nephrology and urology Flashcards
most active secretion happens in the
distal convulted tubel
most reabsorption occurs at the
proximal tubule
early proximal convulted tuble
tubular reabsoprtion
acetazolamide and mannitol are diuretics that work on this
loop of hnle
thin descending loop of henre- passively absorbs H20, but does not let sodium and solutes through
THICK ASCENDING limb of loop of henley
impereable to h20 but allows na, k , cl via na/k/2cl trasportor reabsortpi on of magnesium and calciumloop diuretics work on this!!! ---STRONGEST class of diuretics!!
s.e of loop diuretics
hypocalcemia, hypomag, hypokalemia!!
thiazides
more likely to cause hyponatremia
early distal convuluted tuble
tubular SECRETION MAIN JOB!!- dilutes the urine!!
parathyroid hormone acts on the distal tuble to increase calcium reabsorption!!
THIazides also work on this- causing hyponatremia.
distal collecting tubule
determines the final oslmoalarity of urine (via aldosterone and ADH)
potassium sparing diuretics
associated with hyperkalemia and metabolic acidosis
hyperaldosteronism
associated with hypokalemia
ADH
peremable to H20 only in the presense of ADHD
present of ADH—> concentrated urine
ADH absence::: dilute urine
increased adh: production of a concentrated urine during times of hypoveolemia, hyperosmolarity and RAAS activation
nephrotic syndrome
proteinuria, hypoalmbuinemia, hyperlipidemia and EDEMA
glomerular damage causes tubular protein loss into the urine, urine loss of albumin ases hypoalbumin—which causes hyperlipideamia as liver makes more protein!! including lipoprotein
minimal change disease (nephrotic)
80% of nephrotic syndrome in children
podcyte damage seen on electron microscope- loss/fusion/diffuse effacement of the foot process
loss of negative charge
PREdENISON
focal segemental glomerucslerosis(nephrotic)
HTN- african american- heroin abuse
membranous nephropathy (nephrotic)
thickened glomerular basement membrane!!- idiotpathic!- caucsian male
secondary causes (nephrotic)
mc diabetes - for adults
nephoritc syndrome
edema, peripheral, periorital edeam, worse in morning, scorotal edema, DVT!!!
more than 3.5 g/day of urine is nephrotic syndrome
proteinuria, oval fat bodies, maltese cross shaped, hypoalbuminemia, hyperlipidemia
tx: direetics for edema, ACEI or ARBS for proteinuria
acute glomerulonephitis
htn, mehamturia, rbc casts, dependent enemia, azotemia
iga nephropathy- mc cause of agn in adults worldwide- igA mesangial deopsoits
post infectious: MC AFTER GABHS!!!!!cola clored/dark urine!!
increased antistreptolysis tigers, low serum complement
rapidly progressive glomerulephritis: goodpastuerus disease: anti gbm antibodies, kidney failure and hemoptysis- antibodies to glomerular basement membrae of kidney and lung alveoli
corticosteroids and cyclophosphamide
vasculitis: microscopic polyangitis- vasciulitis of small renal vessel: +p-anca
wegner’s: +c-anca: granulomatosis with polyangitis- necrotizing vasculitis!!!
acute glomerulonephritis
hematuria, peripheral, periorbital edema, cola colored/dark urine, oliguria, RBC cast,
DO RENAL BIOPSY!!
loss of protein and RBC loss!!
acute kidney injury
increased serum creatinine or BUN
prerenal
reduced renal perfusion- hypovoleia, MC type of AKI!!!
leads to intrinsic ATN if not orrected
volume repletion is tx
post renal
obstruction
intrinsic
direct kidney damage: nephrotoxic, cytotoxic, prolonged ischemia- cellular CAST formation!!
ischemic: prolonged prenrenal, hyoptension, hypovolemia
nephrotoxx: aminolycosdes, contrast dye, cyclosoproine- ATN MC type of intrinsic!!
epitehlia cell casts and muddy brown casts
remove offending agents, iv fluids
acute tubulointestial nephritis (intrinsic damage to kidney)
inflammatory or allergic response- penicillins, NSAIDS, SULFA, cephalosporin, cipro, autoimmune,
fever, eosinophilia, WBC CASTS ARE pathognomonic!!! increased serum IGE for allerGEEE
remove offending agents
urinary pattery
muddy brown or epithelial casts: acute tubular necoriss
rbc casts: acute glomerulphenritis
fatty casts: nephroti syndrome
hyaline cats: nonspecific (may be normla)
prerenal
fena less than 1%, decreased urine NA- it keeps all the sodium!!
