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Flashcards in Renal/GU Deck (283):
1

Hypernatremia

Na > 145
- usually due to free water loss than sodium gain

2

Hypernatremia: PE/History

- presents with THIRST due to hypertonicity
- neuro sx: mental status changes, weakness, focal neuro deficits
- "doughy:" skin

3

Hypernatremic causes "6 D's"

- Diuresis
- Dehydration
- Diabetes insipidus
- Docs (iatrogenic)
- Diarrhea
- Disease ( sickle cell, kidney,)

4

Tx: euvolemic hypernatremia

- use hypotonic fluids (e.g. D5W or .45% NaCl)

5

Tx: hypovolemia hypernatremia

- D5W
- if vital signs unstable, use 0.9% NaCL before correcting free water deficit

6

Tx: hypervolemia hypernatremia

Use diuretics and D5W to remove excess sodium

7

Important key facts to keep in mind during correction of hypernatremia

- Chronic hypernatremia (> 36 - 48 hrs) should occur over 48- 72 hrs (<0.5mEq/L/hr to prevent cerebral edema

8

Hyponatremia

Na < 135mEq/L
- almost due to increased ADH

9

Hx/PE: hyponatremia

- may be asymptomatic or may present with confusion, lethargy, muscle cramps, hyporeflexia, and nausea
- can progress to seizures coma, or brainstem herniation

10

Dx: high osmolality hypernatremia

> 295mEq/L
- due to hyperglycemia, hypertonic infusion (e.g mannitol)

11

Dx: normal osmality hyponatremia

280-295mEq/L
- caused by hypertriglyceridemia, paraproteinemia (pseudohyponatremia)

12

Dx: low osmolality hyponatremia

< 280 mEq/L
- majoriity of cases

13

Tx: hypervolemia hyponatremia

- Water resitriction
- consider diuretics
- cortisol replacement w/ adrenal insufficiency
- thyroid replacement w/ hypothyroidism

14

Tx: euvolemia hyponatremia

water restriction

15

Tx: hypovolemia hyponatremia

replete volume w/ normal saline

16

Complication of correcting hyponatremia too quickly?

Central pontine myelinosis
-- hyponatremia > 7 hrs should be corrected more than 0.5mEq/L/hr

17

Hyperkalemia

> 5mEq/L

18

Spurious hyperkalemia

- hemolysis of blood sample
- delays in sample analysis
- extreme leukocytosis or thrombocytosis

19

Hyperkalemia 2/2 to decreased excretion

-Renal insufficiency
- Drugs (e.g. spironolactone, triamterene, acodisos, calcineurin)

20

Hyperkalemia 2/2 to cellular shifts

- Cell lysis
- Tissue injury (rhabdo)
- Insulin deficiency
Drugs (e.g. succinylcholine, digitalis, B-blockers)

21

Hx/PE: hyperkalemia

- may be asymptomatic
- may present w/ nausea, vomiting, intestinal colic, areflexia, weakness

22

Dx: hyperkalemia

- confirm w/ repeat blood draw esp in setting of extreme leukocytosia or thrombocytosis

23

- ECG findings: hyperkalemia

tall peaked T waves, wide QRS,
PR prolongation
loss of P waves

24

Tx: hyperkalemia

C BIG K DROP
1. Give calcium gluconate for cardiac cell membrane stabilization
2. Give bicarb and/or insulin + glucose to temp shift K into cells
3. B-agonists (e.g. albuterol) to promote cellular reuptake of K
4. Kayexalate to remove K from body

25

Contraindications to kayexylate (esp for tx of hyperkalemia)

- Ileus
- Bowel obstruction
- Ischemic gut
- Pancreatic transpants

26

Hypokalemia

< 3.5 mEq/L

27

Etiologies of hypokalemia

1. Transcellular shifts (e.g. insulin, B-agonists)
2. GI losses (e.g. diarrhea, laxatives, vomiting)
3. Renal losses (e.g diuretics, hypomagnesemia)

28

ECG findings: hypokalemia

T wave flattening, U waves (additional wave after T wave)
ST segment depression leading ot AV block and cardiac arrest

29

Tx: hypokalemia

- treat underlying disorder
- Oral and/ IVpotassium repletion
- Don't excess 20mEq/hr

30

Carbonic anhydrase inhibitors: site of action
(e.g acetazolamide)

proximal convoluted tubule

31

Carbonic anhydrase inhibitors (e.g acetazolamide): mechanism of action

inhibit carbonic anhydrase
- increase H+ reabsorption
- block Na+/H+ exchange

32

Carbonic anhydrase inhibitors (e.g acetazolamide): side effects

Hyperchloremic metabolic acidosis
Sulfa allergy

33

Osmotic agents (e.g. mannitol, urea): site of action

entire tubule

34

Osmotic agents: (e.g. mannitol, urea): mechanism of action

increase tubular fluid osmolarit

35

osmotic agents (e.g mannitol, urea): side effects

pulmonary edema due to CHF and anuria

36

Furosemide

- loop diuretic
- inhibits Na/K/2Cl in thick ascending limb loop of Henle
- abolishes hypertonicity of medulla preventing concentration of urine

