Nephrology Flashcards by Graham Fehr

What type of collagen is affected in both Goodpasture’s and Alport?

Type 4 collagen

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How do you distinguish b/w Goodpasture’s & Wegeners?

Wegener’s = 3 areas of involvement

- Kidney (hematuria)
- Lungs (hemoptysis)
- Sinuses (sinusitis or sinus abscess)

Goodpasture = 2 areas

- Kidneys (hematuria)
- Lungs (hemoptysis)

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Aside from lung and kidney involvement, what other finding is present w/ Goodpasture?

Anemia (from chronic hemoptysis)

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How do you differentiate b/w IgA nephropathy and PSGN?

Time from illness to kidney involvement

IgA (Berger) = 1-2 DAYS after URI
PSGN = 1-3 WEEKS after URI

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What findings are seen w/ Alport syndrome?

1) Kidney (hematuria)
2) Hearing loss (sensorineural)
3) Visual problems (loss of collagen that holds lens of eye in place)

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Polyarteritis Nodosa spares what area of the body?

LUNGS!

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If person has Polyarteritis Nodosa, what important health screening test should be performed?

Hepatitis B screen

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Is ANCA present in Polyarteritis Nodosa?

NO NO NO

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Angiography of renal or mesenteric vessels showing aneurysmal dilation + new-onset HTN. What are you thinking?

Polyarteritis nodosa

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Metabolic acidosis effect on blood Ca levels?

Acidosis (increased H+) causes Ca to leave the bone and INCREASE blood levels

Acidosis also decreases citrate levels, which normally acts to bind Ca –> now it’s unbound and available to form stones

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Patients with recurrent UTIs, B/L flank pain, urine pH 8.0, leukocyte esterase (+), nitrite (+). KUB shoes calcification in the kidneys. What is it?

What organism is responsible?

Magnesium Ammonium Phosphate stone (Struvite)

Proteus –> urease (+) that converts urea to NH3 and CO2

- NH3 hydrolyzes to NH4+ and increases urine pH (8-9)
- CO2 eventually precipitates with Ca

Bacteria get stuck in stones and Abx can’t penetrate them –> cause recurrent infections

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Treatment of PSGN?

Supportive

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Pneumonic to remember RTA?

Type 1: H+ (failure of H+ secretion)
Type 2: BIcarb (failure of HCO3 reabsorption)
Type 4: ALDO (aldosterone deficiency or resistance)

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Renal complications of sickle cell trait?

What sign do you look for?

Renal papillary necrosis –> vasa recta blood sickles in papilla due to low partial pressure of O2

Painless massive hematuria that resolves spontaneously

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Focal segmental glomerulosclerosis has what associations?

African American/Hispanic
HIV
Heroin

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Someone’s urine shows presence of rectangular, envelope-shaped crystals. His CMP shows anion-gap metabolic acidosis. What is the cause this?

Ethylene glycol ingestion

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Man has intensive L flank pain that radiates to the groin. He refers to his symptoms as stone passage b/c he has experienced this many times before. Urinalysis reveals hexagonal crystals. What is the cause?

What additional urinary test would be (+)?

Cystinuria –> it’s from a defective transport of dibasic amino acids (cystine, lysine, arginine, ornithine)

Urine sodium nitroprusside (+)

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In hyperkalmeia, if no EKG changes are found, what is the best initial treatment to lower potassium?

Loop diuretics

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Person with 4+ proteinuria, enlarged liver, and controlled HTN. Ultrasound of kidneys show b/l enlargement. What is most common cause? What is greatest factor for this?

What is seen on biopsy?

Amyloidosis –> look for

1) Hx of RHEUMATOID ARTHRITIS
2) Enlarged kidneys on US
3) Hepatomegaly

Rheumatoid Arthritis most common cause of AA amyloidosis

Amyloid deposits that stain w/ Congo red & have apple-green birefringence under polarized light

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What are the 2 causes of hematuria after a recent upper respiratory tract infection?

How do you differentiate between the 2?

PSGN, IgA Nephropathy

PSGN

 - Occurs 10-21 days after URI
 - Complement (C3 C4) are LOW

IgA Nephropathy

 - Occurs 5 days after URI
 - NORMAL complement levels

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36 yo male with occasional morning headaches and new onset HTN. Has B/L, non-tender upper abdominal masses felt. What is this?

What is best initial test?

ADPKD

Abdominal Ultrasound

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What are extra-renal complications of ADPKD?

Hepatic cysts
Cerebral aneurysms
MV prolapse
Aortic regurge
Colonic diverticula
Hernias

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When is a CT scan indicated in pyelonephritis?

