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Renal II Flashcards

1
Q

Type II RTA

A

Defect in bicarbonate reabsorption

Faconi, PAGU

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2
Q

Isolated proximal RTA

A

Hereditary dysfunction of basolateral sodium bicarbonate cotransporter

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3
Q

What causes faconi

A

Inherited or acquired due to myeloma, chronic IN (Chinese herbal nephropathy), or drugs (ifosfamide, tenofovir)

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4
Q

Treat type II or faconi

A

Large doses of bicarbonate which may aggravate hypokalemia

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5
Q

Type IV

A

Hyporeninemic hypoaldosteronism or resistance

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6
Q

50-80% of women have at least one __ and 20-50% have recurrent episodes

A

UTI

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7
Q

Ribs factors for acute cystitis

A

Recent use of diaphragm with spermicide, frequent sexual intercourse, a history of UTI, DM, incontinence; also increase risk of pyelonephritis

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8
Q

Most common UTI bacteria

A

E. coli 75-90

Staph saprophyticus 1-15%

Klebsiella , proteus, enterococcus, citrobacter rest

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9
Q

Iwhat gram positives cause UTI

A

Staph aureus and enterococci

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10
Q

Candida UTI path different than other organisms

A

Hematogenous route

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11
Q

Candida in urine or noninstrumetned immunocompetent

A

Genital contamination or widespread visceral dissemination

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12
Q

Papillary necrosis

A

Can occur in pets with obstruction, dibatetes, sickle cell disease, or analgesic nephropathy

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13
Q

Emphysematous pyelonephritis

A

Severe

Associated with the production of gas in renal and perinephric tissues, and occurs almost exclusively in diabetics

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14
Q

Xanthogranulomatous pyelonephritis

A

Chronic urinary obstruction (often staghorn), together with chronic infection, leads to suppurative destruction of renal tissue

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15
Q

Prostatis

A

Infectious or not

More common not

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16
Q

Complicated UTI

A

Symptomatic disease in a man or woman with an anatomical predisposition to infection, with a foreign body into e urinary tract, or with factors predisposing to a delayed response therapy

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17
Q

Diagnose UTI uncomplicated

A

Clinical history 96% LIEKLYHOO if have dysuria and urinary frequency in absence of vaginal discharge

Confirm with dipstick positive for nitrite or leukocyte esterase in patients with a high pretext probability of disease

Detection of bacteria in a urine culture is gold standard
Want colon count 10^2 OR OVER

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18
Q

What three factors determine the initial rate of spread of any STI within a population

A

Rate of sexual exposure of susceptible to infectious ppl, efficiency of transmission per exposure, and duration of infectivity of those infected

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19
Q

What are 4C’s of sti

A

Contact tracing, ensuring compliance with treatment, counseling on risk education, including condom promotion and provision

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20
Q

What causes urethritis in men

A

Gonococcal or nongonococcal (chlamydia trachomatis)

Mycoplasma genitalium, ureaplasma, urealyticum, trichomonas vaginalic, HSV

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21
Q

What causes most non gonococcal urethritis in men

A

Chlamydia and mycoplasma genitalium

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22
Q

Symptoms or male urethritis

A

Urethral discharge, dysuria, without frequency of urination

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23
Q

Diagnose male urethritis

A

Pts present with mucopurulent urethral discharge can be expressed by milking the urethra

Grams stained smear of an anterior urethral specimen containing 5PMN/1000x field confirms the diagnosis

Centrifuged sediment of the days first 20-30 mL or voided urine can be examined instead

N gonorrhea can be identified if intracellular gram negative diplodocus are present in grams strained samples

Early oring, first voided uring should be used in multiplex acid amplification testes (NAATs ) for gonorrhea and chlamydia

