Clin assess POWERPOINTS renal Flashcards
*** I know these cards have a lot of info. but i tried to make guiding questions on the front and the cards have everything. Hope they help :)
Kidney & Urologic Diseases
- how are these usually discovered?
- what are three things you want to access for in a patient with suspected kidney/urological disease?
- what are three things the last assesment is based on?
- Discovered incidentally or with evidence of disease (eg, HTN, edema, N/V or hematuria)
- Initial approach in both situations:
- Assess cause, severity & duration
- Urinalysis
- Assessment of glomerular filtration rate (GFR)
- Estimated GFR (eGFR) by √ serum creatinine
- Differences in GFR calculations based on patient’s age, sex & race
- ***when Cr goes up, GFR goes down they are indirectly proportional***
Basic Metabolic Panel
measures kidney function and electrolytes
- Na
- K (hyperkalemia: determines arrythmia with peaked T waves)
- Cl
- Bicarbonate
- calcium
- BUN
- Creatinine
- glucose
what will Urinalysis show?
and
decreased glomerular filtration rate= _____
Urinalysis will show products within the urine that are not normally there due to decreased kidney function.
Decreased glomerular filtration rate = eGFR.
how is estimated GFR calculated
Estimated GFR is calculated from serum creatinine (w/ equation)
what is included in a basic metabolic panel (BMP)
√ electrolytes & kidney function
- –Sodium (Na+)
- –Potassium (K+)
- –Chloride (Cl−)
- –Bicarbonate (HCO3−) or CO2
- –Calcium (Ca+)
- –Blood urea nitrogen (BUN)
- –Creatinine (w/ calculated eGFR)
- –Glucose
Urinalysis
what is it
what can it provide?
physical charecteristics (3)
what will acute kidney injury or chronic kindey disease show in urine?
UA includes = physical + urine dipstick + microscopic examination
•Physical characteristics:
–Color: foods, meds, metabolic products & infx can cause abnormal urine color
–Turbidity: cloudy urine may indicate precipitated phosphate or infx
–Odor: fruity smell w/ DKA, ammonia smell from urinary retention
Urinalysis – can provide information similar to kidney biopsy in a way that’s cost effective & noninvasive
DKA = diabetic ketoacidosis
Acute kidney injury or chronic kidney disease will show sediment in the urine, changing the color of the urine.
what consists in a urine dipstick
- Urine pH
- Specific gravity
- Protein
- Blood
- Glucose
- Leukocyte esterase
- Ketones
- Nitrites
- Bilirubin & urobilinogen
what are you looking for in microscopic examination
- √ formed elements or “sediment”
- Crystals
- Cells
- Casts
- Bacteria
Nephrolithiasis
- what is it
- what is the most common type of stone (what is cool about these stones)
- what is the classic presentation? (2)
- Assoicated symptoms
- Less common symptoms
- what is a key finding
- common history
- Renal & ureteral stones (most common – calcium oxalate)
- Classic presentation:
- Renal colic
- Unilateral flank pain
- Pain typically waxes & wanes
- Hematuria (gross or microscopic)
- Renal colic
- Associated symptoms: N/V, ± dysuria, urgency
- Less common – asymptomatic or atypical symptoms s/a vague abdominal pain, difficulty urinating, penile pain or testicular pain
- Nephrolithiasis = kidney stones.
- Most common being calcium. They are radio-opaque so you can see the stones on an x-ray.
- How do people present? Pain related to kidney stone is related to child birth. Sudden presentation, fairly acute. Unilateral flank pain. Really severe pain. Uncomfortable.
- Other symptoms: sweating, anxious, tachycardic. Pain will wax and wane. Smooth muscle contracts causing the pain to wax and wane. Nausea and vomiting associated.
- Common history: dehydration, high salt or animal protein intake. Urine is hyper-concentrated. Might notice hematuria (red blood in the urine).
- Patient could also present with vague abdominal pain radiating into the groin.
- Key finding: blood in the urine! Microscopic or gross.
