GU Block 1 Cram Flashcards
Define Osmolality
Define Osmolarity
Concentration of particles/kg
Concentration of particles/L
Define Tonicity
This is related to its ?
ECF ability to move water in/out of cell via osmosis;
Osmolytes impermeable to cell membrane
Osmolarity
Define Hypotonic
Define Isotonic
Define Hypertonic
ECF has lower osmolarity than ICF, water moves into cell
ECF=ICF
ECF has higher osmolarity than ICF, water moves out of cell
What does a low FEx mean?
What does a high FEx mean?
Why is the FEx a useful tool?
Low: high renal absorption
<1%= prerenal dz- low output HF
High: low avidity, renal wasting
>2%= postrenal dz- tubular necrosis, kidney damage
Indicates if kidney’s response is appropriate to the E+ d/o
Define Ineffective Osmoles
To maintain steady state, how much mosmols/urine needs to be excreted per day?
Substances easily permeate membranes, no tonicity contribution or shifts between compartments
60 mosmols/day
Max urine osmolality= 1200
Min of 500mL/day
What stimulates the sensation of thirst
What stimulates osmoreceptors
Inc osmolality
Dec of ECF volume
Inc tonicity
Average threshold for sensation of thirst to arise is ?
What is the major stimulus for AHD release?
Osmolality is primarily determined by ?
295 mosmol/kg
Hypertonicity
Na concentration
What is the MC cause of hyponatremia in hospitalized PTs
Hyponatremia reflects excess ? to ? ratio
Hypotonic fluid administration
Excess water to Na ratio
Hyponatremia criteria starts at ? and is divided into severity at ? amounts
Isotonic hyponatremia is AKA and can be seen?
<135
Mild: 130-134
Sev: <125
Pseudohyponatremia:
Hyperlipidemia
Hyperprotieniemia
How do PTs get hypovolemic hypotonic hyponatremia
What differentiates if this is caused by renal or extra renal causes?
Volume loss replaced w/ hypotonic fluids
ADH released, retains free water
Dec osmolality to inc vascular volume
Urine Na >20= renal
Urine Na <10= extra renal
What causes Euvolemic Hypotonic Hyponatremia- SIADH
What can cause this?
ADH released d/t hyperosmolarity/dec arterial volume
Inappropriate water retention= concntrated urine >300
CNS Pulm d/o Malignancy
When is Low Solute Diet induced Euvolemic Hypotonic Hyponatremia seen?
When can Exercise Associated Hyponatremia be seen?
Pregnancy
Forced hydration in basic
What are the 4 criteria needed for SIADH Dx
What two findings my also be present
Hypotonic Hyponatremia
No HLK Dz
Normal thyroid/adrenal
Urine Na >20
Dec BUN
Hypouricemia
How is chronic hypotonic hyponatremia Tx
What is the adverse outcome of rapid Txs
4-6mEq/L/24hrs, max 6-8/24hrs
Osmotic demyelination syndrome: flaccid paralysis dysarthria dysphagia
Central Pontine Myelitis
How is hypovolemic hyponatremia Tx
How is hypotonic hypervolemic hyponatremia Tx
Isotonic fluids- corrects fluid loss, suppresses ADH
Loop diuretics
A/CKDz= dialysis
How is hypotonic euvolemic hyponatremia secondary to SIADH Tx
What is added to Tx if case is refractory?
What is used if Na <125 or mild hyponatremia w/ Sx and resistant to fluid restriction?
Fluid/offender restriction
Tx pain/nausea
Loop diuretic- Furosemide
Inc solute intake
Vasopressin 2, not w/ fluid restriction
How are PTs w/ Sx/Sev hyponatremia Tx
Since this Tx is done slowly, what is the goal of Tx?
Admit, d/c offender
100mL 3%NS over 10min
Max correction: 4-6mEq/24hr
Sx relief
When Tx hyponatremia, what finding indicates ADH secretion has stopped?
What is added to hyponatremia Tx if PT has CHF?
High urine output/hr
Vasopressin 2
How is hyponatremia Tx when seizure/coma is present
100ML 3%NS over 10-15min
Measure serum Na after each infusion, max of 3
Stop when 5mEq inc reached
KLO w/ 0.9%NS, max 8mEq in first 24hrs
Causes of HypoNa, normal osmolality
Causes of HypoNa, high osmolality
Hyperprotein
Hyperlipid
Hyperglycemia
Mannitol
Contrast agents
Causes of HypoNa, HypoVol
<10= external: GI Skin, 3rd space
> 20= renal: diuretic nephropathy mineralcorticoid deficient CSWS
Causes of HypoNa, HyperVol
Causes of HypoNa, Euvol
Cirrhosis HF AKDz NephSynd
<100: psych, low solute diet
>100: SIADH Hypothyroid glucocorticoid deficient
Variable: osmostat reset
What are the two main defenses against hypernatremia?
How to differentiate non/renal causes
Thirst, Water intake
Urine osmolality
All PTs w/ hypernatremia will have ?
These PTs are usually hypovolemic due to ? loss such a ?
Hyperosmolality
Hypotonic loss:
Renal- DI
Nonrenal: GI, Burns
Since it’s rare, what can cause hypervolemic hypernatremia
Hypernatremia d/t primary aldosteronism presents as ?
Iatrogenic in admitted PTs
Mild, ASx
What are the early signs of hypernatremia?
Hypernetremia is classified as severe when Na exceeds ?
Weak Irritable Lethargic
> 158mEq
What S/Sxs are seen during hypernatremia hyperosmolality ranges 320-330/340-450?
What will be seen on lab results in hypernatremia?
32-30: somnolence confusion
34-50: coma arrest death
Urine osmolality >400
Hypernatremia w/ dilute urine, <250, is characteristic of ? Dx
What are some etiolgies of this Dx?
