Renal Function

quantitative

measurement of the amount of a substance present, not exact 

crystals in the urine:

acid urine will have crystals from...

alkaline urine will have crystals from...

acid urine = uric acid, calcium oxalate

alkaline urine = triple phosphates

what type of casts are not a major finding?

what do they look like?

hyaline casts

rounded, smooth, may have flecks of phosphates in them

RBC casts =

WBC casts =

RBC casts = glomerular disease, renal failure

WBC casts = pyelonephritis

most common pathogen in a urine culture/stain

what two findings indicate a UTI?

E. coli

UTI = >20 WBC/HPF and 1 bact/OIF

what test reflects acid-base balance?

what is measured? (3)

give normal ranges for each

serum electrolytes

Extracellular ions:

Na+  135 - 145 mEq/L

Cl-    95 - 105 mEq/L

Intracellular ion:

K+    3.5 - 5 mEq/L **

**most critical**   K+ <3.5 = cardiac conduction issues

this represents 52-60% of total protein in the serum and is a key transporter for hormones, enzymes, and drugs.

what is it?

what is  a normal level?

Albumin

normal level = 3.5-5.0 gm%

this is the end product of purine metabolism and is a sensitive indicator of                function. 

it is also increased in... (2)

Uric Acid

key indicator of renal function.  Increased in renal disease before serum creatinine increases. 

**Have to lose >1/2 of renal function before elevated creatinine levels will be seen.**

Also increased in gout and high cell turnover (i.e. leukemia)

BUN is a gross index of                   function.

will be                with dehydration, decreased renal function

will be                  with dietary intake of protein

normal ratio of BUN:Cr is

BUN is a gross index of glomerular funtion.

will be decreased with dehydration, decreased renal function

will be increased  with dietary intake of protein

normal ratio of BUN:Cr is 15:1 or 20:1 (depeding on the source of info)

this is the byproduct of nucleic acid breakdown and is produced by blood cells.

it is a more stable and sensitive indicator for kidney damage than creatinine but it is not widely used.

what is it and why is it better than creatinine?

Cystatin-C

better than creatinine b/c levels are not affected by muscle mass, age, gender, or race

140 - age x wt (kg)

_________________

72 x serum creatinine

what is this an equation for?

what does it reflect?

what is normal?

140 - age x wt (kg)

_________________

72 x serum creatinine

Creatinine clearance

reflects glomerular filtration rate

normal = 100 - 125 ml/min

**End stage renal disease = 10 - 12 ml/min**

renal biopsy is indicated for what systemic disease? (2)

what are the complications?

SLE and Amyloidosis

complications:  bleeding, infection, morbidity (3-5%), and nephrectomy with uncontrolled hematoma

UTI and Renal Calculi

DM pts

pts on anti-cholinergics

brain dysfunction (stroke)

increased risk for what?

A UTI due to hematogenous spread of infection is seen in               and                         

from other organs in intraperitoneal abcess,               or              .

hematogenous spread = TB or cortical renal abcess

direct extension from other organs = IBD or PID

most common bacteria in UTI:

nosocomial acquired UTI:

G + UTI:

most common bacteria in UTI: E. Coli

nosocomial acquired UTI: Pseudomonas

G + UTI: S. saprophyticitus

Signs:  frequency, dysuria, bladder spasm, cloudy or malodorous urine

S/Sx of...

examples (3)

Lower urinary tract infection

cysititis

urethritis

prostatitis**

UTI's in males require f/u

Signs:  flank pain, fever and chills, nausea, vomiting, malaise

may be preceded by...

upper urinary tract infection

may be preceded by lower UTI

Tx:  TMP/SMX, cephalosporins, fluroquinolones x 3-days, 10-14 days if pregnant (and appropriate ABX), pyridium for pain.

What type of URI is the appropriate for?

uncomplicated URI

Tx:  TMP/SMX, cephalosporins, fluroquinolones x 7-10-days

What type of URI is the appropriate for?

"complicated" UTI

if renal parenchymal infection suspected

more than 3-4 previous episodes

pts >65 y/o

if f/u is uncertain

if possible underlying systemic uerelogical problem

Pyelonephritis of hematogenous route is associated w/ what bug?

S. aureus

Signs:  fever, flank pain, sking chills, nausea, vomiting, irratative voiding

PE:  CVA tenderness, fever, tachycardia

UA:  pyuria, bacteriuria, hematuria, WBC casts

CBC:  leukocytosis w/ L shift

Dx?

