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Flashcards in Nephrology Deck (241):
1

first step in evaluating renal failure

1. PRErenal (perfusion)
2. RENAL (parenchymal)
3. POSTrenal (drainage)

2

clues renal failure is ACUTE

1. normal kidney size
2. normal hematocrit
3. normal Ca2+

3

clues renal failure is CHRONIC

1. smaller kidneys
2. renal failure of more than 2 weeks will drop Hct (decreased erythropoietin production)
3. Ca2+ levels drop (decreased vitamin D hydroxylation)

4

causes of PRErenal azotemia

- ANY cause of hypOperfusion

- hypOtension (SBP less than 90)
- hypOvolemia (dehydration or blood loss)
- low oncotic pressure (low albumin)
- CHF (heart can't PUMP)
- constrictive pericarditis (heart can't FILL)
- RAS

5

characteristic diagnostic tests for PRErenal azotemia

- BUN:Cr ratio of more than 15:1, and often more than 20:1
- LOW urinary Na+ (less than 20)
- urine osmolality more than 500
- may have hyaline casts on UA

6

treatment for PRErenal azotemia

treat UNDERLYING cause

7

mechanism of BUN elevation in PRErenal azotemia

low volume status, increases ADH, and ADH increases urea transporter activity in collecting duct

8

causes of POSTrenal azotemia (postobstructive uropathy)

- stones
- strictures
- cancer
- neurogenic bladder (MS or DM)

9

BUN:Cr ratio seen in POSTrenal azotemia

also more than 15:1

10

clues to obstructive uropathy

- distended bladder on exam
- large volume diuresis after Foley catheter placement
- B/L hydronephrosis on US

11

what must be true in order for postobstructive uropathy to cause renal failure?

MUST BE BILATERAL

(UNIlateral obstructive cannot cause renal failure)

12

INTRArenal causes of renal failure

- ATN (acute tubular necrosis)
- AGN (acute glomerulonephritis)
- AIN (acute interstitial nephritis)

13

causes of ATN (acute tubular necrosis)

- either hypOperfusion or toxic injury

- surgery
- severe burns

- aminoglycosides/amphotericin/contrast/chemotherapy
- rhabdomyolysis

14

causes of AGN (acute glomerulonephritis)

(name 11)

- Goodpasture's syndrome
- Churg-Strauss syndrome
- Wegener's granulomatosis
- polyarteritis nodosa
- IgA nephropathy (Berger's disease)
- Henoch-Schonlein purpura
- poststreptococcal glomerulonephritis
- cryoglobulinemia
- lupus nephritis
- Alport syndrome
- TTP/HUS

15

causes of AIN (acute interstitial nephritis)

- antibiotics
- NSAIDs
- infection (e.g. Streptococcus, viral, Legionella)

16

characteristic diagnostic tests for INTRArenal renal failure

- BUN:Cr ratio of 10:1
- urinary sodium more than 40
- urine osmolality less than 350

17

how many days of use does it usually take for aminoglycosides to cause kidney damage?

4-5 days

18

mechanism of rapid onset of renal failure with contrast agent

- directly toxic to kidney tubules

- also, causes intense vasoconstriction of Afferent arterioles (decreased perfusion)

(hypOperfusion = LOW urine sodium)

19

what does UA show in ATN?

"muddy brown," or granular casts

20

treatment for ATN

NO specific therapy

21

adverse effect of cyclophosphamide

hemorrhagic cystitis

22

cause of renal failure from rhabdomyolysis

direct TOXIC effect of MYOGLOBIN on kidney tubule

23

causes of rhabdomyolysis

- crush injury
- seizure
- cocaine toxicity
- prolonged immobility
- hypOkalemia resulting in muscle necrosis
- recent initiation of STATIN

24

best INITIAL test for rhabdomyolysis

UA (large blood)

25

rhabdomyolysis labs:

- CPK level
- potassium level
- calcium level
- serum bicarbonate level

- ELEVATED CPK
- hypERkalemia
- hypOcalcemia
- decreased bicarb

26

MOST ACCURATE test for rhabdomyolysis

urine myoglobin

27

mechanism of hypOcalcemia in rhabdomyolysis

damaged sarcolemma outside of SER can bind as much Ca2+ as it wants

28

treatment for rhabdomyolysis

1. NS bolus
2. mannitol (decrease contact time of myoglobin with the tubules)
3. alkalinization of urine (decreases precipitation of myoglobin in the tubules)

