Renal Flashcards
What do you see in the maintenance phase of acute renal failure?
Hyperkalemia and oliguria
What do you see in recovery phase of acute renal failure?
Hypokalemia and polyuria
What does exposure to rubber, plastics, textiles, leather increase risk for?
Transitional Cell carcinoma
What is the proximal ureter supplied by?
Renal artery
What is the distal ureter supplied by?
Superior vesicular artery
Where does RCC commonly metastasize?
Lungs
What has clear polygonal cells and can be paraneoplastic?
RCC
What are the symptoms of RCC?
Flank pain, hematuria, palpable mass, polycythemia
What do you treat calcium urine stones with?
Citrate, thiazides
What is the diagnosis? Oxalate crystals, coma, metabolic acidosis
Ethylene glycol poisoning
What do you treat UTI with?
Fluoroquinolones
What do you treat UTI in children with/
Penicilin, cephalosporins, TMP/sulfamethaxozole, nitrofurantoin
Where is urine most dilute?
Distal tubule
Where is urine most concentrated?
Collecting duct
What causes first dose hypotension?
ACE-I
What are the side effects of spironolactone?
Gynecomastia, antiandrogen effects, hyperklaemia
How do you reduce nephrolisthiasis?
Consume fluids because supersaturation is a major cause
Where is RCC most commonly found in the kidney?
Proximal tubule
Which one do you see antibodies to phospholipase A2?
Membranous glomerulonephritis
What is the diagnosis? Easy fatiguability, back pain, azotemia, constipation, eosinophilic casts?
Multiple Myeloma
What are the causes of renal papillary necrosis?
Phenacetin, Sickle Cell, Diabetes, pyelonephritis
What does renal papillary necrosis present with?
Acute colicky flank pain, hematuria, passage of tissue fragments
What is decreased in PSGN?
C3 levels
What are WBC casts seen with?
Pyelonephritis, interstitial nephritis
Which one will show clear and green IF?
Goodpasture
What prevents bradykinin breakdown?
ACE-I (ACE breaks it down)
Where is majority of water reabsorbed?
Proximal tubule (60%) regardless of hydration status
How can ethylene glycol affect the kidneys?
Causes oxalate crystals –> tubular injury –> ballooning and vacuolar degeneration of proximal tubules
What happens to RPF and GFR in hypovolemia?
Decreased RPF and slightly decreased GFR (due to ang II release from renin activation; causes constriction of efferent so GFR decreases to lesser extent than RPF)
What drug do you avoid in renal artery stenosis?
ACE-I because need efferent constriction to maintain GFR
What is the prognosis for acute PSGN in adults?
Poor
What happens to kidneys in BPH?
Renal parenchyma becomes atrophic and scarred due to reflux of urine
How do you tell PSGN and IgA nephropathy apart?
IgA nephropathy is after a few days and will show mesangial IgA deposits and normal complement levels. PSGN takes a few weeks to develop.
Whats the MCC of kidney stones?
Kidney stones usually Ca. Ca stones caused usually by idiopathic hypercalciuria with normocalcemia
Diagnosis: ballooning and vacuolar degeneration of proximal tubules, oxalate crystals, vomiting, oliguria?
Ethylene glycol ingestion: causes high anion gap metabolic acidosis and oxalate crystals
What diuretic stimulates PGE release and is inhibited by NSAIDs?
Furosemide
What are the causes of Potter sequence?
ARPKD, bilateral renal agenesis, posterior urethral valves
What cancer can horseshoe kidney lead to?
Turner syndrome
What is multicystic dysplastic kidney?
Abnormal interaction b/w ureteric bud and metanephric mesenchyme leading to cystics in kidney
What is the BF though kidney?
Renal –> segmental –> lobar –> interlobar –> arcuate –> interlobular
What is hypotonic fluid loss?
Dehydration, alcoholism, DI
What is isotonic fluid loss?
Hemorrhage, diarrhea, vomiting
What is the renal handling of creatinine?
Freely filtered and moderately secreted but still a good estimate of GFR
What is a normal FF?
20%
What inhibits afferent arteriolar dilation?
Age, chronic kidney disease, NSAIDs
What is the excretion rate?
(V)(Ux)
What does normal pregnancy do to glucose handling?
Decreases amino acid and glucose absorption proximal tubule
What is Hartnup disease?
AR disorder leading to deficiency of neutral aa transporters in gut and proximal tubule (ie tryptophan). Leads to pellagra like symptoms. Treat with high protein diet and nicotonic acid
What is the renal handling of NH3?
Secreted in proximal tubule
How does acetazolamide work?
Inhibits CA so HCO3 + H not being converted. Since H+ is hanging around now there is less of a drive to reabsorb Na since it uses Na/H antiporter (Na reabsorbed for H secretion)
How does Ang II affect tubules?
