GU Flashcards
What class of diuretic is bumetanide?
Loop
What diuretic most helpful in acute pulmonary edema
Loops
Which diuretics most helpful in glaucoma
CAI or mannitol
Which diuretic most helpful in edema a/w nephrotic syndrome
Loop or metolazone (very powerful thiazide)
Which diuretic used in increased ICP
Mannitol
Which diuretics used in altitude sickness
Acetazolamide
Most common nephrotic syndrome in adults
Membranous GN
IF: granular pattern of immune complex deposition; LM: hyper cellular glomeruli
Post strep GN
IF: linear pattern of immune complex deposition
Goodpastures
Nephrotic syndrome associated with Hep B
Membranoprolif (type I)
EM: sub endothelial humps and tram-track appearance
Membranoproliferative
L: crescent formation in the glomeruli
Rapidly progressive GN
Which nephropathy associated with HSP?
IgA nephropathy
EM: spike and dome pattern of basement membrane
Membranous nephritis
60 yo smoker found to have a varicocele that does not empty when pt is recumbent. What are you suspicious of?
Renal cell CA! Get a CT. DO NOT BIOPSY
Dietary recommendations in treatment of nephrolithiasis
Adequate dietary calcium (don’t reduce)
Increase fluids
Decrease Na and oxalate
Young black male with painless hematuria
Sickle cell trait
Treatment for uric acid renal stones
Alkalinize urine with sodium bicarb or sodium citrate
MCC of nephrotic syndrome in AA male
FSGS
Treatment of Wegeners granulomatosis
Cyclophosphamide, steroids
MCC of morbidity/mortality in SLE?
Lupus nephritis
Defining characteristics of nephrotic syndrome
Proteinuria > 3.5 g/day
Hyperlipidemia
Hypoalbuminemia
Biggest risk factor for RCC
Smoking
5 etiologies of temporary hematuria
Exercise UTI Nephrolithiasis Trauma Endometriosis
Most common location of renal stone impaction
Uretero-vesico junction
What size calcium renal stone has a 50% likelihood of passing without surgical intervention
8-9 mm
Metabolic acidosis, normal anion gap, and low serum potassium
Diuretics, renal tubular acidosis types I and II, diarrhea, Fanconis syndrome
Metabolic acidosis, normal anion gap, high serum potassium
Addison’s, RTA type IV, potassium sparing diuretics, hyperalimentation from TPN
Volume status after thiazides
Dehydrated – hypovolemic OR euvolemic
Volume status in SIADH
Euvolemic
Volume status in hepatic cirrhosis
Hypervolemic
Volume status in Addison’s disease
Hypovolemic
Volume status in hypothyroidism
Euvolemic
Volume status in renal failure
Hypervolemic
Volume status in psychogenic polydipsia
Euvolemic
Urine sodium and urine osmolality in SIADH
Urine sodium >20
Urine osmol >100
Urine sodium and urine osmolality in psychogenic polydipsia
Urine sodium
Urine sodium and urine osmolality in Thiazides
Urine sodium >20
Urine osmolality > 100
Urine sodium and urine osmolality in alcoholism
Urine sodium
Urine sodium and urine osmolality in hypothyroidism
Sodium >20
Osmolality > 100
Hypovolemic hyponatremia and urine sodium
Extrarenal losses, so GI losses, fluid sequestration (peritonitis, pancreatitis), insensible loss such as sweating or extensive burns
Hypovolemic hyponatremia when Urine sodium >20
Renal losses. Diuretics, salt-wasting renal disease, partial urinary tract obstruction, adrenal insufficiency
If hypervolemic hyponatremia and urine so
CHF, cirrhosis, nephrotic syndrome
If hypervolemic hyponatremia and urine sodium >20?
