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356 Cards in this Set
- Front
- Back
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Sudden onset of signs of renal dysfunction with associated inflammatory cell infiltrate within the interstirium
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Acute Interstitial Nephritis
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What history is typical with acute interstitial nephritis?
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Recently started on new medication
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Accounts for 10-20% of acute kidney injury
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Acute Interstitial Nephritis
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SLE patients may have both..
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glomerulonephropathy and acute interstitial nephrpathy
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What antimicrobials cause acute interstitial nephritis?
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penecillins-esp methicillin
acyclovir sulfonamides cipro cephalosporins |
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Name some drugs that cause acute interstitial nephritis
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NSAIDS
cimetidine omeprazole phenytoin allopurinol |
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Name the diuretics that cause acute acute interstitial nephritis
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thiazides
furosemide triamterene |
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What systemic infections can cause acute interstitial nephritis?
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Legionnaire's
Leptospirosis Strep CMV |
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Classic Triad of Allergy related AIN
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fever
rash peripheral eosinophilia |
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What is very uncommon in drug induced AIN?
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hypertension and edema
-because it doesn't affect the glomerulus |
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In drug induced AIN, a _________ is positive for eosinophilia
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Hansel Stain
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What is the treatment for AIN?
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Discontinue the offending drug
Short course of high dose steroids |
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_______ lights up in AIN
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gallium stain
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Clinical Manifestations that suggest Chronic Interstitial Nephritis
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Hyperchloremic metabolic acidosis
Hyperkalemia Reduced maximal urinary concentrating ability Fanconi syndrome modest proteinuria |
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5 findings that suggest fanconi syndrome
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phosphaturia
bicarbonaturia aminoaciduria uricosuria glycosuria |
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Name some conditions associated with chronic interstitial nephritis
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taking lithium or cyclosprines
wegener's granulomatosis sjogren's syndrome sle sarcoidosis multiple myeloma sickle cell lymphoma chronic pyelonephritis or obstruction |
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Causes of proximal tubule injury in CIN
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multiple myeloma
heavy metal toxicity |
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S/S of Proximal Tubule CIN
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RTA
glycosuria aminoaciduria uricosuria |
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Causes of distal tubule CIN
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chronic obstruction
amyloidosis |
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S/S of distal tubule CIN
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salt wasting
hyperkalemia |
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CIN Medullary Involvement
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analgesic nephropathy
sickle cell PKD S/S- polyuria secondary to urinary concentration defect |
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deformity of the renal pelvis/calyces from both the previous infection and vesicoureteral reflux with associated obstruction
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Chronic Pyelo/Reflux Nephropathy
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What indicates a poor prognosis for chronic pyelo/reflux nephropathy?
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heavy proterinuria
-will cause hyperkalemia, acidosis, hyponatremia, poor concentrating ability |
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_______ occurs more frequently in women who have ingested large quanitities of antipretic analgesic mixtures
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analgesic nephropathy
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Analgesic nephropathy is commonly caused by combinations of aspirin and...
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acetaminophen
phenacetin caffeine codeine |
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Analgesic nephropathy causes and increased risk of...
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bladder cancer
-transitional cell carcinoma of the urinary tract |
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What cytotoxic agents may cause CIN?
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cisplatin, cyclosporine, tacrolimus, nitrosureas
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Radiation Nephritis
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-within 1 year of high dose radiation
-injures vascular endothelium -causes HTN, anemia, edema |
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urate tophi in kidney
think... |
hyperuricemia
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inborn error of metabolism and enteric hyperoxaluria
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hyperoxaluria
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bowel cleansing products can cause...
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hyperphosphatemia
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multiple myeloma aka...
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light chain cast nephropathy
causes hypercalcemia and nephrosclerosis |
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Pts with multiple myeloma get...
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renal insufficuency 2/3
tubular casts in urine tubular atrophy interstitial fibrosis |
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Classic Triad of Lead Nephropathy
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Hypertension
Gout Chronic Renal Insufficiency |
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Most common cause of renal dysfunction in sarcoidosis pts
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hypercalcemia
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Lead poisoning causes...
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aminoaciduria
glycosuria CIN |
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How do you diagnose lead nephropathy?
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elevated lead measurement after EDTA is administered
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If patient has anuria think of...
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urinary tract obstruction
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Most common cause of true anuria
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bilateral complete obstruction
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Most common cause of obstruction in males
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prostate hypertrophy
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PVR>200 may indicate...
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bladder outlet obstruction
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In which renal cystic disorder are hematuria, recurrent infection, renal calculi, and hypertension all common?
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Autosomal Dominant Polycystic Kidney Disease
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Which renal cystic disorder presents in the neonatal period?
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Autosomal Recessive PKD
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Which renal cystic disease disorder presents in adolescence?
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medullary cyst disease
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Which renal cystic disease is diagnosed by excretory urogram?