Nephrolithiasis diagnostic tests
- 3 types
- what is the bottom line to know about Nephrolithiasis
Types
-
Non-contrast CT scan (imaging test of choice)
- Calcium stones are radiopaque; CT scan can identify stone type and is more sensitive/specific when compared to KUB or ultrasound
- Non-contrast CT: more sensitive and specific than other tests available. It can identify the stone and tell you what kind of stone it is.
- Ultrasound (less sensitive)
- Others:
- IVP (intravenous pyelogram): this used to be the diagnostic study of choice, but now it is getting phased out. This has more radiation and exposure than CT.
- KUB x-ray (consider if pt w/ hx radiopaque calculi): : choice for a patient for knows what kidney stones feel like due to having them before
- Bottom line:
- Suspect in all patients with the acute onset of atraumatic flank pain, particularly if hematuria is present & abdominal tenderness is absent
what is this
CT scan showing large renal pelvic stone
Kidney stone on the right side. This is a very large stone.
Urinary Incontinence
- Types (4)
- History
- Types (women > men):
-
Stress:
- leaking with ↑intra-abdominal pressure
- urinary leaking with cough, sneeze, run or jump due to increased intra-abdominal pressure. If the urinary sphincter is weak, this can happen. Weakening caused by intra-abdominal pressure due to morbid obesity.
- poor urethral sphincter function
- surgical intervention
-
Urge (“overactive”):
- nocturia & urinary frequency
- “I gotta go, I gotta go”. Patient has constant urge to go. This is due to over activity of the detrusor muscle in the bladder.
- give med to relax the muscle
-
Mixed (stress + urge)
- Combination of urge and stress.
-
Incomplete emptying (“overflow”):
- continuous urinary leakage or dribbling, ± weak or intermittent urinary stream, hesitancy, frequency, nocturia, nocturnal enuresis (bedwetting)
- when urinating, the ureter is squeezed because of the prostate gland.
- Dripping after urination.
- Digital rectal exam will show an enlarged prostate.
- detrusor underactivity (eg, peripheral neuropathy from DM) or bladder outlet obstruction (eg, uterine fibroids)
- think spinal cord injury, they don’t get the urge to go so the bladder overflows because it is full, or obstruction, benign prostatic hypertrophy
-
Stress:
-
History
- Age, gender, PMH (eg, prolapse, diabetes, obesity, neurologic disease), surgical hx, voiding diary
Urinary Incontinence
- Physical exam
- workup (5)
- what are the exams in men/women
- if you have acute onset of urinary and bowel incontinence do what?
- what should you get in the habbit of?
*
- Physical exam
- Pelvic/bimanual exam, DRE (√ rectal masses, prostate), neuro exam if sudden onset (absent perineal sensation w/ decreased rectal tone à cauda equina syndrome)
- Workup
- Urinalysis
- Prostate specific antigen (PSA): used to detect prostate cancer.
- Postvoid residual
- via ultrasound or catheterization
- What is a Bladder scan: shows you how much urine is retained, but wont show you the activity of the detrusor muscle.
- ± Urodynamic testing: can measure ureteral sphincter done, contractility of the detrusor muscle, etc. This is super time consuming and hasn’t been shown to really change the outcomes.
-
Referral to urology – cystoscopy ± additional imaging
- Cystocopy: taking a look inside the bladder.
- Pelvic exam in a women to feel the size of the uterus.
- Digital rectal exam in males.
- Acute onset of urinary incontinence and bowel incontinence, do a neural exam.
- Workup: get in the habit of ordering the UA. Urinary tract infections are the most common condition and can easily be ruled out with a UA.
Acute cystitis
- what is this?
- who is it common in
- why women
- what if in men?
- what can lead to infection
- risk factors (3)
- Classic presentaiton
- how is it different then kidney infection
- classic symptoms
- what happens when you push on bladder
- what is something common to see but not always present
- Physical exam
- Infection of bladder (lower urinary tract)
- Common in healthy sexually active young women
- This is caused in women due to short urethras.
