Renal Flashcards
RBC casts
Glomerular disease, vasculitis
WBC casts
interstitial nephritis, pyelonephritis
ATN
Hypovolemia, urine Osm >300, urine Na >20, FE Na>2% ——-> MUDDY BROWN casts/epithelium
CRF casts
Broad and waxy
EOSINOPHILIURIA, WBC casts, hematuria, rash, arthralgias
Drug-induced interstitial nephritis = lymphocytic or eosinophilic infiltration
Uncomplicated cystitis tx
Nitrofurantoin 5d, TMP-SMX 3d, Fosfomycin
Complicated cystitis tx (DM, CKD, obstruction, cath)
Fluoroquinolones + culture
Gross hematuria
Bladder cancer
Recurrent hematuria, child, deafness, thick+thin capillary + GBM splitting
Alport syndrome
Coffin lid shaped crystals
Urease producing UTI organisms
Most common type in elderly/nursing home
Urge
Sudden need when walking, drinking, large volume, nocturnal wetting
Urge
Causes/mech of urge incontinence
UTI, stroke, MS, dementia, Parkinson –> uninhibited detrusor contractions
Dx & Tx of urge incontinence
Urodynamic - timed-voiding/training –> oxybuntin, imipramine
Urine leak w/ laughing, sneezing, small PVRV
Stress - weak muscles
Tx stress incontinence
Kegel, estrogen, pessary, urethropexy
Urinary incontinence in woman of childbearing age
MS - Urge or overflow
Incomplete emptying, dribbling, frequency, PVRV >100ml, nocturnal
Overflow
Causes/mech of overflow incontinence
Poor contraction (DM, anti-cholinergics, a-agonist) or obstruction (BPH, CA, constipation)
Tx overflow incontinence
Intermittent cath, bethanachol, a-blockers
Can’t sense need to urinate
Reflex incontinence - SC injury»_space; MS, DM, disc, SC compression/tumor
Non-inflammatory chronic prostatitis
WBC <10
Inflammatory chronic prostatitis
WBC >10
Nocturia, difficulty starting stream, Cr 0.7, smooth firm prostate next step?
Urinalysis - hematuria/stones, infection, cancer, obstruction
Difficulty starting, nocturia, hesitancy, Cr 1.2 –> 2.1, smooth firm prostate next step?
Abd US –> hydronephrosis –> Foley –> TURP
Indication for prostate bx
Elevated PSA or nodule
Causes of priapism
Trazodone, prazosin, sickle cell, leukemia, SC, cauda equina, cavernous a ligation
Urgency, frequency, NO dysuria, difficulty starting urination, dribbling
BPH –> U/A, Cr
Tx for BPH
a-blocker (Tamsulosin), 5-a-reductase inhib (Finasteride), Foley –> TURP
Fever, N/V, + urine WBC, bacteria, tender DRE
Bacterial prostatitis –> UA & cx –> Cipro
Tx aseptic prostatitis
High dose NSAIDs
Sudden testicular pain, NO fever, horizontal testis, high riding
Testicular Torsion –> US or surgery untwist & b/l orchipexy
Sudden testicular pain, NO fever, bacturia, vertical, tender cord
Epidimytis –> US –> abx
Penis fracture work-up
Retrograde urethrogram + surgical exploration
Low urine pH and stone tx
Uric acid = K-citrate, limit protein
Hypercalciuric stone tx
HTCZ, hydration
Blood at end of urine stream
Bladder or prostate
Hematuria for entire stream
Kidney or ureter
Urine sodium <10, ascities, cirrhosis
Renal hypoperfusion - Pre-renal failure
Indication for cystoscopy
Hematuria suggesting stone, CA, stricture
Flank pain, hematuria
Kidney stone –> CT scan, U/S
Tx of kidney stone
Small 3cm = surgical; between = lithotripsy
Work-up of hematuria
CT scan, cystoscopy
Causes of acute urinary retention
anti-histamines, BPH –> cath for 3d –> a-blocker & 5-a reductase inhibitors
Pneumaturia work-up
Diverticulitis –> CT, sigmoidoscopy to r/o CA
Evaluate RLQ pain + urine crystals
Uric acid stones –> CT or IVP
Blood at meatus + scrotal hematoma, high riding prostate next step
Retrograde URETHROGRAM - pelvic fx
Hematuria + flank pain + mass
Renal cell carcinoma –> CT, bx –> resection and chemo
Hematuria, varicocele not empty supine, anemia + thromboytosis
RCC –> CT abd
Hematuria, hydronephrosis, hydroureter, smoking, b-alanine dye
Bladder CA –> US = hydro but 1st step = cystoscopy, best = bx, CT stage
Dribbling, urgency, frequency, difficulty starting urination
Prostate CA = 5-DHT (testosterone responsive)
When to get PSA
Firm, nodular DRE –> PSA for Dx
Work-up for Prostate CA
DRE –> PSA –> Bx rectal > urethral for Gleason score –> tx
Tx for prostate CA
Anti-androgens (Flutamide), GnRH analog (Leuprolide), orchiectomy, surgical +/- rads
Germ cell, painless mass
Testicular CA –> transilluminate fails –> orchiectomy
Seminoma tx
Platinum chemo + rad, follow LDH
Non-seminoma (yolk sac, choriocarcinoma, teratoma)
Follow AFP, b-HCG, teratomas are very malignant
Dialysis, excessive bleeding mech
Platelet dysfxn d/t uremic coagulopathy
Colicky abd pain –> stones Dx and prevention
CT –> NSAIDs –> inc hydration >2L/d, inc Ca, reduce protein, Na and oxalate in diet
HypoNa, low serum osmolarity, high urine
SIADH - NASAID use
Dehydration, HypoNa, low serum osmolarity
