PANCE Prep- Nephro/Uro Flashcards
Most active secretion happens in ___
Most reabsorption happens in ___
DCT
PCT
If serum glucose rises about ___, it reaches saturation and spills into the urine
180mg/dL
SE of loop diuretics
Site of action and most unique use
- *HypoK+, hypoCa++, hypoMg++
- HypoNa+ (less than thiazides)
- Hyperglycemia
- Hyperuricemia- caution in gout
- Ototoxicity
- Sulfa allergy
- Hypochloremic metabolic alkalosis
Thick ascending loop of henle
Use: hyperCa++
SE of thiazide diuretics
Site of action and most unique use
- *HypoNa+ (more than loop diuretics)
- HyperCa++
- HypoK+
- Hyperglycemia
- Hyperuricemia- caution in gout
- Sulfa allergy
DCT
Use: nephrogenic DI
SE of K+ sparing diuretics
Site of action and most unique use
- HyperK+
- Metabolic acidosis
- gynecomastia (w/ spironolactone)
Collecting ducts/tubules- inhibits aldosterone
Use: CHF and hyperaldosteronism
SE of Mannitol
Site of action and most unique use
- Pulmonary edema
PCT
Use: intracranial HTN/shock
SE of acetazolamide
Site of action and most unique use
- hyperchloremia metabolic acidosis
- kidney stones
PCT
Use: intracranial HTN and Glaucoma*
What hormones affect kidney absorptions and secretion?
- PTH- increases phosphate excretion in PCT and Ca++ resportion in DCT
- Angiotensin II- increases Na/H20 resportion in PCT
- Aldosterone- increases Na resorption in Collecting ducts/tubules
- ADH- inhibits H20 resportion
Diagnostic Components of Nephrotic Syndrome
- Proteinuria (>3.5g/day on 24hr urine or 3-4+ on dip, UA shows “OVAL FAT BODIES “MALTESE CROSS SHAPED)
- Hypoalbuminemia (<3.4g.dl)
- Hyperlipidemia
- Edema (often periorbital in kids)- worse in AM
80% of nephrotic syndrome in children is due to ___.
Dx and Tx?
Minimal change disease
-etiologies: idiopathic, allergies, viral infection
DX: podocyte damage on electron microscope, loss of neg. charge of glomerular basement membrane
TX: prednisone
MC cause of focal segmental glomerulosclerosis (FSGS)
TX?
- HTN esp. in AA
tx: Corticosteroids/prednisone
Clinical manifestations of acute glomerulonephritis (AGN)
Dx and tx?
- HTN
- Hematuria*** (RBC casts and “cola-colored urine)
- Dependent edema (periorbital in kids)
- Proteinuria
- Azotemia (nitrogen in urine)
- fever
- Oliguria (decreased UOP)
DX: hematuria (RBC casts), proteinuria, high specific gravity
**Renal biopsy is GOLD STANDARD
TX: usually self-limited
-Rapidly progressive AGN or severe: corticosteroids + Cyclophosphamide
Causes of acute glomerulonephritis
- IgA Nephropathy (Berger’s Disease)- MC cause in adults worldwide (young males s/p URI or GI infection)
- Post infection- GABHS
- Membranoproliferative
- Rapidly progressive glomerulonephritis
- Goodpastures’s Disease
- Vasculitis/ Wegener’s
Dx and Tx of IgA Nephropathy (Berger’s Disease)
DX: IgA mesangial deposits on immunostaining
TX: ACEI +/- Corticosteroids
Nephrotic vs Nephritic Syndrome
Nephrotic:
- increased urinary protein loss
- Proteinuria, HYPOALBUMINEMIA, EDEMA**, HYPERLIPIDEMIA
