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Renal Flashcards

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1
Q

Renal CC hx/pe

A

Hematuria
Flank pain
Abdominal mass

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2
Q

Hypernatremia path, etiologies, presentation, dx, tx**

A

Usually 2/2 water loss, not Na gain

Hyperaldosteronism: inhibits ADH
Central / nephrogenic DI
Dehydration
Diarrhea

People who don’t drink enough: babies, demented folks

MS changes
Weakness
Doughy skin

Na >145

NS ==> D5W 1/2 NS once euvolemic
NS 1st prevents cerebral edema by normalizing slowly

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3
Q

Hyponatremia path/etiology, presentation, ddx/workup, tx

A

2/2 ADH increase, usually from hypovolemia

MS change
Hyporeflexia
Cramps

Measure serum osmolality:

  • Hypertonic (>295) measure for glucose, mannitol, contrast overload
  • Isotonic (280-295) ==> measure for glucose, lipid, protein, mannitol overload

-Hypotonic (AKI, CKD)
=hypervolemic & UNa cirrhosis, CHF, nephrotic
#euvolemic ==> psychogenic polydypsia, SIADH, hypothyroid, secondary adrenal insufficiency
@hypovolemia & UNa >10 ==> diuretics, primary adrenal insufficiency, RTA, metabolic alkalosis
@hypovolemia & UNa diarrhea, bleeding, vomit, burns

Water restriction: hypervolemia & euvolemia
Normal saline: euvolemia
*unless severe ==> hypertonic saline
*Slowly @ avoid central pontine myelinolysis!!!

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4
Q

Hyperkalemia etiologies**, presentation, dx, tx

A
  • Spurious: hemolyzed blood draw
  • Reduced excretion: renal insufficiency, type IV RTA, drugs: ACE-I, spironolactone/triamterene,amiloride, NSAIDs, trimethoprim*
  • Cellular shift: lysis, rhabdo, exercise, insulin deficiency, acidosis, hyperosmolarity, drugs: beta-blockers, digitalis, succinylcholine

Colic
Areflexia
N/V/weakness

K+ > 5

-Repeat blood draw
-ECG: tall peaked T waves, QRS prolongation, PR prolongation, loss of P waves ==> sine waves ==> V-fib
**If: ECG changes and/or >6.5
1st: Calcium gluconate (stabilizes cardiac membrane)
Then:
bicarb / insulin + glucose / beta-2-agonist [albuterol] (drives K+ into cells)
Kayexalate [sodium polysterene sulfate] (removes K+)
**If no ECG change of K just sodium polysterene sulfate
-Dialysis if above fails

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5
Q

Hypokalemia etiologies, presentation, dx, tx

A
  • Cellular shift: insulin, beta-agonists, alkalosis
  • GI loss: diarrhea, laxative, vomiting
  • Renal loss: type I RTA, hypomagnesemia, mineralcorticoid excess, hyperaldosteronism, bartter’s, gittleman’s, drugs: loops/thiazide diuretics, gentamicin, amphotericin
  • Persistent hypomagnesemia (prevents K+ reabsorption)

Weakness
Cramps
Hyporeflexia

K+ < 3.6

IV K+
Mg repletion = essential
(Monitor ECG & K+ closely)

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6
Q

Hypercalcemia etiologies, presentation, dx, tx*

A 
CHIIMPANZEES:
Calcium supplement
*Hyper:  -thyroid & -parathyroid [most common]
Iatrogenic:  thiazides, TPN & Immobility*
Milk-alkali syndrome
Paget's
Adrenal insufficiency & Acromegaly
*Neoplasm
ZE (e.g. MEN-1)
Excess vit A
Excess vit D
Sarcoid & other granulomatous diseases

Stones
Bones: osteopenia & fracture
Groans: anorexia, constipation*
Tones: weakness, fatigue, MS change

Ca++ > 10.2
Order: ionized calcium, albumin, PTH, vitamin D

Immediate: normal saline +/- calcitonin
Long term/malignancy: bisphosphonate (zalendronate etc.)
If no other options: Furosemide ==> increase Ca++ excretion

