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Emergency Medicine > Renal/Urology > Flashcards

Renal/Urology Flashcards

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1
Q

Acute Renal Failure - Intrinsic

A

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

  • necrosis of renal tubules d/t ischemia or nephrotoxic drugs
  • 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

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2
Q

Acute Renal Failure - Postrenal

A

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)
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3
Q

Acute Renal Failure - Pre-Renal

eti, sxs, dx, tx

A

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
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4
Q

Acute Renal Failure Criteria

A

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

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5
Q

Goodpasture’s Syndrome

Acute Glomerulonephritis

A

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
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6
Q

IgA Nephropathy (Berger’s Syndrome)

Acute Glomerulonephritis

A

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
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7
Q

Post Infectious Strep Glomerulonephritis​

Acute Glomerulonephritis

A

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
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8
Q

Vasculitis

Acute Glomerular Nephritis

A

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)
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9
Q

Cystitis

A

Infection of bladder; MC d/t E.coli, ascends up urethra

sxs:

  • dysuria, frequency, urgency, suprapubic tenderness
  • following sexual intercourse
  • unremarkable PE

dx:

  • urine dipstick; nitrite, leukocyte esterase
  • UA - pyuria, bacteriuria, +/- hematuria
  • Urine culture - definitive >10^5 CFU clean catch
    • if epithelial squamous cells = contamination
  • imagine reserved for pyelo

Tx:

  • Uncomplicated - Bactrim DS BID x3d or Nitrofurantoin 100mg x5-7d
  • Increased fluids, prevention
  • hot sitz bath/urinary analgesics - phenazopyridine/Azo - pee orange
    • Lower UTI in pregnancy
      • Macrobid/nitrofuratoin 100 mg PO BID x 7 days
      • Cephalexin/Keflex 500mg PO BID x 7d
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10
Q

Epididymitis

A

Acq’d retrograde spread of organism through vas deferens

  • Men < 35 - G & C
  • Men > 35 = E coli

Sxs:

  • Dysuria
  • unilateral dull aching scrotal pain r-> ipsilateral flank
  • Swollen epididymitis, tender
  • fever/chills
  • Positive (+) Prehn’s sign - relieve w/ elevation
  • Positive (+) Cremasteric sign (normal) - ele of testicle after stroking on inner thigh

Dx:

  • UA - pyuria - bacteriuria + culture
  • scrotal US - increased testicular blood flow

Tx:

  • Supportive care; bed rest, scrotal elevation, analgesics
  • <35 yo
    • Ceftriaxone 250mg IM x1 + Doxycycline/Azithromycin 100 mg PO BID x 10d
    • treat partner as well
  • >35 yo E coli
    • Levofloxacin 500mg PO x 10 days
    • Ofloxacin 300 mg PO BID x 10d
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11
Q

Hemolytic Uremic Syndrome (HUS)

Acute Glomerulonephritis

A

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
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12
Q

Hypercalcemia

A

Serum total Ca > 10.5 mg/dL; ionized fraction of Ca > 5.6 mg/dL

MCC - hyperparathyroidism, sarcoidosis, Tb, Paget dz, Mets, Mult myeloma

Sxs:

  • Stones, bones,
  • abd groans - abd pain
  • psychiatric moans (apathy/mood swings)
  • Hyperextensibility
  • Brady
  • Polyuria, constipation, anorexia
  • Renal Stones
  • Muscle weakness, confusion

Dx:

  • ionized Ca level
  • Shortened QT invl
  • Slit lamp - bandkeratopathy
  • Incr PTH - primary
  • decr PTH - malign
  • Bone lytic lesions

Tx:

  • IVF
  • Furosemide - loop diuretic - forces Ca out
  • Bisphosphonate - inhibit bone resorption w/ malignancy
  • Calcitonin
  • If refr to bisphosphonate - Denosumab
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13
Q

Hyperkalemia

A

serum K > 5.0 mEq/L

Eti:

  1. Incr K release from cells - BBs, insulin deficiency, AKI
  2. decr K excretion - aldosterone secreition
  3. 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
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14
Q

Hypermagnesium

A

RARE; Mg > 3.2

2 MCC = 1. Renal insufficiency or 2. Incr Mg intake

Sxs:

  • N/V
  • Skin flushing
  • dizziness
  • hyporeflexia

Dx:

  • HyperMg
  • HyperK and HyperCa
  • EKG - prolonged PR and QT intvl
  • arrhythmias

Tx

  • mild to mod - IV fluids and Furosemide
  • Sev - Calcium Gluconate
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15
Q

Hypernatremia

A

Serum Na > 145 mmol/L

impaired thirst mechanism, Unreplaced water by vomiting or diarrhea, Diabetes inspidus, DKA, HHS,

