P2- Tp1 (Exam 3)

Front 1

Nephrotic Syndrome Features

Back 1

Hypoalbuminemia (low levels of albumin in blood serum)
Edema
Hyperlipidemia
Lipiduria (lipids in urine)

Front 2

Nephrotic Syndromes Induced by Primary Glomerular Diseases

Back 2

1. Minimal Change Glomerulopathy
2. Membranous Glomerulopathy
3. Focal Segmental Glomerulosclerosis (FSGS)
4. Type 1 Membranoproliferative
5. Other GN diseases

Front 3

Nephrotic Syndromes Induced by Secondary Systemic Diseases

Back 3

1. Diabetes mellitus
2. SLE
3. Amyloidosis
4. Infections, Hepatitis, HIV

Front 4

Causes 90% of primary nephrotic syndromes in young children and 50% in older children

Back 4

The Minimal-Change Glomerulopathy (Lipid Nephrosis/ Nil Disease)

Front 5

What do you see in the light microscope and electron microscope when there is The Minimal-Change Glomerulopathy?

Back 5

LM: Normal Glomeruli
EM: Effacement of Podocyte Foot Processes

Front 6

What is the Common Cause of Nephritic Syndrome in Adults?

Back 6

Membranous Glomerulopathy; caused by accumulation of immune complexes in the subepithelial zone of glomerular capillaries

Front 7

What do you see in the light microscope and electron microscope when there is Membrane Glomerulopathy?

Back 7

LM: diffuse thickening of glomerular capillary walls; mutliple projections or "spikes" in GBM
EM: not mentioned

Front 8

What is Focal Segmental Glomerulosclerosis (FSGS)?

Back 8

Nephrotic Syndrome induced by primary glomerular disease

Describes a heterogeneous group of glomerular diseases with different causes, pathologies, responses to treatment and outcomes

can be primary or secondary to sickle cell nephropathy, HIV, IV drug abuse, cyanotic CHD or morbid obesity

Front 9

What is Membranous Glomerulopathy?

Back 9

Nephrotic Syndrome induced by primary glomerular disease

common cause of nephrotic syndrome in adults; caused by accumulation of immune complexes in the subepithelial zone of glomerular capillaries

Front 10

What is Minimal-Change Glomerulopathy?

Back 10

Nephrotic Syndrome induced by primary glomerular disease

causes 90% of primary nephrotic syndrome in young children and 50% in older children and 15% in adults

Front 11

What is scene in the light microscope if there is Focal Segmental Glomerulosclerosis (FSGS)?

Back 11

Segmental obliteration of capillary loops; the insudation of plasma proteins and lipids gives lesions a glassy appearance= Hyalinosis

Front 12

Nephrotic vs Nephritic

Back 12

Nephrotic= nonspecific disorder in which kidneys are damaged, causing them to leak large amounts of protein (atleast 3.5 grams per day per 1.73 m2) from the blood to the urine; NO hematuria

Nephritic= RBC pass through the pores causing hematuria

Front 13

What are the main features of Nephritic syndrome?

Back 13

PHARAOH

Proteinuria, Hematuria, Azotemia, RBC casts, Anti-strep titres, Oliguria, Hypertension

Front 14

Types of Nephritic Syndrome

Back 14

1. Acute Postinfectious
2. Good Pasture Syndrome
3. Rapidly Progressive GN
4. ANCA GN
5. IgA Nephropathy (Berger Disease)
6. Membranoproliferative GN
7. Alport Syndrome

Front 15

one of the most common childhood renal diseases; primary infection involves the pharynx or the skin; infectious agents are B-hemolytic Group A Streptococci and Staphylococcal Infections; immune complex deposition in glomeruli is responsible for this Disease; syndrome begins abruptly with oliguria, hematuria, facial edema, and hypertension

Back 15

Acute Proliferative/ Post infectious GN

Front 16

What is the Molecular Pathogenesis of Nephritic Syndrome?

Back 16

1. In situ Immune Complex
2. Deposition of Circulation immune complex (IC)
3. Antineutrophilic Cytoplasmatic Autoantibodies (ANCAs)

Front 17

What is seen in the light microscope and electron microscope in Acute Proliferative GN (Acute Post Infectious GN)?

Back 17

LM: Hypercellular (glomeruli)
EM: Subepithelial humps due to immune complex deposits

Front 18

What is Anti-GBM Disease?

