What is the Crockroft-Gault Equation?

For Females we multiply our final number by what?

CrCl=(140-age)xLeanbodyweight

72 x Serumcreatine

0.85

Which Kidney is positioned lower than it's counterpart?

T/F Arcuate Arteries are more distal in the blood flow through the kidney than Lobar arteries

Innervation of Kidneys includes Adrenergic alpha receptors only

What are the roles of innervation to the Kidney.

Right

True..renal-->posterior-->anterior-->lobar-->

interlobar-->arcuate-->Afferent-->glomerulus-->

Efferent arterioles

Alpha and beta Receptors

Solute/water exchanges and Hormone release (renin, prostaglandins)

What is the blood flow rate through the kidney?

What % of blood flow is allocated to teh kidney

The amount of nephrons in the kidney shrinks as you get older?

**What are the 4 determinants of filtration?

1200ml/min

 20%

 True (avg adult has 1.2 million)

**1.    Rate of nephron plasma flow
2.    Hydrostatic pressure gradient
3.    Systemic colloid osmotic pressure (ALBUMIN IS BIGGEST INDICATOR OF THIS)
4.    Glomerluar ultrafiltration coefficient (what size particles can go through the membranes…what is the surface area of Glomerulas)
 

Most reabsorbtion occurs where?

What chemicals are reabsorbed here?

What is reabsorbed at the DCT

PCT

bicarbonate…sodium chloride, glucose, amino acids, phosphates, calcium, uric acid, and urea

Sodium and water

What is reabsorbed in Thin Descending?

In Thin Ascending?

In Thick Ascending?

These are all parts of what larger structure?

THIN descending=water…

Thin ASCENDING=sodium chloride…

Thick ascending=Sodium Chloride reabsorbtion….

Loop of Henle

GFR Markers

What is the normal BUN level?

What is BUN a marker of (a derivative of?)

What factors can affect/skew results?

o    Normal range is 6 – 20 mg/dl

o    Derived from protein (amino acid) degradation…if you have poor muscle mass…BUN can be inaccurate

o    Is affected by many factors other than GFR (Diet, Fever, dehydration, edema, and Medications)

Creatine..GFR marker

o    A product of ______ metabolism therefore is related to lean body mass

What is a normal BUN:Creatine Ratio?

What does a high Ratio tell us?...a low Ratio?

Muscle

10-20:1

o    A higher ratio may be indicative of dehydration
o    A low ratio may be indicative of malnourishment
 

What does Creatine Clearance mean?

What do we compare to obtain CrCl

 The volume of blood from which all the creatinine can be removed in one minute

   Determined by measuring the concentration in the plasma and comparing it to the amount appearing in the urine over a period of time (COLLECTION PROBLEMS….a 24-hour test…people soemtiems forget to “bring their jug”

What is normal Urine Output?

What can weight changes tell us about renal function?

What is this....Definition:  an abrupt decline in renal function characterized by the inability of the kidney to excrete metabolic waste products and maintain acid-base balance.

0.5 ml/kg/hr

Whthr pt has edema

Acute Renal Failure

What is the major reason for death during Acute renal failure?

What is the dz often associated with (chief sign )

30-70% mortality rate...USUALLY from Electrolyte imbalance complications (arrhythmias...homeostasis complications)

Oliguria

Acute Renal Failure Etiologies

Prerenal disease: 
  

Postrenal disease: 

    Intrinsic renal disease (nephron damage):

HYPOPERFUSION (blood flow)…CHF, sepsis, shock, Open heart Surgery….

OBSTRUCTION (look for stone…prostate enlargement..)

  glomerular disease, tubulointerstitial disease, and drugs or  toxins (Usually a toxic problem due to a medication)

1)  ARF...the period of time beween the onset of diminished renal function and the development of renal failure no longer reversible by treating the primary cause of renal failure.  This phase is often marked by oliguria

2)  ...improvement in GFR to cause BUN and serum creatinine to fall toward baseline; usually occurs within 4 weeks but gradual improvement may occur for even a year.

