Renal / Genitourinary Flashcards
Hypernatremia (etiologies, PE)
Na >145
Esp free water loss (not Na+ gain)
6 D’s: Diuresis, Dehydr, Db insip, Docs (iatrog), Diarrh, Disease (kidn, SCD)
Thirst, neuro sympt (alt mental stat, weak, focal def, hyporefl, seiz)
Hypernatremia (dg)
Urin osmol <100 central DI 100-300 nephro DI 300-600 osmotic diuresis >600 extrarenal loss (vomit, diarr, ... with Na+ur <25) or Na+ gain (hypertonic saline w/ Na+ur >100)
Hypernatremia (ttt)
ttt: hypoVol + unstable vitals give isotonic 0.9% NaCl
If Nl vitals + asympt give D5W
Determine water deficit: replace w/ D5W, 0.45% NaCl or enteral water
!!! rate of replacement (48-72h if chronic hyperNa)
EuVol and hyperVol hyperNa: diuretics + D5W
Hyponatremia (PE, dg)
Na <135
Esp ↑ADH
Asympt or confus, lethargy, M cramps, hyporefl, nausea
Seiz, coma, brainstem herniat
Dg: calculate serum osmol (#1 is hypotonic hypoNa) then check volume (usually for hypotonic; hypoVol isoVol hyperVol) then measure urine Na and urine osmol
Hyponatremia (ttt)
Underl cause HyperVol + euVol: water restrict* +/- diuretics HypoVol: Nl saline Sev hypoNa (Na <120): hypertonic saline Chron hypoNa (>72h): correct slowly
Hyperkalemia (etiologies)
K >5
- Spurious: hemolysis, delay in analysis, extreme ↑WBCs or ↑plts
- ↓excret*: renal insuff, drugs, hypoaldost, T4 RTA
- Cellular shift: rhabdomyolysis, tumor lysis sd, insulin def, acidosis, drugs, exo, bld resorpt*
- ↑intake: fruits, potatoes, iatrog
Hyperkalemia (PE, dg)
Asympt; N/V, intest colic, areflexia, weak, arrhythm, paresthesia
Dg: repeat bld draw, ECG (tall + peak T, wide QRS, ↑PR, loss P), sine waves, VFib, card arrest
Hyperkalemia (ttt)
K >6.5 or ECG changes: emergent ttt #1 Calcium gluconate (if sev) Bicar +/or insulin + glucose Beta⊕ helps Stop diet/fluid K+ Kayexalate removes K+ but !!! CI Loop diuretics Dialysis: if renal failure or sev refractory
Hypokalemia (etiologies)
K <3.6
- Transcellular shifts: insulin, B2⊕, alkalosis
- GI loss: diarrh, laxative abuse, vomit, NG
- Renal loss: diuretics (loop, thiazid), hypoMg2+, 1* mineralocort excess, 2* hyperaldost, ↓vol, Bartter sd, Gitelman sd, drugs, DKA, T1-2 RTA, polyuria
Hypokalemia (PE, dg, ttt)
Fatigue, weak, M cramps, ileus, hyporeflex, paresthesia, rhabdomyol, ascend paralysis
Dg: 24h or spot urine K+ (GI vs renal loss); ECG (flat T, U wave, ST depress*), AV block, cardiac arrest
ttt: underl cause, oral +/or IV K+ (not >20mEq/L/hr)
Replace Mg2+
Hypercalcemia (etiologies, PE)
Ca >10.2 (corrected for albumin)
By hyperparathyr, cancer (breast, SCC, MM), Ca supplem, iatrog, immobil, Milk-alkali sd, Paget ds, adren insuff, acromeg, hyperthyr, Zollinger-Ellison sd, ↑vitA, ↑vitD, granulomatous ds (sarcoid, …)
Asympt; osteopenia, fx, kidn stones, anorex, constip, weak, fatig, alt ment status
