Renal Flashcards
1
Q
What do Nitrites indicate on Urinalysis?
A
Gram-negative bacteria on dipstick
2
Q
What are the 2 parts of the Urinalysis?
A
- Dipstick if positive (leukocyte esterase, nitrites, etc.)
- Microscopic analysis (RBCs, WBCs, bacteria, casts, crystals)
3
Q
What does moderate vs. proteinuria mean?
A
Moderate = Tubular or Glomerular disease
Severe = Glomerular disease
4
Q
What can increase urine protein excretion in normal individuals?
A
Standing & physical activity
5
Q
If proteinuria persists & is not related to prolonged standing, what should be the next step?
A
Kidney biopsy
6
Q
What type of protein does urine dipstick test?
A
Albumin ONLY
7
Q
Method used to assess total amount of protein excreted in a day?
A
Protein : Creatinine ratio
also 24-hr urine collection, but less rarely performed b/c takes longer
8
Q
Normal protein excretion per 24-hr?
A
< 300mg
9
Q
What do you do for a diabetic patient w/ Microalbuminuria (30-300 mg/24hrs)?
A
Start them on ACE-inhibitor
L-T microalbuminuria in diabetic patients worsens renal function
10
Q
Eosinophils present on urinalysis indicate what?
A
Allergic interstitial nephritis
specific
11
Q
Does NSAID-induced renal disease show eosinophils?
A
No
12
Q
Possible etiologies of hematuria?
A
- Stones in bladder, ureter, or kidney
- Coagulopathy (causing bleeding)
- Infection (cystitis, pyelonephritis)
- Cancer of bladder, ureters, or kidney
- Tx (cyclophosphamide – hemorrhagic cystitis)
- Trauma
- Glomerulonephritis
13
Q
What to do next if urine dipstick is markedly positive for blood?
A
Microscopic examination of the urine
- to rule out hemoglobin & myoglobin w/out red cells (false positive)
14
Q
Most accurate test of the bladder?
A
Cystoscopy
obtain when bladder sonography shows a mass
15
Q
When to obtain cystoscopy w/ hematuria?
A
- Renal U/S or CT doesn’t show an etiology
or - Bladder sonography shows a mass
16
Q
Significance of a red cell cast?
A
Glomerulonephritis
17
Q
Significance of a white cell cast?
A
Pyelonephritis
18
Q
Significance of an eosinophilic cast?
A
Acute (allergic) interstitial nephritis
19
Q
Significance of a hyaline cast?
A
Dehydration concentrates the urine & normal Tamm-Horsfall protein precipitates or concentrates into a cast
20
Q
Significance of a broad, waxy cast?
A
Chronic renal disease
21
Q
Significance of a granular “muddy-brown” cast?
A
Acute tubular necrosis; they are collections of dead tubular cells
22
Q
T or F?
You must obstruct both kidneys for the Cr to rise.
A
True
23
Q
AKI symptoms?
A
- Nausea & vomiting
- Tired/malaise
- Weakness
- SOB & edema from fluid overload
VERY severe disease p/w: Confusion, arrhythmia from hyperkalemia & acidosis, sharp pleuritic CP from pericarditis
24
Q
Electrolyte imbalance typically caused by AKI?
A
Hyperkalemia & Acidosis
25
ATN -- urine osmolality?
< 300 mOsm/kg
| low b/c kidney cells cannot reabsorb water
26
Prerenal azotemia -- urine osmolality?
>500 mOsm/kg
27
ATN -- FeNa?
> 1%
| high b/c kidney cells cannot reabsorb Na
28
Prerenal azotemia -- FeNa?
< 1%
29
What should be given prior to chemotherapy to prevent renal failure from tumor lysis syndrome?
Allopurinol, Hydration, & Rasburicase
| b/c TLS causes hyperuricemia, which damages kidneys
30
How does Tumor Lysis Syndrome cause renal failure?
Hyperuricemia
31
What type of kidney damage do injection opiates cause?
Focal Segmental Glomerulonephritis
32
How does Ethylene Glycol cause ATN?
Precipitation of Calcium Oxalate in the renal cortex
| thus look for suicidal pt ingesting something w/ kidney damage & hypocalcemia
33
3 major causes of hypERvolemic hypOnatremia?
CHF
Nephrotic Syndrome
Cirrhosis
**pressure receptors in atria & carotids sense decrease in volume & stimulate ADH production/release
34
4 most common causes of Euvolemic hypOnatremia?
- Hyperglycemia (pseudo-hyponatremia -- glucose pulls H2O out of cells, diluting Na)
- Psychogenic polydipsia (massive ingestion of H2O)
- Hypothyroidism
- SIADH
35
Common causes of HypOvolemic HypOnatremia?