 3) ... the period of nonreversible renal function until function spontaneously improves.  This phase may last a few hours to six or more weeks.

1) Initiation phase

2)  Recovery phase:  

3) Maintenance phase

Risk factors for ARF include? (name some)

If you must be on a nephrotoxic drug...what are 2 steps you can take to prevent ARF?

Risk factors include:  preexisting renal or hepatic disease, diabetes mellitus, dehydration, advanced age, and concomitant treatment with other nephrotoxins. 

Lots of sodium...Lots of water

Definition: a progressive loss of function occurring over several months to years, and is characterized by the gradual replacement of normal kidney architecture with interstitial fibrosis. Classification is based on the presence of structural or functional kidney damage that has been present for more than 3 months with or without decreased GFR.

Chronic Kidney Failure

T/F...Acute kidney disease is described as a silent epidemic with estimates of at least 5% of the adult population having elevated serum creatinine. 

False...it is Chronic Kidney Disease that is the silent disease.

The four most common medical conditions associated with progressive CKD are:
    1.  Diabetes mellitus
    2.  hypertension
    3.  glomerulonephritis
    4.  polycystic kidney disease (PKD)

 what are the 2 'modifiable' comorbidities to prevent CKD?

HTN and DM

 Classification of Abnormal Proteinuria
        Nephrotic:  > ___g per day
                        Indicative of glomerular damage
                                 Urinary protein to urinary creatinine ratio > 3.5
        Non-nephrotic:  < ___
                   Usually indicative of inadequate reabsorption of normally filtered proteins
                  Urinary protein:creatinine ration usually < 3.0
 

3.5gm ( or 3,500mg)

3.5 gm per day

DM that leads to CKD is a progressive dz....what are the 2 stages (relates to protein in urine)?

What are the 5 Tx recommendations for  DM with CKF?

Microalbuminuria to overt proteinuria

1.)  Reduce protein load (dietary restriction 0.6 gm/kg/day)
            2.)  Tight glycemic control
            3. ) Blood pressure control
            4.)  Smoking cessation
            5. ) ACE Inhibitors/Angiotensin II Receptor Blockers…protects kidneys..regardless of bloodpressure or presence of HTN

What is the leading cause of CKD?

What can we give to treat anemias associated with CKD? (2 drugs we talked about)

HTN

Erythropoetin (PROCRIT) or Darbopoetin (ARANESP)

T/F...Uremia, a comlication fo CKD, affects mainly the CNS.

What are some ways to treat Uremia through nutrition?

True

Limit protein, potassium, and phosphate intake..fluid restriction...supplement watersoluble vitamins. (no tomatoes, bananas, oranges, coke, red meat or chocolate...ouch)

False...Dialysis:  goal is to rid the body of accumulated toxins and maintain fluid, acid-base, and electrolyte balance

Which Diuretic is this?... inert materials that are filtered at the glomerulus and not reabsorbed to an appreciable extent.

Name the most common one 

Osmotic diuretics

Mannitol..the most commonly used in the prophylaxis                 and treatment of acute renal failure.

What kinda of Drug am I?

 Agents which interfere with production of H+ which is needed by the proximal tubular cell to exchange for Na+ filtered at the glomerulus.  Inhibition of CA  increases excretion of HCO3 and Na+ along with alkalinzing the urine.

Which one did we talk about?

Adverse Effects?

 Carbonic Anhydrase Inhibitors  

Acetazolamide (Diamox)  (little use for diuresis)
      

Adverse effects:  drowsiness, parasthesias, and possible metabolic acidosis
 

Which Drug group am I?

act in the thick ascending limb  to inhibit inwardly directed Na+/K+/ 2Cl- co-transport.  They are capable of producing a diuresis of up to 4 liters/day.

Name the 4 we talked about in this class?

____ is a possible side effect of these drugs, as these drugs tend to compete for Uric acid

Loop Diuretics

Furosemide (Lasix), Bumetanide (Bumex), torsemide                 (Demadex), ethacrynic acid (Edecrin)

GOUT

Which Drug group am I?... Act in the distal tubule to decrease the reabsorption of Na+ by inhibition of a Na/Cl cotransporter on the luminal membrane.  
            

