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141 Cards in this Set
- Front
- Back
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What is a urinary tract infection?
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Inflammatory response of urothelium to microorganisms in the urinary tract, resulting in clinical symptoms including dysuria, frequency, urgency, hematuria, and suprapubic or costovertebral angle tenderness
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What is bacteriuria?
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Presence of bacteria in the urine; not considered to represent a UTI in the absence of clinical manifestations. Should only be treated in certain populations eg. pregnant women
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How do you classify urinary tract infections?
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Uncomplicated = UTI in a structurally and functionally normal urinary tract
Complicated: UTI associated with underlying neurologic, structural or medical problems all of which may reduce the efficacy of standard antimicrobial therapy |
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what is urethritis?
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Inflammation of the urethra secondary to either an infection (STI) or trauma
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What is cystitis?
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Inflammation of the bladder resulting in increased urinary frequency, urgency, dysuria and suprapubic pain. Cystitis can be separated into bacterial and nonbacterial (radiation, trauma)
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What is pyelonephritis?
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UTI of the renal parenchyma and collecting system manifested by the clinical syndrome of fever, chills and flank pain
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Who gets UTIs?
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Anyone, but most common in sexually active women
elderly (women more than men) infants (boys more than girls) young girls patients who have had instrumentation of the urinary tract or indwelling catheters patients with incomplete bladder emptying or obstruction patients with congenital abnormalities of the urinary tract diabetics pregnant women immunosuppressed patients |
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How do bacterial enter the urinary tract?
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in most people through the urethra, in debilitated and chronically ill, immunosuppressed patients by hematogenous or lymphatic spread from distal foci of infection
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What are the most common organisms causing UTI?
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E coli
Staph saprophyticus (less common proteus, klebsiella, enterobacter) |
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What are some of the more unusual pathogens to consider in complicated UTIs?
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More resistant strains fo ecoli, klepsiella, proteus and enterobacter as well as pseudomonas, enterococcus, staphylococcus, providencia, serration, salmonella, shigella, haemophilus, m tuberculosis and fungi
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How often is UTI polymicrobial?
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In more than 95% of true UTIs, a single bacterial species is responsible.
True polymicrobial UTI is observed in very few clinical situations: long term urinary catheter or another FB patinet has a stagnant pool of urine because of inadequate emptying fistulous communication Otherwise two or more bacterial species on urine culture signifieds a contaminated specimen |
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What are some of the common bacterial contaminants of urine cultures that are unlikely causes of true UTIs?
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Staph epidermidis
corynebacterium lactobacillus gardnerella anaerobic bacteria |
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How should you manage a male patient complaining of dysuria?
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Evaluate for the presence of urethral discharge before urinalysis
If there is purulent urethral discharge test for chlamydia, gonorrhoea and syphillis and treat empirically for STI If there is no urethral discharge and the patient complains predominantly of dysuria, frequency and urgency send a UA Male patients with bacteriuria in the absence of clinical signs of urethritis or prostatitis should be considered to have a complicated UTI and should be treated with antibiotic therapy and receive a urologic follow up for further evaluation |
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What are different ways of collecting urine specimens in children?
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Suprapubic aspiration - invasice, though safe
Catheterization: more often successful, low complication rate, but scary Perineal bag: noninvasive but often contaminated Midstream void: often contaminated in girls, but noninvasive and not scary, works well in boys |
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What are different ways of collecting urine specimens in adults?
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Midstream void: easy and non-invasive but often contaminated in women esp those menstruating
Catheterization: quick and accurate, risk of infection increases if pregnant, elderly or debilitated In men the timing of the collection is not important |
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What are the dipstick tests for leucocyte esterase and nitrite? How accurate are they for diagnosing UTI?
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-Leukocyte esterase is an enzyme found in neutrophils. Sensitivity 75-96% in detecting pyuria associated with UTI
-Nitrite is produced from urinary nitrate by nitrate reductase which is present in gram negative bacteria (except pseudomonas) sensitivity 35% to 50% and a specificity of 90% |
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What are the pitfalls of urine microscopy to diagnose UTI?
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-Lack of standardized technique
-Urine specimens that are allowed to sit become alkaline which may provide falsely positive results |
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What is the definition of UTI on culture?
