Term
chronic kidney disease
end-stage renal disease required dialysis |
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Definition
a slowly progressive loss of renal
function over a period of months or years
abnormally low GFR; increased serum creatinine level |
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Term
endocrine: secretion of renin and erythropoietin (EPO), activation of vitamin D3
removal of waste products: urea, uric acid, creatinine
electrolyte balance: K, Na, phosphate, Ca
acid/base balance: H+, bicarbonate
excretory: glomerular filtration, tubular secretion, reabsorption, elimination of drugs |
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Definition
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Term
diabetic nephropathy
hypertension - results of end organ damage of hypertension
glomerulonephritis
bilateral renal artery stenosis
kidney stones
polycystic kidney disease |
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Definition
| causes of chronic kidney disease |
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Term
blood pressure is increased due to fluid overload (leads to hypertension and congestive heart failure)
uremia: high urea levels, can lead to pericarditis (inflammation of the area around the heart) and encephalopathy
hyperkalemia: cardiac arrhythmias
erythropoietin synthesis is decreased (aneamia)
fluid volume overload (edema, pulmonary edema)
hyperphosphatemia
hypocalcemia: due to hyperphosphatemia and vitamin D3 deficiency
hyperparathyroidism: due to low Ca levels
metabolic acidosis |
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Definition
| ***signs and symptoms of chronic kidney disease*** |
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Term
erythropoietin supplementation - Epoetin Alfa, Darbepoetin
iron supplementation - oral iron: ferrous sulfate, ferrous gluconate, ferrous fumarate. parenteral iron: iron dextran, iron sucrose |
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Definition
| drugs used for the treatment of anemia in chronic kidney disease |
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Term
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Definition
produced by the peritubular fibroblasts in the kidney
stimulates erythrocyte differentiation and proliferation |
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Term
erythropoietin is a glycoprotein that stimulates erythrocyte differentiation and proliferation
EPO is primarily secreted by the kidneys
epoetin alpha, beta, delta are recombinant EPO
unwanted effects are influenza-like symptoms (etiology unknown), hypertension, thrombosis of arteriovenous shunts, and red cell aplasia due to antibody formation |
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Definition
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Term
erythropoietin is a glycoprotein that stimulates erythrocyte differentiation and proliferation
erythropoietin (EPO) is primarily secreted by the kidney
darbepoetin is a hyperglycosylated derivative of EPO, which has a longer half life
unwanted effects are influenza-like symptoms (etiology unknown), hypertension, thrombosis of arteriovenous shunts, and red cell aplasia due to antibody formation |
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Definition
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Term
[image]
ingested iron is absorbed from the intestinal mucosa into the circulation, where it is bound to transferrin. Iron is distributed to tissues for incorporation into hemoglobin, myoglobin, and enzymes, or it is stored as ferritin. After about 3 months, erythrocytes are degraded by reticuloendothelial cells in the spleen and the iron is returned to the plasma or stored. |
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Definition
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Term
normal erythropoiesis is dependent on the concentration or *iron* and *EPO* available in the plasma
about 2/3 of total body iron is in the circulating RBC mass as hemoglobin
iron is a component of hemoglobin, myoglobin, and multiple enzymes
adverse effects of iron salts include N/V, diarrhea, constipation, black stools
iron dextran is a mixture of ferric hydroxide and dextran
adverse effects of parenteral iron include N/V, flushing, headache, arthralgia, myalgia |
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Definition
| MOA of iron for anemia in chronic kidney disease |
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Term
[image]
parathyroid hormone: increases Ca in the blood by releasing Ca from the bones, increasing Ca reabsorption from the renal tubules, increasing Ca absorption by the intestines
calcitonin: decreasing Ca levels in the blood by decreasing osteoclast activity in bones, decreasing Ca reabsorption from the renal tubules, decreasing Ca absorption by the intestines |
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Definition
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Term
| vitamin D supplementation with calcitriol, ergocalciferol, or calcifediol |
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Definition
| treatment of hypocalcemia in chronic kidney disease |
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Term
[image]
vitamin D3 can be synthesized in the human body from acetate through a pathway that requires UV radiation.
