Term
| What hormones can function to counteract insulin? |
|
Definition
| Glucagon, epinephrine, cortisol, and growth hormone |
|
|
Term
| What is the major source of fasting glucose? |
|
Definition
|
|
Term
| Which hormones facilitate the delayed response (2-3hrs) to hypoglycemia? |
|
Definition
|
|
Term
| What hormone provides the primary defense against acute hypoglycemia? |
|
Definition
|
|
Term
| What is normal blood glucose? |
|
Definition
|
|
Term
| What is normal fasting and preprandial glucose? |
|
Definition
|
|
Term
| In healthy individuals, 2 hour postprandial values do not exceed what value? |
|
Definition
|
|
Term
| What is the predominant fuel for the CNS? |
|
Definition
|
|
Term
| Significant Hypoglycemia can cause what serious complications? |
|
Definition
| Acute and/or permanent brain dysfunction, and may result in brain death |
|
|
Term
| How long can the CNS supply itself with glucose without additional supply? |
|
Definition
|
|
Term
| The glycemic threshold for CNS symptoms is what value? |
|
Definition
|
|
Term
| CNS cognitive dysfunction begins when the blood glucose hits what value? |
|
Definition
|
|
Term
What are the neurogenic signs of increased autonomic activity
due to inadequate glucose? |
|
Definition
Sweating
Tachycardia
Tremor
Nervousness
Irritability
Paresthesias
Nausea/vomiting |
|
|
Term
| What are the neuroglycopenic signs of depressed CNS activity? |
|
Definition
Headache
Drowsiness
Dizziness
Blurred vision
Confusion
Abnormal Behavior
Seizures
Coma |
|
|
Term
| Hypoglycemia occurs most commonly as a side effect of the treatment of what? |
|
Definition
|
|
Term
| What are the symptoms of nocturnal hypoglycemia? |
|
Definition
| Night sweats, vivid dreams, deep sleep. Occurs in as many as 50% of Insulin users |
|
|
Term
| What is Whipple's Triad for insulinoma? |
|
Definition
1) Signs and Symptoms of hypoglycemia
2) In the presence of a low plasma glucose concentration.
3) Symptoms relieved by restoration of plasma glucose to normal concentrations. |
|
|
Term
| How are insulinomas treated? |
|
Definition
| Surgical resection is the preferred treatment |
|
|
Term
| What is alimentary hypoglycemia? |
|
Definition
| Consequence of hyperinsulinism resulting from rapid gastric emptying of ingested food. Occurs after gastric surgery, jejunum fills too quickly with undigested food from the stomach |
|
|
Term
| How is alimentary hypoglycemia treated? |
|
Definition
Frequent small meals
Elimination of simple sugars and liquids at mealtime |
|
|
Term
| What should you do if you suspect someone is unconscious due to hypoglycemia? |
|
Definition
| Treat the unconscious patient suspected of Hypoglycemia first if there is going to be any delay in getting a blood sugar |
|
|
Term
| What would be low in Facititious Hypoglycemia? |
|
Definition
|
|
Term
| What is the initial treatment of a comatose or confused hypoglycemic patient? |
|
Definition
| Infusion of 50mL IV bolus of 50% glucose (“one amp of D50”) |
|
|
Term
| What is the normal ECF level for potassium? |
|
Definition
|
|
Term
| What are the most common causes of potassium loss and hypokalemia? |
|
Definition
Shifting potassium intracellularly from the extracellular space.
Extrarenal potassium loss
Renal potassium loss
Decreased potassium intake |
|
|
Term
| What can cause a shift of potassium intracellularly from the extracellular space? |
|
Definition
Increased insulin secretion
Alkalosis causes a shift of K+ from the plasma into cells |
|
|
Term
| How is insulin used to treat hyperkalemia? |
|
Definition
K+ uptake by cells is stimulated insulin in the presence of glucose
Also facilitated by B-adrenergic stimulation |
|
|
Term
| Does a patient lose more K+ from vomiting or diarrhea? |
|
Definition
|
|
Term
| What is the most common cause of hypokalemia? |
|
Definition
GI loss due to diarrhea
May also occur due to gastric suctioning or chronic laxative abuse |
|
|
Term
| What effect does aldosterone have on potassium levels? |
|
Definition
| Facilitates urinary potassium excretion through enhanced potassium secretion at the distal renal tubules |
|
|
Term
| What is the most important regulator of potassium levels in the body? |
|
Definition
|
|
Term
| What diuretics can cause the excretion of potassium? |
|
Definition
Diuretics: Furosemide, Thiazides
B2-adrenergic agonists |
|
|
Term
| What is the role of magnesium in the maintenance of serum K+? |
|
Definition
| An important cofactor for potassium uptake and for maintenance of intracellular K+ levels |
|
|
Term
| What are the causes of renal tubular acidosis? |
|
Definition
Fanconi’s syndrome
Interstitial Nephritis
Metabolic alkalosis (bicarbonaturia) |
|
|
Term
| What effect does refractory hypokalemia have on magnesium levels? |
|
Definition
| Mg+ depletion should be suspected despite K+ replacement |
|
|
Term
| What are the symptoms of mild to moderate hypokalemia? |
|
Definition
Muscular Weakness*
Fatigue*
Muscle cramps*
Constipation/Ileus* |
|
|
Term
