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on 15-Apr-2016 (Fri)

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Flashcard 1332536282380

Tags
#nephrology
Question
Approach to AKI
Answer
Causes:
1) pre-renal
2) renal
3) post-renal

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Flashcard 1332538117388

Tags
#nephrology
Question
What are pre-renal causes of AKI?
Answer
↓ renal blood flow d/t:

1) ↓ ECF volume (volume depletion)
2) ↓ effective ECF volume (volume overloaded - CHF - but not getting to kidneys; fluid shift to interstitial space - liver ds)
3) disruption of hemodynamics/autoregulation​
-drugs (NSAIDs, RAAS blockers)
-endogenous mediators (accumulation of vasoactive compounds in liver failure - hepatorenal syndrome)

NB: could be losing Na or ↓ intake

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Flashcard 1332539952396

Tags
#exam #nephrology
Question
What is a renal cause of AKI?
Answer
inj d/t dysfn of renal parenchyma.

look for:
-systemic ft's (ds could also be affecting kidneys)
-HTN (NB: hypo for pre-renal)
-mild to mod ECF volume overload
-anemia/thrombocytopenia
-***abn urine sediment (RBC, WBC, protein, abn casts)***

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Flashcard 1332541787404

Tags
#nephrology
Question
What is a cause of post-renal AKI?
Answer
inj secondary to not passing urine from kidneys (urine backs up)

dx = imaging (kidney & bladder u/s)

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Flashcard 1332543622412

Tags
#exam #nephrology
Question
What are 2 methods of urine evaluation?
Answer
1) dip stick → **alb, Hg, WBC**, others (glu, pH, urobilinogen, specific gravity)
2) microscopy → cells, crystals, casts

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Flashcard 1332546243852

Tags
#exam #nephrology
Question
What are 3 types of renal AKI causes?
Answer
1) tubulo-interstitial → acute tubular necrosis (atn), allergic/acute interstitial nephritis (ain), tubular obstruction
2) glomerular → prolif ds, non-prolif ds (rarely causes aki)
3) vascular → arteries (renal a stenosis, vasculitis), arterioles (atheroembolic ds, vasculitis), capillaries (thrombotic microangiopathies, vasculitis), veins/venules (thrombosis)

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Flashcard 1332548078860

Tags
#nephrology
Question
pre-renal aki vs atn:
Testpre-renalatn
urine dipstick[...][...]
urine microscopynormalhemegranular casts
urinary [Na]<20mmol/L>20mmol/L
FENa<1%>1%
Answer
pre-renal aki vs atn:
Testpre-renalatn
urine dipsticknormalHg +/- alb
urine microscopynormalhemegranular casts
urinary [Na]<20mmol/L>20mmol/L
FENa<1%>1%

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Flashcard 1332549913868

Tags
#nephrology
Question
pre-renal aki vs atn:
Testpre-renalatn
urine dipsticknormalHg +/- alb
urine microscopy[...][...]
urinary [Na]<20mmol/L>20mmol/L
FENa<1%>1%
Answer
pre-renal aki vs atn:
Testpre-renalatn
urine dipsticknormalHg +/- alb
urine microscopynormalhemegranular casts
urinary [Na]<20mmol/L>20mmol/L
FENa<1%>1%

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Flashcard 1332552797452

Tags
#nephrology
Question
pre-renal aki vs atn:
Testpre-renalatn
urine dipsticknormalHg +/- alb
urine microscopynormalhemegranular casts
urinary [Na][...][...]
FENa<1%>1%
Answer
pre-renal aki vs atn:
Testpre-renalatn
urine dipsticknormalHg +/- alb
urine microscopynormalhemegranular casts
urinary [Na]<20mmol/L>20mmol/L
FENa<1%>1%

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Flashcard 1332554632460

Tags
#nephrology
Question
pre-renal aki vs atn:
Testpre-renalatn
urine dipsticknormalHg +/- alb
urine microscopynormalhemegranular casts
urinary [Na]<20mmol/L>20mmol/L
FENa[...][...]
Answer
pre-renal aki vs atn:
Testpre-renalatn
urine dipsticknormalHg +/- alb
urine microscopynormalhemegranular casts
urinary [Na]<20mmol/L>20mmol/L
FENa<1%>1%

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Flashcard 1332556467468

Tags
#exam #nephrology
Question
What is ATN (acute tubular necrosis)?
Answer
  • 2nd most common cause of AKI
  • d/t ischemia/toxins
  • look for signs of ↓ volume (pre-renal hypotension can cause ATN)
  • **hemegranular casts** = dx

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Flashcard 1332558302476

Tags
#exam #nephrology
Question
What is allergic/acute interstitial nephritis (ain)?
Answer
interstitial inflm d/t:
  • usually allergic rxn to drugs (abx, NSAIDS, PPIs, etc)
    • usually present 7-10d post-exposure
    • urine → RBC, WBC, protein, **WBC casts**
  • autoimmune ds
  • inf's

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Flashcard 1332560137484

Tags
#exam #nephrology
Question
What is prolif glomerulonephritis?
Answer
  • too many cells in glomerulus so can't filter → AKI
  • present w/:
    • rapid ↓ in GFR
    • ​HTN, anemia
    • ↑ inflm markers
    • other systemic ft's (if 2ndary)
    • ECF volume full/mildy overloaded
  • urine → **RBC casts** (nephrologic emerg)

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Flashcard 1332564856076

Tags
#nephrology
Question
What is non-prolif glomerular ds?
Answer
structural problem - rarely causes AKI - just see proteinuria

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Flashcard 1332566691084

Tags
#exam #nephrology
Question
What are causes of renal artery stenosis?
Answer
  • athrosclerosis
  • ​fibromuscular dysplasia

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Flashcard 1332568526092

Tags
#nephrology
Question
What are causes of thrombotic microangiopathies?
Answer
TTP, hemolytic uremic syndrome (HUS), hypertensive emerg

