Renal Flashcards by Mikey Montalbano

Clues for ADPKD

Hypertension
Palpable bilateral abdominal masses
Microhematuria

Common complication - Intracranial berry aneurysm (5 - 10% of cases)

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Major extra-renal complications of ADPKD

Hepatic Cysts (Most common)
Valvular Heart Disease (Most often mitral valve prolapse & aortic regurg)
Colonic Diverticula
Abdominal Wall & Inguinal Hernias

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Thickened Basement Membrane

Sub-Epithelial “Spikes”

Membranous Glomerulonephritis

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Mesangial hypercellularity

Membranoproliferative glomerulonephritis

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When do we biopsy the kidney in Minimal Change Disease?

If the patient is >10 years old

If the disease is resistant to corticosteroids

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Severe symptoms if Sodium <120mEq/L

Profound Confusion
Seizures
Coma

Increased risk of cerebral edema & brainstem herniation

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Maximum rate of safely correcting hyponatremia

<=8mEq/L increase over the first 24 hours

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Complication of correcting hyponatremia too quickly

Osmotic Demyelination Syndrome

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Complication of correcting hypernatremia too quickly

Cerebral Edema

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How do you correct electrolyte imbalances of SIADH?

Hypertonic saline

Saline must be more concentrated than urine.

NS has 300 mOsm/kg H2O
1/2NS has 150 mOsm/kg H2O

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Desmopresin

ADH Analogue

Treats Diabetes Insipidus

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Hyponatremia with Hypovolemia

Adrenal Insufficiency

Treat with IV Hydrocortisone

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Hyponatremia with Euvolemia

Think SIADH

Treat with hypertonic saline (gradually)

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Sodium Nitroprusside

Potent Vasodilator (Arterial AND Venous)
Used in hypertensive emergencies

Contains 5 cyanide groups
Undergoes rapid conversion to cyanide
Then Thiocyanate
Eliminated by kidneys

In CKD patients, can lead to cyanide toxicity

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Typical findings of cyanide toxicity

Headache
Confusion
Arrhythmias
Flushing
Respiratory Depression

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Post-Operative Urinary Retention

Precipitating Event: Bladder distension during general anesthesia or epidural anesthesia use

Inefficient detrusor activity leads to acute urinary retention

Risk increases with age
Risk increases with high fluid intake during surgery
Risk increases with concomitant use of other medications (Opiates, anticholinergics)

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Postop Oliguria Rate

<= 0.5mL/kg/hr

In a 70kg patient, that’s 35 mL/hr

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Cardiorenal Syndrome

CHF Patient

Volume overload but low CO
Poor renal perfusion

Renal perfusion can improve with loop diuretics

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Urine Sediment Analysis - Muddy Brown Casts

Acute Tubular Necrosis

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Urine Sediment Analysis - Eosinophils

Acute Interstitial Nephritis

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Signs & Symptoms of Hypernatremia

Most common:
Lethargy
AMS
Irritability
Seizures

Also:
Muscle Cramps
Muscle Weaknesses
Decreased DTRs

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Causes of Hypovolemic Hypernatremia

Renal Losses:
Diuretics
Glycosuria

Extrarenal:
GI Upset
Excessive Sweating

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Causes of Hypervolemic Hypernatremia

Exogenous Sodium Intake
Mineralocorticoid Excess (Hyperaldo)

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Why not use hypotonic fluids (like 1/2 NS or 5% Dextrose) to lower the sodium in a hyponatremic patient?

Hypotonic solutions exit the intravascular space too quickly and cause precipitous drops in sodium (Cerebral Edema)

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Hepatorenal Syndrome

Severe Cirrhosis leads to Portal HTN Leads to increased nitric oxide generation in splanchnic circulation Leads to systemic vasodilation, reducing peripheral vascular resistance & BP Leads to renal hypoperfusion & activation of RAAS Leads to increased water & sodium retention, worsening volume overload

Lab findings of Hepatorenal Syndrome

Similar to prerenal azotemia ``` Elevated Cr (>1.5mg/dL) Very low urine sodium (<10 mEq/L) ``` Unremarkable sediment Does not respond to IV fluids or cessation of diuretics. Renal function continues to decline

Membranoproliferative Glomerulonephritis

Associated with HCV

Acute Renal Vein Thrombosis - Presentation

Abdominal Pain | Hematuria

Most common drug-induced chronic renal failure

Analgesic Nephropathy Seen in women 50 - 55 yo who use combined analgesics (ASA & Naproxen) Pappilary necrosis & Chronic tubulointerstitial nephritis most common Sterile Pyuria

At what level of PaCO2 is CO2 Narcosis seen?

PaCO2 > 60 mm Hg

How do you calculate Anion Gap?