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medullary sponge kidney
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Most comon renal mass
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simple cysts
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A complex cyst is more likely to be malignant if...
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it has increased wall nodularity, septations or vascularity
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What is the prognosis for Autosomal Recessive PKD?
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death within one year
-requires a liver/kidney transplant for survival |
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Most common hereditary renal disorder in the US
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Autosomal Dominant PKD
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Presentation of ADPKD
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dull lumbar pain
hematuria-most common in 4th decade HTN nocturia |
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What brain situation is common with ADPKD?
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cerebral aneuysm
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Diagnostic of Choice for ADPKD
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Ultrasound
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Chloramphenicol can cause...
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gray baby syndrome
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Which disease is associated with a 409 fold increased risk of renal cell carcinoma?
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acquired cystic kidney disease
-usually comes from being on dialysis for 10+ years |
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Which disease is associated with retinitis pigmentosa and retinal abnormalities, short stature, occulomotor defects and MR?
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Medullary Cystic Disease
aka Juvenile Nephrophthisis |
|
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How is medullary sponge kidney diagnosed?
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Plain film KUB shows nephrocalcinosis
IVP shows bunch of grapes |
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Which stones are radiolucent?
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Uric acid
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Calcium phosphate stones are more common in?
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alkaline urine
RTA primary hyperthyroidism milk alkaline syndrome |
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Diagnostic of choice for renal stones
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spiral CT without contrast
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Stones of what size will usually pass within 6 weeks?
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5-7mm
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What medication do you give for high urine calcium to prevent stones?
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thiazide
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What do you give for high oxalates in the urine to prevent stones?
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B6
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What do you give for high uric acid in urine to prevent stones?
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allopurinol
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What do you give if urine has low citrate to prevent stones?
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alkali
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if a patient has stones due to hyperoxaluria what changes should he make?
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restrict dietary oxalate and add calcium carbonate
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if a patient has stones due to hypocitraturia what changes should he make?
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further protein restriction and potassium citrate
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What medication is associated with hypocitraturia?
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Vitamin C
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What type of stone needs antibiotic treatment?
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struvite aka staghorn
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When should you not limit calcium intake?
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with cysteine stones from acidic urine
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Which renal stone-prone state is associate with inflammatory bowel disease?
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hyperoxaluria
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Most common intrinsic renal disease leading to Acute Kidney Injury..
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ATN
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Syndrome in which there is abrupt and sustained decreased GFR occuring within minutes to days in repsonse to ischemia or nephrotoxic insult
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acute tubular necrosis
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most common cause of acute azotemia
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prerenal
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Eosiniphils, fever, rash, antibiotic exposure think...
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acute interstitial nephritis
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Most important lab findings associated with loss of renal function
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azotemia, decreased creatinine clearance, hyperkalemia
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dirty brown granular casts and renal tubular epithelial cells are associated with...
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ATN
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BUN/Creatinine>20:1 indicates
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prerenal
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BUN/Creatinine<20:1 indicates
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ATN
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If oligurina lasts more that 4 weeks...
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further evaluation of ARF is necessary
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Most common biochemical abnormality responsible for death in ATN
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hyperkalemia
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Main cause of death for patients with ATN
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infection, sepsis
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Most common organism in sepsis is
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clostridium
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Postpartum ARF
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hemolytic uremic syndrome
elevated LDH |
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How do you avoid ARF when giving cisplatin?
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keep well hydrated before administering
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As CRF progresses nephrons adapt but patient eventually becomes...
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hyperchloremic and metabolic acidotic
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What is the protein restriction for CRF?
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40g/day or .6g/kg
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Renal osteodystrophy is indicated by...
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increased PO4
decreased Ca Increased PTH |
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In addition to the classic triad, AIN patients can have...
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flank pain
arthralgia hematuria |
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What is very uncommon in AIN?
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hypertension and edema
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UA of AIN shows...
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hematuria-micro or macro
sterile pyuria WBC casts Mild to moderate proteinuria <1g/day rare to have RBC casts |
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In AIN, _______ is positive for eosinophiluria.
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Hansel Stain
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Serum of AIN patient shows..
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increased KCl
RTA Renal Na Wasting Hyponatremia Eosinophiluria |
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Treatment(s) for AIN
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discontinue offending drug-most cases will resolve
Short course of high dose steroids |
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What is standard to diagnose AIN?
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biopsy
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What lights up in AIN?
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gallium stain
ATN doesn't light up but false negatives are common |
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In chronic interstitial nephropathy, is proteinuria mild, moderate, or severe?
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mild
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Slow progresive insufficiency with mild proteinuria functional tubular defect, tubular cell atrophy and progressive interstitial fibrosis
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Chronic Interstitial Nephropathy
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What % of ESRD is caused by Chronic Interstitial Nephropathy?
