Renal and STD

Question 1

GONORRHEA
A bacterial STD–>Neisseria gonorrhea–>leading cause of infertility in women
causes cervicitis in women–> urethritis in men
Found in GU tract, oropharynx, or anorectum.
Transmission rates are 80-90% after exposure (incubation 2-8 days)

TESTING
LABORATORY AND DIAGNOSTIC TESTS
Pap smear-cervical culture, First AM urine-NAAT (nuclei -acid amplification test)

Discharge smear on gram stain shows gram-negative diplococcic and WBCs

Question 2

Gonorrhea

SIGNS AND SYMPTOMS
80% of females are asymptomatic

BURNING ON URINATION

Females:
Dysmenorrhea, Fever, Lower abdominal pain, Labial pain and swelling, Green vaginal discharge, Urinary frequency, Dysuria

Males:
Dysuria, Urinary frequency, Nausea and vomiting, Testicular pain, White or yellow-green discharge

Question 3

GONORRHEA TREATMENT

Rocephin 500 mg IMx1 dose <150 kg or 1 gram IM x 1 >150 kg

+ TX for Chlamydia prophylactic
Azithromycin 1G orally x1 dose (Preferred for pregnant) or Doxycycline 100 mg BID x 7 days

NP must report positive results to the local health department

Question 4

Gonorrhea
*leading cause of infertility in females
*Asymptomatic in females:copious penile discharge in males
(GG )
*Gonococcal arthritis can produce joint pain and swelling
*First line tx-rocephin 500 mg x 1 or 1000 mg if >150 kg (330 lbs)
*all pts chold also be treated for chlamydia

Question 5

SYPHYLLIS
A complex STD caused by Treponema pallidum, a spirochete.

Transmission may occur through oral, vaginal, or anal intercourse or from mother to fetus.
Rarely transferred through blood transfusion

It is the 3rd most commonly reported infection in the US.

Question 6

Syphilis
*Moves through several stages
* Primary —-Chancre
*Secondary—rash
* Latent –No symptoms
*Tertiary —organ involvement, most common brain
*Nontreponemal antibody testing to screen –RPR or VDRL
*Treponemal confirmation with FTA-ABS
*Treatment –<1 year –Benzathine PCN G 2.4 million units IM x 1 with alternative Doxy for 14 days
*Unknown length –or Tertiary stage then Benzathine PCN G 2.4 million IM weekly x 3 weeks .
*Neurosyphilis–Aqueons PCN G 18-24 million units q 3-4 hours or or as a continuous infusion for 10-14 days

Question 7

SYPHILIS
LABORATORY TESTS
Nontreponemal (blood test) : VDRL & RPR

Treponemal-Treponemal tests, also called confirmatory tests (FTA, TP-PA, EIA), detect antibodies specific to syphilis.

Microhemegglutination assay for T. Pallidum and the T pallidum particle agglutination are comparable in specificity and sensitivity to the fluorescent treponemal antibody absorption test.
Review Table 34-2

Question 8

4 Stages of syphilis:
Primary - painless chancre arises. There may be a clean base and firm indurated ulcer at site of exposure.

Secondary - Patient presents with flu like symptoms, lymphadenopathy, alopecia, malaise, anorexia, arthralgia, skin rash (macular, papular, pustular) on hands and feet.

Latent - Asymptomatic but seropositive

Tertiary - Meningitis, hemiparesis, hemiplegia, aortic aneurysm, cardiac insufficiency, leukoplakia (white patches in the mouth)

Question 9

SYPHILIS TREATMENT
Primary, secondary, or early syphilis of less than 1 year duration: Benzathine penicillin G 2.4 million units IM

Late, latent, and unknown length, tertiary stage: Benzathine penicillin G 2.4 million units IM for 3 weeks

If allergy to penicillin: doxycycline 100mg BID or erythromycin 500mg QID

NP must report finding to the health department

Question 10

CHLAMYDIA

SIGNS AND SYMPTOMS
Men and women are often asymptomatic
Women: dysuria, vaginal discharge, bleeding after sex, dyspareunia, painful intercourse, intramenstrual bleeding.

