Nephrology and Urology Flashcards
What is Acute Renal Failure
Rapidly deteriorating glomerular filtration rate with accumulation of nitrogenous waste like urea and creatinine (Azotemia)
High Creatinine, Decreased GFR
What are the categories of Acute Renal Failure
Pre-Renal
Intrinsic
Post-Renal
Sx of Acute Renal Failure
N/V, Diarrhea, pruritis, hiccups, SOB
Tachycardia, hypotension, CVA tenderness, enlarged prostate, oliguria, change in volume status, edema
Dx of Acute Renal Failure
GFR and Cr measurement
BUN, but not as reliable indicator
Dx features of Prerenal Cause
Hyponatremia
Urine Osmolality greater than 500
Elevated BUN:Plasma Cr ratio
Dx features of Intrinsic Cause
Hypernatremia
Low Urine Osmolality
Decreased BUN:Plasma Cr ratio
Dx features of Postrenal Causes
Variable depending on cause
Tx of Acute Kidney Injury
Tx underlying problem
Prerenal: IV fluids, improved CO
Avoid triggering meds
Postrenal: Ureteral stends, urethral catheter
What is Chronic Kidney Disease
What defines each stage
Most common Causes
Progression of ongoing loss of kidney function
Stage 1: Normal GFR (>90mL/min)
Stage 2: Mild decrease in GFR (60-90)
Stage 3: Moderate decrease in GFR (30-60)
Stage 4: Severe decrease in GFR (15-30)
Stage 5: Kidney failure with GFR <15
DM is most common cause followed by HTN, Glomerulonephritis, PCKD
Sx of Chronic Kidney Disease
Patients typically become sx ate stage 3 and 4 with anemia, acidosis, hyperkalemia, hypocalcemia
Fatigue, anorexia, N/V, hiccups, dyspnea
Cachexia, weight loss, muscle asting, pallor
Dx of Chronic Kidney Disease
GFR is gold standard with Cockcroft-Gault Formula (needs patient age, body weight, serum creatinine) or Modification of Diet in Renal Disease Equation (MDRD), but the latter needs serum albumin and BUN as well
Microalbumin occurs early
Proteinuria
BUN and Cr are elevated
Tx of Chronic Kidney Disease
Ace-I/ARB Control HTN, DM, and Cholesterol Erythropoietin and iron supplements Restriction of protein, limitation of water, sodium and potassium Pneumococcal vaccine Hemodilaysis
What is Glomerulonephritis
Most common causes
Think Protein and RBC in urine
Damage of renal glomeruli by inflammatory proteins
Children: Post-infectious GN is most common
IGA Nephropathy, Post-Infectious, Membranoproliferative, Goodpasterus, Vasculitis
Dx of Glomerulonephritis
Hematuria, cola or tea colored urine Oiguria or anuria Edema of face and eyes HTN Antistreptolysin-O titer will indicate recent Strep Infection, indicating post-infectious GN UA: Hematuria, RBC casts, Proteinuria
Tx of Glomerulonephritis
Steroids
Salt and lfuid restriction
Ace-I/ARB
What is Nephrotic Syndrome
Types
Protein in urine, hypoalbuminemia, hyperlipidemia, edema
Excretion of more than 3.5g of protein in 24 hours
Minimal Change Disease (most common in children)
Focal Segmental Glomerulosclerosis
Membranous Nephropathy
Systemic disorders that damage kidney
Sx of Nephrotic Syndrome
Malaise, abdominal distention, anorexia, facial edema
Ascites, edema, HTN
Dx of Nephrotic Syndrome
UA: Proteinuria, Lipiduria, Glycosuria, Foamy Urine
Micro: Granular, Hyaline Casts, FAtty casts
Hypoalbuminemia, azotemia, hyperlipidemia
Tx of Nephrotic Syndrome
Ace-I, Diuretics
Sodium and water restriction to manage edema
What should you think about with each urinary pattern
RBC Casts
Muddy Brown Casts or Epithelial Cell Casts
