Nephrology Flashcards
Newborn Cr 83. Is that mother’s Cr or baby’s?
Mother’s.
- 2nd half of gestation fetus + mom Cr equilibrate Thus birth Cr= mother - usually see drop by 1 wk - GFR estimated by serum Cr - Rise in > 20= RF - vs BUN affect hydration
What anomaly is most likely to be seen with single umb. artery:
- renal
- cardiac
- other
Renal anomaly
Increased risk of renal agenesis
Absent left kidney. Right small. Will this progress to ESRD?
YES - in Childhood
Chronic kidney disease and RF. Most likely category if < 5 y.o. RF or > 5 y.o.
< 5= congenital anomaly
- renal hypoplasia, dysplasia, obstructive anomaly, prune belly syn
> 5= acquired or inherited
- glomerulonephritis, SLE, alport syndrome, cystinosis
List 5 findings with kidney failure:
- HTN (vol + excess renin made)
- Neuro symptom (uremia)
- Growth retardation
- Acidosis
- Buildup nitrogenous waste
- HyperK
- Anemia
- Renal osteodystrophy (impaired vit D= bone pain, #)
What is true of multi cystic kidney disease:
- VUR chance
- inherited
- hematuria
- early HTN
Chance of VUR
NOT inherited \++++ cysts Most common abdo mass in newborn HTN rare No hematuria (PCKD more) Associated: Contralateral UPJ, hypoplasia F/U US and BP See kidney f'n and if bad kidney involute (usually by 3 y.o.) Small malignancy risk.
Versus PCKD:
- inherited
- hematuria, RF in early childhood
- HTN
- resp +/- liver complication
B/L palpable kidney + pulmonary hypoplasia + HTN. Dx?
Polycystic kidney dx
Big bright echogenic kidney on U/S.
Issue: pul hypoplasia
Neonate with multcystic kidney disease. Which is true:
- ipsilateral hydrometer
- posterior uretheral vale
- sensorineural hearing loss
- cataract
- risk of CA
Risk of Malignancy (Wilm’s even if cyst regress)
VUR
Contralateral hydronephrosis
No association with cataract or hearing.
6 y.o. incidental finding of 2cm renal cyst. What to do:
F/U only.
Observe +/- repeat US
T or F: multi cystic kidney disease is inherited.
False!
Polycystic Kidney Dx IS (AR or AD)
Most common cause of abdo mass in NEWBORN
Hydronephrosis
Or MCKD
Weak abdo muscle. Cryptorchidism. B/L Abdo mass. Likely:
- bilateral will
- PCKD
- MCKD
- hydronephrosis
Hydronephrosis
*usually pt= males
Prune Belly Triad:
- deficient abdo muscle
- b/l undescended testes
- GU (severe urethral obstruction; VUR, hydronephrosis)
What is the prune belly triad?
Deficient Abdo Muscle
Undescended testes B/L
GU (severe urethral obstruction, VUR, hydronephrosis)
False (+) for protein on dipstick.
High urine pH (>7)
Highly [urine specimen]
Contamination w/ urine blood
Most common reason for persistent routine proteinuria in healthy 16 y.o.. What tests do you order?
Postural Proteinuria (aka orthostatic proteinuria)
First morning urine
Urine Protein:Cr ratio x 3d
List reasons for false (-) on proteinuria on dipstick
Dilute urine
Lg vol. of U/O
T or F: orthostatic proteinuria can be associated with HTN, low alb, or hematuria.
False
List 5 reasons for proteinuria:
**Transient (fever, exercise, infection)
**Orthostatic (Postural)
Overload > **Rhabdo (myoglobinuria), Hemolysis (hemoglobinuria)
Glomerular
> **Nephrotic Syn (minimal change, focal segmental, glomerular sclerosis, membranopathy)
> **Nephritic Syn (post infectious, IgA, alport, SLE, HSP etc.)
Tubular > **Acute tubular necrosis > Tubulointerstitial nephritis > Cystinosis > Wilson Dx > Fanconi syndrome > Drugs (pen, lithium, NSAID) > Metal (gold, lead)
GAS 2 wk ago. Now anemia, low plt, rising Cr, BUN. Dx?
- HUS or HSP
HUS
- non immune microangiopathic hemolytic anemia
- thrombocytopenia
- acute renal injury
Usually E coli. O157:H7
Can be Strep pneumoniae etc.
Which Glomerulonephritis have LOW C3?
