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Nephrology > Test #1 > Flashcards

Test #1 Flashcards

1
Q

Azotemia

A

Elevated BUN/Creatinine

The buildup of abnormally large amounts of nitrogenous waste products in the blood

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2
Q

Types of azotemia

A

Pre-renal failure

Intrinsic renal failure

Post-renal obstruction

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3
Q

Oliguria

A

Urine output < 400 mL/day

Urine output < 20 cc/hr

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4
Q

Anuria

A

Urine output < 100 mL/day

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5
Q

Glomerular filtration rate (GFR)

A

The sum filtering rate of all functioning neurons

-Kidney filtration rate

Measure Creatinine, Urea, or Inulin clearance

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6
Q

GFR Normals by gender

A

Men = 130 mL/min/173 m2

Women = 120 mL/min/173 m2

Decrease normally w/ age

Influenced by age, sex, body size, and renal blood flow

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7
Q

Creatinine clearance

A

Assess GFR

Normals: Men = 107-139

-Women = 87-107

Can overestimate the GFR by 40%, especially with decreased renal function

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8
Q

Major body cations and normal values

A

Sodium: 135-145

Potassium: 3.8-5.5

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9
Q

Major body anions and normal values

A

Chloride: 98-106

Bicarbonate: 21-28

Total CO2: 23-30

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10
Q

Typically secreted electrolytes

A

Hydrogen

Potassium

Urate

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11
Q

Odors indicate:

Ammonia-like

Foul/offensive

Sweet

Fruity

Maple syrup-like

A

Ammonia-like: Urea-splitting bacteria

Foul/offensive: Old, pus, inflammation

Sweet: Glucose

Fruity: Ketones

Maple syrup-like: Maple syrup urine disease

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12
Q

Colors indicate:

Colorless

Deep yellow

Yellow-green

Red

Brownish-red

Brownish-black

A

Colorless: Dilute urine

Deep yellow: Concentrated urine

Yellow-green: Bilirubin

Red: Blood/Hemoglobin

Brownish-red: Acidified blood (acute glomerulonephritis)

Brownish-black: Homogentisic acid (Melanin)

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13
Q

Globulinuria DDx

A

Glomerulonephritis

Tubular dysfunction

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14
Q

Bence Jones proteinuria DDx

A

Multiple myeloma

Leukemia

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15
Q

Fibrinogen proteinuria DDx

A

Severe renal disease

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16
Q

Types of ketone bodies

A

Acetoacetic acid

Acetone

Betahydroxybutyric acid (most common)

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17
Q

Nephrotic syndrome vs nephritic syndrome

A

Lots of protein loss w/ nephrotic

Lots of blood loss w/ nephritic

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18
Q

Acute renal failure

Heath’s intro

A

Abrupt kidney function loss w/in 7 days

Pre-renal, intrinsic, or post-renal

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19
Q

Chronic kidney disease

Heath’s intro

A

Progressive renal function loss over months/years

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20
Q

End-stage renal disease

Heath’s intro

A

Chronic kidney disease at stage 5 progression

GFR <15

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21
Q

Glomerulopathy

Heath’s intro

A

Disease of glomeruli or nephron

Can be inflammatory or non-inflammatory

Nephritic syndrome, IgA nephropathy, Nephrotic syndrome

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22
Q

Hydrostatic vs osmotic pressure

A

Hydrostatic pressure pushes fluid into the interstitium

Osmotic pressure pushed fluid from interstitium back into capillary/tubule

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23
Q

Fluid and electrolyte intake and output regulation

A

Fluid intake - hypothalamus regulates thirst

Electrolyte intake - dietary habits regulate

Output of both is regulated by kidneys

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24
Q

Mechanisms to stimulate hypothalamic thirst center

A

Increased plasma osmolality (Dry mouth and osmoreceptors stimulated)

Decreased plasma volume (RAAS and decreased BP)

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25
Q

ADH stimulation and mechanism

A

Stimulated by dehydration, increase in osmolality, or RAAS

Increases water absorption by increasing the number of aquaporins in the collecting tubule

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26
Q

Kidney blood vessel order

A

Aorta - renal artery - segmental artery - interlobar artery - arcuate artery - cortical radiate artery - afferent arteriole - glomerulus

