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150 Cards in this Set
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- Back
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What is defn of ARF?
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rapid decline in renal function w/incr in ser Cr level (rel incr of 50% or absolute incr of .5-1.0mg/dL)
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What are the most common clinical findings in pts w/ARF? Why does this happen?
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i)wt gain and edema ii)+ water and Na balance. B/c hypovolemic, so need to incr pressure
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What is azotemia? What is elevated BUN also seen in? (x3) Elevated Cr? x2
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i)elevated BUN and Cr ii)a)catabolic drugs (steroid) b)GI/Soft tissue bleed c)dietary protein iii)a)incr muscle breakdown b)drugs
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What is prerenal failure due to? x4
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Any decr in systemic arterial blood or renal perfusion. i)hypovolemia (excess diuretics, poor fluid intake, vomit); ii)Peripheral vasodilation iii)cirrhosis, hepatorenal syndrome iv)decr renal perfusion, NSAIDs, ACE-I and cyclosporin
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What do you monitor in pt w/ARF? x5
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i)daily wts, intake, output ii)BP iii)serum lytes iv)Hb and Hct for anemia v)infection
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What is diagnostic approach for ARF?
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i)Baseline Cr level to determine duration ii)type of ARF and cause: a)vol depletion and CHF=prerenal b)rash means AIN c)suprapubic mass, BPH, bladder dysfcn=postrenal iii)med review iv)urinalysis. v)Urine chemistry (FENa, osmolality, urine Na, urine Cr) vi)renal U/S: r/o obstruction
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What is pathophysiology of prerenal ARF?
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i)decr flow to kidney, so decr GFR and decr clearance of metabolites. ii)renal parenchyma is unchanged, so tubules work and kidney conserves as much Na and H2O as possible. iii)reversible, but if persists, get ATN. iv)have signs of vol depletion
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What are labs of prerenal vs ATN?
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i)Prerenal: a)Urine osmolarity>500 b/c tubules can reabsorb H2O b)<20 Urine Na w/FENa <1% b/c Na is reabsorbed c)Bland urine sediment. ii)ATN: a)urine osmolairty <350 b/c renal water reabsorption is impaired. b)Incr Urine Na and FENa b/c not absorbed. c)Urine sediment: brown, granular casts w/epithelial casts
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What is always found in prerenal azotemia? What is ratio of BUN and Cr and why? What is urine/plasma Cr ratio
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i)oliguria: always in prerenal failure ii)incr BUN: Cr ratio (>20:1) b/c kidney can reabsorb urea iii)Incr urine/plasma Cr ratio (>40:1) b/c much of filtrate reabsorbed (but not Cr)
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What happens in intrinsic renal failure? What are the causes? x4 and what are ex's of each?
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i)kidneys can't concentrate urine effectively b/c damaged. ii)ATN* iii)Glomerular dz a)Goodpastures b)Wegener's c)poststreptococcal d)Lupus iv)Vascular dz: renal A occlusion, TTP, HUS v)Interstitial dz: allergic interstitial nephritis (Hypersensitivity to meds
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What are the 2 causes of ATN? what are 5 causes of each
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i)Ischemic ARF: prerenal ARF leads to death of tubules (shock, sepsis, DIC, CHF) ii)nephrotoxic ARF: substances directly injure renal parenchyma->cell death. a)Abx, contrast, NSAIDs, myoglobinuria, kappa and light chains in MM, Cisplatin
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What is the BUN:Cr ratio in intrinsic failure? What is urine plasma Cr ratio? why?
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i)<20:1 b/c less urea reabsorbed, but BUN/Cr are both elevated. ii)incr urine Na b/c Na poorly reab iii)Decr urine plasma Cr ratio b/c filtrate can't be reabsorbed
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What is the course of ATN?
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i)onset ii)Oliguric phase: azotemia and uremia for 10-14 days. urine output of <400-500 mL/day. iii)Diuretic phase: a)begins when urine output is >500 mL/day. b)high urine output due to: fluid overload (excrete retained H2O and salt from oliguric phase); osmotic diuresis b/c of retained solutes in oliguric phase; tubular cell damage(delayed recovery of epi cell fcn relative to GFR iv)Recovery
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What are 3 basic tests for postrenal failure?
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i)PE: palpate bladder ii)U/S: look for obstruction, hydronephrosis iii)catheter: look for urine
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What is postrenal failure due to? Is it reversible? What can it lead to?
