Term
| which drug may damage the small vessels to cause acute kidney injury |
|
Definition
| calcineurin inhibitors - cyclosporine |
|
|
Term
| 2 endogenous causes of Toxic ATN to cause acute kidney injury |
|
Definition
| rhabdomyolysis, hemolysis |
|
|
Term
| 3 drugs to cause Toxic ATN and acute kidney injury |
|
Definition
| cisplatin, gentamicin, contrast |
|
|
Term
| 5 types of Abx that may cause acute renal injury by interstitial nephritis |
|
Definition
| penicillins, cephalosporins, quinolones, sulfonamides, and rifampin |
|
|
Term
| what are the urine findings in prerenal azotemia |
|
Definition
| FeNa <1%, hyaline casts in urine sediment |
|
|
Term
| 3 electrolyte disturbances associated with tumor lysis syndrome |
|
Definition
| Hyperphosphatemia, hypocalcemia, hyperuricemia |
|
|
Term
| 4 drugs which may cause nephrotoxigenic AKI |
|
Definition
| Aminoglycoside antibiotics, cisplatin, tenofovir, zoledronate |
|
|
Term
| urine findings nephrotoxigenic AKI |
|
Definition
| granular casts, tubular epithelial cell casts. FeNa typically >1%. |
|
|
Term
| urine findings in interstitial nephritis AKI |
|
Definition
| Eosinophilia, sterile pyuria |
|
|
Term
| 2 causes of interstitial nephritis AKI that are not drug related |
|
Definition
| tubulointerstitial nephritis-uveitis (TINU) syndrome, Legionella infection |
|
|
Term
| 2 triggers of TTP/HUS induced AKI |
|
Definition
| Recent GI infection or use of calcineurin inhibitors |
|
|
Term
| what is a skin manifestation associated with thromboembolic induced AKI |
|
Definition
|
|
Term
| a finding in serum and another finding in urine typical of atheroembolic induced AKI |
|
Definition
| hypocomplementia, eosinophiluria |
|
|
Term
| Complete anuria early in the course of AKI is uncommon except in the following situations |
|
Definition
| complete urinary tract obstruction, renal artery occlusion, overwhelming septic shock, severe ischemia (often with cortical necrosis), or severe proliferative glomerulonephritis or vasculitis |
|
|
Term
| 4 drugs which demonstrate crystaluria in acute kidney injury |
|
Definition
| acyclovir, indinavir, sulfa, amoxicillin |
|
|
Term
| when should sodium bicarbonate be administered in the setting of acute kidney injury |
|
Definition
| if pH <7.2 to keep serum bicarbonate >15 mmol/L |
|
|
Term
| what is a treatment to consider in rhabdomyolysis induced AKI |
|
Definition
|
|
Term
| cockcroft equation for estimated creatinine clearance |
|
Definition
Estimated creatinine clearance (mL/min)
= (140–age) x body weight (kg)
72 x PCr (mg/dL) |
|
|
Term
| 4 leading causes of chronic kidney disease |
|
Definition
Diabetic glomerular disease
Glomerulonephritis
Hypertensive nephropathy
Autosomal dominant polycystic kidney disease |
|
|
Term
|
Definition
| seen in CKD. ischemic necrosis of the skin d/t vascular calcification. seen in patients who are on dialysis and warfarin (the latter blocks GLP, which protects vessels from calcification) |
|
|
Term
| 8 reasons for anemia in CKD |
|
Definition
Relative deficiency of erythropoietin
Diminished red blood cell survival
Bleeding diathesis
Iron deficiency
Hyperparathyroidism/bone marrow fibrosis
"Chronic inflammation"
Folate or vitamin B12 deficiency
Hemoglobinopathy |
|
|
Term
| what is a GI phenomenon in CKD |
|
Definition
| Uremic fetor - a urine-like odor on the breath, derives from the breakdown of urea to ammonia in saliva |
|
|
Term
| endocrine abnormality in females with CKD |
|
Definition
| low estrogen levels - elevated rates of fetal loss |
|
|
Term
| a skin manifestation seen in patients with CKD who have been exposed to gadelinium |
|
Definition
| nephrogenic fibrosing dermopathy - induration of skin on arms and legs |
|
|
Term
| 5 CIs to renal biopsy in CKD |
|
Definition
| bilaterally small kidneys, uncontrolled hypertension, active urinary tract infection, bleeding diathesis (including ongoing anticoagulation), and severe obesity |
|
|
Term
| clues that help determine chronicity vs. an acute process (CKD) |
|
Definition
| metabolic bone disease with hyperphosphatemia, hypocalcemia, and elevated PTH and bone alkaline phosphatase, Normochromic-normocytic anemia, bilaterally reduced kidney size (<8.5 cm) |
|
|
Term
| what is the most common acute complication of hemodialysis |
|
Definition
| Hypotension, particularly among patients with diabetes mellitus |
|
|
Term
| 3 complications of dialysis for ESRD |
|
Definition
hypotension
anaphylactic reaction
muscle cramps |
|
|
Term
| complications of peritoneal dialysis |
|
Definition
| peritonitis, catheter-associated nonperitonitis infections, weight gain, hypoproteinemia, hypertrigliceridemia, hyperglycemia |
|
|
Term
| what should be the immunosuppressive treatment immediately after kidney transplantation? what should be avoided |
|
Definition
| Cyclosporine therapy prolongs ATN, and some patients do not diurese until the dose is reduced drastically. Many centers avoid starting cyclosporine for the first several days, using ALG or a monoclonal antibody along with mycophenolic acid and prednisone until renal function is established |
|
|
Term
| what treatment is mandatory in the first 48 hrs post kidney transplatation |
|
Definition
|
|
Term
| what is the role of ACEi and NSAIDs in the kidney transplanted patient |
|
Definition
| ACEi can be initiated several months post-op, where as NSAIDs should be avoided altogether |
|
|
Term
| what is the initial treatment for the first kidney rejection episode |
|
Definition
| methylprednisolone, for 3 days |
|
|
Term
| first episode of rejection: if methylprednisolone fails to aleviate the rejection process |
|
