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371 Cards in this Set
- Front
- Back
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What are the tools of detection for renal disease?
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history & PE
urinalysis GFR, -Cr, Cr Clearance, BUN blood chemistries renal U/S |
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What can be assesed during the history for renal disease?
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urination changes
flank pain uremic symptoms NSAID use family Hx |
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What can be assesed during the PE of renal disease?
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high blood pressure
jugular venous distension rales pericardial rub edema asterixis |
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What type of urinary symptoms may be seen in urinary tract diseases or kidney diseases?
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oliguria
polyuria nocturia flank pain gross hematuria |
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What type of urinary symptoms generally imply urinary collecting system problems?
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urinary hesitancy
urinary urgency dysuria |
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What are 5 uremic symptoms?
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generalized weakness
anorexia N/V dysgeusia (things taste funny) pruitus |
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What are the early manifestations of uremic syndrome?
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anorexia, pruitus, fatigue, difficulty w/ memory and concentration
-advanced stages of renal failure associated w/ involvement of multiple organ systems |
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What are 6 metabolic manifestations of uremia (uremic syndrome)?
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metabolic acidosis
hyperkalemia hypocalemia hyperphosphatemia/hyperparathyroidism hyperuricemia hypermagnesemia |
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What are the S/S of metabolic acidoses associated w/ uremia?
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abdominal pain
weakness Kussmaul respirations |
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What are the S/S of hyperkalemia associated w/ uremia?
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muscle weakness
cardiac arrhythmias (EKG changes of peaked T waves) |
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What are the S/S of hypocalcemia associated w/ uremia?
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tetany
perioral numbness |
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What are the S/S of hyperphosphatemia/hyperparathyroidism associated w/ uremia?
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itiching
bone pain |
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What disease is hyperuricemia associated with?
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gout
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What are the S/S of hypermagnesemia associated w/ uremia?
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reduced DTRs
arrhythmias |
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Within what time frame should urine be examined?
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within 1 hour
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What does the urine dipstick measure? (5)
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specific gravity
pH protein glucose hemoglobin |
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What are 3 things that the urine sediment after centrifuge evaluates?
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presence of cells, crystals, casts
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What does the presence of significant proteinuria highly suggest?
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renal disease
-24 hour urine collection more accurate |
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What do dysmorphic RBCs suggest?
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glomerular disease
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What does pyuria imply?
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infection or inflammation of the kidney or urinary tract
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What are 4 types of casts that can be seen in urinalysis?
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WBC casts (kidney inflammation)
RBC casts (glomerular inflammation) granular casts (acute tubular necrosis; non-specific) *broad/waxy casts (chronic renal disease) |
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What is GFR?
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-volume of plasma filtered in a given period of time, typically expressed ml/min
-indirect estimate of functional renal mass -can determine presence of renal insufficiency and follow progression -may be normal in many renal diseases |
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What is BUN?
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end product of protein metabolism
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What is creatinine?
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breakdown product of muscle creatine
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What is azotemia?
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abnormal elevation of BUN and creatinine?
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What is creatinine clearance?
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-amount of creatinine cleared from the plasma in a given time
-overestimates GFR b/c it is secreted & freely filtered (urinary Cr x urine volume) / (plasma creatinine x 1440) |
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What is the normal for creatinine clearance?
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100-140 ml/min
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What is nephritic syndrome?
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S/S of a urinary tract disorder, including hematuria, HTN, and renal failure; inflammation
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What are 3 types of renal failure?
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acute (hours to days)
rapidly progressive (weeks to few months) chronic (months to years) |
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What do the PE and labs of acute renal failure show?
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baseline Cr normal
baseline UA normal normal kidney size PTH normal no broad casts oliguria possible |
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What do the PE and labs of chronic renal failure show?
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baseline Cr abnormal
baseline UA abnormal reduced kidney size (lose nephrons) PTH elevated broad, waxy casts normal urine output |
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What are 5 common causes of acute renal failure?
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acute tubular necrosis (renal)
prerenal azotemia (prerenal) acute interstitial nephritis (renal) acute glomerulonephritis (renal) urinary tract obstruction (postrenal) |
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What are 6 common causes of chronic renal failure?
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*diabetic nephropathy
*HTN nephrosclerosis chronic glomerulonephritis chronic tubulointerstitial disease inherited diseases ischemic nephropathy |
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What is the most common cause of rapidly progressive renal failure?
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rapidly progressive glomerulonephritis
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What manifestations show up with nephrotic syndrome?
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proteinuria >3.0 to 3.5 gm/day
hypoalbuminemia edema hyperlipidemia lipiduria (oval fat bodies) hypercoagulable states ascites pleural effusions |
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What are the common causes of nephrotic syndrome?
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minimal change disease
focal segmental glomerulonephritis membranous nephropathy membranoproliferative glomerulonephritis diabetic nephropathy IgA nephropathy lupus nephritis |
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What are the manifestations of acute nephritic syndrome?
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acute renal failure
HTN edema (periorbital, scrotal) dysmorphic RBCs RBC casts proteinuria < 3.5gm/day |
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What are the common causes of acute nephritic syndrome?
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post-strep GN
IgA nephropathy vasculitis lupus nephritis rapidly progressive glomerulonephritis |
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What is isolated hematuria?
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presence of > 2 RBCs per hpf in the absence of renal insufficiency, proteinuria, or pyuria
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What are the common causes of isolated hematuria?
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UTI
vaginal bleeding tumors (bladder/ureter/kidney) nephrolithiasis sickle cell disease/trait glomerular disease |
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What is isolated proteinuria?
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>250mg/24hours urinary protein in the absence of hematuria, renal failure, or manifestations of nephrotic syndrome
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What are the common causes of isolated proteinuria?
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glomerular disease
inherited kidney disease (PCKD) tubulointerstitial disease vascular disease |
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What is the formula for body fluid composition?
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Wt (kg) x TBW%
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How much % of body weight is total extracellular volume?
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20%
-plasma 5% -interstitial 15% |
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How much % of body weight is total intracellular volume?
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40%
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What is the normal serum osmolality?
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285-295 mosm/kg
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What is tonicity?
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osmolytes that are impermeable to the cell wall
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What do imbalances in tonicity lead to?
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osmosis
fluid shifts stimulation of thirst secretion of ADH |
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What is the most common electrolyte abnormality seen in hospitalized patients?
