Nephrology: Kidney Function and Renal Diseases
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Questions and Answers

What is the first treatment given to a patient with hyperkalemia?

  • Insulin
  • Calcium gluconate (correct)
  • Sodium bicarbonate
  • Resins

    • What hormone is the main regulator of calcium in the body?

    Parathyroid hormone

    Hypocalcemia is associated with muscle weakness.

    True (A)

    Hypercalcemia is defined by total calcium levels greater than _ mmol/L.

    <p>2.6</p> Signup and view all the answers

    Match the following signs/symptoms with the corresponding condition: Tetany, Muscle Weakness, Polyuria

    <p>Tetany = Hypocalcemia Muscle Weakness = Hypercalcemia Polyuria = Hypercalcemia</p> Signup and view all the answers

    What mainly affects the sodium concentration ratio in the body?

    <p>Water content (C)</p> Signup and view all the answers

    Hyponatremia is a disorder of water balance rather than sodium balance.

    <p>True (A)</p> Signup and view all the answers

    Define Hyponatremia.

    <p>Hyponatremia is a condition in which the serum sodium concentration is less than 135 mmol/L.</p> Signup and view all the answers

    What can cause low sodium concentration due to accumulation of plasma constituents like triglycerides and proteins? Pseudohy__natremia.

    <p>ponatremia</p> Signup and view all the answers

    Match the following definitions of hyponatremia: [Acute], [Chronic], [Mild], [Moderate], [Profound]

    <p>Hyponatremia documented to exist for less than 48 hours = Acute Hyponatremia documented to exist for at least 48 hours = Chronic Serum sodium concentration between 130 and 135 mmol/L = Mild Serum sodium concentration between 125 and 129 mmol/L = Moderate Serum sodium concentration lower than 125 mmol/L = Profound</p> Signup and view all the answers

    What is the most frequent glomerular disease that presents with macroscopic hematuria?

    <p>IgA nephropathy</p> Signup and view all the answers

    How is the diagnosis of asymptomatic urinary abnormalities obtained?

    <p>By urinalysis (B)</p> Signup and view all the answers

    What is the main clinical manifestation of nephrotic syndrome?

    <p>Edema</p> Signup and view all the answers

    What should be used to treat a hypovolemic patient with extrarenal salt loss?

    <p>Isotonic saline (A)</p> Signup and view all the answers

    What is the formula to calculate water deficit in a patient with hypernatremia?

    <p>Water deficit = TBW x ([Na+]s/140-1)</p> Signup and view all the answers

    Hypernatremia always reflects a __________ state.

    <p>hyperosmolar</p> Signup and view all the answers

    Hypernatremia is always a water problem, never a salt problem.

    <p>False (B)</p> Signup and view all the answers

    Match the following symptoms with Diabetes insipidus: Altered mental status, Polyuria, Muscle twitching

    <p>Altered mental status = Central DI Polyuria = Nephrogenic DI Muscle twitching = Central DI</p> Signup and view all the answers

    What is the main function of the kidneys?

    <p>Clearing the body from wastes and toxic substances (B)</p> Signup and view all the answers

    Nocturia can be an early sign of renal dysfunction.

    <p>True (A)</p> Signup and view all the answers

    What is the normal range of glomerular filtration rate (GFR)?

    <p>90-120 ml/min</p> Signup and view all the answers

    High levels of __________ in the blood may indicate that the kidneys are not clearing wastes properly.

    <p>urea and serum creatinine</p> Signup and view all the answers

    Match the symptom with the condition:

    1. Peaked T waves
    2. Muscle weakness
    3. Prolonged QRS complex
    4. Cardiac arrhythmias

    <p>1 = hyperkalemia 2 = hyperkalemia 3 = hyperkalemia 4 = hyperkalemia</p> Signup and view all the answers

    What are the main functions of the kidney?

    <p>Monitoring blood pressure (B), Converting vitamin D (C), Filtering wastes (D)</p> Signup and view all the answers

    What is the ideal substance used to evaluate glomerular filtration rate?

    <p>inulin</p> Signup and view all the answers

    A healthy individual has ___ nephrons.

    <p>2 million</p> Signup and view all the answers

    Match the following symptoms with hyperkalemia:

    <p>Muscle weakness or paralysis = Symptom of hyperkalemia Cardiac arrhythmias = Symptom of hyperkalemia</p> Signup and view all the answers

    What is the normal value for sodium in the body?

    <p>140</p> Signup and view all the answers

    Which hormone mainly regulates osmolarity by regulating water reabsorption at the collecting duct?

    <p>Vasopressin (C)</p> Signup and view all the answers

    The normal osmolality is usually _____ mOsm/kg.

    <p>285-295</p> Signup and view all the answers

    Hyponatremia is a condition where sodium concentration in the blood is higher than 135 mmol/L.

    <p>False (B)</p> Signup and view all the answers

    Match the following terms:

    1. Hyponatremia
    2. SIADH (Syndrome Of Inappropriate Antidiuretic Hormone Secretion)
    3. Hypovolemic hyponatremia
    4. Hypervolemic hyponatremia

    <p>A. Condition where sodium concentration is low = 1 B. Syndrome characterised by excessive ADH release = 2 C. Sodium loss due to extrarenal salt loss = 3 D. Sodium increase causing increased blood volume = 4</p> Signup and view all the answers

    According to the content, what is the first treatment given to a patient with hyperkalemia?

    <p>Calcium gluconate (C)</p> Signup and view all the answers

    Hyperkalemia is unusual in healthy patients. Is this statement true or false according to the content?

    <p>False (B)</p> Signup and view all the answers

    What hormone is the main calcium regulator in the body?

    <p>Parathyroid hormone</p> Signup and view all the answers

    Hypocalcemia is associated with _______, which is neuromuscular irritability.

    <p>tetany</p> Signup and view all the answers

    Match the following symptoms with their respective electrolyte imbalance: Muscle weakness, Polyuria, Polydipsia, Dehydration

    <p>Muscle weakness = Hypercalcemia Polyuria = Hypercalcemia Polydipsia = Hypercalcemia Dehydration = Hypercalcemia</p> Signup and view all the answers

    What is the first step in treating a hypovolemic patient with extrarenal salt loss?

    <p>Administer isotonic saline (D)</p> Signup and view all the answers

    What are the recommended drugs to use in a hypervolemic patient with hyponatremia?

    <p>Diuretics</p> Signup and view all the answers

    Sodium concentration provides information about total body salt or volume status.

    <p>False (B)</p> Signup and view all the answers

    The opposite of SIADH is _____________.

    <p>Diabetes insipidus</p> Signup and view all the answers

    Match the following symptoms with Diabetes insipidus: Altered mental status, Muscle twitching, Seizures

    <p>Altered mental status = Signs and symptoms of Diabetes insipidus Muscle twitching = Signs and symptoms of Diabetes insipidus Seizures = Signs and symptoms of Diabetes insipidus</p> Signup and view all the answers

    How is the water deficit calculated in a patient with hypernatremia?

    <p>Water deficit = TBW x ([Na+]s/140-1)</p> Signup and view all the answers

    What is the most frequent glomerular disease that presents with macroscopic hematuria?

    <p>IgA nephropathy</p> Signup and view all the answers

    How is the diagnosis for asymptomatic urinary abnormalities typically obtained?

    <p>Urinalysis (C)</p> Signup and view all the answers

    What is the typical range of proteinuria in asymptomatic urinary abnormalities?

    <p>Higher than 150 mg/day but lower than 3g/day</p> Signup and view all the answers

    What can be detected by a dipstick test in asymptomatic urinary abnormalities?

    <p>Hematuria (D)</p> Signup and view all the answers

    What is the main clinical manifestation of nephrotic syndrome?

    <p>Edema</p> Signup and view all the answers

    What is a hallmark of nephrotic syndrome in terms of proteinuria?

    <p>Higher than 3.5g/day (B)</p> Signup and view all the answers

    What is the first sign of renal dysfunction according to the clinical case?

    <p>Nocturia (A)</p> Signup and view all the answers

    What hormone stimulates the bone marrow to produce red blood cells?

    <p>Erythropoietin</p> Signup and view all the answers

    High levels of serum creatinine and urea are associated with proper kidney function.

    <p>False (B)</p> Signup and view all the answers

    The normal range of Glomerular Filtration Rate (GFR) is ____ ml/min.

    <p>90-120</p> Signup and view all the answers

    Match the following signs/symptoms with hyperkalemia:

    <p>Muscle weakness or paralysis = Associated with hyperkalemia Cardiac arrhythmias = Associated with hyperkalemia</p> Signup and view all the answers

    What is the most simple lab test used to evaluate kidney functionality?

    <p>Serum creatinine (A)</p> Signup and view all the answers

    Hypernatremia always reflects a hyperosmolar state.

    <p>True (A)</p> Signup and view all the answers

    What is the formula to calculate water deficit in hypernatremia?

    <p>Water deficit = TBW x ([Na+]s/140-1)</p> Signup and view all the answers

    Macroscopic hematuria is characterized by the presence of visible _________ in the urine.

    <p>blood</p> Signup and view all the answers

    What is the most frequent glomerular disease that presents with macroscopic hematuria?

    <p>IgA nephropathy</p> Signup and view all the answers

    How is the diagnosis of asymptomatic urinary abnormalities obtained?

    <p>Urinalysis (B)</p> Signup and view all the answers

    What level of proteinuria is typically seen in asymptomatic urinary abnormalities?

    <p>higher than 150 mg/day but lower than 3g/day</p> Signup and view all the answers

    Microscopic hematuria is characterized by isomorphic erythrocytes only.

    <p>False (B)</p> Signup and view all the answers

    What is the main clinical manifestation of nephrotic syndrome?

    <p>edema</p> Signup and view all the answers

    What is the level of proteinuria associated with nephrotic syndrome?

    <p>higher than 3.5g/day</p> Signup and view all the answers

    What is the normal osmolarity range in the body?

    <p>285-295 mOsm/kg</p> Signup and view all the answers

    Which condition results in the patient losing a great amount of proteins in the urine?

    <p>Nephrotic syndrome (C)</p> Signup and view all the answers

    Hyponatremia is the most common disorder of body fluid and electrolyte balance encountered in clinical practice.

    <p>True (A)</p> Signup and view all the answers

    Hyponatremia is a condition in which ______ is less than 135 mmol/L.

    <p>Na^+^</p> Signup and view all the answers

    What causes pseudohyponatremia?

    <p>Accumulation of other plasma constituents (B)</p> Signup and view all the answers

    Match the following definitions based on time of development:

    <p>Acute = Hyponatremia documented to exist for less than 48 hours Chronic = Hyponatremia documented to exist for at least 48 hours</p> Signup and view all the answers

    What is the first treatment given to a patient with hyperkalemia?

    <p>calcium gluconate</p> Signup and view all the answers

    What is the primary cause of Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH)?

    <p>Excessive release of ADH</p> Signup and view all the answers

    Osmotic demyelination syndrome is a reversible neurological condition.

    <p>False (B)</p> Signup and view all the answers

    What can be used to shift potassium back into cells to lower potassium levels?

    <p>all of the above (D)</p> Signup and view all the answers

    Hypocalcemia is associated with muscle weakness.

    <p>True (A)</p> Signup and view all the answers

    What is the safe recommended increase in serum sodium concentration per 24 hours to avoid osmotic demyelination syndrome?

    <p>10 mmol/24 hr or 18 mmol/48 hr</p> Signup and view all the answers

    In hypocalcemia, we expect ____ PTH.

    <p>high</p> Signup and view all the answers

    Match the hormone with its role in calcium regulation:

    <p>Parathyroid hormone = Main calcium regulator Calcitonin = Counteracts the effects of PTH</p> Signup and view all the answers

    What is the initial treatment for a patient with symptomatic hypercalcemia?

    <p>intravenous hydration with isotonic saline and glucose</p> Signup and view all the answers

    What is the most frequent glomerular disease that presents with macroscopic hematuria?

    <p>IgA nephropathy</p> Signup and view all the answers

    How is the diagnosis obtained for asymptomatic urinary abnormalities?

    <p>Urinalysis (C)</p> Signup and view all the answers

    Proteinuria in asymptomatic urinary abnormalities is typically higher than the normal range of _____ mg/day.

    <p>150</p> Signup and view all the answers

    Is edema the main clinical manifestation of nephrotic syndrome?

    <p>True (A)</p> Signup and view all the answers

    What is the first sign of renal dysfunction mentioned in the clinical case of Antonio?

    <p>Nocturia (A)</p> Signup and view all the answers

    What hormone do kidneys produce to stimulate red blood cell production?

    <p>Erythropoietin</p> Signup and view all the answers

    The presence of proteinuria and hemoglobin in Antonio's urinalysis indicates alteration in the __________.

    <p>glomerular basement membrane</p> Signup and view all the answers

    Match the following electrolytes with their abnormal levels found in Antonio's blood tests:

    <p>Low sodium (Na) = 7.8 mg/dl High potassium (K) = 9.1mg/dl Low calcium (Ca) = 5.8 mmol/L High phosphorus (P) = 8.2 mg/dl</p> Signup and view all the answers

    Hyperkalemia is a common condition in healthy individuals.

    <p>False (B)</p> Signup and view all the answers

    What is the normal range for osmolality in the body?

    <p>285-295 mOsm/kg</p> Signup and view all the answers

    Which of the following symptoms is associated with hypovolemia?

    <p>Dry mouth (C)</p> Signup and view all the answers

    True or False: Dysnatremias are primarily disorders of sodium balance.

    <p>False (B)</p> Signup and view all the answers

    Hypernatremia is a condition in which water deficit leads to dehydration and sodium concentration is greater than __ mmol/L.

    <p>135</p> Signup and view all the answers

    What is the main solute other than sodium that can cause a relative decrease in sodium concentration despite unchanged plasma osmolality?

    <p>Glucose (D)</p> Signup and view all the answers

    Match the type of hyponatremia with its main causes:

    <p>Hypovolemic hyponatremia = Extrarenal salt loss such as diuretics Hypervolemic hyponatremia = Heart failure, liver disease Euvolemic hyponatremia = Syndrome of inappropriate ADH secretion</p> Signup and view all the answers

    What is the recommended rate of sodium increase in correcting hyponatremia to avoid osmotic demyelination syndrome?

    <p>10 mmol/24 hr or 18 mmol/48 hr</p> Signup and view all the answers

    What is the first treatment recommended for a patient with hyperkalemia?

    <p>Calcium gluconate</p> Signup and view all the answers

    What can be used to shift potassium back into cells for the treatment of hyperkalemia?

    <p>All of the above (D)</p> Signup and view all the answers

    What is the first step in treating a severe symptomatic case of hyponatremia?

    <p>Administer a hypertonic solution (D)</p> Signup and view all the answers

    Hyperkalemia is unusual in healthy patients. True or False?

    <p>False (B)</p> Signup and view all the answers

    Severe symptomatic hyponatremia should always be rapidly corrected to avoid complications.

    <p>False (B)</p> Signup and view all the answers

    Hypocalcemia is associated with ______, which is neuromuscular irritability.

    <p>tetany</p> Signup and view all the answers

    What is the treatment for a hypervolemic patient with hyponatremia?

    <p>diuretics</p> Signup and view all the answers

    Match the following treatments with the corresponding condition: Intravenous hydration with isotonic saline, Bisphosphonates, Loop diuretics, Glucocorticoids and Dialysis.

    <p>Hypercalcemia = Dialysis</p> Signup and view all the answers

    Hyponatremia is always a _ problem, just sometimes a salt problem.

    <p>water</p> Signup and view all the answers

    What hormone is the main calcium regulator in the body?

    <p>Parathyroid hormone</p> Signup and view all the answers

    Match the symptoms of Diabetes Insipidus with their description:

    <p>Altered mental status = CNS-related symptom Polyuria and polydipsia = Main characteristic of DI Muscle twitching = Neurological symptom Hyperreflexia and spasticity = Neurological symptom</p> Signup and view all the answers

    What is the likely cause of hypercalcemia when the parathyroid hormone (PTH) levels are high?

    <p>Primary hyperparathyroidism (B)</p> Signup and view all the answers

    Hypercalcemia can be aggravated by a high-calcium diet. True or False?

    <p>True (A)</p> Signup and view all the answers

    Dysnatremias are disorders of water homeostasis, not disorders of ______.

    <p>sodium</p> Signup and view all the answers

    What is the first sign of renal dysfunction if the patient does not take large doses of diuretics?

    <p>Nocturia</p> Signup and view all the answers

    Which substances are important indicators of renal function in the blood tests mentioned?

    <p>Serum creatinine (B), Urea (D)</p> Signup and view all the answers

    Erythropoietin is a hormone produced by the kidneys that stimulates bone marrow to produce white blood cells.

    <p>False (B)</p> Signup and view all the answers

    The main function of kidneys is to act as filters, clearing the body from wastes and returning vital substances into the bloodstream. Two important wastes that should be eliminated are serum creatinine and _____.

    <p>urea</p> Signup and view all the answers

    Match the following symptoms with the condition:

    1. Muscle weakness or paralysis
    2. Cardiac arrhythmias

    <p>Hyperkalemia = Cardiac arrhythmias</p> Signup and view all the answers

    What is the first treatment given to a patient with hyperkalemia?

    <p>Calcium gluconate (B)</p> Signup and view all the answers

    In hypercalcemia, what is the main treatment used to lower serum calcium concentration?

    <p>Isotonic saline and glucose</p> Signup and view all the answers

    Hypocalcemia is associated with muscle weakness.

    <p>False (B)</p> Signup and view all the answers

    The system that regulates the amount of sodium in the body is the __________.

    <p>RAAS</p> Signup and view all the answers

    What is the key treatment for a hypovolemic patient with extrarenal salt loss?

    <p>Isotonic saline (A)</p> Signup and view all the answers

    Hyponatremia can be both a water problem and a salt problem.

    <p>True (A)</p> Signup and view all the answers

    What is the most basic lab test used to evaluate kidney functionality?