Definition
| antibody therapy: OKT3 or antithymocyte globulin |
|
|
Term
| what is the next course of action in rejection if methylprednisolone and OKT3/antithymocyte globulin fail? |
|
Definition
|
|
Term
| in kidney rejection, if renal Bx demonstrates an antibody-mediated injury, what is the course of action |
|
Definition
| plasmapheresis, immunoglobulin infusions, or anti-CD20 monoclonal antibody (rituximab) |
|
|
Term
| The Most Common Opportunistic Infections in Renal Transplant Recipients during the Peritransplant (<1 month) period |
|
Definition
Bacterial infections
Wound infections
Herpesvirus
Oral candidiasis
Urinary tract infection |
|
|
Term
| The Most Common Opportunistic Infections in Renal Transplant Recipients during the Early (1–6 months) period |
|
Definition
Pneumocystis carinii
Cytomegalovirus
Legionella Listeria
Hepatitis B
Hepatitis C |
|
|
Term
| The Most Common Opportunistic Infections in Renal Transplant Recipients during the Late (>6 months) period |
|
Definition
Aspergillus Nocardia
BK virus (polyoma)
Herpes zoster
Hepatitis B
Hepatitis C |
|
|
Term
| what is a feared complication in the immediate post op period of kidney transplantation |
|
Definition
| rapidly occurring pulmonary lesions, which may result in death within 5 days of onset - stop immunosuppression |
|
|
Term
| 5 absolute Indications for Corticosteroids and Immunosuppressives in Interstitial Nephritis |
|
Definition
Sjögren's syndrome
Sarcoidosis
SLE interstitial nephritis
Adults with TINU
Idiopathic and other granulomatous interstitial nephritis |
|
|
Term
| 4 relative Indications for Corticosteroids and Immunosuppressives in Interstitial Nephritis |
|
Definition
Drug-induced or idiopathic AIN with:
Rapid progression of renal failure
Diffuse infiltrates on biopsy
Impending need for dialysis
Children with TINU |
|
|
Term
| The classic presentation of AIN |
|
Definition
| fever, rash, peripheral eosinophilia, and oliguric renal failure occurring after 7–10 days of treatment with methicillin or another b-lactam antibiotic is the exception rather than the rule |
|
|
Term
| acute interstitial nephritis most commonly (and not classically) presents with... |
|
Definition
| a rising serum creatinine or symptoms attributable to acute renal failure |
|
|
Term
| when is a renal Bx indicated in suspected acute interstitial nephritis? |
|
Definition
| when presenting signs are atypical and no remission after 1 wk of conservative therapy |
|
|
Term
| what are the 3 main causes of papillary necrosis |
|
Definition
Analgesic nephropathy
Sickle cell nephropathy
Diabetes with urinary tract infection |
|
|
Term
| what is the treatment of lithium induced nephropathy |
|
Definition
|
|
Term
| 3 conditions that through obstruction of the ureters may cause acute interstitial nephritis |
|
Definition
Light chain cast nephropathy ("myeloma kidney")
Acute phosphate nephropathy
Acute urate nephropathy |
|
|
Term
| 5 drugs/agents that through chronic exposure may cause acute interstitial nephritis |
|
Definition
Analgesics, especially those containing phenacetin
Lithium
Heavy metals (lead, cadmium)
Aristolochic acid (Chinese herbal and Balkan endemic nephropathies)
Calcineurin inhibitors (cyclosporine, tacrolimus) |
|
|
Term
| 5 metabolic abnormalities that may cause acute interstitial nephritis |
|
Definition
Hypercalcemia and/or nephrocalcinosis
Hyperuricemia
Prolonged hypokalemia
Hyperoxaluria
Cystinosis (see Chap. 284 |
|
|
Term
| 4 hereditary conditions that may cause acute interstitial nephritis |
|
Definition
Polycystic kidney disease
Nephronophthisis
Adult medullary cystic disease
Medullary sponge kidney |
|
|
Term
| what are the 2 imaging tests to determine amount of blood flow to each kidney |
|
Definition
Captopril renography with technetium 99mTc mertiatide (99mTc MAG3
Nuclear imaging with technetium mertiatide or technetium-labeled pentetic acid (DTPA |
|
|
Term
| which is the best imaging modality to demonstrate the renal arteries if implanted with a stent |
|
Definition
|
|
Term
| 5 Factors Favoring Medical Therapy and Revascularization for Renal Artery Stenosis |
|
Definition
Progressive decline in GFR during treatment of systemic hypertension
Failure to achieve adequate blood pressure control with optimal medical therapy (medical failure)
Rapid or recurrent decline in the GFR in association with a reduction in systemic pressure
Decline in the GFR during therapy with ACE inhibitors or ARBs
Recurrent congestive heart failure in a patient in whom the adequacy of left ventricular function does not explain a cause |
|
|
Term
| 6 Factors Favoring Medical Therapy and Surveillance of Renal Artery Disease |
|
Definition
Controlled blood pressure with stable renal function (e.g., stable renal insufficiency)
Stable renal artery stenosis without progression on surveillance studies (e.g., serial duplex ultrasound)
Very advanced age and/or limited life expectancy
Extensive comorbidity that make revascularization too risky
High risk for or previous experience with atheroembolic disease
Other concomitant renal parenchymal diseases that cause progressive renal dysfunction (e.g., interstitial nephritis, diabetic nephropathy) |
|
|
Term
| atheroembolic disease usually manifests itself after a precipitating factor, such as... |
|
Definition
| angiography, vascular surgery, anticoagulation with heparin, thrombolytic therapy, or trauma |
|
|
Term
| 7 Criteria for Establishing Microangiopathic Kidney Injury Associated with Hematopoietic Stem Cell Transplantation |
|
Definition
RBC fragmentation and at least 2 schistocytes per high-power field
De novo, prolonged, or progressive thrombocytopenia
