Renal & GU Flashcards
best initial test in nephro
- urinalysis
- BUN
- Cr
urinalysis consists of
- dipstick if positive
2. microscopic analysis
normally excrete which protein
Tamm Horsfall (30-50mg/24hrs)
transient proteinuria
BENIGN, 2-10% of population
benign causes of proteinuria
exercise
orthostatic proteinuria
single protein: creatinine = efficacy to
24hr urine collection
urine dipstick detects
ALBUMIN ONLY
normal protein excretion in 24hrs
less than 300mg
best initial test proteinuria
urinalysis
most accurate test proteinuria
protein:creatinine ratio
P/Cr accuracy vs. 24hr urine
GREATER ACCURACY– faster and easier
finding out cause of proteinuria
biopsy
microalbuminuria
30-300mg/24hrs
microalbuminuria can lead to….
worsening renal function
tx of microalbuminuria in diabetic patient
ACEI/ ARB
diabetic patient with kidney disease, do BIOPSY when there is…
NO OPHTHALMIC DISEASE (recall what’s going on in the kidneys, reflects what’s going on in the eyes of a diabetic)
WBC’s in urine
inflammation– acute interstitial nephritis
infection
eosinophils with NSAID induced kidney disease
NOOOOOOOPE!!!
stains used to detect eosinophils in urine
Wright and Hansel stains
common cause for mild recurrent haematuria
IgA nephropathy
False positives for dipstick haematuria
Hb or Mb
patient presents with trauma to kidneys and dark urine… what next
microscopic exam of urine– to detect if Hb/Mb present (Cannot tell the difference between the two, but can tell if its present or not)
IVP nephro answer
ALWAYS WRONG– since slow and renal toxicity with contrast
dysmorphic RBC’s
glomerulonephritis
cystoscopy indications
- hematuria without infection or trauma
- haematuria– without cause on CT/US
- hematuria with bladder mass on sonography
Diagnostic test for bladder cancer
cystoscopy with biopsy
hyaline casts
DEHYDRATION–tamm horsfall protein
mgmt of pre and post-renal azotemia
underlying cause; MOST ARE REVERSIBLE
obstruction with increasing creatinine
need BOTH kidneys to be obstructed for the creatinine to rise
weird cause of post-renal azotemia
retroperitoneal fibrosis
causes of retroperitoneal fibrosis
CTX: bleomycin, methylsergide
RTX
HYPOtn causes of pre-renal azotemia
- sepsis
- anaphylaxis
- bleeding
- dehydration
HYPOvol causes of pre-renal azotemia
- diuretics
- burns
- pancreatitis
- decrease pump function: CHF/ constrictive pericarditis/tamponade
- low albumin
- cirrhosis
one other cause of pre-renal azotemia– non-hypoTN/VOL
renal artery stenosis
ATN causes toxins
- NSAIDs
- aminoglycosides
- amphotericin
- cisplatin
- cyclosporine
miscellaneous causes of intrinsic renal azotemia
- rhabdomyolysis
- hyperuricaemia
- crystals
- contrast
- BJ proteins
- Post-strep infection
- heavy metals
- ethylene glycol
immediate increase in Cr cause
contrast induced nephropathy, within 1 day
2 days post CTX with cisplatin cause of increase Cr
tumor lysis syndrome
5-10 days, get increase in Cr
DRUGS– cisplatin, ahminoglycosides etc.
PC AKI early
- N/V
- malaise
PC AKI SEVERE
- confusion
- pericarditis
Pre-Renal Azotemia
BUN:Cr >20:1
UNa: 500mOsm/kg, = HIGH specific gravity
Intra-Renal Azotemia
BUN:CR 20
FeNa: >1%
UOsm:
bladder distended and get a MASSIVE RELEASE of urine after catheter
POST-renal azotemia (Since obstruction now being relieved)
if AKI cause is not clear, NEXT BEST STEP
URINALYSIS
sickle cell trait AVOID
DEHYDRATION– since get stuck in renal medulla, can’t concentrate
Contrast induced nephropathy
HYDRATION—- both BEFORE and DURING contrast study
LABS in contrast induced nephropathy
YES IT’S ATN, BUT…contrast causes spasm of the afferent arteriole– thus get BIG reabsorption water and Na thus…
UNa 500= HIGH specific gravity
how to prevent tumor lysis syndrome
- allopurinol
- rasburicase
- hydration
BEFORE CTX
ethylene glycol
calcium oxalate stones– thus LOW CALCIUM
methanol ingestion…
INFLAMMATION OF RETINA
calcium levels with NSAID ingestion
NO CHANGE
toxins are more likely to develop ATN if…
HYPO perfusion of kidney and if there is..
