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Flashcards in UW - Med/Renal Deck (87):
1

What is membranous nephropathy and what are its major clinical associations?

Nephrotic syndrome (2nd most common)

AdenoCA, NSAIDs, Hep B, SLE

2

What is focal segmental glomerulosclerosis and its major clinical associations?

#1 nephrotic syndrome

African Americans, HIspanics, Obesity, HIV, Heroin use

3

What symptoms are characteristics of mixed cryoglobulinemia?

Palpable purpura, proteinuria, hematuria, arthralgias, hepatosplenomegaly, decreased complement

Older patients, most have HCV infection

4

What are the causes of normal anion gap metabolic acidosis?

HARDUP
Hyperalimentation; hyperchloremic acidosis, Hypoaldosteronism
Acetazolamide, Argenine
Renal tubular acidosis
Diarrhea
Ureteral diversion
Pancreatico-duodenal fistula

5

What are the etiologies of primary adrenal insufficiency?

HIMA
Hemorrhagic infarct (meningococcemia, anticoagulants)
Infections (TB, HIV, disseminated fungal)
Metastatic cancer (lung)
Autoimmune

6

What are the main symptoms in acute and chronic primary adrenal insufficiency?

Acute - SHOCK, Ab tenderness w/ deep palp, FEVER, N/V/Wt loss/Anorex, HypoNa, HyperK, HyperCa, Eosinophilia

Chronic - Fatigue, WEAK, anorex, GI (n/v/ab pain), Weight loss, HyperPIGMENT/VITILIGO, LOW BP, same ion imbalance, Eosinophilia, ANEMIA

7

Where does aldosterone primarily act and what does it do? What can happen if it gets blocked?

Distal renal tubules, "saves sodium", secretes K+ and H+

If blocked, K+ and H+ are saved --> Normal AG Met Acid

8

What is the treatment for uric acid stone?

Hydration, Alkalization of urine (to 6-6.5 w/ potassium citrate), low purine diet,

Add allopurinol for recurrent symptoms

9

What is the risk of calcium restriction, or decreased Ca in renal tubules for patients with kidney stones (Ca or Uric acid)?

Ca restriction in diet --> Negative calcium --> Hyperoxaluria from increased GI absorption of oxalate

10

What is the effect of Furosemide on urine Ca?

Increased excretion (because action of Na/K/Cl transport brings Ca in)

11

What is the treatment for severe hypernatremic hypovolemia? Less severe?

Severe = 0.9% saline which gradually corrects hyperosmolality while normalizing patient's volume status then switch to 0.45% saline to replace free water deficit

Less = 5% dextrose in .45% saline

12

What is D5W (5% dextrose in water) used in the treatment of?

Euvolemic and hypervolemic hypernatremia (oral free water in stable patients)

13

What possible medication in diabetics should be removed during acute kidney injury and/or sepsis and why?

Metformin -> can cause lactic acidosis, withhold until renal function improves

14

What is the target blood glucose level in patients who are acutely ill and have hyperglycemia? What treatment can facilitate this?

140-180 mg/dL, use short acting insulin

15

What should always be considered in patients getting CT scan w/ contrast? What alternatives are available?

Pts w/ renal insufficiency (Cr >1.5) or history of diabetes are increased risk of contrast induced nephropathy

Use non-ionic contrast agents

16

What is the most common cause of AA amyloidosis and what can result from this?

Rheumatoid arthritis -> amyloidosis can lead to Nephropathy via glomerular amyloid deposits (congo red staining etc.)

17

What are linear glomerular deposits seen with immunoflorescence staining characteristic of? Granular deposits?

Linear = Antiglomerular basement membrane disease (Goodpasture's)

Granular = immune complex glomerulonephritis (Lupus nephritis, IgA nephropathy, postinfection glomerulonephritis)

18

What are common causes of nephrogenic DI?

HyperCa, severe HypoK+, tubulointerstitial renal disease, and medication (lithium, cidofivir, foscarnet, demeclocycline, amphotericin)

19

What is detrusor sphincter dyssnergia?

Neurological disease where detrusor contracts while urethral spinchter contracts --> difficult voiding/interruption of urine stream

20

What are the causes of hypervolemic hypernatremia?

CHF, cirrhosis, chornic kidney disease or nephrotic syndrome

21

What are the causes of euvolemic and hypovolemic hypoNa+?

Euvol = SIADH, primary psycho polydipsia, Hypothyroid, secondary adrenal insufficiency

Hypovol = Volume loss (hemorrhage), Primary adrenal insufficiency, GI loss (diarrhea, vomit), Renal loss (diuretics)

22

How do you calculate serum osmolality and osmolar gap?

