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464 Cards in this Set

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Polycystic Kidney Disease -
genetics
AD or AR
Polycystic Kidney Disease -
AD -
b/l
cysts progressively develop
Polycystic Kidney Disease -AD -
late onset
usu asymp until 30 y/o
50% - ESRD with dialysis
by 60 y/o
Polycystic Kidney Disease -
AR -
less common
more severe
often lethal in 1st few years
infants and kids
Polycystic Kidney Disease -
AR -
renal failure
liver fibrosis
portal HTN
Polycystic Kidney Disease -
Hx/PE
Hematuria
HTN
Polycystic Kidney Disease -
Hx/
pain -
sharp & localized
from ruptured cysts,
infection,
renal calculi
Polycystic Kidney Disease -
PE
large, palpable kidneys
liver cysts
berry aneurysms
Polycystic Kidney Disease -
mitral valve prolapse (MİT valve)
colonic diverticula
Polycystic Kidney Disease -
Dx
US
or CT
Polycystic Kidney Disease -
Tx
Prevent complications,
slow progression to ESRD:
early management of UTI -
prevent renal cyst infection
control BP
Polycystic Kidney Disease -
Tx ESRD -
dialysis
renal transplant
Nephrolithiasis -
MC in what population
Risk factors
MC in older men
Nephrolithiasis -
Risk factors
fam Hx
low fluid intake
gout
postcolectomy
postileostomy
spec. enzyme d/o
RTA
hyperparathyroidism
Nephrolithiasis -
Hx/PE
Acute onset
severe colicky flank pain
may radiate to testes or vulva
n/v
pt. freq. shift position
Nephrolithiasis -
Dx - best 1st test
UA
Nephrolithiasis -
Dx - test of choice
Spiral CT
Nephrolithiasis -
Dx
KUB
renal US
IVP - confirm
noncontrast abdom CT
Nephrolithiasis -
Dx UA -
hematuria
altered urine pH
Nephrolithiasis -
Init Tx -
hydration
analgesia
Nephrolithiasis -
Tx < 5mm -
can pass thru urethra
Nephrolithiasis -
Tx < 3 cm -
ESWL
(extracorporeal shock wave
lithotripsy)
percutaneous nephrolithotomy
Nephrolithiasis -
MC (83%)
Calcium Oxalate/
Calcium Phosphate
Nephrolithiasis -
Calcium Oxalate/
Calcium Phosphate
Characteristics
idiopathic hypercalciuria
primary hyperparathyroidism
hyperoxaluria
hypocitraturia
alkaline urine
radiopaque
Nephrolithiasis -
Calcium Oxalate/
Calcium Phosphate
Tx
Tx -
hydration
thiazide diuretic
Nephrolithiasis -
Struvite (Mg-NH4-PO4)
Characteristics
"Triple phosphate stones"
due to urease-producing org. -
Proteus
staghorn calculi
alkaline urine
radiopaque
Nephrolithiasis -
Struvite (Mg-NH4-PO4)
Tx
Tx -
hydration
treat UTI, if present
Nephrolithiasis -
Uric Acid
Characteristics
Hyperuricemia
gout
high purine turnover states
acidic urine (pH < 5.5)
radiolucent
Nephrolithiasis -
Uric Acid
Tx
hydration
alkalinize urine with citrate
citrate converted to
HCO3 in liver
Nephrolithiasis -
Cystine
Characteristics
Tx
Due to defect of tubular
amino acid transporter for
cystine, ornithine, lysine
& arginine (COLA)
yellow-brown hexagonal crystal
radiopaque
Nephrolithiasis -
Cystine
Tx
hydration
alkalinize urine
Nephrolithiasis -
Cystine
Tx if neither works -
penicillamine
Ureteral Reflux -
What is it
Retrograde flow of urine
from bladder back up
due to insuff. submucosal
length of ureter
Ureteral Reflux -
when it cause problem
=> ineffect. restricting
retrograde flow during
contraction of bladder
recurrent UTIs
Ureteral Reflux -
Dx
Tx
Dx -
VCUG:
Voiding CystoUrethroGram
detects abnorm at ureteral
insertion site
classifies grade of reflux
Ureteral Reflux -
Tx -
Tx -
tx infections aggressively
Ureteral Reflux -
Tx ■ mild reflux -
no dilation
often resolves spontan
Ureteral Reflux -
Tx ■ mod to severe reflux -
surgery
(uret. reimplantation)
MC kidney cancer (80-90%)
Renal Cell Carcinoma -
Renal Cell Carcinoma -
adeno or squa
adenocarcinoma
Renal Cell Carcinoma -
arises from
tubular epith cells
Renal Cell Carcinoma -
What is it
Risk factors
=> renal vein => IVC
=> mets to lung & bone
Renal Cell Carcinoma -
risk factors -
men
smoking
VHL disease
Renal Cell Carcinoma -
Classic triad -
hematuria
flank pain
palpable flank mass
Renal Cell Carcinoma -
Hx
polycythemia
constitutional Sxs
enlargement of left testicle
Renal Cell Carcinoma -
Tx
Surgical resection -
curative if local
notoriously resistant to
chemo & radiation
Cryptorchidism -
Failure of testes to
descend into scrotum
b/l assoc. with
oligospermia & infertility
Cryptorchidism -
risk factor -
prematurity
Cryptorchidism -
Hx/PE
Testes can't be manipulated
into scrotal sac with
gentle pressure
Cryptorchidism -
Hx/PE
may be palpated anywhere along
inguinal canal or in abdomen
Cryptorchidism -
Tx
Orchiopexy -
after 1 y/o & before 5 y/o
in 99%, testes descend by 1 yr
Cryptorchidism -
Tx
find later in life -
orchiectomy
to avoid risk of testicular Ca
What is it
10-25% of mid-aged or elderly
fail to init, fill or store
Erectile Dysfunction -
risk factors -
DM
atherosclerosis
meds - B-blockers, SSRIs
HTN
heart dis.
