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nephrology Flashcards

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1
Q

alternative marker for GFR thats not affected by age or muscle mass

A

serum cystatin c

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2
Q

what can cause an overestimation of GFR

A

falsely low Cr from loss of muscle mass because of advanced age, liver failure, or malnutrition

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3
Q

what is the only protein detected on a UA

A

albumin

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4
Q

what test thats not widely use can detect albumin with other proteins

A

sulfosalicylic acid (SSA) test

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5
Q

urine protein of >150 mg/g but <200 mg/g can indicate while protein >3500 indicates

A

tubulointerstitial disease or glomerular disease

vs glomerular disease

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6
Q

Proteinuria is a marker of and cand indicate

A

l parenchymal and glomerular disease and an independent predictor of progressive kidney disease,
cardiovascular disease, and peripheral vascular disease.

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7
Q

how to diagnose orthostatic/positional proteinuria

A

by obtaining split daytime

(standing) and nighttime (supine) urine collections.

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8
Q

coexisiting protein and hematuria can indicate what subtype of disease

A

glomerular causes of hematuria, even in the absence of casts.

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9
Q

Hematuria with preserved erythrocyte morphology in the urine, often without proteinuria or casts, is consistent with

A

extraglomerular bleeding (GU cancer, kidney stones, trauma, infection, and medications)

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10
Q

work up for hematuria

A
  • urinalysis or urine culture to exclude infection, and if normal…
  • noncontrast helical CT to detect calculi and contrast CT to detect renal cell carcinoma, and if normal…

• urine cytology, then stop evaluation if normal and patient is at low risk for malignancy (age <35 years, female sex, no other
risk factors), otherwise…

• cystoscopy for patients with positive urine cytology, aged >35 years, male, or if risk factors for malignancy are present
(cigarette smoking, analgesic abuse, benzene exposure, or voiding abnormalities)

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11
Q

leukocytes in urine indicate

A

glomerular or tubulointerstitial inflammation, infection, or an allergic reaction.

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12
Q

sterile pyuria (pyuria and a negative urine culture) suggests

A

Mycobacterium tuberculosis, interstitial cystitis, or

interstitial nephritis.

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13
Q

Eosinophiluria indicates

A

AIN, postinfectious GN, atheroembolic disease of the kidney, septic emboli, or small-vessel vasculitis but abscence doesn’t rule out any of these either

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14
Q

causes for for blood on dipstick urinalysis in the absence of intact erythrocytes on urine microscopy

A

dialysis and rhabdo

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15
Q

Urine lipids and fat are almost always associated with

A

heavy proteinuria or the nephrotic syndrome.

These may appear as free lipid droplets, round or oval fat bodies, or fatty casts.

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16
Q

what are kidney us used for

A

nephrolithiasis
• kidney size and cortical thickness (increased echogenicity implies parenchymal disease)
• renal cysts and tumors
• obstruction and hydronephrosis
• bladder size, postvoid residual, and the prostate in bladder outlet obstruction

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17
Q

what are kidney CT used for

A

nephrolithiasis (noncontrast abdominal helical CT)
• renal tumors and cysts (contrast abdominal CT)
• causes of unexplained urologic/nonglomerular hematuria (CT urography)

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18
Q

what are kidney MRI used for

A
  • when radiocontrast agents must be avoided (risk of nephrogenic systemic fibrosis in patients with CKD)
  • to characterize renal masses, cysts, and renal vein thrombosis
  • to look for renal artery stenosis using MRA with gadolinium contrast
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19
Q

indications for kidney biopsy

A

glomerular hematuria
• severely increased albuminuria
• acute or CKD of unclear origin
• kidney transplant dysfunction

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20
Q

contraindications for kidney biopsy

A

bleeding diatheses, severe anemia, UTI, hydronephrosis, uncontrolled
hypertension, renal tumor, and atrophic kidneys.

