Renal II Final

Question 1

What is Acute Kidney Injury “AKI”? What is it also know as?

Answer 1

Measurable increase in serum creatinine by 50% if patient’s previous values known, or absolute increase by 0.5 – 1.0 mg/dL.

Also known as Acute Renal Failure “ARF

Question 2

What is Chronic Kidney Disease “CKD” ? What is it also know as?

Answer 2

Irreversible impairment of kidney function.

Also known as “CRF”

Question 3

What are the five stages of CKD, and what are they based upon?

Answer 3

Based on estimated GFR “eGFR”:

1: eGFR 90 or greater with evidence of kidney damage o 2:60–90“mild”
3: 30 – 59 “moderate”
4: 15 – 29 “severe”
5: Less than 15 mL/min per 1.73 m2

Question 4

What are the common symptoms of Uremia?

Answer 4

 Nausea
 Vomiting
 Anorexia
 Bleeding
 Headache
 Dizziness
 Pruritus (“Uremic frost” – deposit of urea crystals on skin)
 Mental status changes

Question 5

What are the (potentially) reversible causes of prerenal kidney injury?

Answer 5

 True volume depletion
o Blood loss, GI loss, over- diuresis

 Effective volume depletion (volume overload with reduced renal perfusion) ie “3rd spacing”
o Congestive Heart Failure “CHF”, Cirrhosis, Pancreatitis, Systemic
Inflammatory Response

 Renovascular disease

 Drugs

Question 6

What are the (potentially) reversible causes of intrinsic kidney injury?

Answer 6

 Tubulointerstitial Disease
   o ATN (Acute Tubular Necrosis) 
   o Allergic Interstitial Nephritis
   o Pyelonephritis
   o Heavy metal poisoning

 Glomerulonephritis

 IgA Nephropathy

 Glomerular endotheliopathies

Question 7

What are the (potentially) reversible causes of postrenal kidney injury?

Answer 7

 Bladder neck – stones

 Prostatic hypertrophy

 Ureter – stones or external compression from abdominal or pelvic mass, or
retroperitoneal fibrosis

 Nephrolithiasis “stones” in kidney

 Papillary necrosis

Question 8

How do you calculate the fractional excretion of sodium “FeNa” (%) and what does it determine?

Answer 8

(Urine sodium x Plasma Creatinine / Plasma sodium x Urine Creatinine) X 100

Pre-renal if less than 1.
Intrinsic if greater than 1.

Question 9

What is the typical clinical presentation for Nephritic Syndrome i.e. Acute Glomerulonephritis?

Answer 9

 Edema

 Hypertension

 Proteinuria – NON-nephrotic range i.e. less than 3.5 gm/24hr (24 hr urine collection)

 Hematuria

Question 10

How does Nephrotic Syndrome present?

Answer 10

 In addition to the edema and hypertension seen with Nephritic, the protein exceeds 3.5 gm/24 hrs and patients may present w/ protein-calorie malnutrition

 Hyperlipidemia is also seen

Question 11

What does “active” urine sediment on microscopy indicate?

Answer 11

 Underlying renal process
o Red cell casts – glomerular disease
o White cell casts – tubulointerstitial disease

Question 12

What are the primary causes of kidney disease?

Answer 12

Primary processes originating in the kidney itself “intrinsic” such as glomerular and tubular disorders.

Question 13

What are the secondary causes of kidney disease?

Answer 13

o TOXINS
 ENDOGENOUS – potential causes: Trauma, Marathons (unusually strenuous exercise, particularly with dehydration, Seizures, Prolonged immobility eg after a fall or injury, Viral Syndrome)
 Rhabdomyolysis – breakdown of muscle produces myoblobin
 Lactic acidosis – due to tissue hypoxia and anaerobic metabolism

 EXOGENOUS
      Non-steroidal anti-inflammatory pain relievers –   multiple are Over- The-Counter (OTC)
         o Ibuprofen (IBF) – several generic versions in  addition to brand names such as Motrin, Advil, Aleve)
         o Aspirin (ASA)
      Iodinated contrast dye used in medical imaging such as CT scan or intravenous pyelogram
      Other medications 

o HYPERTENSION (Hypertension “HTN” also has primary and secondary causes o Diabetes Mellitus Types 1 and 2

o AUTOIMMUNE DISORDERS

o INFECTION

o MALE GENITOURINARY DISORDERS
 Prostatic hypertrophy
 Prostatitis

Question 14

What values do you use to determine treatment for hyperkalemia?

