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Board Basics > Nephrology > Flashcards

Nephrology Flashcards

1
Q 
What are the 3 GFR estimation equations? 
When do you use which?
1) best when GFR <60
2) best when near nromal GFR values
3) least accurate
4) which to use drug dosing
A

Cockcroft-Gault equation, Modification of Diet in Renal Disease (MDRD) study equation, CKD Epidemiology (CKD-EPO) collaboration equation

1) MDRD study
2) CKD-EPO
3) Cockcroft-Gault equation
4) Cockcroft-Gault equation

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2
Q

What is the BUN:Cr ratio for dehydration?

A

> 20:1

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3
Q

What is the only protein to be detected in dipstick?

A

albumin

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4
Q

What test can detect presence albumin and other proteins like urine light chains or immunoglobulins?

A

sulfosalicylic acid

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5
Q

What is the follow up test after detecting protein on a dipstick?

A

24 hour urine collection or protein/albumin creatine ratio

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6
Q

What is cutoff for protein Cr ratio for

1) tubulointerstitial or glomerular disease?
2) glomerular disease

A

1) >150mg/g but <200mg/g

2) >3500mg/g

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7
Q

When do you use albumin Cr ratio?

A

to measure diabetic kidney disease

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8
Q

What cut off is used for albumin cr ratio for

1) moderately increased albuminuria (microalbuminuria)
2) severely increased albuminuria (macroalbuminuria or overt proteinuria)

A

1) 30-300mg/g

2) >300mg/g

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9
Q

What findings in the urine can indicate glomerular disease? (2)

A

erythrocyte casts and dysmorphic erythrocytes (acanothcytes, RBCs with mickey mouse ears)

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10
Q

If there are no casts in urine, what other finding with hematuria can support glomerular cause or hematuria?

A

coexisting proteinuria

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11
Q

If hematuria is preserved morphology, what extraglumerular bleeding differential diagnosis can it indicate? (5)

A

GU cancer, kidney stones, infection, trauma, medications

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12
Q

What can sterile pyuria suggest? (3)

A

interstitial cystitis, interstitial nephritis, mycobacterium tuberculosis

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13
Q

What can eosinophiluria suggest? (5)

A

AIN, postinfectious GN, atheroembolic disease of kidney, septic emboli, small vessel vasculitis

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14
Q

What disorders are associated with the following casts:

1) erythrocyte casts
2) leukocyte casts
3) muddy brown casts
4) broad casts

A

1) glomerular disease
2) inflammation or infection of renal parenchyma
3) ATN
4) CKD

Casts=aggregates of Tamm-Horsfall mucoproteins that trap intraluminal contents

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15
Q

What imaging needs to be obtained to look for renal artery stenosis and renal vein thrombosis?

What is the risk if this imaging is used with CKD

A

MR with gadolinium (nongad for the thrombosis)

nephrogenic systemic fibrosis

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16
Q

What are 4 indications for renal biopsy?

A

glomerular hematuria, severely increased albuminuria, acute or CKD of unclear etiology kidney transplant dysfunction

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17
Q

What are 7 reasons not to do a kidney biopsy?

A

bleeding diatheses, severe anemia, UTI, hydronephrosis uncontrolled HTN, renal tumor, atrophic kidneys

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18
Q

What is the first thing to measure in hyponatremia?

What are 2 things that can cause pseudo hyponatremia and have a normal serum osm?

A

serum Osm–>hyper or hypo

severe hyperlipidemia and hyperproteinemia

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19
Q

What are 6 things that can cause hypertonic (hyperosm) hyponatremia?

A

glucose, BUN, alcohols, mannitol, sorbitol, glycine (used on bladder irrigation)

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20
Q

What is the next thing to look at when you have hypo-osmolar hyponatremia?

A

volume status

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21
Q

What are the following lab values for hypovolemia hypo-osmolar hyponatremia?

1) spot urine sodium
2) BUN/Cr ratio

What is the cause of this? (3)

A

1) <20mEq/L
2) >20:1

GI/kidney fluid losses, dehydration, mineralocorticoid insufficiency

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22
Q

What are the following spot urine sodium values for hypervolemia hypo-osmolar hyponatremia in

1) HF and cirrhosis in abscence of diuretic therapy
2) acute and chronic kidney failure

A

1) <20meq/L

2) >20meq/L

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23
Q

What is the following lab values for euvolemic hypo-osmolar hyponatremia due to SIADH, hypothyroidism, glucocorticoid deficiency (Addison disease)?

