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DIT Level 2 > Nephrology > Flashcards

Nephrology Flashcards

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1
Q

Poststreptococcal glomerulonephritis

A

Subepithelial IgG immune complex depositions
MC in children
1-3 weeks after strep infection

Findings:
HTN
Edema
Brown urine - tea color, cola color
high ASO titer
Anti-DNAse B

EM: subepithelial “humps”, hypercellular glomeruli

Tx: supportive, self limited

"PHARAOH"
Proteinuria
hematuria
Azotemia
RBC casts
Anti Strep/Anti DNAseB
Oliguria
Htn
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2
Q

Lupus nepritis

A

Mesangial
Membranous
Focal nephritis
Diffuse nephritis - MC and worse

SLE -> variable changes
-Immune deposits, proliferation of mesangial cells, thickening of GBM

Findings:
Proteinuria
ANA
Anti-DNA Ab
LM - endothelial deposits cause "wire loops"
Tx:
glucocorticoids
ACE-I
statin
Immunosuppressant - cyclophosphamide or mycophenolate mofetil
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3
Q

Granulomatosis with polyangiitis (Wegener’s)

A

Granulomatous vasculitis - kidneys, lungs, upper airwas

Findings:
Microscopic hematuria
Pulmonary nodules/infiltrates
Saddle nose, sinus disease, pallet granuloma/ ulcers
c-ANCA

Tx:
glucocorticoids
cyclophophamide

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4
Q

Goodpasture’s syndrome

A

IgG antibodies against the glomerular basement membrane

Findings:
Proteinuria and hematuria
Cough/hemoptysis
Pulmonary infiltrates
IF: linear deposits

Tx:
Plasmapheresis
Glucocorticoids

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5
Q

IgA nephropathy (Berger dz)

A

IgA immune complexes in the mesangium
Mesangial proliferation

Findings:
URI/tonsillitis
children with Henoch-Schonlein purpura

EM/IF: mesangial deposits - dark/dense

Tx:
ACE-I
Glucocorticoids
cyclophosphamide

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6
Q

Alport syndrome

A

X linked - type IV collagen synthesis
Defective basement membranes - splitting BM

Findings:
Cataracts
Nephritis
High frequency hearing loss

Tx:
Ace I
renal transplant

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7
Q

Pauci-immune rapidly progressive glomerulonephritis (RPGN)

A

Cresent-shaped fibrin deposits int he glomeruli
Scarce immune complex deposits

Findings:
microscopic hematuria
proteinuria
p-ANCA

Tx:
rapid progression to ESRD - weeks to months
Glucocorticoid
Cyclophosphamide

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8
Q

Nephrotic syndrome

A

proteinuria >3.5 g/24 hrs
hypoalbuminemia less than 3
peripheral edema

Hypercoagulability
hld
htn
Ascites
foamy urine
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9
Q

Minimal change disease

A

Effacement of podocyte foot processes
MC children

Findings:
proteinuria
hypoalbuminemia
edema - periorbital, sacral, scrotal
HTN

Tx: glucocorticoids

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10
Q

Focal segmental glomerular sclerosis

A

Sclerosis is focal - less than half of glomeruli, darker pink
Segmental - only part of each glomerulus

MC cause of nephrotic sn in adults
higher in AA, latinos, HIV

Tx:
glucocorticoids
ACE-I
Statin
\+/- cyclosporine
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11
Q

Membranous nephropathy

A

Thickinging of BM
Spike and dome

Idiopathic or secondary to SLE or Hep B

Proteinuria MC than hematuria

Tx:
ACE-I
statin
+/- Cyclophosphamide + steroid

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12
Q

Membranoproliferative glomerulonephritis

A

train track appearance
Subendothelial humps of IgG along GBM -> formation of second GBM
Mesangial cells proliferate between GBMs
Mesangial immune deposits

