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169 Cards in this Set

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Polycystic Kidney Disease -
What is it
AD -
b/l
cysts progressively develop
late onset
usu asymp until 30 y/o
50% - ESRD with dialysis
by 60 y/o

AR -
less common
more severe
often lethal in 1st few years
infants and kids
renal failure
liver fibrosis
portal HTN
Polycystic Kidney Disease -
Hx/PE
Hematuria
HTN
pain -
sharp & localized
from ruptured cysts,
infection,
renal calculi

large, palpable kidneys
liver cysts
berry aneurysms
mitral valve prolapse
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

ESRD -
dialysis
renal transplant
Nephrolithiasis -
MC in what population
Risk factors
MC in older men
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
Spiral CT - test of choice
UA - best 1st test

KUB
renal US
IVP - confirm
noncontrast abdom CT
UA -
hematuria
altered urine pH
Nephrolithiasis -
Tx
Init Tx -
hydration
analgesia

< 5mm -
can pass thru urethra

< 3 cm -
ESWL
(extracorporeal shock wave
lithotripsy)
percutaneous nephrolithotomy
Nephrolithiasis -
Calcium Oxalate/
Calcium Phosphate
Characteristics
Tx
MC (83%)
idiopathic hypercalciuria
primary hyperparathyroidism
hyperoxaluria
hypocitraturia
alkaline urine
radiopaque

Tx -
hydration
thiazide diuretic
Nephrolithiasis -
Struvite (Mg-NH4-PO4)
Characteristics
Tx
"Triple phosphate stones"
due to urease-producing org. -
Proteus
staghorn calculi
alkaline urine
radiopaque

Tx -
hydration
treat UTI, if present
Nephrolithiasis -
Uric Acid
Characteristics
Tx
Hyperuricemia
gout
high purine turnover states
acidic urine (pH < 5.5)
radiolucent

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

Tx -
hydration
alkalinize urine
if neither works -
penicillamine
Ureteral Reflux -
What is it
Retrograde flow of urine
from bladder back up
due to insuff. submucosal
length of ureter
=> 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

Tx -
tx infections aggressively
■ mild reflux -
no dilation
often resolves spontan
■ mod to severe reflux -
surgery
(uret. reimplantation)
Renal Cell Carcinoma -
What is it
Risk factors
MC kidney cancer (80-90%)
adenocarcinoma
arises from
tubular epith cells
=> renal vein => IVC
=> mets to lung & bone

risk factors -
men
smoking
VHL disease
Renal Cell Carcinoma -
Hx/PE
Classic triad -
hematuria
flank pain
palpable flank mass

polycythemia
constitutional Sxs
enlargement of left testicle
Renal Cell Carcinoma -
Tx
Surgical resection -
curative if local
notoriously resistant to
chemo & radiation
Cryptorchidism -
What is it
Failure of testes to
descend into scrotum
b/l assoc. with
oligospermia & infertility

risk factor - prematurity
Cryptorchidism -
Hx/PE
Testes can't be manipulated
into scrotal sac with
gentle pressure

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

find later in life -
orchiectomy
to avoid risk of testicular Ca
Erectile Dysfunction -
What is it
Risk factors
10-25% of mid-aged or elderly
fail to init, fill or store

risk factors -
DM
atherosclerosis
meds - B-blockers, SSRIs
HTN
heart dis.
spinal cord injury
surgery or radiation for
prostate cancer
Erectile Dysfunction -
Hx/PE
Ask about -
risk factors
meds
recent life changes
psych stressors

