Renal

Question 1

Declining kidney function with aging

Answer 1

Decrease GFR maybe due to comorbidities or medication’s
Increase risk of hyponatremia due to increase secretion of antidiuretic hormone maybe due to medications or morbid conditions
Decrease sensitivity of kidneys
Decrease sodium conservation
Decrease sodium excretion
Decreased ammonia, production and generation of bicarbonate can result in acidosis

Question 2

Kidney labs

Answer 2

Serum creatinine can be misleading as declining muscle mass parallels declining kidney function can lead to stable serum, creatinine despite declining GFR
So GFR is the most important indicator of kidney function and older adults
But can be unreliable and very obese patients those with Exiä or amputees

Question 3

GFR calculation

Answer 3

Cockcroft/gault (140-age) X kg in body weight/72Xserum creatinine X 0.85 (female)

Question 4

Secondary hypertension

Answer 4

Suspect in patient with new onset very severe or accelerated high blood pressure
Maybe due to renal disease high cortisol, Pheochromocytoma, kidney disease, mineralocorticoid HTN

Question 5

Renal artery disease

Answer 5

RF: smoking high blood pressure, high cholesterol, diabetes, dissecting, aortic aneurysms
Suspect in patient with other vascular disease like new onset, high blood pressure, acceleration of previously controlled high blood pressure resistant high blood pressure, progressive azotemia after starting ACEI or ARB
Manage- blood pressure control with ACEI or ARB
Renal angiogram and instant, but this is usually not indicated unless extreme cases

Question 6

Hematuria and nephrolithiasis

Answer 6

Blood in urine Maybe due to glomerular disease, infection, stones, AV malformation, neoplasms
Order urine culture microscopic evaluation of urine abdomen screenings like CT scan ultrasound urology consult for cystoscopy

Question 7

Acute kidney injury

Answer 7

Acute increase in creatinine and oliguria less than 5 ml/kg/hr
Even minor increases and creatinine have been associated with increased risk of prolonged hospitalization and death
Three types pre-renal, intrinsic, renal, and post renal
Most common cause in older adults is acute tubular necrosis, followed by prerenal azotemia what are you doing

Question 8

Pre renal azotemia

Answer 8

Diagnose by a suggesting bun to creatinine ratio is greater than 20
RF: psychological changes with aging acute illness, leading a poor or intake G.I. fluid loss, CHF and Renal artery disease, meds like diuretics, ACEI or ARB, and reduce access to fluids
TX with volume resuscitation, discontinue or reduce offending med, consider colloid infusion in hypoalbuminemic states

Question 9

Cardio renal syndrome

Answer 9

Acute and chronic kidney injury that occurs in CHF due to a combination of diminished forward flow and increased central venous pressure
Poor prognosis
TX- optimization of cardiac function, typically with diuretic and after loading agents, inotropics, DC or reduce meds that unpair renal auto regulation

Question 10

Obstructive uropathy

Answer 10

Bladder outlet obstruction- BPH, anticholinergic agents, bladder CA, urethral stricture

ureteral obstruction- stones, strictures, retro peritoneal malignancies, imaging and urology consult

Question 11

Acute tubular necrosis

Answer 11

Ischemia is most common cause
Can evolve to frank ATN
DX-urine sediment includes renal tubular epithelial cells and grandiose muddy brown casts
TX- supportive, can be reversible

Question 12

Acute interstitial nephritis

Answer 12

Allergic response to medication or viral infection
Antibiotics most common especially beta lactam and fluoroquinolones
DX- sterile pyuria, with WBC casts and or eosinophils on UA, CB with diff with eosinophilia
TX- DC agent, steroids may help

Question 13

Multiple myeloma

Answer 13

Malignant plasma cells, generate monoclonal proteins that form cast and obstruct renal tubules
Abnormal proteins can deposit and renal Pakama light chains or heavy chain deposition and form fibers that deposit as amyloid
Often have heavy, proteinuria, high calcium, low anion. gap increase protein gap, anemia, and bone pain
TX-chemotherapy

Question 14

Vascular disease

Answer 14

Atheroembolic disease-cholesterol micro emboli that lodge in small vessels of the kidney, risk include geography and use of warfarin
Thrombotic microangiopathy- play lit microphone by include small, renal arterial, such as TTP and hemolytic mix syndrome or malignant, hypertension, antiphospholipid antibody syndrome, and sclerodermal renal crisis
Acute renal artery occlusion-occurs in renal artery stenosis, or as a result of emboli from a fib or VTE

