Renal & Urology 🍆 Flashcards
Lactic acidosis following tonic clonic seizure…. tx
Since it is usually transient, observe and repeat labs in 2 hours
Managment for patient with posterior urethral injury
Retrograde urethrography first. Then catheterise etc.
Septic shock Tx overview
Focus on finding and treating cause. But do fluid resus, then pressors if that doesn’t work out
Renin and Aldo levels in hypovolemia. And ADH Levels
All elevated. Recall why?? This also means we get low Na in hypovolemia often
Signs that a hematuria is glomerular origin, not lower UT
Proetineuria, brown (rather than pink red), Cr elevation etc.
How to confirm a Dx of renal veing thrombosis
CTA or MRS
How to treat renal vein thrombosis. Given if AKI present or not
AKI present: thrombolysis
No AKI: anticoag
Hyponatremia due to SIADH Tx
Initially do fluid restriction with or without salt tabs. Can give demeclocycline if it doesn’t work. If very severe and have neuro signs…. Give hypertonic saline
PUV dx
Do US first, then voiding cystourethrogram, then cystoscope to confirm and ablate the PUV
Rhabdomyolysis can be due to electrical injury? Why? Tx to prevent?
Bone electrical resistance is high, meaning heat is generated internally, killing muscle. Give IV fluid aggressively
When dealing with hypercalcemia in the setting of potential malignancy, order what mainly
PTHrP, CXR, whole body bone scan
Why is pregnancy a risk for pyeloneph
increased progesterone levels cause smooth muscle relaxation and ureteral dilation. Because
of these physiologic changes, pregnant women with untreated ASB are at increased risk for acute pyelonephritis
When tx’ing UTI in preg, what do we do after
As a test of cure, a repeat urine culture is performed after antibiotic treatment due to the risk of persistent or recurrent bacteriuria.
Membranous nephropathy vs minimal change…
Minimal change is more a acute
1° vs 2° membranous nephropathy… which is more adult and which is children
Primary more in adults… so if a child has it, assume secondary causes
Cause of edema in nephritic vs nephrotic. MoA, which causes pulmonary edema
Nephrotic is due low albumin, and doesn’t cause pulmonary edema (since fenestrations are large enough to allow albumin equil across the vessels). Where as nephritic will cause pulmonary edema and is due decreased GFR causing huge hydrostatic pressure
When do you reassure in bed wetting in paeds
No other abnormalities, less than 5years old
Extrarenal issues of PCKD
Cerebral aneurysms
• Hepatic & pancreatic cysts
• Mitral valve prolapse, aortic regurgitation
• Colonic diverticulosis
• Ventral & inguinal hernias
Risk factors for renal veing thrombosis
Hypercoagulability
• Nephrotic syndrome
o Malignancy (particularly renal)
• OCP
• Volume depletion (infants)
Trauma
Dx of renal vein thrombosis and Tx?
CT or MR angiography
• Renal venography
Anticoagulation
• Thrombolysis/thrombectomy (if AKI present)
We all know the main CVD risk factors, but what other aspects of chronic kidney disease/dialysis increases risk. Name 3
Anemia of chronic kidney disease
• Vascular calcifications (1 phosphorus, 1 calcium)
Oxidative stress related to uremia and dialysis
3 differentials for renal colic not identifying anything on US OR X-ray
- Radiolucent stones (uric acid stones, xanthine stones)
- Small calcium stones (<1-3 mm in diameter)
- Nonstone ureteral obstruction (eg, blood clot, tumor)
Other than UTI, what can cause positive leuk esterase on urinalysis’s
Interstitial nephritis
Dx sign of posterior urethral injury, on which modality? Why before catheter
Extravasation of contrast
om the urethra is diagnostic of urethral injury. Urethrography should precede any attempts at urethral (eg, Foley)
atheterization because it can worsen the injury, potentially converting a partial urethral tear into a complete urethral
Iceration
Main causes of….
anterior urethral injury
posterior urethral injury
straddle-type falls or direct blows
anterior urethral injury
pelvic fractures
most often from motor vehicle accidents
posterior urethral injury
Post void residuals limits (for men and women)
, ≤150 mL in women, ≤50 mL in men).
Main three bac causing interstitial nephritis
Legionella, Mycobacterium tuberculosis, Streptococcus).
ECG changes for hyperkalemia…. Name as much as poss
If uti presents with blood, do we need to do anything extra in followup?