1) spot urine sodium
2) urine osm

A

1) >20mEq/L

2) >300mOsm/L

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24
Q

What is the following lab values for euvolemic hypo-osmolar hyponatremia due to compulsive water drinking?

1) spot urine sodium
2) urine osm

A

1) >20mEq/L

2) 50-100 mOsm/L

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25
Q

What are some medications that can cause SIADH? (6)

A

thiazides, SSRIs, TCAs, narcotics, phenothiazines, carbamazepine

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26
Q

What is the risk of overcorrection of hyponatremia?

A

central pontine myelinolysis; aim to correct 4-6mEq/L within the first 6 hours w/ 3% NaCl if symptomatic

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27
Q

How do you correct an overcorrection of hyponatremia?

A

desmopressin and D5W

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28
Q

How do you treat asymptomatic/minimally symptomatic outpatients with SIADH?

A

water restriction, loop with oral salt supplementation, demeclocycline

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29
Q

What is the treatment or euvolemic and hypervolemic hyponatremia

A

V1 and V2 receptor antagonist conivaptan and tolvaptan(reserve for Na <120)–not necessarily better than other conventional treatments

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30
Q

What are 5 reasons for hypernatremia?

A

inadequate access to water, defective thirst mechanism, kidney concentrating defect (with lithium), impared pituitary secretion of ADH (2/2 sarcoidosis), loss of hypotonic fluids

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31
Q

What is the formula for water deficit in hypernatremia?

A

(Na-140 divided by 140) x TBW

TBW=0.5 (in woman) or 0.6 (in men) x weight

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32
Q

What is treatment for hypernatremia due to central DI?

A

IN desmopressin

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33
Q

What are 5 causes of hyperkalemia?

A

hyporeniemic hypoaldosteronism, acute/chronic kidney failure, low urine flow states, meds, potassium shifts

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34
Q

What number is suggestive of excessive potassium urinary losses?

A

> 20

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35
Q

What number is suggestive of cellular shift, decreased intake or extrarenal losses of potassium?

A

<24 mEq/24 hours

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36
Q

What are 5 rare causes of hypokalemia?

A

1) primary aldosteronism
2) Bartter syndrome
3) Gitelman syndrome
4) inhalted beta2 agonists
5) hypokalemic periodic paralysis

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37
Q

What are the causes of hypokalemia?

1) HTN, urine Cl >40mEq/L, low plasma renin and elevated aldosterone?
2) normal BP, hypoK, metabolic alkalosis, elevated renin and aldosterone
3) normal BP, hypoK, hypoMg

A

1) primary aldosteronism
2) Bartter syndrome
3) Gitelman syndrome

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38
Q

What are the causes of hypokalemia?
-rare familial or acquired disorder characterized by flaccid generalized weakness from sudden shift precipitated by strenuous exercise or high CHO meal

  • who do we see it in for inherited?
  • what do we see it with if acquired?
A

hypokalemic periodic paralysis seen in Asian/Mexican men

if acquired, see with thyrotoxicosis

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39
Q

What are 4 symptoms of hypokalemia?

EKG findings?

A

ileus, muscle cramps, rhabdomyolysis, hypomagnesemia

EKG: U waves and flat/inverted T waves

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40
Q

What are two concurrent electrolyte/pH abnormalities with hypokalemia?

A

hypomag and metabolic alkalosis

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41
Q

What two electrolyte abnormalities are seen with hypomagnesemia?

A

hypocalcemia and hypokalemia

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42
Q

What are 4 medications associated with hypomagnesemia?

A

cisplatin, aminoglycosides, amphotericin B, cyclosporine

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43
Q

What does PTH do in phosphate regulation?

A

decreases phosphorus reabsorption and promotes kidney phosphate excretion

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44
Q

What does calcitriol do in phosphate regulation?

A

stimulates phosphate absorption in gut

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45
Q

What are 5 characteristic findings in severe hypophosphatemia?

A

HF, muscle weakness, rhabdo, hemolytic anemia, metabolic encephalopathy

46
Q

What is the formula to calculate FEPO4?

A

(Urine PO4 x Cr serum x 100) / (serum PO4 x UCr)

47
Q

What is the % of FEPO4 and renal phosphate excretion that indicates renal phosphate wasting?

A

> 5% and >100 mg/d

48
Q

What are the 4 questions to ask when approaching acid/base problem?

