Approach to the Kidney Patient
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What are signs of acute kidney dz?
- Rapidly increasing BUN and creatinine (azotemia)
What are signs of chronic kidney dz?
- Loss of renal function over months to years
- Slowly increasing BUN and Cr
- Renal Atrophy
Hormonal functions of the kidney
- BP control
- RBC production
- Calcium regulation
Where is filtrate converted into urine?
What is the first step in urine formation?
Fluid collects in Bowman's capsule and is transported to the PCT
What does the PCT do?
Responsible for reabsorbing NaCl, H20, bicarb, glucose, and amino acids
What does the Loop of Henle do?
- Reabsorbs NaCl, K, Cl, and H20
- Controls fluid balance
- Involved in concentration of urine
Where do loop diuretics work?
The ascending loop of Henle
What does the DCT do?
- Reabsorbs NaCl, Ca, and K
- Involved in PH balance
- Very little water permeability
Where do thiazide diuretics work?
What regulates the final composition of urine?
Where does hormone regulation of Na and H2O balance take place?
What encourages filtration and opposes filtration across the glomerular capillary wall?
- Encourages: hydrostatic pressure
- Opposes: oncotic pressures in capillary lumen
How is Angiotensin II involved in GFR?
If it feels a reduction in blood flow, it will vasoconstrict
How does GFR react in a state of shock or with dehydration?
It decreases to maintain ions
How does GFR react if pt has severe uncontrolled HTN?
Arterioles would constrict because there is so much pressure going at the kidney, it is a protective mechanism
How is GFR measured?
What is a nl GFR?
What is the relationship between serum creatinine and GFR?
When serum Cr is increased, GFR is decreased (there is an inverse relationship)
What components make up a GFR?
- Weight and Height
- Serum Creatinine
What GFR levels are a sign of chronic kidney dz?
GFR < 60 for 3 or more months
What creatinine level is an indication for dialysis?
CrCl < 15
What are nl serum creatinine levels?
Describe how creatinine is dealt with in the body
- It's cleared by renal excretion
- Not bound to plasma proteins
- Freely filtered by the glomerulus
What factors can increase serum creatinine levels?
- ASA, Cimetidine, or probenicid
- ASA or NSAIDS (via analgesic nephropathy)
What factors can decrease serum Cr levels?
How is CrCl measured?
24 hour urine collection and plasma creatinine on the same day
What is the CrCl formula?
- (140-age) x (weight in kg)
- Serum creatinine x 72
Name certain meds that might have to be changed with renal function
What is urea?
An end product of protein catabolism that is synthesized in the liver
What is a nl BUN:Cr ratio?
What can cause an increased BUN?
- GI bleed
- Cell lysis
- High protein diet
What can cause a decreased BUN?
- Hepatocellular dz
- Chronic dialysis
Why is Urea NOT a better predictor of renal function as Cr is?
- It's not as sensitive in picking up smaller decreases in GFR
- It's affected by outside factors:
- Protein intake
- Hydration status
- GI bleeding
How soon should a UA be done?
- Within 1 hour of collection
- WBCs should be done 2 mins after you dip
Describe clinical albumin levels
- <30 is nl
- 30-300: microalbuminuria
- >300: macroalbuminuria
What can cause functional proteinuria?
- Acute illness
- Orthostatic proteinuria
An abundance of Bence Jones proteins is what type of proteinuria?
What are examples of overload proteinuria?
- Multiple myeloma (Bence Jones)
- Rhabdo (myoglobinuria)
- Hemolytic anemia (hemoglobinuria)
- Amyloidosis (overproduction of proteins)
What it tubular proteinuria?
Decreased reabsorption of proteins in the proximal tubules
What can cause tubular proteinuria?
- Toxins (lead, aminoglycosides)
- Hereditary metabolic disorders (Wilsons, Fanconi)
What can cause a false positive with hematuria?
Myoglobin, beets, and rhubarb
What causes hyaline casts to be in urine?
- Concentrated urine
What causes red cell casts to be in urine?
What causes white cell casts to be in urine?
- interstitial nephrities
- any inflammation or infection
What causes renal tubular casts to be in urine?
- Interstitial nephritis
What causes coarse, granular casts to be in urine?
What causes broad, waxy casts to be in urine?
- Indicative of statis in the tubules
What imaging method do you use for hydronephrosis?
What imaging method do you use for pyelonephritis?
What imaging method do you use for PCKD?
What imaging method do you use for cysts?
- U/S for regular
- CT scan for complex
What are indications for a renal bx?
- Unexplained chronic kidney dz
- Unexplained acute kidney dz
- Unexplained proteinuria/hematuria
- Treatment guide
- Acute nephritic syndrome
- Systemic dz with kidney involvment (DM, SLE)
- Suspected transplant rejection
What are contraindications of a renal bx?
- Solitary kidney
- Horseshoe kidney
- Severe uncontrolled HTN
- Uncontrolled bleeding d/o
What do you need in order to be cleared for a renal bx?
- d/c anticlotting Rx
- Well controlled HTN
- HGB, platelet count, Pt, PTT
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