Nephrology and Urology 6% Flashcards
1
Q
Primary d/o
A
Dec’d HCO3 (met acidosis) -> dec’d PCO2 (resp alk compensation) -> 1.3(change in HCO3) +-2
Inc’d HO3 (met alkalosis) - -> inc’d PCO2 (resp acidosis compensation) -> 40+0.7 (change HCO3)
Inc’d PCO2 (resp acidosis) -> Inc’d HCO3 (met alkalosis compensation)-> Acute 1 HCO3 for 10 PCO2, Chronic 3.5 HCO3 for 10 PCO2
Dec’d PCO2 (resp alkalosis) -> dec’d HCO3 (met acidosis - compensation)-> Acute 2 HCO3 for 10 PCO2, Chronic 5HCO3 for 10 PCO2
2
Q
Acid/base Method
A
- Check pH >7.4 alkalotic - met if bicarb inc, resp if CO2 dec
met if bicarb dec, resp if CO2 inc - Check AG - Na+- (Cl+HCO3)
- Compensation
- Met Acidosis with AG - 1:1 rule - change in AG = change bicarb (only if doing AG met acidosis)
3
Q
Non gap metabolic acidosis causes?
A
Lower GI losses (diarrhea) /ureteral diversion (like diarrhea)
RTA
Prox: MM, acetazolamide, lead, topamax,
Distal: Sjogrens, lupus, amphote, foscarnet, toluene
4
Q
RTAs
A
Proximal RTA (II) - pH=5, urine AG neg (not able to reclaim bicarb) - spills bicarb - UpH alkaline at first but then acidifes in functional distal tubule Distal RTA (I) pH>5.5 - pos Urine AG (inappropriately alkaline urine in setting of systemic acidosis) - a/w CaPO4 kidney stones
Diarrhea - pH=5 - tubules are working - diarrhea gets rid of lots of bicarb in blood - kidneys still get rid of ammonium and hydrogen to compensate - pH of urine still acidic - neg AG urine
Hyporenin hypoaldo (IV) - no aldo, can’t get rid of K -> get hyperkalemia - alkaline pH
5
Q
Confirm RTA
A
Urine anion gap = negative (normal) - measure for urine - when can acidify urine/diarrhea ammonium (unmeasured cation)
When AG + -> not dumping ammonium
6
Q
Proximal RTA vs diarrhea
A
check products that would be dumping due to prox RTA (AA, glucose, phosphate) - not diarrhea if see these
7
Q
Anion Gap metabolic acidosis
A
M ethanol U remia D iabetic ketoacidosis P ropylene glycol, paraldehyde I sonazid (INH) L actate E thylene glycol, ethanol S alicylates - ** also causes respiratory alkalosis
8
Q
Metabolic gap acidosis with Osmolar gap
A
AG and Osmolar Gap Methanol Propylene glycol Ethylene glycol, ethanol Osmolar gap=
9
Q
Ketosis without acidosis in substance AG normal bicarb normal
A
Isopropyl etoh
10
Q
Metabolic alkalosis
PCO2 inc’d = 0.6(change in bicarb)
A
MC acid base abnormality - everyone on diuresis and vomiting (bicarb up, lose hydrogen) - maintained cuz pre-renal - can’t get bicarb out
pH high - high bicarb level
PCO2 inc’d = 0.6(change in bicarb)
Chloride responsive (to saline) - Ucl 20 (hyperaldo)
Mineralocorticoid excess
Diuretic (recent)
Gittleman - like HCTZ dec K, normal BP, UCl>15
Barter’s syndrome - like lasix, normal BP Ucl ?15
Little’s/licorice ingestion - high BP, Ucl>15, dec’d K
11
Q
Respiratory Acidosis
A
not breathing - too much PCO2 (chest wall injury, obstruction, CNS resp depression, COPD (chronic)
Acute 1 inc HCO3 for 10 inc PCO2
Chornic 4 inc HCO3 per 10 inc PCO2
12
Q
Respiratory Alkalosis
A
Hyperventilating - PE, high altiutde, PNA, sepsis
Acute - dec 2 HCO3 per 10 dec PCO2
Chronic - 5 dec HCO3 per 10 dec PCO2
13
Q
Glue sniffing
A
distal RTA (alkalotic urine)
14
Q
Serum Osm=
A
2(Na+) + BUN/2.8+Gluc/18
15
Q
Osm gap=
Ethylene glycol->glycolic acid->CaOx crystals->ATN
A
Measured serum osm-calculated Osm
if osm gap>50 needs HD
if osm gap <50
16
Q
Non-gap Met acidosis
A
Loss of bicarb or unable to excrete H+ RTA Diarrhea Ureterosigmoiostomy Early renal failure Post hyperventillation (blowing off PCO2 - kidney dumps bicarb, absorbs Cl-)
17
Q
Toner fluid/acetone/isopropyl etoh
A
NOT converted to acid
converts to ketone - not acidic
No AG
inc’d serum osm
18
Q
Dec’d transportaion defect in ascending loop of henle
A
Bartter’s syndrome (Lasix), low BP, low K, UCl>15
19
Q
Dec’d transportationd ef in deistal tubule
A
Gitelman’s (HCTZ) low BP, low K, UCl>15
20
Q
INc’d (aldo independent) transport in distal tubule
A
Liddle’s syndrome (high BP) low K, UCl>15
21
Q
Pt p/w ingestion unknown substance pH7.18, PCO2 23, Bicarb 8, Na 136, Cl 100 HCO3 10 - Ca Ox crystals
A
Gap metabolic acidosis
Ethylene glycol
tx: ethanol if Osm Gap 20
HD if osm gap >50
22
Q
pt brought in with confusion, convulsions and blindness after injesting uknown substance - pH 7.24, PCO2 28, HCO3 14 Na 136, Cl 100 HCO3 15 dx?
A
Methanol poisoning
formic acid - blindness
23
Q
Pt to ER depressed/somnolent - friend says was initially excited - injgested unknown substance - smells acetone/ acetone urine +, likely ingested?
A
Isopropyl etoh
24
Q
18yo brought to ER with confusion, seizure and ataxia dec’d DTR, fruity odor on breath - dx?
A
Toluene toxicity (glue sniffing)
25
Pt with tinnitus, lethargy, tachycardia - pH7.48, Na+140, Cl 100, HCO3 16 - pt has?
ASA tox
| Resp alkalosis -> Met acidosis
26
76yo pt needs to inc' TV to hear better - c/o ringing in ear mild dizziness - pt with HTN taknig ASA x 10 years - VSS dx?
