Renal Flashcards
1
Q
Where is horseshoe kidney normally found? Why?
A
- Lower abdomen
- Gets stuck on IMA as it ascends from pelvis
2
Q
What is dysplastic kidney?
A
- Non inherited, congenital malformation of renal parenchyma
- With cysts and abnormal tissue eg: cartilage
3
Q
Ddx with bilateral dysplastic kidney?
A
Inherited PKD “Polycystic kidney disease”
4
Q
What is PKD?
A
“Polycystic kidney disease”
- Inherited defect of bilaterally enlarged kidneys
- Cysts in renal cortex and medulla
5
Q
Associations with recessive PKD?
A
- Hepatic fibrosis and cysts: portal HTN
6
Q
Presentation of ARPKD?
A
- Infantile presentation with HTN and worsening renal failure
- Potter’s sequence
- Hepatic fibrosis and cysts
7
Q
ADPKD associations?
A
- Berry aneurysm
- Hepatic cysts
- Mitral valve prolapse
8
Q
Presentation ADPKD?
A
Adults with HTN, hematuria, and renal failure
- Cysts in brain, heart, and liver
9
Q
What is medullary cystic kidney disease?
A
- Inherited AD defect
- Cysts in medullary collecting ducts
- Parenchymal fibrosis = shrunken kidneys with renal failure
10
Q
What is hallmark of acute renal failure?
A
- Azotemia: increased nitrogenous waste products
2. Oliguria
11
Q
What are the renal parameters indicative of prerenal failure?
A
- BUN:CR > 15
2. FeNa 500 (tubular function still in tact)
12
Q
What is normal BUN:Cr?
A
15
13
Q
Why does BUN:Cr increase in prerenal failure?
A
- Low blood flow increases renin / aldosterone
- Aldosterone increase Na / H2O absorption
- Bun follows water and Na out of tubules
14
Q
What is normal FENa and urine osmolality?
A
FENa: 500
15
Q
Difference between ST / LT post renal azotemia?
A
ST: tubular function preserved to FENa and OSM normal and BUN:CR increases as bun pushed back
LT = tubular damage: FENA > 2%, osm
16
Q
What is most common cause of ARF?
A
- ATN
17
Q
What happens in ATN?
A
- Injury and necrosis of tubular epithelial cells
- Necrotic cells plug tubules decreasing GFR
- Brown casts will be seen in urine
18
Q
What are brown casts in urine indicative of?
A
ATN
19
Q
Urine parameters in ATN?
A
- BUN:CR 2%
3. Urine OSM
20
Q
2 etiologies of ATN?
A
- Ischemic: preceded by prerenal azotemia
2. Nephrotoxic
21
Q
Which part of kidney most susceptible to ischemic ATN?
A
- Proximal tubule
2. Medullary segment thick ascending limb
22
Q
Part of kidney most affected in toxic ATN?
A
Proximal tubule
23
Q
Causes of toxic ATN?
A
- Aminoglycosides
- Heave metals
- Myoglobinuria: crush injury
- Ethylene glycol: antifreeze
- Radiocontrast dye
- Urate: tumor lysis syndrome
24
Q
How to prevent tumor lysis syndrome?
A
- Hydrate patient
- Allopurinol to prevent formation of uric acid
25
Prognosis of ATN?
- Damage is reversible but often requires dialysis due to deadly electrolyte imbalances that can ensue
- Oliguria persists for 2 - 3 weeks
26
What is acute interstitial nephritis?
- Drug induced HSR of interstitium and tubules
| - Causes ARF
27
What can cause AIN?
1. NSAIDs
2. PCN
3. Diuretics
28
Presentation of AIN?
1. Rash
2. Fever
3. Oliguria
4. EOSs in urine
* **Days to weeks after drug
29
What are eosinophils in urine indicative of?
AIN
30
What can AIN progress to?
Renal papillary necrosis
31
Presentation of renal papillary necrosis?
1. Flank pain
| 2. Gross hematuria
32
Causes of AIN?
1. Chronic analgesic use
2. TIIDM
3. Sickle cell
4. Severe pyelonephritis
33
Presentation of nephrotic syndrome? and why are they occurring?
1. Proteinuria > 3.5 g / day
2. HYPOalbuminemia = edema
3. HYPOgammaglobulinemia = increased risk infx
4. Hypercoagulable state = loss of ATIII
5. Hyper lipids and cholesterol = liver drops fat to counteract thin blood
34
Most common cause of nephrotic syndrome in kids? Cause?
