Nephrology

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Renal Disease Clinical findings: May present with no sx or non specific complaints of ________,___________,________ Consequently, many present with advanced dz More specific sx HTN Edema Polyuria Hematuria Dar: fatigue, malaise, or anorexia
Renal Disease History: _________(duration and complications) ____________(duration and complications) Recurrent ____ Renal ______ Family history of renal dz Arthralgias, skin rash, fever, and weight loss Medication: Diabetes

Hypertension

UTIâ€™s

calculi
Renal Disease Physical Exam: Signs of __________ illness responsible for renal dz __________ exam may suggest HTN, DM, or bacterial endocarditis (_______) Skin may show edema, rash, purpura Joints examination for signs of _______: systemic

Retinal

Rothâ€™s spot

arthritis

urinary obstruction
Renal Disease GFR: ____________ concentration in serum assesses GFR Creatinine comes from __________ as a result of muscle breakdown Daily rate is constant and determined by skeletal muscle mass Is eliminated by glomerular filtra: Creatinine

creatine

0.8-1.3

0.6-1.1

Cimetidine, trimethoprim, triamterene, amiloride
Renal Disease BUN: Urea is product of ________ metabolism Levels reflect dietary intake and catabolic rate of protein Excreted by glomerular filtration, but reabsorbed in high ________ states such as volume depletion So, varies w: protein

sodium

10:1
Disproportionate Increase in Blood Urea Nitrogen: Volume depletion "__________" _____ hemorrhage Corticosteroid or cytotoxic agents High-_____ diet Obstructive uropathy Sepsis Catabolic states tissue breakdown: prerenal azotemia

GI

protein

Liver
Renal Disease Creatine Clearance: Provides a reasonable estimate of GFR Errors that limit its accuracy are - Increasing creatinine secretion & improper ______ collection *Normal Ccr in men is ______ mg/kg/day* *Normal Ccr in: urine

20-25

15-20
Renal Disease Lab and renal function: Renal tubular function evaluated by examining kidneys ability to maintain Na+ and H2O balance and acid base balance (urine __) Fe Na = fractional excretion of sodium in urine useful in the ddx of _____: pH

oliguric

water deprivation test
Renal Disease Proteinuria: Normal excretion < ___ mg/day Transient abnormal proteinuria occurs with (3): 150

Fever
CHF
Exercise
Renal Disease Proteinuria: _______________ (benign) Characterized by lack of protein in urine collected overnight while patient is supine: Orthostatic proteinuria
Renal Disease Proteinuria: Persistant proteinuria Should get timed urine specimen with urine creatinine to help determine accuracy of collection More than ___ g of protein/day have glomerular dz Less than 3.5 g of protein/day is: 3.5

microalbuminuria

Albumen
Renal Disease Urinalysis: Color Normal urine is colorless to deep yellow depending on pigment concentration Abnormal colors may mean ________,__________, pigment, drug, or dye _______ or __________ results in smoke colored urine: disease, infection

RBCâ€™s or myoglobin

WBCâ€™s
Renal Disease Urinalysis: Chemistry (dipstick) pH , hemoglobin, protein, glucose, ketones, leukocyte esterase, nitrites Protein on dipstick detects only ______, not immunoglobulins or Bence Jones proteins Concentrated urine may show t: albumen

Blood

LE and nitrites
Renal Disease Urinalysis: Microscopic exam Test of urine sediment for cells, casts, crystals, and organisms Microscopic hematuria is > __ rbc/hpf in urine not contaminated by menses _________ cells are dysmorphic Non glomerula: 2

Glomerular

RBC
Urinalysis: Microscopic exam _______ is the presence of more than 4 wbc/hpf Suggests _____ or __________ ________ pyuria is pyuria with negative culture~ Prostatitis Chronic urethritis Renal tuberculosis Renal stones: Pyuria

UTI or inflammation

Sterile
Renal Disease Urinalysis: Microscopic Eosinophyls on Wrights stain suggests ___________ Renal tubular epi cells are seen in ___________,___________, and ___________ Free fat droplets seen in heavy ___________: interstitial nephritis

acute tubular necrosis, glomerulonephritis, and pyelonephritis

proteinuria
Renal Disease Urinalysis: Microscopic exam ________ are cylindrical structures from intratubular protein precipitation RBCâ€™s or WBC casts mean inflammatory ___________ disease RBCâ€™s alone usually indicates a significant __________: Casts

parenchymal

glomerular lesion or interstitial nephritis

tubular necrosis

pyelo
Renal Disease Urinalysis: Microscopic exam Crystals â€“ Ca oxylate are ________ shaped, and uric acid are _________ shaped In the absence of sx, have little clinical significance But, cystine crystals indicate ________ Triple pho: envelope

rhomboid

cystinuria

alkaline

UTI

Trichomonas
Acute Nephritic Syndrome: Abrupt onset of renal dysfunction with _________ that is nephronic in origin (glomerular or tubular in origin) _____ casts and dysmorphic erythrocytes in urine sediment also highly suggests nephronic origin Signif: hematuria

RBC

proteinuria
Acute Nephritic Syndrome: Clinical findings- _______ retention leading to HTN, circulatory overload, and CHF Causes: Kids- post ___________ glomerulonephritis is the most well known, also ____________ purpura Adults- SLE, ____: sodium

streptococcal

Henoch-Scholein

lupus

endocarditis
Nephrotic Syndrome: Increased glomerular __________ resulting in proteinuria of >3.5g/d/1.73m2 body surface area with~ (3)`: permeability

Edema
Hypoalbuminemia
Hyperlipidemia
Nephrotic syndrome: Proteinuria charactistic of both nephritic and nephrotic syndrome However on urinalysis Nephrotic syndrome has: _____ fat bodies Course granular ______ Cellular elements But lack the â€œ______â€ se: Oval

casts

active
Nephrotic Syndrome: Causes- Membranous nephropathy ____ _________ nephropathy Multiple myeloma __________(abnormal deposition of protein called amyloid into tissues causing serious harm in some organs, no harm in others): SLE

Diabetic

Amyloidosis
Rapidly progressive renal failure: Rapid deterioration of renal function over weeks to months Causes- _________ uropathy Malignant ________ ____ with hemolytic uremic syndrome Bilateral __________ Multiple myeloma: Obstructive

hypertension

TTP

renal artery stenosis
Acute Renal Failure: Abrupt decline in renal function over days to weeks Causes- Decreased renal blood flow (____________) Intrinsic parenchymal disease (_________) Obstruction to urine flow (____________): pre-renal azotemia

renal azotemia

post renal azotemia
Tubulointerstitial nephropathy: Glomeruli and vasculture are spared but the _________ and __________ are affected Can be classified as acute interstitial nephropathy or chronic interstitial nephropathy depending on how quickly renal dysfunction: interstitium and tubules
Tubointerstitial nephropathy: Chronic characterized by _____ insufficiency __________ range proteinuria Severe tubular damage Significant ________ wasting, hyperkalemia and metabolic __________ even with modest renal insufficienc: Renal

Non nephrotic

sodium

acidosis
Tubointerstitial nephropathy: Acute characterized by Usually caused by _____ Sudden onset of signs of renal dysfunction ____________ cell infiltrates in renal interstitium Important in the ddx of ____________: drug