White Blood Cell Casts, Pyuria
Waxy Casts
Hyaline Casts
RBC Casts: Acute Glomerulonephritis, Vasculitis
Muddy Brown Casts/Epithelial: Acute Tubular Necrosis
WBC Casts: Acute Interstitial Nephritis, Pyelonephritis
Waxy Casts: Chronic Acute Tubular Nephritis
Fatty Casts: Nephrotic Syndrome
Hyaline Casts: Nonspecific
What is Polycystic Kidney Disease
What is the most common form
Many cysts in the kidney, made of epithelial cells from renal tubules and collectins sytem
Autosomal dominant polycistic kidney disease is most common, almost always bilateral
Sx of Polycystic Kidney Disease
Back and Flank Pain Headaches Nocturia Hematuria, HTN, recurrent UTI Palpable flank mass
Dx of Polycystic Kidney Disease
Ultrasound
UA: Proteinuria, hematuria, pyuria, bacteriuria
Tx of Polycystic Kidney Disease
Supportive, Ace-I, increase fluid intake, decrease protein intake
What is Nephrolithiasis
Most common type
Kidney Stones
Calcium is most common, they are radiopaque
Which type of kidney stone in common in people with frequent UTI’s, abnormal kidney/urine anatomy, frequent catheterizations
Struvite
Sx of Nephrolithiasis
Back pain, renal colic that waxes and wanes
Hematuria, dysuria, frequency, fever, chills, N/V
Diaphoresis, tachycardia, tachypnea, restlessness, CVA tenderness
Dx of Neprholithiasis
UA: Hematuria
CT without contrast
Tx of Nephrolithiasis
Less than 5mm: Fluids, analgesics, alpha-blocker or CCB
5mm-10mm: Increased fluids, analgesics, elective lithotripsy or ureteroscopy with stent
Greater than 10mm: Percutaneous Nephrostomy, for Struvite too
What are features of Hypernatremia What causes it Sx Dx Tx
Too much salt or not enough water
Due to inadequate fluid intake or excess water loss: Deficit of thirst, urinary loss, GI loss, burns, osmotic diuresis, dosium excess, DI
Sx: Thirst, restlessness, irritability, disorientation, convulsions, coma, dry mouth, lack of tears
Dx: Plasma Sodium>145
Tx: Oral free water is preferred, IV or 5% dextrose solution in water or saline
Hypovolemia is treated first with Isotonic Saline or Lactated Ringers then Hypernatremia
Why do you need correct Hypernatremia slowly
It can cause pulmonary or cerebral edema especially in patients with DM
What are features of Hyponatremia What causes it Sx Dx Tx
Too much water/fluid intake not enough salt
CHF, Nephrotic syndrome, renal failure, Hypothyroidism, glucocorticoid excess, SIADH
Sx: Lethargy, disorientation, muscle cramps, anorexia, hiccups, N/V, seizures, weakness, agitation, hyporelfexia, Cheyne-Stokes, Delirium
Dx: Serum sodium <135
Tx: Treat underlying cause, suually needs fluid restriction
Why do you need to correct Hyponatremia slowly
Central Pontine Myelinolysis, resulting in neurologic damage
What is Diabetes Insipidus
Sx
Dx
Tx
Disorder of water
Central: No vasopressin produced
Nephrogenic: Kidneys are unresponsive to normal vasopressin
Sx: Polyuria, nocturia, polydipsia
Dx: Withold water, if patient continues to produce DILUTE urine
Nephrogenic: Give vasopressin and patient resopnds with decreased urine ouput and increase in urine osmolality
Central: No change in urine output or urine osmolality
Tx: Central: Give Desmopressin
Nephrogenic: Diuretics, HCTZ or other diuretics, limit salt and protein intake
What are features of Hyperkalemia
What do you see on EKG
Tx
Can result in dysrhythmia and cardiac arrest