29

suicide by antifreeze ingestion (ethylene glycol)

HAGMA

oxalate crystals

30

best INITIAL test for ethylene glycol poisoning

UA (envelope-shaped oxalate crystals)

31

best INITIAL treatment for ethylene glycol poisoning

- ethanol or fomepizole

- with IMMEDIATE dialysis

32

tumor lysis syndrome

uric acid crystals

33

treatment for tumor lysis syndrome

1. hydration
2. allopurinol
3. rasburicase

34

rasburicase MOA

breaks down uric acid

35

what to do in a patient who MUST have a radiologic procedure with contrast and renal insufficiency

hydrate with NS, and give bicarbonate and N-acetylcysteine

36

diagnostic clues for AIN

- medication ingestion
- fever and rash
- UA shows white cells (can't discern between neutrophils and eosinophils)

37

MOST ACCURATE test for eosinophils in UA

Wright stain or Hansel's stain

38

treatment for AIN

no specific therapy, resolves on its own

39

ALL forms of glomerulonephritis (GN) can have the following:

(5 findings)

- RBCs in urine
- red cell casts in urine
- mild proteinuria (less than 2G/24H)
- may lead to nephrOtic
- edema

40

MOST ACCURATE test for GN (but not always necessary)

kidney biopsy

41

diagnostic clues for Goodpasture syndrome

- COUGH
- HEMOPTYSIS
- SOB
- lung findings (e.g. diffuse infiltrates)

42

best INITIAL test for Goodpasture syndrome

anti-basement membrane Abs

43

MOST ACCURATE test for Goodpasture syndrome

kidney biopsy = LINEAR DEPOSITS

44

treatment for Goodpasture syndrome

plasmapheresis and steroids

45

diagnostic clues for Churg-Strauss syndrome

- ASTHMA
- COUGH
- EOSINOPHILIA

46

best INITIAL test for Churg-Strauss syndrome

CBC (check eosinophil count)

47

MOST ACCURATE test for Churg-Strauss syndrome

kidney biopsy

48

best INITIAL treatment for Churg-Strauss syndrome

glucocorticoids (e.g. prednisone)

49

what do you do for Churg-Strauss syndrome if NO response to prednisone?

ADD cyclophosphamide

50

diagnostic clues for Wegener granulomatosis (now known as, granulomatosis with polyangiitis)

- SINUSITIS, or OTITIS (biggest clues to diagnosis, and main distinguishing factor between Goodpasture syndrome)

- lung findings (e.g. nodules)

51

best INITIAL test for granulomatosis with polyangiitis

c-ANCA (antineutrophil cytoplasmic Abs)

52

MOST ACCURATE test for granulomatosis with polyangiitis

kidney biopsy

53

best INITIAL treatment for granulomatosis with polyangiitis

cyclophosphamide and steroids

54

diagnostic clues for polyarteritis nodosa (PAN)

- systemic vasculitis with involvement of every organ EXCEPT the lungs

- MULTIPLE MOTOR DEFICITS
- SENSORY NEUROPATHY WITH PAIN
(are key to diagnosis)

55

best INITIAL test for PAN

ESR

56

MOST ACCURATE test for PAN

SURAL nerve biopsy, or kidney biopsy

57

what should be tested for in PAN?

hepatitis B and C (30% association)

58

what test for PAN can spare the need for biopsy?

angiography showing "beading"

59

best INITIAL treatment for PAN

steroids and cyclophosphamide

60

diagnostic clues for IgA nephropathy (Berger's disease)

- PAINLESS RECURRENT HEMATURIA
- Asian
- recent viral respiratory tract infection

61

best INITIAL test for IgA nephropathy

NO specific test (IgA may be elevated...)

(complement levels are normal)

62

MOST ACCURATE test for IgA nephropathy

kidney biopsy is ESSENTIAL

63

treatment for IgA nephropathy

NO proven effective therapy

- steroids: for sudden worsening of proteinuria
- ACEIs: used for all patients with proteinuria

64

diagnostic clues for Henoch-Schonlein purpura

- child or adolescent
- RAISED, NONTENDER, PURPURIC SKIN LESIONS (especially on buttocks and LE's)
- abdominal pain
- possible bleeding
- joint pain

65

best INITIAL test for Henoch-Schonlein purpura

clinical

66

MOST ACCURATE test for Henoch-Schonlein purpura

kidney biopsy = IgA deposition

(not necessary though)

