Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
150 Cards in this Set
- Front
- Back
|
What are the functions of the kidney?
|
Water and electrolyte balance, metabolic waste excretion, blood pressure control, erythropoietin, acid base balance, excretion of drugs and hormones, activation of vitamin D and gluconeogenesis
|
|
|
What does a urine dipstick evaluate?
|
Ph, blood, protein, leukocytes, nitrites, urobilogen and specific gravity
|
|
|
When might urine pH be higher (time of day)?
|
Late afternoon
|
|
|
What’s the normal pH range of urine?
|
4.5 to 8.5
|
|
|
What causes alkaline urine?
|
Bacteriuria, renal failure, presence of abx and sodium bicarb and a diet high in vegetables, citrus fruits and dairy products
|
|
|
What causes acidic urine?
|
Acidosis, presence of certain drugs, out of control DM, starvation, diarrhea and high protein diet
|
|
|
T or F: Neg nitrites rules out UTI?
|
False – poor sensitivity
|
|
|
T or F: Pos nitrites means pos UTI?
|
True – high specificity
|
|
|
What’s a more sensitive indicator for UTI than nitrites?
|
Leukocyte esterase
|
|
|
What’s the definition of hematuria?
|
1+ of higher reaction on urine dipstick for blood, greater than 5 RBCs/HPE in 3 consecutive fresh centrifuged urine specimens over a 2-3 week period
|
|
|
What is the dipstick reacting to when assessing hematuria?
|
Hemoglobin
|
|
|
How does hematuria get discovered?
|
Onset of gross hematuria, onset of other urinary symptoms or others with incidental finding of microscopic hematuria, inadvertent discovery of microscopic hematuria during routine UA
|
|
|
What causes a false negative for hematuria?
|
Formalin (urine preservative) and high urine concentration of ascorbic acid
|
|
|
What causes a false positive for hematuria?
|
Peroxidase (skin cleaner), alkaline urine with pH greater than 9, menses, fever and exercise
|
|
|
What is pigmenturia?
|
Discolored urine
|
|
|
What foods cause pigmenturia?
|
Rhubarb, beets, blackberries, blueberries, paprika, fava beans and food dyes
|
|
|
What meds cause pigmenturia?
|
Rifampin, nitrofuratin, sulfas, metronidazole, phenytoin, quinine, chloroquine, levedopa, methyldopa and deforoxamide
|
|
|
When do pts get UA?
|
In preschool and sexually active adolescent
|
|
|
What are the 4 groups of hematuria?
|
1. Gross hematuria, 2. Microscopic hematuria with clinical symptoms, 3. Asymptomatic hematuria and 4. Asymptomatic microscopic hematuria with proteinuria
|
|
|
What does tea/smoky color of urine indicate?
|
Nephrologic disorder
|
|
|
What does 1+ heme equal in RBCs?
|
At least 3
|
|
|
What doe the presence of RBC casts indicate?
|
Glomerular disease
|
|
|
What do you do when you find protein in urine?
|
Send to nephrology
|
|
|
What tests do you want to do with hematuria?
|
UA, culture, CBC w/diff, ppd, C3, C4, ANA, ASO, Dnase B test and renal u/s
|
|
|
How do you measure urinary protein?
|
Dipstick measures albumin (does not measure low molecular weight protein), 24 hour protein (difficult), spot urine for creatinine ratio preferable in a first morning urine
|
|
|
What’s normal Cr ratio?
|
6-24 mos: 0.5, over 2 years: 0.2
|
|
|
What are the hx questions for gross hematuria?
|
Color of urine, clots of blood, when during micturation, changes in urinary pattern, dysuria, increase or decrease in output, swelling at ankles, abdomen or eyes, headaches, fatigue, chest pain, dizziness, new medications, recent pharyngitis or skin infection
|
|
|
What are the glomerular causes of gross hematuria?
|
Post-strep glomerularnephritis, IgA nephropathy, Alport’s syndrome and thin basement membrane
|
|
|
What are the systemic causes of gross hematuria?
|
HSP, lupus nephritis, HUS, Wegener’s granulomatosis, Goodpasture disease
|
|
|
What are the Neoplastic causes of gross hematuria?
|
Wilm’s Tumor and renal cell carcinoma
|
|
|
What are the vascular causes of gross hematuria?
|
Trauma, SCD with trait and renal artery/vein thrombosis
|
|
|
What are the UTI causes of gross hematuria?
