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Flashcards in Renal/Genitourinary - Step UP Deck (170):
1

definition of acute kidney injury

rapid decline in renal function with an increase in serum BUN or Cr (relative = 50% or absolute increase of 0.5-1.0 mg/dL)

2

MC clinical findings in AKI

weight gain and edema - due to positive water and Na+ balance

3

azotemia

elevated BUN and Cr

4

causes of elevated BUN

catabolic drugs (steroids)
GI/Soft tissue bleeding
dietary protein intake

5

BUN may be falsely low in..

liver disease
SIADH
malnutrition

6

etiology of prerenal AKI (7)

decrease in systemic arterial blood volume or renal perfusion
- hypovolemia
- CHF
- hypotension, 3rd spacing
- renal arterial obstruction
- cirrhosis/hepatorenal syndrome
- NSAIDs, ACE i and cyclosporin
- low albumin states

7

prerenal failure:
- urine osmolarity (1)
- urine Na+ (2)
- FE-Na+ (3)
- urine sediment (4)
- BUN/Cr ratio (5)
- urine-plasma Cr ratio (6)

(1) Uosm > 500; s.g. > 1.010 (concentrated)
(2) UNa < 20
(3) FENa < 1%
(4) hyaline casts; scant sediment
(5) BUN/Cr > 20:1
(6) urine-plasma Cr > 40:1

8

pt presents with muscle pain, weakness and dark urine - what should you suspect?

rhabdomyolysis

9

what can cause rhabdomyolysis?

trauma/crush injuries
prolonged immobilities
seizures
snake bites
drugs - cocaine
alcohol
infections

10

lab findings in rhabdomyolysis

elevated CPK (usually > 100, 000)
hyperkalemia
myoglobinuria (positive dipstick w/o RBCs)
hypocalcemia
hyperuricemia

11

Tx of rhabdomyolysis

IV fluids - maintain urine output of > 300 ml/hour until urine neg. for Myoglobin
Mannitol
Bicarbonate

12

intrinsic renal failure:
- BUN/Cr ratio (1)
- Urine Na (2)
- FE-Na (3)
- Urine osmolarity (4)
- urine plasma-Cr ratio (5)
- urine sediment (6)

(1) BUN/Cr < 20:1 (usually 10:1)
(2) Urine Na > 40
(3) FE-Na > 2-3%
(4) Uosm < 350
(5) urine plasma-Cr ratio < 20:1
(6) brown pigmented casts, epithelial casts

13

pt presents with envelope shaped crystals on UA with an increased AG metabolic acidosis - dx?

ethylene glycol poisoning

14

pt who recently underwent angioplasty develops renal failure and blue discoloration of fingers/toes - dx?

atheroembolic disease
- skin biopsy will show cholesterol crystals

15

how can you prevent contrast induced nephrotoxicity? (3)

hydration - 1-2L NS 12 hrs before
isotonic bicarbonate
N-acetylcysteine

16

three basic tests in post-renal failure

1. physical examination - palpate bladder
2. USG - obstruction, hydronephrosis
3. catheter - large volume of urine ; residual volume > 50 ml

17

causes of post-renal failure

1. BPH - MCC
2. nephrolithiasis
3. obstructing neoplasm
4. retroperitoneal fibrosis
5. neurogenic bladder

18

what kind of renal failure does a dipstick positive for protein suggest?

intrinsic renal failure due to glomerular insult

19

red cell casts

indicate glomerular disease - i.e. GN

20

broad waxy casts

chronic renal failure

21

muddy brown, granular casts

acute tubular necrosis

22

WBC casts

renal parenchymal inflammation
- pyelonephritis
- interstitial nephritis

23

fatty casts

nephrotic syndrome

24

formula for FE-Na

FEna = 100 x [Una x Pcr / Pna x Ucr]

25

formula for renal failure index

(Una x Pcr) / Ucr
- > 1% = prerenal failure
- < 1% = ATN

26

MC mortal complications in early AKI

hyperkalemic cardiac arrest
pulmonary edema

27

metabolic complications in AKI

hyperkalemia
metabolic AG acidosis
hypocalcemia
hyponatremia
hyperphosphatemia
hyperuricemia

28

how do you monitor fluid balance in AKI?

daily weight measurements - most accurate
input/output records

29

when should you order dialysis in AKI?

symptomatic uremia
intractable acidemia, hyperkalemia or volume overload develop

30

Tx. of prerenal AKI

eliminate any offending agents
give normal saline to restore BP

31

Tx. of intrinsic AKI

therapy is supportive
may try furosemide to increase urine output

32

Tx. of postrenal AKI

bladder catheter
urology consult

33

uremia

signs and symptoms associated with accumulation of nitrogenous waste due to impaired renal function; BUN > 60