A

1) what is primary disturbance
2) is the compensation appropriate
3) what is the anion gap
4) does the change in anion gap equal the change in serum bicarbonate concentration?

49
Q

What is the compensation formula for metabolic acidosis?

1) acute
2) chronic

A

1) 1.5 (HCO3) +8 +/-2
2) HCO3 + 15
* if the pCO2 is higher than expected, then have a concomitant respiratory acidosis
* if the pCO2 is lower than expected, then have a concomitant respiratory alkalosis

50
Q

What is the compensation formula for respiratory acidosis?

1) acute
2) chronic

A

1) 1 mEq/L increase in HCO3 for each 10mmHg increase in pCO2
2) 3.5 mEq/L increase in HCO3 for each 10mmHg increase in pCO2
* if HCO3 is lower than expected, then also have metabolic acidosis
* if HCO3 is higher than expected, then also have metabolic alkalosis

51
Q

What is the compensation formula for metabolic alkalosis?

A
  1. 7 mmHg increase in pCO2 for each 1mEq/L increase in HCO3

* response is limited by hypoxemia

52
Q

What is the compensation formula for respiratory alkalosis?

1) acute
2) chronic

A

1) acute: 2 mEq/L decrease in HCO3 for each 10 mmHg decrease in pCO2
2) chronic: 4mEq/L decrease in HCO3 for each 10 mmHg decrease in pCO2
* if HCO3 is higher than expected, there is also metabolic alkalosis
* if HCO3 is lower than expected, then there is also metabolic acidosis

53
Q

What is the anion gap calculator? Which acid disturbance is this important for?

A

Na - Cl + HCO3
AG normal 10 +/-2
metabolic acidosis

54
Q

What does a reduced anion gap <4 suggest? (2)

A

multiple myeloma or hypoalbuminemia

55
Q

what are 6 reasons to have an elevated anion gap metabolic acidosis?

A

DKA, CKD, lactic acidosis, aspirin toxicity, alcoholic ketosis, methanol and ethylene glycol poisoning (also have osmolar gap)

56
Q

What are 5 reasons to have a normal anion gap metabolic acidosis?

A

diarrhea (GI losses), ileal bladder/proximal RTA (kidney losses), reduced kidney H secretion (distal RTA, type IV RTA), fanconi syndrome (phosphaturia, glucosuria, uricosuria, aminoaciduria), carbonic anhydrase inhibitor use (acetazolamide and topiramate)

57
Q

What is the urine anion gap calculation?

A

Na + K - Cl

58
Q

What 2 situations is the urine anion gap calculation used?

A

1) normal anion gap metabolic acidosis when there is extra renal bicarb–>UAG will be very neg
2) type 1 RTA–>UAG will be positive

59
Q

What is the expected ratio between the change in anion gap (normal - measured) and change in plasma HCO3 (normal - measured)

A

1-2

60
Q

What if delta anion gap/delta HCO3 is <1?

What if delta anion gap/delta HCO3 is >2?

A

if <1–>concurrent normal anion gap acidosis

if >2–>concurrent metabolic alkalosis

61
Q

Which RTA is this?

1) normal AGMA, hypoK, positive UAG, urine pH >5.5, serum bicarb=10
2) what are 4 associated findings?
3) treatment?

A

1) Distal (type 1) RTA
2) nephrolithiasis and nephrocalcinosis, autoimmune disorders, amphotericin B, urinary obstruction
3) bicarb

62
Q

Which RTA is this?

1) normal AGMA, normal or negative UA, hypokalemia, urine PH <5.5, serum bicarb 16-18
2) what is associated finding?
3) treatment?

A

1) proximal (type 2) RTA
2) fanconi syndrome (glucosuria, phosphaturia, uricosuria, aminoaciduria, tubular proteinuria)
3) thiazide + potassium-sparing diuretic

63
Q

Which RTA is this?

1) normal AGMA, hyperkalemia, positive UA, urine pH <5.5
2) what is 2 associated findings?
3) treatment?

A

1) type 4 RTA
2) DM, urinary tract obstruction
3) correct hyper K

64
Q

How do you calculate osmol gap? What is the normal osmol gap?

A

2 x serum Na + BUN/2.8 + blood glucose/18

10 is normal

65
Q

What osmol gap would you consider an alcohol poisoning? What is the most common alcohol poisoning?

