Harrisons Flashcards
Type II RTA characteristics
defect in bicarb reabsorption
features of Fanconi syndrome, including glycosuria, aminoaciduria, phosphaturia, and uricosuria (all indicate proximal tubular dysfunction)
Type II RTA inheritiance
Isolated proximal RTA = hereditary dysfunction of the basolateral Na-HCO3 cotransporter
Fanconi syndrome = inherited or acquired due to myeloma, chronic IN, or drugs
Type II RTA treatment
treatment requires large doses of bicarb (may make hypokalemia worse)
Type IV RTA characteristics
May be due to hyporeninemic hypoaldosteronism or to resistance of the distal nephron to aldosterone
Associated with volume expansion and most commonly seen in elderly and/or diabetic patients with CKD.
hyperkalemic, ,may have mild NAGMA with urine pH < 5.5 and a positive urinary anion gap.
Type IV RTA associated disorders
forms of distal tubular injury and tubulointerstitial disease (interstitial nephritis)
Type IV RTA treatment
Reduce serum K, treat with oral bicarb or citrate
Risk factors for acute cystitis
Women > men recent use of a diaphragm with spermicide frequent sexual intercourse a history of UTI DM incontinence
Causes of cystitis
E. coli (75-90%)
S. sparophyticus (5-15%)
Klebsiella spp., Proteus spp., Enterococcus spp. Citrobacter spp. (5-10%)
In what patients can papillary necrosis occur?
Patients with obstruction, DM, sickle cell, and analgesic nephropathy
What is and who gets emphysematous pyelonephritis?
It is associated with the production of gas int renal and perinephric tissues and occurs almost exclusively in diabetic patients.
What is xanthogranulomatous pyelonephritis?
It occurs when chronic urinary obstruction (often by staghorn caliculi), together with chronic infection, leads to suppurative destruction of renal tissue.
What confirms diagnosis of uncomplicated cystitis?
urine dipstick positive for nitrite or leukocyte esterase
What three factors determine the initial rate of spread of any STI within a population?
- rate of exposure of susceptible to infectious people
- efficiency of transmission per exposure
- duration of infectivity of those infected
What are the four C’s of control of STI treatment?
- contact tracing
- ensuring compliance with treatment
- counseling risk reduction
- condom promotion and provision
What are common causes of STIs?
N. gonorrhoeae C. trachomatis Mycoplasma genitalium Ureaplasma urealyticum Trichomonas vaginalis HSV
N. gonorrhea Dx and Tx
N. gonorrhoeae can be presumptively identified if intracellular gram-negative diplococci are present in Gram-stained samples
Treat with single dose of ceftriaxone plus azithromycin
Chlamydia treatment
azithromycin or doxycycline (azithromycin may be more effective for M. genitalium)
Symptoms of septic shock (2+ for Dx)
fever ( >38 C/100.4 F) hypothermia ( <36 C/96.8 F) Tachypnea ( >24 breaths/min) Tachycardia ( >90 beats/min) (Leukocytosis, leukopenia, or > 10% bands may have a noninfectious etiology)
What is the major mechanism for multi organ dysfunction in septic shock?
widespread vascular endothelial injury
Clinical Features of Septic Shock
hypoventilation leading to respiratory alkalosis
encephalopathy
acrocyanosis and ischemic necrosis of peripheral tissues due to hypotension and DIC
Skin: hemorrhagic lesions, bull, cellulitis, pustules
GI: N/V, diarrhea, ileus, cholestatic jaundice
What do petechiae and purpura with septic shock suggest?
N. meningitidis infection
What does ecthyma gangrenosum with septic shock suggest?
P. aeruginosa infection
What are the cardiopulmonary complications of septic shock?
- ARDS caused by: ventilation-perfusion mismatch increased alveolar capillary permeability increased pulmonary water content decreased pulmonary compliance
- Hypotension: normal/increased cardiac output and decreased systemic vascular resistance
- Decreased ejection fraction (ventricular dilation allows for normal stroke volume)
Adrenal and renal major complications of septic shock?
Adrenal insufficiency
Renal: oliguria or polyuria, azotemia, proteinuria, renal failure due to acute tubular necrosis
Neurologic major complications of septic shock?
delirium in the acute phase, polyneuropathy with distal motor weakness in prolonged sepsis
May have long-term cognitive impairment
Lab Findings in Septic Shock
CBC: leukocytosis with left shift, thrombocytopenia
Coagulation: prolonged thrombin time, decreased fibrinogen, evidence of DIC
Chemistries: HAGMA, elevated lactate levels
LFTs: transaminitis, hyperbilirubinemia, azotemia, hypoalbuminemia
What disorders can be associated with nephrogenic diabetes insipidus?
Tubulointerstitial diseases, lithium therapy, resolving acute tubular necrosis, and urinary tract obstruction
Also can be caused rarely by mutations in the V2 ANP receptor, aquaporin-1 channel in descending thin limb of LOH, and the ANP-regulated water channel in principal cells, aquaporin 2
What pharmacological actions can be taken to reduce proteinuria?
ACE inhibitors or Angiotensin II blockers (ARBs)
Definition of acute renal failure (ARF) or acute kidney injury (AKI)
defined as a measurable increase in the serum creatinine (Cr) concentration
Causes of prerenal failure
volume depletion (diarrhea, vomiting, GI or other hemorrhage) or reduced renal perfusion in the setting of adequate or excess blood volume (CHF, hepatic cirrhosis, severe hypoproteinemia)
Most common cause of intrinsic renal failure?
Acute tubular necrosis (ATN)
ATN can be caused by an ischemic event, toxic exposure (aminoglycosides0, rhabdomyolysis
What are predisposing factors to rhabdomyolysis?
Alcoholism, hypokalemia, various drugs (statins)
What disorders are associated with TTP?
HIV, bone marrow transplantation, SLE, antiphospholipid syndrome
Lab findings of prerenal azotemia
BUN:Cr > 20:1, uric acid elevation, low urine [Na+], fractional excretion of sodium <1% (FEN)
urinary sediment of pts with ischemic or toxic ATN
muddy-brown granular casts and casts containing tubular epithelial cells
FEN is typically >1%
What are absolute indications for dialysis?
severe volume overload refractory to diuretic agents
severe hyperkalemia and/or acidosis
severe encephalopathy not otherwise explained
pericarditis or other serositis
