Exam 1: Renal Flashcards
What is normal specific gravity of urine?
1.003 (dilute) - 1.030 (very concentrated)
What is the normal pH of urine?
5-8
Which vaccines should never be given to patients with acute renal issues?
Do not give live vaccines if acute renal issues (MMR, varicella)
Which type of cast is most commonly found in urine and is usually due to dehydration or vigorous exercise?
Hyaline casts; frequently seen in athletes
How many RBC found in spun urine is considered normal?
Asynch: < 5 RBCs are normal
Book: < 3-5 are normal
What are some differential diagnoses for hematuria in children?
UTI Trauma/irritation Glomerulonephritis Coagulopathy Hemoglobinopathy Stones Hydronephrosis Tumor Epididymitis
Also: gonorrhea and chlamydia
What is the initial work-up for hematuria?
Initial workup for hematuria:
UA
Urine culture
CBC, renal function, sed rate
** Don’t get too excited about hematuria in kids unless there’s a ton of it and is accompanied by protein
What would the initial work-up be for proteinuria?
UA
24-hour urine collection for proteinuria
What would be present in the urine to make you suspect nephrotic syndrome?
Protein 1+
Increased specific gravity
T/F: Always look at protein and specific gravity together?
True; specific gravity of urine can be affected by protein
If there is protein in the urine and specific gravity is > 1.105; is this concerning?
Yes:
Concerning if specific gravity is >1.015
Needs to be checked again if specific gravity is =/< 1.015
What are conditions that put patients at risk for renal disease?
Diabetes HTN OTC meds (NSAIDs, APAP, ASA) Polycystic disease Trauma
What is a big concern when hematuria is found in adults?
85% of bladder cancer presents with hematuria
What abnormal results will be found in the UA of someone with probable UTI?
+ Leuks
+ Nitirites
Possibly hematuria
Cloudy
Why would you want to recheck a patient’s urine after antibiotic treatment for UTI has been completed if there was hematuria present on the original diagnosis?
Check to see if hematuria still present; could be sign of cancer and needs work-up
What are the stages of chronic kidney disease?
Stage: 1 - normal; GFR >90 2 - mild loss; GFR 60-90 3a - mild to moderate; GFR 45-59 3b - moderate to severe; GFR 30-44 4 - severe loss; GFR 15-29 5 - kidney failure: GFR < 15 (needs dialysis and/or transplant)
An acute infection in the kidneys of children and adults that is most commonly caused by strep; symptoms typically appear 7-10 days after infection
Acute Glomerulonephritis
What are signs and symptoms of glomerulonephritis?
Acute onset Hematuria, proteinuria Oliguria Low grade fever Headache HTN Periorbital edema Edema of hands and face in morning Edema of feet/ankles in evening Weight gain Lethargy N/V Abdominal pain
How would the primary care office treat acute glomerulonephritis?
Refer urgently to nephrology to be seen that day or send to the ED
Other than post-strep infection, what are some other causes of glomerulonephritis?
Lupus
Henoch-Schonlein purpura
Vasculitis
Good Pastures Syndrome (rare autoimmune attacks lungs, kidneys)
Drug hypersensitivity
IgA Nephropathy (Berger disease - local inflammation of kidneys)
Hereditary problems
What are signs and symptoms of nephrotic syndrome?
Signs and symptoms of nephrotic syndrome:
N/V/D
Fatigue
Edema (eyes, hands, feet, legs) - may c/o tight underwear
Weight gain
HTN or hypotension if hypovolemic
Ill appearing
Muscle wasting, malnourishment, growth failure
Which factors increase risk of renal stones? (Choose all that apply)
Excess antacid use Living in cold climate Obesity History of gout Vitamin D excess
Excess antacids
Obesity
History of gout
Which is a prerenal cause of acute kidney injury?
Hemorrhagic shock
Hydronephrosis
HTN
Renal calculi
Hemorrhagic shock interferes with perfusion of kidney and would be a prerenal cause
Which tests should be monitored regularly for complications of chronic renal disease? (Choose all that apply)
Liver enzymes Parathyroid hormone levels Serum glucose Serum lipids Vitamin D
CKD can cause the following: Hyperparathyroidism Hyperlipidemia Alterations to vitamin D Calcium Phosphorus
What are we concerned for if a pregnant woman has protein in her urine?
Proteinuria after 24 weeks gestation is a sign of pre-eclampsia and should be evaluated by her OB/GYN
Preeclampsia symptoms can include: HTN, edema (weight gain), proteinuria
An older male patient presents with gross hematuria and is without flank pain or fever? What are you concerned for and what will you do?
Significant risk of malignant disease
Refer for cystoscopy and imaging
Which type of kidney stone is most common in patients with diabetes?
Citrate
Cystein
Oxalate
Uric acid
Most common in DM: Uric acid stones
Oxalate is the most common stone in patients with few comorbidities
A child has gross hematuria, abdominal pain, and arthralgia as well as a rash. What is the likely diagnosis?
Henoch-Schonlein purpura
Rhabdomyosarcoma
Sickle Cell Disease
Systemic Lupus Erythematosus
HSP can present with:
Gross hematuria
Abdominal pain with or without bloody stools
Arthralgias
Purpuric rash
An adolescent has 2+ proteinuria in a random dipstick urinalysis. A subsequent first morning void is negative. What is the next step?
