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Block 9; Week 5-M > Patterson-Kidney > Flashcards

Patterson-Kidney Flashcards

1
Q

What are some symptoms of kidney dysfunction?

A

gross hematuria or flank pain OR extra-renal signs/symptoms- hypertension, edema or confusion
OR asymptomatic w/ abnormal creatinine, BUN, GFR, urinalysis
Can also use ultrasound, CT, biopsy

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2
Q

What is GFR a measure of? What is a normal value for men & women?

A

GFR is a measured or estimated value of # of total functioning nephrons

men: 130ml/min
women: 120ml/min

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3
Q

How much fluid is filtered in humans per day?

A

180L/day

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4
Q

In the elderly the GFR decreases by how much each year?

A

0.75 ml/min per year

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5
Q

What is a normal GFR in a >70 yo w/o HTN or diabetes?

A

60ml/min

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6
Q

What does a low GFR suggest?

A

a decreasing GFR suggests loss of nephron function OR a superimposed problem influencing filtration

  • does not always suggest physical loss of nephrons
  • possible to have progressive renal disease and a normal GFR
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7
Q

How can you measure the GFR?

A

clearance (x) = U(x) x V/ P(x)

inulin-best but tough
creatinine clearance good estimate; Scr inverse to GFR

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8
Q

When might you want to use inulin?

A

chemo drugs–need a more specific knowledge of GFR

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9
Q

What is creatinine a product of?

A

diet & muscle mass. Need these to stay the same to make GFR comparisons.

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10
Q

Someone has Scr of 3 & it changes to 3.5
Another pt has Scr of 0.7 & it changes to 0.9
Which patient are you more concerned about?

A

0.7-0.9 represents a bigger change in GFR.

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11
Q

What is a normal Scr for women &men? Ethnicity relationship?

A

Average SCr 1.13 mg/dl men and 0.93 mg/dl women
Higher in Blacks, young patients
and lower in Hispanics, elderly

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12
Q

What are some factors that can cause lower Scr?

A

amputees
vegetarians
elderly

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13
Q

What are some factors that can cause higher Scr?

A

H2 blockers, trimethoprim, tenofovir–decrease secretion of creatinine, increase serum conc’n
assays can mistake Cefotaxime, flucytosine
for creatinine.
lots of meat intake, supplements

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14
Q

Is creatinine reabsorbed, secreted, metabolized by kidney?

A

secreted only in PCT 10-40%

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15
Q

How can you measure creatinine clearance to estimate GFR?

A

Cockcroft-Gault equation
MDRD (modification of diet in renal disease) equation
CKD- EPI equation

OR
Measure the CrCl with a 24 hr. urine collection

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16
Q

What’s the deal with the Cockcroft-Gault equation?

A

Male GFR = (140 - age) x (weight) / (sCr x 72)
Female GFR = (140 - age) x (weight) x 0.85 / (sCr x 72).

Good for younger person of normal weight with renal disease (GFR b/w 15-60)

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17
Q

What’s the deal with MDRD equation?

A

Less accurate in extremes of age or weight, pregnancy, amputees and cirrhosis. Good for patients w/ CLK & GFR 15-60.

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18
Q

What is the deal with the CKD-EPI equation?

A

Good for GFR >60. Better for elderly.

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19
Q

What is the equation for 24 hour clearance? When is it useful?

A

CrCl = (uCr x uV) / (sCr x 1440)

Use in pregnancy, extremes of age or weight, amputees, malnutrition. Not used very often.

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20
Q

Which is more accurate in estimating GFR: SCr or BUN?

A

Scr is more accurate b/c it isn’t reabsorbed in the kidney. BUN is reabsorbed (40-50%) in the PCT

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21
Q

What are some things that will raise BUN?

A

high protein diet
trauma
hemorrhage (GI bleed)

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22
Q

What are some things that will lower BUN?

A

low protein diet

liver disease

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23
Q

What is a case when you want to compare BUN & Scr?

A

when a person is dehydrated, body wants to reabsorb as much as it can
reabsorbs most of the urea in PCT–>increases BUN
creatinine isn’t reabsorbed, so SCr doesn’t rise.
BUN/SCr goes up!!
dehydration could mean hypovolemia/hypotension–>pre-renal failure.
BUN/SCr>20 suggest pre-renal failure.

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24
Q

What is FENa? What’s the equation?

A

fractional excretion of sodium

FENa % = [Una x Scr / Ucr x Sna] x 100%

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25
Q

If you’re not excreting a lot of sodium…what could that mean?

A

could mean that you need it all + your water! Hypovolemia/Hypotension
maybe it could even mean pre-renal AKI

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26
Q

What is the FENa value consistent with pre-renal AKI? What are possible ddx?

A

<1%

could mean acute interstitial nephritis, myoglobinuria, contrast induced nephropathy

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27
Q

What are 2 things that can make FENa less accurate?

A

person w/ normal GFR

person on diuretics

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28
Q

If a person is on diuretics & you want to evaluate them for pre-renal AKI…what measurement should you use?