    <p>Serum creatinine</p> Signup and view all the answers

    In hypernatremia, the sodium concentration is higher than ______ mmol/L.

    <p>145</p> Signup and view all the answers

    Match the Diabetes insipidus causes with their descriptions:

    <p>Central DI = Due to deficiency of ADH Nephrogenic DI = Due to being unresponsive to ADH Gestational DI = Due to degradation of ADH</p> Signup and view all the answers

    What is the most frequent glomerular disease that presents with macroscopic hematuria?

    <p>IgA nephropathy</p> Signup and view all the answers

    How can the diagnosis of asymptomatic urinary abnormalities be obtained?

    <p>By urinalysis</p> Signup and view all the answers

    What is a common characteristic of asymptomatic urinary abnormalities?

    <p>Higher proteinuria than normal range (A)</p> Signup and view all the answers

    In asymptomatic urinary abnormalities, hematuria can be detected by a dipstick test if there are more than 2 ___ cells per high power field.

    <p>red blood</p> Signup and view all the answers

    Is nephrotic syndrome characterized by proteinuria higher than 3.5g/day?

    <p>True (A)</p> Signup and view all the answers

    What is the main clinical manifestation of nephrotic syndrome?

    <p>Edema</p> Signup and view all the answers

    What is the normal osmolarity range?

    <p>285-295 mOsm/kg</p> Signup and view all the answers

    Dysnatremias are mainly disorders of which balance?

    <p>Water balance (D)</p> Signup and view all the answers

    Hyponatremia is the most common disorder of body fluid and electrolyte balance encountered in clinical practice.

    <p>True (A)</p> Signup and view all the answers

    Hyponatremia is a condition in which sodium concentration is mmol/L.

    <p>135</p> Signup and view all the answers

    Match the hyponatremia classification with the correct serum sodium concentration range:

    <p>Mild = 130-135 mmol/L Moderate = 125-129 mmol/L Profound = Lower than 125 mmol/L</p> Signup and view all the answers

    What is the main cause of euvolemic hyponatremia?

    <p>SIADH</p> Signup and view all the answers

    What can cause pseudohyponatremia?

    <p>Accumulation of triglycerides and proteins (D)</p> Signup and view all the answers

    Hyponatremia symptoms are primarily due to peripheral nerve dysfunction.

    <p>False (B)</p> Signup and view all the answers

    Osmotic demyelination syndrome occurs when hyponatremia is corrected too .

    <p>rapidly</p> Signup and view all the answers

    What is the recommended sodium concentration increase per day to avoid osmotic demyelination syndrome?

    <p>10 mmol/24 hr or 18 mmol/48 hr</p> Signup and view all the answers

    What is the main function of kidneys related to clearing the body?

    <p>Filtering wastes and toxic substances, returning vital substances to the bloodstream.</p> Signup and view all the answers

    Which hormone stimulates the bone marrow to produce red blood cells?

    <p>Erythropoietin (D)</p> Signup and view all the answers

    The ideal substance to evaluate glomerular filtration rate is ________.

    <p>inulin</p> Signup and view all the answers

    Hyperkalemia is very common in healthy individuals.

    <p>False (B)</p> Signup and view all the answers

    Match the following symptoms with the condition: Muscle weakness, Cardiac arrhythmias

    <p>Muscle weakness = Hyperkalemia Cardiac arrhythmias = Hyperkalemia</p> Signup and view all the answers

    What is the treatment for a hypovolemic patient with extrarenal salt loss?

    <p>Isotonic saline (D)</p> Signup and view all the answers

    Hypernatremia always reflects a hyperosmolar state.

    <p>True (A)</p> Signup and view all the answers

    What is the formula to calculate water deficit in a patient?

    <p>Water deficit = TBW x ([Na+]s/140-1)</p> Signup and view all the answers

    Macroscopic hematuria refers to visible _______ in the urine.

    <p>blood</p> Signup and view all the answers

    Which of the following statements is true about hyponatremia?

    <p>Hyponatremia is a disorder of water balance. (B)</p> Signup and view all the answers

    Define hyponatremia.

    <p>Hyponatremia is a condition where the level of sodium in the blood is below 135 mmol/L.</p> Signup and view all the answers

    In hyponatremia, water will flow from the extracellular fluid to the intracellular fluid by ________.

    <p>osmosis</p> Signup and view all the answers

    Match the following with their respective terms:

    1. Effective circulating volume
    2. Osmolarity
    3. Hyponatremia
    4. SIADH

    <p>A. Regulated by RAAS and baroreceptors = 1 B. Depends on water balance = 2 C. Condition where [Na+] &lt; 135 mmol/L = 3 D. Syndrome of inappropriate ADH secretion = 4</p> Signup and view all the answers

    Osmotic demyelination syndrome is reversible if treated promptly.

    <p>False (B)</p> Signup and view all the answers

    What is the most frequent glomerular disease that presents with macroscopic hematuria?

    <p>IgA nephropathy</p> Signup and view all the answers

    How is diagnosis for asymptomatic urinary abnormalities obtained?

    <p>Urinalysis (D)</p> Signup and view all the answers

    Proteinuria higher than ______ is a common indicator of asymptomatic urinary abnormalities.

    <p>150 mg/day</p> Signup and view all the answers

    Asymptomatic urinary abnormalities typically have abnormal blood pressure readings.

    <p>False (B)</p> Signup and view all the answers

    Match the type of erythrocytes with their characteristics:

    <p>Isomorphic erythrocytes = Similar to those found in the blood Dysmorphic erythrocytes = Irregular shapes and contours due to passage through glomerular membrane</p> Signup and view all the answers

    What is the main clinical manifestation of nephrotic syndrome?

    <p>Edema</p> Signup and view all the answers

    What is the first treatment given to a patient with hyperkalemia?

    <p>Calcium gluconate (A)</p> Signup and view all the answers

    What hormone is the main regulator of calcium in the body?

    <p>Parathyroid hormone (PTH) (B)</p> Signup and view all the answers

    True or False: Vitamin D deficiency is widespread worldwide, especially in Northern nations.

    <p>True (A)</p> Signup and view all the answers

    What are the possible causes of hypocalcemia?

    <p>The possible causes of hypocalcemia include high PTH levels, genetic, autoimmune or iatrogenic diseases affecting the parathyroid gland, vitamin D deficiency, reduced gastrointestinal reabsorption, chronic kidney disease, bisphosphonates use, and hypomagnesemia.</p> Signup and view all the answers

    Hypercalcemia is defined as having a total calcium concentration greater than ______ mmol/L.

    <p>2.6</p> Signup and view all the answers

    Match the following signs and symptoms with the corresponding condition:

    1. Muscle weakness
    2. Polyuria
    3. Tetany
    4. Neuromuscular irritability

    <ol> <li>Muscle weakness = hypercalcemia</li> <li>Polyuria = hypercalcemia</li> <li>Tetany = hypocalcemia</li> <li>Neuromuscular irritability = hypocalcemia</li> </ol> Signup and view all the answers

    What is the first treatment given to a symptomatic patient with hypercalcemia?

    <p>Intravenous hydration with isotonic saline and glucose</p> Signup and view all the answers

    What is the primary function of kidneys?

    <p>Maintain electrolyte balance (C)</p> Signup and view all the answers

    Nocturia is usually the first sign of renal dysfunction.

    <p>True (A)</p> Signup and view all the answers

    What hormone do the kidneys produce to stimulate red blood cell production?

    <p>erythropoietin</p> Signup and view all the answers

    The primary function of kidneys is to manage the concentration of ___ and salts.

    <p>water</p> Signup and view all the answers

    Match the following symptoms with hyperkalemia:

    <p>Muscle weakness = Hyperkalemia Cardiac arrhythmias = Hyperkalemia</p> Signup and view all the answers

    What is the first treatment that can be given to a patient with hyperkalemia?

    <p>Calcium Gluconate (C)</p> Signup and view all the answers

    What hormone is the main regulator of calcium levels in the body?

    <p>Parathyroid Hormone</p> Signup and view all the answers

    Hypocalcemia is associated with muscle weakness.

    <p>True (A)</p> Signup and view all the answers

    Hypercalcemia is defined by a total calcium concentration greater than __ mmol/L.

    <p>2.6</p> Signup and view all the answers

    Match the possible causes of hypercalcemia with their descriptions:

    <p>Primary Hyperparathyroidism = Tumor (adenoma) of the parathyroid gland Vitamin D Intoxication = Taking excessive vitamin D supplements Granulomatous Diseases = Activation of a sort of vitamin D by granulomas Bone Metastases = Tumors like multiple myeloma inducing calcium release</p> Signup and view all the answers

    What is the most frequent glomerular disease that presents with macroscopic hematuria?

    <p>IgA nephropathy</p> Signup and view all the answers

    How is the diagnosis of asymptomatic urinary abnormalities obtained?

    <p>By urinalysis (A)</p> Signup and view all the answers

    In asymptomatic urinary abnormalities, ___ will be higher than normal range (>150 mg/day), but lower than 3g/day.

    <p>proteinuria</p> Signup and view all the answers

    What is the immediate treatment for a severely hyponatremic patient in an emergency setting?

    <p>Hypertonic solution (A)</p> Signup and view all the answers

    Is it important to differentiate between isomorphic and dysmorphic erythrocytes in case of microscopic hematuria?

    <p>True (A)</p> Signup and view all the answers

    What should be checked to understand if a patient is hypo-, eu-, or hypervolemic in the context of hyponatremia?

    <p>Volume status</p> Signup and view all the answers

    What is generally the main clinical manifestation of nephrotic syndrome?

    <p>Edema</p> Signup and view all the answers

    Severe symptomatic hyponatremia should be corrected rapidly.

    <p>False (B)</p> Signup and view all the answers

    What drug class are Vaptans, used to treat SIADH, which act as antagonists of receptors for vasopressin?

    <p>Vasopressin receptor antagonists</p> Signup and view all the answers

    Match the symptoms with Diabetes Insipidus:

    <p>Altered mental status = CNS symptom of Diabetes Insipidus Polyuria = Common symptom of Diabetes Insipidus Seizures = Can occur in children with Diabetes Insipidus</p> Signup and view all the answers

    What is the normal value for sodium?

    <p>140</p> Signup and view all the answers

    What is the main factor that affects the ratio of sodium concentration?

    <p>Water content (C)</p> Signup and view all the answers

    Hyponatremia is a condition where sodium concentration is higher than normal.

    <p>False (B)</p> Signup and view all the answers

    Hyponatremia is a condition in which [____] is less than 135 mmol/L.

    <p>Na+</p> Signup and view all the answers

    Match the following definitions with the correct serum sodium concentration range (mmol/L):

    <p>Mild hyponatremia = between 130 and 135 Moderate hyponatremia = between 125 and 129 Profound hyponatremia = lower than 125</p> Signup and view all the answers

    What is the main cause of pseudohyponatremia?

    <p>Accumulation of plasma constituents (triglycerides and proteins)</p> Signup and view all the answers

    Which disorder is always associated with a derangement of water balance?

    <p>Dysnatremias (C)</p> Signup and view all the answers

    SIADH causes the production of dilute urine.

    <p>False (B)</p> Signup and view all the answers

    What does Osmotic demyelination syndrome result from?

    <p>Rapid correction of hyponatremia</p> Signup and view all the answers

    How should severe hyponatremia be treated?

    <p>Infusion of hypertonic saline (A)</p> Signup and view all the answers

    What is the first treatment given to a patient in hyperkalemic emergencies to stabilize their cardiac rhythm?

    <p>Calcium gluconate (B)</p> Signup and view all the answers

    What is the hormone responsible for regulating calcium levels in the body?

    <p>Parathyroid hormone</p> Signup and view all the answers

    Hypocalcemia is associated with muscle weakness.

    <p>True (A)</p> Signup and view all the answers

    Hypercalcemia is defined by serum calcium concentration of total calcium > _______ mmol/L.

    <p>2.6</p> Signup and view all the answers

    Match the symptom with the electrolyte imbalance: Tetany - _________.

    <p>Hypocalcemia = Tetany Hypercalcemia = Muscle weakness</p> Signup and view all the answers

    What is the main function of the kidneys?

    <p>Monitoring and managing water and salt concentrations (D)</p> Signup and view all the answers

    Hyperkalemia is a condition where there is an unusually low level of potassium in the blood.

    <p>False (B)</p> Signup and view all the answers

    What are two tests that are particularly important for evaluating kidney function?

    <p>urea and serum creatinine</p> Signup and view all the answers

    The ideal substance to evaluate the glomerular filtration rate is _____

    <p>inulin</p> Signup and view all the answers

    Match the following with their correct description:

    <p>Anuria = Defined as a urinary output less than 50 mL/day Hyperkalemia = High levels of potassium in the blood GFR = Glomerular filtration rate, measuring kidney function Proteinuria = Presence of excessive protein in the urine</p> Signup and view all the answers

    What mainly affects the sodium concentration ratio in the body?

    <p>Water content (A)</p> Signup and view all the answers

    Hyponatremia is a condition where the sodium concentration is greater than 135 mmol/L.

    <p>False (B)</p> Signup and view all the answers

    What is the most common symptom of hypovolemia?

    <p>low blood pressure</p> Signup and view all the answers

    SIADH stands for Syndrome Of Inappropriate _______ Secretion.

    <p>Antidiuretic Hormone</p> Signup and view all the answers

    Match the following biochemical severity classifications with their corresponding serum sodium concentration:

    <p>Mild = between 130 and 135 mmol/L Moderate = between 125 and 129 mmol/L Profound = lower than 125 mmol/L</p> Signup and view all the answers

    What is the most frequent glomerular disease that presents with macroscopic hematuria?

    <p>IgA nephropathy</p> Signup and view all the answers

    How is the diagnosis of asymptomatic urinary abnormalities obtained?

    <p>Urinalysis (C)</p> Signup and view all the answers

    In cases of asymptomatic urinary abnormalities, ___ will be higher than normal range.

    <p>proteinuria</p> Signup and view all the answers

    Is edema the main clinical manifestation of nephrotic syndrome?

    <p>True (A)</p> Signup and view all the answers

    What is the key initial step in treating severe symptomatic hyponatremia?

    <p>Administer hypertonic solution immediately (B)</p> Signup and view all the answers

    Sodium concentration provides information about total body salt or volume status.

    <p>False (B)</p> Signup and view all the answers

    Hypernatremia results from a water deficit, which leads to a sodium concentration higher than ______ mmol/L.

    <p>145</p> Signup and view all the answers

    What is the opposite condition of Syndrome of Inappropriate Antidiuretic Hormone secretion (SIADH)?

    <p>Diabetes insipidus</p> Signup and view all the answers

    Match the correct type of patient with the appropriate treatment for hyponatremia:

    <p>Hypovolemic with extrarenal salt loss = Isotonic saline (0.9%) Hypervolemic patient = Diuretics Euvolemic patient = Water restriction with potential use of Vaptan drugs Hypovolemic with renal salt loss = Isotonic saline with discontinuation of responsible drugs</p> Signup and view all the answers

    What lab test is used to evaluate kidney functionality?

    <p>Serum creatinine (D)</p> Signup and view all the answers

    What is the first treatment given to a patient with hyperkalemia to stabilize cardiac rhythm?

    <p>Calcium gluconate (C)</p> Signup and view all the answers

    What hormone is the main regulator of calcium levels in the body?

    <p>Parathyroid hormone</p> Signup and view all the answers

    Hypocalcemia is associated with tetany.

    <p>True (A)</p> Signup and view all the answers

    Hypercalcemia is defined by a total calcium concentration of total calcium > _____ mmol/L.

    <p>2.6</p> Signup and view all the answers

    Match the hormone with its function in calcium regulation:

    <p>Parathyroid hormone = Increases bone turnover and favors calcium release by bones Calcitonin = Counteracts the effects of PTH and lowers serum calcium concentration</p> Signup and view all the answers

    What is the first sign of renal dysfunction according to the clinical case?

    <p>Frequent urination at night (nocturia) (B)</p> Signup and view all the answers

    Proteinuria and hematuria are observed in Antonio's urinalysis.

    <p>False (B)</p> Signup and view all the answers

    What is the ideal substance used to evaluate the glomerular filtration rate?

    <p>inulin</p> Signup and view all the answers

    The normal range of glomerular filtration rate (GFR) is ____ mL/min.

    <p>90-120</p> Signup and view all the answers

    Match the following kidney dysfunction stages with their respective GFR values (ml/min/1.73m2):

    <p>G1 = GFR &gt;90 G2 = GFR 60-89 G3a = GFR 45-59 G3b = GFR 30-44 G4 = GFR 15-29 G5 = Kidney failure: GFR &lt;15</p> Signup and view all the answers

    What is the immediate treatment for severe hyponatremia in an emergency setting?

    <p>Hypertonic solution (A)</p> Signup and view all the answers

    How is a hypovolemic patient with extrarenal salt loss treated?

    <p>Normal isotonic saline (0.9%)</p> Signup and view all the answers

    Hypernatremia results from a salt deficit.

    <p>False (B)</p> Signup and view all the answers

    Hypernatremia always reflects a __________ state.

    <p>hyperosmolar</p> Signup and view all the answers

    Match the symptoms with Diabetes Insipidus:

    <p>Altered mental status = Central DI Seizures = Central DI Polyuria and polydipsia = Nephrogenic DI Muscle twitching = Nephrogenic DI</p> Signup and view all the answers

    What is the most simple lab test used to evaluate kidney functionality?

    <p>Serum creatinine</p> Signup and view all the answers

    What is the normal osmolarity range in the body?

    <p>285-295 mOsm/kg</p> Signup and view all the answers

    Which of the following symptoms are typical of hypovolemia?

    <p>Reduced refill capillary time (A), Low blood pressure (B), Dry mouth (C), Dry skin (D)</p> Signup and view all the answers

    Hypernatremia is a condition characterized by water excess.

    <p>False (B)</p> Signup and view all the answers

    Hyponatremia is a condition in which ______ is less than 135 mmol/L.

