Urology/Renal Flashcards
1
Q
Kidneys synthesize vitamin ___
A
D
2
Q
Normally, GFR is ___ ml/min
A
125ml/min, 180L/day
3
Q
Most active secretion happens in the _____ (what part of the nephron)
A
Distal convoluted tubule
-uric acids, K+, H+, drugs, foreign substances, creatinine, uric acid, bile salts
4
Q
Most reabsorption happens at the ______ (what part of the nephron)
A
Proximal tubule
5
Q
Renal threshold for glucose is a serum level of _____ mg/dL. If serum glucose rises above _____ mg/dL, it reaches saturation and glucose begins to spill into the urine.
A
180 mg/dL
6
Q
Angiotensin II acts in the proximal tubule to increase ___ & _____ reabsorption.
A
Na & H2O
*Acetazolamide and Mannitol are diuretics that work at the proximal tubule.
7
Q
_____ diuretics work at the thick ascending limb of the loop of Henle and produce very dilute urine. Strongest class of diuretics!
A
Loop (Furosemide- Lasix)
8
Q
Some side effects of loop diuretics include (think of the hypos…):
A
- Hypokalemia, hypocalcemia, hypomagnesemia, hypochloremia
- Hypochloremic metabolic alkalosis
- Hyponatremia
9
Q
_____ hormone works on the distal tubule to increase Ca+ reabsorption.
A
Parathyroid
*Thiazide diuretics work here. May cause HYPONATREMIA in setting of increased free water intake.
10
Q
_____ (specific diuretic) can cause pulmonary edema due to increased fluid shift (this drug is filtered but not easily reabsorbed and pulls fluid intravascularly)
A
Mannitol
*Used for increased intracranial pressure
11
Q
____ diuretics are specifically indicated for edema and HTN (pulmonary, CHF, nephrotic syndrome, and cirrhosis).
A
Loop (Lasix)
*Can cause hyperglycemia and hyperuricemia so use caution in patients with DM and GOUT
12
Q
_____ diuretics are indicated for patients with CHF (reduce mortality).
A
Potassium sparing (Spironolactone).
13
Q
Nephrotic Syndrome and EDEMA…
A
- Glomerular damage causes large tubular protein loss into the urine which leads to urinary loss of ALBUMIN
- This leads to decreased oncotic pressure and causes EDEMA
- Hyperlipidemia also results due to low protein levels stimulating the liver to synthesize proteins (including lipoproteins)
14
Q
Nephrotic syndrome is diagnosed by _____.
A
24 hour urine protein collection, >3.5g/day= nephrotic syndrome
-fatty casts, oval fat bodies, “maltese cross”
15
Q
Edema reduction is treated by ____ diuretics if mild and ____ diuretics if severe.
A
Thiazide; Loop
16
Q
Orthostatic hypotension is diagnosed by a drop in systolic BP of ____ mmHg or a drop in diastolic BP of ____ mmHg.
A
≥20 mmHg;
≥10 mmHg
*If secondary to hypovolemia there may be an increase in HR > 15 bpm
17
Q
Pharmacologic management of orthostatic hypotension includes:
A
Fludrocortisone and Midodrine
18
Q
In men, acute urinary retention is most often secondary to ____. It is rare in women.
A
BPH
*AUR most common in men > 60y
19
Q
3 main causes of AUR are:
A
- Outflow obstruction
- Neurologic impairment
- Inefficient detrusor muscle
20
Q
Other causes of outflow obstruction in men include:
A
Constipation, cancer (prostate or bladder), urethral stricture, urolithiasis, phimosis, or paraphimosis
21
Q
Is PSA checked when a patient presents with AUR?
A
No, because it is expected to be elevated anyway
22
Q
A bladder ultrasound that suggests a volume of ≥ ___cc in a patient unable to void suggests urinary retention.
A
300
*Patients with volumes less than 200cc (following catheterization) likely do not have acute urinary retention and the patient should be evaluated for other causes of abdominal and/or suprapubic discomfort.
