Internal Flashcards
(197 cards)
1
Q
Define prerenal AKI?
Give 8 examples
A
Any injury leading to decreased renal perfusion
Hypovolemia Hypotension Cardiorenal syndrom Hepatorenal syndrom Abdominal compartment syndrom Acute pancreatitis Drugs Renal artery stenosis
2
Q
Define intrinsic AKI?
Give 4 examples
A
Conditions leading to severe and direct renal damage
Acute tubular necrosis
Acute interstitial nephritis
Vascular diseases
GN: RPGN
3
Q
Define Postrenal AKI
Give 8 examples
A
Acquired obstruction BPH Iatrogenic (catheter injuries) Tumors Stones Bleeding causing blood cloth Neurogenic bladder Congenital malformations
4
Q
Causes of ATN?
A
Ischemia
Nephrotoxic drugs
Endogenous toxins: Hb in hemolysis, Mb in rhabdomyolysis, uric acid in tumor lysis, Bence-Jones protein light chains in MM
5
Q
Define Hemolytic uremic syndrom? (HUS)
A
thrombotic microangiopathy occluding the microvasculature
6
Q
what is hepatorenal syndrom?
A
Liver cirrhosis - portal HT - increased speelic artery vasodilators (NO) - decreased BP - RAAS activation - renal vasoconstriction - decreased GFR
7
Q
what is abdominal compartment syndrom?
A
increased pressure in the abdomen causing compression of vessels
8
Q
vascular injuries in interstitial AKI (6)
A
HUS TTP HT crisis vasculitis scleroderma renal vein infarct
9
Q
define AKI
A
acute/sudden decrease in renal function withing hours to 7 days (creatinine/urinary output)
10
Q
Normal creatinine level?
A
60-99
11
Q
diagnosis of AKI
A
- patient history
- Physical examination
- lab test - stage with creatinine
- pre, intrinsic or post
12
Q
what can you calculate to differentiate Prerenal and intrinsic renal AKI?
A
FeNa: (Pre <1%) (Intrinsic >2-3%)
FeUrea: (Intrinsic > 50%)
13
Q
Define CKD
A
Chronic kidney disease (CKD) is defined as an abnormality of kidney structure or function that persists for > 3 months
14
Q
most common causes of CKD (5)
A
- Diabetic nephropathy
- Hypertensive nephropathy
- Glomerulonephritis
- PKD
- NSAIDs
15
Q
inflammatory GN?
A
- RPGN
- PSGN
- SLE nephritis
- HUS
16
Q
Non-inflammatory GN?
A
MCGN
Membranous nephropathy
FSGN
17
Q
what happens in our body when CKD?
A
- decreased urin production - volume retention
- no toxin excretion - uremia
- hyperphosphatemia (when FGF23 subsides)
- amenia due to EPO insufficiency
- HPTH
18
Q
What can uremia do in the heart?
A
uremic pericarditis - fibrinous pericarditis
19
Q
Define end stage kidney disease?
is it reversible?
A
GFR < 15 mL/min
not reversible
20
Q
What disease can we frequently see in CKD and have to treat?
A
Osteodystrophy due to hyperphosphatemia, hypocalcemia and vit D deficiency causing hyperparathyroidism
21
Q
Indications of dialysis?
A
Acidosis Electrolyte disorder - hyperkalemia Intoxication Overload of fluids Uremic syndrom (pericarditis)
22
Q
Nephritic syndrom presentation
A
proteinuria < 3.5 hematuria - acanthocytes RBC casts in urin might be seen no edema/general little proliferative hypertension due to oliguria
23
Q
nephrotic syndrom?
A
proteinuria > 3.5 no hematuria edema hyperlipidemia non-proliferative
24
Q
why is there a increased risk of thromboembolism in nephrotic syndrom?
