Nephro

Question 1

What defines AKI?

Answer 1

• increase in Cr by 30+ in 48h
• Cr 1.5x baseline in 7d
• U/O <0.5mL/kg/hr over 6hr

Question 2

What ratio values represent a pre-renal cause of AKI?

Answer 2

Ur/Cr >100
FENa <1%
UrNa <20

Question 3

List Clinical Features of Acute Kidney Injury

Answer 3

CARDIOVASCULAR:
- Pulmonary edema
- Arrhythmia
- HTN
- Pericarditis
- Pericardial effusion
- MI
- PE

METABOLIC:
- HypoNa
- HyperK
- Acidosis
- HypoCa
- HyperPO4
- HyperMg
- Hyperuricemia

NEUROLOGIC:
- Asterixis
- Neuromuscular irritability
- Mental status changes
- Somnolence
- Coma
- Seizures

GASTROINTESTIONAL:
- Nausea
- Vomiting
- Gastritis
- Gastroduodenal ulcer
- GIB
- Pancreatitis
- Malnutrition

HEMATOLOGIC:
- Anemia
- Hemorrhagic diathesis

INFECTIOUS:
- PNA
- Septicemia
- UTI
- Wound infection

Question 4

List 15 Causes of Prerenal AKI

Answer 4

VOLUME LOSS:
- Gastrointestinal = vomiting, diarrhea, NG drainage
- Renal = diuresis
- Blood loss
- Insensible losses
- Third-space sequestration
- Pancreatitis
- Peritonitis
- Trauma
- Burns

LOW CARDIAC OUTPUT:
- MI
- Valvular disease
- Cardiomyopathy
- Decreased effective arterial volume
- AntiHTN meds
- Nitrates

VOLUME REDISTRIBUTION:
- Sepsis
- Anaphylaxis
- Hypoalbuminemia
- Nephrotic syndrome
- Liver disease

Question 5

List 10 Causes of Postrenal AKI

Answer 5

Intrarenal & Ureteral Causes:
- Kidney stones
- Sloughed papillas
- Bilateral ureteral compression 2/2 malignancy or benign gynecologic causes
- Retroperitoneal fibrosis
- Uric acid, oxalic acid, or phosphate crystal precipitation (Renal stones)
- Sulfonamide, methotrexate, acyclovir precipitation

Bladder:
- Kidney stone
- Blood clot
- Prostatic hypertrophy
- Bladder carcinoma
- Neurogenic bladder

Urethra:
- Phimosis
- Stricture

Question 6

List 15 Intrinsic Renal Diseases That Cause AKI

Answer 6

VASCULAR:
Large Vessel Dz:
- Renal artery thrombosis or stenosis
- Renal vein thrombosis
- Atheroembolic disease

Small & Medium Sized Vessel Dz:
- Scleroderma
- Malignant hypertension
- HUS
- TTP
- HIV-associated microangiopathy

GLOMERULAR:
Systemic Dz:
- SLE
- Infective endocarditis
- Systemic vasculitides
- HSP/IgA nephropathy
- anti-GBM/Goodpasture
- HIV-associated nephropathy
- Essential mixed cryoglobulinemia

Primary Renal Dz:
- Post-streptococcal GN
- Rapidly Progressive GN

AIN & TUBULOINTERSTITIAL:
- Drugs
- Toxins
- Infections
- Multiple myeloma

ACUTE TUBULAR NECROSIS:
Ischemia:
- Shock
- Sepsis
- Severe prerenal azotemia
- Post-burn
- Heat stroke
- HHS

Nephrotoxins:
- ABX (aminoglycosides)
- Radiographic contrast agents
- Myoglobinuria
- Hemoglobinuria

OTHER:
- Severe liver dz
- Allergic rxns
- NSAIDs

Question 7

List U/A microscopic findings consistent with a glomerulonephritis

Answer 7

Red cell casts
Proteinuria
Hematuria

Question 8

List 4 clinical features of Acute Interstitial Nephritis

Answer 8

Fever
Rash
Arthralgias
Eosinophilia
Eosinophiluria

Question 9

List 10 Causes of Pigment-Induced AKI

Answer 9

Rhabdomyolysis & Myoglobinuria:
- Crush injury
- Compartment syndrome
- Electrical injury
- Myonecrosis from coma or immobilization
- Acute arterial occlusion
- Vigorous exertion
- Status epilepticus
- Hyperthermia & Heat stress
- Metabolic myopathy
- Drugs/toxins

Hemoglobinuria:
- Acute hemolysis
- Transfusion reaction
- Drugs/toxins
- Infections

Question 10

Define oliguria and anuria

Answer 10

Oliguria = 100-400mL/24h urine output

Anuria = <100mL/24h urine output

Question 11

Outline causes of urinary ‘casts’ on U/A

Answer 11

Hyaline casts = dehydration, after exercise

Red cell casts = glomerulonephritis, vasculitis

White cell casts = renal parenchymal inflammation

Fatty casts = heavy proteinuria, nephrotic syndrome

Granular casts = ATN

Question 12

What ratio values represent an ATN cause of AKI?

