Nephrology Flashcards
(222 cards)
1
Q
What type of acid-base disorder is seen in those with mesenteric infarcts
A
Metabolic Acidosis
2
Q
What conditions are seen in normal anion gaps (metaboic acidosis)
A
GI bicarbonate loss: Diarrhoea, uterosigmoidostomy, fistula
Renal tubular acidosis
Drugs (Acetazolamide)
Ammonium chloride injections
Addison’s
3
Q
What conditions cause a raised anion gap (metabolic acidosis)
A
Lactate (shock, hypoxia)
Ketones (Diabetic Ketoacidosis, alcohol)
Urate: renal failure
Acid posioning (salicylates, methanol)
4
Q
What defines a normal anion gap
A
8-14 mmol/L
5
Q
What medication commonly causes nephrogenic diabetes insipidus
A
Lithium
6
Q
What psychiatric drug often causes SIADH
A
Fluoxetine (SSRIs)
7
Q
What medication should all diabetic patients with an albumin:creatinine ratio of 3mg/mmol or more be started on
A
ACEi or ARBs
8
Q
What does an albumin: creatinine ratio > 2,5 indictae
A
Microalbuminuria
9
Q
What is the most likely complication for a patient with CKD on haemodialysis
A
Ischaemic Heart Disease
10
Q
When should someone over the age of 45 be referred for painless haematuria
A
Unexplainied visible haematuria or visible haematuria that persists after UTi treatment
11
Q
When should someone over the age of 60 be referred for haematuria
A
Unexplained nonvisible haematuria AND dysuria or raiswed WCC
12
Q
Why is calcium carbonate given to people with hyperkalaemia
A
Protects against arrythmias (but doesn’t correct calcium levels)
13
Q
What should be given to correct hyperkalaemia
A
Calcium Resonium
14
Q
ECG changes seen in hyperkalaemia
A
Peaked t waves
Loss of p waves
Broad QRS complex
Sinusoidal wave pattern
15
Q
How should hyperkalaemia be managed
A
IV Calcium Gluconate
Combined insulin/dextrose infusion
Nebulised Salbutamol
Calcium Resonium or loop diuretics
16
Q
When should dialysis be considered in hyperkalaemia
A
Persistent + accompanied with AKI
17
Q
What indicates severe hyperkalaemia
A
6.5mmol/L or higher
18
Q
Management of severe hyperkalaemia
A
IV Calcium Gluconate
Insulin/dextrose infusion (to shift K+ from ECF to ICD)
Stop ACEi
19
Q
What creatinine changes indicate AKI
A
> 26 mmol/L in 48 hours
> 50% in 7 days
20
Q
What urinary output changes indicate AKI
A
<0.5 ml/kg/hour for more than 6 hours
21
Q
What eGFR increases the risk of AKI
A
<60
22
Q
When should someone with AKI be referred to nephrologist
A
- Renal transplant
- Unknown cause
- Vasculitis
- Myeloma
- No repsonse to treatment
- Stage 3 AKI
- CKD 4 or 5
- Meets criteria for dialysis
23
Q
WHen does acute graft failure occur following a renal transplant
A
6 months
24
Q
Three signs of an acute graft failure
A
Pyruira
Proteinuria
Rising Creatinine
25
What is acute tubular necrosis of graft vs acute graft failure
Acute graft failure is ASYMPTOMATIC vs symptomatic
Acute tubular necrosis happens in teh first few weeks after a renal transplant
26
What is the preferred method of access for haemodialysis
Arteriovenous fistulas
27
What drugs should be stopped in an AKI
DAMN:
Diuretics
Aminoglycosides and ACEi
Metformin
NSAIDs
28
If patients have no identifiable cause for an AKI, what should be the next invetsigation of choice
Renal USS within 24 hours
29
What NSAID does not need to be stopped in an ANKI
Aspirin if it's at 75mg (cardiac dose)
30
When should someone with suspected minimal change disease be given a renal biopsy
ONLY if there is no response to prednisolone
31
What serum level indicates prerenal acute kidney injury over any oter cause
Raised serum urea:creatinine ratio
32
What distinguishes Acute tubular necrosis over other causes of AKIs
Hypernatraemia (>30 mmol/L) + low urine outout
33
Apperaance of urine in prerenal AKI vs acute tubular necrosis
Normal vs brown granular with casts
34
First line management of rhabdomyolysis
IV normal saline
35
How long does it take to develop an arteriovenous fistula for haemodialysis
6-8 weeks
36
What should be given to prevent contrast-induced nephropathy
1L IV 0.9% NaCl
37
How does Lithium cause nephrogenic diabetes inspidus
Desensitises the kdiney's ability to respond to ADH
38
Signs of Anti-GBM disease
Haemoptysis + AKI/proteinuria/haematuria
39
What is AntiGBM disease
Small vessel vasculitis (goodpasture syndrome)
40
What osmolality level indicates acute tubular necrosis
<350
41
What defines stage 1 AKI
1.5-1.9 x baseline
<0.5ml for over 6 hours
42
What defines stage 2 AKI
2-2.9 from baseline
<0.5 ml urine output >12 hours
43
What defines stage 3 AKI
3> baseline
44
How often does a patient require haemodialysis a week
3 times a week
45
How does a peritoneal dialysis work
Has a high dextrose concentration solution to draw waste products from the peritoneum.
