What are the 6 functions of the kidneys?
- Blood Pressure Regulation
- Excretion of waste
- Maintenance of blood pH
- Produce EPO
- Vitamin D Synthesis(last 2 steps)
- Gluconeogenesis
What is the estimated daily urine output
1440-2880mL
What is a normal GFR
120/mL/min
What are the functions of the basement membrane?
-allows only certain size molecules through and has a charge which repels protein to allow blood to continue down stream
What happens when the basement membrane is damaged?
blood and large molecules will pass through and proteins can get spilled leading to proteinuria and hematuria
What is secreted when there is low blood volume? What does this do?
- Renin is secreted
- increased blood pressure
What is intractable blood pressure?
What population is it common in?
- renin increases leading to even higher blood pressure
- Atherosclerosis
When a patient has kidney pain what is causing the pain?
Inflammation
What simple urine test reveals the concentration ability of the kidneys?
Urinalysis/Specific Gravity
What finding in a patients vitals can help differentiate between simple cystitis and pyelonephritis?
Temperature
What type of casts are found in people with renal failure?
Waxy Casts
What specific lymph node is palpated when concerned about a testicular condition?
Left supraclavicular lymph node
What are common urological ddx’s for fever?
- Acute PN
- Malignancy
- Acute Prostatitis
- Epididymitis
What are common urological ddx’s for No fever?
- Simple Cystitis
- Chronic PN
What are common urological ddx’s for weight loss?
- advcanced
- renal insufficiency due to obstruction
- renal insufficiency due to infx
What are common urological ddx’s for failure to thrive?
-Children suspect chronic obstruction, UTi or Both
how do you differentiate between nephritic and nephrotic syndrome?
24 hour urine test
Constant pain indicates?
Infx
Pain that comes and goes indicates?
Obstruction
What is normal specific gravity
What level do you start to see diminished renal function?
- 00-1.030
1. 010
What does Bun indicate
Blood urea nitrogen
-indicates GFR, influenced by dietary proteins, hydration, GI bleeding and drugs
What is a normal BUN
7-20
What does an elevated Bun indicate
decreased kidney function
What is a normal BUN/creatinine ration
> 20:1 signifies increased BUN ) indicates something is happening prior to the kidneys
<10:1 signifies renal damage leading to decreased reabsorption of BUN
what is a normal GFR for males and females
Males: 56-84
Females: 50-80
Why would you run serum creatinin
to estimate glomerular function
Blood and casts think?
renal endothelial damage
What are 6 characteristic findings of nephritic syndrome?
- Hematuria
- HTN
- Milder
- Mild proteinuria <3.5
- RBC casts
- Mild Edema
What are 7 characteristic findings of nephrotic syndrome?
- Slower development
- Polyuria
- Severe Proteinuria >3.5
- Edema (severe)
- Dyslipdemia
- Lipiduria
- Some HTN
What is the classic presentation of Nephritic syndrome?
PHAROH
- protinuria
- Hematuria
- Azotemia
- RBC casts
- Oliguria
- HTN
other sx:
edema, rash, heart murmur
What is glomerular bleeding RBC morphology?
Dysmorphic
Treatment for IgA nephropathy
- ACEi
- ARB
- Steriod if resistant
What lab is commonly found in goodpastures
Anti GBM antibodies
What is a common lab test in RPGN?
ANCA
-microscopy shows crescentic GN
What disease does microscopy show diffuse proliferation
PSGN
What disease does microscopy show focal proliferation
IgA nephropathy
What are the physical exam findings in Neprotic syndrome?
- Pretrial pitting edema
- Periorbital edema
- Asess JVD
- Ascities
- Terry’s nails
What are the lab findings in nephrotic syndrome?
- Protenuria
- Microalbumia
- Hypoalbuminemia
- Hematuria
- Azotemia
- Lipiduria
- Dyslipidemia
- Oval Fat bodies
What would a UA for acute tubular necrosis show?