surgery or radiation for
prostate cancer
spinal cord injury
Erectile Dysfunction -
Hx/PE
Ask about -
risk factors
meds
recent life changes
psych stressors
Erectile Dysfunction -
Hx/PE
psychological -
if pt. has nocturnal or
early-morning erections
situation dependent
Erectile Dysfunction -
Dx
Check for hypogonadism
testosterone levels
gonadotropin levels
prolactin levels
Erectile Dysfunction -
Dx
eval for neuro dysfunction -
anal tone
lwr ext sensations
Erectile Dysfunction -
Tx
Psychotherapy
sex therapy
Erectile Dysfunction -
Tx
- if hypogonadism
testosterone
Erectile Dysfunction -
Tx
sildenafil -
PDE5 inhibitor
inc. cGMP
=> smooth mus relaxation
=> inc. blood flow in
corpora cavernosa
Nephritic Syndrome -
What is it
Manifestation of glomerular
inflammation (glomerulonephritis)
Nephritic Syndrome -
Hx/PE
Hematuria - smoky-brown
HTN
oliguria
Nephritic Syndrome -
Hx/PE
edema -
low pressure areas
(periorbital,
scrotum)
Nephritic Syndrome -
Dx
UA -
hematuria
(possible) mild proteinuria
dec. GFR
inc. BUN/Cr
c'
ANA
ANCA
anti-gbm Ab
renal Bx
Nephritic Syndrome -
Tx (in general)
Tx HTN, fluid overload
and uremia -
salt restriction
water restriction
diuretics
dialysis (if nec.)
corticosteroids
Postinfectious GN -
What is it
Nephritic Syndrome
Postinfectious GN -
usu assoc. with
recent strep infection
group A, B-hemolytic
Postinfectious GN -
Hx/PE
Smoky-brown urine
HTN
oliguria
periorbital edema
Postinfectious GN -
Labs & Histology
Low serum C3
inc. ASO titer
Postinfectious GN -
immunofluorescence
lumpy-bumpy
Postinfectious GN -
Tx & Prognosis
Supportive
almost all kids & most adults
have complete recovery
MC type worldwide
nephritic syndrome
IgA Nephropathy (Berger's) -
IgA Nephropathy (Berger's) -
age sex
young men
IgA Nephropathy (Berger's) -
assoc. with
URI or
GI infections
IgA Nephropathy (Berger's) -
Hx/PE
Gross hematuria
Postinfectious GN -
What is it
Nephritic Syndrome
Postinfectious GN -
usu assoc. with
recent strep infection
group A, B-hemolytic
Postinfectious GN -
Hx/PE
Smoky-brown urine
HTN
oliguria
periorbital edema
Postinfectious GN -
Labs & Histology
Low serum C3
inc. ASO titer
Postinfectious GN -
immunofluorescence
lumpy-bumpy
Postinfectious GN -
Tx & Prognosis
Supportive
almost all kids & most adults
have complete recovery
MC type worldwide
nephritic syndrome
IgA Nephropathy (Berger's) -
IgA Nephropathy (Berger's) -
age sex
young men
IgA Nephropathy (Berger's) -
assoc. with
URI or
GI infections
IgA Nephropathy (Berger's) -
Hx/PE
Gross hematuria
IgA Nephropathy (Berger's) -
Labs & Histology
Inc. serum IgA
IgA Nephropathy (Berger's) -
Bx & immunofluorescence -
mesangial IgA deposits
IgA Nephropathy (Berger's) -
Tx
Glucocorticoids
IgA Nephropathy (Berger's) -
Prognosis
20% progress to ESRD
Wegener's Granulomatosis -
What is it
Nephritic Syndrome
granulomatous inflammation of
respiratory tract & kidney
necrotizing vasculitis
paucimmune form of RPGN
Wegener's Granulomatosis -
Hx/PE
Fever
weight loss
hematuria
respiratory & sinus Sxs
Wegener's Granulomatosis -
cavitary pulmonary lesions -
bleed
=> hemoptysis
Wegener's Granulomatosis -
Labs & Histology
c-ANCA
Wegener's Granulomatosis -
Tx
High-dose corticosteroids
cytotoxic agents
Wegener's Granulomatosis -
Prognosis
pts. tend to have
freq relapses
Alport's Syndrome -
What is it
Nephritic Syndrome
hereditary
Alport's Syndrome -
age sex
boys 5-20 y/o
Alport's Syndrome -
Hx/PE
Asymp hematuria
nerve deafness
eye disorders
Alport's Syndrome -
Labs & Histology
GBM splitting on
electron microscope
Alport's Syndrome -
Tx & Prognosis
Progress to RF
anti-GBM nephritis may recur
after transplant
Goodpasture's Syndrome -
What is it
Nephritic syndrome
GN & pulmonary hemorrhage
immune form of RPGN
Goodpasture's Syndrome -
age sex
men in mid 20's
Goodpasture's Syndrome -
Hx/PE
Hemoptysis
dyspnea
possible respiratory failure
Goodpasture's Syndrome -
Labs & Histology
