UW - Med/Renal Flashcards
What is membranous nephropathy and what are its major clinical associations?
Nephrotic syndrome (2nd most common)
AdenoCA, NSAIDs, Hep B, SLE
What is focal segmental glomerulosclerosis and its major clinical associations?
1 nephrotic syndrome
African Americans, HIspanics, Obesity, HIV, Heroin use
What symptoms are characteristics of mixed cryoglobulinemia?
Palpable purpura, proteinuria, hematuria, arthralgias, hepatosplenomegaly, decreased complement
Older patients, most have HCV infection
What are the causes of normal anion gap metabolic acidosis?
HARDUP Hyperalimentation; hyperchloremic acidosis, Hypoaldosteronism Acetazolamide, Argenine Renal tubular acidosis Diarrhea Ureteral diversion Pancreatico-duodenal fistula
What are the etiologies of primary adrenal insufficiency?
HIMA
Hemorrhagic infarct (meningococcemia, anticoagulants)
Infections (TB, HIV, disseminated fungal)
Metastatic cancer (lung)
Autoimmune
What are the main symptoms in acute and chronic primary adrenal insufficiency?
Acute - SHOCK, Ab tenderness w/ deep palp, FEVER, N/V/Wt loss/Anorex, HypoNa, HyperK, HyperCa, Eosinophilia
Chronic - Fatigue, WEAK, anorex, GI (n/v/ab pain), Weight loss, HyperPIGMENT/VITILIGO, LOW BP, same ion imbalance, Eosinophilia, ANEMIA
Where does aldosterone primarily act and what does it do? What can happen if it gets blocked?
Distal renal tubules, “saves sodium”, secretes K+ and H+
If blocked, K+ and H+ are saved –> Normal AG Met Acid
What is the treatment for uric acid stone?
Hydration, Alkalization of urine (to 6-6.5 w/ potassium citrate), low purine diet,
Add allopurinol for recurrent symptoms
What is the risk of calcium restriction, or decreased Ca in renal tubules for patients with kidney stones (Ca or Uric acid)?
Ca restriction in diet –> Negative calcium –> Hyperoxaluria from increased GI absorption of oxalate
What is the effect of Furosemide on urine Ca?
Increased excretion (because action of Na/K/Cl transport brings Ca in)
What is the treatment for severe hypernatremic hypovolemia? Less severe?
Severe = 0.9% saline which gradually corrects hyperosmolality while normalizing patient’s volume status then switch to 0.45% saline to replace free water deficit
Less = 5% dextrose in .45% saline
What is D5W (5% dextrose in water) used in the treatment of?
Euvolemic and hypervolemic hypernatremia (oral free water in stable patients)
What possible medication in diabetics should be removed during acute kidney injury and/or sepsis and why?
Metformin -> can cause lactic acidosis, withhold until renal function improves
What is the target blood glucose level in patients who are acutely ill and have hyperglycemia? What treatment can facilitate this?
140-180 mg/dL, use short acting insulin
What should always be considered in patients getting CT scan w/ contrast? What alternatives are available?
Pts w/ renal insufficiency (Cr >1.5) or history of diabetes are increased risk of contrast induced nephropathy
Use non-ionic contrast agents
What is the most common cause of AA amyloidosis and what can result from this?
Rheumatoid arthritis -> amyloidosis can lead to Nephropathy via glomerular amyloid deposits (congo red staining etc.)
What are linear glomerular deposits seen with immunoflorescence staining characteristic of? Granular deposits?
Linear = Antiglomerular basement membrane disease (Goodpasture’s)
Granular = immune complex glomerulonephritis (Lupus nephritis, IgA nephropathy, postinfection glomerulonephritis)
What are common causes of nephrogenic DI?
HyperCa, severe HypoK+, tubulointerstitial renal disease, and medication (lithium, cidofivir, foscarnet, demeclocycline, amphotericin)
What is detrusor sphincter dyssnergia?
Neurological disease where detrusor contracts while urethral spinchter contracts –> difficult voiding/interruption of urine stream
What are the causes of hypervolemic hypernatremia?
CHF, cirrhosis, chornic kidney disease or nephrotic syndrome
What are the causes of euvolemic and hypovolemic hypoNa+?
Euvol = SIADH, primary psycho polydipsia, Hypothyroid, secondary adrenal insufficiency
Hypovol = Volume loss (hemorrhage), Primary adrenal insufficiency, GI loss (diarrhea, vomit), Renal loss (diuretics)
How do you calculate serum osmolality and osmolar gap?
