Final Exam Flashcards
1
Q
What are the most common causes of hyporeninemic hypoaldosteronism
A
CKD or DM; leads to RTA IV
2
Q
What are predisposing factors in women for UTI
A
Use of spermicide, frequent sex, recurrrence in post menopausal, diabetes
3
Q
What should you include in your ddx of a women with dysuria
A
Cystitis or cervicitis
4
Q
What can UTIs cause in pregnant females
A
Premature labor, low birth weight babies *untreated asymptomatic bacteriuria in pregnant female more likely to result in pyelonephritis and sepsis.
5
Q
What can cause complicated UTIs
A
- anatomical variant (ie: polycystic kidneys)
- foreign body
- extrinsic compression (tumors, profound constipation)
- immune suppression (DM, drug induced, HIV)
6
Q
What is important about the abx tx for prostatitis
A
Requires prolonged ab course (4-6wks)
7
Q
Which bacteria can cause hematogenous spread to kidneys
A
Candida, salmonella, staph aureus
8
Q
What are the 3 main complications of pyelonephritis
A
- Papillary necrosis
- Emphysematous pyelonephritis
- Xanthogranulomatous pyelonephritis
9
Q
What can cause papillary necrosis
A
Obstruction, DM, sickle cell, analgesic nephropathy
10
Q
What patients does emphysematous pyelonephritis usually occur in
A
Diabetic
11
Q
What are the causes of xanthogranulomatous pyelonephritis
A
Chronic obstruction, chronic infections
-cause suppurative destruction of renal tissue and can lead to abscess formation
12
Q
What are the features of septic shock
A
Subset of sepsis; vasopressor therapy needed to maintain arterial pressure at 65 or greater; serum lactate greater than 2 mil/L *hypotension that cannot be reversed with infusion of fluids
13
Q
What causes the tubular damage in acute ischemia
A
Endotoxins and inflammatory cytokines
14
Q
What is the initiating treatment for sepsis/septic shock
A
Volume resuscitation (IV fluids), cultures, initiate broad spectrum abx, pressors (NE, vasopressin), correct acid/base imbalance, monitor electrolytes
15
Q
What does increased BUN:Cr ratio indicate
A
Pre-renal azotemia
16
Q
What labs would you we with sepsis and ischemic AKI
A
Decreased urine concentration, FeNA <1%, minor proteinuria, hematuria, muddy brown casts on micro (sloughing of renal tubular epithelial cells)
17
Q
What are preventive strategies for UTI
A
Wipe front to back, empty bladder after sex, showers not baths, lactobacillus probiotics, cranberry products, vitamin C, increased fluid intake
18
Q
What level of albumin will show up on a dipstick
A
300 mg
19
Q
What do you do after a dipstick reveals protein
A
Quantify the protein
20
Q
When is the preferable time to test the albumin/creatinine (ACR)
A
First morning void
21
Q
What does 24 hr urine collection provide testing for
A
Protein, albumin, Cr clearance; sample to do electrophoresis to determine which types of protein
22
Q
What are the components of nephrotic syndrome
A
Nephrotic range proteinuria, hyperlipidemia, hypoalbuminemia, edema
23
Q
What tests should T2DM patients get annually
A
ACR
24
Q
How do you slow progression of proteinuria
A
ACEI and ARBs
25
What drugs can cause nephrotic syndrome
NSAIDs, Lithium, IV heroin abuse
26
What can cause hematuria in athletes
Heavy exercise; can be accompanied by proteinuria; likely related to decreased RBF; also NSAID use
*evaluation: r/o infection, rest 48-72 hrs and recheck
27
What does ibuprofen do to GFR
Decreases it
28
What does indomethacin and celecoxib do to the kidney
Decrease free water clearance
29
What can give you false positives for blood on UA
Myoglobinuria, hemoglobinuria, high alkaline pH, ascorbic acid; confirm with micro
30
What is considered negative for hematuria on micro
Less than 3 RB/hpf
31
When do you do radiogaphic evaluations on someone with kidney trauma
Only if they are hemodynamically unstable
32
What can sickle cell trait cause
Impaired urinary concentration, renal papillary necrosis, hyperfiltration leas to albuminuria, interstitial fibrosis, decrease # of nephrons (FSGN), renal medullary carcinoma (actually more of an increased risk than SCD)
33
What are the risk factors for transitional cell and bladder CA
Male, >35 yo, smoking, analgesic abuse, exposure to chemical or dyes, exposure to chemo or carcinogens, chronic UTI, chronic foreign body
34
What is US good for
Tumors >3cm, cysts and hydronephrosis; may miss urothelial cancers
35
What can cystoscopy test for
Urethral stricture, benign hyperplasia and bladder masses *requires sedation, risk of post procedural UTI
36
What does activation of RAAS do
Vasoconstriction of afferent and efferent arterioles; increases glomerular pressures (hyperfiltration), causes direct glomerular damage; activates inflammatory system and leads to interstitial and tubular fibrosis
