Urology/Nephrology Flashcards
primary nocturnal enuresis
lifelong enuresis
Secondary nocturnal enuresis
bedwetting after being dry for at least 6 months
At what age should you become concerned about bed wetting?
6
What are causes of bed wetting?
small bladder capacity, detrusor muscle instability, UTI, bacteruria without dysuria, constipation, hypercalcuria, bladder foreign body. Also associated with nighttime snoring
Desmopressin
reduces urine production in the distal tubules (vasopressin). one nasal spray nightly, Side effects, Headache, abdominal pain, expensive $1.50 per spray
Imaprimine
anticholinergic and noradrenergic effect to stabilize detrusor muscles. Overdose can be lethal (VT, sz)
Oxybutyrin
Anticholinergic, antispasmotic to stabilize detrusor muscle. Side effects are dry mouth, constipation, drowsiness. Drug of choice is have polysymptomatic enuresis.
When to use drugs for nocturnal enuresis?
Pts> 8, for special occasions.
Mpgn
Hematuria, htn, low c3 , nephrotic range proteinuria Does not respond to high dose steroids
Treatment of congenital nephrotic syndrome
Unilateral or bilateral nephrectomy with pd and albumin infusion until transplant. Disease does not recur in new kidney
Postural proteinuria
Occurs when supine not upright
Which diseases have decreases c3?
Sle, post strepto gn, mp gn
Adrenoleukodystrophy
X linked disorder characterized by Cns demyelination and adrenal failure
Best way to evaluated proteinuria
early morning urine sample (Prot:Cr ratio >0.2)
Management of prenatal hydronephrosis
Put on prophy antibiotics - amox for first month, then bactrim or nitrofurantoin therafter. Continue until nature of lesion is defined. Should have renal u/s and VCUG early on.
Posterior urethral valves
rare cause of postnatal b/l hydronephrosis. Treated with primary valve ablation in first few days of life
Waht is the most common cause of prenatally detected hydronephrosis?
Uteropelvic junction obstruction
What is the appropriate age for an ochioplexy?
6-12 months.
Causes of pediatric nephrolithiasis
hereditary hypercalciuria, hyperparathyroidism, defects of purine metabolism, distal RTA, UTIs
What is hypophoshatemic rickets?
x linked inherited disorder, not 2/2 vitamin D deficiency. Normal calciu and bicarb, normal PTH and vita D. Treat with phosphate supplements but must be judicious as to not cause nephrocalcinosis.
Cystinosis
AR metabolic disorder caused by mutations in the lysosome. Causes global proximal RTA and progressive glomerular dysfunction. Growth failure, light complexion, rickets. Diagnose via slit lamp or BMB to see cystine crystals.
How does secondary hyperparathyroidism manifest from renal failure?
Kidneys failing thus effectively vita d deficient and increase PTH leading to osteitis fibrosa cystica
What is paraphimosis?
Inability to retract a tight prepuce and it is retracted over the glans to the level of the corona. The constricted ring of skin can act as a tourniquet and ischemia may results.
Bartters syndrome
which is a genetic disorder typically involving the Na/K/2Cl- channel in the thick ascending limb of the loop of Henle. Due to the electrolyte losses, patients develop hypokalemia, hyponatremia, and contraction alkalosis with severe dehydration. Like on Lasix
Fanconi syndrome
Fanconi syndrome, which is a proximal tubulopathy related to a number of underlying causes (nephropathic cystinosis is most common), can present in the first postnatal year with hypokalemia, hypophosphatemia, metabolic acidosis, glycosuria, and failure to thrive.
Gitelman syndrome
Gitelman syndrome is a defect of the Na/Cl transporter in the distal convoluted tubule that has a later age of onset and is characterized by hypokalemia, hypomagnesemia, and hypocalciuria. Like on Thiazide
When should cryptorchidism be surgically corrected?
No later than 6 mos
When should hypospadias be surgically corrected?
