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Internal Medicine > Nephrology > Flashcards

Nephrology Flashcards

1
Q

Discuss the KDIGO definition and stages of acute renal failure

A

Acute Renal Failure if any of the following:
- urine volume <0.5mL/kg/hr for 6 hrs
- increased serum creatinine by 26.5 within 48hrs
- increased serum creatinine by >1.5x baseline within 7 days
Stage 1 Any of the following
- increase in serum creatinine by >26.5
- increase in serum creatinine by 1.5-1.9x baseline
- urine <0.5mL/kg/hr for 6-12hrs
Stage 2 Any of the following
- Increase in serum creatinine by 2-2.9x baseline
- urine <0.5mL/kg/hr for >12hrs
Stage 3 any of the following
- increase in serum creatinine by >353.6
- increase in serum creatinine by >3x baseline
- urine volume <0.5mL/kg/hr for >24hrs
- anuria for >12hrs
- Initiation of renal replacement therapy

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2
Q

Discuss the definition and stages of chronic renal failure

A

Chronic Renal Failure if Any of the Following
- GFR <60mL/min/1.73m2 for >=3mon
- kidney damage for >3mon as defined as structural or functional abnormalities with or without decreased GFR
- proteinuria, hematuria
- polycystic kidney disease, hydronephrosis
Stage 1
- kidney damage with normal or high GFR >90
Stage 2
- kidney damage with mildly decrease GFR: 60-89
Stage 3
- moderately decreased GFR 30-59
Stage 4
- severely decreased GFR 15-29
Stage 5
- kidney failure GFR <15 or requiring dialysis

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3
Q

Discuss the presentation of acute renal failure

A 
Volume
- overload resulting in peripheral and pulmonary edema
Uremia
- malaise, fatigue
- n/v
- pruritus
- restless leg syndrome
- encephalopathy
- pericarditis
- glove and stocking sensory neuropathy
Metabolic acidosis with increased anion gap
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4
Q

Discuss the presentation of chronic renal failure

A 
Metabolic Syndrome
- hypertension, hyperlipidemia
- CHF
Anemia
- decreased EPO
Electrolyte abnormality
- hyperkalemia
- hyperphosphatemia
- hypocalcemia
Renal Osteodrystrophy
- bone lytic lesion due to increase PTH
Platelet Dysfunction
Hormone Imbalance
- thyroid hormone
Malnutrition
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5
Q

Discuss the pre-renal causes of renal failure

A 
Acute
- Fluid loss
      - renal loss from diuretic
      - GI loss from diarrhea, vomiting
      - shock
      - decreased circulating volume from CHF, cirrhosis, nephrotic syndrome
- Vascular
      - thromboembolism
      - aortic dissection
- Medication
      - NSAID from constriction of afferent arteriole
      - ACE inhibitor through dilatation of efferent arteriole
      - diuretics
Chronic
- fluid loss
      - hypervolemic state
- vascular
      - renal artery stenosis
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6
Q

Discuss the renal causes of renal failure

A

Acute
- Acute Tubular Necrosis (most common cause of hospitalization for ARF)
- any prolonged pre-renal cause
- medication: Aminoglycosides, Vancomycin, Methotrexate
- rhabdomyolysis, tumour lysis syndrome
- IV contrast
- Acute Interstitial Nephritis
- medication: all antibiotics, NSAID, PPI, phenytoin
- infection: Legionella, strep, EBV
- Glomerular Nephritis
- nephrotic syndrome
- nephritic syndrome
- Intrinsic Renal Vascular
- microangiopathy and hemolytic anemia: TTP, malignant hypertension
- cholesterol emboli
- vasculitis
Chronic
- instrinsic tubular and interstitial disease
- polycystic kidney disease
- nephrolithiasis
- sarcoidosis
- Sjogren’s
- Glomerular Nephritis
- nephrotic: diabetic
- nephritic
- Intrinsic Renal Vascular Pathology
- nephrosclerosis due to hypertension

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7
Q

Discuss the post-renal causes of renal failure

A 
Tumor
- male: BPH, prostate cancer
- female: cervical, ovarian
- bladder
Structural Urologic Obstruction
- bladder stones
- strictures along urinary tract
- papillary necrosis
Neurogenic Bladder
- multiple sclerosis
- diabetes mellitus
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8
Q

Discuss how to differentiate different causes of renal failure

A

Rule out Post-Renal
- put in foley catheter to relieve post-bladder obstruction
- would get urine outflow
- pelvic and renal ultrasound
Rule in Pre-renal
- hypovolemia
- medications
Differentiate Pre-Renal and Renal on Urinalysis
- Urine Na concentration: <20 in pre-renal
- Fractional excretion of Na: <1% in pre-renal
- Fractional excretion of Urea: <35% in pre-renal
- Sediment and protein:
- Muddy brown casts in ATN
- WBC casts and eosinophils in AIN
- proteinuria, RBC cast in GN

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9
Q

Differentiate between nephrotic and nephritic syndrome

A 
Urine Analysis
- heavy proteinuria in nephrotic vs mild
- PCR >200 in nephrotic
- 24hr urine protein >3g in nephrotic
- hematuria and RBC casts in nephritic
Urine Appearence
- frothy in nephrotic
- gross hematuria in nephritic
Labs
- low albumin and increased lipids in nephrotic
- high creatinine and urea in nephritic
Systemic Features
- edema in nephrotic
- hypertension and peripheral edema in nephritic
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10
Q

