Nephro Flashcards
How to reduce contrast induced kidney injury?
Vigorous intravenous hydration has proven to reduce risk of contrast induced nephropathy
what is side effect of giving EPO in ESRD?
Erythopoitein is given to patients on dialysis in order to correct anemia of chronic kidney disease. EPO can worsen hypertension though.
When should EPO be given to ESRD patients?
EPO therapy is indicated for ESRD patients w/ Hgb <10
African American and AIDS nephropathy?
Focal Segmental glomerular sclerosis (FSGS)
IgA nephropathy:
Hx of strep infx (pharyngitis/URI/ skin infx)
Kimmelstiel- wilson Nodules:
Associated it Diabetes
Calcium oxalate stone in kidney treatment:
Most common type of kidney stone
1) Reduce calcium w/ thiazide diuretics
2) Reduce oxolate by decreasing meat consumption & VITAMIN C
3) Increase citrate levels by eating more fruit
If you suspect kidney stone.. what is best test for size and location?
Non-contrast CT scan
U/S in pregnant patient
Treatment for kidney stone <5mm
Stone will pass spontaneously. Hydration (IVF) and pain control is all that is needed
Treatment for kidney stone <7mm
Use medical expulsive therapy: CCB (amlodipine) and Alpha blockers (terazosin) to dilate the ureters.
Treatment for kidney stone <1.5cm
Stone will need to be broken down in order to pass. Use ureteroscopy for distal stones and lithotripsy for proximal stones
Treatment for kidney stone >1.5cm
Stone will need to be resected.
Proximal stones w/ laparoscopic exploration
Distal stones w/ percutaneous anterograde nephrolithotomy
Treatment for kidney stone w/ sepsis, kidney failure etc
Use nephrostomy tube for proximal stone and stent for distal stone until pt is stabilized and ready for surgery.
Old man w/ frequent UTIs and alkaline urine. What kind of kidney stone?
Alkaline environment is perfect for magnesium ammonium phosphate stones (struvite stones) staghorn calculi throughout renal pyramids
Management of hyperkalemia WITHOUT ECG changes:
1) Furosemide diuresis- renally excreting the potassium
2) Kayexalate - Excreting it thru the stool
Management of hyperkalemia WITH ECG changes:
Intravenous calcium carbonate is used to stabilize the myocardium in hyperkalemia with abnormal ECG findings.
Person with hypokalemia due to HCTZ. What can you add to manage HTN and prevent hypokalemia?
Add Ace-inhibitor or ARb which are K sparing. Will help with BP and hypokalemia
what is used to replete potassium?
Potassium chloride
what are the 3 phases of treating symptomatic hyperkalemia with EKG changes?
1) Stabilization of the myocardial membrane (IV Ca carbonate or gluconate)
2) Temporizing the potassium out of the blood (Na bicarbonate, insulin D50 & Beta-2 agonists (albuterol)
3) Eliminate K from blood (Furosemide, kayexalate, hemodialysis
Young man with a family history of calcium disorders who has an asymptomatic hypercalcemia. He has a modestly elevated calcium, modestly elevated PTH, and a barely low phosphorous.
familial hypocalciuric hypercalcemia-Diagnosis is made by urinary calcium
Patient is older, has a smoking history, and has a lung mass.
PTH is undetectable, the calcium elevated and the phosphorous is low. How to diagnose?
Serum PTH-rp
Sestamibi scan of neck showing a single adenoma definitively means
primary hyperparathyroidism- high calcium, low phos, and high PTH in the setting of normal renal function- biopsy would be prudent to confirm it is non malignant, but the treatment is still resection, parathyroidectomy.
Treatment for acute, severe, and symptomatic hypercalcemia as a temporizing measure while fluids are being given
Calcitonin (calci-tone-down)
Hungry Bone syndrome
Hungry bone syndrome occurs after a parathyroidectomy; a parathyroid adenoma resection. As the adenoma autonomously secretes PTH the calcium rises and phos falls. The high calcium activates the calcium sensing receptor and turns off endogenous production of PTH, leading to atrophy of the normal parathyroid glands. When the adenoma is removed the normal parathyroid glands need time to “turn back on,” presenting with low phos, low calcium, and low PTH immediately post-operatively. Unlike the total loss of parathyroid glands that can accompany thyroidectomy, hungry bone syndrome will resolve as the parathyroid glands come back on line.
If symptomatic hypocalcemia, give
intravenous calcium (Ca gluconate)
When is Intravenous calcitriol used to treat hypocalcemia in patients?
Calcitriol is 1, 25-Vit D analogue. Intravenous calcitriol is used to treat hypocalcemia in patients where the impairment of 25-Vit D to 1, 25-Vit D is so severe is causes hypocalcemia. This would be in chronic kidney disease patients.
How is hypercalcemia due to sarcoid treated?
