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NURP 533 > Week 3 Renal Disorders > Flashcards

Week 3 Renal Disorders Flashcards

1
Q

Which of the following commonly-used medications can cause drug-induced nephrotoxicity? (Select all that apply)

A Naprosyn

B Macrolides

C Lithium

D Omeprazole

E Beta blockers

F Select serotonin reuptake inhibitors (SSRIs)

G Angiotensin-converting enzyme inhibitors (ACEIs)

H Furosemide

A

A Naprosyn

C Lithium

D Omeprazole

G Angiotensin-converting enzyme inhibitors (ACEIs)

H Furosemide

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2
Q

Which of the following is NOT a function of the kidneys?

A Control of the production of red blood cells

B Removal of waste products from the body

C Regulation of sodium and potassium in the body

D Production and regulation of calcium levels in the body

A

D Production and regulation of calcium levels in the body

The kidneys
remove waste products from the body
remove drugs from the body
balance the body’s fluids
release hormones that regulate blood pressure
produce an active form of vitamin D that promotes strong, healthy bones
control the production of red blood cells
Parathyroid hormone causes calcium reabsorption in the kidney, but the kidney does not produce calcium.

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3
Q

Describe the physiology of the nephron by placing the following in the correct order:

A

Blood flow from afferent arteriole

glomerular filtration

tubular reabsorption

tubular secretion

reabsorption of water

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4
Q

Parts of a UA

A 
color 
clarity/turbidity 
pH
specific gravity 
glucose 
ketones 
nitrites 
leukocyte esterase 
bilirubin 
urobilrubin 
blood 
protein 
RBCs
WBCs
squamous epithelial cells 
casts 
crystals 
bacteria 
yeast
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5
Q

normal UA color

A

yellow (light/pale to dark/deep amber)

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6
Q

normal UA clarity/turbidity

A

clear or cloudy

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7
Q

normal UA pH

A

4.5- 8

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8
Q

normal UA specific gravity

A

1.005- 1.025

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9
Q

normal UA glucose

A

= 130 mg/dL

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10
Q

normal UA ketones

A

none

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11
Q

normal UA nitrites

A

negative

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12
Q

normal UA leukocyte esterase

A

negative

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13
Q

normal UA bilirubin

A

negative

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14
Q

normal UA urobilirubin

A

small amount (0.5- 1 mg/dL)

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15
Q

normal UA blood

A

= 3 RBCs

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16
Q

normal UA protein

A

= 150 mg/d

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17
Q

normal UA RBCs

A

= 2 RBCs/hpf

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18
Q

normal UA WBCs

A

= 2 - 5 WBCs/hpf

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19
Q

normal UA squamous epithelial cells

A

= 15- 20 squamous epithelial cells/hpf

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20
Q

normal UA casts

A

0- 5 hyaline casts/lpf

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21
Q

normal UA crystals

A

occasionally

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22
Q

normal UA bacteria

A

none

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23
Q

normal UA yeast

A

none

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24
Q

Urine specimen interpretation analyzed

A

in 3 parts:
gross visual examination
chemical exam/urine dipstick
microscopic exam/urine sediment

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25
Q

can distinguish type of kidney stone

A

urinary pH

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26
Q

measures how the kidney concentrates urine

A

specific gravity

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27
Q

results when blood glucose is > 180

A

glucose

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28
Q

results from fat metabolism

A

ketones

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29
Q

caused by bacteria in the urine capable of converting nitrates

A

nitrite

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30
Q

enzyme of WBCs which indicates pyuria

A

leukocyte esterase

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31
Q

related to certain liver diseases

A

bilirubin

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32
Q

if significant or persistent, may suggest kidney dx

A

protein

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33
Q

suggests presence of greater than three RBCs per hpf or myoglobinuria

A

blood

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34
Q

An adolescent has 2+ proteinuria in a random dipstick urinalysis. A subsequent first-morning voided specimen is negative for protein and urine creatinine ratio is less than 0.2. What will the primary care nurse practitioner do to manage this condition?

A Repeat the first morning urine dipstick test in one year

B Order a 24-hour timed urine collection for creatinine and protein excretion

C Reassure the parents that this is a benign condition with no follow-up needed

D Refer the child to a pediatric nephrologist for further evaluation

A

A Repeat the first morning urine dipstick test in one year

Orthostatic proteinuria is the most common cause of proteinuria in children and is more common in adolescent males. It is a benign condition but does require follow up urine testing at one year.

