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IPAP > GU Block 1 Cram > Flashcards

GU Block 1 Cram Flashcards

1
Q

Define Osmolality

Define Osmolarity

A

Concentration of particles/kg

Concentration of particles/L

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2
Q

Define Tonicity

This is related to its ?

A

ECF ability to move water in/out of cell via osmosis;
Osmolytes impermeable to cell membrane

Osmolarity

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3
Q

Define Hypotonic

Define Isotonic

Define Hypertonic

A

ECF has lower osmolarity than ICF, water moves into cell

ECF=ICF

ECF has higher osmolarity than ICF, water moves out of cell

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4
Q

What does a low FEx mean?

What does a high FEx mean?

Why is the FEx a useful tool?

A

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

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5
Q

Define Ineffective Osmoles

To maintain steady state, how much mosmols/urine needs to be excreted per day?

A

Substances easily permeate membranes, no tonicity contribution or shifts between compartments

60 mosmols/day
Max urine osmolality= 1200
Min of 500mL/day

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6
Q

What stimulates the sensation of thirst

What stimulates osmoreceptors

A

Inc osmolality
Dec of ECF volume

Inc tonicity

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7
Q

Average threshold for sensation of thirst to arise is ?

What is the major stimulus for AHD release?

Osmolality is primarily determined by ?

A

295 mosmol/kg

Hypertonicity

Na concentration

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8
Q

What is the MC cause of hyponatremia in hospitalized PTs

Hyponatremia reflects excess ? to ? ratio

A

Hypotonic fluid administration

Excess water to Na ratio

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9
Q

Hyponatremia criteria starts at ? and is divided into severity at ? amounts

Isotonic hyponatremia is AKA and can be seen?

A

<135
Mild: 130-134
Sev: <125

Pseudohyponatremia:
Hyperlipidemia
Hyperprotieniemia

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10
Q

How do PTs get hypovolemic hypotonic hyponatremia

What differentiates if this is caused by renal or extra renal causes?

A

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

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11
Q

What causes Euvolemic Hypotonic Hyponatremia- SIADH

What can cause this?

A

ADH released d/t hyperosmolarity/dec arterial volume
Inappropriate water retention= concntrated urine >300

CNS Pulm d/o Malignancy

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12
Q

When is Low Solute Diet induced Euvolemic Hypotonic Hyponatremia seen?

When can Exercise Associated Hyponatremia be seen?

A

Pregnancy

Forced hydration in basic

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13
Q

What are the 4 criteria needed for SIADH Dx

What two findings my also be present

A

Hypotonic Hyponatremia
No HLK Dz
Normal thyroid/adrenal
Urine Na >20

Dec BUN
Hypouricemia

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14
Q

How is chronic hypotonic hyponatremia Tx

What is the adverse outcome of rapid Txs

A

4-6mEq/L/24hrs, max 6-8/24hrs

Osmotic demyelination syndrome: flaccid paralysis dysarthria dysphagia
Central Pontine Myelitis

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15
Q

How is hypovolemic hyponatremia Tx

How is hypotonic hypervolemic hyponatremia Tx

A

Isotonic fluids- corrects fluid loss, suppresses ADH

Loop diuretics
A/CKDz= dialysis

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16
Q

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?

A

Fluid/offender restriction
Tx pain/nausea

Loop diuretic- Furosemide
Inc solute intake

Vasopressin 2, not w/ fluid restriction

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17
Q

How are PTs w/ Sx/Sev hyponatremia Tx

Since this Tx is done slowly, what is the goal of Tx?

A

Admit, d/c offender
100mL 3%NS over 10min
Max correction: 4-6mEq/24hr

Sx relief

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18
Q

When Tx hyponatremia, what finding indicates ADH secretion has stopped?

What is added to hyponatremia Tx if PT has CHF?

A

High urine output/hr

Vasopressin 2

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19
Q

How is hyponatremia Tx when seizure/coma is present

A

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

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20
Q

Causes of HypoNa, normal osmolality

Causes of HypoNa, high osmolality

A

Hyperprotein
Hyperlipid

Hyperglycemia
Mannitol
Contrast agents

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21
Q

Causes of HypoNa, HypoVol

A

<10= external: GI Skin, 3rd space

> 20= renal: diuretic nephropathy mineralcorticoid deficient CSWS

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22
Q

Causes of HypoNa, HyperVol

Causes of HypoNa, Euvol

A

Cirrhosis HF AKDz NephSynd

<100: psych, low solute diet
>100: SIADH Hypothyroid glucocorticoid deficient
Variable: osmostat reset

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23
Q

What are the two main defenses against hypernatremia?

How to differentiate non/renal causes

A

Thirst, Water intake

Urine osmolality

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24
Q

All PTs w/ hypernatremia will have ?

These PTs are usually hypovolemic due to ? loss such a ?

A

Hyperosmolality

Hypotonic loss:
Renal- DI
Nonrenal: GI, Burns

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25
Q

Since it’s rare, what can cause hypervolemic hypernatremia

Hypernatremia d/t primary aldosteronism presents as ?

A

Iatrogenic in admitted PTs

Mild, ASx

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26
Q

What are the early signs of hypernatremia?

Hypernetremia is classified as severe when Na exceeds ?

A

Weak Irritable Lethargic

> 158mEq

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27
Q

What S/Sxs are seen during hypernatremia hyperosmolality ranges 320-330/340-450?

What will be seen on lab results in hypernatremia?

A

32-30: somnolence confusion
34-50: coma arrest death

Urine osmolality >400

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28
Q

Hypernatremia w/ dilute urine, <250, is characteristic of ? Dx

What are some etiolgies of this Dx?