37
What would be your plan for someone with cardiomyopathy in terms of their kidney
U/S; daily BP checks, send US for micro evaluation, BUN, Cr, Na, 24 hr urine for albumin and microalbumin/Cr ration
38
What does RBC casts or dysmorphic RBCs in the urine indicate
Glomerulonephritis
39
What diseases does gross hematuria usuallly appear in
IgA nephropathy and sickle cell
40
What can pyuria be seen in
Inflammatory glomerulonephritis or UTI
41
What is sustained proteinuria
> -2 g/24 hr; sx include edema and foamy urine
42
What is benign proteinuria
<1-2 g/24 hrs; aka functional or transient; fever, exercise, obesity, sleep apnea, emotional stress, and CHF; orthostatic proteinuria
43
What is the normal Albumin: Cr ratio
<30
44
What gene puts ppl at an increased risk for HTN nephroslcerosis
APOL1
45
What are risk factors for HTN nephrosclerosis
Smoking, male, hyper cholesterolemia , duration of HTN, low birth weight and preexisting renal injury
46
What are the signs of HTN nephrosclerosis
HTN, microhematuria, moderate proteinuria
47
What is damaged in diabetic nephropathy
- ECM; imbalance btw synthesis and degredation of ECM causes expansion of mesangium; GFR surface decreased
- Type I: glomerular, tubular, interstitial and vascular lesions progress in parallel and independent of albuminuria
- Type II: variable in progression and can develop albuminuria without change to the nephron
48
What are the change in flow seen in unilateral ureteral obstruction
- initial phase: urine backflow (increases hydrostatic pressure), increase in glomerular capillary pressure induced by afferent vasodilation which maintains GFR
- activation of RAAS; 6 hours; decrease glomerular blood flow due to vasoconstriction
- decreased luminal hydrostatic pressure and RBF; reduced GFR
49
What are the changes in flow from a bilateral ureteral obstruction
- urine backflow (same as unilateral)
| - RAAS activated; decreased RBF; but maintains GFR; ANP may play a role in maintaining GFR
50
What is the difference in salt reabsorption in Unilteral vs bilateral tubular dysfunction
Unilateral: inability to reabsorb salt (salt wasting); downregulation of receptor and enzyme activity
Bilateral: presence of volume expansion; ANP blocks effects of renin -> decreased Angio II, diuresis and natiuresis
51
What does high urinary K+ delivery to the collecting duct result in (low flow luminal state)
Hyperkalemia b/c no gradient for it to be pumped across
52
What is the pathophysiology that occurs as a result of b/l ureteral obstruction
Acute: increase in RBF, decrease in GFR, increase in prostaglandins and NO increased tubule pressure and increased reabsorption of Na, urea, and water *oliguria
Chronic: decreased RBF, decreased GFR, vasoconstrictor prostaglandins, increased RAAS; decreased concentration ability; decreased transport function *polyuria, hyperkalemia, hyperchorlemic acidosis
53
What should you always consider in someone who presents with azotemia, hyperkalemia, and metabolic acidosis
Urinary tract obstruction
54
How do you evaluate for residual volume in the bladder after voiding
US; >100 ml indicates incomplete emptying
55
What can cause neurogenic bladder
Spinal cord trauma, spinal myelomeningocele, spinal stenosis, herniated disc
56
What imaging is preferred for dx of kidney stones
CT
57
What do you do for hydronephrosis caused by pregnancy
Just monitor unless becomes symptomatic (then relieve with a stent)
58
When does postobstructive diuresis occur
After bilateral obstruction; combo of fluid overload, urea accumulation, and electrolyte imbalance; results from downregulation of sodium transporters during obstruction; ANP released in response to cardiac preload during obstruction
59
What factors can alter serum Cr
Age, sex, muscle mass, race, catabolic rate
60
What are some intrarenal causes of AKI
Glomerular injury, tubules, vascular injury (Vasculitis, rheumatologic, malignant HTN, TTP-HUS)
61
What are some exogenous nephrotoxins that can cause tubulointerstitial injury
Iodinated contrast, aminoglycosides, amphotericin B, cisplatin, PPIs, NSAIDs
62
What are some endogenous nephrotoxins that cause tubulointerstitial injury
Hemolysis, rhabdomyolysis, myeloma, intratubular crystals
63
How do you treat pre renal AKI
Remove/treat underlying cause; stop med offenders: NSAIDs, cyclosporine, ACEI/ARB
64
How do you treat post renal AKI
Drain bladder; eliminate obstruction
65
How do you treat intrinsic AKI
Improve renal perfusion; optimize CO, minimize 3rrd spacing, fluids
66
What is distinct about the pathogenesis of candida in UTI
Hematogenous route
67
What is the diagnostic gold standard for cystitis
Bacteria in the urine culture.
