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Renal/Genitourinary - Step UP Flashcards

1
Q

definition of acute kidney injury

A

rapid decline in renal function with an increase in serum BUN or Cr (relative = 50% or absolute increase of 0.5-1.0 mg/dL)

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2
Q

MC clinical findings in AKI

A

weight gain and edema - due to positive water and Na+ balance

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3
Q

azotemia

A

elevated BUN and Cr

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4
Q

causes of elevated BUN

A 
catabolic drugs (steroids)
GI/Soft tissue bleeding
dietary protein intake
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5
Q

BUN may be falsely low in..

A

liver disease
SIADH
malnutrition

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6
Q

etiology of prerenal AKI (7)

A

decrease in systemic arterial blood volume or renal perfusion

  • hypovolemia
  • CHF
  • hypotension, 3rd spacing
  • renal arterial obstruction
  • cirrhosis/hepatorenal syndrome
  • NSAIDs, ACE i and cyclosporin
  • low albumin states
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7
Q

prerenal failure:

  • urine osmolarity (1)
  • urine Na+ (2)
  • FE-Na+ (3)
  • urine sediment (4)
  • BUN/Cr ratio (5)
  • urine-plasma Cr ratio (6)
A

(1) Uosm > 500; s.g. > 1.010 (concentrated)
(2) UNa < 20
(3) FENa < 1%
(4) hyaline casts; scant sediment
(5) BUN/Cr > 20:1
(6) urine-plasma Cr > 40:1

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8
Q

pt presents with muscle pain, weakness and dark urine - what should you suspect?

A

rhabdomyolysis

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9
Q

what can cause rhabdomyolysis?

A 
trauma/crush injuries
prolonged immobilities
seizures
snake bites
drugs - cocaine
alcohol
infections
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10
Q

lab findings in rhabdomyolysis

A 
elevated CPK (usually > 100, 000)
hyperkalemia
myoglobinuria (positive dipstick w/o RBCs)
hypocalcemia
hyperuricemia
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11
Q

Tx of rhabdomyolysis

A

IV fluids - maintain urine output of > 300 ml/hour until urine neg. for Myoglobin
Mannitol
Bicarbonate

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12
Q

intrinsic renal failure:

  • BUN/Cr ratio (1)
  • Urine Na (2)
  • FE-Na (3)
  • Urine osmolarity (4)
  • urine plasma-Cr ratio (5)
  • urine sediment (6)
A

(1) BUN/Cr < 20:1 (usually 10:1)
(2) Urine Na > 40
(3) FE-Na > 2-3%
(4) Uosm < 350
(5) urine plasma-Cr ratio < 20:1
(6) brown pigmented casts, epithelial casts

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13
Q

pt presents with envelope shaped crystals on UA with an increased AG metabolic acidosis - dx?

A

ethylene glycol poisoning

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14
Q

pt who recently underwent angioplasty develops renal failure and blue discoloration of fingers/toes - dx?

A

atheroembolic disease

- skin biopsy will show cholesterol crystals

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15
Q

how can you prevent contrast induced nephrotoxicity? (3)

A

hydration - 1-2L NS 12 hrs before
isotonic bicarbonate
N-acetylcysteine

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16
Q

three basic tests in post-renal failure

A
  1. physical examination - palpate bladder
  2. USG - obstruction, hydronephrosis
  3. catheter - large volume of urine ; residual volume > 50 ml
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17
Q

causes of post-renal failure

A
  1. BPH - MCC
  2. nephrolithiasis
  3. obstructing neoplasm
  4. retroperitoneal fibrosis
  5. neurogenic bladder
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18
Q

what kind of renal failure does a dipstick positive for protein suggest?

A

intrinsic renal failure due to glomerular insult

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19
Q

red cell casts

A

indicate glomerular disease - i.e. GN

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20
Q

broad waxy casts

A

chronic renal failure

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21
Q

muddy brown, granular casts

A

acute tubular necrosis

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22
Q

WBC casts

A

renal parenchymal inflammation

  • pyelonephritis
  • interstitial nephritis
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23
Q

fatty casts

A

nephrotic syndrome

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24
Q

formula for FE-Na

A

FEna = 100 x [Una x Pcr / Pna x Ucr]

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25
Q

formula for renal failure index

A

(Una x Pcr) / Ucr

  • > 1% = prerenal failure
  • < 1% = ATN
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26
Q

MC mortal complications in early AKI

A

hyperkalemic cardiac arrest

pulmonary edema

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27
Q

metabolic complications in AKI

A 
hyperkalemia
metabolic AG acidosis
hypocalcemia
hyponatremia
hyperphosphatemia
hyperuricemia
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28
Q

how do you monitor fluid balance in AKI?

