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2020 ABIM Awesome Review edited > Nephrology and Urology 6% > Flashcards

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

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2
Q

Acid/base Method

A
  1. Check pH >7.4 alkalotic - met if bicarb inc, resp if CO2 dec
    met if bicarb dec, resp if CO2 inc
  2. Check AG - Na+- (Cl+HCO3)
  3. Compensation
  4. Met Acidosis with AG - 1:1 rule - change in AG = change bicarb (only if doing AG met acidosis)
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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

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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

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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

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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

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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
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8
Q

Metabolic gap acidosis with Osmolar gap

A 
AG and Osmolar Gap
Methanol
Propylene glycol
Ethylene glycol, ethanol
Osmolar gap=
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9
Q

Ketosis without acidosis in substance AG normal bicarb normal

A

Isopropyl etoh

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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

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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

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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

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13
Q

Glue sniffing

A

distal RTA (alkalotic urine)

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14
Q

Serum Osm=

A

2(Na+) + BUN/2.8+Gluc/18

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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

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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-)
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17
Q

Toner fluid/acetone/isopropyl etoh

A

NOT converted to acid
converts to ketone - not acidic
No AG
inc’d serum osm

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18
Q

Dec’d transportaion defect in ascending loop of henle

A

Bartter’s syndrome (Lasix), low BP, low K, UCl>15

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19
Q

Dec’d transportationd ef in deistal tubule

A

Gitelman’s (HCTZ) low BP, low K, UCl>15

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20
Q

INc’d (aldo independent) transport in distal tubule

A

Liddle’s syndrome (high BP) low K, UCl>15

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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

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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

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23
Q

Pt to ER depressed/somnolent - friend says was initially excited - injgested unknown substance - smells acetone/ acetone urine +, likely ingested?

A

Isopropyl etoh

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24
Q

18yo brought to ER with confusion, seizure and ataxia dec’d DTR, fruity odor on breath - dx?

A

Toluene toxicity (glue sniffing)

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25
Q

Pt with tinnitus, lethargy, tachycardia - pH7.48, Na+140, Cl 100, HCO3 16 - pt has?

A

ASA tox

Resp alkalosis -> Met acidosis

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26
Q

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?

A

ASA tox (confusion, fever, hyperventilation, acidosis)

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27
Q

Non AG

A

Chronic renal failure

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28
Q

HyperK

A

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

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29
Q

Hypo K

A

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

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30
Q

Type IV RTA

A

no aldo
hyperkalemic
no renin

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31
Q

Osmolarity

A

2x[Na+]+gluc/18+BUN/2.8

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32
Q

Pre-renal

A

baro rct’s
No blood to JGA/macula densa
Kicks out renin/angio/aldo secreted
ADH released to hold onto water

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33
Q

Thirst center

A

hypothalamus releases ADH-> reabsorbs water from urine

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34
Q

CHF/GIB

A

both high aldo/renin

low urine Na+

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35
Q

SIADH

A

hyponatremic with high urine osm (inappropriate - should be dilute)

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36
Q

Hypernatremia

A 
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
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37
Q

Diabetes insipidus

A

hypernatremic and urine osm is low

urine is too dilute - should be concentrated and keeping water to combat high Na in blood

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38
Q

Central vs nephrogenic DM

A

Give DDAVP - better? Central DI

not better? nephrogenic DI

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39
Q

Hyperosmolar hyponatremia

A

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

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40
Q

Hypoosmolar hyponatremia

A

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

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41
Q

Primary polydipsia

A

Serum osm low, urine osm low

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42
Q

Too much ADH (SIADH)

A

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)

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43
Q

SIADH

A 
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
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44
Q

SIADH vs HCTZ hyponatremic hyponatremia

A

SIADH - all blood numbers look dilute (BUN, Cr Uric acid)

HCTZ - BUN Cr is high, bicarb high ish

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45
Q

Primary polydipsia vs
Central DI vs
Nephrogenic DI

A

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

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46
Q

Central DI

A

after DDAVP - urine OSM goes up, UOP goes down, serum Na goes down

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47
Q

Primary polydipsia

A

after water deprivation, Uosm goes up, UOP goes down, Serum Na goes down (not diluted)

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48
Q

28yo M DM pt with anusea, BS 310 - Na 135, K 5.6, Cl 94, HCO3 20

A

AG=21 - DKA (BS 310)

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49
Q

28yo M DM p/w nausea, BS 310 Na 135, K 5.6, Cl 104, HCO3 20

A

AG = 11 (no gap) - non- gap -> Type IV RTA?

