Renal Urinary System part 1 Flashcards
Hyponatremia
x
cause
x
what is a cause?
CHF, cirrhosis
pathophys
x
how does it occur in context of CHF?
low cardiac output leads to decreased perfusion, which leads to increased ADH, leads to water reabsorption and dilutional hyponatremia
management
x
initial therapy for hyponateremia?
water intake restriction
if serum sodium is resistant to mainstay trx, what is another option?
vasopressin receptor antagonist (eg tolvaptan)
Euvolemic Hypo-osmolar Hyponatremia
x
cause
x
what is a cuase?
hypothyroidism
risk
x
what is a major cause of hypothyroidism?
postpartum thyroiditis
Evalutation of Hyponatremia
x
if serum osmols greater than 290, when what is the cause?
marked hyperglycemia, advanced renal failure
if serum osmols less than 290,and urine osmolality less than 100, urine sodium less than 25 , then what is the cause?
primary polydipsia, malnutrition (beer drinkers potomania)
if serum osmols less than 290,and urine osmolality less than100, and urine sodium greater than 25 when what is the cause?
volume depletion, CHF, cirrhosis
if serum osmols less than 290,and urine osmolality greater than 100, and urine sodium greater than 25 when what is the cause?
SIADH, adrenal insufficiency, hypothyroidism
HTN after Kidney Transplant
x
causes
x
what are other causes of transplant renal dysfunction?
rejection, calcineurin inhibitor toxicity, recurrent glomerular disease, obstruction, thrombotic microangiopathy
what is another immunotherapy cause of HTN after kidney transplant?
corticosteroids
Kidney transplant
x
complications
x
what are immediate long term complications of kidney transplant?
very low and very few (DVT, infxns)
in females, what do they have an increased risk of having after kidney donation after pregnancy?
gestational complications (fetal loss, preeclampsia, gestational diabetes, and gestational hypertension)
optimal kidney donor
x
who is an optimal kidney donor for a child?
living related donor with an identical blood type (donor must also be an adult capable of making informed decisions)
Living Kidney Donation
x
risks
x
what are risks of living kidney donation?
perioperative: mortality, hemorrhage, infection, thromboembolic events
long-term: ESRD, HTN
what are absolute contraindications to living kidney donation?
Inability to consent (age less than 18, intellectual
disability, untreated psychiatric disease)
Diabetes mellitus
Hypertension with end-organ dysfunction
BMI greater than 35 kg/m2
Malignancy
Analgesic Induced Nephropathy
x
Syx
x
what are syx of nephropathy?
worsening fatigue, nausea, malaise, bilateral pedal edema, flank pain radiating to groin
acute syx of nephropathy?
usually chronic, but can present with hematuria, pyuria, proteinuria, and renal colic
PE
x
what would you see on Physical Exam?
CVA tenderness
Dx
x
what does the UA show?
florid nephrotic range proteinuria, WBC count and casts, and no evidence of UTI
what does CMP show?
elevated Cr
what does CT non contrast show?
mild dilation of pelvicalyceal system
what would 24 hr urine protein show?
elevated protein
cause
x
what are the analgesic causes?
NSAIDs (reversible decline in GFR from inhibiting vasodilatory PG production)
what are other analgesic causes?
aspirin, phenacetin, acetaminophen, NSAIDs
risk
x
what are risks?
hx of chronic NSAID use, and new condition requiring further OTC meds
Post Strep Glomerulonephritis (PSGN)
x
Dx
x
UA would show?
RBC and RBC casts
what would be a good test to check post strep glomerulonephritis?
streptozyme test
what are other labs associated with PSGN?
renal insufficiency, nephritis, and low C3 complement levels.
SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion)
x
Dx
x
what would serum sodium measure?
low
what would serum osmols measure?
low (<275)
what would urine osmols measure?
high (>100)
what would urine sodium conc measure?
high (>40)
what would the volume state be for a person in SIADH?
euvolemic
cause
x
what would cause SIADH?
Pneumonia, Meds (SSRI, carbamazepine, valproic acid), CNS issues (stroke, hemorrhage, trauma), ectopic ADH secretion (eg Small cell lung cancer), pain and or nausea
stimuli for secretion of ADH
x
what are osmotic stimuli for ADH secretion?
serum osmolality >285 mOsm/kg H20
what are nonosmotic stimuli for ADH secretion?
