GU/Renal Flashcards
Rhabdomyolysis Overview
S/Sx
- acute onset of muscle pain (not r/t physical exertion)
- muscle weakness
- dark urine (myoglobinuria) d/t myoglobins released from damaged muscle → reddish-brown or tea-colored urine; damages kidney → AKF (common complication of rhabdo)
- muscle tenderness & swelling may be seen → r/o compartment syndrome
Labs
- Serum creatine kinase markedly ↑ (5x normal)
- Blood chemistry abnormalities
- ↑ aldolase, LDH
- electrolyte abnormalities
- DIC possible complication
Ask pt if hx of severe exercise, crush injury, high fever, or high-dose statin use
REFER TO ED!
Acute Pyelonephritis Overview
S/Sx
- acute onset of high fever
- chills,
- N/V
- dysuria
- frequent urination
- unilateral flank pain described as “deep ache”
- hx of URI
Indications for hospitalization:
- inability to maintain oral hydration
- persistently high fever >101º/38.4º
- toxic appearance
- immune compromise
- suspicion of sepsis
- noncompliance to treatment
Acute Kidney Injury (Acute Renal Failure) Overview
S/Sx
- abrupt onset of oliguria
- edema
- weight gain (fluid retention)
- lethargy
- nausea
- loss of appetite
characterized by rapid ↓ in renal function and ↑ serum creatinine
During early stages, serum creatinine and eGFR may not accurately reflect true renal function
Most causes of AKI; acute decline of GFR are usually reversible when offending substance is stopped
Most common causes:
- drug-induced AKI (e.g., aminoglycosides, contrast agents, NSAIDs, ACEi, and protease inhibitors)
** Serum potassium should be monitored upon initiation of ACEi or ARB if pt has kidney disease; potassium levels may initially rise and then tape off in 2-3 months; continued monitoring of serum potassium is recommended
Bladder Cancer Overview
S/Sx
- elderly male (median age at dx: 73 years) who smokes w/ painless hematuria (can be microscopy or gross [pink- to reddish-color urine])
- some pts only notice problem after see blood-tinged stain on underwear (males, menopausal females)
- hematuria may only appear at end of voiding
may have irritative voiding sx, NOT related to UTI:
* dysuria
* frequent urination
* nocturia
Dx:
- Order UA, urine C&S, and urine cytology
Those w/ advanced disease may c/o lower abdominal or pelvic pain, perineal pain, low-back pain, or bone pain
Normal Findings: Kidneys
1. Location
2. Function
- Located on retroperitoneal area
- R kidney is lower than L kidney d/t liver displacement
- Basic functional units of kidney: nephrons which contain glomeruli - regulates body’s electrolytes and fluids (affects BP)
- water is reabsorbed back into body by action of antidiuretic hormone and aldosterone
- kidneys excrete water-soluble waste products of metabolism (e.g., creatinine, urea, uric acid) into urine
- secrete several hormones (e.g., erythropoietin-RBC production, renin, and bradykinin-BP, prostaglandins-renal perfusion, and calcitriol/vitamin D3-bone)
- average daily urine output is 1,500 mL
- regulates body’s electrolytes and fluids (affects BP)
Oliguria
urinary output of <400 mL/day (adults)
Lab testing: Serum Creatinine, M vs F
end product of creatinine metabolism, which comes mostly from muscle
- may be falsely ↓ in people w/ low muscle volume (older adults)
** Elevated values seen in pts w/ kidney damage/failure ,use of nephrotoxic drugs, etc
M: 0.7-1.3 mg/dL
F: 0.6-1.1 mg/dL
Factors affecting serum creatinine:
- gender (M > F)
- race (African Americans have more muscle mass)
- muscle mass
When renal function ↓, creatinine level will ↑
** Serum creatinine is a better measure of renal function than BUN or BUN:Cr ratio; but eGFR** is considered the best measure of renal function in primary care
Lab Testing: Estimated Glomerular Filtration Rate
Normal: eGFR >90 mL/min
CKD: eGFR <60 mL/min for at least 3+ months
*Best test to measure kidney function; used to determine chronic kidney ds stages
Calculated by using serum creatinine, age, and gender (with adjustment for those of African American descent)
Estimation Equations, used to calculate eGFR:
- Modification of Diet in Renal Disease (MDRD)
- Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI)
- Cockcroft-Fault equation
GFR: amount of fluid filtered by the glomerulus within a certain unit of time; the more damaged the kidneys, the ↓ the eGFR; affected by age (↓ w/ age), sex (M have more muscle mass), and body size
- African Americans’ eGFR values are higher than other races
- Some pts w/ underlying kidney ds may have a normal eGFR
- eGFR is LESS reliable in these cases: pregnancy, muscle wasting, elderly, and LE amputees
Chronic Kidney Disease Stages
1. Stage 1
2. Stage 2
3. Stage 3a
4. Stage 3b
5. Stage 4
6. Stage 5
- > 90 mL/min → Kidney damage w/ normal kidney fx
- 89-60 mL/min → Mild loss of kidney fx
- 59-45 mL/min → Mild-to-mod loss of kidney fx
- 44-30 mL/min → Mod-to-severe loss of kidney fx
- 29-15 mL/min → Severe loss of kidney fx
- <15 mL/min → Kidney failure
Blood Urea Nitrogen (BUN)
- Definition
- What does an elevated BUN mean?