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21
Q

hypertonic hyperosmolar causes of hyponatremia

A
  • glucose (most common)
  • BUN
  • alcohols
  • mannitol
  • sorbitol
  • glycine (bladder irrigation during urological procedures)
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22
Q

lab studies consistent with hypovolemic hypoosmolar hyponatremia

A

Spot urine sodium <20 mEq/L

BUN/creatinine >20:1

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23
Q

causes of hypovolemic hyponatremia

A

GI or kidney sodium losses, mineralocorticoid

insufficiency

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24
Q

hypervolemic hyponatremia lab findings

A

Spot urine sodium <20 mEq/L (HF and cirrhosis
in absence of diuretic therapy)
Spot urine sodium >20 mEq/L (acute and
chronic kidney failure)

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25
causes of hypervolemic hyponatremia
HF, cirrhosis, kidney failure
26
euvolemic lab finding possibilities
Spot urine sodium >20 mEq/L Urine osmolality usually >300 mOsm/L vs Urine osmolality 50 to 100 mOsm/L
27
euvolemic hyponatremia with spot sodium <20 and osm >300 causes
SIADH, hypothyroidism, adrenal insufficiency (Addison disease), cerebral salt wasting syndrome Euvolemia (normal volume)
28
euvolemic hyponatremia with spot sodium <20 and osm 50-100 causes
Compulsive water drinking
29
illness that cause siadh
malignancy (SCLC); intracranial pathology; and pulmonary diseases, especially those that increase intrathoracic pressure and decrease venous return to the heart
30
MEDS that cause siadh
thiazides, SSRIs, | tricyclic antidepressants, narcotics, phenothiazines, and carbamazepine.
31
what can happen with overcorrecting hyponatremia
Central pontine myelinolysis (osmotic demyelination syndrome) may occur if hyponatremia is corrected too rapidly.
32
tx for siadh hyponatremia
1st water restriction 2nd option loop diuretic with salt 3rd Demeclocycline
33
causes of hypernatremia
inadequate access to water (older patients in nursing homes), a kidney concentrating defect (DI, most commonly caused by lithium), and/or impaired pituitary secretion of ADH (e.g., sarcoidosis). Most commonly, hypernatremia results from loss of hypotonic fluids (GI, kidney, skin) with inadequate water replacement
34
causes of hyperkalemia
• hyporeninemic hypoaldosteronism (Type 4 RTA; commonly seen among patients with diabetes) • acute and chronic kidney failure • low urine flow states • medications (ACE inhibitors, ARBs, potassium-sparing diuretics, pentamidine, trimethoprim-sulfamethoxazole, and cyclosporine) • potassium shifts (rhabdomyolysis, hemolysis, hyperosmolality, insulin deficiency, β-adrenergic blockade, and metabolic
35
ekg changes in hyperkalemia
peaking of the T waves and shortening of the QT interval. As hyperkalemia progresses, the PR interval is prolonged, a loss of P waves occurs, and eventual widening of the QRS complexes is seen with a “sinewave” pattern that can precede asystole.
36
significant hyperkalemia but no ecg changes likely means
pseudohyperkalemia
37
what matters more of severity of hyperkalemia serum amount or ekg changes
ekg
38
If hypomagnesemia is suspected, look for
neuromuscular irritability, hypocalcemia, and hypokalemia
39
causes of hypomagnesemia
* GI losses (diarrhea, steatorrhea, intestinal bypass, pancreatitis) * kidney losses (loop and thiazide diuretics, alcohol-induced) * medictxations (cisplatin, aminoglycosides, amphotericin B, cyclosporine) * hungry bone syndrome following parathyroidectomy
40
tx for magnesium deficiency
Administer oral slow-release magnesium and IV magnesium sulfate to achieve a serum magnesium level >1 mg/dL
41
anion gap equation
e anion gap = [Na+] − ([Cl–] + [HCO3–])
42
causes of high anion gap metabolic acidosis
DKA • CKD • lactic acidosis (usually because of tissue hypoperfusion) • aspirin toxicity • alcoholic ketoacidosis • methanol and ethylene glycol poisoning (also typically associated with an osmolar gap)
43
cause of normal anion gap metabolic acidosis
• GI HCO3 – loss (diarrhea) • kidney HCO3 – loss (ileal bladder, proximal RTA) • reduced kidney H+ secretion (distal RTA, type IV RTA) • Fanconi syndrome (phosphaturia, glucosuria, uricosuria, aminoaciduria) • carbonic anhydrase inhibitor use (acetazolamide and topiramate)
44
Urine anion gap for normal AG metabolic acidosis to differentiate RTA from extrarenal losses ie diarrhea