ASA tox (confusion, fever, hyperventilation, acidosis)
27
Non AG
Chronic renal failure
28
HyperK
peaked T wave
Renin problem
Aldo problem - not enough aldo (blocked by ACEi, spironolactone), hyperK, acidosis
Pre-renal state, no distal Na+, can't dump K into urine (needs K for pump to work)
Insulin def (cellular shifting)
Impaired renin (NSAIDS, BB, cyclosporin, tacrolimus, DM, age)
ACEi
ARB
Impaired aldo metabolism
Aldo rct blockers (spironolactone, epleronone)
Na+ channel blockers (need Na+ into cell to get K out of cell)
Acidosis - Type IV RTA (hypoaldo, hyporenin), CKD
29
Hypo K
Hyperaldo prim or sec
GI losses - diarrhea/vomiting
Conn's primary hyperaldo - tumor producing too much aldo - suppresses renin
Acidosis - RTA I/II, diarrhea, toleune
Alkalosis - hyperaldo, loop/thiazinde diuretics, genetic d/o, vomiting
30
Type IV RTA
no aldo
hyperkalemic
no renin
31
Osmolarity
2x[Na+]+gluc/18+BUN/2.8
32
Pre-renal
baro rct's
No blood to JGA/macula densa
Kicks out renin/angio/aldo secreted
ADH released to hold onto water
33
Thirst center
hypothalamus releases ADH-> reabsorbs water from urine
34
CHF/GIB
both high aldo/renin
| low urine Na+
35
SIADH
hyponatremic with high urine osm (inappropriate - should be dilute)
36
Hypernatremia
```
Neg free water balance
abn thirst mech/no access to wate
excessive free water loss (sweat, diarrhea, osm diuresis, DI (no vasopressin or kidney not responsive to vasopressin)
kidney should conc for level of hyperosm
Excessive hypertonic saline
```
37
Diabetes insipidus
hypernatremic and urine osm is low
| urine is too dilute - should be concentrated and keeping water to combat high Na in blood
38
Central vs nephrogenic DM
Give DDAVP - better? Central DI
| not better? nephrogenic DI
39
Hyperosmolar hyponatremia
Glucose - sugar 1000 - all in blood - osm high because of glucose - water rushes into blood from cells - sodium goes down - hyponatremia
Correction factor gluc >300, for every inc 100, dec Na 2.5
40
Hypoosmolar hyponatremia
serum osm low, sodium low - too much water in blood - urine should be dilute
If Uosm high - kidneys not working or too much ADH
Example:
Hypovolemic - cerebral salt wasting, diarrhea, beer potomania
Isovolemic - SIADH, exstacy
Hypervolemic - CHF
41
Primary polydipsia
Serum osm low, urine osm low
42
Too much ADH (SIADH)
Etio
Renin-angio system elev
Urine Na low - pre-renal - has CHF/GIB/sepsis - stimulating ADH release
If not pre-renal (Urine Na+ high)
HCTZ/salt losing nephropathy
Inc'd ADH from non-volume, non-osmotic source (tumor)
43
SIADH
```
Inapprop conc urine in setting of watery blood
normal effective circulating volume (no renin-aldo issue)
Causes
CNS
Pulm - PNA
Oat cell carinoma
Post op
Drugs - NSAID, SSRI,
```
```
Tx:
restrict water
Vaptan (block adh)
Diuretic - lasix
If MS changes - hypertonic saline
```
44
SIADH vs HCTZ hyponatremic hyponatremia
SIADH - all blood numbers look dilute (BUN, Cr Uric acid)
| HCTZ - BUN Cr is high, bicarb high ish
45
Primary polydipsia vs
Central DI vs
Nephrogenic DI
Baseline Serum Na 140, Uosm 100, UOP 8
Water deprivation Serum Na 147, Uosm 110, UOP 7.8 (not primary polydipsia - without water input, still peeing a lot, still dilute urine, Na going up)
DDAVP Serum Na 149, UOsm 115, UOP 7.5 - (Not central DI, if it was DDAVP would cause UOP to go down, urine osm would go up significantly) -> Nephrogenic DI
46
Central DI
after DDAVP - urine OSM goes up, UOP goes down, serum Na goes down
47
Primary polydipsia
after water deprivation, Uosm goes up, UOP goes down, Serum Na goes down (not diluted)
48
28yo M DM pt with anusea, BS 310 - Na 135, K 5.6, Cl 94, HCO3 20
AG=21 - DKA (BS 310)
49
28yo M DM p/w nausea, BS 310 Na 135, K 5.6, Cl 104, HCO3 20
AG = 11 (no gap) - non- gap -> Type IV RTA?
50
80yo taking NSAID and tylenol for OA - Na 138, Cl 100, bicarb 16, ABG pH 7.3, PCO2 32
```
Met Acidosis
AG=22 - > Gap
Compensation - 1.3 (8) about 10 - pCO2 is 37 should be 30 -> concominant respiratory acidosis
Tylenol toxicity (salicylate)
```
51
Na 135, Cl 80, HCO3 24, BUN cr 110/11, pH 7.4, pCO2 37, HCO3 22 pt has?
```
pH normal
2. Compensation -
3. change in AG - 31-12=19
if bicarb serum > change in AG (19) then
met alkalosis
if delta gap/delta bicarb>2 then met alk + metabolic acidosis
```
change in anion gap from normal should equal change in bicarb from usual level - if not then indicates other process - so there is concurrent metabolic acidosis
Chronic renal failure with vomiting
52
Na 142 K 3.3, Cl 95, HO3 38 BP 150/100, Renin level low Ucl >20 most likely has?
Licorice ingestion (high BP, low K) or could be little's defect (not gittleman or barrters - low/normal BP low K)
53
Pt with exacerbation of COPD PCO2 70 pH 7.45, pedal edema intubated/vent -> PCO2 now 50, furesemide gien -> extubated and d/cd on tiotropium albuterol steroids and lasix - 1 week later pH 7.46, PO2 55, PCO2 60, bicarb 40 - most likely cuase - ?
Diuretics
54
COPD pt with PCO2, PO2 60, bicarb 28, pedal edema - tx'd wit htiotropium and diuretics - 1 week later PCO2 60, bicarb 40 - pt on O2 and pedal edema decreased - wtd?
KCl runs - fixes hypo K, decreases bicarb
55
pH 7.6, PCO2 30, PO2 70, bicarb 32
```
Respiratory alkalosis (CO2 low)
Metabolic alkalosis (HCO3 high)
```
pCO2 reduced despite high bicarb - when pCO2 and HCO3 move in different directions from reference values there are at least 2 acid base problems present - low PCO2 indicates resp alkalosis, high HCO3 shows metabolic alkalosis
Scenario - pre-existing metabolic alkalosis from thiazide therapy - develops PNA with hyperventilation causing respiratory alkalosis
56
pH 7.3 PCO2 50, HCO3 22, Na135, HCO3 24, Cl 82
```
Resp acidosis (low pH, high PCO2)
compensated - HCO3 should be 22-26
AG=29 - > AG metabolic acidosis
Delta delta - 17/0= infinity (>2) so AG met acidosis+met alkalosis
```
57
pH7.5, PCO2 30, HCO3 24, Na 144, Cl 80
```
Resp alkalosis (high pH, low PCO2)
compensated - HCO3 should be 20-24
AG=40 - AG metabolic acidosis
delta delta - 28/0 = infinity - AG met acidosis + metabolic alkalosis
```
58
pH 7.48, PCO2 32, PO2 90, HCO3 24, Na 135, Cl 84, HCO3 24
Resp alk alkalosis (high pH, low PCO2)
compensated (HCO3 should be 20-24)
AG=27 - AG metabolic acidosis
delta delta - 15/0 >2 -> AG met acidosis + met alkalosis
59
RTA
```
Prox RTA (II)
Defect - reabsorbtion of HCO3 -> temporarily alk urine then acidifies in functional distal tubule
Dz: Fanconi's
MM
Acetazolamide
Topiratmate
Osteomalcia
+- stones
hypoK+
UpH 5.5
```
60
Fanconi's
RTA II
61
Osteomalaica
RTA II
62
Hypokalemia
RTA I&II
63
Nephorlitiasis
RTA I&II
64
Urine pH>5.5
RTA I
65
HyperK+
RTA IV
66
DM
RTA IV
67
MM/Acetazolamide
RTA II
68
Dry mouth, enlarged partid, arthralgia
Sjogrens -> RTA I
69
Hyponatremia problems
Normal - Serum Na 135-145, UNa>20, UOsm 600, post water dep Ur Osm inc'd, post DDAVP UOsm inc'd
Central DI Serum Na inc'd, UNa dec'd, UOsm Dec'd, Post water depriv UOsm no change, Post DDAVP U OSm inc'd
Nephorgenic DM Ser Na inc'd, UNa dec'd, UOsm dec'd, Post water UOsm no change, Post DDAVP UOsm no change
Psychogenic polydypsia Ser Na dec'd, UNa dec'd, UOsm dec's, post water dep UOsm inc'd, Post DDAVP UOsm inc'd
SIADH Ser Na dec'd, UNa inc'd, Ur Osm inc'd
70
Ser Na 146, UNa 10 UOsm 73 post H20 depriv UOsm 76 post DDAVP UOsm 600
Central DI
71
Ser Na 148 UNa12 UOsm 71 Post H20 restric UOsm 75 Post DDAVP UOSm 77
Nephrogenic DI
72
Ser Na 131 UNa 12 UOsm 65 Post H20 restriction UOsm 500 Post DDAVP UOsm 600
Psychogenic polydypsia
73
Ser Na 132 UNa 45 UOsm 600 Young female rec Sx or Lung Ca
SIADH
74
NH Pt Ser Na 160 UNa 10 UOsm 800
Hypernatremic dehydration
75
Ser Na 130 UNa 5 H/o Liver dz
Hepatorenal syndrome
76
Best long term management SIADH
Demecyclocine
77
Hypertonic hyponatremia
DKA
78
Isotonic hyponatremia
Pseduohyponatremia TG>1000
79
Acute sx hyponatremia (MS change - lethargy/sz)
Aggressive tx with 3% saline >1mEq/hr for several hours - 12mEq/hr x 24 hrs
If Chronic hyponatremia do not correct >0.5mEq/hr
80
Central Pontine myelinolysis
Pt is chronic hyponatremic - then sudden correction with hypertonic saline causes fluid shift out of neurons causing shrinkage of cells and myelin sheaths -> paralysis
81
Conivaptan
V1/V2 rct antagonist - causes iatrogenic nephrogenic DI - free water diuresis
82
Pt undergoes CTS - started on D5W alternating with 1/2 NS - day one Na 142, UNa 42, Day 6 Serum Na 118, UNa 20 wtd?