Nausea Pain Physical or emotional stress Hypotension Hypovolemia Hypoxia Hypoglycemia
syx
x
what are syx of mild/ moderate hyponatremia?
nausea, forgetfullness
what are syx of severe hyponatremia?
seizures, coma
PE
x
how do you know someone is euvolemic?
mois mucous membranes, no edema, no JVD
management
x
how do you manage SIADH?
- mild to moderate hyponatremia=asyx: fluid restriction +/- salt tabs
- severe hyponatremia (<120mEq/L) = seizures, ; hypertonic 3% saline
Hypovolemic Hyponatremia
x
cause
x
what is the cause?
decreased solute intake
dx
x
what is the urine sodium levels?
low (<40) as kidneys attempt to retain as much salt as possible
Gross Hematuria
x
causes
x
what are renal causes ?
glomerulonephritis, infection
what are ureteral causes?
nephrolithiasis
what are bladder causes?
cystitis, malignancy
whata are urethral cuases?
urethritis, prostatitis
evaluation
x
what is the first step of evaluating gross hematuria?
ask if there is hx of trauma or suspected stone
if there is a hx of trauma or suspected stone, what do you get before a UA?
imaging CT or U/S
if there is no hx of trauma or suspected stone, what is the next step?
get a UA and Urine Culture
why do we first get a UA?
to evaluate infectious, glomerular, and extraglomerular causes
if UA shows infection , what do you do?
give Abx
if UA shows new proteinuria, RBC casts, what do you do?
evaluate for glomerular causes
if UA shows other causes (ie cancer), what do you get?
imaging CT , cystoscopy, urine cytology
management
x
how do you evaluate gross hematuria?
evaluate both upper and lower urinary tracts
to evaluate upper urinary tracts, what do you do?
CT urogram or U/S
to evaluate lower urinary tracts, what do you do?
cystoscopy
risk
x
what are high risks for urinary tract malignancy?
> 35 y.o , male, smoking hx, pelvic radiation , exposure to aniline dyes, chronic analgesic abuse, chemical exposure
Excercise induced Hematuria
x
cause
x
what is a causes of hematuria ?
strenuous excercise
what are other causes?
rhabdomyolysis, excercise induced hematuria, march hemoglobinuria from RBC trauma
dx
x
what are the dx findings on UA?
positive UA, absence of RBC casts (exclude glomerular cause)
how do you dx it?
by exclusion
management
x
what do you for it?
nothing, f/u UA in 1 week to ensure resolution
if it persists for >1 week, what do you do?
cystoscopy
Cystoscopy
x
is gross hematuria with no evidence of glomerular disease (no RBC casts or dysmorphic red cells) or infection an indication for cystoscopy?
yes
is microscopic hematuria with no evidence of glomerular disease (no RBC casts or dysmorphic red cells) or infection but increased risk of cancer an indication for cystoscopy?
yes
is recurrent UTI an indication for cystoscopy?
yes
is obstructive symptoms with suspicion for stricture, stone an indication for cystoscopy?
yes
is irritiative syx without urinary infection an indciation for cystoscopy?
yes
is abnormal bladder imaging or urine cytology an indication for cystoscopy?
yes
IgA Nephropathy
x
syx
x
what are the typical syx of IgA nephropathy?
hematuria following an acute upper respiratory infection (flu like syx, nasal drainage, throat pain)
pathophys
x
what is the usual pathophys?
deposition of IgA in the renal glomerulus
PE
x
what is the physical exam findings?
flank pain (secondary to stretching of the renal capsule)
Dx
x
what would you see in UA?
RBC casts, dysmorphic RBCs
management
x
what is the management of IgA nephropathy?
ACEi for HTN, fish oil
Acute Cystitis and Pyelonephritis in Non pregnant women
x
evaluation
x
what must you always get in young sexually active chilbearing women?
pregnancy test
uncomplicated cystitis in non pregnant women
x
cause
x
what is the common cause?
E coli, proteus mirabilis, klebsiella penumoniae
dx
x
when is urine culture indicated?
only if initial trx w abx fails
trx
x
what is the trx?
