Renal Flashcards
Renal CC hx/pe
Hematuria
Flank pain
Abdominal mass
Hypernatremia path, etiologies, presentation, dx, tx**
Usually 2/2 water loss, not Na gain
Hyperaldosteronism: inhibits ADH
Central / nephrogenic DI
Dehydration
Diarrhea
People who don’t drink enough: babies, demented folks
MS changes
Weakness
Doughy skin
Na >145
NS ==> D5W 1/2 NS once euvolemic
NS 1st prevents cerebral edema by normalizing slowly
Hyponatremia path/etiology, presentation, ddx/workup, tx
2/2 ADH increase, usually from hypovolemia
MS change
Hyporeflexia
Cramps
Measure serum osmolality:
- Hypertonic (>295) measure for glucose, mannitol, contrast overload
- Isotonic (280-295) ==> measure for glucose, lipid, protein, mannitol overload
-Hypotonic (AKI, CKD)
=hypervolemic & UNa cirrhosis, CHF, nephrotic
#euvolemic ==> psychogenic polydypsia, SIADH, hypothyroid, secondary adrenal insufficiency
@hypovolemia & UNa >10 ==> diuretics, primary adrenal insufficiency, RTA, metabolic alkalosis
@hypovolemia & UNa diarrhea, bleeding, vomit, burns
Water restriction: hypervolemia & euvolemia
Normal saline: euvolemia
*unless severe ==> hypertonic saline
*Slowly @ avoid central pontine myelinolysis!!!
Hyperkalemia etiologies**, presentation, dx, tx
- Spurious: hemolyzed blood draw
- Reduced excretion: renal insufficiency, type IV RTA, drugs: ACE-I, spironolactone/triamterene,amiloride, NSAIDs, trimethoprim*
- Cellular shift: lysis, rhabdo, exercise, insulin deficiency, acidosis, hyperosmolarity, drugs: beta-blockers, digitalis, succinylcholine
Colic
Areflexia
N/V/weakness
K+ > 5
-Repeat blood draw
-ECG: tall peaked T waves, QRS prolongation, PR prolongation, loss of P waves ==> sine waves ==> V-fib
**If: ECG changes and/or >6.5
1st: Calcium gluconate (stabilizes cardiac membrane)
Then:
bicarb / insulin + glucose / beta-2-agonist [albuterol] (drives K+ into cells)
Kayexalate [sodium polysterene sulfate] (removes K+)
**If no ECG change of K just sodium polysterene sulfate
-Dialysis if above fails
Hypokalemia etiologies, presentation, dx, tx
- Cellular shift: insulin, beta-agonists, alkalosis
- GI loss: diarrhea, laxative, vomiting
- Renal loss: type I RTA, hypomagnesemia, mineralcorticoid excess, hyperaldosteronism, bartter’s, gittleman’s, drugs: loops/thiazide diuretics, gentamicin, amphotericin
- Persistent hypomagnesemia (prevents K+ reabsorption)
Weakness
Cramps
Hyporeflexia
K+ < 3.6
IV K+
Mg repletion = essential
(Monitor ECG & K+ closely)
Hypercalcemia etiologies, presentation, dx, tx*
CHIIMPANZEES: Calcium supplement *Hyper: -thyroid & -parathyroid [most common] Iatrogenic: thiazides, TPN & Immobility* Milk-alkali syndrome Paget's Adrenal insufficiency & Acromegaly *Neoplasm ZE (e.g. MEN-1) Excess vit A Excess vit D Sarcoid & other granulomatous diseases
Stones
Bones: osteopenia & fracture
Groans: anorexia, constipation*
Tones: weakness, fatigue, MS change
Ca++ > 10.2
Order: ionized calcium, albumin, PTH, vitamin D
Immediate: normal saline +/- calcitonin
Long term/malignancy: bisphosphonate (zalendronate etc.)