- MCD
| - Usually idiopathic but can be associated with hodgkin lymphoma
35
What do the podocytes sit on?
Epithelial layer
36
What is happening in MCD?
- Flattening of podocyte foot processes from production of cytokines
37
MCD on imaging?
HE: normal
EM: podocyte foot effacement
IF: negative as no IC involved
38
Proteinuria characteristics in MCD?
- Selective with loss of albumin but no loss of immunoglobulin
39
Rx for MCD?
- Great response to steroids
| - Makes sense as caused by cytokines
40
3 layers of filtration barrier?
1. Endothelial layer: next to vessels
2. Basement membrane
3. Epithelial layers: podocytes
41
Who is FSGS common in?
1. Hispanics
| 2. Blacks
42
What can cause FSGS?
1. Idiopathic
2. HIV
3. Heroin
4. Sickle cell disease
43
Imagine of FSGS?
HE: Focal / segmental pink sclerosis
EM: effacement of foot processes
IF: negative
44
What does MCD progress to?
FSGS if they do not respond to steroids
45
Prognosis of FSGS?
- Poor response to steroids with progression to chronic renal failure
46
What are the nephrotic syndromes?
1. MCD
2. FSGS
3. Membranous nephropathy
4. Membranoproliferative glomerulonephritis
5. TIIDM
6. Amyloidosis
47
Most common cause of nephrotic syndrome in white people?
Membranous nephropathy
48
Causes of membranous nephropathy?
1. Idiopathic
2. HBV / HCV
3. SLE
4. Solid tumors
5. Drugs
49
Most common cause of death in SLE?
- Renal failure
- Membranous nephropathy in nephrotic
- Diffuse proliferative glomerulonephritis if nephritic
50
Imaging in membranous nephropathy?
HE: Thick basement membrane
EM: spike and dome
IF: granular, this is what is thickening membrane
51
What is spike and dome appearance on EM indicative of?
Membranous nephropathy
52
WHat is happening in all renal diseases with membranous in name?
Thickening of GBM from IC deposition
53
WHat is causing membranous nephropathy?
- IC deposition under the podocytes
- Leads to granular / spike and dome appearance
- Podocyte does not like having IC under it so secretes more basement membrane on top of it leading to spike and dome
54
When is tram track appearance seen?
Membranoproliferative Glomerulonephritis
55
2 locations of IC deposit in membranoproliferative glomerulonephritis? How does it lead to imaging?
"Proliferative" mesangial cell is proliferating through IC
1. Basement membrane: mesangial cell splits it in half with its cytoplasm
2. Endothelium
56
Location in type 1 / 2 membranoproliferative? Associations?
Type 1: Subendothelial
- HBV / HCV
Type 2: Intramembranous
- C3 nephritic factor
57
What is C3 nephritic factor associated with?
- Type II membranoproliferative glomerularnephritis
58
What is going on in type II membranoproliferative?
- C3 convertase normally converts C3 -> C3a/b
- Normally has short 1/2 life: in disease is stabilized by Ig
- Leads to drop in C3 and overactive complement
- Leads to inflammation in kidneys
59
Where are subepithelial deposits seen?
Membranous nephropathy
60
Pathogenesis of TIIDM nephrotic syndrome?
- High glucose = non enzymatic glycosylation of vascular basement membrane = hyaline arteriolosclerosis
61
Does diabetic nephrotic system like afferent or efferent arterioles?
- Efferent - this is why GFR increases
62
How to slow progression of diabetic nephrotic syndrome?
ACEIs
- Angiotensin II is squeezing down on efferent as well
- So if we stop this we decrease the already increased hyperfiltration that is occurring from the hyaline arteriolar sclerosis of efferent
63
Classic histology in diabetic nephropathy?
- Sclerosis of mesangium
| - Formation of kimmelstiel wilson nodules
64
What are kimmelstiel wilson nodules indicative of?
Diabetic nephropathy
65
Most common site of systemic amyloidosis?
- Kidney where amyloid deposits in mesangium
66
Imaging of renal amyloidosis?
Apple green birefringence under polarized light
67
Presentation of nephrotic syndrome?
"Glomerular inflammation and bleeding"
1. RBC casts and RBCs in urine
2. Oliguria / azotemia
3. Salt retention: periorbital edema
4. HTN
5. Proteinuria
68
What is periorbital edema associated with?