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105 CFU/mL is considered significant
However the results must be put into the clinical context |
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What are indications for urine culture (15)?
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Children
Adult men Immunocompromised Treatment failure Symptom duration >4-6 days Elderly patients at risk for bacteria Ill appearing patients with signs of pyelonephritis or bacteremia Pregnant women Known anatomic urologic abnormality Known chronic or recurrent renal infection Suspected urinary tract obstruction Serious co-morbidity (diabetes, SCD, cancer, alcoholism, drug dependence) -Recent hospitalization -On antibiotics -Recent urinary instrumentation |
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When is imaging indicated in the setting of UTI?
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-patients with apparent pyelonephritis but unremarkable urinalysis (?obstruction that doesn't allow to reach the bladder)
-patients with UTI, on antibiotics with persistent fever, chills, toxicity. -female patient with multiple episodes of complex infection -patient with diminishing renal function -first episode of UTI in selected patients (girls and boys <4 years) |
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What is very suggestive of a complicated urine infection?
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Persistance of fever beyond 72 hours after starting antibiotics - these patients should be imaged
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Why should asymptomatic bacteriuria be treated in pregnant women?
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-Physiologic changes in pregnancy increase the risk of pyelonephritis
-untreated bacteriuria may result in premature labour, perinatal mortality, maternal anemia, maternal pyelonephritis |
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What serious complication of UTI occurs more often in diabetic patients?
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Papillary necrosis
perinephric and renal abscess, emphysematous cystitis |
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What is the management of bacteriuria in a patient with an indwelling catheter?
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-Do not treat if asymptomatic
-Treat if the symptoms suggest UTI -Always culture before treatment -most of the time you will also change the catheter |
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In which adult female patients should you use a 7-day regimen of antibiotics (6)?
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-Pregnant women
-Age >65 -Diabetes -Symptoms >7days -Recent UTI -Diaphragm use |
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What are antibiotic options for treating pregnant women with acute uncomplicated cystitis?
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nitrofurantoin (first choice)
TMP-SMX (not in 3rd trimester) Amoxicillin Amox-clav Cephalexin Cepodoxime |
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What non-antibiotic medications can be used to treat dysuria?
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Pyridium (body excretions and secretions will turn orange)
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What are indications to admit patients with UTI?
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Clinical toxicity
Inability to take oral meds Immunocompromised Third trimester pregnancy Inadequate social circumstances Failure of outpatient oral therapy Urologic abnormalities Patients with significant co-morbid conditions |
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What symptoms are suggestive of UTI in neonates (<3 months)
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Poor feeding
Vomiting Jaundice Hypothermia Fever FTT Sluggishness |
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What is the incidence of sepsis in neonates with UTI?
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30%
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What is the significance of pneumaturia?
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-May be indicative of emphysematous cystitis
-May indicate a vesicoenteric or vesicovaginal fistula |
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What 3 qualifying factors must always be addressed in dealing with UTI in men?
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-always rule out obstruction
(pyelonephritis typically involves stone, prostate, stricture, tumor) -refer all men to a urologist -do not catheterize to collect a urine sample unless the patient is in retention |
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What are the primary organisms responsible for bacterial prostatitis?
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80% Ecoli
Also klebsiella, enterobacter, proteus, pseudomonas) |
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What is the clinical presentation bacterial prostatitis?
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-Dysuria, frequency and urgency
-Perineal and low back pain associated with fever, chills, arthralgia, myalgia and generalized malaise -exquisitely tender and boggy prostate -usually accompanied by cystitis |
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What is the treatment of bacterial prostatitis?
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Non-toxic patients:
4-6 weeks of outpatient treatment with PO cipro or TMP-SMX Toxic patients: admit and treat with ciprofloxacin or ceftriaxone +/- gentamicin -avoid urethral catheterization |
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What is the clinical presentation of chronic prostatitis?
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-Hallmark is relapsing UTI caused by the same organism
-irritative voiding symptoms, low back and perineal pain -fever and chills are uncommon except during an acute exacerbation -prostate exam is often unremarkable |
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How is chronic prostatitis treated?