|
Drug induced hemorrhagic cystitis, UTI, hypercalciuria and UPJ obstruction
|
|
|
What’s the most common type of chronic glomerular nephritis?
|
IgA nephropathy
|
|
|
What happens in IgA nephropathy?
|
Globular deposits of IgA in the mesangium and along the glomerular capillary wall
|
|
|
What are the symptoms of IgA nephropathy?
|
Gross hematuria, proteinuria, edema, hypertension and may be asymptomatic microscopic hematuria
|
|
|
What’s the classic hx of IgA nephropathy?
|
Intermittant gross hematuria triggered by URI, presents with protein or nephritic syndrome
|
|
|
T or F: IgA Nephopathy is progressive?
|
True
|
|
|
How do you dx IgA nephopathy?
|
Renal u/s
|
|
|
IgA nephropathy with will have recurrent episodes of painless _______ hematuria.
|
Macroscopic
|
|
|
How long does an episode of hematuria last in IgA Nephropathy last?
|
72 hours
|
|
|
What will be normal in IgA nephropathy?
|
BP and C3 (all complements)
|
|
|
What should be monitored in IgA nephropathy?
|
Cr, BUN, CBC, IgA
|
|
|
Is there an accepted tx for IgA Nephropathy?
|
No
|
|
|
What are tx options for IgA nephropathy?
|
ACE-I if they have proteinuria, steroids, fish oil and tonsillectomy
|
|
|
What % of pts with IgA nephropathy progress to ESRD?
|
20-30
|
|
|
What are the general symptoms associated with microscopic hematuria?
|
Fever, fatigue, weight loss, edema and HTN
|
|
|
What are the non urinary tract specific symptoms of microscopic hematuria?
|
Rash, purpura, arthritis, jaundice and GI
|
|
|
What are the urinary tract specific symptoms associated with microscopic hematuria?
|
Dysuria, frequency and abdominal pain
|
|
|
What are the etiologies of microscopic hematuria?
|
Infection (systemic or GU), rheumatologic, immunologic, glomerular, interstitial disease, lower UTI, stones, tumors, hematologic disease, drugs and medications
|
|
|
What does Post Strep glomerularnephritis look like on exam/hx?
|
Cola or tea colored urine lasting a few days, microscopic hematuria, HTN, edema, fatigue, proteinuria, pt had pharyngitis or impetigo about 2-3 weeks prior, ASO titer will be elevated, C3 and maybe C4 will be low
|
|
|
What happens in Post Strep Glomerular nephritis?
|
Antigens produced by certain group A and Beta hemolytic strep causing complement activation and immune complex deposition within the glomeruli, immune complex causes inflammation and leads to hematuria
|
|
|
What should be monitored in Post Strep Glomerularnephritis?
|
Cr, BUN, CBC, C3 and C4 (should begin to normalize in 6-8 weeks) and UA (gross hematuria for up up 6mos)
|
|
|
What kind of supportive therapy do pts with Post Strep Glomerular Nephritis need?
|
HTN control
|
|
|
T or F: Post Strep Glomerularnephritis has a poor prognosis?
|
False, good prognosis
|
|
|
T or F: Significant renal disease is very rare if there is only microscopic hematuria
|
True
|
|
|
What’s the workup for hematuria?
|
UA, culture and sensitivity, CBC, Cr, BUN, electrolytes, C3, C4, PT, PTT, immunoglobulins, ASO, ANA, streptozyme and renal and bladder u/s
|
|
|
What % of pts with kidney stones have HCU?
|
30-50
|
|
|
What do you need to measure in a pt with HCU?
|
Ca/Cr ratio
|
|
|
How do you manage HCU?
|
Very conservative – only increase fluid intake
|
|
|
T or F: Restricting dietary intake has an effect on urinary calcium excretion?
|
False
|
|
|
How does a thiazide diuretic help in HCU?
|
Reduces urinary Ca excreted but this is reserved for pts with nephrolithiasis
|
|
|
How do you test for HCU?
|
24 hour collection is gold standard but random specimen is fine
|
|
|
T or F: Microscopic hematuria causes proteinuria?
|
False
|
|
|
What is proteinuria suggestive of?
|
Renal glomerular or tubulo-interstitial origin
|
|
|
What should you do with a pt with proteinuria?
|
Send to nephrology
|
|
|
What is hereditary nephritis associated with?
|
Sensorineural hearing loss
|
|
|
What is hereditary nephritis?
|
Heterogenous group of inherited renal diseases
|
|
|
What are the types of heredity nephritis?
