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Colin CPR II Exam 3 > Approach to Oliguria and/or Proteinuria > Flashcards

Approach to Oliguria and/or Proteinuria Flashcards

1
Q

Anuria is described as a urine output of ___ mL/day

A

< 50-100 mL/day

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2
Q

Oliguria is described as a urine output of ___ mL/day

A

< 400-500 mL/day

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3
Q

Polyuria is described as a urine output of ___ mL/day

A

> 3,000 mL/day

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4
Q

What is Azotemia?

A

Elevated blood urea nitrogen (BUN) WITHOUT symptoms

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5
Q

What is Uremia?

A

Elevated BUN with symptoms

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6
Q

What symptoms are associated with Uremia?

A
  • Nausea/vomiting
  • Confusion
  • Pruritus (uncomfortable irritating sensation that creates an urge to itch)
  • Metallic taste in mouth
  • Fatigue
  • Anorexia
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7
Q

Differential diagnosis of Cardiorenal Syndrome in the setting of a pt that presents with oliguria and proteinuria implies what?

A

Cardiorenal Syndrome implies Heart failure

Either Systolic Heart Failure (reduced Ejection Fraction)

OR

Diastolic Heart Failure (preserved Ejection Fraction)

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8
Q

What is Cor pulmonale?

A

Pulmonary HTN causing Right Sided Heart Failure

Can cause kidney damage, resulting in oliguria/proteinuria

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9
Q

What valvular abnormalities can lead to oliguria/proteinuria?

A 
Aortic Regurgitation
Aortic Stenosis
Mitral Regurgitation
Tricuspid Regurgitation
Tricuspid Stenosis
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10
Q

What issues of the pericardium can cause oliguria/proteinuria?

A

Constrictive pericarditis

Pericardial effusion/Cardiac Tamponade

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11
Q

What pulmonary issues can cause oliguria/proteinuria?

A

ANCA-vasculitis

Goodpasture Syndrome (anti-GBM disease)

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12
Q

What ANCA-vascultiis diseases cause pulmonary pathologies that can cause oliguria/proteinuria?

A

p-ANCA (MPO - Myeloperoxidase)

c-ANCA (PR3 - Proteinase 3)

Churg-Strauss

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13
Q

What liver pathology can result in oliguria/proteinuria?

A

Hepatorenal Syndrome

- Cirrhosis

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14
Q

What is Pre-renal Azotemia?

A

Effective Circulating Volume is decreased

- Shock

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15
Q

What causes decreased Effective Circulating Volume?

A

Hypovolemic shock

  • Dehydration
  • GI Bleed

Cardiogenic Shock

Neurogenic Shock

Septic Shock

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16
Q

What are the 3 general causes of AKI?

A

Pre-renal Azotemia

Intrinsic Kidney Dysfunction

Post-renal Obstruction

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17
Q

What are the tree examples of Intrinsic Kidney Dysfunctions that cause AKIs?

A

Acute Tubular Necrosis (ATN)

Interstitial Nephritis

Glomerulonephritis

  • Nephrotic Syndrome
  • Nephritic Syndrome
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18
Q

What can cause Chronic Kidney Disease?

A

Diabetes

HTN

Acute Kidney Injury

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19
Q

What are you trying to learn from a patient when asking “Have you been drinking enough fluids?”

A

How much water, coffee, tea, soda is the pt drinking each day

Normal total fluid intake is around 1.5-2.0 L/day (50-60oz/day)

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20
Q

What are you trying to learn from a patient when asking “Are you lightheaded or dizzy with position changes (laying -> sitting; sitting -> standing)?”

A

Pts that get dizzy with position changes have orthostatic hypotension

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21
Q

What are you trying to learn from a patient when asking “Do you have a history of hypertension and if so for how long?” What follow up question can you ask?

A

Hypertension is one of the major causes of kidney disease.

Follow up with “what is your typical home blood pressure?” if they measure their BP at home.