A

DI
Central- inadequate release
Nephrogenic- insensitivity

Demeclocycine Interstitial nephritis Obstruction relief
Lithium HyperCa, HypoK

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29
Q

What can happen if hypernatremia is not Tx slowly w/ fluid/E+ replacement?

A

Cerebral edema

Neuro impairment

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30
Q

What is the fluid of choice for Tx HyperNa/Hypovol

How is HyperNa/Euvol Tx

How is hyperNa/Hypervol Tx

A

Isotonic

PO Water or IV 5% Dextrose

5% dextrose
Loop diuretics

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31
Q

What extra calculation is done when Tx hyperNa

What fluids are used for Tx this calculation

A

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

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32
Q

Free water deficit equation

What fluids are used after completing calculations

A

TBW * Na-140/140

0.9% NS or LR

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33
Q

HypoK starts at ? level

Severe deficiency can lead to ?

What is used to differentiate non/renal causes

A

<3.5

Arrhythmia Rhabdo

TTKD
Transtubular Potassium Concentration Gradient

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34
Q

What is the MC cause of hypokalemia

Hypokalemia + acidosis suggests ?

A

GI loss from infectious diarrhea

Profound depletion

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35
Q

The use of ? two meds in presence of hypokalemia increase risk for arrhythmias?

Hypokalemia places ? cardiac PTs at risk for adverse outcomes

A

B-2 agonists
Diuretics

Digoxin use- Digitalis toxicity

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36
Q

S/Sx of mild/mod hypokalemia

S/Sx of sev <2.5

A

Weak Fatigue Cramps

Hyporeflexia Paralysis Tetany

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37
Q

If PT has hypokalemia and HTN, what needs to be a DDx

What renal manifestations can develop too?

A

Aldosterone/corticoid excess

DI
Interstitial nephritis

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38
Q

What would be seen on lab results when working up hypokalemia?

TTK gradient >4 suggests ?

A

Urine K <20- V/D
Urine K >40- corticoid excess

Renal K loss w/ inc distal K secretion

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39
Q

What is seen on EKG during hypokalemia

How is hypokalemia Tx

A

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

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40
Q

How to differentiate K leak from blood cells and true HyperK

What is the ratio of pH/K shifts?

A

Serum levels

Serum K inc 0.7 / 0.1 pH dec

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41
Q

What is seen on EKG during hyperkalemia

What meds need to be Rx w/ caution d/t risk for hyperkalemia?

A

Brady
Wide PR/WRS
Peaked T
Biphasic QRS-T complex

ACEI/ARB Sprionolactone
Eplerenone Triamterene

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42
Q

HypoCa is usually mistaken as a ?

What are 3 issues that can cause this deficiency

A

Neuro d/o

Dec PTH, Vit D, Mg

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43
Q

True cases of HypoCa implies insufficient actions of ?

What is the MC cause of HypoCa

A

PTH or Vit D

Adv CKDz causing decreased active Vit D3
Hyperphosphatemia

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44
Q

What would be seen on lab results of suspected HypoCa

How is Sx/Sev HypoCa Tx

How is ASx HypoCa Tx

A

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

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45
Q

MC cause of HyperCa

What lab finding may be seen prior to onset of HyperCa

A

Primary hyperparathyroid
Malignancy

Hypercalcuira

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46
Q

ASs/Mild hypercalcemia is ? level

This is usually due to ?

Sx/Sev hypercalcemia starts at ? and is usually due to ?

A

> 10.5mg

Primary hyperparathyroid- MC cause in ambulatory PTs

> 14mg
Malignancy

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47
Q

Chronic hypercalcemia or manifestations such as nephrolithiasis suggest ?

What is the MC cause of hypercalcemia in InPTs

A

Benign courses

Tumor production of PTH proteins, MC paraneoplastic endocrine syndrome

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48
Q

How do granulomas Dzs like sarcoidosis or TB cause hypercalcemia

Define Milk-Alkali Syndrome

A

Over production of Vit D3

Ca ingestion from milk to prevent osteoporosis causes AKI from constriction

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49
Q

Sxs from hypercalcemia don’t usually start until ? level

What Sxs are seen

A

> 12mg

Consipation N/V
Anorexia PUD

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50
Q

What may be seen for clinical findings that indicate etiologies of HyperCa

A

Hyperparathyroid- High Cl, low PO4

Milk Synd- low Cl, high HCO3 BUN and creatinine

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51
Q

Milk alkali syndrome can be AKA ?

What is the difference between hyperthyroidsim and malignancy induced HyperCa

A

Hypocalciuric hypercalcemia

Hyper- inc PTH
Malig- dec PTH, inc PTHrP

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52
Q

How is HyperCa Tx

If PT is hypovolemic w/ HyperCa, what Dx is possible

A

Bisphosphonates-TxOC, bridge w/ Cacitonin
Promote calciuresis w/ hydration

Nephrogenic DI- Tx w/ 0.9% NS 250-500/hr

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53
Q

Kidney is the most important regulator of ? component in serum

Where/what does PTH do

A

Phosphate

Dec reabsorption of phosphate in Prox tube , Vit D inc reabsorption

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54
Q

If suspected HypoPhos, what lab order is placed?

What are the levels for mod/sev hypophos?

Where is sev hypophos commonly seen?

A

Fasting serum

Mod: 1-2.4
Sev: <1

Alcoholics

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55
Q

What are S/Sxs of acute/severe <1mg hypophos?

What are the S/Sxs of chronic/sev hypophos?