If no other options: Furosemide ==> increase Ca++ excretion
Hypocalcemia etiology, presentation, dx*, tx
PhD-V-CAB-R:
Pancreatitis
Hypoparathyroidism
Hypomagnasemia
DiGeorge (baby in tetany)
Vitamin D deficiency
Blood loss requiring transfusion* (citrate in transfusion binds ionized calcium)
*Rhabdomylosis (calcium precipitates with phosphate release)
*Chronic kidney disease (low 1 alpha hydroxylation of vitamin D)
*Alkalosis (increases albumin affinity for ionized calcium, thus decreasing active ionized form)
*False hypocalcemia 2/2 hypoalbuminemia (i.e. proteinuria) ==> measure ionized only
Cramps Hyperactive tendon reflexes Tetany Parasthesias Chvostek: spasm 2/2 facial nerve tap Trousseau: carpal spasm 2/2 BP cuff
Ca < 8.5
Order: ionized calcium, albumin, PTH, vitamin D
ECG: prolonged QT
==> if PTH high, consider vitamin D or renal disease
==> if PTH low-normal, consider thyroid or parathyroid or other…
Calcium & Mag repletion
Hypomagnesemia etiologies, presentation, dx, tx
Intake: malnutrition (alcoholics!), bowel surgery, TPN
Loss: diuretics, diarrhea, vomiting, hypercalcemia
Other: DKA, pancreatitis
Hyperactive reflex
Tetany
MS change
ECG: prolonged QT or PR
Respiratory acidosis labs & ddx
pH 40
Narcotics
Lung disease
Obstruction
Metabolic acidosis labs & ddx
pH < 7.4 & pCO2 8-12 = Na + (Cl + HCO3) C-MUDPILES Chronic renal failure Methanol Uremia DKA Paraldehyde INH (isoniazid?) Lactic acidosis (2/2 shock, CO ingestion) Ethylene glycol Salicylates (aspirin)
Non-gap acidosis:
Diarrhea
RTA
Hyperchloremia
Type 1 RTA path, presentation, dx, tx
Inability to excrete H+ @ distal tubule ==> hyperexcretion of Na, Calcium, K, phosphate ==> non-anion gap acidemia, hypovolemia, hypokalemia, nephrolithiasis, nephrocalcinosis
2/2 multiple myeloma, autoimmune, amphotericin B
Renal stones
UpH >6
Hypokalemia
Hyperchloremic
Non-gap acidosis: 8-12, pH <40
Sodium bicarb & phosphate salts
Type 2 RTA path, presentation, dx, tx
Inability to reabsorb HCO3- @ proximal tubule ==> K+ & Na+ losses ==> non-gap acidemia
Multiple myeloma
Rickets & osteomalacia result over time
*No stones like type 1 RTA!
Hypokalemia
Hyperchloremia
Non-gap acidosis
Thiazides
*Don’t give bicarb! It will be excreted.
Na+ restriction to increase proximal reabsorption
Type 4 RTA path, presentation, dx*, tx
Hypoaldosteronism or tubular resistance to aldosterone (diabetics etc.) ==> decreased Na+ reabsorption & decreased H+ & K+ secretion @ distal tubule ==> HYPERkalemic non-gap metabolic acidosis
Diabetics
Intrinsic renal disease
No stones
Hyperkalemia*
Non-gap acidosis
Mineralcorticoid replacement
Furosemide
Pre-renal AKI path, presentation, dx, tx
Hypovolemia, renal artery stenosis, drugs (ACE-i, NSAIDs) ==> prostaglandin efferent arteriole dilation & RAAS efferent arteriole constriction to maintain GFR, thus BUN stays high
Hypovolemia (orthostatic hypotension)
BUN:Cr >20:1 Urine: hyaline casts FeNa < 1% UNa < 20 Urine osmolality > 500
Fluids
Uremia sequelae*
Pericarditis ==> pericardial rub
Intrinsic AKI path, presentation, ddx/dx*, tx
nephron injury 2/2 ATN, nephritis, embolic, rhabdo, drugs (NSAIDs, aminoglycosides)
Hematuria
Tea-colored urine
Foamy urine
Red casts: glomerulonephritis
White casts/eosinophils: AIN
Granular, muddy brown casts: ATN
BUN:Cr < 20:1, usually 10:1 because intrinsic injury prevents BUN reabsorption (ATN)**
FeNa > 1% (ATN)
UNa > 20
Urine osmolality < 300
Postrenal AKI path, presentation, dx, tx
Outflow obstruction 2/2 prostate disease, malignancy, stones
Distention
Bladder tenderness
White casts
Catheter
Ultrasound
Dialysis indications
AEIOU Acidosis Electrolyte abnormalities Ingestion Overload Uremia (pericarditis, encephalopathy, etc.)
