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Nephrology Flashcards

1
Q

Glomerular testing

A
  • large protein proteinuria (albuminuria) or urine albumin or PCR
  • hematuria/casts on microscopy
  • Cr, BUN, GFR, lytes, PO4, Ca, VBG (usually high levels of K, PO4 in serum) (anemia nad high PTH may be seen)
    Imaging: DTPA-GFR nuclear med scan
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2
Q

Tubular testing

A

Urine: mild, small protein proteinuria, tubular indices: glucosuria, aminoaciduria, phosphaturia, Na, K etc
Blood: Cr, BUN, GFR, lytes, PO4, Ca, VBG (usually low levels of K and PO4)

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3
Q

Nephritic syndrome

4 cardinal features

A
  • hematuria
  • proteinuria
  • hypertension
  • renal dysfunction
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4
Q

Post-infection GN

- features

A
  • 10-14 days after infection (strep)
  • C3 level is low (normal within 8-12 weeks)
  • ASOT is high
  • proteinuria should disappear by 6 months
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5
Q

HSP GN

- features

A
  • IgA mediated small vessel vasculitis
  • skin, joints, GI, kidneys
  • 40% of HSP develop nephritis (within 6 months)
  • symptomatic control
  • possible steroids for severe skin/GI/renal involvement
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6
Q

IgA nephropathy
- features
= red flags

A
  • URTI trigger
  • gross hematuria 1-2 days after URTI
  • only lasts a few voids/days
    Tx = ACEi or ARB or steroids if severe
    Red flags: First Nations, male, persistent proteinuria, renal dysfunction at dx, evidence of frank nephritic/nephrotic
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7
Q

Low complement GN

A
  • SLE nephritis - low C3 and C4
  • MPGN - low C3 that persists
  • PIGN - low C3 resolves in 8-12 weeks
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8
Q

Nephrotic syndrome

4 cardinal features

A
  1. proteinuria
  2. hypoalbuminemia
  3. edema
  4. hypercholesterolemia
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9
Q

Complications of nephrotic syndrome

A
  1. infections (loss of IgG, complement factors)
  2. clots - loss of antithrombin III, protein C + S, hemoconcentrated/high fibrinogen
  3. shock, IV volume depletion
  4. hypercholesterolemia
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10
Q

Red flags for nephrotic syndrome (7)

A
  • African Canadian
  • age < 1 yr, or pubertal
  • renal failure
  • gross hematuria
  • unresponsive to 4 weeks of steroids
  • HTN
  • features of SLE, malignancy, infection
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11
Q

Benign orthostatic proteinuria

A
  • seen in up to 5% of teen population
  • positive orthostatic test (first am urine PCR normal, afternoon is elevated)
  • will outgrow by age 20-30
  • may need to monitor
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12
Q

Wide anion gap metabolic acidosis

differential

A

MUDPILES

  • methanol
  • uremia
  • DKA
  • propylene glycol, paraldyhyde
  • iron, isoniazid
  • lactic acid
  • ethyanol, ethylene glycol
  • solvents, saliculates
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13
Q

Non-anion gap metabolic acid

- DDX

A

Renal: RTA, renal failure
GI: diarrhea, pancreatic fistula

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14
Q

Renal tubular acidosis - proximal

A

Proximal RTA (type 2)

  • acidosis
  • renal K wasting (possibly hypokalemia)
  • renal Na wasting (possible hyponatremia)
  • renal PO4 wasting (posisbly hypoP and renal rickets)
  • aminoaciduria
  • high urine alpha-1MG
  • glucosuria
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15
Q

RTA

- distal

A

Distal RTA (type 1)

  • alkalotic urine (despite metabolic acidosis)
  • hypercalciuria usually present
  • hypocitraturia
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16
Q

RTA - type 4

A

RTA type 4 = alodsterone issues

  • decreased aldosterone secretion
  • HYPERkalemia
  • hyponatremia
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17
Q

Nephrolithiasis - most common stones

A
  • Calcium

other causes = struvite, uric acid, metabolic - cystinuria, xanthinuria etc

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18
Q

Treatment of calcium stones

A
  • high fluid intake
  • low Na intake
  • citrate therapy
  • HCTZ for hypercalciuria
  • treat hypercalcemic states
  • rarely: ESWL shock wave lithotripsy or surgery
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19
Q

Struvite stones features

A
  • staghorn calculi
  • urease-splitting organisms e.g. proteus
  • often in urology pts with complex systems
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20
Q

Tubulointerstitial nephritis (TIN)

  • presentation
  • causes
A
  • sterile pyuria
  • AKI
  • renal tubular wasting

Causes:
- infection, drugs, collagen vascular disease, idiopathic

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21
Q

Bartters

A

= genetic form of lasix (loop of henle)