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22
Q

What are you trying to learn from a patient when asking “Do you have a history of diabetes and if so how long?” What follow up questions can you ask if Pt does have DM?

A

Diabetes is a leading cause of kidney disease.

Follow up with “how well is it controlled?” and “what was your last HgbA1C?”

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23
Q

What are you trying to learn from a patient when asking “Do you use certain medications?” What follow up questions can you ask?

A

Some medications can be nephrotoxic

  • NSAIDs
  • Antibiotics
  • Proton Pump Inhibitors

Follow up with “Which ones?” “How often do you take them?” “How long have you been taking them?”

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24
Q

What are you trying to learn from a patient when asking “Have you had any recent IV iodine contrast dye?”

A

IV contrast dye is a nephrotoxin
- It is used in cardiac catheterizations and CT scans

NOTE:
- Oral iodine contrast does not result in contrast induced nephropathy, only IV contrast

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25
Q

What are you trying to learn from a patient when asking “Do you empty your bladder completely or feel like you are retaining urine?”

A

Urinary retention can be caused by

  • Benign Prostatic Hyperplasia (BPH)
  • Neurogenic Bladder
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26
Q

What are you trying to learn from a patient when asking “Any family history of kidney disease?”

A

Many kidney pathologies can be inheritable

You want to make sure to ask Pt about family history with

  • Hematuria
  • Proteinuria
  • Kidney Cysts (PKD)
  • Chronic Kidney Disease/ End Stage Renal Disease
  • Family members requiring dialysis
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27
Q

What are some important findings to look for when examining volume status in a Pt presenting with Oliguria/Proteinuria?

A
  • JVD
  • Oral Mucosa (dry, tongue fissuring, moist)
  • Capillary Refill (normal < 3 seconds)
  • Skin tenting (best to use forehead in elderly)
  • S3 (heart failure)
  • Crackles (non-specific, pulmonary edema)
  • Ascites
  • LE pitting edema
  • Sacral edema (elderly, non-mobile, hospitalized Pts)
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28
Q

What are some important findings to look for when examining HEENT in a Pt presenting with Oliguria/Proteinuria?

A
  • Tonsillar exudates (Post-infectious GN)
  • Oral Ulcers (autoimmune conditions, SLE, etc)
  • Retinopathy (HTN or diabetic)
  • Nasal ulcers or crusting (ANCA vasculitis)
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29
Q

What are some important findings to look for when examining the heart in a Pt presenting with Oliguria/Proteinuria?

A
  • S3 (heart failure)
  • Heart rhythm (i.e., atrial fibrillation may cause hypotension, intracardiac thombus, or indicate electrolyte abnormality)
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30
Q

What are some important findings to look for when examining the lungs in a Pt presenting with Oliguria/Proteinuria?

A
  • Crackles

- Pleural effusions (systemic disease, CHF, infection)

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31
Q

What are some important findings to look for when conducting an abdominal exam in a Pt presenting with Oliguria/Proteinuria?

A
  • Abdominal bruits (Renal Artery Stenosis, Abdominal Aortic Aneurysm, Iliac Arteries)
  • Palpable kidneys (ADPKD or Kidney transplant—Usually RLQ)
  • Tense abdomen (abdominal compartment syndrome)
  • Ascites
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32
Q

What are some important findings to look for when examining the skin of a Pt presenting with Oliguria/Proteinuria?

A
  • Malar rash (SLE)
  • Palpable purpura (vasculitis)
  • Non-blanching purpura (Thrombocytopenia)
  • Buttock and Leg purpura (Henoch-Schonlein Purpura; aka IgA Vasculitis)
  • Livedo reticularis (SLE, cryoglobulinemia, hypercoagulable states, vasculitis)
  • Emboli (septic or thrombotic)
  • Drug Rash
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33
Q

What are some important findings to look for when conducting a musculoskeletal exam in a Pt presenting with Oliguria/Proteinuria?

