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Nephrology > Week 2 > Flashcards

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
Q

Does nephrotic or nephritic syndrome have a major increase in GFR?

A

nephritic syndrome

kidney function is ramped up

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26
Q

What type of drug is amlodipine?

A

Calcium channel blocker

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27
Q

Maltese cross is a sign of …

A

nephrotic syndrome

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28
Q

Dilating efferent arteriole effect on GFR …

A

dilating efferent = less glomerular pressure

less pressure difference = less GFR

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29
Q

ACE / ARB effect on GFR

A

lowers GFR by preventing constricting of the efferent arteriole

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30
Q

What is treatment for renal artery stenosis?

A

decrease RPF and GFR

use SGLT2 inhibitor

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31
Q

How do SGLT2 inhibitors work?

A

block sodium / glucose reabsorption

RPF decreases since there is less sodium delivery

intraglomerular pressure also decreases

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32
Q

What renal medications can you not give to pregnant women?

A

ACE / ARBs

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33
Q

GFR and RPF in pregnancy

A

GFR is increased

RPF decreases across pregnancy

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34
Q

Why do we give citrate for kidney stones?

A

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

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35
Q

What type of diuretics should be given for kidney stones?

A

thiazide diuretics

increase Ca2+ reabsorption out of urin

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36
Q

How can PCT cause metabolic alkalosis?

A

decreased EACV causes increased Na/H20 reabsorption in PCT due to RAAS

HCO3- follows Na/H2O and is reabsorbed

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37
Q

How can volume depletion cause metabolic alkalosis?

A

increase Na+ reabsorption through ENaC in principal cells

this causes increased K+ secretion and hypokalemia

hypokalemia = metabolic alkalosis

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38
Q

What type of acid base disturbance does pulmonary edema cause?

A

pulmonary edema = hyperventaliation

leads to respiratory alkalosis

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39
Q

What acid base disturbance can follow loop / thiazide diuretic use? How?

A

metabolic alkalosis

more Na+ is being delivered to the principal cells

this leads to increased ENaC and more K+ secretion which furthers metabolic alkalosis

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40
Q

Difference between tCO2 and pCO2

A

tCO2 includes the serum bicarbonate and dissolved CO2

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41
Q

How does decreased GFR contribute to metabolic alkalosis?

A

less filtered bicarb = less secreted bicarb and pH remains high

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42
Q

How can chloride depletion cause metabolic alkalosis?

A

less chloride = more bicarb reabsorption

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43
Q

What acid-base disorder does hyperaldosterism lead to?

A

aldosterone = increased H+ secretion which leads to alkalosis

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44
Q

What is the relationship between low pH and K+ secretion?

A

decreased pH = increased H+ ions

when H+ moves into the cell, K+ is secreted out of the cell causing hyperkalemia

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45
Q

What is the relationship between high pH and K+ secretion?

A

increased pH = decreased H+ ions

when H+ moves out of the cell, K+ is absorbed into cell which causes hypokalemia

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46
Q

What is the end result of acidemia on K+ secretion?

A

acidemia means you have less K+ in the cell

this leads to less K+ secretion

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47
Q

What is the end result of alkalemia on K+ secretion?

A

alkalemia means you have more K+ in the cell

this leads to increased K+ secretion

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48
Q

What is the end result of hypokalemia on ammonia secretion?

A

hypokalemia = K+ secreted out of cells and H+ into cells

the lower H+ pH triggers the production of ammonia

49
Q

What is the end result of hypokalemia on H+ secretion?

A

Hypokalemia increases H+ secretion

(just memorize this)

50
Q

Although essential HTN is common in older patients, what should they also be evaluated for?

A

renovascular HTN

this can be caused by atherosclerosis which worsens as you age

51
Q

What organ is generally not affected by hypertension?

A

the liver

52
Q

Which organ is seriously affected by hypertension?

A

the brain

HTN can lead to stroke

53
Q

When is someone in HTN emergency?

A

180/120 mmHg or higher

54
Q

What is masked HTN? What are its risked?

A

BP is fine in office but is elevated in clinic

Has same risks as someone that always has elevated BP

55
Q

Will simple cysts cause hematuria?

A

no

56
Q

When do you use penicillamine therapy for kidney stones?

A

for cystine stones

57
Q

What type of stones respond to alkalization of urine?

A

cystine and uric acid stones

58
Q

What type of urine do struvite stones form in?

A

more alkaline urine

59
Q

What does the serum albumin look like in nephrotic syndrome?

A

serum albumin of < 3.5 g since there is so much urine excretion

60
Q

What happens when you give IV saline?

A

you increase ECF and decrease RAAS

this will decrease reabsorption of Na+

61
Q

How do you treat hypercalcemia?

A

loop diuretics (NaKCC pump inhibited stops positive potential to reabsorb Ca2+)

IV saline (decrease RAAS, more Na+ excreted, Ca2+ will follow)

62
Q

What are the 2 effects of increased NaCl in the macula densa?

A

1) decrease RAAS / renin

2) constrict afferent through adenosine

63
Q

Is sodium ever excreted in the nephron?

A

no!

64
Q

How is fixed acid secretion regulated?

A

locally by the kidneys

65
Q

Which type of kidney stone is most likely to progress to CKD?

A

anything that causes staghorn calculi that can quickly destroy the kidneys

66
Q

What type of kidney stones cause staghorn calculi?

A

normally struvite stones or triple-phosphate stones

67
Q

What are defining features of triple-phosphate (struvite) stones?

A

they are produced when urease containing bacteria (E. Coli) invade the upper urinary tract

68
Q

What is a distinctive feature of medullary sponge kidney?

A

papillary blush by CT

69
Q

What can high urine calcium cause?