A sudden and persistent increase in LDH
Negative direct and indirect Coombs test
Decrease in hemoglobin or increased RBC transfusion requirement
Concurrent renal and/or neurologic dysfunction without other explanations
Decrease in haptoglobin concentration |
|
|
Term
| 8 conditions that cause Thrombotic Microangiopathy injury to the kidney |
|
Definition
HUS/TTP
Transplantation-Associated Thrombotic Microangiopathy
HIV-Related Tma
Radiation Nephropathy
Scleroderma (Progressive Systemic Sclerosis)
Antiphospholipid Syndrome (Aps)
HELLP Syndrome
Sickle Cell Nephropathy |
|
|
Term
| colonization of the vagina with e.coli is a risk factor for developing UTI in females. what seems to affect the risk of e.coli colonization? |
|
Definition
sex
old age - less lactobacilli more gram neg
Nonoxynol-9 in spermicide is toxic to the normal vaginal microflora |
|
|
Term
| 3 conditions that require treatment for asymptomatic bacteriurea |
|
Definition
| pregnancy, underwent renal transplantation, will undergo invasive urological treatment |
|
|
Term
| what should be considered in a male with recurrent urinary symptoms? what should be done? |
|
Definition
chronic bacterial prostatitis
mears-stamey test (4 urine samples right after prostate massage) |
|
|
Term
| what are 3 strategies for UTI prophylaxis in females? 3 drug options |
|
Definition
continuous, postcoital, or patient-initiated therapy
TMP-SMX, a fluoroquinolone, or nitrofurantoin |
|
|
Term
| what is the treatment of renal artery stenosis |
|
Definition
stable blood pressure and then angiography or maintain medical therapy
ARBs, ACEi allowed |
|
|
Term
| major causes of intrinsic acute kidney injury |
|
Definition
| ATN; DIC; hypertensive nephropathy; MTX, penicillin; TTP/HUS; TINU, renal artery dissection, thromboembolism, thrombosis, and renal vein compression or thrombosis |
|
|
Term
| nephrotic syndrome may present with hypercholesterolemia |
|
Definition
|
|
Term
| patients with normal anion gap acidosis have hyperchloremia |
|
Definition
|
|
Term
| 6 groups of drugs that can cause hyperkalemia and renal insufficiency, and thus normal anion gap acidosis |
|
Definition
A. Potassium-sparing diuretics (amiloride, triamterene, spironolactone)
B. Trimethoprim
C. Pentamidine
D. ACE-Is and ARBs
E. Nonsteroidal anti-inflammatory drugs
F. Cyclosporine and tacrolimus |
|
|
Term
| 2 drugs that may cause distal renal tubular acidosis type 1, which in its turn causes normal gap metabolic acidosis |
|
Definition
| amphotericin B, ifosfamide |
|
|
Term
| 2 drugs that may cause proximal renal tubular acidosis type 2, which in its turn causes normal gap metabolic acidosis |
|
Definition
| acetazolamide, topiramate |
|
|
Term
| what is the treatment of infected kidney or liver cyst in ADPKD? |
|
Definition
| Resprim and for the pain cyst drainage by percutaneous aspiration |
|
|
Term
| what is the treatment of ADPKD? |
|
Definition
| No treatment has been proved to prevent cyst growth or the decline in kidney function. the goal is to keep BP at 130/80 using ACEi or ARBs |
|
|
Term
| a patient with acute kidney injury and the following clinical findings: retinal plaques, palpable purpura, livedo reticularis, GI bleed. what is the cause of the kidney injury and what are some lab findings |
|
Definition
thromboembolic disease
Hypocomplementemia, eosinophiluria (variable), variable amounts of proteinuria |
|
|
Term
| causes of secondary membranous glomerulonephritis? |
|
Definition
| malignancy (solid tumors of the breast, lung, colon), infection (hepatitis B, malaria, schistosomiasis), or rheumatologic disorders like lupus or rarely rheumatoid arthritis |
|
|
Term
| causes of secondary FSGS? |
|
Definition
Viruses: HIV/Hepatitis B/Parvovirus
Hypertensive nephropathy
Reflux nephropathy
Cholesterol emboli
Drugs: Heroin/analgesics/pamidronate
Renal dysgenesis
Alport's syndrome
Sickle cell disease
Lymphoma
Radiation nephritis |
|
|
Term
| what is the workup of suspected goodpasture's syndrome |
|
Definition
|
|
Term
| risk factors for contrast nephropathy |
|
Definition
| CHF, DM, MM, dehydration, old age |
|
|
Term
| what is the treatment of ethylene glycol intoxication - high AG metabolic acidosis and high osmolal gap? |
|
Definition
| saline or osmotic diuresis, thiamine and pyridoxine supplements, fomepizole or ethanol, and hemodialysis |
|
|
Term
| when is hemodialysis indicated in ethylene glycol intoxication |
|
Definition
| arterial pH is <7.3, or the osmolar gap exceeds 20 mOsm/kg |
|
|
Term
| what is the treatment of metabolic acidosis d/t renal failure, whether hyperchloremic or uremic? |
|
Definition
| correct bicarbonate to 20-24 and if hyperkalemia, give fusid |
|
|
Term
| which cystic kidney disease is associated with retinal pigmentation |
|
Definition
|
|
Term
| which cystic kidney disease is associated with situs inversus |
|
Definition
|
|
Term
| what are the cardiac manifestations of ADPKD |
|
Definition
| aortic root and annulus dilation. Cardiac valvular abnormalities occur in 25% of patients, most commonly mitral valve prolapse and aortic regurgitation |
|
|
Term
| what is the MCC of ESRD in children and adolescents |
|
Definition
|
|
Term
| medullary cystic kidney disease with small kidneys, salt wasting, cysts restricted to medulla etc. what is a clinical clue that this is the diagnosis |
|
Definition
|
|
Term
| what is the mgmt of tuberous sclerosis with cysts or angiomyolipomas |
|
Definition
| regular imaging to monitor for the development of renal cell carcinoma |
|
|
Term
| when do you treat angiomyolipomas in tuberous sclerosis and how |
|
Definition
