Renal Flashcards
Potter sequence
- Lung hypoplasia –> death
- Flat face
- Low set ears
- Defects in extremities - club feet
Assoc w/ Oligohydramnios
- B/L adrenal aplasia
BL kidneys cysts containing cartilage and other abnormal tissue
Dysplastic kidney
NON-inherited (vs. PKD)
Hispanics & Blacks with Proteinuria >10g, lipiduria, edema
HIV, heroin, sickle cell
Effacement of foot processes
NO response to steroids
FSGS
- Collapsing w/ HIV
- can be a progression of minimal change
Caucasian adult male with hematuria, proteinuria mild HTN
HBV, HCV, Tumors (lung & colon), SLE, drugs, DM
Thick BM, Sub-EPIthelial deposits - SPIKE & DOME
Granular IC deposition of IgG4 to PLA2R
Membranous
- SLE usually nephritic
Pt w/ HCV, cryoglobulinemia or IVDU with palpable purpura, weakness, arthralgia, red and fatty casts
MPGN
TRAM-TRACK
I - sub-ENDOthelial - HBV, HCV, early complement
II - intramembranous - C3 nephritic factor
- low serum complement
Non-enzymatic glycosylation –> hyaline arteriosclerosis of EFFERENT –> hyperfiltration –> microalbuminuria
Diabetic nephropathy
Sclerosis of mesanigum = Kimmelsteil-wlison nodules
ACE-I slow progression
Light chain casts Kidney = most common Large amorphous nodular mesangium Apple-green birefringence Congo red
Amyloidosis
Primary = AL light chains, multiple myeloma Secondary = AA
Massive proteinura, no HTN, no hematuria in Kids or adults w/ NSAID abuse
Normal glomeruli
Foot process effacement - t-cell cytokines
RESPONDS to steroids (vs. FSGS)
Minimal change
Assoc Hodgkin lymphoma*
Muddy/Brown, granular casts, oliguria, elevated BUN, Cr, hyperK w/ acidosis
Acute Tubular Necrosis = PROXIMAL TUBULE
Dec GFR
- BUN:Cr 2%
- Urine Osm <500
Ischemic - MI
Nephrotoxic - aminoglycosides, lead, ethylene glycol, contrast
Pre/Post-Renal azotemia
Pre - Dec RNF
Post - Obstruction downstream
BUN:Cr >15
Osm 500
Fractional Na excrestion (FENa) 2%
AD - PKD
AD
HTN - inc renin
hematuria
BERRY ANEURYSM, hepatic cysts, MVP
AR - PKD
AR mutation on PKHD1
SMOOTH, sponge-like kidneys (vs. AD)
Infants w/ HTN
Hepatic fibrosis & cysts
SLE w/ nephrotic
Membranous
SLE w/ nephritic
Diffuse proliferative
Sub-endothelial, granular deposits
Nephritic syndrome
Proteinuria neutrophil damage***
RBC CASTS
HYPERCELLULAR
Kid w/ hx of skin infection 2 wks ago has hematuria, oliguria, HTN, periorbital edema.
Post-Strep GN
Nephritic
M-protein
Hypercellular - neutrophils & MO
Histology shows sub-EPIthelial HUMPS and low serum C3.
Granular “starry sky” !gG & C3 deposits
Nephritic syndrome w/ CRESCENTS w/ FIBRIN + MO. Collaped glomerular tufts, severe oliguria
Rapidly progressing GN
Goodpasture Diffuse proliferative Wegeners Microscopic polyangiitis Churg-Strauss
Young male presents with hematuria and hemoptysis. Anti-GBM Abs, proteinuria
Goodpasture
- LINEAR
- Kidney + lung hemorrhage
- Crescent formation (RPGN)
Diffuse proliferative
Nephritic
GRANULAR
Sub-ENDOthelial
MOST COMMON SLE renal disease
Persistent sinusitis does not resolve w/ antibiotics. Hematuria, hemoptysis, HTN, high Cr, Abs against neutrophils and monocytes. Non-caseating granuloma and focal cresentric or RPGN
Wegener’s
- c-ANCA (cytoplasmic antineutrophil cytoplasmic antibody)
- SINUSITIS, No asthma or eosinophils
Polyangitis is similar but w/o granuloma
Polyangiitis vs. Churg Strauss
Nephritic NO IF (pauci-immune)
Churg
- ASTHMA
- Granulomatous
- eosinophilia
NO FEVER
Frequency, urgency, suprapubic pain
> 10WBC
+ Leukocyte esterase
+ Nitrates
+ culture >100,000
1 = E. coli
Cystitis
> 10WBC
+ Leukocyte esterase
- culture ***
Sterile pyuria
chlamydia or gonorrhoeae
FEVER Flank pain WBC casts* Neutrophils Pyuria*
1 = E. coli
Acute Pyelonephritis
—> Pre-mature labor
WBC casts
Pyelonephritis, transplant rejection
Waxy casts
Chronic pyelonephritis, CRF
Thyroidization of the kidney
Chronic pyelonephritis
Chronic pyelonephritis
Fibrosis + atrophy from recurrent pyelonephritis –> scarring, blunted calyces
Kids - VUR
Adults - obstruction
Thyroidization (eosinophilic protein)
Waxy casts
Calcium stones
Idiopathic hypercalciuria - normal serum Ca
Anything that inc serum Ca - PTH, cancer
CD
Tx = HTCZ = reabs Ca so its not in urine
Mg stones
Urease + bacteria
- PV
- Kleb
Alkaline urine
STAGHORN calculi in ADULTS (vs. cysteine)
Tx = Acidify urine or surgical removal
Uric acid stones
RADIOLUCENT
GOUT, Leukemia
Tx = alkalinize urine w/ potassium bicarb
allopurinol
Acetazolamide
Cysteine stones
Staghorn calculi in KIDS
Defect in cysteine reabs - cysteinuria
Chronic RF
DM HTN Glomerular disease Dec EPO --> anemia Dec Vit D & PO4- --> hypoCa Renal osteodystrophy - 2 HPTH, osteomalacia, osteoporosis
Dialysis –> cysts, SHRUNKEN, RENAL CELL CARCINOMA
Renal mass composed of fat, smooth muscle and blood vessels (Angiomyolipoma) is assoc w/?
