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Flashcards in nephro Deck (164):
1

basic filtering unit of kidney

nephron

2

area where you can hear a bruit

L1

3

3 layers fluid must go through in bowman's capsule

Fenestrated endothelial cell
Glomerular basement membrane (GBM)
Epithelial cell (with podocytes and little feet)

4

Macula Densa in the ______ and JG cells in the ____ arteriole make up the JGA.

distal tubule, afferent

5

what stucutre helps regulate the GFR?

Juxtaglomerular apparatus (tubuloglomerular feedback)

6

what structure synthesizes pro renin?

JGA cells

7

when is pro renin secreted?

when decreased circulating volume or hypoperfusion

8

T or F: the kidney Regulats volume and composition of body fluids to maintain a constant extracellular environment for adequate functioning of cells.

T

9

what waste and metabolic breakdown does kidney filter?

Ammonia, urea and creatinine
Uric Acid
Drugs and toxins.

10

T or F: impaired kidney function will not affect insulin

F: impaired kidney function can extend half life of insulin!

11

what hormones does the kidney degrade?

Metabolic degradation of peptide hormones such as pituitary hormones, glucagon, insulin

12

Increased EPO in states of hypoxemia:

anemia, chronic lung disease, high altitudes.

13

when do you see decreased EPO?

Chronic Kidney Disease due to reduced EPO production by the kidney.

14

kideny enzyme that forms 25 oH D from vitamin D product from liver

1 alpha hydroxylase

15

most potent form of vitamin D that helps us absorb calcium

25 OH D

16

what converts angiotensinogen (made in liver) to angiotensin?

renin

17

what does angiotensin II do?

Systemic Vasoconstriction which raises systemic BP
Na and water reabsorption in PT  helps to restore volume
Secretion of Aldosterone

18

vague sx in renal disease

fatigue, weight loss, anorexia.

19

specific sx in renal disease

hematuria, dark urine, foamy urine, peri-orbital and peripheral edema, HTN, rashes, joint pains/arthralgias, recent URI, incomplete bladder emptying

20

med questions in taking renal history

what meds (esp antibx) have they taken, drug abuse, hx of NSAID use

21

FH questions to ask in renal patients

renal dz/transplant/dialysis

22

PMH to ask in renal patients

hx of stones, UTIs

23

PE signs in renal disease patients

Signs of systemic illness: DM, HTN
Assess volume status: edema, JVP, BP.
Examine skin for rash, purpura.
Examine joints if hx of arthralgia

24

what can flank pain or tenderness mean?

Renal infection
Renal infarction
Glomerulonephritis
Rarely obstruction

25

what can severe/colicky pain mean in renal patients?

Renal or ureteric colic +/- radiation to iliac fossa, groin and genitalia
Acute obstruction of the renal pelvis and ureter by renal calculus or blood clot

26

sx of lower UTI

Dysuria
Frequency
Urgency

27

bladder outflow obsturction sx

Impaired urinary flow
Hesitancy
Dribbling
Incomplete emptying of bladder

28

sphincter or bladde real dysfcn a

Urinary retention
Incontinence
Enuresis

29

abnormal urine volume ddx

Acute renal failure or obstruction to urine flow
Anuria
Oliguria
Failure to concentrate urine (Diabetes Insipidus, CKD)
Polyuria, nocturia.

30

what does proteinuria suggest?

Suggest glomerular disease
Massive proteinuria causes edema

31

best time for UA

early AM, mid-stream clean catch specimen.

32

what do these colors in urine mean?
Dark yellow to green
Red to black
Purple to brown on standing to light

Dark yellow to green (Bilirubin)
Red to black (erythrocytes, hemoglobin, myoglobin)
Purple to brown on standing to light (porphyrins)

33

normal urine color

(yellow to amber)

34

normal urine ph

(Normal pH 4.6 to 6.0)

35

increased urine ph

Infection with urea-splitting organism (proteus)
Systemic alkalosis, renal tubular acidosis, carbonic anhydrase inhibitors

36

normal specific gravity

(Normal 1.003 to 1.030)

37

increased urine specific gravity ddx

Fasting and dehydration, glycosuria, proteinuria, radiographic contrast media.