Renal disease
5 things that shift K out of cells
Low insulin Beta blockers Acidosis Digoxin Cell lysis (i.e., leukemia)
4 things that shift potassium into cells
Insulin
Beta agonists
Alkalosis
Cell creation/proliferation
IVF used in hyperkalemia tx
D50 1 amp IV followed immediately by 10 units regular insulin IV (4-6 hr effect)
If K+ isn’t responding to treatment (for hyperkalemia), what should you check?
Magnesium.
Next step in mgmt if you see peaked T waves on EKG?
Calcium gluconate to stabilize cardiac membrane
Flattened T waves on EKG
Hypokalemia
U waves on EKG
Hypokalemia
QT prolongation
Hypocalcemia
QT shortening
Hypercalcemia
Urine pH, serum K and serum bicarb in Type I RTA
This is distal. Urine pH is classically HIGH (>5.3). Serum K is decreased and serum bicarb is variable, but usually low.
URine pH, serum K and serum bicarb in Type II RTA
Proximal. Urine pH is variable (usually normal), serum K is decreased, and serum bicarb is LOW *
Urine pH, serum K and serum bicarb in Type IV RTA
Hypoaldosteronism therefore, urine pH is normal, serum K is HIGH*, and serum bicarb is normal.
How rapidlly can hypernatremia be corrected?
No faster than 12 mEq/day
What are the causes of euvolemic hyponatremia
SIADH, polydipsia, hypothyroidism
Meds known to cause hyperkalemia
ACE/ARB
Digoxin
Beta blockers
K+ sparing
Meds known to cause hypokalemia
Albuterol
Insulin
Loops, thiazides, CAI
Treatment for neprogenic DI
HCTZ +/- indomethacin
Treatment for nephrogenic DI if due to lithium: HCTZ + amiloride
HCTZ + amiloride
How are sodium levels corrected for high glucose
For every 100 mg above 100, 1.6 mEq/L of Na. However, when glucose >400, this number becomes 2.4
How are total calcium levels corrected for low albumin
For every 1 g albumin below 4, calcium decreases by 0.8 mg/dL
Causes of normal AG metabolic acidosis
Diarrhea
RTA
TPN (hyperalminetation)
Why are statins used in end stage renal disease
Not only do they lower risk of CAD, they also decrease the sepsis risk.
2 alternative medications used to treat BPH
Isoflavone (found in soy) decrease the growth of hyper plastic prostate.
Saw palmetto is as effective as finasteride, has fewer SE and decreases prostate size without changing PSA.
Selective a1 blocker used in BPH
Tamsulosin. This is used particularly if pt does not have comorbid HTN
Indications for surgery to treat BPH
Failure of medical therapy Refractory urinary retention Inability to express urine without a catheter Recurrent infection Persistent hematuria Bladder stones, renal insufficiency
Most common surgery for BPH and most common side effect?
TURP. Retrograde eject seen in 70%
Next step in mgmt of 65 year old male that presents to ER wit hinability to urinate and painful bladder distention
Decompression of bladder with 14-18 gauge French Foley. If h/o BPH, may require a cath withth a firm Coude tip to “power through” narrowed erethra. If unable to pass, suprapubic cath under US guidance. If no one is trained, do suprapubic needle compression.
Tx of epididymitis in
Ceftriaxone IM then doxy or azithro x 10 days
Tx of Epididymitis in >35 or h/o anal intercours
FQ x 10-14 days
Tx of testicular torsion
Surgical detorsion with bilateral orchiopexy within 5 hours
Somewhat common symptom in infertile men
Varicocele – present in 25% of infertile men
Ultrasound on varicocele will show?
Retrograde flow to scrotum
Onset difference between torsion vs epidiymitis
In torsion: acute, abrupt, associated with physical activity
Epididymitis: subacute and may be associated with STDS and/or anal intercourse
Visual changes in torsion vs. epidydmitis
In torsion, testicle may be raised and horizontal. In epid, normal position and lie.
Support relieves pain in torsion or epididymitis?
Epididymitis!!!!
Cremasteric reflex absent in torsion or epididymitis?
