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Renal Flashcards

1
Q

Nephrotic syndrome key features

A
  1. Massive proteinuria (>3.5g/24h or 40mg/hr/m2 for children)
  2. Hypoalbuminemia (<30g/L)
  3. Generalized edema
  4. HL
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2
Q

Nephrotic syndrome PE findings

A
  1. Periorbital edmea
  2. Ankle edema
  3. Muehrcke’s nails
  4. Xanthelasma
  5. Frothy urine
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3
Q

S/S of CKD

A
  1. Fatigue
  2. Nocturia
  3. Thirst
  4. Fluid retention
  5. Itch
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4
Q

Tx target of DM nephropathy

A
  1. Control HT, DM, HL
  2. ACEI for reducing proteinuria
  3. Anti-inflammatory/fibrosis
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5
Q

Acidosis/Alkalosis on K

A

Acidosis –> HyperK

Alkalosis –> HypoK

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6
Q

Normal pH / QM ref range

A

Normal pH: 7.35-7.45

[H] = 40nmol/L @ 7.4pH

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7
Q

Acid/Alkalosis vs Acid/Alkalemia

A
  • osis = a process

- emia = too much/too little H in blood

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8
Q

Metabolic acidosis features

A 
Decreased HCO3 (Normal: 22-28mmol/L)
Hyperventilation to compensate
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9
Q

Dx of Metabolic acidosis

A

Determine Anion gap
If high –> Done
If normal –> determine Urine anion gap
Look for any osmolar gap

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10
Q

Normal value Anion gap

A

8-14
[Na - Cl - HCO3]

If normal AG –> Cl is increased

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11
Q

Metabolic acidosis with increased AG

Causes

A
  1. DKA
  2. Alcoholic KA
  3. Lactic acidosis
  4. Renal failure
  5. Rhabdomyolysis
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12
Q

Metabolic acidosis with normal AG

Causes

A
  1. HCO3 loss with compensatory Cl increase
    • Diarrhea (GI loss), Proximal renal tubular acidosis (RTA; Renal loss)
  2. Failure to excrete H (Distal RTA / Type 4 RTA)
  3. Ingestion of NH4Cl
  4. Increased reabsorption of Cl (Ureterosignmoidostomy)
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13
Q 
Osmolar gap (OG)
How to calculate
A

Actual - Calculated plasma osmolarity

Calculated = 2xNa + Urea + Glucose

Increased = Something osmolar inside, e.g. alcohol related compounds)

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14
Q

Lactic acidosis type A and B

A 
Type A
- Over-production --> O2 deficiency
- Causes: 
       Hypotension
       Hypoxia
       CO poisoning
       Grand mal seizure
- Tx = Improve O2 delivery; NaHCO3 won't help unless controlled production; HD with HCO3 dialysis

Type B

  • Reduced metabolism, w/o hypoxemia
  • Liver problem, alcoholism, thiamine deficiency, Metformin
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15
Q

Risk of NaHCO3 therapy

A
  1. HypoK (shifts K into cells)
  2. HypoCa
  3. Paradoxical cerebral acidosis if too rapid correction (CO2 can diffuse to brain but not HCO3)
  4. Volume expansion (from Na load)
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16
Q

RTA (Renal tubular acidosis) types and features

A

Type 1

  • Distal RTA (due to failure of H excretion)
  • HypoK
  • Acid loading test (NH4Cl): Urine cannot be acidified, pH remains >6.0 (N <5.5)

Type 2

  • Proximal RTA (due to loss of HCO3)
  • HypoK
  • Fractional excretion of HCO3: Test for excessive loss of HCO3 in urine (>15%; cf <5% in Type 1)

Type 3

  • Mixed
  • HypoK

Type 4

  • HyperK
  • Aldo deficiency or resistance
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17
Q

Mx of RTA

A

Type 1,2

  • Oral NaHCO3 to correct acidosis (v high dose needed for Type 2; K citrate better for Type 1)
  • K supplement for HypoK
  • Distal RTA due to Sjogren’s –> Steroids

Type 4

  • Stop / decrease inciting drugs
  • Loop diuretics + low K diet for HyperK
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18
Q

