Renal

Question 1

Hepatorenal syndrome mechanism and symptoms

and treatment

Answer 1

Cirrhotic liver makes NO -> systemic vasodilation -> renal hypoperfusion (BUN/Cr>20) -> RAAS, ADH activated -> ascites worse, hyponatremia

No tubular injury, no RBC/protein/granular casts in urine. No improvement in renal function with fluids

Tx:
Octreotide (venodilation)
Midodrine (increases arterial BP)

Question 2

What is FENA?

What is it in prerenal vs. intrinsic renal?

Answer 2

Fractional excretion of sodium

FeNa<1 in prerenal
FeNa>2 in intrinsic

Question 3

What is Urine sodium and urine Osm in prerenal vs intrinsic?

Answer 3

Prerenal: urine sodium <20 mEq/L, urine Osm >500 mOsm/kg
(Because if hypoperfusion, trying to retain all the sodium -> low sodium in urine, and trying to retain all the water -> high urine Osm)

Intrinsic: urine sodium >40mEq/L, urine Osm<350

Question 4

Child
Palpable purpura (symmetric), arthralgias, abd pain, renal (hematuria, non-nephrotic range proteinuria, mildly high Cr)

Platelets are NORMAL
Complement is NORMAL

Answer 4

HSP

Hematuria
Spots
Palpable purpura
A (IgA-mediated)

Question 5

WEEKS after illness

C3 deposits in GBM -> IF looks “lumpy bumpy”

Answer 5

Postinfectious glomerulonephritis (e.g., post-strep)
Increased ASO, anti-DNAse
Type III hypersensitivity = circulating immune complex

Question 6

DAYS after URI or GI infection
Hematuria
Normal C3

Answer 6

IgA nephropathy (Berger)
Immune complex-mediated

Tx glucocorticoids

Question 7

Upper: sinusitis, epistaxis, otitis, saddle-nose
Lower resp: lung nodules/cavitation -> hemoptysis
Skin: nonhealing ulcers, livedo reticularis
Segmental necrotizing glomerulonephritis
+ c-ANCA

Answer 7

Granulomatous with polyangiitis (GPA/ Wegeners)

C is for Crazy Nazi (Weceners)
Cyclophosphamide, Corticosteroids. Crescents on bx.

Question 8

Glomerulonephritis with lung involvement but NO nasopharyngeal involvement
+ p-ANCA

Answer 8

Microscopic polyangiitis

No granulomas

Question 9

Eosinophils, asthma, sinusitis (can be confused with an allergy)
Peripheral neuropathy, P-ANCA and Purpura
Granulomas

Answer 9

Churg-Strauss

Question 10

Glomerulonephritis
Hemoptysis (no upper resp involvement)
Linear anti-GBM deposits
Iron-deficiency anemia, hemosiderin-filled macrophages in sputum
Men in mid-20s

Answer 10

Goodpasture syndrome

Tx: plasma exchange
May progress to ESRD

Question 11

Boys
Genetic defect in basement membrane -> sensorineural deafness, asymptomatic hematuria
GBM splitting on EM

Answer 11

Alports

Question 12

Children
Risk: Hodgkins
Light microscopy: normal
EM: podocyte effacement (fusion)

Answer 12

Minimal change disease

Tx: steroids (prognosis good)

Question 13

IVDU, HIV, African American, HTN
Microscopic hematuria
Bx: sclerosis in capillary tufts

Answer 13

FSGS

Question 14

Immune complexes from solid tumors, infections (HBV, malaria), SLE, NSAIDs/gold damage podocytes

-> “spike and dome”, IgG and C3 deposits in basement membrane -> thickened basement membrane

Answer 14

Membranous nephropathy

Question 15

HBV, HCV, cryoglobulinemia, SLE
“Tram-track” double-layered basement membrane
Low C3

Answer 15

Membranoproliferative nephropathy

Type2 has antibodies not to anything in the nephron, but to the enzyme that degrades C3. C3 accumulates in BM

Question 16

Palpable purpura
Arthralgias 
Nephrotic/nephritic syndrome 
Low C3
Positive HCV

Answer 16

Mixed cryoglobulinemia

Note: this is like HSP in adults with HepC. But in HSP, complement is normal!

Question 17

3 kidney probs associated with low complement

Answer 17

1. Lupus
2. Strep
3. Membranoproliferative/cryoglobulinemia

Question 18

Acute abd pain, fever, hematuria in nephrotic syndrome

Answer 18

Renal vein thrombosis due to loss of antithrombin III
(can be progressive too: gradual worsening of renal function and proteinuria in an asymptomatic patient)

Most commonly seen in membranous nephropathy

Question 19

Muddy brown granular cast

Answer 19

Acute tubular necrosis (ATN)

eg from prolonged hypotension - >tubular epithelial cells just die

Question 20

RBC casts

Answer 20

glomerulonephritis

Question 21

WBC casts

Answer 21

interstitial nephritis (fever, maculopapular rash, renal failure), usually caused by antibiotics etc

or pyelonephritis

Question 22

Fatty casts

Answer 22

nephrotic syndrome

Question 23

broad and waxy casts

Answer 23

chronic renal failure

Question 24

Systolic-diastolic abdominal bruit

Answer 24

Renovascular hypertension

Question 25

Blood at urethral meats
High-riding prostate

What to do?

Answer 25

Pelvic fracture -> posterior urethral injury

Get a retrograde urethrogram (don’t get foley!)

Question 26

Effect of thiazides vs loops on calcium

Answer 26

Thiazides Take in calcium

Loops Lose calcium

Question 27

crescent formation

Answer 27

rapidly progressive glomerulonephritis

Question 28

post renal transplant
-> oliguria, hypertension, increased Cr/Bun

What to do?

Answer 28

Acute rejection (2/2 ureteral obstruction, acute rejection, cyclosporine tox, etc)

Tx with IV steroids!!!

Question 29

Tx of renal artery stenosis

Answer 29

ACEIs or Arbs as initial therapy

Renal artery stenting or surgical revascularization resreved with resistant HTN or recurrent flash pulm edema

Question 30

Arteriosclerotic lesions of renal arterioles and glomerular capillary tufts…

due to what?

Answer 30

Hypertension

Question 31

Increased ECM, thickening of basement membrane, mesangial expansion, fibrosis

due to what?

Answer 31

Diabetes

Question 32

personal and family history of recurrent kidney stones
stones are hard, opaque, hexagonal
positive urinary cyanide nitroprusside test

Answer 32

Cystinuria
(impaired transport of cystine, lysine, arginine, ornithine)

cystine is poorly soluble -> forms stones