TORSION!
Blood flow in epididymitis
Normal
Serum lab tests to check in patient presenting with ED
Total T, prolactin, TSH, +/- PSA
What age should tx for nocturnal enuresis be treated?
At least 7 y.o.
Why is intranasal DDAVP no longer indicated?
Risk of hyponatremic seizures
Most common cause of congenital urethral obstruction
Posterior urethral valves
A patient has signs of peritonitis and his clinical scenario favors rupture of the bladder (blunt trauma to fully distended bladder). What portion of th bladder mustt have been injured to allow for a chemical peritonitis to have developed?
Dome of bladder.
What med is used to reduce urotoxic effects of cyclophosphamide?
MESNA
What infection increases risk for bladder cancer?
Schistosomiasis
When dysmorphic red cells are described, the correct answer is?
Glomerulonephritis
Most accurate test of the bladder?
Cystoscopy
A woman is admitted to the hospital with trauma and dark urine. The dipstick is markedly positive for blood. What is the best initial test to confirm etiology?
Microscopic examination of the urine.
Initial test to assess proteinuria
UA
Most accurate to determine amount of proteinuria
Protein to creatinine ratio. If both P/Cr ratio and 24-hour urine are in the choices, choose the P/cr ratio. It is faster and technically easier to perform.
2 stains that detect eosinophils in the urine
Wright and hansel stains
Hyaline casts cause
Dehydration concentrates the urine and the normal Tamm-Horsfall protein precipitates or concentrates into a cast
Broad waxy casts are seen in?
chronic renal disease
Granular “muddy brown” casts are seen in?
Acute tubular necrosis.
NSAIDs constrict what part of the arteriole?
Afferent. therefore, they cause pre-renal azotemia.
ACE inhibitors do what to the arteriole?
Cause efferent arteriole vasodilation – > prerenal azotemia.
3 random things that can cause retroperitoneal fibrosis
Bleomycin
Methylsergide
Radiation
Pre-renal azotemia is usually a clear dx if the question describes … ?
BUN:cr ratio >20:1 AND clear hx of hypoperfesuion or hypotensio
Post renal azotemia is usually a clear dx with the question describing
BUN:Cr > 20:1 AND distended bladder/massive release of urine with cath placement AND Bilateral/unilateral hydronephrosis.
Why is urine osmolality in ATN inappropriately low?
Normal tubule cells resorb water. in ATN, the urine cannot be concentrated because the tubule cells are damaged. The urine produced in ATN, therefore, is similar in osmolality to the blood (aboutt 300). This is called isosthenuria.
Usual findings in ATN from nephrotoxins
UNa >20
FENa > 1%
Low specific gravity / urine osmolality
Contrast induced renla failure: lab values
Contrast causes spasm of afferent arteriole. There is tremendous reabsorption of sodium and water, leading the specific gravity of the urine to become very high. This results in profoundly low urine sodium.
UNa
Drug that prevents renal failure due to chemo
Allopurinol
Two days after chemo, the creatinine rises in a person with a hematologic malignancy. Most likely due to ?
Tumor lysis syndrome which lead to hyperuricemia
Most drug toxicities that cause rise in creatinine take how many days for the effect to be seen?
5-10
Why does hypocalcemia occur in rhabdo?
Increased calcium binding to damaged muscle
Tx of rhabdo
Saline hydration, mannitol as osmotic diuretic, and bicarb which drives potassium back into cells and may prevent precipitation of myoglobin in the kidney tubule.
Next best step in mgmt of patient with rhabod
Check EKg for life threatening hyperkalemia.
tX of hepatorenal syndrome
Albumin, midodrine, octreotide
Diagnostic tests in atheroemboli-induced AKI
Eosinophilia
Low complement levels
Eosinophiluria
Elevated ESR
Most accurate test for papillary necrosis
CT scan – shows abnormal internal structures of kidney from loss of papillae
Which classes of diuretics are associated with hyperuricemia?
