Nephro Flashcards
IGA nephropathy vs post infectious GN
→ IgA nephropathy is hematuria during infection (vs. post infectious is weeks later)
→ IgA normal C3, PIGN low C3
nephrotic syndrome
hypoalbuminemia, increased edema, and presence of ascites due to the low oncotic pressure
Hyperlipidemia thought to be a result of the liver increasing production of lipoproteins to compensate for the low serum albumin, increased production of clotting factors, and increased risk of thrombosis
Low vs normal C3
Low C3
Post infectious GN
Membranoproliferative GN
C3 Glomerulopathy
Lupus
VP shunt nephritis
Subacute bacterial endocarditis
Normal C3
IgA nephropathy
anti-GBM disease
Anca vasculitis (typically normal but can be low)
Hereditary nephritis
IgA vasculitis (HSP)
GPA
Goodpastures
Alports
lax abdominal muscles, bilateral cryptorchidism, poor urine stream and bilateral abdominal masses
prune belly syndrome
SIADH
hyponatremic
euvolemic
low serum osmolality <280
high urine sodium, high urine osmolality
decreased urine output
Triggers: CNS, Resp, post-op
Dysnatremia correction rate
0.5mmol/hr
10mmol/24hr
Risks:
- hyponatremia central pontine myelinolysis
- hypernatremia cerebral edema
Distal RTA (Type 1)
metabolic acidosis
acid secretion problem at distal tubule (pee will be higher pH because we can’t secrete H+)
K low (hold onto H, pee out K)
Stones (ONE)
Hypercalciuria
Nephrocalcinosis
Etiology
- hereditary
- drugs
- nephrocalcinosis
- cirrhosis
Treatment
- bicarb, K citrate
Proximal RTA (Type 2)
Metabolic acidosis
Cant resorb bicarb in the proximal tubule
Urine phosphate high
Urine calcium normal
Proteinuria + glucosuria if Fanconi
Plasma Na low
Etiology
- hereditary
- fanconi
- cystinosis
Treatment
- bicarb
Type 4 RTA
Mild metabolic acidosis
Urine pH low
Plasma Na low (can’t reabsorb Na)
Plasma K high (inability to secrete K)
Plasma Cl high (due to inability to secrete K)
Etiology
- aldosterone resistance
- hypertension
Treatment
- Acei
Nephrotic range proteinuria
> 3.5 g / day
Nephrotic syndrome
Proteinuria
Hypoalbuminemia
Hypercholesterolemia
Edema
*usually no hematuria or AKI or HTN
Most common causes of nephrotic syndrome
Minimal change disease (80% for kids < 7 yrs) (should have normal C3)
Focal segmental glomerulosclerosis
Membranoproliferative GN (low C3)
Treatment for nephrotic
pred 2mg/kg/day
12 week course followed by taper
if no response consider biopsy
Supportive care
- salt restriction
- loop diuretics (esp if hyponatremic)
- careful albumin + lasix
- pneumococcal vaccines
nephrotic sx complications
infection
- lose immunoglobulins and complement in urine
- bacteremia or SBP
- esp encapsulated bugs (strep pneumo, e coli, klebsiella)
- give vaccine for pneumococcus
Thromboemolism
- lose anticoagulant proteins (antithrombin 3 and protein S)
- think of clot for headaches, leg swelling, chest pain, SOB
Child with arthralgia, abdo so pain, purpuric rash, BP was normal. Has protein 1g/L in the urine and 3-5 blood. What do you do next?