Nubmness, tingling, weakness, falccid paralysis
EKG: Peaked T-waves
Tx: Calcium gluconate via IV, Sodium Bicarbonate, Glucose, Insulin to drive potassium back into cellular compartment
Sodium Polystyrene Sulfonate removes potassium from body
What are features of Hypokalemia
What do you see on EKG
Tx
Usually due to diruetics, renal butular acidosis or GI loss
Ventricular arrhythmias, hypotension and cardiac arres
Malaise, cramps, ileius, constipation
EKG: Flattened or inverted T-waves, U-Waves, Depression of ST segments
Tx: Ptoassium therapy in acute cases, if emergency IV replacement
What is Cystitis
Sx
Dx
Tx
Infection of the bladder usually by E.Coli and occasionally Gram-Positive Bacteria (Enterococci)
Sx: Frequency, rugency, d ysuria, suprapubic discomfort
May see gross hematuria
Dx: UA shows Pyuria, bacteriuria, Urine culture may be positive
Tx: Uncomplicated is FQ (Cipro) or Nitrofurantoin (Macrobid), Bactrim can be used for resistant
Complicated: FQ or Aminoglycosides
What is Pyelonephritis
Sx
Dx
Tx
Ifnectious process involving kidney parenchyma and renal pelvis
Usually due to E.Coli, Proteus, Klebsiella, Pseudomonas
Sx: Fever, Flank Pain, Shaking Chills, N/V, CVA tenderness
Dx: Leukocytosis, UA shows pyuria, bacteriuria, WBC casts
Tx: FQ or Bactrim for 1-2 weeks or Aminoglycoside
What is Prostatitis
Sx
Dx
Tx
Usually due to Gram-Negatives
Sx: Sudden onset of high fever, chills, low back pain and perineal pain, Frequency, urgency, dysuria, some obstruction
Prostate is swollen and tender
Dx: UA shows pyuria, hematuria and bacterieuria
Tx: FQ or Bactrim, if chronic use FQ for 1-3 weeks
NSAIDS, Alpha-1 Blockers for sx
What is Orchitis
Sx
Dx
Tx
Usually due to ascending bacteria from urinary tract
Associated with Mumps
Sx: Testicular swelling and tenderness, fever, tachycardia
Dx: UA shows pyruia, bacteriuria, positive cultures
Tx: If mumps is cause tx sx, ice, and analgesia
If bacteria is cause tx with Ceftriaxone and Azithromycin (if young men), or Cipro for older men
What is Epididymitis
Infection of epididymis usually spread through vas deferens
Young Men: Chlamydia and Gonorrhea
Older Men: E.Coli
Sx: Heavy, dull, aching discomfort, may radiate to flank, swollen testes, elanrged scrotal mass
Positive Prehn sign (relief with elevation), Positive Cremasteric reflex
Dx: UA shows pyruia and bacteriuria, culture shows organism
Tx: Young men tx like STD (Ceftriaxone and Azithromycin)
Older men tx with FQ (Cipro) for 10-14 days
What is Benign Prostatic Hyperplasia
Sx
Dx
Tx
Proliferation of fibrostromal tissue of prostate that leads to compression of prostatic uretrha, creates outlet obstruction
Sx: Hesitancy, straining, postvoid dribbling, sensation of incomplete emptying, frequency, nocturia, urgency
DRE shows uniformly enlarged prostate
Dx: DRE, PSA
Tx: 5-Alpha Reductase Inhibitors (Finasteride, Dutasteride) slow progression of disease
Phosphodiesterase-5-Inhibitors (Tadalafil, Verdenafil) alleviate sx
TURP
What are sx of Stress Incontinence
Leakage of urine with increased intra-abdominal pressure, like sneezing, coughing, laughing
Usually due to dysfunctional uretrhal sphincter allowing urine to leak with increased pressure
What are sx of Overflow Incontinence
Involuntary release of urine from overfull bladder
Absence of urge to urinate
Frequency, Urgency, Nocturia
Tx of Incontinence
Pelvic floor muscle training, bladder training
