I GOTTA GO!!

Renal Anatomy

100

What are the three regions of the kidney?

1. cortical: outer region 

2. medullary: inner region ^{contains pyramids}

3. renal pelvis: large collecting area for urine

200

What is a normal Glomerular Filtration Rate?

90-120 mL/min/1.73m2

300

Which region of the kidney is most susceptible to hypoxia 

a. cortex

b. medulla

c. renal pelvis 

BONUS: how much oxygen does it extract

b. medulla

^{only 10% of renal blood flow but 80% of oxygen extraction} 

^{Cortex received 90% of blood flow but only <20%extraction}

20% of CO goes to kidneys!

400

Let's see how well we know our kidney anatomy!

(trust this will help when we get to the diuretics)

https://www.purposegames.com/game/the-nephron-of-the-kidney-quiz

GREAT JOB!

500

Fill in the blank:  the _____ arteriole brings blood to the Glomerulus and the ______ arteriole brings blood away 

BONUS: can you name the renal blood flow pathway?

afferent    efferent

Remember: Running So Im Am Cool (renal, segemental, interlobar, arcuate, cortal radiate)

^{aorta --> renal artery--> segmental artery--> interlobar artery--> arcuate artery--> cortical radiate artery--> afferent arterioles--> glomerulus--> efferent arteriole--> peritubular capillaries--> cortical radiate vein--> arcuate vein--> interlobar vein--> renal vein--> inferior vena cava} 

More renal anatomy and Kidney disease

100

Match the anatomic location with its osmotic gradient: 

1. Cortex 

2. Juxtamedullary zone 

3. deep medulla 

A. 1200mOsm

B. 300 mOsm

C. 600 mOsm 

1. B

2. C

3. A

^{gradients are maintained by vasa recta removing water and adding solute to the medullary interstitium as they pass} 

200

A patient must have a decreased kidney function from more than __ months and characterized by a GFR of less than ___ to be considered to have CKD 

A. 2 months, 85

B. 5 months, 65

C. 3 months, 60

D. 4 months, 70

C. 3 months, 60

300

The RIFLE criteria (Risk of renal dysfunction, injury to the kidney, failure of kidney function, loss of kidney function, end-stage kidney disease) uses all of these measurements to determine AKI severity EXCEPT: 

A. Creatinine clearance

B. Serum Creatinine

C. GFR

D. urine output 

A. Creatinine clearance

This is another method that has the same predictability: 

AKIN ^{(acute kidney injury network) – three stages of AKI, 48 hour time frame for diagnosis, changes the risk criteria to include smaller SCr increases}

400

Order the structures based off the flow of filtrate 

A. bowman's capsule 

B. loop of Henle 

c. Major calyx 

D. proximal tubule 

E. distal tubule 

F. bladder 

G. renal papilla 

H. minor calyx 

I. renal pelvis

J. ureter 

K. glomerulus 

L. collecting duct

K. Glomerulus 

A. bowman capsule 

D. proximal tubule 

B. loop of Henle

E. distal tubule 

L. collecting duct 

G. renal papilla

H. minor calyx 

C. major calyx

I. renal pelvis 

J. ureter

F. bladder 

500

Which of the following AKIs if left untreated would lead to acute tubular necrosis? 

A. intrinsic AKI

B. Postrenal AKI

C. Prerenal AKI 

C. Prerenal AKI: ^{absolute or relative decrease in renal perfusion – uncorrected hypoperfusion will cause ischemic acute tubular necrosis (ATN)}

A. Intrinsic AKI – ^{glomerular, tubular, vascular, interstitial}

B. Postrenal AKI – ^{bladder or ureter obstruction}

Renal Function

100

Select all that apply: 

Which of the following are functions of the kidney 

A. regulate extracellular fluid volume and composition 

B. acid-base homeostasis

C. production calcidiol

D. erythropoietin production 

E. Regulation of blood pressure 

F. Glycogenolysis 

A, B, D, E

C: ^{kidney CONVERTS calcidol (produced by liver) into calcitriol which regulates calcium and phosphate levels}

F. ^{kidney produces gluconeogenesis (liver produces glucogenolysis). IMPORTANT IN PROLONGED FASTING}

200

All of these are functions of Angiotensin II except: 

A. low concentrations cause efferent arteriole vasoconstriction 

B. high concentration causes afferent arteriole constriction 

C. peripheral vasoconstriction 

D. stimulate release of aldosterone from the posterior pituitary 

D. 

angiotensin II stimulates the release of aldosterone from the adrenal cortex. Aldosterone will then cause sodium reabsorption. Angiotensin II will stimulate the posterior pituitary to release ADH which enhances water reabsorption

Heres a 2 min video for review: https://www.youtube.com/watch?v=dTqadSSWsZk

 

300

Which of the following is NOT a part of the vasodilating salt excreting systems responsible for protecting against hypervolemia, hypertension, and hypernatremia 

A. epinephrine and norepinephrine

B. dopamine 

C. Prostaglandins 

D. Atrial Natriuretic peptide 

A. this stimulates the Renin-angiotensin-aldosterone system 

B. Endogenous dopamine – ^{produced in the renal tubular cells – acts as autocrine and paracrine factor that inhibits activity of Na+K+ATPase and other sodium influx pathways}

C. Prostaglandins – ^{PGD2, PGE2, prostacyclin – maintain renal medullary perfusion}

D. Atrial natriuretic peptide – ^{synthesized in atrial myocytes and released in response to atrial stretch – vasodilator and natriuretic activity}

