Renal Flashcards
1
Q
winter’s formula
A
hco3 x 1.5 + 6to10
= expected PaCO2 if sufficient respiratory compensation for metabolic acidosis
2
Q
delta gap
A
anion gap - normal anion gap
add that difference to HCO3
compare that total to normal HCO3 (24)
if elevated, primary metabolic alkalosis on top of primary anion gap metabolic acidosis going on (e.g. contraction alkalosis)
3
Q
contraction alkalosis mechanism
A
not certain, here are a few theories:
- fluid loss w/o bicarb loss ^bicarb conc
- volume contraction -> aldo secretion -> H+ secretion, bicarb resorption
- chloride depletion, failure of Cl-/HCO3- exchanger in distal tubule
4
Q
anti-___ antibodies correlate with lupus disease activity
A
anti-dsDNA
5
Q
TF
need kidney biopsy to diagnose lupus nephritis
A
F
evidence of AKI with anti-dsDNA antibodies sufficient
6
Q
anti-Histone antibodies are positive in ____
A
anti-Histone antibodies positive in Drug-Induced Lupus
7
Q
drug-induced lupus does Not induce ___ ___ or ___ like non-drug induced lupus does
A
DI Lupus does NOT induce Nephritis, Serositis, or Cerebritis like non-drug induced lupus does
8
Q
FeNa can’t be used in pt taking ___
A
FeNa useless if pt taking FUROSEMIDE
9
Q
TF
CHF pt can be volume up but have prerenal AKI
A
T
give furosemide
10
Q
common complication of EPO administration to ESRD patients
A
hypertension
11
Q
TF
hypertension in ESRD pt may be due to calcium and vit D supplementation
A
F
ESRD pts chronically low in Ca and VitD
more likely due to EPO
12
Q
TF
Meloxicam causes AKI
A
T
Meloxicam is an NSAID
13
Q
2 meds most notorious for causing AKI
A
NSAIDS
Pip/Tazo (sulfa abx and penicillin)
14
Q
Meloxicam drug class
A
NSAID
15
Q
Metformin is contraindicated in AKI and CKD because
A
Metormin is Contraindicated in AKI and CKD because it can cause METABOLIC ACIDOSIS
16
Q
TF
Metformin is contraindicated in AKI and CKD
A
T
can cause METABOLIC ACIDOSIS
17
Q
what is the concern with Glipizide in setting of AKI?
A
HYPOGLYCEMIA, because it reduces insulin clearance
18
Q
TF
Nifedipine and other CCBs are contraindicated in CKD
A
F
CCBs strongly indicated in CKD to control HTN
19
Q
urine microscopy is used to…
A
assess for Casts when Intrinsic renal disease is on the ddx – ATN AIN Glomerulonephritis
20
Q
contrast-induced kidney injury occurs how long after contrast study
A
7-10 days…?
21
Q
contrast causes ___ of the kidney
NSAIDS cause ___ of the kidney
A
contrast - ATN
NSAIDS - AIN
22
Q
how is EPO administered to ESRD pts
what is the goal
A
IV, during dialysis
goal is Hb of 10
23
Q
60 pack-year smoking history, microhematuria, flank pain
2 ddx
A
urologic cancer
kidney stone
24
Q
African American and AIDS Nephropathy means ___ on kidney biopsy
A
AA and AIDS Nephropathy means FSGS on kidney biopsy
Focal Sclerosing Glomerular Sclerosis
25
what to expect on kidney biopsy:
African American AIDS nephropathy
Post-Strep Pharyngitis or Skin Rash or URI with neprhotic range proteinuria
Diabetes
Idiopathic Nephrotic Syndrome, Autoimmune Disease, Hepatitis infection, Drug-Induced Nephrotic Syndrome
Hep C in absence of cryoglobulinemia
Peds asymptomatic other than spilling protein
AA AIDS - FSGS focal segmental glomerular sclerosis
Post-Strep - IgA Nephropathy
DM - Kimmelstiel-Wilson nodules
Idiopathic, AutoImmune, Hepatitis, Drug-Induced -- Membranous Nephropathy
HepC without cryoglobulinemia - FSGS
Peds - MCG minimal chage disease
26
first thought with kidney biopsy:
FSGS
IgA nephropathy
Kimmelstiel-Wilson nodules
Membranous Nephropathy
Minimal Change Disease
FSGS - AfAm AIDS or HepC without cryoglobulinemia
IgA - Post-Strep Pharyngitis, Skin Rash, or URI
K-W nodule - DM
