USMLE Nephrology Flashcards
5 oxoproline / pyroglutamic acid acidosis
Anion gap metabolic acidosis
Patients with Liver dz / Kidney failiure who ingest therapeutic amouts of acetaminophen can develop HAGMA due to 5 oxoproline accumulation.
No therapy currently / supportive care
Accomplish Trial finding with BP
Stage II HTN better results with ACEi and CCB then ACEi and HCTZ ( 20% better results
Acute Tubular Necrosis
- associated with ischemia and/or nephrotoxins
- < 500 mL/day or < 20 ml hr/ Diuretics do NOT change prognosis
- Prototypically runs a 3-week course Acute Tubular Necrosis: Ischemic
- FENa (fractional excretion of sodium) > 3%
- U/A: muddy brown granular casts
Alport Syndrome
- Type IV collagen defect / glomerulonephritis,
- X linked
- Kidney / EYE / EAR
Autosomal dominant polycystic kidney disease (ADPKD) infected Cysts
Ciprofloxacin
B/L Renal artery stenosis
Tx:
- First treat with diuretic + ACEi or ARB since it is as efficacious as agioplasty or surgery.
- Patients with inadequate blood pressure control or worsening renal function on medical therapy should considered for angiotplasty
Bartter syndrome
- Hypokalemia
- Normotensive
- Hypercalciuria with Polydepsia / Polyuria
Behcet’s syndrome
- Complex of recurrent oral aphthous ulcers, genital ulcers, and uveitis
- Crescentic Glomerulonephritis
BP meds for Elderly
Choose HCTZ( complication in old frail elderly / hyponatremia)
ACEi ARBs Long acting CCB < 80 yr
Calcineurin inhibitors and Effect on Kidney
Cyclosporine and tacrolimus
- Can cause acute and chronic nephrotoxic in renal transplant pt that at times my require bx to differentiate from other causes
- Bx: Obliterative arteriopathy, tubular vacuolization and focal segmental glomerulosclerosis
Chronic kidney rejection
- increasing proteinuria
- worsening htn
- biopsy looks like MPGN
Chronic respiratory alkalosis
Hepatopulmonary syndrome in cirrhosis
Causes of Urinary incontinance
- Severe constipation
- UTI
- Atrophic vaginitis
- Metabolic Conditions
- Medications
- Alcohol
- Impared ability to reach tiolet
- Severe constipation
- laxitives
- UTI
- Abx
- Atrophic vaginitis
- Topical estrogen
- Metabolic Conditions
- Do your job and treat it
- Medications
- ID and DC
- Alcohol
- Blame it on the alcohol
- Impared ability to reach tiolet
- Bedside shitting arrangments
Cinacalcet
Calcimimietics decrease Ca/PO4/PTH levels
Increase the sensitivity of ca sensing receptors on parathyroid glands to ca.
Improve symptoms of secondary hyperparathyroidism (pruritus, bone pain, fx, calciphylaxis, avascular necrosis)
Colonic pseudo-obstruction
Up-regulation of potassium channels in the colon, resulting in secretory diarrhea, intestinal potassium loss, and hypokalemia.
CKD Phosphate
CKD III-V
- Dietary restriciton
- Non HD goal of 2.7-4.6
- HD goal of 3.5-5.5
- If Ca > 9.5
- Sevalamer or Lanthanum
- < 9.5 Adynamic bone dz, low PTH
- if Yes - Sevelamer or lanthanum
- if No Ca Acetate/ carbonate - if continues to be high > 5.5 then Sevelamer or lanthanum
IN CKD secondary hyperparathyroidism is due to hyperphosphatemia
Contraindications to Transplant
- Active infection
- Uncontrollable malignancy
- Anti-GBM antibodies
- ABO incompatibility
- Antilymphocyte antibodies against donor
Cystinuria and cystine kidney stones *
- Cystinuria: inherited disorder, excessive “COAL” Cystine Ornithine Arginine, Lysine
Diuretic abuse and surreptitious vomiting vs Lasitavie abuse(diarrhea)
All cause hypokalemia
One losses H+ (vomit / piss)
One looses Bicarb( diarrhea)
Diuretic abuse and surreptitious vomiting can cause hypokalemic metabolic alkalosis
which is inconsistent with the hypokalemic metabolic acidosis observed in this patient.