Linear anti-GBM on IF
iron-def. anemia
Goodpasture's Syndrome -
CXR
- pulmonary infiltrates
Goodpasture's Syndrome -
sputum- pasteurun elindeki beher
- hemosiderin-filled
macrophages
Goodpasture's Syndrome -
Tx & Prognosis
Plasma exchange therapy (plasmapheresis)
pulsed steroids
cyclophosphamide
Goodpasture's Syndrome -
Prognosis
may progress to ESRD
Nephrotic Syndrome -
What is it
Inc. permeability of
glomerulus to protein =>
proteinuria = or > 3.5 g/day
hypoalbuminemia
hyperlipidemia
hyperlipiduria
edema
predisposed to hypercoag state
Testere
1/3 due to systemic dis. -
DM
SLE
amyloidosis
TestereHx/PE
Generalized edema
foamy urine
Testereif severe -
dyspnea
ascites
Testere
inc. susceptibility to -
infections
ven. thrombosis
PE
Nephrotic Syndrome -
Testere
Testere
Dx
UA -
proteinuria > 3.5g/day
lipiduria
Testere
Dx
blood
dec. albumin (< 3g/dL)
hyperlipidemia
Testere
Dx Bx -
Dx underlying etiology
Testere Tx (in general)
Steroids - best init. Tx
cyclophosphamide
restrict salt
diuretics
statins
Minimal Change Disease -
What is it
Mini Testere
Mini Testere
Nephrotic syndrome
common in children
idiopathic etiology
Mini Testere Tendency towards -
infections
thrombosis
Mini Testere Labs & Histology
Normal under light microscope
electron microscope shows -
fusion of epith foot processes
Mini Testere Tx & Prognosis
Steroids
excellent prognosis
Focal Segmental
Glomerulosclerosis (FSGS) -
What is it
NA TV odasi
NA TV odasi
Nephrotic syndrome
idiopathic
IVDU
HIV
NA TV odasi
Especially common in black men
with uncontrolled HTN
NA TV odasi
Labs & Histology
Microscopic hematuria
NA TV odasi Bx -
sclerosis in capillary tufts
NA TV odasi
Tx & Prognosis
Prednisone
cytotoxic therapy
Poor prognosis
Membranous Nephropathy -
What is it
NA Mutfak
MC white adult nephropathy
NA Mutfak
Membranous Nephropathy -
What is it
NA Mutfak
NA Mutfak
MC form in adults
MC idiopathic form in adults
MC white adult nephropathy
NA Mutfak
NA Mutfak Neph...?
Nephrotic syndrome
NA Mutfak
Hx/PE
immune-complex disease
NA Mutfak
MC form in adults
MC idiopathic form in adults
NA Mutfak
Associated with - dolap
HBV Ates B
syphilis Filiz abla
malaria
gold (drug)
NA Mutfak Neph...?
Nephrotic syndrome
NA Mutfak
Associated with - dolap
penicillamine -penis in mine-
cancer
SLE
NA Mutfak
Hx/PE
immune-complex disease
NA Mutfak
Associated with - dolap
HBV Ates B
syphilis Filiz abla
malaria
gold (drug)
NA Mutfak
Labs & Histology
"spike and dome"
due to granular deposits
of IgG and C3
at basement membrane
NA Mutfak
Associated with - dolap
penicillamine -penis in mine-
cancer
SLE
NA Mutfak
Tx & Prognosis
Steroids are of little use
NA Mutfak
Labs & Histology
"spike and dome"
due to granular deposits
of IgG and C3
at basement membrane
Diabetic Nephropathy -
What is it
NA Yatak odasi
NA Mutfak
Tx & Prognosis
Steroids are of little use
Diabetic Nephropathy -
What is it
NA Yatak odasi
NA Yatak odasi
Nephrotic syndome-testere
Diffuse hyalinization-plastik
nodular glomerulosclerosis
Kimmelstiel-Wilson lesions
NA Yatak odasi
Hx/PE
Usually have long-standing,
poorly-controlled DM
NA Yatak odasi
Labs & Histology
Thickened glomerular
basement membrane
increased mesangial matrix
NA Yatak odasi
Tx & Prognosis
Tight glucose control
protein restriction
ACEIs
Lupus Nephritis -
wolf
wolf Nephritis -
Nephrotic & nephritic syndrome
WHO types I-V
severity of renal disease
determines overall prognosis
wolf Nephritis -
Hx/PE
Proteinuria
or RBCs in UA
wolf Nephritis -
Labs & Histology
Mesangial proliferation
subendothelial immune-complex
deposits
wolf Nephritis -
Tx & Prognosis
May reduce dis. progression -
prednisone
cytotoxic therapy
Renal Amyloidosis -
What is it
Nephrotic syndrome
Renal Amyloidosis -
primary -
plasma cell dyscrasia
Renal Amyloidosis -
secondary -
infectious
inflammatory
Renal Amyloidosis -
Labs & Histology
Pts may have multiple myeloma
or chronic inflammatory dis.
