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Elaina: Hospital Medicine > Nephrology Lecture > Flashcards

Nephrology Lecture Flashcards

1
Q

what is the term used for elevated nitrogen containing compounds (urea, creatinine) in the blood?

A

azotemia

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2
Q

what is the term for symptomatic azotemia? what type of acid/base disorder will these patients have?

A

uremia

metabolic acidosis

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3
Q

according to KDIGO guidelines, what are the criteria for defining acute kidney injury?

A

1) rise in creatinine greater than 0.3 mg/dL

2) decrease in UO to less than 3 mL/kg over 6 hours

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4
Q

what is the most common presentation of acute kidney injury? what are some other presentations?

A

frequently asymptomatic with NO visible signs

other: HTN, edema, decreased UO

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5
Q

what will labs look like in AKI?

A

albuminuria
increased BUN
hyperkalemia
hyponatremia

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6
Q

in general, what type of physiologic state causes prerenal azotemia?

A

hypovolemic states with decreased perfusion to the kidneys

can cause prolonged renal ischemia

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7
Q

which two chronic conditions cause prerenal azotemia?

A

CHF and hepatic failure (cirrhosis) due to third spacing and hypoperfusion

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8
Q

which two more acute conditions cause prerenal azotemia?

A

1) dehydration (inadequate PO intake, GI losses, diuretics)

2) sepsis

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9
Q

type 1 renal tubular acidosis occurs where in the renal tubules? what problem does it cause?

A

type 1 = distal

causes decreased tubular H+ excretion – hypokalemia

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10
Q

type 2 renal tubular acidosis occurs where in the renal tubules? what problem does it cause?

A

type 2 = proximal

causes decreased proximal HCO3 reabsorption and hypokalemia

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11
Q

type 4 renal tubular acidosis causes impaired ____ and ____ excretion

A

type 4 = impaired hydrogen and potassium excretion

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12
Q

an ______ deficiency, as seen in addison’s disease and DM, is likely to cause type 4 renal tubular acidosis

A

aldosterone deficiency

we need aldosterone to help us excrete potassium, without it we become hyperkalemic

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13
Q

glomerulonephritis, nephrosis, minimal change disease, and nephritis are all causes of what type of renal azotemia?

A

intrinsic acute kidney injury

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14
Q

he did a terrible job at explaining these. but flip the card for a brief explanation of

1) glomerulonephritis
2) interstitial nephritis
3) acute tubular necrosis

A

1) glomerulonephritis – see RBC casts and blood on urinalysis
2) interstitial nephritis – caused by nephrotoxic drugs (NSAIDS, lithium), INFECTION, etc. – see WBC casts on urinalysis
3) acute tubular necrosis – causes are prolonged ischemia, contrast reaction, sepsis – see muddy brown casts (or nothing) on urinalysis

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15
Q

what are a few causes of postrenal AKI azotemia?

A

urinary obstruction!

prostatism, bladder, pelvic or retroperitoneal tumors, calculi, urethral obstruction

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16
Q

why might a low hemoglobin/hematocrit indicate renal disease?

A

kidneys responsible for making erythropoietin for RBC stimulation

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17
Q

what are the two ways we can prevent AKI?

A

1) sustain renal perfusion (fluid balance, BP maintenance)

2) don’t clog the pipes (see next card)

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18
Q

how can you prevent AKI in the following situations?

1) about to give contrast dye to someone with weak kidneys
2) patient presents with hemolysis and/or rhabdomyolysis

A

1) aggressive IVF to limit contact w/ kidneys or avoid exposure if possible
2) aggressive IVF to protect kidneys

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19
Q

what is the MOST important component of diagnosing AKI?

A

identify the underlying cause

almost can ALWAYS reverse AKI in a normal healthy patient

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20
Q

if patient is developing profound hyperkalemia, what can we give?

A

kayexelate

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21
Q

what are the four MC etiologies of chronic kidney disease?