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24
Q

Treat gonorrhea

A

Ceftriaxone

Azithromycin

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25
Treat chlamydia
Azithromycin
26
Treat mycoplasma genitalium
Azithromycin
27
Treat recurrent symptoms of male urethritis
Both patient and partner treated if re exposure Without re exposure, infection with T vaginalis (with culture or NAATs)
28
Shock
Ok
29
Possibly harmful systemic response to shock
Two or more of the following - fever or hypothermia - tachypnea - tachycardia - leukocytosis
30
Sepsis
Harmful systemic response with a proven or suspected microbial etiology
31
Septic shock
Sepsis with hypotension (90< or below pts normal bp for at least 1 h despite fluid resuscitation) or need for vasopresors to maintain systolic bp 290 mmHg or MAP 270 mmHg
32
Etiology shock
Blood cultures are positive in 20-40% of sepsis causes and in 40-70% of septic shock cases For infected patients in ICUs, respiratory infections have been most common (64%) . Microbiological results have revealed that 62% of isolates are gram negative bacteria (pseudomonas spp and E. coli) , 47% are gram positive (staph aureus) and 19% are fungi (candida)
33
Epidemiology shock
Incidence of severe sepsis and septic shock in US increases with >750000 cases each year contributing to over 200000 deaths. Invasive bacterial infections are a prominent cause of death areound the world, especially among young kids Sepsis related incidence and mortality rates increases with age and preexisting comorbidity, with 2/3 of cases occurring in pts with significant underlying disease
34
What has the increased incidence of sepsis been attributed to
The aging population, longer survival of patients with chronic disease, a relatively high frequency of sepsis among AIDS, and medical treatments that circumvent host defenses 9immunosuppresive agents, catheters)
35
Local and systemic host response to septic shock
Hosts have numerous receptors that recognize highly conserved microbial molecules, triggering the release of cytokines and other host molecules that increase blood flow and neutrophil migration to the infected site, enhance local vascular permeability, and elicit pain
36
Many local and systemic control mechanisms for septic shock dismiss cellular responses to what
Microbial molecules, -intravascular thrombosis (which prevents spread of infection and inflammation) and an increase in anti inflammatory cytokines (IL4 and 10(
37
Organ dysfunction and shock
Widespread vascular endothelial injury is believed to be the major mechanism for multiorgan dysfunction Septic shock is characterized by compromised oxygen delivery to tissues followed by a vasodilary phase ( a decrease in peripheral vascular resistance despite increased levels of vasopressin catecholamines)
38
Clinical features septic shock
Hyperventilaition that produces respitoary alkalosis Encephalopathy (disorientation, confusion) Acrocyanosis and ischemic necrosis of peripheral tissues due to hypotension and DIC Skin-hemorrhagic lesions, bullae, cellulitis, pustules. Skin lesions may suggest specific pathogens GI-nausea, vomiting, diarrhea, ileus, cholestatic jaundice
39
What infection suggested petechiae and purpura
Neisseria meningitidis
40
What skin infection ssuggests pseudomonas aeruginosa
Acthyma and gangrene
41
Cardiopulmonary manifestations of septic shock
Ventilation-perfusion mismatch, increased alveolar capillary permeability, increased pulmonary water content, and decreased pulmonary compliance impede oxygen exchange and lead to ARDS (progressive diffuse pulmonary infiltrates and arterial hypoxemia) in 50% of patients Hypotension: normal or increased cardiac output and decreased systemic vascular resistance distinguish septic shock from cardiogenic and hypovolemia shock The ejection fracture is decreased, but ventricular dilation allows maintence of a normal stroke volume
42
Adrenal insuffiency of septic shock
May be difficult to diagnose in critically ill patients
43
Renal manifestations septic shock
Oliguria and polyuria, azotemia, proteinuria and renal failure due to tubular necrosis
44
Neurological manifestations of septic shock
Delirium in the acute phase, polyneuropathy with distal motor weakness in prolonged sepsis. Survivors may have long term cognitive impaiement
45
Immunosuppression with septic shock
Patients may ave reactivation of HSY, CMV, or VZv
46
CBC SEPTIC SHOCK
LEUKOCYTOSIS WITH A LEFT SHIFT, thrombocytopenia
47
Coagulation with septic shock
Prolonged thrombin time, decreased fibrinogen, presence of n diners suggestive of DIC. With DIC , platelet counts usually fall below 50000
48
Chemistries septic shock
Metabolic acidosis, elevated anion gap, elevated lactate levels
49
LFTs septic shock
Transaminitis, hyperbilirubinemia, azotemia | Hypobilirubinemia
50
Diagnose septic shock
Need isolation of microorganisms from blood or a local site of infection. Culture of infected cutaneous lesions may help establish the diagnosis
51
Treat septic shock and sepsis
Antibiotic Removal of drainage of a focal source of infection Hemodynamics, respiratory, and metabolic support -saline, hydrocortisone(if hypotension not responding), erythrocytes transfusion General support
52
Prognosis septic shock
20-35% of patients with severe sepsis and 40-60% of patients with septic shock die within 30 days , and further deaths occur within 6 months. Prognostic stratification systems can estimate the risk of dying of severe sepsis
53
Oliguria
Less than 400
54
Anuria
No Rhine
55
Setting of oliguria
Volume depletion and/or renal hypoperfusion, resulting in prerenal azotemia and acute renal failure
56
What can cause anuria
Complete bilateral urinary tract obstruction; a vascular catastrophe, renal vein thrombosis; renal cortical necrosis; severe acute tubular necrosis; nonsteroidal antiinflammatory drugs, ACE I, angiotensin receptor blockers , hypovolemia, cardiogenic or septic shock
57
Polyuria
Over 3 Lid
58
Setting of polyuria
Nocturnal and urinary frequency , hypernatremia and can occur as a response to solute load and vasopressin ADH
59
Diabetes insipidus
Central insufficient AVP Nephrogenic-insensitivity
60
What is associated with nephrogenic diabetes insipidus
Tubulointerstitial diseases, lithium therapy, and resolving acute tubular necrosis or urinary tract obstruction can be associated with nephrogenic diabetes insipidus, which is more rarely caused by mutations in the V2 AVP receptor, the aquaporin 1 water channel in the descending thin limb of the loop of henle and the AVP regulated water channel in principal cells, aquaporin 2
61
Proteinuria causes
Excessive fluid intake-primary polydipsia, latrogenic (IV) Therapeutic-diuretics Osmotic diuresis-hyperglycemia Azotemia Mannitol
62
Nephrogenic diabetes insipidus cause
Lithium, UT obstruction, papillary necrosis, reflux nephropathy, interstitial nephritis, hypercalcemia, hereditary
63
Causes central diabetes insipidus
Tumor, postoperative, head trauma, basilar meningitis, neurosarcoidosis
64
Polyuria with <250 mosmol and low serum sodium
Primary polydipsia =psychogenic, hypothalamic disease drugs(thioridazine, chlorpromazine, anticholinergic agents)
65
Polyuria urine osmolarity <250 and diabetes insipidus
Nephrogenic DI vasopressin
66
Polyuria urine osmolarity >300
Solute diuresis
67
Diagnose proteinuria
Dipstick estimates protein concentration Detect albumin, not light chains (require testing with sulfosalicylic acid) Urine albumin 24 hour protein collection
68
When may transient proteinuria be seen
After vigorous exercise, changes in body position, fever, or CHF
69
What is nephrotic range proteinuria
3 g/d
70
When can massive proteinuria be seen
MCD, primary focal segmental glomerulosclerosis, membranous nephropathy, diabetic nephropathy, collapsing glomerulopathy
71
How treat proteinuria
ACE inhibitor or angII blocker This will decrease rate of progression to end stage renal disease in diabetic nephropathy
72
Hematuria causes
Lower urinary tract disease or intrinsic renal disease | Cyst rupture in polycystic kidney disease and postpharyngitic flares of IgA nephropathy
73
Microscopic hematuria accompanies by proteinuria, HTN, and an active urinary sediment is most likely related to an inflammatory glomerulonephritis, classically post streptococcal glomerulonephritis
Ok
74
Major causes of hematuria lower urinary tract
``` Bacterial cystitis Interstitial cystitis Urethritis Passes or passing kidney stone Transitional cell carcinoma of bladder or structures proximal to it Squamous cell carcinoma of bladder ```
75
Upper urinary tract causes of hematuria
Renal cell arcinoma Age related renal cysts Neoplasms Acquired renal cystic disease Congenital cystic disease, including autosomal dominant form Glomerular diseases Intestinal renal diseases)interstitial nephritis Nephrolithiasis, pyelonephritis Renal infarction, hypercalcuria, hyperuricosuria
76
Free hemoglobin and myoglobin on dipstick and negative urinary sediment with strong heme positive dipstick
Hemolysis or rhabdomyolysis, which can be differentiated by clinical history and laboratory testing
77
RBC cast specific for what
Glomerulonephritis
78
Acute renal failure/ AKI
Measurable increase in serum Cr concentration and happens in 5% of hospitalized patients and associated with increase in hostpital mortality and morbidity
79
Treat AKI
Nothing specific maintain renal perfusion and intravascular volume
80
Cofactors of AKI
Hypovolemia and drugs that interfere with renal perfusion and/or glomerular filtration (NSAIDS) ACE I ang blockers
81
Prerenal failure
Most common in hospital May result from true volume depletion or arterial underfilling (reduced renal perfusion in the setting of adequate or excess blood volume Reduced renal perfusion may be seen in CHF
82
Pre renal causes of AKI
Volume depletion-blood loss, diuretic use Volume overload with reduced renal perfusion-CHF, hepatic cirrhosis, severe hypoporteinemia Renovascular disease Drugs-NSAIDS, ciclosporin, Hypercalcemia “third spacing )pancreatitis, systemic nflammatory response, whepatorenal syndrome
83
Intrinsic causes of AKI
ATN Ttubulointerstitial diseaseatheroembolic disease after vascular procedures Glomerulonephritis IgA nephropathy Glomerular endoliopathies
84
Post renal AKI
Bladder neck obstruction, bladder calculi Prostatic hypertrophy, urethral obstruction due to compression -pelvic or ab malignancy Nephrolithiasis Papillary necrosis with obstruction
85
Causes of intrinsic failure in hspoiratl
Surgical services or ICU, ATN, rhabdomyolyssi, allergic penicillins, NSAIDS, radiographically contrast dies, thrombotic microangiopathies,
86
Post renal
Ambulatory more common than hospitalized more common men
87
AKI with prerenal azotemia due to volume depletion presentation
Orthostatic hypotension, tachycardia, low jugular venous reassure, anddry mucoud membranes
88
Prerenal azotemia and CHF
Jugular venous distention and S gallop, peripheral and pulmonary edema.
89
Signs pre renal
BUN Cr high, volume depletion and CHF cirrhosis Uric acid may be up Na <10-20 urine FEN <1% Hyaline and few granular casts, without cells or cellular casts . Renal ultrasonography is usually normal
90
Intrinsic renal disease GN
HTN and edema
91
Fractional excretion of Na Urine Na Urine Cr to plasma ratio Urine urea N to plasma uraea N Urine specific gravity Urine osmolality Plasma BUN/Cr ration Renal failure index Urnary sediment Prerenal vs intrinsic
<1, >1 <10, >20 >40, >20 >8, <3 >1.018, <1.015 >500, <300 >20, <10-15 <1, >1 Hyaline casts, muddy brown granular casts
92
Dialysis
ESRD-depends on patients symptoms, comorbid conditions and laboratory parameters, unless a living donor is identified, transplantation is deferred by necessity, due to the scarcity of decreased donor organs . Dialysis options include hemodialysis and peritoneal dialysis. Roughly 85% of US patients are started on hemodialysis. Absolute indications for dialysis include severe volume overload refractory to diuretic agents, severe hyperkalemia and/or acidosis, severe encephalopathy not. Otherwise explained, and pericarditis or other serositis. Additional indications for dialysis include symptomatic uremia, nause, vomiting , pruritis, difficulty maintains attention and concentration. And protein every malnutrition failure to thrive without other overt cause.
93
Complications of hemodialysis