psychological -
if pt. has nocturnal or
early-morning erections
situation dependent
Erectile Dysfunction -
Dx
Check for hypogonadism
testosterone levels
gonadotropin levels
prolactin levels
eval for neuro dysfunction -
anal tone
lwr ext sensations
Erectile Dysfunction -
Tx
Psychotherapy
sex therapy
testosterone - if hypogonadism
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
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
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
lumpy-bumpy immunofluorescence
Postinfectious GN -
Tx & Prognosis
Supportive
almost all kids & most adults
have complete recovery
IgA Nephropathy (Berger's) -
What is it
Nephritic Syndrome
MC type worldwide
assoc. with URI or
GI infections
young men
IgA Nephropathy (Berger's) -
Hx/PE
Gross hematuria
IgA Nephropathy (Berger's) -
Labs & Histology
Inc. serum IgA
Bx & immunofluorescence -
mesangial IgA deposits
IgA Nephropathy (Berger's) -
Tx & Prognosis
Glucocorticoids
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
cavitary pulmonary lesions -
bleed => hemoptysis
Wegener's Granulomatosis -
Labs & Histology
c-ANCA
Wegener's Granulomatosis -
Tx & Prognosis
High-dose corticosteroids
cytotoxic agents
pts. tend to have
freq relapses
Alport's Syndrome -
What is it
Nephritic Syndrome
hereditary
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
men in mid 20's
immune form of RPGN
Goodpasture's Syndrome -
Hx/PE
Hemoptysis
dyspnea
possible respiratory failure
Goodpasture's Syndrome -
Labs & Histology
Linear anti-GBM on IF
iron-def. anemia
CXR - pulmonary infiltrates
sputum - hemosiderin-filled
macrophages
Goodpasture's Syndrome -
Tx & Prognosis
Plasma exchange therapy (plasmapheresis)
pulsed steroids
cyclophosphamide
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
1/3 due to systemic dis. -
DM
SLE
amyloidosis
Nephrotic Syndrome -
Hx/PE
Generalized edema
foamy urine
if severe -
dyspnea
ascites

inc. susceptibility to -
infections
ven. thrombosis
PE
Nephrotic Syndrome -
Dx
UA -
proteinuria > 3.5g/day
lipiduria

dec. albumin (< 3g/dL)
hyperlipidemia
Bx -
Dx underlying etiology
Nephrotic Syndrome -
Tx (in general)
Steroids - best init. Tx
cyclophosphamide
restrict salt
diuretics
statins
Minimal Change Disease -
What is it
Nephrotic syndrome
common in children
idiopathic etiology
Minimal Change Disease -
Hx/PE
Tendency towards -
infections
thrombosis
Minimal Change Disease -
Labs & Histology
Normal under light microscope
electron microscope shows -
fusion of epith foot processes
Minimal Change Disease -
Tx & Prognosis
Steroids
excellent prognosis
Focal Segmental
Glomerulosclerosis (FSGS) -
What is it
Nephrotic syndrome
idiopathic
IVDU
HIV
Focal Segmental
Glomerulosclerosis (FSGS) -
Hx/PE
Especially common in black men
with uncontrolled HTN
Focal Segmental
Glomerulosclerosis (FSGS) -
Labs & Histology
Microscopic hematuria
Bx -
sclerosis in capillary tufts
Focal Segmental
Glomerulosclerosis (FSGS) -
Tx & Prognosis
Prednisone
cytotoxic therapy
Poor prognosis
Membranous Nephropathy -
What is it
Nephrotic syndrome
MC white adult nephropathy
MC idiopathic form in adults
immune-complex disease
Membranous Nephropathy -
Hx/PE
Associated with -
HBV
syphilis
malaria
gold (drug)
penicillamine
cancer
SLE
Membranous Nephropathy -
Labs & Histology
"spike and dome"
due to granular deposits
of IgG and C3
at basement membrane
Membranous Nephropathy -
Tx & Prognosis
Steroids are of little use
Diabetic Nephropathy -
What is it
Nephrotic syndome
Diffuse hyalinization
nodular glomerulosclerosis
Kimmelstiel-Wilson lesions
Diabetic Nephropathy -
Hx/PE
Usually have long-standing,
poorly-controlled DM
Diabetic Nephropathy -
Labs & Histology
Thickened glomerular
basement membrane
increased mesangial matrix
Diabetic Nephropathy -
Tx & Prognosis
Tight glucose control
protein restriction
ACEIs
Lupus Nephritis -
What is it
Nephrotic & nephritic syndrome
WHO types I-V
severity of renal disease
determines overall prognosis
Lupus Nephritis -
Hx/PE
Proteinuria
or RBCs in UA
Lupus Nephritis -
Labs & Histology
Mesangial proliferation
subendothelial immune-complex
deposits
Lupus Nephritis -
Tx & Prognosis
May reduce dis. progression -
prednisone
cytotoxic therapy
Renal Amyloidosis -
What is it
Nephrotic syndrome