- Causes of elevated BUN? Low BUN?
- Mortality?
- Which lab should you check if abnormal BUN level?
- Liver breaks down amino acids into ammonia → converts it into urea
- BUN = measure of kidneys’ ability to excrete urea (waste product of protein metabolism)
If kidneys are damaged or renal blood flow is ↓, urea level ↑
- NOT as sensitive as serum creatinine or eGFr
High BUN may be caused by:
- acute kidney failure (lowers GFR)
- high-protein diet
- hemolysis
- CHF
- drugs
- Among HF, lower GFR w/ higher BUN = higher mortality; in ICU, ↑ BUN is independently associated w/ higher mortality
Low BUN causes:
- liver damage/disease
- If abnormal BUN level, check eGFR. If eGFR is normal, renal fx is normal
BUN-to-Creatinine Ratio
- ↓ in blood flow of kidneys will ↑ BUN:Cr ration
- used to help evaluate dehydration, hypovolemia, and AKF
- useful for classifying type of failure (renal, infrarenal, or postrenal)
Urinalysis (with Microscopic Exam)
- 3 components of a complete UA
A complete UA consists of 3 components:
- gross evaluation
- dipstick analysis
- microscopic exam of urine sediment
UA: Epithelial Cells
- Large amount of squamous epithelial cells = contamination
- A few epithelial cells = normal
Squamous epithelial cells are associated w/ external urethra and transitional epithelial cells w/ the bladder
UA: Leukocytes
Normal WBC in urine: ≤2-5 WBCs/hpf (high-power field)
- Called leukocyte esterase test w/ urine dipstick strips
- Presence of leukocyte sin urine (pyuria) is ALWAYS abnormal in males →infection
- UA is more sensitive test for infection in males than females
UA: Urine for C&S
≥ 10^5 colony-forming units (CFU)/mL is one dominant bacteria (usually E. coli)
* E. coli = Gram- Enterobacteriaceae
- If multiple bacteria are present = contaminated
- Lower vales = bacteriuria
UA: Reb Blood Cells
- Microscopic vs gross hematuria
- Few RBCs (<3 cells) = normal
- Microscopic hematuria refers to RBCs that are visible only by microscopy
- Gross hematuria = see blood in urine
- Color ranges from pink, red, to cola, or brown
- source of bleeding may come from urethra (urethritis), bladder (cystitis, bladder cancer), or kidneys (kidney stones, pyelonephritis, polycystic kidneys, cancer)
- can be contaminated by menses, vaginal discharge, semen, hemorrhoids, rectal bleeding
UA: Protein
- Indicates kidney damage if persistent (CKD)
Next step: order serum creatinine and eGFR and send midstream urine for microscopic exam
- If normal microscopic exam for urine sediment and normal kidney fx → isolated proteinuria
-Transient proteinuria is common, esp in age ≤18 years (8-12%) and among young adults (4%)
Benign causes:
- fever
- intense physical activity
- acute illness
- dehydration
- emotional stress
- May be present in acute pyelonephritis (resolves after tx) → recheck urine after tx
- Urine dipsticks detect only albumin
- False-positive results w/ urinary dipstick testing may be seen w/ alkaline urine (pH >7.5), if dipstick is immersed too long, highly concentrated urine, gross hematuria, presence of semen, or vaginal secretions
- To quantify proteinuria, order 24-hour urine for protein-to-creatinine ratio (UPr/Cr)
UA: Nitrates
- Positive → highly indicative of UTI
- Due to breakdown of urea into nitrate by bacteria
UA: Casts
- Casts are shaped like cylinders d/t forming in the renal tubules
Hyaline casts: nonspecific; can be seen in small volumes in concentrated urine or w/ diuretic therapy
WBC casts: seen w/ infections (pyelonephritis) or inflammation (interstitial nephritis)
RBC casts: Caused by microscopic bleeding in glomeruli; suspect glomerulonephritis (accompanied by edema, weight gain, dark cola-colored urine, or HTN)
UA: pH
4.6-8.0 (reference range)
- useful in evaluation of kidney stones and infections
- citrus and low-carbohydrate diet are associated w/ lower acidity and high-protein is associated w/ higher acidity
Hematuria
1. Definition/Etiology
2. Clinical Presentation
3. Lab/Diagnostics
4. Treatment Plan
- 2 types: microscopic vs gross
- either transient or persistent
- blood can come from urethra (urethritis), bladder (cystitis), bladder cancer), prostate (prostatitis), or kidneys (pyelonephritis, polycystic kidneys, cancer)
- microscopic → only revealed by microscopic UA (presence of ≥3 RBCs/hpf)
- Gross (or visible) hematuria if color is pink, red, or brown or blood clot present → next step, look for source of blood
- If infection suspected → urine for C&S
- New onset of dark reddish-brown urine, edema, proteinuria, fatigue, and ↓ urine output after a recent strep through, scarlet fever, or impetigo → possible poststreptococcal glomerulonephritis (an immune reaction from infection); can occur 10 days after infection and up to 3 weeks after; rare complication; more common in children
- If malignancy suspected → urine for cytology and refer to specialist
- RF: >50 years, male, smoker, and gross hematuria
- Red urine NOT d/t bleeding can be caused by some meds (e.g., rifampin, phenytoin), and ingestion of certain foods (e.g., beets, rhubarb, senna, food dyes)
- Causes & treatment:
- Female w/ hx of vigorous sexual activity/exercise → stop exercise and repeat 4-6 weeks
- Menses → repeat UA ~1wk after last day of menses; repeat UA w/ microscopic exam
- If infection (e.g., urethritis, cystitis, pyelonephritis) is suspected, UA will show WBC (w/ or w/out nitrates) + associated s/sx (dysuria, frequency, urgency, nocturia) → order UA w/ urine for C&S
- Persistent unexplained microscopic hematuria that does not resolve → refer to nephrologist
Proteinuria
1. Definition/Etiology
2. Types of proteinuria
3. Urine dipstick
4. Benign causes
5. Serious causes
- excretion of >150 mg/day of protein
- If persistent, find the cause!
