renal treatment/dx Flashcards
dx SIADH
Serum osmolality < 280 mOsm/kg (hypotonic).
■ Urine osmolality > 100 mOsm/kg in the setting of serum hypoosmolarity
without a physiologic reason for ↑ ADH (eg, congestive heart failure, cir-
rhosis, hypovolemia).
■ Urinary sodium level often ≥ 20 mEq/L.
tx SIADH
Explore and address the underlying cause.
■ Best initial treatment: Restrict fluid.
■ Persistent or symptomatic hyponatremia (< 120 mEq/L): IV hypertonic
saline therapy.
■ Severe SIADH: ADH antagonists (eg, tolvaptan, conivaptan).
■ Chronic SIADH: Demeclocycline.
SIADH CAUSING DRUGS
Carbamazepine, Cyclophosphamide, SSRIs
calcium correction for albumin formula
0.8( normal albumin- measured albumin) + measured calcium
normal albumin 4.0
hypo albumin may cause false low ca+ levels
increase pH –> affinity of albumin (negative charge) to bind Ca2+ hypocalcemia acidosis decrease AB-bind H+
every reduction of albumin by 1 reduces ca+ by 0.8
acute hypercalcemia treatment t
0.9% saline + loop diuretic
diarrhea
vomiting
diarrhea - loss of HCO3 and K+
vomiting - loss of HCL and then RAAS compensates worse metabolic alkalosis and causes hypokalemia
hypokalemia ECG
T-wave flattening, U waves (an additional wave after the T wave), and ST-segment depression, leading to AV block and cardiac arrest
hypo K treatment
Treat the underlying disorder. hypomag can cause hypokalemia
■ Oral and/or IV K+ repletion. Oral is the preferred route for safety pur-
poses. If IV is necessary, a continuous rate of K+ as an additive is preferred over an IV K+ bolus. Reserve IV boluses for symptomatic hypokalemia or ECG changes. Do not exceed 20 mEq/L/h.
■ Replace magnesium, as this deficiency makes K+ repletion more difficult.
hypo MG most common in
Alcoholics are the most common patient population with hypomagnesemia.
Mg2+ (low levels can induce PTH resistance)
most accurate test for hypocalcemia
ECG changes
- Most accurate test: Ionized Ca2+ and PTH.
2. prolong QT - 3 phase decrease ca enter
hypo Ca+ treatment
Treat the underlying disorder.
administer oral calcium supplements; give oral
and IV calcium for severe symptoms or signs.
Ensure magnesium repletion.
hyperkalemia tx
C BIG K
Calcium chloride or gluconate (intravenous)
heart > 6.5
Bicarbonate, β2-agonists
Insulin + Glucose
Kayexalate (sodium polystyrene sulfonate)
diuretics
hyperkalemia dx
Diagnosis
■ Confirm hyperkalemia with a repeat blood draw for suspected spurious results. In the setting of extreme leukocytosis or thrombocytosis, check plasma K+.
spurious- blood hemolysis, fist clenching
■ Other work-up: ECG to evaluate for cardiac complications. ECG findings include tall, peaked T waves; a wide QRS; PR prolongation; and loss of P waves (see Figure 2.16-4). Can progress to sine waves, ventricular dys- rhythmias, and cardiac arrest.
If hypokalemia is not responding to K+ repletion
check magnesium levels.
hypo Mg treatment
Tetany, torsades de pointes,
trEatmEnt
■ Generally most causes respond to IV and/or oral supplements, depending on severity.
■ Hypokalemia and hypocalcemia will not correct without magnesium correction.
hypvolemic hypernatremia
if hypovolemic with unstable vital signs, use isotonic 0.9%
Use isotonic 0.9% NaCl until the patient is euvolemic, even with stable vital signs.
normal volume and asymptomatic
If normal volume status and asymptomatic, can treat with D5W, 0.45% NaCl or enteral fluids.
hypervolemic hypernatremia
with a combination of diuretics and D5W to remove excess Na.
hypernatremia determine
determine free water deficits
determine rate of replacement
Determine free water deficit. Water deficit = Total body water × ([serum Na/140] − 1).
■ Total body water (TBW) is ± 60% of lean body weight.
■ Replace with D5W, 0.45% NaCl, or enteral water.