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Same antibiotics as acute prostatitis but optimal duration is unclear, may be as long as 16 weeks
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List risk factors for urolithiasis?
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Metabolic:
Crohn's Milk-alkali Primary hyper-parathyroidism Hypernitratemia Hyperuricosuria Sarcoidosis Recurrent UTI Renal tubular acidosis Gout Laxative abuse Family history Hot arid climate Male gender Dehydration |
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What are the different types of renal calculi and which is the most common (4)?
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Calcium oxalate/phosphate (most common)
Struvite Uric acid Cystine |
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When are struvite stones found?
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Almost exclusively in patients with UTI. They cause staghorn calculi
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What are three primary predictors of spontaneous stone passage?
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1. Calculus size: 90% of stones <5mm pass within 4 weeks, 15% of stones 5-8mm pass. 95% of stones >8mm will become impacted
2. Location: spontaneous passage is more frequent with stones located below the midureter 3. Degree of patient pain at discharge: patients with well-controlled pain are less likely to require surgical intervention |
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Describe the clinical presentation of renal colic?
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-Abrupt onset of pain in the flank, extending around the abdomen and radiating into the groin
-Constant underlying dull ache -Symptoms or urinary urgency and frequency develop as the stone nears the bladder -Nausea and vomiting -Gross hematuria -fever/chills -writhing -flank tenderness |
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What are the usual findings on urinalysis and microscopy in patients with renal colic?
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Hematuria
Pyuria (may be due to ureteral inflammation but UTI should be ruled out) |
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How does the urinary pH help determine the cause of urolithiasis?
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pH >7.5 suggests presence of urea splitting organisms such as proteus, RTA or ingestion of absorbable alkali
pH <7.5 is associated with uric acid calculi |
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When is imaging indicated with cases of suspected renal colic (5)?
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Atypical signs and symptoms
Suspicion for alternate diagnosis Toxicity Suspected high-grade obstruction First episode |
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Compare and contrast non-contrast CT, US, IVP and KUB for work-up of suspected renal colic?
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NCCT: can detect calculi as small as 1mm as well as demonstrating hydroureter, hydronephrosis and ureteral edema. It can also identify other pathology. Disadvantage is the radiation exposure, lack of dynamic information abotu renal function and underestimates the size of the stone by up to 12%
IVP - very accurate and can quantitate the presence and severity of obstruction. Requires the use of contrast and takes a long time to perform US safe and easily performed but less reliable than CT for detecting stones <5mm. Shows hydronephrosis. No radiation therefore the study of choice in pregnancy KUB: unreliable for diagnosing urolithiasis, can be used as a progress film after CT has identified a radioopaque stone |
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What vascular conditions can cause pain that mimics renal colic? What test should be performed if this is suspected?
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Renal artery embolism
Renal vein thrombosis Dissection of the renal artery Rupture of a renal artery aneurysm Aortic dissection Abdominal aortic aneurysm Contrast enhanced CT or angiogram |
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Outline your management of the patient with renal colic?
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Analgesia (NSAID and narcotics)
Antiemetics prn IV fluids if not able to tolerate PO Medical expulsive therapy (alpha 1 antagonists and CCB block ureteral smooth muscle contraction and improve ante grade stone movement |
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What are indications for hospital admission or urological consultation in the ED for patients with renal colic?
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Absolute
Obstructing stone with signs of UTI Intractable vomiting or pain Urinary extravasation or pain Hypercalcemic crisis Relative Significant co-morbid disease High grade obstruction Leucocytosis Size of the stone Solitary kidney/transplant/intrinsic renal disease Pregnancy |
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What discharge instructions should you give the patient with renal colic who does not require admission to hospital?
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-Work and driving restrictions for patients on narcotics
-Drink moderate amount of fluids -Strain urine to save calculus for the urologist -Return immediately to the ED for intractable pain, persistent vomiting, fever/chills or difficulty voiding -Outpatient urologic evaluation should be scheduled |
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Why are NSAIDs beneficial in the treatment of renal colic?