A

Parasthesia
Encephalopathy
Anemia
Rhabdo

Pain Anorexia Fxs

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56
Q

What is a normal kidney response to hyophos and is used for lab findings?

How is HypoPhos in PTs w/ DKA Tx

A

24hr collection
Dec phos excretion to less than 100mg/day

Dietary intakes

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57
Q

How is mild/chronic HypoPhos Tx

How is sev/Sx HypoPhos Tx

A

PO intake
Chronic- Na + KPO4 mixute

IV infusions

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58
Q

What are c/is to conducting phosphate infusions to Tx HypoPhos

What is the MC cause of HyperPhos

A

Hypoparathyroid
Adv CKDz
Tissue damage/necrosis
HyperCa

Adv KDz w/ dec urinary excretion

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59
Q

How is HyperPhos Tx

HypoMg presents as ? Sxs and impairs release of ?

A

Absorb dietary phosphate w/ PO binders- Ca carbonate/acetate
+KDz- dialysis

Neuro Sxs, Arrhythmias
PTH release

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60
Q

What are possible etiologies of HypoMg

What co-existing issues will be seen

A 
Diuretics
Diarrhes
Alcoholism
Aminoglycosides
Amphotericin

End organ resistance to PTH and low Vit D levels, refractory HypoCa to Tx

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61
Q

What are S/Sxs of HypoMg

How is chronic HypoMg Tx

How is Sx HypoMg Tx

A

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

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62
Q

HyperMg is almost always due to?

What are two common exogenous sources of Mg

A

Adv KDz and impaired excretion

Antacids
Laxatives

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63
Q

What would be seen on PE of HyperMg

What would be seen on lab results?

What would be seen on EKG?

A

Dec DTR Confusion Weakness

Inc BUN Creatinine K PO4 and Uric acid
Low Ca

Inc PR
Broad QRS

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64
Q

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?

A

IV Ca Cl 500mg at 100mg/min
Dialysis

HypoNa

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65
Q

Assessing PTs acid-base balance requires measuring ? 3 things

Blood gas analyzers measure ? two

A

Arterial pH
Pco2
Plasma BiCarb

pH
Pco2

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66
Q

Arterial and venous blood gases will not be equivalent during ?

Which ones should be used during this time?

A

Cardiopulmonary arrest

Arterial- most accurate method for obtaining pH/Pco2

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67
Q

For this class, what are the acidic baselines?

Define a Simple Acid-Base d/o

A

Acidic: pH <7.4 Pco2 >40
HCO3 <24

One respiratory/metabolic d/o w/ appropriate compensatory response

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68
Q

What are the 5 steps to analyze an acid-base d/o

What is the Anion Gap formula

A 
Determine d/o
Determine if mixed d/o
Calculate anion gap
Calculate corrected HCO3
Examine PT

Gap= Na - (HCO3 + Cl)

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69
Q

If an anion gap is larger than 20mEqs, what does it suggest?

What is this?

A

Primary metabolic a-b d/o regardless of pH/serum BiCarb levels

Abnormal anion gap is never a compensatory response to respiratory d/o

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70
Q

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 ?

A

HCO3

Back to normal, only close

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71
Q

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?

A

Lactic acidosis
Ketoacidosis
Toxins

GI BiCarb loss
Renal Tubular Acidosis

Urinary anion gap

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72
Q

What is the ratio between albumin and anion gaps?

What 4 factors can make anion gap calculations difficult

A

2 mEq dec of gap= 1g albumin decline

Hypoalbuminemia
Hyper/onatremia
ABX- carbenicillin, unmeasured anion; polymyxin, unmeasured cation
Toxins

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73
Q

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

A

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

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74
Q

When would a PT be seen with a severe form of metabolic acidosis but a small gap?

What are better markers of PT improvement?

A

DKA + normal kidneys

Clinical status
pH

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75
Q

What does an alcoholic ketoacidosis gap look like?

What are the 3 types of metabolic acidosis seen on alcoholics?

A

Dec HCO3, most have normal/alkaline pH

Ketoacidosis
Lactic acidosis
Hyperchloremic acidosis from BiCarb loss in urine

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76
Q

What causes metabolic alkalosis?

What type of metabolic issue develops during alcohol withdrawal, pain, sepsis or liver dz?

A

Volume contraction
Vomit

Respiratory alkalosis

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77
Q

What supports a Dx of alcoholic ketoacidosis

What type of toxin can present with a normal anion gap acidosis?

A

No Hx of diabetes
Normoglycemic after therapy

Toluene

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78
Q

What type of poisoning presents w/ an increase osmolar gap but normal anion gap?

How is uremic acidosis acquired?

A

Isopropanol

Dec GFR <30 reduces kidneys ability to synthesize NH3, reduce excretion of H+ inc anion gap metabolic acidosis

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79
Q

What are two major causes of normal anion gap acidosis

What lab result is used to differentiate between the two?

A

GI BiCarb loss
Renal tubular acidosis

Urine anion gap

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80
Q

What criteria defines Renal Tubular Acidosis

What is the defect with this condition?

A

Hyperchloremic acidosis
Normal anion gap
Normal GFR w/out diarrhea

Dec H+ excretion
Dec generation/absorption of HCO3

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81
Q

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?

A

Hyperaldosteronism

Nephrocalcinosis
Nephrolithiasis

Paraprotienemias
Autoimmune
Amphterecin

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82
Q

Define RTA Type II

What results due to this issue?

What can cause this?