| What are the symptoms of severe hypokalemia? |
|
Definition
Flaccid paralysis
Hyporeflexia
Hypercapnia
Tetany
Rhabdomyolysis |
|
|
Term
| What ECG findings will you see in cases of hypokalemia? |
|
Definition
Decreased amplitude
Broadening of T waves
Prominent U waves |
|
|
Term
| Which is more dangerous and life threatening, acute or chronic hypokalemia? |
|
Definition
|
|
Term
| What is the safest way to treat mild to moderate hypokalemia? |
|
Definition
| Oral potassium unless the patient has severe hypokalemia and/or ECG changes |
|
|
Term
| What is the best way to treat severe hypokalemia? |
|
Definition
Give IV potassium
Correct Magnesium deficiency |
|
|
Term
| What is the fastest possible K+ transfusion rate? |
|
Definition
|
|
Term
| What is the max amount of K+ that can be given in a liter of IV fluid? |
|
Definition
|
|
Term
| What is the max amount of K+ that can be given in one hour? |
|
Definition
|
|
Term
| Hypokalemia patients need to be observed in the ICU when receiving what amount of IV K+? |
|
Definition
|
|
Term
| Hyperkalemia is defined as a potassium level greater than what? |
|
Definition
|
|
Term
| What are factitious causes of hyperkalemia? |
|
Definition
Vigorous phlebotomy can result in lysis of RBC’s, which releases intracellular K+ into the serum sample
Thrombocytosis
Leukocytosis
Prolonged tourniquet time |
|
|
Term
| Which renal dysfunctions can cause hyperkalemia? |
|
Definition
Renal Insufficiency/failure
Adrenal or aldosterone insufficiency |
|
|
Term
| What drugs can cause hyperkalemia? |
|
Definition
K+ sparing diuretics: Captopril
Triamterene, Spironolactone |
|
|
Term
| How might potassium load be increased in order to create a hyperkalemic state? |
|
Definition
Cellular breakdown (trauma, tumor-lysis, rhabdomyolysis)
Potassium-containing salt substitutes
Hemolysis
GI bleeding |
|
|
Term
| What can cause decreased cellular uptake of K+, causing hyperkalemia? |
|
Definition
Ketoacidosis (K+ rises .6mEq/L for every .1 decrease in pH)
Drugs: Beta-blockers, digoxin, succinylcholine |
|
|
Term
| What are the neuromuscular findings for hyperkalemia? |
|
Definition
| Lethargy, Weakness, Paralysis and Areflexia |
|
|
Term
| What are the cardiac findings for hyperkalemia? |
|
Definition
| Hypotension, Dysrhythmias, ECG changes |
|
|
Term
| All patients suspected of hyperkalemia must always receive what diagnostic? |
|
Definition
|
|
Term
| What kind of ECG changes do you see due to hyperkalemia? |
|
Definition
Tall (Peaked) T waves
Absent P waves, Wide QRS, Prolonged QT interval, Sinus brady, conduction defects |
|
|
Term
| o If the serum K+ is < 6.5 and there are no ECG signs, treatment can be restricted to methods that increase potassium excretion using what drug? |
|
Definition
|
|
Term
| What drug provides the fastest method but short-lived method of correcting hyperkalemia? |
|
Definition
| Calcium gluconate and sodium bicarbonate |
|
|
Term
| How does calcium gluconate and sodium bicarbonate help treat hyperkalemia? |
|
Definition
| Antagonize excess K+ in the myocardium, thus lowering the membrane potential and reducing the risk of developing a ventricular dysrhythmia |
|
|
Term
| How do glucose and insulin help treat hyperkalemia? |
|
Definition
| Redistribute excess K+ from the extracellular compartment to the intracellular compartment |
|
|
Term
| How does Albuterol (Beta agonists) help treat hyperkalemia? |
|
Definition
| Stimulate cellular K+ uptake |
|
|
Term
| Bicarbonate therapy is used to treat hyperkalemia in what cases? |
|
Definition
| Effective in cases of metabolic acidosis. The bicarbonate ion will stimulate an exchange of cellular H+ for Na+, thus leading to stimulation of the sodium-potassium ATPase |
|
|
Term
| What effect does thyroid hormone have the basal metabolic rate? |
|
Definition
| Increased oxygen consumption and heat production increases basal metabolic rate |
|
|
Term
| What kind of thyroid nodules are at higher risk for malignancy? |
|
Definition
Cold/non-functioning nodules
16% chance of malignancy |
|
|
Term
| How are thyroid peroxidase/antimicrosomal antibodies (TPO Ab) used to detect thyroid disease? |
|
Definition
| Strongly associated with autoimmune thyroid disease, accompanies lack of T3/T4 |
|
|
Term
| What are the possible causes of Thyrotoxicosis? |
|
Definition
Graves Disease
Toxic Adenoma
Multinodular goiter
Thyroiditis |
|
|
Term
| What are the anti-thyroid drugs? |
|
Definition
| Propylthiouracil, methimazole, carbimazole |
|
|
Term
| What are the side effects of anti-thyroid drugs? |
|
Definition
| Pruritis and rash, cholestatic jaundice, acute **arthralgias, and rarely agranulocytosis |
|
|
Term
| What are the classic complications of hyperglycemia? |
|
Definition
| Retinopathy, nephropathy, neuropathy |
|
|
Term
| Random plasma glucose (RPG) refers to what? |
|
Definition
| Plasma glucose without regard to time of last meal |
|
|
Term
| Fasting plasma glucose (FPG) refers to what? |
|
Definition