67

treatment for Henoch-Schonlein purpura

NO specific therapy; RESOLVES SPONTANEOUSLY

68

diagnostic clues for post-streptococcal glomerulonephritis (PSGN)

- dark, "tea," or "cola" colored urine
- PERIORBITAL EDEMA
- HTN
- can occur after throat and skin infections

69

best INITIAL test for PSGN

- antistreptolysin O (ASLO)
- anti-DNase
- antihyaluronidase
- LOW complement levels

70

MOST ACCURATE test for PSGN

kidney biopsy = SUBepithelial IgG and C3 deposits

but should NOT always be done; blood test are usually enough

71

treatment for PSGN

- PCN or other antibiotics for infection
- diuretics for HTN and edema

72

diagnostic clues for cryoglobulinemia

- h/o hepatitis C with renal involvement
- joint pain
- purpuric skin lesions

73

best INITIAL test for cryoglobulinemia

- serum cryoglobulin component levels
- LOW complement levels (especially C4)

74

MOST ACCURATE test for cryoglobulinemia

kidney biopsy

75

treatment for cryoglobulinemia

- hepatitis C genotype 1: ledipasvir and sofosbuvir
- for treatment-experienced pts: add ribavirin
- for other genotypes: sofosbuvir and ribavirin

76

diagnostic clues for lupus nephritis

- h/o SLE

77

what does drug-induced lupus spare?

kidney and brain

78

best INITIAL test for lupus nephritis

- ANA and anti-dsDNA Ab

79

MOST ACCURATE test for lupus nephritis

kidney biopsy

(very important; not for diagnosis, used to determine extent of disease, which determines therapy)

80

treatment for lupus nephritis: sclerosis ONLY

NO treatment

81

treatment for lupus nephritis: mild disease, early stage, nonproliferative

steroids

82

treatment for lupus nephritis: severe disease, advanced, proliferative

mycophenolate mofetil AND steroids

83

diagnostic clues for Alport syndrome

- congenital
- eye and ear problems (deafness)
- renal failure in second/third decade of life

84

treatment for Alport syndrome

- NO specific treatment

85

HUS triad (think about the name)

1. intravascular hemolysis
2. elevated creatinine
3. thrombocytopenia

(h/o E. coli O157:H7)

86

TTP findings (again, think about the name)

1. intravascular hemolysis
2. elevated creatinine
3. thrombocytopenia

PLUS

4. fever
5. neurological abnormalities

87

treatment for HUS

supportive; do NOT treat with antibiotics

88

treatment for TTP

plasmapheresis in SEVERE cases; do NOT treat with platelets

89

ANY of the glomerulonephritides can lead to?

nephrOtic syndrome

90

nephrOtic syndrome has the following:

1. hypERproteinuria (more than 3.5G/day)
2. hypOproteinemia
3. hypERlipidemia
4. edema
5. HTN
6. thrombosis

91

best INITIAL test for nephrOtic syndrome

UA; shows markedly elevated protein level

92

NEXT best test for nephrOtic syndrome

spot urine for protein:creatinine ratio; more than 3.5:1

(equal in efficacy to 24H urine protein collection)

93

MOST ACCURATE test for nephrOtic syndrome

kidney biopsy

94

primary renal d/o with NO specific PE findings (only associations): MC in children

minimal change disease

95

primary renal d/o with NO specific PE findings (only associations): seen in adults with cancer such as lymphoma

membranous

96

primary renal d/o with NO specific PE findings (only associations): hepatitis C

membranoproliferative

97

primary renal d/o with NO specific PE findings (only associations): HIV/heroin use

focal segmental

98

primary renal d/o with NO specific PE findings (only associations): unclear

mesangial

99

best INITIAL test for primary renal d/o with NO specific PE findings (only associations)

UA, then spot urine

100

MOST ACCURATE test for primary renal d/o with NO specific PE findings (only associations)

kidney biopsy

101

best INITIAL treatment for ALL primary renal d/o with NO specific PE findings (only associations)

steroids

102

if NO response to steroids AFTER 12 WEEKS for primary renal d/o with NO specific PE findings (only associations), then next in treatment

cyclophosphamide

103

first step when patient presents with mild proteinuria

(can occur in 2-10% of population at any given time)

REPEAT UA

104

if proteinuria persists on repeat UA, what are 4 possibilities that need to be ruled out?

