Flashcards in Nephrology Deck (93):
Which malignancy is associated with which renal disorder?
Hodgkin Lymphoma and Minimal Change Disease
What is the work-up for new onset hypertension (5)?
3. CBC for Hct
4. BMR for glucose, K, Ca++ and Cr
What are clinical features of primary aldosteronism (4)?
3. Metabolic Alkalosis (mild)
4. Suppressed plasma renin
If a patient with renal artery stenosis is given an ACEI for blood pressure, what happens to the BMR?
Increased creatinine without improvement in blood pressure
List features of nephrotic syndrome (5)
1. Proteinuria > 3.5g / 24h
2. Hypoalbuminemia < 3g / 24
5. Lipiduria (oval fat bodies in urine, Maltese cross)
1. List causes of primary nephrotic syndrome (4)
2. List causes of systemic nephrotic syndrome (4)
1. Minimal change - children
2. Membranous nephropathy - whites
3. FSGS - blacks
4. Membranoproliferative GN
4. Infection: HBV, HCV, HIV
Which cause of primary nephrotic syndrome is most common in:
3. African Americans
1. Minimal change disease
2. Membranous nephropathy
3. Focal Segmental Glomerulosclerosis
What are complications of nephrotic syndrome (3)?
1. VTE - DVT or renal vein, loss of inherent anticoags
3. Infection - loss of IgG
For IgA Nephropathy:
1. What is the pathophysiology?
2. Who is most commonly affected?
3. What is a common outcome?
1. Accelerated by mucosal IgA stimulation from URI or acute gastroenteritis leads to nephropathy with hematuria
3. 20% progress to dialysis in 20 years
What are secondary causes of IgA Nephropathy (7)?
1. Henoch Schonlein Purpura - IgA vasculitis
3. Celiac Disease - mucosal surfaces
4. Dermatitis Herpetiformis
6. Seronegative Arthritis
Compare IgA Nephropathy with Post-Infxn GN:
2. Urine features
Contrast IgA Nephropathy with Post-Infxn GN:
1. 2-3 days after..........2-4 weeks after
2. gross hematuria..........coca-cola urine
3. C3 normal..........C3 low
4. ASO - - .......... ASO ++
5. IgA deposits..........Subepithelial humps
6. Recurrent..........Not usually recurrent
What is the differential for low complement (6)?
2. Post-infxn GN
4. Bacterial endocarditis
5. Membranoproliferative Glomerulonephritis
6. Renal atheroemboli
List features of nephritic syndrome (5)
1. Hematuria/RBC casts
2. Proteinuria < 3g / 24h
5. Reduced GFR
1. List causes of primary nephritic syndrome (3)
2. List causes of systemic nephritic syndrome (5)
1. IgA Nephropathy
2. Post-Strep GN
3. Anti-GBM disease
Which diseases overlap nephrotic and nephritic syndromes (4)?
1. IgA Nephropathy
If immune staining is positive then...
...not ANCA associated
What is the pathophysiology for anti-GBM?
Antibodies to glomerular basement membrane lead to COMPLEMENT activation with subsequent leukocyte infiltration
What is treatment for anti-GBM (3)?
1. Plasmapheresis to remove antibodies to glomerular basement membrane
What is the microscopic renal feature of RPGN?
What appears in urine microscopy in patients with rhabdomyolysis?
Hemoglobin but no RBC
What are three categories of ATN (3, 2, 7)?
2. Pigment Induced
- Ethylene glycol
What are causes of AIN (3)?
3. Autoimmune Disease
Other than AKI, what other lab abnormality occurs with AIN?
Eosinphilia (although not specific)
List non-renal manifestations of Polycystic Kidney Disease (6)
1. Cerebral berry aneurysm
2. Aortic and Mitral Valve Prolapse
3. Thoracic and Abdominal Aortic Aneurysms
4. Liver and Pancreatic Cysts
5. Diverticular Disease
6. Polycythemia - from excess Epo
What increase in creatinine correlates to a decrease in GFR by 50%?
Creatinine 1 --> 2
Which populations may have an artificially low creatinine (3)?
Those with very low muscle mass:
1. Liver disease
3. Advanced age
Which populations may have an artificially high BUN (3)?
1. High-protein diets
2. Catabolic states
3. GI bleeding
What is seen on urine microscopy with glomerulonephritic causes of hematuria?