46
How long does a continuous ambulatory peritoneal dialysis last for
30-40 minutes
47
What is an automated peritoneal dialysis
Done while the patient is sleeping
48
At what eGFR should dialysis be considered
5-7 ml/min/1.73 m^2
49
At what age is peritoneal dialysis considered first-line
2 or younger
50
At what Na level is dialysis considered
Over 155 or below 120
51
At what pH level should dialysis be considered in AKI
Under 7
52
At what ureamic level should dialysis be considered
>30 mmol/L
Creatinine over 500
53
What is the most common side effect of haemodialysis
ypotension
54
Name two contraindications to peritoneal dialysis
Intra-abdominal adhesions and abdominal wall stomas
Obesity, resp disease and hernias (relative)
55
What is the main complication of peritoneal dialysis
Peritonitis
56
What happens to CK levels in tubular cell necrosis
Becomes very high (can be caused by rhabdomyolysis)
57
IgA Nephropathy vs Post-strep glomerulonephritis
IgA Nephropathy happens within DAYS of a sore throat
Post-strep glomerulonephritis happens 1-2 weeks after a URTI
58
What variables are considered when calculating an eGFR
CAGE:
Creatinine, Age, Gender, Ethnicity
59
What are the indications for acute renal dialysis
HAVEPEE:
H- Hyperkalaemia
A - Acidosis
V - Volume overload
E- Elevated Urea
P - Pericarditis
E - Encephalopathy
E - Oedema
60
What is the most common drug that causes acute interstitial nephritis
Amoxicillin
61
What urine results would indicate acute interstitial nephritis
Raised urinary WCC and eosinophils
62
Symptoms of Acute interstitial Nephritis
Allergy type reaction: Rash and fever and arthralgia
63
What defect causes nephrotic syndrome with a hypercoagulable state
Antithrombin III deficiency
64
What is a major complication of membranous glomerulonephritis
A hypercoagulable state - look out for DVTs
65
Acute tubular necrosis vs Acut einterstitial Nephritis on urine dip
WCC seen in urine dip vs no raised WCC in urine dip
66
What defines CKD 1
>90
67
What defines CKD 2
6090
68
What defines CKD 3a
45-59
69
What defines CKD 3b
30-44
70
What two thing sar eneeded to define CKD stages 1 and 2
eGFR and supporting evidence (urinalysis or renal USS abnormal)
71
What screening test is used for adult PCKD
Renal USS
72
What is the most common infection in those with organ transplants
CMV infection
73
What is the treatment of choice in those with CMV infections
Ganciclovir
74
What is the most common extra-renal manifestation of PCKD
Hepatomegaly (hepatic cyst formation)
75
Where do berry aneurysms commonly occur
Anterior communicating artery and anterior cerebral artery
76
What is the most common cardiac com[lication of ADPKD
Mitral valve prolapse
77
What causes a hyperacute rejection of a renal transplant
ABO incompatibility (within minutes of tranpslant)
78
WHat causes an acute rejection of graft
Cell mediated autoimmunity
79
What malignancy is secondary to immunosupression from transplants
Squamous cell carcinoma or Luymphoma
80
Name causes of prerenal AKI
Systolic Heart Failure
Hypoalbuminaemia from decompensated liver disease
Cardiorenal and Hepatorenal syndrome
81
What symptom is commonly seen across both cardiorenal and hepatorenal syndrome
Hypotension
82
Name some medications that can cause prerenal AKI
NSAIDs
ACE-i
ARBs
83
What is pre-renal AKI
Damage to blood vessels supplying the kidney
84
What is acute tubular necrosis
Damage to the tubules following ischaemia (prerenal AKI)
85
Name some common compounds that can lead to Acute Tubular Necrosis
-mycins (e.g., gentamicin)
