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184 Cards in this Set
- Front
- Back
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"doughy skin"
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hypernatremia
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when may serum calcium be falsely low?
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hypoalbuminemia
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how is oliguria defined?
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<500 cc/day
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cause of prerenal acute renal failure
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decreased renal perfusion
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cause of postrenal acute renal failure
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urinary outflow obstruction
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symptom of uremia
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mlaise, fatigue, confusion, oliguria, anorexia
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pericardial rub, asterixis, hypertension
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acute renal failure
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causes of prerenal failure
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hypovolemia, cardiogenic shock, sepsis, anaphylaxis, drugs, renal artery stenosis, cirrhosis with ascites
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causes of intrinsic renal failure
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ATN, acute/allergic interstitial nephritis, glomerulonephritis, thromboembolism
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causes of postrenal failure
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prostate disease, nephrolithiasis, pelvic tumors, recent pelvic surgery, retroperitoneal fibrosis
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what drug is classically associated with intrinsic renal failure?
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methicillin
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what kind of renal failure should you think of when you hear history of drug exposure (aminoglycosides, NSAIDs), contrast, myoglobin, myeloma protein
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intrinsic renal failure
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renal failure and subcutaneous nodules, livedo reticularis, digital ischemia
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intrinsic disease - atheroemboli
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what does FeNa <1% suggest?
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prerenal etiology
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what does UNa <20 suggest?
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prerenal
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a specific gravity above what suggests a prerenal etiology?
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1.020
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a BUN/Cr ratio above what suggests a prerenal etiology?
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20
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increased amount of hyaline casts suggests what type of ATN?
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prerenal/volume depletion
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red cell casts, dysmorphic red cells suggests what?
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glomerulonephritis
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white cells and eosinophils suggest what?
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allergic interstitial nephritis, atheroembolic disease
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granular casts, renal tubular cells, "muddy brown cast" indicates what?
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ATN - hb, myoglobin, toxins, ischemia
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white cells, white cell casts
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pyelonephritis
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what are the indications for urgent dialysis?
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AEIOU
Acidosis, Electrolyte abnormalities (e.g. hyperkalemia) Ingestions (salicylates, theophylline, methanol, barbituates, lithium, ethylene glycol) Overload (fluid) Uremic symptoms (pericarditis, encephalopathy, bleeding, nausea, pruritis, myoclonus) |
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oliguria, macro/microscopic hematura (smoky brown urine), hypertension, and edema
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nephritic syndrome
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what should you check in a patient with suspected nephritic syndrome?
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complement, ANA, ANCA, and anti-GBM antibody levels
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treatment for nephritic syndrome?
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treat HTN, fluid overload, and uremia with salt and water restriction, diuretics, and dialysis if necessary; corticosteriods are sometimes useful
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proteinuria, generalized edema, hypoalbuminemia, hyperlipidemia
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nephrotic syndrome
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level of proteinuria in nephrotic syndrome?
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>3.5 g/day
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1/3 of cases of nephrotic syndrome are due to what?
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systemic disease (DM, SLE, amyloidosis)
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patient who presents with edema and foamy urine
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nephrotic syndrome
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lumpy-bumpy immunofluorescence
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postinfectious glomerulonephritis
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level of C3 in post-strep GN
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low
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what do you check in suspected post-strep GN
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ASO titer
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treatment for post-strep GN?
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supportive
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level of C3 in Berger's disease
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normal
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most common cause of nephritic syndrome
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IgA nephropathy (Berger's)
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with what disease is IgA nephropathy sometimes associated?
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HSP
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young man wiht upper respiratory or GI infection and glomerulonephritis
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IgA nephropathy
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treatment for Berger's?
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glucocorticoids; ACEIs if have proteinuria
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what percent of patients with Berger's progress to end-stage renal disease?