Stimulates Na/H exchange –> increased Na, water and Hc03 reabsorption
What is Bartter?
Na/2Cl/K transporter defect —> hypkalemia, metabolic alkalosis, hypercalciuria,
What is Gitelman?
NaCl transporter defect –> hypokalemia, metabolic alkalosis
NO hypercalciuria
What is Liddle?
Increased ENac activity –> hypertension, hypokelamia, metabolic alkalosis, decreased aldosterone
How is Cl handled in the proximal tubule?
It’s reabsorbed slower than Na so its concentration increases at first along the proximal tubule but then its reabsorption matches Na so its concentration in the tubule levels.
How do beta adrenergics do to potassium levels?
Shift K into cell because of increased Na/K ATPase
What does alkalosis affect your K?
Shift K into cell
What are the causes of high anion gap metabolic acidosis?
MUDPILES: methanol, uremia, DKA, propylene glycol, INH, iron tablets, Lactic acidosis, ethylene glycol, salicylates (mixed metabolic acidosis and resp alkalosis)
What are the causes of normal anion gap metabolic acidosis?
HARDASS: hyperalimentation (artificial nutrient supply), addison, renal tubular acidosis, diarrhea, acetazolamide, spironolactone, saline infusio
What do you see fatty casts with?
Advanced renal disease/chronic renal failure
LM, IF, EM for FSGN?
LM: segmental sclerosis, hyalinosis
IF: -
EM: effacement of foot processes
LM, IF, EM for Membranous?
LM: diffuse capillary & GBM thickening
IF: granular from immune complex deposition
EM: spike and dome with subepithelial deposits
Which has a poor response to steroid therapy and may progress to chronic renal disease?
Membranous, FSGN
Causes of FSGN?
African americans, Hispanics, HIV!!, sickle cell disease, interferon, heroin, obesity, chronic kidney disease
Which glomerular disease has an excellent response to steroids?
Minimal Change Disease
Which glomerular disease is associated with hodgkin’s lymphoma?
Minimal Change
What triggers minimal change in kids?
Recent infection, immunization, immune stimulus
Microscopy for type I MPGN?
IF: subendothelial IC deposits with granules
Tram track appearance from GBM splitting caused by mesangial ingrowth
Hypercellular and thickened
Microscopy for type II MPGN
Intramembanous IC deposits “dense deposits”
What are type I and II MPGN associated with?
I: HCV, HBV
II: C3 nephritic factor (stabilizes C3 convertase –> dec C3 levels)
What do you see with diabetic nephropathy?
LM: Eosinophilic nodular glomerulosclerosis (kimmelstiel wilson), GBM thickening, mesangial expansion
IF, LM, EM for PSGN?
LM: glomeruli enlarged and hypercellular
IF: starry sky, lumpy bumpy from IgG, IgM and C3 deposition
EM: subepithelial immune complex (Humps)
LM and IF for RPGN?
Fibrin and plasma proteins (c3b) with glomerular parietal cells, monocytes, macrophages
LM, EM, IF, of DPGN?
LM: wire looping of capillaries
EM: Subendothelial IgG based ICs with C3
IF: granular
IgA nephropathy LM, EM
LM: mesangal proliferation
EM: IC deposits mesangial
IF: IgA based IC deposits
What presents with deafness, lens and eye problems and glomerulonephritis?
Alport (mutation in type IV collagen –> thinning and splitting of GBM); XR
Which kidney stones form in alkaline environment?
Both the phosphate stones (calcium phosphate and ammonium magnesium phosphate)
What do cystine stones look like?
Hexagonal
Which ones have staghorn caliculi?
Ammonium phosphate (aka struvite), and cystine stones
What causes oxalate stones?
Crohn’s, Vit C abuse, ethylene glycol
What causes struvite stones?
Urease positive bugs
What is sodium nitroprusside test positive?
Cystinuria
Which of the renal cancers is paraneopalstic?
RCC! Can make EPO, ACTH, PTHrp
How do you treat RCC?
CAN’T DO RADIATION Or CHEMO. Immune or targeted therapy or resect
What is a benign epithelial tumor with central stellate scar, large eosinophilic cells with abundant mitochondria without perinuclear clearing?
Oncocytoma
What presents with neonatal hypoglycemia, muscular hemihypertrophy, organomegaly?
Beckwith- Wiedmann (aw/ wilms tumor)
What is the WAGR complex?
Wilms tumor, aniridia, GU malformation, mental retardation
What is a huge palpable flank mass with embryonic glomerular structures in early childhood?
Wilms Tumor (WT1 or 2 mutation on chromosome 11)
What is a common tumor of renal calyces, pelvis, ureters, bladder that presents with painless hematuria without casts?
Transitional Cell Carcinoma
What is transitional cell carcinoma ssociated with?