DI
Central- inadequate release
Nephrogenic- insensitivity
Demeclocycine Interstitial nephritis Obstruction relief
Lithium HyperCa, HypoK
What can happen if hypernatremia is not Tx slowly w/ fluid/E+ replacement?
Cerebral edema
Neuro impairment
What is the fluid of choice for Tx HyperNa/Hypovol
How is HyperNa/Euvol Tx
How is hyperNa/Hypervol Tx
Isotonic
PO Water or IV 5% Dextrose
5% dextrose
Loop diuretics
What extra calculation is done when Tx hyperNa
What fluids are used for Tx this calculation
Free Water Deficit
M: 50%
F: 40%
Acute: 5% Dextrose then .45% NS w/ Dextrose
Chronic: Restore to 140, max 10mEq/day w/ PO water/IV 5% dextrose
Free water deficit equation
What fluids are used after completing calculations
TBW * Na-140/140
0.9% NS or LR
HypoK starts at ? level
Severe deficiency can lead to ?
What is used to differentiate non/renal causes
<3.5
Arrhythmia Rhabdo
TTKD
Transtubular Potassium Concentration Gradient
What is the MC cause of hypokalemia
Hypokalemia + acidosis suggests ?
GI loss from infectious diarrhea
Profound depletion
The use of ? two meds in presence of hypokalemia increase risk for arrhythmias?
Hypokalemia places ? cardiac PTs at risk for adverse outcomes
B-2 agonists
Diuretics
Digoxin use- Digitalis toxicity
S/Sx of mild/mod hypokalemia
S/Sx of sev <2.5
Weak Fatigue Cramps
Hyporeflexia Paralysis Tetany
If PT has hypokalemia and HTN, what needs to be a DDx
What renal manifestations can develop too?
Aldosterone/corticoid excess
DI
Interstitial nephritis
What would be seen on lab results when working up hypokalemia?
TTK gradient >4 suggests ?
Urine K <20- V/D
Urine K >40- corticoid excess
Renal K loss w/ inc distal K secretion
What is seen on EKG during hypokalemia
How is hypokalemia Tx
Dec amplitude
Broad T/Prominent U
PVCs
Depressed ST segments
Mild/Mod- PO K easiest
Sev- IV K, or if intolerant
No glucose, check Mg
How to differentiate K leak from blood cells and true HyperK
What is the ratio of pH/K shifts?
Serum levels
Serum K inc 0.7 / 0.1 pH dec
What is seen on EKG during hyperkalemia
What meds need to be Rx w/ caution d/t risk for hyperkalemia?
Brady
Wide PR/WRS
Peaked T
Biphasic QRS-T complex
ACEI/ARB Sprionolactone
Eplerenone Triamterene
HypoCa is usually mistaken as a ?
What are 3 issues that can cause this deficiency
Neuro d/o
Dec PTH, Vit D, Mg
True cases of HypoCa implies insufficient actions of ?
What is the MC cause of HypoCa
PTH or Vit D
Adv CKDz causing decreased active Vit D3
Hyperphosphatemia
What would be seen on lab results of suspected HypoCa
How is Sx/Sev HypoCa Tx
How is ASx HypoCa Tx
Phosphate:
Inc= hyperparathyroid ACKDz
Dec= early CKD/Vit D deficient
Serum Mg low
IV Ca gluconate
Monitor serum q4-6hrs
PO Ca Mg Vit D
MC cause of HyperCa
What lab finding may be seen prior to onset of HyperCa
Primary hyperparathyroid
Malignancy
Hypercalcuira
ASs/Mild hypercalcemia is ? level
This is usually due to ?
Sx/Sev hypercalcemia starts at ? and is usually due to ?
> 10.5mg
Primary hyperparathyroid- MC cause in ambulatory PTs
> 14mg
Malignancy
Chronic hypercalcemia or manifestations such as nephrolithiasis suggest ?
What is the MC cause of hypercalcemia in InPTs
Benign courses
Tumor production of PTH proteins, MC paraneoplastic endocrine syndrome
How do granulomas Dzs like sarcoidosis or TB cause hypercalcemia
Define Milk-Alkali Syndrome
Over production of Vit D3
Ca ingestion from milk to prevent osteoporosis causes AKI from constriction
Sxs from hypercalcemia don’t usually start until ? level
What Sxs are seen
> 12mg
Consipation N/V
Anorexia PUD
What may be seen for clinical findings that indicate etiologies of HyperCa
Hyperparathyroid- High Cl, low PO4
Milk Synd- low Cl, high HCO3 BUN and creatinine
Milk alkali syndrome can be AKA ?
What is the difference between hyperthyroidsim and malignancy induced HyperCa
Hypocalciuric hypercalcemia
Hyper- inc PTH
Malig- dec PTH, inc PTHrP
How is HyperCa Tx
If PT is hypovolemic w/ HyperCa, what Dx is possible
Bisphosphonates-TxOC, bridge w/ Cacitonin
Promote calciuresis w/ hydration
Nephrogenic DI- Tx w/ 0.9% NS 250-500/hr
Kidney is the most important regulator of ? component in serum
Where/what does PTH do
Phosphate
Dec reabsorption of phosphate in Prox tube , Vit D inc reabsorption
If suspected HypoPhos, what lab order is placed?
What are the levels for mod/sev hypophos?
Where is sev hypophos commonly seen?
Fasting serum
Mod: 1-2.4
Sev: <1
Alcoholics
What are S/Sxs of acute/severe <1mg hypophos?
What are the S/Sxs of chronic/sev hypophos?
Parasthesia
Encephalopathy
Anemia
Rhabdo
Pain Anorexia Fxs
What is a normal kidney response to hyophos and is used for lab findings?