    <p>Na+</p> Signup and view all the answers

    Match the following definitions:

    <p>SIADH = Syndrome Of Inappropriate Antidiuretic Hormone Secretion RAAS = Renin-Angiotensin-Aldosterone System TBW = Total Body Water</p> Signup and view all the answers

    What is the formula to calculate the estimated sodium concentration change upon infusion?

    <p>Change in [Na+] = (Final sodium concentration - Initial sodium concentration) / (TBW in L) + 1</p> Signup and view all the answers

    What is the most frequent glomerular disease that presents with macroscopic hematuria?

    <p>IgA nephropathy</p> Signup and view all the answers

    How is the diagnosis of asymptomatic urinary abnormalities typically obtained?

    <p>Urinalysis (A)</p> Signup and view all the answers

    In asymptomatic urinary abnormalities, proteinuria is higher than normal range (>150 mg/day), but lower than ___.

    <p>3g/day</p> Signup and view all the answers

    In cases of microscopic hematuria, it is important to differentiate between isomorphic and dysmorphic erythrocytes.

    <p>True (A)</p> Signup and view all the answers

    Match the following clinical manifestations with Nephrotic syndrome:

    <p>Presence of edema = Main clinical manifestation Proteinuria higher than 3.5g/day = Associated feature Low serum protein and low albumin = Characteristic lab findings</p> Signup and view all the answers

    What is the typical number of nephrons in a healthy individual?

    <p>2 million (D)</p> Signup and view all the answers

    What is the formula to calculate creatinine clearance?

    <p>urinary creatinine (mg/ml) x urinary volume (ml) / serum creatinine (mg/dl) (C)</p> Signup and view all the answers

    What is the value of serum creatinine that indicates a significant reduction in creatinine clearance?

    <p>2 mg/dl (C)</p> Signup and view all the answers

    What is the GFR of Antonio using the Cockcroft and Gault method?

    <p>8 ml/min (C)</p> Signup and view all the answers

    What is the normal value of creatinine clearance in a healthy individual?

    <p>120 ml/min (B)</p> Signup and view all the answers

    What is the characteristic of bilateral renal diseases?

    <p>They start with one kidney and then involve the other (B)</p> Signup and view all the answers

    What is the significance of a serum creatinine value of 8.2 mg/dl?

    <p>Severe kidney disease (B)</p> Signup and view all the answers

    Why is it difficult to calculate creatinine clearance?

    <p>It requires a 24-hour urine collection (A)</p> Signup and view all the answers

    What is the main reason why creatinine levels may not accurately represent GFR in certain patients?

    <p>All of the above (D)</p> Signup and view all the answers

    What is the normal range of GFR?

    <p>90-120 mL/min (B)</p> Signup and view all the answers

    What is the purpose of performing urinalysis in addition to serum creatinine test?

    <p>To rule out any kidney functionality abnormality (D)</p> Signup and view all the answers

    What are glomerular diseases characterized by?

    <p>Variable combinations of serum creatinine, amount of proteinuria, and alterations of urinary sediment (A)</p> Signup and view all the answers

    Why is it important to recognize the correct nephrological syndrome?

    <p>Because different complications may arise and different treatments will be needed (A)</p> Signup and view all the answers

    What is the significance of low creatinine levels in elderly people?

    <p>It is due to physiological reduction of muscle mass (D)</p> Signup and view all the answers

    What is the significance of normal serum creatinine level but low GFR in patients with Rheumatoid Arthritis?

    <p>It is due to prolonged use of corticosteroids (B)</p> Signup and view all the answers

    What is the next step if both serum creatinine and urinalysis indicate kidney dysfunction?

    <p>Perform further tests (A)</p> Signup and view all the answers

    What is the normal range of Glomerular Filtration Rate (GFR)?

    <p>90-120 ml/min (B)</p> Signup and view all the answers

    What is the effect of aging on Glomerular Filtration Rate (GFR)?

    <p>GFR decreases with age, particularly after 50 years (A)</p> Signup and view all the answers

    What is the effect of muscle mass on serum creatinine levels?

    <p>Increased muscle mass increases serum creatinine levels (C)</p> Signup and view all the answers

    What is the minimum number of functional kidneys required to sustain normal renal function?

    <p>One kidney (C)</p> Signup and view all the answers

    What is the effect of diet on Glomerular Filtration Rate (GFR)?

    <p>A diet rich in amino acids and proteins increases GFR (D)</p> Signup and view all the answers

    What is the relationship between serum creatinine levels and Glomerular Filtration Rate (GFR)?

    <p>High serum creatinine levels indicate low GFR (A)</p> Signup and view all the answers

    What is the stage of kidney dysfunction if the GFR is 45-59 ml/min/1.73m2?

    <p>G3a: mildly to moderately decreased (A)</p> Signup and view all the answers

    What is defined as an osmotic diuresis or renal concentrating defect?

    <p>Anuria (D)</p> Signup and view all the answers

    What can cause reduced urinary potassium excretion?

    <p>All of the above (D)</p> Signup and view all the answers

    What is the primary mechanism of hyperkalemia in healthy individuals?

    <p>None of the above (D)</p> Signup and view all the answers

    What is the main consequence of reduced sodium and water delivery to the distal tubule?

    <p>Impaired potassium secretion (A)</p> Signup and view all the answers

    What is the characteristic of CKD?

    <p>GFR ranging from 15-20 ml/min/1.73m2 (A)</p> Signup and view all the answers

    What is the primary reason for anuria?

    <p>All of the above (D)</p> Signup and view all the answers

    What is the typical classification of GFR values for kidney dysfunction?

    <p>G1 to G5 (C)</p> Signup and view all the answers

    What is the significance of nocturia in the patient's symptoms?

    <p>It is a sign of mild kidney dysfunction (B)</p> Signup and view all the answers

    What is indicated by the high levels of urea and serum creatinine in the patient's blood tests?

    <p>Severe kidney dysfunction (A)</p> Signup and view all the answers

    What is the significance of the high levels of uric acid in the patient's blood tests?

    <p>It can be altered for other reasons beyond kidney function (C)</p> Signup and view all the answers

    What is the significance of the low sodium levels in the patient's blood tests?

    <p>It is a sign of water imbalance (C)</p> Signup and view all the answers

    What is the significance of the high potassium levels in the patient's blood tests?

    <p>It is a sign of electrolyte imbalance (B)</p> Signup and view all the answers

    What is the significance of the low bicarbonate levels in the patient's blood tests?

    <p>It is a sign of metabolic acidosis (A)</p> Signup and view all the answers

    What is the significance of the proteinuria in the patient's urinalysis?

    <p>It is a sign of kidney damage (A)</p> Signup and view all the answers

    What is the significance of the hemoglobin in the patient's urinalysis?

    <p>It is a sign of hematuria (B)</p> Signup and view all the answers

    What percentage of end-stage renal disease is caused by untreated glomerulonephritis?

    <p>15% (D)</p> Signup and view all the answers

    What is the characteristic of bright red hematuria?

    <p>Considerable bleeding in progress (C)</p> Signup and view all the answers

    What is the main difference between symptomatic and asymptomatic hematuria?

    <p>The presence of other symptoms such as urinary tract infections or kidney stones (D)</p> Signup and view all the answers

    What is the term for hematuria that occurs at the beginning of urination?

    <p>Initial hematuria (B)</p> Signup and view all the answers

    What is the term for glomerulonephritis that progresses to end-stage kidney disease if left untreated?

    <p>End-stage renal disease (B)</p> Signup and view all the answers

    What is the characteristic of coke-like hematuria?

    <p>Previous bleeding or hemoglobinuria (A)</p> Signup and view all the answers

    What is the term for hematuria that occurs throughout urination?

    <p>Total hematuria (A)</p> Signup and view all the answers

    What is the significance of hematuria in terms of kidney function?

    <p>It indicates severe kidney dysfunction (D)</p> Signup and view all the answers

    What is the significance of recognizing the correct nephrological syndrome?

    <p>To decide on the correct treatment approach (B)</p> Signup and view all the answers

    What is the range of normal GFR?

    <p>90-120 mL/min (B)</p> Signup and view all the answers

    In cases of rheumatoid arthritis, what is often observed?

    <p>Normal serum creatinine level but low GFR (C)</p> Signup and view all the answers

    What is the significance of urinalysis in assessing kidney functionality?

    <p>It is used in conjunction with serum creatinine to assess kidney functionality (A)</p> Signup and view all the answers

    What is the term used to describe glomerular diseases that present in different clinical forms?

    <p>Nephrological syndromes (C)</p> Signup and view all the answers

    What is the typical characteristic of elderly people in terms of creatinine levels?

    <p>Lower creatinine levels due to physiological reduction of muscle mass (A)</p> Signup and view all the answers

    What are the symptoms that can vary in glomerular diseases?

    <p>Asymptomatic forms, mild/severe clinical manifestations, and acute renal dysfunction (D)</p> Signup and view all the answers

    What are the three variables that originate nephrological syndromes?

    <p>Serum creatinine, proteinuria, and urinary sediment (D)</p> Signup and view all the answers

    What is the percentage of end-stage renal disease caused by untreated glomerulonephritis?

    <p>15% (B)</p> Signup and view all the answers

    What type of hematuria is associated with a considerable bleeding in progress?

    <p>Bright red hematuria (C)</p> Signup and view all the answers

    What is the term used to describe hematuria that lasts for a prolonged period of time?

    <p>Persistent hematuria (B)</p> Signup and view all the answers

    What is the term used to describe hematuria that is not accompanied by any symptoms?

    <p>Asymptomatic hematuria (B)</p> Signup and view all the answers

    What is the consequence of untreated glomerular disease?

    <p>End-stage kidney disease (A)</p> Signup and view all the answers

    What is the term used to describe the classification of hematuria based on its timing?

    <p>Initial, total, or terminal (A)</p> Signup and view all the answers

    What is the characteristic of bright red hematuria?

    <p>Considerable bleeding in progress (A)</p> Signup and view all the answers

    What is the consequence of glomerulonephritis if left untreated?

    <p>End-stage kidney disease (B)</p> Signup and view all the answers

    Which of the following laboratory results is indicative of a severe renal dysfunction?

    <p>Urea 190 mg/dl and S.creatinine 8.2 mg/dl (D)</p> Signup and view all the answers

    What is the first sign of renal dysfunction according to the clinical case?

    <p>Frequent urination at night (D)</p> Signup and view all the answers

    What is the significance of a high level of uric acid in this case?

    <p>It is an expression of kidney function but can be altered also for other reasons (B)</p> Signup and view all the answers

    What is the likely diagnosis based on the patient's symptoms and laboratory results?

    <p>Nephritic syndrome (A)</p> Signup and view all the answers

    What is the significance of proteinuria in this case?

    <p>It is a sign of kidney dysfunction (A)</p> Signup and view all the answers

    What is the likely cause of the patient's anemia?

    <p>Kidney dysfunction (A)</p> Signup and view all the answers

    What is the significance of the patient's edema in the lower limbs?

    <p>It is a sign of kidney dysfunction (C)</p> Signup and view all the answers

    What is the significance of the patient's high blood pressure?

    <p>It is a sign of kidney dysfunction (A)</p> Signup and view all the answers

    Study Notes

    Introduction to Nephrology

    • Nephrology is the study of kidney function and diseases
    • Kidney function is essential for maintaining overall health

    Kidney Function

    • Kidneys act as filters, clearing the body of waste and toxic substances
    • They monitor and regulate blood pressure through the juxtaglomerular apparatus
    • They produce erythropoietin, which stimulates the production of red blood cells
    • They manage water and salt concentrations in the body, responding to antidiuretic hormone and aldosterone
    • They convert vitamin D to its active form, increasing calcium levels in the body

    Evaluation of Renal Function

    • The best test to evaluate renal function is the glomerular filtration rate (GFR)
    • GFR measures the volume of plasma cleared of a substance in a unit of time (mL/min)
    • An ideal substance to evaluate GFR should be produced endogenously, filtered by the glomerulus, and not reabsorbed or secreted by the renal tubule
    • Inulin is the ideal substance, but it is not produced by the body, so serum creatinine is used instead

    Serum Creatinine

    • Serum creatinine is a waste product that is produced by the body and cleared by the kidneys
    • High levels of serum creatinine indicate impaired kidney function
    • Normal range of serum creatinine is 0.5-1.0 mg/dL
    • Serum creatinine levels are influenced by factors such as aging, diet, and muscle mass

    Glomerular Filtration Rate (GFR)

    • GFR is the volume of plasma cleared of a substance in a unit of time (mL/min)
    • Normal range of GFR is 90-120 mL/min
    • GFR is calculated using serum creatinine levels, urinary volume, and creatinine in urine
    • GFR is influenced by factors such as aging, diet, and muscle mass

    Stages of Kidney Dysfunction

    • G1: normal or high GFR (>90 mL/min/1.73m²)
    • G2: mildly decreased GFR (60-89 mL/min/1.73m²)
    • G3a: mildly to moderately decreased GFR (45-59 mL/min/1.73m²)
    • G3b: moderately to severely decreased GFR (30-44 mL/min/1.73m²)
    • G4: severely decreased GFR (15-20 mL/min/1.73m²)
    • G5: kidney failure (GFR ≤15 mL/min/1.73m²)

    Case Study: Antonio

    • Antonio is a 70-year-old man with a history of high blood pressure and recent symptoms of nocturia, headaches, and fatigue
    • Lab tests reveal high levels of serum creatinine, urea, and potassium, and low levels of sodium and calcium
    • Urinalysis shows proteinuria and hemoglobinuria
    • Diagnosis is severe renal dysfunction, with a GFR of <15 mL/min

    Hyperkalemia

    • Hyperkalemia is a medical emergency characterized by high levels of potassium in the blood
    • Causes of hyperkalemia include potassium shift outside the cells, drugs interfering with potassium balance, and kidney injury
    • Symptoms of hyperkalemia include muscle weakness, paralysis, and cardiac conduction abnormalities
    • Treatment of hyperkalemia includes calcium gluconate, insulin, beta2-adrenergic agonists, and sodium bicarbonate

    Calcium and Phosphorus

    • Calcium and phosphorus are essential for bone health
    • Parathyroid hormone (PTH) is the main calcium regulator
    • PTH increases calcium reabsorption in the kidneys, favors intestinal calcium and phosphorus reabsorption, and increases bone turnover
    • Calcitonin is another hormone involved in calcium regulation, which counteracts the effects of PTH
    • Vitamin D is essential for calcium regulation, and its deficiency can lead to hypocalcemia

    Hypocalcemia

    • Hypocalcemia is a condition characterized by low levels of calcium in the blood
    • Symptoms of hypocalcemia include tetany, seizures, hypotension, and psychiatric manifestations
    • Causes of hypocalcemia include vitamin D deficiency, reduced gastrointestinal reabsorption, chronic kidney disease, and hypomagnesemia
    • Treatment of hypocalcemia includes intravenous and oral calcium, and vitamin D supplements

    Hypercalcemia

    • Hypercalcemia is a condition characterized by high levels of calcium in the blood
    • Symptoms of hypercalcemia include muscle weakness, polyuria, polydipsia, dehydration, nausea, and changes in sensorium
    • Causes of hypercalcemia include hyperparathyroidism, vitamin D intoxication, and cancer
    • Treatment of hypercalcemia includes hydration, diuretics, and bisphosphonates### Hypercalcemia Treatment
    • In medical emergencies, treat the patient first and understand the causes later
    • First treatment: intravenous hydration with isotonic saline and glucose (no calcium)
    • Next, administer subcutaneous calcitonin to lower serum calcium concentration (not available in Italy)
    • Then, give bisphosphonates to the patient
    • Consider the onset and duration of action of these drugs
    • Isotonic saline takes hours to work, bisphosphonates take a lot of hours
    • Loop diuretics can also be used to treat hypercalcemia because they eliminate sodium and calcium
    • Glucocorticoids and dialysis may also be useful

    Factors that Aggravate Hypercalcemia

    • Thiazide diuretics
    • Lithium carbonate
    • Volume depletion
    • Prolonged bed rest or inactivity
    • High-calcium diet (>1000 mg/day)
    • Calcium supplements
    • Vitamin D supplements (>800 IU/day)
    • Multivitamins containing calcium

    Causes of Hypercalcemia

    • Measure parathyroid hormone (PTH) levels after the patient is stabilized
    • If PTH is low, the patient may have a tumor (e.g., multiple myeloma) or paraneoplastic syndrome
    • If PTH is high, the patient may have primary hyperparathyroidism (e.g., tumor of the parathyroid gland)
    • Vitamin D intoxication and granulomatous diseases (e.g., sarcoidosis and TB) can also cause hypercalcemia

    Disorders of Water Balance (Dysnatremias)

    • Dysnatremias are not disorders of sodium balance, but of water balance
    • Sodium concentration is not equal to sodium amount in the body
    • Blood volume depends on sodium content (regulated by RAAS and baroreceptors)
    • Hypovolemia: sodium depletion → decreased blood volume
    • Hypervolemia: sodium increase → increased blood volume

    Sodium Concentration

    • Not related to sodium amount in the body
    • Depends on water balance (regulated by vasopressin and thirst)
    • Hyponatremia: water excess → low sodium concentration
    • Hypernatremia: water deficit → high sodium concentration

    Hyponatremia

    • Most common disorder of body fluid and electrolyte balance
    • Occurs in 1-2% of hospitalized patients and 30% of ICU patients
    • Can lead to various clinical symptoms, from subtle to severe or life-threatening
    • Prompt recognition is crucial, as it increases in-hospital mortality by 40%

    Symptoms of Hyponatremia

    • Expression of central nervous system dysfunction caused by brain cell swelling
    • Acute hyponatremia: reversible if properly treated
    • Chronic hyponatremia: usually asymptomatic or paucisymptomatic

