Flashcards in Nephrology Deck (204)
How does IV contrast cause renal failure?
vasospasm of afferent arteriole (decrease perfusion to glomeruli)
How long after an infection does post-Strep glomerulonephritis occur?
1-2 weeks after infection
Renal toxicity of a medication is due to the .... of the medication
trough (space interval of medications to decrease toxicity of medication)
What is the side effect of aminoglycosides (gentamicin)?
1. renal toxic
What is the difference between azotemia and uremia?
azotemia: renal insufficiency but no need for dialysis
uremia: renal insufficiency resulting in need for dialysis
What are complications of uremia? (9)
1. need for dialysis
2. anemia (decrease epo production)
5. hypocalcemia (decrease active vitamin D)
6. infections (wbc cant degranulate)
7. metabolic acidosis & fluid overload (b/c cant get rid of organic acid)
8. altered mental status
9. bleeding (platelets cant degranulate)
What is the treatment for uremia induced bleeding?
DDAVP (desmospressin causes release of subendothelial stores of vWf and factor 8)
What are causes of pre-renal azotemia?
1. dehydration/ shock/ blood loss
2. renal artery stenosis
3. hepatorenal syndrome
4. ACE inhibitor effect on kidney
5. low albumin states (nephrotic and liver disease)
What are causes of post-renal azotemia?
1. bladder stone/clot
2. bladder cancer
3. prostate hypertrophy/ cancer
4. bilateral ureteral disease
What is the driving force of GFR in kidney?
hydrostatic pressure in the glomeruli capillary
What is the initial clue to pre-renal azotemia?
BUN: creatinine ratio >20
(b/c more time for urea to be reabsorbed b/c slow flow)
What can falsely elevate BUN?
1. increased protein in diet
2. GI bleeding (protein release)
What happens to urine sodium in pre-renal azotemia?
urine sodium < 10 (low b/c body reabsorbs sodium to increase intravascular volume)
What happens to the urine osmolality in pre-renal azotemia?
urine osmolality is high (>500); concentrated urine
(high specific gravity >1.010)
A pt presenting with hypertension with renal insufficiency most likely suffers from ...
1. primary hyperaldosteronism
2. renal artery stenosis
(distinguish w/ aldosterone/renin ratio)
A pt with liver disease who develops renal insufficiency that does not respond to 1.5 liters of colloid (albumin) most likely suffers from ...
What dilates the afferent arteriole of the glomeruli?
How does NSAIDs result in pre-renal azotemia?
inhibit prostaglandins which prevent afferent arteriole dilation (results in constriction of arteriole)
What constricts the efferent arteriole of the glomeruli?
How do ACE inhibitors result in pre-renal azotemia?
inhibit conversion of angiotensin 1 to angiotensin 2 preventing constriction of efferent arteriole (results in dilation of efferent arteriole)
Why is it that ACE inhibitors diminish the rate of progression to renal failure and uremia in pts with diabetes, HTN, multiple myeloma?
dilation of efferent --> decreased hydrostatic pressure in glomeruli --> decrease intraglomerular HTN
(never withhold ACE inhibitor)
What is the best blood pressure medication for pt with diabetes?
What is orthodeoxia?
Change positions (sitting up) cause oxygen desaturation
What disease is associated with orthodeoxia?
What medications can cause retroperitoneal fibrosis (leading to post-renal azotemia)?
1. bleomycin (along with pulmonary fibrosis)
What chemo medication results in hemorrhagic cystitis?
What are the most common causes of neurogenic bladder?
2. multiple sclerosis
What is the normal post-voiding residual volume?
50 ml of urine (if elevated, implies obstruction to flow out of bladder)
What are causes of interstitial renal insufficiency?
3. pigments (hemogloin/ myoglobin)
4. proteins (bence jones)
A pt with a BUN/cr of 10, high urine sodium, urine osmolarity (similiar to serum osmolarity; isothenuria), and FeNa > 1% most likely suffers from ...
acute tubular necrosis
What type of casts/ sediment is associated with acute tubular necrosis?
granular, muddy brown, pigmented cast
(dead tubular cells sloughed off)
What drugs can result in allergic interstitial nephritis, drug induced hemolysis, and/ or rash?