- low Na, low K, low Cl, alkalosis, normal BP, high renin

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22
Q

Gittelman

A

= genetic form of HCTZ (convoluted tubule)

- low Na, low K, low MAGNESIUM, alkalosis, high renin

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23
Q

Nephrogenic diabetes insipidus

inheritance

A 
90% = x-linked
10% = AR
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24
Q

Alport’s features

A
  • X-linked 85% (rarely AD or AR)
  • mutation in type 4 collagen (GBN)
  • hematuria and proteinuria, renal dysfunction over time
    other manifestations: hearing loss, ocular (anterior lenticonus), lyomeiyoma
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25
Q

HUS triad

A
  • AKI (oliguric)
  • anemic - coomb’s negative hemolytic anemia, shistoctyes on smear
  • thrombocytopenia
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26
Q

Treatment HUS

A
  • avoid antibiotics if possible
  • avoid giving platelets if possible
  • treat AKI, 50% need dialysis
  • 30% have long term sequelae
27
Q

AKI - acute tubular necrosis

features

A
  • often consequence of pre-renal insult
  • muddy brown casts (not RBC casts)/urine
  • on recovery become polyuric
28
Q

Clues for CKD vs. AKI

A
  • anemia
  • high parathyroid hormone
  • small, shrunken, cystic, hyperechoic kidneys on u/s
29
Q

CKD etiologies

A
  1. CAKUT (50%)
  2. genetic (15%)
  3. GNs (15%)
30
Q

Dialysis indications

A
  • Acidoses
  • Electrolyte - hyperkalemia, hyperphosphatemia
  • Intoxication
  • Overload
  • Uremia
31
Q

AD Polycystic Kidney disease

A
  • AD inheritance
  • HTN age 30-50, CKD age 50-80
  • large kidneys with macrocysts
  • extra-renal manifestations: heart, brain, cysts
  • diagnosis AUS and positive fam hx (genetics)
32
Q

AR Polycystic kidney disase

A
  • enlarged (massive) kidneys with microcysts (diagnosed in utero)
  • 1/3 die by pulmonary hypoplasia
  • HTN common and CKD
  • liver disease may occur
    dx: genetics
33
Q

Multicystic dysplastic kidneys

A

Generally not inherited

  • usually unilateral (fatal if bilateral)
  • kidney replaced by cysts and does not function
  • contralateral hydronephrosis present in 5-10%, usually low grade VUR
  • risk of HTN, Wilms
34
Q

Significant antenatal hydronephrosis and management

A

> = 7mm in 3rd trimester

- manage with RBUS in first 1-3 months of age but within first 2 weeks if high grade aka >15mm and do prophylaxis

35
Q

Cystinosis

A
  • e.g. french Canadians
  • cystine crystals in liver, eye, brain
    present with nephropathic cystinosis, tubular dysfunction, fanconi syndrome
36
Q

Low complement GN

A
  • lupus nephritis
  • acute post-infection GN
  • membranoproliferative GN

Other: subacute bacterial endocarditis, shunt nephritis etc.

37
Q

Goodpasture syndrome

A

positive anti-GBM antibody

features: pulmonary hemorrhage, iron deficiency anemia, nephritic syndrome

38
Q

Complications post-infectious GN

A
  • overload –> pulmonary edema, heart failure
  • HTN
  • PRES
39
Q

Risk of rapid hyponatremia correction

A

central pontine myelonlysis

= axonal demyelination and potential for brain damag

40
Q

Emergency treatment of hyponatremia <120

A
  • water restriction
  • 3% NaCl in some cases
  • only correct high enough to improve mental status
    NOT faster than 0.5 meq/L/hr or 12 meq/L/24hr
41
Q

Most common HUS etiologies

A

E.coli, shigella, shiga-like toxin producing e.coli (STEC)

  • E.coli O157:H7
    other: pneumococcal
42
Q

Prune Belly Syndrome triad

A
  1. abdominal muscle deficiency
  2. severe urinary tract abnormalities (megaureter, VUR)
  3. bilateral cryptorchidism
43
Q

Nephrotic range proteinuria

A

urine dipsitic >3+, urinalyis >3g/L or urine PCR > 200mg/mmol

or urine protein > 3.5g/24hr

44
Q

Nephrotic syndrome reasons for hospital admission

A
  1. severe edema
  2. impaired renal function
  3. severe infection
  4. thrombosis
  5. symptomatic hypertension
45
Q

4 types of RTA

A
  1. Proximal (type II) RTA = From impaired bicarb reabsorption
  2. Classic distal (Type I) RTA = From failure to secrete acid
  3. Hyperkalemic (Type IV)
  4. And combined proximal and distal (type III)
46
Q