- UA: FATTY CASTS, OVAL FAT BODIES “Maltese cross”
- Biopsy: HYPOcellular
Nephritic: via inflammation
- increased urinary protein loss AND RBC loss
- Proteinuria, HTN, AZOTEMIA, OLIGURIA, HEMATURIA (RBC CASTS), FEVER, FLANK PAIN
- UA: Hematuria, RBC casts
- Biopsy: HYPERcellular, crescent shaped in RPGN
RIFLE Criteria for AKI
and phases of AKI
Risk, Injury, Failure:, Loss and ESRD
Phases: Oliguric (maintenance)–> diuretic–> recovery
Hallmark of Intrinsic AKI: ____
Causes of intrinsic AKI:
hallmark: CELLULAR CAST FORMATION
Causes:
-
**Acute tubular Necrosis (ATN): prolong ischemia/hypovolemia vs nephrotoxic
- aminoglycosides, contrast dye, gout crystals, rhabdomylolysis, MM (Bence-Jones) - Acute tubulointerstital nephritis (AIN): inflammatory or allergic response
- PCN, NSAIDS, sulfa drugs, infections, autoimmune/idiopathic - Glomerular (AGN)
- Vascular
Dx and TX:
- Acute tubular necrosis
- Acute tubulointerstital nephritis
- ATN
DX: UA: epithelial cell cast and Muddy brown cast*
TX: remove offending agent, IVF (recovers in 7-21 days) - AIN
DX: UA: WBC casts are pathognomonic*, EOSINOPHILIA, increases serum IgE
TX: remove offending agent (recovers in 1 yr)
What are the following casts seen in?
- RBC casts
- Muddy brown casts
- WBC casts
- Waxy casts
- Hyaline casts:
- RBC casts- AGN or vasculitis
- Muddy brown casts- ATN
- WBC casts- AIN or pyelonephritis
- Waxy casts- (narrow) CHRONIC ATN or (broad) ESRD*
- Hyaline casts: nonspecific
Describe the urine Na+ and specific gravity in prerenal AKI and ATN AKI
Prerenal: LOW urine Na+ and HIGH specific gravity
ATN: HIGH urine Na+ and LOW specific gravity
DX:
- Abdominal/flank pain, palpable flank mass, HTN, hematuria,
- CERBRAL “berry” aneurysm, hepatic cysts, MVP, colonic diverticula
Adult Polycystic Kidney Disease (AD disorder)
DX: renal US
What can cause Hyper and hypo-phosphatemia
Hyper: causes muscle weakness/flaccid paralysis
- Renal failure (MC)
- Primary HypoPTH
- Vit. D. INTOX
Hypo: causes soft tissue calcifications
- Primary HyperPTH
- Refeeding
- Antacids
Causes of Chronic kidney disease
*first presenting sx/ single best predictor of disease progression
- DM (MC)
- HTN (2nd MC)
- Glomerulonephritis
1st: proteinuria- microalbumuria
**Best to test w/ SPOT U.Albumin/U. Creatinine ratio
(use spot over 24hr)
*metabolic acidosis seen later on
What are the 2 most important modifiable risk factors for CKD
- HTN (goal <140/90 w/ ACEI)
- proteinuria- restrict protein in diet (w/ ACEI)
*goal HgbA1c <6.5%
Complications of CKD
- Anemia of chronic disease (normochromic, normocytic)
* TX: oral FeSO4+/- EPO or Darbepoetin-alpha - Coagulopathy- platelet dysfunction, increased bleeding
- Osteodystrophy (bone and prox. muscle pain and pathologic fx)
- Osteitis fibrosis Cystica- periosteal erosions (“salt and pepper on skull xray”)
- Increased PO4 and HYPOCALEMEMIA
- LOW Vit. D (cannot be produced by kidney) and High PTH
When is dialysis indicated for CKD
GFR = 10mL/min or serum creatinine >/= 8mg/dL
What is SIADH and its etiologies?