A

daily weight measurements - most accurate

input/output records

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29
Q

when should you order dialysis in AKI?

A

symptomatic uremia

intractable acidemia, hyperkalemia or volume overload develop

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30
Q

Tx. of prerenal AKI

A

eliminate any offending agents

give normal saline to restore BP

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31
Q

Tx. of intrinsic AKI

A

therapy is supportive

may try furosemide to increase urine output

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32
Q

Tx. of postrenal AKI

A

bladder catheter

urology consult

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33
Q

uremia

A

signs and symptoms associated with accumulation of nitrogenous waste due to impaired renal function; BUN > 60

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34
Q

signs and symptoms of uremia (8)

A 
severe acidosis
mental status changes
hyperkalemia
fluid overload
anemia
hypocalcemia
pericarditis
impaired cellular and humoral immunity
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35
Q

chronic renal insufficiency

A

renal function is compromised but not failed

serum Cr between 1.5-3.0 mg/dL

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36
Q

CV symptoms in CRF

A

HTN - secondary to salt and H20 retention
CHF
pericarditis - uremic

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37
Q

Neurologic findings in CRF

A

lethargy, confusion, somnolence, peripheral neuropathy, seizures
P/E findings - weakness, asterixis, hyperreflexia, “Restless legs”

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38
Q

Hematologic findings in CRF

A
  1. normochromic normocytic anemia (def. EPO) Tx. EPO replacement
  2. bleeding dysfunction - platelets cant degranulate in uremic envt (Tx. DDVAP)
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39
Q

endocrine disturbances in CRF

A

hyperphosphatemia –> decreased vit D production –> hypocalcemia –> elevated PTH –> renal osteodystrophy and eventually hyPERcalcemia

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40
Q

calciphylaxis

A

in high phosphate states, the phosphate may precipitate with calcium causing vascular calcifications and necrotic skin lesions

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41
Q

what drugs can slow the progression of ESRD?

A

ACEi - dilate efferent arteriole and control BP

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42
Q

diet in CRF

A

low protein - 0.7-0.8 g/kg body weight

restrict K+, phosphate and Mg2+ intake

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43
Q

how do you tx. hyperphosphatemia in CRF?

A

phosphate binders

  • calcium citrate
  • sevelamer/levanthum (esp. when due to vit D intake)
  • cinacalcet (mimics effect of Ca2+ on PTH)
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44
Q

what type of replacement therapy should CRF pts be on?

A

long term oral Calcium and vit D

oral Bicarb if acidotic

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45
Q

when should you treat anemia with EPO?

A

if Hct < 30 or Hb < 10 mg/dl AFTER iron deficiency has been ruled out and pt w/ symptoms of anemia on dialysis

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46
Q

non-emergent indications for dialysis:

A
  1. symptoms of uremia i.e. NV, bleeding, lethargy, mental status changes, pericarditis
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47
Q

emergency indications for dialysis (5)

A
  1. pulmonary edema
  2. refractory HTN emergency
  3. refractory hyperkalemia, hypermagnesemia
  4. severe metabolic acidosis
  5. certain drug overdoses
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48
Q

which drugs are dialyzable?

A

Lithium
Salicylates
Ethylene glycol/Methanol
Mg2+ containing laxatives

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49
Q

“First use” syndrome in dialysis

A

chest pain, back pain and anaphylaxis (rare) occuring immediately after patient uses a new dialysis machine

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50
Q

complications associated with peritoneal dialysis

A

peritonitis - cloudy fluid
abdominal/inguinal hernia
hyperglycemia/hypertriglyceridemia
protein malnutrition

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51
Q

what should you do if you suspect orthostatic proteinuria in someone?