Men: dysuria, testicular pain, thick and cloudy penile discharge

LABORATORY FINDINGS
Nucleic acid test confirms diagnosis

Screening should occur in pregnant women, sexually active women <25years of age, older women with risk factors for STD and men with risk factors STD

Question 11

CHLAMYDIA

TREATMENT
Azithromycin 1G oral x1 dose-preferred and safe in pregnancy

Doxycycline 100mg oral x7 days- contraindicated in pregnancy

Question 12

CHLAMYDIA
**Bacteria **STD caused by chlamydia trachomatis which results in reproductive tract complications

It is the most common STD in the US.

Question 13

UTIs
Barkley
Management of Pyelonephritis (Upper UTIs)

1. IDS Guidelines for empiric treatment of pyelonephritis
   a. Recommended: Ciprofloxacin 500 mg PO BID (7 days if uncomplicated)
   b. Levofloxacin - OK, but not Moxifloxacin
   c. Ceftriaxone 1 gm IV every 24 hours (14 days)
2. Not recommended: TMP-SMX (high resistance) or nitrofurantoin (does not reach therapeutic concentrations in the kidney)
3. Health-care associated pyelonephritis: Use antipseudomonal agent other than a fluoroquinolone (e.g., ampicillin and an aminoglycoside, cetepime, impenem, meropenem, piperacillin-tazobactam, others)

Question 14

Renal insufficiency
Causes
1. Hypertensive nephrosclerosis
2. Glomerulonephritis
3. Diabetic nephropathy
4. Interstitial nephritis
5. Polycystic kidney disease
6. Other

Question 15

Renal insufficiency

Symptoms/General Concepts
1. Patients are often asymptomatic until the late stages of disease
2. Direct relationship between nephron loss and renal function
3. Systemic changes are not evident until overall renal function is
< 20%-25% of normal

Question 16

Bacterial STDs
syphilis, chlamydia, gonorrhea

Viral STDs
genital warts, genital herpes, HIV

Parasitic STD
Trichomonas

Question 17

VULVOGANITIS

Occurs when the vagina or vulva becomes inflamed or infected by bacteria or fungi.

The most common causes are trichomoniasis, bacterial vaginosis, and candidiasis.

Of the 3 “trich” is the only transmitted through sexual contact.

Question 18

VULVOGANITIS

PHYSICAL EXAM FINDINGS

Trichomoniasis: Malodorous, frothy yellow green discharge, vaginal erythema, “strawberry patches” on the cervix and vagina. Patient complains of itching, dysuria, and dyspareunia.

Bacterial vaginosis “BV”: Fishy smelling, watery and gray vaginal discharge. Patient complains of vaginal spotting.

Candidiasis: White curd like discharge, appears like cottage cheese. NP may observe vulvovaginal erythema with itching.

Question 19

VULVOGANITIS

LABORATORY AND DIAGNOSTIC FINDINGS

Trich: microscope wet prep reveals motile trichomonads

BV: microscope wet prep reveal clue cells

Candidiasis: wet prep KOH reveal pseudo hyphae

Question 20

VULVOGANITIS

TREATMENT
Trich: Flagyl as a single oral dose of 2 grams x 1 or a 500 mg BID x 7 days.

BV: Flagyl as a single oral dose of 2 grams x 1 or a 500mg BID x 7 days. Intravaginal x 5 days. Clindamycin (vaginal cream x 7 days, oral dose x 7 days)

Candidiasis: OTC treatment available. Monistat or Clotimazole (available in 1 day, 3 day and 7 day applications), Terconazole suppository, Butaconazole

Question 21

HERPES
A reoccurring viral STD that has no cure. Herpes is associated with painful genital lesions

There are 2 causes:

Herpes simplex virus type 1- infection of the lips, face or mucosa.
Herpes simplex virus type 2- infection of the genitals (anus, rectum, vagina)
Transmission occurs through direct contact with active lesions or by virus contained fluid such as saliva or cervical secretions

Question 22

HERPES

SIGNS AND SYMPTOMS
First 12 days: Present with fever, malaise, dysuria, and painful or itching ulcers/lesions
Recurrent lesions are less painful and least about 5 days.

