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34 Cards in this Set

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*Acute Tubular Necrosis (ATN) Clinical*

... - < 400 mL/day
-oliguria
-... BUN
-... creatinine
-metabolic ...
-...kalemia
-urine with brown ... casts and ... casts
Acute renal failure
elevated
elevated
acidosis
hyper
granular
epithelial
acute tubular necrosis:

The distribution of the areas of necrosis is more segmental with ... injuries, while ... injuries result in more diffuse proximal tubular injury.
ischemic
toxic
*Acute Tubular Necrosis*

Key points
-The most common cause of ... (50% of hospitalized pts)!
-... tubular injury
-Many causes: ... (shock), ... (drugs)
-Most patients ... if they have recovered from underlying illness (ischemic) and no serious damage to other organs (toxic)
Acute renal Failure
Reversible
ischemic
toxic
recover
*... *

Rapid clinical onset

Histology
-interstitial edema – fluid in the interstitial space separates tubules
-leukocytic infiltration of the interstitium and tubules (separates tubules even more, increases size of interstitial space), may see eosinophils
-focal tubular necrosis
Acute Tubulointerstitial Nephritis
*... *

Invasive bacterial infection (invades kidney parenchyma)
-85% are gram negative bacilli that inhabit gastrointestinal tract (enterics)
*... (#1)
*Proteus
*Klebsiella
*Enterobacter
-Streptococcus faecalis
-Staphylococcus spp.
Acute Pyelonephritis
Escherichia coli
*Acute Pyelonephritis*

Commonly associated with ... infection
-colonization of ...
-urethra to ... (instrumentation, coitus)
-multiplication in ...
-... (to get to kidney)
*incompetence of vesicoureteral valve

Less commonly associated with ... infection (blood seething into the kidneys)
ascending urinary tract
urethra
bladder
bladder
vesicoureteral reflux
hematogenous
In the absence of vesicoureteral reflux, the infection usually remains localized in the ...
bladder
*Acute Pyelonephritis*

Risk factors
-Urinary tract ...– lost flushing action
-Instrumentation – i.e. catheter
-... – key for travel to kidney
-Pregnancy
-Females ... Males – due to shorter urethra
-Preexisiting renal pathology
-Diabetes
-Immunosuppression (polyoma virus in renal transplant patients)
-Immunodeficiency
obstruction
Vesicoureteral reflux
>
*Acute Pyelonephritis*

Clinical
-Fever, Malaise, Flank pain. Costovertebral angle tenderness, Dysuria, Frequency , Urgency, Hematuria (30-40% of cases)
-UA: (2 key findings) ..., ... (formed only in tubules)
-Confirm infection with ...
WBCs
WBC casts
culture
look at slide 37-39 in lecture 25
ok
*Acute Pyelonephritis*

Key Points
-Usually ascends from ...
-Fever
-Flank pain
-Organisms -->..., gram negative enterics
lower urinary tract
E. coli
*... *

Prominent scarring due to urinary tract infections occurring in conjunction with congenital vesicoureteral reflux and intrarenal reflux

May be unilateral or bilateral

Occasionally severe ... may lead to scarring and atrophy even without infection

Scars are usually ... (either at upper or lower poles of kidney) and associated with ... or ... calyces
Reflux-associated Chronic Pyelonephritis
obstruction
polar
deformed or blunted
*Reflux-associated Chronic Pyelonephritis*

May have ... onset (problematic b/c of delay of tx)

May present with renal insufficiency and/or ... in a child

Tubule damage causes loss of urine ... ability

Symptoms (pee more often)
-polyuria
-nocturia
silent
hypertension
concentrating
*Chronic Obstructive Pyelonephritis*

Gross findings
-Irregular ... scarring
-Typical scar is ... and overlies a deformed or ... calyx

Microscopic findings
-Focal areas of tubular ... and atrophy
-Colloid casts in tubules
-Chronic ... inflammation
-Interstitial fibrosis
asymmetric
corticomedullary
blunted
dilation
interstitial
*Xanthogranulomatous Pyelonephritis*

Rare form of chronic pyelonephritis
-Associated with ... infection and obstruction

Gross
-yellow orange nodules that may mimic ...