38

decreased urine specific gravity ddx

Compulsive water drinking, diabetes insipidus

39

T or F: protein in urine is normal

F: persistent proteinuria indicates renal disease; if one time it is elevated, retake the test if no indication of a glomerular problem

40

Persistently positive dipstick proteinuria should be quantified how?

24 hour Urine collection or Spot albumin-to-creatinine ratio.

41

what do ketones in the urine mean? causes?

Ketones in urine indicate that metabolism is dependent upon fatty acids rather than glucose for energy
causes: Diabetic Ketoacidosis, starvation, fasting, alcoholic ketoacidosis.

42

Glycosuria in setting of normal plasma glucose:

Defect of Proximal tubule reabsoprtion such as Fanconi syndrome, myeloma, exposure to meds such as tenofovir, lamivudine, cisplatin, valproic acid and aminoglycoside

43

what can cause a false + blood on dipstick?

hemoglobin and myoglobin, even when no RBCs on micro

44

high BUN seen with...

dietary intake (high protein diet)
high catabolic rate and tissue breakdown (hemorrhage, trauma, glucocorticoid therapy.
Dehydration

45

nml or low bun seen with

Muscle wasting and liver disease.

46

causes of pre-renal 20:1 BUN/cr

decreased blood flow

47

causes of normal or post renal 10-20:1 BUN/cr

obstruction

48

causes of

Renal damage causes reduced reabsorption of BUN, therefore lowering the Bun: Cr ratio.

49

Eliminated exclusively by the kidneys and therefore can serve as an indicator of renal function

creatinine

50

creatinine vary according to...?

person's size and muscle mass hence lower in women and elderly

51

what is a 24 hour creatinine clearance?

estimate Glomerular Filtration Rate (GFR) by comparing the level of creatinine in urine with the creatinine level in the blood
Requires serum sample and 24 hour urine collection: Ucr x Volume/ Pcr.

52

equation used to calculate GFR

cockcroft gault EQ

53

best initial test to visualize kidney

US

54

indications for renal ultrasound

renal masses
obstruction/hydronephrosis
fluid collections or other signs of inflammation/infection
MAY detect nephrolithiasis (but CT better)
hematuria,
Acute Kidney Injury
flank pain
safe during pregnancy
+ doppler for suspicion of renal artery stenosis

55

T or F: CT is better than MRI for characterizing abnormal tissues/masses especially when there is concern for malignancy

F

56

special test you can do if someone has frequent UTIs, hematuria, incontinence, painful urination, etc

cystoscopy or voiding cystourethrogram

57

can you biopsy a kidney/

no! leave that to urologists--you could create a tract for malignant cells to go

58

American urologic association of hematuria

> than 3 RBCs per High Power Field in 2-3 properly collected urine on two separate urinalysis over a 2 week period.

59

T or F: its normal for someone on warfarin to have a few RBCs in urine

F: they should not have hematuria

60

what is it called when RBCs may get trapped in a specific protein in the distal convoluted tubule and stick together and can be seen on microscopy

casts

61

causes of glomerular hematuria:

glomerulonephritis, vasculitis, Iga nephropathy, thin basment membrane nephropathy, hereditary nephritis (alport syndrome), chronic intersitial nephritis (inf

62

how do you distinguish extraglomerular hematuria from glomerular hematuria?

normal appearing RBCs in urine (b/c haven't been crunched when going through glomerulus)

63

causes of extraglomerular hematuria

Infections
Nephrolithiasis (kidney)
Calculus (bladder, urethra)
Malignancy
Cystic disease (PKD)
Vascular disorders
AVM, renal vein/artery emboli/infarct, papillary necrosis (DM, Sickle Cell Disease, NSAIDs)

64

symptoms of extra glomerular hemauria

Dysuria, pyuria, fevers
UTI, pyelonephritis, prostatitis, urethritis, malignancy
Urethral discharge
Urethritis, prostatitis
Flank pain
Pyelonephritis, stones, neoplasm, ischemia, GN
Hesitancy, dribbling
BPH

65

signs or sx of glomerular hematuria

Gross, painless hematuria :bladder cancer, post-infectious GN, Cancer
Fevers, rash, arthritis : GN associated with Vasculitis such as Systemic Lupus Erythematosus.

