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Nephrology > Renal ID > Flashcards

Renal ID Flashcards

1
Q

What is a renal abscess?

A

abscess that is confined to the kidney, and is caused either by bacteria from an infection traveling to the kidneys through the bloodstream or by a UTI traveling to the kidney and then spreading to the kidney tissue

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2
Q

usual causes of renal abscess?

A
  • kidney inflammation
  • VUR
  • multiple skin abscesses
  • DM
  • nephrolithiasis
  • IVDA
  • pregnancy
  • neurogenic bladder (autonomic nephropathies - DM, MS)
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3
Q

What are sxs of renal abscess?

A
  • fever
  • chills
  • abdominal pain
  • wt loss
  • dysuria
  • hematuria
  • malaise
  • usually figure out that it is an abscess after sxs persist after t of abx
  • abscess needs an IND
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4
Q

Dx renal abscess?

A
  • UA: WBCs, bacteria, hematuria, proteinuria?
  • CBC: leukocytosis
  • KUB: small abscesses may be difficult to recognize - enlarged kidney, non-distinct outlines
  • CXR: pleural effusion
  • US: more helpful than XR
  • CT: dx procedure of choice - 96% accurate in dx renal abscess, don’t use dye at first (worried about kidney function)

imaging: start off with U/S

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5
Q

Tx of renal abscess?

A
  • IV abx covering causative organism (ampicillin + amino glycoside) - use urine cultures
  • open drainage - old school
  • now: percutaneous drainage more common, abscesses greater than 5 cm need to be IND
  • end stage: nothing else works, nephrectomy
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6
Q

What is acute pyelonephritis?

A
  • affects the cortex with sparing of glomeruli and vessels. WHITE CELL CASTS in urine are pathognomic.
  • bacteria infection can result from hematogenous spread or from ascending infection (usually due to predisposing condition) - usually E.coli, also proteus, klebsiella, and enterobacter
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7
Q

Prognosis of acute pyelonephritis?

A
  • healthy adults usually recover complete renal fxn
  • if coexistent renal disease is present, scarring or chronic pyelonephritis may result
  • inadequate therapy could result in abscess formation
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8
Q

What is emphysematous pyelo?

A
  • life threatening necrotizing infection of the kidneys characterized by gas formation within or surrounding kidneys
  • the majority of pts have poorly controlled DM
  • non DM pts are usually immunocompromised or have asscd urinary tract obstruction due to lithiasis
  • pts with VUR, indwelling cath, stones, neurogenic bladder at risk
  • w/o early therapeutic intervention this condition becomes rapidly progressive, generalized to fulminant sepsis and carries a high mortality rate
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9
Q

Sxs of acute pyelonephritis?

A
  • shaking chills
  • high fever
  • arthralgias
  • myalgias
  • flank pain with CVA tenderness: colicky pain, urgency, frequency, N/V/D in peds
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10
Q

Dx of acute pyelonephritis?

A
  • UA: WBC, bacteria, hematuria, WHITE CELL CASTS
  • CBC: leukocytosis with left shift
  • blood culture may also be positive
  • U/S: may show hydronephrosis from a stone or other source of obstruction
  • CT scan: dx procedure of choice - may show hydronephrosis and attentuation caused by inflammation/infection
    (DON’T use dye)
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11
Q

Tx of acute pyelo? What other tests are needed?

A
  • severe or complicating factors may require hospital admission
  • blood and or urine cultures reqd to determine antimicrobial sensitivity
  • cath may be neccssary in the case of urinary retention
  • nephrostomy drainage may be reqd if there is ureteral obstruction
  • common abx: IV: ampicillin(24 hrs after fever subsides), and then put on PO: cipro, ofloxacin, bactrim DS (weak) (abx are given for 21 days, f/u tx includes re-culturing urine several weeks after drug therapy is finished to rule out re-infection)
  • pts that are at high risk for recurring infections (caths) require long term f/u
  • fevers can persist up to 72 hrs (if its lasts longer - dx or tx isn’t right)
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12
Q

Cause of chronic pyelonephritis?

A
  • caused by renal injury by recurrent or persistent renal infection
  • occurs almost exclusively in pts with major anatomical anomalies:
    urinary tract obstruction
    struvite calculi
    renal dysplasia
    VUR: most common (30-40% of young children with UTIs have VUR)
  • assoc with progressive renal scarring which can lead to ESRD
  • may occur in utero with renal dysplasia, although dysplasia may also be caused by obstruction
  • UTIs also induce renal injury, which heals with scar formation, infection w/o reflux is less likely to produce injury
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13
Q

What is VUR?

