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103 terms

Renal Failure I

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How does the kidney regulate endocrine function?
Renin = BP
Erytrhopoetine= RBC prod.
Ca+/Phosphorus balance = activate Vit D, incr Ca+ absorption=Calcitrol
Why do we have to urinate when we are cold?
vasoconstriction pushes excess fluid out to keep body warm and gets rid of that fluid via urine
__________ will produce concentrated urine _______ will produce dilute urine
diaphoresis + eating salty food= conc.
drinking and cold weather = dilute
kidneys can't remove urea
wastes accumulate disrupting endocrine/metabolic fx
systemic diesase
Renal Failure
sudden onset
rapid reduction in urine output
reversible
tubular cell death and regeneration
acute renal failure
progressive
not reversible
nephron loss
Chronic renal failure
True or False
We can loose up to 75% of function before we notice kidney failure
True
occurs when the kidneys are unable to excrete the daily load of toxins in the urine
ARF
<400mL/day of urine
Oliguria
<50mL/day of urine
Anuria
Oliguria + anuria + high serum creatinine + high BUN levels =
ARF
High levels of BUN
Azotemia
What is the most cause of acute renal failure?
Acute tubular necrosis r/t shock or chemicals
Perfusion, filtration and water balance (shock) are___________ problems
Prerenal
Selective reabsorption and water balance are ________ problems
Renal
Urine collection, storage and elimination are ______ problems
Postrenal
Vascular supply effects
Perfusion = Prerenal
Problems with the glomerulus causes
Filtration problems=Prerenal
Issues in the tubules cause
Selective reabsorption, secretion, excretion=Renal
Problems between the collecting ducts and the bladder cause
urine collection and storage problems=postrenal
Urination and micturition effect
elimination=postrenal
_____________ is a classic reason for drop in GFR is an early sign of___________
HTN
hypoperfusion of the kidneys
What is the key to determining how much perfusion is getting to the kidney?
MAP <80 = rapid decline
MAP=
(CO X SVR) + CVP
What causes renal artery obstruction and contributes to hypoperfusion of the kidneys?
Tumor
Blood clot
Aneruysm
Pregnancy Pressure
Vomiting, diarrhea, poor fluid intake, fever, diruetics and HF all contribute to _______________
shock = hypoperfusion of kidneys
What causes cardiogenic shock?
Hemorrhage
MI
HF
Sepsis
Anaphylaxis
Nephron & Microcirculation are implicated in ____________ problems
intrarenal problems
Actual parenchymal damage to the glomeruli, interstitial nephritis, acute glomerulonephritis, tubular necrosis, ischemia and toxins cause problems where?
Intrarenal
What causes tubular necrosis?
Burns
Crush injuries
Infx
nephrotoxic agents
In burns and crush injuries ___________ is released causing renal toxicity, ishemia or both
myoglobin
(released from muscle injury)
GFR, Tubular reabsorption and tubular secretion are considered _____________
intrarenal
Common genetic kidney disease that becomes symptomatic after 30 with hematuria, chronic UTI's and HTN
Polycystic disease
Presents as hematuria, smokers have 2x the risk, metastasizes to lung & bone
Renal cell carcinoma
obstruction somewhere distal to the kidney is considered
postrenal
If the psi rises in the kidney tubules and affects the GFR its considered
postrenal
Neurogenic bladder as seen in MS, ALS, DMD and Quads
postrenal
What are common causes of psi rise in the tubules?
Calculi (stones)
Tumors (prostate/cervix/bladder)
BPH
Bilateral renal alculi
Strictures
Blood clots
What causes calculi?
Calcium
Infx
Uric acid
What are the sx's of calculi?
PAIN
hematuria
Who is at risk for calculi?
People with higher Ca+ levels
Electrolyte imbalances
Gout
Infections
Secondary to constant UTI's which causes acute neutrophilic inflamm exudates and small abscesses
acute pyelonephritis
What are the sx's of acute pyelonephritis?
Flank pain
fever
High WBC
Pyuria
Water in the kidneys d/t blockage
Hydronephrosis
From most to least what area of the kidneys cause acute renal failure?
Pre-renal = 55%
Renal parenchymal (intrinsic) = 40%
Post-renal= 5-15%
What is normal output?
30mL/hr
1mg/Kg/hr
What is normal urine replacement?
output + 600mL per 24hrs
<400mL/day urine output
oliguric
>500mL/day urine output
nonoliguric
very little or no urine output
Anuric
What are the major systemic disease that cause kidney failure?
HTN
Diabetes
Rhabdomyolosis (ETOH, heat stroke, cocain, siezures, low Phosphate, DVT/VTE)
BUN is a measure of
products of protein breakdown
Serum creatinine is a measure of
muscle breakdown compares blood with urine
What is normal serum creatinine?
0.7-1.3mg/dL =men
0.6-1.1mg/dL=women
What is a normal GFR?