Anticholingerics like oxybutynin or tolterodine
What is Prostate Cancer
Sx
Dx
Tx
Adenocarcinoma
Sx: Urinary obstruction, irritative voiding
Dx: Elevated PSA, Biopsy using Gleason Grading System
Tx: Staging done by CT or MRI
Stages A and B tx with radical retropubic prostatectomy, or external beam readiation
Stage C same
Stage D with hormonal manipuation using antiandrogens, orchiectomy, LH-releasing hormone agonists or estrogen
What is Bladder Cancer
Sx
Dx
Tx
Tobacco exposure is most common reason, folllowed by occupational exposure from rubber, dye, printing and chemical industries
Uroepithelial tumors, most are transitional cell carcinomas
Sx: Painless hematuria, Bladder irritability and infection
Dx: Cytostcopy with Biopsy. IV urogram, Pelvic and abdominal CT, chest xray, retrograde pyelograph for staging
Tx: If muscle is involved, bladder must be removed, Chemo
What is Renal Cell Carcinoma
Sx
Dx
Tx
Adenocarcinoma is most common
Cigarette smoking is most common cause
Sx: Gross or microscopic hematuria, abdominal mass
Dx: Ultrasound to rule out stone, CT without contrast is diagnositc
Tx: Radical nephrectomy for localized
Radiation for disseminated to brain, bone, and lungs
Interferon-Alpha and Interleukin slow growth of cancer
What is Wilms Tumor
Sx
Dx
Tx
Nephroblastoma
Most common solid renal tumor in KIDS
Sx: Abdominal mass, anorexia, N/V, Fever, abdominal pain, hematuria
Dx: Abdominal CT is diagnostic, but ultrasound done first
UA first shows hematuria, ultrasound is initial study of choice to evaulate mass, then CT or MRI shows tumor extension, Chest Xray for mets assessment
Tx: Surgery, chemo and radiation
What is Testicular Cancer
Sx
Dx
Tx
Most common malignancy in YOUNG men
SEMINOMA is most common type, spread in stepwise fashion
Rf are cryptorchidism or previous hx of testicular CA
Sx: Painless, solid testicular swelling, Heaviness in testicle
Dx: Ultrasound first, followed by CT of chest, abdoimen and pelvis, CXR for mets
Tx: Seminoma is sensitive and simple (radiosensitive and no tumor markers), tx with radiation therapy, more severe stages use chemo
Nonseminoma has elevated alpha-fetoprotein or Beta-HCG, tx with Surgery or chemo
What is Phimosis
Sx
Dx
Tx
Inability to retract foreskin over gland penis
Sx: Erythema with tenderness, purulent drainage
Tx: Circumcision, Broad Spectrum Abx if infection present
What is Paraphimosis
Sx
Dx
Tx
Entrapment of foreskin behind glans penis
Usually seen in pts with frequent caths, vigorous sexual activity
Sx: Pain, edema, tenderness, erythema of glans and foreskin
Tx: Emergency, manual retraction first (squeeze glans to reduce tissue edema then try bringing foreskin back over glans), surgery if this fails, then referral for circumcision
What is Erectile Dysfunction
Sx
Dx
Tx
Consistent inability to maintain erect penis
Sx: Medications like antihypertensives (Beta Blockerss)
Dx: Rule out underlying biological causes with CBC, UA, Lipid, Thyroid
Tx: Phosphodiesterase-5 (PDE-5) inhibitor (sildenafil, Vardenafil, Tadalafil)
SE: Headache, flushing, dyspepsia, rhinitis, AVOID NITRATES WITH THIS may lead to severe hypotension
What is a Hydrocele
Sx
Dx
Tx
Mass of fluid-filled congenital remnants of tunica vaginalis
Sx: Soft, non-tender fullness of hemiscrotum
It does transilluminate, mass may wax and wane
Dx: Ultrasound, UA
Tx: Surgery