(RA, TB)
Renal Amyloidosis -
Labs & Histology
Abdom fat Bx
congo red stain
apple-green birefringence
under polarized light
Renal Amyloidosis -
Tx & Prognosis
Prednisone
melphalan
BMT - for multiple myeloma
Membranoproliferative
Nephropathy (MPGN) -
What is it
Nephrotic (TESTERE) & nephritic (a.o.) syndrome
3 types
Membranoproliferative
Nephropathy (MPGN) -
Immune deposits
low complement
associated with HCV
Membranoproliferative
Nephropathy (MPGN) -
slow progression to RF
Membranoproliferative
Nephropathy (MPGN) -
Labs & Histology
"Tram tracks" -
double-layered basement memb
Membranoproliferative
Nephropathy (MPGN) -
type I -
subendo deposits
Membranoproliferative
Nephropathy (MPGN) -
Labs & Histology
type II -
dec. C3
C3 nephritic factor
(IgG autoAb)
Membranoproliferative
Nephropathy (MPGN) -
Tx & Prognosis
Corticosteroids
cytotoxic agents
BPH -
What is it
Normal part of aging
seen in > 80% by age 80
pts. usually > 50 y/o
BPH -
Hx/PE
Obstructive -
hesitancy
weak stream
intermittent stream
incomplete emptying
urinary retention
bladder fullness
BPH -
irritative -
nocturia
daytime frequency
urge incontinence
opening hematuria
BPH -
DRE -
uniformly enlarged
rubbery
BPH in central zone
(may not be detected on DRE)
BPH -
Dx
R/o possible dangerous causes
DRE
UA/UC
Cr
BPH -
Dx
Not recommended for BPH -
PSA & cystoscopy
BPH -
Tx
Mild - reassurance
mod to severe - surgery
BPH -
Tx
terazosin
finasteride
TURP
open prostatectomy
Membranoproliferative
Nephropathy (MPGN) -
Labs & Histology
type II -
dec. C3
C3 nephritic factor
(IgG autoAb)
Membranoproliferative
Nephropathy (MPGN) -
Tx & Prognosis
Corticosteroids
cytotoxic agents
BPH -
What is it
Normal part of aging
seen in > 80% by age 80
pts. usually > 50 y/o
BPH -
Hx/PE
Obstructive -
hesitancy
weak stream
intermittent stream
incomplete emptying
urinary retention
bladder fullness
BPH -
irritative -
nocturia
daytime frequency
urge incontinence
opening hematuria
BPH -
DRE -
uniformly enlarged
rubbery
BPH in central zone
(may not be detected on DRE)
BPH -
Dx
R/o possible dangerous causes
DRE
UA/UC
Cr
BPH -
Dx
Not recommended for BPH -
PSA & cystoscopy
BPH -
Tx
Mild - reassurance
mod to severe - surgery
BPH -
Tx
terazosin
finasteride
TURP
open prostatectomy
MC cancer in men
Prostate Cancer -
second cause of
cancer death in men
Prostate Cancer -
Prostate Cancer -
risk factors -
age
family Hx
Prostate Cancer -
Hx/PE
Usually asymp
rarely causes Sxs until advanced
urinary retention
Prostate Cancer -
dec. force of urine stream
lymphedema
constitutional Sxs
back pain
Prostate Cancer -
DRE -
palpable nodule
area of induration
early Ca usually not detectable
tender prostate = prostatitis
Prostate Cancer -
Dx
Clinical
markedly elevated PSA
US-guided transrectal Bx
Gleason grade
CXR
bone scan
Gleason grade -
based on histology
Gleason grade -grades 1-5 on two features –
level of differentiation
structural architecture
the two scores are added
Poorly differentiated tumors -
score 8-10
worst prognosis
Prostate Cancer -
■ Tx based on -
aggression of tumor
pt's risk of dying
Prostate Cancer -
Tx
■ watchful waiting -
elderly & low-grade
Prostate Cancer -
Tx
■ radical prostatectomy & RT -
inc. risk of incontinence
inc. risk of impotence
Prostate Cancer -
Tx
■ PSA -
use to eval post-Tx
check for dis. recurrence
Prostate Cancer -
Tx
■ metastasis -
chemo & androgen ablation:
GnRH agonists
flutamide
orchiectomy
Prostate Cancer -
Prevention
Annual DRE -
> 50 y/o
> 45 y/o if Black
> 45 y/o if pos. family Hx
Prostate Cancer -
Prevention
also screen
also screen with PSA
2nd MC urologic cancer
Bladder Cancer -
MC malig tumor - urinary tract
transitional cell Ca
Bladder Cancer -
Bladder Cancer -
SEX AGE
men - 60s & 70s
Bladder Cancer -
risk factors -
smoking
chronic bladder infections
calculous dis.
aniline dye
hair dye
Bladder Cancer -
Hx/PE
Asymp in early stages
gross hematuria
freq.
urgency
dysuria
Bladder Cancer -
Dx
UA
cytology
IVP
Bladder Cancer -
diagnostic
cystoscopy with Bx -
Bladder Cancer -
may also -
may also -
US
MRI
pelvic CT
Bladder Cancer -
Tx
■ superficial -
transurethral resection or
intravesicular chemo with
mitomycin-C or BCG
Bladder Cancer -
Tx
■ CIS -
intravesicular chemo
Bladder Cancer -
Tx
■ large, hi-grade recurrent -
intravesicular chemo
Bladder Cancer -
Tx
■ invasive without mets -
chemo
Bladder Cancer -
Tx
■ distant mets -
aggressive surgery
RT
MC malignancy in 15-35 y/o
Testicular Cancer -
Testicular Cancer -
Heterogenous group
almost all are malignant
Testicular Cancer -
95% derive from ????
95% derive from germ cells
Testicular Cancer -
seminomas peak at ???? y/o
seminomas peak at 40-50 y/o
Testicular Cancer -
- risk factor
Klinefelter's
cryptorchidism
cryptorchidism -
RISK OF NEOPLASIA
cryptorchidism -
inc. risk of neoplasia
in both testes
Testicular Cancer -
Hx/PE
Painless enlargement of testis
Testicular Cancer -
Dx
B-hCG -
inc. in
B-hCG -
inc. in choriocarcinomas
inc. in 10% of seminomas
Testicular Cancer -
Dx
AFP -
inc. in
AFP -
inc. in endodermal sinus
(yolk sac) tumors
Testicular Cancer -
Tx
Seminomas -
very radiosensitive
also respond to chemo
Testicular Cancer -
Tx
nonseminomatous germ cell -
platinum-based chemo
SIADH -
What is it
What is it associated with
Euvolemic hyponatremia
from nonosmotically-stimulated
SIADH -
ADH release
associated with -
CNS dis.
pulmonary dis.