| Plasma glucose before breakfast (8 hour fast – can drink water but no calories) |
|
|
Term
| Postprandial plasma glucose (PPG) refers to what? |
|
Definition
| Plasma glucose 2 hours after a meal |
|
|
Term
| Hemoglobin A1c (A1C) is used to measure what? |
|
Definition
Mean glucose over 2–3 months
Gives a long term picture because RBC survive about 3 months in circulation |
|
|
Term
| Fructosamine/glycated serum protein can be used to measure what? |
|
Definition
| Mean glucose over 1–2 weeks |
|
|
Term
| What is required to diagnose diabetes? |
|
Definition
Symptoms of diabetes plus random plasma glucose >200 mg/dL
FPG > 126 mg/dL
2-h PPG during a 75-g OGTT >200 mg/dL
A1C > 6.5% |
|
|
Term
| Impaired Fasting Glucose refers to what? |
|
Definition
FPG > 100 but < 126 mg/dL
Predicts increased risk of diabetes |
|
|
Term
| Impaired Glucose Tolerance (IGT)refers to what? |
|
Definition
2-h PG on OGTT > 140 but < 200 mg/dL
Predicts increased risk of diabetes and cardiovascular disease |
|
|
Term
| Abnormal A1C revers to what? |
|
Definition
A1C > 5.7% but < 6.5%
Predicts increased risk of diabetes |
|
|
Term
| What is latent autoimmune diabetes of adults (LADA)? |
|
Definition
Type 1 diabetes are diagnosed after age 18
Often mistaken for type 2 diabetes because of late onset (usually 30-40 yo)— |
|
|
Term
| How is Late-Onset Type 1 Diabetes diagnosed? |
|
Definition
| ICA or GAD antibodies (need one for diagnosis) |
|
|
Term
| What is gestational diabetes? |
|
Definition
Hyperglycemia during pregnancy—usually resolves after birth
High risk of later type 2 diabetes in both mother and baby |
|
|
Term
| Under what criteria are adults recommended to undergo testing for diabetes? |
|
Definition
| In all adults who are overweight (BMI ≥25 kg/m2*) and have additional risk factors |
|
|
Term
| What is considered "overweight"? |
|
Definition
BMI ≥25 kg/m2
BMI >85th percentile for age and sex, weight for height >85th percentile, or weight >120% of ideal for height |
|
|
Term
| What are risk factors for diabetes? |
|
Definition
physical inactivity
first-degree relative with diabetes
members of a high-risk ethnic population
women who delivered a baby weighing >9 lb or were diagnosed with GDM
hypertension, hypercholesterolemia, hyperlipiedemia
polycystic ovary syndrome
A1C ≥5.7%
history of CVD |
|
|
Term
| When should diabetes risk assessment be done for gestational diabetes? |
|
Definition
First prenatal visit
Women at very high risk should be screened for diabetes as soon as possible after the confirmation of pregnancy |
|
|
Term
| What are high risk values for gestational diabetes? |
|
Definition
Severe obesity
Prior history of GDM or delivery of large-for-gestational-age infant
Presence of glycosuria
Diagnosis of PCOS
Strong family history of type 2 diabetes |
|
|
Term
| When should all pregnant women not known to have diabetes undergo GDM screening? |
|
Definition
| 24–28 weeks using a 75 gram 2-hr OGTT |
|
|
Term
| What is the diagnostic criteria for gestational diabetes using a 75 gram 2-hr OGTT? |
|
Definition
Fasting ≥ 92 mg/dl
1 hr ≥ 180 mg/dl
2 hr ≥ 153 mg/dl |
|
|
Term
| What is the most common diabetes induced microvascular complication? |
|
Definition
| Stocking gloves (peripheral) neuropathy |
|
|
Term
| What are the non-modifiable risk factors for diabetes induced macrovascular disease? |
|
Definition
| Genetics and family history |
|
|
Term
| What are the modifiable risk factors for diabetes induced macrovascular disease? |
|
Definition
Hyperglycemia
Hypertension
Dyslipidemia
Smoking
Obesity
Physical inactivity |
|
|
Term
| Does fixing high blood sugar make a difference in the prognosis of diabetes? |
|
Definition
Intensive therapy reduces the risk of Retinopathy and Nephropathy
Slowed progression of disease if already had disease |
|
|
Term
| What are the serum glucose targets in diabetes? |
|
Definition
Preprandial: <110
Postprandial: <140
A1C <5.7% (normal) |
|
|
Term
| What is the Basal-Bolus Insulin Concept? |
|
Definition
Basal insulin is used to control glucose production between meals and overnight with near constant levels
Bolus insulin is given at mealtime to limit hyperglycemia after meals |
|
|
Term
| What are the benefits of insulin pens? |
|
Definition
Faster and easier than syringes
Improve patient attitude and adherence
Have accurate dosing mechanisms, but inadequate mixing may be a problem |
|
|
Term
|
Definition
Continuous subcutaneous insulin infusion (CSII). External, programmable pump connected to an indwelling subcutaneous catheter to deliver rapid-acting insulin
Can be used to avoid "dawn phenomenon" when patients have low resistance during the night |
|
|
Term
| What is an intraperitoneal insulin infusion |
|
Definition
| Implanted, programmable pump with intraperitoneal catheter. Not available in the United States |
|
|
Term
| What are the chemical markers of kidney function? |
|
Definition
|
|
Term
| Why is creatinine a good marker for renal function? |
|
Definition
| Metabolized by the kidney alone |
|
