renal disorders. renal functions cleanse ecf maintain acid-base balance excretion of metabolic...
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Renal Disorders
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Renal Functions
Cleanse ECFCleanse ECF Maintain acid-base balanceMaintain acid-base balance Excretion of metabolic wastesExcretion of metabolic wastes Maintenance of blood volume (pressure)Maintenance of blood volume (pressure)
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A&P of the Kidney
Nephron is theNephron is thebasic functionalbasic functionalunit of the kidneyunit of the kidney
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Nephron
GlomerulusGlomerulus Proximal Convoluted tubuleProximal Convoluted tubule Loop of HenleLoop of Henle Distal convoluted tubuleDistal convoluted tubule Collecting ductCollecting duct
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Kidney Processes
Filtration – Filtration – Occurs in glomerulusOccurs in glomerulus passive, nonselectivepassive, nonselective
ReabsorptionReabsorption active transport, water follows soluteactive transport, water follows solute
Active tubular secretionActive tubular secretion Proximal convoluted tubuleProximal convoluted tubule Acid pumpsAcid pumps Base pumpsBase pumps
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Reabsorption
Proximal Convoluted TubuleProximal Convoluted Tubule 65% of Na and Cl65% of Na and Cl Virtually all bicarb and KVirtually all bicarb and K
Loop of HenleLoop of Henle 20% of Na and Cl20% of Na and Cl Descending – permeable to water Descending – permeable to water Ascending – not permeable to waterAscending – not permeable to water
DistalDistal 10% of Na and Cl10% of Na and Cl
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Reabsorption
Late distal Convoluted Tubule and Late distal Convoluted Tubule and Collecting ductCollecting duct Sodium-potassium exchange – aldosteroneSodium-potassium exchange – aldosterone• Actually causes more pumps to be madeActually causes more pumps to be made
Final concentration of urine – ADHFinal concentration of urine – ADH• Controls water permeability of collecting ductControls water permeability of collecting duct
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Diagnostic and Laboratory
Blood Urea Nitrogen (BUN): 10 – 20Blood Urea Nitrogen (BUN): 10 – 20 Creatinine: 0.7 – 1.2Creatinine: 0.7 – 1.2 Creatinine ClearanceCreatinine Clearance Variety of Urinalysis testsVariety of Urinalysis tests
pHpH Specific gravitySpecific gravity Presence of Proteins, Blood, Urobilinogen, Presence of Proteins, Blood, Urobilinogen,
Leukocytes, Bacteria, Glucose, KetonesLeukocytes, Bacteria, Glucose, Ketones Microscopic examinationMicroscopic examination
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Diuretics
Most work by inhibiting reabsorption of Most work by inhibiting reabsorption of NaClNaCl Earlier in the tubule they work, the strongerEarlier in the tubule they work, the stronger Fun with MathFun with Math 180 liters of filtrate produced daily180 liters of filtrate produced daily 1% blockade of NaCl 1% blockade of NaCl 1.8 liters urine 1.8 liters urine 3% blockade of NaCl 3% blockade of NaCl 5.4 liters urine 5.4 liters urine• 12 pounds in one day12 pounds in one day
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Adverse Impact
HypovolemiaHypovolemia Acid-base imbalanceAcid-base imbalance Electrolyte imbalanceElectrolyte imbalance
MitigatingMitigating Use short actingUse short acting TimingTiming
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Diuretics
High Ceiling (Loop) diureticsHigh Ceiling (Loop) diuretics Thiazide diureticsThiazide diuretics Potassium-sparingPotassium-sparing
Aldosterone antagonistsAldosterone antagonists Non-aldosterone antagonistsNon-aldosterone antagonists
Osmotic DiureticsOsmotic Diuretics Carbonic anhydrase inhibitors (not Carbonic anhydrase inhibitors (not
used for diuresis; used for IOP)used for diuresis; used for IOP)
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Loop Diuretics
Act in ascending loop of HenleAct in ascending loop of Henle StrongestStrongest DrugsDrugs
