Renal and Urology Flashcards

1
Q

What do abnormal findings for the following Urine Sediment results mean?
Epithelial cells?
Red Blood Cells?
White Blood Cells?
Crystals?
Eosinophils?

A

Epithelial cells: Suggests contamination of the specimen d/t unhygienic meatus.

Red Blood Cells: Suggests infection, ureteral stones, glomerulonephritis, malignant hypertension

White Blood Cells: Suggests infection, acute interstitial nephritis, exudative glomerulonephritis

Crystals: Kidney stone or gout

Eosinophils: Allergic interstitial nephritis

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2
Q

Types of casts and what they mean:
Hyaline Casts?
Granular casts?
Red blood cell casts?
White blood cell casts?

A

Hyaline casts - Most common type of casts. They are solidified proteins that are presents because there was low urine flow or dehydration at one point in time and now the urine is flowing again so the hyaline casts are moving. Benign.

Granular casts - Can results as either the breakdown of cellular casts or inclusion of aggregate of plasma. Indicate chronic renal disease or “Muddy brown casts” in acute tubular necrosis

Red Blood Cell Casts: Always pathologic - indicative of glomerular damage. Something immunologic is occurring.

White Blood Cell casts: Severe inflammation or infection, pyleonephritis, nephrotic syndrome

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3
Q

Causes and treatment of urethritis

A

Frequently a sexually transmitted infection (gonorrhea or chlamydia)

Treatment: Azithromycin 1000mg PO x1 AND metronidazole 1000mg PO x1 AND ceftriaxone 250mg IM x1

A gram for the clam!

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4
Q

Treatment of cystitis/pyelonephritis

A

Simple/uncomplicated
—Bactrim 1 tab PO every 12 hours x3 days
—Macrobid 100mg PO every 12 hours x7 days
–Fosfomycin 3g PO x1

Serious/complicated
—Ciprofloxacin 200-400mg IV every 12 hours or Levofloxacin 250-500mg IV daily
—Piperacillin-tazobactam (Zosyn) 3.375 grams IV every 6 hours
For those with ESBL - producing gram negative infections: Imipenem 500mg IV every 6 hours

If they have a catheter, remove it and change it

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5
Q

Symptoms of nephrolithiasis

A

Sudden onset, severe flank pain, unrelieved by any position
Nausea, vomiting
Hematuria - gross or microscopic
Urinary urgency/frequency

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6
Q

Pre-renal vs Post renal: What lab results will help you determine which it is?

A

Pre-renal: Rise in BUN and Creatinine together (>10:1)
—The higher the BUN, the most likely that it is pre-renal
—Hyaline casts - dehydration
—Urine sodium <20
—Specific gravity >1.015
—FENa <1

Post-renal: Low BUN to creatinine ratio (BUN high but creatinine is not - 10:1)
—Urine sodium >40
—Specific gravity <1.015
—Normal urine sediment
—FENa >3

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7
Q

What other labs could you order to determine if acute renal failure is pre-renal, intrinsic or post-renal?

A

Urine osm
FENa
Urine Sodium

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8
Q

Pre-renal causes of acute renal failure

A

Hypovolemia - most common
Severe cardiac dysfunction
Loss of vascular tone - septic or neurogenic shock
Poor renal artery perfusion
Drugs that promote renal vasoconstriction (NSAIDs) or drugs that reduce glomerular filtration pressure (ACE-I)

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9
Q

Intrinsic causes of acute renal failure

A

Source of damage to the kidney itself
Most serious type of acute renal failure

Glomerulonephritis
Acute tubular necrosis
Acute interstitial nephritis
Tumor lysis syndrome - uric acid rises d/t lysis of tumor cells in chemo
Physical damage to the kidney (crush injury)

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10
Q

Clinical differences between nephrotic syndrome and nephritic syndrome

A

Glomerulonephritis can cause either nephrotic or nephritic syndrome

Nephrotic Syndrome (usually chronic) - Nephrotic is chronic
Characterized by edema (including in the face) with severe proteinuria and decreased total blood protein with hyperlipidemia

Nephritic syndrome (usually acute)
Characterized by hematuria, oliguria (decrease in urine output) and hypertension

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11
Q

Causes of glomerulonephritis

A

Non-proliferative - chronic
-Involve changes to the glomerulus where the number of cells is not changed
-Usually present in nephrotic syndrome
-Examples include: Chronic HTN, Lupus, HIV, OUD
Treatment: Long term steroid therapy