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7
Q

Hypocalcemia etiology, presentation, dx*, tx

A

PhD-V-CAB-R:
Pancreatitis
Hypoparathyroidism
Hypomagnasemia
DiGeorge (baby in tetany)
Vitamin D deficiency
Blood loss requiring transfusion* (citrate in transfusion binds ionized calcium)
*Rhabdomylosis (calcium precipitates with phosphate release)
*Chronic kidney disease (low 1 alpha hydroxylation of vitamin D)
*Alkalosis (increases albumin affinity for ionized calcium, thus decreasing active ionized form)
*False hypocalcemia 2/2 hypoalbuminemia (i.e. proteinuria) ==> measure ionized only

Cramps
Hyperactive tendon reflexes
Tetany
Parasthesias
Chvostek:  spasm 2/2 facial nerve tap
Trousseau:  carpal spasm 2/2 BP cuff

Ca < 8.5
Order: ionized calcium, albumin, PTH, vitamin D
ECG: prolonged QT
==> if PTH high, consider vitamin D or renal disease
==> if PTH low-normal, consider thyroid or parathyroid or other…

Calcium & Mag repletion

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8
Q

Hypomagnesemia etiologies, presentation, dx, tx

A

Intake: malnutrition (alcoholics!), bowel surgery, TPN
Loss: diuretics, diarrhea, vomiting, hypercalcemia
Other: DKA, pancreatitis

Hyperactive reflex
Tetany
MS change

ECG: prolonged QT or PR

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9
Q

Respiratory acidosis labs & ddx

A

pH 40

Narcotics
Lung disease
Obstruction

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10
Q

Metabolic acidosis labs & ddx

A 
pH < 7.4 & pCO2 8-12 = Na + (Cl + HCO3) 
C-MUDPILES
Chronic renal failure
Methanol
Uremia
DKA
Paraldehyde
INH (isoniazid?)
Lactic acidosis (2/2 shock, CO ingestion) 
Ethylene glycol
Salicylates (aspirin)

Non-gap acidosis:
Diarrhea
RTA
Hyperchloremia

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11
Q

Type 1 RTA path, presentation, dx, tx

A

Inability to excrete H+ @ distal tubule ==> hyperexcretion of Na, Calcium, K, phosphate ==> non-anion gap acidemia, hypovolemia, hypokalemia, nephrolithiasis, nephrocalcinosis
2/2 multiple myeloma, autoimmune, amphotericin B

Renal stones

UpH >6
Hypokalemia
Hyperchloremic
Non-gap acidosis: 8-12, pH <40

Sodium bicarb & phosphate salts

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12
Q

Type 2 RTA path, presentation, dx, tx

A

Inability to reabsorb HCO3- @ proximal tubule ==> K+ & Na+ losses ==> non-gap acidemia

Multiple myeloma
Rickets & osteomalacia result over time
*No stones like type 1 RTA!

Hypokalemia
Hyperchloremia
Non-gap acidosis

Thiazides
*Don’t give bicarb! It will be excreted.
Na+ restriction to increase proximal reabsorption

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13
Q

Type 4 RTA path, presentation, dx*, tx

A

Hypoaldosteronism or tubular resistance to aldosterone (diabetics etc.) ==> decreased Na+ reabsorption & decreased H+ & K+ secretion @ distal tubule ==> HYPERkalemic non-gap metabolic acidosis

Diabetics
Intrinsic renal disease
No stones

Hyperkalemia*
Non-gap acidosis

Mineralcorticoid replacement
Furosemide

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14
Q

Pre-renal AKI path, presentation, dx, tx

A

Hypovolemia, renal artery stenosis, drugs (ACE-i, NSAIDs) ==> prostaglandin efferent arteriole dilation & RAAS efferent arteriole constriction to maintain GFR, thus BUN stays high

Hypovolemia (orthostatic hypotension)

BUN:Cr >20:1
Urine:  hyaline casts
FeNa < 1%
UNa < 20
Urine osmolality > 500

Fluids

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15
Q

Uremia sequelae*

A

Pericarditis ==> pericardial rub

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16
Q

Intrinsic AKI path, presentation, ddx/dx*, tx

A

nephron injury 2/2 ATN, nephritis, embolic, rhabdo, drugs (NSAIDs, aminoglycosides)

Hematuria
Tea-colored urine
Foamy urine

Red casts: glomerulonephritis
White casts/eosinophils: AIN
Granular, muddy brown casts: ATN

