CR IV MEDI Renal

Question 1

In AKI presently, what will you see in labs?

Answer 1

High urine osm
U[Na] < 10
FEna < 1

Question 2

What must a patient be off of for 24 hours prior to obtaining urine to diagnose pre-renal AKI?

Answer 2

Diuretics

Question 3

If muddy brown casts are seen, what type of AKI is it?

Answer 3

Acute tubular necrosis

Question 4

What is the most common cause of acute tubular necrosis?

Answer 4

Ischemia from hypovolemia

Question 5

What is the definition of AKI?

Answer 5

Abrupt decline in GFR or [Cr]>.3 increase in 48 hours

Question 6

What should be removed immediately in AKI?

Answer 6

ACEI or ARB

Question 7

Is there a drug to treat AKI? What are some corrective measures?

Answer 7

No drug to cure it
If volume depleted, give NaCl
If in sepsis - give NaCl and vasopressors

Question 8

When should dialysis be used to treat AKI?

Answer 8

Last resort - If uremic, K >6.5, pulmonary edema, or metabolic acidosis

Question 9

Does Cr equal GFR in older people? Why or why not?

Answer 9

No because it does not rise like it should due to decreased mobility and muscle mass

Question 10

What three things are older people at increased risk for due to their aging kidney?

Answer 10

Anemia
Vit D deficiency -> fractures
Insulin clearance impairment -> susceptible to diabetes

Question 11

Why are older women slightly more protected from aging kidney than men?

Answer 11

Due to lack of testosterone

Question 12

What precedes hypertension and diabetes in obese individuals?

Answer 12

Renal disease

Question 13

What is the most important predisposing factor for insulin resistance?

Answer 13

Central obesity

Question 14

What is seen in presentation/pathology in kidneys of obese individuals?

Answer 14

Glomerulomegaly

Question 15

What does thiazolidendiones do?

Answer 15

Improves insulin sensitivity

Question 16

What are the 5 types of Cardiorenal syndrome?

Answer 16

Type I - Acute CHF - Acute AKI - most common
Type II - Chronic CHF -> CKD
Type III - Acute/worsening kidney -> acute cardiac
Type IV - Primary CKD -> cardiac dysfunction
Type V - systemic -> cardiac and renal dysfunction

Question 17

What is the major cause of Cardiorenal syndrome?

Answer 17

Reduced renal perfusion

VOlume overload and venous congestion

Question 18

How do you treat Cardiorenal syndrome?

Answer 18

Loop diuretics
ACEI/ARB
Etc.

Question 19

What does hepatorenal syndrome resemble? However, what does it not respond to?

Answer 19

Pre-renal azotemia

However, does not respond to volume

Question 20

How does portal hypertension cause renal dysfunction?

Answer 20

Portal hypertension -> vasodilator splanchnic -> reduced systemic VR -> constriction at kidney = decreased perfusion

Question 21

What is needed for diagnosis of hepatorenal syndrome?

Answer 21

Cr > 1.5 or GFR <40
AND
Chronic/active liver disease

Question 22

What are the two types of hepatorenal syndrome? Which is worse? What can cause one to convert to the other?

Answer 22

Type I - rapid renal decline, in hosp. Pts usually >90% death in 3 months
Type II - less severe, slow, life exp. > 6 months
Triggers for II to I - bacterial peritonitis, hypovolemia, NSAIDs, ACEI, ARB

Question 23

What is seen in a urinalysis of a hepatorenal patient?

Answer 23

<500 ml urine
Na < 10 (lowest you will see!)
Serum Na also low

Question 24

Is treatment for Heptorenal syndrome easy? What can be done?

Answer 24

Albumin and terlipressin
Antibiotic (if needed)
Paracentesis
IV steroids - if septic and renal failure

Question 25

What is toxic in rhabdo? What is the most common cause? Others?

Answer 25

Myoglobin Trauma Others: spin class, propefol, quail, statin + gemfibrozil, surgery

Question 26

What color will the urine be in rhabdo? What will not be found?

Answer 26

Urine - red-brown, NO RBC, +4 on dipstick

Question 27

What is the treatment for Rhabdomyolysis? What can be used to reduce uric acid?

Answer 27

Aggressive saline and maintain urine flow Allopurinol - reduce uric acid Stop statins and fimbrates

Question 28

When does Cr rise in contrast nephropathy?

Answer 28

1-3 days after dye use

Question 29

What are two risk factors for contrast nephropathy?