GOLD STANDARD: 24-hour urine for protein
- glomerular
- tubular
- overflow
- postrenal
- glomerular
- Urine dipstick cannot detect low levels of albumin
- pts w/ moderately ↑ albuminuria (previously known as microalbuminuria) may not be detected unless urine is concentrated - fever
- intense physical activity
- acute illness
- dehydration
- emotional dress
- drugs
- fever
- sign of damaged kidneys
- diabetic nephropathy
- hypertensive nephropathy
- polycystic kidney disease
- sarcoidosis
- lupus
- rhabdomyolysis
- preeclampsia
- eclampsia
- sign of damaged kidneys
Nephrotic Drugs
- ACE inhibitors or ARBs
- Acyclovir
- Allopurinol (Zyloprim)
- Aminoglycosides (vancomycin)
- Antiretrovirals (adefovir, cidofovir, tenofovir, indinavir)
- Beta-lactams (penicillins, cephalosporins)
- Chemotherapeutics
- Contrast dyes
- Diuretics (thiazides, loop, triamterene)
- Drugs of abuse (cocaine, heroin, ketamine, amphetamines)
- Lithium
- NSAIDs and analgesics (acetaminophen)
- Proton-pump inhibitors (lansoprazole, omeprazole, pantoprazole)
- Quinolones (ciprofloxacin)
- Sulfanomides
** Pts w/ preexisting kidney disease and/or diabetes are at higher risk of kidney damage from contrast media; CT, MRI, and angiogram contrast media may damage kidneys (2%) or cause nephrogenic systemic fibrosis
Asymptomatic Bacteriuria
1. Definition/Etiology
2. Screening for/Treating Asymptomatic Bacteriuria
- presence of one or more species of bacteria growing in urine (≥10^5 CFU/mL) in absence of UTI symptoms, irrespective of presence of pyuria
- Healthy premenopausal (nonpregnant) and health postmenopausal women
- Older community-dwelling persons who are functionally impaired
- older persons who are residents of long-term care facilities (nursing homes)
- Diabetics
- Spinal cord injury
- long-term indwelling catheters
- infants and children
- Healthy premenopausal (nonpregnant) and health postmenopausal women
Bacteruric pt w/ fever → symptomatic bacteriuria w/ systemic signs of potentially severe infection (sepsis); treat w/ broad-spectrum antimicrobial therapy → Refer to hospital
Pregnant women: screening and treating for ASB is recommended (2-7% have ASB)
- higher risk (30%) for pyelonephritis
- Tx w/ antibiotics for 4-7 days
- Nitrofurantoin and beta-lactams (ampicillin, cephalexin) preferred
* Avoid nitrofurantoin near term d/t risk of fetal hyperbilirubinemia
Urinary Tract Infections
1. Definition
2. Etiology in different populations
3. Risk factors
- Cystitis (urinary bladder inflammation) can be uncomplicated, recurrent, a reinfection, or relapse
- majority of infections are caused by E. coli (75-95%), klebsiella
