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GU Exam Flashcards

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1
Q

How do you estimate GFR?

A

Creatinine clearance

GFR is inversely related to serum creatinine

GFR = (Urine Cr x V)/ PCr

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2
Q

What is a urogram?

A

CT Scan used for urinary obstructions, polycystic disease, and masses

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3
Q

What does foamy urine indicate?

A

foamy or frothy indicates proteinuria

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4
Q

What is the definition of microscopic hematuria?

A

> 3RBCs/hpf in 2/3 specimens

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5
Q

What is the next step for someone with microscopic hematuria?

A

blood culture

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6
Q

All hematuria (gross and microscopic) get urologic evaluation except….

A

history of vigorous exercise

leukocyte esterase or nitrate (most likely due to an infection so just go ahead and treat)

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7
Q

What is the most common reason to see hematuria in pts under the age of 20?

A

glomerulonephritis, UTI, congenital

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8
Q

What is the most common reason to see hematuria in pts over the age of 60?

A

BPH (if male)
UTI
Cancer

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9
Q

What is the most common reason to see hematuria in pts between 20-60?

A

UTI
Stone
Cancer

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10
Q

Characteristics of glomerular urine analysis

A

acanthocytes
RBC casts
Cola colored urine
NO blood clots

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11
Q

Characteristics of non-glomerular urine analysis

A

WBC casts
Brown muddy casts
blood clots
pink or red colored urine

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12
Q

Brown muddy casts

A

non-glomerular

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13
Q

RBC cast

A

glomerular

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14
Q

Blood clots found in urine

A

non-glomerular

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15
Q

What is the most common nosocomial infection?

A

UTIs

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16
Q

What pathogens are responsible for hospital acquired pyelonephritis?

A

klebsiella

pseudomonas

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17
Q

What is the most common pathogen in UTIs of younger females?

A

S. saprophyticus

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18
Q

What is the most common pathogen in UTIs of older men?

A

S. epidermidis

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19
Q

What is the Tamm-Horfall protein?

A

host defense

it binds to the E.coli preventing it from attaching to the epithelium

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20
Q

Pyelonephritis clinical presentation?

A 
flank pain 
fever 
CVAT 
dysuria 
urgency 
frequency 
\+/- N/V, chills, diarrhea, tachycardia
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21
Q

Cystitis clinical presentation?

A 
suprapubic pain 
dysuria 
urgency 
frequency 
usually afebrile 
NO vaginal discharge
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22
Q

What is pyuria?

A

6-10 WBC/hpf

will see more pyruria with pyelonephritis than cystitis

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23
Q

Why does a negative dipstick test not rule out cystitis?

A

the dipstick is negative in 20% of patients with cystitis

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24
Q

If a pt has a UTI secondary to an obstruction, what might you see on US?

