1.

SUinPNCinafaraacutizarii

densitateurinarajoasa(scadecapacitdeaconcNa)

proteinurie<1g

piuriapoatelipsi

bacteriurie

cilleucocitari,celrotundeleuco

hemocultura+inacutizare

2.Acetazolamidadoza,compr,ind,efsec

pefoi

ind:alcalozametabolica,respiratorie,Cordpulmcrcompensat,atacacutde
glaucom

mact:lanivTCP

inhanhidrazacarbonica>scadeformacidcarbonic>scadesecrdeH+>
scadeschimbulNa/H
doza:cp250mg

efsec:acidozametab(maifrecvlavarstnici),HiperCl,hiperglicem,
miopatietrecatoare,hipoK,HiperUricem

3.PatogeniaHTAinstenozabilatdeaa.ren

obstraren>hipoperfrin+stiminexcesasecrdereninaincelmioepitale
arterioleiaferente.

angiotensinogen>angiotensinaI(catalizderenina)>angiotensinaII(cat:
ECA)

AngII>cresteTAprin2mec:vasoconstrsiretentiehidrosalina

HTARVerezacestor2act,hiperreninemiaeresponsabdecresterea
imediataaHTA,iarpersistentaedataderetentiahidrosalina+lezde
nefroangiosclerozadinrinichiulcontralat.

Dacastenozaestebilatsauperinunic,HTAdevinerapidvolumdep;
episoadeleEPAlapacHTAcuretentiesiVSputinhipertrofiatsugereazadg
desclerozabilat.

4.IndaleDP(dializaperitoneala)
 absolute:

o
lipsaaborduluivascularpthemodializa
alergielaheparina
sdhemoragipare

majore:

o
IRA,IRC,IRChipercatab
EPAcarenecesitatransferlent,custrescardscazut
temporarptIRCetionec
temporarpericardite,AVC

altele:

o
ICCneresponsivaladiuretice
pancreatitaacutanecroticohemoragica
hiposiHipertermie
afectaremetab
intoxmedicam

discutabile:

malnutritie,herniehiatala,BRGE,gastroparezadiabeticasevera

5.ITUladiabetic:patogenie,complicatii
 factfavaiinfurininnefropatiadiabetica:

o
angiopatia
neuropatia>staza
infgenitaledevecinatate
glicozurieGluinurinaeunexcelentmediudecultura
>uretritasivaginitadiabetica,pecaleretrogradanefropatiediabcunecroza
papilara
disfctleucocitarecaractdecompensarilormetab

complicatii:

septicemie
necrozapapilara
abceseren
PNemfizematoasa

6.densitateaurinara1005,proteinurie0,5g/24hdgposibile

o
NTIC,NTIA,NTAisch/tox,IRAfazadereluarea
diurezei,ICC(stazaretrogr)poliurieeliberatoare

leziunidirectetubulare

admdediuretice

7.AnommetabfosfocalcicinIRCvezi68.
 8.IRAhipercatabolic:elemcaract

cresteuremia>50mg/dl/zi

crestecreatininemia>1mg/dl/zi

cresteK>0,5mEq/zi

9.Piuriasterila:cauze

tbcurogenit(hematur,pHurinacid,polakiur)

calcullaJVU,migrare

tumorialecailorexcr,deshidr,analgetice,infcuC.trachomatis,U.
urealyticum,BPR(bpolichisticaren)

10.IndHDinIRA

absolute:

HiperKseverasi/sauprogresiva
acidoza/alcalozametabsevera
incarcarevolemicamarcatacuperturbfct
diverselororgane
 complicGIsineuroaleuremiei
pericarditauremica

relative:

tulbCV:aritmii,HTA,
anomaliimetab:Hiperuricemie,hipoNa<
125mEq/L,hipercatabprot

orientative:

oligoanuriededurata>3zile
ureesg>150mg/dl
C>68/dl
varsta>60ani

11.Solutiamolaradebicarbonatconcentratia

8,4%=23mEq/kg

corectareaechilibacba

12.Elemnegativealetransfuzieilarenalulcronic

suprimafocareleendogenedeEPO

supraincarccuFeadiforg:ficat,pancr,cord(inadmrepetata)

risccrescdetransmahepatiteivir,HIV,CMV
aducAgHLAstrainecudezvdeAccitotox,ceeacecresterisculderejetin
cazulunuitransplantrenal

potaccentacidozasiHiperK

13.ComparatieHDhemofiltrare

HemofiltrlapaccuIRAinstabhemodinam(postintervCV,socseptic)

permiteelimuneicantimpdeultrafiltrat,

Hemodializa:Hemofiltr

instabilithemodininitialstabhemodinam

dezechhidroelectrsiacidoblipsadezechhidroelectr
brutale

(alcaloza,acidozametab,hipoNa,corectiaagresivaadezechac
ba

hipo/HiperK,HiperCa)

sefacede3ori/saptimobilizprelung

14.Modifsugestivepentrumielomulmultiplulafelsipt38
pefoi/dintratat

15.ValoriletintaaleHbincursultratcuEPO

pefoi/dintratat

16.Renagel(sevelamer)doza,modadm,ind

pefoi/MemoMed

17.SUinPCCinafaraacutizarii

normal

18.Indterapeuticedozaunicadeantibiotic
ITU(joase,necompliclafemei)fluoroqsaubiseptol,profilaxITUla
femei,dupacontactsexual

infgonococice(uretrale,endocervicale,vaginale)

19.Miofilinnumelesubst(DCI),dozacompr,dozafiola,mact,efsec

pefoi/MemoMed

aminofilina

caps100mg

solinj24mg/ml,Fi10ml

20.Modactaldiureticelordeansa

inhcotranspNa,K/2Cl

actioneazalanivsegmascendentalanseiHenleinhreabssariifaraapa

duratadeact:26h
 riscde

hipoNa,
hipoMg,
hipoK(aritm),
hipoCa(cresteelimurindeCa)

