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Renal Urinary System and Electrolytes > Renal Urinary System part 1 > Flashcards

Renal Urinary System part 1 Flashcards

1
Q

Hyponatremia

A

x

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2
Q

cause

A

x

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3
Q

what is a cause?

A

CHF, cirrhosis

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4
Q

pathophys

A

x

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5
Q

how does it occur in context of CHF?

A

low cardiac output leads to decreased perfusion, which leads to increased ADH, leads to water reabsorption and dilutional hyponatremia

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6
Q

management

A

x

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7
Q

initial therapy for hyponateremia?

A

water intake restriction

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8
Q

if serum sodium is resistant to mainstay trx, what is another option?

A

vasopressin receptor antagonist (eg tolvaptan)

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9
Q

Euvolemic Hypo-osmolar Hyponatremia

A

x

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10
Q

cause

A

x

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11
Q

what is a cuase?

A

hypothyroidism

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12
Q

risk

A

x

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13
Q

what is a major cause of hypothyroidism?

A

postpartum thyroiditis

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14
Q

Evalutation of Hyponatremia

A

x

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15
Q

if serum osmols greater than 290, when what is the cause?

A

marked hyperglycemia, advanced renal failure

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16
Q

if serum osmols less than 290,and urine osmolality less than 100, urine sodium less than 25 , then what is the cause?

A

primary polydipsia, malnutrition (beer drinkers potomania)

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17
Q

if serum osmols less than 290,and urine osmolality less than100, and urine sodium greater than 25 when what is the cause?

A

volume depletion, CHF, cirrhosis

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18
Q

if serum osmols less than 290,and urine osmolality greater than 100, and urine sodium greater than 25 when what is the cause?

A

SIADH, adrenal insufficiency, hypothyroidism

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19
Q

HTN after Kidney Transplant

A

x

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20
Q

causes

A

x

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21
Q

what are other causes of transplant renal dysfunction?

A

rejection, calcineurin inhibitor toxicity, recurrent glomerular disease, obstruction, thrombotic microangiopathy

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22
Q

what is another immunotherapy cause of HTN after kidney transplant?

A

corticosteroids

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23
Q

Kidney transplant

A

x

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24
Q

complications

A

x

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25
Q

what are immediate long term complications of kidney transplant?

A

very low and very few (DVT, infxns)

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26
Q

in females, what do they have an increased risk of having after kidney donation after pregnancy?

A

gestational complications (fetal loss, preeclampsia, gestational diabetes, and gestational hypertension)

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27
Q

optimal kidney donor

A

x

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28
Q

who is an optimal kidney donor for a child?

A

living related donor with an identical blood type (donor must also be an adult capable of making informed decisions)

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29
Q

Living Kidney Donation

A

x

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30
Q

risks

A

x

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31
Q

what are risks of living kidney donation?

A

perioperative: mortality, hemorrhage, infection, thromboembolic events

long-term: ESRD, HTN

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32
Q

what are absolute contraindications to living kidney donation?

A

Inability to consent (age less than 18, intellectual
disability, untreated psychiatric disease)

Diabetes mellitus

Hypertension with end-organ dysfunction

BMI greater than 35 kg/m2

Malignancy

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33
Q

Analgesic Induced Nephropathy

A

x

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34
Q

Syx

A

x

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35
Q

what are syx of nephropathy?

A

worsening fatigue, nausea, malaise, bilateral pedal edema, flank pain radiating to groin

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36
Q

acute syx of nephropathy?

A

usually chronic, but can present with hematuria, pyuria, proteinuria, and renal colic

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37
Q

PE

A

x

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38
Q

what would you see on Physical Exam?

A

CVA tenderness

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39
Q

Dx

A

x

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40
Q

what does the UA show?

A

florid nephrotic range proteinuria, WBC count and casts, and no evidence of UTI

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41
Q

what does CMP show?

A

elevated Cr

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42
Q

what does CT non contrast show?

A

mild dilation of pelvicalyceal system

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43
Q

what would 24 hr urine protein show?

A

elevated protein

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44
Q

cause

A

x

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45
Q

what are the analgesic causes?

A

NSAIDs (reversible decline in GFR from inhibiting vasodilatory PG production)

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46
Q

what are other analgesic causes?

A

aspirin, phenacetin, acetaminophen, NSAIDs

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47
Q

risk

A

x

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48
Q

what are risks?

A

hx of chronic NSAID use, and new condition requiring further OTC meds

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49
Q

Post Strep Glomerulonephritis (PSGN)

A

x

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50
Q

Dx

A

x

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51
Q

UA would show?

A

RBC and RBC casts

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52
Q

what would be a good test to check post strep glomerulonephritis?

A

streptozyme test

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53
Q

what are other labs associated with PSGN?

A

renal insufficiency, nephritis, and low C3 complement levels.

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54
Q

SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion)

A

x

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55
Q

Dx

A

x

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56
Q

what would serum sodium measure?

A

low

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57
Q

what would serum osmols measure?

A

low (<275)

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58
Q

what would urine osmols measure?

A

high (>100)

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59
Q

what would urine sodium conc measure?

A

high (>40)

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60
Q

what would the volume state be for a person in SIADH?

A

euvolemic

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61
Q

cause

A

x

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62
Q

what would cause SIADH?