primary -
plasma cell dyscrasia

secondary -
infectious
inflammatory
Renal Amyloidosis -
Hx/PE
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 & nephritic syndrome
3 types
Membranoproliferative
Nephropathy (MPGN) -
Hx/PE
Immune deposits
low complement
associated with HCV

slow progression to RF
Membranoproliferative
Nephropathy (MPGN) -
Labs & Histology
"Tram tracks" -
double-layered basement memb

type I -
subendo deposits

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

irritative -
nocturia
daytime frequency
urge incontinence
opening hematuria

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

Not recommended for BPH -
PSA & cystoscopy
BPH -
Tx
Mild - reassurance
mod to severe - surgery

terazosin
finasteride
TURP
open prostatectomy
Prostate Cancer -
What is it
Risk factors
MC cancer in men
second cause of
cancer death in men

risk factors -
age
family Hx
Prostate Cancer -
Hx/PE
Usually asymp
rarely causes Sxs until advanced
urinary retention
dec. force of urine stream
lymphedema
constitutional Sxs
back pain

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
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
■ Tx based on -
aggression of tumor
pt's risk of dying
■ watchful waiting -
elderly & low-grade
■ radical prostatectomy & RT -
inc. risk of incontinence
inc. risk of impotence
■ PSA -
use to eval post-Tx
check for dis. recurrence
■ 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

also screen with PSA
Bladder Cancer -
What is it
Risk factors
2nd MC urologic cancer
MC malig tumor - urinary tract
transitional cell Ca
men - 60s & 70s
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
cystoscopy with Bx - diagnostic
may also -
US
MRI
pelvic CT
Bladder Cancer -
Tx
■ superficial -
transurethral resection
or
intravesicular chemo with
mitomycin-C or BCG
■ CIS -
intravesicular chemo
■ large, hi-grade recurrent -
intravesicular chemo
■ invasive without mets -
aggressive surgery
RT
■ distant mets -
chemo
Testicular Cancer -
What is it
Risk factors
Heterogenous group
95% derive from germ cells
almost all are malignant
MC malignancy in 15-35 y/o
seminomas peak at 40-50 y/o

Klinefelter's - risk factor
cryptorchidism -
inc. risk of neoplasia
in both testes
Testicular Cancer -
Hx/PE
Painless enlargement of testis
Testicular Cancer -
Dx
B-hCG -
inc. in choriocarcinomas
inc. in 10% of seminomas

AFP -
inc. in endodermal sinus
(yolk sac) tumors
Testicular Cancer -
Tx
Seminomas -
very radiosensitive
also respond to chemo

nonseminomatous germ cell -
platinum-based chemo
SIADH -
What is it
What is it associated with
Euvolemic hyponatremia
from nonosmotically-stimulated
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
and if
mild - restrict fluids
moderate - NS and furosemide
severe (Sxs) -
hypertonic saline
then furosemide

if chronic -
demeclocycline or lithium -
ADH antag
Diabetes Insipidus -
What is it
What is it caused by
Central or nephrogenic

central -
post pit. doesn't secrete ADH
causes -
tumor
ischemia (Sheehan's)
trauma
infection
autoimmune d/o

nephrogenic -
kidneys don't respond to ADH
causes -
renal dis.
drugs
(lithium, demeclocycline)
Diabetes Insipidus -
Hx/PE
Polydipsia
polyuria
persistent thirst
dilute urine

if don't have unlimited
access to water -
dehydration
hypernatremia
Diabetes Insipidus -
Dx
Water deprivation test