Glomerulus - efferent arteriole - peritubular capillaries and vasa recta - cortical radiate vein - arcuate vein - interlobar vein - renal vein - inferior vena cava

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27
Q

Renal clearance

A

Volume of plasma completely cleared of waste by kidneys per minute

Clearance = (Urine concentration * urine flow rate) / plasma concentration

Can be used to estimate GFR if substance excreted is freely filtered w/o absorption

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28
Q

Renal autoregulation

A

Allows GFR to remain stable in spite of arterial blood pressure changes

Afferent and efferent arterioles change resistance to modify GFR and blood flow

Myogenic response and tubuloglomerular feedback (macula densa)

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29
Q

Feedback that triggers an increase in GFR

A

Prostaglandins

Fever/pyrogens

Glucocorticoids

Hyperglycemia (DM)

Macula densa senses low NaCl

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30
Q

Feedback that triggers a decrease in GFR

A

NSAIDs

Aging (10% decline/decade after 40 years)

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31
Q

PCT

A

Most reabsorption of vital substances - glucose, aa, bicarb, Na, Cl, water

Ammonia is generated and secreted here

Mannitol and acetazolamide diuretics work here

Angiotensin II increases sodium and water reabsorption

PTH increases phosphate excretion

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32
Q

Transport maximum

A

Some substances (glucose) can only be absorbed to a certain threshold, and all excess gets excreted

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33
Q

Loop of Henle - thin descending loop

A

Water is passively absorbed here

Loop is impermeable to sodium and solutes (medulla hypertonicity)

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34
Q

Loop of Henle - ascending loop

A

Not permeable to water, but active electrolyte reabsorption occurs here w/ Na/K/Cl pump

Loop diuretics (Lasix) work here to shut down pump and produce very dilute urine

The high osmotic gradient created here allows for urine concentration later

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35
Q

DCT

A

Subjected to hormonal control (Aldosterone, ADH, Angiotensin II, ACEI, ANP)

Early DCT only electrolytes permeable

Late DCT and CT - ADH controls water permeability

-principal and intercalated cells assist w/ concentration here

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36
Q

Aldosterone

A

Secreted from adrenal gland

Increases sodium absorption and potassium secretion in order to maintain blood volume and pressure

Triggered by RAAS

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37
Q

Angiotensin II

A

End of RAAS

Causes Aldosterone, ADH release

Also causes arterial constriction, increases GFR and increases thirst

Results in BP increase, water retention, and increased fluid intake

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38
Q

ACEI/ARB effect on kidneys

A

Inhibits RAAS - decreased aldosterone and ADH secretion

Decreases efferent arteriolar resistance and directly inhibits sodium reabsorption

Results in natriuresis, diuresis, and decreased BP

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39
Q

ANP

A

Secreted by atrial BP increase

Inhibits sodium and water reabsorption to reduce BP and volume

Inhibits RAAS while increasing the GFR

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40
Q

Common secreted by the tubule

A

Bile salts

Oxalate

Urate

Creatinine

Catecholamines

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41
Q

Collecting duct

A

Concentrates the urine according to the ECF osmolality and ADH levels

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42
Q

Cockcroft-Gault Formula

A

GFR/CrCl = [(140-age)*kg] / (72-SCr)

Multiply by 0.85 for women

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43
Q

MDRD

A

Takes gender and race into account for eGFR

Normal: >60mL/min/1.73 m2

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44
Q

Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI)

A

Measure creatinine w/ external filtration markers in order to provide a more accurate eGFR in patients w/ normal/mildly reduced GFR

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45
Q

BUN

A

Normal: 6-20 mg/dL

Waste of protein breakdown - urea that becomes BUN as soon as its in the blood

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46
Q

Increased BUN DDx

A

Renal disease

Excess protein breakdown

High protein diet

GI bleed

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47
Q

Decreased BUN DDx

A

Liver disease

Starvation

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48
Q

Creatinine

A

Muscle breakdown byproduct

Normal: 0.8-1.4 (men) 0.6-1.2 (women)