Correction of chronic hypernatremia (> 48 hours) should be accomplished gradually over 48–72 hours (≤ 0.5 mEq/L/h) to prevent neurologic damage secondary to cerebral edema.
hypernatremia determine
determine rate of replacement
Correction of chronic hypernatremia (> 48 hours) should be accomplished gradually over 48–72 hours (≤ 0.5 mEq/L/h) to prevent neurologic damage secondary to cerebral edema.
hypervolemic and euvolemic hyponatremia x
Treat hyponatremia from hypervolemic and euvolemic etiologies with water restriction ± diuretics.
hypovolemic hyponatremia tx
replete with NS
sever hyponatremia range or symptomatic and treatment
If severe hyponatremia (Na < 120 mEq/L), con- sider 3% hypertonic saline, particularly if symptomatic.
chronic hyponatremia def and tx
Correct chronic hyponatremia (> 72 hours’ duration) slowly (< 8−10 mEq/L/day) to prevent osmotic demyelination syndrome (symptoms include paraparesis/quadriparesis, dysarthria, and coma)
indication for urgent dialysis
AEIOU Acidosis Electrolyte abnormalities (hyperkalemia) Ingestions (salicylates, theophylline, methanol, barbiturates, lithium, ethylene glycol) Overload (fluid) Uremic symptoms (pericarditis, encephalopathy, bleeding, nausea, pruritus, myoclonus)
increase anion gap
> 12 MUDPILES: Methanol (formic acid) Uremia- NH4 urine production Diabetic ketoacidosis Propylene glycol Iron tablets or INH Lactic acidosis Ethylene glycol (oxalic acid) Salicylates (late)
normal anion gap
normal 8-12 artificial nutrients
HARDASS: Hyperalimentation( artificial nutrients) Addison disease Renal tubular acidosis Diarrhea Acetazolamide Spironolactone Saline infusion
osmolar gap increase
Both present with ↑ osmolal gap (Measured osmolality-calculated osmolality > 10 mOsmol/L)
chloride resistant metabolic alkalosis
mineral chloride >20 mEq /per day urine
not corrected with saline
ECF expansion
primary hypaldo, batter, gietlamn
chorlide sensitive MA
< 20 cholride urine
corrected with saline, ECF loss
thiazide, loop, vomiting,
HCO3– > 28 mEq/L >7.45 ph
metabolic alkalosis
type II RTA causes
Multiple myeloma, amyloidosis, all other causes of Fanconi syndrome (eg genetic and acquired), aminoglycosides, ifosfamide, cisplatin, acetazolamide
type II RTA tx
sodium and K+ bicarbonate supplementation
type I RTA cause
Autoimmune disorders, hypercalciuria, amphotericin B, ifosfamide, genetic disorders
type I RTA treatment
K+ bicarbonate supplementation
fanconi syndrome
Wilson disease, tyrosinemia, glycogen storage disease), ischemia, multiple myeloma, nephrotoxins/drugs (eg, ifosfamide, cisplatin, expired tetracyclines), lead poisoning
prerenal failure and increase ECF
IV fluids will not help hepatorenal syndrome, nephrotic syndrome, or CHF, or other causes of increased total body volume
postrenal failure
post- void residual > 50 mL
metformin C/I
septic patients or those with renal or hepatic failure, because it can worsen the metabolic acidosis.
CRF
erythropoietin analongues
ace and arbs
Oral phosphate binders (calcium acetate, calcium carbonate, sevelamer, lanthanum) and calcitriol (1,25-OH vitamin D) for renal osteodystrophy.
Use desmopressin in cases of abnormal bleeding (complication of uremia).
■ Renal replacement therapy options include hemodialysis, peritoneal dialy- sis, and renal transplantation.
nephritic tx
If present, treat hypertension, fluid overload, with salt restriction, RAAS blockade, +/− diuretics.
nephrotic thrombosis most common
membranous b.c
antithrombin III, protein C, and protein S in urine.
Spike-and-dome” appearance caused by granular deposits of IgG and C3
membranous
Nodular glomerulosclerosis
amyloid
nephrotic dx
proteinuria (≥ 3.5 g/day) lipiduria (Maltese crosses signify- ing lipids on microscopic urine exam).
spot protein-to-creatinine ratio rather than 24-hour urine. Cutoff for nephrotic syndrome is 2.0 mg/mg on this ratio.
↓ albumin (< 3 g/dL) and hyperlipidemia.
work-up for 2° causes.
■ Renal biopsy diagnose the underlying
etiology.
nephrotic tx
ace/arbs for hypertension
salt restriction
Vaccinate with 23-polyvalent pneumococcus vaccine (PPV23) b/c immunodeficiency
renal stone treatment
Best initial treatment: Hydration and analgesia.
