Respiratory/renal Test 4 Set1

Front 1

Acute Renal Failure is...

Back 1

abrupt decline in renal fxn resulting in an inability to excrete metabolic wastes and maintain proper F&E balance

Front 2

2 declines that constitute ARF

Back 2

1)NORMAL renal fxn @ baseline w/ a 50% incr in SCr over 1d
2)SCr is over 2mg/dl @ baseline w/ a greater than 1mg/dl incr

Front 3

For CrCL use what equation in ARF?

Back 3

Chiou, not CG (only works in stable renal fxn)

Front 4

Hospitalized pts that develop ARF have...

Back 4

sig incr mortality

Front 5

Why might SCr not be a good measure of acute changes in renal fxn (2)

Back 5

1)accumulation of metabolic wastes may be out of proportion to the change in SCr
2)SCr may not decline/recover at the same rate as renal fxn

Front 6

Community ARF
a)incidence
b)common causes (3)
c)surivial

Back 6

a)less than 1%

b1)volume depletion
b2)prostate obstruction
b3)meds

c)70-95%

Front 7

Hospital ARF
a)incidence
b)common causes (3)
c)surivial

Back 7

a)2-5%

b1)volume depletion
b2)hypotension
b3)meds

c)30-50%

Front 8

ICU ARF
a)incidence
b)common causes (3)
c)surivial

Back 8

a)6-23%

b1)sepsis
b2)multi-organ failure
b3)meds

c)10-30%

Front 9

Nonoliguric?

Back 9

normal urine production (over 400mL/day)

Front 10

Oliguric?

Back 10

decr urine production (less than 400mL/d)

Front 11

Anuric

Back 11

no urine production (less than 50mL/day)

Front 12

"Prerenal"

"Postrenal"

"Intrinsic"

Back 12

a)decr renal perfusion (prerenal azotemia)

b)obstruction of urine flow

c)structural kidney damage

Front 13

Urinalysis
a)what is it
b)what does it include (5)

Back 13

a)chemical/microscopic analysis of urine
b1)pH
b2)specific gravity
b3)protein/glucose
b4)ketones
b5)WBC/RBC

Front 14

Urine Sodium (Una)
a)measures...
b)values (2)

Back 14

a)urine []ing ability of kidney

b1)5-10 when volume depleted so incr [] of urine
b2)over 30 when kidney can NOT concentrate urine

Front 15

Urine Osmolality (Uosm)
a)measures... (2)
b)values (2)

Back 15

a)urine []ing ability of kidney; # of osmotically active particles in urine

b1)normal is 50-1200 (depending on hydration status of pt)
b2)highly []ed urine is over 500

Front 16

Fractional Excretion of Na (FEna)
a)measures...
b)why gotten? (2)
c)values (3)

Back 16

a)urine []ing ability
b1)does NOT require 24h collection
b2)reflects acute changes

c)normal is 1%
c)less than 1% when volume depleted (b/c kidney will [] urine by retaining Na)
c)over 1% = kidney can NOT [] urine due to damage/diuretics

Front 17

FEna equation

Back 17

(Una x SCr) / (Ucr x Sna)

Front 18

BUN:SCr ratio
a)normal value
b)values

Back 18

a)10:1

b1)volume depletion = 20:1 or more = ability to [] urine
b2)10:1 can mean inability to [] urine

Front 19

Volume depletion =

Back 19

WILL = CONCENTRATED URINE

Front 20

PreRenal ARF CAUSES (3)

Back 20

1)hypovolemia (decr circulating blood volume = decr kidney perfusion; v/d, dehydration, hemmorhage)

2)hypotension (decr effective blood volume; sepsis, CHF)

3)Meds (vasospasm of kidney vessels = decr kidney perfusion; ACEI, NSAIDs)

Front 21

Clinical Findings of Prerenal ARF (7)

Back 21

1)hypovolemia (v/d, diuretics, hemorrhage)
2)hypotension (CHF, sepsis)
3)tachycardia
4)orthostatic hypotension (positive tilt test)
5)dry mucous membranes
6)poor skin tugor (tenting)
7)wt loss

Front 22

"Positive Tilt Test"?