|
Acute (post strep glomerularnephritis), Hereditary or familial nephritis (Alports, benign familial hematuria, thin basement membrane disease) and chronic (membranoproliferative GN)
|
|
|
Low protein excretion in the urine is related to?
|
Restriction of proteins across the capillary beds and reabsorption of freely filtered low molecular weight proteins by the proximal tubule
|
|
|
What is the rate of protein excretion?
|
150mg/day
|
|
|
T or F: Isolated asymptomatic proteinuria is uncommon in children and adolescents?
|
False, very common
|
|
|
What is the etiology of thin basement membrane nephropathy?
|
Genetic, autosomal dominant
|
|
|
What does thin basement membrane nephropathy look like on exam?
|
Persistent asymptomatic, microscopic hematuria, renal function usually remains normal and thin base membrane is seen on renal biopsy
|
|
|
How does Alport Syndome present?
|
Persistent asymptomatic hematuria with progression to proteinuria, can have neural hearing loss and ocular abnormalities
|
|
|
How do you dx Alport Syndrome?
|
By either skin or kidney biopsy
|
|
|
What’s the pathophys of Alport syndrome?
|
Abnormality in type 4 collagen that leads to secondary changes in glomerular basement membrane composition that predisposes to the development of glomerular nephritis
|
|
|
ESRD occur in males with Alport Syndrome between what ages?
|
16-35
|
|
|
What is the genetics of Alport Syndrome?
|
80% is X linked, 15% are autosomal recessive and 5% are dominant types
|
|
|
What’s the tx for Alport Syndrome?
|
ACE-I slows the proteinuria and renal replacement therapy
|
|
|
What do you need to monitor in Alport Syndrome?
|
Protein excretion, Cr, BUN and blood pressure
|
|
|
What should be done before you refer a pt for hematuria?
|
Repeat urine eval
|
|
|
Asymptomatic isolated microscopic hematuria has a _______ risk of significant renal disease.
|
Low
|
|
|
Patient who have hematuria and proteinura belong to who?
|
A nephrologist
|
|
|
Proteinuria is a marker of?
|
Renal disease
|
|
|
Small amounts of protein in the urine is _______.
|
Physiological
|
|
|
What’s the most accurate way to quantify protein in urine?
|
24 hour protein and calculating spot protein/Cr ratio
|
|
|
What’s the normal physiology of proteinuria?
|
Healthy children secrete protein in the urine, ½ comes from plasma and the rest originates from the renal tubules, filtration barrier consists of glomerular capillary wall, basement membrane and visceral epithelial cells
|
|
|
What is the mechanism of glomerular proteinuria?
|
Hemodynamic changes in glomerular blood flow, increase filtration of macromolecules across the glomerular capillary wall usually from a functional or anatomic lesion, may also be caused by glomerular disease, exercise, fever or orthostatic
|
|
|
What’s the mechanism of tubular or low molecular weight proteinuria?
|
Freely filtered at the glomerulus and subsequently absorbed and catabolized by proximal tubule, increased excretion of low molecular weight proteins such as beta 2 microglobulin, alpha 1 microglobulin and retinol binding protein that are reabsorbed in the tubule, tubulointerstitial diseases like Fanconi’s, glycosuria, proximal renal tubular acidosis with bicarb wasting and phosphaturia
|
|
|
What is the mechanism of overflow proteinuria?
|
Increased excretion of low molecular weight proteins due to overproduction of a protein to an amount that exceeds tubular reabsorptive capacity
|
|
|
What are good hx questions to ask about proteinuria?
|
How was it discovered, when did it start, changes in patterns, frequency, dysuria, color, malodorous, fluid intake, rash, bruising, swelling, swollen or painful joints, fam hx of renal disease, hearing problems, trauma, infection, failure to thrive and growth
|
|
|
What are the things to look at on physical when assessing proteinuria?
|
Swelling at eyes, extremities, testicles or vulva, blood pressure, rash, joint swelling, dyspnea, abdominal distention, early morning facial swelling that get better throughout day
|
|
|
If the urine sample has specific gravity of less than or equal to 1.015 and 1+ protein, what is this?
|
Proteinuria
|
|
|
If the urine sample has a specific gravity of greater than or equal to 1.015 and protein greater than 2, what is this?
|
Proteinuria
|
|
|
Since the dipstick method measures the concentration of urine protein, a false negative means?
|
Very dilute urine specimen sample
|
|
|
What can cause a false positive proteinuria?