21.TriadaactivariiSRAA

reninasecrlanivapjuxtaglomcaurmascaderiipresdeperfren(sau
vasoconstraferenta),ascaderiiconcdeNalanivmaculeidensasauastim
receptbetaadrenergicirenali.

reninacatalizeazatransfangiotensinogenuluiinangI,caresubactECA
devineangII

efangII:

crestetonusvasomotoralvaselorderezistenta

crestetonussimp

stimreabsdeNaprinefectdirecttubular,limitareanatriurezeidepresiune

stimfactdecrest,cufavhipertrofvascsiafibrozeiglom

stimsecrdealdost,carestimreabsdeNa

22.GauraanionicavalN
reprezintaconcentratiaanionilornemasurabili:proteinat,fosfat,sulfat,
anioni,aciziorganici

(Na++K+)(Cl+HCO3)=16+/2mEq

sau

Na+(Cl+HCO3)=12+/2mEq

val>15mEq/Lindicaoacidozametabolica;exceptie:acidozeleaparutedupa
administrareadesarurideanionianorganici(lactat,aa,peniciline)

23.Etionefropatiabalcanica

MostrecentstudiessuggestthatBalkannephropathyresultsfrom
contaminationofwheatflourwitharistolochicacids,whicharederivedfrom
theseedsofAristolochiaclematitis.Analysisoftherenalcortexofpatients
withBalkannephropathyidentifiedDNAadductsderivedfromaristolochic
acid.Thus,thediseasemostlikelyoccursingeneticallypredisposed
individualswhoarechronicallyexposedtoacausativefactor(aristolochic
acid)intheenvironmentwithinendemicareas.

Comprehensive_Clinical_Nephrology__Expert_Consult___Online_and_Prin
t__Fourth_Edition,p756
altiagentitoxiciimplicati:substantetoxicedinlignit

24.RegimaliminODR

pefoi

restrictiafosforuluidinalimente(lapte,lactate,carne)regimhipoprot

dietapoatefisingmasuradereducereafosfatilorinpredializa

dinsubiectelerezolvatedeOanaDanciu:

3035kcal/zi

prot1,3g/kg/zi

aportNaaprox2g/zicu130mmoliinsoldeD

restrictiedeK(nuinexcescartofi,banane,rosii,pepene,dovleac,spanac,
lapte,sucdeportocale)

aporthidric7001000ml/zi

saevitemancarurilecucontcrescutinCho

restrictiedeP(mancareprocesatasau>de50gprotpezi)

posibilsuplimcuvitDsiFe
 lapaccucrampevitC(250mg/zi)sivitE(450UI/zi)

25.Indpunctieibiopsierenale(PBR)

pefoi/dintratat

26.CIDP

pefoi/dintratat

27.CeluleleSternheimerMalbinsemnif

leucocitetumefiateinurinihipotone(cudensitate
mica)
suntperoxidazo+
aparspecificinPNCdacasunt>10%din
leucociteledinurina
contingranulatiievidprincoloratieicuvioletde
gentianasisafranina("glittercells"/celulestralucitoare)
28.LezanatopatGNDAPS

pefoi/dintratat

dinnotite:

MO:prolifdifuzaacelendot,infiltrcuPMN;disparespdefiltrare(se
scurtcircuiteazaglom)

ME:depoziteelectronodensedispusesubepit

Imunofluorescenta:depozitealcdinIgGsicompl

29.FcttubularainNTA(necrozatubularaacuta)vezinotapeevernote

30.SUinlitiazacoraliforma

pHurinaralcalin

piurie
 Only during infections with urease-producing organisms will there be
a simultaneous elevation in urine NH4+, pH, and carbonate
concentration.

31.EfsecaleIEC

scadRFG,crescC
IRAlabolncuanompreexistentealvascren
HiperKprinhipoaldosteronismhiporeninemic
bronhospasm
vasoconstr
tuse
eruptiicutanate
hTA
neutropenie

32.IndsiCIalecarbonatuluideCainODRvezi71

ind:chelatordefosfat,corecteazapartialacidozametab

efsec:HiperCa,maialeslapactrataticucalcitriol,intoxaluminica,
constipatie

tratsubcontrolulCaemiei
33.Proteinuriainlitiazaurinara

b Wilson da Hypercalciuria, renal calculi, hyperphosphaturia, partial

fanconi, syndrome,proteinuria, distal tubular acidosis

proteinuria apare ca ef sec al tratamentului medicamentos pentru

cistinurie:

D-Penicillamine or -mercaptopropionyglycine form solu-ble

heterodimers with cysteine and thereby reduce the cystine available
for crystallization, but both can produce loss of taste (remediable
through zinc supplementation), fever, proteinuria, serum sickness
reactions, and even nephritic syndrome.

defecte monogenice care cauzeaza hipercalciurie

Dent's Disease (X-linked recessive nephrolithiasis, X-linked

hypophosphatemic rickets, low-molecular weight proteinuria) - da
proteinurie tubulara
34.PseudoporfiriainIRC

=sensibilitatebuloasacaremimeazafizicsiclinicporfiriacutaneatarda

constituiedermatitabuloasaahemodializatilor

InIRCseprodoinhauroporfirinodecarboxilazei,careinflsinthepaticade
porfirina,ceeaceducelasupraproductiadeprecursoriaihemului(porfirine
fotoactive,careausiclearancerenalredus)cudepozitareaacestorain
tesuturi:

depoziteledefiercrescactivitateafotodinamicaaporfirinelor

lezkeratozicepotfisediuluneitransfneoplazice

35.TratpruritinIRC

Pruritulaparelamajorituremicilor;uneoriscadesaudisparedupadializa,
darpersistentasauaccentuareasaesteregula:circa6090%dintredializati
seplangdeprurit.

