Renal Flashcards
8 yo boy is recovering from a URI. His mother has noticed swelling around his testicles and puffiness around his eyes, especially in the morning. Urinalysis shows: 3+ proteinuria and Maltese cross-shaped oval fat bodies. What is management of choice? A. prednisone B. cyclophosphamide C. simvastatin D. amoxicilln E. IV immunoglobulin
A, prednisone
*Edema, proteinuria and hyperlipidemia are hallmark for nephrOTIC syndrome!
(nephrotic syndrome in children is due to minimal change disease and tx is prednisone)
Edema, proteinuria and hyperlipidemia..think?
Nephrotic syndrome
During a neurological exam, tapping of the cheek over the facial nerve causes facial spasms. There are also carpal spasms with inflation of a BP cuff. Which of the following electrolyte abnormalities is responsible? A. hypernatremia B. hyperkalemia C. hypercalcemia D. hypomagnesemia E. hyponatremia
D, hypomagnesemia
These symptoms are CLASSIC WITH HYPOCALCEMIA! Because magnesium is needed to make PTH, hypomagnesemia is often associated with hypocalcemia!!
Hypomagnesemia is often associated with?
Hypocalcemia
A 36 yo male with a recent head trauma develops a stable epidural hematoma. He is placed on seizure prophylaxis and given hypotonic saline infusion. After the saline infusion, he develops nausea, weakness and headache. a CT show no change in the bleed. Labs show: serum Na of 125 (normal 135-145) and serum osmolarity of 268 (norm 280-290)
The serum sodium should be corrected no faster than 0.5 mEq/L per hour to prevent what?
A. seizures
B. cerebral edema
C. vision loss
D. vomiting
E. central pontine myelinolysis
E, central pontine myelinolysis
Demyelination occurs if hyponatremia is corrected too rapidly. Hyponatremia causes cerebral edema (due to hypotonicity) and the rapid correction leads to shrinkage of the brain cells with demyelination of the nerves
When can cerebral edema occur?
Rapid FLUID correction of hypernatremia
A 43 yo male presents to the ER with a fever and joint pains. The pt was recently treated for a dental infection with oral Penicillin VK. Pt is febrile and has a generalized maculopapular rash without target lesion appearance. Labs show an increased BUN and creatinine with an elevated WBC count and eosinophilia. A urinalysis shows 2 RBC/high power field and presence of many WBC casts. Which of the following is likely the dx? A. erythema multiforme minor B. erythema multiforme major C. acute tubular necrosis D. acute tubulointerstitial nephritis E. acute glomerulonephritis
D, acute tubulointerstitial nephritis
Acute tubulointerstitial nephritis is a rope of INTRINSIC acute kidney injury. It is due to an inflammatory or allergic response in the interstitium. 70% of AIN is due to drugs (such as penicillin). AIN is associated with ever, eosinophilia, arthralgias and a maculopapular rash
*WBC casts are hallmark for acute interstitial nephritis (AIN)
WBC casts in urinalysis are hallmark for…
Acute interstitial nephritis
Acute tubulointersitial nephritis is a type of _____ acute kidney injury
intrinsic
70% of acute interstitial nephritis is due to…
drugs (i.e. penicillin)
Fever, eosinophilia, arthralgias, maculopapular rash and WBC CASTS**
Acute interstitial nephritis
A 50 yo male smoker presents to clinic with painless gross hematuria that he says occurs from the start of urination through the end of urination. He states no hx of recent trauma. Prostate is firm and mobile with no nodules or tenderness. Urinalysis shows more than 10 RBCs per high power field but otherwise unremarkable. Which of the following is the most appropriate next step?
A. CT scan of abdomen and pelvis without contrast
B. CT scan of abdomen and pelvis with contrast and cystoscopy
C. Fasting plasma glucose
D. observation and nephrologist follow up in hematuria persists
E. kidney biopsy
B, CT scan of abdomen and pelvis with contrast and cystoscopy
In pts older than 40 who present with hematuria and a negative urinalysis, one MUST rule out malignancy. Cystoscopy allows for possible biopsy if bladder cancer is seen
What diagnostic should you run if you are suspecting nephrolithiasis (renal colic and constant abdominal pain that may radiate)
CT scan without contrast
Which of the following is not classically associated with pure pre-renal azotemia?