Assoc with:
SLE
Subacute bacterial endocarditis
Hep C

Tx:
underlying cause
glucocorticoids
+/- cyclophosphamide

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13
Q

Diabetic nephropathy

A

Thickening of the GBM
Kimmelstiel-Wilson nodules - aceullular eosinophilic nodules in the mesangium
Expansion of the mesangium

proteinuria more common than hematuria

Tx:
Aggressive glycemic control
Aggressive BP control
ACE-I or ARB

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14
Q

Renal Amyloidosis

A

Abnormal amyloid proteins deposit in tissues - kidney, heart, liver, muscles, brain

Expansion of mesangial matrix
Congo red stain: amyloid proteins apple-green birefringence

May be due to:
Plasma cell dyscrasia (Ig light chains)
Chronic inflammatory diseases - RA, spondyloarthropathy, IBD
hemodialysis
heritabile amyloidosis

Tx:
mephalan - suppress BM
Hematopoietic cell transplant

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15
Q

Hyaline casts

A

Concentrated urine - low flow urine, diuretics, dehydrated

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16
Q

RBC casts

A

Glomerular bleeding - nephritis, vasculitis

17
Q

WBC casts

A

Tubular interstitial disease, acute pyelo, other glomerular dz

18
Q

Epithelial cells casts

A

ATN, acute interstitial nephritis, glomerulonephritis

19
Q

Granular casts

A

ATN (MC)

Muddy brown casts

20
Q

Acute interstitial nephritis

A

Causes:
MC - drugs: B-lactams, sulfonamides, aminoglycosides, NSAIDs, allopurinol, PPIs, diuretics
Infections - strep, TB, EBV, CMV, E. coli, candida
Autoimmune: SLE, sarcoidosis, Sjogren

Presentation:
Rash
Fever
Elevated creatinine
Eosinophilia - serum and urine

Dx: renal bx

Tx: stop offending agent
Refractory - corticosteroids
Hydrate, supportive

Complications: acute tubular necrosis, ESRD

21
Q

Pyelonephritis

A

Organisms:
E. coli, S. saprophyticus, klebsiella, Proteus
Candida - immunocompromised

Risk:
Urinary obstruction
BPH
Cancer
Previous pyelonephritis
Diabetes
Indwelling catheter
Pregnancy
Presentation:
Suprapubic/ flank pain
Fever/ chills
N/V
Urinary frequency, dysuria, and urgency

Labs:
Elevated WBCs
WBC casts
positive urine cx >100000 bacteria

CT/US to r/o obstruction

Tx:
Inpatient - empiric antibiotics IV
Ceftriaxone
Cefepime
Levofloxacin
Ciprofloxacin
astreanam
22
Q

Polycystic kidney disease

A

AR - kids, early death w/o transplant
AD - adults, MC

Presentation:
Asx until advanced
Flank pain
Chronic UTIs
Gross hematuria
Palpable kidneys
Hypertension

Labs:
elevated BUN, Cr
Anemia - low epo
Hematuria, proteinuria

US and CT - large multicystic kidneys

Tx:
ACE/ARB to control htn
statins
vasopressin receptor antagonists (tolvaptan) to decrease cAMP and decrease cysts

Complications:
ESRD
Hepatic cysts
Intracranial aneurysms
MVP
AR
23
Q

Renal cell carcinoma

A

MC primary malignant neoplasm of renal parenchyma

Risk factors:
Smoking
Exposure to cadmium and asbestos
Increase stage

Presentation:
Flank pain
Weight-loss
Abdominal/ flank mass
Hypertension
Fever
Hematuria
Scrotal varicocele

Labs:
Renal failure
Polycythemia - elevated epo activity

Dx:
Biopsy not necessary - risk seeding peritoneum
Imaging adequate

Tx:
Nephrectomy or renal sparing resection with LN dissection
Immunotherapy
Radiation, chemo

Poor prognosis if not caught early

24
Q

Acute kidney injury criteria

A

Abrupt increase in creatinine >0.3 in 48 hrs
>50% increase in Cr
Oliguria of less than 0.5 ml/kg/hr for more than 6 hrs

25
Q

Causes of acute kidney injury

A 
Prerenal:
Hypovolemia - acute hemorrhage
Systolic heart failure
NSAIDs
Septic shock

