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533 > Final: CKD, proteinuria, hematuria, nephrotic > Flashcards

Final: CKD, proteinuria, hematuria, nephrotic Flashcards

1
Q

proteinuria is a hallmark of

A
  • renal disease
  • Urinary protein excretion of >150 mg/day (10 to 20 mg/dL)
  • can be benign or something bad
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2
Q

once proteinuria identified, order what test?

A

get 24 hour urine collection or spot urine urinary protein/creatinine ratio

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3
Q

proteinuria before 24 weeks gestation indicates

A

glomerulonephritis./renal related

refer to OB (even if BP is normal)

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4
Q

Proteinuria after 24 weeks’ gestation is usually a sign of

A

preeclampsia

refer to OB

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5
Q

what to assess in HPI for proteinuria?

A
  • personal and family history (esp. renal and DM).
  • Assess: Chronic illness, surgery, diagnostic procedures (contrast media), urinary frequency or symptoms suggesting infection, risk factors, HIV infection
  • Prescription and OTC (NSAIDs)
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6
Q

proteinuria intial diagnostics

A
  • repeat dipstick
  • 24 hr urinary protein excretion or spot urinary protein/creatinine ratio
  • bens jones proteins (tests for Multipe myeloma)
  • urine dipstick
  • UA C&S
  • CBC w diff
  • fasting blood glucose
  • HbA1c
  • lipid profile
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7
Q

proteinuria differentials

A

Transient proteinuria
• Persistent proteinuria
• Orthostatic proteinuria or nonorthostatic proteinuria • Glomerulonephritis
• Diabetic nephropathy
• Nephrotic syndrome
• Vasculitis
• Medications

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8
Q

proteinuria management

A
  • ACE inhibitors reduce proteinuria by decreasing interglomerular pressure
  • If have hyperlipidemia and/or hypertension, treat aggressively
  • Patients with chronic renal failure should be managed aggressively
  • eliminate trigger
  • Na/ protein restricted diets
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9
Q

hematuria characterized by

A
  • more than 3 RBCs per high-power microscopic field (hpf)
  • transient - 1 occasion
  • persistent - 2 or more consecutive occasions
  • visible vs occult
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10
Q

what is the first q you want to ask a child bearing woman if have hematuria?

A

when was your last menstrual period

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11
Q

what can cause hematuria

A
  • Diet, physical activity, and menstrual history, recent travel, nephrolithiasis
  • meds: beta lactam antiboitics, sulfonamides, NSAIDs, rifampin, zyloprim, Tagamet, dilantin, anticoagulant
  • caffeine, spices, chocolate, alcohol, citrus fruits, soy sauce
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12
Q

hematuria physical exam

  • Costovertebral angle tenderness:
  • Abdominal mass:
  • Suprapubic tenderness:
  • Urethral discharge:
  • Enlarged and/or tender prostate: b
A
  • Costovertebral angle tenderness: pyelonephritis / UTI
  • Abdominal mass: neoplasm, polycystic kidney disease
  • Suprapubic tenderness: bladder etiology
  • Urethral discharge: urethritis
  • Enlarged and/or tender prostate: benign prostatic hyperplasia, prostatitis
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13
Q

if see casts in urine…

A

injury to NEPHRON!

Glomeruonephritis related

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14
Q

proteinuria AND hematuria suggests

A
  • glomerular or interstitial nephritis
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15
Q

proteinuria AND hematuria suggests

A
  • glomerular or interstitial nephritis
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16
Q

Gross hematuria suggests

A
  • acute cystitis, urethritis, UTI

often seen with acute obstruction and is usually caused by calculi or bladder tumor, or infection

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17
Q

in pregnant or pediatric pt, what diagnostic would you want to do?

A

ultrasound spare radiation from CT

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18
Q

if microscopy is positive for RBC and negative for heme,

A

look at microscopy and morphology of RBC

if abnormal RBC, can be glomerular cause

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19
Q

Oliguria, gross hematuria, strep rash or HSP, lethargy, anorexia, nausea, vomiting, abdominal pain, weight gain with abrupt onset

A

post infectious glomerulonephritis

send to urology asap

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20
Q

after treating UTI with hematuria, always

A

repeat UA just in case there’s is hematuria

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21
Q

does isolated, transient hematuria or hematuria related to a UTI need a referral?

