00 Renal And Urology Step 2 Lange Outline

Front 1

Symptoms
Dysuria, chills/fever, low back pain, perineal pain, frequency.

Back 1

Prostatitis

Pathology
Escherichia coli (usually aerobic gram-negative rods). Chlamydia, nonspecific inflammation.

Hint 1

Diagnosis
History and physical, large (boggy if chronic) tender prostate gland.
Avoid prostate massage (bacteremia risk).

Treatment Steps
1. Antibiotics (e.g., fluoroquinolones, tetracycline), often treated
for up to 6 weeks.
2. Nonsteroidal anti-inflammatory drugs (NSAIDs).
3. Sitz baths.

Front 2

Symptoms
Tender, enlarged testicle and/or epididymis; fever; scrotal thicken-
ing.

Back 2

Epididymitis

Pathology
Organisms include Neisseria gonorrhoeae, E. coli, and Chlamydia

Hint 2

Diagnosis
History and physical, scrotum may be red/tender. Pyuria, epididymis tender. Urethra/urine culture and Gram stain (if patient is having discharge).

Treatment Steps
1. Tetracycline, fluoroquinolones, or antibiotic as per culture.
2. NSAIDs.
3. Scrotal support.

Front 3

Symptoms
Fever, testicular size increase, scrotal pain, and erythema.

Back 3

Orchitis (Testicular Inflammation)
Orchitis may be associated
with mumps, tuberculosis,
or other infections.

Hint 3

Diagnosis
History and physical, rule out mumps or torsion, usually no urethral
symptoms/discharge.

Treatment Steps
1. Antibiotic (if bacterial).
2. NSAIDs.
3. Scrotal support.
4. Warm soaks.

Front 4

Symptoms/Diagnosis
Urethral discharge, dysuria. Urethral culture and Gram stain (to
rule out sexually transmitted diseases and other infection).

Back 4

Urethritis

Pathology
Sexual transmission common. Gonococcal and nongonococcal ure-
thritis (Chlamydia, Trichomonas, herpes simplex).

Hint 4

Treatment Steps
Antibiotics tailored to the specific etiology.

Front 5

Symptoms
Caused by infection with N. gonorrhoeae. Dysuria, urethritis/dis-
charge (thick yellow). Less commonly can cause pharyngitis.

Back 5

Gonorrhea

Hint 5

Diagnosis
History and physical, culture/Gram stain (gram-negative intracellular diplococci).
TREATMENT OPTIONS
FOR GONORRHEA
• Cefixime (Suprax) 400
mg PO × 1
• Ceftriaxone (Rocephin)
400 mg PO × 1
• Ciprofloxacin 500 mg
PO × 1
• Ofloxacin 400 mg
PO × 1

Front 6

Symptoms
Penile painless lesion: chancre

Back 6

Syphilis
See also Chapter 9, section I.C.4.

Description
STD caused by the spirochete Treponema pallidum. Four stages: primary, secondary, latent, and tertiary.

Hint 6

Diagnosis
Serologic test for syphilis (rapid plasma reagin [RPR], Venereal Dis-
ease Research Laboratory [VDRL]) and fluorescent treponemal antibody absorption (FTA-ABS) studies.

Treatment Steps
Benzathine penicillin G, 2.4 million U IM (if allergic to penicillin, give doxycycline). For primary disease, one injection.

Front 7

Symptoms
Dysuria, frequency, or asymptomatic. Possible abnormal vaginal dis-
charge. Often coinfection with gonorrhea. Caused by infection with
Chlamydia trachomatis.

Back 7

Chlamydia

Hint 7

Diagnosis
Urethral culture/Gram stain, Chlamydia culture.

Treatment Steps
1. Doxycycline 100 mg twice daily for 1 week (not safe in pregnancy).
2. Azithromycin 1 g PO.
3. Metronidazole 2 g PO.

Front 8

Symptoms
Testicular pain/swelling, vomiting and/or abdominal pain. May have initially only abdominal pain; check scrotum!

Back 8

Testicular Torsion

Description
Testicular rotation and loss of blood supply. Most common cause of scrotal swelling in children.
Testicular torsion is a
urologic emergency! If not
diagnosed and treated
promptly, infarction and
loss of testicle may occur

Pathology
Abnormal tunica vaginalis attachment allowing room for testicular twisting (“bell-clapper deformity”).

Hint 8

Diagnosis
History and physical, pain unchanged or worse with testicular elevation. Urine negative, and affected testicle may be elevated in position.

Treatment Steps
Surgery (within 4–6 hours, if possible).

Front 9

Symptoms
None. Pick up on exam only (50% of premature males have undescended testicle).

Back 9

Cryptorchidism (Undescended Testicle)

Pathology
Failure of testes to descend normally. Exact cause not defined.
RYPTORCHIDISM
• Undescended testicle
has an increased risk of
developing cancer.
• Risk is not reduced with
orchiopexy.

Hint 9

Diagnosis
History and physical. Rule out retractile testis (hyperactive cremaster muscle pull). In adults, consider computed tomography (CT)

Treatment Steps
1. Surgery by age 1 (orchiopexy).
2. Hormones have been tried (human chorionic gonadotropin
[hCG]).