CKD path, presentation, dx*, tx
> 3 months of GFR < 60
2/2 HTN, diabetes, nephritis, polycystic kidney disease
Uremia: malaise, anorexia, pericarditis, CNS change
Azotemia (elevated BUN & Cr)
Fluid overload
Metabolic acidosis
Anemia of chronic disease (2/2 decreased epo)
Hypocalcemia (2/2 decrease 1 alpha hydroxylation of vitamin D)
Hyperphosphatemia
Fluid restriction
ACE-i / ARBs
Epo analogs etc.
Polycystic kidney disease path, association
Bilateral cysts in kidney, spleen, liver, pancreas
Adult-onset: autosomal dominant (30-ish)*
Youth-onset: autosomal recessive
*Cerebral aneurysm!!!
Goodpasture’s path, presentation, dx*, tx
Cytotoxic antibody against GBM ==> rapidly progressing
Young men
Hematuria w/ dysmorphic cells & hemoptysis
No upper respiratory involvement (sinusitis, like Wegener’s)
Light: CRESCENT formation
Immunoflouresence: linear GBM deposits
Sputum: Hemosiderin-filled macrophages
Steroid pulses
Nephritic syndrome general path, presentation*
Inflammatory infiltration @ endothelial or mesangial areas ==> “tram tracking” 2/2 endothelial proliferation
PHAROH Proteinuria (mild) Hematuria (frank) Azotemia RBC casts Oliguria Hypertension
Nephritic syndrome ddx
Post-infectious glomerulonephritis IgA nephropathy / Berger's Wegener's Goodpasture's Alport's SLE nephritis
Post-infectious glomerulonephritis path, presentation, dx, tx
2-6 weeks post ANY infection (usually group A beta-hemolytic strep) ==> C3 complement deposition (?)
PHAROH
Low C3* ASO elevation RBC casts Light: hypercellular, lumpy bumpy EM: IC humps Immuno: granular* antibody deposition in GBM
Diuretics ==> self-resolving
IgA nephropathy name, path, presentation, dx*, tx
Berger’s*
2/2 GI or respiratory infection or Henoch-Schonlen purpura
Young male w/ PHAROH
Usually 2/2 URI or gastroenteritis
IgA deposits
Normal C3
Corticosteroids ==> can progress to ESRD
Nephrotic syndrome general path, presentation, risks, dx, tx
Non-inflammatory. Immune complex deposits occur @ sub-epithelial space, out of reach of circulating inflammatory cells
Edema Foamy urine (lipids + protein)
HYPERCOAGULABLE, esp. renal vein thrombosis*
Atherosclerosis 2/2 hyperlipidemia*
Strep pneumo infection
Proteinuria > 3.5 g/day Hypoalbumenemia Hyperlipidemia Relatively normal Cr Renal biopsy
Protein & salt restriction
ACE-i (decrease proteinuria)
Pneumo 23 vaccine
Minimal change disease presentation, dx, tx
Children, Hodgkins**, thrombotic events
Nephrotic >3g/day protein in urine Edema Hypoalbuminemia Light microscope: normal EM: fusion of foot processes
Steroids ==> resolves
Focal segmental glomerulosclerosis presentation*, dx, tx
Blacks, HIV, drug users, obese
Nephrotic >3g/day protein in urine Edema Hypoalbuminemia Microscopic hematuria Light microscope: tuft sclerosis & foot process fusion
Steroids
Membranous nephropathy other names, presentation*, dx, tx
Membranous glomerulonephritis
White adults
Most commonly associated with any malignancy other than minimal change w/ Hodgkins**
Nephrotic >3g/day protein in urine
Edema, hypoalbuminemia
EM: Spike & dome deposition of C3 & IgG
Steroids
Lupus nephritis presentation, dx, tx
Lupus
Nephrotic & nephritic
Mesangial proliferation
Subendothelial & subepithelial complex deposits
Steroids
Renal amyloidosis path, dx, tx
Plasma cell (multiple myeloma) or inflammatory (2/2 RA, TB etc.)
