Renal Flashcards
Hepatorenal syndrome mechanism and symptoms
and treatment
Cirrhotic liver makes NO -> systemic vasodilation -> renal hypoperfusion (BUN/Cr>20) -> RAAS, ADH activated -> ascites worse, hyponatremia
No tubular injury, no RBC/protein/granular casts in urine. No improvement in renal function with fluids
Tx:
Octreotide (venodilation)
Midodrine (increases arterial BP)
What is FENA?
What is it in prerenal vs. intrinsic renal?
Fractional excretion of sodium
FeNa<1 in prerenal
FeNa>2 in intrinsic
What is Urine sodium and urine Osm in prerenal vs intrinsic?
Prerenal: urine sodium <20 mEq/L, urine Osm >500 mOsm/kg
(Because if hypoperfusion, trying to retain all the sodium -> low sodium in urine, and trying to retain all the water -> high urine Osm)
Intrinsic: urine sodium >40mEq/L, urine Osm<350
Child Palpable purpura (symmetric), arthralgias, abd pain, renal (hematuria, non-nephrotic range proteinuria, mildly high Cr)
Platelets are NORMAL
Complement is NORMAL
HSP
Hematuria
Spots
Palpable purpura
A (IgA-mediated)
WEEKS after illness
C3 deposits in GBM -> IF looks “lumpy bumpy”
Postinfectious glomerulonephritis (e.g., post-strep) Increased ASO, anti-DNAse Type III hypersensitivity = circulating immune complex
DAYS after URI or GI infection
Hematuria
Normal C3
IgA nephropathy (Berger) Immune complex-mediated
Tx glucocorticoids
Upper: sinusitis, epistaxis, otitis, saddle-nose
Lower resp: lung nodules/cavitation -> hemoptysis
Skin: nonhealing ulcers, livedo reticularis
Segmental necrotizing glomerulonephritis
+ c-ANCA
Granulomatous with polyangiitis (GPA/ Wegeners)
C is for Crazy Nazi (Weceners)
Cyclophosphamide, Corticosteroids. Crescents on bx.
Glomerulonephritis with lung involvement but NO nasopharyngeal involvement
+ p-ANCA
Microscopic polyangiitis
No granulomas
Eosinophils, asthma, sinusitis (can be confused with an allergy)
Peripheral neuropathy, P-ANCA and Purpura
Granulomas
Churg-Strauss
Glomerulonephritis Hemoptysis (no upper resp involvement) Linear anti-GBM deposits Iron-deficiency anemia, hemosiderin-filled macrophages in sputum Men in mid-20s
Goodpasture syndrome
Tx: plasma exchange
May progress to ESRD
Boys
Genetic defect in basement membrane -> sensorineural deafness, asymptomatic hematuria
GBM splitting on EM
Alports
Children
Risk: Hodgkins
Light microscopy: normal
EM: podocyte effacement (fusion)
Minimal change disease
Tx: steroids (prognosis good)
IVDU, HIV, African American, HTN
Microscopic hematuria
Bx: sclerosis in capillary tufts
FSGS
Immune complexes from solid tumors, infections (HBV, malaria), SLE, NSAIDs/gold damage podocytes
-> “spike and dome”, IgG and C3 deposits in basement membrane -> thickened basement membrane
Membranous nephropathy
HBV, HCV, cryoglobulinemia, SLE
“Tram-track” double-layered basement membrane
Low C3
Membranoproliferative nephropathy
Type2 has antibodies not to anything in the nephron, but to the enzyme that degrades C3. C3 accumulates in BM
Palpable purpura Arthralgias Nephrotic/nephritic syndrome Low C3 Positive HCV
Mixed cryoglobulinemia
Note: this is like HSP in adults with HepC. But in HSP, complement is normal!
3 kidney probs associated with low complement
- Lupus
- Strep
- Membranoproliferative/cryoglobulinemia
Acute abd pain, fever, hematuria in nephrotic syndrome
Renal vein thrombosis due to loss of antithrombin III
(can be progressive too: gradual worsening of renal function and proteinuria in an asymptomatic patient)
Most commonly seen in membranous nephropathy
Muddy brown granular cast
Acute tubular necrosis (ATN)
eg from prolonged hypotension - >tubular epithelial cells just die
RBC casts
glomerulonephritis
WBC casts
interstitial nephritis (fever, maculopapular rash, renal failure), usually caused by antibiotics etc
or pyelonephritis
Fatty casts
nephrotic syndrome
broad and waxy casts
chronic renal failure
Systolic-diastolic abdominal bruit
Renovascular hypertension
Blood at urethral meats
High-riding prostate
What to do?
Pelvic fracture -> posterior urethral injury
Get a retrograde urethrogram (don’t get foley!)
Effect of thiazides vs loops on calcium
Thiazides Take in calcium
Loops Lose calcium
crescent formation
rapidly progressive glomerulonephritis
post renal transplant
-> oliguria, hypertension, increased Cr/Bun
What to do?
Acute rejection (2/2 ureteral obstruction, acute rejection, cyclosporine tox, etc)
Tx with IV steroids!!!
Tx of renal artery stenosis
ACEIs or Arbs as initial therapy
Renal artery stenting or surgical revascularization resreved with resistant HTN or recurrent flash pulm edema
Arteriosclerotic lesions of renal arterioles and glomerular capillary tufts…
due to what?
Hypertension
Increased ECM, thickening of basement membrane, mesangial expansion, fibrosis
due to what?
Diabetes
personal and family history of recurrent kidney stones
stones are hard, opaque, hexagonal
positive urinary cyanide nitroprusside test
Cystinuria
(impaired transport of cystine, lysine, arginine, ornithine)
cystine is poorly soluble -> forms stones