3. sulfa drugs
(1 dose can cause problem)
What medications can result in acute tubular necrosis?
A pt presents with renal insufficiency with associated fever, rash, and eosinophils most likely suffers from ...
Allergic interstitial nephritis
What is the most accurate test for eosinophils in the urine?
Hansel stain (or Wright stain)
What are causes of myoglobinuria (rhabdomyloysis)?
1. severe crush injury
4, severe exertion
What is the initial best step in management of a pt with severe crush injury or seizure?
EKG or potassium level (hyperkalemia causes peaked t waves)
What is treatment for hyperkalemia with peaked T waves on EKG?
calcium chloride/ gluconate
What is the initial best test for rhabdomyolysis?
urinalysis (dipstick positive for blood but no RBCs seen)
What is treatment for rhabdomyolysis?
1. hydration (decrease contact time)
2. mannitol (osmotic diuretic-> decrease contact time)
3. alkalinize urine w/ bicarb
What is confirmatory test for rhabdomyolysis?
elevated CPK (>10,000)
What is treatment for hyperkalemia without EKG changes?
1. insulin with glucose
A pt presents with metabolic acidosis with gap due to ethylene glycol develops renal insufficiency due to...
calcium oxalate stone formation (enveloped shaped)
(oxalate is toxic metabolite of ethylene glycol)
What is the treatment for ethylene glycol intoxication?
1. ethanol or fomepizole (prevents formation of oxalate)
A pt with Crohn disease develops renal insufficiency due to ...
oxalate crystals (calcium bound to fat in gut instead of w/ oxalate)
A pt with cancer being treated with chemotherapy develops renal insufficiency due to ...
tumor lysis syndrome (uric acid release leading to urate crystals)
What treatment should pt with cancer being treated with chemotherapy be given to prevent urate crystal associated renal insufficiency?
allopurinol and hydration
What is the most common cause of hypercalcemia?
When should primary hyperparathyroidism need to be treated?
if associated with renal stones and renal insufficiency
A pt who underwent a vascular catheter procedure (angioplasty) who develops renal failure, bluish discoloration of extremities and livedo reticularis most likely suffers from ...
What is the most accurate test for atheroembolic disease?
skin biopsy showing cholesterol crystals in skin
What can be done to prevent contrast induced renal failure?
2. N-acetyl cysteine
A pt with hx of diabetes/ sickle cell disease/ NSAID use presents with sudden flank pain, hematuria, pyuria and fever most likely suffers from ...
What is the most accurate test for papillary necrosis?
CT scan (bumpy contours in the renal pelvis where papillae have sloughed off)
What is the next best step in management of a diabetic pt found to have microalbuminuria?
Start ACE inhibitor (or ARBs)
What is consider nephrotic range proteinuria?
3.5 grams/day or more
What is the best step in management of a pt with trace amounts of protein in urine?
repeat urinalysis or split 24 hour urine sample (if no protein in first 8 hours, but in second part --> orthostatic proteinuria)
How do you distinguish hematuria due to glomerular disease versus other causes?
glomeruli disease results in dysmorphic RBCs
What does nitrite positive urinalysis suggests?
gram negative bacteria presence (infection if WBCs)
What pt should be screened and treated for bacteriruia despite presence of WBCs or symptoms?
What do hyaline casts signify?
(accumulation of normal amount of tubular/Tomm-Horsfall protein)
What is the most common complication of peritoneal dialysis?
Why does anemia develop in ESRD and what is the treatment?
decreased production of epo; replace epo
What do eosinophilic casts suggest?
Allergic interstitial nephritis
What do broad, waxy casts suggest?
chronic renal disease
What is the cause of hypocalcemia and hyperphosphatemia in ESRD?
decrease production of active vitamin D so decrease calcium absorption --> elevated PTH stimulating bone breakdown and release of phosphate (kidney can't excrete)
What is treatment for hypocalcemia in ESRD?
vitamin D replacement
What is treatment for hyperphosphatemia in ERSD?
1. phosphate binders (calcium carbonate/ acetate/ sevelamer)
2. Cinacalcet (decreased PTH to decrease release of phosphate from bone)
What is cause of osteodystrophy in ERSD?