Name the 3 we spoke of?

Adverse Effects?

Thiazide and related agents:

Hydrochlorothiazide (HCTZ)

Chlorthalidone

Metolazone (Zaroxolyn)

Indapamide (Lozol)

Adverse effects:  potassium depletion, hyperuricemia, hypercalcemia, hyperglycemia,                      and volume depletion

Which Thiazide Diuretic is the most potent?

Thiazides have no effect on pts. with CrCL lower than ____?

T/F...Thiazides are good diuretics for people on Dialysis?

Metolazone (Zaroxolyn)

 30.  

False

Potassium Sparing Drugs block __ channels resulting in a decreased Potassium loss.

Are these very effective diuretics?

What are the  ones we spoke of?

It's adverse effects?

Na

Nope..usually used to prevent hypokalemia in association with other diuretics

Amiloride and Tramterene (work directly on pumps)

Spironolactone (Aldactone) ..a synthetic aldosterone antagonist

HYPERkalemia, gynecomastia, menstrual Irregularities

Dialysis is a ____-based process.

    Dialysis is a _____ discriminatory process

T/F..AV fistulas are preferred when doing hemodialysis?

diffusion

size (relationship between solute size and its rate of transport from blood to dialysis fluid:  small solute—fast, large solute – slow)

True...though you may have to wait 3-5 wks post-op before 1st dialysis.

T/F...Faster dialysis is usually accompanied by fewer side effects?

T/F...Larger dialyzers (artificial kidneys) work faster due to greater surface areas

False..more

True

Dialyzers: The membrane’s permeability to water is referred to as ______. 

Definition: a water electrolyte solution

flux

Dialysate

T/F...Hormone secretion and/or metabolism is also  addressed by the “artificial kidney”

The Artificial Kidney regulates normal tubule fcts as well?

False it is not a fct of these machines

False, it acts only as a glomerulus (blood is only filtered without any electrolyte exchanges that would occur in the tubules)

Protein binding

Solute Charge

Volume of Distribution

Membrane characteristics

Blood flow rate

Dialysate flow rate

T/F..Dialysis pts have more complications and resistant germs than others?

True

What are the Hemodynamically Mediated Renal Failure Drugs

Interstitial Nephritis Drugs? (4)

Penicillins
    NSAIDs
    Lithium
    Cyclosporin(immunosuppresent used post-transplants)

TBW (total body water)=___% of total body weight

It increases with age?

What Percent of TBW is Interstitial Fluid?

Which Ion makes up most of the ECF osmotic activity?

What Ion determines up most of the ICF volume levels?

60%

Nope, Decreases

75%

Sodium (90%)

Potassium

Potassium

Normal Levels?

The two main mechanisms that regulate serum K to prevent if from becoming too high or too low are...?

3.5-5.0mEq/L

(1) transfer of K between ECF and ICF and

(2) renal excretion of potassium 

Hypokalmia occurs when?

    Signs and symptoms include ?

What is the Treatment rule of thumb for overcoming hypokalemia in the blood?

plasma K concentration < 3.5 mEq/L

muscle weekness, cramps, cardiac arrhythmias 

For each 1 mEq/L fall in K from normal plasma levels, the resultant potassium deficit is approx 200 mEq.  Oral and IV available

Sign's/Symptoms of Hyperkalemia?

Principles of Tx?

  Signs and symptoms include EKG changes, muscle weakness/paralysis

 Principles of treatment:  **Protect the heart** membrane stabilization with IV calcium if EKG changes are present

Drug Regiments for Hyperkalemia?

albuterol,

calcium chloride,

dextrose,

sodium bicarbonate,

insulin,

SPS

What are some underlying causes for Hypokalemia?

For Hyper kalemia?

hypo:  renal/ GI losses, drugs, internal potassium shifts

Hyper: lab error, decreased renal elimination, drug therapy

Monitoring what for Hypokalemia?