Causes of Metabolic alkalosis

A

H loss

  1. GI loss (Vomiting, Nasogastric drainage)
  2. Renal loss
    • Diuretics, HypoK
    • MC excess (Primary/Secondary)
    • Bartter’s (looks like Loop diuretics) / Gitelman’s (looks like Thiazides)

HCO3 retention

  1. Intake of NaHCO3
  2. Milk-Alkali syndrome (taken too much Ca supplements / alkali for PU)
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19
Q

Tx of Metabolic alkalosis

A

If ECF contracted –> Give Saline (HCO3 will fall with expansion)
IF ECF expanded –> IV HCl or Oral NH4Cl to correct alkalosis
Correct HypoK

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20
Q

SIADH

A

Euvolemic hypoNa
Urine [Na] >20 mmol/L
Urine osmolarity >2x serum osmolarity

Tx
- Treat underlying cause (CNS/RS/Drugs)
If asymptomatic + Na>110
- Fluid restriction (<800/day), oral NaCl
If symptomatic + Na <110
- IV 500ml NS + 25ml 5.85% NaCl (=100mol NaCl) over 4-6h + IV Lasix 40mg until Serum Na >120
- Then fluid restriction
- Too rapid correction –> Central pontine myelinolysis

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21
Q

Causes of SIADH

A

CNS
1. Meningitis, Encephalitis, Brain abscess
2. Head trauma, SAH, CVA, Increase ICP
RS
3. CA Lung
4. Chest infection, positive pressure breathing
Drugs
5. SSRI, Ecstasy
Hypothyroidism

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22
Q

S/S of HypoNa

A

Non-specific: Malaise, lethargy, headache

Confusion, convulsion, coma

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23
Q

S/S of HyperNa

A

Thirst
Muscle spasm, twitching
Seizure, coma

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24
Q

Mx of HyperNa

A 
Pure water loss
   Water deficit = BW x (Na/140 - 1)
1/3 rule in rate of replacement
   1/3 in first 8h
   1/3 in second 16h
   1/3 in third 24h
   Replace ongoing loss

Too rapid –> Cerebral edema (influx of water into cells due to decreased serum osmolarity)
Max correction rate <12mmol/L/day

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25
Q

TTKG

A

Transtubular K gradient
Tubular [K] / Serum [K]
= (Urine [K] x Serum osmolarity / Urine osmolarity) / Serum [K]

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26
Q

HypoK + TTKG >4

A

Renal loss

- High [K] in terminal cortical collecting duct

27
Q

S/S of HypoK

A

Muscle weakness, proximal muscle myopathy
Cardiac arrhythmia (esp <2.0)
ECG: Large U wave, Loss of T wave, Prolong QT interval
Ileus, constipation
Rhabdomyolysis
Polyuria

28
Q

Mx of HypoK

A

Oral if mild
IV KCl if mod to severe; oral not possible, e.g. Vomiting
Dilute KCl in NS before giving

29
Q

S/S of HyperK

A 
Muscle weakness (when >8)
Cardiac arrhythmia (when >6; rate is more important)
ECG
 - Peak T
 - Widen QRS complex
 - Loss of P wave
30
Q

Cockcroft-Gault formula
Modified of Diet in Renal Disease (MDRD) equation
RB

A

Cockcroft-Gault formula
- Plasma creatinine, BW, age, gender

Modification of Diet in Renal Disease (MDRD) equation

  • More complex
  • Plasma creatinine, serum albumin, BUN, age, gender, race
31
Q

GFR from 24h urine

RB

A

UV / P

Urine Cr x 24h urine volume / Plasma Cr
x1000)/(24*60

32
Q

Long term Cx of CRF

RB

A 
Anemia
Renal bone disease
Bleeding diathesis
Metabolic disturbances
   - HyperK
   - HypoCa
   - Hyperphosphatemia
   - Hyperuricemia
   - Metabolic acidosis
Malnutrition
CVS morbidities (HT, HL, fluid retention, HF, vascular and valvular calcifications)
Dermatological abnormalities
   - Pruritus, skin pigmentation, nail changes
Defective immune responses, susceptible to infection
Menstrual disturbance
Sexual dysfunction
33
Q