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50
Q

80yo taking NSAID and tylenol for OA - Na 138, Cl 100, bicarb 16, ABG pH 7.3, PCO2 32

A 
Met Acidosis
AG=22 - > Gap
Compensation - 1.3 (8) about 10 - pCO2 is 37 should be 30 -> concominant respiratory acidosis
Tylenol toxicity (salicylate)
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51
Q

Na 135, Cl 80, HCO3 24, BUN cr 110/11, pH 7.4, pCO2 37, HCO3 22 pt has?

A 
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

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52
Q

Na 142 K 3.3, Cl 95, HO3 38 BP 150/100, Renin level low Ucl >20 most likely has?

A

Licorice ingestion (high BP, low K) or could be little’s defect (not gittleman or barrters - low/normal BP low K)

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53
Q

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 - ?

A

Diuretics

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54
Q

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?

A

KCl runs - fixes hypo K, decreases bicarb

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55
Q

pH 7.6, PCO2 30, PO2 70, bicarb 32

A 
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

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56
Q

pH 7.3 PCO2 50, HCO3 22, Na135, HCO3 24, Cl 82

A 
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
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57
Q

pH7.5, PCO2 30, HCO3 24, Na 144, Cl 80

A 
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
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58
Q

pH 7.48, PCO2 32, PO2 90, HCO3 24, Na 135, Cl 84, HCO3 24

A

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

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59
Q

RTA

A 
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
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60
Q

Fanconi’s

A

RTA II

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61
Q

Osteomalaica

A

RTA II

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62
Q

Hypokalemia

A

RTA I&II

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63
Q

Nephorlitiasis

A

RTA I&II

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64
Q

Urine pH>5.5

A

RTA I

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65
Q

HyperK+

A

RTA IV

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66
Q

DM

A

RTA IV

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67
Q

MM/Acetazolamide

A

RTA II

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68
Q

Dry mouth, enlarged partid, arthralgia

A

Sjogrens -> RTA I

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69
Q

Hyponatremia problems

A

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

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70
Q

Ser Na 146, UNa 10 UOsm 73 post H20 depriv UOsm 76 post DDAVP UOsm 600

A

Central DI

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71
Q

Ser Na 148 UNa12 UOsm 71 Post H20 restric UOsm 75 Post DDAVP UOSm 77

A

Nephrogenic DI

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72
Q

Ser Na 131 UNa 12 UOsm 65 Post H20 restriction UOsm 500 Post DDAVP UOsm 600

A

Psychogenic polydypsia

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73
Q

Ser Na 132 UNa 45 UOsm 600 Young female rec Sx or Lung Ca

A

SIADH

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74
Q

NH Pt Ser Na 160 UNa 10 UOsm 800

A

Hypernatremic dehydration

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75
Q

Ser Na 130 UNa 5 H/o Liver dz

A

Hepatorenal syndrome

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76
Q

Best long term management SIADH

A

Demecyclocine

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77
Q

Hypertonic hyponatremia

A

DKA

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78
Q

Isotonic hyponatremia

A

Pseduohyponatremia TG>1000

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79
Q

Acute sx hyponatremia (MS change - lethargy/sz)

A

Aggressive tx with 3% saline >1mEq/hr for several hours - 12mEq/hr x 24 hrs

If Chronic hyponatremia do not correct >0.5mEq/hr

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80
Q

Central Pontine myelinolysis

A

Pt is chronic hyponatremic - then sudden correction with hypertonic saline causes fluid shift out of neurons causing shrinkage of cells and myelin sheaths -> paralysis

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81
Q

Conivaptan

A

V1/V2 rct antagonist - causes iatrogenic nephrogenic DI - free water diuresis

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82
Q

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?

A

Normal saline + lasix (isovolemic hyponatremia)

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83
Q

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?

A

SIADH (similar presentation pt with small ll lung Ca, post in young woman)

Tx: Stop NS IVF, start 3% saline and Diuretics

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84
Q

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?

A

Psychogenic polydypsia

tx: fluid restriction, 3% Saline/diuretics (MS change)

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85
Q

45yo long h/o bipolar d/o ON LITHIUM found in coma - Na 169 dx?

A

Hypernatremia 2/2 lithium thrapy

Water deficit - replace half in 24 hour - use D5w with 1/4 NS
If hypotensive NS until stable

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86
Q

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?

A

Diuretic abuse

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87
Q

Pt with HEAD injury p/w urinary incontinence UOsm 42, plasma OSm 310 (nl 280) Na 150, BUN/Cr 50/1.8 etiology?