A
  • Synovitis
  • Myalgia
  • CVA (Costovertebral Angle) tenderness - Urinary infection; Kidney stone
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34
Q

How do you diagnose CKD?

A

You need 1 of the 2 criteria for more than 3 months

  • Markers of Kidney damage
  • Decreased GFR (<60 mL/min)
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35
Q

What are markers of kidney damage?

A
  • Albuminuria (proteinuria)
  • Urine sediment abnormalities (casts in urine)
  • Electrolyte and other abnormalities due to tubular disorders (i.e., Renal tubular acidosis)
  • Abnormalities detected by Histology
  • Structural Abnormalities detected by imaging
  • History of kidney transplantation (even if transplanted kidney is functioning normally, it is still considered a kidney damage marker)
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36
Q

What happens if you have 1 of the 2 criteria for CKD but for less than 3 months?

A

Acute Kidney Injury (AKI)

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37
Q

At what value is a GFR considered reduced?

A

< 60 mL/min

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38
Q

What are the 6 stages of CKD?

A

Stage 1

  • GFR >90 mL/min
  • Normal or High

Stage 2

  • GFR 60-89 mL/min
  • Mild decrease

Stage 3a

  • GFR 45-59 mL/min
  • Mild to moderate decrease

Stage 3b

  • GFR 30-44 mL/min
  • Moderate to severe decrease

Stage 4

  • GFR 15-29 mL/min
  • Severe decrease

Stage 5

  • GFR <15 mL/min
  • Kidney Failure/ End Stage Renal Disease (ESRD)
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39
Q

Do the GFR categories Stage 1 and Stage 2 meet the criteria for CKD?

A

In the absence of evidence of kidney damage, Stages 1 and 2 do not meet the criteria for CKD

Recall that the GFR criteria for CKD requires that GFR be less than 60 mL/min for 3 months

Stage 1 describes GFR at > 90 mL/min
Stage 2 describes GFR at 60-89 mL/min

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40
Q

The three most common causes of CKD are ____

A

Diabetes, HTN, Glomerulonephritis

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41
Q

The vast majority of CKD cases are caused by____

A

Diabetes and HTN

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42
Q

The most common cause of CKD is____

A

Diabetes

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43
Q

Many patients with CKD are _____

A

Asymptomatic

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44
Q

Many patients discover they have CKD from ____

A

Routine laboratory testing, as many are asymptomatic

45
Q

The signs and symptoms of CKD include:

A
  • Edema
  • HTN
  • Decreased Urinary Output (UOP)
  • Foamy urine (proteinuria)
  • Uremia (Nausea/Vomiting, confusion, pruritis, metallic taste in mouth, fatigue, anorexia
  • Pericardial friction rub (pericarditis/pericardial effusion due to uremia)
  • Asterixis (flapping wrist, due to uremia)
  • Uremic Frost
46
Q

What are the 3 simple necessary tests required to identify most CKD patients?

A
  • Estimated GFR (eGFR)
  • Urine Albumin:Creatinine ratio or Urine Protein:Creatinine ratio
  • Urinalysis (with microscopy)
47
Q

What is a major limitation of eGFR?

A

eGFR is not accurate in settings of rapidly changing creatinine (i.e. AKI)

48
Q

What is the common error when using Creatinine Clearance to estimate GFR?

A

Creatinine Clearance tends to overestimate GFR

This is because creatinine is freely filtered at the glomerulus but is also secreted by tubules making urine creatinine concentration higher than expected

49
Q

What is wrong with having a patient do a 24 hour urine collection?

A

It is very cumbersome and patients struggle to accurately collect their urine

50
Q

How is the Albumin:Creatinine/Protein:Creatinine ratio measured?

A

Random Spot Urine Sample

- easy to collect

51
Q

What is the most commonly used imaging technique for analyzing the kidneys?

A

Renal Ultrasound

52
Q

What are the signs seen on ultrasound that indicate CKD?