A

Pneumonia, Meds (SSRI, carbamazepine, valproic acid), CNS issues (stroke, hemorrhage, trauma), ectopic ADH secretion (eg Small cell lung cancer), pain and or nausea

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63
Q

stimuli for secretion of ADH

A

x

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64
Q

what are osmotic stimuli for ADH secretion?

A

serum osmolality >285 mOsm/kg H20

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65
Q

what are nonosmotic stimuli for ADH secretion?

A 
Nausea
Pain
Physical or emotional stress
Hypotension
Hypovolemia
Hypoxia
Hypoglycemia
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66
Q

syx

A

x

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67
Q

what are syx of mild/ moderate hyponatremia?

A

nausea, forgetfullness

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68
Q

what are syx of severe hyponatremia?

A

seizures, coma

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69
Q

PE

A

x

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70
Q

how do you know someone is euvolemic?

A

mois mucous membranes, no edema, no JVD

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71
Q

management

A

x

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72
Q

how do you manage SIADH?

A
  • mild to moderate hyponatremia=asyx: fluid restriction +/- salt tabs
  • severe hyponatremia (<120mEq/L) = seizures, ; hypertonic 3% saline
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73
Q

Hypovolemic Hyponatremia

A

x

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74
Q

cause

A

x

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75
Q

what is the cause?

A

decreased solute intake

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76
Q

dx

A

x

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77
Q

what is the urine sodium levels?

A

low (<40) as kidneys attempt to retain as much salt as possible

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78
Q

Gross Hematuria

A

x

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79
Q

causes

A

x

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80
Q

what are renal causes ?

A

glomerulonephritis, infection

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81
Q

what are ureteral causes?

A

nephrolithiasis

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82
Q

what are bladder causes?

A

cystitis, malignancy

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83
Q

whata are urethral cuases?

A

urethritis, prostatitis

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84
Q

evaluation

A

x

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85
Q

what is the first step of evaluating gross hematuria?

A

ask if there is hx of trauma or suspected stone

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86
Q

if there is a hx of trauma or suspected stone, what do you get before a UA?

A

imaging CT or U/S

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87
Q

if there is no hx of trauma or suspected stone, what is the next step?

A

get a UA and Urine Culture

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88
Q

why do we first get a UA?

A

to evaluate infectious, glomerular, and extraglomerular causes

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89
Q

if UA shows infection , what do you do?

A

give Abx

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90
Q

if UA shows new proteinuria, RBC casts, what do you do?

A

evaluate for glomerular causes

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91
Q

if UA shows other causes (ie cancer), what do you get?

A

imaging CT , cystoscopy, urine cytology

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92
Q

management

A

x

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93
Q

how do you evaluate gross hematuria?

A

evaluate both upper and lower urinary tracts

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94
Q

to evaluate upper urinary tracts, what do you do?

A

CT urogram or U/S

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95
Q

to evaluate lower urinary tracts, what do you do?

A

cystoscopy

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96
Q

risk

A

x

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97
Q

what are high risks for urinary tract malignancy?

A

> 35 y.o , male, smoking hx, pelvic radiation , exposure to aniline dyes, chronic analgesic abuse, chemical exposure

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98
Q

Excercise induced Hematuria

A

x

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99
Q

cause

A

x

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100
Q

what is a causes of hematuria ?

A

strenuous excercise

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101
Q

what are other causes?

A

rhabdomyolysis, excercise induced hematuria, march hemoglobinuria from RBC trauma

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102
Q

dx

A

x

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103
Q

what are the dx findings on UA?

A

positive UA, absence of RBC casts (exclude glomerular cause)

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104
Q

how do you dx it?

A

by exclusion

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105
Q

management

A

x

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106
Q

what do you for it?

A

nothing, f/u UA in 1 week to ensure resolution

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107
Q

if it persists for >1 week, what do you do?

A

cystoscopy

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108
Q

Cystoscopy

A

x

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109
Q

is gross hematuria with no evidence of glomerular disease (no RBC casts or dysmorphic red cells) or infection an indication for cystoscopy?

A

yes

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110
Q

is microscopic hematuria with no evidence of glomerular disease (no RBC casts or dysmorphic red cells) or infection but increased risk of cancer an indication for cystoscopy?

A

yes

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111
Q

is recurrent UTI an indication for cystoscopy?

A

yes

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112
Q

is obstructive symptoms with suspicion for stricture, stone an indication for cystoscopy?

A

yes

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113
Q

is irritiative syx without urinary infection an indciation for cystoscopy?

A

yes

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114
Q

is abnormal bladder imaging or urine cytology an indication for cystoscopy?

A

yes

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115
Q

IgA Nephropathy

A

x

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116
Q

syx

A

x

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117
Q

what are the typical syx of IgA nephropathy?

A

hematuria following an acute upper respiratory infection (flu like syx, nasal drainage, throat pain)

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118
Q

pathophys

A

x

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119
Q

what is the usual pathophys?

A

deposition of IgA in the renal glomerulus

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120
Q

PE

A

x

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121
Q

what is the physical exam findings?

A

flank pain (secondary to stretching of the renal capsule)

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122
Q

Dx

A

x

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123
Q

what would you see in UA?

A

RBC casts, dysmorphic RBCs

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124
Q

management

A

x

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125
Q

what is the management of IgA nephropathy?

A

ACEi for HTN, fish oil

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126
Q

Acute Cystitis and Pyelonephritis in Non pregnant women

A

x

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127
Q

evaluation

A

x

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128
Q

what must you always get in young sexually active chilbearing women?