A

Proximal RTA
Prox tube can’t absorb BiCarb

Bicarbonaturia
Metabolic acidosis

Plasma myeloma
Acetazolamide
Nephrotoxic drugs
Carbonic anhydrase inhibitors-

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83
Q

Type II RTA can exist w/ ? genetic d/o

RTA Type 1 Distal

RTA Type 2 Prox

RTA Type 4 Hypo Hypo

A

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

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84
Q

What is the defect in RTA Type IV

What two issues are frequently present

A

Aldosterone deficiency impairs distal nephron Na absorption/K,H secretion

Renal salt wasting
HyperK*

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85
Q

What are common causes of RTA Type 4

What drugs need to be avoided to prevent exacerbating HyperK

A

Tubulointerstitial renal Dz
HTN nephroscleoriss
AIDS
Diabetic nephropathy

Spironolactone
ACEI/ARBs
NSAIDS

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86
Q

Inc renal NH4Cl causes kidney to respond w/ an attempt to ?

What is a normal NH4Cl excretion amount in response to acidosis

A

Inc H+ removal

30-200/day

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87
Q

What is the benefit of the urinary anion gap

How does the urinary anion gap change depending on the etiology

A

Differentiate GI/Renal cause of hyperchloremic acidosis

GI loss= normal renal acid, neg urine anion gap
D-RTA= + anion gap
P-RTA= - anion gap

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88
Q

what is an important clinical finding in metabolic acidosis

Define Kussmaul respirations

What will lab results show in metabolic acidosis

A

Hyperventilation

Deep regular sighing respirations in sev met acid

Dec pH, BiCarb, Pco2
HyperCl= normal gap
NormoCl= inc gap
Possible HyperK

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89
Q

How is alcoholic ketoacidosis Tx

What is the Triad for an adverse issue of Tx

A

Thaimine w/ glucose to avoid Wernicke Encephalopathy

Ataxia
Opthalmoplegia
AMS

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90
Q

How is normal gap acidosis Tx

What can be added to Tx reduce amounts but with caution

A

Alkali- BiCarb or Citrate
Prox-RTA- NaK mixture

TZDs, possible hypoK

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91
Q

When do metabolic acidosis PTs need to be referred?

What is used to differentiate between saline-responsive alkalosis from saline-unresponsive alkalosis

A

PTs w/ tubular necrosis

Urine Cl concentrations

92
Q

Define Initiation Factors

Define Maintenance Factors

A

Abnormalities generating BiCarb

Abnormalities promoting conservation of BiCarb

93
Q

Saline responsive alkalosis is a sign of ?

Saline unresponsiveness is a sign of ?

A

Extra cellular volume contraction

Excessive BiCarb w/ Eu/Hypervolemia

94
Q

Compensatory Pco2 values can rarely exceed ?

Saline Responsive Metabolic Alkalosis

A

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

95
Q

Saline Unresponsiveness Alkalosis

A

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

96
Q

What lab result differentiates Saline Responsive and Unresponsive Alkalosis

What is seen on lab results in metabolic alkalosis

A

Responsive- Cl <25
Unresponsive- >40

Inc pH, BiCarb, PCO2, anion gap
Dec Cl K

97
Q

Metabolic alkalosis only needs Tx when pH reaches ?

How are they Tx

A

> 7.60

Responsive-HIPPA

Unresponsive- PASS

98
Q

Metabolic alkalosis in primary aldosteronism can only be Tx w/ ?

How does respiratory acidosis develop?

A

K repletion

Hypoventilation
Hypercapnia

99
Q

What happens if chronic respiratory acidosis is Tx too quickly

What PE finding may be seen during respiratory acidosis

A

Posthypercapnic metabolic alkalosis until kidneys excretes BiCarb

Papilledema

100
Q

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

A

Hypochloremia

Wide= acidosis
Normal= non-pulm etiology

Improve ventilation

101
Q

How does respiratory alkalosis develop?

What is the MC cause

This can also naturally develop during ?

A

Hyperventilation dec PCO2, inc serum pH

Septic
Anxiety*
Cirrhosis

Pregnancy d/t Progerstone

102
Q

Why does tetany develop during respiratory alkalosis

What happens if chronic respiratory alkalosis is corrected too quickly?

A

Low ionized Ca, severe alkalosis inc Ca binding to albumin

Metabolic acidosis

103
Q

Define Fanconi Syndrome

Respiratory acidosis PCO2
Respiratory alkalosis PCO2

Metabolic acidosis HCO3
Metabolic alkalosis HCO3

A

Dysfunction Prox Tubules= impaired BiCarb absorption leading to RTA

Acid: <38
Alk: >42

Acid: <24
Alk: >28

104
Q

Acid Base can be determined by ordering what two tests?

Define Winter’s Formula

A

ABG and Chem-7 (HCO3, Na, Cl)

PCO2= 1.5 (HCO3) +8 +/-2

105
Q

Where are casts developed?

If protein is present in UA, ? is the cause

Define Acanthocytes

A

Distal tubule/CD

Glomerular Dz

Scrunched RBCs from squeezing between basement membrane

106
Q

How does glomerulonephritis present

How does Nephrotic Syndrome present

How does ATN present

A

Protein/Hematuria
Acanthocytes
Casts

Heavy protein
Lipiduria

Pigmented granular casts (muddy brown) and epithelial cells

107
Q

How does pyelonephritis present

How does Eosinophiluria present

How does UTIs present

A

WBCs casts and protienuria

Wright/Hansel stains

Pyuria alone, possible hematuria

108
Q

What is the best type of UA sample

Inc in urobilinogen suggests ? issues

A

Clean catch mid stream w/in 1st morning void

Hemolysis
Hepatocellular Dz
Hepatitis/cirrhosis

109
Q

How is hematuria Dz?