ectopic tumor/
paraneoplastic syndromes
drugs
surgery
SIADH -
Dx
Urine osmolality > 50-100 mOsm/kg
concurrent serum hyposmolarity
no physio reason for inc. ADH
urinary sodium > 20 mEq/L
SIADH
Tx
Tx underlying cause

moderate - NS and furosemide
severe (Sxs) -
hypertonic saline
then furosemide
SIADH
Tx
and if
mild
- restrict fluids
SIADH
Tx
and
if chronic -
demeclocycline or lithium -
ADH antag
Diabetes Insipidus -
TYPES
Central or nephrogenic
Diabetes Insipidus -
central -
post pit. doesn't secrete ADH
Diabetes Insipidus -
central -
causes -
tumor
ischemia (Sheehan's)
trauma
infection
autoimmune d/o
Diabetes Insipidus -
kidneys don't respond to ADH
nephrogenic -
Diabetes Insipidus -
causes -AND DRUGS
renal dis.
drugs
(lithium, demeclocycline)
Diabetes Insipidus -
Hx/PE
Polydipsia
polyuria
persistent thirst
dilute urine
Diabetes Insipidus -
if don't have unlimited
access to water -
dehydration
hypernatremia
Diabetes Insipidus -
Dx
Water deprivation test
Water deprivation test
medical test[1] for the purposes of diagnosing the causes of polydipsia
Water deprivation test RESULT FOR
excessive intake of fluid (primary polydipsia)
> 800 mosmol/kg
Water deprivation test
RESULT FOR a defect in the kidneys' response to ADH production (nephrogenic diabetes insipidus)
< 300 mosmol/kg
Water deprivation test
RESULT FOR a defect in ADH production (central/neurogenic diabetes insipidus)
< 300 mosmol/kg
Diabetes Insipidus -
Dx DDAVP challenge -
desmopressin mimics ADH
Diabetes Insipidus -
Dx if central -
DDAVP challenge =>
dec. urine output
inc. urine osmolarity
thus, MRI (to check for mass)
Diabetes Insipidus -
Dx if nephrogenic -
DDAVP challenge
will not dec. urine output
Diabetes Insipidus -
Tx
central -
DDAVP subcutaneously
Diabetes Insipidus -
Tx
nephrogenic -
thiazide diuretics (HCTZ)
amiloride
chlorthalidone
Acetazolamide -
Site of Action
Proximal convoluted tubule
Acetazolamide -
Mechanism
inhibits carbonic anhydrase
Acetazolamide -
Clinical Use FOR EYE
Glaucoma
Acetazolamide -
Clinical Use FOR ACID BASE
urinary alkalinization
metabolic alkalosis
altitude sickness
Acetazolamide -
Clinical Use MET DISEASE
cysteinuria
Acetazolamide -
Toxicity
Hyperchloremic metab acidosis
sulfa allergy
Renal Tubular Acidosis -
What is it
Failure of kidneys to
acidify urine
net dec. in -
tubular H+ secretion
or HCO3 reabsorption
=> nonanion-gap metab acidosis
RTA Type I -
What is it
Distal tubule
H+/K+ pump is broken
=> failure to secrete H+
RTA Type I -
K? pH?
serum K+ stays low
urinary pH > 5.3
RTA Type I -
Causes
usually sporadic
lithium
amphotericin
analgesics
collagen vascular dis.
cirrhosis
chronic urinary tract obstruct
sickle cell
nephrocalcinosis -
also a consequence
RTA Type I -
Complications
nephrolithiasis
secondary hyperaldosteronism
RTA Type I -
Tx
potassium citrate
RTA Type I -
Dx/Test -
acid load
RTA Type II -
What is it
Proximal tubule
cells don't reabsorb HCO3
urinary pH init > 5.3
RTA Type II -
distal tubular cells work OK
=> urinary pH < 5.3 when
serum gets acidic
RTA Type II -
Causes
hereditary
carbonic anhydrase inhibitors
Fanconi's syn
multiple myeloma
RTA Type II -
Complications
rickets
osteomalacia
RTA Type II -
Tx
Tx -
potassium citrate
RTA Type II -
Dx/Test
Dx/Test -
bicarb load
RTA Type IV -
What is it
Adrenal insensitivity to
angiotensin 2
aldosterone deficient
RTA Type IV -
What is it
serum K+ is high
usually asymp hyperkalemia
hyperchloremic metab acidosis
(nonanion/normal metab acidosis)
RTA Type IV -
Causes
hyporeninemic hypoaldosterone:
DM (infarcts JG)
ACEIs
NSAIDs
RTA Type IV -
Causes
addison's
sickle cell
renal insufficiency
RTA Type IV -
Complications
hyperkalemia
RTA Type IV -
Tx
fludrocortisone
furosemide - if HTN
kayexelate
RTA Type IV -
Dx/Test
restrict salt
Acute Renal Failure -
What is it
Rapid dec. in renal function
over days to weeks
=> accum of nitrogenous products,
fluid & electrolyte d/o dev.
Acute Renal Failure -
prerenal caused by -
dec. renal plasma flow
(inadequate renal perfusion)
Acute Renal Failure -
renal caused by -
intrinsic renal dis. or damage
Acute Renal Failure -
postrenal caused by -
obstruction of urinary outflow
both kidneys must be
obstructed to cause
significant azotemia
Acute Renal Failure -
Hx -
uremia:
malaise
oliguria
fatigue
anorexia
n/v
Acute Renal Failure -
PE -
asterixis
HTN
dec. urinary output
inc. RR
Acute Renal Failure -
pericardial friction rub -
if uremic pericarditis
asterixis
(also called the flapping tremor, or liver flap) is a tremor of the wrist when the wrist is extended (dorsiflexion)
Acute Renal Failure -
Hx/PE
prerenal -
hypovolemia
orthostasis
oliguria
Acute Renal Failure -
Hx/PE
postrenal -
anuria
distended bladder
Acute Renal Failure -
Hx/PE
acute interstitial nephritis -
fever
rash
Acute Renal Failure -
Dx
CBC
BUN/Cr
electrolytes
FE(Na) - if oliguric
Acute Renal Failure -
Dx
urine sediment -
RBC
WBC
casts
eosinophils
Acute Renal Failure -
Dx
urinary catheter
renal US
Acute Renal Failure -
Tx
■ Balance fluid & electrolytes
■ dialysis if indicated
Acute Renal Failure -
Tx ■ acute/allergic
interstitial nephritis -
adjust/discontinue
offending meds
Acute Renal Failure -
Tx ■ glomerulonephritis -
corticosteroids
cytotoxics
Acute Renal Failure -
Complications
Chronic renal failure
=> dialysis
dialysis -
■ prevent buildup of:
K+
H+
toxic metabolites
dialysis -■ inc. risk for ???