■ α1-receptor blockers (eg, tamsulosin) and calcium channel blockers (eg,
nifedipine) reduce ureteral spasm and facilitate stone passage of ureteral
stone < 10 mm, reducing the need for analgesics.
■ Treatment varies according to the size and diameter of the stone:
■ < 5 mm: May pass spontaneously.
■ < 10 mm: Higher rate of spontaneous passage with α-blocker or cal-
cium channel blocker therapy.
■ 5–20 mm: May be treated with shock wave lithotripsy or ureteroscopy.
■ > 20 mm: percutaneous nephrolithotomy.
■ Best initial treatment: Hydration and analgesia.
calcium stone prevention
Dietary changes to prevent calcium stones include ↑ fluid intake (most important), normal calcium intake (RDA recommended intake), and ↓ sodium intake. If caused by hyperoxaluria, then ↓ oxalate intake.
APCKD
ace and arbs
hydronephrisis neurogenic bladder
starting a clean intermittent catheterization regimen for bladder emptying.
hydronephrosis causes
ureteropelvic junction but may also be at ureterovesicular junction (at the insertion into the bladder) or at the bladder outlet (eg from “posterior urethral valves”)
neurogenic bladder (spinal cord injuries), tumors, aortic aneurysms, or renal calculi.
treatment urethral obstruction vs ureter obstruction
Ureteral stent placement across the obstructed area of the urinary tract and/or percutaneous nephrostomy tube placement to relieve pressure may be appropriate if the urinary outflow tract is not sufficiently cleared of obstruction. Foley or suprapubic catheters may be required for lower uri- nary tract obstruction (eg, BPH).
- ⊕ Prehn sign ↑ blood flow to teste
- ⊝ Prehn sign in torsion ↓ blood flow in torsion
- absent cremaster reflex, N/v
- bag of worms”
- transluminates vs doesn’t
- epididymitis, decrease pain with scotal elevation
- testicular torsion
- testicular torsion
- variocele
- varociele no translumination vs hydrocele + translation
- Hydrocele
- Varicocele: May need surgery if large or symptomatic.
- Epididymitis and acute prostatitis
- Testicular torsion
- resolve within 12 months. not resolve should be removed surgically because of risk for inguinal hernia.
2.May need surgery if large or symptomatic.
3.Antibiotics (ceftriaxone, doxycycline,
fluoroquinolones)
4.Immediate surgery (< 6 hours) to salvage testis. Attempt manual detorsion only if surgery is unavailable or if it will not delay surgery. Orchiopexy of both testes to prevent future torsion.
overflow incontinence dz causes, s/s, dx tx
- Associated with polyuria (eg, diabetes), bladder outlet obstruction (eg, BPH), neurogenic bladder (eg, MS)
- Constant leakage
- post-void residual (urinary retention) on catheterization or ultrasound.
- cholinergic agents, intermittent catheterization, sacral nerve stimulation PSN
urge incontinence dz causes, s/s, dx tx
- Older age, detrusor hyperactivity (eg, spinal cord injury)
- Sudden need to urinate fol- lowed closely by leakage
- Topical estrogen Antimuscarinics or mirabegron
stress incontince tx
Lifestyle modifications and pelvic floor exercises (for all types of incontinence)
Topical estrogen
Pessary
Surgery (eg, midurethral sling)
BPH location of enlargement
BPH most commonly occurs in the central (periurethral) zone of the prostate and may not be detected on DRE.
BPH r/o
Obtain a UA and urine culture to rule out infection and hematuria.
BPH
- best initial therapy
- best next step
- recurrent UTI, bladder stones or Renal insufficiency
■ Best initial treatment: α-blockers (eg, tamsulosin, terazosin), which
relax smooth muscle in the prostate and bladder neck.
■ Next best treatment: 5α-reductase inhibitors (eg, finasteride), which
inhibit the production of dihydrotestosterone.
■ Transurethral resection of the prostate (TURP) or open prostatectomy is
prostate cancer
most accurate test
findings on DRE
type of bone lesions
1.DRE may reveal a palpable nodule or an area of induration
2. Suggested by clinical findings and/or a markedly ↑ PSA (> 4 ng/mL).
■ Most accurate test: Ultrasound-guided transrectal biopsy.
■ Tumors are graded by the Gleason histologic system, which sums the scores
(from 1 to 5) of the two most dysplastic samples (10 is the highest grade).
■ Look for metastases with CT of the abdomen/pelvis and bone scan (meta-
static lesions show an osteoblastic or ↑ bone density).
prostate cancer screening
- annual DRE and/or PSA testing starting at 50 years
- Screening should begin earlier in African-American men and in those with a first-degree relative with prostate cancer.
prostate treatment
Watchful waiting may be the best approach for elderly patients with low- grade tumors, as many cases of prostate cancer are slow to progress.
