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161 Cards in this Set
- Front
- Back
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What is dysuria? |
-Pain or a burning sensation on urination -Frequency, urgency, hesitation, and strangury |
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What is the most common cause of dysuria? |
-Most commonly due to lower urinary system infections -Most often associated with a bladder problem and rarely with renal disease |
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What are some differential diagnosis for dysuria? |
-Inflammatory lesions of prostate, bladder, and urethra -Outside the renal system: STIs -Symptoms that may lead to other diagnosis: urethral strictures, prolapsed uterus, pelvic peritonitis, and cancer of the cervix or prostate -Bladder tumors, CRF, nephrolithiasis, and disease of the upper urinary system |
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What else should women with dysuria should be questioned about? |
Vaginal discharge or irritation present with dysuria |
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What else should men with dysuria should be questioned about? |
Penile discharge present with dysuria |
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What is the easiest way to test for dysuria? |
Urinalysis -Easiest, most non-invasive, and most economical way to identify UTIs and other renal problems |
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What should urine not contain? |
Bacteria, odor, turbidity, nitrites, casts, proteins, RBC and WBCs |
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What does dark yellow urine mean? |
-Can be sign of dehydration -More common first morning urine |
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What does red urine mean? What does brown urine mean? |
Hematuria |
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Describe the clarity of urine. |
-Healthy urine is clear to maybe slightly cloudy -Cloudy or turbid urine may indicate (pus, blood, sperm, yeast calcium crystals, and mucus) |
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Describe the odor of urine. |
-Most often described as a nutty smell -You never want a sweet, fruity odor which means ketoacidosis -Foul smelling urine means UTI |
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What is the pH of healthy urine? What does a high pH mean in urine? |
-Slightly acidic: pH 5.0 to 6.0 -High pH or excessive alkaline reading can be caused by UTI (6 to 8) due to increased ammonia -High pH can also be caused by severe vomiting, kidney disease, URI and asthma |
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Explain the results of specific gravity in urine in relation to water |
The specific gravity of water is 1 so the closer the number comes to 1, the fewer particles will be found on it. -Shows the kidney's ability to concentrate urine -Normal: 1.010-1.030 |
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What are some causes to high specific gravity? |
-Volume loss (dehydration, vomiting, diarrhea, fever) -Heart failure, renal artery stenosis, shock, and SIADH |
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What are some causes to low specific gravity? |
Diabetes inspidus, renal failure, pyelonephritis, glomerulonephritis, psychogenic polydipsia, increased ICP, and malignant hypertension |
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What does the presence of nitrites mean on a urinalysis? |
Presence of bacteria -E.coli, proteus, and Klebsiella |
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If you see leukocyte esterase on a urinalysis, what does it mean? |
-Evidence of immune system response to a UTI, vaginitis, or urethritis -May see increased WBCs |
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What is glucosuria? |
When glucose spills into the urine -Happens when blood sugar exceeds 200 -Causes increased water loss due to dehydration -Seen commonly in uncontrolled diabetes mellitus -SLGT2 inhibitors (involved in glucose reabsorption) |
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What happens if you see protein (albumin) in your urine? |
-If there are large amounts of albumin, there is a problem such as: kidney disease, infection, glomerulonephritis, diabetes, cancer, HTN, lupus, HF, mercury poisoning -There should be no large proteins in urine -Athletes will have trace amounts |
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What happens if you see ketones in the urine? |
-Should not have detectable ketones in your urine -If present, this may be a sign of uncontrolled diabetes -May even show starvation, eating disorders, or special diet like Atkin's |
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If you see RBCs in the urine, what could it mean? |
-Kidney or bladder injury, kidney stones, UTI, inflammation of the kidneys, or kidney or bladder tumor |
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What is bilirubin and what does it mean if it is present in urine ? |
-By product of RBC breakdown -It is usually carried in the blood and removed by the liver through bile -Bilirubin in urine may indicate liver damage or disease -High levels of urobilinogen may indicate liver disease |
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What are the different types of acellular cast? |