``` Hypotension Accelerated vascular disease Rapid loss of residual renal function Access thrombosis Access or Cather sepsis ``` Dialysis related amyloidosis Protein energy malnutrition Hemorrhage Anaphylactic reaction Thrombocytopeniab
94
Hemodialysis
Direct access to the circulation, either via a native arteriovenous fistula; an arteriovenous graft, usually make of polytetra fluoriethylele; a large bore IV catherter , or a subcutaneous device
95
Solution in dialysis
Isotonic, free of urea and other nitrogenous compounds and generally low in K a Dialysate (K) is varied from 1 to 4 , depending on predialysis K and clinical setting Ca is typically and Na can be modified , depending on clinical Usually 3 times a week for 3-4 hours
96
Peritoneal dialysis
Peritoneal catheter allows infusion of a dialysate solution into the abdominal cavity; this allows transfer of solutes across the peritoneal membrane, which serves as the artificial kidney, this solution is similar to that used for hemodialysis, except that is must be sterile
97
LO
Differentiate between uncomplicated UTI and complicated Develop a differential diagnosis for dysuria based on pre disposing factors, clinical presentation, history and physical Distinguish cystitis from pyelonephritis and their predisposing factors Compare and contrast pyelonephritis with sepsis
98
35 male with dysuria for three days, urine is cloudy and yellow There is drainage noted from end of penis Multiple female partners with occasional condom use
Ok
99
Frequency
Every hour or two
100
Urgency
Abrupt strong and overwhelming
101
How frond ABU
Urine sample is obtained for another reason and shows bacteria on microscopic evaluation , like health screening or diabetes follow up
102
What is an uncomplicated UTI
Non pregnant female No anatomical abnormalities No instrumentation or urinary tract
103
Predisposing factors for female UTI
Use of spermicide with diaphragm Frequent sex
104
What percent of women have recurrent UIT
20-30%
105
Recurrent of UTI in post menopausal females predisposing factors
Pre menopausal UTI Anatomic factors affecting bladder emptying - cystocele - urinary incontinence - residual urine - tissue effect of estrogen depletion
106
Predisposing factors for male UTI
Prostatic hypertrophy Non circumcised Diabetic
107
Diabetic women are _x more likely to get UIT
2-3
108
Differential diagnosis for UTI
Cystitis Cervicitis - chlamydia - neisseria Vaginitis - candida - trichomonas Urethritis-herpetic Interstitial cystitis Non infectious vaginal or vulvar irritation
109
Complicated UTI
Pregnant female-can lead to premature labor or low birth weight babies More likely to develop sepsis
110
Untreated asymptomatic bacteriuria is more likely to cause what in pregnant women
Symptomatic pyelonephritis
111
Causes of complicated UTI in men and women
Anatomic variant (polycystic kidney Foreign body in the urinary tract -stones, urinary catheters, nephrostomy tubes/ureteral stents Extrinsic compression of ureter/bladder - tumors - profound constipation - other anomalies Immune suppression conditions - diabetes - drugs induced - HIV/AIDS
112
Prostatis
Can be chronic in prostatic hypertrophy | Prolonged antibiotic course necessary for 4-6 weeks
113
Most common precursors of pyelonephritis
Same as UTI -since most commonly ascending from lower tract Bacteremia develops in 20-30% of cases Can be hematogenous but rare - candida - salmonella - staph aureus
114
Three major subtypes/complications of pyelonephritis
Papillary necrosis Emphysematous pyelonephritis Xanthogranulomatous pyelonephritis
115
When does papillary necrosis occur
Obstruction Diabetes Sickle cell Analgesic nephropathy
116
Emphysematous pyelonephritis
Production of gas in nephrin and perinephric area | Occurs almost exclusively in diabetic patients
117
Xanthogranulomatous pyelonephritis
Chronic obstruction Chronic infections Causes suppurative destruction of renal tissue Can lead to abscess formation
118
Bacteremia
Blood cultures are positive
119
Sepsis/septicemia
Suspected or documented infection and an acute increase in organ failure Dysregulated host response to infection
120
Septic shock
Progressive organ dysfunction leading to marked increase in mortality - suspect of sepsis - serum lactate greater than 2mmol/L (18 mg/dL)
121
When does acute ischemia occur
Defect in effective circulating volume - decreased oxygen delivery - impaired removal of cellular waste - kidney receives 20-25% of CO Couple whammy: direct tubular damage by endotoxins and inflammatory cytokines
122
Sepsis
Multiorgan involvement in infection removed from the source Hypofunction of uninflected organs Septic shock; hypotension that cannot be reversed with infusion of fluids
123
Shock: hypoperfusion regardless
Tachycardia Hypotension Tachypnea Hypothermia/fever Low oxygen-> celllular injury->inflammatory mediators-> worsening microvascular circulation
124
What history when shock
Trauma, recent surgery, signs of illness/infection
125
Three flow charts
Signs of inf
126
Septic shock signs
Infection sign: fever or hypothermia Tachycardia: cardiac response to hypoperfusion and fever Tachypnea: compensatory respiratory response Hypotension!: sign of critical illness, responsive to fluid resuscitation -how can you identify the source of infection Circulating cytokines Endothelial injury: decreased tone, increased permeability Edema Decreased oxygenation of tissues Build up of lactic acid
127
Initiating treatment for sepsis/septic shock
Volume resuscitation (IV fluids) Cultures: blood, urine, CSF, Initiate antibiotics for most likely cause; generally broad spectrum Pressers: norepinephrine, vasopressin, in addition for severe cases Correct acid/base imbalance-fluids oxygenation(ventilator support) Monitor electrolytes
128
Which is most important for treating sepsis/septic shock
Getting cultures or getting x ray lab results?
129
BUN :Cr sepsis and ischemia
Increase | -pre renal azotemia
130
FENa sepsis and ischemia
>1%
131
Urine sepsis and ischemia
Decreased concentration Proteinuria (minor) Hematuria Muddy brown casts on microscopy-sloughing of renal tubular epithelial. Cells
132
Prevent recurrent UTI: do it when they are interfering with patients lifestyle
Antibiotic therapy-continuous, post coital, patient initiated
133
Non medication preventative strategies for women
Empty bladder as soon as reasonable after intercourse Wipe front to back Shower not baths Lactobacillus probiotics Cranberry supplements Vitamin c Increase fluid intake!
134
Treat febrile UTI sepsis
Stabilize, resuscitate, treat with culture specific antibiotics for 2 weeks
135
Treat febrile UTI pyelonephritis
Treat with culture specific antibiotics 2 weeks
136
Treat non febrile UTI
Culture specific antibiotics 1 week
137
LO
Distinguish types of proteinuria and nephrotic syndrome Develop a differential diagnosis for proteinuria based on pre disposing factors, clinical presentation, history and physical Evaluate nephrotic range proteinuria Recommend screening for proteinuria in patients with DM based on guidelines Determine diagnostic approach for proteinuria Discuss treatment strategies for diabetic nephropathy to prevent deterioration of renal function
138
Routine dipstick
Teststrip threshold is to turn positive for over 300 mg of albumen Multiple types of proteins possible and multiple underlying causes
139
Quantify protein
Albumen Cr ratio Can be done on random urine sample Preferably first morning void OR 24 hour urine collection-protein, albumen, Cr clearance -also provides sample to do electrophoresis to determine which types of protein
140
Next step
Based on differential DDx derived from thorough history and PE
141
Nephrotic range proteinuria vs nephrotic syndrome
Nephrotic syndrome-nephrotic range proteinuria, hyperlipidemia, hypoalbuminemia, edema
142
Screening recommendations
T2DM | -established diagnosisL annual ACR (albumen/Cr ratio)
143
Slow progression of proteinuria
Drug classes-ace inhibitors, arbs
144
Other possible causes of nephrotic syndrome
SLE, rheumatoid arthritis Infection 0hepBC, HIV, syphilis, TB Hematologists/oncologist -amyloidosis, multiple myeloma, sickle cell, liquid and solid tumors Drugs-NSAIDS, lithium, IV heroin
145
Routine dipstick
Teststrip threshold is to turn positive for over 300 mg of albumin Multiple types of proteins possible and multiple underlying causes
146
Case 2
Ok
147
Exercise induced hematuria
50-80% of athletes May also be accompanied by proteinuria
148
What does heavy exercise cause
Proteinuria Decreased RBF leads to nephron ischemia, increased permeability , and subsequent passage of RBC
149
Who gets exercise issues
Swimmers, track, lacrosse
150
___ are common among athletes and another cause of microscopic hematuris
NSAIDS
151
Evaluate heavy exercise
Rule out infection
152
Treat heavy exercise
48-72 hours and recheck
153
NSAIDS how do they damage kidney
Inhibiting cyclooxygenase within the kidney - cyclooxygenase is the rate limiting enzyme for prostaglandins - PGE2 and PGI2 protect kidney by modulating renal vasoconstriction Ibuprofen decreases GFR compared to placebo or acetaminophen Indomethacin and celecoxib decreases free water clearance
154
Menstruation
Sloughingsee blood History will help Rule out infection
155
False positive dipstick
35%
156
UA false positives
Clean catch, mid strea, | -this eliminates urethral irritation and contamination from perineum
157
What else can give false positive
Myoglobinuria, hemoglobinuria High alkaline (pH>9) Ascorbic acid
158
How deal with false positives
Confirm with microscopy Less than 3 RBBC/Hpv is negative for hematuria
159
Trauma of kidney common?
No due to location
160
What can traumatize the kidney
Blunt force, rapid deceleration
161
Who gets exercise issues
Swimmers, track, lacrosse
162
___ are common among athletes and another cause of microscopic hematuris
NSAIDS
163
Evaluate heavy exercise
Rule out infection
164
Treat heavy exercise
48-72 hours and recheck
165
NSAIDS how do they damage kidney
Inhibiting cyclooxygenase within the kidney - cyclooxygenase is the rate limiting enzyme for prostaglandins - PGE2 and PGI2 protect kidney by modulating renal vasoconstriction Ibuprofen decreases GFR compared to placebo or acetaminophen Indomethacin and celecoxib decreases free water clearance
166
Menstruation
Sloughingsee blood History will help Rule out infection
167
False positive dipstick
35%
168
UA false positives
Clean catch, mid strea, | -this eliminates urethral irritation and contamination from perineum
169
What else can give false positive
Myoglobinuria, hemoglobinuria High alkaline (pH>9) Ascorbic acid
170
How deal with false positives
Confirm with microscopy Less than 3 RBBC/Hpv is negative for hematuria
171
Trauma of kidney common?
No due to location
172
What can traumatize the kidney
Blunt force, rapid deceleration
173
How does renal trauma present
Hematuria (But lack doesn’t exclude) Evidence of rib fracture Guided on suspicion
174
Radiographically evaluation kidney trauma
Not if hemodynamically stable
175
Sickle cell screening
At birth History is often lost, forgotten Single hemoglobin S mutation
176
What does sickle cell cause
Impaired urinary concentration Can develop renal papillary necrosis Hyperfiltration elads to albuminuria, interstitial fibrosis, decreased number of nephrons RENAL MEDULLARY CARCINOMA
177
Males at risk for transitional cell and bladder cancer
``` Males >35 Current or past smoker Analgesic Exposure to chemicals or dyes Exposure to carcinogenic agents or chemo ```
178
Other history of cancer
``` Gross hematuria Urologic disorder or disease Irritation voiding symptoms -what does this mean? Pelvic irradiation Chronic urinary tract infection chronic indwelling ```
179
Diagnosis of BHP should not preclude further evaluation of underlying cause
Huh
180
How evaluate malignancy
Know risk Rule out infection with culture and sensitivity Confirm with microscopy Serum BUN Cr Radiographically US VC CTU
181
US
No radiation Low cost May miss other causes of hematuria: small stones, small bladder mass and urothelial transitional cell carcinoma Very good for tumors >3cm, cysts, and hydronephrosis
182
CTU
CT or kidney, ureters, and bladder With or without contrast Sensitive for renal calculi! Able to detect small renal parenchymal masses, aneurysm, and renal and perirenal abscesses Higher radiation Exposure to contrast agents Higher cost More info
183
Cytoscope