Radiopaque vs. radiolucent stones

A

Radiopaque: calcium, struvite

Radiolucent (but often slightly opacified): cystine, xanthine, uric acid

47
Q

Eval for child with history of nephrolithiasis/urolithiasis

A
  • serum: calcium, PO4, uric acid, electrolytes and anion gap, creatinine, ALP

Urine: U/A, urine culture, Ca:Cr ratio, spot test for cystinuria, 24hr collection for: creatine clearance, calcium, phosphate, oxalate, uric acid, dibasic amino acids (if cystine spot test is positive)

48
Q

Treatment for stones

A
  • reduce dietary sodium
  • dietary calcium at RDA
  • daily fluid of 2-2.5L
  • citrate
    consider thiazide diuretics
49
Q

Testicular torsion vs. torsion of appendix tests

  • pain
  • position
  • cremasteric reflex
  • blue dot sign
A

Torsion: pain is severe, sudden, with n+V, tender throughout scrotum; may be high riding or transverse, cremasteric reflex often absent
Appendix torsion: mild to severe pain, gradual onset and localized to upper pole, cremasteric reflex often present, the blue dot sign is rare but pathognomonic!

50
Q

Treatment testicular torsion vs. torsion of testis appendix

A

Torsion: surgical reduction ideally within 4-6hrs of onset of pain
Torsion of appendix: NSAIDs and decrease activity

51
Q

Imaging indications

  1. voiding cystourethrogram
  2. nuclear cystogram
  3. renal scans
  4. renal bladder ultrasound
  5. urodynamic studies
A
  1. VCUG - grades of reflux, only test to confirm PUV
  2. Nuclear cystogram = VUR in females only
  3. Renal scans- assesses differential renal function; DMSA shows scarring, Mag3 diuretic shows obstruction
  4. U/S - anatomic imaging
  5. UDS: assess bladder function
52
Q

45X/46XY mixed gonadal dysgenesis

features

A

2nd most common DSD
- partially virilized
- assortment of mullerian and wolfian structures
- impalpable gonads
Mgmt: gender assignment, surgery, sex hormone replacement

53
Q

Reasons to do an orchiopexy

A
  • improve fertility
  • improve ability to detect testicular cancer
  • decrease the risk of future cancer
54
Q

Congenital hydronephrosis
investigations
1. SFU grade 1-2, APD 7-10mm in 3rd trimester
2. SFU grade 3-4, APD>15mm in 3rd trimester

A
  1. RBUS in first 1-3 months of life

2. RBUS in first 2 weeks of life, continuous antibiotic prophylaxis

55
Q

Causes of high grade congenital hydronephrosis

A
  1. ureteropelvic junction obstruction
  2. high grade VUR
  3. ureterovesical junction obstruction
  4. posterior urethral valves
56
Q

Suspected PUV postnatal management

A
  1. stabilize if resp issues
  2. urgent postnatal RBUS
  3. bladder decompression
  4. serial serum creatinine levels
  5. consult with nephro: fluid, acid-base, electrolyte management
  6. consult with urology for surgical management
57
Q

idiopathic overactive bladder features

A
  • no neuro anomalies
  • frequency > 8 voids per day
  • urgency
  • urine holding postures
  • small functional bladder capacity
  • commonly associated with: constipation, recurrent cystitis and nocturnal enuresis
58
Q

overactive bladder management

A 
1st line: 
- treat constipation and UTIs
- timed voiding q1.5-2hrs
- obervation is option
2nd line: anticholinergics
59
Q

Diagnosis of renal stones

and initial management

A

Dx: RBUS (may miss small stones), if confirmation then do CT spiral abdominal scan (CT KUB)
Management: - conservative = analgesics +/- alpha blockers
- interventional tx if: too large to pass, unremitting pain, persistent severe obstruction, solitary kidney or infected, obstructed kidney

60
Q

Hydrocele

  • communicating
  • non-communicating
A

Communicating: congenital defect, risk of indirect hernia, surgical repair at 18 mo

Non-communicating: may be resolution of communicating hydrocele but may also be reactive (infection, inflammation, trauma, tumour)
- refer if large/bothersome

61
Q

Foreskin retraction

  • age 6
  • age 17
A

Age 6 yrs - 50% retract

Age 17 yrs - 95% retract

62
Q

Medical indications for surgical consultation for circumcision

A
  1. scarred phimosis
  2. recurrent balanoposthitis
  3. recurrent UTIs
  4. Delayed retraction of the foreskin > 10 yrs of age
    * referral ideally follows a failed course of topical steroids for 2-4
63
Q

Choice of antimicrobial for high grade VUR

A
  • TMP/SMX or
  • Nitrofurantoin
  • if resistant to both then consider stopping
  • if used, use for 3-6 months then re-evaluate

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