Approach to Renal or Genitourinary Complaint Flashcards
What is important to ask about for kidney specific complaint?
precipitating event for pain
diabetic or hypertensive
drinking enough fluids
NSAID use
IV contrast exposure
Why is medication information important in kidney complaint?
medications are often the cause of kidney problems
Specific PE exams for kidney complaint
**volume status
cardiac exam
lung exam
abdominal exam
Definition of Chronic Kidney Disease
present for 3 months:
low GFR (<60ml/min) markers of kidney disease
What are some markers of kidney disease?
protein in urine abnormal urinary sediment abnormal biopsy abnormal imaging electrolyte abnormalities hx of kidney transplant
What is acute kidney injury?
low GFR or marker of kidney damage that is less than 3 months
because kidneys usually recover w/ in 3 months of damage
What is urinary sediment?
RBC cast, WBC cast
Do stages 1 or 2 fulfill criteria for CKD?
No b/c no evidence of kidney damage (only lowered GFR)
What is the prevalence of CKD in US?
15% of US adults have CKD (about 1 in 7 adults)
What are the major CKD risk factors?
diabetes mellitus hypertension CVD acute kidney injury family history of kidney disease nephrotoxic agents
What are the majority of CKD cases caused by?
diabetes or hypertension (64%)
When will patients have symptoms of CKD?
significant kidney dysfunction before start presenting w/ symptoms
Signs & symptoms of CKD
edema hypertension decreased urine output foamy urine hematuria uremia pericardial friction rub asterixis uremic frost
What are the signs of uremia?
high urea in blood
nausea/vomiting confusion metallic taste in mouth fatigue anorexia
How do you diagnose CKD?
serum creatinine GFR creatinine clearance proteinuria UA w/ microscopy
Does elevated serum creatinine always indicate CKD?
NO because creatinine comes from muscle
so if more muscle mass, will have more creatinine
What are the 3 tests used to identify most CKD patients?
eGFR (an estimation!)
urine albumin to creatinine ratio (or urine protein to creatinine ratio)
UA
What should you look at on renal ultrasound?
renal size (should be proportional to height & not always symmetric)
What is suggestive of CKD on renal ultrasound?
small kidneys
What is hydronephrosis?
dilation of renal calyx (urine obstructed from leaving thru ureter)
What are key renal ultrasound findings for CKD?
atrophic/small kidneys
cortical thinning
increased echogenicity
elevated resistive indices (how much blood is flowing in kidney)
What is important in relationship of serum creatinine & GFR?
once get to 5-7 serum Cr, not a huge change in GFR so not huge change in kidney function
What happens to GFR with age?
GFR declines by 1ml/min/year after age of 30-40
What are complications assoc w/ CKD?
CVD CKD-MBD anemia of CKD electrolyte abnormalities metabolic acidosis volume overload uremia hypertension
How is CKD related to secondary hyperparathyroidism?
CKD leads to hypocalcemia, hyper phosphate & vitamin D deficiency
leads to increase secretion of PTH by parathyroid gland so increase reabsorption of bone
What is the major cause of death in end-stage renal disease?
cardiovascular disease (54%)
What are indications for dialysis?
A (severe acidosis) E (electrolyte disturbance) I (ingestion) O (volume overlaod) U (uremia)
What is azotemia?
elevated BUN w/o symptoms
What is uremia?
elevated BUN w/ symptoms (confusion, pruritus, metallic tase in mouth, fatigue)
What does renal replacement therapy include?
Hemodialysis
Peritoneal dialysis
Renal Transplant
What is important for hemodialysis?
good access to blood
How do you define acute kidney injury (AKI)?
based on change in creatinine level from baseline or urine output
What are major risk factors for AKI?
old age proteinuria CKD HTN DM CVD exposure to nephrotoxins cardiac surgery fluid overload sepsis
What are the 3 main etiologies of AKI?
pre-renal
intrinsic
post-renal
What is pre-renal AKI?
not enough blood to kidneys due to hypotension, hypovolemia, reduced CO, systemic vasodilation
What is post-renal AKI?
obstruction to kidney
bladder outlet or ureter obstruction or renal pevlic stones
What is intrinsic AKI?
acute tubular necrosis
interstitial nephritis
glomerulonephritis
Which drugs tend to cause acute interstitial nephritis?
antibiotics, NSAIDs, and PPIs
Complications of AKI
development of CKD
progression of CKD
end stage renal disease
CVD
What do you always need to do to diagnose AKI?
UA w/ urine microscopy
random sample to determine albumin/creatinine ratio
What are main causes of AIN?
drugs, infections or autoimmune disorders
What are common diagnostic tests for AKI?
UA w/ microscopy
urine albumin/cr or protein/cr
renal ultrasound
Acute tubular necrosis (urinary pattern)
renal tubular epithelial cells, transitional epithelial cells, granular or waxy casts
Acute interstitial nephritis or pyelonephritis (urinary pattern)
WBC, WBC cast, urine eosinophils
Vasculitis or glomerulonephritis (urinary pattern)
dysmorphic RBCs, RBC casts
Nephritic syndrome (urinary pattern)
proteinuria, hematuria, dysmorphic RBC & RBC casts
Nephrotic syndrome (urinary pattern)
heavy proteinuria, lipiduria, minimal hematuria
Non-specific pre-renal azotemia (urinary pattern)
hyaline cast
Urinary tract infection (urinary pattern)
WBCs, RBCs, bacteria
What is the purpose of ordering FeNA or FeUrea?
to differentiate pre-renal azotemia from intrinsic renal injury
When is FeNa or FeUrea valid?
in oliguric patients (<400 to 500ml/day)
intended for low urine output pts (due to intrinsic problem in kidney or due to low circulating volume?)
Anuria
<50 to 100 ml/day
Polyuria
> 3000 ml/day
Why are urine eosinophils limited for AIN diagnosis?
not very sensitive or specific
many causes for urine eosinophils
What are common causes of urine eosinophils?
AIN
pyelonephritis or UTI
Atheroembolic renal disease
What influences AKI treatment?
etiology of disease
