Clinical Introduction to Renal Disease

Question 1

Major functions of the kidney (6)

Answer 1

1. glomerular filtration
2. excretion (metabolic by-products, drugs, toxins)
3. Electrolyte and acid-vase homeostasis
4. BP regulation
5. Volume homeostasis
6. Endocrine regulation(EPO, Vit D, renin)

Question 2

Acid Base Values

1. normal pH
2. acidemia
3. alkalemia
4. acidosis
5. alkalosis

Answer 2

1. 7.35-7.45
2. 7.35-7.40
3. 7.40-7.45
4. 7.45

Question 3

1. simple GFR equation
2. What does MDRD stand for?
3. When can these equations be used?
4. When is MDRD not used?

Answer 3

1. GFR= Ucre*V/Pcre
2. Modification of Diet in Renal Disease
3. in pts with stable renal function
4. high/nl/near nl renal function, children, certain ethnic groups, pregnant women, unusual muscle mass, body habitus, or weight

Question 4

1. Fractional Excretion of Na equation (FE Na)
2. Fraction Excretion of Urea (FE Urea)
3. What are they useful for?
4. What values for FeNA are useful?
5. FE Urea?

Answer 4

1. FE NA = (Una/Pna)/(Ucr/Pcr)*100
2. FE Urea = (Uurea/Purea)/(Ucr/Pcr)*100
3. determining the cause of acute kidney injury
4. 2%, 1-2=indeterminate
5. 35%

Question 5

Volumes of

1. Normal urine output
2. Oligouria
3. Anuria
4. Polyuria

Answer 5

1. 1500 mL/24 hours

2. 3000 mL/24 hrs

Question 6

1. Define Azotemia
2. Define Uremia
3. Symptoms/Signs

Answer 6

1. elevation in renal indices (BUN, technically)
2. clinical syndrome that can accompany kidney failure, usually when advanced and/or severe
3. fatigue, anorexia, nausea, mental status changes, itching; serositis (pericarditis, pleural effusion); platelet dysfunction

Question 7

1. What is an acute decline in renal function called?
2. What is a chronic decline in renal function called?
3. What is the most advanced stage of renal dysfunction called?

Answer 7

1. Acute Kidney Injury (AKI)
2. Chronic Kidney disease (CKD)
3. End Stage Renal Disease (ESRD)

Question 8

1. Define Acute Kidney Injury (3 criteria)

Answer 8

1. abrupt reduction in kidney function, defined as:
   Increase in serum creatinine of >0.3 mg/dl
   OR
   Percentage increase in serum creatinine of 50%
   OR
   Oliguria of 6 hours

Question 9

1. Define Chronic Kidney Disease
Describe Stage and give GFR
2. Stage 1
3. Stage 2
4. Stage 3
5. Stage 4
6. Stage 5

Answer 9

1. progressive decline in GFR over time (at least 3 months), with/without albuminemia
2. kidney damage with nl or increased GFR (>=90)
3. Kidney damage with mild decrease in GRF (60-89)
4. Moderate drop in GFR (30-59)
5. Severe drop in GFR (15-29); also has significant dysregulation of Fe, Vit D
6. Kidney failure (<15)

Question 10

Proteinuria

1. Normal Urinary protein/Urinary Albumin
2. Nephrotic range of Proteinuria
3. How is it quantified?

Answer 10

1. 3-3.5 gm/24 hrs

3. 24 hr urinary collection or random urine protein/creatinine ratio

Question 11

Hematuria

1. Types
2. Locations or origins
3. False +s

Answer 11

1. Gross vs Microscopic (>= 2 RBC/hpf)
2. Upper vs Lower Urinary Tract
3. free Hb, myoglobin, menstrual contamination

Question 12

Nephrolithiasis

1. How does it present?
2. Most common stones
3. Treatment (2)

Answer 12

1. moderate-severe renal colic
2. calcium oxalate, Ca phosphate stones
3. active stone management (medical vs interventional);
   Prevention of future stones (fluid intake/dietary changes, medications)

Question 13

What can be in Abnormal Urinary Sediment (

Answer 13

1. Hematuria
2. Dysmorphic RBCs
3. Pyuria
4. Casts (RBC, WBC, Tubular)

Question 14

Types of Tubular Casts and what they represent

Answer 14

1. Epithelial casts (muddy brown casts)- acute tubular necrosis
2. Fatty casts- lipiduria, usually seen in nephrotic syndrome
3. Granular casts- CKD, nonspecific finding
4. Hyaline casts- dehydration, exercise, diuretic therapy
5. Waxy casts- advanced kidney disease

Question 15

Describe Nephrotic Syndrome

Answer 15

> 3-3.5 gm protein/24 hours (lots of protein loss)
Hypoalbuminemia
Periphereral edema
Hyperlipidemia
Thrombophilia (lose antithrombin III –> DVTs)
Bland Urinary sediment
Noninflammatory renal biopsy