A
  1. Atrophic or small kidneys
  2. Cortical thinning
  3. Increased echogenicity (brighter)
  4. Elevated resistive indices (High resistive indices indicates resistance to arterial flow within the kidney)
53
Q

What is doppler renal ultrasound used for?

A

To evaluate:

  • Renal Artery Stenosis (RAS)
  • Renal Vein Thrombosis
  • Resistive Index
54
Q

What is resistive index?

A

High Resistive Indices (>0.7-0.8) indicates resistance to arterial blood within the kidney

55
Q

What values indicate a High Resistive Index?

56
Q

What is Abdominal CT used for?

A

Abdominal CT is better at detecting masses and kidney stones

Can also evaluate for the same things as renal ultrasound

57
Q

What is Abdominal MRI used for?

A

Evaluates:

  • Renal Artery Stenosis (RAS)
  • Renal Vein Thrombosis
  • Really good at evaluating Renal Masses**
58
Q

What are the complications of CKD?

A
  • Proetinuria
  • HTN
  • Hyperlipidemia
  • Anemia
  • Metabolic Acidosis
  • Hyperkalemia
  • CKD-BMD (Bone and Mineral Disorder)
  • Volume Overload
59
Q

How do you treat Proteinuria secondary to CKD?

A
  • Low salt diet
  • BP control
  • RAAS Blockers (ACEi, ARB, aldosterone antagonist, renin inhibitor, non-dihydropyridine CCB)
60
Q

How do you treat HTN secondary to CKD?

A

Reduce blood pressure, different goals depending on proteinuria

No Proteinuria: Goal BP < 140/90

Proteinuria: Goal BP < 130/80

61
Q

How do you treat Hyperlipidemia secondary to CKD?

A

Statin therapy

62
Q

How does CKD cause anemia?

A

Healthy kidney makes Erythropoietin (EPO), promoting RBC generation

Unhealthy kidney does not produce enough EPO -> anemia

63
Q

How do you treat anemia secondary to CKD?

A

Oral or IV iron

Erythropoietin Stimulating Agents (ESA)

64
Q

How do you treat metabolic acidosis secondary to CKD?

A

Bicarbonate supplementation if HCO3- is <22 mEq/L

65
Q

How do you treat Hyperkalemia secondary to CKD?

A
  • Renal Failure diet (low salt, potassium, and phosphorus)
  • Diuretics
  • Sodium Polystyrene sulfonate (Kayexalate) or Patiromer (Veltassa)
66
Q

How does CKD cause Bone and Mineral Disorder (CKD-BMD)?

A

Decreased GFR causes Phosphorus retention and Reduced Calcium

Increased serum Phosphorus/Decreased Serum Calcium promotes Parathyroid Hormone secretion –> Secondary Hyperparathyroidism

Hyperparathyroidism promotes Bone mineralization (decreasing bone density)

67
Q

How do you treat Bone and Mineral Disorder secondary to CKD (CKD-BMD)?

A
  • Low Phosphorus diet
  • Phosphorus Binder (lowers phosphorus absorption in the gut)
  • Vitamin D supplementation (lowers PTH)
  • Calcimimetics (lowers PTH)
  • Dialysis (extreme move just to control phosphorus)
68
Q

How do you treat volume overload secondary to CKD?

A
  • Diuretics
  • Fluid Restriction
  • Dialysis
69
Q

How do you treat CKD?

A

Renal Replacement Therapy

  • Hemodialysis
  • Peritoneal Dialysis
  • Renal Transplantation (living or deceased donor)
70
Q

What are the indications for Dialysis?

A

A, E, I, O, U

Acidosis (severe)
Electrolyte Disturbance (usually hyperkalemia)
Ingestion (of dialyzable materials: ethylene gloycols, methanol, etc)
Overload (volume)
Uremia

71
Q

What are the three categories of AKI?

A

Pre-renal

Intrinsic

Post-renal

72
Q

What causes Pre-renal AKI?