A

Diabetes insipidus
wtd?
Give DDAVP check for dec in UOP and inc’d UOsm

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88
Q

Pt pw polyuria - severe polydipsia - Uosm 60 blood sugar 120 - after water dep UOsm to 72, after DDAVP to 82 - dx?

A

DDAVP not working so nephrogenic DI

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89
Q

Hyperkalemia

A

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

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90
Q

Hypophophatemia

A 
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
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91
Q

Hypomagnesemia

A 
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!!!***
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92
Q

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?

A

HypoMg

tx: correct Mg

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93
Q

Urinalysis

A 
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
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94
Q

Pt with fever, UTI, U+ for protein wtd?

A

Repeat U/A after fever/UTI resolved

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95
Q

Pt on NSAIs fo rpain - U/A + protein

A

repeat after d/c NSAID x 2 weeks

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96
Q

Pt with protein + in uprigh tposition wtd?

A

Check first void AM urine specimen - if neg then no further w/u

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97
Q

Pt with proteinuria on dipstick post excercise - wtd?

A

repeat U/A after stopping excercise x 2 weeks

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98
Q

Hematuria

A

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
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99
Q

Pt with urine diptick + blood, RBC neg - cauesed by?

A 
Rhabdo
High vit C
Paroxysmal nocturnal hemoglobinuria
Contamination with Povidine
(NOT BY NEPHROLITIASIS)
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100
Q

20yo p/w asx hematuria - U/a 20-30 RBC, WBC neg, protein 1+ no casts h/o run marathon day after dx?

A

Excreme exc indued hematuria

repeat UA in few weeks

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101
Q

22yo asx man with persistent asx hematuria - US nromal kidneys BUN/Cr 6/0.7 wtd?

A

f/u rneal eval in 1 year (Age<25)

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102
Q

50yo M routine phsyical, U/A >5RBC no casts wtd?

A

Repeat U/A - repeat with persisten microhematuria - Renal US needed

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103
Q

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?

A

CT Scan r/o PAPILLARY NECROSIS (high incidence in sickle cell dz)

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104
Q

All can cause papillary necrosis

A 
Analgesics
Sickle Cell trait
Sickle Cell dz
DM
Pyelonephritis
(NOT Aminoglycoside -> cuases ATN)
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105
Q

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?

A

IVP

if neg then cystoscopy

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106
Q

22yo college student p/w hematuria and dysuria x 3 days, UA >30 RBCs WBC 10-15, no casts dx?

A

Hemmorragic cystitis

tx: 3 days bactrim/cipro/nitrofurantoin

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107
Q

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?

A

Urine chlamydia and gonococcal test

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108
Q

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?

A

IgA nephropathy
(normal complement - time table within days of sore throat)
If was post strep GN then would be weeks later, decreased complement

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109
Q

60yo M p/w dull ache in L flank region, 9lb involuntary wt loss - BP 14090, UA RBC 15, no casts or WBC dx?

A

Renal cell CA (older, dull ache L flank, wt loss)

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110
Q

Pt with flank pain, hematuria HTN h/o UTI in past - Renal US stone - fhx stones and Renal faiure dx?

A

ADPKD - Autosomal dom poly cystic kidney dz
h/o parents/relatives with renal failure
a/w hepatic cysts and berry aneurysms
tx: Tolvaptan->

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111
Q

Mother wants to donate kidney to son with poly cystic kdney dz with renal failure wtd?

A

US, HLA matching

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112
Q

Autosomal dominant poly cystic kidney dz a/w the following

A 
Cerebral aneurysm - need to screen pts
Hepatic/Pancreatic cyt
elev Hematocrit
CV Conduction issues
MVP
(NOT AS)
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113
Q

Medulllary sponge dz

A

hematuria
hyperCalciuria->stones
DOES NOT cause renal failure
IVP-> outpouching of renal papillary ducts

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114
Q

Alport’s syndrome

A 
Xlinked - in males
Hemturia
proteinuria
Renal failure in 2nd or 3rd decade
Problem in colagen IV/V synthesis
a/w deafness
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115
Q

Urine Analysis

A 
WBC in urine (pyuria)
-tubular injury
Interstitial nephritis
UTI
Pyelonephritis
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116
Q

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?

