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CPR Exam 3 > Approach to Oliguria/Proteinuria DSA > Flashcards

Approach to Oliguria/Proteinuria DSA Flashcards

1
Q

The following are defined as:

Anuria

Oliguria

Polyuria

A

Anuria: less than 50-100 mL/day

Oliguria: less than 400-500 mL/day

Polyuria: more than 3,000 mL/day

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2
Q

What is the difference between azotemia and uremia?

A
  • Azotemia: High BUN w/o symptoms
  • Uremia: High BUN with symotoms (N/V, confusion, pruritis, metabolic tast in mouth, fatigue, anorexia)
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3
Q

The kidney can maximally concentrate ______.

A

~1200 mOsm/L

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4
Q

If a person consumes 600mOsm/day, what is the minimal urine output?

A

600/1200=

0.5 L/day

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5
Q

If a patient is experiencing oliguria and proteinuria, what are the 3 DDx if a cardiac problem?

A
  1. Cardiorenal syndrome (systolic/diastolic HF)
    1. starves the kidney of blood
  2. Cor pulmonale
  3. Valvular abnormalities

Other: constrictive pericarditis, pericardial effusion/ cardiac tamponade

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6
Q

If a patient is experiencing oliguria and proteinuria, what are the 2 DDx if a pulmonary problem?

A
  1. ANCA-vasculitis
  2. Anti-GBM syndrome (Goodpastures)
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7
Q

If a patient is experiencing oliguria and proteinuria, what are the 4 DDx if a renal problem?

A
  • 1. Prerenal azotemia
  • 2. Acute kidney injury (AKI)
  • 3. Chronic kidney injury (CKD)
  • 4. ESRD
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8
Q

What is a normal fluid intake?

What fluids does this include?

A

1.5 -2 L/day (50-60 oz)

Includes ALL fluids (water, coffee, tea, soda, etc)

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9
Q

What are commmon questions to ask patients with oliguria or proteinuria?

A
  1. Have you been drinking enough fluids? (all fluids)
  2. Do you get lightheaded or dizzy when you change postions?
  3. Do you have a history of HTN, DB and if so, for how long?
  4. Do you use certain meds, like nephrotoxins (NSAIDS, recent abx or PPIs)?
  5. Have you had any recent IV iodine contrast?
  6. Do you empty bladder completely or do you feel like you are retaining urine?
  7. Do you have a history of kidney disease?
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10
Q

Patients with oliguria/proteinuria can present with symptoms that related to volume status?

A
  1. JVD or flat veins
  2. Oral mucosa (dry, moist)
  3. Capillary refill (NL is less than 3 seconds)
  4. Skin tenting)
  5. S3
  6. Crackles
  7. Ascities
  8. LE pitting edema
  9. Sacral edema
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11
Q

Patients with oliguria/proteinuria can present with symptoms that related to HEENT?

A
    1. Retinopathy (could mean HTN or DB)
    1. Nasal ulcers (ANCA vascultis)
    1. Tonsilar exudates (post-infectious GN)
    1. Oral ulcers (autoimmune)
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12
Q

Patients with oliguria/proteinuria can present with symptoms that related to cardiac?

A
  1. S3 (HF)
  2. Heart rhythm
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13
Q

Patients with oliguria/proteinuria can present with symptoms that related to lungs?

A
  1. Crackles (pulmonary edema or ILD)
  2. Pleural effusions (systemic diseases. CHF)
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14
Q

Patients with oliguria/proteinuria can present with symptoms that related to abdominal exam?

A
  1. Bruits
  2. Palpable kidneys
  3. Tense abdomen (abdominal compartment syndrome)
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15
Q

Patients with oliguria/proteinuria can present with symptoms that related to skin?

A
  1. Malar rash (SLE)
  2. Palpable purpura (vasculitis)
  3. Non-blanching purpura (thrombocytopenia)
  4. Buttock and leg purpura (HSP)
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16
Q

Patients with oliguria/proteinuria can present with symptoms that related to MSK?

A
  1. Synovitis
  2. Myalgia
  3. CVA tenderness
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17
Q

CKD diagnosis criteria

A

Patient must have [marker for kidney damage or a decreased GFR] for more than 3 months.