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35
Q

A 40-year-old female patient reports hematuria and a urine dipstick and culture indicate a urinary tract infection. After treatment for the urinary tract infection (UTI), what testing is indicated for this patient?

A 24-hour urine collection to evaluate for glomerulonephritis

B Bladder scan

C Repeat urinalysis

D Voiding cystourethrogram

A

C Repeat urinalysis

After treatment has been completed, repeated urinalysis is necessary to ensure that the hematuria has resolved. Failure to follow hematuria to resolution may result in failure to diagnose a serious condition.

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36
Q

A patient presents to the clinic for red-brown colored urine for the past eight hours. The nurse practitioner orders a urinalysis and and notes there is 2+ heme but negative for red blood cells. What does the nurse practitioner suspect?

A Hemoglobinuria or myoglobinuria

B Acute kidney injury

C A glomerular etiology

D Urethritis

A

A Hemoglobinuria or myoglobinuria

If a urinalysis is positive for heme but negative for red blood cells, the nurse practitioner should suspect myoglobinuria or hemoglobinuria.

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37
Q

A healthy 14-year-old female has a dipstick urinalysis that is positive for 5-6 RBCs per hpf but otherwise normal. What is the first question the primary care nurse practitioner will ask this patient?

A “Are you sexually active?”

B “Are you taking any medications?”
C “Have you had a recent fever?”

D “When was your last menstrual period (LMP)?”

A

D “When was your last menstrual period (LMP)?”

Menstrual history should be part of the initial assessment of microscopic hematuria in females of reproductive age since a positive UA for blood can be due to bleeding from the reproductive tract.

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38
Q

An older male patient reports gross hematuria but denies flank pain and fever. What will the nurse practitioner do to manage this patient?

A Monitor his blood pressure closely

B Obtain a catheterized urine sample

C Perform a 24-hour urine collection

D Refer for cystoscopy and imaging

A

D Refer for cystoscopy and imaging

Gross hematuria in older men denotes a significant risk of malignant disease, so cystoscopy and imaging are indicated. Proteinuria is concerning for hypertension. The patient does not have flank pain or fever, so the likelihood of infection is lower. Catheterizaton and a 24-hour urine collection is not indicated.

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39
Q

A child is diagnosed with nephrotic syndrome, and the nurse practitioner provides primary care in consultation with a pediatric nephrologist. The child was treated with steroids and responded well to this treatment. What will the nurse practitioner tell the child’s parents about this disease?

A “Future episodes are likely to have worse outcomes.”

B “Steroids will be used when relapses occur.”

C “This represents a cure from this disease.”

D “Your child will need to take steroids indefinitely.”

A

B “Steroids will be used when relapses occur.”

Nephrotic syndrome is a chronic disease characterized by periods of remission and relapse. It is important for the patient and parent to monitor for proteinuria to identify relapse. Steroids are usually taken for 2.5-3 mo. The prognosis is good with steroid responders, relapses decrease as the child gets older.

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40
Q

A child who has nephrotic syndrome is on a steroids and a salt-restricted diet for a relapse of symptoms. A dipstick urinalysis shows 1+ protein, down from 3+ at the beginning of the episode. In consultation with the child’s nephrologist, what is the correct course of treatment considering this finding?

A Begin a taper of the steroid medication while continuing salt restrictions

B Continue with steroids and salt restrictions until the urine is negative for protein

C Discontinue the steroids and salt restrictions now that improvement has occurred

D Consider starting non-corticosteroid medication such as cyclophosphamide

A

B Continue with steroids and salt restrictions until the urine is negative for protein

Relapses are treated with a short course of steroids and the patient is weaned as soon as proteinuria resolves. During active disease, sodium restrictions may be placed by the nephrologist. Non-corticosteroid medication is started by a nephrologist if the child is steroid dependent, steroid resistant or has frequent relapses.

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41
Q

Which of the following are consistent with a diagnosis of nephrotic syndrome?