| >4 cm, transcatheter arterial embolization or surgical excision |
|
|
Term
| how do you manage kidney tumors in VHL |
|
Definition
under 3 cm - monitor closely
over 3 cm and no mets - partial nephrectomy |
|
|
Term
| what inherited kidney disease is associated with recurrent nephrolithiasis, and maybe RTA type 1 |
|
Definition
|
|
Term
| how is the diagnosis of medullary sponge kidney made? |
|
Definition
| hyperdense papillae with clusters of small stones on renal ultrasonography or abdominal x-ray - paintbrush like |
|
|
Term
| in medullary sponge kidney, with partial dRTA and hypocitraturia, what is a preventive treatment for new stone formation |
|
Definition
|
|
Term
| Hypokalemia and hypochloremic metabolic alkalosis without hypertension are more often due to surreptitious vomiting or diuretic abuse than to Bartter's or Gitelman's syndrome. In contrast to Bartter's and Gitelman's syndromes, urinary chloride levels are very low in patients with surreptitious vomiting. Diuretic abuse can be diagnosed by screening the urine for the offending agents. Gitelman's syndrome is distinguished from most forms of Bartter's syndrome by the presence of severe hypomagnesemia and hypocalciuria. |
|
Definition
|
|
Term
| treatment of bartter and gittleman syndromes |
|
Definition
maintain kalium with spirinolactone or amiloride
NSAIDs reduce the polyuria in bartter's but not gittelman's |
|
|
Term
| Hereditary Tubular Disorders Causing Hypertension Due to Salt Retention |
|
Definition
| liddle's syndrome, gordon's syndrome |
|
|
Term
| what is the treatment of RTA type 1 |
|
Definition
| alkali replacement (bicarbonate loss) |
|
|
Term
| what do brown casts in the urine indicate? |
|
Definition
|
|
Term
| how is the diagnosis of IgA nephropathy made? |
|
Definition
|
|
Term
| 2 clinical presentations of IgA nephropathy |
|
Definition
recurrent episodes of macroscopic hematuria during or immediately following an upper respiratory infection often accompanied by proteinuria or
persistent asymptomatic microscopic hematuria |
|
|
Term
| renal failure seen in only 25–30% of patients with IgA nephropathy over 20–25 years (duration of disease) |
|
Definition
|
|
Term
| risk factors for CKD in patients with IgA nephropathy, first one being the most predictive |
|
Definition
| persistent proteinuria > 6 months, hypertension or proteinuria, the absence of episodes of macroscopic hematuria, male age, older age of onset, and extensive glomerulosclerosis or interstitial fibrosis on renal biopsy |
|
|
Term
| how is IgA nephropathy treated in patients presenting with RPGN |
|
Definition
| steroids, cytotoxic agents, and plasmapheresis |
|
|
Term
| infection in which 2 organs precede the onset of poststreptococcal GN? |
|
Definition
| Skin and throat infections |
|
|
Term
| 20% of adults with PSGN have proteinuria in the nephrotic levels |
|
Definition
|
|
Term
| 3 serologic findings (and their frequencies) in PSGN? |
|
Definition
| ASO (30%), anti-DNAse, (70%), or antihyaluronidase antibodies (40%) |
|
|
Term
| 2 complement factors depressed and one which remains normal in PSGN |
|
Definition
| depressed - C3, CH50 (total complement activity) normal C4 |
|
|
Term
| what is the treatment of PSGN with crescents on glomerular Bx? |
|
Definition
| There is no role for immunosuppressive therapy, even in the setting of crescents |
|
|
Term
| what is the gross appearance of the kidneys in subacute bacterial endocarditis associated GN? |
|
Definition
| subcapsular hemorrhages with a "flea-bitten" appearance |
|
|
Term
| 3 other conditions that resemble subacute bacterial endocarditis may cause associated GN |
|
Definition
| ventriculoatrial and ventriculoperitoneal shunts; pulmonary, intraabdominal, pelvic, or cutaneous infections; and infected vascular prostheses |
|
|
Term
| what is the treatment and prognosis of lupus nephritis class I/II? |
|
Definition
| they are limited to the mesangium and hence do not deteriorate to renal failure and do not need treatment |
|
|
Term
| which serologic marker is typical of class IV lupus nephritis, in relation to the rest of the lupus nephritis classes |
|
Definition
| high anti-DNA antibody titers |
|
|
Term
| what is considered remission in class III and IV lupus nephritis, predicting good renal outcome |
|
Definition
| a return to near-normal renal function and proteinuria < 330 mg/dL per day |
|
|
Term
| what is the treatment of class III, IV and V lupus nephritis |
|
Definition
| high-dose steroids and either cyclophosphamide or mycophenolate mofetil for 2–6 months, followed by maintenance therapy with lower doses of steroids and mycophenolate mofetil |
|
|
Term
| Patients with lupus nephritis class V, like patients with membranous GN, are predisposed to which type of conditions? |
|
Definition
| renal-vein thrombosis and other thrombotic complications |
|
|
Term
| what is a bad prognostic sign in class V lupus nephritis? |
|
Definition
|
|
Term
| 4 environmental factors that are involved in the pathophysiology of anti-GBM GN, by exposing collagen type IV to antibody detection |
|
Definition
| infection, smoking, oxidants, or solvents |
|
|
Term
| what are 2 bad prognostic signs in goodpasture's syndrome |
|
Definition
| abscence of hemoptysis and presence of oliguria |
|
|
Term
| what is a predominant symptom in young smokers with goodpasture's syndrome |
|
Definition
|
|
Term
| what is the most urgent step in the workup of a patient suspected of goodpasture's syndrome? |
|
Definition
|
|
Term
| 4 bad prognostic factors in goodpasture's syndrome |
|
Definition
>50% crescents with advanced fibrosis
creatinine >5–6 mg/dL
oliguria
need for acute dialysis |
