Urology/Renal

Question 1

Respiratory Acidosis
Path:
Pt:
Dx:
Tx:

Answer 1

Path: Hypoventilation

Pt:
Opiates-> pinpoint pupils, track marks
Asthma/COPD-> wheezing
OSA-> Fat, daytime somnolence

Dx: pH < 7.35, CO2 > 45

Tx: Treat underlying cause, Support respiration

Question 2

Respiratory Alkalosis 
Path:
Pt:
Dx:
Tx:

Answer 2

Path: Hyperventilation

Pt:
Pain, anxiety
Hypoxemia
Fast respiratory rate

Dx: pH >7.45, CO2 < 35

Tx: Tx underlying cause

Question 3

Metabolic Alkalosis
Path:
Pt:
Dx:
Tx:

Answer 3

Path: Hyperaldosteronism

Pt: Volume deplete (diuresis, dehydration, NG tube suction, emesis)

Dx: pH > 7.45, HCO3 > 26

Tx: Urine chloride

UCl < 10 -> fluids

UCl >10

• HTN: RAS, Conn’s
• No HTN: Bartter, Gitelman

Question 4

Metabolic Acidosis 
Path:
Pt:
Dx:
Tx:

Answer 4

Path: ap vs Non-Gap

Dx: pH < 7.35, HCO3 < 22

Tx: Anion Gap = Na+ - (Cl + HCO3)

>12 elevated anion gap
Path: MUDPILES
Methanol
Uremia
DKA
Propylene 
Iron
Lactic acidosis
Ethylene glycol
Salicylates

<12 -> non-anion gap
Urine anion gap
-Positive: renal tubular acidosis
-Negative: diarrhea

Question 5

AKI-Path

Answer 5

Pre-renal (MC type of AKI, often progresses to intrinsic if not corrected)

• Hypovolemia
• Afferent arteriole constriction: NSAIDs, IV contrast
• Efferent dilation: ACEI, ARBs

Intrinsic

• Acute tubular necrosis (ATN)-> MC cause of intrinsic AKI
• Acute Tubulointerstitial Nephritis (AIN)
• Acute Glomerulonephritis (AGN)
• Vascular

Post-renal: Obstruction

Question 6

AKI- Acute tubular necrosis (ATN)
Path:
Dx:
Tx:

Answer 6

Acute destruction/necrosis of renal tubules of the nephron
Ischemic: prolonged prerenal, hypotension, hypovolemia, post-op
Nephrotoxic:
-exogenous: aminoglycosides, contrast dye, cyclosporine
-endogenous: crystal precipitation (gout), myoglobinuria (rhabdomyolysis), lymphoma, leukemia, Bence-Jones (multiple myeloma)

Dx: epithelial cell casts and muddy brown casts

Tx:
Remove offending agent(s)
IV fluids
furosemide (if pt is euvolemic and not urinating)

Question 7

AKI- Acute Tubulointerstitial Nephritis (AIN)
Path:
Pt:
Dx:
Tx:

Answer 7

Path:
Inflammatory/allergic response
Drug hypersensitivity-> penicillins, NSAIDs, sulfa drugs
Infections: Strep, legionella, CMV, EBV, HIV
Autoimmune: SLE, sarcoidosis, cryoglobulinemia
Idiopathy

Pt: fever, eosinophilia, maculopapular rash, arthralgias

Dx: WBC casts

Tx: Remove offending agent

Question 8

AKI- Acute Glomerulonephritis (AGN)]
Dx:
Tx:

Answer 8

Dx: Hematuria (RBC casts), HTN, azotemia, proteinuria

Tx:
High-dose corticosteroids
cytotoxic agents

Question 9

AKI- Vascular

Path:

Answer 9

Microvascular: TTP, HELLP syndrome, DIC

Macrovascular: aortic aneurysm, renal artery dissection, renal artery/vein thrombosis, malignant hypertension, atheroembolic disease

Question 10

AKI-> U/A
RBC casts:
Oval Fat Bodies:
Muddy Brown casts:
WBC casts:
Waxy casts:
Fatty casts:
Hyaline casts: 
Normal U/A:
Epithelial Cell casts:
Maltese Crosses:

Answer 10

RBC casts: AGN, vasculitis 
Oval Fat Bodies: Nephrotic syndrome 
Muddy Brown casts: ATN
WBC casts: AIN, pyelonephritis 
Waxy casts:
-narrow: chronic ATN, glomerulonephritis 
-broad: ESRD
Fatty casts: Nephrotic syndrome 
Hyaline casts: Nonspecific 
Normal U/A: prerenal, postrenal
Epithelial Cell casts: ATN
Maltese Crosses: Nephrotic syndrome

Question 11

BPH
Path:
Pt:
Dx:
Tx:

Answer 11

Path: Enlarged prostate
MC by stroll and epithelial cell growth in transitional zone of prostate

Pt:
Incomplete voiding, urinary frequency, straining to begin urination, urgency, nocturia, change in force or the urinary stream

Dx:
DRE-> smooth and symmetrically enlarged “rubbery”
Elevated PSA

Tx:
Alpha-blockers-> doxazosin, terazosin, prazosin, tamsulosin
Relax smooth muscle of bladder neck

5-alpha-reductase inhibitors-> finasteride, dutasteride
Shrink the prostate

Surgery: Transurethral resection of the prostate (TURP)