Renal, GU, Electrolytes Flashcards
Hyperactive DTRs - result of what electrolyte abnormality?
HypOCa
- during or immediately after surgery in those undergoing major surgery and needing transfusions (ionized Ca decreases due to citrate binding)
- also causes prolonged QT, spasm/tetany
- hypOmag can mimic this - causes dec. PTH and responsiveness to PTH
Note:
HyperMag - causes decreased DTR, muscle paralysis, apnea, cardiac arrest
Loop Diuretics - electrolyte abnormalities?
Blocks NaK2Cl channel
- HYPONA
- HYPOK
Increased distal solute delivery -> more aldo -> more H secretion
- MET ALKALOSIS
reduction in circulating blood volume
- prerenal failure
Laxative Abuse/Diarrhea
VS.
Vomiting - electrolyte abnormalities?
Diarrhea:
HYPOK - lose in stool; bc dec. volume more aldo
Non-anion gap Metabolic ACIDOSIS
Vomiting - lose HCl
HYPOK, HYPOCl
Metabolic ALKALOSIS
1. Loss of H+ -> unbalanced retention of HCO3
2. Loss of Vol -> Aldo -> lose K and contraction alkalosis
Tx: Normal Saline + K
Renal Tubular Acidosis
Non-anion gap met acidosis.
Proximal (type II) - can’t reabsorb bicarb
- urine pH varies
- hypoK
- Dx: administer bicarb - urine pH rises
- Tx: thiazide (vol depletion increases bicarb reabsorption)
Distal (type I) - can’t secrete H
- urine pH high
- hypoK
- assoc. with Ca oxalate crystals (alkalotic urine)
- Dx: administer acid - urine pH remains high
- Tx: Bicarb - will be absorbed at proximal tubule
Hyporenin, Hypoaldo (type IV) - no aldo
- urine pH ACIDIC*
- hyperK
- Dx: U Na is high - can’t reabsorb
- Tx: fludrocortisone (like aldo)
Adrenal Insufficiency - Sx and electrolytes
Anorexia, Fatigue, weight loss
Hypotension
GI complaints
No aldo - HyPONa, HyPERK, met ACIDOSIS
Causes of Nephrotic Syndrome and Associations
FSGS- HIV, heroin, obesity, African American
MCD - NSAIDS, Lymphoma
Membranous - solid cancers, NSAIDS, hep B, SLE
MPGN - Hep B/C, lipodystrophy
IgA - URI
Which pulmonary-renal syndrome should be treated with emergency plasmaphresis?
Goodpasture’s: anti-GBM antibodies
- lung, kidney, hemoptysis (anemia)
Trimethoprim - electrolyte changes?
HyperKalemia
Artificial increase in creatinine - GFR unchanged.
How to prevent acyclovir crystalline nephropathy?
Aggressive intravenous hydration
Nephrotic Syndrome + Rheumatoid Arthritis + Enlarged kidneys + Hepatomegaly = Dx?
Amyloidosis:
Bx: stain congo red, apple green birefringence
AL amyloidosis - light chains
- MM, Waldenstrom’s
AA amyloidosis - beta2, apolipo
- chronic inflam: RA, IBD
- chronic infec: osteo, TB
Aspirin Toxicity
Resp alkalosis (stimulates medullary response center to cause tachypnea/hyperventilation)
+
Met acidosis (dec. renal elimination of organic acids - lactic, keto)
Tx: Na HCO3 in the urine - speeds excretion
Lithium causes what?
Nephrogenic diabetes insipidus
Renal Cell carcinoma
Flank pain + hematuria + palpable abd mass
+ scrotal varioceles (L-sided)
+ epo secretion -> polycythemia
+ constitutional sx
Dx: CT scan
Nephrotic Range Proteinuria + Hematuria = Most likely what? And how does it look on microscope?