A Gross hematuria, microalbuminuria, and decreased GFR

B Proteinuria, peripheral edema, and low serum albumin

C Pyuria, elevated blood pressure, and flank pain

D Hyaline casts, microscopic hematuria, and elevated creatinine

A

B Proteinuria, peripheral edema, and low serum albumin

Nephrotic range proteinuria, edema, and low serum albumin are all present with nephrotic syndrome. Hyperlipidemia is also a common finding. Microscopic hematuria can occur, but gross hematuria is not characteristic of NS.

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42
Q

Which of the following symptoms commonly occurs with acute glomerulonephritis?

A Fever

B Heavy proteinuria

C Hematuria

D Polyuria

A

C Hematuria

Acute GN is characterized by HTN, edema, hematuria, azotemia, and slight proteinuria.

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43
Q

A child diagnosed with Group A beta-hemolytic streptococci (GABHS) two weeks prior is in the clinic with periorbital edema, dyspnea, and elevated blood pressure. A urinalysis reveals tea-colored urine with hematuria and mild proteinuria. What will the primary care nurse practitioner do to manage this condition?

A Prescribe a 10- to 14-day course of high-dose amoxicillin

B Prescribe high-dose steroids in consultation with a nephrologist

C Reassure the parents that this condition will resolve spontaneously

D Refer the child to a pediatric nephrologist for hospitalization

A

D Refer the child to a pediatric nephrologist for hospitalization

Consultation with a nephrologist is recommended for all cases of nephritis and glomerulonephritis. During the peak of the illness of PSGN, in the first few days when the patient has HTN and oliguria, hospitalization may be required with fluid and sodium restriction and diuretic, antihypertensive, and antibiotic therapy if cultures are positive.

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44
Q

An adult patient diagnosed with acute renal colic is experiencing flank pain and nausea without vomiting. A urinalysis reveals hematuria but is otherwise normal. A radiographic exam shows several radiopaque stones in the ureter which are 1 to 2 mm in diameter. What will the primary nurse practitioner do initially to manage this patient?

A Consult with a urology specialist

B Order pain medication and increased oral fluids

C Prescribe desmopressin and a corticosteroid medication

D Prescribe nifedipine and hospitalize for intravenous antibiotics

A

B Order pain medication and increased oral fluids

Stones that are less than 5 mm in diameter will usually pass spontaneously. The provider should counsel the patient to increase fluid intake and should prescribe adequate pain medication. A consultation is not necessary unless initial measures fail. Desmopressin and corticosteroids have not been shown to be effective. Nifedipine and IV fluids may be used as a secondary option.

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45
Q

Which factors increase the risk of renal stones? (Select all that apply)

A Excess antacid use

B Living in a cold climate

C Obesity

D History of gout

E Vitamin D excess

A

A Excess antacid use

C Obesity

D History of gout

Excess antacids, obesity, and a history of gout are linked to renal stone risk. Tropical climates are also linked to renal stone development. Vitamin D excess is not a risk factor.

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46
Q

The primary care nurse practitioner sees a new patient who reports having a diagnosis of chronic kidney disease for several years. The patient is taking one medication for hypertension which has been prescribed since the diagnosis was made. The nurse practitioner orders laboratory tests to evaluate the status of this patient. Which laboratory finding indicates a need to refer the patient to a nephrologist?

A Albumin/creatinine ratio (ACR) of 325 mg/g

B Blood pressure of 145/85 mm Hg

C Glomerular filtration rate (eGFR) of 45

D Urine red blood cell (RBC) count of 10/hpf

A

A Albumin/creatinine ratio (ACR) of 325 mg/g

An albumin/creatinine ratio greater than 300 mg/g warrants referral. A specialist is necessary for persistent hypertension refractory to treatment with four or more agents, a GFR of less than 30, and urine RBC greater than 20/hpf.

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47
Q

Which tests should be monitored regularly to monitor for complications of chronic renal disease (CRD)? (Select all that apply)

A Liver enzymes

B Parathyroid hormone levels

C Serum glucose

D Serum lipids

E Vitamin D levels

A

B Parathyroid hormone levels

D Serum lipids

E Vitamin D levels

CKD can cause hyperparathyroidism, hyperlipidemia, and alterations in vitamin D, calcium, and phosphorus metabolism, so these should be monitored. Liver function and serum glucose are not affected by CKD.

