Clin Med Exam 3 Flashcards
1
Q
Most common intrinsic cause
A
Acute Tubular Necrosis
2
Q
Causes of Prerenal (decreased perfusion)
A
True volume depletion Hypotension Edematous state Selective renal ischemia Drugs (NSAIDs, ACE-I)
3
Q
Intrinsic causes
A
Renal ischemia
Sepsis
Nephrotoxins
4
Q
Acute Tubular Necrosis d/t IV Contrast
A
Contrast causes tubular epith cell toxicity and Renal medulary ischemia frm vasoconstriction
Risk factors:
Pre-existing renal dz
Volume depletion
Repeated dose of contrast
5
Q
Reduction in GFR will only occur if:
A
there is a Bilateral obstruction or an issue LOW
6
Q
Obstruction most commonly d/t
A
Prostatic dz (hyperplasia or CA)
or Mets
or Neurogenic bladder
7
Q
Normal urine output
A
1-2 L /day
8
Q
Oliguric (little urine)
A
<400 mL in 1 day
9
Q
Anuric
A
<50- 100 mL in 2 day
10
Q
Muddy brown casts
A
Acute Tubular Necrosis
11
Q
FENa
A
How is kidney handling sodium? (Na)
% of filtered Na that is actually excreted in urine
12
Q
FENa <1%
A
Pre-Renal
13
Q
FENa >2%
A
Intra-renal (Acute tubule necrosis)
14
Q
FENa is NOT useful for:
A
Pts on diuretics
pts in AKI (bc serum Cr is not stable)
15
Q
When to perform Renal biopsy
A
No other explanation
Cr markedly elevated or significantly worsening quickly
Purpose: to prevent ESRD
16
Q
Contra to Renal biopsy
A
Bleeding issues Severe HTN Pyelonephritis Renal tumor Solitary native kidney
17
Q
Life threatening complications of Acute Kidney Injury
A
Volume imbalance Metabolic Acidosis Hyperkalemia, Hyperphosph Uremia HypOOOcalcemia
18
Q
Severe AKI can cause
A
Altered mental status
19
Q
First step to managing AKI
A
Correct volume status (this can improve or reverse AKI)
20
Q
Fluid challenge
A
identify Pre-renal failure
Crystalloid isotonic IVF
21
Q
Pt doesn’t respond to Fluid challenge
A
Likely Acute Tubular Necrosis or other forms of Intrinsic or Post renal
22
Q
If pt is still producing urine,
A
give diuretic
BUT should not be used for prolonged tx
23
Q
Metabolic acidosis happens in AKY why?
A
Not excreting the acid Not making bicarb Low GFR Many causes of AKI produce inc acids Diarrhea net loss of bicarb
24
Q
Tx of Metabolic Acidosis
A
Dialysis or
Bicarb administration
25
Dialyze pts with Metabolic Acidosis IF
Not producing urine (or V little)
Volume overloaded
pH <7.1
26
Bicarb can make what worse?
Volume overload
27
When to give bicarb for Metabolic Acidosis?