Inflammatory

acute renal failure
Urinary Tract Imaging Renal ________: Useful for the detection of renal masses, cysts, and dilation of collecting system (____________) In unexplained renal failure can help assess size and __________ uropathy In renal failure, US sho: Ultrasound

hydronephrosis

obstructive

small

normal
Urinary Tract Imaging Renal Ultrasound: _________ US with doppler imaging detects disease of major _____________ Simple _________ identified by US Kidney size on ultrasound with a discrepancy of more than ___ cm may suggest renovascul: Duplex

renal arteries or veins

cysts

1.5
Urinary Tract Imaging ____________: IV administration of contrast medium that is excreted through the kidney through glomerulo filtration Nephrogram image produced due to contrast medium concentrating in the renal tubules When it pass: IVP (intravenous pyelography)

papillary necrosis

nephrotoxicity
Urinary Tract Imaging Retrograde Pyelography: Contrast material injected into _________ at time of cystoscopy Helpful in defining __________ in the ureter or renal pelvis, especially with non visualized kidney on IVP Stones can be mov: ureter

obstruction

basket
Urinary Tract Imaging CT of the Kidney: Usually done with contrast medium Helpful in evaluation of ______,________, perinephric pathology Helpful in vascular pathology such as __________ Used to guide kidney ________, or collecti: masses, cysts

renal vein thrombosis

biopsy

perinephric abcess
Urinary Tract Imaging _______: Helpful in evaluating complex masses, staging tumors, detecting invasion of renal veins Diagnosing renovascular disease in lieu of CT in patients with renal failure to avoid use of contrast material: MRI

MRA (magnetic resonance angiography)

pacemakers
Urinary Tract Imaging ___________: Injection of contrast media into the aorta and renal arteries to see renal vasculature Helpful in renal artery stenosis, thrombosis, or renal mass Important in the workup of _________ Used to lo: Renal arteriography

kidney donors
Urinary Tract Imaging Radionuclide imaging: IV radiolabeled compounds Images taken with gamma camera Used in evaluation of ___________ problems Renovascular _________ GFR estimation Pyelonephritis/renal abcess: Renal perfusion

hypertension

obstruction
Renal Biopsy: Performed when glomerular lesion suspected or unexplained acute renal failure ____________ bx most commonly done Complications are __________, renal hematoma, laceration with development of av fistula, accidental _______ of l: Percutaneous

hematuria

biopsy
nephrotic sydrome persistent proteinuria hematuria asso w/ abnormal urine sediment or proteinuria unexplained hematuria after exclusion of lower urinary tract cause systemic disorders w/ kidney involvement acute renal failure (at: Indications for kidney biopsy
Capillary bed that recieves blood from afferent arteriole and drains by efferent arteriole 4 cell types Visceral epithelial (podocyte) Endothelial Mesangial cell Parietal epithelial: Glomerulus
__________ supports the GBM by trebecular network _________ provides skeletal framework to capillary network and controls blood flow of glomerular capillaries in response to different mediators __________ line the capillary lumen: epithelial

mesangium

endothelial

parietal epithelium
Clinical manifestations of glomerular disease: Urinary abnormalities __________ and ___________ Nonspecific systemic symptoms _______,_________,________ Altered glomerular function Changes in GBM permeabili: Proteinuria and hematuria

Hypertension, edema, malaise

proteinuria
Clinical manifestations of glomerular disease: RBC casts or dysmorphic RBCâ€™s means nephronal bleeding and characteristic of ______________ RBC casts sometimes seen in acute ______________ Renal _____ retention is common in GN and causes:: glomerulonephritis

interstitial nephritis

salt
Nephritic Syndrome: Abrupt onset of _________ with RBC casts __________(non-nephrotic range) Temporary impairment of renal function with oliguria, increased BUN and Creatinine Salt and water retention and ______ Most commonly due: hematuria

Proteinuria

HTN

PSGN (post streptococcal glomerulonephritis)
PSGN: Postinfectious complication of _________ infection Strept throat leads to PSGN in fewer than 5% of those not treated (within 7-28 days) More common in ________(up to 50% in some accounts) Typically in kids aged 3-12, but can occ: GABHS

impetigo
PSGN: Symptoms and signs- ________,__________,________ Laboratory findings- Low serum ___________ levels ASO titers high _______ colored urine with RBCâ€™s and RBC cast Proteinuria less than 3.5 g/dl (_________): Oliguria, edema, hypertension

complement

Cola

non-nephrotic

IgG
PSGN: Treatment- _________ Appropriate __________ ____________ and salt restriction if needed _________ not helpful: Supportive

antibiotics

Antihypertensives

Steroids
PSGN: Prognosis- Very favorable in children Less than 5% of adults will develop _______________ and smaller percentage will develop _______________: RPGN (rapidly progressive glomerulonephritis)

ESRD (end stage renal dz)
Nephritic Syndrome: IgA nephropathy (_________ disease) Renal disease of _____ deposition in the glomerular mesangium Cause unknown, same lesion seen in H-S purpura Is associated with ________,__________ and ________ as in HIV and CMV: Bergerâ€™s

IgA

cirrhosis, celiac dz, and infections
Nephritic Syndrome: IgA nephropathy (Bergerâ€™s Disease) Episode of ___________ is the most common presenting complaint Frequently associated with ____, ____ or ____ like illness Urine is ____ or ____ colored 2 days after onset of sx: gross hematuria

URI, GI sx, or flu

red or cola
Nephritic Syndrome: IgA nephropathy (Bergerâ€™s Disease) 1/3 of patients experience clinical remission 40-50% develop progressive ____________ Remainder show _____________ but stable serum creatinine Ominous sign is proteinuria >__: renal insufficiency

microscopic hematuria

1 g/dl

persistent
Nephritic Syndrome: IgA nephropathy IgA increased up to 50% of normal, but normal IgA doesnâ€™t r/o dz ________ is the standard for dx _________ shows IgA granular deposits in dermal capillaries: Renal bx

skin bx
Nephritic Syndrome: IgA nephropathy Treatment- In significant proteinuria (>1g/dl) ______ and _______ are used to decrease proteinuria and reach target BP of 125/75 With proteinuria of 1.0-3.5 g/dl, ________ have been used and are benef: ACE-I and ARBâ€™s

steroids

Fish oil
Nephritic Syndrome: Henoch-Schonlein purpura Leukocytoclastic vasculitis of unknown cause Definition: leukocytoclastic vasculitis is an acute cutaneous vasculitis that is characterized by purpura, especially of the ______, and by exudatio: legs

neutrophils

RBCs

children

males
Nephritic Syndrome: Henoch-Schonlein purpura Clinical presentation- Palpable purpura mostly on lower extremities ___________ GI sx such as _______, ______ and _______ Renal insufficiency with nephritic presentation Renal les: Arthralgias

nausea, colic, and melana

IgA nephropathy
Nephritic Syndrome: Pauci-immune glomerulonephritis _______ granulomatosis, ___________ disease, and microscopic polyangitis All are ________ vessel vasculitis: Wegners

Churg-Strauss

small
Nephritic Syndrome: Anti-glomerular Basement Membranne GN and Goodpastures syndrome Goodpastures dz is GN and __________ hemorrhage preceded by _____ and causing hemoptysis, dyspnea and respiratory failure ______ and _______ are component: pulmonary