Evaluate bladder by direct visualization Better assessment of bladder wall for microstructiral changes Can identify urethral stricture disease, BHP and bladder masses Invasive, requires sedation, risk for UTI
184
Recommendations for cytoscopy
Vary Primary care: after negative US or IVP AUA: all patients >35 with asymptomatic microhematuria Or all patients with risk factors for urologic malignancies regardless of age
185
Chronic glomerulonephritis
Glomerular scarring Corticular tubular atrophy Interstitial inflammation Interstitial fibrosis Atherosclerosis
186
Vascular/ hemodynamics effect of RAAS
Vasoconstriction of affferent and efferent and systemic arterioles Increases glomerular pressures Causes direct glomerular damage
187
Inflammatory effects of RAAS
Activated inflammatory system Leads to interstitial and tubular fibrosisi
188
Glomerulonephritis
Hematuria -microscopic vs gross Proteinuria -albumineria vs protein Acute vs chronic
189
How tell acute vs chronic glomerulonephritis
HISTORY Genetic disorders, systemic disease Family history of lupus, sickles cell, autoimmune, diabetes, coronary artery Recent infectionsL staph, malaria, schistomiasis Infection HIC hep BC ROS-itching, nausea, headache, anorexia, dyspnea, vomiting, diarrhea, hiccup, restlessness and depression UA and chemistry US-for size
190
Size of kidney in chronic disease
Smaller
191
Hematuria glomerulonephritis
Asymptomatic can be 3-5 RBC RBC casts or dystrophic Gross hematuria in sickle or IgA nephropathy Always get UA with microscopy to verify findings Culture and sensitivity to rule out infection Microscopic hematuria needs to be differentiated from anatomic lesions-BPH, tumors, stones Pyruvate in inflammatory glomerulonephritis and should be differentiations from UTI
192
Acanthocytes
Contracted, dense irregular
193
Dystrophic
Mickey Mouse
194
RBC have lost typical disc shape indicating what
Moved through nephron not just the Collecting system
195
Proteinuria sustained
1-2 g/24 h Symptoms of edema and foamy urine
196
Benign proteinuria
Functional or transient <1-2 g/24 hours Fever, exercise, obesity, sleep apnea, emotional stress and CHF Orthostatic proteinuria-only occurs with standing
197
24 hours albumin in normal, microalbuminuria and proteinuria
8-10 30-300 >300
198
Albumin/creatinine ratio | Normal, microalbuminuria, proteinuria
<30 30-300 >300
199
Dipstick microalbuminuria proteinuria
+1 | +3
200
24 hour protein normal proteinuria
<150 | >150
201
Send for UA with microscopic evaluation
+15 dystrophic RBC
202
Return to office
Review BP log Initiate antihypertensice-low fat sodium diet Diabetic protocol
203
What is the mechanism of damage in hypertensive nephropathy
Ok
204
Hypertensive nephrosclerosis
Five times more common in black APOL1 increased risk in black
205
Other risk of hypertensive nephrosclerosis
Smoking, male, hyerclorestelemia, HTN, low birth weight and preexisting renal injury
206
Signs hypertensive nephrosclerosis
HTN, microhematuria and moderate proteinura
207
Why blood pressure control with hypertensive nephrosclerosis
Delays progression to end stage renal
208
Diabetic nephropathy
Damage related to extracellular matrix accumulating in both GBM and tubular BM Imbalance between synthesis and degradation of the ECM causes expansion of mesangial The glomerular filtration surface is decreased by the reduced glomerular luminal space with leads to the reduction in GFR
209
Type 1 glomerular, tubular, interstitial and vascular lesions tend to progress more or less in parallel and independent of albuminuria
Type 2 variable in progression and can develop albuminuria with little change to the nephron
210
Both present how
Clinically stable. Edema and worsening HTN are late findings
211
What can traumatize the kidney
Blunt force, rapid deceleration
212
How does renal trauma present
Hematuria (But lack doesn’t exclude) Evidence of rib fracture Guided on suspicion
213
Radiographically evaluation kidney trauma
Not if hemodynamically stable
214
Sickle cell screening
At birth History is often lost, forgotten Single hemoglobin S mutation
215
What does sickle cell cause
Impaired urinary concentration Can develop renal papillary necrosis Hyperfiltration elads to albuminuria, interstitial fibrosis, decreased number of nephrons RENAL MEDULLARY CARCINOMA
216
Males at risk for transitional cell and bladder cancer
``` Males >35 Current or past smoker Analgesic Exposure to chemicals or dyes Exposure to carcinogenic agents or chemo ```
217
Other history of cancer
``` Gross hematuria Urologic disorder or disease Irritation voiding symptoms -what does this mean? Pelvic irradiation Chronic urinary tract infection chronic indwelling ```
218
Diagnosis of BHP should not preclude further evaluation of underlying cause
Huh
219
How evaluate malignancy
Know risk Rule out infection with culture and sensitivity Confirm with microscopy Serum BUN Cr Radiographically US VC CTU
220
US
No radiation Low cost May miss other causes of hematuria: small stones, small bladder mass and urothelial transitional cell carcinoma Very good for tumors >3cm, cysts, and hydronephrosis
221
CTU
CT or kidney, ureters, and bladder With or without contrast Sensitive for renal calculi! Able to detect small renal parenchymal masses, aneurysm, and renal and perirenal abscesses Higher radiation Exposure to contrast agents Higher cost More info
222
Cytoscope
Evaluate bladder by direct visualization Better assessment of bladder wall for microstructiral changes Can identify urethral stricture disease, BHP and bladder masses Invasive, requires sedation, risk for UTI
223
Recommendations for cytoscopy
Vary Primary care: after negative US or IVP AUA: all patients >35 with asymptomatic microhematuria Or all patients with risk factors for urologic malignancies regardless of age
224
Chronic glomerulonephritis
Glomerular scarring Corticular tubular atrophy Interstitial inflammation Interstitial fibrosis Atherosclerosis
225
Both present how
Clinically stable. Edema and worsening HTN are late findings
226
Type 1 glomerular, tubular, interstitial and vascular lesions tend to progress more or less in parallel and independent of albuminuria
Type 2 variable in progression and can develop albuminuria with little change to the nephron
227
Diabetic nephropathy
Damage related to extracellular matrix accumulating in both GBM and tubular BM Imbalance between synthesis and degradation of the ECM causes expansion of mesangial The glomerular filtration surface is decreased by the reduced glomerular luminal space with leads to the reduction in GFR
228
Why blood pressure control with hypertensive nephrosclerosis
Delays progression to end stage renal
229
Signs hypertensive nephrosclerosis
HTN, microhematuria and moderate proteinura
230
Other risk of hypertensive nephrosclerosis
Smoking, male, hyerclorestelemia, HTN, low birth weight and preexisting renal injury
231
Hypertensive nephrosclerosis
Five times more common in black APOL1 increased risk in black
232
What is the mechanism of damage in hypertensive nephropathy
Ok
233
Return to office
Review BP log Initiate antihypertensice-low fat sodium diet Diabetic protocol
234
Send for UA with microscopic evaluation
+15 dystrophic RBC
235
24 hour protein normal proteinuria
<150 | >150
236
Dipstick microalbuminuria proteinuria
+1 | +3
237
Albumin/creatinine ratio | Normal, microalbuminuria, proteinuria
<30 30-300 >300
238
24 hours albumin in normal, microalbuminuria and proteinuria
8-10 30-300 >300
239
Benign proteinuria
Functional or transient <1-2 g/24 hours Fever, exercise, obesity, sleep apnea, emotional stress and CHF Orthostatic proteinuria-only occurs with standing
240
Proteinuria sustained
1-2 g/24 h Symptoms of edema and foamy urine
241
RBC have lost typical disc shape indicating what
Moved through nephron not just the Collecting system
242
Dystrophic
Mickey Mouse
243
Acanthocytes
Contracted, dense irregular
244
Hematuria glomerulonephritis
Asymptomatic can be 3-5 RBC RBC casts or dystrophic Gross hematuria in sickle or IgA nephropathy Always get UA with microscopy to verify findings Culture and sensitivity to rule out infection Microscopic hematuria needs to be differentiated from anatomic lesions-BPH, tumors, stones Pyruvate in inflammatory glomerulonephritis and should be differentiations from UTI
245
Size of kidney in chronic disease
Smaller
246
How tell acute vs chronic glomerulonephritis
HISTORY Genetic disorders, systemic disease Family history of lupus, sickles cell, autoimmune, diabetes, coronary artery Recent infectionsL staph, malaria, schistomiasis Infection HIC hep BC ROS-itching, nausea, headache, anorexia, dyspnea, vomiting, diarrhea, hiccup, restlessness and depression UA and chemistry US-for size
247
Glomerulonephritis
Hematuria -microscopic vs gross Proteinuria -albumineria vs protein Acute vs chronic
248
Inflammatory effects of RAAS
Activated inflammatory system Leads to interstitial and tubular fibrosisi
249
Vascular/ hemodynamics effect of RAAS
Vasoconstriction of affferent and efferent and systemic arterioles Increases glomerular pressures Causes direct glomerular damage
250
Issue with kidney
Effects every part in the body
251
Hyperfiltration
Kidneys beat themselves up when not functioning Usually starts with AKI-damage to nephrons-problem linked to how quickly you turn around and co morbididies
252
What happens with hyperfiltration
Sclerosis, damage to nephron, lose function,
253
RAAS
Originally protective Then damaging
254
How RAAS hurt
Build up in kidney with chronic kidney disease
255
Most common disease to cause kidney damage
Diabetes then HTN
256
Acute injury renal injury/failure related to what
Rise in Cr
257
Normal GFR
90, 100
258
Stage 2 AKI
GFR 60-89
259
Stage 3
30-59
260
Stage 5
Less than 15 for GFR
261
Stage 2
HTN that starts to get harder to control,
262
Stage 3
``` Increase Parathyroid hormone (doesn’t get filtered out) Bone effects (calcium, P, Mg) ```
263
Stage 4
Acidosis | Changes in K
264
Stage 5
Uremic syndrome
265
Na
Decrease Na excretion in dysfunctional kidney, making more water hang around, goes into third spaces (non vascular non cellular)->dependent edema easrly(becomes systemic later on)
266
Why will Na labs be in normal range
Bc extra water Use diuretics
267
K
Doesn’t change a lot till late stages unless high intake or start pharmacologically getting rid of it (loop diuretics) RAAS system
268
How one increase K
Foods-sweet potato
269
Acidosis
Once start losing functional nephrons (LOSS OF NEPHRONS IS PROBLEM) bc related to ammonia production Initially hyperchloremia acidosis NAGMA at gfr 40 Then HAGMA bc of retained organic anions—— GFR 15 20 HAGMA
270
Late stages kidney disease
Catabolic state Get sicker and sicker *acidosis of kidney-inadequate ammonium production
271
Signs of uremia
Fatigue, anorexia, vomiting, hiccup, metallic taste Hwy?changes in hormone an electrolytes Chronic inflammation- Really sick-effect bone, blood skin -effects everything
272
Late stage 3 changes uremia
Decreased P excretion, PTH and growth of parathyroid, D3 down, all effecting bone! Hyper parathyroid-muscle weakness and fatigue, malaise, low energy High turn over-fibrosis cystica-bone cysts, soft bones more likely to break (not recycling)
273
Without bone turnover
Lots of mineralization defects
274
Symptoms chronic kidney
HyperP? HypoCa HypoVD Secondary hyperparathyroidism
275
Loss of nephron mass
Triggers cascade Some decreased renal biosynthesis-vitamin D Decreased VD-hypoCa (gut function) Hyper P changes in excretion
276
Hyper P
Capture Ca so get P Ca complex and deposit in soft tissue PTH keeps goes up
277
Parathyroid
Cardiac muscle fibrosis | Changes in flow bc CO
278
P up Ca down treat
Exogenous VD
279
Do people die of renal failure
No atherosclerosis changes in heart kill them All related to inflammatory state
280
Patient with chronic renal disease
Cholesterol levels, have a better lifestyle , lose weight
281
Symptoms uremia
Fatigue, decreased appetite, malaise CAREFULLY MANAGE
282
Anemia AKI
Associated with changes in EPO or bone marrow fibrosis Dysfunctional platelets and decreased immune function
283
Normochronmic normocitic anemia how long do the red cells live
Not as long
284
Neocytolysis
Changing and destroying red cells
285
Anemia leads to what symptoms
Fatigue, decreased exercise tolerance, decrease cognition, heart hypertrophy(but parathyroid making it fibrose)
286
Can we replace EPO
Yup increase red cell count
287
Neuromuscular changes AKI when