Steady-state relationship w/ GFR

Used w/ BUN to distinguished types of azotemia

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49
Q

Increased Creatinine DDx

A

Renal failure

High protein diet

Meds (ACEI, NSAIDs, diuretics)

Muscular disease

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50
Q

Decreased Creatinine DDx

A

Pregnancy - normal effect 0.4-0.6 mg/dL

Occurs because GFR and volume increase

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51
Q

Creatinine and BUN filtration dynamics

A

BUN can be absorbed over time w/ a decreased GFR

Creatinine is not absorbed, is secreted into CT for excretion

-Any Creatinine increase may be caused by blocked secretion (cimetidine (antacid, antihistamine), trimethoprim (Bactrim)

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52
Q

BUN:Creatinine increases

A

Both should increase proportionally to indicate intrinsic or post-renal disease

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53
Q

Increased BUN w/ normal creatinine DDx

A

Pre-renal azotemia

Catabolic state (increased breakdown)

GI bleed

High protein diet

Drugs (tetracyclines, steroids)

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54
Q

Decreased BUN:Creatinine DDx

A

ATN

Low protein/starvation

Liver disease

Dialysis

SIADH

Pregnancy

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55
Q

Decreased BUN w/ Increased Creatinine DDx

A

Rhabdomyolysis

Muscular patient in renal failure

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56
Q

Hyponatremia DDx and treatment

A

Volume overload

Excess sodium and water loss

Tx: sodium and water replacement, treat underlying cause

57
Q

Hypernatremia DDx and Treatment

A

Excessive water loss -> dehydration

Tx: Fluid replacement w/ diuretics to eliminate excess sodium

58
Q

Hypochloremia DDx

A

GI upset

DKA

Mineralocorticoid excess

Salt-losing renal disease

High bicarbonate levels

59
Q

Calcium normal levels

A

8.5 - 10.5

60
Q

Magnesium normal levels

A

1.4 - 2

61
Q

Sodium normal levels

A

135-145 mmol/L

62
Q

Potassium normal levels

A

3.5-5.5 mmol/L

63
Q

Chloride normal levels

A

96 - 106

64
Q

Phosphorus normal levels

A

2.0 - 4.5

65
Q

Glucose normal levels

A

80-120 mg/dL

66
Q

Hyperchloremia DDx

A

Metabolic acidosis

GI loss

Mineralocorticoid deficiency

67
Q

Urine Chemical analysis

A

Glucose

Bilirubin

Ketones

Specific gravity

Blood

pH

Protein

Urobilirubin

Nitrite

Leukocyte esterase

68
Q

Specific gravity

A

Normal: 1.010-1.025

Indicates degree of urine concentration/dilution

Low: Diabetes insipidus, tubular/renal damage, well-hydrated

High: DM, adrenal insufficiency, hepatic disease, CHF, excessive water loss

69
Q

Urine pH

A

Normal: ~6

Low: high protein diet, meds, DKA/metabolic acidosis

High: Post-prandial, high veggie/dairy diet, meds, UTI (depends on organism)

70
Q

Urine Protein

A

Single most important indicator of kidney disease

Can also be benign - functional changes or orthostatic (adolescents)

71
Q

Urine Glucose

A

Shows up when maximum threshold is reached (>180)

Investigate for diabetes

May be benign - renal glycosuria from heavy meals or emotional stress

72
Q

Urine Ketones

A

Fatty-acid metabolism

Betahydroxybutyric acid most common

DDx: DKA, restrictive carb diet/starvation

73
Q

Urine Bilirubin

A

Indicates liver disease

  • Hepatocellular disease
  • Biliary obstruction
  • Increase in conjugated (direct) bili
74
Q

Urine Urobilinogen

A

Converted from bilirubin in the intestinal tract

Indicates liver problem, rules out bile duct obstruction if present

DDx: hepatitis, cirrhosis, CHF, pernicious anemia

75
Q

Urine blood

A

Hematuria (rbc intact): renal disease, infection, neoplasm, trauma

Hemoglobinuria: same as hematuria + transfusion reaction, anemia, burns, poisoning

