Smart Phrases And Workups – Nephro

AGMA	Anion Gap Metabolic Acidosis
pH ***, CO2 ***, AG ***
lactate ***
- consider HCO2 pushes
AKI	
AKI
Ddx: pre-renal (hypovolemia vs cardiorenal)
- f/u urine Na (FENa <1% pre-renal, FEN >2% ATN), Cr, urea (if on diuretics), osm (>500 pre-renal)
- f/u renal US to r/o hydronephrosis or chronic disease (BMC Nephrol 2013;14:188)
- consider adding C3/4, ANCA, anti-GBM, ANA, anti-dsDNA, HBV/HCV/HIV, cryo, SPEP/UPEP/FLC if evidence of intrinsic disease
CKD	
Chronic Kidney Disease
Stage 1 >90, Stage 2 60-89, Stage 3a 45-59, Stage 3b 30-44, Stage 4 15-29, Stage 5 <15
GFR *** (GFR <60 or albuminuria >30mg/d for >3 months JAMA 2015;313:837)
Etiology: DM (44%), HTN (29%), cystic kidney disease (20%)
- f/u renal US if new dx
- goal protein <500-1000mg/d (NEJM 2013;369:1892) >> ACEi/ARB
- goal BP <130/80 (ACEi, non-DHP CCB, furosemide)
- goal Hgb 10-11.5 | IV iron for transferrin sat >20% (hold if ferritin >500)
- ASA, statin, exercise, smoking cessation given 2-4x elevated CVD risk
- diet: Na <2g/d, fluid <2L/d, protein 0.6-0.8 mg/kg/d
- goal HCO3 >22 | NaHCO3 650-1300 mg BID may slow progression (JASN 2015;26:515)
GLOMERULONEPHRITIS	
Glomerulonephritis
- f/u UA, C3/C4, ESR, CRP, HBV/HCV, HIV, SPEP, FLC, IgA, ANA, dsDNA, Sm, ANCA, anti-GBM, FR, cryo, anti-DNAse, ASO

- rapidly progressive (decrease GFR >50% in 3 months) consider methylprednisolone 500-1000 mg IV qd x3 days + rituximab
HYPERKALEMIA	Hyperkalemia
K ***
- f/u EKG
- Ca gluconate, lasix, insulin + D50, albuterol
HYPERNATREMIA	Hypernatremia
Ddx:
Admission Na:
Free water deficit: TBW(ideal body weight x0.4 men or 0.5 women) x (Na/140-1)
- f/u BMP q6h
- goal Na increase 1-2 per hour
HYPONATREMIA	
Hyponatremia
Ddx:
Admission Na:
- f/u BMP q6h
- f/u serum Osm, >300 = hypertonic hyponatremia
- f/u urine Osm, >100 = appropriate ADH
- UNa <30 = hypovolemia
- Uurea if recent diuretics
- goal Na: increase 4-6 in 24h
NEPHROLITHIASIS	Kidney Stone
Non-con CT:
UCx:
- NS @150 mL/h
- tamsulosin 0.4 mg PO daily for ureteral relaxation
- opioids
NEPHROTIC SYNDROME	
Nephrotic syndrome
Etiology: loss of podocyte integrity with podocyte foot effacement
Presented with: proteinuria >3.5g/d, albumin <3, periorbital edema, HLD
Classifications: DM (most common), FSGS (AA, viral, NSAIDs, heroin, obesity, CKD, hypoxia), minimal change (NSAIDs, HL), C3GN (HCV, SLE, lymphoma, MM), membranous (APA, SLE, HBV/HCV, syphilis, solid tumors), amyloid (MM or chronic inflammation)
- f/u UA, spot urine protein/Cr ratio, Hgb A1c
- if A1c normal, consider ANA, anti-dsDnA, anti-PLA2R, SPEP, FLC, HBV, HCV, HIV, C3/C4 + nephrology consult
- consider steroids, ACEi, statin
SIADH	
Hypervolemic hypotonic hyponatremia
Hypervolemic hypotonic hyponatremia
Admission Na
Patient has symptoms of nausea, vomiting, and increased fatigue and somnolence
- Collect urine Na, urine Cr, urine osmolality, serum osmolality, TSH, T4 and morning cortisol
- Q4h Na checks and neuro checks
- Fluid restriction < 1 L/day
- Na restriction - caution w/use of salt tabs as can worsen edema and hypervolemic hyponatremia iso heart failure
- Continue Lasix diuresis
- Goal 4-6 mEq increase in Na for the first 24 hours to avoid osmotic demyelination syndrome
- If overcorrection occurs, will add D5W at ~150 cc/hr for 2 hours and give desmopressin 2mcg IV Q6h if with  Q2h Na checks
Indications for Emergent HD
Acidosis: pH <7.2
Electrolytes: K >6 or rapidly rising
Ingestion: Lithium, ASA, methanol/ethylene glycol, metformin, phenobarbitol, dabigatran)
Overload: diuretic-refractory
Uremia: encephalopathy, pericarditis, coagulopathy with bleeding
Access	ouble-lumen central catheter (tunneled or temporary, ↑ infection); AV graft (↓ maturation time but ↑ thrombosis and long-term complications); AV fistula (↓ infection, ↓ overall mortality vs catheters/AVG, but 6+ week maturation time + 50% primary failure rates)
AGMA Anion Gap Metabolic Acidosis
pH ***, CO2 ***, AG ***
lactate ***
- consider HCO2 pushes
AKI
AKI
Ddx: pre-renal (hypovolemia vs cardiorenal)
- f/u urine Na (FENa <1% pre-renal, FEN >2% ATN), Cr, urea (if on diuretics), osm (>500 pre-renal)
- f/u renal US to r/o hydronephrosis or chronic disease (BMC Nephrol 2013;14:188)
- consider adding C3/4, ANCA, anti-GBM, ANA, anti-dsDNA, HBV/HCV/HIV, cryo, SPEP/UPEP/FLC if evidence of intrinsic disease
CKD
Chronic Kidney Disease
Stage 1 >90, Stage 2 60-89, Stage 3a 45-59, Stage 3b 30-44, Stage 4 15-29, Stage 5 <15
GFR *** (GFR <60 or albuminuria >30mg/d for >3 months JAMA 2015;313:837)
Etiology: DM (44%), HTN (29%), cystic kidney disease (20%)
- f/u renal US if new dx
- goal protein <500-1000mg/d (NEJM 2013;369:1892) >> ACEi/ARB
- goal BP <130/80 (ACEi, non-DHP CCB, furosemide)
- goal Hgb 10-11.5 | IV iron for transferrin sat >20% (hold if ferritin >500)
- ASA, statin, exercise, smoking cessation given 2-4x elevated CVD risk
- diet: Na <2g/d, fluid <2L/d, protein 0.6-0.8 mg/kg/d
- goal HCO3 >22 | NaHCO3 650-1300 mg BID may slow progression (JASN 2015;26:515)
GLOMERULONEPHRITIS
Glomerulonephritis
- f/u UA, C3/C4, ESR, CRP, HBV/HCV, HIV, SPEP, FLC, IgA, ANA, dsDNA, Sm, ANCA, anti-GBM, FR, cryo, anti-DNAse, ASO