Since is transient hematuria, when is it not an issue?

A

> 3 RBCs w/ high power field on 2 occasions across 1wk

PTs >40y/o, low malignancy concerns

110
Q

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

A

Proteinuria

Dipstick, albumin

Bence-Jones- overload proteinuria, excess plasma protein production

111
Q

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

A

Eval of daily urine protein excretion

> 150mg

> 3-3.5g

112
Q

What are the different etiologies of proteinuria

A

Glomerular- damaged podocytes

Tubular- faulty reabsorbtion (Wilson Dz, Fanconi)

Functional- orthostatic, benign usually in Peds PTs

Overload- overproduction of plasma proteins

113
Q

UA w/ leukocyte esterase can indicate ?

What can make false positives?

What can cause false negatives?

A

End product from neutrophils=
Infection/Inflammation

Contamination from squamous/vaginal cells

Glycosuria
Concentrated urine
Drugs

114
Q

How does nitrite get in urine?

This indicates ? Dx

What is the best sample for this?

A

Gram neg (E Coli) reduce nitrate to trite

Pos bacterial infection
False pos by hematuria

1st morning void

115
Q

Squamous cells in UA+ ?

Transitional/urothelial cells in UA = ?

A

Contamination, repeat test

Possible neoplasm, confirm w/ cytology

116
Q

Renal tubular cells indicate ? Dx

Where does urea come from, what is it a marker for and what is it inversely related to?

A

Dx ATN

Protein catabolism
BUN= serum urea level
Inverse to GFR

117
Q

What do different shapes of RBCs mean:

Roundnormal

Dysmorphic

Crenated

Cell Ghosts

A

Round: dz in epithelial tract

Dysm: nephritic syndrome

Cren: concentrated urine

Cell: swollen RBCs due to diluted urine

Any/all= further work ups

118
Q

What is the Dx criteria for pyuria, which is a ?

What do the presence of neutrophil or Eosinophils mean

A

> 5 leukocytes per high field
UT injury

Neut: bacterial infection
Eo: allergic interstitial nephritis

119
Q

What is indicative of a TB infection seen on UA?

Casts are the precipitation of ? and they make ?

A

Sterile pyuria- WBCs but neg culture

Tamm Horsefall mucoproteins, organic matrix

120
Q

Presence of casts suggests ?

Red cell casts are indicative of ? and the hallmark of ?

A

Renal Parenchymal Dz

Parenchymal bleeding
Glomerulonephritis

121
Q

Renal tubular epithelial cell casts are characteristically seen in ?

What are white cell casts characteristic of?

White cell casts can be used to distinguish ?

A

Acute tubular necrosis

Acute pyelonephritis, can be seen in acute interstitial nephritis

Kidney or lower GI issue

122
Q

White cell casts seen in acute pyelonephritis may also be seen in ?

Granular casts are AKA and represent ?

What do waxy casts represent

A

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

123
Q

When are broad casts seen?

When are fatty casts seen?

A

Tubules dilated/atrophic due to chronic parenchymal dz
Indicates severe urine stasis
Suggests end stage renal dz

Nephrotic syndrome (lipiduria)

124
Q

What type of case is non-specific

What are they associated w/

A

Hyaline cast

Concentrated urine
Fever Exercise Diuretics

125
Q

Struvite crystals are associated w/ ?

What is the MC yeast seen in urine

A

Infection stones- organisms like Proteus, Klebsiella

C Albicans, characteristic buds/hyphae

126
Q

When are urine cultures ordered?

What finding is Dx

A

Suspected UTI/pyelonephritis

100K CFUs

127
Q

UA is AKA ?

What are the 3 parts of a UA

Define Azotemia

A

Poor man’s renal biopsy

Appearance
Chemical test
Microscopic exam

Elevated BUN and SrCr

128
Q

What can cause pre-renal azotemia

What can cause post-renal azotemia

What can cause intrinsic azotemia

A

Hemorhage Dehydration Burn Shock CHF

Recurrent UTIs BPH Nephrolithiasis Hydrnephrosis

Toxin Inflammation Drugs Infection

129
Q

When is BUN inc but is not an indicator of ?

What can cause dec BUN?

A

RF Obstruction Dehydration
Dec perfusion
Not indicator of dec GFR

SIADH Malnutrition Liver Dz

130
Q

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

A

Pre/Post renal azotemia

Intrinsic renal dz

0.5-1.2mg

131
Q

Creatinine clearance is a usual way to estimate ?

When is a SrCr Inc or dec

A

GFR- 90-120mL/min

Inc: failure obstruction mass/meat intake
Dec: Dec mass Methyldopa Vegetarian

132
Q

What controls the surface area of glomerular cells?

What does GFR indicate

A

Mesangial cells

Kidney function at glomerulus level, ability to filter
Most important parameter for renal function

133
Q

When are FEx of Na used ?

When is this most accurate

A

Suspected acute renal failure
<1%= dec perfusion/dehydraion
>1%= intrinsic renal dz

Oliguric, <400mL/day

134
Q

Gross hematuria in adults is ? until proven otherwise

Define Initial Hematuria and cause

A

Malignancy

Blood at beginning of stream, anterior urethra source, urethritis/stricture

135
Q

Define Terminal Hematuria and cause

Define Total Hematuria and cause

A

Blood at end of stream, prostate/bladder neck, polyp/vesicle tumor

Blood throughout, bladder or upper tract, stone, tumor, TB, nephritic

136
Q

What is the reflex test done after post dipstick UA for blood

A

Urine microscopy

137
Q

Define Pseudohematuria

What can cause Hgburia

What can cause Myoglobinuria

A

Pos dipstick neg culture- beets, pigments, food colors

Black urine- hemolysis anemia malaria

Rhabdo Trauma Shocks ATN

138
Q

What drugs can cause pseudohematuria

A 
Pyridium* 
Sulfameth
Nitro
Rifampin
Ibuprofen
Phenytoin
Levodopa
139
Q

Older PT w/ smoking Hx, presenting w/ painless hematuria= ?