66

signs of extraglomerular hematuria

Suprapubic tenderness
UTI
CVA tenderness
Pyelonephritis
Urethral discharge
Urethritis
Enlarged prostate
BPH
Prostatitis (tender)
Nodular (malignancy)

67

signs of glomerular hematuria

Skin lesions such as ecchymosis, petechiae, rash
Coagulopathy, vasculitis, SLE
Hypertension, periorbital edema, generalized edema.

68

ECF determined by

sodium and water

69

Plasma sodium concentration is regulated by changes in ____ intake and excretion, not by changes in sodium balance.

water

70

Hyponatremia is primarily due to the intake of water that cannot be ____

excreted

71

Hypernatremia: primarily due to :

loss of water that has not been replaced

72

tx of chronic moderate hyponatremia

fluid restircion

73

tx of sx hyponatremia

hypertonic saline (usually as a 100 mL bolus given over 10 to 15 minutes=small bolus).

74

causes of hypernatremia

GI losses (like osmotic diarrhea in cholera),

75

difference between dehydration and hypovolemia

Hypernatremia due to water loss is called dehydration. This is different from hypovolemia, in which both salt and water are lost
skin (sweat), or the urine (diabetes insipidus or an osmotic diuresis due to glucosuria (which pulls water with it) in uncontrolled diabetes mellitus or increased urea excretion resulting from catabolism or recovery from renal failure)

76

tx of hypernatremia

dilute fluids

77

most common causes of hypokalemia

most cases result from unreplenished gastrointestinal or urinary losses due, for example, to vomiting, diarrhea, or diuretic therapy

78

causes of hyperkalemia

increased potassium release from the cells and, most often, reduced urinary potassium excretion

79

how does acidosis caused by serum bicarb and pCo2

This can be caused by a fall in the serum bicarbonate (HCO3) concentration and/or an elevation in PCO2.

80

A disorder that reduces the serum HCO3 concentration and pH.

metabolic acidosis

81

A disorder that elevates the serum HCO3 concentration and pH.

metabolic alkalosis

82

A disorder that elevates the arterial PCO2 and reduces the pH

respiratory acidosis

83

A disorder that reduces the arterial PCO2 and elevates the pH.

respiratory alkalosis

84

definition of acute kidney injury

• Abrupt (within 48h) reduction in kidney function (usu lasts 0.3 mg/dL
• Percentage increase of > 50%
• Reduction in urine output- oliguria of 6hr

85

most common etiology of kidney failure

− Acute tubular necrosis 55%

86

Functionally, urine output less than that required to maintain solute balance (can’t excrete all solute taken in).
− Defined as urine output

oliguric renal failure

87

Suggests complete obstruction, major vascular catastrophy, or more commonly severe ATN, less common and indicates more severe renal failure
− Defined as urine output

anuric renal failure

88

causes of non oliguric renal failure

intrarenal causes – nephrotoxic ATN, acute GN, AIN.

89

causes of non oliguric renal failure

more common with obstruction, prerenal azotemia

90

how can you discriminate between acute and chronic renal failure?

➢ Oliguria supports a diagnosis of acute renal failure
clues to chronic disease: DM, HTN, age, vascular `, fatigue, nausea, anorexia, pruritus, altered taste sensation, atrophied (small) kidneys by ultrasound

91

pre-renal causes of renal failure

decrease in ECF volume(GI losses, hemorrhage), decreased renal blood flow (HF, renal artery stenosis), altered intra renal hemodynamics (NSAIDS, ACE, sepsis, hypercalcemia, cirrhosis)

92

intra renal causes of renal failure

tubulointerstitial disorders (tubular injury, ishcemic, nephrotoxic, interstitial nephritis--allergic or NSAID)
and glomerular disorders (glomerulonephritis, thrombotic microangiopathies, atheroembolic disease)

93

post renal causes of acute renal failure

anatomic obstruction (bladder outlet, prostate, pelvic tumor, ureteral--tumor, stones, stricture)
tubular obstruction (crystals (calcium oxalate--ethylene glycol poisoning), drugs (indoor, MTX), proteins (myeloma cast nephropathy)

94

things that can "insult" the kidneys

• Volume depletion (diarrhea, blood loss, emesis, over-diuresis), Hypotension, CHF (d/t MI or HTN).
• Drug exposure – toxin or reduction of renal perfusion (aminoglycosides, vancoymycin).
• Contrast exposure.
• Infections – inflammatory mediators v. direct infection
• Endogenous toxins/insults – myoglobin, hemoglobin, uric acid.

