Renal/Urology - 5% Flashcards
Metabolic Acidosis (high Anion Gap)
Acid-Base Disorders
pH < 7.3 and HCO3 < 20
determine Anion Gap = Na - (Cl- + HCO3)
- Carbon monoxide, cyanide, Congenital Heart Dz
- Aminoglycosides
- Toluene/glue sniffing
- Methanol
- Uremia
- DKA/ETOH/Starvation
- Paracetamol/Acetaminophen, paradelhyde
- Iron/Isoniazide
- Lactic acidosis
- Ethanol/Ethylene gylcol - Antifreeze
- Salicylates/ ASA/Aspirin
Metabolic Acidosis (normal Anion Gap)
Acid-Base Disorders
pH < 7.3 and HCO3 < 20
Excess production or ingestion of HCO3
Need to determine whether High Anion Gap Met Acidosis or Normal = 8 to 12 mEq/L
Eti:
- MCC diarrhea
- Type 2 Renal Tubular Acidosis
- Spironolactone
Compensation via hyperventilation = decr CO2
Metabolic Alkalosis
Acid Base Disorders
pH > 7.4 and HCO3 > 26 mEq/L
Eti:
- Loop diuretics
- Antacid
- Vomiting
- Aldosterone
- up
Compensation - increase CO2 = hypoventilation/decrease breathing
Respiratory Acidosis
Acid Base Disorders
pH < 7.3 and pCO2 > 45
Acute Resp Acid
- pH - very llow
- HCO3 - slightly ele or normal
Chronic Resp Acid
- pH - close to nl
- HCO3 - very ele > 30
Eti: Hypoventilation
- Airway obstruction
- Sedative use
- Acute lung dz
- Chronic lung dz
- Opioid
- Weakening resp muscle
Compensation - increase HCO3 retention/reabsorption via kidneys = takes 24 hrs
aka decr HCO3 excretion
Respiratory Alkalosis
Acid Base Disorders
pH > 7.4 and pCO2 < 35
CO2 decr < 36 mmHg = Decr HCO3 & decr H+
Eti: Hyperventilation
- Panic attacks
- Anxiety attacks
- Salicylates
- Tumor
- Pulm Embolism
- Hypoxia
Compensation - decrease HCO3 retention/reabs via kidneys aka incr HCO3 excretion, get rid of more HCO3
Acute Renal Failure - Intrinsic
Direct damage to kidneys
Eti - nephrotoxic drugs (aminoglycosides), cyclosporine, Tumor lysis syndrome, Vasculitis (SLE, Sarcoidosis), crystals from gout, Myoglobin from rhabdo
Three different types
1. Acute Tubular Necrosis /MC
- necrosis of renal tubules d/t ischemia or nephrotoxic drugs
- MCC - Rhabdo
- UA - epithelia cell casts and muddy brown casts*, hyperK, hyperphosphatemia
2. Acute Interstitial Nephritis (AIN)
- Inflammatory or allergic reaction in the interstitium
- eti NSAIDs, sulfa, penicillin, bacterial infx
- UA - WBC Casts**, eosinophilia, Incr IgE
3. Acute Glomerular Nephritis aka NEPHRITIC SYNDROME
- Immunologic inflammation of the Glomerular = protein and RBG leakage
- Many ETI - IgA Nephropathy, Post infectious GABHS,
- UA - hematuria*, coca cola urine (GABHS), proteinuria, oliguria
- Fever, flank pain
Dx
- U Na > 40
- BUN:Cr 15:1
- FENa high > 2%
Tx - IV fluids to remove drugs, Lasix to get kidneys moving
Acute Renal Failure - Postrenal
Obstruction downstream from kidneys
Eti: kidney stones, BPH, tumors, congenital abnormalities
Sxs:
- Anuria or oligouria
- pain from hydronephrosis - abd discomfort
Dx:
- KUB, X ray or CT scan
- Serum Cr and BUN follows pre-renal pattern of azotemia 20:1
Tx:
- Bladder cath
- remove obstruction (stones)
Acute Renal Failure - Pre-Renal
eti, sxs, dx, tx
MCC of AKI
usu d/t hypovolemia or hypoperfusion; NSAIDs, IV contrast, ACEI or ARBS
Sxs:
- decr skin turgor
- hypotensive
- ortho hypotension
- dry mucosa