URI

HTN and edema
Nephritic Syndrome: Cryoglobulin-associated GN Cold precipitable immunoglobulins precipitating in glomerular capillaries Cause is underlying infection such as ________, or other occult viral, bacterial, or fungal infections Patients have n: Hepatitis B or C

skin

underlying infection
Rapidly Progressive Glomerulonephritis: Syndrome characterized by ___________(RBC casts and dysmorphic RBCâ€™s) Renal failure over weeks to months Renal bx showing diffuse _________ formation Can occur with or without immune depo: Nephronal hematuria

crescent

idiopathic
Rapidly Progressive Glomerulonephritis: Anti GBM GN 2/3 of patients have ___________ syndrome - a form of rapidly progressive glomerulonephritis, which involves a progressive decrease in the kidney's ability to function properly, accompanied by a __: Goodpastures

cough

bloody
Rapidly Progressive Glomerulonephritis: AntiGBM GN Goodpastures more common in the _______ Affects men more than women Presents with RPGN, hemoptysis, and dyspnea Strong association between ___________ and pulmonary hemorrhage in Good: young

cigarette smoking

prednisone

Cyclophosphamide
Rapidly Progressive Glomerulonephritis: ___________ RPGN Almost always associated with another underlying dz Correct dx made by identifying clinical and lab features of those diseases (see table 27-4 Cecil) Makes up 30% of all RPGN cases<: Immune Complex
Rapidly Progressive Glomerulonephritis: Pauci-immune RPGN (_____ associated) Associated with systemic vasculitides - (2) Also an idiopathic form with vasculitis only of glomeruli 80% of Pauci-immune RPGN is associated with ANCA (antineutro: ANCA

Wegners granulomatosis & Polyarteritis nodosa

Cytoxan and corticosteroids
Nephrotic Syndrome: Urine _______ of >3.5g/1.73m2 per 24 hrs Hypoalbumenemia Hyperlipidemia Peripheral _______: protein

edema
Nephrotic Syndrome: 1/3 of patients have systemic renal dz- ____________ Amyloidosis SLE HIV Remainder have idiopathic nephrotic syndrome. 3 most common are Minimal change disease Focal ____________ ___: Diabetes mellitus

glomerular sclerosis

Membranous
Nephrotic Syndrome: Signs and Symptoms ____________ is the hallmark of the syndrome When serum _________ concentration less than 3g/dl But more likely due to ________ retention than low plasma oncotic pressure Presents in the dependen: Peripheral edema

albumen

sodium

Dyspnea

ascites
Nephrotic Syndrome: Lab ___________ due to alteration in GBM Urinary dipstick analysis indicates albumin only Addition of sulfosalicylic acid allows other paraproteins to be detected by dipstick Can detect as little as 15mg/dl Mu: Proteinuria

concentrated

dilute
Nephrotic Syndrome: Lab - Microscopic urinalysis Urinary sediment has few cellular elements With significant ____________, ________ bodies - are lipid deposits in sloughed renal tubule epithelial cells Appear as â€œ_________â€ and â: hyperlipidemia

Oval fat

grape clusters and maltese
Nephrotic Syndrome: Lab - Blood chemistries Decreased serum _________(<3g/dl) ___________ - 50% of patients with early nephrotic syndrome The more protein excreted, the more hyperlipidemia Due to fall in oncotic pressure (inc: albumen

Hyperlipidemia
Nephrotic Syndrome: Lab - Blood chemistries Other tests depending on clinical presentation ________ levels Serum ________ electrophoreisis ANA Serologic tests for _________: Compliment

protein

Hepatitis
Nephrotic Syndrome: Renal Biopsy Performed in new onset idiopathic nephrotic syndrome if primary renal disorder that may require drug therapy is suspected Not done in patients with very high _________ levels (irreversible renal dz) Not don: creatinine

nephrotic
Nephrotic Syndrome: Management - Protein Loss Daily dietary ________ intake should be increased to offset the loss and avoid negative _________ balance Protein malnutrition occurs when urinary protein exceeds ____g/d: protein

nitrogen

10
Nephrotic Syndrome: Management - Edema _____________ is essential ________ in most patients Usually thiazide or loop diuretics Both are protein bound so with hypoalbumenemia delivery to the kidney is decreased So combination of t: Salt restriction

Diuretics
Nephrotic Syndrome: Management - Hyperlipidemia Dietary management of little value But, should be advocated _________ ___________ therapy: Exercise

Pharmacologic
Nephrotic Syndrome: Management - Hypercoaguable states Serum with low ________ (<2g/dl) can be hypercoagulable Nephrotic syndrome patients lose antithrombin III, protein C, and protien S through the urine Have increased _______ activati: albumen

platelet

thrombosis

anticoagulants
Nephrotic Syndrome: _______ Renal Disorders Minimal Change Disease Membranous Nephropathy Focal segmental glomerular schlerosis: Primary
Nephrotic Syndrome: Primary Renal Disorders - Minimal change disease Etiology Mostly in _______, ______ predominence Idiopathic or following _____ URI Associated with _________ dz Associated with drugs (gold and lithium): children, Male

viral

Hodgkins

NSAIDS and bee stings

prednisone
Nephrotic Syndrome: Primary Renal Disorders - Membranous Nephropathy Most common cause of primary nephrotic syndrome in adults Most commonly in adults in their ______ decades Almost always after age 30 Treatment based on renal dz prog: 5th to 6th

proteinuria

immunosupression
Nephrotic Syndrome: Primary Renal Disorders - Focal Segmental Glomerular Sclerosis Can be idiopathic or secondary Secondary due to morbid ______, ______ usage, and ______ infection Typically progress to ______ in 6-8 years Treat: obesity

heroin

HIV

ESRD

steroids
Nephrotic Syndrome: Systemic Disorders - Amyloidosis Extracellular deposition of a fibrous protein (amyloid) in one or more sites in the body Serum amyloid A is synthesized in ______ and deposited in tissues in primary renal amyloidosis,: liver

multiple myeloma

older

Enlarged
Nephrotic Syndrome: Systemic Disorders - Amyloidosis Treatment and Prognosis Treat inciting agents if present ____________ ______ in 2-3 years 5 yr survival is 20%: Corticosteroids

ESRD
Nephrotic Syndrome: Systemic Disorders - Diabetic Nephropathy *Most common cause of _______ in the US* More common in type ___ diabetics, but increasing in type ___ diabetics Patients at higher risk are males, African Americans, and Native: ESRD

1

2

microalbuminuria

proteinuria
Nephrotic Syndrome: Systemic Disorders - Diabetic Nephropathy Strict glycemic control slows progression of nephropathy _____ and _____ lower progression to clinical proteinuria and ESRD ____ patients also prone to papillary necrosis, chron: ACE-I and ARBâ€™s

DM

dialysis
Nephrotic Syndrome: Systemic Disorders - HIV associated Nephropathy Can present as nephrotic syndrome in HIV patients Mostly ________ men More associated with ________ use _______ slows progression of renal disease Recommended fo: young black

IV drug

HAART (highly active antiretroviral therapy)

Corticosteroid
Asymptomatic Urinary Abnormalities: Hereditary Nephritis (______ Syndrome) Starts in childhood with microscopic hematuria with or without gross hematuria Mild proteinuria, nephrotic syndrome rare __________ after age 15 in 50% of pat: Alports

