Renal path 2 Flashcards
Presenting signs of ____ most commonly include hypertension, hypokalemia, metabolic alkalosis and decreased plasma renin activity
hyperaldosteronism
*treat with aldosterone antagonist (Eplerenone/Spironolactone)
is the cause of type IV renal tubular acidosis
hypoaldosteronism
symmetric bilateral lower extremity pitting edema and tortuous, vertical abdominal veins are concerning for an _______ obstruction, which, in the setting of a left-sided flank mass, suggests renal cell carcinoma (RCC)
with extension into the IVC.
Inferior vena cava (IVC)
Renal cell carcinoma causes a variety of paraneoplastic syndromes including _____ and hypercalcemia (due to parathyroid hormone–related peptide). *Also, ACTH or Renin tumors
erythrocytosis (due to excessive erythropoietin production causing high Hb levels)
intermittent, painless gross hematuria, in an older patient, raises suspicion for _____
A history of smoking or occupational exposure to rubber, plastics, aromatic amine–containing dyes, textiles, or leather increases the risk
urinary tract cancer, especially
urothelial (transitional cell) bladder cancer (UBC)
Clear cell carcinoma originates from proximal tubular epithelial cells and contains copious amounts of intracellular ____ & _____.
glycogen
lipids
Urothelial (transitional cell) carcinoma is the most common type of bladder cancer.Tumor invasion into the muscularis propria layer of the bladder wall carries an ____ prognosis.
bad/unfavorable
- Tumor stage (depth & LN invasion) is the most important factor for determining prognosis
Angiomyolipomas are rare tumors that arise from ___ epithelioid cells.
perivascular
Benign renal neoplasms often associated with tuberous sclerosis.
Angiomyolipomas
Hyperphosphatemia induces hypocalcemia directly by binding free calcium and depositing in tissues, and indirectly by triggering ___ secretion (decreases calcitriol production and intestinal calcium absorption).
fibroblast growth factor 23
*Hypocalcemia = neuromuscular excitability (carpal spasm).
This patient’s symptoms (eg, fatigue, weakness, itching) are most likely due to accumulation of uremia toxins secondary to progressive
chronic kidney disease
Widespread renal arteriolar vasoconstriction +
Renal biopsy shows deposition of glassy, eosinophilic PAS+ material in the intima and media of small arteries and arterioles, which is characteristic of
hyaline arteriolosclerosis
hyaline arteriolosclerosis is typically seen in patients with (2)
untreated or poorly controlled hypertension (HTN) diabetes mellitus (DM)
Nephropathy in multiple myeloma is most often due to excess excretion of free light chains (Bence Jones proteins) that precipitate with Tamm-Horsfall protein to form obstructing tubular casts (cast nephropathy). These casts are seen as amorphous hyaline material in the
tubular lumen
Nephropathy in multiple myeloma is most often due to excess excretion of free ____ that precipitate with Tamm-Horsfall protein to form obstructing tubular casts (cast nephropathy).
Ig light chains (Bence Jones proteins)
__ and fibrinoid necrosis of the renal arterioles are typical morphologic findings in hypertensive (malignant) nephrosclerosis.
Hyperplastic arteriosclerosis (“onion-skinning”)
Due to Malignant HTN, leakage of fibrinogen and coagulation factors through the damaged endothelium causes fibrin deposition in vessel walls, which appear as circumferential, acellular eosinophilic deposits (fibrinoid necrosis).
Over time, release of growth factors by damaged tissue stimulates the formation of concentric layers of collagen and ____ cells, resulting in an “onion skin” appearance (hyperplastic arteriosclerosis) of the arteriole.
proliferating smooth muscle
___ occur more commonly in patients with chronic kidney disease due to electrolyte abnormalities
(hyperphosphatemia, hypercalcemia)
and
chronic inflammation
(secondary to atherosclerosis and/or uremia).
Vascular calcifications
ex: calcified abdominal aorta wall
Sevelamer/Lanthanum is a nonabsorbable anion-exchange resin that binds intestinal ___ to reduce systemic absorption.
phosphate
Creatinine, a waste product generated by the breakdown of creatine in the muscles, is used to estimate the _____.
glomerular filtration rate (GFR)
*Creatinine formation is dependent on muscle mass and meat intake
narrowed arteriolar lumens, due to HTN or DM, causes a progressive decrease in renal blood flow, resulting in glomerular ischemia and
fibrosis (glomerulosclerosis).