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15-30%
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What is the presentation of CIN?
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interstital fibrosis and scarring
-tubular defecits disproportionately severe relative to the degree of azotemia in the abscence of glomerular disease -modest pyuria and minimal hematuria |
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Clinical Findings that Suggest CIN
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Hyperchloremic Metabolic Acidosis
Hyperkalemia Reduced Urinary Concentraiting Ability Fanconi Syndrome Modest Proteinuria<2g/day |
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Fanconi Syndrome
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Aminoaciduria
Phosphaturia Bicarbonaturia Uricosuria Glycosuria |
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Causes of Proximal Tubule CIN
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multiple myeloma
heavy metal toxicity |
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Patients with Proximal Tubule CIN present with what signs and symptoms?
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Proximal RTA
-glycosuria -aminoaciduria -uricosuria |
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Causes of Distal Tubule CIN
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Chronic Obstruction
Amyloidosis |
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Patient with Distal Tubule CIN present with what signs and symptoms?
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Distal RTA
-salt wasting -hyperkalemia |
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Causes of Medullary CIN
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analgesic nephropathy
sickle cell PKD |
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S/S of Medullary CIN
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polyuria secondary to urinary concentrating defect
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Due to deformity of the renal pelvis/calyces from previous infection and vesicoureteral reflux with associated obstruction
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Chronic Pyelo/reflux Nephropathy
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What implies poor prognosis in Chronic Reflux Nephropathy?
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heavy proteinuria(focal segmental sclerosis)
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Focal segmental sclerosis in reflux nephropathy causes...
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hyperkalemia, acidosis, hyponatremia, poor concentrating ability
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Analgesic nephropathy occurs more commonly in...
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women, especially with comorbidities like stress or neuropsychiatric problems
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Analgesic nephropathy is due to overconsumption of aspirin plus...
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acetaminophen
phenacetin caffeine codeine |
|
|
Analgesic nephropathy may result in what GI problem?
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blood loss from the aspirin
heme positive stool |
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Analgesic nephropathy cause flank painand hematuria due to...
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sloughing of the papillae aka papillary necrosis
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Pts with analgesic nephropathy are at increased risk for...
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bladder cancer
transitional cell carninoma of the urinary tract |
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CT of Analgesic nephropathy shows...
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papillary calcification and abnormal contour of the renal cortex
|
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What cytotoxic agents may produce CIN?
|
Cisplatin
Cyclosporine Tacrolimus Nitrosureas |
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What drug is a major cause of late renal transplant failure?
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cyclosprorine
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Radiation Nephritis occurs within _______ of treatment.
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1 year
-injures vascular endothelium |
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S/S of Radiation Nephritis
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HTN
Edema Anemia |
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S/S of the more chronic Radiation Nephritis
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HTN
Mild Proteinuria Mild Renal Insufficiency |
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Hyperuricemia causes CIN by...
|
urate tophi in kidney
|
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Hyperoxaluria causes CIN by...
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inborn error in metabolism and enteric hyperoxaluria
|
|
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Hyperphosphatemia in CIN
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bowel cleansing products
|
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Hypercalcemia in CIN
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disorder of calcium metabolism
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_______ is also known as light chain cast nephropathy.
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multiple myeloma
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Multiple Myeloma causes...
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hypercalcemia and nephrosclerosis
|
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Characteristics of Light chain cast nephropathy
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2/3 get renal insufficiency
tubular casts in urine tubular atrophy interstitial fibrosis |
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Treatment of Light Chain Cast Nephropathy
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Chemo
Volume repletion Alkalinization of the urine |
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Most common cause of renal dysfunction in Sarcoidosis patients...
|
hypercalcemia
|
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Lead nephropathy causes...
|
aminoaciduria
glycosuria CIN |
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Classic Triad of Lead Nephropathy
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Hypertension
Gout Chronic Renal Insufficiency |
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How do you diagnose Lead nephropathy?
|
elevated lead after EDTA administration
|
|
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What is the nephrotoxic component of diet pills?
|
aristolochia
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Patients diagnosed with Chinese Herb Nephropathy should be monitored for:
|
urothelial malignancy
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Congenital Urinary Tract Malformations that cause obstruction
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meatal stenosis
ureterocele posterior urethral valves |
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Causes of Intraluminal Obstruction
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Calculi
Blood Clots Sloughed Papillary Tissue |
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Extrinsic Compression that causes obstruction
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pelvic tumors
prostatic hypertrophy retroperitoneal fibrosis |
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Acquired Anomalies that cause obstruction
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urethral strictures
neurogenic bladder intratubular precipitates |
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Unilateral ureteral obstruction usually causes no...
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detectable change in urinary flow or total renal function
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Most common cause of true anuria
|
bilateral complete obstruction
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_________ is common with partial obstruction secondary to concentrating defects.