- Mild proteinuria
- Hematuria
- RTE
- RTE Casts
What is normal protein level in the urine?
0-2
symptoms of chronic tubulointerstitial disease?
- Nocturia
- Uremia Sx
- Small Kidneys
- Hyperkalemia
- Reduced SG
- Hyperchloremic metabolic acidosis
What are symptoms of Intrinsic acute renal failure?
-Salient hx of URI
-Diarrhea
-Use of ab or Iv drugs
-Back pain
-Gross hematuria
-Fever
Maculopapular rash
-Dehydrationand shock
What would you expect laboratory tests in patients with Intrinsic acute renal failure to show?
- change in SG
- High urine sodium
- RBC Casts
- Increased BUN
What is the presentation of Postrenal Acute Renal Failure
- renal pain
- renal tenderness
- lower abdominal pain
- post-surgery urine leak
- over-hydration
- edema
- ileus with abdominal distention
- enlarged prostate
- distended bladder
What would lab results show that suggest Uremia
- microalbuminuria
- WBC’s
- Waxy casts
optimal daily urine volume should be:
2500 ml
How much water intake is required to make the optimal amount of daily urine?
250 ml qh
Burning pain with voiding felt in suprapubic area may be a sign of what?
acute cystitis
Painful suprapubic area may be a sign of what?
Acute urinary retention
Is chronic retention painful in the bladder (suprapubic) area
No
renal pain description
Sudden distention of the renal capsule
Urethritis sx’s
- Burning Pain throughout urination
- Frequent, urethral d/c
- Inflammed urethra
- Local LA
What UA findings suggest urethritis
- Pyuria
- Bacteriuria
- Hematuria
- Suprapubic palpation is painless
- negative CVA tenderness
What are the sx of cystitis
- Burning Midstream/late pain that does not radiate
- gross hematuria
- Fatigue
- mildly positive CVA
What UA findings suggest cystitis
- Pyuria
- Bacteriuria
- Hematuria
Pyelonephritis sx
- timing of pain is variable
- Pain refers to flank/abdomin
- fever
- myalgia, fatigue, weakness
- N&V
- suprapubic palpation is painless
- postive CVA
What UA findings suggest pyelonephritis
- Pyuria
- bacteriuria
- hematuria
Signs and sx of chronic prostatitis
- pelvic dullness
- pain radiates from testicular pan to general pelvic pain
- altered libido
- pain on ejaculation
- suprapubic palpation is painless
- most UA show no results
Oliguria and Anuria causes
- acute renal failure due to shock or dehyrdation
- fluid-ion imbalance
- bilateral uretral obstruction
always refer for immediate treatment
Oliguria definition
<500ml urine output daily
Anuria definition
<100 ml urine output daily
Gross hematuria is commonly from what source
uroepithelial
What is the most common cause of hematuria in children without UTI or GN
-Hypercalcicuria with microcalculi
history of hematuria and first UA is clear when do you repeat?
one week
history of trauma and exercise induced hematuria when do you repeat?
24-48 hours
Dip sticks pick up what type of protein?
albumin
not globulin
bence jones proteins are misses
What level of plasma glucose needed to see positive glucose in the urine?
170
What test will often be the first indication of viral hepatitis
urine urobilinogen
What type of cast is pathognomonic for acute GN or vasculitis
RBC casts
What is endogenous creatinine clearance used for?
reliable measure of renal function without need for infusion
Gold standard for measuring GFR?