Prolonged elevation of systemic blood pressure causes the renal arterioles to undergo compensatory medial ____ and fibrointimal proliferation.
hypertrophy
Prolonged elevation of systemic blood pressure causes the renal arterioles to undergo compensatory medial hypertrophy and ___ proliferation.
fibro-intimal
*anemia due to low EPO
Elevated levels of phosphate and FGF-23 also reduce ___ synthesis by inhibiting the proximal tubular expression of 1-alpha-hydroxylase, resulting in decreased intestinal calcium and phosphate absorption.
calcitriol
Analgesic nephropathy is a form of chronic kidney disease caused by prolonged, heavy intake of nonsteroidal anti-inflammatory drugs and/or acetaminophen. Pathologic characteristics include (2)
chronic interstitial nephritis
renal papillary necrosis
Atrophic renal tubules with THICKENED basement membrane.
Interstitial mononuclear inflammatory infiltrate
Proteinuria, WBCs on UA
Bilateral, SHRUNKEN kidneys
(+/-) Papillary calcifications
chronic interstitial nephritis
usually occurs acutely after a prolonged period of hypotension (eg, sepsis, major surgery); muddy brown casts would be expected on urinalysis.
Ischemic tubular necrosis
Symptoms of renal ____ include
resistant hypertension
recurrent flash pulmonary edema
chronic kidney disease.
renal artery stenosis
visualized histologically as focal tubular epithelial necrosis, often with extensive granular casts that obstruct the tubular lumen and lead to rupture of the basement membrane
ATN
fever and rash, and urinalysis shows pyuria and WBC casts (DONT FORGET)
Leukocytic infiltration of the interstitium and tubules
acute (allergic) interstitial nephritis
*occurs after introduction of a new drug.
Hypovolemia (ex: excessive diuresis) can cause acute kidney injury due to reduced ____
Urine Na+ and fractional excretion of Na+ levels are low
BUN/creatinine ratio is elevated.
renal blood flow (prerenal azotemia)
should be suspected in elderly patients with any combination of hypercalcemia, normocytic anemia, bone pain, elevated gamma gap, or renal failure (waxy casts)
Multiple myeloma
Cardiorenal syndrome is due to low cardiac output state results in renal hypoperfusion, leading to activation of the RAAS, increased ADH release and increased Beta 1 stimulation.
The resultant increase in sodium and water reabsorption and systemic vasoconstriction have detrimental effects on left ventricular systolic function, further worsening cardiac output and renal perfusion.
What happens to levels
BUN
CRE
Aldosterone
all are elevated
(Aldosterone increases BUN levels due to increase UREA reabsorption)
(Hypoperfusion = increased CRE because not being filtered out fast enough)
Livedo reticularis (blue streaks), a blue toe, and acute kidney injury following and Invasive vascular procedure
Light microscopy shows a partially or completely obstructed arterial lumen with needle-shaped cholesterol clefts within the atheromatous embolus.
this presentation is concerning for ___
atheroembolic disease
Kidney or bowel ischemia or Brain stroke commonly affected
causes acute tubular necrosis with vacuolar degeneration and BALLOONING of the proximal tubular cells.
Typical clinical findings include altered mentation, renal failure, high anion gap metabolic acidosis, increased osmolar gap, and ____ crystals in the urine.
Ethylene glycol ingestion
calcium oxalate
Advanced liver disease with portal hypertension and splanchnic vasodilation may lead to renal failure (hepatorenal syndrome). The hallmark of this condition is renal vasoconstriction, resulting in
prerenal azotemia.