95

sx of acute renal failure

• Fever, rash, joint pains, myalgias- concern for SLE, vasculitis, acute interstitial nephritis.
• Dyspnea – heart failure.
• Hemoptysis – Goodpasture’s (genetic defect in collagen that affects basement membranes in kidneys and lungs), Wegener’s.
• Preceding bloody diarrhea – HUS.
• Preceding pharyngitis – post-Strep Glomerular nephritis (GN)-

96

what are some ways to assess volume status?

JVP, peripheral edema or lack of it, orthostatic vitals, signs of right sided heart disease (SOB)

97

what do dysmorphic hematuria/red cells casts in urine indicate?

renal cause of ARF: glomerulonephritis or atherembolic disease (albuminuria)

98

What do oval fat bodies and fatty casts indicate in urine?

minimal change disease focal (albuminuria)

99

what do muddy brown casts in urine indicate?

tubular epithethial injury--ischemic (tubular proteinuria)

100

what do white cells and white cell casts and eosinophiliuria indicate in urine?

interstitial nephritis, UTI (tubular proteinuria)

101

what does crystals in urine mean?

drug toxicity, urate, nephropathy, calcium oxalate

102

when do you bx kidney?

• Exclude pre- and post-renal failure, and clinical findings are not typical for ATN
• Extra-renal manifestations that suggest a systemic disorder
• Heavy proteinuria
RBC casts

103

urine sodium level indicative of prerenal level? Acute tubular necrosis (ATN) level?

prerenal= 40

104

urine/plasma creatinine ratio indicative of prerenal level? Acute tubular necrosis (ATN) level?

prerenal: >40 (higher creatinine in urine because kidney is working to excrete it); ATN

105

A 42 year male is admitted to the SICU after sustaining multiple trauma. His course is complicated by Enterobacter sepsis with profound hypotension requiring support with intravenous dopamine. The urine output has gradually decreased to only 300 ml per day. The urine sodium is 78. Urine sediment showing multiple muddy brown granular casts. what does he have?

• Acute tubular necrosis- tubules sensitive to low blood pressure
• How did we know?
• Sudden onset
• Hypotensive=RF for pre-renal failure
• Trauma could have led to shock and hypooperfusion
• sepsis can cause vasodilation and decrease perfusion
• Post trauma, probably sympathetic system is activated and maintaining blood flow to brain and heart but less to kidneys.
• Also renal causes:
• High urine sodium (>40), kidney is damaged and can’t reabsorb

106

renal failure type where kidney is reacting to some sort of irritant and is marked by non-oliguric ARF, fever in allergic and infectious types, rash in allergic types, eosinophilia, WBC casts +/- hemeaturia

acute interstitial nephritis

107

drugs that can cause AIN

NSAIDS
abx: PCNS, quinolones, anti-TB meds, sulfas (TMP-SMX, furosemide, thiazides), allopurinol, cimetidine, dilantin

108

causes of AIN

• Allergic/Drug induced
• Autoimmune: Sarcoid, SLE, Sjogren’s
• Toxins: Chinese herb nephropathy, Heavy metals, Light chain cast nephropathy
• Infiltrative: Leukemia, Lymphoma
• Infections (Legionella, CMV, HIV, Toxoplasma)

109

tx of AIN

withdraw offending agent (drug, etc), tx underlying disease, corticosteroids

110

(+) dipstick for blood but no RBCs means what?

rhabdomyolysis

111

Amino glycoside Nephrotoxicity Generally presents ____ after exposure

1 week

112

how does radioconstrast induce acute renal failure?