A

Urine for AFB

Place PPD r/o TB

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117
Q

AKI

A

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

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118
Q

Post Renal Etiology AKI

A

intrinsic or extrinsic obstruction
b/l obstruction - prostate,
unilateral stone, fibrosis, aortic anursym, papillary necrosis, clot, RCC
Hydronephrosis - dilated calyx/ureter

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119
Q

Pre-renal

A

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

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120
Q

Hepatorenal

A

perpetually vasodilated - renin/aldo always elevated
BP low
Only thing that works is spironolactone

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121
Q

FENA

A

UNaxPCr/PNaxUCr *100
If pre-renal - 99% filtered sodium is reabsorbed
If FENA <1% - pre-renal

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122
Q

ATN

A

UA - abnormal - hematuria, proteinuria, RBC casts

Does not respond to volume

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123
Q

Casts to remember

A

RBC casts - glomerular nephritis
WBC casts - pyelonephritis/acute interstitial nephritis
Granular/Muddy brown casts - ATN - casts of tubular death

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124
Q

Intrinsic Renal Disease

A

Tubular -> ATN
Interstitial -> AIN
Glomerular
Vascular -> afferent (atherembolic dz,

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125
Q

ATN

A

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

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126
Q

Pre-renal -> ATN

A

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

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127
Q

Contrast Nephropathy ATN

A

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

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128
Q

Intersitial Nephritis - allergy in kidney

A

drug rash, fever, maculpapular rash, eosinophilia
NSAIDs
U/A - sterild pyuria, eosinpiluria (hansel/wright stain)
glomeruli surround by lymphocytes

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129
Q

Vascular dz

A

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

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130
Q

Glomerular dz

A

Active sediment, RBC casts, RBC, oval fat bodies
>3gm protein
Albumin (fenestrated epithelial, GBM, podocyte)
Edema
Low albumen
Lipiduria
HLD

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131
Q

Glomerular dz

A

Primary
Nephortic
nephritic

Secondary
DM
Amyloid
MM
Lupus
HIV
Sarcoid
132
Q

Lupus glomerulonephritis

A

Immune complexes everywhere - green

wire loops, capillary wall

133
Q

Amyloid GN

A

apple green birefringence

Congo red, randomly arranged fibrils on EM

134
Q

Cast nephropathy from MM

A

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
Q

Nephrotic

A

Min Ch dz
Foc seg glomerulosclerosis
Membranous (MGN)

136
Q

Nephritic

A 
IgA (only GNephritic with 6gm protein) - Cr elev days later
Post infectious (Cr elev weeks later)
Anti - GBPM
Alports
Membranoprolif - HCV
137
Q

Nephoritc Dz

A

FSGS
MGN

In AA - FSGS
Whites - MGN

138
Q

Min Change Dz

A

Effacement of podocytes (explosive nephorisis)

liquid malignancies

139
Q

Focal Segmental Glomerular Sclerosis

A 
not all glomeruli, only some parts of glomeruli
Primary FSGS (most common)
Secondary
HIV
parvo B19
Heroin
Pamidronate, Li, steroids
Gene mutations
140
Q

Membranous Glomerulonephopathy

A

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
Q

Tx Glomerular dz

A

Treat primary dz
Prednisone (esp min change)
Cyclosprin, Cytoxan, Cell cept

142
Q

Nephritic dz

A

Active sediment
Renal insuff
Proteinuria 1-3 gm
anemia, edema, hypoalbumin

143
Q

Post Strep Glomerulophritis

A 
lot of neutrophils in bx
Exudative
Subepithelial hump
GR A strep
Dec'd C3
Elevated ASO/Anti DNase
144
Q

Membranoproliferative

A 
Lobular pattern
Tram tracks - GBM splits into 2 pieces
Causes
Hep C (90%)
SLD
MCTD
cryoglobulin
SCDz
145
Q

Hypocomplement GN’s

A 
SLE
Post infectious
MPGN (Hep C)
Lobulated glomeruli, tram tracking of BM
Low complement
146
Q

Non-hypocomplement GN

A

IgA - normal complement
Stain IgA +, all others neg (on mesangium)
Young adults
Normal C3
Sore throat - same day or next day hematuria/renal

147
Q

Hen Sl Purpura

A 
small vessel vasculitis
rash, arthralgia
Abd pain - mimik's appendicitis
Purpura
glomerulnephritis
148
Q

Crescentic Glomerulnephritis

A 
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
Q

Pulmonary Renal syndromes

A

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
Q

Churgg strauss

A

eos lungs - rare kidney (15%)

Asthma, sinuisitc, peripheral eos

151
Q

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

A

Minimal change dz - podocyte effactement

explosive nephorosis

152
Q

Rhabdomyolysis Cr elev after tx with daptomycin for endocarditis -

A

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
Q

Fabry’s dz

A

lysosomal storage d/o

Deposits all over body including kidney -> renal failure

154
Q

Isolated Microhematuria

A

No renal failure
without proteinuria, without HTN
90% uro - stones, bladder CA, rcc - need cystoscopy or CT scan upper tracts (IVP)
10% nephrologic