HSP
HSP (IgA vasculitis)
age 2-6
purpuric rash (must have), abdo pain, arthritis
Renal in 35% due to IgA deposition in glomeruli
–> GN or nephrotic syndrome
–> all will do it by 6 mo (so monitor urine for 6 mo)
Urinalysis
- microscopic hematuria
- usually no proteinuria
- check UA weekly while active disease, then monthly x 6mo
Refer to nephro if
- significant proteinuria
- hypertension
- Cr/Urea abnormal
normal complement
Prune belly syndrome
- bilateral cryptorchidism
- hydronephrosis
- lax abdo muscles
- can die early due to pulmonary hypoplasia d/t oligohydramnios
- often ESRD
Nephrotic syndrome + fever
paracentesis of ascites
ceftriaxone
strep pneumo is most common, then e coli (encapsulated)
Hypertension
needs 3 separate high measurements in stage 1 range to diagnose
Hypertension cut off
130/80s for age 13+
Blood pressure measurement
width 40% of circumfurence
length 80-100% of circumference
BP monitoring
annual over age 3
start sooner if risk factors (prem, umbilical caths, CHD, malignancy, drugs that raise BP)
Coarct patients should be checked at every visit
most ommon cause of secondary hypertension
renal parenchymal or renalvascular
Investigations for hypertension
urinalysis
Cr, Urea
lipids, HBA1C
renal doppler US
echo for everyone (canada) or before starting meds (AAP)
retinal exam (canada)
Ambulatory BP monitoring
If elevated for 1 year or stage 1 x 3 visits
Consider if high risk conditions (coarct repair, CKD obese, diabetes) in order to rule out masked hypertension (might occur only overnight) or if suspected white coat hypertension
Management hypertension
- first line is non-pharm for all patients for 6 mo if stage 1
Meds if:
- symptomatic
- diabetes
- CKD
- stage 2 or higher
Meds
- thiazide first
- ACE or CCB 2nd
- dont do beta blockers
**use ACEi in diabetic pt with proteinuria)
Antihypertensive med side effects
ACEi s/e: cough, headache, dizziness, asthenia, hyperkalemia, acute kidney injury, angioedema, fetal toxicity
ARB s/e: headaches, dizziness, hyperkalemia, acute kidney injury, fetal toxicity
Thiazide diuretic s/e: dizziness, hypokalemia, cardiac dysrhythmias, cholestatic jaundice, new onset diabetes mellitus, pancreatitis
CCB s/e: flushing, peripheral edema, dizziness, angioedema
acute hypertension management for urgency
IV therapy
Tx goals to reduce MAP by 25% over the first 8-12hrs, then by another 25% over the next 8-12hrs and the final 50% in the 24hrs following
Labetalol (a and B blocker)
Nicardipine (CCB)
Na nitroprusside (vasodilator)
Hydralazine
Esmolol (best in cardiac cases)
Hypertension cutoffs
age 1-13
Elevated: 90th - 95%
Stage 1: 95th - 95th+12
Stage 2: > 95th+12
Age 13+
Elevated: >120/80
Stage 1: >130/80
Stage 2: >140/90
Post Strep GN
LOW C3, normal C4
ANA negative
ASO titer may be elevated (usually weeks into illness)
Symptoms
- hematuria and edema 5 days post cellulitis or 7-10 days post pharyngitis
- hypertension
Management
- supportive
- fluid management
- treat hypertension
-
IgA Nephropathy
synpharngitic episodes of hematuria
recurrent
Normal C3, Normal C4
Dx biopsy (but usually not needed)
AKI etiology
pre renal
Renal
Post renal
ATN
urinalysis = granular casts
ATN vs AIN
Tubular (ATN): hypoxemia, crystal obstruction, medications, toxins, tumor lysis syndrome
(brown urine with granular casts) * majority of renal AKI
Acute interstitial nephritis: allergic interstitial nephritis, pyelonephritis, sarcoidosis
(white cell casts)
Neonate with midline mass + kidney injury
Posterior urethral valves.
Diagnosis =VCUG.
At risk pulmonary hypoplasia (oligohydramnios) and CKD
Keyhole sign on US
most common long term complication Htn
left ventricular hypertrophy
do an echo
Prophylaxis for UTI
Grade 4 or 5 VUR
reassess q3-6 mo
Use septra or nitrofurantoin
If the child is resistant to septra and macrobid, DONT use abx for prophyalxis
Hypertensive urgency cut offs
Stage 2 HTN + symptoms
Stage 2:
- Age 1-12: >/= 95%ile + 12
- Age 13+: >/= 140/90
fanconi syndrome
proximal tubule dysfxn
lose electrolytes in urine
hypokalemia, hypophosphatemia, glucosuria, acidosis
cystinosis is most common cause
anterior lenticonus
pathognemonic eye finding in Alport syndrome
conical protrusion of the lens