Serum Osm = [2Na + Glu/18 + BUN/2.8]

Osm Gap = Observed Osm - Calculated Osm

23

What causes omsolar gap met acidosis?

Methanol, ehtylene glycol, ethanol poisoning

24

How do you treat patients with sever hyperK+ with major EKG changes?

1. Emergent administration of IV calcium gluconate to stabilize cardiac membrane
2. Lower serum K+ by driving into cell w/ insulin and glucose, sodium bicarb, and beta 2 agonists
3. Lower total body K+ --> loop diuretic

25

What does hyponatremia in the setting of serum Osm > 290 mOsm/kg suggest?

Marked hyperglycemia, Advanced renal failure

26

When should bicarb be used for the treatment of lactic acidsosis?

Only very severe cases where pH

27

How do you manage severe hypercalcemia?

Short term: NS hydration + Calcitonin (avoid loop diuretics, only use in small doses for HF pts)

Long term: bisphosphonates,

28

What are common meds that can cause hyperkalemia?

Nonselective beta blockers, potassium sparing diuretics (esp triamterene), ACE inhibitors, ATII-R blockers, NSAIDs

29

What are some features of cyanide toxicity?

Skin flushing (cherry red), AMS/seizures/coma, Arrhythmias, Tachypnea then resp depression/pulm edema/cyanosis, Ab pain/N/V, Metabolic acidosis (lactic acid) and renal failure

30

What is the presentation for patients with acute nephritic syndrome + fluid overload?

Anasarca, pulmonary + facial edema, HTN, proteinuria and micro hematuria (>50 rbcs, rbc casts)

31

What acid/base disorder can result with aspirin toxicity (give abg) and how does this occur?

Direct stimulation of medullary respiratory centers -> Tachypnea -> Resp alkalosis
Anion gap metabolic acidosis from increased production and decreased renal excretion of organic acids

Normal pH, low PaCO2 and bicarbonate

32

What is the etiology of Familial Hypocalciuric Hypercalcemia?

PT gland and renal tubule cell receptors resistant to Ca --> secrete excess PTH (can be high or high normal)

33

What is renal tubular acidosis?

Normal Anion Gap Met Acidosis w/ preserved renal fxn (usually elderly w/ poorly controlled DM

Resistance to or deficiency of Aldosterone --> K+/H+ retention

34

What is the cause in 70% of cases of interstitial nephritis?

Drugs like cephalosporins, penicillins, sulfonamides, sulfonamide containing diuretic, NSAIDs, rifampin, phenytoin and allopurinol

35

What two compounds are frequently observed in the urine of pts with UTI and what do they indicate?

Leukocyte esterase - significant pyuria

Nitrites - Enterobacteriae convert Nitrates to nitrites

36

Which medications can lead to hyperkalemia?

Nonselective beta blockers, ACEI, ARBs, K+ sparing diuretics, Digitalis, Cyclosporine, Heparin, NSAIDs, Succinylcholine, Trimethoprim (HIV pts on high doses)

37

What is the pathophysiology of membranoproliferative glomerulonephritis? Patients sx?

Dense intramembranous deposits of C3, caused by IgG antibodies (C3 nephritic factor) that react with C3 convertase leading to persistent activation of the complement pathway

Signs of Nephrotic Syndrome & dense deposits in glomerular basement membrane w/ IF + for C3

38

What are the main clinical features of renal cell carcinoma?

1. Classic Triad = Flank pain, hematuria, and palpable abdominal renal mass
2. Scrotal vericoceles that don't improve with lying down (left sided)
3. Paraneoplastic signs - Anemia/erythrocytosis, Thrombocytosis, fever, hypercalcemia, cachexia

39

What is a major risk factor in using Succinylcholine and what patients should it not be used in?

Significant potassium release, and life threatening arrthymias (do not use in patients with high risk for hyperkalemia)

Do not use in Crush or Burn injuries >8 hours old (rhabdomyolysis), demyelinating syndromes (GBS), tumor lysis syndrome

40

What are the features of non-ketotic hyperglycemic coma and most important management?

Very elevated glucose, BUN, Cr, K+, Unconscious/AMS

If volume depleted FLUID RESUSCITATE

41

What important complication should you look for in patients with GTC with high Cr, urine ketones, and blood, but low RBCs?

Rhabdomyolysis - large amounts of myoglobin released to urine

42

What drug can be very helpful in facilitating stone passage and why?

stone impaction causes reflex ureteral spasm causing ureter to constrict leading to renal colic

Alpha-1-adrenergic receptor blockers will decrease the pain by relaxing the ureteral muscles

43

What are the key associations for minimal change disease?

