Renal Diagnosis and Treatment

Question 1

Prerenal failure lab findings and treatment

Answer 1

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

Question 2

Intrinsic renal failure lab findings and treatment

Answer 2

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

Question 3

Postrenal failure lab findings and treatment

Answer 3

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

Question 4

ATN diagnosis

Answer 4

Urine sediment: Muddy brown casts, granular casts,

Trace proteins, no blood

Question 5

Acute glomerulonephritis diagnosis

Answer 5

Urine sediment: dysmorphic RBCs, RBCs with casts, WBCs with casts, fatty casts
Protein: 4+
Blood: 3+

Renal biopsy indicated

Question 6

Acute interstitial nephritis diagnosis

Answer 6

Urine sediment: RBCs, WBCs, WBCS with casts, eosinophils
Protein: 1+
Blood: 2+

Renal biopsy indicated

Question 7

AKI Electrolyte/Metabolite complications

Answer 7

Hyperkalemia
Hyponatremia
Hyperuricemia
Hypocalcemia (cannot activate Vitamin D)
Hyperphosphatemia
Metabolic acidosis

Question 8

Treatment of general AKI

Answer 8

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

Question 9

Amyloidosis diagnosis and treatment

Answer 9

Diagnosis: abdominal fat pad aspiration biopsy

Treatment: underlying condition
Colcichine for prevention and treatment

Question 10

Diagnosis and treatment of Chronic kidney disease

Answer 10

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

Question 11

Indications for Dialysis

Answer 11

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)

Question 12

Rhabdomyolysis

Answer 12

lab findings: markedly elevated creatinine phosphokinase, hyperkalemia, hypocalcemia, hyperuricemia

Treatment: IV fluids, mannitol (osmotic diuretic), and bicarbonate (drives K back into cells)

Question 13

Proteinuria diagnosis and treatment

Answer 13

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

Question 14

Diagnosis, Lab and clinical findings of nephritic syndrome

Answer 14

labs: hematuria, AKI- azotemia and oliguria, Proteinuria (not in nephrotic range)

Clinical: HTN, edema

Diagnosis: urinalysis, blood studies, needle biopsy of kidney

Question 15

Diagnosis, Lab and clinical findings of nephrotic syndrome

Answer 15

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

Question 16

Minimal change disease treatment

Answer 16

steroids for 4-8 weeks

Question 17

Focal segmental glomeruloscerosis treatment

Answer 17

cytotoxic agents, steroids, and immunosuppressie agents

ACE and ARBs are indicated

Question 18

Diagnosis and treatment of poststreptococcal GN

Answer 18

low complement levels, proteinuria, antisterptolysin-O

Treatment: generally self limited so treat supportively
Antihypertensives, loop diuretics for edema, steroids may be helpful

Question 19

Diagnosis and treatment of goodpastures syndrome

Answer 19

Diagnosis: crescenteric, linear immunofluroscence patter on renal biopsy
IgG anti-glomerular basement membrane Ab

Treatment: plasmapharesis, cyclophosphamide, and steroids

Question 20

HIV nephropathy diangnosis and treatment

Answer 20

Histopathology shows pattern similar to FSGS

Treatment: prednisone, ACE inhibitors, and antiretroviral therapy

Question 21

Diagnosis and treatment of AIN

Answer 21

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

Question 22

Diagnosis and treatment of renal papillary necrosis

Answer 22

Diagnosis: excretory urogram-note change in papilla or medulla

Treat the underlying cause and stop offending agent

Question 23

Diagnosis and treatment of ADPKD

Answer 23

Diagnosis: ultrasound

Treatment: no curative treatment
drain cysts if symptomatic, treat infection with antibiotics, control HTN

Question 24

Diagnosis and treatment of medullary sponge kidney

Answer 24

Hematuria, UTIs or nephrolithiasis

Associated withy hyperparathyroidism and parathyroid adenoma

Diagnosed by IVP

No treatment necessary, symptomatic

Question 25

Diagnosis and treatment of renal artery stenosis

Answer 25

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

Question 26

Neprholithiasis diagnosis, treatment and prevention

Answer 26

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

Question 27

Diagnosis and treatment of urinary tract obstruction

Answer 27

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

Question 28

Treatment of testicular torsion

Answer 28

Surgical emergency
Bilateral orchopexy and detorsion of scrotum

do not delay beyond 6 hours

Orchiectomy if nonviable testicle is found