  1. Marker for kidney damage (one or more) (7)
    • ​Albuminuria
      • =/> 30 mg/24 hours
      • Albumin- to- creatinine ratio (=/> 30mg/g or 3mg/mmol)
    • Abnormalities in urine sediment
    • Abnormalities in electrolytes due to tubular disorders
    • Abnormalities detected by histology
    • Structural abnormalities detected by imaging
    • History of kidney transplant
  2. Decreased GFR
    1. Less than 60 mL/min
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18
Q

When is a patient diagnosed with AKI?

A
    1. GFR below 60mL/min
    1. Markers of kidney damage

for less than 3 months

After 3 months => CKD

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19
Q

Describe the stages of CKD (1-5)

A
  1. CKD stage 1
    1. GFR is 90 or above
  2. CKD stage 2
    1. GFR (60-89)
  3. CKD stage 3a
    1. GFR (45-59)
  4. CKD stage 3b
    1. GFR (30-44)
  5. CKD stage 4
    1. GFR (15-29)
  6. CKD stage 5/ESRD
    1. GFR (<15)

Without evidence of kidney damage, Stage 1 or stage 2 does not meet the full criteria of CKD.

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20
Q

The vast majority of CKD is caused by what, in order of predominance

A

DM & HTN

  • 1. DM (38%)
  • 2. HTN (26%)
    1. Glomerulonephrrtis
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21
Q

Clinical presentation of CKD is ___________, depending on ___________.

A
  • variable
  • the severity
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22
Q

Many patients with CKD are _________, thus, we find out they have CKD via what?

A
  • Asymptomatic
  • Lab testing (abnormal Cr; ↓GFR)
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23
Q

Signs and symptom of CKD include what? (8)

A
  1. Edema
  2. HTN
  3. Decrease UO
  4. Foamy urine
  5. Uremia
  6. Pericardial friction rub (pericarditis & pericardial effusion)
  7. Asterixis
  8. Uremic frost
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24
Q

___________ is a sign of CKD where when you fully extend the wrist and it flaps (flexes forward).

A

Asterixis

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25
Q

What 3 simple tests, most commonly used way to DX most CKD patients?

A
    1. eGFR (estimated GFR)
    1. Urine [albumin/Cr ratio] or urine [protein/Cr ratio]
    1. UA
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26
Q

Serum creatinine is a ______ marker of kidney function.

A

Poor

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27
Q

What is a limitation of eGFR?

A

Note accurate when Cr levels are changing rapidly, like in AKI.

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28
Q

Why is urine [albumin:creatinine ratio —vs—protein:creatinine ratio] are used to ID CKD?

A

Random spot urine test, so easy to collect.

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29
Q

Measured GFR, a measure of GFR at that time, is more accurate than eGFR, so why is it not used?

A

Only performed in some institutions

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30
Q

Why is creatinine clearance not one of the best tests to dx CKD?

A
  1. Overestimates GFR because creatinine is freely filtered at the glomerulus
  2. Secreted by the tubules, making urine concentration higher than expected.
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31
Q

If we suspect the bladder is causing the issue of proteinuria/oliguria, what do we do?

A

US of the size of the bladder

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32
Q

How do we treat a CKD patient presenting with proteinuria?

A
  1. Low salt diet
  2. Control BP
  3. ACE-I, ARB, aldoesterone ANT, Renin-inhibitor, non-DHP CCB
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33
Q

What is the goal BP for a CKD patient?

A
  1. Is proteinuria present?
    1. No: Goal BP is <140/90
    2. Yes: Goal BP is <130/80
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34
Q

How do we treat a CKD patient presenting with hyperlipidemia?

A

Statins

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35
Q

How do we treat a CKD patient presenting with anemia?

A
  • - Oral or IV iron
  • - ESA
36
Q

How do we treat a CKD patient presenting with metabolic acidosis?

A
  1. If bicarb is less than 22mEq/L, give bicarb supplimentation
37
Q

How do we treat a CKD patient presenting with hyperkalemia?