increased ADH–> hypoNa and free water retention
***ISOVOLEMIC, Hypotonic, hyponatremia
Etiologies: 1. Stroke (MC), head trauma, post-op 2. Small cell lung CA 3. Meds: narcotics, anticonvulsants, Carbamazepine, IV cyclophosphamide, antidepressants (TCA/SSRIs), hydrochlorothiazide, ectasy "AC-CANE"
Tx of SIADH
- H20 restriction*
- Demelocycline (inhibits ADH)
- IV HYPERTONIC saline w/ furosemide
Etiologies of diabetes inspidius
- Central- decreased ADH production (MC)
- Nephrogenic- partial/complete insensitivity to ADH
*Large amounts of dilute urine (polyuria, polydipsia, nocturia, HYPERNATREMIA)
DX and TX DI
DX:
- fluid deprivation test- continues to produce dilute urine
- Desmopressin (ADH) stimulation test
- Central DI- reduction in UOP
- Nephrogenic- no change
TX:
- Central DI: Desmopressin/DDAVP or carbamazepine
- Nephrogenic: HCTZ, restrict Na+ and protein in diet
*if sx–> hypotonic fluid (oral is best)
The following conditions will cause what type of HypoNA+?
- CHF
- SIADH
- HyperTG or Hyperproteinemia
- Hyperglycemia or mannitol infusion
- Cirrhosis
- Nephrotic Syndrome
- CHF: HYPERvolemic hypoNa+
- SIADH: Iso/eu+olemic hypoNa+
- HyperTG or Hyperproteinemia: Isotonic HypoNa+
- Hyperglycemia or mannitol infusion: Hypertonic hypoNa+
- Cirrhosis: HYPERvolemic hypoNa+
- Nephrotic Syndrome: HYPERvolemic hypoNa+
*HYPOTONIC HYPONA+ IS CLINICALLY SIGNIFICANT (volume depletion)
What values go into calculating serum Osm?
2x [Na+] + glucose/18 + [BUN]/2.8
Etiologies, lab findings, and EKG findings for Hypo and Hyper- Mg++
Hypo:
- etiologies: malabsportion, ETOHics, PPIs, Loop/thiazide diuretics
- Labs: HypoMg, HypoK, HypoCa++ (increased DTRs), low PTH
- EKG: Prolonged QT and PR interval, Torsades
Hyper:
- etiologies: renal insuff./AKI/CKD, lithium
- Labs: HyperMg, HyperK+, HyperCa++ (decreased DTRs)
- EKG: Prolonged QT and PR interval, Hyper K- peaked T waves, short QR, wide QRS
EKG changes with Hypo and Hyper- K+
and TX
Hypo:
EKG: Flat T waves, prominent U waves
**ASSOCIATED risk with increased risk of Digoxin toxicity
TX: K+ replacement- tx hypoMg++ if present
Hyper:
EKG: Peaked T waves, flat P waves, short QR, wide QRS
TX: IV Calcium gluconate- stabilizes cardiac membranes
-Insulin w/ glucose (shifts K+ intracellularly)
-Kayexalate
-B2agonists
Epididymitis is usually caused by: ____
Orchitis is usually caused by: ___
Epididymitis: bacterial, >35y/o and kids: enteric organism (E. coli or Klebsiella), if <35y/o: Chlamydia*, gonorrhea
Orchitis: viral, Mumps**
DX and TX:
- gradual onset of scrotal pain, erythema, swelling, +/- fever
- Positive Prehn’s sign: relief of pain w/ elevation of affected scrotum
- Positive/normal cremasteric reflex
Epididymitis and Orchitis
DX: scrotal US: enlarged epididymis, increased testicular blood flow*
UA: pyuria/bacteriuria
TX: bed rest, elevate scrotum, cool compresses, NSAIDS
- Acute epididymitis s/s C and GN: Doxycycline + Ceftriaxone
- Acute epididymitis >35y/o: Fluoroquinolones, or cephalexin or amox for kids
DX and TX:
- abrupt onset of scrotal, inguinal or lower abdominal pain (usually <6hr), N/V
- Negative Prehns sign: no relief of pain w/ elevation of affected scrotum
- Negative cremasteric reflex
- Blue dot sign at upper pole
Testicular torsion
DX: testicular doppler US
TX: Detorsion and orchiopexy within 6 HOURS!