6-12mos
How does x linked hypophosphatemic rickets present?
Short stature, frontal bossing, genu varum, recurrent dental abscesses and low phosphate
What is the triad of prune belly syndrome?
Bilateral hydrouretal nephrosis, absence I’d abdominal wall musculature, in descended testicles. Occurs almost exclusively in males. 1:50:000
Nephrogenic diabetes insipidus
X linked disorder. kidneys dont respond to vasopressin therefore have dilute urine and hypernatremic dehydration. If you give desmopressin, they will not respond
What urine osmolality and urine sodium is found in SIADH
> 300 and >25
Reasons for SIADH
Surgery, Infection, Axon injury, Day after surgery, Head and Hemorrhage
Treatment of vaginal adhesions
topical estrogen bid 4-6 weeks first, then betamethasone 0.05% bid for 4-6 weeks second line, the surgery if fails conservative treatment. Only need to treat if symptomatic. Most resolve by adolescence.
BUN/Cr ratio suggetive of prerenal azotemia
> 20:1
What is the difference between Cr clearance and GFR
GFR is the creatinine filitration (overall measurement of filtration). CrCl is creatinine clearance and creat secretion.
When Does CrCl not match the GFR?
Decreased CrCL, but normal GFR: Drugs like probenecid, cimetidine, bactrim decrease Cr secretion. Also, in advanced CKD, tubules leak Cr therefore CrCl is higher than actual GFR
FeNA
Measures Na excreted over Na filtered. Best test for differentiating AGN and prerenal azotemia from other causes of kidney injury. 1 in ATN, other cuases of AKI
How does alkalosis affect Ca?
causes Ca to bind to albumin thus ion Ca drops and causes a relative hypocalcemia - symptoms of weakness, numbness, paresthesias - this can happen acutely when rapidly infuse bicarb or citrate (blood products)
What is a normal anion gap?
10-12
When do you use a urine AG?
when working up a normal AG metab acidosis. UAG = Na +K - Cl. Normal UAG is negative, because there is an unmeasured cation, ammonia. If UAG is >10, this suggests RTA because no NH4 is present. If UAG is <0 in normal AG metab acidosis this says ammonia can be made, and there is extrarenal NH4 loss (diarrhea).
What does Cl go up in normal AG metabolic acidosis?
Because this time of acidosis is secondary to loss of bicarb. Cl- increases to balance the loss of negative charge.
How do you calculate AG?
AG = Na - (Cl + HcO3)
CRF can cause what type of metabolic acidosis?
increased AG because decreased acid excretion
What tests should be ordered in unexplained AG acidosis?
lactate, urine and serum ketones, osmolal gap
What is osmolal gap?
difference between measured and calculated osmolality. 2[Na] + BUN /2.8 + glc/18. Normal osm gap is <10.
What does a large osmol gap suggest?
> 20 = alcohol posioning (methanol, ethyl, ethanol)
What is mechanism of acetazolamide?
Causes increased excretion of HCO3 causes a metabolic acidosis
What is normal bicarb?
23-28
4 causes of persistent aymptomatic hematuria in otherwise healthy child
- ) idiopathic hypercalcemia (urn ca:cr >0.2)
- ) IgA nephropathy
- ) thin basement membrane disease
- ) early alport syndrome
What tests should be ordered for when kid presents with hematuria?
CBC, UA and culture, BMP, UCa:Cr, Upr:Cr, serum C3, then consider U/S
What diseases is C3 low in?
poststreptococcal GN, SLE (also C4 can be low), MPGN (C4 can also be low)
What things must you be careful with an ASO titer?
Kids can chronically have strep colinization and have persistently elevated ASO levels. Also, ASO titers do not elevate as readily with skin infection.
What is DNase B test?
a serologic test for strep antigen, this is the best single antibody titer becuase highest sens and spec.