How is HypoPhos in PTs w/ DKA Tx
24hr collection
Dec phos excretion to less than 100mg/day
Dietary intakes
How is mild/chronic HypoPhos Tx
How is sev/Sx HypoPhos Tx
PO intake
Chronic- Na + KPO4 mixute
IV infusions
What are c/is to conducting phosphate infusions to Tx HypoPhos
What is the MC cause of HyperPhos
Hypoparathyroid
Adv CKDz
Tissue damage/necrosis
HyperCa
Adv KDz w/ dec urinary excretion
How is HyperPhos Tx
HypoMg presents as ? Sxs and impairs release of ?
Absorb dietary phosphate w/ PO binders- Ca carbonate/acetate
+KDz- dialysis
Neuro Sxs, Arrhythmias
PTH release
What are possible etiologies of HypoMg
What co-existing issues will be seen
Diuretics Diarrhes Alcoholism Aminoglycosides Amphotericin
End organ resistance to PTH and low Vit D levels, refractory HypoCa to Tx
What are S/Sxs of HypoMg
How is chronic HypoMg Tx
How is Sx HypoMg Tx
Tremor Babinski HTN/Tachy
Mg oxide 250-500 PO daily
IV Mg Sulfate in Dextrose/NS
IM Mg Sulfate
Torsades- 2g IV Mg Sulfate w/ 5% Dextrose over 15min
HyperMg is almost always due to?
What are two common exogenous sources of Mg
Adv KDz and impaired excretion
Antacids
Laxatives
What would be seen on PE of HyperMg
What would be seen on lab results?
What would be seen on EKG?
Dec DTR Confusion Weakness
Inc BUN Creatinine K PO4 and Uric acid
Low Ca
Inc PR
Broad QRS
How is HyperMg Tx
78 y/o PT in ER for AMS after placed on gabapentin for diabetic neuropathy. +4 pitting edema, nausea, PO fluid tolerant. What E+ is imbalanced?
IV Ca Cl 500mg at 100mg/min
Dialysis
HypoNa
Assessing PTs acid-base balance requires measuring ? 3 things
Blood gas analyzers measure ? two
Arterial pH
Pco2
Plasma BiCarb
pH
Pco2
Arterial and venous blood gases will not be equivalent during ?
Which ones should be used during this time?
Cardiopulmonary arrest
Arterial- most accurate method for obtaining pH/Pco2
For this class, what are the acidic baselines?
Define a Simple Acid-Base d/o
Acidic: pH <7.4 Pco2 >40
HCO3 <24
One respiratory/metabolic d/o w/ appropriate compensatory response
What are the 5 steps to analyze an acid-base d/o
What is the Anion Gap formula
Determine d/o Determine if mixed d/o Calculate anion gap Calculate corrected HCO3 Examine PT
Gap= Na - (HCO3 + Cl)
If an anion gap is larger than 20mEqs, what does it suggest?
What is this?
Primary metabolic a-b d/o regardless of pH/serum BiCarb levels
Abnormal anion gap is never a compensatory response to respiratory d/o
In an increased anion gap acidosis, there is a mole-to-mole dec of ? as the gap decreases
Compensatory responses will never allow the system to be ?
HCO3
Back to normal, only close
What 3 etiologies produce the largest metabolic acidosis anion gaps?
What are the two etiologies of a normal anion gap acidosis?
What lab result is used to distinguish?
Lactic acidosis
Ketoacidosis
Toxins
GI BiCarb loss
Renal Tubular Acidosis
Urinary anion gap
What is the ratio between albumin and anion gaps?
What 4 factors can make anion gap calculations difficult
2 mEq dec of gap= 1g albumin decline
Hypoalbuminemia
Hyper/onatremia
ABX- carbenicillin, unmeasured anion; polymyxin, unmeasured cation
Toxins
What type of anion gap discrepancy does uremia create?
What are the 4 principle causes of metabolic acidosis?
What consequence/alternate metabolic state may develop during DKA Tx
Inc anion gap metabolic acidosis
Ketoacidosis RF Ingested toxins Lactic acidosis
Hyperchloremic non-anion gap acidosis
NS causes Cl retention, restoration of GFR and ketoaciduria
When would a PT be seen with a severe form of metabolic acidosis but a small gap?
What are better markers of PT improvement?
DKA + normal kidneys
Clinical status
pH
What does an alcoholic ketoacidosis gap look like?
What are the 3 types of metabolic acidosis seen on alcoholics?
Dec HCO3, most have normal/alkaline pH
Ketoacidosis
Lactic acidosis
Hyperchloremic acidosis from BiCarb loss in urine
What causes metabolic alkalosis?
What type of metabolic issue develops during alcohol withdrawal, pain, sepsis or liver dz?
Volume contraction
Vomit
Respiratory alkalosis
What supports a Dx of alcoholic ketoacidosis
What type of toxin can present with a normal anion gap acidosis?
No Hx of diabetes
Normoglycemic after therapy
Toluene
What type of poisoning presents w/ an increase osmolar gap but normal anion gap?
How is uremic acidosis acquired?
Isopropanol
Dec GFR <30 reduces kidneys ability to synthesize NH3, reduce excretion of H+ inc anion gap metabolic acidosis
What are two major causes of normal anion gap acidosis
What lab result is used to differentiate between the two?
GI BiCarb loss
Renal tubular acidosis
Urine anion gap
What criteria defines Renal Tubular Acidosis
What is the defect with this condition?
Hyperchloremic acidosis
Normal anion gap
Normal GFR w/out diarrhea
Dec H+ excretion
Dec generation/absorption of HCO3
PTs can develop ? issue in response to RTA Type I
What two issues are seen as a result of the chronic dec Ca reabsorption in RTA type 1?
