Renal Urinary System part 1 Flashcards
(486 cards)
1
Q
Hyponatremia
A
x
2
Q
cause
A
x
3
Q
what is a cause?
A
CHF, cirrhosis
4
Q
pathophys
A
x
5
Q
how does it occur in context of CHF?
A
low cardiac output leads to decreased perfusion, which leads to increased ADH, leads to water reabsorption and dilutional hyponatremia
6
Q
management
A
x
7
Q
initial therapy for hyponateremia?
A
water intake restriction
8
Q
if serum sodium is resistant to mainstay trx, what is another option?
A
vasopressin receptor antagonist (eg tolvaptan)
9
Q
Euvolemic Hypo-osmolar Hyponatremia
A
x
10
Q
cause
A
x
11
Q
what is a cuase?
A
hypothyroidism
12
Q
risk
A
x
13
Q
what is a major cause of hypothyroidism?
A
postpartum thyroiditis
14
Q
Evalutation of Hyponatremia
A
x
15
Q
if serum osmols greater than 290, when what is the cause?
A
marked hyperglycemia, advanced renal failure
16
Q
if serum osmols less than 290,and urine osmolality less than 100, urine sodium less than 25 , then what is the cause?
A
primary polydipsia, malnutrition (beer drinkers potomania)
17
Q
if serum osmols less than 290,and urine osmolality less than100, and urine sodium greater than 25 when what is the cause?
A
volume depletion, CHF, cirrhosis
18
Q
if serum osmols less than 290,and urine osmolality greater than 100, and urine sodium greater than 25 when what is the cause?
A
SIADH, adrenal insufficiency, hypothyroidism
19
Q
HTN after Kidney Transplant
A
x
20
Q
causes
A
x
21
Q
what are other causes of transplant renal dysfunction?
A
rejection, calcineurin inhibitor toxicity, recurrent glomerular disease, obstruction, thrombotic microangiopathy
22
Q
what is another immunotherapy cause of HTN after kidney transplant?
A
corticosteroids
23
Q
Kidney transplant
A
x
24
Q
complications
A
x
25
what are immediate long term complications of kidney transplant?
very low and very few (DVT, infxns)
26
in females, what do they have an increased risk of having after kidney donation after pregnancy?
gestational complications (fetal loss, preeclampsia, gestational diabetes, and gestational hypertension)
27
optimal kidney donor
x
28
who is an optimal kidney donor for a child?
living related donor with an identical blood type (donor must also be an adult capable of making informed decisions)
29
Living Kidney Donation
x
30
risks
x
31
what are risks of living kidney donation?
perioperative: mortality, hemorrhage, infection, thromboembolic events
long-term: ESRD, HTN
32
what are absolute contraindications to living kidney donation?
Inability to consent (age less than 18, intellectual
disability, untreated psychiatric disease)
Diabetes mellitus
Hypertension with end-organ dysfunction
BMI greater than 35 kg/m2
Malignancy
33
Analgesic Induced Nephropathy
x
34
Syx
x
35
what are syx of nephropathy?
worsening fatigue, nausea, malaise, bilateral pedal edema, flank pain radiating to groin
36
acute syx of nephropathy?
usually chronic, but can present with hematuria, pyuria, proteinuria, and renal colic
37
PE
x
38
what would you see on Physical Exam?
CVA tenderness
39
Dx
x
40
what does the UA show?
florid nephrotic range proteinuria, WBC count and casts, and no evidence of UTI
41
what does CMP show?
elevated Cr
42
what does CT non contrast show?
mild dilation of pelvicalyceal system
43
what would 24 hr urine protein show?
elevated protein
44
cause
x
45
what are the analgesic causes?
NSAIDs (reversible decline in GFR from inhibiting vasodilatory PG production)
46
what are other analgesic causes?
aspirin, phenacetin, acetaminophen, NSAIDs
47
risk
x
48
what are risks?
hx of chronic NSAID use, and new condition requiring further OTC meds
49
Post Strep Glomerulonephritis (PSGN)
x
50
Dx
x
51
UA would show?
RBC and RBC casts
52
what would be a good test to check post strep glomerulonephritis?
streptozyme test
53
what are other labs associated with PSGN?
renal insufficiency, nephritis, and low C3 complement levels.
54
SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion)
x
55
Dx
x
56
what would serum sodium measure?
low
57
what would serum osmols measure?
low (<275)
58
what would urine osmols measure?
high (>100)
59
what would urine sodium conc measure?
high (>40)
60
what would the volume state be for a person in SIADH?
euvolemic
61
cause
x
62
what would cause SIADH?