- Sweating
- Burns
- Fever
- Pneumonia (insensible losses 2/2 hyperventilation)
- Diarrhea
- Diuretics
* *all are causes of hypernatremia, but w/ chronic H2O replacement, eventually cause hypOnatremia
- Addison Disease
36
Glomerulonephritis: describe the urine sodium & FeNa
Both low
37
Goodpasture Syndrome involves what organs?
Lung & Kidney
38
How to differentiate Goodpasture Syndrome vs. Wegener Granulomatosis?
- WG has upper respiratory tract involvement
| - GS is limited to lung & kidney
39
Goodpasture Syndrome: best initial & most accurate test(s)?
Best initial = Antiglomerular basment membrane antibody
Most accurate = Lung or Kidney biopsy w/ "linear deposits"
40
Most common cause of acute glomerulonephritis in the USA?
IgA Nephropathy (Berger Disease)
41
Dx?
| Asian patient w/ recurrent episodes of gross hematuria 1-2 days after URI.
IgA Nephropathy (Berger Disease)
- Poststreptococcal Glomerulonephritis follows pharyngitis by 1-3 wks
42
Poststreptococcus Glomerulonephritis presentation?
- Dark (cola-colored) urine
- Edema (often periorbital)
- Hypertension
- Oliguria
43
Alport Syndrome - what is it?
Congenital defect of Type 4 Collagen
Presentation = Glomerular disease, Sensorineural hearing loss, & Visual disturbance (lens dislocation)
44
Polyarteritis Nodosa - what is it?
Systemic vasculitis of small & medium-sized vessels
- almost always affects kidneys & spares lungs
- can affect virtually all other organs of the body
- ass'd w/ Hep B
45
Stroke or MI in a young person suggests what pathology?
Polyarteritis Nodosa (vasculitis)
46
Pathology of nephrotic syndrome?
Any damage to the kidney that causes such high proteinuria that the liver cannot keep up its production of albumin
> 3.5 grams of protein / 24hrs
47
Nephrotic Syndrome -- presentation?
- Edema (Periorbital)
- Hyperlipidemia (lipoprotein signals that turn off production of circulating lipids are lost in urine)
- Thrombosis (urinary loss of Protein C, Protein S, & antithrombin)
- Infections frequent (loss of Igs & complement)
48
Nephrotic Syndrome - best initial & most accurate test(s)?
Best initial = Urinalysis (Maltese crosses)
Most accurate = Renal biopsy
49
What are Maltese Crosses?
Lipid deposits in sloughed-off tubular cells, seen on UA in Nephrotic Syndrome
50
Nephrotic Syndrome - Tx?
Glucocorticoids (then other IMs like Cyclophosphamide, if necessary)
- ACE-inhibitors or ARBs (proteinuria)
- Salt restriction & diuretics (edema)
- Statins (hyperlipidemia)
51
Dialysis indications?
- Metabolic acidosis
- Fluid overload
- Encephalopathy
- Hyperkalemia
- Pericarditis
(any life-threatening condition that can NOT be corrected another way)
52
Uremia definition?
Presence of any of these:
- Metabolic acidosis
- Fluid overload
- Encephalopathy
- Hyperkalemia
- Pericarditis
(Uremia = conditions for which dialysis is answer as therapy)
53
Manifestations of ESRD?
- Anemia (loss of erythropoietin)
- Hypocalcemia (no conversion of 25, vit D to 1,25)
- Hyperparathyroidism (2o) & Osteodystrophy (low calcium)
- Bleeding (platelets don't degranulate in uremic environment)
- Infection (neutrophils don't work w/out degranulation)
- Pruritis (uremia)
- Hyperphosphatemia (hyperparathyroidism + cannot excrete)
- Hypermagnesemia (cannot excrete)
- Accelerated Atherosclerosis & HTN (immune system usually clears arteries of lipid accumulation)
- Endocrinopathy: women are anovulatory & men have low testosterone & impotence. Insulin levels increase as does resistance
54
How to treat Hypocalcemia in ESRD?
Give vitamin D & oral Phosphate binders
- b/c vit D will increase phosphate absorption from GI & secondary hyperparathyroidism causes hyperphosphatemia in ESRD
55
How to treat hyperphosphatemia?
- Calcium acetate
- Calcium carbonate
if hypercalcemia, use:
- Sevelamer
- Lanthanum
56
5 manifestations of TTP?
- Intravascular hemolysis (schistocytes, helmet cells, & fragmented red cells on smear)
- Renal insufficiency
- Thrombocytopenia
- Neurological symptoms
- Fever
57
TTP & HUS Tx?