Phencetin, smoking, aniline dyes, cyclophosphamide
What causes type 2 renal tubular acidosis (proximal, pH
Fanconi, toxins, and CA inhibitors
What causes type 1 renal tubular acidosis (distal, pH > 5.5)
Amphotericin, analgesics, multiple myeloma, congenital
What are the risk factors for SCC of the bladder?
Schistosoma, smoking, chronic nephrolithiasis, chronic cystiits
What does it mean if you have sterile pyuria with negative urine cultures but symptoms of UTI?
Chlamydia or Neisseria
Diagnosis: CT show sstriated parenchymal enhancement?
Acute pyelonephritis
What does chronic pyelonephritis cause
Corticomedullary scarring, blunted calyx
What causes tubules to have eosinophilic casts resembling thyroid tissue?
Chronic pyelonephritis
What drugs cause drug induced interstitial nephritis?
Penicillin, sulfonamides, diuretics, rifampin
How does drug induced interstitial nephritis present?
Maculopapular rash, hematuria, CVA tenderness, fever
What are the causes of ATN?
Ischemic: from decreased BF (hypotension, shock, CHF etc)
Nephrotoxic: cisplatin, aminoglycosides, radiocontrast dye, crush injury (myglobinuria), hemoglobinuria
What decreases BUN/creatinine ratio?
Intrinsic renal failure because can’t reabsorb BUN
What happens with intrinsic renal failure?
Patchy necrosis leads to debris that obstructs tubule and causes backflow which decreases GFR!
What happens with prerenal azotemia?
Decreased BF to kidney so dec GFR. Try to reabsorb and conserve water to compensate.
What happens to with postrenal azotemia?
Obstruction in ureter that will back up and decrease GFR and FF. Can’t reabsorb or concentrate but will have high BUN/Creatinine ratio since GFR is decreased
Where is the ADPKD mutation?
Chromosome 16 (MC) or chromosome 4
What is ADPKD associated with?
Benign hepatic cysts, MVP, berry aneurysms
What is ARPKD associated with?
Hepatic fibrosis, Potter sequence
What is medullary cystic disease?
Tubulointerstitial fibrosis –> can’t concentrate urine. Can’t see medullary cysts. Poor prognosis
When is a cyst bad?
Septated, enhanced, solid and not in the outer cortex –> increased risk for RCC
What is mannitol?
Osmotic diuretic for increased intracranial/ocular pressure.. Causes pulmonary edema and dehydration. Don’t use in CHF and anuria
What are the side effects of acetazolamide?
Hyperchloremic, metabolic acidosis, paresthesias, NH3 toxicity, sulfa allergy
What diuretic can you use for nephrogenic DI?
Hydrochlorothiazide
What diuretics can you not use in gout patients?
Loop, thiazide
What diuretic do you not give to pregnant women?
ACE- I because its teratogen
What are the two buffers in the tubules?
NH3 and HPO4 which combine in the lumen with H to become NH4 and H2PO4. Hence they increase during metabolic acidosis as kidneys are trying to get rid of H+
What is the relationship between GFR and creatinine?
Nonlinear. As GFR goes down Creatinine increases (exponential decrease as GFR goes up)
Every time GFR halves, creatinine doubles
What do you test to determine what is causing metabolic alkalosis?
Urine Cl:
Vomiting (low urine Cl), thiazide/loop diuretic use (high urine CL) that is saline responsive
Hyperaldosteronism or cortisolism: urine cl high that is saline unresponsive
Where is the MC obstruction in fetus?
Ureteropelvic junction
What do you see pyuria with no casts?
Acute cystitis
What is lost i the urine that may cause a varicocele?
Antithrombin (that’s why proteinuria has hypercoagulable state)
What drug do you give to CHF patients who have a sulfa allergy?
Ethacrynic Acid
What diuretics are sulfa?
Loop and thiazides and acetazolamide
What stains densely adjacent to glomerulus on IHC?
Juxtaglomerular cells containing renin
What is ACE inhibitor fetopathy?
Blockade of angiotensingin II from mom being on ACE-I –> fetal renal atrophy and ishcemia. Causes fetal anuria, oligohydramnios, limb contractures, growth defect, pulmonary hypoplasia.
Patient taking simvastatin and furosemide who has to pee a lot at night and has muscle weakness and cramps is due to which medication?
Furosemide (hypokalemia and contraction alkalosis)
Diagnosis: microscopic hematuria + high HB?
RCC
How does hypercalcemia affect water reabsorption?
Hypercalcemia causes nephrogenic DI by downregulating aquaporins –> can’t concentrate urine in collecting tubules
A 56-year-old man comes to the emergency department because of a 4-day history of colicky right flank pain that radiates to the groin and hematuria. Ultrasound examination of the kidneys shows right-sided hydronephrosis and a dilated ureter. Which of the following is most likely to be found on urinalysis?
Kidney stone. In this case the answer was uric acid.
