Renal Flashcards
1
Q
Define serum anion gap
A
Accounts for unmeasured anions in metabolic acidosis
Na - (Cl + HCO3)
*normal 10-12
*over 12 means high gap
2
Q
CUTE DIMPLES (AG metabolic acidosis)
A
cyanide uremia toluene ethanol DKA isoniazid methanol propylene glycol lactic acidosis ethylene glycol salicylates
3
Q
Clinical features metabolic alkalosis
A
High pH + CO2
- muscle cramping, tetany, parathesia
- confusion, obtundation, seizures
4
Q
Metabolic alkalosis ddx
A
caused by:
- lose acid from vomiting, NG suction, diarrhea, diuretic
- post-hypercapnia (lag for excretion)
- pee out low bicarb fluid, bicarb concentrated
- mineralcorticoid excess
- hypercalcemia
- citrate 2nd to blood transfusion
- refeed (insulin ^ makes H+ go intracellular)
- hypokalemia (K goes out of cells; H+ goes in)
- hypovolemia causes prolonged met alk
5
Q
Metabolic alkalosis tx
A
Cl responsive (urine Cl <25): give NaCl, K Cl resistant (urine Cl >40): tx disease
Cl resistant
- low urine K: laxative abuse/sev. K depletion
- HTN: check renin/cortisol
- high cortisol = Cushing
- high renin, NL cortisol = RAS, malg HTN, renin tumor
- NL renin+cortisol = licorice, aldosteronism
6
Q
HARDUPS (non-AG metabolic acidosis)
A
hyperalimentation (tube feed) acetozolamide rental tubular acidosis diarrhea uretero-pelvic shunt post-hypocapnia spironolactone
7
Q
Causes of metabolic alkalosis
A
- lose acid from vomiting, NG suction, diarrhea, diuretic
- post-hypercapnia (lag for excretion)
- pee out low bicarb fluid, bicarb concentrated
- mineralcorticoid excess
- hypercalcemia
- hypochloremia
- citrate 2nd to blood transfusion
- refeed (insulin ^ makes H+ go intracellular)
- hypokalemia (K goes out of cells; H+ goes in)
- volume depletion causes prolonged met alk
8
Q
Kidney normal response to acid load
A
Excrete as NH4
9
Q
Clinical features metabolic acidosis
A
hyperventilation
decreased myocardial contractility, arrthymia
decreased vasc R (dec response to catecholamine)
N/V/D/abdominal pain
muscle weakness
osteomalacia/osteopenia…hypercalcemia
ostetitis fibrosa
lethargy, coma
kids: imp bone growth, listless, anorexia
10
Q
Winters formula (metabolic acidosis)
A
expected pCO2 = (1.5 x HCO3) + 8 +/- 2
lower: + resp alk
wnl: hyperventilating approps
high: +resp acid
11
Q
Delta gap
when the anion gap >12
A
(AG-12) / (24-HCO3)
between 1-2 means AG metab acid alone
less than 1 means + non AG metab acid
over 2 means + metabolic alkalosis
12
Q
“Winters” but for
metabolic alkalosis
A
pCO2 = 0.7(24-HCO3) + 40 +/-2
low: uncomp
WNL: comp
high: + resp acidosis
13
Q
Glomerular hematuria - what does the urine look like?
A
Dysmorphic RBC
RBC cast
Red-brown urine
No clots
14
Q
Nonglomerular hematuria - what does the urine look like?
A
Scant normally shaped RBC
WBC cast, muddy brown casts
Pink-red
Clots
15
Q
Asymptomatic hematuria
A
think of Ca risk
low = CT urography + urine cytology
high = CT urography + cystoscopy + cytology
16
Q
Bladder Ca risk
A
smoking occupational gross hematuria >40 yo voiding sx cyclophosphomide
17
Q
MCC hematuria F>60
A
UTI, then bladder Ca
18
Q
MCC hematuria M>60
A
BPH, then bladder Ca
19
Q
MCC hematuria 40-60
A
UTI, bladder Ca, calculi
20
Q
MCC hematuria 20-40
A
UTI, calculi, bladder Ca
21
Q
MCC hematuria <20
A
glomerulonephritis, UTI, congenital
22
Q
Way to tell if pre-renal, intra-renal, post-renal
A
Labs
BUN/Creat > 20 pre-renal
BUN/Creat <10 post-renal
BUN/Creat 10-20 intra-renal
23
Q
Urethritis, orchititis, prostatitis MCC
A
STI
24
Q
Why nosociomal UTI more deadly?
