Nephrology + Urology Flashcards
amount of Na and Cl in NS
154 mEql/L
Insensible Losses?
300-500 ml/m2/day
Anion Gap met acidosis DDX
Methanol Uremia DKA/other ketoacidosis Paraldehyde/paracetamol/acetaminophen Iron/Isoniazid/IEM Lactic acidosis Ethanaol/ethylene glycol Salicyclates/ASA
Marker of acid excretion in the urine
NH4+
Urinary anion gap - equation and what is it normally?
Na + K - Cl
should be negative
if not - urine is not being acidified
what is normal urine pH
~6.0
Types of RTA
Type 1 - distal = impaired H+ secretion hypokalemia hypercalciuria renal stones
Type 2 - proximal (faconi - cystinosis)
=impaired bicarb reabsorption
hypokalemia
Type 4
= decreased aldosterone secretion/aldosterone resistance
HYPERkalemia
Type 2 RTA - main cause
cystinosis
Hypertension
- cutoffs for 1-13yo
- elevated:
>/= 90th % to < 95th %
OR
120/80 to < 95th %
- stage 1 htn: >/= 95th % to < 95th % + 12 OR 130/80 to 139/89 (whichever is lower)
- stage 2 htn:
>/= 95th % + 12
OR
>/= 140/90
Hypertension
- cutoffs for >13yo
- elevated:
120/<80 to 129/<80 - stage 1 htn:
130/80 to 139/89 - stage 2 htn:
>/= 140/90
what are BP cutoffs based on
sex
age
height
Mgmt: elevated BP
1) lifestyle
2) repeat BP in 6 mo
- if elevated at 6mo, do UE + LE BP, lifestyle, recheck in 6mo
- if elevated at 12mo, do ABPM + dx evaluation
Mgmt: Stage 1 htn
1) lifestyle
2) recheck in 1-2 weeks
- if stage 1 at 1-2w, do UE + LE BP, lifestyle, recheck in 3mo
- if stage 1 at 3mo, do ABPM + dx evaluation + start tx
Mgmt: Stage 2 htn
1) UE + LE BP + lifestyle
2) recheck within 1 week
- if stage 2 at recheck, do ABPM + dx evaluation + start tx
Diagnostic evaluation for elevated BP/htn
U/A BUN, Cr, lytes Lipid Profile Echo Fundoscopy Renal U/S if <6yo
medical treatment for hypertension
ACEi
ARB
CaCh blocker
thiazide
What type of htn when can you not play sports
stage 2
Hypertension
- most common cause
Babies: vascular (RAS, CoA, RVT, ARPCK)
<6yo: Renovascular
> 6yo: Essential
most common cause of Type 1 RTA
idiopathic
which type of RTA can have nephrocalcinosis
Distal/type 1
What type of RTA is Fanconi syndrome
Type 2
Investigations for End organ damage
1) Echo
2) Retinal examination
3) Albumin-to-creatinine ratio (1st AM)
Screening investigation for new dx of htn?
U/A
Chem: BUN, Cr, lytes
Lipid profile
Renal U/S if <6yo
if obese:
HbA1C (DM)
AST, ALT (NAFLD)
Fasting lipid panel
VCUG: what does it dx
Degree of VUR
PUV
best test for: PUV
VCUG
best test for: UPJ
MAG-3 lasix or DPTA lasix
best test for: renal scarring
DMSA scan
best test for: overall kidney funcion
GRF
UPJ obstruction: where is it
as ureter coming out of kidney
Multicystic dysplasic kidney
- describe both kidneys
NON functioning kidney (cysts - no renal tissue)
One solitary functioning kidney
15% will have contralateral VUR
Orthostatic proteinuria
- how to dx
- tx
Dx: 3 consecutive first AM urine pn: negative
normal serum albumin
(need to show
no tx
What can cause transient proteinuria
Exercise
Fever
Infecton
Nephrotic syndrome
- age
- characteristics
- mgmt
- Age 2-10 yo
- Heavy proteinuria
- Generalized edema
- Hypoalbuminemia
- Hypercholesterolemia
Normal BP and kidney fn
Can have hematuria
Normal C3
Actually decreased effective circulation
Mgmt
- Steroids: prednisone 60mg/m2/day for 4-6 weeks and then wean
- Edema: albumin/lasix
What is steroid resistant nephrotic syndrome
no response to steroids
or
relapse after 2 weeks
Nephrotic syndrome
complications
Infection
Hypercoagulable state/thrombosis
Hyperlipidemia
Fluid overload
Hematuria
- ddx
Hypercalciuria with nephrolithiasis
IgA nephropathy
PSGN
Exercise
Nephrotic dx
24 hour urine collection:
protein > 3.5g/day
>50mg/kg/day
>40mg/m2/hr
one time urine protein to creatinine
>200mg/mmol
Nephritic syndrome
- dx
- other features
DX:
gross hematuria
hypertension
RBC or granular casts
Common:
proteinuria
azotemia (incr BUN/Cr)
edema
IgA nephropathy
features
labs
young adults
microscopic hematuria
gross hematuria when sick
