Internal Flashcards
Define prerenal AKI?
Give 8 examples
Any injury leading to decreased renal perfusion
Hypovolemia Hypotension Cardiorenal syndrom Hepatorenal syndrom Abdominal compartment syndrom Acute pancreatitis Drugs Renal artery stenosis
Define intrinsic AKI?
Give 4 examples
Conditions leading to severe and direct renal damage
Acute tubular necrosis
Acute interstitial nephritis
Vascular diseases
GN: RPGN
Define Postrenal AKI
Give 8 examples
Acquired obstruction BPH Iatrogenic (catheter injuries) Tumors Stones Bleeding causing blood cloth Neurogenic bladder Congenital malformations
Causes of ATN?
Ischemia
Nephrotoxic drugs
Endogenous toxins: Hb in hemolysis, Mb in rhabdomyolysis, uric acid in tumor lysis, Bence-Jones protein light chains in MM
Define Hemolytic uremic syndrom? (HUS)
thrombotic microangiopathy occluding the microvasculature
what is hepatorenal syndrom?
Liver cirrhosis - portal HT - increased speelic artery vasodilators (NO) - decreased BP - RAAS activation - renal vasoconstriction - decreased GFR
what is abdominal compartment syndrom?
increased pressure in the abdomen causing compression of vessels
vascular injuries in interstitial AKI (6)
HUS TTP HT crisis vasculitis scleroderma renal vein infarct
define AKI
acute/sudden decrease in renal function withing hours to 7 days (creatinine/urinary output)
Normal creatinine level?
60-99
diagnosis of AKI
- patient history
- Physical examination
- lab test - stage with creatinine
- pre, intrinsic or post
what can you calculate to differentiate Prerenal and intrinsic renal AKI?
FeNa: (Pre <1%) (Intrinsic >2-3%)
FeUrea: (Intrinsic > 50%)
Define CKD
Chronic kidney disease (CKD) is defined as an abnormality of kidney structure or function that persists for > 3 months
most common causes of CKD (5)
- Diabetic nephropathy
- Hypertensive nephropathy
- Glomerulonephritis
- PKD
- NSAIDs
inflammatory GN?
- RPGN
- PSGN
- SLE nephritis
- HUS
Non-inflammatory GN?
MCGN
Membranous nephropathy
FSGN
what happens in our body when CKD?
- decreased urin production - volume retention
- no toxin excretion - uremia
- hyperphosphatemia (when FGF23 subsides)
- amenia due to EPO insufficiency
- HPTH
What can uremia do in the heart?
uremic pericarditis - fibrinous pericarditis
Define end stage kidney disease?
is it reversible?
GFR < 15 mL/min
not reversible
What disease can we frequently see in CKD and have to treat?
Osteodystrophy due to hyperphosphatemia, hypocalcemia and vit D deficiency causing hyperparathyroidism
Indications of dialysis?
Acidosis Electrolyte disorder - hyperkalemia Intoxication Overload of fluids Uremic syndrom (pericarditis)
Nephritic syndrom presentation
proteinuria < 3.5 hematuria - acanthocytes RBC casts in urin might be seen no edema/general little proliferative hypertension due to oliguria
nephrotic syndrom?
proteinuria > 3.5 no hematuria edema hyperlipidemia non-proliferative
why is there a increased risk of thromboembolism in nephrotic syndrom?
loss of antithrombin III
causes of nephrotic syndrom? (6)
- MCD
- FSGS
- membranous nephropathy
- diabetic nephropathy
- amyloid light chain AL amiloidosis
- lupus nephritis
Causes og nephritic syndrom (9)
- PSGN
- RPGN
- Lupus nephropathy
- IgA nephropathy
- granulomatosis with polyangiitis
- microscopic polyangiitis
- good pasture syndrom
- Alport syndrom
- Thin basement membrane
systemic symptoms of RPGN
fever weight loss joint pain weakness palpable purpuras
treatment of minimal change disease
good respons to steroids
treatment of FSGS
long steroid treatment
cyclosporins if steroid resistant
membranous nephropathy treatment
steroid + cyclophosphamides/cyclosporin
treatment of diabetic nephropathy
ACEI/ARBs to control BP and proteinuria
treatment of amyloidosis
hematogenic treatment
labs in PSGN
Anti-streptolysin titer
Low C3/Normal C4
Elevated IgM and IgG/normal IgA
lab parameters in ANCA vasculitis RPGN
elevated anti-MPO
elevated ant-PR3
eosinophilia
normal complement level
lab tests in Good-Pasture RPGN
anti-GBM
rarely ANCA positivity
normal complement
IgG deposits on immunofluorecent in Good-pasture RPGN?