A

hydronephrosis

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25
Children under 2 with a UTI present with what type of sxs?
fever, vomiting, failure to thrive
26
What makes something a complicated UTI?
functional, anatomical, or metabolic abnormalities of the urinary tract
27
WBC casts are dx for...?
Upper UTI
28
How do you treat pyelonephritis?
Start strong with ABX until cultures come back 10-14 days Cipo (x7d) Bactrim
29
For which UTI are you going to get a urine culture?
Pyelonephritis Complicated UTIs you dont have to get a culture for women with sxs and no vaginal discharge --> just treat
30
What are the predisposing factors to recurrent UTIs?
Stones VUR obstruction incomplete bladder emptying
31
How do you treat acute cystitis?
ABX 3-5 days Nitrofurantoin x 5 days Bactrim x 3 days
32
When do you treat asymptomatic bacteruria?
pregnancy before urologic procedure young children with high incidence of VUR
33
What is the treatment for complicated cystitis?
Cipro (any FQ) Aminoglycocides for 7-10 days (which is longer than the 3-5 days for uncomplicated)
34
Which UTI do you see WBC casts with?
pyelonephritis
35
CUTE DIMPLES
DDx for high anion gap metabolic acidosis Citrate Uremia Toluene Ethanol ``` DKA Iron Methanol Paraldehyde Lactate Ethylene Glycol Salicylate ```
36
What are the hallmark findings for nephrotic syndrome?
Proteinuria Hypoalbuminemia Edema Hyperlipidemia --> Lipiduria
37
What is the most common cause of nephrotic syndrome?
Diabetic nephropahty
38
Is there a change in GFR with nephrotic syndrome?
NO
39
Is there a change in GFR with nephritic syndrome?
yes
40
When do you see oval fat bodies?
nephrotic syndrome
41
What is the treatment for Minimal Change GN?
prednisone for 8 weeks with gradual tapering over 1 - 2 months
42
What do you do if a pt does not respond to treatment for minimal change GN?
relapse for the first time just treat the same if they continue to relapse switch to Cyclophosphamide if it is STILL not responding --> rituximab for kids we assume their nephrotic sxs are minimal change so we start them on steroids, unless they dont respond, then we get biopsy for adults we get biopsy
43
What is the hallmark findings for nephritic syndrome?
Remember that nephritic syndrome is also called acute GN and is due to immune and inflammation crap ``` HTN Hematruia RBC casts Edema (periorbital + dependent) Azotemia ```
44
How do you dx most nephrotic and nephritic syndromes?
renal biopsy
45
What is the gold standard for dx nephrotic syndrome?
24 hour urine protein collection | >3.5 g/day
46
Which drugs might help with proteinuria reduction?
ACEI or ARB
47
Which, nephrotic or nephritic, are you more likely to see uremia?
Nephritic this is because nephritic occurs more globally in the kidneys (glomerulus) and the thickening due to inflammation that decreases GFR, thus an increase in BUN and creatinine --> uremia
48
Minimal change GN is commonly associated with ....?
Hodgkin's Lymphoma MC in kids
49
What is the most common cause of ESRD?
DM
50
FSGS
focal segmental GS (FSGS) --> scarring of some parts of some nephrons nephrotic MC in AA asymptomatic
51
What signs and sxs will you see with someone who has FSGS?
hypoalbuminemia proteinuria lipiduria most likely will be asymptomatic
52
FSGS is associated with...?
HIV Morbid Obestity Sickle cell disease
53
What is different about minimal change GN from FSGS in regards to prognosis?
Minimal change, once treated, is likely to regress | FSGS can progress to ESRD
54
What causes membranous nephropathy?
nephrotic syndrome | immune complexes get deposited into GBM making it thick and inflamed --> inflammatory complex leads to damage
55
What will you see on electron microscopy or membranous nephropathy?
spike and dome deposits on the subepithelium | effacement of podocytes
56
What is the prognosis of membranous nephropathy?
33% progress to ESRD 33% remain --> years of proteinuria 33% regress
57
Most common cause of nephrotic syndrome in adults?
diabetic nephropathy
58
What is the most common cause of ESRD?
diabetic nephropathy
59
When might you see "tram track"?
splitting of the basement membrane with membranoproliferative GN
60
What are the clinical presentations and findings of poststreptococcal GN?
impetigo sore throat edema ``` hematuria proteinuria HTN Oliguria low serum C3 ``` immune "humps"
61
What is the prognosis of poststreptococcal GN?
some progress to ESRD | 25% get RPGN
62
What titer can you get for poststretococcal GN?
ASO titer
63
What titer can you get for Lupus Nephritis?
Anti-DNA titer | ANA
64
What is the Anti-GBM titer used for?
goodpasture
65
What are the clinical presentations and findings for lupus?
Malar rash Low C3 hematuria proteinuria
66
What is the most common GN worldwide?
IgA MC in children
67
What is IgA nephropathy?