LABORATORY AND DIAGNOSTIC FINDINGS
Viral culture is the most definitive lab

Positive tzanck stain

Question 23

HERPES

TREATMENT
Table 32-1 in Current Textbook

There is no intervention that will cure the disease

The goal is symptomatic treatment

Acyclovir is recommend for topical, oral and intravenous use

Famicilovir

Valcyclovir- assists in treating asymptomatic viral shedding of type 2

Question 24

Leading cause of infertility —->Gonorrhea

Question 25

The most COMMON STD—>Chlamydia

Question 26

UTI

Urinary tract infections are caused by inflammation and infection of the kidneys, ureters, bladder, or urethra.

Types of lower UTI: cystitis, urethritis (affecting the bladder and urethra)

Types of upper UTI: pyelonephritis, renal abscess (affecting the kidney and ureter)

Question 27

UTI

E. Coli is the most common organism resulting in female UTIs.
Bacteria of the proteus species are the most common resulting in male UTI.

UTIs are the most common bacterial infection of the elderly.

Catheter associated UTI are caused by pathogens living along the catheter.

Question 28

UTI

Risk factors for male and female contracting UTI: Diabetes mellitus, urinary catheterization, neurogenic bladder, obstruction of urine flow due to tumor/calculi/urethral strictures

Risk factors specific to women contracting UTI: Short urethra, sexual intercourse, previous UTI, pregnancy, 1st degree relative with UTI-mother

Risk factors specific to men contracting UTI: Lack of circumcision, homosexuality, prostatitis, HIV infection, prostate enlargement, sexual partner with vaginal colonization of pathogens

Question 29

SIGNS AND SYMPTOMS OF LOWER UTIS
Dysuria, urinary frequency, urinary urgency, suprapubic pain, hematuria, malodorous urine, urinary incontinence, rare to have fever or chills, no flank pain

Question 30

SIGNS AND SYMPTOMS OF UPPER UTIS
Flank pain, fever (38.0), hematuria, nausea and vomiting, confusion/mental status changes (elderly), malaise, rigors, tachypnea, and tachycardia

Question 31

UTI
LABORATORY AND DIAGNOSTIC FINDINGS
Urine culture and sensitivity is the gold standard. Culture results require at least 24 hours.
Clean catch urinalysis may diagnose UTI with positive nitrites or leukocyte esterase test.
Hematuria may also diagnose UTI.
Urine microscopy reveal pyuria (> 10 leukocytes/ml), bacteriuria (> 100,000 bacteria/ml indicates active infection), bacterial count 10k-100k may indicate infection if accompanied by pyuria
Elevated ESR noted in pyelonephritis.

Leukocyte esterase dipstick: positive (purple in 60 seconds), signifies WBC or pyuria.

False positive may result with kidney stones, tumors, or poor collection technique.

Urine dipstick test is positive for blood, protein, nitrates.

Additional test may include: CBC and blood culture.

Diagnostics that may be ordered : CT of the abdomen and pelvis, pelvic ultrasound

Question 32

BPH

A progressive condition characterized by enlargement of the prostate gland.

BPH is most common in men > age 50.

The cause is unknown but thought is to be related to response to the androgen hormone over time. In addition dietary fat may be a causative agent.

Question 33

BPH

SIGNS AND SYMPTOMS
Urinary frequency, dysuria, urinary urgency, nocturia, incontinence,
hesitancy, dribbling, retention, starting and stopping urinary flow

Physical exam
Digital rectal exam reveals enlarged prostate gland.
The “normal” prostate should feel smooth and rubbery
Focal enlargement, hardness, or nodularity may indicate malignancy.

Question 34

BPH
LABORATORY AND DIAGNOSTIC FINDINGS
Urinalysis-detects infection
Hematuria may be a sign of malignancy
Urine culture to rule out UTI
BUN/creatinine to detect renal insufficiency
PSA>4ng/ml is abnormal but NP must evaluate PSA based on patients age.
PSA below 4 does not guarantee patient does not have cancer.
A transrectal ultrasound should be ordered if palpable nodule or elevated
PSA

Question 35

Chlamydia
*most common bacterial STD
*frequently asymptomatic but can cause seroius reproductive issues
*first line tx azithromycin 1 gram oral x 1 dose OR doxy 100 mg BID x 7 days
*Can use Azithromycin if pregnant

Question 36

What is the most common bacterial STD in the US

Chlamydia

Question 37

THe most common STD is

HPV

Question 38

Gonorrhea treated with

Rocephin

Question 39

Chlamydia treated with

Azithromycin

Question 40

KIDNEY STONES
RENAL CALCULI

A condition in which one or more kidney stones are present in the pelvis, kidney, or in the ureter.