Nitrofurantoin for 5 days (avoid in suspected pyelonephritis or creatinine clearance <60 mL/min)
Trimethoprim-sulfamethoxazole for 3 days (avoid if local resistance rate >20%)
Fosfomycin single dose
Fluoroquinolones only if above options cannot be used
complicated cystitis in non pregnant women
x
define
x
what is the definition for complicated cystitis?
DM, pregnancy, renal failure, Urinary tract obstruction, indwelling catheter, urinary procedure (eg cystoscopy) , immuonsuppression, hospital acquired
dx
x
when is urine culture indicated?
prior to initiating therapy and adjust abx as needed
trx
x
what is the trx?
Fluoroquinolones (5-14 days),
extended-spectrum antibiotic (eg, ampicillin/gentamicin) for more severe cases
Pyelonephritis
x
risk
x
what are risk factors in pregnancy ?
smoking, pregestational DM, asyx bacteruria
dx
x
when is urine culture indicated?
prior to initiating therapy and adjust abx as needed
trx
x
what is the trx OP?
Fluoroquinolones (eg, ciprofloxacin, levofloxacin)
what is the trx inpatient?
Intravenous antibiotics (eg, fluoroquinolone, aminoglycoside ± ampicillin)
UTI antibiotics in pregnancy
x
what are the antibiotics recommended for UTI in pregnancy ?
nitrofurantoin, amoxicillin, amoxicillin-clavulanate, cephalexin, fosfomycin
what are the antibiotics contraindicated for UTI in pregnancy?
tetracylcines, fluoroquinolones, trimethoprim-sulfamethoxazole (NTD, cardiac defects, cleft palate, neonatal kernicterus), aminoglycosides (ie gentamicin)
Hypophosphatemia
x
risk
x
who is at risk of low phsophate?
chronic alcoholic
dx
x
what is important to note regarding serum phosphate levels?
chronic alcoholics can have frequent phosphate depletion even though serum phosphate levels may initially be normal
cause
x
what is a major cause of of hypophosphatemia in alcholics?
refeeding syndrome, especially if respiratory alkalosis, may lead to shift of phsophate intracellularly and a decrease serum phosphate
Complications
x
what is a common complication of hypophosphatemia in alcholics with underlying myopathy to begin with ?
rhabdomyolysis (new complaints of weakness)
pathophys
x
why do chronic alcholics have low phophate and why do they have get refeeding syndrome?
chronic depletion of phosphate secondary to low vit D and phosphate intake and decrease oral intake and diarrhea. Despite depletion of phosphate , you still have normal extracelluar phosphate levels, until patient is fed or given IV fluids with glucose and insulin, which shift phosophate intracellularly (in addition to a respiratory alkalosis which shifts phosphate into the cells)
UTI in children
x
risk factors
x
what are risk factors?
female sex, uncirumscribed male infants, vesicoureteral reflux, anatomic defects, dysfunctional voiding, constipation
syx
x
what are symptoms ?
dysuria, fever, suprapubic pain (cystitis) and/or flank/back pain (pyelonephritis)
what are syx of UTI in younger patients <2y.o. ?
poor feeding, irritability
dx
x
what are lab findings?
pyuria
what does urine culture show?
bacteriuria
management
x
what is the management of UTI in children?
antibiotic therapy
+/- renal U/S and voiding cystourethrogram
(in patients < 2 y.o. should get renal U/S
in patients >2 y.o. you get an isolated UTI do not require imaging )
why do you need a renal U/S in <24 month olds ?
to evaluate for hydronephrosis and ureteral dialtion
Recurrent UTIs
x
management
x
what is the indication for abx prophylaxis in young females with recurrent UTIs?
> = 2 UTIs in 6months or >=3 UTIs in 1 year
how often do you give prophylaxis ?
continuous or solely postictal
when would you order a non contrast CT?
if there is concerns for nephrolithiasis
what are behavioral interventions for recurrent UTIs?
postcoital voiding, increased intake of cranberry juice
Postoperative Urinary Retention
x
risk factors
x
what are risk factors for postoperative urinary retention?
