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Nephrology
nephro
559
Medical
Graduate
04/13/2012

Additional Medical Flashcards

 


 

Cards

Term

 

Benign Prostatic Hyperplasia

Definition
  • Obstructive or irritative voiding symptoms.

  • May have enlarged prostate on rectal examination.

  • Absence of urinary tract infection, neurologic disorder, stricture disease, prostatic or bladder malignancy.

Term

Benign Prostatic Hyperplasia 

Definition
  • Most common benign tumor in men

  • Incidence is age related

    • Poorly understood risk factors

Term

Obstructive void symptoms

Definition
  • Hesitancy

  • Decreased force

  • Decreased caliber of stream

  • Sensation of incomplete bladder emptying

  • Double voiding (going twice in 2 hours)

  • Straining to urinate

  • Postvoid dribbling

Term
Irrritative void symptoms
Definition
  • Urgency

  • Frequency

  • Nocturia

Term
urinary tract infection, neurogenic bladder, or urethral stricture
Definition

With BPH...a detailed history focusing on the urinary tract should be obtained to exclude other possible causes of symptoms such as prostate cancer or disorders unrelated to the prostate such as?

Term
    • Physical exam (note size of prostate)

    • DRE

    • Focused neurological exam

Definition
All patients with BPH should get?
Term

smooth, firm, elastic enlargement of the prostate.  

Definition
BPH usually results in _______ of the prostate. 
Term
cancer...and further evaluation is needed
Definition
  • On exam, BPH noted with induration must alert the clinician to the possibility of 

Term
  • UA

    Creatinine

  • PSA is optional

    Upper track CT or ultrasound

Definition
Labs and imaging in BPH:
Term
  • Watchful waiting- Risk of progression is uncertain and is not inevitable. Some men undergo spontaneous improvement or resolutions
  • Medical Therapy
  • Conventional Surgical Therapy
  • Minimally Evasive Therapy
Definition
Clinical practice guidelines for BPH
Term

1. -Blockers

  • (The human prostate and bladder base contains 1-adrenoceptors, and the prostate will show a contractile response to such agonists.)

      • Phenoxybenzamine (1 & 2 blockers)

      • Prazosin

      • Terazosin

      • Doxazosin

      • Alfuzosin

      • Tamsulosin (1a blocker) 

2.   5-Reductase Inhibitors

(Blocks the conversion of testosterone to dihydrotestosterone. This drug impacts upon the epithelial component of the prostate, resulting in reduction in size of the gland and improvement in symptoms. 

  • Finasteride

3. Combination Therapy 

  • Finasteride + Terazosin 

 4. Phytotherapy (Use of plants/plant extracts for medicine)

Definition
Medical Therapy For BPH
Term
    1. Transurethral resection of the prostate (TURP)

    2. Transurethral incision of the prostate (TUIP)

    3. Open simple prostatectomy

Definition
Conventional Surgical Therapy for BPH
Term

 

    1. Laser therapy

    2. Transurethral needle ablation of the prostate (TUNA)

    3. Transurethral electrovaporization of the prostate

    4. Hyperthermia

Definition
Minimally Evasive Therapy for BPH
Term

Cryptorchidism

Definition

Inability of testicle to descend into scrotum

Term

Cryptorchidism 

Definition

 

  • 3-8% full term infants

  • 0.8% at 1 year of life

  • Higher incidence of torsion and hernia

  • Also associated with infertility and neoplasia

 

Term
  • Cosmetic

  • Undescended testes increases risk of cancer therefore can be more easily palpated in the scrotum

  • Fertility is improved

Definition

Rationale for Treatment for Cryptorchidism

 

Term
  • Surgery prior to the age of 2 or during that year

  • Surgery – Orchiopexy placement of the testes in scrotum

 

Definition

Tx for Cryptorchidism 

Term

Erectile Dysfunction 

Definition
  • can have organic and psychogenic etiologies.

  •  may be an early sign of cardiovascular disease and requires evaluation.

  • Incidence increases with age

Term

Erectile Dysfunction 

Definition
  • Occasional inability to obtain a full erection

  • Inability to maintain an erection throughout intercourse

  • Complete inability to achieve an erection

  • Approximately 25% of all men older than age 65 years suffer from this disorder

  • Most cases have an organic rather than a psychogenic cause

Term
Patho Erectile Dysfunction
Definition
  • Vast majority is organic secondary to lack of arterial blood supply (atheroma) involving the common or internal iliac arteries or their more distal branches

  • Venous leakage: veno-occlusive mechanisms don’t work

Term
Erectile Dysfunction Physical Exam
Definition
  • Secondary sexual characteristics should be assessed

  • Neurologic and peripheral vascular examination should be performed

  • Motor and sensory examination

  • Palpation of peripheral pulses

  • Genitalia examined noting the presence of penile scarring or plaque formation (peyronie’s disease) and any abnormalities in size or consistency of the testicles

  • Prostate exam essential

Term
Loss of erection
Definition
________ may result from arterial, venous, neurogenic or psychogenic causes.
Term
organic
Definition
  • If normal erections in early morning or during sleep occur an____ cause is unlikely

Term
organic
Definition

The gradual loss of erections over time is more suggestive of an ___ cause

Term
Retrograde ejaculation (loss of emission)
Definition
    • _________ may occur as a result of mechanical disruption of the bladder neck especially after prostate resection or from sympathetic denervation from meds, diabetes, pelvic or retroperitoneal surgery

Term
psychological
Definition
  • If libido and erection are intact, lack of orgasm is usually of _______ origin

Term
Adrogen
Definition
    • ______ deficiency decreases prostate and seminal vesicle secretions

Term
Premature ejaculation
Definition
  • ___________ is usually an anxiety-related disorder and rarely has an organic cause

Term
serum follicle-stimulating hormone and luteinizing hormone
Definition
  • Patients with abnormalities of prolactin or testosterone require further evaluation with measurement of _______ & ________. Endocrinologic consultation is advised

Term

Treatment

  1. Hormonal Replacement

    • Testosterone replacement therapy (for hypogonadism)
  2. Vasoactive Therapy

    • Sexual stimulation with subsequent nitric oxide release from the parasympathetic nerves and endothelium initiates penile erection.
    • Nitric oxide enters smooth muscles cells, increases cyclic guanosine monophosphate (cGMP) production, which mediates calcium sequestration and cellular hyperpolarization.

 

Medications: PDE 5 Inhibitors

  • Sildenafil (Viagra)

  • Vardenafil (Levitra)

  • Tadalafil (Cialis)

 

  1. Vacuum Erection Devices

  2. Penile Prostheses

  3. Vascular Reconstuction

Definition
Treatment of Erectile Dysfunction
Term

Hydrocele 

Definition

Fluid accumulation in scrotum between tunica albuginea and tunica vaginalis of testes

Term

Hydrocele 

Definition
  • Congenital lack of obliteration of process vaginalis

    • Most infant hydroceles should resolve by 2 years of age

  • Infectious

  • Traumatic

Term
Hydrocele
Definition
  • Physical - located superior and anterior to the testis

  • Bilateral in 7-10%

  • Often associated with hernia (often right sided)

  • Becomes smaller and softer after lying down

  • Scrotal ultrasound

  • Transilluminates brightly

Term
Hydrocele
Definition
  • Adult onset secondary to orchitis or epididymitis, tuberculosis or some tropical infections

Term
Hydrocele
Definition
  • Testicular torsion can cause a _____20% of the time

  • Testicular tumors can cause 

  • Traumatic nature are common

Term
  • Observation

  • Hydrocelectomy may recur < 5%

Definition
Tx Hydrocele
Term
Variocele
Definition

Dilation of vein of pampiniform venous plexus and the internal spermatic vein

  • 15% of male population

  • Most common cause of male factor infertility resulting in reduced motility and stress pattern on semen analysis

Term
  • I. Palpable by valsalva maneuver

  • III. Bag of “worm” visible through scrotal sac

Definition
  • Variolcele has Grade I, II, III

  • Which grade is Palpable by valsalva maneuver?

  • Which grade is Bag of “worm” visible through scrotal sac

 

Term

transscrotal doppler 

Definition
Variocele diagnosed primarily by PE, but ___________may be used. 
Term
Variocele
Definition
Symptoms are infertility and pain
Term

 

Varicocelectomy

Definition
Treatment of variocele
Term
Incontinence
Definition
Involuntary loss of urine
Term
neurogenic, anatomic, iatrogenic
Definition
3 types of etiology responsible for icontinence
Term
neurogenic
Definition
What etiology of incontinence are: Spinal cord paralysis, Multiple sclerosis, Parkinson’s, Alzheimer's?
Term
    • anatomic

Definition
What etiology of incontinence are hypermobility of bladder of neck (Incidence 10% of women)? 
Term
Iatrogenic
Definition
What etiology of incontinence are Post surgical, Radiation therapy, Prostate surgery?
Term
Incontinence Diagnosis
Definition

Diagnosed by 

  • H & P

  • Focused neurological exam

  • Post void residual

  • UA

Term
  1. Kegel exercises

  2. Medical therapy

    • Detrol

    • Enablex

    • Ditropan

    • Sanctura

    • Vesicare

      • All may cause confusion in the elderly

  3. Surgical treatment

    • Midurethral slings

    • Periurethral bulking agents

    • Male sling

    • Artificial urinary sphincter

 



Definition
Treatment of incontinence
Term

Nephro/urolithiasis 

Definition
  • Most 90% are calcium oxalate

  • 10% are uric acid

Term

 

  • Iatrogenic

  • Hypercalcuria

  • Hyperuricuria

Definition
3 causes of nephro/urolithiasis
Term

Nephro/urolithiasis (BPH Lecture) 

Definition
  • Flank pain

  • Pain is colicky in nature

  • Sudden

  • Lasting 30 minutes, rarely lasting more than 6 hours

  • Not related to movement

Term

Nephro/urolithiasis  

Definition
Diagnose by CT scan and a UA
Term
Nephro/urolithiasis
Definition
  • Infection and obstruction may cause loss of kidney or life in 24-48 hours

Term
5 mm or less
Definition

Most stones _______ greater than 90% will pass spontaneously

Term
two
Definition

In Nephro/urolithiasis:

May have complete obstruction with no renal damage for up to____ weeks

Term
renal imaging study
Definition

In Nephro/urolithiasis:

  • If hydronephrosis was present _________ should be done following passage of the stone

Term

Nephro/urolithiasis Treatment

Definition

Surgical Treatment

  • ESWL (Extracororeal shock wave lithotripsy) uses sound waves to break 

  • Ureteroscopy (visualization;  grabbed by forceps or basket device)

  • Percutaneous Nephrolithotomy: 1 cm incision made in the back ; a tube is inserted into the kidney, through which removed

  • Either removed whole or after breaking up with laser or shock wave

 

Term
  • Increase fluid intake

  • Reduce salt intake

  • Reduce protein intake


Definition

Nephro/urolithiasis Prevention

Term
serum calcium and PTH and 24 hour urine for possible medical therapy
Definition
Recurrent stone formers should have medical evaluation including:
Term

Paraphimosis

Definition
  • Occurs when the foreskin of an uncircumcised male canot be pulled back over the head of the penis

  • Causes: direct trauma to the area


Term

Paraphimosis

Definition
  • Failure to return the foreskin to its normal location after urination of washing (common in hospitals and nursing homes)

  • Infection, which may be due to poor personal hygiene

Term

Paraphimosis

Definition
  • Inability to pull the retracted foreskin over the head of the penis

  • Painful swelling at the end of the penis

  • Pain in the penis

  • A physical examination confirms the diagnosis; the health care provier will usually find a “doughnut” around the shaft near the head of the penis

Term
  • Pressing on (compression of) the head of the penis while pushing the foreskin forward may reduce the swelling.

  • If it cannot be pushed back into place, prompt circumcision is needed


Definition

Tx of Paraphimosis

Term

Damage to the penis tip, gangrene, loss the the penis tip

Definition

Complications of Paraphimosis

Term

Phimosis

Definition
 defined as the inability of the prepuce (foreskin) to be retracted behind the glans penis in uncircumcised males.
Term
  • hysiologic phimosis occurs naturally in newborn males, usually resolves by age 3.

  • Pathologic phimosis defines an inability to retract the foreskin after it was previously retractible or after puberty, usually secondary to distal scarring of the foreskin.

Definition
Two types of Phimosis
Term

Phimosis S/S

Definition
  • S/S The foreskin may be red, swollen and tender

Term
  • If the cause is from an underlying condition, treat the condition.

  • Circumcision may be needed

 

Definition
Tx phimosis
Term
Testticular torsion 
Definition

 twisting of the spermatic cord, wich cuts off the blood supply to the testicle and surrounding structures within the scrotum.

Can result from trauma to the scrotum, especially is significant swelling occurs.

It can be cuased from strenuous exercise or may not have an obvious cause

Term
Testicular Torsion S/S
Definition
  • S/S sudden onset of severe pain in one testicle with or without a previous predisposing event

    • Swelling within one side of the scrotum

    • Nausea or vomiting

    • Light-headedness

    • Affected testicle will be higher than unaffected testicle

    • Testicle lump

    • Blood in semen

Term
PE Testicular Torsion
Definition
  • Physical exam will reveal tenderness and usually extreme swelling (it is more common on the right side)

Term
    • Doppler ultrasound of the testicle can show blood flow

Definition
Imaging for Testicular Torsion
Term
  • surgery as soon as possible, if preformed within 6 hours most testicles can be saved (if blood supply has been cut off for too long the testicle may atrophy days to weeks after the event.  
  • During surgery the other testicle will be anchored to prevent a further occurrenc

Definition

Tx testicular torsion

Term
Acute Cystitis
Definition
  • Infection of the bladder that is most commonly due to the coliform bacteria E. Coli and enterococi.

  • The route of infection is typically ascending from the urethra.

  • Rare in men and implies a pathological process such as infected stones, prostatitis, or chronic urinary retention requiring further investigation.

Term

coliform bacteria E. Coli and enterococi.  

Definition
Acute Cystitis most commonly due to pathogens:
Term
Acute Cystitis Essentials of Diagnosis
Definition

Essentials of Diagnosis: 

  • Irritative voiding symptoms
  • Pt usually afebrile

  • Positive urine culture; blood cultures may also be positive 

Term
Acute Cystitis
Definition
  • Irritative voiding (frequency, urgency, dysuria)

  • Suprapubic discomfort

  • Women may experience gross hematuria and s/s following sexual intercourse

  • Physical exam may exhibit suprapubic tenderness, but physical exam is often unremarkable

  • Systemic toxicity is absent.

