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• Acute renal failure (ARF):

o Aka acute kidney injury (AKI)
o =GRF abruptly ↓ (w/i 48hrs) →sudden retention of normally cleared endogenous and exogenous metabolites (urea, K, PO4, SO4, creatinine, drugs)
o High risk: DM2, HTN, geriatrics
o General presentation (variable): Azotemia (N&/V, malaise, altered sensorium), Arrythmias from hyperkalemia, Ecchymoses dt plt dysfxn, Pericardial effusion, cardiac tamponade, Sz dt electrolyte imbalance, Fasciculations and mm cramps, Perioral paresthesias dt hypocalcemia, Peripheral edema (↑wt), Skin pallor, Hyper/hypovolemia


• Pre-renal ARF, causes, ssx:

o MC (60% community-acquired): inadequate perfusion to KD dt inadequate circulation or volume
o ↓intravascular vol= Hemorrhage, dehydration, ↑diuresis, extravascular space sequestration, pancreatitis, burns, trauma, peritonitis
o Change in vascular resistance= Sepsis, anaphylaxis, drugs (ACE inhibitors, NSAIDs, epi, norepi, cyclosporine), RAS
o ↓CO= CHF, pulm emb, pericardial tamponade
o SSX: Dehydration, thirst, dizziness, mental status change, Poor skin turgor, collapsed neck veins, dry mucous membranes, orthostatic BP


• Pre-renal ARF work-up:

o Oliguria (↓400ml/d), emergency! If ↓100 mL (anuria), SG >1.018
o Normal urine osm (>500 mOsm/kg), Urine Na ↓10 mEq/L, FENa ↓1%
o BUN/creatinine >20:1 (azotemia)
o UA: No changes in urine sediment, no protein, cells or casts
o MRI or doppler US: Locate and assess vascular abnormality
o CXR: to evaluate CHF


• Renal (intrinsic) ARF, causes:

o Dt injury in renal tubules, interstitium, vasculature or glomeruli
o mc ATN (80%), ischemic or toxic
o ATIN (10-15%)
o Acute GN (eg PIGN, RPGN)
o Acute PN
o Vascular dzs: vasculitis, polyarteritis nodosa
o Nephrotic syndrome (mult causes)


• Renal ARF ssx, work-up:

o Ssx: vary w cause: Hx URI, diarrhea, use of Abx or IV drugs; Back pain, gross hematuria, fever (PN), Maculopapular rash (interstitial nephritis), Dehydration and shock
o UA: SG ↓1.012, Urine osm ↓350 mOsm/kg, Urine Na >40 mEq/L, FENa >1%
o Variables: Granular casts=ATN, GN, ATIN; WBC casts=PN; RBC casts=PIGN; Eosinophiluria=ATIN
o CBC: ssx anemia, infx
o CMP: ↑ BUN, Creatinine, ratio ↓10:1
o Cystatin C: ↑ when creatinine is still N (early in course)
o ↓serum complement, circulating immune complexes
o Renal bx shows characteristic changes


• Post-renal ARF, causes, ssx:

o urinary flow from both KDs obstructed → ↑nephron intraluminal back pressure, ↓GFR
o Causes: BPH, tumors of bladder, prostate, cervix or pelvic area, urolithiasis, renal V stenosis, neurogenic bladder; post-surgical or trauma; anticholinergic drugs
o SSX(depend on cause): Renal pain and tenderness, lo abd pain, post-surgery urine leak, edema, ileus w abd distention, enlarged prostate on DRE, distended bladder


• Post-renal ARF work-up, management:

o Lab: normal urine osm, ↑BUN and creatinine, crystals or hematuria
o US: mb hydronephrosis
o Cystoscopy: mb utereral obstruction
o CT or MRI: mb mass causing obstruction
o Manage: mb Refer for dialysis; Find and treat cause, assess pt vitality; Monitor Vitals, input/outputs, electrolytes, BUN/creatinine


• Chronic renal failure, ssx:

o Aka ESRD or “chronic kidney dz” CKD
o = ↓ KD clearance of certain solutes → retain fluids/toxins, progress over mos-yrs. Difficult to identify onset and predict course
o ARF may →irreversible CRF
o General SSX: HTN, edema, osteodystrophy, anemia of chronic dz, uremia