- It is not normal for a male to present with a bladder infection due to the anatomy, so this is should be a red flag if they are presenting with this.
- Catheterization is a sterile procedure. Introduction of e coli into the urinary tract can lead to infection.
- RF – recent sexual intercourse, recent spermicide use, and hx UTI
- Classic presentation:
- dysuria, frequency, urgency, suprapubic pain ± hematuria
- patient is well-groomed, they might be sitting comfortably. This is different than a kidney infection. Patient with a kidney infection will present very sick and distressed and uncomfortable.
- Classical symptoms with UTI: painful urination, increased frequency with urination (urgency and frequency).
- Pressing over the bladder can cause super pubic tenderness due to bladder infection.
- Hematuria is a common finding to note on the analysis but may not always be present with the UTI.
- PE –
- often not necessary, but if performed, should include √ CVA tenderness & abdominal exam; pt afebrile
- Not really necessary. Limited-focused exam. Due a skin inspection and listen to heart and lungs.
- Press over the bladder to note tenderness.
- Always check for CVA tenderness (where you tap on the back to cause kidney tenderness).
- Usually patient is afebrile. With kidney infections, patient will be febrile.
Acute Cystitis
- what are the diagonostic exams (2)
- what is the bottom line?
-
Urinalysis (either by microscopy or by dipstick)
- “Clean catch” midstream urine specimen
- Clean catch is very important. Skin flora in the vagina. This will contaminate your analysis, but there will be contamination like epithelial cells and bacteria. If patient cannot provide one, might want to consider a straight catheterization, but that often isnt necessary.
-
Presence of leukocyte esterase and nitrite ± hematuria
- leukocyte esterase – enzyme released by leukocytes, reflecting pyuria
- “Clean catch” midstream urine specimen
-
Urine culture: Escherichia coli (most common)
- √ causative organism & antimicrobial resistance
- Urine culture will take about 24 hours to come back. Base your diagnosis on patient’s clinical presentation and UA. 85% of the time the bacteria is E. coli so treat for E. coli. This is okay to do before you get the urine culture back.
- Bottom line – In young nonpregnant women, dysuria, frequency, urgency, suprapubic pain, or hematuria, particularly in the absence of vaginal symptoms, are highly suggestive of an UTI
Acute pyelonephritis
- symptoms (6)
- diagbostic tests
- Fever (>38ºC), chills, flank pain, CVA tenderness & N/V ± irritative voiding sx
Diagnostic tests
- Urinalysis & urine culture
- Leukocyte esterase, nitrite ± hematuria PLUS white cell casts (always come from kidney)
- ± Urine pregnancy test, CBC & blood culture
- ± CT scan (or renal ultrasound):
- √ presence of underlying anatomic abnormality, calculus or obstruction
- √ complication of infection (eg, renal abscess
white cell casts mean what origin
renal
Casts come from the kidney so that will clue you in to it being a kidney infection.
when to consider imaging ?
consider in severally ill patients, those with renal colic or hx kidney stones, hx prior urologic surgery, or persistent clinical symptoms after 48-72 hours of antibiotics
presentation of acute pyelonephritis
febrile, chills, nausea/vomiting, flank pain, bilateral.
when to consider a CT scan
when you think kidney infections are due to an obstruct and the patient is not getting better on the antibiotics. This is when you would want to look for an underlying infection. This is not commonly done, but it is something to think about.
when is urine pregnancy tests important to consider
Urine pregnancy test: this is always important to consider when ordering an imaging when exposing a patient to radiation.
what is this
This is a white cell cast from the kidney. This will clue you in that it is pylonephritis.
whats goin on here?
Tumor on the left side. And there is necrosis within the tumor.
what are these
Wims Tumor
When you see this, precede with a careful abdominal exam. Do not press firmly on this because it could rupture the tumor.
Also, order a renal ultrasound in children because there is no radiation exposure. Refer if you see abnormal finding.
Diagnosing bladder cancer
who is it done by?