A

> 10; ethanol

66
Q

What alcohol would you suspect:

1) somnolence or coma and normal acid/base?
2) severe increased AGMA and acute visual symptoms or severe abdominal pain?
3) severe increased AGMA and AKI
4) increased AGMA and ketoacidosis that improves with NS and glucose

A

1) isopropyl alcohol
2) methanol (pancreatitis and retinal toxicity)
3) ethylene glycol (metabolizes to glycoxylate and oxalic acid–>nephrolithiasis and AKI)
4) ethanol

67
Q

How do you treat the following alcohol poisonings?

1) mild isopropyl
2) severe isopropyl
3) methanol
4) ethylene glycol
5) alcoholic ketoacidosis

A

1) IV fluids, gastric lavage
2) HD
3) fomepizole and HD
4) fomepizole and HD
5) IV NS, glucose, thiamine

68
Q

What is the treatment for the following RTAs?

1) distal (type 1)
2) proximal (type 2)
3) type 4

A

1) bicarb but correct K first
2) thiazide (volume depletion to lower GFR and decrease filtered load of bicarb); can also add Ksparing diuretic
3) correct hyperK

69
Q

What are the 4 common causes of nephrotic syndrome?

A

membranous glomerular nephropathy, diabetic nephropathy, minimal change nephropathy, focal segmental nephropathy

70
Q

1) What is the most common cause of nephrotic syndrome in blacks?
2) What are 2 things that are associated with it?
3) What is the treatment?

A

1) focal segmental glomerulosclerosis
2) HIV, morbid obesity
3) glucocorticoids or calcinurin inhibitors

71
Q

1) What is the most common cause of nephortic syndrome in whites?
2) What antibody is positive?
3) What are 4 secondary causes
4) What is the treatment?

A

1) membranous glomerulopathy
2) phospholipase A2 receptor
3) infectious (hep B/C, malaria, syphilis), SLE, drugs (NSAIDs, gold slats), cancer (solid tumors, lymphoma)
4) spontaneous, glucocorticoids, cyclphospamide/calcineurin inhib

72
Q

1) What is the most common cause of primary nephortic syndrome in children?
2) What is the treatment

A

minimal change

glucocorticoids

73
Q

When do you measure albumin-creatinine ratio for diabetic nephropathy?

A

5 years after T1DM, at time of diagnosis for T2DM

74
Q

What is the hallmark thing you see in the UA for nephritic syndrome?

A

dysmorphic erythrocytes

75
Q

What is the most common cause of rapidly progressive GN in young/old?

A

young: anti GBM
old: pauci-immune

76
Q

What GNs have normal complement? (4)

A

anti GBM, pauci-immune, IgA nephropathy, IgA vasculitis

77
Q

What is the treatment for:

1) anti GBM?
2) pauci-immune?
3) IgA
4) lupus nephritis

A

1) cyclophosphamide and glucocorticoids with daily plasmapharesis
2) glucocorticoids and cyclophospamide/rituximab +/-plasmapharesis
3) spontaneous or ACEI/ARB
4) glucocorticoids with cyclophospamide/MMF

78
Q

What GNs have decreased complement?

A

lupus, infection related, membranoproliferative glomerulonephritis, cryoglobulinemia, atheroembolic disease

79
Q

What is membranoproliferative glomerulonephritis associated with? (3)

A

SLE, hep C, monoclonal gammopathy

80
Q

Match the monoclonal gammopathies with the pathology:

1) apple green with congo red
2) congo red-negative light or heavy chain deposits
3) light chains in renal tubules or light chains absorbing and crystallizing in proximal tubular cells
4) vasculitis syndrome with GN with membranoproliferative features

A

1) amyloidosis
2) monoclonal immunoglobulin deposition disease
3) multiple myeloma
4) cryoglobulinemia

81
Q

Which nephritic syndrome has low C4 only

A

cyroglobulinemia

82
Q

How many cysts would give a diagosnis of ADPKD to a patient?

A

> 2 if under 60 yo

>4 if over 60 yo

83
Q

What is the gene mutation in ADPKD?

A

PKD1 and PKD2

84
Q

What abx should be used to treat cyst infection/pyelonephritis in ADPKD?

A

bactrim or fluroquinolones

85
Q

What can be used to reduce the rate of increasing kidney size and loss of GFR in ADPKD? What is limiting its use?

A

Tolvaptan; drawbacks: hepatotoxicity and $$$

86
Q

What is the most serious extrarenal complication of ADPKD?

