ZHANG CONCEPT MAP REVIEW/SI SESSION

what are the organs in renal anatomy

• kidney

• ureter

• bladder

• urethra

urine flow for renal anatomy

• collecting ducts

• minor calices

• major calices

• renal pelvis

• ureter

• bladder

• urethra

what is the blood flow in renal anatomy

• renal artery

• segmental

• interlobar

• arcuate

• interlobular

• afferent arterioles

• glomerular capillaries

• efferent arterioles

basic histological and functional unit for renal is what

nephron

what are the functions in renal

1. glomerular filtration

2. tubular reabsorption

3. aldosterone regulated sodium reabsorption in collecting duct

4. arginine vasopressin regulates water reabsorption in the collecting duct

5. tubular secretion active secretion from the peritubular capillaries into the renal tubules hydrogen ions, potassium in the distal tubule

fluid flow of renal

• bowman’s capsule

• proximal convoluted tubule

• loop of hence

• distal convoluted tubule

• collecting ducts

normal values of GFR for men

127

normal value of GFR in women

118

best index in renal is what

GFR

regulation of GFR by vessel tone is what

angiotensin ll

PGE2/PGI

• constrict efferent

• increases GFR

is what class?

angiotensin ll

• dilate afferent

• increase GFR

what class?

PGE2/PGI

Cl < GFR

molecule that is what ?

reabsorbed

Cl > GFR

molecule that is what?

secreted

1. water

2. small molecules

3. proteins

are in what category

glomerular filtration

in proteins what is not permeable ?

• <5kDa

• >60kDa

>60kDa

normal serum concentration range for potassium is what

3.5-5 mEq/L

intracellular potassium concentration is usually aprox what

150 mEq/L

what is responsible for the compartmentalization in potassium

Na+-K+-ATPase

what are primary causes of hypokalemia

• loop and thiazide diuretic administration

• excessive loss of potassium rich GI fluid as a result of diarrhea and/or vomiting

what are the drug induced hypokalemia

• beta2 agonists

• insulin overdose

• high dose of penicillin

what are the primary causes of hyperkalemia

• increase potassium intake

• decrease potassium excretion

• tubular unresponsiveness to aldosterone

• redistribution of potassium into the extracellular space

what are the drug induced hyperkalemia

• ACE-l

• ARBs

• direct renin inhibitors

• potassium spring diuretics

• NSAIDs

• beta blockers

hypomagnesemia contributes to the development of what

hypokalemia

it is imperative to correct the hypomagnesemia before the hypokalemia (t/f)