Nodular glomerulosclerosis
Apple-green amyloid deposits on Congo red stain under polarized light*
Prednisone
Membranoproliferative nephropathy path*/dx/tx
…is this the same as membranous glomerulonephritis above??
Multiple types (?)
IgG against C3 convertase causes C3 deposition in GBM
HCV, SLE
“Tram-tracking”: double-layered BM
Low C3
Steroids
Kidney stone presentation, general dx, general dx, general tx… ddx w/ tx
Intense flank pain radiating to genitals
Alkaline urine (except uric acid stones)
CT: gold standard bc some stones radiolucent
*Ultrasound: pregnant & children
Analgesia & fluid if 5mm 24 hour u/a if repeated event ------------------------ Calcium oxalate: -most common; idiopathic, hyperparathyroidism -radiopaque, alkaline urine -envelope shaped* -hydration, thiazides to decrease urine Ca+ excretion*, decrease Na+ intake*, normal to high calcium intake, decreased protein & oxalate*
Struvite (Mg-PO4)
- Urease-producing Proteus
- radiopaque, alkaline urine, STAGHORN
- surgical removal
Uric acid
- gout etc.
- RADIOLUCENT, acidic urine
- K+bicarb or K+citrate alkalization of urine*
Cystine
- AA transport defect
- radiopaque, hexagonal crystals, +cyanide nitroprusside test
- hydration
Polycystic kidney presentation, dx, tx
Pain, hematuria
Adult onset about 30
Palpable kidney
Ultrasound or CT
HTN control ==> dialysis ==> transplant
Hydronephrosis path, presentation, dx, tx*
Dilation of renal calyces 2/2 obstruction, often BPH ==> progresses to renal failure
Asymptomatic Pain Decreased urine output UTI hx BPH hx Hypertension, sepsis
Cr bump
Ultrasound or CT showing dilation of calyces
Surgery and/or catheter placement
Vesicoureteral reflux path, hx, dx, tx
Reflux of bladder urine backward ==> can progress to hydronephrosis & calyx damage
UTIs
Voiding cystourethrogram (especially if young child presenting with UTI)
Grade 1-2: no dilation
Grade 3-4: ureteral & pelvic dilation
Prophylactic TMP-SMX until resolved
Surgery if severe
Cryptorchidism path, risk, hx, dx, tx
Undescended testicle x1 or x2
Testicular cancer
Low birth weight, other syndromes
Can’t pull into scrotal sac
Orchioplexy
Hydrocele path, hx, pe, dx, tx*
Failure to close processus vaginalis ==> abdominal fluid leaks into scrutum
Painless
Transilluminating balls
*If persisting beyond 12 months, close to reduce hernia risk
Varicocele path, hx, pe*, dx, tx
Dilated pampiniform plexus
Dull aching pain
Worsened with valsalva*
Bag of worms in scrotum
U/S
Surgery if big or symptomatic
Epididymitis path/hx/pe/dx/tx
Epididymis infection usually 2/2 STD
Tender, relieved by lifting (+ Prehn sign)
UA, culture
U/S: increased flow to testes
Abx
Testicular torsion path/hx/pe/dx/tx
Torsion of testes
Intense pain, not relieved by lifting (- Prehn’s)
U/S: decreased flow to testes
Surgery
Erectile dysfunction presentation, dx, tx
DM
Atherosclerosis
HTN
Meds: beta-blockers, SSRIs
*Nocturnal or morning wood & situational dependence = psychological
Check for hypogonadism: prolactin, testosterone, gonadotropin
Check anal tone
Sildinafil etc.
