Renal Step UP Flashcards
What improves the prognosis of CRF patients?
Protein restriction and the use of ACE inhibitors
When do ACE inhibitors actually hurt CRF?
When the Cr is >3-3.5
Captopril is a….
ACE inhibitor
What doesn’t affect CRF prognosis?
Salt restriction and potassium restriction
HIV kidney damage is
Collapsing focal and segmental glomerulosclerosis
Typical presentation of focal segmental glomerulosclerosis
Nephritic range proteinuria, azotemia, and normal sized kidneys
Nitrites signify what
The presence of Enterobacteriaceae
Elderly patient with bone pain, renal failure, and hypercalcemia has
Multiple myeloma until proven otherwise
Initial hematuria
Urethral damage
Terminal hematuria
Bladder/Prostatic damage
Total hematuria
Kidney/Ureter damages
Clots and kidney disease
Not seen
BPH starts where in the prostate
Center
Prostate cancer starts where in the prostate
Peripheral
Metformin is bad for what
RF, hepatic failure or sepsis, it causes Lactic Acidosis! which RF and HF already make worse
Nephritic syndrome presents with
Dependent edema, HTN, hematuria (dysmorphic RBCs and red cell casts). May also see Rash, low-grade fever, and proteinuria.
Workup of BPH starts with
Serum Cr and UA
Signs of dehydration
Dry Mucosa, higher values for Hct and serum electrolytes, BUN/Cr >20. Use crystalloid
What to do for testing in an old person with irritative voiding symptoms and negative urine culture
R/o bladder cancer: e.g. urinary cytology and cystoscopy
Treating recurrent hypercalciuric renal stones
Increased fluid intake, sodium restriction, and a thiazide.
Cystinuria presents with
H/o recurrent kidney stones from childhood and positive FH. Stones are radiopaque, hexagonal.
Test for cystinuria
Urinary cyanide nitroprusside test positive
Most common kidney stones?
Calcium oxalate 75-90%
Small bowel disease, surgical resection, or chronic diarrhea can lead to what
Calcium oxalate stones from malabsorption of fatty acids and bile salts….???
Acyclovir and the kidney
Can precipitate in renal tubules and cause ARF. Prevent with adequate hydration.
Acute pyelonephritis: UCx/BCx or Abx first
UCx/BCx before starting Abx
Hodgkin’s lymphoma causes what
Minimal change disease: nephrotic syndrome
Most common nephropathy associated with cancer
Membranous nephropathy
Renal vein thrombosis and what condition connected
Membranous glomerulonephritis: nephrotic syndrome
Most common nephrotic syndrome
Membranous glomerulonephritis in adults
Contrast-induced nephropathy risk factors
Patients with diabetes and elevated baseline Cr
How to prevent contrast damage
IV hydration with isotonic bicarb and acetylcysteine
Most common nephrotic syndrome in blacks
FSGS
Nephrotic syndrome in HIV and IV drug abuse
FSGS
Fibromuscular disease can present in children?
Yes with a bruit or venous hum at CVA. Angiogram reveals string of beads sign.
Signs of diabetic nephropathy
Glomerular hyperfiltration is the earliest sign, which also causes the glomerular injury.
The first sign of diabetic nephropathy that can be quantitated
Thickening of the glomerular basement membrane
Presence of hematuria in a patient with irritative voiding…
Bladder cancer
BPH and hematuria
Not related, neither is suprapubic pain and systemic complaints
Most common cause of overflow incontinence in old males
Enlarged prostate
What to do when you have isolated proteinuria
Dipstick on at least two other occasions
Most common causes of interstitial nephritis
Cephalosporins, penicillins, sulfonamides, lasix, NSAIDs, rifampin, phenytoin, allopurinol.
Treatment for drug induced interstitial nephritis
Discontinue the drug
Medullary cystic disease presents with
Recurrent UTI, renal stones, and contrast filled cysts demonstrated by IVP
Old patients with poor oral intake and NSAIDs, ACEIs, and diuretics can have
Prerenal azotemia due to intravascular volume depletion and poor renal perfusion
Causes of acute pericarditis
Viral infection (most common), bacterial infections, connective tissue diseases, uremia
How to treat patients with pericarditis and RF
Hemodialysis to get rid of the uremia that is causing the pericarditis
Indications for hemodialysis
Refractory hyperkalemia, volume overload not responding to diuretics, refractory metabolic acidosis (pH<7.2), uremic pericarditis, uremic encephalopathy or neuropathy, coagulopathy due to renal failure
Treating pericarditis
NSAIDs can help, but they are bad in RF
Most common glomerulonephritis
IgA nephropathy
IgA Nephropathy presents with
Episodes of gross hematuria, beginning 1-3 days after an upper respiratory infection. Serum complement levels are normal.