Inulin infusion
Nephritic syndrome definition
glomerular inflammatory process causing renal dysfunction
MC cause of (post) infectious nephritic syndrome
PSGN
Glomerular bleeding characteristics
- Dark red/cola
- Proteinuria
- RBC morphology:dysmorphic
- HTN
- Edema
- Back/flank pain
- Reduced renal function
- URI/Fever/Rash hx
Urologic bleeding characteristics
- Bright red urine
- Clots
- RBC morphology
- Urinary voiding sx
- Normal renal function
- RBC morphology : isomorphic
- positive trauma hx
Sx of PSGN
- 1-3weeks post prior strep infection
- impetigo
- infx, fever, confusion
- HTN
- periorbital edema
- hematuria
- Ha
- N&V
- malaise
Ua results of PSGN
- Cola colored urine
- Oliguria
- RBC
- RBC Casts
- protenuria <3.5
What ua finding is pathognomonic for PSGN
RBC Casts
What serology is used to dx PSGN
Streptozyme test for 5 antibodies
What are complement levels like in PSGN
Decreased C3 and CH50
Normal C4 and C2
PSGN TX
1) Treat infection if present (penicillin, erythromycin)
2) Treat any edema or HTN (conventional: loop diuretics)
3) Limit protein (about 1g/kg per day) and sodium
4) Bed rest
5) Botanicals: Curcuma, Echinacea
6) Quercitin, bromelain
7) Vit C to bowel tolerance Vit E 800 IU
8) Constitutional hydrotherapy, skin brushing
ANCA associated GN (necrotizing GN) sx
- hematuria
- proteinuria
- bleeding respiratory tract nodules (hemoptysis, crackles)
- asthma
Anti-GBM GN and Goodpasture’s syndrome s/sxs
Concomitant pulmonary hemorrhage—dyspnea, hemoptysis, crackles—and renal symptoms (edema, HTN). Type II hypersensitivity reaction.
MC cause of primary nephritic syndrome
Berger’s disease (IgA nephropathy)
IgA nephropathy cause
Idiopathic
IgA nephropathy sx
-Episodic gross hematuria <5 days after viral or bacterial URI
-Gastroenteritis
-Microscopic hematuria
-HTN
-Persistent proteinuria
asymptomatic
General treatment approach to Nephritic syndromes:
1) Avoid sodium, avoid high-potassium foods, low protein diet, low antigen diet (gluten, meat, dairy), Grifola, Withania, Tinospora)
3) diuretics (use with caution)
4) fish oil (12 g/d)
5) treat HTN: goal BP is <125/75 mm Hg in presence of proteinuria >1g/d. Pharmacologic: ACEi
6) remove other allergens (environmental, etc)
7) Conventional approach: corticosteroids, alkyating agents (cyclophosphamide), calcineurin inhibitors, rituximab and ocrelizumab
Nephrotic syndrome definition
The end result of a variety of diseases that damage (immunological or other assaults) the GBM ⇒protein wasting (from alteration of the negative charge), and increased permeability of glomerular capillaries.
What type of casts are the hallmark sign of nephrotic syndrome?
broad waxy casts
“Renal Failure casts”
Primary glomerular diseases that cause nephrotic syndrome
minimal change dz, focal segmental glomerulosclerosis, Membranous nephropathy, Membranoproliferazive
Glomerulonephritis (MPGN)
LUPUS NEPHRITIS s/sxs
specific “wire loop” lesions, recurrent hematuria, HTN, rash, joint problems
systemic diseases that cause nephrotic syndrome
LUPUS NEPHRITIS
BACTERIAL ENDOCARDITIS-ASSOCIATED GN
AMYLOIDOSIS
DIABETIC NEPHROPATHY
When to order a renal biopsy with a patient with suspected nephrotic syndrome
persistent proteinuria with unclear cause!