    Causes of Hyponatremia

    • Hypovolemic hyponatremia: extrarenal salt loss (e.g., diuretics, nephropathies, mineralocorticoid deficiencies)
    • Euvolemic hyponatremia: SIADH (syndrome of inappropriate ADH secretion), hypothyroidism, psychogenic polydipsia, adrenocorticotropic deficiency
    • Hypervolemic hyponatremia: heart failure, liver disease, nephrotic syndrome, advanced kidney disease

    Treatment of Hyponatremia

    • Exclude hyperglycemia and pseudohyponatremia
    • Assess severity of symptoms
    • If severe, give 150 mL of 3% hypertonic saline over 20 minutes
    • if asymptomatic, focus on etiology of the disease
    • Avoid rapid correction to prevent osmotic demyelination syndrome### Diabetes Insipidus
    • Can be hereditary (x-linked recessive, defect of V2 receptors or aquaporins) or acquired (electrolyte disorders, certain medications, chronic intestinal kidney disease, malnutrition)
    • Gestational DI: caused by degradation of ADH, occurs in peripheral circulation

    Symptoms of Diabetes Insipidus

    • Altered mental status
    • Lethargy
    • Irritability
    • Restlessness
    • Muscle twitching
    • Hyperreflexia and spasticity
    • Seizures (usually in children)
    • Coma

    Treatment of Hypernatremia

    • Determine volume status (sodium balance)
    • Calculate water deficit
    • Choose a replacement fluid
    • Determine the rate of depletion
    • Estimate ongoing sensible and insensible losses
    • Use the formula: Water deficit = TBW x (Na+s / 140 - 1)
    • Replace water deficit with hypotonic solution (e.g. 5% dextrose)
    • Monitor and adjust rate of repletion

    Key Points of Hypernatremia

    • Always reflects a hyperosmolar state
    • Always a water problem, sometimes a salt problem
    • Requires defect in thirst mechanism or limited access to free water
    • Sodium concentration does not provide information about total body salt or volume status
    • Calculation of water deficit is useful, but represents only a snapshot
    • Use clinical judgment and carefully monitor the patient
    • Consider sensible and insensible losses

    Approach to Glomerular Diseases

    • Simple lab test: serum creatinine
    • Accurate test: measurement of glomerular filtration rate (GFR) through inulin clearance
    • Other methods: use serum creatinine and GFR to assess renal function
    • Urinalysis should be performed in case of altered kidney functionality
    • Recognize nephrological syndromes, which can vary from asymptomatic to severe clinical manifestations

    Glomerular Diseases

    • May present in different clinical forms (nephrological syndromes)
    • Variations depend on combinations of serum creatinine, proteinuria, and alterations of urinary sediment
    • Recognizing the correct syndrome is crucial for treatment and prognosis

    Hematuria

    • Macroscopic hematuria: visible blood in urine
    • Can be symptomatic or asymptomatic, persistent or intermittent
    • Causes: inflammation of urinary bladder, urethra or prostate, urinary infections, kidney stones, polycystic kidney diseases, blood clotting disorders, sickle cell diseases, cancer, trauma
    • Glomerular diseases can cause macroscopic hematuria, especially IgA nephropathy
    • Asymptomatic urinary abnormalities: diagnosis obtained by urinalysis, proteinuria > 150 mg/day, hematuria, and hyaline or hyaline-granular casts
    • Nephrotic syndrome: characterized by proteinuria > 3.5g/day, low serum protein, and low albumin, with edema as the main clinical manifestation

    Introduction to Nephrology

    • Nephrology is the study of kidney function and diseases
    • Kidney function is essential for maintaining overall health

    Kidney Function

    • Kidneys act as filters, clearing the body of waste and toxic substances
    • They monitor and regulate blood pressure through the juxtaglomerular apparatus
    • They produce erythropoietin, which stimulates the production of red blood cells
    • They manage water and salt concentrations in the body, responding to antidiuretic hormone and aldosterone
    • They convert vitamin D to its active form, increasing calcium levels in the body

    Evaluation of Renal Function

    • The best test to evaluate renal function is the glomerular filtration rate (GFR)
    • GFR measures the volume of plasma cleared of a substance in a unit of time (mL/min)
    • An ideal substance to evaluate GFR should be produced endogenously, filtered by the glomerulus, and not reabsorbed or secreted by the renal tubule
    • Inulin is the ideal substance, but it is not produced by the body, so serum creatinine is used instead

    Serum Creatinine

    • Serum creatinine is a waste product that is produced by the body and cleared by the kidneys
    • High levels of serum creatinine indicate impaired kidney function
    • Normal range of serum creatinine is 0.5-1.0 mg/dL
    • Serum creatinine levels are influenced by factors such as aging, diet, and muscle mass

    Glomerular Filtration Rate (GFR)

    • GFR is the volume of plasma cleared of a substance in a unit of time (mL/min)
    • Normal range of GFR is 90-120 mL/min
    • GFR is calculated using serum creatinine levels, urinary volume, and creatinine in urine
    • GFR is influenced by factors such as aging, diet, and muscle mass

    Stages of Kidney Dysfunction

    • G1: normal or high GFR (>90 mL/min/1.73m²)
    • G2: mildly decreased GFR (60-89 mL/min/1.73m²)
    • G3a: mildly to moderately decreased GFR (45-59 mL/min/1.73m²)
    • G3b: moderately to severely decreased GFR (30-44 mL/min/1.73m²)
    • G4: severely decreased GFR (15-20 mL/min/1.73m²)
    • G5: kidney failure (GFR ≤15 mL/min/1.73m²)

    Case Study: Antonio

    • Antonio is a 70-year-old man with a history of high blood pressure and recent symptoms of nocturia, headaches, and fatigue
    • Lab tests reveal high levels of serum creatinine, urea, and potassium, and low levels of sodium and calcium
    • Urinalysis shows proteinuria and hemoglobinuria
    • Diagnosis is severe renal dysfunction, with a GFR of <15 mL/min

    Hyperkalemia

    • Hyperkalemia is a medical emergency characterized by high levels of potassium in the blood
    • Causes of hyperkalemia include potassium shift outside the cells, drugs interfering with potassium balance, and kidney injury
    • Symptoms of hyperkalemia include muscle weakness, paralysis, and cardiac conduction abnormalities
    • Treatment of hyperkalemia includes calcium gluconate, insulin, beta2-adrenergic agonists, and sodium bicarbonate

    Calcium and Phosphorus

    • Calcium and phosphorus are essential for bone health
    • Parathyroid hormone (PTH) is the main calcium regulator
    • PTH increases calcium reabsorption in the kidneys, favors intestinal calcium and phosphorus reabsorption, and increases bone turnover
    • Calcitonin is another hormone involved in calcium regulation, which counteracts the effects of PTH
    • Vitamin D is essential for calcium regulation, and its deficiency can lead to hypocalcemia

    Hypocalcemia

    • Hypocalcemia is a condition characterized by low levels of calcium in the blood
    • Symptoms of hypocalcemia include tetany, seizures, hypotension, and psychiatric manifestations
    • Causes of hypocalcemia include vitamin D deficiency, reduced gastrointestinal reabsorption, chronic kidney disease, and hypomagnesemia
    • Treatment of hypocalcemia includes intravenous and oral calcium, and vitamin D supplements

    Hypercalcemia

    • Hypercalcemia is a condition characterized by high levels of calcium in the blood
    • Symptoms of hypercalcemia include muscle weakness, polyuria, polydipsia, dehydration, nausea, and changes in sensorium
    • Causes of hypercalcemia include hyperparathyroidism, vitamin D intoxication, and cancer
    • Treatment of hypercalcemia includes hydration, diuretics, and bisphosphonates### Hypercalcemia Treatment
    • In medical emergencies, treat the patient first and understand the causes later
    • First treatment: intravenous hydration with isotonic saline and glucose (no calcium)
    • Next, administer subcutaneous calcitonin to lower serum calcium concentration (not available in Italy)
    • Then, give bisphosphonates to the patient
    • Consider the onset and duration of action of these drugs
    • Isotonic saline takes hours to work, bisphosphonates take a lot of hours
    • Loop diuretics can also be used to treat hypercalcemia because they eliminate sodium and calcium
    • Glucocorticoids and dialysis may also be useful

    Factors that Aggravate Hypercalcemia

    • Thiazide diuretics
    • Lithium carbonate
    • Volume depletion
    • Prolonged bed rest or inactivity
    • High-calcium diet (>1000 mg/day)
    • Calcium supplements
    • Vitamin D supplements (>800 IU/day)
    • Multivitamins containing calcium

    Causes of Hypercalcemia

    • Measure parathyroid hormone (PTH) levels after the patient is stabilized
    • If PTH is low, the patient may have a tumor (e.g., multiple myeloma) or paraneoplastic syndrome
    • If PTH is high, the patient may have primary hyperparathyroidism (e.g., tumor of the parathyroid gland)
    • Vitamin D intoxication and granulomatous diseases (e.g., sarcoidosis and TB) can also cause hypercalcemia

    Disorders of Water Balance (Dysnatremias)

    • Dysnatremias are not disorders of sodium balance, but of water balance
    • Sodium concentration is not equal to sodium amount in the body
    • Blood volume depends on sodium content (regulated by RAAS and baroreceptors)
    • Hypovolemia: sodium depletion → decreased blood volume
    • Hypervolemia: sodium increase → increased blood volume

    Sodium Concentration

    • Not related to sodium amount in the body
    • Depends on water balance (regulated by vasopressin and thirst)
    • Hyponatremia: water excess → low sodium concentration
    • Hypernatremia: water deficit → high sodium concentration

    Hyponatremia

    • Most common disorder of body fluid and electrolyte balance
    • Occurs in 1-2% of hospitalized patients and 30% of ICU patients
    • Can lead to various clinical symptoms, from subtle to severe or life-threatening
    • Prompt recognition is crucial, as it increases in-hospital mortality by 40%

    Symptoms of Hyponatremia

    • Expression of central nervous system dysfunction caused by brain cell swelling
    • Acute hyponatremia: reversible if properly treated
    • Chronic hyponatremia: usually asymptomatic or paucisymptomatic

    Causes of Hyponatremia

    • Hypovolemic hyponatremia: extrarenal salt loss (e.g., diuretics, nephropathies, mineralocorticoid deficiencies)
    • Euvolemic hyponatremia: SIADH (syndrome of inappropriate ADH secretion), hypothyroidism, psychogenic polydipsia, adrenocorticotropic deficiency
    • Hypervolemic hyponatremia: heart failure, liver disease, nephrotic syndrome, advanced kidney disease

    Treatment of Hyponatremia

    • Exclude hyperglycemia and pseudohyponatremia
    • Assess severity of symptoms
    • If severe, give 150 mL of 3% hypertonic saline over 20 minutes
    • if asymptomatic, focus on etiology of the disease
    • Avoid rapid correction to prevent osmotic demyelination syndrome### Diabetes Insipidus
    • Can be hereditary (x-linked recessive, defect of V2 receptors or aquaporins) or acquired (electrolyte disorders, certain medications, chronic intestinal kidney disease, malnutrition)
    • Gestational DI: caused by degradation of ADH, occurs in peripheral circulation

    Symptoms of Diabetes Insipidus

    • Altered mental status
    • Lethargy
    • Irritability
    • Restlessness
    • Muscle twitching
    • Hyperreflexia and spasticity
    • Seizures (usually in children)
    • Coma

    Treatment of Hypernatremia

    • Determine volume status (sodium balance)
    • Calculate water deficit
    • Choose a replacement fluid
    • Determine the rate of depletion
    • Estimate ongoing sensible and insensible losses
    • Use the formula: Water deficit = TBW x (Na+s / 140 - 1)
    • Replace water deficit with hypotonic solution (e.g. 5% dextrose)
    • Monitor and adjust rate of repletion

    Key Points of Hypernatremia

    • Always reflects a hyperosmolar state
    • Always a water problem, sometimes a salt problem
    • Requires defect in thirst mechanism or limited access to free water
    • Sodium concentration does not provide information about total body salt or volume status
    • Calculation of water deficit is useful, but represents only a snapshot
    • Use clinical judgment and carefully monitor the patient
    • Consider sensible and insensible losses

    Approach to Glomerular Diseases

    • Simple lab test: serum creatinine
    • Accurate test: measurement of glomerular filtration rate (GFR) through inulin clearance
    • Other methods: use serum creatinine and GFR to assess renal function
    • Urinalysis should be performed in case of altered kidney functionality
    • Recognize nephrological syndromes, which can vary from asymptomatic to severe clinical manifestations

    Glomerular Diseases

    • May present in different clinical forms (nephrological syndromes)
    • Variations depend on combinations of serum creatinine, proteinuria, and alterations of urinary sediment
    • Recognizing the correct syndrome is crucial for treatment and prognosis

    Hematuria

    • Macroscopic hematuria: visible blood in urine
    • Can be symptomatic or asymptomatic, persistent or intermittent
    • Causes: inflammation of urinary bladder, urethra or prostate, urinary infections, kidney stones, polycystic kidney diseases, blood clotting disorders, sickle cell diseases, cancer, trauma
    • Glomerular diseases can cause macroscopic hematuria, especially IgA nephropathy
    • Asymptomatic urinary abnormalities: diagnosis obtained by urinalysis, proteinuria > 150 mg/day, hematuria, and hyaline or hyaline-granular casts
    • Nephrotic syndrome: characterized by proteinuria > 3.5g/day, low serum protein, and low albumin, with edema as the main clinical manifestation

    Introduction to Nephrology

    • Nephrology is the study of kidney function and diseases
    • Kidney function is essential for maintaining overall health

    Kidney Function

    • Kidneys act as filters, clearing the body of waste and toxic substances
    • They monitor and regulate blood pressure through the juxtaglomerular apparatus
    • They produce erythropoietin, which stimulates the production of red blood cells
    • They manage water and salt concentrations in the body, responding to antidiuretic hormone and aldosterone
    • They convert vitamin D to its active form, increasing calcium levels in the body

    Evaluation of Renal Function

    • The best test to evaluate renal function is the glomerular filtration rate (GFR)
    • GFR measures the volume of plasma cleared of a substance in a unit of time (mL/min)
    • An ideal substance to evaluate GFR should be produced endogenously, filtered by the glomerulus, and not reabsorbed or secreted by the renal tubule
    • Inulin is the ideal substance, but it is not produced by the body, so serum creatinine is used instead

    Serum Creatinine

    • Serum creatinine is a waste product that is produced by the body and cleared by the kidneys
    • High levels of serum creatinine indicate impaired kidney function
    • Normal range of serum creatinine is 0.5-1.0 mg/dL
    • Serum creatinine levels are influenced by factors such as aging, diet, and muscle mass

    Glomerular Filtration Rate (GFR)

    • GFR is the volume of plasma cleared of a substance in a unit of time (mL/min)
    • Normal range of GFR is 90-120 mL/min
    • GFR is calculated using serum creatinine levels, urinary volume, and creatinine in urine
    • GFR is influenced by factors such as aging, diet, and muscle mass

    Stages of Kidney Dysfunction

    • G1: normal or high GFR (>90 mL/min/1.73m²)
    • G2: mildly decreased GFR (60-89 mL/min/1.73m²)
    • G3a: mildly to moderately decreased GFR (45-59 mL/min/1.73m²)
    • G3b: moderately to severely decreased GFR (30-44 mL/min/1.73m²)
    • G4: severely decreased GFR (15-20 mL/min/1.73m²)
    • G5: kidney failure (GFR ≤15 mL/min/1.73m²)

    Case Study: Antonio

    • Antonio is a 70-year-old man with a history of high blood pressure and recent symptoms of nocturia, headaches, and fatigue
    • Lab tests reveal high levels of serum creatinine, urea, and potassium, and low levels of sodium and calcium
    • Urinalysis shows proteinuria and hemoglobinuria
    • Diagnosis is severe renal dysfunction, with a GFR of <15 mL/min

    Hyperkalemia

    • Hyperkalemia is a medical emergency characterized by high levels of potassium in the blood
    • Causes of hyperkalemia include potassium shift outside the cells, drugs interfering with potassium balance, and kidney injury
    • Symptoms of hyperkalemia include muscle weakness, paralysis, and cardiac conduction abnormalities
    • Treatment of hyperkalemia includes calcium gluconate, insulin, beta2-adrenergic agonists, and sodium bicarbonate

    Calcium and Phosphorus

    • Calcium and phosphorus are essential for bone health
    • Parathyroid hormone (PTH) is the main calcium regulator
    • PTH increases calcium reabsorption in the kidneys, favors intestinal calcium and phosphorus reabsorption, and increases bone turnover
    • Calcitonin is another hormone involved in calcium regulation, which counteracts the effects of PTH
    • Vitamin D is essential for calcium regulation, and its deficiency can lead to hypocalcemia

    Hypocalcemia

    • Hypocalcemia is a condition characterized by low levels of calcium in the blood
    • Symptoms of hypocalcemia include tetany, seizures, hypotension, and psychiatric manifestations
    • Causes of hypocalcemia include vitamin D deficiency, reduced gastrointestinal reabsorption, chronic kidney disease, and hypomagnesemia
    • Treatment of hypocalcemia includes intravenous and oral calcium, and vitamin D supplements

    Hypercalcemia

    • Hypercalcemia is a condition characterized by high levels of calcium in the blood
    • Symptoms of hypercalcemia include muscle weakness, polyuria, polydipsia, dehydration, nausea, and changes in sensorium
    • Causes of hypercalcemia include hyperparathyroidism, vitamin D intoxication, and cancer
    • Treatment of hypercalcemia includes hydration, diuretics, and bisphosphonates### Hypercalcemia Treatment
    • In medical emergencies, treat the patient first and understand the causes later
    • First treatment: intravenous hydration with isotonic saline and glucose (no calcium)
    • Next, administer subcutaneous calcitonin to lower serum calcium concentration (not available in Italy)
    • Then, give bisphosphonates to the patient
    • Consider the onset and duration of action of these drugs
    • Isotonic saline takes hours to work, bisphosphonates take a lot of hours
    • Loop diuretics can also be used to treat hypercalcemia because they eliminate sodium and calcium
    • Glucocorticoids and dialysis may also be useful

