nephrology

Question 1

the decrease in sodium… what do you do?

1. hypovolemic hypoNa
2. hypovolemic hypoNa
3. Euvolemic hypoNa

correct?

Answer 1

gain of water…. check osm then check volume status

1. hypovolemic hypoNa- CHF, nephrotic, cirrotic
2. hypovolemic hypoNa- diuretics or vomiting + free water
3. Euvolemic hypoNa- SIADH (check CXrR if smoker) addisons, hypothyroidism

correct w/ NS if hypovolemic, 3% saline only if seizures or Na<120. otherwise fluid restric + diuretics

Question 2

overcorrecting low sodium

Answer 2

central pontine myelinolysis

Question 3

increased sodium… correct?

Answer 3

loss of water… replace water w/ D5W or other hypotonic fluid

Question 4

overcorrecting high sodium

Answer 4

cerebral edema

Question 5

numbness, chvostek, or troussaeu, prolonged QT interval

Answer 5

decreased Ca

Question 6

bones, stones, groans, psycho. shortened QT interval

Answer 6

increased calcium

Question 7

paralysis, ileus, ST depression, U waves… tx?

Answer 7

decreased potassium….. tx w/ K but make sure patient can pee

Question 8

peaked t waves, prolonged PR and QRS, sine waves….tx?

Answer 8

increased potassium….. tx w/ Ca-gluconate then insulin +glc, kayexalate, albuterol and sodium bicarb

last resort- dialysis

Question 9

metabolic alkalosis… what do you do next?

Answer 9

check urine chloride

> 20- hyperaldo (conns), barter’s or gitelmans
<20 Vomiting/NG suction, antiacids, diuretics

Question 10

non-anion gap metabolic acidosis

Answer 10

diarrhea, diuretic, RTAs (I, II and IV)

Question 11

RTA and how to tx?

1. cause- lithium/amphB/SLE/sjorgens/analgesics
2. urine pH>5.4
3. hypoK, kidney stones= cannot excrete H+

Answer 11

Type I distal- tx w/ replete k and oral bicarb

Question 12

RTA and how to tx?

1. fanconi’s syndrome, myeloma, amyloid, vit D def, autoimmune
2. hypo K
3. osteomalacia– cannot reabsorb Bicarb

Answer 12

type II proximal- tx w/ replete k, mild diuretic, bicarb won’t help

Question 13

RTA and how to tx?

1. > 50% caused by diabetes, addisons, sickle cell, any cause of aldo def.
2. hyper K
3. hyper Cl
4. high urine [Na] even w/ salt restriction

Answer 13

type IV hyperrenin-hypoaldo- tx w/ fludrocortisone

Question 14

Muddy brown casts in a pt w/ ampho, AG, cisplatin or prolonged ischemia? tx?

Answer 14

ATN

tx w/ fluids, avoid nephrotox and dialysis of indicated

Question 15

protein, blood and Eos in the urine + fever and rash who took trim-sulfa 1-2 wks ago? tx?

Answer 15

AIN

tx w/ stop offending agent; add steroids if no improvement

Question 16

army recruit or crush victim w/ CPK of 50k + blood on dip but no RBCs. test? tx?

Answer 16

rhabdomyolysis
1st test- check potassium or ekg
tx w/ bicarb to alkalinize urine to prevent precipitation

Question 17

enveloped shaped crystals on UA? tx?

Answer 17

ethylene glycol intox

tx w/ dialysis or NaHCO3 if pH <7.2

Question 18

bump in creatinine 48-72 hr s/p cardiac cath or ct scan? prevent?

Answer 18

contrast nephropathy

prevent by hydrating before or giving bicarb or NAC

Question 19

indications for emergent dialysis

Answer 19

A- acidosis
E- electrolyte imbalance–> particularly high K >6.5
I- intoxication –> particularly antifreeze,Li’
O- overload volume–> sxs of CHF or pulmonary edema
U- uremia –> pericarditis alt. mental status

Question 20

patient peeing protein….

1. best 1st test?
2. definition of nephrotic syndrome?
3. MC in kiddos?
4. MC in adults?
5. Assoc. w/ heroin use and HIV
6. Assoc w/ chronic hepatitis and low complement?
7. if nephrotic patients suddenly develops flank pain?
8. other random causes?

