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Renal Internal Medicine Flashcards

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0
Q

Common meds causing hyperkalemia? (6)

A

Non-selective Beta blockers, potassium sparing diuretics (eg. triamterene), ACE inhibitors, ARBS, cardiac glycosides (eg. digoxin) and NSAIDS

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1
Q

Most common causes of hyperkalemia?

A

acute or chronic kidney disease, medications, or d/o’s blocking RAAS

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2
Q

Sx’s of acute hyperkalemia?

A

Ascending muscle weakness, and flaccid paralysis.

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3
Q

EKG findings of hyperkalemia?

A

peaked T waves, followed by short QT interval, QRS widening, and sine wave with ventricular fibrillation.

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4
Q

Initial eval of hyperkalemia?

A

ECG to eval for conduction abnormalities.

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5
Q

Acute therapy for hyperkalemia? What situation?

A

Calcium gluconate and insulin with glucose. Give to pts with ECG changes, K+ greater or equal to 7.0 with no ECG changes, or rapidly rising K+ due to tissue breakdown.

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6
Q

Next step if someone with hyperkalemia does not have ECG changes?

A

Exclude acute treatable secondary causes (like uncontrolled hyperglycemia, tumor lysis syndrome). Then review recent/current medications.

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7
Q

Basic pathology of nephrotic syndrome?

A

altered perm of the glomerular membrane for proteins.

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8
Q

Diseases which are the MCC’s of nephrotic syndrome

A

minimal change disease (in children), memb glomerulopathy (adults), mesangial prolif glomerulonephritis, and FSGS.

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9
Q

Frequent complications of nephrotic syndrome?

A

Hypercoagulability, leading to renal vein thrombosis most commonly (esp in membranous glomerulopathy), but arterial thrombosis and pulmonary embolism may also occur.

protein malnutrition, iron-def microcytic hypochromic anemia due to transferrin loss, vit D def due to inc urinary excretion of cholecalciferol-binding protein, dec thyroxine levels, and inc susc to infection.

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10
Q

Most likely dis of patient with nephrotic range proteinuria and hematuria?

A

Membranoproliferative GN

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11
Q

Basic pathology leading to Membranoprolif GN?

A

Caused by IgG Ab’s (termed C3 nephritic factor) directed against C3 convertase of the alternate complement pathway. It stabilizes the convertase, leading to persistent complement activation and kidney damage. (sustained activation of C3–> leading to low levels of C3)

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12
Q

Causes of V/Q mismatch? (4) Lab values indicating mismatch?

A

Pulm embolism, atelectasis, pleural effusion, and pulm edema.

Inc A-a gradient with ABG showing respiratory alkalosis due to compensatory hyperventilation.

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13
Q

ABG value suggestive of alveolar hypoventilation?

A

High PaCO2 (50-80 range), and low PaO2 (but O2 value not needed for Dx)..

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14
Q

Causes of alveolar hypoventilation and respiratory acidosis?

A

1) Pulm/thoracic disease (COPD, OSA , obesity hypoventilation, scoliosis)
2) Neuromuscular dis: myasthenia gravis, LE syndrome, Guillan-Barre synd.
3) Drug-induced hypoventilation: Anaesthetics, narcotics, sedatives.
4) Primary CNS dysfxn: Brainstem lesion, infection, stroke.

Subdiaphragmatic surgery may also cause it.

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15
Q

Alveolar oxygen tension (PAO2)=

A

(FiO2 x [Patm - PH2O])- (PaCO2/R)…Where FiO2 (usually)= 0.21, Patm= 760, PH2O= 47, and R= 0.8. So, 150- PaCO2/0.8. PAO2 great for calculating A-a gradient.

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16
Q

which type of patients are at increased risk of contrast nephropathy?

A

Hx of diabetes and chronic kidney disease (baseline Cr at 1.5-3).

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17
Q

MC presentation of contrast nephropathy?

A

Spike in Cr in 24 hours of contrast administration, followed by a return to normal renal fxn within 5 days.

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18
Q

What is used to prevent contrast nephropathy?

A

IV hydration (with isotonic bicarb or NS) prior to CT scan and several hours afterwards. Another method is giving acetylcysteine (likely due to vasodil and antioxidant properties)

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19
Q

which drug is used to prevent hypersensitivity reaction to contrast media?

A

Prednisone…..prevents Sx’s like flushing, urticaria, angioedema, and bronchospasm.

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20
Q

Which lab value can replace FeNa in patient who take diuretics?