Back 22

decr BP and incr pulse when going from lying down to upright

Front 23

Renal assessment in Prerenal ARF (6)

Back 23

1)oliguria
2)incr BUN:SCr
3)incr Uosm
4)decr Una
5)FEna less than 1%
6)UA normal

Front 24

Tx of Prerenal ARF (4)

Back 24

1)hypovolemia
a)FLUID REPLACEMENT
b)stop v/d, diuretics, bleeding

2)hypotension (treat CHF, sepsis)

Front 25

What is done in body to incr BP/ maintain kidney perfusion (2)

Back 25

1)RAAS activation
2)incr Na/water reabsorption

Front 26

Determine IV fluid to use (2)

Back 26

1)If serum Na is greater than normal pt is: hypernatremic hypovolemia
a)means they have a greater water deficit than salt deficit so use 0.45% NaCl

2)If serum Na is less than normal then pt is hyponatremic hypovolemia
b)means greater salt deficit than water deficit so use 0.9% NaCl

Front 27

Calculating how much to use for
a)0.45% NaCl
b)0.9% NaCl

Back 27

a)formula given on exam (so don't worry)

b)formula's given just remember to convert to L of NS to infuse (154mEq/L)*****

Front 28

Other Fluid replacement steps after calculating need (6)

Back 28

1)Serum Na correction should never be more than 0.5mEq/L/hr*******
2)How much will we change the serum Na--(Na-140)=mEq/L to correct
3)(mEq/L to correct) x ((L/hr)/(0.5mEq)) = minimum hours to infuse volume
4)IV bolus rate (fluids gotten in first 24h) should replace half of deficit in first 24hrs (unless this requires replacement faster than 0.5mEq/L/hr)
6)Continuous IV infusion rate (rate after 1st 24h); infuse @ rate of 1mL/kg/hr

Front 29

When to incr/decr rate of IV bolus of fluids

When to incr/decr rate of continuous IV infusion rate

Back 29

1)incr if acute onset of hypovolemia
2)decr if prolonged onset of hypovolemia


1)incr if symptomatic, nonolguric, can tolerate
2)decr if oliguric/anuric, heart disease, unable to tolerate fluid load

Front 30

S/sx of volume overload that tell you to DECREASE IV FLUIDS (4)

Back 30

1)edema
2)pulmonary edema (rales)
3)incr BP
4)wt gain

Front 31

S/sx of volume depletion that tells you to INCREASE IV FLUIDS (6)

Back 31

1)wt loss
2)decr BP
3)tenting (poor skin tugor)
4)dry mucous membranes
5)positive tilt tachycardia
6)BUN:SCr is increased

Front 32

PostRenal ARF CAUSES (3)

Back 32

1)ureter obstruction (in both kidneys or 1kidney if pt only has 1)
2)bladder obstruction
3)urethra obstruction

Front 33

PostRenal ARF
a)clinical findings (4)
b)renal assessment (2)

Back 33

a1)decr urine stream/output
a2)distended bladder
a3)enlarged prostate
a4)pelvic/abdominal mass

b1)oliguria
b2)UA normal

Front 34

Treatment of PostRenal ARF
a)Ureter obst (2)
b)Bladder obst (2)
c)Urethra obst (2)

Back 34

a1)crystal/calculi: analgesics and IV fluids to incr urine flow
a2)clot/tumor: surgery

b1)prostatic hypertrophy/tumor: surgery
b2)Neurogenic bladder: alpha-antagonist, I/O catheterization

c1)catheter
c2)surgery

Front 35

Intrinsic ARF BROAD CAUSES (4)

Back 35

1)damage to renal vasculature/vessels
2)damage to glomerulus (glomeruluonephritis)
3)damage to interstitium (intersitial nephritis)
4)acute tubular necrosis (ATN--damage to tubules)

Front 36

Damage to renal vasculature/vessels (INTRINSIC ARF)
a)causes
b)manifestations (2)
c)tx

Back 36

a)vasculitis

b)systemic vasculitits
b)UA normal

c)tx underlying cause

Front 37

Glomerulonephritis (INTRINSIC ARF)
a)causes (2)
b)manifestations (5)
c)tx (2)