Calculi may be made up of calcium oxalate or calcium phosphate. The stones may also be composed of uric acid struvite, or cystine. It is thought that 10% of the population will be diagnosed with a kidney stone.

Stones are more common in men. The average age of onset is during the 30s.

Causes of stones include life stressors, saturation of urine with stone-forming salts, dehydration, diet: low fluid intake, high sodium intake, high fructose intake, low calcium intake.

Risk factors: male, 30+years in age, family history, immobility, UTI, medical conditions: obesity, DM, gout, sarcoidosis, primary hyperparathyroidism, inflammatory bowel disease,

surgical comorbidities: colectomy, gastric bypass,

medications: steroids, colchicine, chemotherapy, vitamin D supplements, triamterene, foods high in oxalate: green leafy vegetables, rhubarb, beets, okra

Question 41

Types of stones

Calcium stones: account for 80% of renal calculi. Can be caused by absorptive (secondary to increased absorption of calcium at the small bowel), resorptive (secondary to hyperparathyroidism: hypercalcemia, hypophosphatemia, hypercalciuira, and elevated serum PTH are found), and renal (renal tubules are unable to efficiently reabosrd filtered calcium) disorders

Hyperuricosuric: caused by dietary excess uric acid. Client frequently has comorbidity of gout. Urinary pH>5.5

Hyeroxaluric: usually due to primary intestinal disorders. Patient frequently has history of chronic diarrhea associated with irritable bowel disease. Calcium is unavailable to bind to oxalate, which is then freely and rapidly absorbed.

Hypocitraturic: can be idiopathic, due to chronic diarrhea, type I renal tubular acidosis, or diuretic use. Citrate binds to calcium

Uric acid calculi: pH level <5.5, increasing pH >6.5 increases solubility and can dissolve stones

Struvite calculi: magnesium-ammonium-phosphate stones. Frequently occurs in women with frequent UTIs. Urine pH>7-7.5. Caused by urease producing organism.

Cystine calculi: result of abnormal excretion of cysteine, ornithine, lysine, and arginine. Very difficult to manage. Cystine is the only amino acid that is insoluble in urine

Question 42

KIDNEY STONES

SIGNS AND SYMPTOMS
Acute flank pain, testicular pain, nausea and vomiting, costovertebral angle tenderness, urinary frequency, urinary dysuria, urinary urgency, hematuria, and oligura and acute renal failure may develop when both collecting systems are obstructed.

Question 43

KIDNEY STONES

LABORATORY AND DIAGNOSTIC FINDINGS
Noncontrast CT abdomen and pelvis is the gold standard radiographic test.

X-ray of abdomen reveal calculi
Renal ultrasound has no radiation but less sensitive in detecting stones
Urinalysis shows blood
Leukocytosis
Urine culture: results reveal urease-producing organism
Serum chemistry to evaluate calcium, electrolytes, phosphate, and uric acid

People with recurrent stones should have 24-hour urine collection for calcium, uric acid, oxalate, and citrate excretion.

Question 44

KIDNEY STONES

TREATMENT
NP should attempt to relieve pain, nausea and vomiting
NSAIDs have found to be as effective as narcotics. Avoid use in people with renal disease because it may lower GFR
Opioids like morphine or Dilaudid or combination analgesics such as Norco when pain is unrelieved by NSAIDs.
Antiemetics such as Phenergan or Zofran for nausea

To help with stone passage and to induce urine output increase oral fluid intake to at least 2-3L of fluid per day.

