Clin assess CURRENT MEDICAL DIAGNOSIS AND TREATMENT BOOK renal Flashcards
1
Q
worsening of the kidney function over hours to days, resulting in retention of the nitrogenous wastes (like urea nitrogen) and creatinine in the blood.
A
acute kidney disease/injury
2
Q
retention of the nitrogenous wastes (like urea nitrogen) and creatinine in the blood.
A
Azotemia
3
Q
results from an abnormal loss of kidney function over months to years
A
Chronic kidney disease
4
Q
small kidneys are most consistent with
A
CKD
5
Q
normal to large size kidneys can be seen with
A
CKD and Acute disease
6
Q
test that can give the same type of information as biopsy but is cost effective and non-invasive
A
urinalysis
7
Q
how is urinalysis collected?
A
midstream or cath
8
Q
within what time should the urine be examined
A
1 hour to avoid destruction of formed elements
9
Q
urinalysis includes:
A
dipstick exam followed by microscopic assessment if the dipstick has positive finsings
10
Q
measures pH, protein, hemoglobin, glucose, ketones, bilirubin, nitrates, and leukocytes esterase
and urinary specific gravity is often reported
A
dipstick examination
11
Q
examination of formed elements- crystals, cells, casts., and infecting organisms
A
microscopy examination
12
Q
_______ are composed of TammHorsfall urinary mucoprotein in the shape of the nephron segment where they were formed.
A
Casts
13
Q
Heavy proteinuria and lipiduria are consistent with the _____syndrome
A
nephrotic syndrome
14
Q
what is indicative if they have presence of hematuria with dysmorphic red blood cells, red blood cell casts, and proteinuria
A
glomerulonephritis
15
Q
pigmented granular casts and renal tubular epithelial cells alone alone or in casts suggest
A
acute tubular necrosis
16
Q
pyuria alone can indicate
A
urinary tract infection
17
Q
excessive protein excretion in the urine, gernally > 150-160 mg/24h in adults.
A
proteinuria
18
Q
sign of an underlying kidney abnormality usually glomular in origin
A
proteinuria
19
Q
accompanied by elevated blood urea nitrogen (BUN), and serum creatinine levels, abnormal urinary sediment, or evidence of systemic illness (fever, rash, vasculitis)
A
Proteinuria
20
Q
Reasons for the development of proteinuria (4)
A
- functional proteinuria
- overload proteinuria
- glomerular proteinuria
- tubular proteinuria
21
Q
benign process stemming from stressors such as acute illness, exercise, and orthostatic proteinuria.
A
functional proteinuria
22
Q
generally found in people under age 30 years old usually results in urinary protein excretion of
A
orthostatic proteinuria
23
Q
result from an overproduction of circulating, filterable plasma proteins, such as Bence Jones proteins associated with multiple myeloma. urinary electrophoresis will exhibit a discrete protein peak. other examples of this include myoglobinuria in rhabdomyolysis and hemoglobinuria in hemolysis.
A
Overload proteinuria
24
Q
results from effacement of epithelial cell foot processes and altered glomerular permeability with an increased filtration fraction of normal plasma proteins, as in diabetic nephropathy. Exhibits some degrees of proteinuria. The urinary protein electrophoresis will have a pattern exhibiting a large albumin spike indicative of increased permeability of albumin across a damaged GBM
A
glomerular proteinuria
25
occurs as result of faculty reabsorption of normally filtered proteins in the proximal tubule, such as micro globulin and immunoglobulin light chains. causes include acute tubular necrosis, toxic injury, drug induced interstitial nephritis, and hereditary metabolic disorders.
Tubular proteinuria
26
urinary dipstick primarily detect
while overlooking
albumin
| while over looking: positively charged light chains of immunoglobulins
27
how can proteins be detected when overlooked in a urinary dipstick ?
by addition of sulfosalicylic acid to the urine specimen
28
if patient has proteinuria with out without loss of kidney function, what may be indicated
kidney biopsy, especially if the kidney disease is acute in onset
29
__________ is significant if there is more than three red cells per high-power field on at least two occasions. usually is detected incidentally by the urine dipstick exam or clinically following and episode of macroscopic _______.