Front 10

Symptoms
Obstruction (hesitancy, dribbling, reduced stream force), and ur-
gency, nocturia, frequency. Some cases of BPH can cause near total
obstruction of urinary flow and result in renal failure

Back 10

Prostate Neoplasm—Benign
Prostatic Hyperplasia (BPH)

Description
Enlargement of the prostate gland due to glandular and/or stromal
hyperplasia. Exceedingly common in men as they age.

Pathology
Hyperplasia or increased tone of bladder neck/prostatic urethra, increasing incidence with age.

Hint 10

Diagnosis
History and physical. Ultrasound, urodynamics, cystoscopy

Treatment Steps
1. Watchful waiting.
2. α-Blocker (prazosin, terazosin, doxazosin [Cardura], tamsulosin
[Flomax]).
3. Bulk reducers (finasteride [Proscar]), 5α-reductase inhibitor. In-
hibits conversion of testosteron to dihydrotestosterone.
4. Surgical reduction (transurethral prostatectomy [TURP])

Front 11

SCROTAL MASS
differential diagnosis

Back 11

SCROTAL MASS
• Testicular tumor
• Hydrocele
• Varicocele
• Epididymal cyst
• Testicular torsion
• Epididymal orchitis
• Hernia
• Inguinal cord tumor
• Hematoma

Front 12

Symptoms
None. May be associated with chordee (ventral penile curve).

Back 12

Penile Disorders—Hypospadias

Description
Most frequent urologic anomaly, with meatus below penis tip.

Pathology
Urethral ridges do not fuse, possibly hereditary.
• Commonly associated
with other conditions
such as inguinal hernias
and cryptorchidism
(undescended testes).
• The penis is more likely
to have chordee, which
is ventral shortening and
curvature

Hint 12

Treatment Steps
Surgical if meatus too proximal. Look for associated anomalies.

Front 13

Symptoms
Nontender scrotal mass.

Back 13

Hydrocele and Varicocele

Description
Hydrocele—Fluid around testis (in tunica vaginalis layers).
Varicocele—Pampiniform plexus vein dilation.

Pathology
Hydrocele—Patent processus vaginalis.
Varicocele—Inefficient pampiniform valves.

Hint 13

Diagnosis
Transillumination, history and physical, ultrasound. Varicocele may
be absent when supine, increase if straining/standing (Valsalva).

Treatment Steps
1. Observation.
2. Surgical if not resolving on own, or if resulting in infertility (vari-
cocele), or symptoms (pressure).

Front 14

Symptoms
May be asymptomatic, prostatitis, obstruction (abnormal stream an-
gle/spraying, or narrow stream), cystitis.

Back 14

Urethral Stricture

Pathology
May have history of gonorrhea, trauma, or other infections causing
fibrotic narrowing of the urethra.

Hint 14

Diagnosis
Cystourethrogram, history and physical, flow studies, culture, cystoscopy.

Treatment Steps
1. Optical internal urethrotomy.
2. Primary resection.
3. Dilation.

Front 15

SIGN OR SYMPTOM:
HEMATURIA

Back 15

hink of: Kidney stones,
cystitis, menstrual cycle,
anticoagulation/coagulopa-
thy, bladder cancer,
trauma, Foley catheter
manipulation, infections
(common as well as
uncommon, such as
Schistosoma haematobium), renal failure (in some ways

Front 16

Urinary Tract Infection

Back 16

Epidemiology—More frequent in females (except in neonates), and
increases with age.
Impact—Recurrent infections and renal damage.
Risk Factors—Obstructive uropathy (calculus, stricture/valves),
vesicoureteral reflux, diabetes mellitus, sexual activity, and pregnancy.

Hint 16

Prevention—Patient education, for both prevention/hygiene, early
intervention/treatment, and prophylactic antibiotics where indi-
cated.

Front 17

Toxic Nephropathy

Back 17

Epidemiology—Common causes include analgesics, penicillin/
sulfa, phenytoin sodium (Dilantin), cimetidine (Tagamet), heavy
metals, and aminoglycosides. Noted in chronic pain patients
with continued analgesic use.
Impact—Papillary necrosis/renal failure.
Risk Factors—Compounds listed, occupational/environmental ex-
posure to toxins, and both calcium disorders (sarcoid, multiple
myeloma, etc.) and antineoplastic agents.

Hint 17

Prevention—Patient education and early intervention/diagnosis
(discontinue the offending agent). Special consideration is given
to the elderly in whom reduced renal function may contribute to
elevated serum toxin levels and earlier toxicity.

Front 18

Renal Failure/Disease
For absorptive hypercalciuria
For renal hypercalciuria
For hyperuricosuria
For struvite/chronic infection stones
For hypercystinuria
For obstructions

Back 18

Renal Failure/Disease Prevention
Prevention of acute renal failure and of urinary tract disease
secondary to formation of calculi and/or obstruction.
Where absorptive hypercalciuria is noted, reduced-calcium diet, ion-exchange resin (sodium cellulose), hydration, and orthophosphates.
For renal hypercalciuria use thiazides.
For hyperuricosuria use allopurinol.
For struvite/chronic infection stones, use repeat
cultures/antibiotics.
For hypercystinuria, alkalinize the urine.
For obstructions, treat/remove obstruction when indicated

Front 19

Limiting Renal Disease Progression

Back 19

Control underlying disorder (hypertension, diabetes mellitus, etc.).
Dietary measures include protein/potassium/phosphorus restric-
tion for chronic renal failure. Limit extra dietary magnesium, treat
acidosis, and supply additional calcium when required.