1. decrease active vitamin D --> decrease Ca --> increased PTH --> increase bone resorption to increase Ca
2. bone resorption to buffer acidosis
Why does hypermagnesium occur in ERSD and what is treatment?
decreased excretion; restrict magnesium intake
What is the most common cause of death in pt with ERSD on dialysis?
accelerated athersclerosis (coronary artery disease)
Why is there increased infections in pts with ERSD and what is the most common organism?
WBCs cant degranulate in uremic environment; S. aureus due to dialysis
Why is there increased bleeding in patient with ERSD?
uremia induced platelet dysfunction
What is the blood pressure goal for pt with diabetes or renal disease?
BP < 130/80
What are the indications for dialysis in pts with renal disease?
2. fluid overload (refractory to diuretics)
What are medications used to prevent post-transplantation renal graft rejection?
A pt presenting with edema, hematuria, red cell casts, hypertension and dysmorphic red cells in urine most likely suffers from ...
What is the most accurate test for glomerulonephritis?
What is the best initial test for glomerulonephritis?
A pt presents with recurrent URI and lung infections with hematuria most likely suffers from ...
What is the best initial test that is specific for Wegener granulomatosis?
C-ANCA (anti-proteinase 3 antibody)
A pt presenting with adult onset asthma, atopy, eosinophilia and hematuria most likely suffers from ...
What is treatment for Churg-Strauss syndrome?
steroids and cyclophosphamide
What is the treatment for Wegener granulomatosis?
steroids and cyclophosphamide
A young adult or child presents with periorbital edema, cola/tea colored urine and hypertension 1-2 weeks after recent Strep infection most likely suffers from ..
What is the best initial test for post-infectious glomerulonephritis?
Antistreptolysin test (ASO) and antihyaluronic acid (AHT)?
What are findings on renal biopsy for post-infectious glomerulonephritis?
subepithelial humps on electron microscopy with IgG and C3 deposited in mesangium
What is treatment for post-infectious GN?
fluid overload and diuretics
A pt presents with hematuria and lung disease without other manifestations (no skin or eye involvement) and hemosiderin laden macrophages most likely suffers from ...
What is the best initial test for Goodpasture syndrome?
antibasement membrane antibodies to type 4 collagen
What is treatment for Goodpasture?
plasmapheresis and steroids
An asian pt presents with hematuria 1-2 days after a viral URI most likely suffers from ...
IgA nephropathy (Berger disease)
What is the diagnostic finding in Berger's disease?
IgA deposit in kidney
A pt presenting with hematuria along with manifestations in every organ except lung most likely suffers from ...
Polyarteritis Nodosa (PAN)
What infection is associated with Polyartritis Nodosa?
Hep B infection (especially in IV drug users)
What antibody is associated with polyarteritis nodosa (PAN)?
What nerve is frequently biopsied for polyarteritis nodosa?
sural nerve (most accurate test)
What is the treatment for polyarteritis nodosa?
steroids and cyclophosphamide
A pt presents with palpable purpura, hematuria, abdominal pain, and arthralgias most likely suffers from ...
Henoch-Schonlein purpura (self-limited so no biopsy needed)
What can be seen on biopsy of a patient with henoch schonlein purpura (HSP)?
IgA deposits in blood vessels along with leukocytoclastic vasculitis
A pt presents with hemolytic anemia (schistocytes), uremia and thrombocytopenia most likely suffers from ...
Hemolytic Uremic Syndrome (HUS associated with E. Coli 0157:H7)
A pt presents with altered mental status, fever, hemolytic anemia (schistocytes), uremia, and thrombocytopenia most likely suffers from ...
Thrombotic thrombocytopenic purpura (TTP)
What is treatment for thrombotic thrombocytopenic purpura?
plasmapheresis (can use dipyridamole to prevent platelet aggregation)
A pt with hx of hep C presenting with hematuria, joint pain, neuropathy and purpura most likely suffers from ..
Cryoglobulinemia (no GI symptoms unlike HSP)
What should be used to screen for renal disease in diabetics?
What is the treatment for albuminuria in a diabetic patient?