A
  • retrograde flow of urine from bladder to upper urinary tract
  • normally ureter has antireflux action by: 1 - actively by trigonal muscle contraction and 2 - passively by flap valve mechanism
  • One of the most common problems encountered by pediatric urologist
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14
Q

Incidence of VUR?

A
  • overall: 10%
  • 70% of infants presenting with a UTI has VUR
  • female more like than males
  • usually male has higher grade VUR than females
  • genetic predisposition is positive in up to 40%
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15
Q

Etiology of primary VUR?

A
  • congenital deficiency in the longitudinal muscle fibers in ureterovesical junction
  • altering the normal ratio of length: width from 5:1 down to 1.4:1
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16
Q

Etiology of secondary VUR?

A
  • bladder outlet obstruction at the posterior urethral valve or stenosis
  • fxnl obstruction: neurogenic and non neurogenic bladder dysfxn (cerebral palsy)
  • raised pressure due to obstruction (anatomical stricture, too tight)
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17
Q

How does a VUR UTI present in a newborn? older children? prenatally?

A
  • newborn: usually nonspecific manifestation such as failure to thrive, difficult feeding, or lethargy
  • older children: flank pain or abdominal pain, fever
  • prenatally: dx by US with abdominal sweeling (late finding) - see hydronephrosis
18
Q

Work up for VUR?

A
  • UA: (for sig colony count)
    greater than 100,000 count in mid-stream sample, or gerater than 10,000 in cathed or aspirated urine sample
  • std VCUG (used for grading VUR 1-V) and US reqd in:
    1 - child younger than 5 with UTI
    2 - any male child with UTI
    3 - febrile UTI
19
Q

Prognosis of VUR?

A
  • resolves spontaneously before adolescence in:
    90% of Gr 1 reflux
    80% of Gr 2
    50% of Gr 3
    10% of Gr 4
    0% in Gr 5
  • kidney most suscpetible to scarring in first year of life and at time of first upper tract infection
  • scars develop less frequently after the age of 5
  • VUR and scarring lead to HTN, progressive renal insufficiency and failure
20
Q

Characteristics of chronic pyelonephritis?

A
  • coarse, asymmetric, corticomedulalry scarring
  • thyroidization of kidney
  • eosinophilic casts seen in tubules:
    chronic pye and
    T - thyroidization (ext inflamm.)
    E - eosinophilic casts
    A - assymetric scarring
21
Q

Sxs of chronic pyelonephritis?

A
  • fever
  • lethargy
  • N/V
  • flank pain or dysuria: some children present with failure to thrive
22
Q

Dx of chronic pyelonephritis?

A
  • UA: WBCs, bacteria, hematuria. Urine culture will usually isolate bacteria, although a neg culture doesn’t exclude diagnosis as pt has most likely been on abx
  • imaging: IVP helps est dx b/c they reveal caliceal dilation and blunting with cortical scars. Ureteral dilation and reduced renal size may be evident
    CT also used
    VCUG: may document reflux of urine to the renal pelvis and ureteral dilation
  • cystoscopy images show evidence of reflux at the ureteral orifices
  • renal sonogram may show calculi
23
Q

Tx of stages 1 and 2 VUR for chronic pyelonephritis?

A
  • this is reflux of urine to the ureter or renal pelvis without ureteral dilatation
  • medical therapy with ABOs (amoxicllan, bactrim, septa, and nitrofurantoin)
  • continue ABOs until puberty (most children will outgrow reflux by puberty) or until reflux resolves
  • stage 1 and 2: get better on their own
24
Q

Tx for stage 3 and 4 VUR (severe reflux)?

A
  • surgery and medical therapies are equally effective

indications for surgery include:

  • medical noncompliance with formation of new scars
  • persistent reflux after puberty in women
  • breakthrough infections in pts who are compliant
  • surgery involves the reimplantation of the ureters
25
Q

Other tx for chronic pyelonephritis?

A
  • eliminate recurrent UTIs and ID and correct any underlying anatomic or functional urinary problems (ex: obstruction, urolithiasis)
  • dietary protein restriction should be advised to prevent progressive renal injury
  • aggressive BP control is beneficial to slow the progression of renal failure. ACEIs/ARBs are particularly beneficial
  • careful f/u and monitoring for pregnant women with prompt tx for UTIs to prevent renal failure, preeclampsia, miscarriages
  • routine screening is recommended for siblings of pts with VUR
26
Q

What is XPN? (xanthogranulomatous pyenonephritis)

A
  • unusual variant of chronic pyelonephritis that in 2/3 of cases is a complication of obstruction induced by infected renal stones.
  • affected pts usually have massive destruction of kidney requiring nephrectomy
  • shares many characteristics with a true neoplasm, in terms of radiographic appearance and ability to involve adjacent structures or organs
  • pts are often immunocompromised in some manner
  • although most cases of XPN are unilateral, bilateral disease has been reported
27
Q

How common is XPN?

