Kidney Functions and Chronic Kidney Disease, Exams of Nursing

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Manitoba Nephrology Nursing Course

State the regulatory bodies that guide nephrology practice. - National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI ™) or KDOQI and Canadian guidelines through the Society of Nephrology (CSN). Describe the location of the kidneys and state the average size of each kidney. - Bean-shaped organs, each about the size of an average fist. They are located in the flank regions on either side of the spine. State the five key functions of the kidneys. -

1. Removal of waste products (urea, creatinine, and uric acid.)
2. Balance electrolytes & fluids
3. Balance pH (Making Bicarb/absorbing hydrogen ion)
4. Hormonal & Enzymatic functions
5. Blood Pressure control How much glomerular filtrate do healthy kidneys make each day? How much urine does that produce? - The body makes 180 litres of Glomerular filtrate each day and 1-3 litres of urine. Which hormones regulate urine production? What specifically do they regulate? - Urine produced is regulated by ADH and Aldosterone. These hormones regulate volume of ECF and quantity of electrolytes excreted/reabsorbed. Where is ADH produced and secreted? What is it's main function? - Produced in hypothalamus and secreted by posterior pituitary gland. Signals the kidneys to either concentrate or dilute urine. Where is aldosterone produced and what is it's main function? - Produced in the adrenal cortex. Regulates volume of blood and ECF through reabsorption of sodium by kidneys (water follows sodium). What is a normal blood Ph? State how the kidneys achieve acid base balance. - Ph 7.35-7. (High = Alkalosis, Low =Acidosis) If Ph is too high, kidneys INCREASE EXCRETION of bicarb and INCREASE ABSORPTION of hydrogen ions. If Ph is too low, kidneys DECREASE EXCRETION of bicarb and DECREASES ABSORPTION of hydrogen ions. State three hormonal functions that the kidney is involved in. -
6. Activates Vitamin D for maintaining the calcium-phosphate balance. Vitamin D is important for: Absorption of calcium from GI tract Formation of bone Maintaining calcium-phosphate balance.
7. Erythropoietin stimulates red blood cell production.
8. Renin is released by kidneys when BP is low to cause vasoconstriction. State the two terms most often used in describing kidney function. What are their normal values? -

Creatinine clearance (CrCl) (75-125 ml/min/1.73m2) .or glomerular filtration rate (GFR) ( ml/min). State how much cardiac output the kidneys receive. - 25% of the body's total cardiac output. State two unique traits of the kidneys shared by no other part of the human body. -

1. The only place in the body where capillaries are joined by two arteries and
2. Having two sets of capillary beds in each circulation loop. Describe the pathway of renal circulation from the aorta to the inferior vena cava. -
3. Renal artery to enter the kidney at the hilum.
4. Interlobar arteries
5. Arcuate arteries
6. Interlobular arteries
7. Afferent arterioles
8. Glomerulus (glomerular capillaries) where glomerular filtration occurs.
9. Efferent arterioles
10. Peritubular capillary network
11. Vasa Recta
12. Interlobular Veins
13. Renal Vein
14. Vena Cava What are the 3 primary functions of the nephron? How many nephrons in a normal, healthy kidney?

1. Filtration of the blood
2. Reabsorption of substances
3. Concentration and dilution of urine. 1-1.5 million nephrons What happens in the glomerulus? - Filtration. The pressure created by the heart forces water, electrolytes, urea, creatinine, uric acid, glucose and other substances through tiny filtration slits inside of these small glomerular capillaries. The glomerular filtrate collects where? Where does it go after? - Bowman's capsule. The glomerular filtrate flows from the Bowman's capsule to the proximal convoluted tubule. How much of the glomerular filtrate is reabsorbed by the proximal convoluted tube? What does it contain? - 2/3 of the glomerular filtrate is reabsorbed into the bloodstream such as plasma, water, nutrients and electrolytes. What structure comes after the proximal convoluted tube? What is its function? What is the next structure called and what is it's function? - Loop of Henle. Reabsorbs water and electrolytes. Distal Convoluted tube. Regulates Ph, potassium, sodium and calcium.

