Electrolytes + Fluids
What causes pseudohyperkalemia?
Hemolysis of labs
What is the most useful initial test in metabolic alkalosis?
urinary chloride
SIADH- treat with fluid restriction, salt tablets +/- furosemide, consider tolvaptan or empaglifozin
What is the systolic blood pressure goal for patients with CKD? What medications are preferred for BP control?
<120 systolic
ACE or ARB especially with any proteinuria
Most pre-renal AKIs resolve to baseline with ____________ and/or _________, but if ________ occurs prognosis becomes poor
adequate fluid replacement and/or removal of offending agent; oliguria
24 hour urine protein- it can distinguish protein type
What are the two named signs of hypocalcemia? Describe each
Trousseau's sign: hands and fingers spasm into flexion with inflation of BP cuff
Chvostek's sign: Tap the face just anterior to the ear and facial twitching will occur
What are the three main categories of respiratory acidosis?
2. disorders of chest wall, pleural, respiratory muscles
3. disorders of the airways and lung parenchyma
What is the classical triad of third spacing?
hypovolemia, hypoalbuminemia, peripheral edema
What type of polycystic kidney disease is more common? What are some extra renal complications?
Autosomal dominant; cerebral aneurysms, cysts in liver or pancreas, aortic root dilation
What is the classic triad of interstitial AKI presentation? What are interstitial AKIs most often caused by?
rash, fever, eosinophilia; most often caused by medication
Orthostatic proteinuria is seen in what age group? What is the procedure for definitive diagnosis?
<30
collect first morning UA + micro and UPCR
What are the four R's for why patients would need IV fluids in the hospital?
Routine Maintenance, Replacement, Resuscitation, Redistribution
What is a-a gradient useful for in respiratory alkalosis? What does a normal gradient indicate? Elevated gradient?
Determine why the patient is hyperventilating
Normal- extra pulmonary cause
Elevated- intrinsic pulmonary cause
What are some etiologies of ADH independent hyponatremia? Name 3 for points
psychogenic polydipsia, tea and toast diet, beer potomania, reset osmostat, renal failure (cannot get rid of water)
What is the difference between hemodialysis and peritoneal dialysis?
HD- blood leaves body through port or AV fistula and enters machine where osmotic membranes bathed in dialysate solution allow toxins/waste to be extracted, clean blood is returned to body
Peritoneal dialysis- Dialysate solution instilled into peritoneal cavity, peritoneum acts as membrane and waste pulled into fluid which is then drained off.
What two primary renal diseases are non-infectious causes of glomerulonephritis?
IgA nephropathy (Berger's disease) and membranoproliferative glomerulonephritis
Nephritic syndrome is caused by inflammatory damage to __________ cells, while nephrotic syndrome is caused by damage to ________ cells on the ________ of the capillay
endothelial; epithelial, outside
What are the cons of Lactated Ringers as a fluid?
Not compatible with blood products and can't be used in severe kidney or liver dysfunction
Metabolic Alkalosis can be divided into chloride responsive and chloride resistant. Describe the difference between these two in terms of causes and responsiveness to treatment
Chloride responsive- usually involves volume or chloride depletion, responds to NaCl and KCl replacement
Chloride resistant- usually due to mineralocorticoid excess or renal tubular defects, does not respond to NaCl replacement
What are the two kinds of diabetes insipidus? What sodium imbalance would you expect to see and what other labs would help confirm?
Central (pituitary process decreases ADH production) and nephrogenic (renal process causes ADH resistance).
Would see hypernatremia with very low urine osmolality (suggests inability to retain water or concentrate urine)
What are dialysis indications using the AEIOU acronym?
E- electrolytes (hyperkalemia)
I- Intoxication (poisoning with dialyzable substance)
O- overload of fluid
U- uremia complications
What are the three things AKI can be defined by?
- 1.5x increase in baseline serum creatinine within 7 days
- urine output of less than 0.5 mL/kg/hr for at least 6 days
What are some things that can cause transient proteinuria? Name 3 for points
strenuous exercise, fever, UTI, illness, stress, exposure to cold, heart failure
What fluids are used for severe hyponatremia? What can happen if the hyponatremia is corrected too quickly?
hypertonic fluids; 3% normal saline
osmotic demyelination syndrome
What are the causes of HAGMA using the GOLD MARK mnemonic?
Glycols, oxoproline (Tylenol), lactate, D-lactate, methanol, aspirin, renal, ketones
In ADH dependent hypovolemic hyponatremia (lol) urine sodium <20 would indicate ______ ______ and urine sodium >20 wound indicate ______ _____
extrarenal losses (diarrhea, vomiting, hemorrhage, third spacing, burns)
renal losses (diuretics, salt-wasting nephropathy, adrenal insufficiency, cerebral salt wasting)
UACR values:
normal
moderate
severe
<30 normal
30-300 moderate
>300 severe
What is the triad of HUS presentation? What is the treatment?
acute kidney injury, hemolytic anemia, thrombocytopenia
Treatment is plasmapheresis
If your adult patient has persistent proteinuria <3.5 gm/hr without hematuria or hypertension, what is the next most reasonable test to send?
UPEP
if no hematuria or hypertension do not need to work up for nephritic syndrome so are looking to characterize the proteins and screen for multiple myeloma
What are the three steps in the treatment of hyperkalemia?
1. stabilize electrical activity
2. redistribute potassium
3. remove potassium
What is the delta delta gap used for in HAGMA? How would you interpret 1:1, ratio <1, and ratio >2?
to evaluate for a secondary metabolic disorder- evaluate if the fall in bicarb matches the rise in anion gap
1:1- simple, uncomplicated AGMA
<1: concurrent NAGMA (bicarb lower than expected)
>2: concurrent metabolic alkalosis (bicarbonate higher than expected)
In the setting of hypotonic hyponatremia, how do you evaluate if the hyponatremia is ADH dependent or independent? Describe results you would expect to see in each
Check urine osmolality
ADH independent: urine osm low- urine is dilute which suggests suppression of ADH (the appropriate response to hyponatremia)
ADH dependent: urine osm high, concentrated urine suggesting impaired water excretion
What electrolyte abnormalities (3) and acid base disorder would you expect to see in CKD Stages 4-5? How would you manage them?
hyperphosphatemia- treat with dietary phosphate restriction
hypocalcemia- supplementation
hyperkalemia- careful with medications, low potassium diet
metabolic acidosis- oral alkali supplementation
In patients with post-renal AKI, what will you typically see in regards to their serum osmolality and urine osmolality? why?
urine osmolality is equal to serum osmolality, because the kidneys are compressed from fluid backup/hydronephrosis so are unable to concentrate fluid (urine will be very dilute)
Why is nephrotic syndrome considered a hyper coagulable state?
Patients will have hypoalbuminemia and the liver will produce more clotting factors to try to compensate for low protein in the blood