A
loss of antithrombin III
25
causes of nephrotic syndrom? (6)
1. MCD
2. FSGS
3. membranous nephropathy
4. diabetic nephropathy
5. amyloid light chain AL amiloidosis
6. lupus nephritis
26
Causes og nephritic syndrom (9)
1. PSGN
2. RPGN
3. Lupus nephropathy
4. IgA nephropathy
5. granulomatosis with polyangiitis
6. microscopic polyangiitis
7. good pasture syndrom
8. Alport syndrom
9. Thin basement membrane
27
systemic symptoms of RPGN
```
fever
weight loss
joint pain
weakness
palpable purpuras
```
28
treatment of minimal change disease
good respons to steroids
29
treatment of FSGS
long steroid treatment
| cyclosporins if steroid resistant
30
membranous nephropathy treatment
steroid + cyclophosphamides/cyclosporin
31
treatment of diabetic nephropathy
ACEI/ARBs to control BP and proteinuria
32
treatment of amyloidosis
hematogenic treatment
33
labs in PSGN
Anti-streptolysin titer
Low C3/Normal C4
Elevated IgM and IgG/normal IgA
34
lab parameters in ANCA vasculitis RPGN
elevated anti-MPO
elevated ant-PR3
eosinophilia
normal complement level
35
lab tests in Good-Pasture RPGN
anti-GBM
rarely ANCA positivity
normal complement
36
IgG deposits on immunofluorecent in Good-pasture RPGN?
LInear deposition
37
labs in SLE nephritis
```
ANA-positivity
elevated anti-dsDNA
elevated anti-C1q
low C3 and C4
potential pancytopenia
```
38
immunofluorecent in SLE nephritis
FULL HOUSE
| granular Ig G, A, M, C3, C1q
39
oliguria value?
< 400 ml urine /day
40
Diagnosis in acute tubulointerstitial diseases, treatment?
Biopsy
| treatment depends on cause but corticosteroids in almost every case
41
caused of acute TIN
drugs
infection
systemic infection
idiopathic
42
name the tubulointerstitial diseases (4)
1. Acute TIN
2. MM cast nephropathy
3. isolated tubulopathies
4. renal tubular acidosis
43
what is the most common kidney injury in multiple myeloma (MM)
multiple myeloma cast nephropathy
44
pathophysiology of MM cast nephropathy?
light chains are filtered and excreted in urine
they precipitate in tubules clogging them
obstruction and toxic to tubular cells
45
forms of isolated tubulopathies
Fanconi and
| Gitelman
46
pathophysiology in Gitelman syndrome?
like the patient is taking continous Thiazides
| Na wast - no K+ exchange - hypokalemia - alkalosis
47
Fanconi syndrom pathophysiology
impaired bicarbonate reabsorption
48
what other diseases does ARPKD manifest with?
pulmonary insufficiency
| progressive liver failure - portal and hepatic fibrosis
49
what other diseases does ADPKD manifest with?
arterial hypertension
| progressive liver disease
50
curative treatment of PKD
transplantation
51
mutation in ADPKD
PKD1 ch 16 - polycystein-1
| PKD2 ch 4 polycystein-2
52
mutation in ARPKD
PKHD1 ch 6 - fibrocystin
53
mechanism of PKD1 and PKD1
PKD1 - cell-cell / cell-matrix interaction
PKD2 nonselective cation channel transporter Ca2+
renal cysts in medulla and cortex compressing vessels activation RAAS
54
PKHD1 mutation mechanism
defect fibrocystin - cystic dilation of collecting duct and bile ducts (intrahepatic and extrahepatic)
55
where may the cysts also be in ADPKD
pancreas, liver, ovary and testicle
hepatic benign cysts increases with age
56
what is important to monitor in ADPKD if family history of stroke?
barrys aneurism - subarachnoid bleeding
57
what can be seen in children born with ARPKD?
potter syndrom during pregnancy (no embryo urin)
clubbed feet
craniofacial abnormalities
58
what is the difference between the cysts in AR and ADPKD on US?
both bilateral but AD varying in size and AR same size
59
whend do you use MRI in PKD?
to screen for berry's aneurysms if family history
60
what mediation can slow down a rapid progression of ADPKD
tolvaptan
61
which medication should not be given in polycystic kidney disease?
