Nephrology Flashcards
tamm horsfall protein is
normal <30-50 mg/24 hrs
very large amounts of protein =
glomerular disease
persistent proteinuria requires
biopsy
urine dipstick only detects what proteins
albumin
to detect bence jones proteins use
immunoelectrophoresis
best 24 hr protein measure
protein to creatinine ratio
tx for proteinuria in DM
ACEi and ARBs
microalbuminuria values
30-300mg/24 hrs
eosinophils in urine =
allergic or acute interstitial nephritis
wright stain detects
eosinophils in urine
hansel stain detects
eosinophils in urine
are there eosinophils in the urine of NSAID induced renal disease
no
persistent WBCs in urine with negative culture
TB
dysmorphic RBCs in urine =
glomerulonephritis
IV pyelogram is the answer when
NEVER
most accurate test of bladder
cytoscopy
do cystoscopy when
hematuria w/o infection or prior trauma and renal US or CT does not show etiology or bladder US shows mass (possible biopsy)
red cell casts =
glomerulonephritis
white cell casts =
pyelonephritis
eosinophil casts =
acute interstitial nephritis
hyaline casts =
tamm horsfall protein from dehydration
broad waxy casts =
chronic renal disease
granular muddy brown casts =
ATN
urine osmolality in ATN
In ATN urine cannot be concentrated because cells are damaged → inappropriately low urine osmolality (isosthenuria – same osmolality as blood) aka renal tubular concentrating defect
BUN:creatinine >20:1
UNa 500
prerenal azotemia
BUN:creatinine 10:1
UNa >20, FeNa >1%
Urine osmolality <300
Intrinsic renal disease (ATN)
NSAIDs constrict
afferent arteriol
ACEi cause vasodilation of
efferent arteriol
retroperitoneal fibrosis is caused by
bleomycin, methylsergide, radiation
prevention of contrast renal toxicity
saline hydration
low magnesium can increase risk of renal toxicity from
aminoglycosides or cisplatin
time frame for drugs causing ATN
5-10 days
prevent tumor lysis syndrome with
allopurinal, hydration, and rasburicase prior to chemo
ethylene glycol causes precipitation of what in tubules
oxalic acid, calcium oxalate
best initial test for rhabdomyolysis
UA
most specific test for rhabdomyolysis
urine for myoglobin
tx of rhabdomyolysis
saline hydration, mannitol, bicarb
how does bicarb help in rhabdomyolysis
drives K back into cells preventing precipitation of myoglobin in kidney tubule
best initial test for ATN
BUN and creatinine
best initial imaging test for ATN
renal US
most accurate test for allergic interstitial nephritis
renal biopsy
most accurate test for poststreptococcal glomerulonephritis
renal biopsy
furosemide adverse effect
ototoxicity, dose and how fast its given dependent
dialysis if
fluid overload, encephalopathy, pericarditis, metabolic acidosis, hyperkalemia
things that do NOT help ATN
Low dose dopamine, diuretics, mannitol, steroids
Cirrhosis, low urine sodium, FeNA 20:1
hepatorenal syndrome
tx for hepatorenal syndrome
midodine, octreotide, albumin
After catheter procedure, blue/purplish skin lesion in fingers/toes, livedo reticularis, ocular lesions
atheroemboli
most accurate test for atheroemboli
biopsy of purplish skin lesion
tx of atheroemboli
no specific tx
dx of atheroemboli
eosinophilia, low complement, eosinophiluria, elevated ESR
most common meds causing allergic interstitial nephritis
PCN, cephalosporins, sulfa (diuretics), phenytoin, rifampin, quinolones, allopurinol, PPIs
the meds that cause allergic interstitial nephritis also cause
drug allergy and rash, stevens Johnson syndrome, TEN, hemolysis
rising BUN/creatinine, fever, rash, arthralgias, eosinophilia, eosinophiluria
acute interstitial nephritis
most accurate test for acute interstitial nephritis
hansel or wright stain
acute interstitial nephritis, inciting drug stopped, but creatinine continues to rise, tx?