23
Q
Urethral catheterization is contraindicated in patients who have had recent urologic surgery (eg, radical prostatectomy or urethral reconstruction), and these patients should have _______.
A
Suprapubic catheterization
24
Q
In men with BPH these medications are recommended for treatment of AUR:
A
Alpha-1-adrenergic blocker (ALFUZOSIN, TAMSULOSIN) and a 5-alpha reductase inhibitor (FINASTERIDE, DUTASTERIDE)
25
Some common causes of dysuria in men and women include:
1. Cervicitis- dx with STD testing
2. Cystitis- accompanied with urinary frequency and urgency, dx with clinical eval +/- urinalysis
3. Epididymo-orchitis- dx clinically
4. Prostatitis- dx clinically
5. Urethritis- usually have a visible discharge, dx with STD testing
6. Vulvovaginitis- dx clinically, urinalysis and culture to rule out UTI
7. Contact irritant or allergen (eg, spermicide, lubricant, latex condom), foreign bodies in the bladder, parasites, calculi, chemotherapy (cyclophosphamide), and radiation
8. Tumors (bladder, prostate, or urethral cancer)- will usually have hematuria without pyuria or infxn, dx with cystoscopy and urine cytology
26
When does third spacing occur postoperatively?
POD #3- fluids mobilize back into the intravascular space
| *make sure to switch to HYPOTONIC fluid and decrease IV fluid rate to avoid FLUID OVERLOAD
27
What are classic signs of third spacing?
Tachycardia, decreased UOP
*Treated with ISOTONIC IV fluids
28
What are the surgical causes of metabolic acidosis?
1. Loss of bicarb: diarrhea, ileus, fistula, high-output ileostomy
2. Increase in acids: lactic acidosis (ischemia), ketoacidosis, renal failure, necrotic tissue
29
What are the causes of hypochloremic alkalosis?
NGT suction, loss of gastric HCl through vomiting/NGT
30
What are the causes of metabolic alkalosis?
Vomiting, NG suction, diuretics, alkali ingestion
31
What are the causes of respiratory acidosis?
Hypoventilation (CNS depression), PTX, pleural effusion, parenchymal lung disease, acute airway obstruction
32
What are the causes of respiratory alkalosis?
Hyperventilation (anxiety, pain, fever, wrong ventilator settings)
33
What is the "classic" acid-base finding with significant vomiting or NGT suctioning?
Hypokalemic, hypochloremic metabolic alkalosis
Treatment= IVF, Cl-/K+ replacement
34
What can be followed to assess fluid status?
UOP, base deficit, lactic acid, vitals, weight changes, skin turgor, JVD, mucosal membranes, rales, central venous pressure, PCWP, chest x-ray findings
35
With hypovolemia, what changes occur in vitals?
Tachycardia, tachypnea, initial rise in diastolic BP because of clamping down (peripheral vasoconstriction) with subsequent decrease in both systolic and diastolic BPs
36
What are the surgical causes of hyperkalemia?
Iatrogenic overdose, blood transfusion, renal failure, diuretics, acidosis, tissue destruction (injury/hemolysis)
37
What are the S&S of hyperkalemia?
DECREASED DTRs, weakness, paraesthesia, paralysis, respiratory failure
*ECG: peaked T waves
38
Urgent treatment for hyperkalemia?
IV calcium, Lasix
39
What is the acronym for the treatment of acute symptomatic hyperkalemia?
"CB DIAL K"
C- Calcium
B- Bicarb
D- Dialysis
I- Insulin/dextrose
A- Albuterol
L- Lasix
K- Kayexalate
40
What are the surgical causes of HYPOkalemia?
Diuretics, some abx, steroids, alkalosis, diarrhea, NG aspiration, vomiting, insulin
41
What are the S&S of HYPOkalemia?
Weakness, tetany, nausea, vomiting, ILEUS, paraesthesia
42
What is the rapid treatment for HYPOkalemia?
KCl IV
43
What electrolyte deficiency can actually cause HYPOkalemia?