Normal saline + lasix (isovolemic hyponatremia)
83
70yo pt with PNA - Na at presentation 135 started on NS 1100cc/hr - 3 days later pt no fever, WBC dec's pt confused and has seizure Na is 110 - UNa is 80 dx?
SIADH (similar presentation pt with small ll lung Ca, post in young woman)
Tx: Stop NS IVF, start 3% saline and Diuretics
84
35yo man found in bathroom brought to ER - gluc 90, pulse ox 96% on room air h/o schizophrenia BP 130/84 Serum Na110, BUN/Cr 8/0.7, Cl 88, CO2 18, Ur Na 10, UOsm 40 - dx?
Psychogenic polydypsia
| tx: fluid restriction, 3% Saline/diuretics (MS change)
85
45yo long h/o bipolar d/o ON LITHIUM found in coma - Na 169 dx?
Hypernatremia 2/2 lithium thrapy
Water deficit - replace half in 24 hour - use D5w with 1/4 NS
If hypotensive NS until stable
86
24yo F body buidling competition c/o wk and cramps - admits to polyuri and slightly dizzy when gets up - Serum Na 148, K 2.7, bicarb 28 UOsm 80, spot lyte K>25 dx?
Diuretic abuse
87
Pt with HEAD injury p/w urinary incontinence UOsm 42, plasma OSm 310 (nl 280) Na 150, BUN/Cr 50/1.8 etiology?
Diabetes insipidus
wtd?
Give DDAVP check for dec in UOP and inc'd UOsm
88
Pt pw polyuria - severe polydipsia - Uosm 60 blood sugar 120 - after water dep UOsm to 72, after DDAVP to 82 - dx?
DDAVP not working so nephrogenic DI
89
Hyperkalemia
Causes
Factitious (leading cause)
Cell bkdn (hemolysis, rhabdo)
Adrenal hypofunction (decreased excretion of K)
-hyporeninemic hypoaldo (Type IV RTA)
-Addition's dz
Acidosis
-DKA
-Renal failure
EKG changes - peaked twaves -> flattened p waves-> sine wave, -> vfib
Tx: stabilze cardiac memb - calcium gluconate (1st)
Push K back in cells - insulin/albuterol, HCO3
Excretion - sodium polystyrene sulfonate resin or HD
90
Hypophophatemia
```
Renal wasting
-hyperPTH
-Fanconi (prox RTA)
Dec'd absorbtion
-vit D def (inc'd alk phos)
-malabsorption
-etoh abuse
-phosphate binder
INc'd cellular uptake
-tx of DKA
-carb repletion in etoh abuse - refeeding syndrome
```
91
Hypomagnesemia
```
Dec'd intake
-starvation
-eto abuse
-NGT aspiration
Renal loss
-Diuretics
-anminoglycosides
-ampho B
Pancreatits - precipitate as Mg Soap
PTH ectomy - deposit in bone "hungry bone syndrome - p/w lethargy anorexia, nausea, tetany convulsions
**Can't correc tK or Ca+ until you correct Mg!!!***
```
92
Pt p/w weakness, anorexia, leethargy
| Na 136, K 3, Cl 105, Ca 6, phos 1.3 - started on IVF, 40 Meq K - next day K and Ca not corrected - etio?
HypoMg
| tx: correct Mg
93
Urinalysis
```
Proteinuria
1. Overflow proteins - MM, MGUS
2. INc'd filtratio nof protein -
-glomerular dz
-Nephortic protein >3g/day
Nephritic protein < 2g/day
4. Transient
-fever
-Excercise
-Upright position
-Seizure
Normal < 100mg protein exxr/day
5g - check protein electrophoresis r/o MM, MGUS
```
94
Pt with fever, UTI, U+ for protein wtd?
Repeat U/A after fever/UTI resolved
95
Pt on NSAIs fo rpain - U/A + protein
repeat after d/c NSAID x 2 weeks
96
Pt with protein + in uprigh tposition wtd?
Check first void AM urine specimen - if neg then no further w/u
97
Pt with proteinuria on dipstick post excercise - wtd?
repeat U/A after stopping excercise x 2 weeks
98
Hematuria
Nephronal
w/ RBC casts & proteinuria -> Glomerular dz's
w/o RBC casts -> renal cysts, SCDz, intersitial dz
```
Non-nephronal
w/o RBC casts or proteinuria
Renal pelvis -> tumors
-nephrolithiasis
UTI/Hemorrhagic cystitis
Coaguloapthy
Post extreme excercise
```
99
Pt with urine diptick + blood, RBC neg - cauesed by?
```
Rhabdo
High vit C
Paroxysmal nocturnal hemoglobinuria
Contamination with Povidine
(NOT BY NEPHROLITIASIS)
```
100
20yo p/w asx hematuria - U/a 20-30 RBC, WBC neg, protein 1+ no casts h/o run marathon day after dx?
Excreme exc indued hematuria
| repeat UA in few weeks
101
22yo asx man with persistent asx hematuria - US nromal kidneys BUN/Cr 6/0.7 wtd?
f/u rneal eval in 1 year (Age<25)
102
50yo M routine phsyical, U/A >5RBC no casts wtd?
Repeat U/A - repeat with persisten microhematuria - Renal US needed
103
Pt with SCDz p/w sudden onset flank pain, fever, passage dark tissue in urine - U/A RBC no casts, BUN/Cr inc'd wtd?
CT Scan r/o PAPILLARY NECROSIS (high incidence in sickle cell dz)
104
All can cause papillary necrosis
```
Analgesics
Sickle Cell trait
Sickle Cell dz
DM
Pyelonephritis
(NOT Aminoglycoside -> cuases ATN)
```
105
30yo Sickle cell trait with microhematuria BUN/CR 14/0.8, U/A with RBC>20, no casts no protein 24 hr protein 300mg/day wtd?
IVP
| if neg then cystoscopy
106
22yo college student p/w hematuria and dysuria x 3 days, UA >30 RBCs WBC 10-15, no casts dx?
Hemmorragic cystitis
| tx: 3 days bactrim/cipro/nitrofurantoin
107
21yo M pt with recurrent UTI - sexually active with one partner x 1 year - 3rd episode in last 6 months - each episode resolved with tx with quinolone - no h/o urethral d/c - no d/c on exam - best way to establish cause?
Urine chlamydia and gonococcal test
108
20yo with cola colored urine - athlete - had sore throat 4 days ago UA RBC 10-20, RBC cast +, protein 1+, complement in serum normal likely has?
