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MTB STEP 3 (R) > MTB 3 - Renal > Flashcards

MTB 3 - Renal Flashcards

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1
Q

You can differentiate chronic renal failure from acute renal failure by what 3 things?

A

Chronic renal failure will have:

  • Small kidneys
  • Drop in hematocrit from loss of erythropoietin
  • Low calcium from loss of Vitamin D hydroxylation
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2
Q

What are 6 things that can cause prerenal azotemia?

A

Anything that causes hypoperfusion:

  1. Hypotension
  2. Hypovolemia
  3. Low oncotic pressure (low albumin)
  4. CHF
  5. Constrictive pericarditis (can’t perfuse kidney)
  6. Renal artery stenosis
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3
Q

What are the characteristics of prerenal azotemia?

A
  1. BUN:Cr > 20:1
  2. Urinary sodium 500
  3. Possible hyaline casts on urinalysis
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4
Q

Why does BUN increase with prerenal azotemia?

A

Low volume –> Increase in ADH –> increase urea absorption

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5
Q

Name causes of postrenal azotemia:

A
  1. Stones in bladder or ureters
  2. Strictures
  3. Cancer of bladder, prostate, cervix
  4. Neurogenic bladder (think DM or MS)
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6
Q

What are some clues to obstruction of the urinary system?

A

Distended bladder
Large volume diuresis with catheter placement
Bilateral hydronephrosis on ultrasound

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7
Q

What’s the BUN:Cr ratio for postrenal azotemia?

A

> 15:1

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8
Q

What are 3 characteristics of intrinsic kidney failure?

A

BUN:Cr ~ 10:1
Urine sodium >40
Urine osmolality

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9
Q

What are some common agents that induce renal insufficiency?

A
  1. Aminoglycosides (-mycin)
  2. Amphotericin
  3. Contrast (extremely rapid in onset)
  4. Chemotherapy (Cisplatin)
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10
Q

What is allergic interstitial nephritis?

A

Hypersensitivity to penicillin, sulfa, phenytoin, allopurinol, rifampin, quinolones.

Rash and fever with a rise in BUN and Creatinine

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11
Q

How do you diagnose interstitial nephritis?

A

Wright Stain or Hansel stain in urine to show eosinophils

Urinalysis shows white cells, but can’t distinguish neutrophils from eosinophils

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12
Q

What does rhabdomyolysis do to the potassium level?

A

Hyperkalemia from cellular destruction

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13
Q

Best initial test for rhabdo? Most accurate?

A

Initial: Urinalysis showing large amounts of blood with no cells seen (remember this is myoglobin)

Accuate: Urine myoglobin

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14
Q

What to order in pts with possible rhabdo?

A

Potassium level
Calcium level (low)
Chemistries looking for low bicarb

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15
Q

Why does rhabdo cause hypocalcemia?

A

Damaged muscle binds calcium

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16
Q

Tx of rhabdo?

A
  • Bolus of NS
  • Mannitol and diuresis to decrease contact time
  • Alkalinization of urine to decrease precipitation of myoglobin at the tubule
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17
Q

Most urgent step in an acute case of rhabdomyolysis?

A

EKG b/c hyperkalemia can lead to arrhythmia with peaked T-waves

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18
Q

What types of crystals can cause crystal-induced renal failure?

A

Oxalate and uric acid

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19
Q

Oxalate crystals can form if someone ingests ____

A

Antifreeze (ethylene glycol)

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20
Q

What will be the acid-base disturbance with antifreeze intoxication?

A

Metabolic acidosis with elevated anion gap

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21
Q

Best test for oxalate crystals? Best treatment?

A

Test: Urinalysis showing envelope-shaped oxalate crystals
Treatment: Ethanol or fomepizole w/immediate dialysis

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22
Q

Uric acid crystals most commonly occur after what?

A

Chemotherapy for lymphoma (tumor lysis syndrome)

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23
Q

How to treat uric acid crystals?

A

Hydration, allopurinol, and rasburicase (breaks down uric acid)

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24
Q

What’s the best method to prevent contrast induced renal failure?