Hypercalcemia (dg, ttt)
Dg: total/ionized Ca, album, P, PTH
If suspic*: PTHrP (cancer), prot electrophor (MM), vit D (sarc, TB), ECG (short QT)
ttt: IV hydrat*, avoid thiazides; steroids for granulom ds
If Ca>14: IV fluids + calcitonin + bisphosph
Hypocalcemia (etiologies, PE)
Ca <8.5 By hypoparath (post-surg, idiop), 2* hyperparath (CKD), malnutrit*, hypoMg2+, acute pancreatitis, vitD def, citrate chelat*, pseudohypoparath, DiGeorge sd
Abdo M cramps, dyspn, tetany, perioral/acral paresth, convuls*; Chvostek, Trousseau
Hypocalcemia (dg, ttt)
Dg: ionized Ca + PTH (#1); Hx of thyroidect; Mg2+, album, vitD (25 + 1,25), ECG (prolong QT)
ttt: underl cause, Mg2+ replet*, PO Ca2+ supplem (IV if severe)
Hypomagnesemia (etiologies, PE)
Mg <1.5
↓intake (malnutrit*, malabs, short bowel sd, TPN, PPIs)
↑loss (diuret, diarrh, vomit, hyperCa, alcoholism+++)
Miscellan: DKA, pancreatitis, ↑extracell volume
If sev: hyperreflexia, tetany, paresth, irritab, confus*, lethargy, seiz, arrhyth
Hypomagnesemia (dg, ttt)
Dg: concurrent hypoCa and hypoK; ECG (prolong PR + QT)
ttt: IV/PO Mg supplem, !!! correct Mg first (before hypoCa and hypoK)
Respiratory acidosis
Hypoventilat*
- Airway obstruct*
- Acute lung ds
- Chronic lung ds
- Opioids, narcotics, sedatives
- Weak respiratory muscles
Metabolic acidosis with compensation (hyperventilation) + normal AG
- Diarrhea
- Glur sniffing
- Renal tubular acidosis
- Hyperchloremia
Metabolic acidosis with compensation (hyperventilation) + ↑ AG
MUDPILES:
Methanol; Uremia; DKA; Paraldehyde; Iron/INH; Lactic acidosis; Ethylene glycol; Salicylates (late)
Respiratory alkalosis
Hyperventilat*
- Early high altitude expo
- Aspirin (early)
Metabolic alkalosis with compensat* (hypoventilation)
Chloride sensitive (hypochloremic, saline responsive, urine Cl <20):
- Vomiting
- Diuretic
Chloride resistant (saline resistant, urine Cl >20): -Hyperaldosteronism
Renal tubular acidosis
Net ↓tubular H+ secret* or HCO3- reabsorpt*
Non-AG metabolic acidosis
Types: I; II; IV (#1 fqt)
Renal tubular acidosis type I
Def H+ secret* (distal) HypoK Urin pH >5.3 Autoimmune dso; hypercalciuria; ifosfamide ttt: replace bicarb Compl: nephrolithiasis
Renal tubular acidosis type II
Def HCO3- reabsorpt* (proximal) HypoK Urin pH 5.3 (then <5.3) MM; amyloidosis; Fanconi; cystinosis; ifosfamide ttt: thiazides, volume deplet* Compl: Rickets, osteomalacia
Renal tubular acidosis type IV
Aldost def or resistance (distal) HyperK Urin pH <5.3 Hyporeninemic hypoaldost (renal insuff); ACEIs/ARBs; heparin ttt: furosemide, replace mineralocortic
Acute kidney injury (complications)
= Acute renal failure
Abrupt ↓fct; retent of creat+BUN
Oliguria (<500mL/d) not required
Compl: metabolic acidosis, e- abNl, volume overload; CKD!!!
