Nephrology Flashcards
Hyaline casts are associated with…
concentrated urine, febrile disease, strenuous exercise, diuretic therapy
RBC casts are associated with…
glomerulonephritis
WBC casts are associated with…
pyelonephritis, interstitial nephritis(indicative of infection or inflammation, allergy)
Renal epithelial cell casts are associated with…
acute tubular necrosis, interstitial nephritis
Muddy granular casts are associated with…
non-specific, can represent acute tubular necrosis
Broad/Waxy casts are associated with…
Chronic renal failure - indicative of stasis in enlarged collecting tubules
Indications for dialysis
AEIOU: acidosis, Electrolytes(K >6.5, rapidly rising K), Intoxications(SLIME: Salicylates, Lithium, Isopropanol, Methanol & Ethylene glycol can all be removed with dialysis), Overload, Uremia
What is Prerenal Azotemia? What are some causes?
hypoperfusion of the kidneys leading to failure. May be due to: hypotension, Hypovolemia, Low oncotic pressure, CHF, Constrictive Pericarditis, Renal Artery Stenosis
Urine sodium with prerenal azotemia? low or high?
LOW!
What type of casts will you see with prerenal azotemia?
Hyaline Casts
Why do you get elevation of BUN with prerenal azotemia? (i want mechanism)
low volume = increased ADH –> ADH increases urea transport activity =D
What are some causes of Postrenal Azotemia?
Stone in bladder or ureters, bilateral strictures, cancer of the bladder, prostate cancer, cervical cancer or neurogenic bladder
Urine sodium with intrarenal failure? high or low?
high >40
What is Acute Tubular Necrosis(ATN)?
death of the tubular cells of the kidney due to either hypoperfusion or various toxic injuries to the kidney(aminoglycosides, amphotericin, chemo, contrast)
What is the mechanism of contrast induced renal failure?
Contrast is directly toxic to the kidney tubule and causes vasoconstriction of the afferent arteriole. ==> decreased perfusion = rapid increase in Cr & decreased in urine Na.
What type of casts would you see with Acute tubular necrosis(ATN)?
“muddy brown” or granular
What is Allergic/Acute Interstitial Nephritis(AIN)?
Hypersensitivity reaction to medications. Look for UA with WBCs, fever and rash. *use Wright Stain or Hansel Stain of the urine to detect eosinophils.
Pt has AIN for >48hrs. What do you do?
give them steroids
What is Rhabdomyolysis? What do you see with kidneys?
large-volume muscular necrosis –> Myoglobin from muscles is toxic to kidney tubules = UA with blood, Elevated Urine myoglobin, elevated CPK level, increased K & decreased Ca.
What is the mechanism of hypocalcemia with rhabdomyolysis?
damaged muscle releases SERCA. SERCA takes up Ca lowering the blood level of Ca.
How do you treat rhabdomyolysis?
Bolus NS, mannitol diuresis(decrease contact time of myoblin with tubule) & Alkalinization of urine to help precipitate myoglobin + EKG(hyperkalemia induced arrhythmia)
Pt with a UA showing envelope-shaped oxalate crystals. What did this person do? How do you tx them?
prob suicide by ingestion of antifreeze(ethylene glycol). Treat with Ethanol or Fomepizole + immediate dialysis
Pt with UA showing uric acid crystals. Whats the most common cause of this? How do you treat?
MCC = tumor lysis syndrome due to chemotherapy(often for lymphoma). tx: hydration, allopurinol & rasburicase(breaks down uric acid)
What blood stuff would you see with a cholesterol embolism?
on skin = livedo reticularis blood = low C3 &C4 + eosinophilia
What can you do to prevent contrast induced renal failure?
Pt who can still get contrast with renal failure will have a Cr between 1.5-2.5. Give NS + N-acetylcysteine + bicarb
Slight elevations of Cr above normal(1.5-2.5) means a loss of _______% of renal function at a minimum.
60-70%
How do NSAIDs cause kidney damage?
*directly toxic and cause papillary necrosis *Allergic Interstitial nephritis = WBC + eosinophilia *Nephrotic Syndrome *afferent arteriolar vasoconstriction & decreased perfusion to the glomerulus = worsening renal function
Goodpastures Syndrome sx?
cough, hemoptysis, SOB, lung shit
Goodpastures Syndrome Best initial test? dx? tx?
best initial: Anti-basement membrane Abs
Most accurate: bx = crescentic glomerulonephritis
Tx: plasmapheresis + steroids
Churg-Strauss Syndrome sx? whats another name for this?