Methotrexate
Myoglobin (rhabdomyolysis)
Uric Acid
86
What type of syndrome is seen in membranoproliferative glomerulonephritis
Nephrotic syndrome
87
Proteinuria in nephritic syndrome vs nephrotic syndrome
Nephrotic >3,5 g/day
Nephritic 1-3g/day
88
What can cause renal artery stenosis
Atherosclerosis
Fibromuscular dysplasia
89
Symptoms of renal artery stenosis
Persistent Hypertension despite on medication
90
What causes postrenal AKI
Obstruction of urine from kidneys
91
What commonly causes postrenal AKI in males
BPH and prostatic cancer
92
If one ureter is obsturcted, do we end up with postrenal AKi
No
93
Prerenal AKI vs Intrarenal AKI in urine osmolality
Urine osmolality >500
urine osmolality <500
94
Why is urine osmolality >500 in prerenal AKI
As RAAS system is activated causing more Na+ retention
95
What is the acid-base formula that occurs in the body
CO2 + H2O ->/
96
Where is HCO3- ions regulated in the body (ie., excreted)
Kidneys
97
How is the level of CO2 regulated by th ebody
Lungs
98
What is the normal blood pH in th ebody
7.37 -> 7.42
99
Why do pH levels decrease if there is a loss in HCO3- ions
CO2 + H20 -> HCO3- + H+
So this equiilibrium shifts to the right, causing more dissociation of H2CO3 into H+ ions
100
If HCO3- ions rise, what happens to the pH
Equilibrium shifts to the left, and the pH rises as less H+ ions are formed
101
If CO2 levels rise in the body, what happens to the equilibrium
Equilibrium shifts to the right, causing pH to lower
102
What are the four parameters of acidosis/alkalosis
1. pH
2. pCO2
3. HCO3-
4. Compensatory response
103
What causes metabolic acidosis
Build up of acid in blood causing equilibrium to shift to the left, causing excess HCO3- loss.
Low bicarbonate levels
104
What symptom is associated with a low pH level (< 7.37)
Hyperventilation to lower pCO2
105
Why is lowering pCO2 important
Causes less H+ ions to be produced.
106
What is the formula for the anion gap
Na+ - (CL- + HCO3-)
107
What does the anion gap show us in metabolic acidosis
The anion gap is high
108
What defines a high anion gap
>12
109
What is a normal anion gap
8-12
110
What causes the anion gap in metabolic acidosis
An excess in H+ ions cause the equilibrium to shift to the left:
CO2 + H20
111
Name three ways we can get a high anion gap (increased organic acid production)
Lactic Acidosis: Increased anaerobic respiration causes increased lactic acid
Diabetic Ketoacidosis: Causes increase in ketoacids
CKD: Increase in urea
112
Name two ways we can get a high anion gap (accidental ingestion)
Oxalic Acid (Antifreeze)
Formic Acid (Methanol)
Salicylates
113
What three compounds can increase lactic acid production and thus, metabolic acidosis
Propylene Glycol
Iron Overdose
Isoniazid overdose
114
What acronym tells us about the causes of metabolic acidosis
MUDPILES:
Methanol
Uraemia
Diabetic Ketoacidosis
Propylene Glycol
Iron Tablets/Isoniazid
Lactic Acidosis
Ethylene Glycol
Salicylates
115
What causes a normal anion metabolic acidosis
A build up of chloride ions instead:
Na+ - (Cl- + HCO3-)
Cl- increases
HCO3- decreases
116
What is the most common cause of normal anion gap metabolic acidosis
Severe Diarrhoea
117
Why does diarrhoea cause metabolic acidosis
Inestinal and pancreatic secretions of HCO3- and Cl- cannot be re-absorbed fast enough
118
How does Type 2 renal tubular acidosis cause a normal anion gap metabolic acidosis
PCT cannot re-absorb HCO3- ions, causing them to decrease
119
How does Addison's cause normal anion metabolic acidosis