IgA nephropathy
(normal complement - time table within days of sore throat)
If was post strep GN then would be weeks later, decreased complement
109
60yo M p/w dull ache in L flank region, 9lb involuntary wt loss - BP 14090, UA RBC 15, no casts or WBC dx?
Renal cell CA (older, dull ache L flank, wt loss)
110
Pt with flank pain, hematuria HTN h/o UTI in past - Renal US stone - fhx stones and Renal faiure dx?
ADPKD - Autosomal dom poly cystic kidney dz
h/o parents/relatives with renal failure
a/w hepatic cysts and berry aneurysms
tx: Tolvaptan->
111
Mother wants to donate kidney to son with poly cystic kdney dz with renal failure wtd?
US, HLA matching
112
Autosomal dominant poly cystic kidney dz a/w the following
```
Cerebral aneurysm - need to screen pts
Hepatic/Pancreatic cyt
elev Hematocrit
CV Conduction issues
MVP
(NOT AS)
```
113
Medulllary sponge dz
hematuria
hyperCalciuria->stones
DOES NOT cause renal failure
IVP-> outpouching of renal papillary ducts
114
Alport's syndrome
```
Xlinked - in males
Hemturia
proteinuria
Renal failure in 2nd or 3rd decade
Problem in colagen IV/V synthesis
a/w deafness
```
115
Urine Analysis
```
WBC in urine (pyuria)
-tubular injury
Interstitial nephritis
UTI
Pyelonephritis
```
116
Pt pw polyuria and nocturia, no c/o dysuria or flank pain, no uretheral d/c, UA 10 WBC/hpf - no casts, pt tx'd with abx - repeat UA 2 wk later still WBCs - renal US one kidney smaller than other, IVP multiple strictures wtd?
Urine for AFB
| Place PPD r/o TB
117
AKI
ischemic hit to kidney - ATN - do not apply Cr clearance in ARF
Non-oliguric UOP>400cc/24hr
Oliguric <100cc/24hrs
obstruction, vascular even, severe ATN, cortical necrosis
Post renal
Pre-renal
Renal
118
Post Renal Etiology AKI
intrinsic or extrinsic obstruction
b/l obstruction - prostate,
unilateral stone, fibrosis, aortic anursym, papillary necrosis, clot, RCC
Hydronephrosis - dilated calyx/ureter
119
Pre-renal
Volume depletion
senses volume depletion
senses CHF (low flow to kidney but body is overloaded)
and sepsis - true low volume as same (both reduced effective arterial blood volume)
kidney inc'd renin, angiotensin, aldo
If continues kidney dies -> ATN -> starts to spill Na (can't reabsorb)
Typical U/A - bland - kidney still reabsorbs Na UNa20:1 - BUN more easily reabsorbed than Cr
120
Hepatorenal
perpetually vasodilated - renin/aldo always elevated
BP low
Only thing that works is spironolactone
121
FENA
UNaxPCr/PNaxUCr *100
If pre-renal - 99% filtered sodium is reabsorbed
If FENA <1% - pre-renal
122
ATN
UA - abnormal - hematuria, proteinuria, RBC casts
| Does not respond to volume
123
Casts to remember
RBC casts - glomerular nephritis
WBC casts - pyelonephritis/acute interstitial nephritis
Granular/Muddy brown casts - ATN - casts of tubular death
124
Intrinsic Renal Disease
Tubular -> ATN
Interstitial -> AIN
Glomerular
Vascular -> afferent (atherembolic dz,
125
ATN
Ischemic - hypotension, sepsis, needs CVVH,
Nephrotoxic - aminoglycosides
Urine Na>20 (to distinguish from pre-renal) -> FENA 3% - can't just tx with normal saline - only time will heal and remove offending agent or solve hypotension
Brush border sloughing off - granular casts
126
Pre-renal -> ATN
Normal
GIB - dec'd perfusion - autoregulation prostoglandins dilate afferent - renin-angio-aldo constrict efferent
NSAID prevent prostoglandin induced dilation of afferent, ACE inhibitor prevents efferent constriction
Triple threat - Pre-renal on NSAID and ACEi
127
Contrast Nephropathy ATN
10% of all hospital ARF, MCC ATN
Usually 48hrs later Cr peak** (vs 2-3 weeks for atheroembolic)
initial low urine Na looks like pre-renal
then becomes ATN
risk factor CKDz
also DM, MI, CHF, dec vol, lots o fcontrast
Prevent - alt imaging, isotonic IVF
Mucomyst doesn't work but doesn't help necessarily
128
Intersitial Nephritis - allergy in kidney
drug rash, fever, maculpapular rash, eosinophilia
NSAIDs
U/A - sterild pyuria, eosinpiluria (hansel/wright stain)
glomeruli surround by lymphocytes
129
Vascular dz
atheroembolic dz
cholesterol emboli (2-3 weeks after cath**)
a/w abd pain, lividoreticularis, holererst plaques (eyes)
TTP, HUS, DIC, sleroderma, microangiopathy
TTP - vasc dz in arterioles - less blood to kidney
130
Glomerular dz
Active sediment, RBC casts, RBC, oval fat bodies
>3gm protein
Albumin (fenestrated epithelial, GBM, podocyte)
Edema
Low albumen
Lipiduria
HLD
131
Glomerular dz
Primary
Nephortic
nephritic
```
Secondary
DM
Amyloid
MM
Lupus
HIV
Sarcoid
```
132
Lupus glomerulonephritis
Immune complexes everywhere - green
| wire loops, capillary wall
133
Amyloid GN
apple green birefringence
| Congo red, randomly arranged fibrils on EM
134
Cast nephropathy from MM
look for Ca in 9 range with low albumin (this is hyperCa in setting of CKD) and high protein on 24hr with trace protein on urine dipstick (detects only albumin - means that light chains are spilling) -> bencejones -> MM
135
Nephrotic
Min Ch dz
Foc seg glomerulosclerosis
Membranous (MGN)
136
Nephritic
```
IgA (only GNephritic with 6gm protein) - Cr elev days later
Post infectious (Cr elev weeks later)
Anti - GBPM
Alports
Membranoprolif - HCV
```
137
Nephoritc Dz
FSGS
MGN
In AA - FSGS
Whites - MGN
138
Min Change Dz
Effacement of podocytes (explosive nephorisis)
| liquid malignancies
139
Focal Segmental Glomerular Sclerosis
```
not all glomeruli, only some parts of glomeruli
Primary FSGS (most common)
Secondary
HIV
parvo B19
Heroin
Pamidronate, Li, steroids
Gene mutations
```
140
Membranous Glomerulonephopathy
Immune complex mediated
Deposits onto GBM of kidney - check immunoflorescene
granular pattern
spikes and holes on silver stain
Hep C
Lupus
Solid malignancy (from antig/Ab complex from CA)
141
Tx Glomerular dz
Treat primary dz
Prednisone (esp min change)
Cyclosprin, Cytoxan, Cell cept
142
Nephritic dz
Active sediment
Renal insuff
Proteinuria 1-3 gm
anemia, edema, hypoalbumin
143
Post Strep Glomerulophritis
```
lot of neutrophils in bx
Exudative
Subepithelial hump
GR A strep
Dec'd C3
Elevated ASO/Anti DNase
```
144
Membranoproliferative
```
Lobular pattern
Tram tracks - GBM splits into 2 pieces
Causes
Hep C (90%)
SLD
MCTD
cryoglobulin
SCDz
```
145
Hypocomplement GN's
```
SLE
Post infectious
MPGN (Hep C)
Lobulated glomeruli, tram tracking of BM
Low complement
```
146
Non-hypocomplement GN
IgA - normal complement
Stain IgA +, all others neg (on mesangium)
Young adults
Normal C3