A

obtain daytime and nighttime urine samples

- decrease protein in night-time samples

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52
Q

what is orthostatic proteinuria associated with?

A

nutcracker syndrome - entrapment of Left renal vein b/w aorta and SMA

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53
Q

key features of nephrotic syndrome

A 
proteinuria > 3.5 g/day
hypoalbuminemia --> edema
hyperlipidemia/lipiduria
hypercoagulable state
increased infections
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54
Q

initial test once proteinuria is detected on urine dipstick

A

urinalysis –> if UA confirms proteinuria, next step is 24 hr urine collection

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55
Q

how do you test for microalbuminuria?

A

special dipsticks can detect 30-300 mg/day of protein –> if these are positive, do a radioimmunoassay to confirm

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56
Q

most sensitive and specific test for microalbuminuria

A

radioimmunoassay

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57
Q

definition of proteinuria

A

> 150mg/24 hrs

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58
Q

definition hematuria

A

> 3 RBCs/hpf on urinalysis

- persistent if in > 2 samples

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59
Q

microscopic hematuria is more commonly (1) whereas, gross hematuria is more commonly (2)

A

(1) glomerular origin

(2) nonglomerular or urologic

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60
Q

in adults, gross hematuria is what? unless proven otherwise

A

malignancy - consider bladder cancer or renal cell carcinoma

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61
Q

what are the initial diagnostic tests in gross hematuria?

A
  1. upper urinary tract CT scan or IVP

2. endoscopic assessment of bladder and urethra

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62
Q

what medications can cause hematuria?

A 
Rifampin
cyclophosphamide
anticoagulants
salicylates
sulfonamides
analgesics
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63
Q

what do you do if you find RBC casts and dysmorphic RBCs on UA? what does this mean?

A

evaluate for intrinsic renal disease –> likely a glomerular cause

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64
Q

what does it mean if the dipstick if positive for blood but no RBCs can be seen under microscope?

A

hemoglobinuria or myoglobinuria is present

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65
Q

how do you approach hematuria if U/A and urine culture turn up negative?

A
  1. do a coag study - if +, coagulopath
    - if negative proceed to 2) KUB
    - if shows stones, tx stones
    - if normal, do 3) IVP, CT scan and cytology
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66
Q

classic lab findings in nephritic syndrome

A 
hematuria
anuria/oliguria
proteinuria < 3 g/day
HTN
edema
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67
Q

Tx. of nephrotic syndrome

A

1) steroids
2) if no effect: add cyclophosphamide or azathioprine
3) ARBs/ACEi can inhibit proteinuria

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68
Q

young child presents with nephrotic syndrome; you note fusion of foot processes on EM - dx? what is this dx associated with?

A

dx = minimal change disease

- assoc. with Hodgkins and NH lymphomas

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69
Q

Tx. of minimal change disease

A

excellent response to steroids

70
Q

what is FSGS associated with?

A
  • common in blacks

- assoc with HIV, obesity and heroin use

71
Q

what are some causes of membranous GN?

A

infection - endocarditis, hepB/C, syphilis, malaria
drugs - gold, captopril, penicillamine
neoplasms
lupus

72
Q

young Asian patient presents to you because she noticed blood in her urine; she recently had an URI

A

IgA nephropathy aka. Berger’s disease

73
Q

young boy is brought in bc his mother noticed he couldnt hear properly (high frequency sounds especially); she also said his pee looks red - dx?

A

consider Alport’s disease - XL or AR

-hematuria, proteinuria and sensorineural hearing loss w/o deafness

74
Q

what is essential for dx. of lupus nephritis?

A

biopsy - guides tx

  • sclerosis = no tx
  • proliferative = steroids + mycophenolate
75
Q

what is membranoproliferative GN associated with?

A

Hep. C infection, cryoglobulinemia

76
Q

Hep C patient presents with renal dz, joint pain, neuropathy and purpuric skin lesions; you find he has elevated ESR and low complement - dx? tx?

A

cryoglobulinemia

Tx. IFN and ribavirin

77
Q

Tx. of membranoproliferative GN

A

dipyramidole
aspirin
- rarely effective

78
Q

mother brings young child in because she noticed blood in their urine; upon exam you notice the child has periorbital edema and HTN; history reveals pharyngitis infection 2 weeks ago - what should you be considering?