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Flashcard 1332570361100

Tags
#nephrology
Question
How do you manage AKI?
Answer
general
  • prevent additional nephrotoxins (drugs, contrast)
  • rx ECF volume status
  • avoid complications
    • ECF volume overload (↓Na intake, ↑ diuretics)
    • avoid ↑K (↓ intake, diuretics, laxatives, shift into ICF)
    • renally dose meds
​pre-renal aki
  • improve hemodynamics
    • ↑ ECF w/ IV fluids
    • ↑ cardiac output
​renal AKI
  • ATN → time
  • AIN → remove offending agent, consider corticosteroids
  • glomerulonephritis → maybe immunosuppresive therapy (urgent)

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Flashcard 1332572196108

Tags
#nephrology
Question
What is the 7 step approach to drugs in nephro?
Answer
  1. What is the individual’s GFR? → no adjustment until <60ml/min (Cockcroft ‐Gault Equation)
  2. Is the drug effective in the setting of a reduced GFR? → e.g. thiazide doesn't work
  3. Is the drug safe in CKD? (metformin, bisphosphonates, meperidine)
  4. Is the drug itself nephrotoxic? (aminoglycosides, amphotericin B, NSAIDS)
  5. Is an immediate effect desired or needed? → loading dose will often be same but usually ↓ maintenance dose or ↑ interval to maintain the drug level at a safe therapeutic level
  6. Is the drug extensively eliminated by the kidney? (aminoglycosides, penicillins, cephalosporins, digoxin, vancomycin, lithium)
  7. Does the drug have an active / toxic metabolite that is renally eliminated? (meperidine)

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Flashcard 1332978781452

Tags
#nephrology
Question
Drugs with Renal Effects
Answer
• Renin‐Angiotensin‐Aldosterone System (RAAS) blockers
• Diuretics
• Antidiuretic Hormone (ADH)

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pdf

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Flashcard 1333178273036

Question
Angiotensin II stimulation causes:
Answer
↑ aldo
vasoconstriction
↑ Na reabsorption

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Flashcard 1333184040204

Tags
#nephrology
Question
Direct renin inhibitors (i.e. aliskiren) do what?
Answer
Blocking Renin Action

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Flashcard 1333186399500

Tags
#nephrology
Question
ACE inhibitors do what?
Answer
Blocking Angiotensin II production

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Flashcard 1333188758796

Tags
#nephrology
Question
Angiotensin receptor blockers do what?
Answer
Blocking Angiotensin II action

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Flashcard 1333193477388

Tags
#nephrology
Question
Spironolactone/Eplerenone does what
Answer
Blocking action of Aldosterone

NB: spironolactone = K+ sparing diuretic

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Flashcard 1333200555276

Tags
#nephrology
Question
Diuretics do what?
Answer
  • ↓ Na to ↓ ECF volume
  • can cause over-diuresis
  • if acts prox to CCD = K wasting
  • if acts @ CCD = K sparing

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Flashcard 1333202390284

Tags
#nephrology
Question
Weak diuretics..
Answer
  • work at prox tubule
  • carbonic anhydrase inhibitors (not used much as diuretics) - blocks reabsorption of HCO3 (Na stays out with it)

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Flashcard 1333204225292

Tags
#nephrology
Question
Potent diuretics..
Answer
loop diuretics (furosemide, bumetanide)
work on asc limb of loop
blocks NKCC2
can add to thiazide diuretics

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Flashcard 1333206060300

Tags
#nephrology
Question
Thiazides..
Answer
hydrochlorothiazide (HCTZ), Chlorthalidone, Indapamide, Metolozone
works on DCT (distal convoluted tubule)
imp s/e:
  • Dyslipidemia
  • Hyponatremia
  • Hyperuricemia
  • Hypercalcemia

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Flashcard 1333207895308

Tags
#nephrology
Question
Potassium Sparing Diuretics..
Answer
weak
2 mechanisms:
  • block aldosterone from binding its receptor (spironolactone, epeleronone)
  • bind ENaC

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Flashcard 1333209730316

Tags
#nephrology
Question
ADH..
Answer
aquaporin insertion in CD
VAPTANS (new)
  • Competitive inhibitors for ADH

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Flashcard 1333211565324

Tags
#nephrology
Question
Nephrotoxic drugs contributing to pre-renal AKI
Answer
diuretics → ↓ ECF volume d/t ↑ Na loss
RAAS blockade → Block either the formation or action of AngII (which maintains GFR) → efferent vasodilation
NSAID → Inhibit the formation of prostaglandins (which vasodilate afferents)

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Flashcard 1333213400332

Tags
#nephrology
Question
What are tubulo-toxic drugs causing ATN?
Answer
Aminoglycosides Antibiotics (Gentamicin, Tobramycin, Amikacin)
Amphotericin B (antifungal)
Cisplatin (chemo)
IV radiocontrast dye

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Flashcard 1333215235340

Tags
#nephrology
Question
medications implicated with AIN
Answer
Acute interstitial nephritis:
  • NSAIDS
  • abx
  • PPI
  • allopurinol

Chr interstitial fibrosis:
  • lithium (most common), etc

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Flashcard 1333219167500

Tags
#nephrology
Question
What would you check on hx to differentiate AKI and CKD?
Answer
• Review of Systems (Is this acute?)
– Symptoms during urination (stones, UTI, obstruction)
– Recent infections (post‐infectious GN)
– Skin rashes or arthritis (Connective tissue ds)
– Risk for transmitted infections (HIV, Hepatitis B and C)
• Chronic Diseases
– Hypertension, diabetes
• Past Medical History
– Abnormal urinalysis in the past
– Problems with pregnancies
– Urologic procedures
• Any NEW medications
• Family History
– Polycystic kidney disease

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Flashcard 1333223886092

Tags
#nephrology
Question
u/s in CKD shows:
Answer
small shrunken kidneys

↑ cortical echogenicity

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Flashcard 1333225721100

Tags
#nephrology
Question
Chronic kidney disease (CKD) is defined by:
– The presence of [...] or an eGFR < 60 ml/min/1.73 m^2
– AND Present for ≥ 3 months
– AND Not treated with dialysis or transplant
Answer
Chronic kidney disease (CKD) is defined by:
– The presence of kidney damage (hematuria, proteinuria, or anatomic abnormalities) or an eGFR < 60 ml/min/1.73 m^2
– AND Present for ≥ 3 months
– AND Not treated with dialysis or transplant