A

Hydration with normal saline and possible bicarb, NAC, or both

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25
A slight elevation of creatinine means the loss of ___ to ___% of renal function at minimum
60-70
26
How do NSAIDs affect the kidney
Afferent vasoconstriction which decreases glomerular perfusion
27
What are 3 problems NSAIDs can cause to the kidneys?
Direct toxicity w/papillary necrosis Allergic interstitial nephritis Nephrotic syndrome
28
All forms of glomerulonephritis have what 6 characteristics?
1. RBCs in urine 2. RBC casts in urine 3. Mild proteinuria (
29
Goodpasture's sxs:
Cough Hemoptysis SOB Lung findings
30
Best initial and most accurate tests for Goodpastures?
Initial: Anti-basement membrane antibodies Accurate: Renal biopsy showing Linear deposits
31
Tx of Goodpastures?
Plasmapheresis and steroids
32
Churg-Strauss sxs:
Asthma Cough Eosinophilia Renal abnormalities
33
Best initial test and most accurate test for Churg-STrauss?
Initial: CBC for eosinophil count Accurate: Biopsy
34
Tx for Churg-Strauss?
Glucocorticoids (prednisone) | -Add cyclophosphamide if there's no response
35
Wegener's granulomatosis sxs?
Upper and lower respiratory problems (sinusitis, otitis) Lung (cough, hemoptysis, abnormal CXR) Systemic vasculitis (joint, skin, eye, brain, GI problems) *upper and lower respiratory involvement + renal involvement* Often misdiagnosed as pneumonia
36
Best initial test for Wegener's? Most accurate?
Initial: c-ANCA Accurate: Biopsy of kidney
37
Best treatment for Wegener's?
Cyclophosphamide and steroids
38
What is PAN?
Systemic vasculitis affecting every organ EXCEPT the lungs. 1. Renal 2. Myalgias 3. GI bleeding and abdominal pain 4. Purpuric skin lesions 5. Strokes 6. Uveitis 7. Neuropathy
39
Key to diagnosis of PAN?
Multiple motor and sensory neuropathy with pain
40
Best initial test and most accurate test for PAN?
Initial: ESR and markers of inflammation Accurate: Biopsy of sural nerve or the kidney
41
What to always additionally test for with PAN?
Hep B and C
42
Best therapy for PAN?
Cyclophosphamide and steroids
43
How does IgA nephropathy present?
Painless recurrent hematuria in an Asian pt usually after a viral URI.
44
Best test for IgA nephropathy?
*Renal biopsy* is essential
45
Tx of IgA nephropathy?
No proven effective therapy that reverses it 1. Steroids in boluses for sudden worsening of proteinuria 2. ACE-i for all pts with proteinuria
46
In whom does Henoch-Schonlein purpura present? What are the sxs?
Adolescent or child 1. Raised, nontender, purpuric skin lesions (buttocks usually) 2. Abdominal pain 3. Joint pain 4. Renal involvement 5. Bleeding
47
Diagnostic testing for HSP?
Almost always a clinical diagnosis (GI, joint, skin, and renal involvement is best indicator) Biopsy is the most accurate test showing IgA deposition but this isn't a test you need to do.
48
Tx of HSP?
Resolves spontaneously
49
Sxs of PSGN?
Dark urine (tea or cola colored) Periorbital edema HTN
50
What leads to PSGN?
Throat and skin infections
51
Best initial and most accurate test for PSGN?
Initial: Antistreptolysin O, anti-DNase, antihyaluronidase in blood AccuratE: Biopsy (don't do this routinely)
52
Treatment of PSGN?
Penicillin and other antibiotics | Diuretics for fluid overload
53
PResentation of cryoglobulinemia:
Renal involvement, joint pain and purpuric skin lesions in pts with a hx of Hep C
54
Best initial and most accurate test for cryoglobulinemia?
Initial: Serum cryoglobulinemia component levels (immunoglobulins and light chains, IgM) Accurate: Biopsy
55
Tx of cryoglobulinemia?
Ledipasvir and sofosbuvir for type 1
56
Drug induced lupus spares what 2 organ systems?
Brain | Kidneys
57
For lupus nephritis, what's the best initial test and most accurate test?
Initial: ANA and anti-double stranded DNA Accurate: Renal biopsy (very important b/c it determines extent of disease which guides therapy)
58
Tx of lupus nephritis?
Sclerosis only: No tx Mild disease: Steroids Severe: Mycophenolate mofetil and steroids
59
Alport syndrome presentation? Tx?
Congenital eye and ear problems like deafness Renal failure in 2nd or 3rd decade of life No therapy
60
HUS triad:
Intravascular hemolysis (fragmented cells on smear) High creatinine Thrombocytopenia
61
TTP pentad?