- other casual agents: Staph saprophyticus, enterococci, and Pseudomonas aeruginosa
- UTIs in children <3 years and pregnant women (20-40%) are more likely to progress to pyelonephritis - Infancy: UTIs common in boys in the first 6 months of life (d/t anatomic abnormality)
- Children: UTIs in children need further evaluation. ~2.5% of all children will get a UTI; may indicated vesicoureteral reflux or even possible sexual abuse
- Females: Highest incidence is during reproductive-age years
- Older females: sx can be subtle, but onset of new incontinence can be sign of UTI
- Infancy: UTIs common in boys in the first 6 months of life (d/t anatomic abnormality)
UTI
4. Clinical Presentation
5. Labs/Diagnostics
- new onset of dysuria
- frequency
- urgency
- nocturia
- may c/o suprapubic discomfort
- NOT associated w/ fever
- new onset of dysuria
- urine dipstick → mod-large leukocytes, POSITIVE for nitrates
- UA dipstick (midstream): leukocyte positive (WBCs ≥10/mcL)
- Nitrates: negative or positive (indicative of enterobacteriaceae)
- Sometimes hematuria (>5 RBCs)
- Urine C&S (clean voided sample):
* UTI infection → 100,000 CFU/mL (or 10^5 CFU/mL) of a single organism or 100,000 CFU/mL of one organism and growth of a second organism ≥50,000 CFU/mL
* Multiple bacteria →contaminated sample (growth of >2 organisms)
* Bacteriuria (w/ or w/out indwelling catheter): >100,000 CFU/mL
- urine dipstick → mod-large leukocytes, POSITIVE for nitrates
- Study showed that some women w/ classic sx of acute UTi may have lower counts of bacteria (<10,000 CFU/mL); of these women, 88% had a UTI
UTI: Uncomplicated UTIs
Acute Simple Cystitis in Health Adult Females
- For most health females w/ suspected acute simple cystitis (dysuria, frequency, nocturia) → no additional testing needed beyond UA
- BUT if fever >99.9ºF, chills, significant fatigue or malaise, flank pain, or CVA tenderness → R/O pyelonephritis
- Nitrofurantoin (Macrobid) 100 mg BID x 5 days
- Trimethoprim-sulfamethoxazole (Bactrim, Septra) BID x 3 days
- Fosfomycin 3 g x 1 dose
Bacteria resistance >20% or sulfa-allergic:
- Nitrofurantoin BID x 5 days OR
- Fosfomycin 3 g x 1 dose OR
- Augmentin 875/125 mg BID x 5-7 days
Alternatives:
- Ciprofloxacin (Cipro) BID OR levofloxacin (Levaquin) daily (≥18 years) x 3 days
Phenazopyridine (Pyridium) PO BID x 2 days PRN (as Uristat, AZO)
- Pyridium will turn urine an orange/yellow color
- will stain contact lenses
- avoid if lever/renal disease, glucose-6-phosphate dehydrogenase (G6PD) anemia
- ↑ fluid intake to 2-3 L/daily (except if HR)
- Restrict dietary oxalate → high oxalate foods are beans, spinach, beets, potato chips, french fries, nuts, tea