high specific gravity- increased urine osmolarity
bun and cr ore tha n20:1
ATN
increased urine NA, FENA more than 2%- releases all the sodium out in the urine.! kidney is damaged and can’t really reabsorpt solutes
adult polycystic kideny disease
autosomal dominant
kidney cysts and cysts in other organs
can lead to ESRD over time
abd flank pain, palpable flank mass, htn, hematuriaRENAL ULTRASOUND!!!
simple cysts: ace and observation
multiple: increase fluid intake- control htn
chronic kidney disease
gfr less than 15 is ESRD dm is most common cause htn 2nd mc cause of esrd spot uablumin/ucreativene ration 24/hour urine coloection broad waxy casts small kidneys classic!! bp goal less than 140/90
siadh
posterior pitutary secrets ADH!!!- free water retention- adh is increased from pitutary or ectopic source
MC: STROKE, head trauma, cns tumors!!!
pulm: SMALL cell lung cancer
hypotnatremia!!
h20 restriction!!! cuz everytime u drink water- it gets retained otherwise!!
severe hyponatremia or intracranial bleed: iv hypertonic saline with furosemide
DIABETES INSIPIDUS
ADH (vasopressin deficiency) central DI or insensitive to ADH due to kidney problems!!
central DI mc type
nephrogenic: lithium!!
polyuria, polydipsia, ncturia!!, hypernatremia!
fluid deprivation test!!!- continues to produce dilute urine which is abnormal!
adh stimulations tests: differentiates nephro from central DI
if its nephro: continued production of dilute urine which is abnormal!!
central dI: replace adh- desmopressin!!
nephrogenic di: hydrochlorithiazide, na/protein restriction!
hyponatremia!!!
hypotonic hyponatremia is TRUE hyponatreia
if its normal serum osmlarity and hyopnatremia: lab error- increased protein and increased triglycerides
if its high serum osmolarity and hyponatremia: hyperglyemia and mannitol
in the true hypotnonic hyponatremia!!:
- hypovoleia- thiazides, extra renal loss like bleed, burns, n/vdiarrhea- correct with normal saline
isovolemia: SIADH, post op- WATER RESTRICTION!!
hypervolemic: chf, cirrhosis, nephrosis,–h20/salt restriction!!
hyponatremia
can cause cns dysunction to cerebral edema- ams, vomiting, muscle cramps,siezures, coma
hypernatremia
shrinkage of brain cells: cns dynsfucntion- seizures, coma, muscle waekness
hypovolemic: sweating, resp loss, gi loss, dehydration, severe hyperglycemia, osmotic diurectics
isoovelmica: diabetes inspidus
hypervolemic: mineralocorticoid excess
hypomag
malabsopriton, ETOHics!! proton pump inhibitors!
increased DTR, tetany, arrhythmias palpiations
prolonged PR and QT interval!!- can lead to torsades!!
mild: magensium oxide (ORAL)
severe: iv mag sulfate!!
(hypocalcemia and hypokalemia associated with hypo mag will need to be treated first)
hypermag
mg intake, renal insufficiency!!, acute or chronic renal failure
decreased DTR
respiratory depression!!!
mild: iv fluids and foresemide- leads to hypomag
severe: calcium gluconate!!- stabilizes cardiac membrane
hypokaelmia
mc: diuretic tehrapy!!, vomiting , diarrhea, metabolic alkalosis
severe muscle weakness, decreased DTR
prominent U waves, t wave flattening first
give potassium, kcl oral , hypokalemia increases risk of digoxin tox
hyperkalemia
t wave is tall!!
acute or chornic renal failure, ace/arbs/beta blockers, k sparing diuretics!
pseudohyperkalemia- venipuncture mc
weakness, flaccid paralysis,
iv calcium gluconate - stabilizes cardiac membrane
insuline
kayexlate!
epidiymitis and orchitis
men less than 35: chlamydia
men more than 35 and childrren: Ecoli most common
viral: mumps
postiive phren’s sign: elevation of scorotum relieves pain
positive remasteric refeex: testicle elevates after stroking inner thigh!!
pyruia, bacteriuria
DOXY plus ceftraixone for less than 35
flouroquinoes for e.coli - for children: ephalexin or amoxcillin
cryptorchidism
orchiopexy recommended at 6 months- performed before 1y ears old.
observation only if less than 6 months of age!!- most descend by 3 months!
testicular cancer
15-40 year old- mc solid tumor!!