A
  1. Renal Failure Diet (low salt, K and phosphorus)
  2. Diuretics (loop)
  3. Sodium polystyrene sulfonate (Kayexlate) or Patiromer (Veltassa)
38
Q

What will we see in a CKD patient presenting with CKD-BMD?

A

↑ in phosporus and ↓ in Ca2+, which can cause secondary hyperparathyroidism

39
Q

How do we treat a CKD patient presenting with CKD-BMD?

A
  1. Renal failure diet (low salt, K+ and phosphorus)
  2. Phosphorus binder, which ↓ phosphorus absorbution in the gut
  3. Vit D suppliment, which will ↓ PTH.
  4. Calcimimetics, which ↓ PTH
  5. Dialysis
40
Q

How do we treat a CKD patient presenting with volume overload?

A
  1. Diuretics
  2. Fluid restriction
  3. Dialysis
41
Q

What are the 3 types of renal replacement therapy (RRT) used to treat CKD?

A
  • 1. Hemodialysis
  • 2. Peritoneal dialysis
  • 3. Renal transplant
42
Q

*** Indications for dialysis in a CKD patient***

A

AEIOU

  1. Severe acidosis
  2. Electrolyte disturbances (usually high K+)
  3. Ingestion (ethylene glycol, methanol)
  4. Volume overload
  5. Uremia
43
Q

AKI is staged based on what 2 things?

A
  • 1. Serum creatinine

OR

  • 2. UO

Use whichever is worst

44
Q

Stages of AKI

A
  • Stage 1
    • Serum creatinine: ≥ 0.3 mg/dL increase or 1.5-1.9x baseline
    • UO: less than 0.5 mL/kg/hours for 6-12 hours
  • Stage 2
    • Serum creatinine: 2-2.9x the baseline
    • UO: less than 0.5 mL/kg/hours for ≥ 12 hours
  • Stage 3
    • Serum creatinine:
      • ≥4.0 mg/dL or 3x the baseline
      • initiation of renal replacement therapy
      • OR, eGFR less than 35 mL/minute in less than 18 years.
    • UO
      • Less than 0.5 mL/kg/hours for ≥ 24 hours
      • Anuria for ≥ 12 hours
45
Q

AKI can be caused by what 3 categories of problems?

A
  1. Prerenal
  2. Intrinsic
  3. Postrenal
46
Q

What prerenal issues can cause AKI?

A
  1. Hypotension
  2. Hypovolemia
  3. ↓ CO
  4. Systemic vasodilation seen in sepsis, SIRS, hepatorenal syndrome
47
Q

What intrinsic issues can cause AKI?

A
  1. Tubular necrosis (ischemia cause 50%, 35% due to toxins)
  2. Interstitial nephritis
  3. GN
48
Q

What post-renal issues can cause AKI?

A
  1. Obstruction of bladder
  2. Obstruction of ureter
  3. Renal pelvis necrosis or stones
49
Q

Clinical presentation of AKI is ___________, depending on ___________.

A

variable

severity

similar to CKD

50
Q

A patient with AKI may experience the same symptoms listed as CKD, as well as what other symptoms?

A
  1. Hematuria
  2. SOB, if pulmonary edema is present.
51
Q

ALL patients with AKI should receive what labs?

A
  1. UA with microscopy
  2. Urine albumin/Cr ratio or protein/Cr ratio

All other diagnostic tests are performed based on H&P.

52
Q

What are the most common diagnostic tests of acute kidney injury (AKI)?

A
  1. UA with microscopy
  2. Urine albumin/Cr ratio or protein/Cr ratio.
  3. Renal US

All other diagnostic testing is performed based on H&P.

53
Q

What diagnostic test is ran to rule out

  • hydronephrosis, look at kidney size, cortical thickness?
54
Q

What diagnostic test is ran to:

diagnose prerenal azotemia?

A
  1. BUN/Cr ratio ( >20:1)
  2. Fractional Excretion of Sodium (FeNa) less than 1%
  3. Fractional Excretion of Urea (FeUrea) less than 35%
55
Q

What diagnostic test is ran to:

diagnose ATN?