BUN:Cr < 20:1, usually 10:1 because intrinsic injury prevents BUN reabsorption (ATN)**
FeNa > 1% (ATN)
UNa > 20
Urine osmolality < 300

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17
Q

Postrenal AKI path, presentation, dx, tx

A

Outflow obstruction 2/2 prostate disease, malignancy, stones

Distention
Bladder tenderness

White casts

Catheter
Ultrasound

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18
Q

Dialysis indications

A 
AEIOU
Acidosis
Electrolyte abnormalities
Ingestion
Overload
Uremia (pericarditis, encephalopathy, etc.)
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19
Q

CKD path, presentation, dx*, tx

A

> 3 months of GFR < 60
2/2 HTN, diabetes, nephritis, polycystic kidney disease

Uremia: malaise, anorexia, pericarditis, CNS change

Azotemia (elevated BUN & Cr)
Fluid overload
Metabolic acidosis
Anemia of chronic disease (2/2 decreased epo)
Hypocalcemia (2/2 decrease 1 alpha hydroxylation of vitamin D)
Hyperphosphatemia

Fluid restriction
ACE-i / ARBs
Epo analogs etc.

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20
Q

Polycystic kidney disease path, association

A

Bilateral cysts in kidney, spleen, liver, pancreas
Adult-onset: autosomal dominant (30-ish)*
Youth-onset: autosomal recessive

*Cerebral aneurysm!!!

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21
Q

Goodpasture’s path, presentation, dx*, tx

A

Cytotoxic antibody against GBM ==> rapidly progressing

Young men
Hematuria w/ dysmorphic cells & hemoptysis
No upper respiratory involvement (sinusitis, like Wegener’s)

Light: CRESCENT formation
Immunoflouresence: linear GBM deposits
Sputum: Hemosiderin-filled macrophages

Steroid pulses

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22
Q

Nephritic syndrome general path, presentation*

A

Inflammatory infiltration @ endothelial or mesangial areas ==> “tram tracking” 2/2 endothelial proliferation

PHAROH
Proteinuria (mild)
Hematuria (frank)
Azotemia
RBC casts
Oliguria
Hypertension
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23
Q

Nephritic syndrome ddx

A 
Post-infectious glomerulonephritis
IgA nephropathy / Berger's
Wegener's
Goodpasture's
Alport's
SLE nephritis
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24
Q

Post-infectious glomerulonephritis path, presentation, dx, tx

A

2-6 weeks post ANY infection (usually group A beta-hemolytic strep) ==> C3 complement deposition (?)

PHAROH

Low C3*
ASO elevation
RBC casts
Light:  hypercellular, lumpy bumpy
EM:  IC humps
Immuno:  granular* antibody deposition in GBM