ADH - increase cyst growth
62
risk factors for renal cell carcinoma (7)
```
smoking
acquired cysts
nephrolithiasis
long term acetaminophen use
hepatitis C
HT
Sickle cell anemia
```
63
when does RCC usually become symptomatic?
tumor size > 10 cm and/or if merastasis is present
64
causes of calcium oxalate stones
hypercalcemia
hyperoxaluria
hypocitraturia
65
causes of uremic acid stones
hyperuricemia - hyperuricosuria
increased cell turnover (leukemia, chemo)
gout
66
cause of calcium phosphate stones
hyper parathyroidism
| type 1 tubular acidosis
67
clinical symptoms of urinary tract stones
```
unilateral colicky pain
radiates to the groin
progressive worsening
hematuria
nausea, vomiting, reduced bowel sounds
dysuria, frequency, urgency,
passing stones
unable to sit still
```
68
if imaging is needed in nephrolithiasis which?
CT without contrast - hydronephrosis
69
what imaging is used in follow up after nephrolithiasis treatment?
KUB X-ray (kidney, ureter, bladder)
70
is x-ray always good in nephrolithiasis?
not for small stones
71
when do you consult with nephrology in UTI stones?
if size > 10mm
72
what analgesic is given in nephrolithiasis?
diclofenac
73
conservative treatment of nephrolithiasis?
1. Tamsulosin (alpha blocker) if < 10 mm
| 2. Nifedipine (CCB)
74
Interventional treatment of nephrolithiasis?
ureteroscopy (URS) or
extracorporeal shockwave lithotripsy (ESWL)
renal stones larger then 20 mm percutaneous nephrolithotomy
75
indication of a glomerular hematuria?
```
light color/normal color urine
acanthocytes
RBC cast might be seen
no cloths
proteinuria > 500mg/day
```
76
indication of non-glomerular bleeding
```
dark urine
no acanthocytes
no RBC casts
cloths might be seen
proteinuria < 500mg/day mostly albumin
```
77
normal protein excretion?
up to 200mg/day
| mostly Tomm Horsfall proteins from LOH
78
normal albumin excretion
< 30mg/day
79
proteinuria level
> 150mg/day urin
| just remember that it IS normal up to 200mg/day
80
normal protein in a spot urin test?
20 mg protein/ mmol creatinine
3g albumin/mmol creatinine
100mg/mmol spot urin corr to 1g/day proteinuria
81
clinically significant proteinuria?
> 500mg/day
| so on a spot test that is 50mg
82
indication of renal biopsy?
1. nephrotic syndrome
2. nephritic syndrom
3. RPGN
4. asymptomatic proteinuria (1-3g/day)
5. AVI if not ATN
6. CKD (if US does not show small scarred kidneys)
7. dysfunction after transplant
83
contraindications of renal biopsy
1. uncooperative patient
2. one kidney
3. multiple cysts
4. renal neoplasia
5. acute pyelonephritis
6. uncontrolled bleeding
7. uncontrolled BP (165/95)
84
two types of esophageal diverticula and their cause?
pulsion diverticula: increased P and decreased relaxation og LES causing fals diverticula
Traction diverticula: mediastinal inflammation, scarring and retraction (tuberculosis or fungi)
85
most common site of esophageal diverticula?
UES (Zenker)
middle 3rd
epiphrenic
86
indications of esophageal diverticula
```
dysphagia
food regurgitation
halitosis (bad breath)
coughing when eating
retrosternal pressure and pain
weight loss
neck mass
```
87
types of hiatal hernia
1. sliding
2. paraoesophageal
3. mixed
4. multiorgan
88
when is reflux defined as GERD?
when it causes troublesome symptoms and complications
89
3 types of GERD
NERD (non-erosive)
ERD
Barret esophagus
90
treatment of GERD?
start giving PPI and see if it gives a response, if yes then GERD if no do an EGDC to confirm and do a 24h esophageal pH monitoring
91
what esophageal pH indicated GERD
dropp below 4
92
surgical method in GERD
fundoplication where the fundus if stomach is wrapped around the lower esophagus narrowing the distal esophagus
93
how many biopsies to take to diagnose Barret esophagus?
8 random - if negative repeat after 1-2 years
94
endoscopic ablative techniques in Barret esophagus
1. EMR - endoscopic mucosal resection
2. ESD - endoscopic submucosal dissection
3. RFA - radiofrequency ablation
95
what is eosinophilic esophagitis?
| how is it diagnosed?
