Nephrology Flashcards
Nephritic
OHH
Oliguria
Hypertension
Hematuria
Azotemia
Nephrotic
PALE (EPHAL)
Proteinuria (nephrotic range)
Albumin low
Lipid high
Edema
Grossly red urine
LOWER URINARY TRACT
brown, cola, tea, burgundy colored urine
proteinuria >100 mg/dL
RBC casts
dysmorphic EBCs (acanthocytes)
GLOMERULAR
leukocytes or renal tubular casts
TUBULAR SYSTEM
Documentation of prior strep infection
ASO - throat
DNAse B antigen - skin
Serotype ff throat infection
1,2,4,12,18,25
Serotype ff THROAT infection
49,55,57,60
Patient develops nephritic syndrome how many weeks after throat infection
1-2 weeks
Patient develops nephritic syndrome how many weeks after skin infection
3-6 weeks
Poststreptococcal Glomerulonephritis
5-12 y/o
RARE before 3 y/o
LM: diffuse proliferation
IF: granular IgG, C3
EM: subepithelial humps
Laboratory findings Poststreptococcal Glomerulonephritis
INCREASED ASO titers
(+) streptozyme
decreased C3-C9; normal C1,C4
When will the abnormalities resolve
urinary protein excretion and HPN - 4-8 weeks
acute phase - 6-8 weeks
C3 level - 6-8 weeks
microscopic hematuria - 1-2 years
The only causes of renal insufficiency that cause DECREASED C3
PSGN
MPGN
Lupus Nephritis
Indications for Renal Biopsy in APSGN
acute renal failure nephrotic syndrome (-) evidence of strep infection normal complement level hematuria and proteinuria low C3 that persists > 2 mos
Bilateral sensory hearing loss
Anterior lenticonus (pathognomonic)
macular flecks, corneal erosions
Alport Syndrome (Hereditary Nephritis)
(+) hematuria 2 of the ff *macular flecks *recurrent corneal erosions *GBM thickening or thinning *sensorineural deafness
(+) hematuria, HPN
signs of renal insufficiency
history of hemoptysis and severe RDS
Goodpasture syndrome
(+) hematuria, HPN
signs of renal insufficiency
(+) SVI 3 weeks ago
purpuric rash (buttocks) pain in the joints
Henoch Schonlein Purpura (HSV)
(+) hematuria, HPN
signs of renal insufficiency
vomiting, bloody diarrhea and fever
history of eating hamburger
dehydrated hepatosplenomegaly
hemolytic uremic syndrome (HUS )
Sudden onset of gross hematuria
febrile with LRTI or GIT infection
normal C3
IgA nephropathy
Sudden onset of gross hematuria
History of strep throat or pyoderma
severely depressed C3
APSGN
asymptomatic microscopic hematuria
wears thick glasses and hearing aid
has uncles with the same condition
Alport Syndrome (Hereditary Nephritis)
IgA nephropathy
10-35 y/o
follows viral syndrome
INCREASED serum IgA
LM: focal proliferation
IF: diffuse mesangial IgA
EM: mesangial deposits
Goodpasture syndrome
15-30
pulmonary hemorrhage; IDA
(+) anti GBM antibody
LM: focal –> diffuse proliferation w/ crescents
IF: linear IgG, C3
EM: (-) deposits
Idiopathic Rapidly Progressive Glomerulonephritis
adults
(+) ANCA (in some)
LM: crescentic GN
IF: (-) immune deposits
EM: (-) deposits
3 mechanisms of proteinuria
Glomerular proteinuria – ineffective filtration
Tubular proteinuria – ineffective reabsorption
Increase plasma protein – i.e. rhabdomyolysis
Urine dipstick
3+ - 300 mg/dL
4+ - >2g/dL
Nonpathologic causes of proteinuria
Postural
Febrile (>38 C)
Exercise - resolves after 48 h
24 hr urine protein determination
NEPHROTIC RANGE > 40 mg/m2/hr
Urine protein: Creatinine ratio
NEPHROTIC RANGE >2
Causes of Transient Proteinuria
Fever Exercise Dehydration Cold Exposure CHF Seizure Stress
Idiopathic Nephrotic Syndrome
MInimal Change Disease
Focal Segmental Glomerulosclerosis
Mesangial Proliferation