-Hyaline casts are most common and seen in dehydration -Granular casts are 2nd most common -Waxy Casts due to low urine flow -Fatty casts are seen with nephrotic syndrome |
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What are the different types of cellular casts? |
-RBC casts are pathologic, glomerular damage -WBC casts are seen with infection -Bacterial casts are seen with pyelonephritis -Epithelial casts are seen with tubular necrosis |
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When bacteria, yeast, and parasites are present in urine, what does it usually mean? |
Present in an infection |
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Who are lower UTIs most common with? |
More prevalent in sexually active adults, spermicide and diaphragm use, very young children, and presence of cystocele -Other risk factors: pregnancy, diabetes, older age, menopause, MS, spinal cord injury, immunocompromised, catheter dependency, and urologic abnormalities |
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What is the most common pathogen of a lower UTI? |
E coli |
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What are some presenting symptoms and signs you would see on a physical exam in a UTI? |
Frequency, urgency, pressure, hematuria, dysuria, nocturia, low back or suprapubic pain, urinary incontinence, cloudy or foul-smelling urine -Fever, tachycardia, tachypnea -Suprapubic tenderness -Costovertebral angle tenderness |
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What will the diagnostic tests of a UTI show? |
Urine dip stick may reveal: cloudy appearance, alkaline pH, hematuria, positive nitrites, and positive leukocyte esterase -A negative dip does not rule out infection -Must do a urinalysis |
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If you have a persistent or chronic UTI, what are some tests you can run? |
-Check post void residual urine -Renal and pelvic ultrasound to evaluate the urinary system and to identify stones and obstructions |
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What is the gold standard for laboratory confirmation of a UTI? |
Urine culture |
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What is the MIC value and its relation to antibiotics? |
The lower the MIC value for a specific antibiotic-bacteria combination, the more sensitive the bacteria is to the antibiotic -Determines if the bacteria is sensitive, intermediate, and resistant to the given antibiotic |
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What are some differential diagnosis for lower UTI? |
Vaginitis, urethritis, pelvic organ prolapse, trauma/previous bladder surgery, overactive bladder urge incontinence, interstitial cystitis, bacterial vaginosis, tumor/bladder cancer, irritant urethritis |
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Does lower UTI exhibit signs of sepsis? |
NO |
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What are some medications to treat lower UTI? |
-Ciprofloxacin 500mg BID for 7 days -Levofloxacin 750mg Daily for 5 days -Bactrim BID for 14 days |
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If you have a fungal UTI, how do you treat it? |
-Fluconazole 200mg Daily for 7-14 days |
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If you are pregnant, how do you treat a UTI? |
-Amoxicillin 500mg BID for 10 days -Nitrofurantoin 100mg BID for 10 days -CEphalexin 500mg BID for 10 days |
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What medication should you avoid during pregnancy when treating a UTI? |
Fluoroquinolones -Associated with cartilage damage and arthropathies |
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When you are treating a recurrent UTI, what are some prevention strategies? |
-Change contraceptive methods if using diaphragm or spermicide -Consider using pads instead of tampons -Drink cranberry juice daily -Void regularly -Increase fluids -Avoid douching and scented bubble baths -Post sex voiding |
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How do you treat a recurrent, uncomplicated UTI and what is considered a recurrent UTI? |
-2 to 4 UTIs per year -Post sex prophylaxis -Take 1 hour before or after sex -Nitrofurantoin 100mg Once or -Bactrim DS PO Once |
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What is the prophylactic treatment for a chronic UTI? |
Treatment is either on a daily basis or 3 to 6 months -Nitrofurantoin 50 or 100mg Daily at bedtime -TMP-SMX (1/2 strength) once daily at bedtime |
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Does interstitial cystitis respond to antibiotics? |
No, interstitial cystitis does not respond to antibiotics. Antibiotics may also relieve pain and discomfort with UTI |
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If you want to decrease pain associated with UTI, what can you prescribe? |
Analgesics -Phenazopyridine (Pyridium) OTC 100 to 200mg PO TID for 2 days after meals |
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What should you advise the patient to do when having a lower UTI? |
