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
Since it's rare, what can cause hypervolemic hypernatremia Hypernatremia d/t primary aldosteronism presents as ?
Iatrogenic in admitted PTs Mild, ASx
26
What are the early signs of hypernatremia? Hypernetremia is classified as severe when Na exceeds ?
Weak Irritable Lethargic >158mEq
27
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
28
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
29
What can happen if hypernatremia is not Tx slowly w/ fluid/E+ replacement?
Cerebral edema | Neuro impairment
30
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
31
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
32
Free water deficit equation What fluids are used after completing calculations
TBW * Na-140/140 0.9% NS or LR
33
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
34
What is the MC cause of hypokalemia Hypokalemia + acidosis suggests ?
GI loss from infectious diarrhea Profound depletion
35
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
36
S/Sx of mild/mod hypokalemia S/Sx of sev <2.5
Weak Fatigue Cramps Hyporeflexia Paralysis Tetany
37
If PT has hypokalemia and HTN, what needs to be a DDx What renal manifestations can develop too?
Aldosterone/corticoid excess DI Interstitial nephritis
38
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
39
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
40
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
41
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
42
HypoCa is usually mistaken as a ? What are 3 issues that can cause this deficiency
Neuro d/o Dec PTH, Vit D, Mg
43
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
44
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
45
MC cause of HyperCa What lab finding may be seen prior to onset of HyperCa
Primary hyperparathyroid Malignancy Hypercalcuira
46
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
47
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
48
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
49
Sxs from hypercalcemia don't usually start until ? level What Sxs are seen
>12mg Consipation N/V Anorexia PUD
50
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
51
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
52
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
53
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
54
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
55
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
56
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
57
How is mild/chronic HypoPhos Tx How is sev/Sx HypoPhos Tx
PO intake Chronic- Na + KPO4 mixute IV infusions
58
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
59
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
60
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
61
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
62
HyperMg is almost always due to? What are two common exogenous sources of Mg
Adv KDz and impaired excretion Antacids Laxatives
63
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
64
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
65
Assessing PTs acid-base balance requires measuring ? 3 things Blood gas analyzers measure ? two
Arterial pH Pco2 Plasma BiCarb pH Pco2
66
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
67
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
68
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)
69
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
70
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
71
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
72
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
73
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
74
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
75
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
76
What causes metabolic alkalosis? What type of metabolic issue develops during alcohol withdrawal, pain, sepsis or liver dz?
Volume contraction Vomit Respiratory alkalosis
77
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
78
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
79
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
80
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
81
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
82
# 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-
83
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
84
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*
85
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
86
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
87
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
88
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
89
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
90
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
91
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
92
# Define Initiation Factors Define Maintenance Factors
Abnormalities generating BiCarb Abnormalities promoting conservation of BiCarb
93
Saline responsive alkalosis is a sign of ? Saline unresponsiveness is a sign of ?
Extra cellular volume contraction Excessive BiCarb w/ Eu/Hypervolemia
94
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
95
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
96
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
97
Metabolic alkalosis only needs Tx when pH reaches ? How are they Tx
>7.60 Responsive-HIPPA Unresponsive- PASS
98
Metabolic alkalosis in primary aldosteronism can only be Tx w/ ? How does respiratory acidosis develop?
K repletion Hypoventilation Hypercapnia
99
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
100
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
101
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
102
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
103
# 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
104
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
105
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
106
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
107
How does pyelonephritis present How does Eosinophiluria present How does UTIs present
WBCs casts and protienuria Wright/Hansel stains Pyuria alone, possible hematuria
108
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
109
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
110
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
111
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
112
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
113
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
114
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
115
Squamous cells in UA+ ? Transitional/urothelial cells in UA = ?
Contamination, repeat test Possible neoplasm, confirm w/ cytology
116
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
117
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
118
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
119
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
120
Presence of casts suggests ? Red cell casts are indicative of ? and the hallmark of ?
Renal Parenchymal Dz Parenchymal bleeding Glomerulonephritis
121
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
122
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
123
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)
124
What type of case is non-specific What are they associated w/
Hyaline cast Concentrated urine Fever Exercise Diuretics
125
Struvite crystals are associated w/ ? What is the MC yeast seen in urine
Infection stones- organisms like Proteus, Klebsiella C Albicans, characteristic buds/hyphae
126
When are urine cultures ordered? What finding is Dx
Suspected UTI/pyelonephritis 100K CFUs
127
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
128
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
129
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
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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
131
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
132
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
133
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
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Gross hematuria in adults is ? until proven otherwise Define Initial Hematuria and cause
Malignancy Blood at beginning of stream, anterior urethra source, urethritis/stricture
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# 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
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What is the reflex test done after post dipstick UA for blood
Urine microscopy
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# 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
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What drugs can cause pseudohematuria
``` Pyridium* Sulfameth Nitro Rifampin Ibuprofen Phenytoin Levodopa ```
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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
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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
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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
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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
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What is the goal for proteinuria Tx How is it Tx
<0.5g/day ACEI/ARB, dec protein more important than dec HTN
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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
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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
146
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 ```
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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
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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
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When would an IVP be ordered This is a good test for Dx ?