A

FE(urea). Reason is that urea is not affected by diuretics, but Na is affected.

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21
Q

MC glomerulonephritis in adults?

A

IgA nephropathy

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22
Q

Hematuria classified into two general categories

A

Glomerular (microscopic hematuria), and Non-glom (gross “)

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23
Q

Glomerular hematuria shows what on urinanalysis

A

proteinuria, dysmorphic RBC’s, RBC casts

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24
Renal papillary necrosis--> MCC's of this?
mneumonic NSAID N= NSAIDs (chronic use, not intermittent) S= SCD A= analgesic abuse (chronic use, not intermittent) I= infection (pyelo) D= DM
25
Does hypoalbuminemia cause pulm edema? Cause of hypoalb?
No, only peripheral edema. It's bc alveolar capillaries have higher perm (reducing oncotic P difference) and greater lymphatic flow than skeletal muscle, protecting lungs from edema. Caused by protein loss (nephrotic or protein losing enteropathy) or dec protein synth (cirrhosis and malnutrition)
26
Does cirrhosis cause pulm edema?
No, bc venous P above hepatic veins is N or reduced. Ascites and LE edema is common, though.
27
Why is there edema in nephritic synd?
dec GFR and retention of Na and water by kidneys.
28
75-90% of kidney stones
Composed of Calcium oxalate
29
How to visualize uric acid kidney stone?
Radiolucent, so can't view on X-ray. Use CT and U/S.
30
When are Calcium oxalate stones common?
in situations leading to fatty acid and bile salt malabsorption (small bowel dis, surgical resection, chronic diarrhea). Bc FA's chelate Calcium. Thus Oxalate free to be absorbed, and reaches kidney to form stone.
31
When patients with BPH have elevated Cr in acute situation, what is the next step?
Cr significantly increases only if bilateral obstruction Imaging with U/S to exclude other obstructive causes and assess for hydronephrosis. If no other cause found, most likely due to BPH.
32
Presentation of allergic interstitial nephritis?
acute renal failure, assoc with arthralgias and rash, PABA analogue Abx (sulfonamides), and WBC casts made mostly of eosinophils.
33
Drugs causing allergic interstitial nephritis?
Abx (like TMP-sMX, PCNs, cephalosporins), NSAIDS, diuretics, and captopril
34
Etiologies of crystal induced AKI. How to prevent?
acyclovir (high dose), sulfonamides, methotrexate, ethylene glycol, protease I's. Prevent: admin IV fluids with the drug reduces risk. Also dosage adjustment and slowing rate of IV infusion.
35
Interstitial cystits--> classic presentation
pain exacerbated by bladder filling (and exercise, sex, and alcohol) and relieved by voiding....>6 weeks..No attributable cause, normal UA. other characteristics= urgency, freq, and chronic pelvic pain.
36
What test must be gotten when suspecting interstitial nephritis?
Dx is primarily clinical, but need to exclude other causes of bladder pain, like UTI, STD, and CA) with UA.
37
Unilateral varicoceles even when recumbent should raise suspicion for ...
underlying mass pathology (like RCC), that obstructs venous flow.
38
Normal blood pH range
7.35-7.45
39
typical causes of respiratory alkalosis
hypervent due to pneumonia, high altitude, or salicylate toxicity
40
Is plasmapharesis effective for those with SLE associated nephritis?
No
41
Which pulm-renal syndrome requires emergency plasmapheresis? Others that may benefit as adjunctive therapy?
Goodpasteurs Wegener's, severe polyarteritis nodosa, idiopathic rapidly progressive GN
42
Treatment of uncomplicated cystitis
nitrofurantoin, TMP SMX, or fosfomycin
43
Tx of complicated cystitis
FQ's, or Amp/Gent. Adjust Abx according to Cx results.... However, don't use FQ's in pregnancy. Consider nitrofurantoin, amoxicillin and cephalexin.
44
What is complicated cystitis?
infxns assoc with factors that inc Abx resistance or treatment failure. Eg. diabetes, chronic renal disease, pregnancy, immunocompromised, UT obstruction, hospital-acquired infxn, or infxn assoc with procedure or indwelling foreign body.
45
Tx of pyelo
Outpt: FQ Inpt: IV Abx (FQ, Ceftriaxone). Adjust Abx according to Cx results
46
Why does hypokalemia occur in Cushings Synd? If severe, treat with...
Bc cortisol has some mineralocorticoid activity..Binds Aldo receptors in kidney..K+ wasting. Tx= spironolactone
