Acute Renal Failure and Chronic Kidney Failure

Question 1

Sudden impairment of kidney function

Leads to retention of nitrogenous waste products called

With or without decrease in UO

Answer 1

Acute Kidney Injury

Azotemia

Question 2

UO in AKI

Answer 2

Oliguria <400ml/day

Anuria <100ml/day

Question 3

Increase in Creatinine 0.5mg/dl/day

Increase in BUN 10mg/dl/day over several days

Answer 3

AKI

Question 4

AKI Creatinine value

Answer 4

Inc 0.5 mg/dl/day

Question 5

BUN AKI value

Answer 5

Increase 10mg/dl/day over several days

Question 6

Clinical forms of acute renal failure

Answer 6

Prerenal azotemia
Intrinsic renal azotemia
Postrenal azotemia

Question 7

AKI epidemiology

Complication of hospital and ICU patients

Answer 7

5% admission

30% ICU

Question 8

50-70% of all cases of ARF
Most common form
Due to renal hypoperfusion without compromising the integrity of renal parenchyma

ECF depletion as in hemorrhage or dehydration

Answer 8

Prerenal azotemia

Prerenal AKI

Question 9

30% of all AKI
due to diseases that involve the renal parenchyma
Mostly triggered by
ischemia (ischemic ARF)
nephrotoxin (nephrotoxic ARF)
acute tubular necrosis (ATN)

Answer 9

Renal azotemia

Intrinsic Renal AKI

Question 10

5-10% of all ARF

Diseases that cause urinary tract obstruction

Answer 10

Postrenal azotemia

Postrenal AKI

Question 11

Most common cause of postrenal azotemia is

Answer 11

Bladder neck obstruction from prostatic disease

BPH

Question 12

ARF Diagnostic procedures

Answer 12

Laboratory exams

Urinalysis - casts or proteinuria suggests the specific type of ARF

Fractional excretion of sodium (FeNa) - distinguished prerenal azotemia from other typed

Serial measurements of BUN and Crea

Serum potassium, phosphate, calcium, uric acid, creatine kinase levels - can point to etiology of ARF

Question 13

BUN/Crea ratio in Pre-Renal

Answer 13

> 15

Question 14

BUN/Crea ratio in Renal

Answer 14

<15

Question 15

AKI Radiographic findings

Answer 15

UTZ - useful to exclude obstructive uropathy

CT Scan and MRI - alternative

Pyelography/IVP - to locate obstruction in the urinary tract

Plain film of abdomen can detect nephrolothiasis

Doppler UTZ, MRI, renal angiography

Renal biopsy - for cases where prerenal and postrenal failures are excluded and the cause of intrinsic renal azotemia is still unclear

Question 16

Encompasses a spectrum of different pathophysiologic processes associated with abnormal kidney function and a progressive decline in GFR

Most last >3 months

Irreversible

Small shrunken kidneys

Answer 16

Chronic Kidney Disease

Question 17

CKD Stage 1

Answer 17

90 ml/min per 1.73m2

Question 18

CKD Stages 2,3,4 GFR

Answer 18

60-89 ml/min per 1.73m2
30-59 ml/min per 1.73m2
15-29 ml/min per 1.73m2

Question 19

CKD RF

Answer 19

Hypertension
Diabetes
Autoimmune
Age
African ancestry
Family history

Question 20

Stage of CKD where anemia is prominent

Answer 20

Stage 3 (30-59 ml/kg/min)

Question 21

CKD Etiology and Epidemiology

Answer 21

Diabetic glomerular disease
Glomerulonephritis
Hypertensive nephropathy (Primary glomerulopathy with hypertension, Vascular and ischemic renal disease)
Autosominal dominant polycystic kidney disease
Other cystic and tubulointerstitial nephropathy

Question 22

Bone manifestations of CKD

Answer 22

High bone turnover - increased PTH
Low bone turnover - decreased or normal PTH level

PTH reabsorbs calcium at PCT, ALOH (physiologic) additionl at DCT and CD

PTH blocks reabsorption of phosphate in PCT
Reduction of phosphate ions result in a more ionized Ca in blood due to lack of phosphate ion-calcium salt formation (insoluble) dec plasma calcium.

Question 23

Cardiovascular manifestation of CKD

Answer 23

Vascular calcification
HTN
Heart failure
Pericarditis

Question 24

Calcemic uremic arteriolopathy

Answer 24

Calciphylaxis

Question 25

Anemia in CKD

Answer 25

Normocytic normochromic anemia Stage 3 Decreased EPO

Question 26

Neurologic abnormalities in CKD are from

Answer 26

retained nitrogenous metabolites Evident in Stage 3 Early signs include: disturbance in memory, concentration and sleep Neuromuscular irritability Periphera neuropathy (Stage 4)

Question 27

GI manifestations in CKD

Answer 27

Uremic fetor - urine like odor on breath Gastritis Peptic disease Mucosal ulceration

Question 28

Endocrine metabolic disease in CKD

Answer 28

Glucose metabolism impaired | Decreased estrogen and testosterone

Question 29

Dermatologic manifestation in CKD

Answer 29

Pruritus | Nephrogenic fibrosing dermopathy

Question 30

Leading cause of ESRD in US | Major cause of morbidity and mortality from persons with either Type 1 DM or Type 2 DM

Answer 30

Diabetic nephropathy

Question 31

Edema Foamy appearance or excessive frothing of urine (proteinuria) Unintentional weight gain (from fluid accumulation) Anorexia Nausea and vomiting Fatigue

Answer 31

Diabetic nephropathy

Question 32

24 h urine collection reveals Microalbuminuria: 150-300 mg/day Macroalbuminuria: 300 mg/day N: <150 mg/day

Answer 32

Diabetic nephropathy

Question 33

Diabetic nephropathy pathologic hallmark

Answer 33

Kimmelsteil-Wilson lesions (glomerular nodular sclerosis) Thickening of basement membrane on light microscopy

Question 34

Diabetic nephropathy Tx

Answer 34

Control hyperglycemia Optimal therapy for diabetic nephropathy Strict blood pressure control Uncontrolled hypertension accelerates the rate of decline of renal function Adequate control of blood presse <130/80 is recommended

Question 35

First line therapy for all patients with DM and HTN Lowers intraglomerular pressure and posses renoprotective properties Reduces progression from microalbuminuria to macroalbuminuria Reduces the decline in GFR

Answer 35

ACEI or ARB

Question 36

Alternative in patients who develop ACE inhibitor associated cough and angioedema

Answer 36

ARB

Question 37

Cough and angioedema from ACEI use is caused by

Answer 37

bradykinin

Question 38

Patchy interstitial suppurative inflammation Intratubular aggregates of neutrophils Tubular necrosis

Answer 38

Acute Pyelonephritis

Question 39

Complications Acute Pyelonephritis

Answer 39

Papillary necrosis Pyonephrosis Perinephric abscess

Question 40

Important cause of ESKD in adults and kidney destruction in children with severe lower urinary tract abnormalities

Answer 40

Chronic Pyelonephritis

Question 41

Forms of chronic pyelonephritis

Answer 41

Reflux nephropathy - most common Chronic obstructive nephropathy Xanthogranulomatous pyelonephritis

Question 42

Most common cause of Pyelonephritis

Answer 42

E coli 75-90% S saprophyticus 5-15% Klebsiella 5-10% Enterococcus Proteus - staghorn calculi, alkaline urine from urease Citrobactee