Hematuria
30
diagnosis must be confirmed via microscopic exam. a false positive dipstick test can be caused by myoglobin, oxidizing agents, beets and rhubarb, hydrochloric acid, and bacteria
hematuria
31
common, but in pts younger then 40 years old, it is less often of clinical significance due to lower concern for malignancy.
transient hematuria
32
hematuria can be due to 2 causes
renal or extrarenal
33
account for approx 10% of cases and are best considered anatomically as glomerular or nonglomerular.
renal cause
34
most common ________ sources include cysts, calculi, interstitial nephritis, and renal neoplasia.
Extraglomerular sources
35
provides a useful index of kidney function at the level of the glomerulus. this can be decreased in pt with kidney disease which is from any process that causes loss of nephron mass. but this can be increased or normal either from hyperfiltration at the glomerulus or disease at a different segment of the nephron, intersititium, or vascular supply.
GFR
36
measures the amount of plasma ultrafiltered across the glomerular capillaries and correlated with the ability of the kidneys to filter fluids and various substances.
GFR
37
can be measured by determining the renal clearance of plasma substances that are not bound to plasma proteins, are freely filterable across the glomerulus, and are neither secreted nor reabsorbed along the renal tubules
GFR
38
C= (U x V)/ (P)
formula used to determine the renal clearance of a substance
C: clearance
U: urine concentration
P: plasma concentration
39
product of muscle metabolism produced at a relatively constant rate and cleared by renal excretion. Freely filterable by the glomerulus and not reabsorbed by the renal tubules.
Creatinine
40
when is creatinine production and excretion equal thus plasma creatinine concentration remain constant?
with stable kidney function
41
what are the four variable estimated GFR equation incude
serum creatinine, age, weight, race
more accurate then creatinine clearance
42
another endogenous marker of GFR filtered freely at the glomerulus and produced at a relatively constant rate, irrespective of muscle mass. it is reabsorbed and partially metabolized i the renal tubular epithelial cells.
Cystatin C
43
Creatinine clearance can also be estimated using the ____________ formula, which incorporates age, sex, and weight to estimate creatinine clearance from plasma creatinine levels without any urinary measurements.
Cockcroft and Gault formula
44
index used for assessing kidney function. synthesized mainly in the liver and is the end product of protein catabolism
BUN
45
______ is freely filtered by the glomerulus and about 30-70% is reabsorbed in the renal tubules.
urea
46
reduced _____ is seen in liver disease and in the syndrome or inappropriate antidiuretic hormone and secretion.
BUN
47
what are these 7 indications for?
1) unexplained acute kidney injury CKD
2) acute nephritic syndromes
3) unexplained proteinuria and hematuria
4) previously identified and treated lesions to plan future therapy
5) systemic diseases associated with kidney dysfunction
6) suspected transplant rejection
7) to guide treatment
indications for percutaneous needle biopsy
48
defined as a sudden decrease in kidney function, resulting in an inability to maintain acid-bas fluid and electrolyte balance and to excrete nitrogenous wastes.
acute kidney injury
49
three progressive levels: risk, injury, and failure
acute kidney injury
50
usually non-specific symptoms. when symptoms are present often due to underlying uremia or its underlying cause. uremia can cause nausea, vomiting, malaise, and altered sensorium. HTN can occur and fluid homeostasis is often altered.
signs and symptoms of acute kidney injury
51
Hypovolemia can cause states of low blood flow to the kidneys , sometimes termed :
prerenal states
52
hypervolemia can result from intrinsic or :
postrenal disease
53
elevated BUN and serum creatinine levels are present though these elevations do not distinguish _________ from ____________
Acute kidney injury from CKD
54
peaked t waves, PR prolongation and QRS widening on EKG
hyperkalemia
55
long QT segment can occur with
hypocalcemia
56
THREE CATEGORIES of Acute Kidney injury
1) prerenal causes
2) intrinsic causes
3) postrenal causes
57
most common etiology of acute kidney injury . due to renal hypoperfusion. if reversed quickly damage does not occur. if hypoperfusion exists ischemia can occur causing intrinsic kidney injury.
prerenal causes
58
what happens if there is a:
- decrease in intravascular volume
- change in vascular resistance
- low CO
decreased renal perfusion
59
causes include:
- hemorrhage
- GI losses
- dehydration
- excessive diuresis
- extravascular space sequestration
- pancreatitis
- burns
- trauma
- peritonitis
causes of volume depletion
60
least common reason for acute kidney injury. 5-10 % of cases. occur when urinary flow from both kidneys, or a single functioning kidney is obstructed. obstruction leads to elevated intraluminal pressure, causing kidney parenchymal damage, with marked effects on renal blood flow and tubular function, and a decrease in GFR.
