Nephrology step2

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gm1147
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166134
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Nephrology step2
Updated:
2012-08-15 13:43:25
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Neph nephrology renal step2
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kaplan
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  1. Tamm Horsfall protein
    • normal protein excretion into urine
    • Can be normally increased by standing and physical activity
  2. Proteinuria tests
    • Initial: U/A
    • Accurate: P/Cr ratio
  3. Test for Ur eos
    Wrghit and Hansel stains
  4. Dysmorphic RBC is sign of what
    Glomerulonephritis
  5. Casts
    • Red cell: glomerulonephritis
    • White cell: pyelonephritis
    • Eos: Acute interstitial nephritis
    • Hyalin: Dehydration
    • Broad/waxy: Chronic renal disease
    • Granular/muddy: Acute tubular necrosis
  6. Retroperitoneal fibrosis causes
    • bleomycin
    • methylsergide
    • radiation
  7. Most common toxins causing ATN
    • Aminoglycosides - esp if low mg
    • Cisplatin - esp if low mg
    • Amphotericin
    • Cyclosporine
    • NSAIDs

    • Vanc
    • Acyclovir
  8. AKI tests
    • Initial: BUN/Cr
    • Prerenal - >20:1
    • Intrinsit - 10:1
    • Postrenal - >20:1
    • Initial imaging: renal sonogram
    • U/A
    • UNa - <20 in prerenal, high in ATN (except contrast induced)
    • FeNa - <1% in prerenal, high in ATN (except contrast induced)
    • UrOsm - high in prerenal, low in ATN (isosthenuria, <300)
  9. Timing of ATN from toxin
    • Contrast - next day
    • Drugs - 5-10days
  10. Ppx for renal failure in chemo related tumor lysis syndrome
    • Allopurinol
    • hydration
    • rasburicase
  11. Rhabdomyolysis mangement
    • EKG or K level first to predict arrhythmia
    • Dipstick, U/A
    • accurate: Ur myoglobin
    • Fluids
    • Mannitol
    • Bicarb
  12. Indications for dialysis
    • Fluid overload
    • Encephalopathy
    • Pericarditis
    • Metabolic acidosis
    • Hyperkalemia
  13. Hepatorenal syndrome tx
    • Albumin
    • Midodrine
    • Octreotide
  14. Fat emboli to kidney presentation, dx, tx
    • Post cath, purple skin, livedo reticularis, ocular lesions, AKI
    • Eos in blood and urine, low complement, inc ESR. Accurate is bx
    • No tx
  15. Most common meds causing AIN
    • penicillines
    • cephalosporins
    • sulfa drugs
    • Phenytoin
    • Rifampin
    • Quinolones
    • Allopurinol
    • PPIs
    • (same as rash, SJS, TEN, hemolysis)
  16. Non drug causes of AIN
    • infections
    • SLE
    • Sjogren
    • Sarcoid
  17. AIN tx
    • cause
    • if still rising, steroids
  18. Analgesic nephropathy presentation
    • ATN
    • AIN
    • Membranous GN
    • Vascular insufficiency (constrict afferent)
    • Papillary necrosis
  19. Papillary Necrosis causes, presentation, dx, tx
    • NSAIDs plus underlying sickle, DM, obstruction, chonic kidney disease
    • Sudden flank pain, F, hematuria
    • Initial: UA, accurate: CT
    • No tx
  20. Glomerulonephritis labs
    • Hematuria
    • Proteinuria
    • Dysmorphic red cells
    • Red cell casts
    • Low UrNa and FeNa
  21. Goodpasture tx
    • Plasmapharesis
    • Steroids
  22. IgA nephropathy presentation, prognosis, tx
    • Asian, recurrent gross hematuria, post URI by 1-2 days (strep is 1-2weeks)
    • Most common GN in US
    • 30% completely resolve, 50% to ESRD
    • If severe proteinuria, ACEi and steroids
  23. Post infectious GN labs
    • ASO titiers
    • anti-DNAse Ab titers
    • Low complement
  24. Lupus nephritis management
    • Bx
    • If mild, steroids
    • If severe such as membranous, steroids with cyclophosphamide or mycophenolate
  25. Large kidney causes
    • Amyloid
    • HIV nephropathy
    • PCKD
    • DM
  26. Amyloidosis causes and tx
    • Myeloma
    • Chonic inflammatory disease
    • RA
    • IBD
    • Chronic infections
    • Primary
    • Tx: underlying, melphalan and prednisone
  27. GN associated with
    Solid cancers
    Children
    IVDU
    AIDs
    NSAIDs
    • Solid cancers: membranous
    • Children: minimal change
    • IVDU: focal segmental
    • AIDs: focal segmental
    • NSAIDs: minimal change and membranous
  28. Nephrotic syndrome complications, tx
    • thrombosis, infections
    • Steroids then cyclophosphamide.
