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
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)
3
Q
Nephritic syndrome
4 cardinal features
A
- hematuria
- proteinuria
- hypertension
- renal dysfunction
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
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
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
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
8
Q
Nephrotic syndrome
4 cardinal features
A
- proteinuria
- hypoalbuminemia
- edema
- hypercholesterolemia
9
Q
Complications of nephrotic syndrome
A
- infections (loss of IgG, complement factors)
- clots - loss of antithrombin III, protein C + S, hemoconcentrated/high fibrinogen
- shock, IV volume depletion
- hypercholesterolemia
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
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
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
13
Q
Non-anion gap metabolic acid
- DDX
A
Renal: RTA, renal failure
GI: diarrhea, pancreatic fistula
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
15
Q
RTA
- distal
A
Distal RTA (type 1)
- alkalotic urine (despite metabolic acidosis)
- hypercalciuria usually present
- hypocitraturia
16
Q
RTA - type 4
A
RTA type 4 = alodsterone issues
- decreased aldosterone secretion
- HYPERkalemia
- hyponatremia
17
Q
Nephrolithiasis - most common stones
A
- Calcium
other causes = struvite, uric acid, metabolic - cystinuria, xanthinuria etc
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
19
Q
Struvite stones features
A
- staghorn calculi
- urease-splitting organisms e.g. proteus
- often in urology pts with complex systems
20
Q
Tubulointerstitial nephritis (TIN)
- presentation
- causes
A
- sterile pyuria
- AKI
- renal tubular wasting
Causes:
- infection, drugs, collagen vascular disease, idiopathic
21
Q
Bartters
A
= genetic form of lasix (loop of henle)
- low Na, low K, low Cl, alkalosis, normal BP, high renin
22
Q
Gittelman
A
= genetic form of HCTZ (convoluted tubule)
- low Na, low K, low MAGNESIUM, alkalosis, high renin
23
Q
Nephrogenic diabetes insipidus
inheritance
A
90% = x-linked 10% = AR
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
25
HUS triad
- AKI (oliguric)
- anemic - coomb's negative hemolytic anemia, shistoctyes on smear
- thrombocytopenia
26
Treatment HUS
- avoid antibiotics if possible
- avoid giving platelets if possible
- treat AKI, 50% need dialysis
- 30% have long term sequelae
27
AKI - acute tubular necrosis
| features
- often consequence of pre-renal insult
- muddy brown casts (not RBC casts)/urine
- on recovery become polyuric
28
Clues for CKD vs. AKI
- anemia
- high parathyroid hormone
- small, shrunken, cystic, hyperechoic kidneys on u/s
29
CKD etiologies
1. CAKUT (50%)
2. genetic (15%)
3. GNs (15%)
30
Dialysis indications
- Acidoses
- Electrolyte - hyperkalemia, hyperphosphatemia
- Intoxication
- Overload
- Uremia
31
AD Polycystic Kidney disease
- 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
AR Polycystic kidney disase
- 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
Multicystic dysplastic kidneys
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
Significant antenatal hydronephrosis and management
>= 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
Cystinosis
- e.g. french Canadians
- cystine crystals in liver, eye, brain
present with nephropathic cystinosis, tubular dysfunction, fanconi syndrome
36
Low complement GN
- lupus nephritis
- acute post-infection GN
- membranoproliferative GN
Other: subacute bacterial endocarditis, shunt nephritis etc.
37
Goodpasture syndrome
positive anti-GBM antibody
features: pulmonary hemorrhage, iron deficiency anemia, nephritic syndrome
38
Complications post-infectious GN
- overload --> pulmonary edema, heart failure
- HTN
- PRES
39
Risk of rapid hyponatremia correction
central pontine myelonlysis
| = axonal demyelination and potential for brain damag
40
Emergency treatment of hyponatremia <120
- 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
Most common HUS etiologies
E.coli, shigella, shiga-like toxin producing e.coli (STEC)
- E.coli O157:H7
other: pneumococcal
42
Prune Belly Syndrome triad
1. abdominal muscle deficiency
2. severe urinary tract abnormalities (megaureter, VUR)
3. bilateral cryptorchidism
43
Nephrotic range proteinuria
urine dipsitic >3+, urinalyis >3g/L or urine PCR > 200mg/mmol
or urine protein > 3.5g/24hr
44
Nephrotic syndrome reasons for hospital admission
1. severe edema
2. impaired renal function
3. severe infection
4. thrombosis
5. symptomatic hypertension
45
4 types of RTA
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
Radiopaque vs. radiolucent stones
Radiopaque: calcium, struvite
Radiolucent (but often slightly opacified): cystine, xanthine, uric acid
47
Eval for child with history of nephrolithiasis/urolithiasis
- 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
Treatment for stones
- reduce dietary sodium
- dietary calcium at RDA
- daily fluid of 2-2.5L
- citrate
consider thiazide diuretics
49
Testicular torsion vs. torsion of appendix tests
- pain
- position
- cremasteric reflex
- blue dot sign
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
Treatment testicular torsion vs. torsion of testis appendix
Torsion: surgical reduction ideally within 4-6hrs of onset of pain
Torsion of appendix: NSAIDs and decrease activity
51
Imaging indications
1. voiding cystourethrogram
2. nuclear cystogram
3. renal scans
4. renal bladder ultrasound
5. urodynamic studies
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
45X/46XY mixed gonadal dysgenesis
| features
2nd most common DSD
- partially virilized
- assortment of mullerian and wolfian structures
- impalpable gonads
Mgmt: gender assignment, surgery, sex hormone replacement
53
Reasons to do an orchiopexy
- improve fertility
- improve ability to detect testicular cancer
- decrease the risk of future cancer
54
Congenital hydronephrosis
investigations
1. SFU grade 1-2, APD 7-10mm in 3rd trimester
2. SFU grade 3-4, APD>15mm in 3rd trimester
1. RBUS in first 1-3 months of life
| 2. RBUS in first 2 weeks of life, continuous antibiotic prophylaxis
55
Causes of high grade congenital hydronephrosis
1. ureteropelvic junction obstruction
2. high grade VUR
3. ureterovesical junction obstruction
4. posterior urethral valves
56
Suspected PUV postnatal management
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
idiopathic overactive bladder features
- 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
overactive bladder management
```
1st line:
- treat constipation and UTIs
- timed voiding q1.5-2hrs
- obervation is option
2nd line: anticholinergics
```
59
Diagnosis of renal stones
| and initial management
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
Hydrocele
- communicating
- non-communicating
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
Foreskin retraction
- age 6
- age 17
Age 6 yrs - 50% retract
| Age 17 yrs - 95% retract
62
Medical indications for surgical consultation for circumcision
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
Choice of antimicrobial for high grade VUR
- TMP/SMX or
- Nitrofurantoin
- if resistant to both then consider stopping
- if used, use for 3-6 months then re-evaluate