What to do first in complicated acute pyelonephritis
Start empiric antibiotics
Signs of drug induced interstitial nephritis
Eosinophiluria, rash, arthralgias, renal failure
MOA of cyclosporine
Calcineurin inhibitor
Most common SE of cyclosporine
Nephrotoxicity. Most serious as well.
MOA of tacrolimus
Calcineurin inhibitor, same as cyclosporine
Other SEs of cyclosporine
Nephrotoxicity, hyperkalemia, HTN, gum hypertrophy, hirsutism, and tremor.
Tacrolimus SEs
Nephrotoxicity, hyperkalemia, HTN, and tremor
Major toxicity of azathioprine
Dose-related diarrhea, leukopenia, and hepatotoxicity
Major toxicity of mycophenolate
bone Marrow suppression
Meds that cause hyperkalemia
ACEIs, NSAIDs, potassium-sparing diuretics
Potassium-sparing diuretics
Spironolactone and amiloride
Cholesterol embolization
Follows surgical or interventional manipulation of the arterial tree. Renal failure, livedo reticularis, systemic eosionphilia, and low complement levels should make you think of cholesterol embolism.
Tx of cholesterol embolization
Conservative, stop anticoagulation to allow healing of ruptured plaques, steroids don’t help.
Tx of contrast-induced nephropathy
Hydration, low-osmolality contrast (non-ionic too), limiting amount of contrast. With borderline RF, use prophylactic N-acetylcysteine and fenoldopam (dilates vessels).
DM nephropathy and eosinophils
NOPE!
DM nephopathy time course
Takes a long time, rapid decline over months is not diabetes
Post-strep glomerulonephritis
Nephritic syndrome with strep throat or skin infections. Low complement.
Acute Allergic Interstitial Nephropathy signs
Rash, RF, eosinophilia, eosinophiliuria (Hansel stain)
most common causes of Acute allergic interstitial nephropathy
Antibiotics, NSAIDs, Thiazides, Phenytoin, Allopurinol
High protein diet and stones
Increased risk of calcium stones
Recommendations for patients with renal calculi
- Decreased dietary protein and oxalate.
- Decreased sodium intake
- increased fluid intake
- Increased dietary sodium
Tx for uric acid stones
Alkalinize the urine with Oral Sodium Bicarb or Sodium Citrate to dissolve the stones
Classic triad of Renal cell carcinoma
Flank pain, hematuria, and a palpable abdominal renal mass (rare triad tho)
Persistent varicocele should make you worry about….
RCC
RCC can produce what
Paraneoplastic conditions like too much erythropoetin.
tx of BPH
Finasteride or alpha-1 blockers.
Finasteride MOA
5-alpha reductase inhibitors, acts on epithelial hyperplasia
Terazosin MOA
Alpha-1 antagonist: Acts on smooth muscle hyperplasia in BPH
Collagen predominance in BPH
Neither finasteride or alpha-1 blockers work
Most common causes of rhabdo
- Alcoholism. 2. Cocaine use, electrolyte abnormalities (e.g. hypokalemia, hypophosphatemia)
signs of rhabdo
Positive dipstick blood, no RBCs. Disproportionate elevation of Cr compared to BUN.
Tx rhabdo
IV hydration and alkalinize the urine, possible osmotic diuresis
Rhabdo histology
Acute Tubular Necrosis. measure serum CK
Cryoglobulinemia presentation
Palpable purpura, glomerulonephritis, non-specific systemic symptoms, arthralgias, hepatosplenomegaly, peripheral neuropathy, and hypocomplementemia.
What dz makes you think of Cryoglobulinemia
Hep C
Henoch-Schonlein purpura
Childhood, palpable purpura on butt, abd. pain, arthalgias, proteinuria, and hematuria with RBC casts on UA. normal serum complement. No HCV connection.
Microscopic Polyangiitis presentation
Constitutional symptoms of fever and malaise. Abd. pain, hematuria, with active urinary sediment and purpura. Positive ANCAs. Normal serum complement, serology usually negative.
Membranoproliferative glomerulonephritis
Nephrotic-range proteinuria and hematuria.
