming constituents: Calcium, oxalate and uric acid!
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which gender tend to get kidney stones more often?
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Men
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What are the causes of kidney stones?
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Hypercalciuria
Decreaes levels of urinary magnesium a low fluid intake |
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What is the hallmark symptom of kidney stones/
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Renal cholic; pain. Flank pain in the lower back that radiates to the groin
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How do you treat kidney stones?
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Analgesics and sometimes calcium channel blockers
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What is the result of polycystic kidney disease?
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The fluids will replace enough cysts to cause ESRF
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What are the 2 major inheritied forms of polycystic kidney disease?
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1. Autosomal Dominant PKD
2. Autosomal recessive PKD |
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What is autosomal dominant PKD?
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Most common cause of PKD (90%). Symptoms develop between 30-40
First sign is renovascular HTN. Bilateral involvement. Will progress to ESRF |
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What is autosomal recessive PKD?
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Infant onset PKD and can be recognized in the womb.
Can lead to death quickly or can live to their teens. Very rare. |
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What is ACKD and what % of PKD pts have it?
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Acquired Cystic Kidney Disease
about 10% have this form No genetic association, and is caused by long term kidney problems especially people on dialysis for long periods of time. Actually increased the risk for renal cancer |
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What are the symptoms of polycystic kidney disease?
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Pain in the back and the sides (between ribs and hips), and headaches.
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What are some comorbidities with PKD?
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1. UTIs
2. Hematuria 3. Liver and pancreatic cysts 4. Abnormal heart valves 5. HTN 6. kidney stones |
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What can cause prostate enlargement?
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Acute inflammation, benign prostatic hyperlasia or prostate cancer
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What is benign prostatic enlagement? What % of men get it?
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A noncancerous enlargement of the prostate gland that may restrict the flow of urine from the bladder.
1/3 of men over the age of 50 will get it. Up to 90% of men by age 80. |
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What are the common symptoms of Benign prostatic hyperplasia?
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1. Urinary frequency
2. Urinary urgency 3. urinary hesitancy 4. incomplete bladder emptying |
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What are the screening techniques for BPH?
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1. Digital rectal exam: can feel the enlargement. It will feel spongy and when pushing on it the man will have the desire to urinate. Usually a symetrical enlargement
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What is one of the most important structural aspects of the prostate gland?
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The fibrous capsule: inelastic. When it enlarges, it cannot get bigger because of the capsule and thus causes impingement on the urethra
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What is the purpose of the prostate?
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contributes to seminal fluid (70%) and is very alkaline. Also during ejaculation the prosate clamps down and prevents retrograde ejaculation and potentially infecting the bladder
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Why has prostate cancer detection been improved?
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Due to widespread availability of serum PSA testing and digital rectal exams and biopsy
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Someone with prostate cancer will have what levels of PSA?
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Extremely high
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What is the Tx for prostate cancer?
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1. Active Surveillance
2. Radiation 3. Prostatectomy 4. Androgen deprivation Therapy |
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What are the side effects to Prostatecomy?
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Can damage the penile nerve and thus lead to sexual dysfunction and incontinence
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When is androgen deprivation therapy used and why>?
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Palliateive only
Because of the side effects: 1. sexual dysfunction 2. Osteoporosis and bone fractures 3. Vasomotor symptoms (hot flashes) 4. Gynomastia (breast formation) |
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What is the most likely Dx is the prostate is symetrically enlarged?
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Benign Prostate Hyperplasia
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How would one describe a cancerous growth in the prostate gland?
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Nodular and asymmetrical
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What is the definition of hydronephrosis?
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Dilation of the renal pelvis and calyces
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What does a hydronephrosis and hydroureters cause?
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increases pressure upstream that causes dilatio of the tract and affects renal function and glomerular filtration
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What does a rise in ureteral pressure lead to?
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Decline in renal blood flow and glomerular filtration. Can lead to ischemia and nephron loss
-can also lead to Renovascular HTN |
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What is Post obstructive renal failure?
