Renal/GU/Nephro Flashcards
Renal tubular acidosis (RTA) associated with abnormal H+ secretion and nephrolithiasis
Type I/distal RTA
RTA associated with abnormal HCO3- and rickets
Type II/proximal RTA
RTA associated with aldosterone defect
Type IV/distal RTA
Doughy skin
Hypernatremia
Differential of hypervolemic hyponatremia
Cirrhosis
CHF
Nephritic syndrome
Chvostekβs and Trousseauβs signs
Hypocalcemia
Most common causes of hypercalcemia
Malignancy
Hyperparathyroid
T wave flattening and U waves
Hypokalemia
T wave peaked and wide QRS
Hyperkalemia
First line Tx moderate hypercalcemia
IVF and loops (furosemide)
Type ARF with FeNa<1%
Prerenal
49 yo man presents with acute onset flank pain and hematuria
Nephrolithiasis
Most common type nephrolithiasis
Calcium oxalate
20 o man presents with palpable flank mass and hematuria. US shows bilat enlarged kidneys with cysts. ASsociated brain anaomly
PCKD- berry aneurysm
Hemturia, HTN, oliguria
Nephritic syndrome
Proteinuria, hypoalbuminemia, hyperlipidemia, hyperlipiduria, edema (periorbital swelling in am)
Nephrotic syndrom
Most common form nephritic syndrome
Membranous glomerulonephritis
Most common form glomerulonephritis
IgA nephropathy/Bergers
Glomerulonephritis with deafness
Alportβs syndrome
Glomerulonephritis with hemoptysis
Wegenerβs granulomatosis and Goodpasture syndrome
Presence of red cell casts in urine sediment
Glomerulonephritis/nephritic syndrome
Waxy casts in urine sediment and Maltese crosses (seen with lipiduria)
Nephrotic syndrome
Drowsiness, asterixis, nausea, pericardial friction rub
Uremic syndrome in pts with renal failure
55 yo man Dx with prostate CA. Tx option?
Wait, surgical resection, rad/androgen suppression
Low urine specific gravity with high serum osmolality
DI
Tx SIADH
Fluid restriction
Democlocycline
Hematuria, flank pain, palpable flank mass
Renal cell carcinoma
Testicular cancer associated with beta hCG and AFP
Choriocarcinoma
Most common type testicular cancer
Seminoma, type of germ cell tumor
Most common histology of bladder cancer
Transitional cell carcinoma
Complication of overly rapid correction of hyponatremia
Central pontine myelinosis
Salicylate ingestion occurs in what type of acid base disorder
Anion gap acidosis and primary respiratory alklosis due to central respiratory stimulation
Acid bas disturbance in pregnant women
Respiratory alkalosis
Elevated EPO, elevated HCT, normal O2 sats
Renal cell carcinoma or other EPO producing tumor
Evaluate with CT
55 yo man presents with irritative and obstructive urinary Sx. Tx?
Likley BPH
Options: nothing, terazosin, finasteride, TURP
6 D - hypernatremia causes
Diuresis Dehydration DI Docs (iatrogenic) Diarrhea Disease (kidney, sickle cell, etc)
Tx HyperK
C BIG K
Calcium gluconate
Bicarbonate or Insulin and glc
Kayexalate
Pts with metabolic acidosis, hypokalemia, normal BP - have what conditions
Surreptitious vomiting
Diuretic abuse
Bartterβs syndrome
Gitelmanβs syndrome
Causes of hyperglycemia
CHIMPANZEES
Most common: hyperparathyroidism, CA
Calcium supplementation Hyperparathyroidism/hyperthyroidism Iaotrogenic-thiazides, parental nutrition Immobility- esp ICU Milk alkali syndrome Paget's disease Adrenal insufficiency Acromegaly Neoplasm Zollinger Ellision syndrome - MEN I Exces Vit A Excess Vit D Sarcoidosis and other granulomatous disease
Calcium: loops vs thiazides
Loops lose calcium
Thiazide reabsorb calcium
Pt develops cramps and tetany following thyroidectomy
Hypocalcemia
Important to check in hypoalbuminemia, why
Ionized calcium
Serum Ca can be falsely low in hypoalbuminemia
Most common pt with hypomagnesium
Alcoholics
pH imbalance with ASA
Metabolic acidosis and respiratory alkalosis
Tx for anion gap causes of renal tubular acidosis
MUDPILES Methanol: fomepizole Uremia: dialysis DKA: insulin, fluids Paraldehyde, Phenformin Iron, INH: GI lavage, charcoal (INH) Lactic acidosis Ethylene glycol: fomepizole Salicylates: alkalinize urine
Calculate anion gap
Na - (Cl+HCO3)
RTA:
Type I
Type II
Type IV
I: distal
II: proximal
IV: distal
prerenal, intrinsic, vs postrenal cause
Prerenal: dec renal perfusion