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48
Q

A patient diagnosed with diabetes has symptoms consistent with renal stones. Which type of stone is most likely in this patient?

A Citrate

B Cysteine

C Oxalate

D Uric acid

A

D Uric acid

Uric acid stones are more prevalent in diabetics. Citrate, cysteine, and oxalate are less common in all patients

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49
Q

Cardiovascular failure is a major cause of what type of renal failure?

a. Prerenal
b. Intrarenal
c. Postrenal
d. Perirenal

A

a. Prerenal

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50
Q

A 6 yo patient presents with abdominal distension, pain, right sided abdominal mass, fever, and hematuria. What is the top differential diagnosis?

a. A urinary tract infection
b. Appendicitis
c. Wilms’ tumor
d. An intestinal obstruction

A

c. Wilms’ tumor

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51
Q

The most common cause of nephrotic syndrome is

a. Systemic lupus erythematosus
b. Diabetes mellitus
c. Routine use of NSAIDs
d. Glomerulosclerosis

A

b. Diabetes mellitus

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52
Q

Which anti-hypertensive medications are contraindicated in clients with renal artery stenosis?

a. Calcium channel blockers
b. Beta blockers
c. ACE inhibitors
d. Cardiac glycosides

A

c. ACE inhibitors

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53
Q

Your patient has had proteinuria on two separate office visits. What is the best management plan?

a. Schedule CBC, complete metabolic panel, BUN, Cr, GFR, renal ultrasound
b. Order an intravenous pyelogram
c. Recommend the patient attend to the hospital
d. Collect a urine specimen upon first waking and then another 2 hours later

A

d. Collect a urine specimen upon first waking and then another 2 hours later

54
Q

A patient with glomerulonephritis will oftentimes have a history of

a. Beta hemolytic streptococcal infection
b. Frequent urinary tract infections
c. Kidney stones
d. Hypotension

A

a. Beta hemolytic streptococcal infection

55
Q

JG is an 8-year-old boy with no past medical history who presented to primary care clinic with facial edema for two days. He also complained of rhinorrhea, epistaxis, and a frontal headache. He was diagnosed with sinusitis and started on antibiotic therapy. The following day he developed abdominal swelling. He was again evaluated in the office where he was found to be hypertensive to 142/90 mm Hg. His exam was significant for mild periorbital edema, but he did not have pharyngitis, lymphadenopathy, swollen joints, or a rash. His urinalysis showed 2+ protein, numerous red blood cells (RBCs), and RBC casts.

What is the most likely diagnosis based on the given information?

A

most consistent with an acute postinfectious glomerulonephritis. The infection would not be the spurious diagnosis of sinusitis, but would have been a preceding streptococcal infection one to two months before presentation.

Pediatric GN can be classified as acute or chronic. This is a good example of a GN case with an acute presentation. The most common cause in children is poststreptococcal glomerulonephritis (PSGN). The differential diagnoses also include other types of postinfectious GN, as well as secondary causes of GN, such as Henoch-Schönlein purpura (HSP) and, very rarely, shunt nephritis or subacute bacterial endocarditis.

56
Q

S/S & exam findings of acute postinfectious glomerulonephritis

A

HTN, periorbital edema, proteinuria, hematuria, RBC casts

Oliguria, gross hematuria, strep rash or HSP, lethargy, anorexia, nausea, vomiting, abdominal pain, weight gain with abrupt onset

57
Q

labs for glomerulonephritis

A

UA
BMP
CBC
ESR
ASO titer - elevated indicative of recent GAS infection and consistent w/ dx poststreptococcal GN
complement - C3 should be decreased in ALL types of postinfectious GN

58
Q

Dx PSGN

A

based on clinical presentation of glomerulonephritis, hypocomplementemia, and hx or documentation of recent GAS infection

59
Q

C3 in PSGN

A

typically decreased in postinfectious GN

normal 83- 152

should return to normal in 6- 8 weeks

if persistently decreased, raise concern for other types of GN

60
Q

PSGN tx

A

consult with nephrologist

typically resovles spontaneously and does not require specific tx

acute phase: elevated BP and edema - antihypertensives (CCBs), salt/fluid restriction

ABX does NOT decrease incidence

61
Q

PSGN education

A

course of GN and importance of regular follow up care to monitor renal function

62
Q

Pt with PSGN returns in 8 weeks. His C3 is normal, his HTN and edema have resolved, but he continues to have trace proteinuria and microscopic hematuria. What further evaluation or tx necessary?

