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Renal Flashcards

1
Q

Danger Signals

Rh_______

Acute P________

Acute _____ Injury/Failure

B____ Cancer

A

Rhabdomyolysis

Acute Pyelonephritis

Acute Kidney Injury (Acute Renal Failure)

Bladder Cancer

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2
Q

Rhabdomyolysis

Patient complains of an acute onset of _____ pain (not related to physical exertion), muscle ____ness, and _____ urine (myoglobinuria). Muscle tenderness and swelling may be seen, which rules out compartment syndrome.

M______ released from damaged muscle result in r____-br____ or t___-colored urine. They damage the ______ and can result in acute kidney failure, a common complication of rhabdomyolysis.

Serum (1) levels are markedly elevated (____ times normal value or higher). Blood chemistry abnormalities, elevated aldolase, _____ dehydrogenase, electrolyte abnormalities, and disseminated (1) can complicate the condition. Ask patient if he or she has a history of severe exercise, cr_____ injury, high fever, or high-dose ____ use. Refer to ED.

A

Patient complains of an acute onset of muscle pain (not related to physical exertion), muscle weakness, and dark urine (myoglobinuria). Muscle tenderness and swelling may be seen, which rules out compartment syndrome.

Myoglobins released from damaged muscle result in reddish-brown or tea-colored urine. They damage the kidneys and can result in acute kidney failure, a common complication of rhabdomyolysis.

Serum creatine kinase levels are markedly elevated (five times normal value or higher). Blood chemistry abnormalities, elevated aldolase, lactate dehydrogenase, electrolyte abnormalities, and disseminated intravascular coagulation (DIC) can complicate the condition. Ask patient if he or she has a history of severe exercise, crush injury, high fever, or high-dose statin use. Refer to ED.

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3
Q

Acute Pyelonephritis

Patient presents with acute onset of high ____, chills, nausea/vomiting, dys____, fr_____ urination, and ___lateral f____ pain. The flank pain is described as a deep ____. May complain of nausea (with/without vomiting) and may have a recent history of (1).

Indications for hospitalization include inability to maintain oral h_____, per_____ high fever (>101.0°F/>38.4°C), toxic appearance, immune compromise, or suspicion of s_____ or noncompliance to treatment.

A

Patient presents with acute onset of high fever, chills, nausea/vomiting, dysuria, frequent urination, and unilateral flank pain. The flank pain is described as a deep ache. May complain of nausea (with/without vomiting) and may have a recent history of urinary tract infection (UTI).

Indications for hospitalization include inability to maintain oral hydration, persistently high fever (>101.0°F/>38.4°C), toxic appearance, immune compromise, or suspicion of sepsis or noncompliance to treatment.

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4
Q

Acute Kidney Injury (Acute Renal Failure)

Patient presents with abrupt onset of ____uria, ed____, and weight gain (fluid _____) and complains of lethargy, nausea, and loss of appetite.

The condition is characterized by rapid decrease in renal _____ and elevated serum ______. During early stages, serum creatinine and the estimated glomerular filtration rate (eGFR) may not accurately reflect true renal function. Most cases of acute kidney injury (AKI; acute decline of GFR) are usually _______ when the offending substance is stopped.

Some of the most common causes of drug-induced AKI are amino_____, con_____ agents, N____s, A_ _ inhibitors, and pro_____ inhibitors.

A

Patient presents with abrupt onset of oliguria, edema, and weight gain (fluid retention) and complains of lethargy, nausea, and loss of appetite. The condition is characterized by rapid decrease in renal function and elevated serum creatinine. During early stages, serum creatinine and the estimated glomerular filtration rate (eGFR) may not accurately reflect true renal function. Most cases of acute kidney injury (AKI; acute decline of GFR) are usually reversible when the offending substance is stopped. Some of the most common causes of drug-induced AKI are aminoglycosides, contrast agents, nonsteroidal anti-inflammatory drugs (NSAIDs), angiotensin-converting enzyme (ACE) inhibitors, and protease inhibitors.

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5
Q

Bladder Cancer

(1) aged (1) gender patient (median age at diagnosis: 73 years) who sm_____ presents with pain____ ____turia.

The hematuria can be ____scopic or g____ (pink- to reddish-color urine). Some patients only notice this problem after they see a blood-tinged stain on underwear (males, menopausal females). The hematuria may only appear at the ___ of voiding.

May have irr_____ voiding symptoms (dysuria, frequent urination, nocturia) that are not related to a UTI. Order a (3) labs. Patients who have advanced disease with metastases may complain of lower ab____ or p____ pain, perineal pain, low-b____ pain, or b___ pain.

A

Elderly male patient (median age at diagnosis: 73 years) who smokes presents with painless hematuria.

The hematuria can be microscopic or gross (pink- to reddish-color urine). Some patients only notice this problem after they see a blood-tinged stain on underwear (males, menopausal females). The hematuria may only appear at the end of voiding. May have irritative voiding symptoms (dysuria, frequent urination, nocturia) that are not related to a UTI. Order a urinalysis (UA), urine culture and sensitivity (C&S), and urine for cytology. Patients who have advanced disease with metastases may complain of lower abdominal or pelvic pain, perineal pain, low-back pain, or bone pain.

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6
Q

Kidneys Normal Findings

Kidneys location =

Which kidney is lower than the other? why?

The basic functional units of the kidney are the _____, which contain the _____.

A

The kidneys are located in the retroperitoneal area.

The right kidney is lower than the left kidney because of displacement by the liver.

The basic functional units of the kidney are the nephrons, which contain the glomeruli.

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7
Q

Normal Kidney Function

The kidneys regulate the body’s el_____ and fl____, which affects blood _____.

Water is reabsorbed back into the body by the action of (2)

The kidneys excrete ____-soluble waste products of metabolism (e.g., cr_____, urea, uric acid) into the urine.

They secrete several hormones such as ______ (red blood cell [RBC] production), r____ and br______ (blood pressure), pr______ (renal perfusion), and cal____/vitamin __ (bone).

The average daily urine output is _____ mL.

Oliguria is defined as a urinary output of

A

The kidneys regulate the body’s electrolytes and fluids, which affects blood pressure.

Water is reabsorbed back into the body by the action of antidiuretic hormone and aldosterone.

The kidneys excrete water-soluble waste products of metabolism (e.g., creatinine, urea, uric acid) into the urine.