Diuretics ==> self-resolving

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25
IgA nephropathy name, path, presentation, dx*, tx
Berger's* 2/2 GI or respiratory infection or Henoch-Schonlen purpura Young male w/ PHAROH Usually 2/2 URI or gastroenteritis IgA deposits Normal C3 Corticosteroids ==> can progress to ESRD
26
Nephrotic syndrome general path, presentation, risks*, dx*, tx
Non-inflammatory. Immune complex deposits occur @ sub-epithelial space, out of reach of circulating inflammatory cells ``` Edema Foamy urine (lipids + protein) ``` HYPERCOAGULABLE, esp. renal vein thrombosis* Atherosclerosis 2/2 hyperlipidemia* Strep pneumo infection ``` Proteinuria > 3.5 g/day Hypoalbumenemia Hyperlipidemia Relatively normal Cr Renal biopsy ``` Protein & salt restriction ACE-i (decrease proteinuria) Pneumo 23 vaccine
27
Minimal change disease presentation*, dx*, tx
Children, Hodgkins**, thrombotic events ``` Nephrotic >3g/day protein in urine Edema Hypoalbuminemia Light microscope: normal EM: fusion of foot processes ``` Steroids ==> resolves
28
Focal segmental glomerulosclerosis presentation*, dx, tx
Blacks, HIV, drug users, obese ``` Nephrotic >3g/day protein in urine Edema Hypoalbuminemia Microscopic hematuria Light microscope: tuft sclerosis & foot process fusion ``` Steroids
29
Membranous nephropathy other names, presentation*, dx, tx
Membranous glomerulonephritis White adults Most commonly associated with any malignancy other than minimal change w/ Hodgkins** Nephrotic >3g/day protein in urine Edema, hypoalbuminemia EM: Spike & dome deposition of C3 & IgG Steroids
30
Lupus nephritis presentation, dx, tx
Lupus Nephrotic & nephritic Mesangial proliferation Subendothelial & subepithelial complex deposits Steroids
31
Renal amyloidosis path*, dx*, tx
Plasma cell (multiple myeloma) or inflammatory (2/2 RA, TB etc.) Nodular glomerulosclerosis Apple-green amyloid deposits on Congo red stain under polarized light* Prednisone
32
Membranoproliferative nephropathy path*/dx/tx | ...is this the same as membranous glomerulonephritis above??
Multiple types (?) IgG against C3 convertase causes C3 deposition in GBM HCV, SLE "Tram-tracking": double-layered BM Low C3 Steroids
33
Kidney stone presentation, general dx, general dx*, general tx... ddx w/ tx*
Intense flank pain radiating to genitals Alkaline urine (except uric acid stones) CT: gold standard bc some stones radiolucent *Ultrasound: pregnant & children ``` Analgesia & fluid if 5mm 24 hour u/a if repeated event ------------------------ Calcium oxalate: -most common; idiopathic, hyperparathyroidism -radiopaque, alkaline urine -envelope shaped* -hydration, thiazides to decrease urine Ca+ excretion*, decrease Na+ intake*, normal to high calcium intake, decreased protein & oxalate* ``` Struvite (Mg-PO4) - Urease-producing Proteus - radiopaque, alkaline urine, STAGHORN - surgical removal Uric acid - gout etc. - RADIOLUCENT, acidic urine - K+bicarb or K+citrate alkalization of urine* Cystine - AA transport defect - radiopaque, hexagonal crystals, +cyanide nitroprusside test - hydration
34
Polycystic kidney presentation, dx, tx
Pain, hematuria Adult onset about 30 Palpable kidney Ultrasound or CT HTN control ==> dialysis ==> transplant
35
Hydronephrosis path, presentation, dx, tx*
Dilation of renal calyces 2/2 obstruction, often BPH ==> progresses to renal failure ``` Asymptomatic Pain Decreased urine output UTI hx BPH hx Hypertension, sepsis ``` Cr bump Ultrasound or CT showing dilation of calyces Surgery and/or catheter placement
36
Vesicoureteral reflux path, hx, dx, tx
Reflux of bladder urine backward ==> can progress to hydronephrosis & calyx damage UTIs Voiding cystourethrogram (especially if young child presenting with UTI) Grade 1-2: no dilation Grade 3-4: ureteral & pelvic dilation Prophylactic TMP-SMX until resolved Surgery if severe
37
Cryptorchidism path, risk, hx, dx, tx
Undescended testicle x1 or x2 Testicular cancer Low birth weight, other syndromes Can't pull into scrotal sac Orchioplexy
38
Hydrocele path, hx, pe, dx, tx*