A

1) AKI
2) HTN
3) DM
4) vascular disease

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22
Q

microalbuminuria is defined as ____ albumin in the urine

A

30-300 mg/24 hour period

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23
Q

what levels indicate microalbuminuria on a spot urine albumin-to-creatinine ratio in men vs. women?

A

17-250 mg/g (men)

25-355 mg/g (women

anything lower = normal
anything higher = albuminuria

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24
Q

what are the 5 (technically 6) stages of kidney failure with their corresponding GFR?

A 
1: GFR greater than 90
2 (mild): GFR 60-89
3 (mod): GFR 45-59
4 (mod): GFR 30-44
4 (sev): GFR 15-29
5 (ESRD): GFR less than 15
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25
Q

what does the diet of a CKD patient look like when being managed in the hospital?

A

low sodium, low protein, low potassium, low phosphate

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26
Q

what should we avoid in all patients being hospitalized for CKD?

A

NSAIDS, radiocontrast, other nephrotoxins

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27
Q

where is the only place that you can measure potassium levels?

A

extracellular fluid volume (ECFV)

28
Q

adrenal insufficiency will cause which electrolyte disturbance?

A

hyperkalemia

29
Q

insulin deficiency will cause which electrolyte disturbance?

A

hyperkalemia

need insulin to get K into cell

30
Q

being on a beta blocker puts you at risk for developing which electrolyte disturbance?

A

hyperkalemia

they impeded K’s ability to get into cell

31
Q

aldosterone antagonists (spironolactone) will cause which electrolyte disturbance?

A

hyperkalemia

32
Q

what are 5 ways we treat hyperkalemia?

A

1) IVF if fluid depleted
2) kayexelate if not hypovolemic
3) limit potassium intake
4) insulin + dextrose (drive K into cells)
5) beta adrenergics (counteract BB effect)

33
Q

being hypomagnesemic can put you at risk for developing what electrolyte disturbance?

A

hypokalemia

ALWAYS get Mg level in the face of hypokalemia

34
Q

what two drugs can cause hypokalemia?

A

insulin

beta agonists

35
Q

manifestations of hyperkalemia? (3)

A

1) weakness
2) paralysis
3) cardiac arrhythmias!! peaked T waves, widening PR, QRS, eventual PEA

36
Q

manifestations of hypokalemia? (3)

A

1) weakness/rhabdomyolysis
2) glucose intolerance
3) cardiac arrhythmias (U waves after T waves)

37
Q

treatment of hypokalemia?

A

1) potassium replacement

2) magnesium replacement

38
Q

what are the two types of loss that can cause hypokalemia? examples of both?

A

GI losses: vomiting, diarrhea, laxatives, tube drainage

Renal losses: diuretics, hypomagnesemia, non-absorbable ions

39
Q

____ is the primary extracellular cation

A

sodium

40
Q

in general, what are the two major causes of hypernatremia?

A

1) extrarenal water loss

2) renal water losses

41
Q

what are examples of extrarenal water loss leading to hypernatremia?

A

fever, sweating, diarrhea

mechanical ventilation

42
Q

what are some examples of renal water loss leading to hypernatremia?

A

1) osmotic diuresis (DKA, mannitol, sodium)
2) diabetes insipidus
3) iatrogenic (1 amp of NaHCO3 has twice the concentration of 3 percent saline)

43
Q

what is the difference between central and nephrogenic diabetes insipidus?

A

central: low ADH production
nephrogenic: unresponsive to ADH

both cause polyuria, polydipsia, and hypernatremia

44
Q

if urine osmols are greater than 300, what is the likely culprit of the hypernatremia?

A

osmotic diuresis

45
Q

if urine osmols are less than 150, what is the likely culprit of the hypernatremia?

A

diabetes insipidus

46
Q

treatment for hypernatremia? what do we need to be cautious of?