|
|
Term
| what is a good prognostic factor in goodpasture's syndrome |
|
Definition
|
|
Term
| what is the treatment of goodpasture's syndrome |
|
Definition
10 courses of plasmapheresis and oral prednisone and cyclophosphamide in first 2 weeks
renal failure progresses rapidly - dialysis
kidney transplantation only 6 months into complete serologic remission - otherwise danger of recurrence with new organ |
|
|
Term
| which disease is more frequently associated with anti MPO? and which with anti-PR3? |
|
Definition
churg-strauss and microscopic polyangiitis
Wegener's |
|
|
Term
| what is the treatment of all 3 ANCA associated GN |
|
Definition
induction with plasmapheresis, methylprednisolone, and cyclophosphamide
maintenance for up to a year with cyclophosphamide or azathioprine after achieving remission |
|
|
Term
| which type of GN do the following s/s implicate - fever, purulent rhinorrhea, nasal ulcers, sinus pain, polyarthralgias/arthritis |
|
Definition
|
|
Term
| findings on CXR of Wegener's |
|
Definition
| nodules and persistent infiltrates, sometimes with cavities |
|
|
Term
| finding on lung Bx of Wegener's |
|
Definition
|
|
Term
| which environmental factor increases the risk of "contracting" Wegener's granulomatosis? and which inheritable disease? |
|
Definition
silicosis
alpha 1 antitrypsine |
|
|
Term
| in which type of anca induced GN is relapse most probable? |
|
Definition
|
|
Term
| how do you distinguis microscopic polyangiitis from Wegener's |
|
Definition
| Bx, the former will lack granulomas |
|
|
Term
| which type of GN is implicated with the following s/s: peripheral eosinophilia, asthma, allergic rhinitis, Hypergammaglobulinemia, elevated levels of serum IgE |
|
Definition
|
|
Term
| what is the prognosis of membranoproliferative GN |
|
Definition
| 50% renal failure at 10 yrs |
|
|
Term
| 3 predictors of bad outcome in MPGN |
|
Definition
| Nephrotic syndrome, hypertension, and renal insufficiency |
|
|
Term
| what is the treatment of primary MPGN, not associated with HCV, autoimmune diseases of malignancies/ |
|
Definition
| steroids, plasma exchange and immunosuppressive drugs |
|
|
Term
| what is a good prognostic indicator of outcome in Mesangioproliferative Glomerulonephritis (not to be confused with membranoPGN)? what is a bad one? |
|
Definition
isolated hematuria - good
proteinuria - bad |
|
|
Term
| what metabolic/endocrinologic/hematologic disturbance is usually present in nephrotic syndromes |
|
Definition
hypercholesterolemia
hypothyroidism (decreased TBG)
procoagulable state |
|
|
Term
| if not primary, minimal change disease may be associated with what 3 conditions |
|
Definition
| Hodgkin's disease, allergies, or use of NSAIDs |
|
|
Term
| what is the finding on electron microscopy of renal biopsy from a patient with minimal change disease |
|
Definition
| effacement of the foot process |
|
|
Term
| what can be found in the urine of patients with minimal change disease |
|
Definition
| acellular urinary sediment - only protein and mild hematuria if at all |
|
|
Term
| in patients thought to have minimal change disease, what is the course of action in they are not responding to steroid treatment |
|
Definition
| repeat Bx: maybe they have FSGS |
|
|
Term
| what is the treatment of minimal change disease? |
|
Definition
|
|
Term
| which children are considered primary responders to the treatment of minimal change disease |
|
Definition
| after one dose of prednisone they achieve remission (<0.2 mg/24 h of proteinuria) |
|
|
Term
| how would you assess for remission in minimal change disease? |
|
Definition
| 24 hr urine collection for proteinuria |
|
|
Term
| 3 treatment options for remission of minimal change disease |
|
Definition
| cyclophosphamide, chlorambucil, and mycophenolate mofetil |
|
|
Term
| prognosis of focal segmental glomerular sclerosis |
|
Definition
| 50% renal failure at 6-8 yrs |
|
|
Term
| 3 predictors of poor prognosis in alport's syndrome (nephrotic syndrome + deafness + anti GBM) |
|
Definition
| Early severe deafness, lenticonus, or proteinuria |
|
|
Term
| which nephrotic syndrome should include clincial evaluation for eye-sight and hearing defects? |
|
Definition
|
|
Term
| what risk factor for ESRD in hypertensive glumerulosclerosis is not intuitive? |
|
Definition
|
|
Term
| how is the diagnosis of hypertensive nephrosclerosis made? |
|
Definition
|
|
Term
| some patients with cholesterol kidney emboli have 2 rather bizarre lab findings, what are they? |
|
Definition
| eosinophilia, or eosinophiluria |
|
|
Term
| how is the diagnosis of cholesterol kidney emboli made? |
|
Definition
| with the right clinical presentation a biopsy from more convenient tissues like the skin is preferable |
|
|
Term
| typical finding on urine examination of patients with sickle cell related kidney disease |
|
Definition
| hyposthenuria - diluted urine which leads to volume depletion |
|
|
Term
| what distinguishes patients with HIV presenting with FSGS from the other patients with nephrotic syndromes? |
|
Definition
| absence of hypertension, edema, or hyperlipidemia |
|
|
Term
| 2 types of kidney injuries can be seen in patients with syphillis? |
|
Definition
interstitial nephritis
MGN (nephrotic syndrome) |
|
|
Term
| 2 classes of leprosy to manifest with kidney injury and what 3 types of kidney injury |
|
Definition
borderline lepromatous and lepromatous
FSGS, mesangioproliferative glomerulonephritis, or renal amyloidosis |
|
|
Term
| 4 parasitic infections that may manifest with some sort of glomerular kidney injury |
|
Definition
| toxoplasma, leishmania, Filariasis and trichinosis |
