Rnwk4- 5-5 Internal Med Actue And Chronic Renal

Front 1

Why are BUN and Cr levels elevated in ARF?

How much is Cr elevated? What affects Cr amounts?

elevated BUN = ?
elevated BUN + confusion = ?

Most common form of ARF?

Back 1

kidneys can't excrete

0.5-1 mg above normal; affected by muscle mass of pt

elevated BUN = azotemia
elevated BUN + confusion = uremia

pre-renal

Front 2

Define what "pre-renal" means?

Differring from intrinsic renal disease?

Back 2

before the blood gets to kidney (dehydration etc)

(vs. Intrinsic caused by occlusion/infarct of the kidney)
rugs – can affect multiple locations +/or mechanisms in
the kidney – not just “pre‐renal

Front 3

Pre-renal ARF:
common cause of pre-renal ARF?

_____ renal artery stenosis is a cause.

Case #1: 42 y/o m c/o abd pain x 6 hrs.

Explain significance of:
HPI: No N/V/D, F/C/NS
elevated serum amylase,lipase

Back 3

effective volume depletion

EARLY renal artery stenosis

Case #1:
HPI - no infection
amylase,lipase - pancreatitis

Front 4

Case #1:
Significance of:
BUN 80, Cr 3
K+ 6.7
Fe(Na) < 1.0

What is third spacing?

Back 4

BUN/Cr ratio > 20 = dehydration or effective volume depletion

hyperkalemia 2ndary to ARF

Fe(Na) < 1.0 = pre-renal

third spacing = non vascular, non cells

Front 5

Post renal most common cause?

How do we tell if chronic vs acute usually for kidney disease?

Back 5

BPH

- for chronic most likely see anemia

Front 6

Examples of volume depletion and effective volume depletion:

radiology imaging you can use? Which one is better, but why can it be worse?

Back 6

volume depletion - diarrhea/vomiting, dehydration

effective volume depletion - heart failure (decreased CO), sepsis (vasomotor dilation)

Abd U/S, CT - CT better imaging, but contrast can further compromise tubular lining

Front 7

Treatment basics for pre-renal ARF?

Case #2: 35 y/o m, construction worker, R flank pain, gross hematuria, mild edema

Why is renal lithiasis more common in summer?

Back 7

maintain optimal renal perfusion, intravascular volume

Case #2: renal lithiasis

dehydration more common

Front 8

What labs should you check in renal lithiasis? Why check Mg?

What radiologic imaging? Why is it important for kidney stones?

Back 8

BMP, CMP, CBC

Mg is important for K+ exchange in electrolyte or kidney alteration

U/S - advantage - can show dilation proximal to stone, kidney size

Front 9

Case #2:
Would you expect his Fe(Na) to be < 1?

Complications of ARF?

Back 9

No - post renal ARF

ARF complications
intravascular volume overload
hyperkalemia/hyponatremia, other electrolyte abnormalities
metabolic acidosis

Front 10

Describe "post-renal" treatment differences for pt compared to pre-renal for renal lithiasis...

Back 10

• May need urinary catheter
• Strain all urine for stone identification
• Pain medication
• Urology consult

Front 11

Indications for dialysis:
______ to conservative measures
______ overload refractory to diuretics
______kalemia
________ otherwise unexplained
Severe _________ acidosis compromising respiratory or circulatory fxn

Back 11

unresponsive to conservative measures
volume overload
hyperkalemia
encephalopathy otherwise unexplained
severe metabolic acidosis

Front 12

Pre, Intra, or Post Renal:

#1: dehydration, viral syndromes, diuretics, pancreatitis:

#2: renal artery obstruction, glomeruli, ATN from contrast dye:

Back 12

#1: Pre-renal

#2: Intra-renal

Front 13

Pre, Intra, Post-Renal?

#1: CHF, sepsis, cirrhosis:

#2: myeloma, interstitial nephritis:

#3: stone in ureter, blood clot, tumor compression:

#4: BPH, phimosis, neurogenic bladder:

Back 13

#1: Pre-renal

#2: intra-renal

#3: post-renal

#4: post-renal

Front 14

1. Clinical syndrome resulting from profound loss of renal fxn:
2. 3 ways to measure GFR?
3. Which equation is generally more accurate for GFR?
4. Cockcroft-Gault equation? women?

Back 14

1. uremia
2. inulin, serum Cr, 24 hr urine Cr
3. MDRD

4. (140-age) x wt in kg
--------------------
SCr x 72

multiply above by .85 for women

Front 15

% renal fxn for 5 stages of CKD: IMPORTANT
1: kidney damage, normal/increased GFR:
2: mild
3: moderate
4: severe
5: kidney failure

Early stage: usually symptom _____, overall function _____, _______ diminished

Back 15

Stage 3 is 30-60, 1 is 90 above, 5 is 15 below

1: >90
2: 60-89
3: 30-59
4: 15-29
5: <15, or dialysis

early stage: symptom free, overall function intact, reserve function diminished

Front 16

1. Effect of uremic toxins:
________ of transmembrane voltage. (intracellular Na and intracellular K) How?
2. uremia and effects are largely reversible with _______.
3. How do uremic toxins affect cells?

