Renal Final Review

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what is the predominant cell type in renal carcinoma?: clear cell
high levels of PGs: Dilate afferents, but dilate efferents more --> big inc in RPF, smaller inc in GFR
NSAIDs: block the effects of high level PGs

Constrict afferents, but constrict efferents more --> big dec in RPF, smaller dec in GFR
what do NSAIDs do to renin secretion?: they block renin secretion
what is the hallmark of hepatorenal syndrome?: patient appears to be "pre-renal" with low FeNa, low urine sodium, low urine output. renal fxn does not improve as the patient is given fluid.
name three things that can cause a normal AG metabolic acidosis: (1) RTA

(2) diarrhea

(3) mild chronic renal insuffiency
do salicylates cause a resp. acidosis or alkalosis?: resp. alkalosis as breathing is stimulated
does pregnancy cuase a resp. acidosis or alkalosis?: resp alkalosis
for distal and proximal RTA, what happens with K balance?: usually see a hypokalemia
desc the classic presentation of Goodpasture's syndrome: coughing up blood, dark urine, urinalysis: 2+ protein 3+ blood and many rbc casts

kidney biop: prolif of cells within glomerulus with linear staining for IgG on immunofluorescence
Amt filtered / min eqn: = GFR x [P]
Amt excreted / min eqn: = V x [U]
Amt. reabsorbed or secreted: = Filtered - excreted
GFR > 90 corresponds to which stage of Kidney disease?: Stage 1 (Kidney Damage)
GFR < 15 corresponds to which stage of kidney disease?: Stage 5 (Kidney failure)
GFR 15-29 corresponds to which stage of kidney disease?: Stage 4 (Severe decrease in kidney function)
GFR 30-59 corresponds to which stage of kidney disease?: Stage 3 (moderate decrease in kidney function)
GFR 60-89 corresponds to which stage of kidney disease?: Stage 2 (mild dec in kidney function)
Broad eqn for FENa: Excreted Na / Filtered Na
what type of ARF does a low FENa suggest?: pre-renal
what are the two forms of NDI?: (1) a vasopressin receptor defect that is X-linked

(2) a water channel defect that is autosomal recessive
what are the rates of correction for hypo and hypernatremia? what are the major complications of too rapid a correction?: Hyponatremia

- 1.0 mEq/L/hr
- too rapid: central pontine myelinolysis

Hypernatremia

- 0.5 mEq/L/hr
- cerebral swelling with herniation
what effect do demeclocyclin and Li+ have RE: ADH?: demeclocycline and Li+ cause an NDI
what type of RTA can be caused by CA-i?: Type II (Proximal) RTA
what two drugs can cause Type I (distal) RTA?: Amphotericin B / Li+
can aminoglycosides be implicated in renal tubular acidosis?: YES
name four causes of hyperkalemia (non-intake): (1) dec GFR

(2) metabolic acidosis

(3) beta blockade

(4) hyperglycemia
albuterol -- what general type of drug?: beta agonist
what are the effects of hypomagnesemia on calcium, potassium, and phosphate?: hypomagnesemia causes hypocalcemia, hypokalemia, and hypophosphatemia
is magnesium required for PTH secretion and/or action?: YES to both
2 causes of hypermagnesemia: (1) renal failure

(2) exogenous admin
repiratory alkalosis caused by (5): (1) hysteria / stage fright

(2) pregnancy

(3) hepatic cirrhosis

(4) pneumonia

(5) aspirin intoxication
pneumonia can be implicated in respiratory alkalosis and acidosis. which is more likely in SEVERE pneumonia: acidosis
which type of RTA in particular is associated with kidney stones?: Type 1 (distal)
what is the treatment for Type 1 RTA?: replace the bicarb consumed each day by normal metabolism
what is the urine pH in Type 1 RTA?: Urine pH is always greater than 6 in Type 1 RTA
is type II RTA associated with hyper or hypokalemia?: hypokalemia
how much bicarb is needed to treat type II RTA?: LOTS, b/c bicarb given is dumped in the urine
how is hyperkalemia associated with Type IV RTA?: hyperkalemia inhibits NH3 synth; Type IV RTA is due to dec NH3 production
urinalysis: - RBC indicates what?: glomerular disease
urinalysis: - WBC casts indicates what?: pyelonephritis or allergic interstitial nephritis
urinalysis: - significance of many coarse brown granular casts?: ATN
cystine crystals - urine pH - genetics - crystal color / shape: acidic urine

