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61 Cards in this Set

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What should be the treatment for a patient with hyponatremia and edema?
Hyponatremia - treat with water restriction, because it means that there is a water excess diluting the sodium. Important to treat to prevent brain swelling.

Edema - treat with salt restriction or diuretic, because it means that there is excess salt causing ECFV expansion.
What controls ECFV?
What controls intracellular volume?
ECFV is controlled by body sodium content.

Intracellular volume is controlled by sodium concentration. Exception is hyperglycemia, where glucose becomes an important osmole.
What are some causes of hyponatremia?
SIADH (pain, nausea, med side effects)

Hyperglycemia (which causes water movement from ICF compartment into ECF compartment, diluting the sodium)

Severe CHF, where ADH will be overactive
What are the major effects of prostaglandins in the kidneys?

What stimulates PGI2 (prostacyclin) production in the kidneys?
Afferent arteriolar dilation
Natriuresis

Low ECFV (CHF, cirrhosis) will stimulate PGI2 levels to rise to maintain renal perfusion.
What is the usual stimulus/effectors for sodium regulation? water regulation?
Sodium regulation is stimulated by stretch receptors. Effectors of sodium regulation include:
-RAAS
-Prostaglandins
-Renal sympathetic nerves
-ANP
-Nitric oxide

Water regulation is stimulated by osmolarity in early stages. However, if the effective circulating volume drops to severe levels, then water reabsorption will be increased at the expense of osmolarity.
Effectors include:
-ADH
What are the normal ranges in terms of volume of urine excretes in a day?
450 ml - 10 L/day
What equation is used to estimate creatinine clearance?
Cockcroft Gault equation

CrCl (ml/sec) = [(140 - age) * lean body wt] / (serum creatinine * 50)

► Multiply by 0.85 for women
► Multiply by 60 for ml/min
► Weight measured in kg, creatinine in µmol/L
What are complications of chronic kidney disease?
• Anemia
• Bone disease (abnormal Ca2+ and PO₄ metabolism)
• Hypertension and CVD
• Malnutrition
What is the equation to calculate FE(Na), or fractional excretion of Na?
How do you interpret FE(Na) values?
FE(Na) < 1% → hypovolemia

FE(Na) > 2% → acute tubular necrosis
What is the equation used to assess renal tubular potassium handling?
What is the interpretation of the equation's values?
Transtubular Potassium Gradient

Interpretation:
□ In hyperkalemia, TTKG should be > 7 if tubules functioning normally
□ In hypokalemia, TTKG should be < 2 if tubules functioning normally
What are the most common pathogens that cause UTIs?
The most common: E. coli, Staphylococcus saprophyticus
Others:
Klebsiella pneumoniae
Proteus mirabilis
Group B Strep
Enterococcus
What are the symptoms of lower UTI (cystitis)? What is the difference in symptoms with upper UTI (pyelonephritis)?
Lower UTI (cystitis):
□ Dysuria with turbid urine
□ Urgency
□ Frequency
□ Suprapubic pain
□ Hematuria
□ NO FEVER/CHILLS

Upper UTI (pyelonephritis)
□ Lower UTI symptoms (for 1-2 days)
□ Fever and chills
□ Flank pain
How quickly after a previous void can urine collection for culture be done?

How quickly must it be transported to the lab for processing?
Collect no sooner than 2 hours after previous voiding.

Transported and processed in the laboratory within 2 hours
- If not, then the specimen should be refrigerated, transported on ice, and processed within 24 hours
- This is because certain bacteria can double every 20 mins at room temp.
What are the risk factors for developing asymptomatic bacteriuria?
Women sexually active
Diabetic women
Increase in prevalence with age
◊ 50% of women in long term care
◊ 40% of men in long term care
Impaired urinary voiding
Indwelling urinary devices (catheters)
When should pregnant women be screened for asymptomatic bacteriuria? Why is it important?
12-16 weeks GA

Asymptomatic bacteriuria puts pregnant women at higher risk for
○ Pyelonephritis
○ Premature delivery
○ Infants of low birth weight
When should asymptomatic bacteriuria be treated?
Pregnancy

Prior to urologic/gynecologic surgery
○ Treat with antibiotics the day before surgery, or just before surgery to ensure appropriate antibiotic levels at the time of the procedure

