Renal: Treatments

Question 1

hypovolemia

Answer 1

goal=hemodynamic stability

• treat underlying problem
• treat volume deficit
• address ongoing losses
• be aware of co-morbidities

1. 0.9% NaCL 1st line– to expand ECF—- ONE LITER WILL INCR PLSAMA VOLUME BY 200 mL while the rest goes interstitially
2. blood/products
   * ***multiple studies show no benefit to albumin/colloids vs NSS

Question 2

hypervolemia

Answer 2

fix underlying problem

• restrict salt and fluids
• diuresis if volume is causing significant clinical problems–> SOB for ex

Question 3

hypotonic hypovolemic hyponatremia

Answer 3

volume replacement–>NSS 0.9% IV and tx undrelying cause

Question 4

hypotonic hypervolemic hyponatremia

Answer 4

. volume removal–>diruetics, sodium + water restriction

Question 5

hypotonic isovolemic hyponatremia

Answer 5

water restriction

fix underlying cause

Question 6

SIADH

Answer 6

3% NSS

Question 7

Severe hyponatremia

Answer 7

IV HYPERtonic saline + furosemide

-be so so so cautious about rate to avoid cerebral pontine myelinolysis

Question 8

symptomatic hyponatremia without severe s/s

Answer 8

serum NA not raised >4-6 mEq/L in 24 hours

• rate no greater than 0.5 mEq/hr
• fluid restriction

Question 9

symptomatic hyponatremia with severe s/s

Answer 9

100 mL bolus or 2ml/kg bolus infusion of 3% NSS at a rate of 1-2 ml/hr/kg
rate should not be greater than 1 mEq/hr

Question 10

chronic symptomatic hyponatremia

Answer 10

TX

-no greater than 8 mEq/24 hours

Question 11

hypernatremia

Answer 11

1. Hypotonic fluids–>pure water PO, D5W, 0.45% NS, 0.2% saline
   * pref route is PO or tube feeding
2. isotonic fluids if hypovolemic—- NSS or LR
   * then switch to hypotonic fluids to correct hyponatremia once volume is repleated

**8Rapid correction (>0.5 mEq/L/hr) can result in cerebral edema

tx goals for HYPERVOLEMIC
-gradually correct hyperNA using NA restriction, diuresis (loops), water replacement or hemodyalysis

tx goals for HYPOVOLEMIC

• significant volume depletion ie shock–>isotonic NaCl at rate no more than 10mEq/24 hrs
• rate of correction 0.5 mEq/Hr
• fluids to use: D5W, 0.2% NACL or 0.45% NACL

Question 12

DI
central
nephrogenic

Answer 12

• volume replacement
• central: DDAVP
• nephrogenic: thiazides and salt restriction, amiloride for lithium pt, and NSAIDs

Question 13

pseudohyperkalemia

Answer 13

no tx

-re-do sample

Question 14

hyperkalemia

Answer 14

1. stabilize cardiac membrane
   * IV Calcium gluconate (or Calcium chloride)—.CONTRAINDICATED WITH DIGOXIN TOXICITY
   * does not lower K+ but protects against arrhythmias
2. Drive K+ back into cell:
   * IV insulin with glucose
   * high dose beta 2 agonists–albuterol nebs
   * Bicarb if patient is acidotic
   * Resin Binder–>K+ removal
   * diuretics–loop and thiazides if kidney function normal
   * Sodium Polysteryene sulfonate—removes K from body via bowel movement
   * DIALYSIS IS FASTEST AND MOST EFFECTIVE

Question 15

hypokalemia

Answer 15

STOP THE LOSSES

• for each decrease of 1.0 mEq/L there is a K+ deficit of approx 100 mEq/L
  1. Asympto/mild–>PO K+

2. SEVERE:
   * SLOW IV potassium chloride (usually 10-20 mEq/L/hr)
   * peripheral infusions >40 mEq/L/hr can lead to burning, sclerosis or phlebitis
3. if patietns dont respond– always check the mag
4. montor cardiac status

*do not add glucose or sodium bicarb to solutions initially bc they cause intracellular intake of K+

Question 16

Metabolic acidosis

Answer 16

ECLS

Emergency

• assess need for ventilation or cardiopulmonary resusitation
• check electrolyte abnormalities—HYPERK ***

Cause

• tx underlying cause
  1. lactic acidosis—tx the sepsis
  2. DKA–tx diabetes and check for causes like infection
  3. ETOH ingestion/poisoning–ethanol/methanol
  4. Uremia–tx renal failure
  5. salicylate OD–>alkalinize urine +/- hemodialysis

Losses

• repalce fluid and electorlyte losses
• remember giving bicarb not always necessary

Specifics
*tx specific problems to underlying cause

Question 17

when would you give biacarb for metabolic acidosis

Answer 17

ESRD—CKD stages 2-4

DKA–only for extreme cases

Lactic acidosis with pH < 7.0

Question 18

IGA nephropathy

Answer 18

ACEI, ARGS

• lipid lowering therapy
• corticosteroids 6 MO

Question 19

post infectious GN

Answer 19

• manage the renal effects—renal insuff, HTN (Nifedipine)
• ABX –>PCN for strep
• NO STEROIDS
• referral to nephrology might need HD

Question 20

MPGN

Answer 20

• underlying cause— HEP C etc
• monoclonal gammopathy
• ACEI

Question 21

Wegenrs aka Granulomatosis Polyangiitis

Answer 21

• steroids alone–mild
• moderate-severe: steroids + immune modulators
• severe pulmonary hemorrahge/renal dz or not respoidng to above tx–> Plasma exchange

Question 22

Goodpastures

Answer 22

• plasmaphoresis + prednisone

* anti-GBM abs

Question 23

general tx for nephrotic syndome

-1st line tx for minimal change dz

Answer 23

1. immunosupresive therapy
   * steroids
   * immunomodulators
2. PU
   * goal=lower intra glomerular pressure–>reduction in protein excretion
   * ACEI* or ARBS
   * want efferent arteriolar diltion–>reduces renal blood flow, GFR and protein loss
3. Hyperlipidemia
   * diet mod
   * statins
4. Edema
   * thiazides or loops
   * 1 liter fluid and NA restriction

MINIMAL CHANGE
1st line=glucocorticoids—prednisone

Question 24

FSGS

Answer 24

-steroids—prenisone 1st line

ACEI to reduce PU

Question 25

membranous nephropathy

Answer 25

Patients at moderate to high risk should be treated with a combination of glucocorticoids and cytotoxic therapy (cyclophosphamide). Those at low risk can be treated with ACE-Is. Lipid-lowering agents should be used in cases of persistent nephrotic syndrome.

Question 26

RAS

Answer 26

• MEDS FIRST
  1. ACEI or ARB
• ->contra for bilateral RAS or if PT with a solitary kidney
  2. Add on tx= thiazides, long acting CCB, mineralcorticoid receptor angatonist
• SURGICAL
  1. revascularization definitive tx—angioplasty or bypass
  2. can also do a stent