|
Term
| If GFR moves from 0.5 to 1, what does this mean? |
|
Definition
A 50% loss of function
Doubling of Scr (serum creatinine) = 50% decreased in Ccr (creatinine clearance rate) |
|
|
Term
| The abbreviated MDRD study equation takes what variables into account when calculating GFR? |
|
Definition
Creatinine, age, sex, race
Has not been studied extensively in populations that are not white or black, may be less accurate for GFR values above 60 |
|
|
Term
| What is the MDRD equation? |
|
Definition
| eGFR = 186 * (0.742 if female) * (1.212 if black) * creatinine^-1.153 * age^-0.203 |
|
|
Term
| What is more important than the exact GFR? |
|
Definition
| GFR variability and whether or not the patient is improving |
|
|
Term
| At what stage of chronic kidney disease is intervention necessary in order to prevent dialysis? |
|
Definition
| Stage 3 eGFR between 30-59 |
|
|
Term
| Is it possible to diagnose chronic kidney disease based off of a single creatinine reading? |
|
Definition
| You cannot call it CKD from only 1 creatinine reading regardless of its value |
|
|
Term
| What is required for the diagnosis of chronic kidney disease? |
|
Definition
| Following the first abnormal creatinine reading, the patient is followed for 90 days, and observed for multiple abnormal creatinine levels |
|
|
Term
| What are the two primary causes of chronic kidney disease? |
|
Definition
| Diabetes and hypertension |
|
|
Term
| What are the risk factors for chronic kidney disease? |
|
Definition
HTN, Diabetes, Age >60, Family history of CKD
Nephrotoxic drug exposure (including NSAIDs)
CVD, History of acute renal failure
Autoimmune disease, Urologic disorders
Infection, Cancer, Ethnic minority |
|
|
Term
| What are indicators for kidney damage? |
|
Definition
Proteinuria
Hematuria
Other urine sediment abnormalities
Structural (imaging) abnormalities
GFR <60 mL/min (GFR preferred over creatinine alone for accessing kidney function)
Other abnormal blood tests |
|
|
Term
| What early indicator of chronic kidney disease of often overlooked? |
|
Definition
|
|
Term
| What are the usual signs of chronic kidney disease? |
|
Definition
None
Until they’re down to almost no renal function, patients don’t complain
Symptoms do not present until disease is advanced |
|
|
Term
| How likely is end stage renal disease in a patient with chronic kidney disease? |
|
Definition
| They are more likely to die than to progress to ESRD |
|
|
Term
| What is the absolute best treatment for chronic kidney disease? |
|
Definition
|
|
Term
| What is the target of anti-hypertensive treatment when treating CKD? |
|
Definition
BP 130/85 without proteinuria
BP 125/75 with proteinuria |
|
|
Term
| What are some complications associated with CKD? |
|
Definition
Anemia
HTN
CV disease
Diabetes
Osteodystrophy
Malnutrition
Metabolic Acidosis
Dyslipidemia |
|
|
Term
| How is anemia related to mortality in CKD? |
|
Definition
| Multiplies odds of mortality when combined with any other complication of CKD |
|
|
Term
| What are the consequences of metabolic acidoses due to CKD? |
|
Definition
↓ tubular phosphate reabsorption
↑ filtered load of calcium & phosphate
↓ tubular calcium reabsorption
Increased resorption of bone
Increased muscle catabolism |
|
|
Term
| What are the target goals in the treatment of metabolic acidosis in patients with CKD? |
|
Definition
Serum HCO3- >31mEg/L
pH >7.35 |
|
|
Term
| What are the benefits of dietary protein restriction in CKD patients? |
|
Definition
dec Complications of uremia
dec Rate of loss of renal function
Increase long term suvival |
|
|
Term
| When should Renal Replacement Therapy be initiated? |
|
Definition
| When symptoms (N/V, uncontrolled swelling, hyperkalemia) begin to present |
|
|
Term
| Which is more hormonally active, T3 or T4? |
|
Definition
|
|
Term
| What stimulates the release of TSH by the anterior pituitary? |
|
Definition
| Hypothalamic thyrotropin-releasing hormone (TRH) |
|
|
Term
| What are the effects of TSH? |
|
Definition
| Increases thyroidal iodide uptake and iodination of thyroglobulin, releases T3 and T4 from the thyroid gland by increasing hydrolysis of thyroglobulin, and stimulates thyroid cell growth |
|
|
Term
| What are the limitations of using total serum T3 and T4 as a diagnostic? |
|
Definition
| can include low thyroid-binding protein seen with congenital disease, enteropathy, cirrhosis, nephrotic syndrome |
|
|
Term
| Calcitonin levels can help diagnose what? |
|
Definition
|
|
Term
| Serum Thyroglobulin is useful for the diagnosis of what? |
|
Definition
| Papillary and follicular thyroid carcinoma and their followup evaluations |
|
|
Term
| What radioactive substance is used for radioactive imaging of the thyroid? |
|
Definition
|
|
Term
| What are the advantages of fine needle biopsy when used for thyroid evaluation? |
|
Definition
| Best way to differentiate benign from malignant disease |
|
|
Term
| What are the signs and symptoms of thyrotoxicosis? |
|
Definition
