week 3 Renal Flashcards
proteinuria is a hallmark of
- renal disease
- Urinary protein excretion of >150 mg/day (10 to 20 mg/dL)
- can be benign or something bad
what is the most accurate way to quantify protein in urine?
24 hour urine collection
proteinuria before 24 weeks gestation indicates
glomerulonephritis./renal related
refer to OB (even if BP is normal)
Proteinuria after 24 weeks’ gestation is usually a sign of
preeclampsia
refer to OB
what to assess in HPI for proteinuria?
- personal and family history (esp. renal and DM).
- Assess: Chronic illness, surgery, diagnostic procedures (contrast media), urinary frequency or symptoms suggesting infection, risk factors, HIV infection
- Prescription and OTC (NSAIDs)
proteinuria diagnostics
- repeat dipstick
- bens jones proteins (MM)
- urine dipstick
- UA C&S
- CBC w diff
- fasting blood glucose
- HbA1c
- lipid profile
- 24 hr urinary protein excretion or spot urinary protein/creatinine ratio
proteinuria differentials
Transient proteinuria
• Persistent proteinuria
• Orthostatic proteinuria or nonorthostatic proteinuria • Glomerulonephritis
• Diabetic nephropathy
• Nephrotic syndrome
• Vasculitis
• Medications
proteinuria management
- ACE inhibitors reduce proteinuria by decreasing interglomerular pressure
- If have hyperlipidemia and/or hypertension, treat aggressively
- Patients with chronic renal failure should be managed aggressively
- eliminate trigger
- Na/ protein restricted diets
hematuria characterized by
- more than 3 RBCs per high-power microscopic field (hpf)
- transient - 1 occasion
- persistent - 2 or more consecutive occasions
- visible vs occult
what is the first q you want to ask a child bearing woman if have hematuria?
when was your last menstrual period
what can cause hematuria
- Diet, physical activity, and menstrual history, recent travel, nephrolithiasis
- meds: beta lactam antiboitics, sulfonamides, NSAIDs, rifampin, zyloprim, Tagamet, dilantin, anticoagulant
- caffeine, spices, chocolate, alcohol, citrus fruits, soy sauce
hematuria physical exam
- Costovertebral angle tenderness:
- Abdominal mass:
- Suprapubic tenderness:
- Urethral discharge:
- Enlarged and/or tender prostate: b
- Costovertebral angle tenderness: pyelonephritis / UTI
- Abdominal mass: neoplasm, polycystic kidney disease
- Suprapubic tenderness: bladder etiology
- Urethral discharge: urethritis
- Enlarged and/or tender prostate: benign prostatic hyperplasia, prostatitis
if see casts in urine…
injury to NEPHRON!
proteinuria AND hematuria suggests
- glomerular or interstitial nephritis
proteinuria AND hematuria suggests
- glomerular or interstitial nephritis
Gross hematuria suggests
- acute cystitis, urethritis, UTI
often seen with acute obstruction and is usually caused by calculi or bladder tumor, or infection
in pregnant or pediatric pt, what diagnostic would you want to do?
ultrasound spare radiation from CT
risks/triggers of kidney stones
- Diet (e.g., salt, oxalate, calcium)
- Dehydration
- High-mineral-content drinking water
- Tea, grapefruit/apple juice, cola, sports/energy drinks
- Sedentary lifestyle/occupation—drivers/desk workers
- Family history
- Gout, primary hyperparathyroidism, short bowel syndrome, hyperinsulinism, etc.
how do kidney stones form?
d/t elevated levels of stone forming salts and inadequate inhibitory proteins
most common stone in diabetics
uric acid stones
majority of acute renal and urinary calculi can be managed
- conservatively through oral hydration, pain management, and expectant stone passage.
kidney stone clinical presentation
- sx based on location
- acute renal or ureteral colic
- n/v
- hematuria
- fever and cills
- dysuria
- increase urinary frequency
- vague abdominal flank or groin pain
stones < 6-8mm…
conserv management
stones > 8mm…
- Surgical management
- Extracorporeal shock wave lithotripsy (ESWL)
- Percutaneous nephrolithotomy (PCNL)
- Ureteroscopy (URS)
- Monitor/lifestyle adaptations, ongoing pH surveillance
if microscopy is positive for RBC and negative for heme,
look at microscopy and morphology of RBC
if abnormal RBC, can be glomerular cause
Oliguria, gross hematuria, strep rash or HSP, lethargy, anorexia, nausea, vomiting, abdominal pain, weight gain with abrupt onset
post infectious glomerulonephritis
send to urology asap
after treating UTI with hematuria, always
repeat UA just in case there’s is hematuria
does isolated, transient hematuria or hematuria related to a UTI need a referral?