Dx:
- Urine osmolality High
- Urine Na < 20
- BUN:Cr > 20:1**
- FENa low < 1%
Tx
- reversible - correct underlying condition
- replenish fluids and maintenance
Acute Renal Failure Criteria
Sudden change in kidney fx in a day or week
RIFLE Criteria
Risk
- Incr Cr x 1.5 or GFR decre > 25%;
- UO < 0.5 ml/kg/hr x 6 hr
Injury
- Incr Cr x 2 or GFR decr > 50%;
- UO < 0.5 ml/kg/hr x 12 hr
Failure
- incr Cr x 3 or GFR decr > 75%;
- UO < 0.3 ml/kg/hr x 24 hr or anuria x 12h
Loss
- persistent ARF - complete loss of renal fx > 4 wks
ESRD
Goodpasture’s Syndrome
Acute Glomerulonephritis
Autoimmune, production of anti-GBM (basement membrane of endothelial cells in glomeruli)
Type of Rapidly progressive GMN
Sxs:
- Hemoptysis
- hematuria - Kidney failure
Dx:
- UA - nephritic findings
- RBC casts
- Mild proteinuria
- Anti-GBM antibodies
- Linear IgG deposits
Tx:
- Plasmapheresis = remove circ abs
- cyclophosphamide
- CS
- remission w/in a few weeks
IgA Nephropathy (Berger’s Syndrome)
Acute Glomerulonephritis
MCC GMN world wide’ M>W, 20-40s, Asian pop
IgA complexes deposit in mesangial cell in glomeruli
Sxs:
- gross hematuria
- preceded 1-2d w/ URI or GI
- typically benign
Dx:
- RBC casts
- Renal bx - IgA deposit in diffuse pattern in mesangium
Tx:
- Control BP
- ACE-I for proteinuria
- CS if rapid decr in renal fx
Post Infectious Strep Glomerulonephritis
Acute Glomerulonephritis
Eti - GABHS from Strep pharyngitis or Impetigo; MC kids 2-13yo
Sxs:
- 2 wks post infection
- Nephritic syndrome
- coca cola urine
- rise In CR and BUN
- Periorbital edema
Dx:
- Hematuria
- low C3 complement
- high ASO titers
Tx:
- resolves in 4 wks
- Symptomatic tx - tx HTN and edema with loop diuretics
- Dialysis if rapid progression to RF
Vasculitis
Acute Glomerular Nephritis
Rapidly Progressive GMN
A/w granulomatosis with Polyangitis (Wegeners’s) or microscopy polyarteritis nodosa (vasculitis of small renal arteries)
Sxs:
- flu like syndrome - fever, arthralgias, anorexia, wt loss
- +/- hemoptysis or pulmonary hemorrhage
Dx
- +ANCA Antibodies
Tx
- cyclophosphamide + corticosteroids (methylprednisolone)
Horseshoe Kidney
Congenital Renal Disorders
Kidney fused together to form horseshoe in womb
a/w with Turner’s syndrome
Sxs
- Usy asymptomatic
- N, abd discomfort
- Kidney stones, UTIs
- Incr risk of Renal Cancer
Dx
- Palp bilaterally
- Incidental finding on imaging
- US, Intravenous pyelogram, CT or MRI
Tx
- No tx needed, tx complications
- Symphysiotomy - unpopular nowadays
Hydronephrosis
Congenital Kidney Disorders
Water inside the kidney - distention and dilation of renal pelvis and calyces d/t obstruction of urine free flow from kidney =
> atrophy of kidney
Sxs
- severe back pain
- difficulty urinating
- +/- CVA tenderness, r-> groin
Dx
- UA - ele pH, ele Cr, BUN
- PE w/ palpable abd or flank mass
- IV Urogram, US, CT or MRI for cause of obstruction
Tx
- Remove obstruction, drain urine
- Upper urinary tract - nephrostomy tube
- if chronic - insertion of ureteric stent or pyeloplasty
- Lower UT - urinary catheter insertion or suprapubic cath
Polycystic Kidney Disease
Congenital Renal Disorders
Autosomal Dominant - growth of numerous cysts in kidneys.