** If clinical sx persists 48-72 hrs after initiating antibiotics → order urine C&S and UA. RULE OUT pyelonephritis.
- Switch to another antibiotic drug class and treat for 7-10 days
UTI:
1. Complicated UTIs population
2. Treatment regimens
3. Labs/Diagnostics
- males
- poorly controlled diabetes
- pregnant women
- children
- older adult
- immunocompromised (chronic high-dose steroids, biologics, HIV infection)
- recurrent UTIs or reinfections
- anatomic abnormalities (including kidney stones, reflux, obstruction)
- males
- Ciprofloxacin (Cipro) 500 mg BID or 1,000 mg extended release once daily OR
- levofloxacin 750 mg daily x 5-7 days
- If high risk of multidrug-resistant organisms → Nitrofurantoin (Macrobid) 100 mg PO BID
- Ciprofloxacin (Cipro) 500 mg BID or 1,000 mg extended release once daily OR
- UA and urine C&S before and after treatment (to document resolution)
- UTIs: see Special categories
- UA and urine C&S before and after treatment (to document resolution)
UTIs: Special Categories - Males
1. Definition
2. Clinical Presentation
3. Labs/Diagnostics
4. Treatment
- What if recurrent infection?
- UTIs in newborn males, infants, and older men → complicated
- underlying structural issues (urethral stricture, BPH, calculi, uncircumcised) should be considered - dysuria
- frequency
- hesitancy
- slow urinary stream
- nocturia
- urgency
- some have suprapubic pain
- if sexually active, R/O gonorrhea and chlamydia infection w/ NAAT
- dysuria
- UA and urine culture pretreatment
- then ~1 weeks after completing antibiotic treatment
- UA and urine culture pretreatment
- Treat w/ antibiotics for 7 days
If recurrent infection → RULE OUT ureteral stricture, infected kidney stones, anatomic abnormality, acute prostatitis, sexually transmitted diseases, etc.
** Must be evaluated further → Refer to urologist
UTIs: Recurrent UTIs (Women) Treatment
1. Definition
2. Postcoital UTIs
3. Sulfa allergy
4. Postmenopausal women
5. Strategies w/ no demonstrate efficacy to prevent UTI in women
6. Rule out what abnormalities?
- ≥3 U TIs (culture positive) in 1 year or 2 UTIs within 6 months
- Nitrofurantoin (Macrobid) 100 mg
- Bactrim DS one tablet
- trimethoprim 100 mg
- cephalexin (Keflex) 250 mg
- ↑ fluid intake (2-3 L/daily) esp before and after sex
- avoid spermicide (nonoxynol 9), cranberry prophylaxis
- Nitrofurantoin (Macrobid) 100 mg
- Cephalexin (Keflex)
- ciprofloxacin (if >18 years)
- Cephalexin (Keflex)
- Intravaginal estrogen (Estriol cream)
- ↑ fluid (1.5 L/daily)
- postcoital antibiotics (as above)
- Intravaginal estrogen (Estriol cream)
- cranberry products
- oral probiotics
- cranberry products
- infected stones
- reflux
- fistulas
- ureteral stenosis
- infected stones
What can occur w/ long-term use of nitrofurantoin? Nitrofurantoin is contraindicated in what? What baseline information should you obtain and monitored closely?