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abotu 20%
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hemoptysis and nephritic syndrome
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Wegener's or goodpastures
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segmental necrotizing glomerulonephritis with few Ig deposits
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wegener's
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check what lab in suspected Wegener's
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C-ANCA
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glomerulonephritis with pulmonary hemorrhage
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anti-GBM disease/Goodpasture's
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linear anti-GBM deposits on immunofluorescence
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Goodpasture's
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glomerulonephritis with iron deficiency anemia hemosiderin-filled macrophages in sputum; pulmonary infiltrates on CXR
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Goodpasture's
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treatment for Goodpasture's
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plasma exchange; pulsed steroids
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asymptomatic hematuria with nerve deafness and eye disorders
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Alport's syndrome
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hereditary glomerulonephritis that presents in boys 5-20
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Alport's
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GBM splitting on EM
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Alport's
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prognosis of Alport's
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progresses to renal failure; anti-GBM nephritis may recur after transplant
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what does light microscopy show in minimal change disease?
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appears normal
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what does EM show in minimal change disease?
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fusion of epithelial foot processes with lipid-laden renal cortices
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causes of minimal change disease?
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usually idiopathic; NSAIDs, hematologic malignancies
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treatment for minimal change disease?
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steriods
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prognosis for minimal change disease
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excellent
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typical patient with focal segmental glomerular sclerosis
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young black male with uncontrolled HTN
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causes of focal segmental glomerular sclerosis
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idiopathic, IV drug use, HIV infection, obesity
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sclerosis in capillary tufts on renal biopsy
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focal segmental glomerular sclerosis
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treatment for focal segmental glomerular sclerosis
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prednisone, cytotoxic therapy
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most common nephropathy in caucasian adults
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membranous nephropathy
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nephrotic syndrome associated iwth HBV, syphillis, malaria, and gold
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membranous nephropathy
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secondary causes for membranous nephropathy
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solid tumor, immune complex disease
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spike and dome appearance
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membranous nephropathy - due to granular deposits of IgG and C3 at the basement membrane
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treatment for membranous nephropathy
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prednisone and cytotoxic therapy for severe disease
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thickened GBM, increased mesangial matrix
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diabetic nephropathhy
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nodular glomerulosclerosis
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Kimmelstiel-Wilson lesions (in diabetic nephropathy)
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2 forms of diabetic nephropathy
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diffuse hyalinization and nodular glomerulosclerosis
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seen with congo red stain; apple-green birefringence under polarized light
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renal amyloidosis
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patients with renal amyloidosis may have what other conditions
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multiple myeloma or chronic inflammatory disease, e.g. RA
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treatment for renal amyloidosis
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prednisone
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histology classic for membranoproliferative nephropathy
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tram-track double-layered basement membrane; type I has subendothelial deposits and mesangial deposits
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level of C3 in membranoproliferative nephropathy
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low (type II by way of C3 nephritic factor)
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what is associated with HCV, cryoglobulinemia, lupus, and SBE
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membranoproliferative nephropathy
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level of albumin in nephrotic syndrome
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less than 3.5g/dL
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what are patients with nephrotic syndrome at increased risk for?
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infection with strep pneumo - give vaccine
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with drug is used in nephrotic syndrome
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ACEIs - decrease proteinuria and diminish progression of renal disease in pts with diabetic nephropathy
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risk factors for nephrolithiasis
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family hx, low fluid intake, gout, post-colectomy/ileostomy, specific enzyme disorders, RTA, and hyperPTH
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what does UA commonly show in nephrolithiasis
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gross or microscopic hematuria and altered urine pH
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treatment for nephrolithiasis
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initially: hydration and analgesia
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what size stones can pass through the urethra?
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<5mm
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in what other organs are cysts found in PKD?
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spleen, liver, pancreas
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renal failure, liver fibrosis, portal HTN in infants/young children
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PKD (autosomal recessive form)
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most common presenting symptoms of PKD
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pain and hematuria
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additional findings in PKD
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HTN, hepatic cysts, cerebral berry aneurysms, diverticulosis, and MV prolapse
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most common form of RTA
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type IV
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defect in type I RTA
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decreased H+ secretion
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defect in type II RTA
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increased HCO3- reabsorption
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defect in Type IV RTA
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aldosterone deficiency or resitstance that leads to defects in Na+ reabsorption, H+ and K+ excretion
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serum K+ in type I RTA
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high or low
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serum K+ in type II RTA
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low
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serum K+ in type IV RTA
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high
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urinary pH in type I RTA
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>5.3
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urinary pH in type II RTA
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5.3 initially, then <5.3 once serum is acidic
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urinary pH in type IV RTA
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<5.3
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amphotericin, dirrhosis, AI disorders, sickle cell, lithium are all causes of what type of RTA
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type I
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carbonic anhydrase inhibitors, Fanconi's syndrome, and multiple myeloma are all causes of what type of RTA?