>50 y.o, surgery >2 hours duration >750 cc intraop fluids regional anesthesia neurologic disease underlying bladder dysfunction previous pelvic surgery
PE
x
what are physical exam findings?
decreased urine output
abdominal distention
suprapubic pressure/pain
not passing gas
management
x
what is the management for postop urinary retention?
indwelling catheter
clean intermittent catheterization
pathophys
x
what is the pathophys of postop urinary retention?
anesthesia + IV fluids cause bladder stretch receptor dysfunction and decreased detrusor contractility
Urethral Diverticulum
x
pathophys
x
what is the pathophys of urethral diverticulum ?
herniation of urethral mucosa through the muscle wall into the surrounding tissue
syx
x
what are symmptoms of urethral diverticulum?
postvoid dribbling, dysuria, dyspareunia
PE
x
what do you see on pelvic exam?
anterior vaginal mass (i.e fullness of the anterior vaginal wall)
what happens when you examine the mass?
tender anterior wall vaginal mass that expresses bloody, purulent fluid
risk
x
what are risks of urethral diverticulum?
Urethral diverticula in women form due to repeated infection, inflammation, and trauma of the urethra from previous pelvic trauma (eg, vaginal delivery) or surgery.
dx
x
how do you dx urethral diverticulum?
UA, UCx, MRI pelvis, TVUS
trx
x
what are the trx of urethral diverticulum?
manual compression, needle aspiration, surgical repair
Vesicovaginal Fistula
x
dx
x
how do you dx of vesicovaginal fistula?
methylene blue instilled into the bladder- test is positive if vagina becomes blue after the dye is instilled in the bladder
Urinary Incontinence
x
risk
x
what are risk factors?
increased age, hx of multiple vag deliveries, obesity, vaginal atrophy, tobacco use, caffeine intake
Stress Incontinence
x
syx
x
what are the symptoms of stress incontinence?
leakage with coughing, sneezing, laughing, lifting
dx
x
how do you dx stress incontinence?
Q tip test- hypermobile urethra (>30 degree angle of movement)
trx
x
what is the trx of stress incontinence?
lifestyle modification, pelvic floor excercises, pessary, urethral sling surgery
Urge incontinence
x
syx
x
what are the symptoms of urge incontinence?
Sudden, overwhelming, or frequent need to urinate
trx
x
what is the trx of urge incontinence?
Lifestyle modification
Bladder training
Antimuscarinic medications
Overflow incontinence
x
syx
x
what are the symptoms of overflow incontinence?
Constant dribbling of urine, incomplete bladder emptying
dx
x
how do dx overflow incontinence?
PVR>200mL
trx
x
what is the trx of overflow incontinence?
Intermittent catheterization
Correct underlying etiology
Ureteral Stones (kidney stones)/nephrolithiasis
x
management
x
if stones <5 mm, what can you expect?
they will pass spontaneously
if stones 5-10mm, how do you manage ?
trial of medical therapy (gentle hydration, pain contorl, alpha blockers-tamsulosin) and don’t need hospital admission if syx are controlled
if stones >=10mm, persistent pain, acute renal failure, or signs of sepsis,then what do you do?
surgical removal of stones
abx are indicated in the presence of _____?
infection
trial of medical therapy (gentle hydration, pain contorl, alpha blockers) and don’t need hospital admission if syx are controlled in patients with ureteral stones for what size?
5-10mm
kidney stones that will spontaneously pass
<5mm
surgical removal of kidney stones indicated for?
if stones >=10mm, persistent pain, acute renal failure, or signs of sepsis,then what do you do?
patients with obstructing ureterolithiasis w infection, AKI, severe pain that have failed initial measurs require what?
decompression with percutaneous nephrostomy or ureteral stent placement.
Inpatient Ureteral Stones/nephrolithiasis
x
management
x
if symptomatic ureteral stone , and urosepsis and acute renal failure and complete obstruction present , what is the next step?
urology consult
if symptomatic ureteral stone , and there is no urosepsis and acute renal failure or complete obstruction present , what is the next step?
stone size
if symptomatic ureteral stone , and there is no urosepsis and acute renal failure or complete obstruction present , and stone size <10mm?
medical management (hydration, pain control, alpha blockers-tamsulosin, strain urine)
if symptomatic ureteral stone , and there is no urosepsis and acute renal failure or complete obstruction present , and stone size <10mm and after medical management doesn’t control or pass pain, what is next step?
urology consult
if symptomatic ureteral stone , and there is no urosepsis and acute renal failure or complete obstruction present , and stone size >=10mm?
urology consult
Renal Cell Carcinoma Module
x
syx
x
what are syx of Renal Cell Carcinoma?
profound fatigue and anorexia for the past few weeks, weight loss
risk
x
what are risks of Renal Cell Carcinoma?
smoking, drinking
ddx
x
what is the differential for fatigue, weight loss, and anorexia?
malignancy, infectious disease, autoimmune disease
workup
x
what does the work up for Renal Cell Carcinoma include?
anemia, CBC, FOBT, red cell indices, iron studies
what additional labs for Renal Cell Carcinoma that should be ordered?
