Renal II Flashcards by Katherine E Nordstrom

Acidosis of any kind can lead to what electrolye imbalance?

hyperkalemia

b/c cells are exchanging K for H ions to increase pH

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What is the form of pH imbalance if the pH & bicarb move in the same direction?

If they move in opposite directions?

same: metabolic
opposite: respiratory

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What is Winter’s formula?

calculates expected CO2 in metabolic acidosis

pCO2 = 1.5(HCO3-) + 8+/-2

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What is the equation to determine the expected pCO2 in metabolic alkalosis?

increse in pCO2 0.7mmHg per 1.0meq/L increase in [HCO3-]

delta pCO2 = 0.7 * (delta[HCO3-])

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Why does aspirin overdose initially cause respiratory alkalosis?

stimulates the medulla

leads to hyperventilation

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What are the risk factors for uric acid kidney stone formation?

increased uric acid excretion (gout, myeloproliferative disorders)

increased urine concentration (hot + arid climates, dehydration)

low urine pH (chronic diarrhea, metabolic syndromes/DM)

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typical presentation of renal tubular acidosis?

low [HCO3-] and abnormal K+

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What is a type II tubular acidosis?

Seen in what conditions?

defect in proximal tubule HCO3- resorption

Fanconi Syndreom

Multiple myeloma

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general bicarb levels for type II, I, and IV renal tubular acidosis?

II: 12-20

I: <10

IV: >17

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What is type I renal tubular acidosis?

Presentation?

Associated w/ what conditions?

impaired acidification of urine by distal nephron

alkaline urine & chronic kidney stones

rickets (d/t suppressed calcium resorption) & growth failure in childen

autoimmune diseases (Sjogren’s, rheumatoid arthritis), amphotericin B

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How do you calculate the urinary anion gap?

UAG = Na + K - Cl

(shoudl be negative in acidosis w/ functioning kidneys)

positive in RTA type I and type IV

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What is a type IV renal tubular acidosis?

Symptom?

Associated conditions?

Treatment?

distal tubule fails to respond to aldosterone (deficiency or resistance) - decreased NH4 excretion, loss of urinary buffering and causes decreased urine pH + hyperkalemia

low renin activty, decreased aldosterone production, diabetes, NSAIDS

treatment: fludrocortisone

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What are the causes of intracellular translocation hypokalemia?

insulin

B-adrenergic activity (drugs / stress)

alkalosis

increased cell reproduction

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What is the difference in osteoporosis caused by aging vs. primary hyperparathyroidism?

aging: mainly affects trabecular bone

PHPT: mainly affects cortical bone

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What cells in the kidney produce erythropoietin?

peritubular fibroblasts in the interstitial cortex

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What is the treatment for infants with nephrogenic diabetes insipitus?

frequent water supplementation & thazide diuretics

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What is one of the earliest counterregulators for maintaining appropriate phosphate levels in patients with chronic kidney disease?

inhibits synthesis of 1,25-dihydroxyvitamin D

suppresses renal sodium/phosphate cotransporter IIa

(net effect is to greater elimination of phosphate)

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What is the pentad of symptoms for thrombotic microangiopathy?

fever, neurologic symptoms, renal failure, anemia, and thrombocytopenia w/ schistocytes

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Why are patients on dialysis predisposed to developing intravascular calcifications?

hyperphosphatemia & hypercalcemia (iatrogenic)

chronic inflammation

atherosclerosis

Describe the histology of renal cell carcinoma

cuboid or polygonal cells w/ abundant, clear cytoplasm

branching “chicken wire” vasculature

What is the pneumonic associated with anion gap metabolic acidosis?

M - methanol
U - uremia
D - diabetic ketoacidosis
P - propylene glycol
I - iron tablets or INH
L - lactic acidosis
E - ethylene gycol
S - salicylates

key features of methanol induced acidosis?

metabolized into?

confusion, vision loss, coma

formic acid

key features of ethylene glycol nduced acidosis?

metabolized into?

kidney toxins

glycolate (toxic to renal tubules) & oxalate (precipitates calcium oxalate crystals)

key features of propylene glycol nduced acidosis?

metabolized into?