A. increased specific gravity of urine
B. fractional excretion of sodium greater than 2%
C. presence of Tamm-Horsfall proteins in urinalysis
D. BUN/Cr ratio greater than 20:1
E. decreased skin turgor
B, fractional excretion of sodium greater than 2%
Pre-renal is due to reduced renal perfuson. In pre-renal azotemia, there is no structural damage to the nephron. Because there is no structural damage, the natural response is for the kidney to try to maintain volume by increasing Na reabsorption and water, leading to a fractional excretion of sodium characteristically less than 1% and a concentrated urine (with a high specific gravity)
Can Tamm-Horsfall proteins be seen in normal urine specimens?
Yes! They are proteins that form hyaline casts that are nonspecific and can be seen in normal urine specimens
What is fractional excretion of sodium characteristically in pre-renal azotemia?
less than 1%
45 yo male with hx of diabetes mellitus and polycystic kidney dz is admitted to ICU for subarachnoid hemorrhage. He is placed on stool softness and seizure prophylaxis. His home meds are aspirin and chloropropramide. He has developed nausea and fatigue over last few days. Labs show: Serum glucose 128 (64-128 norm) Serum sodium 129 (135-145 norm) Serum BUN 7 (7-10 norm) Serum Cr 0.7 (0.8-1.4 norm) Serum osmolarity 257 (280-290 norm) Urine osmolarity 680 (300-900) Urine sodium 35 (norm 20) What is the following tx? A. hypertonic saline B. normal saline C. fluid restriction D. fluid and sodium restriction
C, fluid restriction
This pt has SIADH prob due to combination factors: intracranial bleed, antivonsulants and chloropropramide
(this is pretty complicated i think…dont think there will be Qs like this one)
A 37 yo male with a hx of chronic hep B presents to ER with SOB. Pt has dullness to percussion, decreased tactile remits and decreased breath sounds bilaterally with no crackles. There is bilateral peripheral and sacral edema. Labs are consistent with hypotonic hypervolemic hyponatremia and hyperlipidemia. Urinalysis shows: proteinuria, oval fat bodies and fatty casts. 24H urine protein collection shows 4g of protein. Which of the following would most likely be seen on biopsy?
A. IgA deposits in glomerulus
B. normal cellularity with thickened glomerular basement membrane
C. nodular glomerulosclerosis with pink hyaline material
D. hypercellularity with increased monocytes and positive immune humps
E. hypercellularity with presence of crescent shaped collapse of Bowman’s capsules
B, normal cellularity with thickened glomerular basement membrane
membranous nephropathy, which is one of the most common causes of primary nephrotic syndrome in adults, is often caused by viral hepatitis (this pt has viral hep B). membranous nephropathy is classically associated with basement membrane thickening on kidney biopsy.
*nephrotic syndrome is classically associated with proteinuria, hypoalbuminemia, edema and hyperlipidemia
Membranous nephropathy is a very common cause of what in adults?
Primary nephrotic syndrome
proteinuria, hypoalbuminemia, edema, hyperlipidema = nephrotic
IgA deposition in the glomerular is classic of…
Berger disease associated glomerulonephritis
Dysmorphic RBCs, RBC casts and HTN
Seen in glomerulonephritis (ie Berger dz)
Hypercellularity with the presence of crescent shaped collapse of the bowman’s capsules would be seen in what type of glomerulonephritis?
Rapidly progressing
A 43 yo female w hx of Ehlers-Dalos syndrome presents with a sudden onset of thunderclap headache. CT shows subarachnoid hemorrhage. Pt is admitted to ICU and is give phenytoin seizure prophylaxis along w bed rest. Which of the following electrolyte abnormalities are most likely to occur? A. hyperkalemia B. hypocalcemia C. hyponatremia D. hypokalemia E. hypernatremia
C, hyponatremia
Ehlers-Dalos syndrome is a connective tissue disorder that puts pts at risk of developing aneurysms. SIADH is often caused by CNS lesions (such as subarachnoid hemorrhage) as well as anticonvulsants. The increased ADH causes increased free water retention, which lowers serum sodium levels.