Question 16

Describe Nephritic Syndrome

Answer 16

Inflammatory renal biopsy
Active urinary sediment (hematuria, dysmorphic RBCs, RBC casts)
Variable proteinuria
Azotemia, oliguria
Mild/moderate HTN
Other systemic features (vasculitis, arthralgias, myalgias)

Question 17

Common electrolyte imbalances in Acid-Base disease

Answer 17

Hyper/hyponatremia
Hyper/hypochloremia
Hyperkalemia
Hyperphosphatemia
Hypocalcemia
Anion gap metabolic acidosis
Non anion gap metabolic acidosis

Question 18

Blood Pressure Values

1. Nl
2. PreHTN
3. Stage 1 HTN
4. Stage 2 HTN

Answer 18

1. =160 / >=100

Question 19

Secondary Causes of HTN

Answer 19

Anatomic/Vascular causes
Endocrinopathies
Renal dieases, volume overloaded states
Pregnancy related diseases
Medications

Question 20

1. What is total body water (TBW)?
2. What is Intracellular water (ICW)?
3. What is Extracellular water (ECW)?
4. What is interstitial space (ISS)?
5. What is plasma volume (PV)?

Answer 20

1. 60% of total body weight
2. 2/3 of TBW
3. 1/3 of TBW
4. 3/4 of ECW
5. 1/4 of ECW

Question 21

Correction of Volume Depletion (3)

Answer 21

1. Oral fluid replacement (mild/moderate depletion)
2. IV Crystalloid solutions (disperse across ECW): 0.9% Normal saline or Lactated Ringers Solution
3. IV colloid solutions (tend to remain within PV)- made of Packed RBCs, Albumin, Synthetic solutions (costly, impractical)

Question 22

1. What is in 0.9% Normal saline?
2. Who tends to use it?
3. What is in Lactated Ringer’s Solution?
4. Who tends to use it?

Answer 22

1. Na and Cl
2. medicine
3. Na, Cl, lactate (replaces HCO3), K, Ca
4. surgeons, if pt is given blood, it has citrate, which may bind Ca in pt’s blood, so ringer’s replaces it

Question 23

How is Volume Overload treated? (4)

Answer 23

1. Fluid restriction
2. Diuretic therapy (loop)
3. Removal of accessible third space fluid (thoracentesis, paracentesis)
4. Hemodialysis w/ ultrafiltration)

Question 24

1. Role of Erythropoietin
2. Role of Vitamin D
3. What happens in advanced kidney disease to each? (2)

Answer 24

1. regulates HGB/HCT concentrations
2. regulates calcium absorption, maintains nl levels of Ca and Phosphorus
3. chronic EPO deficiency–> anemia of chronic disease, typically normocytis
4. Chronic hyperphosphatemia, decreased renal activation of vit D3 (1,25), hyperparathyroidism, renal osteodystrophy

Question 25

1. What are some nonspecific signs seen in many forms of renal function? 2. What renal function?

Answer 25

1. fever/pain/rash/eosinophilia 2. UTI, nephrolithiasis, renal infarction, papillary necrosis, renal cell carcinoma, Vasculitis (SLE, Wegener's), cholesterol atheroembolic disease

Question 26

1. How may AKI/CKD present? 2. What may cause it? 3. Management

Answer 26

1. drug toxicity from renal dysfunction 2. endogenous substances as well, such as insulin --> hypoglycemia 3. drug dosage therapy, drug holiday; antidote therapy (digoxin), hemodialysis in certain circumstances (Li)

Question 27

How is Renal Dysfunction detected on 1. History? 2. PE? 3. Lab 4. Imaging studies

Answer 27

1. symptoms of uremia or volume overload; fever, rash, pain in some instances, more global symptoms from a disease affecting multiple organ systems 2. abnormal volume status (too wet/dry), abnormal BP, rashm synovitis, serositis, pulmonary/sinus findings, microvascular disease (retinopath, neuropathy) 3. BUN/Creatinine, serum electrolytes, arterial blood gases, urinalysis, other tests (autoimmune) 4. change in renal size/parenchyma, neoplastic or cystic changes, urinary obstruction findings

Question 28

Clinical Detection of Renal Dysfunction 1. Biopsy Approaches 2. What is done to specimen?

Answer 28

1. percutaneous, transjugular | 2. histology (H+E stain), IHC, electron microscopy

Question 29

Treatment of Renal Dysfunction 1. Depends on 2. What can happen?

Answer 29

1. cause 2. can be reversible 3. may be irreversible, but can be stabilized and managed 4. may progress to ESRD despite treatment, requiring renal replacement therapy (RRT)

Question 30

ESRD and RRT 1. Hemodialysis methods 2. Peritoneal Dialysis method 3. Kidney Transplant from (3)

Answer 30

1. AV Graft, AV Fistula, Central Venous catheter 2. intra-abdominal catheter 3. deceased-donor, living-related donor, living-unrelated donor