37

Furosemide: Clinical Use

edematous states (CHF cirrhosis, nephrotic syndrome, pulmonary edema)
- HTN
- Hypercalcemia

38

Furosemide: Side effecs

OH DANG
- Ototoxicity
- Hypokalemia
- Dehydration
- Allergy (sulfa)
- Nephritis (interstinal)
- Gout

39

Ethacrynic acid

- loop diuretic
- inhibits Na/K/2Cl in thick ascending limb loop of Henle
- abolishes hypertonicity in medulla

40

Ethacrynic acid: clinical use

- diuresis in patients allergic to sulfa drugs

41

Ethacrynic acid: toxicity

- can cause hyperuricemia
** never use to treat gout

42

Hydrochlorothiazide

- thiazide diuretic
- inhibits NaCl reabsorption in early distal tubule, reducing diluting capacity of neuron
- decreases Ca excretion

43

Hypothiazide: clinical use

- HTN
- CHF
- idiopathic hypercalciuria
- nephrogenic insipidus

44

Hydrochlorothiazide: toxicity

Hyper GLUC
- hypokalemic metabolic alkalosis
- hyponatremia
- hyperglycemia
- hyperlipidemia
- hyperuricemmia
- hypercalcemia

45

K sparing diuretics

- spironolactone
- triamterene
- amiloride

46

K sparing diuretics: mechanism

- sprironolactone and epelerone are aldosterone receptor antagonists in the cortical collecting tubules

- triamterene and amiloride block Na channels in CCT

47

K sparing diuretics: clinical use

Hyperaldosteronism
K depletion
CHF

48

K sparing toxicity

Hyperkalemia (can lead to arrhythmias)
Endocrine effects w/ spironolactone (e.g. gyncecomastia, antiandrogen effects)

49

ACE inhibitors

- captopril, enalapril, lisinopril

50

ACE inhibitors: mechanism

inhibit ACE --> decr. angiotensin II --> decr. GFR by preventing constriction of efferent arterioles
- levels of renin incr due to feedback inhibitor

51

ACE inhibitors: clinical use

HTN
CHF
proteinuria
diabetic renal disease
- prevent heart remodeling due to chronic hypertension

52

ACE inhibitor toxicity

CATCHH
- Cough
- Angioedema
- Teratogen (fetal renal malformations)
- Creatinine increase (decr. GFR)
- Hyperkalemia
- Hypotension

53

Renal Tubular Acidosis I

- found in distal tubules
- defect in H+ secretion
- hypokalemia
- pH > 5.3

54

Etiology of RTA

- hereditary
- cirrhosis
- autoimmune disorders (e.g. SLE, Sjorgen's syndrome, sickle cells disease)
- Drugs (lithium, amphotericinB

55

RTA I: Treatment

Replace bicarbonaate

56

RTA I: Complications

Nephrolithiasis

57

RTA II

defect in bicarb reabsorption
- low K
initially urine pH is 5.4 , then < 5.3 once serum becomes more acidotic

58

RTA II: Etiologies

Hereditary (Fanconi's syndrome or cystinosis)
Drugs (carbonic anhydrase inhibitor)
Multiple myeloma
Amyloidosis
Heavy metal poisoning
Vitamin D deficiency

59

RTA II: Treatment

Thiazide
Volume depletion to increase absorption

60

Complications of RTA: II

Rickets, osteomalacia

61

RTA IV

- in distal tubules
- aldosterone deficiency
- high K
urine pH > 5.3

62

RTA IV: Etiologies

1st aldosterone deficiency
hyporeninemic hypoaldosteronims
(e.g. kidney disease, ACEis, NSAIDS(
Drugs (e.g amilorde

63

Treatment of RTA IV

- Furosemide
- Mineralcorticoids +/- glucocorticoid replacement

64

Acid Base Disorder: pH < 7.4, pCO2 > 40 mmHG

respiratory acidosis

65

Causes of Respiratory Acidosis

Hypoventilation (retaining CO2)
- Airway obstruction
- Acute lung disease
- Chronic lung disease
- Opioids, narcotics
- Weakening of respiratory muscles

66

Acid Base Disorder: pH < 7.4, pCO2 < 40 mmHg

Metabolic acidosis
**check anion gap (Na - [K + Cl])

67

Anion gap metabolic acidosis

MUDPILES
- Methanol
- Uremia
- Diabetic ketoacidosis
- Paraldehyde or pheniform
- Iron tablets or INH
- Lactic acidosis
- Ethylene glycol --> kidney stons
- Salicylates

68

Normal anion gap acidosis

HARDUP
Hyperalimentation
Acetazolamide use
Renal tubular acidosis
Diarrhea
Uretocolonic fistula
Pancreatic fistula

69

Acid Base Disorder: pH >7.4, pCO2 < 40 mm Hg

respiratory alkalosis

70

Causes of respiratory alkalosis

Hyperventilation (e.g. high altitude exposure)
Aspiration ingestion (early)

71

Acid base disorder: pCO2 > 40 mm Hg

Metabolic alkalosis with compensation (hypoventilation)
- Diuretic use
- Vomiting
- Antacid use
- Hyperaldosteronism