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Flashcard 1333228342540

Tags
#nephrology
Question
Chronic kidney disease (CKD) is defined by:
– The presence of kidney damage (hematuria, proteinuria, or anatomic abnormalities) or [...]
– AND Present for ≥ 3 months
– AND Not treated with dialysis or transplant
Answer
Chronic kidney disease (CKD) is defined by:
– The presence of kidney damage (hematuria, proteinuria, or anatomic abnormalities) or an eGFR < 60 ml/min/1.73 m^2
– AND Present for ≥ 3 months
– AND Not treated with dialysis or transplant

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Flashcard 1333230177548

Tags
#nephrology
Question
Chronic kidney disease (CKD) is defined by:
– The presence of kidney damage (hematuria, proteinuria, or anatomic abnormalities) or an eGFR < 60 ml/min/1.73 m^2
– AND Present for [...]
– AND Not treated with dialysis or transplant
Answer
Chronic kidney disease (CKD) is defined by:
– The presence of kidney damage (hematuria, proteinuria, or anatomic abnormalities) or an eGFR < 60 ml/min/1.73 m^2
– AND Present for ≥ 3 months
– AND Not treated with dialysis or transplant

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Flashcard 1333232012556

Tags
#nephrology
Question
Chronic kidney disease (CKD) is defined by:
– The presence of kidney damage (hematuria, proteinuria, or anatomic abnormalities) or an eGFR < 60 ml/min/1.73 m^2
– AND Present for ≥ 3 months
– AND Not treated with [...] or [...]
Answer
Chronic kidney disease (CKD) is defined by:
– The presence of kidney damage (hematuria, proteinuria, or anatomic abnormalities) or an eGFR < 60 ml/min/1.73 m^2
– AND Present for ≥ 3 months
– AND Not treated with dialysis or transplant

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Flashcard 1333233847564

Tags
#nephrology
Question
What are the most common causes of CKD?
Answer
DM + vasc ds
(glomerular ds can also cause it)

NB: CKD has 5 stages

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Flashcard 1333235682572

Tags
#nephrology
Question
6 steps to slowing progression of CKD:

NB: Remember CHD risk equivalent

1. [...] or [...] (slow progression to ESRD with additional advantages over blood pressure lowering alone)
2. Tight blood pressure control
Multiple antihypertensive medications and dietary sodium restriction may be required
Targets: < 140/90 mmHg without DM, < 130/80 mmHg with DM
3. Use of a statin in patients with dyslipidemia (target LDL < 2 mmol/L) - shown to prevent CV events and may slow the rate of decline
4. Recommend smoking cessation (independent risk for development/progression of CKD)
5. glycemic control in patients with diabetes mellitus (HbA1C < 7%)
6. Patients with eGFR <60 ml/min/1.73m2 should avoid NSAIDS, COXIBs and other nephrotoxins such as intravenous contrast if possible
Answer
ACE inhibitor
Angiotensin receptor blocker

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Flashcard 1333239352588

Tags
#exam #nephrology
Question
CKD and Indications for dialysis
Answer
•**Persistent metabolic disturbances refractory to medical therapy
– Hyperkalemia
– Metabolic acidosis
• Fluid overload refractory to diuretics
• Progressive uremia
– Encephalopathy
– Persistent nausea and vomiting
– Evidence of malnutrition
• Pericarditis**

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Flashcard 1333241187596

Tags
#nephrology
Question
Goals of Dialysis
Answer
Solute/toxin removal (“blood purification”)

Salt and water removal (“ultrafiltration”)

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Flashcard 1333243022604

Tags
#nephrology
Question
CKD & transplant:

living donor = [...] y kidney survival
deceased donor = [...] y survival
Answer
living donor = 15-25y kidney survival
deceased donor = 5-15y survival

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Flashcard 1333245119756

Tags
#exam #nephrology
Question
Sodium [...] determines [...]
Sodium concentration determines intracellular fluid (ICF) volume
Sodium concentration does NOT predict ECF volume status
Answer
**Sodium content determines extracellular fluid (ECF) volume status
Sodium concentration determines intracellular fluid (ICF) volume
Sodium concentration does NOT predict ECF volume status**

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Flashcard 1333246954764

Tags
#exam #nephrology
Question
Sodium content determines extracellular fluid (ECF) volume status
Sodium [...] determines [...]
Sodium concentration does NOT predict ECF volume status
Answer
**Sodium content determines extracellular fluid (ECF) volume status
Sodium concentration determines intracellular fluid (ICF) volume
Sodium concentration does NOT predict ECF volume status**


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Flashcard 1333248789772

Tags
#exam #nephrology
Question
Sodium content determines extracellular fluid (ECF) volume status
Sodium concentration determines intracellular fluid (ICF) volume
Sodium [...] does NOT predict [...]
Answer
**Sodium content determines extracellular fluid (ECF) volume status
Sodium concentration determines intracellular fluid (ICF) volume
Sodium concentration does NOT predict ECF volume status**


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Flashcard 1333252459788

Tags
#nephrology
Question
normal [Na] = [...]
Answer
normal [Na] = 140mmol/L

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Flashcard 1333256916236

Tags
#exam #nephrology
Question
Na balance:

input (determined by diet)

output
--small extrarenal loss
--Renal excretion controlled by [...]
• Activation of RAAS results in [...]
Answer
**Renin‐Angiotensin‐Aldosterone System (RAAS)

sodium retention**

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Flashcard 1333258751244

Tags
#nephrology
Question
RAAS is activated by:
Answer
↓ BP activates the baroreceptors

↓ GFR → lower NaCl delivery to the juxtaglomerular apparatus

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Flashcard 1333260586252

Tags
#exam #nephrology
Question
H2O balance:

input (thirst → intake)

output
--extrarenal loss small
--Renal excretion controlled by [...]
• Release of ADH results in [...]
Answer
**antidiuretic hormone (ADH)
water retention**

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Flashcard 1333262683404

Tags
#exam #nephrology
Question
What triggers ADH release?
Answer
• Hypernatremia (osmotic stimulus)
• Non‐osmotic stimuli (inapproriate)
– Low volume states: real or “effective”
– Stress states: surgery, pain
– SIADH states: cancers, drugs, brain or respiratory disease
– Other states: Pregnancy, low cortisol, low thyroid