mutated IgA so that body doesn't recognize it as self and send IgG to attack
68
What is goodpasture's syndrome?
autoimmune disease that targets lungs and GBM | type 2 hypersenitivity --> activation of complement pathways
69
What clinical presentation and findings would you see with goodpastures?
``` flu like sxs myalgia hemoptysis dyspnea rales, bronchi CXR: infiltrates ``` hematuria proteinuria
70
How do you dx goodpasture?
renal biopsy preferred anti-GBM titer
71
What is microscopic polyangiitis?
small vessel vasculitis inflammation of blood vessels presents with flu like sxs and purpura of the skin
72
How do you dx microscopic polyangiitis?
ANCA titer positive P - microscopic positive C - granulomatosis
73
RPGN
rapidly progressive GN a complication of nephritic syndrome presents with nephritis and acute renal failure
74
What is type one RPGN?
goodpastures
75
what is type 2 RPGN?
SLE, post-infective GN, IgA nephropathy
76
What is type 3 RPGN?
microscopic polyagniitis
77
ANCA
anti-neutrophilic-cytoplasmic-antibody a titer you use for microscopic polyangiitis the pauci-immune type 3 RPGN
78
What is the prognosis for RPGN?
progress to ESRD in weeks to months if untreated
79
What is a common site of lodgment for bladder stones?
``` ureterovesical junction (UVJ) more likely to be bladder stones ```
80
What is the MC cause of obstructive uropathy in children's?
anatomical abnormalities
81
What is the MC cause of obstructive uropathy in young adults?
Kidney stones
82
What is the MC cause of obstructive uropahty in older pts?
BPH, prostate CA, pelvic tumors, kidney stones
83
What should you suspect if you have periods of anuria or oliguria followed by polyuria?
obstructive uropathy
84
When should a pt be catheterized?
anuria, distended bladder, or suprapubic pain
85
What does the VCUG show?
Voiding cystourethrography shows the neck of the bladder and urethral obstruction and the urine that remains in the bladder after voiding
86
What is the initial imaging test for obstructive uropathy?
abdominal US (aimed at detecting hydronephrosis) per the American Urological Association its non-contrast CT (more sensitive for obstructive nephropathy)
87
What is renal colic pain?
excruciating and intermittent pain lasting 20-60 minutes | can radiate to groin/anteriorly
88
What are the risk factors for Calcium oxalate stones?
hypercalcuria hypocituria renal tubular acidosis
89
Rank the types of stones from most common to least common
Calcium oxalate > uric acid stones > Struvite stone > cystine stones
90
Struvite stones are associated with .....
UTI caused by urea-splitting bacteria like proteus or klebsiella more likely to be alkalouria
91
What is the path behind kidney stones?
slow urine flow causing super saturation of urine forming crystals that later become stones
92
When do you send a stone in for stone analysis?
when it was collected by strainer i think normally they just assume it is a calcium oxalate stone since they're the most common
93
What is the treatment for kidney stones <5mm?
Flomax or tamsulosin | An alpha receptor blocker --> facilitates passage (shortens explusion duration by 3 days by relaxing smooth muscle)
94
What are the side effects of alpha blockers?
given for kidney stones to help passage | SE include HA, dizziness, postural hypotension, palpitations
95
What are the contraindications for stone manipulation (removal)?
active, untreated UTI pregnancy blood thinning or coagulation problems (uncorrected bleeding diathesis)
96
What is a percutaneous nephrostilithotomy?
useful in stones >2cm, staghorn gold standard = percutaneous nephrostomy tube
97
What is the treatment of choice for stones <2cm and lodged in the upper or middle calyx?
shockwave lithotripsy
98
When is ureteroscopy used?
when the stone is directly visualized typically 1-2cm in size and lodged in the lower calyx or below stent must be placed to prevent obstruction form ureter spasm or edema
99
Shockwave lithotripsy is contraindicated in....?
Pregnancy uncontrolled bleeding disorders this is used to treat stones that are <2cm and lodged in upper or middle calyx least invasive
100
When do symptoms typically begin for kidney stones?
once the stone starts moving down the urinary tract | until obstruction or infection is usually when symptoms begin
101
What are the risk factors for kidney stones?
``` decreased fluid intake medications (loop diuretics, chemo drugs) hypercalcemia polycystic kidney disease UTIs (urea-splitting organisms) ```
102
explain the work up for a pt you suspect has a kidney stone
``` get UA (hematuria ---culture if signs of infection) non-contrast CT ``` depending on size will determine treatment most likely start with an alpha antagonsits such as tamsulosin as well as giving fluids and something for the pain
103
What is the prevention for kidney stones?