Criteria for proteinuria Dx

Dipsticks turn pos when ? amount is present

A

Bladder Ca until proven otherwise

> 150mg/24hrs

> 300mg/day

140
Q

Criteria for nephrotic proteinuria

When is low amounts of albuminuria, not detectable by dipstick, clinically important?

A

> 3.5g/day

DM- hallmark of diabetic nephropathy, reqs annual screening

141
Q

Microalbuminuria is a RF for ?

Sequence to eval proteinuria

What is the gold standard test for quantifying protein levels

A

CV Dz

Pos dipstick
Rpt w/ first morning void, not after exercise

24hr collection, <150mg/day

142
Q

What urine sample is more sensitive for DM proteinuria

What sample is better for monitoring established proteinuria

A

Urinary Albumin Cr Ratio

Urinary Protein Cr Ration

143
Q

What is the goal for proteinuria Tx

How is it Tx

A

<0.5g/day

ACEI/ARB, dec protein more important than dec HTN

144
Q

BP needs to be below ? prior to kidney biopsy

Kidney size less than ? is likely irreversible

Size difference of more than ? indicates unilateral Dz

A

<160/90

<9cm

> 1.5cm

145
Q

What is the best first choice for IDing various degrees hydronephrosis

What are the c/i to doing this ID test

A

US

Can’t lay down

146
Q

What US probe would be used for prostate biopsy

Renal CT is the MC used eval of ?

A

Transrectal

Flank pain
Stagin renal neoplasm
Hematuria
Infxn
Trauma
147
Q

What image is used to ID renal stones and test of choice for Dx nephrolithiasis

When does contrast need to be avoided

A

Non contrast helical CT

Calcifications
Hemorrhage
Urine extravasation

148
Q

What image is preferred for viewing Upper GU tracts

Intravenous Pyelogram is AKA

When is this image c/i

A

CTU- combo IVP and CT

Intravenous Urogram

ARF CKD MMyeloma

149
Q

When would an IVP be ordered

This is a good test for Dx ?

A

Pelvicaliceal system
Renal size
Renal stones

Sponge kidney
Papillary necrosis
Hydronephrosis

150
Q

When is an MRI used

When is gadolinium c/i

A 
RVThrombosis
Dx/Stage carcinoma
Cysts
C/i contrast 
Adrenals

CKD stage 4/5
Transplant- risk of systemic fibrosis

151
Q

What imaging is used in Dx renovascular HTN due to stenosis

What image is used and BEST for Dx renal vein thrombosis

A

CT angiogram

Venography

152
Q

? image has nearly the best quality for Dx renal artery stenosis

Prior to IVP, PT SrCr must be below ?

A

MRA
Renal arteriogram- gold standard

<2mg

153
Q

What are the indications to do a RUG

When is a VCUG done?

A

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

154
Q

Define Azotemia

What is the consequence of this issue?

A

Abnormal high level of nitrogen waste- urea, creatinine

Uremia

155
Q

What are the essentials of Dx fo AKI

What are the 3 categories

A

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

156
Q

What is the first step towards AKI Tx

What are the most common etiologies of AKI

A

ID cause

Pre-renal:
Azotemia= hypoperfusion

157
Q

What are 3 causes of renal hypoperfusion

What lab result can help ID a pre-renal AKI

A

Dec volume
Change in resistance
Low CO

BUN:Cr exceeds 20:1

158
Q

What are the 3 stages of AKI

What lab result is usually ordered for AKIs and what may seen that is Dx?

A

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

159
Q

What are the benchmarks of AKI Tx

What is the MC cause of post-renal AKI

A

Euvolemia
E+ balance
Avoid nephrotoxic meds

BPH
Anti-cholinergics
Obstructions

160
Q

How is post-renal AKI Tx

What is the hallmark/MC issue of intrinsic AKI

A

Cath- US or MRI
Remove obstructions
Avoid volume depletion

ATN AGN AIN

161
Q

When do AKIs need to be referred?

Why are ACEi and NSAIDS lethal combo

A

AKI not reversed in 2wks w/out uremia= nephrologist
Persistent Sxs of obstruction= urologist

Stop filtrate flow in both directions

162
Q

What are essentials for ATN Dx

Major two causes are ?

A

AKI- ischemic/toxic result or sepsis
Pigmented granular castsa dn epithelial cells= pathognomonic

Ichemia
Nephrotxin exposure

163
Q

What causes ischemic ATN

What will be seen on lab results

A

Inadequate GFR and blood flow or shock

Muddy brown granular casts
Epithelial cells/casts
<20:1 BUN:Cr
Inc FEx
HyperK HyperPhosph
164
Q

What are the 3 phases of ATN

What are the leading causes of death

A

Initial injury
Maintenance- non-oligo= better prognosis
Recovery- diuresis, inc GFR, dec SrCr/BUN

Infection
Fluid/E= disturbance

165
Q

What is pathognemonic for multiple myeloma

How is ATN Tx

A

Bence Jones protein casts

HyperKAvoid volume overload and
Protein restriction
ICU admit

166
Q

How is AIN characterized

What usually causes this

What is seen on peripheral blood smears

A

Fever
Arthralgia
Maculopapular rash

Drugs Infxn Imm D/o

Eosinophilia

167
Q

What is seen on lab results in AIN

How is it Tx

A

Dec BUN ratio
RBC WBC and WBC casts

Nephrology
Short steroids for failure- methylprednisone

168
Q

What are the essentials of Dx for Acute Glomerulonephritis

This is an uncommon cause of ?