CNS lesions and anticonvulsant meds can cause…
SIADH
which causes too much ADH release, therefore leading to increased water retention and HypoNa
Staghorn calculi and struvite stones are composed of ammonium magnesium phosphate due to urea splitting organisms, which is most commonly associated with what type of bacteria?
Proteus mirabilis
proteus mirabilis are urea splitting organisms
a CT shows presence of staghorn calculi in R kidney measuring 1 mm. Stone is composed of ammonium magnesium phosphate (struvite). What organism likely causes?
Proteus mirabilis
Central diabetes insipidus is the absence of….
ADH
nephrogenic diabetes insipidus is kidney insensitivity to ADH
Desmopressin stimulation test distinguishes between what types of diabetes insidious?
Central and Nephrogenic
urine osmolarity increases with central, nephrogenic urine is still dilute
32 yo male with a hx of HTN presents with abdominal and flank pain in addition to 2 day hx of dark urine. No significant PMH. Hepatomegaly and palpable kidneys are noted. There is a mid-systolic ejection click and a holosystolic murmur that radiates to axilla. Urinalysis is positive for blood. No signs of anemia. Which is the best next step? A. cystoscopy B. renal ultrasound C. renal biopsy D. 24H urine protein collection E. urine culture
B, renal ultrasound
Hallmarks of adult polycystic kidney dz is abdominal/flank pain, palpable flank mass as well as cysts in other organs (i.e. liver, causing hepatomegaly). Extra renal manifestation of polycystic kidney dz include: mitral regurg and mitral prolapse
Flank pain, palpable kidneys (and possible other organs)..must think?
Polycystic kidney disease
Extra renal manifestations of polycystic kidney disease..
Mitral regurgitation
Mitral prolapse
Development of berry aneurysms (which can rupture, leading to subarachnoid hemorrhage)
Which of the following is not used in the routine management of severe hyperkalemia? A. IV insulin with glucose B. IV calcium gluconate C. IV metoprolol D. oral sodium polystyrene sulfonate
C, IV metoprolol
Beta blockers can cause potassium shift out of cells so it can worsen hyperkalemia
IV calcium gluconate is used in the management of hyperkalemia pts with….
ECG changes (or if severe hyperkalemia and at a high risk of developing arrhythmia)
Insulin with glucose causes potassium shift into the cells and therefore can be used in the treatment of….
Hyperkalemia
A 32 yo male with recent bipolar dx is placed on Lithium. 1 month later he complains of insatiable thirst in which he says he drinks about 5L a day and wakes up at night to urinate frequently. Which of the following would be seen in this pt if the Lithium is the cause of these symptoms? A. hyponatremia B. increased arginine vasopressin levels C. decrease urine osmolarity D. elevated glucose levels E. peripheral edema
C, decreased urine osmolarity
Lithium can induce nephrogenic diabetes insipidus, which is an insensitivity to ADH. This leads to production of lg amounts of dilute urine with decreased urine osmolarity. Diabetes insipidus is associated with hypernatremia
Lithium can induce nephrogenic diabetes insipidus, which is an insensitivity to…..
ADH
URINE osmolarity decreases
SERUM osmolarity increases
(large amounts of dilute urine with hypernatremia) is seen in…..
Diabetes insipidus
can be brought on by Lithium
Oxybutynin can be used for what type of incontinence?
Urge incontinence
use in addition to bladder training
47 yo male presents with R sided flank pain. CT of abdomen and pelvis shows an 11mm struvite staghorn calculi. Which of the following is recommended management?
