Week 8 (Exam 3) Flashcards
Etiology of Lower Urinary Tract Symptoms (LUTS)
probably from both bladder outlet obstruction from BPH
And detrusor muscle overactivity secondary to BOO somehow
ANCA associated Small Vessel Vasculitises
Microscopic Polyangiitis
Granulomatosis with Polyangiitis (Wegener’s)
Eosinophilic Granulomatosis with Polyangiitsi (Churg-Strauss)
Indications for Cyclophosphamide
Malignancies
Minimal Change Nephrotic Syndrome in Pediatric patients who are confirmed on bx and cant take /don’t respond to adrenocorticosteroids
Which ADPKD is involved in Cell-Cell or Cell-Matrix Interaction?
Defective PDK1 on Chr 16p13.3 (polycystin 1): integral membrane glycoprotein
85% of cases
Medium Vessel Vasculitises
Polyarteritis Nodosa
Kawasaki Disease
Adverse reactions of Rituximab
Lymphoid malignancies, RA, renal toxicity w/ Cisplatin
What staging of bladder cancer is bad?
T2-T4: muscle invasion is the major prognostic factor
Associated conditions of Nephritic Syndrome
SLE
Bacterial Endocarditis: Acute Proliferative Glomerulonephritis
Goodpasture: Rapidly Progressive Glomerulonephritis
HSP: IgA Nephropathy
What is renal scarring and what are the complications?
Loss of parenchyma between the calyces and renal capsule
HTN, decreased renal function, proteinuria, ESRD
Renal US findings in CKD
Atrophic or small kidneys
Cortical thinning
Increased Echogenicity
Elevated resistive indices
Nephrotic syndrome complications
Edema Hyperlipidemia Infection (from loss of IgG) Thrombosis Vitamin D Deficiency (urinary loss of Vit D) Anemia (loss of transferrin and EPO)
Urinary pattern of ATN
Renal tubular epithelial cells
Transitional epithelial cells
Granular or Waxy casts
Clinical manifestations of AKI
Rapid decline in GFR
Most severe forms have oliguria or anuria
Maybe from glomerular, interstitial, vascular, ATN
Reversible or goes to CKD
Pathogenesis of Membranous Nephropathy
In Situ Immune Complex Formation PLA2R Ag (mostly primary disease)
Nephrotic/Nephritic Syndrome Diagnostic method
Renal Biopsy
Which diseases often progress to Chronic GN?
90% Crescentic GN
50-80% Focal Segmental Glomeruloscerosis
50% Membranoproliferative GN
Kidney Stone Recurrence Likelihood over time
15% at 1 year
35-40% at 5 years
50% at 10 years
ESRD clinical manifestations
GFR blow 5% of normal
End stage of uremia
What 4 drug classes are used for managing BPH?
a1 blockers: improves in 1-2 weeks
5a-Reductase inhibitors: improves in 6-12 months
Anticholinergic agents
Phosphodiesterase-5 inhibitors
Treat a UTI
Not acutely ill: cefixime, cefdinir 3-4 days
Acutely ill: Ceftriaxone 10-14 days
Fosfomycin
Single dose tx for UTI
Hypersthenuria
Consistently high specific gravity
Due to deprivation of water
Urinary pattern of vasculitis or GN
Dysmorphic RBCs, RBC casts
Hyposthenuria
Consistently low specific gravity (<1.007)
From Concentration problem
Genes associated with bladder cancer
CDKN2A (encodes p16/INK4a and ARF for p53 fxn)
PTCH (negative to hedgehog)
TSC1 (negative to mTOR)
FGFR3 and RAS (on chronic 9, two-pathway model)
Pathalogic diagnosis of anti-GBM disease requirement
Diffuse linear IgG staining along the GBMs in the setting of crescentic glomerulonephritis on immunofluorescence
Contraindications of cyclophosphamide
hypersensitivity, urinary outflow obstruction
ANCA staining patterns
PR3 causes C-ANCA with Cytoplasmic pattern
MPO causes P-ANCA with Perinuclear pattern
Main complications of Anti-GBM disease
Lungs: Hemoptysis from Diffuse Alveolar Hemorrhage
Respiratory Failure
Crescentic, rapidly progressive glomerulonephritis
EGPA / Churg-Strauss symptoms
Necrotizing vasculitis with granulomas in the upper and lower respiratory tract with asthma symptoms and eosinophilia
MPO Abs
Imaging findings of advanced renal hyaline arteriolosclerosis
Thickened, tortuous afferent arteriole
Amorphous (thickened) vascular wall
Why does urea go up in dehydration?