Primary
- *> Post infectious (post strep for ex.)
- *> Membranoproliferazive GN
Secondary **> AI (SLE) **> Subacute Bac Endocarditis > Abscess or shunt nephritis > Cryoglobinemia
Which glomerulonephritis have NORMAL C3?
Primary
**> IgA nephropathy
> Anti-GBM Dx
> Idiopathic rapid progressive GN
Secondary **> HSP **> Alport Syn **> HUS > polyarteritis nodosa > Granulomatosis with polyangiitis (Wegner)
Decreased C3 in:
- IgA
- HUS
- post strep GN
- nephrotic syndrome
Post strep glomerulonephritis
All are true about Alport except:
- progressive sensorineural hearing loss
- 15% have ESRD by 15 y.o.
- 2-3% of all end stage renal dx due to Alport
- F have worse prognosis
- gross hematuria= bad prognosis
MALE have worse prognosis in Alport Syn.
T or F: Kids with HSP have increased IgA.
True
IgA deposition of small vessel skin, joint, GI, kidney.
What is the most common vasculitis of childhood
HSP
What is the HSP triad
- Arthritis (large joint)
- Abdominal Pain (V/D, intussusception)
- Purpuric Rash (limb, buttocks)
+ Renal (IgA nephropathy, hematuria, proteinuria, HTN)
How do you dx HSP?
Petechiae/purpura
+ 1 of (joint, GI, renal, histology)
Resolve within 1 month.
1/3 Recur
What do you monitor if HSP?
HTN + U/A (wkly x 4 wk then q2wk till 3 month then monthly) x 6 month
Note: almost anyone who will have renal complication do by 6 month but most by 6 weeks!
Child present w/ bloody diarrhea, abdo pain, petechiae rash. UTI one week ago. Dx?
HSP
Note bowel angina= abdo pain or bloody diarrhea
What two lab test to her confirm dx of post strep glomerulonephritis?
ASOT
Low C3
Most common presenting symptom for nephrotic syn?
Edema
Weaned off steroids for nephrotic syndrome. Now relapse. Name 3 specific therapies?
- Repeat prednisone
- Cyclophosphamide
- Cyclosporine
+/- loop diuretic for extravasation and edema
What is the nephrotic syndrome Clinical triad?
Edema + Hypoalbuminemia (<25 g/L) \+ Hypercholesterolemia \+ Heavy proteinuria Pr:Cr > 250 or > 40 mg/m2/hr
Proteinuria suggestive of nephrotic syn?
Proteinuria > 3.5 g/ 24h
What is the most common type of nephrotic syndrome?
Primary
** Minimal Change Dx
What type of nephrotic syn?
Primary
- Minimal Change Dx
- Focal Segmental Glomerulosclerosis
- Memb Nephropathy
Secondary
- Infection (Hep B, C, HIV, Malaria)
- Drugs (Lithium, NSAID, Pen, Gold)
- CA (lymphoma, leuk)
- Other (SLE, amyloidosis, IgA)
Which vaccine contraindicated for child w/ nephrotic syn on steroids?
- Pneumococcal 13
- Hep B
- Flu
- Varicella Zoster
Varicella Zoster
= Live Vaccine!
Define FTT
wt < 3rd % tile
OR crossing 2 major %tile
OR < 80% for ideal wt for ht and age
List DDX for normal AG Metabolic Acidosis
Bicarb loss matched by serum ++ Cl
> Extra CL= IVF
GI Bicarb loss= diarrhea, ureterosigmoidostomy, NG loss, intestinal fistula
Renal Bicarb= RTA, early uremic acidosis, hyperparathyroid, low aldosterone etc.
Lose Renal H+ = RTA 1 and 4
T or F: renal tubular acidosis has anion gap metabolic acidosis.
FALSE
NORMAL AG
Met Acidosis
> Less H+ out
Less Bicarb Absorbed
FTT. Polyuria. Constipation (low K). BW non AG metabolic acidosis. Likely Dx?
Renal Tubular Acidosis
K low as H move into cell as K move out
Low K= GI muscle wkness= constipation
Describe Type 1 RTA
Type 1= One Letter
**Less H+ out
“i” sooner in distal
= Distal Tubule Issue
> Congenital
Secondary (Obstructive uropathy, Genetic like ethler-danlos, Sickle, SLE, Toxin like lithium)
**CC: stones
> Ca2+ in kidney
> Rickets, Osteomalacia
**Bicarb Low (<15)
**Urine pH > 5.5
Stones
Describe Type 2 RTA
Not 1.