IRCeceamaifrecvcauzdepruritcronic.

CauzaprincestehiperparatiroidismulseccudepinpieleasarurilordeCa,P,
Mg.

Paratiroidectomiaduceladisparitiapruritului
Altecauzeluateindiscutie:HipervitamA,nevritauremica,prolif
mastocitelor,HiperserotoninemiasiHiperhistaminemiadializatilor,
subdializarea.

Alteori,pruritulaparepefondulunorlezcutanate:keratozafoliculara,
onicodistrofia,chiciurauremicilor(cristaledeureecareaparlauremie
>500mg/dl),uremide(depozitesubcutandeCa).

Lezdegratajinsotescpruritulsiilaccentueaza.

Terapiiincercate:mixturiemoliente,colestiramina,expunerealaUV,
antihistaminice,dietahipoproteica,alcoolIV,nicergolina.

Efterapcert:paratiroidectomiasubtotalasilidocainaIV(efeevidentdoar
pedurataperfuziei)

36.DgdifIRAprerenNTA(pebazaSU)

IRApreren:SUnormal;densitateurin>1020launpacoliguric
(mecanismeledeconcentrareurinarasuntintacte)+/pH<5,5(azotemie
preren);sedimenturinarsarac,cucatevacelulesiraricilindrihialini

NTA:proteinuriemica,celuleepittubulare,cilindrinecelulari,agranulosi
noroiosi;

urinamaronie,densit1010,pH67,prot:urmefine,sange:prezent,
sediment:hematii,leuco,celepittubulare,cilindriepitsipigm.

37.Teraplitiazeiurice
Curapermanentadediureza

Restrictiepurinicaatuncicanduricozuria>800mg/zi(viscere,peste,oaie,
animaltanar,cacao,cafea,linte,spanac)

Alcalinizareauriniimasuraobligat(preventie,catsirolcurativ,dizolva
calculiiexistenti)estemasuraceamaiimpinteraplitiazeiurice

pHurinoptim:6,57

mijldealcalinizare:bicarbdesodiup.o.45lingurite/zi,citratdepotasiu30
60mEq/zi,THAM412g/zi

lapaclacarepersistaHiperuricozuriesauHiperuricemieduparestrictie
purinicasaulaceicucompliantascazutaladietaseadauga

allopurinolindozede200300mg/zi(lapaccugutasitofigutosidoze
panala400600mg/zi)

38.Nefropatiamielomatoasavezi14

39.IndsiCIaleAINSinbrencr
 40.CIPBR

Absolute

diatezelehemoragice(admdedesmopresina
permiterealizPBRlapaccutulbdecoag)
terapieanticoag(nusevafolheparina10ziledupa
PBR)
tumoraintrarenriscmajordediseminare
rinichiunicotehnicaprecisapoateevitacomplic

Relative

TAcrescuta
afectiunilefebrileimpunamanareabiopsiei
hidronefroza
abceseperinefretice
nefrocalcinozaextensiva
anemiasevera
IRCterminala
obezitateamarcata

41.CauzealeEPOrezistentei

deficientaabsoluta(feritinaserica
<100micrograme/L)sirelativa/functionaladeFe(feritinasericaNsau
scazuta(?euaszicemaidegrabacrescuta),darsaturatiatransferinei<20%,
nreritrocitehipocromepefrotiu>10%,VEM<80micronilacub)
 infectiilesauinflcron
neoplaziile
malnutritia
deficientelevitam(B6,B12,C),acfolic
HPTHS
medicamente(IEC)
toxineleuremice(inpredializasauincazulunei
dializeineficiente)
intoxicatiacuAl(seelimnumairenal)
dozeinsuficiente

42.SUGNCacutizata,formacuSN(sindromnefrotic)

proteinurie>3,5g/zi/1,73m2

lipuriecorelatacuhiperlipemia(crucideMalta)

cilindrihialini,granulosisaugrasosi

43.Izostenurialaprobadeconcentratie

izostenuria=densituriniide1010,aceeasicuaplasmeideproteinizate

probadeconc=probafunctrenala;seimpunerestrictiedelichide(max
800ml)pt1824h.
scadereacapacitconc=semndesuferintatubularaprimarasausecunei
nefropatiiinterstitiale

scaradensiturinare:

N=10021020

eustenurie=10181022

izostenurie=1010

subizostenurie=<1009

44.Opsiuriacauze

=elimcuintarzierealichingerate

celmaifrecvdecauzaextraren:HTP,InsufHep,b.Addison,tulbabs
digestiva

tulburareaabs,transpsicontroluluihormonalalcircuituluiapei

cirozahep+HTP

tulbsecraldosteronului
hipoADH

Hiperestrogenism

45.Hiperhidratareaextracelularatratvezi88

46.Diazoxiddoza,m.adm,ind

actiune:

scadeelibinsulineidincelulelebetapancr,ceeacecresteglicemia

relaxeazamusculaturanetedaavaselor(arterioleleperiferice)

efect:

scadeTA

cresteglicemia

ind:

urgentehipertensiveinclusivHTAseveraasociataboliirenale

hipoglicemia

doze:

afectarearenalanecesitareducereadozelor
injIVrapida(maiputinde30sec),13mg/kgpanaladozamaxde150mg

poatefirepetatadupa515minutelanevoie

dozeunicede300mgaufostasociatecuanginasiIMAsiAVC

efadverse:

tahicardie,hTA,

Hglicemie,

retentiehidrosalina,

rar:cardiomega,comahiperosmolaranoncetonica,leucopenie,trombocitop,
hirsutism

47.ClearanceureevalN,cumseface,etc

N=6070ml/min

definitiasiformulaclearanceului=volvirtualdeplasmapecarerineste
capabsaldepurezedeoanumitasubstintrunminut;

formuladecalcul:U*V/P(undeU=concentratiaurinaraasubst,mg/ml;
V=debiturinar,ml/min;P=concplasmaticaasubst,mg/ml)

conditiaesentialaestecadebitulurinarsafieminimum2ml/min
ClureenuesteunmkbunalRFGdeoarecedepderatacatabprotiarexcr
depdediureza;existasiexcrextraren

