Renal

Question 1

Specific treatments for anion-gap causes of RTA- MUDPILES?

Answer 1

Methanol: Fomepizole; Uremia: Dialysis; DKA: Insulin, fluids; Paraldehyde; Phenformin; Iron, INH: Gl lavage, charcoal (INH); Lactic acidosis; Ethylene glycol: Fomepizole; Salicylates: Alkalinize urine

Question 2

Nongap metabolic acidosis, hypophosphatemia, glycosuria, aminoaciduria, normal blood glucose, pH<5.5; w/ rickets, osteomalacia.

Answer 2

RTA2 - Proximal (Fanconi’s) rx Thiazides, volume depletion to increase reabsorption.

Question 3

Nongap metabolic acidosis, hypokalemia, ca phosphate kidney stones, urine pH>5.5

Answer 3

RTA1 - Distal (H+ secretion defect); rx replace bicarbonate; can be genetic, autoimmune (sjogrens), medication tox

Question 4

Nongap metabolic acidosis, hyperkalemic, hyperchloremia, pH<5.5 (can be a/w obstructive uropathy, CAH)

Answer 4

RTA4 - Hyperkalemia impairs ammoniagenesis, buffering capacity, H+ excretion; rx Furosemide, mineralocorticoid, glucocorticoid

Question 5

RTA 2 etiology?

Answer 5

Defect in proximal tubule HCO3− reabsorption: Hereditary (Fanconi’s or cystinosis), drugs (carbonic anhydrase inhibitors), multiple myeloma, amyloidosis, heavy metal poisoning, vitamin D deficiency

Question 6

RTA 4 etiology?

Answer 6

1 aldosterone deficiency, hyporeninemic hypoaldosteronism (kidney disease, ACEis, NSAIDs), drugs (amiloride, spironolactone, heparin), pseudo­hypoaldosteronism.

Question 7

RTA 1 etiology?

Answer 7

Defect α intercalated cell H+ secretion:Hereditary, cirrhosis, autoimmune disorders (Sjogren’s syndrome, SLE), hypercalciuria, sickle cell disease, drugs (lithium, amphotericin)

Question 8

Indications for acute Dialysis; AEIOU

Answer 8

Acidosis; Electrolyte abnormalities (hyperkalemia sx or >6.5) Ingestions (salicylates, theophylline, methanol, barbiturates, lithium, ethylene glycol); Overload (fluid); Uremic symptoms (pericarditis, encephalopathy, bleeding, nausea, pruritus, myoclonus)

Question 9

Diabetic pt w/ chest pain, significant azotemia, friction rub, ST elevations, absent pulsus paradoxus, pruritis, elevated BUN, dx, rx?

Answer 9

Uremic pericarditis w/o tamponade; emergent dialysis

Question 10

Diabetic w/ H2O depletion, hyperglycemia, post rx w/ insulin p/w flattened T waves, flaccid paralysis, hypercapnia, rhabdomyolysis

Answer 10

Hypokalemia via insulin, aldosterone increase form dehydration (Na in/K out)

Question 11

Hypokalemia resistant to correction, explained via another electrolyte abnormality?

Answer 11

Hypomagnesium

Question 12

Hypernatremia causes­ The 6 D’s

Answer 12

Diuresis; Dehydration; Diabetes insipidus; Docs (iatrogenic); Diarrhea; Disease (eg, kidney, sickle cell)

Question 13

Hyperkalemia rx? C BIG K

Answer 13

Calcium, Bicarb, Insulin, Glucose, Kayexalate

Question 14

Hypercalcemia causes? CHIMPANZEES

Answer 14

Ca supplements; Hyper-thyroid/parathyroidism; Iatrogenic (thiazides)/lmmobility; Milk-alkali sx; Paget’s; Adrenal insufficiency/Acromegaly; Neoplasm; Zollinger-EIIison sx (MEN 1); Excess vit A, D; Sarcoidosis

Question 15

Hypocalcemia w/ Hypoalbuminemia correction?

Answer 15

Each 1 g/dL reduction in albumin, total Ca is lowered by 0.8 mg/dL, but not ionized Ca and thus will not cause clinical hypocalcemia.

Question 16

Hereditary defect of renal PCT and intestinal amino acid transporter for Cysteine, Ornithine, Lysine, and Arginine (COLA); dx, rx?

Answer 16

Cystinuria: Precipitation of hexagonal cystine stones. dx- Urinary cyanide-nitroprusside; Rx: urinary alkalinization (potassium citrate, acetazolamide), chelating agents, hydration.

Question 17

Nephritic dz sx? PHAROH

Answer 17

Proteinuria, Hematuria, Azotemia, RBC casts, Oliguia, HTN

Question 18

Water retention, Euvolemic hyponatremia, urinary Na excretion Una>20, Urine osm> 300 serum <270, cerebral edema, seizures

Answer 18

SIADH, decreased aldosterone -> hyponatremia, Rx fluid restriction, IV hypertonic saline, conivaptan, tolvaptan, demeclocycline.