A

pregnancy test

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129
Q

uncomplicated cystitis in non pregnant women

A

x

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130
Q

cause

A

x

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131
Q

what is the common cause?

A

E coli, proteus mirabilis, klebsiella penumoniae

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132
Q

dx

A

x

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133
Q

when is urine culture indicated?

A

only if initial trx w abx fails

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134
Q

trx

A

x

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135
Q

what is the trx?

A

Nitrofurantoin for 5 days (avoid in suspected pyelonephritis or creatinine clearance <60 mL/min)

Trimethoprim-sulfamethoxazole for 3 days (avoid if local resistance rate >20%)

Fosfomycin single dose

Fluoroquinolones only if above options cannot be used

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136
Q

complicated cystitis in non pregnant women

A

x

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137
Q

define

A

x

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138
Q

what is the definition for complicated cystitis?

A

DM, pregnancy, renal failure, Urinary tract obstruction, indwelling catheter, urinary procedure (eg cystoscopy) , immuonsuppression, hospital acquired

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139
Q

dx

A

x

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140
Q

when is urine culture indicated?

A

prior to initiating therapy and adjust abx as needed

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141
Q

trx

A

x

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142
Q

what is the trx?

A

Fluoroquinolones (5-14 days),

extended-spectrum antibiotic (eg, ampicillin/gentamicin) for more severe cases

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143
Q

Pyelonephritis

A

x

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144
Q

risk

A

x

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145
Q

what are risk factors in pregnancy ?

A

smoking, pregestational DM, asyx bacteruria

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146
Q

dx

A

x

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147
Q

when is urine culture indicated?

A

prior to initiating therapy and adjust abx as needed

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148
Q

trx

A

x

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149
Q

what is the trx OP?

A

Fluoroquinolones (eg, ciprofloxacin, levofloxacin)

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150
Q

what is the trx inpatient?

A

Intravenous antibiotics (eg, fluoroquinolone, aminoglycoside ± ampicillin)

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151
Q

UTI antibiotics in pregnancy

A

x

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152
Q

what are the antibiotics recommended for UTI in pregnancy ?

A

nitrofurantoin, amoxicillin, amoxicillin-clavulanate, cephalexin, fosfomycin

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153
Q

what are the antibiotics contraindicated for UTI in pregnancy?

A

tetracylcines, fluoroquinolones, trimethoprim-sulfamethoxazole (NTD, cardiac defects, cleft palate, neonatal kernicterus), aminoglycosides (ie gentamicin)

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154
Q

Hypophosphatemia

A

x

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155
Q

risk

A

x

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156
Q

who is at risk of low phsophate?

A

chronic alcoholic

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157
Q

dx

A

x

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158
Q

what is important to note regarding serum phosphate levels?

A

chronic alcoholics can have frequent phosphate depletion even though serum phosphate levels may initially be normal

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159
Q

cause

A

x

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160
Q

what is a major cause of of hypophosphatemia in alcholics?

A

refeeding syndrome, especially if respiratory alkalosis, may lead to shift of phsophate intracellularly and a decrease serum phosphate

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161
Q

Complications

A

x

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162
Q

what is a common complication of hypophosphatemia in alcholics with underlying myopathy to begin with ?

A

rhabdomyolysis (new complaints of weakness)

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163
Q

pathophys

A

x

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164
Q

why do chronic alcholics have low phophate and why do they have get refeeding syndrome?

A

chronic depletion of phosphate secondary to low vit D and phosphate intake and decrease oral intake and diarrhea. Despite depletion of phosphate , you still have normal extracelluar phosphate levels, until patient is fed or given IV fluids with glucose and insulin, which shift phosophate intracellularly (in addition to a respiratory alkalosis which shifts phosphate into the cells)

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165
Q

UTI in children

A

x

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166
Q

risk factors

A

x

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167
Q

what are risk factors?

A

female sex, uncirumscribed male infants, vesicoureteral reflux, anatomic defects, dysfunctional voiding, constipation

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168
Q

syx

A

x

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169
Q

what are symptoms ?

A

dysuria, fever, suprapubic pain (cystitis) and/or flank/back pain (pyelonephritis)

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170
Q

what are syx of UTI in younger patients <2y.o. ?

A

poor feeding, irritability

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171
Q

dx

A

x

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172
Q

what are lab findings?

A

pyuria

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173
Q

what does urine culture show?

A

bacteriuria

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174
Q

management

A

x

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175
Q

what is the management of UTI in children?

A

antibiotic therapy

+/- renal U/S and voiding cystourethrogram

(in patients < 2 y.o. should get renal U/S

in patients >2 y.o. you get an isolated UTI do not require imaging )

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176
Q

why do you need a renal U/S in <24 month olds ?

A

to evaluate for hydronephrosis and ureteral dialtion

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177
Q

Recurrent UTIs

A

x

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178
Q

management

A

x

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179
Q

what is the indication for abx prophylaxis in young females with recurrent UTIs?

A

> = 2 UTIs in 6months or >=3 UTIs in 1 year

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180
Q

how often do you give prophylaxis ?

A

continuous or solely postictal

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181
Q

when would you order a non contrast CT?

A

if there is concerns for nephrolithiasis

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182
Q

what are behavioral interventions for recurrent UTIs?