How is it characterized

A

RBC casts- pathognomonic, not req’d
HTN Dependent edema AKI

AKI/ARF

Inflammatory glomerular lesions

169
Q

What are the markers of acute glomerulonephritis

Which one is associated w/ Goodpastures

A

Anti-GBM Abs
Anti-neutrophil cytoplasmic Abs

Anti-GMB + pulm hemorrhage

170
Q

What PTs would you likely see a mixed acid-base issue in

Tx of inc anion gap acidosis

A

Sepsis
DKA + asthma/COPD
DM + LF

Insulin/fluids if diabetic
Volume resuscitation to restore tissue perfusion
Add BiCarb is HyperK

171
Q

How is methanol intoxication induced acidosis Tx

What are BiCarb levels at in chronic respiratory alkalosis

A

Fomepizole- inhibits alcohol dehydrgenase

Dec

172
Q

Normal anion gap= ?

Define ImmComplex Deposition glomerulonephritis

What can cause this

A

<14

Exaggerated imm response causes Ag/Ab deposition

HCV IgA Lupus Infection

173
Q

Define Pauci Immune Glomerulonephritis

What are the 4 types

How is it definitively Dx

A

Causes kidney Dz w/out immune complex deposition

Granulomatosis
Microscopic
c-ANCA
ANCA and anti-GBM

Biopsy

174
Q

Define Monoclonal Imm mediated Glomerulonephritis

What are the two types

A

Deposition of monoclonal immunoglobulins

C3
Other: HTN emergency HUS TTP

175
Q

S/Sxs of acute glomerulonephritis

Wlab results are used for Dx

A

HTN
Edematous- peri-orbital, scrotal
Abnormal urine sediment

Hematuria w/ red cell casts
Mild proteinuria
SrCr rise x months

176
Q

When would ASO titers be drawn

How is acute glomerulonephritis Tx

A

Post-strep glomerulonephritis

CCS
Rituximab
Cytotoxic agents
Goodpasture/Pauci= plasma exchange

177
Q

What are the 5 types of cardiorenal syndromes

A

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

178
Q

Criteria for Dx of CKDz

How is it classified

A 
Renal damage d/t:
Proteinuria/Hematuria
Structural abnormality
GFR <60 
3mon or more

GFR and albuminuria

179
Q

What are the stages of CKDz

A

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

180
Q

What are the 2 MC causes of CKDz

PTs w/ ? gene have inc risk of developing CKDz

A

DM or HTN

APOL-1

181
Q

? CKDz PTs have the highest risk for CVDz

Most PTs w/ Stage 3 CKD die of ?

A

Proteinuria

CVDz

182
Q

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?

A

Half

Glomerular sclerosis

ACE/ARBs

183
Q

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

A

HTN, impaired Na secretion

Mees lines on nails

Admit, nephrology consult
Dialysis

184
Q

PTs w/ GFRs below ? need nephrology referral

US screening results of ? size suggest chronic scarring

A

<60

<10cm

185
Q

What are two examples of radiological evidence of CKDz

What is the sequence of Sxs as kidney function declines

A

Osteodystrophy in hands/clavicles

HTN PTHinc Anemia Phosphinc Acidosis/HyperK Uremic syndrome

186
Q

What is our goal BP for PTs w/ CKD

Metabolic bone Dz of CKD is a disturbance of ?

How is it Tx

A

<140/90

Ca PO4 PTH Vit D and FGF-23

Control HyperPhosph

187
Q

What is the MC bone dz in CKDz

What type of anemia may be seen

A

Osteitis fibrosa cystica

Normo Normo
Dec EPO
Dec Fe absorption= IDA

188
Q

HyperK isn’t seen in CKDz until ? stage

How can it be managed/Tx

A

4-5

BB
Loop diuretics

189
Q

Nutritionist may have CKDz PTs restrict ? parts of diet

What meds need to be avoided?

A

Protein
Na/water
K
Phosph

Mg- lax, antacids
Morphine
IV contrast

190
Q

MC type of dialysis

What is the MC s/e of peritoneal dialysis and from ? microbe

A

CAPD

Peritonitis from Staph A

191
Q

When is CKD referred to nephrologist

When is an earlier referral needed

A

Stage 3-5

Proteinuria >1g/day or
Polycystic Kidney Dz

192
Q

When/where would RVDz commonly be seen

What is the MC cause of this?

A

AKI in PTs starting ACEI w/ bilateral stenosis

Atherosclerosis

193
Q

Renal artery dz can be AKA ?

What are clues PTs may have renal artery stenosis

A

Spillover aorta dz

HTN <20 or >50, <40 if female
ACE Inc 25% SrCr
Resistant HTN to +3 anti-HTNs
Pulm edema

194
Q

What is seen on labs for RAS?