ACE inhibitor (ACE)
What is the essential diagnostic test for lupus nephritis and why is it essential?
biopsy; to assess whether proliferative disease
What is the treatment for renal sclerosis in lupus and for renal proliferative disease in lupus?
no therapy; mycophenolate w/ steroids
What is difference between cryoglobulinemia and cold-agglutinin?
Cryo: pupura & renal disease, associated w/ hep C
cold agglutinin: hemolytic anemia, associated w/ EBV and mycoplasma
What is treatment for cryoglobulinemia?
treat hep C (interferon and ribavirin)
A pt presenting with hematuria with sensorineural hearing loss and congential eye problems most likely suffers from ..
Alport syndrome (family hx)
What is the finding on renal biopsy in a pt with Goodpasture syndrome?
What diagnostic test can be done in a pt with polyarteritis nodosa with abdominal pain?
angiogram of GI vessels
What is the diagnostic finding associated with amyloidosis?
green birefringence with congo red staining
What is diagnostic criteria for nephrotic syndrome?
1. > 3.5 grams of protein in urine in day
3. edema anywhere including non-dependent areas like face (due to low oncotic pressure)
What tests can be done to detect nephrotic syndrome level protein?
1. 24 hour urine collection
2. spot urine protein:creatinine ratio >3.5
What is nephrotic syndrome a hypercoagulable state?
due to urinary loss of anti-thrombotic proteins (anti-thrombin, protein S, protein C) more than thrombotic proteins
What is the most common cause of nephrotic syndrome in adults?
What is the most common cause of nephrotic syndrome in children?
Minimal Chane disease (Nil Lesion)
What are two things that are associated with Minimal Change Disease?
2. Hodgkin's Lymphoma
What is biopsy finding associated with Minimal Change disease?
fusion of foot processes on electron microscopy
.... is a steroid-resistant type nephrotic syndrome that has IgM deposits in an expanded mesangium on immunofluorecent staining of biopsy
A pt with hematuria with crescent formation on biopsy is most likely ...
Rapidly progressive glomerulonephritis
(tx w/ steroid and cyclophosphamide)
A pt with restrictive cardiomyopathy, nephritis, carpal tunnel syndrome (peripheral neuropathy), and macroglossia most likely suffers from ...
What is the treatment for Amyloidosis?
melphalan and prednisone
(correct underlying infection/ cancer)
What is the treatment for mild hyponatremia (aymptomatic low Na)?
What is the treatment for moderate hyponatremia (low Na with symptoms)?
normal saline with furosemide (free water loss)
What do maltese crosses signify?
droplet of lipids forming cross signifying hyperlipiduria
What is the treatment for severe/ chronic hyponatremia (Na<120, coma/seizure)?
1. 3% hypertonic saline
2. V2 receptor-antagonist (conivaptin or tolvaptan)
What disease can result if the sodium is corrected too rapidly in hyponatremia?
Central Pontine Myelinolysis
What conditions/diseases are associated with focal-segmental glomerulonephritis?
What rate should sodium be corrected in order to avoid central pontine myelinolysis?
0.5-1 meq per hour
What are causes of pseudohyponatremia (low Na serum level but total Na is normal)?
1. Hyperglycemia (glucose osmotic causing water to move out of cell--> dilutional)
2. hyperlipidemia (lab error)
What are causes of hyponatremia in pt who is in hypervolemic state (increased extracellular fluid w/ intravascular volume depletion leading to increased ADH)?
2. Nephrotic syndrome & low albumin
4. renal insufficiency (impaired free water excretion)
What are causes of hyponatremia in pt who is in hypovolemic state (decreased ECF)?
1. GI loss
2. burns/sweating replacing w/ free water
4. renal sodium loss
5. adrenal insufficiency (no aldosterone to reabsorbs Na)
6. ACE inhibitors
(high urine Na: diuretics, ACEI, renal salt wasting, adrenal insufficiency, cerebral salt wasting)
(low urine Na b/c body retains Na to retain volume: dehydration, vomiting, diarrhea, sweating)
What are causes of hyponatremia in euvolemic state?
1. psychogenic polydipsia (drink too much water)
4. ACE inhibitors (increase ADH)
5. endurance exercise
A pt presents with hyponatremia in the setting of elevated urine osmolality (>100) and elevated urine Na most likely suffers from ...