400

The _______________________ reabsorbs 2/3 of filtered Na+ (and draws with it H2O), Cl-, K+, 100% of filtered glucose, lactate and amino acids, secretes endogenous anions (bile salts and urate), cations (creatinine, dopamine) and drugs

A. Distal Convoluted Tubule

B. Collecting Tubule

C. Loop of Henle

D. Proximal Convoluted Tubule

 

D. proximal convoluted tubule

A. distal tubule:^{reabsorbs 5-8% of filtered Na+ and Cl- and water follows in exchange for K+ secretion, AVP enhances receptor permeability to water}

B. collecting duct: ^{H2O permeable – dependent on AVP (ADH), hypovolemia and arterial hypotension increase the reabsorption of water}

C. loop of Henle: ^{Descending limb (absorbed water) and Ascending limb (absorbed 20% of Na, K, and bicarb. IMPERMEABLE TO WATER)}

 

Diuretics: Where does it work?

100

Which of the following classes of diuretics works on the thick ascending loop of Henle? (Select all that apply)

A. osmotic diuretics

B. loop diuretics

C. Thiazide diuretics 

D. potassium-sparing diuretics 

B. loop diuretics

200

Which of the following classes of diuretics works distal convoluted tubule? (Select all that apply)

A. osmotic diuretics

B. carbonic anhydrase inhibitors

C. Thiazide diuretics 

D. potassium-sparing diuretics

C. thiazide 

D. potassium-sparing  

300

Which of the following classes of diuretics works at the proximal convoluted tubule? (Select all that apply)

A. osmotic diuretics

B. carbonic anhydrase inhibitors

C. Thiazide diuretics 

D. Loop diuretics

A. osmotic diuretics 

B. carbonic anhydrase inhibitors

400

Which of the following classes of diuretics works at the descending loop of Henle? (Select all that apply)

A. osmotic diuretics

B. carbonic anhydrase inhibitors

C. Thiazide diuretics 

D. Loop diuretics

A. osmotic diuretics

500

Now that we know where they work,  let's make sure we can match the med to the class:  

A. Mannitol: ______

B. Acetazolamide: ______

C. Furosemide: _______

D. Chlorothiazide: _______ 

E. Spironolactone: ________

A. Mannitol: osmotic diuretic 

B. Acetazolamide: carbonic anhydrase inhibitor 

C. Furosemide: loop diuretic

D. Chlorothiazide: Thiazide 

E. Spironolactone: potassium sparing diuretic

Pharmacologic considerations

100

Chlorothiazide works on the Distal Convoluted tubule, would this mean it would have increased or decreased natriuresis? 

decreased

^{remember only 5-8% of sodium is reabsorbed here}

200

The surgeon asks the SRNA to give the patient Mannitol for increased ICP. The SRNA knows all of the following are true about Mannitol EXCEPT: 

A. mannitol can only be given IV 

B. monitor for hypernatremiaia 

C. mannitol must be run with a filter 

D. the dosing will be 50-100g as 5-25% solution 

E. mannitol should be used with caution in patients with CHF 

D.50-100g as a 5-25% solution (this is the oliguria dose)

^{the correct dosing is 1.5-2g/kg in 30-60min for ICP.}

 A. mannitol can only be given IV ^{(poorly absorbed PO)}

B. monitor for hypernatremiaia ^{(has minimal naturesis so hypovolemia can increase Na levels)}

E. mannitol should be avoided in patients with CHF ^{(Exacerbates pulmonary edema and CHF, Contraindicated in patients with anuria, dehydration and intracranial hemorrhage without surgical intervention)}

300

Which of the following drugs when given as a dose of 100mcg/kg or greater inhibits phosphodiesterase which results in an increase in cAMP antagonizing Nondepolarizing NMB. 

A. furosemide

B. Mannitol

C. spironolactone 

D. acetazolamide 

A. furosemide

^{Dose of less than 100 μm/kg blocks protein kinase which decreases influx of calcium at the motor nerve ending thus potentiates nondepolarizing drugs}

^{Heres a good video on how Furosemide works: https://www.youtube.com/watch?v=fWD4AipDsUs}

400

Your patient's lab comes back with elevated Cl- levels and pH of 7.33. You suspect the patient might have metabolic hyperchloremic acidosis. The SRNA knows this is side effect of which medication:

A. Mannitol

B. Furosemide

C. Spironolactone

D. Acetazolamide

D. Acetazolamide

acidosis d/t reabsorption of sodium chloride and excretion of HCO3 

^{Other side effects include: renal stones, hypokalemia, hyperammonemia}

^{The first 6 min video was super helpful: https://www.youtube.com/watch?v=bdCarhO8zxU}

500

Match the mechanism of action with the diuretic:  

A. spironolactone

B. Chlorothiazide 

C. Mannitol

D. Furosemide

E. Aceazolamide 

1. ^{competes with aldosterone at the receptor sites, resulting in sodium retention in the tubules and decreased secretion of potassium to the tubules}

2. ^{Inhibits the sodium-chloride symporter at the DCT}

3. ^{Inhibits the sodium, potassium and chloride symporter – decreased reabsorption of sodium, potassium and chloride from the ascending thick loop of henle. Inhibits feedback mechanism from macula densa – increases the GFR & production of prostaglandins}

4. ^{Inhibits the carbonic anhydrase present in high concentrations in the PCT}

5. ^{Freely filtered through the glomerulus – its osmotic pressure prevents reabsorption of water from the PCT and descending loop of Henle}

A. spironolactone: 1

B. Chlorothiazide: 2 

C. Mannitol: 5

D. Furosemide: 3

E. Aceazolamide: 4