1. CHF
2. fever
3. exercise
4. infection

105

if there is no apparent reason for proteinuria, what is the next possibility?

ORTHOSTATIC proteinuria

(h/o patient standing all day; waiter/teacher/security guard)

106

first step to CONFIRM orthostatic proteinuria

SPLIT THE URINE: morning urine AND afternoon urine

107

what result indicates a patient has orthostatic proteinuria?

protein in AFTERNOON urine ONLY, and NOT in the morning

108

treatment for orthostatic proteinuria

none; does not need to be treated

109

if proteinuria is PERSISTENT and not orthostatic, next step is

24H urine, OR spot protein:creatinine ratio

110

when evaluating for persistent proteinuria, if 24H urine, OR spot protein:creatinine ratio is elevated next step is

kidney biopsy

111

absolute indications for dialysis (3)

1. uremic pericarditis
2. uremic pleuritis
3. uremic encephalopathy

112

common indications for dialysis (8)

1. declining nutritional status (MC reason to initiate dialysis)
2. volume overload
3. fatigue and malaise
4. mild cognitive impairment
5. refractory metabolic acidosis
6. refractory hyperkalemia
7. refractory hyperphosphatemia
8. toxicity with dialyzable drug (lithium/ethylene glycol/aspirin)

113

phosphate binders

- sevelamer
- lanthanum
- calcium acetate
- calcium carbonate

114

manifestation of uremia and treatment: hyperphosphatemia

- calcium acetate
- calcium carbonate

115

manifestation of uremia and treatment: hypermagnesemia

dietary magnesium restriction

116

manifestation of uremia and treatment: anemia

erythropoietin replacement

117

manifestation of uremia and treatment: hypocalcemia

vitamin D replacement

118

hypERnatremia always implies

free water deficit

119

treatment for dehydration, even in hypERnatremia

normal saline

120

possible causes of hypERnatremia, aside from dehydration

- poor oral intake
- fever
- pneumonia
- other insensible losses

121

the other main cause of hypERnatremia

diabetes insipidus (DI)

122

what are the 2 types of DI?

1. central = failure to produce antidiuretic hormone (ADH) in the brain
2. nephrogenic = insensitivity of the kidney to ADH (can result from hypOkalemia, hypERcalcemia, or lithium toxicity)

123

hypERnatremia leads to

NEUROLOGICAL ABNORMALITIES:

- confusion
- disorientation
- seizures
- COMA

124

what will the urine osmolality, urine Na+, and urine volume be in BOTH central and nephrogenic DI, and what will happen to the urine osmolality with water deprivation?

- LOW urine osmolality
- LOW urine sodium
- INCREASED urine volume
- NO change in urine osmolality with water deprivation

125

what happens in CENTRAL DI to urine volume, and urine osmolality when you give DDAVP/vasopressin?

- DECREASE in urine volume
- INCREASE in urine osmolality

126

what happens in NEPHROGENIC DI to urine volume, and urine osmolality when you give DDAVP/vasopressin?

- NO CHANGE in urine volume
- NO CHANGE in urine osmolality

127

what is the difference between vasopressin and DDAVP?

- vasopressin aka ADH = natural de novo hormone
- DDAVP is the trade name for desmopressin = synthetic ADH replacement

128

treatment for central DI

desmopressin or vasopressin

129

treatment for nephrogenic DI

correct underlying cause

130

hypOnatremia presents with

NEUROLOGICAL ABNORMALITIES:

- CONFUSION
- DISORIENTATION
- SEIZURES
- COMA

131

FIRST STEP in management of hypOnatremia

ASSESS VOLUME STATUS

132

hypERvolemic hypOnatremia causes (3)

1. CHF
2. nephrotic syndrome
3. cirrhosis

133

treatment for hypERvolemic hypOnatremia

correct/manage underlying cause

134

hypOvolemic hypOnatremia causes (3)

1. diuretics (urine Na+ ELEVATED)
2. GI loss of fluids (vomiting, diarrhea) (urine Na+ LOW)
3. skin loss of fluids (burns, sweating) (urine Na+ LOW)

lose water and a little salt, but patient replaces free water only

135

treatment for hypOvolemic hypOnatremia

correct underlying cause, and replace with NORMAL (ISOTONIC) SALINE

136

EUvolemic hypOnatremia causes (4)