Diagnosing bladder CA with biopsy.
This is diagnosed with cystoscopy.
This is done by a urologist.
for your knowledge
CT with or without contrast.
Tumor growing inside the bladder, want to see the definition of it. With contrast, you can clearly see the line of the tumor.
Stages of CKD
THIS IS AN L.O. SO I WOULD KNOW IT :
Determine the stages of chronic kidney disease and acute kidney injury when provided with a case vignette that includes the patient’s laboratory test results (serum creatinine and estimated glomerular filtration rate) via correct selection on multiple choice examination
GFR units = mL/min/1.73 m2
Need to know these stages. These can help with your prognosis and whether or not the patient needs a refer (30 or less).
Stage 5. dialysis. Kidney transplant.
Stage 1: modify underlying risk factors.
know your anatomy folks :)
????
hydroephorsis
Early, is reversable.
Later, can cause permanent damage.
dilation of what?
dilation within the renal pelvis
for your info
parts of nephron
Nephrotic Syndrome
- charecterized by
- what else do we see
- what are suuayly normal (2)
- casues (4)
- what is in urine because kindey is not filtering well?
- what may this cause especially in the dae and around the lips or peri-orbital area?
- Characterized by proteinuria (> 3.5 g/day) & lipiduria w/ fatty casts
- Edema in the face & hyperlipidemia with fatty casts/droplets in urine
- Hypoalbuminemia; serum creatinine usually normal
- Causes: minimal change disease, amyloidosis, focal glomerulosclerosis, diabetic nephropathy
Nephrotic syndrome: classically associated with proteinuria. Fat droplets in the urine because they kidneys are filtering them any longer. Patient may have a history of hyperlipidemia. This may cause non-dependent edema, especially in the face like around the lips or peri-orbital.
picture: Not a lot of sediment, but you will see fatty droplets and fatty casts.
Polycystic Kidney Disease
- genetic link? what is it
- disease is often clincally _________.
- what can it present with number/lab wise? (4)
- how can this present clincally
- diagnosis
- At risk for what?
- what may prevent progression of renal disease and ecrease the risk of cardiovascular morbidity
- how may the pt know they have this?
- what may they present with and what may this cause?
- how is this often found?
- overtime this disorder can lead to? and the patient needs to take speical measures to prevent progression … what are these special measurs? (2)
- what are the pros and cons to CT (or MRI)
- Autosomal dominant – ask about positive family hx
- Disease is often clinically silent
- Can present with HTN, hematuria, proteinuria, or renal insufficiency detected by routine laboratory tests
- Flank pain due to renal hemorrhage from cyst rupture, calculi or UTI is the most common symptom reported by patients
- Diagnosis – renal ultrasound (findings include large kidneys w/ extensive cysts scattered throughout both kidneys) ± genetic testing
- Risk for ESRD (↓GFR)
- Rigorous control of blood pressure may prevent progression of renal disease and decrease the risk of cardiovascular morbidity
- Patient may know they have this due to family history.
- May present with flank pain due to cyst rupture. This may cause gross or microscopic hematuria. This is often found incidentally.
- Offer genetic testing for other family members.
- Overtime, this disorder can lead to CKD. Patient needs to take special measures (avoid NSAIDs, keep BP low) to prevent progression.
- CT (or MRI) – “pros” more sensitive, can detect smaller cysts but “cons” more costly & radiation exposure.
- Picture: Huge kidneys full of cysts.
Renal Artery Stenosis
- what is there a decrease in and why?
- what does it result in?
- who do we consider diagnosis in?
- gold standard (imaging)
- 3 things we see this in (gender, age, due to?, high___)
- what % of pt may have stenosis due to atherosclerosis? what kind of patient do we see this in?