Nephritic syndrome
69
What is causing nephritic syndrome?
- IC deposition activates complement
| - C5a attracts neuts who mediate damage
70
Biopsy in nephritic syndrome?
Inflamed, hypercellular glomeruli
71
What causes PSGN?
Group A, beta hemolytic strep infx of skin or pharynx
72
What makes strep capable of causing PSGN?
M protein
73
PSGN presentation?
1. 2 - 3 weeks post infx
2. Cola colored urine
3. Oliguria
4. HTN
5. Periorbital edema
6. Subepithelial humps on imaging
74
When are subepithelial humps seen? What is happening?
- PSGN
| - IC is deposited endothelial then moves epithelial creating hump
75
PSGN prognosis?
Kids: rarely progress to failure
Adults: RPGN
76
What is characteristics of RPGN?
Crescents in bowman's space
77
What are crescents indicative of?
RPGN
78
What are crescents composed of?
Fibrin and macrophages
79
When is linear IF seen? What is causing it?
- Goodpasture's
| - Anti GBM Ig is binds membrane in linear fashion
80
Presentation and pathogenesis of goodpasture's?
- Ig against collagen in GBM and alveolar basement membrane
- Presents as hematuria and hemoptysis
- Classic in young males and adults
81
Causes of granular IF?
1. PSGN
2. Diffuse, proliferative glomerulonephritis
* ***Caused by IC deposition in both cases
82
What is occurring in diffuse proliferative glomerulonephritis?
- Most often seen in SLE
| - Subendothelial IC deposition
83
Possible causes of pauci immune crescents?
1. Wegener's granulomatosis: c-ANCA
2. Microscopic polyangiitis: p-ANCA
3. Churg Strauss: p-ANCA
84
Presentation of wegener's?
1. Hemoptysis
2. Hematuria
3. Nasopharynx involvement
85
How do differentiate wegener's from goodpasture's?
Both: renal and pulm symptoms
| Wegener's also involves nasopharynx
86
How to tell churg strauss from microscopic polyangiitis?
Churg strauss has:
1. Asthma
2. Eosinophils
3. Granulomatis inflammation
87
What happens in IgA nephropathy?
- IgA, IC deposition in mesangium
| - Most common worldwide nephropathy
88
Presentation of IgA nephropathy?
- Episodic hematuria
- Usually in kids following mucosal infx
- Can slowly progress to renal failure
- IgA IC deposition in mesangium
89
Imaging of IgA nephropathy?
- Granular IF
90
Cause / presentation of Alports?
X linked defect in collagen Type IV:
1. Thinning and splitting of GBM
2. Sensory hearing loss
3. Hematuria
4. Ocular disturbances
91
What is cystitis?
Bladder infx
92
Presentation of cystitis?
1. Dysuria
2. Frequency / urgency
3. Suprapubic pain
4. No systemic signs
93
Labs in cystitis?
Urinalysis: cloudy, > 10 WPCs / hPF
Dipstick: Leukocyte esterase and nitrate +
Culture: > 100k colony forming units
94
What is sterile pyuria and what does it suggest?
- Pyuria but culture does not meet 100k colony forming units
Suggests URETHRITIS due to:
1. Chlamydia
2. Gonorrhea
95
Pyelonephritis symptoms?
1. Cystitis symptoms
2. Fever
3. Flank pain
4. WBC casts
5. Leukocytosis
96
Most common causes of pyelonephritis?
1. E Coli
2. Klebsiella
3. Enterococcus
97
What is chronic pyelonephritis?
- Interstitial fibrosis and tubules atrophy from recurrent acute infx
- Causes cortical scarring and blunted calyces
98
What is cortical scarring and blunted calyces characteristic of?
Chronic pyelonephritis
99
What is scarring at upper poles of kidneys indicative of?
Vesicoureteral reflux
100
What is the following indicative of:
- Atrophic tubules w/ eosinophilic proteinaceous material
- Reminiscent of thyroid follicles
- Waxy casts in urine
"Thyroidization of kidney"
| - Chronic pyelonephritis
101
What is the following indicative of:
- Collicky pain
- Hematuria
- Flank tenderness
Nephrolithiasis
102
Rx for Ca stones?
1. Hydrochlorothiazide and other Ca sparring diuretics
| 2. Citrate
103
What disease are Ca stones seen in?
Chrohns
104
What orgs cause AMP stones?