They secrete several hormones such as erythropoietin (red blood cell [RBC] production), renin and bradykinin (blood pressure), prostaglandins (renal perfusion), and calcitriol/vitamin D3 (bone).

The average daily urine output is 1,500 mL.

Oliguria is defined as a urinary output of <400 mL/day (adults).

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8
Q

Serum Creatinine

  • Male:* ___ to ___ mg/dL
  • Female:* ___ to ___ mg/dL

Factors that affect creatinine (3)

A
  • Male:* 0.7 to 1.3 mg/dL
  • Female:* 0.6 to 1.1 mg/dL

Factors that affect creatinine Gender, Race, Muscle Mass

(males > females, greater in African Americans, greater with larger muscle mass (low in elderly))

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9
Q

Creatinine Clearance (24-hour Urine)

This test is used to assess what?

24 Cr Clearance vs. Serum Creatinine?

24 hr Creatinine Clearance is _____ for every 50% reduction in GFR

Ideally, exercise should be avoided immediately prior to and during the period of specimen collection.

A

Evaluates proteinuria, albuminuria, microalbuminuria

24CrCl is a more sensitive test than serum creatinine alone because it reflects the renal function within a 24-hour period. Creatinine clearance is relatively constant and is not affected by fluid status, diet, or exercise.

Creatinine clearance is doubled for every 50% reduction of the GFR.

Ideally, exercise should not exercise immediately prior to and during period of specimen collection

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10
Q

Estimated Glomerular Filtration Rate

Normal =

Chronic kidney disease =

  • eGFR is the best test to measure kidney ____ and is used to determine stages of?
  • The eGFR is calculated by using (3) (with adjustment for those of African American descent).
  • The estimation equations (3) are used to calculate the eGFR, which one is the most accurate?
A

Normal: eGFR >90 mL/min

Chronic kidney disease: eGFR <60 mL/min for at least 3 months (or longer)

  • The eGFR is the best test to measure kidney function. It is used to determine chronic kidney disease stages
  • The eGFR is calculated by using serum creatinine, age, and gender (with adjustment for those of African American descent).
  • The estimation equations (i.e., Modification of Diet in Renal Disease [MDRD], Chronic Kidney Disease Epidemiology Collaboration [CKD-EPI], Cockcroft–Gault equation) are used to calculate the eGFR. - CKD-EPI most accurate (from columbia lecture)
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11
Q

Estimated Glomerular Filtration Rate

GFR definition =

The more damaged the kidneys, the ____ the eGFR. The GFR is affected by ___ (decreases), ___ (males have more muscle mass), and body ____.

(1) race eGFR values are higher than values for other races.

Some patients with underlying kidney disease may have a _____ eGFR.

eGFR is _____ reliable in these cases: Pregnancy, muscle wasting, elderly, and lower-extremity amputees.

A

The GFR is the amount of fluid filtered by the glomerulus within a certain unit of time. The more damaged the kidneys, the lower the eGFR. The GFR is affected by age (it decreases with age), sex (males have more muscle mass), and body size.

African Americans’ eGFR values are higher than values for other races.

Some patients with underlying kidney disease may have a normal eGFR. (compensating)

eGFR is less reliable in these cases: Pregnancy, muscle wasting, elderly, and lower-extremity amputees.

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12
Q

CKD Stages

A
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13
Q

Blood Urea Nitrogen

The ____ breaks down (1) → into (1) and then converts it into (1)

Blood urea nitrogen (BUN) =

  • If the kidneys are damaged or the renal blood flow is decreased, the urea level becomes ______.
  • BUN vs. SrCr or eGFR?
A

The liver breaks down amino acids into ammonia and then converts it into urea.

Blood urea nitrogen (BUN) = measure of the kidneys’ ability to excrete urea (waste product of protein metabolism).

  • If the kidneys are damaged or the renal blood flow is decreased, the urea level becomes elevated.
  • BUN is not as sensitive as serum creatinine or the eGFR.
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14
Q

Blood Urea Nitrogen

A high BUN may be caused by

  • acute kidney ____ (lowers GFR)
  • high-____ diet
  • ____lysis
  • c____ h____ failure
  • dr___

Among patients with heart failure, lower GFR with higher BUN is associated with higher mortality.

Among critically ill patients in the ICU, elevation of BUN is independently associated with mortality.

Low BUN can be caused by liver damage or liver disease. If a patient has an abnormal BUN level, check the eGFR. If the eGFR is normal, the renal function is probably normal.

A

A high BUN may be caused by

  • acute kidney failure (lowers GFR)
  • high-protein diet
  • hemolysis
  • congestive heart failure
  • drugs.

Among patients with heart failure, ____ GFR with ____ BUN is associated with higher mortality.

Among critically ill patients in the ICU, elevation of BUN is ind_____ associated with mortality.

Low BUN can be caused by ____ damage or disease. If a patient has an abnormal BUN level, check the eGFR. If the eGFR is normal, the renal function is probably normal.

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15
Q

Bun-to-Creatinine Ratio

A decrease in the blood flow of the kidneys will _____ the BUN-to-creatinine (BUN:Cr) ratio. It is used to help evaluate dehydration, hypovolemia, and acute kidney failure. This ratio is useful for classifying the ____ of failure (renal, infrarenal, or postrenal).

A

A decrease in the blood flow of the kidneys will increase the BUN-to-creatinine (BUN:Cr) ratio. It is used to help evaluate dehydration, hypovolemia, and acute kidney failure. This ratio is useful for classifying the type of failure (renal, infrarenal, or postrenal).

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16
Q

Urinalysis

(with Microscopic Exam)

A complete UA consists of (3) components

A

A complete UA consists of three components

  1. gross evaluation
  2. dipstick analysis,
  3. microscopic exam of urine sediment
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17
Q

Urinalysis Components

(7)

A

Epithelial Cells

Leukocytes

RBCs

Protein

Nitrates

Casts

pH

  • Urine for culture and sensitivity
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18
Q

Epithelial Cells

What does it mean if you see large amounts of squamous epithelial cells in the urine sample?

A

Contamination

A few epithelial cells are considered normal. (Squamous epithelial cells are associated with the external urethra and transitional epithelial cells with the bladder.)

