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73 Cards in this Set
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- 3rd side (hint)
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Presence of casts
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Renal origin (hematuria/pyuria)
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RBC casts
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glomerulonephritis, ischemia, or malignant hypertension
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RBCs, no casts in urine
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bladder cancer, kidney stones
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WBC casts
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tubulointerstitial inflammation, acute pyelonephritis, transplant rejection
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WBCs, no casts in urine
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acute cystitis
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Granular ("muddy brown") casts
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acute tubular necrosis
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Waxy casts
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advanced renal disease/CRF
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Hyaline casts
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nonspecific
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Primary nephrotic syndromes
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Minimal change
Membranous glomerulonephritis Focal segmental glomerulosclerosis Membranoproliferative glomerulonephritis (MPGN I and II) Mesangial proliferative |
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Secondary nephrotic syndromes
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Diabetic nephropathy
Amyloidosis SLE |
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Nephritic syndromes
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IgA nephropathy (Berger's disease)
Poststreptococcal SLE TTP/HUS Alport's syndrome MPGN I and II Henoch-Schonlein purpura |
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Anti-GBM RPGN
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Goodpastures
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Linear immunofluoresence staining
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Immune complex RPGN
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Henoch-Schonlein purpura
Hypersensitivity vasculitis Cryoglobulinemia SLE |
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Pauci-immune RPGN
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Wegener's
Churg-Strauss Microscopic polyarteritis PAN |
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Subepitherial deposits
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Membranous nephropathy
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Basement membrane spikes
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Mesangial deposits
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IgA nephropathy
SLE (class II) MPGN PIGN |
Mesangial proliferation
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Subendothelial deposits
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MPGN
SLE (class IV) |
Endocapillary proliferation
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Nephritic syndrome
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Hematuria, RBC casts and dysmorphic RBCs, azotemia, oliguria, hypertension, mild proteinuria (<3.5 g/d)
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Inflammed, swollen glomeruli
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Acute poststreptococcal glomerulonephritis
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LM - glomeruli enlarged and hypercellular, neutrophils, "lumpy-bumpy" appearance
EM - subepithelial immune complex humps IF - grannular |
Children
Peripheral and periorbital edema Resolves spontaneously |
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Rapidly progressive (crescentic) glomerulonephritis (RPGN)
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LM and IF - crescents (fibrin, plasma proteins w/ glomerular parietal cells, monocytes, and macrophages)
Poor prognosis |
Goodpasture, Wegener's, microscopic polyarteritis
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Goodpasture syndrome
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RPGN
type II hypersensitivity, anti-GBM antibodies, linear IF |
Nephritic
Male-dominant disease Hematuria and hemoptysis |
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Wegener's granulomatosis
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RPGN
c-ANCA |
Nephritic
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Microscopic polyarteritis
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RPGN
p-ANCA |
Nephritic
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Diffuse proliferative glomerulonephritis (SLE or MPGN)
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Subendothelial DNA-anti-DNA immune complexes ("wire looping" of capillaries), granular IF
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Nephritic (SLE and MPGN can present as nephrotic)
Most common cause of death in SLE |
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Berger's disease (IgA glomerulopathy)
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Increased IgA synthesis, mesangial immune complex deposits
Often presents/flares with URI or acute gastroenteritis |
Nephritic
Most common cause of idiopathic GN Secondary causes - celiac sprue, liver disease Henoch-Schonlein purpura (systemic) |
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Alport's syndrome
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Mutation in type IV collagen (split basement membrane)
aka Hereditary Chronic Nephritis (AD/X-linked) |
Nephritic
Nerve disorders, ocular disorders, sensorineural deafness |
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Nephrotic syndrome
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Massive proteinuria (>3.5 g/d, frothy urine), hyperlipidemia, fatty casts/lipiduria, edema (hypoalbuminemia)
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Associated w/ thromboembolism, increased infection risk (loss of Ig)