Normal C3 and C4
IgA increased in 50%
Low C3 ddx
lupus PSGN MPGN C3 glomerulopathy shunt nephritis endocarditis
renal mass newborn ddx
MCDK
Hydronephrosis
Renal vein thrombosis
PIGN
- peak age
- classic presentation
- labs
5-15yo
presentation: - gross hematuria - edema - hypertension after GAS infection (cellulitis, pharyngitis)
low C3
normal C4
ANA negative
ASOT may be elevated
PIGN
when do the following resolve:
gross hematuria
proteinuria
low C3
microscopic hematuria
gross hematuria: 1-2 weeks
proteinuria: 1-2 weeks
low C3: 6-8 weeks
microscopic hematuria: up to 1 year
HSP
- other name
- presentation
- labs
- prognosis
- followup
Henoch-Schonlein Purpura
IgA vasculitis
joint + abdo pain
rash
renal involvement
(hypertension)
Normal C3
Elevated IgA
Microscopic hematuria, macroscopic hematuria
Albuminuria
Mixed nephritic-nephrotic syndrome (severe cases)
normal CBC and coats
Usually self limited
Monitor for 6 months w urine dipstick and ACR
Hemolytic uremic syndrome
- triad
- microangiopathic hemolytic anemia
- thrombocytopenia
- renal insufficiency
Alport syndrome
- inheritance
- clinical features
- associations
X linked
(females can have mild)
- microscopic hematuria
- hypertension
- proteinuria
- renal failure by 2-3 decade
- hearing loss
- anterior lenticonus
Prune belly syndrome
- triad
1) Abdo wall musculature partial/complete absence
2) B/L cryporchidism
3) urinary tract malformation (hydronephrosis/ureter, bladder distension, urinary tract obstruction, VUR)
Chronic kidney disease
- stages
1: >90%
2: 60-90%
3: 30-60%
4: 15-30%
5: <15%
Indications for dialysis
A: Acidosis
E: electrolytes anomalies:
(HYPERKALEMIA),Hyperphosphatemia
I: Intoxication: methanol,Ethylene glycol, ASA
O: fluid overlaod
U: uremia symptoms (encephalopathy, pericarditis, seizures, bleeding)
First steps in mgmt of likely testicular torsion
NPO
Surgical consult
(don’t wait doing US if likely torsion)
Ddx Torsion
Testicular torsion
Torsion of the appendix testis or appendix epididymis Infectious epididymitis/epididymo-orchitis
Inguinal hernia
Key features of testicular torsion
- sudden severe pain
- tender throughout testis
- can be high riding
- can be transverse lie
- often absent cremasteric reflex
- can have a recite hydrocele
Nuclear cystogram
- what does it look for
VUR
not PUV
What scan provides info on renal filtration function and drainage
MAG3 diuretic Renal Scan
MAG3 diuretic Renal Scan
Provides info on filtration function & drainage from urinary collecting system
DMSA Renal Scan
Only provides information on function
Congenital Adrenal Hyperplasia
- inheritance
- most common type
Autosomal recessive
21-hydroxylase deficiency
Role of hydrocortisone in CAH
to restore cortisol & suppress further virilization by providing negative feedback to the hypothalamus and pituitary gland
What hormones do the testes excrete in sexual development
Sertoli: AMH
Leydig: testosterone
3 potential anomalies for hypospadias
- Foreskin is incomplete ventrally
- Urethral meatus not at tip of penis
• Ventral proximal meatus - Erections curve downward (AKA chordee)
most common fetal anomaly
Congenital Hydronephrosis
Antenatal hydronephrosis:
when to do ultrasound
3rd trimester APD
7-10mm: in first 3 months
> 15mm: in first 2 weeks
Causes of high grade congenital hydronephrosis
High grade VUR
UPJO
UVJO
PUV
UPJO presentation
Sig hydronephrosis without hydroureter
PUV
- where is abnormality
- presentation
- key sign on US
bladder outlet obstruction - Bilateral sig hydroureter and hydronephrosis in a Male - distended thick walled bladder *key hole sign
VUR
sig hydroureter and hydronephrosis
First line investigation for kidney stones
Renal bladder ultrasound
second line: CT
Kidney stones: mgmt
Analgesics +/- α blockers (tamsulosin)
Hx calcium oxalate stones: how to prevent
- Add lemon or orange juice to water
- Increase fluid intake
- Reduce sodium intake
most common type of kidney stone
calcium oxalate
Imaging for UTI
RBUS for first febrile UTI < 2yo