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Flashcard 1333264518412

Tags
#nephrology
Question
Rx of ECF volume expansion (heart failure)
Answer
Reduce sodium content:
1. Decrease intake
2. Promote excretion
– Use of diuretics
3. Remove stimulus for RAAS activation (if possible)

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Flashcard 1333266615564

Tags
#nephrology
Question
Rx of ECF volume depletion (diarrheal illness)
Answer
Oral rehydration
Isotonic saline (154 mmol/L NaCl)

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Flashcard 1333268450572

Tags
#exam #nephrology
Question
Hyponatremia ALWAYS a result of [...]
Answer
**Hyponatremia ALWAYS a result of relative water retention**

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Flashcard 1333270285580

Tags
#exam #nephrology
Question
Why is there H2O retention in hyponatremia?
Answer
**ADH** (main cause)
no kidney fn/GFR
no osmoles to excrete in urine

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Flashcard 1333272120588

Tags
#nephrology
Question
Hyponatremia presentation
Answer
If rapid onset then cell swelling can occur
– Biggest concern is cerebral edema (Headaches, Confusion, Seizures, Death)

If slow onset (over days) then often asymptomatic as brain can adapt

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Flashcard 1333273955596

Tags
#exam #nephrology
Question
hyponatremia rx
Answer
• Restrict fluid/water intake
• Remove underlying cause (ADH)
• If acute and symptomatic → rapid partial correction to reduce cerebral edema (can use hypertonic saline)
• If chronic and severe (<120 mmol/L ) treat slowly as rapid correction can cause devastating brain injury

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Flashcard 1333275790604

Tags
#nephrology
Question
Causes of hypernatremia
Answer
Failure to drink fluid:
– Infancy
– Elderly (reduced thirst, dementia, stroke, nursing home, bed‐bound etc.)
– Coma, impaired consciousness, surgery

Excess losses (frequently present but not required)
– Hyperglycemia
– Diabetes insipidus (no ADH)

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Flashcard 1333277625612

Tags
#nephrology
Question
Presentation of hypernatremia
Answer
presentation = confusion, ↓ LOC (brain cell shrinkage)

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Flashcard 1333279460620

Tags
#nephrology
Question
normal [K] = [...]
Answer
normal [K] = 3.5-5 mmol/L

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Flashcard 1333281295628

Tags
#nephrology
Question
Hypokalemia causes
Answer
1) Decreased intake (not major)
2) Shift into cells → insulin, B2 agonists (salbutamol)
3) Excess loss:
• Renal → high aldo + high flow to collecting duct
– Diuretics (thiazides, furosemide)
– Vomiting (driven by bicarbonaturia)
– Primary hyperaldosteronism (hypertension)
• GI (diarrhea)

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Flashcard 1333283130636

Tags
#nephrology
Question
K excretion & Aldo
Answer
(1) Aldosterone stimulation leads to insertion of epithelial sodium channels (ENaC) in the luminal membrane of collecting duct
(2) Na+ reabsorbed faster than Cl‐, leaving a net negative charge in lumen
(3) K+ secretion due to net negative charge

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Flashcard 1333284965644

Tags
#nephrology
Question
S&S of hypokalemia (<3.5mmol/L)
Answer
--weakness (hyperpolarized msc)
--cardiac arrhythmias

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Flashcard 1333286800652

Tags
#nephrology
Question
Hypokalemia mgmt
Answer
• Acute:
– Oral KCl (pills or liquid)
– Intravenous KCl – important to limit the concentration and amount to prevent hyperkalemia
• Chronic/prevention:
– High K+ foods – fruits, vegetables
– K+ sparing diuretics (amiloride, spironolactone)

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Flashcard 1333288635660

Tags
#nephrology
Question
Causes of Hyperkalemia
Answer
(1) Increased intake

(2) Shift of K+ out of cells
--Insulin deficiency – DKA, hyperglycemia
--Muscle necrosis – rhabdomyolysis
--Hemolysis (red cell destruction)

(3) Failure of renal excretion of K+
--Low flow to CCD (↓ ECFV, very low GFR)
--Low aldosterone:
  • Adrenal disease (rare)
  • ACE inhibitors, angiotensin blockers (common)
  • K‐sparing diuretics (common)
  • Tubular dysfunction (advanced renal failure)

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Flashcard 1333290470668

Tags
#exam #nephrology
Question
hyperkalemia s&s
Answer
• Muscle weakness, stiffness (cells are depolarized)
• ECG changes:
– Small or absent P waves
– Broad QRS
– Peaked T‐waves

• Arrhythmias
[K+] > 7.0 mmol is life‐threatening

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Flashcard 1333292305676

Tags
#exam #nephrology
Question
Treatment of Life‐Threatening Hyperkalemia
Answer
**Four principles of management:
(1) Stabilize myocardium
--Give Calcium Gluconate IV

(2) Shift potassium into cells
--IV insulin
--IV or inhaled beta2‐agonist

(3) Potassium excretion
--90% renal - ↑ ECFV w/ IV saline to promote flow to CCD, then give IV furosemide
--10% GI - promote diarrhea (cation exchange resins) -
avoid post-op use

(4) Hemodialysis - if above insufficient**

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Flashcard 1333294664972

Tags
#exam #nephrology
Question
pH = [...]
plasma CO2 = 40mmHg
plasma HCO3 = 24mmol/L
plasma anion gap = 12mEq/L
Answer
pH = 7.40
plasma CO2 = 40mmHg
plasma HCO3 = 24mmol/L
plasma anion gap = 12mEq/L

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Flashcard 1333296499980

Tags
#exam #nephrology
Question
pH = 7.40
plasma CO2 =
[...]
plasma HCO3 = 24mmol/L
plasma anion gap = 12mEq/L
Answer
pH = 7.40
plasma CO2 = 40mmHg
plasma HCO3 = 24mmol/L
plasma anion gap = 12mEq/L

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Flashcard 1333298334988

Tags
#exam #nephrology
Question
pH = 7.40
plasma CO2 = 40mmHg
plasma HCO3 =
[...]
plasma anion gap = 12mEq/L
Answer
pH = 7.40
plasma CO2 = 40mmHg
plasma HCO3 = 24mmol/L
plasma anion gap = 12mEq/L