true

alkalosis leads to what type of K

hypokalemia

acidosis leads to what type of K

hyperkalemia

when aldosterone is activated what happens to K

hypokalemia

when aldosterone is inhibited what happens to K

hyperkalemia

what are the drugs in aldosterone activation

loops and thiazide

what are the drugs in aldosterone inhibition

ACE

ARB

direct renin inhibitors

potassium sparing diuretics

NSAIDs

what happens to K when there is Na+-K+-ATPase activation

hypokalemia

what happens to K when there is Na+-K+-ATPase inhibition

hyperkalemia

1. hyperphosphatemia & hypocalcemia

2. secretion of PTH

3. PTH decreases phosphorus absorption and increase calcium reabsorption

4. PTH also increases calcium mobilization from bone

5. FGF-23 production in bone

6. resetting of calcium and phosphorus homeostasis with elevated PTH level

pathophysiology of CKD-MBD

what happens to PTH in vitamin D therapies

decrease PTH synthesis

calcitriol has more risk of what

hypercalcemia and hyperphosphatemia

paricalcitol and doxercalciferol has less risk of what

hypercalcemia and hyperphosphatemia

what does phosphate binders do to the phosphorus

lowers phosphorus absorption in GI

hypercalcemia and calcification is disadvantage of what

calcium containing binders

lower LDL & increases HDL is advantage of what

sevelamer

for patients with ESRD and hypercalcemia is advantage of what

lanthanum carbonate

• CNS toxicity worsening

• anemia

disadvantages of what

almuinum containing binders

what stage of CKD is >90

stage 1

what stage of CKD is 60-89

stage 2

what stage of CKD is 30-59

stage 3

what stage of CKD is 15-29

stage 4

what stage of CKD is <15

stage 5

1. loss of nephron mass

2. remaining nephrons hypertrophy

3. intraglomerular hypertension

4. proteinuria

5. damage of kidney tubular cells

6. progressive reduction in GFR

order for what

pathophysiology of CKD

what are the etiology of CKD

1. susceptibility factor

2. initiation factor

3. progression factor

what are the factors in initiation factor of CKD

• diabetes

• hypertension

• glomerulonephritis

what are the factors in progression factor of CKD

• smoking

• obesity

what are the preferred agents in CKD

• ACE and ARBs

what class has no effect on bradykinin metabolism and are therefore more selective blockers of angiotensin effects than ACE

ARBs

ARBs also have the potential for more complete inhibition of angiotensin action compared with ACE inhibitor because there are enzymes other than ACE that are capable of generation angiotensin ll

true

What is less likely to cause cough than ACEs

ARBs

what balance determines the serum sodium concentration

water balance

what balance determines the volume status

sodium

hypertonic solution to the ECF does what to the volume

decrease in ICF (cell) volume

hypotonic solution to the ECF does what to the volume

increase in cell volume

hypertonic hyponatremia, the presence of excess, effective osmoses other than sodium in the ECF is what

glucose, glycine, sorbitol

in hypovolemic what drug causes hyponatremia

thiazide diuretics

diarrhea

in hypovolemic what causes hypernatremia

osmotic diuresis

in euvolemic what causes hyponatremia

SIADH

in euvolemic what causes hypernatremia

diabetes insipidus

in hypervolemic what causes hyponatremia

edema

in hypervolemic what causes hypernatremia

water weight, bloat (sodium overload)

in cortex how much percentage of renal blood flow goes to the cortex

90%

Which of the following best describes the chronological order of urine flow?

A. Renal artery → segmental → interlobar → arcuate → interlobular → afferent

arterioles → glomerular capillaries → efferent arterioles

B. Renal artery → segmental → interlobar → arcuate → interlobular → efferent

arterioles → glomerular capillaries → afferent arterioles

C. Collecting ducts → minor calyces → major calyces → renal pelvis → ureter →

bladder → urethra

D. Collecting ducts → minor calyces → major calyces → renal pelvis → bladder →

ureter → urethra

C

Which of the following best describes the chronological order of renal blood flow?

A. Renal artery → segmental → interlobar → arcuate → interlobular → afferent

arterioles → glomerular capillaries → efferent arterioles

B. Renal artery → segmental → interlobar → arcuate → interlobular → efferent

arterioles → glomerular capillaries → afferent arterioles

C. Collecting ducts → minor calyces → major calyces → renal pelvis → ureter →

bladder → urethra

D. Collecting ducts → minor calyces → major calyces → renal pelvis → bladder →

ureter → urethra

A

what is the functional unit of kidney

nephron

what are the major electrolytes that the kidney regulates

Potassium

sodium

chloride

list some endogenously produced waste materials

creatinine

urea

uric acid

what is the fluid flow ?

1. Bowman’s capsule

2. Proximal convoluted tubule

3. Descending limb of the loop of Henle

4. Ascending limb of the loop of henle

5. Distal convoluted tubule

6. Collecting ducts

Which of the following are functions of the nephron? SATA

A. Glomerular filtration

B. Tubular secretion

C. Tubular reabsorption

D. Protein synthesis

E. Erythropoietin production

A, B, C

Where does glomerular filtration take place in the nephron?

A. Proximal convoluted tubule

B. Bowman’s capsule

C. Loop of Henle

D. Collecting duct

B

Which hormone increases sodium reabsorption in the collecting duct?

A. Vasopressin (ADH)

B. Aldosterone

C. Renin

D. Atrial natriuretic peptide (ANP)

B

Which part of the nephron is impermeable to water? SATA

A. Descending limb of loop of Henle

B. Ascending limb of loop of Henle

C. Proximal tubule

D. Distal tubule

E. Collecting duct (with ADH present)

B,D

Which nerve carries parasympathetic innervation to the bladder?