Effects of Trimethoprime and Cimetidine on Creatnine
Increase serum creatnine without decreasing GFR
Epididymitis tx
Ceftriaxone and doxycyclin
Bladder issues
- Anti Muscarinic agents
- 5-alph reductase inhibitor
- Alpha adrenergic blocking agent
Anti Muscarinic agents (tolterodin, oxybutynin, propiverine)
- Work well with pateints with overactive bladders (will need post woid residual volume measurements before start of treatment.
5-alph reductase inhibitor
- Improves lower urinary tract sx in men with bph - works best with alpha adrenergic blocking agents
Alpha adrenergic blocking agent
helps with bph as well
Features of tuberous sclerosis complex
Tuberous SC
- Hypopigmneted macules, brown fibrous plaque on forehead, angiofibromas
- Glioneuromas, subependymals nodules, seizures
- Cognitive deficits
- Renal angiomyolipomas -hematuria
- Pulmonary LAM
- _Retinal hamartomas -_grayish white
Neurofibromatosis (does not involve renal)
PCKD (not associated with antiomyolipomas)
Von Hippel-Lindau hemangioblastomas of the CNS, retinal angiomas, pheochromocytoma, pancreatic lesions, renal cyst, RCC
FSGS
- Primary - nephrotic syndrome
- Secondary (proteinuria 2-3 grams/day) non nephrotic syndrome
Primary:
- Acute onset with edema, nephrotic syndrom, progresses to ESRD
- Tx: Corticosteriods
- Cyclosporine or tacrolimus
- Mycophenolate
Secondary
- Insidious onset without nephrotic syndrome
- Slowly decrease GFR and increase protienuria
- HIV / IV drug use / SLE nephritis / Atheroembolic dz, Vesicouretera reflux
- Tx: ACEi and ARB
- Non dihydropyridine ca antagonist
FSGS / Focal segmental glomerulosclerosis / Nephrotic Syndrome
- Intravenous drug abuse
- HIV infection
- Malignancy
- HTN*
- Obesity *
- African-American *
Granulomatosis with polyangiitis (also known as Wegener granulomatosis) i
- Granulomatosis with polyangiitis (also known as Wegener granulomatosis) is a necrotizing vasculitis that typically affects the respiratory tract and the kidneys. More than 70% of patients present with upper airway symptoms, particularly sinusitis.
- Kidney biopsy specimens reveal a pauci-immune crescentic glomerulonephritis; medium-sized artery aneurysms and stenosis are not found.
- induction therapy for severe ANCA vasculitis includes plasmapheresis, cyclophosphamide, and corticosteroids.
Hemolytic-uremic syndrome
- Hemolytic anemia (anemia caused by destruction of red blood cells) microangiopathic hemolytic anemia (MAHA)
- Acute kidney failure (uremia)
- Low platelet count (thrombocytopenia)
Clinical Dx / Supportive therapy HD
Henoch Schonlein purpura
Arthralgia and abd complaints
IgA deposits
- Skin: Ecchymosis, petechiea
- Musculoskeletal: Arthritis 1-4 large joints
- GI N/V, ABD pain
- Renal: Hematuria, protienuria renal insufficiency
Henoch-Schb’nlein purpura
- “Classic Triad” Purpura, arthritis and abdominal pain
- Crescentic Glomerulonephritis/RPGN
- C3 and IgA
High serum or urine aldosterone + urinary K+loss of > 30 mEq/day + HTN + low renin =
Aldosterone:renin ratio > 20 is suggestive of primary hyperaldosteronism.