Adrenal glands cannot produce enough aldosterone, so less Na+ is re-absorbed at the DCT, causing less excretion of H+ = metabolic acidosis
120
What drug can cause normal anion gap metabolic acidosis
Spironolactone
121
How does Acetazolamide cause a normal anion gap metabolic acidosis
Reduces HCO3- reabsorption at the PCT
122
How does IV Saline cause normal anion gap metabolic acidosis
Saline has a pH 5.5, so reduces pH in the blood (rare
123
What acronym can help us to remember the causes of normal gap acidosis
HARDASS:
H - Hyperalimentation
A - Addison's
R - Renal Tubular Acidosis
D - Diarrhoea
A - Acetazolamide
S - Spironolactione
S - Saline Infusion
123
What acronym can help us to remember the causes of normal gap acidosis
HARDASS:
H - Hyperalimentation
A - Addison's
R - Renal Tubular Acidosis
D - Diarrhoea
A - Acetazolamide
S - Spironolactione
S - Saline Infusion
124
What range of pCO2 defines if compensation is adequate in metabolic acisosis
28.5 -> 32.5
125
If the calculated pCO2 < Measured pCO2, what does this entail
Metabolic acidosis WITH associated repiratory acidosis
126
If the calculated pCO2 is greater than the measured pCO2, what does this mean
Metabolic acidosis with associated respiratory alkalosis
127
What causes respiratory acidosis
Hypoventilation, causing an increase in CO2
Equilibrium shifts to the right causing an increase in H+ ions
128
What compensation occurs in respiratory acidosis
The kidneys try to absorb more HCO3- ions to shift the equilibrium to the left (to reduce H+ ions)
129
How long does the compensation by th ekidneys take
24 hours
130
Acute vs Chronic respiratory acidosis
Acute: pH is VERY low and HCO3- is normal
Chronic: pH is NORMAL and HCO3- is very elevated
131
Two causes of hypoventilation
Airway obstruction
Diaphragm or chest wall muscles not working properly (e.g., obesity)
COPD
Opioids etc
132
What causes metabolic alkalosis
Loss of H+ ions
133
Describe the compensatory mechanism for metabolic alkalosis
Immediate hypoventilation
134
Nma eto GI causes of H+ loss
Vomiting
Inability for the pancreas to excrete HCO3- ions
Hyperaldosteronism
135
What drugs can cause metabolic alkalosis
Using loop diuretics
Antacids (contain HCO3- ions)
136
What acronym can help us to remember the causes of metabolic alkalosis
LAVA
L - Loop Diuretics
A - Antacid Use
V - VOmiting
A - Aldosterone Increase
137
What can cause respiratory alkalosis
Hypoxia
Pulmonary Embolisms
High Altitudes
Anything that can cause hyperventilation:
Salicylates overdose (initial)
Anxiety + Panic Attacks
Tumours in the brain
138
What acronym can help us remember the cuases of respiratory alkalosis
PAST PH
Panic Attacks
Anxiety Attacks
Salicylates
Tumour
Pulmonary Embolism
Hypoxaemia
139
Why does metabolic acidosis cause hyperkalaemia?
In order for H+ ions to enter the cell, K+ ions have to be pushed out (exchanged).
Lots of H+ ions enter the cells, causes lots of K+ ions to be pushed out -> leading to hyperkalaemia
140
How do beta blockers cause hyperkalaemia
Block the Na+-K+-ATPase, causing more K+ to be left outside the cell
141
Why does cell lysis (and apoptosis) cause hyperkalaemia?
Detsruction of cells causes lots of internal K+ ions (ICF) to be released into the ECF
142
Name three components to tumour lysis sydnrome
Hyperkalaemia
Hyperphosphataemia
Hyperurecaemia
Hypocalcaemia
143
What injuries cause hyperkalaemia
Crush Injuries
144
Where does aldosterone act
Collecting Duct
DCT
145
What cells are responsible for K+ secretion in th ekidneys
Principal cells
146
What drugs can cause hyperkalaemia and how?