ADH binds V2R, increasing cAMP and therefore AQP-2 and Urea transporters on collecting duct
Pharmacologic treatments for Overflow Incontinence
Alpha Adrenergic Antagonists
Urinary pattern of Non-specific, prerenal azotemia
Hyaline Cast
Isosthenuria
Fixed specific gravity of 1.010
Indicates poor tubular reabsorption
Large Vessel Vasculitises
Takayasu and Giant Cell Arteritis
Criteria for UTI diagnosis
clean catch with both pyuria and 50K colonies at least
Clinical presentation of Goodpastures
Hematuria
High BP, Foamy urine, leg swelling
Normal Urine Volume
800-1000 ml/day
Nitrofurantoin
5 day lasting treatment of UTIs
Standard treatment for ANTI-GBM disease
Plasmapharesis + High dose corticosteroids + Cyclophosphamide
Non-seminomatous testicular cancers by least to most differentiated
Embryonal carcinoma
Choriocarcinoma
Yolk Sac Tumor (endodermal sinus)
Teratoma
How is polyuria induced by hypercalcemia?
Basolateral Calcium Sensor (CaSR) degrades AQP-2 channels by autophagosomes
Hexagonal crystals on urine microscopy
Cystine Crystals
Urinary findings of glomerular hematuria
Maybe RBC casts Dysmorphic RBCs Maybe Proteinuria No Clots Red or brown color
Treatment of AKI by etiology
Prerenal gets IV fluid
ATN gets supportive care
GN maybe gets immunosuppression or plasmapheresis
AIN needs getting off the offending agent
Favorable Wilms tumor Histomorphology
Usually Triphasic: mimics germinal development of normal kidney with Blastemal, Epithelial (tubular), and Stromal cells
Bladder tumors often present with just hematuria. What may follow if the ureteral orifice is involved?
Pyelonephritis or Hydronephrosis
Palpable vs non-palpable purpura
Palpable is suggestive of Vasculitis
Non-Palpable is suggestive of thrombocytopenia
How long does a dose of Bactrim last for a UTI?
3 Days
Urinary pattern of Nephritic Syndrome
Proteinuria <3.5g/day
Hematuria
Dysmorphic RBC and RBC casts
Associated conditions of Nephrotic Syndrome
Proteinuria Diabetic Nephropathy SLE Hep C HIV Nephropathy: Focal Segmental Glomerulosclerosis
UI interventions for women with urogenital atrophy and LUTS
Vaginal Estrogen
Envelope shaped crystals on urine microscopy
Calcium oxalate dehydrate crystals
Urinary pattern of AIN
WBC, WBC cast, or Urine Eosinophils
Classic presentation of cystitis
Dysuria, Urinary frequency, urinary urgency
GPA symptoms
Necrotizing vasculiutis with granulomas in the upper and lower respiratory tract with no asthma or eosinophilia
PR3 Abs
ENT sx more common here
Coffin-Lid crystals on urine microscopy
Struvite (magnesium ammonium phosphate crystals)
Immune complex small vessel vasculitises
Cryoglobulinemic Vasculitis
IgA Vasculitis (HSP)
Hypocomplementemic Urticarial Vasculitis
Tx for Diabetes Insipidus
Central: Vasopressin
Nephrogenic: Thiazide diuretics, NSAIDs, Vasopresin
Hypernatremia: Replace free water deficit
Pharmacologic treatments for Urge Incontinence
Antimuscarinics
Intravaginal Estrogen
Mirabegron
Rhombic plates or rosette-shaped crystals on urine microscopy
Uric Acid Crystals
Diabetes Insipidus
Polyuria over 3L/day
Solute Diuresis: Glucosuria, Urea, Sodium, Mannitol
Water Diuresis
Extra-renal manifestations of ADPKD
82% have diverticular disease of the colon
40% have hepatic cysts
25% have mitral valve prolapse (normally 2%)
4-10% have subarachnoid hemorrhage from Berry A
Urinary findings of extra-glomerular hematuria
No RBC casts Uniform RBC morphology No Proteinuria Maybe clots Maybe Red color
Labs to obtain on all patients with AKI
UA with microscopy
Urine Albumin:cr or Protein:cr
(renal US also common)
Unfavorable Wilms tumor Histomorphology
Focal (not always bad) or Diffuse (always bad)
Associated with p53 mutations, chemo resistance
Clinical presentation of Cystitis
ALL of them: Frequency + Abdominal Pain + Dysuria
Etiology of Sporadic papillary renal cell carcinoma
trisomy 7 (also 16 and 17, but mainly 7)
Loss of Y
Mutated, activated MET
Targets in the Lamina Densa
Type 4 collagen: a3 (Anti-GBM abs) and a5 (Alport mut)
HSP preentation
Gross hematuria, abdominal pain, hives, emesis, diarrhea etc
Active Urinary Sediment and Bland Urinary Sediment
Nephritic Syndrome and Nephrotic Syndrome
Urine Culture with sensitivities
True UTIs have >10^3 CFU (colony forming units)
Rituximab Warnings
Black Box: fatal infusion reactions, tumor lysis syndrome, severe mucocutaneous reactions, progressive multifocal leukoencephalopathy
Serum albumin is normal in setting of nephrotic range proteinuria
not true nephrotic syndrome but instead has nephrotic range proteinuria
Indications for Dialysis
AEIOU: Severe acidosis, Elecrolyte disturbance, Ingestion, Overload of volume, Uremia
Hypercalciuria
urine calcium:creatinine ratio above 0.2
Etiology of hereditary papillary renal cell carcinoma
Trisomy 7
mutated, activated MET
When do you do imaging after a pediatric UTI
Boys after 1st, girls after 2nd
VCUG if there’s abnormalities, >39C + non-Ecoli, poor growth + HTN
Look for vesicoureteral reflux (scars ureters)
Major clinical finding of IgA nephropathy
Recurrent Hematuria
Complications of UTIs
Sepsis, Septic Shock AKI Perinephric Abscesses Emphysematous Pyelonephritis Papillary Necrosis
Clinical presentation of Nephritic Syndrome
New Onset HTN and Hematuria
AKI
Proteinuria below 3.5/day with foamy urine
PUNLMP vs Papilloma
PUNLMP has thicker urothelium, larger than papillomas
Dx of prostatitis
Digital rectal exam, Urinalysis, Urine culture
test for gonorrhea, chlamydia
95% of renal cell carcinomas are sporadic clear cell. What’s the etiology?