extrarenal bicarb loss - a markedly negative (-20 to -25 mEq/L) UAG. RTA type 1 (urine bicarb/cl is impaired) - UAG being markedly positive (20-40 mEq/L).
45
Type 1 RTA metabolic findings
``` Normal anion gap metabolic acidosis hypokalemia positive UAG, urine pH >5.5 (only in the setting of systemic acidosis) serum [HCO3] ≅ 10 mEq/L ```
46
Type 1 RTA associated findings
``` Nephrolithiasis and nephrocalcinosis, autoimmune disorders (SLE, Sjögren syndrome), amphotericin B use, urinary obstruction ```
47
Type 2 RTA metabolic findgs
``` Normal anion gap metabolic acidosis, normal or negative UAG, hypokalemia, urine pH <5.5, serum [HCO3] ≅ 16-18 mEq/L ```
48
Type 2 RTA associated findings
Glycosuria, phosphaturia, uricosuria, aminoaciduria, and tubular proteinuria (Fanconi syndrome)
49
Type 4 RTA metabolic findings
Normal anion gap metabolic acidosis, hyperkalemia, positive UAG, urine pH <5.5
50
Type 4 RTA associated findings
Diabetes mellitus, urinary tract obstruction
51
treatment of Type 1 RTA
A, administration of bicarbonate
52
treatment for type 2 RTA
The addition of a thiazide diuretic may help by inducing volume depletion, lowering the GFR, and thereby decreasing the filtered load of bicarbonate.
53
treatment for type 4 RTA
a, which will treat the acid-base disturbance. These patients, often with early CKD and diabetes, may develop severe hyperkalemia following treatment with ACE inhibitors or ARBs.
54
how to treat etoh ketoacidosis
IV normal saline, glucose, and thiamine
55
• If (Δ anion gap/Δ [HCO3]) is <1, consider concurrent normal anion gap acidosis.
concurrent normal anion gap acidosis.
56
• If (Δ anion gap/Δ [HCO3]) is >2
concurrent metabolic alkalosis
57
what does it mean when you have an increased osmolar gap
gap> 10 can suggest alcohol poisoning Ethanol is the most common cause of alcohol poisoning. Methanol, isopropyl alcohol, and ethylene glycol can also increase the osmolal gap.
58
major findings in ethanol poisoning and tx
CNS depression, oliguria, flank pain and hematuria No anion gap but increased osmolar gap Tx- supportive
59
major findings in isopropyl alcohol and tx
CNS depression, ↑ Ketones No anion gap but increased osmolar gap Tx- supportive
60
major findings in methonol and tx
windshield wiper fluid CNS depression, Vision loss increased anion gap and osmolar gap Tx- Fomepizole, Dialysis (severe) and Folic acid
61
major findings in ethylene glycol and tx
anti-freeze -CNS depression, Acute kidney injury, Calcium oxalate crystals in the urine increased anion gap and osmolar gap Tx- Fomepizole, Dialysis (severe)
62
types of nephropathy
Focal segmental glomerulosclerosis membranous minimal change and DM
63
Focal segmental | glomerulosclerosis associations
Most common cause of nephrotic syndrome in blacks “Collapsing” variety associated with HIV Associated with morbid obesity
64
Membranous | glomerulopathy Associations
Most common cause of nephropathy in whites Positive antibody against phospholipase A2 receptor Secondary causes include: infection (hepatitis B and C, malaria, syphilis); SLE; drugs (NSAIDs); cancer (solid tumors, lymphoma) High propensity for thrombosis, especially renal vein thrombosis
65
Minimal change | glomerulopathy
Most common cause of primary nephrotic syndrome in children | 10% of nephrotic syndrome in adults
66
Diabetic | nephropathy
Most common secondary cause of the nephrotic syndrome and the most common overall cause in adults Annual measurement of albumin-creatinine ratio measured beginning 5 years after diagnosis of type 1 diabetes and at time of diagnosis of type 2 diabetes
67
hallmark sign of nephritis
dysmorphic erythrocytes and erythrocyte casts
68
types Pauci-immune GN (necrotizing GN with few immune | deposits, normal complement)
Granulomatosis with polyangiitis Microscopic polyangiitis Eosinophilic granulomatosis with polyangiitis
69
type of gns with Immune complex deposition (low complement with exception of IgA nephropathy)
IgA nephropathy IgA vasculitis (Henoch-Schönlein purpura) LN Infection-related GN Membranoproliferative GN Cryoglobulinemia (see Monoclonal Gammopathies and Cryoglobulinemia)
70
what is anti–Glomerular Basement Membrane Antibody Disease and what is it if pulmonary capillaries are involved
autoimmune disease caused by antibodies directed against type IV collagen. it causes pulmonary hemorrhage (Goodpasture syndrome).
71
