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237 Cards in this Set
- Front
- Back
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Renal Disease
Clinical findings: May present with no sx or non specific complaints of ________,___________,________ Consequently, many present with advanced dz More specific sx HTN Edema Polyuria Hematuria Dark colored “cola colored” urine |
fatigue, malaise, or anorexia
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Renal Disease
History: _________(duration and complications) ____________(duration and complications) Recurrent ____ Renal ______ Family history of renal dz Arthralgias, skin rash, fever, and weight loss Medications Prescription, OTC, illicit drugs, herbs Review of records to determine previous renal functions |
Diabetes
Hypertension UTI’s calculi |
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Renal Disease
Physical Exam: Signs of __________ illness responsible for renal dz __________ exam may suggest HTN, DM, or bacterial endocarditis (_______) Skin may show edema, rash, purpura Joints examination for signs of __________ Rectal exam in men and pelvic exam in women to reveal signs of ________________ |
systemic
Retinal Roth’s spot arthritis urinary obstruction |
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Renal Disease
GFR: ____________ concentration in serum assesses GFR Creatinine comes from __________ as a result of muscle breakdown Daily rate is constant and determined by skeletal muscle mass Is eliminated by glomerular filtration, and is a marker of renal function Normal is ______ mg/dl in men, and ______ mg/dl in women (decreased muscle mass in women) Certain drugs may interfere with creatinine excretion and cause false elevation (4) |
Creatinine
creatine 0.8-1.3 0.6-1.1 Cimetidine, trimethoprim, triamterene, amiloride |
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Renal Disease
BUN: Urea is product of ________ metabolism Levels reflect dietary intake and catabolic rate of protein Excreted by glomerular filtration, but reabsorbed in high ________ states such as volume depletion So, varies with extra cellular fluid volume, where creatinine usually doesn’t Ratio of BUN to creatinine is _____ |
protein
sodium 10:1 |
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Disproportionate Increase in Blood Urea Nitrogen:
Volume depletion "__________" _____ hemorrhage Corticosteroid or cytotoxic agents High-_____ diet Obstructive uropathy Sepsis Catabolic states tissue breakdown Disproportionate Decrease in Blood Urea Nitrogen: Low-protein diet ________ disease |
prerenal azotemia
GI protein Liver |
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Renal Disease
Creatine Clearance: Provides a reasonable estimate of GFR Errors that limit its accuracy are - Increasing creatinine secretion & improper ______ collection *Normal Ccr in men is ______ mg/kg/day* *Normal Ccr in women is ______ mg/kg/day* If it deviates significantly, may be problem with urine collection of 24 hour urine Cockroft-Gault formula may be a simpler approach if this is a persistant problem |
urine
20-25 15-20 |
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Renal Disease
Lab and renal function: Renal tubular function evaluated by examining kidneys ability to maintain Na+ and H2O balance and acid base balance (urine __) Fe Na = fractional excretion of sodium in urine useful in the ddx of __________ renal failure (volume depletion vs renal dz) In polyuric patient, __________ helps determine renal ability to concentrate urine (Diabetes insipidus vs nephrogenic diabetes insipidus) |
pH
oliguric water deprivation test |
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Renal Disease
Proteinuria: Normal excretion < ___ mg/day Transient abnormal proteinuria occurs with (3) |
150
Fever CHF Exercise |
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Renal Disease
Proteinuria: _______________ (benign) Characterized by lack of protein in urine collected overnight while patient is supine |
Orthostatic proteinuria
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Renal Disease
Proteinuria: Persistant proteinuria Should get timed urine specimen with urine creatinine to help determine accuracy of collection More than ___ g of protein/day have glomerular dz Less than 3.5 g of protein/day is glomerular and tubular dz *_______________(30-300 mg/24h)* associated with renal dz progression and high CV morbidity and mortality in diabetic and hypertensive patients _________ to creatinine ratio on spot urine can assess the amount of albuminuria with ratio of 30mg/g or higher suggesting microalbuminuria Need 1st morning urine |
3.5
microalbuminuria Albumen |
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Renal Disease
Urinalysis: Color Normal urine is colorless to deep yellow depending on pigment concentration Abnormal colors may mean ________,__________, pigment, drug, or dye _______ or __________ results in smoke colored urine Cloudiness with high concentration of _______, or high amorphous phosphates in alkaline urine |
disease, infection
RBC’s or myoglobin WBC’s |
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Renal Disease
Urinalysis: Chemistry (dipstick) pH , hemoglobin, protein, glucose, ketones, leukocyte esterase, nitrites Protein on dipstick detects only ______, not immunoglobulins or Bence Jones proteins Concentrated urine may show trace to 1+ protein in normal patients ________ detected is due to hemoglobin or myoglobin ____ and _________ mean infection, but negatives does not rule out infection |
albumen
Blood LE and nitrites |
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Renal Disease
Urinalysis: Microscopic exam Test of urine sediment for cells, casts, crystals, and organisms Microscopic hematuria is > __ rbc/hpf in urine not contaminated by menses _________ cells are dysmorphic Non glomerular cells are normal _______ casts means nephronic origin of blood |
2
Glomerular RBC |
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Urinalysis: Microscopic exam
_______ is the presence of more than 4 wbc/hpf Suggests _____ or __________ ________ pyuria is pyuria with negative culture~ Prostatitis Chronic urethritis Renal tuberculosis Renal stones Papillary necrosis |
Pyuria
UTI or inflammation Sterile |
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Renal Disease
Urinalysis: Microscopic Eosinophyls on Wrights stain suggests ___________ Renal tubular epi cells are seen in ___________,___________, and ___________ Free fat droplets seen in heavy ___________ |
interstitial nephritis
acute tubular necrosis, glomerulonephritis, and pyelonephritis proteinuria |
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Renal Disease
Urinalysis: Microscopic exam ________ are cylindrical structures from intratubular protein precipitation RBC’s or WBC casts mean inflammatory ___________ disease RBC’s alone usually indicates a significant __________ lesion or _______________ Renal tubular cell (course granular) casts in renal failure means acute ___________ Leukocyte casts in infection means _______ rather than cystitis and may also be seen in interstitial nephritis |
Casts
parenchymal glomerular lesion or interstitial nephritis tubular necrosis pyelo |
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Renal Disease
Urinalysis: Microscopic exam Crystals – Ca oxylate are ________ shaped, and uric acid are _________ shaped In the absence of sx, have little clinical significance But, cystine crystals indicate ________ Triple phosphate crystals are in ________ urine Bacteria in unspun urine means ____ __________ means treat patient and sex partner |
envelope
rhomboid cystinuria alkaline UTI Trichomonas |
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Acute Nephritic Syndrome:
Abrupt onset of renal dysfunction with _________ that is nephronic in origin (glomerular or tubular in origin) _____ casts and dysmorphic erythrocytes in urine sediment also highly suggests nephronic origin Significant _________ also Caused by inflammation causing dysfunction of the glomerulus (filtering and excretion problems) |
hematuria
RBC proteinuria |
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Acute Nephritic Syndrome:
Clinical findings- _______ retention leading to HTN, circulatory overload, and CHF Causes: Kids- post ___________ glomerulonephritis is the most well known, also ____________ purpura Adults- SLE, _______ nephritis, vasculitis, infective _________ |
sodium
streptococcal Henoch-Scholein lupus endocarditis |
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Nephrotic Syndrome:
Increased glomerular __________ resulting in proteinuria of >3.5g/d/1.73m2 body surface area with~ (3)` |
permeability
Edema Hypoalbuminemia Hyperlipidemia |
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Nephrotic syndrome:
Proteinuria charactistic of both nephritic and nephrotic syndrome However on urinalysis Nephrotic syndrome has: _____ fat bodies Course granular ______ Cellular elements But lack the “______” sediment of nephritic syndrome |
Oval
casts active |
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Nephrotic Syndrome:
Causes- Membranous nephropathy ____ _________ nephropathy Multiple myeloma __________(abnormal deposition of protein called amyloid into tissues causing serious harm in some organs, no harm in others) |
SLE
Diabetic Amyloidosis |
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Rapidly progressive renal failure:
Rapid deterioration of renal function over weeks to months Causes- _________ uropathy Malignant ________ ____ with hemolytic uremic syndrome Bilateral __________ Multiple myeloma Rapidly progressive glomerulonephritis |
Obstructive
hypertension TTP renal artery stenosis |
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Acute Renal Failure:
Abrupt decline in renal function over days to weeks Causes- Decreased renal blood flow (____________) Intrinsic parenchymal disease (_________) Obstruction to urine flow (____________) |
pre-renal azotemia
renal azotemia post renal azotemia |
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Tubulointerstitial nephropathy:
Glomeruli and vasculture are spared but the _________ and __________ are affected Can be classified as acute interstitial nephropathy or chronic interstitial nephropathy depending on how quickly renal dysfunction progresses |
interstitium and tubules
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Tubointerstitial nephropathy:
Chronic characterized by _____ insufficiency __________ range proteinuria Severe tubular damage Significant ________ wasting, hyperkalemia and metabolic __________ even with modest renal insufficiency |
Renal
Non nephrotic sodium acidosis |
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Tubointerstitial nephropathy:
Acute characterized by Usually caused by _____ Sudden onset of signs of renal dysfunction ____________ cell infiltrates in renal interstitium Important in the ddx of ____________ |
drug
Inflammatory acute renal failure |
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Urinary Tract Imaging
Renal ________: Useful for the detection of renal masses, cysts, and dilation of collecting system (____________) In unexplained renal failure can help assess size and __________ uropathy In renal failure, US showing ________ kidneys suggests chronic renal failure where _______ size suggests acute renal failure or chronic renal failure caused by DM, amyloidosis, or multiple myeloma |
Ultrasound
hydronephrosis obstructive small normal |
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Urinary Tract Imaging
Renal Ultrasound: _________ US with doppler imaging detects disease of major _____________ Simple _________ identified by US Kidney size on ultrasound with a discrepancy of more than ___ cm may suggest renovascular disease |