treatment for nephrotic syndrome
1) Allopathic: prednisone, cyclophosphamide, Mycophenolate Mofetil (lupus), oral galactose
2) HTN: ACE inhibitors, angiotensin II receptor blockers, Furosemide
3) limit dietary protein and sodium
4) remove allergens
5) FSGS: Ubiquinone and Ganoderma lucidium
6) MPGN: Alpha-lipoic acid, Vitamin E, Rosmarinic acid (Perilla frutescens eg), Rhubarb
7) Membranous nephropathy: Astragalus 15g/d to lower proteinuria
8) Fish oil 12g/day
9) Anti inflammatory herbs (curcumin, boswellia)
10) Anti-oxidants: Gingko
11) Immune amphoteric herbs
12) Constitutional hydro
13) Control diabetes
14) Renal protectives: nettle seed extract, Salvia miltiorrhiza (DanShen)
ACUTE INTERSTITIAL NEPHRITIS (AIN), “Hypersensitivity Nephropathy” definition
Inflammation of the renal interstitium, from cell-mediated immune response binding to interstitial proteins, leading to a decrease in renal function. Interstitial compartment infiltrated by T-cells, monocytes, and plasma cells
MC form of AIN
Drug hypersensitivity (75%)
s/sxs of AIN
Presentation (acute onset of decrease in renal function days to 2 weeks post admin of meds or infx)
Symptoms (variable): fever, rash, hematuria, oliguria, nausea, vomiting, malaise. (uveitis in TINU)
Signs: decreased urine concentration, decreased GFR
UA of AIN
UA: hematuria, mild to moderate proteinuria, (higher when NSAIDs), high WBCs, WBC casts, NO bacteria Eosinophiluria often present
Management of AIN
1) Normal renal fxn usu occurs with discontinuation of suspected causative agent
2) Low protein, low K, low Na diet;
3) anti-inflammatories, antioxidants
4) Renafood® (Standard Process)
5) Alternative natural treatments for conditions treated with offending agents
6) Pharmacologic—if no spontaneous recovery, short course prednisone (1mg/kg, rapidly tapering)
7) Some pts may require dialysis
CHRONIC INTERSTITIAL NEPHRITIS (CIN) may develop in what conditions?
Polycystic KI dz, analgesic nephropathy, sarcoidosis, SLE, multiple myeloma, Lead poisoning ⇒ fibrotic scar tissue replacing cellular infiltrate
ACUTE TUBULAR NECROSIS (ATN) definition
Damage to renal tubular epithelium (RTE) cells from:
ischemia: shock (sepsis, anaphylaxis, hemorrhage), trauma, surgery, DIC
OR
“Toxic Nephropathy”: aminoglycosides, amphotericin B, lithium, cisplatin, radiographic dyes, bath salts (recreational drug), solvents, heavy metals, toxic mushrooms; also Strep, Legionella, EBV, Toxoplasmosis and others
Treatment of ATN
1) correct ischemic cause or removal of toxic exposure, manage ARF
2) Chelation treatment may be needed once symptoms managed
3) NAC to prevent radiation nephropathy: 600-1200 mg bid on day prior and day of procedure
4) Cisplatin- induced nephropathy: Lipoic acid, NAC, ginkgo (1:1 ½ tsp bid), Capsaicin, selenium, quercitin
5) General protectives: Silybum marianum, gingko biloba, Cordyceps, Urtica seed, CoQ10, selenium, Vit C
Causes of chronic tubulointerstitial disease
Prolonged obstructive uropathy, reflux nephropathy, Analgesic nephropathy, Lead nephropathy, Fanconi syndrome
MC cause of chronic tubulointerstitial disease
bstructive uropathy
Tx of chronic tubulointerstitial disease
1) Prevent renal scarring (irreversible!) if early stages: Treat the cause!
2) Tubular dysfunction may require K and Ph restriction, Na, Ca and bicarbonate supplementation
3) Chelation therapy for heavy metals
4) Natural analgesics, HP and physical medicines for chronic pain syndromes
5) Anti-inflammatories such as tumeric, boswellia, bromelain (eg, BCQ®)
6) Renal protectives: nettle seed, Salvia miltiorrhiza
7) Renal anti-oxidants: Ginseng, Coptis, Vaccinium, Quercitin, Vit C, Alpha Lipoic acid
8) Fish oil 12 g/d
9) Fanconi: Phosphate supplementation, vit D
RTA definition
Renal Tubular Acidosis (RTA) results in metabolic acidosis when the kidneys fail to either reabsorb bicarbonate in the proximal tubule or secrete acid into the distal tubule. Presentation includes urinary stone formation, bone demineralization, hypokalemia.