Drop to 30-44
288
Effects neuromuscular
Cramping hicccups Neuropathy lower extremities first more sensory then becomes motor
289
GI effects AKI
Uremic fetter-urine breath ``` Gastricis PUD Don’t want to eat Vomit Constipation ``` Catabolic state-
290
Treat AKI
Protein restriction Na restict——-but become calorie depleted
291
Insulin AKI
Increased plasma cells-largely excreted by kidney so if around longer prob
292
AKI testosterone and estrogen
Young woman-decreased estrogen and problems bearing children, irregular menstrual cycles, on top of bone disease
293
Kid CKI
Growth retardation failure to thrive
294
Skin changes
Hyperpigmentation Pigments not filtering out Will look spray on tanned-skin gets itchy as P up
295
Why chronic itching
P up
296
Treat AKI
Monitor BP ACE and ARB(we have dysfunctional RAAS) Monitor volume, volume can be measured in a lot of ways -daily weight check Na restrict-canned food Avoid nephrotoxicity drug-anti inflammatory-IBUEPROFIN AND ALEVE EFFECT KIDNEY BC DONT FEEL WELL AND MORE TAKE MORE DAMAGE DO Gentamycin Contrast agents-CT skan? Catch lab? Iodine based bad
297
When a person gets to stage 4
Send to nephrologist GFR less than 30 Nephrolegist on board Build relationship between attention and nephrologist bc if continue to more forward and need transplant and dialysis-
298
Dialysis types
Emergent-if no urine, can be short term-port in neck, can be used temporality maybe week or 2 at most Peritoneal-uses abdominal cavity and lining as membrane-insert hyperosmolar solution with large amount of glucose or sugar creating osmotic gradient to pull solvents across and some albumin comes -leave till become steady state then flush it out
299
Complications peritoneal dialysis
Hernia Avenue for infection Can do at bedtime at night get flow then excreted in morning Can do hourly Not as reliable and failure rates are high-omentum can sclerosing and cause obstruction of GI Solution is sugar so diabetic need to adjust insulin
300
Sclerosing encapsulating peritonitis
Peritoneal dialysis
301
External hemodialysis
Fistula in forearm join an artery and vein they will vibrate bc of change in pressure-palpable thrill Blood out run though so solute move across membrane taking 4-6 hours then back in
302
Transplant list
Can’t have active malignancy, infection, CV and pulmonary evaluation If any other underlying disease move further and further down on list
303
As kidney fail the ___
Shrink
304
How do transplant
Put kidney low in abdomen connect o iliac artery and create a ureter.
305
GFR 30
Send to nephrology
306
GFR15 or less
Dialysis transplant
307
Pediatric renal topics
Ok
308
Kids with HTN
End organ damage | Kidney
309
Normal BP in kid
Less than 90th percentile
310
When start check bp in kid
3 | Unless risk factor-premature, known renal disease
311
How many times have to do bp to say someone is htn
Blood pressure over 90th percentile at three different visits
312
Primary vs secondary
Systolic high Systolic and diastolic high
313
White coat
Up, from stress of doctor Measure bp outside of clinical settting is important
314
Ambulatory measure
Good
315
Diastolic
Sound disappear
316
If found never goes away use 4th
Ok
317
ECG good enough to say if there is left ventricular hypertrophy
Establishment of cronicity of high bp!!!!!!
318
Too small
High bp
319
Too big
Low bp
320
Hematuria
3-5 RBC per high power field (microscopic)
321
How many blood cells to turn urine red
A ton hundreds of thousands
322
Urine dipstick positive for blood
Myoglobin, hemoglobin (need to determine which? Rhabdo-myoglobin is devastating to the kidneys-happens a lot in army bases get rhabdoid and get liters of IV fluid to keep kidney working)
323
Does positive dipstick tell you if RBC in urine in tact
No Need to do microscopy -
324
Color urine babies
Uric acid crystals-red brick colorjust hydration will make it go away Bilirubin
325
If want to confirm blood of urine is from blood
Look under microscope
326
Glomerular bleeding
RBC dysmorphic
327
Bleeding along urinary tract
More normal appearing
328
Blood in urine
Is there protein? Protein with blood is diagnostic for...
329
Post strep glomerulonephritis kids
Edema, urine dark, gross hematuria, elevated ASO, serum compliment low (used up in immune complex forming)
330
Lupus
Glomerulonephritis
331
Most common cause of glomerulonephritis in lupus
MPGN
332
Henoch schonlein purpura
Bruise then come in with lots of them - usually after viral(cold) - immune complex vasculitis, IgA - gross hematuria - ab pain - intestinal vasculature - really sick
333
Every kid with henoch
Blood in urine If blood and protein-SIGNIFICANT-progress to end stage renal failure We know blood there, but if protein then nephrologist involved
334
Rarely kids with asymptomatic isolated hematuria
Have prob Usually goes away But monitor for protein and and htn
335
UTI kids
Same signs and symptoms BUT cant tell you anything, if not potty trained harder
336
Fever and cant find source of infection
Always urine in kids espicially if non verbal
337
Best way to get urine sample from kids
Catheter or suprapubic tap-used in neonates(rarely newborns or young infants) Bag urine-negative fine , but if positive cant send bag in for culture bc contaminants, so gotta do catheter or suprapubic tap
338
Urine nitrate testing on dipstick
Some bacteria change nitrates to nitrites So positive nitrites indicative of bacteria present
339
Most common bacterial pathogen for kid UTI
E. coli
340
Treat
Cephalosporin is standard If too sick use parenteral or IV or shot
341
When image kid urinary tract
After first UTI in boys Get renal and bladder US And VCUG Girls-first UTI both renal US and renal UCVG if symptoms of chronic renal disease or HTN .... weird pathogen Second or third if no other symptoms of renal disease
342
AKI
Onset days increase in serum Cr Volume of output decreases
343
What can alter serum Cr
Age -less muscle mass , sex, race, muscle mass, catabolic rate
344
AKI prognosis
50% mortality
345
Acute non chronic
Obtain the most recent serum cr
346
Pre renal
Affects kidney How it originates Dehydration, fluid shift into different place in body from heart or liver problems, NSAIDS,
347
Intrinsic
Renala glomerular, tubulointerstitial/interstitial Vascular-vascultis/rheumatologist, malignant HTN, TTP HUS
348
Tubulointerstitial causes
``` Ischemia Sepsis/infection Exogenous nephrotoxicity -iodinated contrast -aminoglycosides, amphotericin B, cisplastin, PPI, NSAIDS ```
349
OTC PPI, NSAIDS
Make sure know herbal, vitamin
350
Endogenous nephrotoxicity
Hemolysis, rhabdomyolysis (myoglobin), myeloma, intratubular crystals
351
Flu, running
Rhabdomyolysis
352
Dipstick rhabdomyolysis
Positive blood, but its not blood-its myoglobin! Make sure get microscopic.
353
Myeloma
Tylenol 3 lots post phoned diagnose cancer | -
354
Post renal AKI
Bladder outlet obstruction Bilateral pelvoureteral obstruction
355
History
all medications Toxins-work/home -lead, PMH/PSH?ROS
356
Physical signs AKI
Dehydration, ascites, jaundice, fluid in lungs
357
What order
Serum na and cr | Urine na and cr
358
Why order serum and urine na and cr
FENa.
359
When order UA with micro
Don’t get Cr and Na
360
Need BMP and urine specified Na and Cr
For pre post or intrinsic important o order
361
For AKI why use K and Cl
Anion gap
362
Hemoglobin and hematocrit CBC, platelet count
Need may be changes
363
Coagulation time
PT TPP May lead to liver problem if have ascites If have to do procedures or biopsy if put in dialysis catheter need to know
364
Ekg
See if k problem going on
365
Treat presok
Ok
366
Night before fulllness suprapubically size of golf ball no fever
Flocked fluids
367
Routing dipstick
Positive if 300 mg of albumin Multiple types of protein though and multiple underlying causes
368
Negative dipstick
Doesn’t mean have no albumin
369
UA
Get dipstick
370
UA and micro
Dipstick and microscopic evaluation-casts, cells, bacteria
371
Next step
Quantify | ACR-albumin/Cr ration
372
Spot urine
Random urine sample
373
Best urine
First morning , bc false negative increases as patient takes in more fluid
374
24 hour urine
Protein, albumin, Cr clearance Sample that need for electrophoresis-tell what type of protein , has to be on 24 hours urine
375
Issue with 24 hour urine
Lot of urine Containers to store Arthritis in hands Store on ice
376
Other possible next steps
Based on differential | DDX derived from thorough history and PE
377
Blood test
Albumin eleven
378
Chemistry panel
Electrolytes, lipid(must specify), blood sugar
379
Blood count CBC
Hemoglobin hematocrit If have protein in urine -kidney primary MCD or a secondary cause (anemic and chronic disease) Platelets
380
What systemic disease effect the kidney
``` Lupus Rheumatologist disorders -ANA for possible lupus -CHF look at CMP -chest x ray see if fluid in pulmonary ``` Not having these symptoms yet still check
381
Syndrome
Constellation of problems
382
Nephrotic range proteinuria
Large amount of protein 3.5 g/3500 mg
383
Negative dipstick
Doesn’t mean have no albumin
384
UA
Get dipstick
385
UA and micro
Dipstick and microscopic evaluation-casts, cells, bacteria
386
Next step
Quantify | ACR-albumin/Cr ration
387
Spot urine
Random urine sample
388
Best urine
First morning , bc false negative increases as patient takes in more fluid
389
24 hour urine
Protein, albumin, Cr clearance Sample that need for electrophoresis-tell what type of protein , has to be on 24 hours urine
390
Issue with 24 hour urine
Lot of urine Containers to store Arthritis in hands Store on ice
391
Other possible next steps
Based on differential | DDX derived from thorough history and PE
392
Blood test
Albumin eleven
393
Chemistry panel
Electrolytes, lipid(must specify), blood sugar
394
Blood count CBC
Hemoglobin hematocrit If have protein in urine -kidney primary MCD or a secondary cause (anemic and chronic disease) Platelets
395
What systemic disease effect the kidney
``` Lupus Rheumatologist disorders -ANA for possible lupus -CHF look at CMP -chest x ray see if fluid in pulmonary ``` Not having these symptoms yet still check
396
Syndrome
Constellation of problems
397
Nephrotic range proteinuria
Large amount of protein 3.5 g
398
Nephrotic syndrome
Need proteinuria Hyperlipidemia-fasting cholesterol/lipids Hypoalbuminemia Edema
399
63 yo male polyuria polydipsia (drinking a lot) and facial swelling for 3 months.
Anytime patient thirsty or urinating a lot | -tip off for diabetes (losing sugar and fluid-osmotic diuretic)
400
What is DM associated with
Nephrotic syndrome-may cause it | Hypoalbuminemia
401
Why low albumin in blood stream and spilling protein in urine cause swelling
Lose colloid osmotic so leak out interstitial then think low so raas
402
DM with edem
Most likely effecting kidney
403
Drug decrease proteinuria
ACE ARB
404
Type II DM
Annual ACR (albumen/Cr ratio)
405
lupus and rheumatoid arthritis and nephrotic syndrome
Ok
406
Infection nephrotic
Hep BC-cryoglobinuremia HIV Syphilis Tuberculosis
407
HIV
Focal segmental glomerulosclerisus
408
Hematologic/oncologist cause of nephrotic
Amyloidosis Multiple myeloma Sickle cell Liquid and solid tumors
409
Drugs cause nephrotic
NSAIDS Lithium IV heroin
410
72 year old male severe back pain for year. Works a small farm. No specific identifiable injury. He works in hostpital. Couple different physician give pain pill on separate occasion, not aware of other. Tylenol 3.
Hazards of opoids. Codeine is controlled. Any prescription should be done with caution. They didn’t do PE, no chart, they just gave him pills. Huge risk to patient and postponed care
411
What else might patient take with this constellation
NSAIDS twice the recommended
412
Effect
Proteinuria -as did evaluation, did 24 hour urine to quantify and get protein electrophoresis bc his age group prone to multiple myeloma-he has indirectly transposed treatment to malignancy
413
AAFP article on hematuria in adult
Ok
414
22 yo male going to do triathlon needs physical before . Runs and does weight. He has 1+ blood
Hematuria in athletics | Heavy exercise induce hematuria in 80% of athletes and may have proteinuria
415
Why
Exercising heavily, get renal ischemia for short periods of time. Result in red cells in urine. More common in swimmers, track, and lacrosse.
416
Athletes have pains
Take NSAIDS | Also can cause hematuria
417
Take home message
Occult hematuria always get a microscopy and a culture and sensitivity Then re check
418