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Analgesic effects
Diminish GFR in obstructed kidney which decreases ureterospasm and renal capsular pressure |
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List predisposing factors for the development of bladder calculi
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-Infection of residual bladder urine with urea-splitting organisms (most commonly ureaplasma urealyticum and proteus)
-indwelling catheter -bladder neck obstruction -neurogenic bladder -vesical diverticula -damage from irradiation -schistosomiasis |
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What is the usual clinical presentation of bladder calculi?
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-Irritative voiding symptoms
-hematuria -sudden interruption of the urinary stream -UTI is common -Plain radiographs of the pelvis reveal a bladder stone in 50% of cases -contrast scans may demonstrate obstructive changes in the upper tracts or bladder diverticula -Ultrasonography also is useful |
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Among patients presenting to the ED with scrotal pain, how common is testicular torsion as the cause?
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16-42%
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At what age do patients present with testicular torsion?
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Can occur at any age but most common in the first year of life and at puberty
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What are risk factors for testicular torsion?
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Bell clapper deformity of the testis
increased length of the spermatic cord history of cryptorchidism trauma |
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In a patient who presents with scrotal pain after trauma, how can you differentiate between the pain from the trauma and pain from a secondary testicular torsion?
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You can check for a horizontal lie of the testical
Check for a testicle that sits high in the scrotum Check the cremasteric reflex As a general rule, scrotal pain persisting for an hour after traumatic injury should raise suspicion |
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In boys under 30 months old, how often is the cremasteric reflex absent normally?
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50%
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What clinical features should lead you to suspect torsion?
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-age <1 year or adolescence
-typically awakens from sleep or develops several hours after exercise -usually presents earlier than other causes of acute scrotal pain -pain can be in the scrutum, inguinal area or lower abdomen -nausea and vomiting are common -may describe similar pain in the past that resolved spontaneously -absence of the cremasteric reflex -normal urinalysis -entire testicle is tender -involved testicle may be higher and may lie transversely -testicular swelling is common |
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Describe your management of patients with suspected testicular torsion?
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Consult urology immediately
Provide analgesia Attempt manual detorsion If suspicion is low, imaging may be obtained rather than immediate surgical exploration (doppler US is not sufficiently sensitive to definitively rule out torsion in patients with suspicious clinical findings, radioisotope scanning has improved sensitivity but is time-consuming and inappropriate for the ED) |
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What are the scrotal appendages?
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Appendix testis: remenant of the paramesonephric duct.
Appendix epididymis: remnant of the mesonephric duct These appendages are prone to torsion due to their pedunculated shape |
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What is the clinical presentation of appendix testis?
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Scrotal pain (milder and more gradual than testicular torsion)
Often localized to one point No change in lie of the testicle intact cremasteric reflex Blue dot appearance on transillumination |
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What is the treatment of appendix testis?
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Scrotal support
Ice NSAIDs Resolution within 7-10 days |
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Where is the epididymis located?
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Along the posterolateral aspect of the testicles
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What is epididymitis?
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Inflammation of the epididymis
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What causes epididymitis?
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bacterial infection
amiodarone GU abnormalities postinfectious inflammatory reaction Sarcoidosis Kawasaki Henoch Schonlein chemical irritation idiopathic |
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What specific pathogens are usually responsible for causing epididymitis?
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Sexually active men: chlamydia and gonorrhoea, syphillis, coliforms (anal intercourse)
Older men with urinary tract abnormalities or instrumentation: uropathogens (esp e coli) immunocompromised: fungal and other opportunistic infections Children: uropathogens or postinfectious inflammation |
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What are the clinical features of epididymitis?
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-Gradual onset of scrotal pain
-pain initially felt in the lower abdomen or flank -may have urinary symptoms -fever is common -tenderness initially to the epididymis but spreads to the testicle -later scrotum becomes oedematous |
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What is Prehn's sign?
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Decrease in pain with scrotal elevation
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What are possible complications of epididymitis?
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Orchitis
Testicular abscess Sepsis Peritubular fibrosis Testicular infarction Testicular atrophy |
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How do you make the diagnosis o epididymitis in the ED?
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First priority is to rule out torsion so US is usually needed
Any patient at risk of STI needs to be tested |
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What is the treatment of epididymitis?