UNDERLYING RENAL INSUFF
risk of ATN with age
INCREASES with age– body loses 1% of renal function for every year past 40yo
what may increase risk of amino glycoside or cisplatin toxicity
LOW MAGNESIUM
causes of rhabdomyolysis
- trauma
- crush injuries
- immobility
initial test rhabdomyolysis
- positive urine dipstick for blood, NO cells
most accurate test rhabdomyolysis
urine test for myoglobin
labs in rhabdomyolysis
INCREASE CPK
hyperuricaemia
hyperkalaemia
hypocalcemia
tx of rhabdomyolysis
- saline
- mannitol
- bicarb
need to tx hypocalcemia in rhabdomyolysis
NOOOOO– it will correct itself
at risk of what with rhabdomyolysis
HYPERKALAEMIA–> LIFE THREATENING ARRHYTHMIA– thus do an EKG
any proven therapy to benefit ATN
NOOOO, just have to correct the underlying cause
use of diuretics in ATN
DO NOT change the overall outcome
wrong answers for tx of ATN
- low dose dopamine
- diuretics
- mannitol
- steroids
indications for dialysis when…
RISK OF LIFE THREATENING condition which CANNOT be corrected any other way
hypocalcemia an indication for dialysis?
NOOOO– because it can be corrected with calcium and it D
ototoxicity with furosemide based on
TOTAL DOSE and
HOW FAST its injected
prerenal azotemia + cirrhosis
= hepatorenal syndrome
blue toe syndrome and lived reticularis
atheroemboli
scenario where you would get atheroemboli
catherization– causes the cholesterol plaques to be broken off
urine findings for atheroemboli
EOSINOPHILURIA
EOSINOPHILURIA seen in…
- acute (allergic) interstitial nephritis– EXCEPT NSAID
- atheroemboli
most accurate diagnostic test for atheroemboli
BIOPSY
tx for atheroemboli
NONE– the biopsy doesn’t change the management
pulses with atheroemboli
NORMAL– because the emboli are too small to occlude vessels
tx of acute interstitial nephritis
usually resolves SPONTANEOUSLY with stopping the drug or controlling the infection
if creatinine continues to rise after stopping drug for AIN give…
glucocorticoids
analgesic nephropathy causes..
- ATN
- AIN
- membranous glomerulonephritis
- vascular insufficiency
- papilary necrosis
triad of symptoms in acute interstitial nephritis
rash
fever
eosinophiluria
TWO MAIN symptoms in papillary necrosis
flank pain
gross hematuria
most accurate test in diagnosis of papillary necrosis
CT scan– shows bumpy contour of interior
description of urine in papillary necrosis
necrotic material in urine VISIBLY
tx of papillary necrosis
NO TREATMENT
MAIN difference between nephrotic and nephritic syndrome
AMOUNT OF PROTEINURIA
best initial test for good pastures
anti-GBM ab’s
most accurate dx for good pastures
BIOPSY
tx of good pastures
- plasmapharesis
- steroids
gross hematuria 1-2 days after URTI
synpharyngitis—berger disease/ IgA nephropathy
gross hematuria 1-2 WEEKS after URTI
PSGN
most accurate test for berger disease
kidney biopsy
tx of berger disease
NO TREATMENT PROVEN– 30% resolve, 40-50%–> ESKD
tx of proteinuria in berger disease
ACE inhibitors and steroids
biopsy for PSGN
NOOOTTTT routineyl done
supportive tx for PSGN
antibiotics and diuretics
tx of alports
NOOO specific tx to reverse collagen defect
skin findings of PAN
livedo reticular and gangrene
MI in young person, or stroke in young person
PAN
ANCA in PAN
NOT present in most cases
best initial test for PAN
angiography
most accurate test for PAN
biopsy
tx of PAN
- prednisone
- cyclophosphamide
biopsy in lupus
NOT for dx of lupus, it’s to check severity– FOCUS TREATMENT
mild lupus nephritis
steroids
severe lupus nephritis
steroids + mycophenolate OR cyclophosphamide
tx of renal amyloidosis
melphalan and prednisone
Ddx LARGE KIDNEYS
- amyloid
- HIV nephropathy
- PCKD
nephrotic syndrome based on….
SEVERITY> cause
edema in nephrotic vs. CHF
nephrotic= EVERYWHERE SWOLLEN; where as CHD goes to legs mainly
best initial test for nephrotic syndrome
urinalysis– NOT sufficiently accurate
albumin:Cr ratio, 5.4:1= 5.4g excreted over 24hrs
most accurate test for nephrotic syndrome
RENAL BIOPSY
initial tx of nephrotic syndrome
steroids
unresponsive to steroids for nephrotic syndrome….
cyclophosphamide
control proteinuria in nephrotic syndrome with..
