Week 3 Renal Disorders Flashcards
Which of the following commonly-used medications can cause drug-induced nephrotoxicity? (Select all that apply)
A Naprosyn
B Macrolides
C Lithium
D Omeprazole
E Beta blockers
F Select serotonin reuptake inhibitors (SSRIs)
G Angiotensin-converting enzyme inhibitors (ACEIs)
H Furosemide
A Naprosyn
C Lithium
D Omeprazole
G Angiotensin-converting enzyme inhibitors (ACEIs)
H Furosemide
Which of the following is NOT a function of the kidneys?
A Control of the production of red blood cells
B Removal of waste products from the body
C Regulation of sodium and potassium in the body
D Production and regulation of calcium levels in the body
D Production and regulation of calcium levels in the body
The kidneys
remove waste products from the body
remove drugs from the body
balance the body’s fluids
release hormones that regulate blood pressure
produce an active form of vitamin D that promotes strong, healthy bones
control the production of red blood cells
Parathyroid hormone causes calcium reabsorption in the kidney, but the kidney does not produce calcium.
Describe the physiology of the nephron by placing the following in the correct order:
Blood flow from afferent arteriole
glomerular filtration
tubular reabsorption
tubular secretion
reabsorption of water
Parts of a UA
color clarity/turbidity pH specific gravity glucose ketones nitrites leukocyte esterase bilirubin urobilrubin blood protein RBCs WBCs squamous epithelial cells casts crystals bacteria yeast
normal UA color
yellow (light/pale to dark/deep amber)
normal UA clarity/turbidity
clear or cloudy
normal UA pH
4.5- 8
normal UA specific gravity
1.005- 1.025
normal UA glucose
= 130 mg/dL
normal UA ketones
none
normal UA nitrites
negative
normal UA leukocyte esterase
negative
normal UA bilirubin
negative
normal UA urobilirubin
small amount (0.5- 1 mg/dL)
normal UA blood
= 3 RBCs
normal UA protein
= 150 mg/d
normal UA RBCs
= 2 RBCs/hpf
normal UA WBCs
= 2 - 5 WBCs/hpf
normal UA squamous epithelial cells
= 15- 20 squamous epithelial cells/hpf
normal UA casts
0- 5 hyaline casts/lpf
normal UA crystals
occasionally
normal UA bacteria
none
normal UA yeast
none
Urine specimen interpretation analyzed
in 3 parts:
gross visual examination
chemical exam/urine dipstick
microscopic exam/urine sediment
can distinguish type of kidney stone
urinary pH
measures how the kidney concentrates urine
specific gravity
results when blood glucose is > 180
glucose
results from fat metabolism
ketones
caused by bacteria in the urine capable of converting nitrates
nitrite
enzyme of WBCs which indicates pyuria
leukocyte esterase
related to certain liver diseases
bilirubin
if significant or persistent, may suggest kidney dx
protein
suggests presence of greater than three RBCs per hpf or myoglobinuria
blood
An adolescent has 2+ proteinuria in a random dipstick urinalysis. A subsequent first-morning voided specimen is negative for protein and urine creatinine ratio is less than 0.2. What will the primary care nurse practitioner do to manage this condition?
A Repeat the first morning urine dipstick test in one year
B Order a 24-hour timed urine collection for creatinine and protein excretion
C Reassure the parents that this is a benign condition with no follow-up needed
D Refer the child to a pediatric nephrologist for further evaluation
A Repeat the first morning urine dipstick test in one year
Orthostatic proteinuria is the most common cause of proteinuria in children and is more common in adolescent males. It is a benign condition but does require follow up urine testing at one year.
A 40-year-old female patient reports hematuria and a urine dipstick and culture indicate a urinary tract infection. After treatment for the urinary tract infection (UTI), what testing is indicated for this patient?