Tx?

Dx:  pyelonephritis

Tx:  TMP/SMX or quinolones x 14days

F/U urine cultures (clear, no bact.)

what is the most common type of renal calculi?

calcium...

calcium oxalate (70%)

note:  hypercalcemia is present in 40-60% of calcium stone formers

hyperparathyroid, hyperthyroid, cushings, sarcoid, TB, bone disease, vit. D intox

secondary causes of what

calcium, struvite, cystine renal calculi are radio                  

ruic acid stones are radio                  

radiopaque

radiolucent

most kindey stones will pass if they are...

removal if they are..

< 5mm  will pass

> 10mm need removal (lithoripsy, pyelotithotomy, ureterolithotomy)

35 y/o male pt

Signs:  abrupt swelling of the scrotum (generalized or hemi-scrotum), fever, chills, irritative bladder Sx, scrotal pain that may radiate along the spermatic cord/flank

UA:  pyuria, inflammatory cells (+/- leuko.)

PE:  clear watery urethral discharge...likely bug?  what if it was mucopurulent?

Dx?

Tx?

what if the pt was 55?

Dx: epididymitis

Bug:  chlamydia  (N. gonorrhea if mucopurulent discharge)

Tx:  scrotal support/elevation, bed rest

ABX:  dioxycycline 100mg BID x 10days

55 y/o pt

Bug:  E. coli or coliform organism

Tx:  quinolone or ampicillin x 3-4weeks (E. coli)

Signs:  suprapubic/perineal/sacral/back pain, fever, chills, tender prostate, irritative voiding sx

UA:  pyuria, bacteriuria, menaturia, and urine culture

CBC:  leukocytosis w/ L shift

Dx:

Tx:

Dx:  acute bacterial prostatitis

Tx:  TMP/SMX or Cipro x 3 weeks (if sx are minimal)

Hospitalization:  if septic, use ampicillin and aminoglycocides parentally.

signs:  irritative voiding, perineal/suprapubic discomfort, painful ejaculation +/- hematospermia, h/o UTI

PE:  prostate normal, tender, or boggy, WBC's in prostatic fluid or urine (have to do a prostatic massage..gooo)

Dx:

Tx:

Dx:  chronic bacterial prostatitis

Tx:  depending on culture...TMP/SMX or Bactrim or Quinolone x 6-12 weeks, anti-inflamm, sitz baths

edema, HTN, hematuria, dec. GFR, RBC casts

what is this?

Tx of nephritic syndrome:

anti-HTN

Na, H2O restriction

diuretics

primary renal disorder in kids that causes nephrotic syndrome

what about in adults?

secondary systemic disorders that cause nephrotic syndrome?

nephrotic syndrome

kids = minimal change disease

adults = membranous nephropathy

secondary systemic disorders...

DM

amyloidosis

HUV ass. nephropathy

SLE

treat cause

Na restriction

diuretics

statin or other lipid lower drug

maybe anticoagulation

ACE-I and/or ARB for DM

increased renal excretion of bicarb (results in what?)

increased renal excretion of glucose, Na

decreased renal excretion of K+ (results in what?)

may see proteinuria and heaturia

Sx of what?

tubulointerstitial disorders

bicarb out = acidosis

K+ retention = hyperkalemia

PCN's, ceph's, rifampin, infections, SLE, NSAIDS are all causes of what?

 tx?

Acute tubulointerstitial disorders (hypersensitivity)

tx

stop offending drug, supportive tx, maybe steroids

drugs usually will cause acute TIN between 2-40 days of tx

chronic TIN is caused by what?

vascular disease: vasculitis

chronic HTN

prolonger urinary tract obstruction (post renal problem) **most common cause**

DM and HTN are major causes of what disease that affect 20 million people in the US?

usually asymptomativ until late, is usually no reversible

Complications:  HTN, metabolic acidosis, CHF, anemia, coagulopathy, renal osteodystrophy (what is this?)

US:  bilateral small kindeys

UA:  broad waxy casts

what disease are we talking about?

tx?

HTN, anemia, Ca/Phos, acidosis

chronic renal failure

renal osteodystrophy = inc. phos, dec. calcium, inc. PTH

cause bone pain, fx

tx

HTN:  ACE-I and ARB's, watch for inc. K and restrict Na+.  May need to adjust meds based on GFR

Anemia:  erythropoietin

Ca and Phos:  phosphate binders, Ca supplements, vit. D. 