MN - Idiopathic, AutoImmune, Drug-Induced
MCG - Peds, asymptomatic other than spilling protein
27
treat acute severe hyponatremia, eg from water drinking contest
3% saline
| HYPERTONIC
28
when to give 3% vs .9% saline vs fluid restriction for hyponatremia
3% if acute and severe volume up eg water drinking contest seizure coma
.9% if more chronic volume down eg hiking over the week or inpatient falling behind on fluids with daily lab draws
fluid restriction for SIADH -- free water toxicity but more chronic less sever than chugging contest
29
HTCZ treats what kind of hyponatremia
Furosemide for what kind
HCTZ for Euvolemic hyponatremia
Furosemide for hypERvolemic hyponatremia
30
how does PTH affect Ca and Phos
vs how does Vit D affect Ca and Phos
PTH ups Ca, downs Phos
Vit D ups both Ca and Phos
31
when is the only time you measure Calcitonin
MEN syndromes only
32
high PTH despite high calcium levels... primary, secondary, or tertiary hyperparathyroidism?
primary or tertiary
| secondary is caused by low calcium
33
young healthy guy with family history of calcium disorders has asymptomatic hypercalcemia -- Modestly high Ca, PTH, little low Phos, asymptomatic
likely dx
inheritance
next test
likely Familial Hypocalcuric Hypercalcemia (benign)
Autosomal Dominant
next test Urinary Calcium (low)
34
what are you suspecting when you get 1,25-vit D level in workup of hypercalcemia
Granulomatous disease like TB or Sarcoid
35
when do you get serum 25-vit D level
working up hypOcalcemia suspecting vitD Deficiency
36
what is Hungry Bone syndrome
low PTH after parathyroid adenoma resection (remaining pth glands have been suppressed, need a while to turn back on)
37
difference in calcium levels between early CKD and ESRD
early CKD may be hypOcalcemic because not making vit D
ESRD is hypERcalcemic because not excreting it
38
treat hypercalcemia from multiple myeloma
vigorous Fluids and Alendronate (bisphosphonates)
39
TF
| fluids fluids fluids fluids - and a little lasix is the treatment for hypercalcemia
Fish
not anymore
Furosemide can cause initial worsening of hypercalcemia via concentration by diuresis...
40
when is Cincacalcet used
moa
for secondary and tertiary HyperParathyroidism
stimulates Calcium-sensing receptor in Parathyroid glands, Reducing PTH secretion
41
how do Granulomatous diseases (Sarcoid, TB) cause hypercalcemia?
HyperVitaminosis D
| increased 1,25-vitD
42
how could Prednisone possibly treat hypercalcemia?
if due to Granulomatous disease
Prednisone decrease granulomatous inflammation, decrease hypervitaminosis 1,25-D
43
when is Calcitonin administered
during acute, severe, and symptomatic hypercalcemia -- as a temporizing measure while fluids are being given
44
calcitriol is ___
it does ___
use it for
calcitriol is 1,25-vitD
it increases Absorption of Ca and Phos from the gut
use it for Renal Failure when Hypocalcemia is driving Parathyroid production -- to prevent secondary and tertiary hypercalcemia
45
Pamindronate is a ____
used to treat ___ and ___
Paindronate is a Bisphosphonate
used to treat Osteopenia in teh elderly and HyperCalcemia from Cancer
46
If symptomatic hypocalcemia (perioral and fingertip paresthesias), give _______
Gove IV Calcium Gluconate
47
Black woman, bilateral hilar lymphadenopathy, hypercalcemia
Dx
Pathophys of hypercalcemia
Treat hypercalcemia
Sarcoid
Granulomatous inflammation converts 25-vitD to 1,25vitD
treat with Prednisone
48
Hypokalemia with non-gap metabolic acidosis can be 2 things
Proximal Renal Tubular Acidosis
(distal would cause hyperkalemia)
Diarrhea
49
Hypertensive with hypokalemia, best first antihypertensive drug?