A

FEurea instead of FENa

FEurea<35% consistent with pre-renal AKI

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29
Q

What are the 3 aspects of the UA?

A

Appearance: color, clarity
Dipstick Evaluation
Microscopic Analysis

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30
Q

What do you look for in the dipstick evaluation?

A

Blood, leucocyte esterase, nitrates, pH, S.G, urobilinogen, protein, ketones and glucose, pH

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31
Q

WHat do you look for in the microscopic analysis?

A

Cells, casts, crystals, bacteria

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32
Q

We are talking clarity/color on UA. WHat would a turbid appearance mean?

A

Turbid urine suggests infection, crystals or leucocytes

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33
Q

What would a hazy urine suggest?

A

mucus

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34
Q

What would a milky urine suggest?

A

chyluria from nephrotic syndrome (severe) with dyslipidemia and oval fat bodies, profofol

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35
Q

What would blue, black, pink urine suggest?

A

inborn errors of metabolism

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36
Q

How should you interpret red/brown urine?

A

spin it!

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37
Q

How do you differentiate infection from crystals if you see a turbid UA?

A

spin it.

crystals will precipitate. infection won’t.

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38
Q

How would hematuria present w/ UA?

A

see brown/red urine. spin it.

clear supernatant on top. red sediment on bottom.

39
Q

How would hemoglobinuria, myoglobinuria present w/ UA?

A

see brown/red urine. spin it.
pink/red supernatant on top. red sediment on bottom.
dipstick in supernant, reacts + for blood.

40
Q

How would beets, rifampin, food dyes show up on UA?

A

see brown/red urine. spin it.
pink/red supernatant on top. red sediment on bottom.
dipstick in supernant, no reaction for blood.

41
Q

What are 2 weird things that can cause your urine to turn green?

A

asparagus

propofol

42
Q

What is a normal pH range for a kidney?

A

4.5-8.5

43
Q

What are some things that can cause a low pH of urine?

A

metabolic acidosis

44
Q

What can make the pH of the urine higher?

A

UTIs
urease producing organisms such as proteus mirabilis
urea–>NH3

45
Q

What do you worry about if the pH of the urine is greater than 5 but the patient is in metabolic acidosis?

A

renal tubular acidosis

46
Q

What is specific gravity? How is it different from Uosmolality?

A

conc’n of blood based off of # & size of particles.

Uosm is just based off of #.

47
Q

Give an example of something that increases s.g. but not Uosm.

A

glucose
contrast dye
protein

48
Q

What serum glucose is required to exceed Tmax of glucose reabsorption in PCT & get glucose in the urine?

A

serum glucose of 180

49
Q

Which ketones are detected on UA? What can cause an elevation of them?

A

ONLY acetoacetic acids
NOT beta-hydroxybutyric acid or acetone
elevated w/ starvation, Atkin’s

50
Q

So….your patient appears to be in diabetic ketoacidosis. You check their UA & there are no ketones. T/F He’s fine.

A

False. Ketones on UA only detect acetoacetic acids.

Check his serum ketones!

51
Q

What’s the story of urobilinogen? When is it elevated?

A

comes from bilirubin. converted in the gut. 2% of it is excreted in the urine.
can be elevated with: hemolytic anemia, intestinal obstruction

52
Q

Which protein is measured on the UA? What is it not useful in detecting?

A

albumin ONLY is detected

not immunoglobulin light chains–>can’t tell you if you have multiple myeloma

53
Q

Urine protein less than _____mg/day is not detected on UA.

A

300

54
Q

IF you see protein on UA, you need to further investigate. What are your options–which of them is best?

A

24 hr urine

spot urine protein/creatinine ratio–BEST option.

55
Q

How is blood detected on uA?

A

see if it reacts with peroxidase.

will be + with blood, free hemoglobin, myoglobin

56
Q

What can cause a false positive on UA? False negative?

A

FP–>semen

FN–>Vit C

57
Q

How do you get nitrites in the urine?

A

nitrate reductase, found in E coli

can’t get with enterococcus.

58
Q

WBCs in urine and + nitrites/LE= ?

A

UTI

59
Q

WBCs in urine and – nitrites/LE = ?

A

sterile pyuria (urine contains pus, w/o infection)

60
Q

What are some different crystals that can be seen on microscopic analysis of urine?

A

uric acid
calcium phosphate
magnesium phosphate (struvite)

61
Q

When do you see uric acid crystals?

A

Seen in acidic urine

Due to uric acid crystals from too much uric acid- lymphoma, leukemia esp. after treatment (tumor lysis syndrome)

62
Q

When do you see calcium phosphate crystals?

A

Seen in alkaline urine

Associated with nephrolithiasis

63
Q

When do you see struvite crystals?

A

Seen in alkaline urine

Esp with urease producing organisms: Proteus and Klebsiella

64
Q

When is it common to see RBCs in the urine?