Unmkbunarfirapureesangv/creatininasangv,careesteinmodN=10;
introscadereacutaaRFG,insotitadescaderevolurin,Usangvcrestemai
multdecatCsirapU/Ccrestela2030.

valNureeserica=2045mg/dl

48.ClearancecreatininacauzealesupraestimariiRFG

oferaoestimaremaibunaaRFGdecatformulaCockroftGaultsipoatefi
aproxprinformula:

Clcreat=creatur(mg/dl)*volur(ml/24h)/creatserica(mg/dl)*1440min

ClearanceulcreatinineiestemaimaredecatRFGlaoricenivalfctren.

LaperscufctrenNcreatininaseexcrnumairenal;labolncuIRC,panala
2/3dincreatsepoateelimextraren,fiinddegraddemicroorgintest
reabscreatinineiaparenumailaoligurici,DZ,ICC,laacestiaClcreat<
RFG

barbati:97137ml/min

femei:88128ml/min

valNcreatserica=0,61,3mg/dl

49.ProteinuriainHTAE

microalbuminuria=crestexcrNaalbumineiinprezuneiproteinuriitotale>
150mg/zi;tranzitorie/permanenta;mkinHTAEcarese"renalizeaza"siin
nefropatiadiabeticaladebut,candavemHiperglicemsicrestRFG,darfara
lezglom

innefrosclerozaHTAproteinuriaesteminima(discreta),nedepasind
0,5g/24h

50.Polakiuriadiurnacauze

litiazavezicala
prolapsuterin

cistitaacuta

compresiepelvina(chisturi,tumora,sarcina)

sdhidropigentratcudiuretice

50b.AfectareareninSIDA

glomerulosclerozafocalasisegmentara(GSFS),nefropatieIgA

infectii

edemesevere,CsericN,Igcrescute,azotemiecrescuta

tratsimpcurestrictiesalina,diuretice,suplimprot

tratprecocecuzidovudine

HD

50b'.SUinSIDA:proteinuriemasiva>3,5g,hematurie

51.HTAsialcoolulpatogenie
Thereisalinearrelationshipbetweenalcoholconsumption,BPlevels,and
theprevalenceofhypertensioninpopulations.45InJapan,alcoholintake
above300g/wk(aboutthreedrinksperday)wasassociatedwith
significantlygreaterincreasesofBPduringa7yearperiod,andbaselineBP
washigherindrinkersconsuming200g/wk,withtheeffectsmoremarkedin
men.46,47Heavydrinkingisassociatedwithincreasedriskofstroke,
increaseinBPafteralcoholwithdrawal,andattenuationofanti
hypertensiveefficacy.Paradoxically,alcoholhasaJshapedrelationship
withcoronaryheartdisease,withmoderateconsumption(1to2drinksper
day)havingthelowestrisk.Inalargeepidemiologicstudy,modestalcohol
consumptionwasprotectiveagainstfirstmyocardialinfarction.48Alcohol
mayincreaseBPthroughactivationofthesympatheticnervoussystem,
whereasitsprotectiveeffectsincludeincreasingHDLcholesterol,lowering
fibrinogen,andinhibitingplateletactivation.TheJNC7guidelines
recommendlimitingalcoholconsumptiontonomorethantwodrinksper
day(24ozofbeer,10ozofwine,or3ozof80proofwhiskey)inmostmen
andnomorethanonedrinkperdayinwomenorlighterweightmen(seeFig.
34.1).

52.FumatulsiHTA

Cigarettesmokingisawellestablishedmajorriskfactorforcardiovascular
disease,butitsroleinthedevelopmentofhypertensionisnotwell
elucidatedandnotroutinelyincludedinrecommendationsforprevention
andtreatmentofhypertension.1Therelationshipwithhypertensionmaybe
confoundedbychangesinweightduringandafterthecessationofsmoking.
Inalargeepidemiologicstudyofmiddleagedandoldermenfromthe
UnitedStates,smokingwasassociatedwithamodestbutimportantriskfor
developmentofhypertension;butinastudyofTurkishadults,current
smokingcarriedaborderlineprotectiveeffect,whereasformersmokerswith
abdominalobesityhadahigherriskofincident
hypertension.43,44Nevertheless,smokingincreasesoverall
 noncardiovascularandcardiovascularmorbidityandmortality,andall
smokersshouldbeadvisedtoquit.

53.FactderiscaiHTAlaEPO

IntimpulterapcuEPOpotapareauneler.a.InstalareaHTAsauagravarea
uneiHTApreexistestenotatafrecvintimpultrat.

InetiopatHTAsuntimplicmaimultifact:

cresterearezistperifprininlaturareavasodil
compensat
crestvascozitsangv
lipsadecorectielauniibolnaDClacorectarea
anemiei
crestereaproductieideendotelina
efectulpresordirectalEPO

54.HTAunisi/saubilatmecsidiferente

55.Cauzeanatopatalestenozeia.rendpvalvarstei

56.TratHTArenovasc

instenozabilatdeaarennusedauIECsinicidiuretice
sedahidralazinftalazine(vasodildirecte)
hipopresol25mg/fi=Neopresol

bloccanCa:nifedipinasubling1/8h

minoxidil,metildopa

clonidina0,1mg/cp,0,15mg/cp,0,3mg/fi

diazoxidincriza300mg/fi

nitroprusiatdeNa12%

ultimele2subcontrolTA

dintratatulluiCiocalteu:

Medicalrec,deexceptie,doarcelorcuCIptprocedeelederevascularizare
(varstnicicupatolasocimp)

particdetrat:

IECsiBRAscadTA,darcupeazaefdementinereaRFGpecareilareAT
IIpeunrinisch:potcrestevalR.A.siaccentueazadistructiaglominrin
hiperperf.

inHTARVnuexistaoscaderenoctaTA>sevoradmantihipertensivecu
actprelungita;suntpreferateblocantelecandeCa.