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i)obstruction; have decreased GFR b/c of back up; blood and renal parenchyma are intact. ii)Restored renal function if obstruction relieved b/4 kidneys damaged. iii)can get ATN
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What are causes of postrenal failure? x4
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i)BPH* ii)nephrolithiasis iii)neoplasm obstruction (bladder, cervix, prostate). iv)ureteral obstruction uncommon b/c need it to be bilat to get RF
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What tests should you get if you have pt w/ARF? x5
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i)U/A ii)urine Chem iii)electrolytes, CBC iv)bladder cath to r/o obstruction v)renal U/S for obstruction
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What is seen on U/A for types of intrarenal failure? ATN, Acute GN, AIN?
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i)ATN: muddy brown casts, renal tubular cells/casts, granular casts. ii)AGN: dyspmorphic RBCs, RBCs w/casts, WBCs w/casts. iii)AIN: RBCs, WBC, eosinos
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What do the diff types of casts signify in U/A?
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i)hyaline: no content ii)RBC casts: glomerular dz iii)WBC casts: renal parenchymal inflamm iv)ratty casts: nephrotic syndrome
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what does FENa do? When is it most useful? How do you figure out FENa? How do you figure out RF index? What do values above and below 1% mean?
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i)differentiates types of ARF ii)if oliguria is present iii)UNa/PNa/UCr/PCr *100. iv)UNa/[UCr/PCr]*100. v)value <1% means prerenal failure; >1% means ATN
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When do you do a CT in ARF? Renal BX?
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i)if renal U/S shows hydronephrosis ii)if think Acute GN or acute allergic interstitial nephritis
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What are the most common mortal complications of early phase of ARF? x2
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i)hyperkalemic cardiac arrest ii)pulm edema
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What are the metabolic complications of ARF?
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ii)metabolic: a)hyperkalemia: 1)decr excretion of K+; 2)K movement from ICF to ECF b/c of tissue destruction and acidosis. b)metabolic acidosis (w/incr anion gap): decr excretion of H+ions. c)hypocalcemia: no Vit D making and PTH resistance d)hyponatremia if drink excessive hypotonic soln's. e)hyperphosphatemia, hyperuricemia
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What are 4 complications of ARF?
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i)ECFV expansion and resulting pulm edema--treat w/furosemide. Consider dialysis if no response in 2 hrs. ii)metabolic iii)uremia: toxic end products accumulate, esp from protein metabolism. iv)infection: serious complication of ARF (uremia impairs immunity)--pneumonia, UTI, sepsis
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How to treat ARF in general?
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i)avoid meds that decr RBF (NSAIDs) or nephrotoxic. ii)adjust meds for level of renal fcn. iii)correct fluid imbalance: may be depleted, but may also need diuresis. Monitor w/daily wts and ins/outs. iv)correct lytes v)optimize CO vi)dialysis: uremia, intractable acidemia, hyperkalemia, vol overload
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How do you treat prerenal ARF?
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i)prerenal: a)treat underlying d/o b)Give NS to maintain volemia and restore BP, but not to edemic or ascitic. c)eliminate offending agents (NSAID, ACEI) d)Swan ganz may be needed if unstable
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intrinsic ARF treatment?
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i)Once ATN happens, therapy is supportive. Need to eliminate the cause ii)if oliguric, lasix may help and improve fluid balance
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Post renal ARF treatment?
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bladder catheter to decompress urinary tract.
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What is most common causes of CRF? x5
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i)Diabetes* ii)HTN iii)Chronic GN iv)Interstitial nephritis v)PCKD; ARF for long time
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What is pathophys of CRF?
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increase in plasma Cr indicates dz progression, but decr suggests recovery of renal function.
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what is first thing to do if pt has elevated Cr levels? Why?
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i)determine baseline Cr level ii)helps figure out if pt has ARF, CRF, chronic renal insuff/failure w/superimposed ARF
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What is azotemia?
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elevated BUN
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What CV features may be present in CRF? x3
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i)HTN: b/c of Na and H2O retention (decr GFR->RAA system activated); renal failure is most common cause of 2ndary HTN. ii)CHF: b/c of vol overload, HTN, anemia. iii)pericarditis: uremic
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What GI features might be present in CRF? x3 Why?
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i)N/V; anorexia ii)uremia
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What neurologic features in CRF? x5?
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i)somnolence ii)confusion iii)uremic seizures iv)restless legs: neuropathic pain in legs relieved w/movement. v)hypocalcemia: lethargy, tetany
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What hematologic problems occur in CRF? x2
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i)normocytic normochromic anemia: def of EPO ii)bleeding 2ndary to plt dysfcn (uremia); avoid antiplt agents
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What Calcium endocrine/metabolic problems arise in CRF? x3
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i)Ca-PO4 disturbance: a)hyperPO4 b/c decr clearance so less Vit D made->hypocalcemia causing 2ndary hyperPTH. Can also get hyperCa w/longstanding hyperPTH b)get renal osteodystrophy w/2ndary hyperPTH causing bone pain and fractures. c)Calciphylaxis: hyperPO4 causes Ca and PO4 to precipitate->vascular calcifications->necrotic skin lesions
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What endocrine/metabolic problems in CRF x3?