A
Bugs themselves
Immunocompromised hosts
25
Most common type of nosocomial infection
UTI
26
Why do elderly people get more UTIs
Decreased elasticity of bladder
27
Structural UTI cause
Female (short urethra), BPH, stones, tumors
28
Functional UTI cause
```
Neurogenic bladder (nerve damage from DM, Parkinson, MS)
Sex/honeymood cystitis
Pregnancy (hormone changes)
Foley catheters
Tampons
Diaphragms
```
29
Tam-Horsfall protein
Immunodefensive protein that bind to protein and prevents epithelial attachment
30
Common UTI pathogen
E. coli, Staph, Proteus, Klebsiella, Psuedomonas, Enterobacter
31
S. epidermidis UTI pt
| coagulase negative
No sex preference, >50
90% asymptomatic!
hospitalized
MDR
32
S. saphrophyticus UTI pt
95% female, 16-35
90% sypmtomatic
sensitive to abx
33
Elderly pt presentation of UTI
Mental status change, fever
34
<2 UTI presentation
fever, vomiting, FTT
35
Cystitis presentation
dysuria, suprapubic pain
36
Pyelonephritis sx?
| How do you treat it?
fever, dysuria, flank pain
culture (try cipro while results pending)
7-14d abx (cipro)
hospitalize: fever, tachypnea, tachycardia, hypotension, debilitated (sepsis!)
37
UTI UA findings
WBC casts - upper tract infection
| > 10 WBC/hpf
38
Women w/ UTI and no vaginal discharge have >90% chance of?
| How do you treat it?
Acute cystitis
| 3d of abx
39
Complicated UTI means what?
| How do you treat it?
Function, anatomic, or metabolic abnormality
Hx MDR
Hx pyelonephritis
Culture and start empiric abx
40
Uncomplicated UTI tx
1) nitrofurantoin (100mg x 5d)
2) TMP/SMX (160/800mg bid x 3d)
If MDR...
fluroquinolones
41
Uncomplicated UTI tx
1) nitrofurantoin (100mg x 5d)
2) TMP/SMX (160/800mg bid x 3d)
If MDR...
fluroquinolones
42
Pregnant UTI
1) nitro (same as uncomplicated)
| 2) amoxicillin or amox-clauv
43
Treat asymptomatic bacturia in these people
Pregnant, before urologic procedure, young kids
44
Prostatitis sx and tx
Sx: back pain, pooping pain, high fever, UTI-like sx; VERY tender on PE
Tx: SMX/TMP x 6 weeks or...
if STI ceftraxone + azithromycin
45
Nephrotic distinguishing features
Lipiduria and lipidemia
Proteinuria >3.5 f/d
Hypoalbumenimia
Lotsa edema
46
Nephritic distinguishing features
```
Hematuria w/ dysmorphic RBC
RBC casts, granular casts
Oliguria
Pyruia
HTN, renal insufficiency
```
47
Minimal change glomerularpathy
Nephrotic kids, 2-3week onset, corticosteriods
onset may have to do w/ allergens, Hodgkins
48
Membranous glomerulonephropathy
Nephrotic adults, corticosteriods/immune suppressor depending on cause
"rule of 1/3" prognosis
49
Focal segmental glomerulosclerosis
Nephrotic adults
HIV/hep, obesity, sickle cell, pamidronate are risk factors
50
Membranous proliferative glomerulonephritis
Nephrotic, immune-mediated, thick BM but no inflammation
No tx
51
Diabetic nephropathy
Nephrotic
ACEI, glycemic control BP control
52
Post-streptococcal glomerulonephritis
Brown urine + casts; infiltrative lymphocytes in glomerular tuft
- Na HTN d/t ^ENaC
- Low C3
Tx: supportive/antimicrob
53
Lupus nephritis
Rash, joint pains
Class 1-2: no tx
Class 3-4: steroid+immunosup
54
IGA nephropathy
Hematuria
| Chronic, no tx, no inflammation
55
Rapidly progress glomerulonephritis
```
Macrophages go from glomerular capillaries to Bowmans space, compress capillaries, GFR ceases
"crescenteric"
==anuria==
==hemoptysis==
Tx: transplant, dialysis
```
56
Defense against hypernatremia
Thirst (osmoreceptors)