Acanthocytes or "Mickey Mouse cells"
1. What renal cystic/mass features on CT would warrant a nephrectomy (4)?
2. What test would be contraindicated?
1. Enhancement after contrast
2. Diameter > 3 cm
3. Areas of necrosis
4. Marginal irregularities
***Biopsy is contraindicated!!
1. What are contraindications to kidney biopsy (8)?
2. What is an alternative to biopsy when tissue is imperative?
1. Solitary kidney
2. Uncooperative patient
3. Bleeding history
4. Uncontrolled severe HTN
5. Cystic kidneys
7. Multiple renal artery aneurysms
8. Renal abscesses
***Alternative = open-wedge kidney biopsy
Name three causes of pseudohyponatremia
1. Hyperglycemia (100 Glu : 1.6 Na)
3. Elevated proteins (Waldenstrom's)
What are risk factors for hyponatremia with concurrent use of SSRI (4)?
1. Older age
2. Gender: women
3. Diuretic use
4. Low body weight
1. What drug is off-label for treatment of chronic SIADH, and how does it work?
2. What drug is used for Central Diabetes Insipidus, and how does it work?
1. Demeclocycline - tetracycline antibiotic which reduces renal responsiveness to ADH
2. Desmopressin (dDAVP) - ADH (vasopressin) receptor agonist
1. What is the formula for Anion Gap?
2. What is a normal AG?
3. What does an AG mean (2)?
1. Na - (Cl + HCO3)
3. a. Loss of HCO3
b. Gain of acid from an unmeasured anion
What is the differential for an AG metabolic acidosis?
Diabetic ketoacidosis **SERUM KETONES
Methanol **OSMOL GAP
Lactic acidosis **HIGH LACTATE
Ethylene glycol **OSMOL GAP
When comparing pH with PaCO2, how can you determine if it is a metabolic or respiratory process?
pH and PaCO2:
Same direction = METABOLIC
Opposite directions = RESPIRATORY
What is a delta-delta, and how is it used?
Delta delta = Delta-AG / Delta-HCO3
*(calculated AG -12) / (24 - HCO3)
If less 1, metabolic acidosis + nonAG acidosis
If 1-2, metabolic acidosis
If >2, metabolic acidosis + metabolic alkalosis
1. What is the formula for an Osmole Gap?
2. What is a normal Osmole Gap?
3. What abnormal value leads to a differential?
1. Measure Osm - Calculated Osm where:
2xNa + BUN/2.8 + Glu/18
3. >10 indicates EtOH, Ethylene or Methanol
What is the differential for a NON-AG metabolic acidosis?
Carbonic anhydrase inhibitors (acetazolamide)
RTA **HYPERKALEMIA for RTA4
Describe the difference between RTA1, RTA2 and RTA4
RTA1 = decreased distal acidification
*Think stones, autoimmune
RTA2 = decreased proximal HCO3 reabsorption
*Think myeloma (urine light chain, trace protein on dipstick but greater measured proteinuria)
*Treat with HCO3
RTA4 = decreased Aldosterone (thus hyperK)
1. When should mixed acid-base disorder be suspected?
2. Metabolic Acidosis + pH 7.47 =
1. Normal pH with known primary acid-base disturbance
2. Accompanying Respiratory Alkalosis
1. What additional features would suggest Ethylene Glycol poisoning (2)?
2. What is treatment?
3. What is it also treatment for?
1. a. Oxalate crystals in urine
b. Urine fluorescence with Wood's lamp
2. Fomepizole - inhibits EtOH dehydrogenase
3. Methanol poisoning
1. What is prehypertension?
2. What is stage 1 hypertension?
3. What is stage 2 hypertension?
1. 120-139 / 80-89
2. 140-159 / 90-99
3. >160 / 100
1. Describe three cation channels that are activated by Aldosterone, and what does it cause?
2. If primary aldosteronism is considered, what imaging modality should be ordered?
1. a. Activates Na+ causing hypernatremia
b. Activates K+ causing hypokalemia
c. Activates H+ causing metabolic alkalosis
2. CT scan through adrenal glands
What tests are used for pheochromocytoma (4)?
1. Plasma free metanephrines
2. Plasma or urine catecholamines
3. Urine metanephrines
4. Urine vanillymandelic acid
What imaging modalities are used for pheochromocytoma?