(aka Eosinophilic Granulomatosis with Polyangiitis) sx: asthma, cough, eosinophilia + renal abnormalities
Churg-Strauss Syndrome best initial test? dx? tx?
Best initial test: CBC for eosinophilia count, MPO-ANCA dx: bx tx: Glucocorticoids, if no response add cyclophosphamide
Wegeners Granulomatosis with Polyangiitis sx?
“C-disease” Upper respiratory problems(sinusitis, otitis), lung problems(cough, hemoptysis, abnormal CXR), Systemic vasculitis(joint, skin, brain, GI probs) + renal involvement
Wegeners Granulomatosis with Polyangiitis best initial test? dx? tx?
initial: C-ANCA or anti-proteinase 3-ANCA dx: bx tx: cyclophosphamide + steroids
Microscopic Polyangiitis sx? dx? tx?
necrotizing vasculitis w/o granulomas
sx: lung + renal vasculitis, no eosinophils or asthma. just lung and kidneys
dx: NO GRANULOMAS on bx, MPO-ANCA present,
tx: steroids + cyclophosphamides
Polyarteritis Nodosa(PAN) sx?
sx: SYSTEMIC vasculitis involving EVERY ORGAN EXCEPT lungs. (myalgias, GI bleed + ab pain, purpuric skin lesions, stroke, renal shit, uveitis, neuropathy) *multiple nonspecific findings + fever and weight loss with multiple motor and sensory neuropathy with pain = dx key!
Polyarteritis Nodosa(PAN) initial test? dx?
initial: ESR for inflammation markers, Hepatitis B & C(associated with 30% of PAN) dx: Bx of sural nerve or the kidney, angiography showing “beading”
Polyarteritis Nodosa(PAN) tx?
tx: cyclophosphamide & steroids
IgA Nephropathy whats another name for this? sx?
aka Berger Disease sx: painless recurrent hematuria, recent viral respiratory infection, Proteinuria
IgA Nephropathy tx?
no proven effective therapy! - give steroids for worsening proteinuria - ACEi - Fish oil MAY delay progression
Henoch-Schonlein Purpura sx?
- Raised, nontender, purpuric skin lesions(particularly on buttocks) - abdominal pain - possible bleeding - joint pain - renal involvment **seen in a kid
Henoch-Schonlein Purpura best initial test? dx?
initial: physical exam! dx: bx showing IgA deposits but it is not necessary to make dx
Henoch-Schonlein Purpura tx?
no specific tx = will resolve on its own! *give steroids if proteinuria worsens with the use of ACEi
Post-streptococcal Glomerulonephritis(PSGN) sx?
recent illness followed by “tea/cola colored” urine, periorbital edema, HTN.
Post-streptococcal Glomerulonephritis(PSGN) best initial test? dx?
initial: Anti-streptyolysin O, anti-DNase, Anti-hyaluronidase & low compliment lvls dx: bx! but not done routinely bc blood test are often sufficient. bx would show IgG depo + C3
Post-streptococcal Glomerulonephritis(PSGN) tx?
Penicillin for infection, control HTN and fluid overload with diuretics
Cryoglobulinemia sx?
hx of hepatitis C with renal involvement, joint pain, purpuric skin lesions + low compliment & cryoglobins(igm)
Cryoglobulinemia best initial test? most accurate?
initial: serum cryoglobin component leves, compliment levels low (especially C4) most accurate: bx
Cryoglobulinemia tx?
tx: treat hep C + rituximab
Alport Syndrome sx? dx? tx?
sx: congenital problem with eye and ear + deafness & renal failure in 2nd decade of life. no dx & no specific tx
Thrombotic Thrombocytopenic Purpura(TTP) sx? tx?
TTP = FAT RN *fever *anemia(intravasular hemolysis) *Thrombocytopenia *renal probs(elevated Cr) *Neurological abnormalities tx with plasmapheresis in severe cases. steroids
Hemolytic Uremic Syndrome(HUS) sx? tx?
HUS = ART *anemia(intravasular hemolysis) *renal probs(elevated Cr) *Thrombocytopenia tx with plasmapheresis in severe cases. **DO NOT GIVE ABX as they may worsen
Nephrotic Syndrome sx?