BMP, LFTs, and UA
if your anemia workup for Renal Cell Carcinoma comes back showing nromocytic normochromic anemia with low serum iron, low TIBC, and elevated ferritin, what is the dx?
anemia of chronic disease
if you have anemia of chronic disease and the presence of hematuria on UA, what do you think about?
GU -malignancy (urinary tracts, kidney, prostate)
what is the preferred test for investigating suspected GU-malignancy?
abd CT and cytoscopy
dx
x
what syx make you suspect Renal Cell Carcinoma?
unexplained hematuria, flank pain, palpable flank mass
what does abdominal CT help show for Renal Cell Carcinoma?
provides presumptive dx and provides staging information
if renal mass on CT abd is seen without involvement of renal capsule, renal vein , or IVC, what stage is that Renal Cell Carcinoma
stage I renal cell cancer
management
x
if abd CT provides presumptive dx of Renal Cell Carcinoma, then what is next step?
- obtain CT chest for further staging information.
- bone scan if there is bone pain or elevated ALP
once you determine the stage based on Renal Cell Carcinoma of abdominal CT,chest CT, +/- bone scan , what is the next step?
- nephrectomy is preferred for isolated renal mass (diagnostic and therapeutic)
- biopsy preferred for supsected metastatic disease; further treatment dictated by result
therapy
x
what are next steps after dx of Renal Cell Carcinoma in the module?
NPO, IV NS 0.9%, onc consult, surg consult, PT, PTT/INR, blood type and cross match, IV cefazolin, nephrectomy, counseling (no smoking, no alcohol, cancer diagnosis)
Renal Cell Carcinoma (RCC)
x
risk
x
what are the risks of RCC?
cigarette smoking, obesity, HTN
syx
x
what are the syx of RCC?
flank pain, hematuria, palpable abdominal mass
association
x
what is the associated syndrome?
paraneoplastic syndrome (EPO production leading to erythrocytosis)
dx
x
what is the dx test to evlaute for RCC?
CT scan of abdomen
what would CT scan of RCC show?
enhancing mass with thickened, irregular septa
management
x
if renal mass isolated to renal capsule (stage 1), what is the trx?
parial nephrectomy
if renal mass extends through the renal capsule but not beyond Gerota’s fascia (stage II), what is the trx?
radical nephrectomy
if renal mass extends through renal capsule with invasion of major veins, abdominal lymph nodes and adrenal glands, (stage III)
radical nephrectomy, with chemo and immunotherapy
Hyperkalemia
x
cause
x
what are some causes of hyperkalemia?
NSAID use, renal failure, lisinopril use
dx
x
what are the progressive EKG changes you see with hyperkalemia?
peaked T waves, then subsequently prolongation of the PR interval and QRS complex, disappearance of P waves, and eventually sine wave
trx
x
what is most appropriate first line trx?
IV calcium gluconate
what are follow up trx options to reduce serum potassium?
beta agonist or combination of glucose and insulin
Calcium Homeostasis
x
transport
x
what are the 3 different ways calcium is transported in blood?
albumin bound calcium (45%), ionized calcium (40%), calcium bound to inorganic and organic anions (15%)
management
x
when evaluating hypocalcemia, what must you always look at?
serum albumin
how do you adjust for hypocalcemia in the hypoalbuminemia?
serum calcium concentration decreases by 0.8 mg/dL for every 1 g/dL decrease in serum albumin concentration.