Answer 29

Renal insufficiency | Diabetes

Question 30

How can contrast induced nephropathy be prevented?

Answer 30

Hydration (saline before if in hospital)

Question 31

When does renal function decline in Contrast nephropathy? What does it usually improve by?

Answer 31

Function decreased days 3-5 | Returns - day 10

Question 32

When does nephrogenic systemic fibrosis occur?

Answer 32

When gadolinium is given for and MRI in pts with kidney disease

Question 33

What is the most common cause of primary tubulointerstitial nephritis?

Answer 33

Drug induced - long term antibiotics

Question 34

What is found in the urine of someone with tubulointerstitial nephritis?

Answer 34

Sterile pyuria No protein or albumin Unable to concentrate urine

Question 35

What three symptoms point you towards tubulointerstitial nephritis?

Answer 35

Fever, rash, eosinophilia

Question 36

What is the gold standard for diagnosing someone with tubulointerstitial nephritis?

Answer 36

Renal biopsy

Question 37

What is the treatment for tubulointerstitial nephritis?

Answer 37

Steroids only if caught in first 7-14 days

Question 38

What must be ordered if you suspect glomerular disease?

Answer 38

Microalbumin

Question 39

Should you get a 24 hour urine in someone with mild proteinuria? When do you treat? When do you recheck?

Answer 39

Mild - <1g/day - Do not get 24 hour urine If asymptomative, reassess at 6-12 months If protein has gone up, get biopsy If protein has not gone up, reassess at 6-12 months

Question 40

What is the most common cause of glomerular hematuria?

Answer 40

IgA nephropathy our Thin Basement membrane nephropathy

Question 41

What are differences between nephrotic and nephritic syndrome?

Answer 41

Nephrotic - slow developing asymptomatic, symptoms at flare ups include edema, hyperlipidemia, hypoproteinemia. Thrombolitic disease Nephritic - acute onset, lots of blood, Increase in BP and JVD, no edema because no time. RBC casts

Question 42

What is the most common nephrotic syndrome? Nephritic?

Answer 42

Nephrotic - membranous nephropathy or focal segmental glomerulosclerosis Nephritic - Cresenteric, IgA, proliferating

Question 43

How does Alport syndrome differ from IgA Nephropathy?

Answer 43

Alport Syndrome will always have microscopic hematuria in between episodes of gross hematuria

Question 44

What is the most common nephrotic syndrome in children?

Answer 44

Minimal change disease

Question 45

What is the clinical presentation of minimal change disease?

Answer 45

Abrupt nephrotic Normal Cr, low albumin Effacement of podocytes

Question 46

What is the treatment for Minimal change disease? If recurrent, what can you treat with? What do you use to reduce triglycerides?

Answer 46

Prednisone Cyclosporine 1-2 years Statins to reduce triglycerides

Question 47

How does focal segment glomerulosclerosis differ from Minimal Change disease?

Answer 47

It does not respond to steroids

Question 48

Which primary glomerulonephritis is aggressive in coming back in transplant kidneys? Which doesn’t usually come back?

Answer 48

Focal Segmental - aggressive in transplant kidneys | IgA glomerular nephropathy - does not usually come back in transplant kidneys

Question 49

What is the most common GN leading to ESRD? What population is it more common in? What is seen clinically?

Answer 49

Focal Segmental Glomerulosclerosis African Americans Proteinuria, hematuria (>50%), renal failure (>33%), hypertensive

Question 50

What is the most common primary GN in adults? Where is the autoimmune antibody deposited? How is it treated?

Answer 50

Membranous Nephropathy Subepithelial deposits destroy basement membrane Month 1,3,5 - Solumedrol for 3 days, prednisone for 27 Months 2,4,6 - Oral cyclophosphamide

Question 51

What are the two types of MPGN? Which is worse? What is associated with each? What is the hallmark seen histologically?

Answer 51

Type I - Hep C - deposits all over Type II - worse - C3 nephritic factor Thickened capillary loops - “tram track”

Question 52

What is the histological hallmark of rapidly progressive glomerulonephritis? What is the treatment?

Answer 52

Crescent formation | IV solumedrol, prednisone, cytoxan - be aggressive!

Question 53

What is the most common GN in the world? What is deposited where?

Answer 53

IgA glomerular nephropathy | IgA in mesangium

Question 54

What is seem simultaneously to IgA nephropathy? Is serum IgA helpful?

