E2 Flashcards
when can you conclude that the pt has AKI?
if sx are present for less than 3 months with GFR < 60 ml/min and/or markers of kidney damage present
what are the markers of kidney damage?
protein in urine
- abnormal urinary sediment
- abn kidney biopsy
- abn renal imaging
- electrolyte abn from tubular disorders
- hx of kidney transplantation
what does chronic kidney disease entail?
1) GFR < 60 ml/min
2) markers of kidney damage
whats the prevalence of CKD in US?
around 15% of US adults have CKD (so, 1 in 7)
- thats 37 million adults in US
what are the top CKD risk factors?
- diabetes
- hypertension
- cardiovascular disease
- acute kidney injury
- family hx of kd
what is the major etiology of CKD?
diabetes (38%) or HTN (26%)
t = 64%
what are some clinical presentations of CKD?
- edema
- HTN
- decr urine output
- foamy urine
- hematuria
- uremia (raised nitrogen levels)
- pericardial friction rub
- asterixis (hand thing)
- uremic frost (powder foot)
what are the 3 simple tests to id most CKD pts?
- eGFR (estimated)
- urine albumin-to-creatinine ratio; or urine protein-to-creatinine ratio
- urinalysis
what are the limitations of eGFR>
not reliable in acute kidney injury
in diagnosing CKD, what are the renal ultrasound findings found?
- atrophic kidneys
- cortical thinning
- incr echogenicity
- elevated resistive indices
What happens to GFR with age?
GFR declines by 1 ml/min/year after the age of 30-40
what are the majority of deaths in ESRD patients?
cardiovascular (54%)
what are the indications for dialysis?
A: severe acidosis
E: electrolyte disrubances (usually hyperK)
I: ingestion (ethylene glycols, methanol)
O: volume Overload
U: uremia
define azotemia
elevated BUN without symptoms
define uremia
elevated BUN w sx (N/V, confusion, pruritus, metallic taste in mouth, fatigue, anorexia
what tells you AKI?
KDIGO guidelines of 2012
serum creatine vs urine output
-(which is worse)-
what are the major risk factors for AKI?
old age
- proteinuria
- CKD
- HTN
- DM
- CVD
- exposures to nephrotoxins
- cardiac surgery
- fluid overload
- sepsis
what drugs are associated with AIN?
- antibiotics
- NSAIDs
- proton pump inhibitors
- can be caused by drugs, inf, or autoimm. do’s
- drugs account for >75% of all cases with antibiotics, NSAIDs and PPIs being the main culprits
what are some complications of AKI?
- development of CKD
- Progression of CKD
- ESRD
- CVD
Whwat are some common diagnostic tests
- UA with microscopy
- urine albumin/cr ratio or protein/cr ratio
- renal U/S
what kidney disease does this urinary pattern suggest?
renal rubular epithelial cells, transitional epithelial cells, granular casts, or waxy casts?
ATN
acute tubular necrosis
what kidney disease does this urinary pattern suggest?
WBC, WBC cast, or urine eosinophils?
AIN
acute intersitial nephritis or pyelonephritis
what kidney disease does this urinary pattern suggest?
dysmophic RBCs, RBC casts
vasculitis or glomerulonephritis
what kidney disease does this urinary pattern suggest?
proteinuria (<3.5 g/day), hematuria, dysmorphic RBC and RBC casts
nephritic syndrome
what kidney disease does this urinary pattern suggest?
heavy proteinurea (>3.5g/day), lipiduria, minimal hematuria
nephrotic syndrome
what kidney disease does this urinary pattern suggest?
hyaline cast
non-specific, prenatal azotemia
what kidney disease does this urinary pattern suggest?
WBCs, RBCs, bacteria
urinary tract infection
FeNa or FeUrea is only valid in which type of patients, oliguric or non-oliguric pts?
oliguric pts only (<400-500 ml/day)
what is the purpose of ordering a FeNa or FeUrea?
to differentiate prerenal azometia from intrinsic renal injury (ATN usually)
define anuria, oliguria, polyguria, numerically
a: <50 to 100 ml/day
O: <400-500 ml/day
P: >3K ml/day
what are the dietary sources of Vitamin A?
eggs, dairy products,
meat, oily salt-water fish
- dark green and yellow veggies
- tomatoes
what is the dietary source of vitamin D?
fortified milk, orange juice, cereal;
cod liver oil
swordfish, salmon, herring, trout
egg yolks, muschrooms
what is the dietary source of Vitamin E
wheat germ, sunflower seeds, almonds, peanuts, sunflower oil, avocado,
abalone, atlantic salmon, rainbow trout
sources of vit K?