Postrenal causes
61
include urethral obstruction, bladder dysfunction or obstruction, and obstruction of both ureters or renal pelvises.
in men benign prostatic hyperplasia is the most common cause.
pt taking anticholinergic are at risk
postrenal causes
62
______ occurs in the setting of partial obstruction with resultant tubular dysfunction and an inability to appropriately reabsorb salt and water loads. obstruction can be constant or intermittent and partial or complete. on exam the pt may have an enlarged prostate. distended bladder, or mass detected on pelvic exam.
polyuria
63
lab exam of postrenal cause may reveal:
high urine osmolality, low urine sodium, high BUN creatinine ratio, and low FE sodium
64
pt with acute kidney injury and suspected postrenal insults should undergo:
bladder cath and ultrasonography to assess for hyproureter and hyronephrosis.
after reversal of underlying process these pt can undergo a post obstructive saliuresis and diuresis, and care should be taken to avoid volume depletion
65
obstruction usually found with
some situation where it is not found with that
ultra sound
if pt has retropertineal fibrosis from tumor or radiation may not show dilation of urinary tract so get CT scan or MRI to make diagnosis
66
prompt tx with what can have partial or complete reversal of the acute process of post renal causes?
catheters, stents, or other surgical prociedures
67
account for 50% of all cases of acute kidney injury . considered after prerenal and postrenal causes have been excluded. sites of injury are tubules , intersititum, vasculature, and glomeruli.
intrinsic acute kidney injury
68
if patient has signs of acute kidney injury that have not reversed over 1-2 weeks but no signs of acute uremia
can usually be REFERRED to a nephrologist rather than admitted
69
pt has signs of persistant urinary tract obstruction
patient should be referred to a urologist.
70
sudden loss of kidney function resulting in abnormalities that cannot be handled expeditiously in an outpatient setting (ie. hyperkalemia, volume overload, uremia) or other requirements for acute intervention, such as emergent urologic interventions or dialysis
ADMIT THIS PERSON!
71
hematuria, dysmorphic red cells, red cell casts, and mild proteinuria
dependent edema and hypertension
acute kidney injurt
Glomerulonephritis
72
Decline of GFR over months to years
persistent proteinuria or abnormal renal morphology may be present
HTN most cases
symptoms and sigs of uremia when nearing end stage disease
bilateral small or echogenic kidneys on ultrasound in advanced disease
Chronic kidney disease
73
affects 20 million americans
| most are unaware of the condition because they remain asymptomatic until the disease is near end stage
CKD
74
70% of cases of late stage CKD are due to:
diabetes mellitus or HTN/vascular disese
75
major causes of chronic kidney disease (5)
1. glomerular disease : primary and secondary
2. tubulointersiitial nephritis
3. cystic disease
4. obstructive nephropathies
5. vascular diseases
76
destruction of nephrons leads to
compensatory hypertrophy and supranormal GFR of the remaining nephrons in order to maintain overall homeostaisis
77
what meds can help reduce hyperinflation injury and are particularly helpful in slowing the progression of proteinuric CKD
ARBs and ACE
78
what is an independent risk factor of CVD
CKD
79
symptoms of CKD
early stages is asymptomatic
symp develop slowly with decline in GFR.
non specific and do not manifest until kidney disease is far advanced.
uremic syndrome (from build up of wastes) : fatigue, weakness, anorexia, nausea, vomiting, metallic taste.
may report irritability, memory impairment, insomnia, restless legs, paresthesias, twitching
generalized pruritus without rash
decreased libido and menstrual irregularities are common
80
what is the most common physical finding with CKD
HTN
| most often in early stages and worsens with CKD progression as sodium excretion is impaired.