Duplex
renal arteries or veins cysts 1.5 |
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Urinary Tract Imaging
____________: IV administration of contrast medium that is excreted through the kidney through glomerulo filtration Nephrogram image produced due to contrast medium concentrating in the renal tubules When it passes through the collecting system, the calyces, renal pelvis, ureters, and bladder are seen Advantage is you can see the site and cause of obstruction and detect __________ or calyceal blunting Disadvantage, contrast medium can cause ____________ especially in patient with renal insufficiency, volume depletion, diabetes, or multiple myeloma |
IVP (intravenous pyelography)
papillary necrosis nephrotoxicity |
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Urinary Tract Imaging
Retrograde Pyelography: Contrast material injected into _________ at time of cystoscopy Helpful in defining __________ in the ureter or renal pelvis, especially with non visualized kidney on IVP Stones can be moved during this procedure using _______ |
ureter
obstruction basket |
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Urinary Tract Imaging
CT of the Kidney: Usually done with contrast medium Helpful in evaluation of ______,________, perinephric pathology Helpful in vascular pathology such as __________ Used to guide kidney ________, or collection of fluid as in aspiration of ____________ |
masses, cysts
renal vein thrombosis biopsy perinephric abcess |
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Urinary Tract Imaging
_______: Helpful in evaluating complex masses, staging tumors, detecting invasion of renal veins Diagnosing renovascular disease in lieu of CT in patients with renal failure to avoid use of contrast material _______ has inhanced the detection and hemodynamic significance of renal artery stenosis Cannot be used in people with _________ or other ferromagnetic devices |
MRI
MRA (magnetic resonance angiography) pacemakers |
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Urinary Tract Imaging
___________: Injection of contrast media into the aorta and renal arteries to see renal vasculature Helpful in renal artery stenosis, thrombosis, or renal mass Important in the workup of _________ Used to look for microaneurysms in polyarteritis nodosa |
Renal arteriography
kidney donors |
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Urinary Tract Imaging
Radionuclide imaging: IV radiolabeled compounds Images taken with gamma camera Used in evaluation of ___________ problems Renovascular _________ GFR estimation Pyelonephritis/renal abcess Interstitial nephritis __________ |
Renal perfusion
hypertension obstruction |
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Renal Biopsy:
Performed when glomerular lesion suspected or unexplained acute renal failure ____________ bx most commonly done Complications are __________, renal hematoma, laceration with development of av fistula, accidental _______ of liver, spleen or bowel |
Percutaneous
hematuria biopsy |
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nephrotic sydrome
persistent proteinuria hematuria asso w/ abnormal urine sediment or proteinuria unexplained hematuria after exclusion of lower urinary tract cause systemic disorders w/ kidney involvement acute renal failure (atypical features or failure to recover in 6 wk) rapidly progressive renal failure renal allograft dysfunction |
Indications for kidney biopsy
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Capillary bed that recieves blood from afferent arteriole and drains by efferent arteriole
4 cell types Visceral epithelial (podocyte) Endothelial Mesangial cell Parietal epithelial |
Glomerulus
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__________ supports the GBM by trebecular network
_________ provides skeletal framework to capillary network and controls blood flow of glomerular capillaries in response to different mediators __________ line the capillary lumen ________ covers interior of bowman's capsule |
epithelial
mesangium endothelial parietal epithelium |
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Clinical manifestations of glomerular disease:
Urinary abnormalities __________ and ___________ Nonspecific systemic symptoms _______,_________,________ Altered glomerular function Changes in GBM permeability causing ___________(protein filtered based on size, shape and electrical charge, less than 50mg/day in urine) Decreased GFR due to abnormal filtration Increased BUN and Creatinine |
Proteinuria and hematuria
Hypertension, edema, malaise proteinuria |
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Clinical manifestations of glomerular disease:
RBC casts or dysmorphic RBC’s means nephronal bleeding and characteristic of ______________ RBC casts sometimes seen in acute ______________ Renal _____ retention is common in GN and causes: Edema Volume overload CHF HTN |
glomerulonephritis
interstitial nephritis salt |
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Nephritic Syndrome:
Abrupt onset of _________ with RBC casts __________(non-nephrotic range) Temporary impairment of renal function with oliguria, increased BUN and Creatinine Salt and water retention and ______ Most commonly due to proliferative GN, protoype being _____________ |
hematuria
Proteinuria HTN PSGN (post streptococcal glomerulonephritis) |
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PSGN:
Postinfectious complication of _________ infection Strept throat leads to PSGN in fewer than 5% of those not treated (within 7-28 days) More common in ________(up to 50% in some accounts) Typically in kids aged 3-12, but can occur in adults |
GABHS
impetigo |
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PSGN:
Symptoms and signs- ________,__________,________ Laboratory findings- Low serum ___________ levels ASO titers high _______ colored urine with RBC’s and RBC cast Proteinuria less than 3.5 g/dl (_________) Microscopy shows diffuse proliferative glomerulonephritis Immunoflorescence shows ____ and C3 along the mesangium and capillary basement membrane |
Oliguria, edema, hypertension
complement Cola non-nephrotic IgG |
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PSGN:
Treatment- _________ Appropriate __________ ____________ and salt restriction if needed _________ not helpful |
Supportive
antibiotics Antihypertensives Steroids |
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PSGN:
Prognosis- Very favorable in children Less than 5% of adults will develop _______________ and smaller percentage will develop _______________ |
RPGN (rapidly progressive glomerulonephritis)
ESRD (end stage renal dz) |
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Nephritic Syndrome: IgA nephropathy (_________ disease)
Renal disease of _____ deposition in the glomerular mesangium Cause unknown, same lesion seen in H-S purpura Is associated with ________,__________ and ________ as in HIV and CMV Most common form of acute GN in the US More common in children and young adults Males 3x more than females |
Berger’s
IgA cirrhosis, celiac dz, and infections |
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Nephritic Syndrome: IgA nephropathy (Berger’s Disease)
Episode of ___________ is the most common presenting complaint Frequently associated with ____, ____ or ____ like illness Urine is ____ or ____ colored 2 days after onset of sx |
gross hematuria
URI, GI sx, or flu red or cola |
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Nephritic Syndrome: IgA nephropathy (Berger’s Disease)
1/3 of patients experience clinical remission 40-50% develop progressive ____________ Remainder show _____________ but stable serum creatinine Ominous sign is proteinuria >__g/dl Other unfavorable indicators are HTN, ___________ microscopic hematuria and proteinuria, glomeruloschlerosis and abnormal renal functions |
renal insufficiency
microscopic hematuria 1 g/dl persistent |
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Nephritic Syndrome: IgA nephropathy
IgA increased up to 50% of normal, but normal IgA doesn’t r/o dz ________ is the standard for dx _________ shows IgA granular deposits in dermal capillaries |
Renal bx
skin bx |
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Nephritic Syndrome: IgA nephropathy
Treatment- In significant proteinuria (>1g/dl) ______ and _______ are used to decrease proteinuria and reach target BP of 125/75 With proteinuria of 1.0-3.5 g/dl, ________ have been used and are beneficial Other treatments- ________ Renal transplantation But there is recurrent dz in 30% of patients 5-10 yrs post transplant |
ACE-I and ARB’s
steroids Fish oil |
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Nephritic Syndrome: Henoch-Schonlein purpura
Leukocytoclastic vasculitis of unknown cause Definition: leukocytoclastic vasculitis is an acute cutaneous vasculitis that is characterized by purpura, especially of the ______, and by exudation of _________ and sometimes fibrin around dermal venules, with extravasation of ______. Most common in ________ More in ______ |
legs
neutrophils RBCs children males |
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Nephritic Syndrome: Henoch-Schonlein purpura
Clinical presentation- Palpable purpura mostly on lower extremities ___________ GI sx such as _______, ______ and _______ Renal insufficiency with nephritic presentation Renal lesions are identical to those in ____________ Most recover fully over several weeks |
Arthralgias
nausea, colic, and melana IgA nephropathy |
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Nephritic Syndrome: Pauci-immune glomerulonephritis
_______ granulomatosis, ___________ disease, and microscopic polyangitis All are ________ vessel vasculitis |
Wegners
Churg-Strauss small |
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Nephritic Syndrome: Anti-glomerular Basement Membranne GN and Goodpastures syndrome
Goodpastures dz is GN and __________ hemorrhage preceded by _____ and causing hemoptysis, dyspnea and respiratory failure ______ and _______ are components of the nephritic syndrome |
pulmonary
URI HTN and edema |
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Nephritic Syndrome: Cryoglobulin-associated GN
Cold precipitable immunoglobulins precipitating in glomerular capillaries Cause is underlying infection such as ________, or other occult viral, bacterial, or fungal infections Patients have necrotizing ______ lesions in dependent areas, arthralgias, fever, and hepatosplenomegaly Treatment is treating ____________ |
Hepatitis B or C
skin underlying infection |
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Rapidly Progressive Glomerulonephritis:
Syndrome characterized by ___________(RBC casts and dysmorphic RBC’s) Renal failure over weeks to months Renal bx showing diffuse _________ formation Can occur with or without immune deposits Can be ___________ or superimposed on other glomerular disease |
Nephronal hematuria
crescent idiopathic |
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Rapidly Progressive Glomerulonephritis: Anti GBM GN
2/3 of patients have ___________ syndrome - a form of rapidly progressive glomerulonephritis, which involves a progressive decrease in the kidney's ability to function properly, accompanied by a ________ with ______ sputum. Occurs in two peaks, 3rd to 4th decade and 6th to 7th decade |
Goodpastures
cough bloody |
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Rapidly Progressive Glomerulonephritis: AntiGBM GN