Hypocalcemia
x
causes
x
what are causes of acute hypocalcemia?
neck surgery (parathyroidectomy), pancreatitis, sepsis, tumor lysis syndrome, acute alkalosis, chelation (blood citrate transfusion, EDTA, foscarnet)
packed RBCs are preserved and anticoagulated using sodium citrate (which contains calcium)
risk
x
who are at high risk of hypocalcemia?
liver or renal failure, hypothermia, shock
when can hypocalcemia occur?
immediately after surgery, after car accident with several fractures, where multiple transfusions required
pathophys
x
what is the pathophys of hypocalcemia in the context of citrate ?
as citrate binds ionized calcium , you get symptomatic calcium deficiency
also in situations with volume expansion and hypoalbuminemia
dx
x
what would serum calcium look like?
you can have normal serum calcium , though ionized calcium is low
syx
x
what are syx of hypocalcemia?
oral paresthesias, carpopedal spasm, tetany, seizures
PE
x
what are physical exam findings?
muscle cramps, chvostek (ipsilateral facial twitch with tapping) and trousseau (BP cuff contraction) signs , perioral paresthesias, hyperreflexia/tetany, seizures
trx
x
for mild acute hypocalcemia (corrected calcium of 7.5-8.5mg/dL), what is trx?
oral calcium citrate or carbonate
what is the best treatment for acute hypocalcemia?
IV calcium gluconate/chloride
Familial Hypocalciuric Hypercalcemia
x
epid
x
what is the inheritance pattern?
auto dominant
cause
x
what is the major cause of hypercalcemia?
inactivation of the calcium sensing receptor, so the normal suppression of PTH secretion when calcium levels are normal gets blocked, and you get increased reabsorption of calcium reabsorption in the renal tubules.
dx
x
what does labs show?
mild hypercalcemia
syx
x
what do syx show?
no clinical findings of symptoms
trx
x
what is the treatment?
nothing
Hypomagnesemia
x
syx
x
what is hypomagnesemia similar to?
mimics hypocalcemia
risk
x
what are the risks of hypomagnesemia?
alcoholism, prolonged NG suction or diarrhea, diuretic use
Nephrolithiasis in Pregnancy
x
epid
x
most commonly seen in which trimester?
2nd and 3rd trimester
risk
x
what are risk factors of pregnancy?
increasd calcium excretion, urinary stasis, and decreased bladder capacity
what are other risk factors?
obesity, hyperPTH, DM, IBS, hx of kidney stones outside pregnancy
syx
x
what are the syx of nephrolithiasis in pregnancy?
paroxysmal severe flank pain that radiates to the labia, n/v, hematuria, dysurai, pyuria
dx
x
what is the first like imaging in pregnancy?
renal and pelvic ultrasound to minimize fetal radiation exposure
if renal and pelvic ultrasound negative, what is next best test?
TVUS
if TVUS is also negative, but still high suspision for kidney stone, next step?
treat empirically for a stone and observe closely
-OR-
MRI urogram
-OR-
Low dose CT urogram (2nd and 3rd trimester only)
PKD (Polycystic Kidney Disease)
x
syx
x
what are syx of PKD?
hematuria and flank pain
dx
x
what does imaging show?
CT abdomen shows multiple bilateral kidney cysts that are round, thin walled nonenhancing and sharply demarcated
what genetic test do you test for?
PKD gene mutation
trx
x
what do you trx PKD with?
ACEi
Paralytic Ileus
x
syx
x
what are syx of paralytic ileus?
n/v, soft distended abdomen, decreased bowel sounds
PE
x
what are physical exam findings?
possible gaseous distension, reduced/absent bowel sounds
cause
x
what is a major cause of paralytic ileus?
recent surgery (hours to days), metabolic (eg hypokalemia), medication induced
risk
x
what is a risk for hypokalemia induced paralytic ileus
diuretic induced therapy
dx
x
do you see small bowel dilation typically?
yes
do you see large bowel dilation typically?
yes
trx
x
if hypokalemia is cause, what do you do?