HTN + high renin + high urinary K+ loss =
Renovascular
HTN + low renin + low aldosterone + high urinary K+ loss + low K+ =
- Ingestion of exogenous mineralocorticoid or licorice
HUS Hemolytic Uremic Syndrome
Triad:
- Microangiopathic hemolytic anemia (hb < 8 negative coombs test, schistocytes)
- thrombocytopenia (< 140 000)
- AKI
LDH / billi high with low heptaglobin
Hypercalciuria to avoid ca in urine
Restrict:
- Na and Animal protien
Increase:
- Ca, Citrate, Fluids and fruits
Hyperkalemia
EKG changes
Causes
EKG:
- peaked Twaves
- prolonged QT
- widened QRS
- absent P waves
Causes
- Metabolic acidosis
- insulin deficiency
- increased tissue catabolism
- drugs
- exercise
Hypocomplementemia in Renal Disease
- Membranoproliferative GN (includes SLE / Cryo)
- Lupus
- Cryoglobulinemia
- Post-infectious GN
- Atheroemboli
Hypokalemia and metabolic alkalosis
Vomiting / purging
- Low urinary chloride
_Diuretic use _
- High urinary chloride
Idiopathic Postpartum Renal Failure
• Clinical Features: - Microangiopathic hemolytic anemia - Renal thrombotic microangiopathy - Acute renal failure - Malignant hypertension - Thrombocytopenia • Begins days to weeks following a normal pregnancy • Treatment: usually plasma exchange
IgA nephropathy
- Recurrent epidosdes of gross hematuria (glomerulonephritis) following an upper respiratory infection
- Renal Bx: needed with protein excretion of > 500 mg/day, elevated serum creatinin > 1.5 and hypertension
Incontinence types
- URGE
- Stress
- Overflow
- Mixed
URGE
- Involuntary leakage with urgency / sudden desire to pass
- provoked by running water etc
Stress
- Sneezing, coughing, exertion
- intraabdominal pressure overcomes urinary sphinter
- younger population
Overflow
- Dribblind aor continous leakage with incomplete emptying
- low stream high freq. usually outlet obstruction
Mixed
- Stress and urge together in women
Increased BUN
- Steroids
- Gl bleeding
- High protein intake (TPN)
- Severe cardiomyopathy
- Catabolic states (burns, sepsis, etc.)
Indications for Dialysis
- AEIOU
- Acidosis
- Electrolyte abn
- Uremia
- Intoxication
- Overload
- AEIOU
- Unresponsive hypervolemia
- Unresponsive hyperkalemia
- Unresponsive acidosis
- Uremic pericarditis or symptomatology
- Undesirable poisonings
- CAN NOT HD DIGOXIN
JC virus
BK virus
EBV virus
- PML progressive multifocal leukoencephalopahty when on NATALIZUMAB
- BK tubulointersitial nephritis ureteral stenosis / renal trasnplant
- EVB symptomatic mono associated with 2-3 fold increase of developing MS
Kidney stones
Calcium oxalate
Uric Acid
Struvite
Cystine
Calcium oxalate
- Envelope shaped crystals
- Hyperparathyroidism / Malabsorption / distal RTA
Uric Acid
- Rhomboid cyrstals / radiolucent stones
- Gout / Myeloproliffrative DO
Struvite
- Staghorn calcula / coffin lid /ammonium phosphate
- Recurrent UTI
Cystine
- hexagonal green / larg branche calculi
- Decreased reabsorption of cystine in kidney
Major Medical Complications Post-Transplant
- Cardiovascular events
- Malignancies: skin and lymphoma
- Infections: CMV, EBV, hepatitis
Manage a patient with progressing mycosis fungoides/Sézary syndrome.
The most appropriate management of this patient is alemtuzumab monoclonal antibody therapy directed against CD52. Mycosis fungoides (which affects the skin) and Sézary syndrome (which affects the skin and blood) are the most common forms of cutaneous T-cell non-Hodgkin lymphoma.
Membranoproliferative Glomerulonephritis
AKA crescentic glomerulonephritis
- Low complement
- Hematuria / Tram traks
- HTN
- Tumors and CLL
- Infections — endocarditis, hepatitis B and C
- Cryo - Mixed essential cryoglobulinemia
- Anti-GBM glomerulonephritis.
- SLE - Systemic lupus erythematosus
- HSP - Henoch-Schönlein purpura
- IgA nephropathy
- polyarteritis nodosa
- ANCA-associated Wegener granulomatosis, microscopic polyangiitis and Churg-Strauss syndrome.
Tx: Plasmapheresis, Corticosteroids, and Cytotoxic drugs
MPGN causes
.