= Less Bicarb reabsorbed
= In proximal tubule
> Isolated RTA (primary, carbonic anhydrase deficiency) > Generalized = Fanconi - primary - IEM (**cystinosis) - vit D deficiency - Sjogren - Toxin (lead)
CC: **glucosuria, a. acuduria, low P, K, Na
- *Plasma Bicarb > 15
- *Urine pH < 5.5
No stones but Rickets from low P and Vit D
Describe Type 4 RTA
= Hypoaldosterone (which usually promote acidifying urine)
= Less H+ out
> Congenital (CAH)
Acquired (Addison, Post B/L adrenlectomy, SLE)
** High K +++
Plasma Bicarb >15
No stones
3 wk old FTT. BP okay. Na 142, K 3.6. Metabolic acidosis. Urine pH 5. Likely:
- HIGH aldosterone
- Proximal RTA
- CF
- Psychosocial FTT.
Proximal RTA (Type 2)
Met acidosis + Urine acidic (not RTA 1 or 4)
Vs.
High aldosterone= K out and Na in.
CF and Psychosocial not met acidosis.
Distal RTA.
- Glycosuria
- Hypercalcuria
- Met Alkalosis
Hypercalciuria
Polyuria. Polydipsia. Hypokalemic. Metabolic alkalosis. Dx?
Bartter Syndrome.
= defect in loop of Henle (lose Na, Cl= vol contract= aldosterone so K out)
= Low K
+ Met ALKALOSIS
+ Hypercalciuria
+ Salt wasting.
14 mo. FTT. Met Acidosis. Bicarb 14. Urine pH 6.3
- Distal RTA
- Proximal RTA
- Bartter
DISTAL
urine alkalotic
Tell me about Cystinosis.
= cysteine accumulate in renal tubular cell
- French Canadian
- Fair, Blond hair
- Corneal bodies by 1
- Rickets
- Primary etiology of RTA 2
- Glycosuria
- Aminoaciduria
- Phosphate/Na/K wasting
- Tubular proteinuria
**WBC cysteine level dx
Tx: Cystagon Fanconi: water, lytes Feeds: NG, GT Indomethacin slow salt loss Rickets (phosphate, vit D) Etc. (thyroid, GH etc.
What do you get from infantile cystinosis?
- Cataracts
- ESRD
- Nephrocalcinosis
ESRD
Post cardiac Sx. Poor U/O. BUN 25. Cr 177. Concentrated Urine.
- ATN
- Pre-Renal
- Anaesthetic injury to kidney
- Obstructive uropathy
- Renal vein thrombosis
Pre-Renal
Urine Sp. Gravity high (> 1.020)
Low Urine Na
FeNa < 1%
Urine osmolality high (> 500 most/kg)
What are parameters suggestive of intrinsic AKI?
Urine Sp. gravity < 1.01 (Normal/ Dilute)
Urine Osmolality Low (< 350)
High urine Na (>40)
Fractional Excretion > 2%
ATN: brown granular cast
AIN: WBC, eosinophil, cellular cast
What does an obstructive post-renal cause parameter look like?
Urine na low if acute.
Urine osmol Low
FeNa low if acute process
Versus Intrinsic usually FeNa > 1%
Describe three examples of AKI:
- Prerenal
- Intra-renal
- Post renal
Pre renal
- Dehydration
- Hemorrhage
- Cardiac failure
- Sepsis
- Third space (low albumin)
Intra-renal
- Vascular (HUS)
- GN
- Acute interstitial nephritis (NSAID, pen, TB, Sjogren)
- Acute tubular necrosis secondary to ischemia (volume loss like hemorrhage, low intravascular volume like HF, rhabdo cause renal artery obstruction, Vasculitis, HUS)
- Tumour lysis Syn
Post-Renal
- PUV
- Ureteropelvic junction obstruction
- Ureterovesicular junction obstruction
- Hemorrhagic cystitis
- Tumour
List three complications of acute kidney injury:
- ++ K
- Fluid status (pulmonary edema)
- HTN
- Neuro (from HTN and lytes - h/a, sz, confusion)
- Uremic Pericarditis
List three indications for Dialysis:
“AEIOU”
> Acidosis
- severe intractable acid
> Electrolytes
- persistent ++ K
> Ingestion
- ASA/ salicylate
- Lithium
- Na Valproate
- Carbamazepine
> Overload or Not enough
- Oliguria/ Anuria
- Pul Edema refractory to diuretics
> Uremia
- encephalopathy, pericarditis, bleeding, neuropathy
15 y.o. post trauma. Next day orange urine. Oliguria. High Cr. No improvement w/ fluid.
