Nephrology Flashcards
1
Q
Approach to NAGMA
A
1) Urine AG –> Negative = GI (ileal conduit, diarrhea) or dilutional after fluids; Positive = Renal
2) If renal, look at K-> Low = Type 1/2 RTA, High = Type 4
3) If Low K: Look at associated features
a) Type 1: ++ low K, Bicarb <10, Urine PH >5.5
- Clues: Stones, hypercalciuria
- Assoc diseases: Sjogrens, RA, SLE
b) Type 2: + low K, Bicarb 10-20, Urine pH variable
- Clues: Glucosuria, hypoPO4, hypouricemia, low vitD
- Assoc Dz: Fanconi’s, MM, Tenofovir, Acetazolamide
Tx for both types: NaHCO3, K citrate (if K low)
4) If High K = Type 4 RTA - med review/ROS to ID cause
- Drugs: MRA, RAAS blockade, heparin, calcineurin inhib
- Diseases: DM, Adrenal Insufficiency
- Tx: low BP = florinef; HTN = thiazide
2
Q
Hyponatremia - calculating volume to give
A
[(0.5 or 0.6 x Weight) x (target Na - current Na) ] / [Na infusate]
*Na infusate: RL = 130, NS= 154, 3% 513
3
Q
Hypernatremia - free water deficit
A
[(0.5 or 0.6 x Weight) x (current Na - target Na)] / (Target Na)
4
Q
HypoK Approach
A
1) Urine K: If <20 = GI (villous adenoma, diarrhea, laxatives).
2) If >20 = renal: Acidotic = RTA 1/2
Alkalotic –> look @ BP
a) Low/Normal BP: Look @ UCl. If >20 = diuretic, Barters, Gittlemans. If <20 = past diuretic, vomiting.
b) High BP: Look at renin and aldo.
Both high = RAS/reninoma.
Both low = steroid/cushings/licorice, Liddle’s.
High aldo and low renin = Conn’s.
5
Q
Manifestations of Glomerulonephritis
A
PHAROH Proteinuria (<3g/day) Hypertension AKI Red cell casts/dysmorphia Oliguria Hematuria
6
Q
Manifestations of Nephrotic Syndrome
A
Hypoalbuminemia
Edema
HyperLipidemia
Proteinuria >3.5g/24 hr
7
Q
Differential Diagnosis Glomerulonephritis
A
Pauci-Immune:
- ANCA associated SVV (GPA, eGPA, MPA)
- ANCA negative SVV
- Anti-GBM Disease
Immune Complex Mediated
- IgA nephropathy
- Post strep GN
- SLE/APLA
- IE
- MPGN (Hep C, Hep B, Cryo, aHUS, Complement dysregulation, monoclonal gammopathies)
8
Q
Normal C3 and C4 GN
-what it’s assoc’d w/ and treatment
A
IgA Nephropathy (assoc’d w/ celiac, HIV, cirrhosis) - RPGN OR nephrotic syndrome; SYN-pharyngitic
Tx: ACEi/ARB if >0.5g/d (target <500mg/d)
-Target BP <120
-Consider steroids x6mo if high risk progresive CKD (ie >0.75-1g proteinuria despite OMT x90d)
9
Q
Low C3 and Normal C4 GN
-presentation, tests
A
Post-Strep/infectious GN (eg strep throat/cellulitis, abscess, IE)
+anti-DNase B, +ASOT,
-Hematuria, proteinuria, HTN
10
Q
Low C3 and C4 GN
A
Nephritic: Class 3/4 SLE (steroids, cyclo/mmf)
Nephrotic: Class 5 SLE (ACE/ARB, antiHTN, statin)
-progressive dyscn –> renal US r/o thrombus or repeat bx
11
Q
Normal C3 and low C4 GN
A
MPGNs (MC Type 1)
- Infections: Hep C > Hep B
- Autoimmune: Cryoglobulinemia, TMA/HUS, complement dysregulation syndrome
- Haem: Monoclonal gammopathies
12
Q
Treatment of ANCA associated GN
*induction and maintenance
A
Induction: Steroids 1g/d x3d –> 1mg/kg PO pred
RPGN (Cr>354): Cyclophosphamide > ritux unless (young M/F for fertility, frail elderly, relapsed disease; no RPGN)
PLEX if antiGBM overlap, consider if: Cr >500, risk of ESRD, or severe pulmonary hemorrhage
Maintenance phase: Add Aza or Ritux (no maintenance in HD dependent x3mo w/o extrarenal manifestations)
13
Q
Treatment of anti-GBM associated GN
A
Steroids (pulse –> taper)
Cyclophosphamide or ritux