Sore throat - same day or next day hematuria/renal
147
Hen Sl Purpura
```
small vessel vasculitis
rash, arthralgia
Abd pain - mimik's appendicitis
Purpura
glomerulnephritis
```
148
Crescentic Glomerulnephritis
```
Really bad
Break in GBM, podocyte and fenestrated epidth - blood spills into bomans space - cells in space don't like and proliferate - crescent
Etio:
Anti-GBM ab -> Good pastrues
Lupus - immune complexes destroy GBM
Cryo, hep C, etc
Pauci immune - Anca Ab - recruits PMN - they destroy GBM
Floresecne - continuous linear staining
Pulm Renal syndrome
(ab vs colagen)
```
149
Pulmonary Renal syndromes
Good pastures - lung and renal ab - Anti=GBM ab
SLE
Wegeners - sinuisitis, lungs, kidney - pr3 ANCA (c-ANCA)
Microsopic polyarteritis - MPO=ANCA (p-ANCA)
Tx: Cytoxan + Prednisone, plasmaphoresis, cytoxan, solumedrol
If alvolar hemorrhage then plasmphersis
150
Churgg strauss
eos lungs - rare kidney (15%)
| Asthma, sinuisitc, peripheral eos
151
27yo F no pmhx p/w sudden onset LE edema with frothy urien, normal C3 complement, no blood, low albumin (1.2), + protein, no cells on u/a
Minimal change dz - podocyte effactement
| explosive nephorosis
152
Rhabdomyolysis Cr elev after tx with daptomycin for endocarditis -
See +Udip for blood but no RBCs on U/A
(no RBC/RBC casts so no glomerulo dz)
Low FENA
Cr MORE THAN DOUBLES in 24 hrs - think rhabdo
153
Fabry's dz
lysosomal storage d/o
| Deposits all over body including kidney -> renal failure
154
Isolated Microhematuria
No renal failure
without proteinuria, without HTN
90% uro - stones, bladder CA, rcc - need cystoscopy or CT scan upper tracts (IVP)
10% nephrologic
155
Kidney stones
>5mm - needs intervention
| <5mm pass on own
156
Stone prevalance
CaOx, CaPO4 - 37%
Uric acid stones - only in acidic urine - alkalze urine
Struvite - infection associate urease producing organism
Cystine stones
Calcium Phosp - formin alkaline pH
Tx:
Prev with lots of fluid
Don't give lots of sodium and oxalate
DO NOT RESTRICT CALCIUM - gets MORE oxalate in urine
157
Diarrhea pt - gets stones
lots of diarrhea - FFA in diarrhea gets rid of Ca+, more oxalate gets in urine -> CaOxalate stones
158
Coffin lid stone
Struvite stone (triple phophate stone)
159
Envelope
Ca Oxalate
160
Spicule stones
Uric Acid
161
Hexagonal
Cystine stones
162
Pregnancy normals
All blood numbers low,
BP low
High renin/aldo
163
Disease in pregnancy
HELLP - hemolysis, edema, low plts
Pre-eclampsia - blood pressure high with proteinuria
eclampsia - pre eclampsia + seizures
For BP DO NOT USE ACEi (teratogenic)
OK - methyldopa, Labetolol, CCB, alpha blockers, clonidine
164
MC reason for HD
DM, HTN, GN, cytic kidney dz
165
GFR Staging
1: >90
2: 60-89
3: 30-59
4 15-29
5: < 15 or HD
166
W/U reduced GFR
```
US - r/o obstruction
U/A
Serum/urine immunofix
Glomer dz w/u
Antemia/iPTH
```
167
Tx CKD
```
BP goal < 130/80
RAAS blockade unless contraindicated (ACEi)
Lipid control
Gluc control
ANemai
```
168
Urgent need for HD
```
Met acidosis
Electrolyes
Ingestions
Volume overload
uremia
```
169
Contraindications for Renal Transplant
| Much better than HD
```
uncorrectable CAD
acitve malignancy
Non-compliance
unresolved infxn
untreated +PPD
Active drug use
mental incompetance
Severe liver dz
```
170
Maintenance of Renal tx
Keep BP< 130/80
Yearly derm exam
monitor for drug drug interactions
171
HTN goals
160 or >100 - 2 drug regimen
172
Seconary w/u HTN
```
CKD
primary hyperaldo
OSA
Renovascular
chornic steroids
Pheo
coarctation aorta
thryoid dz
```
```
Check renin/aldo
ipTH, ca+
TSH,
catecholamines
aldo
screen for renovascular dz - fibromuscular dysplasia vs atheroslerotic dz
```
173
Pheo
urine metanephrines
| Treatment - surgery with pre=op alpha blocade before BB
174
HTN Emergency
```
HTN urgeny with endo organ damage
UA, MI
dissecting AAA
RF
Enccephalopathy
Retinoptay - blurred optic disc
```
Tx: dec BP 25% within 2 hours with IV labetolol, nitroprusside, enalapril, nicardipine
175
Cyclosporin
levels inc'd by verapamil/diltiazem - cause failure of renal tx
176
Nephrotic syndrome cast
Hyaline (protein), fatty, oval fat bodies
177
Glomerular Nephritis casts
RBC casts
178
Prerenal azotemia casts
Hyaline
179
ATN casts
Muddy/Dirty brown/Granular casts
180
CRF casts
Broad casts
181
Chronic progressive renal failure casts
Waxy casts
182
Eosinophiluria seen in...
Interstitial nephritis
Atheremboism
Rapidly progressive GN
Acute prostatitis
183
Hyaline cast
Prerenal
184
Muddy brown cast
ATN
185
RBC only (no cast)
Nephrolithiasis
186
RBC Cast
Glomerulonephritis
187
Oval fat bodies
Nephrotic syndrome
188
Eosinophils
Interstitial dz
189
Xray
shows all stones EXCEPT URIC ACID
190
Renal US
size, obstruction, masses, screening for polycystic dz, stones>5mm
191
IVP
Non-glomerular hematuria, rneal stones, voiding dz, unexplanined flank/abd pain
192
Spiral CT wihtout contrast
stone hunt/perirenal hemorrhage
193
CT with contrast
Staging of renal mass
| OK if pt already on dialysis with little residual fxn
194
Radionuclide scan
Renal perfusion assessment in case of transplant eval
195
MRA/Rneal arteriography
renal arter dz
196
MRI
Renal vein thrombosis
197
Renal bx
Glomerular dz
198
Nephrotic Syndrome
Urine: Fatty casts, fat oval bodies
Proteinuria >3g/day
Hematuria + or -
Cl features: Genralized edema, priorbiatal edema, HTN
Histopath: Minimal change, Focal Segmental, membranous, membranoproliferative
199
Nephritic syndrome
```
Urine - RBC casts, cola/smoky urine
Proteinuria <2.5g/day
Hematuria +
Cl features - HTN
Histopath
Post strep -
IgA nephropathy -
Henlock schonlein
RPGN
```
200
Minimal Change (Nephrotic)
```
Etio - Hodgkins, Leukemia, NSAID, Lithium
Bx/LM - Normal
Immuno - Normal
EM - Podocyte Effacement
Complement - normal
Treatment - Steroids/cyclophophamide
```
201
Focal Segmental (Nephrotic)
Etio: Blacks, HIV, Heroin, Sickle, Obesity
Bx/LM - sclerosis part of glomerululs in few glomeruli
IM - IgM+C3
EM - Effacement of epith podocytes
Complement - normal
Treatment Steroids/Cyclophosphamide
202
Membranous (Nephrotic)
```
Etio - Hep B,C, syphilis, tumors, malaira, NSAID, SLE, ACi, Gold, PCN
Bx/LM - Thickened capillary loops
IM: Granular IgG+C3
EM: Subepithelial dep/hump
Complement: Normal
Treatment: Steroids/cyclophosphamide
```
203
Membranoproliferative (Nephrotic)
Etio: Hep B,C, SLE, SBE, Mixed Cryoglobulinemia
Bx/LM: Tramtrack
IM: Mesangial deposit
EM: Ribbon/sausaging of memarne in type II
Complement: LOW!!!