Urinalysis should be repeated a few weeks after completion of antibiotics for patients initially presenting with blood in the urine to ensure resolution of hematuria after UTI treatment; a UTI without initial hematuria can typically be followed clinically for resolution of symptoms
What med can be given to treat hypervolemia and met alk
Acetazolamide, a diuretic that inhibits proximal renal bicarbonate reabsorption, may be used in patients with hypervolemia
and metabolic alkalosis.
Why is IV fluids very helpful for vomiting
In vom, we get met alk and BP drop (which worsens the contraction alkalosis). intravenous fluids (such as normal saline) removes the stimulus for RAAS activation so helps the BP and the alkalosis
What can happen to the diurnal variation in blood pressure in DM
IT can disappear
Waxy casts and broad casts are seen in which disease
CKD
Can transplanted kidneys have RAS
it can occur in patients with a transplanted kidney, and is commonly associated with operative abnormalities (eg, trauma during organ procurement, abnormal suture placement), occurring within two years
Three main symptoms of renal A stenosis
Abdominal bruit, HTN, flash pulmonary edema
Most common occult infx location cause in infants
UTI, So do urine tests
If need to do urine tests on infants prior to toilet training… do what
Catheterise to get urine sample
initial treatment of symptomatic hypovolemic hypernatremia
s restore circulatory volume and
tissue perfusion by emergency fluid resuscitation. NS
How does PCKD cAUSE HTN
Hypertension is a typical early disease manifestation
that results from localized renal ischemia with increased renin secretion.
Can you explain the link between ADH and PCKD
In effect, a mild nephrogenic diabetes insipidus is created in PCKD, with resulting increased circulating vasopressin levels. So vaptans can help reduce cyct growth
What ocular issue do we see in alports
Anterior lenticonus (lens protrusion)
Vit C good or bad for calcium stones
Increased vitamin C intake also promotes hyperoxaluria.
High potassium good or bad for calcium stones
A high-potassium diet decreases urinary calcium excretion. Foods rich in potassium enhance urinary citrate excretion (likely from urinary alkalization), forming soluble calcium citrate and thereby preventing stone formation.
How does low sodium diet help Ca stones
Increased sodium intake enhances calcium excretion (hypercalciuria), and low sodium intake promotes sodium and calcium reabsorption through its effect on the medullary
concentration gradient.
Risk factors for post partum urine retention
Primiparity
• Regional neuraxial anesthesia
• Operative vaginal delivery
• Perineal injury
• Cesarean delivery
Generally when to do suprapubic catheter
If need to catheter and it’s CI to do urethral.
What would be considered normal urine outPut for neonates
1 or more wet diaper in 24hr
Neonatal AKI sus, first invx?
Renal and UT US. need to rule out intra or post renal causes before giving fluid bolus
Most commons symptom in FMD
Recurrent headache
Recall strange symptom in FMD
SUBAURICULAR bruit (pulsatile tinnitus ). Due to involvement of internal carotid
Difference in carotid involvement in carotid artery stenosis from atherosclerosis, and FMD
Atherosclerosis involves carotid bulb, FMD involves internal carotid
Analgesic nephropathy, what is it caused by, who is it high in, and how does it present
Analgesic nephropathy is the most common form of drug-induced chronic renal failure. It accounts for 3-5% of end stage renal disease in the USA, and is most commonly seen in females (peak at age 50-55 years) who habitually use combined analgesics (eg, aspirin and naproxen).
Can present as renal papillary necrosis or chronic tubointerstitial nephritis
Why is Cl high in NAGMA
Because HCO3 and chloride (CI-) are the predominant anions in the body, the loss of HCO3, increases serum CI to maintain an electronegative balance. Due to this relationship, NAGMA is also referred to as hyperchloremic acidosis.
If suspect glomerular hematuria… what invx are good
Compliment, FBC, Cr
General mx of asymptomatic hematuria microscopic
asymptomatic microscopic hematuria may be followed by serial urinalyses
Can Cr be high or low In DM NEPHROPATHY
For example, creatinine clearance can be elevated in early DN (due to glomerular hyperfiltration), it can also be normal even in the setting of MIA. Then clearance can be low later on.
Recall strange diagram of diabetic nephropathy… in the different stages.
What kind of voiding and almost UTI symptoms can bladder cancer cause and why?