NSAID use and Lymphoma (most common nephrotic syndrome in hodgkins)

44

What hematological conditions are associated with Amyloidosis nephrotic syndrome?

Multiple myeloma

45

What type of nephropathy is often associated with solid tumor malignancies?

Membranous glomerulopathy

46

How do you treat hypovolemic hypernatremia?

Volume replete w/ NS (.9%) and hypotonic fluid (D5W + .45% saline) once euvolemic

47

What complication of pneumonia in an elderly patient can result w/ hypotension?

HoTN -> Decr Blood flow --> Renin/AT system activates -> glomerular arterioles constriction --> PreRenal Azotemia

48

What is the indication to operate/amputate in diabetic foot ulcers?

Grade 4 (localized gangrene) and Grade 5 (Extensive gangrene of whole foot)

49

How may Chronic Kidney Disease affect Calcium metabolism?

Decreased renal production of Vit D leading to hypocalcemia, hyperphosphatemia, and compensatory rise in PTH

50

How can malignancy affect Calcium metabolism?

Tumor production of 1,25 - dihydroxyvitamin D (lymphoma), increased IL6 (multiple myeloma), increased tumor secretion of PTH related peptide (PTHrP), bony destruction by mets

All would cause Hypercalcemia and compensatory suppression of PTH

51

If a patient presents with waxing and waning abdominal pain and pees out needle-shaped crystals, what may this indicate and how can you confirm?

Uric Acid stones

CT abdomen or IV pyelography (if radiolucent)

52

What metabolic ion destabilization can occur following a large high risk surgery (e.g. laparotomy for liver laceration)? Symptoms?

Hypocalcemia, which can often occur following large surgeries requiring extensive transfusions (decreased ionized calcium from binding citrate) --> Hyperactive DTRs, muscle cramps, rarely convulsions

53

What may be the cause of urinary retention in someone w/ herniated intravertebral disk and BPH?

Pain is limiting patient's ability to valsalva to overcome intrabdominal pressure required to urinate

54

What is the most common cause of erectile dysfunction in a patient with recent pelvic surgery?

Neurogenic - I.E. nerve injury

55

What toxicity should you suspect highly in a patient who recently escaped a house fire? How do you treat?

Cyanide (tx w/ hydroxocobalamin or sodium thiosulfate) and CO poisoning (intubation/O2 therapy)

56

What is methemoglobinemia?

Oxidation of ferrous (Fe2+) to Ferric (Fe3+) iron in Hb causing left shift of Hb curve

Caused by oxidizing agents (dapsone, nitrates, topical/local anesthetics)

57

What are the reversible causes of urinary incontinence in elderly?

DIAPPERS
Delirium, Infection (UTI), Atrophic urethritis/vaginitis, Pharma (alpha blockers, diuretics), Psych (depression), Excessive urine output (diabetes, CHF), Restricted mobility (post surgical), Stool impaction

58

When would you require long term urinary catheter placement?

Neurogenic bladder, urinary retention due to anatomic obstruction

59

What are the clinical features of mixed cryoglobulinemia?

Moderate-Severe glmoerulonephritis (low complement, blood, prot in urine), arthralgias, palpable purpura, elevated transaminases, associated w/ Hep C (IgM Abs)

60

What is anti-phospholipid syndrome?

Elevated anti-cardiolipin Abs, A/V thrombosis, loss of pregnancy, Neuro findings (cog defect), microangiopathic hemolytic anemia

61

What are 2 major risk factors for Rhabdomyolysis? What is the pathophysiology and complications that can result?

Immobilization and Cocaine abuse

direct muscle dmg and release of CPK (elevated potassium and CPK) --> acute tubular necrosis from excessive myoglobin filtration

62

How can chronic renal failure affect hemostasis and why does this occur? How can this be corrected?

UREMIC COAGULOPATHY
-Platelet to vessel wall or platelet to platelet binding dysfunction -> hemorrhage, increased bleeding time
-From Uremic toxins (guanidinosuccinic acid)
-Tx: DDAVP, Cryoprecipitate, and conjugated estrogens

63

What medications should be avoided in patients w/ severe renal insufficiency requiring anti-coagulation and why?

LMWH (enoxaparin), Fondaparinux (injection Factor Xa inhibitor), and Rivaroxaban (oral FXa inhib)

B/c reduced renal clearance increases anti-Xa activity levels, leading to increased bleeding risk

64

An elderly patient presented w/ signs of pyelonephritis w/ a multi-drug resistance organism. What type of bacterial species was it and what tx would have been used? Risks of this treatment?