ACEI / ARB
| ~potassium sparing diuretics in a way and first line for HTN
50
Hydralazine dilates ____
used to treat ____
main side effect is ____
Hydralazine dilates Arteries
used to treat HTN
main side effect is Reflex Tachycardia
51
guy passed out found to have 3rd degree AV block and hyperkalemia to 9. Heart is paced, treat the hyperkalemia
same as any symptomatic hyperkalemia
3 steps
stabilize myocardial membrane with CALCIUM GLUCONATE or CALCIUM CARBONATE
temporize potassium out of the blood with INSULIN with D50
eliminate potassium from body with KAYEXYLATE (stool), FUROSEMIDE (urine) or HEMODIALYSIS (last resort)
52
TF
| Calcium Carbonate can be used to stabilize myocardial membrane in hyperkalemia just like Calcium Gluconate
T
| equivocal
53
TF
| asymptomatic hyperkalemia with no EKG changes can be treated with Furosemide or Kayexylate
T
| no need for calcium or insulin and glucose if no manifestations
54
CHF exacerbation getting diuresed with furosemide now hypokalemic, what do you do?
give potassium
continue furosemide if still a ways to go to dry weight
55
Patient had a calcium oxalate kidney stone
how to prevent more in the future?
Thiazide diuretic
(hypercalcemia, hypocalcuria)
also avoid vitamin C excess and animal protein excess (oxalate)
also avoid vit D excess, hyperparathyroidism, familial hypocalcemic hypercalcuria
56
allipurinol is used for...
gout
| uric acid stones -- particularly to ppx in setting of tumor lysis syndrome
57
alkaline urine causes ___ stones
often a byproduct of...
alkaline urine causes STRUVITE stones
often a byproduct of UTI with Urea-Splitting Bacteria such as Proteus
58
TF
| advise large water intake for large urine volumes to prevent recurrence of kidney stone
F
this can help pass a stone v5mm
BUT NOT A LONG TERM PPX STRATEGY... will do more harm than good
59
TF
| ppx against calcium oxylate stones with furosemide
F
loop diuretics prevent paracellular calcium absorption and WORSEN calcium oxalate stones, avoid
--ppx with THIAZIDE diuretic (hypercalcemia, hypocalcuria)
60
struvite stone =
magnesium ammonium phosphate
61
how does a struvite stone present on imaging
Staghorn Calculi
| single large continuous stone throughout the kidney
62
without any hints otherwise, assume kidney stone is made of...
hints that would make you think otherwise...
calcium oxalate
(most common stone)
if uti with alkaline urine - struvite
if gout or tumor lysis syndrome - uric acid
if cystinuria - cyseine
63
single stone obstructing ureter suggests this makeup
calcium oxalate
64
staghorn calculi suggests this stone makeup
struvite
| magnesium ammonium phosphate
65
Obstructing stone ^3cm with hydronephrosis
Manage
Nephrostomy tube to relieve obstruction then get urology involved to cut it out
66
Lithotripsy can be done for kidney stone of what size
v3cm for Lithotripsy
67
Vigorous IV Fluids is appropriate management for a kidney stone of what size
v5mm to try to wash it out
68
manage kidney stone:
```
incidental finding
v5mm
v3cm
^3cm
with hydronephrosis
```
```
incidental - ntd, observation
v5mm - hydration
v3cm - lithotripsy
^3cm - surgery
with hydronephrosis - nephrostomy tube then according to above
```
69
you think there is cancer in the kidney - bopsy or resect?
resect (that's your biopsy)
biopsy may bleed excessively...
70
TF
| a complex renal cyst can be followed
F
| complex renal cyst is Always Abnormal and must be Worked Up
71
complex renal cyst with history of flank pain, hematuria, and palpable mass is ___ until proven otherwise
complex renal cyst with history of flank pain, hematuria, and palpable mass is RCC until proven otherwise
72
Adult Polycystic Kidney Disease starts around age __ and causes ESRD around age __
Adult Polycystic Kidney Disease starts around age 20 and causes ESRD around age 60
73
is Polycystic Kidney Disease of the Newborn compatible with life?
Inheritance pattern?