VCUG (or NC in female) for those w/ an abnormal RBUS or if have a 2nd febrile UTI
When to refer to nephrologist or urologist for UTI
VUR IV-V or significantly abnormal RBUS findings
acute tubular necrosis
- secondary to
- most common cause
- presentation
- recovery phase
- secondary to hypoxic or nephrotoxic event
- most common cause AKI
- edema, elevated Cr/BUN and decreased UO
- recovery phase: diuretic phase
Pathophys of cerebral salt wasting
Clinical presentation
some kind of brain injury leads to renal Na wasting - > hyponatremia and volume depletion
and ADH turns on
hypovolemia
concentrated urine
How to treat hyponatremia
if <120 and sx present, Treat with 3% saline until symptoms resolve
then
slow correction < 0.5mmol/l/hr or =10- 12mmol/day
what lab to do to look for cystinosis
Leukocyte cysteine
Investigation for older child w hydonephrosis
Nuclear scan with Lasix washout
how to diagnose UPJO
Renal Diuretic scan – DTPA Lasix scan
Diabetic nephropathy
- dx
- tx
First morning urine showing albumin:creatinine ratio (ACR) >2.5mg/mmol on two occasions
Treatment: ACE inhibitors
Nephrotic syndrome
- treatment starting dose
60mg/m2 for 6 weeks (max 60mg)
then start to wean slowly
Nephritis table low C3, renal limited low C3, systemic N C3, renal limited N C3, systemic
low C3, renal limited: PIGN
low C3, systemic: SLE
N C3, renal limited: IgA nephropathy
N C3, systemic: HSP, Alports
PIGN/PSGN
- mgmt
- Fluid and salt restriction
- Furosemide (1-2mg/kg/day)
- Short-acting or long-acting antihypertensive medications: Nifedipine/Hydralazine or Amlodipine
- AKI management - <1% will require dialysis
- Antibiotics, if associated with GAS infection
anti epileptic that causes bilateral renal calculi
topiramate
MCKD - associations (3)
- hypetension
- contralateral VUR
- Wilms
Simple cyst - mgmt
follow
no investigations if simple
Barter syndrome
hypokalemia, alkalosis, hyperaldosteronism, polyuria, polydipsia, hypercalciuria and salt wasting
** like giving somone too much Lasix!!! (hypoK, met alkalosis, increased Ca in urine, polyuria)
most common cause of microscopic hematuria
Hypercalciuria
most common cause of gross hematuria
cystitis
struvite stone - cause
UTIs caused by urease-splitting organisms
how to diagnose Hypercalciuria
- initial investigates
24 hr urinary calcium excretion
Initial evaluation = urine culture, then spot urine for hypercalciuria with a calcium: creatinine ratio in culture-negative patients
what vaccine to give to someone with nephrotic syndrome
23 valent pneumococcal
(at least 8 weeks after the last dose of the 13-valent pneumococcal conjugate vaccine)
should be >3 months off prednisone
When to refer inguinal hernia
right away
when to refer for undescended testes
by 6-9 months
won’t descend after 4 mo
Protein on dip stick - false positive
concentrate urine exercise fever gross hematuria semen
when is a renal cyst not simple
calcifications
loculations
septae
thickened walls
hypertensive crisis - how to treat
IV hydralizine bolus IV Labetalol bolus or infusion IV nicardipine infusion IV Sodium Nitroprusside (venodilator) IV Nicardipine (calcium channel blocker)
How fast to correct Na
6-8 per day
Potassium - what do you need in labs
Serum and urine K
Serum and urine osmolarity
How to tell if aldosterone is working appropriately
TTKG
hypokalemia - expect TTKG <5
hyperkalemia - expect TTKG >8
- if this is not the case it means aldosterone is not working
Hyperkalemia - EKG
Peaked T waves
Shortening of the QT
Prolonged PR
Widening of QRS
Hematuria - dx
5 or more RBC per HPF in 3 consecutive samples
False positive hematuria
myogloburia, hembloginuria drugs toxins food urate crystals
membranoproliferative GN
looks like PIGN initially
but C3 persists
and you may have elevated Cr
benign familial hematuria
Autosomal dominant
microscopic hematuria, occasional gross
proteinuria and HTN unusual
FAMILIAL
(FHX)
Definition of AKI
Acute decrease in GFR causing increase in serum Cr