Failure to close processus vaginalis ==> abdominal fluid leaks into scrutum Painless Transilluminating balls *If persisting beyond 12 months, close to reduce hernia risk
39
Varicocele path, hx, pe*, dx, tx
Dilated pampiniform plexus Dull aching pain Worsened with valsalva* Bag of worms in scrotum U/S Surgery if big or symptomatic
40
Epididymitis path/hx/pe/dx/tx
Epididymis infection usually 2/2 STD Tender, relieved by lifting (+ Prehn sign) UA, culture U/S: increased flow to testes Abx
41
Testicular torsion path/hx/pe/dx/tx
Torsion of testes Intense pain, not relieved by lifting (- Prehn's) U/S: decreased flow to testes Surgery
42
Erectile dysfunction presentation, dx*, tx*
DM Atherosclerosis HTN Meds: beta-blockers, SSRIs *Nocturnal or morning wood & situational dependence = psychological Check for hypogonadism: prolactin, testosterone, gonadotropin Check anal tone Sildinafil etc.
43
BPH path, dx*, tx
Estrogen-sensitive enlargement of central zone ``` Digital rectal: uniformly smooth, firm + UA & culture: r/o hematuria, UTI + Creatinine: r/o obstruction ==> if blood, do biopsy! ==> if obstructed, to renal ultrasound ``` Alpha-blocker (terazosin) to relax prostate 5-alpha-reductase inhibitor (finasteride) to reduce dihydrotestosterone Surgery if severe
44
Prostate cancer presentation w/ cord met warning signs*,
``` Urinary retention Back pain Constitutional Regional lymphadenopathy *Hyperreflexia, LE weakness, incontinence ``` DRE with asymmetric nodule Usually non-tender (tender = prostatitis) *Elevated PSA ==> biopsy + CXR + bone scan Controversial...
45
Prostate routine screening
Yearly DRA after 50 years old
46
Hematuria ddx*
``` I PEE RBCSx2 Infection Polycystic kidney disease External trauma (urethra damage = blood early void)* Exercise Renal glomerular disease BPH Cancer (bladder > renal)* (bladder = blood/clot @ end void)* Stones Sickle cell trait: painless hematuria ```
47
Bladder cancer presentation, dx, tx
``` Smoking Schistosomiasis Analine dye Hematuria Urinary frequency/urgency ``` Biopsy Chemo unless diffuse ==> cystectomy
48
Renal cell carcinoma path*, presentation*, dx, tx
Adenocarcinoma of tubular epithelium ==> spreads to IVC, lung, bone ``` Hematuria Flank pain Fever Palpable kidney Anemia L-sided varicocele (L gonadal blockage before draining into L renal vein whereas R gonadal drains into IVC) ==> unresolving when recumbent ``` Ultrasound or CT Surgery / chemo
49
Testicular cancer presentation*, dx*, tx*
Male 15-34 Painless nodule on testis Ultrasound Tumor markers: beta-hcg and alpha-feto-protein (?) NO BIOPSY: highly malignant and could seed by biopsying Radical orchiectomy without biopsy!
50
Rhabdo labs**
Elevated: CPK, K+ Decreased: Ca++ Urinalysis: blood (2/2 myoglobin) Urine sediment: few RBCs
51
Contrast nephropathy hx, tx*
Patient types: diabetics, baseline Cr > 1.5 Aggressive hydration Non-ionic contrast Acetylcysteine
52
Simple renal cyst dx*, tx
CT: symmetric, non-loculated, non-enhancing No treatment
53
Diabetes insipidus path*, presentation*, dx**, tx*
Central: decreased ADH production 2/2 trauma, infection, tumor, ischemia (Sheehan's) -------- Nephrogenic: ADH insensitivity 2/2 hypercalcemia, hypokalemia, meds (lithium, amphotericin, foscarnet, cidofivir, demecocycline) Polydipsia Polyuria* ==> ddx: DI, primary/psychogenic polydipsia, DM Euvolemic hypernatremia Decreased urine osmolality (dilute urine) Water deprivation test: if urine osmolality increases significantly ==> primary polydipsia, if not, central vs nephrogenic DI ADH analog test (arginine vasopressin or desmopressin DDAVP) ==> if urine osmolality increases ==> central DI Salt restriction Remove offending agent DDAVP if central
54
Winter's formula purpose & formula*
Testing appropriate respiratory compensation to metabolic acidosis pCO2 = 1.5[HCO3] + 8
55
UTI dx, tx**
Uncomplicated: -healthy patients w/ dysuria ++ dipstick: +esterase (pyuria) & +nitrite (Enterobacteriaceae coli) ==> TMP/SMX, nitrofurantoin, or fosfomycin Complicated: -comorbidities, pregnant, catheter -requires dipstick & culture ==> floroquinolone or ceftriaxone
56
Cholesterol embolization presentation*, dx
Recent vascular procedure Blue, mottled LE skin Livedo reticularis Renal failure Urine: WBC