Term
Acute Cystitis Labs
Definition
  • Urinalysis shows pyuria (pus in urine) and bacteruria and varying degrees of hematuria.

  • The degree of pyuria and bacteruria does not necessarily correlate with the severity of the symptoms.

  • Urine culture is positive for the offending organism, but colony counts exceeding (10)5/mL are not essential for the diagnosis

Term
Imaging of Acute Cystitis
Definition
  • Ultrasonography or cystoscopy (especially in males)

Term
  • Short term antimicrobial therapy

  • Fluoroquinolones and nitrofurnation are drugs of choice in uncomplicated cases

  • Trimethoprim-sulfamethoxazole can be ineffective b/c of the emergence of resistant organisms.  

Definition
Tx of Acute Cystits  
Term
Interstitial Cystits Essentials of Diagnosis
Definition
  • Pain with a full bladder or urinary urgency – relief when emptied

  • Submucosal petechiae or ulcers on cytoscopic exam

  • Diagnosis of exclusion

 

Term
Interstitial Cystits
Definition

Pt must have a negative urine culture and cytology and no other obvious cause such as radiation cystitis, chemical cystitis, vaginitis, uretheral diverticulum or genital herpes.

Unknown etiology 

Term
  • No cure

  • Most pts achieve symptomatic relief with hydrodistension

  • Amitriptyline

  • Nifedipine

  • Elmiron

  • Other treatment options: transcutaneous electic nerve stimulation

Definition
Treatment Interstitial Cystitis
Term

Epididymitis Essentials of Diagnosis

Definition
  • S/S

    Fever

  • Irritative voiding symptoms

  • Painful enlargement of epididymis

Term
Chlamydia trachomatis or Neisseria gonorrhoeae
Definition

In Epididymitis, most cases are infectious and are either _____ or _______ sexually transmitted from , or non-sexually transmitted forms, usually in older men with urinary tract infections and prostatitis.   

Term
Amiodrone
Definition

_____has been associated with self-limited epididymis, which is a dose dependent phenomenon. 

Term
Epidiymitis S/S
Definition
  • May follow acute physical strain, trauma, or sexual activity

  • Urethritis (pain at the tip of the penis and uretheral discharge)

  • Cystitis (irritative voiding s/s)

  • Pain develops in the scrotum and may radiate along the spermatic cord or the the flank.

  • Fever

  • Scrotal swelling

  • Early may be distinguished from the testis, however later it may appear as one swollen mass.

  • Prostate may be tender on rectal exam

  • Prehn sign- elevation of the scrotum above the pubic symphysis improves the pain. (not in every case) 

Term
Epididymitis  & Acute Bacterial Prostatitis Labs
Definition
  • CBC shows leukocytosis and a left shift

  • In a sexully transmitted variety urethral discharge may be gram stained

  • In non-sexually transmitted, urinalysis shows pyuria, bacteruria and varying degrees of hematuria.

  • Urine cultures will show offending pathogen

Term

Orchitis

Definition

swelling of one or both of the testicles

Term
Orchitis
Definition
  • Blood in the semen

  • Discharge from penis

  • Fever

  • Groin pain

  • Pain with intercourse or ejaculation

  • Pain with urination

  • Scrotal swelling

  • Tender, swollen groin on affected side

  • Heavy feeling in the testicle

  • Pain is made worse by bowel movement or straining

  • On physical exam; enlarged, tender testicle or prostate, tender and enlarged lymph nodes in the groin area on the affected side

Term
Orchitis
Definition
  • nfections from bacteria or viruses

  • Most common virus is mumps

  • Can occur with infections of the prostate of epididymis

  • STD’s such as gonorrhea or chlamydia

  • Long term use of a foley catheter

  • Congenital birth defects

  • Regular UTIs

  • Surgery of the urinary tract 

Term
  • Treat the underlying cause

  • Pain meds

  • Best rest with scrotum elevated and ice the scrotum

 

Definition
Tx Orchitis
Term
Acute Bacterial Prostatitis
Definition
  • Fever

  • Irritative voiding symptoms

  • Perineal or suprapubic pain; exqusite tenderness common on rectal exam

  • Positive urine culture

  • Usually caused by E coli and pseudomonas

  • The most likely routes of infection ascent up the urethra and reflux of infected urine into the prostatic ducts.

Term
Usually caused by E coli and pseudomonas
Definition

Acute Bacterial Prostatitis most common organisms? 

Term

Acute Bacterial Prostatitis

Definition
  • Perianal, sacral or supra pubic pain

  • Irritative voiding complaints

  • Urinary retention from prostate swelling

  • Warm and tender prostate 

Term
  • Possible hospitalization

  • Ampicillin and aminoglycoside depending on the pathogen

  • After the pt is afebrile for 24-48 hours the ABX are continued for 4-6 weeks

  • If urinary rentention, suprapubic tube is required

 

Definition

Tx of acute bacterial prostatits

 

Term

Chronic Bacterial Prostatitis 

Definition
  • Irritative voiding symptoms

  • Perianal or suprapubic discomfort, often dull and poorly localized

  • Positive expressed prostatic secretions and culture

  • May evolve from acute prostatitis or have no history of acute infection 

Term

Chronic Bacterial Prostatitis 

Definition
  • some pts are asymptomatic

  • low back pain

  • perianal pain

  • history of UTIs

Term

Chronic Bacterial Prostatitis 

Definition
  • urinalysis is usually normal

  • expressed prostatic secretions demonstrate increased leukocytes, especially macrophages – the count does not correlate with severity

Term
  • trimethoprim has the best cure rates

 

  • carbenicillin, erythromycin, cephalexin, and the quinolones

  • treat for 6-12 weeks

  • anti-inflammatory agents for symptomatic relief

 

Definition
Chronic Bacterial Prostatitis Treatment

Term

Nonbacterial Prostatitis

Definition
  • Irritative voiding symptoms

  • Perianal or suprapubic discomfort, similar to that of chronic condition

  • Positive expressed prostatic secretions, but culture is negative

  • Most common cause of symptoms

  • The cause is unknown, diagnosis is one of exclusion

    Same symptoms as chronic condition without history of UTI's

Term
Labs Nonbacterial prostatitis
Definition
Increased number of leukocytes are seen on prostatic secretions but all cultures are negative
Term
  • Because the etiology is unknown a trial of antibiotics against ureaplasma, mycoplasma and Chlamydia is tired. Erythromycin for 14 days and then continued for 3-6 weeks if there is a favorable response.

  • Symptomatic relief with NSAIDs 

Definition

 

    • Treatment Nonbacterial Prostatitis 

Term

PYELONEPHRITIS 

Definition

Essentials of diagnosis:

*FEVER ** FLANK PAIN ** IRRITATIVE VOIDING SX ** POSITIVE URINE CULTURE*

Term

PYELONEPHRITIS 

Definition
  • Infectious inflammatory disease involving the kidney parenchyma and renal pelvis

  • Gram negative bacteria most common (E. coli, proteus, klebsiella, enterobacter and pseudomonas); gram positive less common)

  • The infection usually ascends from the lower urinary tract (except for the gm positive staph aureus which is usually spread by the blood).

Term

PYELONEPHRITIS S/S

Definition
  • Fever, flank pain, shaking chills (rigors), and irritative voiding sx (urgency, frequency and dysuria)

  • Can have associated nausea, vomiting, diarrhea

  • Tachycardia

  • Costovertebral angle tenderness

Term

PYELONEPHRITIS LABS

Definition
  • CBC: leukocytosis and a left shift (high WBCs with high neutrophils)

  • UA shows pyuria, bacteriuria, and varying degrees of hematuria; white cell casts may be seen

  • Urine culture will show heavy growth of the bacteria responsible

  • Blood cultures may be positive

Term
Imaging PYELONEPHRITIS
Definition
  • renal US may show hydronephrosis from a stone or other source of obstruction 

Term
  • Admit to hospital if severe or there are complicating factors

  • Obtain urine and blood culture to identify organism

  • Start with IV ampicillin and an aminoglycoside prior to getting sensitivity results; continue IV ABX for 24 hours after fever resolves and then switch to oral for a complete 14 day course.

  • Outpatient treatment—quinolones or nitrofurantoin (macrobid)

  • Adjust ABX for sensitivities

  • Fever may last up to 72 hours; if longer, do CT or US to exclude other issues

  • Obtain repeat urine cultures after treatment is complete

Definition

Tx of PYELONEPHRITIS


Term

URETHRITIS 

Definition
Inflammation of the urethra caused by an infection. 
Term
N. gonorrhoeae or Chlamydia trachomatis
Definition
Urethritis is commonly caused by sexual transmission of __________ & ________.
Term
reactive arthritis with associated urethritis (Reiter syndrome). 
Definition

 

  • Noninfectious causes of urethritis include _____ .

Term

URETHRITIS 

Definition

pain at the tip of the penis and urethral discharge

 dysuria

Term
  • Good hx, including sexual hx
  • Do exam, looking for evidence of discharge

  • Take samples from urethra

  • Treat for gonnorhea and chlamydia if urethral Gram stain is positive for Gram negative intracellular diplococci

  • Give tmt for Chlamydia if the urethral smear shows 5 or > wbcs per high power field and if Gram stain does not suggest gonorrhea

  • Explain dx, tmt and methods of prevention

  • Tell pt to avoid sex until tmt and follow-up are completed

  • Advise treatment of partners

  • Retest for gonorrhea after all tmt completed

  • Symptomatic gonorrhea usually develops within a few days ofexposure

  • Chlamydial infections take slightly longer

  • Mild infections may cause urethral discomfort and dysuria without discharge and may be confused with cystitis.

 

Definition
Management of urethritis:
Term
Volume Depletion
Definition
  • Defined as reduced total body water

     

Term
Volume Depletion
Definition

 

  • Occurs when rate of salt water intake is less than the combined rates of renal and extrarenal losses
Term
    1. Renal Losses Include: 
    • Hormonal deficit:
      • Primary diabetes insipidus
      • Aldosterone insufficiency
    • Renal deficit

      • Renal tubular acidosis

      • Bartter’s syndrome

      • Secondary diabetes insipidus

      • Diuretic abuse

      • Osmotic diuresis

      • Chronic renal failure

      • Interstitial nephritis

    • Extrarenal losses

      • Hemorrhage

      • Sweating and burns

      • Vomiting

      • Diarrhea

      • Tube drainage

Definition

Volume Depletion Due to Increased Fluid Loss (2 types) 

Term
  • Decreased fluid intake

  • Increased fluid loss

Definition
2 reasons for Volume Depletion
Term
Clinical Manifestations for Volume Depletion
Definition
  • Signs and symptoms vary with degree 

  • Orthostatic hypotension and tachycardia are common

    • Orthostatic hypotension with have a 20-mmHg drop in systolic or 10 mmHg drop in diastolic pressure

  • PE: decreased skin turgor and dry mucosa membranes

  • Positive response to a fluid challenge

 

Term

 

  • Fluid replacement with normal saline

  • Most potent fluid replacement substance is blood

    • Used typically in cases of hemorrhage

Definition
Tx Fluid Depletion
Term
Volume Excess
Definition
  • Increase in total body water


 

 

Term
Volume Excess
Definition
Occurs when rate of salt and water intake exceeds renal and extrarenal losses
Term
 
    • Right-sided heart failure

    • Constrictive pericarditis

Definition
Systemic increase in venous pressure includes:
Term
  • Left-sided heart failure

  • Vena cava obstruction

Definition
    • Local increase in venous pressure includes:

Term
  • Nephrotic syndrome

  • Hypoabuminemia

Definition
    • Reduced oncotic pressure includes: 

Term
    • Systemic increase in venous pressure

    • Local increase in venous pressure

    • Reduced oncotic pressure

    • Cirrhosis

Definition
Reduced effective circulating volume includes:
Term

Primary Aldosteronism

Cushing's Syndrome

Syndrome of Inappropriate Antidiuretic hormone

Definition
Primary Hormone Excess for volume excess
Term

Renal failure

 

Definition
Primary Renal sodium retention for volume excess:
Term
Volume Excess S/S
Definition
  • Symptoms related to cause of volume excess

  • Cases due to reduced effective circulating volume will have edema

Term

Diuretics are the treatment of choice for volume excess:

  • Proximal diuretic (acetazolamide)

  • Loop diuretic

  • Early distal diuretic (thiazide)

  • Late distal diuretic (spironolactone)

Definition
Volume Excess Tx
Term

Proximal diuretic (acetazolamide)

 tx: volume excess

Definition
      • Primary effect: ↓ Na+/H+

      • SE: hypokalemic, hyperchloremic acidosis

Term

Loop Diuretic

 tx: volume excess

Definition
      • Primary effect: ↓Na+/K+:2 Cl- absorption

      • SE: hypokalemic alkalosis (furosemide)

      • SE: hearing deficit (bumetanide)

Term
    • Early distal diuretic (thiazide)

       tx: volume excess

Definition
      • Primary effect: ↓NaCl absorption

      • SE: hypokalemic alkalosis, hyperglycemia

Term
    • Late distal diuretic (spironolactone)

       tx: volume excess

Definition
      • Primary effect: ↓ Na+ absorption

      • SE: hyperkalemic acidosis

Term

Acute Renal Failure (Acute Kidney Injury)

Definition
  • Sudden increase in BUN or serum creatinine

  • Oliguria often associated

  • Symptoms and signs depend on cause

 

Term

Acute Renal Failure (Acute Kidney Injury)

Definition
  • Rapid deterioration of renal function

  • Abrupt decrease in Glomerular Filtration rate (GFR)

  • Can’t maintain fluid and electrolyte balance

  • Causes AZOTEMIA (elevated BUN and creatinine)

  • Possibly oliguria (< 400 mL output in 24 hrs)

  • Occurs in hours to days in people who had previously normal kidney function or In people with chronic renal disease (Acute on chronic)

Term
Acute Renal Failure
Definition
  • Defined as a sudden decrease in kidney function, resulting in an inability to maintain acid-base, fluid, and electrolyte balance, and to excrete nitrogenous wastes

  • Serum creatinine is a convenient marker

Term

 

    • Describes the progressive levels of acute kidney injury (risk, injury, and failure) based on the elevation in serum creatinine or decline in urinary output with two outcome measures (loss and ESRD)

    • Risk= 1.5-fold increase in serum creatinine

    • Injury= two- or threefold increase in serum creatinine

    • Failure= decline in urinary output to 0.5mL/kg/h over 6, 12, or 24 hours

  • In absence of kidney functioning, serum creatinine will increase by 1-1.5 mg/dL daily

 

Definition
RIFLE CRITERIA : Acute Renal Failure
Term
Acute Renal FAILURE
Definition
  • Uremic milieu can cause nonspecific symptoms

  • When present, often due to azotemia or its underlying cause

    • Azotemia can cause nausea, vomiting, malaise, and altered sensorium.

