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Block 9 Week 5 > Approach to Patients with Renal disease-Patterson > Flashcards

Approach to Patients with Renal disease-Patterson Flashcards

1
Q

What are the basic functions of the kidneys?

A
  • Maintain extracellular content/volume for normal cell function
  • Excrete products of metabolism: urea, creatinine, uric acid
  • Adjust excretion of water and solutes (sodium, potassium, hydrogen ions) to match endogenous production and intake
  • Produce hormones to support blood pressure, erythropoiesis and calcium/phosphorus levels
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2
Q

patients with renal disease can present with dysfunction of (blank) to all of these functions

A

1

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3
Q

How will some kidney patients with compromised kidney function present?
How willl most?

A

SOME patients present with kidney symptoms- gross hematuria or flank pain OR extra-renal signs/symptoms- hypertension, edema or confusion

MOST patients are asymptomatic and will present with an abnormal:
Creatinine
GFR 
Urinalysis
BUN
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4
Q

What are adjunct tests to assist in eval of Kidney function?

A

Ultrasound, CT scan or Kidney Biopsy

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5
Q

(blank) is a measured or estimated value of # of total functioning nephrons

A

GFR

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6
Q

Humans roughly (blank) plasma filtered per day (125 ml/min)

A

180 L

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7
Q

Normal GFR = (blank) ml/min men and (blank) ml/min for women

A

130

120

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8
Q

You should expect a decreased in GFR in (blank) patients. How much is this decrease and what is an average GFR greater than 70 yrs of age?

A

Expect a decrease in elderly patients

0.75 ml /min per year decrease
accelerated in those with diabetes or hypertension
>70 yrs. average GFR 60 ml/ min (without HTN or diabetes)

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9
Q

What does a decreasing GFR suggest?

A

loss of nephron function OR a superimposed problem influencing filtrations

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10
Q

T or F

GFR always suggests a physical loss of nephrons

A

F

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11
Q

T or F

Possible to have progressive renal disease and normal GFR

A

T

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12
Q

How do you measure the GFR?

A

Clearance of inulin (cuz its not reabsorbed or excreted)

usually dont use this cuz its time consuming, expensive and not practical clinically in most cases

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13
Q

(blank) will tell you the baseline of kindey function as long as the muscle mass and diet stay the same.

A

Creatinine

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14
Q

(blank) can estimate the GFR

A

serum creatinine (no reabsorption or excretion by the kidneys)

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15
Q

(blank) is a product of muscle and dietary meat metabolism.

A

Creatinine

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16
Q

There is an (Blank) relationship between Serum creatinine and GFR

A

inverse

I.e the less creatinine in serum the higher the GFR

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17
Q

In patients with mild kidney disease, a small rise in serum creatinine usually reflects a (blank) in GFR, whereas a marked rise in serum creatinine in patients with advanced disease reflects a (blank) in GFR.

A

marked fall

small absolute reduction

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18
Q

A small increase in creatinine in a healthy person represents a (blank) in renal function

A

significant drop

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19
Q

What is the average serum Creatinine in men? in women? What type of people have higher serum creatining rates?
Lower serum creatinine rates/

A

1.13 mg/dl men
0.93 mg/dl women
higher- young people and blacks
lower- hispanics and elderly

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20
Q

WHat are the limitations of a serum creatinine test?

A
  • variations in creatine production (amputees and vegitarians)
  • drugs block secretion of creatinine (H2 blockers, trimethoprim, and Tenofovir)
  • Creatine assay can mistake compounds for creatinine (cefotaxime, flucytosine)
  • Increased intake of creatinine (large meat meal, supplemental creatinine)
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21
Q

What are ways you can vary creatinine production?

A

amputees and vegitarians

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22
Q

What drugs block secretion of creatinine?

A

H2 blockers
Trimethoprim
Tenefovir

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23
Q

What compounds can be mistaken for creatinine?

A

cefotaxime, flucytosine

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24
Q

What increased the intake of creatinine?