Hyperproteinuria, hypoprotemia, hyperlipidemia(lipoprotein lost in urine = not available to uptake LDL & VLDL), Edema, Thrombosis(due ot loss of antithrombin 3, PC & PS)
In what age group do u see minimal change diseaese? treatment?
children <10 MC, treat w/steroids > cyclohosphamide
What is associated with membranous nephropathy? What deposits and where?
adults, cancer(especially lymphoma), HBV
*Antibody-immune complex deposition resulting in compliment driven podocyte injury = spike & dome
What is associated with Membranoproliferative glomerulonephritis? Where and what are the deposits?
hepatitis C, SLE & decrease in C3/C4
*Immune-complex and/or complement protein deposition in the mesangium and subendothelium of the capillaries = Tram track
What is associated with Focal Segmental Glomerulonephritis(FSGN)?
HIV, heroine use, more common in african americans
*scarring of the podocytes w/effacement causing decreased filtration
Under what circumstances is dialysis essential?
hyperkalemia, metabolic acidosis, uremia with encephalopathy, fluid overload, uremia with pericarditis, drug intoxication that requires dialysis(lithium, ethylene glycol, ASA), uremia induced malnutrition
4 main blood symptoms of uremia & how to treat them
- hyperphosphatemia: Ca-acetate, Ca-carbonate phosphate binders 2. hypermagnesemia: restrict intake 3. Anemia: EPO 4. Hypocalcemia: Vita D replacment
What is Calciphylaxis?
type of extraskeletal calcification = calcification of blood vessels and skin vessels clotting and necrosis. See with ESRD, hyperparathyroidism, milk-alkali syndrome tx by increasing dialysis and normalizing Ca lvls
What is Nephrogenic Systemic Fibrosis? When would you see this?
skin fibrosis in response to the MRI contrast agent Gadolinium in patients with ESRD or severely low GFR (<30). Proliferation of dermal fibrocytes, leading to hardened areas of fibrotic nodules developing in the skin and in some cases joint and skin contractions.
Central DI sx? tx? What will giving DDAVP do?
sx: low urine osmolality, low urine sodium, increased urine volume + NO CHANGE IN URINE OSMOLALITY WITH WATER DEPRIVATION. Giving DDAVP: decrease in urine vol, increase urine osmolality. tx: Give DDAVP or vasopressin
Nephrogenic DI sx? tx? What will giving DDAVP do?
sx: low urine osmolality, low urine sodium, increased urine volume + NO CHANGE IN URINE OSMOLALITY WITH WATER DEPRIVATION. Giving DDAVP: no change in urine volume, no change in urine osmolality. tx: correct underlying cause such as hypokalemia, hypercalcemia & in the meantime use TZD.
3 common causes of hypervolemic hyponatremia? tx?
congestive heart failure(CHF), nephrotic syndrome, cirrhosis tx: treat underlying cause
3 common causes of hypovolemic hyponatremia? tx?
Diuretics(elevated urine Na), GI loss of fluids/vomiting/diarrhea(low urine Na), Skin loss of fluids/burns/sweating(low urine Na) tx: correct cause and replace with NS
4 common causes of euvolemic hyponatremia?
SIADH, hypothyroidism, psychogenic polydipsia, hyperglycemia
Hyperglycemia causes an _____ drop in Na by ___ for each ___ points of glucose.
ARTIFICAL, 1.6, 100
Addisons Disease cause? electrolyte sx? tx?
hyponatremia due to insufficient aldosterone production. sx: hyponatremia, hyperkalemia, mild metabolic acidosis tx: alosterone replacement(fludrocortisone)
4 common causes of SIADH
any problems with CNS, any lung disease, cancer, medications(sulfonylureas, SSRIs, carbamazepine)
Electrolyte abnormalities with SIADH
high urine Na(>20), High urine Osm(>100), Low serum Osm(<290), Low serum uric acid, normal BUN, normal Cr, normal Bicarb
Treatment of Mild, Moderate & chronic SIADH?
mild: fluid restriction Mod: NA, loops, ADH blockers(conivaptan, tolvaptan) *do not correct Na more than 10-12 mEq/L in the first 24 hr Severe: Demeclocycline to block ADH on kidney.
List some causes of Hyperkalemia
*metabolic acidosis from transcellular shift out of cells *adrenal aldosterone deficiency(addisons disease) *BB *digoxin tox *insulin deficiency (DKA) *diuretics(spironolactone) *ACEi, ARBs *prolonged immobility, seizures, Rhabdomyolysis, or crush injury *T4 RTA *renal failure preventing K secretion
How do BB cause hyperkalemia?
Normal Na/K ATPase lowers blood K. BB decrease the activity of the Na/K ATPase, causing K levels to increase.
Effects of hyperkalemia on EKG
1st peaked Twaves then loss of P waves then widened QRS
tx of severe hyperkalemia(you have EKG abnormalities)
Ca-gluconate IV to protect the heart, insulin + glucose IV & kayexalate
tx of moderate hyperkalemia(no EKG abnormalities)
insulin +glucose, Bicarb to shift K into cells when acidosis is the cause, Kayexalate PO.