Back 37

a1)lupus
a2)post infectious (immune mediated damage to glomerulus) glomerulonephritis

b1)s/sx of lupus
b2)h/o of recent infexn
b3)UA shows heavy protein (>3g/day), "foaming" urine (severe proteinuria)
b4)RBCs, RBC casts
b5)"cola-colored" urine (hematuria)

c1)tx underlying cause
c2)immunosuppressants

Front 38

Interstitial nephritis (INTRINSIC ARF)
a)cause
b)manifestations (4)
c)tx (2)

Back 38

a)allergic rxn to meds (MOSTLY ABX)

b1)rash
b2)h/o of abx use
b3)loss of urine []ing ability (Fena over 1%, incr Una, decr Uosm)
b4)WBCs and eosinophils in UA

c1)dc offending med
c2)consider corticosteroids

Front 39

ATN (INTRINSIC ARF)
a)what is ATN? (3)
b)cause (3)

Back 39

a1)predominant cause of ARF in hospitalized pts
a2)tubule cells die and slough off into tubule lumen
a3)this forms casts that obstruct the tubule and prevent glomerular filtration

b1)tubules are highly susceptible to injury b/c of high metabolic activity
b2)ischemia (hypovolemia, hypotension, vasoconstrictors)
b3)toxins (nephrotoxic meds)

Front 40

ATN (INTRINSIC ARF)
a)clinical findings (3)
b)renal assessment (3)

Back 40

a1)s/sx of hypovolemia/hypotension (h/o PreRenal)
a2)h/o of vasoconstricting meds
a3)h/o of nephrotoxin meds

b1)loss of urine []ing ability (FEna over 1%, incr Una, decr Uosm)
b2)DIRTY BROWN CASTS IN UA****
b3)oliguria

Front 41

ATN (INTRINSIC ARF)
a)tx (3)
b)maintaining fluid status (3)
c)goal

Back 41

a1)treat underlying cause
a2)avoid nephrotoxic meds
a3)provide hemodynamic support

b1)restrict Na (less than 2g/d)
b2)restrict water (less than 1L/d)
b3)avoid excessive fluid hydration

c)INCR URINE PRODUCTION TO GREATER THAN 1mL/kg/hr

Front 42

Purpose of Incr Urine Production? (5)

Back 42

1)convert oliguric to non-oliguric renal failure
2)no evidence that this improves outcomes
3)but may be good at maintaining fluid balance (preventing pulmonary/peripheral edema)
4)forcing elimination of nephrotoxins
5)stabilizing hemodynamics

Front 43

Incr Urine Production
a)drugs used (3)
b)mechanism
c)adv of them

Back 43

a)HIGH DOSE: lasix, torsemide, bumetanide
b)incr GFR and cause vasodilation
c)safe, cheap

Front 44

Equivalent IV dosing of the 3 loops

Back 44

Furosemide (80mg po) 40mg IV = 20mg torsemide = 1mg bumetanide

Torsemide Twenty
Furosemide Forty

Front 45

Dosing of furosemide (3)

Back 45

1)initiated @ 80mg IV q8h
2)or continuous infusion of 10mg/hr
3)TITRATE URINE OUTPUT UP TO GOAL OF 1mL/kg/hr******

Front 46

Monitoring parameters of loops (5)

Back 46

1)fluid status (diuresis goal is 1kg/day)
2)BP
3)HR
4)Na, K, Mg, Ca
5)renal fxn

Front 47

ADR's of loops (4)

Back 47

1)tinnitus
2)vertigo
3)fullness in ear
4)rates of 4mg/min associated w/ ototoxicity

Front 48

Diuretic resistance
a)mechanismS (4)
b)methods to overcome (4)

Back 48

a1)inadequate diuretic dose
a2)excessive Na intake
a3)reduced renal blood flow/perfusion
a4)meds, hypotension, hypovolemia

b1)combine loop and thiazide (metolazone)
b2)continuous IV infusion of IV loop (furosemide 1mg/kg/hr)
b3)Na restriction (less than 1g/day)
b4)renal dose dopamine

Front 49

ARF Tx Goals of the following COMPLICATIONS:
a)develop chronic renal failure (4)
b)fluid overload (3)

