Renal/GU Flashcards
Difficult to control HTN w increase in Creatinine after adding ACE-I. DX?
Hypertension that is difficult to control, hypokalemia, and an increase in creatinine > 30% after adding an ACE inhibitor are characteristic of renal artery stenosis. Decreased renal perfusion in renal artery stenosis activates the renin-angiotensin-aldosterone system, which causes efferent arteriole constriction and increased sodium and water retention. This autoregulatory process maintains glomerular capillary hydrostatic pressure and GFR, but the increased elimination of potassium (caused by aldosterone) would result in hypokalemia, while systemic vasoconstriction caused by angiotensin II and Na+/H2O retention would result in hypertension. The administration of ACE inhibitors (e.g., lisinopril) to patients with renal artery stenosis inhibits the autoregulatory mechanism, resulting in a decrease in GFR and an increase in creatinine, as seen here. The use of a diuretic (hydrochlorothiazide) in this patient also contributes to a decrease in glomerular filtration pressure and GFR.
Most common cause of urinary tract obstruction in male newborns? Dx/Tx?
This patient presents with urosepsis, a palpable bladder (midline lower abdominal mass), and a history of oligohydramnios, all of which are features of urinary tract obstruction due to posterior urethral valves. Urethral valves are present in about 1/8,000 live births, making them the most common cause of urinary tract obstruction in newborn boys. The treatment of choice is cystoscopy with primary valve ablation.
Kid with edema, proteinuria and casts in urine. Dx? What type of casts?
Minimal change dz. Fatty casts are very common in the urinary sediment of patients with nephrotic syndrome. Massive proteinuria (> 3.5 g/24 h) results in low serum albumin, which reduces capillary oncotic pressure, thereby causing edema secondary to fluid leaking into tissue. Consequently, the liver increases all synthetic activity (involving albumin as well as other macromolecules, such as lipids) to compensate. Some of these excess lipids are reabsorbed by the proximal tubular epithelial cells. Once the cytoplasm becomes engorged, chunks of the cell can slough off into the tubular lumen, leading to the classic fatty casts on urinary sediment.
Kids 2-24 months w first presentation of UTI. First line imaging?
Renal and bladder u/s. In children between 2 and 24 months of age, voiding cystourethrography (VCUG) is only recommended if the first-line imaging modality revealed ureteric dilation, hydronephrosis, and/or renal scarring. In this age group, VCUG is also indicated as an adjunct to the first line of imaging if any of the following are present: a previously confirmed UTI, failure to respond within 48 hours of appropriate antibiotic therapy, poor urine flow, flank or suprapubic mass, organisms other than E. coli on urine culture, and increased creatinine levels. Since this child does not meet any of these criteria, VCUG is not the most appropriate next step. In any case, VCUG cannot be performed during an active UTI (as seen here) and should only be performed once the infection clears and bladder irritability subsides.
You suspect nephrolithiasis in pt w gout. what will urine pH be?
In patients with urolithiasis, a low urine pH (<5.5) is characteristic for calcium oxalate, uric acid, or cystine stones. The stones are formed from organic acids that are less soluble when protonated and therefore tend to form crystals in an acidic environment. Of these, only uric acid forms radiolucent stones that cannot be detected on plain x-ray, as seen in this patient. Persistently acidic urine is the most common risk factor for uric acid stones, which are also associated with gout and other states of hyperuricemia such as increased cell turnover, e.g., myelodysplastic syndrome. Gout is likely the reason for this patient’s history of toe pain and swelling (podagra). Gouty stone is “rhomboid”
young woman w fbromuscular dysplasia, causing bilateral renal artery stenosis. Tx?
An ACE inhibitor such as ramipril is indicated for the control of hypertension in patients with renal fibromuscular dysplasia. In patients with severe bilateral disease, as seen here, PTA without stent placement is also indicated and is indeed the first-line revascularization procedure. Stent placement is avoided because it does not confer any additional benefit, and might in fact make subsequent aortorenal bypass grafting much more difficult, should PTA prove ineffective.
Urinary stone in diatal ureter and 10 mm. Tx?