What will you see on a EKG for hypokalemia?
U-waves = extra wave after the T wave
Hypermagnesemia sx? tx
sx: muscular weakness, loss of DTRs tx: restrict intake, NS to promote diuresis +/- dialysis depending on severity
Hypomagnesia always presents with hypo—- & cardiac arrhythmias.
hypocalcemia
causes of metabolic acidosis
MUDPILES: methanol, uremia, DKA, Paracetamol, INH, Lactic Acidosis, Ethylene Glycol, ASA
Clinical indications for emergent dialysis?
AEIOU = acidosis, electrolyte/hyperkalemia specifically, ingestion of toxins, Overload volume, Uremic symptoms/encephalopathy
Evaluation of Hyponatremia:
Serum Na <290, patient is euvolemic with a UNa>20, UOsm>100
ddx?
Evaluation of Hyponatremia:
Serum Na <290, patient is euvolemic with a UNa>20, UOsm<100
Evaluation of Hyponatremia:
Serum Na <290, patient is hypervolemic with a UNa<20
Evaluation of Hyponatremia:
Serum Na <290, patient is hypervolemic with a UNa>20
Evaluation of Hyponatremia:
Serum Na <290, patient is hypovolemic with a UNa<20
Evaluation of Hyponatremia:
Serum Na <290, patient is hypovolemic with a UNa>20
Which type of hypernatremia is diabetes insipidus?
Whats this?
Kimmelstiel-Wilson lesion = seen w/diabetic nephropathy – BM thicking due to non-enzymatic glycosylation causing hypoperfusion and loss of albumin
When correcting hyponatremic you should correct no more than — mEq/L/hr and a goal increase of no more than — mEq/L per day.
When correcting hyponatremic you should correct no more than 0.5 mEq/L/hr and a goal increase of no more than 8-10 mEq/L per day.
Whats a Uwave on EKG? When would u see this? 2 common causes & the acid base disorder they are associated with?
Uwave is the additional wave after the flattened Twave seen w/HYPOkalemia.
2common causes: laxative abuse = metabolic acidosis & vomiting or NG suction = metabolic alkalosis
Pt is Hyperkalemic with ECG changes(peaked Twaves &/or wide QRS)…. what do u give & why?
Ca-gluconate = stablize cardiac membranes & prevent arrhythmias
B-ag, insulin w/glucose & Na-bicarb = temporary treatment to move K into cells
Loop diuretics, dialysis or Kayexalte = removes K from body
PSGN vs IgA nephropathy
differences…
PSGN = 3 weeks after URI or skin infection, ASO+, low C3
IgA = normal compliment & 1-2 days after URI or GI infection
Causes of Anion gap metabolic acidosis: MUDPILES
Methanol
Uremia
DKA
Propylene glycol
Iron or INH
Lactic acidosis
Ethylene glycol/oxalic acid
Salicylates(late)
Causes of non anion gap metabolic acidosis: HARDASS
Hyperalimentation
Addisons disease
RTA- kidneys not removing acid properly
Diarrhea - loss of bicarb
Acetazolamide - loss of bicarb
Spironolactone
Saline infusion - elevated Cl causes Cl & bicarb to be eliminated in the urine
RTA type 1
whats the defect? causes?
tx?
distal tubular defect in H excreation caused by AI disorders, hypercalcinuria, amphotericin B, ifosfamide or genetic
TX: K-bicarb supplementation
*often get kidney stones
RTA type 2
whats the defect? causes?
tx?
proximal defect in bicarb reabsorption – caused by MM, amyloidosis, fanconi syndrome, aminoglycosides, ifosfamide, cisplatin & acetazolamide
tx: tx cause & replace whats missin
RTA type 4
whats the defect? cause?
tx?
defect in aldosterone deficiency or RESISTANCE – hypoaldosteronism, ACE/ARB, urinary tract obstruction, heparin
TX: replace aldo if needed, Nabicarb supp or K wasting diuretics
T/F Use of omeprazole is a common cause of AIN
True
FENa < 1%, 1-2% and >2-3% etiology
1% = prerenal 1-2% = intrinsic renal 2-3% = ATN
What type of of acid-base imbalance occurs with an AK I? What happens to phosphate in potassium?
Metabolic acidosis, hyperphosphatemia, hyperkalemia
What’s an acceptable increasing creatinine after starting an ace inhibitor?
No more than 30%