Back 49

a1)treat reverse underlying cause
a2)maintain hydration
a3)monitor/adjust meds
a4)avoid nephrotoxin meds

b1)restrict Na/water
b2)incr urine production when oliguric
b3)minimize excess exogenous fluids (TPN, IV meds)

Front 50

ARF Tx Goals of the following COMPLICATIONS:
a)Arrhythmia (due to electrolyte abnormality)
b)Acidosis/Alkalosis (due to electrolyte abnormality)
c)HTN
d)Sepsis

Back 50

a)manage K
b)manage H
c)manage BP
d)prevent/early recognition/aggressive tx

Front 51

ARF Tx Goals of the following COMPLICATIONS:
a)GI bleeds
b)altered mentation
c)malnutrition (2)

Back 51

a)maintain BP
b)manage electrolytes/toxins/meds

c1)enteral/parenteral supplements to meet catabolic state
c2)consider nutrients lost w/ dialysate

Front 52

Complications of ARF (9)

Back 52

1)chronic renal failure
2)fluid overload
3)arrhythmia/acidosis/alkalosis due to electrolyte abnormality
4)toxin accumulation
5)HTN
6)sepsis
7)GI bleeding
8)altered mentation
9)malnutrition

Front 53

Indications for ACUTE Dialysis in ARF (5)

Back 53

AEIOU

a)Acidosis (resistant to tx)
b)Electrolytes abnormal (incr in K, resistant to tx)
c)Intoxications (ethylene glycol, lithium)
d)Overload (volume overload resistant to tx)
e)Uremia (symptomatic)

Front 54

Monitor/adjust drug dosing (3)

Back 54

1)adjust current meds according to renal fxn
2)inability to efficiently estimate CrCL in ARF requires PK monitoring
3)avoid nephrotoxins, but when have to be used take measures to prevent renal damage

Front 55

Mechanisms of Drug Induced Renal Failure (4)

Back 55

1)hemodynamic
2)acute tubular necrosis (ATN)
3)allergic interstitial nephritis
4)rhabdomylosis

Front 56

Drugs that induce hemodynamic renal failure (3)

Back 56

1)NSAIDs
2)ACEI/ARB
3)contrast media

Front 57

Regulation of Glomerular Filtration by PG and angiotensin2 (3)

Back 57

a)PG at the afferent arteriole causes vasodilation (incr renal perfusion)
b)AG2 acts to constrict the afferent arteriole BUT is heavily outweighed by PG effect (so dc this effect)
c)AG2 @ the efferent artierole causes vasoconstriction

Front 58

NSAIDs effect on kidney (2)

Back 58

1)vasoconstrict afferent arteriole (decr perfusion)
2)in normal people there will be autoregulation to maintain GFR

Front 59

COX2 effect on kidney?

Back 59

1)they may also precipitate renal failure b/c COX2 is in the kidney as well

Front 60

NSAIDs and people w/ ___ and ___ causes problems...(2)

Back 60

1)volume depletion (dehydration)
2)effective volume depletion (CHF, cirrhosis)

1)PG synthesis is incr to preserve renal blood flow and the GFR
2)these pts are dependent on PGs to maintain renal perfusion

Front 61

Risk factors for NSAID-induced renal failure (7)

Back 61

1)renal insufficiency
2)CHF
3)cirrhosis
4)hypovolemia
5)elderly
6)dehydration
7)concomitant ARB/ACEI use

Front 62

ACEI/ARB and people w/ ___ and ___ causes problems...(3)

Back 62

1)volume depletion (dehydration)
2)effective volume depletion (CHF, cirrhosis)

1)angiotensin2 increases the intraglomerular pressure in order to maintain/incr GFR
2)these pts are dependent on AG2 to maintain renal perfusion
3)pts w/ bilateral renal artery stenosis are dependent on AG2 to maintain renal perfusion

Front 63

Risk Factors for ACEI/ARB induced renal failure (7)

Back 63

1)CHF
2)cirrhosis
3)hypovolemia
4)elderlly
5)dehydration
6)renal insufficiency
7)concomitant NSAID/COX2 use

Front 64

Mechanism of Radiocontrast media induced renal failure (2)

Back 64

1)osmotic diuresis (causing volume depletion and hypotension)
2)direct tubular toxin

Front 65

Risk factors for Radiographic Contrast Media induced renal failure (3)