Goodpastures more common in the _______ Affects men more than women Presents with RPGN, hemoptysis, and dyspnea Strong association between ___________ and pulmonary hemorrhage in Goodpastures Treatment- High dose _________ _____________(Cytoxan) High index of suspicion causing early dx and tx has increased survival to 50%. Was 10% survival 20 yrs ago |
young
cigarette smoking prednisone Cyclophosphamide |
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Rapidly Progressive Glomerulonephritis: ___________ RPGN
Almost always associated with another underlying dz Correct dx made by identifying clinical and lab features of those diseases (see table 27-4 Cecil) Makes up 30% of all RPGN cases (granular deposits of immunoglobulins and complement on GBM initiates glomerular injury) |
Immune Complex
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Rapidly Progressive Glomerulonephritis: Pauci-immune RPGN (_____ associated)
Associated with systemic vasculitides - (2) Also an idiopathic form with vasculitis only of glomeruli 80% of Pauci-immune RPGN is associated with ANCA (antineutrophil cytoplasmic antibodies) Treated with cytotoxic agents (______) and _________ |
ANCA
Wegners granulomatosis & Polyarteritis nodosa Cytoxan and corticosteroids |
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Nephrotic Syndrome:
Urine _______ of >3.5g/1.73m2 per 24 hrs Hypoalbumenemia Hyperlipidemia Peripheral _______ |
protein
edema |
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Nephrotic Syndrome:
1/3 of patients have systemic renal dz- ____________ Amyloidosis SLE HIV Remainder have idiopathic nephrotic syndrome. 3 most common are Minimal change disease Focal ____________ __________ nephropathy |
Diabetes mellitus
glomerular sclerosis Membranous |
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Nephrotic Syndrome: Signs and Symptoms
____________ is the hallmark of the syndrome When serum _________ concentration less than 3g/dl But more likely due to ________ retention than low plasma oncotic pressure Presents in the dependent areas of the body initially then becomes generalized ________ due to pulmonary edema, pleural effusions, decreased diaphragmatic excursion due to _______ Symptoms and signs of infections (more than normal) due to loss of immunoglobulins and compliment fomation |
Peripheral edema
albumen sodium Dyspnea ascites |
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Nephrotic Syndrome: Lab
___________ due to alteration in GBM Urinary dipstick analysis indicates albumin only Addition of sulfosalicylic acid allows other paraproteins to be detected by dipstick Can detect as little as 15mg/dl Must do specific gravity Trace protein on ___________ specimen may mean nothing Trace protein on _________ specimen may mean true renal dz |
Proteinuria
concentrated dilute |
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Nephrotic Syndrome: Lab - Microscopic urinalysis
Urinary sediment has few cellular elements With significant ____________, ________ bodies - are lipid deposits in sloughed renal tubule epithelial cells Appear as “_________” and “_______” crosses under light microscopy and polarized light |
hyperlipidemia
Oval fat grape clusters and maltese |
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Nephrotic Syndrome: Lab - Blood chemistries
Decreased serum _________(<3g/dl) ___________ - 50% of patients with early nephrotic syndrome The more protein excreted, the more hyperlipidemia Due to fall in oncotic pressure (increased protein excretion) Decreased clearance of VLDL causing hypertriglyceridemia Elevated ESR |
albumen
Hyperlipidemia |
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Nephrotic Syndrome: Lab - Blood chemistries
Other tests depending on clinical presentation ________ levels Serum ________ electrophoreisis ANA Serologic tests for _________ |
Compliment
protein Hepatitis |
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Nephrotic Syndrome: Renal Biopsy
Performed in new onset idiopathic nephrotic syndrome if primary renal disorder that may require drug therapy is suspected Not done in patients with very high _________ levels (irreversible renal dz) Not done in amyloidosis or DM with __________ range proteinuria (irreversible renal damage) |
creatinine
nephrotic |
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Nephrotic Syndrome: Management - Protein Loss
Daily dietary ________ intake should be increased to offset the loss and avoid negative _________ balance Protein malnutrition occurs when urinary protein exceeds ____g/d |
protein
nitrogen 10 |
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Nephrotic Syndrome: Management - Edema
_____________ is essential ________ in most patients Usually thiazide or loop diuretics Both are protein bound so with hypoalbumenemia delivery to the kidney is decreased So combination of the two can potentiate the effect |
Salt restriction
Diuretics |
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Nephrotic Syndrome: Management - Hyperlipidemia
Dietary management of little value But, should be advocated _________ ___________ therapy |
Exercise
Pharmacologic |
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Nephrotic Syndrome: Management - Hypercoaguable states
Serum with low ________ (<2g/dl) can be hypercoagulable Nephrotic syndrome patients lose antithrombin III, protein C, and protien S through the urine Have increased _______ activation Prone to renal vein ________ Patients with evidence of thrombus are treated with ___________ for 3-6 months Renal vein thrombosis and recurrent thromboemboli require indefinite anticoagulation |
albumen
platelet thrombosis anticoagulants |
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Nephrotic Syndrome: _______ Renal Disorders
Minimal Change Disease Membranous Nephropathy Focal segmental glomerular schlerosis |
Primary
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Nephrotic Syndrome: Primary Renal Disorders - Minimal change disease
Etiology Mostly in _______, ______ predominence Idiopathic or following _____ URI Associated with _________ dz Associated with drugs (gold and lithium) Associated with hypersensitivity reactions especially to ________ and ______ Treatment - ________ |
children, Male
viral Hodgkins NSAIDS and bee stings prednisone |
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Nephrotic Syndrome: Primary Renal Disorders - Membranous Nephropathy
Most common cause of primary nephrotic syndrome in adults Most commonly in adults in their ______ decades Almost always after age 30 Treatment based on renal dz progression marked by __________ Ranges from low salt diet to corticosteroids to ____________ depending on risk of progression predicted by proteinuria |
5th to 6th
proteinuria immunosupression |
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Nephrotic Syndrome: Primary Renal Disorders - Focal Segmental Glomerular Sclerosis
Can be idiopathic or secondary Secondary due to morbid ______, ______ usage, and ______ infection Typically progress to ______ in 6-8 years Treatment Supportive High dose ________ can induce remission in 5-9 months in over ½ the patients |
obesity
heroin HIV ESRD steroids |
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Nephrotic Syndrome: Systemic Disorders - Amyloidosis
Extracellular deposition of a fibrous protein (amyloid) in one or more sites in the body Serum amyloid A is synthesized in ______ and deposited in tissues in primary renal amyloidosis, may occur in absence of systemic disease or with ____________ Secondary renal amyloidosis (amyloid AA) due to chronic inflammatory dz such as RA, IBD, or chronic infection Usually in ________ patients ________ kidneys due to amyloid deposits |
liver
multiple myeloma older Enlarged |
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Nephrotic Syndrome: Systemic Disorders - Amyloidosis
Treatment and Prognosis Treat inciting agents if present ____________ ______ in 2-3 years 5 yr survival is 20% |
Corticosteroids
ESRD |
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Nephrotic Syndrome: Systemic Disorders - Diabetic Nephropathy
*Most common cause of _______ in the US* More common in type ___ diabetics, but increasing in type ___ diabetics Patients at higher risk are males, African Americans, and Native Americans Diabetic screening should always include ______________(>30mg/dl is abnormal) In patients prone to nephropathy, microalbuminuria develops within 10-15 yrs of DM onset and progresses to overt ___________ over next 3-7 years |
ESRD
1 2 microalbuminuria proteinuria |
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Nephrotic Syndrome: Systemic Disorders - Diabetic Nephropathy
Strict glycemic control slows progression of nephropathy _____ and _____ lower progression to clinical proteinuria and ESRD ____ patients also prone to papillary necrosis, chronic interstitial nephritis, and renal tubular acidosis Poor prognosis once _________ has begun |
ACE-I and ARB’s
DM dialysis |
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Nephrotic Syndrome: Systemic Disorders - HIV associated Nephropathy
Can present as nephrotic syndrome in HIV patients Mostly ________ men More associated with ________ use _______ slows progression of renal disease Recommended for use in these patients ____________ treatment with cyclosporine and ACE inhibitors used with some success |
young black
IV drug HAART (highly active antiretroviral therapy) Corticosteroid |
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Asymptomatic Urinary Abnormalities: Hereditary Nephritis (______ Syndrome)
Starts in childhood with microscopic hematuria with or without gross hematuria Mild proteinuria, nephrotic syndrome rare __________ after age 15 in 50% of patients ________ (x linked) Boys more than girls, renal failure by age 30 No effective treatment currently available |
Alports
Sensorineural deafness Inherited |
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Asymptomatic Urinary Abnormalities: Thin Basement Membrane Dz
Autosomal dominant Basement membrane glomerulopathy Presents as _________ in otherwise healthy young adult Excellent prognosis with only rare cases of ____________ |
microscopic hematuria
progressive renal failure |
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Asymptomatic Urinary Abnormalities: Benign Recurrent Hematuria
_______ adults with microscopic hematuria on routine exam Gross hematuria with _________,__________,________ |
Young
febrile illness, exercise or immunization |
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Characterized by epithelial lined cavities in the kidneys filled with fluid or semi solid debris
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Renal Cystic Diseases
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Renal Cystic Diseases:
Clinical Settings may suggest etiology Abdominal mass in neonate or infant suggests _______ Renal failure in an adolescent suggests ARPKD or ____________ Solitary cyst in healthy 50 year old suggests _______ A _______ history of renal disease suggests ADPKD, ARPKD, or medullary cystic disease Recurrent __________ mostly in patients with ADPKD or medullary sponge kidney Hematuria onset in a ________ patient indicates acquired cystic disease |
ARPKD (autosomal recessive polycysitc kidney dz)
medullary cystic dz simple cyst family renal stones dialysis |
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Renal Cystic Diseases: Simple cyst (Solitary Cysts)
Increase in frequency with age In up to 50% of people over age ___ Account for 65-70% of all renal masses Found at the ________ and contain fluid which is an ultrafiltrate of plasma Most often asymptomatic Incidental finding during imaging study Renal ___ and ___ differentiates benign from malignant lesions, abcess, or PKD |
50
outer cortex US and CT |
