nephrology Flashcards
normal calcium with high pth
secondary due to CKD with normal phos
cannot be primary, has to be secondary
start activated vitamin D
hyponatremia+ normal plasma osmolarity in the presence of lipids/proteins (panc/ multiple myeloma) with no ingested osmoles
pseudohyponatremia
minimal change disease (podocyte foot processes) treatment
steroids, if contraindicated->cyclosporine
if refractory->cyclophosphamide
Thyrotoxic periodic paralysis
2/2 hypokalemia
precipitated by strenous exercise/high carb meal
treat hyperhyroidism
Metabolic alkalosis+ hypokalemia+ normal-low BP
Bartter syndrome
autosomal recessive
Preggo htn
No ACEI/ARB/direct renin inhibitor
labetalol if >160/105
lithium kidney
diagnosis
nephrogenic diabetes insipidus
water restriction test, then desmopressin administration
> 60 yo BP goal
150/90. Adding a second agent is more effective than increasing existing dose.
Acute acid-base compensation
chronic
for every 10 drop in co2, 2 drop in bicarb
for every 10, 4-5
for every 10 increase, 3-4
CKD with normal anion gap metabolic acidosis
oral bicarb, maintain bicarb 23-29
interstitial nephritis urinalysis
cause
membranous glomerulopathy
rapidly progressive glomerulonephritis
sterile pyuria and leukocyte casts
drugs (mesalamine)
heavy proteinuria and nephrotic syndrome (primary: anti pla2r, sec: cancer, autoimmune disease, hepatitis b, syphilis, meds). most associated with clots
hematuria, erythrocyte casts, hypertension
Preeclampsia
HELLP
hypertension+ proteinuria OR htn+end organ damage
hemolysis+ elevated LFTs+ low platelets
hyperphosphatemia in CKD treatment
sevelamer/ lanthum
hyporesponsiveness to EPO
give iron especially if
iron deficiency
transferrin <30% / ferritin <500
Lines in CKD5/ESRD patient
central venous access
preggo na
mild hyponatremia and hypo osmolality
IgA vasculitis (henoch-schonlein purpura)
URI->then fatigue, jt pain, abd pain, glumeronephritis, palpable purpura
NORMAL COMPLEMENT LEVELS
Vomiting urine labs
bartter
sjogren’s
increased sodium, low chloride, elevated urine potassium
increased everythang
hyperchloremic metabolic acidosis
Shiga-toxin associatd hemolytic uremic syndrome
diagnosis
bloody diarrhea, then microangiopathic hemolytic anemia, thrombocytopenia, kidney failure, shiga toxin e. coli
peripheral blood smear (even in TTP, smear before ADAMST13)
**can also be caused by chemo(bevacizumab, sunitinib)
Suspected kidney stone when CT is contraindicated (preggo)
kidney ultrasound
calcium oxalate stones with elevated urine oxalate (from too much oxalate or low calcium/fatty acids binding calcium)
deceased citrate in urine
idiopathic hypercalciuria
increase calcium intake/ cholestyramine (esp in patients who have undergone small bowel resection)/ UOP of at least 2L
give citrate to bind calcium in urine and prevent stones
thiazide
Medication induced tubulointerstitial disease (AIN/CIN) (tenofovir, PPI)
slowly progressive, no clear trigger, subnephrotic proteinuria, bland sediment, atrophic kidneys on u/s
glucosuria, hypophosphatemia
membranoprolif glomerulonephritis
chronic hep b, hematuria, dysmorphic casts, proteinuria, reduced GFR
Beware of refeeding syndrome in alcoholics and malnourished. can occur even with dextrose containing fluids, due to
hypophosphatemia
Hypertension diagnosis
Rule out meds such as
140/90 3 different times over 1 week or longer
NSAIDs (also cause hyperkalemia) and herbs
Anion gap metabolic acidosis in patients with short bowel
ethylene glycol/methanol/propylene glycol
D-lactic acidosis
confusion, slurred speech, ataxia
osmolal gap >10
dialysis catheter related infection
abx, then remove catheter if blood cultures are positive
Metabolic alkalosis with uncertain volume status
measure urine chloride
low: hypovolemia, give saline
high: saline resistant
Bilateral abdominal masses with kidney symptoms
ADPKD, hematuria and acute pain occur with rupture of cysts
MRA to screen for cerebral aneurysm only if family history of aneurysm/hemorrhage or personal history or occupation where sudden rupture would affect others
TLS
Rasburicase
Dialysis if
hyperphosphatemia, hyperuricemia, hyperkalemia, hypocalcemia
rapidly decreases uric acid
oliguric/anuric/persistent hyperkalemia/syptomatic hypocalcemia/
Rasburicase vs allopurinol
reduces circulating uric acid vs prevents formation
IgA nephropathy treatment
low risk: observe, serial BP, urine studies and creatinine
high risk: steroids (urine-protein creatinine ratio >1000, low GFR, hypertension, kidney dysfunction)
preeclampsia treatment
delivery at 37 weeks
FSGS
primary treatment
secondary
collapsing form FSGS caused by
low albumin, podocyte foot process effacement, hypertension, nephrotic range proteinuria
immunosupression
weight loss and ACEI/ARB (enlarged glomeruli, mild effacement, minimal edema)
HIV (can be slowed by HAART and ACEI/ARB)
atheroembolism
treatment
peripheral eosinophilia, hypocomplementemia, eosinophiluria
supportive care
black people hypertension