Prerenal acute kidney injury (etiologies, PE, ttt)
↓renal perfus*
Hypovol, shock, cirrhosis, nephrot sd, renal art stenosis, hepatorenal sd, drugs (NSAIDs, ACEIs), CHF
Tachycard, hypoTN, other sympt (of liv failure, nephrot sd)
ttt: fluids, avoid nephrotoxic drugs; dialysis if AEIOU criteria
Prerenal acute kidney injury (labs)
BUN/Creat >20:1 FeNa <1% Urin Na <20 Urin osm >500 Hyaline casts in urine
Intrinsic acute kidney injury (etiologies, PE, ttt)
Nephron injury
ATN (isch or toxin), AIN, glomerulonephritis, emboli, rhabdomyolysis
Hx drug expo (aminogl, NSAIDs, peni), contrast media
Creat spikes in 5-10d (drugs) or 24h (contrast)
ttt: IVF if contrast needed; nonionic contrast; stop meds
Intrinsic acute kidney injury (labs)
BUN/Creat <15:1 FeNa >2% Urin Na >40 Urin osm <350 RBC casts (glomerulonephritis); WBC/eosino (AIN); muddy-brown cast (ATN); WBC (pyelonephritis); fatty (nephrot sd)
Postrenal acute kidney injury (etiologies, PE, ttt)
Urin outflow obstruct*
Prostat ds, pelvic tumor, intratubul obstruct* (crystalluria), bilat stones
↓urin output, suprapub pain, distend bladder, scan w/ postvoid residual >50mL
ttt: bladder cath
Postrenal acute kidney injury (labs)
BUN/Creat varies
FeNa >1-2%
Urin Na >40
Urin osm <350
Chronic kidney disease (etiologies, PE, dg)
> 3mo of GFR <60 or kidney damage
Esp by DM, HTN, glomerulonephritis, PKD
Asympt until GFR <30; gradual signs of uremia (anorex, N/V, pericarditis, “frost”, delirium, seiz, coma)
Dg: azotemia, fluid retent, metab acidosis, hyperK, anemia, abNl hemostasis, hypoCa, hyperP, 2 hyperparath, urin (waxy casts), osteodystrophy
Chronic kidney disease (ttt, complications)
ttt: ACEIs/ARBs, HTN control, DDAVP (if abNl bleed), EPO, fluid restrict*, ↓Na/K/P intake, P binders/calcitriol (Osteodystr), hemodialysis, peritoneal dialysis, renal transplant
Compl: acquired renal cystic ds (if long-term dialys), CV (MI, sudden card death)
Carbonic anhydrase inhibitors
Acetazolamide
In proximal conv tubule
Inhib CA, ↑H reabs, block Na/H exchange
Side eff: hyperchlor metab acidosis, sulfa allergy
Osmotic diuretics
Mannitol, urea
In entire tubule
↑tub fluid osmolarity
Side eff: pulm edema (CHF + anuria)
Loop diuretics
Furosemide, ethacrynic acid, bumetanide, torsemide
In ascend loop of Henle
Inhib Na/K/2Cl transporter
Side eff: water loss, metab alkal, ↓K/Ca/Mg, ototoxicity, sulfa allergy, hyperuricemia
Thiazide diuretics
HCTZ, chlorothiazide
In distal conv tubule
Inhib Na/Cl transport
Side eff: water loss, metab alkal, ↓Na/K, ↑glu/Ca/uric acid, sulfa allergy, pancreatitis
K+-sparing diuretics
Spironolactone, triamterene, amiloride
In cortical coll tub
Aldost recep antag (spirono); block Na channel (triam/amil)
Side eff: metab acid, ↑K, antiandrogenic (gynecom; spironol)
Nephritic syndrome
Glomerular inflamm (glomerulonephritis)
Proteinuria <1.5g/d
Oliguria, macro/micro hematuria, HTN, edema (also pulm)
Dg: UA, ↓GFR, ↑BUN+crea, renal biopsy
ttt: salt+water restrict*+diuretics (HTN, fluid overload, uremia) +/- dialysis; sometimes CS
Postinfectious glomerulonephritis
Nephritic sd w/ immune complex Recent (2-6wks) GAS inf; or any inf Oliguria, cola-urin, HTN, edema Low C3 (then Nl in 6-8wks); ↑ASO, ↑anti-DNase Lumpy-bumpy imm.fluoresc ttt: diuretics
IgA nephropathy (Berger ds)