A 24-hour urine collection to evaluate for glomerulonephritis
B Bladder scan
C Repeat urinalysis
D Voiding cystourethrogram
C Repeat urinalysis
After treatment has been completed, repeated urinalysis is necessary to ensure that the hematuria has resolved. Failure to follow hematuria to resolution may result in failure to diagnose a serious condition.
A patient presents to the clinic for red-brown colored urine for the past eight hours. The nurse practitioner orders a urinalysis and and notes there is 2+ heme but negative for red blood cells. What does the nurse practitioner suspect?
A Hemoglobinuria or myoglobinuria
B Acute kidney injury
C A glomerular etiology
D Urethritis
A Hemoglobinuria or myoglobinuria
If a urinalysis is positive for heme but negative for red blood cells, the nurse practitioner should suspect myoglobinuria or hemoglobinuria.
A healthy 14-year-old female has a dipstick urinalysis that is positive for 5-6 RBCs per hpf but otherwise normal. What is the first question the primary care nurse practitioner will ask this patient?
A “Are you sexually active?”
B “Are you taking any medications?”
C “Have you had a recent fever?”
D “When was your last menstrual period (LMP)?”
D “When was your last menstrual period (LMP)?”
Menstrual history should be part of the initial assessment of microscopic hematuria in females of reproductive age since a positive UA for blood can be due to bleeding from the reproductive tract.
An older male patient reports gross hematuria but denies flank pain and fever. What will the nurse practitioner do to manage this patient?
A Monitor his blood pressure closely
B Obtain a catheterized urine sample
C Perform a 24-hour urine collection
D Refer for cystoscopy and imaging
D Refer for cystoscopy and imaging
Gross hematuria in older men denotes a significant risk of malignant disease, so cystoscopy and imaging are indicated. Proteinuria is concerning for hypertension. The patient does not have flank pain or fever, so the likelihood of infection is lower. Catheterizaton and a 24-hour urine collection is not indicated.
A child is diagnosed with nephrotic syndrome, and the nurse practitioner provides primary care in consultation with a pediatric nephrologist. The child was treated with steroids and responded well to this treatment. What will the nurse practitioner tell the child’s parents about this disease?
A “Future episodes are likely to have worse outcomes.”
B “Steroids will be used when relapses occur.”
C “This represents a cure from this disease.”
D “Your child will need to take steroids indefinitely.”
B “Steroids will be used when relapses occur.”
Nephrotic syndrome is a chronic disease characterized by periods of remission and relapse. It is important for the patient and parent to monitor for proteinuria to identify relapse. Steroids are usually taken for 2.5-3 mo. The prognosis is good with steroid responders, relapses decrease as the child gets older.
A child who has nephrotic syndrome is on a steroids and a salt-restricted diet for a relapse of symptoms. A dipstick urinalysis shows 1+ protein, down from 3+ at the beginning of the episode. In consultation with the child’s nephrologist, what is the correct course of treatment considering this finding?
A Begin a taper of the steroid medication while continuing salt restrictions
B Continue with steroids and salt restrictions until the urine is negative for protein
C Discontinue the steroids and salt restrictions now that improvement has occurred
D Consider starting non-corticosteroid medication such as cyclophosphamide
B Continue with steroids and salt restrictions until the urine is negative for protein
Relapses are treated with a short course of steroids and the patient is weaned as soon as proteinuria resolves. During active disease, sodium restrictions may be placed by the nephrologist. Non-corticosteroid medication is started by a nephrologist if the child is steroid dependent, steroid resistant or has frequent relapses.
Which of the following are consistent with a diagnosis of nephrotic syndrome?
A Gross hematuria, microalbuminuria, and decreased GFR
B Proteinuria, peripheral edema, and low serum albumin
C Pyuria, elevated blood pressure, and flank pain
D Hyaline casts, microscopic hematuria, and elevated creatinine
B Proteinuria, peripheral edema, and low serum albumin
Nephrotic range proteinuria, edema, and low serum albumin are all present with nephrotic syndrome. Hyperlipidemia is also a common finding. Microscopic hematuria can occur, but gross hematuria is not characteristic of NS.