It's Hallmark diagnosis is?

Back 18

Anti-Glomerular Basement Membrane Glomerulonephritis (Nephritic Syndrome)

uncommon but aggressive GN that may only affect the kidneys or be combined with pulmonary hemorrhage

aka Goodpasture Syndrome

caused by an autoimmune response against type IV collagen in the GBM

Pathologic Hallmark: GBM immunostaining for IgG, indication autoantibodies bound to base membrane

Front 19

What is Crescentic GNF?

Back 19

Rapid Progressive GNF/ Crescentic GNF (Nephritic Syndrome)

Post streptococcal, SLE, Berger Disease, after vasculitis or it is idiopathic

there is proliferation of epithelial cells and monocytes in Bowman space, which occurs in response to fibrin leaked from damaged capillary loops= crescents

Front 20

What is ANCA GN?

Back 20

Anti-Neutrophil Cytoplasmic Antibody Glomerulonephritis (Nephritic Syndrome)

Neutrophil-mediated RPGN with crescents and glomerular necrosis; 80% will develop ESRD within 5 years and 15% recurrence in renal transplants

Front 21

What is IgA Nephropathy?

What is essential for its diagnosis?

Back 21

Berger Disease (Nephritic Syndrome)

Most common type of GNF in developed countries; often initiated by respiratory or GI infections

Immunofluorescent Microscopy using mesangial staining for IgA is essential for diagnosis of IgA Nephropathy

Front 22

What is Membranoproliferative (MPGN) Type I?

LM Hallmark?

Back 22

Chronic Immune Complex Disease (Nephritic Syndrome)

type of glomerulonephritis caused by deposits in the kidney glomerular mesangium and basement membrane (GBM) thickening, activating complement and damaging the glomeruli.

LM Hallmark: "Tram-Tracking"

Type II is characterized by Electron Dense Deposits in GBM with extensive Complement deposition

Front 23

What is Alport Syndrome?

Back 23

Hereditary Nephritis (Nephritis Syndrome) aka Alport Syndrome

X-linked genetic disorder (85%)

defect in type 4 collagen hereditary nephritis→ hearing loss→ ocular abnormalities→ renal failure→early hematuria→ proteinuria→ progressive renal failure in 2nd-4th decade of life

Front 24

What is end-stage glomerular disease resulting from various types of GN?

Back 24

Chronic Glomerulonephritis

irreversible and progressive glomerular and tubulointerstitial fibrosis leading to a decrease in the GFR with retention of uremic toxins→ chronic kidney disease (CKD)→ end-stage renal disease (ESRD)

Front 25

What is the pathology of chronic glomerulonephritis?

Back 25

Granular Contracted Kidney (GCK)→ both kidneys small, symetrically contracted, and cortical surfaces show diffuse fine granularity

Front 26

What is the leading cause of ESRD in the USA, accounting for a third of all chronic renal failure?

Back 26

Diabetic Nephropathy

this condition is called Kimmelsteil-Wilson Syndrome

Front 27

What is the autoimmune disorder with production of auto antibodies to nuclear and no nuclear antigens? renal disease develops in 70% of patients with the disease

Back 27

Lupus Nephritis

SLE is the autoimmune disorder

Front 28

What is the most common cause of Intrarenal acute kidney injury?

Back 28

Ischemic Acute Tubular Injury

Front 29

What is the cause of these Acute renal Failure classifications?
1. Prerenal
2. Intrarenal
3. Postrenal

Back 29

1. Prerenal→ due to decrease blood flow to the kidney
2. Intrarenal→ due to injury to the renal parenchyma
3. Postrenal→ caused by urinary tract obstruction

Front 30

Acute renal Failure (ARF)
vs
Chronic Renal Failure

Back 30

ARF→ an acute rise in serum creatinine

CRF→ failure of kidney functions (homeostasis, excretory, endocrine)

Front 31

Azotemia vs Uremia

Back 31

Azotemia→ elevation of BUN and Scr

Uremia→ Azotemia + clinical features

Front 32

How does chronic renal disease lead to renal osteodystrophy?

