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MTB STEP 3 (R) > MTB 3 - Renal > Flashcards

MTB 3 - Renal Flashcards

1
Q

You can differentiate chronic renal failure from acute renal failure by what 3 things?

A

Chronic renal failure will have:

  • Small kidneys
  • Drop in hematocrit from loss of erythropoietin
  • Low calcium from loss of Vitamin D hydroxylation
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2
Q

What are 6 things that can cause prerenal azotemia?

A

Anything that causes hypoperfusion:

  1. Hypotension
  2. Hypovolemia
  3. Low oncotic pressure (low albumin)
  4. CHF
  5. Constrictive pericarditis (can’t perfuse kidney)
  6. Renal artery stenosis
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3
Q

What are the characteristics of prerenal azotemia?

A
  1. BUN:Cr > 20:1
  2. Urinary sodium 500
  3. Possible hyaline casts on urinalysis
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4
Q

Why does BUN increase with prerenal azotemia?

A

Low volume –> Increase in ADH –> increase urea absorption

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5
Q

Name causes of postrenal azotemia:

A
  1. Stones in bladder or ureters
  2. Strictures
  3. Cancer of bladder, prostate, cervix
  4. Neurogenic bladder (think DM or MS)
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6
Q

What are some clues to obstruction of the urinary system?

A

Distended bladder
Large volume diuresis with catheter placement
Bilateral hydronephrosis on ultrasound

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7
Q

What’s the BUN:Cr ratio for postrenal azotemia?

A

> 15:1

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8
Q

What are 3 characteristics of intrinsic kidney failure?

A

BUN:Cr ~ 10:1
Urine sodium >40
Urine osmolality

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9
Q

What are some common agents that induce renal insufficiency?

A
  1. Aminoglycosides (-mycin)
  2. Amphotericin
  3. Contrast (extremely rapid in onset)
  4. Chemotherapy (Cisplatin)
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10
Q

What is allergic interstitial nephritis?

A

Hypersensitivity to penicillin, sulfa, phenytoin, allopurinol, rifampin, quinolones.

Rash and fever with a rise in BUN and Creatinine

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11
Q

How do you diagnose interstitial nephritis?

A

Wright Stain or Hansel stain in urine to show eosinophils

Urinalysis shows white cells, but can’t distinguish neutrophils from eosinophils

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12
Q

What does rhabdomyolysis do to the potassium level?

A

Hyperkalemia from cellular destruction

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13
Q

Best initial test for rhabdo? Most accurate?

A

Initial: Urinalysis showing large amounts of blood with no cells seen (remember this is myoglobin)

Accuate: Urine myoglobin

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14
Q

What to order in pts with possible rhabdo?

A

Potassium level
Calcium level (low)
Chemistries looking for low bicarb

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15
Q

Why does rhabdo cause hypocalcemia?

A

Damaged muscle binds calcium

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16
Q

Tx of rhabdo?

A
  • Bolus of NS
  • Mannitol and diuresis to decrease contact time
  • Alkalinization of urine to decrease precipitation of myoglobin at the tubule
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17
Q

Most urgent step in an acute case of rhabdomyolysis?

A

EKG b/c hyperkalemia can lead to arrhythmia with peaked T-waves

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18
Q

What types of crystals can cause crystal-induced renal failure?

A

Oxalate and uric acid

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19
Q

Oxalate crystals can form if someone ingests ____

A

Antifreeze (ethylene glycol)

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20
Q

What will be the acid-base disturbance with antifreeze intoxication?

A

Metabolic acidosis with elevated anion gap

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21
Q

Best test for oxalate crystals? Best treatment?

A

Test: Urinalysis showing envelope-shaped oxalate crystals
Treatment: Ethanol or fomepizole w/immediate dialysis

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22
Q

Uric acid crystals most commonly occur after what?

A

Chemotherapy for lymphoma (tumor lysis syndrome)

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23
Q

How to treat uric acid crystals?

A

Hydration, allopurinol, and rasburicase (breaks down uric acid)

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24
Q

What’s the best method to prevent contrast induced renal failure?