decrease proteins and salt intake increase fluid intake an increase in protein can precipitate stones just like calcium
104
What does urinary incontinence mean?
involuntary loss of urine
105
What is the most common type of incontinence in the elderly?
urge incontinence
106
What is the second MC type of incontence in women?
stress incontinence
107
What is the second MC type of incontinence in men?
overflow incontinence
108
What causes stress incontinence?
increase in intra-abdominal pressure more severe in obese pts
109
A women post-childbirth is likely experiencing which type of incontinence?
stress incontinence | laxity of pelvic floor
110
Dribbling is a common complaint in pts with what type of incontinence?
overflow incontinence
111
What is functional incontinence?
urine loss d/t cognitive or physical impairments or environmental barriers that interfere w/ control of voiding might be a person that know they have to urinate but lack the mental ability, like with delirium or dementia?
112
Small volume voids are seen with which types of incontinence?
urge and overflow
113
What are the most common mixed incontinence?
stress + urge stress + functional
114
____ doubles the risk of incontinence in elderly pts?
CVA
115
Which types of brain lesions can cause incontinence?
cortical lesions
116
What are some causes of incontinence?
delirium, acute confusion, infection, atropic vaginitis, psych disorders, restricted mobility, stool impaction Meds --> think drugs that cause too much relaxation or drugs that cause too much urine Pharm (anticholinergics, antidepressants, alpha blockers, alpha agonists, diuretics, CCB, ACEI, sedatives, anti-parkinsons)
117
What PE should you do for a pt with incontinence?
neuro, rectal, pelvic
118
What does the workup look like for a pt with urinary incontinence?
UA, UC Serum BUN/Cr Post-void residual volume urodynamic testing
119
What are the pharm and non pharm treatments for incontinence?
bladder training --> timed voiding while awake kegel exercise avoid caffeine or other fluids that irritate the bladder TCAs, antispasmodics
120
What is interstitial cystitis?
noninfectious bladder inflammation that causes pain (mostly pain when the bladder is full) the bladder wall gets more damaged and scarred overtime causing more pain unknown etiology 90% occur in women
121
What food make interstitial cystitis pain worse?
foods high in potassium EtOH tabacco
122
What does the workup look like for a pt with interstitial cystitis?
rule out other more common dz | CYSTOSCOPY is necessary to dx
123
A pt comes in complaining of lower abdominal pain that goes away after she has peed. She notices the pain gets worse when she drinks wine. What are you suspicious of?
interstitial cystitis
124
What is polycystic kidney disease?
a hereditary disorder causing renal cysts (in the cortex and medulla) that cause gradual enlargement of both kidneys can lead to renal failure can be a systemic disease (cysts on liver, etc) but more commonly affects the kidneys
125
What is the difference between autosomal dominant and recessive for polycystic kidney disease?
dominant is the MC, typically found in adulthood (dx in 4th decade of life) and affects both kidneys the recessive is typically seen in children and has a worst prognosis
126
What is the MC mutation associated with polycystic kidney disease?
PKD1 --> polycystin 1 on chromosome 16
127
What is the path behind polycystic kidney disease?
tubules dilate and fill with glomerular filtrate --separating from the functioning nephron ---impair kidney function
128
How do pts with polycystic kidney disease usually present?
for something else this is an incidental finding, typically, asymptomatic might have low grade flank and back pain 40-50% have HTN +/- palpable kidneys
129
What does the work up look like for a pt with polycystic kidney disease?
UA - hematuria, proteinuria, +/- signs of UTI FAT OVAL BODIES (also seen in nephrotic syndrome) start with abdominal US get CT if US is unclear
130
What is the dx criteria for polycystic kidney disease?
2 kidney cysts on either kidney (like you could have one on each) before 30 y/o 2 kidney cysts on the same kidney at age 31-59 4 kidney cysts in 1 kidney after 60
131
What is the treatment for pts with polycystic kidney disease?
``` symptomatic control (might have to get nephrectomy if pt gets infections and pain) control HTN to prevent progression to ESRD ```
132
What is the equation for urine anion gap?
Urine (Na+ K) - Cl
133
What does a positive urine anion gap indicate?
RTA
134
What does a negative urine anion gap indicate?
diarrhea
135
What is the equation for delta gap?
change in AG/change in HCO3
136
What does a delta gap <1 mean?
normal anion gap metabolic acidosis
137
What does a delta gap >2 mean?
metabolic alkalosis co-exists
138
What is considered a normal delta gap?
between 1-2
139
