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Week 2 Flashcards

1
Q

What is the predominant unmeasured anion that could cause anion gap?

A

albumin

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2
Q

What does a normal anion gap tell you?

A

hyperchloremic

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3
Q

What is MUDPILES referring to?

A

high anion gap metabolic acidosis

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4
Q

What is multiple myeloma associated with?

A

proximal tubular renal acidosis

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5
Q

What contributes to acidosis in proximal tubular acidosis?

A

not reabsorbing HCO3- properly and spilling too much base into urine

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6
Q

What other urine values are seen with proximal renal tubular acidosis?

A

glucose spilled into urine (PCT damage)

low phosphate (phosphate normally reabsorbed at PCT)

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7
Q

When do we use the urine anion gap?

A

to determine whether urine NH4+ is increased or decreased

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8
Q

How does urine anion gap work?

A

since Cl- is excreted with NH4+, the anion gap should be negative in acidosis since you are secreting NH4+ to get rid of excess protons

if the urine AG is high, this means that you are not excreting NH4+ properly

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9
Q

When do you not excrete acid properly?

A

distal renal tubular acidosis

urine pH is high because you are not excreting H+ properly

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10
Q

Why does metabolic alkalosis persist after vomiting is done (no more acute acid loss)?

A

volume depletion

volume depletion activates RAAS / aldosterone which leads to increased H+ secretion and K+ secretion

K+ secretion causes hypokalemia which worsens metabolic alkalosis

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11
Q

What acid base disturbance can a drug overdose lead to?

A

respiratory acidosis

hypoventaliation = more CO2

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12
Q

What acid base disturbance can COPD lead to?

A

respiratory acidosis as a result of chronic hypotension

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13
Q

What acid base disturbance can asthma lead to?

A

respiratory alkalosis due to hyperventaliation expelling the CO2

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14
Q

When do you use Winter’s formula?

A

in metabolic acidosis

want to see what appropriate respiratory compensation should be

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15
Q

Winter’s formula

A

Expected PaCO2 = (1.5 x serum HCO3)+(8±2)

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16
Q

What does Winter’s formula tell you?

A

if PaCO2 < expected, we have a respiratory alkalosis / mixed disorder

if PaCO2 > expected, we have a respiratory acidosis / mixed disorder

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17
Q

What is AG II effects on filtration fraction?

A

AG II constricts the efferent arteriole which leads to decrease in RPF and increase the GFR

GFRis increased because efferent constriction increases glomerular pressure

overall, this increases the FF

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18
Q

What 2 things happen when the macula densa senses increases in Na+?

A

1) afferent constriction

2) decreased renin (don’t want more absorption)

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19
Q

How does adenosine constrict the afferent arteriole?

A

through Ca2+

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20
Q

If you want to decrease proteinuria, what do you want to do? How can you accomplish this?

A

you want to decrease GFR

can do this by either constricting afferent or dilating efferent

normally use an ACE / ARB

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21
Q

Calcium channel blocker effects on GFR?

A

increase

prevent constriction of the afferent arteriole

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22
Q

Why is there edema in glomerular disease?

A

decreased capillary oncotic pressure leads to fluid leaving the capillaries

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23
Q

What types of proteins are lost in nephrotic syndrome? What is the result?

A

1) albumin - hypercholesterolemia (liver up) / edema

2) immunoglobin - prone to infection

3) antithrombin III - hypercoagulability

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24
Q

What is a cause of nephritic syndrome?

