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Kidney Physiology Kidney Functions: • • • • • activate vitamin D (renal 1-alpha hydroxylase) produces erythropoietin which stimulates RBC formation helps regulate blood pressure ELIMINATES METABOLIC WASTE PRODUCTS HELPS MAINTAIN FLUID, ELECTROLYTE, AND ACID-BASE IMBALANCES Kidney Diseases of Note Glomerulonephritis (acute or chronic) Nephrotic Syndrome Acute Renal Failure Chronic Renal Failure Dialysis Urinary Calculi Renal Filtrate: fluid from the blood filtered by the kidneys that forms urine. GFR: Glomerular Filtration Rate the rate at which the kidney forms renal filtrate. Normal: 90-120 ml/min Renin: enzyme secreted by kidney in response to low blood flow; results in adrenal signal (aldosterone) to cause kidney to retain Na and water. Nephrotic Syndrome: a cluster of symptoms • • • • proteinuria low serum albumin edema hyperlipidemia Sometimes an early sign of renal failure. Caused by: infections, certain drugs, toxins, DM, renal blood clots. Proteinuria Albumin Immunoglobulins (immunity) Transferrin (anemia) Vitamin D-BP (rickets) Low serum proteins Low Blood Volume Kidneys Respond fluid shift into interstitial spaces Edema Retain Na and fluids!!!! Energy: 35 kcal/ kg Protein: 0.8-1.0 g / kg Fat: < 30% of kcals; low in saturated fatty acids. Sodium: During edematous phase 250 mg/day As edema resolves to ~ 1500 mg/ day Prerenal LOW RENAL BLOOD FLOW Postrenal OBSTRUCTION IN URINARY TRACT Intrarenal KIDNEY DAMAGE SUDDEN PRECIPITOUS DROP IN GFR, URINE OUTPUT UREMIA/ AZOTEMIA: Build-up of urea nitrogen in the blood (BUN). Normal: Uremia: ESRD: ARF Phases: 10-20 mg/dl 50-150 mg/dl 150-250 mg/dl 1. Oliguric= reduced urine volume; 2. Diuretic= large fluid/electrolyte losses; 3. Recovery= NL renal function Build-up of toxic waste products in the blood (e.g., urea, potassium) Symptoms: Weakness, Fatigue “Dull” mental state Anorexia, N/V/D, altered taste, subdermal hemorraging Causes of Chronic Renal Failure Diabetic or HIV-Related Nephropathy Recurrent Glomerulonephritis or Pyelonephritis Acute Non-Responsive Kidney Failure Nephrosclerosis Cardiac Failure Extensive Atherosclerosis Malignant Hypertension Early & Accurate Assessment Anthropometrics (< 20 BMI or < 80% body weight Biochemistry (albumin, prealbumin, cholesterol, K, creatinine, BUN) Clinical Assessment (edema, GIT) Dietary Intake( protein, calories, K, PO4) Without Adequate Protein/ Kcals: Hypermetabolic state= Break down visceral protein stores; Hyperkalemia worsens. Kcal needs: 30-50 kcal/kg (depending on level of catabolism) Oliguric phase: Diuretics, restrict fluids, Na and K. Diuretic phase: Fluids and K supplements Measuring fluid needs: Measure urinary output, then add 500 ml for insensible losses. Non-Dialyzed Pts Dialyzed Pts 0.6 to 1.0 g/ kg 1.1-2.5 g/ kg Feeding in Enteral and Parenterally-Fed Patients Less Protein, Electrolytes High Kcal Density Lower amino acid [ ] Higher Dextrose [ ] Insulin may be used to control hyperglycemia Medications Hyperkalemia - Exchange resins (po or enema) e.g.polystyrene sulfonate to increase fecal potassium losses by exchanging sodium. Hyperphosphatemia - Phospate binders e.g. Phosphlo & Tums (Ca based); Magnabid (Mg based); Amphogel (Al based); Renagel (polymer) Anemia - Iron Edema - Diuretics Removal of blood waste products through a semi-permeable membrane via diffusion/osmosis. Hemodialysis Peritoneal Dialysis Large blood vessel tapped,blood routed through dialysis machine, excess fluid/ electrolytes are removed. Dialysed blood returned to body. Dialysis is accomplished using peritoneal cavity as the semi-permeable membrane.