Reason for Abnormal skin complexion for CRF

RB

A

Co-existence of anemia + retention of beta-melanocyte-stimulating hormone, as well as pigment deposition (urochromogens)

34
Q

Indications of Emergency dialysis

RB

A
  1. HyperK
  2. APO
  3. Severe metabolic acidosis
  4. Uremic pericarditis or Cardiac tamponade
  5. Uremic encephalopathy
35
Q

DM nephropathy clinical definition

RB

A

?Persistent proteinuria >500mg/24h in a patient with DM with no other renal diseases

36
Q

ANCA

A

Anti-neutrophil cytoplasmic Ab

Mainly IgG

37
Q

Tx of IgAN

RB

A

Low salt and low protein diet

ACEI or ARB to block RAAS and reduce BP, reduce proteinuria, provides renal protection

38
Q

Tx for Lupus nephritis

RB

A

Corticosteroid (mod to high dose) with gradual tapering
Combined with Cyclophosphamide (IV/PO) for 2-6m
Followed by maintenance with Azathioprine (or MMF)

39
Q

Diagnostic features of peritonitis complicating PD

RB

A
  • Fever
  • Abd pain
  • Turbid peritoneal dialysis effluent with WBC >100/mm3
40
Q

Common organisms for peritonitis complicating PD

RB

A 
Gram pos
   - Coagulase neg Staphylococcus
   - S. aureus
Gram neg
   - E coli
M tb
Fungal
41
Q

Continue PD while having peritonitis?

RB

A

Yes, unless peritonitis refractory to ABX

42
Q

When to initiate RRT

A

GFR <10 ml/min/1.73m2
or
Symptomatic of uremia

43
Q

Tx for Peritonitis complicating PD

A

Intraperitoneal
1st gen cephalosporin + Aminoglycoside
(e.g. Cefazolin + Amikacin)

44
Q

Cx of PD

A
  1. Exit site infection
  2. PD related peritonitis
  3. PD failure
  4. PD catheter malposition
  5. Peritoneal leakage
45
Q

Cx of HD

A

Related to vascular access

  • Vascular access stenosis / thrombosis
  • UL ischemia

Related to catheter access

  • Catheter exit site infection
  • Catheter associated bacteremia
  • Catheter malfunction

During HD

  • Hypotension, cardiac arrhythmia
  • Muscle cramps
  • Technical (should not happen): Air embolism, blood loss
46
Q

Classification of GNs

A

Primary/Secondary

Proliferative/Non-proliferative

47
Q

Primary proliferative and non-proliferative GNs

A

Prim pro

  1. IgAN
  2. IgMN
  3. Membranoproliferative GN
  4. Crescenteric GN

Prim non-pro

  1. Minimal change disease
  2. Membranous nephropathy
  3. FSGS
  4. Thin basement membrane disease
48
Q

Secondary proliferative and non-proliferative GNs

A

Secondary pro

  1. Lupus nephritis
  2. Post-strep GN
  3. Hep B/C related membranoproliferative GN
  4. Systemic vasculitis
  5. Goodpasture syndrome

Secondary non-pro

  1. DM nephropathy
  2. HT nephrosclerosis
  3. Amyloidosis
  4. Light/heavy chain deposition disease
  5. Alport’s syndrome
  6. Infection-related membranous glomerulopathy
  7. HIV nephropathy (FSGS or collapsing glomerulopathy)
  8. Drug-induced glomerulopathy
  9. Malignancy-associated nephropathy
  10. Reflux nephropathy
49
Q

GN present as 1 of 6 of these clinical syndromes

A
  1. Asymptomatic microscopic hematuria/proteinuria
  2. Macroscopic hematuria
  3. Acute nephritic syndrome
  4. Nephrotic syndrome
  5. Rapidly progressive GN
  6. Chronic GN / CKD
50
Q

HypoNa pathway

A

Normal serum osmolarity –> PseudohypoNa due to HL or hyperproteinemia
High serum osmolarity –> Hypergly
Low –> Check urine osmolarity