  • Hypertension is rare, but fluid homeostasis is often altered

  • Hypovolemia can cause prerenal dz, whereas hypervolemia result from intrinsic/postrenal dz

  • Pericardial effusions can occur with azotemia, and a pericardial friction rub

    • Effusions may result in cardiac tamponade

  • Arrhythmias occur especially with hyperkalemia

  • Lung examination may show rales in the presence of hypervolemia

  • Nonspecific diffuse abdominal pain and ileus as well as platelet dysfunction; thus, bleeding and clotting disorders are more common

  • Neurologic exam reveals encephalopathic changes with asterixis and confusion; seizures

Term
Hypovolemia can cause prerenal dz, whereas hypervolemia result from intrinsic/postrenal dz
Definition
Hypovolemia can cause ______ dz, whereas hypervolemia result from__________ dz
Term
Labs for acute renal failure
Definition
  • Elevated BUN and creatinine are present (Do not in themselves distinguish acute from chronic kidney disease)

  • Hyperkalemia from impaired renal potassium excretion

  • ECG can reveal peaked T waves, PR prolongation, and QRS widening

    • Long QT segment can occur with hypocalcemia

  • Anion gap metabolic acidosis (due to decreased organic acid clearance)

  • Hyperphosphatemia occurs when phosphorus cannot be secreted by damaged tubules either with or without increased cell catabolism

  • Hypocalcemia with metastatic calcium phosphate deposition may be observed when the product of calcium and phosphorus exceeds 70 mg2/dL2

  • Anemia can occur as a result of decreased erythropoietin production over weeks, and associated platelet dysfunction is typical

Term
hyperkalemia (possibly dt/ acute renal failure)
Definition

Arrhythmias occur especially with

Term
hypervolemia (possibly dt/ acute renal failure)
Definition

Lung examination may show rales in the presence of 

Term
hypocalcemia (possibly dt/ acute renal failure)
Definition

Long QT segment can occur with

Term
Acute renal failure
Definition
  • ECG can reveal peaked T waves, PR prolongation, and QRS widening

Term
hypocalcemia
Definition
Long QT segment can occur with 
Term

Hyperphosphatemia

Definition

occurs when phosphorus cannot be secreted by damaged tubules either with or without increased cell catabolism

Term

Hypocalcemia (d/t acute renal failure)

Definition

metastatic calcium phosphate deposition may be observed when the product of calcium and phosphorus exceeds 70 mg2/dL2

Term
anemia (d/t acute renal failure)
Definition

can occur as a result of decreased erythropoietin production over weeks, and associated platelet dysfunction is typical

Term
    • Hypovolemia

      Hypotension

      Pharmacologic

      Large Vessel (Renal artery or vein)

Definition
    • Prerenal causes of Kidney Disease

       

Term
renal ischemia, causing ATN.
Definition
Prolonged prerenal states can cause .....
Term

Ureteral

Bladder Outlet

Neurogenic Bladder

Foley Cath

Postobstructive

 

Definition
Post Renal causes of Renal Dz
Term
Volume and electrolyte depletion
Definition
Post Renal Kidney Dz can cause severe....
Term
  1. Glomeruli (capillary membrane)
    • Immune

      • IgA nephropathy (Berger’s disease)

      • Lupus

      • Wegener’s

      • Goodpastures

    • Infectious

      • Hepatitis B/C

      • Post-strep (Glomerulonephritis): Common in kids

      • HIV

      • Endocarditis

    • Toxic
      • Heroin
  1. Interstitium (interstitial nephritis)
  2. Tubules (Acute tubular necrosis/ ATN)

 

Definition
  • Intra-renal Kidney Dz due to 
Term
  • Interstitium (interstitial nephritis)

Definition
    • Inflammation in interstitial space caused by allergies to meds or infectious dz

    • Either asymptomatic, or may have fever, rash, joint pain

Term
S/S of ARF
Definition
    • Nonspecific, Due to accumulation of nitrogenous wastes or volume overload

    • N/V

    • Anorexia

    • Cardiopulmonary sxs

      • Chest pain (pericarditis): Due to fluid buildup

      • Dyspnea (pulmonary edema)

    • Fatigue

    • Confusion

    • Pruritis

  • Signs of volume overload

    • Elevated jugular venous pressure

    • Cardiac murmur

    • Cardiac gallop

  • Bladder obstruction

    • Abdominal mass

    • Suprapubic dullness (distended bladder)

  • Chronic renal failure

    • Pallor from anemia

    • Skin excoriations from pruritis

Term
Hypvolemia
Definition
    • Bleeding

    • Diarrhea

    • Diuretics

    • Third Spacing

    • Decreased effective circulating volume

    • CHF

    • Cirrhosis

      SIGNS OF??

Term
Hypotension
Definition
    • Sepsis

    • Cardiogenic shock

    • Anaphylaxis

    • Anesthesia and medication induced

    • Relative hypotension

      SIGNS OF??

Term

renal artery failure

afferent arteriolar narrowing

Definition
      • Don’t give NSAIDs to a patient with renal artery stenosis because it will cause ______ due to the renal afferent artery losing its ability to autoregulate

      • NSAIDs block prostaglandins, causing ___________

Term

NSAIDs

COX-2s

ACEI: ACEIs dilate efferent arterioles

Definition
Pharmacologic causes of renal failure
Term
  1. Acute oliguric renal failure
    • Foley catheter (r/o obstruction)

       

    • U/S :look for hydronephrosis
    • Use fluid challenge or diuretics to establish urine output

  • Review meds and remove nephrotoxins

  • Collect fresh urine sample

    • Check urine sediment

      • Cells or casts in a fresh, centrifuged urine

      • Indicates presence of intrinsic renal disease

      • Urine sediment in prerenal and postrenal injury does NOT usually have cells or casts

  • Get BUN and Creatinine

    • Ratio > 20:1: prerenal state (urea reabsorbed because of conservation)

  • FeNa

    • If FeNa is < 1, nephron working hard to retain salt and water: prerenal

    • If FeNa> 2, nephron cannot retain Na: intrinsic

    • Diuretics falsely increase FeNa

 

Definition

Diagnostic Steps

Acute Renal Failure

Term

 

 Chronic

Definition
  • Anemia (descreased erythropoeitin)

  • Low calcium

  • Small kidneys on ultrasound

    WHICH TYPE OF RENAL FAILURE?

Term
ACUTE
Definition

WHAT TYPE OF RENAL FAILURE?

  • Anemia less likely

  • Kidneys not small

Term
prerenal
Definition

If FeNa is < 1, nephron working hard to retain salt and water:

Term
intrinsic
Definition
    • If FeNa> 2, nephron cannot retain Na:

Term
FENA
Definition
diuretics falsely increase____
Term
intrinsic renal disease
Definition
      • Cells or casts in a fresh, centrifuged urine, Indicates presence of: 

Term
does NOT usually have cells or casts
Definition


      • Urine sediment in prerenal and postrenal injury usually 

Term
  • Hospitalize (for dx and management)

  • Volume depletion or volume overload?

    • Get daily weights

    • Ins and outs including free water losses (~ 10 mL/kg/d)

    • Examine pts

    • Decide on volume repletion or diuresis

  • Watch for infection (increase risk)

  • Nutrition priority (anorexia common)

  • Do a renal dose for all meds based on calculated creatinine clearance:

  • Lab tests to follow:

    • In oliguric ARF: expect daily increases in creatinine (Cr) of 0.5 to 1.0 mg/dL and BUN of 10-20 mg/dL

    • Get electrolytes at least daily (acidemia and hyperkalemia common)

    • CBC, uric acid, Ca++, Mg, Phosphate at admission and during illness

    • Check ABGs as needed to monitor pH and acidosis

  • Dialysis

    • When symptomatic renal failure present

    • Severe volume overload

Definition

Treatment/management acute renal failure


Term

0.5 to 1.0(Cr)

10-20 (BUN)

Definition

In oliguric ARF: expect daily increases in creatinine (Cr) of  _______mg/dL and BUN of ______ mg/dL

Term
Lab tests for acute renal failure
Definition
    • Check CBC, uric acid, Ca++, Mg, Phosphate at admission and during illness

    • Check ABGs as needed to monitor pH and acidosis

Term
    • When symptomatic renal failure present

    • Severe volume overload

    • Life-threatening acidosis

    • Severe electrolyte abnormalities (esp. hyperkalemia)

    • Pericarditis

    • Toxins that dialysis can remove

Definition
Dialysis in acute renal failure when??
Term

Prerenal Azotemia

Definition
Benign or hyaline casts
Term

Postrenal Azotemia

Definition

Normal or red cells, white cells, or crystals

Term

Acute Tubular Necrosis

Definition

Granular (muddy brown) casts, renal tubular casts

Term

Acute Glomerulonephritis

Definition

Red cells, dysmorphic red cells and red cell casts

Term

Acute Interstitial Nephritis

Definition

White cells, white cell casts, with or without eosinophils

Term

Acute Tubular Necrosis

Definition

Ischemia, nephrotoxins

Term

Acute Glomerulonephritis

Definition

Immune complex-mediated, pauci-immune, anti-GBM related

Term

Acute Interstitial Nephritis

Definition

Allergic rxn; drug rxn; infection, collagen vascular dz

Term
Chronic Kidney Disease
Definition
  • Progressive azotemia over months to years

  • Symptoms and sings of uremia when nearing end-stage disease

  • HTN in the majority

  • Isosthenuria and broad casts in urinary sediment are common

  • Bilateral small kidneys on ultrasound are diagnostic

Term
Chronic Kidney Failure
Definition
  • Most pts are unaware of this condition because they remain asymptomatic until the disease has progressed

  • Rarely reversible and leads to progressive decline in kidney function even if inciting event has been removed

  • Reduction in renal mass leads to hypertrophy of the remaining nephrons wih yperfiltration

  • GFR is transiently supranormal

  • Places a burden on the remaining nephrons and lead to progressive glomerular sclerosis and interstitial fibrosis, suggesting hyperfiltration may worsen kidney function

Term

Stage #1- Kidney damage with normal or GFR (90)

#2- Kidney damage with mildly ↓ GFR (60-89)

#3-Moderately ↓ GFR (30-59)

#4- Severely ↓GFR (15-29)

#5-Kidney failure (<15)

 

Definition
Stages of chronic kidney disease
Term
Stage 1 Kidney failure tx
Definition

Diagnosis and treatment. Treatment of comorbid conditions. Slowing of progression. Cardiovascular disease risk education.

Term
Stage 2 tx for kidney Dz
Definition

Diagnosis and treatment. Treatment of comorbid conditions. Slowing of progression. Cardiovascular disease risk education.

AND

estimating progresion

Term
Stage 3 Kidney Dz Tx
Definition

Diagnosis and treatment. Treatment of comorbid conditions. Slowing of progression. Cardiovascular disease risk education. Estimating Progression.

AND

Evaluating and treating complications

Term
Stage 4 Kidney Dz Management
Definition

Diagnosis and treatment. Treatment of comorbid conditions. Slowing of progression. Cardiovascular disease risk education. Estimating Progression.

Evaluating and treating complications

AND Preparation for Kidney replacement

Term
Kidney Failure
Definition

Diagnosis and treatment. Treatment of comorbid conditions. Slowing of progression. Cardiovascular disease risk education. Estimating Progression.

Evaluating and treating complications

Prep for kidney replacement and Replacement if uremia is present. 

Term

 

  • Glomerulopathies

    • Primary glomerular diseases

      • Focal and segmental glomerulosclerosis

      • Membranoproliferative glomerulonephritis

      • IgA nephropathy

      • Membrane nephropathy

    • Secondary glomerular diseases

      • Diabetic nephropathy

      • Amyloidosis

      • Postinfectious glomerulonephritis

      • HIV-associated nephropathy

      • Collagen-vascular diseases

      • Sickle cell nephropathy

      • HIV-associated membranoproliferative glomerulonephritis

  • Tubulointestinal nephritis

    • Drug hypersensitivity

    • Heavy metals

    • Analgesic nephropathy

    • Reflux/chronic pyelonephritis

    • Idiopathic

  • Hereditary diseases

    • Polycystic kidney disease

    • Medullary cystic disease

    • Alport syndrome

  • Obstructive nephropathies

    • Prostatic disease

    • Nephrolithiasis

    • Retroperitoneal fibrosis/tumor

    • Congenital

  • Vascular diseases

    • Hypertensive nephrosclerosis

    • Renal artery stenosis

Definition
Causes of chronic kidney dz
Term
Primary glomerular diseases
Definition

 

  • Focal and segmental glomerulosclerosis

  • Membranoproliferative glomerulonephritis

  • IgA nephropathy

  • Membrane nephropathy

    ALL ARE?

Term
Secondary glomerular diseases
Definition

 

  • Diabetic nephropathy

  • Amyloidosis

  • Postinfectious glomerulonephritis

  • HIV-associated nephropathy

  • Collagen-vascular diseases

  • Sickle cell nephropathy

  • HIV-associated membranoproliferative glomerulonephritis

    ALL ARE??

Term
Tubulointestinal nephritis
Definition

 

  • Drug hypersensitivity

  • Heavy metals

  • Analgesic nephropathy

  • Reflux/chronic pyelonephritis

  • Idiopathic

    ALL ARE??

Term
  • Hereditary diseases

Definition
    • Polycystic kidney disease

    • Medullary cystic disease

    • Alport syndrome

      ALL ARE??

Term
Obstructive nephropathies
Definition
 
    • Prostatic disease

    • Nephrolithiasis

    • Retroperitoneal fibrosis/tumor

    • Congenital

      ALL ARE??

Term
Vascular diseases
Definition


  • Hypertensive nephrosclerosis

  • Renal artery stenosis

    ALL ARE?