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i)Ca-PO4 inbalance ii)sexual/repro sxs due to hypothalamic pituitary disturbances and gonadal response to sex hormones: decr testo; amenorrhea, infertile, hyperprolactin iii)pruritis
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What electrolyte and immunologic problems arise w/CRF?
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i)lytes: a)vol overload: pulm edema may happen b)hyperK: b/c decr urinary secretion c)hypermg: b/c reduced urine loss d)hyperPO4 e)met acidosis: kidney can't excrete H+ and loss of renal mass ii)immune: uremia inhibits cellular and humoral immunity
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How to Dx CRF x5?
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i)U/A: sediment ii)Cr clearance measurement for GFR iii)CBC: anemia, thrombocytopenia iv)serum lytes: PO4, K, Ca, protein. v)U/S: rule out obstruction and see size (small=CRF)
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How to treat CRF? x9
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i)diet: low protein; restrict salt if HTN or CHF; restrict K, PO4, Mg. ii)ACE-I: dilate efferent arteriole of glomerulus: slow progression of proteinuria; can cause hyperK. iii)BP control: decr rate of dz progression; use ACE-I iv)glycemic control (prevent proteinuria). v)lytes: PO4 binder and Ca/VitD. Treat acidosis vi)anemia: EPO vii)pulm edema: dialyze if unresponsive to diuresis. viii)pruritis: capsaicin cream ix)dialysis. Transplant is only cure
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what are most common complications needing urgent intervention w/CRF
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i)symptomatic vol overload ii)severe hyperkalemia (look at EKG) iii)infection: pneumonia, UTI, sepsis
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What is dialysis?
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fluid and toxic solutes removed from circulation when kidneys can't do so sufficiently
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When is dialysis considered? x3 (besides AEIOU)
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i)CRF: bridge to xplant or if not able to xplant ii)ARF: temporary measure until pt's renal fcn improves iii)o/d of meds cleared by kidneys
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What are absolute indications for dialysis? x5 (emergency)
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A:acidosis E:electrolytes--severe, persistent hyperK I:intox--MeOH, ethylene glycol, Li, Asa O:overload--hypervolemia U:uremia--based on clinical presentation, not labs
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What are 2 nonemergent indications for dialysis?
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i)Cr and BUN are not absolute indications ii)sxs of uremia: a)N/V; b)lethargy/deterioration in mental status, encephalopathy, seizures; c)pericarditis
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What are the access methods in hemodialysis? x3
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i)central catheter in subclavian v ii)AV fistula: best for permanent dialysis; audible bruit means fistula is patent iii)implantable graft
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What are adv of hemodialysis? x2 Disadvantage? x2
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i)a)more efficient than peritoneal b)initiated more quickly in emergency ii)a)hypotension(removal of extravascular vol) and hypo osmolality (solute removal); b)need vascular access
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what are adv of peritoneal dialysis? x2 disadv? x3
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i)a)pt can dialyze on own b)more similar to kidney function ii)a)high glucose load->HyperTGs and hyperglycemia b)peritonitis c)incr ab girth b/c of fluid
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What are limitations of dialysis?
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no synthesis in kidney: still get EPO and vit D deficient
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What are complications ass'd w/hemodialysis? x5 Of peritoneal dialysis? x4
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i)a)hypotension b)hypo-osmolality: N/V, H/A, seizure or coma. c)1st use syndrome: CP, back pain, anaphylaxis d)complications ass'd w/anticoag e)infection of vascular access site ii)a)peritonitis b)ab/inguinal hernia b/c incr ab pressure c)hyperglycemia d)protein malnutrition
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What is defn of proteinuria? What are the 4 types?
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i)>150mg/24 hr. ii)a)Glomerular: incr glomerular permeability to proteins; can lead to nephrotic b)tubular: small proteins filtered not reabsorbed (SCD, UTO, interstitial nephritis) c)overflow proteinuria: BJ in MM. iv)Other: UTI; fever; heavy exertion/stress; pregnant; CHF
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What are 3 key features of nephrotic syndrome? Why does each happen? What are 3 other features of nephrotic?