Sxs:

  • Confusion
  • lethargy
  • Hyperreflexia
  • Seizures, or comas

Tx

  • Hypotonic Fluids - PO preferred
    • IV D5W or D5W 1/2 NS
  • rapid correction causes cerebral edema and pontine herniation
    • Correct = 0.5 mEq/L/h
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16
Q

Hypocalcemia

A

Serum Total Calcium < 8.4 mg/dL; Ionized fraction of Ca < 4.4 mg/dL

Muscles become more excitable = neuromuscular irritability

a/w Ricketts, Osteomalacia, PTH

MCC hypoparathyroidism

Sxs:

  • numbness/tingling
  • tetanus
  • grand mal sz

Signs

  • Incr DTRs
    • Chvostek’s sign - facial m twitch
    • Trousseau’s sign - BP incr x3 systolic carpal spasm

Dx:

  • QT prolongation
  • PTH low

Tx -

  • IV calcium gluconate
  • PTH deficit - calcitrol + High Ca intake
  • Thiazide - decr Ca excretion, lowers urolithiasis
17
Q

Hypokalemia

A

normal is 3.5 to 5 mEq/L; Serum K < 3.5 mEq/L

Eti: V/D, diuretic tx

  1. Decr K intake - malnutrition = Etoh
  2. K+ shift in cells - insulin/hypothermia
  3. Rare disx - hyperaldosteronism

Sxs:

  • Severe m. weakness
  • Rhabdomyolysis
  • Cardiac arrhythmias

Tx:

  • PO or IV potassium chloride
18
Q

Hypomagnesia

A

Mg < 1.3 mEq/L

Eti -

  • GI losses from malabsorption/ETOHics, celiac dz, Small bowel bypass
  • Renal Losses = diuretics (thiazides, loop), meds (PPI, Ampho B, Cisplatin, cyclosporine)

Sxs:

  • AMS, Lethargy, weakness, incr DTR, weakness, tetany
  • HypoCa - impaired PTH secretion (Mg needed to make PTH)

Dx

  • hypoMg, +/- HypoK or HypoCa
  • EKG = prolonged PR and QT intvl, torsades, V-tach (R on T)

Tx

  • mild - PO Mg oxide
  • Severe - IV Mg sulfate
19
Q

Hyponatremia - Euvolemic

A

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

  1. Renal Tubular Acidosis IV - r/o electrolytes
  2. Addison’s - r/o Cortisol levels
  3. Thyroid (hyper) - TSH
  4. Polydipsia
  5. SIADH - dx of exclusion

Tx - water restriction

20
Q

Hyponatremia - Hypervolemic

A

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

21
Q

Hyponatremia

etiologies

A

Serum Na < 135 mmol/L

  1. Determine serum Osmolality, then
  2. 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
22
Q

Hyponatremia - Hypotonic

A

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.

23
Q

Metabolic Acidosis (high Anion Gap)

Acid-Base Disorders

A

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
24
Q

Metabolic Acidosis (normal Anion Gap)

Acid-Base Disorders

A

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

25
Q

Metabolic Alkalosis

A

pH > 7.4 and HCO3 > 26 mEq/L

Eti:

  • Loop diuretics
  • Antacid
  • Vomiting
  • Aldosterone
  • up

Compensation - increase CO2 = hypoventilation/decrease breathing

26
Q

Nephrolithiasis

dx, tx

A

Dx:

  • UA - microscopic/gross hematuria, leukocytes/crystals
  • non-contrast CT - gold std*
  • Renal US - ID stones in kidney, prox ureter, UVJ

Tx:

  • <5mm - likely to pass on own, lots of fluid - strain urine, adq analgesics
  • 5-10mm - can’t pass spont., incr fluids & 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
27
Q

Nephrolithiasis

eti, sxs

A

50% recurrence w/in 10 yrs of 1s stone

Renal Calculi - occur in urinary tract

Calcium stones MC > uric acid > struvite > 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
28
Q

Nephrotic Syndrome

Glomerulonephritis

A

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
29
Q

Orchitis

A

Inflammation of testicles - bacteria or virus ascending through urinary tract

25% postpubertal M w/ MUMPS

MCC - Coxsackie Rubella, Echovirus, Parvovirus

Sxs:

  • Unilateral swollen testicles
  • tenderness w/ erythema and shininess of overlying skin
  • fever/tachy
  • usu a/w epididymitis, unless MUMPS

Dx:

  • UA - pyuria, bacteriuria
  • positive Prehn’s sign - relieve of pain with elevation of scrotum
  • Positive (normal) Cremasteric Reflex - testicle draws upward w/ inner thigh stroke