Question 19

Pt w/ renal artery stenosis p/w decreased urine output, BUN:Cr>20, FENa<1%, new med, iatragenic?

Answer 19

ACEi induced prerenal failure (decreasing GFR by dilating afferent arteriole, hypoperfusion of the kidney)

Question 20

FENa calculated?

Answer 20

(urine sodium × plasma creatinine)/(plasma sodium × urine creatinine) × 100

Question 21

Indications for Emergent Dialysis

Answer 21

refractory K>6.5, pH<7.1, Uremia, refractory fluid overload, BUN>100, dialyzable toxic o/d

Question 22

FENa%? Prerenal Azotemia vs. Tubular Necrosis

Answer 22

FENa<1% (normal kidney fnc) Prerenal Azotemia vs. FENa>2% Tubular Necrosis

Question 23

Prerenal Azotemia (kidney hypoperfusion) signs

Answer 23

FENa<1%, BUN:Cr>20, UNa<20, Uosm> 500

Question 24

BUN:Cr>20, FENa<1%, UNa<20, UOSM>500, U specgravity>1.02

Answer 24

Pre-Renal AKI/Azotemia

Question 25

BUN:Cr\<20, FENa\>1%, UNa\>20, UOSM\<300, U specgravity\<1.02

Answer 25

ATN, Intrinsic Renal

Question 26

Prerenal AKI p/w thirst, orthostatic hypotension, tachycardia, skin turgor, dry mucous membranes, etiology?

Answer 26

Hypovolemia, cardiogenic shock, sepsis, anaphylaxis, drugs (ACEis, NSAIDs), renal artery stenosis, hypoalbuminemia (cirrhosis, nephrotic syndrome), abdominal compartment syndrome, hepatorenal syndrome

Question 27

Postrenal AKI p/w prostatic disease, low urine output, suprapubic pain, distended bladder, flank pain, etilogy?

Answer 27

Obstruction via prostatic disease, pelvic tumors, intratubular crystalluria (indinavir/acyclovir), retroperitoneal fibrosis, bilateral nephrolithiasis.

Question 28

Intrinsic AKI p/w ischemia or nephrotoxic ATN, allergic interstitial nephritis, glomerulonephritis, thromboembolism, atheroembolic, rhabdomyolysis. Etiology?

Answer 28

Drug (aminoglycosides, NSAIDs), infection, contrast, toxins (myoglobin, myeloma protein).

Question 29

Recent Pneumonia treated, now p/w rash, fever, eosinophilia, WBCs and WBC casts on urinalysis, BUN:Cr

Answer 29

Acute interstitial nephritis (AIN) via antibiotics: Penicillins, cephalosporins, and sulfonamides

Question 30

Bipolar p/w Hypernatremia, dehydration, thirst, decreased Uosm 200, Plasma Osm 300; dx, rx?

Answer 30

Lithium induced nephrogenic diabetes insipidus (DI); Rx salt restriction and fluids, 1st Thiazide diuretic (decreases filtrate at DT and urine vol), NSAIDs (decrease filtration at glomerulus), amiloride (decrease Li at CT)

Question 31

Pt w/ new HTN med p/w exquisitely painful ankle joint, aspiration shows needle crystals w/ negatively birefringence, dx/rx?

Answer 31

Acute Gout via Hydrochlorothiazide- increases plasma urate levels by blocking the secretion of urate at the distal tubule.

Question 32

Hematuria in 25yoM 5 days post URI, most common cause? Workup?

Answer 32

IgA Nephropathy (w/ GN or nephrotic sx); normal complement, IgA deposits at mesangial membrane

Question 33

Hematuria in 8yo 10(-21) days post URI, most common cause? Workup?

Answer 33

Postinfectious (strep)-Glomerulonephritis; decreased complement C3, decreased anti-streptolysin O, anti-DNAse B; Subepithelial humps of C3

Question 34

Pt p/w palpable purpura, arthalgia, increased Cr, elevated ALT/AST, low complement, increased Rheumatoid factor, hematuria, proteinuria; dx, rx?

Answer 34

Cryoglobulinemia w/ Vasculitis and MPGN (Mesangial Porliferative GlomeruloNephritis); monoclonal IgM anti IgG (HepC); rx Plasmapherisis, Glucocorticoids, Cyclophosphamide

Question 35

Pt p/w edema, proteinuria, enlarged liver/kidneys, hx RA, HTN, workup? Rx?

Answer 35

AA Amyloidosis w/ apple-green birefringence on congo-red bx

Question 36

SE of Furosemide (loops)?

Answer 36

Ototoxicity

Question 37

Renal failure sequence of pathology in DM?

Answer 37

Glomerular hyperfilteration (HTN), basement membrane thickenin, mesangial expansion, nodular sclerosis

Question 38

Serum Osmolarity Formula?

Answer 38

S Osm = 2xNa + BUN/2.8 + Glu/18

Question 39

Increased BUN/Cr ratio?