Serum Osm = [2Na + Glu/18 + BUN/2.8]
Osm Gap = Observed Osm - Calculated Osm
What causes omsolar gap met acidosis?
Methanol, ehtylene glycol, ethanol poisoning
How do you treat patients with sever hyperK+ with major EKG changes?
- Emergent administration of IV calcium gluconate to stabilize cardiac membrane
- Lower serum K+ by driving into cell w/ insulin and glucose, sodium bicarb, and beta 2 agonists
- Lower total body K+ –> loop diuretic
What does hyponatremia in the setting of serum Osm > 290 mOsm/kg suggest?
Marked hyperglycemia, Advanced renal failure
When should bicarb be used for the treatment of lactic acidsosis?
Only very severe cases where pH
How do you manage severe hypercalcemia?
Short term: NS hydration + Calcitonin (avoid loop diuretics, only use in small doses for HF pts)
Long term: bisphosphonates,
What are common meds that can cause hyperkalemia?
Nonselective beta blockers, potassium sparing diuretics (esp triamterene), ACE inhibitors, ATII-R blockers, NSAIDs
What are some features of cyanide toxicity?
Skin flushing (cherry red), AMS/seizures/coma, Arrhythmias, Tachypnea then resp depression/pulm edema/cyanosis, Ab pain/N/V, Metabolic acidosis (lactic acid) and renal failure
What is the presentation for patients with acute nephritic syndrome + fluid overload?
Anasarca, pulmonary + facial edema, HTN, proteinuria and micro hematuria (>50 rbcs, rbc casts)
What acid/base disorder can result with aspirin toxicity (give abg) and how does this occur?
Direct stimulation of medullary respiratory centers -> Tachypnea -> Resp alkalosis
Anion gap metabolic acidosis from increased production and decreased renal excretion of organic acids
Normal pH, low PaCO2 and bicarbonate
What is the etiology of Familial Hypocalciuric Hypercalcemia?
PT gland and renal tubule cell receptors resistant to Ca –> secrete excess PTH (can be high or high normal)
What is renal tubular acidosis?
Normal Anion Gap Met Acidosis w/ preserved renal fxn (usually elderly w/ poorly controlled DM
Resistance to or deficiency of Aldosterone –> K+/H+ retention
What is the cause in 70% of cases of interstitial nephritis?
Drugs like cephalosporins, penicillins, sulfonamides, sulfonamide containing diuretic, NSAIDs, rifampin, phenytoin and allopurinol
What two compounds are frequently observed in the urine of pts with UTI and what do they indicate?
Leukocyte esterase - significant pyuria
Nitrites - Enterobacteriae convert Nitrates to nitrites
Which medications can lead to hyperkalemia?
Nonselective beta blockers, ACEI, ARBs, K+ sparing diuretics, Digitalis, Cyclosporine, Heparin, NSAIDs, Succinylcholine, Trimethoprim (HIV pts on high doses)
What is the pathophysiology of membranoproliferative glomerulonephritis? Patients sx?
Dense intramembranous deposits of C3, caused by IgG antibodies (C3 nephritic factor) that react with C3 convertase leading to persistent activation of the complement pathway
Signs of Nephrotic Syndrome & dense deposits in glomerular basement membrane w/ IF + for C3
What are the main clinical features of renal cell carcinoma?
- Classic Triad = Flank pain, hematuria, and palpable abdominal renal mass
- Scrotal vericoceles that don’t improve with lying down (left sided)
- Paraneoplastic signs - Anemia/erythrocytosis, Thrombocytosis, fever, hypercalcemia, cachexia
What is a major risk factor in using Succinylcholine and what patients should it not be used in?
Significant potassium release, and life threatening arrthymias (do not use in patients with high risk for hyperkalemia)
Do not use in Crush or Burn injuries >8 hours old (rhabdomyolysis), demyelinating syndromes (GBS), tumor lysis syndrome
What are the features of non-ketotic hyperglycemic coma and most important management?
Very elevated glucose, BUN, Cr, K+, Unconscious/AMS
If volume depleted FLUID RESUSCITATE
What important complication should you look for in patients with GTC with high Cr, urine ketones, and blood, but low RBCs?
Rhabdomyolysis - large amounts of myoglobin released to urine
What drug can be very helpful in facilitating stone passage and why?
stone impaction causes reflex ureteral spasm causing ureter to constrict leading to renal colic
Alpha-1-adrenergic receptor blockers will decrease the pain by relaxing the ureteral muscles
What are the key associations for minimal change disease?