Ureterorenoscopy (URS) with stone removal is the first-line therapy for patients with urinary stones in the middle or distal ureter ≥ 10 mm, and – unlike shock wave lithotripsy – it is effective even in morbidly obese patients and, therefore, recommendable in this patient. It is also the suggested treatment in patients with ureteral stones who decide against or fail a trial of spontaneous stone passage. Overall, URS is the intervention with the greatest stone-free rate.
Kidney stone < 5mm. Tx?
IVF and analgesia
Kidney stone <7mm. Tx?
CCB or tamsulosin (alpha-blocker)
Kidney stone <1.5 cm and proximal. Tx?
Lithotripsy
Kidney stone >1.5 cm. Tx?
Surgery.
Kidneystone + infxn. Tx?
Nephrostomy if proximal. Stent if distal.
RTA associated w abnormal H+ secretion and nephrolithiasis. High urine pH. Low serum K+
RTA Type I (distal)
TA associated with abnormal HCO3- reabsorption and rickets. Low serum K+
RTA Type II (proximal)
RTA associated w low aldosterone state. Low urine pH.
RTA Type IV (distal)
Treat of hypernatremia
NS if unstable VS. D5W or 1/2 NS to replace free water loss
DDX for hypotonic hypervolemic hyponatremia
CHF, Cirrhosis, Nephrotic syndrome, AKI, CKD
T-wave flattening and U waves. Etiology?
HypoKalemia
Peaked T waves and wide QRS
Hyperkalemia
Treatment of Hyperkalemia
C BIG K Calcium gluconate Bicarb Insulin Glucose Kayexalate
First line treatment for moderate hypercalcemia
IV hydration
FeNA less than 1%. Type of AKI?
Prerenal
Most common type of nephrolithiasis?
Calcium Oxalate
Test of choice for nephrolithiasis work up?
Noncon CT
Hematuria, HTN, oliguria. DX classification?
Nephritic syndrome
Hypoalbuminemia, Edema, Hyperlipidemia, Hyperlipiduria, Proteinuria. DX classification?
Nephrotic syndrome
Most common form of nephrotic syndrome in adults?
Focal Segmental Glomerulosclerosis
Nephritic syndrome 3 days after a URI w NL C3.
Berger/IgA nephropathy
Abdominal pain, Arthralgias, palpable purpura. Dx?
Henoch-Schonlein purpura
Glomerulonephritis w deafness. Dx?
Alport syndrome
Glomerulonephritis w hemoptysis. Dx?
Granulomatosis w polyangiitis and Goodpasture syndrome
Presence of red cell casts in urine sediment
glomerulonephritis/nephritic syndrome
Eosinophils in urine sediment
Allergic Interstitial Nephritis
Waxy casts in urine sediment and maltese crosses (seen w lipiduria)
Nephrotic syndrome
Muddy Brown Casts. Dx?
ATN
Pericardial friction rub, drowsiness, nausea, asterixis. Dx?
Uremic syndrome in pts w renal failure
Hematuria in 55 yo smoker. Dx?
Bladder cancer
Hematuria, flank pain, palpable flank mass
RCC
Testicular cancer assc’d w beta-hCG
choriocarcinoma
Most common histology of bladder cancer?
transitional cell carcinoma
Salicylate ingestion causes what acid-base changes
Primary respiratory alkalosis due to central respiratory stimulation w anion-gap acidosis
Acid-base in a pregnant woman?
Respiratory alkalosis. OR metabolic alkalosis 2/2 hyperemesis gravidarum.
55 yo w irritative and obstructive urinary sx. Tx options?
BPH. Terazosin (alpha-blocker),
Terazosin and other alpha-blockers (e.g., tamsulosin, doxazosin) are the first-line pharmacotherapy in patients with symptomatic BPH and decreased quality of life. Alpha-blockers are smooth muscle relaxants, which decrease the resistance to urinary outflow by causing smooth muscle relaxation of the bladder neck and the urethra, thereby causing a symptomatic improvement in patients with BPH. Alpha-blockers have no effect on prostate growth or PSA level.
OR finasteride (5alpha-reductase inhibitor).