glucocorticoids
Sudden flank pain, fever, hematuria, grossly necrotic material in urine
analgesic nephropathy (papillary necrosis)
best initial test for analgesic nephropathy
UA
most accurate test for analgesic nephropathy
CT
tx for analgesic nephropathy
no specific tx
Acute, toxins, none nephrotic, no biopsy, no steroids, never immunosuppressive agents
tubular disease
Chronic, not from toxins, all potentially nephrotic, biopsy, steroids
glomerular diseases
best initial test for goodpasture syndrome
antiglomerular basement membrane antibodies
most accurate test for goodpasture syndrome
lung or kidney biopsy
goodpasture syndrome affects what organs
lungs and kidney
tx for goodpasture syndrome
plasmapheresis and steroids
kidney biopsy in goodpasture disease shows
linear deposits
most common cause of glomerulonephritis
IgA nephropathy (berger disease)
Recurrent gross hematuria 1-2 DAYS post URI
IgA nephropathy
tx of IgA nephropathy
ACEi and steroids if severe proteinuria
hematuria 1-2 WEEKS Post URI
postinfectious glomerulonephritis
dark (cola) urine, periorbital edema, HTN, oligouria
postinfectious glomerulonephritis
tx for postinfectious glomerulonephritis
supportive (antibiotics and diuretics)
dx of postinfectious glomerulonephritis
confirm with ASO titer and anti DNAse antibody titers
hematuria, Sensorineural hearing loss, visual disturbances
alport syndrome
alport syndrome is d/t
congenital defect of type IV collafen
tx for alport syndrome
no specific therapy
best initial test for polyarteritis nodosa
Angiogrpahy of renal, mesenteric, or hepatic artery showing aneurysmal dilation in association with new onset HTN and characteristic symptoms
biopsy is done in lupus nephritis to
gage tx, not to dx, but is most accurate test
tx for lupus nephritis
glucocorticoids with cyclophophomide or mycophenolate
most accurate test for amyloidosis
biopsy
Green birefringence with congo red
amyloidosis
tx of amyloidosis
control underlying disease, then melphalan and prednisone
edema, hyperlipidemia, thrombosis, infection
nephrotic syndrome
thrombosis in nephrotic syndrome is d/t
urinary loss of protein C, S and antithrombin
infection in nephrotic syndrome is d/t
urinary loss of Ig and complement
most common cause of nephrotic syndrome
DM and HTN
nephrotic syndrome in CA of solid organs
membranous
nephrotic syndrome in children
minimal change disease
nephrotic syndrome in IV drug users and AIDS
focal segmental
nephrotic syndrome SLE
any
best initial test for nephrotic syndrome
UA (maltese crosses)
Hyperproteinuria (>3.5/24hr), hypoproteinemia, hyperlipidemia, edema
nephrotic syndrome
best initial tx for nephrotic syndrome
glucocorticoids –> cyclophosphamide
end stage renal disease most commonly from
DM and HTN
metabolic acidosis, fluid overload, encephalopathy, hyperkalemia, pericarditis
uremia
hypocalcemia in end stage renal disease d/t
decreased conversion of 25 to 1,25 vit D
osteodystrophy in end stage renal disease d/t
low Ca leads to secondary hyperparathyroidism
bleeding in end stage renal disease d/t
failure of platelet degranulation
infection in in end stage renal disease d/t
failure of neutrophil degranulation
hyperphosphatemia in end stage renal disease d/t
high PTH releases phosphate from bones
hypermagnesemia in end stage renal disease d/t
loss of ability to excrete
why are aluminum phosphate binders never used
cause dementia
when Vit D replaced for hypocalcemia always give
phosphate binders or vit D will increase GI absorption of phosphate
phosphate binders used in end stage renal disease
calcium acetate, Calcium carbonate, sevelamer, lanthanum
most common cause of death in end stage renal disease
atherosclerosis and HTN –> cardiac
next step in management of complex renal cysts
aspirate to r/o malignancy
TTP is associated with
HIV, CA, cyclosporine, ticlopidine, clopidogrel
intravascular hemolysis, renal insufficiency, thrombocytopenia
HUS and TTP
TTP is associated with what symptoms in addition to the ones seen in HUS
neuro symptoms and fever
PT and PTT in HUS and TTP
normal
tx of TTP or severe HUS
plasmapheresis
best initial test for diabetes insipidus
water deprivation test
high volume nocturia =
diabetes insipidus
tx of nephrogenic diabetes insipidus
correct K and Ca, hydrochlorothiazide or NSAIDs
