Final_Renal

Question 1

Kidneys are responsible for

Answer 1

• water conservation
• electrolyte homeostasis
• acid-base balance
• several neurohumoral/ hormonal functions

Question 2

AKI- types

Answer 2

• prerenal (azotemia)
• renal (kidney itself)
• post-renal (outflow obstruction)

Question 3

AKI- tx

Answer 3

● No specific tx
● Management aims to limit further injury in sepsis:
○ Treat underlying cause
○ MAP>65mmHg
○ Fluid resuscitation (LR)
○ Vasopressor therapy (Norepi in sepsis = safe for kidneys)
○ Activated C-Protein
○ Steroid replacement (for adrenal insufficiency)
○ Dialysis - mainstay for severe AKI

Question 4

AKI - anesthesia management

Answer 4

• Rx dosing adjustments: decrease dose, increase interval
• same as tx of AKI
• only life saving surgery for pts with AKI

Question 5

CKD - what is it?

Answer 5

Kidney damage with GFR <60 mL/min/1.73m​ for 3 mos or more

Question 6

CKD - progression

Answer 6

● Stage I
○ GFR decreases→ increases in BUN + Creat
○ Non-linear process - i.e. Creatinine can be normal while 50% dec. GFR
● Stage II
○ Hyperkalemia
○ Body compensates - ↑ blood flow to collecting tubules to get rid of K+
● Stage III
○ Homeostasis and regulation of extracellular fluid compartment volume
■ System starts to become overwhelmed
■ Biggest increase in damage over last ~ decade

Question 7

CKD complications

Answer 7

• uremic syndrome
• renal osteodystrophy
• anemia
• uremic bleeding
• neuro changes
• CV changes (HTN, HL, silent MI, uremic pericarditis)

Question 8

CKD management

Answer 8

● Aggressive tx of underlying cause
● Pharmacologic therapy (delay dx progression, prevent further complications)
● Preparation for RRT (access, AV fistula–> peritoneal HD, iHD, RRT)
● Manage BP
● Dietary interventions
● Epo for anemia​ at all stages​ of CKD
● Lifestyle modifications

Question 9

CKD - anesthesia management (pre-op, induction)

Answer 9

Preop: LABS (chem), coagulopathies, anemia; HD regimen

Induction:

-Induction drugs?
■ Most safe to use
■ Thiopental=Dose ↓
(d/t ↑ volume of distribution, ↓ protein binding)

• response
  HOTN​ almost immediately after: be prepared=pressors

-Is succinylcholine safe to use?
K+ released from Sux not exaggerated in CKD=safe to use

*Attenuated SNS activity impairs compensatory vasoconstriction
○ Exaggerated (​HD) response to:
■ blood volume
■ PPV
■ body position changes

○ ACEs/ARBS → more HOTN intraop esp if haven’t followed guidelines for pre-op use of Rx

Question 10

CKD - anesthesia management (maintenance)

Answer 10

Maintenance:

• Balanced anesthesia
  (VA + muscle relaxants + opioids = equal mix)
• What about sevoflurane?
  ○ Fluoride Toxicity + Compound A accumulation
  ○ Do providers use Sevo? Yes in real world (higher flows)

● What about volatile agents?
○ Safe - but could use cause precipitous drop in BP d/t decreased SVR
○ Know which VAs drop SVR more than others
● What about TIVA? ✔ Fine
● What about muscle relaxants?
○ Slowed excretion of Roc/Vec
○ Cisatracurium: No change
● What about neostigmine?
○ MOA prolonged
○ Not a problem if ​reversing
● What about opioids?
○ morphine/meperidine depends on renal clearance
○ Morphine metabolite may accumulate & cause post-op respiratory depression
○ Careful use of ​longer acting​ opioids → make sure breathing well post-op

Question 11

nephrolithiasis

Answer 11

Kidney Stone

Question 12

Biggest causative factor of nephrolithiasis

Answer 12

Calcium Oxylate

Question 13

Struvite

Answer 13

Magnesium ammonium phosphate (often formed from infxn process: UTI)

Question 14

Biggest growth in which kidney failure over 2014-2017?

Answer 14

Stage 3: GFR 30-59

Question 15

TURP syndrome is due to

Answer 15

IV fluid volume shifts + plasma solute effects caused by absorption of irrigation solution

Question 16

CKD - anesthesia management (ivf)

Answer 16

-Intraoperative UO is not predictive of post-op renal insufficiency

-When to bolus IVF? What about K in the fluid?
○ Severe renal dysfunction that don’t req HD or pts w/o renal dx undergoing surgical procedure with high incidence of post-op renal failure – these patients may benefit from pre-op hydration with balanced salt solution

Question 17

Risks - CKD

Answer 17

• avoid bp cuff on AVF arm
• use hand for PIV, access catheter LAST
• prone to infxn, skin breakdown

Question 18

Caution with which Rx in CKD?

Answer 18

Opioids

Question 19

Technique used for AV fistula placement

Answer 19

PNB: brachial plexus block

Question 20

TURP syndrome

Answer 20

complication characterized by symptoms changing from an asymptomatic hyponatremic state to convulsions, coma and death due to absorption of irrigation fluid during TURP

Question 21

Location of kidney stones

Answer 21

Pelvis
-usually painless
Ureter
-extremely painful, flank pain, N/V, sweaty, pale, hematuria

ureteral obstruction may cause s/s of renal failure

Question 22

What may occur if close to passing a kidney stone?

Answer 22

Increased hematuria

Question 23

Treatment: Nephrolithiasis

Answer 23

ESWL

also ID-ing the composition of stone + correcting predisposing factor: hyperparathyroidism, UTI, or gout

Question 24

ESWL

Answer 24

• Extracorporeal Shock wave Lithotripsy (non-invasive)
• Focused high intensity acoustic impulses directed at stone in renal pelvis
• Basically pulverizes stone → dust → washed out thru urine

Question 25

BPH Surgical Options

Answer 25

TUIP Trans-urethral incision of the prostate TURP (Trans-urethral resection of the prostate) ● Surgical resection of prostate (radical=remove entire gland: indicated for CA; retropubic, peritoneal (lose nerve fxn)) ● Electrocautery or sharp excision ● Laser ablation (laser prostatectomy): req goggles

Question 26

How to alter course of CKD progression?

Answer 26

Biggest: HTN/BG | -ACEI/ARBs + strict glycemic control

Question 27

ACEI/ARBs

Answer 27

- Decrease systemic HTN + glomerular HTN | - Renoprotective effects (Reductions in proteinuria, Slowing progression of glomerulosclerosis/neuropathies)

Question 28

Cause of anemia in CKD

Answer 28

Decreased erythropoietin production by kidneys | *also: excess PTH production -- replacing bone marrow with fibrous tissue

Question 29

Tx: Anemia in CKD

Answer 29

``` exogenous Erythropoietin (Epoetin) or darbopoetin *in ALL stages of CKD ```

Question 30

Target Hgb in CKD

Answer 30

10-11.5 mg/dL | *AVOID BLOOD TRANSFUSIONS

Question 31

Target Hgb in CKD

Answer 31

10-11.5 mg/dL | *AVOID BLOOD TRANSFUSIONS

Question 32

Why is it important to avoid blood transfusions in CKD?

Answer 32

Result in sensitization of antigens of human leukocyte antigen complex → makes future kidney transplantation less successful

Question 33

principal factor contributing to TURP syndrome

Answer 33

hypo-osmolality | contributes to neuro + hypovolemic changes