What can urine Cl- levels tell you?
if the alkalosis is responsive or resistant to chloride
140
Urine [Cl-] <20 means...
chloride responsive alkalosis --> hypovolemia
141
Urine [Cl-] >40 means
chloride resistant alkalosis --> HTN, aldosterone problems, cortisol
142
What medications can you use for PKD?
RAAS inhibitors Somatostatin Tolvaptan (ADH antagonist)
143
What is the most common type of kidney cancer in adults?
Renal Cell Carcinoma (RCC)
144
What is the most common type of renal tumor in children?
Wilms tumor (malignant)
145
Which gender and age are more likely to have RCC?
Men ages 50 -70
146
What are risk factors for RCC?
``` Smoking!!!! Obesity (especially in women) ESRD, dialysis HTN Family hx of Von Hipple Lindau Sydnrome Horse shoe shaped kidney ```
147
Which type of RCC is MC?
``` Clear cell (60%) Followed by papillary cell (10-15%) ```
148
What is the "classic triad" for RCC?
``` Flank pain Macroscopic hematuria (MC finding) palpable abdominal mass ```
149
What are the signs and sxs of RCC?
``` Classic triad (flank pain, hematuria, palpable abdominal mass) HTN weight loss fever of unknown origin swelling in veins around testicles ``` parencoplastic syndrome seen in 20% of pts less commonly seen is polycythemia, excessive hair growth in women, visual problems
150
How are most RCC normally dx?
accidentally, on abdominal imaging Confirmed with CT or MRI (wow contrast) --> circumscribed mass with sharp margins bright yellow/orange d/t lipid + glycogen content
151
Solids lesions of the kidney are ____ unless proven otherwise
RCC
152
What does the workup for a pt with RCC look like?
UA, CBC, CMP (w/ LFTs), CXR | if alkaline phosphatase is elevated or pt has bone pain --> get bone scan
153
How are RCC tumors staged?
AJCC 1 = <7 cm in diameter, confined to the kidney 2 = >7 cm in diameter, confined to the kidney 3 = extension to the renal capsule, confined to Gerota's fascia 4 = invasion to other organs, involve multiple lymph nodes, distant metastasis
154
What is the treatment for localized RCC?
radical nephrectomy
155
What is the treatment for advanced RCC?
palliative surgery, radiation therapy, targeted drug therapies, and/or interferon alpha 2b or IL-2 THERE IS NO EFFECT CHEMOTHERAPY FOR RCC
156
What factors are seen to have poor prognosis for RCC?
low Hb higher corrected Ca abnormal LDH
157
What is the most likely first location for metastasis of RCC?
lungs | that is why you have to get CXR during your initial work up!
158
What is the path behind Wilms tumor?
arise from primitive metanephric bastema (precursor of normal kidney)
159
What is the age range for Wilms tumors?
typically 2-5 years (lecture says 3-3.5 years) | 95% hve been dx by the age of 10
160
What is the clinical presentation of Wilms tumor?
Palpable abdominal mass that doesn't cross the midline is the most common finding --> because 90-95% are unilateral tumors abdominal pain fever HTN hematuria
161
What is the best initial test for Wilms tumor?
abdominal US
162
What other structures must you check in a pt you suspect has Wilms tumor?
chest and inferior vena cava | the tumor could have extended from the kidney
163
What is the DDx for Wilms tumor?
PKD RCC hydronephrosis other renal tumors
164
What is the treatment for Wilms tumor?
controversial | immediate nephrectomy followed by adjuvant chemotherapy
165
Which incontinence has nocturia?
urge incontinence
166
"underactive bladder"
``` overflow incontinence urinary retention (incomplete bladder emptying) ```
167
"overactive bladder"
urge incontinence | urine leakage + detrusor muscle overactivity
168
What is the treatment for stress incontinence?
pelvic floor exercises kegel exercises alpha agonists (Midodrine)
169
What is the treatment for urge incontinence?
Bladder training (timed voiding during the day) anticholinergics (are first line) --oxybutynin, tolterodine TCA - imipramine
170
What is the treatment for overflow incontinence?
bladder atony (intermittent or indwelling catheterization is 1st line) cholinergics (bethanacol) BPH --> Flomax (alpha 1 antagonists)
171
Bladder cancer is the ___ most common cause of cancer in men
4th M > F 3:1
172
What is the most common type of bladder cancer?
Transitional cell
173
What are the risk factors for bladder cancer?
``` SMOKING old age (60-80) occupational exposures chronic analgesic use heavy cyclophosphamide use (chemo drug that is also used for nephrotic) ```
174
What are the signs and sxs for bladder cancer?
painless hematuria = classic sxs frequency, urgency, dysuria (resembles a UTI) hydronephrosis
175
What are the 2 types of urothelial carcinomas?
Flat and papillary papillary is MC and less progressive
176
What is the gold standard for bladder cancer?
cytoscopy +/- transurethral resection of visible tumors to confirm w/ biopsy
177
What is the definition of AKI?
