Oliguria and/or Proteinuria DSA and CIS

Question 1

What defines anuria, oliguria, and polyuria?

Answer 1

anuria: < 50-100 ml/day
oliguria: < 400-500 ml/day
polyuria: > 3000 ml/day

Question 2

What is significant about the sx of uremia?

Answer 2

(must have elevated BUN)

sx are often non-specific w/ multiple etiologies causing them

Question 3

What common drugs are nephrotoxic?

What do you always ask about them?

Answer 3

NSAIDs

antibiotics

proton pump inhibitors

always ask which ones, how many at a time, and for how long

Question 4

What type of contrast dye can be nephrotoxic?

Answer 4

IV iodine contrast

(not the oral kind)

Question 5

What defines acute kidney injury vs CKD?

Answer 5

< 3 mos w/ GFR < 60 ml/min and/or markers of kidney damage present = AKI

after 3 mos, pt can be labeled w/ CKD

Question 6

What are the clinical markers of kidney damage?

How many are required to dx AKI or CKD

Answer 6

one or more required:

albuminuria

urine sediment abnormalities

electrolyte and other issuew due to tubular damage

histology or structural abnormalities

Hx of kidney transplant

Question 7

What are the stages of CKD?

Answer 7

Question 8

GFR greater than or equal to 90 is CKD stage ___

Answer 8

stage 1 = normal or high GFR

Question 9

GFR btw 60-89 is CKD stage ___

Answer 9

2 = mild decrease

Question 10

GFR btw 45-59 is CKD stage ___

btw 30-44 is stage ___

Answer 10

3a = mild to moderate decr

3b = moderate to severe decrease

Question 11

GFR btw 15-29 is CKD stage ___

Answer 11

4 = severe decrease

Question 12

GFR < 15 is CKD stage ___

Answer 12

5 = kidney failure/ESRD

Question 13

Neither GFR category stage 1 or 2 apply (with the associated decreased GFR) if what?

Answer 13

if no sx

Question 14

What are the top two causes of CKD?

Answer 14

diabetes = 38%

HTN = 26%

(total cause 64%)

Question 15

What is asterixis?

Answer 15

type of negative monoclonus where body parts can just flop around according to google

(he has a picture of a flopping hand)

Sx of CKD and AKi

Question 16

What is uremic frost?

Answer 16

deposition of urea crystals on skin

seen in CKD and AKI

Question 17

What is the formula for estimating creatinine clearance?

Answer 17

the cockroft-gault formula

Question 18

How can creatinine clearance skew estimated GFR?

Answer 18

tends to overestimate GFR because creatinine is freely filtered at glomerulus but is also secreted by tubules making urine creatinine concentration higher than expected

(use cockcroft-gault equation instead)

Question 19

What tests can you do measure proteinuria?

Answer 19

urine albumin to creatinine ratio or urine protein to creatinine ration = random, spot urine

24 hr urine total protein collection = annoying, usually not done unless completely necessary

Question 20

When is is eGFR not accurate?

What is the most accurate way to measure GFR?

Answer 20

in settings of rapidly changing creatinine (AKI)

measured GFR most accurate but only performed in limited institutions

Question 21

How is serum creatinine used in diagnosis of CKD?

Answer 21

not often = poor marker of kidney function

Question 22

What are the renal U/S findings for CKD?

Answer 22

atrophic or small kidneys

cortical thinning

increased echogenicity

elevated resistive indices

Question 23

What is a doppler renal US used for?

Answer 23

to look for renal A stenosis or renal vein thrombosis or resistive index

high resistive indices (>0.7-0.8) indicate resistance to arterial flow w/in kidney

Question 24

What is an abdominal CT scan better for evaluating in kidney dz?

Answer 24

better at detecting masses and kidney stones

can evaluate for same things as renal US

Question 25

What is the most commonly used imaging of kidney?

Answer 25

renal US

Question 26

What are the indications for dialysis?

Answer 26

AEIOU A: severe acidosis E: electrolyte disturbance (usually hyperkalemia) I: Ingestion of toxins O: volume overload U: uremia

Question 27

What are the 3 types of renal replacement therapy?

Answer 27

hemodialysis peritoneal dialysis renal transplant

Question 28

What are BP goals in CKD?

Answer 28

no proteinuria: \< 140/90 proteinuria: \< 130/80

Question 29

Tx for proteinuria

Answer 29

low salt diet BP control ACEi, ARB, aldosterone antagonist, renin inh, non-D CCB

Question 30

Tx for anemia in CKD?

Answer 30

oral or IV iron EPO stimulating agents

Question 31

Tx for metabolic acidosis in CKD?

Answer 31

bicarbonate supplementation if HCO3 \<22

Question 32

Tx for hyperkalemia in CKD?

Answer 32

renal failure diet = low salt, potassium, and phosphorus diuretics sodium plystyrene sulfonate or patiromer

Question 33

What is CKD-BMD and how do you tx?

Answer 33

secondary hyperparathyroidism to CKD (previously renal osteodystrophy) tx w/ renal failure diet posphorus binder Vit D supplementation calcimimetics to lower PTH dialysis

Question 34

AKI definitions and stages

Answer 34

Question 35

What category of AKI do renal pelvis issues fall under (papillary necrosis, stones)?

Answer 35

postrenal AKI

Question 36

What are the 3 intrinsic causes of AKI?

Answer 36

tubular necrosis (ischemia = 50%, toxins = 35%) interstitial nephritis = 10% glomerulonephritis = 5%

Question 37

What sx is seen in AKI but not often in CKD?

Answer 37

shortness of breath if pulmonary edema is present

Question 38

What labs do you obtain on all pts w/ AKI? What imaging is commonly run?