Question 15

Rapidly progressing glomerular nephritis

Answer 15

Many causes, including ANCA associated vasculitis, good pasture disease, lupus nephritis, IgA neuropathy, infection associated with glomerular nephritis
TX: IV followed by oral steroids and additional immune suppression plasma, recesses and acute severe cases maintenance using mycophenolate or azathioprine

Question 16

Acute nephritic syndrome

Answer 16

Decreasing kidney function blood in the urine with dysmorphic, red cells and red cell cast variable proteinuria high blood pressure and fluid retention
Diagnosis is often delayed due to incorrectly attribute symptoms to common conditions like UTI heart failure, or venous stasis disease

Question 17

Post infection glomerular nephritis

Answer 17

The occurs in the setting of an infection, such as strep of the skin or throat or staphylococcal infections
Treatment is supportive, usually self limiting

Question 18

Berger disease

Answer 18

IgA nephropathy
Maybe primary or secondary to cirrhosis celiac disease infection with HIVCMV Himas para influenza, staphylococcus, aureus disseminated tuberculosis and toxoplasmosis
TX: control underlying condition blood pressure control with ace inhibitor, management of kidney disease, steroid or other immune suppressant

Question 19

Nephrotic syndrome

Answer 19

You’re an excretion greater than 3.5 g of protein per day associated with low albumin, high cholesterol, and swelling
High blood pressure and renal failure are also seen
Can result from primary glomerular disease or from infection exposure to allergies or medication’s diabetes or high blood pressure
Biopsy is key for early diagnosis
TX: blood pressure control use of RAAS blocker, sodium restrictions for high cholesterol anti anticoagulation when albumin is less than 2.8

Question 20

Membrane nephropathy

Answer 20

Idiopathic disease
NSAID use and malignancy are the two most common causes
The prognosis for adults is quite variable does depend on severity of disease
TX- calcineurin inhibitors may have a low-dose steroid, cortical, steroids and cytotoxic agents

Question 21

Focus segmental glomerulosclerosis

Answer 21

Idiopathic mainly can be secondary to infection like hepatitis B Pavo virus or HIV or lymphoma medication such as pamidronate, morbid obesity, other forms of advanced kidney disease
TX: correct reversible causes control blood pressure using ace inhibitor or ARB, minimize protein, moderately restrict, diet protein, prolonged course of steroid therapy or calcineurin inhibitor if primary disease

Question 22

Minimal change disease

Answer 22

Idiopathic or associated with hypersensitivity reactions, hematologic, cancers or drug drugs like NSAIDs
Can present with full grown nephrotic syndrome and normal blood pressure but risk of acute kidney injury is increased
TX: prolonged course of high dose steroids along with calcineurin inhibitors or cyclophosphamide

Question 23

Amyloidosis and other protein, depositing diseases

Answer 23

Renal biopsy and abdominal fat pad biopsy stain with Congo red or Theo Flavin T for diagnosis
Renal tissue should be examined by electron microscope for myeloid fibers
Paraproteinuria
Order about serum and urine immuno Electrophoresis for all older adults with nephrotic syndrome if these findings are abnormal order a bone marrow biopsy to exclude multiple myeloma
Treatment with chemotherapy regiment to delay, progression to end stage renal disease

Question 24

Chronic kidney disease

Answer 24

Kidney function measured by GFR declines on average of 8 mL per minute per decade after 40 years
Frequently manifested with a decompensation of pre-existing medical conditions like heart failure, diabetes, high blood pressure or dementia
Managing -emphasize preserve of residual, renal function and limiting complications, correct reversible causes control, blood pressure controlled, diabetes, restrict, dietary protein
All patients with chronic kidney disease at all, stagers are at increase risk for cardiovascular events, aggressively control, blood pressure, lipid smoking sensation and advocate for a heart, healthy diet

Question 26

Medication’s to avoid in chronic kidney disease

Answer 26

Radio, contrast agents Amphotericin B Aminoglycosides NSAIDs Gadaolinium

Question 27

Managing anemia and chronic kidney disease

Answer 27

Screening starts at stage 3B Exclude other cause Otherwise use erythropoietin stimulate agents