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polyuria
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________ is indicative of bladder outlet obstruction
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PVR >200
|
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Post obstructive diuresis is caused by...
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retained salt and urea
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Chronic partial obstruction may be treated with..
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alpha antagonist or alpha reductase inhibitor
|
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Most common renal mass
|
Simple Cysts
|
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Simple Cysts are found in what % of adults over 50?
|
50%
increases with age asymptomatic and incidental finding |
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How are Simple Cysts diagnosed?
|
With ultrasound or an incidental finding on CT
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_______ may be benign or malignant.
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Complex Cysts
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Complex cysts are more likely to be malignant if the cyst wall has increased:
|
nodularity
septations vascularity |
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DMOC for indeterminate Complex Cysts
|
MRI
|
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Treatment of Complex Cysts I and II
|
no further study
|
|
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Treatment of COmplex Cysts III
|
biopsy must be done prior to cryoablation
|
|
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How prevalent is ARPKD?
|
1 in 20,000 live births
|
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What % of neonates with ARPKD have HTN within months?
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70-80%
|
|
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What is the prognosis for ARPKD?
|
death within the first year of life from renal failure
30-50% of the time |
|
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What is the tx for ARPKD?
|
liver/kidney transplant
|
|
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Accounts for up to 10% of all ESRD
|
ADPKD
|
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Presentation of ADPKD
|
Dull lumbar pain
Hematuria most common in 4th decade HTN in 75% of patients-often prior to renal insufficiency nocturia |
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|
Most common hereditary renal disorder in the US
|
ADPKD
-500,000 affected |
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In ADPKD, nocturia is common due to...
|
concentrating defects, especially if on a low salt diet
|
|
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In ADPKD who has a better prognosis?
|
females
|
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Labs for ADPKD show:
|
Hematuria
Anemia Proteinuria Pyruia Bacteruria |
|
|
What are some entities associated with ADPKD?
|
UTI
Hernias 80% Cerebral aneurysm 25% MVP Diverticulosis Calcium and uric acid stones, low citrate Polycystic liver disease |
|
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What % of ADPKD progress to ESRD by age 60?
|
50%
|
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DMOC fo ADPKD?
|
ultrasound
|
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ADPKD-Plain xray may show:
|
enlarged kidneys
|
|
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What is the treatment for ADPKD?
|
no good treatment
pain control, low protein/high fluids, agressive infection treatment with cipro, chloramphenicol and sulfa dialysis/transplant |
|
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Which kidney disease is preneoplastic?
|
Acquired Cystic Kidney Disease
|
|
|
When does Acquired cystic kidney disease occur?
|
80-100% when patients have been on dialysis 10 years or more
|
|
|
Acquired Cystic kidney disease carries a 40 fold increased risk of:
|
renal cell carcinoma
|
|
|
What is the best test for Acquired Cystic Kidney Disease?
|
CT-because lesions are small
|
|
|
Medullary Cystic Disease is also known as:
|
Juvenile Nephronophthisis or Congenital Tubulointerstitial Nephropathies
|
|
|
Is Medullary Cystic Disease autosomal dominant or recessive?
|
Autosomal Recessive
-appears in juveniles |
|
|
Medullary Cystic Disease is associated with:
|
retinitis pigmentosa and retinal abnormalities, short stature, occulomotor defects and MR
|
|
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Pts with Medullary Cystic Disease exhibit ______ secondary to concentrating defects.
|
enuresis
|
|
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Pts with Medullary Cystic Disease exhibit _______ secondary to decreased erythropoetin.
|
anemia
|
|
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Patients with Medullary Cystic Disease get ESRD by the time they reach...
|
adolescence
|
|
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10% of patiens with stones have:
|
Medullary Sponge Kidney
|
|
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Medullary Sponge Kidney is _____ and ______ ______.
|
benign and fairly common.
-its often found incidentally |
|
|
Plain film KUB of Medullary Sponge Kidney shows:
|
nephrocalcinosis in 50% of patients
|
|
|
IVP of Medullary Sponge Kidney shows:
|
radial pattern of "bunch of grapes"
|
|
|
Treatment of Medullary Sponge Kidney
|
treat UTIs and Stones
Rule out renal failure |
|
|
Symptoms of Nephrolithiasis
|
pain
hematuria infection obstruction polyuria dysuria vomiting |
|
|
Nephrolithiasis occurs in what % of the population?
|
1%
|
|
|
What are the 3 locations of narrowing that can lead to stone obstruction?
|
ureterovesical junction
ureteropelvic junction ureter at iliac vessels -pts are asymptomatic until it gets lodged |
|
|
What is the peak age range for nephrolithiasis?
|
20-45 y/o
|
|
|
Who gets nephrolithiasis more often?
|
Males 5:1
Caucasians Developed Countries-animal protein, no fiber |
|
|
If you have a family history of nephrolithiasis, that makes you...