-Complete your full course of antibiotics -Increase fluid intake to eight glasses of water -Cranberry supplement and cranberry juice -Avoid bladder irritants (Coffee, tea, carbonated beverages, dietary sweeteners, and tomato based foods -Self medicate as needed -Wear cotton underwear -Avoid harsh soaps or feminine hygiene products -Empty bladder completely and frequently -Take showers instead of tub baths -Keep a diary of urinary symptoms |
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What is pyelonephritis? |
Infection of the kidney characterized by infection within the renal pelvis, tubules, or interstitial tissue |
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What can cause pyelonephritis? |
-Anatomic abnormalities (ureterovesical reflux) -Urinary obstruction (stones) -Stress incontinence -Multiple or recurrent UTIs -Renal disease -Kidney trauma -Pregnancy -Metabolic disorders |
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What is a common bacteria that causes pyelonephritis? |
E. Coli |
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What is important to remember with pyelonephritis and pregnant women? |
Upper UTI can cause premature delivery -Treatment in pregnant women is critical |
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Describe the signs and symptoms in acute pyelonephritis. |
Sudden onset -Fever, shaking, chills, nausea, vomiting, unilateral or localized flank pain, fatigue, and diarrhea |
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Describe the signs and symptoms in chronic pyelonephritis. |
Fatigue, nausea, decreased appetite with sudden weight loss, nocturia, polyuria, and symptoms of renal failure |
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What will you see on the physical exam of a patient with pyelonephritis? |
Marked tenderness on deep abdominal palpation -May be hypertensive -Flank pain or costovertebral angle tenderness which is usually unilateral |
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What is the diagnostic testing for pyelonephritis? |
Urinalysis -Positive for bacteria, proteinuria, leukocyte estrace, nitrites, hematuria, pyuria, and WBC casts |
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Because pyelonephritis is difficult to differentiate from cystitis, what is one quality that differentiates pyelonephritis from cystitis? |
Presence of WBC casts through urinalysis is diagnostic for pyelonephritis -Will also see persistent pyuria and positive urine cultures |
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What is the management for mild pyelonephritis? |
Oral antibiotics. Pick 1: -Ciprofloxacin 500mg BID for 2 weeks Ofloxacin 200-300mg BID for 2 weeks -CEfpodoxime 200mg PO Q12 hours for 2 weeks -Bactrim PO BID for 2 weeks |
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What happens if a patient does not respond within 48 hours of treatment of pyelonephritis? |
-Reevaluate and cultures -Can do Ultrasound, IVP, DMSA renal scan -IV Antibiotics -Increase fluid intake and I/O -Surgery? |
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What is the follow up for mild, recurrent, and chronic pyelonephritis? |
-Mild: Assessed 48 hours to assess responsiveness to therapy -Recurrent: Reculture at 2, 6, and 12 weeks after antibiotics -Chronic: refer to nephrologist |
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What is nephrolithiasis? |
A condition in which stones originate in the kidney. -Stones form form calcium salts, struvite, uric acid, and cystine |
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What are risk factors for nephrolithiasis? |
Sedentary lifestyle, high environmental temperatures, diets high in salt animal fat and proteins, oxalate from green leafy vegetables, vasectomy and hypertension |
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What are some reasons nephrolithiasis occurs? |
-Obstruction, urinary stasis, infection, dehydration, urine concentration -Increased consumption of calcium and vitamin D -Excessive excretion of uric acid -Vitamin A deficiency -Too much black tea, nuts, spinach, beets, rhubarb, chocolate, breads, cereals, potatoes |
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What is the most common type of nephrolithiasis in men? |
Calcium oxalate or calcium phosphate stones -Light in color, resemble RBC's in shape and size |
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What is the most common type of nephrolithiasis found in women? |
Struvite stones -Associated with UTI -Urine is alkaline -Stones are flat and hexagon shaped. Staghorn stones |
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What are two elements that can inhibit stone formation? |
Magnesium and citrate work to inhibit kidney stones |
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Describe the clinical presentation of nephrolithiasis |
-Varies on location, size, and type of stone -Onset is usually sudden with renal colic -Nausea, urinary frequency, vomiting, diaphoresis, dysuria, hematuria, and weakness -History of recent or chronic UTI -Abdominal distention and guarding -Flank tenderness on percussion -Decreased or absent bowel sounds -Fever -BP elevated due to pain |
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What is the diagnostic testing for nephrolithiasis? |
-Routine UA -CBC (elevated WBC) -Blood chemistry (electrolytes, BUN/Cr, Calcium, phosphorus, and uric acid) -If renal calculi present, strain urine and send stone for analysis -KUB x-ray studies |