A
  1. Fractional excretion of sodium (FeNa) greater than 2%
  2. Fractional excretion of urea (FeUrea) greater than 50%
56
Q

How do we calculate Fractional excretion of Sodium (FeNa)?

A

[Urine Na+ * Serum Cr] / [Serum Na+ * Urine Cr]

57
Q

When the etiology of severe AKI is unclear, what specific diagnostic test do we run?

A

Renal biopsy

58
Q

What are complications of AKI?

A
    1. Hypervolemia d/t pulmonary edema or HF
    1. Electrolyte abnormalities (hyperkalemia, hyperphosphatemia, hypermagnesemia, hypocalcemia)
    1. Hyperuricemia
    1. Uremia
    1. Pericarditis
    1. Metabolic acidosis
    1. Bleeding (BUN >100 mg/DL)
    1. Need dialysis
59
Q

What is the main approach to treating AKI?

A

Treat underlying disease. Treatment is mainly supportive and timing is important!

  • 1. Avoid hypotension
  • 2. Stop taking nephrotoxins (ABX, NSAIDS, ACE-I/ARBS, PPI, IV constrast)
  • 3. Renal replacement, if needed (usually hemodialysis)
60
Q

Treatment of AKI depends on underlying disease.

  • - Prerenal patients
  • - Acute tubular necrosis pts
  • - Glomerulonephritis
  • - Acute interstitial nephritis
A
    • Prerenal patients: IV fluid
    • Acute tubular necrosis pts: supportive care
    • Glomerulonephritis: immunosupression or plasmaphoresis
    • Acute interstitial nephritis: discontinue offtending agent or steroid
61
Q

What is the deficintion of a nephrotic syndrome?

A
  • Proteinuria >3-3.5 grams/day
  • Hypoalbuminemia
  • Peripheral edema
  • Hyperlipidemia
  • Lipiduria
62
Q

In order for the patient to have true nephrotic syndrome, they must have BOTH _____________ and ___________.

A

Proteinuria > 3-3.5 grams/day and hypoalbuminemia

63
Q

Nephrotic range proteinuria + NL serum albumin, does the patient have nephrotic syndrome?

A

No, the patient has nephrotic range proteinuria.

64
Q

What complications can occur with nephrotic syndrome?

A
  1. Edema
    1. ↓ albumin => ↓ in plasma oncotic pressure => ↓ ECV/GFR => + RAAS => Na+ retention
  2. Increase risk of infection
    1. ↓ in IgG, which must sometimes be supplement with IVIG
  3. Increase risk of thrombosis
    1. ↑ ​loss of antithrombotic factors and ↑ levels of procoagulant factors
  4. Hyperlipidemia
    1. ↓ oncotic pressure => ↑ hepatic lipoprotein synthesis => hypercholestermia
  5. Vit. D deficiency
    1. ↓ of vit D binding protein
  6. Anemia
    1. ↓ of transferrin and EPO
65
Q

Nephrotic syndrome causes increase risk of infection, especially when _______.

A

Albumin levels are less than 2.0-2.5 g/dL.

66
Q

What are the 2 mechanisms Nephrotic Syndrome causes edema?

A
  1. Underfill theory
    1. Hypoalbuminemia => ↓ plasma oncotic pressure
  2. Overfill theory
    1. ↓ plasma oncotic pressure => + RAAS => ↑ Na+ and H20 rentention
67
Q

What is the clinical presentation of nephrotic syndrome?

A
  1. Proteinuria (>3.5 g/day) that causes foamy urine
  2. Minimal hematuria
  3. Hyperlipidemia/lipiduria
  4. New onset HTN and edema
    1. Edema can cause anasarca and SOB
  5. Pts can get renal failure (AKI vs CKD) depending on duration of glomerulonephritis
68
Q

Nephrotic syndrome DDx, what is the most common cause?

A
  • 1. Diabetic nephropathy***
  • 2. MCD (children)
  • 3. FSGS
    1. Membranous nephropathy
      * often assx with underlying cancer and/or renal vein thrombosis
  • 5. Monoclonal related diseases.
69
Q

What tests do we perform to diagnose with nephrotic syndrome? (6)

A
  1. Serum creatinine with eGFR
  2. UA with microscopy
  3. Urine albumin/Cr & protein/Cr ratio
  4. 24 hour urine total protein ocllection
  5. Glomerulonephritis serology evaluation
  6. Renal biopsy
70
Q

What is the main goal in treating Nephrotic syndrome?

