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What is the functional unit of the kidney?
The nephron
Name 5 functions of the kidney
1. Body water regulation
2. Electrolyte balance
3. Acid-base balance (metabolic compensation)
4. Excretory regulation (nitrogenous waste, drugs etc...)
5. Metabolic (endocrine) regulation (erythropoitin, renin-angiotensin-aldosterone, Vit. D)
Renin-angiotensin system:
Renin is released from the juxtaglomerular apparatus of the nephron in response to _1__ arterial blood pressure, __2__ ischemia, ECF _3__, __4__ norepinephrine, and _5___ urinary Na+ concentration.
1. decreased
2. renal
3. depletion
4. increased
increased
Renin-angiotensin system:
Renin catalyzes the splitting of the plasma protein _1__ (from the liver) into __2__, which is subsequently converted to _3__ by _4__ __4__ __4__ (made in the lungs.
1. angiotensin
2. angiotensin I
3. angiotensin II
4. Angiotensin Converting Enzyme (ACE)
Renin-angiotensin system:
Angiotensin II stimulates the release of __1__ from the __2__ __2__.
Angiotensin II also causes __3__ peripheral vasoconstriction.
1. aldosterone
2. adrenal cortex
3. increased
Renin-angiotensin system:
Aldosterone causes __1__ of __2__ and __3__, leading to a(n) ____ ECF (extra cellular fluid) volume and a rise in _5___ __5__.
1. retention
2. Na+
3. water
4. increased
5. blood pressure
Normal range for BUN?
7-20 mg/dL
Normal range for serum creatinine?
0.8-1.4 mg/dL
Normal rate for creatinine clearance?
125 mL/min
Name 4 markers used to assess kidney function.
1. BUN
2. Creatinine
3. GFR (measured by creatinine clearance)
4. Urine output

(GFR is most definitive, followed by creatinine, then BUN and urine output.)
Acute Renal Failure (ARF) definition:
The SUDDEN decrease in glomerular filtration rate.
Accumulation of nitrogenous waste.
Inability to maintain Na=, electrolyte, acid-base, and water homeostasis.
Azotemia:
Elevated BUN
Not yet symptomatic.
Uremia:
Showing clinical manifestations of excess nitrogenous waste (high BUN) such as:
changes in mental status, lethargy, stupor
Anorexia, nausea, metallic taste
tremor, pruritis, asterixis
coagulopathy and bleeding
pericardial and pleural rubs
Oliguria:
<400 mL/day
Anuria:
<100 mL/day
True or false?
ARF is always oliguric.
False. ARF can be oliguric or non-oliguric
Categories of ARF:
Pre-renal:
4 Causes?
hypovolemia (dehydration, diarrhea)
decreased cardiac output (MI, valve disorder)
decreased peripheral vascular resistance (meds, shock, head injury)
Decreased renovascular blood flow (bad vascular disease, vascular stenosis)
Categories of ARF:
Intra-renal:
5 causes?
Acute tubular necrosis (prolonged ischemia/nephrotoxic injury)
Glomerulonephritis
malignant hypertension
systemic lupus erythematosus
interstitial nephritis (from untreated strep throat)
Categories of ARF:
Post-renal:
6 causes?
BPH/Prostate cancer
Bladder cancer
Nephrolithiasis (kidney stone)
Spinal cord disease
Strictures
Trauma
Indications for hemodialysis?
(A_E_I_O_U)
A cidosis
E lectrolye abnormalities (K>6)
I ngestion (ethylene glycol)
O verload (volume)
U remia (BUN, Creatinine levels with Sx)
CKD definition:
Kidney damage or GFR <_1__ mL/min per __2__m2 for _3__ months or longer.
1. 60
2. 1.73
3. 3
Stages of CKD:
1= kidney damage with normal or increased GFR (GFR> or = _1__ mL/min/1.73m2)
2= kidney damage with min decreased GFR (GFR _2__ - __2_ mL/min/1.73m2)
3= moderate decreased GFR (GFR _3__-_3__ mL/min/1.73m2)
4=severe decrease in GFR (GFR _4__-__4_ mL/min/1.73m2)
5=kidney failure (GFR<_5__mL/min/1.73m2)
1. 90
2. 60 - 89
3. 30 - 59
4. 15 - 29
5. 15
At what stage of CKD would you surgically create a fistula?
Stage 3 - GFR 30-59 mL/min/1.73m2
At which stage of CKD would you need to start dialysis?