155
Q

Kidney stones

A

> 5mm - needs intervention

<5mm pass on own

156
Q

Stone prevalance

A

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
Q

Diarrhea pt - gets stones

A

lots of diarrhea - FFA in diarrhea gets rid of Ca+, more oxalate gets in urine -> CaOxalate stones

158
Q

Coffin lid stone

A

Struvite stone (triple phophate stone)

159
Q

Envelope

A

Ca Oxalate

160
Q

Spicule stones

161
Q

Hexagonal

A

Cystine stones

162
Q

Pregnancy normals

A

All blood numbers low,
BP low
High renin/aldo

163
Q

Disease in pregnancy

A

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
Q

MC reason for HD

A

DM, HTN, GN, cytic kidney dz

165
Q

GFR Staging

A

1: >90
2: 60-89
3: 30-59
4 15-29
5: < 15 or HD

166
Q

W/U reduced GFR

A 
US - r/o obstruction
U/A
Serum/urine immunofix
Glomer dz w/u
Antemia/iPTH
167
Q

Tx CKD

A 
BP goal < 130/80
RAAS blockade unless contraindicated (ACEi)
Lipid control
Gluc control
ANemai
168
Q

Urgent need for HD

A 
Met acidosis
Electrolyes
Ingestions
Volume overload
uremia
169
Q

Contraindications for Renal Transplant

Much better than HD

A 
uncorrectable CAD
acitve malignancy
Non-compliance
unresolved infxn
untreated +PPD
Active drug use
mental incompetance
Severe liver dz
170
Q

Maintenance of Renal tx

A

Keep BP< 130/80
Yearly derm exam
monitor for drug drug interactions

171
Q

HTN goals

A

160 or >100 - 2 drug regimen

172
Q

Seconary w/u HTN

A 
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
Q

Pheo

A

urine metanephrines

Treatment - surgery with pre=op alpha blocade before BB

174
Q

HTN Emergency

A 
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
Q

Cyclosporin

A

levels inc’d by verapamil/diltiazem - cause failure of renal tx

176
Q

Nephrotic syndrome cast

A

Hyaline (protein), fatty, oval fat bodies

177
Q

Glomerular Nephritis casts

178
Q

Prerenal azotemia casts

179
Q

ATN casts

A

Muddy/Dirty brown/Granular casts

180
Q

CRF casts

A

Broad casts

181
Q

Chronic progressive renal failure casts

A

Waxy casts

182
Q

Eosinophiluria seen in…

A

Interstitial nephritis
Atheremboism
Rapidly progressive GN
Acute prostatitis

183
Q

Hyaline cast

184
Q

Muddy brown cast

185
Q

RBC only (no cast)

A

Nephrolithiasis

186
Q

RBC Cast

A

Glomerulonephritis

187
Q

Oval fat bodies

A

Nephrotic syndrome

188
Q

Eosinophils

A

Interstitial dz

189
Q

Xray

A

shows all stones EXCEPT URIC ACID

190
Q

Renal US

A

size, obstruction, masses, screening for polycystic dz, stones>5mm

191
Q

IVP

A

Non-glomerular hematuria, rneal stones, voiding dz, unexplanined flank/abd pain

192
Q

Spiral CT wihtout contrast

A

stone hunt/perirenal hemorrhage

193
Q

CT with contrast

A

Staging of renal mass

OK if pt already on dialysis with little residual fxn

194
Q

Radionuclide scan

A

Renal perfusion assessment in case of transplant eval

195
Q

MRA/Rneal arteriography

A

renal arter dz

196
Q

MRI

A

Renal vein thrombosis

197
Q

Renal bx

A

Glomerular dz

198
Q

Nephrotic Syndrome

A

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
Q

Nephritic syndrome

A 
Urine - RBC casts, cola/smoky urine
Proteinuria <2.5g/day
Hematuria +
Cl features - HTN
Histopath
Post strep - 
IgA nephropathy - 
Henlock schonlein
RPGN
200
Q

Minimal Change (Nephrotic)

A 
Etio - Hodgkins, Leukemia, NSAID, Lithium
Bx/LM - Normal
Immuno - Normal
EM - Podocyte Effacement
Complement - normal
Treatment - Steroids/cyclophophamide
201
Q

Focal Segmental (Nephrotic)

A

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
Q

Membranous (Nephrotic)

A 
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
Q

Membranoproliferative (Nephrotic)

A

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
Q

Complications of Nephrotic syndrome

A 
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
Q

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?