|
|
Term
| Postobstructive Diuresis - what cases have polyuria with relief of obstruction |
|
Definition
bilateral - polyuria, hypotonic
polyuria would stop when extracellular volume returns to normal |
|
|
Term
| urinary tract obstruction - 4 conditions where hydronephrosis will not be seen on US |
|
Definition
| less than 48 hours in duration or associated with volume contraction, staghorn calculi, retroperitoneal fibrosis, or infiltrative renal disease |
|
|
Term
| in which disturbance, chronic or acute urinary obstruction is there decreased renal blood flow? |
|
Definition
|
|
Term
| what is the first lab sign of PSGN |
|
Definition
|
|
Term
| autoimmune disease usually cause which type of glomerular injury |
|
Definition
|
|
Term
| 5 possible presenting s/s of renal vein thrombosis |
|
Definition
| flank pain, tenderness, hematuria, rapid decline in renal function, and proteinuria |
|
|
Term
| what is the most sensitive test for renal vein thrombosis? |
|
Definition
|
|
Term
| nephrolithiasis with alkali urine pH>5.5 |
|
Definition
| calcium stones - Distal RTA |
|
|
Term
| which type of kidney stone is radioluscent |
|
Definition
|
|
Term
| nephrotic findings in urine examination, low C3 and C4, no ANCA? |
|
Definition
|
|
Term
| 4 elements in the assessment of metabolic alkalosis |
|
Definition
| extracellular fluid volume (ECFV), the recumbent and upright blood pressure, the serum [K+], and the renin-aldosterone system |
|
|
Term
| chronic hypertension and chronic hypokalemia in an alkalotic patient suggests either |
|
Definition
| mineralocorticoid excess or that the hypertensive patient is receiving diuretics |
|
|
Term
| Low plasma renin activity and normal urine [Na+] and [Cl–] in a patient who is not taking diuretics indicate... |
|
Definition
| a primary mineralocorticoid excess syndrome |
|
|
Term
| 4 causes of hyperaldosteronism with low renin |
|
Definition
| licorice, primary hyperaldosteronism, adrenal enzyme deficiency (17 and 11), and cushing's |
|
|
Term
| 5 causes of hypokalemia and alkalosis in a normotensive, nonedematous patient |
|
Definition
| Bartter's or Gitelman's syndrome, magnesium deficiency, vomiting, exogenous alkali, or diuretic ingestion |
|
|
Term
| how to further workup hypokalemia and alkalosis in a normotensive, nonedematous patient |
|
Definition
If the urine is alkaline, with an elevated [Na+] and [K+] but low [Cl–], the diagnosis is usually either vomiting (overt or surreptitious) or alkali ingestion
If the urine is relatively acid and has low concentrations of Na+, K+, and Cl–, the most likely possibilities are prior vomiting, the posthypercapnic state, or prior diuretic ingestion
neither the urine sodium, potassium, nor chloride concentrations are depressed, magnesium deficiency, Bartter's or Gitelman's syndrome, or current diuretic ingestion should be considered |
|
|
Term
| Bartter's syndrome is distinguished from Gitelman's syndrome |
|
Definition
| by hypocalciuria and hypomagnesemia in the latter disorder |
|
|
Term
| 4 situations where you might be receiving alkali solutions |
|
Definition
| HCO3– (PO or IV), acetate loads (parenteral hyperalimentation solutions), citrate loads (transfusions), or antacids plus cation-exchange resins (aluminum hydroxide and sodium polystyrene sulfonate) |
|
|
Term
| diuretics that cause hyperchloriuria and thus bicarbonate retention |
|
Definition
|
|
Term
| acute kidney injury with hyperkalemia, hyperphosphatemia and hypocalcemia, suggests... |
|
Definition
| rhabdomyolysis or the tumor lysis syndrome |
|
|
Term
| in acute kidney injury, how to distinguish rhabdomyolysis from tumor lysis syndrome |
|
Definition
| CPK levels and serum uric acid are elevated in rhabdomyolysis, while tumor lysis syndrome shows normal or marginally elevated creatine kinase and markedly elevated serum uric acid |
|
|
Term
| how is the urination in partial urinary tract obstruction |
|
Definition
| excess urination, isosthenuria (damaged ability to concentrate urine) for several days |
|
|
Term
| presentation of renal vein thrombosis |
|
Definition
| flank pain, hematuria, proteinuria, decreasing renal function |
|
|
Term
| 3 mechanisms of renal vein thrombosis |
|
Definition
endothelial damage: Homocystinuria, endovascular intervention, and surgery
venous stasis: dehydration in peds, kinking/compression from retroperitoneal process |
|
|
Term
| what is the most sensitive imaging test for renal vein thrombosis? |
|
Definition
|
|
Term
| 6 risk factors for acute kidney injury after PTCA? |
|
Definition
| metformin, DM, diuretics, CHF, ACEi, MM |
|
|
Term
| 6 causes of acute renal failure and hypocomplementemia |
|
Definition
| HCV cryoglobulinemia, PSGN, MPGN, SBE, shunt, lupus nephritis |
|
|
Term
| prognosis in renal amyloidosis |
|
Definition
| bad when azothemia (unrelated to proteinuria) |
|
|
Term
| clinical manifestations of barrter's syndrome |
|
Definition
| hypokalemia, hypochloremia, hypotension, nephrolithiasis, hyper pge2, alkalosis |
|
|
Term
|
Definition
| hypokalemia, metabolic alkalosis, hypertension, low aldosterone and renin |
|
|
Term
| treatment of familial hypocalciuric hypercalcemia |
|
Definition
|
|
Term
| what is the safest diabetic drug to administer in CKD? |
|
Definition
| rosiglitazone, also has a protective effect |
|
|
Term
| in which patients should you screen for HCV? |
|
Definition
|
|
Term
| what does fanconi's syndrome consist of? |
|
Definition
| RTA type 2, hyperphosphaturia, hyperuricosuria, hypercalciuria, nonselective aminoaciduria, glycosuria, hyperchloremic acidosis, rickets and osteomalacia |
|
|
Term
| clinical manifestations of RTA type 1 |