Answer 38

urinalysis w/ urine microscopy urine albumin/Cr ration or urine protien/Cr ratio renal US

Question 39

Equation for fraction excreted Na

Answer 39

Question 40

What is the general tx of AKI?

Answer 40

mostly supportive avoid hypotension discontinue nephrotoxins renal replacement if needed - usually hemodialysis

Question 41

What is the association w/ serum albumin and nephrotic syndrome?

Answer 41

if serum albumin is normal w/ nephrotic range proteinuria, then the pt DOES NOT have true nephrotic syn but instead nephrotic range proteinuria

Question 42

Why can thrombosis occur in nephrotic syndrome?

Answer 42

not well understood - can be venous or arterial higher risk w/ albumin \< 2.0 or 2.5 g/dL urinary loss of antithrombotic factors (antithrombin III, plasminogen, protein S, etc) increased levels of procoagulant factors

Question 43

Who is at high risk for thrombo-embolism in nephrotic pts?

Answer 43

serum albumin \< 20 g/L climical hypovolemia bed rest/intercurrent illness membranous nephropathy

Question 44

What are the two theories of pathogenesis of edema in nephrotic syn?

Answer 44

low intravascular oncotic pressure bc low albumin = underfill theory renal sodium retention secondary to low renal perfusion from low RAAS or primary sodium retention by kidneys = overfill theory

Question 45

What is the classic presentation of nephrotic syndrome?

Answer 45

new onset hypertension new onset edema proteinuria lipiduria hyperlipidemia minimal hematuria

Question 46

What are the monoclonal disease related etiologies of nephrotic syndrome?

Answer 46

multiple myeloma amyloidosis monoclonal Ig deposition disease (MIDD) = light chain, heavy chain, or both

Question 47

What are the 5 main etiologies of nephrotic syndrome to know?

Answer 47

diabetic nephropathy minimal change dz FSGS membranous nephropathy monoclonal disease related

Question 48

How do you tx thrombosis in nephrotic syn?

Answer 48

heparin or warfarin consider prophylactic anticoagulation for serum albumin \< 2.5 g/dL

Question 49

How to do tx predisposition to infection seen in nephrotic syndrome?

Answer 49

give IV Ig

Question 50

In what kidney dz do you usually have active urinary sediment?

Answer 50

nephritic syndrome (nephrotic syn usually has "bland" urinary sediment)

Question 51

What kidney dz is due to thrombotic microangiopathy?

Answer 51

nephritic syndrome

Question 52

What heart dz can cause nephritic syndrome?

Answer 52

endocarditis

Question 53

When are complement levels helpful in kidney dz dx?

Answer 53

low complement levels are very helpful in ddx of nephrITIC syndrome low C4 and C3 --\> classical pathway low C3 onl --\> alternative pathway activated

Question 54

What do you see in urine in acute tubular necrosis?

Answer 54

renal tubular epithelial cells transitional epithelial cells granular casts waxy casts

Question 55

What do you see in urine in acute interstitial nephritis or pyelonephritis?

Answer 55

WBC WBC casts urine eosinophils

Question 56

What do you see in urine in vasculitis or glomerulonephritis?

Answer 56

dysmorphic RBCs RBC casts

Question 57

What do you see in urine in nephritic syndrome?

Answer 57

proteinuria \< 3.5 g/day hematuria dysmorphic RBC and RBC casts

Question 58

What do you see in urine in non-specific, prerenal azotemia?

Answer 58

hyaline casts

Question 59

What do you see in urine in UTI?

Answer 59

WBCs RBCs bacteria

Question 60

How does hyperkalemia affect resting membrane potential?

Answer 60

makes membrane potential less negative --\> easier to depolarize

Question 61

D-dimer and BNP lab findings should be interpreted with caution in what setting?

Answer 61

renal failure

Question 62

What does a CXR look like in pulmonary edema?

Answer 62

diffuse alveolar consolidation

Question 63

What is the initial management and tx of hyperkalemia?

Answer 63

**calcium gluconate** to antagonize cardiac AP To **lower potassium** levels: **insulin** and **dextrose** **furosemide** (will also help w/ pulm edema and anasarca) **albuterol** nebulizer could give sodium polystyrene sulfonate

Question 64

What glomerular disorders have subEPIthelial deposits?

Answer 64

post-strep glomerulonephritis membranous glomerulonephritis

Question 65

What glomerular dzs have subENDOthelial deposits?

Answer 65

MPGN type I SLE (diffuse proliferative GN) (probably more but these are the main ones I memorized for the last test)

Question 66

What is the general management for most cases of AKI?

Answer 66

avoid nephrotoxins (NSAIDs, IV contrast, etc) renal dose all medications (discontinue metformin) avoid hypotension avoid dehydration

Question 67

What is meloxicam?

Answer 67

prescription NSAID | (consider nephrotoxicity)

Question 68

What is normal capillary refill time?

Answer 68

\<2-3 seconds anything greater --\> sign of dehydration or anemia

Question 69

What are signs of hypovolemia or prerenal azotemia?

Answer 69

hemoconcentration hypovolemic hyponatremia contraction metabolic alkalosis BUN/Cr ration \> 20:1 hyaline casts in urine

Question 70

What are signs of acute tubular necrosis seen in urinalysis?

Answer 70

proteinuria renal tubular epi cells transitional epi cells granular casts FENA \> 2%

Question 71

How are prerenal azotemia and acute tubular necrosis connected?

Answer 71

if prerenal azotemia is present long enough, the pt will start to develop ATN

Question 72

What is the prognosis of AKI?

Answer 72

once kidney fxn declines regardless of etiology, there is no guarantee that fxn will recover or improve if it improves, still no guarantee it will go back to baseline can take up to 3 mos for recovery --\> after 3 mos, if not to baseline = CKD