green leafy vegetables
fruits
dairy products
vegetable oils and cereals
intestinal microflora
what is the source of B1
aka thiamin
- whole and enriched grains, lean pork, legumes
what is the source of vitamin B2?
riboflavin
dairy products,
meat, poultry,
wheat germ,
leafy vegetables
what is the source of B3?
aka niacin
- meats, poultry, fish,
- legumes, wheat
all foods except fat
what is the source of B6?
animal products, veggies, whole grains
what are the sources for B9?
folate
- leafy veggies (destroyed in cooking)
- fruits
- whole grain, wheat germ
- beans and nuts
what is the source for B12?
cobalamin
eggs, dairy products
liver and meats
none In plants; vegans need supplements
what is the source for vitamin C?
fruits and veggies
what are the sources for calcium?
dairy products
dark leafy veggies (collard, kale, spinach, swiss chard, turnip and mustard green)
tofu, broccoli, cauliflower, flax seed, beans and lentils
what is the source of iron?
dark leafy veggies (collards, kale)
broccoli, cauliflower
nuts, seeds, legumes (lentils and tofu), quinoa, fortified cereal (cream of wheat)
lean meat, clams, oysters, dried prunes and raisins
what aids and what inhibits absorption of iron?
vitamin C aids in non-heme iron
caclium inhibits both heme and non-heme
role of vitamin A
retinol/ retinoic acid
vision
- embryo devel; maintenance of epithelia; cell growth, prolif and diff
role of vitamin D
aka cholecalciferol; ergocalciferol
- bone metabolism
- calcium homeostasis
role of vitamin E
tocopherols
ROS scavenger (membrane antioxidant)
role of vitamin K
blood cotting factors ( II, VII, IX, X)
Role of B1
aka thiamine
- carb metabolism
- aa metabolism
role of B2
riboflavin
- oxidoreductase, FMN, FAD
Role of B3
niacin
- oxidoreductase, NAD, NADP
role of B6
pyridoxine
- carb, lipid, and aa metabolism
- synthesis of neurotransmitters, sphingolipids, and heme
role of B9
folic acid
- one-C-transfer rx
- choline synthesis of aa
- synthesis of purins and pyrimidine (thymine)
what is the role of B12
cobalamin
- heme structure, folate recycling
role of Vitamin C
ascorbic acid
- antioxidant fx
- collagen synthesis
- bile acid synthesis
- nt synthesis
role of calcium
muscle contraction, cell transport, bone metab
role of iron
hemoglobin, myoglobin and cytochromes a, b, and c
BMI ranges
obese >30
over weight 25-29.9
healthy 18-25
how do you counsel pts about food choices?
follow healhty eating pattern
- focus on variety, nutrient density and amount
- limit calories from added sugars and saturated fats and reduce sodium intake
- shift to healthier food and beverage choices
vaccine
a product that stimulates a persons immune system to produce immunity to a specific disease, protecting the person from the disease
*initiates the immunization process
vaccination
the process of getting a vaccine into the body or the act of introducing a vaccine into the body to produce immynity to a specific disease
- needle; nose
immunity
when a person is protected from getting a disease by virtue of receiving a vaccine or by previously having the disease in question
immunization
the process whereby a person is made immune or resistant to an infectious disease either by receiving a vaccine or by having the infectious disease. immunization describes the actual changes the body goes through after receving a vaccine
what is active immunization?
- antigen is administered to host to induce formation of antibodies and cell-mediated immunity
what are vaccines with sub-unit angtigens?
- includes the “parts” that best stimulate immune response
what type of vaccine are pathogens surrounded by a polysaccharide capsule and are immunogenic
conjugated vaccines
facts on live attenuated vaccines
aka version of microbe weakened in lab
- stronger mucosal immunity develops
- not if immunocompromised
- not if they have received blood products in recent past
examples of conjugate vaccines
meningococcal
pneumococcal
haemophilus flu type B
HepB
Flu
HPV
non-conjugate, inactivated or killed vaccines
HepA
Polio
rabies
live, attenuated vaccines
MMR
Varicella
rotavirus
influenza
zoster
toxoid vaccines
tetanus
diptheria
what are preventitive services?
screenings
immunizations
general health guidance
counseling to reduce risk
what is primary intervention and some examples
intervention to PREVENT disease
- vaccines, diet counseling, tobacco counseling
what is secondary intervention and examples
screening test for a disease early while pt may still be asymptomatic or before onset of diease
- BP checks
- Labs
- mammograms
what is tertiary prevention and examples
clinical intervention that prevent progression or disease or reduce complication (tx of pt condition)
- medications
- chemotherapy
when should people get check ups?
