CR IV MEDI Renal Flashcards
In AKI presently, what will you see in labs?
High urine osm
U[Na] < 10
FEna < 1
What must a patient be off of for 24 hours prior to obtaining urine to diagnose pre-renal AKI?
Diuretics
If muddy brown casts are seen, what type of AKI is it?
Acute tubular necrosis
What is the most common cause of acute tubular necrosis?
Ischemia from hypovolemia
What is the definition of AKI?
Abrupt decline in GFR or [Cr]>.3 increase in 48 hours
What should be removed immediately in AKI?
ACEI or ARB
Is there a drug to treat AKI? What are some corrective measures?
No drug to cure it
If volume depleted, give NaCl
If in sepsis - give NaCl and vasopressors
When should dialysis be used to treat AKI?
Last resort - If uremic, K >6.5, pulmonary edema, or metabolic acidosis
Does Cr equal GFR in older people? Why or why not?
No because it does not rise like it should due to decreased mobility and muscle mass
What three things are older people at increased risk for due to their aging kidney?
Anemia
Vit D deficiency -> fractures
Insulin clearance impairment -> susceptible to diabetes
Why are older women slightly more protected from aging kidney than men?
Due to lack of testosterone
What precedes hypertension and diabetes in obese individuals?
Renal disease
What is the most important predisposing factor for insulin resistance?
Central obesity
What is seen in presentation/pathology in kidneys of obese individuals?
Glomerulomegaly
What does thiazolidendiones do?
Improves insulin sensitivity
What are the 5 types of Cardiorenal syndrome?
Type I - Acute CHF - Acute AKI - most common
Type II - Chronic CHF -> CKD
Type III - Acute/worsening kidney -> acute cardiac
Type IV - Primary CKD -> cardiac dysfunction
Type V - systemic -> cardiac and renal dysfunction
What is the major cause of Cardiorenal syndrome?
Reduced renal perfusion
VOlume overload and venous congestion
How do you treat Cardiorenal syndrome?
Loop diuretics
ACEI/ARB
Etc.
What does hepatorenal syndrome resemble? However, what does it not respond to?
Pre-renal azotemia
However, does not respond to volume
How does portal hypertension cause renal dysfunction?
Portal hypertension -> vasodilator splanchnic -> reduced systemic VR -> constriction at kidney = decreased perfusion
What is needed for diagnosis of hepatorenal syndrome?
Cr > 1.5 or GFR <40
AND
Chronic/active liver disease
What are the two types of hepatorenal syndrome? Which is worse? What can cause one to convert to the other?
Type I - rapid renal decline, in hosp. Pts usually >90% death in 3 months
Type II - less severe, slow, life exp. > 6 months
Triggers for II to I - bacterial peritonitis, hypovolemia, NSAIDs, ACEI, ARB
What is seen in a urinalysis of a hepatorenal patient?
<500 ml urine
Na < 10 (lowest you will see!)
Serum Na also low
Is treatment for Heptorenal syndrome easy? What can be done?
Albumin and terlipressin
Antibiotic (if needed)
Paracentesis
IV steroids - if septic and renal failure
What is toxic in rhabdo? What is the most common cause? Others?
Myoglobin
Trauma
Others: spin class, propefol, quail, statin + gemfibrozil, surgery
What color will the urine be in rhabdo? What will not be found?
Urine - red-brown, NO RBC, +4 on dipstick
What is the treatment for Rhabdomyolysis? What can be used to reduce uric acid?
Aggressive saline and maintain urine flow
Allopurinol - reduce uric acid
Stop statins and fimbrates
When does Cr rise in contrast nephropathy?
1-3 days after dye use
What are two risk factors for contrast nephropathy?
Renal insufficiency
Diabetes
How can contrast induced nephropathy be prevented?
Hydration (saline before if in hospital)
When does renal function decline in Contrast nephropathy? What does it usually improve by?
Function decreased days 3-5
Returns - day 10
When does nephrogenic systemic fibrosis occur?
When gadolinium is given for and MRI in pts with kidney disease
What is the most common cause of primary tubulointerstitial nephritis?
Drug induced - long term antibiotics
What is found in the urine of someone with tubulointerstitial nephritis?
Sterile pyuria
No protein or albumin
Unable to concentrate urine
What three symptoms point you towards tubulointerstitial nephritis?
Fever, rash, eosinophilia
What is the gold standard for diagnosing someone with tubulointerstitial nephritis?
Renal biopsy
What is the treatment for tubulointerstitial nephritis?
Steroids only if caught in first 7-14 days
What must be ordered if you suspect glomerular disease?
Microalbumin
Should you get a 24 hour urine in someone with mild proteinuria? When do you treat? When do you recheck?
Mild - <1g/day - Do not get 24 hour urine
If asymptomative, reassess at 6-12 months
If protein has gone up, get biopsy
If protein has not gone up, reassess at 6-12 months
What is the most common cause of glomerular hematuria?
IgA nephropathy our Thin Basement membrane nephropathy
What are differences between nephrotic and nephritic syndrome?
Nephrotic - slow developing asymptomatic, symptoms at flare ups include edema, hyperlipidemia, hypoproteinemia. Thrombolitic disease
Nephritic - acute onset, lots of blood, Increase in BP and JVD, no edema because no time. RBC casts
What is the most common nephrotic syndrome? Nephritic?
Nephrotic - membranous nephropathy or focal segmental glomerulosclerosis
Nephritic - Cresenteric, IgA, proliferating
How does Alport syndrome differ from IgA Nephropathy?