5-α-reductase inhibitors like dutasteride are used to treat BPH, which this patient most likely has. They prevent the conversion of testosterone to dihydrotestosterone, which decreases the size of the prostate, causing symptomatic relief, as well as reducing the risk of acute urinary retention and need for prostatic surgery. Symptomatic improvement as well as a decrease in PSA levels is seen after at least 6 months of 5-α-reductase inhibitor use, which is consistent with this patient.
or TURP
First line tx for UTI in non-pregnant woman?
Empiric oral fosfomycin is a first-line antibiotic for uncomplicated UTI in a woman who is not pregnant. Other first-line antibiotics for uncomplicated UTI are trimethoprim-sulfamethoxazole (TMP-SMX) and nitrofurantoin. Persistent symptoms after 2–3 days of treatment with a first-line antibiotic indicate possible complicated UTI or a need to change antibiotic therapies.
this agent. Oral ciprofloxacin is reserved as a first-line antibiotic for patients with uncomplicated pyelonephritis, which classically manifests with fever, flank pain, and/or costovertebral angle tenderness, none of which are seen in this patient. Oral ciprofloxacin is also reserved for the treatment of complicated UTI or as a second-line agent in uncomplicated UTI. Because this patient has no risk factors for a complicated UTI (e.g., pregnancy, underlying urinary tract abnormality, or immunocompromised status), and she has not received a trial of first-line therapy, oral ciprofloxacin is not indicated.
Potassium citrate helps to dissolve what type of kidney stone?
Although most kidney stones are visible on x-ray, uric acid stones are radiolucent. They can be visualized on ultrasound or CT scan. Uric acid stones are usually soluble in alkaline urine. Thus, this patient should be treated with potassium citrate for urine alkalinization to help dissolve current stones and prevent the formation of new ones. Alternatively, sodium bicarbonate or sodium citrate can be used to alkalinize the urine. He should also be advised to decrease his daily alcohol intake.
PSGN pt presentation?timing?
Poststreptococcal glomerulonephritis can present with gross hematuria, flank pain, and myalgia following an episode of acute tonsillitis or skin infection. However, PSGN usually manifests 10–30 days following acute infection. Also, other features of PSGN, such as hypertension and edema, are absent in this patient. Finally, PSGN is most common in young children (between 3–12 years of age) and the elderly (> 60 years of age).
Treatments for urge incontinence?
Bladder training. Lifestyle modifications (not fluid restriction). Antimuscarinics
Treatments for Overflow incontinence
Identify and correct underlying cause. Cholinergic agonists. Intermittent Self-Cath.
Most effective method for slowing diabetic nephropathy
tight BP control <140/90
5 primary causes of nephrotic syndrome & classic associations
- Minimal change disease - NSAIDS, lymphoma
- IgA Nephropathy - URI
- FSGS-HIV/IVDU/AA or Latino/Obesity
- Membranous nephropathy - adenocarcinoma of breast or lung, NSAIDS, Hep B, SLE
- Membranoproliferative glomerulonephritis-Hep B, Hep C, lipodystrophy
Urge Incontinence clinical features?
sudden urge to urinate, resulting in involuntary leakage of urine. The condition is caused by sensory or motor dysfunction
Sensory urge incontinence
-Pathological increased bladder sensitivity, which results in the reflex action of bladder emptying
Motor urge incontinence
-Autonomous detrusor overactivity
Normal serum osms?
280-295
Calcium, PTH, Phos levels in CKD. Tx?
Kidneys cant respond! High PTH, Low Ca, High Phos Tx: Calcimimetics: Cinacalcet Phos Binders: Sevelamer Ca+Vitamin D3
Acute interstitial nephritis drugs and lab findings?
Interstitial nephropathy (also known as tubulointerstitial nephritis) is most commonly an allergic-type reaction to medications, typified by eosinophils in the urine. The nonspecific maculopapular reaction is also the common type of drug reaction rash and is seen in a minority of cases, as is low-grade fever (not critical to the question). Several medications can cause this: penicillins, cephalosporins, and NSAIDs are the most common.
In assessing AKI, what measurement is unreliable in patients taking diuretics?
FENa. Sketchy: FURy T-shirt Kid with loop straw:
FENa is unreliable w/ diuretic use → use FEUrea → <35% suggests prerenal AKI (>50% suggests intrinsic renal AKI) (Intrinsic/Labs)
