GU/Nephrology 6% Flashcards
Proximal convoluted tubules (resorb/secrete) ____
What medication work here?
Resorb All organic nutrients (glucose, AA) Bicarb Na, Cl 75-90% of H2O
Acetazolamide
Mannitol
Thin Descending Limb of Loop of Henle (resorbs/secretes) ___
Resorbs
H20 passively
Impermeable to Na and solutes
Thick Ascending Limb of Loop of Henle (resorbs/secretes) ___
What medication work here?
Resorbs
Actively Na+, K+, Cl-
Indirectly resorbs Mg+ and Ca+
Loop diuretics –> inhibit water, Na, K, Cl cotransport
Early distal convoluted tubule (resorbs/secretes) ____
Other functions?
What medication work here?
SECRETES
Organic acids, toxins, drugs
K+, H+
Dilutes urine by actively resorbing Na+ and Cl-
Thiazide diuretics –> impairs urinary dilution
____ determine final osmolarity of urine via ____
What medication work here?
Distal collecting tubules
Via Aldosterone, ADH
K-sparing diuretics: inhibit aldosterone mediated Na/H2O absorption –> hyperkalemia, metabolic acidosis
Nephrotic syndrome is characterized by ___ (4)
Proteinuria
Hypoalbuminemia
Hyperlipidemia
Edema
80% of nephrotic syndrome in children =
Microscopy findings:
Tx:
Minimal change disease
Loss of foot processes of podocytes
Loss of negative charge of glomerular basement membrane
Tx: Prednisone
Sclerosis(fibrosis) within glomerulus
Seen in ___
Tx:
Focal segmental glomerulosclerosis
Seen in HTN in blacks
Tx: steroids
Thickened glomerular basement membrane
Caused by:
Membranous Nephropathy
Caused by SLE, viral hepatitis, malaria, drugs (Pencillamine)
D/t immune complex deposition
MC cause of nephrotic syndrome in adults
Diabetes mellitus
Gold standard of dx of nephrotic syndrome
Urinalysis shows:
24 hrs urine protein collection > 3.5 g/d
Oval fat bodies “maltese cross shaped”
Acute glomerulonephritis is characterized by (4)
HTN
Hematuria (RBC casts)
Dependent edema (proteinuria)
Azotemia (build up of nitrogen waste in blood)
All of the following are causes of Acute glomerulonephritis EXCEPT: A. IgA Nephropathy (Berger's dz) B. Goodpasture's syndrome C. Post infectious D. Membranousproliferative GN E. Vasculitis
TRICK QUESTION. All are causes of AGN.
IgA Nephropathy (a.k.a. ____)
T/F: MC cause of AGN in children worldwide
When does it usually occur? Why?
Dx?
Tx?
Berger’s dz
False. MC cause of AGN in ADULTS worldwide
Young men within days after URI or GI infection d/t IgA overproduction
Dx: IgA depositis in mesangium w/ immunostaining
Tx: ACE-I + Corticosteroids
Post infectious AGN occurs MC after ____
Presentation:
Dx:
Tx:
Group A Beta-hemolytic Strep (can occur after any infection)
Skin/pharyngeal infection
2-14 y/o boys w/ puffy eyelids, facial edema, cola colored/dark urine
Dx: Increased antistreptolysin (ASO) titers
Low serum complement (C3)
Tx: supportive, abx
Rapidly progressive glomerulonephritis (RPGN) is (good/bad) prognosis
Bx findings?
Tx?
bad prognosis –> rapid progression to ESRD
Cresent formation d/t fibrin and plasma protein deposition
Tx: steroids + cyclophosphamide
+ Anti-GBM antibodies seen in ____
Results in ___
Often occurs ____
Dx:
Tx:
Goodpasture’s syndrome
Kidney failure and HEMOPTYSIS (d/t ab against type 4 collagen of GBM in kidney and lung alveoli)
Often occurs after URI
Dx: Linear IgG deposits
Tx: High dose steroid immunosuppression + Cyclophosphamide + plasmapharesis
Vasculitis AGN is characterized by ___
2 types:
lack of immune deposits, + ANCA ab
Microscopic polyangiitis = vasculitis of small renal vessels –> + P-ANCA
Granulomatosis w/ polyangiitis (Wegener’s) = necrotizing vasculitis –> + C-ANCA
Gold standard dx of AGN
renal bx
Urinalysis: RBC casts, high specific gravity > 1.020osm
WBC casts are pathognomonic for ___
Other clinical features?
acute tubulointerstitial nephritis (AIN)
EOSINOPHILIA
fever
maculopapular rash
arthralgia
4 causes of intrinsic AKI
MC type?
