Genitourinary and Renal Flashcards
Signs of nephrotic syndrome:
Anasarca (extreme edema)
Bilateral Lower ext. edema
Microscopic hematuria
Sign’s of impending strangulation of bowel:
In the setting of SBO or LBO:
Acidosis
Fever
Leukocytosis
Tachycardia
Diagnostic Workup of SBO:
Abdominal Plain Films
CT
Indications for Emergent Surgery for SBO:
Hemodynamic instability
Peritonitis
Signs of Impending Strangulation
No response to conservative tx (NPO, analgesia, fluids, NG tube)
Clinical differences between pyogenic and amebic liver abscesses:
History: Pyogenic liver abscesses are typical in patients with recent GI surgery, appendicitis, or other GI infection. Amebic is associated with travel to endemic areas and recent bloody diarrhea (from colonic infiltration by entameoba histolytica).
Presentation: Pyogenic abscesses have a much more severe presentation–the patients look and are very ill.
Differentiating between colonic angiodysplasia and diverticulosis:
Colonic angiodysplasia is associated with aortic stenosis and end stage renal disease. Aortic stenosis causes disruption of the vWF multimers and increases bleeding–allowing the angiodysplastic vessels in the colon to be discovered.
In ESRD there is uremic dysfunction of platelets causing increased bleeding and discovery of bleeding colonic dysplastic vessels.
Diverticulosis is evident on colonoscopy–whereas angiodyplasia is not–unless the patient is bleeding.
Electrolyte complications of Renal Failure:
Hyperkalemia - reduced excretion, increased release from dying cells and increased ICF –> ECF transfer due to associated metabolic acidosis of renal failure
Hyponatremia - occurs if water intake is greater than body losses.
Hyperphosphatemia
Metabolic Acidosis
Hyperphosphatemia
Hypocalcemia - due to loss of ability to activate vitamin D and decreased sensitivity to PTH
Indications for dialysis in renal failure:
GFR ≤15
Symptomatic Uremia
Intractable Acidemia
Intractable Hyperkalemia
Intractable volume overload
Definition of Chronic Kidney Disease:
GFR < 60
or
Kidney damage for over 3 months
Uremic Platelet Dysfunction:
Platelets do no degranulate, and therefore fully activate, in an uremic environment
Seen in renal failure.
Can induce unveiling of colonic angiodysplasia.
Calciphylaxis
Necrotic skin lesions caused by vascular calcium deposits secondary to Ca-Po4 precipitates resulting from hyperphosphatemia, which commonly results from renal failure.
Common US findings in CKD:
Smaller kidneys–however–normal sized kidneys do not rule out CKD
Main electrolyte complication of ACE inhibitors. Explain.
Hyperkalemia
Reduction in AngII reduces aldosterone production –> decreased action of Na/K pump in distal tubules, etc.