■ inc. risk for CAD
Acute Renal Failure -
What is Prerenal % for FE(Na)
FE(Na) is < 1%
Acute Renal Failure -
What is Prerenal No. for U(Na)
U(Na) is < 20
Acute Renal Failure -
What is Prerenal Ratio
for BUN/Cr
BUN/Cr is > 20
Acute Renal Failure -
FE(Na) -
How do you calculate it
U/P Na
divided by
U/P Cr
Dialysis -
What are the indications
AEIOU
AEIOU
Acidosis
Electrolyte abnormalities
(hyperkalemia)
Ingestions
Overload of fluid
Uremic Sxs -
bleeding
nausea
pruritus
myoclonus
Uremic Sxs -
pericarditis
encephalopathy
Hyponatremia -
What is it
Serum sodium < 135 mEq/L
Hyponatremia -
Hx/PE
May be asymp
Hyponatremia -
conciousness
confusion
lethargy
Hyponatremia -
Hx/PE muscle ??
muscle cramps
Hyponatremia -
Hx/PE GIS
nausea
Hyponatremia -
Hx/PE can progress to -
seizures
status epilepticus
coma
Hyponatremia -
Dx Classified by - 3 factor
serum osmolality
volume status (by PE)
urinary Na+
Hyponatremia -
What are the types
of osmolalities
Low - < 280 mEq/L
High - > 295 mEq/L
Normal -280-295 mEq/L
High -
hyperglycemia
hypertonic infusion (mannitol)
Normal -
hyperlipidemia
hyperproteinemia
pseudohyponatremia
Low -
hypervolemic hyponatremia
euvolemic hyponatremia
hypovolemic hyponatremia
Hyponatremia -
Tx
Chronic hyponatremia should
be corrected slowly
to prevent central pontine
myelinolysis
Hypervolemic Hyponatremia -
What is it
Inc. in Na+ & total body wt.
Inc. greater in TBW
Hypervolemic Hyponatremia -
Etiologies
edematous states:
renal failure
nephrotic syndrome
cirrhosis
CHF
Hypervolemic Hyponatremia -
Tx -
restrict salt and water
Euvolemic Hyponatremia - LAZ ziya
What is it
Total body Na+ normal
total body water has inc.
LAZ ziya
Etiologies
SIADH- JC and the car
hypothyroidism- tirtil
renal failure death ren
drugs
psychogenic polydipsia
adrenal insufficiency
LAZ ziya
Tx
restrict salt and water
Hypovolemic Hyponatremia - husrev aga
What is it
Etiologies
Tx
Dec. in total body Na+
and total body water
more Na+ than water is lost
husrev aga
Etiologies
diuretics
vomiting
diarrhea
third spacing
dehydration
husrev aga
Tx
replete volume with
normal saline
Hypernatremia -
What is it
Serum Na+ > 145 mEq/L
Hypernatremia -
Hx/PE
Thirst
oliguria or polyuria
(depends on etiology)
mental status changes
Hypernatremia -
Hx/PE
weakness
focal neuro deficits
seizures
"doughy" skin
Hypernatremia -
Dx
Measure urine vol.
measure urine osmolality
Hypernatremia -
Dx
hypervolemic hyperNa+ -
inc. aldosterone or
excess Na+ (IV saline)
Hypernatremia -
Dx
min vol (500 mL/day) of
max concentrated urine
(> 400 mOsm/kg) -
adequate renal response
Hypernatremia -
Dx
inadequate free water replaced
fluid loss from -
dec. intake
diuretics
glycosuria
3rd spacing
Hypernatremia -
Dx
lg vol of dilute urine -
diabetes insipidus
Hypernatremia -
Tx
■ Tx underlying causes
■ correct gradually over
48-72 hrs
(to prevent neuro damage
secondary to cerebral edema)
■ replace free water deficit -
isotonic fluids
Hypercalcemia -
What is it
What causes it
Serum Ca2+ > 10.2 mg/dL
> 15 mg/dL = medical emergency
Hypercalcemia -
MCC -
hyperparathyroidism
malignancy
Hypercalcemia -
common causes -
CHIMPANZEES
Calcium supplementation
Hyperparathyroidism
Iatrogenic (thiazides)
Immobility
Milk alkali syndrome
Paget's dis.
Addison's
Acromegaly
Neoplasm
Zollinger-Ellison syndrome
Excess vitamin A
Excess vitamin D
Sarcoidosis
and other granulomatous dis.