Nervousness, heat intolerance, fatigue and weakness, palpitations, increased appetite, weight loss, oligomenorrhea
Tachycardia, atrial fibrillation, wide pulse pressure, brisk reflexes, fine tremor, proximal limb-girdle myopathy, chemosis |
|
|
Term
| What kind of events most often precipitate a thyroid storm attack? |
|
Definition
Surgery, radioactive iodine therapy, severe stress: uncontrolled DM, MI, acute infection
Stress releases large amounts of T3/T4 |
|
|
Term
| What antithyroid drugs can be used for the treatment of Grave's disease? |
|
Definition
Propylthiouracil, methimazole, carbimazole
Beta blocking agents often helpful to alleviate tachycardia, hypertension, atrial fibrillation in acute phase of thyrotoxicosis |
|
|
Term
| What is given prior to thyroidectomy for Graves disease? |
|
Definition
| Antithyroid medications given over 6 weeks prior to surgery so that a euthyroid state present at the time of surgery |
|
|
Term
| How are toxic thyroid adenomas treated? |
|
Definition
| Radioactive Iodine vs antithyroid medications until euthyroid followed by unilateral lobectomy for large nodules |
|
|
Term
| How are toxic multinodular goiters treated? |
|
Definition
| Radioactive iodine ablation |
|
|
Term
| How is thyroiditis differentiated from other forms of hyperthyroidism? |
|
Definition
| Suppressed uptake of radioactive iodine, due to decreased hormone production by damaged cells |
|
|
Term
| What are the characteristics of acute suppurative thyroiditis? |
|
Definition
| High fever, erythema, thyroid gland tenderness |
|
|
Term
| How do you treat acute suppurative thyroiditis? |
|
Definition
| Antibiotic treatment based on aspiration and culture of causative organism if blood cultures are negative |
|
|
Term
| What is subacute thyroiditis? |
|
Definition
| Acute inflammatory disorder of the thyroid, likely secondary to viral infection, exhibits very tender thyroid |
|
|
Term
| How is subacute thyroiditis treated? |
|
Definition
| NSAIDs, +/-- prednisone, +/-- levothyroxine as needed during hypothyroid phase |
|
|
Term
| What is postpartum thyroiditis? |
|
Definition
| Usually occurs within the first 6 months after delivery, mimics subacute thyroiditis. Has a triphasic course: hyperthyroidism, hypothyroidism, then +/-- euthyroidism |
|
|
Term
| How is Hashimoto's thyroiditis treated? |
|
Definition
| Leothyroxine indicated with hypothyroidism and significant goiter, which will usually resolve with treatment |
|
|
Term
| What causes euthyroid sick syndrome? |
|
Definition
Acute illness
Free T4 low, TSH usually normal to mildly elevated |
|
|
Term
|
Definition
Life-threatening form of untreated hypothyroidism with decompensation
Reduced metabolic rate and decreased oxygen consumption result in peripheral vasoconstriction. Occurs in longstanding hypothyroidism |
|
|
Term
| What kinds of serum markers are expected in myxedema coma? |
|
Definition
Hypoglycemia is common, may also suggest adrenal insufficiency
Bands and/or a left shift may be the only sign of infection
CK levels are often elevated
Remember to do chest radiograph and ECG |
|
|
Term
| How is a myxedema coma treated? |
|
Definition
| 300-400 mg levothyroxine IV loading dose, followed by 50 mg daily with hydrocortisone 100 mg IV TID, IVF |
|
|
Term
| What are signs of malignant thyroid nodules? |
|
Definition
| Hard consistency of nodule, Fixation of nodule, Lymphadenopathy, Vocal cord paralysis, Distant metastasis |
|
|
Term
| What kind of serum markers might you see with malignant thyroid nodules |
|
Definition
| Elevated serum calcitonin, Cold nodule on technetium scan, Solid lesion with microcalcifications on ultrasonography |
|
|
Term
| What is more invasive, follicular or papillary carcinoma? |
|
Definition
|
|
Term
| What is the most common type of thyroid carcinoma? |
|
Definition
|
|
Term
| What is the most important prognostic indicator for thyroid carcinoma? |
|
Definition
Age and sex
Higher recurrence rate and death in men older than 40 years, women older than 50 years |
|
|
Term
| Oliguria is defined as what? |
|
Definition
| urine output < 400-500 ml/day |
|
|
Term
| Anuria is defined as what? |
|
Definition
| urine output < 50-100 ml/day |
|
|
Term
| What conditions are associated with an elevated BUN and preserved GFR? |
|
Definition
Upper GI bleeding
Hypercatabolic state and increased tissue breakdown
Steroids
Increased protein intake
Tetracycline antibiotics |
|
|
Term
| What medications are associated with an elevated Cr and preserved GFR? |
|
Definition
| Trimethoprim* and Cimetidine* inhibit proximal tubular secretion of Cr |
|
|
Term
| What causes the majority of acute kidney injury? |
|
Definition
Acute tubular necrosis
Pre-renal issues are #2 |
|
|
Term
| What can cause pre-renal azotemia? |
|
Definition
Volume depletion due to lack of intake, diarrhea, vomiting, burns, hemorrhage,etc.
Decreased effective arterial blood volume due to CHF, liver disease with ascites, Nephrotic syndrome, sepsis, third spacing, etc.