Why need microscopy
See where cellls come from
419
NSAIDS
Inhibit COX in kidney ibueprofin bigger offender than acetaminophen In drug classes have variation Net effect of renal ischemia activates RAAS*** vasoconstriction
420
RAAS from NSAID
Up up vasoconstrict
421
26 yo female ab paina fter meal better if eat tums UA-2+ blood
Menstruation give false positive up to 24 hours realize starting mesntral cycle and can persist for several days after Need UA epigastric pain? No
422
Dipstick false positive
Up to 35% false positive
423
UA how collect
Mid stream mid catch, wash urethra this eliminates debris around urethra that would give false information
424
Myoglobin in urin
Give heme positive result false positive in dipstick
425
Ph>9 urine, certain types of proteus infection get
False positive
426
Vitamin C false positive
Can give false positive in cold a flu season can get this
427
What is hematuria
3 RBC per high powered field
428
19 yo male presents with blood in urine. Plays football was struck from right and has bruise since then urine darker than usual but has continued to play foot ball 1+ blood 2+ urobilinogen
Kidney protected can just observe these patients and re check in 48 to 72 hours. Need US depending on history and physical Falls and rapid deceleration injuries hurt kidney?
429
If they are hemodynamics stable do not need a US or CT to look at kidney
Ok
430
22 yo african American male need veal so can play college basketball . Exam normal. 6’7 2+ blood
Sickle cell trait
431
Sickle cell trait
Infants screened at birth If not causing problem then, don’t worry Can get renal papillary necrosis and get focal segmental glomerulonephropsis-RENAL MEDULLARY CARCINOMA
432
What cancer worry about with sickle cell trait
Renal medullary carcinoma
433
What do
Send for UA and culture and sensitivity
434
55 yo male comes for refill bp meds. Former smoker quick when given high BP 1+ blood . UA neg for blood and protein a year ago
Probably cancer related to smoking
435
Number one risk for bladder cancer
Smoking
436
Other question
How much NSAIDS | Other exposures
437
Gross hematuria painless
CANCER until proven otherwise
438
Irritation voiding symptoms with hematuria
Dysuria, urgency, frequency Tips balance away from cancer-
439
What could have
Catheter, chronic UTI, pelvic irritation, schistosomiasis
440
Blood with urine
Also microscopy and culture and sensitivity and Get BUN, Cr serum eval Radiographically?
441
US
No radiation cheaper | Less sensitive for smalls tones, small bladder mass, good for hydronephrosis!!!
442
CTU
2 phase radiographically test sensitive for renal calculi bc done in two phases Expensive , radiation,
443
CTU. Work
1st scan wo contrast second with
444
Cytoscopy
Direct visualization if sure its a lower GU how we go in to get renal stones If stone can get with basket , can get biopsy, can cauterize active bleeding, it is invasive (risk UTI and different thought)
445
US or IVP negative
Can go straight to cystoscopy
446
RBC gone through glomerulus
Dysmorphic
447
Rbc from down
Looks fine
448
Chronic glomerulonephritis
Scarring Cortical tubular atrophy Interstitial inflammation Interstitial fibrosis Atherosclerosis
449
RAAS effect
Vasoconstriction | Increase
450
50 yo male quick smoking last week when brother died from heart attack. Works for postal service, no exercise. What are his risk factors
Male Smoker (non smoker until haven’t touched for 6 months) Diet Obese No exercise 2+ edema Prolonged expiration-typical of obstructive disease Bilateral carotid bruits Sinus rhythm with left ventricular hypertrophy and no t wave abnormalities
451
What’s wrong with this guy
Atherosclerosis , HTN,
452
What get
24 hour urine and BUN, Cr, Na, 24 hour urine
453
Glomerulonephritis
Hematuria)microscopic vs gross) Have some degre of proteinuria
454
Acute vs chronic glomerulonephritis
Detailed history | Renal US-chronic kidney smaller
455
All nephropathy
Give some hematuria
456
Red cell casts or sysmorphic
Glomerulonephritis | As few as 3-5
457
Sustained proteinuria
>1-2 g/24 hours Edema and or foamy urine
458
Benign proteinuria
Functional or transient 1-2 g/24 Fever exercise, orthostatic
459
Treat
Low fat diet and salt reduction | Exercise lose weight
460
MOA in HTN nephropathy
RAAS and hyperfiltration HTN initiate RAAS and glomerulus comes under pressure with hyperfiltration from changes and fibrosis
461
Hypertensive nephrosclerosis who gets
African americans-young | All old people
462
POL1
In black people
463
Risk factors for hypertensive nephrosclerosis
Smoking, HTN< low birth weight, preexisting renal injury
464
Signs hypertensive nephrosclerosis
HTN, microhematuria and moderate proteinuria
465
How control progression
BP
466
Diabetic nephropathy
ECM damage changes the glomerular filtration surface makes more leaks.
467
Type I vs Type 2 diabetics
1-changes in parallel independent of albuminuria 2-develop albuminuria without changes to nephron Both present with edema and worsening of HTN are late findings and related to LOSS OF NEPHRONS NOT CHANGE IN GLOMERULUS
468
Changes in flow
Ok
469
Initial phase obstruction of unilateral obstruction
Urine backflow-increases intraluminal hydrostatic pressure A simultaneous increase in glomerular capillary pressure induced by afferent arteriolar vasodilation which maintains GFR Activation of RAAS leads to the second phase
470
Second phase 6 hours
Decrease glomerular blood flow due to afferent arterioles vasoconstriction
471
Third phase unilateral
Decreased luminal hydrostatic pressure and renal blood glow below baseline
472
Persistence unilateral obstruction>24 hours can cause what
50% drop in GFR
473
US
Solid white fluid black
474
Inject dys to find obstruction
Dye see how dilated ureter is in unilateral obstruction
475
Bilateral 2 phases
Initial-urine backflow-increases intraluminal hydrostatic pressure -simultaneous increase in glomerular capillary pressure induced by afferent arteriolar vasodilation which maintains GFR RAAS is activated which leads to second phase
476
Second phase bilateral
Decrease glomerular blood flow due to afferent arterioles vasoconstriction maintains GFR
477
Why just two phases
ANP may maintain GFR and arteriolar function
478
Tubular dysfunction unilateral
Inability to reabsorbed sodium Salt eating Downregulation of receptor and anxyme activity Have high salt regular urine from the one kidney
479
Tubular dysfunction bilateral obstruction
Presence of volume expansion | ANP blocks effects of renin->decreased angiotensin II therefore net result is diuresis and natiuresis
480
Urinary concentration
Inability to absorb Na int he ascending limb and dilute the filtrate int he distal convoluted tubule, the solutes are excreted Defective urea recycling: transporter defect reduces concentrating effect and allows urea to be excreted
481
Potassium tubular dysfunction
Low flow luminal state and high urinary K Small amounts of urine high K , but minimal have hyperK Even though lot of K in urine is small opposed to what is supposed to be filtered
482
Acute and chronic outlet obstruction
Acute-stone, one ureter Chronic-enlarged prostate as time goes on not emptying bladder backflow reasons
483
Acute bilateral ureteral obstruction
Increase RBF Decrease GFR Decrease medullary blood flow Increased vasodilator prostaglandins, NO Increase ureteral and tubule pressure Increase reabsorption of Na, urea, water Pain , azotemia, oliguria or anuria
484
Chronic bilateral ureteral obstruction
Decrease RBF Decrease GFR Increase vasoconstrictor prostagladin Increase refine Decreasemedullary osmolarity Decrease concentrating ability Structural damage; parenchymal atrophy Decrease transport functions for Na, K, H Azotemia HTP-AVP insensitive polyuria/nature’s is, hyper Khyper Cl
485
Ring picture of outlet obstruction
Patient with azotemia, hyper K and metabolic acidosis
486
343 Harrison table 19th edition
Ok
487
Causes of obstruction
``` Nephrolithiasis Strictures Malignancy BPH/prostate Neurogenic bladder Congenital Pregnancy ```
488
VUR
VU has one way valve that fails Primary or secondary More in male kids Most common inherited anomaly of GU Frequent UTI and pyelonephritis
489
Kid with upper and lower infections
Evaluated for reflex
490
Adults with voiding trouble may develop reflux that predisposes them to what
UTI and pyelonephritis
491
BPH
Slow stream increase urgency Dribble Nocturnal Urine forced into the ureters cause hydronephrosis Vague pain pattern-may include low back, perineum or suprapubic area
492
BPH can lead to hydronephrosis
Ok
493
Overflow incontinence
Ok
494
Post void residual
US on full and empty bladder If >100ml indicate incomplete emptying See overflow incontinence
495
100mL urine
Crest pool for bacteria and infections
496
Stress incontinence
Women child birth Muscles of perineum lost ability to control urethra and emptying Cough sneeze laugh too hard lose control
497
What do with stress incontinence
Kegal sit on toilet start and stop urine stream will take time to get msucle control to stop them can do kegal anywhere
498
Neurogenic bladder
Spinal cord trauma Spinal myelomeningocele Less common-spinal stenosis, herniated disc Disruption of coordination of relaxation of sphincter during bladder contraction As volume increases, resting pressure rises
499
>40 cm H2) increases risk of
Hydronephrosis and subsequent decrease in GFR
500
Treat neurogenic bladder
Monitor as hydronephrosis may occur before irreversible injury
501
Renal Lithiasis cause
RTA, other hormone
502
Result renal lithiasis
Unilateral obstruction Pain back pain radiates to groin and episodic
503
Insert dye into renal lithiasis
See where caught
504
Treat lithiasis
Try to pass drink a on of water and strain urine Unable to pass-in through urethra with basket and pull through and stento to keep it open and drains hen remove stent
505
Pregnancy and obstruction
Proximity to uterus May persist 6 weeks post partum First trimester-hydronephrosis in 10-15 percent Do stent if problem but usually monitor
506
Malignancy obstruction
Constitutional symptoms but may come in for fatigue, weight loss,
507
Kidney cancer
Transitional CA can obstruct ureter But can be colon, ovarian, lymphoma
508
Postobstructive diuresis
Combo of fluid overload, urea accumulation and electrolyte imbalance 250ml/hr but can be as high as 750 ml/h
509
Why get it
Down regulation of Na transporters during obstruction ANP released in response to cardiac preload during obstruction
510
Treat post obstructive
Fluid replacement in response to diuresis-75% of ruine volume and careful monitor or urine and serum osmolality as well as serum electrolytes
511
58 male dysuria 8 days pain radiates back and perineum. Chills, achiness, cant start stream . Doesn’t feel like bladder is empty when finish pee. Now small amounts of urine and spontaneous incontinence
Spontaneous incontinence-overflow BPH, prostatis, UTI, Get UA with microscopy, US, CT,
512
Found he had enlarged bladder Ureteral dilation Hydronephrosis either unilateral or bilateral
Ok
513
Nephrotic range proteinuria
Large amount of protein 3.5 g
514
Nephrotic syndrome
Need proteinuria Hyperlipidemia-fasting cholesterol/lipids Hypoalbuminemia Edema
515
63 yo male polyuria polydipsia (drinking a lot) and facial swelling for 3 months.
Anytime patient thirsty or urinating a lot | -tip off for diabetes (losing sugar and fluid-osmotic diuretic)
516
What is DM associated with
Nephrotic syndrome-may cause it | Hypoalbuminemia
517
Why low albumin in blood stream and spilling protein in urine cause swelling
Lose colloid osmotic so leak out interstitial then think low so raas
518
DM with edem
Most likely effecting kidney
519
Drug decrease proteinuria
ACE ARB
520
Type II DM
Annual ACR (albumen/Cr ratio)
521
lupus and rheumatoid arthritis and nephrotic syndrome
Ok
522
Infection nephrotic
Hep BC-cryoglobinuremia HIV Syphilis Tuberculosis
523
HIV
Focal segmental glomerulosclerisus
524
Hematologic/oncologist cause of nephrotic
Amyloidosis Multiple myeloma Sickle cell Liquid and solid tumors
525
Drugs cause nephrotic
NSAIDS Lithium IV heroin
526
72 year old male severe back pain for year. Works a small farm. No specific identifiable injury. He works in hostpital. Couple different physician give pain pill on separate occasion, not aware of other. Tylenol 3.
Hazards of opoids. Codeine is controlled. Any prescription should be done with caution. They didn’t do PE, no chart, they just gave him pills. Huge risk to patient and postponed care