A

Hydration with normal saline and possible bicarb, NAC, or both

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25
Q

A slight elevation of creatinine means the loss of ___ to ___% of renal function at minimum

A

60-70

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26
Q

How do NSAIDs affect the kidney

A

Afferent vasoconstriction which decreases glomerular perfusion

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27
Q

What are 3 problems NSAIDs can cause to the kidneys?

A

Direct toxicity w/papillary necrosis
Allergic interstitial nephritis
Nephrotic syndrome

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28
Q

All forms of glomerulonephritis have what 6 characteristics?

A
  1. RBCs in urine
  2. RBC casts in urine
  3. Mild proteinuria (
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29
Q

Goodpasture’s sxs:

A

Cough
Hemoptysis
SOB
Lung findings

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30
Q

Best initial and most accurate tests for Goodpastures?

A

Initial: Anti-basement membrane antibodies
Accurate: Renal biopsy showing Linear deposits

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31
Q

Tx of Goodpastures?

A

Plasmapheresis and steroids

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32
Q

Churg-Strauss sxs:

A

Asthma
Cough
Eosinophilia
Renal abnormalities

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33
Q

Best initial test and most accurate test for Churg-STrauss?

A

Initial: CBC for eosinophil count
Accurate: Biopsy

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34
Q

Tx for Churg-Strauss?

A

Glucocorticoids (prednisone)

-Add cyclophosphamide if there’s no response

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35
Q

Wegener’s granulomatosis sxs?

A

Upper and lower respiratory problems (sinusitis, otitis)
Lung (cough, hemoptysis, abnormal CXR)
Systemic vasculitis (joint, skin, eye, brain, GI problems)

upper and lower respiratory involvement + renal involvement Often misdiagnosed as pneumonia

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36
Q

Best initial test for Wegener’s? Most accurate?

A

Initial: c-ANCA
Accurate: Biopsy of kidney

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37
Q

Best treatment for Wegener’s?

A

Cyclophosphamide and steroids

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38
Q

What is PAN?

A

Systemic vasculitis affecting every organ EXCEPT the lungs.

  1. Renal
  2. Myalgias
  3. GI bleeding and abdominal pain
  4. Purpuric skin lesions
  5. Strokes
  6. Uveitis
  7. Neuropathy
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39
Q

Key to diagnosis of PAN?

A

Multiple motor and sensory neuropathy with pain

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40
Q

Best initial test and most accurate test for PAN?

A

Initial: ESR and markers of inflammation
Accurate: Biopsy of sural nerve or the kidney

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41
Q

What to always additionally test for with PAN?

A

Hep B and C

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42
Q

Best therapy for PAN?

A

Cyclophosphamide and steroids

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43
Q

How does IgA nephropathy present?

A

Painless recurrent hematuria in an Asian pt usually after a viral URI.

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44
Q

Best test for IgA nephropathy?

A

Renal biopsy is essential

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45
Q

Tx of IgA nephropathy?

A

No proven effective therapy that reverses it

  1. Steroids in boluses for sudden worsening of proteinuria
  2. ACE-i for all pts with proteinuria
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46
Q

In whom does Henoch-Schonlein purpura present? What are the sxs?

A

Adolescent or child

  1. Raised, nontender, purpuric skin lesions (buttocks usually)
  2. Abdominal pain
  3. Joint pain
  4. Renal involvement
  5. Bleeding
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47
Q

Diagnostic testing for HSP?

A

Almost always a clinical diagnosis (GI, joint, skin, and renal involvement is best indicator)

Biopsy is the most accurate test showing IgA deposition but this isn’t a test you need to do.

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48
Q

Tx of HSP?

A

Resolves spontaneously

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49
Q

Sxs of PSGN?

A

Dark urine (tea or cola colored)
Periorbital edema
HTN

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50
Q

What leads to PSGN?

A

Throat and skin infections

51
Q

Best initial and most accurate test for PSGN?

A

Initial: Antistreptolysin O, anti-DNase, antihyaluronidase in blood

AccuratE: Biopsy (don’t do this routinely)

52
Q

Treatment of PSGN?