68
What are the 4 C’s of control of STIs
- contact tracing
- ensuring compliance
- counseling on risk reduction
- condom promotion
69
What are the sx of urethritis in men
Urethral discharge, dysuria, but no frequency
70
How can you dx an STI in males
Smear of anterior urethra
| Centrifuged sediment of first 20-30 mL of urine
71
What is a possible harmful systemic response
Two or more of:
Fever or hypothermia
Tachypnea
Leukocytosis
72
What is septic shock
Sepsis with hypotension (<90 or 40 below patients normal BP for at least. Hr despite fluid resuscitation or need for pressors
73
What are the cardiopulmonary manifestations of shock
- Ventilation perfusion mismatch, increased alveolar capillary permeability, leads to ARDS
- hypotension, normal or increased CO, decreased PVR; normal stroke volume
74
What lab findings would you see with someone in septic shock
Leukocytosis, thrombocytopenia, prolonged PT, decreased fibrinogen, HAGMA, elevated lactate, hypoalbuminemia
75
What should you give if your septic patient doesn’t respond to fluid therapy
Hydrocortisone
76
What is an important tool for dx diabetic nephropathy
Miccroalbuminuria (urin albumin: Cr >30)
77
What are detection of RBC casts specific for
Glomerulonephritis
78
What is post renal failure more common in
Ambulatory ppl vs hospitalized patients
79
What are the clinical features of pre renal azotemia
Orthostatic hypotension, tachycardia, low JVP, dry mucous membranes; high BUN:Cr (>20:1); low sodium urine (<10-20) and FeNa<1% ; renal US usually normal; UA shows hyaline and few granular casts
80
What are the lab findings of intrinsic renal azotemia
FeNa >1; urine sodium >20, urine Cr:plasma Cr >20; urine urea:plasma urea <3; low urine specific gravity; plasma BUN:Cr <10-15; muddy brown granular casts
81
What are the lab values for prerenal azotemia.
FeNa <1, urine sodium <10; urine Cr:plasma Cr >40; urine urea: plasma urea >8; plasma BUN:Cr >20; hyaline casts
82
What is the main dif in the presentation of interstitial disease vs GN
Interstitial dont normally have HTN or proteinuria (except NSAID induced interstitial nephritis)
83
What are the absolute indications for dialysis
Severe volume overload refractory to diuretic agents, severe hyperkalemia and/or acidosis, encephalopaathy and pericarditis or serositis
84
What are the complications of dialysis
Hypotension, acccelerated vascular dz, rapid loss of residual renal function, access thrombosis, access or catheter sepsis, dialysis related amyloidosis, protein energy malnutrition, hemorrhage, anaphylactic reaction, thrombocytopenia
85
What is peritoneal dialysis
Catheter that infuses dialysate solution into the abdomen; allows for transfer of solutes across peritoneal membrane
86
What does hyperfiltration result in
Sclerosis and decrease number of nephrons
87
How do you define acute renal injury/disease vs chronic kidney dz
Acute: rise in serum Cr
Chronic: GFR
88
What are the ranges for each of the stages of CKD
```
G1: >90
G2: 60-89
G3a: 45-59
G3b: 30-44
G4: 15-29
G5: <15
```
89
What are the categories for albuminuria
A1: <30
A2: 30-300
A3: >300
90
What pathologies do you see at each stage of CKD
```
Stage 1:nothing
Stage : HTN
Stage 3: increased PTH, anemia
Stage 4: hyperphosphatemia, acidosis and hyperkalemia
Stage 5: uremic syndrome
```
91
What sodium levels do you get on serum labs for CKD
Fictitious normal levels b/c of fluid overload
92
What causes the metabolic acidosis seen in CKD
Reduce ammonia production *initially Hyperchloremic metabolic acidosis but as functional worsens becomes HAGMA b/c of retain organic acids;; presence of acidosis induces protein catabolic state
93
What does uremia lead to
Accumulation of multiple toxins, loss of fluid and electrolyte homeostasis and hormone regulation, progressive increase in systemic inflammation
94
What happens to the bones in CKD
Decreased phosphate excretion from the kidney leads to stimulation of PTH and growth of parathyroid gland -> decreased D3; leads to m weakness, osteitis fibrosis cystica (high turnover bone dz - cysts w/in bones), osteomlcia (defective mineralization), adynamic bone dz (decreased rate of bone turnover w/o mineralization defect; worse in DM)
95
What is the effect of acidosis on the bone