Etiology: endothelial, BM, podocytes (components of size/charge barrier) |
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Membranous glomerulonephritis (diffuse membranous glomerulopathy)
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LM - diffuse capillary and GMB thickening
EM - "spike and dome" appearance, subepithelial deposits IF - grannular |
Nephrotic (most common cause of adult nephrotic)
Caused by drugs, infections, SLE, solid tumors |
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Minimal change disease (lipoid nephrosis)
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LM - normal glomeruli
EM - food process effacement Selective loss of albumin (not Ig) due to GBM polyanion loss |
Nephrotic
Most common in children Triggers - recent infection, immune stimulus Tx: corticosteroids |
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Amyloidosis
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LM - Congo red stain, apple-green birefringence
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Nephrotic
Associated with multiple myeloma, chronic conditions, TB, rheumatoid arthritis |
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Diabetic glomerulonephropathy
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Nonenzymatic glycosylation of GBM (permeable) and efferent arterioles (increased GFR)
LM - mesangial expansion, thickened GBM, nodular sclerosis |
Nephrotic
Kimmelsteil-Wilson nodules |
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Focal segmental glomerulosclerosis
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LM - segmental sclerosis and hyalinosis
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Nephrotic
Most common glomerular disease in HIV patients (more severe in HIV) |
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Membranoproliferative glomerulonephritis
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Subendothelial IC w/ grannular IF
Type I - EM - "tram track" (mesangial growth - GBM splitting) Type II - EM - dense deposits |
Nephrotic (can be nephritic)
Slow progression to CRF Type I - associated with HBV (>HCV) Type II - C3 nephritic factor |
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Kidney stones
Complications |
hydronephrosis, pyelonephritis
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Tx/Prevention: fluid intake
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Kidney stones
Calcium |
Most common (75-85%)
Ca oxalate, Ca phosphate (or both) Cancer, inc PTH, inc vit D, milk-alkali syndrome - hypercalcemia |
Radiopaque
Oxalate crystals can result from ethylene glycol (antifreeze) or vit C abuse |
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Kidney stones
Ammonium magnesium phosphate |
2nd most common
Urease+ bugs (Proteus, vulgaris, Staph, Klebsiella) Staghorn calculi (nidus for UTIs) |
Radiopaque or radiolucent
Worsened by alkauria |
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Kidney stones
Uric acid |
Strong association w/ hyperuricemia (ex. gout)
Result of increased cell turnover (leukemia, myeloproliferative disorders) |
Radiolucent
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Kidney stones
Cystine |
Secondary to cystinuria
Hexagonal shape, can form cystine staghorn calculi (rarely) |
Faintly radiopaque
Tx: alkanization of urine |
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Renal cell carcinoma
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Most common renal malignancy.
Invades IVC; mets to lung and bone. Most common in men (age 50-70). Increased incidence w/ smoking, obesity. Associated w/ vHL and gene deltion (chr 3). Originates in renal tubule cells - polygonal clear cells |
Hematuria, palpable mass, secondary polycythemia, flank pain, fever, weight loss
Paraneoplastic - ectopic EPO, ACTH, PTHrP, prolactin |
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Wilms' tumor (nephroblastoma)
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Most common early childhood renal malignancy (age 2-4).
Palpable flank mass and/or hematuria. Hemihypertrophy syndromes. Contains embryonic glomerular structures. Deletion of WTI gene (chr II) - tumor suppressor. |
WAGR complex:
Wilms tumor, Aniridia, Genitourinary malformation, mental-motor Retardation |
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Transitional (urothelial) cell carcinoma
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Most common tumor of urinary tract (renal calyces,..., bladder)
Painless hematuria - bladder cancer |
Phenacetin (analgesic), smoking, aniline dyes, cyclophosphomide
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Bladder cancer
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Painless hematuria, urethral invasion, obstruction, hydronephrosis, pyelonephritis, renal failure
Schistosomasis - usually squamous cell carcinoma |
p53 mutation (17p), gene deletion in chr 9
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Pyelonephritis (acute)
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Affects cortex w/ relative sparing of glomeruli/vessels
WBC casts, fever, CVA tenderness, N/V |
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Pyelonephritis (chronic)
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Coarse, asymmetric corticomedullary scarring, blunted calyx
Eosinophili casts in tubules (thyroidization of kidney) |
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Drug-induced interstitial nephritis
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Pyuria (eosinophils), azotemia, fever, rash, hematuria, CVA tenderness
1-2 weeks after administration of drugs (act as haptens - induce hypersensitivity) |
Diuretics, NSAIDs, penicillin derivatives, sulfa drugs, rifampin
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Renal effects of NSAIDs
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Acute renal failure, glomerulonephritis (uncommon), papillary necrosis, dec GFR, inc Na/water reabsorption
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Diffuse cortical necrosis
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Acute, bilateral cortical infarction due to vasospasm and DIC
Associated with obstetric catastrophes and septic shock |
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Acute tubular necrosis
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Most common cause of acute renal failure in hospital
