Renal disorders Flashcards
What is the most common symptom of bladder cancer?
Hematuria
What is the definition of proteinuria?
Urinary protein excretion of >150 mg/day (10-20 mg/dL)
What is the hallmark of renal disease?
Proteinuria
What is microalbuminuria?
Excretion of 30-150 mg/day of protein
- A sign of early renal disease (especially in patients with DM)
True/false: Proteinuria clinical presentations may vary from patient to patient due to exercise (causing excretion of albumin) to an advanced diabetic with nephrotic syndrome
True
Proteinuria physical exam components
- Complete personal and family history (especially renal and DM)
- Assess: chronic illness, surgery, diagnostic procedures (especially those requiring contrast media), urinary frequency or symptoms suggesting infection, risk factors, HIV infection
- Medications → prescription and OTC
Proteinuria diagnostic studies
- Urine dipstick
- UA and culture
- 24 hour urinary protein excretion or spot urinary protein/creatinine ratio
- Microscopic exam of urinary sediment, urinary protein electrophoresis, assess renal function
- CBC w/ diff, Bence Jones proteins, FBG, A1c, lipid profile
When collecting a 24 hour urinary protein excretion or spot urinary protein/creatinine ratio, what value is considered nephrotic syndrome?
Excretion rate of 3.5 g/day or more
Proteinuria management
- Treat the underlying disease
- Eliminate known trigger medications
- ACE inhibitors and ARBs
- Sodium and protein restricted diets
How do ACE inhibitors and ARBs reduce proteinuria?
Inhibit the RAAS which reduces proteinuria by decreasing systemic arterial pressure and intraglomerular filtration rate
What is nephrotic syndrome?
Kidney disorder that causes your body to pass too much protein in the urine
Symptoms:
- Proteinuria
- Hypoalbuminemia
- Edema
- Hyperlipidemia
What is the definition of hematuria?
3+ RBCs per hpf
- Can be transient (exercise induced) or persistent (suggesting serious illness)
- May be a result of an acute infection (UTI) or complex disease (diabetic nephropathy, glomerular, or interstitial cystitis)
What are the two types of hematuria?
- Microscopic hematuria
- Gross hematuria
What is Goodpasture syndrome?
Autoimmune disordered characterized by a group of acute illness that affect the lungs and kidneys (hemoptysis and hematuria)
Hematuria clinical presentation
- Often accompanied by clinically significant symptoms or by abnormalities in the urinalysis that can aid in identifying the source of bleeding
- Consider age, gender, level of physical activity
Symptoms suggestive of Goodpasture syndrome
- Hemoptysis
- Acute renal failure
- Hematuria
Hematuria physical exam components
- Obtain thorough personal and familial history (especially renal and DM)
- Pelvic exam
- Prostate exam
Hematuria diagnostic studies
- Obtain catheterized urine specimen if clean-catch cannot be obtained
- Urine and urinary sediment analysis (may see RBC casts)
- Intravenous urography (IVU)
- Ultrasound
- CT scan
- Cystoscopy
Hematuria management
- Identify and diagnosis of the problem
- Urological referral
- Surgery
- Encourage smoking cessation
What is renal failure also referred to as?
- End stage renal disease (ESRD)
- Stage 5 chronic kidney disease (CKD)
- AKI and CKD can progress to kidney failure or the absence of kidney function
What is the GFR in the early stages of renal failure?
>35 mL/min
Hallmark clinical signs of renal failure
- Decreased GFR
- Increased serum creatinine and albuminuria
What is the most common cause of kidney failure in the U.S.?
- DM
- HTN
For patients who develop AKI, what are identifiable risk factors?
- CKD
- Advanced age
- Liver disease
- DM
- Vascular disease
What are the goals of physical examination for patients with kidney failure?
- Identify primary diseases that contribute to kidney damage
- Broader examination that evaluates the effects of kidney disease
- Stage or categorize kidney damage
Renal failure physical exam components
- BP (including orthostatic)
- Fundoscopic exam → arteriovenous nicking, diabetic retinopathy, papilledema
- Cardiac → pericarditis, pleural effusion
- Abdominal exam
- Rectal exam in males
- Skin assessment → ecchymosis, rashes, uremic frost
- MSS
What is the most important labs to obtain when assessing for renal failure?
- Serum creatinine
- Estimated GFR
- First morning or random urine sample (albuminuria screening)
What other diagnostic studies can be obtained when assessing for renal failure?