A

No further eval or tx likely indicated

Diuresis and resolution of edema often occurs within first 2 weeks, Cr usually returns to normal within first 4 weeks. Hypocomplementemia should resolve by 8 weeks. Proteinuria usually clears in following weeks to months. Microscopic hematuria, may take 6- 12 months to resolve. Persistence of hypocomplementemia after 8 weeks or proteinuria at 1 year should prompt nephrology evaluation.

63
Q

What is the most common cause of acute glomerulonephritis in children?

A.. post- strep glomerulonephritis

B. focal segmental glomeruclosclerosis

C. membranoproliferative glomerulonephritis

D. IgA nephropathy

A

A. post- strep glomerulonephritis

64
Q

Which of the following lab value patterns is most likely to be found 4 weeks after streptococcus pharyngiits in a child that has developed PSGN?

A. Elevated C3 level, elevated ASO titer

B. normal C3 level, normal ASO titer

C. low C3 level, elevated ASO titer

D. Elevated C3 level, decreased ASO titer

A

C. low C3 level, elevated ASO titer

65
Q

What is the most common type of chronic GN in adults?

A. post-step GN

B. lupus nephritis

C. membranoproliferative GN

D. IgA nephropathy

A

D. IgA nephropathy

IgA nephropathy is the most common cause of chronic glomerulonephritis in both adults and children. About 75% of adults & children present with hematuria after URI.

Post-strep GN is most common cause of acute GN in children.

Both lupus nephritis and membranoproliferative GN cause GN but are less common causes in both children and adults

66
Q

CKD complications

A 
HTN
pulmonary edema
HF
HLD
electrolyte abnroms 
anemia 
erythropoeiten deficiency
67
Q

CKD defined by KDIGO

A

kidney damage or GFR < 60 for 3 months or more, regardless of cause

68
Q

CKD stage 1

A

normal eGFR (>90)

with other evidence of kidney damage: persistent microalbuminuria, proteinuria, hematuria, structural abnorms, biopsy proven GN

69
Q

CKD stage 2

A

eGFR 60- 89

with other evidence of kidney damage: persistent microalbuminuria, proteinuria, hematuria, structural abnorms, biopsy proven GN

70
Q

CKD stage 3a

A

eGFR 45-59

71
Q

CKD stage 3b

A

eGFR 30- 44

72
Q

CKD stage 4

A

eGFR 15- 29

73
Q

CKD stage 5

A

eGFR < 15

74
Q

when do you refer a CKD pt to nephrology?

A

patients under 18 = immedaite referral to pedi nephrologist

For adults, per KDIGO:

  • AKI or abrupt sustained fall in GFR
  • GFR < 30 (CKD stge 4-5)
  • consistent finding of significant albuminuria
  • progression of CKD
  • urinary red cell casts, RBC > 20 per hpf sustained and not readily explained
  • CKD & HTN refractory to tx w/ 4 or more antihypertensive agents
  • persistent abnorms of serum K
  • recurrent or extensive nephrolithiasis
  • hereditary kidney dx
75
Q

Which of the following patients would be characterized as having stage 2 CKD?

A. GFR > 90 w/ urine albumin/cr ratio of 100 mg/g measured one time

B. GFR > 90 w/ urine albumin/Cr ratio of 100mg/g for past 6 months

C. GFR 70 w/ urine albumin/Cr ratio of 100mg/g for past 3 months

D. GFR 70 w/ urine albumin/Cr ratio of 100mg/g measured once

A

C. GFR 70 w/ urine albumin/Cr ratio of 100mg/g for past 3 months

ALL stages of CKD are based on evidence of renal dysfunction for more than 3 months

person w/ GFR > 90 and proteinuria measured one time may have transient or persistent proteinuria and should be evaluated for further causes.

stage 1 CKD is normal GFR > 90 w/ evidence of kidney damage > 3 months

Stage 2 CKD GFR 60- 89 w/ evidence of kidney damage > 3 months

Stage 3 CKD GFR 30- 59 > 3 months

Stage 4 CKD GFR 15- 29 > 3 months

Stage 5 CKD GFR < 15 > 3 months or kidney failure tx w/ dialysis or transplantation

76
Q

normal urinary albumin/creatinine ratio lab value

A

< 30 mg/g

77
Q

microalbuminuria lab value

A

urine albumin/cr ratio 30- 300 mg/g

78
Q

macroalbuminuira lab value

A

> 300mg/g

79
Q

A 40 y.o. M with HTN and T2DM has a normal creatinine, an eGFR > 90 and a urine albumin/cr between 100- 200 mg/g on repeat UA for past 6 months. Which of the following best describes his kidney function?