Tx: Steroids/Cyclophosphamide +- ASA
204
Complications of Nephrotic syndrome
```
Hypoalbuminemia -> Edema
Hypogammaglobulin -> infections
Loss of ATIII, anti plasmin -> thrombosis/PE
Loss of transferrin -> IDA
Loss of Vit D prodution - osteomalacia
Lipiduria - Fat boides, fatty cast in urin, HLD
Tx: ACEi - reduce porteinuria and HLD
Low salt
Loop diretics
Statin
```
205
21yo Football player with microhematuria - used HEROIN intermittently - father had difficult to tx HTN, pt BP 140/94, U/A RBC cast postitve - 4+ protein dx?
Focal segmental glomerulosclerosis
206
AA
Focal segmental
207
Hodkins
Minimal Change
208
Heroin
Focal segmental
209
NSAID
Minimal change, Membranous
210
Liquid malignancy
Minimal change
211
Solid tumor
Membranous
212
Lithium
Minimal Change
213
Obestiy
Focal segmental
214
Amyloid (Rh arthr, crohns, MM
Diffuse deposition
215
Post Strep GN (nephritis)
```
Etio Strep infxn
Bx/LM: hypercellularity
IM: granular/lumpybumpy Ig+C3
EM: Sub epithelial deposits
Complement: Low C3, CH50, normal C4
Tx: Supportive Abx
```
216
IgA nephropathy (nephritis but can have >>protein)
```
Etio: Post exc, URI
Bx/LM: Mesangial proliferation
IM: IgA, IgG, C3 deposit in mesangium
EM:
Complement: Normal
Tx: Fish oil, ACEi, steroids
```
217
Henoch-Scholnlein (Nephritis)
```
Etio: Idiopathic abd pain, palpapble purpura on butt/thigh
Bx/LM: Mesangial proliferation
IM: IgA, IgG, C3 deposit in mesangium
EM:
Complement: Normal
Treatment: Suppressive
```
218
Rapidly progressive GN (Nephritis)
```
Etio Type I good pasture
Bx/LM: Cresents (exracapillary) formation)
IM: Linear IGG
EM:
Complement: normal
Treatment: Immunosupp/Plasma pharesis
```
219
Rapidly progressive GN (Nephritis)
```
Etio Type II: D pcnamine
Bx/LM: Cresents (exracapillary) formation)
IM: Granular complex
EM:
Complement: Normal/low
Treatment?
```
220
Rapidly progressive GN (Nephritis)
Etio: Type III p-ANCA -> PAN, c-ANCA -> Wegers
Bx/LM: Cresents (exracapillary) formation)
IM: neg (pauci-immune)
EM:
Complement: Normal
Treatment: Steroids/Cyclophosphamide
221
Serum complement levels decreased in....(mostly nephritic)
```
Post strep GN
Membranoprolif GN (SLE, Cryoglobulemia, SBE, Atheroembolism)
```
222
Serum Complement NORMAL in...
IgA, Minimal change, Focal segmental, membranous, Goodpastures/wegeners (pauci-immune)
223
Lupus nephritis
```
nephrotic or nephritis
No renal findings
mesnagial dz
Focal prolif
Membranous
Membranoprlif
Tx: Cyclophophmide IV monthly, oral steroids, mycophenolate
If pt to get pregnant needs lupus inactive for 6 months
```
224
Pt with type II DM U albumin <5mg/24hrs best way to obtain renal fxn measure
Cockroft-Gault or Modification of Diet in Renal Disease equation
Ideal body wt (140-Age)/72x Serum Cr
225
55yo M hematuria and edema, pmhx recurrent palpable lesions on legs aw joint aches - palpable purpura, UA protein 4+, labs ANA+, ANti-dsDNA neg, Anti smith neg, HCV +, C3 normal, C4 low dx?
Mixed cryoglobulineia
226
Vasculitdies
PAN -> P-panca - Hep B ag +
Wegeners -> C-anca - Pauci immune/no immune depostis
Best way to confirm renal vasculitis -> bx (not angiography)
227
Minimal change and Focal segmental
Epithelial cell foot processes
228
Membranous
Basement membrane
229
Mesangioprolfi/Glomerulosclerosis
Mesangial cell
230
Cresentic RPGN
Epithelial cell
231
ARF
Endothelial cell
232
21yo College student pw coca cola urine after playing soccer, no trauma, rash fever, sore throat less than 1 week ago, complement NORMAL protein 1+ dx?
IgA nephropathy
| Bx shows?: IgA, IgG, C3 deposition on MESANGIUM
233
50yo persistent microhematuria BP 130/80 - UA RBC 20, no protein, no prtein, no cast, US normal kidney, cystoscopy eng, renal bx with IgA pattern, no fibrosis no capillary invovlement - outcome?
Stable in 20 years (likely no HD)
234
21yo student cola colored urine, sore throat 2 WEEKS ago, BURN Cr 40/4.5, ASO titer inc'd, ANA neg, RBC cast, protein 1+, C3 DEC, C4 normal CH50 DEC dx?
Post Strep GN
235
45yo F p/w hemoptysis, h/o recurrent sinusitis, BUN/Cr 50/5.1, UA 1+ protien RBC 15-20, RBC cast, ANA neg, complement normla, Renal bx: NO IMMUNE DEPOSIT, ANCA+
Wegeners
236
24yo pw cough, hemoptysis, cola colored urine - SOB, BUN/Cr inc'd, U/A 50-100 RBC, RBC cast 1+ protien, CXR b/l hilar patchy infiltrates, renal bx: LINEAR IgG DEPOSITS, complement normal
Goodpastures
237
24yo F arthraligas, low grade fever raynuds malar flush , b/l pedal edema+, b/l metacarpophalengeal and interphalaneal jnts swollen, BUN cr 35/2.2 complement dec'd U/A RBC 15-20 with RBC casts, Protein 4+, 24 hr protein 4g/day wtd?
```
Renal bx
Membrnaoproliferative nephritis (SLE nephritis)
```
238
All have low complement
Post strep GN
| SLE (C3
239
All with NORMAL complement
```
Minimal change
Focal segemental sclerosis
Membrnaous nephropathy
IgA nephropathy
Henolock Scholnlein nephropathy
Wegener's/PAN
(NOT CRyoglobulinemia - dec'd C3, CH50)
```
240
45yo MVA 1990 multiple blood tx at time - c/o fatigue and occasional arthralgias - petecial purpura on legs BUN cr 30/2.2, C3, C4, CH50 low ANA, anti DNA neg
U/A RBC+, RBC cast +, protien 1+
What is next test?
Hep C/cryoglobulin determination
241
Acute renal failure
Sudden drop in GFR - inc'd BUN/Cr (1/3 ICU pts)
| Pre-renal azotemia MCC ARF
242
ARF
Pre-renal - decreased renal perfusion
Intrinsic renal - Glomerular dz, ATN, Tubulintersitial dz
Post renal - obstruction
243
Indomethacin
constriction of AFFERENT arteriole
244
ACEi (bradykinin)
vasodilation of EFFERENT arteriole
245
Dec'd renal perfusion
Volume depletion: Vom/Diarrhea/Diuretics/bleed/burn
Volume Overload: CHF, Cirrhosis, Nephrotics (decreased effective arteriole volume)
Others: NSAIDs, ACEi, RAS
246
Lab findings pre-renal azotemia
```
Serum - inc'd BUN/Cr
Urine - dec'd urine vol, inc'd UOsm
Dec UNa-> FENA1%)
Urine Sediment: Hyaline cast or neg
Tx: Optimize volume status, tx underlying dz
```
247
FENA
(UNa/Ser Na)/(UCr/Ser Cr)
248
Acei
Dec'd efferent constriction via inc'd bradykinin
| inc'd Cr 30% ok with ACEi
249
NSAIDs
Constricts afferent blood supply - preciptates ARF in pt with underlying renal compromise
250
Elderly man with h/o HLD, DM, HTN on BB, statin HCTZ BP still at 170/115 - serum cr 1.6, started on ACEi/ARB, 1 week later - BP controlled at 145/90, BUN Cr 70/2.6, K 5.6, U/A - no sediment - cause of ARF
Pre-renal azotemia 2/2 ACEi/Angiotensin inhib
| WTD? D/C ACEi and rehck BUN/Cr
251
HTN pt started on ACE - also taking ibuprofen for OA pain - Cr increases 1.4 to 1.9 wtd?