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hyponatremia
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What is considered hyponatremia?
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serum sodium level <130mEq/L
-most are caused by water imbalance not sodium imbalance |
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What are 2 causes of isotonic hyponatremia ("pseudohyponatremia")?
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hyperproteinemia
hyperlipidemia |
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What are the causes of hypertonic hyponatremia ("dilutional")?
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*hyperglycemia
mannitol, sorbitol, glycerol, maltose radiocontrast agents |
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What is "true" hyponatremia?
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hypotonic hyponatremia
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What happens with hypotonic hyponatremia?
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water shifts into the cell, usually causing increased intracellular fluid
most often due to impaired excretion of free water -renal failure -inappropriate ADH production |
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What are 3 types of hypotonic hyponatremia?
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hypovolemic
euvolemic hypervolemic |
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What are the S/S of hypovolemic hypotonic hyponatremia?
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low BP
orthostatic hypotension ↓ skin turgor sunken eyes |
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What are the causes of hypovolemic hypotonic hyponatremia?
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renal loss
-diuretics, ACE-I, nephropathies, mineralocorticoid deficiency, cerebral sodium-wasting syndrome extrarenal loss -dehydration -diarrhea -vomiting |
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Why should the rate of correction be adjusted with hypovolemic hypotonic hyponatremia?
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to prevent permanent cerebral damage
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What is the treatment plan for hypovolemic hypotonic hyponatremia?
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volume replacement w/ isotonic or half-normal saline or Lactated Ringer's
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What are the causes of euvolemic hypotonic hyponatremia
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renal failure (kidneys cannot excrete free water), water intoxication, SIADH, reset osmostat
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Is edema present with euvolemic hypotonic hyponatremia
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NO
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What causes hypervolemic hypotonic hyponatremia
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expanision of extracellular fluid and excess of water relative to Na+
-CHF -nephrotic syndrome -cirrhosis |
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What are the S/S of hypervolemic hypotonic hyponatremia
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edema and other signs of volme overload
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Symptoms of hyponatremia are commen when sodium is below ___.
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125 mEq/L
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How should severe hyponatremia be treated?
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3% saline at 1ml/kg per hour, not to correct sodium level above 125mEq/L
loop diuretic to enhance free water excretion |
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Why should hyponatremia be corrected slowly?
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b/c of risk of cerebral edema and potential for central pontine myelinolysis
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What is acute tubulinterstitial disease most commonly associated with?
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toxins and ischemia
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What does acute tubulointerstitial disease cause?
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interstitial edema, infiltration with PMN's, and tubular cell necrosis
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What are the essentials of diagnosis for chronic tubulointerstial disease?
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small contracted kidneys
↓ urinary concentrating ability hyperchloremic metabolic acidosis hyperkalemia reduced GFR |
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What are the 4 main causes of chronic tubulointerstitial disease?
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*obstructive uropathy
vesicoureteral reflux analgesics heavy metals |
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Partial obstruction for chronic tubulointerstitial disease has urinary output that alternates b/t ___ and ___, azotemia, and HTN.
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polyuria
oliguria |
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What are the 3 major causes of obstructive uropathy from chronic tubulointerstitial disease?
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prostatic disease
bilateral ureteral calculi cancer |
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What does the urinalysis for obstructive uropathy from chronic tubulointerstitial disease show?
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hematuria
pyuria bacteriuria |
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What are best diagnostic tests for obstructive uropathy from chronic tubulointerstitial disease?
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CT scanning
MRI |
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What does reflux of urine cause?
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inflammatory response and fibrosis
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What can analgesics lead to in the kidney?
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tubulinterstitial inflammation and papillary necrosis
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What heavy metals can cause chronic tubulointerstitial disease?
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*lead & cadmium (welders & moonshine drinkers)
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What do heavy metals which lead to chronic tubulointerstitial disease commonly cause?
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hypertension
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What are the S/S of chronic tubulointerstitial disease?
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polyuria
dehydration (salt-wasting defect) |
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What do the labs for chronic tubulointerstitial disease show?
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hyperkalemia
hyperchloremic renal tubular acidosis mild proteinuria |
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What will happen once scarring has occured with chronic tubulointerstitial disease?
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ESRD (end stage renal disease)
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What are 4 important S/S of polycystic kidney disease?
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arterial aneurysms in circle of Willis
mitral valve prolapse aortic aneurysms aortic valve abnormalities |
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How can polycystic kidney disease be diagnosed?
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U/S
urinalysis? blood cultures? CT scan cerebral arteriography (if family Hx of aneurysms) |
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What is the treatment plan for polycystic kidney disease?
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cyst rupture
-bed rest -analgesics, not NSAIDs cyst pain -decompression cyst infection -antibiotics hydration antihypertensive agents limit caffeine |
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What type of kidney disease causes a "swiss cheese" appearance?
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medullary sponge kidney
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What are 4 clinical findings of medullary sponge kidney?
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gross/microscopic hematuria
recurrent UTI's nephrolithiasis ↓ urinary concentrating ability |
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What is the Tx plan for medullary sponge kidney?
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no known therapy
adequate fluid intake to prevent stone formation |
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What are 3 types of non-glomerular diseases?
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tubulointerstitial diseases
polycystic kidney disease medullary sponge kidney |
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What is the most common cause of glomerulonephritis in the US and worldwide?
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IgA nephropathy
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What is the most common cause of ESRD in US?
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diabetic nephropathy
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How many glomeruli are in each kidney?
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~500,000 to 1 million
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What are Mesangial cells?
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"glue" of the glomerulus
-modified smooth muscle cells that are continuous w/ the vascular smooth muscle cells in the hilar arterioles -contractile and can tug on the edges of the capillaries and therefore help control blood flow through the glomerulus -regulate filtration surface area |
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What are podocytes?
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foot processes and slit diaphragms of visceral epithelial cells
-glomerular filtration SIZE barrier -electrostatic charge barrier |
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What 2 terms are used when referring to a state of glomerular injury?
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glomerulonephritis or glomerulopathy
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What is primary glomerular injury?
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confined to the kidney
-may cause HTN, uremia, edema (minimal change disease) |
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What is secondary glomerular injury?
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occurs as part of a systemic disorder (ex. diabetic nephropathy)
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What are 3 conditions that most glomerular diseases are triggered by?