Urease positive orgs:
1. Proteus vulgaris
2. Klebsiella
* **The alkaline urine is leading to formation of stone
105
Which stones cause staghorn calculi?
1. AMP: adult
| 2. Cysteine: kid
106
Which stone is radiolucent?
Uric acid = not visible on xray
107
Risk factors for uric acid stones?
1. Hot / arid climate
2. Low urine volume
3. Low PH
4. Gout
108
Rx for uric acid stone?
1. Hydration
2. Alkalization of urine: K/bicarb
3. Allopurinol: if gout
109
Types of Ca stones and environment they prefer?
1. Oxalate: acidic
| 2. Phosphate: basic
110
Which stones are envelope or dumbbell shaped?
Ca
111
Some causes of Ca stones?
1. Antifreeze
2. Hypocitraturia
3. Chrons
4. Vitamin C abuse
112
Which stone looks like coffin lid?
AMP
113
Which stones are rhomboids or rosettes?
Uric acid
114
Which stones are hexagonal?
Homocystinuria: 'cyxteine' six sides
115
Most common causes of renal failure?
1. TIIDM
2. HTN
3. Glomerular disease
116
What is uremia?
Increased nitrogenous products in blood causing:
1. Nausea
2. Anorexia
3. Pericarditis
4. Platelet dysfunction
5. Encephalopathy + asterixis
6. Urea deposition in skin
* *Cause by end stage renal failure
117
Where is EPO made?
Renal peritubular interstitial cells
118
Signs of end stage renal failure?
1. Uremia
2. HTN from salt and water retention
3. Hyper K with metabolic acidosis
4. Anemia - decrease EPO
5. HYPOcalcemia: decreased 1-a-hydroxylation of vit. D
- Also cannot excrete P - increased P
6. Renal osteodystrophy
119
3 components of renal osteodystrophy?
1. Osteitis fibrosis cystica
2. Osteomalacia
3. Osteoporosis
120
What is osteitis fibrosis cystica?
- Low Ca = increased PTH pulling more Ca out
| - Leads to fibrosis and cysts in bone
121
What is osteomalacia?
- Cannot mineralize osteoid being make by osteoblasts
122
What do osteoblasts do?
Lay down osteoid that needs to be mineralized by Ca and P
123
What leads to osteoporosis?
Metabolic acidosis seen in renal failure being buffered b lead of Ca from bone
124
Negative impact of dialysis on kidneys?
1. Renal cell carcinoma
2. Cysts
3. Shrunken kidneys
125
Renal tumor at increased risk in tuberous sclerosis?
Angiomyolipoma
126
What is renal cell carcinoma?
- Malignant epithelial tissue arising from kidney tubules
127
Presentation of renal cell carcinoma?
1. Hematuria
2. Palpable mass
3 Flank pain
4. Fever / weight loss
5. Many paraneoplastic syndromes
128
Appearance of RCC?
Gross: yellow mass
Micro: clear cytoplasm if clear cell type
129
Pathogenesis of RCC?
- Loss of VHL tumor suppressor gene causing:
* ***IN both sporadic and herediatary
1. Increase IGF 1
2. Increased HIF: TF increasing VEGF and PDGF
130
Who is sporadic RCC most commonly seen in?
- Adult spoker
| - Single tumor in upper pole
131
What is VHL disease?
Increased risk of:
1. RCC
2. Hemangioblastoma of cerebellum
* Autosomal dominant inactivation of VHL suppressor
132
What nodes does RCC spread to?
Retroperitoneal
133
Presentation of wilms tumor?
1. Unilateral flank mass in kid
134
Composition of wilms tumor?
- Blastema
- Stromal cells
- Primitive glomeruli and tubules
135
Mutation in wilms tumor?
WT1 mutation
136
What is WAGR syndrome?
1. Wilms tumor
2. Aniridia
3. Genital abnormalities
4. Mental / motor retardation
137
What is beckwith wiedeman syndrome?
1. Wilms tumor
2. Neonatal HYPOglycemia
3. Muscular hemihypoertrophy
4. Organomegaly - tongue
138
What makes up lower renal tract?
Everything past kidney:
1. Bladder
2. Renal pelvis
3. Ureter
4. Urethra
139
Where does urothelial cancer usually arise and from what does it?
- Usually in bladder
| - Arises from urothelial lining
140
What lines the lower urinary tract?
Urothelium
141
Risk factors for urothelial carcinomas?
1. Cigarettes
2. Naphthylamine
3. Azo dyes
4. Cyclophosphamide
5. Phenacetin
142
What is painless hematuria indicative of?