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19
Q

Leukocytes

Normal white blood cells (WBCs) in urine: ≤__ to __ WBCs/hpf (high-power field)

Called leukocyte _____ test with urine dipstick strips

Presence of leukocytes in urine (pyuria) is always abnormal in _____ (infection)

UA is a more sensitive test for infection in males than females

A

Normal white blood cells (WBCs) in urine: ≤2 to 5 WBCs/hpf (high-power field)

Called leukocyte esterase test with urine dipstick strips

Presence of leukocytes in urine (pyuria) is always abnormal in males (infection)

UA is a more sensitive test for infection in males than females

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20
Q

Urine for Culture and Sensitivity

≥___5 colony-forming units (CFU)/mL of one dominant bacteria (usually (1)).

E. coli belongs in the gram-_____ Enterobacteriaceae family.

What does multiple types of bacteria in the culture show?

_____ values are indicative of bacteriuria.

A

≥105 colony-forming units (CFU)/mL of one dominant bacteria (usually Escherichia coli).

E. coli belongs in the gram-negative Enterobacteriaceae family.

If multiple bacteria are present, it is considered a contaminated sample.

Lower values are indicative of bacteriuria.

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21
Q

Red Blood Cells

Few RBCs

Microscopic hematuria =

Gross hematuria =

Can be contaminated by m____, vaginal dis____, s____, hem____, r____ bleeding.

A

Few RBCs <3 cells is considered normal

Microscopic hematuria = refers to RBCs that are visible only by microscopy.

Gross hematuria = means you can see blood in the urine.

(The color ranges from pink, red, to cola or brown. The source of the bleeding may come from the urethra (urethritis), bladder (cystitis, bladder cancer), or the kidneys (kidney stones, pyelonephritis, polycystic kidneys, cancer)

Can be contaminated by menses, vaginal discharge, semen, hemorrhoids, rectal bleeding.

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22
Q

Protein

What does it mean when you see protein in the urine?

  • The next step is to order the (2) and send ___stream urine for microscopic exam.
  • If the patient has normal microscopic exam for urine sediment and normal kidney function, it is called ______ proteinuria.
A

Indicates kidney damage if it is persistent (chronic kidney disease).

  • The next step is to order the serum creatinine and eGFR, and send midstream urine for microscopic exam.
  • If the patient has normal microscopic exam for urine sediment and normal kidney function, it is called isolated proteinuria.
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23
Q

Proteinuria

Transient Proteinuria =

Benign causes of proteinuria =

Proteinuria during acute pyelonephritis =

Urine dipsticks detect only _____.

A

Transient proteinuria = is common, especially in patients age 18 years or younger (8% to 12%) and among young adults (4%).

Benign causes of proteinuria = include fever, intense physical activity, acute illness, dehydration, and emotional stress.

May be present in acute pyelonephritis (resolves after treatment), recheck urine after treatment.

Urine dipsticks detect only albumin.

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24
Q

Proteinuria

In what situations can you see false positive proteinuria with urinary dipstick?

What test quantifies proteinuria? order 24-hour urine for protein-to-creatinine ratio (UPr/Cr).

A

False-positive results with urinary dipstick testing may be seen with alkaline urine (pH >7.5), if dipstick is immersed too long, highly concentrated urine, gross hematuria, presence of semen, or vaginal secretions.

24hr urine/Cr ratio = To quantify proteinuria

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25
Q

Nitrates

Positive result is highly indicative of what?

What produces nitrates?

A

Positive result is highly indicative of UTI

Nitrates result from when bacteria breakdown urea into nitrite

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26
Q

Casts

  • WBC casts:* May be seen with infections (1) or inflammation (1)
  • RBC casts:* Caused by microscopic bleeding in the glomeruli; suspect (1) (accompanied by edema, weight gain, dark cola-colored urine, or hypertension)
  • Casts are shaped like ______ because they are formed in the renal tubules.
  • _____ casts are nonspecific; it can be seen in small volumes in concentrated urine or with diuretic therapy.
A
  • WBC casts:* May be seen with infections (pyelonephritis) or inflammation (interstitial nephritis)
  • RBC casts:* Caused by microscopic bleeding in the glomeruli; suspect glomerulonephritis (accompanied by edema, weight gain, dark cola-colored urine, or hypertension)
  • Casts are shaped like cylinders because they are formed in the renal tubules.
  • Hyaline casts are nonspecific; it can be seen in small volumes in concentrated urine or with diuretic therapy.
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27
Q

pH

___–___ reference range

Useful in the evaluation of kidney _____ and in______.

Citrus and low-carbohydrate diet are associated with low or high acidity?

High-protein diet are associated with low or high acidity?

A

4.6–8.0 reference range

Useful in the evaluation of kidney stones and infections.

Lower acidity (high pH) = Citrus and low-carbohydrate diet

Higher acidity (low pH) = high-protein diet

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28
Q

Hematuria

(2) Types of Hematuria

Can be either tr_____ or per______

The blood may come from the

  • urethra (1)
  • bladder (2)
  • prostate (1)
  • kidneys (3)

Test for microscopic hematuria (1) (presence of ≥__ RBCs/hpf).

A

2 Types = Microscopic or Gross hematuria

Transient or Persistent

The blood may come from the

  • urethra (urethritis)
  • bladder (cystitis, bladder cancer)
  • prostate (prostatitis)
  • kidneys (pyelonephritis, polycystic kidneys, cancer).

Microscopic hematuria is revealed by a microscopic UA (presence of ≥3 RBCs/hpf).

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29
Q

Hematuria Cases

What should you do if you find hematuria in a

  • female with a history of vigorous sexual activity or exercise?
  • female with menses?
A
  • Stop exercise and repeat 4–6 weeks
  • menses = repeat UA with microscopic exam about 1 week after last day of menses
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30
Q

Hematuria Cases

If infection (e.g., urethritis, cystitis, pyelonephritis) is suspected, the UA will show ____ blood cells (with or without nitrites).

It is accompanied by symptoms (4).

Order UA with urine for (1). Persistent unexplained microscopic hematuria that does not resolve, what should you do?

A

If infection (e.g., urethritis, cystitis, pyelonephritis) is suspected, the UA will show white blood cells (with or without nitrites).

It is accompanied by symptoms (dysuria, frequency, urgency, nocturia).

Order UA with urine for C&S. Persistent unexplained microscopic hematuria that does not resolve; refer to nephrologist.