Front 20

Dysuria

Back 20

may be symptom of cystitis, or
urethral syndrome in females.

Front 21

leukocytes in urine
need to r/o

Back 21

Pyuria is leukocytes in
urine, but not
necessarily infection
(pyuria and negative
culture: rule out
tuberculosis).

Front 22

Hematuria

Back 22

may be sign of infection, cancer, found in runners, renal
disease.

Hint 22

Always
abnormal in males; IVP
and cystocope to rule
out tumor

Front 23

Casts in urine
leukocyte =
RBC cast =

Back 23

uggest renal
disease (leukocyte,
pyelonephritis; red blood
cell [RBC] casts,
glomerulitis).

Front 24

Symptoms/Diagnosis
Cystitis presents as dysuria, frequency, nocturia, urgency. Urine dip,
urinalysis, and culture used in certain cases.

Back 24

Cystitis

Description
Cystitis is bladder infection.

Pathology
Cystitis usually from E. coli.

Hint 24

Treatment Steps
1. Antibiotics.
2. Intravenous pyelogram (IVP), cystoscopy for recurrent/persistent cases

Front 25

Symptoms
Severe pain, nausea/vomiting, flank pain, hematuria. Caliceal, may
be asymptomatic; proximal ureter, severe intermittent flank pain,
colic; distal ureter/ureterovesicle junction, radiating pain, bladder
irritation, groin pain.
• Pain is often
excruciating.

Back 25

Nephrolithiasis

Description
Calculi (stones) in the urinary tract

Hint 25

Diagnosis
History and physical, IVP, urine analysis. Uric acid stones not visible
on plain x-ray (see Fig. 17–1).

Treatment Steps
1. Prevention of further episodes: hydration and medical evalua-
tion.
2. Symptomatic stones: small stones (5 mm) supportive measures
and spontaneous passage (6 weeks). Larger or completely obstructive stones: upper tract—extracorporeal lithotripsy, lower
tract—ureteroscopy.
• Requires aggressive
hydration and pain
medications.
• Urinalysis will often show
microscopic hematuria.
• Calcium-containing
stones are seen on x-ray.
• CT scanning is now
used to visualize calculi.

Front 26

Symptoms
Infection/pyelonephritis, kidney damage/uremia.

Back 26

Ureteral Reflux

Description
Reflux of urine into ureter with voiding

Pathology
Short intramural ureter

Hint 26

Diagnosis
History and physical, urine analysis and culture, IVP, voiding cystourethrography.

Treatment Steps
1. Medical (watch and wait, antibiotics).
2. Surgical (ureteral reimplantation)

Front 27

Symptoms
Voiding dysfunction. Failure to empty urine; failure to store urine

Back 27

Neurogenic Bladder

Pathology
Sensory, motor, uninhibited, reflex, and autonomous.
Sensory—No sensation of full bladder, diabetics, herniated disk.
Motor—Sensation okay, but cannot initiate contraction, disk, po-
lio, tumor.
Uninhibited—No control, brain/central nervous system (CNS) le-
sion or disease.
Reflex Spinal Cord Injury, Autonomous—No connection from bladder to
brain, spinal trauma.

Hint 27

Diagnosis
History and physical, urodynamic testing (cystometrogram [CMG],
flowmeter, etc.)

Treatment Steps
Failure to empty:
1. Clean intermittent catheterization.
2. Sphincterotomy.
Failure to store:
1. Anticholinergics.
2. Collagen injections.
3. Bladder sling or artificial sphincter.

Front 28

Symptoms
Loss of urine with activity, coughing, or without reason.

Back 28

Stress-Related Urinary Incontinence

Pathology
Hypermobility of urethra and/or sphincteric incompetence.

Hint 28

Diagnosis
History and physical, urinalysis and culture to rule out infection,
urodynamic studies, cystoscopy, IVP (see Fig. 17–2).

Treatment Steps
1. Pelvic floor exercise (Kegel exercises).
2. Bladder neck suspension.
3. Bladder sling surgery.

Front 29

Symptoms
Unable to retain urine, day or night, typically nighttime bedwetting

Back 29

Enuresis

Pathology
Psychological, organic disease, or delayed CNS/neuromuscular de-
velopment (most common etiology).

Hint 29

Diagnosis
History and physical, excretory urogram, urine analysis, and culture

Treatment Steps
1. Reassurance.
2. Evening fluid restriction.
3. 1-desamino-8-D-arginine vasopressin (DDAVP)

Front 30

Symptoms
May be asymptomatic, also flank/back pain, decreased urine output, abdominal pain, infections. In infant may have multiple nonspecific symptoms.

Pathology
Obstruction, in child often uteropelvic junction obstruction; in adult
may be BPH, calculus, tumor, aortic aneurysm (see Fig. 17–3)

Back 30

Hydronephrosis

Description
Kidney/ureter damage from ureter obstruction

Hint 30

Diagnosis
History and physical, ultrasound, IVP, check electrolytes, blood urea
nitrogen (BUN), creatinine

Treatment Steps
1. Surgical correction.
2. Stent obstructed area.

Front 31

INCONTINENCE
Urge incontinence

Back 31

Detrusor hyperreflexia, neurologic origin, detrusor origin
r/o?

Hint 31

rule out infection, carcinoma in situ.
Treat with anticholinergics, bladder augmentation when appropriate.