    Factors that Aggravate Hypercalcemia

    • Thiazide diuretics
    • Lithium carbonate
    • Volume depletion
    • Prolonged bed rest or inactivity
    • High-calcium diet (>1000 mg/day)
    • Calcium supplements
    • Vitamin D supplements (>800 IU/day)
    • Multivitamins containing calcium

    Causes of Hypercalcemia

    • Measure parathyroid hormone (PTH) levels after the patient is stabilized
    • If PTH is low, the patient may have a tumor (e.g., multiple myeloma) or paraneoplastic syndrome
    • If PTH is high, the patient may have primary hyperparathyroidism (e.g., tumor of the parathyroid gland)
    • Vitamin D intoxication and granulomatous diseases (e.g., sarcoidosis and TB) can also cause hypercalcemia

    Disorders of Water Balance (Dysnatremias)

    • Dysnatremias are not disorders of sodium balance, but of water balance
    • Sodium concentration is not equal to sodium amount in the body
    • Blood volume depends on sodium content (regulated by RAAS and baroreceptors)
    • Hypovolemia: sodium depletion → decreased blood volume
    • Hypervolemia: sodium increase → increased blood volume

    Sodium Concentration

    • Not related to sodium amount in the body
    • Depends on water balance (regulated by vasopressin and thirst)
    • Hyponatremia: water excess → low sodium concentration
    • Hypernatremia: water deficit → high sodium concentration

    Hyponatremia

    • Most common disorder of body fluid and electrolyte balance
    • Occurs in 1-2% of hospitalized patients and 30% of ICU patients
    • Can lead to various clinical symptoms, from subtle to severe or life-threatening
    • Prompt recognition is crucial, as it increases in-hospital mortality by 40%

    Symptoms of Hyponatremia

    • Expression of central nervous system dysfunction caused by brain cell swelling
    • Acute hyponatremia: reversible if properly treated
    • Chronic hyponatremia: usually asymptomatic or paucisymptomatic

    Causes of Hyponatremia

    • Hypovolemic hyponatremia: extrarenal salt loss (e.g., diuretics, nephropathies, mineralocorticoid deficiencies)
    • Euvolemic hyponatremia: SIADH (syndrome of inappropriate ADH secretion), hypothyroidism, psychogenic polydipsia, adrenocorticotropic deficiency
    • Hypervolemic hyponatremia: heart failure, liver disease, nephrotic syndrome, advanced kidney disease

    Treatment of Hyponatremia

    • Exclude hyperglycemia and pseudohyponatremia
    • Assess severity of symptoms
    • If severe, give 150 mL of 3% hypertonic saline over 20 minutes
    • if asymptomatic, focus on etiology of the disease
    • Avoid rapid correction to prevent osmotic demyelination syndrome### Diabetes Insipidus
    • Can be hereditary (x-linked recessive, defect of V2 receptors or aquaporins) or acquired (electrolyte disorders, certain medications, chronic intestinal kidney disease, malnutrition)
    • Gestational DI: caused by degradation of ADH, occurs in peripheral circulation

    Symptoms of Diabetes Insipidus

    • Altered mental status
    • Lethargy
    • Irritability
    • Restlessness
    • Muscle twitching
    • Hyperreflexia and spasticity
    • Seizures (usually in children)
    • Coma

    Treatment of Hypernatremia

    • Determine volume status (sodium balance)
    • Calculate water deficit
    • Choose a replacement fluid
    • Determine the rate of depletion
    • Estimate ongoing sensible and insensible losses
    • Use the formula: Water deficit = TBW x (Na+s / 140 - 1)
    • Replace water deficit with hypotonic solution (e.g. 5% dextrose)
    • Monitor and adjust rate of repletion

    Key Points of Hypernatremia

    • Always reflects a hyperosmolar state
    • Always a water problem, sometimes a salt problem
    • Requires defect in thirst mechanism or limited access to free water
    • Sodium concentration does not provide information about total body salt or volume status
    • Calculation of water deficit is useful, but represents only a snapshot
    • Use clinical judgment and carefully monitor the patient
    • Consider sensible and insensible losses

    Approach to Glomerular Diseases

    • Simple lab test: serum creatinine
    • Accurate test: measurement of glomerular filtration rate (GFR) through inulin clearance
    • Other methods: use serum creatinine and GFR to assess renal function
    • Urinalysis should be performed in case of altered kidney functionality
    • Recognize nephrological syndromes, which can vary from asymptomatic to severe clinical manifestations

    Glomerular Diseases

    • May present in different clinical forms (nephrological syndromes)
    • Variations depend on combinations of serum creatinine, proteinuria, and alterations of urinary sediment
    • Recognizing the correct syndrome is crucial for treatment and prognosis

    Hematuria

    • Macroscopic hematuria: visible blood in urine
    • Can be symptomatic or asymptomatic, persistent or intermittent
    • Causes: inflammation of urinary bladder, urethra or prostate, urinary infections, kidney stones, polycystic kidney diseases, blood clotting disorders, sickle cell diseases, cancer, trauma
    • Glomerular diseases can cause macroscopic hematuria, especially IgA nephropathy
    • Asymptomatic urinary abnormalities: diagnosis obtained by urinalysis, proteinuria > 150 mg/day, hematuria, and hyaline or hyaline-granular casts
    • Nephrotic syndrome: characterized by proteinuria > 3.5g/day, low serum protein, and low albumin, with edema as the main clinical manifestation

    Introduction to Nephrology

    • Nephrology is the study of kidney function and diseases
    • Kidney function is essential for maintaining overall health

    Kidney Function

    • Kidneys act as filters, clearing the body of waste and toxic substances
    • They monitor and regulate blood pressure through the juxtaglomerular apparatus
    • They produce erythropoietin, which stimulates the production of red blood cells
    • They manage water and salt concentrations in the body, responding to antidiuretic hormone and aldosterone
    • They convert vitamin D to its active form, increasing calcium levels in the body

    Evaluation of Renal Function

    • The best test to evaluate renal function is the glomerular filtration rate (GFR)
    • GFR measures the volume of plasma cleared of a substance in a unit of time (mL/min)
    • An ideal substance to evaluate GFR should be produced endogenously, filtered by the glomerulus, and not reabsorbed or secreted by the renal tubule
    • Inulin is the ideal substance, but it is not produced by the body, so serum creatinine is used instead

    Serum Creatinine

    • Serum creatinine is a waste product that is produced by the body and cleared by the kidneys
    • High levels of serum creatinine indicate impaired kidney function
    • Normal range of serum creatinine is 0.5-1.0 mg/dL
    • Serum creatinine levels are influenced by factors such as aging, diet, and muscle mass

    Glomerular Filtration Rate (GFR)

    • GFR is the volume of plasma cleared of a substance in a unit of time (mL/min)
    • Normal range of GFR is 90-120 mL/min
    • GFR is calculated using serum creatinine levels, urinary volume, and creatinine in urine
    • GFR is influenced by factors such as aging, diet, and muscle mass

    Stages of Kidney Dysfunction

    • G1: normal or high GFR (>90 mL/min/1.73m²)
    • G2: mildly decreased GFR (60-89 mL/min/1.73m²)
    • G3a: mildly to moderately decreased GFR (45-59 mL/min/1.73m²)
    • G3b: moderately to severely decreased GFR (30-44 mL/min/1.73m²)
    • G4: severely decreased GFR (15-20 mL/min/1.73m²)
    • G5: kidney failure (GFR ≤15 mL/min/1.73m²)

    Case Study: Antonio

    • Antonio is a 70-year-old man with a history of high blood pressure and recent symptoms of nocturia, headaches, and fatigue
    • Lab tests reveal high levels of serum creatinine, urea, and potassium, and low levels of sodium and calcium
    • Urinalysis shows proteinuria and hemoglobinuria
    • Diagnosis is severe renal dysfunction, with a GFR of <15 mL/min

    Hyperkalemia

    • Hyperkalemia is a medical emergency characterized by high levels of potassium in the blood
    • Causes of hyperkalemia include potassium shift outside the cells, drugs interfering with potassium balance, and kidney injury
    • Symptoms of hyperkalemia include muscle weakness, paralysis, and cardiac conduction abnormalities
    • Treatment of hyperkalemia includes calcium gluconate, insulin, beta2-adrenergic agonists, and sodium bicarbonate

    Calcium and Phosphorus

    • Calcium and phosphorus are essential for bone health
    • Parathyroid hormone (PTH) is the main calcium regulator
    • PTH increases calcium reabsorption in the kidneys, favors intestinal calcium and phosphorus reabsorption, and increases bone turnover
    • Calcitonin is another hormone involved in calcium regulation, which counteracts the effects of PTH
    • Vitamin D is essential for calcium regulation, and its deficiency can lead to hypocalcemia

    Hypocalcemia

    • Hypocalcemia is a condition characterized by low levels of calcium in the blood
    • Symptoms of hypocalcemia include tetany, seizures, hypotension, and psychiatric manifestations
    • Causes of hypocalcemia include vitamin D deficiency, reduced gastrointestinal reabsorption, chronic kidney disease, and hypomagnesemia
    • Treatment of hypocalcemia includes intravenous and oral calcium, and vitamin D supplements

    Hypercalcemia

    • Hypercalcemia is a condition characterized by high levels of calcium in the blood
    • Symptoms of hypercalcemia include muscle weakness, polyuria, polydipsia, dehydration, nausea, and changes in sensorium
    • Causes of hypercalcemia include hyperparathyroidism, vitamin D intoxication, and cancer
    • Treatment of hypercalcemia includes hydration, diuretics, and bisphosphonates### Hypercalcemia Treatment
    • In medical emergencies, treat the patient first and understand the causes later
    • First treatment: intravenous hydration with isotonic saline and glucose (no calcium)
    • Next, administer subcutaneous calcitonin to lower serum calcium concentration (not available in Italy)
    • Then, give bisphosphonates to the patient
    • Consider the onset and duration of action of these drugs
    • Isotonic saline takes hours to work, bisphosphonates take a lot of hours
    • Loop diuretics can also be used to treat hypercalcemia because they eliminate sodium and calcium
    • Glucocorticoids and dialysis may also be useful

    Factors that Aggravate Hypercalcemia

    • Thiazide diuretics
    • Lithium carbonate
    • Volume depletion
    • Prolonged bed rest or inactivity
    • High-calcium diet (>1000 mg/day)
    • Calcium supplements
    • Vitamin D supplements (>800 IU/day)
    • Multivitamins containing calcium

    Causes of Hypercalcemia

    • Measure parathyroid hormone (PTH) levels after the patient is stabilized
    • If PTH is low, the patient may have a tumor (e.g., multiple myeloma) or paraneoplastic syndrome
    • If PTH is high, the patient may have primary hyperparathyroidism (e.g., tumor of the parathyroid gland)
    • Vitamin D intoxication and granulomatous diseases (e.g., sarcoidosis and TB) can also cause hypercalcemia

    Disorders of Water Balance (Dysnatremias)

    • Dysnatremias are not disorders of sodium balance, but of water balance
    • Sodium concentration is not equal to sodium amount in the body
    • Blood volume depends on sodium content (regulated by RAAS and baroreceptors)
    • Hypovolemia: sodium depletion → decreased blood volume
    • Hypervolemia: sodium increase → increased blood volume

    Sodium Concentration

    • Not related to sodium amount in the body
    • Depends on water balance (regulated by vasopressin and thirst)
    • Hyponatremia: water excess → low sodium concentration
    • Hypernatremia: water deficit → high sodium concentration

    Hyponatremia

    • Most common disorder of body fluid and electrolyte balance
    • Occurs in 1-2% of hospitalized patients and 30% of ICU patients
    • Can lead to various clinical symptoms, from subtle to severe or life-threatening
    • Prompt recognition is crucial, as it increases in-hospital mortality by 40%

    Symptoms of Hyponatremia

    • Expression of central nervous system dysfunction caused by brain cell swelling
    • Acute hyponatremia: reversible if properly treated
    • Chronic hyponatremia: usually asymptomatic or paucisymptomatic

    Causes of Hyponatremia

    • Hypovolemic hyponatremia: extrarenal salt loss (e.g., diuretics, nephropathies, mineralocorticoid deficiencies)
    • Euvolemic hyponatremia: SIADH (syndrome of inappropriate ADH secretion), hypothyroidism, psychogenic polydipsia, adrenocorticotropic deficiency
    • Hypervolemic hyponatremia: heart failure, liver disease, nephrotic syndrome, advanced kidney disease

    Treatment of Hyponatremia

    • Exclude hyperglycemia and pseudohyponatremia
    • Assess severity of symptoms
    • If severe, give 150 mL of 3% hypertonic saline over 20 minutes
    • if asymptomatic, focus on etiology of the disease
    • Avoid rapid correction to prevent osmotic demyelination syndrome### Diabetes Insipidus
    • Can be hereditary (x-linked recessive, defect of V2 receptors or aquaporins) or acquired (electrolyte disorders, certain medications, chronic intestinal kidney disease, malnutrition)
    • Gestational DI: caused by degradation of ADH, occurs in peripheral circulation

    Symptoms of Diabetes Insipidus

    • Altered mental status
    • Lethargy
    • Irritability
    • Restlessness
    • Muscle twitching
    • Hyperreflexia and spasticity
    • Seizures (usually in children)
    • Coma

    Treatment of Hypernatremia

    • Determine volume status (sodium balance)
    • Calculate water deficit
    • Choose a replacement fluid
    • Determine the rate of depletion
    • Estimate ongoing sensible and insensible losses
    • Use the formula: Water deficit = TBW x (Na+s / 140 - 1)
    • Replace water deficit with hypotonic solution (e.g. 5% dextrose)
    • Monitor and adjust rate of repletion

    Key Points of Hypernatremia

    • Always reflects a hyperosmolar state
    • Always a water problem, sometimes a salt problem
    • Requires defect in thirst mechanism or limited access to free water
    • Sodium concentration does not provide information about total body salt or volume status
    • Calculation of water deficit is useful, but represents only a snapshot
    • Use clinical judgment and carefully monitor the patient
    • Consider sensible and insensible losses

    Approach to Glomerular Diseases

    • Simple lab test: serum creatinine
    • Accurate test: measurement of glomerular filtration rate (GFR) through inulin clearance
    • Other methods: use serum creatinine and GFR to assess renal function
    • Urinalysis should be performed in case of altered kidney functionality
    • Recognize nephrological syndromes, which can vary from asymptomatic to severe clinical manifestations

    Glomerular Diseases

    • May present in different clinical forms (nephrological syndromes)
    • Variations depend on combinations of serum creatinine, proteinuria, and alterations of urinary sediment
    • Recognizing the correct syndrome is crucial for treatment and prognosis

    Hematuria

    • Macroscopic hematuria: visible blood in urine
    • Can be symptomatic or asymptomatic, persistent or intermittent
    • Causes: inflammation of urinary bladder, urethra or prostate, urinary infections, kidney stones, polycystic kidney diseases, blood clotting disorders, sickle cell diseases, cancer, trauma
    • Glomerular diseases can cause macroscopic hematuria, especially IgA nephropathy
    • Asymptomatic urinary abnormalities: diagnosis obtained by urinalysis, proteinuria > 150 mg/day, hematuria, and hyaline or hyaline-granular casts
    • Nephrotic syndrome: characterized by proteinuria > 3.5g/day, low serum protein, and low albumin, with edema as the main clinical manifestation

    Introduction to Nephrology

    • Nephrology is the study of kidney function and diseases
    • Kidney function is essential for maintaining overall health

    Kidney Function

    • Kidneys act as filters, clearing the body of waste and toxic substances
    • They monitor and regulate blood pressure through the juxtaglomerular apparatus
    • They produce erythropoietin, which stimulates the production of red blood cells
    • They manage water and salt concentrations in the body, responding to antidiuretic hormone and aldosterone
    • They convert vitamin D to its active form, increasing calcium levels in the body

    Evaluation of Renal Function

    • The best test to evaluate renal function is the glomerular filtration rate (GFR)
    • GFR measures the volume of plasma cleared of a substance in a unit of time (mL/min)
    • An ideal substance to evaluate GFR should be produced endogenously, filtered by the glomerulus, and not reabsorbed or secreted by the renal tubule
    • Inulin is the ideal substance, but it is not produced by the body, so serum creatinine is used instead

    Serum Creatinine

    • Serum creatinine is a waste product that is produced by the body and cleared by the kidneys
    • High levels of serum creatinine indicate impaired kidney function
    • Normal range of serum creatinine is 0.5-1.0 mg/dL
    • Serum creatinine levels are influenced by factors such as aging, diet, and muscle mass

    Glomerular Filtration Rate (GFR)

    • GFR is the volume of plasma cleared of a substance in a unit of time (mL/min)
    • Normal range of GFR is 90-120 mL/min
    • GFR is calculated using serum creatinine levels, urinary volume, and creatinine in urine
    • GFR is influenced by factors such as aging, diet, and muscle mass

    Stages of Kidney Dysfunction

    • G1: normal or high GFR (>90 mL/min/1.73m²)
    • G2: mildly decreased GFR (60-89 mL/min/1.73m²)
    • G3a: mildly to moderately decreased GFR (45-59 mL/min/1.73m²)
    • G3b: moderately to severely decreased GFR (30-44 mL/min/1.73m²)
    • G4: severely decreased GFR (15-20 mL/min/1.73m²)
    • G5: kidney failure (GFR ≤15 mL/min/1.73m²)

    Case Study: Antonio

    • Antonio is a 70-year-old man with a history of high blood pressure and recent symptoms of nocturia, headaches, and fatigue
    • Lab tests reveal high levels of serum creatinine, urea, and potassium, and low levels of sodium and calcium
    • Urinalysis shows proteinuria and hemoglobinuria
    • Diagnosis is severe renal dysfunction, with a GFR of <15 mL/min