Furosemide (Lasix)Furosemide (Lasix) Bumetinide (Bumex)Bumetinide (Bumex) Torsemide (Demadex)Torsemide (Demadex) Ethacrynic acid (Edecrin)Ethacrynic acid (Edecrin)
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Furosemide (Lasix) PharmacokineticsPharmacokinetics
PO onset 60 minutes, duration 8 hoursPO onset 60 minutes, duration 8 hours IV onset 5 minutes, duration 2 hoursIV onset 5 minutes, duration 2 hours Hepatic metab, renal excretionHepatic metab, renal excretion
Therapeutic usesTherapeutic uses Pulmonary edemaPulmonary edema CHFCHF EdemaEdema HypertensionHypertension Work even with severe renal impairmentWork even with severe renal impairment
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Adverse effects
Hyponatremia, Hypochloremia, DehydrationHyponatremia, Hypochloremia, Dehydration HypotensionHypotension
Monitor BP at homeMonitor BP at home Get up slowlyGet up slowly
HypokalemiaHypokalemia OtotoxicityOtotoxicity Hyperglycemia – caution in DMHyperglycemia – caution in DM Elevated uric acidElevated uric acid Lipids, Calcium, MagnesiumLipids, Calcium, Magnesium
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Drug Interactions
DigoxinDigoxin Ototoxic drugsOtotoxic drugs Potassium sparing diureticsPotassium sparing diuretics HTN drugsHTN drugs NSAIDSNSAIDS
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Thiazide Diuretics
Hydrochlorothiazide (HCTZ)Hydrochlorothiazide (HCTZ) Action – blocks NaCl in early DCTAction – blocks NaCl in early DCT
Do not work when GFR < 15-20 ml.minDo not work when GFR < 15-20 ml.min PharmacokineticsPharmacokinetics
PO, Onset 2 hours, peaks 2 – 6 hoursPO, Onset 2 hours, peaks 2 – 6 hours Excreted unchanged in kidneysExcreted unchanged in kidneys
UsesUses HTNHTN EdemaEdema
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Adverse effects
Hyponatremia, Hypochloremia, DehydrationHyponatremia, Hypochloremia, Dehydration HypotensionHypotension
Monitor BP at homeMonitor BP at home Get up slowlyGet up slowly
HypokalemiaHypokalemia Hyperglycemia – caution in DMHyperglycemia – caution in DM Elevated uric acidElevated uric acid Lipids, Calcium, MagnesiumLipids, Calcium, Magnesium
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HCTZ dosing
Smaller is better these daysSmaller is better these days Starting dose 6.25 or 12.5 mgStarting dose 6.25 or 12.5 mg Max dose 50 mg/dayMax dose 50 mg/day Prefer max of 25 mg/dayPrefer max of 25 mg/day Dirt cheapDirt cheap Frequently combined with other Frequently combined with other
antihypertensive medicationsantihypertensive medications
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Potassium Sparing
Spironolactone (Aldactone)Spironolactone (Aldactone) Aldosterone antagonistAldosterone antagonist• HTN and EdemaHTN and Edema• Portal Hypertension/AscitesPortal Hypertension/Ascites• CHFCHF
Adverse effectsAdverse effects• HyperkalemiaHyperkalemia• Endocrine effectsEndocrine effects
InteractionsInteractions• Other Diuretics, Potassium raising drugsOther Diuretics, Potassium raising drugs
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Potassium Sparing
Non-aldosterone affectingNon-aldosterone affecting Inhibit Sodium-Potassium pumpInhibit Sodium-Potassium pump TriamtereneTriamterene• Combination with HCTZ: Maxzide, DyazideCombination with HCTZ: Maxzide, Dyazide
AmilorideAmiloride
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Osmotic Diuretics
MannitolMannitol 6 carbon sugar6 carbon sugar Not metabolizedNot metabolized Not reabsorbedNot reabsorbed Increases osmolality of filtrateIncreases osmolality of filtrate UsesUses• Renal failure prophylaxisRenal failure prophylaxis• ICPICP• IOPIOP
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Measures of Renal Function
BUNBUNCreatinineCreatinineElectrolytes: esp. Na, K, ClElectrolytes: esp. Na, K, ClEstimated GFR: 85 – 135 (insuff <60)Estimated GFR: 85 – 135 (insuff <60)Creatinine ClearanceCreatinine ClearanceUrine volumeUrine volumeUrinalysisUrinalysis
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Urinalysis
ColorColorOdorOdorProtein (uria)Protein (uria)Glucose (uria)Glucose (uria)Ketones (uria)Ketones (uria)UrobilinogenUrobilinogen