BPH path, dx*, tx
Estrogen-sensitive enlargement of central zone
Digital rectal: uniformly smooth, firm \+ UA & culture: r/o hematuria, UTI \+ Creatinine: r/o obstruction ==> if blood, do biopsy! ==> if obstructed, to renal ultrasound
Alpha-blocker (terazosin) to relax prostate
5-alpha-reductase inhibitor (finasteride) to reduce dihydrotestosterone
Surgery if severe
Prostate cancer presentation w/ cord met warning signs*,
Urinary retention Back pain Constitutional Regional lymphadenopathy *Hyperreflexia, LE weakness, incontinence
DRE with asymmetric nodule
Usually non-tender (tender = prostatitis)
*Elevated PSA ==> biopsy + CXR + bone scan
Controversial…
Prostate routine screening
Yearly DRA after 50 years old
Hematuria ddx*
I PEE RBCSx2 Infection Polycystic kidney disease External trauma (urethra damage = blood early void)* Exercise Renal glomerular disease BPH Cancer (bladder > renal)* (bladder = blood/clot @ end void)* Stones Sickle cell trait: painless hematuria
Bladder cancer presentation, dx, tx
Smoking Schistosomiasis Analine dye Hematuria Urinary frequency/urgency
Biopsy
Chemo unless diffuse ==> cystectomy
Renal cell carcinoma path, presentation, dx, tx
Adenocarcinoma of tubular epithelium ==> spreads to IVC, lung, bone
Hematuria Flank pain Fever Palpable kidney Anemia L-sided varicocele (L gonadal blockage before draining into L renal vein whereas R gonadal drains into IVC) ==> unresolving when recumbent
Ultrasound or CT
Surgery / chemo
Testicular cancer presentation, dx, tx*
Male 15-34
Painless nodule on testis
Ultrasound
Tumor markers: beta-hcg and alpha-feto-protein (?)
NO BIOPSY: highly malignant and could seed by biopsying
Radical orchiectomy without biopsy!
Rhabdo labs**
Elevated: CPK, K+
Decreased: Ca++
Urinalysis: blood (2/2 myoglobin)
Urine sediment: few RBCs
Contrast nephropathy hx, tx*
Patient types: diabetics, baseline Cr > 1.5
Aggressive hydration
Non-ionic contrast
Acetylcysteine
Simple renal cyst dx*, tx
CT: symmetric, non-loculated, non-enhancing
No treatment
Diabetes insipidus path, presentation, dx**, tx*
Nephrogenic: ADH insensitivity 2/2 hypercalcemia, hypokalemia, meds (lithium, amphotericin, foscarnet, cidofivir, demecocycline)
Polydipsia
Polyuria* ==> ddx: DI, primary/psychogenic polydipsia, DM
Euvolemic hypernatremia
Decreased urine osmolality (dilute urine)
Water deprivation test: if urine osmolality increases significantly ==> primary polydipsia, if not, central vs nephrogenic DI
ADH analog test (arginine vasopressin or desmopressin DDAVP) ==> if urine osmolality increases ==> central DI
Salt restriction
Remove offending agent
DDAVP if central
Winter’s formula purpose & formula*
Testing appropriate respiratory compensation to metabolic acidosis
pCO2 = 1.5[HCO3] + 8
UTI dx, tx**
Uncomplicated:
-healthy patients w/ dysuria
++ dipstick: +esterase (pyuria) & +nitrite (Enterobacteriaceae coli)
==> TMP/SMX, nitrofurantoin, or fosfomycin
Complicated:
-comorbidities, pregnant, catheter
-requires dipstick & culture
==> floroquinolone or ceftriaxone
Cholesterol embolization presentation*, dx
Recent vascular procedure
Blue, mottled LE skin
Livedo reticularis
Renal failure
Urine: WBC
Most common cause of death in dialysis patients*
Cardiac
Early post-op renal transplant dysfunction ddx, dx, tx
Acute rejection ==> lymphocytic infiltration ==> IV steroids
Cyclosporine toxicity ==> measure levels
Ureteral obstruction
ATN
Aspirin ingestion dx*
Mixed anion gap metabolic acidosis + respiratory alkalosis (2/2 tachypnea)
Ethylene glycol ingestion dx
Anion gap metabolic acidosis
Calcium renal stones (envelope shaped)
CO inhalation acid-base path*
CO displaces O2 from Hb & shifts unloading curve such that O2 doesn’t unload ==> anaerobic metabolism ==> lactic acidosis
Renal vein thrombosis hx/pe
Nephrotic syndrome
Abrupt onset fever, abdominal pain, hematuria
Allergic interstitial nephritis (AIN) presentation*, dx, tx
Arthralgia
Rash
Renal failure
Drugs: sulfonamide, TMP, penicillin, cephalosporin, rifampin, allopurinol, NSAIDs, diuretics, captopril
Renal failure (Cr bump)
WBC casts
Urine eos
Prostatitis presentation*, dx, tx
UTI: dysuria
+pronounced systemic symptoms: fever, chills
“Boggy, tender” prostate
Dipstick + mid-stream urine culture
Only suprapubic catheter if necessary; AVOID catheter
TMP/SMX or floroquinlone 4-6 weeks
Metabolic alkalosis compensation formula use & formula*
For metabolic alkalosis to determine if respiratory compensation is correct
PaCO2 = (0.9 x Bicarb) + 16 +/-2
Hyponatremia ddx workup**
Reconcile this with above entries??