Intrinsic: injury of nephron unit
Postrenal: outflow obstruction
Indications for urgent dialysis
AEIOU
Acidosis (<7.25
Electrolyte abnormalities (hyperkalemia)
Ingestion (salicylate, theophylline, methanol, barbs, lithium, ethylene glycol)
Overload (fluid)
Uremic Sx (pericarditis, encephalopathy, bleeding, nausea, pruritis, myoclonus)
Hyaline casts
Etiology
Prerenal, intrinsic, postrenal
Normal, inc suggest V depletion
Prerenal
Red cells casts, dimorphic red cells
Etiology
Prerenal, intrinsic, postrenal
Glomerulonephritis
Intrinsic
White cells, eosinophils
Etiology
Prerenal, intrinsic, postrenal
Allergic interstitial nephritis, atheroembolic
Intrinsic
Granular cell casts, renal tubular cells, muddy brown cast
ATN
Intrinsic
White cells, white cells casts
Pyelonephritis
Postrenal
Prevention of contrast induced nephropathy
IVF before and during scan
Also use N-acetylcystine and NaHCO3 - controversial
Anorexia N/V Uremic pericarditis Uremic frost Delirium Seizures Coma
Uremia
Definition of azotemia
Increased BUN and creatinine
Nephritic syndrome findings
PHAROAH
Proteinuria Hematuria Azotemia RBC casts Oliguria HTN
Nephritic syndrome cause: immune complex (2)
Postinfectious GMN IgA nephropathy (Berger)
Nephritic syndrome cause: pauci-immune
Wegenerβs granulomatosis
Nephritic syndrome cause: anti-GBM
Goodpasture
Alportβs
GABHS or other infection, Low C3, +ASO, lumpy bumpy immunofluorescence of IgG and C3
Oliguria, edema, HTN, tea or cola colored urin
Good recovery with diuretics
Dx confirmed with RBC casts
Postinfectious GMN
Typically follows upper resp or GI infections, young men, deposition of IgA in mesengial cells
Episodic gross hematuria or persistent
microscopic
Dx: increased IgA, mesangial prolix on EM, histo - looks like HSP
Glucocorticoids, ACEI if proteinuria
20% to ESRD, steroids if turns to nephrotic, cyclosporine, azothioprine, mycophenolate mofetil
IgA nephropathy/Berger
Granulomatous inflammation of respiratory tract and kidney with necrotizing vasculitis
Hematuria, hearing disturbances, resp and sinus, cavitary pulm lesions bleed and lead to hemoptysis
C ANCA (cell mediated IR), biopsy shows: segmental necortizing GMN with few IG deposits immunofluorescence
Tx: cyclophosphamide and steroids/methotrexate
Wegeners granulomatosis
Rapidly progressing GMN with pulm hemorrhage, mid 20s
Hemoptysis, dyspnea, possible resp failure (anti-BM/ anti-alveolar ab also hit lungs)
Linear anti-GBM (IgG) on immunofluorescence, Fe def anemia, hemosiderin macrophages in sputum, pulm infiltrates on CXR, IgG antiglomerular BM Ab
Tx: plasma exchange, pulsed steroids, progress to ESRD, cyclophosphamide
Methotrexate or azothioprine for maintenance
Goodpasture syndrome
Hereditary GMN defect of collage IV BM, boys 5-20, ASx hematuria with SENSORINEURAL DEAFNESS/ HIGH FREQUENCY HEARING LOSS and eye disorders
GBM splitting on EM, red cell casts,
Progresses to renal failure, may recur after transplant; corticosteroids, plasmapheresis, immunosuppression
Alport
Lumpy bumpy immunofluorescence
Postinfectious GMN
Segmental necrotizing GMN with few Ig deposits on immunofluorescence
Wegeners
Linear anti GBM deposits on immunofluorescnece
Goodpastures
GBM splitting on EM
Alports
Most common cause nephrotic syndrome in children
Cause: NSAIDS and heme malignancy (Hodgkins)
Tendency: infections and thrombotic events
Lab: HLD, hypoalbumin
Light micro: normal
EM: fusion/flattening/effacement epi foot processes with lipid laden renal cortices
Tx: steroids
Minimal change disease
Cause: IVDU, HIV, obesity
Typical pt: young Afr Am male w/ uncontrolled HTN
Labs: microscopic hematuria, biopsy shows sclerosis in capillary tufts
Tx: prednisone, cytotoxic Tx, ACEI/ARBs for proteinuria
Focal segmental glomerulosclerosis
Most common nephropathy in Caucasian adults. 2nd causes - solid tumor malignancies and immune complex
Associated HBV, syphilis, malaria, gold
Labs: spike and dome appearance due to IgG and C3 deposits at BM
Tx: prednisone and cytotoxic
Membranous nephropathy
Has 2 forms: diffuse hyalinization and nodular glomerulosclerosis (Kimmelstiel Wilson lesions)
