renal/GU sect 10 Flashcards
List the Ddx for pre renal ARF?
• Hypovolemia o GI decree intake, v/d o Diuretics o Third spacing o Skin losses: fever, burns o Hypoaldosteronism o Salt losing nephropathy o Post obstructive diuresis
• Hypotension (frank and relative) o Septic vasodilation o Hemorrhage o Decreased CO o Pharm- bb, ccb, others o High output failure (thyrotoxicosis, thiamine deficiency, paget disease)
• Renal artery and small vessel disease o Embolism o Thrombosis- atherosclerosis, vasculitis, sickle cell disease o Dissection o Pharm: nsaid, ace I, arbs o Cyclosporine and tacrolimus o Microvascular thrmobosis (HUS, preeclampsia, DIC, vasculitis, sicke cell disease) o Hypercalcemia
List the Ddx for intrinsic renal disease causes of ARF?
• Tubular disease:
o ATN
o Nephrotoxins (aminoglycosides, radiocontrast, rhabdo)
• Intersitial disease:
o AIN- typically drug reactions (NSAODS
What is clinical presentation of Goodpastures/wegners?
• Goodpasture or wegeners (pulm-renal syndromes)
o Ass with cough, dyspnea, heomptysis
Clinical presentation of acute interstitial nephritis?
o Fever, arthralgia, and rash
Clinical presentations of Contrast induced nephropathy?
o Incr cr 3-5 days after followed by complete resolution
o Risk fxs: crf, dm, older age, hypovolemia, hypoalbumienemia, certain contrast agents
List the Ddx for post renal ARF?
• Infants and Children:
o Anatomic malformations: urethral atresia, meatal stenosis, ant or post urethral valves
o Anatomic malformations of ureter: VUR, UVJ obstruction, uretrocele, megaureter
o Retroperitoneal tumor
• All ages
o Trauma
o Blood clot
o Phimosis or urtheral stricture
o Neurogenic bladder: dm, spnal cord disease, MS, PD, pharm anticholinergics, a adrenergic agonists, opiates
o Calculus (children SE asia, adults mech intervention)
• Adults
o BPH
o Cancer of prostate, bladder, cervix, colon
o Obstructed catheters
o Calculi
o Papillary necrosis
o Tumor anywhere including uterus
o Retroperitoneal fibrosis: idiopathic, tuberculosis, sarcoidoisis,
o Stricture: tb, nsaids, radiation
o AAA, pregnant, IBD, blood clot, trauma, accidental ligation
List the stages of CKD and their associated GFR?
1- > 90 2- 60-89 3- 30-59 4- 15-29 5-
What are the urine findings in pre renal/renal/post renal azotemia?
pre- a few hyaline casts, Una 1
renal- waxy granulated casts, uNa > 1
post- crystal, rbcs, wbcs, uNa> 1
Which drugs can cause direct renal tubular toxicity?
o Aminoglycosides, radiocontrast, cyclosporine, methotrexate, heavy metals
Which drugs can cause allergic interstitial nephritis?
o Pcns, cephalosporin’s, sulfonamides, cipro, nsaids, thiazie diuretcs, furosemide, phenytoin
What causes an incr/decr BUN?
• BUN is decreased in the pts with malnutrition, hepatic dysfunction
-increased in setting of protein loading, GI hemorrhage, or trauma
What should you watch for after relief of obstruction?
o Watch for post obstructive diuresis, more common with prolonged obstruction and renal failure
o Admit if >250 cc/hr for > 2 hrs after relief
what are the acute indications for dialysis?
- K > 6.5 or rising
- Intractable fluid overload – ass with persitent hypoxia or lack of response to other measures
- Uremic pericarditis
- Progressive uremic metabolic encephalopathy; asterixis, seizures
- Serium na level 165
- Severe metabolic acidosis resitant to nahc03 or in situations where nahc02 is CI
- Life threatening poisoning with dialyzable drug such as lithium, asa, methanol, ethylene glycol, or theophylline
- Bleeding dyscrasia secondary to uremia
- Excessive BUN and cr levels * relative in clinical context (BUN >100)
At what GFR is contrast induced nephropathy a concern?
GFR
List the causes of rhabdomyolysis?