Magnesium
44
What are the surgical causes of HYPERnatremia?
Inadequate hydration, DI, diuresis, vomiting, diarrhea, diaphoresis, tachypnea, iatrogenic (TPN)
45
What are the S&S of HYPERnatremia?
Seizures, confusion, stupor, pulmonary/peripheral edema, tremors, respiratory paralysis
46
What IV fluids are used to treat HYPERnatremia?
D5W, 1/4 or 1/2 NS
47
What are surgical causes of HYPOnatremia?
1. Hypovolemic: diuretic excess, hypoaldosteronism, vomiting, NG suction, burns, pancreatitis, diaphoresis
2. Euvolemic: SIADH, CNS abnormalities, drugs
3. Hypervolemic: seizures, coma, nausea, vomiting, ileus, lethargy, confusion, weakness
48
What are the S&S of HYPOnatremia?
Seizures, coma, nausea, vomiting, ileus, lethargy, confusion, weakness
**Don't want to correct too quickly with fluids due to risk of Central pontine myelinolysis!
49
What are the causes of HYPERcalcemia?
"CHIMPANZEES"
```
C- Calcium supplementation
H- Hyperparathyroidism
I- Immobility/Iatrogenic (thiazide diuretics)
M- Mets
P- Paget's disease
A- Addison's dz/Acromegaly
N- Neoplasm
Z- Zollinger-Ellison syndrome
E- Excessive Vitamin D
E- Excessive Vitamin A
S- Sarcoid
```
50
What are the S&S of HYPERcalcemia?
"Stones, bones, abdominal groans, and psychiatric overtones"
-Polydipsia, polyuria, and constipation
51
What is the acute treatment of HYPERcalcemic crisis?
Volume expansion with NS, diuresis with Lasix
52
What are the surgical causes of HYPOcalcemia?
Short bowel syndrome, intestinal bypass, vitamin D deficiency, sepsis, acute pancreatitis, osteoblastic mets, diuretics, renal failure, hypomagnesemia
53
What is Chvostek's sign?
Trousseau's sign?
Chvostek's- Facial muscle spasm with tapping of facial nerve
Trousseau's- Carpal spasm after occluding blood flow in forearm with blood pressure cuff
54
What are the S&S of HYPOcalcemia?
Perioral paraesthesia (early), increased DTRs (late), confusion, abdominal cramps, stridor, seizures, psychiatric abnormalities
55
What is the acute treatment of HYPOcalcemia?
IV Calcium gluconate
*Be wary of tissue necrosis!! (if IV infiltrates)
56
What is the treatment for HYPERmagnesemia?
IV Calcium gluconate, insulin plus glucose, dialysis, Lasix
57
The "HYPERs" of electrolyte imbalances are usually associated with _____ (increased/decreased) DTRs
Decreased!
58
The "HYPOs" of electrolyte imbalances are usually associated with ______ (increased/decreased) DTRs
Increased!
59
Hypomagnesemia may make it impossible to correct what other electrolyte abnormality?
Hypokalemia!
60
What are the surgical causes of HYPERglycemia?
DM, infection, stress, TPN, drugs, lab error
61
What are the S&S of HYPERglycemia?
Polyuria, hypovolemia, confusion/coma, polydipsia, ileus, DKA (Kussmaul breathing), abdominal pain, hyporeflexia
62
What is the goal glucose level in the ICU?
80-110 mg/dL
63
What are the surgical causes of HYPOglycemia?
Excess insulin, decreased caloric intake, insulinoma, drugs, liver failure, adrenal insufficiency, gastrojejumostomy
64
What are the S&S of HYPOglycemia?
Diaphoresis, tachycardia, palpitations, confusion, coma, HA, diplopia, seizures
65
What is a complication of severe HYPOphosphatemia?
Respiratory failure
66
HYPOphosphatemia can be caused by:
Alcohol abuse, GI losses
67
What are the S&S of HYPERphosphatemia?
Calcification (ectopic), heart block
68
What electrolyte is an inotrope (affects force and speed of contraction)?