Microscopic
-mixed inflammation with ... (key finding!), plasma cells, neutrophils, giant cells
Proteus
renal cell carcinoma
foamy macrophages
*Acute Drug-Induced Interstitial Nephritis*

Causes
-...
*sulfonamides, methicillin, ampicillin, rifampin
-NSAIDS
-... – tx gout
-... – 1st non-surgical tx for ulcer
-Thiazide diuretics – MC is ... and combos w/ thiazides in it
Antibiotics
Allopurinol
Cimetidine
HCTZ
*Acute Drug-Induced Interstitial Nephritis*

Typically begins ... days post drug exposure (can be as short as 2 days)

Clinical
-... --> think infx
-... --> think hypersensitivity
-renal abnormalities
*hematuria, proteinuria, leukocyturia (with eosinophils)
-rash (minority of patients)

Drugs act as haptens that bind to tubular epithelial cells

... and T-cell mediated immune response
15
fever
eosinophilia
IgE
*Acute Drug-Induced Interstitial Nephritis*

... edema and inflammation
-macrophages, lymphocytes, eosinophils, neutrophils (mixed! key feature)

... offending drug and patient typically recovers and renal function usually returns to normal

Problem: in many patients an offending drug is not identified

slide 18 in lecture 26
Interstitial
Stop
Drug-Induced Acute Interstitial Nephritis*

Key points:
-... (rifampin, ampicillin), NSAIDS
-... and ... -cell-mediated immune reaction
-Fever, ... (key feature), hematuria
-Patient usually recovers
-... nephritis is worse!
Antibiotics
IgE and T
eosinophilia
Analgesic
*Analgesic Nephropathy*

Cause by excessive intake of analgesics

Chronic ... nephritis and ...

Highest incidence in ... U.S.

Mixtures of analgesic cause ... problems than single analgesics
-phenacetin
-acetaminophen
-aspirin
tubulointerstitial
papillary necrosis
Southeast
more
*Urate Nephropathy*

Acute
-precipitation of urate crystals in ...
-leads to ... and acute renal failure
-patients getting chemotherapy for .../...
-uric acid is released as tumor cells die
*... helps keep kidneys flushed out

Chronic
-urate crystals in ...
-seen in patients with ...
-form ...
*giant cells, mononuclear cells, fibrosis, giant cells
-renal dysfunction progresses ...
tubules
obstruction
leukemia/lymphoma
hydration
tubules or interstitium
gout
tophi
slowly
*... *

Affect 5-10% of Americans at some time in their life

Men>women

Peak age 20-30 yo

Composition
-... -> 70%
-... (magnesium ammonium phosphate aka “triple phosphate stones”)-> 15%
-... -> 10% (won’t show up on plain x-ray)
-Cystine -> 1-2%

Diagnosis
-IVP
-CT
-Ultrasound
Renal Stones
Calcium oxalate
Struvite
Uric acid
*Renal Stones*

Calcium oxalate
-often seen in patients with ... w/o ...
-also seen in patients with uricosuria

Struvite
-associated with infection by urea-splitting bacteria (...)
-may form large "..." calculi in renal pelvis

...
-gout, leukemia

Cystine
-genetic defect in renal ... of cystine
hypercalciuria
hypercalcemia
Proteus
staghorn
Uric acid
reabsorption
Key points about labs:

(1) renal compromise - a creatinine of 2.1 in a healthy boy is too high, and implies renal impairment if there are no features of ...

(2) a mildly increased WBC count with eosinophilia - an indicator of ...

(3) the urinalysis findings - the presence of blood, protein, and WBCs - suggest ... in a patient with a history of a streptococcal infection.
hypovolemia
hypersensitivity
glomerulonephritis
look at slides 32-37
ok
A 55-year-old man frequently takes large quantities of analgesics containing phenactein, aspirin, and acetaminophen. His blood pressure is 160/96, BUN 61 mg/dL, and creatinine 6.5 mg/dL. Which renal complication is he most likely to develop?

1. Hydronephrosis
2. Chronic glomerulonephritis
3. Papillary necrosis
4. Carcinoma
5. Acute tubular necrosis
3. Papillary necrosis

He has analgesic nephropathy which damages the renal interstitium and can result in papillary necrosis
A clinical study is performed of laboratory findings in subjects with renal diseases. Loss of physiologic function accompanies many diseases. Loss of which of the following renal functions is most likely to be identified by laboratory measurement of the urine specific gravity?

1. Filtration
2. Reabsorbtion
3. Secretion
4. Concentration
5. Blood flow
4. Concentration

Renal concentrating ability is reflected by the specific gravity. In a person with normal concentrating capacity, less water intake is reflected by an increased specific gravity.
A 47 year-old man is has an acute myocardial infarction. He has decreased cardiac output with hypotension requiring multiple pressor agents. His urine output drops over the next 3 days. His blood urea nitrogen increases to 59 mg/dL, with serum creatinine of 2.9 mg/dL. Urinalysis reveals no protein or glucose, trace blood, and numerous hyaline casts. Five days later, he develops polyuria and his blood urea nitrogen declines. Which of the following pathologic findings in his kidneys is most likely to have caused his azotemia?