IV potassium
Small Bowel Obstruction (SBO)
x
cause
x
what is the major cause of SBO?
prior surgery (weeks to years)
PE
x
what does exam look like?
distention, increased bowel sounds
dx
x
do you see small bowel dilation typically?
yes
do you see large bowel dilation typically?
no
Renovascular (Hypertension) HTN
x
epid
x
what is the most common cause of secondary HTN?
renovascular HTN
risk
x
who is at risk?
atherosclerotic disease elsewhere in the body, renal failure
syx
x
what are signs of renovascular HTN?
resistant HTN to multiple meds (3 drug regiment)
malignant HTN (with end organ damage)
onset of severe HTN (>180/120mmHg) after age 55
severe HTN with diffuse atherosclerosis
recurrent flash pulmonary edema with severe HTN
PE
x
what are physical exam findings?
abd bruits, asymmetric renal size (>1.5cm)
dx
x
how do you evaluate such patients?
renal duplex Doppler U/S or CT or MRA of renal arteries
what dx imaging studies should be avoided?
CT and gadolinium MR angiography, because of risk of contrast induced nephropathy and nephrogenic systemic fibrosis
what labs support renovascular HTN?
unexplained rise in serum Cr (>30%) after starting ACEi or ARBs
what imaging rsults support renovascular HTN?
unexplained atrophic kidney
Renal Artery Stenosis
x
cause
x
what is the cause?
RAAS
dx
x
marked increase in serum Cr after initiation of ACE i is highly suggestive of what?
Renal Artery Stenosis 2/2 renal transplant
risk
x
what is a big risk factor for causing Renal Artery Stenosis?
kidney transplant (improper surgical anastomosis)
Secondary Causes of Hypertension (HTN)
x
Conditions
Clinical clues/features
Renal parenchymal disease, Clinical clues/features?
Elevated serum creatinine Abnormal urinalysis (proteinuria, red blood cell casts)
Renovascular disease, Clinical clues/features?
Severe hypertension (≥180 mm Hg systolic and/or 120 mm Hg diastolic) after age 55
Possible recurrent flash pulmonary edema or resistant heart failure
Unexplained rise in serum creatinine Abdominal bruit
Primary aldosteronism, Clinical clues/features?
Easily provoked hypokalemia
Slight hypernatremia
Hypertension with adrenal incidentaloma
Pheochromocytoma, Clinical clues/features?
Paroxysmal elevated blood pressure with tachycardia
Pounding headaches, palpitations, diaphoresis
Hypertension with an adrenal incidentaloma
Cushing syndrome, Clinical clues/features?
Central obesity,
facial plethora
Proximal muscle weakness,
abdominal striae
Ecchymosis,
amenorrhea/erectile dysfunction
Hypertension with adrenal incidentaloma
Hypothyroidism, Clinical clues/features?
Fatigue,
dry skin,
cold intolerance
Constipation,
weight gain,
bradycardia
Primary hyperparathyroidism, Clinical clues/features?
Hypercalcemia (polyuria, polydipsia)
Kidney stones
Neuropsychiatric presentations (confusion, depression, psychosis)
Coarctation of the aorta, Clinical clues/features?
Differential hypertension with brachial-femoral pulse delay
Mixed Cryoglobulinemia Syndrome
x
triggers
x
what is the disease that triggers typically mixed cryoglobulinemia syndrome?
hep C virus infection
what are other triggers?
hep B, HIV, malignancy, rheumatological disease
syx
x
what is the usual triad?
palpable purpura, fatigue, and arthralgias
what are other symptoms?
peripheral neuropathy, systemic symptoms, glomerulonephritis with renal insufficiency
dx
x
how is the diagnosis made?
measuring serum cryoglobulin levels
what are other lab findings in mixed cryoglobulinemia syndrome?
elevated RF, hypocomplementemia
pathohpys
x
how does mixed cryoglobulinemia syndrome occur?
is a vasculitis due to the deposition of immune complexes (polyclonal IgG and IgM rheumatoid factor) within the vascular wall of small- and medium-size vessels
complications
x
what are other complications?
glomerulonephritis (RBC, RBC casts, proteinuria)
trx
x
what is the best intial trx to stabilize end organ damage?
immunosuppressive therapy (corticosteroid and rituximab)
what is the best long term trx if they have underlying hep C?
antiviral trx
Granulomatosis with Polyangitis (Wegners)
x
syx
x
what are the usual syx?
palpable purpura, fatigue, and arthralgias, respiratory tract syx (sinusisitis, rhinorrhea)
what are other symptoms?
peripheral neuropathy, systemic symptoms, glomerulonephritis with renal insufficiency
dx
x
what is the dx test of choice?
cANCA
how do you distinguish it from Mixed Cryoglobulinemia Syndrome?
normal or elevated complement levels and respiratory tract syx (sinusisitis, rhinorrhea)
Benign Prostatic Hyperplasia (BPH)
x
syx
x
what are syx of BPH?
lower urinary tract syx (hesistancy , weak stream)
risk
x
who is at risk of BPH?