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i)a)proteinuria: >3.5g/24 hr b)hypoalbumin: albumin synth doesn't keep up w/protein loss c)hyperlipidemia: 2ndary to liver's incr albumin synth ii)a)edema: hypoalbumin; hyperaldo worsens b)hypercoag: lose anticoags in urine and can get embolism c)infection: Igs lost
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What are the most common primary causes of nephrotic syndrome x4? What are 2ndary causes? x5
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i)Membranous nephropathy*; FSGS; Membranoproliferative GN. MCD is in kids. ii)a)systemic dz: DM; CVD; SLE b)drugs: captopril, NSAID, penicillamine c)infection d)MM; malignant HTN
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How do you DX nephrotic syndrome: what are 3 main tests?
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i)1st: urine dipstick: sp for albumin, so can get false neg if Igs. ii)If + protein->U/A:RBC casts=GN; WBC=pyelonephritis and interstitial nephritis; Fatty casts=nephrotic syndrome (lipiduria). If + protein, need 24 hr for albumin and Cr. iii)Microalbumin test: early sign for diabetic nephropathy. If +, do a radioimmunoassay
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What other tests besides dipstick, U/A, microalbumin could you do for nephrotic syndrome? x7
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i)Cr clearance for renal function ii)Ser BUN/CR iii)CBC: anemia due to RF. iv)serum albumin: inverse w/amt of proteinuria v)renal U/S: obstruction, mass, cysts vi)IVP: pyeloneph vii)BX
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How to treat nephrotic syndrome if asympto?
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i)Asympto: transient=no further. Persistent=further tests->BP; examine urine sediment. Treat underlying condition and problems
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How to treat sympto nephrotic syndrome?x6
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i)treat underlying dz (DM, MM, SLE, MCD). ii)ACE-I: decr urinary albumin loss iii)diuretics: if edema iv)limit dietary protein v)treat hypercholesterolemia vi)flu and pneumovax b/c incr infection
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What is origin of microscopic hematuria? gross? what do you assume gross hematuria is? What complication can happen w/hematuria? x2
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i)micro=glomerular; gross=nonglom or urologic. ii)bladder or kidney cancer iii)a)obstruction b)Fe def anemia
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What are most common causes of gross hematuria?
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Post renal causes: i)trauma ii)stones iii)malignancy
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What are causes of hematuria besides cancer, trauma, stones? x5
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i)Infection: UTI, urethritis, pyelo ii)glom dz, IgA nephropathy iii)systemic dz: SLE, Rheum fever, HSP, Wegeners, HUS, Goodpasture, PAN iv)bleeding d/o: hemophilia v)SCD vi)meds
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What tests do you need if have hematuria? x7
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i)dipstick ii)U/A: if pyuria=need culture; if dipstick + but -- U/A=hemoglobinuria or myoglobinuria iii)cytology for CA iv)cystoscopy=if malignancy suspicion is high. v)24 hr urine: Cr and protein for renal fcn. Collect if proteinuria present. vi)bloods: coags, CBC, BUN/Cr vii)IVP, CT, U/S: stones, tumor, cyst, stricture
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What is RPGN?
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GN where rapid deterioration of renal fcn happens->RF and ESRD. GN usually immune-mediated
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What are clinical features of glomerular dz? x2
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i)impaired selective filtration of blood->GFR decr->renal failure. ii)proteinuria, hematuria or both. nephrotic range proteinuria=pathognomonic
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How do you DX glomerular dz? x3
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i)U/A: hematuria, proteinuria, RBC casts ii)bloods: RFTs iii)needle BX
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What is presentation of nephritic syndrome? nephrotic syndrome? other 2 possible presentations of glomerular dz?
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i)HTN, azotemia, hematuria ii)hyperlipid (fatty casts also), edema, proteinuria, hypoalbumin iii)a)isolated proteinuria b)isolated hematuria
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What is ass'n with MCD? What is LM and EM? What is treat?
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i)NHL and Hodgkin's ii)no LM; EM=fused feet iii)steroids
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What type of glom dz is FSGS? What are common findings? What is PX? How to treat?
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i)Nephrotic ii)HTN and hematuria in addition iii)poor=go to RF iv)cytotoxic agents, immunosuppressants, steroids
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What type is membranous glomerulonephritis and what is 1 clinical feature? What are causes? x4 What is PX?
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i)nephrotic; thickened glom capillary walls. ii)idio; 2ndary=a)infection (HBV, HCV, syphilis) b)drugs (captopril, penicillamine) c)lupus. iii)PX is fair: 33% in RF; steroids don't change survival
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What is most common cause of glomerular hematuria? What is clinical features? x3 What is EM? What is PX? What is TX?
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i)IgA nephropathy ii)a)asympo hematuria/mild proteinuria; b)gross hematuria s/p exercise or infection c)RF is normal iii)IgA and C3 on EM iv)good, preserved RF v)none
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What is hereditary nephritis (Alport's) inheritance? x2 What are features? x5 What is TX?