DDAVP challenge -
desmopressin mimics ADH

if central -
DDAVP challenge =>
dec. urine output
inc. urine osmolarity
thus, MRI (to check for mass)

if nephrogenic -
DDAVP challenge
will not dec. urine output
Diabetes Insipidus -
Tx
central -
DDAVP subcutaneously

nephrogenic -
thiazide diuretics (HCTZ)
amiloride
chlorthalidone
Acetazolamide -
Site of Action
Mechanism
Proximal convoluted tubule
inhibits carbonic anhydrase
Acetazolamide -
Clinical Use
Glaucoma
urinary alkalinization
metabolic alkalosis
altitude sickness
cysteinuria
Acetazolamide -
Toxicity
Hyperchloremic metab acidosis
sulfa allergy
Loop Agents
Furosemide
Bumetanide
Torsemide
Ethacrynic Acid -
Site of Action
Mechanism
Ascending loop of Henle
Inhibits Na/K/2 Cl cotransport
Loop Agents
Furosemide
Bumetanide
Torsemide
Ethacrynic Acid -
Clinical Use
HTN
hypercalcemia
edematous states -
CHF
cirrhosis
nephrotic syndrome
pulmonary edema
Loop Agents
Furosemide
Bumetanide
Torsemide
Ethacrynic Acid -
Toxicity
OH DANG
Ototoxicity
Hypokalemia
Dehydration
Allergy - sulfa
(not ethacrynic acid)
Nephritis - interstitial
Gout
Hydrochlorothiazide -
Site of Action
Mechanism
Distal convoluted tubule
inhibits Na+/Cl- cotransporter
Hydrochlorothiazide -
Clinical Use
HTN
CHF
idiopathic hypercalciuria
nephrogenic diabetes insipidus
Hydrochlorothiazide -
Toxicity
HyperGLUC
hyperGlycemia
hyperLipidemia
hyperUricemia
hyperCalcemia
and
hypokalemic metab alkalosis
hyponatremia
sulfa allergy
K+ Sparing Agents
Spironolactone
Triamterene
Amiloride -
Site of Action
Mechanism
Cortical collecting tubule

Spironolactone -
aldosterone receptor antag

triamterene & amiloride -
block Na+ channels
K+ Sparing Agents
Spironolactone
Triamterene
Amiloride -
Clinical Use
Hyperaldosteronism
K+ depletion
CHF
K+ Sparing Agents
Spironolactone
Triamterene
Amiloride -
Toxicity
Hyperkalemia
gynecomastia
antiandrogen effects
Mannitol -
Site of Action
Mechanism
Entire tubule
sorbitol stereoisomer
osmotic diuretic
filtered by glomerulus
can't be reabsorbed
inc. tubular fluid osmolarity
=> dec. water reabsorption
=> inc. urine flow
Mannitol -
Clinical Use
Shock
drug overdose
dec. intracranial or
intraocular pressure
Mannitol -
Toxicity
Pulmonary edema
dehydration
contraindicated in -
anuria
CHF
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+
serum K+ stays low
urinary pH > 5.3
RTA Type I -
Causes
Complications
Causes -
usually sporadic
lithium
amphotericin
analgesics
collagen vascular dis.
cirrhosis
chronic urinary tract obstruct
sickle cell
nephrocalcinosis -
also a consequence

complication -
nephrolithiasis
secondary hyperaldosteronism
RTA Type I -
Tx
Dx/Test
Tx -
potassium citrate

Dx/Test -
acid load
RTA Type II -
What is it
Proximal tubule
cells don't reabsorb HCO3
urinary pH init > 5.3
distal tubular cells work OK
=> urinary pH < 5.3 when
serum gets acidic
RTA Type II -
Causes
Complications
Causes -
hereditary
carbonic anhydrase inhibitors
Fanconi's syn
multiple myeloma

complications -
rickets
osteomalacia
RTA Type II -
Tx
Dx/Test
Tx -
potassium citrate

Dx/Test -
bicarb load
RTA Type IV -
What is it
Adrenal insensitivity to
angiotensin 2
aldosterone deficient

serum K+ is high
usually asymp hyperkalemia
hyperchloremic metab acidosis
(nonanion/normal metab acidosis)
RTA Type IV -
Causes
Complications
Causes -
hyporeninemic hypoaldosterone:
DM (infarcts JG)
ACEIs
NSAIDs

addison's
sickle cell
renal insufficiency

complication -
hyperkalemia
RTA Type IV -
Tx
Dx/Test
Tx -
fludrocortisone
furosemide - if HTN
kayexelate

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.

prerenal caused by -
dec. renal plasma flow
(inadequate renal perfusion)

renal caused by -
intrinsic renal dis. or damage

postrenal caused by -
obstruction of urinary outflow
both kidneys must be
obstructed to cause
significant azotemia
Acute Renal Failure -
Hx/PE
Hx -
uremia:
malaise
oliguria
fatigue
anorexia
n/v