A

intracranial cerebral aneurysm–need periodic MRAs especially if have family history

87
Q

What are 2 findings classic for Alport syndrome?

A

sensorineural hearing loss and lenticonus

88
Q

What type of AKI is the following?

1) BUN Cr >20:1, UOsm >500, UNa <20, FeNa <1%
2) BUN Cr 10:1, UOsm 300, UNa >40, FeNa >2%
3) BUN Cr >20:1, variable UOsm, UNa, FeNa

A

1) prerenal
2) ATN
3) post renal

89
Q

What type of AKI is associated with the following UA findings?

1) normal or hyaline casts
2) muddy brown casts and tubular epithelial cells
3) mild proteinuria, leukocytes, erytheocytes, leukocyte casts, eosinophiluria
4) proteinuria, dysmorphic erythrocytes, erythrocyte casts
5) variable, bland

A

1) prerenal
2) ATN
3) AIN
4) acute GN
5) post renal

90
Q

What are 2 medications that can be used to expulse stones?

A

tamsulosin and nifedipine

91
Q

What is the minimum amount of fluid to ingest for someone who is prone for kidney stones?

A

> 2 L

92
Q

What meds should someone be on if they are prone to the following stones:

1) calcium composite
2) large struvite

A

1) thiazide, allopurinol, citrate

2) percutaneous nephrostolithotomy and long term prophylactic antibiotics

93
Q

What is the threshold for early microabluminuria?

A

spot albumin-creatin ratio 30-300mg/g

94
Q

Which diuretic should be used in GFR<30?

A

loop

95
Q

Yes/No: Treat patients on dialysis with statins

A

No

96
Q

In CKD patients, if PTH elevated, what 2 medications can you use?

A

calcitriol to supress PTH and phosphate binders

97
Q

In CKD, if patients who are receiving dialysis therapy who don’t respond to vit D analogues, calcium supplements and phosphate binders?

A

cinacalcet

98
Q

How far in advance do you prep patients who are receiving:

1) peritoneal dialysis
2) HD
3) transplant

A

1) 1 month prior
2) AV fistula before eGFR drops below 15
3) refer once GFR<20

99
Q

What are 2 calcineurin inhibitors? What are their side effects?

A

1) cyclosporine-HTN, decreased GFR, dyslipidemia, hirsutism

2) tacrolimus-DM, decreaseed GFR, HTN

100
Q

what are 2 antimetabolite immunosuppressants and their side effects?

A

1) MMF-leukopenia, anemia

2) azathioprine-leukopenia

101
Q

What are 2 mTOR inhibitors and their side effects?

A

sirolimus and everolimus–protinuria; dyslipidemia, DM, anemia, leukopenia

102
Q

What is a glucocorticoid receptor agonist immunosuppressant?

A

prednisone–osteopenia, HTN, edema, DM

103
Q

After kidney transplant, what is the most common complications:

1) in the 1st month (2)
2) 2 infections after the 1st month
3) BK virus causes 2 issues
4) most common malignancy

A

1) UTI, surgical wound
2) CMV–give prophy valganciclovir and bactrim against pneumocystis jirovecii
3) decrease immunosuppression, rise in serum creatinine
4) most common malignancy-cutaneous SCCs

104
Q

What do you do if a kidney transplant recipient gets kaposi sarcoma?

A

reduce immunosuppression and switch to sirolimus-based immunosuppression

105
Q

Posttransplant lymphoproliferative disease is associated with which infection? What do you do?

A

EBV–reduce immunosuppression and give rituximab if have CD20+ tumors

106
Q

Which antacids do you not want to give to ESRD?

A

magnesium-based

107
Q

In CKD, which renal osteodystrophy is caused by secondary hyperparathyroidism and has subperiosteal resorption of bone most prominently at the phalanges?

A

osteitis fibrosa cystica

108
Q

In CKD, which renal osteodystrophy is caused by supresed levels of PTH or aggressive treatment with vit D analogues and has increased risk of fractures and made worse with bisphosphonate therapy?

A

adynamic bone disease

109
Q

In CKD, which renal osteodystrophy is caused by vit D deficiency and has bone pain and fractures?

A

osteomalacia

110
Q

Which CKD is this:

proteinuria, glycosuria, concentrating defect, sterile pyruria with leukocyte casts and papillary necrosis on US

A

tubulointerstitial disease

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