```
Pt is not volume overloaded
no other indication for acute dialysis
ESP IF:
diarrhea is cause
ph <7.1 and awaiting dialysis
```
28
Low Calcium
Chvostek sign (face)
Trousseaus sign (arm)
Paresthesias
Tetany
NEED IV Calcium (but don't replace too quickly)
29
If pt has no sx and Calcium is low,
correct the High phosphate with: Phosphate binders
30
Uremia
urine in the blood
31
Uremia can lead to
Pericarditis
Neuropathy
Decline in mental status
32
Uremia is more common in
CHRONIC kidney dz
33
Leading cause of kidney failure
DM and HTN
34
Those with CKD and DM are at much higher risk of also developing
Cardiovascular dz
35
CHRONIC Kidney Dz
3 OR MORE MONTHS OF:
Decreased kidney fx (GFR <60)
OR
Kidney Damage (Albuminuria ACR 30 or more, abnormal imaging, abnormal urinary sediment, hx transplant)
36
RBC casts
GLOMERULOnephritis
37
Pts "at risk" for developing CKD should be screened by:
Urine ACR
| Serum Cr to estimate GFR (eGFR)
38
Uremic syndrome
accumulation of metabolic Waste products or Uremic toxins
39
Uremic syndrome
seen w profound decrease in GFR
40
Uremic syndrome
Fatigue, anorexia, n/v, pruritus, bruising, METALLIC tase in mouth, SOB, DOE, Pericarditis, restless leg syndrome, seizure, encephalopathy
41
Secondary hyperparathyroidism
Hyper-phosphatemia, hypocalcemia, decrease in vitamin D
42
Secondary hyperparathyroidism
| PTH
High phosphorus
Low Ca2+
In an effort to raise Ca levels, we stimulate PTH
43
Meds that lower GFR
ACE-I
| NSAIDs
44
ACE-I and ARBs
dilate Efferent arteriole, decreasing glomerular pressure
45
When ACE-I and ARBs can be harmful:
Bilateral Renal Artery Stenosis
caution in Acute Kidney Injury (may see acute reduction in GFR and hyperkalemia)
46
When to refer to nephrologist
GFR <30
47
Chronic intertubulo dz of kidney
Obstructive uropathy
Reflux uropathy
Analgesic uropathy
48
Chronic tubulointerstitial
spares the glomeruli
49
Chronic tubulointerstitial dz General findings
Polyuria
Hyperkalemia
UA nonspecific- proteinuria (<2), broad waxy casts
50
Obstructive sx
PAIN, change in UOP, HTN, hematuria, inc serum Cr
51
Obstructive pathology UA
Hematuria, pyuria, bacteriuria but often bland
52
Obstructive pathology US
Detect mass, hydroureter, hydronephrosis
53
Reflux Nephropathy
the result of Vesicoureteral Reflux (VUR)
54
VUR
urine can extravasate into the interstitium--> inflammatory response--> scarring/fibrosis of kidney
55
Reflux Nephropathy
typically in young children w hx of recurrent UTI
56
Analgesic Nephropathy
long term consumption of Analgesics (often seen in those w chronic back pain)
57
Analgesic Nephropathy labs
Often no sx
Labs show elevated serum Cr
UA: hematuria, sterile pyruia, mild proteinuria
Anemia
58
Analgesic Nephropathy
| CT Scan:
Renal papillary necrosis/calcification
59
Nephrotic syndrome
Non-inflamm
Proteinuria: >3.5
"foamy" oval fat bodies
More edema than in the other
60
Proteinuria >3.5g/day
Nephrotic syndrome
61
Nephrotic synd: primary dz (3 subtypes)
Minimal change dz
Membranous nephropathy
Focal segmental glomerulosclerosis
62
Nephrotic synd: secondary dz
Diabetic nephropathy
| Amyloidosis
63
Oval fat bodies
| Lipiduria
Nephrotic synd
64
Minimal change dz (MCD)
Most common nephrotic synd in KIDS
Most idiopathic, but can be secondary following URI or Allergic rxn
65
1st line tx for Minimal change dz (primary nephrotic synd)
Prednisone
66
MCD Minimal change dz primarily affects
Podocyte
| podocyte foot process fusion
67
Membranous nephropathy
adults
peak in 40s, 50s
Primarily idiopathic, thought to be immune mediated
68
Membranous nephropathy sx
Typical of Nephrotic synd