- Rhabdo
- Renal vein thrombosis
- Pre renal failure
Rhabdomyolysis
15 y.o. w/ rhabdo. Given lots of fluid but Cr still rises. Next step:
- epi infusion
- norepi infusion
- mannitol infusion
Mannitol
*Theoretical benefit by pulling fluid into vasculature
10 y.o. Post MCV. # and low BP. Lots of fluid. Over 48h get polyuria and Cr rise. Likely Dx?
- Fat embolus
- ATN
- DM
ATN
Necrosis secondary to ischemia (volume deplete, myoglobinuria like rhabdo, HF etc.)
Child with RF has anemia. Describe 4 mechanisms?
- EPO= Decreased erythropoietin production
- Fe deficiency from chronic blood loss (frequent BW, dialysis)
- Anemia of chronic dx
- B12 or folate deficiency
- Hyper parathyroidism
Toddler w/ gastro. Moderate dehydration. Most appropriate:
- IV fluid
- IVF if vomiting
- PO w/ Na
- Stop BF and lytes
- Hold refeeding
PO solution
Na 75 K 20 Cl 65 Glucose 75 (2%) Osm 245
T or F: ORT as effective than IV for mild-mod dehydration.
True
T or F: glucose in ORT help enhance cotransport of Na which help Na/K ATP pump draw water in.
True
List contraindications to PO feed in ORT if mild-mod dehydration:
- Protracted vomit despite small f feed
- Severe dehydration
- Paralytic ileus
- Monosacc malabsorption
T or F: You should give plain water for dehydration.
False.
T or F: you should not refeed if dehydrated.
False
Continue BF throughout if tolerated
Best ORT for gastro and dehydration
- Na 20; K 20; Glucose 10%
- Na 75; K 20; Glucose 2%
- Na 75; K 0; Glucose 8%
- Gingerly
- Apple Juice
Na 75
K 20
Glucose 2%
Which accompanies hypernatremic dehydration:
- Low BG; High Ca
- High BG; Low Ca
- High BG; High Ca
- Low BG; Low Ca
HIGH BG
Low Ca2+
List three etiology for Hypernatremia:
- Intake= **Excess Na in (PO, IV), **poor mix formula, ++ aldosterone
- Loss (Fluid loss> Na loss)
- Pure water out= **DI, prem phototherapy
- Water > Na out= GI (V/D), skin (burn, sweat), Renal (osmotic diuretic like mannitol) - Other
- Pharm: Lithium, Cyclophosphamide, Cisplastin
How do you manage Hypernatremia:
Text: 0.45NS + D5
x 1.5 maintenance w/ monitoring
AHD:
1. +/- Bouls (20cc/kg NS over 20 minute)
- Calc Fluid Deficit= X
wt x 10 x % (5-10-15 if < 10kg or 3-6-9 if > 10 kg) - Total deficit = X- bolus = Y
- Replace Y over 48 h
+ Maintenance
Start w/ D5W 0.45 naCl w/ 20 KCL
- Serum Na monitoring q 2-4 hour
Do not lower by > 12 mEq/L/day (or 0.5 per hour)
6 y.o. 10 minute GTC. HTN. Na 115. Urine Na 30. Euvolemic. Initial Tx? List two possible Dx?
Sz= 3% NS 3-5cc/kg IV push
Euvolemic Low Na:
- *- SAIDH
- *- Glucocorticoid deficiency
- Hypothyroidism
- Water intoxication
Nephrotic syndrome w/ edema. Na 125. Best fluids?
Nothing (usually water + Na restrict and if need resus albumin + diuretics)
List ddx for hyponatremia based on fluid status.
Hypovolemic
- ** CSW
- ** Adrenal insuff
- ** Renal (Addison, Diuretic, excessive loop diuretic)
Extra renal: GI (V/D), Burn, third space sepsis
= Restore vol w/ isotonic fluid
Euvolemic
- ** SIADH (urine osmol < serum)
- **Glucocorticoid deficiency
- Low thyroid
= Eliminate excess water
Hypervolemic
- **Nephrotic Syn
- **CHF
- Cirrhosis
- Low Alb FPIES
= Water + Na restrict +/- diuretic (after alb)
List three symptoms of hyponatremia:
N/V
H/A
Muscle Cramp
If < 120= sz, coma, resp arrest
3 wk old infant w/ lethargy. Na 118. K 8. Most important next test?