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Renal Cystic Disease: Simple Cysts (Solitary Cysts)
In dialysis patients, simple cysts may progress to _________ Ultrasound and CT used to differentiate Simple cysts must have three criteria on sonogram to be considered benign: _____ free Sharply demarcated mass with _________ Enhanced ________(means good transmission through cyst) _______ cysts - Thick walls, calcifications, solid components, and mixed echogenicity |
malignancy
Echo smooth walls back wall Complex |
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Renal Cystic Disease: Simple cysts (solitary cysts)
Criteria on ___- Simple cyst Smooth thin wall Sharply demarcated _______ enhance with contrast media Renal Cell Carcinoma: Enhances but is of lower _______ than the rest of the parenchyma __________ can also be done pre-op RCC is hypervascular in 80% of cases |
CT
Does not density Arteriography |
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If cyst meets criteria for being benign-
Periodic _________ is the standard of care If findings not consistent with simple cyst- ____________ |
evaluation
Surgical exploration |
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Polycystic Kidney Disease:
ADPKD adult polycystic kidney dz ARPKD infantile or childhood PKD Can occur with congenital __________ causing death from renal failure in first year of life |
hepatic fibrosis
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Polycystic Kidney Dz: ADPKD
Most common __________ renal dz in the U.S. 500,000 people or 1 in 800 live births 50% of patients will have ESRD by age ____ Accounts for 10% of dialysis patients in the U.S. |
hereditary
60 |
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Polycystic Kidney Dz: ADPKD
Three genes involved, two most important are ADPKD1 and ADPKD2 ADPKD 1 is on chromosome ___ ADPKD 2 is on chromosome ___ PKD 2 has slower progression and longer life expectancy than PKD 1 |
16
4 |
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Polycystic Kidney Dz: Clinical manifestations
Rarely presents before age ______ So people of childbearing age pass it on before they know they have it Patients either present for screening because of family hx, or due to symptoms |
20-25
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Polycystic Kidney Dz: Symptoms
Acute _________ pain and back pain with hematuria is the most common presentation Non specific dull lumbar pain occurs when kidneys large enough to be palpable on PE Sharp localized pain from ________,________, or calculus _________- Frequently the initial sign of PKD, may also have gross hematuria |
abdominal flank
cyst rupture, infection Microhematuria |
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Polycystic Kidney Dz: S/S
_____ - Most common cardiovascular complication In 60% of patients before the onset of renal insufficiency ______ - From urinary concentrating defect, usually present at the time of diagnosis ____,_________, and cyst infections are common complications |
HTN
Nocturia UTI, pyelonephritis |
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Polycystic Kidney Dz: S/S
1/3 have _______ 10% have ________ 25% have _____ Also, __________ associated with ADPKD Renal function - Impairment is variable 50% of patients ESRD by age 60 |
hepatic cysts
cerebral anneurysms MVP (mitral valve prolapse) diverticulosis |
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Polycystic Kidney Dz: Poor prognostic indicators
ADPKD __ gene Male ______ race HTN Progression at ______ Episodes of gross hematuria |
1
Black early age |
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Polycystic Kidney Dz: Dx
Radiographic evidence of multiple cysts in parenchyma associated with: _______ enlargement Increased _________ thickness Elongation of the ________ Renal Ultrasound and CT used CT with contrast usually shows more _______ involvement Presence of extrarenal involvement (eg hepatic cysts) aids in dx of ADPKD |
Renal
cortical calyces cystic |
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Polycystic Kidney Dz: Dx
Gene location helps identify _______________ of ADPKD1 through gene linkage analysis Is expensive Involves other family members Reserved for those with ___________ imaging studies |
asymptomatic carriers
nondiagnostic |
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Polycystic Kidney Dz: Tx of ADPKD
Preventing __________ Preserving renal function Education regarding inheritance Screening in patients with strong family hx of ____________ |
disease complications
cerebral aneurysmal hemorrhages |
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Polycystic Kidney Dz: Therapy
Control ____ Prevent ____ Treat cyst infections with antibiotics that penetrate cyst walls and attain therapeutic levels(3) Dialysis or transplantation for ESRD _________ prior to transplantation in patients with large kidneys or frequent or persistent UTI’s |
HTN
UTI’s TMP/SMX, cipro, or chloramphenicol Nephrectomy |
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Polycystic Kidney Disease: ARPKD
Most common inheritable cystic renal dz occuring in ________ Is autosomal recessive, distinct from ADPKD Involves pathologic changes in the _____ and/or kidney Kidneys may be massively enlarged in infants Contain multiple small subscapsular cystic spaces |
infancy
liver |
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Polycystic Kidney Disease: ARPKD
Accounts for 1.5% of kids needing renal replacement prior to age 15 .6 % of patients with renal failure (ESRD) before the age of 20 No ______ predominance Males ___ females May occur at any time from perinatal period to 5 yrs old depending on classification |
racial
= |
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Polycystic Kidney Disease: ARPKD
______ & ______ involvement Both manifest _________ degrees of severity If severe renal dz early, they succumb to renal dz prior to hepatic problems But, milder forms of renal dz develop severe hepatic complications later in life |
Kidney and liver
opposite |
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Medullary Cystic Disorders
part of a group of ______________ known as juvenile nephronophthisis-medullary cystic disease complex Almost universal progression to _______ Childhood type (____________) is autosomal recessive Adult type (___________) is autosomal dominant |
congenital nephropathies
ESRD Juvenile nephronopthisis medullary cystic |
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Medullary Cystic Disorders: Clinical findings
Sometimes accompanied by _____________ _______ and prolonged enuresis in childhood due to concentrating defect which is early indication of renal dz ______ stature Failure to thrive Almost universal progression to ______ During adolescence or early adulthood Before age 20 in juvenile form |
eye deformities
Anemia Short ESRD |
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Medullary Cystic Disorders: Dx
US and CT - ___________ kidneys Doesn’t usually show the cysts because they are only 1-2 mm in diameter Renal biopsy - *Open renal bx* to recover tissue from ____________ junction Treatment - No current medical therapy to prevent renal failure ______ & ______ intake to prevent renal losses |
Small scarred
corticomedullary Salt and water |
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Medullary Sponge Kidney
Common and benign disorder Present at birth, not usually diagnosed until 4th or 5th decade of life Autosomal dominant Kidneys have very __________ enlargement in the medullary and interpapillary collecting ducts With medullary cysts giving “________” appearance in these areas |
irregular
swiss cheese |
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Medullary Sponge Kidney: Clinical findings
Gross or microscopic _________ Recurrent ____ or stones - may manifest itself initially as passage of renal stone Estimated that 10% of patients who present with stones have medullary sponge kidney Decreased urinary _________ ability Nephrocalcinosis Diagnosis is confirmed with ______ Accumulation of contrast in dilated collecting ducts |
hematuria
UTI’s concentrating IVP |
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Medullary Sponge Kidney: Tx
No known therapy Increasing ______ to prevent stone formation ________ diuretics to decrease calcium excretion in hypercalcuric patients ______ therapy if RTA is present |
fluid
Thiazide Alkali |
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Urinary Tract Obstruction
Obstruction can occur anywhere from the renal pelvis to the urethral meatus _________ obstruction usually causes no change in flow or total renal function If drainage of both kidneys significantly compromised, ________ or _________ can occur Total urinary tract obstruction is an important cause of ESRD and RF |
Unilateral
azotemia or renal failure |
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Obstruction: Clinical Presentations
Change in _________ habits frequently presenting sign True anuria – (inability to urinate) __________ is the most common cause Nocturia and polyuria – can result from ____________ due to defective urinary concentration |
urinary
complete obstruction partial obstruction |
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Obstruction
In the absence of __________, always consider obstruction as a cause of renal failure of unknown etiology Total anuria in ____________ highly suggestive of urinary tract obstruction |
proteinuria
acute renal failure |
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Obstruction: Diagnosis
________ is preferred means of diagnosing urinary tract obstruction Depends on identification of __________ May not be evident in 1st 24 hrs or in severly dehydrated patient _____ helpful in situations such as dehydration Shows prolonged nephrogram phase with delayed filling 24 or 48 hour film may show contrast in renal pelvis or in dilated calyces |
Renal US
hydronephrosis IVP |
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Obstruction: Management
Identify the ________ Relieve the __________ - Usually through surgical intervention If cant relieve obstruction, perform urinary diversion ________ and obstruction - Control of UTI is mandatory UTI in obstruction is a urologic emergency and calls for prompt relief of the obstruction |
site & cause
obstruction Infection |
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Vascular Disorders of the Kidney: Diseases affecting the renal vasculature
Those affecting larger vessels - ________________ Ischemic nephropathy and atheroembolic disease - __________ _________ hypertension Schleroderma Thrombotic miroangiopathy |
Renal artery occlusion
smaller vessels Malignant |
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Renal Arterial Occlusion:
Potentially reversible cause of renal failure Cause: ________ trauma or surgery ________ (heart or paradoxical thromboemboli) Dissecting AAA or renal aneurysm ________ (polyarteritis nodosa, Kawasaki’s dz) Renal artery _________(fibromuscular dysplasia or atherosclerosis) External _________ of renal artery (lymph nodes, malignancy) |
Abdominal
Embolism Vasculitis stenosis compression |
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Clinical Findings of Renal Artery Occlusion:
Depend on collateral circulation Acute renal infarct sx- ______ or _______ pain Nausea, _______ Fever Acute _____ due to activation of renin angiotensin system LAB __________, increased AST (serum aspartate aminotransferase), LDH, and alk phos. Microscopic _________ *Renal dysfunction if bilateral/unilateral _______* |
Lumbar or flank
vomiting HTN Leukocytosis hematuria infarct |
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Clinical findings in renal artery occlusion: Imaging
