Renal #

Hypertension (HTN) #

• Measured on at least two occasions
• Ambulatory BP measurements good, have pts do them
  • Cuffs to get (link/table???)
• Some data suggest that taking BP meds at night (save loops) has better outcomes.

RAAS System #

Drug Classes #

Drug Preference Order #

Special situations:

• Angina: CCB or BB
• Afib/flutter: metoprolol or nd-BB
• BPH: alpha-1 blocker
• Essential tremor: BB, propranolol
• Hyperthyroidism: BB
• Migraines: BB, propranolol, metoprolol
• Reynaud’s: nd-CCB, nifedipine

ARBs #

Above table is general, probably not clinically significant. Generally, recommend olmesartan.

AKI #

Dx:

• ↑ SCr > 0.3 mg/dL or 1.5x baseline or
• Urine output < 0.5 mL/kg/hour for 6 hours

Workup:

• Labs
  • UA
  • BMP/RFP
  • Urine Osms
  • Urine Na, Cr
• Renal US

DDx:

• US
  • If hydro → obstruction
  • If small, echogenic → AKI on CKD
  • If normal then
• Oliguria or otherwise volume down?
  • FeNa >1% and UOsm <350 mOsm/kg, muddy casts → ATN
  • FeNa <1% and UOsm >350 mOsm/kg, hyaline casts → prerenal azotemia
• Normal volume status
  • UA
    • Fever, rash, WBCs → Interstitial nephritis
    • Dysmorphic RBCs, RBC casts, proteinuria → Glomerulonephritis
      • Check ANCA, anti-GBM, C3, C4, hepatitis
    • UA no cells, protein → p/c, SPEP, UPEP

CKD #

NSAIDs in CKD #

Specific risk factors that put patient’s at higher risk.

Orthostatics #

• SBP decrease >20mmHg
• DPB decrease >10mmHg
• HR increase >30BPM Any one true = positive orthostatic test

Treatment #

• Midodrine
• Florinef

Diuresis #

Prominent side effect of diuresis: cramping (pull back)

Diuresed urine is approximately 1/2 NS with 20mEq K.

• Lasix (fursomide)
  • 20-80mg q6-8h PO (max 600mg/day in severe edematous states)
  • 20-40mg q1-2h IV (max 200mg/day)
  • 2x SCr is a good ballpark place to start with IV dose for diuresis
• Bumex (Bumetanide)
  • 0.5-2mg 1-2x/day, can repeat after 4-5hrs (max 10mg/day)
  • 0.5-1mg, can repeat in 2-3hrs (max 10mg/day)
• Demadex (torsemide)
  • 10-20mg starting, usually need 20-40mg
  • Max 200mg/day
• Metolazone (thiazide)
  • 5-10mg PO Qday (max 20mg/day)
  • Dosed before loop for combinatory effect

Dialysis #

Indications for urgent/emergent dialysis: AEIOU
Acedemia
Electrolyte abnormalitites
Intoxicated
Overload (volume)
Uremia

Fluids #

Maintenence Rate #

Ballpark rule of thumb:

• Weight in kg x 1-2 = maintenence rate
  • 1 is more gentle
  • 2 is more agressive, but not a resuccitation

Rate calculator

Sodium (Na) #

Hypernatremia #

• AMS
• Seizures
• resp arrest (rare)

Signs/Symptoms #

Workup #

• Hypovolemic
  • Urine Osms >800 AND FeNa² <1% → extrarenal loss of Na and water
    • N/V/D
    • Sweating/burns
    • Mechanical ventilation
  • Urine Osms 300-800 → renal loss
    • Diuretics
    • Osmotic diuresis
    • Partial DI
• Euvolemic
  • Urine Osms <300 → DI, do desmopressin challenge test
    • If responsive → central DI
    • If resistant → nephrogenic DI
      • Usually caused by hypercalcemia, hypokalemia or meds (lithium)
  • Urine Osms 300-800
    • Partial DI
    • Osmotic diuresis
    • Primary hypodipsia
• Hypervolemic
  • Ingestion of salt (sea water)
  • Primary aldosteronism
  • Iatrogenic (hypertonic saline, HD errors)

Treatment #

• D5W +/- lasix (with lasix usually an ICU only thing)
• Correct serum sodium by 1 mmol/L/hour in the first 6-8 hours

