Renal complaint

Question 1

Proteinuria

Answer 1

Protein in the urine

Question 2

Glucosuria

Answer 2

Glucose in urine

Question 3

Hematuria

Answer 3

Blood in the urine

Question 4

Dysuria

Answer 4

Painful urination

Question 5

Polyuria

Answer 5

Frequent Urination

Question 6

Uremia

Answer 6

Elevated levels of BUN

Question 7

BUN

Answer 7

BUN: Blood Urea Nitrogen
–Urea nitrogen is a waste product, created when the liver breaks down proteins
–Urea nitrogen travels from liver to kidneys and is excreted as waste product
–BUN is blood test that allows clinicians to gauge kidney function

Question 8

Cr

Answer 8

Cr: Creatinine
–Waste product of muscle break down
–Created constantly and properly functioning kidneys excrete this waste product
–Cr is a blood test that allows clinician to gauge kidney function

Question 9

AKI

Answer 9

Acute Kidney Injury - Impairment of renal filtration and excretory function over days to weeks that results in retention of nitrogenous and other waste products, normally cleared by the kidney.

Question 10

AKI may progress to Chronic Kidney Disease (CKD) if the renal dysfunction is not resolved in ______

Answer 10

AKI may progress to Chronic Kidney Disease (CKD) if the renal dysfunction is not resolved in 3 months.

Question 11

Pre-Renal AKI

Answer 11

Insult/injury occurring ”upstream to the kidney”

–Ex: Hypotension

Question 12

Intrinsic AKI

Answer 12

Insult/injury occurring at the level of the kidney

–Ex: Glomerulonephritis (conditions leading to inflammation of the glomerulus)

Question 13

Post-Renal AKI

Answer 13

Insult/injury occurring “down-stream to the kidney”
–Ex: Bladder outlet obstruction

Question 14

Labs to obtain on all patients with AKI

Answer 14

Basic Metabolic Panel*
–Increase in Cr 1.5x the patient’s baseline OR > 0.3mg/dL increase
–BUN:Cr>20:1 suggestive of prerenal AKI

•Urinalysis with urine microscopy*
–Protein? Blood? Glucose?

•Other tests that may be useful
–Urine Albumin/creatinine ratio or urine protein/creatinine ratio
–Renal Ultrasound
–Renal Biopsy

Question 15

Treatment of AKI

Answer 15

–Pre-Renal patients need IV fluid
–Intrinsic renal patients need underlying cause of disease addressed
–Post-Renal patients need obstruction removed

Question 16

Chronic Kidney Disease (CKD)

Answer 16

Definition (either present for 3 months):
1. GFR < 60 ml/min/1.73m2

2. Markers of Kidney Damage:
   –Protein in urine *
   –Abnormal Urinary Sediment•ex: RBC cast, WBC cast, etc…
   –Abnormal Kidney Biopsy
   –Abnormal Renal Imaging
   –Electrolyte Abnormalities from tubular disorders
   –History of kidney transplantation

Question 17

Several risk factors for CKD - major ones :

Answer 17

• Diabetes mellitus
• Hypertension
• Cardiovascular disease (CVD)
• Acute Kidney Injury

Question 18

Three Simple test to identify most CKD patients

Answer 18

1.Glomerular filtration rate (GFR)
–Limitations:
•Not reliable when GFR > 60 m/min
•Not reliable in Acute Kidney Injury (rapidly changing creatinine)
•Not reliable in low muscle mass (cachexia, paraplegia, etc..)

2.Proteinuria–Urine albumin to creatinine ratio or urine protein to creatinine ratio
•Random, spot urine sample so easy to collect
–24 hour urine total protein collection

3.Urinalysis with microscopy

Question 19

Indications for dialysis:

Answer 19

A: Severe Acidosis
E: Electrolyte disturbance (usually hyperkalemia)
I: Ingestion (ex: ethylene glycols, methanol, etc…)
O: Volume overload
U: Uremia

Question 20

Asymptomatic Bacteriuria

Answer 20

(UTI) Presence of bacteria without symptoms

Question 21

Cystitis

Answer 21

(UTI) Symptomatic bladder infection

Question 22

Prostatitis

Answer 22

(UTI) Symptomatic prostate inflammation due to infection

Question 23

Pyelonephritis

Answer 23

(UTI) Symptomatic infection of the kidneys

Question 24

UTI - common strain, common causes?

Answer 24

Most commonly E. Coli (70-90% of the time)

•Most common causes of UTI:
–Fecal contamination
–Outflow obstruction (benign prostatic hyperplasia, urethral stricture etc)
–Sexual activity
–Catheterization

Question 25

Diagnostic Approach for Cystitis

Answer 25

History and Physical exam are important!

•Basic Labs
–CBC, BMP, Urinalysis, Urine culture
•Look for > 100,000 cfu/mL on urine culture

Question 26

Diagnostic Approach for Pyelonephritis

Answer 26

H&P
Basic Labs

Imaging
-Mild - not necessary
-Severe cases: Sepsis, septic shock, concern for obstruction (decreased urine output) or no improvement in symptoms after 48 hours of antibiotics therapy warrant imaging.
•CT scan of the abdomen and pelvis is the gold standard

Question 27

Nephrolithiasis

Answer 27

“Kidney Stones”

Caused by precipitation of minerals in the kidney and ureters that were soluble in the blood

Types of Stones:
–Calcium Oxalate (80%) >>>> Calcium phosphate
–Uric Acid
–Struvite
–Cystine

Question 28

Diagnostic Approach for Nephrolithiasis

Answer 28

H&P
Basic Labs (plus stone composition analysis)
Imaging:
–Non-Contrast CT: Preferred imaging study for patients with nephrolithiasis
–Ultrasound: Preferred for patients where radiation is contraindicated: pregnant women, children

Question 29

GU Autonomics - Bladder

Sympathetics?
Parasympathetics?

Answer 29

S: T10-L2
P: S2-S4 (sacrum)

Question 30

GU Autonomics - Ureter - upper

Sympathetics?
Parasympathetics?

Answer 30

S: T10-T11
P: Vagus n. (OA, AA)

Question 31

GU Autonomics - lower Ureter

Sympathetics?
Parasympathetics?

Answer 31

S: T12-L2
P: S2-S4 (sacrum)

Question 32

Chapman’s Reflex Points can be manipulated to reduce ___

Answer 32

Can be manipulated to reduce adverse sympathetic influence of a particular organ or visceral system