Pneumonia, Meds (SSRI, carbamazepine, valproic acid), CNS issues (stroke, hemorrhage, trauma), ectopic ADH secretion (eg Small cell lung cancer), pain and or nausea
63
stimuli for secretion of ADH
x
64
what are osmotic stimuli for ADH secretion?
serum osmolality >285 mOsm/kg H20
65
what are nonosmotic stimuli for ADH secretion?
```
Nausea
Pain
Physical or emotional stress
Hypotension
Hypovolemia
Hypoxia
Hypoglycemia
```
66
syx
x
67
what are syx of mild/ moderate hyponatremia?
nausea, forgetfullness
68
what are syx of severe hyponatremia?
seizures, coma
69
PE
x
70
how do you know someone is euvolemic?
mois mucous membranes, no edema, no JVD
71
management
x
72
how do you manage SIADH?
- mild to moderate hyponatremia=asyx: fluid restriction +/- salt tabs
- severe hyponatremia (<120mEq/L) = seizures, ; hypertonic 3% saline
73
Hypovolemic Hyponatremia
x
74
cause
x
75
what is the cause?
decreased solute intake
76
dx
x
77
what is the urine sodium levels?
low (<40) as kidneys attempt to retain as much salt as possible
78
Gross Hematuria
x
79
causes
x
80
what are renal causes ?
glomerulonephritis, infection
81
what are ureteral causes?
nephrolithiasis
82
what are bladder causes?
cystitis, malignancy
83
whata are urethral cuases?
urethritis, prostatitis
84
evaluation
x
85
what is the first step of evaluating gross hematuria?
ask if there is hx of trauma or suspected stone
86
if there is a hx of trauma or suspected stone, what do you get before a UA?
imaging CT or U/S
87
if there is no hx of trauma or suspected stone, what is the next step?
get a UA and Urine Culture
88
why do we first get a UA?
to evaluate infectious, glomerular, and extraglomerular causes
89
if UA shows infection , what do you do?
give Abx
90
if UA shows new proteinuria, RBC casts, what do you do?
evaluate for glomerular causes
91
if UA shows other causes (ie cancer), what do you get?
imaging CT , cystoscopy, urine cytology
92
management
x
93
how do you evaluate gross hematuria?
evaluate both upper and lower urinary tracts
94
to evaluate upper urinary tracts, what do you do?
CT urogram or U/S
95
to evaluate lower urinary tracts, what do you do?
cystoscopy
96
risk
x
97
what are high risks for urinary tract malignancy?
>35 y.o , male, smoking hx, pelvic radiation , exposure to aniline dyes, chronic analgesic abuse, chemical exposure
98
Excercise induced Hematuria
x
99
cause
x
100
what is a causes of hematuria ?
strenuous excercise
101
what are other causes?
rhabdomyolysis, excercise induced hematuria, march hemoglobinuria from RBC trauma
102
dx
x
103
what are the dx findings on UA?
positive UA, absence of RBC casts (exclude glomerular cause)
104
how do you dx it?
by exclusion
105
management
x
106
what do you for it?
nothing, f/u UA in 1 week to ensure resolution
107
if it persists for >1 week, what do you do?
cystoscopy
108
Cystoscopy
x
109
is gross hematuria with no evidence of glomerular disease (no RBC casts or dysmorphic red cells) or infection an indication for cystoscopy?
yes
110
is microscopic hematuria with no evidence of glomerular disease (no RBC casts or dysmorphic red cells) or infection but increased risk of cancer an indication for cystoscopy?
yes
111
is recurrent UTI an indication for cystoscopy?
yes
112
is obstructive symptoms with suspicion for stricture, stone an indication for cystoscopy?
yes
113
is irritiative syx without urinary infection an indciation for cystoscopy?
yes
114
is abnormal bladder imaging or urine cytology an indication for cystoscopy?
yes
115
IgA Nephropathy
x
116
syx
x
117
what are the typical syx of IgA nephropathy?
hematuria following an acute upper respiratory infection (flu like syx, nasal drainage, throat pain)
118
pathophys
x
119
what is the usual pathophys?
deposition of IgA in the renal glomerulus
120
PE
x
121
what is the physical exam findings?
flank pain (secondary to stretching of the renal capsule)
122
Dx
x
123
what would you see in UA?
RBC casts, dysmorphic RBCs
124
management
x
125
what is the management of IgA nephropathy?
ACEi for HTN, fish oil
126
Acute Cystitis and Pyelonephritis in Non pregnant women
x
127
evaluation
x
128
what must you always get in young sexually active chilbearing women?
pregnancy test
129
uncomplicated cystitis in non pregnant women
x
130
cause
x
131
what is the common cause?