34

signs and symptoms of uremia (8)

severe acidosis
mental status changes
hyperkalemia
fluid overload
anemia
hypocalcemia
pericarditis
impaired cellular and humoral immunity

35

chronic renal insufficiency

renal function is compromised but not failed
serum Cr between 1.5-3.0 mg/dL

36

CV symptoms in CRF

HTN - secondary to salt and H20 retention
CHF
pericarditis - uremic

37

Neurologic findings in CRF

lethargy, confusion, somnolence, peripheral neuropathy, seizures
P/E findings - weakness, asterixis, hyperreflexia, "Restless legs"

38

Hematologic findings in CRF

1.normochromic normocytic anemia (def. EPO) Tx. EPO replacement
2. bleeding dysfunction - platelets cant degranulate in uremic envt (Tx. DDVAP)

39

endocrine disturbances in CRF

hyperphosphatemia --> decreased vit D production --> hypocalcemia --> elevated PTH --> renal osteodystrophy and eventually hyPERcalcemia

40

calciphylaxis

in high phosphate states, the phosphate may precipitate with calcium causing vascular calcifications and necrotic skin lesions

41

what drugs can slow the progression of ESRD?

ACEi - dilate efferent arteriole and control BP

42

diet in CRF

low protein - 0.7-0.8 g/kg body weight
restrict K+, phosphate and Mg2+ intake

43

how do you tx. hyperphosphatemia in CRF?

phosphate binders
- calcium citrate
- sevelamer/levanthum (esp. when due to vit D intake)
- cinacalcet (mimics effect of Ca2+ on PTH)

44

what type of replacement therapy should CRF pts be on?

long term oral Calcium and vit D
oral Bicarb if acidotic

45

when should you treat anemia with EPO?

if Hct < 30 or Hb < 10 mg/dl AFTER iron deficiency has been ruled out and pt w/ symptoms of anemia on dialysis

46

non-emergent indications for dialysis:

1. symptoms of uremia i.e. NV, bleeding, lethargy, mental status changes, pericarditis

47

emergency indications for dialysis (5)

1. pulmonary edema
2. refractory HTN emergency
3. refractory hyperkalemia, hypermagnesemia
4. severe metabolic acidosis
5. certain drug overdoses

48

which drugs are dialyzable?

Lithium
Salicylates
Ethylene glycol/Methanol
Mg2+ containing laxatives

49

"First use" syndrome in dialysis

chest pain, back pain and anaphylaxis (rare) occuring immediately after patient uses a new dialysis machine

50

complications associated with peritoneal dialysis

peritonitis - cloudy fluid
abdominal/inguinal hernia
hyperglycemia/hypertriglyceridemia
protein malnutrition

51

what should you do if you suspect orthostatic proteinuria in someone?

obtain daytime and nighttime urine samples
- decrease protein in night-time samples

52

what is orthostatic proteinuria associated with?

nutcracker syndrome - entrapment of Left renal vein b/w aorta and SMA

53

key features of nephrotic syndrome

proteinuria > 3.5 g/day
hypoalbuminemia --> edema
hyperlipidemia/lipiduria
hypercoagulable state
increased infections

54

initial test once proteinuria is detected on urine dipstick

urinalysis --> if UA confirms proteinuria, next step is 24 hr urine collection

55

how do you test for microalbuminuria?

special dipsticks can detect 30-300 mg/day of protein --> if these are positive, do a radioimmunoassay to confirm

56

most sensitive and specific test for microalbuminuria

radioimmunoassay

57

definition of proteinuria

> 150mg/24 hrs

58

definition hematuria

> 3 RBCs/hpf on urinalysis
- persistent if in > 2 samples

59

microscopic hematuria is more commonly (1) whereas, gross hematuria is more commonly (2)

(1) glomerular origin
(2) nonglomerular or urologic

60

in adults, gross hematuria is what? unless proven otherwise

malignancy - consider bladder cancer or renal cell carcinoma

61

what are the initial diagnostic tests in gross hematuria?

1. upper urinary tract CT scan or IVP
2. endoscopic assessment of bladder and urethra

62

what medications can cause hematuria?

Rifampin
cyclophosphamide
anticoagulants
salicylates
sulfonamides
analgesics

63

what do you do if you find RBC casts and dysmorphic RBCs on UA? what does this mean?

evaluate for intrinsic renal disease --> likely a glomerular cause

64

what does it mean if the dipstick if positive for blood but no RBCs can be seen under microscope?

hemoglobinuria or myoglobinuria is present

65

how do you approach hematuria if U/A and urine culture turn up negative?