    Hyperkalemia

    • Hyperkalemia is a medical emergency characterized by high levels of potassium in the blood
    • Causes of hyperkalemia include potassium shift outside the cells, drugs interfering with potassium balance, and kidney injury
    • Symptoms of hyperkalemia include muscle weakness, paralysis, and cardiac conduction abnormalities
    • Treatment of hyperkalemia includes calcium gluconate, insulin, beta2-adrenergic agonists, and sodium bicarbonate

    Calcium and Phosphorus

    • Calcium and phosphorus are essential for bone health
    • Parathyroid hormone (PTH) is the main calcium regulator
    • PTH increases calcium reabsorption in the kidneys, favors intestinal calcium and phosphorus reabsorption, and increases bone turnover
    • Calcitonin is another hormone involved in calcium regulation, which counteracts the effects of PTH
    • Vitamin D is essential for calcium regulation, and its deficiency can lead to hypocalcemia

    Hypocalcemia

    • Hypocalcemia is a condition characterized by low levels of calcium in the blood
    • Symptoms of hypocalcemia include tetany, seizures, hypotension, and psychiatric manifestations
    • Causes of hypocalcemia include vitamin D deficiency, reduced gastrointestinal reabsorption, chronic kidney disease, and hypomagnesemia
    • Treatment of hypocalcemia includes intravenous and oral calcium, and vitamin D supplements

    Hypercalcemia

    • Hypercalcemia is a condition characterized by high levels of calcium in the blood
    • Symptoms of hypercalcemia include muscle weakness, polyuria, polydipsia, dehydration, nausea, and changes in sensorium
    • Causes of hypercalcemia include hyperparathyroidism, vitamin D intoxication, and cancer
    • Treatment of hypercalcemia includes hydration, diuretics, and bisphosphonates### Hypercalcemia Treatment
    • In medical emergencies, treat the patient first and understand the causes later
    • First treatment: intravenous hydration with isotonic saline and glucose (no calcium)
    • Next, administer subcutaneous calcitonin to lower serum calcium concentration (not available in Italy)
    • Then, give bisphosphonates to the patient
    • Consider the onset and duration of action of these drugs
    • Isotonic saline takes hours to work, bisphosphonates take a lot of hours
    • Loop diuretics can also be used to treat hypercalcemia because they eliminate sodium and calcium
    • Glucocorticoids and dialysis may also be useful

    Factors that Aggravate Hypercalcemia

    • Thiazide diuretics
    • Lithium carbonate
    • Volume depletion
    • Prolonged bed rest or inactivity
    • High-calcium diet (>1000 mg/day)
    • Calcium supplements
    • Vitamin D supplements (>800 IU/day)
    • Multivitamins containing calcium

    Causes of Hypercalcemia

    • Measure parathyroid hormone (PTH) levels after the patient is stabilized
    • If PTH is low, the patient may have a tumor (e.g., multiple myeloma) or paraneoplastic syndrome
    • If PTH is high, the patient may have primary hyperparathyroidism (e.g., tumor of the parathyroid gland)
    • Vitamin D intoxication and granulomatous diseases (e.g., sarcoidosis and TB) can also cause hypercalcemia

    Disorders of Water Balance (Dysnatremias)

    • Dysnatremias are not disorders of sodium balance, but of water balance
    • Sodium concentration is not equal to sodium amount in the body
    • Blood volume depends on sodium content (regulated by RAAS and baroreceptors)
    • Hypovolemia: sodium depletion → decreased blood volume
    • Hypervolemia: sodium increase → increased blood volume

    Sodium Concentration

    • Not related to sodium amount in the body
    • Depends on water balance (regulated by vasopressin and thirst)
    • Hyponatremia: water excess → low sodium concentration
    • Hypernatremia: water deficit → high sodium concentration

    Hyponatremia

    • Most common disorder of body fluid and electrolyte balance
    • Occurs in 1-2% of hospitalized patients and 30% of ICU patients
    • Can lead to various clinical symptoms, from subtle to severe or life-threatening
    • Prompt recognition is crucial, as it increases in-hospital mortality by 40%

    Symptoms of Hyponatremia

    • Expression of central nervous system dysfunction caused by brain cell swelling
    • Acute hyponatremia: reversible if properly treated
    • Chronic hyponatremia: usually asymptomatic or paucisymptomatic

    Causes of Hyponatremia

    • Hypovolemic hyponatremia: extrarenal salt loss (e.g., diuretics, nephropathies, mineralocorticoid deficiencies)
    • Euvolemic hyponatremia: SIADH (syndrome of inappropriate ADH secretion), hypothyroidism, psychogenic polydipsia, adrenocorticotropic deficiency
    • Hypervolemic hyponatremia: heart failure, liver disease, nephrotic syndrome, advanced kidney disease

    Treatment of Hyponatremia

    • Exclude hyperglycemia and pseudohyponatremia
    • Assess severity of symptoms
    • If severe, give 150 mL of 3% hypertonic saline over 20 minutes
    • if asymptomatic, focus on etiology of the disease
    • Avoid rapid correction to prevent osmotic demyelination syndrome### Diabetes Insipidus
    • Can be hereditary (x-linked recessive, defect of V2 receptors or aquaporins) or acquired (electrolyte disorders, certain medications, chronic intestinal kidney disease, malnutrition)
    • Gestational DI: caused by degradation of ADH, occurs in peripheral circulation

    Symptoms of Diabetes Insipidus

    • Altered mental status
    • Lethargy
    • Irritability
    • Restlessness
    • Muscle twitching
    • Hyperreflexia and spasticity
    • Seizures (usually in children)
    • Coma

    Treatment of Hypernatremia

    • Determine volume status (sodium balance)
    • Calculate water deficit
    • Choose a replacement fluid
    • Determine the rate of depletion
    • Estimate ongoing sensible and insensible losses
    • Use the formula: Water deficit = TBW x (Na+s / 140 - 1)
    • Replace water deficit with hypotonic solution (e.g. 5% dextrose)
    • Monitor and adjust rate of repletion

    Key Points of Hypernatremia

    • Always reflects a hyperosmolar state
    • Always a water problem, sometimes a salt problem
    • Requires defect in thirst mechanism or limited access to free water
    • Sodium concentration does not provide information about total body salt or volume status
    • Calculation of water deficit is useful, but represents only a snapshot
    • Use clinical judgment and carefully monitor the patient
    • Consider sensible and insensible losses

    Approach to Glomerular Diseases

    • Simple lab test: serum creatinine
    • Accurate test: measurement of glomerular filtration rate (GFR) through inulin clearance
    • Other methods: use serum creatinine and GFR to assess renal function
    • Urinalysis should be performed in case of altered kidney functionality
    • Recognize nephrological syndromes, which can vary from asymptomatic to severe clinical manifestations

    Glomerular Diseases

    • May present in different clinical forms (nephrological syndromes)
    • Variations depend on combinations of serum creatinine, proteinuria, and alterations of urinary sediment
    • Recognizing the correct syndrome is crucial for treatment and prognosis

    Hematuria

    • Macroscopic hematuria: visible blood in urine
    • Can be symptomatic or asymptomatic, persistent or intermittent
    • Causes: inflammation of urinary bladder, urethra or prostate, urinary infections, kidney stones, polycystic kidney diseases, blood clotting disorders, sickle cell diseases, cancer, trauma
    • Glomerular diseases can cause macroscopic hematuria, especially IgA nephropathy
    • Asymptomatic urinary abnormalities: diagnosis obtained by urinalysis, proteinuria > 150 mg/day, hematuria, and hyaline or hyaline-granular casts
    • Nephrotic syndrome: characterized by proteinuria > 3.5g/day, low serum protein, and low albumin, with edema as the main clinical manifestation

    Introduction to Nephrology

    • Nephrology is the study of kidney function and diseases
    • Kidney function is essential for maintaining overall health

    Kidney Function

    • Kidneys act as filters, clearing the body of waste and toxic substances
    • They monitor and regulate blood pressure through the juxtaglomerular apparatus
    • They produce erythropoietin, which stimulates the production of red blood cells
    • They manage water and salt concentrations in the body, responding to antidiuretic hormone and aldosterone
    • They convert vitamin D to its active form, increasing calcium levels in the body

    Evaluation of Renal Function

    • The best test to evaluate renal function is the glomerular filtration rate (GFR)
    • GFR measures the volume of plasma cleared of a substance in a unit of time (mL/min)
    • An ideal substance to evaluate GFR should be produced endogenously, filtered by the glomerulus, and not reabsorbed or secreted by the renal tubule
    • Inulin is the ideal substance, but it is not produced by the body, so serum creatinine is used instead

    Serum Creatinine

    • Serum creatinine is a waste product that is produced by the body and cleared by the kidneys
    • High levels of serum creatinine indicate impaired kidney function
    • Normal range of serum creatinine is 0.5-1.0 mg/dL
    • Serum creatinine levels are influenced by factors such as aging, diet, and muscle mass

    Glomerular Filtration Rate (GFR)

    • GFR is the volume of plasma cleared of a substance in a unit of time (mL/min)
    • Normal range of GFR is 90-120 mL/min
    • GFR is calculated using serum creatinine levels, urinary volume, and creatinine in urine
    • GFR is influenced by factors such as aging, diet, and muscle mass

    Stages of Kidney Dysfunction

    • G1: normal or high GFR (>90 mL/min/1.73m²)
    • G2: mildly decreased GFR (60-89 mL/min/1.73m²)
    • G3a: mildly to moderately decreased GFR (45-59 mL/min/1.73m²)
    • G3b: moderately to severely decreased GFR (30-44 mL/min/1.73m²)
    • G4: severely decreased GFR (15-20 mL/min/1.73m²)
    • G5: kidney failure (GFR ≤15 mL/min/1.73m²)

    Case Study: Antonio

    • Antonio is a 70-year-old man with a history of high blood pressure and recent symptoms of nocturia, headaches, and fatigue
    • Lab tests reveal high levels of serum creatinine, urea, and potassium, and low levels of sodium and calcium
    • Urinalysis shows proteinuria and hemoglobinuria
    • Diagnosis is severe renal dysfunction, with a GFR of <15 mL/min

    Hyperkalemia

    • Hyperkalemia is a medical emergency characterized by high levels of potassium in the blood
    • Causes of hyperkalemia include potassium shift outside the cells, drugs interfering with potassium balance, and kidney injury
    • Symptoms of hyperkalemia include muscle weakness, paralysis, and cardiac conduction abnormalities
    • Treatment of hyperkalemia includes calcium gluconate, insulin, beta2-adrenergic agonists, and sodium bicarbonate

    Calcium and Phosphorus

    • Calcium and phosphorus are essential for bone health
    • Parathyroid hormone (PTH) is the main calcium regulator
    • PTH increases calcium reabsorption in the kidneys, favors intestinal calcium and phosphorus reabsorption, and increases bone turnover
    • Calcitonin is another hormone involved in calcium regulation, which counteracts the effects of PTH
    • Vitamin D is essential for calcium regulation, and its deficiency can lead to hypocalcemia

    Hypocalcemia

    • Hypocalcemia is a condition characterized by low levels of calcium in the blood
    • Symptoms of hypocalcemia include tetany, seizures, hypotension, and psychiatric manifestations
    • Causes of hypocalcemia include vitamin D deficiency, reduced gastrointestinal reabsorption, chronic kidney disease, and hypomagnesemia
    • Treatment of hypocalcemia includes intravenous and oral calcium, and vitamin D supplements

    Hypercalcemia

    • Hypercalcemia is a condition characterized by high levels of calcium in the blood
    • Symptoms of hypercalcemia include muscle weakness, polyuria, polydipsia, dehydration, nausea, and changes in sensorium
    • Causes of hypercalcemia include hyperparathyroidism, vitamin D intoxication, and cancer
    • Treatment of hypercalcemia includes hydration, diuretics, and bisphosphonates### Hypercalcemia Treatment
    • In medical emergencies, treat the patient first and understand the causes later
    • First treatment: intravenous hydration with isotonic saline and glucose (no calcium)
    • Next, administer subcutaneous calcitonin to lower serum calcium concentration (not available in Italy)
    • Then, give bisphosphonates to the patient
    • Consider the onset and duration of action of these drugs
    • Isotonic saline takes hours to work, bisphosphonates take a lot of hours
    • Loop diuretics can also be used to treat hypercalcemia because they eliminate sodium and calcium
    • Glucocorticoids and dialysis may also be useful

    Factors that Aggravate Hypercalcemia

    • Thiazide diuretics
    • Lithium carbonate
    • Volume depletion
    • Prolonged bed rest or inactivity
    • High-calcium diet (>1000 mg/day)
    • Calcium supplements
    • Vitamin D supplements (>800 IU/day)
    • Multivitamins containing calcium

    Causes of Hypercalcemia

    • Measure parathyroid hormone (PTH) levels after the patient is stabilized
    • If PTH is low, the patient may have a tumor (e.g., multiple myeloma) or paraneoplastic syndrome
    • If PTH is high, the patient may have primary hyperparathyroidism (e.g., tumor of the parathyroid gland)
    • Vitamin D intoxication and granulomatous diseases (e.g., sarcoidosis and TB) can also cause hypercalcemia

    Disorders of Water Balance (Dysnatremias)

    • Dysnatremias are not disorders of sodium balance, but of water balance
    • Sodium concentration is not equal to sodium amount in the body
    • Blood volume depends on sodium content (regulated by RAAS and baroreceptors)
    • Hypovolemia: sodium depletion → decreased blood volume
    • Hypervolemia: sodium increase → increased blood volume

    Sodium Concentration

    • Not related to sodium amount in the body
    • Depends on water balance (regulated by vasopressin and thirst)
    • Hyponatremia: water excess → low sodium concentration
    • Hypernatremia: water deficit → high sodium concentration

    Hyponatremia

    • Most common disorder of body fluid and electrolyte balance
    • Occurs in 1-2% of hospitalized patients and 30% of ICU patients
    • Can lead to various clinical symptoms, from subtle to severe or life-threatening
    • Prompt recognition is crucial, as it increases in-hospital mortality by 40%

    Symptoms of Hyponatremia

    • Expression of central nervous system dysfunction caused by brain cell swelling
    • Acute hyponatremia: reversible if properly treated
    • Chronic hyponatremia: usually asymptomatic or paucisymptomatic

    Causes of Hyponatremia

    • Hypovolemic hyponatremia: extrarenal salt loss (e.g., diuretics, nephropathies, mineralocorticoid deficiencies)
    • Euvolemic hyponatremia: SIADH (syndrome of inappropriate ADH secretion), hypothyroidism, psychogenic polydipsia, adrenocorticotropic deficiency
    • Hypervolemic hyponatremia: heart failure, liver disease, nephrotic syndrome, advanced kidney disease

    Treatment of Hyponatremia

    • Exclude hyperglycemia and pseudohyponatremia
    • Assess severity of symptoms
    • If severe, give 150 mL of 3% hypertonic saline over 20 minutes
    • if asymptomatic, focus on etiology of the disease
    • Avoid rapid correction to prevent osmotic demyelination syndrome### Diabetes Insipidus
    • Can be hereditary (x-linked recessive, defect of V2 receptors or aquaporins) or acquired (electrolyte disorders, certain medications, chronic intestinal kidney disease, malnutrition)
    • Gestational DI: caused by degradation of ADH, occurs in peripheral circulation

    Symptoms of Diabetes Insipidus

    • Altered mental status
    • Lethargy
    • Irritability
    • Restlessness
    • Muscle twitching
    • Hyperreflexia and spasticity
    • Seizures (usually in children)
    • Coma

    Treatment of Hypernatremia

    • Determine volume status (sodium balance)
    • Calculate water deficit
    • Choose a replacement fluid
    • Determine the rate of depletion
    • Estimate ongoing sensible and insensible losses
    • Use the formula: Water deficit = TBW x (Na+s / 140 - 1)
    • Replace water deficit with hypotonic solution (e.g. 5% dextrose)
    • Monitor and adjust rate of repletion

    Key Points of Hypernatremia

    • Always reflects a hyperosmolar state
    • Always a water problem, sometimes a salt problem
    • Requires defect in thirst mechanism or limited access to free water
    • Sodium concentration does not provide information about total body salt or volume status
    • Calculation of water deficit is useful, but represents only a snapshot
    • Use clinical judgment and carefully monitor the patient
    • Consider sensible and insensible losses

    Approach to Glomerular Diseases

    • Simple lab test: serum creatinine
    • Accurate test: measurement of glomerular filtration rate (GFR) through inulin clearance
    • Other methods: use serum creatinine and GFR to assess renal function
    • Urinalysis should be performed in case of altered kidney functionality
    • Recognize nephrological syndromes, which can vary from asymptomatic to severe clinical manifestations

    Glomerular Diseases

    • May present in different clinical forms (nephrological syndromes)
    • Variations depend on combinations of serum creatinine, proteinuria, and alterations of urinary sediment
    • Recognizing the correct syndrome is crucial for treatment and prognosis

    Hematuria

    • Macroscopic hematuria: visible blood in urine
    • Can be symptomatic or asymptomatic, persistent or intermittent
    • Causes: inflammation of urinary bladder, urethra or prostate, urinary infections, kidney stones, polycystic kidney diseases, blood clotting disorders, sickle cell diseases, cancer, trauma
    • Glomerular diseases can cause macroscopic hematuria, especially IgA nephropathy
    • Asymptomatic urinary abnormalities: diagnosis obtained by urinalysis, proteinuria > 150 mg/day, hematuria, and hyaline or hyaline-granular casts
    • Nephrotic syndrome: characterized by proteinuria > 3.5g/day, low serum protein, and low albumin, with edema as the main clinical manifestation

    Introduction to Nephrology

    • Nephrology is the study of kidney function and diseases
    • Kidney function is essential for maintaining overall health

    Kidney Function

    • Kidneys act as filters, clearing the body of waste and toxic substances
    • They monitor and regulate blood pressure through the juxtaglomerular apparatus
    • They produce erythropoietin, which stimulates the production of red blood cells
    • They manage water and salt concentrations in the body, responding to antidiuretic hormone and aldosterone
    • They convert vitamin D to its active form, increasing calcium levels in the body