Membranoproliferative Glomerulonephritis
- EM: Dense intramembranous deposits
- Immunofluoresence: C3
- IgG antibodies against C3 convertase -> persistent activation of complement
Renal disease caused by HTN vs. Diabetes
HTN:
Nephrosclerosis: arteriosclerotic lesions of afferent and efferent renal arterioles -> -> Glomerulosclerosis: glomerular capillary tufts fibrosis
Diabetes: leading cause of nephropathy
1st yr - glomerular hyperperfusion - inc. GFR
(note: ACEi help by reducing intraglomerular HTN and decreasing glomerular damage)
First 5 yrs - glomerular BM thickening, extracellular matrix inc, mesangial expansion, fibrosis - GFR normalizes
5-10yrs - microalbumineria, nephropathy overt
Pathognomonic: Nodular Glomerulosclerosis (Kimmelstiel-Wilson nodules)
Correct HyperK
CBIGK
Calcium gluconate - stabilize cardiac
Shift intracellularly
Beta2 agonist, Bicarb
Insulin + glucose (FASTEST)
Remove
Kayxelate
Loop diuretics
Familial Hypocalciuric HyperCa VS. Primary HyperPTH
BOTH have HyperCa
primary hyperPTH - secondary to high PTH
FHH - secondary to “normal” PTH (Ca sensors are defective)
BUT
FHH - hypOcalciuric - low Ca in urine.
urinary ca/cr ratio 0.02
Needle shaped crystal indicate?
Uric acid stones - radiolucent - evaluate with CT
Gross painless hematuria in a smoker?
Bladder cancer!
Sx: gross painless hematuria, UA to rule UTI and renal disease
RF: smoking, occupation, cyclophosphamide, chemicals, dyes
Dx: CT urogram or cystoscopy
Pt on multiple analgesics (naproxen and aspirin) likely to develop?
Analgesic Nephropathy: drug induced chronic renal failure
- papillary necrosis
- chronic tubulointerstitial nephritis
UA: polyuria, sterile pyuria, microscopic hematuria, proteinuria.
Metformin should not be given to who and why?
Acute renal failure, Liver failure, Sepsis
Causes lactic acidosis.
Types of Stones and Associations
Ca Oxalate
- RTA type I (distal)
- crohn’s, fat malabsorption (increases oxalate absorption)
- prevent with hydrochlorothiazide - increases distal tubular absorption.
- decrease in dietary Ca actually increases risk bc increased oxalate absorption
Uric acid - radiolucent
- Tx: alkalinization of urine (potassium citrate), low purine diet, allopurinol
Cystine stones
- Tx: alkalinize the urine, surgery
Struvite stones (mg,ammonium.phos) - assoc. with UTI - Tx: surgery
Palpable purpura + Arthralgia + Abnl LFTs
UA: Proteinuria, Hematuria, dysmorphic RBC
Hypocomplement
Cryoglobulinemia - associated with Hep C
- IgM against viral hep c IgG
- also low complement levels
TB is associated with what electrolyte and acid base disturbances?
TB causes Addison’s disease
- no aldo -> hypoNa, HyperK, non-anion gap met acidosis.
In mixed GNephritis, what is the edema due to?
Mixed - IgA, Lupus, MPGN, RPGN
Primary glomerular damage - dec GFR - significant volume overload (PULM edema, distended neck veins, anasarca)
But eventually significant proteinuria leads to hypoalbuminemia, which further contributes. If it was just due to hypoalbuminemia, no pulmonary edema.
Acute oliguria + abd discomfort after surgery = ?
Postoperative urinary retention.
- immediate assessment with bladder scanner
- bladder catherization
How to manage severe hyperCa (>14) or symptomatic hyperCa?
Immediate:
- NS
- Calcitonin
- Avoid Loop diuretics unless volume overload (it increases Ca excretion but use is discouraged since pt is volume depleted usually)
Long term
1. Bisphosphonate (zoledronic acid)
Interstitial Cystitis Presentation
Painful Bladder Syndrome:
- bladder pain that is worse with filling and relieved with voiding
- dyspareunia, urinary freq, urgency
- Tx: behavioral, trigger avoidance, analgesics
VS: PID - has pelvic pain, CMT, fever. no urinary sx
PCKD (also vs. RCC)
PCKD:
Renal
- causes renal failure - most common genetic cause
- intermittent flank pain (stones, infection, cyst rupture)
- hematuria, HTN, proteinuria (less nephrotic..)
- palpable kidneys
Extrarenal:
- cerebral aneurysm
- hepatic/pancreatic cyst
- cardiac valve (MVP, AR)
- diverticulosis
- ventral/inguinal hernia
Dx: U/S
Tx:
- HTN: ACEi
- ESRD: dialysis, renal transplant
RCC
- has weight loss, constitutional
- doesn’t cause renal failure alone
- not intermittent flank pain
How to prevent contrast associated ATN?