72

Acute Kidney Injury

- defined as abrupt decline in renal fxn
- retention of BUN and Cr
- decreased urine output ( < 500 cc/day)

73

Prerenal AKI

- cause by hypoperfusion

74

Common causes of prerenal AKI

- Hypovolemia
- Sepsis
- Drugs (ACEis, NSAIDS)
- Renal artery stenosis
- De

75

Intrinsic AKI

- injury within nephron unit

76

Common causes of instrinscicAKI

ischemic or nephrotoxic ATN
Allergic interstitial nephritis
Glomerulonephritis

77

Post renal AKI

- urinary outflow obstruciton

78

Common causes of post renal AKI

- prostatic disease
- pelvic tumors
- intratubular causing obstruction

79

Ddx scrotal swelling

- Hydrocele
- Varicocele
- Epididymitis
- Testicular torsion

80

Painless causes of scrotal swelling

- Hydrocele
- Varicocele

81

Hydrocele

- remnant of processus vaginalis
- usually asymptomatic, transilluminates

82

Varicocele

- dilation of pampiniform venous plexus ("bag of worms")
- asymptomatic or presents with vague scrotal pain
- affects left testicle more than right
- may disappear in supine position
- DOES NOT TRANSILLUMINATE

83

Hydrocele: Dx

Lab and radiologic workups rarely indicated
- obtain U/S if concern for inguinal hernia or testicular cancer

84

Epididymitis

- infection of epididymitis, usually for STDs, prostatitis and/or reflux
- affects > 30 y/o
- presents w/ epididymal tenderness
- enlarged testicles, fever, scrotal thickening, erythema, and pyuria
- pain may decrease with elvevation

85

Epididymitis: Dx

- UA, culture (pyuria)
- Culture often shows N. gonorrhoeae, E.coli, or Chlamydia
- Doppler ultrasound shows normal to increased flow to testes

86

Hydrocele: Tx

Typically none unless hernia is present beyond 12-18 mths age
- indicates patent processus vaginalis, which leads to increased risk for inguinal hernia

87

Varicocele: Dx

Ultrasound

88

Varicocele: Tx

- if symptomatic or if testes makes < 40% of total volume, maybe treated surgically w/ a varicocelectomy or ligation or through embolization via IR

89

EpididymitisL Tx

Abx (tetracyclines, fluoroquinolone)
NSAIDS
Scrotal support

90

Testicular torsion

- twisting of spermatic cord, leading to ischemia and possible testicular torsion

91

Testicular torsion:

Typically affects those < 30 y.o
- presents with intense, acute-onset scrotal pain that increases or remains the same w/ scrotal elevation
- pain accompanied by N/V and/or dizxiness
- loss of cremestaric reflex

92

Testicular torsion: dx

Doppler ultrasound shows DECREASED blood flow to testes
- SURGICAL EMERGENCY

93

Testicular torsion: tx

attempt manual detorsion
- immediate surgery to salvage testis (testis is often unsalvageable after 6 hrs of ischemia)
- orchiopexy of both testes to prevent future torsion

94

BPH

- enlargement of prostate that is normal part of aginge
> 80% of men by 80
- can result in urinary retension, recurrent UTIs, bladder and renal calculi, hydronephrosis and kidney damange

95

BPH: Hx

Obstructive sx: hesitancy, weak stream, urinary retenton
Irritative sx: nocturi, daytime frequency, urge incontinence
- DRE shows uniformly enlarged with rubbery texture

96

BPH: Dx

DRE to screen for masses, if findings are suspicious
Obtain UA and urine culture to r/o infection and hematuria
Measure creatinine levels to r/o obstructive uropathy and renal insufficiency

97

BPH : Treatment

Alpha-blockers (e.g. terasozin) - relax smooth muscles in prostate and bladder neck
5-alpha reductase inhibitors (e.g. finasteride) - inhibit production of DHT
- TURP or open prostatectomy is appropriate for patients

98

Renal Cell Carcinoma

- adenocarcinoma from tubular epithelial cells ( 80-90% malignant tumors of kidney)
- tumors can spread along renal vein to IVC
- can metastasize to lung and bone

99

Risk factors for RCC

- Male gender
- Smoking
- Obesity
- Acquired cystic kidney disease in ESRD
- von Hippel Lindau disease

100

RCC: Hx

- presenting signs: hematuria, flank pain, and palpable mass
- left sided varicocele often seen due to blockage of gonadal vein into left renal vein then into IVC
- anemia is common but may see polycythemia

101

DDx for hematuria

I PEE RBCS
Infection (UTI)
Polycystic kidney disease
Exercise
External trauma
Renal glomerular disease
Benign prostatic hyperplasia
Cancer
Stones

102

RCC: Dx

Ultrasound and/or CT to characterie renal mass as complex cysts or solid tumor

103

RCC: Treatment

Surgical resection may be curative in localized disease
Response rate from radiation or chemotherapy are only 15-30%

104

Sx of ARF

- fatigue, nausea and vomiting, anorexia, SOB, menal status changes

105

Signs of ARF

- increased BUN and Cr
- metabolic acidosis
- hyperkalemia
- tachypnea (due to acidosis and hypervolemia)
- hypervolemia (b/l rales on exam, JVD, and dilutional hyponatremia)