Term
Chronic Renal Dz
Definition

Symptoms and Signs

  • Often develop slowly and are nonspecific

  • Can remain asymptomatic until kidney disease is advanced (GFR<10-15 mL/min)

  • Fatigue, weakness, and malaise

  • GI complaints: anorexia, nausea, vomiting, a metallic taste in the mouth, and hiccups

  • Neurologic problems: irritability, difficulty in concentrating, insomnia, subtle memory defects, restless legs, and twitching

  • Pruritus

  • As progresses, decreased libido, menstrual irregularities, chest pain from pericarditis, and paresthesias

  • Sxs of drug toxicity (esp. those eliminated by the kidney) increase as renal clearance worsens

Term
Chronic Renal Dz
Definition
  • Physical exam:

    • Pt appears chronically ill

    • HTN common

    • Skin may be yellow, with signs of easy bruisability

      • Uremic frost, a cutaneous reflection of ESRD, is rarely seen

    • Uremic fetor is the characteristic fishy odor of the breath

    • Cardiopulmonary signs: rales, cardiomegaly, edema, and a pericardial friction rub

    • Mental status: decreased concentration to confusion, stupor, and coma

    • Myoclonus and asterixis are signs of uremic effects on the CNS

  • Term "uremia" is used for this clinical syndrome, but the exact cause remains unknown

  • BUN and serum creatinine are considered markers for unknown toxins

  • In any patient with kidney disease, it is important to identify and correct all possibly reversible causes

    • Urinary tract infections, obstruction, extracellular fluid volume depletion, nephrotoxins, hypertension, and CHF should be excluded. Any can worsen underlying chronic kidney disease

Term
Chronic Renal Dz
Definition
  • Diagnosis made by documenting elevations of the BUN and serum creatinine concentrations

  • Evidence of previously elevated BUN and creatinine, abnormal prior urinalyses, and stable but abnormal serum creatinine on successive days is most consistent with a chronic process

  • Anemia, metabolic acidosis, hyperphosphatemia, hypocalcemia, and hyperkalemia can occur with both acute and chronic kidney disease

  • Urinalysis shows isosthenuria if tubular concentrating and diluting ability are impaired

  • Urinary sediment can show broad waxy casts as a result of dilated, hypertrophic nephron

Term
Imaging chronic renal dz
Definition
  • Small echogenic kidneys bilaterally (< 10 cm) by ultrasonography

    • Although normal or even large kidneys can be seen with adult polycystic kidney disease, diabetic nephropathy, HIV-associated nephropathy, multiple myeloma, amyloidosis, and obstructive uropathy

  • Radiologic evidence of renal osteodystrophy is another helpful finding, since radiographic changes of secondary hyperparathyroidism do not appear unless parathyroid levels have been elevated for at least 1 year

  • Evidence of subperiosteal reabsorption along the radial sides of the digital bones of the hand confirms hyperparathyroidism

Term

GFR is < 10–20 mL/min

Definition

Potassium balance generally remains intact in chronic kidney disease until the

Term
  • Endogenous causes include any type of cellular destruction such as hemolysis and trauma, hyporeninemic hypoaldosteronism (type IV renal tubular acidosis, seen particularly in diabetes mellitus), and acidemic states 
  • Exogenous causes include diet (eg, citrus fruits and salt substitutes containing potassium) and drugs that decrease K+ secretion (amiloride, triamterene, spironolactone, NSAIDs, ACE inhibitors) or block cellular uptake (B-blockers).
Definition
    • Certain states pose an increased risk of hyperkalemia at higher GFRs

Term
>6.0–6.5 mEq/L
Definition
    • Cardiac monitoring is indicated for any ECG changes seen with hyperkalemia, or a serum potassium level 

Term
dietary potassium restriction (2 g/d) and sodium polystyrene sulfonate (Usual dose is 15–30 g once a day in juice or sorbitol).
Definition
    • Chronic hyperkalemia is best treated with 

Term

Hyperkalemia

Acid Base d/o

cardio complications

hematologic complications

neruro complications

d/o of mineral metabolism

endocrine d/o

Definition
Complications of chronic renal dz
Term
1 mEq/kg/d
Definition
  • Damaged kidneys are unable to excrete the ______ of acid generated by metabolism of dietary proteins
Term
renal mass
Definition
  • Resultant metabolic acidosis in chronic renal dz is primarily due to loss of _____.
Term
chronic renal dz
Definition
    • Limits production of ammonia (NH3) and limits buffering of H+ in the urine

Term
chronic renal dz
Definition
  • Although pts are in positive hydrogen ion balance, the arterial blood pH is maintained at 7.33–7.37 and serum bicarbonate concentration rarely falls below 15 mEq/L
Term
calcium carbonate and calcium phosphate stores in bone
Definition
  • Excess hydrogen ions are buffered by the large ______ and ______.
Term
21 mEq/L
Definition
  • In chronic renal dz Serum bicarbonate level should be maintained at greater than 
Term

 

  • sodium bicarbonate, calcium bicarbonate, and sodium citrate
  • Administration should begin with 20–30 mmol/d of oral alkali divided into two doses per day and titrated as needed

 

Definition
In chronic renal dz- Alkali supplements include:
Term
    • HTN

    • Pericarditis

    • CHF

Definition
cardio complications of chronic renal dz
Term
    • Anemia

    • Coagulopathy

Definition
hematologic complications of chronic renal dz
Term
    • Encephalopathy

    • Peripheral neuropathy

Definition
Neuro complications of chronic kidney dz
Term
mineral bone d/c of chronic kidney disease
Definition
    • Mineral bone disorders 

    • Osteomalacia

    • Adynamic bone disease

Term
    • Hyperglycemic or hypoglycemic depending on disturbance

    • Decrease libido and impotence

Definition
endocrine d/o of chronic renal dz
Term
  • Dietary (Protein restriction, salt and water restriction, K+ and phosphorus restriction, magnesium restriction) 
  • Dialysis
  • Kidney Transplant
Definition
Tx chronic renal dz
Term
10-20mL/min
Definition
    • Potassium restriction, Restriction is needed once the GFR has fallen below

Term
cachexia upon the initiation of dialysis
Definition
      • Protein restriction slows the progression to ESRD; however, this has not been consistently proved in clinical trials

      • The benefits of protein restriction in slowing the rate of decline of GFR must be weighed against the risk of ________

Term
Low serum albumin 
Definition
 what at the start of dialysis is one of the strongest predictors of mortality in this population?
Term

1 g/kg/d, 

0.6–0.8 g/kg/d

Definition
In chronic renal dz, n general, protein intake should not exceed _______and if protein restriction proves to be beneficial, the level of restriction may be decreased to _____.
Term
 3–4 g/d
Definition
      • In advanced dz, the kidney is unable to adapt to large changes in sodium intake

      • Intake >____ can lead to edema, hypertension, and congestive heart failure, 

Term
1 g/d 
Definition
In chronic renal dz, Intake of < ______sodium can lead to volume depletion and hypotension
Term

2 g/d

1-2L

Definition
  • For nondialysis pt approaching ESRD, ____ of sodium is an initial recommendation. And daily intake of _____of fluid maintains water balance. 
Term
Potassium Restriction < 50–60 mEq/d (2 g). 
Definition
      • Pts should receive detailed lists concerning potassium content of foods and should limit their intake to ______.Normal intake is about 100 mEq/d

Term

(< 4.6 mg/dL) 

3.5 - 5.5 

Definition
    • Phosphorus restriction

      • Lvl should be kept in the 'normal' range predialysis_____    and between ____mg/dL when on dialysis, with a dietary restriction of 800–1000 mg/d

Term

20–30 mL/min, 

Definition
      • Foods rich in phosphorus such as cola beverages, eggs, dairy products, nuts, and meat should be limited in chronic kidney failure.  Below a GFR of ___phosphorus binders are usually required. 

Term

medications

magnesium-containing laxatives

Definition
      • Magnesium is excreted primarily by the kidneys

      • Dangerous hypermagnesemia is rare unless pt ingests ______ high in magnesium or receives it parenterally

      • All _________ and antacids are relatively contraindicated 

Term

 GFR 10 mL/min

8 mg/dL creatinine

Definition
    • Dialysis should be started when a pt has a GFR of __or serum creatinine of _____.

Term

GFR 15

CR 6

Definition

Diabetic pt should start when the GFR reaches ___ mL/min or serum creatinine is ___.

Term

Dialysis 

AEIOU
acidosis

electrolyte-severe hyperkalemia

Ingestions (MEAL, methanol, ethlyne glcol, asa, lithium)

Overload-unresponding hypvolemia

Uremia 

Definition
    • These conditions present:

      • (1) uremic symptoms, such as pericarditis, encephalopathy, or coagulopathy

      • (2) fluid overload unresponsive to diuresis

      • (3) refractory hyperkalemia

      • (4) severe metabolic acidosis (pH < 7.20)

      • (5) neurologic symptoms, such as seizures or neuropathy

Term
      • hemiodialysis

Definition
      • Requires a constant flow of blood along one side of a semipermeable membrane with a cleansing solution (dialysate) along the other

      • Diffusion and convection allow the dialysate to remove unwanted substances from the blood while adding back needed components

      • Pts require  3x/week and sessions last 3–5 hours depending on patient size, type of dialyzer used, and other factors

Term
Peritoneal dialysis
Definition
      • Peritoneal membrane is the "dialyzer"

      • Fluids and solutes move across the capillary bed that lies between the visceral and parietal layers of the membrane into the dialysate

      • Dialysate enters the peritoneal cavity through a catheter

      • Most common kind is CAPD

        • Pts exchange the dialysate 4-6x/day

      • Continuous cyclic dialysis (CCPD) utilizes a cycler machine to automatically perform exchanges at night

        • Dialysate remains in the peritoneal cavity between exchanges

      • Permits greater patient autonomy; its continuous nature minimizes the symptomatic swings observed in hemodialysis patients; and poorly dialyzable compounds such as phosphates are better cleared, which permits less dietary restriction

      • Dialysate removes large amounts of albumin, and nutritional status must be closely watched

      • Most common complication of is peritonitis

      • Pt can experience nausea and vomiting, abdominal pain, diarrhea or constipation, and fever

Term

 

Glomerulonephritis (Currents p. 877)

Definition
    • Hematuria, dysmporohic red cells, red cell casts, and mild proteinuria

    • Dependent edema and hypertension

    • Acute renal insufficiency

Term

 

Glomerulonephritis 

Definition

mesangioproliferative, focal and diffuse proliferative and crescent lesions

Term
worse prognosis and more severe lesion
Definition
      • More glomeruli involved=

Term

Glomerulonephritis

Definition

Categorization by serologic analysis: Anti-GBM antibodies, antineutrophil cytoplasmic antibodies (ANCA), other immune disease markers (table 20-10)

Term

Anti-GBM-associated acute glomerulonephritis  (Good Pasture syndrome)

Definition
      • Either confined to the kidney or associated with pulmonary hemorrhage d/t autoantibodies against type IV collagen in the GBM rather than to immune complex deposition

Term

IgA nephropathy (Berger dz)

peri-onfectious or post-infectious glomerulonephritis

endocarditis

lupus nephritis

cryoglobulinemic glomerulonephritis (assoc w Hep C)

membranoproliferative glomerulonephritis

Definition

Immune complex deposition occurs when moderate antigen excess over antibody production occurs

Large antigen-antibody aggregates usually results in phagocytosis and clearance of the precipitates by mononuclear phagocytic system in the liver and spleen

CAUSES?

Term
Pauci-immune acute glomerulonephritis
Definition
Form of small-vessel vasculitis associated w anti-neutrophil cytoplasmic antibodies (ANCA)
Causes primary and secondary kidney disease that do not have direct immune complex deposition and antibody binding
Tissue injury d/t cell-mediated immune processes
Pt presents w upper airway, pulmonary, and skin manifestations
Term
Pauci-immune acute glomerulonephritis
Definition

Wegner granulomatosis example of

Term
Microscopic polyangiitis
Definition
________ is another pauci-immune vasculitis with peri-nuclear staining (P-ANCA)
Term
poor outcome unless treated early
Definition
    • ANCA-associated and anti-GBM-associated acute glomerulonephritis can progress to crescent glomerulonephritis and often have:

Term
acute glomerulonephritis
Definition

HTN crisis, thrombotic microangiopathies (hemolytic-uremic syndrome and thrombotic thrombocytopenic purpura

Vascular causes of?

Term

acute glomerulonephritis

Definition
    • HTN, edematous, abnormal urinary sediment

      • Edema is body parts w low tissue tension: periorbital and scrotal region

Term

acute glomerulonephritis

Definition
  • Serum creatinine: rises over days to months
  • UA (dipstick and microscopic): hematuria, moderate proteinuria (<3g/d), cellular sediment (RBC, RBC casts, WBCs)
  • RBC casts are specific for 
Term

Depends on nature and severity of disease

  • High-dose corticosteroids and cytotoxic agents (ie cyclophosphamide)

    -Plasma exchange in Goodpasture disease and pauci-immune glomerulonephritis; temporary measure until chemotherapy takes effect

Definition
Tx glomerulonephritis



Term

Acute Tubular Necrosis 

Definition

Acute kidney injury
Ischemic or toxic insult
Urine sediment w granular casts and renal tubular epithelial cells is pathognomonic but not essential

Term

Acute Tubular Necrosis 

Definition
    • Acute kidney injury d/t tubular damage; accounts for 85% of intrinsic acute kidney injury

      • 2 primary causes: ischemia & nephrotoxin exposure

Term

Acute Tubular Necrosis d/t ischemia

Definition

tubular damage d/t low perfusion state and often preceded by state of prerenal azotemia

  • Inadequate GFR, and renal blood flow inadequate to maintain parenchymal cellular formation

    • Occurs in setting of prolong hypoTN or hypoxemia d/t volume depletion, shock, sepsis

    • Also consider major surgical procedures: prolonger hypoperfusion exacerbated by vasodilating anesthetic agents

Term
Exogenous, endogenous 
Definition
      • _______ nephrotoxins more commonly cause damage than ______nephrotoxins

Term
exogenous nephrotoxins in acute tubular necrosis
Definition
 
Aminoglycosides:
Amphotericin B nephrotoxic after 2-3g dose
Vancomycin, IV acyclovir and several cephalosporins have been known to cause tubular necrosis
Radiographic contrast media
NSAIDS, ACEI
Cyclosporine:
Other: antineoplastics (cisplatin), organic solvents, heavy metals (mercury, cadmium, arsenic)
Term
Endogenous nephrotoxins resulting in acute tubular necrosis
Definition
    • Heme-containing products, uric acid, paraproteins 
    • Myoglobinuria: consequence of rhabdomyolysis leading to tubular necrosis 
    • Hemoglobin:
    • Hyperuricemia:
    • Bence Jones protein (In conjunction w multiple myeloma may cause direct tubular toxicity and tubular obstruction)
Term