Back 32

1. reduced GFR→ retention of phosphate→ hyperphosphatemia→ driving down serum calcium levels→hypocalcemia

2. kidney fails to produce calcitriol→ hypocalcemia

3. hypocalcemia stimulates PTH production leading to secondary hyperparathyroidism

Front 33

Normal Hgb Values

Back 33

Male:14-17.5 g/dL

Female:12.3-15.3 g/dL

Front 34

Normal RBC Values

Back 34

Male: 4.5-5.9 x10^6 cells/uL

Female:4.1-5.1 x10^6 cells/uL

Front 35

Normal HCT Values

Back 35

aka Packed Cell Volume (PCV)

Male: 42-50%

Female: 36-45%

Front 36

What does the MCV measure and what are normal values?

Back 36

Mean Cell Volume (MCV)→ assesses average RBC size

low MCV= microcytic RBC like in iron deficiency

high MCV= macrocytic RBC like in vitamin B12 and folic acid deficiency

Normal Range: 80-96 fL/cell

Front 37

What does MCH measure and what are the normal values?

Back 37

Mean cell hemoglobin (MCH)→ assesses he average weight of Hgb in a RBC

low MCH→ hypochomic RBC
high MCH→ vitamin B12 and folic acid deficiency

Normal MCH: 27.5-33.2 pg/cell

Front 38

What is MCHC and what are the normal values?

Back 38

Mean Cell Hgb Concentration (MCHC)→ more useful than MCH

low MCHC always indicates hypochromia= iron deficiency

Front 39

What is RDW and what are the normal values?

RDW is increased in what?

Back 39

RBC Distribution Width (RDW)→ indicates variation in red cell size

Normal Values: 11.5-14.5%

RDW increases in iron deficiency

Front 40

What is RI and what are the normal values?

Back 40

Reticulocyte Count or Reticulocyte Index (RI)→ useful in monitor anemic patient's response to vitamin or iron therapy

increase is good

Normal Values: 0.5-2.5%

Front 41

What do theses tests measure?
1.Serum Iron
2. TIBC
3. Transferrin Saturation
4. Serum Ferritin

Back 41

1.Serum Iron→ measures iron bound to transferrin
2. TIBC→ measures total iron binding capacity of transferrin protein
3. Transferrin Saturation→percentage of transferrin saturated
4. Serum Ferritin→ levels of ferritin are proportional to total iron stores (best indicator if IDA or iron overload)

Front 42

high TIBC and low serum iron= ?

low TIBC and low serum iron=?

Back 42

high TIBC and low serum iron= IDA

low TIBC and low serum iron= anemia of chronic disease (ACD)

Front 43

increased homocysteine levels suggest what?

Back 43

folate or vit B 12 deficiency

folate and B12 are required to convert homocysteine to methionine

Front 44

elevated MMA levels suggest what?

Back 44

B12 deficiency

Methylmalonic Acid (MMA) needs B12 to be converted to final product

Front 45

What things reduce the gastrointestinal absorption of iron?

What things improve non-heme iron absorption?

Back 45

Decrease→Calcium, Tannates, Antacids, H2RA Blockers, PPI, Tetracyclines, and Fluroquinolones

Increase→ Ascorbic Acid (like orange juice)

Front 46

Describe the different stages of Iron Deficiency

Back 46

1. Prelatent→ decrease in ferritin (normal serum iron levels)
2. Latent→ decrease in transferrin saturation and increase in TIBC (Hgb is above lower limits of normal)
3. IDA→ decreased Hgb, Hct, MCV, serum iron, ferritin, and increased TIBC (Hgb falls below normal)

Front 47

Consider blood transfusion if Hgb is below what?

Back 47

<7 g/dL

Front 48

Which Iron treatment provides the highest amount of elemental iron?

Back 48

Carbonyl Iron (Ferracap, Feosol with Carbonyl iron, Icar Pediatrics)

Front 49

What is the formulation of choice for treatment of IDA?

Back 49

Ferrous Sulfate Dried (Feosol, Slow FE)

Front 50

Which Iron treatment contains the dye tartrazine (yellow dye) that has to be used in cause with patients sensitive to ASA?

Back 50

Ferro-Sequels (Ferrous Fumarate)

Front 51

What is typical dosing of elemental iron for treatment of IDA?

Back 51

Adults: 50-100mg 3 times a day
Children: 3-6 mg/kg/day 2-3 times daily
Pregnant: 60-120mg/day at the first prenatal visit

Front 52

Iron decreases the absorption or bioavailability of what other medications?

Back 52

Bisphosphonates
Levodopa-Carbidopa
Oral thyroid hormones

Front 53

How do you calculate the parenteral iron dose for patients with IDA?