abrupt decrease in GFR that causes retention of nitrogenous waste products
178
What is the most common cause of AKI?
Pre-renal (decreased RBF and thus hypoperfusion)
179
Of the intrinsic causes for AKI, what is the most common cause?
acute tubular necrosis
180
Where do nephrotic and nephritic syndromes fall under AKI?
Intrinsic --make up GN which is 5%
181
What is the most common cause of AKI in hospital setting?
Acute tubular necrosis
182
What are the sxs for mild to moderate AKI?
asymptomatic
183
FENa <1% suggests?
pre-renal
184
What are the 3 different guidelines for staging AKI?
KDIGO AKIN RIFLE
185
What is the difference between AKIN and RIFLE AKI guidelines?
RIFLE includes changes in GFR in addition to Cr AKIN scores 1-3 RIFLE is risk, injury, failure, loss, esrd
186
What is the treatment for any AKI?
treat the underlying problem and restore the hemodynamic balance if serum Cr is greater than 5 --> short term dialysis
187
What are some of the causes for pre-renal AKI?
vomiting, diarrhea, low fluid intake, HF, diuretics liver dysfunction septic shock anesthesia (in surgery this decreases effective blood volume and can decrease RBF)
188
What is the "hallmark" of intrinsic AKI?
Cellular cast formation
189
Muddy brown casts
Acute tubular necrosis also referred to as "brown granular casts" makes up 85% of AKI
190
WBC casts are pathognomonic for?
AIN - acute interstitial nephritis
191
If you are given a case study and the UA mentions casts, what automatically can you start thinking of?
Intrinsic causes for AKI post and pre-renal dont have casts
192
BPH can cause what?
post-renal AKI via obstruction
193
_____ is associated with Berry aneurysms, mitral valve prolapse and hepatic cysts
Adult Polycystic Kidney disease
194
What is the treatment for acute tubular necrosis?
Stop the offending agent + supportive therapy (IV fluids)
195
Which part of the tubule is more likely to be affected by acute tubular necrosis?
PCT > DCT
196
You have a pt complaining of a fever, with a small rash, and some side and lower back pain. She recently had a UTI and was prescribed a PCN. What might be causing these symptoms?
``` Allergic Interstitial nephritis AKI post drug exposure 1-2 weeks Fever Skin rash Eosinophilia flank pain oliguria ```
197
How do you dx AIN?
Acute interstitial nephritis regardless of if it is drug induced or due to an infection Renal Biopsy is dx
198
You have a concern parent in front of you stating her son just got over having diphtheria but now seems tired, not eating well, N/V, not urinating often. What do you suspect?
Infectious AIN
199
What is the treatment for allergic AIN?
stop the offending agent and watch Cr levels for 5-7 days | if Cr doesn't improve start them on prednisone
200
What are some of the offending pathogens that can cause infectious AIN?
``` Diphtheria (children) legionella histoplasmosis TB CMV EBV ```
201
WBC casts are seen with....
AIN and pyelonephritis
202
What are risk factors for multiple myeloma nephropathy?
Low urine flow hypercalcemia IV contrast Volume depletion
203
What is multiple myeloma nephropathy?
When there is an overproduction of Ig light chains that then get into the lumen and cause obstruction and toxicity Bence Jones proteins can precipitate in the lumen as well
204
What are the signs and sxs for multiple myeloma nephropathy?
elevated serum Cr tace albumin on UA NO hematuria WBCs in urine
205
Multiple myeloma nephropahty is a type of....
AIN
206
BenceJones Proteins or light chains lead to | kidney failure through
direct tubular toxicity | tubule cast formation
207
Fanconi Syndrome is associated with...
multiple myeloma nephropathy
208
What is the next step for someone you suspect has multiple myeloma nephropathy?
Hematology eval for bone marrow biopsy | kidney biopsy
209
What is the treatment for multiple myeloma nephropathy?
chemotherapy bone marrow transplant controversial is plasmaphoresis
210
What is the most common inherited kidney disease?
Polycystic Kidney Disease
211
Livedo Reticularis
``` Skin lesions (pupura, mottling - lower legs, toes, feet) see in pts with atheroembolic renal disease ```
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Hollenhorst plaques
can be found in the eye of pts with atheroemoblic renal disease whitish yellow flecks that are often asymptomatic but can cause transient visual field defects
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What is atheroembolic renal disease?
post arterial manipulation (say from a CABG), cholesterol emoblizes from athersceloritc plaques getting stuck in renal artery systemic embolization can cause gangreen or ischemia
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Cholesterol emboli are pathognomonic for...
atheroemoblic renal disease
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What is the treatment for atheroembolic renal disease?