Thiazides and loops
Class of diuretics associated with ototoxicity
Loops
Small bowel disease causes what type of renal stones?
Calcium oxalate
Some toxic causes of AIN
Cadmium, lead, copper, mercury, certain poisonous mushrooms
“Split basement membrane” on EM
Alport syndrome
Defect in Type 1 RTA
Impaired H+ secretion leading to secondary hyperaldosteronism. The distal tubule is responsible for generating new bicarb under the influence of aldosterone. If new bicarb cannot be generated, acid cannot be excreted into the tubule, thus raising the pH of the urine.
Treatment of Type 1 RTA
Oral bicarb, K+, thiazides
Defect in Type 2 RTA
Damage to proximal tubule decreases the ability of the kidney to reabsorb most of the filtered bicarb. Bicarb is lost in the urine until the body is so depleted of bicarb that the distal tubule can absorb the rest. When this happens, the urine pH will become low.
Random causes of Type 2 RTA
Multiple Myeloma, Fanconi syndrome, Wilson disease, amyloidosis, vitamin D deficiency
Which RTA is associated with nephrolithiasis?
Distal / Type 1
Which RTA is associated with hyperkalemia
Type 4
Treatment of Type 4 RTA
Fludrocortisone, K+ restriction
DM is associated with which RTA?
Type 4.
Sickle cell disease is associated with which RTA?
Type 4
Normal anion gap acidosis suggests?
HCO3 loss
Increased anion gap acidosis suggests?
H+ excess
Some fun causes of respiratory alkalosis
Hyperventilation/fever High altitude Asthma Aspirin toxicity Pulmonary embolism Pain Interstitial lung disease
Some causes of respiratory acidosis
COPD Respiratory depression Neuromuscular diseases Drowning Opiate overdose Alpha 1 antitrypsin deficiency Kyphoscoliosis Sleep apnea/morbid obesity
Causes of metabolic alkalosis
Vomiting Diuretics Cushing syndrome Hyperaldosteronism Adrenal hyperplasia
Electrolyte disturbances that can cause nephrogenic DI
Hypercalcemia
Hypokalemia
Tx of urge incontinence
Bladder training
Anti-muscarinics (oxybutynin, tolterodine, solifenacin)
Causes of overflow incontinence
Bladder outlet obstruction from BPH or urehtral strictures
Impaired detrusor contractility
Neurogenic bladder
Where in the prostate does BPH develop>
Central zone.
Which types of testicular cancers have increased B-hCG and AFP?
Germ cell tumors
Whichh testicular cancers have increased estrogen?
Streams cell tumors
Which testicular cancers have lower cure rates and increased risk of recurrence?
Nonseminomas
Treatment for cryptorchidism
Exog hCG admin or orchiopexy before age 5 to reduce risk of cancer and allow testicular development
Extra NSAID use and a history of sickle cell disease points you to what kidney problem?
Papillary necrosis
Proteinuria levels correspond to ?
Severity of disease and likelihood of progression.
Most accurate test to dx IgA nephropathy
Kidney biopsy
Tx of Goodpasture syndrome
Plasapheresis and steroids. Cyclophosphamide can be helpful.
Complement levels in PSGN
Low
Defect that causes Alport syndrome
Type IV collagen. The loss of collagen fibers that hold the lens of the eye in place cause the visual disturbances.
Importantly, polyarteritis nodosa spares what organ?
lungs
Infectious association with PAN
Hep B
Skin mx of PAN
Purpura and petechiae, ulcers, digital gangrene, livedo reticularis.
Standard of care and lower mortality in PAN
Prednisone + cyclophosphamide
Tx of lupus nephritis
Glucocorticoids with either cyclophosphamide or mycophenolate
Amyloid kidney is associated with what 5 disease states
MYELOMA Chronci inflame disease RA IBD Chronic infections
Treatment of amyloidosis
Melphalan and prednisone
UA in nephrotic syndrome
Maltese crosses, which are lipid deposits in sloughed off tubular cells
Why do you see HLD in nephrotic syndrome
Lipid levels rise because the lipoprotein signals that turn off the production of circulating lipid are lost in the urine.