> 50 y.o. male,
who is at risk of acute urinary retention?
bladder/urethral infection, genitourinary trauma, and use of certain meds (eg baclofen, anticholinergics)
management
x
what is the most effective immediate management?
immediate bladder decompression-
first line: urethral catheter first
second line: suprapubic catheter
Dx
x
what would labs show?
elevated cr
PE
x
what does PE show?
abd tenderness, and suprapubic fullness
Posterior Urethral Valve (PUV)
x
epid
x
who does it occur in ?
exclusively in males
define
x
what is it?
most common cause of obstructive uropathy, at level of urethra (congenital urethral membrane)
dx
x
how are they generally diagnosed?
prenatally
what are the hallmark features?
thickening and distention of the bladder and dilation of the proximal urinary system , bilateral hydronephrosis, oligohydraminos
what is a highly specific feature?
antenatal U/S showing dilated bladder
what is the best way to confirm PUV?
VCUG (voiding cystourethrogram)
complications
x
if the obstruction is severe, oligohydraminos can occur leading to?
potter sequence (pulm hypoplasia, flattened facies)
trx
x
what is the best next step?
foley catheter to temporarily relieve the obstruction
what is definitive trx?
cystoscopy and ablation of valve
Anemia in ESRD
x
cause
x
what isthe cause of anemia in ESRD?
decreased EPO, iron deficiency
evaluation
x
what is the initial step in evaluation of anemia in ESRD?
check B12, folate, fecal occult blood, iron studies (ferritin, TIBC, serum iron, transferrin saturation), reticulocyte count
if iron deficiency is present, what do you do?
iron supplementation
if no improvement after iron supplementation, then what?
ESA (erythropoietin stimulating agent ) therapy
if there is an abnormality other than iron deficiency, then what do you do?
treat as indicated,
if no improvement after trying to treat abnormality appropriately, then what?
ESA (erythropoietin stimulating agent ) therapy
CKD/ESRD and iron deficiency anemia
x
complications
x
advanced chronic kidney disease or end-stage renal disease patients commonly develop what?
hypoproliferative, normocytic, normochromic anemia /iron deficiency anemia
cause
x
what is the cause of CKD/ESRD leading to hypoproliferative, normocytic, normochromic anemia ?
underproduction of erythropoietin by the failing kidneys.
management
x
why should ESRD patients get their iron stores checked?
Vigorous hematopoiesis after administration of erythropoiesis-stimulating agents (ESAs) can lead to rapid depletion of iron stores; therefore, all patients who require ESAs (eg, many CKD patients with hemoglobin <10 g/dL) should have iron levels checked prior to initiation of EPO and at scheduled intervals while on therapy
Contrast Induced Nephropathy
x
risk factors
x
what are risk factors of contrast induced nephropathy?
> 75y.o, , CKD (diabetic nephropathy), reduced renal perfusion (eg hypotension), high contrast load
prevention
x
how do you prevent contrast induced nephropathy?
- periprocedural saline hydration (before and after procedure)
- use lowest volume of contrast agent possible
- hold NSAID drugs
cause
x
what causes contrast induced nephropathy?
contrast induced renal vasoconstriction
Primary Nocturnal Enuresis
x
define
x
what is it?
urinary incontinence in >=5y.o. w/o dysuria and daytime incontinence
management
x
what is first step when managing primary nocturnal enuresis?
screening UA (exclude infection, Diabetes Mellitus-glucosuria, or Diabetes Insipidus-low specific gravity on first morning void)
what are intial treatment options for treating primary nocturnal enuresis?
bhv modifications (eg limiting evening fluid intake, avoid sugary/caffeinated beverages, void before bedtime, institute reward system-gold star chart)
motivational therapy
what is first line therapy?
enuresis alarms (best long term outcome-low relapse rates)
what is second line therapy?
desmopressin therapy
what can be used in refractory cases?
TCA’s (imipramine)