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type II
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hyporeninemic hypoaldosteronism, chronic kidney disease from DM, HTN, and HIV can call cause which type of RTA
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type IV
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treatment for types I and II RTA
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potassium citrate
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treatment for type IV RTA
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furosemide, fludrocortisone, low K diet in patients with aldosterone deficiency
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major complication of type I RTA
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nephrolithiasis
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major complications of type II RTA
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rickts, osteomalacia
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major complication of type IV RTA
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hyperkalemia
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what is diabetes insipidus?
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failure to concentrate urine through central or nephrogenic dysfunction of ADH
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causes of central DI
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(posterior pituitary fails to secrete ADH) tumor, ischemia (Sheehan's syndrome), traumatic cerebral injury, infection, and AI disorders
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causes of nephrogenic DI
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(kidneys fail to respond to ADH) renal diseases and drugs - lithium and demeclocycline
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how does DI present
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polydipsia, polyuria, and persistent thirst with dilute urine
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how do you make the diagnosis of DI?
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during water deprivation test, pts excrete high volume of dilute urine
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what happens with a DDAVP challenge in central DI? in nephrogenic DI?
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cental: decreased urine output and increased urine osmolarity
nephrogenic: won't decrease urine output significantly (DDAVP is an ADH analog) |
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treatment for central DI
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intranasal DDAVP
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treatment for nephrogenic DI
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salt restriction and increased water intake; thiazides can be used to promote mild volume depletion and to promote proximal absorption of salt and water
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what is SIADH
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common cause of euvolemic hyponatremia that results from nonosmotically stimulated ADH release
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with what is SIADH associated?
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CNS disease (head injury, tumor), pulmonary disease (sarcoid, PNA, ectopic tumor production/paraneoplastic syndromes), drugs (antipsychotics, antidepressants), or surgery
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how do you diagnose SIADH?
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urine osmolality or greater than 50-100 wth concurrent serum hyposmolarity in absence of physiologic reason for increased ADH
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what are some physiologic reasons for increased ADH?
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CHF, cirrhosis, hypovolemia
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what is urinary sodium in SIADH?
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greater than 20 - demonstrates that patietn is not hypovolemic
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treatment of SIADH
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fluid restriction; demeclocycline (antagonizes action of ADH in collecting duct)
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what do you do if a patient with SIADH has severe hyponatremia (less than 110)
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cautiosuly give hypertonic saline
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what can elevated PSA be due to?
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BPH, prostatitis, UTI, prostatic trauma, carcinoma
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what is considered a markedly elevated PSA?
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>4
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risk factors for bladder CA
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smoking, diets rich in meat/fat, schistosomiasis, chronic treatment with cyclophosphamide, and exposure to aniline dye
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most common presenting symptom of bladder CA
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gross hematuria
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treatment for bladder carcinoma in situ?
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intravesicular chemo
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treatment for superficial bladder CA
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complete transurethral resection or initravesiuclar chemo with mitomycin C or BCG
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treatment for large, high grade recurrent bladder CA
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intravesicular chemo
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treatment for invasive bladder CA without metastases
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radical cystectomy or radiotherapy for patients who are poor candidates for radical cystectomy
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treatment for bladder CA with distant mets
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chemo alone
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what is the classic triad of renal cell carcinoma?
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hematuria, flank pain, and palpable flank mass
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risk factors for testicular cancer?
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cryptorchidism and Klinefelters
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peak incidence of seminomas
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40-50 years
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elevation of B-HCG in what testicular CA
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choriocarcinoma; also elevated in 10% of seminomas
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elevation of AFP in what testicular CA
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nonseminomatous germ cell tumors, especially endodermal sinus (yolk sac) tumors
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which type of testicular CA is sensitive to XRT and chemo
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seminomas
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for what type of testicular caners is platinum-based chemo used?
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nonseminomatous germ cell tumors
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what is bilateral cryptorcidism associated with?
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oligospermia and infertility
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treatment for cryptorchidism?
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orchiopexy after age one (in all but 1%, testes will have descended)but before age 5 to preserve fertility
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what if cryptorchidism is discovered later in life?