Cysts replace kidney mass and reduce fx => kidney failure
Sxs:
- > 30yo, fam hx, abd flank mass
- Young patient with HTN and abd/flank mass = PKD
- 10% w/ brain aneurysm
- MV prolpase, LVH
Dx
- US - fluid filled cysts
Tx
- no cure
- control BP <130/80 w/ ACE-I or ARB
- tx infx vigorously
- Dialysis or transplant
Renal Artery Stenosis
Congenital Renal Disorders
Narrowing of one or both renal arteries => MCC atherosclerosis or fibromuscular dysplasia
2/2 high blood pressure
Sxs
- Renal artery bruit on ausc
- htn before 30yo
- HTN w/ CAD or PVD
- HTN resistant to 3 or more drugs
- if placed on ACE-I but develops acute renal failure or sharp rise in BUN/Cr = renal artery stenosis
Dx
- US - initial imaging < 60yo w/ suspected RAS
- Renal arteriography - gold**
Tx
- Percutaneous transluminal angioplasty + Stenting of renal arteries
- surgical bypass for revascularization
Hemolytic Uremic Syndrome (HUS)
Acute Glomerulonephritis
MCC AKI in children 0-5yo;
a/w E.coli O157:H7, Shiga toxins
Sxs:
- Diarrheal illness - bloody
- Petechial rash
Dx:
- UA - Nephritic findings
- ele Cr BUN
- Thrombocytopenia
- incr PTT
Tx:
- supportive; self limited 2-4 wks
- Correct e- abns
- dialysis rare
Hyperkalemia
serum K > 5.0 mEq/L
Eti:
- Incr K release from cells - BBs, insulin deficiency, AKI
- decr K excretion - aldosterone secreition
- Meds - K sparing diuretics
Sxs:
- muscle weakness or paralysis
- Cardiac abn
- decr urinary acid excretion - Metabolic Acidosis
Dx
- tall peaked T waves => QR Intvl shortening, wide QRS
Tx
- C BIG K Drop
- IV Ca gluconate - used for K>6.5
- Insulin + glucose
- Kayexalate - GI K excretion
- B-agonists
- Bicarbonates
- Diuretics
Hypokalemia
normal is 3.5 to 5 mEq/L; Serum K < 3.5 mEq/L
Eti: V/D, diuretic tx
- Decr K intake - malnutrition = Etoh
- K+ shift in cells - insulin/hypothermia
- Rare disx - hyperaldosteronism
Sxs:
- Severe m. weakness
- Rhabdomyolysis
- Cardiac arrhythmias
Tx:
- PO or IV potassium chloride
Hyponatremia - Euvolemic
Normal volume (Na + free water) and Incr free water
UNa > 20 = Aldosterone off aka kidneys NOT reabsorping Na into body circulation
Uosm > 300 = ADH on = water being reabsorped
- Renal Tubular Acidosis IV - r/o electrolytes
- Addison’s - r/o Cortisol levels
- Thyroid (hyper) - TSH
- Polydipsia
- SIADH - dx of exclusion
Tx - water restriction
Hyponatremia - Hypervolemic
high volume (Na + free water) and high free water
Edema = third spacing = reducing intravascular volume/perfusion to kidneys =
UNa < 20 = Aldosterone ON
- Eti - CHF, Cirrhosis, Nephrosis
UNa > 20 = Aldosterone OFF
- Eti - Acute/Chronic Renal Failure
Tx - H2O or Na restriction
Hyponatremia
etiologies
Serum Na < 135 mmol/L
- Determine serum Osmolality, then
- Volume status
HYPERTONIC HypoNa
- Presence of osmotically active molecules = *decrease free water
- glucose in hyperglycemia
- Mannitol infusion
ISOTONIC HypoNa
- lab artifact or error - free water is normal
HYPOTONIC HypoNa - true hyponatremia
- a/w Incr free water
- determine volume (ECF) status
1. Hypovolemic HyperNa
2. Euvolemic Hyper Na
3. Hypervolemic HyperNa
Tx:
- Acute Tx = 50mL bolus of 3% saline
- Watch for central pontine myelinolysis - 10-12mm in 1st 24 hrs or >18mm in 1st 48 hrs
Hyponatremia - Hypotonic
Hypovolemic Hyponatremia = low volume (Na + h2O)
Incre free water loss or decrease access to free water => RAAS activation => ADH release
Sxs:
- Fever, tachycardia
- heat exposure
- Water rescriction
Dx
- Aldosterone increases Na reabsoption = decr Na in urine = UNa low <20
- ADH - increases H2O reabsorption = decr H2O in water = Uosm high >300
-
Renal Loss UNa >20 (aldosterone is off)
- Diuretics (thiazides, K sparing)
- ACE-I or ARBS
- Hypoaldosteronism
-
Extra Renal Loss (UNa < 20, FeNa <1) -kidneys functioning properly to HOLD onto Na
- Bleeding
- Burns
- GI - N/V, diarrhea
- Pancreatitis
Tx - Normal saline 0.9% Saline = correct the volume
beware of central pontine myelitis - dont correct Na by >10-12mM within first 24 hrs or by >18 In first 48hrs.