A

large meat meal and supplemental creatinine

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25
Q

Creatine clearance represents the GFR since creatinine is neither reabsorbed or metabolized by the kidney BUT (blank)% is secreted into the proximal tubules

A

10-40%

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26
Q

What are the three formulas you can use to estimate GFR? What is an easier way to find it?

A

Cockcroft-Gault equation
MDRD (modification of diet in renal disease) equation
CKD- EPI equation

Measure the CrCl with a 24 hr urine collection

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27
Q

What GFR equation should you use?

when GFR is 15-60 and normal BMI and less than 65 y/o

A

CGE

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28
Q

What GFR equation should you use?
GFR is 15-60
Normal weight
For patints with CKD

A

MDRD

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29
Q

What GFR equation should you use?
GFR>60
elderly patients

A

CKD-EPI

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30
Q

What GFR equation should you use?
Overestimates the GFR by 10-20%
Incomplete or excessive urine collection limits the accuracy
Use in pregnancy, extremes of age or weight, amputees, malnutrition

A

24 hour creatinine clearance

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31
Q

What is less accurate than SCr in estimating renal function?

A

BUN (Blood urea nitrogen)

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32
Q

What can result in an increase in BUN?

What can result in a decrease in BUN?

A

high protein diet or trauma, hemorrhage (GI Bleed) OR dehydration

Low protein diet or liver disease

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33
Q

(blank) percent of BUN is passively reabsorbed in proximal tubule

A

40-50%

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34
Q

A BUN/SCr> (blank) is suggestive of pre renal AKI

A

20:1

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35
Q

What does the fractional excretion of sodium measure?

A

percent of filtered sodium that is excreted in the urine

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36
Q

What is the equation of fractional excretion of sodium (FENa)?

A

FENa % = [Una x Scr / Ucr x Sna] x 100%

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37
Q

FENa of (blank) is suggestive of pre-renal AKI

A

less than 1%

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38
Q

An FEurea less than (blank) suggests pre-renal AKI

A

35%

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39
Q

What are other ways to get a FENa <1%?

A

Acute interstitial nephritis, myoglobinuria, contast induced nephropathy

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40
Q

What is the most essential diagnostic study when evaluating renal disease?

A

UA (often the first indicator of renal disease)

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41
Q

What are the three parts to a UA?

A

Appearance (color or clarity)
Dipstick evaluation
Microscopic analysis

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42
Q

What are you looking for in the UA appearance?

A

Color, clarity

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43
Q

What are you lookin for in the Dipstick eval of UA?

A

blood, leucocyte esterases, nitrates, pH, S.G, urobilinogen, protein, ketones and glucose, pH)

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44
Q

What are you looking for in the microscopic analysis of the UA?

A

Cells, casts, crystals, bacteria

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45
Q

Anyone with a kidney problem, look at the (blank X 3)

A

GFR, Cr, and UA

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46
Q

When doing a UA you must interpret it (blank)

A

immediately

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47
Q

When looking at a UA, what will a turbid urine suggest?

A

infection, crystals or leukocytes

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48
Q

What will a hazy urine suggest?

A

mucus

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49
Q

What will a milky urine suggest?

A

chyluria from nephrotic syndrome (severe) with dyslipidemia and oval fat bodies, profofol

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50
Q

What will a blue, black, pink urine suggest?

A

inborn erros of metabolism

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51
Q

People with retinopathy have (blank)

A

proteinuria

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52
Q

If you have nephritis what will be in the urine?

A

blood or casts

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53
Q

If you have red/brown urine what should you do to it?

A

Spin it to separate out supernantent and check the color

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54
Q

If you spin a red/brown urine and you have a clear supernatent + red sediment, what does this mean?

A

hematuria

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55
Q

What does a red supernatant indicate? How can you differentiate between the causes of this?

A

hemogloburia or myoglobinuria
-beets, rifampin, food dyes

A dipstick

56
Q

What drug turns your urine green?

A

profofol

57
Q

What is normal urine pH?

A

4.5-8.5

58
Q

In metabolic acidosis except kidneys to excrete H+ and lower the urine pH at least to (blank). If urine pH is greater than 5 in metabolic acidosis then what does the patient probably have?

