Nephrology Flashcards
What are irritative urinary symptoms?
Increased frequency, dysuria
What are common obstructive voiding symptoms?
Feeling of incomplete void, dribbling, nocturia, and straining to urinate
What disease presentations can cause irritative urinary symptoms?
SIT (stones, infection, and tumors)
What disease presentation can cause obstructive voiding symptoms?
SIT (stones, infection, and tumors)
What is the first step in assesing irritative urinary symptoms?
Urinalysis
What is the first step in assessing obstructive voiding symptoms?
Also urinalysis, but if a patient has benign prostatic hyperplasia consider doing a digital rectal exam.
A 25 yo F presents to your office with urinary urgency, and dysuria. Vaginal exam shows white discharge from the urethra what is the diagnosis and next best step in management?
Urethritis, and first get a urinalysis
A 30yo male presents with frequency and difficulty emptying his entire bladder. The patient is febrile and digital rectal examination is painful especially around the perineal region. What is the diagnosis and next step in treatment?
Prostatitis, and urinalysis
A pregnant patient gravida 1 para 0 presents with flank pain, dysuria, and urgency. What is the diagnosis?
Pyelonephritis
If a urinalysis is positive for nitrate negative bacteria think of these organisms?
Staph or an STD like chlamydia or ghonerrea.
What is the presentation for a patient with cystitis?
The patient has pyuria and irritative urinary symptoms discussed without discharge or a tender prostate
What is the treatment for a simple cystitis?
“Three nitrogen foxes.” TMPSMX, nitrofuratoin, and fosfomysin
What is the treatment of a patient that has asymptomatic bacturia?
Treatment is not necesary unless the patient is pregnant.
What is a complicated UTI?
Is an infection of the lower urinary tract that extends to the prostate or to the kidneys. Patients that are pregnant, immunocompromised, have diabetes are at increased risk.
A patient who was recently treated for urinary tract infection is still having irritative symptoms and fever despite treating with antibiotics what is the dx?
Perinerphric or renal abcess
_______ is contraindicated in patients with acute prostatitis?
bladder catheterization and prostate massage
Patients < 35 yo of age most likely suffer from prostatitis from these bacteria?
Chlamydia and N.Gone
What organism causes prostatitis in patients older than 35?
E. Coli
What organisms causes orchitis in children?
Mumps
A male has recurrent irritative symptoms of the urinary tract. Mid stream culture is positive what is dx?
chronic bacterial prostatis?
Patients that experience voiding symptoms in addition to irritative sxm’s should have these labs and imaging checked?
ultrasound to see if there is evidence of hydronephrosis and creatinine levels
What drugs can we use to treat BPH?
alpha-1 blockers (-zosins), 5 alpha reductase inhibitors like finasteride, and treatment is unsuccessful we consider a transurethral resection.
What are the risk factors of prostate cancer?
Black males and BRCA mutation
Screening is generally not indicated for the prostate, but if a patient opts to screen for it at what age can the start?
50
If the PSA is > than _____ we should consider a transrectal biopsy.
7ng/ml
Drugs that reduce the size of a prostatic tumor?
Anti-androgen drugs like GnRH agonist (leuprolide).
What are the symptoms of a patient with bladder cancer?
Patient may present with gross or microscopic hematuria.
What is the age that we usually see the presentation for testicular cancer?
15-35 yo
What is the presentation of a patient with testicular cancer?
An asymptomatic firm mass on palpation and inguinal lymphadenopathy.
What are risk factors associated with bladder cancer?
smoking, schistosoma, aniline dyes, cyclophosphamide,
What is the next step in work up for a patient with painless hematuria?
cytoscopy with biopsy or and urine cytology
What is the first step in managment of a patient with a kindey stone?
pain control and then continue to diagnostic steps first of which would be a urinalysis
What is the best imaging type for a patient we suspect of having nephrolithiasis?
CT scan without contrast
A pregnant mom suspected of having nephrolithiasis should get what imaging?
Ultrasound
A patient with kidney stones should be hospitalized if…
They are septic, significant pain with symptoms of nausea and vomiting, or you see creatinine elevation.
Treatment for a patient with a stone that is less than 1cm?
Hydrate hydrate and tamsulosin
Treatment for a patient with a stone 1-2 cm in size?
Lithotripsy
Treatment for a patient with a stone >2cm
percutaneous nephrolithotomy
When calcium binds with _____ it cannot be reabsorbed by the GI system and enters the urine forming stones. The same is similar is caclium binds to fats the left over oxalate goes into the urinary system.
Oxalate
____ prevents calcium oxalate crystals from forming?
citrate
What is the most common stone?
Calcium oxalate
Calcium phosphate stones happen as a result of more phosphorus in the urine which can be caused by?
Hyperparathyroidism, because the parathyroid hormone secretes PO3-
Stone that forms in an alkaline environment?
magnesium, ammonium, phosphate. The urine is alkaline because bacteria like proteus are urease positive organisms
The only radiolucent stone
uric acid
These stones are a result of a hereditary disorder that fails to reabsorb amino acids?
cystine stones.
Early signs of blood in the urine would tell us the bleed is coming from where?
urethra
Later signs of hematuria tells us that the bleed may be coming from?
The prostate, the bladder trigone, or the or the neck of the bladder.
Continuous hematuria indicates that the bleed is coming from?
Higher up in the bladder or even higher past the bladder.
BUN/creatinine > 20 indicated what type of kidney failure?
Pre-renal
BUN/Creatnine <20 indicates?
An intrinsic cause
What other lab is detected in pre-renal injury besides the BUN/creatnine ratio?
FeNa although if a patient is on diuretics then FeUrea is more accurate. A patient with AKI will try and reabsorb sodium to maintain perfusion. So FeNa should be low.