Answer 14

EKG changes, comorbidities, volume status and response to previous treatment measures.

Question 15

What is Polystyrene resin (Kayexalate) and what is it used for?

Answer 15

Removes potassium via GI tract, Furosemide but depends on renal function, and possibly Albuterol to redistribute potassium into cells, but weakest effect.

It is initial (conservative) approach to treatment for hyperkalemia.

Question 16

What do you do if treatment with Polystyrene resin (Kayexalate) does not work?

Answer 16

1. Calcium IV – stabilizes cardiac membrane
2. Insulin IV – redistributes potassium back into cells
3. Consider glucose – to counteract insulin if necessary
4. Hemodialysis if poor response to above
5. Consider bicarbonate – in severe metabolic acidosis without response to above

Question 17

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Answer 17

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Question 18

Calculate the anion gap.

Answer 18

Na – (Cl + HCO3)

Question 19

Mnemonic for differential diagnosis in “gap” (high anion gap) metabolic acidosis.

Answer 19

MUDPILES :
Methanol

Uremia (Chronic Kidney Disease)

Diabetic Ketoacidosis (DKA)

Paracetamol, Propylene glycol (Inactive stabilizer in many medications)

Infection, Isoniazid, Iron, Inborn errors of metabolism (peds)

Lactic acidosis

Ethylene glycol (antifreeze)

Salicylates (aspirin)

Question 20

Mnemonic for differential diagnosis in “non-gap” (normal anion gap) metabolic acidosis.

Answer 20

HARDUPS:
Hyperalimentation

Acetazolamide and other carbonic anhydrase inhibitors

Renal Tubular Acidosis – second most likely cause

Diarrhea – MOST common cause – lose bicarbonate which leads to increased concentration of Chloride

Ureteroenteric fistula

Pacreaticoduodenal fistula

Spironolactone

Question 21

What is the goal BP when treating the general >60y/o population?

Answer 21

SBP <150 mm Hg and goal DBP <90 mm Hg. (Strong Recommendation – Grade A).

Question 22

What is the corollary recommendation for HTN

Answer 22

In the general population aged over 60 years, if pharmacologic treatment for high BP results in lower achieved SBP (eg, <140 mm Hg) and treatment is well tolerated and without adverse effects on health or quality of life, treatment does not need to be adjusted. (Expert Opinion – Grade E).

Question 23

What is the goal BP when treating the general <60y/o population?

Answer 23

SBP <140mmHg. DBP <90mmHg. (For ages 30-59 years, Strong Recommendation – Grade A; For ages 18-29 years, Expert Opinion – Grade E).

Question 24

What is the goal BP when treating the general >18y/o population with CKD?

Answer 24

SBP <140mmHg and goal DBP <90mmHg. (Expert Opinion – Grade E).

Question 25

What is the initial HTN treatment for non-blacks with diabetes?

Answer 25

Thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB). (Moderate Recommendation – Grade B).

Question 26

What is the initial HTN treatment for the black population with diabetes?

Answer 26

Thiazide-type diuretic or CCB. (For general black population: Moderate Recommendation–Grade B; for black patients with diabetes: Weak Recommendation – Grade C).

Question 27

What is the HTN treatment for the general >18y/o population with CKD?

Answer 27

ACEI or ARB to improve kidney outcomes. This applies to all CKD patients with hypertension regardless of race or diabetes status. (Moderate Recommendation – Grade B).

Question 28

What are the complications of HTN?

Answer 28

Brain: TIA, stroke
Eye: retinopathy
Blood Vessels: Peripheral vascular disease
Kidney: Renal failure
Heart: LVH, CHD, HF