thera II test II renal

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thera II test II renal
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thera II test II renal
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  1. Molecules transported from blood into urine via capillaries at the glomerulus
    Filtration
  2. Molecules transported from urine back into blood
    Reabsorption
  3. Molecules transported from blood into urine via capillaries along the tubule
    Secretion
  4. Role of the Kidney
    • Excretion of waste products and foreign substances
    • Fluid and electrolyte balance
    • Arterial blood pressure control
    • Acid-base balance
    • Erythropoietin and vitamin D production
  5. Proximal tubule action site for what meds
    • Carbonic anhydrase inhibitors (acetazolamide)
    • Osmotic diuretics (mannitol)
  6. proximal tubule reabsorption of
    • Water and sodium primarily
    • 67% of sodium reabsorption occurs here
    • Glucose
    • Bicarbonate
    • Chloride
    • Potassium
    • Amino acids
    • Urea
    • Phosphorus
  7. proximal tubule secretion of
    • Diuretics
    • antibiotics
    • creatinine
    • uric acid
  8. descending loop of henle reabsorption of
    • Water alone
    • Impermeable to sodium and chloride
  9. descending loop of henle secretion of
    urea
  10. descending loop of henle action site for what medications
    none
  11. ascending loop of henle reabsorption of what
    • Na+/K+/2Cl- cotransport
    •    Sodium (25% reabsorbed here)
    •    Potassium, chloride
    • Calcium, magnesium, bicarbonate
    • Impermeable to water
  12. ascending loop of henle secretion of
    nothing
  13. ascending loop of henle action site for what meds
    • Loop diuretics
    •    Furosemide
    •    torsemide
    •    bumetanide
    •    ethacrynic acid
  14. distal convoluted tubule reabsorption of
    • Na+/Cl- cotranpsport
    •    Sodium (5% reabsorbed here)
    •    Water- Follows sodium out of tubule
    •    Chloride
    • Na+/Ca2+ cotransport
    •    Calcium
  15. distal convoluted tubule secretion of
    none
  16. distal convoluted tubule action site for what meds
    • Thiazide diuretics
    •    Hydrochlorothiazide
    •    chlorthalidone
    •    indapamide
    •    metolazone
    •    chlorothiazide
  17. loop vs. thiazide diuretics
    • Thiazide
    • Ineffective if CrCl<30
    •    Exception:  Metolazone
    • Na+ excretion > H2O
    • Best for HTN > edema
    • Loop
    • Effective if CrCl <30
    • H20 excretion > Na+
    • Best for edema > HTN
  18. collecting duct reabsorption of
    • Sodium (30% reabsorbed here)
    • Water
    • Bicarbonate, urea
  19. collecting duct secretion of
    • Potassium via Na+/K+-ATPase pump
    •    Major site for potassium secretion
  20. collecting duct action site for what meds
    • Potassium-sparing diuretics:  Triamterene, amiloride
    • Aldosterone antagonists:  Spironolactone, eplerenone
    • Vasopressin (ADH, AVP):   Stimulates water reabsorption
    • Vasopressin-2 antagonists:  Tolvaptan, conivaptan:  Opposes water reabsorption
  21. 3 negative effects of the RAAS
    • Indirect vasoconstriction via sympathethic stimulation
    • Increased contractility of the heart
    • Vascular and myocardial hypertrophy
  22. 2 positive effects of RAAS
    • Increased aldosterone
    • Potent and direct arteriole constriction
  23. 2 strategies for diuretic resistance
    Change to continuous IV infusion of loop diuretic

