Renal Lecture

Question 1

Acute kidney injuy (AKI) complicates _____% of hospital admissions

Answer 1

15-20%

Question 2

Increased nitrogen containing compounds (urea, creatinine)

Answer 2

Azotemia

(can have preenal, renal, postrenal)

Question 3

RIFLE
AKIN
KDIGO

Answer 3

ways to stage AKI

Question 4

Rise in creatinine > 0.3
Decreased urine output to < 3 mL over 6 hours

Answer 4

AKI

Question 5

Severe azotemia
Symptomatic
Metabolic acidosis
Electrolyte disturbances

Answer 5

Uremia

Question 6

Often no visual signs or noticeable sxs
Edema
HTN
Decreased urine output
Labs: albuminuria, increased BUN, hyperK, hypoNa

Answer 6

AKI

Question 7

Causes:
Inadequate perfusion
Hypovolemia
Inadequate PO intake
GI losses
Diuretics
Blood loss
Cardiac or hepatic failure
Sepsis

Answer 7

AKI pre-renal azotemia

Question 8

MC cause of acute renal failure

*excess nitrogen compounds due to lack of blood flow to each kidney

Answer 8

Pre renal azotemia

Question 9

Prolonged renal ischemia from prerenal azotemia can cause..

Answer 9

Acute tubular necrosis (ATN)

Question 10

Which type of renal tubular acidosis..?

Decreased H+ excretion
Hypokalemic

Herditary vs acquired (hyperPTH)

Answer 10

Type I (distal)

Question 11

Which type of renal tubular acidosis..?

Decreased proximal bicarb reabsorption
Hypokalemic

Hereditary vs acquired (multiple myeloma, chem exposures)

Answer 11

Type II (proximal)

Question 12

Which type of renal tubular acidosis..?

Impaired hydrogen and potassium excretion
Aldosterone deficiency or tubular unresponsiveness to aldosterone
Hyperkalemia

ie..Addison’s dz, DM

Answer 12

Type IV

Question 13

Glomerulonephritis vs nephorsis

Caused by nephrotoxic things:
Ischemia
Radiocontrast
Toxins
DIC
Intrinsic arterial or venous obstruction
Intrarenal precipitation
Nephritis
Minimal change Disease

Answer 13

Renal azotemia (intrinsic)

Question 14

Urinary obstruction
Prostratism
Bladder, pelvic, retroperitoneal tumors
Calculi
Urethral obstruction

Answer 14

Postrenal Azotemia

Question 15

Causes:

AKI
HTN
DM
Vascular disease

Answer 15

CKD

Question 16

30-300 mg/day albumin

Answer 16

microalbuminuria

Question 17

17-250 mg/g for men

25-355 mg/g for women

Answer 17

Spot Ur albumin:creatinine ratio

Question 18

What stage CKD:

GFR>90

Answer 18

Stage 1

Question 19

What stage CKD:

GFR 60-89

Answer 19

Stage 2 (mild)

Question 20

What stage CKD:

GFR 45-59

Answer 20

3A (moderate)

Question 21

What stage CKD:

GFR 30-44

Answer 21

3B (moderate)

Question 22

What stage CKD:

GFR 15-29

Answer 22

stage 4 (severe)

Question 23

What stage CKD:

GFR <15

Answer 23

stage 5 (end stage)