What causes type I?
Hyperaldosteronism
Nephrocalcinosis
Nephrolithiasis
Paraprotienemias
Autoimmune
Amphterecin
Define RTA Type II
What results due to this issue?
What can cause this?
Proximal RTA
Prox tube can’t absorb BiCarb
Bicarbonaturia
Metabolic acidosis
Plasma myeloma
Acetazolamide
Nephrotoxic drugs
Carbonic anhydrase inhibitors-
Type II RTA can exist w/ ? genetic d/o
RTA Type 1 Distal
RTA Type 2 Prox
RTA Type 4 Hypo Hypo
Fanconi Syndrome
Hyporeninemic Hypoaldosteroniemic- MC in clinical practice
Stone U-ph Clhyper K+ Bicarb
1 Y >5.5 Y L <10, + urine gap
2 N <5.5 Y L 12-20
4 N <5.5 Y H >17
What is the defect in RTA Type IV
What two issues are frequently present
Aldosterone deficiency impairs distal nephron Na absorption/K,H secretion
Renal salt wasting
HyperK*
What are common causes of RTA Type 4
What drugs need to be avoided to prevent exacerbating HyperK
Tubulointerstitial renal Dz
HTN nephroscleoriss
AIDS
Diabetic nephropathy
Spironolactone
ACEI/ARBs
NSAIDS
Inc renal NH4Cl causes kidney to respond w/ an attempt to ?
What is a normal NH4Cl excretion amount in response to acidosis
Inc H+ removal
30-200/day
What is the benefit of the urinary anion gap
How does the urinary anion gap change depending on the etiology
Differentiate GI/Renal cause of hyperchloremic acidosis
GI loss= normal renal acid, neg urine anion gap
D-RTA= + anion gap
P-RTA= - anion gap
what is an important clinical finding in metabolic acidosis
Define Kussmaul respirations
What will lab results show in metabolic acidosis
Hyperventilation
Deep regular sighing respirations in sev met acid
Dec pH, BiCarb, Pco2
HyperCl= normal gap
NormoCl= inc gap
Possible HyperK
How is alcoholic ketoacidosis Tx
What is the Triad for an adverse issue of Tx
Thaimine w/ glucose to avoid Wernicke Encephalopathy
Ataxia
Opthalmoplegia
AMS
How is normal gap acidosis Tx
What can be added to Tx reduce amounts but with caution
Alkali- BiCarb or Citrate
Prox-RTA- NaK mixture
TZDs, possible hypoK
When do metabolic acidosis PTs need to be referred?
What is used to differentiate between saline-responsive alkalosis from saline-unresponsive alkalosis
PTs w/ tubular necrosis
Urine Cl concentrations
Define Initiation Factors
Define Maintenance Factors
Abnormalities generating BiCarb
Abnormalities promoting conservation of BiCarb
Saline responsive alkalosis is a sign of ?
Saline unresponsiveness is a sign of ?
Extra cellular volume contraction
Excessive BiCarb w/ Eu/Hypervolemia
Compensatory Pco2 values can rarely exceed ?
Saline Responsive Metabolic Alkalosis
55mmHg
MC than unresponsive
Normotensive EC volume contraction and HypoK
Inc Na absorbtion= inc Bicarb synthesis but urine remains acidic w/ inc Cl
Correct w/ KCl
Saline Unresponsiveness Alkalosis
Hyperaldosteronism- causes EC volume expasion and HTN due to retained Na
Aldosterone promotes H/K excretion
Inc urine NaCl to decrease volume
Therapy w/ NaCL
What lab result differentiates Saline Responsive and Unresponsive Alkalosis
What is seen on lab results in metabolic alkalosis
Responsive- Cl <25
Unresponsive- >40
Inc pH, BiCarb, PCO2, anion gap
Dec Cl K
Metabolic alkalosis only needs Tx when pH reaches ?
How are they Tx
> 7.60
Responsive-HIPPA
Unresponsive- PASS
Metabolic alkalosis in primary aldosteronism can only be Tx w/ ?
How does respiratory acidosis develop?
K repletion
Hypoventilation
Hypercapnia
What happens if chronic respiratory acidosis is Tx too quickly
What PE finding may be seen during respiratory acidosis
Posthypercapnic metabolic alkalosis until kidneys excretes BiCarb
Papilledema
If respiratory acidosis is chronic, what other lab finding may be seen?
What does the A-a gradient tell?
All respiratory acidosis is Tx w/ ? goal
Hypochloremia
Wide= acidosis Normal= non-pulm etiology
Improve ventilation
How does respiratory alkalosis develop?
What is the MC cause
This can also naturally develop during ?
Hyperventilation dec PCO2, inc serum pH
Septic
Anxiety*
Cirrhosis
Pregnancy d/t Progerstone
Why does tetany develop during respiratory alkalosis
What happens if chronic respiratory alkalosis is corrected too quickly?
Low ionized Ca, severe alkalosis inc Ca binding to albumin
Metabolic acidosis
Define Fanconi Syndrome
Respiratory acidosis PCO2
Respiratory alkalosis PCO2
Metabolic acidosis HCO3
Metabolic alkalosis HCO3
Dysfunction Prox Tubules= impaired BiCarb absorption leading to RTA
Acid: <38
Alk: >42
Acid: <24
Alk: >28
Acid Base can be determined by ordering what two tests?
Define Winter’s Formula
ABG and Chem-7 (HCO3, Na, Cl)
PCO2= 1.5 (HCO3) +8 +/-2
Where are casts developed?