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Flashcard 1333300694284

Tags
#exam #nephrology
Question
pH = 7.40
plasma CO2 = 40mmHg
plasma HCO3 = 24mmol/L
plasma anion gap =
[...]
Answer
pH = 7.40
plasma CO2 = 40mmHg
plasma HCO3 = 24mmol/L
plasma anion gap = 12mEq/L

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Flashcard 1333302529292

Tags
#exam #nephrology
Question
Four Primary Acid‐Base Disorders:

Metabolic acidosis: pH [...] and [...]
Metabolic alkalosis: pH [...] and [...]
Respiratory acidosis: pH < 7.4 and ↑PCO2
Respiratory alkalosis: pH > 7.4 and ↓PCO2

Answer
Four Primary Acid‐Base Disorders:

Metabolic acidosis: pH < 7.4 and ↓[HCO3‐]
Metabolic alkalosis: pH > 7.4 and ↑[HCO3‐]
Respiratory acidosis: pH < 7.4 and ↑PCO2
Respiratory alkalosis: pH > 7.4 and ↓PCO2


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Flashcard 1333304364300

Tags
#exam #nephrology
Question
Four Primary Acid‐Base Disorders:

Metabolic acidosis: pH < 7.4 and ↓[HCO3‐]
Metabolic alkalosis: pH > 7.4 and ↑[HCO3‐]
Respiratory acidosis: pH
[...] and [...]
Respiratory alkalosis: pH [...] and [...]
Answer
Four Primary Acid‐Base Disorders:

Metabolic acidosis: pH < 7.4 and ↓[HCO3‐]
Metabolic alkalosis: pH > 7.4 and ↑[HCO3‐]
Respiratory acidosis: pH < 7.4 and ↑PCO2
Respiratory alkalosis: pH > 7.4 and ↓PCO2

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Flashcard 1333306199308

Tags
#nephrology
Question
metabolic alkalosis is usually associated with [...]
Answer
low serum potassium

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Flashcard 1333308034316

Tags
#exam #nephrology
Question
Five Steps to Solving Acid Base Problems
Answer
(1) Look at the pH: Acidemia vs Alkalemia

(2) What is the primary problem?:
Compare HCO3 vs pCO2

(3) Is there adequate compensation?
met acid = 1:1 (pCO2)
met alk = 1:0.7 (pCO2)
R acid A = 1:10 (pCO2)
R acid C = 3:10 (pCO2)
R alk A = 2:10 (pCO2)
R alk C = 5:10 (pCO2)

(4) a) What is the Anion Gap?
AG = Na – (Cl + HCO3)
--Normal is 12 +/‐ 2 mmol/L

b) Is there an Osmolar Gap?
Osmolar gap = Osm(meas) – Osm(calc)
Osm(calc) = 2Na + Urea + Glucose
--Normal is upto 10 mosm/kg

(5) Is there another metabolic disorder?
Does the Δ AG = Δ HCO3?
Δ AG = Δ HCO3 (only AGMA)
Δ AG < Δ HCO3 (AGMA + met alk)
Δ AG > Δ HCO3 (AGMA + NAGMA)

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Flashcard 1333309869324

Tags
#exam #nephrology
Question
met acid causes w/ ↑ AG
Answer
**• Lactic acidosis
• Ketoacidosis

--diabetic
--alcoholic
--starvation
• Toxins
– Methanol
– Ethylene glycol
– Salicylates
• Severe chronic kidney disease**

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Flashcard 1333312228620

Tags
#exam #nephrology
Question
met acid causes w/ normal AG
Answer
**NaHCO3 Loss
– GI (Diarrhea)
– Renal (Low urine NH4+, Seen in chronic kidney disease or renal tubular acidosis)**


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Flashcard 1333315636492

Tags
#america #benefit #borat #cultural #for #glorious #kazakhstan #learnings #make #nation #of
Question
"What type of dog is this?"
Answer
"You're welcome."

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psyberbullshit:

You don’t have to respect everyone’s religion. You should respect someone’s right to believe whatever they want to believe, but the belief itself is not necessarily deserving or respect.

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&lt;title&gt;<style>figure{margin:0}.tmblr-iframe{buboBlankedOut:absolute}.tmblr-iframe.hide{display:none}</style><title>Untitled Document</title>
= true; ✉ 💸 💕 👼 🎶 <span>psyberbullshit: You don’t have to respect everyone’s religion. You should respect someone’s right to believe whatever they want to believe, but the belief itself is not necessarily deserving or respect. Via: xxpsyberbullyxx 1 year ago 46 notes ailuj-spelled-backwards liked this bussybower liked this georginaisyo reblogged this from ifidieiwillnotcry georginaisyo liked this mod




Flashcard 1333335035148

Tags
#nephrology
Question
What are the 2 clinical presentations of glomerular ds?
Answer
nephrotic syndrome

nephritic syndrome (emerg)

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Flashcard 1333336870156

Tags
#exam #nephrology
Question
What is nephrotic syndrome a constellation of?
Answer
Constellation of:
Hypoalbuminemia
Edema
Lipiduria and Hypercholesterolemia

Proteinuria > 3.5 g/day

Typical Pathology:
• Non‐proliferative Disease (structural abn - glomerulonephropathy)

Nephrotic Syndrome can ONLY be caused by a glomerular disease

No RBC cast

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Flashcard 1333338705164

Tags
#nephrology
Question
What is nephritic syndrome?
Answer
Constellation of:
• Hypertension
• Hematuria
• Proteinuria
• Acute Kidney Injury

Typical Pathology:
• Proliferative Disease (prolif of cells in glomerulus - glomerulonephritis)
--renal emerg - May progress to end‐stage renal disease within days to weeks
--RBC casts

Other parenchymal diseases can present with “nephritic syndrome”

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Flashcard 1333340540172

Tags
#nephrology
Question
What causes prolif glomerular ds?
Answer
Deposition of Immune Complexes
• E.g. Post‐infectious, Systemic Lupus Erythematosus (SLE), HCV/HBV/HIV related

Antibody Deposition within the glomerulus
• E.g. IgA Antibodies, Anti‐GBM Antibodies, ANCA, circulating paraproteins