Self-reversible (intact BM), fatal if untreated (supportive dialysis). Associated w/ renal ischemia, crush injury (myoglobinuria), toxins. Death during early oliguric phase |
Loss of cell polarity, epithelial cell detachment, necrosis, grannular casts
3 stages: inciting event, maintenance (low urine), recovery (2-3 wks) |
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Renal papillary necrosis
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Sloughing of renal papillae - gross hematuria, proteinuria
Triggered by recent infection or immune stimulus |
Associated with diabetes mellitus, acute pyelonephritis, chronic phenacetin use, sickle cell anemia
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Acute renal failure
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Increased Cr and BUN over several days
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Normal nephron - BUN reabsorbed for countercurrent multiplication, Cr not reabsorbed
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Acute renal failure
Prerenal azotemia |
Dec RBF --> dec GFR
Na/water and urea retained |
Elevated serum BUN/Cr ratio (>20)
(to conserve volume) Urine osmolality >500 Urine Na <10 FeNa <1% |
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Acute renal failure
Intrinsic renal |
Due to ischemia/ATN/toxin (GN less common). Patchy necrosis --> debris obstructing tubule --> dec GFR
Epithelial/granular casts |
Decreased serum BUN/Cr ratio (<15)
(BUN reabsorption impaired) Urine osmolality <350 Urine Na >20 FeNa >2% |
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Acute renal failure
Postrenal |
Outflow obstruction (stones, BPH, neoplasia, congenital)
Bilateral obstruction only |
Urine osmolality <350
Urine Na >40 FeNa >4% Serum BUN/Cr >15 |
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Consequences of renal failure
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Inability of make urine and excrete nitrogenous wastes
Failure to make EPO Failure of 1-alpha hydroxylase (vit D) |
Na retention (CV/pulm), hyperkalemia, metabolic acidosis, uremia, anemia, renal osteodystrophy, dyslilpidemia (esp inc TG), growth retardation in children
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Uremia
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Elevated BUN and Cr
Nausea, anorexia, pericarditis, asterixis, encephalopathy, platelet dysfunction |
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Fanconi's syndrome
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Decreased proximal tubule transport (amino acids, glucose, phosphate, uric acid, protein, electrolytes). Congenital or acquired
Etiology: Wilson's, glycogen storage disease, drugs (cisplatin, expired tetracycline) |
Complications:
Rickets (dec phosphate reabsorption) Metabolic acidosis (dec bicarb reabsorption) Hypokalemia (dec proximal/inc distal Na reabsorption) -type 2 RTA |
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ADPKD
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Multiple, large, bilateral cysts - destroy parenchyma. Enlarged kidneys
Flank pain, hematuria, hypertension, UTI, progressive RF. Death from CKD complications or HTN (renin production) |
Autosomal dominant mutation in APKD1 or APKD2 (chr 16) - manifests in adulthood
Associated w/ polycystic liver disease, berry aneurysms, mitral valve prolapse |
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ARPKD
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Infantile presentation of cysts in parenchyma. Renal failure in utero --> Potter's.
After neonatal period - HTN, portal HTN, progressive renal insufficiency |
Autosomal recessive
Associated w/ congenital hepatic fibrosis |
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Dialysis cysts
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Cortical and medullary cysts resulting from long-standing dialysis
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Simple cysts
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Benign, incidental finding
Cortex only |
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Medullary cystic disease
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Medullary cysts --> fibrosis, progressive renal insufficiency w/ urinary concentrating defects.
Small kidney on US. Poor prognosis |
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Low serum Na
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Disorientation, stupor, coma
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High serum Na
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Neurologic: irritability, delirium, coma
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Low serum Cl
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Secondary to metabolic alkalosis, hypokalemia, hypovolemia, inc aldosterone
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High serum Cl
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Secondary to non-anion gap acidosis
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Low serum K
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U waves on ECG, flattened T waves, arrhythmias, paralysis
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High serum K
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Peaked T waves, wide QRS, arrhythmias
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Low serum Ca
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Tetany, neuromuscular irritability
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High serum Ca
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Delirium, renal stones, abdominal pain, not necessarily calciuria
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Low serum Mg
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Neuromuscular irritability, arrhythmias
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High serum Mg
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Delirium, dec DTRs, cardiopulmonary arrest
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Low serum PO4
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Bone loss, osteomalacia
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High serum PO4
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Renal stones, metastatic calcifications
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