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What is the gold standard for diagnosing nephrolithiasis? |
Noncontrast helical CT scan -Preferred test due to high sensitivity and specificity |
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When diagnosing nephrolithiasis, what confirms it? |
-Diagnosis of renal stones is confirmed by urinalysis that is positive for blood and renal visualization by CT scan |
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On a KUB (Kidney, ureters, and bladder) x-ray study, what will calcium phosphate, uric acid, and cystine stones look like on x-ray? |
-Calcium phosphate: greater density followed by calcium oxalate -Uric acid: Radiolucent -Cystine stones: Partially radiolucent |
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What are some differential diagnosis for nephrolithiasis? |
Appendicitis, diverticulitis, mesenteric adenitis, ovarian cysts, pancreatitis, paralytic ileus, peptic ulcer disease, pyelonephritis, abnormalities of the fallopian tubes and ovaries |
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What is the pharmacological treatment of nephrolithiasis? |
Treatment depends on the size and location of stone (4mm stones can pass without surgery) Pain: NSAIDS 600-800g TID Tamsulosin 0.4mg Daily to promote stone passage |
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What are non-pharmacological treatment of nephrolithiasis? |
-Promote water intake 6 to 8 glasses of water/day -Warm compresses to lower back, focused breathing, imagery, diversional activities -Sitting in a warm tub or jaccuzzi -Promote Vitamin B6 and magnesium to decrease oxaluria -Strain urine for passed stones |
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What is the difference between lithotomy and lithotony? |
-Lithotomy: Incision into the bladder or ureter to remove calculi or place a ureteral stent -Lithotony: arthroscopic extraction of a renal stone from the bladder |
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What foods should you limit when you have kidney stones/preventing kidney stones? |
Caffeine, beer, wine, oxalate-rich foods (beets, black tea, cholocate, lamb, nuts, rhubarb, spinach), Eliminate milk and cola products, purine rich foods: organs, red meat, seafood, poultry, legumes, whole grains, and alcohol |
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If a patient has uric acid stones, what foods should they avoid? |
-Decrease consumption of foods containing purines -Read meat, nuts, beer -May need to be started on allopurinol to reduce uric acid levels in the urine |
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What foods should you avoid if you have calcium oxylate stones? |
-DO NOT limit the consumption of calcium foods -Limit high oxalate foods: tea, coffee, cola, chocolate, nuts, green leafy vegetables |
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What is the specific treatment for calcium oxalate stones? |
Water -UroCit-K (Rx stone dissolver) -Can use HCTZ to absorb calcium and prevent excretion -Reduce sodium to 2 grams per day Calcium citrate (an inhibitor of stones) -If the patient is hypercalcemic, check PTH! |
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What is the most common kidney cancer? |
Renal cell carcinomas |
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When a renal tumors present, what is the most common presenting symptom? |
-Gross hematuria (40% of the time is the only presenting symptom) -Can also have dull, achy flank pain, abdominal mass, weight loss fatigue, intermittent fever not associated with infection, palpable abdominal mass, and nephralgia |
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What is the initial testing for renal tumors? |
-Kidney ultrasound or CT scan -Can do an abdominal CT scan or MRI, ureteroscopy or ultrasonography with IVP -Tissue biopsy samples |
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How is a renal cyst differentiated from renal tumor? |
By biopsy |
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What are some differential diagnosis for renal tumors? |
-Renal calculi, renal infarction, renal tuberculosis, polycystic kidney disease, and hydronephrosis |
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Is chemotherapy recommended for the treatment of renal tumors? |
-Chemo is not effective. Radiation is controversial -Kidney cancer may be 1 of the few cancers that the body's immune system can fight |
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What is the most common bladder tumor? |
-Transitional cell carcinomas -Often present multifocally along the urinary tract, spreading via intraluminal seeding or intraepithelial migration |
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What is the most common presentation in bladder tumors? |
Asymptomatic until an episode of hematuria **PAINLESS HEMATURIA |
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What are other signs and clinical presentation of bladder tumors? |
Dysuria, frequency, chills, low grade fever, weight loss, urinary urgency, pelvic pain -Palpable mass |
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What will a urinalysis usually show in bladder tumors? |
Trace to gross hematuria Abnormalities in protein levels, RBC, or WBC -No RBC casts, negative culture |