A

5

renal tubular acidosis

59
Q

If you have a urine pH upwards of 7 what is the cause?

A

proteus mirabilis causing UTIs due to the urease being produced

60
Q

What is the specific gravity of a UA?

A

weight of urine compared with the weight of an equal volume of distilld water.

61
Q

What is SG used for?

A

as an estimate of the concentration of urine (urine osmolality)

62
Q

(blank) is effected by the number of particles in urine but (blank) is effected by the number and size of particles in urine.

A

Uosm

Specific gravity

63
Q

Glucose, contrast dye, protein will all increase the (blanK) but not the (blank)

A

specific gravity

Uosm

64
Q

When will you see glucose in the urine?

A

if plasma glucose is 180 mg/dl (i.e (Tmax proximal tubule reabsorption has been reached)

65
Q

When will you see ketones in the UA? What does a ketone test detect?

A

Starvation
Atkin’s diet

-acetoacetic acids (not beta-hydroxybutyric acid or actone)

66
Q

What happens if you get a false negative in DKA?

A

Check serum ketones for effect of treatment

67
Q

If you have elevated urobilinogen in the urine, then what is the cause?
What are the normal percentage of urobilinogen excreted in the urine?

A

hemolytic anemia
intestinal obstruction
2%

68
Q

What does a protein UA meausre?

A

albumin only (non albumin protein is not detected ex. immunoglobulin light chains)

69
Q

T or F

Urine protein less than 300 mg/ day is NOT detected on UA

A

T

70
Q

T or F

dilute or concentrated urine will effect the measurement of protein in UA

A

T

71
Q

If a dipstick is positive for protein what should you do?

A

Spot urine protein/creatinine ratio (practical and quick results, good correlation with 24 hr urine)
Or Check 24 hr urine protein (cumbersome and over and under collection problems)

72
Q

If you test the urine for blood and the stick causes a color change, what will a positive result mean?
How can you get false negatives?
How can you get a FP?
What do you do after you get your test results?

A

-RBCs or free hemoglobin or myoglobinuria

  • FN with vitamin C
  • FP with semen

Do a microscopic analysis for absence or presence of RBCs (ie. make sure its RBCs and not hemoglobing)

73
Q

What does leukocyte esterase in the urine indicate?

A

WBCs- lysed PMN’s and macrophages

74
Q

What are nitrites in the UA indicate?

(blank) does not produce this enzyme

A

bacteria-> e.coli produces nitrate reductase (converts nitrate to nitrite)
Enterococcus

75
Q

WBCs in urine and nitrities or LE=?

A

UTI

76
Q

WBCs in urine and negative nitrites or LE=?

A

sterile pyuria

77
Q

What is the cause of uric acid crystals in a UA?

A

acidic urine

uric acid crystals from too much uric acid-lymphoma, leukemia esp. after tx (tumor lysis syndrome)

78
Q

What is the cause of calcium phosphate in a UA?

A

seen in alkaline urine

associated with nephrolithiasis

79
Q

What is the cause of magnesium ammonium phosphate crystals (struvite)?

A

seen in alkaline urine

esp with urease producing organisms; Proteus and Klebsiella

80
Q

What can you see on microscopic analysis of the UA?

A

bacteria
yeast
RBCs

81
Q

When can you commonly see RBCs and what should you do about it?

A

-exercise, sexual intercourse, menses, UTI

Repeat it

82
Q

If you see isomorphic RBCs in an UA what does this indicate?

A

non-glomerular hematuria

83
Q

If you see dysmorphic RBCs in a UA what does this indicate?

A

glomerular hematuria

84
Q

if you see acanthocytes in urine what does this mean?

A

glomerulonephritis

85
Q

What causes neutrophils to be in the urine?

A

UTI, nephrolithiasis, glomerulonephritis, interstitial nephritis

86
Q

What stains should you use to check for eosinophils in the urine?

A

Wright’s or Hansel’s

87
Q

What are eosinophils classically linked with?

What are other times you will see eosinophils?