HUS + Fever + Neuro abnormalities
62
Tx of TTP and HUS?
Plasmapheresis
63
Nephrotic syndrome labs:
>3.5 g of protein lost in urine everyday Low albumin (causes edema) Hyperlipidemia Thrombosis b/c loss of antithrombin III, Protein C and S
64
Best initial diagnostic test for nephrotic syndrome?
Urinalysis showing high protein level
65
Next best test for nephrotic syndrome?
Spot-urine for protein:creatinine ratio >3.5:1 *OR* 24-hr urine protein collection showing >3.5 g protein
66
Most accurate test for nephrotic syndrome?
Renal biopsy
67
Give the common pts these types of nephrotic syndromes occur in: 1. Minimal change 2. Membranous 3. Membranoproliferative 4. Focal segmental
1. Minimal change - children 2. Membranous - Adults w/cancer like lymphoma 3. Membranoproliferative - Hep C 4. Focal segmental - HIV, heroin use
68
Tx of nephrotic syndromes?
Steroids | -Cyclophosphamide if no response
69
If pt has mild proteinuria, what do you do first?
Repeat urinalysis b/c it often disappears on repeat
70
What if pt has mild proteinuria on repeat testing?
Make sure they don't have a reason for transient proteinuria: - CHF - Fever - Exercise - Infection
71
What if the above reasons are not present when they have mild proteinuria?
Possible orthostatic proteinuria | -Ppl who stand all day like waiters, teachers, etc
72
How to diagnose orthostatic proteinuria?
Take morning urine protein and then afternoon protein. | -If present in afternoon and not morning its orthostatic
73
What if the morning protein is elevated as well?
Do 24-hr urine or spot protein:cr ratio. If elevated do biopsy
74
Describe the overall steps in the workup of proteinuria:
1. Repeat UA 2. Evaluate for othostatic proteinuria 3. Get protein/cr ratio 4. Get renal biopsy
75
Give 4 manifestations of uremia and their treatment:
1. Hyperphosphatemia - calcium acetate/carbonate 2. Hypermagnesemia: Mg restriction in diet 3. Anemia: erythropoietin replaceent 4. Hypocalcemia: Vit D replacement
76
When do you need dialysis?
1. Metabolic acidosis 2. Hyperkalemia 3. Intoxication with lithium, aspirin, or ethylene glycol (dialyzable drugs) 4. Fluid overload 5. Uremic encephalopathy
77
Name the two types of diabetes insipidus
Central: Brain not making ADH Nephrogenic: Kidney can't respond to ADH These both cause *hypernatremia*
78
What things can cause nephrogenic DI?
Hypokalemia Hypercalcemia Lithium toxicity
79
Sxs of hypernatremia and hyponatremia:
Confusion Seizures Coma
80
First thing to do in a pt with hyponatremia?
Assess volume status
81
Causes of hypervolemic hyponatremia?
CHF Nephrotic syndrome Cirrhosis
82
Causes of hypovolemic hyponatremia:
``` Diuretics - High urine sodium GI loss (vomiting, diarrhea) - Low urine sodium Skin loss (burns, sweating) - Low urine sodium ```
83
Causes of euvolemic hyponatremia:
SIADH Hypothryoidism Psychogenic polydipsia Hyperglycemia
84
How are glucose and sodium levels associated?
Every 100mg of glucose above normal drops the sodium by 1.6
85
What labs does Addison's disease give?
It's low aldosterone, so: - Hyponatremia - Hyperkalemia - Metabolic acidosis Tx with fludrocortisone
86
What can cause SIADH?
Any CNS abnormalities Any Lung disease Sulfa, SSRI, carbamazepine Cancer
87
How to treat mild hyponatremia with no sxs:
Fluid restriction
88
How to treat moderate to severe hyponatremia (confusion, seizures)
Saline infusion with loop diuretics Hypertonic (3%) saline Check Na frequently ADH blockers (conivaptan, tolvaptan)
89
How fast to correct hyponatremia?
No more than 10-12 in 1st 24 hours | Central pontine myelinolysis
90
How to tx chronic SIADH from malignancy?
Demeclocycline to block ADH affect at kidney
91
What usually causes hyperkalemia?
Rhabdo or hemolysis
92
Can you get hyperkalemia from diet?
Yes, but only if your kidneys aren't working well. The kidney excretes it faster than the GI tract can even absorb it
93
Give 10 other causes of hyperkalemia:
1. Hypoaldosteronism (Addison's disease) 2. Metabolic acidosis 3. Beta blockers 4. Digoxin toxicity 5. Insulin deficiency 6. Spironolactone, eplerenone 7. ACE-I and ARBs 8. Prolonged immobility, seizures, rhabdo, crush injury 9. Type IV renal tubular acidosis 10. Renal failure
94
EKG of hyperkalemia?
1st come the Peaked T-waves 2nd comes loss of P-wave 3rd comes widened QRS