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30
Q

Hematuria Cases

Suspect ____ (or visible) hematuria if color of urine is pink, red, or brown or blood clots are present.

The next step is to look for the _____ of the blood.

  • If dipstick is heme positive, next step is to order a _____ UA.
  • If infection is suspected, order urine for (1).
  • New onset of dark reddish-brown urine, edema, proteinuria, fatigue, and decreased urine output after a recent strep throat, scarlet fever, or impetigo infection raises the possibility of (1), an immune reaction from the infection. It can occur 10 days following the infection and up to 3 weeks after. It is a rare complication that is more common in (1).
A

Suspect gross (or visible) hematuria if color of urine is pink, red, or brown or blood clots are present.

The next step is to look for the source of the blood.

  • If dipstick is heme positive, next step is to order a microscopic UA.
  • If infection is suspected, order urine for C&S.
  • New onset of dark reddish-brown urine, edema, proteinuria, fatigue, and decreased urine output after a recent strep throat, scarlet fever, or impetigo infection raises the possibility of poststreptococcal glomerulonephritis, an immune reaction from the infection. It can occur 10 days following the infection and up to 3 weeks after. It is a rare complication that is more common in children.
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31
Q

Hematuria Cases

  • If malignancy is suspected, send urine for ______ , and refer to specialist.
    • Risk factors for urothelial or renal malignancy are age older than ___ years, (1) gender, s_____ , and gross hematuria.
  • Red urine not due to bleeding can be caused by some
    • medications (e.g., r_____, ph_____) and ingestion of certain
    • foods (e.g., b____, rh____, senna, food d____).
A
  • If malignancy is suspected, send urine for cytology, and refer to specialist.
    • Risk factors for urothelial or renal malignancy are age older than 50 years, male, smoker, and gross hematuria.
  • Red urine not due to bleeding can be caused by some
    • medications (e.g., rifampin, phenytoin) and ingestion of certain
    • foods (e.g., beets, rhubarb, senna, food dyes).
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32
Q

Proteinuria

>____ mg/day or protein

Gold Standard Test =

(4) Types

A

>150 mg/day of protein

24-hour urine for protein

Glomerular, Tubular, Overflow, Postrenal

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33
Q

Albuminuria

(previously known as microalbuminuria)

What urine test cannot detect low levels of albumin or moderately increased albuminuria unless concentrated?

A

Urine Dipstick Test cannot detect albumininuria

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34
Q

Benign Causes of Proteinuria

  • f____
  • intense physical ____
  • acute i_____
  • de_____
  • em_____ stress.
  • dr____ that exert a toxic effect on the kidneys.
A
  • fever
  • intense physical activity
  • acute illness
  • dehydration
  • emotional stress.
  • drugs that exert a toxic effect on the kidneys.
35
Q

Nephrotoxic Drugs

  1. (1) inhibitors or (1)
  2. Antiviral (1)
  3. ______ (Zyloprim)
  4. ________ (vancomycin)
  5. Anti______ (adefovir, cidofovir, tenofovir, indinavir)
  6. (1) (penicillins, cephalosporins)
  7. C_____therapeutics
  8. C_____ dyes
  9. (1) (thiazides, loop, triamterene)
  10. Drugs of ____ (cocaine, heroin, ketamine, amphetamines)
  11. L______
  12. N______ and analgesics (acetaminophen)
  13. (1) (lansoprazole, omeprazole, pantoprazole)
  14. Q______ (ciprofloxacin)
  15. Sul________
A
  1. ACE inhibitors or ARBs
  2. Acyclovir
  3. Allopurinol (Zyloprim)
  4. Aminoglycosides (vancomycin)
  5. Antiretrovirals (adefovir, cidofovir, tenofovir, indinavir)
  6. Beta-lactams (penicillins, cephalosporins)
  7. Chemotherapeutics
  8. Contrast dyes
  9. Diuretics (thiazides, loop, triamterene)
  10. Drugs of abuse (cocaine, heroin, ketamine, amphetamines)
  11. Lithium
  12. NSAIDs and analgesics (acetaminophen)
  13. Proton-pump inhibitors (lansoprazole, omeprazole, pantoprazole)
  14. Quinolones (ciprofloxacin)
  15. Sulfonamides
36
Q

Serious Causes of Proteinuria

  • Diabetic and Hypertensive ______
  • _____ kidney disease
  • sar______, l_____
  • rh______
  • pre______ and ec______
A
  • Diabetic and Hypertensive nephropathies
  • polycystic kidney disease
  • sarcoidosis, lupus
  • rhabdomyolysis
  • preeclampsia and eclampsia
37
Q

Presence of one or more species of bacteria growing in the urine (≥105 CFU/mL) in the absence of UTI symptoms, irrespective of the presence of pyuria.

  • Prevalence (______ women):* Ranges from 1% to 5%
  • Prevalence (healthy ________ women in the community):* Ranges from 2.8% to 8.6%.
A

Asymptomatic Bacteruria

  • Prevalence (premenopausal women):* Ranges from 1% to 5%
  • Prevalence (healthy postmenopausal women in the community):* Ranges from 2.8% to 8.6%.
38
Q

Screening for Asymptomatic Bacteriuria

Who should you screen?

  • Healthy _____ (nonpregnant) and healthy _____ women
  • O____ community-dwelling persons who are functionally impaired
  • Older persons who are residents of long-term care facilities (____homes)
  • D_____
  • Sp____ cord injury
  • Long-term indwelling _____
  • In___ and ch_____
A
  • Healthy premenopausal (nonpregnant) and healthy postmenopausal women
  • Older community-dwelling persons who are functionally impaired
  • Older persons who are residents of long-term care facilities (nursing homes)
  • Diabetics
  • Spinal cord injury
  • Long-term indwelling catheters
  • Infants and children
39
Q

Bacteriuric patient with fever:

Symptomatic bacteriuria with systemic signs of potentially severe infection (sepsis)

What should you do?

A

Symptomatic bacteriuria with systemic signs of potentially severe infection (sepsis)

Treat with broad-spectrum antimicrobial therapy. Refer to hospital.

40
Q

Asymptomatic Bacteriuria

What is the one population you should always screen and treat for ASB? Why?

Treatment duration =

3 (Rx) preferred

However avoid (1)rx near term bc of risk of fetal hyperbilirubinemia

A

Pregnant women: Screening and treating for ASB is recommended (2%–7% have ASB). Pregnant women are at higher risk (30%) for pyelonephritis.