PLEX for all (until titers not detectable)
NO maintenance therapy as low risk recurrence
14
Q
Manifestations of IgA Nephropathy
A
“Synpharyngitic” GN
Spectrum: asymptomatic hematuria, flank pain, RPGN, nephrotic syndrome
If accompanied by systemic dz (=HSP) - purpura + arthritis
15
Q
Indications to biopsy suspected IgA nephropathy
A
Systemic manifestations
Heavy proteinuria
Progressive AKI (not recovering spontaneously)
16
Q
Classes of Lupus Nephritis
A
I/II: Bland sediment, proteinuria <3.5g/day, no AKI
III/IV: GN - AKI, Hypertension, Proteinuria, Hematuria
V: Membranous - nephrotic range proteinuria
17
Q
Treatment Class III/IV SLE Nephritis
A
Induction:
Steroids pulse –> 1mg/kg
MMF or cyclo
Maintenance:
ACEi for proteinuria
Steroid taper
MMF or Aza
18
Q
Treatment Class V SLE Nephritis
A
ACEi/ARB for proteinuria
BP control - target <130/80
HCQ
Immunosuppression only if worsening renal function (consider re-bx 1st to r.o class 3/4)
19
Q
Treatment post-strep GN
A
Supportive care
Diuresis
Biopsy if not resolving spontaneously after 3-4 weeks or requiring dialysis (unusual)
20
Q
Treatment MPGN
A
Treat underlying cause
Consider steroids, CNI, MMF, Cyclo if refractory
21
Q
Differential Diagnosis Nephrotic Syndrome
A
DM Amyloidosis Minimal Change DZ - Primary/Secondary MC = Membranous - Primary/Secondary FSGS - Primary/Secondary - MC in blacks
22
Q
Secondary Causes Minimal Change Disease
A
Malignancy: Hogkin’s Lymphoma, Leukemia
Drugs: COX inhibitors, NSAIDs, Li
Bee stings
23
Q
Secondary Causes Membranous Nephropathy
A
Malignancy: Solid tumors > Haem cancers (CLL)
AI Disease: SLE, Sarcoid
Infection: Hep B > Hep C, Syphillis
Drugs: NSAIDs, Anti-TNF, Gold, Penicillamine
24
Q
Secondary Causes FSGS
A
Infection: HIV (HIVAN - CD4<200), parvo, EBV
Drugs: Pamidronate, heroin, anabolic steroids
Hyperfiltration: Obesity, Solitary kidney, reflux nephropathy
25
Treatment of Nephrotic Syndrome
- ACEi/ARB
- Na restriction and diuretics for edema
- BP control (<130/80)
- Statin for hyperlipidemia
- Look for VTE and treat
- Warfarin full dose ppx if Alb <20 in PRIMARY disease AND any of: BMI>35, NYHA3-4, proteinuria>10g/d, thrombophilia, recent ortho/abdo sx, immobilization), if high risk bleed: ASA 81mg daily
- Treat underlying cause (ie. HAART for HIV, chemo for Ca, drug withdrawal, tx Hep B/C, weight loss)
26
Causes of non-nephrotic range proteinuria (without active urine sediment)
Transient (ie. with fever, exercise)
Orthostatic
Overflow - pigment (rhabdo, hemolysis), MM
Tubulointerstitial - heavy metals, sarcoid, sjogrens, nsaids
Post-renal
27
Differential Dx Pre-renal AKI
True hypovolemia
Intravascular depletion (CHF, cirrhosis)
NSAIDs (altered renal flow)
28
Causes of ATN
Prolonged/Severe pre-renal state
Drugs: Contrast, ACE, ARB
Pigment: Hemolysis, Rhabdomyolysis, TLS, Myeloma
29
Causes and presentation of AIN
Drugs: PPI, allopurinol, ABX, NSAIDs, diuretics
AI Disease: SLE, Sarcoid, Sjogren's
Infection
+/- fever, rash, hematuria, non-nephrotic proteinuria, sterile pyuria, WBC casts or eosinophilia/eosinophuria
30
Sick Day Meds
```
SADMANS
SGLT2s
ACE
Diuretics
Metformin
ARB
NSAIDs
Sulfonylureas
```
31
Treatment of hyperkalemia in CKD
Target K <5
1. K-restricted diet (no oranges, tropical fruit, avocadoes, tomatoes, potatoes, beans, leafy greens, seeds, milk)
2. Diuretics (if producing urine)
