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Flashcards in Nephrology Deck (39):
1

Acute Tubular Necrosis:
Most likely cause?

Renal hypoperfusion due to hypovolemia, hemorrhage, rhabdomylysis

2

55/M
MV collision
somnolent
multiple bruises
large abdominal laceration
PE HR135 BP40palp RR24
dry mucous membranes
sunken eyes
doughy skin
UO 5cc/hr
urine sediment = muddy brown granula and epithelial cell casts

Diagnosis?

Acute Tubular Necrosis

probably prerenal (hemorrhage)
and intrinsic renal (rhabdomyolysis d/t MVC)

3

Acute Tubular Necrosis:
other labs besides urinalysis?

serum electrolytes
BUN
Crea

4

Differentiate azotemia from uremia

Azotemia: biochemical (increased urea)
Uremia: clinical signs and symptoms (asterixis, abdominal pain, chest pain -- improves when leaning forward, uremic breath)

5

Three important causes of azotemia?

prerenal disease
intrinsic renal disease
postrenal disease (obstructive uropathy)

6

Differentiate
prerenal disease
versus
intrinsic renal disease
versus
postrenal disease (obstructive uropathy)
(the three important causes of azotemia)

PRERENAL
BUN/Crea ratio >20
FE Na (more specific) 2%
Causes: PSGN, drugs, HTN

OBSTRUCTIVE UROPATHY
BUN/Crea ratio 10 to 20
FE Na (more specific) intermediate
Causes: prostate, cervical cancer (note: MCC of death: uremia due to obstruction)

7

What is chronic kidney disease?

continuing significant irreversible reduction in nephron number

8

What remains to be the most common cause of chronic kidney disease?

diabetes mellitus

9

How is chronic kidney disease staged?

K/DOQI Staging System:
Stage 1: GFR >90
Stage 2: GFR 60 to 89
Stage 3: GFR 30 to 59
Stage 4: GFR 15 to 29
Stage 5: GFR <15 (aka ESRD)

10

What are the indications for dialysis in CKD?

acidosis
electrolytes (hyperkalemia)
ingestion of toxins
overload
uremia

(HAGMA MUDPILES)

11

What are the two modes of dialysis?

Hemodialysis: using Tesio catheter and AV graft
Peritoneal dialysis: using a Tenchkoff catheter

12

Why do patients with CKD develop anemia? What type?

inability to produce EPO causes normocytic, normochromic anemia

13

Why do CKD patient develop secondary hyperparathyroidism?

failing kidneys fail to reabsorpb calcium, leading to hypocalcemia

14

Why do CKD patients require vitamin D supplementation?

inability to form active vitamin D (1,25 DHCC) due to kidney damage

15

What is the clinical effect of hypocalcemia, hyperphosphatemia, and low vitamin D in CKD?

renal osteodystrophy (chondrocalcinosis, osteopenia)

16

What is the most common cause of death in CKD patients?

CAD / MI (ESRD is a CAD equivalent)

17

What medications should be given to prevent cardiac complications in CKD patients?

beta blockers
ACE inhibitors
statins

18

28F
recent onset of flank pains
fever and dysuria
PE temp at 38.9 degrees Celsius, CVA tenderness
urinalysis revealed WBC casts

diagnosis?

Acute Pyelonephritis

19

Acute Pyelonephritis:
What is the most common cause of this condition?

Escherichia coli

20

Acute Pyelonephritis:
most appropriate treatment?

emperic antibiotic therapy (quinolones) --- cipro, norflo

21

Acute Pyelonephritis:
if the patient were diabetic, what complication would you be concerned about?

Renal Papillary Necrosis

22

Acute Pyelonephritis:
if the urine culture of this patient revealed facultative gram negative rods with swarming motility, what will you consider?

Proteus mirabilis

23

Acute Pyelonephritis:
why are these infections more common among females?

females have shorter urethras

24

31M brought to the ER for dyspnea
PE: periorbital puffiness and bilateral pitting edema
auscultation = bibasal crackles
urinalysis revealed 4+ proteinuria

diagnosis?

Nephrotic Syndrome

25

Nephrotic Syndrome:
pathology?

in situ immune complex formation / deposition

26

Nephrotic Syndrome:
what is the most common cause of this condition (young adult to middle aged group)?

Membranous nephropathy

27

Nephrotic Syndrome:
renal biopsy will reveal?

LM: diffuse capillary wall thickening
EM: subepithelial deposits
IF: granular deposits

28

Nephrotic Syndrome:
What other diagnostic tests will you request (aside from urinalysis)?

BUN, Crea, electrolytes, cholesterol panel, 24 hour urine collection

29

Nephrotic Syndrome:
what is the nephrotic proteinuria?

>3.5g protein in 24 hour urine collection

30

Nephrotic Syndrome:
what is the most appropriate treatment?

steroids (predinisone)

31

Nephrotic Syndrome:
complications?

spontaneous bacterial peritonitis
thromboembolic events
hyperlipidemia

32

Nephrotic Syndrome:
if the patient does not respond to steroids after 2 months of treatment, what is the most likely diagnosis?

focal segmental glomerulosclerosis --- adult

33

Nephrotic Syndrome:
what is the most common cause of this condition in children?

minimal change disease (lipoid nephrosis)

34

34F moderate weakness and progressive low back pain
history of kidney stones
urinalysis reveals low urine pH
NAGMA, hypoK, and hyperuricosuria

diagnosis?

Renal Tubular Acidosis

35

Renal Tubular Acidosis:
types?

Type I RTA
Type II RTA
Type IV RTA

36

Renal Tubular Acidosis:
most common causes of this condition?

Type I RTA---sporadic, Hep B or Hep C

Type II RTA---multiple myeloma, amyloidosis, Fanconi's Syndrome (px in PCT)

Type IV RTA---DM, hyperaldosteronism

37

Renal Tubular Acidosis:
pathophysiologic mechanisms (of each type)?

Type I RTA---inability to secrete H+ in DCT

Type II RTA---inability to reabsorb HCO3 in PCT

Type IV RTA---decreased aldosterone

38

Renal Tubular Acidosis:
Differentiate Type I (distal)
vs
Type II (proximal)
vs
Type IV (DM, dec aldosterone)

as to:
urine pH?
stones?
potassium?
diagnosis?
treatment?

Type I (distal)
urine pH?------high, basic, more than 5.5, can't acidify
stones?------present
potassium?------low
diagnosis?------acid load (give NH4Cl)
treatment?------HCO3 + K tabs

Type II (proximal)
urine pH?------normal or low, acidic, less than 5.5
stones?------present
potassium?------low
diagnosis?------HCO3 load (give HCO3)
treatment?------HCO3 + K tabs + diuretics (HCTZ)

Type IV (DM, dec aldosterone)
urine pH?------low, acidic
stones?------ABSENT
potassium?------HIGH
diagnosis?------Na restriction (high urine Na)
treatment?------Fludrocortisone

39

Renal Tubular Acidosis:
Differentiate Bartter's from Gitelman's Syndrome

As to:
site of defect?
channel?
age?
urine Ca2+?
conc ability?
GFR?

Bartter's Syndrome
site of defect?------TAL
channel?------NaK2Cl symport
age?------children
urine Ca2+?------normal or increased (stones)
conc ability?------impaired
GFR?------decrased

Gitelman's Syndrome
site of defect?------DCT
channel?------NaCl symport
age?------adults
urine Ca2+?------decreased, no stones
conc ability?------normal
GFR?------normal