1. CT for adrenal
2. MRI for extra-adrenal
What drugs are used preoperatively prior to pheochromocytoma resection?
1. Alpha-blocker (Phenoxybenzamine) for preoperative catecholamine blockade
2. Beta-blocker - prevents reflex tachycardia from alpha-blocker
3. Alpha-methyl tyrosine inhibitors - prevents catecholamine synthesis
By lowering elevated blood pressure by __ will decrease risk of _(3)_ by _(3)_%.
....10 / 5....
....overall CV mortality...20%
Which two patient populations benefit most from diuretic therapy?
1. What are two NON-dihydropyridine calcium channel blockers?
2. Do dihydropyridine or NON-dihydropyridine calcium channel blockers cause edema and why?
**Dihydropyridines cause dependent edema via localized vasodilation and NOT fluid retention
Which drugs are used for HTN in pregnancy (4)?
B - Methyldopa - alpha-agonist
C - Labetolol
C - Hydralazine
C - beta-blockers
What urine volume defines oliguria?
< 400 mL / 24 h
1. What is the formula for FENa?
2. What do the values mean?
1. (Una x Pcr) / (Pna x Ucr) x 100%
2. 2% ATN
1. What drug is used for acute urate nephropathy associated with tumor lysis syndrome?
2. What are possible side effects (4)?
2. a. Hemolysis
What is the formula for a calculated plasma osmolality?
(2 × Na) + (BUN/2.8) + (Glu/18)
What is the differential for an elevated osmole gap? How are they different?
- AG metabolic acidosis
- RENAL FAILURE
- AG metabolic acidosis
Isopropyl alcohol - None of the above
What medication in combination with OCP will cause hypertension?
In patients with recurrent calcium oxalate stones and hyperoxaluria, recommended treatment includes what?
1. Increased dietary calcium (binds to GI oxalate)
2. Avoidance of oxalate-rich foods:
What does Membranous Nephropathy appear on light and electron microscopy (4)?
1. Glomerular membrane thickening
2. NO cellular infiltration
3. Coarse granular Ig/C3
4. EM: podocyte effacement
What is seen on urine microscopy with ATN?
Muddy brown casts
When suspecting hepatorenal syndrome, what two drugs have been used?
1. Midodrine + Octreotide
1. What are the stages of CKD?
2. Which stage warrants phosphate binders?
0. GFR > 90 with CKD risk factors
1. GFR >=90
2. GFR 60-90
3. GFR 30-59**
4. GFR 15-29
5. GFR < 15 or dialysis
**Phosphate binders because lower GFR causes hyperphosphatemia --> hypocalcemia --> hyperPTH
1. What drug inhibits PTH?
2. What is the goal PTH level?
3. What are alternatives to lower PTH?
2. PTH < 500
3. Calcitriol and Vitamin D analogs
1. How does the urine microscopy appear in analgesic nephropathy?
2. What cancer risk is increased with analgesic nephropathy?
1. Bland with occasional granular casts or WBC
2. Genitourinary Transitional Cell Carcinoma
1. What are two main immunosuppressants used after renal transplant?
2. What are their side effects do they share?
3. What side effects are unique to them?
1. Cyclosporine and Tacrolimus
2. a. HTN
b. Gum hypertrophy
d. Glucose intolerance
1. What type of meningitis should be considered in patients with renal transplants?
2. What viral infection can occur after using Mycophenolate, and how does it manifest?
3. What are three labs that can lead to a diagnosis?
2. BK Virus - asymptomatic rise in creatinine
3. a. Elevated BK viral load in blood/urine
b. Urine "decoy cells" - infected epithelial cells
c. Renal biopsy with simian virus 40
Which medications during pregnancy are safe to use during a lupus flare (2)?
1. What size kidney stones pass spontaneously?
2. What size kidney stone requires surgical removal?
3. What medications can be used for stones that are smaller than the above?
1. Less than 5mm
3. a. Nifedipine - ureteral dilation
b. Tamsulosin - ureteral dilation
c. Corticosteroids - reduce ureteral edema
Infection with which two bacteria leads to which type of nephrolithiasis?
Klebsiella and Proteus --> Struvite
What is treatment for cysteine nephrolithiasis (4)?