```
TTP = urgen plasmapheresis
HUS = usually resolve spontaneously. If severe, needs urgent plasmapheresis
```
- if no Plasmapheresis available, infusion of Fresh Frozen Plasma
- steroids do NOT help
58
Causes of Nephrogenic DI?
Lithium, Demeclocycline, CKD, hypOkalemia, hypERcalcemia
- they make ADH ineffective @ the tubule
59
Dx? inc'd urine volume despite dehydration & hyperosmolality of the blood.
Diabetes Insipidus
60
How to diagnose Diabetes Insipidus?
Water deprivation test
- "positive" = urine volume stays high = NDI
- "negative" = CDI
61
CDI -- Tx?
DDAVP (Vasopressin to replace ADH)
62
NDI -- Tx?
- Correct potassium & calcium
- Stop lithium or demeclocycline
- Give Hydrochlorothiazide or NSAIDs for those still having NDI despite these interventions
63
Hypo- & Hyper-natremia cause what type of symptoms?
CNS --- lethargy, confusion, disorientation, seizures, coma
- Sx are more dependent on the RATE @ which Na levels change
64
SIADH -- describe the uric acid & BUN levels?
Both low
65
Mild Hyponatremia - Sx & Tx?
No symptoms
Tx = restrict fluids
66
Moderate Hyponatremia -- Sx & Tx?
Sx = Minimal confusion
| Tx = Saline & loop diuretics
saline w/out diuretics makes SIADH worse
67
Severe Hyponatremia - Sx & Tx?
Sx = Lethargy, Seizures, Coma
Tx = Hypertonic saline, Conivaptan, Tolvaptan (ADH-antagonists)
68
When to use Conivaptan/Tolvaptan vs. Demeclocycline in SIADH?
Conivaptan/Tolvaptan are part of urgent inpatient therapy for severe, symptomatic SIADH (no oral versions available)
Demeclocycline treats chronic SIADH, blocking ADH action @ the collecting duct
69
Rate @ which Na can be safely corrected?
0. 5-1 mEq/hr (12-24 mEq/day)
| - to avoid Central Pontine Myelinolysis
70
Causes of Pseudohyperkalemia?
- Hemolysis
- Repeated fist clenching w/ tourniquet in place
- Thrombocytosis or Leukocytosis
71
Causes of Hyperkalemia?
- Renal failure
- Aldosterone decrease (ACE-inhibitors/ARBs, RTA type 4, Spironolactone/Eplerenone, Triamterene/Amiloride, Addison disease)
- Tissue destruction (hemolysis, rhabdomyolysis, tumor lysis syndrome)
- Decreased insulin (insulin drives K into cells)
- Acidosis (cells take in H in exchange for K)
- β-blockers & Digoxin (inhibit Na/K ATPase that brings K into cells)
- Heparin
72
Hyperkalemia Sx?
Interferes w/ muscle contraction & cardiac conductance:
- Weakness
- Paralysis (when severe)
- Ileus (paralyzes gut muscles)
- Cardiac rhythm disorders
73
EKG in severe hyperkalemia?
- Peaked T waves
- Wide QRS
- PR interval prolongation
74
Severe Hyperkalemia w/ EKG changes - Tx?
- Calcium chloride or gluconate (protects heart, doesn't affect K levels)
- Insulin & glucose (drives K back into cells)
75
Hyperkalemia - non-urgent Tx?
- Kayexalate (removes K from body via gut)
- Insulin & bicarbonate (esp. if acidosis)
Other methods: Inhaled β-agonists, Loop diuretics, Dialysis
76
Hypokalemia - causes?
- Shift into cells (Alkalosis, inc'd insulin, β-adrenergic stimulation -- accelerates Na/K ATPase)
Renal loss: Loop diuretics, inc'd Aldosterone, Hypomagnesemia, RTA types 1 & 2
GI loss: Vomiting, Diarrhea, Laxative abuse
77
Hypokalemia - Sx?
- Weakness
- Paralysis
- Loss of reflexes
78
Hypokalemia -- EKG findings?
- U waves (most characteristic)
Other findings: PVCs, flattened T waves, ST depression
79
2 most important causes of normal AG acidosis?
RTA & Diarrhea
"Hyperchloremic Acidoses" -- these have a normal AG b/c Chloride levels rise
80
RTA type 1 -- pathology?
"Distal RTA"
- DT cannot produce Bicarbonate (normally should under influence of Aldosterone)
- 2/2 damage of DT by drugs such as Amphotericin or autoimmune diseases like SLE or Sjogren syndrome
81
RTA type 1 -- Tx?
Give Bicarbonate (prox tubule will absorb it & correct acidosis)
82
Which RTA has urine pH > 5.5?
