UTIs & Nephro

Question 1

3 cardinal symptoms of a UTI

Answer 1

Dysuria
Frequency (not POLYuria, more times not more amount)
Urgency

Question 2

Red flags leading you to believe it’s not just a UTI? (ddx)

Answer 2

Gross/painless hematuria (cancer)
Discharge (STI) - males w/ urethritis may have discharge
Colicky/radiating flank pain (kidney stones)

Question 3

5 bacteria commonly causing UTIs + bacterial classifications

Answer 3

E coli (80%; gram neg bacilli, enterobacteriaceae)
Staph saprophyticus (2nd most common in sexually active women; graph + cocci, coagulase negative)
Klebsiella pneumonia (GN baccili, enterobacteriaceae)
Proteus mirabilis (GN baccili, enterobacteriaceae)
Enterococci (GP cocci)

Question 4

Name 5 things that can cause bladder stasis, increasing risk of UTI

Answer 4

1) Benign prostatic hyperplasia
2) Vesicoureteral reflux
3) Urinary bladder diverticulum
4) Neurogenic bladder (flaccid or spastic)
5) Urinary tract calculi

Question 5

Delineate upper vs lower UTI

Answer 5

Upper = ureters or pyelonephritis
Lower = cystitis (most common), urethritis, prostatitis

Question 6

WHat makes a UTI “complicated”?

Answer 6

Pt is…

• male
• immunocompromised
• pregnant or postmenopausal female
• child
• predisposing factors (DM, medical devises, Hx, resistance)

Question 7

Nocosomial UTIs are commonly caused by ____ and must appear ___ after admission

Answer 7

Indwelling catheters

>48 hours post-admission

Question 8

Recurrent UTI is defined as..

Answer 8

3+ per year or 2+ in 6 months

Question 9

what additional symptoms are typical of an upper UTI?

Answer 9

Fever
Flank pain
Nausea/vomiting
Fatigue/malaise

Question 10

Best initial test for UTI = ?

What are you looking for?

Answer 10

Urinalysis:
Pyuria, leukocyte esterase
Bacteriuria, nitrites (E coli convert nitrates), urease
Leukocyte casts (upper UTI)
Hematuria, proteinuria

Question 11

Name 4 types of imaging for UTIs. Are they always indicated?

Answer 11

Generally not indicated unless persistent Sx on ABs, recurrences, suspected obstruction, severe illness

1) CT scan (first line)
2) U/S (esp young children); can determine PVRV
3) Voiding cystourethrogram (VCUG): radioactive dye into bladder via catheter –> serial x-rays during voiding (reflux, strictures)
4) IV pyelogram (dye into arm vein –> X-rays of urinary tract, highlights obstructions)

Question 12

Define interstitial cystitis. AKA? Diagnosis?

Answer 12

AKA painful bladder syndrome
chronic non-infectious cystitis of unknown etiology, more common in women
- diagnosis of exclusion but inflamm patches can be present

Question 13

When should you treat asymptomatic bacteriuria

Answer 13

Pregnanct women
Pt undergoing endourological procedures w/ possible mucosal trauma
Renal transplant recipients

Question 14

What is phenazopyridine (pyridium) and how is it used in UTIs?

Answer 14

Urinary analgesic, can be used for up to 3 days (warning: symptom-masking)

Question 15

Do you need a post-treatment culture for UTI?

Answer 15

No, not if Sx resolve

Question 16

Antibiotic treatment for uncomplicated lower UTI (1st/2nd line)

Answer 16

First line: Nitrofurantoin (5 days) OR TMP-SMX (3 days), fosfomycin (single dose)
2nd line: aminopenicillin + B-lactamase inhib, oral cephalosporines

Question 17

Antibiotic treatment for complicated lower UTI

Answer 17

In men must penetrate prostate tissue (e.g. fluoroquinolones or TMP-SMX, not fosfomycin/nitrofurantoin)

Fluoroquinolones PO or IV (ciprofloxacin, levofloxacin)
Beta-lactams: 2nd or 3rd gen cephalosporins (e.g. ceftriaxone); ampicillin/sulbactam

Question 18

TMP-SMX & nitrofurantoin are both what class of AB?