What is the marker of a chronic renal dz

A

Inc BUN/SrCr
Dec GFR,
HypoK if bilateral stenosis

Asymmetric renal size

195
Q

RAS PTs can’t have ? contrast

What is the preferred image and is definitive Dx

A

Gadollinium

CT angiography

196
Q

S/Sxs of renal infarct

What would be seen on lab results

What is the definitive imaging for Dx

A

Flank pain Nausea/Fever HTN

Leukocytosis LDH 4x norm

Renal angiography or CT

197
Q

How are renal infarcts Tx

Glomerular Dz includes abnormal function due to damage to ? 4 structures

A

IV heparin

Podocytes
Basement membrane
Capillary endothelium
Mesangial cells

198
Q

Define Nephritic

Define Nephrotic

A

Nephritis- hematuria, <1g/day protein

Protein excretion in urine 0.5-1g/day, bland sediment

199
Q

Define Nephritic Syndrome

Define Nephrotic Syndrome

A

Creatinine inc
Hematuria
Edema- orbital/scrotal
Subnephrotic protein <3g/day

Protien <3g/day
Edema
Hypoalbumin
Hyperlipid
Urinary oval body
200
Q

S/Sxs of Nephritic syndrome

How is it definitively Dx

How is it Tx

A

Coca cola urine- RBC casts
Edema
Vol overload HTN

Biopsy

Admit
HTN/fluid reduction
CCS/Cytotoxic agents
ACEI/ARB

201
Q

IgA nephropathy and HS attack ? part of kidney

Post infections and Goodpastures attack ?

A

Mesangial cells

Basement membrane

202
Q

Post-Infectious GN

It is MC due to ? and take ? long

A

Protein/hematuria
Post pharyngitis/impetigo
During pneumonia/endocarditis

GAStrep, 1-3wks

203
Q

What is seen on labs for Post-infectious GN

How is it Tx

A

Low complement
High ASO titers
Proliferative pattern

Anti-HTN
Water/Na restriction
Diuretic
No CCS

204
Q

IgA Nephropathy/Berger Dz

What is seen on lab results

A

Protein/hematuria
Pos IgA stain on biopsy
Gross hematuria 1-2 days after URI

Serum IgA inc
Mesangial proliferation on biopsy

205
Q

What is the MC primary glomerular Dzin the world and Asia

How is it Tx

A

IgA Nephropathy

ACE/ARB w/ BP goal <125/75
CCS/Cytoxic
Nephrology referral

206
Q

Henoch Schonlein Purpura

A

Small vessel leukocytoclastic vasculitis- IgA mediated

Males after GAStrep infection
Palpable purpura on LEs
Dec GFR, hematuria

Tx bed rest, CCS

207
Q

Pauci-Immune GN

A

Systemic rheumatoid issues w/ Staph A or Silica inticement

Weeks/months build up
Mononeuritis

Tx: reduce inflammation w/ CCS

208
Q

Goodpasture

A 
Kidney= anti-BM
Pulm= goodpature

Anti-BGM + 90% of PTs
Batwing CXR

Tx: plasmaphoresis, CCS

209
Q

Cryoglobin associated GN

A

Due to Hep C infection
Purpuric necrotizing skin lesions
Inc rheumatoid factors
Low complement

210
Q

MPGN

A

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

211
Q

How is Lupus Tx

A

CCS
Calcineurin inhibitors
Immunosuppresives

Commonly progresses to ESRD, dialysis prolongs life

212
Q

Post Infx GMN

Anti-GBM GMN/Goodpastures

A

Rising ASO titers, low complement

High anti-GBM Ab titers
Norm complement

213
Q

4 Dzs within nephrotic spectrum

What characterizes this

A

Minimal change dz
Focal Segment GS
Membrane nephropathy
Diabetic neuroapthy

Heavy protein
Hypoalbumin
Edema
Hyperlipid- oval fat bodies

214
Q

What are two uncommon Sxs of nephrotic Syndrome

What PT population is it more common in

A

HTN, Hematuria

15x kids>adults

215
Q

What is the MC cause of nephrotic syndrome and kidney failure in US

What is the presenting Sxs in kids

A

DM

Facial edema due to serum albumin <3g= loss of oncotic pressure

216
Q

What are nephrotic syndrome PTs at risk for clots

How is it definitely Dx

How is it Tx

A

Serum albumin <2g- inc clotting factor synthesis

Biopsy unless Peds PT

ACEI/ARB
Diuretics
Anti-lipids
Albumin <2- albumin to prevent thrombosis

217
Q

What vaccine would be given to Peds PTs w/ nephrotic syndrome

What are the MC primary nephrotic syndromes

A

Pneumoccocal

Minimal
Membranous
Focal

218
Q

What is the MC cause of primary nephrotic syndrome in kids

How does it present

A

Minimal change dz- foot-process

Sudden/rapid swelling
Proteinuria >3g- can cause AKI

219
Q

PTs w/ Minimal change are only biopsies if ?

How is it Tx

Can it progress?

A

Relapse w/ CCS withdrawl

Prednisone

Rare ESRD progression

220
Q

How is FSGS Dx

How is it Tx

A

Pt fails Minimal Tx/relapse, biopsy= dx

ACE/ARB
Statins

221
Q

What is the MC cause of primary nephrotic syndromes in adults

Key term for Dx

Progression?

A

membranous nephropathy

spike and dome pattern

Progresses to ESRD

222
Q

What unique presentation can membranous nephropathy have?

What may be the presenting issue

A

Frothy urine

DVT

223
Q

Kidney biopsies are needed for all glomerular dz except for ?

A

Diabetic neuropathy

Minimal change

224
Q

MC cause of ESRD in US

What do these PTs need annualy

A

DM type 1

Albmuniemia screening

225
Q

What is the MC lesion in diabetic neuropathy

BP goal

A

Diffuse glomerulosclerosis

130/80

226
Q

HIV nephropathy

A

FSGS patter w/ glomerular collapse

Severe tubu/stitial damage

IPAP (212 decks)

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