_________ imaging necessary to diagnose renal vascular occlusive disease _________ imaging shows no blood flow to the kidney Can use CT, MRI, or Doppler *Renal ________ more reliably establishes diagnosis* |
Radiologic
Radionuclide Angiography |
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Clinical findings in renal artery occlusion: Tx
Goal is to avoid irreversible renal damage To localize ________ To re-establish _________ Traumatic renal artery thrombosis- Surgical __________ must be performed within 4-6 hours to prevent irreversible renal damage Acute athroembolic disease- Early diagnosis and prompt (HOURS) ____________- is necessary to preserve renal function |
thrombus
blood flow thrombectomy revascularization |
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Clinical findings in renal artery occlusion: Chronic Ischemic Renal disease and collateral circulation
Renal function may return even if dx and tx delayed for days or weeks Has been documented 6 weeks of return of renal function with surgical treatment up to 6 weeks after the thrombus occurred Treatment options- ___________, IV or intra-arterial thrombolytic therapy Percutaneous ______________, clot extraction by percutaneous catheter, surgical thrombectomy |
Anticoagulation
angioplasty |
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Ischemic Nephropathy
Def: chronic renal impairment secondary to hemodynamically significant renal artery ________ which is a cause of renal insufficiency and ESRD 15% of ESRD patients over 50 have ________ renal disease Prevalence of renal vascular disease is high in patients with _________,__________, or peripheral vascular disease (30-40%) |
stenosis
ischemic coronary, cerebral |
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Diagnosis of Ischemic nephropathy:
Must find significant ________ and show that this is the cause of renal impairment Selection of tests depends on clinical suspicion Example: discrepancy in ________ is good indication for considering renal artery stenosis as cause of impaired renal function |
renal artery stenosis
renal size |
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Diagnosis of Ischemic nephropathy: Imaging
________ Ultrasonography- Good screening test but highly operator dependent and time consuming technically difficult _____ inhibitor renography- Good screening test but not reliable with moderate to severe renal dysfunction CT and MRI __________- Effective noninvasive tests to detect renal artery stenosis |
Doppler
ACE angiography |
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Diagnosis of Ischemic nephropathy: Imaging
*Gold Standard for dx of ischemic nephropathy is ____________* There are risks involved ________ induced acute renal failure - Prevent by _______, or specially prepared contrast Atheroembolic renal disease Irreversible loss of renal function |
renal arteriography
Contrast hydration |
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Recommendations for renal arteriography:
Use in patients with __________ for ischemic nephropathy But in those with equivocal risk factors, start out with _________ tests such as Duplex Doppler US or MRA before proceeding to angiography |
multiple risk factors
less invasive |
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Ischemic Nephropathy: Tx
________ therapy- Doesn’t reliably prevent disease progression But may be the only available option in those patients unable to tolerate invasive procedure Invasive therapy- Percutaneous __________ Surgical ___________ Both can restore renal function lost as a result of renal artery stenosis Depends on the individual patient |
Medical
angioplasty revascularization |
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Ischemic Nephropathy: Tx (cont)
Percutaneous angioplasty with or without ______ is treatment of choice in high surgical risk patients Surgical revascularization is best option in patient with high grade renal artery stenosis that is not amenable to angioplasty or in patients with renal or ______ disease |
stent
aortic |
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Athroembolic Diseases of the Kidney:
progressive disorder with worsening renal insufficiency as a result of ___________ of small and medium sized renal vessels by atheromatous emboli Incidence- Occurs in patients with widespread _________ disease Especially after renal artery manipulation or surgery Or after angiography or percutaneous angioplasty in these patients Can occur after treatment with __________ or ___________agents |
embolic obstruction
athromatous anticoagulants or antithrombolytic |
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Athroembolic Kidney Dz: Clinical concerns
Acute, subacute, or chronic renal dysfunction Labile HTN as a result of renal _______ or activation of renin-angiotensin system Livido reticularis – a manifestation of __________ embolization in retina, muscles, or skin (may help make the dx) Also, cerebrovascular dz, pancreatitis, ischemic bowel, or peripheral gangrene as a result of _______ should warrant consideration of athroembolic dz of the kidney |
ischemia
cholesterol emboli |
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Athroembolic Kidney Dz: Tx
No effective treatment Avoidance of ___________ or ________ procedures in patients with diffuse athroschlerosis Avoid anticoagulants and thrombolytic agents _________ dialysis rather than hemodalysis to avoid heparin use Prognosis – Poor Depends on the extent of organ involvement and the degree of embolization |
angiographic or surgical
Peritoneal |
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Chronic Hypertensive Nephrosclerosis:
intrarenal vascular sclerosis and ischemic changes associated with chronic hypertension. Advanced changes can lead to ESRD Risk factors Race (_________) Marked elevated ________ Underlying chronic renal disease Patients typically have long standing HTN and slowly rising serum _________ |
African Americans
blood pressure creatinines |
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Chronic hypertensive nephrosclerosis:
dx is based on clinical presentation in long term hypertensive pt picture is that of __________ & small kidneys on ____ usually don't need bx degree of renal damage & progression worsened by accelerated _____ |
non-nephrotic proteinuria
US HTN |
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Chronic Hypertensive Nephrosclerosis: Tx
Goal of therapy is to control _____ Outcome depends on BP control and patient compliance with meds, and follow up However, renal function can worsen in some patients despite good BP control _______ may play a part in some of these patients |
BP
Genetics |
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________ Nephrosclerosis:
Renal vascular changes with _______ HTN causing renal ischemia and ________ Rise in arteriolar and capillary pressure causes vascular endothelium fibroid necrosis Plasma renin-angiotensin system is activated and may contribute to this |
Malignant
accelerated acute renal failure |
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Malignant nephrosclerosis:
Patients present with severely elevated DBP’s (>____mm Hg) May have hypertensive ____________ Proteinuria and hematuria with ARF Renal bx shows fibroid necrosis of the _________ |
120
encephalopathy arterioles |
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Malignant Nephrosclerosis: Tx
Rapidly lower the DBP to 100-110 mm Hg within __ hours Don’t lower the mean arterial BP more than 25% for fear of ischemic events due to decreased ________ Gradual lowering of DBP to 80-90 mm Hg over weeks can then occur Renal function decreases initially, but recovers as the lesions heal and autoregulation of blood flow occurs Patients are at risk for coronary, cerebrovascular, and renal dz due to damage done to _________ structures |
6
perfusion vascular |
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Malignant nephrosclerosis:
Patients who develop renal insufficiency as a result of malignant nephrosclerosis tend to do poorly and have lower survival rate All patients with malignant hypertension need workup of secondary causes of this problem Malignant HTN: HTN with _________ and other organ damage such as heart failure, renal failure, and hypertensive encephalopathy |
papilledema
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___________:
progressive connective tissue disorder with proliferation of connective tissue, thickened vascular walls and lumen narrowing. 50% of patients have renal involvement Mild proteinuria Abnormal serum creatinine Systemic hypertension |
Scleroderma
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Scleroderma Renal Crisis:
Occurs in 10-15% of patients Characterized by _____ Abrupt onset of severe hypertension (small % may have normal BP) Risk factors of renal crisis- Rapidly progressing diffuse _____ involvement Cooler months __________ |
ARF
skin African American |
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Diagnosis of scleroderma renal crisis:
Other manifestations of scleroderma Rarely presents as the initial symptom of the disease ____, anticentromere antibody, Scl 70 antibody, and anti-RNP polymerase antibodies may be positive |
ANA
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Scleroderma renal crisis: Tx
Start before irreversible damage ___ control to slow renal damage progression to RF _______ are DOC With good BP control, patients may get enough renal function return to stop _________ |
BP
ACE inhibitors dialysis |
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Hemolytic Uremic Syndrome and TTP:
Consist of thrombotic ___________ & ____________ Clinical features of HUS and TTP are similar Renal involvement more in ____ ______ thrombi in glomerular capillary loops Arterioles develop fibrin thrombi with fibrinoid necrosis |
microangiopathy and thrombocytopenia
HUS Fibrin |
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HUS:
More in kids after non-specific _________ illness Also, certain _______ associated with hemorrhagic colitis and HUS HUS is associated with- Renal failure Thrombocytopenia Microvascular platelet thrombi Microangiopathic hemolytic anemia |
diarrheal
E.coli |
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TTP-
Similar features as in HUS But, more problems with ________ & ________ symptoms Both disorders can be associated with- __________ OCP’s __________ agents Infections __________ diseases |
mental status and neurologic
Malignancy Antineoplastic Autoimmune |
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Clinical course regarding renal involvemt in HUS or TTP can be either acute renal failure or rapidly progressive renal failure
Spontaneous recovery may be high in children who may need only __________ therapy Adult prognosis is less favorable, may need more prolonged and additional therapy _________ is most effective, works in 90% of cases Should be initiated as soon as dx is made In TTP, daily for 1 week, then alternate days until remission __________ used in patients who don’t respond to plasma exchange _________ for TTP patients resistant to therapy |
supportive
Plasma exchange Vincristine Splenectomy |
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removing blood from the patient, mechanically separating blood from plasma, mixing blood cells with replacement plasma and returning blood mixture to the body. Purpose is to rid the blood of the immune factors that stimulates the disease process, and new plasma may dilute strenth of these immune factors
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plasma exchange
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Renal Vein Thrombosis:
________ in the major vein (renal vein) that drains blood from the kidney Incidence high as 30% in _________ syndrome, especially ___________ |
Blood clot
nephrotic membranous nephropathy |
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Acute RVT: S/S
_____ ______ pain Testicular pain ________, gross or microscopic Marked increase in plasma ____ Rise in serum __________ Increased ______ size |
N/V
Flank Hematuria LDH creatinine renal |
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Chronic RVT: S/S
Non specific findings Worsening _________ Evidence of renal ________ dysfunction _______ issues, urinary concentration, ___________ disorders |
proteinuria
tubular Acid base electrolyte |
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Renal Vein Thrombosis: Dx
Gold standard is selected __________ CT, MRA, US, are useful non infasive tests, but are less reliable Treatment- Anticoagulation with _______ acutely, then long term anticoagulation with ________ Continue therapy for __ year or indefinitely if recurrence or risk factors _________ therapy for acute RVT with acute renal failure Rarely, ___________ for those who don’t respond to anticoagulant therapy |
renal venography
heparin warfarin (coumadin) 1 Thrombolytic surgical embolectomy |
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Acute Renal Failure (ARF):
abrupt decrease in GFR significant enough to cause increased ______ & ______ and disruption of extracellular fluid volume and electrolyte and acid base balance Can result from: Diseases causing decreased renal blood flow (_________) Diseases affecting the renal parenchyma (_________) Diseases causing obstruction (___________) |
BUN and creatinine
prerenal azotemia azotemia post renal azotemia |
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*__________ is most common intrinsic renal disease causing ARF*
ATN definition: syndrome of abrupt and sustained decline in ____ within minutes to days after ischemic or nephrotoxic occurrence Diagnosis based on exclusion of _________, and the exclusion of other causes of intrinsic ARF: Glomerulonephritis, acute interstitial nephritis, vasculitis |
Acute tubular necrosis (ATN)
GFR pre or postrenal azotemia |
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ARF: DDX
5% of hospital admissions, 30% ICU admits H&P and lab often all that is needed for DX In hospital: _________ is the most common cause of azotemia ATN is the most common problem causing ARF So, must differentiate between them (ie from volume depletion vs insult due to nephrotoxins or ischemia) Post renal azotemia of __________ has to be excluded in elderly males in hospital |
Pre renal azotemia
bladder outlet obstruction |
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ARF: Diagnosis
__________ Special attention to- Recent reduction in GFR Events leading to deterioration of renal function Consideration of two above factors in relation to chronology of potential causes of ARF Must have knowledge of the natural history of different causes of ARF |
Review of Records
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ARF: Diagnosis - PE
Reduced body weight, postrual changes in BP and P, and decreased jugular venous pulse all suggest decreased ___________ causing prerenal azotemia Expanded extracellular fluid volume with decreased effective blood volume- ________, nephrotic syndrome, cardiac failure Obstruction- __________ that indicates urinary tract obstruction Examine prostate and do “in and out” ____________ Fever and rash with ____________ Livedo reticularis for _________ emboli Hx of recent aortic cath suggests __________ emboli |
extracellular fluid volume
Cirrhosis Distended tender bladder post void bladder cath interstitial nephritis cholesterol atheromatous |
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ARF: Diagnosis - Urinalysis
Urine volume In oliguric ATN usually ____ ml/day (but normal output does not exclude ATN as cause of ARF) Non oliguric ATN usually associated with nephrotoxic ________-induced ARF ________ usually points to something besides ATN as cause of ARF, usually obstruction Also, widely varying daily outputs can mean obstruction |
400
antibiotic Anuria |
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ARF: Diagnosis - Urinalysis
Urine sediment Prerenal failure-increased fine _______ casts ATN – “_______” renal tubular epithelial cells free in sediment and also in casts Obstruction – ______ sediment Deposition of intratubular _______ crystals as a result of methoxyflurane anesthesia in ARF Uric acid crystal deposition seen after chemotherapy for neoplastic dz in acute hyperuricemia associated with this paraneoplastic disorder |
granular
dirty brown benign oxylate |
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ARF: Diagnosis - Urinalysis
Urinary indices Helps in determination of prerenal Azotemia vs ATN: Urine ______ Urine ________ Urine ________ Renal failure index Fractional excretion of filtered sodium |
sodium
creatinine osmolarity |
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ARF: Diagnosis - Renal ______ indications
When dx of prerenal azotemia or ATN is uncertain, especially if clinical setting suggests other possibilities (ie obstruction or vascular accident) When clinical findings make the diagnosis of prerenal azotemia or ATN unlikely (anuria) When oliguria persists beyond 4 weeks |
biopsy
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ARF: Diagnosis
Imaging ________ shows presence or absence of dilated collecting system which excludes post renal ARF (absence) ___________ assesses renal blood flow as well as excretory and secretory function Renal bx Useful when dx thought to be other than ________ or ________ (so may respond to disease specific treatment) GN, vasculitis, HUS, TTP, Allergic interstitial nephritis |
Ultrasound
Radionucleotide nephrotoxic or ischemic injury |
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ARF: Lab
Hospitalized patients usually have _____ as cause of ARF Outpatients, usually cause is _________- disease (once pre and post renal azotemia r/o) Examination of the urine sediment, and blood and protein helps establish diagnosis and suggests further lab evaluation |
ATN
renal parenchymal |
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ARF: Lab - Urine
_________ GN = 3-4+ protien, 2-3+ blood, and active urine sediment with RBC’s and casts Myoglobinuria or hemoglobinuria = few RBC’s in urine sediment, with strongly ____+ urine seen in myoglobinuria or hemoglobinuria (myoglobinuria is prime cause of ARF in clinical “______” syndrome) _____________= damage to muscle cells allowing contents (myoglobin) to spill into systemic circulation Myoglobin, CPK (creatinine phosphokinase), RBC’s, pigmented casts, granular casts |
Proliferative
heme crush Rhabodomyolysis |
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ARF: Diagnosis - Kidney size
*Best evaluated by ___* Gives information as to ARF or CRF, obstruction Ex: normal kidney size in patient with advanced azotemia means ____ rather than CRF However, normal kidney size in patient with renal failure can also point to ___,_____, multiple myeloma, and amyloidosis Normal kidney size in patient with kidney failure indicates need for _______ if dx not evident |
US
ARF DM, HIV renal bx |
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ATN: acute renal failure due to _______ damage and accounts for 85% of intrinsic ARF
2 major causes of ATN are: ________ & _______ |
tubular
Ischemia & Toxin exposure |
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ATN: Causes - Ischemia
Caused by tubular damage from states of low ________ Characterized by inadequate GFR and inadequate renal blood flow Inadequate blood flow cannot maintain parenchymal cellular formation Occurs in _______ or _______ states such as dehydration, shock, and sepsis Also in ________ involving prolonged hypoprofusion and vasodilating anesthetic agents |
profusion
hypotensive or hypoxemic major surgery |
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ATN: Causes - Nephrotoxic exposure
Exogenous nephrotoxins- More commonly cause damage ________, ______, radiographic contrast agents, cysplatin, ethylene glycol, _____ inhibitors Endogenous nephrotoxins- _________, __________ ARF |
Aminoglycosides, NSAIDS
ACE Rhabdomyolysis, hyperuricemic |
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ATN: Exogenous Nephrotoxins - Aminoglycosides
25% of hospitalized patients on aminoglycosides have some degree of ATN Nonoliguric RF _____ days after exposure Mostly in patients with renal damage, dehydration, and advanced age Can remain in tissues up to 1 month Renal functions may not recover for a while after stopping Peak and trough levels should be monitored with _______ more predictable for renal toxicity ________ & _________ are the most nephrotoxic, with ________ being the least toxic of the aminoglycosides |
5-10
trough Gentamycin and tobramycin streptomycin |
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ATN: Exogenous Nephrotoxins - Other anti-infectives
_________ nephrotoxic after 2-3 grams ________, acyclovir, and several cephalosporins have associated with ATN |
Amphotericin B
Vancomycin |
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ATN: Exogenous Nephrotoxins - Radiographic contrast agents
____ leading cause of new ARF in hospitalized patients Predisposing factors: Age, renal dz (serum creatinine >__mg/dl), volume depletion, diabetic nephropathy, _____, repeated dosages of contrast agents, recent exposure to NSAIDS and ACE inhibitors Greatest risk associated with diabetes and renal dysfunction (15-50%) |
3rd
2 CHF |
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ATN: Exogenous Nephrotoxins - Radiographic contrast agents
Toxicity usually ______ hours after contrast study Prevention: ________ of agents recommended for high risk patients Hydration with 1L of .45% ______ over 12 hours before and after procedure ___________ 600mg Q12h before and after dye administration in patients with lower GFR may be beneficial (unknown MOA) |
24-48
Lower volumes saline Acetylcysteine |
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ATN: Exogenous nephrotoxins - Cyclosporin
Dose dependent Distal tubular dysfunction from severe ___________ Monitoring is important to prevent toxicity In renal transplant patients taking cyclosporin to prevent rejection, ________ is necessary to determine if RF is due to transplant rejection or cyclosporin toxicity Renal function improves after stopping drug |
vasoconstriction
renal bx |
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ATN: Exogenous Nephrotoxins - Others
Antineoplastics: _________ Organic solvents, ethylene glycol Heavy metals: ________, cadmium, and arsenic |
Cysplatin
Mercury |
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ATN: Endogenous Nephrotoxins - Heme containing products
________ as a result rhabdomyolosis leads to ATN Necrotic or damaged muscles release myoglobin Large amounts of myoglobin are filtered across glomerulus Myoglobin is resorbed by renal tubules causing damage Obstruction of tubules by _______ casts, and intrarenal __________ also causes damage |
Myoglobinuria
pigmented vasoconstriction |
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ATN: Endogenous nephrotoxins - Heme containing products
Rhabdomyolosis causes of renal failure __________ ____________ from prolonged unconsciousness Seizures Cocaine ________ abuse __________ and acidosis predispose to myoglobinuric renal failure |
Crush injury
Muscle necrosis Alcohol Dehydration |
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ATN: Endogenous Nephrotoxins - Rhabdomyolosis and renal failure