Answer 18

Anti-metabolites

Question 19

___ should be considered for recurrent UTIs in postmenopausal women

Answer 19

Topical estrogen

Question 20

If very recurrent UTIs can try…

Answer 20

chemoprophylaxis

Question 21

Should pregnant women be screened for UTI?

Answer 21

Yes, in the first trimester!

Always treat even if asymptomatic (pyelo risk)

Question 22

Most UTIs in children <1yr are…

Answer 22

Pyelonephritis!

Question 23

Infant w/ bacteriuria + fever with no explanation =

Voiding symptoms + no fever + bacteriuria =

Answer 23

Pyelonephritis

Cystitis (common in girls >2yo)

Question 24

Hydronephrosis =

Answer 24

dilation of ureter/kidney due to distal obstruction of urine outflow

Question 25

In a male patient w/ recurrent acute urinary Sx, consider...

Answer 25

possible chronic bacterial prostatitis, consider urology consult

Question 26

How does calcitriol affect Ca/Phosphate balance in bone, GI, kidney, blood

Answer 26

``` Active vitamin D Bone --> enhance mineralization if sufficient Ca, enhance resorption if low Ca GI --> more Ca & PO4 absorption Renal --> more Ca & PO4 resabsorption Blood: increase serum Ca & PO4 ```

Question 27

How does PTH affect Ca/Phosphate balance in bone, kidney, blood

Answer 27

Bone --> reabsorption Kidney --> Ca absorption, PO4 excretion Blood ---> increase Ca, decrease PO4

Question 28

3 forms of vit D from food version to active version + sites of activation

Answer 28

Cholecalciferol --> liver --> calcidiol --> kidney --> calcitriol

Question 29

At the early stages of CKD there is no hyperphosphatemia. Why?

Answer 29

Because PTH secretion increases renal excretion (but once you reach GFR stage 4-5, kidneys can't keep up with excretion)

Question 30

How does calcitonin affect Ca/Phosphate balance in bone, GI, kidney, blood

Answer 30

Bone --> reduced resorption GI --> reduced Ca absorption Renal --> reduced Ca & PO4 reabsorption (excretion) Blood --> reduced Ca & PO4

Question 31

Indications for renal replacement therapy

Answer 31

``` AEIOU + G Metabolic Acidosis <7.1 Electrolytes: refractory hyperkalemia/hypercalcemia Toxic ingestion/poisoning Fluid overload Uremia GFR <10 or <15 + diabetes ```

Question 32

GFR staging in CKD

Answer 32

``` G1 = 90+ G2 = 60-89 G3 = 30-59 G4 = 15-29 G5 <15 (kidney failure) ```

Question 33

Albuminuria categories CKD

Answer 33

A1 < 3 (ACR, mg/mmol) (normal) A2 = 3-29 (microalbuminuria) A3 = 30+ (macroalbuminuria)

Question 34

Why might CKD cause anemia?

Answer 34

EPO synthesized in kidneys

Question 35

Main electrolyte changes in CKD?

Answer 35

High K Low Ca High PO4

Question 36

Blood sugars in CKD?

Answer 36

Hypoglycemia can occur due to significantly decreased insulin clearance

Question 37

____ are the most common types of incontinence in female patients ___ in male patients

Answer 37

Stress/mixed in female | Urge in male

Question 38

5 neurological causes of incontinence

Answer 38

``` MS Spinal injury Normal-pressure hydrocephalus Dementia Delirium ```

Question 39

Complications of incontinence

Answer 39

Depression/psychosocial distress Dermatitis, skin infections, sores UTIs

Question 40

Antibiotics for UTI during pregnancy

Answer 40

Cephalexin (1st gen PO cephalosporin) Nitrofurantoin (avoid during T1/term) TMP/SMX (avoid during T1/term)