Glomerular Diseases
Membranous Nephropathy
Membranoproliferative Glomerulonephritis
3+ or 4+ proteinuria
urine protein/ creatinine ratio >2
urinary protein excretion > 3.5 h/24 hr in adults and 40 mg/m2/hr in children
normal C3 and C4
Nephrotic Syndrome (Minimal Change Disease)
increased permeability of glomerular capillary wall – proteinuria and hypoalbuminemia
PODOCYTES – EFFACEMENT of foot process, decrease number of podocytes and altered slit diaphragm – LEAKY MEMBRANES
Remission attained w/n initial 4 weeks
RESPONSE
UPCR <0.2 or < +1 protein on dipstick for 3 consecutive days
REMISSION
UPCR > 2 or > 3 dipstick for 3 consecutive days
RELAPSE
Relapse w/n 28 days of stopping prednisone therapy
NON RESPONDERS
Steroid Dependent
Patient who respond well to prednisone therapy but relapse 4 or more tie in a 12 mo period
NON RESPONDERS
Frequent relapser
Children who fail to respond to prednisone therapy w/n 8 weeks
NON RESPONDERS
Steroid dependent
Children who continue to have proteinuria (+2 or greater) after 8 weeks of steroid therapy
NON RESPONDERS
Steroid resistant
Major complication of nephrotic syndrome
Infection
The most frequent type of infection in nephrotic syndrome
Spontaneous bacterial peritonitis
The MC organism causing peritonitis
Pneumococcus
LM: Diffuse thickening of glomerular capillary walls
IF: granular IGG and C3
EM: subepithelial deposits of electron dense material
SPIKE AND DOME APPEARANCE
Membranous Glomerulonephritis
LM: normal
EM: effacement of epithelial foot processes, (-) deposits
MInimal Change Disease
LM: Large hypercellular glomeruli
Increased mesangial matrix
DOUBLE CONTOUR OR TRAM TRACK APPEARANCE
Membranoproliferative Glomerulonephritis
LM: focal segmental sclerosis and hyalinosis
EM: loss of foot process, epithelial denudation
Focal Segmental Glomerulosclerosis
Prevalence of UTI
1st year of life - MALE
beyond 1-2 y/o - FEMALE
3 basic forms of UTI
Pyelonephritis
Cystitis
Asymptomatic bacteriuria
Colonic bacteria that cause UTI
E. coli
Klebsiella
Proteus
abdominal, back or flank pain, fever, malaise, nausea, vomiting and diarrhea (occasional)
Pyelonephritis
(-) fever
(-) permanent renal damage
dysuria, urgency, frequency, suprapubic pain, incontinence and malodorous urine
Cystitis
(+) urine culture (-) manifestation of infection
Asymptomatic Bacteriuria
Recurrent UTI
2 or more acute pyelonephritis/presumptive UTI
OR
3 or more cystitis
OR
1 pyelonephritis + 1-2 cystitis
Presumptive UTI
Clinical symptoms + urinalysis findings suggestive of UTI not supported by urine culture
Indications of urine culture in UTI
significant urinalysis findings
complicated UTI
seriously ill children
recurrent UTI
Gold standard in a properly collected sample
Urine Culture
Collection of urine
< 2 y/o - clean catch urine collection
> 2 y/o - mid-stream sample
Indications for KUB Ultrasound with post void study
Culture proven pyelonephritis
Febrile presumptive UTI
Recurrent UTI
Nitrite +
Leukocyte +
Urine CS
Treat as UTI
Nitrite +
Leukocyte -
Urine CS
Treat as UTI
Nitrite -
Leukocyte +
Urine CS
Treat if with symptoms
Nitrite -
Leukocyte -
NOT UTI
Pyuria
CENTRIFUGED
>5 /HPF
UNCENTRIFUGED
>10/uL
Bacteriuria +
Pyuria +
Urine CS
Treat as UTI
Bacteriuria +
Pyuria -
Urine CS
Treat as UTI
Bacteriuria -
Pyuria +
Urine CS
Treat if with symptoms
Bacteriuria -
Pyuria -
NOT UTI
Management of CYSTITIS
Co-trimoxazole and Amoxicillin – high rate of resistance
Nitrofurantoin
Management of ACUTE PYELONEPHRITIS