A

postcoital voiding, increased intake of cranberry juice

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183
Q

Postoperative Urinary Retention

A

x

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184
Q

risk factors

A

x

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185
Q

what are risk factors for postoperative urinary retention?

A 
>50 y.o, 
surgery >2 hours duration
>750 cc intraop fluids
regional anesthesia 
neurologic disease
underlying bladder dysfunction
previous pelvic surgery
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186
Q

PE

A

x

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187
Q

what are physical exam findings?

A

decreased urine output
abdominal distention
suprapubic pressure/pain
not passing gas

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188
Q

management

A

x

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189
Q

what is the management for postop urinary retention?

A

indwelling catheter

clean intermittent catheterization

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190
Q

pathophys

A

x

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191
Q

what is the pathophys of postop urinary retention?

A

anesthesia + IV fluids cause bladder stretch receptor dysfunction and decreased detrusor contractility

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192
Q

Urethral Diverticulum

A

x

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193
Q

pathophys

A

x

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194
Q

what is the pathophys of urethral diverticulum ?

A

herniation of urethral mucosa through the muscle wall into the surrounding tissue

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195
Q

syx

A

x

196
Q

what are symmptoms of urethral diverticulum?

A

postvoid dribbling, dysuria, dyspareunia

197
Q

PE

A

x

198
Q

what do you see on pelvic exam?

A

anterior vaginal mass (i.e fullness of the anterior vaginal wall)

199
Q

what happens when you examine the mass?

A

tender anterior wall vaginal mass that expresses bloody, purulent fluid

200
Q

risk

A

x

201
Q

what are risks of urethral diverticulum?

A

Urethral diverticula in women form due to repeated infection, inflammation, and trauma of the urethra from previous pelvic trauma (eg, vaginal delivery) or surgery.

202
Q

dx

A

x

203
Q

how do you dx urethral diverticulum?

A

UA, UCx, MRI pelvis, TVUS

204
Q

trx

A

x

205
Q

what are the trx of urethral diverticulum?

A

manual compression, needle aspiration, surgical repair

206
Q

Vesicovaginal Fistula

A

x

207
Q

dx

A

x

208
Q

how do you dx of vesicovaginal fistula?

A

methylene blue instilled into the bladder- test is positive if vagina becomes blue after the dye is instilled in the bladder

209
Q

Urinary Incontinence

A

x

210
Q

risk

A

x

211
Q

what are risk factors?

A

increased age, hx of multiple vag deliveries, obesity, vaginal atrophy, tobacco use, caffeine intake

212
Q

Stress Incontinence

A

x

213
Q

syx

A

x

214
Q

what are the symptoms of stress incontinence?

A

leakage with coughing, sneezing, laughing, lifting

215
Q

dx

A

x

216
Q

how do you dx stress incontinence?

A

Q tip test- hypermobile urethra (>30 degree angle of movement)

217
Q

trx

A

x

218
Q

what is the trx of stress incontinence?

A

lifestyle modification, pelvic floor excercises, pessary, urethral sling surgery

219
Q

Urge incontinence

A

x

220
Q

syx

A

x

221
Q

what are the symptoms of urge incontinence?

A

Sudden, overwhelming, or frequent need to urinate

222
Q

trx

A

x

223
Q

what is the trx of urge incontinence?

A

Lifestyle modification
Bladder training
Antimuscarinic medications

224
Q

Overflow incontinence

A

x

225
Q

syx

A

x

226
Q

what are the symptoms of overflow incontinence?

A

Constant dribbling of urine, incomplete bladder emptying

227
Q

dx

A

x

228
Q

how do dx overflow incontinence?

A

PVR>200mL

229
Q

trx

A

x

230
Q

what is the trx of overflow incontinence?

A

Intermittent catheterization

Correct underlying etiology

231
Q

Ureteral Stones (kidney stones)/nephrolithiasis

A

x

232
Q

management

A

x

233
Q

if stones <5 mm, what can you expect?

A

they will pass spontaneously

234
Q

if stones 5-10mm, how do you manage ?

A

trial of medical therapy (gentle hydration, pain contorl, alpha blockers-tamsulosin) and don’t need hospital admission if syx are controlled

235
Q

if stones >=10mm, persistent pain, acute renal failure, or signs of sepsis,then what do you do?

A

surgical removal of stones

236
Q

abx are indicated in the presence of _____?

A

infection

237
Q

trial of medical therapy (gentle hydration, pain contorl, alpha blockers) and don’t need hospital admission if syx are controlled in patients with ureteral stones for what size?

A

5-10mm

238
Q

kidney stones that will spontaneously pass

A

<5mm

239
Q

surgical removal of kidney stones indicated for?

A

if stones >=10mm, persistent pain, acute renal failure, or signs of sepsis,then what do you do?

240
Q

patients with obstructing ureterolithiasis w infection, AKI, severe pain that have failed initial measurs require what?

A

decompression with percutaneous nephrostomy or ureteral stent placement.

241
Q

Inpatient Ureteral Stones/nephrolithiasis

A

x

242
Q

management

A

x

243
Q

if symptomatic ureteral stone , and urosepsis and acute renal failure and complete obstruction present , what is the next step?

A

urology consult

244
Q

if symptomatic ureteral stone , and there is no urosepsis and acute renal failure or complete obstruction present , what is the next step?

A

stone size

245
Q

if symptomatic ureteral stone , and there is no urosepsis and acute renal failure or complete obstruction present , and stone size <10mm?