- rapidly progressive (decrease GFR >50% in 3 months) consider methylprednisolone 500-1000 mg IV qd x3 days + rituximab
HYPERKALEMIA Hyperkalemia
K ***
- f/u EKG
- Ca gluconate, lasix, insulin + D50, albuterol
HYPERNATREMIA Hypernatremia
Ddx:
Admission Na:
Free water deficit: TBW(ideal body weight x0.4 men or 0.5 women) x (Na/140-1)
- f/u BMP q6h
- goal Na increase 1-2 per hour
HYPONATREMIA
Hyponatremia
Ddx:
Admission Na:
- f/u BMP q6h
- f/u serum Osm, >300 = hypertonic hyponatremia
- f/u urine Osm, >100 = appropriate ADH
- UNa <30 = hypovolemia
- Uurea if recent diuretics
- goal Na: increase 4-6 in 24h
NEPHROLITHIASIS Kidney Stone
Non-con CT:
UCx:
- NS @150 mL/h
- tamsulosin 0.4 mg PO daily for ureteral relaxation
- opioids
NEPHROTIC SYNDROME
Nephrotic syndrome
Etiology: loss of podocyte integrity with podocyte foot effacement
Presented with: proteinuria >3.5g/d, albumin <3, periorbital edema, HLD
Classifications: DM (most common), FSGS (AA, viral, NSAIDs, heroin, obesity, CKD, hypoxia), minimal change (NSAIDs, HL), C3GN (HCV, SLE, lymphoma, MM), membranous (APA, SLE, HBV/HCV, syphilis, solid tumors), amyloid (MM or chronic inflammation)
- f/u UA, spot urine protein/Cr ratio, Hgb A1c
- if A1c normal, consider ANA, anti-dsDnA, anti-PLA2R, SPEP, FLC, HBV, HCV, HIV, C3/C4 + nephrology consult
- consider steroids, ACEi, statin
SIADH
Hypervolemic hypotonic hyponatremia
Hypervolemic hypotonic hyponatremia
Admission Na
Patient has symptoms of nausea, vomiting, and increased fatigue and somnolence
- Collect urine Na, urine Cr, urine osmolality, serum osmolality, TSH, T4 and morning cortisol
- Q4h Na checks and neuro checks
- Fluid restriction < 1 L/day
- Na restriction - caution w/use of salt tabs as can worsen edema and hypervolemic hyponatremia iso heart failure
- Continue Lasix diuresis
- Goal 4-6 mEq increase in Na for the first 24 hours to avoid osmotic demyelination syndrome
- If overcorrection occurs, will add D5W at ~150 cc/hr for 2 hours and give desmopressin 2mcg IV Q6h if with Q2h Na checks
Indications for Emergent HD
Acidosis: pH <7.2
Electrolytes: K >6 or rapidly rising
Ingestion: Lithium, ASA, methanol/ethylene glycol, metformin, phenobarbitol, dabigatran)
Overload: diuretic-refractory
Uremia: encephalopathy, pericarditis, coagulopathy with bleeding
Access ouble-lumen central catheter (tunneled or temporary, ↑ infection); AV graft (↓ maturation time but ↑ thrombosis and long-term complications); AV fistula (↓ infection, ↓ overall mortality vs catheters/AVG, but 6+ week maturation time + 50% primary failure rates)

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