no, only if to evaluate other causes of hematuria, bc high risk of malignancy
if have large amounts of frank hematuria, severe flank pain suggestive of renal calculi, unstable vital signs, signs of urologic obstruction, or acute renal failure = urgent referral
gross hematuria with abdominal pain, with or without bloody stools, arthralgias, and purpuric rash
Consider Henoch-Schönlein purpura (HSP)
gross hematuria, proteinuria, precipitated by viral infections or strenuous exercise,
- episode lasts <72 hrs
blood pressure and C3 is normal & no edema is present
Consider IgA nephropathy aka Bergers disease
orthostatic proteinuria
child excretes abnormal amounts of protein when upright but normal amounts when lying down.
Persistent asymptomatic proteinuria
common, transient phenomenon in which an otherwise healthy child, with normal clinical and laboratory workup, has an abnormally high level of protein in the urine.
if benign etiology or if treat for UTI and there is microscopic hematuria,
repeat UA after treatment. if UA negative, repeat UA yearly
what is considered abnormal trace of protein in urine?
1+ on dip stick
30 mg/dL
sulfosalicyclic acid test can also detect all forms of proteinuria
initial work up for child with proteinuria:
get first morning dipstick test (if >1), get UPR/Cr ratio (if < 0.2) or abnormal urinalysis → get further PE and hx, and lab tests
nephrotic syndrome on lab and sx’s
- 3 to 4+ protein with UA
- > 40 mg/m2/hr or a protein : creatinine ratio on a first morning void of greater than 2 to 3 :1
- hypoalbuminemia (< 2.5 g/dL)
- edema (periorbital, dependent)
- hyperlipidemia
- foamy urine, weight gain
nephrotic syndrome in adults sx’s
- Pedal/ankle edema
- Transverse leukonychia on fingernails
- Xanthomas (fatty deposits in skin)
- periorbital edema unless if advanced
nephrotic syndrome diagnosis
- ALL 3 criteria needed:
- urinary protein excretion rate of >3.5g/day
- Peripheral edema on exam
- Low serum albumin
- Hyperlipidemia
- Start initial workup workup for nephrotic syndrome in primary care
- Check renal, CBC , UA with microscopy
- Check serum albumin
- Electrolytes, glucose
- Lipids
- Refer to nephrology
- If think lupus, order additional testing
consider what with nephrotic syndrome?
lupus, get additional testing
initial workup workup for nephrotic syndrome
- Check renal, CBC , UA with microscopy
- Check serum albumin
- Electrolytes
- Glucose
- Lipids
nephrotic syndrome management
- Refer to nephrology
- If improving with proteinuria, continue with steroids and Na restrictions until negative for protein (don’t taper off)
- Children
- Tx with Oral steroids for 2.5–3 months
- Management of edema • Steroid-resistant—renal biopsy • Diet • Calcium and vitamin D • Blood pressure
- Adults
- ACE inhibitor
- Manage edema
- Diuretics
- Diet
- Statin for hyperlipidemia • Immunosuppressive therapy depending on cause •
- Prophylactic anticoagulant if at high risk
- Elevation of GFR rate
- RBC casts on UA
- mild Proteinuria
Iga Nephropathy
refer!
chronic kidney disease defined as
abnormalities in kidney structure or function for greater than 3 months with marker of kidney damage of 1 or more:
- Albuminuria
- Urine sediment abnormalities
- Electrolyte and other abnormalities from tubular disorders
- Abnormalities detected by histology
- Structure abnormalities detected by imaging
- History of kidney transplantation
- GFR < 60
most common cause of CKD
diabetes (high glucose in glomeruli scars the glomeruli and doesn’t filter blood)
Stage 1 / GFR 1
> 90
with other evidence of kidney damage (persistent microalbuminuria or proteinuria, hematuria, structural abnormalities, biopsy-proven glomerulonephritis.)
Stage 2 / GFR 2
60- 89
mildly decreased
GFR 3a
45-59
mildly to moderately decreased
GFR 3b
30-44
moderately to severely decreased
GFR 4
15-29
severly decreased
GFR 5
< 15
kidney failure
GFR 5
< 15
kidney failure
PE of CKD
vital signs (BP)
funduscopic evaluation for signs of arteriovenous nicking, diabetic retinopathy, and papilledema;
peripheral pulse characteristics
Volume status is determined with auscultation of lung sounds
jugular vein distention
edema
heart sounds. Pericarditis and pleural effusions can be a complication of CKD
skin - ecchymosis, rashes, uremic frost, pruritus
most important diagnostic in monitoring pt’s with CDK
serum creatinine test with GFR and 1st morning or random urine sample to assess for presence of albuminuria
complications of chronic renal failure
HTN, pulmonary edema, HF, hyperlipidemia, electrolyte abnormalities, anemia, erythropoeiten deficit
labs to check in a pt with CKD?