106

Three broad categories of renal failure

- Prerenal
- Renal/intrarenal
- Post renal

107

Prerenal failure

- inadequate perfusion to kidney (which is normal)

108

Common cause of prerenal failure

- HYPOTENSION - (SBP < 90 mm Hg) from sepsis, anaphylaxis, bleeding
- HYPOVOLEMIA - diuretics, burns, pancreatitis
- Renal artery stenosis

109

Dx for prerenal failure

- Urinanalysis
- Urine sodium
- Fractional excretion of Na
- Urine osmolality

110

Prerenal failure (in terms of Una and FeNa)

low Una < 20
low FeNa < 1%

111

Sx of hypovolemia

- tachycardia, weak pulse, decreased fontanelle

112

Postrenal failure

- urine is blocked from excreting at some point beyond the kidneys (ureters, prostate, urethra)

113

Low urine osmolality in healthy persion (no renal issues)

- can be sign of hypervolemia (fluid overload0

114

Urine osmolality in patient with ATN

- inappropriate LOW urine osmolality
** patient cannot absorb water b/c of damaged tubule cells**

115

High urine osmolality in healthy person

Signs of dehydration

116

Why should pts with sickle cell trait avoid dehydration?

- Sickle cell patients have defect in concentrating urine due to defect in renal concentrating ability

117

Lab testing for prerenal failure

BUN:Cr > 20
UNa < 20mEq/L
FeNa < 1%
UOsm > 500 mOsm/kg

118

Acute Tubular Necrosis

- injury to kidneys from ischemia and/or toxins resulting in sloughing of tubulr cells in urne

119

Discuss IV contrast and renal failure

- IV contrast can precipitate renal failure esp in diabetics and pts w. renal sdsase
- if must do so, give saline hydration
- may use acetylcysteine before and day of administration

120

Causes of toxin-induced ATN

- Aminoglycoside abx
- Amphotericin
- Cisplatin
- Vancomycin
- Acyclovir
- Cyclosporine
*** occurs within 5 - 10 days

121

Causes of ATN

- Toxins (e.g. aminoglycosides)
- Contrast media
- Hemoglobin and myoglobin (rhabdomyolysis)
- Hyperuricemia
- Ethylene glycol
- Bence-Jones protein
- NSAIDS

122

Ethylene glycol induced ATN

- caused by precipitation of calcium oxalate in renal cortex
- appears as envelope-shaped crystals
- associated with hypocalcemia

123

Rhabdomyolysis

- caused by trauma
- prolonged immobility
- snake bites, seizures
- crush injuries

124

Best test to diagnosis rhabdomyolysis

URINANALYSIS

125

Lab values associated with rhabdomyolysis

-Urine test positive for myoglobin
- Creatinine phosphokinase (CPK) are elevated
- Hyperkalemia occurs with release K from damaged cells
- Hypocalcemia due to calcium binding to muscle
- Hyperuricemia due to damaged cells releasing nucleaic acids

126

Treatment of rhabdomyolysis

- saline hydration
- mannitol (as osmotic diuretic)
- bicarbonate (to drive potassium back into cells and prevent precipitation from tubtules

127

Prevention of tumor lysis syndrome

Before chemotherapy, give:
- allopurinol
- hydration
- rasburicase

128

Treatment of ATN

-- no therapy proven to benefit ATN
- patients should be managed w/ hydration and correction of electrolyte abnormalities
**DIURETICS HAVE NO ADDED BENEFIT**

129

Indications for dialysis

AEIOU
- Acidosis
- Electrolyte abnormalities
- Intoxicants
- Overload (volume)
- Uricemia

130

How does furosemide cause ototoxicity?

Furosemide damages hair cells of cochlea resulting in sensoneurial hearing loss
- caused by how fast it is injected

131

Hepatorenal syndrome

renal failure developed secondary to liver disease
- kidneys are intrinsically normal

132

Sx of hepatorenal syndrome

- severe liver disease (cirrhosis)
- new-onset renal failure w/ no other explanation
- very low urine sodium (< 1%
- elevated BUN:Cr (> 20:1)

133

Tx of hepatorenal syndrome

Midodrine
Octeotride
Albumin

134

Atheroemboli

- cholesterol plaques in aorta or near coronary arteries that are fragile enough that they can be "broken off" when vessels are manipuated during catheter procedures

135

How can atheroemboli cause AKI?