90-120mL/min/1.73 (m^2)
What is GFR affected by?
AGE
creatinine measurement
gender
height
race
weight
What is a normal BUN?
6-20mg/dL
What causes low BUN?
malnutrition
overhydration
liver failure
low protein diet
What causes excessive proteint levels in GI tract?
CHF
Hypotension
If the kidneys aren't perfused what goes up and why?
BUN
b/c can't clear proteins
high metabolic rate = high fluid need and larger % of body weight that is water is characteristic of
infants and children
Who has larger fluid turnover, losses and fluid requirement/Kg?
infants and children
True or False
We have larger ECF volume until 2years of age
True
lower GFR, drug clearance, shorter tubules, less response to ADH
kids
less ability to conserve and remove excess water, difficulty conserving/excreting NaCL
kids
less ability to handle acid load and difficulty secreting solute load
kids
What are the percent body weight as fluid for
Adults
Newborn
Pre-term infant
55%
75-80%
90%
What is the water/Kg in
Adult
Infant
Adult=550mL/Kg
Infant=750mL/Kg
What is the proportion of ECF in
Adult
Newborn
adult=33%
newborn=50%
Infant water loss is ____ that of an adult
2x
What is the water turnover in an
adult
infant
1/5 = adult
1/2 = infant
What are s's of pediatric moderate volume deficit?
BP= normal or low
Pulse=increase
No tears
Depressed fontanels
50-90mL/Kg fluid loss + gray skin + poor turgor + very dry mucous membranes + oliguria + 2-3sec cap refill
Moderate volume deficit in children
What indicates mild vol. deficit in children?
<50mL/Kg
pale skin
decr turgor
dry mucous membranes
decr output
BP=normal
Puls=normal or increased
cap refill=<2sec
drawn facial expression
Shock + change in LOC, elevated BUN, K+, Creatinine =
Severe vol deficit resulting in acidosis
What kind of fluid loss is considered severe for children?
>100mL/Kg
mottled skin + very poor turgor + parched membranes + oliguria + azotemia
Severe vol deficit in children
Low BP, rapid thready pulse and cap refill >3 sec
evidence of severe vol deficit in children
What changes as we age in respect to kidney fx?
lower/decreased:
Neprons
Renal blood flow
GFR
ability to concerntrate urine
cardiac fx
less able to adjust vol, secrete solute load, bladder elasticity, weaker sphincter, decr bladder capacity, BPH
geronotological differences in fluid balance/renal fx
hypoperfusion AEB ^BUN, ^ Creatinine, decr output, urine NaCL decr <20mEq/L, ^ urine specific gravity
Prerenal ARF
Parenchymal damage AEB, ^BUN, ^ creatinine, variable output often decr, urine NaCL incr >40mEq/L, low normal 1.010 spec. grav.
Intrarenal ARF
Obstruction AEB ^BUN, ^Creatinine, decr or sudden anuria, NaCL decr <20mEq/L, variable urine spec. grav.
Postrenal ARF
Excessive bleeding
Fainting/feeling lightheaded
Hematoma
Infx
UTI
Pregnancy
Water deficit
All will alter GFR
Types of drugs that increase urine Sodium
Antibiotics
Diuretics
Prostaglandins
Drugs that decrease urine sodium
Corticosteriods =cause NaCL retention
NSAIDS
Why do RF patients present tired/confused?
proteins + toxins build up in brain
What are CNS s's/sx's of RF?
Drowsiness
Headache
Muslcle twitiching d/t e- imbalance
Seizures
N/V, diarrhea, ill and lethargic are s's that
They are GOING DOWNHILL
need to be treated FAST
What is the first thing to assess in ARF?
Decreased urine output
DARK URINE
What is next to assses in ARF?
LOC changes
Fatigue/Lethary
N/V, diarrhea
What is a late sx of ARF?
skin turgor
After Skin turgor check
HF
Edema
Pruritis
After pruritis check
Odor of breath
Resp. status
Anemia
After Anemia check
Tachypnia
Cool, pale skin
Abd pain
Finally check
metallic taste in mouth
seizures/coma
What seems like a common sx but may be a late sx
back pain
Why do people develop Hyperkalemia in ARF?
declining GFR = can't excrete K+
protein catabolism = release of K+ into body fluids
Whats the big deal with hyperkalemia?
dysrhythmias and cardiac arrest
ARF managment includes
tx life threatening cond = K+, fluid crisis
ID cause=hypovolemia, toxicity, obstruction
Tx reversible = hydrate, remove drug, relieve obstruction
JK; Mgmt includes
maintain fluid balance
avoid fluid excess
dialysis
How do we determine maintenance of fluid volume?
Body weight
CVP
Serum/Urine conc.
output
BP
clin status of pt
True or false
Parenteral and oral intake, output including insensible loss are calculated and used as basis for fluid replacement
TRUE