Front 32

INCONTINENCE
Stress incontinence

Back 32

Urethral hypermobility, symptoms reproducible, anatomic not neurologic
origin. Subclass of intrisic sphincteric deficiency.

Hint 32

Treat with pelvic floor strengthening, collagen
injections, surgical urethral suspension

Front 33

BLADDER OUTLET OBSTRUCTION
Bulk obstruction

Back 33

Enlarged prostate, high pressure voiding, possible bladder instability. Treat
with bulk reduction

Hint 33

5α-reductase inhibitor (finasteride) or tissue ablation (TURP, laser ablation,
open enucleation).

Front 34

BLADDER OUTLET OBSTRUCTION
Increased tone

Back 34

Increased α-adrenergic tone of bladder neck or prostate/prostate capsule
smooth muscle.

Hint 34

Treat with α-blockers (organ and CNS affect). Major side effect—orthostasis.
Surgery—bladder neck or prostate incisio

Front 35

BLADDER OUTLET OBSTRUCTION
Urethral stricture

Back 35

Occlusion of urethra (usually bulbar).
Status postinfection (gonorrhea),
trauma, prior catheterization

Hint 35

Treatment—dilatation, optical urethrotomy, or surgical repair.

Front 36

Symptoms
Chills/fever, vomiting, flank pain, anorexia

Back 36

Pyelonephritis (Acute and Chronic)

Description
Ascending infxn/inflammation into the kidney

Pathology
Usually E. coli. Also Pseudomonas.

Hint 36

Diagnosis
History and physical, urine analysis (white blood cell [WBC] casts,
pyuria) and culture, blood culture, complete blood count (CBC).
Chronic pyelonephritis: renal damage with persisting infection.

Treatment Steps
Antibiotics (IV cephalosporin and aminoglycoside). If recurrent/chronic infection, rule out organic disease and coexisting medical conditions.
PYELONEPHRITIS
• If patient is not seriously
ill, may be managed with
oral antibiotics.
• However, if patient has
severe nausea/vomiting
or appears ill
(dehydration,
hypotension), IV
hydration and antibiotics
may be needed first.
• Total duration of
treatment usually 10–14
days.

Front 37

Symptoms
Hematuria, proteinuria, reduced glomerular filtration rate (GFR) resulting in hypertension, edema.

Back 37

Glomerulonephritis

Description
Kidney inflammation with glomeruli as area of disorder.

Pathology
Inflammation/immune deposits resulting in glomerular injury.

Hint 37

Diagnosis
History and physical, urine analysis and culture, serologic studies to attempt to define cause.

Treatment Steps
Varies according to etiology.
1. Acute––diuresis, bed rest, antihypertensives.
2. Rapid progression––steroids, cytotoxics, plasmapheresis

Front 38

Multiple diseases cause
glomerulonephritis
Infection
Multisystem
Drugs

Back 38

• Infections: Human
immunodeficiency virus
(HIV), hepatitis B,
endocarditis,
poststreptococcal
• Multisystem: Systemic
lupus erythematosus,
Goodpasture’s,
Wegener’s, rheumatoid
arthritis, polyarteritis
nodosa
• Drugs: Penicillamine,
hydralazine, allopurinol,
rifampin

Front 39

Description/Treatment
MCD refers to a pathologic lesion of the glomerulus. It is the most common cause of nephrotic syndrome in children

Back 39

Minimal Change Disease (MCD)

Pathology
Under light microscopy, the glomerulus is basically normal. Im-
munohistochemistry is also unremarkable. However, changes are
seen on electron microscopy: retraction of the epithelial foot
processes, sometimes referred to as fusion of the foot processes.

Hint 39

usually very responsive to steroids (prednisone), with a good prognosis. It is less responsive to steroids and has a slightly worse prognosis in
adults.

Front 40

Symptoms
Gross hematuria after viral infection, fever, proteinuria, dysuria

Pathology
Immune deposits of IgA on glomeruli

Back 40

Immunoglobulin A (IgA) Nephropathy

Description
Berger’s disease (a variety of Henoch–Schönlein purpura).

Hint 40

Diagnosis
History and physical, possible elevated serum IgA, biopsy.

Treatment Steps
None.

Front 41

Pathology
Microvascular glomerular damage (thickening of the glomerular basement membrane) and Kimmelstiel–Wilson lesions (nodular deposits in glomeruli).

Back 41

Diabetic Nephropathy

Description
This is a clinical syndrome associated with diabetes, proteinuria, and, if uncontrolled, progressive renal failure. Patients are symptomatic as renal failure develops. It is the leading cause of chronic renal failure.

Hint 41

TREATMENT OF DIABETIC NEPHROPATHY
• Prevention is of the utmost importance.
• Excellent diabetic control (goal: hemoglobin A1C < 7.0).
• Excellent blood pressure control (< 120/80).
• Routine screening of urine for microalbuminuria (a small but abnormal degree of albumin in the
urine, 30–300 mg/day).
• Treatment of microalbuminuria with angiotensin-converting enzyme (ACE) inhibitors or
angiotensin receptor blockers.
• Early follow-up with a nephrologist is prudent.
• If renal insufficiency progresses to failure, counseling and preparation should begin for
hemodialysis and/or renal transplant.

Front 42

Symptoms
Polyuria, nocturia, acute renal failure, fever, rash, joint pain.

Back 42

Interstitial Nephropathy

Pathology
Wide variety of infections, toxins (heavy metals), calcium disorders,
drugs, and systemic disorders as etiologic agents.