A

after…menses, exercise, sex, UTI

65
Q

What is a glomerular hematuria?

A

dysmorphic RBCs, come from upper GI tract, may include acanthocytes (look like bite out of them)

66
Q

What is nonglomerular hematuria?

A

isomorphic RBCs from lower GI tract,

67
Q

What does the presence of neutrophils mean in the urine?

A

UTI, nephrolithiasis, glomerulonephritis, interstitial nephritis

68
Q

What does the presence of eosinophils mean in the urine?

A

Acute kidney injury!
interstitial nephritis
seen with prostatitis & renal atheroemboli

69
Q

What is a cast seen in urine?

A

Formed in tubule lumen with organic material and mucoprotein as the ‘cement’

70
Q

Give an example of a normal cast & when it is seen?

A

hyaline cast–hypovolemia

71
Q

Give some examples of pathologic casts & what they suggest.

A

RBC casts- suggest glomerular hematuria / glomerulonephritis
WBC casts – suggest kidney inflammation, pyelonephritis
Granular casts- degraded tubular protein
Muddy brown sediment
ATN-acute tubular necrosis

72
Q

What is acute kidney injury?

A

Rapid loss of kidney function resulting in retention of nitrogenous waste products
Begins with: increase creatinine, decreased urine output, acidosis, hyperkalemia

73
Q

Which patients get a LOT of AKI? What is the criteria associated w/ this?

A 
50% ICU patients
RIFLE criteria (risk, injury, failure, loss, end stage)
74
Q

When you are staging AKI….which creatinine measurements do you compare?

A

most recent to the oldest one you can find

75
Q

What is Stage 1 AKI?

A

best prognosis
SCr increased by 1.5-2X, 0.3
Urine output <0.5 (6 hr)

76
Q

What is Stage 2 AKI?

A

SCr increased by 2-3X

Urine output <0.5 (12 hr)

77
Q

What is Stage 3 AKI?

A

SCr increased by 3X or more, 0.5

Urine output <0.3 (24 hr)

78
Q

Rank the most common types of AKI. Which is the most reversible?

A
  1. Pre-renal (60%) reversible with proper fluids
  2. Renal
  3. Post-renal
79
Q 
Heart attack
Liver failure
Severe burns
NSAIDs
allergic rxn
Which type of AKI do these produce?
A

Pre-renal

NSAIDS decrease prostaglandins, which have a slight vasodilatory effect. Decrease renal blood flow.

80
Q

Blood clots in veins/arteries to kidneys, cholesterol deposits
chemo, antibiotics, alcohol
Which type of AKI do these produce?

A

renal

things that affect the blood vessel

81
Q

What diagnostics do you use in diagnosing acute kidney injury?

A

SCr, Urinalysis with microscopy, BUN, Fena, Urine Osmolality and Urine sodium, renal ultrasound

82
Q

What Una is concerning for pre-renal AKI?

A

Una<20 is a problem. diuretics compromise this test, however.

83
Q

What are the 3 forms of intrinsic AKI?

A
  • disease of small-large vessels of the kidney
  • disease of glomeruli
  • disease of tubules & interstitium
84
Q

Give the 2 categories of disease of the glomeruli.

A

nephritic

nephrotic

85
Q

What do you see with nephritic AKI?

A 
inflammatory cells
active urine sediment
casts
cells
dysmorphic RBCs
86
Q

What do you see with nephrotic AKI?

A

> 3.5 grams protein/24 hours.
minimal cells & casts
bland urine!

87
Q

Give some diseases of the vessels of the kidney that can lead to intrinsic AKI?

A 
Thrombocytic thrombocytopenic purpura
hemolytic uremic syndrome
malignant hypertension
renal infarction
thromboembolism
renal vein thrombus
88
Q

What are some nephrotic syndromes that could produce AKI?

A 
diabetic nephropathy
minimal change disease
focal segmental glomerulosclerosis
membranous glomerulosclerosis
HIV
malignancy
89
Q

What are some nephritic syndromes that could cause AKI?

A

post-strep glomerulonephritis
IgA nephropathy
rapidly progressive glomerulonephritis
membranoproliferative GN

90
Q

What are some tubulointerstitial things that can cause AKI?

A

acute tubular necrosis
acute interstitial nephritis
tumor lysis syndrome

91
Q

When we are talking intrinsic AKI…how do we know it is ATN?

A

FENa >2%

Microscopy muddy brown cast

92
Q

When we are talking acute interstitial nephritis…what are the tip offs?

A 
FENa  >2%
Microscopy leucocytes (eosinophils) , erythrocytes, leucocyte casts, fevers, arthralgias, rash
93
Q

What do you see in acute glomerulonephritis?

A

Microscopy hematuria, proteinuria, erythrocyte casts, dysmorphic erythrocytes

94
Q

If you suspect post-renal AKI…what is the next diagnostic step? What else do you occasionally see?

A

ultrasound of kidneys

occasionally see hyperkalemia

Block 9; Week 5-M (5 decks)

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