What is a Spermatocele
Sx
Dx
Tx
Painless cystic mass containing sperm, usually superior and posterior and distant from testes
Sx: Palpable, round, firm cystic mass with distinct borders, free floating above testicle which transilluminates
Dx: Scrotal Ultrasound
Tx: None needed, large ones may be removed surgically
What is Testicular Torsion
Sx
Dx
Tx
Abnormally twisted testis on spermatic cord, compromises arterial supply and venous drainage
Hx of Cryptocrhcidism is important
Sx: Sudden onset of severe unilateral pain and scrotal swelling
Testis are painful to palpation, Negative Prehn Sign, Negative Cremasteric Reflex
Dx: Doppler Ultrasound shows decreased blood flow
Tx: Surgery, must be done wtihin 6 hours to avoid infertility
What is a Varicocele
Sx
Dx
Tx
Formation of venous varicosity with spermatic vein (Pampiniform Plexus)
Sx: Chronic, nontender mass that does NOT transilluminate
Usually seen on left side
Bag of worms, increases in size with valsavla, decreases in size with supine
Dx: Doppler ultrasound
Tx: Surgery if painful or risk of infertility
What is the most common pathogen for Cystitis/Pyelonephritis
What is the Dx Gold Standard
Tx
E.Coli most common
Urine Culture is gold standard (clean catch)
UA shows WBC in urine, WBC casts indicates pyelonephritis
Tx: Analgesics: Phenazopyridine
FQ is 1st choice (Ciprofloxacin or Levofloxacin), Nitrofurantoin (Macrobid), Amoxicillin, Bactrim if resistant
What is Stress Incontinence
What is Urge Incontinence
What is Overflow Incontinence
Tx
Stress: Small volumes, coughing, sneezing, laughing
-Treat Stress with Kegel, Pessary, Surgery, Estrogen
Urge: Large volumes, spontaneous, nocturia, polyuria
-Treat Urge with Oxybutynin (anticholingerig) or Tolterodine (Anticholinergic) or Antispomadics (Solifenacin, Fesoterodine)
Overflow: Small, Dribbling, High residual Volume, due to Detruso Hypoactivity (inability to contract)
-Tx: Intermitten Catheter, Cholinergic (Bethanechol), Surgical repair
Which Kidney Stones are Radio-Opaque
Visible on Xray, Bright
Calcium (most common type) and Struvite
Which Kidney Stones are Radio-Lucent
Not visible on Xray but may be seen on Ultrasound
Uric Acid, Cysteine
Sx of Kidney Stones
Dx of Kidney Stones
Tx of Kidney Stones
Asymptomatic
Flank Pain, Episodic with radiation, Diaphoresis, Tachycardia, CVA tenderness
Dx: Non-Contrast CT, Renal Ultrasound (especially pregnant pts), UA shows hematuria and pH
Tx: Low sodium diet, increased fluids
>5mm: Fluids, Analgesics, Alpha Blockers
5-10mm: Lithotripsy, Ureteroscopy
>10mm: Ureteral Stent Placement, Percutaneous Nephrostomy
What is the treatment of Erectile Dysfunction
What should you be careful with
PDE-5 Inhibitors, careful with pts who take Nitrates because it can cause hypotension
Injection of Prostaglandins, Vacuum Erection Devices
What is Phimosis
Sx
Dx
Tx
Inability to retract foreskin over glans penis
Sx: Erythema with tenderness, may have purulent drainage
Tx: Refer for circumcision
Abx if infected
Which drugs used for BPH improve the clinical course vs. relieve sx
Improve Clinical Course: 5-Alpha-Reductase Inhibitors (Finasteride)
Improve sx: Alpha-Blockers (Prazosin/Terazosin/Doxazosin)
Which Male Disorder should you associated with MUMPS
Sx
Tx
Orchitis
Unilateral testicular swelling and tenderness, fever, tachycardia
Tx: Scrotal Elevation, Ice, Opioids or Injections for pain