Hint 42

Diagnosis
History and physical, eosinophilia, renal biopsy.

Front 43

increase in BUN and
creatinine

Back 43

Azotemia

Front 44

decreased urine output (100–400mL/day).

Back 44

Oliguria

Front 45

basically no urine output (< 100mL/day).

Back 45

Anuria

Front 46

Acute Renal Failure

Description
A decline in renal function over a short period of time (hours to
days).

Back 46

Symptoms
Vary based on cause of the renal failure. Important to assess a de-
cline in urine output, change in the quality of the urine flow or
color, dysuria, hematuria, increase in abdominal size. Look for signs
of volume status: skin turgor, peripheral edema.

Diagnosis
Assess for symptoms as above. Ask about any new medications that
have been started. Routine labs include chemistries (specifically for
potassium, CO2, BUN, creatinine, magnesium, phosphate, calcium).
Also, urinalysis, urine electrolytes (particularly urine sodium and
creatinine). Routine CBC, liver function tests (LFTs), electrocardio-
gram (ECG), and chest x-ray (CXR). Other studies (e.g., KUB [kid-
neys, ureters, bladder] or CT scan to rule out nephrolithiasis) are
done as indicated.

Hint 46

Treatment Steps
Varies according to the etiology. Some guidelines:
1. Prerenal: Improving renal blood flow may be accomplished with
iv hydration, stopping ACE inhibitors, and in certain cases using
vasopressors (dopamine).
2. Intrinsic renal: Varies according to etiology.
3. Postrenal: Foley catheter can be curative if obstruction caused by
BPH. Removal of kidney stone, or ureteral or urethral stent if
there are stenoses causing a blockage.
4. In all cases, meticulous attention paid to urine output and man-
agement of electrolyte imbalances (hyperklemia). Also, remove
all potentially nephrotoxic medications (NSAIDs, ACE inhibitors)
and adjust the doses of necessary medications according the crea-
tinine clearance.
5. Dialysis is used in certain cases
INDICATIONS FOR DIALYSIS
(AIEOU)
• Acidosis
• Intoxications
• Electrolytes
• Overload (fluid)
• Uremia

Front 47

ACUTE RENAL FAILURE
PRERENAL
differential

Back 47

PRERENAL
Conditions in which there is decreased flow to the kidney.
Commonly includes volume depletion (from
gastrointestinal bleed, overdiuresis, severe dehydration). Also includes relative intravascular volume
depletion and reduced renal blood flow (i.e., congestive heart failure, cirrhosis).

Front 48

ACUTE RENAL FAILURE
INTRINSIC RENAL
differential

Back 48

INTRINSIC RENAL
Conditions affecting the kidney directly. Includes the glomerulonephridites, acute tubular necrosis,
rhabdomyolysis, multiple myeloma, interstitial nephritis, and amyloidosis.

Front 49

ACUTE RENAL FAILURE
POSTRENAL
differential

Back 49

POSTRENAL
Obstruction of flow existing somewhere in the urinary tract.
In men, common cause is BPH. Also extrinsic compression by pelvic mass, kidney stones.

Hint 49

One rule of thumb is when a patient is seen
initially, a Foley catheter should be placed. This will help to see if there is distal obstruction. Additionally,
a renal ultrasound should be done to rule out hydronephrosis.

Front 50

Symptoms
May have reduced urine output, lethargy, hypertension, myopathy,
pruritus, pericarditis, anemia.

Back 50

Chronic Renal Failure

Description
Long-term renal function reduction.

Diagnosis
Assess for symptoms as above. Ask about any new medications that
have been started. Routine labs include chemistries (specifically for
potassium, CO2, BUN, creatinine, magnesium, phosphate, calcium).
Also, urinalysis, urine electrolytes (particularly urine sodium and
creatinine). Routine CBC, liver function tests (LFTs), electrocardio-
gram (ECG), and chest x-ray (CXR). Other studies (e.g., KUB [kid-
neys, ureters, bladder] or CT scan to rule out nephrolithiasis) are
done as indicated.

Pathology
Etiology in numerous disorders.

Hint 50

Treatment Steps
1. Diet control.
2. Balance electrolytes.
3. Treat anemia, osteodystrophy.
4. Dialysis

Front 51

Symptoms
Children—growth retardation, rickets.
Adults—may be asymptomatic, or bone pain, proximal muscle weak-
ness.

Back 51

Renal Osteodystrophy

Description
Skeletal abnormality secondary to chronic renal failure. Diagnose
with typical x-ray findings

Pathology
Subperiosteal bone resorption. Results in osteitis fibrosa and osteomalacia.
Most common skeletal
lesion in chronic renal
failure (CRF): osteitis
fibrosa. Lack of
erythropoietin results in
CRF anemia. Serum
phosphate is elevated
with reduced GFR (e.g.,
chronic renal failure).
Total serum calcium is
reduced in CRF

Hint 51

Treatment Steps
Control serum calcium/phosphorus (phosphate binders), parathy-
roidectomy. Drug of choice for hypocalcemia/secondary hyper-
parathyroidism is vitamin D

Front 52

Symptoms
Hematuria, fever, flank pain, renal failure.

Back 52

apillary Necrosis

Description
Kidney papilla necrosis.