1. syndrome of inappropriate ADH release (SIADH)
2. hypothyroidism
3. psychogenic polydipsia
4. hypERglycemia (Na+ drops by 1.6-2.4 for every 100mg of glucose above normal)
5. Addison's disease (primary adrenal insufficiency)

137

reason Addison's disease (primary adrenal insufficiency) causes hypOnatremia

insufficient ALDOSTERONE production

138

key to diagnosis of Addison's disease (primary adrenal insufficiency)

hypOnatremia with hypERkalemia, and mild metabolic acidosis

139

treatment for Addison's disease (primary adrenal insufficiency)

fludrocortisone

140

causes of SIADH

- any CNS abnormalities
- any lung disease
- medications (sulfonylureas, SSRIs, carbamazepine)
- cancer

141

findings for SIADH

- inappropriately HIGH urine Na+ (more than 20meq/L)
- inappropriately HIGH urine osmolality (more than 100mOsm/kg)
- LOW serum osmolality (less than 290mOsm/kg)
- LOW serum uric acid
- normal BUN, creatinine, and bicarbonate

142

treatment for SIADH: mild hypOnatremia (no symptoms)

fluid restriction

143

treatment for SIADH: moderate to severe hypOnatremia (confusion, seizures)

- SALINE INFUSION with loop diuretics
- HYPERTONIC (3%) saline
- check serum Na+ frequently
- ADH blockers (conivaptan, tolvaptan)

144

at what rate should you correct hypOnatremia?

- 4-6 meq/L in the FIRST 24 HOURS
- SHOULD NOT BE RAISED MORE THAN 9 meq/L within 24H

145

what can happen if you correct hypOnatremia too rapidly?

CENTRAL PONTINE MYELINOLYSIS

146

treatment for CHRONIC SIADH (from malignancy)

- demeclocycline (blocks ADH at kidney)
- conivaptan/tolvaptan (inhibit ADH at V2 receptor of collecting duct)

147

hypERkalemia causes

(predominantly caused by release from tissues)

- muscles = rhabdomyolysis, or crush injury
- RBCs = hemolysis
- dietary K+ ONLY in renal insufficiency

148

other causes of hypERkalemia

- metabolic acidosis (transcellular shift out of cells)
- adrenal aldosterone deficiency (Addison's disease)
- beta blockers
- digoxin toxicity
- insulin deficiency (DKA)
- spironolactone
- ACEIs/ARBs (inhibit aldosterone)
- prolonged immobility
- RTA type 4 (decreased aldosterone effect)
- renal failure (decreased excretion)

149

pseudohypERkalemia

- hemolysis of RBCs
- prolonged tourniquet placement

150

hypERkalemia can lead to

cardiac arrhythmia

151

potassium disorders are NOT associated with

seizures, or neurological disorders

152

sodium disorders are NOT associated with

cardiac arrhythmias

153

EKG changes from hypERkalemia in order

1. peaked T waves
2. prolonged P waves
3. widening of QRS complexes

154

hyperlipidemia mechanism in nephrOtic syndrome

LDL and VLDL are removed from serum by lipoproteins; lipoproteins are lost in urine

155

mechanism of hypERkalemia with beta blockers

block Na+/K+ ATPase channels

156

treatment for moderate hypERkalemia (NO EKG abnormalities)

1. IV insulin and glucose
2. bicarbonate
3. kayexalate

157

treatment for severe hypERkalemia (EKG abnormalities, such as peaked T waves)

1. IV calcium gluconate/calcium chloride
2. IV insulin and glucose
3. kayexalate

158

mechanism of how bicarbonate lower potassium

bicarbonate pulls H+ CATIONS out of cells so K+ goes IN

159

hypOkalemia causes

dietary insufficiency

160

other causes of hypOkalemia

- increased urinary loss caused by diuretics
- Conn syndrome (high aldosterone)
- vomiting (leads to metabolic alkalosis; shifts K+ INTO cells [and volume depletion; increases aldosterone])
- proximal (type 2) and distal (type 1) RTA
- amphotericin (causes RTA)
- Bartter syndrome (LOH can't absorb Na+ or K+; causes secondary hypERaldosteronism)

161

hypOkalemia can lead to

- cardiac rhythm disturbance
- muscle weakness

162

EKG changes in hypOkalemia

U waves (Purkinje fiber repolarization)

163

treatment for hypOkalemia

- replace K+
- avoid glucose-containing fluids (will increase insulin release worsening hypOkalemia)