Tx:

  • if mumps - tx mumps + ice/analgesia
  • if bacterial - tx like epididymitis
    • < 35 yo
      • Ceftriaxone 250 mg IM + doxy 100 mg BID x 10d < 35
    • If > 35 (usu E coli)
      • Cipro 500 mg BID 10-14 d
30
Q

Prostatitis (acute and chronic)

A

Ascending infx of G- rods into prostatic ducts

<35 - Gonorrhea & Chlamydia; >35 - E. coli

Chronic - usu E.coli w/ recurrent UTI, structural abn, sxs > 3mos

sxs:

  • Sudden onset fever, chills, LBP
  • Perineal pain w/ acute prostatitis
  • Chronic - variable - asymp or acute sxs
  • Urinary frequency, urgency, dysuria, some obstruction

Dx

  • PE - DRE
    • Acute tender & enlarged/boggy prostate
    • Chronic - nontender, boggyy prostate
  • UA - pyuria or hematuria
  • prostatic fluid = leukocytosis, culture for E coli
    • chronic = enterococcus
  • DO NOT massage prostate ACUTE –> sepsis

Tx:

  • Acute
    • < 35 - tx for Chlamydia and Gonorrhea
      • Ceftriaxone and Azithromycin/doxy
    • ​> 35 - tx for E coli and pseudomonas
      • FQs or Bactrim for 6 wks
        • culture after 1 wk after finish tx
  • Hospitalized in acute - parenteral FQs
  • Chronic prostatitis - Bactrim or FQ for 6-12 wks
  • NSAIDs for pain
  • Chronic, recurrent prostatitis = Transurethral Resection of Prostate (TURP)
31
Q

Pyelonephritis

dx ,tx

A

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
32
Q

Pyelonephritis

eti, sxs

A

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 childre = fever + abd discomfort
33
Q

Respiratory Acidosis

A

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

34
Q

Respiratory Alkalosis

A

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

35
Q

Testicular Torsion

A

Twisting of spermatic cord => compromised blood flow and ischemia

MC in pt w/ cryptorchidism

SURGICAL EMERGENCY

Sxs:

  • Asymmetric high riding testicle “bell clapper deformity”
  • Neg Prehn’s sign - lifting will not relieve pain
  • Cremaster reflex absent
  • Sudden, severe pain and swelling in testicles
  • N/V
  • Blue dot sign - tender nodule 2-3mm on upper pole
  • V tender to palp

dx:

  • Testicular doppler - best initial test
  • Radionuclide scan = decr uptake in affected testes - gold std

Tx:

  • Detorsion and orchiopexy w/in 4-6 hrs
  • Elective sx on other testes - risk of torsion
36
Q

Urethritis

A

Infx of urethra w/ bacteria => STI (C, G, Trich, HSV = MCC)

Sxs:

  • Dysuria
  • Urethral dx - purulent, whitish mucoid

Dx - UA and urine culture

Tx

  • If sexually active - tx for STD
    • Ceftriaxone 250 mg + Azithromycin 1 g PO QD x 7 days
    • OR Doxy 100mg PO BID x 7d
37
Q

Hypocalcemia

A

Serum Total Calcium < 8.4 mg/dL; Ionized fraction of Ca < 4.4 mg/dL

Muscles become more excitable = neuromuscular irritability

a/w Ricketts, Osteomalacia, PTH

MCC hypoparathyroidism

Sxs:

  • numbness/tingling
  • tetanus
  • grand mal sz

Signs

  • Incr DTRs
    • Chvostek’s sign - facial m twitch
    • Trousseau’s sign - BP incr x3 systolic carpal spasm

Dx:

  • QT prolongation
  • PTH low

Tx -

  • IV calcium gluconate
  • PTH deficit - calcitrol + High Ca intake
  • Thiazide - decr Ca excretion, lowers urolithiasis
38
Q

Hypomagnesia

A

Mg < 1.3 mEq/L

Eti -

  • GI losses from malabsorption/ETOHics, celiac dz, Small bowel bypass
  • Renal Losses = diuretics (thiazides, loop), meds (PPI, Ampho B, Cisplatin, cyclosporine)

Sxs:

  • AMS, Lethargy, weakness, incr DTR, weakness, tetany
  • HypoCa - impaired PTH secretion (Mg needed to make PTH)

Dx

  • hypoMg, +/- HypoK or HypoCa
  • EKG = prolonged PR and QT intvl, torsades, V-tach (R on T)

Tx

  • mild - PO Mg oxide
  • Severe - IV Mg sulfate

Emergency Medicine (13 decks)

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