Emboli lodge in kidney

136

PE signs of atheroemboli

- Purplish skin lesions in fingers and toes
- Livedo reticularis
- normal peripheral pulses (artheroemboli too small to occlude radial or brachial artery)

137

Diagnostic tests for atheroemboli

- Eosinophilia
- Low complement levels
- Eosinophiluria
- Elevated ESR

138

Most accurate test for atheroemboli

Biopsy of purplish skin lesions

139

Acute (Allergic) Interstitial Nephritis

- form of ARF that damages tubules on idiopathic basis
- antibodies and eosinophis attack tubule linings as reaction to drugs

140

Common meds associated with AIN

- Penicillins
- Sulfa drugs (e.g. thiazides and furosemide)
- Phenytoin
- Rifampin
- Quinolones
- PPIs
- Allopurinol

141

Important note about AIN

- Same meds that cause AIN are the same that cause:
- Drug allergy and rash
- Steven-Johnson syndrome
- Toxic epidermal necrolysis
- Hemolysis

142

Common presentation of AIN

- Fever
- Rash
- Arthralgias
- Eosinophilia and eosinophiluria

143

Diagnostic tests for AIN

- Elevated BUN and Cr with ratio < 20
- White and red cells in urine
- Hansel or Wright stain which determines whether eosinophils are present
** UA can't detect eosinophils

144

Treatment of AIN

Usually resolves spontaneously with stopping the drug or controlling the infection
- Severe is managed with dialysis
- If Cr continues to rise after drug has been stopped, give glucosteroids

145

Analgesic nephropathy presents with?

- ATN from direct toxicity
- AIN
- Membranous glomerulonephritis
- NSAID use
- Papillary necrosis

146

How do NSAIDs cause analgesic nepropathy?

Vascular insufficiency inhibit prostaglandins
- prostaglandins dilate afferent arteriole
- NSAIDS constrict afferent arteriole and decrease renal perfusion
- important in elderly or pts with renal insufficiency

147

Papillary necrosis

- sloughing of renal pappilae
- caused by NSAIDS or sudden vascular insufficiency leading to cell death in papillae
- pts usually have baseline renal damage
- usually see 60 - 70% renal fxn loss before Cr begin to rise

148

History of patients with papillary necrosis

- - Look for NSAID use with hx of:
Sickle cell dz OR
Diabetes
Urinary obstruction
Chronic pyelonephritis

149

Papillary necrosis: classic presentation

Sudden onset of flank pain
Fever
Hematuria

150

Diagnostic tests for papillary necrosis

- CT scan
- UA that shows red and white cells -- may show necrotic kidney tissue
- Urine cx wlll be normal

151

Best test for papillary necrosis

CT SCAN
- can show abnormal internal structures of kidney due to loss of papillaw

152

Pyelonephritis

- onset: few days
- symptoms: dysuria
- Positive urine cx
- Swollen kidney on CT

153

Tx of pyelonephritis

Abx such as ampicillin/gentamicin or fluoroquinolones

154

Papillary necrosis

- onset: few hrs
- sx: necrotic material in urine
- Negative urine cs
- Bumpy contour of interior where papillae were loss

155

Tx of papillary necrosis

None

156

Tubular Disease

- usually acute
- caused by toxins (drugs, myoglobin, Hgb)
- none cause nephrotic syndrome
- not treated with steroids
- add'l immunosuppressants are not used
- correct hypoperfusion and remove toxin

157

Glomerular Diseases

- chronic
- not from toxins/drugs
- can cause nephrotic syndrome
- biopsy sample
- often treated with steroids

158

Glomerulonephritis

- UA w/ hematuria
- Dysmorphic red cells (deformed as they squeeze through glomerulus)
- Red cell casts
- Urine sodium and FeNa are low
- Proteinuria

159

Goodpasture Syndrome

- present wit lung and kidney involvement
- NO UPPER RESPIRATORY INVOLVEMENT
- no systemic vasculitis
- no skin, joint, GI, or neuro involvement

160

Diagnostic Test of Goodpasture Syndrome

- antiglomerular basement membrane antibodies
- linear deposits
- most accurate test is kidney or lung biopsy
- anemia is often present due to hemoptysis

161

Tx of Goodpasture's Syndrome

- Plasmapheresis and steroids
** cyclophosphamide can be helpful

162

IgA Nephropathy (Berger disease)

- most common cause of glomerulonephritis in US
- usually Asian pt with recurrent episodes of gross hematuria 1-2 days after URI

163

Diagnosis of IgA Nephropathy

- Kidney biopsy
- may see increase in IgA levels by 50%

164

IgA Nephropathy

- no treatment proven to reverse disease
- 40 - 50% slowly progress to ESRD
- severe proteinuria treated wtih ACEi's and steroids

165

Postinfectious glomerulonephritis

- commonly caused by Streptococcus but can be caused by any organism
- occurs 1-3 WEEKS after throat infection

166

Postinfectious glomerulonephritis

- Dark (coca cola) urine
- Edema that is periorbital
- Hypertensin
- Oliguria

167

Dx of postinfectious glomerulonephritis

- UA with proteinuria, red cells, and recd cells cases
- ASO titers and anti-DNAse Ab tters
- Biopsy is most accurate but blood tests are sufficiently accurate

168

Tx of postinfectious glomerulonephritis

- antibiotics
- diuretics to control fluid overload

169

Alport Syndrome

- congenital defect of collagen that results in glomerular disease combined with:
- senorineural hearing loss
- visual disturbance from loss of the collagen fibers that hold the lens of the eye in place

170

Tx of Alport Syndrome

- No specific therapy to reverse defect of type IV collagen

171

Polyarteritis Nodosa

- systemic vasculitis of small/medium sized arteries that affect kidney
- affects nearly every organ except lung
-

172

Polyarteritis Nodosa associated with which diseases

- Hepatitis B
- PAN should be tested for Hep B

173

Presentation of Polyarteritis Nodisa

- glomerulonephritis
- nonspecific sx of fever, malaise, weight loss, myalgias, and arthralgia developing over months and weeks

