(1.1) Approach to Oliguria and Proteinuria [DSA] Flashcards
Define:
Anuria
UOP < 50-100ml/day
Define:
Oliguria
UOP < 400-500 ml/day
Define:
Polyuria
UOP > 3,000 ml/day
Define:
Azotemia
Elevated blood urea nitrogen (BUN) without symptoms
Define:
Uremia
Elevated BUN WITH SYMPTOMS
(N/V, confusion, pruritus, metallic taste in mouth, fatigue, anorexia, etc…)
What are some examples of common questions to ask in patients presenting with oliguria/proteinuria?
- Have you been drinking enough fluids?
- Are you lightheaded or dizzy w/ position changes?
- Do you have a hx of HTN/DM?
- Have you had any recent IV iodine contrast dye?
- Do you empty bladder completely or feel like you are retaining urine?
- Any family hx of kidney disease?
What are the (2) criteria that must be present for > 3 months to be considered CKD?
Positive markers of kidney damage
Decreased GFR
If a patient has markers of kidney damage AND decreased GFR however this has been occuring for <3 months… what does the patient have?
Acute Kidney Injury (AKI)
What are examples of markers of kidney damage?
Albuminuria
Urine sediment abnormalities
Electrolyte abnormalities
Histologic changes
Hx. of kidney transplantation
What is considered a decreased GFR?
GFR <60ml/min/1.73 m^2
What are the stages of CKD? What do the stages represent?
1 - normal/high
2 - mild decrease
3a - mild-moderate decrease
3b - moderate-severe decrease
4 - severe decrease
***Stages refer to the level of GFR decrease. 1 is nearly normal, while 4 is severe stage of CKD.
What is the GFR of a CKD stage 1 pt. ?
Greater than, or equal to 90
What is the GFR of a CKD stage 4 pt. ?
GFR = 15-29
In the absence of kidney damage, neither GFR category stage ___ or ____ fulfill the criteria for CKD
In the absence of kidney damage, neither GFR category stage 1 or 2 fulfill the criteria for CKD
What is the most common cause of CKD?
What is the second most common cause?
Most common = Diabetes
Second most common = HTN
What are the signs and symptoms of CKD?
-Edema
- HTN
- Decrease urine output (UOP)
- Foamy urine (proteinuria)
- Uremia
- Pericardial friction rub
- Asterixis
- Uremic frost
What are the 3 simple tests to identify most CKD patients?
- eGFR
- Urine albumin-to-creatinine ratio/urine protein-to-creatinine ratio
- Urinalysis
What are the renal ultrasound findings for CKD?
- Atrophic/small kidneys
- Cortical thinning
- Increased ecogenicity
- Elevated resistive indices
What are the indications for dialysis?
AEIOU
A = Severe Acidosis
E = Electrolyte imbalance
I = Ingestion (ethylene glycols, methanol, etc…)
O = Volume overload
U = Uremia
What are the two lab values that are used to stage AKI?
Serum creatinine
OR
Urine output
***Staged based on whichever is worse
What are the stages of AKI?
Stage 1 (most mild)
Stage 2
Stage 3 (most severe)
What are the three potential etiologies of AKI?
Prerenal
Intrinsic
Postrenal
What is the clinical presentation of AKI?
- Edema
- HTN
- Decreased urine output
- Foamy urine
- Hematuria
- SOA
- Uremia
- Pericardial friction rub
- Asterixis
- Uremic frost
What is something you should consider for the clinical presentation of mild AKI?
Many pts with mild AKI have NO SYMPTOMS
What are the three steps involved in the common diagnostic test for AKI?
- UA with microscopy
- Urine albumin/cr ratio or protein/cr ratio
- Renal U/S
What are the treatments for:
Prerenal AKI:
ATN :
Glomerulonephritis :
AIN :
Prerenal AKI: IV fluid
ATN : supportive care
Glomerulonephritis : Immunosuppression/plasmapheresis
AIN : Discontinuationof offending agent
Define:
Nephrotic syndrome
Proteinuria that is…
>3-3.5 grams/day
If ____________ is normal in setting of nephrotic range proteinuria, then patient DOES NOT HAVE true nephrotic syndrome but instead has nephrotic range proteinuria
If serum albumin is normal in setting of nephrotic range proteinuria, then patient DOES NOT HAVE true nephrotic syndrome but instead has nephrotic range proteinuria
What are the 6 most common nephrotic syndrome complications?
- Edema
- Hyperlipidemia
- Infection
- Thrombosis
- Vitamin D deficiency
- Anemia
What is the classic presentation of nephrotic syndrome?
- New onset HTN
- New onset Edema
- Proteinuria
- Lipiduria
- Hyperlipidemia
- Minimal hematuria
What are the 5 primary items on your nephrotic syndrome differential?
- Diabetic nephropathy
- Minimal change disease
- Focal segmental glomerular sclerosis (FSGS)
- Membranous nephropathy
- Monoclonal disease related
How would you diagnose nephrotic syndrome?
- Serum creatinine w/ eGFR
- UA w/ microscopy
- Urine albumin to creatinine ratio, or urine protein to creatinine ratio
- 24 hr urine total protein collection
- Glomerulonephritis serologic evaluation
- Renal biopsy
What is the general rule to treat nephrotic syndrome?
Treat the UNDERLYING etiology
Define
Nephritic syndrome
- Low level proteinuria <3.5 grams/day
-Hematuria
- HTN
- Renal failure common
Key point:
What is usually seen in nephritic syndrome?
ACTIVE URINARY SEDIMENT
(i.e., hematuria, dysmorphic RBCs, RBC casts, WBCs, WBC casts, granular casts, etc…)
What is the classic presentation of nephritic syndrome?
- New onset hematuria and HTN
- AKI
- Low level proteinuria
What are (11) potential items on your differential for nephritic syndrome?
- IgA nephropathy
- Thin Basement Membrane Nephropathy
- Alport’s Nephropathy
- Membranoproliferative Glomerulonephritis (MPGN)
- Lupus
- Goodpasture’s
- ANCA-associated vasculitis
- Cryoglobulinemia
- Thrombotic microangiopathy
- Post-infectious glomerulonephritis
- Endocarditis
How would you diagnose nephritic syndrome?
SAME AS NEPHROTIC SYNDROME!
- Serum creatinine w/ eGFR
- UA w/ microscopy
- Urine albumin-to-creatinine ratio and urine protein-to-creatinine ratio
- 24 hr urine total protein collection
- Glomerulonephritis serologic evaluation
- Renal biopsy
Urinary pattern = Renal tubular epithelial cells, transitional epithelial cells, granular casts or waxy casts
What kidney disease is suggested by this pattern?
ATN
Urinary pattern= WBC, WBC cast or urine eosinophils
What kidney disease is suggested by this pattern?
AIN
or
Pyelonephritis
Urinary pattern= Dysmorphic RBCs, RBC casts
What kidney disease is suggested by this pattern?
Vasculitis
or
Glomerulonephritis
Urinary pattern= Proteinuria (<3.5g/day), hematuria, dysmorphic RBC and RBC casts
What kidney disease is suggested by this pattern?
Nephritic syndrome
Urinary pattern= Heavy proteinuria (>3.5g/day), lipiduria, minimal hematuria
What kidney disease is suggested by this pattern?
Nephrotic syndrome
Urinary pattern= Hyaline cast
What kidney disease is suggested by this pattern?
Non-specific, prerenal azotemia
Urinary pattern= WBCs, RBCs, bacteria
What kidney disease is suggested by this pattern?
Urinary tract infection