A

Focal segmental glomerulosclerosis

206
Q

AA

A

Focal segmental

207
Q

Hodkins

A

Minimal Change

208
Q

Heroin

A

Focal segmental

209
Q

NSAID

A

Minimal change, Membranous

210
Q

Liquid malignancy

A

Minimal change

211
Q

Solid tumor

A

Membranous

212
Q

Lithium

A

Minimal Change

213
Q

Obestiy

A

Focal segmental

214
Q

Amyloid (Rh arthr, crohns, MM

A

Diffuse deposition

215
Q

Post Strep GN (nephritis)

A 
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
Q

IgA nephropathy (nephritis but can have&raquo_space;protein)

A 
Etio: Post exc, URI
Bx/LM: Mesangial proliferation
IM: IgA, IgG, C3 deposit in mesangium
EM:
Complement: Normal
Tx: Fish oil, ACEi, steroids
217
Q

Henoch-Scholnlein (Nephritis)

A 
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
Q

Rapidly progressive GN (Nephritis)

A 
Etio Type I good pasture
Bx/LM: Cresents (exracapillary) formation)
IM: Linear IGG
EM:
Complement: normal
Treatment: Immunosupp/Plasma pharesis
219
Q

Rapidly progressive GN (Nephritis)

A 
Etio Type II: D pcnamine
Bx/LM: Cresents (exracapillary) formation)
IM: Granular complex
EM:
Complement: Normal/low
Treatment?
220
Q

Rapidly progressive GN (Nephritis)

A

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
Q

Serum complement levels decreased in….(mostly nephritic)

A 
Post strep GN
Membranoprolif GN (SLE, Cryoglobulemia, SBE, Atheroembolism)
222
Q

Serum Complement NORMAL in…

A

IgA, Minimal change, Focal segmental, membranous, Goodpastures/wegeners (pauci-immune)

223
Q

Lupus nephritis

A 
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
Q

Pt with type II DM U albumin <5mg/24hrs best way to obtain renal fxn measure

A

Cockroft-Gault or Modification of Diet in Renal Disease equation
Ideal body wt (140-Age)/72x Serum Cr

225
Q

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?

A

Mixed cryoglobulineia

226
Q

Vasculitdies

A

PAN -> P-panca - Hep B ag +
Wegeners -> C-anca - Pauci immune/no immune depostis
Best way to confirm renal vasculitis -> bx (not angiography)

227
Q

Minimal change and Focal segmental

A

Epithelial cell foot processes

228
Q

Membranous

A

Basement membrane

229
Q

Mesangioprolfi/Glomerulosclerosis

A

Mesangial cell

230
Q

Cresentic RPGN

A

Epithelial cell

231
Q

ARF

A

Endothelial cell

232
Q

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?

A

IgA nephropathy

Bx shows?: IgA, IgG, C3 deposition on MESANGIUM

233
Q

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?

A

Stable in 20 years (likely no HD)

234
Q

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?

A

Post Strep GN

235
Q

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+

236
Q

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

A

Goodpastures

237
Q

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?

A 
Renal bx
Membrnaoproliferative nephritis (SLE nephritis)
238
Q

All have low complement

A

Post strep GN

SLE (C3

239
Q

All with NORMAL complement

A 
Minimal change
Focal segemental sclerosis
Membrnaous nephropathy
IgA nephropathy
Henolock Scholnlein nephropathy
Wegener's/PAN
(NOT CRyoglobulinemia - dec'd C3, CH50)
240
Q

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?

A

Hep C/cryoglobulin determination

241
Q

Acute renal failure

A

Sudden drop in GFR - inc’d BUN/Cr (1/3 ICU pts)

Pre-renal azotemia MCC ARF

242
Q

ARF

A

Pre-renal - decreased renal perfusion
Intrinsic renal - Glomerular dz, ATN, Tubulintersitial dz
Post renal - obstruction

243
Q

Indomethacin

A

constriction of AFFERENT arteriole

244
Q

ACEi (bradykinin)

A

vasodilation of EFFERENT arteriole

245
Q

Dec’d renal perfusion

A

Volume depletion: Vom/Diarrhea/Diuretics/bleed/burn
Volume Overload: CHF, Cirrhosis, Nephrotics (decreased effective arteriole volume)
Others: NSAIDs, ACEi, RAS

246
Q

Lab findings pre-renal azotemia

A 
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
Q

FENA

A

(UNa/Ser Na)/(UCr/Ser Cr)

248
Q

Acei

A

Dec’d efferent constriction via inc’d bradykinin

inc’d Cr 30% ok with ACEi

249
Q

NSAIDs

A

Constricts afferent blood supply - preciptates ARF in pt with underlying renal compromise

250
Q

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

A

Pre-renal azotemia 2/2 ACEi/Angiotensin inhib

WTD? D/C ACEi and rehck BUN/Cr

251
Q

HTN pt started on ACE - also taking ibuprofen for OA pain - Cr increases 1.4 to 1.9 wtd?