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immune attack
diabetes mellitus hypertension |
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What are the 3 steps of glomerulonephritis immune complex mediated disease?
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1)immune complex formation & deposition (antigen-antibody complex)
2)inflammatory response to immune complexes 3)altered glomerular function (hematuria, proteinuria, nephrosis, nephritis) |
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What are the S/S of nephritic syndrome?
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*edema (periorbial/scrotal)
*HTN *hematuria *dysmorphic RBCs *RBC casts renal insufficiency oliguria proteinuria <3.5gms |
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What are 3 examples of nephritic syndrome?
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post-infectious glomerulonephritis
lupus nephritis IgA nephropathy |
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What is postinfectious glomerulonephritis most often due to?
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GABHS (especially type 12)
-after pharyngitis or impetigo -onset w/in 1-3 weeks after infection |
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What are the S/S of postinfectious glomerulonephritis?
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*"cola"-colored urine
-oliguira -edema -variable HTN |
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What does the urinalysis for postinfectious glomerulonephritis show?
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RBC's
RBC casts proteinuria <3.5gms (nephritic) |
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How should postinfectious glomerulonephritis be treated?
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SUPPORTIVE
-appropriate antibiotics -antihypertensives, salt-restriction, diurectics |
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What is the prognosis of postinfectious glomerulonephritis?
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children very favorable
adults more prone to crescent formation and chronic renal problems |
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What is Berger's disease?
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IgA nephropathy
-Iga deposition in the glomerular mesangium |
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What is the most common form of acute glomerulonephritis in the US and even more common worldwide?
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*IgA nephropathy
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Who is IgA most common in?
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children & young adults
male >> females |
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What are the S/S of IgA nephropathy?
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-gross hematuria (most common presenting complaint)
-often associated w/ a URI, GI symptoms or a flu-like illness -may see purpuric lesions *no significant latent period |
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What is the standard for diagnosis for IgA nephropathy?
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renal biopsy
-diffuse mesangial IgA deposits -proliferation of mesangial cells |
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How should IgA nephropathy be treated?
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ACE or ARB if significant proteinuria
corticosteroids |
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What 3 small-vessel vasculitic diseases is ANCA-associated glomerulonephritis seen with?
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Wegener's granulomatosis
Churg-Strauss disease microscopic polyangiitis |
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What are the S/S of ANCA-associated glomerulonephritis?
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fever, malaise, weight loss, hematuria/proteinuria, purpura, upper/lower respiratory tract symptoms?
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How is ANCA-associated glomerulonephritis treated?
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-high dose steroids tapered over 6 months
-cytotoxic agents tapered over 1 year |
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What is the prognosis of ANCA-associated glomerulonephritis?
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poor without treatment
earlier treated, better prognosis |
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What disease has a clinical constellation of glomerulonephritis and pulmonary hemorrhage?
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Goodpasture's syndrome
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What type of antibodies are present in Goodpasture's syndrome?
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*anti-GBM antibodies*
(confirms diagnosis) |
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What is the epidemiology of Goodpasture's syndrome?
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males 6x more than females
most common in teens and 20s |
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What are the S/S of Goodpasture's syndrome?
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preceded by URI (20-60% of cases)
hemoptysis dyspnea possible respiratory failure HTN edema |
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How is Goodpasture's syndrome treated?
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combination therapy
-plasma exchange therapy to remove circulating antibodies -immunosuppressive drugs |
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What kidney disease is in between acute and chronic?
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rapidly progressive glomerulonephritis (RPGN)
-not a single disease but a group of diseases |
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With rapidly progressive glomerulonephritis, what do you have in addition to proliferation of cells in the glomeruli (as with acute nephritis)? (5)
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-glomerular capillary rupture
-inflammatory mediators pour into Bowman's space -visceral epithelial cell proliferation (crescent) -crescent can rupture Bowman's capsule and extend into the surrounding interstitium -CRESCENTS are cellular and they become fibrotic |
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What are the S/S of nephrotic syndrome?
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*severe proteinuria (>3.5gms)
*edema *hypoproteinemia dyspnea abnormal fullness w/ ascites more frequent infections hyperlipidemia lipiduria |
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What is the hallmark of nephrotic syndrome?
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*peripheral edema
-starts in dependent areas |
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What is peripheral edema with nephrotic syndrome most likely due to?
|
sodium retention
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What are examples of idiopathic diseases that cause nephrotic syndrome?
|
minimal change disease
membranous nephropathy focal segmental glomerulosclerosis |
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What are 3 examples of secondary diseases that cause nephrotic syndrome?
|
diabetes mellitus
amyloidosis SLE |
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What 2 things show up in urinalysis of nephrotic syndrome?
|
proteinuria
oval fat bodies |
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How is nephrotic syndrome managed?
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-dietary protein to replace protein loss
-dietary salt restriction for edema; combo. of thiazide and loop diurectics -diet/exercise/statin for hyperlipidemia -anticoagulation for pts with thrombosis |
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Is minimal change disease more commonly seen in children or adults?
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children
males>females in children males=females in adults |
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What are the S/S of minimal change disease?
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nephrotic syndrome
↑ infections (especially g+) protein malnutrition |
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What are the histologic findings for minimal change disease?
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fusion of epithelial foot processes
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How is minimal change disease treated?
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*prednisone 1mg/kg/day continued for several weeks after complete remission of proteinuria
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Does minimal change disease commonly progress to end stage renal disease?
|
no
-it is rare |
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What is membranous nephropathy?
|
immune-mediated disease characterized by immune complex deposition in capillary walls
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What is the most common cause of primary nephrotic syndrome in adults?
|
membranous nephropathy
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When does membranous nephropathy most commonly occur?
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in 40's and 50's
-almost always after the age of 30 |
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What are the S/S of membranous nephropathy?
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nephrotic syndrome symptoms
renal vein thrombosis |
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What do the labs for membranous nephropathy show?
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-↑ capillary wall thickness
-IgG and C3 uniformly along capillary loops under immunofluorescence |
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What are the causes of focal segement glomerular sclerosis (FSGS)?
|
idiopathic or secondary to heroin use, morbid obesity, and HIV infection
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What are the S/S of FSGS?
|
nephrotic syndrome w/ nephritic features (microscopic hematuria, HTN)
decreased renal function |
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Is hematuria or proteinuria associated with a thin basement membrane disease?
|
hematuria
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Is hematuria or proteinuria associated with IgA nephropathy?
|
hematuria
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Is hematuria or proteinuria associated with benign isolated proteinuria (fever, CHF, exercise, postural)?
|
proteinuria
|
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Is hematuria or proteinuria associated with Alport Syndrome (hereditary nephritis)?
|
hematuria
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What are 4 non-glomerular conditions that need to be excluded with hematuria before considering glomerular disease?