Dysregulation of the complement system

Idiopathic

NB: look for immune complexes, Ab, complement dysregulation on w/u

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Flashcard 1333342899468

Tags
#nephrology
Question
What are the different cell types noted in pathology of prolif glomerular ds?
Answer
mesangial cell prolif (better)

endothelial cell prolif

epithelial cell prolif (worst)

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Flashcard 1333344734476

Tags
#nephrology
Question
What is the ddx for mesangial cell prolif in glomerulonephritis?
Answer
IgA nephropathy (most common)

SLE

HSP (henoch-schonlein purpura)

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Flashcard 1333347618060

Tags
#nephrology
Question
What are IgA nephropathy associated ds's?
Answer
Cirrhosis
HIV Infection
Celiac Disease

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Flashcard 1333349453068

Tags
#nephrology
Question
How is IgA nephropathy dx?
Answer
renal bx

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Flashcard 1333351288076

Tags
#nephrology
Question
What is the mgmt for IgA nephropathy?
Answer
Blockade of the Renin‐Angiotensin‐Aldosterone System (RAAS)
+/‐ Corticosteroids (↓ inflm)
+/‐ Other immunotherapy (e.g. azathioprine, cyclophosphamide) (↓ IgA formation)

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Flashcard 1333353123084

Tags
#nephrology
Question
What is the ddx for endocapillary prolif? (glomerular ds)
Answer
Proliferative Lupus Nephritis
Post‐infectious Glomerulonephritis
(above 2 are most common)
Membranoproliferative Glomerulonephritis

N.B. Endocapillary Proliferation is usually also associated with mesangial proliferation

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Flashcard 1333354958092

Tags
#nephrology
Question
How do you dx endocapillary prolif?
Answer
renal bx

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Flashcard 1333356793100

Tags
#nephrology
Question
What is the mgmt for endocapillary prolif?
Answer
Corticosteroids

Immunosuppression
• Mycophenolate Mofetil (MMF)
• Cyclophosphamide
• Azathioprine

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Flashcard 1333358628108

Tags
#nephrology
Question
How do you dx epithelial prolif (crescentic glomerulonephritis)?
Answer
etiology based on immunofluorescence (IF) on bx
  • linear GBM staining → anti GBM ds
  • coarse/granular staining → SLE nephritis, post-inf GN
  • little/no staining (Pauci immune) → ANCA vasculitis

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Flashcard 1333361249548

Tags
#nephrology
Question
What is the mgmt for crescentic GN?
Answer
Treatment of underlying disease
• Immunosuppression (commonly d/t autoimmune ds) - High dose (“pulse”) steroids, Other agents (cyclophosphamide, MMF, Azathioprine, Rituximab)
• Consideration of plasma exchange - Rapid removal of inciting factor (e.g. Anti‐GBM Ab)

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Flashcard 1333363084556

Tags
#urology
Question
How can you adjust PSA?
Answer
normal = <4.0ng/mL

age-adjusted PSA
PSA density
PSA velocity
free:total (<0.10 = dangerous; ≥0.25 = safe)

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Flashcard 1333364919564

Tags
#urology
Question
What are PCa risk factors?
Answer
genetics → ≥1 fam member = ↑ risk
race → black ↑, asian ↓
diet → high fat diet, obesity (↑ risk for higher grade PCa)

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Flashcard 1333366754572

Tags
#urology
Question
What are s&s of PCa?
Answer
usually asx

if adv/mets: bone pain, kidney failure, anemia, urinary sx

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Flashcard 1333368589580

Tags
#urology
Question
How do you dx PCa?
Answer
transrectal u/s guided bx

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Flashcard 1333370424588

Tags
#urology
Question
PSA screening should not be offered to [...]
Answer
men >75y/o

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Flashcard 1333372783884

Tags
#urology
Question
annual PSA/DRE is offered @ age [...] or [...] if high risk
it is repeated [...]
Answer
50, 40
q2-4y

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Flashcard 1333374618892

Tags
#urology
Question
How is PCa staged?
Answer
DRE+PSA

bx pathology (gleason score)

staging imaging (CT, bone scan)

TNM - T1 (most common - only via bx), T2 (palpable)

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Flashcard 1333376978188

Tags
#urology
Question
What is the PCa risk stratification?
Answer
low: ≤ gleason 6 + ≤ T2a + PSA <10ng/mL → no imaging

intermed: gleason 7 or T2a or PSA 10-20ng/mL → CT scan

high: gleason 8-10 or ≥T2c or PSA>20ng/mL → CT + bone scan

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Flashcard 1333378813196

Tags
#urology
Question
What are the mgmt options for PCa?
Answer
1. watchful waiting
2. active surveillance
3. radical therapies (radiation/surg)
4. androgen deprivation therapy (met rx for ~3y)
5. others

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Flashcard 1333380648204

Tags
#exam #urology
Question
What are the complications of prostatectomy?
Answer
peri-op: anesthetic risks, bleed/transf, UTI, wound inf, MI, DVT/PE, bowel/rectal/bladder/ureteric injury, etc

post-op: erectile dysfn, stress urinary incontinence, urethral strictures, LUTS, PCa recurrence

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Flashcard 1333382483212

Tags
#urology
Question
What are risk factors for kidney stone ds?
Answer
diet: ↓ fluid, ↑ Na/animal proteins
hot environment
medical: DM, obesity, chr diarrheal states (IBD), hypercalcemia, gout, UTI + urea-splitting organisms

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Flashcard 1333384318220

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#urology
Question
What are the kidney stone types?
Answer
Ca oxalate (80%) - radioopaque
uric acid (10%) - radioluscent
struvite (10%) - radioopaque
rare - cystine (faintly radioopaque), matrix, med stones

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Flashcard 1333386153228

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#urology
Question
What are kidney stone promotors and inhibitors?
Answer
promoters: concentrated urine, ↑ urine Ca/oxalate/uric acid, urinary stasis, inf

inhibiters: citrate, Mg, pyrophosphate, glycoprotein

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Flashcard 1333387988236

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#urology
Question
What are the causes of Ca oxalate stones?
Answer
hypercalciuria (most common)
--renal Ca leak (↓ tubular reabsorption)
--Ca leach from bone (hyperparathyroidism, immobilization, malig, steroids)
--↑ GI Ca absorption

hyperoxaluria (5%)
--bile salts & fatty acids ↑ GI absorption

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Flashcard 1333389823244

Tags
#exam #urology
Question
How do you prevent Ca stones?
Answer
Diet
--**↑ fluid
--↓ animal protein, Na, oxalate, EtOH
--do NOT ↓ Ca intake (Ca binds oxalate)**


meds
--hydrochlorothiazide (hypercalciuria) - promote Ca reabsorption
--K citrate (↑ pH & citrate lvl in urine)

