Renal

Question 1

Managing UTI in non pregnant woman (uncomplicated)

Answer 1

Trimethoprim - 200mg BD x 3 days

Nitrofuratoin - 500mg QDS x 3 days (7D in men)

Question 2

UTI in pregnancy

Answer 2

Amoxicillin - 250mg TDS x 7 days

Cephalexin - 500mg BD x 7 days

Question 3

Lower UTI in children

Answer 3

Refer if < 3months
Trimethoprim: 3mo-12yrs = 4mg/kg BD (max 200mg) x 3 days
Nitrofuratoin: 750mg/kg QDS

Question 4

Upper UTI in children

Answer 4

Amoxicillin, Co-amoxiclav
< 1yr: 168mg max x 7-10 days
1-6 years: 156mg x 7-10days
6-12 years: 312mg TDS x 7-10days

Question 5

Acute pyelonephritis

Answer 5

Ciprofloxacin: 500mg BD x 7 days
Co-amoxiclav: 500mg/125mg TDS x 14 days
If severe: Cefuroxime 1.5g/8hr IV - then oral for 7 days.

Question 6

Cockcroft-Gault Formula: Calculation of GFR

Answer 6

CrCl (ml/min) = [(140-age) x wt (kg) x 1.2 /

[Cr]plasma (umol/L) ] (x0.85 in women)

Question 7

Urea - clinical setting in which it is affected independent of renal function

Answer 7

Increase: volume depletion, GI hemorrhage, high protein intake, sepsis, catabolic state, corticosteroid or cytotoxic drugs

Decrease: low protein diet, liver disease.

Question 8

Electrolyte values:

Answer 8

Na = 135-145 mmol/L
K = 3.5 - 5 mmol/L
Cl = 95-105 mmol/L
HCO3 = 18-23 mmol/L

Question 9

Cause of hyponatremia

HypoNa + hypervolemic + UNa < 20

Answer 9

CHF
Cirrhosis and ascites
Pregnancy

Question 10

Cause of hyponatremia

HypoNa + hypervolemia + Una > 20

Answer 10

ARF, CFR

Question 11

Cause of hyponatremia + euvolemia + Uosm>100

Answer 11

SIADH
Adrenal insufficiency
Hypothyroidism

Question 12

Cause of hyponatremia + euvolemia + Uosm < 100

Answer 12

Psychogenic polydipsia

Question 13

Cause of: hypoNa + hypovolemic + Una>20

Answer 13

Diuretics

Salt Wasting nephropathy

Question 14

Cause of: hypoNa + hypovolemic + Una<10

Answer 14

Diarrhea
Excessive sweating
Third spacing = peritonitis, pancreatitis, burns

Question 15

Symptoms of hyponatremia

Answer 15

Depend on the degree of hypoNa and velocity of progression.
Main symptoms:
Headache, nausea, malaise, lethargy, muscle weakness and cramps, anorexia, somnolence, disorientation, personality changes, depressed reflexes, decrease/LOC

Question 16

SIADH: Definition and causes

Answer 16

Definition:
- Urine that is inappropriately concentrated    
  for the serum osmolality
- High urine Na > 20-40mmol/L
- High FEna
Causes:
-  Tumors: Small cell ca, broncogenic Ca,  
   AdenoCa of pancreas, Hodgkins
-  Resp: pneumonia, TB, PPV
-  CNS: mass, SAH, stroke
-  Drugs: TCA, SSRIs, carbamazepine,  
   barbituates, chlorporpamide.
-  Misc: Postop, pain, nausea, HIV

Question 17

Hypernatremia: Cause

Answer 17

• Too little water relative to total body Na.
  Always associated with a hyperosmolar
  state.
• Usually due to net water loss.
• We are protected against hyperNa due
  to thirst and ADH.
• Causes: Insensible water loss,
  GI/diahrrea, osmotic (lactulose), Renal
  losses - diuretics, osmotic diuresis from
  hyperglycemia, Diabetes inspidious

Question 18

Symptoms of hypernatremia

Answer 18

AMS, weakness, NMJ irritability, thirst, polyuria

Question 19

Diabetes inspidious: Cause, diagnosis.