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malignancy
BPH stones cystic diseases |
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What is chronic glomerulonephritis?
|
persistent proteinuria/hematuria/renal insufficiency that progresses slowly over years
|
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What are the 2 conditions that chronic glomerulonephritis is most commonly related to?
|
1- diabetes
2- HTN |
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Are oval fat bodies and proteinuria more commonly associated wtih nepritic or nephrotic syndrome?
|
nephrotic
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Are dysmorphic RBCs and RBC casts more commonly associated wtih nephritic or nephrotic syndrome?
|
nephritic
|
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CASE
19 y/o AA woman with 3+ protein on dipstick, 2+ blood on dipstick, Cr of 1.6 mg/dl. Comes to the ED complaining of feeling tired all over, and a rash on her face??? |
Lupus Nephritis
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CASE
26 y/o gentleman with shortness-of-breath, hemoptysis, diffuse alveolar infiltrates on CXR, serum creatinine 4.2mg/dL, dysmorphic RBC’s and RBC casts in his urine??? |
Good Pasture's (nephritic)
|
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CASE
9 y/o child comes to you because of a coca-cola colored appearance in her urine x 2 days. She has edema and her blood pressure is elevated. Had a sore throat 14 days ago. Positive family history of intermittent hematuria??? |
postinfectious glomerulonephritis
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What is the definition of acute renal failure?
|
rapid decrease in renal function (GFR) over hours or days characterized by a rapidly rising BUN and creatinine and often accompanied by oliguria
|
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What is uremia?
|
accumulation of nitrogenous wastes in the blood
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What is the hallmark of deciding what's going on with the kidney?
|
BUN/Creatinine ratio
|
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What is the normal BUN/Creatinine ratio?
|
10 to 1
|
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What may cause an increased BUN/Creatinine ratio?
|
prerenal/postrenal failure
protein loads increased catabolism steroids tetracyclines |
|
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What may cause a decreased
BUN/Creatinine ratio? |
severe liver disease
rhabdomyolysis Cimetidine trimethoprim |
|
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What increases with acute renal failure?
|
BUN
creatinine |
|
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What are the 3 causes of acute renal failure?
|
prerenal (hypoperfusion): hypovolemia, renal artery stenosis, embolus
renal (intrinsic renal parenchymal damage): glomerular disease post-renal (obstruction): stone, tumor |
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What are 4 causes of prerenal failure?
|
intravascular volume depletion
decreased cardiac output systemic vasodilation pharm. alteration of intrarenal blood flow |
|
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What are 4 causes of intrinisc acute renal failure?
|
*acute tubular necrosis 85%
acute interstitial nephritis acute glomerulonephritis vascular diseases |
|
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What does the urine sediment for acute tubular necrosis look like?
|
pigmented granular casts and renal tubular epithelial cells
*muddy brown casts |
|
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What are the 2 major causes of acute tubular necrosis?
|
ischemia
nephrotoxin (exogenous/endogenous) |
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What causes ischemic acute tubular necrosis?
|
prolonged hypotension or hypoxemia such as with dehydration, shock, and sepsis and after major surgical procedures
|
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What does acute renal failure due to acute tubular necrosis cause?
|
vasoconstriction
tubular damage obstruction backleak reduction in GFR |
|
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What are the 3 phases of acute tubular necrosis?
|
initiating
maintenance recovery |
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What happens during the initiation phase of acute tubular necrosis?
|
correct prerenal factors
identify/remove potential nephrotoxins anticipate high risk situations for ATN can get blood volume up but can't remove myoglobin |
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What increases during the maintenance phase of acute tubular necrosis?
|
BUN
creatinine potassium calcium phosphate |
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What are S/S that can occur during the maintenance phase of acute tubular necrosis?
|
anorexia, nausea, vomiting, erosive ulcers, GI bleeding, fluid overload, pericarditis, HTN, lethargy, confusion, stupor, coma, asterixis, myoclonus, anemia, bleeding tendency, pulmonary/renal/wound infection
|
|
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What happens during the recovery phase of acute tubular necrosis?
|
-typically creatinine rises steadily, plateaus, then starts to decline
-BUN frequently lags behind creatinine recovery |
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What is usually the first sign of recovery from acute tubular necrosis?
|
increased urine output
|
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What are indications for dialysis?
|
uremic symptoms/signs
volume overload (hypoxemia) acidosis hyperkalemia not responsive |
|
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What are the essentials of diagnosis for acute interstitial nephritis?
|
fever
transient maculopapular rash sterile pyuria white blood cell casts hematuria |
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What is acute interstitial nephritis?
|
sudden onset of renal dysfunction associated with prominent inflammation within the interstitium
|
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What are the causes of acute interstitial nephritis?
|
drugs (esp. antibiotics & NSAIDs)
some infections leptospirosis Legionnaire's disease mononucleosis |
|
|
Does acute pyelonephritis commonly cause renal failure?
|
no
-due to presence of interstitial inflammation BUT inflammation is due to direct bacterial invasion & associated w/ Sx of fever, chills, flank pain, & toxicity |
|
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Are HTN & edema common in acute interstitial nephritis?
|
no
|
|
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What type of stain is used to identify urine eosinophils for acute interstitial nephritis?
|
Wright or Hansel stain
|
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How is acute interstitial necrosis managed?
|
stop offending agent
wait wait a little longer be patient steroids |
|
|
What are the essentials of diagnosis for thrombotic thrombocytopenic purpura?
|
-thrombocytopenia
-microangiopathic hemolytic anemia -normal coagulation tests -elevated serum lactate dehydrogenase -von Willebrand factor deficiency *renal insufficiency |
|
|
Are thrombotic thrombocytopenic purpura and hemolytic uremic syndrome differetials for each other?
|
yes
|
|
|
How is thrombotic thrombocytopenic purpura treated?
|
emergent large-volume plasmapheresis*
-plasma removed & replaced w/ fresh-frozen plasma, continued daily until com;ete remission |
|
|
What are the essentials of diagnosis for hemolytic uremic syndrome?