Alteration in intra-renal hemodynamics |
|
|
Term
| What are physical signs of pre-renal azotemia? |
|
Definition
| Skin turgor, dry mucous membranes, assessment of jugular veins, orthostatics to assess volume status |
|
|
Term
| What BUN/Cr ratio is suggestive (but not diagnostic) for azotemia? |
|
Definition
|
|
Term
| Hemoconcentration as evidenced by elevated Hb and Hct would be indicative of what? |
|
Definition
|
|
Term
| What causes tubular ischemia? |
|
Definition
| causes that decrease blood flow to kidneys i.e. prolonged prerenal azotemia, hypotension, hypovolemic shock, cardiac arrest, and cardiopulmonary bypass |
|
|
Term
| What causes tubular sepsis? |
|
Definition
systemic hypotension
direct renal vasoconstriction
release of cytokines (TNF)
activation of neutrophils by endotoxin |
|
|
Term
| What drugs induce nephrotoxicity? |
|
Definition
Radiocontrast dye*, aminoglycosides*
Amphotericin B, cisplatinum, acetaminophen |
|
|
Term
| Pigment nephropathy (nephrotoxicity) is caused by what? |
|
Definition
|
|
Term
| What BUN/Cr ratio indicates acute tubular necrosis? |
|
Definition
|
|
Term
| What FENA finding would indicate acute tubular necrosis? |
|
Definition
| FENA > 2% (not seen in contrast nephropathy or rhabdomyolysis) |
|
|
Term
| What kind of urine sediment would indicate acute tubular necrosis? |
|
Definition
tubular epithelial cells
granular casts (muddy brown) |
|
|
Term
| What causes acute interstitial nephritis? |
|
Definition
| Lymphocytic infiltration of the interstitium |
|
|
Term
| What is the classic clinical triad for acute interstitial nephritis? |
|
Definition
Rash, Eosinophilia, Fever
All 3 only seen in 10% of pts |
|
|
Term
| How often are cases of acute interstitial nephritis are due to drugs? |
|
Definition
Nearly 3/4 of all cases
The rest are caused by infection |
|
|
Term
| What is the expected urine finding for acute interstitial nephritis? |
|
Definition
WBC’s or WBC casts
In the absence of a urine infection, neg urine culture |
|
|
Term
| How is acute interstitial nephritis treated? |
|
Definition
Discontinue offending drug
If due to infection, treat with steroids (prednisone) |
|
|
Term
| What would suggest the need for a renal biopsy in cases of acute interstitial nephritis? |
|
Definition
uncertainty of diagnosis
advanced renal failure
lack of recovery once drug discontinued |
|
|
Term
| What causes acute glomerulonephritis? |
|
Definition
Can be postinfectious (post-streptococcal, endocarditis-associated)
Can be due to systemic vasculitis (ANCA-associated, Wegener's, mixed cryoglobulinemia, polyangiitis) |
|
|
Term
| What is the hallmark of rapidly progressive glomerulonephritis? |
|
Definition
| Crescent shape on renal biopsy |
|
|
Term
| What urine findings are expected in acute glomerulonephritis? |
|
Definition
| dysmorphic RBC’s, RBC casts |
|
|
Term
| What is required for a definitive diagnosis of acute glomerulonephritis? |
|
Definition
|
|
Term
| Tumor lysis syndrome causes what? |
|
Definition
| Acute uric acid nephropathy |
|
|
Term
| Ethylene glycol toxicity causes what? |
|
Definition
| Calcium oxalate deposition |
|
|
Term
| What medications cause intratubular obstructions? |
|
Definition
|
|
Term
| Intratubular protein deposition causes what pathology? |
|
Definition
| Multiple myeloma - filtered light chains cause cast nephropathy |
|
|
Term
| What are examples of intrinsic upper tract obstructions? |
|
Definition
| Nephrolithiasis, papillary necrosis, blood clot, transitional cell, cancer |
|
|
Term
| What are examples of extrinsic upper tract obstructions? |
|
Definition
| Retroperitoneal or pelvic malignancy, retroperitoneal fibrosis, endometriosis, AAA |
|
|
Term
| What are examples lower tract obstructions? |
|
Definition
Benign prostatic hypertrophy (BPH)*
Prostate cancer, transitional cell carcinoma, urethral stricture, bladder stones, blood clot, neurogenic bladder |
|
|
Term
| What defines a post-void residual bladder volume |
|
Definition
| > 100 ml c/w voiding dysfunction |
|
|
Term
| What types of acute kidney injuries require ultrasound? |
|
Definition
|
|
Term
| Lower tract obstructions are treated with what? |
|
Definition
|
|
Term
| Upper tract obstructions are treated with what? |
|
Definition
| Ureteral stents, percutaneous nephrostomies |
|
|
Term
| What are the first responses to make when you see a highly elevated creatinine? |
|
Definition
1. Put in a foley catheter
2. Ultrasound |
|
|
Term
| What causes contrast nephropathy? |
|
Definition
Occurs within first 48 hrs after intravenous contrast administration
Usually mild and transient decline in renal function |
|
|
Term
| What are risk factors for contrast nephropathy? |
|
Definition
| Underlying renal failure, DM nephropathy, Heart failure or other cause of reduced renal perfusion (hypovolemia), Multiple myeloma, High total dose of contrast, High osmolality ionic agents |
|
|
Term
| How do you prevent contrast nephropathy? |
|
Definition
Low or iso-osmolal non-ionic agents
Isotonic saline at a rate of 1 ml/kg per hour 6-12 hrs. pre- and post-procedure
Acetylcysteine – inconsistent data regarding benefit
MOST IMPORTANT THING IS HYDRATION prior to procedure |
|
|
Term