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i)X linked or AD ii)a)hematuria b)pyuria c)proteinuria d)hi freq hearing loss e)progressive RF iii)no TX
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What is most common cause of ESRD? What are 10 other causes of 2ndary glomerular disorders?
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i)Diabetic nephropathy ii)a)HTN nephropathy b)Lupus c)Membranoproliferative glomerulonephritis d)PSGN e)goodpastures f)dysproteinemias: amyloidosis, light/heavy chain dz g)sickle cell nephropathy h)HIV nephropathy i)glomerulonephritis in endocarditis j)Wegener's k)PAN
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What is most common cause of MPGN? 3 other causes? what is its ass'n? what is PX?
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i)HCV ii)HBV, syphilis, Lupus iii)cryoglobulinemia iv)poor=50% in RF, no TX
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What is most common cause of nephritic syndrome? When does it occur? What are features? x5 What is PX? What is TX?
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i)PSGN ii)2 weeks s/p GAS infection iii)a)hematuria; b)edema c)HTN d)low complement e)proteinuria iv)Resolves on own v)supportive: Anti HTN; loop diuretics for edema
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What kind of dz is Goodpastures? What is triad of Good pasture's? what are 5 clinical features?
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i)2ndary Glom d/o ii)a)prolif GN (cresenteric) b)pulm hemorrhage c)IgG anti GBM iii)a)fever b)rapid RF c)hemoptysis d)dyspnea e)lung dz b/4 kidney dz
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What is triad of HIV nephropathy? What is histo like? What can you treat w/? x3
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i)proteinuria, edema, hematuria ii)like FSGS iii)prednisone, ACE-I, HAART
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What do you look for in diagnosing AIN? x6
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i)recent infection ii)new medication iii)rash iv)fever v)general aches/pains vi)signs/sxs of ARF
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What is AIN? What is most common cause (category)? Types from the category? x4 What are 2 other causes?
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i)inflammation of intersititum ii)allergy to meds: a)PCN b)NSAID c)diuretics d)anticoagulants iii)a)infection: strep, legionella b)collagen vascular dz (sarcoid)
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What are the clinical features of AIN? x4
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i)rash ii)fever iii)acute renal insuff iv)eosinophilia. Possible hematuria or pyuria
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Hhow to DX AIN? x2
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i)RFTs: incr BUN and Cr ii)U/A: eosinophils in urine; mild proteinuria or hematuria may be present. iii)No diff b/w AIN and ATN based on clinical grounds: need BX
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How to treat AIN? x2
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i)remove offending agent ii)treat infection
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What is difference b/w AIN and CIN? x2
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i)rapidity: AIN is rapid deterioration in renal fcn; CIN is indolent ii)path: AIN has eosinos and lymphocytes; CIN has tubulointerstitial fibrosis and atrophy
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What is CIN? What may be present? What are causes x4
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i)indolent interstitial nephritis leading to scarring of interstitium, RF, and ESRD over years ii)Renal papillary necrosis iii)no signs or sxs of hypersensitivity in chronic interstitial nephritis iv)a)prolonged urinary tract obstruction b)heavy use of analgesics c)heavy metal exposure
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How does analgesic nephropathy manifest itself? x2 What can it lead to?
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i)a)interstitial nephritis b)renal papillary necrosis ii)ARF or CRF
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What are the ass'ns for renal papillary necrosis? x5
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i)analgesic nephropathy ii)diabetic nephropathy iii)SCD iv)UTO v)UTI vi)xplant rejection
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How to DX Renal pap necrosis? what is complication? How to treat?
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i)excretory urogram: see change in papilla or medulla ii)sloughed, necrotic papilla->ureteral obstruction iii)treat underlying cause
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What is RTA? What is it characterized by? x3
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i)renal tubule d/o leading to non-AG hyperchloremic metabolic acidosis. ii)a)decrease H+ excreted in urine b)leads to acidemia and urine alkalosis
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What is type ! RTA caused by? What is pH of urine? What does it lead to and what are their effects (x4)?
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i)at DT, inability to secrete H+ (thus new HCO3 can't be generated)->can't acidify the urine->met acidosis. ii)no lower than pH 6. iii)leads to excretion of ions (Na, Ca, K, PO4): iv)a)decrease in ECFV b)hypokalemia c)renal stones and nephrocalcinosis (Ca and PO4 excretion) d)hypokalemic, hyperchloremic non-AG met acidosis
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What are sxs of RTA 1 due to? What are causes x4? How to treat? x2
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i)due to kidney stones and nephrocalcinosis ii)a)congenital b)MM c)nephrocalcinosis d)autoimmune dz iii)a)Correct acidosis w/NaHCO3 (also prevents stones) b)give PO4 salts: excrete titratable acid
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What is the defect in type 2 RTA? What happens 2ndary to this? What kind of met acidosis What are causes x4? What is treat?