Stage 5 - GFR<15 mL/min/1.73m2
(this card could be wrong; need to double check)
Clinical Course of ARF:
4 phases:
Initiating
Oliguric
Diuretic
Recovery
Clinical Course of ARF:
Initiating phase?
Begins at the time of the insult and continues until the signs and symptoms become apparent. Can last hours or days.
Clinical Course of ARF:
Oliguric phase:
Duration?
10-14 days but can last as long as a month
Clinical Course of ARF:
Oliguric phase:
Prerenal failure=urine with high specific gravity (>_1__) and low sodium concentration (<__2__)
1. 1.015
2. 10-20 mEq/L
Clinical Course of ARF:
Oliguric phase:
Intrarenal failure=urine with normal specific gravity (__1__) and a high sodium concentration (>__2__)
1. 0.010
2. 40 mEq/mL
Clinical Course of ARF:
Oliguric phase:
What are the urinary changes?
In about 50% of patients, urinary output decreases to < 400 mL/24 hours.

Urine may (in intrarenal failure) contain casts.
Clinical Course of ARF:
Oliguric phase:
How is fluid volume affected?
Fluid volume increases d/t decreased urinary output. Sx=distended nect veins, edema, hypertension, CHF, pulmonary edema, pericardial and pleural effusion. Depends on extent of fluid retention.
Clinical Course of ARF:
Oliguric phase:
Metabolic changes?
Why does the serum bicarbonate level decrease?
Metabolic acidosis! Kidneys can't synthesize the ammonia necessary for hydrogen ion excretion or excrete acid products of metabolism.
Serum HCO3 level decreases because bicarbonate is used up in buffering hydrogen ions.
Clinical Course of ARF:
Oliguric phase:
What happens to sodium balance?
Normal or below normal levels of sodium because damaged tubules can't conserve sodium.
Clinical Course of ARF:
Oliguric phase:
What happens with potassium?
Potassium EXCESS. Kidneys can't excrete it. Also, any type of cellular destruction (trauma, RBC infusion) will cause K to be released into extracellular fluid.
When does treatment need to be initiated for high potassium levels?
When levels exceed 6 mEq/L or arrhythmias are identified.
EKG changes associated with hyperkalemia?
Tall, peaked T waves
widening of the QRS complex
ST depression
6 ways to treat elevated potassium?
IV insulin administration (drives K into cells)
Sodium bicarbonate (corrects acidosis, which correction drives K into cells)
Calcium gluconate IV raises threshold for myocardial excitation
Dialysis actually REMOVES K from blood
Kayexalate REMOVES K via osmotic diarhhea
Dietary restriction (limited to 40mEq)
Clinical Course of ARF:
Oliguric phase:
Hematologic effects?
anemia d/t lack of erythropoitin
platelet abnormalities (bleeding)
WBCs altered (infection is the major cause of death in ARF)
Clinical Course of ARF:
Oliguric phase:
Calcium levels?
DECREASED (can't be absorbed from GI without vitamin D, which is ACTIVATED in the kidneys)
Clinical Course of ARF:
Oliguric phase:
Phosphate levels?
INCREASED (can't be excreted AND hyperparathyroidism caused by hypocalcemia causes phosphate to be released from bones along with calcium)
Clinical Course of ARF:
Oliguric phase:
BUN and Creatinine levels?
ELEVATED
(caution:BUN can be elevated d/t other factors as well so creatinine levels are a better indicator of ARF.)
Clinical Course of ARF:
Oliguric phase:
Neurological symptoms?
Range from fatigue to seizures to stupor to coma.
Clinical Course of ARF:
Diuretic phase:
May last _1__ to __2_ weeks.
1. 1
2. 3
Clinical Course of ARF:
Diuretic phase:
Increased daily urine output to __1__ to __2__ L/day or higher.
1. 1
2. 3
Clinical Course of ARF:
Diuretic phase:
In this phase the kidneys have recovered their abilities to __1___ waste but not to __2___ urine.
1. excrete
2. concentrate
Clinical Course of ARF:
Diuretic phase:
Because of the large losses of fluid and electrolytes, the patient must be monitored for __1____, ___2____, and ___3___.
1. hyponatremia
2. hypokalemia
3. dehydration
Clinical Course of ARF:
Recovery phase:
__1__ increases, allowing the BUN and serum creatinine levels to plateau and then decrease. Major improvements in first __2_ to __3_ weeks, but may take up to _4__ months to stabilize.
1. GFR
2. 1
3. 2
4. 12