A

interstitial nephritis

-prostatitis, renal artheroemboli, and some glomerular nephritis

88
Q

A hansel stain is (blank) percet sensitive. It is (blank) percent specific.

A

10-90%

60-90%

89
Q

What are casts?

A

formed in the tubule lumen with organic material and mucoprotein as the cement

90
Q

What are normal casts?

A

hyaline casts (formed from hypovolemia)

91
Q

What are pathologic casts?

A

RBC casts
WBC casts
Granular casts

92
Q

What will RBC casts suggest?

A

glomerular hematuria/ glomerulonephritis

93
Q

What will WBC casts suggest?

A

Kidney inflammation, pyelonephritis

94
Q

What will granular casts suggest

A

degraded tubular protein

muddy brown sediment, Acute Tubular Necrosis

95
Q

What is acute kidny injury (AKI)?

A

rapid loss of kidney function resulting in retention of nitrogenous waste products

96
Q

When does acute kindey inury begin?

A

BEFORE loss of excretory function manifesting inreased creatinine, decreased urine output, acidosis, hyperkalemia etc.

97
Q

AKI occurs in up to (blank)% of ICU patients

A

50

98
Q

Can you recover kidney function after AKI?

A

depends

99
Q

What is the definition of AKI?

A

RIFLE: (risk, injury, failure, loss, end stage)

Modified by AKI network

100
Q

What is the serum creatine criteria for stage 1 AKI?

What is the urine output criteria for stage 1 AKI?

A

Scr increase by 1.5-2x or Scr increase by 0.3 mg/dl or more

Urine output: Less than 0.5 ml/kg/h for 6 hours

101
Q

What is the serum creatine criteria for stage 2 AKI?

What is the urine output criteria for stage 2 AKI?

A

SCr increase by 2-3X

less than 0.5 ml/kg/h for 12 h

102
Q

What is the serum creatine criteria for stage 3 AKI?

What is the urine output criteria for stage 3 AKI?

A

SCr increased by more than 3x or SCr increase 0.5 mg/dl with baseline Cr > 4 mg/dl

Less than 0.3 ml/kg/h for 24 h OR anuria for 12 h

103
Q

What percentage of AKI is pre-renal AKI and what causes this?

A 
60% 
Inadequate perfusion (not enough blood at sufficient pressure to allow filtering)
104
Q

What percentage of AKI is renal AKI and what causes this?

A

25%

Cellular damage/intrinsic (damage to the cells that make the filtering mechanism possible)

105
Q

What percentage of AKI is post-renal AKI and what causes this?

A

15%

obstruction (urine able to drain adequately- system “backed up”_

106
Q

What medications should you ask about when get a history on a patient with suspected AKI?

A 
ACEI
diuretics
chemotherapy
NSAIDS
Trimethoprim or H2 blockers
107
Q

WHat are the diagnostic tests you should order for someone with AKI?

A

SCr, Urinalysis with microscopy, BUN, Fena, Urine Osmolality and Urine sodium, renal ultrasound

108
Q

What is the underlying mechanism of Pre-renal AKI?

A
  • hypovolemia and lower BP to afferent arteriole
  • lower solute and uring flow rate through juxtaglomerular apparatus
  • renin-angiotensin system leads to reabsorbtion of sodium
  • low uring sodium, concentrated urine and decreased urine ouput
109
Q

If you have pre-renal AKI, (blank) usually results in a quick recovery

A

hydration

110
Q

What can cause decreased circulating volume that results in pre-renal AKI?

A

CHF
nephrotic syndrome
Cirrhosis

111
Q

What can cause intravascular volume depletion that results in pre-renal AKI?

A 
dehydration
vomiting
diarrhea
hemorrhage
burns
diuretics
nasogastric suction
pancreatitis
112
Q

What can cause reduced renal blood flow that results in pre-rena AKI?

A

Renal artery stenosis
Renal vein thrombosis
Ace inhibitors
NSAIDs

113
Q

What can cause severe vasodilation that results in pre-renal AKI?

A

sepsis
anesthesia
vasodilator dugs

114
Q

Why will you have an INCREASED BUN/Scr ratio in pre-renal AKI?