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Toxic appearing patients:
Admit and treat with IV antibiotics Suspected STI: ceftriaxone 250mg IM plus doxycycline 100mg PO BID x 14 days; treatment of sexual partners Presumed non sexually acquired: TMP-SMX DS 1 tab BID x 14 days Bedrest, scrotal support, sitz baths, ice packs -spermatic cord block -follow up with urology in one week -expected course of resolution is 2-4 weeks -Children do not need to be treated with antibiotics unless there is evidence of UTI |
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What patient populations tend to get orchitis?
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-pre-pubertal boys with viral infections such as mumps
-postpubertal males and men over 50 with BPH |
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What is the usual clinical presentation of orchitis?
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Fever
Scrotal pain nausea, vomiting, myalgias, malaise -unilateral in 70% affected testicle is swollen, tender and erythematous |
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How is orchitis diagnosed?
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Exclude testicular torsion
Urinalysis and culture |
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How is orchitis treated?
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Treatment of viral orchitis is supportive
For others antibiotics should be used as for epididymitis |
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Why does urine volume sometimes increase in the setting of renal failure?
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The failing kidney is not able to concentrate the urine which ends up being isosmolar with serum
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What is the definition of oliguria?
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<100-400cc per 24 hours
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What is the definition of hematuria?
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>5rbc/hpf
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Why should you examine the urine under a microscope if the dipstick is positive for hematuria?
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it may be positive in the presence of free hemoglobin or myoglobin in which case no cells would be seen
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What is the threshold for a positive dipstick result for proteinuria?
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30mg/dL which is about 600mg of protein per day. Since abnormal proteinuria is 150mg per day, the dipstick will not detect many cases of abnormal proteinuria
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What is considered nephrotic range of proteinuria?
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>3.5g/24 hours
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What can cause false positive dipstick for proteinuria?
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Alakaline urine (pH>8), hematuria, contamination with skin disinfectant or prolonged immersion of the dipstick
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Describe how to do urine microscopy.
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10cc urine
place in test tube and spin at 2000rpm for 5 minutes Discard supernatent, resuspend sediment Place on slide with coverslip record number of cells per hpf |
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What is the relationship between GFR and creatinine?
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Changes in serum creatinine generally reflect changes in GFR. Under steady state conditions, if the GFR is halved, the serum creatinine doubles. Abrupt cessation of glomerular filtration causes the serum creatinine to rise by 89-180 umoles/L/day
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What extrarenal conditions can influence the serum urea level?
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Increased protein intake
GI bleeding Catabolic effects of fever trauma infection drugs (tetracyclines, corticosteroids) Decreased urea is seen in liver failure protein malnutrition |
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What useful findings can be seen on non contrast CT and US in patients with ARF?
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NCCT: hydronephrosis, dilated ureters, level of obstruction, cause of obstruction
US: measurement of renal dimensions, reasonably reliable to exclude obstruction |
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MRI in chronic renal disease?
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Gadolinium based contrast agents in patients with chronic renal disease have been associated with nephrogenic systemic fibrosis.
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Describe nephrogenic systemic fibrosis?
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Skin gradually becomes tethered to underlying muscles and severe contractures develop. The disease is usually reversible and untreatable.
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What are the six most common causes of nontraumatic hematuria?
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Kidney stones
Carcinoma of the kidney or bladder Urethritis UTI BPH Glomerulonephritis |
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Outline your approach to examination of patients with unexplained hematuria?
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Palpate the kidneys (PKD or malignancy)
Check for CVA tenderness (pyelonephritis or stone) Check the urethral meatus Pelvic examination in women Prostate examine in men Look for signs to suggest glomerulonephritis (arthritis, skin lesion, HTN, edema) Look for endocarditis and a fib |
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What are the major causes of nephrotic syndrome?
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It always indicates glomerular disease.
Primary renal disease Minimal change nephropathy focal glomerulosclerosis membranous nephropathy Secondary DM SLE Amyloidosis or paraproteinemia Infections Preeclampsia Drugs (corticosteroids, gold) |
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Are patients with renal failure at increased risk for thrombotic events or bleeding?