3. Avoid NSAIDs, careful use of ACE/ARB/MRA, avoid septra and amiloride
4. K binders eg lokelma aka Na zirconium cyclosilicate (S/E: edema, GI, costs) or Patiromer (binds colonic K)
5. Dialysis
32
Treatment of metabolic acidosis in CKD
Target normal HCO3 >22
1. Baking soda or Na Bicarb tabs (slows GFR decline)
2. Dialysis
33
Treatment of anemia in CKD
Target Hgb 100-115, Ferritin >500, Tsat >30%
1. Ensure Iron replete - if ferritin <=500 or Tsat < =30% give iron (IV > oral)
2. Once iron replete, if Hgb still <100, start EPO* (Hgb >115 risk of stroke, CAD, HTN)
*caution if active Ca, previous stroke, or uncontrolled BP
34
PTH/Ca/PO4 targets in CKD
PTH 2-9 x ULN if on HD, pre-HD target unknown
| PO4 and Ca toward normal range
35
Treatment of hyperphosphatemia in CKD
Low PO4 diet (cheese, milk, deli meat, liver, shellfish)
Oral PO4 binders with meals
- Non-Ca containing (sevalamer, lanthanum) preferred but costly
- Ca containing: Tums, Ca Carbonate (avoid in hyperCa, adynamic bone disease, heavy vasc calcifications)
36
Treatment of hypocalcemia in CKD
Calcitriol (1,25-OH VitD) - cannot use if hyperPO4
37
Treatment of CKD-MB
Treat hypocalcemia (Calcitriol)
Treat hyperphosphatemia (tums, sevalamer, lanthanum)
Target PTH 2-9xULN in HD pt, if PTH > 9x ULN despite above:
- Cinecalcet (activates Ca receptor to shut off PTH)
- Parathyroidectomy
- Calcitriol (if PO4 and Ca not high)
Can use bisphosphonate down to eGFR 30 (risedronate, pamidronate) or denosumab (risk hypoCa), but NOT for IHD patients
38
Indications for hypertonic Saline
GCS <=8
Seizures
*Target 4-5 correction ASAP
39
Causes hyponatremia
1) Pseudo: High Tg, High paraprotein (eg MM), icteric sample (eg obstructive jaundice)
2) Hypertonic: High glucose, mannitol
3) Hypotonic - most
a) Hypovolemic (Una <20) - give fluids
b) Hypervolemic (UNa <20) - fluid restrict, diurese
c) Euvolemic (UNa >20)
- Approp ADH (UOsm=SOsm <100-300): Psychogenic polydispsia, beer potomania , tea/toast
- SIADH (UOsm >>SOsm): Pain, NV, hypoT4, AI, lung or brain disorders, SCLC, drugs (carbamazepine, SSRI, TCA, MDMA, thiazides)
40
Rate of Na correction in chronic Na disorders
HypoNa: 4-8/day
HyperNa: 8-12/day
41
Positive Water deprivation test to diagnose DI
Serum Na >=145 and Plasma Osm >=295
| Uosm remains <250-300
42
Causes of central DI
Post pituitary resection
Pituitary infarct or bleed
Trauma
43
Barter's Electrolyte Profile
"Like lasix"
Can cause low serum Na/K/Cl/Ca
High urine Na, K, Cl, Ca
44
Gittleman's Electrolyte Profile
"Like thiazide"
Can cause low serum Na/K/Cl, normal or high Ca
High urine Na/K/Cl, normal or low urine Ca
45
BP Cutoffs by various approaches
Automated in office: >=135/85 (130/80 for DM)
Office BP monitor: >=140/90
At home ABPM: >=135/85 daytime, >=130/80 24hr
HBPM: >=135/85
2nd AOBP visit >140/90 w/ macrovascular dz, CKD, DM2
3rd AOBP visit mean BP of all visits >160/90
4th AOBP visit mean BP of all visits >140/90
46
Definition Hypertensive Urgency
BP>=180/110 with no end organ dysfunction
47
Treatment Isolated Systolic HTN without compelling indications
1st line: ARB, CCB, Thiazide
2nd line: Combination of above
3rd line: ACEi, Alpha-blocker, non-DHP CCBs
48
Treatment diastolic (+/- systolic) HTN without compelling indications
1st line: ACE/ARB, CCB, Thiazide
2nd line: combo above [(ACE or ARB) + (CCB or thiazide)]