Monitor for proteinuria annually
Order 24-hour urine collection
Reassure parents it’s benign & no followup
Refer to nephrology
Monitor annually:
If the first morning void is negative, monitor annually
Is nephrotic syndrome acute or chronic?
Nephrotic syndrome is a chronic disease characterized by remission and relapse
How is nephrotic syndrome managed?
Steroids (Prednisone) 4-6 weeks with taper
Low sodium diet initially, high protein, low cholesterol
Possibly diuretics and albumin
Other needs d/t oral steroids: Calcium/Vit D supplementation Weight bearing exercises Frequent eye exams No live virus vaccines Consider PPD prior to start of immunosuppressive meds
What is first-line therapy for all stone types?
Increase fluids
T/F: Antibiotic therapy for Group A Strep infections decreases the incidence of poststreptococcal glomerulonephritis?
False
What are red flags for renal disease in kids?
Red flags for renal disease in kids:
Failure to thrive
Prolonged N/V, inability to eat, weight loss
Chronic anemia (normocytic, normochromic)
Complicated enuresis
Hypotension
Unusual bone disease
Poor school performance
T/F: An albumin/creatinine ratio greater than 300 mg/g warrants a referral to nephrology?
True
How are you going to treat a patient with a kidney stone and when do you refer to urology?
Increase fluids
Analgesics (Start with NSAIDs)
Flomax for a few days to help dilate the ureters and ease the passing (if you know there’s a stone for sure)
Send home to pass on its own
Typically don’t refer to urology unless > 6mm
How is nephrotic syndrome diagnosed?
Diagnostics for nephrotic syndrome:
UA = protein +2 or higher Elevated urine specific gravity Hyaline and fine granular casts Microhematuria in about 30% Fat bodies in urine
What are the clinical manifestations of renal tubal acidosis in children?
Failure to thrive, poor linear growth Polyuria and polydipsia Muscle weakness Feeding problems V/D Constipation Preference for liquids over solids Poor appetite
What are the diagnostics for renal tubal acidosis?
Diagnostics for renal tubal acidosis:
UA for glucose and pH (if abnormal do 24-hour urine for creatinine clearance)
CMP w/CO2, calcium, phos, alkaline phosphatase
Renal US - check for obstruction
How is renal tubal acidosis managed?
Correct acidosis (Na bicarb, K bicarb, Na citrate) - give bicarb if pH is low Check potassium and treat accordingly Maximize caloric intake Closely follow for weight and labs If no improvement refer
What is the definition of chronic kidney disease?
Persistent/progressive decrease in GFR (<60)
Albuminuria (spilling of protein into urine) >30 mg/g urinary creatinine
How is CKD managed in primary care?
Maintain BP < 140/90 ACE or ARB, and possibly a diuretic Closely monitor Hgb and phosphorus Tight glycemic control for DM Consult nephrology early
What are the ADA recommendations for screening diabetics for CKD?
Annual test for urine albumin for:
T1DM
T2DM
DM > 5 years
Annually serum creatinine
What are the causes of nephrotic syndrome?
Primary (80-90% of cases):
Usually idiopathic
Secondary (10%): Lupus Infections (syphilis, Hep B, HIV, malaria) Henoch-Schonlein Purpura Drugs (NSAIDs, mephenytoin) Allergens
What is nephrotic syndrome?
A chronic condition where excess protein is lost into the urine
How many organisms and WBCs are found for diagnosis of UTI?
A UTI is defined as the presence of 100,000 organisms/mL of urine in ASYMPTOMATIC patients
Or
Greater than 100 organisms/mL of urine with pyuria (WBC >7-10) in a SYMPTOMATIC patient
Name some risk factors for UTI
Some risk factors for UTI:
Female
Diabetes
Immunocompromised patients
Spermicide use during the past year
Having a mother with history of UTI
Having a new sex partner during the past year
Urinary incontinence
Cystocele (prolapsed or herniated bladder)
Anticholinergic drugs (ex: atropine, belladonna) - causes bladder does not to empty as well
If the GFR is decreased to 40, are there specific drugs you would worry about and need to be renally dosed?
Yes, if GFR is dipping below 40 adjust dosages of:
Antibiotics (Gent and Vanc) NSAIDs Lithium Metformin Aminoglycosides (the "mycin"/"micin" meds, ex: Gentamicin
Which renal protective drugs need to be discontinued if GFR <10?
ACEi
What are the Metformin guidelines when GFR gets down below 40?
If GFR < 40, you can’t start Metformin
If GFR < 30, you have to d/c Metformin
Which diagnostic test might you order for abrupt onset of behavioral changes, OCD, tics, separation anxiety, mood changes after a strep infection?
ASO titer: if elevated reveals patient had a recent strep infection
PANDAS: Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus
Rare condition
PANDAS is a controversial diagnoses among MDs
Antibiotics to treat: Amoxicillin Penicillin Azithromycin Cephalosporins
What are some complications of nephrotic syndrome?
Complications of nephrotic syndrome:
Hyperlipidemia Proteinuria Tachycardia HTN Blood clots
Examples of when to think of nephrotic syndrome as a differential:
Patient has a HR of 140 and has protein in the urine.
Patient now has a total cholesterol of 380 when they had a normal cholesterol 6 months ago and is tachycardic.
What are some things to be careful of when prescribing Levaquin?
Levaquin can increase risk of Achilles tendon rupture
Levaquin can change the mentation of the elderly
How many RBC found in spun urine is considered hematuria?
> 5 RBC