If protein is present in UA, ? is the cause
Define Acanthocytes
Distal tubule/CD
Glomerular Dz
Scrunched RBCs from squeezing between basement membrane
How does glomerulonephritis present
How does Nephrotic Syndrome present
How does ATN present
Protein/Hematuria
Acanthocytes
Casts
Heavy protein
Lipiduria
Pigmented granular casts (muddy brown) and epithelial cells
How does pyelonephritis present
How does Eosinophiluria present
How does UTIs present
WBCs casts and protienuria
Wright/Hansel stains
Pyuria alone, possible hematuria
What is the best type of UA sample
Inc in urobilinogen suggests ? issues
Clean catch mid stream w/in 1st morning void
Hemolysis
Hepatocellular Dz
Hepatitis/cirrhosis
How is hematuria Dz?
Since is transient hematuria, when is it not an issue?
> 3 RBCs w/ high power field on 2 occasions across 1wk
PTs >40y/o, low malignancy concerns
What is the first sign of renal Dz seen on UA?
What test is the most sensitive and what is it detecting?
This test won’t detect ? type of proteins
Proteinuria
Dipstick, albumin
Bence-Jones- overload proteinuria, excess plasma protein production
After protein is detected in urine, how is a definitive examination conducted?
24hr collection of proteinuria w/ more than ? mg of protein is considered abnormal
What is the nephrotic range for proteinuria
Eval of daily urine protein excretion
> 150mg
> 3-3.5g
What are the different etiologies of proteinuria
Glomerular- damaged podocytes
Tubular- faulty reabsorbtion (Wilson Dz, Fanconi)
Functional- orthostatic, benign usually in Peds PTs
Overload- overproduction of plasma proteins
UA w/ leukocyte esterase can indicate ?
What can make false positives?
What can cause false negatives?
End product from neutrophils=
Infection/Inflammation
Contamination from squamous/vaginal cells
Glycosuria
Concentrated urine
Drugs
How does nitrite get in urine?
This indicates ? Dx
What is the best sample for this?
Gram neg (E Coli) reduce nitrate to trite
Pos bacterial infection
False pos by hematuria
1st morning void
Squamous cells in UA+ ?
Transitional/urothelial cells in UA = ?
Contamination, repeat test
Possible neoplasm, confirm w/ cytology
Renal tubular cells indicate ? Dx
Where does urea come from, what is it a marker for and what is it inversely related to?
Dx ATN
Protein catabolism
BUN= serum urea level
Inverse to GFR
What do different shapes of RBCs mean:
Roundnormal
Dysmorphic
Crenated
Cell Ghosts
Round: dz in epithelial tract
Dysm: nephritic syndrome
Cren: concentrated urine
Cell: swollen RBCs due to diluted urine
Any/all= further work ups
What is the Dx criteria for pyuria, which is a ?
What do the presence of neutrophil or Eosinophils mean
> 5 leukocytes per high field
UT injury
Neut: bacterial infection
Eo: allergic interstitial nephritis
What is indicative of a TB infection seen on UA?
Casts are the precipitation of ? and they make ?
Sterile pyuria- WBCs but neg culture
Tamm Horsefall mucoproteins, organic matrix
Presence of casts suggests ?
Red cell casts are indicative of ? and the hallmark of ?
Renal Parenchymal Dz
Parenchymal bleeding
Glomerulonephritis
Renal tubular epithelial cell casts are characteristically seen in ?
What are white cell casts characteristic of?
White cell casts can be used to distinguish ?
Acute tubular necrosis
Acute pyelonephritis, can be seen in acute interstitial nephritis
Kidney or lower GI issue
White cell casts seen in acute pyelonephritis may also be seen in ?
Granular casts are AKA and represent ?
What do waxy casts represent
AIN w/ eosinophils
Muddy brown
Degenerating cells of various origins, may be ATN*
End stage disintegration of casts, severe urine stasis
Frequent in chronic renal failure
When are broad casts seen?
When are fatty casts seen?
Tubules dilated/atrophic due to chronic parenchymal dz
Indicates severe urine stasis
Suggests end stage renal dz
Nephrotic syndrome (lipiduria)
What type of case is non-specific
What are they associated w/
Hyaline cast
Concentrated urine
Fever Exercise Diuretics
Struvite crystals are associated w/ ?
What is the MC yeast seen in urine
Infection stones- organisms like Proteus, Klebsiella
C Albicans, characteristic buds/hyphae
When are urine cultures ordered?
What finding is Dx
Suspected UTI/pyelonephritis
100K CFUs
UA is AKA ?
What are the 3 parts of a UA
Define Azotemia
Poor man’s renal biopsy
Appearance
Chemical test
Microscopic exam
Elevated BUN and SrCr
What can cause pre-renal azotemia
What can cause post-renal azotemia
What can cause intrinsic azotemia
Hemorhage Dehydration Burn Shock CHF
Recurrent UTIs BPH Nephrolithiasis Hydrnephrosis
Toxin Inflammation Drugs Infection
When is BUN inc but is not an indicator of ?
What can cause dec BUN?
RF Obstruction Dehydration
Dec perfusion
Not indicator of dec GFR
SIADH Malnutrition Liver Dz
Since BUN/SrCr ratio is usually 10:1, what does a ratio >20:1 indicates ?
When would a ratio be decreased?
What is a normal SCr range
Pre/Post renal azotemia
Intrinsic renal dz
0.5-1.2mg
Creatinine clearance is a usual way to estimate ?
When is a SrCr Inc or dec
GFR- 90-120mL/min
Inc: failure obstruction mass/meat intake
Dec: Dec mass Methyldopa Vegetarian
What controls the surface area of glomerular cells?
What does GFR indicate
Mesangial cells
Kidney function at glomerulus level, ability to filter
Most important parameter for renal function
When are FEx of Na used ?