3rd line: Add on other drug above (CCB if on thiazide or vice versa)
4th line: Alpha blocker
49
Treatment HTN in patient with DM
If ACR >2, eGFR <60, CV dz, or CV RF:
1st line: ACE or ARB
2nd line: Add CCB (thiazide appropriate if hyperK)
3rd line: Add thiazide
If no significant other vascular RFs/renal complications:
1st line: ACE, ARB, CCB, Thiazide
2nd line: Add 2nd 1st line agent (CCB>Thiazide)
3rd line: Add other first line agent
50
Treatment HTN in patient with non-diabetic CKD (ACR >30, protein >150mg/24 hr)
1st line: ACE or ARB
2nd: Thiazide (or loop if vol overload)
3rd: Add CCB
51
Treatment of Chronic HTN Post Stroke/TIA
1st line: ACE, ARB, Thiazide
2nd line: Combine above (ACE/ARB + Thiazide)
w/i 72h of ischemic stroke:
target <185/110 before tpa and <185/105 after
target 15-25% reduction over 24h if no tpa, tx only if >220/120
long term target <140/90 in few days to 1 week
Hemorrhagic: target <140-160 for 1st 24-48h, long term target <130/80
52
Treatment in HTN in patient with CAD +/- angina/MI
CAD alone: ACE/ARB first, then BB or CCB >thiazide
Stable angina: BB + CCB
MI: ACE + BB or CCB
Avoid short acting nifedipine. Caution if DBP <60
53
Treatment of HTN post ACS (within 1 year)
1st line: ACE/ARB, BB
| 2nd line: Add long acting CCB (avoid non-DHP CCB)
54
Treatment of HTN in patient with HFrEF
1st line: ACE/ARB, BB, MRA
2nd line: Hydralazine/ISDN (if ACE/ARB intolerant)
3rd line: Add thiazide +/- DHP-CCB
55
Treatment of HTN in LVH
1st line: ACE, ARB, CCB, Thiazide
2nd line: Combo of above
*avoid vasodilators (hydralazine, minoxidil), BB
56
SPRINT Indications (to target sBP <120)
Age >=75
BP >=130/80 and 1 of:
- Non-diabetic CKD (GFR 20-59, ACR >20 or >500mg/day but <1g/day)
- Clinical or subclinical CVD
- Global 10 year CV risk >=15%
57
SPRINT Exclusions
```
Diabetic
Proteinuria >1g/day
eGFR <20
EF <35%
MI in last 3 months
Past stroke
Institutionalized elderly, frail
Dementia with prognosis <3y
Orthostatic hypotension with SBP <110
Nonadherence
GN, PKD
```
58
BP Targets for HTN Treatment
All CKD (not dialysis/post-transplant): sBP <120
SPRINT candidate: sBP <120
Diabetic <130/80
All others <140/90
PCKD <110
CKD post-transplant: <130/80 (use CCB or ARB)
59
Threshold to initiate BP treatment
```
Hypertensive urgency
SPRINT candidate and >=130/80
Low risk (no end organ or CV RFs) >=160/100
DM >=130/80
CV RFs >=140/90
```
60
Definition resistant HTN
Persistent HTN above target on >=3 drugs at optimal doses (1 should be diuretic if no c/i)
61
Indications to screen for renovascular HTN
2+ of:
- Onset of or worsening HTN at <30 or >55
- >=30% increase Cr after initiation of ACE/ARB
- Abdominal bruit
- Resistant HTN to >=3drugs
- Recurrent pulmonary edema
- Other established atherosclerotic disease, esp in smokers or DLPD
62
Diagnosis Renovascular HTN
CTA, MRA, Doppler, Captopril radioisotope scan
| *NO captopril/CTA if GFR<60
63
Treatment atherosclerotic renovascular HTN
1st line: Medical Tx (ACEi/ARB not C/I, follow Cr/K)
2nd line: Angioplasty & stenting if ANY:
- Resistant HTN (on >=3 drugs)
- Deteriorating renal function
- Acute pulmonary edema
* angioplasty WITHOUT stenting in FMD
64
Treatment renovascular HTN related to FMD
1st line: Angioplasty without stenting
| 2nd line: Surgical revascularization
65
Imaging for confirmed FMD
