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STEP 2CK Review > 5 Nephrology and Acid-Base > Flashcards

5 Nephrology and Acid-Base Flashcards

1
Q

Casts:

  • Fatty casts
  • granular/muddy brown casts
  • RBC casts
  • WBC casts
  • waxy casts
  • hyaline casts
A
  • Fatty–nephrotic
  • granular/muddy brown casts–ATN
  • RBC casts–GN
  • WBC casts–AIN, pyelo
  • waxy casts–CKD
  • hyaline casts–Normal
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2
Q

CKD stages

  • GFR
  • tx goals
A
  1. >
  2. 60-90
  3. 30-60 complications start appearing, tx them
  4. 15-30 prepare dialysis (get AV fistula now so it can heal)/transplant
  5. <15. ESRD, dialysis required
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3
Q

Dialysis indications

A

AEIOU:

acidosis
electrolyte
ingestion
overload (CHF, edema)
uremia
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4
Q

ATN: think what 3 main causes

A

prolonged ischemia, drugs/toxins, and contrast

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5
Q

ATN:

  • 3 phases
  • how long take to recover, what tx
A
  1. prodrome: increased Cr
  2. oliguric: UOP deceased (fluid overload!)
  3. polyuric: UOP increased (diuresis!)

2-3 weeks for tubular cells to regenerate. Do supportive dialysis to prevent life-threatening e-lyte imbalances.

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6
Q

Prerenal ARF:

BUN/Cr
UNa
FENa
FE Urea

A

kidneys think they’re dehydrated, will hold on to salt.

BUN/Cr >20
UNa<10, FENa <1% (tubular fxn intact)
Urine osmols >500 (can still concentrate)

FE Urea<35%. Use FE Urea if on diuretic

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7
Q

Intrarenal ARF:

BUN/Cr
UNa
FENa

A

kidney is broken; can’t reabsorb Na or concentrate urine.

BUN/Cr<10
UNa>20
FENa>1%

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8
Q

Pt with renal damage, but needs contrast for imaging. Do what? (3 things)

A

prevent contrast-induced ATN.

  1. vigorous hydration
  2. NAC
  3. stop diuretics and ACE/ARBs
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9
Q

Pt gets ARF, with increased Cr.

What labs to get first?

A

First, r/o prerenal:

BUN/Cr
UNa
FENa
FE Urea if diuretics

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10
Q

Renal Failure, my mnemonic

A

MR CA PUNK

Met acid, renal osteodystrophy

HypoCa (from low VitD and 2ndary hyperPTH), Anemia (low EPO)

Hyperphosphatemia, Uremia, increased Na, hyperkalemia

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11
Q

CKD:

  • HTN and DM treatment goals.
  • what to be aware of in DM
A

HTN: strict <130/80
DM: A1C<7, same.

In DM, must use oral meds. NOT metformin, NOT insulin. Metformin causes lactic acidosis. Insulin cleared by kidneys, so beware of hypoglycemia with insulin retention

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12
Q

Postrenal ARF:

what are the 2 stages

A

early stage: BUN ‘forced’ back into blood by pressure. BUN/Cr>15.
Tubular fxn intact, so FENa<1%, urine osmol>500
(same numbers as Prerenal)

late stage: Tubular damage, so:
BUN/Cr <15.
FENa>2%
urine osmol <500

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13
Q

Intrarenal ARF: think what main 3 causes? look for what on microscopy? and main causes for each?

A
  1. ATN (muddy casts).
    prolonged ischemia, toxins/drugs, contrast
2. AIN (WBC casts from inflamm). 
drug hypersensitivity (eg NSAIDs), pyelo, infiltrative dz (amyloid, sarcoid)
  1. GN (RBC casts)
    - many causes
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14
Q

Pt with acute leukemia. You treat with chemo. What to be aware of with kidneys and what to do?

A

beware tumor lysis syndrome leading to ATN from high uric acid.

Give hydration and allopurinol (decrease formation of uric acid)

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15
Q

side effect of EPO in ESRD

A

worsening HTN

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16
Q

contrast induced ATN. when after use does it occur?