Treat pregnant women with antibiotics for 4 to 7 days’ duration.

Nitrofurantoin and beta-lactams (ampicillin, cephalexin) are preferred.

Avoid nitrofurantoin near term because of risk of fetal hyperbilirubinemia.

41
Q

Urinary Tract Infections

Cystitis (urinary bladder inflammation) can be uncomplicated, recurrent, a reinfection, or relapse.

(1)* causes majority of infections

(3) other causal agents
(2) populations whose UTIs are more likely to progress to pyelonephritis

A

Enterobacteriaceae (E. coli [75%–95%], Klebsiella)

Staphylococcus saprophyticus, enterococci, and Pseudomonas aeruginosa.

UTIs in children younger than age 3 and pregnant women (20%–40% chance) are more likely to progress to pyelonephritis.

42
Q

Urinary Tract Infections

  • Infancy*: UTIs are common in (1) gender in the first 6 months of life (due to anatomic abnormality).
  • Children*: UTIs in children need further ________. About 2.5% of all children will get a UTI. May indicate vesicoureteral ____ or even possible _____ abuse.
  • Females:* Highest incidence is during the ______-age years.
  • Older females:* Symptoms can be _______, but onset of new _______ can be a sign of a UTI.
A
  • Infancy*: UTIs are common in boys in the first 6 months of life (due to anatomic abnormality).
  • Children*: UTIs in children need further evaluation. About 2.5% of all children will get a UTI. May indicate vesicoureteral reflux or even possible sexual abuse.
  • Females:* Highest incidence is during the reproductive-age years.
  • Older females:* Symptoms can be subtle, but onset of new incontinence can be a sign of a UTI.
43
Q

UTI Risk Factors

  • _____ gender; especially during (1)
  • _____ of a recent UTI or _____ infections
  • D_____ (or immunocompromised status)
  • Failure to void after ____ or recent sexual intercourse (i.e., honeymoon bladder)
  • _______ (nonoxynol-9) use can irritate genital tissue (increases risk of HIV and other STDs)
  • Other risk factors: Infected renal cal____, low f____intake, poor hy_____, cath______
A
  • Female gender; pregnancy
  • History of a recent UTI or history of recurrent infections
  • Diabetes mellitus (or immunocompromised status)
  • Failure to void after sex or recent sexual intercourse (i.e., honeymoon bladder)
  • Spermicide (nonoxynol-9) use can irritate genital tissue (increases risk of HIV and other STDs)
  • Other risk factors: Infected renal calculi, low fluid intake, poor hygiene, catheterization
44
Q

Classic Case of UTI

A s_____ active female complains of new onset of ___uria, fr______, frequent u____ to urinate, and nocturia. May also complain of supra____ discomfort. Not associated with fever. Urine dipstick will show a moderate-to-large number of l______ and will be positive for n______.

A

A sexually active female complains of new onset of dysuria, frequency, frequent urge to urinate, and nocturia. May also complain of suprapubic discomfort. Not associated with fever. Urine dipstick will show a moderate-to-large number of leukocytes and will be positive for nitrites.

45
Q

UTI Labs

  • UA dipstick (midstream sample)*: ______ positive (WBCs ≥___/mcL)
  • Nitrites*: Negative or positive (indicative of _______)
  • Sometimes*: ______ (>__ RBCs)
A
  • UA dipstick (midstream sample)*: Leukocyte positive (WBCs ≥10/mcL)
  • Nitrites*: Negative or positive (indicative of Enterobacteriaceae)
  • Sometimes*: Hematuria (>5 RBCs)
46
Q

UTI Labs

Urine C&S (clean voided sample):

  • UTI infection*: (1) of a single organism or (1) of a single organism + (2) of a second organism
  • Multiple bacteria:* ______ sample (growth of >__ organisms)
  • Bacteriuria* (with or without indwelling catheter): >______ CFU/mL
A
  • UTI infection*: 100,000 CFU/mL (or 105 CFU/mL) of a single organism or 100,000 CFU/mL of one organism and growth of a second organism ≥50,000 CFU/mL
  • Multiple bacteria*: Contaminated sample (growth of >2 organisms)
  • Bacteriuria* (with or without indwelling catheter): >100,000 CFU/mL
47
Q

Uncomplicated UTI Pharm Treatment

(5)

(1) for symptoms

A

Nitrofurantoin

Trimethoprim-Sulfamethoxazole (Bactrim, Septra)

Fosfomycin

Ciprofloxacin (Cipro)

Levofloxacin (Levaquin)

Phenazopyridine (Pyridium) - Uristat or AZO

48
Q

Uncomplicated UTI Treatment Dosing and Frequency

Nitrofurantoin (Macrobid) =

Trimethoprim–sulfamethoxazole (Bactrim, Septra) =

Fosfomycin=

Ciprofloxacin (Cipro) BID or levofloxacin (Levaquin) (age 18 years or older) =

Phenazopyridine (Pyridium) =

A

Nitrofurantoin (Macrobid) 100 mg BID for × 5 days

Trimethoprim–sulfamethoxazole (Bactrim, Septra) BID × 3 days

Fosfomycin 3 g × 1 dose

Ciprofloxacin (Cipro) BID or levofloxacin (Levaquin) daily (age 18 years or older) × 3 day

Phenazopyridine (Pyridium) by mouth BID × 2 days PRN

49
Q

Uncomplicated UTI Treatment Alternatives

Bacterial resistance >20% or sulfa-allergic

(3)

A

Nitrofurantoin BID × 5 days

Fosfomycin 3 g × one dose

Augmentin 875/125 mg BID × 5 to 7 days

50
Q

Phenazopyridine (Pyridium)

by mouth BID × 2 days PRN (as Uristat, AZO)

Will turn urine =

Will stain (1)

Avoid if (2) disease or (1) deficiency

Pyridium will turn urine an orange/yellow color; will stain contact lenses; avoid if liver or renal disease, glucose-6-phosphate dehydrogenase (G6PD) anemia

A

Pyridium will turn urine an orange/yellow color

Will stain contact lenses

Avoid if liver or renal disease

Glucose-6-phosphate dehydrogenase (G6PD) anemia

Use caution in patients with G6PD deficiency; hemolytic anemia may occur in the setting of chronic overdose.