|
3x more likely to get one
|
|
|
Nephrolithiasis is associated with ____, _____, and _____.
|
DM
HTN obesity |
|
|
In nephrolithiasis the risk of recurrence is:
|
50% in five years
67% in 10 years |
|
|
Which renal stone is radiolucent?
|
uric acid
|
|
|
Which renal stones are opaque?
|
Calcium
Mag Phos aka Struvite Cysteine |
|
|
Which renal stones are staghorn?
|
Struvite
sometimes Cysteine |
|
|
What % of stones are calcium?
|
75%
|
|
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What % of stones are Mag Phos?
|
10-15%
|
|
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What % of stones are Uric Acid?
|
10-15?
|
|
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What % of stones are Cysteine?
|
1%
|
|
|
Which stone is associated with urease producing bacteria?
|
Mag Phos aka Struvite
|
|
|
Which type of stone is associated with alkaline urine, is more common in RTA, primary hyerparathyroidism and milk alkaline syndrome
|
Calcium Phosphate
|
|
|
Which stone forms in acidic urine? pH <5.0
|
uric acid
|
|
|
Which stone is more common in females?
|
uric acid
|
|
|
What % of uric acid stones are staghorn?
|
<2%
|
|
|
According to the chart, which stones are likely to be multiple?
|
calcium
|
|
|
When should you consider percutaneous nephrolithotomy for a suspected stone?
|
uric acid stones may not show well on CT, especially if wall shows hydronephrosis, is less dense or <2mm
|
|
|
Describe the pain associated with renal calculi.
|
Acute excrutiating colic
waxes and wanes patient can't sit still |
|
|
What % of patients with stones have hematuria?
|
90%
|
|
|
In renal calculi situations, does the amount of hematuria correlate with the degree of obstruction?
|
No-no hematuria may indicate complete obstruction
|
|
|
What are the signs associated with renal stones/obstruction?
|
diaphoresis
tachycardia tachypnea HTN CVA abdominal distension ileus N/V |
|
|
What labs should you order if you suspect a stone obstruction?
|
Chem 7
Serum Ca PO4 Uric Acid UA-check pH, micro/macro hematuria |
|
|
What is the DMOC for a suspected renal stone?
|
CT without contrast
|
|
|
Sensitivity and Specificity of CT for renal stones is:
|
>90%
|
|
|
CT can visualize radiolucent stones if they are:
|
>1-2mm
|
|
|
Large radiopaque stones are _____ visible on plain film KUB. (what %?)
|
85%
|
|
|
What is the sensitivity of an ultrasound for picking up a renal stone?
|
24%
|
|
|
What is the specificity of ultrasound for identifying a renal stone?
|
90%
|
|
|
If you have a pregnanct woman or a child with a suspected renal stone, what do you do?
|
Ultrasound-DMOC in pregnancy
|
|
|
What % of renal stone pass spontaneously?
|
90%
|
|
|
For renal stones, what drug has been shown to be as effective as narcotics in terms of pain control?
|
Ketorolac
|
|
|
If patient has a renal stone and an infection what should you do?
|
they need antibiotics and admitted
|
|
|
Once you have started a stone patient on fluids, what do you want his urine output to be daily?
|
at least 2 liters
|
|
|
What are some drugs that might be useful for patients with renal stones?
|
Tamulosin-Flomax
alpha blocker/CCB steroid plus nifedipine |
|
|
What size stones should pass?
|
5-7mm
-most pass within 6 weeks, may take a whole lot longer |
|
|
If a stone is estimated to be 5-7mm what interventions might be considered?
|
stent
lithotripsy basket reteival via uteroscopy |
|
|
What size stones are unlikely to pass?
|
>10mm
|
|
|
A patient with a large stone that is unlikely to pass needs what kind of treatment?
|
inpatient lithotripsy ureteroscope fragmentation because these people are likely to have complications
|
|
|
If patient has a stone >10mm in the distal ureter, what might the treatment be?
|
you might give it a chance to pass if it has made it this far
-maybe give it 4 months |
|
|
How does one prevent renal calculi?
|
Low protein diet-1-1.5g/kg/day
low sodium diet High water intake-3 liters/day Check 24hr urine Ca & uric acid levels Stone dependent medication tx |
|
|
If a stone patient has high urinary calcium, what medication might you prescribe?
|
thiazide
|
|
|
If a stone patient has high oxalate in the urine what medication might you consider?
|
Vitamin B6
|
|
|
If a stone patient has high uric acid in the urine what medication might you prescribe?
|
allopurinol
|
|
|
If a stone patient has low citrate in the urine, what medication might you prescribe?
|
Alkali-potassium citrate
|
|
|
What are the 3 factors that promote stone formation?