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treat with orchiectomy to avoid the risk of testicular cancer
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risk factors for ED?
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DM, atherosclersis, meds (B blockers, SSRIs), HTN, heart disease, surgery/XRT for prostate CA, spinal cord injury
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what should you look for on PE in a patient complaining of ED?
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neurologic dysfunction (anal tone, lower ext. sensation) and hypogonadism (small testes, loss of secondary sex characteristics)
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waht labs should you check in pt with ED?
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testosterone and gonadotropin levels; also check prolactin
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why should you check prolactin in a patient with ED?
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elevated prolactin can decrease androgen activity
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treatment for patients with psychological ED?
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psychotherapy or sex therapy
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how do sildenafil and vardenafil work?
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phosphodiesterase-5 inhibitors that lead to prolonged activation fo cGMP-mediated smooth muscle relaxation and increase blood flow in hte corpora cavernosa
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preferred test for suspected kidney stone
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non-contrast CT
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hematuria, HTN, RBC casts, mild proteinuria after skin infection
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post-strep GN
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elderly patient with bone pain, renal failure, elevated Ca2+
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multiple myeloma until proven otherwise
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what type of hypersensitivity reaction is acute allergic interstitial nephritis?
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type 4
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fever, petechial rash, and peripheral eosinophilia in azotemic patient
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allergic interstitial nephritis
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positive leukocyte esterase
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pyuria
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positive nitrites
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enterobacteracae
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hexagonal crystals on UA
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cystinuria
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positive cyanide nitroprusside test
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cystinuria
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cystinuria is the result of what?
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impaired AA transport
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how does renal vein thrombosis present?
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sudden onset of pain, fever, hematuria
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with what type of nephrotic syndrome is renal vein thrombosis most common?
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membranous glomerulonephritis
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pathologies of analgesic nephropathy
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papillary necrosis and tubulointerstitial nephritis
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what can chronic analgesic abuse cause in addition to renal failure
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premature aging, atherosclerosis, urinary tract CA
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class of drugs notorius for causing acute renal failure
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aminoglycosides (amikacin, gentamycin, neomycin, tobramycin, streptomycin)
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classes of drugs known to cause interstitial nephritis
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cephalosporins, sulfonamides, NSAIDs, rifampin, phenytoin, allopurinol
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arthralgias, rash, renal failure, eosinophila
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drug-induced interstitial nephritis
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treatment for problems with renal transplant post-op
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IV steroids
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four hallmark warning signs of urethral injury?
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boggy, movable prostate on exam, blood at urethral meatus, severe pelvic fracture, scrotal/perineal ecchymosis
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what do you order to rule out urethral injury before placing a Foley?
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retrograde urethrogram
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remnant of the processus vaginalis
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hydrocoele
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dilatation of pampminiform venous plexus
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varicocele
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which side is a varicocele usually on?
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left
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bag of worms that does not transilluminate, disappears in supine position, and becomes prominent with standing or valsalva
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varicocele
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treatment for hydrocele
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usually none needed
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where is a transplanted kidney placed?
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in the iliac fossa or pelvis
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what causes hyperacute rejection?
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preformed cytotoxic antibodies against donor kidney; occurs with ABO mismatch and other preformed Abs
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what type of rejection: kidney turns bluish black after vascular clamps are released
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hyperacute
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how do you treat hyperacute rejection
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remove transplant
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what causes acute rejection
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T-cell mediated
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how does acute rejection present?
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days to weeks after transplant with fever, oliguria, weight gain, tenderness/enlargement of graft, HTN
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treatment for acute rejection?
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increase corticosteroiids or use antithymocyte gloulin
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what causes chronic rejection
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T-cell or Ab mediated
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how does chronic rejection present
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gradual decline in kidney function, proteinuria, HTN
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what do steroids inhibit?
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IL-1 production
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what does cyclosporine inhibit?
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IL-2 production
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mechanism of azathioprine
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antineoplastic that is cleaved into mercaptopurine and inhibits DNA/RNA synthesis
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how does antithymocyte globulin work?
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antibody vs. T cells
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how does OKT3 work?
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antibody to CD3 receptor on T cells
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what is epispadias associated with?
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exstrophy of the bladder
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bilateral renal agenesis, limb deformities, abnormal facies, lung hypoplasia
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potter's syndrome
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