51
Q

UTI Nonpharm Treatment

  • Increase _____ intake to __ to __ L/day (except if heart failure)
  • Restrict dietary _____
    • Foods rich in this are b____, sp_____, b____, ____ chips, fr___ fr___, n___, t___
A
  • Increase fluid intake to 2 to 3 L/day (except if heart failure)
  • Restrict dietary oxalate
    • high oxalate foods are beans, spinach, beets, potato chips, french fries, nuts, tea
52
Q

UTI Notes

If clinical symptoms persist 48 to 72 hours after initiating antibiotics

  • Order urine (2)
  • Rule out (1)
  • Switch to (1) and treat for __ to __ days.
A
  • Order urine C&S and UA
  • Rule out pyelonephritis
  • Switch to another antibiotic drug class and treat for 7 to 10 days.
53
Q

Complicated UTIs

M____

Poorly controlled _____

_____ women

Ch_____

O_____ adult

I________ (chronic high-dose steroids, biologics, HIV infection)

______ UTIs or reinfections

Anatomic abnormalities (including kidney st____, reflux, obstruction)

A

Males

Poorly controlled diabetes

Pregnant women

Children

Older adult

Immunocompromised (chronic high-dose steroids, biologics, HIV infection)

Recurrent UTIs or reinfections

Anatomic abnormalities (including kidney stones, reflux, obstruction)

54
Q

Complicated UTIs Treatment

(2)

If high risk of multidrug-resistant organisms: (1)

A

Ciprofloxacin (Cipro) 500 mg BID or 1,000 mg extended release once daily

Levofloxacin 750 mg once a day × 5 to 7 days

If high risk of multidrug-resistant organisms: Nitrofurantoin (Macrobid) 100 mg PO BID

55
Q

UTI Labs

Before and After Treatment

(2)

A

UA and urine C&S

(to document resolution)

56
Q

UTIs in Males

UTIs in newborn males, infants, and older men are considered ______. Underlying ______ issues (urethral stricture, benign prostatic hyperplasia [BPH], calculi, uncircumcised) should be considered.

Symptoms include dysuria, frequency, hesitancy, slow urinary stream, nocturia, and urgency; some have suprapubic pain. If sexually active, rule out (2) infection (use (1) test).

Order (2) tests both (1) and (1) Treat with antibiotics for __-day duration.

If recurrent infection, rule out ureteral st_____, infected kidney _____, anatomic abnormality, acute pr_____, ______ transmitted diseases, and so forth. Must be evaluated further. Refer to ______.

A

UTIs in newborn males, infants, and older men are considered complicated. Underlying structural issues (urethral stricture, benign prostatic hyperplasia [BPH], calculi, uncircumcised) should be considered.

Symptoms include dysuria, frequency, hesitancy, slow urinary stream, nocturia, and urgency; some have suprapubic pain. If sexually active, rule out gonorrhea and chlamydia infection (use nucleic acid amplification test [NAAT]).

Order urinalysis and urine culture pretreatment about 1 week after completing antibiotic treatment. Treat with antibiotics for 7-day duration.

If recurrent infection, rule out ureteral stricture, infected kidney stones, anatomic abnormality, acute prostatitis, sexually transmitted diseases, and so forth. Must be evaluated further. Refer to urologist.

57
Q

Recurrent UTIs (Women)

=

  • Postcoital UTIs = (_____ dose _______ after intercourse): (3)
  • _____ allergy: Cephalexin (Keflex), ciprofloxacin (if >18 years)
  • Postmenopausal women: (1)Rx , increase _____(1.5 L/day), post____ antibiotics (as above)
  • Strategies with no demonstrated efficacy to prevent UTI in women: Cr______ products, oral pro______
  • Rule out urologic ________: Infected stones, reflux, fistulas, ureteral stenosis, and so forth are abnormalities
A

Three or more UTIs (culture positive) in 1 year or two UTIs within 6 months

  • Postcoital UTIs = (single dose immediately after intercourse): Nitrofurantoin (Macrobid) 100 mg, Bactrim DS one tablet, trimethoprim 100 mg, cephalexin (Keflex) 250 mg
  • Sulfa allergy: Cephalexin (Keflex), ciprofloxacin (if >18 years)
  • Postmenopausal women: Intravaginal estrogen (Estriol cream), increase fluids (1.5 L/day), postcoital antibiotics (as above)
  • Strategies with no demonstrated efficacy to prevent UTI in women: Cranberry products, oral probiotics
  • Rule out urologic abnormality: Infected stones, reflux, fistulas, ureteral stenosis, and so forth are abnormalities
58
Q

Long Term Use Nitrofurantoin

(3)

CI with (1)

Get baseline (3) and monitor patients closely

A

Associated with lung problems, chronic hepatitis, neuropathy

CI with renal insufficiency

Get baseline Chest-xray, Liver function tests, and Neuro exam and monitor patients closely

59
Q

Acute Kidney Injury

=

Previously called acute renal failure, many causes

  • (2) most common causes
  • Lasts about __-__ days
  • Some patients recover in a ____days, and some require _____ for several months
  • It is important to triage patients to determine who needs to be referred to the ___.
A

It is the abrupt decline in the glomerular filtration rate (GFR)

  • Most common Pre-renal and Acute Tubular Necrosis (75%)
  • Lasts about 7-21 days
  • Some patients recover in a few days, and some require dialysis for several months
  • It is important to triage patients to determine who needs to be referred to the ED.
60
Q

Kidney disease: Improving Global Outcomes (KDIGO) has a staging system for AKI.

Their guidelines define AKI as:

Increase in serum creatinine by ≥____ mg/dL within __hours

Increase in serum creatinine ≥___ mg/dL from baseline (known or presumed in prior 7 days)

Urine volume

A

Increase in serum creatinine by ≥0.3 mg/dL within 48 hours

Increase in serum creatinine ≥1.5 mg/dL from baseline (known or presumed in prior 7 days)

Urine volume <0.5 mL/kg/hour for 6 hours

61
Q

Prerenal Causes of AKI

Usually due to (1) of kidneys

A

Usually due to hypoperfusion of the kidneys

62
Q

Post-renal Causes of AKI

Usually due to the (1) of the flow of urine in the renal tubular system to the urethra.

To produce AKI, the urethral obstruction must be _____ or occur in a patient with only one functioning kidney. Renal parenchyma is not affected.