SIADH (syndrome of inappropriate ADH)
What are causes of SIADH?
1. anything brain related
2. anything in lung
3. meds (SSRIs, TCAs)
What is the most accurate test for SIADH?
What causes hypernatramia?
1. skin, urine or GI loss of fluid
2. diabetes insipidus
How do you distinguish central diabetes insipidus versus nephrogenic diabetes insipidus?
decrease in urine volume in response to ADH suggests central diabetes insipidus
What are the causes of nephrogenic diabetes insipidus?
What is the treatment for nephrogenic diabetes insipidus?
2. NSAIDs (inhibit prostaglandins that can impair concentrating ability; increase action of ADH)
What are causes hypokalemia?
1. GI loss (colon)
2. alkalosis (H+ come out and K in)
3. insulin (drives K into cells)
4. low magnesium
5. beta agonist (increases ATPase)
6. aldosterone (Na in, K out of kidney; Conn/ Cushing/ licorice)
7. Vitamin B12/ folate treatment (b/c increase cell formation adding K into cells)
What are causes of hyperkalemia?
1. diabetes (low insulin)
3. beta blockers (decrease ATPase)
4. acidosis (H+ into, K out)
5. hemolysis/ cell lysis
6. low aldosterone (addisons; ACEI; type 4 RTA)
7. renal failure
8. potassium sparing diuretics (amiloride, spironolactone)
What is seen on EKG in hypokalemia?
1. T wave flattening
2. U waves (purkinje fiber)
What type of saline should be used in a pt with hypokalemia being repleted with IV KCl?
saline (avoid dextrose bc increases insulin that pushes K into cell)
What are EKG findings associated with hyperkalemia?
1. peaked T waves
2. widened QRS, short QT, prolonged PR
What is the treatment for hyperkalemia with associated changes in EKG?
1. calcium chloride/ gluconate (stabilizes cardiac membrane)
2. insulin & glucose
What are treatments for hyperkalemia without EKG changes?
1. NaHCO3 (drives K into cell)
2. Glucose & insuline (drives K into cell)
3. Kayexalate (removes from body)`
What is type 1 (distal) renal tubular acidosis?
inability to develop high H+ concentrate in urine (can't excrete H+; so urine basic)
What are complications of type 1 (distal) renal tubular acidosis?
1. stones in kidney (nephrocalcinosis and nephrolithiasis)
What is the diagnostic test for type 1 (distal) renal tubular acidosis?
give ammonium chloride (acid) and urine stays basic
What is treatment for type 1 (distal) renal tubular acidosis?
What is type 2 (proximal) renal tubular acidosis?
inability to absorb bicarbonate
(initially urine pH basic then becomes acidic once bicarb depleted)
What are complications associated with type 2 (proximal) renal tubular acidosis?
1. bone lesions (osteomalacia, rickets; acid sucks calcium out of bone)
What is diagnostic test for type 2 (proximal) renal tubular acidosis?
give sodium bicarbonate (urine becomes basic initially b/c can't absorb it)
What is treatment for type 2 (proximal) renal tubular acidosis?
1. diuretic (decrease volume of body
What is type 4 (hyporeninemic/ hypoaldosteronism) renal tubular acidosis?
occurs in diabetic pt with low renin and low aldosterone
What are complications of type 4 (hyporeninemic/ hypoaldosteronism) renal tubular acidosis?
1. hyperkalemia (no aldosterone to cause K excretion)
What is treatment for type 4 (hyporeninemic/ hypoaldosteronism) renal tubular acidosis?
What are the two causes of non-anion gap metabolic acidosis?
2. renal tubular acidosis
How do you distinguish between diarrhea and RTA as causes of non anion gap metabolic acidosis?
urinary anion gap
What are causes of metabolic alkalosis (HCO3 > 24 w/ pH high)?
1. loss of H+ (vomiting, renal loss)
2. hypokalemia (K comes out of cell, driving H into cell)
3. HCO3 retention (volume contraction -> aldosterone excrete H; milk-alkali w/ antacids)
What are causes of respiratory alkalosis?
hyperventilation (anemia, salicylate stimulate respiratory drive, PE, anxiety)
What is the formula for anion gap and what is considered increased?