NSAID use and Lymphoma (most common nephrotic syndrome in hodgkins)
What hematological conditions are associated with Amyloidosis nephrotic syndrome?
Multiple myeloma
What type of nephropathy is often associated with solid tumor malignancies?
Membranous glomerulopathy
How do you treat hypovolemic hypernatremia?
Volume replete w/ NS (.9%) and hypotonic fluid (D5W + .45% saline) once euvolemic
What complication of pneumonia in an elderly patient can result w/ hypotension?
HoTN -> Decr Blood flow –> Renin/AT system activates -> glomerular arterioles constriction –> PreRenal Azotemia
What is the indication to operate/amputate in diabetic foot ulcers?
Grade 4 (localized gangrene) and Grade 5 (Extensive gangrene of whole foot)
How may Chronic Kidney Disease affect Calcium metabolism?
Decreased renal production of Vit D leading to hypocalcemia, hyperphosphatemia, and compensatory rise in PTH
How can malignancy affect Calcium metabolism?
Tumor production of 1,25 - dihydroxyvitamin D (lymphoma), increased IL6 (multiple myeloma), increased tumor secretion of PTH related peptide (PTHrP), bony destruction by mets
All would cause Hypercalcemia and compensatory suppression of PTH
If a patient presents with waxing and waning abdominal pain and pees out needle-shaped crystals, what may this indicate and how can you confirm?
Uric Acid stones
CT abdomen or IV pyelography (if radiolucent)
What metabolic ion destabilization can occur following a large high risk surgery (e.g. laparotomy for liver laceration)? Symptoms?
Hypocalcemia, which can often occur following large surgeries requiring extensive transfusions (decreased ionized calcium from binding citrate) –> Hyperactive DTRs, muscle cramps, rarely convulsions
What may be the cause of urinary retention in someone w/ herniated intravertebral disk and BPH?
Pain is limiting patient’s ability to valsalva to overcome intrabdominal pressure required to urinate
What is the most common cause of erectile dysfunction in a patient with recent pelvic surgery?
Neurogenic - I.E. nerve injury
What toxicity should you suspect highly in a patient who recently escaped a house fire? How do you treat?
Cyanide (tx w/ hydroxocobalamin or sodium thiosulfate) and CO poisoning (intubation/O2 therapy)
What is methemoglobinemia?
Oxidation of ferrous (Fe2+) to Ferric (Fe3+) iron in Hb causing left shift of Hb curve
Caused by oxidizing agents (dapsone, nitrates, topical/local anesthetics)
What are the reversible causes of urinary incontinence in elderly?
DIAPPERS
Delirium, Infection (UTI), Atrophic urethritis/vaginitis, Pharma (alpha blockers, diuretics), Psych (depression), Excessive urine output (diabetes, CHF), Restricted mobility (post surgical), Stool impaction
When would you require long term urinary catheter placement?
Neurogenic bladder, urinary retention due to anatomic obstruction
What are the clinical features of mixed cryoglobulinemia?
Moderate-Severe glmoerulonephritis (low complement, blood, prot in urine), arthralgias, palpable purpura, elevated transaminases, associated w/ Hep C (IgM Abs)
What is anti-phospholipid syndrome?
Elevated anti-cardiolipin Abs, A/V thrombosis, loss of pregnancy, Neuro findings (cog defect), microangiopathic hemolytic anemia
What are 2 major risk factors for Rhabdomyolysis? What is the pathophysiology and complications that can result?
Immobilization and Cocaine abuse
direct muscle dmg and release of CPK (elevated potassium and CPK) –> acute tubular necrosis from excessive myoglobin filtration
How can chronic renal failure affect hemostasis and why does this occur? How can this be corrected?
UREMIC COAGULOPATHY
- Platelet to vessel wall or platelet to platelet binding dysfunction -> hemorrhage, increased bleeding time
- From Uremic toxins (guanidinosuccinic acid)
- Tx: DDAVP, Cryoprecipitate, and conjugated estrogens
What medications should be avoided in patients w/ severe renal insufficiency requiring anti-coagulation and why?
LMWH (enoxaparin), Fondaparinux (injection Factor Xa inhibitor), and Rivaroxaban (oral FXa inhib)
B/c reduced renal clearance increases anti-Xa activity levels, leading to increased bleeding risk
An elderly patient presented w/ signs of pyelonephritis w/ a multi-drug resistance organism. What type of bacterial species was it and what tx would have been used? Risks of this treatment?