Causes include heredity, autoimmune disease (Sjogren’s, Lupus, RA), drugs/toxins (toluene, lithium, amphotericin B, lead), chronic obstruction.
Along with managing the cause, treatment includes oral bicarbonate
ACUTE RENAL FAILURE (ARF)/acute kidney injury (AKI)
GRF abruptly (<48hrs) reduced ⇒sudden retention of normally cleared endogenous and exogenous metabolites (urea, potassium, phosphate, sulfate, creatinine, administered drugs) Markers: Increase in serum creatinine. Decrease in urine volume output <0.5 ml/kg/hr
What might creatinine values do in ARF?
Will rise slower than the BUN, better predictor of imminent kidney failure.
Values approaching 5.5 to 6.0 mg/dl = advanced renal failure
Any increase of up to or greater than 1.5 mg/dl within a short period of time (24 to 48 hours) is sign of significant problem
What might BUN values do in ARF?
will rise faster than creatinine due to its higher rate of production and partial reabsorption
MC category of ARF
pre-renal failure
prerenal renal failure definition
inadequate perfusion TO kidneys from inadequate circulation or volume
When is pre-renal failure reversible?
Reversible (no renal cell damage) if renal blood flow does not fall below 20% of normal
tx of prerenal acute renal failure
1) TREAT UNDERLYING CAUSE
2) Rapid fluid replacement, IV volume expansion
3) May need vasopressor drugs (dopamine) to elevate BP and increase renal blood flow
4) Discontinue antihypertensives or diuretics
INTRARENAL (INTRINSIC) ACUTE RENAL FAILURE definition
due to injury IN renal tubules, interstitium, vasculature or glomeruli leading to loss of function
MC cause of intrarenal acute renal failure
Acute Tubular Necrosis ATN (80% of cases) (ischemic or toxic causes)
Other causes of intrarenal acute renal failure
Acute Interstitial Nephritis AIN (10-15% of cases) Acute glomerulonephritis (eg post-streptococcal--PSGN, RPGN) Acute pyelonephritis Vascular diseases: vasculitis, polyarteritis nodosa, cortical necrosis/intravascular coagulation Nephrotic syndrome (multiple causes)
tx of intrarenal acute renal failure
1) Depending on cause: Eradication of infection; Removal of antigen, toxins, drugs
2) Suppression of autoimmune mechanisms (immunomodulators)
3) Pharma: Low dose dopamine (transient improvement)
4) Monitor BUN/Creatinine
5) Supportive dialysis if needed
POSTRENAL ACUTE RENAL FAILURE definition
urinary flow FROM both kidneys obstructed ⇒incr nephron intraluminal back pressure and dec GFR
causes of postrenal acute renal failure
Obstruction of urine flow: prostatic enlargement, tumors (bladder, prostate, cervix, pelvic area or retroperitoneal area), urolithiasis, renal V stenosis, neurogenic bladder; post-surgical or trauma; medications (acyclovir, sulfonamides, protease inhibitors, anticholinergics)
tx of postrenal acute renal failure
Rapidly treat the obstruction with catheterization or stent
Chronic renal failure definition
reduced Ki clearance of certain solutes ⇒the retention of body fluids, progressing over mos to yrs. Difficult to identify its onset and predict its course
Common causes of chronic renal failure
Glomerulopathies and nephropathies (esp. diabetic nephropathy)
Polycystic kidneys
Obstructive nephropathy
Hypertensive nephropathy
s/sxs of chronic renal failure
General SX: HTN, edema, osteodystrophy, anemia of chronic disease, UREMIA