How does hepatorenal syndrome affect the creatnine?
It slowly increase the creatnine
What happens to creatnine in a patient with cardiorenal syndrome with continuous diuresis?
creatnine levels reduce
What is the next best step in management of a patient with intrinsic kidney failure?
urinalysis with cytology(microscopy)
What are the causes of WBC casts?
Pyelonephritis and acute tubulointerstiial nephritis
What are the causes of RBC casts?
Glomerulonephritis
Muddy brown casts
Acute tubular necrosis
Oxalate crystals on microscopy indicated ingestion of?
ethlyene glycol
Uric acid crystals on microscopy?
gout or tumor lysis syndrome
A patient presented to the emergency room after an accident the patient was hypotensive and aggresive fluid placement was begun. The patient is now hemodynamically stable but his creatnine jumped from 0.9 ->1.6 in the past 24 hrs what is the best step in diagnosis?
BUN/creatnine; FeNa, urinalysis with cytology
____ is the most indicative indicatior of renal function?
Creatnine
What are the common drugs associated with tubulointerstital nephritis?
NSAIDS, penicllins, cephalosporins, rifampin, allopurinol
A FeNa that is >1 % suggests what disease pathology?
ATN
A FeNa <1% suggest what disease pathology?
pre renal AKI
What is the effect of prostaglandins on renal function?
Prostoglandins irritate the renal afferent limb to vasodilate.
A 50 yo M with history of chronic drug abuse, hepatitis C, and liver cirrhosis presents with elevated creatinine levels on annual physical. Oral hydration is suggested, but still shows the patient has climbing creatinine levels even with fluid administation. What is the diagnosis?
This indicative of hepatorenal syndrome
When a patient with cardiorenal syndrome is diuresed what happens to the creatnine levels?
They decrease
AIN is what type of HSR?
Type 4
A 5 yo girl is presenting to her primary care provider due to eye edema that her mother noticed after a URI. EM shows podocyte effacement what is the next step in managmnet?
This patient probably has minimal change disease which is the most common cause of nephrotic syndrome in children. We start patients on a steroid.
What are the risk factors for FSGS?
HAS; Heroin, HIV, African American, sickle cell
Antibody against phospholipase A2 receptor? It is an immune complex disease. An associated with hepatitis, syphillis. There are subepithelial deposits in the glomerular basement membrane.
Membranous nephropathy (membranous glomerulonephritis)
Interstial kidney disease that can lead to progressive rapid decline resulting in hemodilaysis in weeks to months?
Rapid progressive glomerulonephritis
This kidney interstitial disease has mesangial cell proliferation and glomuerular basement membrane proliferation. Has sub-endothelial deposits and has low complement levels.
MPGN
Is an autoimmune condition that attack the basement membrane and can present with hemoptysis and hematuria.
Good pasture
Immune complexes of IgA deposit in the mesangium. The patients present with recurrent urinary tract infections. In children this can manifest with extra-renal symptoms like palpable purpura, abdominal pain and arthralgias.
IgA nephropathy and Hencoh Schlein purpura
What other autoimmune disease is associated with IgA nephropathy and Henoch shulen purpura?
Celiac disease
Nephritic syndrome + hearing loss and visual defects?
Alport syndrome
Nephritic syndrome + lung + sinus
granulomatosis with polyangitis
Nephritic syndorme + hx upper respiratory tract infection 10 days ago?
Post strep
Nephritic syndrome with + URI 5 days ago
IgA
IgA nephropathy is synonymous with
Burgers disease
Rheumatoid arthritis or MM + nephrotic syndrome
Amylodosis
Hepatitis C + nephritic syndrome
cryoglobulinermic vasculitis associated MPGN
“See liquid proliferating in the Red Sea,” is a pneumonic for remember membranoproliferative glomerulonephritis.
See= hepatitic “C”
Liquid= leukemias, MM
Proliferating= GBM proliferation
RED= Red blood cell casts
Sea= C3
What is the pathology behind renal papillary necrosis?
It’s already a low oxygen area of the kidney so lack of perfusion or adequate oxygenation can lead to an asmptomatic patient or a patient with abdominal pain, hematuria, obstructuve urinary symptoms or polyuria
What are common cause of papillary necrosis?
Sickle cell, infection, DM, NSAID abuse
What electrolytes are elevated in CKD?
Phosphorus and Potassium
What are the complications of having a high urea level?
uremic encephalopathy, uremic pericarditis, and uremic coagulopathy (platelet dysfunction)
When a donor kidney is vascularly connected and the donor kidney immediately becomes white and pale, what is the mechanism behind this transplant reaction?
The patient has pre-exisiting antibodies. This is a hyperacute rejection. We can prevent this from happening by doing crossmatching prior to transplant.
A patient is f/u after a kidney transplant a month ago creatinine levels are elevated. A biopsy would show what kind of process?
T cell mediated (lymphocytic infiltration) response. This patient has acute rejection.
A patient is f/u after kidney transplant 3 months ago and the creatinine is higher then his levels last month, what is the next step in diagnosis?
biopsy, which will show vascular fibrosis
When should we consider transurethral ureteral splinting ?
In patients with urinary retention.
Patient presents to the ED with rash and flank pain after getting over pharyngitis. Patient denies any costovertebral tenderness. Patient urinalysis shows RBC and WBC in the urine and no bacteria, what is the likely cause of her presentation?
AIN, more than likely the patient was taking a penicllin which is a common culprit of AIN.
What are the lab findings for a patient with AIN
On urinalysis the patient may have eosinophilia, WBC. Additionally they may also have eosinophils in the blood stream.
what organisms alkalinize the urine
proteus
What is the next step in management of an infant with hypospadis
Yes referral to urology , which will ultimately plan for surgery within a 6 month time frame