A

medical management (hydration, pain control, alpha blockers-tamsulosin, strain urine)

246
Q

if symptomatic ureteral stone , and there is no urosepsis and acute renal failure or complete obstruction present , and stone size <10mm and after medical management doesn’t control or pass pain, what is next step?

A

urology consult

247
Q

if symptomatic ureteral stone , and there is no urosepsis and acute renal failure or complete obstruction present , and stone size >=10mm?

A

urology consult

248
Q

Renal Cell Carcinoma Module

A

x

249
Q

syx

A

x

250
Q

what are syx of Renal Cell Carcinoma?

A

profound fatigue and anorexia for the past few weeks, weight loss

251
Q

risk

A

x

252
Q

what are risks of Renal Cell Carcinoma?

A

smoking, drinking

253
Q

ddx

A

x

254
Q

what is the differential for fatigue, weight loss, and anorexia?

A

malignancy, infectious disease, autoimmune disease

255
Q

workup

A

x

256
Q

what does the work up for Renal Cell Carcinoma include?

A

anemia, CBC, FOBT, red cell indices, iron studies

257
Q

what additional labs for Renal Cell Carcinoma that should be ordered?

A

BMP, LFTs, and UA

258
Q

if your anemia workup for Renal Cell Carcinoma comes back showing nromocytic normochromic anemia with low serum iron, low TIBC, and elevated ferritin, what is the dx?

A

anemia of chronic disease

259
Q

if you have anemia of chronic disease and the presence of hematuria on UA, what do you think about?

A

GU -malignancy (urinary tracts, kidney, prostate)

260
Q

what is the preferred test for investigating suspected GU-malignancy?

A

abd CT and cytoscopy

261
Q

dx

A

x

262
Q

what syx make you suspect Renal Cell Carcinoma?

A

unexplained hematuria, flank pain, palpable flank mass

263
Q

what does abdominal CT help show for Renal Cell Carcinoma?

A

provides presumptive dx and provides staging information

264
Q

if renal mass on CT abd is seen without involvement of renal capsule, renal vein , or IVC, what stage is that Renal Cell Carcinoma

A

stage I renal cell cancer

265
Q

management

A

x

266
Q

if abd CT provides presumptive dx of Renal Cell Carcinoma, then what is next step?

A
  • obtain CT chest for further staging information.

- bone scan if there is bone pain or elevated ALP

267
Q

once you determine the stage based on Renal Cell Carcinoma of abdominal CT,chest CT, +/- bone scan , what is the next step?

A
  • nephrectomy is preferred for isolated renal mass (diagnostic and therapeutic)
  • biopsy preferred for supsected metastatic disease; further treatment dictated by result
268
Q

therapy

A

x

269
Q

what are next steps after dx of Renal Cell Carcinoma in the module?

A

NPO, IV NS 0.9%, onc consult, surg consult, PT, PTT/INR, blood type and cross match, IV cefazolin, nephrectomy, counseling (no smoking, no alcohol, cancer diagnosis)

270
Q

Renal Cell Carcinoma (RCC)

A

x

271
Q

risk

A

x

272
Q

what are the risks of RCC?

A

cigarette smoking, obesity, HTN

273
Q

syx

A

x

274
Q

what are the syx of RCC?

A

flank pain, hematuria, palpable abdominal mass

275
Q

association

A

x

276
Q

what is the associated syndrome?

A

paraneoplastic syndrome (EPO production leading to erythrocytosis)

277
Q

dx

A

x

278
Q

what is the dx test to evlaute for RCC?

A

CT scan of abdomen

279
Q

what would CT scan of RCC show?

A

enhancing mass with thickened, irregular septa

280
Q

management

A

x

281
Q

if renal mass isolated to renal capsule (stage 1), what is the trx?

A

parial nephrectomy

282
Q

if renal mass extends through the renal capsule but not beyond Gerota’s fascia (stage II), what is the trx?

A

radical nephrectomy

283
Q

if renal mass extends through renal capsule with invasion of major veins, abdominal lymph nodes and adrenal glands, (stage III)

A

radical nephrectomy, with chemo and immunotherapy

284
Q

Hyperkalemia

A

x

285
Q

cause

A

x

286
Q

what are some causes of hyperkalemia?

A

NSAID use, renal failure, lisinopril use

287
Q

dx

A

x

288
Q

what are the progressive EKG changes you see with hyperkalemia?

A

peaked T waves, then subsequently prolongation of the PR interval and QRS complex, disappearance of P waves, and eventually sine wave

289
Q

trx

A

x

290
Q

what is most appropriate first line trx?

A

IV calcium gluconate

291
Q

what are follow up trx options to reduce serum potassium?

A

beta agonist or combination of glucose and insulin

292
Q

Calcium Homeostasis

A

x

293
Q

transport

A

x

294
Q

what are the 3 different ways calcium is transported in blood?

A

albumin bound calcium (45%), ionized calcium (40%), calcium bound to inorganic and organic anions (15%)

295
Q

management

A

x

296
Q

when evaluating hypocalcemia, what must you always look at?

A

serum albumin

297
Q

how do you adjust for hypocalcemia in the hypoalbuminemia?

A

serum calcium concentration decreases by 0.8 mg/dL for every 1 g/dL decrease in serum albumin concentration.

298
Q

Hypocalcemia

A

x

299
Q

causes

A

x

300
Q

what are causes of acute hypocalcemia?