LInear deposition
labs in SLE nephritis
ANA-positivity elevated anti-dsDNA elevated anti-C1q low C3 and C4 potential pancytopenia
immunofluorecent in SLE nephritis
FULL HOUSE
granular Ig G, A, M, C3, C1q
oliguria value?
< 400 ml urine /day
Diagnosis in acute tubulointerstitial diseases, treatment?
Biopsy
treatment depends on cause but corticosteroids in almost every case
caused of acute TIN
drugs
infection
systemic infection
idiopathic
name the tubulointerstitial diseases (4)
- Acute TIN
- MM cast nephropathy
- isolated tubulopathies
- renal tubular acidosis
what is the most common kidney injury in multiple myeloma (MM)
multiple myeloma cast nephropathy
pathophysiology of MM cast nephropathy?
light chains are filtered and excreted in urine
they precipitate in tubules clogging them
obstruction and toxic to tubular cells
forms of isolated tubulopathies
Fanconi and
Gitelman
pathophysiology in Gitelman syndrome?
like the patient is taking continous Thiazides
Na wast - no K+ exchange - hypokalemia - alkalosis
Fanconi syndrom pathophysiology
impaired bicarbonate reabsorption
what other diseases does ARPKD manifest with?
pulmonary insufficiency
progressive liver failure - portal and hepatic fibrosis
what other diseases does ADPKD manifest with?
arterial hypertension
progressive liver disease
curative treatment of PKD
transplantation
mutation in ADPKD
PKD1 ch 16 - polycystein-1
PKD2 ch 4 polycystein-2
mutation in ARPKD
PKHD1 ch 6 - fibrocystin
mechanism of PKD1 and PKD1
PKD1 - cell-cell / cell-matrix interaction
PKD2 nonselective cation channel transporter Ca2+
renal cysts in medulla and cortex compressing vessels activation RAAS
PKHD1 mutation mechanism
defect fibrocystin - cystic dilation of collecting duct and bile ducts (intrahepatic and extrahepatic)
where may the cysts also be in ADPKD
pancreas, liver, ovary and testicle
hepatic benign cysts increases with age
what is important to monitor in ADPKD if family history of stroke?
barrys aneurism - subarachnoid bleeding
what can be seen in children born with ARPKD?
potter syndrom during pregnancy (no embryo urin)
clubbed feet
craniofacial abnormalities
what is the difference between the cysts in AR and ADPKD on US?
both bilateral but AD varying in size and AR same size
whend do you use MRI in PKD?
to screen for berry’s aneurysms if family history
what mediation can slow down a rapid progression of ADPKD
tolvaptan
which medication should not be given in polycystic kidney disease?
ADH - increase cyst growth
risk factors for renal cell carcinoma (7)
smoking acquired cysts nephrolithiasis long term acetaminophen use hepatitis C HT Sickle cell anemia
when does RCC usually become symptomatic?
tumor size > 10 cm and/or if merastasis is present
causes of calcium oxalate stones
hypercalcemia
hyperoxaluria
hypocitraturia
causes of uremic acid stones
hyperuricemia - hyperuricosuria
increased cell turnover (leukemia, chemo)
gout
cause of calcium phosphate stones
hyper parathyroidism
type 1 tubular acidosis
clinical symptoms of urinary tract stones
unilateral colicky pain radiates to the groin progressive worsening hematuria nausea, vomiting, reduced bowel sounds dysuria, frequency, urgency, passing stones unable to sit still
if imaging is needed in nephrolithiasis which?
CT without contrast - hydronephrosis
what imaging is used in follow up after nephrolithiasis treatment?
KUB X-ray (kidney, ureter, bladder)
is x-ray always good in nephrolithiasis?
not for small stones
when do you consult with nephrology in UTI stones?
if size > 10mm
what analgesic is given in nephrolithiasis?
diclofenac
conservative treatment of nephrolithiasis?
- Tamsulosin (alpha blocker) if < 10 mm
2. Nifedipine (CCB)
Interventional treatment of nephrolithiasis?
ureteroscopy (URS) or
extracorporeal shockwave lithotripsy (ESWL)
renal stones larger then 20 mm percutaneous nephrolithotomy
indication of a glomerular hematuria?
light color/normal color urine acanthocytes RBC cast might be seen no cloths proteinuria > 500mg/day
indication of non-glomerular bleeding
dark urine no acanthocytes no RBC casts cloths might be seen proteinuria < 500mg/day mostly albumin
normal protein excretion?
up to 200mg/day
mostly Tomm Horsfall proteins from LOH
normal albumin excretion
< 30mg/day
proteinuria level
> 150mg/day urin
just remember that it IS normal up to 200mg/day
normal protein in a spot urin test?