Myoglobinuria: consequence of rhabdomyolysis

Definition
    • d/t necrotic muscle releasing large amts of myoglobin which filters across glomerulus and is reabsorbed by renal tubules causing direct damage
    • Pigmented casts and/or intrarenal vasoconstriction causing direct obstruction of distal tubules
    • d/t crush injury or muscle necrosis after prolonged unconsciousness, seizures, cocaine or EtOH abuse
    • dehydration and acidosis predispose for 
Term
 > 20-50K IU/L
Definition

habdomyolysis of clinical importance: serum CK

Term
myoglobinuric kidney injury
Definition
          • UA dipstick will read falsely (+) for hemoglobin when myoglobin is present in urine; urine appears dark brown but not RBCs are present

          • Muscle cell lysis leads to hyperkalemia,

          • hyperphosphatemia, hyperuricemia and possibily hypocalcemia (d/t phosphorus and calcium precipitation)

Term
 
  • Mainstay of txmt is volume replacement; Adjuct: mannitol for free radical clearance, diuresis, alkalinization of urine

    • Don’t treat hypocalcemia unless pt is symptomatic

Definition
myoglobinuric kidney injury tx
Term

hemoglobin as cause for acute tubular necrosis

Definition
    • Consider massive intravascular hemolysis in transfusion rxns and certain hemolytic anemias
Term

reversal of underlying disorder &hydration

Definition
tx for hemoglobin as cause for acute tubular necrosis
Term
Hyperuricemia:
Definition
Occurs in setting of rapid cell turnover and lysis
Term
Hyperuricemia:
Definition
    • Chemotherapy for germ cell neoplasms and leukemia and lymphoma are primary causes
Term
hyperuricemia
Definition
    • Acute kidney injury d/t intratubular deposition of uric acid crystals, serum uric acid > 600mg/24hr; urine uric acid: urine creatinine > 1.0 indicates risk of acute kidney injury
Term
Bence Jones protein
Definition
          • In conjunction w multiple myeloma may cause direct tubular toxicity and tubular obstruction

Term
Acute tubular necrosis
Definition
    • Hyperkalemia, hyperphosphatemia

    • BUN:creatinine <20:1 (tubular fxn not intact, table 22-4)

    • UA: evidence of acute tubular damage; brown urine,

      • Oliguria or nonoliguria: oliguria is worse prognosis

      • Urine Na elevated; FeNa is more indicative of tubular fxn

      • Sediment: pigments granular casts (aka “muddy brown casts”)

        • Renal tubular epithelial cells and epithelial cell casts may be present

Term
Same as acute kidney injury, Acute tubular necrosis
Definition
    • Nonspecific sx d/t azotemia or its underlying cause

    • Azotemia may cause N/V, malaise, altered sensorium, pericardial effusion (leading to cardiac tamponade), pericardial friction rub, arrhythmias (d/t hyperkalemia)

    • HTN, altered fluid homeostasis

    • Hypovolemia causing prerenal dz; hypervolumia results from intrinsic/postrenal dz

    • Rales (pulmonary) in presence of hypervolemia

    • Nonspecific diffuse abdominal pain and ileus as well as platelet dysfxn (bleeding and clotting disorders)

    • Neuro: encephalopathic changes w asterixis and confusion; seizures

Term
  • Aimed at hastening recovery and avoiding complications
  • Preventative measures to avoid volume overload and hyperkalemia
    •  (loop diuretics (furosemide IV & Chlorothiazide(preferably in heart failure)
    • NUTRITION
    • Avoid magnesium containing antacids and laxatives
Definition
Tx acute tubular necrosis
Term
LARGE DOSE DIURETICS
Definition
  • Therapy not proven effective in clinical trials, still used but discouraged in critically ill pt w AKI
Term
hearing loss & cerebellar dysfxn—use drip administration to avoid side effects
Definition
Large doses diuretics can cause 
Term
initial injury, maintenance and recovery phase
Definition
    • Clinical course divided in 3 phases: 

Term

Maintenance phases: 

Definition
      • oliguric (urinary output <500mL/d) or nonoliguric

      • Lasts 1-3wk but up to several months
Term
Recovery phase
Definition
      •  diuresis, rising GFR, BUN and serum creatinine begin to fall

Term
REFER
Definition
    • Unclear etiology or renal fxn continues to decline despite intervention

    • Fluid, electrolyte or acid-base abnormalities are recalcitrant to interventions

    • Nephron referral improves outcome

      so???

Term

Diabetic Nephropathy

Definition
    • Prior evidence of DM, typically over 10 years

    • Albuminuria (microscopic or macroscopic) precedes decline in GFR

    • Signs of on renal biopsy, if done

    • Other end-organ damage common, such as diabetic retinopathy, but not required

Term
DM
Definition
    • Most common cause of ESRD (end-stage renal disease) in USA (~4000cases/yr)

Term

diffuse glomerulosclerosis

nodular glomerulosclerosis (Kimmelstiel-Wilson nodules) 

Definition

Most common lesion in diabetic nephropathy

      • Pathognomic lesion? 

Term
diabetic neuropathy
Definition
      • Kidneys usually enlarged d/t cellular hypertrophy and proliferation

        • At onset of  there will be an increase in GFR, as dz progresses macroalbuminemia will develop and GFR returns to normal and then declines

Term
Diabetic neuropathy
Definition
    • Nephrotic syndrome develops in pts at risk for nephropathy

      • DM retinopathy often present in these patients

      • UA on all DM pts: microalbuminuria precedes decline in GFR(nephropathy development) by 10-15yrs, progresses during 3-7yr to overt proteinuria

        • 24hr urine not dipstick

        • Albumin >30 mg/d is abnormal or > 30g:1g ratio of albumin:creatinine

        • Early morning spot urine albumin or albumin-creatinine ratio is adequate

Term
    • Treat aggressively at onset of microalbuminuria (before progresses to proteinuria)

    • See treatment of nephrotic syndrome

      • Strict glycemic control

      • HTN treatment: ACE-Is & ARBs 

        • Both reduce intraglomerular pressure as well HTN, even in pts with markedly diminished renal fxn

Definition
Tx for Diabetic neuropathy
Term

Nephrotic Syndrome

Definition
    • Urine protein excretion > 3.5g/1.73 m2 per 24hrs

    • Hypoalbuminemia (albumin <3g/dl)

    • Peripheral edema

Term
Nephrotic Syndrome
Definition
    • 1/3 of pts have systemic renal disease such as DM, amyloidosis, or SLE

      • Remaining 2/3 have  d/t primary renal lesions

Term
nephrotic syndrome d/t primary lesions
Definition
4 most common: minimal change disease, focal glomerular sclerosis, membranous nephropathy and membranoproliferative glomerulonephritis
Term
 nephrotic syndrome
Definition
    • Peripheral edema is hallmark of

Term
nephrotic syndrome
Definition
      • Serum albumin <3g/dl

      • Edema d/t Na+ retention not arterial underfilling from low plasma oncotic pressure

      • Presents in dependent areas of the body: lower extremities

        • Can become generalized edema

      • Pts experience dyspnea (d/t pulmonary edema), pleural effusions, diaphragmatic compromise, abdominal fullness (w/ ascites)

      • More frequent infections d/t loss of immunoglobulins and complement moieties into urine

Term
nephrotic syndrome
Definition
      • Proteinuria d/t effacement of epithelial cell foot processes and alteration of (-) change in GBM

Term
nephrotic syndrome
Definition
      • Hyperlipidemia present may show oval fat bodies in urine

        • Represents lipid deposits in sloughed renal tubular epithelial cells

        • grape clusters” under light microscopy or “Maltese crosses” under polarized light

Term
Nephrotic syndrome
Definition
      • Serum albumin: decreased; <3g/dl

      • Total serum protein <6g/dl

      • Hyperlipidemia 50% of pts w/ early dz

        • Decreased clearance of VLDL leading to hypertriglyceridemia

      • Elevated ESR (d/t increased levels of fibrinogen)

Term

hepatic production of lipids

fall in oncotic pressure

Definition
More protein excreted the worse the hyperlipidemia gets worse d/t increased ________ (cholesterol and apolipoprotein A) because of ________________.
Term
renal biopsy
Definition
      • Performed in adults w new onset idiopathic nephrotic syndrome if primary renal dz that may require drug txmt (corticosteroids, cytotoxic agents) is suspected

Term
      • Significantly elevated creatinine levels may indicate irreversible kidney disease mitigating the usefulness of biopsy

      • No biopsy when amyloidosis or DM is cause of nephrotic syndrome

Definition
NO renal biopsy in nephrotic syndrome when
Term
  • Protein Loss

    • Daily total protein intake should replace the daily urinary protein losses to avoid negative nitrogen balance

    • Reduce proteinuria

      • ACE-I:
      • ARBs
    • Edema
      • Dietary salt restriction
      • Thiazides & Loops (can combine for max efficacy)
    • Hyperlipidemia
      • Aggressive therapeutic measures should be taken
      • Statin 
      • Gemfibrozil + lovastatin = higher risk of rhabdomyolysis in CKD pts
    • Hypercoaguable state
      • anticoag therapy for 3-6m in pt with evidence of thrombosis in any location
Definition
Tx nephrotic syndrome
Term
hypercoaguable
Definition

Serum albumin <2g/dl can make a pt

Term

hypercoagulable; all in coagulation cascade

(Pt prone to renal vein thrombosis and other venous thromboemboli particularly membranous glomerulopathy)

Definition
      • Urinary losses of antithrombin, protein C, protein S and increased platelet activation (THIS makes pt .............)

Term
 referred immediately
Definition
    • Any pt w nephrotic syndrome should be

Term
Renal cysts
Definition

are epithelium-lined cavities filled with fluid or semisolid material

      • Rarely symptomatic & little clinical significance     

Term
ESRD
Definition
    • Generalized cystic diseases are associated w cysts scattered throughout the cortex and medulla of both kidneys: May progress to 

Term
Simple or solitary cysts
Definition
    • Account for 65-70% of all renal masses

    • Found at the outer cortex, contain fluid consistent w/ ultrafiltrate of plasma

      • Found incidentally on U/S; asymptomatic but can become infected

    • Need to differentiate them from malignancy, abscess, or polycystic kidney disease

    • May develop during dialysis

Term
    •  

      • (1) echo free, (2) sharply demarcated mass w smooth walls (3) enhanced back wall (indicated good transmission through the cyst)

      • If benign, periodic reevaluation is standard of care

Definition
    • Renal cysts Must meet 3 sonographic criteria to be considered benign

Term

Complex

vs

Simple

Definition
    • _______ cysts may have thick walls, calcifications, solid components and mixed echogenicity

    • ________   cysts have smooth, thin walls that is sharply demarcated. 

Term
  • AKPKD

Definition
    • Essentials of Diagnosis

      • Multiple cysts in bilateral kidneys; total number depends on age

      • Large palpable kidneys on examination

      • Combination of HTN and abdominal mass is suggestive of disease

      • Family history is compelling but not necessary

      • Chromosomal abnormalities present in some patients

Term
AKPD
Definition
      • Most common hereditary disease in USA; 1:800 live births

        • Two genes: ADPKD1 on short arm of chromosome 16 (85-90%) and ADPKD2 (slower progression)on chromosome 4 (10-15%)

Term
AKPD
Definition
      • Abdominal or flank pain and microscopic or gross hematuria in most pts

      • Hx of UTI and nephrolithiasis

      • Fm Hx (+) in 75% of cases

      • >50% have HTN

      • Large kidneys, often palpable on examination

      • Check for hepatic, pancreatic and splenic cysts

      • No decrease in Hgb or Hct d/t production of erythropoietin by cysts

      • UA: hematuria and proteinuria

Term

U/S

  • 2+ cysts in pts<30yo

  • 2+ cysts in EACH kidney in pts 30-59yo

  • 4+ cysts in EACH kidney in pts 60

Definition

PKD1 pts: _____confirms diagnosis

Criteria????

Term

APKD

  • Bed rest and analgesics are recommend

  • Cyst decompression can help w chronic pain

Definition
      • Pain with AKPD tx:

        • Abdominal or flank pain caused by infxn, bleeding into cysts and nephrolithiasis

Term

r/o kidney stone or UTI

7d w bed rest and hydration

renal cell carcinoma

Definition
      • AKPD tx for complicating Hematuria

        • Gross hematuria d/t rupture of cyst into renal pelvis

          • r/o __________

          • hematuria resolves in ______

        • recurrent bleeding : need to r/o________; particularly in men >50yo

Term
        • Suspect infected cysts in pts w/ flank pain, fever, and leukocytosis

Definition
        • In AKPD, Suspect _______ in pts w/ flank pain, fever, and leukocytosis

Term
  • Use abx w/ cystic penetration: fluoroquinolones, bactrim, chloramphenicol

    • 2wk parenteral treatment followed by long term oral therapy

Definition
Tx AKPD for infected cysts
Term
      •  

        • Hydration: 2-3L/d is recommended

Definition
      • AKPD, Nephrolithiasis (usually calcium oxalate) treatment

Term
        • Cyst decompression can lower blood pressure temporarily

        • Treat HTN aggressively to prolong development of ESRD

          • Use diuretics cautiously—unknown effects on cysts

Definition
Tx of hypertension for AKPD
50% have HTN at time of presentation and it will develop during course of disease
Term
    • Cerebral aneurysms
      • 10-15% of patients have arterial aneurysms in circle of willis
      • Screening arteriography not recommended unless patient has family hx of aneurysms or is undergoing elective surgery w high risk of developing HTN
    • Other Complications
      • Mitral valve prolapse: 25% of pts

      • Aortic aneurysms, aortic valve abnormalities

      • Colonic diverticula

Definition
Other complications for AKPD
Term
      • Prognosis

        • Avoidance of caffeine may prevent cyst formation

        • Treatment of HTN and low protein diet may slow progression

Definition
Prognosis AKPD
Term

Renal Vein Thrombosis

Definition
    • Unilateral or bilateral thrombosis of major renal veins or their segments

      • Common but subtle disorder developing under myriad of conditions

      • Risk of thromboembolic complications and vascular occulusion

Term



Renal Vein Thrombosis 

Definition
    • Causes: nephrotic syndrome, renal cell carcinoma w renal vein invasion, pregnancy or estrogen therapy, volume depletion (especially in infants), extrinsic compression (lymph nodes, tumor, retroperitoneal fibrosis, aortic aneurysm), corticosteroids

    • Predisposing factors: coagulation/fibrinolysis abnormalities

      • Linked to losses of antithrombin III, protein C and protein S in urine seen in nephrotic syndrome

Term
Renal Vein Thrombosis
Definition
      • Dependent on extent and rapidity of development of renal venous occlusion

        • Acute renal vein occlusion: N/V, flank pain, leukocytosis, hematuria, compromised renal fxn, increased renal size

Term
Chronic renal vein thrombosis (adult nephrotic pt): 
Definition
more subtle findings including: dramatic increase in proteinuria or evidence of tubular dysfxn including glycosuria, aminoaciduria, phosphaturia and impaired urinary acidification
Term
Diagnosis of Renal Thrombosis
Definition
      • Evidence of parenchymal edema, stretching of calyces and notching of ureters on intravenous pyelography is much less reliable

Term
      • **selective renal venography is diagnostic*

        MRA for supportive studies*

Definition
Diagnose Renal thrombosis with 
Term
    • Anticoagulation with heparin for both acute and chronic renal vein thrombosis

      • Converted to oral warfarin after 7-10d (remember bridge therapy) and maintained long term (1yr, if reoccurrence then indefinite therapy)
    • In pediatric pts w volume depletion: restore fluids and electrolytes
    • Acute renal vein thrombosis associated w acute renal failure: fibrinolytic therapy
Definition
Tx Renal THrombosis
Term

Analgesic Nephropathy 

Definition

This is a chronic tubulointerstitial disease. It involves damage to one or both kidneys caused by exposure to analgesics. Most commonly seen in patients who ingest large quantities of analgesic combinations. The drugs of concern are phenacetin, paracetamol, aspirin, and NSAIDs, with acetaminophen a possible but less certain culprit. Ingestion of 1g/d for 3 years is the typical amount needed for kidney dysfunction. This disorder occurs most frequently in individuals who are using analgesics for chronic headaches, muscular pains, and arthritis. Most patients grossly underestimate their analgesic use.