E coli, proteus mirabilis, klebsiella penumoniae
132
dx
x
133
when is urine culture indicated?
only if initial trx w abx fails
134
trx
x
135
what is the trx?
Nitrofurantoin for 5 days (avoid in suspected pyelonephritis or creatinine clearance <60 mL/min)
Trimethoprim-sulfamethoxazole for 3 days (avoid if local resistance rate >20%)
Fosfomycin single dose
Fluoroquinolones only if above options cannot be used
136
complicated cystitis in non pregnant women
x
137
define
x
138
what is the definition for complicated cystitis?
DM, pregnancy, renal failure, Urinary tract obstruction, indwelling catheter, urinary procedure (eg cystoscopy) , immuonsuppression, hospital acquired
139
dx
x
140
when is urine culture indicated?
prior to initiating therapy and adjust abx as needed
141
trx
x
142
what is the trx?
Fluoroquinolones (5-14 days),
extended-spectrum antibiotic (eg, ampicillin/gentamicin) for more severe cases
143
Pyelonephritis
x
144
risk
x
145
what are risk factors in pregnancy ?
smoking, pregestational DM, asyx bacteruria
146
dx
x
147
when is urine culture indicated?
prior to initiating therapy and adjust abx as needed
148
trx
x
149
what is the trx OP?
Fluoroquinolones (eg, ciprofloxacin, levofloxacin)
150
what is the trx inpatient?
Intravenous antibiotics (eg, fluoroquinolone, aminoglycoside ± ampicillin)
151
UTI antibiotics in pregnancy
x
152
what are the antibiotics recommended for UTI in pregnancy ?
nitrofurantoin, amoxicillin, amoxicillin-clavulanate, cephalexin, fosfomycin
153
what are the antibiotics contraindicated for UTI in pregnancy?
tetracylcines, fluoroquinolones, trimethoprim-sulfamethoxazole (NTD, cardiac defects, cleft palate, neonatal kernicterus), aminoglycosides (ie gentamicin)
154
Hypophosphatemia
x
155
risk
x
156
who is at risk of low phsophate?
chronic alcoholic
157
dx
x
158
what is important to note regarding serum phosphate levels?
chronic alcoholics can have frequent phosphate depletion even though serum phosphate levels may initially be normal
159
cause
x
160
what is a major cause of of hypophosphatemia in alcholics?
refeeding syndrome, especially if respiratory alkalosis, may lead to shift of phsophate intracellularly and a decrease serum phosphate
161
Complications
x
162
what is a common complication of hypophosphatemia in alcholics with underlying myopathy to begin with ?
rhabdomyolysis (new complaints of weakness)
163
pathophys
x
164
why do chronic alcholics have low phophate and why do they have get refeeding syndrome?
chronic depletion of phosphate secondary to low vit D and phosphate intake and decrease oral intake and diarrhea. Despite depletion of phosphate , you still have normal extracelluar phosphate levels, until patient is fed or given IV fluids with glucose and insulin, which shift phosophate intracellularly (in addition to a respiratory alkalosis which shifts phosphate into the cells)
165
UTI in children
x
166
risk factors
x
167
what are risk factors?
female sex, uncirumscribed male infants, vesicoureteral reflux, anatomic defects, dysfunctional voiding, constipation
168
syx
x
169
what are symptoms ?
dysuria, fever, suprapubic pain (cystitis) and/or flank/back pain (pyelonephritis)
170
what are syx of UTI in younger patients <2y.o. ?
poor feeding, irritability
171
dx
x
172
what are lab findings?
pyuria
173
what does urine culture show?
bacteriuria
174
management
x
175
what is the management of UTI in children?
antibiotic therapy
+/- renal U/S and voiding cystourethrogram
(in patients < 2 y.o. should get renal U/S
in patients >2 y.o. you get an isolated UTI do not require imaging )
176
why do you need a renal U/S in <24 month olds ?
to evaluate for hydronephrosis and ureteral dialtion
177
Recurrent UTIs
x
178
management
x
179
what is the indication for abx prophylaxis in young females with recurrent UTIs?
>= 2 UTIs in 6months or >=3 UTIs in 1 year
180
how often do you give prophylaxis ?
continuous or solely postictal
181
when would you order a non contrast CT?
if there is concerns for nephrolithiasis
182
what are behavioral interventions for recurrent UTIs?
postcoital voiding, increased intake of cranberry juice
183
Postoperative Urinary Retention
x
184
risk factors
x
185
what are risk factors for postoperative urinary retention?