1. do a coag study - if +, coagulopath
- if negative proceed to 2) KUB
- if shows stones, tx stones
- if normal, do 3) IVP, CT scan and cytology

66

classic lab findings in nephritic syndrome

hematuria
anuria/oliguria
proteinuria < 3 g/day
HTN
edema

67

Tx. of nephrotic syndrome

1) steroids
2) if no effect: add cyclophosphamide or azathioprine
3) ARBs/ACEi can inhibit proteinuria

68

young child presents with nephrotic syndrome; you note fusion of foot processes on EM - dx? what is this dx associated with?

dx = minimal change disease
- assoc. with Hodgkins and NH lymphomas

69

Tx. of minimal change disease

excellent response to steroids

70

what is FSGS associated with?

- common in blacks
- assoc with HIV, obesity and heroin use

71

what are some causes of membranous GN?

infection - endocarditis, hepB/C, syphilis, malaria
drugs - gold, captopril, penicillamine
neoplasms
lupus

72

young Asian patient presents to you because she noticed blood in her urine; she recently had an URI

IgA nephropathy aka. Berger's disease

73

young boy is brought in bc his mother noticed he couldnt hear properly (high frequency sounds especially); she also said his pee looks red - dx?

consider Alport's disease - XL or AR
-hematuria, proteinuria and sensorineural hearing loss w/o deafness

74

what is essential for dx. of lupus nephritis?

biopsy - guides tx
- sclerosis = no tx
- proliferative = steroids + mycophenolate

75

what is membranoproliferative GN associated with?

Hep. C infection, cryoglobulinemia

76

Hep C patient presents with renal dz, joint pain, neuropathy and purpuric skin lesions; you find he has elevated ESR and low complement - dx? tx?

cryoglobulinemia
Tx. IFN and ribavirin

77

Tx. of membranoproliferative GN

dipyramidole
aspirin
- rarely effective

78

mother brings young child in because she noticed blood in their urine; upon exam you notice the child has periorbital edema and HTN; history reveals pharyngitis infection 2 weeks ago - what should you be considering?

poststreptococcal GN

79

what additional tests may help with your suspicion of post-streptococcal GN

elevated antistreptolysin O and antihyaluronic acid (AHT)
- kidney biopsy: humps on EM and subepithelial humps (usually not needed)

80

tx. of post-streptococcal GN

supportive - usually self limited dz

81

Tx. of Goodpasture's disease

plasmaphoresis - removes circulating ab's
cyclophosphamide and steroids

82

HIV pt presents with heavy proteinuria and rapid development of renal failure; you do a biopsy and find collapsing FSGS

HIV nephropathy

83

Tx. HIV nephropathy

prednisone
ACEi
antiretroviral therapy

84

patient presents to you with oliguria and fever; you notice he has a rash and on CBC, there is eosinophillia- what should you consider?

acute interstitial nephritis

85

main cause of acute interstitial nephritis

acute allergic reaction to medication

86

what diagnostic tests should you do in suspected cases of acute interstitial nephritis?

renal function tests
urinarlysis

87

Tx of AIN

removal of offending agent
- if sx. worsen, steroids may help

88

pt on chronic pain tx. with NSAIDs presents with sudden onset flank pain, fever, pyuria and hematuria; there are no organisms on culture

think of renal papillary necrosis

89

how can you confirm diagnosis of renal papillary necrosis

CT scan - bumpy contours in renal pelvis where papillae sloughed off

90

defect in type 1 RTA (distal)

defect in ability to secrete H+ at the distal tubule (new HCO3- cannot be generated) - results in inability to acidify urine

91

characteristic findings in type 1 RTA (3)

increased excretion of ions:
- decreased ECF volume
- hypokalemia
- renal stones/nephrocalcinosis (increased Ca2+ and phosphate excretion into alkaline urine)

92

Tx. for Type 1 RTA

1. correct acidosis with NaHCO3
2. give phosphate salts (promote excretion of titratable acid)
3. K+ citrate - replaces K+ and HCO3-

93

urine pH in type 1 RTA

cannot be lowered below 6 - therefore, urine pH > 6

94

defect in Type 2 RTA (proximal)

inability to reabsorb the HCO3- at the proximal tubule resulting in increased excretion of HCO3- in urine; pt also loses Na+ and K+ in urine

95

how can you diagnose type 2 RTA?