RISK OF CLOT
69
Tx for Membranous nephropathy
Supportive, immunosupp, transplant
70
Adverse risk factors for Membranous nephropath
Male sex, older age >50YO
71
FSGS
specific pattern under microscope given this name
72
FSGS
>70% present with typical Nephrotic synd sx
73
FSGS greater risk
African American
| 3-4x more common men
74
FSGS
Damage to podocyte,
| Sclerosis
75
FSGS tx
Supportive, Immunosupp, Dz specific tx for if secondary dz
76
Poor outcome for FSGS IF
Nephrotic range proteinuria
African american
Renal insuff
77
What to order if you suspect Minimal change nephropathy
UA
| Serology
78
Diabetic Nephropathy (secondary dz)
Most common cause of ESRD in US
79
Diabetic nephropathy
usually in pts who have had DM for 10-20 yrs BUT may be present at time of dz in those with DM Type II
80
Diabetic nephropathy
Morphologic changes in kidney
inc proteins in urine
Albuminuria >300
81
Tx of Diabetic nephropathy
```
Strict glycemic control
BP control
ACE-I, ARBs
Statin therapy
Dialysis/ transplant
```
82
Renal Amyloidosis
abn shaped protein that CLUMP together, can deposit in gomerulus
83
Renal Amyloidosis screening
SPEP and UPEP
84
Renal Amyloidosis tx
Refer to nephro
| Tx underlying cause
85
SPEP and UPEP
Multiple Myeloma
86
C-ANCA and P-ANCA
GPA
87
Microalbuminurie
Early sign:
Diabetic nephropathy
Kidney damage
88
Test of choice to RULE OUT obstruction
Renal US
89
Test of choice to DIAGNOSE Kidney stone/Nephrolithiasis
CT non contrast
90
Gold standard test to DIAGNOSE Renal Vein Thrombosis (clot)
MRI
91
Renal biopsy can aid in the dx of:
```
Unexplained AKI
Nephrotic synd
Acute Nephritic synd
Mass
Assess for rejection after transplant
```
92
Cystourethrogram
Contrast injected, X Rays taken while pt is voiding "real time"
Test for VUR,
Bladder distortion
Fistula
Perforation
93
Cystoscopy (camera into bladder) used to diagnose
Interstitial Cystitis "painful bladder synd"
| Bladder tumor, tone, or scarring
94
Nephritic syndrome
| left side
Hematuria
Glomerulonephritis
Rapidly prog GN (RPGN)
95
Nephrotic syndrome
| right side
```
Asymptomatic proteinuria
Nephrotic synd (edema)
```
96
Glomerulonephritis
is INFLAMMATORY
| usually deposits of immune complexes
97
Glomerulonephritis
```
Coca colored, smoky
RBC casts
protein <3
Elevated Cr, dec GFR
Oliguria (little UOP)
HTN
```
98
RPGN
more severe GN
| CRESCENT formation
99
CRESCENT
RPGN
100
IgA Nephropathy
| "Berger"
Most common cause of primary GN in the world
Think everybody loves Bergers
101
IgA Nephropathy
Young Asains and Whites
20s-30s
1-2 DAYS AFTER URI
102
IgA Nephropathy is assoc with
Celiac
Liver cirrhosis
HIV
EBV
103
Tx for IgA if pt has persistent proteinuria >1
elevated Cr
reduced GFR or
HTN
ACE-I/ ARB
104
Post Strep GN
1-3 WEEKS after infection
| Labs: Low C3 complement, ASO titer, + strep culture
105
Tx for Post Strep GN
Supportive
| should feel better in 2 weeks
106
IgA Vasculitis/HSP
```
Tetrad:
Artralgias
Palpable purpura
Abdominal pain
Renal dz*
```
107
IgA Vasculitis/HSP
This is an immune mediated SYSTEMIC vasculitis
unique bc it has all the other system sx
108
IgA Vasculitis/HSP
Adults are at increased risk of PROGRESSIVE Renal dz
Tx: supportive
109
Anti GBM/Goodpasture
"Syndrome": GN and pulm
| "Disease": GN, pulm dz, AND anti-GBM antibodies
110
Anti GBM/Goodpasture
Peak for males: 30s
| Peak for females: 50-70s
111
Anti GBM/Goodpasture sx
classic RPGN (rapidly progressive GN, with CRESCENT)
may need dialysis
112
Anti GBM/Goodpasture pulm sx
Alevoolar hemmorhage, Hemoptysis, SOB
Tx: Plasmapharesis and Immunosupp (PRednisone and Cycloph)
113