RTA type 1
| type 2 has basic urine @ first, then turns acidic
83
RTA type 2 -- pathology?
Proximal tubule damage = cannot reabsorb Bicarbonate
- distal tubule starts to reabsorb if left untreated, causing urine pH < 5.5
- Chronic metabolic acidosis leaches Ca out of bones --- causes osteomalacia
84
RTA type 2 -- Tx?
Thiazide diuretics -- cause volume depletion, which enhances bicarbonate reabsorption
85
RTA type 4 -- pathology?
Hyoaldosteronism or lack of response to aldosterone
- Na loss in urine despite low intake
- Causes hyperkalemia, which impairs ammonia genesis in the PT, leading to dec'd buffering capacity & dec'd urine pH
86
RTA type 4 -- pathology?
Fludrocortisone
| glucocorticoid w/ most mineralocorticoid effects
87
How to distinguish Diarrhea vs. RTA?
Urine Anion Gap (= Na - Cl)
- Normal in Diarrhea
- Positive in RTA (acid excreted as NH4Cl, ammonium chloride, except in RTA there's a prob w/ acid excretion, thus less Cl excretion)
88
Lactic Acidosis -- Tx?
Correct hypoperfusion (since this is cause of LA)
89
Ketoacidosis -- test?
Acetone level
90
Oxalic acid acidosis -- test? Tx?
Test = Crystals on UA
Tx = Fomepizole, dialysis
91
Formic acid acidosis (methanol O/D) -- Test? Tx?
Test = Inflamed retina
Tx = Fomepizole, dialysis
92
Aspirin overdose causing metabolic acidosis -- Tx?
Alkalinize urine
93
Acetazolamide effects?
Alkalinizes urine, causes "ACIDosis"
- Carbonic Anhydrase inhibitor, causes self-limited NaHCO3 diuresis & reduction in total body bicarbonate stores
94
Furosemide -- AEs?
Ototoxicity, Hypokalemia, Allergy (sulfa), Nephritis (interstitial), Gout
"OH DANG!"
95
Hydrochlorothiazide -- AEs?
HypOkalemic metabolic alkalosis, hypOnatremia, sulfa allergy
- hyperGlycemia, hyperLipidemia, hyperUricemia, & hyperCalcemia
"hyperGLUC"
96
Metabolic Alkalosis -- causes?
- GI loss (vomiting or nasogastric suction)
- Inc'd Aldosterone
- Diuretics
- Milk-alkali syndrome: high-volume liquid antacids
- Hypokalemia (hydrogen ions move into cells so K can be released)
97
What is "Minute Ventilation"?
= Resp. Rate x Tidal Volume
98
NSAID that provides analgesia similar to opioids?
Ketorolac
99
Nephrolithiasis -- most appropriate 1st step?
Ketorolac -- can stop excruciating pain before Dx tests
+ Hydration
100
Nephrolithiasis -- most accurate diagnostic test?
CT scan (does not need contrast)
101
Most common cause of nephrolithiasis?
Calcium oxalate (inc'd urine pH, >5.5)
102
How can Crohn's Disease cause nephrolithiasis?
Increased Oxalate absorption
103
Type of stones that aren't visible on x-ray but are on CT?
Uric acid stones
104
Tx of stones 5-7mm?
Nifedipine & Tamsulosin
- < 5mm stones will pass on their own
105
Which diuretic prevents kidney stones & how?
Hydrochlorothiazide -- removes Ca from urine by increasing distal reabsorption
(Furosemide increases Ca excretion into urine & can make it worse)
106
How does Metabolic Acidosis cause stones?
removes Calcium from bones
&
decreases Citrate levels
(citrate normally binds calcium, making it unavailable for stone formation)
107
HTN -- best initial drug Tx?
Thiazide diuretics
108
Pregnancy safe HTN drugs?
β-blockers (use first)
- CCB
- Hydralazine
- α-methyldopa
109
HTN & CAD -- best initial Tx?
BB, ACE, ARB
110
HTN & BPH -- best initial Tx?
α-blockers
111
HTN & Depression -- best initial Tx?
avoid BBs
112
HTN & Asthma -- best initial Tx?
avoid BBs
113
HTN & Hyperthyroidism -- best initial Tx?
β-blockers first
114
HTN & Osteoporosis -- best initial Tx?
Thiazides
115
Hypertensive Crisis -- best initial Tx?
Labetolol or Nitroprusside
(Nitroprusside needs monitoring w/ arterial line, so usually not 1st choice)
- can really go w/ anything IV that works: Enalapril, CCBs (Diltiazem & Verapamil), Esmolol