A

Usually due to the obstruction of the flow of urine in the renal tubular system to the urethra.

To produce AKI, the urethral obstruction must be bilateral or occur in a patient with only one functioning kidney. Renal parenchyma is not affected.

63
Q

AKI Intrinsic Causes

Caused by damage to the _____ of the kidney or renal tubule. Acute (1) causes 90% of cases, and generally it is a reversible injury.

A

Caused by damage to the tissues of the kidney or renal tubule. Acute tubular necrosis causes 90% of cases, and generally it is a reversible injury.

64
Q

Acute Pyelonephritis

=

Most commonly due to gram-negative (3)

  • Outpatient treatment is only for what type of patients?
  • ______ pyelonephritis present if underlying renal disease, male gender, kidney stone, anatomic urinary tract abnormality, or immunosuppression; refer for hospitalization.
A

Acute bacterial infection of the kidney(s)

gram-negative Enterobacteriaceae such as E. coli (75%–95%), Proteus, and Klebsiella

  • Outpatient treatment is only for compliant healthy patients with milder infections that are uncomplicated (immunocompetent adult female with normal urinary/renal systems without comorbidities).
  • Complicated pyelonephritis present if underlying renal disease, male gender, kidney stone, anatomic urinary tract abnormality, or immunosuppression; refer for hospitalization.
65
Q

Classic Case of Acute Pyelonephritis

Adult patient presents with acute onset of high fever, chills, anorexia, nausea/vomiting, and ____-sided ____ pain. Some patients may also have symptoms of cystitis, such as dysuria, frequency, and urgency.

A

Adult patient presents with acute onset of high fever, chills, anorexia, nausea/vomiting, and one-sided flank pain. Some patients may also have symptoms of cystitis, such as dysuria, frequency, and urgency.

66
Q

Acute Pyelonephritis Physical Exam

(1)* tenderness on one kidney

Temperature > 38.0°C (100.4°F)

  • UA* will show (3)
  • Urine C&S* will show (1)
  • Urinary casts (tubular-shaped structures)* will show (1)
  • CBC* will show (2)
A

Costovertebral angle tenderness on one kidney

Temperature > 38.0°C (100.4°F)

  • UA*: Large number of leukocytes, hematuria, +/‑ nitrites, and mild proteinuria
  • Urinary casts (tubular-shaped structures):* WBC casts (seen in microscopic exam of urine sediment)
  • Urine C&S*: Presence of 105 CFU/mL of one uropathogen
  • CBC:* Leukocytosis (WBC >11,000/mcL), neutrophilia (>80%) with shift to the left
  • Shift to the left:* Presence of bands or stabs (immature neutrophils) means serious infection

Chemistry profile (serum creatinine, others)

67
Q

.Acute Pyelonephritis Treatment

(1) cases can be treated outpatient
(1) cases require hospitalization
* Complications*: Gram-negative s_____, septic _____, kidney ab____, renal f_____, and death.

A

Mild, uncomplicated cases can be treated outpatient with close follow up for 12-24 hours

Moderate-Severe cases require hospitalization

Complications: Gram-negative septicemia, septic shock, kidney abscess, renal failure, and death.

68
Q

Uncomplicated Mild Pyelonephritis Treatment

=

who cannot receive treatment with this class of abx?

A

Fluoroquinolone for 5 to 7 days.

  • ciprofloxacin (Cipro) 500 mg PO BID × 7 days or
  • levofloxacin (Levaquin) 750 mg PO daily × 5 to 7 days.

Fluoroquinolones and aminoglycosides are contraindicated in pregnancy

69
Q

Complicated/Severe Pyelonephritis Treatment

=

A

IV antibiotics for 14 days (gram-negative bacteremia) in the hospital.

Coexisting condition that compromises immune system or is toxic: Refer or hospitalize.

70
Q

Nephrolithiasis (Renal Calcui)

(4) Types

Which is most common?

More common in what gender?

A

Calcium oxalate (60%–70%)- most common

Struvite (7%)

Uric Acid (7%)

Cystine (1%)

More common in males

71
Q

Nephrolithiasis Location

The location and the size of the stone determine the pain, which can range from a mild ache to severe pain.

  • stones located in the upper urethra or renal pelvis =
  • stones on the lower urethra =
  • Both can cause _______ pain.
A
  • stones located in the upper urethra or renal pelvis = flank pain and tenderness
  • stones on the lower urethra = cause pain that radiates to the testicle or the labia of the vagina
  • Both can cause abdominal pain.
72
Q

Risk Factors of Calcium Oxalate Stones

H_____ of nephrolithiasis, positive f_____ history, _____ race

_____ surgery/specifically (1) (excrete higher levels of oxalate)

High dietary intake of c____, vitamin __, oxalate foods, s____, pr____

Low ____ intake, obesity, d_____, g____

Certain drugs that may crystallize in urine (indinavir, ac_____, sulfadiazine, triamterene)

A

History of prior nephrolithiasis, positive family history, White race

Bariatric surgery/gastric bypass (excrete higher levels of oxalate)

High dietary intake of calcium, vitamin C, oxalate foods, sodium, protein

Low fluid intake, obesity, diabetes, gout

Certain drugs that may crystallize in urine (indinavir, acyclovir, sulfadiazine, triamterene)

73
Q

Classic Case of Nephrolithiasis

Adult (1) gender (aged 30–40 years) with acute onset of severe colicky _____ pain (renal colic) on one side that comes in w____. When the pain is most severe, the patient cannot stay still and may walk/pace in the exam room. The pain builds in intensity, then lessens and disappears (until the stone moves again). Painful episodes may last 20 to 60 minutes. For some, the pain can be extreme and associated with n____ and v_____.

Majority have gross or microscopic _____.

Majority (50%) will ____ stone within 48 hours.

Patient should be asked about history of previous episodes, high-pr____ diet, g____, gastric _____, c_____ intake, high-dose vitamin__ , fl__ intake, and intake of certain drugs (see the preceding risk factors).

A

Adult male (aged 30–40 years) with acute onset of severe colicky flank pain (renal colic) on one side that comes in waves. When the pain is most severe, the patient cannot stay still and may walk/pace in the exam room. The pain builds in intensity, then lessens and disappears (until the stone moves again). Painful episodes may last 20 to 60 minutes. For some, the pain can be extreme and associated with nausea and vomiting.

Majority have gross or microscopic hematuria.