Ceftriaxone
Cefotaxime
Ampicillin + Aminoglycoside
Management of PSEUDOMONAS
Aminoglycoside
Fluoroquinolone (Ciprofloxacin)
DOH RECOMMENDATION (UTI)
E. coli Klebsiella Enterobacter Enterococcus Group B Strep
< 2 mos - Cefotaxime PLUS Amikacin - 10-14 days
> 2 mos - 18 y/o (7-10 days)
Oral Co-Amoxiclav
Cefuroxime
Nitrofurantoin
Ampicillin Sulbactam
DOH RECOMMENDATION (UTI)
Recurrent UTI
Catheter related comorbidities
Ceftriaxone and/or Amikacin for 7-14 days
DOH RECOMMENDATION (UTI)
Antibiotic Switch
If culture shows different sensitivity pattern and/or poor response after 48-72 hrs
Acute Kidney Injury
Abrupt loss of kidney function – rapid decline in the glomerular filtration rate (GFR), accumulation of waste products such as BUN and CREA, and dysregulation of extracellular volume and electrolyte homeostasis
KDIGO (Kidney Disease Improving Global Outcomes) Definition of AKI
INCREASE in CREA by >/= 0.3 mg/dL from baseline w/n 48 hrs
INCREASE in CREA by >/= 1.5 mg/dL from baseline w/n the prior 7 days
URINE VOLUME = 0.5 ml/kg/hr for 6 hrs
Categories of AKI
Pre renal
Intrinsic
Post renal
Diminished effective circulating arterial volume – inadequate renal perfusion
PRERENAL
dehydration sepsis hemorrhage hypoalbuminemia cardiac failure
Renal parenchymal damage including sustained hypoperfusion and ischemia
INTRINSIC
glomerulonephritis
acute tubular necrosis
ENDOGENOUS - myoglobin, hemoglobin
EXOGENOUS - medications, poisons, radioactive materials
Obstruction of urinary tract
POST RENAL
congenital conditions - posterior urethral valve, uteropelvic junction obstruction
urolithiasis, tumors
Chronic Kidney Injury (NKF KDOQI)
Kidney damage for >3 mo - structural or functional abnormalities of the kidney w/ or w/o decreased GFR manifested by one or more of the ff features
- abnormalities in the composition of the blood or urine
- abnormalities in imaging tests
- abnormalities on kidney biopsy
GFR <60 mL/min/1.73 m2 for 3 mo w/ or w/o the other signs of kidney damage described above
One of the MCC of acute renal failure in young children
Caused by infection, genetics, drugs (calcineurin inhibitors, cytotoxic agents, clopidogrel, ticlopidine, quinine) SLE, HELLP
Hemolytic Uremia Syndrome (HUS)
sudden onset of pallor, irritability, weakness, lethargy and oliguria usually occurs 5-10 days after the initial gastroenteritis or respiratory illness
dehydration, petechiae, hepatosplenomegaly, marked irritability
RAT
Renal insufficiency
Anemia (microangiopathic)
Thrombocytopenia
Hemolytic Uremia Syndrome (HUS)
MC form of HUS
EHEC
Characteristic of all forms of HUS
Microvascular with endothelial cell damage
Laboratory criteria for diagnosis of HUS
anemia (acute onset) with microangiopathic changes - schistocytes, burr cells, helmet cells
renal injury evidenced by hematuria, proteinuria, or elevated creatinine level
Presents similarly with PSGN but the throat infection coincides with appearance of renal symptoms
IgA Nephropathy
Triad of HUS
Renal insufficiency
Anemia (microangiopathic)
Thrombocytopenia
HSP Tetrad
Palpable purpura
Arthritis
Abdominal pain
Glomerulonephritis
Pathognomonic for Alport Syndrome
Anterior lenticonus
Clinical Manifestations that differentiate TTP from HUS
CNS Involvement
Fever
HPN for children 1-13 y/o
elevated BP >90th to <95 OR 120/80 mmHg (whichever is lower)
Stage 1 >95th to <95th + 12 mmHg OR 130/80 mmHg - 139/89 mmHg (whichever is lower)
Stage >95th + 12 mmHg OR >140/90 mmHg (whichever is lower)