```
>50 y.o,
surgery >2 hours duration
>750 cc intraop fluids
regional anesthesia
neurologic disease
underlying bladder dysfunction
previous pelvic surgery
```
186
PE
x
187
what are physical exam findings?
decreased urine output
abdominal distention
suprapubic pressure/pain
not passing gas
188
management
x
189
what is the management for postop urinary retention?
indwelling catheter
clean intermittent catheterization
190
pathophys
x
191
what is the pathophys of postop urinary retention?
anesthesia + IV fluids cause bladder stretch receptor dysfunction and decreased detrusor contractility
192
Urethral Diverticulum
x
193
pathophys
x
194
what is the pathophys of urethral diverticulum ?
herniation of urethral mucosa through the muscle wall into the surrounding tissue
195
syx
x
196
what are symmptoms of urethral diverticulum?
postvoid dribbling, dysuria, dyspareunia
197
PE
x
198
what do you see on pelvic exam?
anterior vaginal mass (i.e fullness of the anterior vaginal wall)
199
what happens when you examine the mass?
tender anterior wall vaginal mass that expresses bloody, purulent fluid
200
risk
x
201
what are risks of urethral diverticulum?
Urethral diverticula in women form due to repeated infection, inflammation, and trauma of the urethra from previous pelvic trauma (eg, vaginal delivery) or surgery.
202
dx
x
203
how do you dx urethral diverticulum?
UA, UCx, MRI pelvis, TVUS
204
trx
x
205
what are the trx of urethral diverticulum?
manual compression, needle aspiration, surgical repair
206
Vesicovaginal Fistula
x
207
dx
x
208
how do you dx of vesicovaginal fistula?
methylene blue instilled into the bladder- test is positive if vagina becomes blue after the dye is instilled in the bladder
209
Urinary Incontinence
x
210
risk
x
211
what are risk factors?
increased age, hx of multiple vag deliveries, obesity, vaginal atrophy, tobacco use, caffeine intake
212
Stress Incontinence
x
213
syx
x
214
what are the symptoms of stress incontinence?
leakage with coughing, sneezing, laughing, lifting
215
dx
x
216
how do you dx stress incontinence?
Q tip test- hypermobile urethra (>30 degree angle of movement)
217
trx
x
218
what is the trx of stress incontinence?
lifestyle modification, pelvic floor excercises, pessary, urethral sling surgery
219
Urge incontinence
x
220
syx
x
221
what are the symptoms of urge incontinence?
Sudden, overwhelming, or frequent need to urinate
222
trx
x
223
what is the trx of urge incontinence?
Lifestyle modification
Bladder training
Antimuscarinic medications
224
Overflow incontinence
x
225
syx
x
226
what are the symptoms of overflow incontinence?
Constant dribbling of urine, incomplete bladder emptying
227
dx
x
228
how do dx overflow incontinence?
PVR>200mL
229
trx
x
230
what is the trx of overflow incontinence?
Intermittent catheterization
| Correct underlying etiology
231
Ureteral Stones (kidney stones)/nephrolithiasis
x
232
management
x
233
if stones <5 mm, what can you expect?
they will pass spontaneously
234
if stones 5-10mm, how do you manage ?
trial of medical therapy (gentle hydration, pain contorl, alpha blockers-tamsulosin) and don't need hospital admission if syx are controlled
235
if stones >=10mm, persistent pain, acute renal failure, or signs of sepsis,then what do you do?
surgical removal of stones
236
abx are indicated in the presence of _____?
infection
237
trial of medical therapy (gentle hydration, pain contorl, alpha blockers) and don't need hospital admission if syx are controlled in patients with ureteral stones for what size?
5-10mm
238
kidney stones that will spontaneously pass
<5mm
239
surgical removal of kidney stones indicated for?
if stones >=10mm, persistent pain, acute renal failure, or signs of sepsis,then what do you do?
240
patients with obstructing ureterolithiasis w infection, AKI, severe pain that have failed initial measurs require what?
decompression with percutaneous nephrostomy or ureteral stent placement.
