Renal Diagnosis and Treatment Flashcards
Prerenal failure lab findings and treatment
Oliguria
Increased BUN to CR ratio>20:1 (kidney reaborbs urea)
Increased urine osmolarity (>500 mOsm/kg H2O)
Decreased urine Na (less than 20 mEq/L)
FeNa less than 1%
increased urine: plasma Cr ratio (>40:1)
Bland urine sediment-hyaline casts, no protein or blood
Treatment:
Give normal saline to maintain euvolemia and restore the blood pressure-not in patients with edema or ascites
Stopping antihypertensive medications may be necessary
Eliminate ACE inhibitors or NSAIDs
Swan-Ganz monitoring is indicated if patient is unstable
Intrinsic renal failure lab findings and treatment
decreased BUN: Cr (less than 20:1)
Increased urine Na (>40 mEq/L)
FeNa >2% to 3%
Decreased urine osmolality (less than 350 mOsm/kg H2O)
Decreased urine:plasma Cr ratio (less than 20:1)
Treatment: Therapy is supportive, eliminate offending agent
Can try furosemide if patient is oliguric
Postrenal failure lab findings and treatment
Benign urine sediment
No protein or blood in urine
Diagnosis by ultrasound (order for most AKI unless its obviously not postrenal)
Catheter will have large volume of urine
Treatment: bladder catheter and urology consultation
ATN diagnosis
Urine sediment: Muddy brown casts, granular casts,
Trace proteins, no blood
Acute glomerulonephritis diagnosis
Urine sediment: dysmorphic RBCs, RBCs with casts, WBCs with casts, fatty casts
Protein: 4+
Blood: 3+
Renal biopsy indicated
Acute interstitial nephritis diagnosis
Urine sediment: RBCs, WBCs, WBCS with casts, eosinophils
Protein: 1+
Blood: 2+
Renal biopsy indicated
AKI Electrolyte/Metabolite complications
Hyperkalemia Hyponatremia Hyperuricemia Hypocalcemia (cannot activate Vitamin D) Hyperphosphatemia Metabolic acidosis
Treatment of general AKI
Avoid medications that decrease renal blood flow (NSAIDs) or are nephrotoxic (aminoglycosides, radiocontrast agents)
Adjust medication dosages for level of renal function
Correct fluid imbalance: IV fluids or diuretics
Monitor fluids by daily weight measurements and intake-output records
Correct electrolyte imbalances
Optimize cardiac output: 120 to 140/80-90
Order dialysis: uremia, hyperkalemia, acidemia, volume overload
Amyloidosis diagnosis and treatment
Diagnosis: abdominal fat pad aspiration biopsy
Treatment: underlying condition
Colcichine for prevention and treatment
Diagnosis and treatment of Chronic kidney disease
Urinaylsis: examine sediment
Measure Cr clearance to estimate GFR (less than 60 signifies CKD)
CBC: normocytic normochromic anemia, thrombocytopenia
Hyperkalemia, hyperphosphatemia, hypocalcemia, metabolic acidosis, hypermagnesia
Renal ultrasound-small size of kidneys
Presence of normal sized kidneys does not exclude CKD
Possible renal biopsy
Treatment:
Low protein: .7-.8 g/kg body weight per day
Low salt diet if HTN, CHF or oliguria present
Restrict potassium, phosphate and magnesium intake
ACE inhibs: slow progression of proteinuria and reduce risk of ESRD
Can cause hyperkalemia
BP control: decreases rate of disease progression
ACE inhibs preferred
Glycemic control: prevents worsening of proteinuria
Smoking cessation
Hyperphosphatemia: calcium citrate
Oral calcium and vitamin D
Acidosis: may require bicarbonate
Anemia: EPO
Pulmonary edema: dialysis if unresponsive to diuretics
Pruritis: capscaian cream or cholestyramine and UV light
Dialysis
Transplantation is only cure
Indications for Dialysis
AEIOU
Acidosis: severe
ingestion of drugs: (ELMMS)-ethylene glycol, lithium, Mg containing laxatives, methanol, salicylates
electrolyte imbalances: severe hyperkalemia and hypermagnesemia
Overload: pulmonary edema, hypertensive emergency refractory ot antihypertensive agents
Uremia: N and V, lethargy/mental deterioration, encephalopathy, seizures, pericarditis (not emergent)
Rhabdomyolysis
lab findings: markedly elevated creatinine phosphokinase, hyperkalemia, hypocalcemia, hyperuricemia
Treatment: IV fluids, mannitol (osmotic diuretic), and bicarbonate (drives K back into cells)
Proteinuria diagnosis and treatment
Diagnosis: Hyperlipidiemia, hypoalbunimea (edema), urine protein >3.5 g/24 hours, hypercoagulable, increased infection risk
Urine dipstick test: albumin detects concentrations of 30 mg/dL or higher (3+ equals nephrotic syndrome)
UA: RBC casts=Glomerulonephritits
WBC casts=pyelonephritis, and interstitial nephritis
Fatty casts suggest nephrotic syndrome
If proteinuria is confirmed-24 hour urine collection
Microalbuminemia: 30-300 mg/day-if positive run radioimmunoassay
Treatment: transient-no further workout If persistent: check BP examine urine sediment Symptomatic: ACE inhibs Diuretics if edema limit protein and sodium treat hypercholestrolemia influenza and pneumococcus