Alport Syndrome will always have microscopic hematuria in between episodes of gross hematuria
What is the most common nephrotic syndrome in children?
Minimal change disease
What is the clinical presentation of minimal change disease?
Abrupt nephrotic
Normal Cr, low albumin
Effacement of podocytes
What is the treatment for Minimal change disease? If recurrent, what can you treat with? What do you use to reduce triglycerides?
Prednisone
Cyclosporine 1-2 years
Statins to reduce triglycerides
How does focal segment glomerulosclerosis differ from Minimal Change disease?
It does not respond to steroids
Which primary glomerulonephritis is aggressive in coming back in transplant kidneys? Which doesn’t usually come back?
Focal Segmental - aggressive in transplant kidneys
IgA glomerular nephropathy - does not usually come back in transplant kidneys
What is the most common GN leading to ESRD? What population is it more common in? What is seen clinically?
Focal Segmental Glomerulosclerosis
African Americans
Proteinuria, hematuria (>50%), renal failure (>33%), hypertensive
What is the most common primary GN in adults? Where is the autoimmune antibody deposited? How is it treated?
Membranous Nephropathy
Subepithelial deposits destroy basement membrane
Month 1,3,5 - Solumedrol for 3 days, prednisone for 27
Months 2,4,6 - Oral cyclophosphamide
What are the two types of MPGN? Which is worse? What is associated with each? What is the hallmark seen histologically?
Type I - Hep C - deposits all over
Type II - worse - C3 nephritic factor
Thickened capillary loops - “tram track”
What is the histological hallmark of rapidly progressive glomerulonephritis? What is the treatment?
Crescent formation
IV solumedrol, prednisone, cytoxan - be aggressive!
What is the most common GN in the world? What is deposited where?
IgA glomerular nephropathy
IgA in mesangium
What is seem simultaneously to IgA nephropathy? Is serum IgA helpful?
Synpharyngitic macroscopic hematuria
Serum IgA not helpful
What are three symptoms of IgA nephropathy? What are mild and progressive treated?
Hypertension, proteinuria, blood
Mild - ACEI or ARB
Moderate - ACEI or ARB and 6 month steroid
Progressive - cytotoxans
What is cANCA pathoneumonic for?
Wegner’s syndrome
What is the classic Wegner’s patient?
Older white male puking blood, cutaneous purpura
What is the treatment for Wegner’s?
Predinsone and cytoxan
Plasmaphoresis last resort
What is seen clinically/labs for Good pastures?
Circulating anti-GBM antibodies, widespread crescents, monophonic lesions
What is the treatment for Goodpastures?
Plasma exchange - to remove antibodies
Steroids - for inflammation control
Cyclophosphamide - stop formation of new antibodies
How is diabetic nephropathy diagnosed?
Persistent proteinuria > 300mg at least twice separated by 3-6 months
What are hallmarks of diabetic nephropathy?
Hypertension
Progressive proteinuria
Progressive GFR decline
What must always be requested when ordering a urinalysis and suspecting diabetic nephropathy? How often should it be screened/checked?
Microalbumin
Every 6 months
For diabetic nephropathy, what test must be done? What is used to treat if GFR > 30? GFR <30? Two additional treatments?
24 hour urine
SGLT-2 inhibitors (lower HbA1c, decrease weight and BP)
Use DPP-4 inhibitor if GFR <30
Antihypertensives and Statins
Do ACEI work prophalactically to prevent diabetic nephropathy?
No
What are family CV disease and hypertension risk factors for?
Diabetic nephropathy
Parental hypertension is a risk factor for which two things?
Diabetic nephropathy
IgA nephropathy
What is seen on labs in chronic renal failure?
Increased BUN and Cr
Uremia in advanced CKD
What is the best hemodialysis? 2nd? Third?
1st - artery to vein
2nd - graft
3rd - catheter (WORST)
What clinical manifestation of CKD is the last function to lose?
Potassium regulation
What is high in CRF that causes sexual dysfunction in men and infertility in women?
Prolactin
What is the most common cause or uremic anemia? What do you need to diagnose it?
Dysfunction of vWF
Diagnose using bleed time only! (Because platelets are still there)
What is used to treat renal osteodystrophy?
REstrict phosphate, use phosphate binders, supplement vit. D
What is the most common kidney stone?
Calcium stones
What is the gold standard for diagnosis of kidney stones? What can be used to avoid radiation?
Non-contrast helical CT - gold standard
Ultrasound
How do you treat all kidney stones?
Allow to pass - pain control, hydration, strain urine
Consult urology - lithotripsy
What is the most common metabolic abnormality causing kidney stones?
What is seen in plasma and urine?
Idiopathic hypercalciuria
Hypercalciuria w/o hypercalciuria
How do you treat hyperoxaluria?
Increased dietary Ca to decrease oxalate absorption
How do you treat hyperuricosuria stones? What population is it often seen in?
Allopurinol
Cancer pts - pre treat them with allopurinol
Which population is more susceptible to struggle stones? DO they usually pass on their own?
Women
No
What causes cysteine stones? What is used to diagnose them? What do you treat them with if hypertension is also present?
Defect in AA transport in kidney
Diagnose using Na nitroprusside test
Treat with catopril
What test is used to diagnose benign positional vertigo? What is used to treat?
Dix-Hallpike - diagnose
Epley - treat
What are the three types of syncope?
Neurally-mediated - increased parasympathetic, decreased sympathetic
Orthostatic hypotension - sympathetic should fire but they don’t
Cardiogenic - collapse and tachycardia