Multiple Myeloma
CRAB
- Ca
- Rrenal insufficieny
- Anemia
- Bone mets
Myasthenia Gravis Crisi
Elective Intubation if VC < 20 ml/kg or MIF (Maximal inspiratory forsce is < -30 cmH2O
Name the Diuretics that work on these section of CT.
- Proxima CT:
- Loop:
- Distal CT:
- Proxima CT:
- Acetazolamide
- AE:Metabolic acidosis
- Loop:
- furosemide Like “Bartter’s”
- AE: Hearing loss if > 500 mg a day
- Distal CT:
- thiazides Like “Gittleman’s”
- A/E HypoNa, hypergly, hyperCa, bone marrow suppression
Nephrogenic DI
Caused by which med:
Test to do:
Treatment:
- Lithium
Test to do:
- Water depervation untill urine osm 300 then give DDAVP
- if > 50% change then Central other wise renal
Treatment:
- Tx: amiloride or thiazides
Nephrolithiasis
75-80% contain calcium
Indinavir causes Crystals
Uric acid stones: typically not visible on x-ray
Rx: alkalinization, allopurinol, increasing fluid intake, and a low purine diet
Liddle syndrome
autosomal dominant disorder that presents with early-onset hypertension and is often accompanied by metabolic alkalosis, hypokalemia, and suppressed renin and aldosterone levels.
Nephronolithisis-MCD Complex
Medullary CYSTIC kidney vs MEDULLARY SPONGE KIDNEY
• Polyuria, polydipsia, anemia, FTT, retinitispigmentosa, * NORMAL U/A •
Medullary CYSTIC kidney - progressiveto ESRD
MEDULLARY SPONGE KIDNEY * - “Paintbrush” pattern / Nephrolithiasis, hematuria - Urinary tract infections / Decreased concentrating ability - *** Good prognosis
Non anion gap Acidosis
Urinary Anion Gap
Urine Na+ K - Chloride
Negative
- Diarrhea
- laxitive
- Enteric fistula
Positive
- RTA
- Carbonic anhydrase inhib
- Low aldosteron state
Non anion gap metabolic acidosis
Meds
Acetazolamide, topiramate
Cisplatin
Bactrim
Ampho B
Pheochromocytoma
- The classic triad: headaches, sweating, and tachycardia
- Orthostatic BP changes
- Screen: 24-hour urine metanephrine measurement, could also measure a 24-hour urine VMA
- Falsely elevated levels of urinary metanephrine due to Sympathetic drugs / Monoamine oxidase inhibitors / Labetalol
- Localization: CT scan (MBIG is rarely used)
Hit > 5 days > 50% plt decrease
stop what to use and why?
Bivalirudin is indicated for use only in patients with HIT or who are at risk for HIT and are undergoing acute cardiac interventions if they are unable to be delayed. Lepirudin is cleared through the kidneys and should be used with caution in patients with kidney impairment.
Argatroban is cleared through the liver, and dose adjustments are necessary in patients with elevated liver chemistry test values, including bilirubin level.
Prevent preeclampsia?
- Low-dose aspirin
- Methyldopa
- Oral calcium supplement
- Oral magnesium supplement
- Reduce blood pressure to less than 120/80 mm Hg
Low-dose aspirin (75 to 150 mg/d) is associated with a 10% to 15% relative risk reduction in preventing preeclampsia and reducing adverse maternal and fetal outcomes.
Polyuria
- Primary polydipsia
- Central DI
- Nephrogenic DI
Primary polydipsia
- H2O depervation increase urin osmolality to > 600 mOsm/Kg
- Desmopressin no response
Central DI
- H2O depervatioin increase urine osmolality to > 300
- Desmopressin increases Urine Osm 50-100%
Nephrogenic DI
- H2O Deperivation increase osmolality < 300
- Desmopression no change in urine osmolality
Pregnancy and HTN
ACE inhibitors, angiotensin receptor blockers, and aldosterone antagonists should be avoided during pregnancy and in women planning to conceive.