Nephritic sd w/ immune complex After URI or GI inf Esp young men Gross hematuria Normal C3 ttt: GC; ACEIs (if proteinuria) !!! Progress to ESRD
Henoch-Schonlein purpura
Nephritic sd w/ immune complex Small Vx vasculitis; esp child Triad: palpable purpura, arthralgia, abdo pain Normal C3 ttt: GC
Granulomatosis with polyangiitis (Wegener ds)
Nephritic sd w/o Ig deposit
Granulom in nasopharyng + kidney w/ necrotizing vasculitis
Resp/sinus sympt; hemoptysis
c-ANCA; segmental necrotizing glomerulonephritis
ttt: ↑dose CS, cytotoxic agent, rituximab
Microscopic polyangiitis
Nephritic sd w/o Ig deposit Small Vx vasculitis (kidney, lung); No granulomas Resp sympt; hemoptysis; No nasophar p-ANCA; necrotizing glomerulonephritis ttt: GC, cyclophosphamide, rituximab
Eosinophilic granulomatosis with polyangiitis (Churg-Strauss)
Nephritic sd w/o Ig deposit Small Vx vasculitis Asthma, sinusitis, skin nodules/purpura, periph neurop p-ANCA, ↑Ig-E ttt: GC
Goodpasture syndrome
Nephritic sd w/ anti-GBM ds
Rapidly progress glomerulonephritis + pulm hge
Esp men in mid-20s
Hemoptysis, dyspn, +/-resp failure, No upper resp
Linear anti-GBM deposits (IF), iron def anem, macroph (sputum), pulm infiltr (CXR)
ttt: plasma exchange, pulse steroids
!!! ESRD progress*
Alport syndrome
Nephritic sd w/ anti-GBM ds Heredit glomerulonephritis Esp boys 5-20yo Asympt hematuria, sensorineural deafness GBM splitting (EM) !!! progr renal failure; may recurr after transplant
Nephritic syndrome with low C3 (#dg)
- Postinfectious
- Membranoproliferative glomerulonephritis (and mixed cryoglobulinemia: purpura, arthralgia, nephrit sd, ↓C3, ⊕HCV)
- Lupus nephritis
Nephrotic syndrome (causes, PE)
Esp from systemic ds (DM, SLE, amyloidosis)
Proteinuria ≥3.5g/d; general edema, hypoalbuminemia (<3), hyperlipidemia, foamy urine, lipiduria
↑R inf, hypercoag (↑venous thromb/PE; loss antithromb3, prot C/S)
Nephrotic syndrome (dg, ttt)
Dg: spot prot/creat ratio, albu, lipid, …; renal biopsy
ttt: prot+salt restrict*, diuretics, antihyperlipidemics
Imm.suppressant (sometimes); ACEIs; Strep pneumo vaccine (PPV23)
Minimal-change disease
#1 in child Idiop; NSAIDs, hemato malign (Hodgkin) ↑R inf, thrombosis; sudden edema Normal (light micro); fus* epith foot process + lipid-laden (EM) ttt: steroids; excellent pg
Focal segmental glomerulosclerosis
1 in adult; Idiop; IVDU, HIV, obes
Esp Afric/Amer man w/ uncontrolled HTN
Microsc hematuria; biopsy (sclerosis in capill tuft)
ttt: prednisone, cytotoxic ttt, ACEIs/ARBs
Membranous nephropathy
Ass w/ solid cancers, inf (HBV, malaria), autoimm (SLE), meds (NSAIDs, gold)
Spike+dome (granular deposits IgG+C3 at basement memb)
ttt: prednisone, cytotoxic ttt
Diabetic nephropathy
2 forms: diffuse hyalinizat* or nodular glomerulosclerosis (Kimmelstiel-Wilson)
Long-standing poorly controlled DM + retinop/neuropathy
Thick GBM, ↑mesangial matrix
ttt: tight glycem control, ACEIs/ARBs
Lupus nephritis
Nephrotic or nephritic sd Severity of renal ds → overall pg UA (prot or RBC) Mesangial prolif; subendoth or subepith imm complex deposit* ttt: prednison and cytotoxic med
Renal amyloidosis
1* (plasma cell dyscrasia); 2* (inf or inflamm)
MM or chronic infl ds (rheum arth, TB)
Nodular glomerulosclerosis; EM (amyloid fibrils); apple-green biref w/ Congo red stain