When is this most accurate
Suspected acute renal failure
<1%= dec perfusion/dehydraion
>1%= intrinsic renal dz
Oliguric, <400mL/day
Gross hematuria in adults is ? until proven otherwise
Define Initial Hematuria and cause
Malignancy
Blood at beginning of stream, anterior urethra source, urethritis/stricture
Define Terminal Hematuria and cause
Define Total Hematuria and cause
Blood at end of stream, prostate/bladder neck, polyp/vesicle tumor
Blood throughout, bladder or upper tract, stone, tumor, TB, nephritic
What is the reflex test done after post dipstick UA for blood
Urine microscopy
Define Pseudohematuria
What can cause Hgburia
What can cause Myoglobinuria
Pos dipstick neg culture- beets, pigments, food colors
Black urine- hemolysis anemia malaria
Rhabdo Trauma Shocks ATN
What drugs can cause pseudohematuria
Pyridium* Sulfameth Nitro Rifampin Ibuprofen Phenytoin Levodopa
Older PT w/ smoking Hx, presenting w/ painless hematuria= ?
Criteria for proteinuria Dx
Dipsticks turn pos when ? amount is present
Bladder Ca until proven otherwise
> 150mg/24hrs
> 300mg/day
Criteria for nephrotic proteinuria
When is low amounts of albuminuria, not detectable by dipstick, clinically important?
> 3.5g/day
DM- hallmark of diabetic nephropathy, reqs annual screening
Microalbuminuria is a RF for ?
Sequence to eval proteinuria
What is the gold standard test for quantifying protein levels
CV Dz
Pos dipstick
Rpt w/ first morning void, not after exercise
24hr collection, <150mg/day
What urine sample is more sensitive for DM proteinuria
What sample is better for monitoring established proteinuria
Urinary Albumin Cr Ratio
Urinary Protein Cr Ration
What is the goal for proteinuria Tx
How is it Tx
<0.5g/day
ACEI/ARB, dec protein more important than dec HTN
BP needs to be below ? prior to kidney biopsy
Kidney size less than ? is likely irreversible
Size difference of more than ? indicates unilateral Dz
<160/90
<9cm
> 1.5cm
What is the best first choice for IDing various degrees hydronephrosis
What are the c/i to doing this ID test
US
Can’t lay down
What US probe would be used for prostate biopsy
Renal CT is the MC used eval of ?
Transrectal
Flank pain Stagin renal neoplasm Hematuria Infxn Trauma
What image is used to ID renal stones and test of choice for Dx nephrolithiasis
When does contrast need to be avoided
Non contrast helical CT
Calcifications
Hemorrhage
Urine extravasation
What image is preferred for viewing Upper GU tracts
Intravenous Pyelogram is AKA
When is this image c/i
CTU- combo IVP and CT
Intravenous Urogram
ARF CKD MMyeloma
When would an IVP be ordered
This is a good test for Dx ?
Pelvicaliceal system
Renal size
Renal stones
Sponge kidney
Papillary necrosis
Hydronephrosis
When is an MRI used
When is gadolinium c/i
RVThrombosis Dx/Stage carcinoma Cysts C/i contrast Adrenals
CKD stage 4/5
Transplant- risk of systemic fibrosis
What imaging is used in Dx renovascular HTN due to stenosis
What image is used and BEST for Dx renal vein thrombosis
CT angiogram
Venography
? image has nearly the best quality for Dx renal artery stenosis
Prior to IVP, PT SrCr must be below ?
MRA
Renal arteriogram- gold standard
<2mg
What are the indications to do a RUG
When is a VCUG done?
Inability to void
Blood at meatus
Perineal ecchymosis
High riding prostate
Detecting urinary vesicoureteral reflux in Peds w/ 3/4 hydronephrosis or
Any Peds w/ ureteral dilation
Define Azotemia
What is the consequence of this issue?
Abnormal high level of nitrogen waste- urea, creatinine
Uremia
What are the essentials of Dx fo AKI
What are the 3 categories
Rapid inc SrCr >0.3mg/48hrs or 1.5x baseline w/in 7 days
Oliguia- 400-500/day, 20mL/hr
Pre: hypoperfusion
Intrinsic
Post: obstructed urine outflow
What is the first step towards AKI Tx
What are the most common etiologies of AKI
ID cause
Pre-renal:
Azotemia= hypoperfusion
What are 3 causes of renal hypoperfusion
What lab result can help ID a pre-renal AKI
Dec volume
Change in resistance
Low CO
BUN:Cr exceeds 20:1
What are the 3 stages of AKI
What lab result is usually ordered for AKIs and what may seen that is Dx?
1: 1-1.5 inc SrCr
2: 2-2.9 inc SrCr
3: 3x inc SrCr
Urine microscopy
Pre: bland sedimants, hyaline casts
ATN: muddy brown casts
What are the benchmarks of AKI Tx
What is the MC cause of post-renal AKI
Euvolemia
E+ balance
Avoid nephrotoxic meds
BPH
Anti-cholinergics
Obstructions
How is post-renal AKI Tx
What is the hallmark/MC issue of intrinsic AKI
Cath- US or MRI
Remove obstructions
Avoid volume depletion
ATN AGN AIN
When do AKIs need to be referred?
Why are ACEi and NSAIDS lethal combo
AKI not reversed in 2wks w/out uremia= nephrologist
Persistent Sxs of obstruction= urologist
Stop filtrate flow in both directions
What are essentials for ATN Dx
Major two causes are ?