diet and vitamin supplements also provide vitamin D3, which is activated by specific hydroxylation steps in the liver and kidneys to form 1,25-dihydroxyvitamin D3 (calcitriol) |
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Definition
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Term
calcitriol is a vitamin D3 analog available for oral and IV use
calcitriol promotes renal reabsorption of Ca, increases intestinal absorption of Ca and phosphorus, and increases Ca and phosphorus mobilization from bone to plasma
***calcitriol decreases PTH levels via a negative feedback mechanism due to increased Ca levels, and by suppressing the synthesis and release of PTH
bile is required for calcitriol absorption (not indicated for patients with hepatic, biliary, GI disease) |
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Definition
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Term
calcifediol is a fat-soluble vitamin D3 analog
calcifediol is less active than calcitriol
calcifediol is an active, intermediate metabolite in the conversion to calcitriol
its action is similar to calcitriol |
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Definition
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Term
a vitamin D analog produced from plant sterols
ergocalciferol is the primary dietary source of vitamin D and is found in fortified milk and cereal products
it requires hydroxylation in the liver or kidneys for activity
bile is required for ergocalciferol absorption
activated ergocalciferol and calcitriol have equal activity and function |
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Definition
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Term
| decreased renal elimination of phosphorus -> hyperphosphatemia -> decreased calcitriol production -> decreased serum Ca levels -> increased PTH release and increased proliferation of chief cells -> secondary hyperparathryroidism |
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Definition
| how does secondary hyperparathyroidism result from chronic kidney disease? |
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Term
vitamin D supplementation with paricalcitol and doxercalciferol
cinacalcet |
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Definition
| treatment of secondary hyperparathyroidism in chronic kidney disease |
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Term
a synthetic vitamin D analog used in the treatment of secondary hyperparathryroidism
paricalcitol reduces PTH levels with small changes in serum Ca and phosphorus
paricalcitol is about 10-fold less active than calcitriol in Ca and phosphorus reabsorption from bones
paricalcitol does not increase Ca absorption from the GI tract
paricalcitol is indicated for secondary hyperparathyroidism associated with chronic kidney disease (IV and oral) |
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Definition
| mechanism of action of paricalcitol |
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Term
a synthetic vitamin D analog
is activated by the liver alone
reduce PTH levels
used for the treatment of secondary hyperthryroidism in patients undergoing chronic renal dialysis (IV or oral) |
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Definition
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Term
treatment for secondary hyperparathyroidism in chronic kidney disease
cinacalcet mimicks Ca
binds to Ca sensing receptor
decreases PTH release
[image] |
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Definition
| mechanism of action of cinacalcet |
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Term
due to decreased phosphate excretion
forms phosphate-calcium complex in blood vessels, vascular calcifications
cause extensive soft tissue calcifications; joints, tendons, ligaments, heart
decrease in free Ca in the blood, stimulates PTH
associated with secondary hyperparathryroidism in response to hypocalcemia
blocks vitamin D activation by blocking alpha-hydroxylase
treated with phosphate binders. |
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Definition
| how does chronic kidney disease lead to hyperphosphatemia? |
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Term
lanthanum carbonate
calcium carbonate
sevelamer |
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Definition
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Term
an oral agent for the management of hyperphosphatemia in patients with chronic renal disease
calcium ions bind to dietary phosphate in the gut, prevent absorption
some free Ca can be absorbed, potentially elevating the phosphorus-calcium product
calcium salts should not be used as phosphate binders if serum phosphorus is extremely elevated |
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Definition
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Term
an oral agent for the management of hyperphosphatemia in patients with end-stage renal disease
lanthanum carbonate dissociates to lanthanum ions in the acidic environment of the upper GIT
lanthanum ions bind dietary phosphate released from food during digestion
the water-soluble lanthanum phosphate complex is excreted in the feces |
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Definition
| MOA of lanthanum carbonate |
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Term
sevelamer binds dietary phosphate in the GIT
amino group in the sevelamer molecule cross-link with phosphate in the gut, thereby preventing phosphate absorption
when taken with meals, sevelamer lowers both serum phosphate and PTH