Tuberous sclerosis
- 80-90% w/ B/L
- cortical tubers & subependymal hamartomas
- seizures, MR, rhabdomyomas, facial angiofibromas
- “ash-leaf” patches of hypopigmentation
60 y/o male smoker w/ painless hematuria, flank pain and palpable mass in RUQ, weight loss
Renal Cell Carcinoma
PARANEOPLASTIC - EPO, PTHrP, ACTH
Left renal vein block –> left varicocele
Hereditary = von Hippel-Lindau
Loss of VHL 3p
Sporadic
- single
- upper pole
- smoking***
Clear-cell = lipid & glycogen accumulation
Most common malignant renal tumor in kids
Wilms Tumor
- Blastema
- WT1 mutation on chr 11p
- WAGR syndrome
- Beckwith-Wiedemann syndrome
WAGR syndrome
Wilms tumor
Aniridia
Genital abnormalities
Motor/mental retardation
Beckwith-Wiedemann syndrome
Wilms tumor
Neonatal hypoglycemia
Muscular hemihypertrophy
Organomegaly (tongue)
Urothelial/transition cell carcinoma
“P-SAC”
- Phenacetin
- SMOKERS
- AZO dyes
- Cyclophosphamide
Flat - high grade - early p53 mutation
Papillary - low grade –> high, no p53 mutation
Squamous cell carcinoma
Squamous cell metaplasia
- Chronic cystitis (old woman)
- S. haematobium (Egyptian male)
- Nephrolithiasis
Adenocarcinoma
- URACHAL REMNANT - DOME of bladder
- Cystitis glandularis
- Exstrophy
Asian or Hispanic w/ cough, pulmonary infiltrates, runny nose about 2 wks prior, presents w/ intermittent hematuria, proteinuria
IgA nephropathy (Berger Disease) Mesangial IgA deposits, widening but NOT hypercellular
Flares w/ URI or gastroenteritis
If it’s in kids w/ palpable purpura = Henoch-Scholein
Teenage male presents w/ red casts proteinuria, difficulty hearing, and seeing
Alport syndrome
X-linked, nerve deafness + lens dislocation/cataracts
Basket-weave GBM
Alport syndrome
How does urine pH affect solute reabsorption?