Proliferative - acute
-Involve an increased number of cells in the glomerulus
-Present with nephritic syndrome
-Frequently post-infectious, usually with Strep pyogenes
-Rapidly Progressing Glomerulophritis
—-Goodpasture’s syndrome - develops anti-glomerular basement membrane antibodies (anti-GBM) which leads to alveoli and glomeruli bleeding
——Looks like hematuria and hemoptysis at the same time
——Likely need dialysis. Treated with immunosuppression and plasmapheresis
—Granulomatosis with polyangiitis (Wegner’s) - small and medium vasculitis in the lungs and kidneys. Check a cANCA
—–Treated with immunosuppression

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12
Q

Acute tubular necrosis: What is it? What are the two types?

A

Acute tubular necrosis results from the death of tubular epithelial cells that form the renal tubules of the kidneys

Toxic:
–Rhabdomyolysis
–Aminoglycoside antibiotics (gentamicin, vancomycin)
– Cytoxic drug (cisplatin)
–Toxic alcohols

Ischemic - hypoperfusion, which overlaps perrenal causes
–Critical renal artery stenosis
–Renal artery embolism
–Shock

Treatment is large volume IVF

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13
Q

Causes of Acute interstitial nephritis

A

Infection or localized allergic reaction to medication

Characterized by sudden renal failure with eosiniphiluria

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14
Q

Causes of post renal acute renal failure

A

Obstructing renal calculi
Renal, ureteral or bladder malignancy
Prostatic hypertrophy
Obstructed urinary catheter
Acute urinary retention

This is a urologic emergency!

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15
Q

Treatment of hypoNa

A

If Na <120 there is a risk for brainstem herniation
Can develop seizures, obtundation, dilated pupils, posturing

3% NaCl (hypertonic saline) bolus over 10 minutes (100cc)
Repeat bolus 1-2 times until symptoms improve
Aim for 2-4mmol/L increase every 2 hours
Follow by continuous infusion (50-100ml/hr)
Monitor Na every 2 hours
Discontinue once symptoms free or acute rise in Na of 10mmol/L in first 5 hours
In first 48 hours, do not exceed 15-20mmol/L of correction
—Can lead to pontine myelination syndrome which is irreversible

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16
Q

Treatment of hyperK

A

Calcium gluconate 2g IV if stable (less bioavailable, not as caustic) OR Calcium chloride 2g IV if arresting (immediately bioavailable, vesicant)

Dextrose 50% 50mL IV - Draws K into the cell and out of the blood

Insulin (regular) 10 units IV

Sodium biocarbonate 50mEq IV - prevents acidosis

IV hydration

Consider dialysis if K is rising

17
Q

Manifestations of Uremia

A

Pericarditis
Neuropathy
Decline in mental status - somnolence
Asterixis
Severe metabolic acidosis

18
Q

Treatment of pyelonephritis (upper UTI) and healthcare associated pyelonephritis

A

Recommended: Ciprofloxacin 500mg PO BID
Levofloxacin ok but def don’t use moxifloxacin

Ceftriaxone 1gm IV every 24 hours x14 days for complicated

Healthcare associated:
Use an antipseudomonal agent:
-Cefepime
-Ampicillin and an aminoglycoside
-Imipenem
-Meropenem
-Zosyn

19
Q

Treatment of cystitis/urethritis (lower UTI)

A

Nitrofurantoin 100mg PO BID x5 days
or
Bactrim 1 tab PO BID x3 days
or
Fosfomycin 3gm PO x1

20
Q

Treatment of prerenal, intrarenal and postrenal kidney injury

A

Pre-renal:
Fluids - expand intravascular volume

Intrarenal:
Maintain renal perfusion
Stop nephrotoxic drugs
Utilize renal replacement therapies as indicated

Postrenal:
Remove source of obstruction
Check Foley
Order renal ultrasound or CT scan

21
Q

Laboratory studies for nephrolithiasis

A

CT scan is GOLD STANDARD

Urinalysis
CBC
BMP

22
Q

Treatment of nephrolithiasis

A

Analgesia and hydration
–Morphine or Dilaudid
–Toradol
–Reglan

Lots of IVF and oral fluids with pain management and watchful waiting
Lithrotripsy may be indicated for large stones