527
What else might patient take with this constellation
NSAIDS twice the recommended
528
Effect
Proteinuria -as did evaluation, did 24 hour urine to quantify and get protein electrophoresis bc his age group prone to multiple myeloma-he has indirectly transposed treatment to malignancy
529
AAFP article on hematuria in adult
Ok
530
22 yo male going to do triathlon needs physical before . Runs and does weight. He has 1+ blood
Hematuria in athletics | Heavy exercise induce hematuria in 80% of athletes and may have proteinuria
531
Why
Exercising heavily, get renal ischemia for short periods of time. Result in red cells in urine. More common in swimmers, track, and lacrosse.
532
Athletes have pains
Take NSAIDS | Also can cause hematuria
533
Take home message
Occult hematuria always get a microscopy and a culture and sensitivity Then re check
534
Why need microscopy
See where cellls come from
535
NSAIDS
Inhibit COX in kidney ibueprofin bigger offender than acetaminophen In drug classes have variation Net effect of renal ischemia activates RAAS*** vasoconstriction
536
RAAS from NSAID
Up up vasoconstrict
537
26 yo female ab paina fter meal better if eat tums UA-2+ blood
Menstruation give false positive up to 24 hours realize starting mesntral cycle and can persist for several days after Need UA epigastric pain? No
538
Dipstick false positive
Up to 35% false positive
539
UA how collect
Mid stream mid catch, wash urethra this eliminates debris around urethra that would give false information
540
Myoglobin in urin
Give heme positive result false positive in dipstick
541
Ph>9 urine, certain types of proteus infection get
False positive
542
Vitamin C false positive
Can give false positive in cold a flu season can get this
543
What is hematuria
3 RBC per high powered field
544
19 yo male presents with blood in urine. Plays football was struck from right and has bruise since then urine darker than usual but has continued to play foot ball 1+ blood 2+ urobilinogen
Kidney protected can just observe these patients and re check in 48 to 72 hours. Need US depending on history and physical Falls and rapid deceleration injuries hurt kidney?
545
If they are hemodynamics stable do not need a US or CT to look at kidney
Ok
546
22 yo african American male need veal so can play college basketball . Exam normal. 6’7 2+ blood
Sickle cell trait
547
Sickle cell trait
Infants screened at birth If not causing problem then, don’t worry Can get renal papillary necrosis and get focal segmental glomerulonephropsis-RENAL MEDULLARY CARCINOMA
548
What cancer worry about with sickle cell trait
Renal medullary carcinoma
549
What do
Send for UA and culture and sensitivity
550
55 yo male comes for refill bp meds. Former smoker quick when given high BP 1+ blood . UA neg for blood and protein a year ago
Probably cancer related to smoking
551
Number one risk for bladder cancer
Smoking
552
Other question
How much NSAIDS | Other exposures
553
Gross hematuria painless
CANCER until proven otherwise
554
Irritation voiding symptoms with hematuria
Dysuria, urgency, frequency Tips balance away from cancer-
555
What could have
Catheter, chronic UTI, pelvic irritation, schistosomiasis
556
Blood with urine
Also microscopy and culture and sensitivity and Get BUN, Cr serum eval Radiographically?
557
US
No radiation cheaper | Less sensitive for smalls tones, small bladder mass, good for hydronephrosis!!!
558
CTU
2 phase radiographically test sensitive for renal calculi bc done in two phases Expensive , radiation,
559
CTU. Work
1st scan wo contrast second with
560
Cytoscopy
Direct visualization if sure its a lower GU how we go in to get renal stones If stone can get with basket , can get biopsy, can cauterize active bleeding, it is invasive (risk UTI and different thought)
561
US or IVP negative
Can go straight to cystoscopy
562
RBC gone through glomerulus
Dysmorphic
563
Rbc from down
Looks fine
564
Chronic glomerulonephritis
Scarring Cortical tubular atrophy Interstitial inflammation Interstitial fibrosis Atherosclerosis
565
RAAS effect
Vasoconstriction | Increase
566
50 yo male quick smoking last week when brother died from heart attack. Works for postal service, no exercise. What are his risk factors
Male Smoker (non smoker until haven’t touched for 6 months) Diet Obese No exercise 2+ edema Prolonged expiration-typical of obstructive disease Bilateral carotid bruits Sinus rhythm with left ventricular hypertrophy and no t wave abnormalities
567
What’s wrong with this guy
Atherosclerosis , HTN,
568
What get
24 hour urine and BUN, Cr, Na, 24 hour urine
569
Glomerulonephritis
Hematuria)microscopic vs gross) Have some degre of proteinuria
570
Acute vs chronic glomerulonephritis
Detailed history | Renal US-chronic kidney smaller
571
All nephropathy
Give some hematuria
572
Red cell casts or sysmorphic
Glomerulonephritis | As few as 3-5
573
Sustained proteinuria
>1-2 g/24 hours Edema and or foamy urine
574
Benign proteinuria
Functional or transient 1-2 g/24 Fever exercise, orthostatic
575
Treat
Low fat diet and salt reduction | Exercise lose weight
576
MOA in HTN nephropathy
RAAS and hyperfiltration HTN initiate RAAS and glomerulus comes under pressure with hyperfiltration from changes and fibrosis
577
Hypertensive nephrosclerosis who gets
African americans-young | All old people
578
POL1
In black people
579
Risk factors for hypertensive nephrosclerosis
Smoking, HTN< low birth weight, preexisting renal injury
580
Signs hypertensive nephrosclerosis
HTN, microhematuria and moderate proteinuria
581
How control progression
BP
582
Diabetic nephropathy
ECM damage changes the glomerular filtration surface makes more leaks.
583
Type I vs Type 2 diabetics
1-changes in parallel independent of albuminuria 2-develop albuminuria without changes to nephron Both present with edema and worsening of HTN are late findings and related to LOSS OF NEPHRONS NOT CHANGE IN GLOMERULUS
584
Changes in flow
Ok
585
Initial phase obstruction of unilateral obstruction
Urine backflow-increases intraluminal hydrostatic pressure A simultaneous increase in glomerular capillary pressure induced by afferent arteriolar vasodilation which maintains GFR Activation of RAAS leads to the second phase
586
Second phase 6 hours
Decrease glomerular blood flow due to afferent arterioles vasoconstriction
587
Third phase unilateral
Decreased luminal hydrostatic pressure and renal blood glow below baseline
588
Persistence unilateral obstruction>24 hours can cause what
50% drop in GFR
589
US
Solid white fluid black
590
Inject dys to find obstruction
Dye see how dilated ureter is in unilateral obstruction
591
Bilateral 2 phases
Initial-urine backflow-increases intraluminal hydrostatic pressure -simultaneous increase in glomerular capillary pressure induced by afferent arteriolar vasodilation which maintains GFR RAAS is activated which leads to second phase
592
Second phase bilateral
Decrease glomerular blood flow due to afferent arterioles vasoconstriction maintains GFR
593
Why just two phases
ANP may maintain GFR and arteriolar function
594
Tubular dysfunction unilateral
Inability to reabsorbed sodium Salt eating Downregulation of receptor and anxyme activity Have high salt regular urine from the one kidney
595
Tubular dysfunction bilateral obstruction
Presence of volume expansion | ANP blocks effects of renin->decreased angiotensin II therefore net result is diuresis and natiuresis
596
Urinary concentration
Inability to absorb Na int he ascending limb and dilute the filtrate int he distal convoluted tubule, the solutes are excreted Defective urea recycling: transporter defect reduces concentrating effect and allows urea to be excreted
597
Potassium tubular dysfunction
Low flow luminal state and high urinary K Small amounts of urine high K , but minimal have hyperK Even though lot of K in urine is small opposed to what is supposed to be filtered
598
Acute and chronic outlet obstruction
Acute-stone, one ureter Chronic-enlarged prostate as time goes on not emptying bladder backflow reasons
599
Acute bilateral ureteral obstruction
Increase RBF Decrease GFR Decrease medullary blood flow Increased vasodilator prostaglandins, NO Increase ureteral and tubule pressure Increase reabsorption of Na, urea, water Pain , azotemia, oliguria or anuria
600
Chronic bilateral ureteral obstruction
Decrease RBF Decrease GFR Increase vasoconstrictor prostagladin Increase refine Decreasemedullary osmolarity Decrease concentrating ability Structural damage; parenchymal atrophy Decrease transport functions for Na, K, H Azotemia HTP-AVP insensitive polyuria/nature’s is, hyper Khyper Cl
601
Ring picture of outlet obstruction
Patient with azotemia, hyper K and metabolic acidosis
602
343 Harrison table 19th edition
Ok
603
Causes of obstruction
``` Nephrolithiasis Strictures Malignancy BPH/prostate Neurogenic bladder Congenital Pregnancy ```
604
VUR
VU has one way valve that fails Primary or secondary More in male kids Most common inherited anomaly of GU Frequent UTI and pyelonephritis
605
Kid with upper and lower infections
Evaluated for reflex
606
Adults with voiding trouble may develop reflux that predisposes them to what
UTI and pyelonephritis
607
BPH
Slow stream increase urgency Dribble Nocturnal Urine forced into the ureters cause hydronephrosis Vague pain pattern-may include low back, perineum or suprapubic area
608
BPH can lead to hydronephrosis
Ok
609
Overflow incontinence
Ok
610
Post void residual
US on full and empty bladder If >100ml indicate incomplete emptying See overflow incontinence
611
100mL urine
Crest pool for bacteria and infections
612
Stress incontinence
Women child birth Muscles of perineum lost ability to control urethra and emptying Cough sneeze laugh too hard lose control
613
What do with stress incontinence
Kegal sit on toilet start and stop urine stream will take time to get msucle control to stop them can do kegal anywhere
614
Neurogenic bladder
Spinal cord trauma Spinal myelomeningocele Less common-spinal stenosis, herniated disc Disruption of coordination of relaxation of sphincter during bladder contraction As volume increases, resting pressure rises
615
>40 cm H2) increases risk of
Hydronephrosis and subsequent decrease in GFR
616
Treat neurogenic bladder
Monitor as hydronephrosis may occur before irreversible injury
617
Renal Lithiasis cause
RTA, other hormone
618
Result renal lithiasis
Unilateral obstruction Pain back pain radiates to groin and episodic
619
Insert dye into renal lithiasis
See where caught
620
Treat lithiasis
Try to pass drink a on of water and strain urine Unable to pass-in through urethra with basket and pull through and stento to keep it open and drains hen remove stent
621
Pregnancy and obstruction
Proximity to uterus May persist 6 weeks post partum First trimester-hydronephrosis in 10-15 percent Do stent if problem but usually monitor
622
Malignancy obstruction
Constitutional symptoms but may come in for fatigue, weight loss,
623
Kidney cancer
Transitional CA can obstruct ureter But can be colon, ovarian, lymphoma
624
Postobstructive diuresis
Combo of fluid overload, urea accumulation and electrolyte imbalance 250ml/hr but can be as high as 750 ml/h
625
Why get it
Down regulation of Na transporters during obstruction ANP released in response to cardiac preload during obstruction
626
Treat post obstructive
Fluid replacement in response to diuresis-75% of ruine volume and careful monitor or urine and serum osmolality as well as serum electrolytes
627
58 male dysuria 8 days pain radiates back and perineum. Chills, achiness, cant start stream . Doesn’t feel like bladder is empty when finish pee. Now small amounts of urine and spontaneous incontinence
Spontaneous incontinence-overflow BPH, prostatis, UTI, Get UA with microscopy, US, CT,
628
Found he had enlarged bladder Ureteral dilation Hydronephrosis either unilateral or bilateral
Ok
629
Acute renal failure/acute renal injury
Increase Cr seen in 6 percent of hospitalized
630
Treat AKI
Nothing proven maintain volume and stuff.
631
Prerenal failure
Most common in host. CHF, cirrhosis, nrenovascular disease
632
Intrinsic renal failure
``` ATN Rhabdo and ATN Radiocontrast dyese Emboli TPP/HUS Drugs HIV/SLE ```
633
Post Renal
Obstruction Ambulatory not hospitalized Stones, malignant, papillae-more proximal obstruction
634
Intrinsic renal finding