CTA or MRA from head to pelvis (must include intracranial, neck, abdomen/pelvis)
66
When to suspect FMD
Asymmetric kidney size (>1.5 cm)
Abdominal bruit without atherosclerosis rf
FHx
FMD in another vascular bed
*workup with CTA/MRA
67
Renal Cysts (Bosniak Criteria)
1-2: Simple cysts with thin walls, no/thin septae, no/fine calcifications, no enhancement --> NO FU
2F: 3+ septae or calcifications, no contrast enhancement --> Rpt img q6mo x2 then q1 yr
3: CONTRAST ENHANCING, thick walls, calcification, multiple septae --> partial nephrectomy
4: As per 3 but with solid enhancing component --> partial nephrectomy
If 3/4 but poor surgical candidate, percut bx then thermal ablation
68
Treatment Polycystic Kidney Disease (PCKD)
++Fluids
Na restriction <2g/day
Target BP <=110/75 if <50 years old with eGFR <60 without major CV comorbidities
Tolvaptan therapy for some
69
Calcium Oxalate Stones Disease Associations
Crohn's Disease
Ileal disease (oxalauria)
PCKD
70
Calcium phosphate kidney stones - disease associations
Type 1 RTA
| HyperPTH
71
Uric Acid stones disease associations
Gout
Haem malignancies
TLS
PCKD
only type radiolucent
72
Struvite stones disease associations
UTIs (proteus, Klebsiella = struvite splitting organisms)
73
Treatment of nephrolithiasis
Increase fluid intake >2g/day
For Ca oxalate: Decrease Na and meat intake, decrease VitC, thiazides (not if hyperCa)
For Ca phosph: Decrease Na and meat intake, thiazides
For uric acid: Allopurinol, urine alkalization with K citrate
For struvite: Treat UTI
74
Prevention of CIN (Contrast induced Nephropathy)
Hold ACE/ARB, NSAIDs, Metformin, diuretics
| Ensure euvolemia with isotonic fluids pre/post
75
Manifestations cholesterol emboli syndrome post cath
```
High urine eos/serum eos
High ESR
Low C3/C4
Normal urine micro
Livedo, blue toes
```
76
Causes of AKI in renal transplant and manifestations
1) REJECTION (bx to dx): proteinuria, hematuria, pyuria, AKI, HTN, no fever/pain over graft, oligouric
2) Meds (Tac, Cyclo): bland urine
3) Infection (bacterial, BK virus late): pyuria, mild proteinuria or hematuria, tender over graft if pyelo
4) Renal A/V thrombosis (early): req urgent US
5) Recurrence of primary DZ
6) Post-transplant lymphoproliferative disorder (PTLD) - late
7) Hydro
77
Indications to do renal biopsy
Nephrotic Syndrome
Nephritic syndrome (except post-strep GN)
Progressive CKD without cause
78
(relative) Contra-indications to renal biopsy
```
Uncontrolled Severe HTN
Solitary Kidney
Hydronephrosis
Active pyelonephritis
Bleeding disorder or on antiplatelet (hold 5-7 days )
Pregnancy
Plts <80-100
Small hyperechoic kidneys <9cm
```
79
FeNa Calculation and interpretation
FeNa% = 100 * [(SCr x Una)/(UCr x SNa)]
Interpretation:
<1% = pre-renal
>1% = renal
80
Fluid administration in post-obstructive diuresis
1) Fluid restrict until euvolemic
| 2) Once euvolemic: Replace 75% urinary losses with 1/2 NS until diuresis resolves
81
Causes of nephrogenic DI
- Meds: Li, Aminoglycosides, Rifampin, Cisplatin, Colchicine, Lasix, Clozapine
- Electrolytes: HyperCa, HypoK
- Post-obstructive
- Infiltrative disease: MM, Amyloid, Sjogrens, Sarcoid
- Sickle Cell Disease
82
Management of Cr rise with ACEi initiation
1) If rise >=50%: Stop ACE, screen for renovascular HTN
2) If rise >=30 but <50%: Reduce dose by 50%, reassess in 2-3 weeks. If still >=30%, stop.