Sensorineural deafness

Inherited
Asymptomatic Urinary Abnormalities: Thin Basement Membrane Dz Autosomal dominant Basement membrane glomerulopathy Presents as _________ in otherwise healthy young adult Excellent prognosis with only rare cases of ____________: microscopic hematuria

progressive renal failure
Asymptomatic Urinary Abnormalities: Benign Recurrent Hematuria _______ adults with microscopic hematuria on routine exam Gross hematuria with _________,__________,________: Young

febrile illness, exercise or immunization
Characterized by epithelial lined cavities in the kidneys filled with fluid or semi solid debris: Renal Cystic Diseases
Renal Cystic Diseases: Clinical Settings may suggest etiology Abdominal mass in neonate or infant suggests _______ Renal failure in an adolescent suggests ARPKD or ____________ Solitary cyst in healthy 50 year old suggests _______: ARPKD (autosomal recessive polycysitc kidney dz)

medullary cystic dz

simple cyst

family

renal stones

dialysis
Renal Cystic Diseases: Simple cyst (Solitary Cysts) Increase in frequency with age In up to 50% of people over age ___ Account for 65-70% of all renal masses Found at the ________ and contain fluid which is an ultrafiltrate of plasma: 50

outer cortex

US and CT
Renal Cystic Disease: Simple Cysts (Solitary Cysts) In dialysis patients, simple cysts may progress to _________ Ultrasound and CT used to differentiate Simple cysts must have three criteria on sonogram to be considered benign:: malignancy

Echo

smooth walls

back wall

Complex
Renal Cystic Disease: Simple cysts (solitary cysts) Criteria on ___- Simple cyst Smooth thin wall Sharply demarcated _______ enhance with contrast media Renal Cell Carcinoma: Enhances but is of lower _______: CT

Does not

density

Arteriography
If cyst meets criteria for being benign- Periodic _________ is the standard of care If findings not consistent with simple cyst- ____________: evaluation

Surgical exploration
Polycystic Kidney Disease: ADPKD adult polycystic kidney dz ARPKD infantile or childhood PKD Can occur with congenital __________ causing death from renal failure in first year of life: hepatic fibrosis
Polycystic Kidney Dz: ADPKD Most common __________ renal dz in the U.S. 500,000 people or 1 in 800 live births 50% of patients will have ESRD by age ____ Accounts for 10% of dialysis patients in the U.S.: hereditary

60
Polycystic Kidney Dz: ADPKD Three genes involved, two most important are ADPKD1 and ADPKD2 ADPKD 1 is on chromosome ___ ADPKD 2 is on chromosome ___ PKD 2 has slower progression and longer life expectancy than PKD 1: 16

4
Polycystic Kidney Dz: Clinical manifestations Rarely presents before age ______ So people of childbearing age pass it on before they know they have it Patients either present for screening because of family hx, or due to symptoms: 20-25
Polycystic Kidney Dz: Symptoms Acute _________ pain and back pain with hematuria is the most common presentation Non specific dull lumbar pain occurs when kidneys large enough to be palpable on PE Sharp localized pain from ________,_____: abdominal flank

cyst rupture, infection

Microhematuria
Polycystic Kidney Dz: S/S _____ - Most common cardiovascular complication In 60% of patients before the onset of renal insufficiency ______ - From urinary concentrating defect, usually present at the time of diagnosis: HTN

Nocturia

UTI, pyelonephritis
Polycystic Kidney Dz: S/S 1/3 have _______ 10% have ________ 25% have _____ Also, __________ associated with ADPKD Renal function - Impairment is variable 50% of patients ESRD by age 60: hepatic cysts

cerebral anneurysms

MVP (mitral valve prolapse)

diverticulosis
Polycystic Kidney Dz: Poor prognostic indicators ADPKD __ gene Male ______ race HTN Progression at ______ Episodes of gross hematuria: 1

Black

early age
Polycystic Kidney Dz: Dx Radiographic evidence of multiple cysts in parenchyma associated with: _______ enlargement Increased _________ thickness Elongation of the ________ Renal Ultrasound and CT used CT with contrast: Renal

cortical

calyces

cystic
Polycystic Kidney Dz: Dx Gene location helps identify _______________ of ADPKD1 through gene linkage analysis Is expensive Involves other family members Reserved for those with ___________ imaging studies: asymptomatic carriers

nondiagnostic
Polycystic Kidney Dz: Tx of ADPKD Preventing __________ Preserving renal function Education regarding inheritance Screening in patients with strong family hx of ____________: disease complications

cerebral aneurysmal hemorrhages
Polycystic Kidney Dz: Therapy Control ____ Prevent ____ Treat cyst infections with antibiotics that penetrate cyst walls and attain therapeutic levels(3) Dialysis or transplantation for ESRD _________ prior to transplantation in: HTN

UTIâ€™s

TMP/SMX, cipro, or chloramphenicol

Nephrectomy
Polycystic Kidney Disease: ARPKD Most common inheritable cystic renal dz occuring in ________ Is autosomal recessive, distinct from ADPKD Involves pathologic changes in the _____ and/or kidney Kidneys may be massively enlarged in infa: infancy

liver
Polycystic Kidney Disease: ARPKD Accounts for 1.5% of kids needing renal replacement prior to age 15 .6 % of patients with renal failure (ESRD) before the age of 20 No ______ predominance Males ___ females May occur at any time f: racial

=
Polycystic Kidney Disease: ARPKD ______ & ______ involvement Both manifest _________ degrees of severity If severe renal dz early, they succumb to renal dz prior to hepatic problems But, milder forms of renal dz develop severe hep: Kidney and liver

opposite
Medullary Cystic Disorders part of a group of ______________ known as juvenile nephronophthisis-medullary cystic disease complex Almost universal progression to _______ Childhood type (____________) is autosomal recessive Adult: congenital nephropathies

ESRD

Juvenile nephronopthisis

medullary cystic
Medullary Cystic Disorders: Clinical findings Sometimes accompanied by _____________ _______ and prolonged enuresis in childhood due to concentrating defect which is early indication of renal dz ______ stature Failure to thrive A: eye deformities

Anemia

Short

ESRD
Medullary Cystic Disorders: Dx US and CT - ___________ kidneys Doesnâ€™t usually show the cysts because they are only 1-2 mm in diameter Renal biopsy - *Open renal bx* to recover tissue from ____________ junction Tre: Small scarred

corticomedullary

Salt and water
Medullary Sponge Kidney Common and benign disorder Present at birth, not usually diagnosed until 4th or 5th decade of life Autosomal dominant Kidneys have very __________ enlargement in the medullary and interpapillary collectin: irregular

swiss cheese
Medullary Sponge Kidney: Clinical findings Gross or microscopic _________ Recurrent ____ or stones - may manifest itself initially as passage of renal stone Estimated that 10% of patients who present with stones have medullary sponge kidne: hematuria

UTIâ€™s

concentrating

IVP
Medullary Sponge Kidney: Tx No known therapy Increasing ______ to prevent stone formation ________ diuretics to decrease calcium excretion in hypercalcuric patients ______ therapy if RTA is present: fluid

Thiazide

Alkali
Urinary Tract Obstruction Obstruction can occur anywhere from the renal pelvis to the urethral meatus _________ obstruction usually causes no change in flow or total renal function If drainage of both kidneys significantly compromise: Unilateral

azotemia or renal failure
Obstruction: Clinical Presentations Change in _________ habits frequently presenting sign True anuria â€“ (inability to urinate) __________ is the most common cause Nocturia and polyuria â€“ can result from ____________ due to defective ur: urinary

complete obstruction

partial obstruction
Obstruction In the absence of __________, always consider obstruction as a cause of renal failure of unknown etiology Total anuria in ____________ highly suggestive of urinary tract obstruction: proteinuria

acute renal failure
Obstruction: Diagnosis ________ is preferred means of diagnosing urinary tract obstruction Depends on identification of __________ May not be evident in 1st 24 hrs or in severly dehydrated patient _____ helpful in situations suc: Renal US

hydronephrosis

IVP
Obstruction: Management Identify the ________ Relieve the __________ - Usually through surgical intervention If cant relieve obstruction, perform urinary diversion ________ and obstruction - Control of UTI is mandatory: site & cause

obstruction

Infection
Vascular Disorders of the Kidney: Diseases affecting the renal vasculature Those affecting larger vessels - ________________ Ischemic nephropathy and atheroembolic disease - __________ _________ hypertension Schleroderma Thrombot: Renal artery occlusion

smaller vessels

Malignant
Renal Arterial Occlusion: Potentially reversible cause of renal failure Cause: ________ trauma or surgery ________ (heart or paradoxical thromboemboli) Dissecting AAA or renal aneurysm ________ (polyarteritis nodosa, K: Abdominal