Back 16

1. reduced transmembrane voltage -
higher Intra Cellular Na+,
lower Intra Cellular K+,
inhibition of Ca++ flux

2. dialysis
3. overhydration, increased EC volume (third spaciing)

Front 17

1. Uremia effect on metabolism?
2. uremia effect on proteins and
3. Uremia effect on lipids?:

Back 17

1. a. hypothermia (decreased Na+ transport)
b. intracellular K+ deficit
c. metabolic acidosis
2. protein intolerance - increased catabolism, decresaed elimination
3. hyper-TriG, lowered HDL, normal cholesterol - less removal, more lipogenesis

Front 18

1. Uremia effect on Na+, volume homeostasis:

2. Excessive salt ingestion can lead to:

3. Excessive H2O ingestion can lead to:

4. recommended fluid intake pre-dialysis?

Back 18

1. total body content of Na+ and H2O are increased modestly in stable CKD

2. Na+: CHF, HTN, ascites, edema

3. H2O: hyponatremia, wt gain

4. urine output + 500 ml/day

Front 19

1. Increased K+ in late stage CKD leads to _________.

Some drugs that can increase serum K+? (STAT ABP)

Back 19

1. cardiac arrhythmias

2. spironolactone
triamterene
amiloride
trimethoprim

ACEI's
B blockers
pentamidine

Front 20

1. Most common complication of ESRD?
2. Chronic dialysis pts also have higher incidence of _________, which contributes to HTN
3. Explain the pulmonary congestion that occurs with CKD:

Back 20

1. HTN
2. accelerated atherosclerosis
3. normal/mildly elevated intracardiac or PCWP
"butterfly wing" distribution on CXR due to increased permeability of alveolar capillary membranes

Front 21

4 other associated conditions with CKD?

Back 21

PANS
1. pericarditis
2. abnormal hemostasis - prolonged PT,PTT, decreased factor III, abnormal platelet aggregation
3. normocytic, normochromic anemia
4. susceptibility to infection - impaired neutrophil formation, leukocyte function

Front 22

1. Bone changes in uremia (renal rickets, osteitis fibrosis cystica) are due to changes in ____.
2. Bone changes in long-term dialysis:_____-induced osteomalacia
3. dialysis-related ________.
4. What supplement should you not give CKD pts? Why?
5. What pain drugs?

Back 22

1. PTH (hyperparathyroidism)
2. aluminum induced osteomalacia
3. dialysis related amyloidosis
4. Mg++ supplements - can lead to hyperK+, --> arrhythmias
5. No NSAID's - large dose Tylenol

Front 23

1. Case: 42 y/o f, c/o increased dyspnea, fatigue, poor appetite; developed elevated BP, lipids, swelling of extremities. D/d

2. Labs showed hematuria, RBC casts, increased K+, low albumin, eGFR 20- what is red flag here?

3. Dx, and explain lab values, PE:

Back 23

1. Dx - idiopathic nephrotic syndrome - proteins in urine

2. RBC casts - glom damage

3. eGFR 20 - means stage 4 (15-29) CKD

Front 24

With conservative treatment what is restricted in diet of CDK?

Back 24

1. restrict dietary potassium
2. Sodium polystyrene sulfonate (kayexalate) binds potassium
3. ACE- inhibitors
4. restrict proteins

Front 25

1. 4 major symptoms of chronic renal failure?

2. 3 other symptoms?

3. What would you expect to find on PE?

Back 25

1. anorexia, weight loss, dyspnea, fatigue

2. pruritus, sleep/taste disturbance, confusion

3. HTN, JVD, pericardial/pleural friction rub, muscle wasting, asterixis, skin changes

Front 26

Chronic renal failure:
1. What labs would be abnormal?
2. Conservative tx of CKD:
a. _____ control of HTN
b. eliminate ___________
c. give ____ to promote RBC formation
d. ______ binders - CaCO3, acetate
e. restrict dietary _______ and _____.
f. ______ drug that binds K+
3. What other drugs?

Back 26

1. Labs: elevated K+, PO4-, uric acid, low Ca++, albumin, hemoglobin, metabolic acidosis
2. a. aggresively tx HTN
b. eliminate volume overload (fluid restriction, diuretics)
c. give EPO for RBC's
d. PO4-- binders - CaCO3, acetate
e. restrict dietary K+ and proteins
f. Kayexalate binds K+
3. ACEI's

Front 27

Most common type of dialysis used in ARF?

Two other dialysis options? Is it better and why wouldnt it be used more often?

Back 27

intermittent hemodialysis

peritoneal dialysis, night-time dialysis- it is much better but can not be used on pts with history of surgery or any perineal membrane weakness

Front 28

Some complications of hemodialysis:
_____tension
accelerated ______ disease
rapid loss of _________ function
access _______/______
______osis
______-______ malnutrition
any blood problems? breathing?

Back 28

hypotension
accelerated vascular disease rapid loss of residual kidney fxn
access thrombosis/sepsis amyloidosis
protein-calorie malnutrition hemorrhage
dyspnea
leukopenia

Front 29

Absolute contraindications for renal transplant:

Relave contraindications:
(Crazy old guy with Hep C: "I don't want to go to dialysis!"

Back 29

active GN, bacterial infection, malignancy, HIV, Hep B, severe co-morbidity

relative: age > 70 y/o, severe psych disease, Hep C, noncompliance w/ dialysis, tx

Front 30

What is CRRT? and when is it used?

Back 30

Continuous Renal Replacement therapy
- if pt intolerant to IHD, used on extremely unstable ICU pt