81
```
Symptoms and signs of uremia
general
skin
ENT
eye
pulmonary
cardio
GU
GI
neuromuscular
neurologic
```
general:
symp- fatigue, weakness
sign-sallow-appearing, chronically ill
skin:
symp: pruritus, easy bruising
sign: pallor, eccymosis, excoriations, edema, xerois
ENT:
symp: metallic taste in mouth, epistaxis
Sign: urinous breath
eye:
Sign: pale conjunctiva
pulmonary:
Symp: SOB
Sign: rales, pleural effusion
cardio:
Symp: dyspnea on exertion, retrosternal pain on inspiration (pericarditis)
Sign: HTN, cardiomeagly, friction rub
GU:
Symp: anorexia, nausea, vomiting, hiccups
GI:
Symp: nocturia, erectile dysfunction
Sign: isosthenuria
neuromuscular:
Symp: restless legs, numbness, cramps in legs
neurologic:
Symp: irritability and inability to concentrate, decreased libio
Sign: stupor, asterixis, myoclonus , peripheral neuropathy
82
- infection
- obstruction
- extracellular fluid volume depletion or significant hypotension relative to baseline
- Hypokalemia, hypercalcemia, and hyperuricemia
- nephrotoxic agents
- severe/urgent HTN
- Heart failure
reversible causes of kidney injury
83
signs and symptoms of uremia warrant?
immediate hospital admission and nephrology consultation for initiation of dialysis. the uremic syndrome improves or resolved with dialytic therapy.
84
defined as an abnormal GFr persisting for t least 3 months
| persistent proteinuria and abnormalities on renal imaging are also diagnostic of....
CKD lab finding
85
the findings of small, echogenic kidneys bilaterally by ultrasonography supports the diagnosis of
CKD
86
normal or even large kidneys can be seen with....
adult polycystic kidney disease, diabetic nephropathy, associated nephropathy, multiple myeloma, amyloidosis, and other obstructive uropathy.
87
both gross and microscopic _________ require evaluation
the upper urinary tract should be imaged and cystoscopy should be performed if there is ________ in the absence of infection
hematuria
88
_______ can be identified in 10% of patients with gross or microscopic hematuria.
Upper tract source
89
what two parts are part of upper tract source
kidneys and urters
90
The lower tract source of gross hematuria is most commonly from
from urothelial cell carcinoma of the bladder.
91
Microscopic hematuria in the male is most commonly from
benign prostatic hyperplasia
92
is gross hematuria what may provide a clue to the localization of the disease
a description of the timing (initial, terminal, total)
93
what should physical exam emphasize for signs of hematuria ?
systemic disease (fever, rash, lymphadenopathy, abdominal or pelvic disease) as well as signs of medical kidney disease (HTN, volume overload)
94
what may urologic evaluation reveal? (in hematuria)
enlarged prostate, flank mass, or urethral disease
95
what are initial lab test for hematuria
urinalysis and urine culture
96
what do proteinuria and casts suggest?
renal origin
97
what all suggest urinart tract infection (3)
irritative voiding symptoms
bacteriuria
positive urin culture
98
what is important after tx to ensure resolution of the hematuria
follow up urinalysis
99
what has replaced intravenous urography when imaging the upper tracts for sources of hematuria
CT urography and MRI
100
what is the role of ultrasonographic evaluation of the urinary tract for hematuria
unclear
| sensitivity is low
101
used to assess for bladder or urethral neoplasm, benign prostatic enlargement, and radiation or chemical cystitis.
for gross hematuria it is ideally performed while the patient is actively blessing to allow better localization
cytoscopy
102
if negative evaluation wha may be warranted to avoid a missed malignancy?
REPEAT EVAL.... FOLLOW UP
103
_________ can be obtained after initial negative evaluation , and ________ and upper tract imaging after a year
urinary cytology can be obtained after initial negative evaluation , and cytoscopy and upper tract imaging after a year
104
if there is an absence of infection or other benign etiology, hematuria (either gross or microscopic) requires?
EVALUATION... REFERRAL