Treatment of APSGN?
supportive care. treat htn. resolves spontaneously, but can have low C2 for 6-12 weeks.
Most common cause of gross hematuria in kids?
IgA nephropathy
Are IgA levels helpful in IgA nephropathy?
No
Treatment of IgA nephropathy?
treat htn. ACE if proteinuria, Usually start steroids. Can use immunosuppressants if biopsy shows crescents
Treatment of anti- GBM disease (goodpasture)
plasmapheresis (only renal disease this is helpful for)
What antibodies are found in granulomatosis with polangiitis (Wageners)?
c ANCA, PR3
Alport syndrome (inheritance, pathophys, presentation)
80% are x linked inherited. Mutation in type IV collagen which makes up basement membrane of kidneys, eyes, ears. Associated with sensorineural deafness and ocular defects. Diagnose with kidney biopsy and genetic testings
Thin glomerular basement membrane disease (inheritance, pathophys, treatment and prog)
aka benign familial hematuria, AD, very thin basement membrane. only affects kidney, no treatment and prognosis is excellent, no kidney failure.
Denys -drash syndrome
Wilms tumor, gonadal dysgenesis with ambiguous genitalia, nephropathy - infant nephrotic syndrome. renal failure by age 3. If diagnosed, go for nephrectomy to avoid wilms tumor. mesangial sclerosis on biopsy
Fabry disease (inheritance, pathophys, treatment)
x linked inheritance, deficiency of a-galactosidase A. Structural probs in kidney, heart and nervous system. ESRD in 40s. ensyme replacement therapy available.
In hyperaldosteronism, what metabolic disturbance happens?
metabolic alkalosis because, absorp NA, excrete K and H
Mechanism of spironolactone?
aldosterone antagonist. therefore K is spared and can cause acidosis.
Why do you lose K with loop and thiazide diuretics?
because block Na, increasing its load to the collecting ducts with it is absorbed resulting in K excretion
Mechanism of amiloride and triampterene?
block enac which reabsorps NA in collecting duct, therefore there is no secretion of K and H.
Why do RTAs cause hyperchloremia?
because HCO3 is being lost, therefore Cl- is reabsorped to balance charges.
What is potassium in the types of RTA?
type 1 = low, type 2 = low to normal, type 4 = high
Causes of type 4 RTA
obstructive uropathy, interstitial renal disease, diabetic nephropathy, 21-hydroxylase def.
Which renal diseases recur after transplant and lead to graft loss?
HUS, FSGS, MPGN
Which type of RTA is usually associated with renal stones?
type 1 RTA - caused by obstructive uropathy.
How does acidosis cause renal stones?
leaches calcium from the bones, causes hypocitraturia (citrate usually chelates calcium), also in rta, the urine is alkaline and this causes stone formation
Which kind of stones are more likely to form in alkaline urine?
struvite and calcium phosphate
what is the most common cause of hydronephrosis in infancy and childhood?
ureteropelvic junction obstruction
Prune Belly Syndrome (presentation, M vs. F, treatment)
congenital absence of abdominal wall musculature, cryptorchidism and dilation of urethra, bladder, ureters. M»F, Can present severely in utero with oligohydramnios and pulm hypoplasia. Treatment, abdominoplasty, ochiopexy, renal transplant
Is hypospadias usually associated with other congenital anomlies?
no, usually dont need to do further GU imaging.
What side do varicoceles usualyl occur on?
left
What are clinical consequences of hypokalemia?
constipation/ileus, muscle aches, breakdown, rhabdo, paralysis, nephrogenic DI, EKG changes and arrthymias (especially with dig)
Why does digitalis worsen hypokalemia?
Dig inhibits ATPase Na-K transporter.
What is spinning top urethral deformity?
is caused by dilation of the proximal muscular urethra against a closed or narrow distal urethral sphincter. STU has been associated with bladder dysfunction arising from contraction of the detrusor muscle of the bladder against a closed urethral sphincter. Often have issues with constipation, too.