Calcium
69
What electrolyte must be monitored closely in patients on digitalis?
Potassium
70
What fluid is used to replace NGT (gastric) aspirate?
D5 1/2 NS with 20 KCl
71
_____ is the MC solid tumor in young men 15-40y.
Testicular CA
| *5 year survival is 90% with treatment--> VERY curable
72
Mostly commonly occurs in the ____ (left/right) testicle.
Right (where cryptorchidism MC occurs)
73
What are the 2 types of germinal cell tumors (usually malignant)?
1. Seminoma (SGCT)
| 2. Nonseminomatous (NSGCT)
74
What are the 4 S's of Seminoma?
Simple (lack tumor markers)
Sensitive (to radiation...)
Slower-growing
Stepwise spread
75
______ is an embryonal cell carcinoma that is MC in young boys 10y.
Nonseminomatous
76
_____ tumors are a type of Non-Germinal cell tumors that may be benign and secrete hormones which can lead to precocious puberty in children or gynecomastia/loss of libido in adults
Leydig cell tumors
77
S&S of testicular CA include:
Painless testicular nodule, solid mass, or enlargement
Gynecomastia
78
Workup of testicular CA includes:
1. Scrotal US- seminomas (hypoechoic mass)
2. Alpha-fetoprotein, p-hCG, LDH
- fetoprotein and p-hCG usually elevated in NSCGT
79
Treatment of testicular CA includes:
1. Low-grade (Stage 1) nonseminoma (limited to testes)- orchiectomy with retroperitoneal LND
2. Low-grade seminoma- orchiectomy-->radiation
3. High-grade seminoma- debulking chemo--> orchiectomy and radiation
80
MC cause of kidney stones is _____.
Decreased fluid intake
Also- males, medications, hypercalcemia, PCKD, UTIs
81
PE findings for kidney stones include:
CVAT, +/- hematuria, frequency and urgency
- Proximal ureter: flank pain, CVAT
- Mid-ureter: mid-abdominal
- Distal ureter: groin pain
82
Work-up for kidney stones reveals:
1. UA: gross hematuria, nitrites (obtain culture if infectious!)
2. Non-contrast CT abdomen!!!
3. Renal US (if CT contraindicated)
4. KUB radiographs
83
Treatment and management of kidney stones:
1. Stones <5mm have an 80% chance of spontaneous passage
2. Give IV fluids, analgesic, antiemetics, TAMSULOSIN (alpha blocker that may facilitate passage)
3. Stones >7mm IN DIAMETER
- Extracorporeal shock wave lithotripsy
- Uteroscopy + stent used for immediate relief
- Percutaneous nephrolithotomy- most invasive used for large stones (>10mm). Incision made in the back and stone is removed via a tube.
84
A nephroblastoma that is MC in CHILDREN within the first 5y of life is known as a _____ tumor.
Wilms
| *MC abdominal malignancy in children
85
MC manifestation of a Wilms tumor is:
Painless, palpable abdominal mass, hematuria, +/- HTN, anemia
*Dx- abdominal US: best initial test. CT w/contrast or MRI is more accurate
**Treatment- nephrectomy followed by chemo (lung common site for METS)
86
MC's of Bladder CA:
Smoking, Age > 40y, White males, Transitional Cell (TCC)
87
S&S of bladder CA include:
Painless gross or microscopic hematuria
88
Bladder CA diagnosed by:
Cystoscopy with biopsy
89
Treatment and Management of Bladder CA:
- Most present early and respond well to treatment- HIGHEST RECURRENCE RATE OF ALL CANCERS
- Localized or superficial: transurethral resection
- Invasive disease: radical cystectomy
- Recurrent bladder CA: BCG- immune reaction stimulates cross reaction with tumor antigens. Do not use BCG if immunocompromised or if gross hematuria present
90
RF for RCC include:
Smoking, dialysis, HTN, obesity, men
91
Classic triad of RCC includes:
Hematuria, Flank/abdominal pain, palpable mass
-HTN and hypercalcemia common
92
Work-up of RCC includes:
CT scan usually first test!