A

D/C ibuprofen first

252
Q

Pt on ACEi Cr inc 1.4 to 1.8 wtd?

A

continue ACEi

253
Q

HTN pt started on ACE Cr 1.0 to 1.8 wtd?

254
Q

Preg F 18weeks - not gaining any weight - c/o persistent nausea/vom x 3 months - Cr inc’s from 0.5 to 1.9

A

pre-renal hyperemesis gravidum

tx: IVF rehydration

255
Q

HTN pt started on ACEi, Cr 1.2 to 2.5 etio?

A

Renal artery stenosis?

256
Q

t/F in Renal artery stenosis, medial tehrapyvs surgical tx with SIMIAR rate of decilne in Serum Cr

257
Q

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?

A

NSAID induced nephrotic syndrome and interstitial nephritis

258
Q

Hepatorenal syndrome

A

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
Q

Intrinsic Acute Renal failure FENA >1

A

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
Q

Radiocontrast nephorpathy

A

12 hrs after contrast

precipated with underlying renal dysfxn

261
Q

Pt with post infarmt angina schedule for cardiac cath - Cr 1.5 - best way to prevent contrast nephropathy ?

A

NS 12 hrs pre and post procedure +- acetylcysteine

262
Q

If pt needs to go urgently to cath ….

A

Give socium bicarb, acetylcystein and start NS

263
Q

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?

A

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
Q

Rhabdomyolysis

A 
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
Q

Tumor Lysis sydorme

A 
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
Q

Rhabdo vs Tumor lysis

A

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
Q

26yo non hodgkin’s lymphoma LDH<2 ULNormal - pretx?

A

Allopurinol

268
Q

26yo with non-hodgkin’s lymphoma LDH>2 ULNormal pretx?

A

Rasburicase

269
Q

35yo diffuse large cell lymphoma with bulky dz pretx?

A

Rasburicase

270
Q

35yo diffuse large cell lymphoma stage III pretx?

A

Rasburicase

271
Q

Diffuse large cell lymhoma stage III with G6PD deficiency pretx?

A

Allopurinol (no rasburicase with G6PD)

272
Q

25yo AML WBC>100K pretx?

A

Rasburicase

273
Q

65yo CLL WBC <100K pretx

A

Allopurinol

274
Q

Any of above pt developed TLS on allopurinol or rasburicase pretx?

A

use Rasburicase

275
Q

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?

A

Rhabdomyolysis

276
Q

Elderly pt lives alone found lethargic withi empty etoh bottles U dip pos for blood, bicarb 17 likely?

A

Rhabdomyolysis

277
Q

Acute Tubular Necrosis can be caused by?

A 
Aminoglycosides Stepto>Genta>tobra
Amphotericin B
Cyclosporin
Rhabdo
(NOT NSAIDs - minimal change and membranous)
278
Q

NSAIDS cause all of the follwoign

A 
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
Q

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?

A

Radiocontrast (ATN)

280
Q

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?

A

Gentamycin induced nephrotoxicity

281
Q

Interstitial nephritis

A

Acute allergic interstitial nephritis

Chronic tubulointerstital nephritis (analgesic nephropathy)

282
Q

All of the following drugs can cause interstitial nephritis…

A 
Abx (PCN, methicillin, ampicillin, cipro, sulfa)
NSAIDs (no EOS)
Diureticss (thiazide, lasxi)
Phenytoin
(NOT ACEi)
283
Q

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?

A

U/A and Hansel/wright stain for EOS

284
Q

U/A shows 10 WBC, 7 RBC, EOS+, casts neg - dx?

A

PCN induced intersitial nephritis

285
Q

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

A

Analgestic nephropathy (chronic tubulointerstitial nephritis causing Papillary necrosis

286
Q

Papillary necrosis causes

A 
P yelonephritis
O bstruction
S ickle cell dz
T B
C hronic etoh
A nalgesic abuse
R V thrombosis
D iabetes Mellitius
287
Q

Post Obstructive Renal Failure

A 
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
Q

IN pt with suspected obstructive renal failure wtd?