|
low daily urine volume
oversaturation with calcium oxalate, calcium phosphate, uric acid, or cysteine acidic urine |
|
|
What % of men get stones?
|
10%
|
|
|
What % of women get stones?
|
5%
|
|
|
Incidence of stones increases with ____.
|
age
|
|
|
When should you do a workup of the first stone?
|
in a patient unwilling to make lifestyle changes
|
|
|
______ is protective against stone formation.
|
Citrate
|
|
|
What is the tx for hyperuricosuria to prevent stones?
|
decrease protein intake
|
|
|
What is the tx of hyperoxaluria to prevent stones?
|
restrict oxalate and calcium carbonate
|
|
|
What is the tx of hyponatruria to prevent stones?
|
further protein restriction
give potassium citrate |
|
|
What is the treatment of hypercalciuria to prevent stones?
|
increase flow rate
restrict salt certain diuretics -if alkaline urine give bicarbonate |
|
|
If a stone patient is in metabolic acidosis how should you treat it?
|
potassium citrate or sodium bibarbonate
|
|
|
Which type of stones require antibiotic treatment?
|
struvite
|
|
|
If a patient has a cysteine stone from acidic urine what are the possible treatments?
|
reduce protein/sodium hydrate
D penicillamine Captopril |
|
|
What is the main determinate of whether a stone will spontaneously pass?
|
size
-where its stuck may also be important |
|
|
If urine microscopy dscribes a stone as dumbell or envelope shaped and under polarized light appears coarse and needle shaped...which stone is it likely?
|
Calcium oxalate
|
|
|
Which stone is coffin lid shaped on urine microscopy?
|
struvite
|
|
|
Urine microscopy describes this stone as pleomorphic often with rhombic plates or rosettes.
|
uric acid
|
|
|
This stone is hexagonal on urine microscopy.
|
Cystseine
|
|
|
Which type of calcium stone is more common?
|
Calcium oxalate
|
|
|
What are the risk factors for developing calcium stones?
|
hypercalciuria-secondary to increased PTH, sarcoidosis, cancer, immobilzation, loops, RTA, hyperoxaluria, high animal protein diet, low urine volume, Cushing's, hyperparathyroidism, Vit D excess, milk alkalosis syndrome
|
|
|
What is the tx for calcium stones?
|
thiazide
-90% of hypercalciuria is idiopathic |
|
|
How does hyperuricosuria lead to calcium stone formation?
|
causes calcium oxalate to precipitate
|
|
|
How does hypocitraturia lead to calcium stone formation?
|
citrate prevents calcium precipitation-so lack thereof is a problem
-this is worse with RTA, hypokalemia, chronic diarrhea, and renal failure |
|
|
What situations can lead to hyperoxaluria and calcium stone formation?
|
inflammatory bowel disease
diet high in peanuts, tea, cola, spinach, citrus juice |
|
|
What are the risk factors for uric acid stone formation?
|
dehydration
hyperuricosuria secondary to hyperuricemia loops |
|
|
Uric acid stone formation is associated with what situations?
|
acidic urine
gout renal failure cyclosporine treatment probenacid use high dose aspirin |
|
|
What are the treatments to prevent uric acid stone formation?
|
fluids
moderate dietary protein intake allopurinol increase urine pH to 6.5-7 acetazolamide at night, bicarb during the day -if all else fails exrtracorporeal shock wave therapy |
|
|
Majority of ________ stones will dissolve in 2 weeks once urine is alkalinized.
|
uric acid stones
|
|
|
Which type of stone is seen with multiple UTIs?
|
struvite
|
|
|
What are the bacteria that are associated with struvite stones?
|
urease producing organisms
-proteus and providencia |
|
|
How do proteus and providencia lead to stone formation?
|
increased NH3
they also raise urine pH |
|
|
Treatment for Struvite Stones
|
treat underlying infection and surgery-antibiotics alone won't cure the infection
|
|
|
What are the urease producing bacteria?
|
Mot species of proteus and providencia
Klebsiella Pseudomonas Serratia Haemophilus Staph Corynebacterium |
|
|
Typically, what shape are the cysteine stones?
|
calyceal or hexagonal
|
|
|
Cysteine stones are refractory to...
|
exracorporeal shock wave lithotripsy
|
|
|
What are treatments for cysteine stones?
|
ultrasonic lithrotripsy is medical management fails
penicillamine and tiopronin for patients who fail fluid management and urine alkalinization |
|
|
Who needs admitted if he has a stone?
|
1. uncontrollable pain
2. UTI with stone 3. Complete Obstruction 4. Sepsis 5. Single kidney or renal transplant |
|
|
When a patient has a stone, what situations warrant urgent urologist consult?
|
1. urosepsis
2. ARF 3. Anuria 4. Unyeilding pain, N/V |
|
|
What diseases are risk factors for stone formation?