17 OHP
What is hyperkalemia?
> 5.5
List 3 etiology for hyperK
high IN:
- KCL tab, IV
redistribute
- metab acidosis
- tissue breakdown like rhabdo
Less renal OUT
- RF
- Spironolactone (K+ sparing diuretic)
- Aldosterone deficiency (Addison, CAH)
list three ECG findings of hyperK
Peaked T wave
Long PR
Wide QRS
List three tx options for high K
- Stop all K in
If > 6.5= ECG
Ca2+ gluconate - ** Inhaled ventolin
- **Insulin (0.1U/kg IV over 30 min x 1) + Glucose (D10 10cc/kg over 30 min x 1)
- **Lasix
- Ion exchange resin (**kayexelate or enema)
- Na bicarb if acid
* *8. Hemolysis
List the table for DI versus SIADH versus CSW:
- Clinical
- Na
- U/O
- Urine Na
- Osmolality
DI: = ADH (don't make enough= CNS or doesn't respond= Renal) - dehydrated **- Na ++ - Serum osm HIGH **- U/O ++ - Urine Na low - Tx: DDAVP, Vasopressin
SIADH:
= too much ADH (neuro Sx, trauma, brain bleed, med)
- euvolemic
- *- Na LO
- urine osm HI
- *- U/O low
- Urine Na hI
- TX: free water restrict (insensible + 1/2 U/O replace only)
CSW: = high atrial natriuretic peptide (= diuresis; secondary to brain injury, neuro Sx) - hypovolemic **- Na LO - osmolality variable **- U/O HI - urine Na HIGH - Tx: underlying Dx, Na/Fluid repletion
How do you treat HYPO-Na dehydration?
- Bolus
- Fluid deficit
wt x 10 x %
- Deficit- Bolus= X
- Replace first 1/2 over 8 hour and next 1/2 over 16 hour
+ Maintenance
Start w/ D5 NS and monitor.
5 y.o. asthma. Lots of ventolin. Nausea + weakness. Which lyte to check?
K
Low K
- alkalemia
- insulin
- ventolin
- refeeding
- GI loss (V/D)
- Renal (RTA, Bartter etc.)
CC: weakness, GI ileus, low DTR, arrhythmia
What rate of ORS do you provide for diff level of hydration?
Think of BB dehydration (5-10-5) and multiply by 10
= cc/kg over 4 hour
i.e. Moderate
= 10cc/kg over 4 hour
30 kg kid….
= 300 cc over 4 hour
List 3 causes of antenatal pelviectasis:
- Transient
- UPJ= Urteropelvic junction obstruction
- VUR= Vesiculoureteral reflux
- MCKD, PUV
When do you want to repeat a US for antenatal pelviectasis?
after DOL #3
What do you do w/ F/U US that still sees prenatal US?
Grade 1-2= Observe; repeat
Grade 3-4= VCUG +/- MAG 3
Newborn w/ antenatal US show 6mm dilatation post-natal. What do you do?
U/S repeat in 1-3 months.
When isolated hydronephrosis < 10mm monitor conservatively and repeat in 3-4 months.
Mod-severe hydro seen on mod-severe hydronephrosis. BW show normal renal f’n and normal U/O. What to do?
Outpatient VCUG
List AP diameter for antenatal hydronehprosis?
Mild: 7-9
Mod: 9-15
Severe > 15
Teen male with struvite stone. What do you look for?
Infection
Urine Cx
Most common kidney stone in peds?
- Ca oxalate
- Struvite
- Cysteine
- Uric acid
Ca oxalate
Renal stone child. Prior prem. Which med in neo stage likely contribute to this?
Lasix
Most common GN in kids
Post streptococcal GN
List 3 causes of gross hematuria
- Trauma.