UA with positive blood but no RBCs on microscopy
↑↑ Creatinine
Myoglobinuria (Rhabdomyolysis)
Prolonged muscle activity (seizure, marathon running)
Drug/medication use (statins, amphetamines, heroin)
Crush injury
Acute kidney injury & electrolyte abnormalities levels of:
K
P
Ca
↑K
↑P
↓Ca
Pathology affecting the ___ is common in severe, acute pyelonephritis and in patients with sickle cell disease, diabetes mellitus, or analgesic nephropathy. Urinalysis shows hematuria or sterile pyuria
renal papillae (papillary necrosis)
Recovery phase of ATN
(months)
Gradual increase in urine output, leading to high-volume diuresis
Continued impairment of renal tubular function, resulting in electrolyte wasting ↓↓ (4 )
potassium,
magnesium,
phosphorus,
calcium
low urine sodium (< ___ mEq/L)
20
BUN/creatinine ratio >20
Pre-Renal Azotemia (hemorrhage, diarrhea, vomitting, CHF)
Early intrinsic renal failure
In hypovolemic states Urea reabsorption increases to help concentrate the urine, resulting in increased serum levels of urea; creatinine continues to be excreted, resulting in the characteristic BUN/creatinine ratio
> 20
intrinsic ARF reflects loss of renal reabsorptive capacity. Water, sodium, and urea are excreted in the urine, leading to lower urine osmolarity, higher urinary sodium, higher urinary FENa (>2) , and a normal serum BUN/creatinine ratio ___
<15
ACE inhibitors (eg, lisinopril) cause efferent ___
vasodilation
Compensatory mechanisms for hypovolemia include activation of the ___ & increased ___ release
RAAS
ADH
This results in increased renal sodium, chloride, water, and UREA reabsorption with increased potassium excretion.
ATN. Patients have increased serum creatinine, a blood urea nitrogen/serum creatinine ratio <20 (indicating intrinsic renal pathology), and __
oliguria.
Benign prostatic hyperplasia (BPH) is associated with stromal and glandular growth in the periurethral and transitional zone of the prostate. The hyperplastic cells are supported by the formation of new blood vessels, which may be friable. Therefore, BPH is often associated with
microscopic or gross hematuria
Crampy Flank Pain, Hematuria
No fever or dysuria
Most likely diagnosis?
Nephrolithiasis
most likely
This patient with CVA tenderness, anuria and suprapubic fullness (suggesting a distended bladder) has acute
acute urinary retention (AUR)
The most common cause of urinary retention is bladder outlet obstruction (urethral compression) due to
benign prostatic hyperplasia
other causes:
- anticholinergics, sympathomimetics
- DM, Spinal Cord injury, stroke = neurogenic bladder
Kidney stones usually cause disruption of the ureteral epithelium/dilation with resulting gross or microscopic hematuria due to the presence of free red blood cells (RBCs) with normal morphology
Urethrolithiasis
Radiotherapy for prostate cancer may lead to urethral fibrosis/strictures and result in
obstructive uropathy
__ stones are typically seen in patients with recurrent upper urinary infection by urease-producing organisms (eg, Proteus, Klebsiella).
Struvite
In, struvite stones:
Urinalysis shows hematuria and ___ urine pH.
elevated
*Hydrolysis of urea yields ammonia, which alkalinizes the urine and facilitates precipitation of magnesium ammonium phosphate.
Hyperparathyroidism is a common cause of recurrent ___ and is typically associated with mild hypercalcemia and hypophosphatemia.
kidney stones
The kidneys compensate for metabolic acidosis by completely reabsorbing filtered bicarbonate (HCO3-) and excreting excess H+ in the urine. Most of the excreted H+ is buffered by ___ and ammonium (NH4+)
phosphate (H2PO4-)
Refeeding syndrome stimulates insulin secretion and drives ___- intracellularly in an effort to maintain cellular energy metabolism (eg, ATP production);
phosphorus
ADH (Vasopressin) effects on
___ Plasma osmolality
___ Urine output
___ Urinary Na+ excretion
Lowers
Lowers
no change
Anti-ADH (Vasopressin) V2 receptor effects on
___ Plasma osmolality
___ Urine output
___ Urinary Na+ excretion
increases
increases
no change
Acute Opioid overdose patients have acute respiratory _____.
Serum bicarbonate is typically near normal in an acute setting
acidosis (low pH, high PaCO2) due to hypoventilation.
causes a primary respiratory alkalosis and a primary metabolic acidosis with an anion gap due to increased lactate production.
Acute salicylate toxicity (Aspirin)
Severe vomiting leads to ______ with a normal anion gap.
metabolic alkalosis
Severe vomiting leads to metabolic alkalosis through:
loss of H+ from the gastrointestinal tract
Cl− depletion that induces renal ____ of HCO3−
_____-induced intracellular shifting of H+.
retention
hypokalemia
___ acid-base disturbances can be recognized by inappropriate secondary compensation for one of the primary disturbances, indicating that an additional primary disturbance must be present
Mixed
increased serum ___ causes intracellular shifting of HCO3− to maintain electronegative balance.