Labetalol and methyldopa
Pregnancy-Induced HTN: Preeclampsia
- HTN and proteinuria (Edema no longer part of the definition)
- Typically 20 wks gestation/ If before 20 wks, suspect underlying chronic renal disease
- Preeclampsia is typically associated with hyperuricemia
- Pregnancy-induced HTN associated with low uteroplacental flow; avoid lasix Tx HTN & pregnancy methyldopa, hydralazine, and metoprolol (probably CBB)
Prerenal Azotemia
- Dx: volume depletion or decreased effective circulatory volume
- U/A: hyaline casts
- FENa < 1 % / Na < 20 / BUN/Cr > 20
- SG > 1.018
- Studies: Pul-Artery catheter, response to restoration of renal perfusion
Prostatitis
Chronic
Acute
Acute: Fever / Chills
- Pyuria, tender prostate, UCx +ve
- Tx: TPM-SMX / Fluoroquinolones
Chronic: Dysuria and increase Freq
- Recurrent UTI no symptoms of acute prostatitis
- May have tender prostate
- Tx: Fluoroquinolones
Pyroglutamic acidosis
Pyroglutamic acidosis usually occurs in critically ill patients receiving therapeutic doses of acetaminophen. Patients present with unexplained increased anion gap metabolic acidosis due to the accumulation of pyroglutamic acid (also known as 5-oxoproline) as a consequence of impaired glutathione regeneration. Lactic acidosis is not a feature of pyroglutamic acidosis.
Rasburicase
Rasburicase directly breaks down uric acid and minimizes xanthine accumulation
Renal Osteodystrophy
- Vitamin D and calcium
- Phosphate control: binders and diet
- Calcimimetics (cinacalcet)
- Monitor secondary hyperparathyroidism(target iPTH 150-300)
Rhabdomyolysis / renal effects
- Muscle enzymes
- UA
- Electrolytes
- Renal Failure
Muscle enzymes
- CPK > 10000
UA
- REd to brown urine with postive gross blood no RBCs
Electrolytes
- Hyperkalemia / Hyperphosphatemia / hyperuricemia
- Hypocalcemia and dehydaraion
Renal Failure
- Tubular injury from myoglobinuria
Ringers lactete and cursh injuries
Contraindicated since it has potassium and can elevate K to life threatening levels
Severe Preeclampsia with HELLP Syndrome
• Haemolysis \ Abnormal peripheral smear \ Bilirubin > 1.2 \ LDH > 600 • Elevated LFT’s \ AST > 70 • Low Platelets: < 100,000
Sickle cell Trait Renal complications
- Impaired ability to concentrate the urine
- Hematuria
SIDE EFFECTS ACEI / ARB / CCB / Clonidine / Beta-blockers / Diuretics / minoxidil, etc.
- ACEI: cough, hyperkalemia
- ARB: hyperkalemia
- CCB: constipation, pedal edema, AV block
- Clonidine: sedation, dry mouth, rebound
- Beta-blockers: fatigue, bronchospasm
- Diuretics
- Hydralazine, minoxidil, etc.
Staghorn calculi
- Uric acid stones (Coffin shape) - Struvite
Struvite stones
Bacteria:
When to expect?
Tx:
- Proteus and Klebsiella / UA nitrite due to conversion to Urea to ammonia, PH elevated,
- Expect when patient has multiple UTI with high ph, nitrite+
- Nephrolithotomy (percutaneouse first line. Open surgical for morbit obese, nephrectomy for patient how have over the years lost function of kidney due to stag horne
Superficical peroneal nerve
Femoral nerve
Sciatic notch
Psterior tibial
Foot eversion / L5 S1
Acute thigh weakness and numbness / L4L3
S1
Testicular pain
- Testicular torsion
- Epididymitis
- Fournier’s Gangrene
Testicular torsion
- No Cremasteric Reflex
- Profound pain
- U/S is the preferred test
Epididymitis
- Fever, Urinary frequency, posterior tenderness
- Urine culture prefered test
Fournier’s Gangrene
- Much pain to abd/scrotum/ penis
- CT/MRI preferred + urgent surgical evaluation
Thrombotic thrombocytopenic purpura
- Microangiopathic hemolytic anemia (anemia, jaundice and a blood film featuring evidence of mechanical fragmentation of red blood cells)