Back 65

1)renal insufficiency
2)volume depletion or effective volume depletion
3)large doses of RCM

Front 66

Manifestations of RCM induced renal failure (3)

Back 66

1)initial diuresis
2)then a PreRenal state (volume depletion and hypotension)
3)then onto ATN (loss of urine []ing ability) (FEna over 1%, incr Una, decr Uosm)

Front 67

Prevention of RCM induced renal failure (3)

Back 67

1)ID high-risk pts
2)saline prehydration (500mL IV over 30min before; 500mL IV over 30min after)
3)Acetylcysteine (600mg po q12h for 4 doses, 2 doses prior/2 doses after RCM)

Front 68

RCM induced renal failure treatment(2) and prognosis (2)

Back 68

1)maintain F&E
2)tx as PreRenal or ATN

1)transient/txable PreRenal ARF up to..
2)irreversible renal failure requiring dialysis

Front 69

Brief ATN description (2)

Back 69

1)tubule cells die and slough off into tubule lumen
2)forms casts that obstruct the tubule and prevent glomerular filtration

Front 70

Drugs that induce ATN (3)

Back 70

1)aminoglycosides
2)amphotericin B
3)cisplatin and carboplatin

Front 71

Aminoglycosides and ATN
a)drugs (2)
b)prevalence
c)mechanism (3)

Back 71

a)gentamicin and tobramycin
b)10-20% of pts

c1)AGs filtered/taken up by and stored in the proximal tubular cells
c2)accumulation of AGs induces renal injury
c3)onset of ATN will be 5days after start of therapy (but can cause renal failure several days after stopping therapy)

Front 72

Aminoglycoside/ATN risk factors (6)

Back 72

1)high doses/long duration
2)high troughs (over 2)
3)renal insufficiency
4)elderly
5)hypotension/volume depletion
6)decr K/Mg

Front 73

AG induced ATN manifestations (5)

Back 73

1)decr K/Mg
2)nonoliguria
3)proteinuria
4)incr SCr
5)ATN (loss of urine []ing ability/dirty brown casts in urine)

Front 74

Prevention of AG induced ATN (3)

Back 74

1)fluids
2)PK monitoring
3)extended interval dosing (24hr vs. normal q8h dosing)

Front 75

Tx of AG induced ATN (3 and one w/ 3)

Back 75

1)F&E management
2)use alternative abx if possible

3)tx as ATN
a)restrict Na (less than 2g/d)
b)restrict water (less than 1L/d)
c)avoid excess fluid hydration

Front 76

AG induced ATN prognosis (3)

Back 76

1)return to baseline renal fxn within 21d after dc of AG
2)will take longer if pt is hypovolemic/hypotensive
3)irreversible renal damage may occur w/ prolonged courses

Front 77

Amphotericin B desc (5)

Back 77

1)IV antifungal
2)many ADRs (amphoterrible)
COMMON:
a)infusion-related rxns
b)electrolyte disorders
c)ARF in 80%

Front 78

Amphotericin B mechanism of nephrotoxicity (6)

Back 78

1)renal vasoconstriction
2)bind tubular cells
3)incr cell permeability
4)histologic damage
5)ischemia
6)tubule cell death

Front 79

Amphotericin B risk factors (3)

Back 79

1)high dose
2)volume depletion
3)renal insufficiency

Front 80

Amphotericin B induced ATN manifestations (2)

Back 80

1)decr K/Mg
2)ATN (loss of urine []ing ability--FEna less than 1%, incr Una, decr Uosm & dirty brown casts in urine & oliguria)

Front 81

Prevention of Amphotericin B induced ATN (3)

Back 81

1)fluids (500mL IV over 30min before & 500mL IV over 30min after)
2)BUT DO NOT THIS 1) FOR A PT W/ ATN
3)ALSO NOT GOOD FOR PTS UNABLE TO TOLERATE THE NA LOAD

Front 82

Tx of Amphotericin B induced ATN (3 and one w/ 3)

Back 82

1)F&E management
2)change antifungal if possible

3)tx as ATN
a)restrict Na (less than 2g/d)
b)restrict water (less than 1L/d)
c)avoid excess fluid hydration