A

poststreptococcal GN

79
Q

what additional tests may help with your suspicion of post-streptococcal GN

A

elevated antistreptolysin O and antihyaluronic acid (AHT)

- kidney biopsy: humps on EM and subepithelial humps (usually not needed)

80
Q

tx. of post-streptococcal GN

A

supportive - usually self limited dz

81
Q

Tx. of Goodpasture’s disease

A

plasmaphoresis - removes circulating ab’s

cyclophosphamide and steroids

82
Q

HIV pt presents with heavy proteinuria and rapid development of renal failure; you do a biopsy and find collapsing FSGS

A

HIV nephropathy

83
Q

Tx. HIV nephropathy

A

prednisone
ACEi
antiretroviral therapy

84
Q

patient presents to you with oliguria and fever; you notice he has a rash and on CBC, there is eosinophillia- what should you consider?

A

acute interstitial nephritis

85
Q

main cause of acute interstitial nephritis

A

acute allergic reaction to medication

86
Q

what diagnostic tests should you do in suspected cases of acute interstitial nephritis?

A

renal function tests

urinarlysis

87
Q

Tx of AIN

A

removal of offending agent

- if sx. worsen, steroids may help

88
Q

pt on chronic pain tx. with NSAIDs presents with sudden onset flank pain, fever, pyuria and hematuria; there are no organisms on culture

A

think of renal papillary necrosis

89
Q

how can you confirm diagnosis of renal papillary necrosis

A

CT scan - bumpy contours in renal pelvis where papillae sloughed off

90
Q

defect in type 1 RTA (distal)

A

defect in ability to secrete H+ at the distal tubule (new HCO3- cannot be generated) - results in inability to acidify urine

91
Q

characteristic findings in type 1 RTA (3)

A

increased excretion of ions:

  • decreased ECF volume
  • hypokalemia
  • renal stones/nephrocalcinosis (increased Ca2+ and phosphate excretion into alkaline urine)
92
Q

Tx. for Type 1 RTA

A
  1. correct acidosis with NaHCO3
  2. give phosphate salts (promote excretion of titratable acid)
  3. K+ citrate - replaces K+ and HCO3-
93
Q

urine pH in type 1 RTA

A

cannot be lowered below 6 - therefore, urine pH > 6

94
Q

defect in Type 2 RTA (proximal)

A

inability to reabsorb the HCO3- at the proximal tubule resulting in increased excretion of HCO3- in urine; pt also loses Na+ and K+ in urine

95
Q

how can you diagnose type 2 RTA?

A

hypokalemia
serum HCO3 low (18-20)
presence of HCO3- in urine (alkaline pH)
malabsorption of glucose, phosphate, urate and aa

96
Q

Tx. of proximal Type 2 RTA (proximal)

A
  1. Na and water restriction - enhances HCO3- reabsorption
  2. thiazide diuretics
  3. K+ replacement
97
Q

what causes Type 4 RTA?

A

any condition that is associated with hypoaldosteronism or increased renal resistance to aldosterone = decreased Na+ absorption and decreased H+/K+ secretion

98
Q

features of Type 4 RTA

A

hyperkalemia

acidic urine

99
Q

Dx of type 4 RTA

A

increase in Urine Na+ after salt restriction is diagnostic

100
Q

Tx. of type 4 RTA

A

fludrocortisone

101
Q

what disease causes decreased intestinal and renal reabsorption of neutral amino acids such as tryptophan resulting in pellagra?

A

Hartnup disease

102
Q

an adult pt presents with intermittent flank pain, HTN, hematuria and a palpable mass on adbominal exam - what should you consider?

A

adult polycystic kidney disease

103
Q

what other associated findings or complications can you suspect in a pt with ADPKD?

A
  • intracranial berry aneurysm
  • liver cystics
  • mitral valve prolapse
  • colonic diverticula
  • HTN
  • hernias
104
Q

what is the confirmatory test for ADPKD?

A

kidney USG

105
Q

CF of infantile PKD?

A
  • liver involvement always - portal HTN, cholangitis
  • HTN
  • increased kidney size (abdominal distention)
  • pulmonary hypoplasia
106
Q

Dx. of infantile PKD

A
  • oligohydramnios during pregnancy

- USG will show renal cysts in collecting ducts and hepatomegaly w/ dilated bile ducts

107
Q

what is medullary sponge kidney?