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i)can't reabsorb HCO3 at PT, so incr HCO3 excretion in urine and met acidosis. ii)loses K and Na in urine iii)hypokalemic hyperCl iv)a)Fanconi's b)Wilson's c)Pb tox d)MM v)Treat underlying cause. a)No HCO3 b/c it will be excreted; b)Na restrict to incr Na reabsorption and thus HCO3 at PT
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What is Type 4 RTA due to? Who is it common in? x2 What lyte imbalance happens?
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i)Due to condition w/hypoaldo or kidney resistance to aldo ii)a)interstitial renal dz b)diabetic nephropathy iii)decr Na absorption; decr H and K secretion in DT. Get hyperkalemia and acidic urine. No stones
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What is Hartnup's due to? What happens? What deficiency? What are clinical features? x3 How to treat?
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i)AR deficiency in AA transporter. ii)decr intestinal and renal absorption of neutral AA like tryptophan->nicotinamide def iii)pellagra like: dermatitis; diarrhea; ataxia; psych iv)supplemental nicotinamide if symptomatic
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What is fanconi's due to? What is happens? What are ass'ns?
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i)defective PT transporters: a)glucose: glucosuria b)AA: proteinuria c)Na: dehydration d)K: hypokalemia e)PO4: phosphaturia, rickets, osteoporosis f)HCO3: type 2 RTA
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How to treat fanconis? x4
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i)phosphate ii)K iii)alkali and Na supplements iv)hydration
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What is PX of PCKD?
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50% w/ESRD
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What are the 4 clinical features of PCKD?
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i)hematuria ii)abdominal pain iii)HTN iv)palpable kidneys on abdominal exam
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What are complications of PCKD? x5
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i)berry aneurysm ii)kidney stones iii)valve problems: MVP iv)diverticula: colon v)hernias: ab/inguinal
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How to DX PCKD? What is treatment? x3
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i)U/S is confirmatory ii)a)no cure b)drain cysts if symptomatic c)control HTN
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What is medullary sponge kidney? What does it present with if symptomatic x3? What are its assns? x2 How to DX? How to treat x2
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i)cystic dilations of the collecting ducts ii)hematuria, UTI's, nephrolithiasis. iii)hyperPTH and PT adenoma. iv)IVP v)no treatment; prevent stone formation and treat recurrent UTIs
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What are causes of renal A stenosis? x2
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i)atherosclerosis: 2/3 of cases; elderly men; b/l in 1/3. ii)fibromuscular dysplasia: young females; b/l in 50%
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What is c/i in renovascular htn?
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ACE-I
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What are clinical features of Renal A stenosis? x3
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i)HTN: sudden onset; malignant HTN; HTN that suddenly worsens; HTN not responding to meds. ii)decr renal fcn iii)ab bruit (RUQ, LUQ, epigastrium), more common w/fibromuscular hyperplasia
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How to DX RAS? x2 (what is gold std?) What is tx?
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i)a)renal arteriogram*: but dye is nephrotoxic. b)MRA: usable w/RF. ii)a)initial tx: revasc w/PRTA (angioplasty). Better in fibromuscular dysplasia type. b)2nd line: bypass c)meds if sx c/i
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In what settings would renal V thrombosis be seens? x4 What are clinical features? x5
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i)a)nephrotic syndrome b)invasion of renal v by RCC c)trauma d)extrinsic compression ii)a)decr renal perfusion b)flank pain c)HTN d)hematuria e)proteinuria
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What is diagnostic tests for renal V thrombosis and which is definitive? x2 What else do you need to do?
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i)a)renal venography: visualize occluding thrombus b)IVP. ii)anticoag w/heparin b/c of PE possibility
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What is 2nd most common cause of ESRD? What is its defn?
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i)nephrosclerosis ii)systemic HTN incr capillary hydrostatic pressure in glomeruli, leading to benign or malignant sclerosis
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What happens in benign nephrosclerosis? What is the result x3? What can advanced dz lead to?
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i)thickening of glomerular afferent arterioles in pts w/long standing HTN ii)a)incr in Cr levels; b)microscopic hematuria; c)mild proteinuria iii)ESRD
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Who does malignant nephrosclerosis occur in? x2 What is it characterized by?
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i)Black men who: a)have chronic benign HTN or b)previously undx'd pt ii)rapid incr in renal fcn and acclerated HTN due to diffuse intrarenal vascular injury.