Membranoproliferative glomerulonephritis histology
Dense intramembranous deposits that stain for C3.
Membranoproliferative glomerulonephritis type 2 cause
IgG against C3 taht leads to persistent complement activation and kidney damage
Goodpasture’s syndrome big sign
Anti-GBM antibodies
What diseases have immune-complex mediated
SLE, post-streptococcal glomerulonephritis
cause of idiopathic crescentic glomerulonephritis
Cell-mediated injury
Definition of Nephrotic syndrome
Proteinuria >3.5 g/day, hypoalbuminemia, edema, hyperlipiedmia, and lipiduria
Most common Nephrotic syndrome in adults and kids
Adults: Membranous glomerulopathy
Kids: Minimal Change disease
Complications of Adult Polycystic Kidney Disease
Rupture of brain aneurysm and AAA
Pulmonary hemorrhage in what disease
Goodpastures and Wegeners
Nephrotic syndrome and blood clotting
Hypercoagulable: watch for venous or arterial thrombosis
Classic findings of amyloidosis
Renal amyloid deposits that show apple-green birefringence under polarized light after congo red staining
Most common cause of painless hematuria in adults
Bladder tumors
Post-streptococcal glomerulonephritis presentation
hematuria, HTN, red cell casts, and mild proteinuria
Goodpasture’s syndrome tx
Emergency plasmapharesis
Wegener’s granulomatosis tx
Cyclophosphamide and steroids
Simple renal cysts tx
Benign and require no further evaluation. They look very simple and cyst like, anything that looks a little different than a thinly walled globe needs more evaluation.
What to do for pyelonephritis that doesn’t respond after 48-72 hrs of appropriate Abx
U/S or imaging
Pathology of DM nephropathy
nodular glomerulosclerosis but diffuse glomerulosclerosis is more common
Tx for serious-gram negative infections
Aminoglycosides like amikacin which are nephrotoxic
Most common cause of priapism
Prazosin, but think of trazodone
Most common cause of acute epididymitis in young vs. old men
Chlamydia and gonorrhea in young men. Gram-negative rods in Older men
Non-inflammatory chronic prostatitis presentation
Afebrile and irritative voiding
Most common cause of abnormal hemostasis in CRF
Platelet dysfunction due to uremia
Treating uremic coagulopathy
DDAVP to release factor VII von Willebrand factor
Anemia and ESRD
Deficiency of erythropoeitein. Normocytic/normochromic. Most common side effect of giving erythropoetin is HTN, HA, and flu like symptoms
HTN nephropathy pathology
Arterioslecrotic lesions of afferent and efferent renal arterioles and glomerula capillary tufts
Diabetes nephorpathy pathology
Increased extracellular matrix, BM thickening, mesangial expansion, and fibrosis
How to treat fibromuscular dysplasia
percutaneous angioplasty with stent placement.
Cause of hepatorenal syndrome
Renal vasoconstriction
Hepatorenal syndrome tx
liver transplantation
Analgesic nephropathy presentation
Woman with chronic headaches with painless hematuria caused by papillary necrosis.
Analgesic nephropathy cause
Chronic tubulointerstial damage leading to papillary necrosis
Tx acute rejection
IV steroids
Most common cause of death in dialysis patients
CV dz
Alport’s syndrome presentation
Familial disorder with recurrent gross hematuria and proteinuria. Sensorineural deafness too.
Alport’s syndrome pathology
Alternating areas of thinned and thickened capillary loops with splitting of the GBM
When to suspect Alport’s syndrome?
Recurrent hematuria, sensorineural deafness, and FH of RF
Preferred treatment for UTIs
Oral Bactrim for uncomplicated cystitis
UCx for uncomplicated cystitis?
Not done
Muddy brown granular casts are from
ATN
RBC casts
Glomerulonephritis
WBC casts
interstitial nephritis and pyelonephritis
Fatty casts
Nephrotic syndrome
Broad and wazy casts
Chronic renal Failure
What causes diabetic glomerulosclerosis
Diabetic microangiopathy
Young black male with painless hematuria is
Sickle Cell Trait
ADPKD signs
HTN, hepatic cysts, intracranial berry aneurysms.
Hep B infection and nephrotic syndrome
Membranous glomerulonephritis
Why wouldn’t you be able to pee if you have BPH and pain
You can’t valsalva
Most common cause of acute bacterial prostatitis in old men
e.coli