A
  • Hypotension
  • Hypovolemia
  • Reduces Cardiac output (heart failure, tamponade, massive PE)
  • Systemic Vasodilation (sepsis, systemic inflammatory response syndrome [SIRS], hepatorenal syndrome)
73
Q

What are the three categories of Intrinsic AKI?

A

Tubular Necrosis

Interstitial Nephritis

Glomerulonephritis

74
Q

What are the two categories of Tubular Necrosis?

A

Ischemia

Toxins (nephrotoxic)

75
Q

Which of the three categories of Intrinsic AKI is the most common?

A

Tubular Necrosis

  • Ischemia (50%)
  • Toxic (35%)
76
Q

What causes Post-renal AKI?

A

Bladder Outler obstruction
- BPH, Cancer, Strictures, blood clots

Ureteral Obstruction

  • Bilateral obstruction
  • Unilateral Obstruction (in the case of a single functioning kidney)
  • Stones, malignancy, retroperitoneal fibrosis

Renal Pelvis
- Papillary Necrosis (NSAIDs), stones

77
Q

What is the clinical presentation of AKI?

A

MANY SYMPTOMS IDENTICAL TO CKD:
- Edema

  • HTN
  • Decreased Urinary Output (UOP)
  • Foamy urine (proteinuria)
  • Uremia (Nausea/Vomiting, confusion, pruritis, metallic taste in mouth, fatigue, anorexia
  • Pericardial friction rub (pericarditis/pericardial effusion due to uremia)
  • Asterixis (flapping wrist, due to uremia)
  • Uremic Frost

SYMPTOMS NOT SEEN IN CKD:

  • Hematuria
  • Shortness of Breath (if pulmonary edema is present)
78
Q

What are the common diagnostic tests for AKI?

A

Urinalysis with Microscopy

Urine Albumine:Creatinine ratio; Protein:Creatinine ratio

Renal Ultrasound

(urinalysis and protein/albumin:cr ratio also used for CKD diagnosis)

79
Q

What are the complications with AKI?

A
  • Hypervolemia
  • Electrolyte Abnormalities
  • Hyperuricemia
  • Uremia
  • Pericarditis
  • Metabolic Acidosis
  • Bleeding (platelet dysfunction, BUN > 100 mg/dL
  • Need for Dialysis
80
Q

How do you treat AKI?

A

Depends on the etiology, correct the underlying disease if possible
- mostly supportive

81
Q

What findings are seen in Nephrotic Syndrome?

A

Proteinuria (> 3.5 g/day)

Hypoalbuminemia

Peripheral edema

Hyperlipidemia

Lipiduria

82
Q

What are the complications associated with Nephrotic Syndrome?

A

Edema

Hyperlipidemia

Infection

Thrombosis

83
Q

How does Nephrotic syndrome cause edema?

A

Two theories:

  1. Low serum albumin causes reduced vascular oncotic pressure, thus reducing water taken up by the vessel
  2. Low renal perfusion from low effective circulating volume causes RAAS activation –> Increased sodium reabsorption (increased Total Body Water and Na+)
84
Q

How does Nephrotic Syndrome cause hyperlipidemia?

A

Etiology not well understood

Low oncotic pressure (from proteinuria) stimulates liver lipoprotein syntehsis –> Hypercholesterolemia

85
Q

How does Nephrotic Syndrome cause infections?

A

Proteinuria includes urinary loss of IgG

Requires occasional IVIg supplementation

86
Q

How does Nephrotic Syndrome cause thrombosis?

A

Etiology not well understood

High Risk Thrombosis factors associated with Nephrotic syndrome:

  • Serum Albumin < 20g/L
  • Clinical hypovolemia
  • Bed rest/intercurrent illness
  • Membranous Nephropathy

Higher risk when Albumin < 2.0-2.5 g/dL

Urinary loss of Antithrombin III, plasminogen, protein S, and other anticoagulant proteins

Increased levels of procoagulant factors
- Fibrinogen, Coagulation Factors (II, V, VII, VIII, X, XIII), etc

87
Q

How does Nephrotic Syndrome cause Vitamin D Deficiency?