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The build up of filtration opposing pressure in the kidney that leads to renovascular HTN due to reduced renal blood flow
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What origin of direction do almost all UTI follow?
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Ascending
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What is bypassed during an UTI?
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The bladder, bladder infections are very rare!
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What do UTI's often lead to?
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Polynephritis: infectious inflammation of the kidneys
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What are the contributing factors for UTIs?
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1. Urinary stasis
2. metabolic changes 3. antibiotics |
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Which gender are more vulnerable to UTIs? Why?
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Women because they have shorter urethras
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List the risk factors for UTIs?
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1. Structural abnormalities
2. Metabolic/hormonal abnormalities 3. Impaired host responses 4. unusual pathogens 5. disturbance in non-harmful urethral flora |
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What are some examples of structural abnormalities increasing risk for UTI?
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Calculi, infected cysts, renal/bladder abscesses, spinal chord injury, catheters
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What metabolic problems have been known to increase the risk for UTI?
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DM and pregnancy
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What is an unusual pathogen that can lead to a UTI?
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yeast
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What is the most common bacteria to cause pyelonephritis?
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E. coli from feces. Cross contamination of self
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List the SxS of a UTI
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1. Urinary frequency
2. burning with urination 3. low urine output |
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What are the SxS of pyelonephritis?
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1. Intense flank pain
2. Fever 3. Person may be tired, or sense of weaknees 4. N/V |
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What is the defintion of acute renal failure?
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Precipitous and significant (>50%) decrease in GFR over a period of hours to days, with an accompanying acumulation of nitrogenous wastes in the body
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What are the 3 main mechanisms of acute renal failure?
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1. Prerenal failure
2. Intrinsic renal failure 3. Postobstructive renal failure |
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Describe prerenal failure.
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Compromise in the GFR because you are not getting enough blood to the kidneys. Don't have enough cap BP to have enough GFR
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What is intrarenal failure?
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problem or injury in the kidneys at the level of the glomerulus or tubules that results in decreased GFR. Associated with release of renal afferent vasoconstrictors
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Describe postobstructive renal failure.
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Acute renal failure caused by an obstruction that causes a backup in bowmans capsule and HTN and decreases the filtration driving force.
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What is unique about acute renal failure?
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it is reversible
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Give some examples of causes of prerenal failure.
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1. Hypovolemia (hemorrhage)
2. MI 3. drugs that cause renal artery vascoconstriction |
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What are some examples of things leading to intrinsic renal failure?
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1. pyelonephritis
2. acute glomerular nephritis 3. uric acid crystals obstructing the nephrons 4. Acute tubular necrosis (MOST COMMON CAUSE) |
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What is acute tubular necrosis?
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acute injury to the cells of the tubules and they start dying and sloughing off. Can do a sedement analysis that results in CAST cells.
It increase the pressure of bowmans capsule and GFR is reduced |
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What can cause acute tubular necrosis?
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Most common cause is ischemic injury, which occurs from untreated PRErenal failure
-2nd most common: nephrotoxic acute tubular necrosis: toxin -Radiographic contrast dyes are nephrotoxic to EVERYONE |
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What is mucomyst? Why is it used?
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Drug given before getting a radiographic dye and is a strong antioxidant. It helps scavenge up the free radicals release from the dye to prevent nephrotoxicity
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What are some causes of postrenal failure?
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Bilateral ureteral obstruction
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What are the 3 phases of renal failure?
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1. Oliguric Phase
2. Diuretic Phase 3. Recovery phase |
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What is the oliguric phase of ARF?
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Little to no urine output. Person is putting out less than 30cc/hour. BUN and creatinine levels rise
hypervolemia can occur causing edema, weight gain, and high BP. -Can cause electrolyte, respiratory, and CV problems -can cause precipitous heart failure |
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Describe the compensatory phase of renal failure.
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Have increased urine output, during his phase the kidneys reduce the ability to hold onto water and Na. Because the BUN levels have risen it creates osmotic diuresis
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What is involved in the recover phase of renal failure?