Acute Tubular Necrosis (ATN) = MC type of intrinsic AKI
Acute tubulointerstitial nephritis (AIN)
Glomerular (AGN)
Vascular
Medication that may cause Acute Tubular Necrosis
Aminoglycosides
Inflammatory or allergic response in interstitium, sparing glomeruli and blood vessels =
Commonly caused by ____
Acute tubulointerstitial nephritis (AIN)
PCN, NSAIDs, Sulfa drugs
All of the following are features of ATN EXCEPT:
A. Epithelial cell casts and muddy brown casts
B. High specific gravity
C. Hypokalemia
D. High phosphate
B, C
LOW specific gravity
HYPERkalemia
Narrow waxy casts seen in ___
Broad waxy casts seen in ___
Chronic ATN/Glomerlonephritis
End stage renal disease
ATN or Prerenal? Low specific gravity Creatinine rapidly improves w/ IVF BUN:Cr > 20:1 UNA > 40 , FeNa > 2% Cr increases at 0.3-0.5 mg/dL/day
Low specific gravity: ATN
Creatinine rapidly improves w/ IVF: Prerenal
Creatinine does NOT improve w/ IVF = ATN
BUN:Cr > 20:1 = Prerenal
BUN:Cr 10-15:1 = ATN
UNA > 40 , FeNa > 2% = ATN
Cr increases at 0.3-0.5 mg/dL/day = ATN
Cr increases slower than 0.3 mg/dL/day = prerenal
Causes of HYPERphosphatemia
Associated Ca, Phosphate and PTH levels of each?
Renal failure (MC) : dec. Ca, inc. phosphate, inc. PTH
Primary hypoparathyroidism: dec. Ca, inc. phosphate, dec. PTH
Vit D intoxication: inc. Ca, inc. phosphate, dec. PTH
Causes of HYPOphosphatemia
Primary HYPERparathyroidism Excessive IV glucose, Tx for DKA Refeeding syndrome in ETOHics Respiratory alkalosis Vit D deficiency (dec Ca and dec phosphate)
Polycystic Kidney Dz = autosomal (dominant/recessive) d/o d/t mutation of ____ gene(s).
Characterized by ___
Extrarenal manifestations:
AD
PKD1, PKD2
formation and enlargement of kidney cysts in other organs (LIVER, spleen, pancreas)
Vasopressin stimulates cystogenesis –> ESRD
Cerebral “berry” aneurysms**
Mitral valve prolapse **
Chronic kidney disease staging
Normal GFR =
0 = at risk; normal GFR and urine 1 = kidney damage w/ normal GFR (>90) 2 = GFR 89-60 3 = GFR 59-30 4 = GFR 29-15 5 = GRF < 15
Normal GFR = 120-130
Best predictor of disease progression in CKD
Proteinuria
Hematologic complications of CKD
Anemia of chronic disease = normochromic, normocytic anemia
Inc. ferritin, dec. serum Fe, dec. TIBC
Tx: Oral FeSO4
Erythropoietin or Darbepoetin-alpha
“salt and pepper” appearance of skull on x ray
Labs:
Osteitis Fibrosis Cystica d/t CKD
Increased osteoclast activity
Increased PO4, HYPOcalcemia (d/t decreased vit D production from kidney) –> Inc PTH –> 2ndary hyperparathyroidism
SIADH causes (iso/hypo/hyper)volemic (hyper/hypo)tonic (hyper/hypo)natremia
Become clinically symptomatic w/ (increased/decreased) oral free H2O intake
(increase/decrease) serum osm (increase/decrease) NA (hyper/hypo)uricemia (increase/decrease) BUN (increase/decrease) urine osm (increase/decrease) UNa
SIADH causes ISOvolemic HYPOtonic HYPOnatremia
–> increase free water retention + impaired water excretion
Become clinically symptomatic w/ INCREASED oral free H2O intake
DECREASED serum osm <280 DECREASED Na<135 HYPOuricemia DECREASED BUN INCREASED urine osm >300 INCREASED UNa > 20
Central DI =
Nephrogenic DI =
Become clinically symptomatic w/ (increased/decreased) oral free H2O intake
What happens?