    • ACEi
    • salt restriction, diuretics
    • statins
  29. ESRD manifestations
    • Anemia - loss of epo
    • HypoCa - loss of vit D reaction
    • Secondary hyperPTH - osteodystrophy, hyperP bc released from bone by PTH but cant be excreted
    • Bleeding - platelets dont degranulate in uremic. Use DDAVP when bleeding
    • Infection - neutrophils dont degranulate
    • Pruritis - urea. Use UV light.
    • HyperMg
    • Atherosclerosis and HTN - WBC not clearing lipids. 1# cause of death
    • Anovulatory, ED
    • Insulin inc but also resistance
  30. HyperP tx
    • Oral P binders to prevent bowel absorption
    • Tx of hyperCa
    • Ca acetate
    • Ca carbonate
    • Sevelamer - esp if Ca is high
    • Lanthanum - esp if Ca is high
  31. Glc correction for Na
    For every 100 Glc above normal, 1.6 dec in Na
  32. SIADH cases
    • Lung disease
    • Brain disease
    • SSRIs
    • Sulfonylureas
    • Vincristine
    • Cyclophosphamide
    • TCAs
    • Small cell lung cancer
    • Pain
  33. Thyroid and Na
    • needed to excrete water
    • Hypothyroid can cause hypoglycemia
  34. Tx of hypoNa
    • Mild: restrict fluics
    • Mod: NS and loop diuretic
    • Severe: Hypertonic saline, conivaptan, tolvaptan (ADH antagonists)
    • Chronic: demeclocyline - blocks ADH
  35. HyperK causes
    • Dec excretion:
    • Renal fail
    • ACEi, spironolactine, triamterene, amiloride
    • Type IV RTA
    • Addisons
    • Release from tissue:
    • hemolysis
    • rhambo
    • tumor lysis syndrome
    • dec insulin
    • acidosis
    • beta blockers, digoxin
    • heparin
  36. HyperK EKG
    • Peaked T
    • Wide QRS
    • Long PR
  37. Tx of HyperK
    • Abnormal EKG:
    • CaCl or Caglconate
    • Insulin and glc
    • Bicarb
    • Kayexelate (sodium polystyrene sulfonate)
    • Albuterol
    • Loop diuretic
    • Dialysis
  38. HypoK causes
    • Alkalosis
    • Inc insulin
    • Beta stimulation
    • Loop diuretics
    • Inc aldo - conn, volume depletion, cushing
    • Bartter syndrome
    • Licorice
    • HypoMg
    • RTA I and II
    • Vomitting, diarrhea, laxatives
  39. Bartter syndrome
    Genetic disease cuasing salt loss in loop of Henle
  40. Normal anion gap
    6-12
  41. Top causes of normal anion gap acidosis
    • RTA
    • Diarrhea
    • aka hyperchlormic acidosis
  42. RTA type I
    • Distal
    • Amphotericin, autoimmune diseases
    • Cant make bicarb in distal tubule
    • Nephrocalcinosis
    • Dx: initial is high pH on UA. accurate is infuse ammonium Cl and Ur pH will stay high
    • Tx by replace bicarb which will be absorbed in proximal
  43. RTA type II
    • Proximal
    • Amyloidosis, myeloma, Fanconi syndrome, acetazolamide, heavy metals
    • Dec reabsorption of filtered bicarb
    • Osteomalacia
    • Urine pH is basic first then low
    • Dx by giving bicarb and Ur pH will rise
    • Tx by thiazide diuretics
  44. RTA type IV
    • Diabetes
    • Dec effect of aldo
    • Loss of Na, retention of K and H
    • Dx: low Na diet, still high UrNa. Only one with HyperK
    • Low Ur pH
    • Tx with Fludrocotisone
  45. Uring anion gap
    • =Na-Cl
    • Diarrhea:Negative
    • RTA: Positive
  46. MetAlk causes
    • Vomiting
    • Aldo
    • Diuretics
    • Milk-alkali
    • HypoK
  47. Nephrolithiasis tx
    • Ketorolac
    • Hydration
    • Imaging - CT is accurate
    • Sonogram
    • Stone analysis
    • Serum Ca, Na, uric acid, PTH, Mg, P
    • 24hr Ur volume, Ca, oxalate, citrate, cystine, pH, uric acid, P, Mg
  48. Nephrolithiasis removal
    • lithotripsy: 5mm-3cm
    • Sugery: >2cm, struvite stones, cystine stones
    • Stent: relieve hydronephrosis from stones caught in distal ureter
    • Basket: half way down
  49. HTN work up
    • EKG
    • UA
    • Glc
    • Chol
  50. HTN tx first line in
    Normal pt:
    Very high:
    CAD:
    DM:
    BPH:
    Depression:
    Asthma:
    Hyperthyroid:
    Osteoporosis:
    2nd line
    • Normal pt: Thiazide diuretics first
    • Very high: 160/100, start on 2
    • CAD: bBlocker, ACEi
    • DM: ACEi
    • BPH: alpha blocker
    • Depression: avoid bblocker
    • Asthma: avoid bblocker
    • Hyperthyroid: bblocker
    • Osteoporosis: thiazide
    • 2nd line: ACEi, ARB, bblocker, CCB
  51. HTN crisis tx
    • Labetolol
    • nitroprusside
    • enalapril
    • CCB
    • Esmolol
    • All IV

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