241
Inpatient Ureteral Stones/nephrolithiasis
x
242
management
x
243
if symptomatic ureteral stone , and urosepsis and acute renal failure and complete obstruction present , what is the next step?
urology consult
244
if symptomatic ureteral stone , and there is no urosepsis and acute renal failure or complete obstruction present , what is the next step?
stone size
245
if symptomatic ureteral stone , and there is no urosepsis and acute renal failure or complete obstruction present , and stone size <10mm?
medical management (hydration, pain control, alpha blockers-tamsulosin, strain urine)
246
if symptomatic ureteral stone , and there is no urosepsis and acute renal failure or complete obstruction present , and stone size <10mm and after medical management doesn't control or pass pain, what is next step?
urology consult
247
if symptomatic ureteral stone , and there is no urosepsis and acute renal failure or complete obstruction present , and stone size >=10mm?
urology consult
248
Renal Cell Carcinoma Module
x
249
syx
x
250
what are syx of Renal Cell Carcinoma?
profound fatigue and anorexia for the past few weeks, weight loss
251
risk
x
252
what are risks of Renal Cell Carcinoma?
smoking, drinking
253
ddx
x
254
what is the differential for fatigue, weight loss, and anorexia?
malignancy, infectious disease, autoimmune disease
255
workup
x
256
what does the work up for Renal Cell Carcinoma include?
anemia, CBC, FOBT, red cell indices, iron studies
257
what additional labs for Renal Cell Carcinoma that should be ordered?
BMP, LFTs, and UA
258
if your anemia workup for Renal Cell Carcinoma comes back showing nromocytic normochromic anemia with low serum iron, low TIBC, and elevated ferritin, what is the dx?
anemia of chronic disease
259
if you have anemia of chronic disease and the presence of hematuria on UA, what do you think about?
GU -malignancy (urinary tracts, kidney, prostate)
260
what is the preferred test for investigating suspected GU-malignancy?
abd CT and cytoscopy
261
dx
x
262
what syx make you suspect Renal Cell Carcinoma?
unexplained hematuria, flank pain, palpable flank mass
263
what does abdominal CT help show for Renal Cell Carcinoma?
provides presumptive dx and provides staging information
264
if renal mass on CT abd is seen without involvement of renal capsule, renal vein , or IVC, what stage is that Renal Cell Carcinoma
stage I renal cell cancer
265
management
x
266
if abd CT provides presumptive dx of Renal Cell Carcinoma, then what is next step?
- obtain CT chest for further staging information.
| - bone scan if there is bone pain or elevated ALP
267
once you determine the stage based on Renal Cell Carcinoma of abdominal CT,chest CT, +/- bone scan , what is the next step?
- nephrectomy is preferred for isolated renal mass (diagnostic and therapeutic)
- biopsy preferred for supsected metastatic disease; further treatment dictated by result
268
therapy
x
269
what are next steps after dx of Renal Cell Carcinoma in the module?
NPO, IV NS 0.9%, onc consult, surg consult, PT, PTT/INR, blood type and cross match, IV cefazolin, nephrectomy, counseling (no smoking, no alcohol, cancer diagnosis)
270
Renal Cell Carcinoma (RCC)
x
271
risk
x
272
what are the risks of RCC?
cigarette smoking, obesity, HTN
273
syx
x
274
what are the syx of RCC?
flank pain, hematuria, palpable abdominal mass
275
association
x
276
what is the associated syndrome?
paraneoplastic syndrome (EPO production leading to erythrocytosis)
277
dx
x
278
what is the dx test to evlaute for RCC?
CT scan of abdomen
279
what would CT scan of RCC show?
enhancing mass with thickened, irregular septa
280
management
x
281
if renal mass isolated to renal capsule (stage 1), what is the trx?
parial nephrectomy
282
if renal mass extends through the renal capsule but not beyond Gerota's fascia (stage II), what is the trx?
radical nephrectomy
283
if renal mass extends through renal capsule with invasion of major veins, abdominal lymph nodes and adrenal glands, (stage III)
radical nephrectomy, with chemo and immunotherapy
284
Hyperkalemia
x
285
cause
x
286
what are some causes of hyperkalemia?
NSAID use, renal failure, lisinopril use
287
dx
x
288
what are the progressive EKG changes you see with hyperkalemia?
peaked T waves, then subsequently prolongation of the PR interval and QRS complex, disappearance of P waves, and eventually sine wave
289
trx
x
290
what is most appropriate first line trx?
IV calcium gluconate
291
what are follow up trx options to reduce serum potassium?
beta agonist or combination of glucose and insulin
292
Calcium Homeostasis
x
293
transport
x
294
what are the 3 different ways calcium is transported in blood?
albumin bound calcium (45%), ionized calcium (40%), calcium bound to inorganic and organic anions (15%)
295
management
x
296
when evaluating hypocalcemia, what must you always look at?
serum albumin
297
how do you adjust for hypocalcemia in the hypoalbuminemia?
serum calcium concentration decreases by 0.8 mg/dL for every 1 g/dL decrease in serum albumin concentration.