• Voiding symptoms:
Tumors often protrude into the bladder and reduce bladder volume or cause detrusor
overactivity, leading to subacute/chronic voiding symptoms such as dysuria, frequency, and urgency. Although bladder cancer is often associated with painless hematuria (no pain during micturition), some patients with bladder cancer have dysuria as part of their voiding symptoms.
• Suprapubic pain:
This usually indicates a more advanced tumor that has penetrated the muscle and invaded the
surrounding soft tissue or nerves. Urinalysis is generally the first test of choice to rule out UTI in these cases
Drugs causing rhabdo
Direct myotoxicity
Statins, fibrates
• Colchicine
• Ethanol
• Cocaine
Vasoconstrictiveischemia
• Cocaine
• Amphetamines
Prolonged immobilization
(compression ischemia)
• Ethanol
• Opioids
• Benzodiazepines
When treating rhabdomyolusis with fluids…. Must be careful of what?
Causing compartment syndrome
How many protein urine grams a day will Dx nephrotic
urinary protein excretion of >3.5 g/day meets all of the major
criteria for nephrotic syndrome.
Advice to give parent of minimal change syndrome
Very responsive to Tx, However, relapse is common and typically requires repeat
corticosteroid courses.
Indications for cystoscopy
Gross hematuria with no evidence of glomerular disease or infection
• Microscopic hematuria with no evidence of glomerular disease or infection but increased risk for
malignancy
• Recurrent urinary tract infections
• Obstructive symptoms with suspicion for stricture, stone
• Irritative symptoms without urinary infection
Abnormal bladder imaging or urine cytology
Triad of dialysis related amyloidosis
Scapulohumeral periarthritis
Bone cyst
Carpal tunnel
Why does low cortisol mean low Na
The hypovolemia provides nonosmotic stimulus
for antidiuretic hormone (ADH) secretion, with consequent water retention and hyponatremia.
When is gastrostomy tube needed
Percutaneous gastrostomy tube placement is indicated in patients with severe dysphagia or those who are unable to maintain adequate nutrition with oral intake alone.
Mg tox Tx
Calcium gluconate
What is pemphigoid gestationis? How is it Txd
pemphigoid gestationis, also known as herpes gestationis, is an autoimmune bullous dermatosis that occurs during the second or third trimester of pregnancy, or in the immediate postpartum period
treatment is usually oral corticosteroids
Invx of choice if sus bladder rupture
Retrograde cystography
Symptoms of bladder rupture
Tender pubis area. Potential pelvic fracture. FAST shows intraP free fluid. Difficulty voiding. hematuria
Renal condition treated, remaining proteinuria only… patient is diabetic
Diabetic nephropathy
Acute vs chronic hyponatremia signs. Relate this to Tx.
Acute usually causes cerebral edema. So patients get headache, nausea etc. and even even coma. In chronic the patient adapts better, so we don’t see these signs. In acute we usually do hypertonics and the risk of ODS is usually low (neurones haven’t adapted to Na change). Chronic only do hypertonic if <120. ODS risk is higher.
Desmopressin use for primary nocturnal enuresis
Considered a first line for immediate results. Tell kids not to drink much in evening to avoid low Na. But patients relapse easily if discontinue
Can constipation cause urine retention
Yes!
Child with UTI. Given Abx. But fever persists and maybe even abscess pyelo signs.
Do US. If abnormal, do voiding cystourthrogram.
Risk factors for UTIs in kids
Female, non circumsized, constipation, VUR etc.
Do we need biopsy for minimal change
Only if atypical case. Otherwise no
Pathophys of minimal change
Dodgy T cells, secrete CKs, causing podocyte damage and loss of negative charge of the GMB
What is hyposethuria.
Inability of the kidney to concentrate urine. Usually seen in SCD or SCT. Low urine gravity, normal serum Na and no increased thirst usually (DI has more serum sodium issue and increase thirst)
List as many AIN causing drugs you can
cephalosporins, penicillins, sulfonamides, sulfonamide containing diuretics, NSAIDs, rifampin, phenytoin, and allopurinol.
Hyponatremia correction rules
<0.5 meq/L/hr. Around less than 8 increase Na a day. Less than 6 Na increase in the first few hours
Pathogenesis of refeeding syndrome
Patient with chronic low PO4, suddenly given dextrose or glucose. Increase insulin, increase shift of PO4 into cells for glycolysis. Causing sudden drop in PO4, thus ATP. Monitor and aggressive electrolyte repleton.