|
Definition
| urine pH > 5.5, hypokalemia, hypocitraturia, hypercalciuria, nephrocalcinosis, nephrolithiasis, rickets/osteomalacia |
|
|
Term
| what is the treatment of RTA type 1 and 2, and what is the difference btwn the treatment of these 2? |
|
Definition
| bicarbonate, RTA type 2 should be treated with higher doses which would cause hypokalemia and hence should also be supplemented with kalium |
|
|
Term
| MCC of acute interstitial nephritis |
|
Definition
| ibuprofen ( without rash and fever) |
|
|
Term
| acute interstitial nephritis goes with heavy proteinuria and acute renal failure |
|
Definition
|
|
Term
| in which cases osmolal gap increased (>15) |
|
Definition
Alcohols
ethanol intoxication
methanol ingestion
ethylene glycol ingestion[7]
acetone ingestion
isopropyl alcohol ingestion
Sugars
mannitol
sorbitol
Lipids
Hypertriglyceridemia
Proteins
Hypergammaglobinemia (M. Waldenstroem) |
|
|
Term
| renal failure + hypocomplementemia |
|
Definition
| cryoglobulinemia, PSGN, lupus nephritis, SBE, MPGN, cholesterol emboli |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| MGN, MPGN, cryoglobulinemia, immune complex GN |
|
|
Term
| glomerular injury in graves |
|
Definition
|
|
Term
| glomerular injury in malignancy |
|
Definition
|
|
Term
|
Definition
|
|
Term
| glomerular injury in penicillamine |
|
Definition
|
|
Term
| what is the treatment for pyelonephritis with complicated histories, previous episodes of pyelonephritis, or recent urinary tract manipulations |
|
Definition
| beta-lactam and a beta-lactamase inhibitor (e.g., ampicillin-sulbactam, ticarcillin-clavulanate, and piperacillin-tazobactam) or imipenem-cilastatin |
|
|
Term
| no hypocomplementemia in HSP |
|
Definition
|
|
Term
| how would you test if a patient adheres to his low sodium diet |
|
Definition
|
|
Term
| indications to initiate dialysis in CKD |
|
Definition
Pericarditis or pleuritis (urgent indication)
Progressive uremic encephalopathy or neuropathy, with signs such as confusion, asterixis, myoclonus, wrist or foot drop, or, in severe cases, seizures (urgent indication)
A clinically significant bleeding diathesis attributable to uremia (urgent indication)
Fluid overload refractory to diuretics
Hypertension poorly responsive to antihypertensive medications
Persistent metabolic disturbances that are refractory to medical therapy; these include hyperkalemia, metabolic acidosis, hypercalcemia, hypocalcemia, and hyperphosphatemia
Persistent nausea and vomiting
Evidence of malnutrition |
|
|
Term
| what is missing in the treatment of a patient on dialysis |
|
Definition
|
|
Term
| hypernatremia is not typical of ARF, hypermagnesemia is |
|
Definition
|
|
Term
| 2 electrolyte disturbances that may cause NDI |
|
Definition
| hypokalemia and hypercalcemia |
|
|
Term
| whats absent in PAN and present in microscopic polyangiitis |
|
Definition
|
|
Term
| both Wegener's and Goodpastures are treated with predinsone, cyclophosphamide and plasmapheresis |
|
Definition
|
|
Term
| how to distinguish diarrhea from RTA as a cause of hyperchloremic normal AG metabolic acidosis |
|
Definition
measure urinary AG (Na+K-Cl)
negative - diarrhea (excretion of NH4+ - kidney is acidifying urine)
positive - RTA |
|
|
Term
| אם אלבומין נמוך זה מוריד את ה-AG. כל ירידה של 1g/dL באלבומין מורידה 2.5 מא"ק ב-AG |
|
Definition
|
|
Term
| interstitial nephritis - findings |
|
Definition
| ירידה ב-GFR, פקוני, אצידוזיס היפר-כלורמי (AG תקין), פרוטאינוריה טובולרית או משקל נמוך, פולי אוריה, isosthenuria, היפר-קלמיה, salt wasting |
|
|
Term
|
Definition
| hyaline cast = pre-renal failure; WBC casts = Allergic interstitial nephritis |
|
|
Term
|
Definition
| איסכמיה, זיהומים, טוקסינים אנדוגנים (רבדומיוליזיס, המוליזיס), טוקסינים אקסוגניים (ח"נ, calcineurin inhibitors, אנטיביוטיקה – AG, כימותרפיה – ציספלטין, אמפוטריצין B, אתילן גליקול |
|
|
Term
| תרופות שגורמות להיפוקלמיה |
|
Definition
• פוסיד
• תיאזיד
• אמפוציטרין B
• לקסטיב
• פרדניזון
• גנטמיצין |
|
|
Term
| 3 תרופות שכיחות ביותר בAIN |
|
Definition
| NSAID אנטיביוטיקה ואומפרדקס |
|
|
Term
|
Definition
• בדם יש C3 נמוך
• במיקרוסקופ אור התעבות אחידה של ה- BM לאורך ה- capillary loops הפריפריים
• האימונופלורוסנציה מדגימה משקעים דיפוזיים גרנולריים של C3/ IgG .
• מיקרוסקופ אלקטרוני באופן טיפוסי מגלה משקעים סאב-אפיתליאליים
• 80% מהחולים עם MGN מופיעים עם סנדרום נפרוטי ופרוטאינוריה לא סלקטיבית.
• המטוריה מיקרוסקופית נראית ב- 50% מהחולים.
• רמיסיה ספונטאנית מתרחשת ב 20-30%- מהחולים
• כ 30%- מהחולים ממשיכים לחוות חזרות של הסנדרום הנפרוטי אבל שומרים על תפקוד כלייתי נורמאלי.
• וכ 30%- נוספים מהחולים מפתחים אי ספיקת כליות או מתים מהסיבוכים של הסנדרום הנפרוטי
• פרוגנוזה רעה קשורה עם: מין זכר, גיל מבוגר, יל"ד והימשכות הפרוטינוריה |
|
|
Term
| ב-FSGS סטרואידים ניתנים רק במחלה ראשונית - אין מקום לסטרואידים במחלה שניונית |
|
Definition
|
|
Term
| אינדיקציות לבירור היפראלדוסטרוניזם ראשוני כסיבה ליל"ד (PRA) |
|
Definition
Hypertension and spontaneous or low dose diuretic-induced hypokalemia
Severe hypertension (>160 mmHg systolic or >100 mmHg diastolic) or drug-resistant hypertension (defined as suboptimally-controlled hypertension on a three-drug program that includes an adrenergic inhibitor, vasodilator, and diuretic)
Hypertension with adrenal incidentaloma
Hypertension and a family history of early-onset hypertension or cerebrovascular accident at a young age (<40 years)
All hypertensive first-degree relatives of patients with primary aldosteronism |
|
|
Term
| a low urine chloride concentration in a patient with unexplained metabolic alkalosis and hypokalemia usually reflects vomiting or prior diuretic therapy |
|
Definition
|
|
Term