Which of the following symptoms commonly occurs with acute glomerulonephritis?
A Fever
B Heavy proteinuria
C Hematuria
D Polyuria
C Hematuria
Acute GN is characterized by HTN, edema, hematuria, azotemia, and slight proteinuria.
A child diagnosed with Group A beta-hemolytic streptococci (GABHS) two weeks prior is in the clinic with periorbital edema, dyspnea, and elevated blood pressure. A urinalysis reveals tea-colored urine with hematuria and mild proteinuria. What will the primary care nurse practitioner do to manage this condition?
A Prescribe a 10- to 14-day course of high-dose amoxicillin
B Prescribe high-dose steroids in consultation with a nephrologist
C Reassure the parents that this condition will resolve spontaneously
D Refer the child to a pediatric nephrologist for hospitalization
D Refer the child to a pediatric nephrologist for hospitalization
Consultation with a nephrologist is recommended for all cases of nephritis and glomerulonephritis. During the peak of the illness of PSGN, in the first few days when the patient has HTN and oliguria, hospitalization may be required with fluid and sodium restriction and diuretic, antihypertensive, and antibiotic therapy if cultures are positive.
An adult patient diagnosed with acute renal colic is experiencing flank pain and nausea without vomiting. A urinalysis reveals hematuria but is otherwise normal. A radiographic exam shows several radiopaque stones in the ureter which are 1 to 2 mm in diameter. What will the primary nurse practitioner do initially to manage this patient?
A Consult with a urology specialist
B Order pain medication and increased oral fluids
C Prescribe desmopressin and a corticosteroid medication
D Prescribe nifedipine and hospitalize for intravenous antibiotics
B Order pain medication and increased oral fluids
Stones that are less than 5 mm in diameter will usually pass spontaneously. The provider should counsel the patient to increase fluid intake and should prescribe adequate pain medication. A consultation is not necessary unless initial measures fail. Desmopressin and corticosteroids have not been shown to be effective. Nifedipine and IV fluids may be used as a secondary option.
Which factors increase the risk of renal stones? (Select all that apply)
A Excess antacid use
B Living in a cold climate
C Obesity
D History of gout
E Vitamin D excess
A Excess antacid use
C Obesity
D History of gout
Excess antacids, obesity, and a history of gout are linked to renal stone risk. Tropical climates are also linked to renal stone development. Vitamin D excess is not a risk factor.
The primary care nurse practitioner sees a new patient who reports having a diagnosis of chronic kidney disease for several years. The patient is taking one medication for hypertension which has been prescribed since the diagnosis was made. The nurse practitioner orders laboratory tests to evaluate the status of this patient. Which laboratory finding indicates a need to refer the patient to a nephrologist?
A Albumin/creatinine ratio (ACR) of 325 mg/g
B Blood pressure of 145/85 mm Hg
C Glomerular filtration rate (eGFR) of 45
D Urine red blood cell (RBC) count of 10/hpf
A Albumin/creatinine ratio (ACR) of 325 mg/g
An albumin/creatinine ratio greater than 300 mg/g warrants referral. A specialist is necessary for persistent hypertension refractory to treatment with four or more agents, a GFR of less than 30, and urine RBC greater than 20/hpf.
Which tests should be monitored regularly to monitor for complications of chronic renal disease (CRD)? (Select all that apply)
A Liver enzymes
B Parathyroid hormone levels
C Serum glucose
D Serum lipids
E Vitamin D levels
B Parathyroid hormone levels
D Serum lipids
E Vitamin D levels
CKD can cause hyperparathyroidism, hyperlipidemia, and alterations in vitamin D, calcium, and phosphorus metabolism, so these should be monitored. Liver function and serum glucose are not affected by CKD.