Diagnosis, Lab and clinical findings of nephritic syndrome
labs: hematuria, AKI- azotemia and oliguria, Proteinuria (not in nephrotic range)
Clinical: HTN, edema
Diagnosis: urinalysis, blood studies, needle biopsy of kidney
Diagnosis, Lab and clinical findings of nephrotic syndrome
lab: urine protein excretion rate greater than 3.5/24 hours
Hypoalbuninemia
Hyperlipidemia, fatty casts in urine
Clinical: edema, hypercoagulable state, increased risk of infection
Diagnosis: urinalysis, blood tests, needle biopsy
Minimal change disease treatment
steroids for 4-8 weeks
Focal segmental glomeruloscerosis treatment
cytotoxic agents, steroids, and immunosuppressie agents
ACE and ARBs are indicated
Diagnosis and treatment of poststreptococcal GN
low complement levels, proteinuria, antisterptolysin-O
Treatment: generally self limited so treat supportively
Antihypertensives, loop diuretics for edema, steroids may be helpful
Diagnosis and treatment of goodpastures syndrome
Diagnosis: crescenteric, linear immunofluroscence patter on renal biopsy
IgG anti-glomerular basement membrane Ab
Treatment: plasmapharesis, cyclophosphamide, and steroids
HIV nephropathy diangnosis and treatment
Histopathology shows pattern similar to FSGS
Treatment: prednisone, ACE inhibitors, and antiretroviral therapy
Diagnosis and treatment of AIN
Diagnosis: renal function tests (increased BUN and Cr)
Eosinophils in the urine suggest the diagnosis
Mild proteinuria and microscopic hematuria
Treatment: remove offending agent
steroids can help
Diagnosis and treatment of renal papillary necrosis
Diagnosis: excretory urogram-note change in papilla or medulla
Treat the underlying cause and stop offending agent
Diagnosis and treatment of ADPKD
Diagnosis: ultrasound
Treatment: no curative treatment
drain cysts if symptomatic, treat infection with antibiotics, control HTN
Diagnosis and treatment of medullary sponge kidney
Hematuria, UTIs or nephrolithiasis
Associated withy hyperparathyroidism and parathyroid adenoma
Diagnosed by IVP
No treatment necessary, symptomatic
Diagnosis and treatment of renal artery stenosis
Abdominal bruit, sudden HTN refractory to medical therapy
Diagnosis: renal arteriogram is the gold standard but contrast dye can be nephrotoxic-do not use in renal failure
MRA is new test that has high sensitivity and specificity-can be used in renal failure
Treatment: revascularization with percutaneous tarnsluminal renal angioplasty initital treatment
Bypass surgery if not successful
Concomitant ACE inhibitors and CCBs
Neprholithiasis diagnosis, treatment and prevention
Calcium oxalate: bypyramidal or biconcave
uric acid: flat square plates
Struvite: rectangular prisms
Cystine: hexagon shpated crystals
Stones less than .5 cm pass spontaneously
Diagnosis:
UA: microscopic or gross hematuria
Associated UTI if pyuria or bacteriruia
Determine pH of urine
imaging: plain radiograph (KUB)-initial study choice (won’t detect cystine or uric acid stones)
CT scan is gold standard
IVP: determining if they need procedural therapy
Renal ultrasonography: cant receive radiation (pregnant)
Treatment: Analgesia: IV morphine, ketorolac (parenteral) Vigorous fluid hydration Antibiotics a1 blockers to help pass stone
Mild to moderate pain: high fluid intake, oral analgesia wait for stone to pass spontaneously
Severe pain: IV fluids and pain control, obtain KUB and an IVP to find site of obstuction, doesn’t pass for 3 days consult urology
Ongoing obstruction and persistent pain: surgery necessary
Extracorporeal shock wave lithotripsy-best for stones greater than 5 mm and less than 2 cm (percutanous nephorlithotomy if fails)
Prevention:
High fluid intake is essential (2L of urine/day)
limit protein amount if hyperuricosuria
Limit calcium intake if calcium stones
Thiazide diruetics, allopurinol
Diagnosis and treatment of urinary tract obstruction
Diagnosis: renal ultrasound is initial test-initial test for identifying hydronephrosis
KUB-reveals stones
intravenous urogram (IVP)-gold standard for ureteral obstruction-CI if pregnant, allergic or renal failure
Voiding cystourethrography-lower tract obstruction
Cystoscopy-evaluate urethra and bladder
Treatment:
Lower obstruction: urethral catheter for acute,
Dilatation or internal uretnrotomy-cause is urehtral strictures, prostatectomy if BPH
Upper urinary tract: nephrostomy tube drainage-for acute
ureteral stent-if ureteral obstruction
Acute complete obstruction: pain or renal failure-immediate therapy
Acute partial: due to stones
Chronic partial: immediate if infection, severe symptoms, renal failure or urinary retention
Treatment of testicular torsion
Surgical emergency
Bilateral orchopexy and detorsion of scrotum
do not delay beyond 6 hours
Orchiectomy if nonviable testicle is found