    Evaluation of Renal Function

    • The best test to evaluate renal function is the glomerular filtration rate (GFR)
    • GFR measures the volume of plasma cleared of a substance in a unit of time (mL/min)
    • An ideal substance to evaluate GFR should be produced endogenously, filtered by the glomerulus, and not reabsorbed or secreted by the renal tubule
    • Inulin is the ideal substance, but it is not produced by the body, so serum creatinine is used instead

    Serum Creatinine

    • Serum creatinine is a waste product that is produced by the body and cleared by the kidneys
    • High levels of serum creatinine indicate impaired kidney function
    • Normal range of serum creatinine is 0.5-1.0 mg/dL
    • Serum creatinine levels are influenced by factors such as aging, diet, and muscle mass

    Glomerular Filtration Rate (GFR)

    • GFR is the volume of plasma cleared of a substance in a unit of time (mL/min)
    • Normal range of GFR is 90-120 mL/min
    • GFR is calculated using serum creatinine levels, urinary volume, and creatinine in urine
    • GFR is influenced by factors such as aging, diet, and muscle mass

    Stages of Kidney Dysfunction

    • G1: normal or high GFR (>90 mL/min/1.73m²)
    • G2: mildly decreased GFR (60-89 mL/min/1.73m²)
    • G3a: mildly to moderately decreased GFR (45-59 mL/min/1.73m²)
    • G3b: moderately to severely decreased GFR (30-44 mL/min/1.73m²)
    • G4: severely decreased GFR (15-20 mL/min/1.73m²)
    • G5: kidney failure (GFR ≤15 mL/min/1.73m²)

    Case Study: Antonio

    • Antonio is a 70-year-old man with a history of high blood pressure and recent symptoms of nocturia, headaches, and fatigue
    • Lab tests reveal high levels of serum creatinine, urea, and potassium, and low levels of sodium and calcium
    • Urinalysis shows proteinuria and hemoglobinuria
    • Diagnosis is severe renal dysfunction, with a GFR of <15 mL/min

    Hyperkalemia

    • Hyperkalemia is a medical emergency characterized by high levels of potassium in the blood
    • Causes of hyperkalemia include potassium shift outside the cells, drugs interfering with potassium balance, and kidney injury
    • Symptoms of hyperkalemia include muscle weakness, paralysis, and cardiac conduction abnormalities
    • Treatment of hyperkalemia includes calcium gluconate, insulin, beta2-adrenergic agonists, and sodium bicarbonate

    Calcium and Phosphorus

    • Calcium and phosphorus are essential for bone health
    • Parathyroid hormone (PTH) is the main calcium regulator
    • PTH increases calcium reabsorption in the kidneys, favors intestinal calcium and phosphorus reabsorption, and increases bone turnover
    • Calcitonin is another hormone involved in calcium regulation, which counteracts the effects of PTH
    • Vitamin D is essential for calcium regulation, and its deficiency can lead to hypocalcemia

    Hypocalcemia

    • Hypocalcemia is a condition characterized by low levels of calcium in the blood
    • Symptoms of hypocalcemia include tetany, seizures, hypotension, and psychiatric manifestations
    • Causes of hypocalcemia include vitamin D deficiency, reduced gastrointestinal reabsorption, chronic kidney disease, and hypomagnesemia
    • Treatment of hypocalcemia includes intravenous and oral calcium, and vitamin D supplements

    Hypercalcemia

    • Hypercalcemia is a condition characterized by high levels of calcium in the blood
    • Symptoms of hypercalcemia include muscle weakness, polyuria, polydipsia, dehydration, nausea, and changes in sensorium
    • Causes of hypercalcemia include hyperparathyroidism, vitamin D intoxication, and cancer
    • Treatment of hypercalcemia includes hydration, diuretics, and bisphosphonates### Hypercalcemia Treatment
    • In medical emergencies, treat the patient first and understand the causes later
    • First treatment: intravenous hydration with isotonic saline and glucose (no calcium)
    • Next, administer subcutaneous calcitonin to lower serum calcium concentration (not available in Italy)
    • Then, give bisphosphonates to the patient
    • Consider the onset and duration of action of these drugs
    • Isotonic saline takes hours to work, bisphosphonates take a lot of hours
    • Loop diuretics can also be used to treat hypercalcemia because they eliminate sodium and calcium
    • Glucocorticoids and dialysis may also be useful

    Factors that Aggravate Hypercalcemia

    • Thiazide diuretics
    • Lithium carbonate
    • Volume depletion
    • Prolonged bed rest or inactivity
    • High-calcium diet (>1000 mg/day)
    • Calcium supplements
    • Vitamin D supplements (>800 IU/day)
    • Multivitamins containing calcium

    Causes of Hypercalcemia

    • Measure parathyroid hormone (PTH) levels after the patient is stabilized
    • If PTH is low, the patient may have a tumor (e.g., multiple myeloma) or paraneoplastic syndrome
    • If PTH is high, the patient may have primary hyperparathyroidism (e.g., tumor of the parathyroid gland)
    • Vitamin D intoxication and granulomatous diseases (e.g., sarcoidosis and TB) can also cause hypercalcemia

    Disorders of Water Balance (Dysnatremias)

    • Dysnatremias are not disorders of sodium balance, but of water balance
    • Sodium concentration is not equal to sodium amount in the body
    • Blood volume depends on sodium content (regulated by RAAS and baroreceptors)
    • Hypovolemia: sodium depletion → decreased blood volume
    • Hypervolemia: sodium increase → increased blood volume

    Sodium Concentration

    • Not related to sodium amount in the body
    • Depends on water balance (regulated by vasopressin and thirst)
    • Hyponatremia: water excess → low sodium concentration
    • Hypernatremia: water deficit → high sodium concentration

    Hyponatremia

    • Most common disorder of body fluid and electrolyte balance
    • Occurs in 1-2% of hospitalized patients and 30% of ICU patients
    • Can lead to various clinical symptoms, from subtle to severe or life-threatening
    • Prompt recognition is crucial, as it increases in-hospital mortality by 40%

    Symptoms of Hyponatremia

    • Expression of central nervous system dysfunction caused by brain cell swelling
    • Acute hyponatremia: reversible if properly treated
    • Chronic hyponatremia: usually asymptomatic or paucisymptomatic

    Causes of Hyponatremia

    • Hypovolemic hyponatremia: extrarenal salt loss (e.g., diuretics, nephropathies, mineralocorticoid deficiencies)
    • Euvolemic hyponatremia: SIADH (syndrome of inappropriate ADH secretion), hypothyroidism, psychogenic polydipsia, adrenocorticotropic deficiency
    • Hypervolemic hyponatremia: heart failure, liver disease, nephrotic syndrome, advanced kidney disease

    Treatment of Hyponatremia

    • Exclude hyperglycemia and pseudohyponatremia
    • Assess severity of symptoms
    • If severe, give 150 mL of 3% hypertonic saline over 20 minutes
    • if asymptomatic, focus on etiology of the disease
    • Avoid rapid correction to prevent osmotic demyelination syndrome### Diabetes Insipidus
    • Can be hereditary (x-linked recessive, defect of V2 receptors or aquaporins) or acquired (electrolyte disorders, certain medications, chronic intestinal kidney disease, malnutrition)
    • Gestational DI: caused by degradation of ADH, occurs in peripheral circulation

    Symptoms of Diabetes Insipidus

    • Altered mental status
    • Lethargy
    • Irritability
    • Restlessness
    • Muscle twitching
    • Hyperreflexia and spasticity
    • Seizures (usually in children)
    • Coma

    Treatment of Hypernatremia

    • Determine volume status (sodium balance)
    • Calculate water deficit
    • Choose a replacement fluid
    • Determine the rate of depletion
    • Estimate ongoing sensible and insensible losses
    • Use the formula: Water deficit = TBW x (Na+s / 140 - 1)
    • Replace water deficit with hypotonic solution (e.g. 5% dextrose)
    • Monitor and adjust rate of repletion

    Key Points of Hypernatremia

    • Always reflects a hyperosmolar state
    • Always a water problem, sometimes a salt problem
    • Requires defect in thirst mechanism or limited access to free water
    • Sodium concentration does not provide information about total body salt or volume status
    • Calculation of water deficit is useful, but represents only a snapshot
    • Use clinical judgment and carefully monitor the patient
    • Consider sensible and insensible losses

    Approach to Glomerular Diseases

    • Simple lab test: serum creatinine
    • Accurate test: measurement of glomerular filtration rate (GFR) through inulin clearance
    • Other methods: use serum creatinine and GFR to assess renal function
    • Urinalysis should be performed in case of altered kidney functionality
    • Recognize nephrological syndromes, which can vary from asymptomatic to severe clinical manifestations

    Glomerular Diseases

    • May present in different clinical forms (nephrological syndromes)
    • Variations depend on combinations of serum creatinine, proteinuria, and alterations of urinary sediment
    • Recognizing the correct syndrome is crucial for treatment and prognosis

    Hematuria

    • Macroscopic hematuria: visible blood in urine
    • Can be symptomatic or asymptomatic, persistent or intermittent
    • Causes: inflammation of urinary bladder, urethra or prostate, urinary infections, kidney stones, polycystic kidney diseases, blood clotting disorders, sickle cell diseases, cancer, trauma
    • Glomerular diseases can cause macroscopic hematuria, especially IgA nephropathy
    • Asymptomatic urinary abnormalities: diagnosis obtained by urinalysis, proteinuria > 150 mg/day, hematuria, and hyaline or hyaline-granular casts
    • Nephrotic syndrome: characterized by proteinuria > 3.5g/day, low serum protein, and low albumin, with edema as the main clinical manifestation

    Introduction to Nephrology

    • Nephrology is the study of kidney function and diseases
    • Kidney function is essential for maintaining overall health

    Kidney Function

    • Kidneys act as filters, clearing the body of waste and toxic substances
    • They monitor and regulate blood pressure through the juxtaglomerular apparatus
    • They produce erythropoietin, which stimulates the production of red blood cells
    • They manage water and salt concentrations in the body, responding to antidiuretic hormone and aldosterone
    • They convert vitamin D to its active form, increasing calcium levels in the body

    Evaluation of Renal Function

    • The best test to evaluate renal function is the glomerular filtration rate (GFR)
    • GFR measures the volume of plasma cleared of a substance in a unit of time (mL/min)
    • An ideal substance to evaluate GFR should be produced endogenously, filtered by the glomerulus, and not reabsorbed or secreted by the renal tubule
    • Inulin is the ideal substance, but it is not produced by the body, so serum creatinine is used instead

    Serum Creatinine

    • Serum creatinine is a waste product that is produced by the body and cleared by the kidneys
    • High levels of serum creatinine indicate impaired kidney function
    • Normal range of serum creatinine is 0.5-1.0 mg/dL
    • Serum creatinine levels are influenced by factors such as aging, diet, and muscle mass

    Glomerular Filtration Rate (GFR)

    • GFR is the volume of plasma cleared of a substance in a unit of time (mL/min)
    • Normal range of GFR is 90-120 mL/min
    • GFR is calculated using serum creatinine levels, urinary volume, and creatinine in urine
    • GFR is influenced by factors such as aging, diet, and muscle mass

    Stages of Kidney Dysfunction

    • G1: normal or high GFR (>90 mL/min/1.73m²)
    • G2: mildly decreased GFR (60-89 mL/min/1.73m²)
    • G3a: mildly to moderately decreased GFR (45-59 mL/min/1.73m²)
    • G3b: moderately to severely decreased GFR (30-44 mL/min/1.73m²)
    • G4: severely decreased GFR (15-20 mL/min/1.73m²)
    • G5: kidney failure (GFR ≤15 mL/min/1.73m²)

    Case Study: Antonio

    • Antonio is a 70-year-old man with a history of high blood pressure and recent symptoms of nocturia, headaches, and fatigue
    • Lab tests reveal high levels of serum creatinine, urea, and potassium, and low levels of sodium and calcium
    • Urinalysis shows proteinuria and hemoglobinuria
    • Diagnosis is severe renal dysfunction, with a GFR of <15 mL/min

    Hyperkalemia

    • Hyperkalemia is a medical emergency characterized by high levels of potassium in the blood
    • Causes of hyperkalemia include potassium shift outside the cells, drugs interfering with potassium balance, and kidney injury
    • Symptoms of hyperkalemia include muscle weakness, paralysis, and cardiac conduction abnormalities
    • Treatment of hyperkalemia includes calcium gluconate, insulin, beta2-adrenergic agonists, and sodium bicarbonate

    Calcium and Phosphorus

    • Calcium and phosphorus are essential for bone health
    • Parathyroid hormone (PTH) is the main calcium regulator
    • PTH increases calcium reabsorption in the kidneys, favors intestinal calcium and phosphorus reabsorption, and increases bone turnover
    • Calcitonin is another hormone involved in calcium regulation, which counteracts the effects of PTH
    • Vitamin D is essential for calcium regulation, and its deficiency can lead to hypocalcemia

    Hypocalcemia

    • Hypocalcemia is a condition characterized by low levels of calcium in the blood
    • Symptoms of hypocalcemia include tetany, seizures, hypotension, and psychiatric manifestations
    • Causes of hypocalcemia include vitamin D deficiency, reduced gastrointestinal reabsorption, chronic kidney disease, and hypomagnesemia
    • Treatment of hypocalcemia includes intravenous and oral calcium, and vitamin D supplements

    Hypercalcemia

    • Hypercalcemia is a condition characterized by high levels of calcium in the blood
    • Symptoms of hypercalcemia include muscle weakness, polyuria, polydipsia, dehydration, nausea, and changes in sensorium
    • Causes of hypercalcemia include hyperparathyroidism, vitamin D intoxication, and cancer
    • Treatment of hypercalcemia includes hydration, diuretics, and bisphosphonates### Hypercalcemia Treatment
    • In medical emergencies, treat the patient first and understand the causes later
    • First treatment: intravenous hydration with isotonic saline and glucose (no calcium)
    • Next, administer subcutaneous calcitonin to lower serum calcium concentration (not available in Italy)
    • Then, give bisphosphonates to the patient
    • Consider the onset and duration of action of these drugs
    • Isotonic saline takes hours to work, bisphosphonates take a lot of hours
    • Loop diuretics can also be used to treat hypercalcemia because they eliminate sodium and calcium
    • Glucocorticoids and dialysis may also be useful

    Factors that Aggravate Hypercalcemia

    • Thiazide diuretics
    • Lithium carbonate
    • Volume depletion
    • Prolonged bed rest or inactivity
    • High-calcium diet (>1000 mg/day)
    • Calcium supplements
    • Vitamin D supplements (>800 IU/day)
    • Multivitamins containing calcium

    Causes of Hypercalcemia

    • Measure parathyroid hormone (PTH) levels after the patient is stabilized
    • If PTH is low, the patient may have a tumor (e.g., multiple myeloma) or paraneoplastic syndrome
    • If PTH is high, the patient may have primary hyperparathyroidism (e.g., tumor of the parathyroid gland)
    • Vitamin D intoxication and granulomatous diseases (e.g., sarcoidosis and TB) can also cause hypercalcemia

    Disorders of Water Balance (Dysnatremias)

    • Dysnatremias are not disorders of sodium balance, but of water balance
    • Sodium concentration is not equal to sodium amount in the body
    • Blood volume depends on sodium content (regulated by RAAS and baroreceptors)
    • Hypovolemia: sodium depletion → decreased blood volume
    • Hypervolemia: sodium increase → increased blood volume

    Sodium Concentration

    • Not related to sodium amount in the body
    • Depends on water balance (regulated by vasopressin and thirst)
    • Hyponatremia: water excess → low sodium concentration
    • Hypernatremia: water deficit → high sodium concentration

    Hyponatremia

    • Most common disorder of body fluid and electrolyte balance
    • Occurs in 1-2% of hospitalized patients and 30% of ICU patients
    • Can lead to various clinical symptoms, from subtle to severe or life-threatening
    • Prompt recognition is crucial, as it increases in-hospital mortality by 40%

    Symptoms of Hyponatremia

    • Expression of central nervous system dysfunction caused by brain cell swelling
    • Acute hyponatremia: reversible if properly treated
    • Chronic hyponatremia: usually asymptomatic or paucisymptomatic

    Causes of Hyponatremia

    • Hypovolemic hyponatremia: extrarenal salt loss (e.g., diuretics, nephropathies, mineralocorticoid deficiencies)
    • Euvolemic hyponatremia: SIADH (syndrome of inappropriate ADH secretion), hypothyroidism, psychogenic polydipsia, adrenocorticotropic deficiency
    • Hypervolemic hyponatremia: heart failure, liver disease, nephrotic syndrome, advanced kidney disease

    Treatment of Hyponatremia

    • Exclude hyperglycemia and pseudohyponatremia
    • Assess severity of symptoms
    • If severe, give 150 mL of 3% hypertonic saline over 20 minutes
    • if asymptomatic, focus on etiology of the disease
    • Avoid rapid correction to prevent osmotic demyelination syndrome### Diabetes Insipidus
    • Can be hereditary (x-linked recessive, defect of V2 receptors or aquaporins) or acquired (electrolyte disorders, certain medications, chronic intestinal kidney disease, malnutrition)
    • Gestational DI: caused by degradation of ADH, occurs in peripheral circulation

    Symptoms of Diabetes Insipidus

    • Altered mental status
    • Lethargy
    • Irritability
    • Restlessness
    • Muscle twitching
    • Hyperreflexia and spasticity
    • Seizures (usually in children)
    • Coma

    Treatment of Hypernatremia

    • Determine volume status (sodium balance)
    • Calculate water deficit
    • Choose a replacement fluid
    • Determine the rate of depletion
    • Estimate ongoing sensible and insensible losses
    • Use the formula: Water deficit = TBW x (Na+s / 140 - 1)
    • Replace water deficit with hypotonic solution (e.g. 5% dextrose)
    • Monitor and adjust rate of repletion