174

GI sx associated with PAN

Abdominal pain, bleeding
Pain worsened by eating

175

Neuro symptoms associated with PAN

vasculitis damages surrounding peripheral nerves (peroneal, ulnar, radial, and brachial nerve)
- mononeuritis multiplex
- stroke in young person

176

Skin symptoms associated with PAN

- Can cause purpura and petechia
- can give ulcers, digital gangrene, and livedo reticularis

177

Diagnostic tests associated with PAn

- anemia and leukocytosis
- Elevated ESR and C-reactive protein
- ANCA _ NEGATIVE
- angiography showing aneurysms of renal, mesenteric, or hepatic arter

178

Most accurate test for PAN

Biopsy of symptomatic site such as skin, nerves, or muscles

179

Tx for PAN

Prednisone and cyclophosphamide
- treat hepatitis when found

180

Lupus nephritis

- SLE can show mild, ansymptomatic proteinuria
- severe disease presents with membranous glomerulonephritis

181

Most accurate test for lupus nephritis

Biopsy
- more important to guide therapy for lupus nephritis

182

Tx for lupus nephritis

Severe nephropathy is treated with glucocorticoids combined with cyclophosphamide or mycophenolate

183

Amyloidosis

abnormal protein produced in association w/
- myeloma
- chronic inflammatory disease
- rheumatoid arthritis

184

Renal amyloidosis

primary (plasma cell dyscrasia)
secondary (infectious or inflammatory) are most common

185

Renal amyloidosis (Hx and PE)

- patients may have multiple myelomaa or chronic inflammatory disease (e.g. rheumatoid arthritis)

186

Renal amyloidosis (Labs/ Histo)

Nodular glomerulosclerosis
- EM reveals amyloid fibrils
- apple green birefringence with Congo red stain

187

Tx of renal amyloidosis

Prednisone and melphalan
- bone marrow transplant may used for multiple myeloma

188

Membranoproliferative nephropathy

- can also be nephritic
- Type I : associated with HCV, cryoglobulinemia, SLE, and subacute bacterial endocarditis

189

Membranoproliferative nephropathy: Hx and PE

idiopathic form is present at 8-30 years of age
- slow progression to renal failure

190

Membranoproliferative nephropathy: Labs and Histo

TRAM TRACK - double layered basement membrane
- Type I: subENDOthelial depositis and mesangial depositis
- all 3 types have low serum C3
- Type II occurs by way of nephritic factor
- IgG leads to constant activation of extrinsic clotting pathway

191

Membranoproliferative nephropathy: Tx

Corticosteroids and cytotoxic agens may help

192

Minimal change disease

- most comon cause of nephrotic syndrome in children
- idopathic etiology: secondary causes include NSAIDS and hematologic malignancies (e.g. Hodgkins disease)

193

Minimal change disease: Hx and PE

tendency towards infections and thrombotic events
- sudden onset of edema

194

Minimal change disease: Labs and Histo

light micropscopy appears normal
- EM shows fusion of epithelial foot processes with lipid containing renal cortices

195

Minimal change disease: Tx

Steroids
- excellent prognosis

196

Focal Segmental Glomerulosclerosis

-idiopathic, IV drug use, HIV, obesity

197

FSGS: History and PE

typical patient is young African American male with uncontrolled hypertension

198

FSGS: Labs and Histo

microscopic hematuria;
biopsy shows sclerosis in capillary tufts

199

FSGS: Tx

Prednisone, cytotoxic therapy, ACEis/ ARBs to decrease proteinuria

200

Membranous nephropathy:

most common nephropathy in Caucasian adults
- secondary causes are solid tumor malignancies, esp in pts > 60 and immune complex disease

201

Membranous nephropathy: History and PE

associated with HBV, syphillis, malaria, and gold

202

Membranous nephropathy: Labs and History

"Spike and dome" appearance due to granular deposits of IgG and C3 at basement membrane

203

Membranous nephropathy: Tx

Prednisone and cytotoxic therapy for severe disease

204

Diabetic nephropathy

has 2 characteristic forms:
diffuse hyalinization and nodular glomerulosclerosis (Kimmlstiel-Wilson lesions)

205

Diabetic nephropathy: History and PE

Patients generally have long-standing, poorly controlled DM with evidence of retinopathy or neuropathy
- increased GFR is pathological mechanism

206

Diabetic nephropathy: Labs and Histo

Thickened GM
- increased mesangial matrix --> nodular sclerosis

207

Diabetic nephropathy:

Tight control of sugar
- ACEis

208

Nephrotic syndrome

- > 3.5 g/dam
- generalized edema
- hypoalbunemia
- hyperlipidemia
- hypercoagulable state
- increased atherosclerosis

209

Nephritic Syndrome Findings

"PHAROAH"
P-roteinuria
H- ematuria
A - zotemia
R -BC casts
O - liguria
H - ypertension

210

Immune Complex nephritic syndromes

- Postinfectious glomerulosclerosis
- IgA Nephropathy

211

Post-infectious glomerulonephritis

- classically associaed with recent Group A B- hemolytic streptococcal infection, but can be seen in any infection (usually 2-6 weeks prior)