Urothelial carcinoma
143
2 pathways of urothelial carcinoma? How do they progress? Mutations?
1. Flat: starts as high grade
- Early p53
2. Papillary: low grade, to high grade, to invasion
144
Prognosis of urothelial carcinoma?
- Many tumors with frequent recurrence
| "Field effect:" urothelium has been hit by so many toxins for so long that it is grossly mutated
145
Risk factors for Squamous cell carcinoma of lower tract?1
1. Chronic cystitis
2. S. haematobium: middle eastern males
3. Long standing kidney stones
* usually seen in bladder
146
Risks of lower tract adenocarcinoma?
1. Urachal remnant - dome of bladder
2. Cystitis glandularis
3. Exstrophy
147
What does PS innervation cause relative to urination?
1. Detrusor contraction
2. Sphincter relaxation
* **Sympathetic does opposite
148
What does ADH cause to be resorbed other than water?
Urea
149
Blood supply to proximal ureter?
Renal artery
| Distal: vesicular
150
Presentation of henoch Schonlein purpura?
1. Abdominal pain
2. Arthralgia
3. Palpable purpura
4. Hematuria
151
Pathogenesis of Henoch?
- IgA IC vasculitis following URI
152
What does PAH clearance estimate?
RPF
153
Handling of PAH?
Some is freely filtered but most is secreted in PCT
154
Where is PAH lowest in kidney?
Bowman's Space
155
Another name for goodpasture's?
Anti GBM disease
156
What is attacking in anti GBM disease?
IgG and C3 complex
157
Impact of angiotensin II?
1. Efferent arteriole constriction
| 2. Systemic constriction
158
Where is angiotensinogen produced?
Liver
159
What does RCC originate from?
Epithelium of PCT
160
Which diuretic can cause hearing deficits?
Loops
161
What causes uric acid to precipitate?
Low PH
162
Lowest PH in kidney?
Distal tubules
| Collecting duct
163
What is the most potent diuretic?
IV loops
164
What are antiphospholipid Igs and what do they cause?
- From SLE
- Falsely elevate PTT when actually hypercoag
- False RPR for syphillis
165
What layer are kidneys derived from?
Mesoderm
| - Muscle, bone, connective tissue as well
166
When is pronephros around?
Until 4 weeks: degenerates to become mesonephros
167
What is the first functional unit of fetal kidney?
- Mesonephros which is functional during the first trimester
168
What becomes permanent kidney and when does it develop?
Metanephros developing in 5th week
| - Metanephric mesenchyme, ureteric bud
169
What is WT1 mutation involved in?
Wilms tumor
170
What does the mesonephros turn into?
1. Collecting duct
2. Calyces
3. Pelvis
4. Ureters
5. Vas def
171
Vertebral level of kidneys?
"1,2,3 is where you find kidneys"
| T12 - L3
172
Which anterior branch of aorta are kidneys next to?
SMA
173
Where do horseshoe kidneys get stuck?
IMA
| - Commonly seen in turner's syndrom
174
Is multicystic kidney disease hereditary?
No
175
How to ureteric bud progress?
Grows laterally from mesonephric duct connecting to mesonephric mesenchyme forming metanephros
176
How would one kidney have 2 ureters?
"Duplex collecting system"
Ureteric bud bifurcates before reaching mesonephros in embryogenesis
*High risk for vesicoureteral reflux and infx
177
What results in unilateral renal agenesis
Aberrant interaction between ureteric bud and metanephric mesenchyme
178
What are the retroperitoneal structures?
"SAD PUCKER"
Suprarenal glands
Aorta + IVC
Duodenum 2 - 4th
```
Pancreas (except tail)
Ureters
Colon (ascending / descending)
Kidneys
Esophagus (lower 2/3)
Rectum
```
179
Where do Renal arteries branch?
L1
180
Where do renal veins run?
Anterior to renal arteries and aorta
181
Which renal vein is longer?
Left: because IVC is right of aorta so left vein has further to go
182
Where do right and left gonadal veins drain?
Right: directly into IVC
Left: Renal vein - > IVC
183
Relation to ureter and gonadal vessels?
- Runs under them "water under the bridge"
| - Also is running under vas def
184
Are autonomic and somatic voluntary or involuntary and how does this related to the two urethral sphincters?
Somatic: voluntary, external sphincter
Autonomic: involuntary, internal sphincter
185
Where does the vasa recta come off?
