Nephro and Urology Flashcards
A newborn infant has Cr of 83. Which of these statements is true?
a) this value reflects the mothers creatinine.
b) this is a normal value for a newborn infant.
a) this value reflects the mothers creatinine.
What anomaly is most likely to be found when there is a single umbilical artery:
d. Renal anomaly
e. No anomaly
f. Cardiac anomaly
d. Renal anomaly
5 day old infant in nursery has low urine output. Creatinine is 120. Renal ultrasound shows absent left kidney. The right kidney is at the low end of normal for size, and has consistent/uniform echodensity throughout. Which of the following is most likely?
a) Prognosis depends on liver and lung status
b) Likely will progress to end stage renal disease in childhood
c) Likely will progress to end stage renal disease in mid adulthood
d) he will have normal renal function
b) Likely will progress to end stage renal disease in childhood (Yes! Kidney should compensate so a normal or small is not normal as it should be hypertrophied. + Cr high + Kidney not uniform consistancy normally so wondering about dysplasia or hypoplasia. Without a good sole kidney can progress to RF)
- lung usually not affected because the single kidney is able to compensate
- ideally, if have unilateral renal agenesis the other kidney compensates - creatinine should be normal and the other kidney should be hypertrophied
What is true of a patient with multicystic dysplastic kidney disease?
a. chance of VUR
b. likely that first degree relative will be affected
c. usually causes hematuria
d. early hypertension
ANSWER: a. chance of VUR
b. likely that first degree relative will be affected (not usually inherited vs. PCKD is)
c. usually causes hematuria (false; AR PCKD can)
d. early hypertension (rare to have HTN; usually late)
What are some key differentiating features between multi cystic dysplastic kidney disease and polycystic kidney disease?
MCDK: kidney replaced by cysts - no normal tissue; can have ureteral atresia/contralateral VUR; not inherited, most common cause of abdo mass in newborn; unilateral
PCKD: AD (most common - large cysts develop over time) or AR, can be associated with syndromes like TS, von Hippel Lindau, Bardet-Biedl; bilateral; other organs affected (especially hepatobiliary)
In a newborn found to have a multicystic-dysplastic kidney, the following is likely:
a. hematuria
b. hypertension
c. ureteropelvic reflux
c. ureteropelvic reflux
A newborn infant has a left sided abdominal mass. A renal ultrasound demonstrates multi cystic kidney disease. Which of following would this be associated with:
a) ipsilateral hydroureter
b) posterior urethral valves
c) sensorineural hearing loss
d) cataracts
e) risk of malignancy
ANSWER: e) risk of malignancy (yes - wilms tumour arising from tissue even if cysts regress)
- hydroureter likely contralateral
- PUV not an association
- SNHL and cataracts not an association
6-year-old girl with incidental finding of a 2 cm renal cyst. Appropriate management:
a) observe and repeat US
b) CT abdomen
c) ultrasound liver
d) urology consult
e) full nephrologic workup
a) observe and repeat US
Re: liver U/S - hepatbiliary issues more related to AR PCKD
- simple cysts with normal renal function only need observation
- complex cysts may have risk of cancer - need more ix
What’s the most common cause of abdo mass in newborn?
a) hydronephrosis
b) polycystic kidneys
c) neuroblastoma
a) hydronephrosis
- hydronephrosis and multi cystic dysplastic kidneys present with abdo masses in newborns (NOT polycystic kidneys)
Baby with weak abdominal musculature. Cryptorchidism. Baby in intubated in NICU. Bilateral abdominal masses on exam. What is this associated with.
a) Bilateral wilms
b) Polycystic kidneys
c) Multicystic kidneys
d) Hydronephrosis
d) Hydronephrosis
- description of Prune Belly syndrome (aka triad or Eagle Barrett syndrome)
- urinary tract abnormalities from urethral obstruction as fetus - massive hydroureter and hydronephrosis, large bladder, patent urachus, VUR
- oligohydramnios, pulmonary hypoplasia, malrotation
Midline mass and E.coli urosepsis, next diagnostic step:
a) VCUG
b) renal U/S
b) renal U/S
- renal U/S is initial screen for first febrile UTI in child less than 2
- mass suspicious for hydronephrosis
Newborn with increased creatinine, palpable mass in midline. How do you confirm the diagnosis?
a. VCUG
b. Abdo Ultrasound
c. CT abdo
b. Abdo Ultrasound - concern is about an obstructive renal lesion
- 2/3 of abdominal masses in neonates are renal in origin
- boys with PUV have walnut size mass above pubic symphysis
You are referred an otherwise healthy 16 year old boy from his family doctor after proteinuria was noted on a routine urine dipstick. What are 2 reasons for a false positive for protein on dipstick? What is the most common reason for persistent proteinuria?