They reduce the effect of aldosterone:
Renin Injbitors
ACE Inhibitors
Angiotensin II receptor antagonist
Selectiev Aldosterone blockers
K+ sparing diuretics
147
How can acute and chronic Kidney Injruy cause hyperkalaemia
Impair K+ Excretion
148
What blood test indicates chronic kidney injury
Uraemia
149
What are the causes for internal balance shifted hypokalaemia
Hyposomolality
150
How does hyponatraemia cause hypokalaemia
Water moves back into the cells (as the concentration gradient shifts), bringing back K+ ions with it.
151
How does hyperglycaemic hyperosmolar state cause hypokalaemia
Osmolairty is so high, it can cause osmotic diuresis (K+ lost in the urine)
152
How does metabolic alkalosis result in hypokalaemia
H+ ions are being secreted from cells to compensate, causing K+ to be exchanged and taken back in - hypokalaemia
153
How does Insulin effect K+ levels
An increase causes hypokalaemia, a deficiency causes hyperkalaemia
154
Why does insulin effect K+ levels in the blood
Stimulates Na+=K+= ATPase
155
What causes an external balance shift hypokalaemia
Reduction in K+ intake: Anorexia, Prolongued fasting and diets
Excretion issues:
Vomiting and Diarrhoea
Sweat (excercise a lot in hot climates)
156
What causes an increased K+ excretion
Hyperaldosteronism:
Conn Syndrome
Compensated Heart Failure
Cirrhosis
Loop Diuretics and Thiazides
157
What are the two main readings on an ECG for hyperkalaemia
Tall tented t waves
Widened QRS complexes
158
Signs of hypokalaemia on an ECG reading
Flattened T Waves
U Waves
159
Signs of hypokalaemia
Muscle weakness and cramps
Spasms
160
What cause hypernatraemia
H20 loss
161
What causes false hyponatraemia
Too much cholesterol
Too much protein (raised) (e.g., multiple myeloma)
Where levels are normal but lab instruments say they're low
162
What is hypervolaemic hyponatraemia
Where total H20 is raised but Na+ stays the same (hyponatraemic)
163
What conditions cause hypervolaemic hyponatraemia
Congestive HF
Cirrhosis
Nephrotic Syndrome
ALL PRESENT WITH OEDEMA
164
What cause hypovaelamic hyponatraemia
Diarrhoea
Vomiting
Diuretics
Cerebral salt wasting
FLUID loss and Na+ loss
165
What is cerebral salt watsing
Intracranail injury (e.g., meningitis) disrupt sympathetic nervous system stimulation of the kidneys (causes loss of Na+)
166
What condition causes euvolaemic hyponatraemia
SIADH
167
What causes Parathyroid hormone related protein-mediated hypercalcaemia
Squamous cell carcinomas of the lung (mimics the effect of the lung)
168
What medication can cause hypercalcaemia and how
Thiazide diuretics
Increase ca2+ absorption at the DCT
169
Symptoms of hypercalcaemia
Stones
Bones
Groans
Thrones
Psychiatric overtones
PLUS resistance to ADH = frequent urination + dehydration
Calcium oxalate kidney stones
170
Name a genetic condition which can cause hypocalcaemia
DiGeorge Syndrome
171
What vitamin deficiency can cause hypocalcaemia
Magnesium Deficiency
172
What condition can result in hypocalcaemia
Pancreatitis (acute)
As destroyed fatty acid tissue of the pancrease from high lipase activity binds to calcium ions in the blood.
173
What medical proceedure can cause hypocalcaemia
Too many blood transfusions
174
Signs of hypocalcaemia
More exciteable
Tetany
Chvostick sign (twitching of facial muscles)
Trousseau sign (BP cuff can cause flexion of the wrist and elbow)
175
Signs of hypocalcaemia on an ECG
Prolongued QT interval
176
MOst common cause of hypermagnesemia
Kidneys cannot excrete Mg2+
Ingestion of mangnesium drugs or substances
177
Why does lethargy and reduced deep tendon reflexes occur in hypermagnesemia
Mg2+ is a cofactor that inhibits passage of neurotransmitters onto receptors
178
How does PTH effect magnesium levels
Stimulates the release of Mg2+ into the blood
179
How does hypermagnesemia affect hormone levels
Inhibits the release of PTH (hypocalcaemia)
180
Cardiac symptoms of hypermagnesemia
Bradycardia
Cardiac Arrest
181
Name four causes of hypomagnesemia
Prolongued malnutrition
Mg2+ not absorbed in the GI tract (PPIs, diarrhoea)
Loop and Thiazide diuretics
182
What is hungry bone syndrome
Surgical removal of the thyroid causes increased bone formation.