Term

Analgesic Nephropathy 

Definition
  • Kidney size is small and contracted

  • Decreased urinary concentrating ability

  • Hyperchloremic metabolic acidosis

  • Reduced GFR 

Term
Analgesic nephropathy
Definition
  •  occurs in about 4 out of 100,000 people, mostly women over 30. The rate has decreased significantly since phenacetin is no longer widely available in OTC preparations

Term
Analgesic Nephropathy
Definition

Symptoms/Signs

  • Hematuria

  • Mild proteinuria

  • Polyuria (from tubular damage)

  • Anemia (from GI bleed)

  • Sterile pyuria

  • As a result of papillary necrosis, sloughed papillae can be found in the urine (An IVP may be helpful in detecting these- contrast will fill the area of the sloughed papillae and leave a “ring shadow” sign at papillary tip. However IVP rarely used in pt's with kidney dysfunction, given need for dye and associated acute kidney injury).  

Term
  • Withdrawal of all analgesics. 

Definition
TX analgesic nephropathy
Term
Lead Nephropathy
Definition

This is a chronic tubulointerstitial disease. It involves damage to one or both kidneys caused by chronic exposure to lead.

 

Essentials of Diagnosis:

  • Kidney size is small and contracted

  • Decreased urinary concentrating ability

  • Hyperchloremic metabolic acidosis

  • Reduced GFR

 

Epidemiology

  • It is seen less frequently now in the US. Individuals at risk are those with occupational exposure and drinkers of ETOH distilled in automobile radiators (moonshine drinkers).

 

Term
Lead Nephropathy
Definition
  • Proximal tubular damage leads to decreased secretion of uric acid, resulting in hyperuricemia, and saturnine gout.

  • Hypertension is common. Polyuria and dehydration may occur. 

    • Urinalysis is nonspecific, as opposed to that seen in acute interstitial nephritis.

    • Proteinuria is typically <2g/d, few cells may be seen, and broad waxy casts are often present. 

Term
  • Most reliably performed with a calcium disodium edetate (EDTA) chelation test.

  • Urinary excretion of >600mg lead in 24 hours following 1g of EDTA indicates excessive lead exposure.

Definition
How to diagnose lead nephropathy
Term
  • Continue chelation therapy w/ EDTA if there is no evidence of irreversible renal damage.

  • Continued lead exposure should be avoided.

  • Pts w/ stage 3-5 chronic kidney dz should be referred when tubulointerstitial dz suspected. Select cases of stage 1-2 chronic kidney disease: refer

Definition
Tx Lead nephropathy
Term

Hypokalemic Nephropathy

Definition

This is a disturbance of renal function and structure caused by chronic hypokalemia (at least several weeks).

Term

Hypokalemic Nephropathy 

Definition
  • Vacuolation of the epithelial cytoplasm of renal convoluted tubules in people seriously depleted of potassium.

  • Tubular cells in proximal tubules contain numerous vacuoles. Glomeruli become smaller and sclerotic.

Term

Hypokalemic Nephropathy

Definition
  • Loss of urinary concentrating ability is the most common functional defect.

  • Nocturia, polyuria and polydipsia (polydipsia may be due to disorder of primary thirst mechanism in addition to renal origin) are the most common symptoms.

  • Polynephritis may develop. 

Term
  • Aimed at replenishment of body potassium stores and correction of mechanisms leading to potassium losses.

  • Return of normal urinary concentration ability may be delayed for several months.

 

Definition
  • Tx hypokalemic nephropathy

 

Term

Hypersensitivity Nephropathy

Aka AIN (Acute interstitial nephritis)

Definition

Acute tubulointerstitial reaction stemming from hypersensitivity to sulfonamides, penicillins, cephalosporins, flouroquinolons, isoniazid, rifampin, thiazide and loop diuretics, cimetidine, ranitidine, omeprazole, and nonsteroidal anti-inflammatory medications. Recently, proton pump inhibitors have been identified as perhaps the most common etiology of acute interstitial nephritis

Term

Hypersensitivity Nephropathy 

Definition
  • Both humoral and cell-mediated immune reactions are implicated in the pathophysiology  

  • Kidneys are enlarged, glomeruli appear normal, but interstitium is edematous and infiltrated by polymorphonuclears, lymphocytes and plasma cells, and sometimes a large number of eosinophils.

  • Most patients require several weeks of exposure to drugs before developing renal damage.

 

Term

Hypersensitivity Nephropathy

Definition
  • Azotemia is usually present and classically associated with fever, skin rash and peripheral eosinophilia (however, minority of patients present in this manner).

  • Urine sediment reveals hematuria, pyuria and sometime eosinophils.

  • Proteinuria is usually minimal to moderate, except in cases caused by nonsteroidal anti-inflammatory medications when it may be massive (minimal change glomerulopathy).

 

Term
  • Stopping the drug exposure results in complete resolution of renal injury in most cases, although permanent damage has been described.

  • Steroids have been used in therapy, but benefit is not clear.

  • Cyclophosphamide therapy is controversial. This treatment causes significant short-term adverse effects in many patients, which makes many clinicians reluctant to use it in primary therapy.

Definition
Tx Hypersensitivity Nephropathy
Term

Uric Acid Nephropathy 

Definition

Definition: Disorder of excess uric acid or urate deposition in kidney. presents similarly to acute tubulointerstitial nephritis with direct toxicity from uric acid crystals. Chronically is caused by deposition of urate crystals in the alkaline medium of the interstitium, this can lead to fibrosis and atrophy.  

Term
Acute uric acid nephropathy
Definition
  • caused by deposition of uric acid crystals within the kidney interstitium and tubules, leading to partial or complete obstruction of collecting ducts, renal pelvis, or ureter. This obstruction is usually bilateral, and patients follow the clinical course of acute renal failure.

Term
chronic uric acid nephropathy
Definition

caused by the deposition of monosodium urate crystals in the renal medulla and pyramids. This can lead to fibrosis and atrophy

Term
Acute uric acid nephropathy 
Definition
  •  observed almost exclusively in the setting of malignancy, especially leukemia and lymphoma, in which rapid cell turnover or cell lysis occurs from chemotherapeutic agents or radiation therapy.

  •  can also be caused by an acute attack of gout. 

Term

 chronic urate nephropathy

Definition
  • chronic hyperuricemia and gout are the only causes of___________, if it exists as a clinical entity.

 

Term
urate nephropathy
Definition
  • In acute presentation, the most frequently observed symptoms are nausea, vomiting, lethargy, and seizures.

  •  

  • Hypertension is common, and pyelonephritis may complicate the presence of obstructing calculi.

  • Hematuria is also common. However, note that uric acid nephrolithiasis often precedes the onset of gouty arthritis in patients with both conditions.

  • Oliguria is the primary sign of the onset of, with edema and congestive heart failure occurring subsequently.

  • PE may reveal subcutaneous tophi or the typical arthritic changes of gout.


Term
  • Treatment is focused on preventing deposition of uric acid within the urinary system by increasing urine volume with potent diuretics such as furosemide..

  • Treatment between gouty attacks involves avoidance of food and drugs causing hyperuricemia, aggressive hydration, and pharmacotherapy aimed at reducing serum uric acid levels.

  • Dialysis (preferably hemodialysis) is started if the above measures fail.

  • The xanthine oxidase inhibitor allopurinol has been a milestone in the prevention of acute uric acid nephropathy.

  • Allopurinol has been used extensively in the prevention of acute uric acid nephropathy in patients with malignancy who are undergoing chemotherapy.

  • For optimal prophylaxis of acute uric acid nephropathy, allopurinol should be administered at 48-72 hours or, preferably, 5 days before the initiation of cancer therapy

Definition
Tx acute uric acid nephropathy
Term
  • the current trend is to not treat hyperuricemia for the prevention of chronic nephropathy alone, The emphasis should be on controlling other risk factors for kidney failure, such as diabetes and hypertension.

  • Treatment between gouty attacks involves avoidance of food and drugs causing hyperuricemia, aggressive hydration, and pharmacotherapy aimed at reducing serum uric acid levels.  

Definition
TX CHRONIC URIC ACID NEPHROPATHY
Term

Gonorrhea and Chlamydia:

Definition
  • Spontaneous discharge of fluid from the urethral meatus: STD

    • usually after holding urine overnight

    • often accompaniedby burning discomfort during urination

    • strongly indicatesa sexually acquired urethral infection (urethritis; see “urethritis” above for management.

Term
  • doxycycline(100 mg twice daily for one week), erythromycin (500 mg twicedaily for two weeks), or azithromycin (1 g single dose)

  • All are active against chlamydial infection and most other pathogensassociated with non-gonococcal urethritis

Definition
      • Patients without evidence of gonorrhea receive: 

Term

Gonorrhea has become so resistant to fluoroquinolones, one class of antibiotics, that the Centers for Disease Control and Prevention announced that the drugs should no longer be used to treat it.

***cephalosporins, injection.

(WHERAS fluoroquinolones come in pill)

Definition

      • only a single class of antibiotics, called ______, is left to treat gonorrhea, the second-most common infectious disease reported to the CDC, after chlamydia

      • Preferred drug in this class is given in an injection, while _______ come in pill form. 

Term
 3-7 days 
Definition
  • Signs of herpes tend to develop within____of skin-to-skin contact with an infected person 

Term
Herpes
Definition
  • look like small blisters or ulcers (round areas of broken skin) on the genitals

  • Each blister or ulcer is typically only 1-3 millimeters in size, and the blisters or ulcers tend to be grouped into “crops,” may be painless, or slightly to tender to very painful.

  • Blisters soon open to form ulcers

  • May be found on penis, around the penis, or anywhere around genitals or anus.

  • First outbreak:

    • usually the most painful, and the initial episode may last longer than later outbreaks

    • Fever, muscle aches, headaches (may be severe)

    • Swollen and tender lymph glands in the groin (glands swell as the body tries to fight the infection) 


  • Second/subsequent outbreaks:

    • Usually less painful

    • Often prodromal pain prior to outbreak

    • pain is due to irritation and inflammation of the nerves leading to the infected area of skin

    • Patient is particularly contagious during this period, even though the skin still appears normal  

Term
    • 10 days of: acyclovir, famciclovir, or valacyclovir

    • For preventing later outbreaks, pts with recurring genital herpes infections may benefit from antiviral medications

    • Treatment is started when the recurrence first begins and continues for 5 days

    • Prophylaxis:

    • Valtrex 500 mg qd

    • Acyclovir 800 mg bid

Definition
Tx herpes
Term
Genital warts (HPV)
Definition
  •  usually appear as small, fleshy, raised bumps, but they can sometimes be extensive and have a cauliflower-like appearance

  • In men, the lesions are often present on the penis or in the anal region

  • Sxs: itching, burning, or tenderness

  • Linked with both anal and penile cancer in men 

Term
HPV
Definition
  • common and does not usually lead to the development of warts, cancers, or specific symptoms

  • The majority of people infected have no symptoms or lesions

  • At least 75% of the reproductive-age population has been infected with this sexually-transmitted dz at some point in their life

  • infected persons without the lesions can still spread the disease!!!

Term
    • Nothing can eradicate the infection

    • The only currently possible treatment is to remove the lesions caused by the virus

    • Removal of the warts does not necessarily prevent the spread of the virus, and genital warts frequently recur

    • None of the available treatment options is ideal or clearly superior to others

      • So how are lesions treated?

      • Podoflox, BID X 3 days, then off for 4. Do this up to 4 weeks.

      • Imiquimod—pt applies 3x/week at bedtime; wash 6-10 hours later. Do this for 16 weeks or until lesions are gone.

      • Podophyllin—in office treatment

      • Interferon alpha

      • Cryotherapy

      • Laser surgery

Definition
Tx genital warts (HPV)
Term
3 months
Definition
  • All pts who seek STD testing should be screened for HIV and syphilis; repeat in____ months if negative

  • Partner notification and treatment is very important!!

Term
  • Gonorrhea*, syphilis*,  Chlamydia*, chancroid*, 

  • Shigellosis*, hepatitis A,B and C*, giardiasis*, cryptosporidiosis*, salmonellosis*

Definition

 

  • STI conditions reportable to public health authorities!!!