- false positives:
- high urine pH (>7)
- highly concentrated urine specimen
- contamination of the urine with blood - most common cause of persistent proteinuria: postural proteinuria (found in 60% of kids with persistent proteinuria)
persistent proteinuria)
- have proteinuria when upright, but normal urine protein when supine
- NOT associated with hematuria, hypertension, hypoalbuminemia, edema or renal dysfunction
What test do you do to confirm postural/orthostatic proteinuria?
diagnosis: obtain first morning urine sample and test for urinalysis and urine protein:cr ratio
- correct method of getting this sample: fully empty bladder before bed at night, then collect sample from first
void immediately upon getting out of bed in the morning
- obtain sample for 3 consecutive days
15 yo female with 2+ protein on routine exam. What to do?
a) 24 hr urine protein
b) first morning urine analysis x 2
c) Renal function tests
b) first morning urine analysis x 2
A child has progressive periorbital and peripheral edema, abd pain and distention for 1 week. She is now febrile
with a temperature of 39.2 degrees. Blood pressure is within normal limits and her abdomen is diffusely tender. On U/A there is no blood but there is 4+ protein. What is the most likely diagnosis:
1. Post-strep GN
2. Nephritic syndrome with peritonitis
3. HUS
4. Appendicitis
- Nephritic syndrome with peritonitis
?nephrotic syndrome more likely - maybe typo?
Pt had GAS 2 weeks ago. Now presents with hemoglobin 70, Platelets of 30 and rising Cr and BUN. What is the
diagnosis?
a) HUS
b) HSP
a) HUS
- HSP should not have anemia or TCP
- patients with familial HUS can be triggered by preceding illness
Decreased C3 is a feature of which of the following:
a. IgA nephropathy
b. HUS
c. post strep glomerulonephritis
d. nephrotic syndrome
c. post strep glomerulonephritis
- other causes of low C3: membranoproliferative GN, SLE
- kidney issues with normal C3: IgA nephropathy, idiopathic rapidly progressive GN, anti-GBM disease, HSP, Goodpasture’s, Alport, granulomatosis with polyangiitis (Wegner’s)
Which of the following is associated with a low C3:
a) Alport’s syndrome
b) nephrotic syndrome
c ) post-streptococcal glomerulonephritis
d) hemolytic uremic syndrome
e) Henoch-Schonlein purpura
c ) post-streptococcal glomerulonephritis (YES)
All of the following about Alport’s are true except:
- Girls have worse prognosis
- Bad prognosis is with gross hematuria in childhood
- Progressive sensorineural hearing loss in childhood
- 15% have end stage renal disease before age 15
- 2-3% of all end stage renal disease is due to Alport’s
- Girls have worse prognosis
- Alport = hereditary nephritis
- all have micro hematuria, may have gross hematuria, may have proteinuria
- progressive bilateral SNHL
- poor prognosis: gross hematuria in childhood, nephrotic syndrome, prominent GBM thickening, male
- mgmt: ACEi slows rate of progression
A child with HSP will have:
a. increased IgA (yes! If done)
b. decreased Hb and platelets
c. decreased immunoglobulins
a. increased IgA
- most common childhood vasculitis
- IgA deposition causing abdo pain (FOBT+, intussusception), arthritis, renal (microscopic hematuria/proteinuria)
Pt with HSP. What would you do to monitor:
a. urinalysis
b. IgA
c. Stool for o/b
d. AXR
a. urinalysis
- weekly while active disease, then mostly x6 months
- also monitor BP
Child had a URTI a week ago. He now presents with bloody diarrhea, abdominal pain and a petechial rash. What is his diagnosis?
HSP
An 8 year old boy presents with hematuria and hypertension. His ASOT is positive. List one test that you
could do that would support your diagnosis of post-infectious glomerulonephritis.
- complement C3 level (reduced in >90% of cases of post strep GN in the acute phase, returns to normal within
6-8 weeks post infection) - PSGN occurs following staph, strep, gram negative bacterial infections, flu, parvo
Post strep GN. What two lab tests that would confirm your dx of PSGN.
- complement C3 (expect to be low)
- ASOT for proof of recent strep infection
Periorbital swelling with no tenderness, no fever and normal blood pressure. What do you do?
a. reassure
b. check for proteinuria
c. start antibiotics
b. check for proteinuria
- edema is the most common presenting symptom in children with nephrotic syndrome
Child with nephrotic syndrome treated with steroids, weaned off 3 months ago and was clinically well. Now
presents with albumin 10, ascites, 3+ protein in urine. Name three specific therapies
mgmt of relapsed nephrotic syndrome:
- repeat course of prednisone
- acute mgmt: Na restriction (<1500mg daily), diuresis (furosemide - loop diuretic), fluid restriction if hyponatremia
- low fat diet if dyslipidemia
What are the diagnostic findings for minimal change nephrotic syndrome (most common type)?
- periorbital edema progressing to generalized
- urine protein:cr ratio >2
- lytes, BUN, Cr usually normal
- hypoalbuminemia
- high cholesterol and triglycerides
When should secondary nephrotic syndrome be suspected and how do you investigate?