If Urine Na >20mmol/L
If –> Euvolemia –> (Chronic water overload) –> SIADH, Drugs, CRF, Hypothyroid, Cortisol deficiency

If –> Hypovolemia –> (Renal Na loss) –> Diuretics, Addison’s disease, Salt losing nephritis

If Urine Na <20mmol/L
If Hypervolemia –> (Renal Na retention) –> Cirrhosis, HF, Nephrotic syndrome

If Hypovolemia –> (Extra-renal Na loss) –> Vomiting, diarrhea, skin loss

If Euvolemia –> (Acute water overload) –> Increased water intake + Hypovolemia / Drugs / Hypothyroidism / Cortisol deficiency / Renal failure

51
Q

Causes of CKD

A
  1. DM (~45%)
  2. HT/Vascular (~10%)
  3. Chronic GN (~20%). *common in China, a lot of IgA disease – more aggressive than in the West
  4. Chronic pyelonephritis
  5. Polycystic kidney disease
  6. Drug induced
  7. Myeloma, vasculitis, SLE, Alport’s
  8. Obstruction
  9. Old age
  10. Unknown (~15%)
52
Q

NcNc anemia in CKD why?

A

Lack of EPO

53
Q

S/S of Uremia

wiki

A 
Progressive weakness
Easy fatigue
LOA due to N/V
Muscle atrophy
Tremors
Abnormal mental function
Frequent shallow respiration
Metabolic acidosis
54
Q

NSAID AKI mechanism, associations

A
  • Na, fluid retention
  • Decrease renal blood flow and GFR
  • Leads to HyperK, Tubulointerstitial nephritis, Minimal change disease
  • Papillary necrosis in DM
  • If Nephrotic syndrome,
    • Asso w/ T cell, Eosinophils
    • Minimal change disease, Tubulointerstital nephritis
55
Q

CI for Percutaneous renal biopsy

TC

A
  1. Uncorrectable bleeding diathesis
  2. Small kidneys which are generally indicative of chronic irreversible disease
  3. Severe HT, which cannot be controlled with antihypertensive
  4. Multiple, bilateral cysts or a renal tumor
  5. Hydronephrosis
  6. Active renal or perirenal infection
  7. An uncooperative patient
  8. Solitary kidney
56
Q

SE of Cyclosporin A
RB
(Calcineurin inhibitor, decrease IL-2)

A
  1. Immunosuppression
  2. Nephrotoxicity (both acute + chronic)
  3. HT
  4. HL
  5. Hypertrichosis
  6. Gingival hypertrophy
  7. Lymphoma
57
Q

SE of Azathioprine
RB
(Purine analog, Antimetabolite)
(Block de novo purine synthesis)

A
  1. Immunosuppression
  2. Myelosuppression (dose-related; caution with Allopurinol)
  3. Alopecia
  4. Hepatitis
    ?Lymphoma
58
Q

Sirolimus (aka Rapamycin; mTOR inhibitor)

A
  • A macrolide
  • SE
    1. HL
    2. HT
    3. Thrombocytopenia
    4. Leukopenia, infection

Interact with Cy A for renal toxicity (and Cy A increases its HL)

59
Q 
Mycophenolate mofetil (MMF; Antimetabolite)
(inhibits inosine monophosphate dehydrogenase (IMPDH) and suppresses de novo purine synthesis)
A

SE

  1. Diarrhea
  2. N/V
  3. Abd pain
  4. Anemia, Leukopenia
60
Q

Tacrolimus (FK 506)

A
  1. Nephrotoxicity
  2. Neurotoxicity (tremor, insomnia, and paresthesias of the extremities)
  3. New-onset DM
61
Q

Phosphate binders

A

CaCO3

Taken with meal to reduce phosphate absorption

62
Q

Amyloidosis Dx

A

Biopsy (can do fat pad biopsy - biopsy of the SC fat)

Stain with Congo red, combine with Polarized light –> apple green on microscopy

63
Q

Nephritic syndrome

A

Gross hematuria
Oliguria
HT
Edema

Medicine (9 decks)

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