A

Penicillin and other antibiotics

Diuretics for fluid overload

53
Q

PResentation of cryoglobulinemia:

A

Renal involvement, joint pain and purpuric skin lesions in pts with a hx of Hep C

54
Q

Best initial and most accurate test for cryoglobulinemia?

A

Initial: Serum cryoglobulinemia component levels (immunoglobulins and light chains, IgM)
Accurate: Biopsy

55
Q

Tx of cryoglobulinemia?

A

Ledipasvir and sofosbuvir for type 1

56
Q

Drug induced lupus spares what 2 organ systems?

A

Brain

Kidneys

57
Q

For lupus nephritis, what’s the best initial test and most accurate test?

A

Initial: ANA and anti-double stranded DNA
Accurate: Renal biopsy (very important b/c it determines extent of disease which guides therapy)

58
Q

Tx of lupus nephritis?

A

Sclerosis only: No tx
Mild disease: Steroids
Severe: Mycophenolate mofetil and steroids

59
Q

Alport syndrome presentation? Tx?

A

Congenital eye and ear problems like deafness
Renal failure in 2nd or 3rd decade of life

No therapy

60
Q

HUS triad:

A

Intravascular hemolysis (fragmented cells on smear)
High creatinine
Thrombocytopenia

61
Q

TTP pentad?

A

HUS + Fever + Neuro abnormalities

62
Q

Tx of TTP and HUS?

A

Plasmapheresis

63
Q

Nephrotic syndrome labs:

A

> 3.5 g of protein lost in urine everyday
Low albumin (causes edema)
Hyperlipidemia
Thrombosis b/c loss of antithrombin III, Protein C and S

64
Q

Best initial diagnostic test for nephrotic syndrome?

A

Urinalysis showing high protein level

65
Q

Next best test for nephrotic syndrome?

A

Spot-urine for protein:creatinine ratio >3.5:1
OR
24-hr urine protein collection showing >3.5 g protein

66
Q

Most accurate test for nephrotic syndrome?

A

Renal biopsy

67
Q

Give the common pts these types of nephrotic syndromes occur in:

  1. Minimal change
  2. Membranous
  3. Membranoproliferative
  4. Focal segmental
A
  1. Minimal change - children
  2. Membranous - Adults w/cancer like lymphoma
  3. Membranoproliferative - Hep C
  4. Focal segmental - HIV, heroin use
68
Q

Tx of nephrotic syndromes?

A

Steroids

-Cyclophosphamide if no response

69
Q

If pt has mild proteinuria, what do you do first?

A

Repeat urinalysis b/c it often disappears on repeat

70
Q

What if pt has mild proteinuria on repeat testing?

A

Make sure they don’t have a reason for transient proteinuria:

  • CHF
  • Fever
  • Exercise
  • Infection
71
Q

What if the above reasons are not present when they have mild proteinuria?

A

Possible orthostatic proteinuria

-Ppl who stand all day like waiters, teachers, etc

72
Q

How to diagnose orthostatic proteinuria?

A

Take morning urine protein and then afternoon protein.

-If present in afternoon and not morning its orthostatic

73
Q

What if the morning protein is elevated as well?

A

Do 24-hr urine or spot protein:cr ratio. If elevated do biopsy

74
Q

Describe the overall steps in the workup of proteinuria:

A
  1. Repeat UA
  2. Evaluate for othostatic proteinuria
  3. Get protein/cr ratio
  4. Get renal biopsy
75
Q

Give 4 manifestations of uremia and their treatment:

A
  1. Hyperphosphatemia - calcium acetate/carbonate
  2. Hypermagnesemia: Mg restriction in diet
  3. Anemia: erythropoietin replaceent
  4. Hypocalcemia: Vit D replacement
76
Q

When do you need dialysis?

A
  1. Metabolic acidosis
  2. Hyperkalemia
  3. Intoxication with lithium, aspirin, or ethylene glycol (dialyzable drugs)
  4. Fluid overload
  5. Uremic encephalopathy
77
Q

Name the two types of diabetes insipidus

A

Central: Brain not making ADH
Nephrogenic: Kidney can’t respond to ADH

These both cause hypernatremia

78
Q

What things can cause nephrogenic DI?