A

calcium oxalate nephrolithiasis

70
Q

When you see someone who weights lifts or eats a lot of protein what are you thinking about

A

uric acid kidney stones

71
Q

Does specific water intake matter in treatment of kidney stone?

A

No, just produce at least 2 liters of urine on a daily basis

72
Q

Should you reduce dietary calcium to treat kidney stones?

A

no

73
Q

How can you treat primary hyperoxaluria?

A

liver transplant to stop the production of excess oxalate / stop stone formation

74
Q

How can you manage patients with mild form of hyperoxaluria?

A

pyridoxine

75
Q

Hyperparathyroidism and kidney stones treatment

A

treat with surgery to remove thyroid mass

76
Q

What can a gastric bypass dispose you to ?

A

calcium oxalate stones due to excess oxalate uptake

77
Q

What type of stones are prevented by alkalization of urine?

A

uric acid stones

78
Q

What type of stones are worsened by alkalization of urine?

A

calcium phosphate stones

struvite stones

79
Q

What type of kidney stones are associated with Crohn’s disease

A

calcium oxalate

80
Q

What is the relationship between chloride and bicarbonate transport?

A

they are inverse

if there is less bicarb available, you increase chloride reabsorption

this occurs at the PCT

81
Q

What would happen if carbonic anhydrase is inhibited?

A

you would have more bicarb excreted in the urine and have metabolic acidosis

82
Q

What is decreased in proximal RTA?

A

decreased HCO3- reabsorption

83
Q

Does proximal RTA cause hypokalemia or hyperkalemia?

A

hypokalemia

increased bicarb secretion = increased K+ secretion to neutralize

84
Q

What happens to the threshold for bicarb reclamation in proximal RTA?

A

lower threshold since you are struggling to reabsorb bicarb

85
Q

urine pH in distal RTA

A

urine pH is high since you cannot excrete H+

(you see a decrease in Cl / NH4+ in the urine)

86
Q

How do you calculate how much to raise the bicarb by?

A

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
Q

What happens to volume in hyperaldosterism?

A

volume expansion due to increased Na+ reabsorption

88
Q

If you administer citrate, does this help alkaloses?

A

not at all!

citrate will be converted to bicarb

89
Q

How long do respiratory and metabolic compensation take?

A

respiratory: minutes to hours

metabolic: 24-72 hours

90
Q

What is normal bicarb level? What does normal bicarb in setting of alkalosis suggest?

A

22-29 mEq

suggests acute respiratory alkalosis

91
Q

Relationship between hypokalemia and bicarb

A

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
Q

What inhibits aminogenesis?

A

high intracellular pH

92
Q

What is the conceptual theory behind checking the anion gap?

A

HCO3- is decreased in metabolic acidosis and this gap can be filled by either Cl- or unmeasured anions

93
Q

What are the 3 AKI etiologies?

A

Prerenal (hypoperfusion)

Intrinsic

Postrenal (obstruction)

94
Q

What type of scenarios can cause hypoperfusion?

A

volume depletion

hypotension

septic shock

constriction of afferent arteriole

diuretics causing volume depletion

95
Q

How do NSAIDs worsen hypoperfusion?

A

they constrict the afferent arteriole by preventing prostaglandin which makes the problem worse

96
Q

What two general scenarios can cause intrinsic AKI?

A

ischemia

infection

97
Q

What type of drugs can cause intrinsic AKI?

A

aminoglycosides (vancomycin)

98
Q

What are muddy brown casts associated with?

A

acute tubular necrosis (ATN)

99
Q

What can bicarb be approximated by?

A

tCO2

100
Q

How do you treat hyperkalemia?

A

1) look at EKG. If acute changes, give calcium

2) if no EKG changes, increase K+ uptake through insulin or albuterol or resin

101
Q

Should you always dose antibiotics based on eGFR?

A

only in a steady state

102
Q

What is a problem of giving saline to someone that is hypokalemic?

A

the increased Na+ is going to result in even more K+ secretion and worsen the problem

103
Q

If you have normal anion gap metabolic acidosis, how can you treat?

A

give supplemental bicarb

104
Q

What is iodinated contrast associated with?

A

intrinsic AKI

ATN

105
Q

How can ARB/ACE or SGLT2i cause intrinsic AKI?

A

they can decrease GFR leading to ATN

this is worse with use of NSAID

106
Q

What is the key sign of AIN vs. ATN?

A

AIN has eosinophils!

107
Q

What BUN/Cr ratio suggests pre-renal azotremia?

A

ratio >20

108
Q

What in the urine is diagnostic of glomerulonephritis?

A

red blood cell casts

109
Q

What do WBC casts indicate?

A

pyelonephritis

110
Q

Why do you get a renal ultrasound for someone with BPH?

A

looking for hydronephrosis related to obstructive uropathy

111
Q

Calculation for fraction excretion of sodium

A

[UNa * PCr] / [PNa * Ucr]

multiple ratio by 100

112
Q

What is ATN frequently associated with?

A

severe volume loss or anything that causes hypoperfusion

113
Q

What are drug ALLERGIES associated with?

A

AIN

114
Q

What is fractional excretion of sodium and urea in pre-renal azotemia? Why?

A

RAAS is activated in pre-renal (low perfusion) problems

this leads to increased sodium and urea reabsorption and decreased fractional excretions

115
Q

What are the urine osmolality and gravity in pre-renal azotemia?

A

urine osmolaltiy > 500

urine specific gravity > 1

116
Q

Can pre-renal azotemia cause ATN?

A

YES

117
Q

What does crystalluria suggest?

A

kidney stone disease or intra-tubular obstruction

Nephrology (6 decks)

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