A

neck surgery (parathyroidectomy), pancreatitis, sepsis, tumor lysis syndrome, acute alkalosis, chelation (blood citrate transfusion, EDTA, foscarnet)

packed RBCs are preserved and anticoagulated using sodium citrate (which contains calcium)

301
Q

risk

A

x

302
Q

who are at high risk of hypocalcemia?

A

liver or renal failure, hypothermia, shock

303
Q

when can hypocalcemia occur?

A

immediately after surgery, after car accident with several fractures, where multiple transfusions required

304
Q

pathophys

A

x

305
Q

what is the pathophys of hypocalcemia in the context of citrate ?

A

as citrate binds ionized calcium , you get symptomatic calcium deficiency

also in situations with volume expansion and hypoalbuminemia

306
Q

dx

A

x

307
Q

what would serum calcium look like?

A

you can have normal serum calcium , though ionized calcium is low

308
Q

syx

A

x

309
Q

what are syx of hypocalcemia?

A

oral paresthesias, carpopedal spasm, tetany, seizures

310
Q

PE

A

x

311
Q

what are physical exam findings?

A

muscle cramps, chvostek (ipsilateral facial twitch with tapping) and trousseau (BP cuff contraction) signs , perioral paresthesias, hyperreflexia/tetany, seizures

312
Q

trx

A

x

313
Q

for mild acute hypocalcemia (corrected calcium of 7.5-8.5mg/dL), what is trx?

A

oral calcium citrate or carbonate

314
Q

what is the best treatment for acute hypocalcemia?

A

IV calcium gluconate/chloride

315
Q

Familial Hypocalciuric Hypercalcemia

A

x

316
Q

epid

A

x

317
Q

what is the inheritance pattern?

A

auto dominant

318
Q

cause

A

x

319
Q

what is the major cause of hypercalcemia?

A

inactivation of the calcium sensing receptor, so the normal suppression of PTH secretion when calcium levels are normal gets blocked, and you get increased reabsorption of calcium reabsorption in the renal tubules.

320
Q

dx

A

x

321
Q

what does labs show?

A

mild hypercalcemia

322
Q

syx

A

x

323
Q

what do syx show?

A

no clinical findings of symptoms

324
Q

trx

A

x

325
Q

what is the treatment?

A

nothing

326
Q

Hypomagnesemia

A

x

327
Q

syx

A

x

328
Q

what is hypomagnesemia similar to?

A

mimics hypocalcemia

329
Q

risk

A

x

330
Q

what are the risks of hypomagnesemia?

A

alcoholism, prolonged NG suction or diarrhea, diuretic use

331
Q

Nephrolithiasis in Pregnancy

A

x

332
Q

epid

A

x

333
Q

most commonly seen in which trimester?

A

2nd and 3rd trimester

334
Q

risk

A

x

335
Q

what are risk factors of pregnancy?

A

increasd calcium excretion, urinary stasis, and decreased bladder capacity

336
Q

what are other risk factors?

A

obesity, hyperPTH, DM, IBS, hx of kidney stones outside pregnancy

337
Q

syx

A

x

338
Q

what are the syx of nephrolithiasis in pregnancy?

A

paroxysmal severe flank pain that radiates to the labia, n/v, hematuria, dysurai, pyuria

339
Q

dx

A

x

340
Q

what is the first like imaging in pregnancy?

A

renal and pelvic ultrasound to minimize fetal radiation exposure

341
Q

if renal and pelvic ultrasound negative, what is next best test?

A

TVUS

342
Q

if TVUS is also negative, but still high suspision for kidney stone, next step?

A

treat empirically for a stone and observe closely

-OR-

MRI urogram

-OR-

Low dose CT urogram (2nd and 3rd trimester only)

343
Q

PKD (Polycystic Kidney Disease)

A

x

344
Q

syx

A

x

345
Q

what are syx of PKD?

A

hematuria and flank pain

346
Q

dx

A

x

347
Q

what does imaging show?

A

CT abdomen shows multiple bilateral kidney cysts that are round, thin walled nonenhancing and sharply demarcated

348
Q

what genetic test do you test for?

A

PKD gene mutation

349
Q

trx

A

x

350
Q

what do you trx PKD with?

A

ACEi

351
Q

Paralytic Ileus

A

x

352
Q

syx

A

x

353
Q

what are syx of paralytic ileus?

A

n/v, soft distended abdomen, decreased bowel sounds

354
Q

PE

A

x

355
Q

what are physical exam findings?

A

possible gaseous distension, reduced/absent bowel sounds

356
Q

cause

A

x

357
Q

what is a major cause of paralytic ileus?

A

recent surgery (hours to days), metabolic (eg hypokalemia), medication induced

358
Q

risk

A

x

359
Q

what is a risk for hypokalemia induced paralytic ileus

A

diuretic induced therapy

360
Q

dx

A

x

361
Q

do you see small bowel dilation typically?

A

yes

362
Q

do you see large bowel dilation typically?

A

yes

363
Q

trx

A

x

364
Q

if hypokalemia is cause, what do you do?

A

IV potassium

365
Q

Small Bowel Obstruction (SBO)

A

x

366
Q

cause

A

x

367
Q

what is the major cause of SBO?

A

prior surgery (weeks to years)

368
Q

PE

A

x

369
Q

what does exam look like?

A

distention, increased bowel sounds

370
Q

dx

A

x

371
Q

do you see small bowel dilation typically?

