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gm1147
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Tamm Horsfall protein
- normal protein excretion into urine
- Can be normally increased by standing and physical activity
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Proteinuria tests
- Initial: U/A
- Accurate: P/Cr ratio
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Test for Ur eos
Wrghit and Hansel stains
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Dysmorphic RBC is sign of what
Glomerulonephritis
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Casts
- Red cell: glomerulonephritis
- White cell: pyelonephritis
- Eos: Acute interstitial nephritis
- Hyalin: Dehydration
- Broad/waxy: Chronic renal disease
- Granular/muddy: Acute tubular necrosis
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Retroperitoneal fibrosis causes
- bleomycin
- methylsergide
- radiation
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Most common toxins causing ATN
- Aminoglycosides - esp if low mg
- Cisplatin - esp if low mg
- Amphotericin
- Cyclosporine
- NSAIDs
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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)
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Timing of ATN from toxin
- Contrast - next day
- Drugs - 5-10days
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Ppx for renal failure in chemo related tumor lysis syndrome
- Allopurinol
- hydration
- rasburicase
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Rhabdomyolysis mangement
- EKG or K level first to predict arrhythmia
- Dipstick, U/A
- accurate: Ur myoglobin
- Fluids
- Mannitol
- Bicarb
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Indications for dialysis
- Fluid overload
- Encephalopathy
- Pericarditis
- Metabolic acidosis
- Hyperkalemia
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Hepatorenal syndrome tx
- Albumin
- Midodrine
- Octreotide
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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
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Most common meds causing AIN
- penicillines
- cephalosporins
- sulfa drugs
- Phenytoin
- Rifampin
- Quinolones
- Allopurinol
- PPIs
- (same as rash, SJS, TEN, hemolysis)
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Non drug causes of AIN
- infections
- SLE
- Sjogren
- Sarcoid
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AIN tx
- cause
- if still rising, steroids
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Analgesic nephropathy presentation
- ATN
- AIN
- Membranous GN
- Vascular insufficiency (constrict afferent)
- Papillary necrosis
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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
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Glomerulonephritis labs
- Hematuria
- Proteinuria
- Dysmorphic red cells
- Red cell casts
- Low UrNa and FeNa
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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
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Post infectious GN labs
- ASO titiers
- anti-DNAse Ab titers
- Low complement
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Lupus nephritis management
- Bx
- If mild, steroids
- If severe such as membranous, steroids with cyclophosphamide or mycophenolate
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Large kidney causes
- Amyloid
- HIV nephropathy
- PCKD
- DM
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Amyloidosis causes and tx
- Myeloma
- Chonic inflammatory disease
- RA
- IBD
- Chronic infections
- Primary
- Tx: underlying, melphalan and prednisone
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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
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Nephrotic syndrome complications, tx
- thrombosis, infections
- Steroids then cyclophosphamide.
- ACEi
- salt restriction, diuretics
- statins
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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
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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
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Glc correction for Na
For every 100 Glc above normal, 1.6 dec in Na
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SIADH cases
- Lung disease
- Brain disease
- SSRIs
- Sulfonylureas
- Vincristine
- Cyclophosphamide
- TCAs
- Small cell lung cancer
- Pain
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Thyroid and Na
- needed to excrete water
- Hypothyroid can cause hypoglycemia
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Tx of hypoNa
- Mild: restrict fluics
- Mod: NS and loop diuretic
- Severe: Hypertonic saline, conivaptan, tolvaptan (ADH antagonists)
- Chronic: demeclocyline - blocks ADH
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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
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Tx of HyperK
- Abnormal EKG:
- CaCl or Caglconate
- Insulin and glc
- Bicarb
- Kayexelate (sodium polystyrene sulfonate)
- Albuterol
- Loop diuretic
- Dialysis
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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
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Bartter syndrome
Genetic disease cuasing salt loss in loop of Henle
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Top causes of normal anion gap acidosis
- RTA
- Diarrhea
- aka hyperchlormic acidosis
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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
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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
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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
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Uring anion gap
- =Na-Cl
- Diarrhea:Negative
- RTA: Positive
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MetAlk causes
- Vomiting
- Aldo
- Diuretics
- Milk-alkali
- HypoK
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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
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Nephrolithiasis removal
- lithotripsy: 5mm-3cm
- Sugery: >2cm, struvite stones, cystine stones
- Stent: relieve hydronephrosis from stones caught in distal ureter
- Basket: half way down
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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
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HTN crisis tx
- Labetolol
- nitroprusside
- enalapril
- CCB
- Esmolol
- All IV
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