Why does renal failure cause bleeding
Platelets do not work normally in a uremic environment. they do not degranulate.
Why is there hypocalcemia in renal failure
Kidney transforms less active 25-hydroxy vitamin D into much more active 1,25-dihydroxyvitamin D. Without this form of vitamin D, the body will not absorb enough calcium from the guy.
Why is there accelerated atherosclerosis and hypertension in renal failure
The immune system helps keep arteries clear of lipid accumulation. WBC don’t work normally in uremic environment.
Only time EPO is ALWAYS used
Anemia from ESRD
Tx of bleeding in ESRD
DDAVP
Tx of hyperphosphatemia in ESRD
Oral phosphate binders (calcium acetate, calcium carbonate, sevelamer, and lanthanum) will prevent phosphate absorption from bowel. Tx of hypocalcemia will also help because it is the hyper PTH that causes increased phos release. When Vit D is replaced, it is critical to also give phosphate binders otherwise vitamin D will increase GI absorption of of phosphate.
When calcium level is high, which phosphate binders should you use
Sevelamer and lanthanum
Drugs assoc with TTP
Cyclosporine
Ticlopidine
Clopidogrel
TTP or severe HUS treatment
Plasmapheresis or infusions of FFP.
STEROIDS DO NOT HELP
MCC of death from PCKD?
Renal failure. Recurrent episodes of peel and nephrolithiasis cause progressive scarring and loss of renal function.
Extra renal mx of PCKD
Liver cysts Ovarian cysts MVP Diverticulosis Cerebral aneurysms
Why is there decreased urine sodium in DI?
These are hypovolemic states. Apparently the body cares more about your volume status than your sodium status.
Name some hypovolemic states
Sweating Burns Fever PNA (from insensible losses from hyperventilation) Diarrhea Diuretics
Why does hypothyroidism lead to euvolemic hyponatremia
Thyroid hormone is needed to excrete water.
Tx of chronic SIADH
Demeclocycline, which blocks the action of ADH at the collecting duct of the kidney tubule
3 causes of pseudo-hyperkalemia
Hemolysis
Repeated fist clenching wit tourniquet in place
Thrombocytosis or leukocytosis
2 causes of hypokalemia due to renal losses that are kind of random
Bartter syndrome which is a genetic disease causing salt loss in the loop of Henle
Licorice.
Relationship between hypokalemia and hypomagnesemia
Magnesium dependent potassium channels. When mag is low, they open and spill potassium into urine.
Drug classic for causing distal RTA
Amphotericin
Tx of Type 2 RTA
Thiazides cause mild volume depletion which will enhance bicarb reabsorption.
Most common risk factor for nephrolithiasis
Overexertion of calcium in the urine
How does crohns cause kidney stones
Increased oxalate absorption
Fat malabsorption and stone formation
Fat malabsorption increased stone formation.
Lithotripsy is used to manage stones between what sizes?
0.5 and 2-3 cm
Why does calcium restriction actually increase the risk of forming calcium stones
CAlcium binds oxalate in the bowel. When calcium ingestion is low, there is increased oxalate absorption in the gut because there is no calcium to bind it.
Metabolic acidosis and stone formation
Metabolic acidosis removes calcium from bones and increases stone formation. In addition, it decreases citrate levels. Citrate is important as it binds calcium, making it unaviailable for stone formation
Citrate and stone formation
Decrease in citrate increases risk of stone formation because citrate binds calcium.
Flutamide is used in what dz
Prostate CA
Besides minoxidil, what other drug can we use to promote hair growth
Finasteride
MOA of cyproterone
Inhibits androgens at testosterone receptor.