Procedeeinvazive:

1.angioplastiarentransluminalapercutana

tehnicaprefinmajcazurilor

avantaje:

spitaliz,costreduse,riscredusdecomplic
 procedeuclasicimbunatatiprinintrodstenturilor

rezultate:

indisplaziafibromusc:60%vindecare,35%ameliorare

instenozaarteriosclerotica:22%vindecare,57%ameliorare

complic:hematom,emboliedecolesterol,disectiasauocluziaa.ren

2.reconstructiachirurg

Indintervchirinocluziacompletaaa.ren:

aparenefrogramasiexistacirccolatlaangiografie
diametrullongitudalrin>9cm
existalateralizareasecrderenina
nefroniviabililaPBR
urinaprezlaexamprincateterizarebilat

arerezmultmaislabeinstenozaarterioscleroticadea.ren

ischrenincursulintervtbsafie<3040min

dacaintervereusita:

normalizTAla46hdupaoperatie
rincresteindimens
Cscadecu>20%

50%vindec
30%amelio

5%mortalit

indisplaziefm:8090%vindecare

tehnicidereconstructiechir:

a.endarterectomiadoarlabolnlacarepredomlezostialesaucandcalea
deabordeaortica;

b.revasccubypassaortorendinvenasafena,arterahipogastrsauDacron
eceamaifrecvintervlaceiculezdistale

c.alteproceduri:reinsertiaa.ren,bypassextraanatomic(splenorenal,
hepatoren)

3.Nefrectomia

recinurm3situatii:

fctrenredusasauabsenta

dupaocluziauneiincercariderevasc

lezalea.rennecorectabprinrevasc

57.Supraveghereapostopinfeocromocitom
dozajcatecolamineurinare,dupa15zile,apoianual

58.Afectiuni,situatiiincaregasimHTA+hipoK

hipoKapareprin:

crestereaelimurinare(dathipercorticism,diureticeindelungadm,NTI)

pierderiextrarendeK(varsat,diaree,laxative)

sdLiddle(mutatieADsecrexcesivadeKsiHlanivtubular,curetentiede
Na>HTA+hipoKlavarstetinere,alcalozametab)

sdConn

reninoame

59.Efsecaletiazidicelor

HiperCa(crescreabstubularadeCa)

hipoNa

hipoK
Hiperglicemietolerantalaglucozaalterataimpiedicapreluareaglucozei
inmuschisificat

Hiperuricemieguta

hipovolemie

alcalozametabolica

letargie,greata,ameteli,dureridecap,constipatie

dislipidemii

vasculite

trombocitopenie

efaditivcuvarstainaintatainhdilutiaurinara,spredeosebiredediureticele
deansa,careinhdilutiasiconcentrarea

estede12xmaiprobabilcatiazidicelesaproducahiponatremiedecat
diureticeledeansa

60.CIaletiazidicelor

61.ElemanatopatinGNDAPSsugestiveptevolfav

62.ElemclinsiparaclininGNDAPSsugestptevofav
63.SUinGNDAvsGNRP

posibilidentic

64.CauzeleanemieiunuibolncuGNDA

anemiedetipdilutionalcuhipoNa

pierdesangesiprinurina(hematurie)impdacaestemacroscopicasi
prelungita

65.Tratnefropatieilupicetip1si2

Cortizonulestesuveraninlupussieindicatintoatetipuriledelezpecarele
intalniminnefropatialupica,reducandratamortalitatii,cuocrestere
semnificativaadurateideviata.

Caregula,corticoteraptiaesteCIinGNcuIRC,darnefropatlupicaesteuna
dintrerarelesituatiiincarecortizonulerecomindifdenivelulcreatininemiei

Frecv,inpofidaefhipercatab,valretentieiazotatescad,dupainitierea
corticoterap
Formelecuproteinurie<1g/Ldetipselectivnunecesitadozemaimaride
1mg/kg/zi

Ingeneral,theclinicalcorrelatesoftheISNandWHOclassification
systemsaresimilar.3,4PatientsassignedtoISNclassIusuallyhaveno
evidenceofclinicalrenaldisease.Likewise,patientsinISNclassIImay
haveelevatedantidsDNAorlowcomplementlevels,butingeneral,their
urinarysedimentisinactive,hypertensionisinfrequent,theGFRis
preserved,andproteinuriaisrarelyabove1g/24h.PatientswithclassI
andclassIIbiopsyfindingshaveanexcellentrenalprognosisunlessthey
transformtoanotherpattern.Anexceptiontothispresentationarelupus
patientswhopresentwithminimalchangenephroticsyndromeorlupus
podocytopathy.21Theyhavethesuddenonsetofnephroticsyndromewith
renalbiopsyspecimensshowingnoabnormalitiesonLMorclassIorclass
IIchangeswithextensivefootprocesseffacement.

UseoftheISNbiopsyclassification(seeFig.25.3)canserveasaguideto
initialtherapy.14,30Ingeneral,patientsassignedtoISNclassIandclassII
neednotherapydirectedatthekidney.Themajorityofpatientswillhavea
benignlongtermoutcome,andthepotentialtoxicityofany
immunosuppressiveregimenwillnegativelyaltertheriskbenefitratioof
treatment.Anexceptionisthegroupoflupuspatientswithminimalchange
syndromeorlupuspodocytopathy(seeearlierdiscussion).Thesepatients
respondtoashortcourseofhighdosecorticosteroidsinafashionsimilarto
patientswithminimalchangedisease(MCD).21
 Corticosteroidtherapyisusuallyeffectiveinsubsidingtubulardysfunction
andpreservingrenalfunction.