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How is the presence of a bladder tumor confirmed? |
Visualization of the lesion through cystoscopy and biopsy -Cystoscopy can determine location and aid in the staging of the tumor |
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What are some differential diagnosis for bladder tumors? |
Stones, infections, trauma, other tumors, AV malformations, and glomerulonephropathies |
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What is the treatment of choice for bladder tumors? |
-Surgical resection is treatment of choice -Can do a radial cystectomy, radiation, or chemo |
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What is the follow up for bladder tumors? |
-Every 3 to 6 months for a urinalysis and cystoscopy |
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What is interstitial cystitis? |
Chronic condition of the bladder Pressure and pain ranges from mild to severe |
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What is the primary function of a kidney? |
Maintain homeostasis -Excretion is a byprouduct of that homeostasis -Cleans the blood |
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What is the purpose of renin in the kidneys? |
-It is an enzyme -Controls the activation of the hormone angiotensin which stimulates the adrenal glands to produce aldosterone -Aldosterone tells the kidneys to retain sodium and water which pushes the blood pressure up |
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What is the gold-standard definition of microscopic hematuria? |
-3 or more red blood cells per hpf on microscopic evaluation of urinary sediment -Found in 2 of 3 properly collected urinalysis specimens -Any blood in the urine needs to evaluated even if it resolves spontaneously |
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Describe the color, clots, RBC morphology, casts and proteinuria in nonglomerular bleeding |
Color: Red or pink urine Clots: May be present RBC: Normal Casts: Absent Proteinura: Usually absent |
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Describe the color, clots, RBC morphology, casts and proteinuria in glomerular bleeding |
Color: red, smoky brown, Coca-cola Clots: Absent RBC: Dysmorphic Casts: May be present Proteinuria: May be present |
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What are some nonglomerular hematuria causes in the upper tract? |
-Transitional cell carcinoma -Urinary obstruction -Acute tubular necrosis -Renal artery stenosis -Embolism of renal arteries -AV malformation of kidney -Sickle cell trait -Infection (pyelonephritis, TB, parasitic) |
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What are some nonglomerular hematuria causes in the lower tract? |
Infection (UTI, prostatitis, epididymitis) -BPH -Strenuous exercise -Transitional cell carcinoma -Spurious hematuria (menses) -Benign hematuria -Dietary substances (bladder irritants) |
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What are some medications that can cause hematuria? |
Aminoglycosides, amitriptyline, NSAIDS, anticonvulsants, ASA, Busulfan, thorazine, cytoxan, diuretics, BCPs, PCN, quinine, vincristine, warfarin |
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What is the most common cause of glomerulonephritis? |
-Renal failure (Glomerular cause of hematuria) |
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What are common clinical presentation of hematuria? |
Depends on condition: -Infection--dipstick will show presence of leukocytes, nitrites, can see positive GC/chlamydia, complaints of dysuria, frequency and urgency (Cystitis), urethritis (urethral d/c), scrotal pain (epididymitis) -CVA tenderness (Pyelonephritis) -Tender suprapubic (bladder infection) -Abdominal/flank pain, colicky (stones) -Enlarged prostate (BPH) -Coagulopathy or vasculitis -Hematuria accompanied by HTN, edema, sore throat (Hlomerulonephritis) |
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If hematuria presented with cancer, what would the signs and symptoms be? |
-Abdominal mass (renal cell tumor or polycystic kidney disease) -Suprapubic tenderness (bladder cancer) -Prostate nodules (poss. prostate cancer) |
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What is the diagnostic workup for hematuria? |
-Usually first identified through urine dipstick -Will detect the presence of heme but not "blood" -Heme is the iron containing portion found in hemoglobin and myoglobin -cystoscopy |
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If the dipstick is positive for heme, but the microscopic exam is within normal limits (No RBCs) then suspect? |
Myoglobinuria (from muscle injury) |
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If a U/A with microscopy were to reveal the following, explain the significance: dysmorphic RBCs, RBC casts, intact RBCs with no cast, and proteinuria and hematuria. |
-Dysmorphic RBC: glomerular disease -RBC Casts: Indicates injury to nephron and is diagnostic of hematuria of a renal origin -Intact RBCs with no casts: Hematuria from teh lower urinary tract -Presence of proteinuria and hematuria: suggestive of glomerular or interstitial nephritis |
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What are the current recommendations for cystoscopy? |