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Both
Nephrotic syndrome: increased risk of VTE Acute and chronic renal failure have qualitative platelet defect HD - patients receive heparin |
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Which pateints with proteinuria can be discharged home with follow up with their PCP?
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No edema
No azotemia No HTN No active urine sediment No known systemic illness affecting the kidney |
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How do you classify the causes of ARF?
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Pre-renal
-intravascular volume depletion -volume redistribution -decreased CO -decreased glomerular perfusion Post-renal -intrarenal/ureteral obstruction -bladder obstruction -urethral obstruction Intrarenal -vascular -glomerular -tubulointerstitial -ATN |
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Why is the combination of ACE and NSAID bad for kidneys?
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Both NSAIDs and ACEi result in afferent arteriolar constriction and efferent arteriolar dilation resulting in reduced GFR
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What 3 intrarenal causes of ARF are amenable to specific therapy and how do they present?
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1. Glomerulonephritis: asymptomatic or dark urine, hypertension, edema, CHF, micro or macroscopic hematuria, proteinuria. Red cell casts on microscopy
2. Interstitial nephritis: classically presents with fever, rash, eosinophilia and eosinophiluria. 3. Intrarenal vascular disease a) bilateral renal arterial thrombosis or embolism. b) malignant hypertension |
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Describe ARF associated with rhabdomyolysis?
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ATN
Often oliguric Rapid increase in Cr, K+, phosphorus and UA Low BUN/Cr ratio Dispstick + for heme in 50% elevated CK |
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How do you prevent ARF secondary to rhabdomyolysis?
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Aggressive volume resuscitation (UO 200-300mL)
Mannitol infusion Urinary alkalinization (maybe useful, makes sense if the patient has hyperkalemia) |
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What are the risk factors for radio contrast induced ATN?
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Preexisting renal insufficiency
DM Multiple myeloma Age >60 Volume depletion Higher doses of contrast material (especially if a second study is performed within 72 hours) |
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How can radio contrast induced ATN be prevented?
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Don't use contrast if possible
Low osmolality contrast agents Aggressive IV hydration Oral NAC (effectiveness not clear in the ED setting) IV NaHCO3 ( 3cc/kg over 1 hour, followed by 1cc/kg/hour for 6 hours post exposure) |
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What is the definition of contrast-induced nephropathy?
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Increase in serum creatinine of >25% over baseline at 48 hours
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What is the best predictor of renal function (when considering the risk of CIN)?
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eGFR
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What is your approach to ARF?
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Stabilize the patient
Look for and treat the acute complications of ARF (volume overload and hyperkalemia) Try to determine the baseline renal function Stop nephrotoxic agents Consider prerenal causes (assess responsiveness) Consider obstructive causes (get US, place a foley, and if strongly suspect and US negative then retrograde urography) Look for clues of intrinsic renal disease (HTN, dark urine, rash, fever, arthritis) UA, microscopy, expanded electrolytes, BUN/Cr, urine sodium and urine creatinine, cbc, +/-CK |
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When should you suspect renovascular disease as the cause of acute or chronic renal failure?
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-Patients with PVD, carotid or CAD
-sudden unexplained worsening of HTN or renal function -Worsening renal function after ACE or ARB (increase in Cr of >15%) -unexplained renal insufficiency in elderly patients -CHF in the absence of significant decrease in ejection fraction -abdominal bruits are highly specific when heard over the flank -absence of active urinary sediment, minimal to moderate proteinuria |
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What is post-obstructive diuresis and how is it managed?
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-UO >200cc/hr occurring after the relief of prior bilateral obstruction
-intrinsic damage to the tubules leads to volume depletion and electrolyte imbalances - hypokalemia, hyponatremia, hypernatremia, hypomagnesemia -it is usually self-limited |
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What is the management of post-obstructive diuresis?
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-0.45% saline given at a rate somewhat slower than the urine output
-frequent monitoring of vital signs, volume status, UO, serum and urine chemistry -there is no role for gradual bladder decompression |
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What is the significance of positive dipstick for bilirubin?
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Only conjugated bilirubin passes into the urine, so it should only be positive in patients with obstructive jaundice or heptocellular injury.
False positive if urine contaminated with stool |
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What is the significance of urobilinogen on the urine dipstick?