    Key Points of Hypernatremia

    • Always reflects a hyperosmolar state
    • Always a water problem, sometimes a salt problem
    • Requires defect in thirst mechanism or limited access to free water
    • Sodium concentration does not provide information about total body salt or volume status
    • Calculation of water deficit is useful, but represents only a snapshot
    • Use clinical judgment and carefully monitor the patient
    • Consider sensible and insensible losses

    Approach to Glomerular Diseases

    • Simple lab test: serum creatinine
    • Accurate test: measurement of glomerular filtration rate (GFR) through inulin clearance
    • Other methods: use serum creatinine and GFR to assess renal function
    • Urinalysis should be performed in case of altered kidney functionality
    • Recognize nephrological syndromes, which can vary from asymptomatic to severe clinical manifestations

    Glomerular Diseases

    • May present in different clinical forms (nephrological syndromes)
    • Variations depend on combinations of serum creatinine, proteinuria, and alterations of urinary sediment
    • Recognizing the correct syndrome is crucial for treatment and prognosis

    Hematuria

    • Macroscopic hematuria: visible blood in urine
    • Can be symptomatic or asymptomatic, persistent or intermittent
    • Causes: inflammation of urinary bladder, urethra or prostate, urinary infections, kidney stones, polycystic kidney diseases, blood clotting disorders, sickle cell diseases, cancer, trauma
    • Glomerular diseases can cause macroscopic hematuria, especially IgA nephropathy
    • Asymptomatic urinary abnormalities: diagnosis obtained by urinalysis, proteinuria > 150 mg/day, hematuria, and hyaline or hyaline-granular casts
    • Nephrotic syndrome: characterized by proteinuria > 3.5g/day, low serum protein, and low albumin, with edema as the main clinical manifestation

    Introduction to Nephrology

    • Nephrology is the study of kidney function and diseases
    • Kidney function is essential for maintaining overall health

    Kidney Function

    • Kidneys act as filters, clearing the body of waste and toxic substances
    • They monitor and regulate blood pressure through the juxtaglomerular apparatus
    • They produce erythropoietin, which stimulates the production of red blood cells
    • They manage water and salt concentrations in the body, responding to antidiuretic hormone and aldosterone
    • They convert vitamin D to its active form, increasing calcium levels in the body

    Evaluation of Renal Function

    • The best test to evaluate renal function is the glomerular filtration rate (GFR)
    • GFR measures the volume of plasma cleared of a substance in a unit of time (mL/min)
    • An ideal substance to evaluate GFR should be produced endogenously, filtered by the glomerulus, and not reabsorbed or secreted by the renal tubule
    • Inulin is the ideal substance, but it is not produced by the body, so serum creatinine is used instead

    Serum Creatinine

    • Serum creatinine is a waste product that is produced by the body and cleared by the kidneys
    • High levels of serum creatinine indicate impaired kidney function
    • Normal range of serum creatinine is 0.5-1.0 mg/dL
    • Serum creatinine levels are influenced by factors such as aging, diet, and muscle mass

    Glomerular Filtration Rate (GFR)

    • GFR is the volume of plasma cleared of a substance in a unit of time (mL/min)
    • Normal range of GFR is 90-120 mL/min
    • GFR is calculated using serum creatinine levels, urinary volume, and creatinine in urine
    • GFR is influenced by factors such as aging, diet, and muscle mass

    Stages of Kidney Dysfunction

    • G1: normal or high GFR (>90 mL/min/1.73m²)
    • G2: mildly decreased GFR (60-89 mL/min/1.73m²)
    • G3a: mildly to moderately decreased GFR (45-59 mL/min/1.73m²)
    • G3b: moderately to severely decreased GFR (30-44 mL/min/1.73m²)
    • G4: severely decreased GFR (15-20 mL/min/1.73m²)
    • G5: kidney failure (GFR ≤15 mL/min/1.73m²)

    Case Study: Antonio

    • Antonio is a 70-year-old man with a history of high blood pressure and recent symptoms of nocturia, headaches, and fatigue
    • Lab tests reveal high levels of serum creatinine, urea, and potassium, and low levels of sodium and calcium
    • Urinalysis shows proteinuria and hemoglobinuria
    • Diagnosis is severe renal dysfunction, with a GFR of <15 mL/min

    Hyperkalemia

    • Hyperkalemia is a medical emergency characterized by high levels of potassium in the blood
    • Causes of hyperkalemia include potassium shift outside the cells, drugs interfering with potassium balance, and kidney injury
    • Symptoms of hyperkalemia include muscle weakness, paralysis, and cardiac conduction abnormalities
    • Treatment of hyperkalemia includes calcium gluconate, insulin, beta2-adrenergic agonists, and sodium bicarbonate

    Calcium and Phosphorus

    • Calcium and phosphorus are essential for bone health
    • Parathyroid hormone (PTH) is the main calcium regulator
    • PTH increases calcium reabsorption in the kidneys, favors intestinal calcium and phosphorus reabsorption, and increases bone turnover
    • Calcitonin is another hormone involved in calcium regulation, which counteracts the effects of PTH
    • Vitamin D is essential for calcium regulation, and its deficiency can lead to hypocalcemia

    Hypocalcemia

    • Hypocalcemia is a condition characterized by low levels of calcium in the blood
    • Symptoms of hypocalcemia include tetany, seizures, hypotension, and psychiatric manifestations
    • Causes of hypocalcemia include vitamin D deficiency, reduced gastrointestinal reabsorption, chronic kidney disease, and hypomagnesemia
    • Treatment of hypocalcemia includes intravenous and oral calcium, and vitamin D supplements

    Hypercalcemia

    • Hypercalcemia is a condition characterized by high levels of calcium in the blood
    • Symptoms of hypercalcemia include muscle weakness, polyuria, polydipsia, dehydration, nausea, and changes in sensorium
    • Causes of hypercalcemia include hyperparathyroidism, vitamin D intoxication, and cancer
    • Treatment of hypercalcemia includes hydration, diuretics, and bisphosphonates### Hypercalcemia Treatment
    • In medical emergencies, treat the patient first and understand the causes later
    • First treatment: intravenous hydration with isotonic saline and glucose (no calcium)
    • Next, administer subcutaneous calcitonin to lower serum calcium concentration (not available in Italy)
    • Then, give bisphosphonates to the patient
    • Consider the onset and duration of action of these drugs
    • Isotonic saline takes hours to work, bisphosphonates take a lot of hours
    • Loop diuretics can also be used to treat hypercalcemia because they eliminate sodium and calcium
    • Glucocorticoids and dialysis may also be useful

    Factors that Aggravate Hypercalcemia

    • Thiazide diuretics
    • Lithium carbonate
    • Volume depletion
    • Prolonged bed rest or inactivity
    • High-calcium diet (>1000 mg/day)
    • Calcium supplements
    • Vitamin D supplements (>800 IU/day)
    • Multivitamins containing calcium

    Causes of Hypercalcemia

    • Measure parathyroid hormone (PTH) levels after the patient is stabilized
    • If PTH is low, the patient may have a tumor (e.g., multiple myeloma) or paraneoplastic syndrome
    • If PTH is high, the patient may have primary hyperparathyroidism (e.g., tumor of the parathyroid gland)
    • Vitamin D intoxication and granulomatous diseases (e.g., sarcoidosis and TB) can also cause hypercalcemia

    Disorders of Water Balance (Dysnatremias)

    • Dysnatremias are not disorders of sodium balance, but of water balance
    • Sodium concentration is not equal to sodium amount in the body
    • Blood volume depends on sodium content (regulated by RAAS and baroreceptors)
    • Hypovolemia: sodium depletion → decreased blood volume
    • Hypervolemia: sodium increase → increased blood volume

    Sodium Concentration

    • Not related to sodium amount in the body
    • Depends on water balance (regulated by vasopressin and thirst)
    • Hyponatremia: water excess → low sodium concentration
    • Hypernatremia: water deficit → high sodium concentration

    Hyponatremia

    • Most common disorder of body fluid and electrolyte balance
    • Occurs in 1-2% of hospitalized patients and 30% of ICU patients
    • Can lead to various clinical symptoms, from subtle to severe or life-threatening
    • Prompt recognition is crucial, as it increases in-hospital mortality by 40%

    Symptoms of Hyponatremia

    • Expression of central nervous system dysfunction caused by brain cell swelling
    • Acute hyponatremia: reversible if properly treated
    • Chronic hyponatremia: usually asymptomatic or paucisymptomatic

    Causes of Hyponatremia

    • Hypovolemic hyponatremia: extrarenal salt loss (e.g., diuretics, nephropathies, mineralocorticoid deficiencies)
    • Euvolemic hyponatremia: SIADH (syndrome of inappropriate ADH secretion), hypothyroidism, psychogenic polydipsia, adrenocorticotropic deficiency
    • Hypervolemic hyponatremia: heart failure, liver disease, nephrotic syndrome, advanced kidney disease

    Treatment of Hyponatremia

    • Exclude hyperglycemia and pseudohyponatremia
    • Assess severity of symptoms
    • If severe, give 150 mL of 3% hypertonic saline over 20 minutes
    • if asymptomatic, focus on etiology of the disease
    • Avoid rapid correction to prevent osmotic demyelination syndrome### Diabetes Insipidus
    • Can be hereditary (x-linked recessive, defect of V2 receptors or aquaporins) or acquired (electrolyte disorders, certain medications, chronic intestinal kidney disease, malnutrition)
    • Gestational DI: caused by degradation of ADH, occurs in peripheral circulation

    Symptoms of Diabetes Insipidus

    • Altered mental status
    • Lethargy
    • Irritability
    • Restlessness
    • Muscle twitching
    • Hyperreflexia and spasticity
    • Seizures (usually in children)
    • Coma

    Treatment of Hypernatremia

    • Determine volume status (sodium balance)
    • Calculate water deficit
    • Choose a replacement fluid
    • Determine the rate of depletion
    • Estimate ongoing sensible and insensible losses
    • Use the formula: Water deficit = TBW x (Na+s / 140 - 1)
    • Replace water deficit with hypotonic solution (e.g. 5% dextrose)
    • Monitor and adjust rate of repletion

    Key Points of Hypernatremia

    • Always reflects a hyperosmolar state
    • Always a water problem, sometimes a salt problem
    • Requires defect in thirst mechanism or limited access to free water
    • Sodium concentration does not provide information about total body salt or volume status
    • Calculation of water deficit is useful, but represents only a snapshot
    • Use clinical judgment and carefully monitor the patient
    • Consider sensible and insensible losses

    Approach to Glomerular Diseases

    • Simple lab test: serum creatinine
    • Accurate test: measurement of glomerular filtration rate (GFR) through inulin clearance
    • Other methods: use serum creatinine and GFR to assess renal function
    • Urinalysis should be performed in case of altered kidney functionality
    • Recognize nephrological syndromes, which can vary from asymptomatic to severe clinical manifestations

    Glomerular Diseases

    • May present in different clinical forms (nephrological syndromes)
    • Variations depend on combinations of serum creatinine, proteinuria, and alterations of urinary sediment
    • Recognizing the correct syndrome is crucial for treatment and prognosis

    Hematuria

    • Macroscopic hematuria: visible blood in urine
    • Can be symptomatic or asymptomatic, persistent or intermittent
    • Causes: inflammation of urinary bladder, urethra or prostate, urinary infections, kidney stones, polycystic kidney diseases, blood clotting disorders, sickle cell diseases, cancer, trauma
    • Glomerular diseases can cause macroscopic hematuria, especially IgA nephropathy
    • Asymptomatic urinary abnormalities: diagnosis obtained by urinalysis, proteinuria > 150 mg/day, hematuria, and hyaline or hyaline-granular casts
    • Nephrotic syndrome: characterized by proteinuria > 3.5g/day, low serum protein, and low albumin, with edema as the main clinical manifestation

    Renal Diseases and Kidney Function

    • Normally, renal diseases are bilateral, affecting both kidneys.
    • A healthy individual has 2 million nephrons, 120 ml/min of creatinine clearance, and 1mg/dl of serum creatinine.
    • If serum creatinine increases from 1 to 2 mg/dl, the creatinine clearance is reduced to 70 ml/min, indicating a significant loss of nephrons.

    Calculating Creatinine Clearance

    • To calculate creatinine clearance, you need:
      • Serum creatinine of the patient
      • Urinary volume (ml) over 24 hours
      • Creatinine in urine
      • Weight of the patient
      • Sex of the patient
    • The formula is: urinary creatinine (mg/ml) x urinary volume (ml) / serum creatinine (mg/dl)

    Glomerular Filtration Rate (GFR)

    • Normal range of GFR is 90-120 ml/min
    • Serum creatinine levels differ between males (0.6-1.2 mg/dl) and females (0.5-1.1 mg/dl)
    • Factors that can influence GFR include:
      • Aging
      • Diet
      • Muscle mass

    Kidney Function and Muscle Mass

    • A single healthy kidney is able to sustain normal renal function
    • Muscle mass affects serum creatinine levels, with reduced muscle mass leading to lower creatinine levels and normal GFR, and abundant muscle mass leading to higher creatinine levels and normal GFR

    Evaluating Renal Function

    • Serum creatinine and urinalysis should be performed to evaluate renal function
    • If both tests are normal, kidney functionality is likely normal
    • If both tests are altered, it's likely a kidney dysfunction
    • If only one test is altered, further tests are needed

    Glomerular Diseases

    • Glomerular diseases can present in different clinical forms, known as nephrological syndromes
    • These syndromes can vary from asymptomatic forms to mild/severe clinical manifestations with acute renal dysfunction
    • Recognizing the correct nephrological syndrome is important for treatment and complication management

    Evaluation of Kidney Dysfunction

    • GFR (Glomerular Filtration Rate) is used to evaluate the stage of kidney dysfunction
    • Stages of kidney dysfunction:
      • G1: normal or high (GFR > 90 ml/min/1.73m2)
      • G2: mildly decreased (GFR 60-89 ml/min/1.73m2)
      • G3a: mildly to moderately decreased (GFR 45-59 ml/min/1.73m2)
      • G3b: moderately to severely decreased (GFR 30-44 ml/min/1.73m2)
      • G4: severely decreased (GFR 15-20 ml/min/1.73m2)
      • G5: kidney failure (GFR ≤ 15 ml/min/1.73m2)

    Hyperkalemia and Kidney Function

    • Hyperkalemia is unusual in healthy individuals
    • Two mechanisms may be associated with the development of hyperkalemia:
      • Increased release from cells (e.g., metabolic acidosis, insulin deficiency, use of beta blockers, exercise)
      • Reduced urinary potassium excretion (e.g., reduced aldosterone secretion, reduced response to aldosterone, oliguria, acute and chronic kidney disease, selective impairment in potassium secretion)

    Clinical Case: Antonio

    • Antonio's symptoms: nocturia, frequent urination at night, headaches, tiredness, lack of appetite, nausea, pale, edema in the lower limbs, and high blood pressure
    • Lab test results:
      • Low sodium (133 mmol/L)
      • High potassium (5.8 mmol/L)
      • Low bicarbonate (16 mmol/L)
      • Anemia (Hb 9.6 g/dl)
      • High urea (190 mg/dl)
      • High serum creatinine (8.2 mg/dl)
      • High uric acid (9.1 mg/dl)
      • Low calcium (7.8 mg/dl)
      • High phosphorus (6.5 mg/dl)
      • Urinalysis: pH 6, protein 3+, Hb 1+ (altered, presence of proteinuria and hemoglobin)
    • Clinical features indicate severe renal dysfunction

    Acute Renal Dysfunction and Kidney Disease

    • Acute renal dysfunction can be classified into three types: pre-renal, renal, and post-renal AKI
    • Renal AKI can include tubulointerstitial diseases and glomerulonephritis
    • Glomerulonephritis can progress to end-stage kidney disease if not treated
    • 15% of cases of end-stage renal disease are due to untreated glomerulonephritis

    Evaluating Renal Functionality

    • GFR (Glomerular Filtration Rate) evaluation can be done with serum creatinine, but it's not always accurate due to muscle mass variation.
    • Elderly people have lower creatinine levels, and patients with Rheumatoid Arthritis may have normal creatinine levels but low GFR.

    Urinalysis

    • Urinalysis should be performed in case of altered kidney functionality.
    • If both serum creatinine and urinalysis are normal, kidney functionality is likely normal.
    • If only one is altered, further tests are needed.

    Glomerular Diseases

    • Glomerular diseases present in different clinical forms called nephrological syndromes.
    • These syndromes vary from asymptomatic forms to mild/severe clinical manifestations with acute renal dysfunction.
    • Recognizing the correct nephrological syndrome is crucial due to different complications and treatments.

    Clinical Case

    • Antonio, a 70-year-old man, experiences frequent urination at night, headaches, and fatigue, indicating possible renal dysfunction.
    • His lab test results show low sodium, high potassium, low bicarbonate, anemia, high urea, high serum creatinine, and proteinuria.
    • These results indicate severe renal dysfunction.

    Renal Function Tests

    • Urea and serum creatinine are very important for evaluating kidney function.
    • Uric acid is also associated with kidney function, but can be altered for other reasons.

    Acute Kidney Injury (AKI)

    • AKI can be classified into pre-renal, renal, and post-renal AKI.
    • Renal AKI can further be classified into tubulointerstitial diseases and glomerulonephritis.

    Glomerulonephritis

    • Untreated glomerulonephritis can progress to end-stage kidney disease.
    • 15% of end-stage renal disease cases are due to untreated glomerulonephritis.

    Hematuria

    • Macroscopic hematuria can be classified based on color, ranging from bright red to coke-like.
    • The color of hematuria is an important factor to consider in diagnosis.
    • Hematuria can be symptomatic or asymptomatic, persistent or intermittent.

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    Description

    This quiz covers the basics of nephrology, including kidney function and pathological renal diseases, through a clinical case study of a 70-year-old bank clerk with hypertension and urinary symptoms.

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