hypokalemia
serum HCO3 low (18-20)
presence of HCO3- in urine (alkaline pH)
malabsorption of glucose, phosphate, urate and aa

96

Tx. of proximal Type 2 RTA (proximal)

1. Na and water restriction - enhances HCO3- reabsorption
2. thiazide diuretics
3. K+ replacement

97

what causes Type 4 RTA?

any condition that is associated with hypoaldosteronism or increased renal resistance to aldosterone = decreased Na+ absorption and decreased H+/K+ secretion

98

features of Type 4 RTA

hyperkalemia
acidic urine

99

Dx of type 4 RTA

increase in Urine Na+ after salt restriction is diagnostic

100

Tx. of type 4 RTA

fludrocortisone

101

what disease causes decreased intestinal and renal reabsorption of neutral amino acids such as tryptophan resulting in pellagra?

Hartnup disease

102

an adult pt presents with intermittent flank pain, HTN, hematuria and a palpable mass on adbominal exam - what should you consider?

adult polycystic kidney disease

103

what other associated findings or complications can you suspect in a pt with ADPKD?

- intracranial berry aneurysm
- liver cystics
- mitral valve prolapse
- colonic diverticula
- HTN
- hernias

104

what is the confirmatory test for ADPKD?

kidney USG

105

CF of infantile PKD?

- liver involvement always - portal HTN, cholangitis
- HTN
- increased kidney size (abdominal distention)
- pulmonary hypoplasia

106

Dx. of infantile PKD

- oligohydramnios during pregnancy
- USG will show renal cysts in collecting ducts and hepatomegaly w/ dilated bile ducts

107

what is medullary sponge kidney?

cystic dilation of collecting ducts associated with hyperparathyroidism or parathyroid adenoma

108

Dx. test for medullary sponge kidney

IVP

109

what features suggest that a cyst is NOT simple and should be aspirated to R/O malignancy?

irregular walls with debris
thickened septae w/in mass
contrast enhanced, multilocular mass

110

a pt presents to you with suddent onset of HTN manifesting as a headache; on exam you hear an abdominal bruit (continuous murmur in periumbilical area that radiates laterally) - dx? and next step?

suspect renal artery stenosis
- perform renal arteriogram
- if pt has signs of renal failure, do MRI

111

Tx. of renal artery stenosis

percutaneous transluminal renal angioplasty with stent placment
- if this is not successful, try surgery
- ACEi and CCB may be tried alone or in combination with the above

112

benign nephrosclerosis

thickening of glomerular afferent arterioles in pts with long-standing HTN

113

malignant nephrosclerosis

rapid decrease in renal function and accelerated HTN due to diffuse intrarenal vascular injury resulting from long-standing benign HTN or in a previously undiagnosed pt

114

CF in malignant nephrosclerosis

1. elevated BP - papilledema, CNS findings
2. renal manifestations
3. microangiopathic hemolytic anemia

115

MC site of impaction of kidney stones

ureterovesicular junction

116

MC type of kidney stone

calcium oxalate
calcium phosphate (less common)

117

causes of calcium stones

hypercalciuria
hyperoxaluria
decreased urinary citrate

118

causes of hyperoxaluria

- severe steatorrhea
- small bowel disease
- Crohns IBD
- pyridoxine deficiency

119

which kinds of stones occur more likely in an acidic pH urine?

uric acid stones

120

what are the main causes of uric acid stones?

gout
chemotherapy of leukemias/lymphomas
- conditions with high levels of cell destuction

121

what kind of stones are MC in pts with recurrent-UTIs due to urease-producing organisms such as Proteus, Klebsiella, Seratia etc?

struvite/staghorn calculi

122

how do struvite stones form?

alkaline environment - urease positive bugs convert urea to ammonia; ammonia then combines with magnesium or phosphate to form stones

123

which stones are NOT visible on radiograph i.e. are radiolucent?

uric acid stones

124

which kidney stones are caused by genetic predisposition?

cystine stones
- hexagon shaped crystals

125

what size of kidney stone usually passes on its own?

< 0.5 cm

126

a pt presents to you with sudden of colicky flank pain that radiates anteriorly toward his groin; what test do you do first?

urinalysis

127

after urinalysis, what is the initial imaging test to be done for kidney stones?

KUB plain radiograph

128

gold standard for diagnosis of kidney stones

spiral CT scan w/o contrast

129

what test is useful for defining degree of obstruction and commonly used if a pt needs procedural therapy?

IVP

130

what is the procedure of choice for diagnosing a kidney stone in pts who cannot receive radiation?