Answer 20

1. best 1st test- repeat test in 2 weeks, then quantify w/ 24hr urine
2. definition of nephrotic syndrome- >3.5g protein/24hrs, hypoalbuminemia, edema, hyperlipidemia (fatty/waxy casts)
3. MC in kiddos- minimal change dz-fusion of foot processes, tx w/ ‘roids
4. MC in adults- membranous- thick cap walls w/ subepi spikes
5. Assoc. w/ heroin use and HIV- focal-segmental-mesangial IgM deposits. limited response to steroids
6. Assoc w/ chronic hepatitis and low complement- membranoprolif-tram track BM w/ subendo deposits
7. if nephrotic patients suddenly develops flank pain- suspect renal vein thrombosis! 2/2 peeing out ATIII, protein C and S. Do CT or U/S stat!!!
8. other random causes?- orthostatic, bence jones in MM, UTI, preggos, fever, CHF

Question 21

flank pain radiating to groin + hematuria

Answer 21

kidney stones

Question 22

best test for kidney stones

Answer 22

CT

Question 23

kidney stones… types:

1. most common
2. kid w/ family hx of stones
3. chronic indwelling foley and alkaline pee?
4. if leukemia being treated w/ chemo?
5. If s/p bowel resection for volvulus?

Answer 23

1. most common- calcium oxalate. tx w/ HCTZ
2. kid w/ family hx of stones- cysteine-cannot resorb certain AA
3. chronic indwelling foley and alkaline pee- Mg/AI/PO4=struvite. proteus, staph, pseudomonas, klebsiella
4. if leukemia being treated w/ chemo- uric acid tx by alkinizing the urine + hydration
5. If s/p bowel resection for volvulus- pure oxylate stone,Ca not reabsorbed by gut.. pooped out

Question 24

kidney stones…tx

1. stones <5mm
2. stones>2cm
3. stones 5mm-2cm

Answer 24

1. stones <5mm- will pass spontaneously. just hydrate
2. stones>2cm- open or endoscopic surgical removal
3. stones 5mm-2cm- extracorporal shock wave lithotropsy

Question 25

CKD...#1 cause...#2 cause?

Answer 25

DM and HTN

Question 26

#1 cause of death in CKD pt?

Answer 26

cardiovascular dx | ldl target<100

Question 27

so your patients is peeing blood: 1. best 1st test? 2. painless hematuria? 3. terminal hematuria + tiny clots 4. dysmorphic RBCs and RBC casts 5. definition of nephritic syndrome?

Answer 27

1. best 1st test- urinanalysis 2. painless hematuria- bladder/kidney cancer until proven otherwise 3. terminal hematuria + tiny clots- bladder cancer or hemorrhagic cystitis (cyclophosphamide) 4. dysmorphic RBCs and RBC casts- glomerular source 5. definition of nephritic syndrome?- proteinuria, hematuria, edema, and azotemia

Question 28

so you are peeing blood? 6. 1-2 days after runny nose, soar throat & cough

Answer 28

Berger's Dz- IgA nephropathy

Question 29

so you are peeing blood? 7. 1-2weeks after sore throat or skin infxn? - best 1st test? - what do you see?

Answer 29

post-strep GN-smoky/cola urine, best 1st test- ASO titer subepithelial IgG humps

Question 30

so you are peeing blood? | hematuria + hemoptysis

Answer 30

goodpastures' syndrome- Abs to collagen IV

Question 31

so you are peeing blood? | Hematuria + deafness

Answer 31

alport syndrome- XLR mutation in collagen IV

Question 32

so you are peeing blood? kiddo s/p viral URI w/ Renal failure + abd. pain, arthralgia and purpura... tx?

Answer 32

Henoch-Schonlein Purpura. IgA tx- supportive tx +/- steroids

Question 33

so you are peeing blood? kiddo s/p hamburger and diarrhea w/ renal failure, MAHA and petechiae..... tx?

Answer 33

HUS-E.Coli )127H7 or shigella dont's x w/ ABX- releases more toxin

Question 34

so you are peeing blood? cardiac patient s/p ticlopidine w/ renal failure. MAHA, decreased plts, fever and AMS. tx?

Answer 34

TTP tx w/ plasmapheresis. dont' give plts can tell from DIC b/c PT and PTT are normal in HUS/TTP

Question 35

so you are peeing blood? c-ANCA, kidney, lung and sinus involvement... tx?

Answer 35

wegner's granulomatosis - most accurate test is bx - tx w/ steroids or cyclophosphamide

Question 36

so you are peeing blood? p-ANCA, renal failure, asthma and eosinophilia....tx?

Answer 36

churg strauss - best test is lung bx. - tx w/ cyclophosphamide

Question 37

so you are peeing blood? p-ANCA, NO lung involvment, Hep ... tx?

Answer 37

polyarteritis nodosa. - affects small/med arteries of every organ except the lung - tx w/ cyclophosphamide