A

lupus

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25
Does nephrotic or nephritic syndrome have a major increase in GFR?
nephritic syndrome kidney function is ramped up
26
What type of drug is amlodipine?
Calcium channel blocker
27
Maltese cross is a sign of ...
nephrotic syndrome
28
Dilating efferent arteriole effect on GFR ...
dilating efferent = less glomerular pressure less pressure difference = less GFR
29
ACE / ARB effect on GFR
lowers GFR by preventing constricting of the efferent arteriole
30
What is treatment for renal artery stenosis?
decrease RPF and GFR use SGLT2 inhibitor
31
How do SGLT2 inhibitors work?
block sodium / glucose reabsorption RPF decreases since there is less sodium delivery intraglomerular pressure also decreases
32
What renal medications can you not give to pregnant women?
ACE / ARBs
33
GFR and RPF in pregnancy
GFR is increased RPF decreases across pregnancy
34
Why do we give citrate for kidney stones?
calcium binds to citrate instead of oxalate by binding to citrate, you can break up the calcium in urine rather than forming a calcium oxalate stone
35
What type of diuretics should be given for kidney stones?
thiazide diuretics increase Ca2+ reabsorption out of urin
36
How can PCT cause metabolic alkalosis?
decreased EACV causes increased Na/H20 reabsorption in PCT due to RAAS HCO3- follows Na/H2O and is reabsorbed
37
How can volume depletion cause metabolic alkalosis?
increase Na+ reabsorption through ENaC in principal cells this causes increased K+ secretion and hypokalemia hypokalemia = metabolic alkalosis
38
What type of acid base disturbance does pulmonary edema cause?
pulmonary edema = hyperventaliation leads to respiratory alkalosis
39
What acid base disturbance can follow loop / thiazide diuretic use? How?
metabolic alkalosis more Na+ is being delivered to the principal cells this leads to increased ENaC and more K+ secretion which furthers metabolic alkalosis
40
Difference between tCO2 and pCO2
tCO2 includes the serum bicarbonate and dissolved CO2
41
How does decreased GFR contribute to metabolic alkalosis?
less filtered bicarb = less secreted bicarb and pH remains high
42
How can chloride depletion cause metabolic alkalosis?
less chloride = more bicarb reabsorption
43
What acid-base disorder does hyperaldosterism lead to?
aldosterone = increased H+ secretion which leads to alkalosis
44
What is the relationship between low pH and K+ secretion?
decreased pH = increased H+ ions when H+ moves into the cell, K+ is secreted out of the cell causing hyperkalemia
45
What is the relationship between high pH and K+ secretion?
increased pH = decreased H+ ions when H+ moves out of the cell, K+ is absorbed into cell which causes hypokalemia
46
What is the end result of acidemia on K+ secretion?
acidemia means you have less K+ in the cell this leads to less K+ secretion
47
What is the end result of alkalemia on K+ secretion?
alkalemia means you have more K+ in the cell this leads to increased K+ secretion
48
What is the end result of hypokalemia on ammonia secretion?
hypokalemia = K+ secreted out of cells and H+ into cells the lower H+ pH triggers the production of ammonia
49
What is the end result of hypokalemia on H+ secretion?
Hypokalemia increases H+ secretion (just memorize this)
50
Although essential HTN is common in older patients, what should they also be evaluated for?
renovascular HTN this can be caused by atherosclerosis which worsens as you age
51
What organ is generally not affected by hypertension?
the liver
52
Which organ is seriously affected by hypertension?
the brain HTN can lead to stroke
53
When is someone in HTN emergency?
180/120 mmHg or higher
54
What is masked HTN? What are its risked?
BP is fine in office but is elevated in clinic Has same risks as someone that always has elevated BP
55
Will simple cysts cause hematuria?
no
56
When do you use penicillamine therapy for kidney stones?
for cystine stones
57
What type of stones respond to alkalization of urine?
cystine and uric acid stones
58
What type of urine do struvite stones form in?
more alkaline urine
59
What does the serum albumin look like in nephrotic syndrome?
serum albumin of < 3.5 g since there is so much urine excretion
60
What happens when you give IV saline?
you increase ECF and decrease RAAS this will decrease reabsorption of Na+
61
How do you treat hypercalcemia?
loop diuretics (NaKCC pump inhibited stops positive potential to reabsorb Ca2+) IV saline (decrease RAAS, more Na+ excreted, Ca2+ will follow)
62
What are the 2 effects of increased NaCl in the macula densa?
1) decrease RAAS / renin 2) constrict afferent through adenosine
63
Is sodium ever excreted in the nephron?
no!
64
How is fixed acid secretion regulated?
locally by the kidneys
65
Which type of kidney stone is most likely to progress to CKD?
anything that causes staghorn calculi that can quickly destroy the kidneys
66
What type of kidney stones cause staghorn calculi?
normally struvite stones or triple-phosphate stones
67
What are defining features of triple-phosphate (struvite) stones?
they are produced when urease containing bacteria (E. Coli) invade the upper urinary tract
68
What is a distinctive feature of medullary sponge kidney?
papillary blush by CT
69
What can high urine calcium cause?
calcium oxalate nephrolithiasis
70