298
Hypocalcemia
x
299
causes
x
300
what are causes of acute hypocalcemia?
neck surgery (parathyroidectomy), pancreatitis, sepsis, tumor lysis syndrome, acute alkalosis, chelation (blood citrate transfusion, EDTA, foscarnet)
packed RBCs are preserved and anticoagulated using sodium citrate (which contains calcium)
301
risk
x
302
who are at high risk of hypocalcemia?
liver or renal failure, hypothermia, shock
303
when can hypocalcemia occur?
immediately after surgery, after car accident with several fractures, where multiple transfusions required
304
pathophys
x
305
what is the pathophys of hypocalcemia in the context of citrate ?
as citrate binds ionized calcium , you get symptomatic calcium deficiency
also in situations with volume expansion and hypoalbuminemia
306
dx
x
307
what would serum calcium look like?
you can have normal serum calcium , though ionized calcium is low
308
syx
x
309
what are syx of hypocalcemia?
oral paresthesias, carpopedal spasm, tetany, seizures
310
PE
x
311
what are physical exam findings?
muscle cramps, chvostek (ipsilateral facial twitch with tapping) and trousseau (BP cuff contraction) signs , perioral paresthesias, hyperreflexia/tetany, seizures
312
trx
x
313
for mild acute hypocalcemia (corrected calcium of 7.5-8.5mg/dL), what is trx?
oral calcium citrate or carbonate
314
what is the best treatment for acute hypocalcemia?
IV calcium gluconate/chloride
315
Familial Hypocalciuric Hypercalcemia
x
316
epid
x
317
what is the inheritance pattern?
auto dominant
318
cause
x
319
what is the major cause of hypercalcemia?
inactivation of the calcium sensing receptor, so the normal suppression of PTH secretion when calcium levels are normal gets blocked, and you get increased reabsorption of calcium reabsorption in the renal tubules.
320
dx
x
321
what does labs show?
mild hypercalcemia
322
syx
x
323
what do syx show?
no clinical findings of symptoms
324
trx
x
325
what is the treatment?
nothing
326
Hypomagnesemia
x
327
syx
x
328
what is hypomagnesemia similar to?
mimics hypocalcemia
329
risk
x
330
what are the risks of hypomagnesemia?
alcoholism, prolonged NG suction or diarrhea, diuretic use
331
Nephrolithiasis in Pregnancy
x
332
epid
x
333
most commonly seen in which trimester?
2nd and 3rd trimester
334
risk
x
335
what are risk factors of pregnancy?
increasd calcium excretion, urinary stasis, and decreased bladder capacity
336
what are other risk factors?
obesity, hyperPTH, DM, IBS, hx of kidney stones outside pregnancy
337
syx
x
338
what are the syx of nephrolithiasis in pregnancy?
paroxysmal severe flank pain that radiates to the labia, n/v, hematuria, dysurai, pyuria
339
dx
x
340
what is the first like imaging in pregnancy?
renal and pelvic ultrasound to minimize fetal radiation exposure
341
if renal and pelvic ultrasound negative, what is next best test?
TVUS
342
if TVUS is also negative, but still high suspision for kidney stone, next step?
treat empirically for a stone and observe closely
-OR-
MRI urogram
-OR-
Low dose CT urogram (2nd and 3rd trimester only)
343
PKD (Polycystic Kidney Disease)
x
344
syx
x
345
what are syx of PKD?
hematuria and flank pain
346
dx
x
347
what does imaging show?
CT abdomen shows multiple bilateral kidney cysts that are round, thin walled nonenhancing and sharply demarcated
348
what genetic test do you test for?
PKD gene mutation
349
trx
x
350
what do you trx PKD with?
ACEi
351
Paralytic Ileus
x
352
syx
x
353
what are syx of paralytic ileus?
n/v, soft distended abdomen, decreased bowel sounds
354
PE
x
355
what are physical exam findings?
possible gaseous distension, reduced/absent bowel sounds
356
cause
x
357
what is a major cause of paralytic ileus?
recent surgery (hours to days), metabolic (eg hypokalemia), medication induced
358
risk
x
359
what is a risk for hypokalemia induced paralytic ileus
diuretic induced therapy
360
dx
x
361
do you see small bowel dilation typically?
yes
362
do you see large bowel dilation typically?
yes
363
trx
x
364
if hypokalemia is cause, what do you do?