76
Q

Urine Leukocyte esterase

A

Released into urine by neutrophilic granulocytes

Indicates pyuria, bacteriuria, UTI

77
Q

Urine Nitrate

A

Nitrate reduced by G(-) bacteria

Indicates infection, usually E. coli

78
Q

RBC casts

A

Indicates kidney is bleeding, either from vascular insult or parenchyma breakdown

Acute inflammatory or vascular disorder

May be only manifestation of acute glomerulonephritis

79
Q

WBC casts

A

Indicate kidney inflammation/infection

DDx: Acute pyelonephritis, interstitial nephritis, proliferative glomerulonephritis

80
Q

Hyaline casts

A

Non-specific

Get with concentrated urine or diuretic therapy

81
Q

Granular casts

A

Leakage and aggregation of protein

Coarse, deeply pigmented granular casts = ATN

82
Q

Waxy casts

A

Last stage of granular cast degeneration

Non-specific, any variety of acute or chronic kidney disease

83
Q

KUB

A

Used to look for kidney stones

Low radiation, inexpensive

Not all stones show up

84
Q

Sonography applications for kidney

A

Characterize renal mass

Detect obstruction or hydronephrosis

Polycystic kidney disease or renal failure (structural/functional abnormalities)

Cannot see ureters

85
Q

IVP indications

A

Really only used for obstruction or hematuria

Medullary sponge kidney

Papillary necrosis

Stones in the ureter

86
Q

CT scan

A

Gold standard for kidney stones and diagnosis renal tumors

87
Q

Renal Arteriography

A

Gold standard for renal artery stenosis

88
Q

Renal venography

A

Used to diagnose renal vein thrombosis

89
Q

Retrograde/Anterograde Pyelography

A

For diagnosis of urinary tract obstruction or tumors

CT and US are more commonly used

90
Q

Hypovolemic hyponatremia DDx and Tx

A

GI or renal loss

Tx: NS with a possible slow bolus and maintenance if ongoing loss

91
Q

Normovolemic hyponatremia DDx

A

SIADH

Primary polydipsia

Low dietary sodium

92
Q

Hypervolemic hyponatremia DDx and Tx

A

CHF

Cirrhosis

Kidney disease

Nephrotic syndrome (rare)

Tx: restrict fluids and sodium (1000-1200 mg/day)

-Loop diuretics to removed excess fluid, watch potassium carefully

93
Q

Hyponatremia and serum osmolality

A

Isotonic: Hyperproteinemia, hyperlipidemia

Hypotonic: Determine volume status

Hypertonic: Hyperglycemia, radiocontrast agents, Mannitol/Sorbitol/Glycerol/Maltose

94
Q

Chronic Hyponatremia

A

Cerebral adaptation

Sx: Fatigue, nausea, dizziness, confusion, lethargy, muscle cramps, gait issues, forgetfulness

95
Q

Acute hyponatremia

A

Acute hyponatremic encephalopathy

Cerebral effects depend on degree of hyponatremia

Fatigue/malaise followed by HA, lethargy, coma, seizures

Eventual respiratory arrest

Causes permanent neurological damage or death

96
Q

SIADH and treatment

A

Get volume depletion and decreased tissue perfusion

Treat underlying cause, fluid restriction w/ oral salt tablets and loop diuretics if hypervolemic

97
Q

Severe Hyponatremia Tx

A

@ high risk for brain herniation

3% hypertonic saline w/ hourly sodium checks - increase sodium by 4-6 mEq/L in 24 hours

Cause osmotic demyelination if corrected too quickly, careful w/ high risk pts (acute post-op, hyperacute hyponatremia, or intracranial pathology)

98
Q

Acute Hypernatremia

A

Rapid brain volume decrease causes cerebral brain rupture and cause intracerebral/subarachnoid brain hemorrhage

Can occur with overly rapid correction of chronic hyponatremia = brain demyelination

99
Q

Chronic Hypernatremia effects

A

Brain adapts w/in 1 day by pulling water from CNS and increasing cell solute uptake (increases water in cells)

Most who get this already have an existing neurological disease that diminishes thirst

100
Q

Hypernatremia Treatment

A

Free water (D5W) + NS if hypovolemic

Decrease serum sodium slowly, monitor closely and calculate total body water replacement