Embolism

Vasculitis

stenosis

compression
Clinical Findings of Renal Artery Occlusion: Depend on collateral circulation Acute renal infarct sx- ______ or _______ pain Nausea, _______ Fever Acute _____ due to activation of renin angiotensin system LAB: Lumbar or flank

vomiting

HTN

Leukocytosis

hematuria

infarct
Clinical findings in renal artery occlusion: Imaging _________ imaging necessary to diagnose renal vascular occlusive disease _________ imaging shows no blood flow to the kidney Can use CT, MRI, or Doppler *Renal ________ more reliabl: Radiologic

Radionuclide

Angiography
Clinical findings in renal artery occlusion: Tx Goal is to avoid irreversible renal damage To localize ________ To re-establish _________ Traumatic renal artery thrombosis- Surgical __________ must be performed within 4-6 h: thrombus

blood flow

thrombectomy

revascularization
Clinical findings in renal artery occlusion: Chronic Ischemic Renal disease and collateral circulation Renal function may return even if dx and tx delayed for days or weeks Has been documented 6 weeks of return of renal function with surgical: Anticoagulation

angioplasty
Ischemic Nephropathy Def: chronic renal impairment secondary to hemodynamically significant renal artery ________ which is a cause of renal insufficiency and ESRD 15% of ESRD patients over 50 have ________ renal disease Prevalence of: stenosis

ischemic

coronary, cerebral
Diagnosis of Ischemic nephropathy: Must find significant ________ and show that this is the cause of renal impairment Selection of tests depends on clinical suspicion Example: discrepancy in ________ is good indication for considering rena: renal artery stenosis

renal size
Diagnosis of Ischemic nephropathy: Imaging ________ Ultrasonography- Good screening test but highly operator dependent and time consuming technically difficult _____ inhibitor renography- Good screening test but not reliab: Doppler

ACE

angiography
Diagnosis of Ischemic nephropathy: Imaging *Gold Standard for dx of ischemic nephropathy is ____________* There are risks involved ________ induced acute renal failure - Prevent by _______, or specially prepared contrast Atheroembolic: renal arteriography

Contrast

hydration
Recommendations for renal arteriography: Use in patients with __________ for ischemic nephropathy But in those with equivocal risk factors, start out with _________ tests such as Duplex Doppler US or MRA before proceeding to angiography: multiple risk factors

less invasive
Ischemic Nephropathy: Tx ________ therapy- Doesnâ€™t reliably prevent disease progression But may be the only available option in those patients unable to tolerate invasive procedure Invasive therapy- Percutaneous ________: Medical

angioplasty

revascularization
Ischemic Nephropathy: Tx (cont) Percutaneous angioplasty with or without ______ is treatment of choice in high surgical risk patients Surgical revascularization is best option in patient with high grade renal artery stenosis that is: stent

aortic
Athroembolic Diseases of the Kidney: progressive disorder with worsening renal insufficiency as a result of ___________ of small and medium sized renal vessels by atheromatous emboli Incidence- Occurs in patients with widespread ____: embolic obstruction

athromatous

anticoagulants or antithrombolytic
Athroembolic Kidney Dz: Clinical concerns Acute, subacute, or chronic renal dysfunction Labile HTN as a result of renal _______ or activation of renin-angiotensin system Livido reticularis â€“ a manifestation of __________ embolization in: ischemia

cholesterol

emboli
Athroembolic Kidney Dz: Tx No effective treatment Avoidance of ___________ or ________ procedures in patients with diffuse athroschlerosis Avoid anticoagulants and thrombolytic agents _________ dialysis rather than hemodalysis to avoi: angiographic or surgical

Peritoneal
Chronic Hypertensive Nephrosclerosis: intrarenal vascular sclerosis and ischemic changes associated with chronic hypertension. Advanced changes can lead to ESRD Risk factors Race (_________) Marked elevated ________ Un: African Americans

blood pressure

creatinines
Chronic hypertensive nephrosclerosis: dx is based on clinical presentation in long term hypertensive pt picture is that of __________ & small kidneys on ____ usually don't need bx degree of renal damage & progression wor: non-nephrotic proteinuria

US

HTN
Chronic Hypertensive Nephrosclerosis: Tx Goal of therapy is to control _____ Outcome depends on BP control and patient compliance with meds, and follow up However, renal function can worsen in some patients despite good BP control __: BP

Genetics
________ Nephrosclerosis: Renal vascular changes with _______ HTN causing renal ischemia and ________ Rise in arteriolar and capillary pressure causes vascular endothelium fibroid necrosis Plasma renin-angiotensin system is activated and m: Malignant

accelerated

acute renal failure
Malignant nephrosclerosis: Patients present with severely elevated DBPâ€™s (>____mm Hg) May have hypertensive ____________ Proteinuria and hematuria with ARF Renal bx shows fibroid necrosis of the _________: 120

encephalopathy

arterioles
Malignant Nephrosclerosis: Tx Rapidly lower the DBP to 100-110 mm Hg within __ hours Donâ€™t lower the mean arterial BP more than 25% for fear of ischemic events due to decreased ________ Gradual lowering of DBP to 80-90 mm Hg over weeks c: 6

perfusion

vascular
Malignant nephrosclerosis: Patients who develop renal insufficiency as a result of malignant nephrosclerosis tend to do poorly and have lower survival rate All patients with malignant hypertension need workup of secondary causes of this problem: papilledema
___________: progressive connective tissue disorder with proliferation of connective tissue, thickened vascular walls and lumen narrowing. 50% of patients have renal involvement Mild proteinuria Abnormal serum creatinine Systemic: Scleroderma
Scleroderma Renal Crisis: Occurs in 10-15% of patients Characterized by _____ Abrupt onset of severe hypertension (small % may have normal BP) Risk factors of renal crisis- Rapidly progressing diffuse _____ involvement: ARF

skin

African American
Diagnosis of scleroderma renal crisis: Other manifestations of scleroderma Rarely presents as the initial symptom of the disease ____, anticentromere antibody, Scl 70 antibody, and anti-RNP polymerase antibodies may be positive: ANA
Scleroderma renal crisis: Tx Start before irreversible damage ___ control to slow renal damage progression to RF _______ are DOC With good BP control, patients may get enough renal function return to stop _________: BP

ACE inhibitors

dialysis
Hemolytic Uremic Syndrome and TTP: Consist of thrombotic ___________ & ____________ Clinical features of HUS and TTP are similar Renal involvement more in ____ ______ thrombi in glomerular capillary loops Arterioles develop f: microangiopathy and thrombocytopenia

HUS

Fibrin
HUS: More in kids after non-specific _________ illness Also, certain _______ associated with hemorrhagic colitis and HUS HUS is associated with- Renal failure Thrombocytopenia Microvascular platelet thrombi Microa: diarrheal

E.coli
TTP- Similar features as in HUS But, more problems with ________ & ________ symptoms Both disorders can be associated with- __________ OCPâ€™s __________ agents Infections __________ diseases: mental status and neurologic