avoid future vascular procedures | avoid anticoagulation to prevent dissolution and embolization of thrombus
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When do you see eosinphilia?
atheroembolic renal disease | allergic interstitial nephritis
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When should you suspect VUR?
in a child less than 5 with UTI repeat UTIs a boy of any age with UTI
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VUR can present as ....
nephrotic syndrome +/- polyuria, nocturia, HTN, proteinuria
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What two kidney diseases can cause chronic interstitial nephritis?
analgesic nephropathy | VUR reflux nephropathy
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What offending agents can cause analgesic nephropathy?
Aspirin NSAIDs Acetaminophen Caffeine
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What is the most common type of chronic interstitial nephritis worldwide?
Analgesic nephropathy
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What gender and age group is most likely to present with analgesic nephropathy?
women ages 60-70
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What do the kidneys look like for someone with analgesic nephropathy?
small bumpy contours/indentations on the kidney microcalcifications at papillary tips
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What is renal artery stenosis?
narrowing of the renal artery most likely due to atherosclerosis --> decrease in GFR the decrease in GFR causes the RAAS to increase BP and GFR -->HTN
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What is a typical pt for renal artery stenosis going to look like?
HTN <30years old that is hard to control hx of CAD recurrent and unexplained flash pulmonary edema abdominal bruits
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What imaging confirms the dx of renal artery stenosis?
CT angiography MR angiography Duplex US
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What is the treatment of renal artery stenosis?
CONTROL BP (ACEI/ARB) statin to lower lipid level lifestyle modifications intervention is controversial --> renal artery stenting + clopidogrel PPx
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Henoch-Schonlein purpura is associated with what....
IgA nephropathy (Berger's) deposits of IgA in the glomerulus post viral URI or something auto immune
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Hep B and C is associated with what glomerularnephritis?
Membranous and membranoproliferative
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positive p-ANCA titer
microscopic polyangiitis
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What is the daily maintenance dose needed?
5D 1/2 NS + KCl 20 mEq at 2 L/day
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How does Ron Swanson play a role in potassium balance?
He is the quintessential hypokalemic pt. ``` Ron doesn't eat bananas Has DM --> takes insulin --> increases Na/K pump increasing K into the cell Has asthma --> beta agonists increase Na/K pump Has BPH --> alpha blocker (prazosin) blocks calcium dependent K channel from allowing K leaving the cell Metabolic alkaloisis (can be caused by vomiting) this is because the body sends out H+ from the cells to counter the high pH, using a K/H pump ``` CHF --> takes loops + HCTZ diuretics hyperaldosteronism
233
What is refeeding?
When a pt who has been starved eats for the first time, they have hypokalemia and when they get glucose and release insulin they increase Na/K pump and take in more K into the cells -- further causing their hypokalemia --> leading to tachyarrythmia and DEATH
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What are the consequences of hypokalemia?
``` weakness paralysis poor GI motility (cramps) tachyarrythmias Rhabdo (your body trying to compensate for hypokalemia by rupturing the cells and letting K+ out) nephrogenic DI respiratory depression ```
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What occurs to the action potential with hypokalemia?
decrease the resting membrane potential so that it hyperpolarizes and is thus less reactive
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What are the EKG changes for hypokalemia?
``` long QT U wave prolonged PR increased P amplitude T wave flattening ``` tachyarrythmias
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What is the treatment for hypokalemia?
treat underlying cause | be sure to check the Mg level
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What is the ROMK?
the potassium channel on the basolateral side of the principal cell that allows potassium to be excreted into the urine blocked by Mg