Tx for Anti-GBM/Goodpasture
Dialysis
Plasmapharesis
Immunosupp (Prednisone and Cyclosporine)
114
Tx for IgA Nephropathy
ACE-I/ARB w the criteria
115
Tx for Post Strep and IgA Vasculitis/HSP
Supportive
116
Tx for Anti-GBM/Goodpasture
```
Plasmapharesis
Immunosupp (Prednisone and Cycloph)
```
117
SLE Nephritis
```
LUPUS
Anti-ds DNA antibodies
Non whites
Elevated Cr
Confirm w biopsy
```
118
Pauci Immune (3 subcategories)
GPA: Granulomatosis w Polyangitis
MPA: Microscopic Polyangitis
EGPA: Eisinophillic Granulomatosis w Polyangitis
119
Pauci Immune
all end in "PA" for Polyangitis
ANCA-associated
120
C-ANCA
GPA: Granulomatosis w Polyangitis
Upper AND Lower
Necrotizing granulomos
"Saddle nose", cough, SOB, nodules/infiltrate/cavitations on CXR
121
All of ANCA associated are
Classically RPGN (rapidly progressing)
122
Unique characteristic of MPA: Microscopic Polyangitis
SPARES upper resp tract
| No granuloma
123
P-ANCA associated
MPA: spares upper, no granulomas
EGPA: asthma and eisonophils
124
Tx for all 3 types of ANCA associated (very necessary! Poor prognosis w/o Tx)
GPA
MPA
EGPA
Immunosupp
- Corticosteroid
- Cytoxic agents
125
EGPA: Eisinophilic Granulomatosis w Polyangitis
"Churg Strauss"
```
Asthma and Eisinophils
3 phases:
1. Atopic, Allergic rhinitis, Asthma
2. Eisinophilic infiltrate
3. Vasculitis
```
126
Tx for Polycystic Kidney Dz
Strict BP control, low salt
TOLVAPTAN
Dialysis, Transplant, Analgesics
127
Gene for A. Dominant PKD
PKD1 or PKD2
128
Sx of PKD
HTN, pain, HEMATURIA, Hx of UTI and stones
129
Other complications of PKD
INTRAcranial aneurysm
Hepatic cysts
Valvular heart dz
130
Tx for PKD
TOLVAPTAN
131
Autosomal Recessive form of PKD
PKHD1 gene
Kidneys AND Hepatobiliary system
K and H
132
Autosomal Recessive form of PKD
Kids and infants
133
Autosomal Recessive PKF
PKHD1 gene
Kidneys and Liver-biliary
Enlarged kidneys AND Liver fibrosis
134
Severe cases of A. Recessive PKD
```
Neonates have ERD
Respiratory distress
Big kidneys
HTN
Portal HTN (liver)
Feeding diff and FTT
```
135
When can you see Autosomal PKF on Ultrasound?
after 24 weeks gestation
136
Tx of PKD
Supportive with multi-disc
137
Definitive Diagnosis of Autosomal Recessive PKF (infants and kids)
Genetic testing
Early screening: Ultrasound
138
ACUTE Kidney Injury results in
Retention of urea and nitrogenous waste
| Dysregulation of volume and electrolytes
139
Criteria for ACUTE kidney injury based on
Serum Cr OR
| Urine output
140
Sometimes Cr isn't a good measure of GFR because
Cr hasnt had time to build up
| Cr was removed by dialysis
141
What is most often used for diagnosing ACUTE kidney injury?
KDIGO
142
Dx ACUTE kidney injury
Inc in Serum Cr 0.3 or more within 48 hours
Inc in Serum Cr 1.5x baseline
Urine volume <0.5 for 6 hours
143
Huge risk for developing AKI
Hospitalized pts
| 60% of ICU pts develop AKI
144
AKI in hospital is most often d/t
Pre-Renal or
| Acute Tubular dz (Intrinsic)
145
Most common etiology of ACUTE kidney injury
Acute Tubular Necrosis (Intrinsic)
146
Rate of occurence
1. ATN (Intrinsic)
2. Pre-Renal (perfusion)
3. Obstruction least common
147
Causes of Pre-Renal (perfusion)
```
Volume depletion (n/v/d/burn)
Hypotension
Edema
Renal ischemia (also in intrinsic)
Drugs (NSAIDs, ACE-I)
```
148
Intrinsic causes
Renal ischemia (in pre-renal also)
Sepsis
Nephrotoxins
149
Risk factors of developing Acute Tubular Necrosis (ATN- Intrinsic cause)
Pre-existing Renal dz
Volume depletion
Repeated dose
150
Most common causes of Post-renal obstruction
Prostate dz
Cancer
Neuro dz
151
How can UA be helpful in diagnosing Acute Kidney Injury?