IV potassium
365
Small Bowel Obstruction (SBO)
x
366
cause
x
367
what is the major cause of SBO?
prior surgery (weeks to years)
368
PE
x
369
what does exam look like?
distention, increased bowel sounds
370
dx
x
371
do you see small bowel dilation typically?
yes
372
do you see large bowel dilation typically?
no
373
Renovascular (Hypertension) HTN
x
374
epid
x
375
what is the most common cause of secondary HTN?
renovascular HTN
376
risk
x
377
who is at risk?
atherosclerotic disease elsewhere in the body, renal failure
378
syx
x
379
what are signs of renovascular HTN?
resistant HTN to multiple meds (3 drug regiment)
malignant HTN (with end organ damage)
onset of severe HTN (>180/120mmHg) after age 55
severe HTN with diffuse atherosclerosis
recurrent flash pulmonary edema with severe HTN
380
PE
x
381
what are physical exam findings?
abd bruits, asymmetric renal size (>1.5cm)
382
dx
x
383
how do you evaluate such patients?
renal duplex Doppler U/S or CT or MRA of renal arteries
384
what dx imaging studies should be avoided?
CT and gadolinium MR angiography, because of risk of contrast induced nephropathy and nephrogenic systemic fibrosis
385
what labs support renovascular HTN?
unexplained rise in serum Cr (>30%) after starting ACEi or ARBs
386
what imaging rsults support renovascular HTN?
unexplained atrophic kidney
387
Renal Artery Stenosis
x
388
cause
x
389
what is the cause?
RAAS
390
dx
x
391
marked increase in serum Cr after initiation of ACE i is highly suggestive of what?
Renal Artery Stenosis 2/2 renal transplant
392
risk
x
393
what is a big risk factor for causing Renal Artery Stenosis?
kidney transplant (improper surgical anastomosis)
394
Secondary Causes of Hypertension (HTN)
x
395
Conditions
Clinical clues/features
396
Renal parenchymal disease, Clinical clues/features?
```
Elevated serum creatinine
Abnormal urinalysis (proteinuria, red blood cell casts)
```
397
Renovascular disease, Clinical clues/features?
Severe hypertension (≥180 mm Hg systolic and/or 120 mm Hg diastolic) after age 55
Possible recurrent flash pulmonary edema or resistant heart failure
Unexplained rise in serum creatinine Abdominal bruit
398
Primary aldosteronism, Clinical clues/features?
Easily provoked hypokalemia
Slight hypernatremia
Hypertension with adrenal incidentaloma
399
Pheochromocytoma, Clinical clues/features?
Paroxysmal elevated blood pressure with tachycardia
Pounding headaches, palpitations, diaphoresis
Hypertension with an adrenal incidentaloma
400
Cushing syndrome, Clinical clues/features?
Central obesity,
facial plethora
Proximal muscle weakness,
abdominal striae
Ecchymosis,
amenorrhea/erectile dysfunction
Hypertension with adrenal incidentaloma
401
Hypothyroidism, Clinical clues/features?
Fatigue,
dry skin,
cold intolerance
Constipation,
weight gain,
bradycardia
402
Primary hyperparathyroidism, Clinical clues/features?
Hypercalcemia (polyuria, polydipsia)
Kidney stones
Neuropsychiatric presentations (confusion, depression, psychosis)
403
Coarctation of the aorta, Clinical clues/features?
Differential hypertension with brachial-femoral pulse delay
404
Mixed Cryoglobulinemia Syndrome
x
405
triggers
x
406
what is the disease that triggers typically mixed cryoglobulinemia syndrome?
hep C virus infection
407
what are other triggers?
hep B, HIV, malignancy, rheumatological disease
408
syx
x
409
what is the usual triad?
palpable purpura, fatigue, and arthralgias
410
what are other symptoms?
peripheral neuropathy, systemic symptoms, glomerulonephritis with renal insufficiency
411
dx
x
412
how is the diagnosis made?
measuring serum cryoglobulin levels
413
what are other lab findings in mixed cryoglobulinemia syndrome?
elevated RF, hypocomplementemia
414
pathohpys
x
415
how does mixed cryoglobulinemia syndrome occur?
is a vasculitis due to the deposition of immune complexes (polyclonal IgG and IgM rheumatoid factor) within the vascular wall of small- and medium-size vessels
416
complications
x
417
what are other complications?
glomerulonephritis (RBC, RBC casts, proteinuria)
418
trx
x
419
what is the best intial trx to stabilize end organ damage?
immunosuppressive therapy (corticosteroid and rituximab)
420
what is the best long term trx if they have underlying hep C?
antiviral trx
421
Granulomatosis with Polyangitis (Wegners)
x
422
syx
x
423
what are the usual syx?
palpable purpura, fatigue, and arthralgias, respiratory tract syx (sinusisitis, rhinorrhea)
424
what are other symptoms?
peripheral neuropathy, systemic symptoms, glomerulonephritis with renal insufficiency
425
dx
x
426
what is the dx test of choice?
cANCA
427
how do you distinguish it from Mixed Cryoglobulinemia Syndrome?
normal or elevated complement levels and respiratory tract syx (sinusisitis, rhinorrhea)
428
Benign Prostatic Hyperplasia (BPH)
x
429
syx
x
430
what are syx of BPH?
lower urinary tract syx (hesistancy , weak stream)
431
risk
x
432
who is at risk of BPH?