Na - (Cl + HCO3) Normal is 10 - 14

Cause of hyponatremia with Serum Osmolarity > 290 mOsm/kg

Marked Hyperglycemia OR Advanced Renal Failure

Cause of hyponatremia with: ``` Dilute serum (<290 mOsm/kg) Dilute urine (<100 mOsm/kg) ```

Primary Polydipsia OR Malnutrition (Beer Drinker's Potomania)

Cause of hyponatremia with: ``` Dilute serum (<290 mOsm/kg) Concentrated urine (>100 mOsm/kg) Low urine sodium (<25 mEq/L) ```

Volume Depletion CHF Cirrhosis

Cause of hyponatremia with: ``` Dilute serum (<290 mOsm/kg) Concentrated urine (>100 mOsm/kg) High urine sodium (>25 mEq/L) ```

SIADH Adrenal Insufficiency Hypothyroidism

Treatment for simple asymptomatic renal cyst

Reassurance

Treatment for Renal Artery Stenosis

Ace Inhibitors first Revascularize if they fail that

Lithium's effect on ADH

Impairs water resorption in collecting duct Leads to ADH Resistance Nephrogenic DI

Most common site for metastatic spread of a Wilms Tumor

Lungs (This is still rare)

Most common cancer in the first year of life

Neuroblastoma Anywhere in sympathetic nervous system Typically involves adrenal glands Abdominal mass that crosses the midline Systemic symptoms

Abdominal Pain Lower Extremity Purpura Arthritis Hematuria in a child

HSP An IgA-mediated vasculitis of small vessels Renal biopsy demonstrates deposition of IgA into mesangium

Typical presentation of FSGS

Nephrotic Range Proteinuria Azotemia Normal-Sized Kidneys

Risk factors for Rhabdomyolysis

Immobilization | Cocaine Abuse

Signs of Lupus

Photosensitive skin Thrombocytopenia Glomerulonephritis with significantly low C3

Immune complexes in mesangium or subendothelial space

If Low C3 & C4, it is Lupus, involving an inflammatory reaction. If normal C3 & C4, it is membranous glomerulonephritis

Cause of metabolic alkalosis with low (<20mEq/L) urine chloride

Vomiting/Nasogastric Aspiration OR Prior diuretic use SALINE RESPONSIVE

Cause of metabolic alkalosis with high (>20mEq/L) urine chloride in a hypervolemic patient

Excess mineralocorticoid activity: Primary hyperaldo Cushing's Ectopic ACTH production SALINE UNRESPONSIVE

Cause of metabolic alkalosis with high (>20mEq/L) urine chloride in a hypovolemic or euvolemic patient

Current Diuretic Use (SALINE RESPONSIVE) OR Bartter / Gitelman Syndromes (SALINE UNRESPONSIVE)

Treatment for pyelonephritis with an MDR organism

Aminoglycosides (like Amikacin) This can cause ARF

Muddy Brown Casts on UA

Hallmark of ATN (Nonspecific, but very sensitive)

Casts seen in Chronic Renal Failure

Broad Casts | Waxy Casts

RBC Casts

Glomerular Disease | Vasculitis

WBC Casts

Interstitial Nephritis | Pyelonephritis

Fatty Casts

Nephrotic Syndrome

Hyaline Casts

Asymptomatic patients Pre-renal azotemia

TB's effect on the adrenals

Chronic primary adrenal insuficiency Fatigue Weakness Borderline hypotension Electrolyte abnormalities

Granulomatous causes of adrenal insufficiency

``` TB Histoplasmosis Coccidioidomycosis Cryptococcosis Sarcoidosis ```

Hypoglycermia Hyperkalemia Eosinophilia

Adrenal Insufficiency

Decreased cortisol Decreased adrenal sex hormone Decreased aldosterone

Addison's Disease Without aldosterone: Sodium is excreted, potassium & H+ are retained Normal anion gap hyperkalemic hyponatremic metabolic acidosis

Normal anion gap Hyperkalemic Hyponatremic Metabolic Acidosis

Lack of aldosterone (likely Addison's) Maybe RTA? Not hyponatremic, though

Anticholinergic effect on bladder

Urinary retention

Most common inciting factors of Hepatorenal syndrome

Spontaneous bacterial peritonitis | GI Bleed

Temporizing options for hepatorenal syndrome while awaiting transplant

Midrodrine Octreotide Norepinephrine (Splanchnic vasoconstrictors)

Seizure patient with metabolic acidosis

Postictal lactic acidosis Transient Resolves within 90 min Repeat chemistry in 2 hours

Renal Tubular Acidosis

Group of disorders: Non-Anion Gap Metabolic Acidosis Preserved kidney function Hyperkalemic RTA (Type 4 RTA) - seen in elderly diabetics

Renal Vein Thrombosis from Nephrotic Syndrome

Loss of Antithrombin III in urine Increases risk of Renal Vein Thrombosis Most commonly seen with Membranous Glomerulopathy