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What do you expect to see with a pt who has acute tubulointertitial nephritis?
``` fever sin rash eosinophilia oliguria flank pain WBC casts increase BUN and Cr (low BUN:Cr) (unable to filter as well) ```
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What are the internal balance shifts for hyperkalemia?
Insulin deficiency metabolic acidosis beta blockers alpha agonists hyperosmolarity of the blood (extracellular fluid) cell lysis (burns, rhabdo, chemo) exercise (decrease ATP keeping K out of the cell)
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What are external shifts affecting hyperkalemia?
adrenal insufficency hypoaldosterone AKI Meds (ACE-I, ARBs, NSAIDs)
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What happens to the membrane potential in hyperkalmeia?
it goes up making the cell more excitable
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What are the EKG changes for hyperkalemia?
Bradyarrythmias At first: peaked T waves, shorted AT interval, ST depression SEVERE: prolonged PR absent P wide QRS
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What is the treatment for hyperkalemia?
``` calcium - stabilize myocardial membrane bicarb (for the acidosis) k+ wasting diuretics resin binding K+ beta agonists (albuterol) insulin + glucose ```
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What is happening to your water and sodium in hypotonic isovolemic hyponatremia?
you are gaining free water
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What are the causes of hypotonic isovolemic hyponatremia?
SIADH hypothyroidism crotisol issues meds
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What is the treatment for hypotonic isovolemic hyponatremia?
water restriction give NS if its chronic also give loop + anti ADH meds + tolvaptan (vasopressin antagonist)
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What is happening to your sodium and water in hypotonic hypovolemic hyponatremia?
loosing Na + H20 just more Na
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What is the cause of hypotonic hypovolemic hyponatremia?
``` vomiting diuretic decrease in ADH ACEI diuretics ``` the magic number is urine [Na] >20 = renal
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What is the treatment for hypotonic hypovolemic hyponatremia?
NS treat the underlying cause be careful about speed of correction d/t cerebral edema
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What is the cause of hypotonic hypervolemic hyponatremia?
increase in sodium and water, just more water
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What is the cause of hypotonic hypervolemic hyponatremia?
cirrhosis CHF Nephrotic intravascular volume depletion renal failure
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What is the treatement for hypotonic hypervolemic hyponatremia?
prevent ADH/aldosterone effects restrict H20 + Na give loop diuretic
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What is the cause of hypovolemic hypernatremia?
``` non renal: sweating diarrhea insensible loss with/ inability to get H20 (like dehydrated old pts) [Na] <10 ``` ``` renal: osmotic diuresis (mannitol) post obstruction [Na] >20 ```
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What is the treatment of hypovolemic hypernatremia?
NS
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What is happening in hypervolemic hypernatremia?
increase in water and sodium but more increase is sodium most commonly due to over resuscitation with NS or d/t mineralocorticoid excess (cushings)
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What is the treatment for hypervolemic hypernatremia?
diuretics + free h2o
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What is happening in isovolemic hypernatremia?
decrease in H20 while Na stays the same
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What is the cause of isovolemic hypernatremia?
DI (decrease in ADH)
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What is DI?
Diabetic insipidus central: due to the body not producing enough ADH nephrogenic: due to the body not responding to ADH dx by H2O deprivation test and checking their urine ---if it stays dilute DI then to see which DI give them ADH and see if they respond
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What is the treatment for isovolemic hypernatremia?
for nephrotic DI give HCTZ and restrict Na for central DI give ADH
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What does a pt with chronic SIADH look like?
might be asymptomatic might be anorexic
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What does demeclocycline do?
its an antibiotic that is given for isovolemic hyponatremia to cause nephrogenic DI??

Clin Med GU (1 decks)

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