AG= Na - (HCO3+ Cl)
AG > 14 is increased
What are causes of anion-gap metabolic acidosis?
4. Propylene glycol/ paraldehyde
5. INH/ isopropyl alcohol
6. Lactate (sepsis, ischemia)
7. ethylene glycol
8. Salicylic acid (aspirin)
What are causes of respiratory acidosis?
hypoventilation (COPD, opiates, sleep apnea, aspiration, myopathies, obesity)
What type of kidney stones are radiolucent?
uric acid stones
What type of infections are associated with struvite stones (magnesium/ aluminum/ phosphate)?
kidney infection with urease producing organisms (Proteus, Staph, Pseudomonas, Klebsiella) which increase pH
Enveloped shaped crystals in a pt attempting suicide most likely suffers from ...
oxalate crystals secondary to ethylene glycol intoxication
A pt presents with constant excruciating flank pain, hematuria, and pain radiating to groin most likely suffers from ..
Nephrolithiasis (kidney stones)
A pt who was in motor vehicle accident who received large amount of transfusion fast who develops seizure most likely had seizure due to ...
hypocalcemia due to citrate (used to preserve blood) binds up all the calcium
What is the best initial step in management for suspected kidney stones?
What is the best initial test for kidney stone?
What is the most accurate test for kidney stone?
What is the treatment for kidney stones that are 5mm to 2 cm in size?
shockwave lithotripsy (if bigger, percutaneous removal)
What is the most common cause of death in adult polycystic kidney disease?
ESRD due to chronic infections and stones
What is the next best step in management of a simple renal cyst with irregular walls or debris inside?
aspiration to exclude malignancy
What is malignant hypertension?
encephalopathy or nephropathy with accompanying papilledema
(DBP > 130)
What is the treatment for hypertensive crisis/ urgency/ emergency?
IV labetolol and nitroprusside and enalapril
(no lower than DBP <95 in initial hours)
What is the initial drug of choice for hypertension?
What is the best anti-hypertensive medication in a pt with diminished LV systolic function?
beta blockers (avoid in asthmatics)
A older pt or young women with hypertension and upper abdominal bruit radiating laterally most likely suffers from ....
renal artery stenosis
What is the best initial diagnostic test for renal artery stenosis?
(other options captopril renogram- decreased uptake)
What is the most accurate diagnostic test for renal artery stenosis?
What is the best treatment for renal artery stenosis?
percutaneous transluminal angioplasty (ACE inhibitor if fails)
A pt presenting with hypertension in there upper extremities but decreased blood pressure in lower extremities most likely suffer from ..
Coarctation of Aorta
What is treatment for primary hyperaldosteronism (Conn's syndrome)?
1. surgical resection (if unilateral adenoma)
2. Spironolactone (bilateral hyperplasia)
A pt presenting with hypertension in setting of hypokalemia most likely suffers from ...
primary hyperaldosteronism (Conn's syndrome)
A pt presenting with episodic hypertension with associated headaches, sweating, palpitations and tachycardia most likely suffers from ..
What is the best initial test for pheochromocytoma?
1. urinary vanillylmandelic acid (VMA)
2. metanephrines 3. free urinary catecholamines
(detect location via CT/MRI)
what is treatment for pheochromocytoma?
alpha blocker followed by surgery
A pt presents with hypertension in the setting of cushiongoid characteristics (truncal obesity, buffalo hump, menstrual abnormalities, straie, etc) most likely suffers from ...
Cushing Disease (ACTH hypersecretion by pituitary adenoma)
What is the best initial test for Cushing disease?
1. dexamethasone suppression
2. 24 hour urine cortisol
What is the most common side effects of diuretics?
What are the most common side effects of beta blockers?
1. worsening asthma (bronchospasm)
2. heart block
What is the most accurate test for detecting location of pheochromocytoma when CT/MRI negative?
What are the most common side effects of ACE inhibitors?
What are the most common side effect of calcium channel blockers?
1. peripheral edema
3. reflex tachycardia
What is treatment of hypertension in pregnant women with eclampsia?
What is minoxidil used?
What is most common side effect of alpha blockers?