IV hydration
Non-ionic contrast agents
Acetylcysteine
PSGN
- 10-20 days after strep infec.
- periorbital swelling/proteinuria, hematuria w. RBC casts, HTN, oliguria.
- serum C3 may be low.
Cystinuria
Cystinuria - due to impaired AA transport
- recurrent renal stone formation (hard, radioopaque, hexagonal)
- FHx
- (+) urinary cyanide nitroprusside test
Dietary Recommendations And Drug Therapies for pts with Renal Stones:
- Decreased dietary protein and oxalate
- Decreased Na intake (Na enhances Ca excretion)
- Increased Fluid
- Increased Ca
- Increased citrate
Drug
- HCTZ removes Ca from urine by increasing distal tubular reabsorption of Ca
- urine alkalinization (K citrate/Bicarb salt)
- Allopurinol (for hyperuricosuria stones)
Best Dx test: CT abd without contrast (NOT KUB)
Refractory HypoK - what is likely abnl?
HypoMag
Cause of death in ESRD?
Cardiac disease!
How does the timing of hematuria in the urinary stream indicate where the lesion is?
Initial - urethra
Terminal - bladder
Entire cycle - kidney, ureter
Renal disease does NOT have clots
What abx used to treat pyelonephritis multidrug resistant can cause acute renal failure?
Amikacin - aminoglycoside
Nitroprusside infusion causes what?
Cyanide Toxicity!
- Cherry-colored flushing
- Altered mental status
- MET ACIDOSIS
- Arrhythmia, Resp, GI
Tx: Nitrates; Na Thiosulfate
How to manage nonketotic hyperglycemic coma?
- NORMAL SALINE - initial infusion for hypovolemia.
- Insulin
- 5% and K once levels are normal.
*presents with hyperK (DUH!)
Signs of Dehydration and what to administer
Dry mucous membranes, AMS
Marginally high values for Hct, electrolytes, BUN/Cr >20
Give: NS (IV crystalloid)
Cast Type and Pathology
Muddy brown cast - ATN (REMEMBER prerenal cause.. -.-) RBC cast - glomerulonephritis WBC cast - interstitial nephritis, pyelonephritis Fatty cast - nephrotic Broad, waxy cast - chronic renal failure
HyperKalemia - Causes
PseudohyperK
- hemolysis
Decreased excretion
- renal fail
- Low aldo: ARB, ACEi, RTA IV, Spironolactone (aldo antagonist), Amiloride (K sparing diuretic), NSAIDS (impaired prostaglandin dec. RAA axis), Addison’s
Increased from tissues
- tumor lysis
- acidosis
- low insulin
- beta blockers
- digoxin (blocks Na/K pump)
- heparin.
Acyclovir causes what kind of AKI?
Crystal induced AKI - it precipitates in renal tubules -> direct tubular toxicity - usually asymptomatic - increase in Cr 1-7d after starting Tx: discontinue drug, volume repletion
Cushing’s associated with what electrolyte abnormalities?
HypoK
HyperNa
Increased aldo.
Dialysis Indications
AEIOU:
Acidosis - metabolic
Electrolyte - HyperK
Ingestion - salicylates, alcohols, lithium, valproate/carbamazepine
Overload fluid
Uremia - encephalopathy, bleeding, pericarditis
What is the cause of hypoNa in pt with GI bleed?
Hypovolemic HypoNa
- GI bleed - volume loss - ADH increases - overshoots because pt is still volume depleted..
Compensation Formulas
Met Acidosis: CO2 = 1.5 x HCO3 + 8
Met Alkalosis: Inc CO2 = 0.7 x change in HCO3
Resp Acidosis: 1 for every 10 inc PaCO2
Resp Alkalosis: 2 for every 10 dec PaCO2
What causes bleeding in pts with CRF?
Platelet dysfunction due to uremic environment.
Tx of choice = DDAVP.
Workup for someone with likely BPH
- Urinalysis - assess for UTI, hematuria (bladder cancer, nephrolithiasis)
- PSA if life expectancy > 10 yrs (prostate cancer)