• Induces renal vasoconstriction

113

what do these major criteria indicate?

hepatorenal syndrome

114

most common bug in UTI

E. coli (80-90%),

115

RFs for UTIs

• Recurrent/previous UTIs
• Atrophy/menopause
• Obstruction, no circumcision
• Antibiotics
• Immunosuppression, DM
• Pregnancy • Incontinence
• Intercourse
• Instrumentation, inwelling catheter
• Personal hygiene
• Urinary retention
• Anatomic abnormality
• Family history

116

sx of UTI

• Frequency, urgency, dysuria
• Suprapubic pain/tenderness
• Odiferous urine
• Hematuria (increase index of suspicion—painless hematuria=cx)

117

ddx of UTI

• Urethritis
• Prostatitis
• Pyelonephritis
• nephrolithiasis
• PID/STI
• Vulvovaginitis (inflammation on outside and vaginitis on inside)
• Urethral syndrome
• Irritable bladder/interstitial cystitis

118

PE to do for uti

• Abdominal exam
• CVA tenderness- push on CVA before percussing, usually no pain
• Female: Vaginal/pelvic prn- suspected STI
• Males need GU and DRE- check for prostatitis
• Elderly need CV/PV/Pulm- r/o other causes of possible sepsis

119

UA findings indicating UTI

• Positive nitrites (bacteria can convert nitrate to nitrite)
• Positive leukocyte esterase
• Cloudy appearance
• Culture findings: Bacteriuria ≥ 105/ml, single species
• Blood + if visible, RBCs microscopic or visible
• May also see protein
• > 10 hpf WBC
• > 5 hpf RBC- hematuria detected at 20 hpf
• ↑ epithelial cells or multiple species indicate a non-clean catch
• Specific gravity: if high suggests dehydration

120

RFs for pyelonephritis

• Ureterovesicular reflux
• Intrarenal reflux
• Dilated/hypotonic ureters
• Indwelling catheters
• Nephrolithiasis • Immunosuppression
• Previous pyelonephritis
• Elderly, institutionalized women
• Pregnancy
• Neurogenic conditions

121

sx of pyelonephritis

• FAST ONSET
• Constitutional symptoms, F/C, N/V
• Dysuria, frequency, urgency
• Flank/loin/back pain or tenderness
• Elderly specific

122

PE findigns on pyelonephritis

• Fever
• CVAT- don’t percuss!
• Diffuse abdominal tenderness
• Female: pelvic exam if needed
• Males: GU exam b/c rare in this group

123

lab findings that differentiates UTI from pyelo

• WBC casts- differentiation from LUTI

124

ddx of pyelonephritis

• UTI
• Appendicitis
• cholecystitis
• Cholelithiasis
• Pancreatitis
• Diverticulitis
• LLL pneumonia
• Epididymitis/prostatitis
• Renal abscess
• Acute prostatitis/cystitis
• PID/STI/vaginitis

125

patient education for uTI/PYELO

• Describe disease
• Pharmacotherapy
o OTC
o Antibiotics
• Nonpharmacotherapy
o Fluids
• Advice
o Frequent / postcoital void
o Proper wiping
o Avoid constipation (blocks urinary flow)
• Follow-up
o Return if…sx get worse or don’t go away (flank pain, etc)
o Repeat UA if hematuria and concern for cx

126

Multisystem disorder
Bilateral renal cysts associated with cysts in other organs like the liver, pancreas, and arachnoid membranes

polycystic kidney disease

127

T or F: polycystic kidney disease is recessively interhrited

F: can be autosomal dominant or recessive

128

gold std for dxing PKd

imaging: US, CT

129

is it normal for people on warfarin to have hematuria?

no! always work up hematuria. 25% have a malignancy

130

complications of pKd

HTN, stones, infections, hematuria, renal failure

131

clinical features of PKd

• Most asymptomatic
• Flank, back, and/or abdominal pain in about 60%- massive kidney enlargement
• UTI and renal stones
• Hematuria, HTN in half
• Intracerebral aneurysm in 6-16%- intracerebral cysts are common, rupture is serious
• Most die of other things before PKD

132

best tx for pKD

V2 receptor antagonists (Tolvaptan)

133

is proteinuria > 1-2 g/24 h normal or abnormal?

abnormal

134

tx of people with nephrotic syndrome

anticoagulants, lipid lowering agents (statins), ACEI to protect kidneys from proteinuria

135

who should get a urine culture?

complicated cystitis, cystitis in a pregnancy, cystisis with clinical failure, pyelonephritis

136

when is post tx culture (1-2 weeks after tx) indicated?