American Urologic Association recommends cystoscopy for microscopic hematuria -All patients older than 40 years -All patients younger than 40 years with a risk of bladder cancer -Only reliable method for detecting transitional cell cancer of the bladder and urethra (Costly, invasive, and uncomfortable) |
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What is the follow up for hematuria? |
-Idiopathic microscopic hematuria: repeat UA with urine cytology every 6 months. -Can repeat cystoscopy every year especially for persons older than 40 years and younger persons who have risk factors for urothelial cancer (smokers, occupation exposure to benzenes or aromatic amines) |
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When hematuria is present, when should you refer to a nephrologist? |
-If 1 or more is present with microscopic hematuria: proteinuria, dysmorphic RBCs or casts, and elevated serum CR |
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What is proteinuria usually indicative of? |
Renal pathology, most often of glomerular origin Most common cause of pathological proteinuria (Glomerular) **Suspect glomerular if more than 2g excreted in 24 hours **Suspect Tubular if less than 2g excreted in 24 hours |
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What is the most accurate way to quantify protein in the urine? |
24 hour urine collection |
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What is albuminuria associated with? |
Kidney disease (Should only have a very small amount in the urine) |
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If a patient's dipstick reveals trace to 2 protein, how should you proceed with other testing? |
-Over the next month, recheck morning urine protein twice with urinalysis -If persistent, proceed to 24 hour urine protein or protein/Creatinine ratio, serum/urine protein elctrophoresis, and CMP, fasting glucose, lipid profile, CBC, urine C/S -If negative, patient has transient protein and does not need further work up |
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If a patient's dipstick reveals >3 protein, how should you proceed with other testing? |
Proceed with a 24 hour urine protein or urine protein/Cr ratio -Ratio: <0.2 is normal. >3.5 is not normal -Serum/urine protein elctrophoresis, and CMP, fasting glucose, lipid profile, CBC, urine C/S |
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If you see a urine protein/creatinine ratio of more than 3.5, what should you do? |
Refer to nephrologist because it is indicative of nephrotic syndrome
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What is orthostatic proteinuria and who is affected and how is it diagnosed? |
-Increased protein excretion while in the upright position, normal excretion while in supine position -Characteristics: less than 30 YO, excrete less than 2 grams of protein per day, normal GFR or creatinine clearance -16 hour daytime specimen is obtained during the day then an 8 hour collection at night |
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If excretion of protein is more than 2 grams in 24 hours, what does that mean? |
Glomerular cause is mostly likely and further evaluation is needed and nephrology consultation 24 hour protein is >2 grams, refer! |
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How do you manage proteinuria? |
-Can try ACE which can reduce proteinuria by decreasing interglomerular pressure Main goal is to prevent or delay ESRD, so treat underlying conditions. Treat HTN, diabetes, and dyslipidemia |
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What is the most common form of kidney injury? |
Acute renal failure |
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What are some symptoms of acute renal failure? |
Fatigue, malaise, nausea, vomiting, pruritus, mental status change, oliguric or anuria may be present (these are also symptoms of Stage 1 ARF) |
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What are some objective signs of ARF? |
-Orthostatic VS, tachycardia, dry mucous membranes, skin turgor, tachycardia, pericardial rub, signs of pulmonary edema (increased RR< rales), distension of jugular veins, bladder mass, renovascular disease, palpable kidneys, petechiae, pelvic mass, enlarged prostate, renal obstruction |
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What are some helpful diagnostic tests for ARF? |
-BUN/Cr: helps to establish the diagnosis -GFR: measures how well kidneys are filtering creatinine -electrolytes, CBC, urinalysis, 24 hour test for protein or random urine protein/creatinine ratio -Renal ultrasound -CT of abdomen -May need a renal biopsy if noninvasive testing is inconclusive |
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What is the gold standard of bilateral renal artery stenosis? |
Renal angiography is the gold standard to diagnosis bilateral renal artery stenosis |
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What are the most list threatening consequences to ARF? |
Hyperkalemia, acidosis, fluid overload, and bleeding |
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In regards to ARF, when should you start to manage hyperkalemia? |
K higher than 6.5 needs emergent care -Make sure to decrease potassium in diet -Avoid all nephrotoxic agents and correct anemia |