A patient diagnosed with diabetes has symptoms consistent with renal stones. Which type of stone is most likely in this patient?
A Citrate
B Cysteine
C Oxalate
D Uric acid
D Uric acid
Uric acid stones are more prevalent in diabetics. Citrate, cysteine, and oxalate are less common in all patients
Cardiovascular failure is a major cause of what type of renal failure?
a. Prerenal
b. Intrarenal
c. Postrenal
d. Perirenal
a. Prerenal
A 6 yo patient presents with abdominal distension, pain, right sided abdominal mass, fever, and hematuria. What is the top differential diagnosis?
a. A urinary tract infection
b. Appendicitis
c. Wilms’ tumor
d. An intestinal obstruction
c. Wilms’ tumor
The most common cause of nephrotic syndrome is
a. Systemic lupus erythematosus
b. Diabetes mellitus
c. Routine use of NSAIDs
d. Glomerulosclerosis
b. Diabetes mellitus
Which anti-hypertensive medications are contraindicated in clients with renal artery stenosis?
a. Calcium channel blockers
b. Beta blockers
c. ACE inhibitors
d. Cardiac glycosides
c. ACE inhibitors
Your patient has had proteinuria on two separate office visits. What is the best management plan?
a. Schedule CBC, complete metabolic panel, BUN, Cr, GFR, renal ultrasound
b. Order an intravenous pyelogram
c. Recommend the patient attend to the hospital
d. Collect a urine specimen upon first waking and then another 2 hours later
d. Collect a urine specimen upon first waking and then another 2 hours later
A patient with glomerulonephritis will oftentimes have a history of
a. Beta hemolytic streptococcal infection
b. Frequent urinary tract infections
c. Kidney stones
d. Hypotension
a. Beta hemolytic streptococcal infection
JG is an 8-year-old boy with no past medical history who presented to primary care clinic with facial edema for two days. He also complained of rhinorrhea, epistaxis, and a frontal headache. He was diagnosed with sinusitis and started on antibiotic therapy. The following day he developed abdominal swelling. He was again evaluated in the office where he was found to be hypertensive to 142/90 mm Hg. His exam was significant for mild periorbital edema, but he did not have pharyngitis, lymphadenopathy, swollen joints, or a rash. His urinalysis showed 2+ protein, numerous red blood cells (RBCs), and RBC casts.
What is the most likely diagnosis based on the given information?
most consistent with an acute postinfectious glomerulonephritis. The infection would not be the spurious diagnosis of sinusitis, but would have been a preceding streptococcal infection one to two months before presentation.
Pediatric GN can be classified as acute or chronic. This is a good example of a GN case with an acute presentation. The most common cause in children is poststreptococcal glomerulonephritis (PSGN). The differential diagnoses also include other types of postinfectious GN, as well as secondary causes of GN, such as Henoch-Schönlein purpura (HSP) and, very rarely, shunt nephritis or subacute bacterial endocarditis.
S/S & exam findings of acute postinfectious glomerulonephritis
HTN, periorbital edema, proteinuria, hematuria, RBC casts
Oliguria, gross hematuria, strep rash or HSP, lethargy, anorexia, nausea, vomiting, abdominal pain, weight gain with abrupt onset
labs for glomerulonephritis
UA
BMP
CBC
ESR
ASO titer - elevated indicative of recent GAS infection and consistent w/ dx poststreptococcal GN
complement - C3 should be decreased in ALL types of postinfectious GN
Dx PSGN
based on clinical presentation of glomerulonephritis, hypocomplementemia, and hx or documentation of recent GAS infection
C3 in PSGN
typically decreased in postinfectious GN
normal 83- 152
should return to normal in 6- 8 weeks
if persistently decreased, raise concern for other types of GN
PSGN tx
consult with nephrologist
typically resovles spontaneously and does not require specific tx
acute phase: elevated BP and edema - antihypertensives (CCBs), salt/fluid restriction
ABX does NOT decrease incidence
PSGN education
course of GN and importance of regular follow up care to monitor renal function
Pt with PSGN returns in 8 weeks. His C3 is normal, his HTN and edema have resolved, but he continues to have trace proteinuria and microscopic hematuria. What further evaluation or tx necessary?