Pathology
Ischemic, usually associated infection. Chronic disease, toxins, ob-
structions. Often seen in patients with sickle cell disease. May be a
complication of pyelonephritis

Hint 52

Diagnosis
History and physical, IVP, urine analysis, and culture.

Treatment Steps
1. Treat primary etiology (infection, etc.).
2. Remove mechanical obstruction

Front 53

Symptoms
Hypertension, may be rapid onset at any age, difficult to control,
childhood or older adult onset.

Back 53

Renovascular Hypertension

Description
Stenosis of the renal arteries can cause systenic hypertension.
• In a young female,?
• In older patients,?

Hint 53

RENAL ARTERY STENOSIS
• In a young female,
suspect fibromuscular
dysplasia, often
amenable to stenting.
• In older patients, suspect
atherosclerosis as the
cause.

Diagnosis
History and physical (epigastric bruit), IVP, renal/digital subtraction
angiography (DSA), renal vein renin ratio > 1.5.

Treatment Steps
1. Medication (captopril).
2. Surgical (including angioplasty).

Front 54

Symptoms
Often asymptomatic. Over time, signs and symptoms of renal disease
develop. Clinical diagnosis. Renal failure, proteinuria, hematuria, small kidneys, or no symptoms.

Back 54

Nephrosclerosis

Description
A clinical syndrome involving long-standing hypertension, hypertensive retropathy, hypertrophy of the left ventricle, minimal protein-
uria, and progressive renal insufficiency/failure.

Hint 54

Treatment Steps
Control blood pressure and renal disease.

Front 55

Symptoms
Hematuria, proteinuria, hypertension, edema, red cell/hyaline casts

Back 55

Lupus Nephritis

Description
Lupus may present as interstitial nephritis or glomerulonephritis.

Pathology
Interstitial fibrosis and inflammation. Includes several histologic
types (minimal, mesangial, focal, diffuse, and membranous).

Hint 55

Diagnosis
History and physical, urine analysis, lupus symptoms (rash, fever, weight loss, joint symptoms, etc.), serologic testing (antinuclear antibodies [ANA], anti-DS-DNA, etc.), renal biopsy.

Treatment Steps
Prednisone, cyclophosphamide, azathioprine. Close follow-up by nephrologist and rheumatologist.

Front 56

Symptoms
Hematuria, flank pain, hypertension, pyelonephritis, uremia.

Back 56

Inherited Disorders—Polycystic
Kidney Disease

Description
Hereditary cystic kidney disorder.
Cysts also in liver and
pancreas. Positive
association of polycystic
kidney disease and
intracranial aneurysms.

Pathology
Adult Polycystic Kidney Disease—autosomal dominant, cysts.
Infantile Polycystic Disease—autosomal recessive, collecting duct dila-
tion

Hint 56

Diagnosis
History and physical (enlarged kidney), IVP, ultrasound. Child: bilateral flank mass.

Treatment Steps
1. Blood pressure control.
2. Dialysis.
3. Renal transplant

Front 57

Electrolyte Disorder differential

Symptoms
Confusion, vomiting, coma, nausea, lethargy

Back 57

Hyponatremia

Description
Sodium < 130 mEq/L.

Pathology
Excess salt loss (diuretic use), water retention (renal/cardiac failure,
syndrome of inappropriate antidiuretic hormone [SIADH]). (See also Chapter 3.
HYPONATREMIA
• Diuretics: Generally mild,
worsened by free water
intake, loss of K+, volume
depletion, usually thiazide
diuretics.
• SIADH: Nonphysiologic
release of antidiuretic
hormone. Impaired water
but normal Na+ excretion.
Multiple etiologies: drugs,
neuropsychiatric,
pulmonary, postsurgical
state. Raise serum Na+ at
appropriate rate and treat
underlying cause.
• Edematous states:
Renal failure, cardiac
failure, cirrhosis. Requires
specific therapeutic
approaches.

Hint 57

Treatment Steps
Salt loss—give saline.
Water excess—restrict water.
• Too rapid correction of
hyponatremia can cause
central pontine
myelinosis (CPM). In
CPM, central nervous
system sequelae can
vary, but the most
devastating is known as
"locked in syndrome," in
which the patient has
paralysis of the limbs
and lower cranial nerves,
but vertical eye
movements, blinking,
and alertness remain
intact.

Front 58

Electrolyte Disorder differential
Symptoms
Thirst, hypotension, oliguria, hyperpnea, coma.

Back 58

Hypernatremia

Description
Elevated sodium, > 145 mEq/L.

Pathology
Excess water loss, impaired thirst, and solute loss (diabetic ketoacidosis).

Hint 58

Treatment Steps
Replace free water slowly. If sodium is corrected too rapidly, cerebral
edema can result. This can be fatal
• Too rapid correction of
hypernatremia can
cause brain edema.

Front 59

Electrolyte Disorder differential

Symptoms
Arrhythmia, muscle weakness/cramps, rhabdomyolysis.

Diagnosis
History and physical, serum electrolytes, ECG (smaller/wider T
wave, U wave, atrioventricular [AV] block).

Back 59

Hypokalemia

Description
Potassium < 3.5 mEq/L.