A
  • occurs in approx 1% fo all renal infections, frequency of XPN appears to be increasing (increased risk in diabetics)
  • XPN is 4x more common in women than men, and is usually noted in 50s, and 60s
  • usually a hx of recurrent UTIs
28
Q

Characteristics of XPN?

A
  • displays neoplasm like properties capable of local tissue invasion and destruction, and has been referred to as a pseudotumor
29
Q

Presentation of XPN in adults?

A
  • most often occurs in middle aged women, with male to female ratio - 1:3 -4
  • typical presenting features:
    flank pain, fever, malaise, anorexia, wt loss, a palpable flank mass may be present, which may be tender or demonstrate CVA tenderness
    (presents like pyelo)
30
Q

Presentation of XPN in children?

A
  • 2 different presentations
  • most common form affects boys and girls equally and involves the entire kidney
  • the other form which is more frequent in girls, is localized and may mimic a tumor (be thinking Wilm’s tumor)
  • presenting features:
    flank and abdominal pain
    fever
    growth and wt retardation
    growth and wt retardation
  • approx 1/2 of children have a palpable abdominal mass
31
Q

What will the UA and culture show in XPN?

A
  • confirms presence of urinary tract infection
  • UA: pyuria and bacteriuria
  • urine culture: typically positive for gram - organisms (E coli, proteus, klebsiella)
    : staph aureus is rare, urine cultures are sterile 25% of time, occasionally, diff organisms may be isolated from urine and from the removed kidney, and combo antimicrobial therapy may be needed
32
Q

What will blood tests show in XPN?

A
  • nonspecific abnorm including:
    anemia and increased ESR
    abnorm results in LFTs are found in 50% of pts, and occasionally assoc with hepatomegaly
  • cause of liver abnorm is not known, but results return to normal after tx
  • creatinine levels prior to nephrectomy may be abnormal, but removal of nonfxning XPN kidney isn’t expected to alter baseline renal fxn
33
Q

Tx of XPN?

A
  • XPN is assoc with almost complete destruction of the kidney
  • tx is therefore surgical (after initial course of antimicrobials to control the local infection) and consists of nephrectomy in which all the involved tissue is removed and any fistulas closed
  • pts with localized form (usually children) or with bilateral disease can be tx with partial nephrectomy
  • pt will die of sepsis or overwhelming infection if not tx
34
Q

What is cystitis?

A
  • infection of the bladder most commonly due to coliform bacteria (E. coli usually) and occasionally from gram + (enterococci)
  • route of infection is typicall ascending from the urethra
  • viral cystitis due to adenovirus is sometimes seen in children but rare in adults
35
Q

Sxs of cystitis?

A
  • irritative voiding (frequency, urgency, dysuria)
  • suprapubic discomfort is common
  • hematuria
  • sxs in women may often appear following sexual intercourse (in men this is rare - so do work up - could be stones, prostatitis)
36
Q

What will you see on PE for cystitis?

A
  • may reveal suprapubic tenderness, but exam is often unremarkable
  • systemic toxicity is absent
37
Q

Work up of cystitis?

A
  • UA: pyuria, bacteriuria, and varying degrees of hematuria
  • urine culture is + for causative organism, but colony counts greater than 10,000 are not essential for dx
  • lab work and imaging are warranted only if following are suspected: pyelo, recurrent infections, or anatomic abnormalities are suspected.
38
Q

What should you think about if a man is presenting with cystitis?

A
  • this is rare and it implies a pathological process such as:
  • infected lithiasis
  • prostatitis
  • chronic urinary retention requiring further work up
39
Q

Tx of cystitis?

A
  • uncomplicated cystitis: short term 1-3 days: fluoroquinolones (complicated pts - pyelo?) and **nitrofurantoin are TOC
  • bactrim and septra can be ineffective in sig number of pts because of resistance
40
Q

When should women be put on proph abx therapy?

A
  • after having more than 3 cases of cystitis, they should have thorough work up ( don’t use nitrofurantoin)
41
Q

When should preg ladies be screened for UTIs? Why do preg ladies get UTIs?

A
  • they should be screened for infections whether they have sxs or not, use nitrofurantoin
  • get infections bceause they have decreased tone of ureter and increased pressure from baby

Nephrology (15 decks)

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