Antispasmodics relax the smooth muscle of the ureters:
Alpha blockers - Doxazosin, Tamulosin
Calcium channel blockers - Procardia

Purine dietary restrictions or starting allopurinol may benefit those with hyperuricemia

For those with uric acid calculi educate to decrease protein intake, start allopurinol if diagnosis of gout

Shock wave lithotripsy and ureteroscopy treat majority of stones
For stones >10mm percutaneous antegrade ureteroscopy, cystoscopy

Question 45

RENAL INSUFFICIENCY
Decrease in renal function leading to decrease in GFR and reduction of clearance of solutes.

Acute kidney injury is an abrupt loss of kidney function.

Chronic kidney disease develops over months to years. The degree of dysfunction is related to the cause and comorbidities.

AKI can resolve with medical management.

CKI is progressive and delayed by medical management.

AKI and CKI may require dialysis depending on level of dysfunction.

Question 46

ACUTE RENAL FAILURE

Acute lost of renal function typically within 24-48 hours.

AKI is cause of about 5% of hospital admissions and 30% of ICU admissions.

AKI typically increases creatinine level from baseline.

AKI can progress to complete renal failure if urine output is < 400ml/day or serum creatinine increases by 0.5mg/dl/day.

RIFLE Method for classification of AKI:
R isk -increased SCR x 1.5 or GFR >25 %
UO <.5 x 6 hrs

I njury -increased SCR x 2 or GFR >50%
UO <.5 x 12 hours

F ailure –increased SCR x 3 or GFR <75%
UO <.3 x 24 hours

L oss -loss of kidney function x 4 weeks

ESRD – Loss of kidney function >3 months

Question 47

ETIOLOGY OF AKI

Prerenal: 60-70% of cases. Diminished renal perfusion resulting from decrease in blood supply to the kidneys. Causes: hemorrhage, GI loss, GU loss, skin loss, sepsis, anaphylaxis, drugs (ACE inhibitors, NSAIDs), CHF, MI, cardiogenic shock, uncontrolled hypertension, liver disease. Results in increased tubular sodium and water reabsorption, BUN to creatinine ratio increases, increased renal threshold for plasma ions, increased uric acid absorption, and hyponatremia.

Fraction of excretion of sodium: FENA= (UrineNA/SerumNA )/ (UrineCR/SerumCR) X 100%

Intrarenal: 25-40% of cases. An abrupt decrease in GFR secondary to tubular cell damage that results from renal ischemia or nephrotoxic injury.

Acute tubular necrosis accounts for most hospital associated intrarenal cases. Causes include decreased cardiac output, prolonged hypotension, volume depletion, liver disease, contrast media, medications (amphotericin B, cyclosporine, antineoplastics). Acute tubulointerstitial nephritis accounts for about 10% of intrarenal cases. This is caused by bacterial pyelonephritis, medications (penicillin, cephalosporing, NSAIDs, rifampin, phenytoin, sulfonamides, allopurinol), immunologic disorders (systemic lupus erythematosus, Sjogren syndrome, sarcoidosis)

Postrenal: 5-10% of cases. Associated with renal calculi, tumors, urethral strictures, BPH, blood clots, occluded catheters, neurogenic bladder, diabetic neuropathy, and spinal cord disease.

SIGNS AND SYMPTOMS
Decreased urine output, although occasionally urine output remains normal
Fluid retention, causing swelling in your legs, ankles or feet
Drowsiness
Shortness of breath
Fatigue
Confusion
Nausea
Seizures or coma in severe cases
Chest pain or pressure

LABORATORY AND DIAGNOSTIC FINDINGS
Assess urinalysis: High urine osmolality, low urine sodium, high BUN: creatinine ratio, low FENA, proteinuria may be present.

In and out catheter may reveal post void residual volume

Renal ultrasound may reveal hydronephrosis.

X-ray of abdomen to assess for differential or cause (i.e. renal calculi).

CT/MRI abdomen/pelvis may show obstruction.

Retrograde urography may be completed to further assess ureters and lower urinary tract.

TREATMENT
Treat the underlying cause

Correct fluid, electrolyte, and uremic abnormalities. If volume depleted hydrate with saline. Adjust I&O based on fluid status.

Optimize blood pressure for renal perfusion
Stop offending drugs (ie NSAIDs)
Restrict protein
Assess for electrolyte imbalance and correct

Nephrology consult: May require hemodialysis