ACE inhibitors/ ARBs
edema mgmt in nephrotic syndrome
- salt restriction and diuretics
uremia defined as
- met acidosis
- fluid overload
- encephalopathy
- hyperKalaemia
- pericarditis
efficacy of peritoneal and hemodialysis
EQUALLY as effective
accelerated what in ESKD
atherosclerosis and HTN
endocrinopathy in ESKD
anovulatory women
low testosterone men– erectile dysfunction
death in ESKD
CARDIAC DISEASE X3> mortality than infection
tx bleeding in ESKD
DDAVP
tx of pruritus in ESKD
UV light and dialysis
tx hyperphosphatemia in ESKD
- calcium carbonate/ citrate
- sevelamer
- lanthanum
tx of hyperMg in ESKD
RESTRICT– high Mg foods, laxatives, antacids
tx of atherosclerosis in ESKD
dialysis
endocrinopathy tx in ESKD
dialysis
replace– estrogen and testosterone
with what calcium levels do you want to add sevelamer and lanthanum?
HIGH calcium levels, secondary to giving patient vit D
aluminum phosphate binders
NEVER NEVER NEVER USED–since cause DEMENTIA
living related kidney donor
95% 1 year survival
88% 3 year survival
72% 5 year survival
hLA matched kidneys last for
24 YEARS
deceased kidney donor
90% 1 ear survival
78% 3 year survival
58% 5 year survival
dialysis alone survival
1 and 3 year= variable
5 year= 30-40%
dialysis + DIABETIC survival
1 and 3 year= variable
5 year= 20%
HUS E.coli tx
RESOLVES SPONTANEOUSLY
what two things don’t work in TTP
platelet transfusion (Worsens it) and steroids
simple cyst
echo free
smooth, thin
sharp demarcation
good through to back
complex–potentially malignant cyst
mixed echogeneticity
irregular thick walls
lower density on back wall
debris in cyst
mcc death in ADPCKD
RENAL FAILURE
causes of nephrogenic DI
- lithium
- demecloycyline
- chronic kidney disease
- HYPOkalaemia
- HYPERcalcemia
nocturia….. first clue to
diabetes insipidus
sodium disorders—>
NEURO symptoms
potassium disorders–>
MUSCLE/ HEART symptoms
hyper-osmolar blood (high Na)
hypo-osmotic urine
hypo-Na urine
diabetes insipidus
water deprivation test in diabetes insipidus
urine osmolality stays low
urine volume stays high
response to ADH CDI
yes
response to ADH NDI
no
ADH level in CDI
low
ADH level in NDI
high
tx of hypernatremia
- correct underlying cause of fluid loss
- CDI: replace ADH= vasopressin= DDAVP
- NDI: correct K/Ca; STOP Li/demeclo, give thiazide or NSAID if above didn’t work
severe hypernatremia tx
0.9% saline
mild hypernatremia tx
glucose or 0.45% saline
causes of hyponatremia divided into
- hypervolemia
- hypovolemia
- euvolemia
hypervolemia causes of hyponatremia
CHF
cirrhosis
nephrotic syndrome
hypovolaemia causes of hyponatremia
sweating/burns/ pneumonia/ diuretics/diarrhea etc.
BECAUSE– will be treating with chronic replacement of free water– thus a little sodium and a lot of water are lost in urine over time– thus decreasing sodium
ADDISONS
euvolaemia causes of hyponatremia
- psychogenic polydipsia
- hyperglycemia
- hypothyroidism
- SIADH
slow loss of sodium
asymptomatic
quick loss of sodium
seizures
SIADH– urine osmolality
HIGH urine osmolality
SIADH–urine sodium
HIGH urine sodium
SIADH vs. primary polydipsia
primary polydipsia: low sodium urine, urine osmolality
mild hyponatremia
asymptomatic– restrict fluids
moderate hyponatremia
minimal confusion– saline AND loops
severe hyponatremia
lethargy, seizures, coma– hypertonic saline AND conivaptan, tolvaptan
conivaptan, tolvaptan
ADH antagonists
SIADH given saline AND….