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Often positive in patients with hemolysis
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What are lab test findings in pre-renal azotemia?
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UNa <20
FENa <1 Urine to plasma Cr ratio >40 |
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What are lab test findings in ATN?
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UNa >40
FENa >1 Urine to plasma Cr ratio <20 |
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Under what circumstances would imaging fail to detect proximal urinary tract dilatation in a patient with obstructive ARF?
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-Bilateral ureteral obstruction produced by malignancy or retroperitoneal fibrosis
-When suspicion is high, and imaging is negative the diagnosis must be made by retrograde pyelography |
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At what level of GFR do patients generally begin to manifest findings of uraemia?
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GFR 15-20% of normal
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What are clinical findings of uremia?
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CV
-cardiac disease due to chronic volume overload -anemia -hyperlipidemia -alterations in calcium and phosphorus metabolism -HTN -pericarditis +/- effusion Pulmonary -pleuritis -pulmonary edema (batwing) Neurologic -lethargy -somnolence -difficulty concentrating -AMS -seizures -uremic encephalopathy -restless leg syndrome GI -anorexia -nausea -vomiting Dermatologic -yellowish tinge -uremic fost -diffuse pruritus MSK -bone pain and fractures from renal osteodystrophy -phosphate retention -arthritis Immunologic -humeral and cellular immunity affected Hematologic -anemia (decreased EPO) |
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What are indications for emergency HD?
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Pulmonary edema
Severe uncontrollable hypertension Hyperkalemia Other severe electrolyte or acid-base disturbances (severe metabolic acidosis, hypercalcemia, hypermagnesemia, hyperphosphatemia) Some overdoses Pericarditis Uremic symptoms (lethargy, nausea, vomiting) do not necessitate immediate dialysis unless severe BUN and Creatinine are not relevant to the decision of whether to start HD |
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How do you manage bleeding from an AV fistula puncture site?
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-document the presence of a thrill
-apply firm pressure without occluding -observe the patient to ensure it doesn't re-bleed -consult vascular surgery if the bleeding persists or recurs -if persistent consider reversing coagulation defects (DDAVP for qualitative platelet dysfunction) |
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What is your management of lost/weakened thrill from an AV fistula?
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Consult vascular surgery immediately - definitive treatment is surgical revision
Do not forcibly manipulate or irrigate the fistula as this may result in rupture or emboli |
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What is different about fever in the dialysis patient?
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-consider the patient immunosuppressed (though most infections are from ordinary community acquired pathogens)
-access sites for HD are common culprits so you must examine them -HD catheter infections can usually be managed with antibiotics. Catheters are only exchanged if in the tunnel or if bacteremia persists -be suspicious of peritonitis in peritoneal dialysis -send a sample of peritoneal fluid for cell count, gram stain and culture -look for exit site infection of peritoneal catheters -patients who look well can follow discharge instruction and have follow up can usually be discharged |
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What is the approach to hypotension post-HD?
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-usually a result of decreased circulating intravascular volume, most will resolve spontaneously with some saline in the dialysis unit.
In the ED consider -cardiac tamponade (RV diastolic collapse) -hemorrhage -anaphylaxis to some component of dialyzer or dialysate -AMI -dysrhythmia -sepsis |
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Can cardiac markers be used in ESRD?
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Troponin is best
Baseline likely to be elevated but the pattern of rise is not altered Troponin is cleared by HD |
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What is dysequilibrium syndrome?
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-A constellation of symptoms and signs that is thought to be due to rapid changes in body fluid composition and osmolality during HD
-Symptoms include HA, malaise, nausea, vomiting, muscle cramps and in severe cases AMS, seizures or coma -symtoms resolve over several hours as things redistribute -This is always a diagnoses of exclusion |
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What is the significance of blood on initiation of voiding, only in the last few drops of urine or throughout urination?
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on initiation of voiding: urethral source
last few drops of urine: prostatic or bladder neck source throughout urination: bladder, ureter or kidney |
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What are the most common causes of hematuria in those <20years old?
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Glomerulonephritis
UTI |
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What are the most common causes of hematuria in those 20-40yr?