A

ARF 7-10 days post procedure

17
Q

hyponatremia:

general approach and decision points

A
  1. Serum osmols. If low <280, then true hypotonic hypoNa. Otherwise, pseudo.
  2. Volume status
    - overload: CHF, nephrosis, cirrhosis

-normal volume: “RATS”
RTA, Addison’s, Thyroid, SIADH

-hypovolemia. give IVF
prerenal vs intrarenal

18
Q

How to corrent Na and Ca

A

Na: every 100 over 100, add 1.6

Ca: every 1 albumin <4, decrease Ca by 0.8

19
Q

HyperCa sxs. what are they really

A

“bones, stones, groans, psychiatric overtones”

  • fx, osteopenia
  • Ca stones
  • N/V, abd pain
  • AMS, only at 13-15 severe
20
Q

hungry bone syndrome

A

after parathyroid adenoma removal, the remaining glands take time to rev back up. So temporary hypoCa

21
Q

HyperCa of malignancy. mechs?

Also, sarcoid mech

A
  1. mets to bone
  2. PTH-rp (Squamous cell carcinoma)
  3. increase in 1,25 VitD
22
Q

Young pt hospitalized after MVC trauma. Now has hyperCa, think what

A

HyperCa of immobilization. Get them walking and out of bed

23
Q

Young pt with asx hyperCa and positive family hx. Think what?

A

FHH: Familial hypocalciuric hypercalcemia

-Bad Ca sensor at parathyroid, so secrete more PTH anyway. No tx

24
Q

hyperparathyroidism: mechs
- primary
- 2ndary
- tertiary

A
  1. adenoma
  2. CKD, starting with low VitD leading to low Ca, stimulating PTH. So, Ca usu low/normal.
  3. CKD/ESRD, autonomous adenomas.
25
Q

hyperCa of malignancy form bone breakdown, Tx

A

Vigorous hydration, alendronate. Lasix probably not, lost favor.

26
Q

HyperK sxs (3) other than EKG change

A
  • areflexia
  • flaccid paralysis
  • paresthesias
27
Q

Hypokalemia:

  • in real life, what 2 main groups of causes to think of
  • on test, what causes to think of: (3)
A
  1. GI losses (diarrhea, vomiting)
  2. Renal losses (diuretics)
  3. Bartter syndrome (Lasix)
  4. RTA
  5. Hyperaldosteronism
28
Q

HypoK

  • how to replace K+, what rates?
  • how fast do you want K to increase
  • if K is not increasing, think what?
A

PO is best.

  1. PIV: <10 meq/h because K+ burns in peripheral
  2. Central: <20 meq/h because fear of arrythmia

Gen rule: 10 mEq increases K by 0.1. increasing K by 0.1/hour is ideal.

-Check Mg. replace that

29
Q

kidney stones: what is medical expulsion therapy

when to use

A

CCB and alpha blockers
amlodipine, terazosin.

Can use if <7mm

30
Q

Struvite stone classic story

A

Elderly pt with frequent UTIs. UA shows hematuria, no pyuria, and ALKALINE urine

31
Q

kidney Stone sizes to know

A

<5mm IVF and analgesia
<7mm can use MET
>30mm surgery for sure

In between: depends, lithotripsy, uretoscopy, etc

32
Q

PCKD

-think what 3 extrarenal things

A

cysts in:

  • brain
  • liver
  • pancreas

So, SAH, cirrhosis, pancreatitis

33
Q

Renal cyst, big picture approach?

A

Ask yourself, is this RCC??

  1. if cyst small, think simple, no tx
  2. if cyst big with septations, think complex cyst, do needle bx
  3. If classic triad, or paraneoplastic sxs (anemia or polycythemia), think RCC. Do CT. Then Cut it out, no bx
34
Q

Predicted anion gap

A

Albumin x3. So, with alb 4, AG predicted is 12

Alb 2, predicted is 6.

35
Q

metabolic alkalosis

-how to approach dx

A
  1. volume responsive?
    Measure Urine Cl. If low (<10), then contraction alk (high aldo retaining NaCl, so Cl low). Give fluids

If Urine Cl >10, not volume responsive.
-urine Cl>10 and HTN, then hyperaldosteronism (not responsive to fluids). eg RAS and Conn’s syndrome

-urine Cl>10 and no HTN, then think genetic. Bartter and Gitelman

36
Q

metabolic acidosis, non-AG.

-how to approach dx

A

Get urine anion gap.
(Urine Na + K - Cl). NOT SAME ELECTROLYTES as blood AG

If +, then RTA
If -, then diarrhea

STEP 2CK Review (20 decks)

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