A. Hypogastric

B. Pelvic

C. Pudendal

D. Vagus

B

Which receptor prevents bladder emptying by contracting the sphincter?

A. M3

B. β3

C. α1

D. M2

C

what nerve is sympathetic

hypogastric

what nerve is somatic

pudendal

Passive process where water and small molecules and ions (< _____ kDa)

diffuse across glomerular-capillary membrane into Bowman’s capsule then

enter the proximal tubule.

5-10

Can proteins be filtered?

no, most proteins are too large

Which of the following is the best index of kidney function?

A. Serum urea concentration

B. Serum creatinine alone

C. Glomerular Filtration Rate (GFR)

D. Urine osmolality

C

Which factor increases GFR by constricting the efferent arteriole?

A. Angiotensin II

B. Prostaglandin E2

C. NSAIDs

D. ACE inhibitors

A

Creatinine clearance tends to ___________ GFR because creatinine undergoes

tubular secretion.

overestimate

creatinine is not only filtered at the glomerulus, but also secreted into

the tubules from the peritubular capillaries. (t/f)

true

Prostaglandin E2 dilates the ________ arteriole, while NSAIDs cause its constriction.

afferent

Rhabdomyolysis

Creatine supplements

High meat diet

increase or decrease SCr

increase

Amputation

Malnutrition

Muscle wasting

Medications

increase or decrease SCr

decrease SCr

what does increase SCr do to CrCl

underestimate

what does decrease SCr do to CrCl

overestimate

Loading doses are dependent on elimination

Maintenance doses are dependent on elimination

You must adjust the loading dose in patients with renal impairment

You must adjust the maintenance dose in patients with renal impairment

answer if each statements are true or false

false

true

false

true

Which of the following drugs require dose adjustment in patients with renal

impairment? SATA

A. Lovenox

B. Warfarin

C. Xarelto

D. Heparin

E. Fentanyl

F. Keppra

G. Morphine

H. Amikacin

A,C,F,G,H

● Enoxaparin, but not unfractionated heparin

● DOACs, but not warfarin

● Digoxin

● Opioids

(Fentanyl does not)

● Metoclopramide

● Lithium

● Vancomycin

● Aminoglycosides

drugs that has to be renally adjusted

Which medications are known to cause hypokalemia? (Select all that apply)

A. Beta2 agonists

B. Insulin overdose

C. Potassium-sparing diuretics

D. High-dose penicillins

E. ACE inhibitors

A, B, D

Hypokalemia due to gastrointestinal loss can occur through which of the following? (Select all that apply)

A. Vomiting

B. Constipation

C. Diarrhea

D. GI suctioning

A,C,D

• Patient’s potassium level is 3.2 mEq/L and does not report muscle weakness or N/V

• Patient’s potassium level is 2.6 mEq/L and does report muscle weakness of N/V

• Patient potassium level is 3.6 mEq/L and reports feeling fatigued

• Patient’s potassium level is 2.4 mEq/L and is currently intubated

• no need for supplements

• initial oral potassium

• each more potassium food

• initiate IV potassium supplements

Which of the following potassium supplement formulations is more likely to cause gastrointestinal upset and therefore should be taken with meals and a full glass of water?

A. Potassium chloride liquid

B. Wax-matrix extended-release tablets

C. Controlled-release microencapsulated tablets

D. Effervescent potassium tablets

B

A 67-year-old woman with diabetic nephropathy (CKD stage 5,not on dialysis yet) presents with weakness and nausea.

Labs:

Na⁺ = 140 mEq/L

K⁺ = 6.8 mEq/L

Mg²⁺ = 2.1 mg/dL

Ca²⁺ = 9.0 mg/dL

EKG: Peaked T waves, wide QRS

What is the first immediate intervention?

A. IV insulin with dextrose

B. IV calcium gluconate

C. Sodium zirconium cyclosilicate (Lokelma®)

D. Hemodialysis

B