• Causes of CRF:

o Glomerulopathies: Primary: FSGS, IgA nephropathy, membranous nephropathy; Secondary: diabetic nephropathy, amyloidosis, heroin abuse, PIGN, SLE
o Tubulointerstitial nephritis: Drug hypersensitivity, heavy metals, analgesic nephropathy, chronic PN
o Heredity: PKD, Alport syndrome
o Obstructive nephropathy: Prostate dz, nephrolithiasis, retroperitoneal tumor, congenital
o Vascular: Hypertensive nephropathy, RAS


• Ssx of uremia (CRF):

o General: Fatigue, weakness; Sallow-appearing
o Skin: Pruritis, easy bruising; Pallor, ecchymosis, edema
o ENT: Metallic taste, epistaxis; Urinous breath
o Eye: Pale conjunctiva
o Pulm: SOB; Crackles, pleural effusion
o CV: DOE, retrosternal pn on inspiration; HTN, cardiomegaly, friction rub
o GI: Anorexia, N/V, hiccup
o GU: Nocturia, impotence; Isosthenuria
o Neuromuscular: Restless legs, numbness, cramps in legs
o Neuro/MSE: Irritability, poor concentration, depression; Stupor, asterixis, myoclonus, peripheral neuropathy


• Labs for CRF:

o Microalbuminuria (N = ↓20 mg/L, abN >50), WBCs, waxy casts,
o Proteinuria: magnitude predicts rate of progression of ESRD
o Blood: total protein, electrolytes, BUN /creatinine, reticulocytes; Spot check Alb/creatinine (want ↓30)
o Hypercholesterolemia (>400 mg/dl); Anemia, met acidosis, ↓Ca, ↑K, ↑P
o ANA (SLE), Cystatin C (cysteine proteinase inhib) (filtered, not secreted)
o Estimate GFR with serum creatinine


• Imaging for CFR:

o US: BL small kidney, cortical thickness
o Xray: slow bone growth, osteomalacia, renal osteodystrophy
o Avoid contrast dyes


• Staging of CRF:

o 0: Risk factors for CRF (HTN, DM), GFR ≥90 w/o albuminuria; Every 6 mos: check BP, microalbumin, creatinine, HbAIC
o 1: KD damage w N GFR (≥ 90 w albuminuria); tx cormorbid dz
o 2: Ki damage w mild ↓GFR (60-89); Estimate progression
o 3: Mod ↓GFR (30-59); Tx complications
o 4: severe ↓ GFR (15-29); prep for replacement
o 4: KD failure, GFR ↓15, replacement, dialysis


• Renovascular dos:

o Benign hypertensive arteriolar nephrosclerosis
o Renal artery stenosis/occlusion
o Renal vein thrombosis


• Benign hypertensive arteriolar nephrosclerosis

o Chronic HTN damages microvasculature, glomeruli, tubules, interstitial tissues → nephrosclerosis. Over years may → ESRD (common!)
o Risk factors: aging, poorly controlled HTN, DM, African-Americans


• Renal artery stenosis/occlusion

o stenosis of one or both renal a (atherosclerosis): → refractory HTN, abd bruit
o occlusion (thromboembolism): → flank pain, abd pain, fever, N/V, hematuria. Mb ARF; Seen on CT angiography


• Renal vein thrombosis:

o → occlusion of one or both renal veins. Causes include hypercoagulability, nephrotic syndrome, amyloidosis, estrogen therapy, pregnancy, SLE
o SSX: RF, st N/V, flank pain, gross hematuria, ↓urine output; Seen on MR venography and Doppler US


• Renal masses:

o Polycystic kidney disease (PKD or ADPKD)
o Renal cell carcinoma (Adenocarcinoma) (RCC)
o Wilms' Tumor (nephroblastoma)


• Polycystic kidney disease (PKD or ADPKD), ssx:

o AD, BL KD cysts that ↑ in size, disrupt normal KD fxn. may become infected and bleed
o typically manifests >40; mb hepatic, splenic, pancreatic, CNS arachnoid cysts
o ssx: asx early; as cysts ↑: Pain over both kidneys, “drag” from heaviness; Pain w infx, obstruction, hemorrhage (ruptured cyst); infx: fever, chills, tender kidney(s)
o Gross hematuria; HTN (look for retinopathy); nocturia
o Renal insufficiency: HA, N/V, ↓wt
o Palpable, nodular kidneys


• Work-up for PKD:

o Lab: mild proteinuria, hematuria varies, pyuria; ↑EPO → ↑Hb and HCT; Anemia from blood loss; Progressive uremia from renal insufficiency (↑BUN and creatinine)
o KUB: ↑renal shadows up to 5x
o CT: 95% accurate for dx, can detect cysts from 0.5cm
o US: can detect cysts from 1-1.5cm (Most cost effective, usu start here)
o MRI can differentiate RCC from cysts