Question 24

Low sodium, protein, potassium, phosphate

Answer 24

CKD diet

Question 25

``` Diet (low Na, protein, potassium, phosphate) Avoid nephrotoxins (NSAIDs, radiocontrast) H20 management (THINK about IVF) ```

Answer 25

CKD management in-patient

Question 26

What is the goal for hospital management of CKD?

Answer 26

prevent acute on chronic kidney disease/injury

Question 27

What is the primary **intracellular cation?**

Answer 27

Potassium!

Question 28

What is the only way to measure potassium?

Answer 28

Extracellular (ECFV) \*there are very small quantities extracellularly

Question 29

Causes: AKI or CKD Adrenal insufficiency Dietary intake (bananas, potatoes) Hemolysis (blood draw, clotting, leukocytosis) Metabolic acidosis Beta blockers Insulin deficiency Aldosterone antagonists

Answer 29

Hyperkalemia

Question 30

Weakness Paralysis Cardiac arrhythmias: peaked T waves, widened PR, QRS, eventual PEA

Answer 30

HyperKalemia

Question 31

Tx: tx the cause IVF Kayexelate Limit intake Insulin + dextrose Beta adrenergics

Answer 31

Hyperkalemia

Question 32

Causes: Decreased intake Increased GI loss: vomit, diarrhea, laxatives, tube drainage Increased renal loss: diuretics, hypoMg, non reabsorbable anions Increased entry into cells: insulin, beta agonists or stress hypothermia, alkalosis

Answer 32

HYPOkalemia

Question 33

Manifestatios: Weakness/**rhabdomyolysis** Glucose intolerance Cardiac arrhythmias- increased U wave amplitude

Answer 33

HYPOkalemia

Question 34

Tx: PO or IV replacement Mg replacement Consideration in hyperglycemia and DKA

Answer 34

HYPOkalemia

Question 35

What is the main **extracellular ion?**

Answer 35

Sodium

Question 36

Causes: * *Extra renal water loss** (fever, sweating, diarrhea, mechanical ventilation) * *Renal water loss** (osmotic diruresis, iatrogenic)

Answer 36

HYPERnatremia

Question 37

DKA, hyperalimentation, mannitol, sodium diabetes insipidus all examples of _____ water loss, which can lead to **hyper**natremia

Answer 37

Renal

Question 38

For diabetes insipidus... which is **LOW ADH** and which is **UNRESPONSIVE TO ADH** (options= central, nephrogenic)

Answer 38

Central= low ADH Nephrogenic= unresponsive to ADH

Question 39

1 amp NaHCO3 has \_\_\_\_x's the concentration of 3% saline

Answer 39

2x's (NaHCO3 **can be an iatrogenic cause of renal water loss**)

Question 40

urine output is \>3L/day

Answer 40

Polyuric

Question 41

\>300 mOsm/L =?

Answer 41

Osmotic diuresis

Question 42

\<150 mOsm/L= ?

Answer 42

Diabetes insipidus

Question 43

Give NS inititally if volume depleted Transition to 1/2 NS vs. D5W (**avoid correction faster than 0.5 mEq/L/hr to avoid cerebral edema)**

Answer 43

Tx for **hyper**natremia

Question 44

When giving hyperNa pt NS, avoid correction faster than 0.5 mEq/L/hr to avoid..?

Answer 44

Cerebral edema

Question 45

**ADH elevation** Increased serum osmolality Decreased circulating volume Inappropriate elevation

Answer 45

Hypoosmolar HypoNatremia

Question 46

Increased levels of another osmolyte - glucose - mannitol - proteins - lipids

Answer 46

Hyperosmolar HypoNatremia

Question 47

"too much salt" Seen with: **CHF Cirrhosis Nephrotic syndrome** \*\*\*increased ADH due to decreased effective circulating volume **kidneys retain both Na and H20**

Answer 47

Hypervolemic HypoNatremia

Question 48

Urine Na \< 30 mmol/L indicates _______ (**renal/extrarenal**) losses

Answer 48

**Extra renal**

Question 49

Urine Na \> 30 mmol/L indicates ______ (**renal/extrarenal**) losses

Answer 49

**Renal**

Question 50

Hypovolemic Hyponatremia (too little salt) can be divided into...

Answer 50

**Renal** (\>30 mmol/L Na in urine) **Extra-renal** (\<30 mmol/L Na in urine)

Question 51

Urine Na \>30 RAA NOT engaged Na is being released

Answer 51

Euvolemic HypoNa

Question 52

Psychogenic polydipsia Beer potomania Tea and toast diet **cause euvolemic hyponatremia with urine osmol ......**

Answer 52

**less than 100**

Question 53

SIADH Reset osmostat Renal insufficiency Hypothyroidism TZDs SSRIs Secondary adrenal insufficiency ## Footnote **cause euvolemic hyponatremia with urine osmol \_\_\_\_\_\_\_**

Answer 53

greater than 100

Question 54

this is an excess of water but we treat it like its a deficiency of Na

Answer 54

Hyponatremia

Question 55

Tx: Saline.. normal (0.9%) vs 3% Loop diuretic Serum Na and urine osmol monitored every 1-2 hours

Answer 55

Acute Hyponatremia

Question 56

For hyponatremia... **Aim for 1-2 mEq/hr the first few hours then no more than 10mEq/L in the first 24 hours.** No more than 18mEq/L in ___ hours

Answer 56

48

Question 57

Pain Volume depletion (followed by LR or hypotonic fluids Trauma Meds (SSRIs, TZDs) Neoplasm Severe nausea Neuropsychiatric meds

Answer 57

common causes of **increased ADH in hospitalized patients**

Question 58

May briefly use 3% saline Stop NaCl when serum Na starts to rise, urine osm decreases or symptoms resolve

Answer 58

Chronic symptomatic HypoNatremia Tx

Question 59

True or False.. There is a risk of **osmotic demyelination syndrome** if correction of chronic hyponatremia happens too rapidly

Answer 59

True

Question 60

154 mOsm/L 77 mEq/L ..which saline?

Answer 60

1/2 NS

Question 61

308 mOsm/L 308 mEq/L which saline?

Answer 61

NS

Question 62

1026 mOsm/L 513 mEq/L which saline?

Answer 62

3% saline

Question 63

130 mEq/L which saline?

Answer 63

LR

Question 64

Fluid restrict Safest initial approach Increase solute intake Discontinue offending agents ADH receptor antagonist tx for?

Answer 64

Chronic asymptomatic hyponatremia

Question 65

Usually asymptomatic NaCl Maintain ≤ 10mEq/24 hours correction

Answer 65

Hypovolemic Hyponatremia