Central DI = ADH (Vasopressin) deficiency
Nephrogenic DI = ADH insensitivity
Become clinically symptomatic w/ DECREASED oral free H2O intake
Both end with production of LARGE amount of DILUTE urine
Lithium causes (central/nephrogenic) DI
Nephrogenic DI
Dx of Diabetes Insipidus
Fluid deprivation test: continued production of dilute urine
Desmopressin Stimulation test: differentiates nephrogenic vs central DI
Central: reduction of urine output, increase Uosm –> response to ADH
Nephrogenic: continued production of dilute urine
Tx of
Central DI:
Nephrogenic DI:
Central DI: Desmopressin/DDAVP, Carbamazepine
Nephrogenic DI: Na/protein restriction –>HCTZ, indomethacin
Alpha-1 activation causes afferent arteriole (dilation/constriction) which (increases/decreases) GFR. This causes (more/less) water to be excreted, thus H2O (conservation/depletion).
Alpha-1 activation causes afferent arteriole CONSTRICTION which DECREASES GFR. This causes LESS water to be excreted, thus H2O CONSERVATION.
Water homeostasis is determined by ___. Stimuli include ___(2)
Na homeostasis is determined by ___. Stimuli include ___(2)
Water: ADH; hypovolemia, hyperosmolarity*
Na: Aldosterone; hypovolemia, hyperkalemia
Tx of:
Isovolemic hypotonic hyponatremia
Hypervolemic hypotonic hyponatremia
Hypovolemic hypotonic hyponatremia
Hypertonic hyponatremia
Severe Iso/hypervolemic hyponatremia
Isovolemic hypotonic hyponatremia: H2O restriction
Hypervolemic hypotonic hyponatremia: H20 + Na restriction
Hypovolemic hypotonic hyponatremia: Normal saline
Hypertonic hyponatremia: Normal saline until hemodynamically stable –> 1/2 normal saline
Severe Iso/hypervolemic hyponatremia: Hypertonic saline w/ Furosemide
Hypomagnesemia causes (increased/decreased) DTR, (hypo/hyper)calcemia
HYPOmagnesemia causes INCREASED DTR, HYPOcalcemia –> Trousseau’s, Chvostek’s sign
Tx of hypermagnesemia
Mild-moderate: IV fluids, Furosemide
Severe: calcium gluconate –> antagnoizes toxic effects of magnesium, stabilizes cardiac membrane
PPI, amphotericin B, cisplatin, cyclosporine, aminoglycosides can cause ____
HYPOmagnesemia
Metabolic acidosis may cause (hypo/hyper)kalemia
HYPERkalemia
Metabolic alkalosis causes HYPOkalemia
Tx of hyperkalemia
IV calcium gluconate
Insulin w/ glucose: shift K+ intracellularly
Beta2 agonists (4-8x dose for asthma)
Kayexalate: enhances GI potassium excretion
MC cause of epididymitis/orchitis in children and men >35
Tx:
Enteric organisms: E. coli, Klebsiella
Fluoroquinolones
Cephalexin, amoxicillin in children
Acute orchitis MC caused by
Mumps**
Dx of testicular torsion
Best initial:
Gold standard:
Best initial: Testicular doppler US
Gold standard: Radionuclide scan
Sudden onset of left-sided varicocele in older men may possibly suggest ____
Right sided varicocele in children <10 y/o may possibly suggest ___
Renal cell carcinoma
Retroperitoneal malignancy
Orchiopexy recommended for cryptorchidism in ____
6 month old, before 1 year old
MC type of testicular cancer
Seminoma (germinal cell tumors)
T/F: Seminomas are radiosensitive and show elevated alpha-fetoprotein and beta-HCG
False: seminomas are radiosensitive BUT lack tumor markers