A

cystic dilation of collecting ducts associated with hyperparathyroidism or parathyroid adenoma

108
Q

Dx. test for medullary sponge kidney

109
Q

what features suggest that a cyst is NOT simple and should be aspirated to R/O malignancy?

A

irregular walls with debris
thickened septae w/in mass
contrast enhanced, multilocular mass

110
Q

a pt presents to you with suddent onset of HTN manifesting as a headache; on exam you hear an abdominal bruit (continuous murmur in periumbilical area that radiates laterally) - dx? and next step?

A

suspect renal artery stenosis

  • perform renal arteriogram
  • if pt has signs of renal failure, do MRI
111
Q

Tx. of renal artery stenosis

A

percutaneous transluminal renal angioplasty with stent placment

  • if this is not successful, try surgery
  • ACEi and CCB may be tried alone or in combination with the above
112
Q

benign nephrosclerosis

A

thickening of glomerular afferent arterioles in pts with long-standing HTN

113
Q

malignant nephrosclerosis

A

rapid decrease in renal function and accelerated HTN due to diffuse intrarenal vascular injury resulting from long-standing benign HTN or in a previously undiagnosed pt

114
Q

CF in malignant nephrosclerosis

A
  1. elevated BP - papilledema, CNS findings
  2. renal manifestations
  3. microangiopathic hemolytic anemia
115
Q

MC site of impaction of kidney stones

A

ureterovesicular junction

116
Q

MC type of kidney stone

A 
calcium oxalate 
calcium phosphate (less common)
117
Q

causes of calcium stones

A

hypercalciuria
hyperoxaluria
decreased urinary citrate

118
Q

causes of hyperoxaluria

A
  • severe steatorrhea
  • small bowel disease
  • Crohns IBD
  • pyridoxine deficiency
119
Q

which kinds of stones occur more likely in an acidic pH urine?

A

uric acid stones

120
Q

what are the main causes of uric acid stones?

A

gout
chemotherapy of leukemias/lymphomas
- conditions with high levels of cell destuction

121
Q

what kind of stones are MC in pts with recurrent-UTIs due to urease-producing organisms such as Proteus, Klebsiella, Seratia etc?

A

struvite/staghorn calculi

122
Q

how do struvite stones form?

A

alkaline environment - urease positive bugs convert urea to ammonia; ammonia then combines with magnesium or phosphate to form stones

123
Q

which stones are NOT visible on radiograph i.e. are radiolucent?

A

uric acid stones

124
Q

which kidney stones are caused by genetic predisposition?

A

cystine stones

- hexagon shaped crystals

125
Q

what size of kidney stone usually passes on its own?

126
Q

a pt presents to you with sudden of colicky flank pain that radiates anteriorly toward his groin; what test do you do first?

A

urinalysis

127
Q

after urinalysis, what is the initial imaging test to be done for kidney stones?

A

KUB plain radiograph

128
Q

gold standard for diagnosis of kidney stones

A

spiral CT scan w/o contrast

129
Q

what test is useful for defining degree of obstruction and commonly used if a pt needs procedural therapy?

130
Q

what is the procedure of choice for diagnosing a kidney stone in pts who cannot receive radiation?

131
Q

indications for admitting a pt with a renal stone to hospital

A
  1. pain not controlled with oral meds
  2. anuria - pts with one kidney
  3. renal colic plus UTI and/or fever
  4. large stone > 1 cm
132
Q

what is the best tx. approach for someone with their first stone?

A

hydration and observation

oral analgesia

133
Q

MC used surgery method for renal stone removal

A

extracorporeal lithotripsy

- best for stones > 5 mm and < 2 cm

134
Q

what kind of removal method is best for renal stones > 2 cm if lithotripsy fails?

A

percutaneous nephrolithotomy

135
Q

dietary measures to prevent recurrences of kidney stones

A

high fluid intake > 3 L/day
restrict Na+, protein and oxalate
normal calcium intake

136
Q

what is the first test you should do in suspected urinary obstruction?