"peritubular capillaries"
| Efferent arteriols
186
Functions of angiotensin II?
1. Enhances aldosterone release
2. Vasoconstriction
3. Constricts efferent arteriole
4. Increased Na absorption in PCT
187
Where is renin secreted
JG cells: Modified smooth muscles cells in afferent tunica media
188
3 things increasing renin?
1. Decreased flow
2. Decrease Na
3. Increased sympathetic tone
189
Where does collecting duct drain?
Minor calyx at the renal papillae
190
Arterial suppel of ureters?
Upper 1/3: Renal artery
Middle: gonadal / common iliac
Lower: Internal iliac
191
What is the break out of water in the body?
```
60 - 40 - 20
60% total body weight is water
- 2/3 of this is ICF (40%)
- 1/3 of this is ECF (20%)
40% of body weight is non water mass
```
192
How is volume of ECF measured?
Inulin
| - Moves out of vasculature but cells do not take up
193
Break out of ECF?
Plasma: 1/4 (volume of fluid inside vascular system)
- Measured by albumin
Interstitial fluid: 3/4
194
How are plasma levels measured?
Radio labeled albumin: moves into vasculature but too large to move into ECF as inulin does
195
Major cations in ICF and ECF?
"The cell is like a banana in the open sea"
ICF: K
ECF: Na
196
What is the charge barrier of the GFR?
- Heparan sulfate in the basement membrane blocks negative molecules
- Lost in nephrotic syndrome which is why albumin is now able to cross barrier as it is a negatively charged molecule
197
Layers of glomerulus from in to out?
Endothelium: size barrier
Basement membrane: heparan charge barrier
Epithelium: podocytes
198
3 things that are freely filtered?
1. AAs
2. Glucose
3. Electrolytes
* Majority resorbed in PCT
199
What is clearance?
Volume of plasma in ml cleared of substance in minutes
C = UV/P
U: urine[x]
V: urine flow rate
P: plasma [x]
200
How is GFR measured?
Inulin clearance: freely filtered neither reabsorbed, nor secreted
* **Creatinine is used clinically and it overestimates since a small amount is secreted in tubules
* Inulin is also measure of ECF fluid volume)
201
What does inulin measure?
GFR - freely filtered and neither secreted nor reabsorbed
| - Cr is actually used in practice
202
What is EPRF, how is it measure?
"Effective renal plasma flow"
- Measured by PAH
- PAH is both filtered and secreted
203
What does PAH measured?
RPF
204
Equation for RBF?
RPF / (1 - hematocrit)
| ***This includes both plasma and cell mass
205
What part of CO do the kidneys receive?
1. 2 L / Min
| - This is 25% of resting CO
206
Filtration fraction equation?
FF = GFR / RPF
| - Normally 20%
207
Effects of angiotensin II and prostaglandins on GFR?
Angiotensin: constricts efferent so increase GFR
Prostaglandins: Dilate afferent increasing BOTH GFR and RPF
208
Effects of dehydration on kidney dynamics?
Decreased in GFR and even greater decrease in RPF
| **Leads to increase in filtration fraction
209
Equation for filtered load?
= GFR x [plasma]
210
Equation for excretion rate?
= V x [U]
| Urine flow x urine [ ]
211
What what plasma glucose is it seen in urine?
- 200
| - PCT transporters are fully saturated at 375
212
What type of drug is acetazolamide? Major indication?
- Carbonic anhydrase inhibitor
| - High altitude pulmonary and cerebral edema "acute mountain sickness"
213
What is permeability of thin ascending limb?
- Impermeable to Na
- Water is passively absorbed
- Urine is being concentrated
* **Being caused by hypertonicity of medulla
214
What is permeability of thick ascending limb?
- Impermeable to water
- Allows for solute resorption
* **Urine is being diluted
215
Transporter found in thick ascending limb?
NaK2Cl
| - Mg/Cl also reabsorbed paracellularly
216
Which diuretics increase renal excretion of Ca?
Loops: Eg, furosemide
217
Contraindication of loops?
- Ca kidney stones as loops are increasing excration / tubular [Ca] which will lead to more stones
218
What diuretics lead to decreased Ca excretion?
- Thiazides
219
Transporter in distal tubule?
NaCl
| - No water being absorbed so filtrate is being diluted
220
Where is PTH functioning?
DCT increasing Ca absorption via Na/Ca apical transporter
221
Where does ADH function?