A

no, only if to evaluate other causes of hematuria, bc high risk of malignancy

if have large amounts of frank hematuria, severe flank pain suggestive of renal calculi, unstable vital signs, signs of urologic obstruction, or acute renal failure = urgent referral

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22
Q

gross hematuria with abdominal pain, with or without bloody stools, arthralgias, and purpuric rash

A

Consider Henoch-Schönlein purpura (HSP)

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23
Q

gross hematuria, proteinuria, precipitated by viral infections or strenuous exercise,

  • episode lasts <72 hrs

blood pressure and C3 is normal & no edema is present

A

Consider IgA nephropathy aka Bergers disease

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24
Q

orthostatic proteinuria

A

child excretes abnormal amounts of protein when upright but normal amounts when lying down.

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25
Q

Persistent asymptomatic proteinuria

A

common, transient phenomenon in which an otherwise healthy child, with normal clinical and laboratory workup, has an abnormally high level of protein in the urine.

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26
Q

if benign etiology or if treat for UTI and there is microscopic hematuria,

A

repeat UA after treatment. if UA negative, repeat UA yearly

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27
Q

what is considered abnormal trace of protein in urine?

A

1+ on dip stick

>30 mg/dL

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28
Q

initial work up for child with proteinuria:

A

get first morning dipstick test (if >1), get Protein/Cr ratio (if < 0.2) or abnormal urinalysis → get further PE and hx, and lab tests

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29
Q

nephrotic syndrome on lab and sx’s

A
  • 3 to 4+ protein with UA
  • adults: 3.5 g/day
  • children: > 40 mg/2 hrs
    • protein/creatinine ratio on a 1st morning void of >2 to 3:1
  • hypoalbuminemia (< 2.5 g/dL)
  • edema (periorbital, dependent)
  • assess lipid panel -> hyperlipidemia
  • foamy urine, weight gain
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30
Q

nephrotic syndrome in adults sx’s

A
  • Pedal/ankle edema
  • Transverse leukonychia on fingernails
  • Xanthomas (fatty deposits in skin)
  • periorbital edema unless if advanced
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32
Q

nephrotic syndrome diagnosis

A
  • ALL 3 criteria needed:
    • urinary protein excretion rate of >3.5g/day
    • Peripheral edema on exam
    • Low serum albumin
  • Hyperlipidemia
  • Start initial workup workup for nephrotic syndrome in primary care
    • Check renal, CBC , UA with microscopy
    • Check serum albumin
    • Electrolytes, glucose
    • Lipids
  • Refer to nephrology
  • If think lupus, order additional testing
33
Q

consider what with nephrotic syndrome?

A

lupus, get additional testing

34
Q

initial workup workup for nephrotic syndrome

A
  • Check renal, CBC , UA with microscopy
  • Check serum albumin
  • Electrolytes
  • Glucose
  • Lipids
35
Q

nephrotic syndrome management

A
  • Refer to nephrology
  • If improving with proteinuria, continue with steroids and Na restrictions until negative for protein (don’t taper off)
  • Children
    • Tx with Oral steroids for 2.5–3 months
    • Management of edema
    • Steroid-resistant—renal biopsy • Diet • Calcium and vitamin D • Blood pressure
  • Adults
    • ACE inhibitor
    • Manage edema
    • Diuretics
    • Diet
    • Statin for hyperlipidemia • Immunosuppressive therapy depending on cause •
    • Prophylactic anticoagulant if at high risk
36
Q
  • Elevation of GFR rate
  • RBC casts on UA
  • mild Proteinuria
A

Iga Nephropathy

refer!

37
Q

chronic kidney disease defined as

A

abnormalities in kidney structure or function for greater than 3 months with marker of kidney damage of 1 or more:

  • Albuminuria
  • Urine sediment abnormalities
  • Electrolyte and other abnormalities from tubular disorders
  • Abnormalities detected by histology
  • Structure abnormalities detected by imaging
  • History of kidney transplantation
  • GFR < 60
38
Q

most common cause of CKD

A

diabetes (high glucose in glomeruli scars the glomeruli and doesn’t filter blood)

39
Q

Stage 1 / GFR 1

A

> 90

with other evidence of kidney damage (persistent microalbuminuria or proteinuria, hematuria, structural abnormalities, biopsy-proven glomerulonephritis.)