A. Normal renal function

B. acute renal failure

C. Stage 1 CKD

D. Stage 2 CKD

A

C. Stage 1 CKD

Normal GFR and persistent proteinuira over past 6 months, so he meets criteria for stage 1 CKD.

This is a chronic not an acute condition. He does NOT have normal renal function as evidenced by persistent proteinuria

80
Q

Which of the following recommendations is NOT part of the 2012 KDIGO guidelines for management of CKD?

A. Avoid giving the MRI contrast gadolinium when GFR is < 15 unless there is no alternative appropriate test

B. Stop metformin when GFR is < 60

C. Avoid giving phosphate-containing bowel prep medication when GFR is < 60

D. Adults w/ CKD should be considered for living donor preemptive transplantation when GFR is < 20 and there is evidence of progressive and irreversible CKD over preceding 6- 12 months

A

B. Stop metformin when GFR is < 60

According to KDIGO guidelines, metformin should be continue when GFR is > 45

Review metformin use in pts w/ GFR 30- 44

DC metformin when GFR < 30

Guidelines recommend all other answer choices

81
Q

hematuria lab values

A

3 or more erythrocytes per HPF

82
Q

UA with microscopy can show

A

presence of RBCs - # of RBCs

presence of casts or significant protein

83
Q

UA indicative of GN

A

presence of protein, RBC casts, & dysmorphic RBCs

84
Q

Ddx for isolated hematuria

A

extrarenal causes: urolithiasis, bladder stones, CA of ureter, bladder CA, prostate CA, infection, trauma

intrarenal causes: nephrolithaisis, neoplasm, infection, renal infarct (papillary necrosis), renal vein thrombosis, GN

85
Q

asymptomatic hematuria workup

A

in absence of gross hematuria: H&P, urine culture, renal imaging, CBC, BMP

presence of gross hematuria w/ HTN and/or proteinuria (GN suspected): further tests complement evaluation, antinuclear antibody (ANA), ASO titer, antineutrophl cytoplasmic antibodies (ANCAs), and anti-glomerular basement membrane

86
Q

Patient recalls episode of gross hematuria that resolved without associated symptoms and current microscopic hematuria on exam. What do you do?

A

Refer to urology with renal function testing, cystoscopy, & imaging

ACP recc urgent referral for all adults with gross hematuria, any hx of hematuria even if self-limiting warrants urgent urologic eval with renal function testing, cystoscopy, and imaging

87
Q

What is the definition of microscopic hematuria according to AUA?

A. postive urine dipstick

B. any presence of RBC in urine sample

C. 3 or more RBCs in non-contaminated UA w/o evidence of infection

D. 1 or more RBCs in non-contaminated UA w/o evidence of infection

A

C. 3 or more RBCs in non-contaminated UA w/o evidence of infection

According to the AUA, microscopic hematuria is defined as 3 or more red blood cells in a noncontaminated urinalysis without evidence of infection. While a positive urine
Three or more red blood cells in a noncontaminated urinalysis without evidence
of infection*
dipstick has a high sensitivity, there is a high rate of false positives and should be confirmed by microscopic analysis.

88
Q

A urinary sediment demonstrates 3 erythrocytes/high-power field (HPF) following an incidental finding of heme-positive urine dipstick in an otherwise asymptomatic patient. The patient is taking warfarin for atrial fibrillation. He reports to you a one-time episode of gross hematuria in the past 6 months. What is the most appropriate next step in evaluation?