- Kidney failure
- Thrombocytopenia (low platelet count), leading to bruising or purpura
- Neurologic symptoms (fluctuating), such as hallucinations, bizarre behavior, altered mental status, stroke or headaches
- Fever
TMP SMX
- Side Effects
- Skin
- Hematologic
- Renal
Skin
- Stevens-Johnson syndrome
- Toxic epidermal necrolysis
- Exfoliative dermatitis
Hematologic
- Megaloblastic pancytopenia
Renal
- Hyperkalemia
- Interstitial nephritis
- Impairs tubular secretion of creat without effecting GFR
- Crystalluria
Toxicity
- Alcohol Ketoacidosis
- Methanol injestion
- Ethylene glycol ingestion
- Isopropyl alcohol ingestion
Serum osmolarity = 2*Na + BUN/2.8 + glucose/18
Osmolar gap greater then 10
Alcohol Ketoacidosis
- Slurred speech unsteady gait
- High Osmolar gap / Anion gap Metabolic acidosis
Methanol injestion
- Visual blurring, central scotomata
- High Osmolar gap / Anion gap Metabolic acidosis
Ethylene glycol ingestion
- Flank pain, hematuria, oliguria, tetany
- High Osmolar gap / Anion gap Metabolic acidosis
- UA Calcium oxalate crystals (Envelope)
Isopropyl alcohol ingestion
- CNS depression, disonjugate gaze
- High osmolar gap but no anion gap / no metabolic acidosis
Transverse myelitis vs Guillian barre syndrome
GBS: will not have bowel bladder symptoms or sensory loss below a spinal cord segment Sx of
TM: paresthesias, bowel bladder and sphinctor dysfunction MRI show enhancing cord segments with surrounding edema
Tx tM: Corticosteriods
Tumor Lysis Syndrome
- LABS
- Clinical
Labs
- K > 6
- Po4 > 6.5
- Calcium < 7
- Uric acid > 8
- Or change of 25% in baseline of any
Clinical
- Labs +
- Cr > 1.5 times upper limit
- cardiac arrhythmia
- seizures
TLS likelihood
- Low: IVF
- Intermediate: allopurinal if Urica acid < 8 + IVF else Rasburicase + IVF
- High: Rasburicase
- Established: HD
Type B lactic acidosis
Type A lactic acidosis
Type B lactic acidosis is often due to medication or toxin exposure and may also occur in patients with advanced malignancy, liver disease, or glucose-6-phosphate dehydrogenase deficiency.
Type A lactic acidosis is associated with tissue hypoperfusion and hypoxia.
Types of GN
- Focal segmental glumerulosclerosis
- Membranoproliferative GN
- Membranou GN
- Minimal Change Disease
FSGS
- Obesity
- Herion
- HIV
- Reflux nerphropathy
- AA
MPGN
- Autoimmune (SLE)
- infection
- Mixed cryoglobulinemia
- Monoclonal gammopathies
Membranous GN
- SLE
- Drugs
- Infection (HBV, HCV)
- Malignancy
Minimal Change
- Drugs
- Lymphomas
Uremic Bleeding
- Decreased Factor III
- Abnormal platelet aggregation
- Increased prostacyclin
- Abnormal vWF-VIII complex production
- Tx:- Desmopressin (DDAVP®) — acute / Cryoprecipitate & FFP / PRBCs - Estrogen — chronic therapy - Dialysis if uremic
Urinary casts
- Granular casts
- Fatty casts
- Pigment casts
- Crystal casts
- Red blood cell casts
- White blood cell casts
- Bacterial casts
- Epithelial cell casts
- Granular casts The “muddy brown cast” seen in acute tubular necrosis is a type of granular cast.
- Fatty casts: Nephrotic syndrome
- Pigment casts: rhabdomyolysis
- Crystal casts: stones
- Red blood cell casts:associated with nephritic syndromes or urinary tract injury
- White blood cell casts: interstitial nephritis
- Bacterial casts: pyelonephritis
- Epithelial cell casts: acute tubular necrosis and toxic ingestion
von Hippel-Lindau (Cystic dz)
- AD - RCC (in 40-70%) * - Retinal angiomas, CNS hemangioblastomas (pancreatic and renal) cysts, pheo
What is Liddle syndrome?
- HTN, hypokalemia, metab alk.
Rx amiloride/triamterene. Due to chronically open Na channels.