20 mg protein/ mmol creatinine
3g albumin/mmol creatinine
100mg/mmol spot urin corr to 1g/day proteinuria
clinically significant proteinuria?
> 500mg/day
so on a spot test that is 50mg
indication of renal biopsy?
- nephrotic syndrome
- nephritic syndrom
- RPGN
- asymptomatic proteinuria (1-3g/day)
- AVI if not ATN
- CKD (if US does not show small scarred kidneys)
- dysfunction after transplant
contraindications of renal biopsy
- uncooperative patient
- one kidney
- multiple cysts
- renal neoplasia
- acute pyelonephritis
- uncontrolled bleeding
- uncontrolled BP (165/95)
two types of esophageal diverticula and their cause?
pulsion diverticula: increased P and decreased relaxation og LES causing fals diverticula
Traction diverticula: mediastinal inflammation, scarring and retraction (tuberculosis or fungi)
most common site of esophageal diverticula?
UES (Zenker)
middle 3rd
epiphrenic
indications of esophageal diverticula
dysphagia food regurgitation halitosis (bad breath) coughing when eating retrosternal pressure and pain weight loss neck mass
types of hiatal hernia
- sliding
- paraoesophageal
- mixed
- multiorgan
when is reflux defined as GERD?
when it causes troublesome symptoms and complications
3 types of GERD
NERD (non-erosive)
ERD
Barret esophagus
treatment of GERD?
start giving PPI and see if it gives a response, if yes then GERD if no do an EGDC to confirm and do a 24h esophageal pH monitoring
what esophageal pH indicated GERD
dropp below 4
surgical method in GERD
fundoplication where the fundus if stomach is wrapped around the lower esophagus narrowing the distal esophagus
how many biopsies to take to diagnose Barret esophagus?
8 random - if negative repeat after 1-2 years
endoscopic ablative techniques in Barret esophagus
- EMR - endoscopic mucosal resection
- ESD - endoscopic submucosal dissection
- RFA - radiofrequency ablation
what is eosinophilic esophagitis?
how is it diagnosed?
Allergen induced inflammation of the esophagus
biopsy of upper and lower part showes > 15 eosinophils/HPF
what is achalasia?
degeneration of the meienteric plexus of the lower 2/3 esophagus + failure to relax LES
two types of achalasia
primary - unknowns etiology
secondary - mechanical cause
causes of secondary achalasia
- esophageal tumor
- gastric tumor
- chagas disease
- amyloidosis
- sarcoidosis
- neurofibromatosis type 1
what type of dysphagia is seen in achalasia?
dysphagia to solids AND fluids
what is the difference between esophageal obstruction vs achalasia?
in obstruction dysphagia only to solids but achalasia to both
diagnosis achalasia?
Barium swallowing test
endoscopy
manometry
CX-ray
treatment of achalasia
surgery: hellers myotomy
surgical risk: botulnum toxin
what is Boerhaave syndrom
spontaneous transmural effort rupture of esophagus (sudden increase in esophageal pressure)
examples of etiology for boerhaave syndrom
forcefull vomiting (ex. after alcohol)
childbirth
prolonged coughing
seizures
gold standard in boerhaave syndrom diagnosis?
esophagography with contrast showing contrast leaked
define Mallory Weiss syndrom
upper GI bleeding due to longitudinal mucous tear at gastroesophageal junction (may continue above or below also)
4 predisposing factors for Mallory Weiss syndrom?
alcohol
bulimia
GERD
hiatal hernia
diagnosis of Mallory Weiss
CBC
pretransfusion testing - blood transfusion
ECG ro rule out ACS
EGD to confirm diagnosis
type of gastritis and their main cause?
Acute: bacteria, fungi, virus, Parasite
Chronic: autoimmune type 1 and H. pylori type 2
causes destruction of the native architecture
Athropic: chronic inflammation with destruction of glands, fibrosis and scarring
Erosive: stress or chemicals causing multiple superficial erosions not extending beyond muscularis
what are the toxic virulence of H. pylori
cytotoxic associated gene A (CagA)
Vacuolating cytotoxin A (VacA)
treatment of H. pylori
2x1 PPI
clarithromycin 2x500mg
amoxicillin 2x1g or metronidazole 3x500mg
define a peptic ulcer
defect in the gastric or duodenal mucosa with a diameter > 0.5 cm a depth reaching the muscularis mucosa
what protects the gastric mucosa from the acidic environment?