Pts poor controlled DM with retinopathy or neuropathy
Labs: thick GBM, inc mesangial matrix
Tx: tight control of blood sugar, ACEI for DMI, ARB for DM II
Diabetic nephropathy
Classified as WHO types I-IV, both nephrotic and nephritic; malar rash and arthritis
Proteinuria or RBC on UA
Labs: mesangial proliferation, subendothelial and/or subepithelial immune complex deposition, + ANA and Anti=DNA Ab
Tx: prednisone and cytotoxic therapy may slow disease progression, ACEI and statin for proteinuria
Lupus nephritis
Primary cause plasma cell dyscrasia, secondary infectious or inflammation
Pts may have multiple myeloma or chronic inflammatory disease (RA, TB)
Labs: nodular glomerulosclerosis
EM: emyloid fibrils
Apple green birefringence with Congo red stain
Tx: prednisone and melphalan; BM transplant MM
Renal amyloidosis
Nephrotic/nephritic; Type I assoc HCV, cryoglobulinemia, SLE, subacute bacterial endocarditis
Slow progression renal failure
Labs: tram track double layered BM
- Type I: subendothelial deposits and mesangial deposits
- All 3 have low serum C3
- Type II: C3 nephritic factor
Tx: corticosteroids and cytotoxic Rx
Membranoproliferative nephropathy
Most common stones
Cause idiopathic hypercalciuria and primary hyperparathyroidism, small bowel disease
RADIOPAQUE, alkaline urine
Calcium oxalate/phosphate
Phosphate more with hyperparathyroidism
Urease forming organisms like Proteus or Klebsiella
Staghorn calculi
Alkaline urine
RADIOPAQUE
Struvite/triple phosphate
Associated gout, XO def, high purine turnover (chemo), acidic urine
RADIOLUCENT - need CT
Uric acid
Alkalinize urine with citrate
Restrict purines
Due to defect in renal transport of certain AA (COLA- Cystine, ornithine, lysine, arginine)
HEXAGONAL CRYSTALS
+URINARY CYANIDE NITROPRUSSIDE TEST
RADIOPAQUE
Cystine
Alkalinize urine, penicillamine
Organs affected by PCKD
Kidney
Spleen
LIver
Pancreas
AD vs AR PCKD
AD: common, no Sx until later in life, increased risk berry aneurysm
AR: more severe, Sx as child
Most common congenital urethral obstruction
Posterior urethral valves
Male with distended palpable bladder and low urine output
Grades of vesicoureteral reflux
Mild I and II - no dilation
Mod - severe: III-IV - ureteral dilation with caliceal blunting if severe
Scrotal swelling that transilluminates
2/2 remnant of processus vaginalis
Hydrocele
Dilation of pampiniform venous plexus - bag of worms, does not transilluminate
Varicocele
Infection of epididymis from STD, prostatitis, reflux
Enlarged or tender testicles, fever, erythema, pyuria; pain relieved by supporting scrotum
UA shows pyuria; often 2/2 GC, E coli, Chlamydia
Doppler: increased bf to testes
Tx: abx - Ceftriaxone or fluoroquinolon ?tetracyclines and fluoroquinolones
Epididymitis
Twisting of spermatic cord Intense, acute onset scrotal pain N/V/ dizzines LOSS OF CREMASTERIC REFLEX Dopper: decreased bf to testes
Must fix immediately- manually or surgery
Orchipexy- attach testes to wall
Testicular torsion
BPH most common zone
Central-periurethral
Leading causes Ca death in men
Lung Prostate Colorectal Pancreatic Leukemia
Prostate Ca- type of cancer
AdenoCa
Prostate cancer - most common zone
Peripheral zone
Differential for hematuria
I PEE RBCS
Infection/UTI PCKD Exercise External trauma Renal glomerular disease Benign prostatic hyperplasia Cancer Stones
Classic triad renal cell carcinoma
Hematuria
Flank pain
Palpable flank mass
All 5-10% present with all 3 components of triad
Industrial risk factor bladder cancer
Aniline dye
beta hCG tumor marker
All choriocarcinomq
10% seminomas
AFP tumor marker
Nonseminoma Ca like endodermal sinus/yolk sac
Hepatocellular
Hepatoblastoma
Neuroblastoma
Tx seminoma
very radiosensitive
Bence Jones proteins/ light chains causes renal failure, can induce hypercalcemia and amyloidosis
Multiple myeloma
UTI causes
E coli - most common Staph saprophyticus Proteus Pseudomonas Klebsiella Enterobacter Enterococcus
Diuretic that would not increase risk of forming calcium stones in kideny
Thiazides- reabsorb calcium back into serum
Right testicular or ovarin v drains?