Mneumonic for Absolute Indications for Dialysis:
AEIOU
A - Acidosis (intractable)
E - Electrolytes (severe persistent hyperkalemia, hyperphosphatemia)
I - Intoxications
O - Overload (volume)
U - Uremia (severe uremic symptoms)
Symptoms of Uremia:
Nausea + vomiting
Lethargy / Deterioration in mental status / seizures / encephalopathy
Pericarditis
Complications of nephrotic syndrome:
Edema - from hypoalbuminemia
Hyperlipidemia - liver produces more along with albumin
Hypercoagulable state - loss of anti-coagulant proteins in urine
Increased Infection - Loss of Ig in Urine
Diagnoses t consider with gross hematuria:
Bladder or kidney cancer (until proven otherwise)
Stones also high on list but less concerning
In general, you should think of post-renal diseases with gross hematuria
4 Possible Presentations of glomerular disease:
Isolated proteinuria
Isolated Hematuria
Nephritic Syndrome - (1) Hematuria; (2) HTN; (3) Azotemia
Nephrotic Syndrome - (1) Proteinuria; (2) Edema; (3) Hypoalbuminemia; (4) Hyperlipidemia
Alport’s Syndrome
Define:
Presentation:
Treatment:
Hereditary nephritis with X-linked or AD inheritance with variable penetrance
Presentation: hematuria, pyuria, proteinuria, high frequency hearing loss without deafness, and progressive renal failure
Treatment: no effective treatment
Classic Triad of Goodpastures:
Proliferative, cresentic glomerulonephritis
Pulmonary Hemorrhage
IgG anti-glomerular basement membrane antibody
Distuinguishing between ATN and AIN:
Can be impossible to do without a renal biopsy
Most common causes of AIN:
Allergies to meds
Collagen Vascular Diseases
Autoimmune Disorders
Infections in kids
Clinical feature most associated with AIN:
Eosinophils in the urine
Short description of each RTA type and the distuinguishing clinical features:
Type 1 (Distal) RTA - Issue with the H+/K+ antiporter in the distal tubules. There is an issue excreting H+ and therefore new bicarbonate cannot be regenerated since the synthetic milleu within the cells is too acidic. As a response, the kidneys excrete all electrolytes, except for H+ and Cl-. Therefore the patients will develop a hyperchloemic, non-anion gap acidosis. There is formation of kidney stones due to massive increase in Ca and PO4 within the tubules and ureters. Treat patients with NaHCO3 and Phosphate.
Type 2 (Proximal) RTA - issue is in reabsorption of HCO3-. There will be no kidney stones now, because HCO3- is taking up all of the “anion space.” Patients will still lose cations like K+ and Na+. Na restriction will help these patients, because there will be increased reuptake of Na, which will indirectly increase uptake of HCO3. Can distinguish by the fact that there will be the same electrolyte issues as in type 1, but without stone formation. Additionally, urinary excretion of Ig light chains is a common feature–therefore multiple myeloma should always be on the differential.
Type 4 RTA - issue is hypoaldosteronism, or reduced reaction to aldosterone due to interstitial renal disease (diabetic nephropathy, or AIN). There will be decreased Na reabsorption and therefore increased K and H reabsoprtion. Therefore the distinguishing feature here is hyperkalemia.
Simple Renal Cysts
Describe + Clinical Course
Extremely common
Increased incidence with age
Asymptomatic and found incidentally
Diagnosed by US
No treatment needed
Renal Artery Stenosis pathophysuilogy and clinical features:
Stenosis usually caused by atherosclerosis or fibromuscular dysplasia (thickening of the walls of arteries–usually in women).
Renal artery stenosis results in restricted blood flow through the glomerulus and therefore the kidney senses a decreased in blood pressure.
This induces RAAS –> HTN
Renal vein thrombosis pathophys and clincal course:
Can be seen in a host of different clinical settings including: preganant women, women using OCPs, dehydrated infants, AAA, LAD, nephrotic syndome, venus invasion by RCC, and trauma.
Patients present with HTN, renal failure, hematuria, proteinuria, flank pain.
Diagnosis is either a doppler test or IVP
Treatment is anticoagulation.
Kidney Stones:
Types and appearance:
Size of stones that will and will not spontaneosly pass:
Rate of Recurrence:
- Calcium Stones - Bipyramidal, biconcave, envelop-shaped / Radiodense (most common)
- Uric Acid Stones - Flat sqaure plates / radiolucent (gout, chemotherapy, acidiuc urine)
- Struvite Stones - Rectangular prisms / Radiodense (urease producing bacteria)
- Cystine Stones - hexagon shaped crystals which are generally poorly visualized (genetic predisposition to cystinuria)
>1cm stones will not spontaneously pass.