1. Patchy tubular necrosis
2. Fusion of podocyte foot processes
3. Glomerular crescents
4. Hyperplastic arteriolosclerosis
5. Mesangial immune complex deposition
1. Patchy tubular necrosis

He has findings of ischemic acute tubular necrosis from heart failure with hypotension.
A 75-year-old woman has had a fever and dysuria for the past 3 days. On physical examination her temperature is 101.2 F and there is pain on palpation of her left lower back. A urine dipstick analysis shows sp gr. 1.017, pH 6, leukocyte esterase positive, nitrite positive, protein negative, glucose negative, and blood negative. Which of the following microscopic urinalysis findings would be most diagnostic for her renal disease?

1. Eosinophils
2. Oval fat bodies
3. Urate crystals
4. White blood cell casts
5. Calcium oxalate crystals
4. White blood cell casts

The WBC casts are most characteristic for an acute pyelonephritis
A 21-year-old woman has been hospitalized for treatment of a Staphylococcus aureus abscess of her left thigh which resulted from a laceration. The wound is incised and drained and she receives antibiotic therapy. She is improving and discharged home a week later, but the next day she develops a fever. On physical examination her temperature is 38.1 C and there is a diffuse erythematous skin rash of her trunk and extremities. A urinalysis shows sp gr 1.020, pH 6.5, 1+ blood, 1+ protein, no glucose, and no ketones. There are 10-20 WBCs/hpf and 1-5 RBCs/hpf, and frequent eosinophils are noted on urine microscopic examination. Which of the following is the most likely diagnosis?

1. Acute tubular necrosis
2. Analgesic abuse nephropathy
3. Acute drug-induced interstitial nephritis
4. Hemolytic-uremic syndrome
5. Urinary tract infection
3. Acute drug-induced interstitial nephritis

This allergic response can occur following drug therapy with such antibiotic agents as methicillin as well as some diuretics and NSAIDs. This allergic response is unrelated to the amount of drug and duration of therapy. This condition is treated by stopping the drug.
A 44-year-old woman has noted fever and right flank pain for the past 3 days. On physical examination her temperature is 38.4 C and there is right costovertebral angle tenderness. A urinalysis reveals sp. gr. 1.010, pH 7.5, no glucose, no protein, no ketones, and 1+ blood. Many WBCs and WBC casts are seen on urine microscopic examination. An abdominal radiograph reveals a radiopaque calculus that forms a cast of a dilated right renal collecting system. A urine culture grows Proteus vulgaris. Which of the following crystals is most likely to be seen in large numbers on microscopic urinalysis in this woman?

1. Calcium oxalate
2. Cystine
3. Calcium phosphate
4. Uric acid
5. Magnesium ammonium phosphate
5. Magnesium ammonium phosphate

She has a staghorn calculus and acute pyelonephritis. These 'infection stones' are typically the 'triple phosphate' stones whose formation is aided by infection with urea-splitting bacteria such as Proteus.
A 24 year-old man passes a stone in his urine. The stone is analyzed and found to be composed of calcium oxalate. He has no other symptoms or prior significant illnesses. Which of the following conditions is he most likely to have?

1. Hypercalciuria
2. Hypercalcemia
3. Hyperparathyroidism
4. Gout
5. Leukemia
1. Hypercalciuria

Calcium oxalate stones are the most common urinary tract stones. About 55% of patients with calcium oxalate stones have hypercalciuria without hypercalcemia
Which is most likely to be reversible in a 25-year-old man with elevated serum creatinine and blood urea nitrogen levels?

1. Analgesic nephropathy
2. Malignant nephrosclerosis
3. Acute tubular necrosis
4. Benign nephrosclerosis
5. Renal papillary necrosis
3. Acute tubular necrosis

ATN causes reversible acute renal failure. The tubular epithelium can regenerate.
A 19 year-old woman presents with acute bacterial pyelonephritis. Which factor is most important in the pathogenesis of this disease?

1. Age
2. Vesicoureteral reflux
3. Gender
4. Diabetes mellitus
5. Coitus
2. Vesicoureteral reflux

In the absence of vesicoureteral reflux, infections tend to remain localized in the urinary bladder