Approach To Renal Complaint Flashcards
What is proteinuria?*
Protein in the urine
What is glucosuria?
Glucose in the urine
What is hematuria?
Blood in the urine
What is albuminuria?
Albumin in the urine
What is dysuria?
Painful urination
What is polyuria?
Frequent urination
What is GFR?
Glomerular filtration rate
What is CrCl?
Creatinine clearance
What is AKI?
Acute kidney injury
Impairment of renal filtration and excretory function over days to weeks that results in retention of nitrogenous and other waste products, normally cleared by the kidney
Clinical diagnosis not a structural injury to kidney
What is CKD?
Chronic kidney disease
What is ESRD?
End stage renal disease
What is uremia?
Elevated levels of BUN
What is blood urea nitrogen (BUN)?
Urea nitrogen is a waste product created when the liver breaks down proteins
Urea nitrogen travels from the liver to kidneys and is excreted as waste product
BUN is a blood test that allows clinicians to gauge kidney function
What is creatinine?
Waste product of muscle breakdown
Created constantly and properly functioning kidneys excrete this waste product
Cr is a blood test that allows clinicians to gauge kidney function
What is tested in a basic metabolic panel?
Na, K, Cl, HCO3, BUN, Cr, glucose
What is tested in a comprehensive metabolic panel?
BMP + liver function tests (AST, ALT, Alkphos, total bilirubin, T protein, albumin)
What’s included in a urinalysis?
Specific gravity (tests urine concentration), pH, protein, glucose, blood, bilirubin, nitrites, leukocytes
What is urine microscopy?
Looking at urine under the microscope for urine casts/sediment to aid in clinical diagnosis
AKI may progress to chronic kidney disease if the renal dysfunction is not resolved in how long?*
3 months
What are the major risk factors for AKI?
Old age, CKD, HTN, DM, exposure to nephrotoxins (NSAIDs, Abx), fluid overload, trauma, malignancy and sepsis
What are the 3 categories of AKI?
Pre-renal AKI (insult/injury occurring before kidney - ex. hypotension) Intrinsic AKI (injury occurring at the level of kidney - ex. Glomerulonephritis) Post-renal AKI (injury occurring down stream to/after the kidney - ex. Bladder outlet obstruction)
Describe a clinical scenario for pre-renal AKI
History of fluid loss or poor fluid intake? (Vomiting, diarrhea, hemorrhage)
History of decreased effective circulatory volume? (Heart failure)
History of new or chronic use of medications? (NSAIDs, BP meds)
PE finding of volume depletion (dry mucous membranes, tachycardia, hypotension and poor skin turgor)
Describe a clinical scenario for intrinsic AKI
History of CKD, DM, HTN? History of recent URI? New meds? (Abx, NSAIDs, BP meds) Systemic sx present that would make you think of auto immune disease? (Oral ulcers, CP, SOB, cough, hemoptysis, abd pain) Hematuria? Foamy urine? (Proteinuria)
Describe a clinical scenario for post renal AKI
Hx of kidney stones (flank pain with hematuria)
Hx of prostate issues (think of elderly male with urinary hesitancy, frequency, and sense of incomplete vomiting)
Hx of pelvic neoplasm (think of pt being up to date on cervical cancer and prostate cancer screening)
Hx of Foley catheter (acute or chronic in nature)
Complaint specific questions to ask?
Urinary frequency, hesitancy, foamy urine, urine color, urine smell, flank pain, pain with urination, hx of kidney stones
Describe evaluating volume status during exam
Jugular venous pressure (distended or flat veins?), oral mucosa (dry, tongue fissuring), capillary refill, skin testing, ascites, lower extremity pitting edema, sacral edema (elderly or immobile pts)
Which labs should always be obtained on all pts with AKI?
BMP*
-increase in Cr 1.5x the pt’s baseline or >0.3mg/dL increase
-BUN:Cr >20:1 suggestive of pre-renal AKI
urinalysis with urine microscopy*
Other tests that may be useful include urine albumin/creatine ratio, renal ultrasound, renal biopsy
What are some treatments for AKI?
Depends on etiology (pre-renal, intrinsic or post renal pt)
Correct underlying disease if possible
Mostly supportive (avoid HTN, discontinue nephrotoxins, renal replacement if needed usually with hemodialysis)
Time is nephrons
Pre-renal pts need what?
IV fluid
Intrinsic renal pt need what?
Underlying cause of disease addressed
Post renal pts need what?
Remove obstruction
What is the definition of chronic kidney disease?
Either present for 3 months
- GFR <60 ml/min/1.73m^2
- Markers of kidney damage including protein in urine, abnormal urinary sediment, abnormal biopsy, abnormal imaging, electrolyte abnormalities, hx of kidney transplantation
If it is <3 months with GFR <60 ml/min and/or markers of kidney damage present then the pt has what?
Acute kidney injury
What are the risk factors for CKD?
DM, HTN, cardiovascular disease, AKI*
Metabolic syndrome or obesity, smoking, high cholesterol, HIV, hep C, cancer or cancer Tx
Signs and sx for CDK are the same as what?
AKI
What questions should also be asked during the history for CKD?