PE -
asterixis
HTN
dec. urinary output
inc. RR
pericardial friction rub -
if uremic pericarditis

prerenal -
hypovolemia
orthostasis
oliguria

postrenal -
anuria
distended bladder

acute interstitial nephritis -
fever
rash
Acute Renal Failure -
Dx
CBC
BUN/Cr
electrolytes
FE(Na) - if oliguric
urine sediment -
RBC
WBC
casts
eosinophils

urinary catheter
renal US
Acute Renal Failure -
Tx
■ Balance fluid & electrolytes
■ dialysis if indicated
■ acute/allergic
interstitial nephritis -
adjust/discontinue
offending meds
■ glomerulonephritis -
corticosteroids
cytotoxics
Acute Renal Failure -
Complications
Chronic renal failure
=> dialysis

dialysis -
■ prevent buildup of:
K+
H+
toxic metabolites
■ inc. risk for CAD
Acute Renal Failure -
What is Prerenal % for FE(Na)
What is Prerenal No. for U(Na)
What is Prerenal Ratio
for BUN/Cr
FE(Na) is < 1%
U(Na) is < 20
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
Acidosis
Electrolyte abnormalities
(hyperkalemia)
Ingestions
Overload of fluid
Uremic Sxs -
pericarditis
encephalopathy
bleeding
nausea
pruritus
myoclonus
Hyponatremia -
What is it
Serum sodium < 135 mEq/L
Hyponatremia -
Hx/PE
May be asymp
confusion
lethargy
muscle cramps
nausea
can progress to -
seizures
status epilepticus
coma
Hyponatremia -
Dx
Classified by -
serum osmolality
volume status (by PE)
urinary Na+
Hyponatremia -
What are the types
of osmolalities
High -
> 295 mEq/L
hyperglycemia
hypertonic infusion (mannitol)

Normal -
280-295 mEq/L
hyperlipidemia
hyperproteinemia
pseudohyponatremia

Low -
< 280 mEq/L
hypervolemic hyponatremia
euvolemic hyponatremia
hypovolemic hyponatremia
Hyponatremia -
Tx
Chronic hyponatremia should
be corrected slowly
to prevent central pontine
myelinolysis
Hypervolemic Hyponatremia -
What is it
Etiologies
Tx
Inc. in Na+ & total body wt.
Inc. greater in TBW

etiologies -
edematous states:
renal failure
nephrotic syndrome
cirrhosis
CHF

Tx -
restrict salt and water
Euvolemic Hyponatremia -
What is it
Etiologies
Tx
Total body Na+ normal
total body water has inc.

etiologies -
SIADH
hypothyroidism
renal failure
drugs
psychogenic polydipsia
adrenal insufficiency

Tx -
restrict salt and water
Hypovolemic Hyponatremia -
What is it
Etiologies
Tx
Dec. in total body Na+
and total body water
more Na+ than water is lost

etiologies -
diuretics
vomiting
diarrhea
third spacing
dehydration

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
weakness
focal neuro deficits
seizures
"doughy" skin
Hypernatremia -
Dx
Measure urine vol.
measure urine osmolality

hypervolemic hyperNa+ -
inc. aldosterone or
excess Na+ (IV saline)

min vol (500 mL/day) of
max concentrated urine
(> 400 mOsm/kg) -
adequate renal response
inadequate free water replaced
fluid loss from -
dec. intake
diuretics
glycosuria
3rd spacing

lg vol of dilute urine -
diabetes insipidus
Hypernatremia -
Tx
■ Tx underlying causes
■ replace free water deficit -
isotonic fluids
■ correct gradually over
48-72 hrs
(to prevent neuro damage
secondary to cerebral edema)
Hypercalcemia -
What is it
What causes it
Serum Ca2+ > 10.2 mg/dL
> 15 mg/dL = medical emergency
MCC -
hyperparathyroidism
malignancy