D/C ibuprofen first
252
Pt on ACEi Cr inc 1.4 to 1.8 wtd?
continue ACEi
253
HTN pt started on ACE Cr 1.0 to 1.8 wtd?
D/C ACEi
254
Preg F 18weeks - not gaining any weight - c/o persistent nausea/vom x 3 months - Cr inc's from 0.5 to 1.9
pre-renal hyperemesis gravidum
| tx: IVF rehydration
255
HTN pt started on ACEi, Cr 1.2 to 2.5 etio?
Renal artery stenosis?
256
t/F in Renal artery stenosis, medial tehrapyvs surgical tx with SIMIAR rate of decilne in Serum Cr
True
257
65yo HTN ventricular arrhythmia controlled on amio - HTN controlled with BB, OA controlled with NSAID - pw pufffiness of face on waking up with b/l pedal edema - U/A 3+ protein - 15-20 WBC, RBC 5
24 hr urine 4g/day, BUN/Cr 80/5.0, Albumin 2.5, TSH normla dx?
NSAID induced nephrotic syndrome and interstitial nephritis
258
Hepatorenal syndrome
Functional renal failure with normal tubular funtion
Pre-renal azotemia pciture with UNa <1%
Precipitated with vigorous diuretic therapy for ascietes (not pedal edema), large volume paracentesis or SBP
Even after fluid challenge or d/c nephorotoxic drug, renal faiulre continues
After LIVER TX - kidney fxn gets back to normal
(if pt dies CAN donate kidney - ok outside of body with liver issue)
259
Intrinsic Acute Renal failure FENA >1
Glomerular Dz
RBGN - RBC casts
ATN -aminoglycosides, ampho B, contrast
- rhabdo, tumor lysis, atheroembolism
- muddy/dirty brown/granular casts
Tubulointersitital nephritis
- allergic - B lactam, PCN, sulfa, phenytoin, quinolon, measalamine (+EOS)
- NSAID (no EOS)
- WBC, EOS, WBC casts
260
Radiocontrast nephorpathy
12 hrs after contrast
| precipated with underlying renal dysfxn
261
Pt with post infarmt angina schedule for cardiac cath - Cr 1.5 - best way to prevent contrast nephropathy ?
NS 12 hrs pre and post procedure +- acetylcysteine
262
If pt needs to go urgently to cath ....
Give socium bicarb, acetylcystein and start NS
263
Pt h/o chronic smoking, atherosclerosis, DM, HTN on med tx c/o chest pain - post cath develops pathcy skin discoloration finger tips and toes, elevated ESR, WBC elev, eosinophilia, DEC'd COMPLEMENT +EOS, Cr inc'd 0.9 to 2.2 dx?
Livedo reticularis 2/2 atheroembolism
confirmation - skin bx - small arteries with biconcave clefts
Irrev cause of renal failures
Tx: Supportive tx and good HTN control
264
Rhabdomyolysis
```
Breakdown of muscle cells
inc'd CPK
inc'd K+
Inc'd PO4, Dec'd Ca+
inc'd uric acid
```
```
Etio:
cocaine
crush injury, prolonged lying position >6hrs, bariatric surgery
strenuous excericse
Heat, etoh
statin
```
Testing: U/A Heme dipstick +, neg RBC, Muddy brown casts, UNa>20
Tx: Hydrate, Diuresie -> Alkalanize only if Renal failure (dissolve heme pigments)
Treat hyperkalemia
265
Tumor Lysis sydorme
```
3 days post chemo (can occur prior to chemo)
Uric acid
Urine UA/Serum UA>1.0
Serum Ca low, Phos high
inc'd K+
U/A - granular casts - rare WBCs
Tx: Allopurinol, hydrate, diurese
```
266
Rhabdo vs Tumor lysis
Rhabdo very inc CPK, inc uric acid, inc K, dec CA, inc'd Phos, +dip stick for heme
Tumor lysis - inc'd CPK, very inc'd uric acid, inc K, dec Ca, inc Phos, neg dipstick heme
267
26yo non hodgkin's lymphoma LDH<2 ULNormal - pretx?
Allopurinol
268
26yo with non-hodgkin's lymphoma LDH>2 ULNormal pretx?
Rasburicase
269
35yo diffuse large cell lymphoma with bulky dz pretx?
Rasburicase
270
35yo diffuse large cell lymphoma stage III pretx?
Rasburicase
271
Diffuse large cell lymhoma stage III with G6PD deficiency pretx?
Allopurinol (no rasburicase with G6PD)
272
25yo AML WBC>100K pretx?
Rasburicase
273
65yo CLL WBC <100K pretx
Allopurinol
274
Any of above pt developed TLS on allopurinol or rasburicase pretx?
use Rasburicase
275
55yo M chronic etoh found lethargic on street after bing ena dbrought to ER, BUN 25, Cr 5, UA 4+ blood 1+ protein, no RBC granular cast + dx?
Rhabdomyolysis
276
Elderly pt lives alone found lethargic withi empty etoh bottles U dip pos for blood, bicarb 17 likely?
Rhabdomyolysis
277
Acute Tubular Necrosis can be caused by?
```
Aminoglycosides Stepto>Genta>tobra
Amphotericin B
Cyclosporin
Rhabdo
(NOT NSAIDs - minimal change and membranous)
```
278
NSAIDS cause all of the follwoign
```
Pre-renal aotemia
AIN
Chroic interstiital nephritis (anagesic nephropathy)
Nephrotic syndrome
Papillary necrosis
Type IV RTA
Lymphocytic interstitial inflammation and tubular atrophy
(NOT ATN)
```
279
65yo F p/w abdominal pian and fever - pt started on ampicillin, gent anf flagyll - CT abd with contrast done - NEXT DAY UOP dec's, BUN/Cr inc'd, U/A no sediment, FENA <1 dx?
Radiocontrast (ATN)
280
45yo F pw fever, chills, flank pain, U/A shows WBC >20, pt started on Amp/gent, 1 week later BUN/Cr inc'd to 40/3.5, Mg 1, Ca 7.5 U/A shows WBC 1 cause of renal failure?
Gentamycin induced nephrotoxicity
281
Interstitial nephritis
Acute allergic interstitial nephritis
| Chronic tubulointerstital nephritis (analgesic nephropathy)
282
All of the following drugs can cause interstitial nephritis...
```
Abx (PCN, methicillin, ampicillin, cipro, sulfa)
NSAIDs (no EOS)
Diureticss (thiazide, lasxi)
Phenytoin
(NOT ACEi)
```
283
60yo p/w cellulits o f leg - started on clinda and PCN - pt deferenveses in 24 hrs 5 days later cellulitis improved and pt with sudden onset feer adn maculopapul ar rash with itching - stop drugs no dysuria or foley std?
U/A and Hansel/wright stain for EOS
284
U/A shows 10 WBC, 7 RBC, EOS+, casts neg - dx?
PCN induced intersitial nephritis
285
Middle aged woman pw long standing h/a and lower back ache, h/o peptic ulcer dz, denies analgesic abuse - has polyuria nd nocturia - Hg 9, MCV 69, BUN/Cr 22/2.2, UA WBC 10, RBC 5-10 no casts, Urine c/s no growth, US normal kidneys and PAPILLARY NECROSIS
Analgestic nephropathy (chronic tubulointerstitial nephritis causing Papillary necrosis
286
Papillary necrosis causes
```
P yelonephritis
O bstruction
S ickle cell dz
T B
C hronic etoh
A nalgesic abuse
R V thrombosis
D iabetes Mellitius
```
287
Post Obstructive Renal Failure
```
Adhesions post surgery
Tumors
Rad tx
Methysergide
Nephorlithiasis
Drugs: Acyclovir/Indinavir
Prostate enlargement
Partial ureteral obstruction can cause polyuria/oliguri with inc'd Cr - urine indices NOT reliable in Post Obstructive renal failure
```
288
IN pt with suspected obstructive renal failure wtd?