- gross hematuria, HTN, renal insufficiency, age <1 or >12
- C3 (normal in MCD, low in other causes), ANA, dsDNA, Hep B, Hep C, HIV; kidney biopsy in kids over 12
A child with nephrotic syndrome has recently been started on a course of oral steroids. Which of the following vaccines is contraindicated? A) Prevnar B) Hep B C) Influenza D) Varicella zoster
ANSWER: D) Varicella zoster - live attenuated vaccine is contraindicated in patients with immunocompromise including high dose steroids
A) Prevnar - inactivated bacterial
B) Hep B - Recombinant Viral
C) Influenza - nasal spray would be contraindicated (live attenuated viral vaccine), but all injected flu vaccines are inactivated or recombinant and would not be contraindicated
You are assessing a 3 week old infant. The weight is 4 kg, the birth weight was 3.6 kg, the blood pressure is 90/55. The mother states that the infant is feeding well. The labs show: Na 142 K 3.6 Cl 113 Cr normal pH 7.25, urine pH 5.0 What is the most likely etiology a. Hyperaldosteronism b. RTA, proximal c. CF d. Psychosocial failure to thrive
b. RTA, proximal
RTA: normal AG metabolic acidosis (less HCO3 reabsorbed - proximal, or less H+ out - distal)
- type 1: distal - HCO3 <15, urine pH >5.5, hyperCauria
- type 2: proximal - HCO3 >15, urine pH <5.5
- type 4: hypoaldosteronism - high K, low Na
*acidic pH means distal tubule is working fine - so not type 1 or 4
Which of the following will be found in a 6 year old with a distal RTA:
a. Glycosuria
b. Hypercalciuria
c. Metabolic alkalosis
b. Hypercalciuria
Child presents with failure to thrive, polydipsia, polyuria, and hypokalemic metabolic alkalosis.
a) hyperaldosteronism
b) Bartter syndrome
c) cystinosis
d) renal tubular acidosis
e) congenital adrenal hyperplasia
ANSWER: b) Bartter syndrome
- hypoK, metabolic alkalosis, hypercalciuria, salt wasting
- dysmorphic: triangle face, protruding ears, large eyes, droopy mouth
a) hyperaldosteronism (K low but not polyuria/dipsia)
c) cystinosis (polyuria/dipsia, low K BUT non AG metabolic acidosis)
e) congenital adrenal hyperplasia ( not enough aldosterone = high K+, low Na)
How do you differentiate Bartter from Gittelman syndrome?
Both metabolic alkalosis and hypoK, but Gittelman has hypocalciurua and low magnesium
A 3-month-old boy born at term is failing to thrive. He is otherwise asymptomatic.
Labs show Na 142, K 6.5, Cl 114, Cr 45, HCO 3 14, pH 7.24.
a) renal failure
b) renal tubular acidosis
c) hyperaldosteronism
d) cystic fibrosis
e) Fanconi syndrome
b) renal tubular acidosis
14 mos male, FTT, vx, met acidosis, pH 7.31, bicarb 14, K 3.5, Na140, Cl 118, urine pH 6.3 a distal RTA b Bartters c organic acidopaty d nutrit. deprivation
a distal RTA
metabolic acidosis with normal K and alkalotic urine= poor H into urine= distal issue= type 1
- Bartters - alkalosis
The following are shared by cystinosis and renal tubular acidosis EXCEPT:
a) hypokalemia
b) nephrolithiasis
c) concentrating defect
d) aminoaciduria
e) hyperchloremic metabolic acidosis
d) aminoaciduria
Features of cystinosis:
- french Cdn, fair complexion and blonde hair
- healthy at birth
- develop FTT, polyuria, polydipsia, dehydration
- photophobia by 3-6 years
- nephrocalcinosis
Infantile cystinosis. What do you get?
a. cataracts
b. end stage renal failure
c. nephrocalcinosis
b. end stage renal failure
Infant post cardiac surgery with poor urine output. BUN 25, Cr 177, urine (low Na, concentrated)
a. ATN
b. prerenal failure
c. anaesthetic injury to kidney
d. obstructive uropathy
e. renal vein thrombosis
b. prerenal failure (likely related to CO; low urine Na means body trying to keep in Na due to perceived low intravascular volume)
- Patients whose urine shows an elevated specific gravity (>1.020), elevated urine osmolality (UOsm > 500 mOsm/kg), low urine sodium (UNa < 20 mEq/L), and fractional excretion of sodium (FENa) <1% (<2.5% in neonates) most likely have prerenal ARF.
What are some lab features that differentiate renal from prerenal causes of AKI?
● Intrinsic AKI: specific gravity < 1.010, urine osmolality low (<350 mOsm/kg), high urine Na (>40), fractional
excretion > 2% (> 10% in neonates)= likely intrinsic
● Pre-renal AKI: elevated specific gravity (> 1.0200), elevated urine osmolality (> 500), low urine Na (< 20),
fractional excretion < 1% (< 2.5 for neonates)