A

Treating underlying etiology

71
Q

Treat the following symptoms associated with nephrotic syndrome

    1. Edema
    1. Proteinuria
    1. Hyperlipidemia
    1. Thrombosis
    1. Infection
    1. Vit D def
A
  • 1. Edema
    • Dietary Na+ restriction & diuretic
  • 2. Proteinuria
    • Lower BP, ACE-i/ARB, antiproteinuric meds (Non-DHP CCD, aldosterone ANT, renin inhibitors)
  • 3. Hyperlipidemia
    • statins
  • 4. Thrombosis
    • Heparin/warfarin
    • If serum albumin is less than 2.5 g/dL, give prophalaxis
  • 5. Infection
    • IVIG suppliment
  • 6. Vit D def
    • Vit D suppliment
72
Q

What is the definition of Nephritic syndrome?

How common is renal failure?

A
  1. Hematuria
  2. Proteinuria <3.5 grams/ day
  3. HTN

Renal failure is common

73
Q

Nephritic syndrome usually has _____________ urinary sediment, whereas nephrotic syndrome usually has _______ urinary sediment.

A

Nephritic syndrome usually has active urinary sediment, whereas nephrotic syndrome usually has bland urinary sediment.

74
Q

What is the classic presentation of a patient with Nephritic syndrome?

A
  1. New onset Hematuria
    1. Microscopic hematuria
    2. If URI, particulary with IgA nephropathy or PIGN => gross hematuria
  2. Proteinuria <3.5g/day, causing foamy urine
  3. New onset HTN
  4. AKI
75
Q

A common classical presentation of nephritic syndrome is AKI.

In severe cases, these patients may have ___________.

A
  • RPGN over days - weeks
76
Q

In nephritic syndrome, edema is ___________, comapred to nephrotic syndrome.

A

Less severe

77
Q

Differential DDx of Nephritic syndromes

A
  1. IgA nephropathy
  2. TBMD
  3. Alports
  4. MPGN
  5. Lupus
  6. Anti-GBM AB
  7. ANCA-assx vascultiits
  8. Cryoglobeimena
  9. Thrombotic microangiopathy (TMA)
  10. PIGN
  11. Endocarditis
78
Q

What is important to note about the diseases that cause that cause nephrotic or nephritic syndrome?

A
  • There is alot of overlap!
  • Not every disease that causes GN will cause nephritic or nephrotic syndrome
79
Q

What is the best way to diagnose nephrotic syndrome?

A

Same way as nephritic!

Renal biopsy is the MOST DEFINITIVE.

80
Q

Low compliment levels are very helpful in the DDx of _____ syndrome.

How so?

A

Nephritic.

  • Only a few diseases cause compliment levels to ↓.
  • ↓ C3/C4 => + of classical path
  • ↓ C3 only => + of alternative path
81
Q

Urinary pattern:

  • Renal tubular epithelial cells
  • Transitional epithelial cells
  • Granular casts, or waxy casts
A

Acute tubular necrosis (ATN)

82
Q

Urinary pattern:

  • WBC
  • WBC cast
  • Urine eosinophils
A

Acute interstitial nephritis (AIN) or pyelonephritis

83
Q

Urinary pattern:

  • Dysmorphic RBCs
  • RBC casts
A
  • Vasculitis
  • Glomerulonephritis
84
Q

Urinary pattern:

  • Nephritic vs nephrotic
A
  • Nephritic: Proteinuria (<3.5 g/day), hematuria, dysmorphic RBC and RBC casts
  • Nephrotic: Heavy Proteinuria (> 3.5g/day), lipiduria, minimal hematuria
85
Q

Urinary pattern:

  • Hyaline casts
A

Non-specific, prerenal azotemia

86
Q

Urinary pattern:

  • WBC
  • RBC
  • Bacteria

CPR Exam 3 (10 decks)

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