95
How to treat severe hyperkalemia (As evidenced by EKG chnages like peaked-T-waves)
Start with: *IV calcium gluconate* Followed by: IV insulin and glucose* Then finish it up with: *Kayexalate*
96
How to fix moderate hyperkalemia (no EKG abnormalities)?
IV Insulin and glucose Bicarb to shift K into cells Kayexalate orally to remove from body (takes hours)
97
Give 7 causes of hypokalemia:
1. Dietary insufficiency 2. Diuretics 3. High-aldosterone states (Conn syndrome) 4. Vomiting (metabolic alkalosis which shifts K into cells) 5. Proximal and distal RTA 6. Amphotericin 7. Bartter syndrome (Loop of Henle can't absorb sodium and chloride --> secondary hyperaldosteronism)
98
What rhythm disturbance does Hypokalemia give?
U-waves
99
Tx of hypokalemia?
Replace potassium orally (no maximum rate) | Avoid glucose-containing fluids
100
Most common cause of hypermagnesemia?
Overuse of laxatives that contain Mg or iatrogenic administration when used as a tocolytic
101
Sxs of hypermagnesemia?
Muscular weakness | Loss of DTRs
102
Tx of hypermagnesemia?
Restrict intake Saline administration to provoke diuresis Occasionally dialysis
103
6 causes of hypomagnesemia:
1. Loop diuretics 2. Alcohol withdrawal or starvaton 3. Gentamicin, amophotericin 4. Cisplatin 5. Parathyroid surgery 6. Pancreatitis
104
Presentation of hypomagnesemia?
Hypocalcemia and cardiac arrythmias
105
Name the 7 causes of metabolic acidosis with an increased anion gap:
1. Lactic acidosis 2. Aspirin overdose 3. Methanol 4. Uremia 5. DKA 6. Isoniazid toxicity 7. Ethylene glycol
106
Methanol causes production of what?
Formic acid and formaldehyde
107
Tx of methanol intoxication?
Get a methanol level | Order fomepizole or ethanol
108
In DKA, what's the fastest single test to tell if a patient's hyperglycemia is life-threatening
Low bicarbonate
109
Causes of meatbolic acidosis with a normal anion gap?
Diarrhea | RTA
110
Name 5 things that cause a metabolic alkalosis:
``` Volume contraction Conn syndrome or Cushing syndrome Hypokalemia Milk-Alkali syndrome Vomiting ```
111
How does volume contraction lead to a metabolic alkalosis?
Because it causes secondary hyperaldosteronism which causes increased urinary excretion of acid
112
What is another name for primary hyperaldosteronism?
Conn syndrome
113
How does hypokalemia cause a metabolic alkalosis?
Potassium ions shift out of the cell to correct the hypokalemia. Thsi shifts hydrogen ions into the cell.
114
What is milk-alkali syndrome?
Too much liquid antacid
115
Man is found to have a BP of 145/95 on a routine visit. What's the next step?
Repeat in 1-2 weeks
116
What should you also order when you diagnose someone with HTN?
Urinalysis EKG Eye exam Cardiac exam
117
Most effective lifestyle modification for HTN?
Weight loss
118
When starting an antihypertensive, which drug will you choose if a pt has: 1. CAD 2. CHF 3. Migraine 4. Hyperthyroidism 5. Osteoporosis 6. Depression 7. Asthma 8. Pregnacy 9. BPH 10. DM
1. CAD - Beta blocker 2. CHF - Beta blocker, ACEI/ARB 3. Migraine - Beta blocker, CCB 4. Hyperthyroidism - Beta blocker 5. Osteoporosis - Thiazide 6. Depression - No beta blockers 7. Asthma - No beta blockers 8. Pregnacy - Alpha methyldopa 9. BPH - Alpha blockers 10. DM - ACEI/ARB
119
BP target for those >60 years old?
150/90
120
When to investigate for secondary hypertension?
1. Pt is 60 2. Failure to control BP with 3 meds 3. If pt has - Bruit - Episodic HTN - Buffalo hump, truncal obesity - Upper extremity > lower extremity pressure - Hirsutism - Hypokalemia
121
When a pt with HTN has each of these, what will you think of? - Bruit - Episodic HTN - Buffalo hump, truncal obesity - Upper extremity > lower extremity pressure - Hirsutism - Hypokalemia
- Bruit = Renal artery stenosis - Episodic HTN = Pheo - Buffalo hump, truncal obesity = Cushing - Upper extremity > lower extremity pressure = Coarctation - Hirsutism = CAH - Hypokalemia = Conn syndrome
122
Describe renal artery stenosis
Bruit in the flanks or abdomen | Hypokalemia may be present
123
How to diagnose renal artery stenosis?
Initially: Renal U/S | Most accurate: Renal angiogram
124
Best treatment for renal artery stenosis?
Renal artery angioplasty and stenting

MTB STEP 3 (R) (9 decks)

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