A

slower flow results in greater urea (BUN) reabsorption and creatinine to be secreted.

115
Q

What is the normal range of urine sodium (Una)?

In pre-renal AKI, what is the Una?

A

greater than 20 mEQ/L

less than 20

116
Q

In pre-renal AKI what is the FeNa like?

A

less than 1%

117
Q

What does the UA microscopy look like in pre-renal aki?

A

bland

118
Q

What is the underlying mechanism intrinisic (renal) AKI?

A
  • disease of small to large vessels of the kidney
  • disease of glomeruli (primary or secondary i.e nephritic or nephrotic)
  • Disease of the tubules and interstitium
119
Q

How can you tell you have intrinsic AKI due to a nephritic disease?

A

inflammatory with active urine sediment-casts, cells, dysmorphi RBCs

120
Q

How can you tell you have intrinsic AKI due to a nephrotic disease?

A

greater than 3.5 grams protein/24 hrs. Very minima cells and casts

121
Q 
In ischemic/toxin acute tubular necoris resulting in intrinisic (renal) AKI what are the following values:
Uosm?
Una?
FENa?
Microscopy?
A

Uosm >300 mosm/kg
Una >40 meq/L
FENa >2%
Microscopy muddy brown

122
Q 
In acute interstitial nephritis resulting in intrinisic (renal) AKI what are the following values:
Uosm?
Una?
FENa?
Microscopy?
A

Uosm variable
Una >40 meq/L
FENa >2%
Microscopy leucocytes (eosinophils) , erythrocytes, leucocyte casts

123
Q 
In acute glomerulonephritis resulting in intrinisic (renal) AKI what are the following values:
Uosm?
Una?
FENa?
Microscopy?
A

Uosm variable
Una variable
FENa variable
Microscopy hematuria, proteinuria, erythrocyte casts, dysmorphic erythrocytes

124
Q

What is the underlying mechanism of post-renal AKI?

A

Due to obstruction that affects both kidneys or a single kidney

125
Q

What are common obstructions that affect both kidneys or a single kidney resulting in post-renal AKI?

A
  • Nephrolithiasis
  • BPH/prostate cancer
  • Pelvic tumors
126
Q

What should you do if you have a patient with suspected post-renal AKI?

A

ultrasound of kidneys

127
Q

Post-renal AKI can present (blank) with no change in urine ouput.

A

asymptomatic

128
Q

What is the Uosm, Una, FENa, and UA and potassium levels like in post-renal AKI?

A

Uosm = variable, Una= variable, FENa= variable, UA = bland

Occasionally associated with hyperkalemia

129
Q

A patient presents with azotemia of unknown duration (eGFR <60 mL/min), what is the next step? Then what after that (regardless of kidney size)?

A

Renal ultrasound

Urinalysis

130
Q

If you have kidneys of normal size and the UA shows proteinuria and RBCs or RBC casts, what does the patient have?

A

Nephritic glomerulopathy caused by SLE, RPGN, post-streptococcal glomerulonephritis

131
Q

If you have kidneys of normal size and the UA shows proteinuria with minimal sedimentation, what does the patient have?

A

nephrotic glomerulopathy caused by DM, HIVAN, amyloid, MCD

132
Q

If you have kidneys of normal size bilaterally andyou do a UA and have minimal proteinuria with coarsely granular casts what does your patient have?

A

Acute tubular necrosis

133
Q

If you have kidneys of normal size bilaterally and you do a UA and have minimal proteinuria with pyuria what does you patient have?

A

Acute interstitial nephritis

134
Q

If you have kidneys of asymmetric size and do a UA, what will the patient have if you see pyuria?
What if you see crystalluria?
If the UA is normal?

A

pyuria- prior pyelonephritis
crystalluria-prior calculus
normal-large renal artery stenosis

135
Q

If you have kidneys of small size and your UA shows proteinuria, what does your patient have?
What if it shows minimal proteinuria?

A

chronic glomerulonephritis caused by MGN, FSGS, MPGN

Chronic nephrosclerosis-HTN

Block 9 Week 5 (5 decks)

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