Baroreceptor > RAAS > ENaC
ADH release (aquaporins reabsorb water)
57
Hypernatremia ddx
- gfr diminished (age, renal dz)
- NaCl reabsorption in TALH diminished (loops, osmotic, interstitial dz)
- dec ADH (diabetes insipidus)
- urea (diuresis, low pro diet)
58
Hypernatremia tx
Hypovolemic
- isotonic saline
- tx cause of loss (obstruction, insulin, remove osmotic diuretic)
- fix water deficit (0.45% saline, D5, or oral water)
Euvolemic
- fix water deficit as above
- monitor serum Na to avoid water intox
- may need SC ADH
Hypervolemic
- remove sodium
- furosemide
- HD
59
Clinical approach to hyponatremia
Symptomatic
- chronic >48h v acute
Asymptomatic
- no immediate tx needed
60
Diabetes insipidus
hypernatremia d/t ADH not being released and not concentrating urine
central: damage to pituatary prevents ADH release
- sarcoid, aneurysm, GBS, meningitis, idiopathic
nephrogenic: kidney tubules can't respond to ADH
- PCKD, amyloid, multiple myeloma, hypercalcemia, hypokalemia, lithium)
61
SIADH causes
```
Inc. hypothalamic production:
CNS infection, neoplasms
Drugs
- cyclophosphamide
- haloperidol
- amytriptline, MAOI
Pulmonary dz (TB, pneumo)
Postop
```
Inc. ectopic production
- oat cell carcinoma
Potentiated affect of ADH
- carbamazine
- cyclophosphamide
62
CKD definition
GFR <60ml/min for 3+ mo
63
GFR level when sx begin
<30 ml/min
64
CKD UA
- elevated Cr
- hematuria
- proteinuria
- imaging abnormality
65
CKD nephrotoxic
Metformin
NSAID
aminoglycoside
IV contrast
66
Indications for dialysis (AEIOU)
```
Acid/base (metabolic acidosis)
Electrolyte abn (hyperK)
Intoxication (remove poison)
Overload volume (CHF)
Uremia (Cr clearance <15, pericarditis, neuropathy, encephalopathy)
```
67
Recurrent calcium stones tx
- 24h urine collection
- thiazide (dec urine Ca)
- citrate supps
- allopurinol if uric acid
68
Urinary incontinence types
urge: MCC elderly, women w/ atrophic vaginitis and irritation of urethra; also diuretics
stress: 2nd MCC women, intra-abdominal pressure
dribbling: 2nd MCC men, overly full bladder
functional: cognitive/physical impairments
Mixed: typically stress+urge, stress+functional
69
Urinary incontinence types (urge, stress, dribbling, functional, mixed) - who gets them most frequently?
urge: MCC elderly, women w/ atrophic vaginitis and irritation of urethra; also diuretics
stress: 2nd MCC women, intra-abdominal pressure
dribbling: 2nd MCC men, overly full bladder
functional: cognitive/physical impairments
Mixed: typically stress+urge, stress+functional
70
Interstitial cystitis sx and dx
Pain w/ full bladder, women
Foods w/ K, tobacco, EtOH, spicy make it worse
Cystoscopy to dx
71
How to dx urinary obstruction
Sx: pain, hydronephrosis causing palpable mass, voiding issues, urine volume decreased if b/l
- urethral: voiding cystourethrography (VCUG)
- proximal: abd US (1st choice, detects hydronephrosis); CT 2nd choice
72
Wilms
- who gets it
- what is it
- treatment?
Kidney tumor in kids <10
- palpable mass+/- hematuria
- well circumscribed
- 90% cure rate
- anaplastic unfavorable
Tx: nephrectomy +/- chemo (depends on stage)
73
PKD
- who gets it
- what is it
- treatment?
dominant: MCC, b/l (40s)
recessive: early death
acquired: blacks
cysts in epithealial cells of CD and tubules; back/flank pain, huge kidneys, nocturia
- anemia
- HA (anuerysm risk)
- recurrent UTI
dx: US
tx: supportive (ACE/ARB, tx infections
74
Wilms
- who gets it
- what is it
- treatment?