Hyperosmolar > 290 serum osmolality
==> renal failure or diabetes
Normal or hypoosmolar < 280
Urine Osmolality < 100 ==> primary polydipsia or beer potomania (malnutrition)
Urine Na > 25 ==> hypovolemia, CHF, cirrhosis
Urine Na < 25 ==> SIADH, adrenal insufficiency, hypothyroid
Acute tubular necrosis hx, dx*
Hypovolemia
Muddy brown cast
FeNa > 2%
UNa > 20
Urine casts & correlating diagnoses**
RBC: glomerulonephritis Fatty: nephrotic WBC: AIN & pyelonephritis Muddy brown: ATN Broad/waxy: chronic renal failure
Vomiting acid-base pathology*
Loss of HCl & KCl in vomit
HCO3- absorbed for each H+ vomited
RAAS tries to restore volume but reabsorbs HCO3
H+ exits cell to reverse alkalosis, K+ enters
==> hypochloremic hypokalemic metabolic alkalosis
Renal artery stenosis path, presentation**, dx*, tx
2/2 to fibromuscular dysplasia in young or atherosclerosis in old
Renal bruit
HTN
Headache
Hypokalemia
STENTING
Anemia 2/2 ESRD dx, tx*
Normocytic, normochromic anemia 2/2 EPO insuffiency
Trial Fe supplement first
Once Hb < 10 or Hct < 30 ==> EPO
EPO supplementation s/e*
Worsened HTN (common)
Headache
Flu-like symptoms
Post-op oliguria tx*
Bladder scan ==> catheterize if obstruction ==> assess for intrinsic or pre-renal if not
ESRD tx*
Living related donor > transplant for survival
Pyelonephritis path, presentation, dx, tx
Gram-negative, usually
Fever, chills
CVA tenderness
Dipstick & culture required**
*ultrasound to assess for obstruction or abscess IF empiric therapy fails
Start empiric therapy, oral or IV: floroquinolone or ceftriaxone*
Dialysis bleeding issue**/tx
Uremia ==> causes platelet dysfunction ==> only increased bleeding time
DDAVP
Diarrhea acid-base path*
Loss of HCO3- in diarrhea ==> non-anion gap, hypernatremic metabolic acidosis
Bartter & gittleman dx
Hypokalemic metabolic acidosis
Cryoglobulinemia hx/pe/dx*
Arthralgia
HCV
Palpable purpura
Hepatosplenomegaly
Glomerulonephritis
Glomerular structure
Afferent arteriole ==> endothelium ==> GBM ==> visceral epithelial podocytes ==> urinary space
Alport’s syndrome path, presentation, dx, tx
Hereditary glomerulonephritis
Young boys
Intermittent hematuria
Sensineural deafness & vision problems
Progresses to renal failure
EM: GBM “splitting”
Transplant
Rapidly progressive glomerulonephritis (RPGN) path, dx*
2/2 goodpasture’s, wegener’s, microscopic polyangiitis
Light: CRESCENT formation
Analgesic nephropathy path, presentation, dx
Renal ischemia 2/2 NSAIDs ==> papillary necrosis
Hematuria
Non-dysmorphic reds (glomerular injury causes dysmorphic reds)