| Acute tubular necrosis is also known as what? |
|
Definition
|
|
Term
| What causes acute tubular necrosis/rhabdomyolysis? |
|
Definition
| Trauma or compression, Drugs and toxins, Extreme exertion, Seizures, Alcoholism, Malignant hyperthermia, Neuroleptic malignant syndrome, Electrolyte abnormalities, Myopathies |
|
|
Term
| What drugs cause acute tubular necrosis/rhabdomyolysis? |
|
Definition
Hyperlipidemic agents such as Statins
Cocaine, Heroin |
|
|
Term
| How do you treat acute tubular necrosis/rhabdomyolysis? |
|
Definition
| Isotonic saline to increase urine flow to protect kidney tubules from myoglobinuric damage. No clear evidence that alkaline diuresis is more effective than a saline diuresis |
|
|
Term
| How long does it take aminoglycoside treatment to be nephrotoxic and cause acute tubular necrosis (rhabdomyolysis)? |
|
Definition
5-7 days of therapy
Monitor peak and trough drug levels |
|
|
Term
| Nephrolithiasis is almost always associated with what? |
|
Definition
|
|
Term
| How do you treat hypercalcemia? |
|
Definition
Isotonic saline to correct volume depletion
Calcitonin
Loop diuretics
Bisphosphonates (definitive treatment)
Zolendronate |
|
|
Term
| What is the most common cause of Atheroembolic Renal Disease? |
|
Definition
| Usually seen after aortic manipulation or instrumentation such as cardiac catheterization |
|
|
Term
| Pulmonary-Renal Syndromes ANCA Positive Vasculitis affects what organs? |
|
Definition
Can see multi-organ involvement
Eyes, joints, skin, nervous system, GI tract, heart |
|
|
Term
| What are examples of Pulmonary-Renal Syndromes ANCA Positive Vasculitis |
|
Definition
Wegener’s granulomatosis
Microscopic Polyangiitis
cytoplasmic-ANCA ab
perinuclear-ANCA Ab |
|
|
Term
| What are indications for dialysis? |
|
Definition
Uremia
Uncontrollable hyperkalemia
Severe metabolic acidosis
Refractory fluid overload
Severe renal failure
Poisoning such as methanol or ethylene glycol or salicylate toxicity |
|
|
Term
|
Definition
| Symptoms and signs which result from the toxic effects of elevated levels of nitrogenous and other wastes in the blood |
|
|
Term
| What are symptoms of uremia? |
|
Definition
Nausea/vomiting
Poor appetite
Fatigue/lethargy
Pruritis
Altered mentation
Personality changes, confusion, somnolence, comatose |
|
|
Term
| What uremic sign is an absolute indication to start dialysis? |
|
Definition
| Pericardial friction rub or pericardial effusion |
|
|
Term
| What are signs of uremia? |
|
Definition
Tremors
Asterixis
Myoclonus
Wrist or foot drop
Seizures
Bleeding diathesis
Pericardial friction rub |
|
|
Term
| What is intermittent hemodialysis? |
|
Definition
| Both in the hospital acute setting and in a chronic dialysis patients |
|
|
Term
| Peritoneal dialysis is used for what patients? |
|
Definition
| chronic outpatient setting |
|
|
Term
| What is the most common renal diagnosis and the most common diagnosis in those pts. with significant renal failure? |
|
Definition
| Multiple Myeloma Cast Nephropathy |
|
|
Term
| What causes multiple myeloma? |
|
Definition
Filtration of toxic light chains
Binding to Tamm-Horsfall mucoprotein
Direct tubular injury
Intratubular cast formation and obstruction |
|
|
Term
| What characterizes T T P – H U S? |
|
Definition
Microangiopathic hemolytic anemia**
Thrombocytopenia**
Acute kidney injury
Neurologic abnormalities
Fever |
|
|
Term
| What causes T T P – H U S? |
|
Definition
Idiopathic (most common)
Shiga-toxin producing E. Coli
Drugs: quinine, ticlid, cyclosporine, mitomycin
Pregnancy/Post-partum
HIV
Sepsis
Post-cardiac bypass |
|
|
Term
| How is T T P – H U S treated? |
|
Definition
|
|
Term
| What is the number 1 cause of kidney disorder? |
|
Definition
|
|
Term
| What causes diabetic nephropathy? |
|
Definition
Macroalbuminuria
OR macroalbuminuria and abnormal renal function |
|
|
Term
| True or false: diabetes is a heart disease equivalent |
|
Definition
|
|
Term
| What is Macroalbuminuria? |
|
Definition
Random urine albumin/creatinine ratio > 300 mg/g
"Spilling protein” into urine is pathognomonic for diabetes |
|
|
Term
| What visible glomerular abnormality is pathognomonic of the Diabetes? |
|
Definition
| KIMMELSTIEL-WILSON NODULES |
|
|
Term
| What are the risk factors for diabetic nephropathy? |
|
Definition
Family History of Hypertension or Kidney Disease
Smoking
Hypertension
Dyslipidemia
Decreased Kidney Function
A1C > 8.5% |
|
|
Term
| What diseases exhibit enlarged kidney? |
|
Definition
| Multiple myeloma, amyloidosis, DM, ADPKD/ARPKD, hydronephrosis, renal cell cancer |
|
|
Term
| Cardiovascular disease patients on dialysis have an increased risk of mortality by how much? |
|
Definition
|
|
Term
| What are diabetics with nephropathy dying from? |
|
Definition
|
|
Term
| NEVER give ACE Inhibitors with what? |
|
Definition
|
|
Term
| Level of Kidney function is an independent risk for CV risk |
|
Definition
|
|
Term
| What are the risk factors for cardiovascular disease? |
|
Definition
| Hypertension, obesity, dyslipidemia, diabetes mellitus, smoking |
|
|
Term
| What is the Most Common Cause of Failing to Reduce Proteinuria with ACE Inhibitor or ARB? |
|
Definition
| High SALT intake (>5 grams/day) |