40
Q

Stage 2 / GFR 2

A

60- 89

mildly decreased

41
Q

GFR 3a

A

45-59

mildly to moderately decreased

42
Q

GFR 3b

A

30-44

moderately to severely decreased

43
Q

GFR 4

A

15-29

severly decreased

44
Q

GFR 5

A

< 15

kidney failure

45
Q

GFR 5

A

< 15

kidney failure

46
Q

PE of CKD

A

vital signs (BP)

funduscopic evaluation for signs of arteriovenous nicking, diabetic retinopathy, and papilledema;

peripheral pulse characteristics

Volume status is determined with auscultation of lung sounds

jugular vein distention

edema

heart sounds. Pericarditis and pleural effusions can be a complication of CKD

skin - ecchymosis, rashes, uremic frost, pruritus

47
Q

most important diagnostic in monitoring pt’s with CDK

A

serum creatinine test with GFR

and 1st morning or random urine sample to assess for presence of albuminuria

48
Q

complications of chronic renal failure

A

HTN, pulmonary edema, HF, hyperlipidemia, electrolyte abnormalities, anemia, erythropoeiten deficit

49
Q

labs to check in a pt with CKD?

A

Electrolytes, calcium, vit D, lipids, CBC, glucose

50
Q

when do you refer to nephrologist with CKD for pediatrics?

A

if < 18, refer immediately! Late referral means referral to specialist services less than one year before start of renal replacement therapy (RRT).

51
Q

When do you refer to a nephrologist for an adult patient with CKD?

A
  • Acute kidney injury (AKI) or abrupt sustained fall in GFR
  • Consistent finding of significant albuminuria
  • Progression of CKD
  • Urinary red cell casts, RBC > 20 per high-power field (HPF) sustained and not readily explained
  • CKD and hypertension refractory to treatment with 4 or more antihypertensive agents
  • Persistent abnormalities of serum K
  • Recurrent or extensive nephrolithiasis
  • Hereditary kidney disease
52
Q

what is a normal urinaryalbumin/creatinine ratio range?

A

< 30 mg/g (abnormal if it is elevated)

recommend method for pt with diabetes

53
Q

A 40-year-old man with hypertension and diabetes type 2 has a normal creatinine, an estimated GFR greater than 90 mL per min per 1.73 m2, and a urinealbumin/creatinine between 100 to 200 mg/g on repeat urinalysis for the past 6 months. Which of the following best describes his kidney function?

A

This patient has a normal GFR and persistent proteinuria over the past 6 months, so he has stage 1 CKD. Stage 1 CKD is defined as normal GFR (greater than 90 mL per min per 1.73 m2) with evidence of kidney damage that is persistent for longer than 3 months. Stage 2 CKD is defined as GFR 60 to 89 mL per min per 1.73 m2 with evidence of kidney damage for longer than 3 months. Stage 3 CKD is defined as GFR 30 to 59 mL per min per 1.73 m2 for longer than 3 months. Stage 4 CKD is defined as GFR 15 to 29 mL per min per 1.73 m2 for longer than 3 months. Stage 5 CKD is defined as GFR less than 15 ml per min per1.73 m2 for longer than 3 months or kidney failure treated with dialysis or transplantation. This is a chronic, and not acute condition. He does not have normal renal function as evidenced by the persistent proteinuria.

54
Q

which medications should NOT be used concurrently or with patients with bilateral renal artery stenosis

A

avoid ACE or ARBs, NSAIDs → increases the risk of hyperkalemia

55
Q

when should metformin be discontinued?

A

GFR < 30

metformin should be reviewed if GFR 30-44

continue metformin if GFR > 45

56
Q

because diabetes and hypertension are highly associated with CKD, clinical guidelines for management of both diabetes and hypertension recommend