pH opposite the substance ionizes it –> can’t be reabs = EXCRETED
60-40-20 rule
60 = TBW - D2O, pyrene
40 = ICF - (TBW - ECF)
20 = ECF - Inulin
“TIE”
Plasma volume % of TBW
1/4 of ECF = 1/12 TBW
- measured w/ Evan’s blue, radiolabeled albumin
Interstitial % of TBW
3/4 of ECF = 1/4 TBW
Nephrotic syndrome
Charge barrie is lost (heparan GBM) –> albuminuria, edema, hyperlipidemia
Renal Clearance
C = [urine] x urine flow rate / [plasma]
C > GFR = secretion
GFR
Inulin
GFR = [urine inulin] x urine flow rate / [plasma inulin]
ERPF
PAH is both filtered and secreted
ERPF = [urine PAH] x urine flow rate / [plasma PAH]
RBF
RPF / (1 - Hct)
{[urine PAH] x urine flow rate / [plasma PAH]} / (1 - Hct)
Filtration fraction
GFR / RPF
Normal = 20%
NSAID / afferent arteriole constriction on FF
NO CHANGE d/t dec in GFR
Can –> acute renal failure
ACE-I / efferent arteriole dilation on FF
Dec FF –> dec hyperfiltration in diabetics to dec nephropathy
AGII constricts to preserve RBF/GFR/renal fxn and inc FF
Inc plasma protein or constriction of ureter on FF
Dec FF
Hartnup disease
Deficiency of NEUTRAL A/A transporter (tryptophan) –> pellagra
PCT
Na/Glucose
Na/Phos - inhibited by PTH
Na/H - Inc by ATII
CA - inhibited by acetazolamide
Concentrating segment
Thin descending loop
Highest [urine] = CD
Thick ascending
NKCC - inhibited by loops
Indirect Mg, Ca reabs
Diluting segment
DCT
DCT
NaCl reabs
- inhibited by thiazides
- Inc by ATII
Ca/Na exchange - inc by PTH
Diluting segment
CD
Na exchange w/ K (Principal cells)
- inc by aldosterone
- inhibited by K+ sparing
ADH - V2 receptors to inc AQ channels in medullary CD (Principal cell)
- reabs H2O and urea
- V1 –> vasoconstriction & inc PG
Isoosmotic expansion/contraction
NaCl
Diarrhea
Hyperosmotic volume contraction
Sweating, fever, DI
Hypoosmotic volume expansion/contraction
SIADH
Adrenal Insufficiency
ANP
Na & volume loss - PCT
PTH
Dec phos - PCT
Inc Ca - Thick ascending
Aldosterone
Inc Na reabs - CD
Inc K, H+ loss - CD
Causes hypoK
Shifts INTO cell
- Insulin
- B-agonist
- Alkalosis
- Hypo-osmolarity
Resp Acidosis/Alkalosis
pH & PCO2 = OPPOSITE
Acidosis - high PCO2, HCO3
Alkalosis - Low PCO2, HCO3
Metabolic Acidosis/Alkalosis
Acidosis = all down
- hyperventilation
Alkalosis = all up
- hypoventilation
Anion gap metabolic acidosis
MUDPILES M - methanol (formic acid) U - Uremia D - DKA P - Paraldehyde, phenformin I - Iron or INH L - Lactic acidosis E - Ethylene glycol (oxalic acid) S - Salicylates
Metabolic alkalosis
Diuretics
Vomiting
Antacid
Hyperaldosteronism
Pt had infection treated with antibiotics and NSAIDs and now presents with fever, arthralgias and a rash that comes and goes
Acute Interstitial nephritis
- eosinophils in urine
Shrunken kidney with parenchymal fibrosis, localized to the medullary collecting ducts
Medullary cystic kidney disease
- Marfans, Ehlers-Danlos, Caroli’s
Eosinophils in urine
Acute interstitial nephritis
- NSAIDs, beta-lactams, diuretics, anti-convulsants
Nephrotic Syndrome
Proteinuria >3.5
Pitting edema
Hypogammaglobulinemia - Infections
Hypercoagulable - loss of AT-III
- Lipiduria - Fatty casts*
- hyperlipid/cholesterolemia
Minimal change assoc w/?
Hogdkin lymphoma
GN assoc w/ sickle cell and HIV
FSGS
Sub-epithelial spike & dome
Membranous
Track-Track
Membranoproliferative
Sub-endothelial
MPGN - I = HBV, HCV (more tram tracks)
Intramembranous deposits
MPGN - II = C3 nephritic factor, low C3
Sclerosis of mesanigum = Kimmelsteil-wlison nodules
Diabetic
What slows the progression of diabetic nephropathy?
ACE-I = dilates efferent
Sub-epithelial humps & low serum C3
Post-strep
Causes of renal papillary necrosis
Chronic analgesic use
DM
Sickle cell
Severe acute pyeonephritis
Loop diuretics
Furosemide
Inhibits NKCC in TAL
Stimulate PG release –> inc RBF, GFR
SE = “OH DANG”
- oto, hypoK, dehydration, allergy, nephritis, gout
(+) Hale’s colloidal iron stain
Chromophobe RCC
Acetazolamide
CA inhibitor in PCT
Use = glaucoma, mountain sickness
SE = acidosis, sulfa, stones
Thiazides
Inhibits NaCl in DCT
Use = HTN, NDI
SE = HyperGLUC
Sulfa
K-sparing diuretics
Spironolactone = blocks aldosterone receptor in CD
Triamterene, Amiloride = block Na in CD
Use = CHF, hyperaldosterone, low K
ACE-I
Use = HTN, CHF, DM - prevents heart remodeling by aldosterone
SE = dec GFR, FF
Type I RTA
Can’t secrete H+ in CD –> Ca stones
Hyperchloremic, non-anion gap acidosis
Type II RTA
Cant reabsorb HCO3- in PCT
- multiple myeloma,amyloidosis
- Hyperchloremic, non-anion gap acidosis
Type IV RTA
Most common
Aldosterone deficiency