“Seminomas are Simple & Sensitive”
Nonseminomatous Germ Cell Tumors are RADIORESISTENT and have ELEVATED alpha-fetoprotein and beta-HCG
Tx of complicated cystitis in pregnancy
Amoxicillin, nitrofurantoin x 7-14 days
T/F: Phimosis is a urologic emergency
False. Paraphimosis is a urologic emergency
Tx of acute prostatitis
Fluoroquinolones, Bactrim
Ampicillin w/ gentamicin
x 1 month
Tx for BPH that has positive effect on clinical course of BPH
5-alpha reductase inhibitors (Finasteride)
Vs. alpha-1 blockers (Tamsulosin) provides rapid sx relief but NO effect on BPH clinical course
90% of bladder cancers are ___
transitional cell
MC abdominal malignancy in children
Wilm’s tumor (Nephroblastoma)
MC in children w/i 1st 5 years of life
Dx of Renovascular HTN
Renogram (best noninvasive)
Captopril test: increase plasma renin activity 1 hr p administration
Renal angiography = gold standard
Tx of Renovascular HTN
Sx: angioplasty w/ stent = definitive
ACE-I/ARB
BUT CI in pts w/ bilateral stenosis or solitary kidney b/c ACEI markedly reduces renal blood flow + GFR
Tx of priapism
Terbutaline* = beta-adrenergic agonist Phenylephrine = selective α1-adrenergic receptor
Infant that develops urethritis, neonatal pneumonia and neonatal conjunctivitis 2-5 days after birth, think ___ pathogen.
5-7 days after birth, think ___
2-5 days: Gonococcal
5-7 days: Chlamydia
Tx of
Stress incontinence:
Urge incontinence:
Overflow incontinence:
Stress incontinence: Alpha agonists (Midodrine, Pseudoephedrine) –> increase urethral sphincter tone/urethral urine flow resistance
Urge incontinence:
- -Antichoinergic (Oxybutynin, Tolterodine, Propantheline) –> block cholinergic receptors in bladder –> decrease involuntary contraction strength (overactive detrusor mm)
- -TCAs: central and peripheral anticholinergic effect + alpha adrenergic agonist
- -Mirabegron (beta-3 agonist) –> bladder relaxant
Overflow incontinence: Cholinergics (Bethanacol) –> increase detrusor mm activity
Bence Jones protein in urine is seen in ____.
Multiple Myeloma
Glucose is excreted into urine when blood glucose exceeds ____
180-200 mg/dL
Unilateral small kidney on US describes ___
renal artery stenosis
Bactrim can cause (hyper/hypo)kalemia, (increase/decrease) serum creatinine, cause ___ kidney injury, thus a poor choice in CKD 4 patients.
HYPERkalemia
DECREASED Cr
Acute interstitial nephritis (AIN)
Phototherapy treats \_\_\_\_ by \_\_\_\_\_. SE include (4)
Physiologic jaundice in newborns
converts bilirubin to lumirubin
SE: fever, rash, diarrhea, dehydration
Type of kidney stone that is radiolucent
Uric acid
Best dx of diverticulosis
Barium edema
MORE specific than colonoscopy
Nitrites on UA indicates presence of ___
Enterobacteriaceae: E. coli, Klebsiella, Proteus, Serratia, Salmonella
Tx of enterobiasis (a.k.a ___)
Pinworms
Mebendazole, albendazole
Uncomplicated pyelonephritis tx
fluoroquinolone
Cipro x 14 days
Chronic renal disease is characterized by (hyper/hypo)kalemia, (hyper/hypo)calcemia, (hyper/hypo)phosphatemia, metabolic (acidosis/alkalosis).
HYPERkalemia
HYPOcalcemia
HYPERphosphatemia
Metabolic ACIDOSIS