For Hyperkalemia?

Hypo:  EKG, pulse, Magnesium concentrations, pH, patient complaints, renal function: 

 Hyper:  EKG, K+ levels, renal function, acid base status

Magnesium :  important _______ for nearly all biochemical and enzyme systems; maintained tightly by the kidneys

Normal Range?

cofactor

1.5 to 2.0 mEq/L or 1.8 to 2.4 mg/dL

Magnesium is also called what? (nature's what?)

Hypomagnesium may be caused by what?

If Mg<1mEq/L what should we do?

"Nature’s physiologic calcium blocker” – modulates the neuromuscular activity of the Ca ion

  Etiology:  poor nutritional status (alcoholics); renal wasting; vomiting/diarrhea, endocrine disorders

Bolus of Mg (IV) 1 g of Mg will set you free

What are some Etiological agents of Hypermagnesemia?

Signs/Symptoms?

renal failure, laxative use, lithium, Addison’s disease

as level increases, severity of symptoms increases from sleepiness, sweating, n/v to QT prolongation, hypotension, respiratory paralysis, heart block, asystole

Treatment of Hypermagnesemia..at what level should we begin to treat....how should we treat?

 levels of 5-8 mEq/L;

give calcium to antagonize magnesium; also IV furosemide promotes excretion of Mg,

emergent hemodialysis if necessary

Normal Phosphate levels?

 3-4.5 mg/dL)

True

Factors affecting phosphate levels?

  Glucose, hormonal effects (vitamin D, PTH, Calcitonin)

 Etiology of Hypophosphateemia?

of Hyperphosphatemia?

 HYPO:  Decreased intake, increased renal excretion, excessive use of phosphate binders, intracellular shifting

HYPER:  Chronic renal insufficiency, administration of exogenous phosphate, hypoparathyroidism, rapid cell lysis

Hyperphosphatemia Clinical Presentation:  soft tissue calcification occurs when calcium phosphate solubility product is >___ mg/dL

Treatment for hyperphosphatemia??

70 mg/dL

  Treatment:  dietary restriction, PO calcium to bind phosphate in gut, aluminum containing phosphate binders...Sevelamer (Renagel)...Lanthanum, or other phosphate binders (Specifically

Calcium:  ___% protein bound (mostly to albumin) – inactive; distributed approx__-__% in the bone.  Calcium levels are measured in the ___ as total calcium.  Correct interpretation of calcium levels are dependent on (what 2 things?)

What is the formula for correcting calcium?

46%

 98 to 99%

 ECF

1) protein binding   2)  ECF pH. 

    Corrected Ca = serum Ca + 0.8 (4 – albumin)

What are the 3 hormones affecting Calcium Levels?

Normal Calcium Levels?

Parathyroid, Calcitonin, Vitamin D

8.5-10.5  mg/dL

Etiologies for Calcemias

Hypo: :

Hyper

Hypo :   hypoalbuminemia, hypoparathyroidism, disorders of Vitamin D3, hypomagnesemia, hyperphosphatemia, drugs such as phenytoin, phenobarbitol, antacids, theophylline, sodium fluoride
 

Hyper :    Hyperparathyroidism, malignancies, drugs

Calcemias...Clinical Presentations?

Hypo:

Hyper:

Hypo:   Hyperexcitability of nerve and muscle cells, weakness, parasthesias, and fatigue, Tetany, hypotension, arrhythmias, acute MI

Hyper:   fatigue, lethargy, weakness, nausea, constipation, mental status changes

Hypocalcemia Tx:

Any side effects?

 IV administration of Calcium for acute hypocalcemia; PO administrations for chronic management

Side effects:  IV – precipitation; PO – irritating to GI tract, constipation

Hypercalcemia Tx

 Drug therapy includes hydration with saline and loop diuretic therapy. based on presence of clinical manifestations;   Bisphosphonates, calcitonin, mithramycin, gallium nitrate, and glucocorticoids may also be used.  

*Discontinue: intake of Calcium, vitamin D, thiazides and NSAIDs*.