1.14.2 Renal Emergencies

Question 1

Your patient presents with flank pain.

• Clinical presentation / things to investigate
• Differentials
  
  • Renal
  • Extrarenal

Answer 1

• Clinical presentation / things to investigate
  
  • Gradual vs. sudden onset
  • Quality of pain
  • Associated n/v
  • Fever
  • Temporal factors
  • Urinary symptoms - hematuria, dysuria, frequency, bladder pressure
  • Trauma/injury - even in the past wk
  • Complete physical exam WITH skin inspection
    
    • Shingles rash?
• Differentials
  
  • Renal
    
    • Pyelonephritis
    • Renal abscess
    • Renal infarct
    • Renal vein thrombus
    • Renal tumor
    • Nephrolithiasis
    • Perirenal hematoma
    • Obstructive uropathy: tumor, ureteral stone, stricture, urinary retention
  • Extrarenal
    
    • Pulmonary: pleurisy, PE, pna
    • Shingles
    • MSK: thoracic radiculopathy, rib fx, muscle strain
    • AAA
    • Retroperitoneal abscess or hematoma
    • Cholecystitis
    • Pancreatitis
    • Hepatitis
    • Appendicitis

Question 2

Your patient presents with flank pain. What diagnostics will you order and why?

Answer 2

• Labs:
  
  • CMC, BMP
  • LFT, lipase (r/o pancreatitis, cholestatic z)
  • UA +/- culture (blood casts, bacteriuria, nitrites, leuk esterase)
  • D-dimer (r/o PE)
• Imaging
  
  • CT ab/d pelvis (with contrast for vascular, without for structural)
  • Renal US: see hydronephrosis but will not see source of obstruction
  • XR KUB: not for dx, but to follow resolution
  • CT urography: usually nephro will order

Question 3

Your patient concerns you for nephrolithiasis.

• What are common types and specific etiologies?
• What is epidemiology?
• Clinical presentation?

Answer 3

• What are common types and specific etiologies?
  
  • Supersaturation of urine and see formation
  • Calcium 75%
    
    • Dehydration
    • Hypercalcemia
    • Low mg and citrate levels
  • Struvite 16%
    
    • Chronic UTI (Proteus, PsA, Klebsiella)
  • Uric Acid 6%
    
    • High purine diet, malignancy
  • Cysteine 2%
    
    • Instrinsic metabolic defect
  • Drug-induced
• What is epidemiology?
  
  • 11% men, 7% women will get
  • Caucasians at higher risk
  • Higher socioeconomic status at higher risk
• Clinical presentation?
  
  • Non-obstructing renal stones may be minimally symptomatic
  • Renal colic
    
    • sudden onset, severe flank/abd pain, radiating to lower abd and genitals
    • N/v
    • Hematuria
    • Frequency, dysuria

Question 4

Your patient has hypercalcemia and complaines of sudden onset severe flank/abd pain with radiation to the genitals, N/v, and urinary frequency.

1. What do you suspect and how will you work up?
2. How will you treat?
3. What are potential complications?

Answer 4

What do you suspect and how will you work up?

• Nephrolithiasis
• Labs:
  
  • CBC, CMP, UA (r/p infxn)
  • Coags
  • CT abd/pelvis without contrast
    
    • 95-100% Se
    • But inaccurate size estimate
  • Renal US
    
    • Low Se for detecting stones
  • KUB
    
    • Less Se and Sp but good for planning procedures and follow up

How will you treat?

• IVF
• Analgesics
  
  • IV Lidocaine equieffective to opioids
  • NSAIDs, opioids
• Antiemetics
• Flomax / tamsulosin (relaxes ureters)
• Abx if UTI
• Strain urine
• Trial Passage if <8mm
• Surgery if >10mm, or >4wks, or severe symptoms

What are potential complications?

• Diminished renal function
• Sepsis
• Abscess
• Ureteral perforation, stenosis, fistula
• Post-Op
  
  • Retained fragments
  • Infection
  • Hematoma

Question 5

Your patient has a renal infarct.

• Define
• Epi
• Etiology
• Presentation
• Diagnostics
• Treatment

Answer 5

• Define
  
  • Sudden disruption of blood flow to the kidney
• Epi
  
  • Rare - 0.004 - 0.007%
• Etiology
  
  • A fib (majority of cases)
  • Ischemic heart disease
  • Endocarditits
  • Hypercoagulation disorder
  • Renal artery dissection
• Presentation
  
  • Flank pain
  • N/v
  • Fever
  • Hematuria
  • Normal/elevated Cr
  • Elevated LDH - helpful in dx
• Diagnostics
  
  • CBC, BMP, LDH
  • UA
  • EKG
  • CT abd/pelv with IV contrast
  • Renal US is not diagnostic for infarct
• Treatment
  
  • Anticoagulation with heparin
  • Normalize BP (ACE or ARB)
  • Percutaneous endovascular therapy

Question 6

Your patient has a perinephric abscess.

• Define
• Causes
• Risk factors
• Presentation
• Diagnostics
• Treatment

Answer 6

• Define
  
  • Collection of suppurative material in the renal parenchyma or perinephric space
• Causes
  
  • Ascending UTI
  • Hematogenous spread from extra renal site (pulmonary, wound)
  • Spread from abdominal structures (appendicitis, PID, diverticulitis, bowel perforation)
• Risk factors
  
  • Neurogenic bladder
  • Vesicoureteral reflux (back up)
  • Bladder outlet obstruction
  • IVDA
  • Trauma, instrumentation, surgery
  • Immunosuppresion
  • DM
• Presentation
  
  • Insidious onset of flank pain
  • History of UTI / infxn
  • Fever, chils
  • Dysuria
  • Weight loss, lethargy
  • N/V/D
• Diagnostics
  
  • CBC: anemia, leukocytosis
  • ESR: inflammation changes
  • BMP: renal function
  • UA: pyuria, hematuria
    
    • UA MAY BE BENIGN!
  • CT abd/pelvis with IV
  • Renal US - low sensitivity, neg does not r/o
• Treatment
  
  • Percutaneous drainage
  • Abx:
    
    • Staph coverage
      
      • Nafcillin, cefazolin
      • Vanco
    • Gram negative
      
      • Amingoglycoside
    • Nephrectomy or surgical debridement

Question 7

Your patient complains they are peeing frank blood.

• Causes
• Diagnostics
• Management

Answer 7

• Causes
  
  • Renal tumor, bladder tumor
  • Prostate cancer, prostatitis
  • Nephro or ureterolithiasis
  • UTI
  • Trauma
  • Coagulopathy
  • Nephritis
• Diagnostics
  
  • CBC, BMP, UA, Coags
  • CT abd/pelvis with and without
    
    • Stones, tumors
• Management
  
  • Continuous bladder irrigation if clots
  • Reverse coagulopathy if present
  • Transfuse if indicated
  • Cytoscopy