Long-term use of nitrofurantoin associated w/ lung problems, chronic hepatitis, and neuropathy
- contraindicated w/ renal insufficiency
Baseline:
- chest x-ray
- LFTs
- neurologic exam
Acute Kidney Injury
1. Definition/Etiology
2. Guidelines for staging considerations
- Previously called Acute Renal Failure
- abrupt decline in GFR d/t many causes
- most cases → d/t prerenal and ATN (up to 75%)
- typically lasts 7-21 days
- some pts recover in a few days, some require dialysis for several months
- important to triage pts to determine who needs to be referred to ED - AKI guidelines per KDIGO:
- ↑ serum creatinine by ≥0.3 mg/dL within 48 hrs
- ↑ serum creatinine ≥1.5 mg/dL from baseline (known or presumed in prior 7 days)
- urine volume <0.5 mL/kg/hr for 6 hours
AKI: Prerenal
- usually due to hypoperfusion of kidneys
Condition/causes
- Hypovolemia → blood loss, vomiting, diarrhea, diuretics
- ↓ CO → HF, MI, PE, pulm edema, tamponade
- 3rd space sequestration → sepsis, anaphylaxis, pancreatitis, hypoalbuminemic states
- Medications limiting GFR → ACEI, ARB, NSAID
AKI: Postrenal
- usually d/t obstruction of flow or urine in renal tubular system to urethra
- to produce AKI, the urethral obstruction must be bilateral or occur in pt w/ only one functioning kidney
- Renal parenchyma is NOT affected
Condition/Causes
- Bladder obstruction → BPH, prostate CA, bladder CA, blood clot
- Urethral/renal obstruction → stones, strictures, blood clots, CA
- Neurogenic bladder → spinal cord injury, diabetes, drugs
AKI: Intrinsic
- caused by damage to tissues of kidney or renal tubule
- ATN causes 90% of cases; generally is reversible injury
Condition/Causes
- ATN → Ischemia, prolonged hypoperfusion, sepsis, hemorrhage
- Nephrotoxins → Aminoglycosides, contrast media, heavy metals, IV immunoglobulins
- Acute interstitial nephritis r/t drugs → NSAIDs, diuretics, penicillins, cephalosporins, sulfa drugs, allopurinol, anticoagulants
- Glomerular disease → Poststreptococcal infection (more common in children, IgA nephropathy, etc
- Thrombosis → Renal artery, renal vein
Acute Pyelonephritis
1. Definition/Etiology/Common Pathogens
2. Outpt vs inpatient
3. Clinical Presentation
- Acute bacterial infection of kidneys
- most common d/t gram- Enterobacteriaceae (E. coli), proteus, klesiella - Outpt treatment only for compliant healthy pts w/ milder infections that are uncomplicated (immunocompetent adult female w/ urinary/renal systems w/out comorbidities)
* Complicated pyelonephritis present if underlying renal disease, male gender, kidney stone, anatomic urinary tract abnormality, or immunosuppression → refer for hospitalization
- Outpt treatment only for compliant healthy pts w/ milder infections that are uncomplicated (immunocompetent adult female w/ urinary/renal systems w/out comorbidities)
- acute onset of high fever
- chills
- anorexia
- nausea/vomiting
- one-sided flank pain
- some pts may also have s/sx of cystitis (dysuria, frequency, and urgency)
- acute onset of high fever
Acute Pyelonephritis
4. Physical Exam
5. Labs/Diagnostics
6. Treatment
7. Special Population/Referral
8. Complications
- Temp ≥ 38ºC (100.4ºF)
- Costovertebral angle tenderness on one kidney
- Temp ≥ 38ºC (100.4ºF)
- UA: large number of leukocytes, hematuria, +/- nitrates, and mild proteinuria
- Urinary casts (tubular-shaped structures): WBC casts (seen in microscopic exam of urine sediment)
- Urine C&S: Presence of 10^5 CFU/mL of one uropathogen
- CBC: Leukocytes (WBC >11,00/mcL), neutrophilia (>80%) w/ left shift
- Left shift: presence of bands/stabs (immature neutrophils) → serious infection!