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 -
Dx
EKG - short QT
total Ca2+
ionized Ca2+
albumin
phosphate
PTH
PTHrP
vit D
TSH
serum immunoelectrophoresis
Hypercalcemia -
Tx
IV hydration
then furosemide

if severe or refractory -
calcitonin
bisphosphonates
(pamidronate)
glucocorticoids
dialysis
Hypocalcemia -
What is it
What causes it
Serum Ca2+ < 8.5 mg/dL

caused by -
hypoparathyroidism
(postsurgery, idiopathic)
malnutrition
hypomagnesemia
acute pancreatitis
medullary thyroid cancer
(excess calcitonin)
vit D def.
pseudohypoparathyroidism
renal insufficiency

serum Ca2+ may be falsely
low in hypoalbuminemia
Hypocalcemia -
Hx/PE
Abdom muscle cramps
tetany
perioral & acral paresthesias
convulsions
dyspnea

Chvostek's sign
Trousseau's sign
EKG - prolonged QT
Hypocalcemia -
Dx
Ionized Ca2+
Mg2+
PTH
albumin
calcitonin
if post-thyroidectomy -
check operative note
to determine no. of
parathyroid glands removed
Hypocalcemia -
Tx
Tx underlying d/o
oral calcium supplements
if severe - IV calcium
Hypomagnesemia -
What is it
What is it caused by
Serum Mg2+ < 1.5 mEq/L

causes:
■ dec. intake:
malnutrition
alcoholism
malabsorption
short bowel syndrome
TPN
■ inc. loss:
diuretics
diarrhea
vomiting
■ miscellaneous:
DKA
pancreatitis
Hypomagnesemia -
Hx/PE
Sxs usu related to
concurrent hypocalcemia
and hypokalemia

anorexia
n/v
muscle cramps
weakness

if levels very low -
paresthesias
irritability
confusion
lethargy
seizures
arrhythmias
Hypomagnesemia -
Dx
Check for concurrent
hypocalcemia & hypokalemia
EKG - prolonged PR & QT
Hypomagnesemia -
Tx
IV or oral Mg2+
hypokalemia & hypocalcemia
won't correct if Mg2+
not corrected also
Hyperkalemia -
What is it
What is it caused by
Serum K+ > 5 mEq/L

causes -
■ spurious -
hemolyzed blood draw
fist clenched during
blood draw
extreme leukocytosis
extreme thrombocytosis
rhabdomyolysis
■ dec. excretion -
renal insufficiency
mineralocorticoid def.
RTA type 4
drugs -
heparin
spironolactone
triamterene
ACEIs
trimethoprim
NSAIDs
■ cellular shifts -
tissue injury
insulin def.
drugs -
succinylcholine
digitalis
arginine
B-blockers
■ iatrogenic
Hyperkalemia -
Hx/PE
Muscle weakness starts > 6.5
MCC of death -
abnorm cardiac conduction

May be asymp
n/v
intestinal colic
areflexia
weakness
flaccid paralysis
paresthesias
Hyperkalemia -
Dx
Verify with repeat blood draw
(if need to)
EKG -
tall peaked T
prolonged PR
wide QRS

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

C BIG K
Calcium gluconate or CaCl
Bicarb or
Insulin and
Glucose
Kayexalate and
loop diuretics

Ca gluconate or CaCl -
immediate but short-lived

bicarb not in same IV line as Ca
(forms CaCO3 precipitate)

insulin & glucose -
takes 30-60 min. to work

give sorbitol to prevent constipation

If RF or severe, refractory -
dialysis
Hypokalemia -
What is it
What is it caused by
Serum K+ < 3.5 mEq/L

causes -
■ transcellular shifts -
insulin
B2-agonists
alkalosis
periodic paralysis
■ GI losses -
diarrhea
chronic laxative abuse
vomiting
NG suction
■ renal K+ losses -
diuretics
primary mineralocorticoid
excess
secondary hyperaldosteronism
drugs
DKA
hypomagnesemia
RTA Types 1&2
■ licorice
■ clay
Hypokalemia -
Hx/PE
Sxs start when K+ <2.5 - 3.0

muscle weakness
cramps
ileus
fatigue
hyporeflexia
paresthesias
if severe - flaccid paralysis
cardiac arrhythmia
Hypokalemia -
Dx
24-hour or spot urine K -
to distingish renal from
GI losses
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