Renal

Question 1

Indications for Dialysis?

Answer 1

Acidemia 
Electrolytes 
Intoxication (ASA) 
Overload of fluid 
Uraemia

Question 2

What to do about renal failure?

Answer 2

Pre-renal = Fluids 
Post-renal = Catheter/ image/ tx for obstruction 
Intra-renal = Refer

Question 3

Types of intra-renal injury

Answer 3

ATN (due to prolonged and irreversible ischemia to the kidney) - like a stroke to the kidney - check pre-renal function
Toxic - figure out what it is, call poison control - can cause a RTA
More of a chronic picture?
- Med review - make sure not causing problem for kidneys
- Diabetes?
- Autoimmune - send to nephrologist (this is where the nephrotic (more of a albumin problem)vs nephritic (more of a GFR problem)

CKD classification and staging.

Question 4

Urine sodium with diuretics?

Answer 4

Not useful as the diabetics make the sodium high - hypovolemic hypevolemia

Question 5

Young female with a fever?

Answer 5

Need to rule out pyelonephritis

Question 6

Criteria for AKI

Answer 6

Increase creatine - 25% increase of baseline within 48 to 72 hours
Decreased urine output over 6 hours 1 ml/kg/hr

• recall that Cr is a delayed marker for AKI

Question 7

Medications causing acute interstitial injury

Answer 7

PPI, NSAIDS, Antibiotics, Penicillins

Question 8

Signs of ATN

Answer 8

Muddy brown casts in the urine (granular), protein (smaller amounts).

Question 9

Signs of GN

Answer 9

Red blood cell casts, less than 1g/ day of protein

Question 10

Criteria for nephrotic syndrome

Answer 10

3.5 g/ day protein , low albumin, edema.

Will also see hyperlipidemia - compensatory mechanism of the liver

Primary - MCD, membranous, FSGS

Question 11

Nephritis causes

Answer 11

Pauci-immune - ANCA,

Immune - Lupus

Question 12

In interstitial disease sign?

Answer 12

WBC casts - look for on urine microscopy.

Question 13

CIN AKI?

Answer 13

Contrast induced kidney injury - a pre-renal picture - has a hyper osmolar effect and sends vessels into spasm - stop ACE/Metformin, give lots and lots of fluids. Will see rise within a few days

Question 14

Emboli to the kidney vasculature

Answer 14

Cholesterol from a CABG - or Angio - delayed - 10-14 days, with WBC and granular cast, look for other sites of emboli, rash, eosinophils

Question 15

Tx for AKI

Answer 15

If suspect pre-renal - challenge 1L and then see if they produce urine, if there is no urine, you should give a lasix challenge

Question 16

Indication for dialysis

Answer 16

Acidosis (refractory)
Electrolytes (K)
Overload
Uraemia (encephalopathy) (pericarditis)

Question 17

Kidney manage HCO3 by?

Answer 17

Can resorbed, can excrete H+ and make new HCO3, can breakdown glutamine, makes NH4 which will also generate HCO3

Question 18

Is it metabolic or respiratory acid/alk- what do you look at?

Answer 18

Acid
PCO2 >40 -resp
HCO3 <24 - met

Alk
PCO2 <40 - resp
HCOS >24 - met

Question 19

How much should Bicarbonate compensate in metabolic acidosis

Answer 19

Should be 1 for every 1 of CO2

Question 20

ACR

Answer 20

Anything less than 2 is normal, best way to interpret is to multiply by 10 for estimated 24 hour. Need a serum albumin too.

Consider PCR - in relation to ACR - if this is high when the ACR is low, then there is some other protein coming out.

Question 21

Nephrotic Syndrome work up

Answer 21

HIV, Heps, SPEP/UPEP, ANA, anti-dsDNA, C3/C4 consider Bx