101
Q

Diabetes Indipidus

A

Central: not enough ADH produced

-Tx: Desmopressin and fluid restriction

Nephrogenic: kidneys are resistant to ADH

-Tx: Thiazide and sodium restriction

102
Q

Hypercalcemia

A

Cause: cancer, primary hyperparathyroidism, drugs (thiazide, lithium)

EKG: Short QT interval

Sx: N/V, polyuria/polydipsia, neuro or psych sx

Causes oliguric renal failure, coma, V-arrhythmias, death

103
Q

Hypercalcemia tx

A

NS and loop diuretics

Drop 2-3 mL in 24-48 hrs

Bisphosphonates (if malignant), Osteoclast inhibitors, dialysis

104
Q

Hypocalcemia

A

Causes: Hypoparathyroidism, Vitamin D deficiency, loop diuretics, phosphates

Sx: tetany, QT prolongation, mouth paresthesias, decreased myocardial contractility

105
Q

Hypocalcemia Tx

A

Calcium salts IV over 5-10 minutes for less than 60 minutes

-Use gluconate if in a peripheral vein

Chronic hypocalcemia: Oral Ca supplements, 1-3 ELEMENTAL grams/day

-Add 1000 Vitamin D if no response

SE: Constipation, GI

106
Q

Hyperphosphatemia

A

Decreased excretion w/ low GFR, chemo, rhabdo

Can be chronic w/ hypocalcemia

Tx: GI binders w/ IV Ca salts, dialysis and dietary restrictions

-avoid aluminum-containing antacids (cause bone dx)

107
Q

Hyperphosphatemia

A

Usually asx until <1.0

Long-term: proximal muscle weakness and osteomalacia

Tx: Severe - Slow IV phosphorus

Mild/moderate - oral phosphates (250mg)

SE: GI upset

108
Q

Hypomagnesemia

A

Cause: Increased excretion, impaired absorption, or reduced intake, drugs (diuretics, aminoglycosides, ETOH)

Sx: Neuromuscular (cramps, tetany), calcium metabolism inhibited

EKG: Widened QRS, AF, VT, VF

109
Q

Hypomagnesemia Tx

A

Only treat if symptomatic or <1.0

IV MgSO4 - bolus and maintenance

-SE: Flushing, sweating

Oral tx if mild/moderate - sustained release

-SE: Diarrhea

110
Q

Hypermagnesemia

A

Sx worse as Mg increases - can cause cardiac or respiratory arrest

Tx: IV calcium to antagonize neuro and CV effects

  • Renal failure: dialysis
  • Normal kidneys: forced diuresis w/ fluid and loop diuretics
111
Q

Hypokalemia

A

Cause: beta-2 agonists, loop diuretics/thiazide, ACEI, PCN, ampho B, Insulin, metabolic acidosis, V/D

EKG: U wave w/ inverted T waves

112
Q

Hypokalemia Tx

A

Loop/thiazide-induced: 40-100 mEq potassium supplements PO

Severe/sx: IV potassium in NS, dextrose to shift K into the cells

-Monitor on EKG, have to give lower dose through a peripheral line

113
Q

Hyperkalemia

A

Cause: increased intake, decreased excretion, Aldosterone resistance, shift to ECF

Sx: Ascending muscle weakness

EKG: Peaked T waves w/ shortened QT initially, progress to long QRS and QT with P wave loss -> dysrhythmias

114
Q

Hyperkalemia Tx

A

Stabilize cardiac w/ calcium gluconate IV

D5W to shift potassium back into the cell

Bicarb if acidotic

Dialysis and K+ binders w/ renal failure

Consider a loop diuretic

115
Q

Hypotonic crystalloids

A

Lower osmotic pressure than blood

Shift fluid into cells and interstitium

D5W (once injected), 1/2 NS

Dont use w/ suspected brain injury, liver disease, trauma, or burns

116
Q

Hypertonic crystalloids

A

Volume expanders

7.5% NS, Dextrose, D50

Higher osmotic pressure - draw fluid into intravascular

For severe hyponatremia, cerebral edema

Cause fluid overload and pulmonary edema

117
Q

Maintenance therapy

A

Daily weights to monitor

Account for obligate fluid loss (1600)

