Nephrology Flashcards by Autumn Brubaker

Poststreptococcal glomerulonephritis

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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Lupus nepritis

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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Granulomatosis with polyangiitis (Wegener’s)

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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Goodpasture’s syndrome

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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IgA nephropathy (Berger dz)

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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Alport syndrome

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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Pauci-immune rapidly progressive glomerulonephritis (RPGN)

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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Nephrotic syndrome

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

Hypercoagulability
hld
htn
Ascites
foamy urine

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Minimal change disease

Effacement of podocyte foot processes
MC children

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

Tx: glucocorticoids

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Focal segmental glomerular sclerosis

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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Membranous nephropathy

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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Membranoproliferative glomerulonephritis

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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Diabetic nephropathy

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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Renal Amyloidosis

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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Hyaline casts

Concentrated urine - low flow urine, diuretics, dehydrated

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RBC casts

Glomerular bleeding - nephritis, vasculitis

WBC casts

Tubular interstitial disease, acute pyelo, other glomerular dz

Epithelial cells casts

ATN, acute interstitial nephritis, glomerulonephritis

Granular casts

ATN (MC)

Muddy brown casts

Acute interstitial nephritis

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

Pyelonephritis

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

Polycystic kidney disease

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

Renal cell carcinoma

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

Acute kidney injury criteria

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

Causes of acute kidney injury

``` 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

Presentation of acute kidney injury

``` Elevated creatinine Edema Hypertension Low urine output Fatigue Anorexia Vomiting Altered mental status Seizures ```

Fractional excretion of sodium

FEna = (Una/SerumNa)/(Ucr/Serumcr) Less than 1%: prerenal - retaining sodium and fluid >2% intrinsic renal disease - post renal

Chronic kidney disease

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 ```

Indications for dialysis

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

Staging of chronic kidney disease

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 ```

DDx for hypovolemic hyponatremia

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

DDX for hypervolemic hyponatremia

Urine sodium less than 10 - CHF Cirrhosis Nephrotic syndrome Urine sodium over 10 Renal failure

SIADH

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 ```

Pseudohyponatremia

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

Treatment of hyponatremia

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

Central pontine myelinolysis

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

Hypernatremia

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