50% recurrence rate
Diagnostic modalities for kidney stones:
Labs: Urinalysisl culture; 24-hr urine; serum chemistry
Imaging: Plain films; CT; IVP; US
Most common treatments for kidney stones:
Analgesia
IV fluids
Antibiotics if there is UTI
Extracorpeal Shock Wave Lithotripsy
Early, later, and late signs of prostate cancer:
Early - asymptomatic since cancer begins in the periphery (might be “lucky” if the doc performs a DRE then)
Later - Some obstructive symptoms (has likely already metastasized)
Late - Bone pain from metastasis
Most common sites of prostate cancer metastasis:
Vertebral bodies
Pelvis
Long bones of legs
How to treat prostate cancer:
Localized to Prostate - radical prostactectomy or nothing if old
Locally Invasive - Radiation + anti-androgen medications
Metastatic Disease - reduction of testosterone levels
Methods for reducing testosterone levels in metastatic prostate cancer:
Orchiectomy (in medically non-adherent patients)
Anti-androgens
Leuprolide (GnRH hormone agonists)
GnRH antagonists
Both the GnRH agonists and antagonists interrupt the pulsatile release of GnRH which will limit the amount of LH and FSH released, which will limit testosterone release
Pathophysiology and clinical features of RCC:
Management?
RCC is the most common cancer of the kidney and is typically sporadic, with few cases caused by AD VHL.
Patients almost always have HEMATURIA.
Often also have flank pain, and a possible flank mass.
Management: Renal US to detect mass followed by CT oto further investagate mass and stage it.
Treat with radical nephrectomy
Septic Abortion
Risk factors, clinical presentation, and management:
Risk factors: retained products of conception following any type of abortion
Patients present with fever, lower abdominal pain, purulent bad smelling vaginal discharge. Boggy and tender uterus with a dilated cervix. Pelvic ultrasound reveals echogenic products within the uterus and a thickened endometrial stripe.
Management: blood and endometrial cultures; IV fluids and antibiotics, suction (surgical) curettage, close observation.
Misoprostol and oxytocin for septic abortions
Not used
While these can be used for early abortions (under 48 weeks) their actions are delayed–and we want to clear out the infection in septic abortions as quickly as possible.
Red flags for juvenile onset diabetes
Diaper Candidiasis
Nocturnal enuresis
Polyuria and polydipsia
Signs of Alport’s Syndrome:
glomerulonephritis
ESRD
Sensorineural hearing loss
Transient Proteinuria clinical features and management:
Extremely common
Caused by stress, fever, seizure, orthostatic proteinuria, exercise.
Perform urine dipstick and if positive you should repeat. If multiple dipsticks are positive you should move onto 24 hr urine collection and further workup the issue. If only one sample is positive, this patient has transient proteinuria which is completely benign.
Acyclovir nephropathy
this is NOT related to allergies. This will happen to anyone with a high enough dose of acyclovir.
tyhe drug is metabolized and secreted by the kidney and can produce crystals in the collecting system and cause renal failure.
Treatment is based on heavy hydration to essentially dissolve those stones.
Indication for allopurinol pre-treatment to protect kidneys:
this can be given to patients undergoing chemotherapy for lymphoma and leukemia since tumor lysis syndrome can result in urate crystal formation and kidney failure.
Allopurinol inhibits xanthine oxidase which is important in the production of urate.
How to minimize contrast induced allergic reactions:
pre-treat with prednisone
Pathogenesis of contrast induced nephropathy:
renal vasoconstriction + tubular injury
Most common sign of contrast nephropathy:
Cr spike within 24hrs of contrast administration
Diuretics for contrast nephropathy:
Do not use
Most important preventative measure for contrast induced nephropathy:
adequate pre-CT IV hydration
(can also add acetylcystine which helps via vasodilatory effects)
patients at higher risk for contrast nephropathy
Diabetics
Elevated baseline Cr
Conditions predisposing to calcium-phosphate stones:
Those associated with greater bone turnover:
Hyperparathyroidism
RTA (loss of calcium in urine)
Different parts of prostate affected by BPH and cancer?
Feel of prostate on DRE with BPH vs cancer?
BPH –> Central portion and therefore can cause urinary symptoms much earlier.
Cancer –> lateral lobes and therefore urinary symptoms come late in the course
BPH will have a smooth, non-indurated prostate; cancer will be nodular.