CNS depression

metabolized into pyrivic acid, acetic acid, lactic acid

What is likely the substance ingested if it is an industrial solvent that causes non-ion gap acidosis?

isopropyl alcohol

What are the classic causes of lactic acidosis?

shock (decreased tissue perfusion) ischemic bowel metformin therapy seizures

Symptoms of initial iron poisoning? Later? Weeks later?

* 0-6 hrs * abdominal pain * 24 hrs * cardiovascular toxicity (shock) * coagulopathy * hepatic dysfunction * acute lung injury * anion gap metabolic acidosis (from ferric ions) * Weeks later * GI obstruction d/t scarring

key features of isoniazid induced anion gap acidosis?

seizures (status epilepticus) lactic acidosis

Key features of aspirin overdose?

* shortly after ingestion * respiratory alkalosis (stimulted the medulla & lead to hyperventilation) * house after ingestion * anion gap metabolic acidosis * uncouple oxidative phosphorylation * accumulation of pyruvate, lactate, ketoacids

What conditions can cause a low anion gap acidosis?

hypoalbuminemia multiple myeloma

Signs & symptoms of hyperkalemia?

* arrhythmia * sinus arrest * AV block * muscle weakness (can lead to paralysis) * lower extremities -\> trunk -\> upper extremities * EKG changes * peaked T waves * QRS widening

Causes of increased K released from cells?

acidosis insulin deficiency beta blockers digoxin lysis of cells (tumor lysis syndrome) hyperosmolarity

Signs & symptoms of hypokalemia?

* arrhythmias * PAC, PVC * bradycardia * muscle weakness (leading to paralysis) * lower extremity -\> trunk -\> upper extremity * EKG changes * u waves * flattened T waves

Common cuases of hypokalemia?

* increased renal losses * diuretics, type I/II RTA * increased GI loss * vomit / diarrhea * increased K entry into cells * hyperinsulinemia states * beta agonist: albuterol, terbutaline, dobutamine * alkalosis * hypomagnesemia * promote urinary K loss * cannot correct K until Mg is corrcted

Signs / symptoms hypercalcemia?

* often asymptomatic * recurrent kidney stones * "stones, bones, groans & psychiatric overtones" * acute hypercalcemia * polyuria (nephrogenic diabetes insipidus)

Common causes of hypercalcemia?

hyperparathyroidism malignancy hypervitaminosis D (sarcoidosis) milk alkali syndrome

Signs / symptoms hypocalcemia?

* tetany * muscle twitches (calcium blocks Na channels in neurons) * Trousseau's sign * hand spasm w/ BP cuff inflation * Chvostek's sign * facial contraction w/ tapping on nerve * seizures

Common causes of hypocalcemia?

hypoparathyroidism renal failure pancreatitis magnesium (hypo / hyper)

Common causes of hyperphosphatemia?

acute & chronic kidney disease hypoparathyroidism huge phosphate load (tumor lysis syndrome, rhabdomyolysis, large amount of phosphate laxative)

Signs/symptoms hyperphosphatemia?

* most are asymptomatic * signs + symptoms usually from hypocalcemia * phosphate precipitate serum calcium * metastatic calcifications * vascular wall calcifications * painful nodules / skin necrosis

Signs & symptoms of hypophosphatemia?

weakness (ATP depletion) - often presents as respiratory muscle weakness if chronic: bone loss, osteomalacia

common causes of hypophosphatemia?

* primary hyperparathyroidism * diabetic ketoacidosis * refeeding syndrome * low PO4 from poor nutrition * food intake -\> metabolism -\> further decrease PO4 * antacids * urinary wasting (Fanconi syndrome)

Signs / symptoms hypomagnesemia? Cause?

* Mg blocks Ca & K * neuromuscular toxicity * decreased reflexes, paralysis * bradycardia, hypotension, cardiac arrest * hypocalcemia (inhibits PTH secretion) renal insuficiency

Signs & symptoms hypomagnesemia?

* neuromuscular excitability * tetany, tremor * cardia arrhythmia * hyopcalcemia * hypokalemia

common causes hyopmagnesemia?

* GI losses * diarrhea * pancreatitis * renal losses * loop & thiazie diuretics * alcohol abuse * drus * omeprazole (impaired absorption) * foscarnet