When you see someone who weights lifts or eats a lot of protein what are you thinking about
uric acid kidney stones
71
Does specific water intake matter in treatment of kidney stone?
No, just produce at least 2 liters of urine on a daily basis
72
Should you reduce dietary calcium to treat kidney stones?
no
73
How can you treat primary hyperoxaluria?
liver transplant to stop the production of excess oxalate / stop stone formation
74
How can you manage patients with mild form of hyperoxaluria?
pyridoxine
75
Hyperparathyroidism and kidney stones treatment
treat with surgery to remove thyroid mass
76
What can a gastric bypass dispose you to ?
calcium oxalate stones due to excess oxalate uptake
77
What type of stones are prevented by alkalization of urine?
uric acid stones
78
What type of stones are worsened by alkalization of urine?
calcium phosphate stones struvite stones
79
What type of kidney stones are associated with Crohn's disease
calcium oxalate
80
What is the relationship between chloride and bicarbonate transport?
they are inverse if there is less bicarb available, you increase chloride reabsorption this occurs at the PCT
81
What would happen if carbonic anhydrase is inhibited?
you would have more bicarb excreted in the urine and have metabolic acidosis
82
What is decreased in proximal RTA?
decreased HCO3- reabsorption
83
Does proximal RTA cause hypokalemia or hyperkalemia?
hypokalemia increased bicarb secretion = increased K+ secretion to neutralize
84
What happens to the threshold for bicarb reclamation in proximal RTA?
lower threshold since you are struggling to reabsorb bicarb
85
urine pH in distal RTA
urine pH is high since you cannot excrete H+ (you see a decrease in Cl / NH4+ in the urine)
86
How do you calculate how much to raise the bicarb by?
divide body weight by 2 multiple half-weight by the amount wanted to raise for example, if you want to raise 12 to 20 bicarb, you multiple half-weight by 8
87
What happens to volume in hyperaldosterism?
volume expansion due to increased Na+ reabsorption
88
If you administer citrate, does this help alkaloses?
not at all! citrate will be converted to bicarb
89
How long do respiratory and metabolic compensation take?
respiratory: minutes to hours metabolic: 24-72 hours
90
What is normal bicarb level? What does normal bicarb in setting of alkalosis suggest?
22-29 mEq suggests acute respiratory alkalosis
91
Relationship between hypokalemia and bicarb
hypokalemia = more H+ in proximal tubule cells since more K+ going into blood this leads to more H+ secretion H+ and bicarb have opposite ways when H+ is secreted into the lumen, more bicarb is reabsorbed
92
What inhibits aminogenesis?
high intracellular pH
92
What is the conceptual theory behind checking the anion gap?
HCO3- is decreased in metabolic acidosis and this gap can be filled by either Cl- or unmeasured anions
93
What are the 3 AKI etiologies?
Prerenal (hypoperfusion) Intrinsic Postrenal (obstruction)
94
What type of scenarios can cause hypoperfusion?
volume depletion hypotension septic shock constriction of afferent arteriole diuretics causing volume depletion
95
How do NSAIDs worsen hypoperfusion?
they constrict the afferent arteriole by preventing prostaglandin which makes the problem worse
96
What two general scenarios can cause intrinsic AKI?
ischemia infection
97
What type of drugs can cause intrinsic AKI?
aminoglycosides (vancomycin)
98
What are muddy brown casts associated with?
acute tubular necrosis (ATN)
99
What can bicarb be approximated by?
tCO2
100
How do you treat hyperkalemia?
1) look at EKG. If acute changes, give calcium 2) if no EKG changes, increase K+ uptake through insulin or albuterol or resin
101
Should you always dose antibiotics based on eGFR?
only in a steady state
102
What is a problem of giving saline to someone that is hypokalemic?
the increased Na+ is going to result in even more K+ secretion and worsen the problem
103
If you have normal anion gap metabolic acidosis, how can you treat?
give supplemental bicarb
104
What is iodinated contrast associated with?
intrinsic AKI ATN
105
How can ARB/ACE or SGLT2i cause intrinsic AKI?
they can decrease GFR leading to ATN *this is worse with use of NSAID*
106
What is the key sign of AIN vs. ATN?
AIN has eosinophils!
107
What BUN/Cr ratio suggests pre-renal azotremia?
ratio >20
108
What in the urine is diagnostic of glomerulonephritis?
red blood cell casts
109
What do WBC casts indicate?
pyelonephritis
110
Why do you get a renal ultrasound for someone with BPH?
looking for hydronephrosis related to obstructive uropathy
111
Calculation for fraction excretion of sodium
[UNa * PCr] / [PNa * Ucr] multiple ratio by 100
112
What is ATN frequently associated with?
severe volume loss or anything that causes hypoperfusion
113
What are drug ALLERGIES associated with?
AIN
114
What is fractional excretion of sodium and urea in pre-renal azotemia? Why?
RAAS is activated in pre-renal (low perfusion) problems this leads to increased sodium and urea reabsorption and decreased fractional excretions
115
What are the urine osmolality and gravity in pre-renal azotemia?
urine osmolaltiy > 500 urine specific gravity > 1
116
Can pre-renal azotemia cause ATN?
YES
117
What does crystalluria suggest?
kidney stone disease or intra-tubular obstruction

Nephrology (6 decks)

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