Gram negative rod, tx w/ aminoglycosides like Amikacin
Can lead to acute renal failure, must monitor renal function closely
What is the earliest renal abnormality in patients w/ diabetes? later abnormality?
Glomerular hyperfiltration -> intraglom HTN -> progressive glomerular damage & renal fxn loss (ACEI decrease HTN)
Thickening of the glomerular basement later
When should osmolar gap be calculated?
increased AG met acidosis, w/ methanol, ethanol, or ethylene glycol tox (calculate by measured and calculated serum Osm)
When should urine anion gap be calculated?
When normal AG met acidosis, to determine if acidosis is due to renal (RTA or acetazolamide) vs. intestinal bicarb loss (diarrhea)
What is a common Tx for patients w/ ascites/hypervolemia from decompensated cirrhosis? Risks involved and why?
- Loop diuretics (Furosemide) –> Blocking channel causes increased Na+ to DTC –> elevated H+ and K+ secretion in urine
- Volume contraction and increased aldosterone further promote H+ secretion
- All this leads to: Hypokalemia, Metabolic Alkalosis, and Prerenal AKI
What are signs of proteus mirabilis UTI? How can you differentiate from Candida, E Coli, enterococci causes?
-Alkalizatio nof urine (pH >7) which promotes struvite stone formation -> staghorn caliculi
-Urease positive
(normal pH and urease negative for others)
What are the symptoms associated w/ hypercalcemia?
-Constipation (altered intestinal smooth muscle tone), anorexia, vomit, weakness, polyuria (defect in concentrating ability of urine), and neuro abnormalities (confusion, lethargy)
What is the proper management of a solid testicular mass and why?
Radical orchiectomy (removal of testes + cord) - examine under microscope to determine cancer type and provide additional surgery, RT, Chemo depending on need
High cure rate w/ aggressive management
What type of drug is chlorthalidone?
Thiazide diuretics
What are the different types of metabolic acidosis and how can you differentiate?
- Saline-resistant has High urine chloride (excess mineralocorticoid causes H+/K+ loss and Na+ retention -> increased extracell volume -> kidneys excrete NaCl) - Cushing’s, Primary hyperaldost, Severe HypoK+
- Saline responsive has Low urine chloride (due to hypovolemia and hypochloremia)
What are the dietary measures to take in preventing recurrent nephrolithiasis and why?
- Increase fluids (>2L urine/day)
2. Reduce sodium (
What drug therapies help prevent recurrent kidney stones?
- Thiazide diuretics -> lead to mild volume depletion -> compensatory rise of Na reabsorption -> increased passive Ca reabsorption
- Urine alkalinization (potassium citrate/ bicarbonate salt)
- Allopurinol (for hyperuricosuria stones)
What does side abdominal pain and positional discomfort that radiates to the groin most likely signify, and what diagnostic study would be most helpful?
Obstructive ureterolithiasis -> Abdominal Ultrasound
What would urine analysis reveal in patients w/ contrast induced nephropathy?
Muddy-brown granular casts, resolves w/in 3-5 days
What does the urinary cyanide nitroprusside test help detect?
Elevated cystine levels –> think Cystinuria, especially w/ hexagonal crystals in urine
What clotting complication often occurs with nephrotic syndrome? What are the symptoms?
Renal vein thrombosis and other thromboembolism because of loss of antithrombin 3 (especially w/ membranous glomerulopathy)
Sx = abdominal pain, fever, hematuria
What is used to treat SLE w/ renal involvement?
Cyclophosphamide
What are the main causes of membranous glomerulonephritis?
Hep B/C, syphillis, gold, penicillamine, SLE and Rheumatoid arthritis
What is the cause of acute kidney injury 2/2 acyclovir?
Crystal induced renal tubular obstruction
How long does it take for drug induced acute interstitial nephritis to set in? What other findings are associated?
7-10 days after drug exposure
-Skin rash, eosinophilia, eosinophiluria, and pyuria
What is the most common initial presentation of patients w/ ADPCKD and how can you diagnose?
HTN + bilateral upper abd masses, renal ultrasound
What are the urine/serum osm and urine/serum Na findings in SIADH?
UNa >20, Uosm > 300, Serum Osm
What is hyposthenuria? What type of patients are at risk?
IMpairment in in kidney’s ability to concentrate urine leading to nocturia
-Pt w/ sickle cell disease/trait may present
What are indications for urgent dialysis?
AEIOU - Acidosis, Electrolyte abnormalities, Ingestion (toxic alcohols, Li), Overload, Uremia