A

yes

372
Q

do you see large bowel dilation typically?

A

no

373
Q

Renovascular (Hypertension) HTN

A

x

374
Q

epid

A

x

375
Q

what is the most common cause of secondary HTN?

A

renovascular HTN

376
Q

risk

A

x

377
Q

who is at risk?

A

atherosclerotic disease elsewhere in the body, renal failure

378
Q

syx

A

x

379
Q

what are signs of renovascular HTN?

A

resistant HTN to multiple meds (3 drug regiment)

malignant HTN (with end organ damage)

onset of severe HTN (>180/120mmHg) after age 55

severe HTN with diffuse atherosclerosis

recurrent flash pulmonary edema with severe HTN

380
Q

PE

A

x

381
Q

what are physical exam findings?

A

abd bruits, asymmetric renal size (>1.5cm)

382
Q

dx

A

x

383
Q

how do you evaluate such patients?

A

renal duplex Doppler U/S or CT or MRA of renal arteries

384
Q

what dx imaging studies should be avoided?

A

CT and gadolinium MR angiography, because of risk of contrast induced nephropathy and nephrogenic systemic fibrosis

385
Q

what labs support renovascular HTN?

A

unexplained rise in serum Cr (>30%) after starting ACEi or ARBs

386
Q

what imaging rsults support renovascular HTN?

A

unexplained atrophic kidney

387
Q

Renal Artery Stenosis

A

x

388
Q

cause

A

x

389
Q

what is the cause?

A

RAAS

390
Q

dx

A

x

391
Q

marked increase in serum Cr after initiation of ACE i is highly suggestive of what?

A

Renal Artery Stenosis 2/2 renal transplant

392
Q

risk

A

x

393
Q

what is a big risk factor for causing Renal Artery Stenosis?

A

kidney transplant (improper surgical anastomosis)

394
Q

Secondary Causes of Hypertension (HTN)

A

x

395
Q

Conditions

A

Clinical clues/features

396
Q

Renal parenchymal disease, Clinical clues/features?

A 
Elevated serum creatinine
Abnormal urinalysis (proteinuria, red blood cell casts)
397
Q

Renovascular disease, Clinical clues/features?

A

Severe hypertension (≥180 mm Hg systolic and/or 120 mm Hg diastolic) after age 55

Possible recurrent flash pulmonary edema or resistant heart failure

Unexplained rise in serum creatinine Abdominal bruit

398
Q

Primary aldosteronism, Clinical clues/features?

A

Easily provoked hypokalemia

Slight hypernatremia

Hypertension with adrenal incidentaloma

399
Q

Pheochromocytoma, Clinical clues/features?

A

Paroxysmal elevated blood pressure with tachycardia

Pounding headaches, palpitations, diaphoresis

Hypertension with an adrenal incidentaloma

400
Q

Cushing syndrome, Clinical clues/features?

A

Central obesity,

facial plethora

Proximal muscle weakness,

abdominal striae

Ecchymosis,

amenorrhea/erectile dysfunction

Hypertension with adrenal incidentaloma

401
Q

Hypothyroidism, Clinical clues/features?

A

Fatigue,

dry skin,

cold intolerance

Constipation,

weight gain,

bradycardia

402
Q

Primary hyperparathyroidism, Clinical clues/features?

A

Hypercalcemia (polyuria, polydipsia)

Kidney stones

Neuropsychiatric presentations (confusion, depression, psychosis)

403
Q

Coarctation of the aorta, Clinical clues/features?

A

Differential hypertension with brachial-femoral pulse delay

404
Q

Mixed Cryoglobulinemia Syndrome

A

x

405
Q

triggers

A

x

406
Q

what is the disease that triggers typically mixed cryoglobulinemia syndrome?

A

hep C virus infection

407
Q

what are other triggers?

A

hep B, HIV, malignancy, rheumatological disease

408
Q

syx

A

x

409
Q

what is the usual triad?

A

palpable purpura, fatigue, and arthralgias

410
Q

what are other symptoms?

A

peripheral neuropathy, systemic symptoms, glomerulonephritis with renal insufficiency

411
Q

dx

A

x

412
Q

how is the diagnosis made?

A

measuring serum cryoglobulin levels

413
Q

what are other lab findings in mixed cryoglobulinemia syndrome?

A

elevated RF, hypocomplementemia

414
Q

pathohpys

A

x

415
Q

how does mixed cryoglobulinemia syndrome occur?

A

is a vasculitis due to the deposition of immune complexes (polyclonal IgG and IgM rheumatoid factor) within the vascular wall of small- and medium-size vessels

416
Q

complications

A

x

417
Q

what are other complications?

A

glomerulonephritis (RBC, RBC casts, proteinuria)

418
Q

trx

A

x

419
Q

what is the best intial trx to stabilize end organ damage?

A

immunosuppressive therapy (corticosteroid and rituximab)

420
Q

what is the best long term trx if they have underlying hep C?

A

antiviral trx

421
Q

Granulomatosis with Polyangitis (Wegners)

A

x

422
Q

syx

A

x

423
Q

what are the usual syx?

A

palpable purpura, fatigue, and arthralgias, respiratory tract syx (sinusisitis, rhinorrhea)

424
Q

what are other symptoms?

A

peripheral neuropathy, systemic symptoms, glomerulonephritis with renal insufficiency

425
Q

dx

A

x

426
Q

what is the dx test of choice?