Question 28

Bone disease and chronic kidney disease

Answer 28

Associated with extremely high cardiovascular, morbidity, and mortality Result of calcium problem caused by the parathyroid gland Screen for calcium phosphorus and PTH abnormality begin in stage three maintain phosphorus concentration between 2.7 and 4.6 and those were stage three or stage four, start dietary phosphorus restrictions if PTH is increased, even if serum phosphorus is normal Use phosphorus binders When PTH starts to increase Markedly increased PTH is associate with high bone, turnover disease, and increase risk of fracture biphosphantes I recommended treatment for osteoporosis and early stages of chronic kidney disease

Question 29

Depression and chronic kidney

Answer 29

Warranted for everybody what diagnosis Functional and cognitive decliner common Very low dose of SSRI are safe, but avoid long acting medication’s

Question 30

Nutrition and chronic kidney disease

Answer 30

Very complex regards and take a protein, phosphorus, and potassium need to be controlled while maintaining adequate energy intake One stage four experienced kidney dietitian should be involved

Question 31

Dialysis

Answer 31

Usually initiated when stage four or five and GFR is less than 10

Question 32

Polycystic kidney disease

Answer 32

Often presents with spontaneous sometimes severe back pain almost always has elevated blood pressure with a few other symptoms Positive family history Cyst collection in the kidney that result in decline and function Order CMP, UA, fasting lipid, CBC, PTH, renal or abdominal US, CT or MRI TX- nutritional changes, control HTN and HLD, pain control, prepare for HD, transplant is needed

Question 33

A 29-year-old male avoided dark brown year in a pot awakening. He also know it’s Malay and achiness which he’s had for the past several days. He attributes this to a new seizure medication started by his neurologist after he had three seizures on his former regiment, he has not felt well since last seizure on exam vitals are normal. There is a tongue laceration which he attribute to the last seizure. The remainder of the examination is unremarkable. Sodium is 133. Potassium is 6.2 BUN is 69. Creatinine is 5.2 calcium 7.8 phosphorus 6.2 uric acid is 10.2 which of the following test would be most helpful to order first.

Answer 33

CPK

Question 34

A 70-year-old man with a history of diabetes, high blood pressure and coronary artery disease is admitted for a heart failure. He underwent an uneventful colonoscopy five days ago in the outpatient clinic studying and denies any voiding difficulties gross hematuria, flank pain or abdominal discomfort denies use of NSAIDs. He notes that his urine output has abruptly declined over the past few days with increasing shortness of breath and swelling. Physical exam is remarkable for crackles on both the lungs 2+ putting edema in the lower extremities. Sodium is 132. Potassium is five chloride is 105 bicarbonate is 20 BUN is 90 creatinine five glucose is 200 calcium of seven phosphorus 11 urine is negative for protein, blood and leukocytes which of the following is most likely the cause of his acute kidney injury

Answer 34

Oral sodium phosphate, bowel prep And acute tubular necrosis caused by dehydration caused by the colonoscopy prep

Question 35

At 34-year-old woman presents the ER with progressive shortness of breath over the past two weeks. She was treated with azithromycin for one week with possible pneumonia. She experienced some improvement initially, but now has a worsening dry, cough and shortness of breath or exam is notable for course crackles in the right base chest x-ray reveals a right lower lobe infiltrate per um creatinine is three per urine protein is +3 and red blood cell cast are notated on the urinalysis. Serologic work up is pending and will be available next 48 hours which of the following would be the next best step.

Answer 35

Antibiotics and kidney biopsy as soon as possible

Question 36

Leslie age 16 says that her mom has polycystic kidney disease and ask about her chances of developing it. How do you respond?

Answer 36

It is hereditary and unfortunately incurable, but there are some measures we can use and dealing with it

Question 37

Which of the following statements about acute turbulence necrosis is true

Answer 37

The removal of the offending agent may allow renal function to return gradually to normal

Question 38

Which is the least expensive method for evaluating renal mass size

Answer 38

Ultrasound imaging

Question 39

The best index of kidney function is

Answer 39

GFR

Question 40

If a client with a acute renal failure excretes 400 cc of urine on Tuesday how much fluid intake both oral and IV should the client have on Wednesday?

Answer 40

900 cc

Question 41

What is the most common cause of chronic renal failure?

Answer 41

Diabetes nephropathy

Question 42

Samuel age 67 is a diabetic with worsening renal function. He has frequent low glucose episodes which he blaze me in his diabetes is getting better. How do you respond?

Answer 42

Because your kidneys are not functioning while your insulin is not being metabolized and excreted as it should so you need less of it

Question 43

What type of bloody urine is consistent with bleeding from the upper urinary tract?

Answer 43

Brown smoky or tea colored urine