|
Very alkalotic or concentrated urine, presence of contaminating antiseptics, radiographic contrast, presence of heavy mucus, blood, pus, semen or vaginal secretions
|
|
|
How does a urine protein/Cr ratio work?
|
Random urine specimen, more accurate quantification and normal ratio is less than 0.2
|
|
|
What is urine albumin/Cr ratio?
|
Normal albumin secretion is less than 20, 30-300 is abnormal but not detected by dipstick (microalbuminuria) and ratio of greater than .03 is abn
|
|
|
What’s the etiology of transient proteinuria?
|
Fever, dehydration, cold exposure, heart failure, serum sickness, epinephrine
|
|
|
What’s the etiology of tubulointerstitial disease with proteinuria?
|
Reflux nephropathy, Fanconi Syndrome, intersitial nephritis, renal dysplasia, ischemic tubular injury, drugs, toxin heavy metal and lithium gold aminoglycoside
|
|
|
What’s the etiology of glomerular proteinuria?
|
May be associated with hematuria, nephritic syndrome, IgA nephopathy, HSP, HUS, Alport, SLE, Vasculitis, HIV and Hep B and C
|
|
|
What’s the most common cause of proteinuria?
|
Orthostatic proteinuria
|
|
|
When is orthostatic proteinuria most common?
|
Adolescence
|
|
|
What causes orthostatic proteinuria?
|
Increase in protein excretion in the upright position but normal protein excretion in supine position
|
|
|
T of F: Pts with orthostatic proteinuria will have abnormal renal function?
|
False will be normal
|
|
|
What do you see in Nephrotic syndrome?
|
Protein excretion more than 1000mg/m2 or greater than 40 mg/kg/day, serum albumin less than 3.0, hypercholesterolemia, proteinuria and edema
|
|
|
What is the classic definition of nephritic syndrome?
|
Proteinuria that is severe enough to cause hypoalbuminemia and edema
|
|
|
What are the symptoms of nephritic syndrome?
|
Edema (initially early in the morning, disappears after ambulation), loss of appetite, diarrhea, edema of intestinal wall, ascites, abdominal pain and respiratory problems
|
|
|
What are the electrolyte disturbances associated with nephritic syndrome?
|
Hyponatremia, low serum calcium, normal ionized calcium and hyperlipidemia
|
|
|
What are the complications of nephritic syndrome?
|
Hypercoagulable state puts patient at risk for thrombolytic events, infections, HTN, peritonitis, hyponatremia, hypocalcemia, pleural effusions, marked ascites, tachycardia, peripheral vasoconstriction, oliguria, decreased GFR, elevated plasma renin aldosterone, norepinephrine and hypercoagulable state
|
|
|
What is primary/idiopathic nephritic syndrome?
|
Minimal change in disease, focal segmental glomerularsclerosis, membranoproliferative glomerularnephritis and membraneous nephropathy
|
|
|
What is secondary nephritic syndrome?
|
Caused by infections (i.e. Hepatitis B, C, HIV, syphilis, malaria and PSGN), drugs, connective tissue disease (SLE), vasculitis, metabolic diseases, cancer and inherited disorders
|
|
|
What are the indications for renal biopsy?
|
Nephrotic range persistent proteinuria, elevated serum Cr or worsening renal function, unresponsiveness to steroids
|
|
|
What’s the most common nephrosis?
|
Minimal change nephritic syndrome
|
|
|
What is minimal change nephritic syndrome caused by?
|
Loss of anion charge and fusion of the epithelial podocyst but no changes on microscopy
|
|
|
What’s the treatment for minimal change nephritic syndrome?
|
High dose steroids at 2mg/kg/day for 4-6 wks and then taper, urine dipsticks at home and lasix 1-2 mg/kg/dose for edema PRN
|
|
|
How do you tx minimal change nephritic syndrome if steroid resistant?
|
Often needs biopsy, low dose steroids, pulse methylpredisone IV, alkylating agent, cyclosporine, mycophenolate
|
|
|
How do you know a pt has steroid resistant nephritic syndrome?
|
Relapsing more than 4 times per year
|
|
|
What’s the most common primary glomerular disease causing ESRD?
|
Focal Segmental Glomerulosclerosis
|
|
|
What are the 3 types of Focal Segmental Glomerulosclerosis?
|
1. Primary – idiopathic nephritic syndrome, 2. Secondary – Response to glomerular hypertrophy or hyperfiltration caused by a vasculitis, lupus nephritis and focal proliferative glomerulonephritis and 3. Other – caused by HIV or drug toxicity
|
|
|
What is the prognosis of FSGS?