Electrolytes, calcium, vit D, lipids, CBC, glucose
when do you refer to nephrologist with CKD for pediatrics?
if < 18, refer immediately! Late referral means referral to specialist services less than one year before start of renal replacement therapy (RRT).
When do you refer to a nephrologist for an adult patient with CKD?
- Acute kidney injury (AKI) or abrupt sustained fall in GFR
- Consistent finding of significant albuminuria
- Progression of CKD
- Urinary red cell casts, RBC > 20 per high-power field (HPF) sustained and not readily explained
- CKD and hypertension refractory to treatment with 4 or more antihypertensive agents
- Persistent abnormalities of serum K
- Recurrent or extensive nephrolithiasis
- Hereditary kidney disease
what is a normal urinaryalbumin/creatinine ratio range?
< 30 mg/g (abnormal if it is elevated)
recommend method for pt with diabetes
A 40-year-old man with hypertension and diabetes type 2 has a normal creatinine, an estimated GFR greater than 90 mL per min per 1.73 m2, and a urinealbumin/creatinine between 100 to 200 mg/g on repeat urinalysis for the past 6 months. Which of the following best describes his kidney function?
This patient has a normal GFR and persistent proteinuria over the past 6 months, so he has stage 1 CKD. Stage 1 CKD is defined as normal GFR (greater than 90 mL per min per 1.73 m2) with evidence of kidney damage that is persistent for longer than 3 months. Stage 2 CKD is defined as GFR 60 to 89 mL per min per 1.73 m2 with evidence of kidney damage for longer than 3 months. Stage 3 CKD is defined as GFR 30 to 59 mL per min per 1.73 m2 for longer than 3 months. Stage 4 CKD is defined as GFR 15 to 29 mL per min per 1.73 m2 for longer than 3 months. Stage 5 CKD is defined as GFR less than 15 ml per min per1.73 m2 for longer than 3 months or kidney failure treated with dialysis or transplantation. This is a chronic, and not acute condition. He does not have normal renal function as evidenced by the persistent proteinuria.
which medications should NOT be used concurrently or with patients with bilateral renal artery stenosis
avoid ACE or ARBs, NSAIDs → increases the risk of hyperkalemia
when should metformin be discontinued?
GFR < 30
metformin should be reviewed if GFR 30-44
continue metformin if GFR > 45
because diabetes and hypertension are highly associated with CKD, clinical guidelines for management of both diabetes and hypertension recommend
regular UA, albumin/creatinine ratio (ACR), & serum creatinine to estimate GFR
if have diabetes, screen at time of diagnosis of db and 5 years after diagnosis
CKD management
- BP < 130/80
- ACE/ARB for diabetics with microalbumuria
- low dose aspirin
- statin if > 50 yrs
- hg A1c < 7%
- refer if ACR > 300 mg, GFR < 30, RBC casts in urine
- acid base electrolytes
- avoid nephrotoxic drugs (NSAIDs)
- vaccines
- diet and weight management
- can cause hyperparathyroid disease, hyperlipidemia, alterations in vitamin D/Ca/phosphorus
intermittent severe pain in flank or groin
renal colic
nephrolithiasis
risk factors for nephrolithiasis
- Obesity (sendentary, diet)
- family history
- hyperparathyroidism
- low fluid intake
- Diet - animal products, high salt diet
- Excess antiacids (from higher levels of calcium)
- Hx gout
- Tropical climates (sweating causes dehydration)
Older male comes in with gross hematorua, denies flank pain and fever…
- Worry about malignancy
- We want to refer for cystoscopy and imaging
Child has nephrotic syndrome, tell kids parents
- Steroids will be used when relapses occur and should be continued until urine is negative for protein
- Steroids are not given continuously and NOT used prophylatc
- Used past experience to help guide what to treat
adolescent with R flank pain, gross hematuria without signs of infection, has renal stones
initial treatment is to increase fluids to 2L daily to flow it out
initial testing for poststreptocococcal glomerulonephritis
CBC, ESR, UA, BMP, creatinine
complement levels and antistreptolysin O (ASO) titer
C3 levels in post infectious GN/poststreptococcus GN should be
decreased in all types [hypocomplementemia]
if < 15, positive (normal 83-152)
elevated Antistreptolysin (ASO) titer means
ASO > 250 is positive (normal 125-250)
recent GAS infection and consistent with dx of poststrep G.N.