HCO3- and mucus secretion
what factors can increase to make a peptic ulcer?
increased pepsin or acid release or disruption of protective mechanism
etiology of peptic ulcer disease
gastric acid hypersecretion nervous system dysfunction genetic factors (inherited hyperpepsinogenemia) environmental factors (alcohol, smoking, eating habits, NSAID, stress)
where does H. pylori most frequently cause an ulcer?
70-90% duodenum
30-60% stomach
what cause of peptic ulcer is more likely to present with symptoms?
NSAID usage
symptomatic differentiation between duodenal and gastric ulcers
gastric ulcers: increased pain after eating + weight loss
dudenal ulcer: decreased pain after eating + weight gain
histamin effect on gastric acid?
increases secretion
treatment of peptic ulcers?
antacids
H2R
PGL
PPI
define gastroparesis
altered emptying > 3 months with no mechanical obstruction
small for size syndrom
liver resection, jaundice, encephalopathy, coagulopathy
most common medication giving acute liver failure
acetaminophen (paracetamol)
what is the dominant symptom in hyperacute liver failure
encephalopathy is the main presentation and jaundice is mild, this can cause late diagnosis
levels of hepatic encephalopathy
level 1 mild with no to very mild clinical presentations
level 5 coma
define Preeclampsia
Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, most often the liver and kidneys
define Eclampsia
Eclampsia is a severe complication of preeclampsia. It’s a rare but serious condition were high blood pressure results in seizures during pregnancy.
why is liver biopsy commonly contraindicated?
due to significant risk of bleeding
hepatitis B treatment
entecavir and tenofovir
what to give in a liver intoxication with acetaminophen?
N-acetylcystein
acute steps in liver failure patients?
- fluids
- vasopressors if nonresponsive to fluids
- treat ARDS (seen in 20%)
- Do early intubation of rapidly progressing HE
- Start Spo2 monitoring and give oxygen in needed
- check for AKI (seen in 30-70%)
- dialysis if needed
treatment of hepatic encephalopathy
Lactulose (to remove ammonia from system) Rifampicin (in minimal HE) Metronidazole Vancomycin Electrolyte supplement if needed Nutrition
pancreatitis 2/3 rule
- epigastric pain
- laboratory studies (x3 normal value)
- imaging (CT/US/MRI)
What is used to decide severity of pancreatitis?
SIRS score and BISAP score
what is used on a pancreatitis BISAP score?
se urea mental state SIRS criteria age hydrothorax
what are the SIRS criteria
core temp HR RR PaCO2 WBC
what is decided with the pancreatitis BISAP score?
< 2 points means mortality is less then 2%
> 2 points means mortality is > 15%
what can a sudden decrease in Hct during an acute pancreatitis indicate?
pancreatic hemorrhage (rare)
what is a worsening of leukocytosis in pancreatitis an indication of?
infected necrosis
what can be an indication of severe necrotizing pancreatitis?
CRP > 150 three days after onset
increased procalcitonin
increased IL-6
LDH high
indications of chronic alcoholism
GGT high
MCV above 100fL
what is a more specific biliary obstruction enzyme?
ALP
ALT > AST
fluid replacement in acute pancreatitis?
rapid early replacement 5-10ml/kg/h
ringer lactate solution
monitor efficacy
what lab parameter informs us about hydration and rehydration? (5)
Hematocrit!! 35-45% urea production BP HR MAP
what parameters is misleading in the early state of pancreatitis?
CRP and WBC rise in the beginning due ti STERILE inflammation - this is not an indication for AB treatment
Procalcitonin PCT is the ONLY indicator of an actual infection if the patient has acute pancreatitis
why is ERCP only recommended to use in case of AP with cholangitis?
it has the highest complication rate in endoscopy
when to do a cholecystectomy in ABP with peripancreatic fluid?
safe after 6 weeks
local complications of pancreatitis
AP fluid collection
pancreatic pseudocyst
acute necrotic collection
pleural effusion
pathophysiology in chrons
dysfunction of IL-23 and Th17
IBD extraintestinal skin manifestations
pyoderma gangrenosum
erythema nodosum
Fistulas in chrons and UC?
Chrons: common
UC: rare
complications in Chron?
abscess
strictures - obstruction
perianal fissures
antibody in Chron?
ASCA
abdominal pain location in Chrons vs UC
LLQ - UC
RLQ - Chrons
complications in ulcerative colitis
Fulminant colitis
toxic megacolon
perforation
antibody in ulcerative colitis
pANCA
where in the GI do you NOT see chrons disease?