93
Treatment for RCC includes:
Radical nephrectomy!
94
CKD is defined by progressive functional decline ≥3 months-years evidenced by:
1. Proteinuria
2. Abnormal urine sediment
3. Abnormal serum/urine chemistries
4. Abnormal imaging studies
5. Inability to buffer pH
6. Inability to make urine
7. Inability to excrete nitrogenous waste
8. Decreased synthesis of Vitamin D and erythropoietin
95
Staging of CKD
Stage 0- At risk: DM, HTN, chronic NSAID use, A.A./Hispanic/Asian, age>60y, SLE, s/p kidney tx, family hx
Stage 1- Kidney damage with normal GFR (or >90), Kidney damage: proteinuria, abnormal UA, serum, imaging
Stage 2- GFR 89-60
Stage 3- GFR 59-30
Stage 4- GFR 29-15
Stage 5- GFR < 15 (End Stage Renal Disease= uremia requiring dialysis and/or transplant)
96
NORMAL GFR= 120-130
Badass kidneys!
97
Etiologies of ESRD include:
1. MC= DM!!!
2. HTN= 2nd MC cause
3. Glomerulonephritis
98
ESRD diagnosed by:
1. Proteinuria- single best predictor of dz progression (ACR v. 24h urine collection- p. 346)
2. UA- abnormal sediment, broad waxy casts
3. Estimated GFR
4. Increased BUN/Creatinine
5. Renal US- small kidneys classic (large kidneys in diabetic nephropathy and PKD)
99
Clinical manifestations of CKD usually not seen until advanced disease
SEE P. 347!!
-think metabolic acidosis (decreased by protein restriction), petechiae (platelet dysfunction)
100
p. 347 for Management of Complications of CKD!!
Browse
101
Dialysis indicated when GFR ≤ ____ and/or serum creatinine ≥ ____.
10mL/min
8mg/dL
102
Renal artery stenosis is a major cause of _____.
HTN
*RAS is MC cause of secondary HTN!!! (HTN due to activation of RAAS)
103
Etiologies of Renovascular HTN include:
1. Atherosclerosis MC in elderly!
104
Clinical manifestations of RAS include:
Abdominal renal bruit, HA, refractory HTN
105
Dx of RAS done by:
Renal arteriography is most definitive (gold standard)!!
Also CT, MRA, and US options
106
RAS management includes:
Surgical revascularization (angioplasty with stent is definitive)
ACEI/ARBs (inhibits aldosterone & angiotensin II-mediated vasoconstriction).--> CONTRAINDICATED if bilateral stenosis or solitary kidney because ACEI markedly reduces renal blood flow and GFR in these patients--> AKI!
107
What is the mainstay of therapy for rhabdomyolysis?
IV rehydration with crystalloids for 24 to 72 hours
108
______ is seen in epididymitis when elevation of the scrotum with the affected epididymis to the level of the symphysis pubis brings relief from the pain.
Prehn's sign
109
Patient with chronic rheumatoid arthritis on maintenance prednisone and methotrexate undergoes surgery. She develops hyponatremia, hypoglycemia, and hypotension. In addition to IV fluid therapy, what is the best initial therapy?
The acute phase of adrenal crisis is treated with IV saline and hydrocortisone.
110
_______ is caused by a decrease in blood flow (hypoperfusion) to the kidneys. However, there is no inherent kidney disease. It can occur following hemorrhage, shock, volume depletion, congestive heart failure, adrenal insufficiency, and narrowing of the renal artery among other things.
Prerenal azotemia.
Patients who have prerenal azotemia with otherwise normal kidneys will have SEVERE SODIUM RETENTION in order to help to save fluid. The amount of sodium in the urine is therefore very low.
111
What is the most common presenting symptom/sign of renal cell carcinoma?
Hematuria (approximately 60%). Flank pain or abdominal mass is present in about 30% of new cases