66.CauzeasocIRCcarepotagravaanemia

InIRCanemiaesteregulalaC>3mg/dlsievolparalelcualterareafctren.

Anemiaestenormocroma,normocitara,cunrdereticulociteNsauscazut,
sideremie,transferinasiferitinaN,maduvaN,eritrocitefragmentatepot
apareapefrotiuldesgperif.

EtiopatoganemieiinIRCestemultifact.Cauzaprincipalaestedeficitulde
prodaEPOlanivrininsuficient

Sepotadauga:

inheritropoezeiprintoxineuremice:spermina,
spermicina,lipidepolare,PTH(inducefibrozamedulara),"moleculemedii"
hemolizacronicaproddetoxineleuremice,
rigidizareahematiilorprinHiperP,Hipersplenism
deficituldeFelapaccusangerari
deficituldeacfolic(aportdeficitar,medicamente
antifolice)

HDnuamelioreazaanemia,ciadaugafactagravanti:

hemolizacronica
deficituldeFe
deficituldefolati
transfuziilerepetate
 acumulareaAldetanemiemicrocitara
HPTHSsever
heparinafavsdhemoragice

67.CauzealeEPOrezistenteivezisubiectul41

68.Cele4anomaliialemetabfosfocalcicinIRC.

Scadereacalcitriolului,hipoCa,HiperPsiHiperPTH

7dehidrocolesterolulsubactUV>colecalciferol(vitD3).Ptadeveni
activavitD3trebuiesasufere2hidrox:primasubact25hidroxilazeihepsi
ceadeadouasubact1alfahidroxilazeirendinTCP,TCD>calcitriolul

stimuliiprincipaliai1alfahidroxilazeiren:scadereaPTHplasmaticsi
hipoCa

factinhprinc:HiperP

CalcitriolulscadesintPTH,cresteabsdeCa,P,mineralizosteoidulsi
mobilizeazaCa.

Pierdereaprogresivaanrdenefronifctactividucelascadereaprodrende
1alfahidroxilazacuscadereaconsecacalcitrioluluiseric

acidozametabolicainhprodde1alfahidroxilaza

toxineleuremiceacumulintes>rezistentalaactiuneacalcitriolului
Scadereacalcitriolului,hipoCasiHiperPsuntfactspecifIRCcarestim
directsiindepunulfatadealtul,sintsielibPTH.HPTHSdinIRCeomodif
adaptativaaorganismuluiinincercaredeapastraechilibPCa.Cresterea
PTHnueinsotitadenormalizCaemieidincauzarezisttestintalaPTHdin
cauzaacumultoxineloruremice.HPTHSreprez60%dinafectosoasespecif
ODRsiapareprecoceinIRC(clearancedecreat<30ml/min)

Stimdelungadurataaglparatirpoateducelaprolifmonoclonacel
glandulare,cazincaresecrdePTHarelocaberantsiindepdenivserical
calcemieisicalcitrioluluiHPTHtertiar(PTHde1012xN;HiperCa,
HiperP),raspnumailaparatiroidectomie

DeficientadevitD3nativa(substratul1alfahidroxilazei)prinscaderea
expuneriilasoare,asintezeicutanateprinrezistentacrescutaapielii;
pierderiledeproteineceleagavitD3inplasma(inSN,DP)

69.Chelatoriifosfatilor

RetentiadePsiHiperPaparlatotipaccuIRCstd5deoareceexcrPinurina
esteinsuf,nusuntneobisnuitevalde67mg/dl(N=4,55,2mg/dl,laceicu
IRC5:3,55,5);existalimitaritehnicecarenupermitoindepartaresuficienta
aPprinHD,DPconventionale.HDzilnicanocturna>hipofosfatemie
ChelatoricareleagaPinlumenulintestinal,seadmlamese.Sefolosea
hidroxiduldeAl,darareriscderetentiesitoxicitatedacaesteadmmaimult
de23sapt.CitratulcresteabsintestinalaaAl,trebuieevitat,

CompusicareleagaCa:

AcetatulsicarbonatuldeCaeficacitatesimilara

SaruriledeCascadnivplasmaticdeP,darsuntnecesaredozemari(se
ajungesila46g/zi;inasoccucapacscazutadeexcraCariscde
calcificaretesmoi,vase).aportuldeCatrebuielimitat,conformghidurilor
K/DOQI,la2000mg/zipentrupacientiidializatisuntnecesaricompusi
faraCa.

CompusifaraCa

SevelamerpolimersinteticcareleagaPinlumenulGIsiiiscadeabs.Nu
contineCasauAl.

LafeldeeficientprecumacetatuldeCaptcontrolulnivPplasmatic,dand
multmaiputineepisoadedeHiperCa

Dozede56gaufostsuficienteptmentinereaPla5,86mg/dllapacHD.Pt
uncontrolmaibunalnivPsuntnecdozemaimari.

SevelamerscadenivplasmaticalcolesteroluluitotalsialLDL,crescand
HDL.

LantanumcarbonatchelatorputernicdePindlapacdializati.Capacitatede
chelarecomparativacuahidroxiduluideAlsimaimaredecatacarbonatului
deCasiasevelamerului.
Dozedepana3000mg/zi.

Unprocentmicdelantanumesteabssisedepuneintes,inclhepsios,dar
nuaufostevidefadversedupa13anidetratament.