ttt: prednisone, melphalan; BMT in MM
Membranoproliferative nephropathy
Nephritic/nephrotic sd; ttt w/ CS and cytotoxic meds
T I: ass w/ HBV, HCV, cryoglob, SLE, subacute bact endocarditis
Tram-track, double BM, subendoth + mesangial deposits
Low C3
T II/III: esp idiop
Intramembran dense deposits
Nephrolithiasis (RF, PE)
RF: ⊕fam Hx, ↓fluid intake, gout, meds (allop, chemoth, loop diur), post-colectomy/ileostomy, enz def, RTA T1, hyperparath; esp older men
Acute severe colicky flank pain; radiat* testes/vulva; N/V
Shift posit*/uncomfort
Nephrolithiasis (dg, ttt)
Dg: UA (macro/micro hematuria), alter urin pH
Noncontrast abdo CT (#1) or AXR; US (#1 in child, pgnt)
KUB (if opaque stone)
ttt: hydrat* + analgesia (#1); <0.5cm pass; 0.5-3cm ttt w/ ESWL or percut nephrolithotomy or retrogr ureteroscopy;
alpha⊖ or CCB (facilitate passage)
Prevent: ↑fluid, ↑Ca intake, ↓prot/oxalate, ↓Na intake
Calcium oxalate / Calcium phosphate nephrolithiasis
1 kidney stone
Esp idiopathic hypercalciuria, 1* hyperparath, fat malabs, alkaline urine
Urine: ↑pH (Ca-P) or ↓pH (Ca-Oxal); Radiopaque
ttt: hydrat*, ↓Na/prot intake, thiazide
Do Not ↓Ca intake
Struvite nephrolithiasis
Mg-NH4-PO4
Ass w/ urease-prod org (Proteus); Staghorn calculi
Urine: ↑pH; Radiopaque
ttt: hydrat*, AB if UTI, surg removal
Uric acid nephrolithiasis
Ass w/ gout, xanthine oxidase def, ↑purine turnover
Urine: ↓pH; Radiolucent
ttt: hydrat*, alkalinize urin w/ citrate, ↓diet purine/allopur
Cystine
Def in renal transport of aa (Cystine, Ornithine, Lysine, Arginine)
Hexagonal crystals, ⊕urin cyanide nitroprusside test
Urine: ↓pH; Radiopaque
ttt: hydrat*, ↓Na intake, alkalinize urine, penicillamine
Polycystic kidney disease (types)
Cystic dilat* of renal tubules
Cysts in spleen, liver, pancreas
ADPKD: #1, asympt until >30yo, 50% will have ESRD then dialysis by 60yo, ↑R cerebral aneurysm
ARPKD: more severe, infants/young child, renal failure, liver fibrosis, portal HTN; death in few years
Polycystic kidney disease (PE, dg, ttt)
Pain, hematuria +/- HTN, hepat cysts, cereb aneur, divertic, MVP
If cyst ruptur/inf: sharp local pain
Dg: US (#1) or CT; genetic test (ADPKD1, ADPKD2)
ttt: Prevent compl + ↓progr to ESRD
Early UTI ttt; BP control (ACEIs/ARBs)
When ESRD: dialysis; renal transplant
Hydronephrosis (etiologies, PE)
Dilat* of renal calyces
2* to obstruct: ureteropelvic junct (child), if adult BPH, neurogenic bladder, tumor, …
2* to ↑output urinary flow and vesicoureteral reflux
Asympt; flank pain, ↓urin output, abdo pain, UTIs
Hydronephrosis (dg, ttt, complications)
Dg: US or CT; ↑BUN+crea
ttt: surg if anatomic obstruct*; laser/sound wave if calcul; ureteral stent; nephrostomy; Foley/suprapub cath (if low UT obstr)
Compl: if unttt, HTN, acute/chronic renal failure, sepsis, poor pg
Scrotal swelling (etiologies, PE)
- Painless: hydrocele, varicocele
- Painful: epididymitis, testic tors*
“Bag of worms” (varicoc; esp left side)
Prehn sign: ⊕ in epididymitis; ⊖ in tors*
Scrotal swelling (dg, ttt)
Dg: transilluminat* on US (⊕ in hydroc; ⊖ in varicoc)
Doppler (↑flow in inf; ↓flow in tors*); UA+Cx (gono, Ecoli, chlam)
ttt: hydroc (none); varicoc (surg if larg/sympt); inf (AB tetracycl/fluoroq; NSAIDs for pain); tors* (immed surg in <6h; orchiopexy bilateral!!!)