Focuses on cystinuria:
1. Potassium citrate
1. What is the most appropriate test for AL (light chain) amyloidosis?
2. What do 20% progress to?
3. What extrarenal diseases are associated?
1. Fat pad biopsy
2. Multiple Myeloma
In Minimal Change Disease:
1. How high can the urine protein go?
2. How does it appear on electron microscopy?
3. What common does not happen (2)?
4. How is it treated (2)?
1. Massive > 9 g / 24h
2. Effacement or flattening of the glomerular epithelial cells
3. HTN or ESRD
4. ACEI/ARB and corticosteroids
1. How does immunofluorescence microscopy appear?
2. How is it treated with nephrosis (3)?
3. How is it treated without nephrosis (1-2)?
1. Coarse deposits of Ig, C3 and fibrin
2. Prednisone, Cyclosporine, Mycophenolate
3. ACEI with/without ARB
In Membranoproliferative Glomerulonephritis:
1. How does it appear on light microscopy?
2. What rheumatologic disorders are related (2)?
3. What infections are related (2)?
4. What complement levels result, and why?
1. Mesangial interposition into capillary wall causing tram-track appearance
2. Lupus, Sjogren's
3. HCV, bacterial endocarditis
4. Low C3 and normal C4 - no classical complement cascade
Describe the pattern of complement in cryoglobulinemia?
Low C3 and Low C4
What microscopic feature is pathognomonic for diabetic nephropathy?
Kimmelsteil-Wilson nodules - large pink nodules
How do kidneys appear in HIV-Associated Nephropath?
Large and highly echogenic
What exam finding distinguishes Cerebral Salt Wasting from SIADH?
CSW = hypotension due to decreased intravascular volume
What two serum labs are effective in the diagnosis of Post-streptococcal Glomerulonephritis?
1. ASO (antistreptolysin)
2. anti-DNAas B antibody titers
In anti-Glomerular Basement Membrane Disease:
1. How does immunofluorescence microscopy appear?
2. What systemic disease does it mirror?
1. Linear staining of IgG lining GMB
2. Goodpasture's - renal and lung
What do these casts indicate?
4. Muddy Brown
1. Glomerular disease
2. Inflammation or infection
3. Protein precipitates
What are the three pulmonary-renal syndromes? For each, list prominent feature and two diagnostic labs.
1. Wegener granulomatosis
*Dx: c-ANCA and p-ANCA
2. Anti-GBM (Goodpastures)
*Dx: anti-GBM ab, linear staining microscopy
*Dx: anti-dsDNA or antij-Smith
In patients with uric acid nephrolithiasis, besides Allopurinol, what can be used to prevent further stones and why does it work?
Potassium Citrate - alkalinizes acidic urine above pH 6.0
What is a major side effect of MRI with Gadolinium?
Nephrogenic Systemic Fibrosis, esp GFR less than 30
1. What are Calcium Stones composed of (2 types)?
2. What are specific treatments (3 types)?
1. a. 80% Calcium-oxalate (insoluble in acid urine)
b. 10% Calcium-phosphate (insoluble in alkaline urine)
a. Hypercalciuria = HCTZ, low sodium diet
b. Hyperoxaluria = oral Ca-Carb
c. HyPOcitraturia = (in RTA) oral K-citrate
1. What are Struvite Stones composed of?
2. What are etiologies of Struvite Stones (2)?
3. How are Struvite Stones treated?
1. Composed of magnesium ammonium phosphate + ca-carb apatite
2. Proteus and Klebsiella
3. Antibiotics and stone removal
What is treatment for Uric Acid Stones (2)?
1. Alkalinization of urine
2. Allopurinol when urine UA greater 1g/d
1. What is the etiology of Cystine Stones?
2. What is seen on urine microscopy?
3. How is it treated (2)?
1. Autosomal recessive cystinuria
2. Hexagonal crystals
3. a. Alkalinization of urine
b. Cystine chelators: Penicillamine or Tiopronin
What ratio helps distinguish renal potassium wasting from extra-renal wasting?
K-Cr Ratio = (Uk x 100) / Ucr
If greater 20 then renal wasting
If less 15 then EXTRA-renal loss
If a renal-transplant patient has rising Cr and a BK-viremia, what a conservative treatment measure?
1. What is Amiloride?
2. What is a potential indication in concert with a psychotropic medication?
1. Diuretic = Na-channel blocker
2. Lithium-induced AIN
1. What is Tolvaptan?
2. What is its indication?
1. Arginine Vasopressin Antagonist
2. SIADH from CHF, cirrhosis