Answer 12

UrNa >40
FENa >1%

Question 13

List 15 Major Causes of CKD

Answer 13

VASCULAR:
- Renal artery disease
- HTN nephrosclerosis

GLOMERULAR:
Primary Glomerulopathies:
- Focal sclerosing GN
- Membranoproliferative GN
- Membranous GN
- Crescentic GN
- IgA nephropathy

Secondary Glomerulopathies:
- Diabetic nephropathy
- Collagen vascular disease
- Amyloidosis
- Post-infectious
- HIV nephropathy

TUBULOINTERSTITIAL:
- Nephrotoxins
- Analgesic nephropathy
- HyperCa or nephrocalcinosis
- Multiple myeloma
- Reflux nephropathy
- Sickle cell nephropathy
- Chronic pyelonephritis
- TB

OBSTRUCTIVE:
- Nephrolithiasis
- Ureteral tuberculosis
- Retroperitoneal fibrosis
- Retroperitoneal tumour
- Prostatic obstruction
- Congenital abnormalities

HEREDITARY:
- Polycystic kidney disease
- Alport syndrome
- Medullary cystic disease

Question 14

List 10 Clinical Features of Uremia and CKD

Answer 14

• Uremic pericarditis
• Uremic pleuritis
• Pulmonary edema
• Lethargy
• Somnolence
• Uremic encephalopathy (hiccups, asterixis, or myoclonic twitching)
• Distal sensorimotor neuropathy
• Anorexia
• Nausea
• Uremic frost
• Diffuse pruritus
• Renal osteodystrophy
• Carpal tunnel syndrome
• Normochromic normocytic anemia
• Defective PLT adhesiveness

Question 15

List 6 “Reversible” Factors in AoCKD

Answer 15

Hypovolemia

Congestive heart failure

Pericardial tamponade

Severe hypertension

Catabolic state, protein loads

Nephrotoxic agents

Obstructive disease

Reflux disease

Question 16

List 6 “Treatable” Causes of AoCKD

Answer 16

Renal artery stenosis

Malignant HTN

AIN

Hypercalcemic nephropathy

Multiple myeloma

Vasculitis (SLE, GPA, Polyarteritis Nodosa)

Obstructive nephropathy

Reflux nephropathy

Question 17

List 8 Mechanisms of Drug Toxicity in Renal Failure

Answer 17

Excessive drug level

Impaired renal excretion of drug

Impaired renal excretion of active metabolite

Impaired hepatic metabolism

Increased sensitivity to drug

Changes in protein binding

Changes in volume of distribution

Changes in target organ sensitivity

Metabolic loads administered with drug

Misinterpretation of measured serum drug level (change in therapeutic range)

Question 18

List Indications for Emergency Dialysis

Answer 18

Acidosis
Electrolyte imbalance (HyperK)
Ingestion/Overdose
Overload (Pulm edema)
Uremia (CNS, pericarditis, etc)

Severe uncontrollable HTN

Question 19

List 10 dialyzable drugs/toxins

Answer 19

I STUMBLED

Isoniazid
Isopropyl alcohol
Salicylates
Theophylline
Uremia
Methanol
Metformin
Barbiturates
Lithium
Ethylene glycol
Dabigatran
Divalproex (VPA)

Question 20

List 5 complications of Hemodialysis

Answer 20

• bleeding from dialysis site
• infection of dialysis site
• hTN
• SOB
• Chest pain
• Disequilibrium syndrome

Question 21

List 15 DDx of causes of hTN in HD Pts

Answer 21

Hypovolemia

Excessive fluid removal

Hemorrhage

Septicemia

Cardiogenic shock

Dysrhythmia

Pericardial tamponade

MI

Myocardial or Valvular dysfunction

HyperK

HypoK

HyperCa

HypoCa

HyperMg

Vascular instability

Drug-related

Dialysate-related

Autonomic neuropathy

Excessive access arteriovenous flow

Anaphylactoid reaction

Air embolism

Question 22

List 15 DDx of causes of Altered Mental Status in HD Pts

Answer 22

STRUCTURAL:
- CVA (particularly ICH)
- SDH
- Intracerebral abscess
- Brain tumour

METABOLIC:
- Disequilibrium syndrome
- Uremia
- Drug effects
- Meningitis
- Hypertensive encephalopathy
- Hypotension
- Postictal state
- HyperNa
- HypoNa
- HyperCa
- HyperMg
- Hypoglycemia
- Severe hyperglycemia
- Hypoxemia
- Dialysis dementia

Question 23

List 3 complications of peritoneal dialysis

Answer 23

• peritonitis
• site infection
• perforated viscus

Question 24

List ABX tx for peritonitis related to peritoneal dialysis

Answer 24

Vancomycin
Cefazidime or Cefepime
or Gentamicin

+ Heparin to reduce formation of fibrin strands that may obstruct catheter