This can be due to excess saline infusion, Diarrhea, or RTA type 2.
Cl−
lithium reduces the ability of the kidneys to concentrate urine primarily by antagonizing the action of ___ in the collecting tubules and ducts.
vasopressin (antidiuretic hormone)
*Lithium induced Diabetes insipidus
Ototoxicity secondary to ____ usually occurs with higher dosages, pre-existing chronic renal disease, rapid intravenous administration, or when used in combination with other ototoxic agents (aminoglycosides, salicylates, and cisplatin).
loop diuretics
Side effects of ___ include hypokalemia, hyponatremia and hypomagnesemia, and hyperCALCEMIA.
HCTZ
a beta blocker with alpha blocking activity. Major side effects include bradycardia, hypoglycemia, and fatigue.
Carvedilol
used in certain patients with heart failure due to systolic dysfunction to help improve symptoms.
Toxicity can cause cardiac arrhythmias, hyperkalemia, nausea, vomiting and confusion.
Digoxin
This patient’s markedly elevated blood urea nitrogen (BUN) and serum creatinine in the setting of uncontrolled hypertension & volume overload suggest advanced
chronic kidney disease (CKD)
elevated anion gap metabolic acidosis
Advanced chronic kidney disease (CKD) elevated anion gap metabolic acidosis effect on levels of: Bicarb PCO2 pH
Lowers all 3 values
Severe diarrhea cause primary ____
metabolic acidosis
normal anion gap
Hypokalemic, hypochloremic metabolic alkalosis
4
Loop abuse
Thiazide abuse
Severe vomiting
Gastric Suctioning from OD
Beta agonist can cause transient
Hypokalemia due to intracellular shift from increases Na+/K+ ATPase activity
Mannitol is freely filtered and not reabsorbed by the renal tubules, resulting in a ___ glomerular filtrate.
hyperosmolar
*lowers serum Na+
Fibroblast growth factor 23 (FGF23) is secreted by osteocytes in response to _____
it suppresses alpha 1 hydroxylase & Renal Na+/Ph cotransporter in PCT
hyperphosphatemia
also referred to as hyperchloremic acidosis because the decrease in serum HCO3− is compensated for by an increase in serum Cl− to maintain electronegative balance.
Normal anion gap Metabolic Acidosis
renal tubular epithelial cells metabolize ___, generating ammonium that is excreted in the urine
glutamine to glutamate
Carbonic anhydrase inhibitor (acetazolamide) effects on:
Na+ K+ Bicarb Calcium Uric acid
↓ Na+
↓ K+
↓ Bicarb
— Calcium
— Uric acid
cocaine use causes ___kalemia
hypokalemia
blocks binding of RANK-L to RANK and reduces formation of mature osteoclasts.
Osteoprotegerin
Low ___ states cause osteoporosis by decreasing osteoprotegerin production, increasing RANK-L production, and increasing RANK expression in osteoclast precursors.
estrogen
This patient has urinary frequency and urge incontinence in the setting of an overactive or spastic bladder due to the presence of an upper motor neuron lesion in the spinal cord. Patients with ___ get this.
multiple sclerosis Bladder hypertonia (due to S2-S4 spinal cord lesion)
___ can cause SIADH by increasing antidiuretic hormone (ADH) secretion and renal sensitivity to ADH.
Carbamazepine (causes ADH sensitivity– High urine osmolality: concentrated)
*Lithium causes ADH resistance–Low urine osmolality: dilute)
- ____ for deficient (CDI) ADH – Polyuria
- ____ for (SIADH) high ADH – Hyponatremia
- ____ for (NDI) high ADH – Polyuria
- Desmopressin
- Salt tablets
- Hydrochlorothiazide
- Polyuria, hyponatremia and high urine specific gravity.
- Polyuria, Low urine specific gravity.
- Polyuria, Low urine specific gravity.
(SIADH) high ADH
(NDI) high ADH
(CDI) low ADH
Urinary urge incontinence is treated with an
antimuscarinic drug (targeting M3 receptors)
Vasopressin/Desmopressin/ ADH cause decreased ___ clearance
urea
Following desmopressin administration during the water deprivation test, urine osmolality increases to normal levels in
central DI
Following desmopressin administration during the water deprivation test, urine osmolality does NOT increase much in
partial nephrogenic DI
*none in complete
ADH works on ___ section of CT
Medullary