A. shock wave lithotripsy
B. uretoscopy with stent
C. observation
D. alkalization of urine to dissolve stone
E. percutaneous nephrolithotomy
E, percutaneous nephrolithotomy
*percutaneous nephrolithotomy is an invasive procedure used for larger stones (greater than 10 mm), struvite stones or staghorn calculi
Invasive procedure used for larger stones of greater than 10 mm, struvite stones or staghorn calculi
Percutaneous nephrolithotomy
Procedure that is used in larger stones to break them into smaller ones
Shock wave lithotripsy
What procedure provides immediate relief to an obstructed or at risk kidney?
Uretoscopy with stent
Alkalization of the urine to dissolve stones can be used to dissolve….
Uric acid stones
Euvolemic HypoNa
Urine osmolality greater than 100
Urine sodium greater than 40
No peripheral edema
SIADH
Which of the following is NOT seen with SIADH? A. isovolemic hyponatremia B. urine sodium above 20 mEq/L C. decreased serum osmolarity D. absence of peripheral edema E. decreased urine osmolarity
E, decreased urine osmolarity
SIADH is associated with increased ADH secretion, which leads to free water overload. This leads to increased urine osmolarity as water is reabsorbed in the collecting tubule via ADH
most common type of intrinsic kidney injury in hospitalized pts and is associated with oliguria and an increase in BUN and creatinine
Acute tubular necrosis
- Epithelial cell or muddy brown casts
- inability to concentrate urine (isosthenuria) or reabsorb Na
- fractional excretion of sodium over 2%
- low urine specific gravity
Acute tubular necrosis
Prolonged prerenal azotemia
contrast dye
aminoglycosides (ie gentamycin)
can all cause…
Acute tubular necrosis
Epithelial cell or muddy brown casts…
Acute tubular necrosis
WBC casts
Acute interstitial nephritis
Pt has renal cell carcinoma. Management of choice?
Radical nephrectomy
RCC is often resistant to..
Chemo and radiation
must tx with radical nephrectomy if RCC is localized
Isovolemia
Lg volumes or DILUTE urine
Hypernatremia
Increased thirst
Diabetes insipidus
Glomerulonephritis associated with…
- hematuria
2. edema
Spot urine albumin to creatinine ratio is preferred for evaluating severity of..
proteinuria
it is more specific than 24H urine protein collection
Nitrofurantoin is the DOC for what category of people with acute cystitis?
Pregnant women!
Calcium gluconate stabilizes….
cardiac membrane! this should be given to patients with positive ECG findings
Pt has positive ECG findings due to hyperkalemia..DOC?
IV calcium gluconate
Staph saprophyticus can cause UTIs in…
young sexually active women
If a pt under 40,who smokes, comes in for yearly physical and has a positive urine dipstick for blood. denies any symptoms..what is the first step to take?
Urinalysis and culture
(bc hes under 40! start with this. if pt was over 40, would check into cancer first via cystoscopy, intravenous pyelogram and/or urine cytology)
White males Smoking Hx of cyclophosphamide use Hx of chemical exposure (rubber, leather, etc) Chronic bladder infections Schistosomiasis infections
Risk factors for bladder cancer
Polycystic kidney disease pts more at risk for developing….
subarachnoid hemorrhage
Furosemide
IV normal saline
Calcitoninc
Bisphosphonates
can all be used to tx this electrolyte abnormality
HYPERcalcemia
Arginine vasopressin test distinguishes…
central vs nephrogenic diabetes insipidus
Pt presents with classic hypokalemic ECG changes (T wave flattening and prominent U waves). Which med is likely responsible? A. spironolactone B. ibuprofen C. enalapril D. losartan E. furosemide
E, furosemide
loop diuretic that is NOT K+ sparing
33 yo female with hx of fibromuscular dysplasia develops HTN that is refractory to beta blockers and HCTZ therapy. Exam reveals abdominal bruit. Which of the following is the next step? A. renal biopsy B. renal ultrasound C. renogram D. renal angiogram
D, renal angiogram
*gold standard for dx renal artery stenosis
Gold standard for dx renal artery stenosis?
Renal angiogram
Decreased deep tendon reflexes seen in what type of electrolyte abnormality?
Hypermagnesemia