(NO maximum rate on ORAL K+; bowel will regulate rate of absorption)

164

hypERmagnesemia causes

- magnesium-containing laxative abuse
- iatrogenic administration

165

hypERmagnesemia leads to

- muscle weakness
- loss of deep tendon reflexes

166

treatment for hypERmagnesemia

- restrict intake
- saline administration (provoke diuresis)
- maybe dialysis

167

hypOmagnesemia causes

- loop diuretics
- alcohol withdrawal/starvation
- gentamicin/amphotericin/diuretics
- cisplatin
- parathyroid surgery
- pancreatitis

168

hypOmagnesemia presents with

hypOcalcemia and cardiac arrhythmias

169

which hormone needs magnesium to function

PTH (parathyroid hormone)

170

metabolic acidosis with increased anion gap (HAGMA) causes

MUDPILES

Methanol
Uremia
DKA
Propylene glycol
Isoniazid
Lactic acidosis
Ethylene glycol
Salicylates

171

metabolic acidosis with normal anion gap (NAGMA) causes

- diarrhea (bicarbonate loss)
- RTA

172

cause of lactic acidosis

any form of hypoperfusion resulting in anaerobic metabolism

173

aspirin overdose mechanism of metabolic acidosis

- respiratory alkalosis from hyperventilation
- metabolic acidosis (loss of aerobic metabolism from mitochondrial poisoning leading to lactic acidosis)

174

treatment for aspirin overdose

bicarbonate

175

what is methanol metabolized into?

formaldehyde than formic acid

176

adverse effect of methanol poisoning

visual disturbance

177

treatment for methanol poisoning

fomepizole or ethanol

178

what 3 substances lead to an increased anion gap in DKA?

1. acetone
2. acetoacetate
3. beta hydroxybutyric acid

179

what will you see in the urine in ethylene glycol poisoning?

oxalate crystals

180

treatment for ethylene glycol poisoning

fomepizole or ethanol

181

distal RTA (type 1)

inability to EXCRETE acid of hydrogen ions in DISTAL tubule

182

diagnostic clues for distal RTA (type 1)

- LOW serum K+ (since body can't excrete H+)
- LOW serum bicarbonate
- metabolic acidosis
- alkaline urine

183

test for distal RTA (type 1)

administer IV acid (AlCl; should lower urine pH secondary to increased H+ formation)

urine will stay abnormally basic

184

treatment for distal RTA (type 1)

bicarbonate

185

proximal RTA (type 2)

inability to REABSORB bicarbonate in PROXIMAL tubule

186

adverse effect of distal RTA (type 1)

alkaline urine = kidney stones

187

diagnostic clues for proximal RTA (type 2)

- initially urine pH is elevated, bc of bicarbonate loss, but then becomes acidic

188

test for proximal RTA (type 2)

administer bicarbonate

- normal person with metabolic acidosis = will absorb bicarbonate, and will still have low urine pH

- proximal RTA patient = cannot absorb bicarbonate, URINE pH WILL RISE

189

treatment for proximal RTA (type 2)

- thiazide diuretic (causes volume contraction which concentrates serum bicarbonate)
- large quantities of bicarbonate

190

hypOreninemic hypOaldosteronism (type 4)

- decreased aldosterone production
- diabetic patient with NAGMA
- ELEVATED K+

191

treatment for hypOreninemic hypOaldosteronism (type 4)

fludrocortisone

192

distal RTA (type 1)

- urine pH
- serum K+
- stones?
- test
- treatment

- HIGH urine pH
- LOW K+
- YES
- give acid (aluminum chloride)
- bicarbonate

193

proximal RTA (type 2)

- urine pH
- serum K+
- stones?
- test
- treatment

- LOW urine pH
- LOW K+
- NO
- give bicarbonate
- thiazide diuretic and high dose bicarbonate

194

hypOreninemic hypOaldosteronism (type 4)

- urine pH
- serum K+
- stones?
- test
- treatment

- LOW urine pH
- HIGH K+
- NO
- urine Na+ loss
- fludrocortisone

195

how do you distinguish between diarrhea and RTA?

URINE ANION GAP

196

how do you calculate the urine anion gap (UAG)?

UAG = urine Na+ - urine Cl-

197

what is the UAG in diarrhea?

NEGATIVE, bc kidneys are working (able to excrete acid)

198

what is the UAG in RTA?