A

Hypokalemia
Hypercalcemia
Lithium toxicity

79
Q

Sxs of hypernatremia and hyponatremia:

A

Confusion
Seizures
Coma

80
Q

First thing to do in a pt with hyponatremia?

A

Assess volume status

81
Q

Causes of hypervolemic hyponatremia?

A

CHF
Nephrotic syndrome
Cirrhosis

82
Q

Causes of hypovolemic hyponatremia:

A 
Diuretics - High urine sodium
GI loss (vomiting, diarrhea) - Low urine sodium
Skin loss (burns, sweating) - Low urine sodium
83
Q

Causes of euvolemic hyponatremia:

A

SIADH
Hypothryoidism
Psychogenic polydipsia
Hyperglycemia

84
Q

How are glucose and sodium levels associated?

A

Every 100mg of glucose above normal drops the sodium by 1.6

85
Q

What labs does Addison’s disease give?

A

It’s low aldosterone, so:

  • Hyponatremia
  • Hyperkalemia
  • Metabolic acidosis

Tx with fludrocortisone

86
Q

What can cause SIADH?

A

Any CNS abnormalities
Any Lung disease
Sulfa, SSRI, carbamazepine
Cancer

87
Q

How to treat mild hyponatremia with no sxs:

A

Fluid restriction

88
Q

How to treat moderate to severe hyponatremia (confusion, seizures)

A

Saline infusion with loop diuretics
Hypertonic (3%) saline
Check Na frequently
ADH blockers (conivaptan, tolvaptan)

89
Q

How fast to correct hyponatremia?

A

No more than 10-12 in 1st 24 hours

Central pontine myelinolysis

90
Q

How to tx chronic SIADH from malignancy?

A

Demeclocycline to block ADH affect at kidney

91
Q

What usually causes hyperkalemia?

A

Rhabdo or hemolysis

92
Q

Can you get hyperkalemia from diet?

A

Yes, but only if your kidneys aren’t working well. The kidney excretes it faster than the GI tract can even absorb it

93
Q

Give 10 other causes of hyperkalemia:

A
  1. Hypoaldosteronism (Addison’s disease)
  2. Metabolic acidosis
  3. Beta blockers
  4. Digoxin toxicity
  5. Insulin deficiency
  6. Spironolactone, eplerenone
  7. ACE-I and ARBs
  8. Prolonged immobility, seizures, rhabdo, crush injury
  9. Type IV renal tubular acidosis
  10. Renal failure
94
Q

EKG of hyperkalemia?

A

1st come the Peaked T-waves
2nd comes loss of P-wave
3rd comes widened QRS

95
Q

How to treat severe hyperkalemia (As evidenced by EKG chnages like peaked-T-waves)

A

Start with: IV calcium gluconate
Followed by: IV insulin and glucose*
Then finish it up with: Kayexalate

96
Q

How to fix moderate hyperkalemia (no EKG abnormalities)?

A

IV Insulin and glucose
Bicarb to shift K into cells
Kayexalate orally to remove from body (takes hours)

97
Q

Give 7 causes of hypokalemia:

A
  1. Dietary insufficiency
  2. Diuretics
  3. High-aldosterone states (Conn syndrome)
  4. Vomiting (metabolic alkalosis which shifts K into cells)
  5. Proximal and distal RTA
  6. Amphotericin
  7. Bartter syndrome (Loop of Henle can’t absorb sodium and chloride –> secondary hyperaldosteronism)
98
Q

What rhythm disturbance does Hypokalemia give?

A

U-waves

99
Q

Tx of hypokalemia?

A

Replace potassium orally (no maximum rate)

Avoid glucose-containing fluids

100
Q

Most common cause of hypermagnesemia?

A

Overuse of laxatives that contain Mg or iatrogenic administration when used as a tocolytic

101
Q

Sxs of hypermagnesemia?

A

Muscular weakness

Loss of DTRs

102
Q

Tx of hypermagnesemia?