No further eval or tx likely indicated
Diuresis and resolution of edema often occurs within first 2 weeks, Cr usually returns to normal within first 4 weeks. Hypocomplementemia should resolve by 8 weeks. Proteinuria usually clears in following weeks to months. Microscopic hematuria, may take 6- 12 months to resolve. Persistence of hypocomplementemia after 8 weeks or proteinuria at 1 year should prompt nephrology evaluation.
What is the most common cause of acute glomerulonephritis in children?
A.. post- strep glomerulonephritis
B. focal segmental glomeruclosclerosis
C. membranoproliferative glomerulonephritis
D. IgA nephropathy
A. post- strep glomerulonephritis
Which of the following lab value patterns is most likely to be found 4 weeks after streptococcus pharyngiits in a child that has developed PSGN?
A. Elevated C3 level, elevated ASO titer
B. normal C3 level, normal ASO titer
C. low C3 level, elevated ASO titer
D. Elevated C3 level, decreased ASO titer
C. low C3 level, elevated ASO titer
What is the most common type of chronic GN in adults?
A. post-step GN
B. lupus nephritis
C. membranoproliferative GN
D. IgA nephropathy
D. IgA nephropathy
IgA nephropathy is the most common cause of chronic glomerulonephritis in both adults and children. About 75% of adults & children present with hematuria after URI.
Post-strep GN is most common cause of acute GN in children.
Both lupus nephritis and membranoproliferative GN cause GN but are less common causes in both children and adults
CKD complications
HTN pulmonary edema HF HLD electrolyte abnroms anemia erythropoeiten deficiency
CKD defined by KDIGO
kidney damage or GFR < 60 for 3 months or more, regardless of cause
CKD stage 1
normal eGFR (>90)
with other evidence of kidney damage: persistent microalbuminuria, proteinuria, hematuria, structural abnorms, biopsy proven GN
CKD stage 2
eGFR 60- 89
with other evidence of kidney damage: persistent microalbuminuria, proteinuria, hematuria, structural abnorms, biopsy proven GN
CKD stage 3a
eGFR 45-59
CKD stage 3b
eGFR 30- 44
CKD stage 4
eGFR 15- 29
CKD stage 5
eGFR < 15
when do you refer a CKD pt to nephrology?
patients under 18 = immedaite referral to pedi nephrologist
For adults, per KDIGO:
- AKI or abrupt sustained fall in GFR
- GFR < 30 (CKD stge 4-5)
- consistent finding of significant albuminuria
- progression of CKD
- urinary red cell casts, RBC > 20 per hpf sustained and not readily explained
- CKD & HTN refractory to tx w/ 4 or more antihypertensive agents
- persistent abnorms of serum K
- recurrent or extensive nephrolithiasis
- hereditary kidney dx
Which of the following patients would be characterized as having stage 2 CKD?
A. GFR > 90 w/ urine albumin/cr ratio of 100 mg/g measured one time
B. GFR > 90 w/ urine albumin/Cr ratio of 100mg/g for past 6 months
C. GFR 70 w/ urine albumin/Cr ratio of 100mg/g for past 3 months
D. GFR 70 w/ urine albumin/Cr ratio of 100mg/g measured once
C. GFR 70 w/ urine albumin/Cr ratio of 100mg/g for past 3 months
ALL stages of CKD are based on evidence of renal dysfunction for more than 3 months
person w/ GFR > 90 and proteinuria measured one time may have transient or persistent proteinuria and should be evaluated for further causes.