Surgery involving prosthetic material

Catheter removal in patients catheterized > 48 hours post surgery involving prosthetic material
What is the definition of recurrent UTIs?
3 or more episodes per year
What makes a UTI a complicated UTI?
DM
Symptoms of UTI for > 7 days
Age > 55
Pregnancy
Functional/anatomical/metabolic abnormalities of the urinary tract
Chronic catheterization
What antibiotics are used to treat UTIs?
Quinolones (cipro)
- good for uncomplicated UTI (3 day therapy)
- good for complicated UTI (7 day therapy)
- expensive

Septra
- good for uncomplicated UTI (3 day therapy)
- inexpensive

Cefixime/Amoxicillin-clavulanate
- good alternative agent for children
- expensive
- side effect: diarrhea

Nitrofurantoin
- clinically equivalent to Septra
- 7 day course, 100 mg bid
What are the classes of diuretics?
• Potassium sparing
• Carbonic anhydrase inhibitors
• Loop
• Osmotic
• Thiazides
MOA of carbonic anhydrase inhibitors
Inhibit CA, which in term inhibits reabsorption of H+ and HCO3-
Indications for acetazolamide
Acetazolamide = carbonic anhydrase inhibitor.

Indications:
-glaucoma
-acute mountain sickness
-metabolic alkalosis
Side effects of carbonic anhydrase inhibitors (acetazolamide)
Side effects
- Metabolic acidosis
- Renal stones: alkaline urine causes calcium phosphate to precipitate
- Hypokalemia
What are the names of the potassium-sparing diuretics, and what is their MOAs?
Pharmacologic antagonists of aldosterone: spironolactone
MOA: antagonizes the mineralocorticoid receptor, preventing the transcription of ENaC on luminal membrane, and Na+/K+ on basolateral membrane.

Physiologic antagonists of aldosterone: triamterene and amiloride
MOA: antagonizes the ENaC on luminal membrane.
What are the indications for using potassium sparing diuretics?
Adjunct for hypertension and CHF
□ Main purpose is to increase serum K⁺ levels, as other diuretics tend to cause hypokalemia

Primary hyperaldosteronism (spironolactone)
What are the side effects of potassium-sparing diuretics?
Hyperkalemia
□ Especially when combined with other agents that also increase K⁺ such as ACEi and ARBs
Metabolic acidosis
□ Reduced absorption of Na⁺ leads to reduced H⁺ excretion

Spironolactone specific: antagonism of androgen or progesterone receptors
What is the net effect of furosemide on plasma ions?
Decreased Na⁺, K⁺, Cl⁻, Ca²⁺, Mg²⁺, H⁺
What can limit the deliver of loop diuretics into the tubule?
Since loop diuretics are highly plasma protein bound, they can't be filtered into the tubules. Instead, they rely on secretion into proximal tubules.

Compete with NSAIDs and probenecid for secretion in the proximal tubule.
Indications for loop diuretics
Edema
Hypertension
Acute hypercalcemia
Which diuretics cause ototoxicity?
Loop diuretics
What drug can be used to treat acute hypercalcemia?
Furosemide
What is the net effect of thiazides on plasma ions?
Decreased: Na⁺, Cl⁻, K⁺, H⁺

Increased: Ca²⁺
What drug interaction can precipitate Torsades de pointes?
Thiazides used with anti-arrhythmics (quinidine, sotalol). Mechanism is unknown.
Indications for thiazides
Hypertension (first-line)
Edema
Nephrogenic diabetes insipidus
Renal stones
What drug can be used to treat nephrogenic diabetes insipidus?
Thiazides

Mechanism not confirmed, but likely due to ability to reduce intravascular volume, in turn stimulating Na⁺ reabsorption and reducing the amount of fluid presented to distal segments of nephron
Dosing for HCTZ
Edema (diuresis): Oral: 25-100 mg/day in 1-2 doses; maximum: 200 mg/day

Hypertension: Oral: 12.5-50 mg/day
Indications for mannitol
Increased intracranial pressure and cerebral edema

Increased intraocular pressure

Disequilibrium syndrome in dialysis
Which diuretics can cause metabolic acidosis? alkalosis?
Acidosis: carbonic anhydrase inhibitors, and potassium-sparing diuretics

Alkalosis: loop and thiazide
Which diuretics can cause gout? kidney stones?
Gout: loop, thiazide

Kidney stones: CAI (alkalinity),
Which diuretic can be used to treat nephrolithiasis?
Thiazides

Enhances reabsorption of calcium, and therefore reduces formation of calcium-containing renal stones
What are the characteristic signs/symptoms of acute nephritic syndrome?
PHAROH
proteinuria
hypertension
azotemia (nitrogen in blood)
RBC casts
oliguria
hematuria
What is the most common offending organism that causes acute post-infectious glomerulonephritis? How much time after the infection passes before patient experiences acute nephritic syndrome?
Group A Streptococcus, usually pharyngitis.