|
-microangiopathic hemolytic anemia
-thrombocytopenia *renal failure (microangiopathy) -may be oliguric -elevated LDH -normalcoagulation tests -absence of neurologic abnormalities |
|
|
In children, what does hemolytic uremic syndrome frequently occur after?
|
diarrheal illness due to Shigella, Salmonella, E. coli, or viruses
|
|
|
In adults, what is hemolytic uremeic syndrome often precipiated by?
|
estrogen use or postpartum state
|
|
|
Are there neurologic manifestations with hemolytic uremic syndrome?
|
no
-other than those due to uremia (unlike TTP) |
|
|
What type of diagnostic procedure should be done for hemolytic uremic syndrome?
|
kidney biopsy (thrombi in afferent arterioles and glomeruli)
|
|
|
What may occur with obstruction from intravascular coagulation with hemolytic uremic syndrome?
|
ischemic necrosis
|
|
|
What is the treatment for hemolytic uremic syndrome?
|
-large volume plasmapheresis (better outcome in adults)
children -HUS is almost always self-limited |
|
|
What is a major complication of hemolytic uremic syndrome?
|
chronic renal insufficiency
|
|
|
What are the causes of chronic renal failure?
|
diabetes mellitus
HTN chronic glomerulonephritis polycystic kidney disease interstitial nephritis lupus nephritis |
|
|
What are 3 things that chronic renal failure can be characterized by?
|
-decreased functioning nephron mass of any cause
-structural & functional hypertrophy of remaining nephrons -hyperfiltration secondary to compensatory capillary pressures & flows |
|
|
Does acute or chronic renal failure have a Hx of normal renal function?
|
acute
|
|
|
Does acute or chronic renal failure have a Hx of altered renal function?
|
chronic
|
|
|
Does acute or chronic renal failure have normal sized kidneys?
|
acute
|
|
|
Does acute or chronic renal failure have small kidneys?
|
chronic
|
|
|
Does acute or chronic renal failure have normal echotexture?
|
acute
|
|
|
Does acute or chronic renal failure have increased echogenicity?
|
chronic
|
|
|
Does acute or chronic renal failure have normal to slightly decreased Hct?
|
acute
|
|
|
Does acute or chronic renal failure have anemia of chronic disease?
|
chronic
|
|
|
Does acute or chronic renal failure has a normal PTH?
|
acute
|
|
|
Does acute or chronic renal failure have increased PTH?
|
chronic
|
|
|
Does acute or chronic renal failure show an acute process on renal biopsy?
|
acute
|
|
|
Does acute or chronic renal failure show a chronic scarring on renal biopsy?
|
chronic
|
|
|
Does acute or chronic renal failure often have active urine sediment?
|
acute
|
|
|
Does acute or chronic renal failure show chronic findings on urinalysis?
|
chronic
|
|
|
What is normal GFR?
|
100-125 ml/min
|
|
|
What is the normal rate of creatinine excretion?
|
15-20 mg/kg
|
|
|
What is the "normal" 24 hour urine volume?
|
~1.5liters
|
|
|
What is the 5th stage of chronic renal failure?
|
kidney failure/ESRD
-GFR <15 |
|
|
How can the progression of chronic renal failure be delayed?
|
-good control of primary etiologic process
-good HTN control -avoidance of nephrotoxins -"blunting" of the hyperfiltration compensatory mechanisms |
|
|
What metabolic derangements need to be managed in chronic renal failure?
|
-metabolic acidosis (uremic & hyperchloremic)
-Ca2+/PO4 imbalance -water balance |
|
|
What dermatologic disorders are associated with chronic renal failure?
|
*uremic pruitis
xerosis skin discoloration |
|
|
How is uremic pruitus associated with chronic renal failure treated?
|
*UV light
antihistamines doxepin |
|
|
What can uremic pericarditis cause with chronic renal failure?
|
*cardiac tamponade (neck vein distension, dec. pulse pressure, pulsus paradoxus)
arrhythmias death |
|
|
What are the metabolic effects of uremia associated with chronic renal failure?
|
hypothermia
carbohydrate metabolism protien "intoleranace" hypertriglyceridemia |
|
|
What is excreted into the blood with protein "intolerance" associated with chronic renal failure?
|
nitrogenous waste products
|
|
|
What happens with hypertriglyceridemia?
|
-decreased rate of removal from circulation (not corrected by dialysis)
-*accelerated atherosclerosis (accl. cardiac disease) |
|
|
What is the most common result of metabolic derangement with water balance in chronic renal failure?
|
*hyponatremia
-hypotonic b/c cannot concentrate the urine |
|
|
How is hyponatremia associated with metabolic derangement of water balance in chronic renal failure usually managed?
|
*fluid restriction
|
|
|
What are the indications for dialysis for chronic renal failure?
|
*major bleeding episode
*uremic pericarditis *uremic neuropathy uremic syndrome volume overload unresponsive to diuretics hyperkalemia resistant to therapy severe metabolic acidosis |
|
|
What GFR level is an indication for dialysis in diabetic chronic renal failure patients?
|
10-15 ml/min
|
|
|
What GFR level is an indication for dialysis in non-diabetic chronic renal failure patients?
|
8-10 ml/min
|
|
|
Is periotoneal dialysis or a hemodialyzer usually used first with chronic renal failure?
|
peritoneal dialysis
|
|
|
What is critical to be given to chronic renal failure patients in order to help avoid infectious agents?
|
vaccinations (flu, pneumonia, hepatitis)
|
|
|
How is uremic pericarditis associated with chronic renal failure treated?
|
intensive HD, intrapericardial steroids (to keep well hydrated), pericardial window
|
|
|
How is Ca2+/PO4 imbalance managed?