Answer 39

Prerenal azotemia, GI bleed (urea absorption in gut), steroid administration

Question 40

Handelson Hasselbach equation? For PaCO2 and bicarb?

Answer 40

PH= Pk + Log([Conjugate base]/[Acid]) = 6.1 + Log[HCO3/(0.03xPaCO2)]

Question 41

Metabolic acidosis compensation? (winter's)

Answer 41

arterial PCO2 = 1.5 x (serum HCO3) + 8 (+/- 2)

Question 42

Metabolic alkalosis compensation?

Answer 42

arterial PCO2 = 0.9 x (serum HCO3) + 16 (+/- 2)

Question 43

Respiratory acidosis compensation?

Answer 43

increase HCO3 by 1 mEq/L for 10mmHg rise in PCO2

Question 44

Respiratory alkalosis compensation?

Answer 44

decrease HCO3 by 2 mEq/L for 10mmHg drop in PCO2

Question 45

Calcium correction for albumin?

Answer 45

Corrected Ca = (measured Ca) - 0.8 x (4 - albumin)

Question 46

AG Met Acidosis?

Answer 46

MUDPILES: Methanol, Uremia (ESRD), Diabetic ketoacidosi, Propylene glycol, INH/Iron, Lactic acidosis, Ethylene Glycol, Salicylates

Question 47

Normal AG (8-12) Met Acidosis?

Answer 47

HARD ASS: Hyperalimentation, Addisons, RTA, Diarrhea, Acetazolomide, Sprinolactone, Saline infusion

Question 48

Metabolic acidosis w/ AG and osmolar gap, envelope shaped crystals in urine; dx?

Answer 48

Ethylene glycol intoxication w/ calcium oxalate crystals; (also methanol, ethanol w/o crystals)

Question 49

Mixed respiratory alkalosis w/ AG metabolic acidosis?

Answer 49

ASA toxicity

Question 50

Arthalgia, rash, renal failure, eosinophiluria, wbc casts; dx?

Answer 50

Drug induced interstitial nephritis; sulfonamides, nsaids, cephalosporins, allopurinol, rifampin, penicillins, phenytoin, diuretics, captopril

Question 51

HTN, hypokalemia, elevated Renin and aldosterone w/ A:R ratio

Answer 51

Fibromuscular dysplasia, female \<50 resistant HTN, Cr rises w/ ACEi, dx via CT angio or duplex, may p/w Cerebrovascular sx

Question 52

HTN, hypokalemia (muscle weakness), slight hypernatremia, elevated aldosterone w/ A:R ratio \>20; dx?

Answer 52

Adrenal hyperplasia (Spirinolactone) or adenoma (resection), primary hyperaldosteronism (Conn sx), renal vein sampling diffeniates between the two

Question 53

HTN, hypercalcemia, low phosphate, recurrent kidney stones, neuropsychiatric presentation (confusion, psychosis, depression); dx?

Answer 53

Primary hyperparathyroidism

Question 54

HTN, fatigue, dry skin, cold intolerence, weight gain, constipation, bradycardia; dx?

Answer 54

Hypothyroidism

Question 55

HTN, obesity, facial plethora, proximal muscle weakness, ecchymosis, amonorrhea/erectile dysfunction; dx?

Answer 55

Cushing's syndrome, HTN w/ adrenal incidentaloma

Question 56

HTN severe \> 180/120 after age 55, possible recurrent flash pulmonary edema, unexplained rise in Cr, abdominal bruit; dx?

Answer 56

Renovascular disease

Question 57

HTN, elevated Cr, abn UA w/ proteinuria, RBC casts; dx?

Answer 57

Renal parenchymal dz

Question 58

HTN paroxysmal w/ tachycardia, palpitations, headaches, diaphoresis, adrenal incidentaloma; dx?

Answer 58

Pheochromocytoma

Question 59

Dietary recommendations for renal calculi?

Answer 59

Increase calcium intake and fluids, decreased sodium, protein and oxalate intake

Question 60

Nephrotic sx a/w Hep B, NSAIDs, SLE, Adenocarcinoma (breast, lung..), renal vein thrombosis?

Answer 60

Membranous Nephropathy

Question 61

Nephrotic sx a/w blacks/hispanics, obesity, HIV, Heroin use?

Answer 61

FSGS Focal Segmental Glomerular Sclerosis

Question 62

Nephrotic sx a/w Hep B, Hep C, lipodystrophy?

Answer 62

Membranoproliferative glomerulonephritis

Question 63

Nephrotic sx a/w lymphoma, NSAIDs?

Answer 63

Minimal change disease

Question 64

Nephrolithiasis w coffin shaped crystals; dx?

Answer 64

Struvite stones via urease producing bacteria

Question 65

muddy brown granular casts

Answer 65

ATN

Question 66

WBC casts

Answer 66

Pyelonephritis or interstitial nephritis

Question 67

RBC casts

Answer 67

Glomerulonephritis

Question 68

Fatty casts

Answer 68

Nephrotic sx

Question 69

Waxy or broad casts

Answer 69

Renal failure