Malignancy

Antineoplastic

Autoimmune
Clinical course regarding renal involvemt in HUS or TTP can be either acute renal failure or rapidly progressive renal failure Spontaneous recovery may be high in children who may need only __________ therapy Adult prognosis is less favorable,: supportive

Plasma exchange

Vincristine

Splenectomy
removing blood from the patient, mechanically separating blood from plasma, mixing blood cells with replacement plasma and returning blood mixture to the body. Purpose is to rid the blood of the immune factors that stimulates the disease process, and new: plasma exchange
Renal Vein Thrombosis: ________ in the major vein (renal vein) that drains blood from the kidney Incidence high as 30% in _________ syndrome, especially ___________: Blood clot

nephrotic

membranous nephropathy
Acute RVT: S/S _____ ______ pain Testicular pain ________, gross or microscopic Marked increase in plasma ____ Rise in serum __________ Increased ______ size: N/V

Flank

Hematuria

LDH

creatinine

renal
Chronic RVT: S/S Non specific findings Worsening _________ Evidence of renal ________ dysfunction _______ issues, urinary concentration, ___________ disorders: proteinuria

tubular

Acid base

electrolyte
Renal Vein Thrombosis: Dx Gold standard is selected __________ CT, MRA, US, are useful non infasive tests, but are less reliable Treatment- Anticoagulation with _______ acutely, then long term anticoagulation with ________: renal venography

heparin

warfarin (coumadin)

1

Thrombolytic

surgical embolectomy
Acute Renal Failure (ARF): abrupt decrease in GFR significant enough to cause increased ______ & ______ and disruption of extracellular fluid volume and electrolyte and acid base balance Can result from: Diseases causing decrease: BUN and creatinine

prerenal azotemia

azotemia

post renal azotemia
*__________ is most common intrinsic renal disease causing ARF* ATN definition: syndrome of abrupt and sustained decline in ____ within minutes to days after ischemic or nephrotoxic occurrence Diagnosis based on exclusion of _________, and the: Acute tubular necrosis (ATN)

GFR

pre or postrenal azotemia
ARF: DDX 5% of hospital admissions, 30% ICU admits H&P and lab often all that is needed for DX In hospital: _________ is the most common cause of azotemia ATN is the most common problem causing ARF So, must differe: Pre renal azotemia

bladder outlet obstruction
ARF: Diagnosis __________ Special attention to- Recent reduction in GFR Events leading to deterioration of renal function Consideration of two above factors in relation to chronology of potential causes of ARF Must have kno: Review of Records
ARF: Diagnosis - PE Reduced body weight, postrual changes in BP and P, and decreased jugular venous pulse all suggest decreased ___________ causing prerenal azotemia Expanded extracellular fluid volume with decreased effective blood: extracellular fluid volume

Cirrhosis

Distended tender bladder

post void bladder cath

interstitial nephritis

cholesterol

atheromatous
ARF: Diagnosis - Urinalysis Urine volume In oliguric ATN usually ____ ml/day (but normal output does not exclude ATN as cause of ARF) Non oliguric ATN usually associated with nephrotoxic ________-induced ARF ________ usually points t: 400

antibiotic

Anuria
ARF: Diagnosis - Urinalysis Urine sediment Prerenal failure-increased fine _______ casts ATN â€“ â€œ_______â€ renal tubular epithelial cells free in sediment and also in casts Obstruction â€“ ______ sediment Deposition of intra: granular

dirty brown

benign

oxylate
ARF: Diagnosis - Urinalysis Urinary indices Helps in determination of prerenal Azotemia vs ATN: Urine ______ Urine ________ Urine ________ Renal failure index Fractional excretion of filtered sodium: sodium

creatinine

osmolarity
ARF: Diagnosis - Renal ______ indications When dx of prerenal azotemia or ATN is uncertain, especially if clinical setting suggests other possibilities (ie obstruction or vascular accident) When clinical findings make the diagnosis of prerenal: biopsy
ARF: Diagnosis Imaging ________ shows presence or absence of dilated collecting system which excludes post renal ARF (absence) ___________ assesses renal blood flow as well as excretory and secretory function Renal bx: Ultrasound

Radionucleotide

nephrotoxic or ischemic injury
ARF: Lab Hospitalized patients usually have _____ as cause of ARF Outpatients, usually cause is _________- disease (once pre and post renal azotemia r/o) Examination of the urine sediment, and blood and protein helps establish diagnosis an: ATN

renal parenchymal
ARF: Lab - Urine _________ GN = 3-4+ protien, 2-3+ blood, and active urine sediment with RBCâ€™s and casts Myoglobinuria or hemoglobinuria = few RBCâ€™s in urine sediment, with strongly ____+ urine seen in myoglobinuria or hemoglobi: Proliferative

heme

crush

Rhabodomyolysis
ARF: Diagnosis - Kidney size *Best evaluated by ___* Gives information as to ARF or CRF, obstruction Ex: normal kidney size in patient with advanced azotemia means ____ rather than CRF However, normal kidney size in patient with rena: US

ARF

DM, HIV

renal bx
ATN: acute renal failure due to _______ damage and accounts for 85% of intrinsic ARF 2 major causes of ATN are: ________ & _______: tubular

Ischemia & Toxin exposure
ATN: Causes - Ischemia Caused by tubular damage from states of low ________ Characterized by inadequate GFR and inadequate renal blood flow Inadequate blood flow cannot maintain parenchymal cellular formation Occurs in _______ or ___: profusion

hypotensive or hypoxemic

major surgery
ATN: Causes - Nephrotoxic exposure Exogenous nephrotoxins- More commonly cause damage ________, ______, radiographic contrast agents, cysplatin, ethylene glycol, _____ inhibitors Endogenous nephrotoxins- _________, __: Aminoglycosides, NSAIDS

ACE

Rhabdomyolysis, hyperuricemic
ATN: Exogenous Nephrotoxins - Aminoglycosides 25% of hospitalized patients on aminoglycosides have some degree of ATN Nonoliguric RF _____ days after exposure Mostly in patients with renal damage, dehydration, and advanced age Can rem: 5-10

trough

Gentamycin and tobramycin

streptomycin
ATN: Exogenous Nephrotoxins - Other anti-infectives _________ nephrotoxic after 2-3 grams ________, acyclovir, and several cephalosporins have associated with ATN: Amphotericin B

Vancomycin
ATN: Exogenous Nephrotoxins - Radiographic contrast agents ____ leading cause of new ARF in hospitalized patients Predisposing factors: Age, renal dz (serum creatinine >__mg/dl), volume depletion, diabetic nephropathy, _____, repe: 3rd

2

CHF
ATN: Exogenous Nephrotoxins - Radiographic contrast agents Toxicity usually ______ hours after contrast study Prevention: ________ of agents recommended for high risk patients Hydration with 1L of .45% ______ over 12 hours befor: 24-48

Lower volumes

saline

Acetylcysteine
ATN: Exogenous nephrotoxins - Cyclosporin Dose dependent Distal tubular dysfunction from severe ___________ Monitoring is important to prevent toxicity In renal transplant patients taking cyclosporin to prevent rejection, ________ is: vasoconstriction

renal bx
ATN: Exogenous Nephrotoxins - Others Antineoplastics: _________ Organic solvents, ethylene glycol Heavy metals: ________, cadmium, and arsenic: Cysplatin