Not compatible with life
Autosomal Recessive
74
complex renal cyst on ultrasound, f/u?
con CT
| to further characterize before deciding on surgery
75
TF
| ESRD can get contrast CT
T
| damage to kidneys already done, end stage
76
when is kideny biopsy the answer for a renal cyst
never
| not for renal cysts
77
incidental renal cyst found in pt otherwise low-risk for cancer, f/u?
just reassure
no need to follow up
if risk factors, can followup with imaging...
78
when to get a urine anion gap
in a non-gap metabolic acidosis, to differentiate renal tubular acidosis from diarrhea as the cause
79
pH 7.24
PCO2 32
pO2 66
Na 124
K 4
Cl 98
Bicarb 10
what acid/base derangement?
respiratory acidosis with gap metabolic acidosis and non-gap metabolic acidosis
pH is acidemic. but PCO2 is low so it is Metabolic Acidosis
Na-Cl-Bicarb = 16 so GAP of 4
add 4 to bicarb = 14 which is still low v24... so ANOTHER METABOLIC ACIDOSIS so GAP AND NON-GAP
expected pCO2 by Winters Formula 1.5bicarb plus 8 = 23... but real pCO2 is 32 so a RESPIRATORY ACIDOSIS ON TOP
80
pH 7.52
PCO2 25
PO2 42
Na 137
K 4
Cl 110
Bicarb 21
what acid/base derangement?
respiratory alkalosis
pH is alkalotic
pCO2 is up 15, this should correspond to a .12 increase in pH, which it does, and a 3 point decrease in bicarb, which it does, so acute respiratory alkalosis with no metabolic derangements yet
81
what kind of urine anion gap points to diarrhea
what kind points to Renal Tubular Acidosis
Negative urine anion gap points to diarrhea
e.g. U Na 14 K 12 Cl 60
26-60 = -34 = negative anion gap
Positive urine anion gap points to RTA
(both in a NON GAP Metabolic Acidosis)
82
TF
| as soon as you see no anion gap, lactic acidosis can be withdrawn from consideration
T
| Lactic acidosis is a GAP acidosis
83
how much should bicarb drop in response to elevated pCO2 in respiratory acidosis?
drop 2 Bicarb for every 10 pCO2
84
pH 7.33
pCO2 34
pO2 80
Na 133
K 4
Cl 101
Bicarb 16
acid/base derangement?
anion gap metabolic acidosis with non-gap metabolic acidosis
pH is Acidic
but pCO2 is low, so Metabolic Acidosis
gap is 133-17 = 16... -12 = GAP of 4
16plus4 = 20 is less than normal 24 bicarb so ADDITIONAL NON-GAP METABOLIC ACIDOSIS
Winters 1.5bicarb plus 8 plusminus 2 = 24 plus 8 = 32 plus 2 = 34 which is what the pCO2 actually is so no respiratory derangement
85
pH 7.50
pCO2 52
pO2 62
acid base derangement?
look for gap?
look for additional derangements?
metabolic alkalosis
-appropriate pH up with PCO2 up... you are pretty much done, just check for gap to rule out gap metabolic acidosis in addition... but don't need to define any respiratory aspect
86
suspect ureteral stone after H and P, next step?
US or Noncon spiral CT
US good imaging little radiation best if no real alternate diagnosis, may miss small stones and technician-dependent
NONcon spiral CT best but more expense and radiation
87
suspect ureteral stone in pregnant pt, best test
ultrasound
avoid radiation of noncont spiral ct
88
how can glucocorticoids affect BMP?
affect Cr?
BUN up maybe from catabolic effect
increase glucose level
NO creatinine elevation
89
DKA typically accompanied by glucose levels in the ___ range
DKA has glucose in ^400 range
90
why use diuretics but use cautiously in COPD exacerbation
use because increased pulmonary pressures cor pulmonale and increased right atrial pressures and peripheral edema
careful because can dehydrate and cause AKI
91
why would a Crohn's pts be predisposed to kidney stones
increased Oxalate resorption
Crohns, fat malabsorption, gut Ca binds to fat instead of oxalate, more oxalate absorbed, more calcium oxalate stones
92
most common cause of symptomatic hyperoxaluria and oxalate stone formation is...
increased GI absorption of oxalate
e.g. from malabsorption of fatty acids which chelate more calcium and prevent calcium binding to oxalate which normally reduces oxalate absorption
93
pt has hypokalemic hypochloremic metabolic acidosis from vomiting... is the cause of the hyochloremia and hypokalemia vomiting? volume depletion? metabolic alkalosis? intracellular shift?
treat
Yes, low Cl simply from GI Loss from vomiting. HCl and KCl lost from GI tract with vomiting.