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Flashcard 1333391658252

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#exam #urology
Question
What causes struvite stones?
Answer
inf w/ urea-splitting bugs (proteus, klebsiella, pseudomonas) → alkaline urine (pH>7.5)
--**NOT ECOLI**

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Flashcard 1333393755404

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#urology
Question
Uric acid stones are always associated with [...] , and often associated with [...]
Answer
↓ pH (<5.5)
gout

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Flashcard 1333395852556

Tags
#exam #urology
Question
What causes cystine stones?
Answer
d/t aa transport problem (autosomal recessive defect)
--↓ reabsorption of COLA (cystine, ornithine, lysine, arginine)

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Flashcard 1333397687564

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#urology
Question
stones are sent to lab for:
[...]
[...]
[...]
Answer
Chemical analysis
X-ray crystallography
Infrared spectrometry

NB: tells us stone type

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Flashcard 1333399522572

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#urology
Question
What metabolic w/u would you do to define cause of kidney stone?
Answer
All patients who pass a stone
– Serum creatinine, calcium, and uric acid
– Urine R&M
– Urine C&S

Recurrent stone formers / high risk patients
– Full metabolic work up
  • TWO 24 hr. urine collections (Volume, pH, Cr., K+, Na+, Ca++, phosphate, uric acid, oxalate, Mg++, citrate)
  • ​Serum (Ca++, PO4, uric acid, creatinine, electrolytes – PTH if hypercalcemic)

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Flashcard 1333401357580

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#urology
Question
What is the clinical presentation of kidney stones?
Answer
• Severe pain (“renal colic”):
– Stone obstructs kidney → Causes hydronephrosis
– Capsular distension → constant flank pain
– Ureteral spasm → pain radiating from flank to groin

• Nausea and vomiting (ileus)

• Urinary frequency and urgency – Due to irritation of bladder by stone near the ureteral orifice (bladder)

• Hematuria

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Flashcard 1333403192588

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#exam #urology
Question
DDx of renal colic
Answer
**• Acute ureteric obstruction (other causes)
– UPJ obstruction
– Sloughed papilla
– Clot colic from gross hematuria
• Pyelonephritis (fever, pyuria, flank pain) without a stone
• Acute abdominal crisis: appendicitis, diverticulitis, biliary colic, bowel obstruction, pancreatitis
• Ruptured abdominal aortic aneurysm (AAA)
• Gynecological: ectopic pregnancy, torsion / rupture of ovarian cyst
• Radiculitis (L1) – herpes zoster, nerve root compression**

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Flashcard 1333405027596

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#urology
Question
Renal colic investigation
Answer
urinalysis (pH, RBC, WBC, crystals) + culture (if +WBC)

blood tests (CBC (WBC), Cr (renal function), electrolytes)

non-contrast spiral CT (abdo + pelvis) = best

KUB (abdo xray) - can combine with u/s if can't do CT

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Flashcard 1333406862604

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#urology
Question
Acute Management of Renal Colic
Answer
Medical:
– Analgesia (narcotics: morphine)
– Anti-emetics (Gravol)
– NSAIDs (lower intra-renal pressure; must stop 48h prior to SWL)
– Antibiotics if evidence of UTI (NOT routine)
– IV fluids (if dehydrated) – may increase pain
– Medical expulsive therapy (alpha blockers help facilitate stone passage)

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Flashcard 1333408697612

Tags
#exam #urology
Question
Indications for admission or urgent intervention in kidney stone ds
Answer
**– Pain not controlled with oral analgesics
– Fever and urinary tract infection with obstructing stone
– Refractory vomiting
– Solitary kidney with obstruction OR bilateral obstructing stones → RENAL FAILURE
– Severe hematuria**

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Flashcard 1333410532620

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#urology
Question
Emergency Management of kidney stone ds
Answer
Patient requires urgent drainage if:
• Persistent high grade obstruction
• Solitary, obstructed kidney
• Bilateral ureteral obstruction
• Persistent uncontrolled pain
• Continued fever after 24 hr. antibiotics

NB: via Ureteric Stent/Percutaneous nephrostomy tube

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Flashcard 1333412367628

Tags
#urology
Question
Definitive Management of ureteral stones
Answer
1) Stones < 5mm: conservative management (75% will pass spontaneously within 2 weeks)
2) Medical Expulsive Therapy (MET):
--α blocking agents (tamsulosin) increase the chance of spontaneous stone passage by 20 to 30%
3) Uric acid stones – alkalinization of urine to pH 6.5 to 7 (with sodium bicarbonate or potassium citrate)
4) Urological therapy for those that fail conservative and medical therapy (shockwave lithotripsy, ureteroscopy)

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Flashcard 1333414202636

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#urology
Question
storage sx's
Answer
urgency, freq, nocturia, urgency-incontinence, other incontinence, mixed incontinence

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Flashcard 1333416037644

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#urology
Question
voiding sx's
Answer
hesitancy, poor flow, intermittency, straining, terminal dribble

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Flashcard 1333420231948

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#urology
Question
LUTS etiology
Answer
prostatic enlargement/obstruction
prostatitis
ureteral stones
bladder tumours
urethral strictures
bladder stones
foreign body
UTI
neurogenic bladder dysfn
detrusor underactivity (weak bladder)
nocturnal polyuria
detrusor overactivity

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Flashcard 1333422066956

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#urology
Question
What are the sx's & complications of BPH?
Answer
BPH → bladder outlet obstruction → hypertrophied & trabeculated bladder

--voiding sx's (measure ↓ flow rate on uroflowmetry)

complications: retention, incontinence, hydronephrosis & renal compromise, inf, stones, gross hematuria