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When would you need temporary dialysis for ARF? |
-Fluid overload unresponsive to diuretic therapy -Hyperkalemia with symptoms or EKG changes -Uremic encephalopathy -Severe metabolic acidosis -Pericarditis |
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How often should you follow up when you have ARF? |
1 week, 1 month, 3 months, 6 months, and then annually -At each visit: BMP, CBC, assess for S/S of fluid overload (JVD, crackles, weight gain, elevated BP, SOB, and edema) |
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What should you do to prevent contrast nephropathy? |
-Hold metformin 48 hours prior to IV contrast -Hold diuretics and NSAIDS and any potentially nephrotoxic medications -Oral acetylcysteine (Mucomyst 600mg BID the day before and the day of the study) along with adequate hydration -Consult with a radiologist |
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Who should you screen for CKD? |
DM, HTN, 60 years or older, family history of renal disease, history of recurrent UTI and urinary obstruction, and chronic disease that may affect the kidney |
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What is the most common cause of death in patients with CKD? |
Cardiovascular disease |
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Why is it important to screen for proteinuria in CKD? |
Screening for proteinuria can detect chronic kidney disease before changes in GFR -Significant kidney disease can present with decreased GFR or proteinuria or both -Proteinuria is associate with a more rapid progression of CKD disease |
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What are other labs you should screen for CKD? |
Blood pressure, creatinine, GFR, random urine for proteinuria, UA with microscopy, electrolytes, phosphate, glucose level, albumin, Vitamin D, elevated ammonia, 24 hour urine, lipids, -Assess renal function with: BUN, Cr, and GFR |
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What is the best indicator for kidney function? |
GFR: gives the percentage of kidney function
-Mathematical equation that is based on creatinine, age, gender, and race) (Normal: 100mL/1.73m2) |
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What does it mean if a GFR is 40? |
The patient has approximately 40% kidney function remaining and 60% of kidney function has been lost |
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Is creatinine the best test to evaluate kidney disease? |
-You could have a normal creatinine level but have kidney disease -You could have an elevated creatinine level but not have kidney disease |
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What does microalbumin mean? |
Describes the amount of protein that is below the sensitivity of the urine dipstick -If you do the urine albumin to creatinine ratio, it can eliminate the need for a 24 hour collection -Normal ratio: <0.25 grams protein per creatinine |
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What is the gold standard for proteinuria testing? |
24 hour urine collection for protein, but it is inconvenient and prone to error |
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What is the national kidney foundation's kidney disease's definition of chronic kidney disease? |
As evidenced by anatomic abnormalities on image studies -Albumin/creatinine ratio >30mg on 2 or 3 measurements over a 2 to 3 month period or -GFR <60mL for 3 or more months with or without kidney damage |
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What is the definition of end-stage renal disease? |
GFR below 15ml per minute per 1.73m2 -Need kidney replacement therapy (dialysis or transplant) |
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What are some subjective findings to chronic kidney disease? |
-Pruritis, dry skin, easily bruises, nausea, vomiting, anorexia, hiccupping, amenorrhea, depression, insomonia, fatigue, confusion, headache, seizures, and coma -Urine odor breath and perspiration, metallic taste in your mouth, nocturia, impotence, SOB, muscle cramps or twitching -Uremic frost, pale, peripheral neuropathy, AMS, ascities, crackles, pericardial rub, severe proteinuria and hypoalbuminemia, and elevated BP |
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What are some diagnostic tests (non-lab) you could run for CKD? |
Renal ultrasound-baseline Renal CT scan/angiography or MRI Duplex doppler ultrasonography |
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How often should you monitor someone with CKD? |
Monitor changes in renal function and labs every 2 to 3 months -BMP, magnesium, CBC, albumin, phosphorus, and calcium |
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What is the BP goal for diabetic patients with proteinuria? |
>1gram/day and the goal BP is 125/75 <1gram/day and the goal BP is 130/80 |
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In order to maintain renal perfusion, what should the systolic blood pressure be? |
Keep systolic blood pressure greater than 110 mmHg |
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What is the purpose of using ACE or ARBs? |
Inhibits the renin-angiotensin-aldosterone system and to limit proteinuria -Also use for blood pressure control -DO NOT USE together! |