HTN, GN, edema NA retention Hemoptysis, pulmonary hemorrhage, vasculitis, Rbc wbc cellular casts characteristic of GN RBC CASTS NSAIDs-proteinuria Allergic nephritis-eosinophils with wrights or Hansel WBC pyelonephritis
635
Post renal
Less ill Delayed until azotemia is up ``` Fena>one Bland microscopic US is key Dilated Exeter calyces May also use furosemide renogram MAGthree ```
636
Treat AKI
Support Pre renal vol loss-IV CHF-vasodilator or inotropy ``` Intrinsic-GN SLE vasculitis corticosteroids and cytotoxic Plasma phones is-HUS Plasma exchange-TPP Pyelonephritis, endocarditis-antibiotics Allergic- Obstruction-urologist catch or stent ```
637
What I’d nonprerenal aki progresses
Dialysis
638
Indication dialysis
Volume overload refractory to diuretic agents, hyperkalemia, encephalopathy not explained, pericarditis, pleuritis, serositis, metabolic acidosis, Provide in advance Inability to requisite fluid for drugs
639
What kind of dialysis most patients given
Intermittent hemodialysis
640
Continuous renal replacement therapy
Only if IHD intolerant
641
SLED
SLOW EFFICIENCY DIALYSIS, HYBRID TECHNIQUES MAY BE SED INSTEAD OF CRRT
642
Chronic kidney disease
Irreversible impairment of kidney function
643
More esk or CKD
CKD
644
First step of ckd diagnosis
Establish chronicity | -history and prior labs and U(small kidney for chronic
645
What chronic diseases have large kidney though
Diabetic nephropathy, HIV, multiple myeloma or amyloidosis
646
Next step
Etiology History, drugs disease, PE masses , Bruit-renovascular Electrophoresis, serum, light chains, D< P, Ca, PTH for bone
647
What labs suggest nephrotic
Hypoalbuminemia, hyperchlosterolemia, edema
648
Uremic syndrome in CKD
Cr to estimate eGFR Cr>five thirty
649
Symptoms uremia
Anorexia, weight loss, dyspnea, fatigue, pruritis, sleep, metallic taste, confusion, encephalopathy Hypertension, jugular distension, pleural friction rub, muscle watering, asterisks, ecchmoyses , excessive bleeding HyperK, P, acidosis, hyperU, anemia, hypoalbuminemia, hypoCa
650
Treat uremia
Dialysis or transplant or drug
651
How treat CKD
Treat the HTN to slow progression -give diuretics bc of the volume overload that causes htn EPO-for anemia, want 90 hemoglobin Iron supp Restrict P eat or calcium based salt K>6
652
What potassium consider dialysis
Over 6 on repeat
653
What big signs start dialysis
Anorexia, hypoalbuminemia, hyper K, weight loss
654
How slow progression ckd
Control that htn ace arb , diuretics—-may also help control the high K
655
Median wait time for transplant
Three to six years
656
Absolute indications dialysis
HyperK, acidosis, encephalopathy no explained, pericarditis, serositis, uremia, failure to thrice,
657
What GFR get these symptoms
Ten
658
Does initiation of dialysis before uremic symptoms improve ESRD
No
659
Hemodialysis
Brescia imino fistula Blood pumped in and bathed Three times a week
660
Efficiency dialysis
Duration, blood flow rate, dialysate flow rate, surface area dialysis
661
Complication hemodialysis
Hypotension-diabetes who’s neuropathy prevents compensatory responses (tachy vasoconstriction) Cns
662
Dialysis disequilibrium syndrome
Headache, confusion, from rapid solute removal early in the pts dialysis history, before adaptation to the procedure
663
How avoid disequilibrium syndrome
Incremental induction of chronic dialysic therapy in uremic patients short durationlower flow rate
664
Peritoneal dialysis
Don’t need circulation access. Allows infusion of a dialysate solution into abdominal cavity across peritoneal membrane which is an artificial kidney
665
Difference between PD and heme dialysi solution
PD must be sterile and uses lactate rather than bicarbonate
666
Prob PD
Longer and less effective,
667
But what are advantages PD
Independence and flexibility, gentle hemodynamics profiles | Better preservation renal function
668
PD complication
Peritonitis -ab pain cloudy dialysate, peritoneal leukocyte count up with neutrophils Protein loss HUGE
669
Organisms of peritonitis
Staph aureus and staph spp gram positice Candida Pseudomonas
670
Treatment of choice esrd
Transplant
671
How get best transplant results
Living related recipient | Less ischemia and waiting time usually done prior to symptoms and better graft survival
672
Graft matching
Improves survival
673
Why is imbalance of patients and donors going to increase
Obesity and diabetes
674
Expanded criteria donor and donors after cardiac death
Developed to increase dead donor kidney
675
ECD kidneys-who gets
People who expected fare less well on dialysis
676
Factors influence graft survival
Pretransplant blood transfusion avoid | -if encessary use leukocyte reduced irradiated blood
677
Contraindications renal transplant
Active GNm infection, malignancy, aids, hepatitis,
678
Patient should have what life expectancy to get kidney
Over five years
679
Rejection
Hyperacute-presensitization Acute-week month
680
How detect rejection
Rise in Cr HTN fever, reduced urine, tenderness
681
How confirm rejection
Percutaneous renal transplant biopsy
682
Treat rejection
Pulse of methylprednisone Monoclonal antibody directed at human t lymphocytes
683
Immunosuppressive therapy transplant
Three dru regimen Calcineurin inhibitors Cyclosporine
684
Cyclosporine side effects
Hyper K, HTN< tremor, hirstiusm, gingival hypertrophy, gout,
685
Tacrolimus
Hyperglycemia | Hair loss
686
Prednisone
Steroid-
687
Complication renal transplant
Neoplasia, infection bc of immunosuppression Polyomavirus DNA virus BK EPV Non Hodgkin and squamous cell skin carcinoma
688
Month one
CMV | Use ganciclovir
689
After one month
Fungal pneumocystisi carinii
690
Nephritic syndrome
Salt and water retention from reduced GFR may get circulatory congestion RBC casts
691
Proteinuria with nephrtis
Less than three
692
Acute post strep GN
Positive pharyngeal skin culture ASO titres Hypocomplementemia GN on biopsy
693
Treat acute post strep GN
Correct fluid and electrolyte balance Self limited
694
Postinfections GN
Bacterial or viral and parasitic Endocarditis, sepsis, hep, pneumococcal pneumonia Feature more mild that post strep
695
Post staph
IgA deposits IF
696
Treat post infections GN
Control infeciton but steroids often given to avoid dialysis
697
RPGN
GFR less than fifty percent Complex like SLE Pauli immune ANA Anti GB
698
SLE lupus
Deposit circulating immune complex Arthralgias-butterfly skin rash, serositis, alopecia, CNS Nephrotic diffuse GN Active sediment, proteinuria, progressive renal insuffiency ANA, hhypocompl, anti ds-DNA
699
Treat SLE lupus
Glucocorticoids and cytotoxic agents Cyclophosphamide First bank sperm and egg before
700
Pauli immune GN
Renal limited or systemic PANCE, MPO, cANCA MPO and PRthree antigens
701
Treat Pauli
Methylprednisone and cyclophosphamide Plasmapheresis Pneumocystitis carnii prophylaxis
702
Diagnosis henoch
Biopsy
703
Urine spot for nephrotic
Yup easier
704
Complications NS
D defiency
705
MCD not respond steroids
Focal sclerosis
706
Membranous GN
Sub epithelial IgG SLE, hep B, tumors, captopril, penicillamine
707
Treat membranous
Ace arb, prophylactic DVT
708
Focal glomerulosclerosis
Primary acute | Secondary chronic
709
MPGN
Ok
710
Diabetic nephropathy
Ace arb Glucose control Loop diuretics is get HyperK that cant be controlled
711
Asymptomatic
Thin basement and IgA nephropathy
712
Distinguish tubulointerstitial
Less HTN, hematuria and proteinuria
713
acute interstitial nephritis drugs
Increase Cr, eosinophilic rash arthralgias Rapid if previously sensitized Rifampin
714
Tubular dysfunction lab
Hyper K metabolic acidosis
715
How see eosinophilic
Hansel or wright stisan
716
Systemic cause AIN
Leptospirosis, strep IgG4 plasma cells
717
Tubulointerstiial nephritis and uveitis syndrome
Weight loss, increase erythrocytes sedimentation ate Self limited give prednisone
718
Chronic interstitial nephrtis
Analgesic nephropathy Asprin phenacetin Transitional cells arcinoma
719
Manifestations chronic IN
Papillary necrosis, calculi, sterile pyruvate, azotemia
720
Chinese herbal meds
Severe chronic tubulointerstitial fibrosis
721
Balkan endemic nephropathy
South east Europe
722
Lithium
Chronic tubulointerstitial nephritis Give valproic acid instead
723
Metabolic cause of chronic IN
Hyper Ca with nephrocalcinosis, oxalosis, hypoK, hyperplastic Uric Emma
724
Chronic IN with what systemic disease
Sjorgen
725
Myeloma
Monoclonal immunoglobulin or light chain and AL amyloidosis Filtered light chains aggregate and cause tubular obstruction, tubular damage, and inflammation Hypercalcemia volume depletion
726
Diagnose cast nephropathy
Light chain in urine or serum By electrophoresis
727
Dipstick negative
Light chain nephropathy Positive AL amyloididid bc of proteinuria
728
Diagnose ADPCK
Between thirty and fifty nine at least two cysts in each kidney
729
ADPCK
HTN, normal GFR RAAS Give ace arb
730
What is common in ADPK
UTI cyst infections
731
RTA
Ok
732
When get renal calculi
Urine supersaturated with insoluble components form low urine volume, excessive or insufficient secretion of selected compounds.
733
Most stones
Ca based
734
Ca oxalate stone
Hypercalcuria, hyperoxaluria High Na diet, loop diuretic, RTA 1, primary hyperPTH, VD excess, milk alkaloids
735
Hyperoxaluria
Malabsorption IBD, pancreatitis
736
Uric acid stone
Chemo low pH
737
Cystine stones
Acidic pH defect in intestinal tranpost
738
Obstruction insert bladder catheter and get diuresis
Obstruction below bladder neck
739
Insert catheter and no diuresis do US
Hydronephrosis obstruction above bladder neck No hydronephrosis —low clinical suspicion—no work up, but high suspicion identify and relieve
740
Hydronephrosis
Identify site and relieve and identify cause
741
US
Hydronephrosis
742
CT IV
Site of obstruction
743
Tc99 MAG3
Renal scan to assess excretion before and after loop diuretic can assess function and difference between two kidneys
744
Distinguish tubulointerstitial
Less HTN, hematuria and proteinuria
745
acute interstitial nephritis drugs
Increase Cr, eosinophilic rash arthralgias Rapid if previously sensitized Rifampin
746
Tubular dysfunction lab
Hyper K metabolic acidosis
747
How see eosinophilic
Hansel or wright stisan
748
Systemic cause AIN
Leptospirosis, strep IgG4 plasma cells
749
Tubulointerstiial nephritis and uveitis syndrome
Weight loss, increase erythrocytes sedimentation ate Self limited give prednisone
750
Chronic interstitial nephrtis
Analgesic nephropathy Asprin phenacetin Transitional cells arcinoma
751
Manifestations chronic IN
Papillary necrosis, calculi, sterile pyruvate, azotemia
752
Chinese herbal meds
Severe chronic tubulointerstitial fibrosis
753
Balkan endemic nephropathy
South east Europe
754
Lithium
Chronic tubulointerstitial nephritis Give valproic acid instead
755
Metabolic cause of chronic IN
Hyper Ca with nephrocalcinosis, oxalosis, hypoK, hyperplastic Uric Emma
756
Chronic IN with what systemic disease
Sjorgen
757
Myeloma
Monoclonal immunoglobulin or light chain and AL amyloidosis Filtered light chains aggregate and cause tubular obstruction, tubular damage, and inflammation Hypercalcemia volume depletion
758
Diagnose cast nephropathy
Light chain in urine or serum By electrophoresis
759
Dipstick negative
Light chain nephropathy Positive AL amyloididid bc of proteinuria
760
Diagnose ADPCK
Between thirty and fifty nine at least two cysts in each kidney
761
ADPCK
HTN, normal GFR RAAS Give ace arb
762
What is common in ADPK
UTI cyst infections
763
RTA
Ok
764
When get renal calculi
Urine supersaturated with insoluble components form low urine volume, excessive or insufficient secretion of selected compounds.
765
Most stones
Ca based
766
Ca oxalate stone
Hypercalcuria, hyperoxaluria High Na diet, loop diuretic, RTA 1, primary hyperPTH, VD excess, milk alkaloids
767
Hyperoxaluria
Malabsorption IBD, pancreatitis
768
Uric acid stone
Chemo low pH
769
Cystine stones
Acidic pH defect in intestinal tranpost
770
Obstruction insert bladder catheter and get diuresis
Obstruction below bladder neck
771
Insert catheter and no diuresis do US
Hydronephrosis obstruction above bladder neck No hydronephrosis —low clinical suspicion—no work up, but high suspicion identify and relieve
772
Hydronephrosis
Identify site and relieve and identify cause
773
US
Hydronephrosis
774
CT IV
Site of obstruction
775
Tc99 MAG3
Renal scan to assess excretion before and after loop diuretic can assess function and difference between two kidneys

► Med Notes (62 decks)

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