Nephrology Flashcards
Presentation of Goodpasture’s syndrome
Cough, hemoptysis, SOB
Glomerulonephritis
What are best initial and most accurate test for Goodpasture’s syndrome?
Initial: anti-basement membrane Abs
Accurate: Renal bx showing “linear deposits”
Tx Goodpasture’s
Plasmapharesis and steroids
Presentation of Churg-Strauss Syndrome
Asthma, cough, eosinophilia with renal abnls
Best initial and most accurate test for Churg-Strauss Syndrome
Initial: CBC for eosinophil count
Accurate: biopsy
Best treatment of Churg-Strauss Syndrome
Prednisone
If not responding then cyclophosphamide
Presentation Wegener’s granulomatosis
Upper respiratory problems (e.g. sinusitis/otitis)
Lung problems
Systemic vasculitis symptoms
Best initial and most accurate test for dx of Wegener’S
Initial: cANCA (antineutrophil cytoplasmic antibodies)
Accurate: biopsy kidney
Tx Wegener’s
Cyclophosphamide and steroids
Presentation of polyarteritis nodosa
Systemic vasculitis affecting every organ system except the lung
Multiple motor and sensory neuropathies are key to dx
Best initial and most accurate test of polyarteritis nodosa
Initial: ESR and markers inflammation
Accurate: Biopsy of sural nerve or kidney
What disease are assd with PAN and should be tested for?
HBV and HCV
Angiography showing “beading” may be positive for what disorder
Polyarteritis nodosa
Tx PAN
Cyclophosphamide and steroids
What is the essential test for IgA/Berger’s nephropathy?
Renal biopsy (no good initial tests)
What is beneficial treatment for IgA/Berger’s nephropathy?
No good treatment really. Steroids and ACEi can be used to alleviate proteinuria; fish oil may delay progression
What is the most accurate test and finding for HSP (even though it isn’t necessary for confirmation)?
Renal biopsy showing IgA deposits
Best initial test and most accurate test for PSGN
Initial: Antistreptolysin O, anti-DNase, antihyaluronidase; also low complement levels
Accurate: biopsy showing subepithelial deposits of IgG and C3
How is HTN managed in PSGN?
Diuretics
A patient presents with joint pains, purpuric skin lesions, and has a hx of HCV. Dx?
Cryoglobulinemia
Best initial test for cryoglobulinemia?
Accurate?
Initial: serum cryoglobulin component levels
Accurate: biopsy
What are treatments of type I cryoglobulinemia? What are other options for other genotypes?
Type I: ledipsavir and sofosbuvir
Sofosbuvir and ribavirin are used for all other genotypes
Unlike other renal diseases, why is the biopsy in lupus nephritis especially important?
Because the extent of disease guides therapy
How is lupus nephritis treated based on the following levels of injury:
Sclerosis only
Mild disease
Severe disease
Sclerosis only: no treatment
Mild: steroids
Severe: mycophenolate mofetil and steroids
What are treatment options in HUS or TTP?
Plasmapharesis
DO NOT GIVE PLATELETS
What amount of protein on spot testing or 24 hr urine is concerning for nephrotic disease?
Spot protein: creatinine >3.5:1
24 hr urine protein > 3.5g or protein
Primary renal disorders such as MCD, FSGS, mesanigal, membranous, or membranoproliferative are all treated in the same manner, how?
Initial: steroids
If no response then add cyclophosphamide
If a patient has isolated proteinuria what should you do first?
Recheck and inquire as to why they might have that (e.g. infection, exercise, CHF, fever)
If still present it may be orthostatic proteinuria (e.g. in people that stand all day)
You suspect a patient to have orthostatic proteinuria. What further testing do you do?
Split the urine testing into morning and afternoon. If only proteinuria in afternoon that confirms orthostatic proteinuria. If persistent then get a 24hr urine or spot protein:creatinine. If that remains elevated consider a renal biopsy
How can you use urine volume in response to DDAVP to distinguish central from nephrogenic DI?
Prompt reduction in urinary volume with central DI but not in nephrogenic
Causes of hypervolemic hyponatremia
CHF
Nephrotic syndrome
Cirrhosis
Causes of hypovolemic hyponatremia
Diuretics
GI loss
Skin loss
What meds may cause SIADH?