Left drain?
Right: IVC
Left: left renal v
Mumps with painful swollen testis, unilat
Mumps
Priapism
2 types, define- which emergent
Tx
Ischemic- failure of detumescene: emergent
nonischemic- fistula between cavernosal a and corpus cavernosum
Tx pain meds and intracavernosal injection sympathomimetic (phenylephrine)
Hypospadia vs epispadia
Hypo: ventral/underside
Epi: dorsal/top
Urge incontinence
Tx
Involuntary leakage with sense of urgency due to inhibited bladder contraction = detrusor overactivity
Tx: bladder training, antimuscarinics (oxybutynin, tolterodine, solefenacin)
Stress incontinence
Tx
Involuntary leakage with exertion, sneezing, coughing, laughing
Tx: weight loss, kegel, pessaries, sling
Mixed incontinence
Tx
Involuntary leakage with urgency, exertion, coughing, sneezing, laughing
Tx: bladder training, antimuscarinics
Overflow incontinence
Tx
Continuous leakage of urine with incomplete bladder emptying usu 2/2 BPH, stricture, cancer
Tx: indwelling catheter, timed voiding, Tx disorder
Enzyme that is the catalyst for HCO3 reabsorption in PCT
Carbonic anhydrase
Common causes pyelonephritis
E coli Staph saprophyticus Klebsiella Proteus Candida in immunocompromised
Tx pyelo
Complications
IV fluoroquinolones, aminoglycoside, cephalosporin - 3rd gen for 1-2 d then outpt abx
Complications: pregnant can cause low birth women and preterm labor
Diuretic good for pulmonary edema because has pulmonary vasodilatory effect
Loops
Most common site of renal stone impaction
Ureto vesical jcn
Impacted stone vs peritonitis activity of pt
Stone: move like crazy
Peritonitis- not moving
Malignancies that increase EPO
Renal cell carcinoma
Pheo
Hemangioblastoma
Kimmelstiel Wilson nodules
Diabetic nephropathy
Formula FeNa
((urine Na)/(serum Na))/ ((urine Cr)/(serum Cr))
Corrected HCO3
Measured gap - normal gap (12) - measured HCO3
If Corrected HCO3 high
metabolic alkalosis with high anion gap acidosis
If corrected HCO3 low
Nonanion gap acidosis with high anion gap acidosis
Central vs nephrogenic DI and testing, Tx central
Central: pituitary not making ADH
Nephro: kidneys not respond ADH
Test: give ADH = central will increase urine osmolality; nephro have no change
Tx central DDVAP
Major cause SIADH, major problem
Paraneoplastic
Hyponatremia
Expected PCO2 formula
1.5 (HCO3) + (8 +/- 2)
Expected pH increase formula
if acute reps acid or alk: 1/10 x 0.08 x (PCO2 - 40)
If chronic resp acid or alk: 1/10 x 0.03 x (PCO2-40)
Pseudhyperkalemia
RBC hemolysis following blood collection
How to adjust total serum Ca if hypoalbuminemia
Ca decreases 0.8 mg/dL for each 1 g/dL albumin <4
FH hypercalcemia, low urine Ca, absence ostoepenia, nephrolithiasis, and metnal status changes
Familial hypocalciuric hypercalcemia
Tx UTI
Amoxicillina
TMP SMZ
Fluoroquinolones
3d