Answer 19

Definition: Collecting tubule inpermeable to water due to absence or impaired response to ADH.
Central DI: neurosurgery, granulomatous disease, trauma, vascular event, malignancy.
Nephrogenic DI: Lithium, hypo-K, hyper-Ca, congenital
Dx: Urine osm inappropriately low in patient with hyperNa (Uosms cannot respond.

Question 20

HypoK: Definition, Causes

Answer 20

Serum K+ < 3.5 mEq/L
Decreased intake
Increased loss:
1. GI - Diarrhea, laxatives, villous adenoma
2. Renal losses: Diuretics, hypo-Mg, hyperaldosterism, inherited rental tubular lesions (Barters, Gitelmans), DKA, RTA.
Redistribution into cells:
1. Metabolic alkalosis
2. Insulin
3. Catecholamines, B2 agonists, theophylline
4. Uptake into newly forming cells - Vit B12 injection, WBC production.

Question 21

Signs and symptoms of hypo-K+

Answer 21

Asymptomatic when mild (3-3.5)
N,V, fatigue, generalized weakness, muscle cramps/spasms, constipation.
If severe: arrhythmias, muscle necrosis, paralysis
ECG changes: U waves, flattened T-waves, depressed ST segment, prolonged QT interval.

Question 22

Hyperkalemia: Definition + Causes

Answer 22

Serum K+ > 5.0mEq/L
Causes:
(1) Factitious - sample hemolysis, sample taken from vein, IV KCL running, prolonged use of tourniquet.
(2) Increased intake: diet, KCL tablets
(3) Cellular release: intravascular hemolysis, rhabdomyolysis, inslin def, hyperosmolar states = hyperglycemia, MA = keto and lactic acidosis, TLS, Drugs = b-blockers, digitalis overdose, succinylcholine.
(4) Decreased excretion: Renal failure, NSAIDs, low effective circulating volume, hypoaldosterism.
(5) Drugs - spironolactone, amiloride, triamterene

Question 23

Signs and symptoms of hyperkalemia

Answer 23

Nauses, palpitations, muscle weakness, paresthesia, areflexia, ascending paralysis, hypoventilation
ECG changes: peaked and narrow T-waves, loss of P waves, prolonged PR interval, widening of QRS, AV block, VF, asystole.

Question 24

Treatment of hyperkalemia

“SEE BIG K DROP”

Answer 24

SEE - Calcium gluconate 10mL 10% solution IV.
BIG: B-agonist, Bicarb, Insulin, Glucose
Ventolin = 10mg inhaled
Bicarb = 1-3 amps of 7.5% NaHCO3 in 1L D5W
Insulin = regular insulin 10-20U with D50W
K: Kayexalate, calcium resonium
DROP: Diuretics, dialysis
Furosemide = > 40mg IV

Question 25

Causes of increased anion gap metabolic acidosis: MUDPILES

Answer 25

``` M - methanol U - uremia D - DKA/alcoholic/starvation P - Paraldehyde I - Iron L - Lactic Acidosis E - Ethylene glycol S - Salicylates ```

Question 26

Causes of non-anion Gap Metabolic acidosis | HARDUP

Answer 26

Diarrhea* RTA* Acetazolamide Ureteroenteric fistula

Question 27

Metabolic alkalosis

Answer 27

UCl < 20 mEQ/L: Saline responsive GI losses - Vomiting, NG tube ``` UCl > 20 mEQ/L: Saline unresponsibe Diuretic use Hyperaldosterism Cushings syndrome Milk alkali syndrome Severe hypo-K Bartter's Kitelmans ```

Question 28

Acute Kidney Injury: Definition + Cause

Answer 28

Definition: Abrupt decline in renal function over hours/days leading to an increase in urea and creatinine. Clinical features: azotemia = increased BUN, Cr + oliguria/anuria Causes: Pre-renal, renal, post-renal Pre-renal - Hypovolemia = hemorrhage, GI losses, renal losses, low CO, cirrhosis, third spacing - NSAIDS, ACEI/ARBS, hyperCa Renal - GN, AIN, ATN, vascular = vasculitis, HTN Post-renal - Neurogenic - Anatomic = ureter, bladder, urethra

Question 29

Chronic kidney disease: Definition + Causes + Complications

Answer 29