GU Tract:
- Hypercalciuria
- Glomerular (PSGN, HSP nephritis, IgA, Alport, SLE)
- Renal vein thrombosis (seen in neonate)
Bladder:
- UTI
- Hemorrhagic cystitis
Lower:
- Meatal Stenosis
- Perineal irritation
Other:
- P/E
- Coagulopathy or Sickle Cell or Plt low
- Tumour
Most common cause of gross hematuria
UTI
2nd= idiopathic hypercalciuria
List other causes of red urine aside from blood
- **hemogloburia (intravascular hemolysis)
- **myoglobin (rhabdomyolysis)
- drugs (chloroquine, ibuprofen, flagyl, nitrofurantoin, **rifampin)
- **food (beet, blackberry, rhubarb)
- Other (melanin, **porphyrin)
Describe post-streptococcal GN
5-12 y.o.
Gross hematuria 1-3wk after infection
Edema
HTN
Proteinuria
Hematuria can recur with febrile illness
C3 Low
ABX does not prevent PSGN
Supportive Tx
Most recover completely.
8 y.o. recurrent episode of asymptomatic gross hematuria triggered w/ intercurrent illness. Dipstick (+) even between illness. Best test for etiology
- immunoglobulin
- C3, C4
- 24h urine protein
- abdo US
- DMSA scan
Immunoglobulin
15% of kids with igA have high IgA
List three glomerular dx causes of recurrent hematuria
IgA nephropathy
Alport Syn
Thin GBM Disease
How can you tell IgA nephropathy from PSGN?
hematuria 1-2 d after viral onset.
Normal C3
Progressive in 1/3 versus rare in PSGN
T or F: Alport Syndrome is AR inherited?
False.
X linked.
CC: hematuria, HTN, proteinuria, RF, hearing loss.
Which test differentiate post-infectious glomerulonephritis versus IgA?
C3
Child w/ hematuria as incidental finding. What do you do?
Repeat UA + microscopy in few day to see if resolution.
Asymptomatic child with (+) micro blood on 3 dips in 2 wk period= investigate!
- Urine Cx
- Urine Ca:Cr
- Sickle Screen
- U/A in FHX
- Renal or Bladder US etc.
Most common cause of HTN in teen:
Primary (essential)
How do you check BP?
Sit quiet x 5 min.
Cuff size cover 2/3 upper arm and 80-100% circumference
Auscultate
T or F: to dx HTN you have to measure BP min. 2 occasion.
False.
Min. 3 occasion.
Definition HTN
HTN= 95% tile for age, gender, ht
NEW DEFINITION: Norm= 1-13 y.o.: < 90th %tile Stage 1: 90 to 95+12 Stage 2: 95 + 12 Or use kids > 13 guideline (whichever is lower)
Norm min. 13: < 120/80
Stage 1: 130-139 sys
Stage 2: min. 140
OLD DEFINITION:
Pre-HTN:
- 90-94% tile OR > 120/80 starting 12 y.o.
Stage 1= 95 to 99+5 mmHg
Stage 2= > 99 + 5 mmHg (usually secondary cause)
** HTN urgency
> acute severe
NO end organ damage
** HTN crisis/Emergency:
> symptomatic
+ end organ damage (brain, eye, heart, kidney)
What are common cause of HTN in young and teen?
Young: (Renal, Coarc)
- **Prem= **umbilical a. cauterization, renal a. thrombosis
- Neo= **renal thrombosis, **coarc, pheo, cushing
- < 6 y.o.= **renal parenchymal dx, coarc, pheo, cushing, meds
- school age= renal parenchymal, vascular, **pheo, **cushing
Teen= **Essential
List secondary causes of HTN head to toe:
**Head: ICP, OSA
Vascular: **Coarc, aortic valve dx, renal artery dx, umbilical a. cath with thrombosis, NF, vasculitis, atherosclerosis
Renal: **renal a. or vein thrombosis, RF, renal tumour, **parenchymal (GN, PCKD, RF)
Endo: **pheo (5% of NF pt), neuroblastoma, hyper-aldosteronism, **CAH, **cushing, **hyper thyroid, hyper parathyroid, GH
Drugs: **OCP, alcohol, nasal decongestant, **steroid, **stimulant
Other: white coat
Approach to HTN
- confirm
- BP R/O coarc
- U/A - renal
- W/U: BUN, Cr, lytes, CBC, renal US w/ doppler
- Screen end organ if > 95% tile= ECG, Echo, retinal exam
- Asymptomatic and no end organ find= lifestyle, reduce wt, diet, exercise, less salt, no smoking
If persist x 4-6 month or End-organ, symptomatic= - **ACEI/ARB, CCB, beta blocker 8. HTN Crisis= ABC, 2 IV, lower BP max 25% over first 8h - Labetalol - Hydralazine
6 y.o. child with HTN and persistent hypokalemia. Likely dx?