sevelamer does not increase serum Ca
sevelamer also lowers serum total and LDL cholesterol levels |
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Definition
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Term
AEIOU
acid/base abnormalities
electrolyte imbalances
intoxications
fluid overload
uremia |
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Definition
| indications for renal replacement therapy (RRT) |
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Term
advantages: use for both acute and chronic situations, technically simple, less staff time, hardware readily available, correction occurs quickly, less pharmacy time and expense
disadvantages: not well tolerated by hemodynamically unstable patients, most patients unable to maintain BP with rapid fluid removal (2-3L/4hrs) with intermittent RRT |
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Definition
| advantages and disadvantages of intermittent renal replacement therapy (RRT) |
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Term
advantages: more precise volume control, gradual filtration and solute removal, better hemodynamic control b/c fluid and electrolyte shift gradually, some forms can remove larger molecular weight substances
disadvantages: technically difficult, more staff time and resources, more electrolyte monitoring and changes in fluid replacement, continuous anticoagulation necessary, data for medication adjustment limited |
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Definition
| advantages and disadvantages of continuous renal replacement therapy (CRRT) |
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Term
[image]
in the dialysate tube there is a semipermeable membrane
countercurrent: blood flows in one direction and dialysate flows in the opposite direction
concentration gradient - dialysate contains small concentration of electrolytes, blood contain accumulated waste products and electrolytes
acid/base control - dialysate has high concentration of bicarbonate that goes into the blood |
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Definition
| dialysis, a type of renal replacement therapy |
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Term
molecular weight
protein binding
volume of distribution
water solubility
ultrafiltrate rate
therapy duration
type of dialyzer |
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Definition
| factors that influence drug removal by dialysis |
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Term
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Definition
the diffusion of solutes across a semipermiable membrane
counter-current flow; the dialysate flows in the opposite direction to blood flow
the efficacy of waste clearance during hemodialysis is much higher than natural kidneys (requires only 3 times a week)
intradialytic complications - hypotension, cramps, N/V, headache, chest pain, back pain, fever, chills.
other complications: thrombosis and infection from grafts, fistula, catheters
dialyzer reactions: anaphylactic (type A): dyspnea, angioedema, burning/heat sensation. nonspecific (type B): chest pain, back pain |
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Term
catheter: inserted into the superior vena cava, access through the internal jugular vein. ADR - infection, narrowing of the vein
AV graft: use synthetic tubing, one tube connected to artery and another to the vein, the vein receives more volume and pressure from the artery and there is remodeling of the vein (increased smooth muscle). dialysis center can use this vein. ADRs - clotting, thrombosis
AV fistula: surgeon sews back artery to vein and remodeling occurs, vein becomes stronger. ADR - steal syndrome (not enough blood getting to the hand) |
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Definition
| what are different methods of hemodialysis access and what are adverse effects of each? |
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Term
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Definition
the peritoneal membrane acts as a natural semipermeable membrane
a special solution is run through a tube into the peritoneal cavity
the fluid is left there for a period of time to absorb waste products, and then removed through the tube
this is repeated a number of times during the day
ultrafiltration occurs via osmosis
complications: mechanical - kinking of the catheter, flow obstruction, pain from impingement of the catheter tip, inflow pain. medical - glucose overload, fluid overload, electrolyte abnormalities, fibrin formation, chemical peritonitis. infectious problems - peritonitis, catheter-related infections |
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Term
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Definition
similar to hemodialysis
hydrostatic pressure drives water and solutes across a filter membrane
the fluid which passes across the membrane is discarded and the remaining blood in the circuit has its desired solutes
the fluid volume is replaced by the addition of a special hemofiltration fluid
it is a slow, continuous therapy (12-24 hours)
ultrafiltration is slow and gentle, make it ideal for patients in intensive care units; acute renal failure. |
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Term
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Definition
a rapid loss of renal function in hours and days
oliguria - decreased production of urine, less than 400ml/day in adults
anuria - absent production of urine |