212

Postinfectious glomerulonephritis: Hx and PE

-oliguria
- edema
- hypertension
- coca-cola urine

213

Postinfectous glomerulonephritis: Labs and Histo

Low serum C3 that normalizes 6-8 weeks after presentation
- increased ASO titer, lumpy-bumpy immunoflourescence

214

Postinfectous glomerulonephritis: Tx

supportive with diuretics to prevent fluid overload
- most patients have complete recovery

215

IgA nephropathy

- most common type: typically follows upper respiratory or GI infections
- commonly seen in young males, may be seen in Henoch Schonlein purpura

216

IgA nephropathy: Hx and PE

episodic gross hematuria or persistent microscopic hematuria

217

IgA nephropathy: Labs and Histo

Normal C3

218

IgA nephropathy: Treatment

Glucocorticoids for select patients
ACEis in patients with proteinuria
Some 20% of cases progress to ESRD

219

Pauci-immune nephritic disease

- Wegener's granulomatosis
- Goodpasture's syndrome
- Alport Syndrome

220

Wegener's granulomatosis

- granulomatous infection of the respiratory tract and kidney with necrotizing vasculitis

221

Wegener's granulomatosis: Hx and PE

-Fever, weight loss, hematuria,
- Hearing disturbances
- Repiratory and sinus symptoms
- Cavitary pulmonary lesions bleed and lead to hemoptysis

222

Wegener's granulomatoisis: labs and histo

ANCA positive
Renal biopy shows segmental necrotizing glomerulonephritis with few immunoglobulin deposits on immunoflourescence

223

Wegener's granulomatosis: Tx

High dose corticosteroids and cytotoxic agents
Patients tend to have frequent relapses

224

Goodpasture's syndrome

rapidly progressing glomerulonephritis with pulmonary hemorrhage
-peak incidence is in males in their mid 20s

225

Goodpasture's syndrome: hx and pe

hemoptysis, dyspnea, possible respiratory failure
No upper respiratory tract involvement

226

Goodpasture's syndrome: labs and histo

Linear anti-GBM deposits on immunofluorescence
Iron deficiency anemia
Hemosiderein filled macrophages in sputum
Pulmonary infiltrates on CXR

227

Goodpasture's syndrome: Tx

Plasma exchange therapy
Pulsed steroids
May progress to ESRD

228

Alport's Syndrome

- hereditary glomerulonephritis
- presents in boys 5-20 years of age

229

Alport's syndrome: Hx and PE

asymptomatic hematuria
associated with sensoneurial hearring loss and eye disorders

230

Alport's syndrome: Labs and histo

GBM splitting on EM

231

Alport's syndrome: tx

Progresses to renal failure
anti-GBM nephritis may recur after transplant

232

Drug induced interstitial nephritis

Bactrum
Sulfonamides
PCNs
Rifampin
Phenytoin

233

Drug induced interstitial nephritis

Arthralgia
Diffuse maculopapular rash

234

Drug induced interstial nephritis

Eosinophils on UA
WBC casts

235

Sx of uremia

- Pericardial rub
- Asterixis
- hHypertension
- Decreased urinary output
- Increased respiratory rate

236

Hyaline casts in urine sediment

normal finding
- increased amt suggests volume depletion
- assoc w/ prerenal AKI

237

Red cell casts, dysmorphic red cells in urine sediment

Glomerulonephritis
- sign of intrinsic AKI

238

White cells, eosinophils in urine sediment

Allergic interstitial nephritis
- atherembolic disease
- sign of intrinsic AKI

239

Granular casts, renal tubular cells, "muddy brown casts" in urine sediment

ATN
- sign of intrinsic AKI

240

White cells, white cell casts in urine sediment

Pyelonephritis
- sign of postrenal AKI

241

Hypercalcemia

> 10.2 mg/DL
- most common causes are hyperparathyroidism and malignancy
- use mneumonic CHIMPANZEE

242

Causes of hypercalcemia

CHIMPANZEE
- Calcium supplementation
- Hyperparathyroidism/Hyperthyoridism
- Iatrogenic (e.g. thiazides, parental nutrition)/ Immobility (esp in ICU setting)
- Milk-alkali syndrome
- Paget's disease
- Adrenal insufficiency/Acromegaly
- Neoplasm
- Zollinger-Ellison (e.g. MEN I)
- Excess Vitamin A
- Escess Vitamin D
- Sarcoidosis adn other granulomatous disease

243

Hypercalcemia: PE and Hx

Asymptomatic but may present with:
Bones (osteopenia, fractures)
Stones (kidney stones)
Groans (anorexia, constipation)
Psychiatric overtones (weakness, fatigue, altered mental status)

244

Hypercalcemia: Diagnosis

- Order Ca
- Order Albumin, phosphate, PTH, PTHrP, Vit D, and ECG
-

245

Hypercalcemia finding on ECG

short QT interval

246

Hypercalcemia: Tx

IV hydration followed by furosemide to increase calcium excretion
- AVOID THIAZIDES which can increase absorption of Ca