A. Repeat urinalysis with microscopy in 6 months

B. Urine cytology

C. FDA-approved urine markers

D. Referral for urologic evaluation

A

D. Referral for urologic evaluation

According to the American College of Physicians’ (ACP) high-value care advice for hematuria as a marker of occult urinary tract tumor, all episodes of gross hematuria, even if self-limited, should warrant consideration of urgent urologic evaluation. Repeating a urinalysis in 6 months may result in a delay of diagnosis of potentially treatable urinary tract tumor. The ACP recommends against urine cytology or urine markers for bladder cancer detection due to their poor sensitivity.

89
Q

Which of the following findings is highly specific to glomerular disease?

A. Microscopic hematuria

B. Leukocyte esterase

C. Proteinuria

D. Red cell casts

A

D. Red cell casts

The presence of red cell casts is a specific marker of glomerular disease although it may be insensitive (the absence of red cell casts does not rule out glomerular disease). Microscopic hematuria, leukocyte esterase, and proteinuria may be present in glomerular disease but are also present in other conditions.

90
Q

A 9 month old female with no significant PMH presents to the office for a follow up weight check. The child has been noted to have growth failure. The mother reports that her child has a poor appetite, is drinking and urinating more and is irritable. The FNP notes that the child previously had consistent growth and is no longer following the curve for weight and height.
What are your differential diagnosis based on this information?

A 
RTA
hypothyroidism
failure to thrive
systemic acidosis
renal disease
type 1 DM
91
Q

transient proteinuria causes

A 
benign or self-limiting 
orthostatic proteinuria
dehydration
fever
exercise
emotional stress
CHF, seizures
92
Q

persistent proteinuria defined as

A

1+ protein on a standard dipstick two or more times during 3 month period

93
Q

persistent proteinuria causes

A

pathologic process:
drugs - lithium, cyclosporine, cisplatin, NSAIDs
PCKD
lupus, vasculitis, IgA nephropathy, sarcoidosis
TB, infection
hyperuricemia, hypercalcemia, amyloidosis
DM, HTN, sickle cell dx, radiation nephritis

94
Q

increased risk of proteinuria

A

AA, Native americans, hispanics, Pacific islanders
aging
obesity

95
Q

proteinuria in pregnancy

A

before 24 weeks gestation = GN

after 24 weeks gestation = preeclampsia

96
Q

proteinuria dx

A

detected on routine dipstick
any value of 1+ of greater > 2 occasions = further workup

24-h urine measurement for protein and Cr 
AND
microscopic exam urine - sediment, electrophoresis, renal function 
urine C&S
CBC & diff 
fasting BG & A1c 
kidney & liver function 
lipid profile
97
Q

glomerular kidney dx associated with

A

1g of proteinuria in 24 hrs

98
Q

functional protienuria

A

secondary to identifiable cause - exercise, fever, CHF

NO further workup needed

99
Q

persistent proteinuria that CANNOT be classified as functional workup

A

24-h protein/Cr ration = gold standard

100
Q

24-h albumin/Cr ratio >/= 3.5 day

A

nephrotic syndrome

accompanied by albuminuria, HLD, edema

101
Q

24-h albumin/Cr ratio < 3.5 g/day

A

normal renal function: determine if orthostatic or non orthostatic = check first AM void, if (-) no further workup needed

Non-orthostatic proteinuria W/O Bence Jones protein = refer nephrologist, may need renal biopsy

Presence on Bence Jones proteins = serum protein electrophoresis and refer to exclude multiple myeloma

102
Q

proteinuria management

A

depends on underlying cause
careful med rec, DC any meds implicated in proteinuria (ACE-I, ARBs)
aggressively manage DM, HLD, HTN
sodium and protein restricted diet

103
Q

proteinuria & hematuria

A

suggestive of glomerular or interstitial nephritis

104
Q

painful hematuria dx

A

urine C&S

if neg - non contrast spiral CT, r/o urolithiasis

105
Q

painless hematuria dx

A

urine for cytology x3, urine C&S
cystoscopy
US kidneys & bladder - mass
proteinuria or RBC casts - 24-h urine collection

106
Q

AKI defined as

A

increase in serum Cr of 0.3mg/dL over 48 hr

increase of serum Cr to 1.5 x baseline over 7 days

urine volume output < 0.5mL/kg/h for 6 hr

107
Q

ESRD S/S

A

early stage, few symptoms
hallmark: decreased GFR, increased serum Cr, albumin in urine

edema, HTN, decreased UO (anuria)