Gram negative rod, tx w/ aminoglycosides like Amikacin

Can lead to acute renal failure, must monitor renal function closely

65

What is the earliest renal abnormality in patients w/ diabetes? later abnormality?

Glomerular hyperfiltration -> intraglom HTN -> progressive glomerular damage & renal fxn loss (ACEI decrease HTN)

Thickening of the glomerular basement later

66

When should osmolar gap be calculated?

increased AG met acidosis, w/ methanol, ethanol, or ethylene glycol tox (calculate by measured and calculated serum Osm)

67

When should urine anion gap be calculated?

When normal AG met acidosis, to determine if acidosis is due to renal (RTA or acetazolamide) vs. intestinal bicarb loss (diarrhea)

68

What is a common Tx for patients w/ ascites/hypervolemia from decompensated cirrhosis? Risks involved and why?

-Loop diuretics (Furosemide) --> Blocking channel causes increased Na+ to DTC --> elevated H+ and K+ secretion in urine
-Volume contraction and increased aldosterone further promote H+ secretion
-All this leads to: Hypokalemia, Metabolic Alkalosis, and Prerenal AKI

69

What are signs of proteus mirabilis UTI? How can you differentiate from Candida, E Coli, enterococci causes?

-Alkalizatio nof urine (pH >7) which promotes struvite stone formation -> staghorn caliculi
-Urease positive
(normal pH and urease negative for others)

70

What are the symptoms associated w/ hypercalcemia?

-Constipation (altered intestinal smooth muscle tone), anorexia, vomit, weakness, polyuria (defect in concentrating ability of urine), and neuro abnormalities (confusion, lethargy)

71

What is the proper management of a solid testicular mass and why?

Radical orchiectomy (removal of testes + cord) - examine under microscope to determine cancer type and provide additional surgery, RT, Chemo depending on need

High cure rate w/ aggressive management

72

What type of drug is chlorthalidone?

Thiazide diuretics

73

What are the different types of metabolic acidosis and how can you differentiate?

1. Saline-resistant has High urine chloride (excess mineralocorticoid causes H+/K+ loss and Na+ retention -> increased extracell volume -> kidneys excrete NaCl) - Cushing's, Primary hyperaldost, Severe HypoK+
2. Saline responsive has Low urine chloride (due to hypovolemia and hypochloremia)

74

What are the dietary measures to take in preventing recurrent nephrolithiasis and why?

1. Increase fluids (>2L urine/day)
2. Reduce sodium (

75

What drug therapies help prevent recurrent kidney stones?

1. Thiazide diuretics -> lead to mild volume depletion -> compensatory rise of Na reabsorption -> increased passive Ca reabsorption
2. Urine alkalinization (potassium citrate/ bicarbonate salt)
3. Allopurinol (for hyperuricosuria stones)

76

What does side abdominal pain and positional discomfort that radiates to the groin most likely signify, and what diagnostic study would be most helpful?

Obstructive ureterolithiasis -> Abdominal Ultrasound

77

What would urine analysis reveal in patients w/ contrast induced nephropathy?

Muddy-brown granular casts, resolves w/in 3-5 days

78

What does the urinary cyanide nitroprusside test help detect?

Elevated cystine levels --> think Cystinuria, especially w/ hexagonal crystals in urine

79

What clotting complication often occurs with nephrotic syndrome? What are the symptoms?

Renal vein thrombosis and other thromboembolism because of loss of antithrombin 3 (especially w/ membranous glomerulopathy)

Sx = abdominal pain, fever, hematuria

80

What is used to treat SLE w/ renal involvement?

Cyclophosphamide

81

What are the main causes of membranous glomerulonephritis?

Hep B/C, syphillis, gold, penicillamine, SLE and Rheumatoid arthritis

82

What is the cause of acute kidney injury 2/2 acyclovir?

Crystal induced renal tubular obstruction

83

How long does it take for drug induced acute interstitial nephritis to set in? What other findings are associated?

7-10 days after drug exposure
-Skin rash, eosinophilia, eosinophiluria, and pyuria

84

What is the most common initial presentation of patients w/ ADPCKD and how can you diagnose?

HTN + bilateral upper abd masses, renal ultrasound

85

What are the urine/serum osm and urine/serum Na findings in SIADH?

UNa >20, Uosm > 300, Serum Osm

86

What is hyposthenuria? What type of patients are at risk?

IMpairment in in kidney's ability to concentrate urine leading to nocturia
-Pt w/ sickle cell disease/trait may present

87

What are indications for urgent dialysis?

AEIOU - Acidosis, Electrolyte abnormalities, Ingestion (toxic alcohols, Li), Overload, Uremia