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What are 3 clinical manifestations of malignant nephrosclerosis
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iii)manifestations: a)markedly incr BP (papilledema; CNS findings) b)renal: rapid incr in Cr, proteinuria, hematuria, RBC and WBC casts in urine sediment c)microangiopathic hemolytic anemia
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What is TX of HTN nephrosclerosis x2
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i)control BP, but not sure which drug ii)advanced dz: treat as for CRF
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Where does sickling occur in SC nephropathy? what happens if it recurs often? What is secondary to ischemic injury? What drug helps?
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i)renal papilla ii)get papillary necrosis, nephrotic syndrome->RF, high freq of UTIs. iii)increased risk of dehydration (impaired urine concentration)->sickling crises
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Where are the 3 places of obstruction in nephrolithiasis?
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i)ureterovesicular jcn * ii)calyx iii)ureteropelvic jcn
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What are 3 risk factors for nephrolithiasis?
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i)low fluid intake ii)meds: lasix; aceazolamide; chemo causing incr uric acid iii)UTIs: esp w/urease producing bacteria
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What are the 4 types of stones and what are they made of?
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i)calcium*: Ca oxalate or CaPO4 ii)uric acid stones: 2nd most common; b/c of gout or chemo tx of leukemias or lymphomas:get released purines iii)struvite stones: ammonia+Mg and PO4: due to UTIs w/urease producers and are facilitated by alkaline urine; also give alkaline urine b/c of urea split to ammonia. iv)cystine stones
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What do the 4 types of stones look like(shape)? How are they on radiograph and if not xray, what imaging is used?
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i)Ca: bipyramidal or biconcave; radiodense. ii)uric: flat square plates; stones are radiolucent and need CT, U/S or IVP iii)struvite: rectangular prisms; radiodense. iv)cystine: hexagon crystals; poorly visualized; cystinurics get them (genetic)
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What size stones pass spontaneously, which don't? What is complication?
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i)<.5 cm pass; >1 don't. ii)recurrence
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What are 2 most common presentations for nephrolithiasis? What are 2 other sxs?
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i)hematuria ii)sudden onset of colicky pain going to groin. it is the stone going into ureter (ureter spasms). iii)a)N/V b)UTI
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What 2 modalities used for nephrolithiasis DX? What labs used?? x4
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i)labs and imaging ii)a)micro or gross hematuria b)UTI if pyuria or bacteruria c)urinary sediment for crystals d)urinary pH: alkaline urine may mean urease producing bacteria causes infection stone. Acidic=uric acid stone iii)urine culture if think infection iv)24 hr urine: get Cr, Ca, uric acid, oxalate, citrate v)serum chem: get BUN and Cr (RFTs); Ca, uric acid, PO4 levels
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What imaging is used for kidney stones? x4 What are each used for?
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i)a)xray: KUB; initial test; no cystine or uric acid stones b)CT: most sensitive; all stones visible c)IVP: defines degree and extent of obstruction;decides if pt needs procedural therapy d)renal U/S: detect hydronephrosis or hydroureter
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What general things do you want to do to treat stones? x3
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i)analgesia control ii)fluid hydration iii)Abx if UTI
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What are indications for hospital admission for kidney stones?? x4
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i)pain not controlled w/oral meds ii)anuria iii)renal colic+UTI and/or fever iv)large stone
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What is the algorithm for treating inpatient stones based on? What do you do for each? What are the indications for sx?
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i)based on severity of pain: a)mild to moderate pain: high fluid intake, oral analgesia and wait b)severe pain (esp w/vomit): IV fluids and pain control; KUB w/IVP to find obstruction. ii)if stone doesn't pass on own; persistent pain not controlled by drugs.
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What are the 2 kinds of stone sx and when to use each?
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i)extracorporeal shock wave lithotripsy: breaks stone apart; best for <2cm diameter ii)percutaneous nephrolithotomy: >2cm in diameter
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What is 3 ways to prevent stones?
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i)high fluid intake ii)limit animal protein intake if hyperuricosuria iii)limit Ca only if Ca stones
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What are pharm treatment for stones? x2
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i)thiazides for Ca (get hyperCalcemia) ii)allopurinal if high serum uric acid
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Who is UTO more common in and why? When does UTO cause ARF? x2
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i)men b/c of BPH and prostate Ca ii)if bilateral or preexisting renal damage
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What is diff b/w acute vs chronic obstruction? What is diff b/w lower vs upper tract obstruction?