Hypercalcemia -
Hx/PE
"Bones, stones, abdom groans,
psych overtones"
fractures
kidney stones
n/v
constipation
anorexia
weakness
fatigue
altered mental status
Hypercalcemia -
Bones
fractures
Hypercalcemia -
stones
kidney stones
Hypercalcemia -
abdom groans
n/v
constipation
Hypercalcemia -
psych overtones
anorexia
altered mental status
Hypercalcemia -
general hx
weakness
fatigue
Hypercalcemia -
Dx
EKG
- short QT
Hypercalcemia -
Dx
total Ca2+
ionized Ca2+
albumin
phosphate
Hypercalcemia -
Dx
PTH
PTHrP
vit D
TSH
serum immunoelectrophoresis
Hypercalcemia -
Tx
IV hydration
then furosemide
Hypercalcemia -
Tx if severe or refractory -
calcitonin
bisphosphonates
(pamidronate)
glucocorticoids
dialysis
Hypocalcemia -
What is it
What causes it
Serum Ca2+ < 8.5 mg/dL
Hypocalcemia -
caused by - hormonal
hypoparathyroidism
(postsurgery, idiopathic)
medullary thyroid cancer
(excess calcitonin)
Hypocalcemia -
nutritional cause
malnutrition
vit D def.
Hypocalcemia -
caused by electrolyte disturbance
hypomagnesemia
Hypocalcemia -
caused by renal
renal insufficiency
Hypocalcemia -
caused by tissue precipitation
pseudohypoparathyroidism
acute pancreatitis
pseudohypoparathyroidism
Pseudohypoparathyroidism is a condition associated primarily with resistance to the parathyroid hormone.[1]
pseudohypoparathyroidism pathogenesis
Its pathogenesis has been linked to dysfunctional G Proteins (in particular, Gs alpha subunit).
Hypocalcemia serum Ca2+ may be falsely
low in
serum Ca2+ may be falsely
low in hypoalbuminemia
Hypocalcemia -
Hx/PE due to musculature
Abdom muscle cramps
tetany
perioral &amp; acral paresthesias
dyspnea
Hypocalcemia -
Hx/PE due to brain functions
convulsions
Hypocalcemia -
Hx/PE
Chvostek's sign
Trousseau's sign
Hypocalcemia -EKG -
prolonged QT
Hypocalcemia -
Dx
Ionized Ca2+
Mg2+
PTH
albumin
calcitonin
Hypocalcemia -
Dx if post-thyroidectomy -
check operative note
to determine no. of
parathyroid glands removed
Hypocalcemia -
Tx
Tx underlying d/o
oral calcium supplements
Hypocalcemia -
Tx if severe -
IV calcium
Hypomagnesemia -
Serum Mg2+ < 1.5 mEq/L
Hypomagnesemia -
causes: ■ dec. intake:
malnutrition
alcoholism
malabsorption
short bowel syndrome
TPN
Hypomagnesemia -
■ inc. loss:
diuretics
diarrhea
vomiting
mg and alcoholism
Magnesium excretion induced by alcohol ingestion as well as poor dietary intake probably contributes to magnesium deficiency in chronic alcoholism.
Hypomagnesemia -
■ miscellaneous:
DKA
pancreatitis
mg and alcoholism
Magnesium excretion induced by alcohol ingestion as well as poor dietary intake probably contributes to magnesium deficiency in chronic alcoholism.
Hypomagnesemia -
Sxs usu related to
concurrent
hypocalcemia
and hypokalemia
Hypomagnesemia -
■ miscellaneous:
DKA
pancreatitis
Hypomagnesemia -
Hx/PE
anorexia
n/v
muscle cramps
weakness
Hypomagnesemia -
Sxs usu related to
concurrent
hypocalcemia
and hypokalemia
Hypomagnesemia -
if levels very low -
paresthesias
irritability
confusion
lethargy
seizures
arrhythmias
Hypomagnesemia -
Hx/PE
anorexia
n/v
muscle cramps
weakness
Hypomagnesemia -
Dx
Check for concurrent
hypocalcemia & hypokalemia
Hypomagnesemia -
if levels very low -
paresthesias
irritability
confusion
lethargy
seizures
arrhythmias
Hypomagnesemia -
EKG -
prolonged PR & QT
Hypomagnesemia -
Dx
Check for concurrent
hypocalcemia & hypokalemia
Hypomagnesemia -
Tx
IV or oral Mg2+
hypokalemia & hypocalcemia
won't correct if Mg2+
not corrected also
Hypomagnesemia -
EKG -
prolonged PR & QT
Hyperkalemia -
Serum K+ > 5 mEq/L
Hypomagnesemia -
Tx
IV or oral Mg2+
hypokalemia & hypocalcemia
won't correct if Mg2+
not corrected also
Hyperkalemia -
causes -
■ spurious -sahte
hemolyzed blood draw
fist clenched during
blood draw
extreme leukocytosis
extreme thrombocytosis
rhabdomyolysis
mg and alcoholism
Magnesium excretion induced by alcohol ingestion as well as poor dietary intake probably contributes to magnesium deficiency in chronic alcoholism.
Hyperkalemia -
Serum K+ > 5 mEq/L
Hypomagnesemia -
■ miscellaneous:
DKA
pancreatitis
Hyperkalemia -
causes -
■ spurious -sahte
hemolyzed blood draw
fist clenched during
blood draw
extreme leukocytosis
extreme thrombocytosis
rhabdomyolysis
Hypomagnesemia -
Sxs usu related to
concurrent
hypocalcemia
and hypokalemia
mg and alcoholism
Magnesium excretion induced by alcohol ingestion as well as poor dietary intake probably contributes to magnesium deficiency in chronic alcoholism.
mg and alcoholism
Magnesium excretion induced by alcohol ingestion as well as poor dietary intake probably contributes to magnesium deficiency in chronic alcoholism.