|
1. hyperparathyroidism
2. Crohn's 3. RTA 4. Hyperthyroidism 5. Infectious stone/Staghorn |
|
|
_____ and _____ have been used a vasodilators with varying success to help pass stones.
|
CCB and nitrates
|
|
|
What is the number one cause of Acute Kidney Injury?
|
Prerenal
|
|
|
What are some prerenal causes of Acute Kidney Injury?
|
Hypovolemia
Hypotension Ineffective Circulating Volume Aortic Stenosis Renal Artery Stenosis |
|
|
What is the most common intrinsic renal disease leading to Acute Kid ney Injury?
|
ATN
|
|
|
Acute Kidney Injury occur in what % of hospital patients?
|
5%
|
|
|
Acute Kidney Injury occurs in what % ICU patients?
|
10-15%
|
|
|
What % of Acute Kidney Injury is due to iatrogenic causes?
|
50%
|
|
|
Even minor increases in ________ are associated with increased hospital mortality.
|
serum creatinine levels
|
|
|
Acute Kidney Injury leads to CKD and dialysis dependency in what % of patients?
|
15%
|
|
|
Syndrome in which there is abrupt and sustained decreased GFR occurring within minutes to days in response to ischemia or nephrotoxic insult.
|
Acute Tubular Necrosis
|
|
|
70-75% of all ARF cases are due to ______ and ______.
|
Reduced renal perfusion and ATN
|
|
|
What is the diagnostic approach to Acute Kidney Injury?
|
1. Review Medical Records
2. Physical Exam-evaluate hemodynamic status 3. Urinalysis 4. Determine urinary indices 5. bladder catheterization 6. fluid diuretic challenge 7. radiologic studies 8. renal biopsy |
|
|
Differential Diagnosis of AKI
|
Outlet Obstruction
AIN Atheromatous Emboli after aortic surgery or aortogram Intrarenal obstruction |
|
|
Symptoms of AKI
|
N/V/D
Pruritis Drowsiness SOB Dizziness Anorexia Hematochezia Hiccups |
|
|
Signs of AKI
|
Mental Status Changes
Edema Weakness Dehydration Rash-AIN or livedo reticularis CVA-embolic Urine infection Ecchymosis |
|
|
How do you tell if reduced kidney function is acute or chronic?
|
look at the medical record for history of prior renal function
|
|
|
What are some nephrotoxic agents that may lead to AKI?
|
aminoglycosides
methicillin cytotoxins Cysplatin contrast dye |
|
|
Sepsis is a posible cause of AKI, even in the absence of______.
|
Hypotension
|
|
|
What can cause typically nonoliguric ATN during the first two weeks of therapy?
|
aminoglycosides-typically gentamycin in hospitalized patients
|
|
|
What causes oliguric ATN within 24-48 hours after administration?
|
contrast dye
|
|
|
Methoxyflurane and enflurane can cause _______
|
non-oliguric ATN
|
|
|
What types of surgery make patients particularly susceptible to ATN?
|
cardiac
vascular obstructive jaundice |
|
|
What PE clues may indicate decreased EFV?
|
weight loss
orthostasis decreased JVP |
|
|
What PE clues may indicate decreased ECV?
|
peripheral edema-R side failure
Ascites Rales in bases |
|
|
What are some PE clues that might indicate bladder outlet obstruction?
|
distended bladder
big prostate anuria or intermittent anuria few sediments in urine |
|
|
Urine volume is < _______ in oliguric ATN.
|
400ml/day
|
|
|
______ is associated with nephrotoxic antibiotic induced AKI.
|
non-oliguric ATN
|
|
|
Hyalin casts, high specific gravity, and highly refined granular casts in the urine sediment is indiciative of...
|
prerenal cause of azotemia
|
|
|
Dirty brown granular casts and renal tubular epithelial cells in the urine sediment are indiciative of...
|
ATN
-intrinsic renal cause -70-80% of ATN patients have this urine |
|
|
Urine indices are inaccurate if the patient is...
|
on diuretics or hyperuricemic
|
|
|
Urine Sodium <20 indicates:
|
Prerenal Azotemia
|
|
|
Urine Sodium >40 indicates:
|
ATN
|
|
|
Urine Creatinine >40 indicates:
|
Prerenal Azotemia
|
|
|
Urine Creatinine <20 indicates:
|
ATN
|
|
|
Urine Osmolarity >500 indicates:
|
Prerenal Azotemia
|
|
|
Urine Osmolarity <350 indicates:
|
ATN
|
|
|
Renal Failure Index <1 indicates:
|
Prerenal Azotemia
|
|
|
Renal Failure Index >1 indicates:
|
Acute Tubular Necrosis
|
|
|
FeNa <1 indicates:
|
Prerenal Azotemia
|
|
|
FeNa >1 indicates
|
ATN
|
|
|
FeNa>20% indicates:
|
Renal causes
|
|
|
BUN/Creatinine<15:1 indicates
|
renal causes
|
|
|
With renal causes of AKI, urine sodium is ______.