1-3 weeks after infection.
What is Goodpasture's syndrome?
Autoimmune disease of kidneys and lung hemorrhage.
Anti-GBM antibodies, may cause RPGN.
What are the characteristics of nephrotic syndrome?
(Mx: PACE - protein, albumin, cholesterol, edema)

Proteinuria (greater than 3.5 g/day), may be albumin only
Hypoalbuminemia
Edema
High serum cholesterol
What is the normal amount of protein in the urine?
< 150 mg/day
What is the normal specific gravity for urine?
1.010 (dilute) - 1.030 (concentrated)
What is the most common cause of nephrotic syndrome in children?
Minimal change disease - a disease of unknown etiology that causes effacement of foot processes of glomeruli.
What is the clinical course of minimal change disease? What is the treatment?
Patients present abruptly with nephrotic syndrome
< 6 years old
No hematuria or hypertension
Responds to treatment with steroids
Not progressive
What test should be ordered to help diagnose post-infectious glomerulonephritis?
ASOT (antistreptolysin O titre) blood test
What are some diseases of the glomerulus?

What are some causes of these diseases?
Focal glomerulosclerosis
-Renal disease
-HIV

Rapidly progressive glomerulonephritis
-Goodpasture syndrome
-Vasculitis
-Post-infectious

Post-infectious glomerulonephritis

Minimal change disease
-Unknown T-cell disorder

Diabetic glomerulosclerosis
What info is contained in a urinalysis?
Specific gravity
pH
Protein
Glucose
Ketones
Blood
Nitrite
Leukocyte esterase
Bilirubin
Urobilinogen
What is the normal physiological pH of blood?
7.4
What is the normal serum concentration of HCO3-?
24 mmol/L
What is the Henderson-Hasselbalch equation?
What is the modified version used to calculate pH from HCO3- and PaCO2?
pH = 6.1 + log ([HCO₃⁻]/0.03*PaCO₂)
What is the anion gap equation? What is a normal AG?
What are the causes of a high AG?
AG = Na⁺ - (Cl⁻ + HCO₃⁻)
Normal is 8-12 mEq/L
Calculated to identify the presence of significant unmeasured anions

Mx: MUDPILES
• Methanol
• Uremia
• Diabetic ketoacidosis
• Propylene glycol
• Isoniazid
• Lactic acidosis
• Ethylene glycol
• Salicylates
What are some cases where anion gap is normal in the presence of metabolic acidosis?
Diarrhea
Renal tubular acidosis

This is called hyperchloremic acidosis.
What is the equation for osmolar gap?
What does a high osmolar gap signify?
Osmolar gap = Measured osmolarity - 2 * [Na⁺] + [glucose] + [Urea] + [EtOH]

High OG identifies presence of uncharged osmols in serum (usually toxic alcohols)
□ Ethanol
□ Methanol
□ Ethylene glycol
□ Acetone
□ Isopropryl alcohol
What are the 3 types of renal tubular acidosis?
Type 1 (distal)
□ Defective H⁺ secretion in distal tubule

Type 2 (proximal)
□ Impaired HCO₃⁻ reabsorption in proximal tubule

Type 4 (aldosterone deficiency/resistance)
□ Impairs H⁺ and K⁺ secretion
□ Patients become hyperkalemic
□ Impairs ammonium production

Note that there is no type 3 RTA
What are the potential causes of metabolic alkalosis?
Vomiting, nasogastric suctioning, diuretic therapy.
What are the three stages of treating hyperkalemia?
a) Stabilize cardiac membrane
• Calcium gluconate

b) Use of agents that cause an intracellular shift of the potassium
• Insulin
• Sodium bicarbonate

c) Removal of potassium from the body
• Diuretics
• Na polystyrene sulfonate (kayexalate)
• Dialysis