Kidney tumor in kids <10
- palpable mass+/- hematuria
- well circumscribed
- 90% cure rate
- anaplastic unfavorable
Tx: nephrectomy +/- chemo (depends on stage)
75
Bladder ca
- who gets it
- MC cell type involved?
- sx
- tx
M:F is 3:1, 60s-80s
- smoking, aryl amines, long term analgesic, schisto, prev. radiation,
- urothelial transitional cells MC
- painless hematuria+irritative sx, hydronephrosis (if obstructive)
- tx: resect via urethra, BCG; radical cystectomy/chemo (only if muscle involvement/mets)
76
Renal cell carcinoma
- who gets it
- risk factors
- sx including "classic triad"
- tx
M:F is 2:1; 60s-70s
MCC renal Ca adult
Not usually inherited
Risk: tobacco, obesity (W), HTN, HRT (W), absestos, petroleum, ESRD, cystic kidney dzs
Classic triad: flank pain, palpable flank mass, hematuria (but mostly asymptomatic)
Common mets upon dx (lung/bone MC)
Tx: partial/full nephrectomy
77
AKI - prerenal
```
hypovolemia
setpic shock
CHF
renal artery occlusion
small vasculitis
anesthesia (low BV+low BP)
```
78
AKI - intrinsic
- sm. vessel (atheroembolism, vasculuitis)
- glomerular diseases
- acute tubular necrosis (toxins, rhabdo)
- acute interstitial nephritis (drugs, infection, systemic dz)
- tubular obstruction (casts, crystals)
79
AKI - post-renal
- tumor
- papillary necrosis
- calculi
- bladder outlet obs
- BPH
80
AKI - most common intrinsic
acute tubular necrosis (ischemia, toxins)
| drugs are MCC
81
AKI - tx
Optimize hemodynamic
Fix volume if needed
Remove toxin/stone
RRT if needed
82
AKI - staging (urine output)
1. <0.5ml/kg/hr >6h
2. same for >12h
3. anuria for 12h OR
<0.3 ml/kg/h for 24h
83
4 factors modulating K excretion
- GFR (minor unless <20)
- Mcorticoid (ENaC resorb sodium, push K to lumen)
- Dietary intake; eat more, pee more
- TALH (Na/K/Cl) - can be inhibited by loops, losing K
84
Role of diet in potassium d/o.. what happens when
- starved + refeed
- eat too much K when you have kidney disease
anorexic then refeed = hypokalemic leading to arrthymia, death
lots of potassium + CKD = hyperkalemia
85
Hyperkalemia complications
Bradycardia
Weakness
Conspitation
86
Hypokalemia complications
```
SVT + vtach
Weakness, flaccidity
Poor GI motility
Low RBF, GFR
Rhabdomyolysis
Nephrogenic DI
^ ammonia
```
87
Tx severe hypokalemia
KCl po or IV + magnesium
88
Potassium d/o first step
```
Transcellular shift
vs
Renal ability to excrete K
vs
Spurious
```
89
CKD epi/risk factors
Older age, M=F
minorities, low income, unedu
DM, HTN, autoimmune dz
hx UTI, stones
90
CKD staging
```
Dependent on GFR + level of albuminuria
GFR > 90 normal
GFR 30-89 moderate
GFR 15-29 severe
GFR <15 dialysis
```
Asymptomatic til <30 ml/min
91
CKD - how to slow progression to ESRD
```
treat BP
reduce hyperfiltration via RAAS inhibition
low protein diet
statin, ACEI to reduce proteinuria
avoid NSAID
```
92
CKD - how does it progress
```
hyperfiltration
proteinuria
hypotension/HTN
nephrotoxins
- NSAIDS
- herbal supplements
- aminoglycosides
- IV contrast
```
93
Cardiovascular dz + CKD connection
anemia: low oxygen to heart
high renin: high BP
high HCy (can't excrete): CAD
high phosphate: CAD
94
CKD complications
```
high or low volume
"" Na
"" Ka
hypocalcemia
hyperphosphatemia
hypermagnesemia
metabolic acidosis>alkalosis
```
95
How does CKD cause anemia?
- Decreased EPO production
- Shortened RBC 1/2 life
- gastrin/mucosa disturbances
- platelet dysfunction
96
CKD - mineral disturbances?
- what are they?
- prevention?
Serum
- low bicarb (dec. acid excretion)
- low K
- low Ca
- high phosphate (dec GFR)
- high Mg (dec GFR)