A

Urinary loss of Vitamin D binding protein (necessary for proper metabolism of Vit D)

88
Q

How does Nephrotic Syndrome cause Anemia?

A

Urinary loss of Transferrin and Erythropoietin

89
Q

What is the number one cause of Nephrotic Syndrome?

A

Diabetic Nephropathy

90
Q

What Nephrotic Syndrome is seen commonly in children?

A

Minimal Change Disease

91
Q

What subtype of FSGS is seen in individuals with HIV infection?

A

Collapsing FSGS

92
Q

Which Nephrotic Syndrome (specifically) is commonly associated with underlying malignancy and/or renal vein thrombosis?

A

SECONDARY Membranous Nephropathy

93
Q

What is monoclonal disease?

A

Abnormal proteins called Monoclonal Proteins (M Protein) accumulate in the system.

In response, light chain and heavy chain immunoglobulins are produced

Deposition of these Igs in the kidney can cause problems

94
Q

What is the most definitive test you can do to diagnose Nephrotic syndromes?

A

Renal Biopsy

- You specifically want to biopsy the cortex, where the glomeruli are located

95
Q

How do you manage Nephrotic syndrome?

A

Treat the underlying etiology of the nephrotic syndrome

- may require immunosuppression

96
Q

How do you treat edema secondary to Nephrotic syndrome?

A

Dietary sodium restriction

Diuretics

97
Q

How do you treat Proteinuria secondary to nephrotic syndrome?

A

LOWER BLOOD PRESSURE

ACEi or ARB

Alternative antiproteinuric medications (non-dihydropyridine CCV, aldosterone antagonist, renin inhibitor)

98
Q

How do you treat hyperlipidemia secondary to nephrotic syndrome?

A

Statin therapy

99
Q

How do you treat thrombosis secondary to nephrotic syndrome?

A

Heparin or Warfarin

Consider prophylactic anticoagualtion therapy for Pts with serum Albumin <2.5 g/dL

(high risk of thrombosis at serum albumin levels <2.0-2.5 g/dL)

100
Q

How do you treat infection secondary to nephrotic syndrome?

A

IVIg supplementation

101
Q

How do you treat vitamin D deficiency secondary to nephrotic syndrome?

A

Vitamin D supplementation

102
Q

What are the findings seen in Nephritic Syndrome?

A

Proteinuria (< 3.5 g/day)

Hematuria*

HTN*

Renal failure is common

(Hematuria and HTN are the required diagnostic criteria for nephritic syndrome)

103
Q

What is commonly found in urine in the case of nephritic syndromes?

A

Nephritic syndromes usually have Active Urinary Sediment

i.e., hematuria, dysmorphic RBCs, RBC casts, WBCs, WBC casts, granular casts, etc

104
Q

How is the uniary sediment described in nephrotic syndrome?

A

Bland urinary sediment

105
Q

What is the classic clinical presentation for nephritic syndrome?

A

New onset HTN

New onset Hematuria (microscopic or gross)

Acute Kidney Injury (severe cases may have RPGN over days to weeks)

Proteinuria (foamy urine, typically < 3.5 g/day)

Edema (less severe than nephrotic syndrome)

106
Q

Is edema typically more severe in nephritic or nephrotic syndrome?

A

Nephrotic syndrome typically has more severe edema

107
Q

In severe cases of AKI due to nephritic syndrome, you may also see what?

A

In severe cases of AKI due to Nephritic syndrome, you may have a Rapidly Progressive Glomerulonephritis (RPGN) over days to weeks

108
Q

What is the most definitive test you can do to diagnose Nephritic syndromes?

A

Renal Biopsy

- You specifically want to biopsy the cortex, where the glomeruli are located

Colin CPR II Exam 3 (7 decks)

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