|
-dietary PO4 restriction
-Ca2+ based phosphate binders -non-calcium based phosphate binders -replacement of active vitamin D -calcium sensing receptor blockade |
|
|
CASE
A 64 yo man presents to your office because of feeling “poorly”. He has a history of longstanding HTN for which he took no medicine because “he felt fine” and 60 pk yr smoking hx. He c/o poor sleep, lack of energy, poor appetite, nausea, bad taste to the food, ankle edema, DOE, pruritus and memory problems. He brings a copy of his last lab work from his prior physician who he fired because he told him he would need dialysis soon. His creatinine was 14 mg/dl, BUN 122 mg/dl, Hgb 8.6 gm/dl, K+ 5.4 meq/l, bicarb 16 meq/l, Ca++ 7 mg/dl, PO4 8 mg/dl and PTH 678 pg/ml. His renal Ultrasound showed small, scarred, echogenic kidneys bilaterally with no obstruction. On exam, BP 198/108, HR 88. Positive findings include + JVD, bibasilar crackles, S4 gallop, pericardial friction rub, right carotid bruit, bilateral femoral artery bruits, 2+ LE edema and multiple excoriations from scratching. |
chronic renal failure
-uremic syndrome |
|
|
What must be the primary consideration in any male complaining of testicular pain?
|
testicular torsion
|
|
|
Is the left side or the right side more common with testicular torsion?
|
left side
|
|
|
What is the epidemiology of testicular torsion?
|
-Age < 35
-usually adolescents or neonates -Rare after age 20 |
|
|
What are the S/S of testicular torsion?
|
-Severe pain, of sudden onset
-May have nausea & vomiting -NO FEVER -Testes in affected side lies higher in scrotum -Spermatic Cord feels thicker -SURGICAL EMERGENCY! |
|
|
How is pediatric testicular torsion repaired?
|
ischemic orchiectomy
|
|
|
What are the causes of hypogonadism?
|
-insufficient testosterone secretion by testes (MOST COMMON)
-Decreased gonadotropin secretion by pituitary -EtOH -Cushing’s chronic illnesses |
|
|
What are the S/S of hypogonadism?
|
-decreased libido, ED, fatigue, depression
-diminished sexual hair growth -decreased testicular mass -loss of muscle mass |
|
|
LH and FSH is high in patients with ___ ___ and low in patients with ___ ___.
|
testicular dysfunction
pituitary disorders |
|
|
What are the diagnostic studies for hypogonadism?
|
-Morning serum testosterone level
-LH and FSH |
|
|
How is hypogonadism managed?
|
evaluation for prostate CA
replacement of testosterone |
|
|
What diagnostic technique is used for testicular torsion?
|
Color flow Doppler
|
|
|
What are 3 types of hypospadias?
|
anterior
middle posterior |
|
|
What typically accompanies the more severe forms of hypospadias?
|
Chordee or penile curvature
|
|
|
What is cryptorchidism?
|
a condition in which one or both testes fail to descend into the scrotum
|
|
|
What is the most common congenital condition involving the testes?
|
CRYPTORCHIDISM
|
|
|
What are 2 big concerns for cryptochidism?
|
Impaired fertility
Risk of Testicular Cancer |
|
|
What tests are used to diagnose cryptochidism?
|
-no testis detected w/ palpation of scrotum
-CT -U/S |
|
|
What is a hydrocele?
|
a collection
of fluid within the tunica vaginalis |
|
|
What is the most common cause of scrotal swelling?
|
hydrocele
|
|
|
What are 8 clinical things to remember about hydroceles?
|
painless swelling
feels like "weight in testes" transilluminates no scrotal erythema any age no infertility no dyuria no systemic symptoms |
|
|
What are 4 conditions that hydroceles occur with?
|
Epididymitis
Trauma Hernia Tumor |
|
|
What is a varicolcele?
|
Dilation of veins within
the Spermatic cord (Pampiniform plexus |
|
|
With a varicocele, swelling can ___ with lying down, can ___ with standing upright.
|
collapse
refill |
|
|
What side is a varicocle more common?
|
left (95%)
|
|
|
What may a varicocle feel like to the patient?
|
“weight in the testes” or “bag of worms”
|
|
|
What are the clinical facts to remember about a varicocele?
|
No scrotal erythema
No pain (usually) DOES NOT transilluminate Most common after puberty No dysuria No systemic symptoms In older men = think bladder/renal tumor CAN CAUSE INFERTILITY |
|
|
What are the 2 types of erectile dysfunction?
|
psychogenic
organic |
|
|
What are 6 causes of organic erectile dysfunction?
|
Vascular
Endocrine Neurologic Medications Alcoholism Postsurgical changes |
|
|
What does abrupt onset of erectile dysfunction suggest?
|
psychogenic cause
|
|
|
What is a gradual onset of erectile dysfunction more indicative of?
|
systemic disease
|
|
|
What type of diagnostic studies can be used for erectile dysfunction?
|
Fasting blood glucose – diabetes
Serum testosterone Blood pressure Duplex ultrasound Nocturnal penile rigidity monitoring Psychological and neurological evaluation |
|
|
What types of therapies can be used for erectile dysfunction?
|
Devices
Oral medications -Yohimbine -Trazodone -Sildenafil (Viagra) Testosterone replacement as indicated Intracorporeal injection therapy Psychotherapy |
|
|
What is phimosis?
|
inability to retract the prepuce
|
|
|
How is phimosis treated if the prepuce does not retract?
|
-corticosteroid cream
-circumcision (if doesn't retract by age 10 or if there is ballooning of the foreskin during voiding) |
|
|
When does paraphimosis occur?
|
when the foreskin is retracted behind the coronal sulcus and the prepuce cannot be pulled back over the glans
|
|
|
HOw is paraphimosis treated?
|
lubrication of the foreskin and glans and then compressing the glans and simultaneously placing distal traction on the foreskin to try to push the phimotic ring beyond the coronal sulcus
|
|
|
What is torn with a penile fracture?
|
traumatic rupture of the corpus cavernosum
-tunica albuginea is torn |
|
|
What is Peyronie's disease?
|
hard, non-tender, subcutaneous
plaques on dorsal or lateral aspect of the penis; plaques may be single or multiple, causing a painful bending with erection; most common 45 y.o. and older |
|
|
What side is testicular cancer most common?
|
right side
|
|
|
What are the most common ages of testicular cancer?
|
15-30
|
|
|
What is the most common cause of bilateral testicular tumors?
|
malignant lymphoma
|
|
|
What is the most common type of testicular cancer?
|
Seminoma
|
|
|
What are 3 risk factors of testicular cancer?
|
Cryptorchidism
Caucasian race Son whose mother took DES during pregnancy |
|
|
What are 3 S/S to look for with testicular cancer?
|
Low back pain
Cough Lower extremity swelling due to lymphatic obstruction |
|
|
What is the staging for testicular cancer?