Mercury
ATN: Endogenous Nephrotoxins - Heme containing products ________ as a result rhabdomyolosis leads to ATN Necrotic or damaged muscles release myoglobin Large amounts of myoglobin are filtered across glomerulus Myoglobin is resorbed by: Myoglobinuria

pigmented

vasoconstriction
ATN: Endogenous nephrotoxins - Heme containing products Rhabdomyolosis causes of renal failure __________ ____________ from prolonged unconsciousness Seizures Cocaine ________ abuse __________ and acidosis predispose to: Crush injury

Muscle necrosis

Alcohol

Dehydration
ATN: Endogenous Nephrotoxins - Rhabdomyolosis and renal failure Clinical and lab findings Muscle ______, muscle ______ ____ levels of 16,000-50,000 signals Rhabdomyolosis of clinical importance Urine dipstick will be falsely ___ for h: pain

injury

CK

+

dark brown

Blood
ATN: Endogenous Nephrotoxins Rhabdomyolysis and renal failure - Treatment _________ is the most important thing ________ for diuresis and alkalinization of the urine Other Endogenous Nephrotoxins _______ in massive in: Hydration

Mannitol

Hemoglobin
ATN: Other Endogenous Nephrotoxins ________ in rapid cell turnover and lysis Caused mostly by ____________ for germ cell neoplasms and leukemias ARF occurs with deposition of uric acid crystals in the tubules Uric acid levels >____: Hyperuricemia

chemotherapy

20

1
ATN: Lab Sediment shows pigmented granular â€œ_______â€ casts _________ epithelial cells and epithelial cells present Hyper______ hyper________: muddy brown

Renal tubular

hyperkalemia

hyperphosphatemia
ATN: Treatment Preventative measures to avoid hyperkalemia and volume overload ______ diuretics have been used for adequate diuresis and may help convert oliguric to nonoliguric renal failure But widespread use in critically ill patients w: Loop

ARF

Protein

magnesium
ATN: Treatment - Dialysis indications Life threatening ________ disturbances such as hyperkalemia Volume overload unresponsive to ________ Worsening _______ or uremia (encephalopathy, pericarditis, seizures) In gravely ill patients, l: electrolyte

diuretics

acidosis
ATN: Prognosis - Mortality 20-50% in medical illness, 70% in surgical setting Increased mortality associated with advanced age, severe underlying disease, and multisystem organ failure Leading causes of death are _________, ________ &: infections

fluid and electrolyte

Prevention
ARF: Other Endogenous Nephrotoxins - Hepatorenal syndrome Kidney failure in patients with severely compromised _______ functions No other clinical, laboratory, or anatomic reasons for renal failure In U.S., mostly advanced __________: liver

alcoholic cirrhosis

antibiotic or NSAID

bleed
ARF: Endogenous Nephrotoxins Hepatorenal syndrome: HALLMARK is ________ with urinosmolality 2-3 times the concentration of plasma, in urine that is almost completely ________ free as in patients with _________ azotemia: oliguria

sodium

prerenal
Endogenous Nephrotoxins: ARF related to pregnancy - Rare in industrialized nations Decrease thought due to legalization of _________ in many countries Associated with _______ following an abortion Most common infection associated with: abortion

infection

Clostridium

hemolysis
ARF: Endogenous Nephrotoxins - ARF of Pregnancy ___________ is one of the most common medical complications of pregnancy 25% of the patients develop a transient decline in GFR Treat with ____ antibiotics with follow up oral antibiotic ther: Pyelonephritis

IV

2

Third
ARF: Interstitial Nephritis 10-15% of causes of RF Pathology â€“ interstitial inflammatory response with _______ and tubular cell damage _______ account for over 70% of cases Can occur in infectious diseases, immunologic or idiopathic: edema

Drugs
ARF: Interstitial Nephritis Most common causative drugs are- __________ __________ Sulphonamides and sulphonamide containing ________ NSAIDS Rifampin ________ Allopurinol: Penicillins

Cephalasporins

diuretics

Phenytoin
ARF: Interstitial Nephritis __________- Streptococcal infection Leptospirosis CMV Histoplasmosis Rocky mountain spotted fever ____________- SLE Sjorgrens Sarcoidosis Cryoglobulinemia: Infections

Immune disorders
ARF: Interstitial Nephritis - Clinical Findings _______ _______ ________ Eosinophilia in peripheral blood ______ contains red cells, white cell, and WBC casts Proteinuria eosinophyluria: Fever

Rash

Arthralgias

Urine
ARF: Interstitial Nephritis - Treatment Good prognosis with recovery usually in weeks to months ________ may be necessary acutely Very rarely progress to _____ Worse prognosis is oliguric RF and ________ Treatment is supportive a: Dialysis

ESRD

advanced age

steroids
progressive and irreversible loss of renal function: Chronic Renal Failure (CRF)
CRF: Watching lab is important Can have up to 75% loss of GFR without ________ due to adaptation of remaining glomeruli and tubules But, rise in serum _________ from .7 to 1.4 signifies 50% loss of GFR Early intervention is important at th: symptoms

creatinine
CRF: CRF vs ARF Past and present serum creatinine measurements Search for causes of CRF _________ for definitive dx Allows for: Diagnosis and treatment Prognosis Determination of need and suitability for _________: Renal bx

renal transplant
CRF: CRF vs ARF If no bx Dx based on Past, present, and family _______ Serology Examination of urine _______ Renal _______ Kidney size- Most CRF associated with ________ kidney size Some have normal kid: history

sediment

ultrasound

decrease
CRF: Conservative management of CRF Slow ________ Control HTN, diabetes, and hyperlipidemia, Avoid nephrotoxins _______ cessation Block production or effect of angiotensin ____ Identify reversible causes when re: progression

Smoking

II
CRF: Managing ____ Slows the rate of renal failure, especially in patients with diabetic nephropathy Nephroprotective effect of meds that block the production and/or effect of angiotensin II in patients with type 1 and 2 diabetic nephropathy: HTN

CCBâ€™s
CRF: Managing Diet Dietary _______ restriction slows the rate of progression of renal insufficiency Also advocated to reduce features of _______ syndrome: protein

uremic
CRF: Managing Diet National Kidney Foundation Practice Guidelines for Nutrition in CRF of patient with GFR of less than 25 ml/min or patients on RRT 35Kcal/day under 60 yrs old 30 Kcal/day for those over 60 yrs old 0.6 - 0.75g/kg/day: Sodium

Malnutrition

calorie
CRF: Management of reversible causes of acute deterioration of renal function Can plot out the rate over time at which a specific patient will reach _____ If the patient shows sudden deterioration in renal disease, look for reversible cau: ESRD

ARF
CRF: Avoiding Toxic Drug effects Avoid __________- Most common offender in hospitalized patients Avoid ________ - Inhibits vasodilitory prostaglandins and decreases GFR; Also causes interstitial nephritis and ARF Avoid __: aminoglycosides

NSAIDS

radiocontrast

Fenoldopam
CRF: General Features of Uremic Syndrome - Clinical Manifestations Uremia def: an excess in the blood or urea, creatinine, and other nitrogenous end products of _______ & ________ metabolism. Also known as _______ Uremic Syndrom: protein and amino acid

Azotemia

Hormone
CRF: Clinical Manifestations ______ causes fatigue, nausea, vomiting, and headaches _______ (product of urea breakdown) can cause carbamylation of lipoproteins and peptides resulting in multiple organ dysfunction _______ (biproducts: Urea