• PKD px:

o > 50% become uremic w/in 10 yrs sx onset
o Course is variable, many reach ESRF > 20 yr
o Dialysis or transplant then required


• Renal cell carcinoma (Adenocarcinoma) (RCC), incidence, risks factors:

o Arise from glandular tissue: 85% of all primary malignant renal tumors, increasing incidence. ~1:10,000 cases/yr
o M (3:1) in 50’s-70’s. ↑ black and Hispanic M
o Risks: Cigarettes, chronic analgesic use, ADPKD, obesity, toxin exposure (Cd, Pb, asbestos, PAHs), coffee, animal fat diet, dialysis, hysterectomy, contrast IVU


• RCC ssx:

o “great masquerader” (mb few sxs)
o Classic triad: gross hematuria, flank pain, palp abd mass
o Fever, ↓wt, HTN
o M: possible L varicocele dt blockage L testicular v
o mets: dyspnea, cough (lung), seizure (brain), bone pain


• RCC work-up:

o Gross or microscopic hematuria in 60%
o ↑ESR; normochromic/normocytic anemia; ↓serum iron, ↓TIBC
o Abn LFT from toxin build-up (↑ALP,↓albumin)
o Possible: ↑alpha-fetoprotein (>500 ng/ml), B-hCG
o renal bx and fine needle aspiration
o US: defines simple cysts, tumor thrombus (do first)
o CT: method of choice to stage, extent of brain mets
o CXR useful for mets; radionucleotide for bone mets; MRI for vascular extension
o PET: monitor response to systemic tx


• Wilms' Tumor:

o aka nephroblastoma
o =Mixed malignant tumor of KD, kids > adults, 3.5 yrs.
o Abn proliferation of metanephric blastema cells, genetic predisposition
o SSX: abd mass, abd pain, HTN
o Lab: hematuria, anemia
o US or CT


• Interstitial Cystitis/ Painful Bladder Syndrome (IC/PBS), hx:

o Fibrosis of bladder wall → ↓bladder capacity. Chronic inflam w mucosal disruptions, cellular infiltrates, sub-urothelial hemorrhages
o Micro: Hunner’s ulcers or glomerulations (petechial hemorrhages)
o ~500,000 people in US, 90% in whites and F
o Dx of exclusion
o Hx: Use “Pelvic Pain/Urgency/Frequency Patient Survey”
o “Flare up” of sxs linked to common foods (do diet diary!)
o Triggers mb: Coffee, carbonated drinks, cranberry, tomatoes, alcohol, vinegar, chocolate, strawberries, tea


• IC/PBS ssx, PE:

o SSX: freq/urgency (mb ever 10 mins!); bladder pain, worse full bladder, better voiding
o Very poor QoL
o Mb non-specific pelvic pain, dyspareunia
o Often exacerbations and remission of symptoms
o PE: mb normal, suprapubic tenderness; Variable tenderness of abd wall, buttocks, pelvic floor, urethra. F: mb no gyn exam dt tenderness. M: mb scrotal and penile tenderness


• IC/PBS work-up:

o Lab: UA: no signs infx, mb hematuria; Normal renal fxn tests unless obstruction or reflux
o Cytology: if at high risk for bladder CA
o Potassium sensitivity test (PST): infiltration causes pain
o Cystoscopy: bladder wall inflam, edema, small mucosal disruptions, cellular infiltrates, glomerulations, punctate hemorrhages


• IC/PBS dx criteria, ddx:

o Patient must have: Either Glomerulations OR Hunner’s ulcers on cystoscopic exam
o AND Either pain assoc w bladder OR urinary urgency
o No other diagnosable condition
o Ddx: TB of bladder, Schistosomiasis, cystitis, vag wall prolapse, urethritis, spastic neurogenic bladder, anxiety do, prostatitis, endometriosis, uterine fibroids, CA (bladder, cx, prostate, colon)


• Neurogenic Bladder:

o Overactive (spastic) bladder: Lesions above S2-4 → loss of inhibition of parasymp effects (MS, stroke), Detrusor hyperreflexia, loss of bladder capacity; frequent urination, triggered by detrusor spasm
o Underactive (flaccid) bladder: Lesions at or below S2-4 → loss of sense of fullness, ↑capacity (nerve injury), Detrusor areflexia; urine retention w overflow incontinence