Majority (50%) will pass stone within 48 hours.

Patient should be asked about history of previous episodes, high-protein diet, gout, gastric bypass, calcium intake, high-dose vitamin C, fluid intake, and intake of certain drugs (see the preceding risk factors).

74
Q

Nephrolithiasis Small Stone Management

= most will pass the stone.

  • Instruct patient to ____ urine for several days and bring kidney stone to ____ (if passed) for stone analysis by laboratory.
  • Most patients can be managed in the outpatient area with p____ medication and hy_____ until the stone passes.
A

<5 mm, most will pass the stone.

  • Instruct patient to strain urine for several days and bring kidney stone to office (if passed) for stone analysis by laboratory.
  • Most patients can be managed in the outpatient area with pain medication and hydration until the stone passes.
75
Q

Nephrolithiasis Large Stone Management

(1) procedure

A

Extracorporeal shock wave lithotripsy (ESWL)

Breaks the stone up to remove it

76
Q

Preferred Imaging for Nephrolithiasis

=

What if 1st choice test is not available or patient is pregnant?

A

CT of abdomen and pelvis

US of the kidneys and bladder if CT not available or patient is pregnant

77
Q

Nephrolithiasis Lab Findings

UA will show what in majority of patients?

A

Hematuria

UA will show hematuria in majority of patients. Hematuria is present in about 95% of patients on day 1 and from 65% to 68% on days 3 and 4

78
Q

Nephrolithiasis Meds

(2) Rx alone or combined for pain control in acute renal colic
(2) Rx can facilitate stone passage (relaxes smooth muscles of ureters)

alpha-blocker or calcium channel blocker can facilitate stone passage (relaxes smooth muscles of ureters).

A

NSAIDS (indomethacin, ketorolac) and or Opioids

Alpha-blocker or Calcium Channel blocker can facilitate stone passage (relaxes smooth muscles of ureters)

NSAIDs can induce AKI in patients with preexisting kidney disease or dehydration.

NSAIDs can also decrease ureteral smooth muscle tone (may help relieve ureteral spasms).

79
Q

Nephrolithiasis Refer to ED

High f____(possible urosepsis)

Extreme p____

Acute renal f_____

L____ stone

Inability to ____ stone

Unable to tolerate ____ medications and fluids

Severe n____ and v_____

A

High fever (possible urosepsis)

Extreme pain

Acute renal failure

Large stone

Inability to pass stone

Unable to tolerate oral medications and fluids

Severe nausea and vomiting.

80
Q

Nephrolithiasis Nonpharm Treatment

Increase ____ intake up to __ to __ L/day; if calcium oxalate stones, dietary modifications should be advised.

Avoid high-oxalate foods such as rh____, sp____, ok___, n___, b____, ch_____, t___, and m_____.

A

Increase fluid intake up to 2 to 3 L/day; if calcium oxalate stones, dietary modifications should be advised.

Avoid high-oxalate foods such as rhubarb, spinach, okra, nuts, beets, chocolate, tea, and meats.

81
Q

Exam Tips

Memorize definition of UTI (>______ CFU/mL of one organism).

Recognize classic case of UTI and acute pyelonephritis, and be able to distinguish between the two.

Become familiar with ___ results of UTIs.

Pyelonephritis may be treated with a shortened 7-day course of antibiotics when using _______.

A

Memorize definition of UTI (>100,000 CFU/mL of one organism).

Recognize classic case of UTI and acute pyelonephritis, and be able to distinguish between the two.

Become familiar with UA results of UTIs.

Pyelonephritis may be treated with a shortened 7-day course of antibiotics when using fluoroquinolones.

82
Q

Exam Tips

WBC casts with proteinuria and hematuria are associated with (1).

Serum creatinine is a better measure of renal function than the BUN or BUN:Cr ratio. But the (1) is considered the best measure of renal function in primary care.

A

WBC casts with proteinuria and hematuria are associated with pyelonephritis.

Serum creatinine is a better measure of renal function than the BUN or BUN:Cr ratio. But the eGFR is considered the best measure of renal function in primary care.

83
Q

Exam Tips

___ kidney sits lower than the ___ kidney because of displacement by the ____.

Large numbers of squamous epithelial cells in the urine sample mean ______.

Use of the spermicide nonoxynol-9 can increase the risk of ____ in females.

A

Right kidney sits lower than the left kidney because of displacement by the liver.

Large numbers of squamous epithelial cells in the urine sample mean contamination.

Use of the spermicide nonoxynol-9 can increase the risk of UTIs in females.

84
Q

Clinical Pearls

Majority of patients (95%) with pyelonephritis will respond to _____ treatment in __ hours.

A study showed that some women with the classic symptoms of acute UTI may have ____ counts of bacteria (<10,000 CFU/mL). Of these women, 88% had a UTI.

Avoid long-term use of _____, if possible (lung problems, chronic hepatitis, and neuropathy).

A

Majority of patients (95%) with pyelonephritis will respond to antibiotic treatment in 48 hours.

A study showed that some women with the classic symptoms of acute UTI may have lower counts of bacteria (<10,000 CFU/mL). Of these women, 88% had a UTI.

Avoid long-term use of nitrofurantoin, if possible (lung problems, chronic hepatitis, and neuropathy).

85
Q

Clinical Pearls

Serum ______ should be monitored upon initiation of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker therapy if the patient has kidney disease.

Potassium levels may initially rise and then taper off in 2 to 3 months. So should you continue to monitor?

A

Serum potassium should be monitored upon initiation of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker therapy if the patient has kidney disease.

Potassium levels may initially rise and then taper off in 2 to 3 months. Continued monitoring of serum potassium is recommended.

86
Q

Clinical Pearls

Patients with preexisting kidney disease and/or diabetes are at higher risk of kidney damage from ____ media. CT, MRI, and angiogram contrast media may damage kidneys (2%) or cause nephrogenic systemic f______.

Imaging test with the highest sensitivity/specificity for kidney stones is (1) (initial imaging is renal (1)).

A

Patients with preexisting kidney disease and/or diabetes are at higher risk of kidney damage from contrast media. CT, MRI, and angiogram contrast media may damage kidneys (2%) or cause nephrogenic systemic fibrosis.

Imaging test with the highest sensitivity/specificity for kidney stones is noncontrast CT scan (initial imaging is renal ultrasonography).

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