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UTI
Stone Trauma Carcinoma (kidney, bladder) |
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What are the most common causes of hematuria in men 40-60yr?
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Carcinoma (bladder)
Stone UTI Carcinoma (kidney) BPH (if >60) |
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What are the most common causes of hematuria in women 40-60?
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UTI
Stone Carcinoma (bladder, kidney) |
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What are the diagnostic criteria for nephrotic syndrome?
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Heavy proteinuria (>3.5g/24hours)
Hypoalbuminemia (<30g/L) Peripheral edema |
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Describe the different types of casts (hyaline, red cell, white cell, granular, fatty)
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Hyaline: seen with dehydration, after exercise or with glomerular proteinuria
Red Cell: indicate glomerular hematuria White cell: from renal parenchyma inflammation Granular: composed of cellular remnants and debris -> ATN Fatty: like oval bodies, generally associated with heavy proteinuria and nephrotic syndrome |
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What are intrinsic diseases that cause ARF?
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Vascular
Renal artery thrombosis or stenosis Renal vein thrombosis Atheroembolic disease Scleroderma Malignant hypertension HUS TTP HIV microangiopathy Glomerular SLE Infective endocarditis Systemic vasculitis HSP HIV nephropathy Goodpasture's PSGN Other postinfectious glomerulonephritis Rapidly progressive glomerulonephritis Tubulointerstitial Drugs Toxins Infections Multiple myeloma ATN Ischemia Nephrotoxins (antibiotics, contrast agents, myoglobinuria) Severe liver disease allergic Reactions NSAIDs |
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What are causes of postrenal ARF?
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Intrarenal and Ureteral
Stone Sloughed papilla Malignancy Retroperitoneal fibrosis Uric acid or oxalic acid crystal Sulfonamide, methotrexate, acyclovir, indinavir Bladder stone Blood clot Prostatic hypertrophy Bladder carcinoma Neurogenic bladder Urethra Phimosis Stricture |
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What suggests papillary necrosis?
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A sudden deterioration in renal function in the setting of DM, analgesic nephropathy or SCD
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What drugs most commonly cause AIN?
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Penicillins
Diuretics Anticoagulants NSAIDs |
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What infections commonly cause AIN?
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Bacterial
Fungal Protozoal Rickettsial |
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What is a scleroderma renal crisis and what is the treatment?
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Malignant hypertension and rapidly progressive renal failure
Treated with ACEi |
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What are dialysable toxins?
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IV STUMBLE NASA
Isopropyl alcohol Valproic Acid Salicylate Theophylline/timolol Uremia Methanol Barbituates Lithium Ethylene Glycol Nadolol Acebutalol Sotalol Atenolol |
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What are dialysable beta blockers?
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Sotalol
Acebutalol Timolol Atenolol Nadolol |
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Name 5 dialyzable toxins
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METALS
Methanol Ethylene Glycol Theophylline Alcohols Lithium Salicylates |
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What causes acute urinary retention in adults?
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Penis
Phimosis Paraphimosis Meatal stenosis FB constriction Urethra Tumor FB Calculus Urethritis Stricture Meatal stenosis Hematoma Prostate BPH Carcinoma Prostatitis Bladder neck contracture Prostatic infarction Neurologic Spinal Shock Spinal cord syndome Tabes dorsalis Diabetes MS Syringomyelia Spinal cord syndromes Herpes zoster Drugs Antihistamines Anticholinergics Antispasmodics TCA alpha adrenergic stimulators Cold tablets Ephedrine derivatives Amphetamine |
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What is the differential of pseudohematuria
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Pyridium
Nitrofurantoin Rifampin Chloroquine Hydroxychloroquine Iodine Bromide Food Coloring Beets Berries Rhubarb |
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What are RF for developing urologic malignancy?
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Age >40
tobacco use Pelvic irradiation Analgesic abuse Occupational exposure Cyclophosphamide Schistosoma haemotobium |
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Which patients with hematuria require imaging in the ED? What is the imaging study of choice
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>40 with microscopic hematuria
Presence of RF Gross hematuria There is no consensus on the imaging study of choice - either a contrast CT scan (non-contrast if nephrolithiasis is suspected) or a renal US. |