- Persistent & progressive ↓GFR due to reduction of blood flow from atherosclerotic ischemia
- Results in CKD (↑serum creatinine & BUN)
- Consider diagnosis in patients who have: severe or resistant HTN, age <30 years w/ no family history of HTN & no obesity, acute rise in serum creatinine after starting ACE inhibitors or ARBs
- Imaging – “gold standard” renal angiography often replaced by less invasive tests (doppler u/s, CTA or MRA)
- Women under the age of 40. Due to FMH. High BP.
- Greater than 80% of patients may just have stenosis due to atherosclerosis. This is your patient who you have on 3 to 4 meds and you cannot bring the BP down.
- Picture: Gold standard is an arteriogram.
Urine Dipstick
- urine pH
- specifc gravity
- Protein
- Blood
- Glucose
- Leujocye esterase
- ketones
- nitrates
- bilirubin
- urobilinogen
- Urine pH
- Generally reflects serum pH
- Specific gravity
- Hydration status, concentrating ability of the kidneys
- Protein
- >150 mg per day (10 to 20 mg per dL), transient proteinuria relatively common
- Hallmark of kidney disease
- On dipstick, 1+ = 30mg per dL, 2+ = 100mg per dL, 3+ = 300mg per dL, 4+ up to 1000mg per dL
- Blood
- Detects peroxidase activity of erythrocytes, however, myoglobin & hemoglobin will also catalyze this rxn so a “positive” result may indicate hematuria, myoglobinuria (rhabdomyoloysis), or hemoglobinuria (hemolytic anemia)
- Glucose
- Top etiologies include DM, Cushing’s syndrome, liver & pancreatic disease
- Leukocyte esterase
- Produced by neutrophils
- Seen in UTI (most common), urethritis, tuberculosis, bladder tumor, viral infx, nephrolithiasis, exercise, foreign bodies or corticosteroid use
- Ketones
- Product of fat metabolism
- seen in uncontrolled diabetes (most common), pregnancy, carb free diets or starvation
- Nitrites
- Bacteria reduce urinary nitrates to nitrites
- Positive result indicates a large number of these organisms present (gram negtive or gram positive bacteria), however, a negative result does not mean that a UTI is not present
- Bilirubin
- Seen in liver dysfunction or biliary obstruction
- Urobilinogen
- Seen in hemolysis or hepatocellular disease
UA Microscopic Examination
- crystals
- where may it be found
- types ?
- cell (3 types)
- casts
- bacteria
- Crystals
- May be found in urinary sediment in healthy patients
- Types of crystals: calcium oxalate, uric acid, triple phosphate crystals (associated w/ UTI), cystine (found in acidic urine)
- Cells
- WBCs: <2 WBCs per HPF for men, < 5 per HPF for women
- Epithelial cells: often seen in urinary sediment, often suggests contamination
- Dysmorphic RBCs: indicates glomerular disease
- Casts
- May be used to localize disease to specific location in urinary tract
- Hyaline casts: pyelonephritis, CKD, may be normal finding
- Red cell casts: GN, may be normal if patient plays contact sports
- White cell casts: pyelonephritis, interstitial nephritis (indicative of infection or inflammation)
- Renal tubular cell casts: ATN, interstitial nephritis
- Course, granular casts: Nonspecific; can represent ATN
- Broad, waxy casts: CKD (indicative of stasis in enlarged collecting tubules)
- Fatty casts: nephrotic syndrome, kidney disease, hypothyroidism
- Bacteria
- Will show gram-negative rods, streptococci & staphylococci
- In females, urine frequently contaminated w/ vaginal flora; 5 bacteria per HPF positive for UTI
- In males, any bacteriuria = UTI and needs to be cultured
so you know : GN= glomerulonephritis
Bladder Catheterization
- what is it used for? (2)
- wht happens too frequently
- what is needed to reduce complications?
- choice of catheter (3)
- Used for urinary drainage or as a means to collect urine for measurement
- Too frequently, used w/o proper indication or continued longer than needed
- Daily evaluation of ongoing need is essential to reduce complications
- Choice of catheter:
- External (condom or urinary pouch)
- Urethral (indwelling “Foley” or intermittent “straight”)
- Suprapubic (placed by surgeon)