ccb, hctz (ccb is not first choice if patient is on statin)
avoid ACEI as they don’t work as well
ethylene glycol intoxication
treatment
anion gap+ osmolal gap+ kidney failure+ AMS
sodium bicarb+ fomepizole+ dialysis+ hydration
ESRD referral
stage 4-5, transplant eval once GFR<20
Kidney dysfunction in patients who have had abd surgery, have received fluids, have ascites + tense abdomen
diagnosis
Abdominal compartment syndrome
bladder pressure management
ESRD on dialysis renal cysts and atrophic kidneys
acquired cystic kidney disease, associated with RCC
CKD screening in DM
urine albumin
hyperosmolar hyponatremia
glucose: every 100 increase, 1.6 drop in sodium
primary respiratory acidosis
hypoventilation, opioids
prevent CIN with
IV isotonic saline, discontinue diuretics
AIN urinalysis
erythrocytes, lekocytes, leukocyte casts
coffin lid shaped crystals
struvite stone->removal
caused by chronic UTI with proteus or klebsiella
worsening kidney function+ htn+ proteinuria+hematuria+ dysmorphic erythrocytes+ erythrocyte casts
fever+arthralgia+ palpable purpura+ weight loss
glomerulonephritis->kidney biopsy
vasculitis
Overcorrection of sodium
treatment
> 8/ 24 hours
desmopressin in dextrose
Hypertension in frail people
frail=can’t complete 6 meter walk in less than 8 secs
don’t need to lower
in non frail elderly people, 130/80
Hypertension in frail people
frail=can’t complete 6 meter walk in less than 8 secs
don’t need to lower
in non frail elderly people, 130/80
SIADH vs beer potomania
high urine osmolality
Type 1 (hypokalemic distal) RTA
acetaminophen Type 2 (proximal) RTA
Type 4 (hyperkalemic distal) RTA
hyperchloremic metabolic acidosis, normal anion gap, ph>6, stones
anion gap metabolic acidosis
normal anion gap, hypokalemia, glycosuria, proteinuria, phosphate wasting, urine ph <5.5
urine ph<5.5, hyperkalemia, hypoaldosteronism
Aminoglycoside AKI
ATN, granular casts, FeNa >1%, 5-10 days after
immunosupression complications
DM and HLD, HTN, infection, cancer
always check for medication interactions before starting treatment
Stone larger than 1cm/ failed medical management/ urosepsis/ AKI/ anuria
mechanical removal
IgG4 related interstitial nephritis
treatment
interstitial nephritis=mild proteinuria, leuks
associated with autoimmune panc, diffusely enlarged kidneys
steroids
ANCA-associated vasculitis
anti-GBM
anti-GBM treatment
vs microscopic polyangitis
lupus nephritis
significant proteinuria and hematuria
pulmonary-renal syndrome, protein, erythrocytes and leuks in urine, normal complements, crescents on biopsy
cyclophosphamide, steroids, plasmapheresis
pauci immune glomerulonephritis on biopsy
significant proteinuria
hypovolemic metabolic alkalosis normal urine response
low urine sodium and choride
if high->suspect diuretic use/Bartter/Gittelman
decreased muscle mass creatinine
decreases
normal anion gap metabolic acidosis workup
urine anion gap (Na+K-Cl)
positive: losing acid in urine
negative: GI loss (laxative abuse)
screening in kidney transplant patients
skin cancer and lymphoprolif disease in addition to age and sex appropriate screening
risk factors for AKI after cardiac surgery
CKD, elevated preop creatinine, age, female, LV dysfunction, DM, PVD, COPD
bone pain + hypophosphatemia+ low 1,25 vitamin D+ normal 25 hydroxy + elevated alk phos
treatment
oncogenic osteomalacia
resection
ATN with oliguria (needing dialysis) + hemodynamic instability
CRRT, not hemodialysis
Bactrim causes creatinine increase without affecting GFR.
Continue therapy
Feurea<35 or FeNa <1
pre-renal
lupus nephritis treatment
Class III/IV->prednisone + mycophenolate/ cyclophosphamide
Balkan endemic nephropathy
tubulointerstitial disease linked to aristolochic acid, increased risk of transitional cell carcinoma
annual urine cytology
hemoglobinuria
no erythrocytes
can be caused by intravascular hemolysis from mechanical valve
Resistant hypertension
In CKD
3 agents including DIURETIC. if BP uncontrolled, start diuretic.
use loop diuretic
AL amyloidosis
infiltration: cardiomyopathy, organomegaly, peripheral neuropathy, purpura, macroglossia, proteinuria , diarrhea, postural hypotension
apple green on congo red staining
Myeloma proteins cannot be seen on dipstick testing
Hematuria
glomerular hematuria
glomerulus vs somewhere else
tea-colored urine with dysmorphic erythrocytes+ proteinuria
Thin glomerular basement membrane disease
hereditary nephritis (Alport syndrome)
family history of hematuria, normal kidney function
ESRD, x-linked, sensorineural hearing loss, lenticonus
combination antihypertensive therapy when
> 20/10 above goal
ESRD in elderly patients with plenty of comorbidities and poor functional status
no dialysis
uric acid kidney stones treatment
if refractory
water for increased UOP, urine alkalinization,
allopurinol
isolated hematuria in young person
serial kidney function and urine protein measurements
infection related glomerulonephritis
treat underlying infection (hematuria and leuks in septic patient)