Cyanate

Guanidines

cardiomyopathy
Cardiovascular Gastrointestinal Neurologic Musculoskeletal Hematologic Endocrine Immunologic Metabolic Dermatologic: Specific Manifestations of Uremic Syndrome
CRF: Cardiovascular Effects Death from ____ in CRF is 3 ½ times greater than age matched population Heart dz accounts for 50% of the deaths of uremic patients 60% of patients have ___ on echo with dilation, systolic, and diastolic dysfun: CVD

CHF

Anemia
CRF: Cardiovascular Effects (cont) 2° hyperparathyroidism causes metastatic _________ in myocardium, heart valves, and arteries _________ is accelerated with high rate of recurrence post angioplasty _______ before and during dialysis due: calcification

Athrogenesis

Pericarditis

NSAIDS
CRF: Gastrointestinal Disease GI disturbances are among the earliest and most common signs of the uremic syndrome ______ taste and ________ early on Later, anorexia continues, nausea, vomiting, and weight loss (improves with dialysis): Metallic

anorexia

GI bleeds
CRF: Neurologic Manifestations CNS manifestations are frequent and occur early Subtle changes in cognitive functions and ______ _______ disturbances Lethargy, irritability, frank encephalopathy, asterixis, and seizures are late manif: memory

Sleep

glove and stocking

DTRâ€™s

vibratory
CRF: Musculoskeletal manifestations Alterations in calcium and phosphate homeostasis Hyperparathyroidism and disturbances of Vit ___ metabolism Hypocalcemia and hyperparathyroidism cause ______ retention and lack of alpha 1 hydroxylase act: D

phosphate

calcitriol

renal osteodystrophy
CRF: Hematologic Effects ____(regulates erythrocyte production) decreases as renal mass decreases ____ and EPO deficiency are common causes of anemia in CRF EPO administration improves quality of life, corrects anemia, and decreases: EPO

Iron

vasopressin, cryoprecipitate, conjugated estrogens
CRF: Endocrine Abnormalities Alterations in _______ function Increased T3 resin uptake (low TBG levels) Low T3 due to impaired conversion of ______ to T3 in the periphery Normal TSH and throxine (T4) _______ is present in 1/3 of: thyroid

thyroxine

Goiter
CRF: Endocrine Abnormalities (cont) Abnormal _________ axis ________ dysfunction manifested by impotence, decreased libido, amenorrhea, sterility, and uterine bleeding Hypoprolactinemia Decreased estrogen, testosterone, and progestero: pituatary-gonadal

Sexual

FSH and LH

Pregnancy
CRF: Immunologic Function Defects in _______ & _______ immune systems in patients with end stage renal disease Patients susceptible infections: Bacterial _______ Microbacterial: humoral and cellular

Fungal
CRF: Metabolic Disorders Decreased renal function means decreased _______ requirement Due to increased half life of exogenous insulin because of decreased insulin clearance Increased insulin ______ due to tissue insensitivity,: insulin

resistance

acidosis
CRF: Metabolic disorders (cont) ______ abnormalities consistant with type IV hyperlipidemia Marked increase in TG, less of an increase in cholesterol Due to decreased lipoprotein lipase in uremia Decreases the conversion of VLDL to LD: Lipids

hypertriglyceridemia

atherosclerosis and mesangial cell
CRF: Dermatologic Manifestations Uremic ___ from retained liposoluable pigments _______ is common Responds to dialysis, control of hyperparathyroidism, balance of calcium and phosphate, UV rays Nail findings ___: Hue

pruritis

Half and half

distal

Splinter hemorrhages
Hemodialysis Peritoneal Dialysis Kidney Transplantation: Treatment of End Stage Renal Failure (ESRD)
Treatment of ESRD: Treatment plan should be in place ______ in the course of renal failure before uremic symptoms appear Criteria for the initiation of dialysis: GFR ___ ml/min or less in diabetic patients GFR ___ ml/min or less: early

15

10
Treatment of ESRD: Choice of renal replacement therapy depends on patientâ€™s physical or sociodemographic characteristics Patients may be started on _________ or _________ ____________ encouraged because it allows for better quality of li: hemodialysis or peritoneal dialysis

Renal transplantation
Treatment of ESRD: ________ The most common modality for RRT in the US Average patient requires 4 hours dialysis 3 times weekly to remove toxins: Hemodialysis
Treatment of ESRD: Peritoneal Dialysis The trend in the US is to move more patients toward peritoneal dialysis Advantages Patients do not have to spend hours in dialysis unit No stringent _______ restrictions as in hemodialysis: dietary

Rehab

longer
Treatment of ESRD: Peritoneal Dialysis Method The ________ acts as a semipermeable membrane similar to a hemodialysis filter 2-3 liters of _______ instilled into the peritoneal cavity for varying amounts of time Exchanged: peritoneum

dialysate

4-6
Treatment of ESRD: Peritoneal Dialysis Method - __________ peritoneal dialysis Patient is connected to machine called a cycler Allows inflow of smaller volumes of dialysate with shorter dwell time through the night while patient slee: Continuous cyclic
Treatment of ESRD: Peritoneal dialysis Rate of removal of solutes depends on: _______ gradient, surface area, and permeability of the peritoneal membrane to the solute _______ molecules move easily and are influenced by the ultrafilt: Concentration

Smaller

dextrose
Treatment of ESRD: Drawbacks of peritoneal dialysis ________ of the percutaneous catheter placed in peritoneum _________ treated with intraperitoneal antibiotics ________ removed in bacterial peritonitis not responding to antibiotics: Infection

Peritonitis

Catheter

large body mass
Treatment of ESRD: Kidney Transplantation The preferred modality of RRT ______________ often required before, during, or after transplantation _________ marked significant improvement in success rate of renal transplantation Fro: Hemo or peritoneal dialysis

Cyclosporine

immunosupressive
Treatment of ESRD: Immunosupressant drug therapy Prophylaxis and treatment of graft rejection are at the heart of the success of kidney transplantation Protocals aimed at disruption of _______ cell cycle Different agents have specific MOA<: lymphocyte

Cytochrome P-450

Cyclosporin, tacrolimus, mycophenolate, Rapamycin
Treatment of ESRD: Kidney Transplantation - Acute Rejection Clinically detected by: Graft ________ Rise in serum _______ Oliguria Resulting tubulitis _______ Frequent monitoring of renal function allows earl: tenderness

creatinine

fever

clinical symptoms

60
Treatment of ESRD: ____________ 2nd only to vascular dz as leading cause of mortality in post transplant patients Community acquired bacterial and viral infections Viral, fungal, and other opportunistic infections which normally donâ: Post Transplant Infection
Treatment of ESRD: Post-Transplant Malignant Disease Immunosuppression increases risk of ________ ________ (mostly squamous cell) has highest incidence in transplant recipients Caution regarding sun exposure Skin protection for: malignancy

Skin cancer

non-Hodgkins

Kaposiâ€™s
Treatment of ESRD: Malignancies _________ is important part of post transplant follow up Patient education to report the following: Early changes in _____ habits _______ symptoms Hematuria Skin changes _____: Cancer surveillance

bowel

Respiratory

Weight
Nephritic Syndrome S/S PHAROH: Proteinuria, Hematuria, Azotemia, RBC casts, Oliguria, Hypertension
Nephrotic syndrome: causes for secondary nephrotic syndrome DAVID: Diabetes mellitus
Amyloidosis
Vasculitis
Infections
Drugs
Renal failure: symptoms/signs My Big Nob Vibrates Gently In Her Purulent Pelvis: Malaise
Breathlessness
Nausea
Vomiting
GI motility
Headache
Pruritis
Pigmentation

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Deck Info

Number of cards 237