Allergen induced inflammation of the esophagus
| biopsy of upper and lower part showes > 15 eosinophils/HPF
96
what is achalasia?
degeneration of the meienteric plexus of the lower 2/3 esophagus + failure to relax LES
97
two types of achalasia
primary - unknowns etiology
| secondary - mechanical cause
98
causes of secondary achalasia
1. esophageal tumor
2. gastric tumor
3. chagas disease
4. amyloidosis
5. sarcoidosis
6. neurofibromatosis type 1
99
what type of dysphagia is seen in achalasia?
dysphagia to solids AND fluids
100
what is the difference between esophageal obstruction vs achalasia?
in obstruction dysphagia only to solids but achalasia to both
101
diagnosis achalasia?
Barium swallowing test
endoscopy
manometry
CX-ray
102
treatment of achalasia
surgery: hellers myotomy
| surgical risk: botulnum toxin
103
what is Boerhaave syndrom
spontaneous transmural effort rupture of esophagus (sudden increase in esophageal pressure)
104
examples of etiology for boerhaave syndrom
forcefull vomiting (ex. after alcohol)
childbirth
prolonged coughing
seizures
105
gold standard in boerhaave syndrom diagnosis?
esophagography with contrast showing contrast leaked
106
define Mallory Weiss syndrom
upper GI bleeding due to longitudinal mucous tear at gastroesophageal junction (may continue above or below also)
107
4 predisposing factors for Mallory Weiss syndrom?
alcohol
bulimia
GERD
hiatal hernia
108
diagnosis of Mallory Weiss
CBC
pretransfusion testing - blood transfusion
ECG ro rule out ACS
EGD to confirm diagnosis
109
type of gastritis and their main cause?
Acute: bacteria, fungi, virus, Parasite
Chronic: autoimmune type 1 and H. pylori type 2
causes destruction of the native architecture
Athropic: chronic inflammation with destruction of glands, fibrosis and scarring
Erosive: stress or chemicals causing multiple superficial erosions not extending beyond muscularis
110
what are the toxic virulence of H. pylori
cytotoxic associated gene A (CagA)
| Vacuolating cytotoxin A (VacA)
111
treatment of H. pylori
2x1 PPI
clarithromycin 2x500mg
amoxicillin 2x1g or metronidazole 3x500mg
112
define a peptic ulcer
defect in the gastric or duodenal mucosa with a diameter > 0.5 cm a depth reaching the muscularis mucosa
113
what protects the gastric mucosa from the acidic environment?
HCO3- and mucus secretion
114
what factors can increase to make a peptic ulcer?
increased pepsin or acid release or disruption of protective mechanism
115
etiology of peptic ulcer disease
```
gastric acid hypersecretion
nervous system dysfunction
genetic factors (inherited hyperpepsinogenemia)
environmental factors (alcohol, smoking, eating habits, NSAID, stress)
```
116
where does H. pylori most frequently cause an ulcer?
70-90% duodenum
| 30-60% stomach
117
what cause of peptic ulcer is more likely to present with symptoms?
NSAID usage
118
symptomatic differentiation between duodenal and gastric ulcers
gastric ulcers: increased pain after eating + weight loss
| dudenal ulcer: decreased pain after eating + weight gain
119
histamin effect on gastric acid?
increases secretion
120
treatment of peptic ulcers?
antacids
H2R
PGL
PPI
121
define gastroparesis
altered emptying > 3 months with no mechanical obstruction
122
small for size syndrom
liver resection, jaundice, encephalopathy, coagulopathy
123
most common medication giving acute liver failure
acetaminophen (paracetamol)
124
what is the dominant symptom in hyperacute liver failure
encephalopathy is the main presentation and jaundice is mild, this can cause late diagnosis
125
levels of hepatic encephalopathy
level 1 mild with no to very mild clinical presentations
| level 5 coma
126
define Preeclampsia
Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, most often the liver and kidneys
127
define Eclampsia
Eclampsia is a severe complication of preeclampsia. It's a rare but serious condition were high blood pressure results in seizures during pregnancy.