Back 53

>15 kg: Dose (ml)= 0.0442 (Desired Hgb- Observed Hgb) x LBW + (0.26 x LBW)

<15 kg: Dose (ml)= 0.0442 (Desired Hgb-Observed Hgb) x Wt + (0.26x wt)

LBW Males= 50kg + (2.3 x in over 5ft)
LBW Females= 45.5 + (2.3 x in over 5ft)

Front 54

which parenteral iron product has BBW for Anaphylactic type reactions?

Back 54

Iron Dextran (INFeD, Dexferrum)

Front 55

Name some oral Fe products and Parenteral Fe products

Back 55

Oral Iron Salts: Carbonyl Iron, Ferrous Fumarate, Ferrous Gluconate, Ferrous Sulfate Dried, Ferrous Sulfate, Heme-iron polypeptid, Polysaccharide-iron complex

Parenteral Iron Products: Iron Dextran, Sodium Ferric Gluconate, Iron Sucrose, and Ferumoxytol

Front 56

Which oral iron salts are 100% elemental iron?

Back 56

Carbonyl Iron and Polysaccharide-iron complex

Front 57

What drugs may cause B12 Deficiency Anemia?

Back 57

Achrolhydria
H2RA and PPIs
Metformin

Congenital intrinsic factor deficiency= decreases absorption

Front 58

What diseases can cause Anemia of Chronic Disease?

Back 58

Chronic Infections (HIV, endocarditis, pneumonia)
Chronic Inflammation (RA, SLE, IBD, gout)
Malignancies (Cancer)
Alcoholic liver disease, CHF, COPD, DM, IHD, CKD

Front 59

What is Anemia of Chronic Disease?

Back 59

mild to moderate anemia associated with the presence of a chronic inflammatory, infectious, or malignant disorder

Front 60

How can we treat Anemia of Chronic Disease?

Back 60

Erythropoiesis Stimulating Agents (ESAs)
1. Epogen
2. Procrit
3. Aranesp

if treatment of underlying cause and ESAs does not work blood transfusion needed

Front 61

When are ESAs indicated?

Back 61

1. Anemia of chronic kidney disease (dialysis or non dialysis is okay)
2. Anemia in cancer patients on chemo
3. Treatment of AIDs related anemia in patients treated with zidovudine

Front 62

What is the BBW of ESAs?

Back 62

Increased mortallity, serious cardiovascular and thromboembolic events, and tumor progression

Front 63

What is the target Hgb in CKD?

Back 63

dialysis and non-dialysis:
11-12 g/dL is target Hgb

Don't exceed 13 g/dL Hgb (KDOQI)
Don't exceed 11g/dL Hgb (FDA)

Monitor Hgb concentrations every 4-6 weeks

Reduce dose if Hgb exceeds 12g/dL or an increase of 1g/dL in a 2 week peroid occurs

Front 64

Compare and Contrast Epogen, Procrit, and Aranesp

Back 64

Epogen and Procrit→ (SQ, IV) Indicated for ACD, Anemia due to chemotherapy, and anemia due to Zidovudine

Aranesp→ (SQ, IV) longer t1/2 (advantage) only approved for anemia of chronic disease and anemia with chemotherapy

Front 65

What are some side effects of ESAs?

Back 65

HTN, nausea, headache, fever, bone pain, peripheral edema, fatigue, seizures, thrombotic events, pain, etc

Front 66

Supplemental iron is administered with ESAs to maintain what levels?

Back 66

Transferrin saturation of >20%

Serum ferritin levels of >100 ng/ml

Front 67

when should you stop ESAs?

Back 67

1. if no meaningful clinical response by 6-8 weeks (0.5g/dL)
2. when chemotherapy concludes for cancer patients

Front 68

What are side effects of Iron Dextran?

Back 68

pain, brown staining at injection site, flushing, hypotension, fevers, chills, myalgia, anaphylaxis

Front 69

What are the side effects of Sodium Ferric Gluconate?

Back 69

cramps, nausea, vomiting, flushing, hypotension, rash, pruritus, upper gastric pain

Front 70

What are the side effects of Iron Sucrose?

Back 70

Leg cramps and hypotension

Front 71

What are side effects of Ferumoxytol?

Back 71

peripheral edema, nausea, dizziness, hypotension, hypersensitivity rxn

Front 72

What is the Definition of Chronic Kidney Disease?