Renal US r/o hydronephrosis
289
In pt with h/o adhesions post srugery pw renal failure wtd before considering dialysis
Rule out obstuction
| If US equivioval -> CT/MRI
290
75yo pw inc'd BUN/Cr - dec'd UOP wtd?
Digital rectal exam r/o enlarged prostate
291
Renal US shows enlarged bladder, ureteral distension and hydronephrosis wtd?
insert foley
-distinguishes between post obstructive physiologic diuresis (replace 2/3 fluids/electrolytes)
vs
Patholic diuresis->volume depletion-> pre-renal azotemia
(need to replace fluids/electrolytes MORE aggressively)
292
Pt with HSV encephalitis started on IV acyclovir - BUN/Cr inc's WTD?
CONTINUE Acyclovir and INCREASE hydration
293
Chronic renal failure
```
Presentation
Fatigue, leg cramps, polyuria, HTN, fluid O/L
Anemia
Dec'd Ca, inc'd Phos
GFR<33
Elev BUN/Cr
Xray with subperiosteal bony lesions
US/CT - small kidneys (except amyloid, polyctic disease, HIV)
```
294
Complication of CRF
```
Acid base & electrolytes
Early - non- gap acidosis
Late - Gap acidosis
Anemia
Cardiac
HLD
CAD
HTN
Pericarditis
Tamponade
Neuro
Peripheral neuropathy
cognificve imoairment when Cr >2
Others
Pseudogout, arthopahty with variable birefringence (Ca OxalateE)
Gastritis, colitis, constipation
```
295
Management of CRF
Strict HTN control - ACE/Angiotensive inhib first choice
Anemia EPO
Acidosis - Bicarb
Secondary HyeprPTH - Oral Calcium, PO4 binder, Vit D3 to decrease PTH, PTHectomy if PTH>1000
Statin - decreases mortality in early renal failure (not shown to dec mortailty in pt on HD)
296
Indications for HD
GFRd albumin)
Pericarditis
Encephalopathy
297
Complications of HD
```
Disequilibration sydnrome
Inf of AV Fistula
HEp B/C
arrhythmia (afib MC arrythmia)
Aluminiu tox
Amyloidosis
Rneal cyst
Renal CA
Bleeding diathesis
```
298
Pt with ESKD pw SOB, Cr 8, K 6, exam b/l pedal edema - BP 150/90, JVD elev, CXR b/l pleural eff, EKG low voltage EKG - best managmement?
HD
299
90yo F in assited livign, tired after walking a block no other complaints - lovers her great grand dhildren and wants to attend graduation in 3 months - BUN/Cr 90/9 wtd?
Monitor for now - discuss outcome swith pt and family recognize goals set by pt and family
300
82yo in NH walks with walker mild confusion found to have BUN/Cr 80/8 - indiitaing HD on this pt woudl result in ?
DECREASED functional status
301
Best manamgement for ESDK pt
Dec'd Na, Dec'd water, Dec'd K Dec'd Phos, NO CA restriction!!
302
T/F MCC CRF in US is DM
True
303
T/F - mortality rates at end of 5 years higher in HD patients than in renal tx patients
T
304
55yo DM pt routein f/u on glipizde, ACE and CaCarbonate BP 138/84 Hg 8.8, BUN/Cr 36/3.2, Ca 9, pho 4.5 iron, TIBC nromal wtd?
Start Darbepoetin alpha plus iron
305
What antacids to avoid in ESKD
No aluminium or Mg based antacids
306
What kind of enema can cause renal failure?
Phosphate enema
307
Pt with ESKD PTH inc, Ca inc, Phos inc, ISCHEMIC SKIN LESIONS? dx?
Calciphylaxis
308
55yo M ESKD pw thickenign of skin in legs and arms like peau d'orange appeanace dx?
Nephorgenic fibrosing dermopathy
309
T/F In pt with renal insufficiency, keeping serum bicarb above 22 has show to decrease rate of lung function decline
T
310
T/F In pt with renal insufficiency, keeping serum bicarb above 22 has show to improve nutrtiional status
T
311
Nephrolitiaisis
1-5% M>F
moderate to sev colicky flnak pain radiating to lower abd or perineum with urgency or inc'd freq with GROSS or MICROSOPIC hematuria
Dx w/u:
First stone, asx - hydration and observe
First stone symoptomati or RECURRENT tones - do further w/u
W/U - Xray abd -> shows all stones EXCEPT URIC ACID
Renal US shows stones >5mm
IVP
Spiral CT (Stone hunt)
312
Nephrolithiasis predisposing factors
HyperCa (HyerPTH, Sarcoid)
Hypercalciuria >300mg/day men >250mg/day women
Hyperoxaluria >40mgday (IBD, short bowlel), vit C, meath
Hyperuricosuria >750mg/day
Hypercystinuira
High Na diet
Hypocitraturia < 300mg/day (IBD, RTA)
313
CaOx stones
ok to contineu oral Ca (actually decreases risk of Ca Ox stones by binding oxalate in gut)
314
What to expect in pt with short bowel syndrome or Crohn's
Increased Oxalate absorbtion - Envelope shaped crystals
315
All these stones formed in acid urine
Uric acid - not seen on xray - spikled shape
Cal oxalate - envelope shaped
Cystine - hexagonal
(NOT STRUVITE - staghorn caliculus - coffin lid shape) - proben miriablis bacteria
316
All are risk factor for stones
```
Hyper Ca
Hypercalciuria
Hyperuricosuria
Hyperoxaluria
HYPOcitraturia
Cystinuria
Renal tubular acidosis
Inflamm bowel dz
High vit C
High Na diet
(NOT HYPERURICEMIA WITHOUT HYERPURICOSURIA)
```
317
You woudl do further dignostic w/u for all these
45yo with kidney stone - h/o passing stone 1 year ago
28yo M kidney stone - fhx of kidney stones
40yo M with flank pain, hematuria and kidney stone FIRST time
(NOt 33yo M with stone for first time and MILDY sx)
318
Kidney stone NOT seen on xray
Uric acid
| CaOx, CaPO4, struvite all radioopaque
319
32yo with dysuria, inc'd frequency h/o recurrent UTI in past couple years tx'd with abx no flank pain or hematuria - U/A pH 6.6, RBC 10-15, WBC 40-50, nitirites +, Gneg rods present - abd xray shows staghorn caliculus
Caused by struvite stone - magnesium ammonium phosphate
320
MCC recurrent nephorlithiasis
Idiopathic hypercalciuria
321
Pt with renal colic Kidney stone 5mm on CT wtd?
Fluids
322
Pt with renla colic 4mm stone at uteropelvic jnc - fluids encourage pt still in pain - wtd?
Tamsulosin - (floppy iris sydrome if taking prior to cataract surgery)
323
Pt dx with inflamm bowel dz - expect all the following
Hyperoxaluria
Hypocitraturia
(NOT CYSTINURIA) - dec'd citrate with IBD
324
Pt dx with distal RTA I and has stone likely compoosition is?
CaPO4
325
T/F - history of renal stones is contraindication to adequate Ca in diet?
False!!
326
Pt with short bowel syndrome - add Ca to diet in order to...
Decrease absorbtion of Oxalate (dec Ca Ox stones) = envelope
327
40yo M renal colic - with CaOx stone - history of similar stone 1 ya - Cr 0.8, PTH 55, CXR neg for adenopathy or infiltrates - U/A 40 RBC, WBC
HCTZ