128
why is liver biopsy commonly contraindicated?
due to significant risk of bleeding
129
hepatitis B treatment
entecavir and tenofovir
130
what to give in a liver intoxication with acetaminophen?
N-acetylcystein
131
acute steps in liver failure patients?
1. fluids
2. vasopressors if nonresponsive to fluids
3. treat ARDS (seen in 20%)
4. Do early intubation of rapidly progressing HE
5. Start Spo2 monitoring and give oxygen in needed
6. check for AKI (seen in 30-70%)
7. dialysis if needed
132
treatment of hepatic encephalopathy
```
Lactulose (to remove ammonia from system)
Rifampicin (in minimal HE)
Metronidazole
Vancomycin
Electrolyte supplement if needed
Nutrition
```
133
pancreatitis 2/3 rule
1. epigastric pain
2. laboratory studies (x3 normal value)
3. imaging (CT/US/MRI)
134
What is used to decide severity of pancreatitis?
SIRS score and BISAP score
135
what is used on a pancreatitis BISAP score?
```
se urea
mental state
SIRS criteria
age
hydrothorax
```
136
what are the SIRS criteria
```
core temp
HR
RR
PaCO2
WBC
```
137
what is decided with the pancreatitis BISAP score?
< 2 points means mortality is less then 2%
| > 2 points means mortality is > 15%
138
what can a sudden decrease in Hct during an acute pancreatitis indicate?
pancreatic hemorrhage (rare)
139
what is a worsening of leukocytosis in pancreatitis an indication of?
infected necrosis
140
what can be an indication of severe necrotizing pancreatitis?
CRP > 150 three days after onset
increased procalcitonin
increased IL-6
LDH high
141
indications of chronic alcoholism
GGT high
| MCV above 100fL
142
what is a more specific biliary obstruction enzyme?
ALP
| ALT > AST
143
fluid replacement in acute pancreatitis?
rapid early replacement 5-10ml/kg/h
ringer lactate solution
monitor efficacy
144
what lab parameter informs us about hydration and rehydration? (5)
```
Hematocrit!! 35-45%
urea production
BP
HR
MAP
```
145
what parameters is misleading in the early state of pancreatitis?
CRP and WBC rise in the beginning due ti STERILE inflammation - this is not an indication for AB treatment
Procalcitonin PCT is the ONLY indicator of an actual infection if the patient has acute pancreatitis
146
why is ERCP only recommended to use in case of AP with cholangitis?
it has the highest complication rate in endoscopy
147
when to do a cholecystectomy in ABP with peripancreatic fluid?
safe after 6 weeks
148
local complications of pancreatitis
AP fluid collection
pancreatic pseudocyst
acute necrotic collection
pleural effusion
149
pathophysiology in chrons
dysfunction of IL-23 and Th17
150
IBD extraintestinal skin manifestations
pyoderma gangrenosum
| erythema nodosum
151
Fistulas in chrons and UC?
Chrons: common
UC: rare
152
complications in Chron?
abscess
strictures - obstruction
perianal fissures
153
antibody in Chron?
ASCA
154
abdominal pain location in Chrons vs UC
LLQ - UC
| RLQ - Chrons
155
complications in ulcerative colitis
Fulminant colitis
toxic megacolon
perforation
156
antibody in ulcerative colitis
pANCA
157
where in the GI do you NOT see chrons disease?
Rectum
158
what are often the first sign of chrons?
perianal fistulas and abscesses
159
what can be seen on a biopsy (histology) of Chron disease?
crypts and granulomas
160
preferred imaging in Chrons
Cross sectional enterography
161
what does steroid-resistant Chrons disease mean
when you give 40-60mg/day prednisone and there is no respons after 30 days
162
what does steroid dependent chrons disease mean?
when there is a clinical respons within 30 days of 25mg/day prednisone
163
90% of patients with primary sclerosing cholangitis are also infected with.....
Ulcerative colitis
| but not the other way around
164
what is elevated on a lab test of UC if there is also primary sclerosing cholangitis
GGT
165
types of ulcerative colitis?