autosomal recessive trait

colorless / 6-sided
does dipstick check for Bence Jones proteins?: No, it checks for albumin only
Bence Jones protein: Immunoglobulin light chains produced in the plasma cell tumor multiple myeloma
what is the differential for Red urine?: RBCs, Hemoglobin (broken down RBCs), Myoglobin (broken down muscle cells), Beets/Rhubarb
?: ?
immunofluorescence - anti-GBM causes what type of staining?: linear IgG staining
immunofluorescence - membranous --> what type of staining?: granular pattern
IgA nephropathy - what type of staining?: mesangial IgA staining
what is the most common nephrotic syndrome in children?: Minimal Change Syndrome
pathogenesis of MCD: disorder in which T cells release a cytokine or other factor that damages epithelial foot processes, leading to proteinuria
MCD - light microscopy - immunofluorescence - EM: - light microscopy: Glomeruli appear normal (minimal change)

- immunofluorescence: negative (minimal change)

- EM: here is the change --> foot processes appear "fused" or smeared over the outer (urinary side) of the GBM
what therapy do you give for MCD?: steroid
how long after infection does post-step GN occur?: 3-4 weeks
pathogenesis of post-strep GN: deposition of IgG complexes in capillary loops, with complement (C3) activation
clinical features of post-strep GN: abrupt onset of nephritic syndrome with oliguria, hematuria, edema, HTN, and eventually azotemia
post-strep GN pathology - LM - Immunofluorescence - EM: - LM: enlarged, hypercellular glomeruli with endothelial and mesangial cell proliferation; neutrophils present; crescent may be seen

- Immunofluorescence: coarsely granular ("lumpy-bumpy") pattern along capillary loops

- EM: subepithelial "hump-like" deposits
T/F Lupus-related diseases have "full-house" immunofluorescence: T
what is the early sign of diabetic nephropathy?: microalbuminuria
Pathology of Diabetic Glomerulosclerosis: Grossly small, contracted kidneys with a granular surface

Microscopically a diffuse glumerulosclerosis with thickening of capillary basement membranes initially, later may become nodular (Kimmelstiel-Wilson nodules) *****
what is the most important thing to remember about pathology of Diabetic Glomerulosclerosis?: Kimmelstiel-Wilson nodules
Amyloidosis - discuss primary vs. secondary causes: primary --> multiple myeloma

secondary --> to chronic inflammation (chronic decubitus ulcers, rheumatoid arthritis)
Amyloidosis - stains how: stains with congo red to give apple-green on polarized microscope
silver stain can show which two things?: (1) spikes on membranous nephropathy

(2) Split or reduplicated GBM (tram tracks) for Membranoproliferative GN
By age 70 what % of men will have BPH to some degree or other?: 90%
BPH responds (worsened) by what hormone in particular?: DHT
major treatment for BPH: 5 alpha reductase inhibitors
what is the only radiolucent stone?: uric acid
kidney stones metabolic workup - blood chemistry - 24-hr urine: blood: Ca, P, CO2, uric acid, BUN, creatinine

24-hr: Ca, uric acid, Na, volume, citrate, oxalate, cystine
what is the most common renal tumor?: renal cell carcinoma
risk factors for Renal Cell Carcinoma: smoking, cadmium exposure, Von Hippel Lindau syndrome, cystic renal disease
"triad" of renal cell carcinoma: hematuria, dull flank pain, and abdominal mass
should you ever biopsy tumor (potential renal cell carcinoma)?: NO, remove surgically & biopsy at same time
what is the most common urogenital tumor of childhood?: Wilms Tumor
Is Wilms Tumor associated with any other genetic abnormalities?: YES, WAGR & DENYS-Drash or Beckwith-Wiedemann Syndrome
does doing a digital rectal examination raise the PSA?: NO
squamous cell carcinoma asstd with what (2) things: non-circumsized males and infection with HPV
Hepatorenal Syndrome: Clinical features of pre-renal ARF except: unresponsiveness to plasma volume expansion and blood pressure elevation.
acute tubular necrosis associated with what on urinalysis?: associated with many muddy brown granular casts on urinalysis
what is one main thing to remember about treatment of chronic renal failure: use ACE-i
reasons (3) for hyperPTH in CRF: (1) hyperphosphatemia