108
Q

ESRD most important diagnostics

A

serum Cr w/ eGFR and first AM or random urine sample to assess albuminuria

109
Q

ESRD dx

A 
CMP - cr & eGFR
urine albumin, urine ACR
Urine Cr
urine volume 
urine NA to differentiate ATN & prerenal dx 
liver enzymes 
serum lipids 
A1c or fasting BG 
serology for glomerulonephritis
110
Q

AKI management

A

remove source of nephrotoxins and manage fluid to avoid over/underhydration

tx electrolyte imbalances

111
Q

CKD management

A

CKD 4 = refer nephrologist

manage BP, reduce proteinuria w/ diet 
use ACE-I to slo progression of CKD
tx metabolic acidosis w/ supplemental bicarb and attaining glycemic control 
protein restriction 
smoking cessation
112
Q

CKD BP management

A

target BP 130/80

sodium restriction
weight loss

ACE-I & ARB - 30% increase in Cr = DC
-monitor K goal < 5 (thiazides can help)

AVOID NSAIDs

113
Q

CKD DM management

A

HbA1c < 7%

metformin:

  • GFR < 30 contraindicated
  • GFT < 45 risk vs benefit

diet: protein restriction, avoid K containing salts, low phos, meet daily Ca, replace Vit D if low

control lipids: Statin
-atorvastatin does not require renal dosing

114
Q

CKD monitor CBC frequency

A

CKD 3 monitor CBC annually

CKD 4-5 monitor 2x y

115
Q

RF urinary calculi

A 
hot, tropical climate
fam hx
obesity
low SES
low fluid intake 
high salt intake 
low Ca intake

insulin resistance, HTN, gout, metabolic syndrome, hyperparathyroidism, chronic metabolic acidosis, CAD

116
Q

most common urinary stone

A

calcium oxalate

117
Q

most common urinary stone DM

A

uric acid

118
Q

urinary calculi labs typically show

A

mostly normal
elevated Cr
microscopic hematuria
elevated WBC - concern non-draining UTI

119
Q

urinary calculi dx

A

UA & C&S = essential

CBC if fever
24-h urine - metabolic testing

CBC, CMP, uric acid, PTH, vit D

KUB, NCCT scan, renal US

120
Q

urinary calculi 1st line tx

A

conservative
oral hydration and pain management
meds that help passage
- CCB an a-blockers (nifedipine & tamsulosin)

121
Q

stones > 10 mm

A

surgical management

122
Q

nephrotic syndrome

A

nephrotic range proteinuria:

  • 3.5 g/day or more in adults
  • more than 40 mg/m/h in children
  • first AM urine protein/Cr ration 2-3 or more

edema
HLD
hypoalbuminemia

123
Q

S/S nephrotic syndrome

A 
edema
foamy urine
weight gain 
fatigue
anorexia
124
Q

nephrotic syndrome needed in dx

A

ALL of the following:

  • nephrotic range protein
  • peripheral edema
  • low serum albumin

HLD

125
Q

nephrotic syndrome management

A

start initial workup:

  • renal function
  • CBC
  • UA w/ microscopy
  • serum albumin
  • electrolytes
  • glucose
  • lipids

Refer nephrology

126
Q

IgA nephropathy

A 
asymptomatic microscopic hematuria 
as it progresses: gross hematuria 
- proteinuria & HTN
- increased GFR
- RBC casts on UA
127
Q

IgA nephropathy dx

A

renal biopsy - definitive

128
Q

IgA nephropathy management

A

REFER nephrology

PCP role:

  • monitor UA
  • manage BP - ACEI, ARB goal < 130/80
129
Q

glomerulonephritis S/S

A 
HA
HTN
facial/periorbital edema
lethargic 
low grade fever
weight gain

proteinuria (not large amounts)
hematuria (mostly gross)
oliguira
dysuria

130
Q

screening for CKD

A

annually if RF present:

  • spot urine for ACR
  • serum Cr and eGFR
  • UA

diabetics:

  • at time of dx T2
  • 5 yrs after dx T1
131
Q

myoglobinuria

A

presence of free myoglobin (which is normally only present in intact muscle cells) in the urine. This may occur during rhabdomyolysis

produces red- brown urine

NURP 533 (11 decks)

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