Pathology
Etiology in gastrointestinal (GI) and urinary loss, decreased intake
(uncommon), shift into cells (delirium tremens, hypothermia, increased
insulin as in hyperglycemia therapy).
HYPOKALEMIA
• Thiazide and loop
diuretics
• Low dietary intake
• Vomiting or other GI loss
• Potassium-free IV fluids
• Mineralocorticoid excess
• Penicillin derivatives
• Periodic paralysis—
hypokalemic form

Hint 59

Treatment Steps
1. Oral potassium replacement.
2. IV replacement under 20 mEq/hour.

Front 60

Electrolyte Disorder differential

Symptoms
Diarrhea, weakness.

Diagnosis
History and physical, serum electrolytes, ECG (wide QRS, peaked T).

Back 60

Hyperkalemia

Description
Potassium > 5 mEq/L.

Pathology
Reduced renal excretion, excess intake, adrenocortical insufficiency
Periodic paralysis: low,
normal, or high potassium,
muscle weakness.

Hint 60

Treatment Steps
1. Stop potassium.
2. Exchange resin (sodium polystyrene sulfonate [Kayexalate]).
3. Insulin/50% glucose.
4. Dialysis in certain cases.
HYPERKALEMIA WITH ECG
CHANGES
Acute treatment includes:
1. Calcium IV to stabilize
the cardiac myocyte
membrane.
2. Insulin and glucose to
facilitate potassium
exchange into the cells.
3. Sodium bicarb used in
certain situations.
4. Kayexalate must also be
given to facilitate
removal of potassium
from the body

Front 61

Electrolyte Disorder differential

Symptoms
Thirst, dehydration (sunken eyes, reduced skin turgor, etc.), coma.

Diagnosis
History and physical, increased serum sodium, BUN, and osmolality.

Back 61

Volume Depletion
Excessive water loss, reduced intake, or “third spacing.”

Hint 61

Treatment Steps
1. Slow replacement of free water.
2. Replace sodium as needed.

Front 62

Electrolyte Disorder differential

Symptoms
Weakness, nausea, seizure, coma.

Diagnosis
History and physical, electrolytes (low sodium, BUN).

Back 62

Volume Excess

Description
Free water excess.

Pathology
SIADH, renal failure, congestive heart failure (CHF).

Hint 62

Treatment Steps
Restrict free water. Subcategory: water intoxication—psychiatric
component, restrict fluids.

Front 63

Electrolyte Disorder differential

Symptoms
May have symptoms of hypokalemia, lethargy, tetany, volume depletion.

Diagnosis
History and physical, elevated anion gap, blood gas (elevated pH and serum bicarbonate).

Back 63

Metabolic Alkalosis

Description
Elevated pH and elevated carbon dioxide.
Reduced acid or gain of bicarbonate. Often caused or worsened by
volume depletion, diuretics.

Hint 63

Treatment Steps
Correct electrolyte abnormality and primary cause.

Front 64

Electrolyte Disorder differential

Symptoms
Syncope, tetany, anxiety, perioral paresthesias.

Back 64

Respiratory Alkalosis

Description
Elevated pH with low carbon dioxide, caused by hyperventilation.
RESPIRATORY ALKALOSIS
Patient is breathing rapidly.
Etiology could be as simple
as anxiety or as serious as
pulmonary embolism. Look
for underlying cause and
treat appropriately.

Front 65

Electrolyte Disorder differential

Symptoms
Thirst, lethargy, coma, dehydration, and primary disease symptoms

Back 65

Metabolic Acidosis

Description
Reduced blood pH and bicarbonate. Separate into elevated or
nonelevated anion gap. Anion gap = sodium – (bicarb + chloride).

Pathology
Elevated Anion Gap—Diabetic ketoacidosis, lactic acidosis, starvation,
methanol/salicylate/ethylene glycol ingestion.
Commonly used mnemonic
is MUDPILES:
Methanol
Uremia
DKA
Paraldehyde (very rare
cause)
Iron or Isoniazid
ingestion
Lactic acidosis (which
itself has many causes)
Ethanol, ethylene glycol
Salicylates
Normal Anion Gap—Diarrhea, renal tubular acidosis.

Hint 65

Diagnosis
History and physical, arterial blood gas. Evaluation of individual disorders

Treatment Steps
Correct primary etiology. Lactic acidosis: acidosis associated with
shock and metabolic disorders, significant mortality.

Front 66

Electrolyte Disorder differential

Symptoms
Lethargy, disorientation, coma, headache, anxiety.

Back 66

Respiratory Acidosis

Description
Reduced pH and elevated PCO2. Often occurs in respiratory failure,
commonly in patients with underlying chronic obstructive pulmonary disease (COPD).

Pathology
Inadequate ventilation.

Hint 66

Diagnosis
History and physical, arterial blood gas (hypercapnia).

Treatment Steps
This is a medical emergency, and ventilation needs to be improved
in order to lower the PCO2 level. Treatment of the underlying condition
is warranted; however, mechanical ventilation is often needed.
In certain scenarios, “noninvasive” ventilation can be used (continuous
positive airway pressure [CPAP] or bilevel positive airway pressure
[BiPAP]) via face mask, but often intubation with mechanical
ventilation is needed.

Front 67

RENAL TUBULAR ACIDOSIS
• Distal
differential

Back 67

Primary, inherited,
drugs, nephrocalcinosis,
idiopathic hypercalciuria,
hypervitaminosis D,
hyperthyroidism, multiple
myeloma,
hyperparathyroidism.