Dissolution of bone buffers leads to bone decalcification and osteoporosis
96
What is the effect of PTH on the heart
Causes cardiac m fibrosis; elevated phosphorus/calcium complex increases vascular calcification and atherosclerosis; *tx with supplemental calcitriol to suppress PTH
97
What is the number one cause of mortality in patients with CKD
CV dz
98
What causes anemia seen in CKD
Decreased EPO; *normochromic, normocytic until late in renal failure; neocytolysis (hemolysis of youngest RBCs in circulation); bone marrow fibrosis *leads to Left ventricular hypertrophy (chronic low O2 to the kidney activates sympathetic to increase HR and stroke volume)
99
What stage of CKD displays neuromuscular problems
3; causes twitching, hiccups, cramps; *peripheral neuropathy seen in stage 4 (sensory >motor and LE>UE)
100
What are the effects of uremia on GI
uremic fetor: urine like odor on breath associated with unpleasant metallic taste
Gastritis, peptic dz, mucosal ulceration, anorexia, N/V, constipation
101
What is the effect of CKD on the endocrine system
Increased plasma insulin, decreased estrogen in women, decreased testosterone in men
102
What does CKD do to the skin
Hyperpigmentation (decreased excretion of pigments), pruritus (worse with hyperphosphatemia)
103
What is the tx for CKD
- control BP: 130/80; ACEI and ARB first line
- monitor for edema
- Na restriction, protein restriction (but monitor for malnutrition)
- avoid nephrotoxic drugs
104
When should you refer someone with CKD to nephrology
GFR <30
105
When are renal transplants considered
CKD stage 4
106
What is peritoneal dialysis
Infusion of hyperosmolar solution which creates osmotic gradient and removes low molecular weight substances (Cr, urea, potassium and albumin)
107
What considerations need to be made with peritoneal dialysis
Nutritional changes (based on needs), diabetics need additional insulin, *can cause sclerosing encapsulating peritonitis (entrap loops of bowel), infection
108
What are contraindications to renal transplant
Malignancy, active infection, significant cardiopulmonary dz
109
What percentile is normal BP for a kid
<90th percentile
110
When should BP be checked in kids
Annually if over 3; if are obese, taking meds known to increase BP, have renal dz or aortic arch obstruction or DM - at every visit
111
When should kids have their BP measured < 3 y/o
History of prematurity, congenital heart dz, recurrent UTI, renal dz, solid organ transplant, malignancy,
112
How many readings do you need to classify a kid as hypertensive
3
113
When do you refer a child to emergency care for high BP
If symptomatic or BP is >30 mm Hg above 95th percentile
114
What is usually more elevated in primary vs secondary HTN
Primary: systolic
Secondary: diastolic
115
When would you not do a further investigation for a secondary cause of HTN in a child
If >6, have a fhx of HTN, or are overweight
116
What is pulse pressure
systolic-diastolic
117
What is the highest acceptable systolic BP for kids 1-10
70 + (2 x age)
118
What is masked HTN
Normal in clinic but HTN outside
119
What is the most targeted organ abnormality seen in kids with HTN
LVH **use ECHO
120
What is the definition of hematuria
Presence of 5 or more RBCs/hpf on 3 consecutive specimens obtains in the span of a few weeks
121
When will hemoglobin be seen in urine
HUS, burns, acute nephritis, hemolysis
122
What can color the urine
Rifampin, nitrofurantoin, pyridium, sulfa drugs, beets, rhubarb, fruit juices
*in newborns, uric acid crystals
123
When is a urinalysis done in a kid
5 year old check up and part of a pre-participation physical
124
What is the difference in glomerular vs extra glomerular hematuria
- glomerular: RBC casts present, dysmorphic RBCs, proteinuria may be present, no clots, red or brown color
- extra glomerular: no RBC casts, uniform RBCs, absent proteinuria, clots may be present, red
125
What findings are seen in kids with post strep glomerulonephritis
Gross hematuria, HTN, swelling, elevated ASO titer, low serum complement
126
What can hypercalciuria cause in kids
Asymptomatic hematuria *urine Ca:Cr ration of > 0.2 is indicative of excess calcium excretion
127
What do you do with a kid who has asymptomatic hematuria and proteinuria
Refer to nephrologist
128
