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Questions and Answers
What is a common clinical feature of chronic pyelonephritis that indicates renal function impairment?
Which condition often precedes the onset of significant proteinuria in chronic pyelonephritis?
In metabolic alkalosis, which compensation mechanism occurs?
What is the effect of toxins in toxin-induced tubulointerstitial nephritis?
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Which of the following is a sign of asymmetrically contracted kidneys observed in chronic pyelonephritis?
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What is the primary primary change in respiratory acidosis?
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Under which condition would you expect urine chloride levels to be greater than 20 in metabolic alkalosis?
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Which non-renal condition can lead to a non-renal cause of metabolic alkalosis?
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What serum electrolyte change is particularly associated with the use of loop and thiazide diuretics?
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What adverse effect is commonly experienced due to carbonic anhydrase inhibitors?
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Which mechanism primarily leads to alkalemia when using loop diuretics?
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What defines the nephrotic range of proteinuria?
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Which type of glomerular condition is characterized by selective albuminuria and response to steroid treatment?
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Which demographic is primarily affected by Focal Segmental Glomerulosclerosis?
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What histological finding is characteristic of Membranous Nephropathy?
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What type of kidney damage involves thick capillary membranes and mesangial proliferation with tram-tracks?
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What does a positive urine anion gap (UAG) indicate?
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Winter's Correction formula is used to estimate which of the following?
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What condition is primarily treated with carbonic anhydrase inhibitors like acetazolamide?
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Which of the following is a common adverse effect of loop diuretics?
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Which diuretic is most effective in managing edema due to heart failure?
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What is the primary site of action for thiazide diuretics?
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Which diuretic class is indicated for treating hyperaldosteronism?
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What does the term 'HARDASS' refer to in relation to NAGMA?
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What is a significant adverse effect associated with acetazolamide?
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How does furosemide primarily exert its diuretic effect?
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What is the mechanism of action for potassium-sparing diuretics like spironolactone?
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Which diuretic class is preferred in treating nephrolithiasis due to idiopathic hypercalciuria?
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What could be a side effect of mannitol, when used improperly?
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Which of the following is NOT an indication for the use of furosemide?
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Which statement is true regarding thiazide diuretics?
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Study Notes
Anion Gap
- Anion Gap (AG) is a measurement of the difference between the major cations and anions in the blood.
- AG formula: [Na+] - ([Cl-]+[HCO3-])= ANS ± 2
- Corrected AG formula: [Na+] - [Cl-] - [HCO3-] + 2.5(4 - Albumin) = ANS
- Urine Anion Gap (UrAG): [UrNa+] + [UrK+] - [UrCl-]= ANS ± 2
- Positive UrAG indicates renal causes
- Negative UrAG indicates non-renal causes
- Winter's Correction formula: PaCO2= 1.5(HCO3-)+10= ANS ± 2
- High Anion Gap Metabolic Acidosis (HAGMA) causes: GOLDMARK (Glycols, Oxoproline, L-Lactate, D-Lactoacidosis, Methanol, Aspirin, Ketoacidosis, Renal failure)
- Normal Anion Gap Metabolic Acidosis (NAGMA) causes: HARDASS (Hyperalimentation, Acidosis (renal tubular acidosis), Respiratory acidosis (hypercapnea), Drugs (Acetazolamide, Ammonium chloride, Spironolactone, Salicylates, Diarrhea, Addison’s disease, Severe hypoaldosteronism, SIRS)
Diuretics
- Diuretics are drugs that increase urine production.
- They work by altering the reabsorption of fluids and electrolytes in the kidneys.
Osmotic Diuretics
- Mannitol is an osmotic diuretic.
- It is used to reduce intracranial pressure, intraocular pressure, and to initiate hemodialysis.
- It can also be used in drug overdose, inhaled for cystic fibrosis, and for chemotherapy-induced side effects.
- Mannitol can cause extracellular volume expansion which can worsen heart failure and pulmonary edema.
- It can also cause dehydration, hyperkalemia, hypernatremia, acute renal failure, and increased urine sodium chloride.
Carbonic Anhydrase Inhibitors
- Acetazolamide is a carbonic anhydrase inhibitor.
- It is used to treat CSF leak, glaucoma, epilepsy, hyperphosphatemia, acute mountain sickness, and to alkalinize urine.
- Acetazolamide can cause metabolic alkalosis, hyperchloremic metabolic acidosis (type 2 RTA), renal stones, and renal potassium wasting (hypokalemia).
- It can also cause drowsiness, paresthesia, increased urine sodium chloride, increased sodium bicarbonate, and can exacerbate hypercalciuria.
Loop Diuretics
- Furosemide is a loop diuretic.
- It is used to treat edema (heart failure, pulmonary edema, cirrhosis, nephrotic syndrome), hypertension, acute renal failure, hypercalcemia, and anion overdose intoxication.
- It can cause ototoxicity, hypokalemia, hypomagnesemia, dehydration, sulfa allergy, metabolic alkalosis, nephritis, gout, increased urine sodium chloride, increased urine potassium, increased urine calcium, and can exacerbate gout.
- It inhibits the sodium-potassium-chloride cotransporter (NKCC2) in the thick ascending loop of Henle, leading to increased sodium, potassium, and chloride loss in the urine.
Thiazides
- Hydrochlorothiazide is a thiazide diuretic.
- It is used to treat hypertension, heart failure, nephrolithiasis due to idiopathic hypercalciuria, and nephrogenic diabetes insipidus.
- It can cause hyperglycemia, hyperlipidemia, hyperuricemia, hypercalcemia, hypokalemic metabolic alkalosis, hypokalemia, hyponatremia, increased urine sodium chloride, increased urine potassium, and decreased urine calcium.