Clinical and lab findings Muscle ______, muscle ______ ____ levels of 16,000-50,000 signals Rhabdomyolosis of clinical importance Urine dipstick will be falsely ___ for hemoglobin due to globin portion of myoglobin Urine is ________ with NO RBC’s _______– hyperkalemia, hyperphosphatemia, and hyperuricemia |
pain
injury CK + dark brown Blood |
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ATN: Endogenous Nephrotoxins
Rhabdomyolysis and renal failure - Treatment _________ is the most important thing ________ for diuresis and alkalinization of the urine Other Endogenous Nephrotoxins _______ in massive intravascular hemolysis such as transfusion reactions and hemolytic anemias |
Hydration
Mannitol Hemoglobin |
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ATN: Other Endogenous Nephrotoxins
________ in rapid cell turnover and lysis Caused mostly by ____________ for germ cell neoplasms and leukemias ARF occurs with deposition of uric acid crystals in the tubules Uric acid levels >____ Urine uric acid > 600mg/24hrs Urine uric acid to urine creatinine ratio of >__ indicates strong risk for ARF |
Hyperuricemia
chemotherapy 20 1 |
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ATN: Lab
Sediment shows pigmented granular “_______” casts _________ epithelial cells and epithelial cells present Hyper______ hyper________ |
muddy brown
Renal tubular hyperkalemia hyperphosphatemia |
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ATN: Treatment
Preventative measures to avoid hyperkalemia and volume overload ______ diuretics have been used for adequate diuresis and may help convert oliguric to nonoliguric renal failure But widespread use in critically ill patients with _____ should be avoided Nutritional support to prevent excessive catabolism ________ restriction to prevent metabolic acidosis Hypocalcemia and hyperphosphatemia treated with diet and phosphate binding agents Avoidance of ________ containing acids due to hypermagnesemia |
Loop
ARF Protein magnesium |
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ATN: Treatment - Dialysis indications
Life threatening ________ disturbances such as hyperkalemia Volume overload unresponsive to ________ Worsening _______ or uremia (encephalopathy, pericarditis, seizures) In gravely ill patients, less severe but worsening problems may indicate dialysis |
electrolyte
diuretics acidosis |
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ATN: Prognosis - Mortality
20-50% in medical illness, 70% in surgical setting Increased mortality associated with advanced age, severe underlying disease, and multisystem organ failure Leading causes of death are _________, ________ & ________ disturbances, and worsening underlying disease Mortality rates haven’t changed in the last 20 years _________ is a high priority |
infections
fluid and electrolyte Prevention |
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ARF: Other Endogenous Nephrotoxins - Hepatorenal syndrome
Kidney failure in patients with severely compromised _______ functions No other clinical, laboratory, or anatomic reasons for renal failure In U.S., mostly advanced __________ Precipitating causes: Deteriorating liver functions, sepsis, nephrotoxic _______ or _______ usage, overuse of diuretics, diarrhea, or GI _______ May have no precipitating cause |
liver
alcoholic cirrhosis antibiotic or NSAID bleed |
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ARF: Endogenous Nephrotoxins
Hepatorenal syndrome: HALLMARK is ________ with urinosmolality 2-3 times the concentration of plasma, in urine that is almost completely ________ free as in patients with _________ azotemia |
oliguria
sodium prerenal |
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Endogenous Nephrotoxins: ARF related to pregnancy -
Rare in industrialized nations Decrease thought due to legalization of _________ in many countries Associated with _______ following an abortion Most common infection associated with ARF of pregnancy is ________ Clinical picture is _________ as a result of toxin production, hypotension, hemorrhage, sepsis, and DIC |
abortion
infection Clostridium hemolysis |
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ARF: Endogenous Nephrotoxins - ARF of Pregnancy
___________ is one of the most common medical complications of pregnancy 25% of the patients develop a transient decline in GFR Treat with ____ antibiotics with follow up oral antibiotic therapy for ___ weeks _____ trimester - ARF associated with pre-eclampsia, post partum hemorrhage, amniotic fluid embolism, placental abruption, and retained fetal placental parts |
Pyelonephritis
IV 2 Third |
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ARF: Interstitial Nephritis
10-15% of causes of RF Pathology – interstitial inflammatory response with _______ and tubular cell damage _______ account for over 70% of cases Can occur in infectious diseases, immunologic or idiopathic conditions |
edema
Drugs |
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ARF: Interstitial Nephritis
Most common causative drugs are- __________ __________ Sulphonamides and sulphonamide containing ________ NSAIDS Rifampin ________ Allopurinol |
Penicillins
Cephalasporins diuretics Phenytoin |
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ARF: Interstitial Nephritis
__________- Streptococcal infection Leptospirosis CMV Histoplasmosis Rocky mountain spotted fever ____________- SLE Sjorgrens Sarcoidosis Cryoglobulinemia |
Infections
Immune disorders |
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ARF: Interstitial Nephritis - Clinical Findings
_______ _______ ________ Eosinophilia in peripheral blood ______ contains red cells, white cell, and WBC casts Proteinuria eosinophyluria |
Fever
Rash Arthralgias Urine |
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ARF: Interstitial Nephritis - Treatment
Good prognosis with recovery usually in weeks to months ________ may be necessary acutely Very rarely progress to _____ Worse prognosis is oliguric RF and ________ Treatment is supportive and removal of offending agent Short course of _______ if renal failure persists |
Dialysis
ESRD advanced age steroids |
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progressive and irreversible loss of renal function
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Chronic Renal Failure (CRF)
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CRF: Watching lab is important
Can have up to 75% loss of GFR without ________ due to adaptation of remaining glomeruli and tubules But, rise in serum _________ from .7 to 1.4 signifies 50% loss of GFR Early intervention is important at this stage So, serum creatinine and creatinine clearance is used for diagnosis and monitoring renal dysfunction |
symptoms
creatinine |
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CRF: CRF vs ARF
Past and present serum creatinine measurements Search for causes of CRF _________ for definitive dx Allows for: Diagnosis and treatment Prognosis Determination of need and suitability for _________ |
Renal bx
renal transplant |
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CRF: CRF vs ARF
If no bx Dx based on Past, present, and family _______ Serology Examination of urine _______ Renal _______ Kidney size- Most CRF associated with ________ kidney size Some have normal kidney size even with advanced failure DM, Multiple Myeloma, polycystic kidney dz, HIV nephropathy, amyloidosis |
history
sediment ultrasound decrease |
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CRF: Conservative management of CRF
Slow ________ Control HTN, diabetes, and hyperlipidemia, Avoid nephrotoxins _______ cessation Block production or effect of angiotensin ____ Identify reversible causes when renal functions decline unexpectedly Identify and treat complications of CRF Prepare patients emotionally and physically for ESRD and renal replacement therapy (RRT) |
progression
Smoking II |
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CRF: Managing ____
Slows the rate of renal failure, especially in patients with diabetic nephropathy Nephroprotective effect of meds that block the production and/or effect of angiotensin II in patients with type 1 and 2 diabetic nephropathy ____(nonhydropyridines) also slow the progression of renal disease (verapamil, diltiazem) Will need an average of 2.7 antihypertensive medications to reach optimal BP in patients with significant proteinuria and diabetes |
HTN
CCB’s |
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CRF: Managing Diet
Dietary _______ restriction slows the rate of progression of renal insufficiency Also advocated to reduce features of _______ syndrome |
protein
uremic |
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CRF: Managing Diet
National Kidney Foundation Practice Guidelines for Nutrition in CRF of patient with GFR of less than 25 ml/min or patients on RRT 35Kcal/day under 60 yrs old 30 Kcal/day for those over 60 yrs old 0.6 - 0.75g/kg/day of protein, with 50% being of high biologic value ______ restriction in hypertensive and edematous patients __________ at the outset of dialysis has higher mortality rate So protein restriction should be approached with caution with assurance of adequate _______ intake |
Sodium
Malnutrition calorie |
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CRF: Management of reversible causes of acute deterioration of renal function
Can plot out the rate over time at which a specific patient will reach _____ If the patient shows sudden deterioration in renal disease, look for reversible cause Patients with CRF are more susceptible to those factors causing ____ |
ESRD
ARF |
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CRF: Avoiding Toxic Drug effects
Avoid __________- Most common offender in hospitalized patients Avoid ________ - Inhibits vasodilitory prostaglandins and decreases GFR; Also causes interstitial nephritis and ARF Avoid ________ agents- High risk patients are those that are volume depleted and those with preexisting renal insufficiency Increase fluid hydration with D5 ½ NS 8-10 hours before and after procedure ________(dopamine receptor agonist) which causes renal and systemic vasodilation may prevent contrast nephropathy in high risk patients |
aminoglycosides
NSAIDS radiocontrast Fenoldopam |
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CRF: General Features of Uremic Syndrome - Clinical Manifestations
Uremia def: an excess in the blood or urea, creatinine, and other nitrogenous end products of _______ & ________ metabolism. Also known as _______ Uremic Syndrome effects every organ system Due to retained molecules, ______ deficiencies, metabolic factors |
protein and amino acid
Azotemia Hormone |
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CRF: Clinical Manifestations ______ causes fatigue, nausea, vomiting, and headaches
_______ (product of urea breakdown) can cause carbamylation of lipoproteins and peptides resulting in multiple organ dysfunction _______ (biproducts of protein metabolism) are increased in renal failure Inhibit alpha 1 hyroxylase in kidney leading to deficient calcitriol production causing secondary hyperparathyroidism High levels of parathyroid hormones implicated in ________ in uremia |
Urea
Cyanate Guanidines cardiomyopathy |
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Cardiovascular
Gastrointestinal Neurologic Musculoskeletal Hematologic Endocrine Immunologic Metabolic Dermatologic |
Specific Manifestations of Uremic Syndrome
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CRF: Cardiovascular Effects
Death from ____ in CRF is 3 ½ times greater than age matched population Heart dz accounts for 50% of the deaths of uremic patients 60% of patients have ___ on echo with dilation, systolic, and diastolic dysfunction ______ and HTN contribute to LVH and CHF |