How can you obtain a urine sample from a child
Catheter or suprapubic aspiration
129
What is the criteria for dx of UTI
- if clean catch: presence of pyuria and at least 50,000 colonies/mL of a single organism
- if catheter: pyuria and colony
- If suprapubic aspiration any growth on culture
130
Which organisms convert nitrate to nitrite
E. coli, klebsiella, proteus, pseudomonas, enterobacter, citrobacter
131
What can you use to tx a child with a UTI
- if can tolerate PO, cephalosporin or fluoroquinolones
- if cant tolerate PO, parenteral 3rd gen cephalosporin; add ampicillin if enterococcus suspected
* length of tx: afebrile 3-4 days; febrile 10-14
132
When do you image a child’s urinary tract
- after first UTI in boys, do renal and bladder US and VCUG
- in girls, after 2nd UTI o renal and bladder US, include VCUG if anomaly’s identified or temp >39 and a pathogen other than E. coli or poor growth and HTN part o clinical presentation
133
What are the complications of renal scarring
HTN, decrease renal function, proteinuria, ESRD
134
What should be included in your PE for a child with suspected UTI
Documentation of BP, temp, ab exam, documentation of growth, CVA tenderness, external genitalia, lower back, examine for other sources of fever
135
When should the primary care pediatrician refer to a specialist for renal cases
-dilating VUR grades III-V, if obstructive uropathy present, when renal abnormalities identified, when kidney function impaired, if HTN, if bladder and bowel dysfunction refractory to primary care measures
136
How do you calculate the urine anion gap
Sodium + potassium - chloride
137
What does a negative urine anion gap indicate
Non renal cause for acidosis
138
What do you look at if the urine pH is > 5.5
Urine anion gap; if negative -> extrarenal loss of base; if positive -> look at serum K -> if decreased, Type 1 RTA; if increased -> generalized tubular defect or ureteral obstruction
139
What drugs can cause RTA I
Lithium, toluene, amphotericin
140
What does RTA type I do to NH4 levels
Decreased in urine; causes urine pH >5.5
141
What are ppl with RTA I prone to
Hypocitraturia and hypercalcuria -> nephrolithiasis, nephrocalcinosis and bone dz
142
What makes RTA IV worse
Any drug that affects RAAS, increase potassium intake and potassium sparing diuretics
143
How do you prove RTA IV
Low renin and aldosterone levels
144
Which RTA do you use the bicarbonate challenge for
II
145
What can cause RTA II
Carbonic anhydrase deficiency, fanconi, Wilson, hyperparathyroidism, vitamin D deficiency lead, drugs
146
What is a generalized tubular defect
Both H and K secretion are impaired; elevated serum K; urine pH >5.5 associated with interstitial kidney dz (SLE, sickle cell, obstructive uropathy)
147
What is the urinary pH in someone with diarrhea
Increased; hypokalemia increases renal production of NH4
148
What is chronic tubulointerstitial disease characterized by.
Isothenuria with polyuria, moderate proteinuria, Type I, II, or IV RTA; broad waxy casts, small kidneys
CAUSES: prostate obstruction, analgesics, VU reflux, lead, gout, myeloma
149
where are the deposits found in MPGN I and II
I: subendothelial
II: intramembranous
150
What kind of cancers are associated with MPGN vs membranous nephropathy
MPGN: leukemia/lymphoma
Membraneous: solid
151
What do cystine crystals look like
Hexagon shape
152
What do tyrosine crystals look like
Spiny
153
What are the complications of mucinous adenocarcinoma
Thrombotic
154
In someone who has polycystic kidneys, what needs to be done in terms of tx for pyelonephritis
Prolonged abx
155
If you have a very alkaline urine, what organism should you suspect
Proteus
156
Is irritative voiding usually a sign of cancer
No
157
What is the MOA of damage in HTN nephropathy
RAAS and hyperfiltration leading to inflammation and fibrosis
158
What ranges of GFR do you usually get NAGMA vs HAGMA in CKD
NAGMA: 40
HAGMA: 20
159
How do you calculate water deficit
.6 x body weight x (1-(140/Na))
160
How do you calculate GFR
(140-age)x weight/Pcr x 72 (x.85 for female) = RPF x .2
161
How do you calculate half life
(.693 x Vd)/Cl
162
How do you calculate clearance
Ux x V/Px
163
How do you calculate filtration fraction
GFR/eRPF
164
How do you calculate fractional excretion
Ux x Pcr/Px x Ucr