Sp. GravSp. GravOsmolalityOsmolalitypHpHRBCs (hematuria)RBCs (hematuria)WBCs (leuckocyte)WBCs (leuckocyte)CastsCastsCultureCulture**
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Renal and Urinary D/Os
Infectious (UTI)Infectious (UTI)Cystitis, Pyelonephritis, Urethritis, Cystitis, Pyelonephritis, Urethritis, Prostatitis, Epydidimitis, PIDProstatitis, Epydidimitis, PID
KidneyKidneyGlomerulonephritisGlomerulonephritisNephrotic syndromeNephrotic syndrome
CalculiCalculiRenal Failures: ATN, Acute, ChronicRenal Failures: ATN, Acute, Chronic
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Infectious Diseases
Lower TractLower TractDOC: TMP/SMXDOC: TMP/SMXFluoroquinoloneFluoroquinolone
Upper tractUpper tractPyeloneprhitisPyeloneprhitis•Inflammation of parenchymaInflammation of parenchyma
Interstitial cystitisInterstitial cystitis““Fake UTI”Fake UTI”
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Glomerulonephritis
Immune damageImmune damageextent of damageextent of damageetiologyetiologyextent of changesextent of changes
MechanismMechanismType IIType IIType IIIType III
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Glomerulonephritis
Acute Poststreptococcal (Type III)Acute Poststreptococcal (Type III)Goodpasture's syndrom (Type II)Goodpasture's syndrom (Type II)Rapidly Progressive (ARF)Rapidly Progressive (ARF)Nephrotic syndromeNephrotic syndrome
1/3 Dz, i.e., DM, SLE; 2/3: Idiopathic1/3 Dz, i.e., DM, SLE; 2/3: Idiopathic↑↑permeability to proteinpermeability to proteinSymptoms:Symptoms:Tx: ACEI, NSAID, sodium-protein restriTx: ACEI, NSAID, sodium-protein restri
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Rhabdomyolysis
Increased muscle destructionIncreased muscle destructionProteinemiaProteinemiaProteins clog glomerulusProteins clog glomerulusMay lead to Renal FailureMay lead to Renal Failure
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Renal Failures
ARF (50% mortality with treatment)ARF (50% mortality with treatment)Prerenal: blood flowPrerenal: blood flowIntrarenalIntrarenalPostrenal: ureteral blockagePostrenal: ureteral blockage
CRI/CRFCRI/CRFGFR < 60 l/minGFR < 60 l/minESRD < 15 l/minESRD < 15 l/min•DialysisDialysis•Kidney TransplantKidney Transplant
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ARF: General
↑↑Fluid, BUN, Creat, electrolytesFluid, BUN, Creat, electrolytes↓↓Urine output (<400ml/day)Urine output (<400ml/day)azotemia: uremic frostazotemia: uremic frostAcidosisAcidosisAnemia, AgranulocytosisAnemia, AgranulocytosisStages: Initiation → Oliguric (1-7 Stages: Initiation → Oliguric (1-7 days) → Diuretic → Recoverydays) → Diuretic → RecoveryDialysis if necessaryDialysis if necessary
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ARF
PrerenalPrerenalDecreased blood flowDecreased blood flow•Renal artery stenosisRenal artery stenosis•Hypovolemis, Shock, Heart failureHypovolemis, Shock, Heart failure•Drugs: e.g. NorepinephrineDrugs: e.g. Norepinephrine
TxTxUnderlying diseaseUnderlying diseaseDrugs: Dopamine, mannitolDrugs: Dopamine, mannitol
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ARF
IntrarenalIntrarenalAcute Tubular Necrosis (ATN)Acute Tubular Necrosis (ATN)Ischemia, toxins, pigments** (contrast)Ischemia, toxins, pigments** (contrast)
PostrenalPostrenalKidney stones or stricturesKidney stones or stricturesCancerCancerHydronephrosisHydronephrosisRemove blockageRemove blockage
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Chronic Kidney Disease
Major risk factorsMajor risk factorsDiabetes 45%Diabetes 45%Hypertension 27%Hypertension 27%
Prevention Prevention PreventionPrevention Prevention PreventionControl above diseasesControl above diseasesACE Inhibitor/ARBACE Inhibitor/ARB
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Manifestations
EarlyEarly↓↓Creatinine ClearanceCreatinine Clearance↑↑BUN/CreatinineBUN/CreatinineProteinuriaProteinuria
LaterLaterFluid retention --> edema, oliguriaFluid retention --> edema, oliguriaAnemia --> reduced erythropoietinAnemia --> reduced erythropoietinAcidosisAcidosis↑↑Electrolytes and other waste productsElectrolytes and other waste products