(2) vit D deficiency

(3) hypocalcemia
indications for acute dialysis in renal failure (6): (1) hyperkalemia

(2) volume overload

(3) intractable acidosis

(4) uremic pericarditis

(5) uremic encephalopathy

(6) "renal support" in a critically ill patient
indications for chronic dialysis (2): (1) early uremic signs

(2) GFR < 15 ml/min
most common complication during dialysis: hypotension
prognosis is better with kidney transplantation or dialysis?: transplantation
pre-renal cause of (kidney) allograft non-function: hypovolemia
post-renal cause of (kidney) allograft non-function: ureteral necrosis / leak

obstructing lymphocele

ureteral blood clot
vascular cause of (kidney) allograft non-function: thrombosis of renal artery
hyperacute rejection: occurs immediately on OR table; kidney becomes flaccid and cyanotic; urine output ceases; due to pre-existing circulating recipient antibody against donor HLA antigens or to donor-recipient ABO incompatibility
subacute (accelerated) rejection: occurs post-op day 5-7; manifested as oligoanuria and graft dysfunction
acute rejection: generally occurs first 3-6 months after transplantation; "classic signs" of fever, graft tenderness; elevation of serum Cr, diminished urine output, edema
chronic rejection hallmarks: progressive azotemia, proteinuria, HTN
why should acetazolamide not be used in hepatic cirrhosis?: b/c alkalinization of the urine decreases the renal excretion of NH4+
what are the three loop diuretics?: furosemide, bumetanide, ethacrynic acid
what does furosemide do to uric acid excretion?: DEC uric acid excretion
what do thiazides do to Ca2+ excretion?: DEC Ca2+ excretion
what is the major side effect of spironolactone?: hyperkalemia
what are the three K-sparing diuretics?: (1) spironolactone

(2) amiloride

(3) triamterene
chlorpropamide: enhances effects of ADH
which diuretics can be used to treat hypercalcemia?: mannitol, acetazolamide (proximal), loop diuretics (loop)
which diuretics can be used to treat hypercalciuria?: thiazides
factors favoring dialysis of medication (4): (1) low MW

(2) limited protein binding

(3) absence of charge

(4) small volume of distribution
renal effects (3) of NSAIDs: potential to:

(1) DEC GFR

(2) potential to INC serum potassium

(3) potential to INC Na/H2O retention --> edema / HTN
what is the first stage of diabetic nephropathy: DN clinical latency

0-10 years

transient microalbuminuria
what is the second stage of diabetic nephropathy?: Microalbuminuria

10-15 years

tubular and glomerular BM thickening; mesangial matrix expansion
what is the third stage of diabetic nephropathy?: Macroalbuminuria

15-20 years

dec GFR, UAE rate more than 300 mg/day; HTN, diffuse or nodular glomerulosclerosis
what is the final stage of diabetic nephropathy?: Renal failure

after 20 years

further declining GFR, nephrotic range proteinuria, HTN
is Renovascular Hypertension more common in black or white people?: white
who should be screened for RVH?: (1) severe or refractory HTN

(2) retinal hemorrhages or papilledema

(3) Cr > 1.5 mg/dl

(4) an acute rise in BP

(5) proven age of onset below 20 or above 50

(6) acute INC in Cr after start of an ACE-i

(7) negative family history for HTN
what happens if you give an ACE-i in unilateral RVH?: When you give an ACEi the GFR of the affected side decreases dramatically. Becuase of removal of the effects of AII, the normal side may have a small increase in GFR.
what happens if you give an ACE-i in bilateral RVH?: In bilateral RAS, both kidneys release renin-angiotensin and aldosterone (the latter fromt he adrenals). The increase in AII will help keep the GFR from falling as low as it should from the decreased renal blood flow alone. When you give an ACEi and take away AII from both kidneys, you develop acute renal failure.
what is the best screening test for renal artery stenosis (RAS)?: captopril renal scan
what is the gold standard diagnostic test for RAS?: angiography
Cystitis: infection of bladder; E. coli main cause
when should you treat asymptomatic bacteruria?: (1) pregnancy

(2) prior to urologic procedure

(3) post removal of a bladder catheter

(4) patients with struvite stones
transient causes of urinary incontinence: Delirium
Retention, Restricted mobility
Infection, Inflammation, Impaction
Polyuria, Pharmaceuticals

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