Mineralocorticoid deficiency
Indications for dialysis
HyperK, pul edema, pH<7.2, uremic pericarditis or enceph, coagulopathy
Associations w/ ADPKD
1 = hepatic cysts, MVP, MR< diverticula, hernias, berry aneurysm
Linear deposits, anti-GBM
Goodpasture’s (cytotoxic ab) –> emergency plasmapheresis
Contraction alkalosis, inc bicarb
Dehydration from furosemide
Prevent contrast induced kidney damage
Non-ionic contrast, NAC, IVFs or pre-tx w/ prednisone if allergic
1 cause of death in dialysis pts
Cardiovascular (#1 overall)
Cell mediated injury renal disease
Idiopathic crescentic GN
days after strep infection –> nephropathy
10 - pharyngitis, 21 - impetigo + LOW complement
Prevent urate crystal neuropathy in lymphoma and leukemia
Pre-tx w/ allopurinol
Hematuria, chronic headaches and analgesic use
Analgesic nephropathy –> ischemic vasa recta –> papillary necrosis
Primary glomerular damage –>
dec GFR –> pul edema, JVD, anasarca, proteinuria, RBCs, HTN
Oliguria w/ inc BUN, Cr - Acyclovir nephrotoxicity mechanism
Renal tubular obstruction - poorly soluble d/t poor hydration
Large amount of blood on UA but, 1 RBC on micro, hx seizure, inc Cr
Rhabdo –> myoglobinuria –> Acute RF
Chronic DM, HTN, 3+ proteinuria, retinopathy, Dec BUN
Diabetic nephropathy = microangiopathy
Recurrent stones, hexagonal crystals, + CN nitroprusside test
Cystinuria –> impaired dibasic a.a. transport
Benign renal cyst characteristics –> reassurance
Thin walls, simple, no enhancement, no divisions
1 umbilical artery assoc
Renal anomalies
1 newborn abd mass
Hydronephrosis
Right flank mass w/ calcification + hemorrhage, weight loss, inc HVA, VMA in urine
Neuroblastoma = neural crest cells, CROSSES midline (vs. nephro)
ASx proteinuria only on dipstick
Repeat on 2 subsequent occasions
Transient proteinuria causes
Fever, exercise, volume depletion, stress, seizure
Nephrotic proteinuria, podocyte effacement
Minimal change –> steroids
Inc serum globulin, 3+ proteinuria, edema, hyperlipidemia, periorbital swelling
Minimal change –> steroids
Hodgkin lymphoma renal disease
Minimal change, sometimes Focal
HIV + HepB renal disease
Membranouns
Renal disease assoc w/ cancers
Membranous
Nephrotic, HBV infection, sub-EPIthelial deposits
Membranous
Nephrotic syndrome, sudden fever, hematuria, abd pain
Renal vein thrombosis = MEMBRANOUS
A.A. HIV
FSGS
Heavy proteinuria, rapid renal failure, HIV+, sickle, Black, obesity, drugs
FSGS
Previous URI, now hematuria, RBC casts, normal complement GN?
IgA - <5d after URI, normal complement
- Berger IgA = days after URI
- PSGN = 1-2 WEEKS after infection
LE purpura, abd pain, hematuria, arthralgia, scrotal swelling
HSP –> IgA nephropathy
RA, enlarged kidneys, hepatomegaly, proteinuria
Amyloidosis - deposits under polarized light + fat pad Bx
Slow diabetic nephropahy
Add ACE
1st renal abnormality w/ DM
Glomerular hyperfiltration –> GBM thickening –> mesangial –> nodular sclerosis
Kimmelstiel-wilson nodules in GBM
Diabetic nephropathy
Etiology of hypercoagulation in nephrotic syndrome
Dec ATIII, dec protein C, S, inc platelet agg –> #1 RV thrombosis
Complications of nephrotic syndrome (think about dec proteins/albumin)
Fe resistant anemia d/t transferrin loss
VitD deficiency –> HyperPTH
Dec thyroxine
Inc infection
Systemic effects of nephrotic syndrome & hypoalbuminemia
Abn lipid metabolism –> faster atherosclerosis –> hypercoag –> Inc MI & Stroke
Low complement GNs
Post-infectious, MPGN, Lupus, Mixed cryglobulinemia
Acute bloody urine, edema, HTN
Step GN
RBC casts, peri-orbital swelling, oliguria, low C3
PSGN
Grannular deposits/immune complexes, low C3
SLE, PSGN
Nephrotic 4+ proteinuria, hematuria
MPGN
URI, hematuria nephropathy
IgA
Dense C3 intramembranous deposits
IgG (C3 nephritic factor) MPGN-II = persistent complement activation
Crescent formation
RPGN
Rapid onset nephritic, hematuria, renal insufficiency
Crescentric
Acidotic, hypoK, urine pH high, fam hx kidney stones
RTA-I
RTA I
No H+ secretion in urine = low ammonium production by tubules
Dec bicarb reabs, Fanconi
RTA-II
RTA II
Defective bicarbonate reabsoprtion, fanconi & carbonic anhydrase inhibitors
HyperK, hyperCl acidosis, uropathy, cystic kidneys
RTA-IV
Renal insufficiency, hyperK, non-anion gap acidosis w/ low Bicarb
Renal tubular acidosis - 4 = aldosterone deficiency, worse w/ ACEs, DM
UTI management
7-14d abx
Renal and bladder US indications
<24mo, recurrent febrile, no abx response
UTI prophylactic abx indications
Grade III-IV vesicoureteral reflux
Indications for voiding cystourethrogram
Hydronephrosis, scarring, high reflux, obstruction, recurrent
Chronic UTI, IVUP shows blunted calyces, scarring Dx
Chronic pyelo