*Persistent symptoms despite 2-3 days of therapy
History of kidney stones
Unusual urinary findings

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In hypovolemic hypernatremia, what is the best method of resuscitation via IV fluids?

0.9% NS –> avoid lowering sodium too quickly

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Immune disorder where you have low complement levels, increased rheumatoid factor, increased LFTs along with nephritic picture?

Cryoglobulinemia --> from chronic Hep C

Person with basic/alkalotic urine and UTI - suspect what bug?

*Proteus --> produces urease that converts urea to CO2 and ammonia --> ammonia combines with H+ to form ammonium hydroxide and causes the Urine to become BASIC/ALKALOTIC!!

Side effects of Loop diuretics?

Hypokalemia Metabolic alkalosis Kidney injury Causes volume contraction

What class of drugs can help pass kidney stones (2 types)?

``` a1 blocker (tamsulosin) CCB ```

Kidney biopsy shows dense deposits on GBM that is (+) for C3 but not immunoglobulins - what disease is this characteristic of? What is pathophys?

Membranoproliferative glomerulonephritis IgG directed against C3 convertase of alternative complement pathway --> persistent complement activation

What are 3 defining features of drug-induced allergic interstitial nephritis?

1. New-onset rash after starting drugs 2. Joint pain 3. Eosinophiluria

Woman is taking naproxen, acetaminophen, oxycodone, aspirin, atenolol, and simvastatin. She is found to have elevated BUN and creatinine with WBC casts present. What is most likely cause of renal symptoms?

Analgesic nephropathy!! **Look for history of aspirin, NSAIDs

What 2 conditions are caused by analgesic (aspirin, NSAIDs) use?

``` Papillary necrosis Tubulointerstitial nephritis (WBC casts) ```

30 yo woman develops recent onset occipital headaches. Her BP is 160/90 and has a R-sided renal bruit. What is the cause? What is best tx?

Fibromuscular dysplasia --> causing renal artery stenosis *Angioplasty w/ stent placement

Woman has transient vision loss in her R eye. Her grandmother had a stroke at age 50. Her BP is 164/103. There is a bruit below the R mandible, but chest and abdomen exams are normal. She has borderline low potassium and high renin. What is going on? Next best step?

Fibromuscular dysplasia * Women 15-50 yo * Resistant HTN * Increase in creatinine AFTER starting ACEi/ARB w/o any changes on BP Amaurosis fugax from FMD of cerebrovascular arteries Can affect renal, carotid, and vertebral arteries *Decreases perfusion to kidneys --> increases renin and aldosterone levels **Test --> CTA of abdomen/ultrasound

Why is someone in end stage renal disease having anemia?

No erythropoietin production *Normocytic normochromic anemia

4 side effects of recombinant erythropoietin?

* 1) Worsening of HTN * 2) Headaches * 3) Flu-like s/s 4) Red cell aplasia

Causes of nephrogenic DI?

Renal ADH resistance * *Hypercalcemia * *Hypokalemia * *Lithium, demeclocycline, foscarnet, cidofovir, amphotericin

Best 2 tests for ureteral stones?

US | CT w/o contrast

Patient has large amt of blood on urinalysis, but only 0-1 RBC on sediment microscopy. What is the most likely cause?

Myoglobin --> rhabdomyolysis (tonic-clonic seizures, immobility, electrocusion)

Most sensitive indicator of hypovolemia?

BUN/Cr ratio >20:1

3 ways to decrease risk of contrast-induced nephropathy?

1) Non-ionic contrast agents 2) IV fluid hydration 3) N-acetylcysteine

Most common drug causes of hyperkalemia?

non-selective B-blockers K-sparing diuretics (spiron, eperl, amiloride, trimaterene) ACEi/ARB NSAIDs (block renin/aldosterone)

Most common cause of RTA in infancy? What is it associated with? Lab findings?

RTA Type 2 --> defect in HCO3 resorption in kidneys *Nephrolithiasis Normal anion gap acidosis Alkalotic urine Low serum HCO3

What urine findings are seen with uric acid stones? How can you prevent formation of these stones in the future?

Acidic urine --> low urine pH (defect in renal ammonia excretion) * Alkalinize the urine to pH (6.0-6.5) * Potassium citrate --> alkalinizes the urine, citrate inhibits stone formation, and reduces crystallization

What is potential complication with IV acyclovir?

Crystalline-induced nephropathy --> prevent with adequate hydration

What osmolality values are seen with SIADH? What common drug is cause of SIADH? How?