AKI- ischemic/toxic result or sepsis
Pigmented granular castsa dn epithelial cells= pathognomonic
Ichemia
Nephrotxin exposure
What causes ischemic ATN
What will be seen on lab results
Inadequate GFR and blood flow or shock
Muddy brown granular casts Epithelial cells/casts <20:1 BUN:Cr Inc FEx HyperK HyperPhosph
What are the 3 phases of ATN
What are the leading causes of death
Initial injury
Maintenance- non-oligo= better prognosis
Recovery- diuresis, inc GFR, dec SrCr/BUN
Infection
Fluid/E= disturbance
What is pathognemonic for multiple myeloma
How is ATN Tx
Bence Jones protein casts
HyperKAvoid volume overload and
Protein restriction
ICU admit
How is AIN characterized
What usually causes this
What is seen on peripheral blood smears
Fever
Arthralgia
Maculopapular rash
Drugs Infxn Imm D/o
Eosinophilia
What is seen on lab results in AIN
How is it Tx
Dec BUN ratio
RBC WBC and WBC casts
Nephrology
Short steroids for failure- methylprednisone
What are the essentials of Dx for Acute Glomerulonephritis
This is an uncommon cause of ?
How is it characterized
RBC casts- pathognomonic, not req’d
HTN Dependent edema AKI
AKI/ARF
Inflammatory glomerular lesions
What are the markers of acute glomerulonephritis
Which one is associated w/ Goodpastures
Anti-GBM Abs
Anti-neutrophil cytoplasmic Abs
Anti-GMB + pulm hemorrhage
What PTs would you likely see a mixed acid-base issue in
Tx of inc anion gap acidosis
Sepsis
DKA + asthma/COPD
DM + LF
Insulin/fluids if diabetic
Volume resuscitation to restore tissue perfusion
Add BiCarb is HyperK
How is methanol intoxication induced acidosis Tx
What are BiCarb levels at in chronic respiratory alkalosis
Fomepizole- inhibits alcohol dehydrgenase
Dec
Normal anion gap= ?
Define ImmComplex Deposition glomerulonephritis
What can cause this
<14
Exaggerated imm response causes Ag/Ab deposition
HCV IgA Lupus Infection
Define Pauci Immune Glomerulonephritis
What are the 4 types
How is it definitively Dx
Causes kidney Dz w/out immune complex deposition
Granulomatosis
Microscopic
c-ANCA
ANCA and anti-GBM
Biopsy
Define Monoclonal Imm mediated Glomerulonephritis
What are the two types
Deposition of monoclonal immunoglobulins
C3
Other: HTN emergency HUS TTP
S/Sxs of acute glomerulonephritis
Wlab results are used for Dx
HTN
Edematous- peri-orbital, scrotal
Abnormal urine sediment
Hematuria w/ red cell casts
Mild proteinuria
SrCr rise x months
When would ASO titers be drawn
How is acute glomerulonephritis Tx
Post-strep glomerulonephritis
CCS
Rituximab
Cytotoxic agents
Goodpasture/Pauci= plasma exchange
What are the 5 types of cardiorenal syndromes
1: AKI from acute cardiac dz
2: CKD from chronic cardiac dz
3: acute cardiac dz from AKI
4: chronic cardiac decompensation from CKD
5: heart and kidney dysfunction
Criteria for Dx of CKDz
How is it classified
Renal damage d/t: Proteinuria/Hematuria Structural abnormality GFR <60 3mon or more
GFR and albuminuria
What are the stages of CKDz
1: kidney damage w/ norm/inc GFR 90+
2: kidney damage, dec GFR 60-89
3a: GFR 45-59
3b: GFR 30-44
4: 15-29
5: ESRDz <15 GFR or dialysis
What are the 2 MC causes of CKDz
PTs w/ ? gene have inc risk of developing CKDz
DM or HTN
APOL-1
? CKDz PTs have the highest risk for CVDz
Most PTs w/ Stage 3 CKD die of ?
Proteinuria
CVDz
Kidneys need to lose ? much function before number changes are seen
Once damage has occurred, why does the kidney start downward spiral of failure
How can it be slowed?
Half
Glomerular sclerosis
ACE/ARBs
What is the MC finding in PTs w/ CKD
What PE finding can be seen?
If PTs present w/ S/Sxs of uremia, what is the next step for Tx
HTN, impaired Na secretion
Mees lines on nails
Admit, nephrology consult
Dialysis
PTs w/ GFRs below ? need nephrology referral
US screening results of ? size suggest chronic scarring
<60
<10cm
What are two examples of radiological evidence of CKDz
What is the sequence of Sxs as kidney function declines
Osteodystrophy in hands/clavicles
HTN PTHinc Anemia Phosphinc Acidosis/HyperK Uremic syndrome
What is our goal BP for PTs w/ CKD
Metabolic bone Dz of CKD is a disturbance of ?
How is it Tx
<140/90
Ca PO4 PTH Vit D and FGF-23
Control HyperPhosph
What is the MC bone dz in CKDz
What type of anemia may be seen
Osteitis fibrosa cystica
Normo Normo
Dec EPO
Dec Fe absorption= IDA
HyperK isn’t seen in CKDz until ? stage
How can it be managed/Tx
4-5
BB
Loop diuretics
Nutritionist may have CKDz PTs restrict ? parts of diet
What meds need to be avoided?
Protein
Na/water
K
Phosph
Mg- lax, antacids
Morphine
IV contrast
MC type of dialysis
What is the MC s/e of peritoneal dialysis and from ? microbe
CAPD
Peritonitis from Staph A
When is CKD referred to nephrologist
When is an earlier referral needed
Stage 3-5
Proteinuria >1g/day or
Polycystic Kidney Dz
When/where would RVDz commonly be seen
What is the MC cause of this?
AKI in PTs starting ACEI w/ bilateral stenosis
Atherosclerosis
Renal artery dz can be AKA ?
What are clues PTs may have renal artery stenosis
Spillover aorta dz
HTN <20 or >50, <40 if female
ACE Inc 25% SrCr
Resistant HTN to +3 anti-HTNs
Pulm edema
What is seen on labs for RAS?