0.45% NS + 20 mEq KCl

For fever >37, increase in 100-150 water needs

4/2/1 degree rule to calculate maintenance flow rate

118
Q

Drugs that do not need adjusting for renal failure

A

Azithromycin

Ceftriaxone

Moxifloxacin

Doxycycline

119
Q

Replacement therapy treatment (hypovolemia)

A

Reduced intake/excess excretion - 0.45% then 0.25% if Na>145, 0.9% if Na<138

V/D - 0.9% until labs

Hemorrhage/burn - 1-2 L wide bore IV, consider PRBC/Albumin

Hydrate until urine production >30 mL/hr occurs

120
Q

Resuscitation (hypovolemic shock)

A

Severe - 1-2L 0.9% rapid infusion

Mild/moderate - 50-100 L/hr then replace loss

May cause fluid overload, be careful and look for signs

121
Q

Colloids

A

Draw fluid into intravascular space

Less volume required and longer duration of action than hypertonic crystalloids

5% Albumin

Hydroxyethalstarches

122
Q

5% Albumin

A

Volume expansion, protein replacement, hemodynamic stability in shock

CI: Anemia, heart failure, sensitivity, ACEI w/in 24 hours (flushing, hypotension)

123
Q

When to use D5W alone

A

Only if pt Na >145 and symptomatic of hypernatremia

124
Q

Uremia symptoms

A

Fishy breath odor

Metallic taste in mouth

Erectile dysfunction

Retrosternal pain w/ inspiration

Restless legs

Numbness

Cramps

125
Q

CKD comorbidities/complications

A

Anemia

Bone/mineral abnormalities

CV and renal risk

Diabetes

126
Q

Dialysis indications

A

Hyperkalemia

Metabolic acidosis

Pericarditis

127
Q

Pre-transplant immunosuppression

A

Steroids - 5mg/kg

Mycophenolate mofetil - 500-1000 mg BID

Basiliximab - 20mg 1 hour before transplant

Gancyclovir and broad spectrum Abx prophylaxis

128
Q

Transplant rejection diagnosis

A

Serial creatinine measurements

>20% over baseline

Rule out non-immunologic causes

129
Q

CKD vaccinations

A

H1N1

Hepatitis A and B

Influenza

Pneumococcal (PPV)

130
Q

Criteria for a benign cyst

A
  1. Echo free on US
  2. Sharply demarcated
  3. Enhanced back wall on US - fluid free of cells

Follow up in 6 months if cyst is benign

131
Q

Autosomal dominant polycystic kidney disease treatment

A

Treat HTN and manage infections

-Bactrim, Chloramphenicol, Ciprofloxin

Dialysis and transplant w/ ESRD

Bilateral nephrectomy w/ recurrent UTIs

132
Q

PKD history symptoms

A

Family history

History of stones/UTIs/Pyelonephritis

HTN

Abdominal masses

133
Q

Autosomal recessive polycystic kidney disease treatment

A

Manage HTN, UTIs - probably w/ constant Abx prophylaxis

Diet supplements, growth hormone

Dialysis/transplant

134
Q

Acquired cystic kidney disease

A

Cysts in dialysis pts w/ CKD/ESRD

Screen pts who have been on dialysis 3-4 yrs

CT scan for Dx

135
Q

Medullary cystic disorders

A

Occurs in kids - can’t potty train, excessive thirst

-low BP, failure to thrive

Causes ESRD in childhood

Tx: liberal fluid/sodium intake

-manage renal failure, dialysis

Transplant these kids

136
Q

Medullary sponge kidney

A

Bunch of grapes/ bouquet of flower on CT/IVP

Pts w/ kidney stones

Renal failure doesn’t occur

Tx: manage UTIs and stone formation

137
Q

When do you calculate the GFR

A

When Scr > 1.5 or the pt is >65 yo

138
Q

Nephrotoxic agents

A

NSAIDs

Aminoglycosides

Heavy metals

Radiocontrast agents

Ethylene glycol (antifreeze, oxalic acid + Ca deposits throughout body)

139
Q

Dosing modification guidelines

A

Need adjustments when GFR < 10 or 10-50

Unless otherwise indicated, not needed when GFR > 50

Nephrology (2 decks)

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