Rectum
what are often the first sign of chrons?
perianal fistulas and abscesses
what can be seen on a biopsy (histology) of Chron disease?
crypts and granulomas
preferred imaging in Chrons
Cross sectional enterography
what does steroid-resistant Chrons disease mean
when you give 40-60mg/day prednisone and there is no respons after 30 days
what does steroid dependent chrons disease mean?
when there is a clinical respons within 30 days of 25mg/day prednisone
90% of patients with primary sclerosing cholangitis are also infected with…..
Ulcerative colitis
but not the other way around
what is elevated on a lab test of UC if there is also primary sclerosing cholangitis
GGT
types of ulcerative colitis?
proctitis proctosigmoiditis distal colitis extensive colitis pancolitis
treatment of distal ulcerative colitis?
mesalamine
steroids
treatment of extensive ulcerative colitis
mesalamin sulfasalazine budesonide steroids immunosupression
Surgical treatment of ulcerative colitis?
can surgery in CD cure the disease?
Ileal pouch-anal anastomosis (IPAA)
curative intent
(CD cannot be cured with surgery)
types of microscopic colitis?
lymphatic MC
Collagenous MC
what should be stopped if a patient is diagnosed with microscopic colitis?
NSAID because it triggers it
mutation in celiac disease?
HLA- DQ2 90%
HLA DQ8 10%
serological tests in celiac disease
anti-Tg (IgA, IgG)
EMA (IgA, IgG
Deaminated glutamin peptide (DGP - IgG)
how to diagnose celiac disease?
4 our of 5 rule
- signs and symptoms
- Ab testing
- HLA gene positive
- histology: villous atrophy and crypt hyperplasia
- clinical respons to gluten free diet
classification of celiac disease based on the 4/5 rule
- 1 Non classic CD
- 2 Seronegative CD
- 4 potential CD
- 5 Non-responsive CD
how many biopsied and where to take them in Celiac disease
at least 5 from duodenum and more then 1 from the duodenal bulb
what is defined as gluten free?
< 20 part per million of gluten (20mg per kg of food)
what can refractory celiac disease lead to?
ulcerative jejunitis
what is acute diarrhea?
< 2 weeks but > 3 days and > 175-200g/day
define chronic diarrhea
> 4w and > 200g/day or >= 3 stools/day
causes of chronic diarrhea? (9)
Chrons UC ischemic colitis colon cancer radiation colitis pancreatic insufficiency bile acid deficiency SIBO SBS
explain hydrogen malabsorption test?
nutrients are fermented by intestinal bacteria leading to increased H+, the level is measured every 30min over 3h (20ppm is the cutoff level)
For Fructose, lactose and glucose, SIBO
anemia in Vit B12 malabsorption?
megaloblastic macrocytic anemia
large RBC and fragmented megaloblasts
in shilling test how much B12 must be absorbed to have a normal uptake?
less then 7-10% meals malabsorption of B12
Lactose intolerance due to?
lactase insufficiency causing bacteria to ferment lactose producing gass
test in lactose intolerance?
H2 breath test + gene testing
what would you recommend to a lactose intolerance patient?
no fermented dairy products
eat yoghurt and kefir
consider vit ADEK, B12 supplement
Define intestinal failure?
when gut function is reduced to the point where IV nutrient supplementation is required to maintane health (IVS)
etiology of intestinal failure?
SBS intestinal fistulas dysmotility obstruction mucosal damage (IBD, cancer treatment)
what is De Ritis ration?
De Ritis ratio is also known as Aspartate aminotransferase/alanine transaminase (AST/ALT) ratio
NORMAL VALUE 1.15
which conditions showes a high De Ritis ratio?
Alcoholic liver disease
Organic toxic hepatitis
cirrhosis
intrahepatic cholestasis
which conditions shows a low De Ritis ratio?
Acute viral hepatitis
Extrahepatic cholestasis
minor fatty liver disease
treatment of H.pylori?
( ACCMMZ)
PPI
AC
MZ
CM
medications given in nephrotic syndrom?
ACEI, ARBs
Statins
Anticoagulants
diuretics: spironolactone/thiazide
What is SIADH and what are diseases associated with it
Increased ADH secretion (Fluid reabsorption)
seen in Pulmonary diseases and CNS diseases
What is the volum status in a SIADH patient?
First water retention and overload, this then decreased aldosterone leading to Na excretion resulting in Euvolemic Hyponatremia and therfore cerebral edema.
what are alarming symptoms where you don’t use the PPI for diagnosis GERD?
dysphagia odynophagia GI bleeding anemia hematemesis weight loss
Normal kidney size?
9-12 cm