Hyponatremia #

Signs/Symptoms #

Workup #

• Serum Osms
  • <280? → clinical volume status
    • Hypovolemic
      • Urine Osms >500 mOsm AND UNa < 20 AND FENa <1% => extrarenal
      • Urine Osms >500 mOsm AND FENa >1% => renal loss
    • Euvolemic (urine Na usually >20-30)
      • Rule out hypothyroidism and adrenal insufficiency
      • Urine Osms >100 => SIADH
      • Urine Osms <100 => primary polydipsia, beer potomania
    • Hypervolemic
      • UNa <20-30mmol/L AND FeNa <1% => HF, cirrohsis w/ ascites, nephrotic syndrome
      • UNa >30 => renal failure or diuretic use
  • 280-295?
    • check for pseudohyponatremia
    • Sodium correction for glucose calculator
  • >295?
    • check serum glucose

Treatment #

• Water restriction (i.e. cause is too much free water)
• Saline infusion (i.e. cause is not enough solute)
  • Can use NS, LR
    • 3% saline only if symptomatic
  • Goal correction 6-8mEq/24hrs
    • Avoid central pontine mylinolysis (CPM)
    • Very low chance of CPM after Na hits 125
    • Infusion rate calculator
      • Be conservative with this, likely oversimplification of the biology in the math

Potassium (K) #

• 10mEq KCl should raise serum K 0.1 (with normal kidneys)
• Can only absorb ≈60mEq q8h

Hyperkalemia #

Signs/Symptoms #

Treatment #

• CaCl2 (transient)
• Albuterol
• D50 + insulin
• Bicarb
• Kayelxylate
• Diurese

Calcium (Ca) #

Hypercalcemia #

• Total calcium > 10.5 mg/dL, or ionized > 5.6 mg/dL
  • Mild: 10.5-12
  • Moderate: 12-14
  • Severe: >14
• Often asymptomatic, if symptomatic likely moderate to severe (also likely rapid rate of change)

Causes #

• Hyperparathyroid or Malignancy (two most common)
• Granulomatous diseases
  • sarcoidosis
  • berylliosis
  • coccidioidomycosis
  • TB
  • histoplasmosis
  • leprosy
  • inflammatory bowel disease
  • foreign body granuloma
• Vitamin D, Vitamin A excess
• Meds
  • Thiazides
  • Lithium
  • Vitamin A (accutane?)
  • Antacids (Tums)
• Some bengin tumors
• Endocrine
  • hyperthyroidism and thyrotoxicosis
  • adrenal insufficiency
  • acromegaly
  • pheochromocytoma
  • Verner-Morrison syndrome

Measurement #

• Must always correct for serum albumin (≈50% bound)
• If not normal serum pH, use ionized calcium (correction formulas assume normal pH for binding energetics)
  • Ionized can also help suss out false positives

Workup #

• PTH
  • If normal/high => GFR, 24hr urine Ca, creatine
    • GFR < 60 will have increase in PTH
    • CaCrCL < 0.01 => familial hypocalciuric hypercalcemia (80%)
    • CaCrCL 0.01-0.02 => primary hyperparathyroidism (≈ 20% fam hypocal hypercal)
    • CaCrCL > 0.02 => primary hyperparathyroidism
  • If low
    • => malignancy eval (CT, sekeletal survey, PET, etc.)
    • Can sometimes be something endocrine

Signs/Symptoms #

• bone pain
• nausea/vomiting
• anorexia/weight loss
• constipation
• abdominal pain
• obtundation, confusion, delirium, or memory loss
• lethargy/fatigue
• muscle weakness

Treatment #

• IV NS
• Bisphosphonates
  • pamidronate 60-90 mg IV/4hrs, zoledronic acid 4 mg IV/15min
  • Takes a day or two to kick in
  • Effect can last for weeks
• calcitonin
  • 4 units/kg subq/IM q6-12hrs x 24 hours

Consider Denosumab (If bisphosphonates not working), steroids (vitamin D excess, granulomatous disease, or hematologic malignancies).

Complications #

• Renal
  • renal tubular acidosis
  • nephrolithiasis
  • nephrogenic diabetes insipidus
  • nephrocalcinosis
  • CKD
• GI
  • constipation
  • pancreatitis
  • peptic ulcer disease
• Neuromuscular
  • impaired concentration and memory
  • dementia
  • muscle weakness
• CV
  • hypertension
  • shortened QT on EKG
  • arrhythmias
  • vascular calcification
  • valvular heart disease
• HEENT
  • corneal calcification (band keratopathy)

Hypocalcemia #

Toxicity #

• Vanc/Zosyn approximately 4x (HR 2.73–6.68) more likely to get AKI than with Vanc/Cefepime (Paper)

The Nephron #

Pearls #

• Lisinopril => teratogenic, caution in young women
• Use renal diet only in ESRD (CKD can handle normal diet)
• Losartan decreases gout (only losartan, not all ARBs)
• Phos repletion is 100% feel, no rules like K
• Reach for labetalol instead of hydralazine for BP control in CKD/ESRD
  • Response to hydralazine really varies from not working at all to bottoming people out