Prednisone can be used to quell inflammatory diseases like sarcoid. Granulomatous diseases can increase Vit D and cause a hypercalcemia through hypervitaminosis D. Steroids decrease the inflammation, decrease the granulomatous disease, and decrease the hypercalcemia.
Patient with high calcium and low phosphorous with normal kidneys. Diagnosis?
The most common cause of hypercalcemia in the outpatient setting is primary hyperparathyroidism. Regardless, with an elevated calcium and a low phos, that speaks to PTH activity in the kidney (which works). To ensure this is true a PTH level should be measured.
Management of hypercalcemia of malignancy
Vigorous fluids and bisphosphonates (Alendronate) are the treatment of choice for sustained reduction in the calcium level.
Diagnosis of hyperparathyroidism is obvious: high calcium, low phosphorous, and very high PTH.
The difficulty is separating WHICH hyperparathyroidism it is - Primary or tertiary?
multiple adenomas in multiple places and the history of chronic kidney disease nearing end-stage renal disease, that is certainly to be tertiary hyperparathyroidism.
Primary hyperparathyroidism will present WITHOUT renal failure and with a SINGLE nodule.
Type I (Distal) Renal tubular acidosis
Impaired distal acid secretion
Urine pH >5.5
Serum Potassium- Low
Positive urine anion gap
Type II (Proximal) Renal tubular acidosis
Impaired proximal bicarbonate reabsorption
Urine pH < 5.5
Serum Potassium- Low
Negative urine anion gap
Type IV
Hypoaldosteronism or aldosterone resistance
Urine pH < 5.5
Serum Potassium- high
Positive urine anion gap
What is Alport syndrome?
Usually in boys aged 5-20
Defect in alpha chain of type 4 collagen
Glomerulonephritis, deafness, eye disorder
Glomerular basement splitting (hematuria)
Nephritic- mild proteinuria of 1 to 2 g/24 hours.
Hypercalcemia affects:
Renal- it causes afferent arteriole vasoconstriction (polyuria, polydipsia, kidney stones, nephrogenic DI, Distal renal tubular acidosis
Cardic- shorterned QT interval , bradycardia, hypertension
Urinalysis of a diabetic patient
1st sign on urinalysis is proteinuria
Nephrotic syndrome (Kimmelstiel-Wilson) that is characterized by a protein loss > 3.5 g/day
Kimmelstiel-Wilson disease because of the presence of pink nodules of hyaline in the glomerular capillaries
Urinalysis of a Acute Tubular necrosis
Muddy brown casts
Can result from ischemia due to shock or chronic renal artery stenosis or nephrotoxic agents, such as cisplatin, aminoglycosides, and ethylene glycol ingestion.
Liddle syndrome
Autosomal dominant condition that causes genetic mutation causing the epithelial sodium channel (ENaC) in the distal tubule to become constitutively active. This causes hypernatremia (HTN) and hypokalemia (metabolic alkalosis)
Look for HTN in young patient
Tx: Amiloride
Bartter syndrome (Mimics loop diuretics)
Autosomal recessive mutation that causes reabsorption defect at thick ascending loop. Affects Na/K/2Cl cotransporter.
Results in hypokalemia and metabolic alkalosis w/ hypercalciuria
Gitelman syndrome (Mimics thiazide diuretics)
Autosomal recessive mutation causing reabsorption defect of NaCl at DCT
Leads to hypokalemia, hypomagnesemia, metabolic alkalosis, hypocalciuria.
Treatment for severe (<120 mEQ/L) hyponatremia
Raising the serum sodium by 4-6 mEq/L should result in relief of symptoms while preventing herniation.
Use 100-mL bolus of 3% saline. If symptoms persist, 2 additional 100-mL doses (total of 300 mL) can be given over 10 minutes
Nail changes and diseases
Koilonychia- Spoon shaped nail- Iron deficiency anemia
Onychorrhexis- Vertically ridged or split nail- Physiologic in elderly
Paronychia- Painful redness and swelling of nail folds- Local bacterial, fungal, or viral infection
Onycholysis- Splitting of distal nail plate from nail bed- Psoriasis, atopic dermatitis, trauma
Pitting- Indentations of nail plate- Psoriasis, alopecia areata
Risk factors for Pancreatic cancer
1) smoking
Male gender
Age > 60 years
Being African American.
Acute interstitial nephritis (AIN) secondary to chronic NSAID exposure
Unlike other etiologies of AIN, NSAID-induced AIN can present months, rather than days, after exposure
Urinalysis is often negative for eosinophils, and patients have significant proteinuria
Diagnosis for acute interstitial nephritis
Renal biopsy provides the definitive diagnosis
Biopsy often reveals mononuclear, eosinophilic cellular infiltrate within the renal parenchyma with sparing of the glomeruli.