UTI Tx in kids
3 Gen ceph is good, TMP SMX ok, but increasing resistance. Amox is ok
Why no quinolones for kids
Risk of cartilage damage
Cirrhosis patient. Has pre renal AKI signs . Fluid resus doesn’t help
Hepato renal syndrome
Hepatorenal syndrome Tx
Address cause. Give splachnic vasoconstrictors (midodrine, ocreotide, NE). Liver transplant last thing to do
Precipitating factors in HR syndrome
GI bleed, vomiting, sepsis, SBP, diuretics, NSAID. All things causing low renal perfusion anyway
RCC varicocele. How would you describe it
Doesn’t disappear when recumbent. Makes sense
Hematuria, big smoker, lil fever, polycythemia, left varicoele. Dx?
RCC. Not likely bladder CA
Excersize induced Hyponatremia. Pathogenesis
Stress causes release of ADH. Patients often drink a lot, which worsens this,
What is HACE and HAPE
High altitude cerebral and pulmonary oedema. Due to vasoconstriction, causing high pressure and thus edema
Signs of bladder rupture
Fluid in abdomen and increasing abdominal girth. BUN and Cr will increase. Voiding is usually not possible. Abdominal trauma with likely full bladder
Dx invx of bladder rupture
Retrograde cystography
When is dialysis good for hypercalcemia
If patient cannot have fluids…. Maybe HF or RF
Why are fluids good for hypercalcemia
Generally, hyperCa is associated with dehydration. These patients can have fluids, which will shift Ca out of the kidneys.
BK virus overview
In heavily immunocompromised. Causes tubulointerstitial nephritis. Ls and Ns in biopsy. Intra nuclear inclusions
Acute rejection can be seen up to how long after
6 mo
Quirky complications of nephrotic syndrome
Hypothyroidism, due to loss of TBG. Vit D defiance, due to loss of its binding protein. Fe deficiency, resistant to Fe Tx, due to loss of transferrin.
Pathophys of HR syndrome
Splanchnic vasodilation. Decease Renal BF. Increased RAAS. Less perfusion and retention
Normal AG
10-14
How to Dx amyloidosis
Biopsy of fat pad. If non Dx, consider doing biopsy of more specific area, like kidney
Name a couple of stranger drugs that cause hyperkalaemia
Succinylcholine, TMPSMX, calciner in inhibitor, Arginine
Clinching first when getting blood drawn, and extreme leucocytosis can cause what electrolyte abnormalities
High potassium
If you get a high potassium result on lamps, and you know the patient has leucocytosis or thrombocytosis, what should the physician do
He should check plasma potassium rather than serum potassium
Contra indications for using Kayexalate in the setting of hyperkalaemia
Anyone with ileus , bowel obstruction, ischaemic gut, pancreatic transplants. These patients can get that necrosis
 If patient has good renal function which two approaches can I take to lowering potassium
Loop diuretics a fluid overload, IV fluids fluids depleted
Why can a hyperkalaemic patient not have penicillin
It contains potassium
Random drugs that cause low potassium
Gentamicin an amphotericin
Is the paralysis in low potassium ascending or descending
Ascending
AV block can be seen in hyper or hypo kalaemia
Hypo
GI losses are particularly common causes of hypo which electrolyte
K
When giving IV potassium, how do we administer this to avoid thrombophlebitis
Continuously, not bolus
Weird causes of high calcium
Vitamin a access, acromegaly, adrenal insufficiency, Zollinger Ellison
How do you correct calcium for albumin
For everyone drop of albumin below four, you can assume calcium is falling by 0.8. 
How to differentiate vitamin D toxicity versus sarcoidosis cause of hypercalcaemia
Vitamin D toxicity will have high 25 0H vitamin D. Whereas sarcoidosis will have high 1 25 0H vitamin D only
Hypercalcaemia, but less than 12. Treatment
No treatment. Just good oral fluid, and avoid exacerbating factors
Hypercalcaemia, between 12 and 14. What’s the mindset when treating
If a symptomatic, you don’t really need to do anything other than good oral hydration. Some doctors may give IV fluids to prevent symptoms developing
Annoying gap metabolic acidosis. And optic disc hyperaemia
Methanol poisoning. Don’t always expect vision loss in the questions that
Does high or low magnesium cause increase reflexes tetany irritability
Low magnesium. Believe it or not. Magnesium toxicity will cause decrease reflexes
What are two drugs beginning with P that can cause increase anion gap at metabolic acidosis
Phenformin, paraldehyde
What is your anion gap
8 to 12
What is the cut off for urine chloride to help you in metabolic alkalosis cases
20
What acid base disturbance to antacid cause
Metabolic alkalosis. With low urine in
What are the causes of saline resistant (hi you’re in chloride) metabolic alkalosis
Barter and Gittelman syndrome. And chronic diuretic use
If someone has a negative urine anion gap. What does this indicate about the normal anion gap acidosis
Negative urine anion gap, means increased chloride excretion, which means more NH for excretion, which means more acid excretion in the kidney. This is either due to GI bicarb loss, or a type two renal tubular acidosis (increase hydrogen excretion in the PCT)
What type of renal tubular acidosis has a positive annoying gap. And please explain
Distal AKA type one RTA.