- Serum nystatin C
- Urinalysis
- CMP
- A1c
- Lipid profile
- CBC w/ diff
- Renal ultrasound
AKI management goals
- Removal of offending toxin (e.g. contrast media, drugs)
- Correct electrolyte imbalances (especially hyperkalemia)
What medication can be given to patients with CKD for HTN management?
ACE inhibitors
Indications for early nephrology consult based on CKD risk factors
- AKI or abrupt sustained decrease in GFR
- GFR <30 mL/min
- Albuminuria >300 mg/g
- Urine RBC >20/hpf
- HTN refectory to treatment with 4+ agents
- Persistent abnormalities to serum potassium or low serum albumin
- Hereditary kidney disease
Where in the urinary tract can stones form?
- Kidneys
- Urinary system
- Ureters
- Lower urinary tract (bladder, urethra)
Renal stone risk factors/triggers
- Genetics
- Diet (e.g salt, oxalate, calcium)
- Dehydration
- High mineral content drinking water
- Tea, grapefruit/apple juice, cola, sports/energy drinks
- Sedentary lifestyle
- Family history
- Gout, primary hyperparathyroidism, short bowel syndrome, hyperinsulinism
What are the five different types of stones?
- Calcium oxalate
- Calcium phosphate
- Uric acid
Less common -
- Struvite
- Cystine
Kidney stone clinical presentation
- Acute renal or ureteral colic
- N/V
- Hematuria
- Fever and chills
- Dysuria
- Increased urinary frequency
- Vague abdominal, flank, or groin pain
Foods high in calcium oxalate
- Rhubarb
- Nuts
- Cocoa
- Tea
- Beans
- Lime peel
- Green leafy vegetables
Kidney stone physical exam
- Obtain detailed personal and family history, medical and medication history, occupation, dietary habits, fluid intake history
- Abdominal exam → often soft, contender, non distended abdomen
Kidney stone diagnostic studies
- Urinalysis, urine culture and sensitivity, urine pH
- Strain urine for stones/sediment
- 24 hour urine collection
- CBC (if fever), serum chemistry
- Serum calcium and vitamin D
- KUB, IVP ultrasound, CT scan
Can kidney stones be managed conservatively?
Yes - oral hydration (>2 L/day), pain management, expectant stone passage
How would the provider manage a kidney stone <8 mm?
Conservative management
- Oral hydration
- Pain relief
- Expectant stone passage
How would the provider management a kidney stone >8 mm?
Surgical management
- Extracorporeal shock wave lithotripsy (ESWL)
- Percutaneous nephrolithotomy (PCNL)
- Ureteroscopy (URS)
- Monitor/lifestyle adaptations, ongoing pH surveillance
How can pH findings drive kidney stone management?
Urine pH >7 = urea (need to obtain urine culture to rule out UTI)
Urine pH <5.4 = uric acid lithiasis (metabolic acidosis)
What are the four hallmarks of nephrotic syndrome?
- Hypoalbuminemia
- Hyperlipidemia
- Edema
- Excessive proteinuria
Nephrotic syndrome clinical manifestations
- Urine looks foamy
- Edema → periorbital edema, dependent areas (tight shoes or underwear), lax tissues (puffy eyes)
- If blood vessels of the kidney are damaged, and they leak proteins (e.g. albumin) there will be third spacing → fluid leaves the blood and enters the interstitial → edema
- Low urine production
True/false: Patients with nephrotic syndrome have a high risk of clotting
True - inability of glomeruli to filter blood properly can lead to loss of blood proteins
What causes nephrotic syndrome?
Usually due to underlying cause (e.g. patients with DM more likely to develop nephrotic syndrome)
Nephrotic syndrome treatment/management
- Diuretics for edema
- Statins, nutrition for hypoalbuminemia (will leak calcium and protein that binds vitamin D, so need to supplement with both)
- In pediatrics, treated with steroids (if they respond well, they have a good prognosis) → Prednisone 2 mg/kg/day to induce remission for 4-6 weeks
What is glomerulonephritis?
- PSGN is immune response to group A beta-hemolytic strep or pharyngeal streptococcal infection (1-4 weeks post infection)
- Most common form of nephritis
Glomerulonephritis clinical manifestations
- Periorbital and pedal edema
- Elevated BP
- UA shows RBCs, protein, and RBC casts
- Cola/tea colored urine
Glomerulonephritis treatment/management
No specific treatment
- Antihypertensives, calcium supplementation, diuretics, low sodium diet
- Will have gross hematuria for 1-2 weeks and urine can be abnormal for 6-12 weeks, but will resolve