Potassium Sparing Diuretics
- Spironolactone, eplerenone, and amiloride are potassium-sparing diuretics.
- They are used to treat primary and secondary hyperaldosteronism, fibriotic/inflammatory aldosterone, hypertension, myocardial infarction, Liddle syndrome, hepatic ascites, and as an antiandrogen.
- They can cause hyperkalemia, hyperchloremic metabolic acidosis type IV RTA, gynecomastia, acute renal failure, kidney stones, increased urine sodium chloride, and decreased urine potassium.
Diuretic Electrolyte Changes
- Urine Sodium Chloride: Increased with all diuretics. The concentration varies based on the potency of the diuretic effect.
- Urine Potassium: Increased with loop and thiazide diuretics, except for potassium-sparing diuretics.
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Blood pH:
- Decreased (acidemia) with carbonic anhydrase inhibitors and potassium-sparing diuretics.
- Increased (alkalemia) with loop diuretics and thiazides.
Chronic Pyelonephritis
- Chronic pyelonephritis is a chronic inflammatory disease of the kidneys that involves the calyces and pelvis.
- It is characterized by gradual onset of renal insufficiency and hypertension.
- Other symptoms include polyuria, nocturia, and asymmetrically contracted kidneys with coarse scars.
- Early stages are characterized by bacteriuria, while late stages usually have no bacteriuria.
- Secondary focal segmental glomerulosclerosis can develop several years after scarring.
- Proteinuria is a poor prognostic sign and can lead to end-stage renal disease.
Toxin-Induced Tubulointerstitial Nephritis
- Toxins are the second most common cause of tubulointerstitial nephritis.
- They can trigger interstitial immunologic reactions, like the acute hypersensitivity nephritis induced by methicillin.
- They can also cause acute tubular injury and subclinical damage to tubules that can progress to chronic kidney disease over time.
### Acid-Base Disorders
- Acid-base disorders are caused by imbalances in the body's pH balance.
- Acidosis is characterized by a decrease in pH, while alkalosis is characterized by an increase in pH.
- There are two main types of acid-base disorders: metabolic and respiratory.
- Metabolic acidosis is caused by a decrease in bicarbonate levels.
- Respiratory acidosis is caused by an increase in carbon dioxide levels.
- Metabolic alkalosis is caused by an increase in bicarbonate levels.
- Respiratory alkalosis is caused by a decrease in carbon dioxide levels.
Alkalosis
- Metabolic alkalosis is characterized by an increase in blood bicarbonate (HCO3-) levels.
- Non-renal metabolic alkalosis (chloride responsive): Urine chloride (<20 mEq/L) is low usually due to vomiting or recent diuretic use.
- Renal metabolic alkalosis (chloride resistant): Urine chloride (>20 mEq/L) is high and is often a sign of increased bicarbonate excretion due to conditions like Bartter or Gitelman syndrome, increased blood pressure associated with hyperaldosteronism, or current use of diuretics.
- Winter's Formula can be used to assess metabolic alkalosis and correct for PaCO2: PaCO2= 0.7(HCO3¯ - 24) + 42 = ANS ± 2.
Nephrotic Syndrome
- Nephrotic syndrome is a kidney disorder characterized by high proteinuria (more than 3.5 g/day) and low serum albumin levels.
- It causes a decrease in oncotic pressure, leading to edema.
- The loss of antithrombin III in the urine also leads to hypercoagulability.
- Other symptoms include hyperlipidemia and hypercholesterolemia, which can manifest as fatty casts in the urine.
Minimal Change Disease
- Minimal change disease is a common cause of nephrotic syndrome in children.
- It is often triggered by an upper respiratory tract infection, immunization, or allergic reactions.
- It is also associated with Hodgkin lymphoma.
- The underlying cause is a release of cytokines, specifically IL-13, which leads to podocyte loss.
- It is characterized by selective albuminuria and responds well to steroids.
- Glomerular filtration is normal, and the glomeruli appear normal on light microscopy.
- The immune complex deposition is negative, but electron microscopy shows podocyte effacement.
Focal Segmental Glomerulosclerosis
- Focal segmental glomerulosclerosis (FSGS) is more common in adults and is often associated with Hispanic and African American individuals.
- It is also a risk factor for individuals with HIV, heroin use, or sickle cell disease.
- Focal segmental collagen deposition is a key feature of this disease.
- FSGS is characterized by effacement of podocyte foot processes.
- The immune complex deposition is nonspecific.
- It does not respond well to steroids.
- There is often progression to renal failure.
Membranous Nephropathy
- Membranous nephropathy is a kidney disorder characterized by a thickened glomerular basement membrane.
- It is commonly observed in individuals of Caucasian descent.
- It can be associated with systemic lupus erythematosus, hepatitis B and C, solid tumors, NSAIDs, or penicillamines.
- There is an absence of hypercellularity, which distinguishes it from membranous proliferative nephropathy.
- Granular immune complex deposition within the glomerular basement membrane can be observed on immunofluorescence microscopy.
- Sub-epithelial deposits form "spikes" on the outside of the glomerular basement membrane, which create a pattern called "spikes and domes."
Membranous Proliferative Nephropathy
- Membranous proliferative nephropathy is a kidney disorder that affects the glomerular capillaries.
- It is characterized by thickened capillaries and mesangial proliferation.
- It is typically associated with hepatitis B and C.
- The glomerular basement membrane appears thickened and has a "tram-track" appearance.
- The immune complex deposition is granular and located beneath the endothelium.
- This condition can lead to nephritis or nephrotic syndrome.
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