How much glomerular filtrate is created each day? How much urine does that produce? How much blood is filtered per minute? - 180 litres. 1-3 litres of urine produced. 1.2 litres per minute. What is the last portion of the nephron structure? What is it's function (ADH is involved here)? - Collecting Duct. When ADH (antidiuretic hormone) is present water absorption occurs in the collecting ducts; in the absence of ADH, little water absorption occurs. What substances are found in urine? - urea, creatinine and uric acid, drugs and electrolytes (sodium, potassium and phosphate, etc.) How does Diabetes Mellitus contribute to CKD? - Most common cause .Diabetic nephropathy occurs when blood sugars aren't controlled for a long time. Causes the glomerular capillaries to harden (GLOMERULAR sclerosis). This causes protein to leak into urine (Microalbuminuria) How does HTN contribute to kidney disease? - Second most common cause. Long term HTN causes NEPHRO sclerosis. What is Glomerular Nephritis (GN)? How does it contribute to CKD? - Third most common cause. GN is an inflammation of the glomerulus leading to impairment of renal function partly due to the formation of antibody/antigen complexes What are the 3 types of GN? - IgA nephropathy is the most common form of GN worldwide. It is a condition in which there is an accumulation of IgA complexes within the glomeruli resulting in hematuria, proteinuria, and peripheral edema. Goodpasture's syndrome (GPS) is a disorder in which the body develops an autoimmune response to the glomerular basement membranes. Permanent and complete loss of renal function can occur in days to weeks. Postinfectious Glomerulonephritis (PIGN) can occur after a betahemolytic streptococcal infection of either the throat or of the skin. The streptococcal infection causes inflammation of the small blood vessels of the glomerulus. Signs include hematuria, mild proteinuria and oliguria. People with "hardening of the kidney", present with the following (4 symptoms): - HTN, Proteinuria, Retinal Changes, LV Hypertrophy. Describe Autosomal Dominant Polycystic Kidney Disease (ADPKD), which is the most common INHERITED kidney disease. - Normal kidney tissue is replaced with grape-like clusters that compress and destroy the surrounding tissue. ADPKD affects both men and women equally. What are some symptoms and complications of ADPKD? - Most common symptoms include pain in the back and sides (between ribs and hips) and headaches. Complications include hypertension, painful rupture of cysts, hemorrhagic cysts, hematuria, urinary tract infections, polyuria and nephrolithiasis. What is Systemic Lupus Erythematosis? How does it contribute to CKD? -

SLE is a chronic systemic inflammatory disorder of the connective tissues resulting from the formation of auto antibodies. Prevalent in females. Immune complexes are deposited in the glomerular capillaries and an inflammatory response follows What is Systemic Vasculitis and what are the 2 types? - Inflammation of any type of blood vessels.

1. Wegner's Granulomatosis is associated with positive antineutrophil cytoplasmic antibodies (ANCA). It predominantly affects the small and medium sized arteries of the kidneys and respiratory tract
2. Henoch-Schonlein Purpura (HSP) is a type of vasculitis /inflammation involving the small vessels in the joints, skin, kidneys, and GI tract. Describe Multiple Myeloma's relation to CKD. - The chains of immunoglobulin produced in excess by the tumor cells are nephrotoxic and cause tubular damage Describe Amyloidosis's relation to CKD. - Accumulation of abnormal fibrillar glycoprotein. The glomerulus is damaged resulting in proteinuria. Renal involvement occurs in more than 90% of patients. Describe Scleroderma. - Connective tissue disease characterized by connective tissue proliferation and vascular lesions. Glomerular ischemia commonly leads to elevated renin levels and subsequent hypertension. Describe Pyelonephritis in relation to CKD. - Pyelonephritis is an inflammation of the renal parenchyma (cellular structure) caused by bacteria that have ascended the urinary tract into the kidney. The kidney becomes edematous from interstitial inflammation, congested circulation and tubular cell necrosis Chronic Drug Induced Tubulointerstitial Nephritis (TIN - The most common form of TIN is analgesic nephropathy. Renal papillary necrosis and chronic interstitial nephritis. Renal Artery Stenosis (RAS) (What happens to the renal artery? What does it trigger?) - Narrowing of the renal artery lumen by 50 % or more. This triggers the renin-angiotensin- aldosterone system with resulting vasoconstriction, retention of fluid causing volume expansion, and hypertension. RAS is due to atherosclerosis in over 90 % of cases. Alport's Syndrome (Think Chromosome) - Genetic disorder with 85% cases related to a mutation on the X chromosome. Patients often present with hematuria with or without proteinuria, with gradual progression to kidney failure in late teens or later. Define Chronic Kidney Disease (CKD). What are the markers of damage? - CKD is defined as irreversible kidney damage for 3 months or more, or GFR < 60ml/min. Markers of damage include abnormalities in the blood or urine tests or imaging studies What are the 6 risk factors for developing CKD? - Diabetes Mellitus Hypertension Urinary tract abnormalities Known systemic autoimmune disorders

