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Exam 1: Renal Flashcards

1
Q

What is normal specific gravity of urine?

A

1.003 (dilute) - 1.030 (very concentrated)

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2
Q

What is the normal pH of urine?

A

5-8

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3
Q

Which vaccines should never be given to patients with acute renal issues?

A

Do not give live vaccines if acute renal issues (MMR, varicella)

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4
Q

Which type of cast is most commonly found in urine and is usually due to dehydration or vigorous exercise?

A

Hyaline casts; frequently seen in athletes

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5
Q

How many RBC found in spun urine is considered normal?

A

Asynch: < 5 RBCs are normal
Book: < 3-5 are normal

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6
Q

What are some differential diagnoses for hematuria in children?

A 
UTI
Trauma/irritation
Glomerulonephritis
Coagulopathy
Hemoglobinopathy
Stones
Hydronephrosis
Tumor
Epididymitis

Also: gonorrhea and chlamydia

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7
Q

What is the initial work-up for hematuria?

A

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

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8
Q

What would the initial work-up be for proteinuria?

A

UA

24-hour urine collection for proteinuria

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9
Q

What would be present in the urine to make you suspect nephrotic syndrome?

A

Protein 1+

Increased specific gravity

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10
Q

T/F: Always look at protein and specific gravity together?

A

True; specific gravity of urine can be affected by protein

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11
Q

If there is protein in the urine and specific gravity is > 1.105; is this concerning?

A

Yes:
Concerning if specific gravity is >1.015
Needs to be checked again if specific gravity is =/< 1.015

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12
Q

What are conditions that put patients at risk for renal disease?

A 
Diabetes
HTN
OTC meds (NSAIDs, APAP, ASA)
Polycystic disease
Trauma
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13
Q

What is a big concern when hematuria is found in adults?

A

85% of bladder cancer presents with hematuria

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14
Q

What abnormal results will be found in the UA of someone with probable UTI?

A

+ Leuks
+ Nitirites
Possibly hematuria
Cloudy

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15
Q

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?

A

Check to see if hematuria still present; could be sign of cancer and needs work-up

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16
Q

What are the stages of chronic kidney disease?

A 
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)
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17
Q

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

A

Acute Glomerulonephritis

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18
Q

What are signs and symptoms of glomerulonephritis?

A 
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
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19
Q

How would the primary care office treat acute glomerulonephritis?

A

Refer urgently to nephrology to be seen that day or send to the ED

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20
Q

Other than post-strep infection, what are some other causes of glomerulonephritis?

A

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

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21
Q

What are signs and symptoms of nephrotic syndrome?

A

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

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22
Q

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
A

Excess antacids
Obesity
History of gout

23
Q

Which is a prerenal cause of acute kidney injury?

Hemorrhagic shock
Hydronephrosis
HTN
Renal calculi

A

Hemorrhagic shock interferes with perfusion of kidney and would be a prerenal cause

24
Q

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
A 
CKD can cause the following:
Hyperparathyroidism
Hyperlipidemia
Alterations to vitamin D
Calcium
Phosphorus
25
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
26
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
27
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
28
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
29
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
30
Is nephrotic syndrome acute or chronic?
Nephrotic syndrome is a chronic disease characterized by remission and relapse
31
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 ```
32
What is first-line therapy for all stone types?
Increase fluids
33
T/F: Antibiotic therapy for Group A Strep infections decreases the incidence of poststreptococcal glomerulonephritis?
False
34
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
35
T/F: An albumin/creatinine ratio greater than 300 mg/g warrants a referral to nephrology?
True
36
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
37
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 ```
38
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 ```
39
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
40
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 ```
41
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
42
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 ```
43
What are the ADA recommendations for screening diabetics for CKD?
Annual test for urine albumin for: T1DM T2DM DM > 5 years Annually serum creatinine
44
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 ```
45
What is nephrotic syndrome?
A chronic condition where excess protein is lost into the urine
46
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
47
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
48
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 ```
49
Which renal protective drugs need to be discontinued if GFR <10?
ACEi
50
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
51
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 ```
52
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.
53
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
54
How many RBC found in spun urine is considered hematuria?
> 5 RBC

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