3) If rise <30% - continue current dose
83
HTN followup
No HTN or organ dmg - yearly
HTN w/ exercise/lifestyle mx - q3-6mo (1-2mo if higher BP)
HTN on meds q1-2mo until at target, then q3-6mo
84
Secondary HTN causes
```
Renovascular
Endocrine: Pheo, Thyroid, Cushing
Primary Hyperaldo
OSA
Coarctation of aorta
```
85
Lifestyle Tx for HTN
```
Exercise: 30-60min, 4-7d/wk, ~150min/wk
Weight: BMI 18.5-24.9, waist <102cm M, <88F to PREVENT HTN
EtOH: abstain or <2/d to PREVENT
DASH diet
Salt <5g/d (<2g sodium, ie 87mmol Na)
Stress reduction
Smoking cessation
NO NEED for Ca or Mg
```
86
anti-HTN meds caution
No BB as 1st line if age>60
NonDHP CCB + BB = risk of brady
No ACEi as monotherapy in black w/o other indication
No alpha blocker as 1st line
87
ANCA associations
c-ANCA/PR3: MPA, GPA
| p-ANCA/MPO: MPA, eGPA
88
Nephritic/Nephrotic Lifestyle
- Smoking cessation
- Na restrict
- Prot restrict if nephrotic range proteinuria (0.8-1.0g/kg/d)
- BP <120 if no orthostasis/frailty
- Vaccines: pneumococcal, influenza, shingrix, COVID, hep B
- Pre-immunosuppresant: TBST, Hep serology, HIV, strongy
- On Tx: contraception, gonadal protection, PJPp for steroids/ritux/cyclo, bone health
89
CKD definition
>3mo of abnormal kdiney structure/fcn:
- Albuminuria ACR>3mg/mmol (>30 = severe)
- AbN urine sediment
- Lyte abN 2/2 tubular d/o
- Structural abN on imaging
- Kidney Tx hx
- GFR <60mL/min/1.73m2
```
Stage 1 >90,
Stage 2 60-89,
Stage 3 30-60,
Stage 4 15-30,
Stage 5=5<15
```
90
Statins in CKD
Target LDL<2 or apoB <0.8, o nonHDL <2.6 if:
- >50yo, stage 3-5 (ie GFR<60) or ACR >3mg/mmol, but NOT on HD
- DO not start in patients on HD (continue if alrdy on statin)
91
Uremic Sx on Hx
- Anorexia, pruritus, N/V, wt/appetite loss
- Metallic taste in mouth
- Pericarditis (without diffuse ST elevation)
- Peripheral neuropathy
- Bleeding (plt dysfcn)
- CNS (mental status change, sz, mood d/o)
- Amenorrhea, decreased libido, ED
- Nocturia, RLS
92
Indications for IHD
```
AEIOU
Acidosis
Electrolyte problems (hyperK)
Intox (methanol, ethylene glycol, Li, ASA)
Overload, vol
Uremia (pericarditis, encephalopathy/sz)
```
93
DM CKD Screening, Tx, FU
T1DM - screen 5y after dx
T2DM - screen at dx then yearly: eGFR <60 or ACR>2 in 2/3 samples >3mo = CKD
Tx:
- Maximally tolerated ACEi/ARB (up to 30% Cr increase)
- Start SGLT2 if eGFR>30, can continue if GFR drops unless adverse events
- Nonpharm: Na<2g/d, Prot <0.8g/kg/d, Exercise 150min/wk
FU: check Cr/K at baseline then 1-2 weeks after starting/titrating or during illness
94
Anion Gap
Na-Cl-HCO3
| For every albumin drop of 10, add 2.5 to AG
95
Delta Delta
12-AG: 24-bicarb
Delta AG > Delta HCO3 - Concurrent metabolic alk (HCO3 higher than expected) with AGMA
Delta AG = Delta HCO3 - Pure AGMA
Delta AG < Delta HCO3 - Concurrent nonAGMA with AGMA
96
Osmolar Gap