Questions about new sx of uremia
Nausea/vomiting, confusion, pruritus, metallic taste in mouth, fatigue, anorexia
Pericardial friction rub (pericarditis and pericardial effusion)
Asterixis (movement of the wrist; hand will flop)
Uremic frost
Which 3 tests are used to ID most CKD patients?
GFR (estimated GFR), proteinuria (urine albumin to creatinine ratio or urine protein to creatinine ratio) and urinalysis with microscopy
What are the limitations for testing GFR to ID CKD pts?
Not reliable when GFR >60m/min
Not reliable in AKI (rapidly chaining creatinine)
Not reliable in low muscle mass (cachexia, paraplegia, etc)
What complications can occur with CKD?
CVD, chronic kidney disease-mineral and bone disease (CKD-MBD), anemia of CKD, electrolyte abnormalities, metabolic acidosis, volume overload, uremia, HTN
How is CKD treated?
Correct/treat underlying disease if possible (HTN, DM, etc) Mostly supportive (prevent HTN, avoid volume overload, avoid nephrotoxins (NSAIDs), treat anemia, renal replacement if needed
What is renal replacement therapy (RRT)?
Hemodialysis, peritoneal dialysis, renal transplantation (living v deceased donor)
What are the indications for dialysis?*
A - severe acidosis
E - electrolyte disturbance (usually hyperkalemia)
I - ingestion (ex. Ethylene glycols, methanol, etc)
O - volume overload
U - uremia
What is asymptomatic bacteriuria?
Presence of bacteria w/out sx
What is cystitis?
Symptomatic bladder infection
What is prostatitis?
Symptomatic prostate inflammation due to infection
What is pyelonephritis?
Symptomatic infection of the kidneys
What is the pathogenesis of a UTI?
Occurs when there is colonization of urethra meatus or urine with a uropathogen
Most commonly E. coli (70-90% of the time)
What are the most common causes of a UTI?
Fecal contamination, outflow obstruction, sexual activity, catheterization
What are the sx of cystitis?
Dysuria, urinary frequency, urinary urgency, suprapubic pain, hematuria
What are the sx of pyelonephritis?
Dysuria, urinary frequency, urinary urgency, suprapubic pain, hematuria, fevers, flank pain, costovertebral angle tenderness, nausea/vomiting
What are the basic labs for cystitis?
CBC, BMP, urinalysis
Urine culture* (look for >100,000 cfu/mL on urine culture)*
What is the diagnostic approach for pyelonephritis?
History and PE are important Basic labs (CBC, BMP, urinalysis, urine culture, microscopy, +/- blood cultures) Imaging (in severe cases CT scan of the abd and pelvis is the gold standard)
What is Lloyd’s sing (punch)?
Special test for kidney inflammation/distention
Pain to deep percussion in the are of the CVA
Positive test = pain in the area of the CVA with deep percussion
-implies pyelonephritis, nephrolithiasis
What is the tx for a UTI?
Abx if the following criteria are met (symptomatic, >100,000cfu)
Duration of Abs will vary based off UTI type and severity (cystitis 3-5 days; pyelonephritis 7-14 days)
What is nephrolithiasis?
Kidney stones
Caused by precipitation in minerals in the kidney and ureters that were soluble in the blood
What are the types of kidney stones?
Calcium oxalate (80%)»_space;» calcium phosphate**
Auric acid
Struvite
Cystine
What are the sx of nephrolithiasis?
Unilateral sharp colicky pain
Location of stone indicates locations of pain
Stone located at kidney or renal pelvis = flank pain
Stone located at lower ureter = groin/lower abd pain
Urinary sx (polyuria, dysuria, hematuria, urinary urgency are common)
What is the diagnostic approach for nephrolithiasis?
HPI and PE are important
Basic labs + stone composition analysis
Imaging (non contrast CT preferred; ultrasound preferred for pts where radiation contraindication like pregnant women or children)
How is nephrolithiasis treated?
Supportive care (treat pain and nausea, consider IV fluids)
If recurrent or strong family hx find cause to treat
If concerned for contaminant infection treat with Abx
Severe cases (large stones) may require surgical intervention
What are the reflex levels for sympathetic to the genitoruinary tract including bladder?
T10-L2
What are the sympathetic levels for the upper ureter?
T10-11
What are the levels to the lower ureter?
T12-L2
What are the parasympathetics to the upper ureter?
Vagus N (OA, AA)
What are the parasympathetics to the bladder and lower ureter?
S2-4 (sacrum)
Describe the anterior Chapman reflex points
Kidneys: about 1 in lateral and 1 inch superior to umbilicus (10 and 2 position)
Ureters: none
Bladder: umbilicus
Urethra: superior surface of pubic bone relative positions
Describe posterior Chapman points*
Kidneys: lateral to spinous process of L1
Ureters: TP of L2
Bladder: TP of L2
What are Chapman reflex points?
Group of palpable points occurring in predictable locations on the anterior and posterior surfaces of the body that are reflections of the visceral dysfunction or disease
Viscerosomatic reflex of both diagnostic and tx value
Can be manipulated to reduce adverse sympathetic influence of a particular organ or visceral system