Cr
GFR
FENa (how is kidney excreting sodium)
152
Signs of ACUTE kidney injury
Muddy brown casts
| *pathognomic for ATN
153
Normal Creatine for M and F
M 0.6-1.2
| F 0.5-1.1
154
FENa is <1
Pre-Renal etiology
155
FENa is helpful in distinguishing
Pre-Renal AKI from ATN (Intrinsic)
156
Biggest reason to perform Renal imaging
Assess for Obstruction
157
Danger with obstruction, Predispose for
UTI --> Urosepsis --> Kidney failure
158
When to do Renal biopsy?
If Cr is MARKEDLY ELEVATED or
| SIG WORSENS in couple days
159
Importance of getting a Biopsy when indicated
More definitive tissue dx
Therapeutic intervention
Prevent ESRD*
160
Contra to getting Renal Biopsy
```
Bleeding diathesis
Severe HTN
Pyelonephritis
Renal tumor
One kidney
```
161
1st Step when dealing with ACUTE Kidney injury?
Volume challenge to see if it can be corrected
162
If pt meets these things, do a fluid challenge:
Clinical hx of volume depletion (vomiting/diarrhea)
Physical showing Hypovolemia (hypotension/tachy), and/or
Oliguria (little urine)
163
How much fluid to give for a fluid challenge?
1-3 L to start
If they DONT RESPOND issue is probably ATN or other Intrinsic
164
What 2 things are we looking for in Fluid Challenge?
Increase Urine output
| Increased Kidney function (Cr or GFR)
165
If a pt is volume overload but still peeing, can give DIURETICS but
not a long term solution
166
What is the MOST EFFICIENT method of volume removal?
Dialysis
167
Diuretics are
Temporizing measure
168
Recap:
| Tx of Volume overload
Diuretics (temporary)
| Dialysis
169
Tx of Metabolic Acidosis
Dialysis
| Bicarb administration
170
How to treat Metabolic Acidosis is pt is VOLUME OVERLOADED?
Dialysis
| Bicarb can make volume overload WORSE
171
When to use Dialysis to treat Metabolic Acidosis?
(it is pretty much preferred)
Not producing urine
Volume overloaded
pH <7.1
172
When to give bicarb to treat Metabolic acidosis?
Volume status is normal (not overloaded)
Acidosis d/t DIARRHEA
ph <7.1 and waiting for dialysis
173
Hyperkalemia as a result of AKI
Very few sx UNTIL YOU DIE
"it's: A F A C T"
174
Hyperkalemia as a result of AKI, Sx can include:
Impaired neuromuscular transmission
Cardiac abnormalities
```
Arrhythmia
Flaccid paralysis
Asc musc weakness
Conduction abnormality
T waves
```
175
Tx for Hyperkalemia
Insulin to drive K into cells
| Remove extra K with Dialysis
176
Hypocalcemia sx
Paresthesia
Chvostek
QT prolongation
177
Hypocalcemia tx if pt is symptomatic
IV calcium
178
Hypocalcemia tx if pt is asymtpomatic
if High Phosphorus levels are present also, 1st step is to correct Phosphorus!
179
Hypocalcemia, no symptoms, and Phosphate is >5.5
Tx with Dietary phosphate binders
180
Low ca, no symptoms, HIGH phosphate, what do we treat with?
Serum ionized Ca low: Ca Acetate or Ca Carbonate
Serum ionized Ca high: Aluminum hydroxide, Lanthanum Carbonate
181
Serum ionized Ca low
Calcium Acetate or
| Calcium Carbonate
182
Serum ioinized Ca is high
(Wierd names)
Aluminum hydroxide
Lanthanum carbonate
183
Dialysis should be given to peeps with SEVERE UREMIA "urine in the blood"
Pericarditis
Neuropathy
Unexplained AMS
184
Females usually get
Pyelonephritis (kidney) or
| Cystitis (bladder)
185
Only upper tract one
Pyelo
186
UTI Risk factors (3)
Reduced urine flow
Promotion of colonization (sex, spermicide, recent abx)
Facilitate ascent (catheter, incontinence)
187
Special populations regarding UTIs
Pregnant
Men
Comorbidities, Immunocomp, Underlying urology conditions
188
Acute SIMPLE Cystitis
confined to bladder
| No s/s suggestive of Upper urinary tract or systemic
189
Systemic sx suggestive of Acute COMPLICATED UTI
Fever
| Chills, fatigue, malaise, Flank pain, CVA tenderness, Pelvic/perineal pain in men
190
Sx of Acute SIMPLE Cystitis
Dysuria, frequency, urgency
+/- hematuria and suprapubic discomfort
191
Culture for Acute SIMPLE Cystitis?