Acidosis:  Oral bicarb supplements

nausea, anorexia, wt loss

cognitive dysfunction

neuropathies

pruritis

platelet dysfunction

sx of what?

GFR <10-15 mL or 6-8mg/dl Cr.

symptomatic uremia

fluid overload

hyperkalemia unresponsive to meds.

metabolic acidosis unresponsive to meds.

hyperuricemia or hypercalemia

indications for what?

PTH is stimulate by...effects..

Calicitonin is stimulated by...effects

Vit D is stimulated by...effects

PTH: stimulated by low Ca, increased Ca+ by stimulating Vit D and bone resorption

Calcitonin:  stimulated by high Ca, decreases Ca+ by promoting bone formation

Vit D (calcitriole):  stimulated by low Ca and by low PHOS, promotes increase in serum Ca by increasing GI absorbtion, promotes increase in PHOS from bone and GI absorbtion

type I osteoperosis:

who gets it

what is affected

common fractures

type 2 osteoperosis:

who gets it

what is affected

common fractures

type I osteoperosis:

postmenopausal

affects trabecular bone

vertebral fractures common

type 2 osteoperosis:

men and women both

affects cortical and trabecular bone

**contributing factors:  reduced renal activation of Vit D and dec. GI sensitivity to Vit D

hip fractures common

**type 2 DM**

Cushings

thyroxine

steroid drugs

hysterectomy/hypogonadism

causes of what?

urinary pyridinolines and N-telopeptides are biochemical markers for what?

what will increase after a fx?

osteoperosis (biochemical bone markers)

alkaline phosphatase will increase after a fx

           is caused by inadequate amounts of Ca and PHOS due to vit D. deficiency

osteomalacia/rickets

also caused by Ca malabsorption

affects mineral part of bone only (not matrix)

diffuse skeletal pain, or hip localized, proximal muscle weakness, tetany, muscle wasting, and hypotonia with hypocalcemia

Sx of what?

important lab finding?

osteomalacia

serum Ca and PHOS are low

Alkaline phosphatase is high

low serum vit D

an autosomal-dominant disease or due to a viral infection that appears before age 40 and causes rapid bone turnover

bones involved:  pelvis, femur, skill, lumbosacral spine

Paget's disease

often Dx due to elevated alkaline phosphatase and N-telopeptide

excess glucocoticosteroids =

excess mineralocorticoids =

hypofunction of adrenal cortex =

excess glucocoticosteroids = Cushing's disease/syndrome

excess mineralocorticoids = Conn's (primary)

hypofunction of adrenal cortex = Addison's disease

mineralcorticoid =

glucocorticoid =

androgen =

catecholemines =

*what part are these all from?

Adrenal Cortex (80%)

steroid hormones

mineralcorticoid = aldosterone

glucocorticoid = cortisol

androgen = DHEA

Adrenal Medulla (20%) 

catecholemines = EPI and NE

hypothalamus

↓

CRH

↓

Ant. pituitary

↓

ACTH

↓

Adrenal cortex

↓

cortisol

this hormone has catabolic effect on bone/muscle/adipose tissue, inhibits GH, increases glucose (gluconeogenesis), increases SNS, and controls immune/inflammatory response

cortisol

has circadian rhythm...peak just before waking and lowest 11pm-1am

this hormone is stimulated by decreased [K+], causes Na to be reabsorbed and K+ to be excreted, resulting in increased ECF volume and BP

aldosterone

only feedback is [K+]

inc. K+ = metabolic acidosis

DHEA (androgen)

secondary sex cx in females

prolonged or excessive use of therapeutic glucocorticoids is the most common cause of what?

also caused by ectopic ACTH from carcinoid tumors and small cell lung CA

Cushing's syndrome

Cushing's disease is due to a pituitary adenoma secreting excess ACTH

Signs: Truncal obesity, Moon face, HTN, Bruising, Muscle weakness

Sx: Wt gain, Impaired glucose tolerance, Menstrual irregularities, hirsutism

Tests:  inc. plasma/salivary cortisol, low-dose dexamethasone suppression test to confirm Dx, high-dose to locate the origin of ACTH.

Dx:

Tx:

Dx: Cushings Syndrome

Tx: lower cortisol concentration by tapering down dose, monitor the HPA axis