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Term
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Definition
abnormality in blood supply to the kidney
systemic hypoperfusion: intravascular volume depletion - dehydration, hemorrhage, overdiuresis. volume redistribution - CHF, liver disease
isolated hypoperfusion: bilateral renal artery stenosis, emboli |
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Term
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Definition
abnormality in the kidney itself
medications: ACEi (blood flow to the kidneys is reduced, contraction of the afferent arteriole decreases glomerular filtration rate), NSAIDs (decrease filtration by the kidneys)
hypercalcemia: afferent vasoconstriction
hepatorenal syndrome |
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Term
| cirrhosis (liver disease) -> hypertension of the hepatic portal vein -> vasodilation of visceral organ circulation -> activation of renin-angiotensin-aldosterone system -> increased sympathetic nervous system -> vasoconstriction of the kidneys |
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Definition
| pathophysiology of hepatorenal syndrome |
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Term
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Definition
vascular: vasculitis
glomerular: lupus erythematosus
acute tubular necrosis: kidney tubules have necrosis. ischemic - hypotension, vasoconstriction. endogenous toxins - myoglobin, hemoglobin. exogenous toxins - contrast dye, heavy metals, nephrotoxic drugs
acute interstitial nephritis: surrounding tissues have inflammation. ***Drugs: penicillins (block cell wall synthesis), ciprofloxacin (block DNA replication, inhibit DNA gyrase), sulfonamides (block a key step in folate synthesis)***. infection - streptococcal (gram positive bacteria) |
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Term
postrenal ARF
consequences of postrenal ARF: accumulation of waste products, metabolic acidosis, hyperkalemia, changes in body fluid balance |
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Definition
bladder outlet obstruction
ureteral obstruction
renal pelvis or tubules obstruction (crystal deposition of kidney stones and drugs): oxalate (stones), indinavir (a protease inhibitor, HIV), sulfonamides (antibiotics), acyclovir (antiviral agent, herpes simplex virus), tumor lysis syndrome (metabolic complications after chemotherapy - hyperkalemia, hyperphosphatemia, hypocalcemia, kidney stone formation) |
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Term
insertion of a urinary catheter - useful for monitoring urine output as well as relieving possible bladder outlet obstruction
administer IV fluids - monitored by a central venous catheter to avoid over or under replacement of fluid
treat *metabolic acidosis* and *hyperkalemia*
dialysis |
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Definition
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Term
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Definition
a state in which the blood pH is low (under 7.35)
causes: increased production of H+, ineffective elimination, or inability to form bicarbonate in the kidney
symptoms: arrhythmias, N/V, headache, coma, seizures
treatment: IV *bicarbonate infusion* or *dialysis* |
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Term
ineffective elimination from the body: renal insufficiency, medications that interfere with urinary excretion (ACEi, ARBs, K-sparing diuretics), mineralocorticoid deficiency
excessive release from cells: rhabdomyolysis, burn, digoxin overdose, succinylcholine (muscle relaxant, can cause malignant hyperthermia)
excessive intake: intoxication with salt-substitute, K-containing dietary supplements |
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Definition
| causes of hyperkalemia - an elevated blood level of K (above 5 mmol/L) |
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Term
palpitations, muscle weakness, cardiac arrhythmia, or sudden death
lethal injection in execution |
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Definition
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Term
| IV infusion of calcium gluconate: does not lower K but decrease myocardial excitability caused by less negative membrane potential. increases threshold potential, increases Vmax of electrical impulse propagation |
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Definition
| treatment of hyperkalemia that protects the heart, decreases myocardiac excitability |
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Term
insulin: IV infusion of insulin along with glucose to prevent hypoglycemia, activates Na/K/ATPase, transports K ions into cell
albuterol: promotes movement of K into cells (B2 receptor activation that activations Na/K/ATPase |
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Definition
| treatment of hyperkalemia that promotes K influx into cells |
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Term
polystyrene sulfonate: binding resin that binds K ions within the large intestine and removes it by defication. ex) polystyrene sulfonate - K lowering activity is relatively slow, and inappropriate for the acute treatment of life-threatening hyperkalemia
dialysis: refractory or severe cases
diuretics: chronic management may include diuretics; furosemide, HCTZ |
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Definition
| treatment of hyperkalemia that removes K from the body |
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