Deletions on Chr 3
Loss of VHL
inactivated, mutated, hypermethylated VHL
Rituxibam MOA
antiCD20 Ab
Typical presentation of acute prostatitis
Often appear acutely ill!
Obstructive sx, suprapubic perineal pain, etc
Chronic is usually more mild appearing
Classic presentation of pyelonephritis
Fever/chills/rigors, flank pain, CVA tenderness on exam, fatigue, N/V/Anorexia
Urinary pattern of Nephrotic syndrome
Heavy proteinuria >3.5g/day
Lipiduria
Minimal Hematuria
Diagnostic imaging for kidney stones
Non-Contrast CT abdomen and pelvis (renal stone protocol CT)
Clinical presentations of UTIs
See: Cystitis, pyelonephritis
Can also have altered mental status in older adults
How long do you take different antibiotics for prostatitis?
Fluoroquinolone (Cipro) and Bactrim, 4-6 weeks
Microscopic Polyangiitis symptoms
Necrotizing vasculitis WITHOUT granulomas or asthma symptoms or eosinophilia
MPO Abs
Immunofluorescence findings of acute proliferative glomerulonephritis
Granular IgG, IgM, C3 deposits in mesangium along GBM, corresponding to sub epithelial “humps” found on electron microscopy
Pulmonary-Renal Syndrome
Alveolar hemorrhage and glomerulonephritis
ANCA-Associated vasculitis
Anti-GBM disease (good pasture)
Complications of AKI
Hypervolemia (P. Edema, HF)
Electrolyte abnormalities, Hyperuricemia, Uremia, Pericarditis, Metabolic Acidosis, Bleeding, need for dialysis
UI interventions for women with contraindications
B3 adrenergic agonists
Microalbuminuria
Urinary excretion of 30-300 mg/24 hours of albumin in urine
Eariles sign of renal damage in DM
Independent risk factor for CV risk factor in DM
Diagnostics of DI
24 hour urine volume collection
Urine osmolality below 300mOsm/kg
Water deprivation test
Main causes of Nephrogenic Diabetes Insipidus
Lithium Toxicity
Hypercalcemia
Contraindications of Azathioprine
Pregnancy (malignancy)
Azathioprine Indications
Adjunct for preventing homorenal transplant rejection
RA management
Major bacteria in prostatitis
G-: E COLI, Klebsiella, proteus, pseudomonas
G+: Enterococcus, normal skin flora
3 simple tests to identify most CKD patients
eGFR
Urine albumin:creatinine or protein:creatinine
Urinalysis
Maintenance Therapy for ANCA associated vasculitis
- Azathioprine or Mycophenolate or Rituximab
2. Methotrexate
Induction therapy for ANCA associated vasculitis
High dose glucocorticoids (IV prednisone) and Rituximab
High dose glucocorticoids and Cyclophosphamide
Dumbell-shaped crystals on urine microscopy
Calcium Oxalate monohydrate crystals
Clinical manifestations of CKD
Mild is silent, moderate is uremia
Persistently GFR below 60ml/min/1.73m for at least 3 mo
OR persistent Albuminuria
CKD is generally irreversible
Imaging findings in diffuse and nodular diabetic glomerulosclerosis
Diffuse increase in mesangial matrix (sclerosis)
Thickened glomerular basement membranes
Characteristic Acellular PAS-positive nodules
Urinary pattern of UTI
WBC, RBC, Bacteria
Polycystin 2
Ca2 permeable cation channel coded by PKD2 gene on Chr 4q13-p23
Mutation leads to 15% of ADPKD cases (better Px)