stage 1 CKD is normal GFR > 90 w/ evidence of kidney damage > 3 months
Stage 2 CKD GFR 60- 89 w/ evidence of kidney damage > 3 months
Stage 3 CKD GFR 30- 59 > 3 months
Stage 4 CKD GFR 15- 29 > 3 months
Stage 5 CKD GFR < 15 > 3 months or kidney failure tx w/ dialysis or transplantation
normal urinary albumin/creatinine ratio lab value
< 30 mg/g
microalbuminuria lab value
urine albumin/cr ratio 30- 300 mg/g
macroalbuminuira lab value
> 300mg/g
A 40 y.o. M with HTN and T2DM has a normal creatinine, an eGFR > 90 and a urine albumin/cr between 100- 200 mg/g on repeat UA for past 6 months. Which of the following best describes his kidney function?
A. Normal renal function
B. acute renal failure
C. Stage 1 CKD
D. Stage 2 CKD
C. Stage 1 CKD
Normal GFR and persistent proteinuira over past 6 months, so he meets criteria for stage 1 CKD.
This is a chronic not an acute condition. He does NOT have normal renal function as evidenced by persistent proteinuria
Which of the following recommendations is NOT part of the 2012 KDIGO guidelines for management of CKD?
A. Avoid giving the MRI contrast gadolinium when GFR is < 15 unless there is no alternative appropriate test
B. Stop metformin when GFR is < 60
C. Avoid giving phosphate-containing bowel prep medication when GFR is < 60
D. Adults w/ CKD should be considered for living donor preemptive transplantation when GFR is < 20 and there is evidence of progressive and irreversible CKD over preceding 6- 12 months
B. Stop metformin when GFR is < 60
According to KDIGO guidelines, metformin should be continue when GFR is > 45
Review metformin use in pts w/ GFR 30- 44
DC metformin when GFR < 30
Guidelines recommend all other answer choices
hematuria lab values
3 or more erythrocytes per HPF
UA with microscopy can show
presence of RBCs - # of RBCs
presence of casts or significant protein
UA indicative of GN
presence of protein, RBC casts, & dysmorphic RBCs
Ddx for isolated hematuria
extrarenal causes: urolithiasis, bladder stones, CA of ureter, bladder CA, prostate CA, infection, trauma
intrarenal causes: nephrolithaisis, neoplasm, infection, renal infarct (papillary necrosis), renal vein thrombosis, GN
asymptomatic hematuria workup
in absence of gross hematuria: H&P, urine culture, renal imaging, CBC, BMP
presence of gross hematuria w/ HTN and/or proteinuria (GN suspected): further tests complement evaluation, antinuclear antibody (ANA), ASO titer, antineutrophl cytoplasmic antibodies (ANCAs), and anti-glomerular basement membrane
Patient recalls episode of gross hematuria that resolved without associated symptoms and current microscopic hematuria on exam. What do you do?
Refer to urology with renal function testing, cystoscopy, & imaging
ACP recc urgent referral for all adults with gross hematuria, any hx of hematuria even if self-limiting warrants urgent urologic eval with renal function testing, cystoscopy, and imaging
What is the definition of microscopic hematuria according to AUA?
A. postive urine dipstick
B. any presence of RBC in urine sample
C. 3 or more RBCs in non-contaminated UA w/o evidence of infection
D. 1 or more RBCs in non-contaminated UA w/o evidence of infection
C. 3 or more RBCs in non-contaminated UA w/o evidence of infection
According to the AUA, microscopic hematuria is defined as 3 or more red blood cells in a noncontaminated urinalysis without evidence of infection. While a positive urine
Three or more red blood cells in a noncontaminated urinalysis without evidence
of infection*
dipstick has a high sensitivity, there is a high rate of false positives and should be confirmed by microscopic analysis.
A urinary sediment demonstrates 3 erythrocytes/high-power field (HPF) following an incidental finding of heme-positive urine dipstick in an otherwise asymptomatic patient. The patient is taking warfarin for atrial fibrillation. He reports to you a one-time episode of gross hematuria in the past 6 months. What is the most appropriate next step in evaluation?