Sulfonylureas, SSRIs, carbamazepine
What does urine look like (electrolyte wise) in SIADH?
High urine sodium and urine osmolality
Low serum osmolality
Tx SIADH
Fluid restriction
*In severe cases give saline infusion with loop diuretics, HTS, or consider ADH blockers like coinvaptan, tolvaptan
What are causes of hyperkalemia?
Metabolic acidosis Beta-blockers Insulin deficiency Digoxin toxicity Aldosterone deficiency (e.g. spironolactone) ACEi/ARBs (inhibit aldosterone) Type IV RTA Renal failure Prolonged immobility, seizures, rhabdo, crush injury
Why do beta blockers cause hyperkalemia?
They inhibit Na/K ATPase which normally brings K into cells
Why does pseudohyperkalemia occur?
Hemolysis in RBC sample from prolonged waiting or excessive time of tourniquet placement during phlebotomy
What ECG abnormalities arise in hyperkalemia and in what order?
1) Peaked T waves
2) Loss of P waves
3) Widened QRS
A patient presents with severe hyperkalemia with ECG abnormalities. What therapies do you want to give and in what order?
Calcium gluconate
Insulin and glucose
Kayexylate
If a patient has moderate hyperkalemia but no ECG abnormalities what therapies do you want to provide and in what order for correction?
Insulin and glucose IV
Bicarbonate if d/t metabolic acidosis
Kayexylate
What acid-base disturbance causes hypokalemia?
Metabolic alkalosis
What potent antifungal med causes hypokalemia?
Amphotericin
How does hypokalemia develop in Bartter syndrome?
Failure to absorb Na and Cl leads to secondary hyperaldosteronism which causes hypokalemia
What ECG abnl seen with hypokalemia?
U wvaes
What are signs and symptoms of hypermagnesia?
Muscle weakness and loss of DTRs
How do you treat hypermagnesia?
Restrict oral intake
Saline to promote diuresis
Occasionally dialysis if needed
How does hypomagnesia present?
Hypocalcemia and cardiac arrhytymias
How does Mg effect Ca levels?
Mg is required for PTH release which then leads to increased Ca. This is why Mg is given during torsades de pointes
What are causes of normal AG metabolic acidosis?
Diarrhea and RTA
Hyperchloremic normal AG metabolic acidosis caused by …
Diarrhea
Type I RTA (distal type) is due to ….
Potassium and bicarb levels are ….
Treatment is ….
Inability to excrete hydrogen ions in distal tubuke
Low
Bicarbonate (still absorbed at proximal tubule)
Type II RTA (proximal type) is due to …
Urine pH is ….
Treat with …
Inability to absorb bicarbonate at proximal tubule
Low
Diuretic (contraction alkalosis increases serum bicarbonate)
Type IV RTA caused by …
Potassium is …
Treat with …
Lack of aldosterone production or effect
High (only RTA to have increased)
Aldosterone (i.e. Fludricortisone)
What is the only RTA with a high urine pH?
Type I (d/t inability to excrete H+ at distal tubule) *as a result kidney stones form in this one
What is the utility of the urine anion gap?
Helps distinguish between diarrhea and RTA as causes of normal AGMA. Urine Na - Urine Cl.
If acid can be excreted from the kidney then urine Cl increases thus in diarrhea UAG is NEGATIVE.
In RTA UAG will be POSITIVE
Ingestion of too much antacid leads to what acid base disorder
Milk-Alkali syndrome (metabolic alkalosis)
What acid base disturbance does volume contraction cause?
Activation of RAAS system leads to secondary hyperaldosteronism which increases Na, decreases K. This leads to increased urinary loss of acid and thus a metabolic alkalosis
What is the most common cause of death in patients with cystic disease which develop cysts throughout body?
ESRD
How do you test for urge incontinence and what is used for treatment?
Urodynamic pressure monitoring
Anticholinergic agents
What therapies are used for stress incontinence?
Kegel exercises
Estrogen cream
What medication is used for HTN control in pregnant woman?
Alpha-methyldopa