LOOPS– must give with loops
chronic SIADH tx
demecloycline– ADH antagonist in kidneys
causes of hyperkalaemia divided into…
- pseudohyperk
- decreased excretion
- cellular shifts
- pseudohyperkalaemia
- hemolysis
- repeated fist clenching with tourniquet
- thrombocytosis or leukocytosis
- decreased excretion of K+
- renal failure
- aldosterone decrease:
ACE, RTA 4, K+ sparing drugs, Addisons
- cellular shift of K+–> hyperkalaemia
- tissue destruction: rhabdomyolyis, tumor lysis
- decreased insulin
- beta blockers
- digoxin
- acidosis
- heparin
PC hyperkaelamia
paralysis– severe
- ileus
- weakness
- cardiac rhythm disorders
most urgent test in severe hyper K
ECG
ECG findings of hyperK
- PEAKED T WAVES
- prolonged Pr
- wide QRS
acronym for tx of hyperk
C-BIG-K
abnormal ECG/ life threatening hyperK tx
CBIG - calcium chloride or gluconate (protective for heart only) - bicarb-- esp. if acidosis caused it - insulin and glucose [consider dialysis]
hyperK tx without abnormal ECG
- kayexalate
- loops
kayexalate
removes potassium from body via bowel
general causes of hypoK
shift into cells
GI loss
renal loss
shift into cells– hypoK
- insulin
- beta 2 agonists
- alkalosis
GI losses of K
- diarrhea
- chronic laxative abuse
- vomiting, NG suction
renal losses of K
- loops
- increased aldosterone
- hypoMg
- RTA proximal and distal
increased aldosterone
- Conns
- volume depletion
- cushings
- bartters
- licorice
EKG findings of hypoK
U waves, and flat T
tx of hypoK
oral or IV K (be careful with IV–> may lead to fatal arrhythmia)
causes of type 1 RTA
amphotericin
autoimmune diseases– SLE or Sjogrens (since can damage the kidneys)
risk of what with type 1 RTA
kidney stones and nephrocalcinosis
tx of type 1 RTA
replace bicarb
urine pH in type 2 RTA
variabel
early: >5.5
later:
tx of type 2 RTA
thiazides–> volume depletion–> enhance bicarb reabsorption
mcc of type 4 RTA
diabetes
tx of type 4 RTA
fludrocortisone
RTA vs. diarrhea normal anion gap?
UAG= Na- Cl
UAG for RTA
positive
UAG for diarrhea
negative
normal AG levels
6-12
elevated AG levels
greater than 12
cause of lactic acidosis
hypotension
hypoperfusion
tx of lactic acidosis
tx of the hypoperfusion
cause of ketacidosis
DKA/ starvation
test for ketoacidosis
acetone level
tx of ketoacidosis
insulin and fluids
cause of oxalic acid increase
ethylene glycol OD
test for oxalic acid
urinalysis– crystals
tx of oxalic acid increase
fomepizole
dialysis
cause of formic acid increase
methanol ingestion
test for formic acid
inflamed retina
tx of formic acid
fomepizole
dialysis
what is more precise than respiratory rate
minute ventilation= RR x TV
analgesia used in nephrolithiasis
ketorolac= nSAID
best imaging for nephrolithiasis
non-contrast CT
stone passes spontaneously
less than 5mm
stone is 5-7mm what to use, to help them pass
nifedepine and tamsulosin
fat malabsorption and kidneys…
INCREASE stone formation
stone is between 0.5cm- 2cm, non-obstructive
lithotripsy– upper half of the ureters
stone is LARGE and obstructing
stent placement
lower half of the ureters
basket
long term tx for nephrolithiasis
THIAZIDES– hypercalcemia– thus remove calcium from urine
tx for urge incontinence
- bladder training
- local anticholinergic: oxybutinin, tolterodine, solifenacin, dariferancin
- surgical tightening of urethra
goal blood pressure in diabetic
140/90mmHg
goal blood pressure if over 60yo
150/90
routine HTN screening for asymptomatic
- CAD
- CVD
- PAD
- CHF
- visual disturbance
- renal insufficiency
bruit in the flank
hypertension
PC of HTN if symptomatic
- bruit in flank
- coarctation of aorta: UL> LL
number one/ FIRST tx for HTN
WEIGHT LOSS– life style modifications for 3-6months before starting on anti-HTN
best initial tx for HTN
D-ABC diuretics= thiazides ---- ACE/arb Beta blocker CCB
90% of HTN patients treated with…
2 medications
pregnancy and HTN
1st= beta blockers
- CCB
- hydralazine
- alpha methyldopa
CAD and HTN
beta blocker
ACE/ARB
BPH and HTN
alpha blockers
depression and asthma with HTN
NOOOOOOOOOOOOOO beta blockers
hyperthyroidism and HTN
beta blockers
osteoporosis and HTN
thiazides
hypertensive crisis
HTN+ end organ damage
best initial tx for htn crisis
FIRST= LABETALOL…… then nitroprusside (because needs arterial line, thus never FIRST)
LOWERING BP IN HTN CRISIS
NOOOOOOOOTTTTTT to normal– since can provoke a stroke
causes of type 2 RTA
- multiple myeloma
- amyloidosis
- fanconi syndrome
- heavy metals
- acetazolamide