when does c3 return back to normal
6-8 weeks of disease onset
if doesn’t decrease, raises concern for other types of G.N. (membranoproliferazive glomerulonephritis MPGN) and C3 glomerulopathy)
Poststrep G.N. management
- consult with neph
- 95% resolve spontaneously w/o treatment
- acute phase → antihypertensives (CCB) with na restrictions for hypertension and edema or diuretics
- antibiotics does NOT decrease incidence of PSGN
- traces of proteinuria /microscopic hematuria normal - resolves in weeks/months, hematuria resolves 6-12 months
besides hematuria, what else can cause a positive blood urine dipstick but have no red blood cells on microscopy?
Myoglobinuria or hemoglobinuria
[pseudohematuria]
microscopic examination for RBCs is needed to differentiate RBCs from hemoglobinuria or myoglobinuria.
What additional information is obtained by UA with microscopy?
confirm the presence RBCs, show # of RBCs, presence of cell casts, or significant protein.
The presence of protein, RBC casts, and dysmorphic RBCs would be indicative of glomerulonephritis. Presence of leukocyte esterase, nitrites, and bacteria = suggestive of infection.
isolated hematuria
(hematuria unaccompanied by any other abnormal urine components) can result from bleeding anywhere from the renal pelvis to the urethra but is rarely caused by systemic disease
extra renal causes of isolated hematuria
urolithiasis, bladder stones, cancer of the ureter, bladder cancer, prostate cancer in a man, infection, and trauma.
if pt has asymptomatic hematuria…
get thorough history and physical can may help guide identification of a benign cause of asymptomatic hematuria.
Diagnostic evaluation for asymptomatic hematuria
urine culture, renal imaging, CBC, CMP
NO urinary cytology or urine-based molecular markers to detect bladder cancer in the initial evaluation of hematuria due to their poor sensitivity and low value.5,6
if suspect glomerulonephritis, what further diagnostics needed
Complement evaluation, antinuclear antibody (ANA), antistreptolysin O (ASO) titer, antineutrophil cytoplasmic antibodies (ANCAs), and anti-glomerular basement membrane.
Urgent or emergent referral with nephrology if unstable patient with suspected GN.
all gross hematuria warrants
referral for urgent urologic evaluation with renal function testing, cystoscopy, and imaging. Regardless of diagnostic evaluation for a benign cause of asymptomatic hematuria, the ACP advises urgent referral for urologic evaluation in all adults with gross hematuria.
if pt is on a anti platelet or anticoagulant and has hematuria
should not be a satisfactory explanation for hematuria and still evaluation even if the patient is on antiplatelet or anticoagulant therapy
diagnostics for renal tubular acidosis
Serum electrolytes, glucose, CO2, BUN, Cr, calcium, phos, Alk Phos, first morning UA void, consider 24 hour creatinine clearance and calcium-creatinine ratio, renal ultrasound
RTA treatment
- Oral alkalizing agents
- Check labs in 3 days after initiating
RTA family education
- Maximize caloric intake, avoid water and non-caloric foods.
- Close follow up
- Weight and labs should be monitored every 2 weeks to monthly until weight gain is established.
- Referral to nephrology if pt is not gaining weight or not responding to treatment.
- Isolated pRTA responds quickly to treatment
- distal RTA lasts lifetime
glomerulonephritis symptoms
- POSTinfectious
- R. O. P. E. L.
- Red urine (gross hematuria)
- oliguria
- proteinuria
- Elevated BP, BUN
- L. ow C3
- strep rash / Henoch-Schonlein purpura
- lethargy
- anorexia
- nausea/vomiting
- abdominal pain
- abrupt weight gain
glomerulonephritis workup
- CBC
- ESR
- UA
- BMP
- complement levels LOW
- antistreptolysin titer (ASO)
- high = recent GAS infection
glomerulonephritis diagnosis
- clinical sx’s
- Low C3’s
- hx of recent GAS infection
glomerulonephritis management
- resolves 95% of time with no treatment
- consult with nephrology
- elevated BP/edema = antihypertensive (CCB & Na restrictions)
- NO antibiotics..doesn’t decrease incidence of PSGN
- creatinine returns to normal w/in first 4 weeks
- hypocomplementemia resolves in 8 weeks (if persits = refer)