MC RIGHT SIDED!!!!- because cryptorchidism mostly coccurs on the right side
seminoma!!!!- most common!= sesntiive to radiation, simple, slower growing , stepwise spread
non seminomas- more aggressive- associated with increased alpha fetoprotein, increased beta hcg
scrotal ultrasound!!
hydrocele
cystic testicular fluid collection- painless scrtoal swelling- most common
transillumination
vacicocele
testicular mass of vacicose veins- pampiniform venous plexus and internal spermatic veins
MC on the LEFT side!!!
bag of warms- can cause inferitility
dilation worsens when patient is upright or valsalva
cystitis
rare for males to have UTI!!!
women: intercourse-honeymoon cystitis, spermidcidal use!
e coli- most common cause for complicated and uncomplicated
pyelo; +cva tenderness , back/flank pain, nausea vomiting- pyuria.
IF WBC casts- pyelo
urine culture= DEFINITIVE DIAGNOSIS!!!- needs clean catch specimen if epithelia- contaminated
uncomp cystitis: nitrofurantoin, cipro, bactrim
complicated: flouro IV or po, aminoglycosides
pregnant: amoxicilin or nitrofurontoin
pyelo: cipro Po or IV, aminoglycosides!!!
prostatis
e coli: more than 35 years old
less than 35 years old: chamlydia and gonorrhea
e.coli!!!!- in chronic prosttius
fever, chills, frequency, urgency, PErinela pain in acute prostatius
acute pro: tender, normal or hot , boggy prostate
chronic: non tender, bogg prostate
no prostatic massage in acute prostatitsi
acute prost : cipro or bactrim
less than 35: ceftriaxone plus doxy
chronic prostitis: bactrim X 6-12 weeks!!! resection (TURP) for refractory
bph
prostate hyperplasia - bladder outlet obstruction, increased dihydrotestoestoner production
UNIFORMLY , ENLARGED< FIRM, RUBBEry prostate!!!
5alpha reductase inhibitors: finasteride- androgen inhibitor- inhibits coversion of testosterone to dihydrotestosterone- psitive effect on clinic course
alpha blockers: tamsulosin MOST urosselective- provides rapid symptom relief!!
surgery!- TURP
prostate cancer
adenocarcinoma
HIGH INCIDENCE OF METS TO BONE- back pain/bone pain!!, uretrhal obstruction!- HARD, NODULAR, eNLARGED ASSYMETRICAL!!! prostate: increased PSA!!! ultrasound with needle biopsy!!!
bladder cancer
TRANSITIONAL CELL - most common!!! smoking MC risk factor cyclophasphamide and pioglitazone!! cystoscopy with biopsy painless gross of microscopic hematuria
renal cell carincoma
smoking, dialysis, htn
flank pain, hematuria, palpable mass, left sided varicocle!!
wilm’s tumor
nephroblsatoma mc in children- 1-5 th year!!
painless, palpable abd mass , heamturia, anemia
abd ultrasound
nephrolithiassis
calcium oxalate MC!!
struvite- infection- proteus, kelbsiella- staghorn calciuli)
renal coliv, CVAT, hematuria, groin apain
non contrast CT ABD/pelvis- !!!!!! NON CONTRAST!!!!
only CALCIUM AND STRUVITE will show up on radiographs, not URIC acid stones!!
iv fluids, analgsic, antimetics, TAMUSOLOSIN!!- FOR STONES LESS THAN 5 mm in diamenter
FOR MORe than 7 mmg- extracorproean shock way lithrtripsy, stet
erectile dysunfciton
phosphodiesterase 5 inhibitors: sildenafil- increased nitric oxide level, cyclic GMP- maintain errction longer- dont use with nitrates!!
priapism
decreased venous outflow- MC! or increased arterial inflow
sickle cell disease- common in it!!
phenylephrine- 1st line!!!
URETHRITIS
urethral discharge or pruritis: CHAMydIA most common!!, or gonorrehea!!
neonatal: gonorreha if 2-5 days, chlamydai if 5-7
renovascular htn
htn!!!!!- ATHEROSCLEROSIS!!
abdominal BRUITS!!!
renal arteriorgraphy!!
stress inconvitnenceq
urine leaks cuz of increased intraabdominal pressure!!- pregnancy, childbirt, surgery, estroge loss, postmenopasual
sneeze, cough, laughing- urine leaks
pevilc floor exercise: kegel exercise,
urge incontinence
URGE to pee!!! detrusor muscle overactivity!! OVERACTIVE BLADADER!!! = bladder training first, or anticholitergics like oxybutynin- blocks cholinergic receptors or TCA!!!- have antichol efects
overflow incontinence
urinary REtentions DUE TO
UNDER ACTIVE BLADDEr
most commoly due to BLADDER ATONY!!!
intermittent or indwelilng catheteriziation!!!
even Bph can cause this!!
for bpha: tamsulosin
for bladder atony: cholinergics: bethancol!