Not recommended, unless:
- Atypical presentation/dx uncertain
- Suspect COMPLICATED
- Unresolving sx
- Suspect abx resistance
- Special pops
192
Culture results (if you ordered one) of Acute SIMPLE cystitis
>10^3 CFU = DIAGNOSTIC
193
Culture results (if you got one) of Acute SIMPLE cystitis
>10^2 in combination with Typical sx= POSITIVE culture
194
Tx of Acute SIMPLE Cystitis
Abx:
Nitrofurantoin (Macrobid)
Bactrim
Fosfomycin
195
Tx of Acute SIMPLE Cystitis in PREGNANT
Fosfomycin or Augmentin
196
Do NOT give to pregnant for Acute SIMPLE Cystitis
Fluoroquinolones
197
Tx for Acute SIMPLE Cystitis
Nitro (5 days)
Bactrim (3 days)
Fosfo (single dose)
198
Is f/u culture needed with Acute SIMPLE cystitis?
NOT IF SX RESOLVE, unless:
| You are pregnant
199
Acute Pyelonephritis
Systemic sx
Involving kidney parenchyma and Renal pelvis
Flank pain, fever, malaiaise
200
MORE labs for Pyelo suspicion
Always UA with C and S
201
Results indicating Pyelo
WBC casts
| CFU > 10^5
202
Do you order CBC and BMP for Acute Pyelo?
Not unless pt is hospitalized
203
Imaging for Acute Pyelo? Not unless:
Severely ill
Sx persist even after 48-72 hrs of Abx
Suspect Obstruction
Recurrent sx w/in few wks of tx completion
204
What imaging to order with Acute Pyelo?
CT A/P with AND without contrast
205
Tx for Mild-Moderate Acute Pyelo
Fluoroquinolones
| (Cipro or Levo) 5-7d
206
Other considerations for Acute Pyelo tx
If pathogen is susceptible to Bactrim, can do that instead
If E.Coli resistance >10%, then give initial does of Rocephin before discharging pt
207
F/u for Acute Pyelo
WITHIN 48-72 HOURS
208
Need f/u culture for Acute Pyelo?
Not unless you are pregnant
209
When is Acute Pyelo considered Severe? --> Hospitalization
Critically ill, Hemodynamically unstable, Pers high fever, Bad pain, Obstruction, Renal dysfx, Unable to eat/drink, Worried about compliance
210
Tx of Acute Pyelo for Severe/Inpatient
IV Abx
- Fluoroquinolones
- ER Cephalosporin
- ER PCN
- Carbapenem
- Aminoglycoside
+supportive
211
Primary tx for Acute Pyelo
Nitro
Bactrim
Fosfo
212
Acute pyelo things you HAVE TO ORDER
UA, C and S
213
Acute Pyelo labs
WBC Casts
| CFU >10^5
214
Acute Pyelo tx for outpatient
Fluoroquinolones
215
IC/Painful bladder synd
Abscence of infection
| >6 weeks
216
Associations with IC/Painful bladder synd
IBS
Fibromyalgia
>40 YO
217
Crazy pathophys of IC/Painful bladder syndrome
```
Glycosaminoglycan layer
Urothelial inj
Pro-inflammaotry
Mast cell
Fibrosis
Neural hypersens
Neuropathic pain
Voiding dysfx
```
218
Presentation of IC/Painful bladder synd highly VARIABLE
In men, usually:
Pelvic pain with Sexual dysfx
219
What you may see on Cytoscopy (camera) with IC/Painful bladder syndrome
Altered urothelium
- Glomerulations
- Hunner lesions
220
1st line tx for IC/Painful bladder syndrome
Behavior/lifestyle
| Pyridium OTC
221
2nd line tx for IC/Painful bladder syndrome
Oral: TCA(Amitriptyline), Pentosan Polysulfate(Elmiron), Antihistamine(Hydroxyzine)
Other: Lidocaine, PT
222
Tx for Overactive blader
1st line: Behavioral
| 2nd line: Antimuscarinics (Oxybutynin, Tolterodine, Solifenacin), Beta-agonist (Mirabegron)