List the differential for nephrotic syndrome

A 
Systemic Nephrotic Syndrome
- Diabetic nephropathy
- hypertensive nephropathy
- multiple myeloma
- amyloidosis
Renal Nephrotic Syndrome
- minimal change glomerulopathy
- focal segmental glomerulosclerosis such as in HIV, malignant hypertension
- Membranous nephropathy in hematological malignancy, HIV, hepatitis
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11
Q

List the differential for nephritic syndrome

A 
Low Complement (C3/C4)
- systemic nephritic syndrome
      - SLE
      - endocarditis  
      - cryoglobunemia such as Hep C
- renal nephritic syndrome
      - post-infectious (strep) glomerulonephritis
      - membranoproliferative glomerulonephritis such as HIV, Hep B/C, IV drug use
Normal Complement
- systemic nephritic syndrome
      - IgA nephropathy
      - Alport syndrome
- Renal nephritic syndrome
      - Wegner's granulomatosis
      - Churg-Strauss syndrome
      - Goodpasture syndrome
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12
Q

List the emergent indications for dialysis

A

AEIOU

  • Acidosis
    - pH <7.2 and refractory to HCO3 or unable to give due volume overload
    - metabolic acidosis with arrthymia
  • Electrolytes
    - hyperkalemia with ECG changes unresponsive to treatment
  • Ingestions
    - salicylates
    - ethylene glycol
  • Overload
    - volume overload unresponsive to therapy
  • Uremia
    - neurologic symptoms
    - pericarditis
    - platelet dysfunction
    - intractable n/v
  • severe renal failure creatinine >1060 or BUN >36
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13
Q

Discuss the management of acute renal failure

A

Treat Reversible Causes
- remove nephrotoxic medication
- restore volume
- remove urological obstruction
- glycemic control in diabetes
- immune suppressive therapy in glomerulonephritis
Slow Progression and Prevent Complications
- control BP
- address cardiovascular risk factors
- heavy proteinuria then protein restricton
- CKD with proteinuria then ACEi or ARB
Treat Complications of CKD
- anemia symptomatic and hemoglobin <100 then EPO replacement with Eprex or Darbepoetin
- hyperkalemia then K restriction and bind resin
- hyperphosphatemia then phosphate restriction and CaCHO3 binder (Tums)
- metabolic acidosis protein restriction and NaHCO3
- volume overload: Na and water restriction and diuretics
- Renal osteodystrophy: active vitamin D, PTH inhibitor
- Platelet dysfunction: dDAVP, cryoprecipitate
Renal Replacement
- peritoneal or hemodialysis
- surgical kidney replacement

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14
Q

Discuss the renin-angiotensin-aldosterone system

A
  • Renin released into blood from juxtaglomerular apparatus in kidney in response to
    - hypotension by baroreceptor in afferent arteriole
    - hypovolemia from renal hypoperfusion and decreased NaCl delivery to macula densa
    - hypotension and hypovolemia increase sympathetic output
  • Renin convert angiotensinogen (from liver) to angiotensin 1
  • Angiotensin converting enzyme (lung) convert angiotensin I to angiotensin II
  • Angiotensin bind to angiotensin receptor which increase extracellular volume and BP
    - systemic arterial vasoconstriction
    - increased thirst
    - vasoconstriction of efferent glomerular arteriole to increase GFR
    - increased Na and water reabsorption in proximal convoluted tubule
  • angiotensin II stimulate adrenal gland to release aldosterone
    - aldosterone increase Na reabsorption
  • angiotensin II stimulate posterior pituitary gland to secrete ADH
    - increase water reabsorption in collecting ducts
    - ADH increase thirst
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15
Q

Discuss the mechanism of action of ACEi and ARB and contraindications and adverse effects

A 
Mechanism of action
- ACEi inhibit ACE to reduce angiotensin II formation therefore inhibiting Na and water retention and vasoconstriction
- ARB block AT1 receptor to inhibit Na and water retention and vasoconstriction
Contraindication
- renal failure
- hyperkalemia
- hypotension, hypovolemia
- black
- pregnancy
- liver failure
- renal artery stenosis
Adverse Effects
- hyperkalemia
- decreased GFR causing ARF
- chronic cough and angioedema in ACEi
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16
Q

List the causes of bilateral and unilateral leg edema

A 
Bilateral
- CHF
- CKD
- Decreased protein: cirrhosis, nephrotic syndrome, protein losing enteropathy, malnutrition
- Vasodilatation: trauma, burns, sepsis, anaphylaxis
- hypothyroidism
- medication (NSAID, CCB, diabetic medication, anticonvulsants - Pregabalin, Gabapentin)
- pregnancy
Unilateral
- Venous obstruction
      - thrombosis
      - venous insufficiency
- Lymphatic obstruction
      - lymph node dissection    
      - malignancy
17
Q

Discuss the treatment for leg edema

A 
Treat Underlying Cause
Non-Pharmacological
- reduce Na intake
- compression stocking
- lie in supine position
Pharmacologic
- Furosemide 10-40mg PO
      - can add thiazide
- Spironolactone and Furosemide for cirrhosis

Internal Medicine (12 decks)

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