|
Depends on if it’s primary or secondary, untreated will progress to ESRD, prognostic factors are amount of proteinuria, response to treatment, degree of renal dysfunction and presence of interstitial fibrosis
|
|
|
What’s the tx for FSGS?
|
Depends on cause, high or low dose steroids, chemotherapeutic agents, immune modulating agents, ACE-I and transplantation
|
|
|
What is membranoproliferative glomerulonephritis?
|
A chronic glomerulonephritis
|
|
|
How can membranoproliferative glomerulonephritis present?
|
Nephrotic level of proteinuria, gross or microscopic hematuria and persistent proteinuria
|
|
|
What do you see on microscopy with membranoproliferative glomerulonephritis?
|
Thickening of the GBM due to immune complex deposits, proliferation of the mesangial and increase in monocytes
|
|
|
Hyper- or hypo-complementernia is seen with membranoproliferative glomerulonephritis?
|
Hypo
|
|
|
What % of pts with membranoproliferative glomerulonephritis will develop ESDR within 10-15 years?
|
50-60
|
|
|
What is the treatment for membranoproliferative glomerulonephritis?
|
Corticosteroids 2mg/kg every other day for 1 year then taper to a maintenance dose of 20mg every other day for 3-10 years. Also ACE-I and antiplatelet meds in adults
|
|
|
What is pheochromocytoma?
|
Catecholamine secreting tumor arising from chromatin cells of adrenal medulla
|
|
|
What is pheochromocytoma associated with?
|
Neuroectodermal syndromes and multiple endocrine neoplasia
|
|
|
How will a pheochromocytoma present?
|
Related to catecholamine release so, headache, palpitations, diaphoresis and hypertension
|
|
|
What’s the most common cause of acute renal in pediatrics?
|
Hemolytic Uremic Syndrome
|
|
|
When does HUS occur?
|
Summer months
|
|
|
Who gets HUS?
|
Kids between 6mos and 4 years, higher socioeconomic standing in the northern US and Canada
|
|
|
What’s the triad of HUS?
|
Acute renal failure, thrombocytopenia and microangiopathic hemolytic anemia
|
|
|
How long does it take to develop HUS?
|
About 1 week
|
|
|
What are the signs and symptoms of HUS?
|
Edema, oliguria, anuria, HTN, abdominal tenderness, altered level of consciousness, seizures, hallucinations, paresis, posturing and blindness
|
|
|
What % of pts develop seizures and coma with HUS?
|
20%
|
|
|
What are the infectious causes of HUS?
|
Ecoli (esp. verotoxin producing), shigella, aeromonas citrobacter, campylobacter, strep pneumonia and HIV
|
|
|
What are the non-infectious causes of HUS?
|
Idiopathic, inherited, drug related (oral contraceptives, cyclosporine, tacrolimus, mitomycin and chemo), pregnancy, malignant hypertension, malignancies and transplantation
|
|
|
What kind of electrolyte abnormalities will you see with HUS?
|
Hyponatremia, hyperkalemia, metabolic acidosis and hyperphosphatemia
|
|
|
You’ll see elevation of cardiac enzymes in HUS if?
|
There’s cardiac involvement
|
|
|
In HUS, what happens to urea nitrogen and creatinine levels?
|
They go up
|
|
|
What does a UA show with HUS?
|
Hematuria, proteinuria, pyuria and casts
|
|
|
T or F: there’s no anemia with HUS?
|
False, there’s moderate to severe anemia
|
|
|
What do you see on peripheral blood smear with HUS?
|
Schistocytes, burr cells, helmet cells, spherocytes and other red cell fragments
|
|
|
What does the hemolytic anemia of HUS cause?
|
Increased bilirubin, reticulocyte count and LDH, decreased hepatoglobulin, Coombs test negative, thrombocytopenia and leukocytosis with a shift to the left
|
|
|
When will a Coombs test be positive with HUS?
|
When caused by strep pneumonia
|
|
|
What are the poor prognostic factors of HUS?
|
Age greater than 2-3 years, BUN greater than 250, proteinuria, anuria more than 3 days, neuro symptoms more than 4 days, frequent transfusions, absence of prodrome, family history, persistent low platelets, pregnancy and severe HTN
|
|
|
What are the overall signs and symptoms of renal disease?
|
Fatigue, anorexia, poor growth, anemia and oliguria
|