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i)a)acute=sudden onset b)chronic: get progressive RF/uremia, recurrent infections, bladder calculi ii)a)lower=below UVJ: affects urination b)upper=renal colic
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What are causes of lower tract obstruction x5? Upper tract obstruction? x2 categories; 5 for each
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i)a)BPH b)prostate Ca c)urethral stricture d)stone e)neurogenic bladder (MS, DM) ii)a)intrinsic: a)stone; clots; sloughed papilla; crystals (uric); tumor b)extrinsic: pregnant; tumor; AAA; retroperitoneal fibrosis
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What are clinical features of UTO? x5
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i)renal colic and pain: acute obstruction; pain on urination ii)oliguria iii)recurrent UTIs iv)hematuria or proteinuria; v)RF
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What is best initial test for DX of UTO? What is gold standard? What other tests do you need? x3
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i)renal U/S*: see urinary tract dilation ii)a)U/A and labs: CBC, lytes, BUN/Cr b)KUB: see stones c)IVP: gold standard for obstruction. Not for pregnant, allergy or RF
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What does tx of stones depend on? how is lower urinary tract obstruction get treated x3? Upper? x2 When do you need imediate therapy?
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i)duration, severity, location, and cause ii)lower urinary tract obstruction: a)urethral catheter for acute obstruction b)dilation or internal urethrotomy: if b/c of urethral strictures c)prostatectomy for BPH iii)a)nephrostomy tube drainage: acute obstruction b)ureteral stent: if ureteral obstruction. iv)if pain or RF are present
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What are 3 risk factors for prostate Ca?
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i)age ii)African-am iii)high fat diet
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What is early clinical feature of prostate CA? later? x3 late? x2
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i)asympto b/c ca moves peripheral to inner ii)urinary obstruction (often already has mets) iii)late: bone pain from mets; wt loss
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How to DX prostate ca? x3
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i)DRE: hard and nodular, and if palpable, most have spread. If abnormal DRE(or PSA)->TRUS ii)PSA: age adjusted PSA; velocity PSA; free vs protein bound PSA iii)TRUS: need repeat bx for def dx.
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How to treat prostate Ca for localized vs locally invasive vs mets?
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i)localized: prostatectomy; watchful waiting in old men ii)local invasion: RT + androgen deprivation iii)mets: reduce testosterone amt via orchiectomy, antiandrogens, Leuprolide
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What are 4 risk factors for RCC?
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i)smoking ii)phenacetin analgesics iii)APKD iv)chronic dialysis
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What is classic triad of RCC? What are the paraneoplastic syndromes that can happen x4?
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i)a)hematuria (gross or micro) b)ab or flank pain c)ab/flank mass ii)a)EPO b)PTHrP c)renin d)cortisol
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How to DX RCC? x2 How to treat?
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i)a)renal U/S to detect mass b)ab CT: test for DX and staging. Do it if U/S shows mass ii)nephrectomy
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What type of cell are bladder cancers? Does it recur? what are 2 risk factors? What is initial presenting sign?
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i)TCC ii)yes iii)a)smoking b)cyclophosphamide c)painless hematuria; dysuria; frequency
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How to DX bladder Ca? x4
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i)U/A and culture: r/o infection ii)urine cytology: find malignant cells iii)IVP iv)cystoscopy and BX
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Testi cancer: what are the 2 categories What are types in each?
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i)germ cell tumors: a)seminoma (most common) b)nonseminoma ii)nongerm cell: a)leydig cells are hormonally active:benign b)sertoli are benign
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what is DDX of testicular ca? x6
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i)varicocele ii)testi torsion iii)spermatocele (testi cyst) iv)hydrocele: fluid in testi v)epididymitis vi)lymphoma
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How does testi cancer present? x2
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i)painless, firm mass ii)gynecomastia: nonseminoma germ cell tumors make gonadotropins
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How to DX testi tumor? x3
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i)PE: mass ii)U/S: initial test for localizing tumor iii)markers: a)BhCG (in chorioCa; high in other types of nonseminomatous germ cell tumors) b)AFP: incr in embryonal tumors
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What can you r/o if elevated AFP in testi tumor?
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i)chorioCA ii)seminoma
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How to treat testi tumor?
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i)orchiectomy if +PE and suspicion ii)CT staging of body iii)hCG and AFP compared with pretest levels iv)a)seminoma: radiation b)nonseminoma: chemo+ retroperi LN dissection
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What is assn for penile cancer x2? treat?
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i)HSV and HPV 18 ii)local excision
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what is diff from epididyitis vs torsion?
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torsion is i)more acute ii)not ass'd w/fever
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What are clinical features of testi torsion? x3 What is treat? If nonviable testi?
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a)acute pain b))swollen and tender scrot c)elevated testicle ii)detorsion and orchiopexy to scrotum iii)orchiectomy
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what is agent for kids and elderly in epididymitis? Young adults? what are clinical features? x4 What should you do to treat?
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i)E coli; gonococcus and chlam ii)swollen testi; fever; dysuria; scrotal pain iii)r/o torsion and give Abx
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