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Flashcard 1333423901964

Tags
#urology
Question
BPH w/u
Answer
hx (international prostate sx score - IPSS)
p/e (abdo, genital, DRE)
urinalysis (to exclude UTI + hematuria)
blood test (cr for renal fn, PSA for malig)
bladder u/s (for voiding sx's)

additional tests: uroflowmetry, cystoscopy, urodynamics, imaging

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Flashcard 1333425736972

Tags
#urology
Question
BPH rx
Answer
mild sx: conservative rx (watchful waiting) - 50% improve spontaneously
--lifestyle changes

med:
--α-adrenergic antagonists (relaxes bladder neck & prostate) - tamsulosin, alfuzosin, silodosin (these don't affect BP)
--5-α reductase inhib (shrink prostate by blocking conversion of testosterone to DHT) - finasteride, dutasteride
--combination (α-blocker + 5-α inhib) → slows progression
--tadalafil (ED drug) - beneficial effects on sx's (works on bladder + prostate)
--antimuscarinics (add to α-blockers if storage sx's) - works on bladder (don't give if no storage sx/poor flow/high residual urine)

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Flashcard 1333428620556

Tags
#urology
Question
BPH rx
Answer
interventional rx:
--transurethral resection of prostate (TURP)
--laser TURP
--retropubic prostatectomy (if super big)

indications:
--refractory retention, renal insufficiency, intolerance/failure of med rx
--other (recurrent UTI, bladder stones, bleeding from prostate)

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Flashcard 1333430455564

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#urology
Question
Define ED
Answer
consistent/recurrent inability to have/maintain erection for sex

min. 3mo (unless assc with specific onset - surg)

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Flashcard 1333432290572

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#urology
Question
Explain the physiology of an erection
Answer
neurovasc bundle (para & sympa) supplies erectile bodies

stimulus → NO → cGMP → s.msc relaxation → blood fills in sinusoids
(PDE-5 inhibs keep cGMP around longer)

parasympathetics control erection
sympathetics control ejaculation
mixed control in orgasm

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Flashcard 1333434125580

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#urology
Question
What are the risk factors for ED?
Answer
age, chr ds (CV ds, HTN, DM, meds), lifestyle (stress, EtOH, drugs, smoking)
NB: smoking → vasc changes

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Flashcard 1333438319884

Tags
#urology
Question
What are causes of ED?
Answer
Vasc (40%)
--atherosclerosis + RF's
--venous leaks
--pelvic/perineal trauma (arterial/neuro trauma)

penile injury/ds
--trauma, priapism, peyronie's ds (scarring)

neurogenic causes
--radical pelvic surg (prostatectomy)
--pelvic/spinal cord injury
--MS, DM, PD, Alz, stroke
--pudendal n injury

hormonal
--hypogonadism
--hypo/hyperthyroidism
--pituitary tumour
--hyperprolactinemia

meds
--anti-HTN, SSRI, hormonal agents, protease inhibs, cytotoxic agents, H2 antagonists

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Flashcard 1333441989900

Tags
#urology
Question
What evaluations do you do for ED?
Answer
Hx & p/e

investigations:
--uncontrolled DM
--hypogonadism
--RF for CV ds (lipid profile)

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Flashcard 1333443824908

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#urology
Question
What are the rx for ED?
Answer
counselling, oral meds, injections, intraurethral, other devices, penile implant (3rd line)

1st line: lifestyle/drug therapy moderations, psychosocial counselling, androgen replacement therapy (younger men), oral (PDE5 inhibs - tadalafil, sildenafil, vardenafil)

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Flashcard 1333445659916

Tags
#urology
Question
benign renal lesions
Answer
renal cyst
angiomyolipoma
oncocytoma

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Flashcard 1333447494924

Tags
#urology
Question
What is a renal cyst?
Answer
--fluid-filled sac in the kidney parenchyma
--most common benign renal mass
--uses Bosniak classification (likelihood of malig)
--anechoic on u/s with post-acoustic enhancement

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Flashcard 1333449329932

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#urology
Question
what is an angiomyolipoma?
Answer
--solid lesion
--the presence of fat is pathognemonic for AML
--usually asx
--hyperechoic on u/s
--no calcifications
--no lymphadenopathy
--rx if risk of bleeding (≥4cm) or symptomatic or pregnant

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Flashcard 1333452213516

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#urology
Question
What is the rx for angiomyolipoma?
Answer
--angioembolization (#1)
--partial/radical nephrectomy depending on size

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Flashcard 1333454048524

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#urology
Question
what is an oncocytoma?
Answer
benign renal lesion that's hard to tell apart from carcinoma
--need pathology for dx

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Flashcard 1333455883532

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#urology
Question
What is renal cell carcinoma?
Answer
--85% of renal cancers
--peak @ 60-70y/o, males

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Flashcard 1333457718540

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#urology
Question
What are risk factors of renal cell carcinoma?
Answer
smoking, exposures, ESRD, HTN, obesity, rad rx

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Flashcard 1333459553548

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#urology
Question
What are mets sites of renal cell carcinoma?
Answer
LN, lung, liver, bone, adrenal gland, brain, the other kidney

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Flashcard 1333461388556

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#urology
Question
What are s&s of renal cell carcinoma?
Answer
--usually asx unless adv/mets
--paraneoplastic syndrome (10-20%) - polycythemia, anemia, HTN, fever, hypercalcemia, neuromyopathy, non-mets hepatic dysfn, amyloidosis, cachexia

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Flashcard 1333463223564

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#urology
Question
What are the histology cell types of renal cell carcinoma?
Answer
--clear cell (70%)
--papillary (10%)
--chromophobe (5%) - less aggressive, less mets
--collecting duct (<1%) - very aggressive, more mets
--other (<1%)

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Flashcard 1333465058572

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#urology
Question
how do you dx renal cell carcinoma?
Answer
imaging
--u/s + CT (pre & post contrast) - look for enhancement, calcifications, staging
--usually solid & hypoechoic on u/s

MRI - if young/pregnant/can't CT
--look for enhancement
--can differentiate b/w clear cell & papillary

percutaneous bx
--if unsure of dx, if may alter mgmt, if good IR & GU pathologist

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Flashcard 1333466893580

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#urology
Question
How can you rx renal cell carcinoma?
Answer
surgery (main)
--radical nx (gold standard for oncologic control)
--partial nx (pref if feasible)
--thermal ablation (newer)

tumours are chemo-resistant
rad not as good

active surveillance

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