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Everything starts to normalize. GFR back to normal state. BUN and creatinine and outputs are normal
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Define chronic renal failure.
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the progressive loss of renal function over month to years. Advancement of the disease can be slowed but the loss of function is irreversible and terminates in ESRD
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What is renal insufficiency?
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decline of about 15% of normal GFR and elevated serum creatinine and ura
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What is the definition of renal failure?
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Significant loss in renal funciton (when less than 10% is left: ESRF)
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define Azotemia.
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increased serum urea levels and frequently increased creatinine levels: renal failure leads to this
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What is uremia?
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syndrome of renal failure that includes elevated blood urea and creatinine levels accompanied by fatigue, anorexia, nausea, vomitting, pruitis, and neuro changes
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What is poststretococcal glomerulonephritis?
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Type 3 hypersensitivity response that results in circulating immune complexes that get lodged in the nephron and cause an immune response. If it happens enough it can lead to chronic renal failure
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What chronic systemic conditions can lead to chronic renal failure?
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1. DM
2. DI 3. HTN 4. Gout 5. Scleroderma 6. Systemic lupus erythematosus |
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What are the stages of chronic renal failure?
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1. Reduced renal reserve
2. Renal insufficiency 3. Renal failure 4. end-stage renal failure |
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What classifies reduced renal reserve?
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GFR drops to 50% of normal state
Usually has no symptoms of impaired renal funciton Increased risk for azotemia and susceptibility to nephrotoxic drugs |
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In terms of CRF, what is the renal insufficiency stage?
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1. GFR is 20-50% of normal
2. Compensatory hypertrophy and hyperfiltration leading to injury, fibrosis, and loss 3. Maintenance of normal function until 75% of nephrons loss 4. Symptoms begin to arise: azotemia, anemia and HTN |
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Describe ESRF
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GFR is less than 5% of normal
The overall mass of the kidneys is reduced Treatment with dialysis or transplantation is necessary for survival |
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Describe Na and water imbalance with ESRF. What does this imbalance lead to?
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When kidneys fail we are not producing urine and thus retaining Na, waste and fluid. End up with HTN, increased vascular volume, pitting edema, increased preload, heart failure.
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In terms of K levels, people with Chronic Renal failure are at risk for?
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hyperkalemia and cardiac arrest
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What is syndrome of urea? Who gets it?
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It is the result of Chronic renal failure and the by products of protein metabolism (urea) are not removed in urine. Affects acid/base balance, clotting problems, increase inflammation of the pericardium, deposition of waste in the skin, can effect brain and sexual function.
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What occurs with erythropoietin production in chronic renal failure? What does it lead to?
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The production goes down which results in less RBC and thus anemia
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How will a person in chronic renal failure's breathing be? Why?
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Hyperventilation and SOB because they are chronically acidodic since they cannot remove H+ from the body.
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How does acid levels relate to bone problems in ESRF?
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Osteodystrophies occur because acid tends to break down bone and thus releases Ca in to the blood stream
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What does CRF do to vitamin D?
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It stops the activation of Vitamin D and thus Ca cannot be absorbed from the gut and thus causing hypocalcemia and resultedly Hyperparathyroidism
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What are the 2 compartments of the dialysis machine?
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Blood compartment and the diasylate
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What will the K concentration of the Diasylate be?
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Low in comparison to the blood
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What is the name of the port for dialysis?
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Artereovenous fistula
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What does the peritoneum act as in peritoneal dyalsis?
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The compartment for the diasylate
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what is the semipermeable membrane in peritoneal dialysis?
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the visceral membrane of the peritoneum
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What are some non-renal indications for hemodialysis?
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1. chronic liver failure
2. acute blood poisoning 3. acute hyperkalemia 4. electrolyte imbalances |
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What vessel does the blood leave the body in hemodialysis? Where does it go back in?
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The vein, goes back in through the artery
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What drugs have a tendency to increase serum creatinine levels? How?
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Sulfamethoxazole and Trimethoprim: antiobiotics.
They decrease the secretion of creatinine from the kidneys |