■ Radical prostatectomy is associated with ↑ risk for incontinence and/or ED. ■ Radiation therapy (eg, brachytherapy or external beam) is associated with
↑ risk for radiation proctitis and GI symptoms.
■ PSA, while controversial as a screening test, is used to follow a patient’s
posttreatment to evaluate for disease recurrence.
■ Treat metastatic disease with androgen ablation (eg, gonadotropin-releasing
hormone agonists, orchiectomy, flutamide) and chemotherapy.
■ Radiation therapy is useful to manage bone pain from metastases after
androgen ablation.
bladder cancer s/s
Gross, painless hematuria is the most common presenting symptom. Ter- minal hematuria (end of voiding) suggests bleeding from bladder.
bladder cancer dx
Screening is not recommended.
■ Cystoscopy with biopsy is diagnostic and is recommended in the evalua-
tion of older adults to rule out malignancy.
■ UA often shows hematuria (macro- or microscopic).
■ Cytology may show dysplastic cells.
■ MRI, CT, and bone scan are important tools with which to define inva-
sion and metastases.
The next best step for diagnosis in
an adult patient with unexplained hematuria is cystoscopy
to evaluate for bladder cancer
In a middle-aged smoker with a left-sided varicocele,
think renal cell carcinoma!
renal cell carcinoma RBC effect
Anemia is common at presentation, but polycythemia caused by ↑ erythro- poietin production can be seen in 5–10% of patients.
Diagnosis
testicular tumor treatment
Radical orchiectomy and classify into seminoma or nonseminomatous germ cell tumor (NSGCT).
■ Seminoma: Radiation therapy for low-stage disease.
■ NSGCT: Retroperitoneal lymph node dissection for low-stage disease.
■ Platinum-based chemotherapy is used for advanced disease of either type.
1.Uncomplicated UTI
Complicated UTI
pregnant
Urosepsis:
- outpatient basis with PO TMP-SMX or a fluoroquinolone for 3 days, or nitrofurantoin for 5 days. The use of fluo- roquinolones should be reserved for severe symptoms in light of resistance and MRSA selection and risk for C difficile infectio
- (urinary obstruction, UTI in men, renal transplant, catheters, instrumentation): Administer the same antibiotics as above, but for 7–14 days.
- reat asymptomatic bacteriuria or symptomatic UTI with nitrofurantoin, oral cephalosporin, or amoxicillin for 3–7 days. Confirm clearance with a posttreatment urine culture.
Prostatiti dx tx c/i
prostate tenderness on exam. Urethral catheterization and prostate massage are highly contraindicated because they increase the likelihood of bacteremia.
Treat with trimethoprim/ sulfamethoxazole (TMP/SMX) or ciprofloxacin for 6 weeks
pyelonephritis dx
UA and culture: Results are similar to those of cystitis, but with WBC casts. Send blood cultures to rule out urosepsis.
■ CBC: Reveals leukocytosis.
■ Imaging: In general, imaging is not necessary. Patients who relapse or do
not respond to therapy within 48–72 hours should be evaluated by ultra- sound or CT for obstruction, abscess, and other complications.
pyelonephritis treatment
■ For mild cases, patients may be treated on an outpatient basis for 7–14 days.
■ Best initial treatment: Fluoroquinolones. Encourage ↑ PO fluids, and
monitor closely.
■ Admit and administer IV antibiotics to patients who have serious medical
complications or systemic symptoms, are pregnant, present with severe nausea and vomiting, or have suspected bacteremia. Fluoroquinolones, third- or fourth-generation cephalosporins, β-lactam/β-lactamase inhibi- tors, and carbapenem can be used depending on disease severity.
■ Abscesses ≥ 3 cm should be drained and cultured.
Mixed cryoglobulinemia presents with
palpable purpura, arthralgias, nephritic/ nephrotic syndrome, low C3, and positive HCV.
membranoproliferative - renal failure
- seminoma
- yolk sac
- choriocarcinoma
- embryonal carcinoma
- fried egg, radiosensitive, ALP
- primitive glomeruli AFP
- metasis lungs, hCG ( hyperthyroidism gynecomastia
- painful necrosis hCG
NGCT
- leydig cell
- sertoli cell
- testicular lymphoma
- reink crystals- androgens, estrogens precious puberty, gynectiomia
- nothing
- metastatic most common old men lymphmoa