Hypomagnesemia -
■ miscellaneous:
DKA
pancreatitis
Hypomagnesemia -
Hx/PE
anorexia
n/v
muscle cramps
weakness
Hypomagnesemia -
■ miscellaneous:
DKA
pancreatitis
Hypomagnesemia -
Sxs usu related to
concurrent
hypocalcemia
and hypokalemia
Hypomagnesemia -
Sxs usu related to
concurrent
hypocalcemia
and hypokalemia
Hypomagnesemia -
if levels very low -
paresthesias
irritability
confusion
lethargy
seizures
arrhythmias
Hypomagnesemia -
Hx/PE
anorexia
n/v
muscle cramps
weakness
Hypomagnesemia -
Dx
Check for concurrent
hypocalcemia & hypokalemia
Hypomagnesemia -
Hx/PE
anorexia
n/v
muscle cramps
weakness
Hypomagnesemia -
if levels very low -
paresthesias
irritability
confusion
lethargy
seizures
arrhythmias
Hypomagnesemia -
if levels very low -
paresthesias
irritability
confusion
lethargy
seizures
arrhythmias
Hypomagnesemia -
EKG -
prolonged PR & QT
Hypomagnesemia -
Tx
IV or oral Mg2+
hypokalemia & hypocalcemia
won't correct if Mg2+
not corrected also
Hypomagnesemia -
Dx
Check for concurrent
hypocalcemia & hypokalemia
Hypomagnesemia -
Dx
Check for concurrent
hypocalcemia & hypokalemia
Hypomagnesemia -
EKG -
prolonged PR & QT
Hypomagnesemia -
EKG -
prolonged PR & QT
Hyperkalemia -
Serum K+ > 5 mEq/L
Hypomagnesemia -
Tx
IV or oral Mg2+
hypokalemia & hypocalcemia
won't correct if Mg2+
not corrected also
Hypomagnesemia -
Tx
IV or oral Mg2+
hypokalemia & hypocalcemia
won't correct if Mg2+
not corrected also
Hyperkalemia -
causes -
■ spurious -sahte
hemolyzed blood draw
fist clenched during
blood draw
extreme leukocytosis
extreme thrombocytosis
rhabdomyolysis
Hyperkalemia -
Serum K+ > 5 mEq/L
Hyperkalemia -
Serum K+ > 5 mEq/L
Hyperkalemia -
causes -
■ spurious -sahte
hemolyzed blood draw
fist clenched during
blood draw
extreme leukocytosis
extreme thrombocytosis
rhabdomyolysis
Hyperkalemia -
causes -
■ spurious -sahte
hemolyzed blood draw
fist clenched during
blood draw
extreme leukocytosis
extreme thrombocytosis
rhabdomyolysis
Hyperkalemia -
■ dec. excretion -
renal insufficiency
mineralocorticoid def.
RTA type 4
serum K+ is high
usually asymp hyperkalemia
hyperchloremic metab acidosis
(nonanion/normal metab acidosis)
Hyperkalemia -
drugs -
heparin
spironolactone
triamterene
ACEIs
trimethoprim
NSAIDs
Hyperkalemia -
■ cellular shifts -
tissue injury
insulin def.
Hyperkalemia -
■ cellular shifts -
drugs -
succinylcholine
digitalis
arginine
B-blockers
Hyperkalemia -
■ iatrogenic
■ iatrogenic
Hyperkalemia -
Hx/PE
Muscle weakness starts > 6.5
Hyperkalemia -
MCC of death -
abnorm cardiac conduction
Hyperkalemia -
Hx/PE
May be asymp
n/v
intestinal colic
Hyperkalemia -
areflexia
weakness
flaccid paralysis
paresthesias
Hyperkalemia -
Dx
Verify with repeat blood draw
(if need to)
EKG -
tall peaked T
prolonged PR
wide QRS
Hyperkalemia -
Dx loss of P can =>
sine waves,
ventricular fibrillation,
cardiac arrest
Hyperkalemia -
Tx Emergent Tx if -
> 6.5 mEq/L or
prolonged PR or
wide QRS
Hyperkalemia -
Tx C BIG K
Calcium gluconate or CaCl
Bicarb or
Insulin and
Glucose
Kayexalate and
loop diuretics
Hyperkalemia -
Tx Ca gluconate or CaCl -
immediate but short-lived
Hyperkalemia -
Tx
bicarb not in same IV line as Ca
(forms CaCO3 precipitate)
Hyperkalemia -
Tx
insulin & glucose -
takes 30-60 min. to work
Hyperkalemia -
Tx
give sorbitol to prevent constipation
Hyperkalemia -
Tx If RF or severe, refractory -
dialysis
calcium kaslari ne yapar
kaslari gesvetir
Hypokalemia -
Serum K+ < 3.5 mEq/L
Hypokalemia -
■ transcellular shifts -
insulin
B2-agonists
alkalosis
periodic paralysis
Hypokalemia -
■ GI losses -
diarrhea
chronic laxative abuse
vomiting
NG suction
Hypokalemia -
■ renal K+ losses -
diuretics
primary mineralocorticoid
excess
secondary hyperaldosteronism
Hypokalemia -
drugs
DKA
hypomagnesemia
RTA Types 1&2
Hypokalemia -
■ licorice
■ clay
Hypokalemia -
Hx/PE
Sxs start when K+ <2.5 - 3.0
Hypokalemia -
Hx/PE
muscle weakness
cramps
ileus
fatigue
Hypokalemia -
Hx/PE
hyporeflexia
paresthesias
if severe - flaccid paralysis
cardiac arrhythmia
Hypokalemia -
Dx 24-hour or spot urine K -
to distingish renal from
GI losses
Hypokalemia -
EKG -
flattened T
U wave
ST depression followed by
AV block and
cardiac arrest
Hypokalemia -
Tx
Tx underlying d/o
oral or IV K+
too fast => fatal arrhythmia
max 10 meq/hr
use 1/2 NS or NS
replace Mg2+
monitor EKG and plasma K+
freq. during replacement