- Chemistry profile (serum creatinine, others)
* WBC cats w/ proteinuria and hematuria are associated w/ pyelonephritis
- UA: large number of leukocytes, hematuria, +/- nitrates, and mild proteinuria
- May treat mild uncomplicated cases as outpt w/ close follow-up
- For mod-severe (or complicated cases) → hospitalization required
- May treat mild uncomplicated cases as outpt w/ close follow-up
- Treat w/ ciprofloxacin (Cipro) 500 mg PO BID x 7 days OR
- levofloxacin (Levaquin) 750 mg PO daily x 5-7 days
- Pyelonephritis may be treated w/ shortened 7-day course of antibiotics when using fluoroquinolones
- Close follow-up needed for 12-24 hrs
- Majority of pts (95%) w/ pyelonephritis will respond to antibiotic tx in 48 hrs
- Complicated or severe cases are treated w/ IV antibiotics for 14 days (gram- bacteremia) in hospital
- Coexisting condition that compromises immune system or is toxic → refer to hospital
- REFER to physician/hospital for treatment:
- Pregnant women
- children/elderly
- male gender
- kidney stone
- anatomic abnormalities
- diabetics
- immunocompromised - Gram- septicemia
- septic shock
- kidney abscess
- renal failure
- death
- Gram- septicemia
Nephrolithiasis
1. Definition/Etiology/Types
2. Risk Factors
- Renal calculi
- more common in males
- location and size determine pain, which can range from mild ache to severe pain (ex: stones located in upper urethra or renal pelvis causes flank pain and tenderness, whereas stones in lower urethra cause pain that radiates to testicle or labia of vagina); both can cause abdominal pain
Four types of stones
- calcium oxalate → majority, 60-70%
- Struvite (7%)
- uric acid (7%)
- cystine (1%)
- RF for Calcium Oxalate Stones
- Hx of prior nephrolithiasis
- positive family hx
- white race
- Bariatric surgery/gastric bypass (excrete higher levels of oxalate)
high dietary intake of calcium,v it C, oxalate foods, sodium, protein)
- low fluid intake
- obesity
- diabetes
- gout
- certain drugs that may crystallize in urine (indinavir, acyclovir, sulfadiazine, triamterene)
Nephrolithiasis
3. Clinical Presentation
4. Labs/Diagnostics
5. Treatment/Diet
- Male (aged 30-40) w/ acute onset of severe colicky flank pain (renal colic) on one side, comes in waves
- pain is most severe → pt cannot stay still and may walk/pace
- pain builds in intensity, then lessens and disappears (until stone moves again)
- painful episodes may last 20-60 mins
- for some, pain can be extreme and associated w/ nausea/vomiting
- majority have gross/microscopic hematuria
- majority (50%) will pass tone within 48 hrs
- Male (aged 30-40) w/ acute onset of severe colicky flank pain (renal colic) on one side, comes in waves
Ask about hx of previous episodes, high-protein diet, gout, gastric bypass, calcium intake, high-dose vit C, fluid intake,a nd intake of certain drugs
- CT abdomen/pelvis w/out contrast is preferred imaging method
→ if not available or if pt is pregnant → US of kidneys/bladder
- UA: hematuria in majority of pts (95% on day 1, 65-68% on days 3-4)
* non-contrast CT scan has the highest sensitivity/specificity for kidneys tomes (initial imaging is renal ultrasonography)
- CT abdomen/pelvis w/out contrast is preferred imaging method
- Management depends on stone osize; stones <5 mm → most will pass the stone
- Instruct pt to strain urine for several days and bring kidney stone to office (if passed) for stone analysis by lab; most pts can be managed in outpt w/ pain med and hydration until stone passes
- for larger stones → methods to break stone and remove include extracorporal shock wave lithotripsy (ESWL)
- NSAIDs (e.g., indomethacin, ketorolac) and opioids (alone or combined w/ NSAIDs) for pain management in acute renal colic; NSAIDs can ↓ ureteral smooth muscle tone (may help relieve ureteral spasms)
* NSAIDs can induce AKI in pts w/ preexisting kidney disease or dehydration
- Alpha-blocker or CCB can facilitate stone passage (relaxes smooth muscles of ureters)
- Management depends on stone osize; stones <5 mm → most will pass the stone
REFER TO ED:
- high fever (possible urosepsis)
- extreme pain
- acute renal failure
- large stone
- inability to pass stone
- unable to tolerate oral meds and fluids
- severe N/V
Diet:
- ↑ fluid intake up to 2.3 L/daily
- if calcium oxalate stones, dietary modifications should ve advised
- Avoid high0oxalate floods such as rhubarb, spinach, okra, nuts, beets, chocolate, tea, and meats