What is the marker of a chronic renal dz
Inc BUN/SrCr
Dec GFR,
HypoK if bilateral stenosis
Asymmetric renal size
RAS PTs can’t have ? contrast
What is the preferred image and is definitive Dx
Gadollinium
CT angiography
S/Sxs of renal infarct
What would be seen on lab results
What is the definitive imaging for Dx
Flank pain Nausea/Fever HTN
Leukocytosis LDH 4x norm
Renal angiography or CT
How are renal infarcts Tx
Glomerular Dz includes abnormal function due to damage to ? 4 structures
IV heparin
Podocytes
Basement membrane
Capillary endothelium
Mesangial cells
Define Nephritic
Define Nephrotic
Nephritis- hematuria, <1g/day protein
Protein excretion in urine 0.5-1g/day, bland sediment
Define Nephritic Syndrome
Define Nephrotic Syndrome
Creatinine inc
Hematuria
Edema- orbital/scrotal
Subnephrotic protein <3g/day
Protien <3g/day Edema Hypoalbumin Hyperlipid Urinary oval body
S/Sxs of Nephritic syndrome
How is it definitively Dx
How is it Tx
Coca cola urine- RBC casts
Edema
Vol overload HTN
Biopsy
Admit
HTN/fluid reduction
CCS/Cytotoxic agents
ACEI/ARB
IgA nephropathy and HS attack ? part of kidney
Post infections and Goodpastures attack ?
Mesangial cells
Basement membrane
Post-Infectious GN
It is MC due to ? and take ? long
Protein/hematuria
Post pharyngitis/impetigo
During pneumonia/endocarditis
GAStrep, 1-3wks
What is seen on labs for Post-infectious GN
How is it Tx
Low complement
High ASO titers
Proliferative pattern
Anti-HTN
Water/Na restriction
Diuretic
No CCS
IgA Nephropathy/Berger Dz
What is seen on lab results
Protein/hematuria
Pos IgA stain on biopsy
Gross hematuria 1-2 days after URI
Serum IgA inc
Mesangial proliferation on biopsy
What is the MC primary glomerular Dzin the world and Asia
How is it Tx
IgA Nephropathy
ACE/ARB w/ BP goal <125/75
CCS/Cytoxic
Nephrology referral
Henoch Schonlein Purpura
Small vessel leukocytoclastic vasculitis- IgA mediated
Males after GAStrep infection
Palpable purpura on LEs
Dec GFR, hematuria
Tx bed rest, CCS
Pauci-Immune GN
Systemic rheumatoid issues w/ Staph A or Silica inticement
Weeks/months build up
Mononeuritis
Tx: reduce inflammation w/ CCS
Goodpasture
Kidney= anti-BM Pulm= goodpature
Anti-BGM + 90% of PTs
Batwing CXR
Tx: plasmaphoresis, CCS
Cryoglobin associated GN
Due to Hep C infection
Purpuric necrotizing skin lesions
Inc rheumatoid factors
Low complement
MPGN
Hep C, bacteria/parasite infections associated
Hematuria
Non-nephrotic protienuria
but w/ Nephrotic syndrome
Tx: ACEI/ARB-mild
Sev: CCS
Likely to progress to ESRDz
How is Lupus Tx
CCS
Calcineurin inhibitors
Immunosuppresives
Commonly progresses to ESRD, dialysis prolongs life
Post Infx GMN
Anti-GBM GMN/Goodpastures
Rising ASO titers, low complement
High anti-GBM Ab titers
Norm complement
4 Dzs within nephrotic spectrum
What characterizes this
Minimal change dz
Focal Segment GS
Membrane nephropathy
Diabetic neuroapthy
Heavy protein
Hypoalbumin
Edema
Hyperlipid- oval fat bodies
What are two uncommon Sxs of nephrotic Syndrome
What PT population is it more common in
HTN, Hematuria
15x kids>adults
What is the MC cause of nephrotic syndrome and kidney failure in US
What is the presenting Sxs in kids
DM
Facial edema due to serum albumin <3g= loss of oncotic pressure
What are nephrotic syndrome PTs at risk for clots
How is it definitely Dx
How is it Tx
Serum albumin <2g- inc clotting factor synthesis
Biopsy unless Peds PT
ACEI/ARB
Diuretics
Anti-lipids
Albumin <2- albumin to prevent thrombosis
What vaccine would be given to Peds PTs w/ nephrotic syndrome
What are the MC primary nephrotic syndromes
Pneumoccocal
Minimal
Membranous
Focal
What is the MC cause of primary nephrotic syndrome in kids
How does it present
Minimal change dz- foot-process
Sudden/rapid swelling
Proteinuria >3g- can cause AKI
PTs w/ Minimal change are only biopsies if ?
How is it Tx
Can it progress?
Relapse w/ CCS withdrawl
Prednisone
Rare ESRD progression
How is FSGS Dx
How is it Tx
Pt fails Minimal Tx/relapse, biopsy= dx
ACE/ARB
Statins
What is the MC cause of primary nephrotic syndromes in adults
Key term for Dx
Progression?
membranous nephropathy
spike and dome pattern
Progresses to ESRD
What unique presentation can membranous nephropathy have?
What may be the presenting issue
Frothy urine
DVT
Kidney biopsies are needed for all glomerular dz except for ?
Diabetic neuropathy
Minimal change
MC cause of ESRD in US
What do these PTs need annualy
DM type 1
Albmuniemia screening
What is the MC lesion in diabetic neuropathy
BP goal
Diffuse glomerulosclerosis
130/80
HIV nephropathy
FSGS patter w/ glomerular collapse
Severe tubu/stitial damage