Front 83

Amphotericin B alternatives (3) and prognosis (2)

Back 83

1)lipid based AmB products (but these are freakin expensive)
2)these have decr ADRs, decr ARFs
3)only use in pts that fail AmB

1)gradual return to baseline
2)may be irreversible

Front 84

Incidence of ARF w/ the -platins (3)

Back 84

1)cisplatin 25-40%
2)less w/ carboplatin
3)rare w/ oxaliplatin

Front 85

Mechanism of nephrotoxicity/ATN by platins (2)

Back 85

1)direct tubular damage (impaired enzymes/energy)
2)onset at 10days, but may be cumulative w/ subsequent cycles

Front 86

Cisplatin induced ATN risk factors (4)

Back 86

1)radiation/nephrotoxins
2)renal insufficiency
3)elderly
4)hypotension/volume depletion

Front 87

Cisplatin induced ATN manifestations (3)

Back 87

1)SEVERE decr Mg (may be irreversible)
2)decr K/Ca
3)ATN (loss of urine []ing ability--FEna over 1%, incr Una, decr Uosm & dirty brown casts in urine & oliguria)

Front 88

Cisplatin induced ATN
a)prevention (3)
b)tx (3 and one w/ 3)

Back 88

a)hydration
b)force diuresis
c)but w/ 1&2 monitor chemotherapy efficacy w/ amifostine

b)F&E management
b)alternative chemo if possible
c)tx ATN
a)restrict Na (less than 2g)
b)restrict water (less than 1L)
c)avoid excessive fluid hydration

Front 89

Cisplatin induced ATN prognosis (2)

Back 89

1)mild and reversible w/ initial course
2)more severe and less reversible w/ subsequent

Front 90

Allergic Interstitial Nephritis
a)happens w/... (3)
b)onset

Back 90

a1)B-lactams (penicillin, cephalosporins
a2)quinolones
a3)sulfonamides
b)7-10d after exposure

Front 91

Allergic Interstitial Nephritis mechanism (4)

Back 91

1)drug-host protein antigen enters renal tubule
2)initiates inflammatory rxn and eosinophils in interstitium
3)enlarges kidney
4)tubule damage occurs

Front 92

Allergic Interstitial Nephritis risk factors (2)

Back 92

1)idiopathic allergic rxn
2)consider/monitor pts w/ other drug allergies

Front 93

Allergic Interstitial Nephritis
a)manifestations (4)
b)tx (2)
c)prognosis (2)

Back 93

a1)fever
a2)rash
a3)loss of urine []ing ability (FEna over 1%, incr Una, decr Uosm)
a4)WBCs and eosinophils on UA

b1)stop offending agent
b2)prednisone 1mg/kg for 7d then taper

c1)most recover to normal renal fxn (when med dc'd)
c2)though permanent damage may occur

Front 94

Rhabdomyolysis mechanism (4)

Back 94

1)muscle necrosis
2)release of muscle breakdown products
3)leads to renal damage
4)severity ranges from asymptomatic to life threatening

Front 95

Rhabdomyolysis
a)drugs causing it (2)
b)drug combo's that incr risk of rhabdo (3)

Back 95

a1)COCAINE (life-threatening cases are mostly w/ this)
a2)statins

1)gemfibrozil w/ statin
2)niacin w/ statin
3)CYP3A4 inhibitors w/ statin (macrolide, antifungals)

Front 96

Mechanism of nephrotoxicity w/ rhabdo (3)

Back 96

1)breakdown of muscle cells releases CPK, lactate deH, myoglobin
2)myoglobin is eliminated by kidneys and forms casts in tubule cells
3)causes obstruction of GFR (CAUSING ATN)

Front 97

Manifestations of rhabdo (7)

Back 97

1)myalgias
2)fatigue
3)incr CPK
4)incr LDH
5)incr lactic acidosis
6)incr K
7)myoglobin on UA

Front 98

Tx of rhabdo incuded nephrotoxicity (3) AND prognosis(2)

Back 98

1)aggressive fluids (to protect kidney from myoglobins)
2)use vigorous diuresis
3)alkalinization of urine (w/ NaHCO3 in IV)

1)prompt tx may reverse renal damage
2)poor prognosis if untreated