POSITIVE, bc kidneys CANNOT excrete acid (urine Cl- decreases)

199

how is acid excreted from the kidneys?

NH4Cl

200

causes of metabolic alkalosis (6)

1. volume contraction
2. Conn syndrome
3. Cushing syndrome
4. hypOkalemia
5. milk-alkali syndrome (too much liquid antacid)
6. vomiting

201

how does volume contraction cause metabolic alkalosis?

secondary hypERaldosteronism, causes increased urinary acid loss

202

how do Conn syndrome and Cushing syndrome cause metabolic alkalosis?

primary hypERaldosteronism, causes increased urinary acid loss

203

how does hypokalemia cause metabolic alkalosis?

K+ shifts OUT of cells to correct hypOkalemia; H+ shift INTO cells

204

how does vomiting cause metabolic alkalosis?

(acid loss from stomach, AND volume contraction leading to secondary hypERaldosteronism

205

- recurrent hematuria
- stones
- infections
- CYSTS THROUGHOUT THE BODY (liver, ovaries, circle of Willis)
- MVP
- diverticulosis

autosomal dominant polycystic kidney disease (ADPKD)

206

MCC of death in ADPKD

ESRD

207

treatment for ADPKD

NO specific treatment

208

urge incontinence

- presentation
- testing
- treatment

- PAIN followed by urge to urinate
- urodynamic pressure monitoring
- behavior modification/anticholinergic medications

209

stress incontinence

- presentation
- testing
- treatment

- NO pain
- COUGHING, and LAUGHING
- observe leakage with coughing
- Kegel exercise/exercise cream

210

next step in management in a patient presenting with HTN

repeat BP measurement

211

what routine tests should be done in a pt with HTN?

- UA
- EKG
- eye exam (retinopathy)
- cardiac exam (murmur/S4 gallop)

212

initial treatment for HTN

lifestyle modifications:

- Na+ restriction
- weight loss
- dietary modification
- exercise
- relaxation techniques

213

what is the MOST effective lifestyle modification for HTN?

WEIGHT LOSS

214

when do you initiate medical therapy for HTN?

3-6 months if lifestyle modifications don't work

215

treatment for HTN, AND: CAD

BB

216

treatment for HTN, AND: CHF

BB, or ACEI/ARB

217

treatment for HTN, AND: migraine

BB, or CCB

218

treatment for HTN, AND: hyperthyroidism

BB

219

treatment for HTN, AND: osteoporosis

thiazide

220

treatment for HTN, AND: depression

AVOID BB

221

treatment for HTN, AND: asthma

AVOID BB

222

treatment for HTN, AND: pregnancy

a-methyldopa, or labetalol

223

treatment for HTN, AND: BPH

a-blocker

224

treatment for HTN, AND: DM

ACEI/ARB

225

check for secondary HTN, when?

- less than 30 yoa, or more than 60 yoa
- uncontrolled HTN with 3 medications
- specific findings on history and PE

226

finding in RAS

bruit

227

finding in pheochromocytoma

EPISODIC HTN

228

finding in Conn syndrome (primary hypERaldosteronism)

hypOkalemia

229

finding in Cushing syndrome

- buffalo hump
- truncal obesity
- striae

230

finding in coarctation of aorta

upper extremity pressure greater than lower extremity pressure

231

finding in congenital adrenal hyperplasia (CAH)

hirsutism

232

best INITIAL test for RAS

renal US with DOPPLER

233

best NEXT test if SMALL kidney is seen in patient suspected to have RAS

- MRA
- duplex ultrasonogram
- nuclear renogram

234

MOST ACCURATE test for RAS

renal angiogram

235

best INITIAL treatment for RAS

renal artery angioplasty and stenting

236

how does radius affect flow?

flow increases as radius increases

(to the fourth power)

237

causes of secondary HTN based on age: children and adolescents (birth to age 18)

- renal parenchymal disease
- coarctation of aorta

238

causes of secondary HTN based on age: young adults (ages 19-39)

- thyroid dysfunction
- fibromuscular dysplasia
- renal parenchymal disease

239

causes of secondary HTN based on age: middle-aged adults (ages 40-69)

- aldosteronism
- thyroid dysfunction
- obstructive sleep apnea
- Cushing syndrome
- pheochromocytoma

240

causes of secondary HTN based on age: older adults (age greater than 65)

- atherosclerotic renal artery stenosis
- renal failure

241

2 medications should be started if baseline BP is >?

160/100