A

Restrict intake
Saline administration to provoke diuresis
Occasionally dialysis

103
Q

6 causes of hypomagnesemia:

A
  1. Loop diuretics
  2. Alcohol withdrawal or starvaton
  3. Gentamicin, amophotericin
  4. Cisplatin
  5. Parathyroid surgery
  6. Pancreatitis
104
Q

Presentation of hypomagnesemia?

A

Hypocalcemia and cardiac arrythmias

105
Q

Name the 7 causes of metabolic acidosis with an increased anion gap:

A
  1. Lactic acidosis
  2. Aspirin overdose
  3. Methanol
  4. Uremia
  5. DKA
  6. Isoniazid toxicity
  7. Ethylene glycol
106
Q

Methanol causes production of what?

A

Formic acid and formaldehyde

107
Q

Tx of methanol intoxication?

A

Get a methanol level

Order fomepizole or ethanol

108
Q

In DKA, what’s the fastest single test to tell if a patient’s hyperglycemia is life-threatening

A

Low bicarbonate

109
Q

Causes of meatbolic acidosis with a normal anion gap?

A

Diarrhea

RTA

110
Q

Name 5 things that cause a metabolic alkalosis:

A 
Volume contraction
Conn syndrome or Cushing syndrome
Hypokalemia
Milk-Alkali syndrome
Vomiting
111
Q

How does volume contraction lead to a metabolic alkalosis?

A

Because it causes secondary hyperaldosteronism which causes increased urinary excretion of acid

112
Q

What is another name for primary hyperaldosteronism?

A

Conn syndrome

113
Q

How does hypokalemia cause a metabolic alkalosis?

A

Potassium ions shift out of the cell to correct the hypokalemia. Thsi shifts hydrogen ions into the cell.

114
Q

What is milk-alkali syndrome?

A

Too much liquid antacid

115
Q

Man is found to have a BP of 145/95 on a routine visit. What’s the next step?

A

Repeat in 1-2 weeks

116
Q

What should you also order when you diagnose someone with HTN?

A

Urinalysis
EKG
Eye exam
Cardiac exam

117
Q

Most effective lifestyle modification for HTN?

A

Weight loss

118
Q

When starting an antihypertensive, which drug will you choose if a pt has:

  1. CAD
  2. CHF
  3. Migraine
  4. Hyperthyroidism
  5. Osteoporosis
  6. Depression
  7. Asthma
  8. Pregnacy
  9. BPH
  10. DM
A
  1. CAD - Beta blocker
  2. CHF - Beta blocker, ACEI/ARB
  3. Migraine - Beta blocker, CCB
  4. Hyperthyroidism - Beta blocker
  5. Osteoporosis - Thiazide
  6. Depression - No beta blockers
  7. Asthma - No beta blockers
  8. Pregnacy - Alpha methyldopa
  9. BPH - Alpha blockers
  10. DM - ACEI/ARB
119
Q

BP target for those >60 years old?

A

150/90

120
Q

When to investigate for secondary hypertension?

A
  1. Pt is 60
  2. Failure to control BP with 3 meds
  3. If pt has
    - Bruit
    - Episodic HTN
    - Buffalo hump, truncal obesity
    - Upper extremity > lower extremity pressure
    - Hirsutism
    - Hypokalemia
121
Q

When a pt with HTN has each of these, what will you think of?

  • Bruit
  • Episodic HTN
  • Buffalo hump, truncal obesity
  • Upper extremity > lower extremity pressure
  • Hirsutism
  • Hypokalemia
A
  • Bruit = Renal artery stenosis
  • Episodic HTN = Pheo
  • Buffalo hump, truncal obesity = Cushing
  • Upper extremity > lower extremity pressure = Coarctation
  • Hirsutism = CAH
  • Hypokalemia = Conn syndrome
122
Q

Describe renal artery stenosis

A

Bruit in the flanks or abdomen

Hypokalemia may be present

123
Q

How to diagnose renal artery stenosis?

A

Initially: Renal U/S

Most accurate: Renal angiogram

124
Q

Best treatment for renal artery stenosis?

A

Renal artery angioplasty and stenting

MTB STEP 3 (R) (9 decks)

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