247

Discuss digitalis and hypokalemia

- digitialis and K fight for same site on Na/K pump so hypokalemia sensitizes patient to digitalis

248

Monosymptomatic enuresis

urinary incontinence in children > 5

249

Management of monosymptomatic enuresis

FIRST LINE: BEHAVIOR MODIFICATION
- avoid sugary drinks
- void regularly during day and immediately before bedtime
- drink ample fluid in morning & early afternoon

Pharm therapy
1st line: desmopression
2nd line: TCA

250

1st line pharm therapy in monosymptomatic enuresis

Desmopression

251

Best test for suspected BPH

Abdominal U/S to check for obstruction

252

Calcium oxalate/calcium phosphate

- most common type of renal stone
- MCCs: idiopathic hypercalcuria and hyperparathyroidsm

253

Tx of calcium oxalate/calcium phosphate

Hydration, Dietary sodium and protein restriction, Thiazide diuretics
- DO NOT DECREASE CA INTAKE
- alkaline urine
- radiopaque

254

Struvite renal stones

associated w/ urease producing organisms (e.g Proteus)
form STAGHORN CALCULI
alkaline urine
radiopaque
- alkaline urine

255

Tx of struvite renal stones

Hydration
treat UT if present
surgical removal of staghorn stone

256

Uric acid stones

associated with gout, xanthine oxidase deficiency and high purine turnover rate (e.g. chemotherapy)
acidic urine (pH < 5.5)
RADIOLUCENT on plain film but detectable on CT

257

Tx of uric acid stones

Hydration
Alkalinize urine w/ citrate with is converted to HCO in liver

258

Cystine renal stone

due to defect in renal transport of certain amino acids (COLA - cysteine, ornithine, lysine, and argine)

259

Dx of cystine renal stone

- HEXAGONAL CRYSTALS
- POSITIVE CYANIDE NITROPRUSSIDE TEST

260

Tx of cystine renal stone

Hydration
Dietary sodium restriction
Alkalinization of urine
Penicillamine

261

Nephrolithiasis: Hx and PE

acute onset of severe, colicky flank pain that may radiate to testes or vulva
- associated w/ nausea and vomtng
- patient unable toget comfortable and shifts position frequently

262

Best test for nephrolithiasis

Non contrast CT for diagnosis of kidney stones

263

U/A for kidney stones

Microhematuria and altered urine PH

264

Best diagnostic modality for suspected kidney stones in children and pregnant women

Ultrasound

265

Tx for renal stones

Hydration and analgesia are intiail streatment
Stones < 5mm can pass spontaneously
Stones > 5mm but < 3cm can be treatmed with ESWL

266

AD Polycystic kidney disease

- usually asymptomatic until > 30 years
- associated with increased risk of cerebral aneurtyrm esp in patients w/ positive family hx

267

Polycystic kidney disease: History and PE

- Pain and hematuria are most common symmptoms
- Large palpable kidneys

268

Dx of Polycystic kidney disease

CT scan
-wlll show multiple bilateral cysts through renal parenchy

269

Tx of polycystic kidney disease

prevent complications and decrease rate of progression of ESRD
- early mgmt of UTIs
- BP control (ACEis and ARBs)

270

Hydronephrosis

dilation of renal calcyces
- usually secondary to obstruction of urinary tract

271

Hx and PE: Hydronephrosis

- may be asymptomatic
- may present w/ flank/back pain
- decreased urine output
- abdominal pain and UTiS

272

Dx of Hydronephrotis

- ULTRASOUND (first line) to detect dilitation of renal calyces or ureter
- can use CT scan

273

Tx of hydronephrosis

surgically tx anatomic obstruction

274

Complications of untreated hydronephrosis

- Urinary obstruction leading to HTN, acute or chronic renal failure
Sepsis

275

Vesiculoureteral reflux

- retrograde projection of urine from bladdder to ureteres and kidney
- may be due to posterior urethral valves, urethral or meatal stenosi

276

Hx and PE: of vesiculouretal reflux

patient present with recurrent UTIs, typically in childhood

277

Dx: of vesiculourethral reflux

Voiding cystogram (VCUG) to detect abnormalities at ureteral insert sites and identify grade of reflx

278

Tx of vesiculourethral reflux

- Treat infxns aggressively. Mild reflux with prophylactiv abx (amoxicillin < 2 mths or bactrim or nitrofurantoin)
- Surgery (urereteral reimplantation) reserved for children with high grade reflux

279

Complication of vesiculourethral reflux

- Progressive renal scarring and ESRD

280

Cryptochordism

- failure of 1 or both testes to descent into scrotum
- LOW BIRTH WEIGHT IS A RISK FACTOR

281

History and PE: cryptochordism

Bilateral cryptochordism associated w prematurity, oligospermia, congenital malformation syndromes (Prader-Willi, Noonan) and infertility)
- associated w increased risk of testicular malignancy

282

Dx: cryptochordism

testes can't be manipuated into scrotal sac with gentle pressure
- may be palpable anywhere along inguinal canal or in abdomen

283

Tx: cryptochordism

Orchiopexy by 6-12 months of age (most testes will spontaneously descend by 3 months)
- treat w/ orchiectomy to avoid testicular cancer