USG

131

indications for admitting a pt with a renal stone to hospital

1. pain not controlled with oral meds
2. anuria - pts with one kidney
3. renal colic plus UTI and/or fever
4. large stone > 1 cm

132

what is the best tx. approach for someone with their first stone?

hydration and observation
oral analgesia

133

MC used surgery method for renal stone removal

extracorporeal lithotripsy
- best for stones > 5 mm and < 2 cm

134

what kind of removal method is best for renal stones > 2 cm if lithotripsy fails?

percutaneous nephrolithotomy

135

dietary measures to prevent recurrences of kidney stones

high fluid intake > 3 L/day
restrict Na+, protein and oxalate
normal calcium intake

136

what is the first test you should do in suspected urinary obstruction?

renal USG

137

gold standard test for dx. urinary obstruction

IVP
- contraindicated in prengnacy, allergy to contrast or renal failure

138

what do you do if a patient has an acute urinary obstruction AND a UTI?

emergency diagnostic tests - USG or IVP

139

RFs for prostate cancer

age - most impt
African-American
high fat diet
positive family history
exposure to herbicides/pesticides

140

an elderly man presents with difficulties in urination and low back pain - what should you consider?

prostate cancer

141

what is the next step in a patient with an abnormal DRE?

transrectal USG with biopsy

142

indications for transrectal USG with prostate biopsy

PSA > 10 ng/dL
PSA velocity > 0.75/year
abnormal DRE

143

what other conditions may increase PSA levels?

prostatic massage
needle biopsy
cytoscopy
BPH
prostatitis
advanced age

144

Tx of localized prostatic cancer

radical prostatectomy

145

when is it ok to "watch and wait" prostate cancer

older men (< 10 yrs life expectancy) who are asymptomatic

146

MC complications of prostatectomy

erectile dysfunction
urinary incontinence

147

tx. for locally invasive prostate cancer

radiation therapy plus androgen deprivation

148

Tx. of metastatic disease

want to reduce the amt of testosterone with any of the following: orchiectomy, antiandrogens, LHRH agonists or GnRH antagonists

149

where does prostate cancer commonly metastasize to?

vertebral bodies
pelvis
long bones of legs

150

RFs for renal carcinoma

smoking
phenacetin analgesics
ADPKD
chronic dialysis - multicystic kidney dz
exposure to heavy metals - mercury, cadmium
HTN

151

pt presents with hematuria, abdominal mass and flank pain - what should you consider?

renal ca.

152

paraneoplastic syndromes caused by renal cell ca.

anemia/erythrocytosis - EPO
thrombocytosis
fever
hypercalcemia - PTHrP
cachexia
HTN - renin
Cushing's - cortisol

153

a pt presents with a left sided scrotal varice that fails to empty when pt is recumbent - what should you consider?

renal cell ca. that has obstructed the renal vein and drainage of gonadal vein

154

optimal test for diagnosis and staging of renal cell ca.

CT scan w/ and w/o contrast

155

Tx. for renal cell ca.

radical nephrectomy and adrenal gland, incl. Gerota's fascia with excision of nodal tissue along the renal hilum

156

MC type of genitourinary tumor

bladder cancer - transitional cell ca.

157

RFs for bladder ca.

smoking
industrial carcinogens - aniline dye, azo dye
long term cyclophosphamide tx

158

classic presentation of bladder ca.

painless hematuria

159

definitive test of bladder cancer.

cystoscopy with biopsy

160

what imaging test can you do in bladder cancer to determine staging?

CXR and CT scan

161

what is the initial test for localizing a testicular tumor?

testicular ultrasound

162

B-hCG is elevated in which testicular tumors?

choriocarcinoma

163

AFP is elevated in which testicular tumors?

embryonal tumors

164

Tx of testicular cancer

after suspected with USG, testicle should be removed surgically to confirm diagnosis (inguinal approach)

165

a young man with a firm, painless testicular mass is presumed to have what? until proven otherwise?

testicular cancer

166

what is penile cancer associated with?

lack of circumcision
HSV and HPV 18 infections

167

young male presents with acute severe testicular pain, swollen and tender scrotum and an elevated testicle - dx?

testicular torsion - surgical emergency

168

tx. of testicular torsion

surgical detorsion and orchiopexy to scrotum (do this bilaterally to prevent recurrence) --> should be done within 6 hours to maintain viability

169

a young male presents with a swollen tender testicle, a scrotal mass and fever/chills - dx?

epididymitis

170

causes of epididimytis

children/elderly - E.coli
sexually active adults - gonorhea, Chlamydia