Hematuria

Question 1

Glomerular vs extraglomerular hematuria

Answer 1

Glomerular: nephritic, IgA nephropathy

Extra-glomerular: renal carcinoma, BPH, UTI, prostate cancer, kidney stones, exercise

Question 2

Risk factors for malignancy in pts w/ gross hematuria

Answer 2

Smoking

Renal:
Cystic Disease
Obesity
Toxins: asbestos, cadmium, leather tanning & petroleum products

Bladder:
Schistosomiasis
Hx radiation treatment to pelvis
Cyclophosphamides 
Exposure to hydrocarbons, tryptophan metabolites, industrial chemicals, aromatic amines, chemicals in rubber

Question 3

Work up for hematuria

Answer 3

** Always work up gross***

Hx
Physical: abdo and kidney

Investigations:
Urinalysis, Urine C & S
Urine microscopy to confirm presence of intact RBCs and RBC casts 
Urine Cytology
Bladder scan
US Abdo & Pelvis
Cystoscopy

Question 4

Pathophysiology of stone

Answer 4

Solutes in urine precipitate and crystallize

Increased solute or decreased solvent

Question 5

Most common stone

Answer 5

Calcium stones (calcium oxalate)

Question 6

Causes of UTI

Answer 6

Stasis and obstruction: (reflux, medication, BPH, urethral stricture, neurogenic bladder, stone)

Foreign body: catheter/other instrumentation

Decreased resistance to organisms: DM, malignancy, low estrogen, immunosuppression, etc.

Other factors: trauma, anatomic abnormalities, female, sexual activity, menopause, fecal incontinence

Question 7

Most likely bacteria UTI?

Answer 7

Ascending (95%): bacteria colonizes mucosa

Most common: E.coli, Staphylococcus, Klebsiella, Proteus Enterobacter

Question 8

Pathophysiology of nephritic syndrome

Answer 8

Deposits in sub-endothelial or mesangial cells
ALWAYS inflammatory
++ hematuria

Question 9

Features of nephrotic

Answer 9

Proteinuria, Edema, hyperlipidemia, Frothy Urine, serum albumin low

Question 10

Features of nephritic

Answer 10

HTN, hematuria, red blood cell casts, azotemia

Abrupt onset

Question 11

Features of nephritic

Answer 11

HTN, hematuria, red blood cell casts, oliguria

Abrupt onset

Question 12

Investigations for renal colic

Answer 12

Ultrasound

CT (non-contrast)- more common

Question 13

Common Nosocomial

Answer 13

Pseudomonas, Enterococci, Enterobacter, Candida albicans, Staphylococcus epidermidis, Corynebacterium species

Question 14

IgA nephropathy

Answer 14

Most common nephropathy; mixed nephritic and nephrotic

Immune complex deposition (IgA) in the mesangial cells

Question 15

Post-infectious glomerulonephritis

Answer 15

Nephritic
Inflammation of glomeruli
Complication of bacterial infection (Group A streptococcus infection, impetigo)
More common in children

Question 16

Lupus nephritis

Answer 16

Nephrotic and Nephritic
Caused by SLE
Immune cells attack –> antibodies (antinucular ) –>
deposit in kidney –> initiate inflammatory rxn

Question 17

Henoch-Schönlein purpura

Answer 17

Vasculitis of small vessels (IgA associated)

Exposure to allergen/ antigen (infection, drugs) → stimulation of IgA production →deposition of IgA immune complexes in vascular walls → activation of complement → vascular inflammation and damage

Question 18

Goodpasture syndrome

Anti-GBM–associated acute glomerulonephritis

Answer 18

Autoimmune disease affecting the lungs and kidneys; Nephritic syndrome

Damaging basement membrane–> causing hemoptysis and hematuria

Question 19

Wegener’s granulomatosis with polyarteritis

Answer 19

Vasculitis of medium sized cells

Necrotizing granulomatous inflammation, small and medium sized vessel vasculitis

Upper and lower respiratory tract, kidneys are affected

Question 20

Indications of Dialysis

Answer 20

AEIOU
Acidosis
Electrolyte abnormalities
Intoxication
Overload of fluid 
Uremia

Question 21

Autosomal Dominant Polycystic Kidney Disease

Answer 21

Hereditary disorder of renal cyst formation causing gradual enlargement of both kidneys

Multisystem disorder - associated with cysts in other organs, such as liver, pancreas, and arachnoid mem­branes

Question 22

In response to low flow to the kidney which arterioles constrict?

Answer 22

Efferent

Question 23

GFR determinants

Answer 23

Hydrostatic pressure - driving force for out of vessels - increases GFR
Oncotic pressure - pulling force into vessels - drops GFR
Basement membrane function

Renal artery blood pressure - not a linear correlation due to the autonomic correction

• myogenic reflex - reflex constriction (like any other arteriole)
• Ang2 reflex - renin - RAAS - EFF - increases GFR
• tubuloglomerular feedback (macula densa feedback either adenosine or NO on the AFF arteriole)

Question 24

Glomerulotublar balance

Answer 24

In response to tubuloglomerular feedback (macula densa/JGA) there can be an increase in GFR, but if the tubules did not respond then there would be ++ loss of fluid as it transited too fast to the distal tubules

SO

The proximal tubules act intrinsically to proportionally increase resorption. Can also act as an extra layer of protection if there is a sudden change in GFR

In other words - Glomerulotubular balance is the action of the tubules in response to GFR (glomerulus) change
Tubuloglomerular feedback is the sensing from the tubules to change the GFR (glomerulus)

Question 25

Approach to an AKI

Answer 25

Take out nephrotoxins, US, urine study, volume and acid base study, get a serum Ca/phos/uric acid

(Basically make sure it isn’t pre- or post- renal before sending to a nephrologist)

Question 26

++Albuminuria?

Answer 26

Indicated glomerulus disease (not filtering well at the start)