Back 72

GFR <60 mL/min/1.73 m2 for at least 3 months

Front 73

Stages of Chronic Kidney Disease based on GFR

Back 73

Stage 1: >90 mL/min (Normal)
Stage 2: 60-89 mL/min (asymptomatic)
Stage 3: 30-59 mL/min (Hypertension, nocturia, anemia)
Stage 4: 15-29 mL/min
Stage 5: <15 mL/min

Front 74

High causes of Chronic Kidney Disease?

Back 74

1. HTN
2. Type 2 DM
3. Type 1 DM

Front 75

When is progress to ESRD unavoidable?

Back 75

kindneys lose critical mass (>70%) and GFR ~30ml/min

Front 76

What should protein intake be limited to in order to delay progression to CRF?

Back 76

0.8-1.0 g/kg/day

0.75 g/kg/day in GFR <25 ml/min

Front 77

What is blood pressure goal for pt with CKD and for pt with proteinuria?

Back 77

CKD= <130/85 mm Hg

Proteinuria= <125/75 mm Hg

Front 78

Which Loop diuretics can be used for treatment of fluid accumulation in pt with CKD

Back 78

Furosemide
Bumetanide
Torsemide
Ethacrynic Acid

Front 79

Name some phosphate binders used in Chronic Kidney Disease

Back 79

1. Aluminum hydroxide, calcium salts, magnesium antacid
2. Sevelamer hydrochloride (Renagel)
3. Lanthanum carbonate (Fosrenol)

Calcium products that bind phosphate:
Calcium acetate
calcium carbonate
calcium citrate

Aluminum products:
Basaljel
Amphogel
Alternagel
Sucralfate

Front 80

What drug is used as a pure antagonist at opioid receptors and can induce withdrawal in dependent patients?

Back 80

Naloxone (Narcan)

Front 81

Which opioid is best for rapid analgesia?

Back 81

Fentanyl

Front 82

Which opioid is best for hemodynamic stability?

Back 82

Morphine

Front 83

Which opioid is best for hemodynamic instability?

Back 83

Fentanyl or Hydromorphone

Front 84

Which opioid is best for Renal impairment?

Back 84

Fentanyl or Hydromorphone

Front 85

Which opioid is best for Intermittent dosing?

Back 85

Morphine or Hydromorphone

Front 86

What does CPOT measure?

Back 86

Critical Care Pain Observation Tool (CPOT)

Facial expression
Body movements
Muscle tension
Ventilator compliance or Vocalization

Front 87

Which Assessments measure Sedation?

Back 87

Ramsay Scale
and
Richmond Agitation-Sedation Scale (RASS)
and
EEG monitoring

Front 88

Which Sedation agent is best used in acute agitation?

Back 88

Midazolam

Front 89

Which Sedation agent is best used in intermittent sedation?

Back 89

Lorazepam

Front 90

Which Sedation agent is best used in Continuous sedation?

Back 90

Propofol (72 hrs)
Midazolam (48 hrs)
Lorazepam (long term)

Front 91

What drug is used for Benzodiazepine Reversal?

Back 91

Flumazenil (Romazicon)

competitive binding to the GABA/benzo receptor complex

Front 92

Which sedation agent is preferred when rapid awakening is important?

Back 92

Propafol (Diprivan)

Requires mechanical ventilation

Propofol Infusion Syndrome if prolonged use (>48 hrs) of high dose

Front 93

Which sedation agent is a selective alpha 2 adrenergic receptor agonist and has no respiratory depression?

Back 93

Dexmedetomidine (Precedex)

Front 94

What is used as a Delirium Assessment?

Back 94

Confusion Assessment Method (CAM-ICU)

mental status change
inattention
Disorganized thinking
altered level of consciousness

Front 95

What is the preferred agent for delirium in the ICU?

Back 95

Haloperidol (Haldol)

Front 96

Name a NMBA used to facilitate endotracheal intubation?

Back 96

Succinylcholine

Front 97

Name the Non-depolarizing NMBAs

Back 97

Pancuronium
Atracurium
Cisatracurium
Vecuronium
Rocuronium

Front 98

Which NMBA is good for normal hepatic and renal function?

Back 98

Pancuronium

Front 99

Which NMBA is good for hepatic or renal impairment?

Back 99

Atracurium
or
Cisatracurium

Front 100

Which NMBA is good for CV disease or hemodynamic instability?

Back 100

Vecoronium
or
Rocuronium