    • Add-on diuretic that acts at later stage of nephron
    •    Thiazide diuretic
    •       Metolazone very potent
    •    Aldosterone antagonist
    •       Spironolactone
    •    Triamterene or amiloride
  24. renal function test used in obese population
    salazar-corcoran
  25. renal function test used in pediatric pts
    schwartz
  26. normal BUN SCR ratio
    15:1
  27. guidelines on which weight to use
    • Less than their ideal body weight
    •    Use actual (total) body weight
    • 100-130% of their ideal body weight
    •    Use ideal body weight
    • >130% of their ideal body weight
    •    Use adjusted body weight
    •       Adjusted body weight = ((Actual weight – IBW) x0.4) + IBW
  28. anuric
    less than 50 mL in the past 24 hours
  29. oliguric
    50-500 mL in the past 24 hrs
  30. non-oliguric
    >500 mL in the past 24 hrs
  31. 3 cases where cockroft-gault is overestimating
    • Rapidly rising SCr
    •    If SCr rises by 0.5 mg/dl or more in a 24-hour period, assume that CrCl is less than 10 ml/min
    • Malnourished
    • Elderly
  32. 3 cases where cockcroft-gault is underestimating
    • Rapidly falling SCr
    • High protein diet or use of creatine supplements
    • High muscle mass (bodybuilders
  33. Acute Kidney Injury (AKI)
    • Rapid deterioration in renal function over a short time-frame
    •    Often see abrupt changes over 48 hours or less
    • Usually reversible
  34. Chronic kidney disease
    • Prolonged kidney damage that occurs for more than 3 months
    • Often progressive in nature and irreversible
  35. 4 risk factors for acute kidney injury
    • Pre-existing chronic kidney disease
    • Volume depletion
    •    Decreased fluid intake, vomiting, diarrhea, diuretic use
    • Effective volume depletion
    •    Congestive heart failure, cirrhosis with ascites
    • Use of nephrotoxic medications
    •    More details to come
  36. RIFLE criteria
    Risk - 1)increase in SCr to 1.5 times higher than baseline. 2)GFR decreased by greater than 25%. 3)<0.5 ml/kg/hr output for 6 hrs

    Injury - 1)increase in SCr to 2 times higher than baseline. 2) GFR decreased by greater than 50%. 3) <0.5 ml/kg/hr output for 12 hours

    Failure - 1)increase in SCr to 3 times higher than baseline OR rise to >4mg/dL OR >0.5 mg/dl rise in a 24-hour period. 2) GFR decreased by greater than 75% 3) <0.3 ml/kg/hr output for 24 hrs or no uring production for 12 hrs

    Loss - Failure for >4wks

    End-stage kidney disease - failure for >3 months
  37. Most common cause of acute kidney injury
    Pre-renal AKI
  38. Results from decreased perfusion of blood to the kidney
    pre-renal AKI
  39. Pre-renal AKI Causes
    • true decrease in blood volume
    • relative decrease in blood volume
    • renal ischemia
  40. Treatment of Pre-renal AKI
    • Usual goal is to increase intravascular volume 
    •    Hydration with IV fluids
    •       Crystalloids (NS, D5W) or colloids (albumin, hetastarches)
    •       Example:  Normal saline 75-125 ml/hr.
    • Blood products if bleeding
    •    Packed red blood cells (PRBC)
    • Usually reversible with rapid improvement if caught early
  41. which drugs dilate the efferent arterioles
    • ACE's 
    • ARBS
    • NSAIDS
  42. which drugs constrict the afferent arterioles
    • NSAIDS
    • cyclosporine
    • tacrolimus
  43. Acute kidney injury accompanied by structural damage to the kidney
    intrinsic AKI
  44. Drug-Induced ATN Prevention
    • aminoglycosides
    • amphotericin B
    • cisplatin, carboplatin
  45. Contrast-induced nephropathy prevention
    • intravenous hydration
    • hold nephrotoxic agents and diuretics
    • use iso-osmolar or low-osmolar contrast and use the lowest volume necessary
  46. Interstitial edema secondary to inflammation without involvement of the glomerulus or tubules
    Acute Interstitial Nephritis (AIN)
  47. hallmarks of acute interstitial nephritis
    • UA often with protein, WBCs, RBCs, and WBC casts
    • Classic triad is rash, fever, and eosinophiluria 
    •    Eosinophils in urine (>1%) has a high    specificity (negative predictive value)
  48. causes of acute interstitial nephritis
    • Drug-induced (>75%) of cases
    • Infection
  49. Drug-induced AIN
    • Antibiotics
    •    All beta-lactams, but especially nafcillin, oxacillin, ampicillin, and penicillin
    •    Sulfonamides and rifampin
    • NSAIDs, PPIs, allopurinol, cimetidine, phenytoin, furosemide

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