After diagnosis of HSP, for how long should you monitor urine?
6 months
Inheritance pattern of nephrogenic diabetes insipidus
x linked disorder
What acid base disturbance can vincristine cause?
SIADH
daily requirements for potassium, sodium, and chloride
1, 2, 3 meq/kg/d
How can histiocytosis x be related to hypernatremia?
pituitary tumor can cause DI
What predisposes you to digitalis toxicity? Low or hi K
Low K
What is nephrotic range proteinuria
2g/d
which drugs increase creatinine
cimetidine, probenecid, trimethoprim - decrease the tubular secretion of Cr
What diseases is minimal change disease associated with?
Hodgkin lymphoma, NSAIDs, autoimmune diseases, atopy
If an adolescent presents with nephrotic syndrome and hypertension, what disease is most common?
FSGS (unusual for MCD to have htn)
Which diseases never have active urine sediment or hypocomplementemia?
MCD, focal sclerosis, membranous nephropathy, diabetic nephropathy, amyloid nephropathy.
What percent of patients with HUS need dialysis?
50%
Which UTI bug doesnt produce nitrites?
Enterococcus. Use ampicillin
The characteristic features include pulmonary hypoplasia (respiratory distress in the newborn), facial appearance (pseudoepicanthus, flattened ears and nose, recessed chin), and limb abnormalities (club feet and hip dislocation).
Potter syndrome - from oligohydramnios
How is alport inherited
x linked
What are the complications of ARPCK
Potters sequence, hepatic fibrosis with dilation of biliary tree, growth failure, osteodystrophy
Most common disease of AD inheritance
ADPCKD
What disease on US shows no good diferentiation befween cortex and medulla
nephronopthisis
NAtural history of medullary sponge kidney
frequent UTI and stones. prognosis is good.
AR. Obesity, retinitis pigmentosa, hypogenitalism, polydactyly, intellectual disability, cystic dysplasia of the kidney
Laurence-Moon-Bardet-Biedl
Amphotericin effect on kidneys
type 1 RTA, direct nephrotoxic effect
Aminoglycoside effect on kidney
cause proximal kideny injury. Usually delayed 7-10d after start of therapy. therapeutic levels are not a guarantee of safety
Cisplatin effect on kidney
magnesiuria
Sirolimus side effect to know
hyperlipidemia
Cyclosporine side effects
hypertrophies the gums, nephrotoxicity, does not affect bone marrow
Tacrolimus side effects
nephrotoxic, diabetogenic
cellcept side effect
GI side effects, less bone marrow suppression that Azathioprine
Does acidosis increase or decrease citrate in the urine?
decreases, putting at risk for stones
what compound makes hexagonal crystals
cystine
For which types of stones is urinary alkalinization performed for?
all types but struvite and calcium phosphate
by which week in utero does babay make urine?
week 12
by which weeks is nephrogenesis complete?
32-34 weeks
Most common cause of hydronephrosis in infancy and childhood
UPJ obstruction
In a duplicated collecting system, which ureter usually have hydronephrosis?
lower pole
Most common cause of urinary obstruction in male infants
PUV
What is VURD syndrome?
Valve, unilateral, reflux, dysplasia - massive unilateral reflux in patients with posterior urethral valves
What percent of patients with PUV have ESRD
30%
PHimosis
when foreskin cannot be retracted
paraphimosis
entrapment of a phimotic prepuce proximal to the coronal margin. Causes edema and swelling of the glans and foreskin. REduction is emergent and requires sedation and local anesthesia
Most common cause of diabetes insipidus in children?
Nephrogenic DI in children is secondary to a mutation in either the ADH-receptor (AVPR 2) or the aquaporin 2 channels. AVPR 2 mutations have an X-linked inheritance and account for 90% of cases; males are more severely affected than females.
At what age do you start evaluating children for incontinence?
age 5