• Most common causes are o Etoh o Drugs of abuse (cocaine, amphetamine, ecstasy) o Medications (antipsychotics, statins, ssris, narcotics, colchicine, lithium, and antihistamines) • Drug combos can as well o Muscle disease o Trauma • Crush injury • Electrical or lightening injury • Compartment syndrome o Neuroleptic malignant sydrome o Seizures o Immobility o Infection- viruses influenza most common, bacterial legionella, salmonella, shigella o Strenuous physical activity- weight lifting, esp with poor hydration, restrictive clothing, and high heat and humidity o Heat related illness • Heat stroke o Contact sport o DTs o Psychosis o Immunologic • Dermatomyositis • Polymyositis • More than half of pts have multiple causes
What is rhabdomyolysis?
injury to skeletal muscle with subsequent effects from release of intracellular contents
These include: CK, LDH, AST, K+
Common terminal event disrupts the N/k/atpase pump and Ca transport, reulsting in incr intracellular Ca and muscle cell necrosis, + free 02 radical production
What are the complications of rhabdo?
• ARF (0-46%)
o Often need other factors such as dehydration, heat stress, trauma, or underlying disease
o May be oliguric or anuric
• Metabolic derrangements: o Hyerkalemia o Hyperphosphatemia o Hyperuricemia o Hypocalcemia (occurs early)
o Hypercalcemia (late) o Hypophophatemia (late)
• DIC
• Mechanical complications
o Compartment syndrome
o Peripheral neuropathy
What are the symptoms of rhabdo?
- Acute myalgias, stiffness, weakness, malaise, low grade fever, and dark brown urine
- n/v abdo pain and tachycardia in severe cases
- urea induced encephalopathy on late cases
- may be normal
How do you dx rhabdo?
• A fivefold increase above the upper threshold of normal serum CK levels in the absence of cardiac or brain injury
• Rises 2-12 hours after onset of injury, peaks 24-72, then decline
• Myoglobin is released and causes brown urine, dipstick testing does not differentiate between hemoglobin, myoglobin, and rbcs
o Therefore suspect myobluniuria when dipstick tests + for blood but no rbcs are present
What is the tx of rhabdo?
- Early and aggressive fluid resusc for first 24-72 hrs
- Avoid k and lactate containing solutions
- Goal of 200-300 cc/hr output
- Calcium only for hyperk induced cardiotoxicity
- Hyper k may not respond as well to insulin and dextrose, may require a resoneium or dialysis
- Treate hypophosphatemia when serum levels
Define uremia/azotemia?
- UREMIA- is contamination of blood with urine
* AZOTEMIA- build up of nitrogen in the blood
List the clinical features of uraemia?
• Neurologic: o Encephalopathy o Dialysis dementia o Subdural hematoma – occurs ten times more frequently in the dialysis pt than in the general population o Peripheral neuropathy
• Cardiovascular:
o CAD
o Htn
o CHF
o Pericarditis- rarely present with beck’s triad if tamponade, instead changes in mental status, hypotension, or SOB
• If unifected uremic pericarditis, the inflamm cells do not penetrate into the myocardium so typical ECG changes of acute pericarditis are absent
• Hematologic
o Anemia
• Witout tx the hematocrit should stabilize at 15-20% with normocytic and normochormic rbcs
o Bleeding diathesis
o Immunodeficiency (humoral and cellular)
• GI o Anorexia, n/v o GI bleeding o Diverticulosis, it is o Ascites
• Renal bone disease
o Hyperparathyroidism (ostetitis fibrosa cystica) – weakened bones are highly susceptible to fracture, bone pain and muscle weakness are other symptoms
o Metastatic calcification – increased mortality rate in ESRD pts with ca-p03 product > 72 hrs
o Vit d deficiency and Aluminum intoxication (osteomalacia)
• Sx are weakened bones, bone pain, and muscle weakness- similar to hyperparathyroidism
How should one treat bleeding complications secondary to ESRD?
• Bleeding issues (r/t decr platelet funcion, abn platelet interaction, altered VW fx, anemia, others
o Tx with desmopressin (benefit in 1 h), cryoprecipitate (4h), conjugated estrogens (6h), erythropoietin (if time is not critical)
• GI bleeding- tranexamic acid, and conjugated estrogens