Low K from GI loss, ALSO intracellular shift caused by alkalosis, and increased renal excretion caused by RAAS activation
loss of H causes increased Bicarb, Alkalosis. additionally, dehydration causes contraction alkalosis - more bicarb resorp in kidney from RAAS activation.... but this is the RESULT of chloride loss, not the cause of it
treat with IV NaCl plus K
94
calcium oxalate stones are ___ shaped
Envelope shaped calcium oxalate stones
95
calcioum phosphate stones are common in....
calcium phosphate stones common in Primary Hyperparathyroidism and Renal Tubular Acidosis
96
small bowel disease
surgical bowel resection
or chronic diarrhea
can cause kidney stones how
by fat and bile acid malabsorption, which binds calcium away from oxalate and allows increased oxalate resorption
97
normal sodium
135-145
98
immigrant from Russia with probable TB has fatigue weakness hypotension and electrolyte abnormalities including low sodium high potassium low glucose and eosinophilia -- what complication does this suggest?
what acid-base disturbance?
What similar diseases can cause a similar complication?
Adrenal Insufficiency aka Addison's Disease
(extrapulmonary TB often goes to liver, spleen , kidney, bone, and adrenal gland)
Non-Gap Metabolic Acidosis aka Renal Tubular Acidosis
other granulomatous diseases e.g. Histoplasmosis Coccidiomycosis Cryptococcosis and Sarcoidosis may also cause adrenal insufficiency
99
4 causes of primary adrenal insufficiency
autoimmune
infections (TB Fungal HIV)
Hemorrhagic infarct
Metastatic cancer (e.g. Lung)
100
3 most common causes of metabolic alkalosis
vomiting
hyperaldosteronism
volume contraction
101
Elderly pt with rheumatoid arthritis, enlarged kidneys and liver, and proteinuria with peripheral edema
most likely finding on renal biopsy? cause?
Glomerular deposits after special staining (Congo Red, Apple Green Birefringence in Polarized Light)
Amyloidosis (RA predisposes, and age, large kidneys and liver tip off)
102
conditions associated with AL amyloidosis
composition of amyloid
Multiple Myeloma
Waldernstrom Macroglobulinemia
light chains usually lambda
103
conditions associated with AA amyloidosis
composition of amyloid
```
RA IBD (chronic inflammatory conditions)
Osteomyelitis TB (chronic infections)
```
abnormally folded proteins - beta2microglobulin, apoliporprotein, transthyretin
104
__ is the most common cause of AA amyloidosis in the united states
Rheumatoid Arthritis
| most common cause of AA amyloidosis in USA
105
glomerular crescent formation on light microscopy classic for
rapidly progressive glomerulonephritis...
| -crescent formation
106
hyalinosis that affects both afferent and efferent glomerular arterioles is pathagnomonic for
Diabetic Nephropathy
| -afferent and efferent hyalinosis
107
normal light microscopy findings in patient with nephrotic syndrome usually suggest...
Minimal Change Disease
| -normal light microscopy with nephrotic syndrome
108
how is a pt with severe proteinuria and low total protein and albumin at risk of developing atherosclerosis?
Hy hypercoagulable? affecting veins or arteries more? any in particular?
what treatment to start? why?
liver increases Lipid production along with protein production
loss of Anithrombin III in urine makes hypercoagulable, Veins more than arteries, Renal Veins in particular
start aggressive Statin therapy, combo hyperlipidemia and hypercoagulablity at risk for MI and Stroke!
109
how can nephrotic syndrome cause HyperParathyroidism
Vit D loss in urine, compensatory HyperParathyroidism
110
why does hypoalbuminuria cause peripheral edema but not pulmonary edema
alveolar capillaries have higher permeability to albumin at baseline (so less oncotic pressure difference) and greater lymphatic flow than skeletal muscle
111
TF
| red blood cells or casts on UA in renal hypoperfusion
F
think more primary glomerular damage
-acute nephritic syndrome -- post strep GN, IgA nephropathy, Lupus nephtiis, MPGN, RPGN...