Front 68

RENAL TUBULAR ACIDOSIS
• Proximal:
differential

Back 68

Primary,
Wilson’s disease, heavy
metals, carbonic
anhydrase inhibitors,
scleroderma, tetracycline,
amyloid, nephrotic
syndrome, acute

Front 69

Electrolyte Disorder differential

Symptoms
Tetany, lethargy, delirium, CNS irritability, muscle cramps. ECG
findings are nonspecific but can include ST depression, loss of voltage,
PR prolongation, and widened QRS.

Back 69

Hypomagnesemia

Pathology
Etiology includes alcoholism, malnutrition, diabetic ketoacidosis, diuretics.

Hint 69

Treatment Steps
Replace magnesium (IV or IM).

Front 70

Electrolyte Disorder differential

Symptoms
Renal failure, nausea/vomiting, confusion, ECG (short QT, long
PR).

Back 70

Hypercalcemia

Description
Serum calcium > 10.2 mg/dL.

Pathology
Etiology includes sarcoidosis, cancer, milk-alkali, hyperthyroid/hyperparathyroidism.
CALCIUM
• Do not forget to correct
the calcium level when
the albumin is abnormal.
• Corrected calcium = 0.8
times (normal albumin –
measured albumin) +

Hint 70

HYPERCALCEMIA
• The most common
etiology in the outpatient
setting is primary
hyperparathyroidism (see
Chapter 3)
• The most common
etiology in the inpatient
setting is malignancy.
• If asymptomatic,
investigate etiology and
follow calcium levels.
• If symptomatic, inpatient
treatment:
• Initially, aggressive
hydration with normal
saline, followed by
diuresis with loop
diuretics (furosemide),
not thiazides.
• Bisphosphonates are
very effective.
Pamidronate (Aredia) is
given as a one-time
intravenous dose.

Front 71

Electrolyte Disorder differential

Symptoms
Tetany, Chvostek’s sign, Trousseau’s sign, perioral paresthesia, muscle
cramps.

Back 71

Hypocalcemia

Description
Low serum calcium (< 8.4 mg/dL).

Pathology
Etiology includes renal failure, vitamin D deficiency, hypoparathyroidism,
malabsorption.
CALCIUM
• Do not forget to correct
the calcium level when
the albumin is abnormal.
• Corrected calcium = 0.8
times (normal albumin –
measured albumin) +

Hint 71

Treatment Steps
1. Control etiology.
2. Administer calcium and vitamin D.
HYPOCALCEMIA AND
NEONATES
Rule out DiGeorge
anomaly, a rare but serious
condition (see Chapter 7).

Front 72

Symptoms
Pain, shock, flank ecchymosis.
Injury to ?—Hematuria.
Injury to ?—Blood at meatus, distended bladder,
voiding difficulty.
? Ligation—Presents as pain, nausea/vomiting, fever postop.

Back 72

Kidney and Urinary System Trauma

Description
Renal injury, minor (contusion, cut, hematoma), and major (deeper
cut/rupture, pedicle injury). Ureteral injury: most often surgical mishap, external cause most often gunshot.
Injury to Upper Urinary Tract—Hematuria.
Injury to Posterior Urethra—Blood at meatus, distended bladder,
voiding difficulty.
Ureter Ligation—Presents as pain, nausea/vomiting, fever postop.
retrograde
cystography to evaluate bladder.

Pathology
Renal—Blunt, by auto accident most common.
Pedicle Injury—Left renal vein most often injured, usually penetrating
injury.
Ureter—Often surgical injury, hysterectomy commonly.

Hint 72

Diagnosis
History and physical, IVP, CT, angiography, KUB. Evaluate urethra
with retrograde study. If blood at meatus: do not catheterize. Do retrograde cystography to evaluate bladder.

Treatment Steps
Kidney—Penetrating, surgical exploration; blunt, medical, or surgical.
Bladder—Contusion, catheter; rupture, surgery.
Ureter—Surgical (may need stent, anastomosis, bladder reimplantation,
depending on injury).
Urethra—Partial rupture, suprapubic cystotomy; complete rupture,
drainage, and suprapubic cystotomy.

Front 73

Symptoms
Lethargy, edema, oliguria, fever. Elevated blood pressure, diminishing renal function and proteinuria may indicate chronic graft rejection.

Back 73

Kidney Transplant Rejection

Description
Allograft rejection. Acute type most common.

Pathology
Immunologic host reaction, where activated helper T cells and macrophages damage donor tissue.

Hint 73

Diagnosis
History and physical, renal scan, renal biopsy.

Treatment Steps
Rejection types: Hyperacute (immediate, no treatment, nephrectomy),
acute accelerated (after several days, no treatment, nephrectomy),
acute (after 1–3 weeks, immunosuppression), chronic (no treatment). Rule out muscular or obstructive pathology.

Front 74

Symptoms
Cirrhosis (jaundice, ascites, etc.), renal failure (azotemia, oliguria).

Back 74

Hepatorenal Syndrome

Description
Cirrhosis and renal failure.
HEPATORENAL SYNDROME
• The kidneys retain the
ability to function
normally.
• If a patient with
hepatorenal syndrome
restores hepatic function
(or gets a liver
transplant), the kidneys
can again function
normally.

Hint 74

Diagnosis
History and physical, clinical picture (oliguria and severe liver disease),
no urine sediment. Low wedge pressure may suggest prerenal
azotemia, not hepatorenal syndrome

Treatment Steps
Treat etiology if possible, dialysis(?), fluids to rule out hypovolemia.