for sure if pregnant or treatment failure

137

tx of acute uncomplicated cystitis: if local resistance

TMP/SMX 1 DS po bid x 3 days

138

alternative drugs for acute uncomplicated cystitis if sulfa allergy

nitrofurantoin, fosfomycin

139

drug for acute uncomplicated cystitis if local resistance of e coli >20%

cipro, levo, moxi OR nitrofurantoin or fosfomycin

140

options for acute UTI in pregnancy and length of tx

TMP/SMX x 7 days
Amox/clav x 7 days
Cephalexin x 7 days
Nitrofurantoin x 7 days
Note: NO FQS, beta lactams instead

141

tx of acute uncomplicated cysts in someone with STD risk factors

azithromycin (1st line) alt: doxy also do pelvic exam to r/o gonorrhea

142

young woman with >3 UTIs per year tx

TMP/SMX SS qd long term or x1 @ sx onset or post coitus

143

duration of UTI tx for males

10-14 days

144

what's different about txing pyelonephritis pts? (outpt)

FQs 1st line, doses are double

145

what pathogen do you have to tx for in inpatient pyelonephritis?

pseudomonas

146

what's different about txing pyelonephritis inpatiently?

FQs course twice as long (14 days, compared to 7 outpt) IV first until afebrile for 24-48 hours, includes meds for pseudomonas (pip/tazo, amp+gent, ceftriaxone)

147

pyridium is urinary analgesic, what can it mask?

can mask signs and sx of UTI not responding to abx

148

when should most UTIs sx be cleared?

12-24 hours with tx

149

fluids in UTIs: help or not?

little effect, may dilute antibacterial properties of urine

150

is cranberry use rec'd for tx of UTIs?

no, just for prevention. makes urine more acidic

151

clinical features of acute nephritic syndromes

1-2 g/24 h of proteinuria, hematuria with RBC casts, pyuria, HTN, fluid retention, rise in serum creatinine, reduction in GFR

152

1-2 g/24 h of proteinuria, hematuria with RBC casts, pyuria, HTN, fluid retention, rise in serum creatinine, reduction in GFR+ lung hemorrhage

good pastures

153

Heavy proteinuria (>3g/24 h), HTN, hypercholesterolemia, hypoalbuminermia, edema/anascara, microscopic hematuria, nml to declining GFR

nephrotic syndrome

154

Microscopic hematuria, mild to heavy proteinuria and HTN with variable serum creatinine elevations

basement membrane syndromes

155

Sx: impetigo or strep pharyngitis with +/- impetigo. usu develops 1-3 wks after strep pharyngitis and 2-6 weeks after impetigo skin infection. Hematuria, pyuria, RBC casts, edema, HTN, oliguric renal failure

post strep glomerulonephritis

156

bag of worms

varicocele

157

MC side of varicocele

Left

158

if right sided varicocele, what do you worry about?

something compressing vein or a renal mass
• Bilateral means all their veins are just not great

159

treatment of varicoele

surgery if assoc with small testis, fertility issues, bilateral palpable varicoceles or symptomatic

160

treatment of hydrocele

• Surgery for symptomatic lesions or if mass changes

161

testicular pain, swelling, urethral discharge. Usu gradual onset. Often unilateral. +/- fever or signs of systemic infection (chills, rigors). +/- sx assoc with urethritis or UTI. Frequency, urgency, hematuria, dysuria. cremasteric reflex intact

epidydimitis

162

RFs for bladder carcinoma

male, smoking, • Chemical exposure: working with chemicals dyes, aromatic amines, textiles, leather pain, dry cleaners, radiation exposure
• Chronic cystitis—increaed risk of squamous cell

163

MC sx of bladder carcinoma

painless hematuria

164

ddx of severe abdominal pain that radiates into groin

Renal or ureteral stone
Hydronephrosis (ureteropelvic junction obstruction)—does he have a tumor or mass compressing?
Bacterial cystitis or pyleonephritis
Acute abdomen (bowel obstruction, biliary, pancreas or aortic abdominal aneurysm sources)
Gynecologic (ectopic pregnancy, ovarian cyst torsion or rupture)
Radicular pain (L1 herpes zoster, sciatica)
Referred pain (orchitis, testicular torsion)
Hernia