- V2 receptor on principal cell of collecting tubule leading to aquaporin insertion in lumen
222
K sparing diuretics?
1. Triamterene
2. Amiloride
* **Inhibit Na reabsorption making lumen more positive driving K into cells
223
Impact of aldosterone?
- Mineralocorticoid receptor in both Principal and A cells in collecting duct
- Causes Na channel insertion on lumen increasing its resorption
- Increases K / H loss
224
What is Cohns syndrome?
"Primary hyperaldosteronism"
1. Hypertension from increase Na/H2O Resorption
2. Hypokalemia
3. Metabolic alkalosis
225
How to remember the renal tubular defects?
The kidneys make "FABulous Glittering LiquidS"
FAnconi syndrome
Bartter syndrome
Gitelman syndrome
Liddle syndrome
Syndrome of apparent mineralocorticoid excess
226
What happens in fanconi?
- Non functional cells in PCT leading to loss of:
1. Glucose
2. AAs
3. Bicarb
4. Phosphate
227
What is bartter's syndrome?
```
Resorption defect in thick limb of NaK2Cl causing:
1. HYOP Ca
2. HYPO K
3. Metabolic alkalosis
Increased: renin / aldosterone
Normal BP
```
228
What is Gitelman syndrome?
- DCT issue, similar to bartter but less severe
| HYPO: Mg/Ca
229
What is liddle syndrome? Treatment?
- Increased Na reabsorption in distal / convoluted tubules
- Increased activity of Na channel here
- Causes HTN and reflex decrease in aldosterone
Rx: Amiloride (K sparing)
230
What happens in syndrome of apparent mineralocorticoid excess?
- 11-B-Hydroxysteroid Dehydrogenase which normally converts cortisol into cortisone
- If enzyme absent, excess cortisol begins to activate mineralocorticoid receptors
231
What causes release of ANP?
- Stretching of cardiac atria from increased BV
| - Can be caused by volume overload or aortic stenosis
232
How does ANP work?
1. Relaxes vascular smooth muscle to lower BP
2. Dilates afferent increasing GFR
3. Decreases renin
233
What does the macula densa do? JG?
MD: Sense [Na] in distal tubule
- MD can stimulate JG to release renin
JG: Sense pressure in afferent
234
What is an endocrine hormone?
Something that acts at a distant site
235
What is a paracrine hormone?
Hormone that acts locally
236
What causes secondary polycythemia?
COPD
237
Processing of vitamin D?
1. Liver 25-a-hydroxylase: vitamin d -> 25-H-vitamin D
| 2. Kidney 1-a-hydroxylase 25-H-vitamin D -> 1-25-OH-2-D
238
What enzyme activated vitamin D and where is it found?
1 alpha hydroxylase in PCT
| - Stimulated by PTH
239
Functions of vitamin do?
1. Increased GI absorption Ca/P
2. Decrease renal absorption P
3. Increased renal reabsorption Ca
240
Drug often associated with renal papillary necrosis?
Chronic NSAID use: stops creation of prostaglandins constricting efferent leading to ischemia
241
Effect of De on kidney?
Low dose: dilates afferent
| High dose: vasoconstrictor via A1 action
242
4 things shifting K into cells?
1. Insulin
2. Adrenergic agonists
3. Alkalosis - exchanging for H
4. HYPOsmolality
243
What do flattened and peak T waves indicated?
Flattened: HYPO K
Peaked: HYPER K
244
Normal PH of blood?
7.4
245
Values in metabolic acidosis?
PH: decreased
CO2: Decreased
Bicarb: Decreased
Response: HYPERventilation
246
Values in metabolic alkalosis?
PH: Increased
CO2: Increased
Bicarb: Increased
Response: HYPOventilation
247
Values in respiratory acidosis?
PH: Decreased
CO2: Increased
Bicarb: Increased
Response: increased renal bicarb
248
Values in respiratory alkalosis?
PH:
CO2:
Bicarb:
Response: decreased renal bicarb
249
What does opiated OD cause relative to acid base?
Respiratory acidosis from respiratory depression
250
Difference in onset between compensatory metabolic / respiratory mechanisms?
```
Respiratory = immediate
Metabolic = delayed
```
251
What is the normal PCO2?
40
252
How to calculate anion gap?
[Na] - ([Cl] + [bicarb])
| **Normal is between 8 and 12
253
What is normal anion gap?
8 - 12
254
Causes of increased anion gap metabolic acidosis?