57
Most common cause of death in dialysis patients*
Cardiac
58
Early post-op renal transplant dysfunction ddx*, dx, tx*
Acute rejection ==> lymphocytic infiltration ==> IV steroids Cyclosporine toxicity ==> measure levels Ureteral obstruction ATN
59
Aspirin ingestion dx*
Mixed anion gap metabolic acidosis + respiratory alkalosis (2/2 tachypnea)
60
Ethylene glycol ingestion dx
Anion gap metabolic acidosis Calcium renal stones (envelope shaped)
61
CO inhalation acid-base path*
CO displaces O2 from Hb & shifts unloading curve such that O2 doesn't unload ==> anaerobic metabolism ==> lactic acidosis
62
Renal vein thrombosis hx/pe
Nephrotic syndrome Abrupt onset fever, abdominal pain, hematuria
63
Allergic interstitial nephritis (AIN) presentation*, dx, tx
Arthralgia Rash Renal failure Drugs: sulfonamide, TMP, penicillin, cephalosporin, rifampin, allopurinol, NSAIDs, diuretics, captopril Renal failure (Cr bump) WBC casts Urine eos
64
Prostatitis presentation*, dx, tx
UTI: dysuria +pronounced systemic symptoms: fever, chills "Boggy, tender" prostate Dipstick + mid-stream urine culture Only suprapubic catheter if necessary; AVOID catheter TMP/SMX or floroquinlone 4-6 weeks
65
Metabolic alkalosis compensation formula use & formula*
For metabolic alkalosis to determine if respiratory compensation is correct PaCO2 = (0.9 x Bicarb) + 16 +/-2
66
Hyponatremia ddx workup** | Reconcile this with above entries??
Hyperosmolar > 290 serum osmolality ==> renal failure or diabetes Normal or hypoosmolar < 280 Urine Osmolality < 100 ==> primary polydipsia or beer potomania (malnutrition) Urine Na > 25 ==> hypovolemia, CHF, cirrhosis Urine Na < 25 ==> SIADH, adrenal insufficiency, hypothyroid
67
Acute tubular necrosis hx, dx*
Hypovolemia Muddy brown cast FeNa > 2% UNa > 20
68
Urine casts & correlating diagnoses**
``` RBC: glomerulonephritis Fatty: nephrotic WBC: AIN & pyelonephritis Muddy brown: ATN Broad/waxy: chronic renal failure ```
69
Vomiting acid-base pathology*
Loss of HCl & KCl in vomit HCO3- absorbed for each H+ vomited RAAS tries to restore volume but reabsorbs HCO3 H+ exits cell to reverse alkalosis, K+ enters ==> hypochloremic hypokalemic metabolic alkalosis
70
Renal artery stenosis path, presentation**, dx*, tx
2/2 to fibromuscular dysplasia in young or atherosclerosis in old Renal bruit HTN Headache Hypokalemia STENTING
71
Anemia 2/2 ESRD dx, tx*
Normocytic, normochromic anemia 2/2 EPO insuffiency Trial Fe supplement first Once Hb < 10 or Hct < 30 ==> EPO
72
EPO supplementation s/e*
Worsened HTN (common) Headache Flu-like symptoms
73
Post-op oliguria tx*
Bladder scan ==> catheterize if obstruction ==> assess for intrinsic or pre-renal if not
74
ESRD tx*
Living related donor > transplant for survival
75
Pyelonephritis path*, presentation*, dx*, tx*
Gram-negative, usually Fever, chills CVA tenderness Dipstick & culture required** *ultrasound to assess for obstruction or abscess IF empiric therapy fails Start empiric therapy, oral or IV: floroquinolone or ceftriaxone*
76
Dialysis bleeding issue**/tx
Uremia ==> causes platelet dysfunction ==> only increased bleeding time DDAVP
77
Diarrhea acid-base path*
Loss of HCO3- in diarrhea ==> non-anion gap, hypernatremic metabolic acidosis
78
Bartter & gittleman dx
Hypokalemic metabolic acidosis
79
Cryoglobulinemia hx/pe/dx*
Arthralgia HCV Palpable purpura Hepatosplenomegaly Glomerulonephritis
80
Glomerular structure
Afferent arteriole ==> endothelium ==> GBM ==> visceral epithelial podocytes ==> urinary space
81
Alport's syndrome path, presentation, dx, tx
Hereditary glomerulonephritis Young boys Intermittent hematuria Sensineural deafness & vision problems Progresses to renal failure EM: GBM "splitting" Transplant
82
Rapidly progressive glomerulonephritis (RPGN) path, dx*
2/2 goodpasture's, wegener's, microscopic polyangiitis Light: CRESCENT formation
83
Analgesic nephropathy path, presentation*, dx*
Renal ischemia 2/2 NSAIDs ==> papillary necrosis Hematuria Non-dysmorphic reds (glomerular injury causes dysmorphic reds)

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