Erectile dysfunction (etiologies, RF)
- Initiate: psychol, endocrin, neuro
- Fill: arteriogenic
- Store: veno-occlusive dysfct*
RF: DM, atheroscl, meds (B⊖, SSRI, TCA, diuretics), HTN, heart ds, surg/radiat* prostate cancer, spinal cord injury
Erectile dysfunction (PE, dg, ttt)
Psy # organic: ⊕ nocturnal/early-morning erect* so nonorganic; situat* dependence Neuro eval (anal tone, LE); hypogonadism eval
Dg: clinic; testosterone, gonadotropin, prolactin
ttt: psychotherapy; PDE5 inhib; testosterone (if hypogonadism)
If PDE5 inhib fails: pump, prostag inj, surg implant
Benign prostatic hyperplasia (PE)
Nl aging process; in >80% of men 80yo
Esp periurethral zone
- Obstruct sympt: hesitant, weak/intermitt stream, incompl empty, urin retent*
- Irritative sympt: nocturia, daytime fqcy, urge incont, hematuria
Benign prostatic hyperplasia (dg, ttt)
Dg: DRE (uniform enlarged, rubbery), UA+Cx, PSA
Creat (r/o obstr uropathy, renal insuff)
ttt: alpha⊖, 5 alpha-reductase inhib
TURP if mod-sev sympt/complic (renal insuff, recurr UTIs, bladd stones)
Prostate cancer (RF, PE, prevention)
In men: #1 cancer; #2 cause of cancer death
RF: adv age, ⊕fam Hx
Asympt, obstr urin sympt, lymphedema (obstr meta), back pain (bone meta)
DRE (palpable nodule, indurat*) (tender prost = prostatitis)
Prevent: annual DRE +/or PSA starting 50yo, earlier in Afr/Am or w/ 1st degree fam cancer
Prostate cancer (dg, ttt)
Dg: clinic, ↑PSA>4, transrectal biopsy (under US, defin dg)
Grade (Gleason); CT abdo/pelv + bone scan (meta; osteoblastic, ↑BMD)
ttt: watchful waiting (elder + low-grade); radical prostatectomy (ass w/ ↑R of incontinence or erect dysfct)
Radiat* (ass w/ ↑R of proctitis, GI sympt); PSA (follow-up)
If meta: androgen ablat* (GnRH agonist, orchiectomy, flutamide) + chemotherapy
Bladder cancer (RF, PE)
1 fqt cancer of UT; esp men 60-70yo
Esp transitional cell carcinoma
RF: smok, ↑meat/fat, schistos, chronic cyclophosph, expo to aniline dye
Gross hematuria, other urin sympt (irritat)
Bladder cancer (dg, ttt)
Dg: cystoscopy w/ biopsy (#1), UA (hematuria), cytology, MRI/CT/bone scan (invas* + meta)
ttt: intravesicular chemoth (carcinoma in situ or large high-grade recurrent); resect* or intravesic BCG/mitomycin-C (superficial cancer); radical cystectomy or radiat* (invasive w/o meta or unresectable); chemoth alone (invasive + meta)
Renal cell carcinoma (RF, PE)
AdenoK from tubular epith cells
Spread: renal vein, IVC then meta lung and bone
RF: male, smok, obes, acquir cystic kidney ds in ESRD, vonHippel-Lindau
Triad: hematuria, flank pain, palpable mass
+/- ↓weight, mal, fever, varicocele, anemia or polycythemia
Renal cell carcinoma (dg, ttt)
Dg: CT (dg+stage); histo on nephrectomy piece (confirm)
ttt: surg resect* (cure if local); metastasectomy
Tyrosine kinase inhib (↓angiogenesis, cell prolif)
Testicular cancer (RF, PE, dg)
Esp men 15-34yo; but seminoma esp 40-50yo
Germ cells (95%)
RF: cryptorchidism, Klinefelter sd
Painless enlarged testes
Dg: testic US; CXR + CT abdo/pelv (meta); tumor markers
Testicular cancer (ttt)
ttt: radical orchiectomy
Platinum-chemoth for nonseminomatous
Radioth +/- chemoth: if seminoma
Testicular cancer (tumor markers)
Germ cell: seminoma (↑placental ALP); yolk sac (↑AFP), choriocarcinoma (↑B-hCG); teratoma (AFP, B-hCG)
Non-germ cell: leydig cell (↑testosterone, estrogen); sertoli cell (none); testicular lymphoma (none)