"MUD PILES" - think, you are piling the anions up
Methanol - formic acid
Uremia
Diabetic Ketoacidosis
```
Propylene glycol
Iron / Isoniazid (INH)
Lactic acidosis
Ethylene Glycol
Salicylates
```
255
Causes of Normal anion gap metabolic acidosis?
```
"HARD ASS"
Hyperalimentation
Addison's
RTA
Diarrhea - Losing both Na / bicarb in stool
```
Acetazolamide
Spironolactone
Saline infusion
256
Causes of hyperventilation?
1. Hysteria
2. Hypoxemia
3. Salicylates
4. Tumor
5. Pulmonary Embolism
257
Causes of metabolic alkalosis?
1. Dehydration
2. Vomit
3. Antacids
4. Hyperaldosteronism
5. Loops / thiazides
258
Other names for type 1, 2, and 4 RTA? What happens to urine PH?
1: Distal: PH > 5.5
2: Proximal: PH
259
Causes of Type I RTA?
1. Amphotericin
2. Analgesics
3. Multiple myeloma
260
Cause of Type I RTA?
Inability of a-intercalated cells in distal to secret H:
1. Leads to HYPO K: decreased lumen charge pulls K
2. Increase lumen PH: Ca/P stones
261
What happens in type II RTA?
PCT can not resorb bicarb, distal secretes H to compensate = Decreased PH
1. K being secreted with H = HYPOkalemia
262
Causes of type II RTA?`
1. Fanconi
2. Lead
3. Aminoclydosides
263
Cuase of Type IV RTA?
HYPOaldosteronism: normally causes Na resorp and K dumb
| - without, K is being held in
264
DDx for RBC casts?
1. Glomerulonephritis
2. Ischemia
3. Malignant Htn
265
Ddx for granular casts?
ATN
266
DDx for fatty casts?
Nephrotic syndrome
267
Ddx WBC casts?
1. Interstitial inflammation
2. Pyelonephritis
3. Transplant rejection
268
What is being disrupted in nephritic/rotic syndromes?
Nephritic: GBM
Nephrotic: Podocytes
269
What type of hypersensitivity is PSGN?
III
270
What hypersensitivity is goodpasture's?
II`
271
What is wire looping of capillaries indicative of?
DPGN: most common cause of death in SLE
| LOOPus for LOOPing
272
Another name for IgA nephropathy?
Bergers
273
RBC casts in kidney stones?
No, problem is after tubules
274
When most likely to die during ATN?
Oliguric / maintenance phase
| - Recovery phase is polyuric
275
Renal drug causing gynecomastia?
Spirinolaction
276
More water resorbed in collecting duct or PCT?
PCT
277
What is hyperacute rejection?
- Occurs immediately upon insertion of transplant
| - Type II IgG mediated
278
First step in working up a metabolic alkalosis?
Volume status and urine chloride
279
What is a positive Na-cyanide-nitroprusside test indicative of?
Homocysteinuria
280
What does hypo K do to muscles?
1. Cramps
2. Weakness
3. Rhabdo
* **Can be caused by thiazides
281
Where in nephron does lowest osmolality occur?
DCT
282
Which diuretic leads to increase in Cr upon administration?
Ace inhibitors as they are dilating the efferent decreasing GFR
283
Most serious complication during recovery phase of ATN?
HYPOk as diuresis but epithelial cells of tubules can not yet function
284
What are phospholipase A2 Receptor (PLAR2) Ig indicative of?
Membranous nephropathy
285
Secondary effect of loops?
Stimulation of Pg release
286
Side effect of aggressive osmotic diuretic therapy?
Pulmonary edema
287
What type of hypersensitivity is serum sickness?
Type II: Ig mediated complement activation
288
What leads to meckel's diverticulum?
Persistence of the vitelline / omphalomesenteric duct
| - Think VITTTTTY for SHITTTTY
289
What does the allantois become?
- The urachus, a duct between bladder and yolk sac
| - Think UUUUUrine, for UUUUURACHUS
290
When is serum C3 decreased?
PSGN
291
What is starry sky appearance indicative of?
PSGN
292
Which vessels cross under and over the ureter?
Over: Gonadal artery and vein
Under: interior iliac artery
293
How do EOSs kill parasites?
Ig dependent, cell mediated toxicity
294
IF in PSGN?
Granular deposits in lumpy bumpy formation
295
Prevalence of posterior urethral valves?
Only seen in males