Diarrhoea as a cause of non-annoying gap metabolic acidosis causes what UAG
Negative. These patients lose bicarb, causing a metabolic acidosis. The kidneys through compensation will excrete more acid. This means we excrete more NH4, this chloride, thus the urine anion gap is negative
BUN to creatinine ratio and fraction excretion of sodium values to remember
The UN to creatinine ratio (remember 20)
FE of sodium less than one percent, or more than 2%
What is the urine osmolality cut off for prerenal and intrarenal AK
Prerenal expect about 500. Intrarenal expect less than 350
Which anti-viral can cause a crystalluria
acyclovir
In AEIOU, Ingestions cover which kind of toxins
Salicylate, theophylline, methanol, barbiturate, lithium, ethylene glycol
Patient above the age of 50 with chronic kidney disease. Give what medication for CAD reduction
Start an
Patient above the age of 18 with chronic kidney disease plus a history of coronary artery disease, diabetes four stroke. Give what
Give statin
CAD is the most common cause of death in adult dialysis patients. What is the most common cause of death in paediatric dialysis patients
Infection
Most common cause of nephritic syndrome in adults
IGA nephropathy
Palpable purpura without thrombocytopenia
HSP…. With the other stuff
 cause of membranoproliferative one and two
One is our HCV (or HBV.SLE) associated with cryoglobulinaemia.
Two Is our tenants deposit disease (associated with C3 nephritic factor antibody)
Both cause the tram track
Good posture disease. What will be seen on sputum microscopy
Haemosiderin filled macrophages
Biopsy difference between Wagners and microscopic polyangiitis
Wagners is granulomatous
What is the P – ANCA antibody
MPO
What is the C – ANCA Ab
Protease
Which ocular problem do we commonly seen in Alport
Lenticonus
Hyper Proteinuria in nephrotic defined as
> = 3.5g/day
Main causes of minimal change. Went to biopsy
Malignant or NSAID. Biopsy if treatment resistant or above 12
Most common cause of nephrotic syndrome in adults overall
FSGS
Patient with palpable purpura, arthralgia, nephrotic syndrome, low C3 and an HCV positive titre
Mixed Cryoglobulinemia
Dumbbell shaped urine crystals
Calcium oxalate. Usually we have envelopes
Calcium phosphate versus calcium oxalate stones. Which has a higher which has a low pH
In that order
Other than Eurich acid stones, which of the stone is only slightly radiopaque (may not be seen on the x-ray)
Cysteine stone
Cystine stone has a pH
Low urine pH
Calcium phosphate stones. When can you not give thiazides for these patients
If the stones are associated with hyper parathyroidism
Sidestreet supplementation is used more for calcium oxalate of calcium phosphate stone
Calcium oxalate
Hyper parathyroidism is associated with calcium oxalate or calcium phosphate stone
Calcium phosphate
Other than stone of 10 mm or more, what other indications are there for urological consultation
Refractory pain and vomiting, signs of sepsis, complete obstruction
Is polycystic kidney disease associated with hernia
Inguinal and abdominal, yes
Urine cyanide nitroprusside test is used for which disorder
Is positive in cystinuria
Why might IV fluids actually decrease the rate of cyst growth in polycystic kidney disease
Increase IV fluids will decrease ADH. And as we know ADH stimulate cyst
What are the behavioural modifications we can do in recurrent UTI
Increase fluid, stop spermicide, post coital void, vag estrogen in post men
Aside form the UTI ABx prophylaxis we do for sexual women… what other stuff can we do
Abx at low dose for a few months
What classifies an uncomplicated UTI
Cystitis only, healthy, non preg, no immunosuppressive, no failed Abx, no systemic signs
UTI in hospital… revealed by red pigment
Serratia
If a patient has the signs of UTI… simple. What next
Can start the Abx, without culture etc. if unsure or compensated for UA first then culture
What is phenazopyridine
A drug that can decrease bladder pain. Used in UTI and interstitial cystitis. Methane mine or pentosan can also we used
Who gets a CT or US in pyelo
High risk patients (my DM, preg, Tx failure, immunocomp etc)
Bear paw sign on renal CT?