| The distinction between vomiting and diuretic therapy in this setting can be made only if the characteristic physical findings of self-induced vomiting are present, if a urine assay for diuretics is positive, or if the urine chloride concentration is high at a subsequent measurement (because the diuretic is acting) while the patient still has metabolic alkalosis |
|
Definition
|
|
Term
| a urine chloride concentration that is not low suggests either continued diuretic therapy or Bartter or Gitelman syndrome |
|
Definition
| These disorders cannot be distinguished in the absence of a history of diuretic use or a positive urine assay for diuretics, since they have identical clinical manifestations and pathogeneses |
|
|
Term
| metabolic alkalosis represents one of the conditions in which volume depletion may not lead to a low urine sodium concentration |
|
Definition
|
|
Term
| The presence of underlying hypovolemia can be detected more accurately by finding a urine chloride concentration below 25 meq/L |
|
Definition
|
|
Term
| he urine chloride concentration, however, may be inappropriately elevated if there is a defect in chloride reabsorption. This most commonly occurs with diuretic therapy and is transient, as chloride is appropriately conserved once the drug effect wears off. Marked hypokalemia (plasma potassium concentration below 2 meq/L) also can reversibly impair chloride transport, leading to a rise in chloride excretion that is independent of volume status |
|
Definition
|
|
Term
| תרופות שגורמות לבססת נשימתית |
|
Definition
o סליציאטים
o תאופילין/אמינופילין
o פרוגסטרון |
|
|
Term
| גורמי סיכון לאס"כ לאחר צינתור/חומר ניגוד |
|
Definition
• מטפורמין
• עמילואידוזיס
• סכרת
• ACEI
• אי ספיקת לב
• גיל מעל 80
• MM
• התייבשות |
|
|
Term
| סדר פעולות בבירור היפונתרמיה |
|
Definition
1. אוסמולריות בדם
2. אם אוסמולריות בדם נמוכה - אוסמולריות בשתן
3. נפח הדם
4. הפרשת נתרן בשתן |
|
|
Term
| סדר פעולות בירור היפונתרמיה - מפורט עד לשלב בו בודקים נפח בדם |
|
Definition
• אוסמולריות גבוהה בהיפרגליקמיה ומניטול
• אוסמלריות תקינה בהיפרפרוטינמיה, היפרליפידמיה ושטיפת שלפוחית
• כל היתר זה אוסמולריות נמוכה
• על כל עליה של 100 בגלוקוז נוסיף 1.4 לנתרן
• תיאזיד הוא המשתן שגורם בעיקר להיפונתרמיה
• לפני שממשיכים לנתח היפונתרמיה היפו אוסמוטית יש לשלול שתיית היתר עקב פולדיפסיה פסיכוגנית או שינוי באוסמוסטאט - במקרים אלו השתן יהיה פחות מ100 אוסמול וSG יהיה 1.003
• לאחר ששללנו פולידפסיה נמשיך כמצוין בדיאגרמה המצורפת |
|
|
Term
| סדר פעולות בירור היפונתרמיה - מפורט עד לשלב בו בודקים נפח בדם |
|
Definition
• אוסמולריות גבוהה בהיפרגליקמיה ומניטול
• אוסמלריות תקינה בהיפרפרוטינמיה, היפרליפידמיה ושטיפת שלפוחית
• כל היתר זה אוסמולריות נמוכה
• על כל עליה של 100 בגלוקוז נוסיף 1.4 לנתרן
• תיאזיד הוא המשתן שגורם בעיקר להיפונתרמיה
• לפני שממשיכים לנתח היפונתרמיה היפו אוסמוטית יש לשלול שתיית היתר עקב פולדיפסיה פסיכוגנית או שינוי באוסמוסטאט - במקרים אלו השתן יהיה פחות מ100 אוסמול וSG יהיה 1.003
• לאחר ששללנו פולידפסיה נמשיך כמצוין בדיאגרמה המצורפת |
|
|
Term
| בהיפר קלמיה נצפה לאיבוד של לפחות 200 ממול אשלגן ליום, אם פחות,זו בעיה כלייתית |
|
Definition
RTA4 –אי ספיקת כליות קלה, מחלה כרונית TI או נפרופתיה סכרתית
NSAID
ACEI/ARB
היפואלדסטרוניזם/פסאודוהיפואלדסטרוניזם
הפרין
ספירנולקטון
אמילורואיד
אי ספיקת כליות חריפה עם אוליגוריה
חסימה של דרכי שתן
סינדרום גורדון –היפרקלמיה,חמצת, GFR תקין ודיכוי רנין ואלדסטרון |
|
|
Term
| עירוי מאסיבי עם תאי דם שהופשרו גורם להיפוקלמיה |
|
Definition
|
|
Term
• TYPE 1 – ל90 אחוז מחולים עם נפרופתיה יש רטינופתיה
• TYPE 2 – ל60 אחוז מחולים עם נפרופתיה יש רטינופתיה |
|
Definition
|
|
Term
|
Definition
• מתבטא בעשור 3-4
• לעד 20 אחוז אבני כליה
• ל75 אחוז יל"ד
• חצי יפתחו ESRD עד גיל 60.
• UTI נפוץ
• סונר משמש לאבחנה וסקר,דרוש 3-5 ציסטות בכל כליה לשם אבחנה
• ציסטות גם בכבד,טחול, לבלב, שחלות
• ל10 אנוריזמות מוחיות
• ל25 אחוז MVP
• דיברטיקולוזיס
• AR/TR בשכיחות מוגברת |
|
|
Term
|
Definition
• פגיעה בDcT
• שכיח יותר מברטר
• מהלך קליני קל יותר מברטר ומופיע בגיל מבוגר יותר
• היפוולמיה מוביל להיפראלדסטרוניזם
• ללא בצקת
• נורמוטנסיבי
• היפוקלמיה
• בססת
• היפומגנזמיה קשה
• היפוקלציאוריה
• סימפטומים וסימנים משמעותיים בשרירים
• טיפול-תוספי אשלגן, מגנזיום וצריכה חופשית של מלח. מינונים גבוהים של ספירנולקטון או אמילורואיד |
|
|
Term
|
Definition
• פגיעה בloop OF HENLE
• תקופה נאונטלית או ילדות מוקדמת עם פוליאוריה, פולידיפסה ורעב למלח
• היפוולמיה מוביל להיפראלדסטרוניזם
• ללא בצקת
• נורמוטנסיבי
• היפוקלמיה
• בססת
• היפומגנזמיה קלה
• היפרקלציאוריה עם אבני כליה
• יצור יתר של פרוסטוגלנדין E2 והפרשתו בשתן– שהכמות מוגברת במיוחד גורם לסינדרום שכולל FTT והתייבשות קשה עם חום הקאות ושילשול
• טיפול-תוספי אשלגן, מגנזיום וצריכה חופשית של מלח. מינונים גבוהים של ספירנולקטון או אמילורואיד, בנוסף NSAID |
|
|
Term
|
Definition
• ספיגה לא מבוססת של נתרן דרך ENAC
• בססת
• היפוקלמיה
• יל"ד קשה
• רמות רנין ואלדוסטרון נמוכות
• טיפול על ידי הגבלת מלח והאמילורואיד |
|
|
Term
• אבני סידן ואוקסולאט נוצרות בPH בסיסי ולכן נרצה להחמיץ את השתן
• אבני חומצה אורית נוצרות בPH חומצי ולכן נרצה להבסיס את השתן |
|
Definition
|
|
Term
| drugs that may cause nephrogenic diabetes insipidus |
|
Definition
Lithium
Demeclocycline
Methoxyflurane
Amphotericin B
Aminoglycosides
Cisplatin
Rifampin
Foscarnet |
|
|
Term
| Causes of an osmolar gap in the absence of a metabolic acidosis include isopropyl alcohol ingestion, sick cell syndrome in patients with multiorgan failure, absorption or systemic infusion of glycine, sorbitol, or mannitol irrigation solutions, and intravenous immune globulin in a maltose solution to patients with renal failure. In addition, a spurious increase in the serum osmolal gap can occur in patients with pseudohyponatremia due to marked hyperlipidemia or hyperproteinemia |
|
Definition
|
|