Renal Cell Carcinoma
Renal Clear Cell carcinoma MCC, transitional 2nd MCC
RF - smoking
Sxs
- TRIAD
- flank pain, painless hematuria, palpable abd/renal mass
Dx
- US or CT
- then biopsy
Tx
- Surgery w/ radical nephrectomy - curative
Wilms Tumor
Nephroblastoma, MC solid renal tumor of childhood; seen in otherwise healthy children <4yo
RF - fam hx, horsehorse kidney
Sxs
- asymptomatic abd mass - DO NOT palpate abd of child w/ Wilm’s tumor -> can rupture encapsulated tumor
- increasing abd size
- mass smooth, firm, well defined but doesn’t cross midline
Dx
- US 1st and CT of chest (mets to lungs)
- Biopsy and resection
Tx
- surgical resection and chemo
Nephrolithiasis
dx, tx
Dx:
- UA - microscopic/gross hematuria, leukocytes/crystals
- non-contrast CT - gold std*
- Renal US - ID stones in kidney, prox ureter, UVJ
Tx:
- 5-6mm - likely to pass on own, lots of fluid - strain urine, adq analgesics
- elective lithotripsy/ureteroscopy
- refer to uro w/ 9mm stone
- >10mm - incr complications
- tx as inpatient - maintain PO intake, vigorous h20
- Ureteral stent - percutaneous nephrostomy = gold std
- ample analgesia
Nephrolithiasis
eti, sxs
50% recurrence w/in 10 yrs of 1s stone
Renal Calculi - occur in urinary tract
Calcium stones MC > uric acid (look for gout sxs) > struvite (nursing home pts) > cystine
Sxs:
- Asymptomatic until inflammation or complete/partial ureteral obstruction develops
- Colicky unilateral back/flank pain radiating to groin
- hematuria
- CVA tenderness
- N/V
- Renal colic - waxes and wanes
- Dysuria, urinary freq, fever, chills
Nephrotic Syndrome
Glomerulonephritis
Abn glomerular permeability = loss of protein
ETI - MCC membraneous GN, DM, SLE, drugs, infx
Sxs:
- Hypoalbuminemia
- Hyperlipidemia - Fatty casts In urine (frothy)
- Proteinuria > 3.5g/24 hr***
- Edema (peripheral) periorbital edema in children
- Increase liver production of clotting factors to balance Albumin loss - decrase in AntiThrombin 3 = high risk of DVT/PE
Dx:
- UA - oval fat bodies
- 24 hr urine collection >3.5g/d
- Renal bx - definitive
- Hypoalbumemia < 3.4 g/dL
- Hyper lipidemia
Tx:
- Corticosteroids + cyclophosphamide/Cyclosporine in minimal change disease
- Diuretics for edema
- ACEI/ARBS for proteinuria reduction
Pyelonephritis
dx ,tx
Dx:
- CBC - leuks and left shift
- > 10^5 CFU in men
- >10^3 CFU in women
- UA - pyuria, bacteriuria, hematuria, WBC casts
- Abd CT - abscess with pyelo
- VCUG for recurrent UTi in men
- US - hydronephrosis 2/2 obstruction
tx:
- Outpatient - Fq (cipro/levaquin) or Bactrim for 1-2wks
- Inpt - IV FQ, 34d or 4th gen Ceph, extended spect PCNs, gentamycin
- Failure to respond -> US/imaging
- F/u urine cultures
Pyelonephritis
eti, sxs
Inflammation of kidney parenchyma and renal pelvis d/t bacterial infx
MC in elderly and DMs; MC E coli
recurrent d/t progressive inflammation of renal interstitium caused by bacterial infx - anatomical urinary trac abns (vesicoureteral reflux)
Sxs:
- Irritative voiding sxs
- Fever
- flank pain + CVA tenderness
- young children = fever + abd discomfort
Testicular Carcinoma
MC solid tumor in young men 15-40yo (avg 32yo); 5 year survival 90%
Seminoma is MC type
Sxs
- RF - hx of cryptorchidism
- firm, painless, nontender testicular mass
Dx
- B-HCG+ and a-fetoprotein in non seminoma germ cell tumors
- Scrotal US
- radio to look for mets
Tx
- Orchiectomy +/- chemo
- seminomatous tumors = radiosensitive XRT
- nonseminomatous are radioresistant
Dehydration
Fluid lost > fluid intake
Sxs
- Mild depletion - incr HR, fatigue, muscle cramps
- Moderate fluid loss - dizziness, hypotension when standing
- Severe - general hypotension, signs of ischemia and shock, lethargy and confustion
Dx
- ele Hematocrit, Serum albumin
- low urinary Na
- Serum bicarb = degree of deH2O, < 17 = mod/sev deH2O in children
- higher urine Osmolality
Tx
- Mild - replete water PO
- Mod - 50 to 100 mL of PO H2O per kg per Bw
- Sev - 20ml/kg NS bolus
Hypervolemia
Fluid overload state - incr in total body Na content - incr in extracellular body water
Eti- CHF, kidney failure, liver failure, hyponatremia
Sxs
- Dyspnea, fatigue, early satiety
- Wt gain, peripheral edema
- Pulm rales, pelm edema
- JVD
- CVP, PCWP
- low hematocrit and albumin concentration
Dx
- UA - protein, Cr, Albumin, PT, LFT, TSH
- Echo
Tx
- Diuretics/furosemide
- Monitor UO, daily weights