A

Renal US r/o hydronephrosis

289
Q

In pt with h/o adhesions post srugery pw renal failure wtd before considering dialysis

A

Rule out obstuction

If US equivioval -> CT/MRI

290
Q

75yo pw inc’d BUN/Cr - dec’d UOP wtd?

A

Digital rectal exam r/o enlarged prostate

291
Q

Renal US shows enlarged bladder, ureteral distension and hydronephrosis wtd?

A

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
Q

Pt with HSV encephalitis started on IV acyclovir - BUN/Cr inc’s WTD?

A

CONTINUE Acyclovir and INCREASE hydration

293
Q

Chronic renal failure

A 
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
Q

Complication of CRF

A 
Acid base &amp; 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
Q

Management of CRF

A

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
Q

Indications for HD

A

GFRd albumin)
Pericarditis
Encephalopathy

297
Q

Complications of HD

A 
Disequilibration sydnrome
Inf of AV Fistula
HEp B/C
arrhythmia (afib MC arrythmia)
Aluminiu tox
Amyloidosis
Rneal cyst
Renal CA
Bleeding diathesis
298
Q

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?

299
Q

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?

A

Monitor for now - discuss outcome swith pt and family recognize goals set by pt and family

300
Q

82yo in NH walks with walker mild confusion found to have BUN/Cr 80/8 - indiitaing HD on this pt woudl result in ?

A

DECREASED functional status

301
Q

Best manamgement for ESDK pt

A

Dec’d Na, Dec’d water, Dec’d K Dec’d Phos, NO CA restriction!!

302
Q

T/F MCC CRF in US is DM

303
Q

T/F - mortality rates at end of 5 years higher in HD patients than in renal tx patients

304
Q

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?

A

Start Darbepoetin alpha plus iron

305
Q

What antacids to avoid in ESKD

A

No aluminium or Mg based antacids

306
Q

What kind of enema can cause renal failure?

A

Phosphate enema

307
Q

Pt with ESKD PTH inc, Ca inc, Phos inc, ISCHEMIC SKIN LESIONS? dx?

A

Calciphylaxis

308
Q

55yo M ESKD pw thickenign of skin in legs and arms like peau d’orange appeanace dx?

A

Nephorgenic fibrosing dermopathy

309
Q

T/F In pt with renal insufficiency, keeping serum bicarb above 22 has show to decrease rate of lung function decline

310
Q

T/F In pt with renal insufficiency, keeping serum bicarb above 22 has show to improve nutrtiional status

311
Q

Nephrolitiaisis

A

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
Q

Nephrolithiasis predisposing factors

A

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
Q

CaOx stones

A

ok to contineu oral Ca (actually decreases risk of Ca Ox stones by binding oxalate in gut)

314
Q

What to expect in pt with short bowel syndrome or Crohn’s

A

Increased Oxalate absorbtion - Envelope shaped crystals

315
Q

All these stones formed in acid urine

A

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
Q

All are risk factor for stones

A 
Hyper Ca
Hypercalciuria
Hyperuricosuria
Hyperoxaluria
HYPOcitraturia
Cystinuria
Renal tubular acidosis
Inflamm bowel dz
High vit C
High Na diet
(NOT HYPERURICEMIA WITHOUT HYERPURICOSURIA)
317
Q

You woudl do further dignostic w/u for all these

A

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
Q

Kidney stone NOT seen on xray

A

Uric acid

CaOx, CaPO4, struvite all radioopaque

319
Q

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

A

Caused by struvite stone - magnesium ammonium phosphate

320
Q

MCC recurrent nephorlithiasis

A

Idiopathic hypercalciuria

321
Q

Pt with renal colic Kidney stone 5mm on CT wtd?

322
Q

Pt with renla colic 4mm stone at uteropelvic jnc - fluids encourage pt still in pain - wtd?

A

Tamsulosin - (floppy iris sydrome if taking prior to cataract surgery)

323
Q

Pt dx with inflamm bowel dz - expect all the following

A

Hyperoxaluria
Hypocitraturia
(NOT CYSTINURIA) - dec’d citrate with IBD

324
Q

Pt dx with distal RTA I and has stone likely compoosition is?

325
Q

T/F - history of renal stones is contraindication to adequate Ca in diet?

326
Q

Pt with short bowel syndrome - add Ca to diet in order to…

A

Decrease absorbtion of Oxalate (dec Ca Ox stones) = envelope

327
Q

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

2020 ABIM Awesome Review edited (14 decks)

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