70.Calcimimeticele

suntactivatorialostericiaireceptorilorcusenzordeCacareregleazasecrde
PTHdecatrecelparatir

seleagareversibillaacestireceptsiscadpragulactivariireceptdecatreionii
deCaextracel

ex:cinacalcethidrocloridindinhiperparatirseclapacdializati

intesparatirinhsecrPTHdirectsiscadnivplasmdePTH

scadusorCa,Pplasmatic

r.a.hipocalcemiesimptomatica,tetanie

eficientsiinformeleusoaresiinceleavansatedeHPTHS

poatefiutilizatsingur,sauincombcuvitD

paccuIRCstd5hiperP,dificildecontrolat,impiedicafolvitD,agraveaza
HPTHS

terapiaconventionala(vitD)inHPTHSdaHiperCasiHiperP

HPTHSestecomunaprintrepaccuIRCusoarasimoderata,iarniv
plasmaticdePTHcresci.p.cufctren

cinacalcetdavariatiiciclicealeconcentratieidePTH(PTHscadedupao
oradelaadm,ajungelaunnivelminimdupa24ore,iarulteriorcrestein
restulzilei);acesteoscilatiialeconcplasmaticeaPTHauefanabolice,
troficeasuprametabosossieffavasupramaseiosoase,scaderisculde
fractura

cinacalcetinasocierecusuplimenteledeCasivitD>hipercalciurie,
nefrolitiaza,nefrocalcinoza,calcificarivasculare.

71.CarbonatuldeCainODR(doze,efpoz,efsec,CI)

ind:HiperP,HDsauDP,IRCfaraDcuP>1,78mmoli/L

CI:HiperCa,HipervitD,HPTH,tumoriosoase

efpozitive:

binetolerat

controleazanivsericedeCa,PsiPTH

aduceaportdeCa

cresteabsintestdeCa

corecteazapartialacidozametabolica

stimmineralizosoasa

efprofilactice
modprezentare:cprmasticabile:250mg,500mg

doze:25g/zi(panala15g/zi)divizatelameseleprincipale

efsecprinc:HiperCa,maialeslapactrataticucalcitriol,laceicuintox
aluminica,ceicuimobilizprelungita,saucubaplasticaosoasa

monitorizCaintimpultratesteobligat

aparitiaHiperCa>reducereadozelor,reducereaconcCainsoldedializa,
adaugareadechelatoricuAlindozemici

potapareacalcificlanictesmoi,vaselor;sdcalcifilaxiei

alteefsec:G&V,constipatia,diaree,anorexie,eructatii

72.IndalevitDactiveinODR+

73.PrecautiisiCIinutilizvitDactiveinODR

ind:

paccuIRCinstduremic

adultiisicopiiiinaintedeincepereadializei
profilacticlaadultisicopiiinaintedeincepereadializeidoarcuHPTHsi
dupacorectareHiperfosfatemie

modprezcalcitriol:capsulemoi0,25microgr,0,5microgr;solinj1
microgr,2microgr

profilactic:

VitDactiva(calcitriol)seadmindozede0,1250,5micrograme/zi(dedoua
orimaimicidecatcelefolositepentru1alfacalcidol)

risculcelmaimareincazdesupradozaj:HiperCa,HiperCauriacudezv
nefrocalcinozei,maialeslapacceprimesccronictiazidice(crescreabs
tubularadeCa).ptaprevaceastacomplicseincepeterapcudozemici
(0,125microgrcalcitriol)simonitperiodaCasericsiurin,Ecoren,PTH
seric(trattrebuieopritdacaPTHscadesub2xN)

intratHPTHSmanifestdozelevitDsuntmaimari:

sepoateincepecu0,5microgr/zicalcitrioloral,marindusedozainfctde
Caemie,PemiesiPTHseric

admintermitenta:1/saptoral/IV

precautii:sarcinasilactatia,calculirenali,afectCV

seadmcuprudentalapacdigitalizatideocareceHiperCapoateprecipo
aritmiecardiaca
efadv:letargie,vertij,febra,palpitatii,tulbdevedere,G&V,diaree,icter,
anorexie,constipatie,crampe,poliurie,HiperCaurie,HiperP,hematurie,
sete

CI:hipersensib,HiperP,HiperCa,toxicitlavitD

74.RegimaliminODRvezi24

75.Iatrogeniamedicamentoasacorelatacudeficitulfctren

(dinsubiectelerezolvatedeOanaDanciu):

CVdiuretice,betablocante,agvasodilat,IEC,ciclosporina,tacrolimus

Efectdirecttubular:aminoglicozide,amfotericinB,cisplatin,manitol

EfectpeTCD:AINS,IEC,ciclofosf,amfotericin,litiu

Obstrtubulara:metotrexat,aciclovir

Nefritaacinterst:betalactamine,vanco,rifamp,ciprofloxacin,AINS,
furosemid

GNFac:penicilamine

Fenacetina

76.Caresuntcorpiicetonici?
 acetona
acidulbetahidroxibutiric(nuesteocetona,ciun
acidcarboxilic)
acidulacetoacetic

(desisuntdenumiticorpi,suntsubstantedizolvate,nuparticule)

77.ExplicatiaprezenteilorinSU

AparinDZ,hipoglicemie,malnutr,alcoolism,Hipertiroidism,efort,curede
slabire,post,voma

O.Danciu:

alterareametabcarbohidratilor

metabolizuneicantcrescutedegrasimi

cetogeneazahepaticainstarideacidoza

varsaturirepetate

dietesevere

deficitdeinsulina(infectii,intervchirurgic)

78.Urobilinogenul
valNaleurobilinogenuluiurinar=14mg/24h

esteunpigmentbiliar

provinedintransfinintestinbilirubineisubactiuneabact;urobilinogenul
esteelimprinfecalesaureabs,fluxprinvenaporta,spreficat;opartescapa
incirculatie,fiindelimren

79.Candestecrescut?

inafectcare

1.crescproddebilirubina:

anemiihemolitice

anemiamegalobl

malarie

2.impiedicaficatulsacaptezeurobilreabs:

hepatitainfsitox,infarctpulm,angiocolite,CH,mononucleoza,ICC

admdeM:clorpromazina,fenotiazine,PAS

80.Candesteabsent?