Xanthogranulomatous pyelo
Xanthogranulomatous pyelo what is it
Rare cause of pyelo. Seen secondary to stone obstruction. Bear paw sign
Cortical medullary scarring of kidneys on imaging is a sign of what cause of chronic pyelo
VUR
Symptoms of acute prostatitis
Fever, chills, perineal pain, back Pain, pain on defecation, dysuria, frequency urgency if obstruction
Symptoms of chronic prostatitis
No systemic signs, dull back, perineal, scrotal pain. Lil urgency or frequency if obs. Recurrent isolation of same organism in urine culture q
When to get blood cultures in acute prostatitis
If systemically unwell
Assymp bacteruria only T.lx when
Preg or prior to uro surgery
We know LGV can cause painless shallow ulcers, and buboe. What can it cause in its tertiary form
Anogenital syndrome (anal itch, discharge, rectal structures, elephantiasis)
Gold standard for chlamydia Dx? But main way we do it
Culture. But often do NAAT
Gonorrhea can cause an STD covering which areas
Cervix, vag a little, PID and above, and even the bartholin glands (recall the NMBE)
Generally what do we give for gonorrhea
IM foxy and PO Azithromycin. Even if chlamydia is ruled out. Need dual therapy due to high resistance
disseminated gonorrhea Tx
IV foxy for 24 hours
Alternative to doxy for chlamydia
Macrolide
What are Rhagades in cong syphilis
Linear scars are edge of mouth
Difference between early and late latent syphilis
Early is within first year. Late is beyond first year.
Symptoms of Jarisch Herxheimer
Flu like (high fever, myalgia, chills and fever)
Penicillin Tx:
Primary or secondary
Latent (early or late)
Neuro syphilis
Primary or secondary - penicillin IM one dose
Latent (early or late) - penicillin one dose if early, 3 doses if late.
Neuro syphilis - IV penicillin for 2 weeks
If allergic to penicillin in syphilis
Give doxy or other tetracycline
If preg must desensitise
Non healing ulcer and inguinal LN. But STD screens negative
Maybe CA
HSV vs Ducreyi on depth
Ducreyi is a deep lesion
Ducreyi Tx
Single dose of Azithromycin or foxy
Donovonosis (kleb granuloma inguinal Ed) Tx
Doxy or Azithromycin
At what age can you just reassure child bedwetting
Less than five
Diagnose this: right flank pain and costovertebral tenderness. Dull pain. Temperature normal. Urine has no casts moderate blood. Ultrasound shows in large kidney but no hydronephrosis
Renal veins thrombosis
40 uric acid stones, we can attempt to alkalinised the urine. What can we give
Potassium citrate
Obviously for post-renal and intrarenal IKI causes, we Do not give fluid bollocks. So say for example in infants what must you do to establish this
Of course to a Renal and bad ultrasound. Rule out post Reno, so that you can do a boss
If a pregnant woman has just given birth cannot avoid for more than six hours, what’s the diagnosis
Postpartum urine retention. Usually due to oedematous vagina.
Do a urethral catheter
M If any child has a UTI less than two years of age, despite severity or sex. What do you do
Ultrasound KUB
Why is creatinine clearance not as reliable as you’re in albumin to creatinine ratio in diabetes screening
Because as you know creatinine clearance me increase in early diabetes
 patient with renal papillary necrosis. Has baseline haemoglobin low-ish, And Reticulocyte count high
Sickle cell trait
Patient with one side flank pain, doll constant and doesn’t radiate. With a varicocoel on that side
Renal vein thrombosis 
Poorly controlled type two diabetes can cause which RTA
4
What is my triad of a MSK symptoms from dialysis amyloidoses
Carpal tunnel, bone cyst, scapulohumeral periarthritis
 Fractional excretion of sodium cut off
Around 40
PUV stages of diagnosis
Do your ultrasound first. Then voiding cystourethrogram. Than a cystoscopy to ablate
