week 5- Renal 1 Flashcards
• Basic renal/GU fxns:
o Filtration, excretion (emunctory)
o water & electrolyte balance, ions in ECF
o acid/base balance- HCO3, H (N urine pH 4.5-6)
o BP reg- renin
o RBC production- EPO
o Bone metabolism- activate vit D3, ↑ Ca abs
o Gluconeogenesis- during fast
o Reproduction (testicles)- sperm, storage
o Production of hormones (testicles)- T
• Normal fluids in and out:
o Min urine: 0.5-1 ml/kg/hr daily
o Optimal: ~2500 ml urine/day = 250+mL water/hr
o Freq: N every 1-2 hrs awake; 0-1 x/ night
• Kidney position:
o R lower than L dt position of liver (T10-T12)
o descend ~4-5 cm w respiration
• bladder and urethra specs:
o B: Adult capacity ~ 350-450 ml (12-16 oz)
o U: F 4-8 cm long, M 15-22 cm
• Hx for renal cc:
o Pain: renal pain in flank or lower back
o PMHx: lupus, DM, HTN (2nd affects on KDs)
o FHx: PKD, AI nephropathies, renal calculi
o Exposures: heavy metals, chems, radiographic contrast media
o Meds: analgesics, abx, NSAID’s, diuretics
o ROS: assoc sx of renal dz; general: fever, ↓wt, fatigue; CV: SOB, chest pn, edema; GI: anorexia, N/V, crampy abd pn (shared plexi, concomitant sx); LUTS: polyuria, dysuria, hematuria; MS: jot pn, swelling; Skin: rash, pruritis
• PE for renal cc:
o Complete PE required
o Observation: severely ill w renal dz, pale, sallow (urochrome), Drowsiness, slurred speech may suggest acute RF; Deep breathing suggests met acidosis
o Lung/Heart: ↑BP, heart failure, pericardial rub, pleural rub, edema
o Neuro: encephalopathy (any brain dysfxn), stupor to coma dt azotemia/uremia, asterixis (hand tremor hand in flexor direction. Dt various dzs - hepatic failure, CO2 narcosis, chronic KD dz
o Fundoscopi: Retinal changes dt DM, HTN
o Abd: renal mass; renal a bruit, ascites, CVA tenderness: inflam kidney, mb ureter
o Skin: xerosis, pallor, petechiae, ecchymosis
• Hx for GU cc:
o Pain: Ureters: R or L side spasms (eg stone), may radiate to thigh or genitalia; Bladder: suprapubic pn (retention, inflam, irritation; Urethral: dysuria dt inflam, irritation, foreign body
o Voiding sxs: Irritative (dysuria, freq, urgency), Obstructive (hesitancy, straining, ↓caliber); Incontinence, Enuresis
o D/c: Amount, color, consistency, fever, chills, rash, assoc sxs, hematuria, dysuria
• PE for GU cc:
o CVA tenderness: pyelonephritis, calculi, UTI
o Abd: Dullness in suprapubic area mb bladder distention (urge to urinate when pressing), may see distention
o Gyn exam
o Male genitalia exam
• Urinary Frequency:
o need to urinate many x during day; often w Urgency (urgent need, w only small amt of urine)
o ask: Fluid consumption, Flow sxs (pain, hesitancy, sensation of incomplete voiding, nocturia), Fever, hematuria, sexual activity, Missed menses, breast swelling, morning sickness (pg)
o DDX: UTI, pg, compression/prolapsed uterus, foreign bodies, stones, ↑fluid intake, substances (coffee, alcohol, diuretics), DM, food sensitivity, BPH, prostatitis, spinal cord injury, urethral stricture, incontinence
o RED FLAGS: Fever, back pain, LE weakness
• Dysuria:
o painful or uncomfortable urination (burning, aching). From irritation, inflam, infx (eg cystitis, urethritis/STI), perineal lesions exposed to urine
o ask: D/c, chills/fever, hematuria, sexual activity, Timing of pain in relation to urination; Location of pain: urethra, suprapubic (bladder), flank (renal), abd (ureter)
o DDX: cervicitis, cystitis, epididymitis, prostatitis, urethritis, contact irritant/allergen, foreign body, interstitial cystitis, ReA, atrophic vaginitis
o RED FLAGS: fever, flank pain, recent instrumentation, immunocomp, recurrence
• Nocturia:
o Etio: excessive fluid late in evening, urine retention, BPH, interstitial cystitis, GU allergies
• Nocturnal enuresis:
o involuntary bedwetting > 5 yo o M > F, w FHx (70% if both parents) o Normally prevented by: ADH secretion at sunset; Ability to wake up when bladder full o Normally uncommon > 4 (under 30%) o 1st and 2nd
• Etio 1st enuresis:
o ~90% of cases, child never achieved continence for > 6mos
o neuro-developmental delay
o genetics
• etio 2nd enuresis:
o incontinence develops > 6 mos of achieving urinary control
o neuro-developmental issues (eg autism, Down’s)
o DM, DI, hypoglycemia, sickle cell dz
o functionally small bladder
o sleep apnea, sleep walking
o bladder irritability (UTI, constipation)
o ADHD
o Psycho stress: sex abuse, bullying, birth of sibling, social isolation, divorce/separation, loss of parent/grandparent or pet
o food allergy/sensitivity (dairy, wheat, apples, oranges)
o parasites (pinworms)
• Urinary incontinence:
o Inability to hold urine; 3 types:
o Overflow: distended bladder from obstruction (BPH, pelvic tumor, fecal impaction, urethra stricture, chronic constipation, unable to completely empty bladder; frequency, dribbling common
o Stress: sudden ↑ intra-abd P from cough, sneeze, exercise → P to bladder →urine leak from sphincter control: childbirth, obesity, aging
o Urge: freq, sudden urge to urinate w little control; ↓parasymp inhib → detrusor mm hyperreflexia, stroke, MS, PD, tumors
o Mixed causes (eg stress and overflow)
• Polyuria:
o ↑output urine (> 3000 ml/day)
o lost fluids and solutes must be replaced (hypotension and CV collapse)
o must distinguish from urinary freq
o ask: Fluid consumption, abrupt/gradual onset, Polyphagia, polydipsia, Dry eyes/mouth, ↓wt/night sweats, drug Hx, FHx
o RED FLAGS: abrupt onset, night sweats, cough, ↓wt, psych do
• Etio of polyuria:
o appropriate response to osmolar, Na or fluid loads; mb 2nd to diuretics, ↑Na intake, ↑water and Na thru IV feedings or rapid resorption of edema fluid
o inappropriate response to pathological state:
o DI: HTH-pit do dt def ADH → polydipsia, polyuria
o nephrogenic DI: urinary concentrating defect unresponsive to ADH. Mb dt chronic RF (nephrons can’t conc urine), recovery from acute RF or acute pyelonephritis, ↑Ca, ↓K, congenital tubular dos, drug-induced dz
o compulsive drinking ↑ fluid: psychogenic polydypspia; overdose of lithium → ADH resistance → polyuria, polydipsia
o osmolar load: glucose osmotically active, spilling → Na & H20 excretion
• Oliguria and Anuria:
o oliguria: ↓ urine output (↓ 400-500 ml/24 hr)
o anuria: ↓ 100 ml/ 24 hours
o etio: Pre-renal (↓ blood to KD), renal, post-renal
o !! refer for immediate eval and tx (catheter)
• Hematuria:
o Microscopic: > 3 RBC/hpf in centrifuged urine or gross; usu renal cause; presence of any RBCs > 1 occasion should be investigated
o Gross: usu uroepithelial (if painless, R/O tumor); Peds: consider GN, child abuse; Geriatric: suspect UTI, st occult
• Ask pt about hematuria:
o Habits: smoking, drug use
o Meds (analgesics, Coumadin)
o Occupational exposures
o Obstructive sxs (incomplete emptying, difficulty starting/stopping stream)
o Irritative sxs (irritation, urgency, frequency, dysuria)
o Recent infx, FHx, drug hx
o Painless urination: consider tumors of Bl, Ki, Prostate until proven otherwise! staghorn calculi, polycystic Ki, sickle cell, hydronephrosis, acute GN
o Dysuria: consider infx
o Flank pain: consider Ki/ureteral stone, PN, trauma, tumor
• Timing of gross blood seen:
o Start of micturation: anterior urethral lesions (urethritis, stricture, meatal stenosis)
o End: bladder trigone, prostate, bladder neck, posterior urethra
o Throughout: Bl, ureteral or renal pathology
o Cyclically with menes: endometriosis of urinary tract
o Blood bw voidings (on underwear): bleeding on either end of urethra
• Common etiologies of hematuria:
o Inflammatory: UTI (mc), STI (esp in F), GN, PN, radiation nephritis/cystitis, IC, TB, endocarditis
o Trauma: Exercise-induced: jarring from running, weight-lifting; Abd/pelvic trauma w renal or ureteral injury; Iatrogenic: post-catheterization, surgery; Foreign body (mb physical/sexual abuse)
o Neoplasms: Prostate, Urethra, Bladder, Ureter, KD
o Metabolic: Calculus dz (85% have hemuturia)
o Congenital: PKD
o Hematologic: Bleeding dyscrasias: hemophilia; H-S purpura; sickle cell
o Vascular: AVM, Renal vein thrombosis, Arterial emboli to KD
o Chem: Nephrotoxins, aminoglycosides, cyclosporin
o Obstruction: Hydronephrosis, BPH
• DDX of hematuria, red flags:
o “look-alikes”
o Pseudohematuria: dehydration, dyes (sudan red), foods (beets, rhubarb, berries}, vag bleed, genital/perineal trauma, rifampin
o RF: Gross hematuria, persistent microscopic hematuria in elderly, Age >50, HTN, edema
• Renal colic:
o Usu dt passage of renal calculi
o usu. UL, severe crescendo-decrescendo pain, origin in flank, radiates from CVA to abd, along ureter, to genitalia region and inner thigh
o concomitants: N/V, chills/fever (if infx), gross hematuria suggests stone or bleeding cysts, frequency
o RED FLAGS: fever, oliguria or anuria
• Edema:
o ↑interstitial fluid volume
o Pitting
o non-pitting: Usu dt coagulation of fibrinogen. Trauma creates coagulation of protein, entraps fluid in gel form
o SSX: unexplained ↑wt, tight rings and shoes, puffy face, swollen extremities, abd distention, pitting on digital pressure
• Some Etiologies of generalized edema:
o heart dz: CHF, pericarditis
o liver dz: jaundice, ascities, spider nevi, red nose, palmar erythema, nausea/ vomiting, enlarged & tender liver, history. of heavy alcohol use
o KD dz: nephrotic syndrome, GN, any other cause chronic RF (DM, HTN)
o myxedema (hypothyroid): periorbital edema dt infiltration of mucopolysacch. hyaluronic acid & chrondroitin sulfate, pretibial-swelling on anterior leg, non-pitting, firm
o lymph edema: e.g. mastectomy, removed LNs → swollen arm
• some labs for renal/GU cc:
o urine eosinophils (Wright’s stain): AIN, RPGN, acute prostatitis, Renal atheroembolism
o CBC: anemia (↓ RBC dt ↓ EPO, blood loss), infx
o Urine cytology: Screen and test for uroepithelial/bladder CA: at-risk population, painless hematuria
o Work up for refractory HTN: plasma renin, aldosterone, cortisol, ACTH
o PSA: ↑ w age, BPH, Prostate CA. Used to screen and monitor CaP
o STI testing: Urine NAAT PCR, gram stain, etc
• Imaging for renal/GU cc:
o X-ray (KUB), plain film (for size, shape, position), radiopaque renal calculi (KUB)
o US: masses, cysts, hydronephrosis, aid w bx; PKD, cystic from solid mass. Doppler for renal a, prostate, testicular, penile blood flow
o IVU/P (dye inj, some people react, replaced by CT): visualize kidney & lower UT. if recurrent UTI, obstruction w hydronephrosis, VUR, HTN, renal calculi
o Retrograde urography: detailed exam of lumen of ureters, bladder
o Cystourethrography: incontinence, strictures, reflux
o CT: CA, stones (helical w/o contrast), after US for masses
o Angiography: most invasive; for vascular lesions (aneurysm, tumors)
o MRI: staging, hemorrhagic vs infx cyst, KD vasculature
o Renal scan (radionucleotide scan): renal emboli, renal parenchymal scarring
• Procedures for renal cc:
o Catheterization: urinary retention
o Cystoscopy: visualize bladder wall (bladder CA, interstitial cystitis), bx
o Bx (renal, bladder, prostate)
o Urethral dilation for strictures
• General info on UTIs:
o Mb asx, esp kids and elderly
o Lower: urethritis, cystitis, prostatitis. Sx: dysuria, urgency, frequency, suprapubic pain, cloudy urine, strong odor to urine, hematuria
o Upper: pyelonephritis, ureteritis. Sx: mb fever ( ≥103° F), chills, flank pain, tender CVA, GI sx (D, N/V), mb dysuria