|
Tumor
Nodes Metastasis |
|
|
How is testicular cancer managed?
|
-Orchiectomy and retroperitoneal radiation therapy
-EARLY DETECTION |
|
|
What are 6 symptoms of obstructive BPH?
|
weak stream
hesitancy dribbling straining intermittency incomplete voiding |
|
|
What are 4 symptoms of irritative BPH?
|
frequency
nocturia urgency incontinence |
|
|
What are the risk factors of prostate carcinoma?
|
Strong family Hx
Environment factors Dietary factors ? High serum testosterone levels ? Other unknown factors |
|
|
What are the symptoms of metastases of prostate carcinoma?
|
Bone pain
Weight loss Anemia Azotemia Fatigue Dyspnea Lymphedema Lymphadenopathy Ureteral obstruction Neurologic symptoms |
|
|
Only ___% of palpable prostate nodules are cancer.
|
50
|
|
|
Is Prostatic Acid Phosphatase (PAP) levels a predictive tumor marker?
|
no
-unreliable for a number of reasons |
|
|
What are 5 conditions that can cause elevated serum PAP levels?
|
Prostate carcinoma
Obstructing BPH Acute bacterial prostatitis prostatic abscess Prostatic infarct |
|
|
Where is renal pain usually located?
|
ipsilateral flank
-pain usually constant w/ infection |
|
|
Where is acute cystitis pain usually referred?
|
distal urethra
|
|
|
What is urgency?
|
sudden desire to void
|
|
|
What is dyuria?
|
painful urination, usually related to inflammation
|
|
|
What is urinary frequency?
|
increased number of voids during the day
|
|
|
What is nocturia?
|
increased number of voids during the night
|
|
|
Which kidney is lower in the body?
|
right
-lower pole may be palpable |
|
|
Is the left kidney generally palpable?
|
not unless enlarged
|
|
|
When is the bladder palpable?
|
filled with 150 ml of urine
|
|
|
What is better that palpation to detect bladder distention?
|
percussion
|
|
|
Does a full bladder percuss as dull or tympanic?
|
dull
|
|
|
What does alkaline urine in UTI suggest?
|
urea-splitting organism, most commonly Proteus mirabilis
|
|
|
What can produce false-negatives with Urobilinogen and bilirubin?
|
ascorbic acid
|
|
|
What can produce false-positives with Urobilinogen and bilirubin?
|
phenazopyridine
|
|
|
What does any positive glucose test require?
|
evaluation for diabetes
|
|
|
Even though ketones are not normal, what conditions may they be seen with?
|
fasting, postexercise states and pregnancy (and Atkin’s diet!!!)
|
|
|
What is nitrites in the urine usually caused by?
|
gram-negative bacteria reducing nitrate to nitrite
|
|
|
What is leukocyte esterase?
|
enzyme produced by white blood cells
|
|
|
What does a dipstick for blood measure?
|
intact RBCs, free hemoglobin and myoglobin
|
|
|
What is considered significant pyuria?
|
more that 5 WBCs per high power field
|
|
|
What is pyuria indicative of?
|
infection, stones, strictures, neoplasm, glomerulonephropathy or interstitial nephritis
|
|
|
What are epithelial cells in a urinalysis indicative of?
|
contamination
|
|
|
What are bacteria and yeast indicative of in urinalysis?
|
infection
|
|
|
What are red cell casts seen with?
|
glomerulonephritis or vasculitis
|
|
|
What are white cells casts indicative of?
|
pyelonephritis
|
|
|
What do epithelial casts represent in urinalysis?
|
may be normal in small numbers; many casts indicate renal disease
|
|
|
What causes granular casts?
|
result from the breakdown of other cellular casts; also indicates renal disease
|
|
|
Are crystals in urinalysis normal?
|
sometimes
|
|
|
What are the 3 essentials of diagnosis for epididymitis?
|
-Fever
-Irritative voiding symptoms -Painful enlargement of epididymis |
|
|
What are the 2 categories of epididymitis?
|
sexually transmitted
-associated w/ urethritis -usually men <40 y.o. -Most commonly C. trachomatis or N. gonorrheae Non-sexually transmitted -Older males Associated with UTI/prostatitis Gram negative rods |
|
|
What do the labs for epididymitis show?
|
Leukocytosis with left shift
Pyuria/bacteriuria/hematuria Scrotal U/S if needed |
|
|
How is epididymitis treated?
|
-Bed rest with scrotal elevation
-Sexually transmitted: ceftriaxone + doxycycline -Non-sexually transmitted: ciprofloxacin (Bactrim is alternative) |
|
|
What may delayed Tx of epididymitis result in?
|
Decreased fertility
Abscess formation |
|
|
What are the 5 essentials of diagnosis for acute bacterial prostatitis?
|
Fever
Irritative voiding symptoms Perineal or suprapubic pain Exquisite tenderness on rectal examination Positive urine culture |
|
|
What type of bacteria generally causes acute bacterial prostatitis?
|
Gram negative rods (E. coli and Pseudomonas)
|
|
|
What do the labs show for acute bacterial prostatitis?
|
Leukocytosis with left shift
U/A with pyuria, bacteriuria and hematuria Urine culture positive |
|
|
How is acute bacterial prostatitis treated?
|
-IV ampicillin and gentamicin until urine culture and sensitivities are available
-Once afebrile for 24-48 hours, switch to ciprofloxacin -For urinary retention, percutaneous suprapubic tube is required -Follow up urine culture to ensure resolution |
|
|
What are the 3 essentials of diagnosis for chronic bacterial prostatitis?
|
-Irritative voiding symptoms
-Perineal or suprapubic discomfort, usually dull in nature -Positive expressed prostatic secretions and culture |
|
|
What causes chronic bacterial prostatitis?
|
-May evolve from acute infection
-Usually Gram negative rods or Enterococcus |
|
|
How is chronic bacterial prostatitis treated?
|
-Ciprofloxacin OR Septra
-NSAIDS and sitz baths for comfort |
|
|
What is the prognosis for chronic bacterial prostatitis?
|
Difficult to cure
Symptoms can be controlled by suppressive antibiotic therapy |
|
|
What are the 3 essentials of diagnosis for nonbacterial prostatitis?
|
-Irritative voiding symptoms
-Perineal or suprapubic discomfort, usually dull in nature -Positive expressed prostatic secretions with negative culture |
|
|
What is the most common of the prostatitis syndromes?