causes of hyponatremia with hypervolemia
CHF, nephrotic syndrome, cirrhosis
causes of hyponatremia with euvolemia
hyperglycemia, psychogenic polydipsia, hyopthyroidism, SIADH
aldosterone causes
Na reabsorption
for every 100 mg/dL glucose above normal, sodium …
decreases 1.6 mEq/L
thyroid hormone effect on water
needed to excrete it
msot accurate test for SIADH
high ADH
tx of acute hyponatremia
hypertonic saline, conivaptan, tolvaptan
conivaptan, and tolvaptan (MOA)
antagonists of ADH
tx of chronic hyponatremia
demeclocycline
demeclocycline MOA
blocks ADH at collecting ducts
insulin effect on K
drives K into cells
acidosis effect on K
cells pick up H and release K
beta blocker and digoxin effect on K
inhibit Na/K/ATPase increasing K
most urgent test in severe hyperkalemia
EKG
EKG changes in hyperkalemia
peaked T waves, wide QRS, PR prolongation
tx of hyperkalemia that is cardioprotective
Calcium chloride and calcium gluconate
tx of hyperkalemia that removes K from body via bowel
Kayexalate (sodium polystyrene sulfonate)
tx of hyperkalemia best used in acidosis
bicarb - drives K into cells
primary hyperaldosteronism aka
conn syndrome
conn syndrome K level
hypokalemic
barter syndrome d/t
salt loss in loop of henle
EKG changes in hypokalemia
U waves, flattened T waves, ST depression
tx of hypokalemia
IV K, but too fast can cause fatal arrhythmia. Oral K – can’t give too much
anion gap =
Na - (Cl + HCO3)
causes of metabolic acidosis with normal anion gap
RTA and diarrhea
tx for lactic acidosis
correct hypoperfusion
dx for anion gap from ketoacids
acetone level
tx for anion gap from ketoacids
insulin and fluids
dx for anion gap from oxalic acid
crystals on UA
RTA type I is d/t
Distal tubule – normally generates new bicarb (under aldosterone)
best initial test for RTA type I
infuse acid into blood with ammonium chloride. Cannot excrete acid so urine pH remains basic
urine pH >5.5, nephrocalcinosis, hypokalemic
RTA type I
tx of RTA type I
replace bicarb
RTA type II d/t
Proximal tubule - normally 85-90% filtered bicarb reabsorbed
variable urine pH, hypokalemic, metabolic acidosis
RTA type II
tx for RTA type II
thiazides cause volume depletion which enhances bicarb reabsorption
most accurate test for RTA type II
give bicarb and test urine pH. Cannot absorb bicarb so urine pH rises
RTA type IV d/t
Most often in DM. Decreased amount or effect of aldosterone on kidney tubule
test for RTA type IV
persistently high urine Na despite Na depleting diet
urine pH <5.5, hyperkalemia
RTA type IV
tx for RTA type IV
fludrocortisone (highest mineralcorticoid or aldosterone like effect)
urine anion gap =
Na - Cl
positive UAG =
RTA
negative UAG =
diarrhea
minute ventilation =
RR*tidal volume
most common cause of kidney stones
calcium oxalate
chrons disease is associated with what type of kidney stone
calcium oxalate, from increased oxalate absorption
kidney stones associated with UTI
struvite stones
struvite stones are composed of
magnesium, ammonium, phosphate
kidney stones that are radiotranslucent
uric acid stones
most accurate test for nephorlithiasis
CT
best initial tx for nephrolithiasis
analgesics and hydration
tx for kidney stones <5 mm
let pass spontaneously
tx for kidney stones 5-7 mm
nifedipine and tamsulosin – helps pass
tx for kidney stones .5-2 cm
lithotripsy
tx for hydronephrosis d/t nephrolithasis
stent placement
tx for chonic nephrolithaisis
hydrochlorothiazide - removes Ca from urine
metabolic acidosis/alkalosis increases kidney stone formation
acidosis
tx for cystine stones
alkalinize urine
tx for struvite stones
surgical
best initial tx for HTN
weight loss
how long should lifestyle modification be tried before treating HTN
3-6 mo
best initial drug tx for HTN
thiazides
best tx for HTN in pregnancy
BB
best tx for HTN in CAD
BB, ACE, ARB
best tx for HTN in DM
ACE, ARB (<130/80)
best tx for HTN in BPH
alpha blockers
best tx for HTN in depression
NOT BB
best tx for HTN in asthma
NOT BB
best tx for HTN in hyperthyroidism
BB
best tx for HTN in osteoporosis
thiazides
tx for hypertensive crisis
labetolol
why isn’t nitroprusside used first in hypertensive crisis
needs monitoring with arterial line
if BP is lowered to normal in hypertensive crisis, increased risk of
stroke