Who is at risk for cryptorchidism
complications?
Tx?
Risk: premature infants, low birth weight (MC on RIGHT SIDE**)
Complications:
- testicular CA (in both testes)
- subfertility
- testicular torsion
TX: Orchiopexy as early as 6 months (ideally before 1 y/o)
Types of testicular CA
MC 15-40y/o- MC on right side
- Germinal cell tumor (97%)- usually malignant
- Seminoma *MC- Simple (lack tumor markers), sensitive (to radiation), Slow growing, stepwise spread
- Nonseminomatous (increased AFP, BhCG and RADIOresistance - Nongerminal cell tumors
- Leydig
- Sertoli
MC cause of painless scrotal swelling
Hydrocele
if communicating: swelling worse w/ valsalva
TX: self-limiting or repair if persists beyond 1 y/o or communicating
Cystic testicular mass, “bag of worms” superior to testicle, dilation worsens when patient is upright or w/ valsalva
Varicocele (MC on LEFT SIDE)
*MC surgically corrected cause of male infertility
MC causes of cystitis and pyelo
TX
E. coli
Staph. saprophyticus in sexually active women
TX:
Phenazopyridine- no longer than 48 hrs (riske of methmoglobinuria, hemolytic anemia
- Uncomplicated: Nitrofurantoin, Fluoroquinolone (Cipro, Bactrim-DS)
- Complicated cystitis (prior tx failure or males): Fluoroquinolone PO or IV, Aminoglycoside
- Pregnancy: Amoxicillin or nitrofurantoin
- Pyelo: Fluoroquinolone PO or IV, Aminoglycoside
Urine culture must show how much growth for it to be a positive UTI
Women: >/= 10^5 (100,000)
Males: >/= 10^2-4 + symptoms
foreskin becomes trapped behind the corona of glans and forms a tight band, constricting penile tissue: ____
Inability to retract foreskin over the glans: ___
Paraphimosis- Urologic emergency!! tx is manual reduction +/- dorsal slit
Phimosis- tx is circumcision
DX and TX Prostatitis
DX:
acute: equisitely tender, normal/hot, boggy prostate
chronic: NONtender, boggy prostate
1. UA/culture: + in acute
2. AVOID PROSTATIC MESSAGE in ACUTE prostatitis
TX:
Acute:
>35y/o (E. coli MC): fluoroquinolones or bactrim
<35 (C, G MC): Ceftriaxone + doxy
Chronic: fluoroquinolones or bactrim x6-12 wks
-Transurethral resection of the prostate (TURP) for refractory chronic
DX and TX:
uniformly enlarged, firm, rubbery prostate with irritative sx or obstructive sx
DX: DRE, PSA
TX:
- observe: avoid antihistamines and anti-cholinergics
- 5-alpha reductase inhibitors (finasteride, duasteride)- reduces size but not immediate relief)
- alpha1 blocker (tamsulosin, doxazosin, terazosin)- relaxes smooth muscles- immediate relief
- TURP
Risk factors for prostate CA
- high fat diet, obesity, AA, adenocarcinoma*
***back/bone pain (increase incidence of METS to bones)
MC type of bladder CA and risk factors for bladder CA
Transitional cell (TCC) **highest recurrance rates of call cancers
RF: smoking (MC), occupational exposure to dyes, rubbers or leather, age >40, white males, Cyclophosphamide, pioglitazone
DX and TX:
hematuria, flank/abdominal pain, palpable mass, weight loss, L-sided varicocele, HTN, hyperCalcemia
Renal cell carcinoma
RF: smoking, dialysis, HTN, obesity, males
DX: CT scan usually first test
TX: radical nephrectomy
Nephroblastoma is MC in ______
presents as ____
DX and TX?