lab and biopsy finding in anti-glomberular basement membrane antibody disease
normal complement levels and elevated levels of anti-GBM antibodies. Kidney biopsy shows proliferative GN with linear deposition of immunoglobulin.
72
tx for anti–Glomerular Basement Membrane Antibody Disease
cyclophosphamide and glucocorticoids, combined with daily plasmapheresis.
73
granulomatosis with polyangiitis anca association
c-anca RP-3
74
MPA is associated with anca
p-anca mpo
75
labs and biopsy in pauci immune gn
Complement levels are normal. Kidney biopsy shows absent or minimal staining with immunoglobulin
76
tx for pauci immune gn (MPO, GPA)
glucocorticoids and cyclophosphamide (or rituximab) with or without plasmapheresis.
77
most common presentations of IGA nephropathy
asymptomatic microscopic hematuria (with or without proteinuria) or episodic gross hematuria coincident with a URI (synpharyngitic nephritis).
78
compliment level and biopsy in iga nephropathy
Kidney biopsy shows glomerular IgA deposits on immunofluorescence. Complement levels are normal.
79
tx for iga nephropathy
benign course without treatment; patients with proteinuria and risk factors for progression may benefit from ACE inhibitors or ARBs
80
IgA vasculitis (HSP) diagnosis
Diagnosis is confirmed either by finding an IgA-dominant leukocytoclastic vasculitis or by kidney biopsy, which shows lesions similar to IgA nephropathy. Complement levels are normal
81
labortory findings of LN
ANA and anti–double-stranded antibodies are positive, and C3 and C4 complement levels are depressed
82
tx for LN based on class
Class I and II (minimal or proliferative mesangial) lesions require no specific therapy. * Classes III and IV (focal and diffuse glomerular lesions) are treated with high-dose glucocorticoids and either IV cyclophosphamide or mycophenolate mofetil. * Class V (membranous) LN has a course similar to idiopathic membranous glomerulopathy
83
post-strep/staph GN occurs when
poststreptococcal GN typically occur after a latent period of 1 to 6 weeks
84
diagnosis of Post-infectious GN
Diagnosis is clinical in nephritic patients who have an ongoing or preceding infection. Complement levels are low
85
membranoproliferative GN is associated with which illness/demographic
children or young adults as proteinuria or the nephrotic syndrome. It is associated with immune complex disease (SLE), infections (hepatitis C), and monoclonal gammopathy
86
Causes of Glomerular Diseases Associated with Low Complement Levels
* postinfectious GN (e.g., endocarditis, Group A streptococcal infection) * SLE * cryoglobulinemia * membranoproliferative GN * atheroembolic disease
87
diagnosis criteria for ADPKD
* ≥2 cysts (unilateral or bilateral) for ages 15 to 29 years * ≥2 cysts in each kidney for ages 30 to 59 years * ≥4 cysts in each kidney for ages >60 years
88
when do you gene analysis test for ADPKD
if imagining is equivical
89
symptoms of ADPKD
Hypertension is a common presentation. More than 50% of patients develop recurrent flank or back pain from kidney stones, cyst rupture or hemorrhage, or infection.
90
urgent uro referral is needed for kidney stones in what settings
``` pyelonephritis or urosepsis • AKI • large stones requiring surgical removal • bilateral obstruction • obstruction of a solitary kidney ```
91
most severe extra renal complication of adpkd
ruptured aneurysm
92
treatment for adpkd
treat symptoms: HTN and pyelo/cyst infection | consider screening for aneurysm for people with adpkd esp if they have fam history
93
what is hereditary nephritis
rare end stage renal disease Xlinked also known as alport syndrome
94
symptoms of hereditary nephritis
sensorineural hearing loss and characteristic ocular findings such as lenticonus. Proteinuria, hypertension, and CKD usually develop over time.
95
Tx for hereditary nephritis
none, patients get end stage renal disease by teenage to 4th decade of life
96
``` Pre-renal AKI: BUN-Creatinine Urine Osmolality (mEq/L) Urine Sodium FENa Urinalysis and Microscopy Ratio ```
``` >20:1 >500 <20 <1% Specific gravity >1.020; normal or hyaline casts ```
97
``` ATN: BUN-Creatinine Urine Osmolality (mEq/L) Urine Sodium FENa Urinalysis and Microscopy Ratio ```
``` 10:1 ~300 >40 >2% (can be low in contrast nephropathy) Specific gravity ~1.010; muddy brown casts and tubular epithelial cells ```
98
post renal BUN: creatinine ratio
20:1

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