obstructiacompletadecaibiliare

icterobstructiv
estescazutinlitiazacoledociana,canceruldecapdepancr

81.NatriurezainIRCpreren

[subiecteledela8188cuexceptia85si86iiapartinO.D.]

incazdesacdereafluxsangvptamentineRFGarelocvasoconsraa
eferente(AGII)sivasodilataaaferente(prinPG)cucrestereaconsecutiva
reabsNAsiureei

vomgasiNaurinar<20mmoli/l

rapBUN/creatinina>20/1

Osmurinara>700mmoli/l

FENa<0,01

FENa(elimfractionata)=(Naurinar/Naplasm)/(Creaturinara/Creatinina
plasm)

82.NatriurezainNTA

acelasimeccamaisusdoarca
Naurinar>40mmoli/l

BUN/creatinina<10/1

Osmolariturinaraaprox300mosm/l

FENa>0,02

83.Kaliureza<10mEq.Cauze

insuficientaadrenala

acidozametab

diureticeeconomdeK

84.Kaliureza>10mEq.cauze

diuretice=>scadereareabsNa=>crestereasecrAld=>cresteelimK

sdrBartersisdrGitelman=afectgeneticealetranspNalanivanseiHenlesi
aTCD

hiperAldI

acidozatubulararenalacucrestereaexcrdeK2cazuri:
proxsecrcrescutadeKdatoritasuneic%crescuteaNa

distafectecrdeiondeH

alcalozametab

altecauze:NTI,nefropatiitubulare,dupasaluretice

85.Formuladecalculaosmolaritatiisangv

(Na+10)*2+U/60+glicemie/180=285mOsm/kgapa

osmolaritatesg=285295mOsm/kgapa

osmolaritateurinara=8001200mOsm/kgapa

86.SolutiamolaradeKCl

Moddeactiune:necesarpttransmitereaadecvataaimpulsurilornervoasesi
pentrumentinereacontractilitatiicardiace,fctrensiechilibionic
DesioseriedesaruripotfiutilizptafurnizacationuldeK,agentulde
electieestecloruradepotasiuintrucathipoClacompaniazafrecventdeficitul
depotasiu.

Ind:profilaxiasitratamentulpierderiimoderate/severedepotasiu

CI:afectiunirenale,afectiunihemoliticesevere,b.Addison,HiperK,
deshidratacuta,distrugeretisularaexcesiva

Modprez:concentratptsolperfuzabila:7,45%,149mg/ml

dozaj,m.adm:

PerfIV:

Kseric<2mEq/L:400mEq/zilaoratacenudepaseste40mEq/h

Kseric>2,5mEq/L200mEq/zilaoratacenudep20mEq/h

Supradozare:HiperKusoara(5,56,5mEq/L)panalamoderata(6,58
mEq/L)poatefiasimptcuexcmodifECG
efadv:confuzie,bradicardie,deprimarecard,aritmii,stopcardiac,undeT
ascutite,prelungireaintervaluluiPR,largireacomplexuluiQRS.

GI:G&V,crampe,durere,diaree,ulceratiialeintestinuluisubtire

GU:oligurie

87.Semnemajorealeeficienteiterapindeshidratareaextracel

D.hipertona:

scadereasausuprimareaaportuluihidric

pierderilichidienedin:starifebrilecutahipnee,transp,diaree,varsat

comadiabeticahiperosmcudeshidratgeneralizata

D.izotona:

hemoragiiac

pancreatiteac

peritonite

arsuriintinse

toatecupierderedepalsma

D.hipertona:

BPR

nefritacupierderedesare
IRAinfazapoliurica

b.Adissson

admcrescutadefurosemidsiacetazolamida

aportinsufdesare

Semne:

oligurie

sete,limbaprajita,dificladeglutsivorbire

hipoTAcucolaps

scadereaDC,aritmii

globiocularihipotoni,adancitiinorbite

teguscate,ridate,cutate,pliucutanatpersistent

simamganditcaspuicadispartoateastea

88.Trathiperhidratariiextracelulare

Izotona:perfuzieexcesivacusolsalinaizotonaNaCl0,9%

HipertonaidemdarcuNaCl3%

HipotonaExcesdeADH,IC,ciroza,sdrnefrotic,IR
Trat:

restrictieNa,Cl

diuretice

hmofiltrare

punctiievacuatorii

albumina,plasmaexpanderifaraNa

restrictieapasisaresihiperhidratintracel

tratetiol(alEPAdeex)

89.Scrietiinclarpreferatioxigenoterapiacontinua/intermitenta
(argumenteptunasiptalta)

90.2dintreefmajaleminoxidilului

91.idempthidrazinftalazine

92.formainjahidralazinftalazinelorptadminurgentehipertensivedoze,
rapidit

93.finjdeclonidinadoze,rapidit

94.finjdenitroprusiatdeNaconc,doza,madm

95.colimicinacapsule500000UIinterapITUind,CI

96.gentamicinadoza,fi,kgcorp,ind,CI

97.efsecalequinolonelor

98.cele3elemesentialealedgtulbechilibacidobazic
99.valNuricemie

100.proteinurieHTA:corelatii

proteinuriamarkeralatingeriiren,initialaltulbhemodinam,leztubulo
interstitiale

HTApoatefisec

Cauzeletransferuluiunuipacientdelacardiologielanefrologie:

edemerefractare

retentieazotata

proteinurie0,5g,cuhematuriepersistenta>cauze>HTA,IC,staza
renala

IRAiatrogena

endocarditabacteriana>glomerulonefritefocare,emboliiseptice,infarcte
renale

IVSsecundarunuiIMA=>IRA

pericardita

tratamentHTA>prabusireTA>nefrosclerozahipertensiva

cateterism>substantadecontrast>IRA