A. Repeat urinalysis with microscopy in 6 months
B. Urine cytology
C. FDA-approved urine markers
D. Referral for urologic evaluation
D. Referral for urologic evaluation
According to the American College of Physicians’ (ACP) high-value care advice for hematuria as a marker of occult urinary tract tumor, all episodes of gross hematuria, even if self-limited, should warrant consideration of urgent urologic evaluation. Repeating a urinalysis in 6 months may result in a delay of diagnosis of potentially treatable urinary tract tumor. The ACP recommends against urine cytology or urine markers for bladder cancer detection due to their poor sensitivity.
Which of the following findings is highly specific to glomerular disease?
A. Microscopic hematuria
B. Leukocyte esterase
C. Proteinuria
D. Red cell casts
D. Red cell casts
The presence of red cell casts is a specific marker of glomerular disease although it may be insensitive (the absence of red cell casts does not rule out glomerular disease). Microscopic hematuria, leukocyte esterase, and proteinuria may be present in glomerular disease but are also present in other conditions.
A 9 month old female with no significant PMH presents to the office for a follow up weight check. The child has been noted to have growth failure. The mother reports that her child has a poor appetite, is drinking and urinating more and is irritable. The FNP notes that the child previously had consistent growth and is no longer following the curve for weight and height.
What are your differential diagnosis based on this information?
RTA hypothyroidism failure to thrive systemic acidosis renal disease type 1 DM
transient proteinuria causes
benign or self-limiting orthostatic proteinuria dehydration fever exercise emotional stress CHF, seizures
persistent proteinuria defined as
1+ protein on a standard dipstick two or more times during 3 month period
persistent proteinuria causes
pathologic process:
drugs - lithium, cyclosporine, cisplatin, NSAIDs
PCKD
lupus, vasculitis, IgA nephropathy, sarcoidosis
TB, infection
hyperuricemia, hypercalcemia, amyloidosis
DM, HTN, sickle cell dx, radiation nephritis
increased risk of proteinuria
AA, Native americans, hispanics, Pacific islanders
aging
obesity
proteinuria in pregnancy
before 24 weeks gestation = GN
after 24 weeks gestation = preeclampsia
proteinuria dx
detected on routine dipstick
any value of 1+ of greater > 2 occasions = further workup
24-h urine measurement for protein and Cr AND microscopic exam urine - sediment, electrophoresis, renal function urine C&S CBC & diff fasting BG & A1c kidney & liver function lipid profile
glomerular kidney dx associated with
1g of proteinuria in 24 hrs
functional protienuria
secondary to identifiable cause - exercise, fever, CHF
NO further workup needed
persistent proteinuria that CANNOT be classified as functional workup
24-h protein/Cr ration = gold standard
24-h albumin/Cr ratio >/= 3.5 day
nephrotic syndrome
accompanied by albuminuria, HLD, edema
24-h albumin/Cr ratio < 3.5 g/day
normal renal function: determine if orthostatic or non orthostatic = check first AM void, if (-) no further workup needed
Non-orthostatic proteinuria W/O Bence Jones protein = refer nephrologist, may need renal biopsy
Presence on Bence Jones proteins = serum protein electrophoresis and refer to exclude multiple myeloma
proteinuria management
depends on underlying cause
careful med rec, DC any meds implicated in proteinuria (ACE-I, ARBs)
aggressively manage DM, HLD, HTN
sodium and protein restricted diet
proteinuria & hematuria
suggestive of glomerular or interstitial nephritis
painful hematuria dx
urine C&S