47
Why does ethylene glycol cause MetAcidosis?
accum of glycolic and oxalic acid
48
Why does uremia cause MetAcidosis?
due to failure to excrete H+ as NH4+
49
When to treat acute hyperkalemia with calcium gluconate? Other treatments to reduce serum K+?
when there are ECG changes. Insulin and/or sodium polystyrene sulfonate.
50
Clues to tell if diabetic with albuminuria does not have diabetic nephropathy yet? When is DN present?
Non-diabetic renal dis--> onset of proteinuria <5 years after dis onset, active urine sediment, and > 30% reduction in GFR within 2-3 months of starting ACE I or ARB. DN usually 10 yrs after dis onset, and coincides with retinopathy or neuropathy.
51
Presentation of diuretic abuse?
Dehydration, weight loss, orthostatic hypotension, as well as hypokalemia and hyponatremia (inc urinary K and Na)
52
Best contrast to use with renal dis patients?
Non-ionic
53
Person has hacking non-productive cough and takes OTC med containing guafenesin and diphenhydramine. Next day, lower abdominal discomfort and difficulty voiding. Why?
First-gen H1 antihistamines have significant anti-cholinergic effects--> leads to detrusor inactivity.
54
Progression of renal abnormalities in Diabetic nephropathy?
1. glomerular hyperfiltration (major mech of glom damage) 2. Thickening of glom BM (first quantitative change) 3. Mesangial expansion
55
Common causes of chronic primary adrenal insufficiency?
MAHI Infxns (TB in endemic areas, HIV, disseminated fungal) Autoimmune Hemorrhagic infarction (meningococcemia, anticoagulants) Metastatic CA (eg, lung)
56
Findings with chronic primary adrenal insuff?
normal anion gap with hyperkalemic (due to not secreting as much K+) and hyponatremic (low ALDO) metabolic acidosis (due to not secreting as much H+). hypoglycemia, eosinophilia, and low BP.
57
MC Ethnic group with FSGS
blacks
58
MC glomerulopathy assoc with HIV...Other HIV assoc nephropathies?
collapsing FSGS Membranous GN (also assoc with Hep B), Mesangioprolif GN, and Diffuse prolif GN (all less common than FSGS)
59
Typical presentation of FSGS
heavy proteinuria (nephrotic), rapid dev of renal failure, azotemia, and normal sized kidneys
60
Usual cause of renal artery stenosis in young? in old? Goals for both? Most optimum treatment for young? for old (and exception)?
young--> fibromuscular dysplasia old--> atheromatous plaque Goal: dec BP and restore perfusion to kidney.. Best Tx for young: Interventional therapy better than medical--> Percutaneous angioplasty with stent placement Best Tx for old: Same as above, except if not a good candidate or refuses surgery....Thus, Medical is MC choice--> Exception-->but ACE-I's CI in bilateral renal artery stenosis!!
61
High BNP indicative of...
CHF highly likely. Poor long term prognosis and less long term mortality.
62
Positive urine leukocyte esterase signifies..
significant pyuria.
63
Positive urine nitrites signifies...
Enterobacteriaceae
64
Problem with urine dipstick?
has high false positive and false negative rate. Thus, even if test shows negative result, still do urine culture.
65
dietary recommendations for patients with renal calculi?
1. Decreased dietary protein and oxalate 2. Decreased sodium intake 3. Increased fluid intake 4. Increased dietary calcium
66
what is the MCC of acute pyelonephritis in all age groups>?
E. coli
67
What is the only oral medication approved as empiric therapy for mild pyelonephritis? If patient is resistant to treatment and Sx's persist or worsen after 2-3 days, what next?
FQ known as ciprofloxacin Next, give IV Abx (after figuring out susceptibility profile) and imaging
68
Is A-a gradient affected by hypoventilation>?
No, normal A-a gradient, but respiratory acidosis present.
69
Risk factors for bladder CA?
cigarette smoking, certain occupational exposures (eg. painters, metal workers), chronic cystitis, iatrogenic causes (eg. cyclophosphamide), and pelvic radiation exposure.
70
Before blaming BPH for a bout of hematuria, do what imaging?
cystoscopy to rule out bladder cancer. If negative, treat with alpha adrenergic antagonists (eg. terazosin, tamsulosin) with or w/o 5-alpha reductase inhibitors (eg. finasteride)
71
Renal transplant dysfunction in early post-op period manifests as (3)...Causes (5)?