(2xNa + Gluc + BUN) - measured serum osm
Normal = 10
With high AG: methanol, ethylene glycol, paraldehyde, EtOH Ketoacidosis
WIth normal AG: EtOH, Isopropyl alcohol, mannitol, sorbitol, EARLY toxic alcohol
97
Urine AG
Na + K - Cl
| NeGUTive = the gut
98
RF for ODS
HypoK, malnutrition, alcoholism, liver dz, low starting Na
| Max correction 4-6 if any RF, otherwise 6-8
99
HyperK causes
1) Intake: supplements, transfusions
2) Decreased Excretion: CKD, vol deplete, drugs (ACEi, ARB, NSAID, MRA), hypoaldo (RTA 4, adrenal insuff)
3) Shifting: lysis (rhabdo, burns, TLS), metabolic (acidosis, low insulin), hyper osmolar (glucose, mannitol), familial hyperK periodic paralysis
4) Factitious: hypercellular blood (eg heme malignancies --> leuko/thrombocytosis, do VBG/ABG), hemolyzed, fist clenching/tourniquet
100
HyperK/HypoK ECG findings
Hyper: Peaked Ts, flat Ps, prolonged PR, bradyarrhythmia, prolonged QRS
Hypo: TWI, STD, U wave
101
HypoK causes
1) Intake
2) Low Mg
3) Shifting:
- Endocrine: insulin, thyrotoxic periodic paralysis
- Stress, catecholamines
- Metabolic alk
- EtOH w/d
- Hypothermia
- Drugs (amphetamines, antipsychotics)
102
Solid Renal Mass WU
CT/MRI
<1cm = active surveillance
>=1cm = likely cancer --> partial nephrectomy if life expectancy >5y (if <5y or not fit for surgery: biopsy then abalate)
103
PCKD Sx
HTN, abdo pain (cyst rupture), hematuria, proteinuria
Stones (uric acid, Ca oxalate)
UTI - 4 weeks abx if infected cyst
Erythrocytosis (increased EPO)
Extra-renal: liver cysts, colonic diverticuli, cerebral aneurysm, pancreatic cysts, MVP and aortic regurg
104
PCKD Dx and WU
Dx if positive family history and:
- Age 15-39 >2 cysts total or
- Age 40-59>1 per kidney
*yearly US with baseline MRI/CT for tot kidney vol
105
Who to Screen Hyperaldo
HTN +1 of:
- Unexplained spontaneous hypoK <3.5 or diuretic related hypoK <3.0
- HTN resistant to >=3 drugs
- Incidental adrenal adenoma and HTN
106
How to Screen Hyperaldo
Screen with: plasma aldo and plasma renin activity (or concentration)*
*OCP causes false positive
Hold MRA/K sparing/K wasting diuretics 4weeks before test. If non-diagnostic, hold ACE/ARB, BB, DHP-CCB 2 weeks and retest
Alpha blockers, nonDHP CCB, hydralazine OK
107
How to confirm positive hyperaldo screen
- Saline loading test (2L NS over 4h, abN if plasma aldo >280)
- Captopril suppression test
- Plasma aldo:renin ratio >270 w/ plasma aldo >440pmol/L
108
Who to screen Pheo
- Paroxysmal, labile, severe HTN (>180/110) refractory to tx
- HTN + H/A, palpitation, sweating, flushing
- HTN from BB, MAOi, surgery, anesthesia, micturition
- Incidental adrenal adenoma
- Hereditary: MEN2A/2B, NF-T1, Von hippel lindau
109
How to screen pheo
-24h urine tot metanephrines and catecholamines
- Consider plasma free metanephrines and free normetanephrines
- NOT urinary VMA