A

1) NS initially if volume depleted
2) transition to 1/2 NS vs. D5Q

**avoid correction faster than 0.5 meq/L to avoid cerebral edema

47
Q

does hyponatremia mean low salt in the blood?

A

NO

decreased sodium CONCENTRATION
more water with relation to sodium

48
Q

hyponatremia is typically associated with elevated _____

A

ADH

49
Q

hyperosmolar or normosmolar hyponatremia is caused by what?

A

elevated levels of another osmolyte (glucose in DKA, diabetes; elevated proteins, lipids)

-these osmolytes are pulling more water into the blood, causing a hyponatremia

50
Q

hypoosmolar hyponatremia is caused by what?

A

too much ADH

51
Q

what causes too much ADH to be released? (3)

A

1) increased serum osmolality (ie uncontrolled diabetes)
2) decreased circulating volume (hypotension)
3) inappropriate (SIADH)

52
Q

which electrolyte disturbance will CHF, cirrhosis, or nephrotic syndrome cause?

A

hypERvolemic hyponatremia

  • third spacing causes decreased effective circulating volume
  • kidneys respond by turning on RAA (retaining more sodium) and rising ADH (even though there’s plenty of volume)
53
Q

vomiting, diarrhea, and dehydration will cause what acid base disturbance (in terms of sodium)?

A

hypovolemic hyponatremia

extrarenal losses

54
Q

salt-wasting nephropathies, thiazide diuretics, and primary adrenal insufficiency will cause what acid base disturbance (in terms of sodium)?

A

hypovolemic hyponatremia

renal losses

55
Q

if urinalysis of your hypovolemic hyponatremic patient shows greater than 30 mmol of sodium per liter, where is the issue? renal or extra renal?

A

RENAL issue. the kidney is releasing salt inappropriately

extra-renal losses will have less than 30 mmol of sodium per liter in their urine, because their kidneys are working properly and can retain sodium

56
Q

SIADH and psychogenic polydipsia are causes of which type of electrolyte disturbance (in terms of sodium)?

A

euvolemic hyponatremia

57
Q

what will urine osmols look like in euvolemic hyponatremia due to SIADH vs. psychogenic polydipsia?

A

urOsm greater than 100 in SIADH (you are reabsorbing so much water that the urine is very concentrated)

urOsm less than 100 is psychogenic polydipsia (kidney’s can’t keep up, very dilutee urine)

58
Q

what will urine sodium of a euvolemic hyponatremia look like?

A

greater than 30 Una

RAA is NOT engaged (we have plenty of fluid) and sodium is being excreted

59
Q

pain, volume depletion (followed by LR or hypotonic fluids), trauma, medications (SSRIs, thiazideS), neoplasms, severe nausea, and neuropsychiatric meds can all cause ____ to elevate

A

ADH

60
Q

generally, how do we treat hyponatremia?

A

its an excess of water, but we treat it like a deficiency of salt

give IVF – percent saline depends on UrOsm
give loop diuretic (get excess water off)
fluid restrict
increase solute intake
ADH receptor antagonist

61
Q

how much do we want to see our sodium rise when treating hyponatremia in a 24 hour period? what number must we not exceed in 48 hours?

A

no more than 10 mEq/L in first 24 hours

no more than 18 mEq/L in 47 hours

62
Q

if our patient has chronic symptomatic hyponatremia, how do we manage? what do we worry about?

A

risk of osmotic demyelination syndrome if corrected too rapidly

may use brief stint of 3 percent saline – ALWAYS consult nephrology

63
Q

under which 3 conditions should you discontinue NaCl administration via IVF for hyponatremia?

A

1) serum Na starts to rise
2) urine Osm falls
3) symptoms resolve

64
Q

how do we treat hypovolemic hyponatremia?

A

NaCl, but usually asymptomatic

65
Q

if you are in metabolic acidosis, will you be hyperkalemic or hypokalemic?

A

hyperkalemic

Elaina: Hospital Medicine (11 decks)

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