oliguria, HTN, and inc BUN/Cr ratio. ureteral obstruction, acute rejection, cyclosporine toxicity, vascular obstruction, and acute tubular necrosis, etc
72
granular deposits seen on IF from renal Bx are indicative of..
immune complex GN (e.g. lupus nephritis or post-streptococcal GN)
73
Linear Ig deposits on IF microscopy typical of...
anti-GBM disease or goodpasteurs dis
74
Crescent formation on light microscopy indicative of..
rapidly progressive GN
75
Clinical presentation of nephrotic syndrome causes by amyloidosis?
nephrotic syndrome Sx's plus Hx of rheumatoid arthritis (that predisposes to amyloidosis), enlarged kidneys, and hepatomegaly.
76
Edema caused by HF (causing renal hypo perfusion) vs edema cause by primary glomerular damage (GN)
Differentiate them bc GN presents with urine sediment, including RBC casts, occasional WBC's, and red cell or mixed cellular casts
77
Clues are HTN, palpable bilateral abdominal masses, and microhematuria in adult. Dx? MC extra renal manifestation? Life threatening manifestation?
ADPKD Extrarenal manifestations: Hepatic cyst (MC), valvular heart disease, colonic diverticula, abdominal wall and inguinal hernia. Life threatening: intracranial bleeding due to berry aneurysm (in 5-10% of patients). Common and dangerous when coupled with HTN
78
Common causes of priapism
1) SCD and leukemia: adol and children. 2) Perineal or genital trauma: results in laceration of the cavernous artery. 3) Neurogenic lesions: such as spinal cord injury, cauda equina compression, etc. 4) Medications: such as prazosin and trazodone.
79
Renal complications of SCD (3)
painless hematuria, Renal medullary carcinoma, and UTIs...Painless hematuria occurs when there is renal papillary necrosis or ischemia.
80
Cause of renal papillary necrosis in SCD patients? What other problems can occur due to this particular cause?
due to low partial pressure of O2 in vasa rectae, and thus sickling of RBC's.. inability to concentrate urine, and distal RTA (impaired H+ secretion)
81
Renal papillary necrosis presentation in SCD patients?
Results in massive hematuria, but episodes are usually mild, resolve spontaneously, and UA shows normal RBC's.
82
Which etiology of anion gap metabolic acidosis can lead to rectangular, envelope-shaped crystals in the urine?
ethylene glycol poisoning
83
ASA toxicity leads to what acid-base disturbance (s)?
mixed AG metabolic acidosis and respiratory alkalosis with no osmolar gap.
84
meds that cause hyperkalemia?
TMP-SMX, Non-selective Beta adrenergic blockers, ACE-I's/ARBS, K+ sparing diuretics, digitalis, cyclosporine, heparin, succinylcholine, and NSAIDS
85
What med for HIV can cause hyperkalemia? How does it affect renal function?
TMP-SMX. GFR is not affected, but serum Cr increases bc it inhibits renal tubular secretion of creatinine.
86
How is hematuria categorized?
initial hematuria (blood only at beginning of stream)--> due to lesion to urethra. total hematuria (blood throughput stream)--> kidney or ureteral injury. Renal cause will not show clots. Painless terminal hematuria with clots (should eval for bladder cancer by cystoscopy).
87
First gen anti-histamine
Diphenhydramine, Chlorpheniramine, doxepin, hydroxyzine
88
Hepatorenal syndrome...defn?
Complication of end stage liver disease. Due to renal vasoconstriction that occurs because of p percieved low volume.
89
Casts present in chronic renal disease
Broad and waxy casts
90
Casts present in GN
RBC casts
91
Casts present in interstitial nephritis and pyelonephritis
WBC casts
92
Casts present in nephrotic syndrome
Fatty casts
93
Casts present in ATN
Muddy brown casts
94
Ethylene glycol poisoning leads to what renal finding
Calcium oxalate crystals, which are rectangular, envelope- shaped crystals
95
If you suspect an ethanol/methanol/ethylene glycol ingestion, what calculation should you make?
Osmolar gap, with less than 10 being normal
96
ASA toxicity and osmolar gap
Normal osmolar gap, but metabolic acidosis and respiratory alkalosis
97
Next step after having lower urinary tract Sx's consistent with BPH
UA to eval for hematuria (bladder ca or kidney stones) and infections.
98
Cause of cauda equina syndrome
Large midline disk herniation
99
Symptoms of cauda equina synd
Bladder atony with overflow incontinence, bilateral sciatica, saddle anesthesia, and loss of anal sphincter tone
100
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