A

cANCA

427
Q

how do you distinguish it from Mixed Cryoglobulinemia Syndrome?

A

normal or elevated complement levels and respiratory tract syx (sinusisitis, rhinorrhea)

428
Q

Benign Prostatic Hyperplasia (BPH)

A

x

429
Q

syx

A

x

430
Q

what are syx of BPH?

A

lower urinary tract syx (hesistancy , weak stream)

431
Q

risk

A

x

432
Q

who is at risk of BPH?

A

> 50 y.o. male,

433
Q

who is at risk of acute urinary retention?

A

bladder/urethral infection, genitourinary trauma, and use of certain meds (eg baclofen, anticholinergics)

434
Q

management

A

x

435
Q

what is the most effective immediate management?

A

immediate bladder decompression-
first line: urethral catheter first
second line: suprapubic catheter

436
Q

Dx

A

x

437
Q

what would labs show?

A

elevated cr

438
Q

PE

A

x

439
Q

what does PE show?

A

abd tenderness, and suprapubic fullness

440
Q

Posterior Urethral Valve (PUV)

A

x

441
Q

epid

A

x

442
Q

who does it occur in ?

A

exclusively in males

443
Q

define

A

x

444
Q

what is it?

A

most common cause of obstructive uropathy, at level of urethra (congenital urethral membrane)

445
Q

dx

A

x

446
Q

how are they generally diagnosed?

A

prenatally

447
Q

what are the hallmark features?

A

thickening and distention of the bladder and dilation of the proximal urinary system , bilateral hydronephrosis, oligohydraminos

448
Q

what is a highly specific feature?

A

antenatal U/S showing dilated bladder

449
Q

what is the best way to confirm PUV?

A

VCUG (voiding cystourethrogram)

450
Q

complications

A

x

451
Q

if the obstruction is severe, oligohydraminos can occur leading to?

A

potter sequence (pulm hypoplasia, flattened facies)

452
Q

trx

A

x

453
Q

what is the best next step?

A

foley catheter to temporarily relieve the obstruction

454
Q

what is definitive trx?

A

cystoscopy and ablation of valve

455
Q

Anemia in ESRD

A

x

456
Q

cause

A

x

457
Q

what isthe cause of anemia in ESRD?

A

decreased EPO, iron deficiency

458
Q

evaluation

A

x

459
Q

what is the initial step in evaluation of anemia in ESRD?

A

check B12, folate, fecal occult blood, iron studies (ferritin, TIBC, serum iron, transferrin saturation), reticulocyte count

460
Q

if iron deficiency is present, what do you do?

A

iron supplementation

461
Q

if no improvement after iron supplementation, then what?

A

ESA (erythropoietin stimulating agent ) therapy

462
Q

if there is an abnormality other than iron deficiency, then what do you do?

A

treat as indicated,

463
Q

if no improvement after trying to treat abnormality appropriately, then what?

A

ESA (erythropoietin stimulating agent ) therapy

464
Q

CKD/ESRD and iron deficiency anemia

A

x

465
Q

complications

A

x

466
Q

advanced chronic kidney disease or end-stage renal disease patients commonly develop what?

A

hypoproliferative, normocytic, normochromic anemia /iron deficiency anemia

467
Q

cause

A

x

468
Q

what is the cause of CKD/ESRD leading to hypoproliferative, normocytic, normochromic anemia ?

A

underproduction of erythropoietin by the failing kidneys.

469
Q

management

A

x

470
Q

why should ESRD patients get their iron stores checked?

A

Vigorous hematopoiesis after administration of erythropoiesis-stimulating agents (ESAs) can lead to rapid depletion of iron stores; therefore, all patients who require ESAs (eg, many CKD patients with hemoglobin <10 g/dL) should have iron levels checked prior to initiation of EPO and at scheduled intervals while on therapy

471
Q

Contrast Induced Nephropathy

A

x

472
Q

risk factors

A

x

473
Q

what are risk factors of contrast induced nephropathy?

A

> 75y.o, , CKD (diabetic nephropathy), reduced renal perfusion (eg hypotension), high contrast load

474
Q

prevention

A

x

475
Q

how do you prevent contrast induced nephropathy?

A
  • periprocedural saline hydration (before and after procedure)
  • use lowest volume of contrast agent possible
  • hold NSAID drugs
476
Q

cause

A

x

477
Q

what causes contrast induced nephropathy?

A

contrast induced renal vasoconstriction

478
Q

Primary Nocturnal Enuresis

A

x

479
Q

define

A

x

480
Q

what is it?

A

urinary incontinence in >=5y.o. w/o dysuria and daytime incontinence

481
Q

management

A

x

482
Q

what is first step when managing primary nocturnal enuresis?

A

screening UA (exclude infection, Diabetes Mellitus-glucosuria, or Diabetes Insipidus-low specific gravity on first morning void)

483
Q

what are intial treatment options for treating primary nocturnal enuresis?

A

bhv modifications (eg limiting evening fluid intake, avoid sugary/caffeinated beverages, void before bedtime, institute reward system-gold star chart)

motivational therapy

484
Q

what is first line therapy?

A

enuresis alarms (best long term outcome-low relapse rates)

485
Q

what is second line therapy?

A

desmopressin therapy

486
Q

what can be used in refractory cases?

A

TCA’s (imipramine)

Renal Urinary System and Electrolytes (2 decks)

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