Pelvicaliceal system Renal size Renal stones Sponge kidney Papillary necrosis Hydronephrosis
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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
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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
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? 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
153
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
154
# Define Azotemia What is the consequence of this issue?
Abnormal high level of nitrogen waste- urea, creatinine Uremia
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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
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What is the first step towards AKI Tx What are the most common etiologies of AKI
ID cause Pre-renal: Azotemia= hypoperfusion
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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
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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
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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
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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
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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
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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
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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 ```
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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
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What is pathognemonic for multiple myeloma How is ATN Tx
Bence Jones protein casts HyperKAvoid volume overload and Protein restriction ICU admit
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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
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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
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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
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What are the markers of acute glomerulonephritis Which one is associated w/ Goodpastures
Anti-GBM Abs Anti-neutrophil cytoplasmic Abs Anti-GMB + pulm hemorrhage
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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
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How is methanol intoxication induced acidosis Tx What are BiCarb levels at in chronic respiratory alkalosis
Fomepizole- inhibits alcohol dehydrgenase Dec
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Normal anion gap= ? Define ImmComplex Deposition glomerulonephritis What can cause this
<14 Exaggerated imm response causes Ag/Ab deposition HCV IgA Lupus Infection
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# 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
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# Define Monoclonal Imm mediated Glomerulonephritis What are the two types
Deposition of monoclonal immunoglobulins C3 Other: HTN emergency HUS TTP
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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
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When would ASO titers be drawn How is acute glomerulonephritis Tx
Post-strep glomerulonephritis CCS Rituximab Cytotoxic agents Goodpasture/Pauci= plasma exchange
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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
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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
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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
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What are the 2 MC causes of CKDz PTs w/ ? gene have inc risk of developing CKDz
DM or HTN APOL-1
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? CKDz PTs have the highest risk for CVDz Most PTs w/ Stage 3 CKD die of ?
Proteinuria CVDz
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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
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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
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PTs w/ GFRs below ? need nephrology referral US screening results of ? size suggest chronic scarring
<60 <10cm
185
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
186
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
187
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
188
HyperK isn't seen in CKDz until ? stage How can it be managed/Tx
4-5 BB Loop diuretics
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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
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MC type of dialysis What is the MC s/e of peritoneal dialysis and from ? microbe
CAPD Peritonitis from Staph A
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When is CKD referred to nephrologist When is an earlier referral needed
Stage 3-5 Proteinuria >1g/day or Polycystic Kidney Dz
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When/where would RVDz commonly be seen What is the MC cause of this?
AKI in PTs starting ACEI w/ bilateral stenosis Atherosclerosis
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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
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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
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RAS PTs can't have ? contrast What is the preferred image and is definitive Dx
Gadollinium CT angiography
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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
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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
198
# Define Nephritic Define Nephrotic
Nephritis- hematuria, <1g/day protein Protein excretion in urine 0.5-1g/day, bland sediment
199
# 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 ```
200
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
201
IgA nephropathy and HS attack ? part of kidney Post infections and Goodpastures attack ?
Mesangial cells Basement membrane
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Post-Infectious GN It is MC due to ? and take ? long
Protein/hematuria Post pharyngitis/impetigo During pneumonia/endocarditis GAStrep, 1-3wks
203
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
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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
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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
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Henoch Schonlein Purpura
Small vessel leukocytoclastic vasculitis- IgA mediated Males after GAStrep infection Palpable purpura on LEs Dec GFR, hematuria Tx bed rest, CCS
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Pauci-Immune GN
Systemic rheumatoid issues w/ Staph A or Silica inticement Weeks/months build up Mononeuritis Tx: reduce inflammation w/ CCS
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Goodpasture
``` Kidney= anti-BM Pulm= goodpature ``` Anti-BGM + 90% of PTs Batwing CXR Tx: plasmaphoresis, CCS
209
Cryoglobin associated GN
Due to Hep C infection Purpuric necrotizing skin lesions Inc rheumatoid factors Low complement
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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
211
How is Lupus Tx
CCS Calcineurin inhibitors Immunosuppresives Commonly progresses to ESRD, dialysis prolongs life
212
Post Infx GMN Anti-GBM GMN/Goodpastures
Rising ASO titers, low complement High anti-GBM Ab titers Norm complement
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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
214
What are two uncommon Sxs of nephrotic Syndrome What PT population is it more common in
HTN, Hematuria 15x kids>adults
215
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
216
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
217
What vaccine would be given to Peds PTs w/ nephrotic syndrome What are the MC primary nephrotic syndromes
Pneumoccocal Minimal Membranous Focal
218
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
219
PTs w/ Minimal change are only biopsies if ? How is it Tx Can it progress?
Relapse w/ CCS withdrawl Prednisone Rare ESRD progression
220
How is FSGS Dx How is it Tx
Pt fails Minimal Tx/relapse, biopsy= dx ACE/ARB Statins
221
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
222
What unique presentation can membranous nephropathy have? What may be the presenting issue
Frothy urine DVT
223
Kidney biopsies are needed for all glomerular dz except for ?
Diabetic neuropathy | Minimal change
224
MC cause of ESRD in US What do these PTs need annualy
DM type 1 Albmuniemia screening
225
What is the MC lesion in diabetic neuropathy BP goal
Diffuse glomerulosclerosis 130/80
226
HIV nephropathy
FSGS patter w/ glomerular collapse | Severe tubu/stitial damage