Excessive use of known nephrotoxins (NSAIDS) Symptoms suggestive of a systemic illness List the Stages of Kidney Disease and the therapeutic focus of each stage. - Stage 1: prevent kidney failure Stage 2: decrease rate of decline Stage 3: decrease rate of decline Stage 4: Manage complications of CKD Stage 5: Prepare for renal replacement Define acute kidney injury (AKI), what causes it? - The sudden inability of the kidneys to remove excess body fluid, minerals and waste products. Caused by trauma, post-surgery, medications, sepsis, poisoning, or as a complication of critical illness. What are some clinical symptoms of AKI? - Elevation in urea, creatinine and potassium Metabolic acidosis Oliguria (urine output < 500ml/day) or anuria (urine output < 100), although non-oliguria (normal urine volume) may occur Fluid overload for those experiencing oliguria or anuria What are the mortality rates for patients with AKI? What is the major cause of death? - Mortality rates are approximately 50% with infection as a major cause of death. In critically ill patients, the mortality rate is as high as 85%. Describe the 3 types of AKI. What percentage of each type makes up total cases? -

1. Pre-renal. Kidneys are structurally normal; damaged by decreased renal perfusion. (35% of cases)
2. Intra-renal. Kidney tissue is injured; damage to glomeruli, vessels, renal tubules. (50% of cases)
3. Post-renal. Kidneys are structurally normal; blockage in flow or urine; pressure causes nephrons to shut down. (5-10% of cases) What are 4 causes of Pre-Renal AKI? -
4. Decreased cardiac output r/t reduced effective circulating volume (MI, pulmonary embolism, cardiac failure, septic shock, CHF)
5. Uncontrolled vasodilation (sepsis, anaphylactic shock)
6. Hypovolemia/hypotension (dehydration, hemorrhage, burns, GI losses)
7. Renal vascular obstruction (renal artery stenosis, renal artery thrombosis) What is the goal of treating Pre-Renal AKI? - Restore renal perfusion and decrease length of ischemic time to prevent permanent damage to kidney function. What are the 5 common causes of Intra-Renal AKI? - 1.Acute tubular necrosis (ATN)
8. Ischemia
9. Nephrotoxic agents
10. Acute interstitial nephritis (AIN)
11. Rapidly progressive Glomerulonephritis and vasculitis What are 2 common causes of Post-Renal AKI? -
12. Obstructions (Enlarged prostate, pregnancy, uterine prolapse, calculi)

2. Tumours Describe the prevalence of ESRD in Manitoba. - Highest incidence and prevalence rate in Canada In Manitoba: 1,739 on Dialysis 1,366 on in- center Hemodialysis 264 Peritoneal Dialysis 109 Home Hemodialysis AND 5,706 Renal Health Clinic Patients What are 8 common complications experienced by those who suffer from CKD? -
   1. CVD (leading cause of death in stage 5)
3. HTN (Also a risk factor and causes CVD)
4. Anemia (reduced EPO synthesis)
5. Protein-Energy Malnutrition (PEM)
6. Metabolic Acidosis occurs as the number of functioning nephrons declines.
7. Mineral and Bone disorders (pruritus, renal osteodystrophy, myopathy, and soft tissue calcifications)
8. Neurological disturbances are a common characteristic of CKD caused by increased levels of uremic toxins, decreased cerebral blood flow and reduced cerebral oxygen utilization.
9. Dyslipidemia (elevated total cholesterol, elevated triglycerides and lowered high-density lipoprotein (HDL) leads to CVD) What are 4 causes of Protein-Energy Malnutrition? -
   1. Poor nutritional intake due to uremia induced anorexia 2. Increased protein catabolism caused by metabolic acidosis
10. Negative effect of inflammation and infection on decreasing visceral protein synthesis
11. Endocrine disorder What are symptoms of Metabolic Acidosis? - Chronic bone loss, muscle wasting, anorexia, weight loss, hypoalbuminemia, and impaired cardiac function What are the primary functions of the nephron? -