Term
 herpes simplex virus, primary syphilis, and chancroid. 
Definition
Genital ulcers could arise from :
Term

 

  1. fever?
  2. Nausea or vomiting?
  3. New back or flank pain?
  4. Vaginal discharge?
  5. Pregnancy risk?
  6. Structural abnormalities? (polycystic kidney dz, nephrolithiasis, or neurogenic bladder)
  7. Instrumentation of urethra or bladder?
  8. (these last 3 questions would affect treatment regimen, such as ABX choice or duration of treatment, in uncomplicated cystitis. )
Definition

DYSURIA 

1. Essential Questions:

Term
dysuria
Definition
  • An inflammatory process underlies most causes of ______.

Term
urethritis
Definition
  • In men, the most common cause of dysuria is ____. 

Term
cystitis
Definition
  • Dysuria accompanied by other irritative voiding sx, such as urgency or frequency, and fever or back pain increases the likelihood of _____.

Term
cystitis
Definition
  • In women, ____ is diagnosed in 50-60% of cases with dysuria. Always exclude ___& ______.

Term
less likely
Definition

If dysuria is accompanied by vaginal discharge or irritation, cystitis is ___________.

Term

hemorrhagic cystitis

bladder cancer


Definition
  • Dysuria plus hematuria more likely to be ______; can also be a sign of _____ (especially in elderly), or upper tract disease. 

Term
chlamydial infection
Definition
  • ________ should be strongly considered in among women age 25 or younger who are sexually active and seeking medical attention for a suspected urinary tract infection for the first time or have a new partner. 

Term
pyelonephritis
Definition
  • Dysuria plus fever, back pain, and nausea and vomiting—consider _________.

Term
urosepsis
Definition
  • Dysuria with Fever, tachycardia, hypotension: must rule out ______.

  • In females, assess costovertebral angle tenderness, as well as do a lower abdominal and pelvic exam.

Term

**Renal imaging—(may do abdominal XR, renal US or CT).

**noncontrast helical CT scan.

Definition
  • when severe flank or back pain is present do ____ to r/o complicated kidney infection or hydronephrosis. If kidney stones suspected, do a _________.

Term
  • Urine culture—do this prior to starting ABX. 

    Treat underlying cause

Definition
tx dysuria
Term

Prostate CA

Definition
  • Prostatic induration or focal nodules on digital rectal exam or elevation of PSA

  • Most often asymptomatic

  • Rarely: systemic symptoms (weight loss, bone pain)

Term

Prostate CA

Definition
  • Risk factors include advancing age, positive family Hx f, and African-American heritage, history of high dietary fat intake

  • No increased risk with benign prostatic hypertrophy

Term
adenocarcinoma
Definition
  • Most prostate cancers are 

Term
Prostate CA
Definition
  • Pts with early-stage dz are typically asymptomatic

  • Develop obstructive voiding symptoms as dz advances(large or locally extensive)

  • Can also develop hematuria with advanced dz

  • Prostate nodule may be noted on digital rectal exam

Term
Many cases are diagnosed with elevated prostate-specific antigen testing(PSA)
Definition
  •  

    • glycoprotein produced only by cells, either benign or malignant, of the prostate gland

Term

abnormal PSA (< 4 ng/mL), abnormal DRE

In pts with values > 4 ng/mL, biopsy should be done

Definition
Screening: Prostate CA
Term
Diagnosis made on transrectal U/S guided biopsy
Definition
Dx Prostate CA with 
Term

Treatment

  • Watchful waiting

  • Androgen deprivation\

  • Radical prostatectomy

  • Radiation therapy

  • Low or intermediate-risk dz is treated with radical prostatectomy or local radiation therapy

Definition
Tx Prostate Cancer
Term
Testicular CA
Definition

Essentials of Diagnosis

  • Commonest neoplasm in men aged 20-35 years

  • Typical presentation as a patient-identified painless nodule

  • Orchiectomy necessary for diagnosis

Term
Prostate CA
Definition
  • High-risk pts are treated with aggressive local therapy and androgen deprivation

Term
Testicular CA
Definition
  • Primary age of onset is 15-35 years

  • Increased risk with a history of cryptorchidism

    • slightly more common on the right, paralleling the increased incidence of cryptorchidism on the right side

  • Rarely bilateral

 

Term
Testicular CA
Definition
  • Most common symptom is painless enlargement of the testis

  • Sensations of heaviness are not unusal

  • Pts are usually the first to recognize an abnormality, yet the typical delay in seeking med attn ranges fom 3-6 months.

  • Acute testicular pain resulting from intratesticular hemorrhage occurs in approximately 10% of cases. Ten percent of pts are asymptomatic at presentation, and 10% of pts manifest symptoms relating to metastatic dz such as back pain(retroperitonaeal metastatses), cough (pulmonary metastases) or lower extremity edema (vena cava obstruction)

  • Discrete mass or diffuse testicular enlargement is noted in most cases

  • Secondary hydrocele may be present in 5-10% of cases

  • In advanced dz, supraclavicualar adenopathy may be present, and abdominal exam may reveal a mass

  • Gynecomastia is seen in 5% of germ cell tumors

  • Testicular pain or testicular mass

  • w/ metatstatic dz, can present with flank pain

  • on P/E, a testicular mass is noted

Term
Labs testicular CA
Definition
    • Human chorionic gonadotropin(hCG), a-fetoprotein, and LD
    • Serum beta-human chorionic gonadotropin (beta-HCG) and/or alpha fetoprotein lvls ↑
    •  

    • LFTs may be elevated in the presence of hepatic metastases, and anemia may be present in advanced disease

Term
Testicular CA imaging
Definition
  • Testicular/scrotal U/S to evaluate the mass

    • can readily determine wheather a mass is intratesticular or extratesticular

  • Once the diagnosis has been established, by inguinal orchiectomy, clinical staging of the dz is accomplished by chest, abdominal, and pelvic CT scanning

Term
  • Orchiectomy w/ radiation therapy are used in stage 1 and II dz

  • With metastatic dz, chemotherapy is added after surgery

  • Patient self-screening should occur monthly

Definition
Tx Testicular CA
Term

Wilm’s Tumor

Definition
  • Occurs most commonly between age 2-5 years

  • Frequently associated w/ other malformations and cytogenetic disorders

SXS

  • Pts present with incrasing abdominal mass

  • Mass is smooth, firm, and well demarcated

  • Microscopic hematuria is often noted, but gross hematuria is uncommon

Term
  • Intrarenal mass noted on U/S or CT scan of the abdomen

Definition
  • Wilm's Tumor Imaging

Term
  • Surgical resection of the tumor

  • Chemotherapy is used in all cases

  • Advanced cases also treated with radiation therapy

Definition
Tx Wilm's Tumor
Term

Bladder Carcinoma 

Definition
  • ESSENTIALS OF Dx

    Irritative voiding symptoms

  • Gross or microscopic hematuria

  • Positive urinary cytology in most patients

  • Filling defect within bladder noted on imaging

Term
Bladders CA
Definition
  • Is the second most common urologic cancer

  • Men>women a 2.7>1 ratio

  • Average age of diagnosis: 65

  • Risk factors include cigarette smoking (60% of new cases) and exposure to industrial dyes or solvents (15% of new cases).


Term
Bladder CA
Definition
  • 98% are epithelial malignancies w/ majority being urothelial cell carcinomas (90%)

  • Adenocarcinomas and squamous cell cancers account for approxiamately 2% and 7% respectively. 

Term
Bladder CA
Definition
  • Hematuria is the presenting symptom in 85-90% of pts

  • Irritative voiding symptoms occur in a small %

  • Most pts do not have signs of disease

  • Abdominal masses may be present in pts w/ large volume or deeply infiltrating.

  • Hepatomegaly or palpable lymphadenopathy may be present in pts with metastatic disease

  • Lymphedema of lower extremeties may be present as a result of locally advanced cancers or metastases to pelvic lymph nodes.

Term
Bladder CA
Definition
  • Urinalysis reveals microscopic or gross hematuria in the majority of cases.

  • May be accompanied by pyuria

  • Anemia may occasionally be due to chronic blood loss or bone marrow metastases

  • Exfoliated cells from normal and abnormal urothelium can be readily detected in voided urine specimens.

Term
cytology
Definition
In Bladder CA,______ can be useful in detecting the disease, but more sensitive in detecting cancers of higher grade and stage
Term

**ultrasound, CT, or MRI where filling defects within bladder are noted

**cystoscopy & biopsy

**cystoscopy and transurethral resection.

Definition
  • Bladder cancers may be identified using__________ .

  • Presence of cancer is confirmed by _____ and _____.

  • The diagnosis and staging of bladder cancer is made by _______&_________.

Term
transurethral resection
Definition
If cystoscopy confirms bladder cancer, pt is scheduled for ??
Term
 size, pleomorphism, mitotic rate, and hyperchromatism
Definition
  • Pathology & Staging Bladder CA

    Grading is based on cellular features: (3)

Term
bladder wall penetration and the presence of regional or distant metastases
Definition
Bladder CA Staging is based on the extent of ______ & presence of  _________.
Term
complete transurethral resection and selective use of intravesical chemotherapy.
Definition
  • Pts with superficial cancers (Ts, T1) are treated with 

Term
adjuvant intravesical therapy
Definition
  • Pts with large high grade recurrent Ta lesions or T1 cancers and those w/ carcinoma in situ are good candidates for . 

Term
radical cystectomy, irradiation, or the combination of chemotherapy and selective surgery or irradiation due to the much higher risk of progression.
Definition
  • Pts with invasive (T2, T3) but still localized cancers are at risk for both nodal metastases and progression and require 

Term
Renal Cell Carcinoma
Definition
  • Gross or microscopic hematuria

  • Flank pain or mass in some pts

  • Systemic symptoms such as fever, weight loss may be prominent.

  • Solid renal mass on imaging 

Term
Renal Cell carcinoma
Definition
  • Peak incidence at 6h decade of life

  • Male to female ratio 2:1

  • May be associated w/ # of paraneoplastic syndromes

  • Cause is unknown

  • Cigarette smoking is only significant environmental risk factor

  • Originates from proximal tubule cells

Term
Renal Cell Carcinoma
Definition
  • Historically, about 60% of pts presented with gross or microscopic hematuria

  • Flank pain or abdominal mass detected in about 30%

  • Triad of flank pain, hematuria, and mass found in only 10-15% of pts and often a sign of advanced disease

  • Fever may be present as paraneoplastic symptom

  • Symptoms of metastatic disease (cough, bone pain) occur in 20-30% of pts at presentation.

  • Frequently detected incidentally 

Term
Renal Cell CA
Definition
  • Hematuria present in 60% of pts

  • Erythrocytosis from increased erythropoietin production occurs in 5%, though anemia is more common.

  • Hypercalcemia may be present in up to 10%


 

Term
Stauffer syndrome 
Definition
is a reversible syndrome of hepatic dysfunction in the absence of metastatic disease
Term
 
  • CT scanning is the most
  • MRI and duplex Doppler ultrasonography are excellent methods of assessing for the presence and extent of tumor thrombus within the renal vein or vena cava.
Definition
  • most valuable imaging test for renal cell carcinoma.

 

Term
  • Radical nephrectomy is the primary treatment for localized renal cell carcinoma

  • Pts w/ single kidney, bilateral lesions, or significant medical renal disease should be considered for partial nephrectomy

  • No effective chemotherapy available for metastatic renal cell carcinoma

  • Vinblastine is the single most effective agent, w/ short term response rates of 15%

  • Bevacizumab can prolong time to progression in those with metastatic disease

  • Several targeted drugs, specifically VEGF and Rafkinase inhibitos are effective (40% response rates) in pts with advanced kidney cancer. 

Definition
  • Tx Renal Cell Carcinoma

Term

Goodpasture Syndrome

Definition
  • Defined by clinical constellation of glomerulonephritis and pulmonary hemorrhage

  • Injury to both is mediated by anti-GBM antibodies

  • Up to 1/3 of pts with anti-GBM glomerulonephritis have no evidence of lung injury

  • Anti-GBM associated glomerulonephritis accounts for about 10% of pts w/ rapidly progressive acute glomerulonephritis

  • Male to female ratio is 6:1

  • Disease occurs most commonly in 2nd and 3rd decades

  • Has been associated with influenza A infection, hydrocarbon solvent exposure, and HLA-DR2 and –B7 antigens. 

Term

Goodpasture Syndrome

Definition
  • Onset of disease is preceded by an upper respiratory tract infection in 20-60%

  • Pts experience hemoptysis, dyspnea, and possible respiratory failure

  • HTN and edema are seen as components of the nephritic syndrome

Term
Goodpasture Syndrome
Definition
  • Iron deficiency anemia

  • Normal complement levels

  • Sputum contains hemosiderin-laden macrophages

  • Chest radiographs can show shifting pulmonary infiltrates due to pulmonary hemorrhage

  • Diffusion capacity of carbon monoxide is markedly increase

  • Diagnosis is confirmed by finding circulating anti-GBM antibodies, positive in over 90% of pts

  • Positive serum for ANCA in 15%

Term
  • Treatment of choice is combination of plasma exchange therapy to remove circulating antibodies and administration of immunosuppressive drugs to prevent formation of new antibodies and control inflammatory response

  • Corticosteroids are typically given initially in pulse doses

    • methyl-prednisolone 1-2 g/d for 3 days

    • then prednisone orally 1 mg/kg/d

  • Cyclophosphamide is administered IV at 0.5-1.0 g/m^2 per month or orally at a dosage of 2-3 mg/kg/d

  • Daily plasmapheresis is performed for up to 2 weeks

  • Poorer prognosis in pts with oliguria and a serum creatinine greater than 6-7 mg/dL

  • Anti-GBM antibody levels should decrease as the clinical course improves

 



Definition
Term

Henoch-Schonlein Purpura

Definition
  • Leukocytoclastic vasculitis of unknown cause

  • Most common in children

  • Male predominance

  • Classically presents with palpable purpura, arthralgias, and abdominal symptoms such as nausea, colic, and melana.

  • Purpuric skin lesions most often found on lower extremeties but may also be seen on hands, arms, trunk, and buttocks

  • Decrease in GFR is common w/ a nephritic presentation

  • Renal lesions are identical to those found in IgA nephropathy

Term

Henoch-Schonlein Purpura

Definition
  • Biopsy of kidney reveals segmental glomerulonephritis with cresents and mesangial deposition of IgA.

  • Most pts recover fully over several weeks

Term
Alport's Syndrome
Definition
  • A genetic disorder characterized by glomerulonephritis, endstage kidney disease, and hearing loss

  • Can also affect the eyes (Leticonus)

  • Hemturia almost always found

  • Cause by mutation in collagen biosynthesis genes

    • Prevents the proper production/assembly of type IV collagen network, an important structural component of basement membranes in the kidney, inner ear, and eye.