LOW plasma osmolality (150) --> no water *NSAIDs --> potentiate the action of ADH

Membranous nephropathy has what associations?

**Hepatitis B SLE NSAIDs Adenocarcinomas

Membranoproliferative glomerulonephritis has what associations?

Hepatitis B Hepatitis C Lipodystrophy

Minimal change disease has what associations?

NSAIDs | Lymphoma

IgA nephropathy is associated with what?

URIs

What pulmonary-renal syndrome needs emergent plasmapheresis to minimize extent of kidney damage?

Goodpasture

Common cause of HTN in person with intermittent flank pain, hematuria, and palpable flank mass? What other organ is involved?

ADPKD Liver cysts (enlarged)

What 2 common classes of drugs will WORSEN renal function, especially during volume depletion?

ACEi --> dilate efferent arteriole NSAIDs/aspirin --> constrict the afferent arteriole *Both act to decrease GFR and RBF

Anyone on loop diuretics (Furosemide), you need to do this frequently? What drug is dangerous while on Loops?

CMP --> monitor for low potassium and magnesium *Can cause DIGOXIN toxicity!

What is suggested with palpable purpura, RBC casts, proteinuria, and hematuria? What systemic disease is associated with it?

Cryoglobulinemia *Hep C

Person with a seizure comes in to ER and has a metabolic acidosis. Why? What is next best step?

Seizures --> lactic acid production in muscles Observe and repeat labs in 2 hours --> this usually resolves in 2 hours

How does pregnancy affect renal physiology?

Renal plasma flow and GFR INCREASE in pregnancy --> decrease in serum BUN and creatinine from patient's pre-pregnancy baseline

What agents are used to drive K+ into cells, lowering serum levels?

Insulin + glucose | B2-agonists

Blood at the beginning of urination - where is lesion? Blood at the end of voiding w/ some clots - where is lesion? Blood during entire urinary stream?

Urethra Bladder/Prostate Ureters/Kidney

Person with systemic sclerosis develops acute onset rise in creatinine (3.8) and her BP is 235/117. Hb is 6.9. What is the cause? What is likely to be seen on peripheral smear?

Scleroderma renal crisis --> sudden-onset renal failure + malignant HTN Schistiocytes --> from HTN

61 yo male with DM and HTN has persistent hyperkalemia despite changes to medications. He also has low HCO3 with normal anion gap and low Na. BUN and Cr are in normal limits. What is the cause?

RTA Type 4 * Normal anion gap metabolic acidosis - Cortical collecting tubule is site for H+ and K+ excretion, regulated by aldosterone - Impaired function due to aldosterone deficiency or resistance will cause retention of H+ and K+ --> hyperkalemic RTA

Person with nephrotic syndrome is at risk for what complications?

*Hypercoagulation --> increased urinary loss of antithrombin 3, altered levels of Protein C and S, increased platelet aggregation * Protein malnutrition * Iron-resistent hypochromic anemia (transferrin loss) * Vit D deficiency * Increased susceptibility to infection (loss of Ig)

Best advice for future prevention of calcium kidney stones? Diagnostic study of choice for nephroliathiasis?

Decrease dietary protein and oxalate *CT scan

Older man has signs of BPH but UA does NOT show proteinuria or hematuria. His serum creatinine has increased from 1.2 to 2.1 over the past 4 months. PSA is normal. What is the cause? Next best step?

Bladder outlet obstruction --> suspect in BPH + acute kidney injury Renal ultrasound to r/o hydronephrosis

In someone with suspected nephrotic syndrome, they suddenly develop severe R-sided abdominal pain, fever, and gross hematuria. What is the cause? What is the likely type of nephrotic syndrome?

Renal vein thrombosis --> loss of antithrombin III (blocks coagulation factors) in the urine due to nephrotic syndrome leads to HYPERcoaguable state *Abd pain, fever, hematuria *Membranous glomerulopathy = most commonly seen with renal vein thrombosis

In CHF, what lab finding parallels the severity of the CHF?

Low Na *Decreased CO --> increased RAA --> more ADH = more free water retention The more dilution of blood = lower Na Increased ADH = decreased CO and blood supply to kidneys

A person with chronic renal failure is at risk for what bleeding condition? What is tx?

Uremic coagulopathy *Platelet dysfunction from several uremic toxins (guanidinosuccinic acid) --> PT/PTT normal, BT increased * BT is reflective of platelet function * Platelet count is NORMAL Tx: DDAVP --> increases release of Factor VIII:vWF multimers from endothelium storage sites