- Hyperaldosterone
- Bartter syn
- Addison
- Renal vein thrombosis
- Coarc
Hyperaldosteronism
VS.
Bartter= Low K, met alkalosis but not usually HTN
Addison= not enough adrenal hormone= poor steroid= low BP, high K and low Na
Hyperaldosteronism Classic PPT
HTN + Hypokalemia
- excess aldosterone = dump K but keep Na= HTN - etiology: > aldosterone producing adenoma > b/l idiopathic hyperaldosteronism > unnatural adrenal hyperplasia > familial hyperaldosteronism
Plasma renin low
Plasma aldosterone: renin (HIGH= good screen)
Tx underlying cause.
7 y.o. acute hematuria. Well. HTN. Initial Med to treat HTN:
- IV nitroprusside
- Salt and water restriction
- SL Nifedipine
S/L Nifedipine
Name 3 drugs and route to treat HTN emergency. List one AE for each.
- IV labetolol
Or IV esmolol
> *Bradycardia, Blurry vision - IV Hydralazine
> palpitation, *SOB - IV Sodium Nitroprusside
> *CP, palpitation - IV nicardipine
> *tachycardia, palpitation
NOTE: you can put palpitation for any of these except beta blocker.
Renal vein thrombosis. Etiology:
- UVC
- IDM with polycythemia and dehydration.
IDM w/ polycythemia + dehydration.
Causes of renal vein thrombosis: 1. Newborn: > dehydration > shock > maternal diabetes
2. Older: > nephrotic syn > cyanotic heart dx > hypercoag. state > sepsis
PPT:
- sudden hematuria
- +/- flank mass
- HTN
- oliguria
THINK of something other than nephrotic syndrome IF:
- < 1.5 y.o. or > 10 y.o.
- chronic dx
- HTN
- ARF
- extra-renal manifestation
- (+) FHX
Initial W/U and Tx for Nephrotic Syn
- CBC
- Lytes
- BUN
- Cr
- albumin
- glucose
- cholesterol
- ANA (if < 2 or > 10)
- Uri (dip and Pro:Cr ratio)
- Thinking ahead: VZV status, Hep B, Hep C serology, HIV, C3, C4
Tx: Steroids x 6 weeks
Edema= Albumin/Lasix, Fluid + salt restrict
If steroid dependent or steroid resistant nephrotic syndrome. What do we do?
- Prednisone
- Cyclophosphamide
- Consider MMF or Cyclosporine
- Bx
Most common cause of microscopic hematuria?
Idiopathic hypercalciuria and for gross= UTI #1.
How can you tell different GN apart that have systemic involvement?
> Multi- Sys= Lupus, ANCA vasculitides
> Only Pul= Granulomatosis with polyangitis, Anti-GBM dx, Lupus, HSP, IE, Pul edema
When should your C3 normalize after PSGN?
8 weeks
F/U BW then…
How do you treat PSGN?
- supportive
- fluid
- HTN (tx; resolves by 2wk)
Expectation:
- C3 back to N in 8 wk
- Proteinuria proteinuria usually gone by 4 month
T or F: 1% of all pt with HSP go on to develop ESRD.
True
T or F: ANCA dx have multi system ppt?
True
i.e. granulomatous w/ polyangiitis, microscopic, renal limited vasculitis etc.
- fever, migratory, arthralgia, wt loss
- skin, ENT, pul etc.
For HTN you need all BUT:
- ht
- sex
- age
- wt
Weight
Most common cause of HTN > 6 y.o.
Primary HTN
RF: fhx, obesity.
Most common cause of secondary HTN
Renal: parenchymal or renovascular.
Post solid transplant. What infections do they get?
Kidney transplant= high risk of UTI
Think Viral:
- CMV, VZV
- EBV
Think Opportunistic:
- Pneumocystis jiroveci
Think: Normal infections
How often should you follow simple kidney cyst?
Annual
Simple
= well defined, < 1 cm, < 3 total, unilateral, slow growth
CT if Ca2+, thick wall
Prenatal signs of PUV:
- severe b/l hydronephrosis
- echogenic kidney cysts
- large bladder: keyhole sign
- oligohydraminos (if severe obstruction)
Note: polycystic kidney disease require screening for cerebral aneurysms?
True
MRA every 2-3 yr.