    • Basement membranes of kidneys are then not able to filter waste pdts from blood and create urine normally, allowing blood and protein into urine

  • Abnormalities cause gradual scarring of kidneys, eventually leading to kidney failure in many.



Term
Alport's Syndrome
Definition
Progression of disease leads to basement membrane thickening and gives a “basket-weave” appearance from splitting of lamina densa
Term
Alport's Syndrome
Definition
  • No known cure for condition

  • Treatments are symptomatic

  • Pts are advised on how to manage the complications of kidney failure

  • Protenuria treated with ACE inhibitors

  • Dialysis for kidney failure 

Term
Azotemia
Definition
 cause nausea, vomiting, malaise, and altered sensorium.
Term

azotemia

cardiac tamponade

Definition

Pericardial effusions can occur with ______, and a pericardial friction rub


Effusions may result in _________.

Term
diabetic ketoacidosis (metabolic acidosis)
Definition
Kussmaul respiration seen in 
Term
Metabolic acidosis
Definition

These diseases are examples of what type of metabolic disorder?

Renal failure

Diarrhea

Diabetic ketoacidosis

Term
metabolic alkalosis
Definition

What metabolic d/o are these sxs?

vomiting

antacid abuse

volume contraction

Term
Respiratory acidosis
Definition

What metabolic d/o are these diseases?

COPD

asthma

hypventilation

drug OD

airway obstruction

ARDS

Term
hypercapnia
Definition
increased CO2 is 
Term
small increase in plasma bicarbonate
Definition
acute respiratory failure: severe respiratory acidosis and only a.....
Term
underlying lung disease (COPD)
Definition
chronic respiratory acidosis appears in patients with 
Term
S/S respiratory acidosis
Definition

acute onset: sonolence/confusion

possible myoclonus and asterixis

coma from CO2 narcosis

severe hypercapnia: increases cerebral blood flow and CSF pressure

signs of increased ICP

Term
hypochloremia
Definition
if respiratory acidosis is chronic, then _____is present too.
Term

Drug OD

Tx by Naloxone

Definition

Important cause of ACUTE respiratory acidosis:

Tx by?

Term
Respiratory alkalosis
Definition
Also called hypocapnia
Term

PCO2

increases PH

Definition
Hyperventilation reduces ____, increases____.
Term
hyperventilation syndrome
Definition
most common cause respiratory alkalosis
Term
respiratory alkalosis
Definition

bacterial septicemia

cirrhosis

hyperventilation syndrome

signs of what type of ACID BASE D/O?

Term
pregnancy (decreased cerebral blood flow)
Definition
cause of chronic resp alkalosis?
Term
progesterone
Definition
stimulates respiratory center?
Term
resp alkalosis
Definition

sxs of what acid base d/o?

light headed

anxiety

numbness 

tingling

tetany

 

Term
low
Definition
in chronic resp alkalosis, serum bicarb is 
Term
Definition
tx resp 
Term

Ofloxacin ;  ciprofloxin ; ceftriaxone (gonorrhea)

azithromycin or doxycycline (nongonorrhea)

Definition

Recommended therapy to Chlamydia and Gonorrhea (like in urethritis


Term
gram negative intracellular diplococci
Definition
Gonorrhea
Term
urethritis
Definition
sign is discharge, tip of penis hurts
Term
more than 3 episodes of cystitis per year
Definition
recurrent cystitis
Term
urosepsis
Definition

often a result of dissemination of bacteria from urine to blood in a patient with bacteriuria who has had catheter removed or changed in previous 24 -48 hours

(bacteria in blood even if cath has been removed, but was there within a few days)
Term
UTI (cystitis)
Definition

dysuria

urinary frequency

nocturia

urinary urgency

normally NO or very low fever 

In sexually active women: cystitis commonly occurs 24-48 hours after intercourse, Especially if post-coital bladder emptying has not been followed



Term
geriatric UTI (cystitis)
Definition

Often don’t have these typical symptoms, or they can’t tell you about them

Unexplained incontinence

Fever

Weakness

Changes in mental status


Term
pyelonephritis
Definition

 

Wbc> 12,000 uL


Term
stones
Definition
causes hydronephrosis, colicky
Term
pyelo
Definition
intense steady pain urinary
Term
BPH
Definition
get up all might to pee, but hardly can pee
Term
grade 1-5
Definition
grades prostate cancer
Term

2-10

less than 6 less aggressive

greater than 7 aggressive

Definition
gleason score for prostate
Term
BPH
Definition
boggy prostate
Term
prostate cancer
Definition
bone pain
Term

BPH

prostatits

cancer

Definition
increase in psa seen in 
Term
prostate ca
Definition
>.75 raise in PSA in one year
Term
prostatitis
Definition
indurated
Term
cancer
Definition
nodule
Term
chronic prostatits
Definition
boggy
Term
squishy
Definition
boggy
Term
epidymitits
Definition
acute cause of pain
Term

CAAL

chemo

acetazolamide

antacids

loops

Definition
medications that cause stones
Term
calcium oxalate (sometimes with calcium phosphate)
Definition
most common form of stone
Term
calcium
Definition
bipyramidal or biconcave ovals (stones)
Term
calcium stone
Definition
stone that is radiodense and visible on abdominal radiography
Term
uric acid stones
Definition
Account for 10% of stones
Term
uric acid stones
Definition
associated with gout or secondary to chemo (lymphoma or leukemia)
Term
hyperuricemia
Definition
release of purines from dying cells lead to 
Term
uric acid
Definition
flat square plates (stones)
Term
uric acid stone
Definition
stones are radioluscent (can't be seen on abdominal radiograph)
Term
CT, US, or IVP
Definition
uric acid stones require what to diagnose?
Term
struvite (staghorn)
Definition
radiodense stone, visible on abd radiograph, rectangular prisms
Term
struvite
Definition
stone that occurs in patients with recurrent UTI's due to urease producing organisms (proteus, klebsiella, serratia, enterobacter, pseudomonas) NOT e.coli!!
Term
struvite calculi
Definition
urea splitting bacteria convert urea to ammonia, thus producing alkaline urine.  The resultant ammonia combines with mag and phos to produce
Term
cystine stones
Definition
account for 1% of stones, genetic predisposition and hexagonic shaped crystals
Term
stone
Definition

pain begins in flank, radiates to groin

n & v common

hematuria

UTI

Term
causes of hypercalciuria
Definition

increased intestinal absorption of calcium

decreased renal reabsorption of calcium

primary hyperparathyroidism

increased bone reabsoption of calcium

sarcoidosis

malignancy

vitamin d excess

Term
causes of hyperoxaluria (calcium stone)
Definition

severe steatorrhea of any cause 

small bowel disease, chron's disease

pyridoxine deficiency

Term
concomittant infection (UTI)
Definition
hematuria plus pyuria with a stone indicates
Term
micropscopic or gross heamturia
Definition
stones have either...
Term

struvite-alkaline

acidic-uric acid

Definition

alkaline urine indicates_____stone

acidotic indicates_____stone

Term

culture if infection

24 hour urine

serum chem (BUN, CR to assess kidney function)

Definition
other labs to draw with stone aside from urine PH
Term
SPiral ct without contrast
Definition
gold standard to diagnose kidney stone
Term
2 L a day
Definition
fluid intake for kidney stone
Term

thiazide diuretic reduces urinary calcium

allopurinol effective in high uric acid 

Definition
2 drugs to help in prevention of recurrent Stones
Term
below ureterovesicular junction (affects urination)
Definition
lower tract obstruction of urinary tract is at 
Term
above uterovesicular junction (causes renal colic)
Definition
upper tract obstruction of urinary tract at 
Term
hydronephrosis
Definition
dilation of urinary tract, enlargment (swelling of kidneys)
Term
acute
Definition

renal and colic pain most common with ______hydronephrosis (may only manifest during urination)

Whereas, chronic obstruction may be asymptomatic

Term

initial renal ultrasound

IVP gold standard (contraindicated in pregnancy or renal failure)

Definition

initial test for hydronephrosis

gold standard for it

Term
prostate cancer
Definition
vertebral metastasis may manifest as low back pain in elderly male.  THINK
Term
TRUS is indicated 
Definition
when DRE is abnormal, regardless of PSA
Term

PSA>10

PSA velocity >.75 per year

Abnormal DRE

Definition
TRUS with biopsy indicated when
Term
radical prostatectomy
Definition
tx localized prostate ca
Term
radiation therapy plus androgen deprivation
Definition
locally invasive prostate cancer tx
Term
acute glomerulnephritis
Definition

causes renal function loss over days to weeks

may or may not resolve

inflammation severe, nephron loss may be 50%

Term
chronic glomerulonephritis
Definition

prolonged inflammatory changes 

renal problems persist and lead to ESRD

Term
alports syndrome
Definition

triad of glomerulonephritis, deafness, and ocular lesions

irregular focci of thickening "basket weave"

Term
post-strep glom
Definition

sore throat

face bloat

pee coke

Term
post strep glom
Definition
appears weeks later after strep infection
Term
post strep glum
Definition
edema, tea colored urine, impetigo, crystal lesions
Term
Post-strep glom
Definition
IgG and C3 immune complexes in magnesium and capillary basement (subepithelial humps)
Term

SSAAD

supportive

Salt restriction

abx (penicillin) 

ACEI to reduce proteinuria

diuretics

Definition
Treatment for post strep-glom
Term
IgA nephropathy
Definition

seen in kids, young adults, males>females

after URI, GI or flu-like illness

Term
IgA ( beurgers dz)
Definition
most common form acute glomerulonephritis
Term
IgA nephropathy
Definition

single episode of macroscopic hematuria (red or cola colored)

may develop chronic microscopic hematuria with stable serum creatinine

Term
IgA nephropathy
Definition
Serum IgA increased in 50% of patients
Term
renal biopsy
Definition
Gold standard for diagnosing IgA nephropathy
Term
IgA nephropathy
Definition
mesangial deposits of IgA and IgG and C3
Term

ACEI/ARB to minimize proteinuria

corticosteroids

fish oil

Definition
tx IgA nephropathy
Term
HS Purpura
Definition

Palpable bumps (usually lower extremities)

Athralgias

abdominal sxs

nephritic renal insufficiency(<3.5g)

IgA deposits

Term
HS purpura
Definition
  1. IgA deposits alone
Term
HS purpura
Definition

cause is unknown.  presents with vasculitis with leukocytes

more common inmales and kids

Term

most recover completely 

bed rest, fluids, NSAIDs

Definition
tx HS purpura
Term
rapidly progressive glomerullonephritis
Definition
any glomerular disease that presents with rapid progressive indromeoss of renal function over days to weeks
Term

goodpastures

wegeners

Definition
2 rapid progressive glomerulonephritis
Term
goodpastures
Definition
rapid progressive with IGg and IgA immune complex disease
Term
wegener's 
Definition
rapid progressive with no immune complexes, and polarteritis nodosa
Term
goodpastures syndrome
Definition

TRIAD

pulm hemorrhage (pulm sys first-mild hemoptysis)

IDA

Glomerulonephritis (due to anti-GM antibody seen on biopsy)

Term
goodpastures
Definition
glomerulo rare, seen in young males 
Term

steroids

plasma exchange

Definition
tx goodpastures
Term

treat quick before perm damage

correct fluid overload, HTN, uremia, and inflammatory injury to kidney

Na and H20 restriction

diuretics

dialysis

antiHTN and steroids

Definition
tx rapid progressive glomerulonephritis
Term
goodpastures
Definition

maybe anca

anti-GBM

Term
wegeners
Definition
anca 90-95% of time
Term

wegeners

goodpastures

Definition

upper and lower resp (includes sinus symptoms) in ____

as oppossed to just lower resp symptoms in___

Term
minimal change or Nils dz
Definition
mostly in kids with allergy, hodgkins, NSAIDs, follow URI, post immunization
Term
nils or minimal change dz
Definition

glomeruli appear normal under light microscopy

immunoflorescent tests are negative

ONLY telling sign under electron microscopy is fusion of epithelial foot processes

Term
nils disease
Definition
Usually does not progress to renal failure (nephrotic syndrome)
Term
infxn, thrombi, hyperlipidemia, malnutrition
Definition
complication of nils disease
Term
focal glomerular sclerosis
Definition
young, black, obese, aids male patient addicted to heroin and nsaids
Term
focal glomerular sclerosis
Definition

signs are HTN and decreased renal function

microscopic hematuria

electron microscopy fusion of epithelial foot processes

light microscopyL focal segmental sclerosing lesions

IgM and C3 in basement membrane

Term
focal glomerular sclerosis
Definition

in addition to prednisone, this nephrotic syndrome has poor prognosis and needs hemodialysis possibly

MOst patients progress to ESRD

Term
membranous nephropathy
Definition
most common form of nephrotic syndrome in adults
Term
membranous nephropathy
Definition
slow progressive loss of renal function over 3-10 years
Term
membranous nephropathy
Definition

nephrotic syndrome caused by hepatitis, SLE, DM, thyroiditis, CA

or

IDIOPATHIC

Term
membranous nephropathy
Definition

often presents in 5th-6th decade

often secondary renal vein thrombosis

with ca of stomach, colon

Term
membranous nephropathy
Definition

light microscopy:  Increase capillary wall thickening

subepithelial deposits/spikes

Term
membranoproliferative glomerulonephritis
Definition

unknown cause, idiopathic

most progress to ESRD in a few months to years

Term
recent UTI's
Definition
type 1: membranoproliferative glomerulonephritis presents after
Term
rare C3
Definition

type 3: membranoproliferative glomerulonephritis

Term

membranoproliferative glomerulonephritis

Definition

tram track 

double layered basement membrane

(splitting)

Term

all steroids

FGS- possible hemodialysis

membranoproliferative- also cytoxic (usually oral cyclophosphamide)

Definition

tx 4 nephrotic syndromes


 

Term
acquired PCKD
Definition
50%have been on dialysis greater than 3 years
Term
medullary sponge
Definition

present at birth but doesn't present normally until 4th-5th decade

RENAL CALCULI

UTI

Term
medullary sponge kidney
Definition

swiss cheese appearance

kidney stones with renal calculi

decreased urine concentrating ability

nephrocalcinosis

recurrent UTI

gross or microscopic hematuria

Term

no known therapy

adequate fluid to prevent calcium stones

Definition
tx medullary sponge
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