if neg - non contrast spiral CT, r/o urolithiasis
painless hematuria dx
urine for cytology x3, urine C&S
cystoscopy
US kidneys & bladder - mass
proteinuria or RBC casts - 24-h urine collection
AKI defined as
increase in serum Cr of 0.3mg/dL over 48 hr
increase of serum Cr to 1.5 x baseline over 7 days
urine volume output < 0.5mL/kg/h for 6 hr
ESRD S/S
early stage, few symptoms
hallmark: decreased GFR, increased serum Cr, albumin in urine
edema, HTN, decreased UO (anuria)
ESRD most important diagnostics
serum Cr w/ eGFR and first AM or random urine sample to assess albuminuria
ESRD dx
CMP - cr & eGFR urine albumin, urine ACR Urine Cr urine volume urine NA to differentiate ATN & prerenal dx liver enzymes serum lipids A1c or fasting BG serology for glomerulonephritis
AKI management
remove source of nephrotoxins and manage fluid to avoid over/underhydration
tx electrolyte imbalances
CKD management
CKD 4 = refer nephrologist
manage BP, reduce proteinuria w/ diet use ACE-I to slo progression of CKD tx metabolic acidosis w/ supplemental bicarb and attaining glycemic control protein restriction smoking cessation
CKD BP management
target BP 130/80
sodium restriction
weight loss
ACE-I & ARB - 30% increase in Cr = DC
-monitor K goal < 5 (thiazides can help)
AVOID NSAIDs
CKD DM management
HbA1c < 7%
metformin:
- GFR < 30 contraindicated
- GFT < 45 risk vs benefit
diet: protein restriction, avoid K containing salts, low phos, meet daily Ca, replace Vit D if low
control lipids: Statin
-atorvastatin does not require renal dosing
CKD monitor CBC frequency
CKD 3 monitor CBC annually
CKD 4-5 monitor 2x y
RF urinary calculi
hot, tropical climate fam hx obesity low SES low fluid intake high salt intake low Ca intake
insulin resistance, HTN, gout, metabolic syndrome, hyperparathyroidism, chronic metabolic acidosis, CAD
most common urinary stone
calcium oxalate
most common urinary stone DM
uric acid
urinary calculi labs typically show
mostly normal
elevated Cr
microscopic hematuria
elevated WBC - concern non-draining UTI
urinary calculi dx
UA & C&S = essential
CBC if fever
24-h urine - metabolic testing
CBC, CMP, uric acid, PTH, vit D
KUB, NCCT scan, renal US
urinary calculi 1st line tx
conservative
oral hydration and pain management
meds that help passage
- CCB an a-blockers (nifedipine & tamsulosin)
stones > 10 mm
surgical management
nephrotic syndrome
nephrotic range proteinuria:
- 3.5 g/day or more in adults
- more than 40 mg/m/h in children
- first AM urine protein/Cr ration 2-3 or more
edema
HLD
hypoalbuminemia
S/S nephrotic syndrome
edema foamy urine weight gain fatigue anorexia
nephrotic syndrome needed in dx
ALL of the following:
- nephrotic range protein
- peripheral edema
- low serum albumin
HLD
nephrotic syndrome management
start initial workup:
- renal function
- CBC
- UA w/ microscopy
- serum albumin
- electrolytes
- glucose
- lipids
Refer nephrology
IgA nephropathy
asymptomatic microscopic hematuria as it progresses: gross hematuria - proteinuria & HTN - increased GFR - RBC casts on UA
IgA nephropathy dx
renal biopsy - definitive
IgA nephropathy management
REFER nephrology
PCP role:
- monitor UA
- manage BP - ACEI, ARB goal < 130/80
glomerulonephritis S/S
HA HTN facial/periorbital edema lethargic low grade fever weight gain
proteinuria (not large amounts)
hematuria (mostly gross)
oliguira
dysuria
screening for CKD
annually if RF present:
- spot urine for ACR
- serum Cr and eGFR
- UA
diabetics:
- at time of dx T2
- 5 yrs after dx T1
myoglobinuria
presence of free myoglobin (which is normally only present in intact muscle cells) in the urine. This may occur during rhabdomyolysis
produces red- brown urine