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When using an ACE or ARB, if your BP is not at goal and still not at goal, what do you do? |
-If BP not at goal: add a diuretic -If BP still not at goal: add a calcium channel blocker or beta-blocker -If still not controlled, refer to specialist |
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What happens when you reduce proteinuria? |
Slows the progression of chronic kidney disease -ACE or ARBs should be adjusted as tolerated to eliminate albuminuria |
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What should you monitor after starting ACEs or ARBs? |
Creatinine and potassium levels |
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What should you look out for when starting a patient on ACEs? |
When starting an ACE, expect a mild decrease in GFR and 20 to 30% increase form baseline in creatinine. -Levels should even out within a few weeks -Wait 1 to 2 weeks. -Do not decrease if you see creatinine go up by 30% (Temporary) |
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Can you use ACEs/ARBs if you have renal artery stenosis? |
No. vasodilating effects on teh efferent renal arterioles will decrease the GFR in the presence of reduced afferent blood flow from stenotic renal arteries -May lead to acute or chronic renal failure |
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What are some clinical clues suggesting the presence of renal artery disease as the cause of HTN and CKD? |
Age of onset of HTN <30 years or 55 years, abrupt onset of HTN, acceleration of previously well controlled HTN, HTN refractory to an appropriate 3 drug regimen, accelerated hypertensive retinopathy, malignant HTN, history of tobacco use, systolic diastolic abdominal bruit, flash pulmonary edema, evidence of generalized atherosclerosis obliterans, asymmetry in kidney size on imaging studies, and AKF with treatment with ACE/ARB |
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What are some non-pharmacological management for kidney disease? |
Quit smoking Meals low in fat and cholesterol Exercise regularly vaccines: pneumococcal, flu, hep B and hep A |
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What is the management of ESRD? |
-Diet: restrict fluids, protein intake, phosphate, potassium -Can use low dose kayexalate 5mg PO TID with meal as a potassium binder for hyperkalemia -Oral phosphate binders if the GFR falls below 30mL -Vitamin D to prevent hypocalcemia -Renal specific multivitamin (Nephrocaps) |
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What can hyperphosphatemia lead to? |
Increased PTH -Causes increased bone turnover Decreased corticol bone and decreases bone strength, causing fractures -Treat hyperphosphatemia and this will reduce hyperparathyroidism (Use phosphate binders, Vitamin D) |
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Why is it important to treat hypercholesterolemia in regards to ESRD? |
Treat this with a statin Goal: LDL <100 CRF is considered a CAD equivalent |
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How should you treat acidosis as CRF progresses? |
Treat with Sodium Bicarbonate 600mg BID to titrate serum bicarbonate to the 16 to 20mEq range |
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When should you consider dialysis? |
When teh GFR is less than 10mL/min, a serum creatinine around 12mg or BUN greater than 100 -Other conditions: pericarditis, pulmonary edema, medication resistant HTN, uremic syndrome, neurologic symptomatology, persistent nausea/vomiting, protein malnutrition |
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What is important to remember with gout and CKD? |
-Avoid NSAIDS -Solumedrol, colchicine, and allopurinol can be safely used -Allopurinol needs renal adjustment -Avoid Toradol and NSAIDs in patients with GFR <40 because of its direct toxic effect on teh renal tubules |
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If the GFR <60, what medications are deemed unsafe? |
-No COX 2 inhibitors -Reduce allopurinol to 100mg/day -Use caution with biphosphanates (Avoid if GFR <30) -No oral phosphate preps like fleets for colonoscopy -IV Contrast -Adjust the dose for beta blockers, antibiotics, zantac, and pepcid -Avoid tricyclic antidepressants |
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Are thiazide diuretics safe to use with CKD? |
-Avoid thiazide diuretics if serum creatinine >2.5mg or if creatinine clearance <30mL per minute |
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What diuretic is common to treat patients with CKD? |
Loop diuretics are most commonly used to treat an uncomplicated HTN in patients with CKD |
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When should you avoid given diabetic medication in patients with CKD? |
Metformin: Avoid when the serum creatinine level is >1.5mg in men or 1.4mg in women and Avoid in 80 years or older or chronic heart failure Glyburide: Avoid in stages 3 to 5 CKD. Half life increases and can cause hypoglycemia Glipizide is SAFE |
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Which lab work should you refer the patient to a nephrologist? |
-Creatinine >1,5mg -GFR <60ml/min -Urine protein >200-250 -Severe and resistant HTN -Hyponatremia <130 -Hematuria -Unexplained edema -Refractory hyperkalemia (>5.5) -Hyperphosphatemia |