CVD
CHF Anemia |
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CRF: Cardiovascular Effects (cont)
2° hyperparathyroidism causes metastatic _________ in myocardium, heart valves, and arteries _________ is accelerated with high rate of recurrence post angioplasty _______ before and during dialysis due to inadequate dialysis Resolves with dialysis intensification If it doesn’t surgical drainage or _______ are used |
calcification
Athrogenesis Pericarditis NSAIDS |
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CRF: Gastrointestinal Disease
GI disturbances are among the earliest and most common signs of the uremic syndrome ______ taste and ________ early on Later, anorexia continues, nausea, vomiting, and weight loss (improves with dialysis) ______ from gastritis, ulcers, and arteriovenous malformations |
Metallic
anorexia GI bleeds |
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CRF: Neurologic Manifestations
CNS manifestations are frequent and occur early Subtle changes in cognitive functions and ______ _______ disturbances Lethargy, irritability, frank encephalopathy, asterixis, and seizures are late manifestations Bilateral __________ neuropathy Restless leg, footdrop, wristdrop PE: decreased _______ and loss of ________ sense |
memory
Sleep glove and stocking DTR’s vibratory |
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CRF: Musculoskeletal manifestations
Alterations in calcium and phosphate homeostasis Hyperparathyroidism and disturbances of Vit ___ metabolism Hypocalcemia and hyperparathyroidism cause ______ retention and lack of alpha 1 hydroxylase activity in the failing kidney, with deficiency of Vit D (_______) as the consequence In time adaptive hyperparathyroidism becomes maladaptive, and this leads to bone disease and tissue calcinosis (___________) Can be controlled with dietary phosphate restriction, phosphate binders, calcium supplements, Vit D and Vit D analogs, and dialysis |
D
phosphate calcitriol renal osteodystrophy |
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CRF: Hematologic Effects
____(regulates erythrocyte production) decreases as renal mass decreases ____ and EPO deficiency are common causes of anemia in CRF EPO administration improves quality of life, corrects anemia, and decreases need for blood transfusions Bleeding disorders- Due to defects in platelet aggregation and adherence Controlled with _______, _________, conjugated ________, and dialysis |
EPO
Iron vasopressin, cryoprecipitate, conjugated estrogens |
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CRF: Endocrine Abnormalities
Alterations in _______ function Increased T3 resin uptake (low TBG levels) Low T3 due to impaired conversion of ______ to T3 in the periphery Normal TSH and throxine (T4) _______ is present in 1/3 of patients with CRF |
thyroid
thyroxine Goiter |
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CRF: Endocrine Abnormalities (cont)
Abnormal _________ axis ________ dysfunction manifested by impotence, decreased libido, amenorrhea, sterility, and uterine bleeding Hypoprolactinemia Decreased estrogen, testosterone, and progesterone with normal ____ & ____ _______ uncommon in female patients with GFR less than 30 mL/min |
pituatary-gonadal
Sexual FSH and LH Pregnancy |
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CRF: Immunologic Function
Defects in _______ & _______ immune systems in patients with end stage renal disease Patients susceptible infections: Bacterial _______ Microbacterial |
humoral and cellular
Fungal |
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CRF: Metabolic Disorders
Decreased renal function means decreased _______ requirement Due to increased half life of exogenous insulin because of decreased insulin clearance Increased insulin ______ due to tissue insensitivity, metabolic _____ , and hyperparathyroidism which impair insulin release and secretion |
insulin
resistance acidosis |
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CRF: Metabolic disorders (cont)
______ abnormalities consistant with type IV hyperlipidemia Marked increase in TG, less of an increase in cholesterol Due to decreased lipoprotein lipase in uremia Decreases the conversion of VLDL to LDL Results in ___________ These abnormalities result in accelerated ________ and _________ proliferation with progressive renal failure |
Lipids
hypertriglyceridemia atherosclerosis and mesangial cell |
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CRF: Dermatologic Manifestations
Uremic ___ from retained liposoluable pigments _______ is common Responds to dialysis, control of hyperparathyroidism, balance of calcium and phosphate, UV rays Nail findings ________ nail Red, pink, or brownish discoloration of the ______ nail bed Pale nails __________ |
Hue
pruritis Half and half distal Splinter hemorrhages |
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Hemodialysis
Peritoneal Dialysis Kidney Transplantation |
Treatment of End Stage Renal Failure (ESRD)
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Treatment of ESRD:
Treatment plan should be in place ______ in the course of renal failure before uremic symptoms appear Criteria for the initiation of dialysis: GFR ___ ml/min or less in diabetic patients GFR ___ ml/min or less in those without diabetes Start above these ranges in patients with- Volume overload resistant to diuretics Metabolic acidosis Pericarditis Persistant hyperkalemia Intractable GI sx, or encephalopathy |
early
15 10 |
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Treatment of ESRD:
Choice of renal replacement therapy depends on patient’s physical or sociodemographic characteristics Patients may be started on _________ or _________ ____________ encouraged because it allows for better quality of life and chance for rehabilitation |
hemodialysis or peritoneal dialysis
Renal transplantation |
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Treatment of ESRD: ________
The most common modality for RRT in the US Average patient requires 4 hours dialysis 3 times weekly to remove toxins |
Hemodialysis
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Treatment of ESRD: Peritoneal Dialysis
The trend in the US is to move more patients toward peritoneal dialysis Advantages Patients do not have to spend hours in dialysis unit No stringent _______ restrictions as in hemodialysis _____ rates are better than in hemodialysis, with more patients returning to full employment Residual renal function is maintained _______ while patient undergoing peritoneal dialysis, reducing morbidity and mortality |
dietary
Rehab longer |
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Treatment of ESRD: Peritoneal Dialysis
Method The ________ acts as a semipermeable membrane similar to a hemodialysis filter 2-3 liters of _______ instilled into the peritoneal cavity for varying amounts of time Exchanged ____ times daily |
peritoneum
dialysate 4-6 |
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Treatment of ESRD: Peritoneal Dialysis
Method - __________ peritoneal dialysis Patient is connected to machine called a cycler Allows inflow of smaller volumes of dialysate with shorter dwell time through the night while patient sleeping |
Continuous cyclic
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Treatment of ESRD: Peritoneal dialysis
Rate of removal of solutes depends on: _______ gradient, surface area, and permeability of the peritoneal membrane to the solute _______ molecules move easily and are influenced by the ultrafiltration rates Ultrafiltration enhanced by increasing _______ in the dialysate |
Concentration
Smaller dextrose |
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Treatment of ESRD: Drawbacks of peritoneal dialysis
________ of the percutaneous catheter placed in peritoneum _________ treated with intraperitoneal antibiotics ________ removed in bacterial peritonitis not responding to antibiotics and in fungal peritonitis Difficulty in achchieving adequate clearance in patients with ________ |
Infection
Peritonitis Catheter large body mass |
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Treatment of ESRD: Kidney Transplantation
The preferred modality of RRT ______________ often required before, during, or after transplantation _________ marked significant improvement in success rate of renal transplantation From 65% graft survival in 1983 to 90% today Further decrease in rejection seen with newer ____________ agents Also, increase in short term allograft survival due to these agents with 1 year graft survival in cadaveric transplants up to 90% |
Hemo or peritoneal dialysis
Cyclosporine immunosupressive |
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Treatment of ESRD: Immunosupressant drug therapy
Prophylaxis and treatment of graft rejection are at the heart of the success of kidney transplantation Protocals aimed at disruption of _______ cell cycle Different agents have specific MOA _________ system is essential for some ot the agents to work and changes in their levels can be due to patients taking one of several drugs that can induce or inhibit the system Major drugs are ________, _________, _________, ________ |
lymphocyte
Cytochrome P-450 Cyclosporin, tacrolimus, mycophenolate, Rapamycin |
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Treatment of ESRD: Kidney Transplantation - Acute Rejection
Clinically detected by: Graft ________ Rise in serum _______ Oliguria Resulting tubulitis _______ Frequent monitoring of renal function allows early detection of increased creatinine (acute rejection) prior to _________ appearing Acute rejection episodes (< __ days) have a negative impact on long term graft survival |
tenderness
creatinine fever clinical symptoms 60 |
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Treatment of ESRD: ____________
2nd only to vascular dz as leading cause of mortality in post transplant patients Community acquired bacterial and viral infections Viral, fungal, and other opportunistic infections which normally don’t cause severe illness in immunocompetent hosts Timetable is predictable Educated guess based on time after transplantation and symptoms associated with each infection helps facilitate early recognition and treatment pending confirmatory tests |
Post Transplant Infection
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Treatment of ESRD: Post-Transplant Malignant Disease
Immunosuppression increases risk of ________ ________ (mostly squamous cell) has highest incidence in transplant recipients Caution regarding sun exposure Skin protection for primary prevention High risk also for _______ lymphoma, ______ sarcoma, and post transplant lymphoproliferative disease (rare in immunocompetent host) |
malignancy
Skin cancer non-Hodgkins Kaposi’s |
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Treatment of ESRD: Malignancies
_________ is important part of post transplant follow up Patient education to report the following: Early changes in _____ habits _______ symptoms Hematuria Skin changes ______ changes Musculoskeletal symptoms |
Cancer surveillance
bowel Respiratory Weight |
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Nephritic Syndrome S/S
PHAROH |
Proteinuria, Hematuria, Azotemia, RBC casts, Oliguria, Hypertension
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Nephrotic syndrome: causes for secondary nephrotic syndrome
DAVID |
Diabetes mellitus
Amyloidosis Vasculitis Infections Drugs |
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Renal failure: symptoms/signs
My Big Nob Vibrates Gently In Her Purulent Pelvis |
Malaise
Breathlessness Nausea Vomiting GI motility Headache Pruritis Pigmentation |