|
increased
|
|
|
BUN/Creatinine >20:1 indicates:
|
Prerenal causes
|
|
|
Urine/Plasma Creatinine
-Concentration of creatinine in urine that is higher than that inthe plasma is due to: |
removal of water
|
|
|
Urine Specific Gravity>1.015 is indicative of:
|
Pre-renal causes
|
|
|
Urine Specific Gravity <1.015 is indiciative of:
|
ATN
|
|
|
Further evaluation of ARF is necessary if:
|
Diagnosis is uncertain or points to obstruction
Anuria Oliguria persists more than 4 weeks |
|
|
Further workup of ARF includes:
|
1. ABG
2. Ultrasound 3. Renal Biopsy 4. Radionuclide methods to check renal blood flow |
|
|
What does ABG look like in ARF?
|
uncompensated metabolic acidosis
|
|
|
Features that suggest CRF
|
history of elevated BUN/Creatinine
small kidneys-with some exceptions renal osteodystrophy anemia |
|
|
What disease maintain normal kidney size in CRF?
|
DM
HIV Multiple Myeloma Amyloidosis PKD |
|
|
What are some complications of renal failure that require urgent dialysis?
|
pericarditis
hyperkalemia asterixis pericardial rub |
|
|
History of statins or tissue trauma and tea colored or pink urine might suggest:
|
rhabdomyolysis
|
|
|
What new kidney marker increases before creatinine in kidney failure?
|
cystatin c
|
|
|
Cystatin C can show ATN 2 days before creatinine rises in what situations?
|
radiocontrast dye nephropathy
kidney transplant AKI in the ICU |
|
|
How do you treat ARF due to a prerenal cause?
|
give fluids
|
|
|
In ATN, BUN will increase ______ per day.
|
10-20mg/dl
|
|
|
In ATN, HCO3 will decrease to:
|
about 18-mild metabolic acidosis
|
|
|
ATN is a _______ event.
|
Catabolic
-weight loss 1/2 lb per day |
|
|
Most common biochemical abnormality causing death in ATN.
|
Hyperkalemia
-requires urgent intervention |
|
|
If patient in ATN is in severe acidosis or hyperkalemia what should be considered for treatment?
|
dialysis
|
|
|
What is the main cause of death in patients with ATN?
|
infection/sepsis
|
|
|
What are the medical treamtents for ARF?
|
NS
Mannitol Furosemide Dopamine |
|
|
What are the indications for dialysis in ARF?
|
hyperkalemia/acidosis not responding to tx
fluid overload not responding to treatment BUN rising more 20/day BUN >80-100-especially if creatinine is 5 or 6 GFR<10% |
|
|
The oliguria phase of ATN typically lasts...
|
1-2 weeks
|
|
|
1/4 of deaths occur during this phase of ATN
|
diuretic phase
|
|
|
What is the mortality rate from ATN?
|
50%
|
|
|
Most ATN patients have ______ or _______.
|
decreased RBF or exposure to nephrotoxic agent
|
|
|
ATN due radiocontrast material happens within...
|
1-4 days
|
|
|
AKI secondary to nephrotoxicity happens to 10% of patients receiving:
|
aminoglycosides
|
|
|
What is another side effect of the aminoglycosides?
|
ototoxicity
|
|
|
Normal Kidney Size in Chronic Disease
|
DM
HIV Multiple Myeloma Amyloidosis |
|
|
Cystatin C is useful for early detection of ATN in what situations?
|
Radiocontrast dye nephropathy
Kidney transplant AKI |
|
|
In ATN, what usually remains normal?
|
K+
|
|
|
In ATN, BUN will rise ______ per day...
|
10-20mg/dl
|
|
|
What is a good indicator of hyperkalema in an ATN patient?
|
peaked T waves on EKG
|
|
|
What are the medical treatments for ATN before going to dialysis?
|
NS
Mannitol Furosemide Dopamine |
|
|
Patients should be well hydrated before receiving _____.
|
Cysplatin
|
|
|
Rhabdomyolysis can be secondary to...
|
Statins
Crush injuries/Burns/Trauma Seizures Infection ETOH/drugs |
|
|
In rhabdomyolysis, ____ is usually very elevated.
|
CPK
|
|
|
What is the treatment of rhabdomyolysis with ATN?
|
fluids
mannitol |
|
|
What is the urolytic drug of choice for hyperuricemia after chemo?
|
Rasburicase
|
|
|
ARF in first trimester is usually due to...
|
septic abortion
hemorrhage DIC |
|
|
ARF in the 3rd trimester is usually due to...
|
preeclampsia
placental abruption post-hemorrhage |