- kids w/in 1st 5 yrs of life
- painless, palpable abdominal mass, hematuria, HTN, anemia
- DX: abdominal US (best initial), CT w / contrast or MRI
- TX: nephrectomy followed by chemo
- 80-90% cure rate
types of kidney stones and their cause
- Calcium oxalate (MC)- increased protein, salt- inhibits Ca resorption
- Uric acid- high protein, increased purines
- Struvite stones (Mg ammonium phosphate)- may form staghorn calculi due to urea-splitting organisms (proteus, Klebsiella, psueudomonas, Serratia, enterobacter)
- Cystine (genetic)
kidney stone w/ urine pH >7.2 (alkaline) is mostly likely ___
associated w/ struvite stones
DX and TX kidney stones
DX:
- Noncontrast CT abd/pelvis (MC initial test)
- Renal US- look for hydronephrosis
- KUB radiograph: only for calcium and struvite stones
- Intravenous pyelography- Gold standard
TX:
<5mm in diameter: 80% chance of sponatenous passage
-IVF, analgesic, antiemetics, tamsulosin)
> 7mm: Extracorpeal shock wave lithotripsy
- Uretoscopy +/- stent- immediate relief for high risk
- percutaneous nephrlithotomy- large stones or struvite
Flaccid penile state is achieved by ____ stimulation
Erected penile state is achieved by ____ stimulation
flaccid= sympathetic stimulation erected= parasympathetic stimulation
Types of priapism and etiologies
Ischemic/low flow (MC): decreased venous outlfow
Nonischemic/high flow: increased arterial flow
Etiologies:
- idiopathic (MC)
- sickle cell
TX of low-flow and high-flow priapism
low-flow:
- phenylephrine*
- Terbutaline
- needle aspiration (esp. if >4hrs)
- shunt surgery
high-flow:
1. observation
MC causes of urethritis TX?
gonococcal- abrupt–> TX: ceftriaxone or azithro
non-gonoccal-chlamydia- 5-8 days –> TX: azithro or doxy
DX: nucleic acid amplification for both
Infant neonatal conjuncvitits (ophthalmia neonatorium)
Presents:
-2-5 DOL: ____ TX?
-5-7 DOL: ___ TX?
2-5 DOL: gonococcal- erythromycin ointment- risk for blindness otherwise
5-7 DOL: chlamydia: azithro
DX and TX of renovascular hypertension (renal artery stenosis)
DX: CT or MRA
-renal arteriography is gold standard*
TX: angioplasty w/ stent- definitive
-ACEI/ARBs- however CI if bilateral stenosis or solitary kidney
TX of enuresis
- Behavioral- motivation, education, reassurance
- Enuresis alarm- use if failed behavioral tx
- Desmopressin (DDAVP)- best for short-term use
- TCA (ex. Imipramine)- use if failed above
What type of urinary incontinence and cause?
- from sneezing, coughing, laughing
- nocturia*, frequency, small volume voids
- Small volume voids, frequency, dribbling, increased post-void residual >200
- Stress incontinence (increased intra-abdominal pressure, laxity of pelvic floor muscles ie child birth)
- Urge incontinence (detrusor muscle overactivity, overactive bladder)
- Overflow incontinence (decreased detrusor muscle activity/atony, underactive bladder)
TX
- Stress incontinence
- Urge incontinence
- Overflow incontinence
- stress- pelvic floor exercises, alpha agonists (midodrine,
pseudoephedrine) , surgery, devices, estrogen - Urge- bladder training, anticholinergics (oxybutynin, tolterodine), TCA (imipramine), Miragegron (B3 agonist-relaxant), surgical, diet
- Overflow- intermittent/indwelling cath*, cholinergics (bethanacol), BPH (alpha-1 blockers: tamsulosin)