|
|
Term
| What is proven to slow progression of diabetes? |
|
Definition
Control blood sugar in diabetes
Strict BP control
Certain meds ACEI and ARBs |
|
|
Term
| What is thought to slow the progression of diabetes but is presently inconclusive? |
|
Definition
Dietary protein restriction
Lipid lowering therapy
Partial correction of anemia
Vitamin D administration |
|
|
Term
| What drugs decrease urinary albumin excretion? |
|
Definition
NSAIDs: never give kidney patients NSAIDs*
ACE inhibitors |
|
|
Term
| What are the major actions of growth hormone? |
|
Definition
| Linear growth (not in utero), induces lipolysis, reduces body fat, stimulate protein synthesis, lean bodymass, opposes insulin |
|
|
Term
| What classic feature presents alongside stunted growth in children with growth hormone deficiencies? |
|
Definition
| Cherubic faces -> increased central adiposity |
|
|
Term
| How do you assess growth hormone levels? |
|
Definition
Insulin induced hypoglycemia test (“ITT”) or insulin tolerance test
Sugar should go down GH should go up |
|
|
Term
| What is a better indicator of GH deficiency than GH levels? |
|
Definition
| IGF-1 levels do not fluctuate, more useful to measure |
|
|
Term
| FDA has approved GH use in short children but they must meet what requirement? |
|
Definition
Height <-2.25 stdev
Epyphyses not closed
Growth rate unlikely to permit attainment of adult height in the normal range |
|
|
Term
| Excess GH is usually due to what? |
|
Definition
|
|
Term
| Acromegaly is most often due to what? |
|
Definition
|
|
Term
|
Definition
Increased soft tissue
Increased bone proliferation causes periosteum, “spurs”
Arthralgia, myopathy, carpal tunnel syndrome |
|
|
Term
| MRI of prolactinomas have what kind of appearance? |
|
Definition
| “Snowman" appearance of the bi-lobed pituitary gland |
|
|
Term
| LDL levels are calculated based on what? |
|
Definition
|
|
Term
| At what level are triglycerides immeasurable? |
|
Definition
| >400mg/dl cannot be measured, cannot estimate LDL |
|
|
Term
| What is considered high LDL? |
|
Definition
|
|
Term
| What is considered high total cholesterol? |
|
Definition
|
|
Term
| What is considered low HDL? |
|
Definition
|
|
Term
| Which people should you do a lipid screen every 5 years? |
|
Definition
LDL <160
Or LDL <130 + or more risk factors |
|
|
Term
| Which people should you do a lipid screen every 1-2 years? |
|
Definition
LDL>160
Or LDL>130 + 2 or more risk factors
Or LDL>100 + Coronary heart disease or equivalent (diabetes) |
|
|
Term
| What are major risk factors for coronary heart disease? |
|
Definition
Age > 45men or 55 women
History of premature CHD in a first degree relative
Current Smoking
Hypertension |
|
|
Term
| What is and ideal LDL goal? |
|
Definition
CHD or CHD risk equivalents (diabetes) LDL < 100mg/dl
2+ risk factors LDL <130
0-1 risk factors LDL <160 |
|
|
Term
| What other kinds of diseases can increase lipids? |
|
Definition
Nephrotic syndrome (triglycerids)
Diabetes (triglicerides primarily and secondary cholesterol)
Hypothyroidism
Cushing’s Syndrome
Renal failure, metabolic syndrome, Alcohol |
|
|
Term
| How much can diet change impact your lipid panel? |
|
Definition
| can reduce total cholesterol 15% and LDL by 25% |
|
|
Term
| What is the mechanism of action for statins? |
|
Definition
HMG CoA reductase inhibitors
Inhibits hepatic synthesis of cholesterol
Side effects: myalgias and rarely rhabdomyolysis
Does not affect triglycerides |
|
|
Term
| What are the effects of Fibrates? |
|
Definition
Lowers triglycerides by about 40%
Little effect on anything else |
|
|
Term
| What are the effects of Niacin? |
|
Definition
Common vitamin, increases metabolism of both triglycerides and cholesterols
Difficult to use due to side effects: Flushing, sleep disturbance, elevated serum glucose, GI dysfunction |
|
|
Term
| What are the effects of Omega 3 Fatty Acids (fish oil)? |
|
Definition
Has been shown in high doses to reduce serum triglycerides by improving myocyte uptake of triglycerides for catabolism
Generally well tolerated, but can cause dyspepsia and other GI side effects
No significant effect on cholesterol |
|
|
Term
| What are the effects of resins? |
|
Definition
Effect mediated by binding cholesterol in the gut and preventing absorption Moderately effective in reducing cholesterol, but may paradoxically increase triglycerides
Major problem is frequency and severity of gastric side |
|
|
Term
| How do you treat Lone Hypertriglyceridemia |
|
Definition
If patient is diabetic, optimally control glucose first before adding an agent.
Begin with fibrates daily
If at maximum doses target is not reached, consider adding Niacin or Omega 3 FA’s |
|
|
Term
| How do you treato Lone Hypercholesterolemia |
|
Definition
Begin with statin, taken optimally at bedtime
If target not reached, consider adding Niacin, Resins |
|
|
Term
| How do you treat Combined Hyperlipidemia |
|
Definition
Begin with a statin
Add fibrate for triglycerides if necessary
CAUTION: the combination of statins and fibrates is associated with an increased risk of potentially life threatening rhabdomyolysis. Patients must be monitored closely |
|
|