137
Q

gold standard test for dx. urinary obstruction

A

IVP

- contraindicated in prengnacy, allergy to contrast or renal failure

138
Q

what do you do if a patient has an acute urinary obstruction AND a UTI?

A

emergency diagnostic tests - USG or IVP

139
Q

RFs for prostate cancer

A 
age - most impt
African-American
high fat diet
positive family history
exposure to herbicides/pesticides
140
Q

an elderly man presents with difficulties in urination and low back pain - what should you consider?

A

prostate cancer

141
Q

what is the next step in a patient with an abnormal DRE?

A

transrectal USG with biopsy

142
Q

indications for transrectal USG with prostate biopsy

A

PSA > 10 ng/dL
PSA velocity > 0.75/year
abnormal DRE

143
Q

what other conditions may increase PSA levels?

A 
prostatic massage
needle biopsy
cytoscopy
BPH
prostatitis
advanced age
144
Q

Tx of localized prostatic cancer

A

radical prostatectomy

145
Q

when is it ok to “watch and wait” prostate cancer

A

older men (< 10 yrs life expectancy) who are asymptomatic

146
Q

MC complications of prostatectomy

A

erectile dysfunction

urinary incontinence

147
Q

tx. for locally invasive prostate cancer

A

radiation therapy plus androgen deprivation

148
Q

Tx. of metastatic disease

A

want to reduce the amt of testosterone with any of the following: orchiectomy, antiandrogens, LHRH agonists or GnRH antagonists

149
Q

where does prostate cancer commonly metastasize to?

A

vertebral bodies
pelvis
long bones of legs

150
Q

RFs for renal carcinoma

A 
smoking
phenacetin analgesics
ADPKD
chronic dialysis - multicystic kidney dz
exposure to heavy metals - mercury, cadmium
HTN
151
Q

pt presents with hematuria, abdominal mass and flank pain - what should you consider?

152
Q

paraneoplastic syndromes caused by renal cell ca.

A 
anemia/erythrocytosis - EPO
thrombocytosis
fever
hypercalcemia - PTHrP
cachexia
HTN - renin
Cushing's - cortisol
153
Q

a pt presents with a left sided scrotal varice that fails to empty when pt is recumbent - what should you consider?

A

renal cell ca. that has obstructed the renal vein and drainage of gonadal vein

154
Q

optimal test for diagnosis and staging of renal cell ca.

A

CT scan w/ and w/o contrast

155
Q

Tx. for renal cell ca.

A

radical nephrectomy and adrenal gland, incl. Gerota’s fascia with excision of nodal tissue along the renal hilum

156
Q

MC type of genitourinary tumor

A

bladder cancer - transitional cell ca.

157
Q

RFs for bladder ca.

A

smoking
industrial carcinogens - aniline dye, azo dye
long term cyclophosphamide tx

158
Q

classic presentation of bladder ca.

A

painless hematuria

159
Q

definitive test of bladder cancer.

A

cystoscopy with biopsy

160
Q

what imaging test can you do in bladder cancer to determine staging?

A

CXR and CT scan

161
Q

what is the initial test for localizing a testicular tumor?

A

testicular ultrasound

162
Q

B-hCG is elevated in which testicular tumors?

A

choriocarcinoma

163
Q

AFP is elevated in which testicular tumors?

A

embryonal tumors

164
Q

Tx of testicular cancer

A

after suspected with USG, testicle should be removed surgically to confirm diagnosis (inguinal approach)

165
Q

a young man with a firm, painless testicular mass is presumed to have what? until proven otherwise?

A

testicular cancer

166
Q

what is penile cancer associated with?

A

lack of circumcision

HSV and HPV 18 infections

167
Q

young male presents with acute severe testicular pain, swollen and tender scrotum and an elevated testicle - dx?

A

testicular torsion - surgical emergency

168
Q

tx. of testicular torsion

A

surgical detorsion and orchiopexy to scrotum (do this bilaterally to prevent recurrence) –> should be done within 6 hours to maintain viability

169
Q

a young male presents with a swollen tender testicle, a scrotal mass and fever/chills - dx?

A

epididymitis

170
Q

causes of epididimytis

A

children/elderly - E.coli

sexually active adults - gonorhea, Chlamydia

Internal Medicine (9 decks)

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