A

regular UA, albumin/creatinine ratio (ACR), & serum creatinine to estimate GFR

if have diabetes, screen at time of diagnosis of db and 5 years after diagnosis

57
Q

CKD management

A
  • BP < 130/80
  • ACE/ARB for diabetics with microalbumuria
  • low dose aspirin
  • statin if > 50 yrs
  • hg A1c < 7%
  • refer if ACR > 300 mg, GFR < 30 (Stage 4/5), RBC casts in urine
  • acid base electrolytes
  • avoid nephrotoxic drugs (NSAIDs)
  • vaccines
  • diet and weight management
  • can cause hyperparathyroid disease, hyperlipidemia, alterations in vitamin D/Ca/phosphorus
58
Q

intermittent severe pain in flank or groin

A

renal colic

nephrolithiasis

59
Q

risk factors for nephrolithiasis

A
  • Obesity (sendentary, diet)
  • family history
  • hyperparathyroidism
  • low fluid intake
  • Diet - animal products, high salt diet
  • Excess antiacids (from higher levels of calcium)
  • Hx gout
  • Tropical climates (sweating causes dehydration)
60
Q

if stones < 5 mm

A

will pass spontaneously

increase fluid intake

rx pain meds

61
Q

Older male comes in with gross hematorua, denies flank pain and fever…

A
  • Worry about malignancy
  • We want to refer for cystoscopy and imaging
62
Q

Child has nephrotic syndrome, tell kids parents

A
  • Steroids will be used when relapses occur and should be continued until urine is negative for protein
  • Steroids are not given continuously and NOT used prophylatc
  • Used past experience to help guide what to treat
63
Q

adolescent with R flank pain, gross hematuria without signs of infection, has renal stones

A

initial treatment is to increase fluids to 2L daily to flow it out

64
Q

initial testing for poststreptocococcal glomerulonephritis

A

CBC, ESR, UA, BMP, creatinine

complement levels and antistreptolysin O (ASO) titer

65
Q

C3 levels in post infectious GN/poststreptococcus GN should be

A

decreased in all types [hypocomplementemia]

if < 15, positive (normal 83-152)

66
Q

elevated Antistreptolysin (ASO) titer means

A

ASO > 250 is positive (normal 125-250)

recent GAS infection and consistent with dx of poststrep G.N.

67
Q

when does c3 return back to normal

A

6-8 weeks of disease onset

if doesn’t decrease, raises concern for other types of G.N. (membranoproliferazive glomerulonephritis MPGN) and C3 glomerulopathy)

68
Q

Poststrep G.N. management

A
  • consult with neph
  • 95% resolve spontaneously w/o treatment
  • acute phase → antihypertensives (CCB) with na restrictions for hypertension and edema or diuretics
  • antibiotics does NOT decrease incidence of PSGN
  • traces of proteinuria /microscopic hematuria normal - resolves in weeks/months, hematuria resolves 6-12 months
69
Q

besides hematuria, what else can cause a positive blood urine dipstick but have no red blood cells on microscopy?

A

Myoglobinuria or hemoglobinuria

[pseudohematuria]

microscopic examination for RBCs is needed to differentiate RBCs from hemoglobinuria or myoglobinuria.

70
Q

what does a UA with microscopy confirm?

A

if it shows RBCs, show # of RBCs, presence of cell casts, or significant protein = glomerulonephritis

Presence of leukocyte esterase, nitrites, and bacteria = suggestive of infection.

71
Q

isolated hematuria

A

(hematuria unaccompanied by any other abnormal urine components) can result from bleeding anywhere from the renal pelvis to the urethra but is rarely caused by systemic disease

72
Q

extra renal causes of isolated hematuria

A

urolithiasis, bladder stones, cancer of the ureter, bladder cancer, prostate cancer in a man, infection, and trauma.

73
Q

if pt has asymptomatic hematuria…

A

get thorough history and physical can may help guide identification of a benign cause of asymptomatic hematuria.

74
Q

Diagnostic evaluation for asymptomatic hematuria

A

urine culture, renal imaging, CBC, CMP

NO urinary cytology or urine-based molecular markers to detect bladder cancer in the initial evaluation of hematuria due to their poor sensitivity and low value.5,6

75
Q

if suspect glomerulonephritis, what further diagnostics needed

A

Complement evaluation, antinuclear antibody (ANA), antistreptolysin O (ASO) titer, antineutrophil cytoplasmic antibodies (ANCAs), and anti-glomerular basement membrane.

Urgent or emergent referral with nephrology if unstable patient with suspected GN.

76
Q

all gross hematuria warrants

A

referral for urgent urologic evaluation with renal function testing, cystoscopy, and imaging.

77
Q

if pt is on a anti platelet or anticoagulant and has hematuria

A

should not be a satisfactory explanation for hematuria and still evaluation even if the patient is on antiplatelet or anticoagulant therapy

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