Intrarenal:
Glomerular disease
Acute tubular necrosis
Poly cystic kidney disease

Postrenal:
Prostate disease
Metastatic cancer
obstruction

26
Q

Presentation of acute kidney injury

A 
Elevated creatinine
Edema
Hypertension
Low urine output
Fatigue
Anorexia
Vomiting
Altered mental status
Seizures
27
Q

Fractional excretion of sodium

A

FEna = (Una/SerumNa)/(Ucr/Serumcr)

Less than 1%: prerenal - retaining sodium and fluid

> 2% intrinsic renal disease - post renal

28
Q

Chronic kidney disease

A

MC causes: htn, DM

Presentation:
Fluid overload: hypertension, edema
Uremia: encephalopathy
Decreased epo: anemia

Labs:
Elevated creatinine, potassium, phosphate
Decreased sodium
Vit D deficiency
Increased urine Micro albumin (DM, HTN) - early sign, start ACE/ARB

Tx:
Stop smoking
Aggressive BP control
-loop diuretic, ACE/ARB
-b-blockers reduce CAD risk
-Nifedipine, amlodipine - risk LE edema
DM: aggressive control - avoid metformin
Aggressive lipid control - Statins
Iron and Epo
Vit D replacement
Phosphate binders - Phos-lo
Daily ASA 81 mg - reduce endothelial injury and CAD risk
29
Q

Indications for dialysis

A 
Severe hyperkalemia
Severe metabolic acidosis
Fluid overload
Uremic syndrome
CKD - Cr over 12, BUN over 100
Severe overdose or toxic exposure
30
Q

Staging of chronic kidney disease

A

by 30s

Stage 1 - GFR over 90
Stage 2 GFR 60-89
Stage 3 a GFR 45-59
Stage 3b GFR 30-44
Stage 4 GFR 15-29
Stage 5 GFR less than 15
31
Q

DDx for hypovolemic hyponatremia

A

Urine sodium less than 10 - extra renal losses

  • GI losses - V/D, NG tube
  • Fluid sequestration - peritonitis, pancreatitis
  • Insensible loses - sweating, extensive burns

Urine sodium greater than 20 - renal losses
Diuretics - thiazides
Salt losing renal disease
Partial urinary tract obstruction
Adrenal insufficiency - inadequate mineralocorticoid, Addison

32
Q

DDX for hypervolemic hyponatremia

A

Urine sodium less than 10 -
CHF
Cirrhosis
Nephrotic syndrome

Urine sodium over 10
Renal failure

33
Q

SIADH

A

Causes:
CNS disease - Head trauma, brain tumor, stroke, CNS infection, pituitary surgery
Pulmonary disease - pneumonia, tumors - small cell
Drugs: NSAIDs, antidepressants, antipsychotics, antineoplastic agents, carbamazepine, ecstasy, vasopressin, DDAVP
Other: HIV/AIDS, major domino or thoracic surgery

Labs:
Hyponatremia
Low serum osmolality
High urine osmolality
Urine sodium > 20
34
Q

Pseudohyponatremia

A

Serum volume is expanded by substance -lipid or protein (multiple myeloma)
Sodium per volume of serum may decrease even though amount of sodium per unit of water is appropriate

35
Q

Treatment of hyponatremia

A 
Treat underlying condition
Restrict free water
Loop diuretic
Hypertonic saline if severe
Vasopressin receptor antagonists (conivaptan, tolvaptan)
36
Q

Central pontine myelinolysis

A

Occurs when sodium is corrected by more than 12-20 over 24 hours or overcorrected to above 140

Sxs irreversible - delayed 2-6 days after correction of hyponatremia

Dysarthria
Dysphasia
Paraparesis or quadriparesis
Behavioral disturbances
Lethargy
Coma

CT/MRI 4 weeks after event - areas of demyelination

37
Q

Hypernatremia

A

Causes:
Dehydration
Osmotic diuresis
Diabetes insipidus

Presentation:
oliguria
Thirst
Weakness, lethargy
Mental status changes
Seizures

Tx:
Correct the volume status
Reduce sodium by no more than 12/day to avoid cerebral edema

DIT Level 2 (49 decks)

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