``` Definition: Irreversible and long standing loss of renal function. 1. GFR < 60 ml/min for > 3mo 2. Kidney pathology seen on biopsy 3. Decreased kidney size on US < 9cm Classified according to GFR (Stage 1-5) Stage 4 GFR 15-29 - symptoms begin Stage 5 GFR < 15 - dialysis needed ``` Causes: - Diabetes - HTN - GN - IN - Pyelonephritis - Cystic/hereditary/congenital - Secondary GN/vasculitis ``` Complications - HyperK, hyperPO, metabolic acidosis, hypo-Ca - Secondary hyperparathyroidism, renal osteodystrophy - Vitamin D deficiency - Anemia/decreased erythropoietic - Fluid overload - HTN - Coagulopathy - Pruritis - Restless leg syndrome - Infection ```

Question 30

Nephrotic syndrome: Definition, cause, investigation, complications, treatment.

Answer 30

Defintion: - Proteinuria > 3.5gday accompanied by generalized oedema, hyperlipedemia, hypoalbuminemia, HTN. ``` Causes: - Glomerular disease: minimal change, membranous GN, proliferative GN. - Systemic disease: DM, SLE, amyloidosis, drugs, syphilis, HIV, cancer, HBV, MM. ``` ``` Investigations: - Creatinine clearance, 24h urinary protein, urine electrophoresis. - FBC, ESR - Urea, electrolytes, serum Cr, albumin. - Serum cholesterol - ANA, p-ANCA, c-ANCA, complement levels. - Renal biopsy ``` ``` Complications: - Thromboembolic events = renal vein thrombosis, DVT - PE - Protein malnutrition - Accelerated atherosclerosis - Infection ``` ``` Treatment: - Diuresis - Heparin, Warfarin, TEDS stockings. - Albumin if symptomatic - Pneumococcal vaccine - INF in HBV and HCV associated nephropathy. - Steroids: Minimal change ```

Question 31

Principals in managing CKD (e.g Stage 4)

Answer 31

- ACEI and target BP < 130/80 - Thiazide diuretic should be replaced with loop diuretic. - Limit dietary protein to 0.8-1g/kg/day - Treat hyperlipedemia with statin - Aspirin to reduce risk of CVD - Tobacco cessation - Anemia: EPO, target Hg 110-120g/L - Phosphate binders. - Low dose Vit D = helps control hyper- PTH - NaHCO3 for MA

Question 32

Indications for renal replacement therapy

Answer 32

1. HyperK > 7mmol - not responsive to medical treatment 2. HCO3 < 12mmol 3. Urea > 20mmol/L 4. Cr > 500umol/L 5. Refractory pericarditis, pulmonary edema, encephalopathy.

Question 33

Causes of nephrotic syndrome

Answer 33

``` Congenital Acquired - GN = minimal change, focal sclerosing, membranous, diabetic nephropathy. - Systemic vasculitis = SLE - SLE drugs = gold, penicillamine - Infection = malaria ```

Question 34

IgA Nephropathy: Presentation

Answer 34

Classical nephritic presentation in teenager/early adulthood. Recurrent episodes of gross hematuria associated with recent infection. Normal complement Treat HTN with ACE-I

Question 35

Wegerner's Granulomatous Disease

Answer 35

``` Midline vasculitic picture Collapse of nasal bridge Sinusitis Hematuria c-ANCA Positive ```

Question 36

Membranous nephropathy

Answer 36

``` Nephrotic syndrome Most common in caucasian adults. Causes: - Idiopathic - Secondary to solid tumors = bronchial ca, Hodgkins lymphoma. - Systemic disease = amyloidosis, SLE - HIV, Heroin - HBV, syphillis, malaria - Gold Treatment: Na restriction+ furosemide ```