- every 3 yrs for people less than 49 yo
- every year for >50 yo
when should men and women consider colonoscopies?
50-75 yo
screening for lung cancer, female and male
low dose lung CT for ages 55-74 yr w at least 30 pack years of smoking
pap smear age
21-65
breast cancer screen
50-65 but can start as early as 40yo
CVS risk assesment
screen for diet, smoking, physical activity, HTN, dyslipemia, DM, obesity
pts aged 20+ should get screened every 3-5 years
immunization age for Td/Tdap?
HPV?
Zozster vaccine
pneumococcal vaccine
hep b
every 10 years
up to age 26
50y and older
19-64 if at incr rate; all 65+
65+
steps of Type I immediate hypersensitivity
step 1: antigen exposure
step 2: IgE cross-linking on mast cell/ basophile surfaces
step 3: histamine, leukotriene, prostaglandin, tryptase (mediators) release
step 4: symptoms of urticaria, rhinitis, wheezing, diarrhea, vomiting, hypotension, anaphylaxis within min of exposure
*may have sx return 4-8 hours after exposure
eg: pollen allergies, dust mite allergy, bee sting
how to treat type I
antihistamines
type II cytotoxic hypersensitivity
IgM or IgG ab destroys cells by:
- opsonization
- complement-mediated
- ab-dependent cell cytotoxicity
egs: ABO mismatch, grave’s dz, myasthenia gravis
tx for type II
acetylcholinesterase inhibitors; plasmapheresis
steps to Type III
step 1) antigen-ab complex formation
step 2) complexes activate complement and neutrophil infiltration of tissue
3) tissue inflammation leading to sx of fever, urticaria, generalized lymphadenoapthy, arthritis, glomerulonephritis, vasculitis
eg: SLE, RA, farmers lung
tx for Type III
supportive, avoidance of antigen
type IV cell-mediated hypersensitivity
step1: antigen exposure activates sensitized T-cells
steps2: T-cell activation leads to tissue inflammation 48-96 hours after exposure to antigen
eg: poison Ivy rash, PPD testing for TB
HIV/AIDS presentation
flu-like sx: myalgias, fever, anorexia
HIV.AIDS diagnosis
ELISA
western blot
HIV RNA viral load
aids diagnosis
CD4 < 200 cells/mm3
MS
presentation
diagnosis
tx
- demyelination disorder of CNS
vision changes, vertigo, Lhermitte’s sign (flex neck + electricity)
MRI, CSF
immunosuppressive, IV steroids, PT
psoriasis diagnosis
ausptiz sign: pinpoint bleeding after removal of scale
RA
presentation
tx
- inflm. dz affecting synovial membranes
- jt swelling, warmth, red, and decr. ROM
- morning stiffness > 1 hr
- PIP, MCP, wrist, knee ankle
tx: DMARDs, NSAIDs, steroids, PT
Stiffness difference between RA and osteoarthritis
RA: morning
Osteo: “evening” stiffness
what is the genetic component for SLE?
HLA-DR2 and -DR3
SLE presentation
- pleuritis, pericarditis, myocarditis
- oral aphthous ulcers
- arthritis
- photosensitivity
- hemolytic anemia
what makes up motivational interviewing?
- patient-centered
- goal directed
- non-confrontational
general techniques for motivational interviewing
OARS
open-ended Qs
affirmations
reflective listening
summaries
stages of change
precontemplation
contemplation
preparation
action
maintenance
describe precontemplation
pt is NOT considering change
- physicians goal: incr awareness of why they should consider change
**establish rapprt, ask permision to talk about shit, build trust, offer facts, express concern
describe contemplation
- pt is considering possibliity of making change, but still uncertain
- physicians goal: acknowledge everyone is uncomfortable w change, weigh pros and cons, reinforce pts power in making choice
describe preparation
- pt is committed to making a change in the near future but still considering what to do
- ps goals: offer advice and expertise regarding tx options, consider barriers and brainstorm steps in overcoming them, discuss whats worked in the past, encourage pt to let friends know
describe action
- pt is actively making changes
- ps goals: acknowledge difficulties, identify high-risk situations, identify new reinforcers for positive change
describe maintenance
pt has made change
ps goals: affirmation and develop plan for any regression