|
nonbacterial
|
|
|
What is the treatment for nonbacterial prostatitis?
|
Trial of antibiotics: Erythromycin
NSAIDS and sitz baths |
|
|
What is the prognosis for nonbacterial prostatitis?
|
May recur
No serious sequelae |
|
|
What is prostatodynia?
|
-Non-inflammatory disorder
-Affects young and middle-aged men -prostate is actually normal -symptoms same as chronic prostatitis without Hx of UTI -Hesitancy and interruption of flow -Physical exam usually normal -Possible increased anal sphincter tone -Possible periprostatic tenderness |
|
|
How is prostatodynia treated?
|
Alpha blockers
Biofeedback and diazepam Sitz baths |
|
|
What are nosocomial urinary tract infections often due to?
|
more resistant bacteria
|
|
|
With UTI, ___ bacteria in most non-nosocomial infections and is easily treated.
|
Coliform
|
|
|
Is the urinary tract sterilized with unresolved bacteriuria?
|
never
|
|
|
What happens with persistent bacteriuria?
|
urinary tract is initially sterilized but there remains a persistent source of infection
|
|
|
What is urinary reinfection?
|
new infection with same or different pathogen
|
|
|
Where is ascending infection from?
|
from the urethra; most common route
|
|
|
What are the female specific susceptibility factors? (3)
|
-Short urethra
-Women with recurrent infections have more adhesive receptors -Women who lack fucosyltransferase activity (“non-secretors”) are more prone to UTI |
|
|
What are the male specific susceptibility factors? (3)
|
-Higher incidence seen in uncircumsized males
-Male prostate normally secretes zinc which reduces ascending infection -Men with bacterial prostatitis have lower zinc levels |
|
|
What is acute cystitis?
|
-Infection of the bladder; most likely due to coliform bacteria
-Usually from an ascending source |
|
|
What is viral cystitis from?
|
adenovirus sometimes seen in children; rare in adults
|
|
|
What are the S/S of acute cystitis?
|
irritative voiding symptoms and suprapubic discomfort
|
|
|
When is imaging needed for acute cystitis?
|
pyelonephritis, recurrent infections, suspected abnormalities of anatomy
|
|
|
What does U/A for acute cystitis show?
|
pyuria and bacteriuria; also may be hematuria
|
|
|
Even though acute cystitis is rare in men what does it imply if found?
|
pathological process like infected stones, prostatitis or chronic urinary retention
|
|
|
What are 4 noninfectious causes of acute cystitis?
|
pelvic irradiation chemotherapy
carcinoma interstitial cystitis |
|
|
How is acute cystitis treated?
|
-nitrofurantoin or fluoroquinolones
-Warm sitz baths or urinary analgesics (phenazopyridine) |
|
|
What conditions are being evaluated with renal U/S in pediatric UTI?
|
gross structural defects, lesions that are obstructive, positional abnormalities, renal size/growth
|
|
|
When is VCUG done for pediatric UTI?
|
when patient is asymptomatic and cleared of bacteriuria to evaluate for vesicoureteral reflux; indicated in all boys, girls <5 years and those >5 years with recurrent or febrile
|
|
|
What is indicated in children with an abnormal VCUG or renal sonography?
|
DMSA
|
|
|
What complications has asymptomatic bacteriuria been associated with in pregnancy?
|
low birth weight
preterm delivery hypertension preeclampsia maternal anemia |
|
|
How is UTI in pregnancy treated?
|
nitrofurantoin, ampicillin, cephalosporins, and short-acting sulfa drugs
-sulfa drugs should be avoided near term |
|
|
What is the most common non-obstetric cause of hospitalization during pregnancy?
|
pyelonephritis
|
|
|
What do patients with recurrent UTI or pyelonephritis during pregnancy need?
|
radiographic evaluation of the upper urinary tract when they are 3 months post-partum
|
|
|
What type of renal problem has been implicated as a cause of fetal death and intrauterine growth restriction (IUGR)?
|
recurrent pyelonephritis
|
|
|
Does the initial treatment of pyelonephritis in pregnant women require hospitalization?
|
yes
|
|
|
What are the 4 essentials of diagnosis for acute pyelonephritis?
|
Fever
Flank pain Irritative voiding symptoms Positive urine culture |
|
|
What causes acute pyelonephritis?
|
-Most common causes are gram negative bacteria
-Infection usually ascends from the lower urinary tract |
|
|
What are the S/S of acute pyelonephritis?
|
Fever/shaking chills
Flank pain Dysuria, urgency, frequency CVA tenderness Tachycardia May be associated N/V and/or diarrhea |
|
|
How is acute pyelonephritis treated?
|
-Hospitalization for severe infections
-IV ampicillin + gentamycin if severe -Outpatient: ciprofloxacin -Antibiotics may be tailored to culture results |
|
|
What are 4 complications of acute pyelonephritis?
|
Sepsis with shock
Renal scarring Chronic pyelonephritis Renal abscess |
|
|
What is the prognosis of acute pyelonephritis?
|
Usually good
Complicating factors may have less favorable outcome |
|
|
What is the 3rd most common type of renal disease?
|
nephrolithiasis
|
|
|
What are the 4 major types of kidney stones?
|
calcium 80%
uric acid struvite cystine |
|
|
What are the risk factors for nephrolithiasis?
|
Gout
Chronic UTI’s Family Hx Medications (Antacids, Loop diuretics, Vitamin C in large doses, EtOH) |
|
|
What type of stones does a urinalysis that shows a ph<5 correlate with?
|
uric acid or cystine stones
|
|
|
What type of stone does a urinalysis that shows a ph>7.5 correlate with?
|
struvite
|
|
|
What type of stone will not show up on KUB x-ray?
|
uric acid
|
|
|
What type of diagnositic studies are used for acute nephrolithiasis?
|
Renal U/S
IV pyelography (IVP) |
|
|
How is acute nephrolithiasis treated?
|
-Initial management fluids and analgesics
-Most stones < 5 mm will pass spontaneously |
|
|
What are 5 indications for kidney stone removal?
|
Intractable pain
Severe obstruction Serious bleeding Infection Stones > 10 mm |
|
|
What are 3 methods of kidney stone removal?
|
-Retrograde passage of a flexible basket
-Pyelolithotomy and ureterolithotomy -Lithotripsy |