112
nephritic glomerulonephritis usually presents with urinary sediment containing __ and __ with occasional __ or __. Edema is due primarily to ___ and ___
nephtiric gn presents with urinary RBCs and Red Blood Cell Casts with occasional WBCs or Mixed Casts.
Edema due to low GFR and Salt and Water Retention
113
major buffer in human blood and its pK
Carbon Dioxide
| pK 6.1
114
how can you calculate HCO3- if you know pH and PaCO2
henderson hasselbach
pH = 6.1 log HCO3/(.03xPaCO2)
115
best two lab values for acid-base status
pH and PaCO2
can calculate Bicarb from henderson hasselbach
pH -= 6.1 log HCO3/(.03xPaCO2)
116
recurrent kidney Stones since childhood, father too (Family History), Hexagonal crystals on UA, positive Urinary Cyanide Nitroprusside test
diagnosis
pathophys
appearance on XR
Cystiniuria
Inherited Defective Tansport of dibasic amino acids by the brush borters of renal tubular and interstitial epithelial cells -- cysteine is poorly soluble -- recurrent stones
radioOpaque
117
TF
| pt with recurrent kidney stones and positive Urinary Cyanide Nitroprusside test think uti's and struvite stones
F
| think Cystinuria and Cysteine stones
118
old guy hospitalize with hip fracture gets lethargic and asterixis with high CK from rhabdo from trauma, taking NSAIDs, diuretics, and ACI, with high BUN but normal LFTs
treat with Lactulose or Hemodialysis?
how is each factor contributing to AKI
treat Uremic Encephalopathy with DIALYSIS... this guy
treat hepatic encephalopathy in decompensated cirrhosis with Lactulose... not this guy
rhabdo CK clogs kidneys? NSAIDS ATN. diuretics prerenal aki, lisinopril loses glomerular autoregulation
119
big renal cyst with thin walls no solid components and no contrast enhancement on CT or MRI
diagnosis?
follow-up?
simple renal cyst (benign)
don't get scared by bigness
no follow-up necessary
120
big renal cyst multiloculated, irregular walls, thickened septae, contrast enhancing on CT or MRI
diagnosis?
follow-up?
malignant renal cyst
urology eval for malignancy
121
normal anion gap 6-12 accounted for by what normal serum anions
protein citrate phosphate sulfate
122
old demented guy with bph now with abdominal pain and midline abdominal fullness below umbilicus after starting amitriptyline
diagnosis?
treat
amitriptyline-induced urinary retention (anticholinergic sideffect)
foley
123
barium enemas are used for...
luminal abnromalities of the colon - Colon Cancer or Diverticulosis
124
why is prerenal AKI a misnomer
not really an injury with bland urinary sediment unless prolonged leading to ATN muddy brown casts
125
normal anion gap
10 plus minus 2 so 8-12
126
low bicarb and hyperkalemia
think
metabolic acidosis
127
non-anion gap metabolic acidosis with preserved kidney function
diagnosis
RTA renal tubular acidosis
128
loop diuretics cause hyp_kalemia and metabolic __osis
loops cause hypERkalemia and metabolic ALKALosis
129
lady with kidney stone v1cm, on top of hydration, what drug can help her pass it?
furosemide?
alpha blocker Tamsulosin
relax ureteral smooth muscle
not furosemide, causes hypercacluria and may exacerbate stone
130
name all the fucking metabolic side effects of thiazide diuretics
which thiazide is worse for these but still preferred based on cardiovascular mortility in teh ALLHAT trial
```
HYPERGLYCEMIA
HYPERLIPIDEMIA
HYPERURICEMIA
hypONatremia
hypOKalemia
hypOMagnesemia
hypERCalcemia
```
chlorthalidone worse than hydrochlorothiazide but still preferred based on allhat cardiovascular mortality DAMMIT
131
how do fucking Thiazide diuretics cause hypERGlycemia
Impair Insulin Release from pancrease and
Impair Glucose Utilization in tissues
call it Thiazide-Induced Glucose Intolerance