Treatment for BPH:
Alpha Blockers (relax smooth muscle of prostate - doxazosin; tamsulosin)
5a-reductase inhibitors (finasteride)
Severe obstructions of the urinary tract should be treated surgically
Similarities and differences in tacrolimus and cyclosporine:
Similarities: Nephrotoxicity / Hyperkalemia / Neuotoxicity / Diarrhea / Glucose intolerance
Differences: Cyclosporine causes gum hypertrophy and hirsutism
Major toxicitity of mycophenolate:
Marrow Suppression
(starts with an “M”)
Major side effects of azathioprine:
Diarrhea
Leukopenia
Hepatotoxicity
Common presentation of cryoglobinemia:
Palpable Purpura
Glomerulonephritis
Non specific systemic symptoms
arthalgias,
hepatosplenomegaly,
peripheral neuropathy,
hypocomplementemia
Most patients also have HCV infections
Clinical manifestations of chronic bacterial prostatitis:
perineal or suprapubic discomfort
Irritative Voiding Symptoms
Urgency
Expressed prostatic secretions: over 10 wbcs/HPF and culture reveals organism
Difference between chronic bacteral prostatitis and inflammatory chronic prostatitis:
exactly the same except that cultures of prostatic secretions are negative in inflammatory chronic prostatitis
Difference between acute and chronic bacterial prostatitis:
Acute - febrile, urinalysis shows many bacteria and WBCs
Possible causes of renal transplant dysfunction in the early post-op setting:
Uretal Obstruction
Acute Rejection
Cyclosporine toxicity
Vascular obstruction
Acute Tubular Necrosis
Renal disease commonly associated with acute hep B infection:
membranous glomerulonephritis
the immune complexes deposit in the BM
ATN is commonly caused by…
prolonged hypotension
Broad casts in urine indicate…
chronic renal failure
RBC casts are indicative of…
Glomerular disease or vasculitis
WBC casts are indicative of:
Diseases causing WBC in the kidney, like:
- Acute interstitial nephritis
- Pyelonephritis
types of casts seen in nephrotic syndrome:
Fatty casts
Hyaline casts
Most common renal disease caused by diabetes:
Diffuse glomerulosclerosis and/or nodular glomerulosclerosis
Histological feature of nodular glomerulosclerosis:
Kimmelstiel-Wilson nodules
Clinical signs of diabetic nephropathy
proteinuria
progressive decline in GFR
Pulmonary renal syndrome you can effectively treat with plasmapheresis and why this works:
Goodpasture’s Syndrome
Clearance of circulating anti-GBM Abs
Treatment of Wegener’s
Combination of cyclophosphamide and steroids
What do dipsticks for UTIs specifically detect:
Esterase and nitrites
Esterase tells you if there is a UTI or not
Nitrites tells you if the UTI is from e. coli (the most common organism)
Causative organisms of sexually and non-sexually transmitted epididymitis:
Sexually: Chylamydia and/or gonorrhea
Non-Sexually: Gram-negative rods (E. Coli)
Acute contraindications to metformin:
Acute Renal Failure
Hepatic Failure
Sepsis
Most common cause of painless hematuria in adults
Bladder cancer
Signs of obstructive uropathies:
Flank pain
Low volume voids (with or w/o intermittent high volume voids)
Labs suggestive rhabdomyolysis:
Hyperkalemia
Elevated CPK
Positive dipstick for blood, but not due to blood
2 main risk factors for rhabdomyolysis:
IV cocaine
Immobilzation
Main side effects of recombinant EPO therapy in ERSD:
Worsening hypertension
Headaches
Flu-like syndrome
Red cell aplasia
What diagnosis to consider in a patient with occasional headaches and palpitations, elevated BP, and bilateral flank masses:
Polycystic kidney disease
CNS complication of polycystic kidney disease:
Berry aneurysm and intracranial bleeding
Diagnosis to consider in patient presenting with chronic headaches, painless hematuria:
Analgesic nephropathy which causes papillary necrosis