Answer 54

Synpharyngitic macroscopic hematuria | Serum IgA not helpful

Question 55

What are three symptoms of IgA nephropathy? What are mild and progressive treated?

Answer 55

Hypertension, proteinuria, blood Mild - ACEI or ARB Moderate - ACEI or ARB and 6 month steroid Progressive - cytotoxans

Question 56

What is cANCA pathoneumonic for?

Answer 56

Wegner’s syndrome

Question 57

What is the classic Wegner’s patient?

Answer 57

Older white male puking blood, cutaneous purpura

Question 58

What is the treatment for Wegner’s?

Answer 58

Predinsone and cytoxan | Plasmaphoresis last resort

Question 59

What is seen clinically/labs for Good pastures?

Answer 59

Circulating anti-GBM antibodies, widespread crescents, monophonic lesions

Question 60

What is the treatment for Goodpastures?

Answer 60

Plasma exchange - to remove antibodies Steroids - for inflammation control Cyclophosphamide - stop formation of new antibodies

Question 61

How is diabetic nephropathy diagnosed?

Answer 61

Persistent proteinuria > 300mg at least twice separated by 3-6 months

Question 62

What are hallmarks of diabetic nephropathy?

Answer 62

Hypertension Progressive proteinuria Progressive GFR decline

Question 63

What must always be requested when ordering a urinalysis and suspecting diabetic nephropathy? How often should it be screened/checked?

Answer 63

Microalbumin | Every 6 months

Question 64

For diabetic nephropathy, what test must be done? What is used to treat if GFR > 30? GFR <30? Two additional treatments?

Answer 64

24 hour urine SGLT-2 inhibitors (lower HbA1c, decrease weight and BP) Use DPP-4 inhibitor if GFR <30 Antihypertensives and Statins

Question 65

Do ACEI work prophalactically to prevent diabetic nephropathy?

Answer 65

No

Question 66

What are family CV disease and hypertension risk factors for?

Answer 66

Diabetic nephropathy

Question 67

Parental hypertension is a risk factor for which two things?

Answer 67

Diabetic nephropathy | IgA nephropathy

Question 68

What is seen on labs in chronic renal failure?

Answer 68

Increased BUN and Cr | Uremia in advanced CKD

Question 69

What is the best hemodialysis? 2nd? Third?

Answer 69

1st - artery to vein 2nd - graft 3rd - catheter (WORST)

Question 70

What clinical manifestation of CKD is the last function to lose?

Answer 70

Potassium regulation

Question 71

What is high in CRF that causes sexual dysfunction in men and infertility in women?

Answer 71

Prolactin

Question 72

What is the most common cause or uremic anemia? What do you need to diagnose it?

Answer 72

Dysfunction of vWF | Diagnose using bleed time only! (Because platelets are still there)

Question 73

What is used to treat renal osteodystrophy?

Answer 73

REstrict phosphate, use phosphate binders, supplement vit. D

Question 74

What is the most common kidney stone?

Answer 74

Calcium stones

Question 75

What is the gold standard for diagnosis of kidney stones? What can be used to avoid radiation?

Answer 75

Non-contrast helical CT - gold standard | Ultrasound

Question 76

How do you treat all kidney stones?

Answer 76

Allow to pass - pain control, hydration, strain urine | Consult urology - lithotripsy

Question 77

What is the most common metabolic abnormality causing kidney stones? What is seen in plasma and urine?

Answer 77

Idiopathic hypercalciuria | Hypercalciuria w/o hypercalciuria

Question 78

How do you treat hyperoxaluria?

Answer 78

Increased dietary Ca to decrease oxalate absorption

Question 79

How do you treat hyperuricosuria stones? What population is it often seen in?

Answer 79

Allopurinol | Cancer pts - pre treat them with allopurinol

Question 80

Which population is more susceptible to struggle stones? DO they usually pass on their own?

Answer 80

Women | No

Question 81

What causes cysteine stones? What is used to diagnose them? What do you treat them with if hypertension is also present?

Answer 81

Defect in AA transport in kidney Diagnose using Na nitroprusside test Treat with catopril

Question 82

What test is used to diagnose benign positional vertigo? What is used to treat?

Answer 82

Dix-Hallpike - diagnose | Epley - treat

Question 83

What are the three types of syncope?

Answer 83

Neurally-mediated - increased parasympathetic, decreased sympathetic Orthostatic hypotension - sympathetic should fire but they don’t Cardiogenic - collapse and tachycardia