>50 y.o. male,
433
who is at risk of acute urinary retention?
bladder/urethral infection, genitourinary trauma, and use of certain meds (eg baclofen, anticholinergics)
434
management
x
435
what is the most effective immediate management?
immediate bladder decompression-
first line: urethral catheter first
second line: suprapubic catheter
436
Dx
x
437
what would labs show?
elevated cr
438
PE
x
439
what does PE show?
abd tenderness, and suprapubic fullness
440
Posterior Urethral Valve (PUV)
x
441
epid
x
442
who does it occur in ?
exclusively in males
443
define
x
444
what is it?
most common cause of obstructive uropathy, at level of urethra (congenital urethral membrane)
445
dx
x
446
how are they generally diagnosed?
prenatally
447
what are the hallmark features?
thickening and distention of the bladder and dilation of the proximal urinary system , bilateral hydronephrosis, oligohydraminos
448
what is a highly specific feature?
antenatal U/S showing dilated bladder
449
what is the best way to confirm PUV?
VCUG (voiding cystourethrogram)
450
complications
x
451
if the obstruction is severe, oligohydraminos can occur leading to?
potter sequence (pulm hypoplasia, flattened facies)
452
trx
x
453
what is the best next step?
foley catheter to temporarily relieve the obstruction
454
what is definitive trx?
cystoscopy and ablation of valve
455
Anemia in ESRD
x
456
cause
x
457
what isthe cause of anemia in ESRD?
decreased EPO, iron deficiency
458
evaluation
x
459
what is the initial step in evaluation of anemia in ESRD?
check B12, folate, fecal occult blood, iron studies (ferritin, TIBC, serum iron, transferrin saturation), reticulocyte count
460
if iron deficiency is present, what do you do?
iron supplementation
461
if no improvement after iron supplementation, then what?
ESA (erythropoietin stimulating agent ) therapy
462
if there is an abnormality other than iron deficiency, then what do you do?
treat as indicated,
463
if no improvement after trying to treat abnormality appropriately, then what?
ESA (erythropoietin stimulating agent ) therapy
464
CKD/ESRD and iron deficiency anemia
x
465
complications
x
466
advanced chronic kidney disease or end-stage renal disease patients commonly develop what?
hypoproliferative, normocytic, normochromic anemia /iron deficiency anemia
467
cause
x
468
what is the cause of CKD/ESRD leading to hypoproliferative, normocytic, normochromic anemia ?
underproduction of erythropoietin by the failing kidneys.
469
management
x
470
why should ESRD patients get their iron stores checked?
Vigorous hematopoiesis after administration of erythropoiesis-stimulating agents (ESAs) can lead to rapid depletion of iron stores; therefore, all patients who require ESAs (eg, many CKD patients with hemoglobin <10 g/dL) should have iron levels checked prior to initiation of EPO and at scheduled intervals while on therapy
471
Contrast Induced Nephropathy
x
472
risk factors
x
473
what are risk factors of contrast induced nephropathy?
>75y.o, , CKD (diabetic nephropathy), reduced renal perfusion (eg hypotension), high contrast load
474
prevention
x
475
how do you prevent contrast induced nephropathy?
- periprocedural saline hydration (before and after procedure)
- use lowest volume of contrast agent possible
- hold NSAID drugs
476
cause
x
477
what causes contrast induced nephropathy?
contrast induced renal vasoconstriction
478
Primary Nocturnal Enuresis
x
479
define
x
480
what is it?
urinary incontinence in >=5y.o. w/o dysuria and daytime incontinence
481
management
x
482
what is first step when managing primary nocturnal enuresis?
screening UA (exclude infection, Diabetes Mellitus-glucosuria, or Diabetes Insipidus-low specific gravity on first morning void)
483
what are intial treatment options for treating primary nocturnal enuresis?
bhv modifications (eg limiting evening fluid intake, avoid sugary/caffeinated beverages, void before bedtime, institute reward system-gold star chart)
motivational therapy
484
what is first line therapy?
enuresis alarms (best long term outcome-low relapse rates)
485
what is second line therapy?
desmopressin therapy
486
what can be used in refractory cases?
TCA's (imipramine)