Bone are 'hungry' for ions so consume all the Mg2+ in the blood
183
What electrolyte imbalance causes Torsades de pointes
Hypomagnesemia
184
Why are hypomagnesemia and hypokalaemia related
Diarrhoea and diuretics cause BOTH
185
What inherited disease can result in fanconi Syndrome
Wilson's
186
What cancer can result in fanconi Syndrome
Multiple Myeloma
187
How does multiple myeloma cause fanconi syndrome (Kidney Damage)
Plasma cells produce abnormally shaped immunoglobulins which damage the PCT
188
Signs of Fanconi Syndrome
Damage to the PCT causes loss of HCO3- ions: Renal tubular acidosis type 2 (Metabolic Acidosis)
Damage to PCT causes loss of phosphate ions (hypophosphataemia)
189
What GI complication can PCKD result in
Divrticulitis
190
Name three peices of advice to give someone with CKD
Avoid Salt containing food
Avoid phosphate containing foods (e.g., meat and dairy foods)
191
What happens to phopsphate levels in later stages of CKD
They become very raised (as the kidneys are unable to excrete them)
192
What is the problem with raised phosphate levels in the blood
Can cause hypocalcaemia
193
How long should cefalexin/co-amoxiclav be used to treat Pylonephritis
7-14 days
194
What drugs should be stopped in hyperkalaemia
Digoxin
Beta blockers
195
If ECG does not normalise with calcium gluconate, what should ve done
Give 10ml every 10 minutes (up to 50ml)
196
Should calcium gluconate be given in the absence of ECG changes?
No
197
Name two ways potassium can be shifted into cells
10 units of insulin + 25g glucose
10% glucose infusion over 5 hours + 7.0 mmol/L glucose
198
Why is glucose given alongside insulin
Prevent hypoglycaemia
199
What medication is used to remove potassium from the body
Calcium Resonium + Lactulose
200
If glucos and IV insulin continue to have no impact on hyperkalaemia, what should be done
Dialysis or Sodium Bicarbonate
201
What is the main presentation of hypercalcaemia (2.8 mmol or less)
Polyuria and Polydipsia
Dyspepsia
202
At what calcium levels do people get ECG changes
>3,5 mmol/L
203
What is the most common cause of raised calclium levels
Primary Hyperparathyroidism
204
In conjuction with what other serum level does hypercalcaemia indicate dehydration as the cause
Raised albumin
205
If there is hypercalcaemia in the presence of NORMAL ALP, what is the cause
Myeloma
206
If there is hypercalcaemia in the presence of raised calcitonin levels, what is the likely cause
B-cell Lymphoma
207
Managmenet of acute hypercalcaemia
0.9% 2-3L of Calcium to increase urinary output
THEN bisphosphonates
208
What hormone does phosphate stimulate and why
PTH, hyperphosphataemia in CKD can cause PTH to be released (secondary hyperparathyroidism)
209
Why do we not get hypercalcaemia in CKD caused secondary hyperparathyroidism
Because PTH mechanisms tend to fail, so phosphates usually stay elecated and calcium levels remain normal
210
What is the role of ANP
Stops RAAS activation + lowers BP
211
What diagnostic is used for vesicoureteric reflux
Micturating Cystourethrogram
212
What investigations is used to check renal perfusion
DTPA
213
Role of podocytes
Has foot processes which allow filtration in the kidneys
214
Management of focal segmental glomerulonephiritis
Prednisolone
215
What is distinctive of rapidly progressive glomerulonephritis under microscopy
Crescent shapes: Aggregated of macrophages and epithelial cells in the Bowman's capsules
216
What immunosuppressive agent is used in kidney transplants
Tacrolimus
217
What does a urine sample show for pre-renal AKI
No proteins and no blood
218
Management of mild hyponatraemia (130-135 mol/L)
Stop medication causing the issue or check for underlying issues at primary care
219
Define accelerated progression of CKD
A sustained decrease of 15 in eGFR over 12 months
220
What albumin:creatinine ratio describes proteinuria that should require referral to nephrology
70 or more
221
At what urianry albumin: creatinine ratio, should antihypertensives be considered in
<30 mg/mmol