```
proctitis
proctosigmoiditis
distal colitis
extensive colitis
pancolitis
```
166
treatment of distal ulcerative colitis?
mesalamine
| steroids
167
treatment of extensive ulcerative colitis
```
mesalamin
sulfasalazine
budesonide
steroids
immunosupression
```
168
Surgical treatment of ulcerative colitis?
| can surgery in CD cure the disease?
Ileal pouch-anal anastomosis (IPAA)
curative intent
(CD cannot be cured with surgery)
169
types of microscopic colitis?
lymphatic MC
| Collagenous MC
170
what should be stopped if a patient is diagnosed with microscopic colitis?
NSAID because it triggers it
171
mutation in celiac disease?
HLA- DQ2 90%
| HLA DQ8 10%
172
serological tests in celiac disease
anti-Tg (IgA, IgG)
EMA (IgA, IgG
Deaminated glutamin peptide (DGP - IgG)
173
how to diagnose celiac disease?
4 our of 5 rule
1. signs and symptoms
2. Ab testing
3. HLA gene positive
4. histology: villous atrophy and crypt hyperplasia
5. clinical respons to gluten free diet
174
classification of celiac disease based on the 4/5 rule
- 1 Non classic CD
- 2 Seronegative CD
- 4 potential CD
- 5 Non-responsive CD
175
how many biopsied and where to take them in Celiac disease
at least 5 from duodenum and more then 1 from the duodenal bulb
176
what is defined as gluten free?
< 20 part per million of gluten (20mg per kg of food)
177
what can refractory celiac disease lead to?
ulcerative jejunitis
178
what is acute diarrhea?
< 2 weeks but > 3 days and > 175-200g/day
179
define chronic diarrhea
> 4w and > 200g/day or >= 3 stools/day
180
causes of chronic diarrhea? (9)
```
Chrons
UC
ischemic colitis
colon cancer
radiation colitis
pancreatic insufficiency
bile acid deficiency
SIBO
SBS
```
181
explain hydrogen malabsorption test?
nutrients are fermented by intestinal bacteria leading to increased H+, the level is measured every 30min over 3h (20ppm is the cutoff level)
For Fructose, lactose and glucose, SIBO
182
anemia in Vit B12 malabsorption?
megaloblastic macrocytic anemia
| large RBC and fragmented megaloblasts
183
in shilling test how much B12 must be absorbed to have a normal uptake?
less then 7-10% meals malabsorption of B12
184
Lactose intolerance due to?
lactase insufficiency causing bacteria to ferment lactose producing gass
185
test in lactose intolerance?
H2 breath test + gene testing
186
what would you recommend to a lactose intolerance patient?
no fermented dairy products
eat yoghurt and kefir
consider vit ADEK, B12 supplement
187
Define intestinal failure?
when gut function is reduced to the point where IV nutrient supplementation is required to maintane health (IVS)
188
etiology of intestinal failure?
```
SBS
intestinal fistulas
dysmotility
obstruction
mucosal damage (IBD, cancer treatment)
```
189
what is De Ritis ration?
De Ritis ratio is also known as Aspartate aminotransferase/alanine transaminase (AST/ALT) ratio
NORMAL VALUE 1.15
190
which conditions showes a high De Ritis ratio?
Alcoholic liver disease
Organic toxic hepatitis
cirrhosis
intrahepatic cholestasis
191
which conditions shows a low De Ritis ratio?
Acute viral hepatitis
Extrahepatic cholestasis
minor fatty liver disease
192
treatment of H.pylori?
( ACCMMZ)
PPI
AC
MZ
CM
193
medications given in nephrotic syndrom?
ACEI, ARBs
Statins
Anticoagulants
diuretics: spironolactone/thiazide
194
What is SIADH and what are diseases associated with it
Increased ADH secretion (Fluid reabsorption)
| seen in Pulmonary diseases and CNS diseases
195
What is the volum status in a SIADH patient?
First water retention and overload, this then decreased aldosterone leading to Na excretion resulting in Euvolemic Hyponatremia and therfore cerebral edema.
196
what are alarming symptoms where you don't use the PPI for diagnosis GERD?
```
dysphagia
odynophagia
GI bleeding
anemia
hematemesis
weight loss
```
197
Normal kidney size?
9-12 cm
