MMD Renal and Urinary

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BostonPhysicianAssist
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149092
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MMD Renal and Urinary
Updated:
2012-04-23 21:40:49
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Urinary sytem Renal failure renal cancer Urinalysis
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Description:
MMD review of the urinary system including both Jay and Maha's lectures with Urinalysis as well
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  1. ____ renal failure has a worsening of renal function over hours to days with retention of BUN and creatinine, while ___ renal failure has worsening renal function over months to years and is usally associated with small kidney size
    Acute, Chronic
  2. What values are given from a urine dipstick?
    • Specific gravity
    • Hgb
    • Glucose
    • Ketones
    • Bilirubin
    • Nitrates
    • Leukocyte esterase
  3. if you find proteins and casts in the urine which is more likely nephrotic syndrome or glomerulonephritis, or Acute tubular necrosis?
    Nephrotic syndrome
  4. If you find hematuria with dysmorphic RBCs, RBC casts and protein what is more likely glomerulonephritis or neprhotic syndrome or acute tubular necrosis?
    Glomerulonephritis
  5. if you find pigmented granular casts and renal tubular epithelial cells in the urine is it Glomerulonephritis, Nephrotic syndrome or Acute tubular necrosis?
    Acute tubular necrosis
  6. If you find WBC (neutrophils and eosinophils) and WBC casts, RBCs and some protein what is the most likely diagnosis Interstitial nephritis (AKA pyelonephritis), Acute tubular necrosis of a wilms tumor?
    Interstitial nephritis or pyelonephritis
  7. Proteinuria is more than how many mg/24 hrs in an adult?
    more than 150 to 160 mg/24 hrs
  8. What is the neprhotic range for proteinuria?
    >3.5 g/24 hrs. WOW THAT IS A S*** ton of protein! eep
  9. What are some benign causes of protinuria?
    • Actue illness
    • Exercise
  10. What are Bence Jones proteins?
    Immunoglobulin light chains (aka paraproteins produced by neoplastic plasma cells.) present in 2/3 of multiple myeloma cases also seen in lytic bone lesions and anemia these are filtered plasma proteins that can be seen in urine
  11. What are 3 tyeps of filtered plasma proteins that can be apparent on a urinalysis OTHER than albumin?
    • Myoglobin (from rhabdomyolysis)
    • Hgb (from hemolysis)
    • Bence Jones proteins (from cancer)
  12. What two parts of the nephron could be damaged if there is a finding of protein in the urine?
    • Glomerular damage- increased permiability across the glomerular basement membrane
    • Tubular damage- faulty reabsobtion in teh proximal tubules (this includes acute tubualar necrosis and toxic injury)
  13. Hematuria is defined as more than ___ RBCs per high powered field
    3
  14. What can give you a false + hematuria
    Vitamin C, Beets, Rhubarb, bacteria, myoglobin
  15. Does most hematuria have a renal or extrarenal eitiology?
    Extrarenal 90% mostly from the bladder and lower urinary tract including infection and bladder cancer
  16. What are some Glomerular causes of Hematuria?
    • Immunoglobin A nephropathy
    • Thin GBM dz
    • Post infectious glomerulonephritis
    • Systemic nephritic syndrome
  17. What are some non-glomerular causes of hematuria?
    Cysts, calculi, interstitial nephritis, renal neoplasm
  18. The amount of plasma ultrafilterd acrossl teh glomerular capillaries (the amount of blood that passes through the glomeruli every minute) is called the ___
    Glomerular Filtration Rate
  19. What is the equation for GFR?
    GFR = (urine concentration X urine flow)/plasma concentration
  20. What is a normal GFR range?
    150-250L/24 hrs or 100-120ml/min/1.73m^2 of the body surface area
  21. ___ is the muscle metabolism product that is found in the urine. Its creation should be (>, < or =) it's excretion
    Creatinine it should be = to its excretion in a stable funcitoning kidney
  22. What is normal creatinine clearance for a healthy young F
    15-20 mg/kg
  23. What is a normal creatinine clearance for a healthy young M
    20-25 mg/kg
  24. How would you calculate the estemated Creatinine clearance value? or the eCCl?
    eCCl = (140-Age) X (mass in kg) X (0.85 if female)/ (72X serum creatine in mg/dL)
  25. If the adult kidney is more than 9 cm in length on ultrasound then this indicates...
    A. Significant irreversible renal disease
    B. Kidney atrophy due to intrinisic kidney disease
    C. I dunno??
    D. Normal kidney
    A. Significant irreversible renal disease
    (this multiple choice question has been scrambled)
  26. If there is a difference in size greater than 1.5 cm between the right and left kidney the pt has ___
    unilateral kidney disease
  27. a "string of pearls" in the kidney on ultrasound incidates what? (Bonus: what if you found a "string of pearls" on ovarian ultrasound?)
    • Polycystic kidney disease
    • or PCO if in ovaries
  28. For Kidney hemorrhage or renal stones would you do a CT with or without contrast?
    Without
  29. To evaluate the urinary tract, pelvicaliceal system or to localize stones in the UTI would you do a CT with contrast or without?
    With
  30. T or F an MRI can help you distinguish the renal cortex from the medulla
    True
  31. What is the most accurate imaging study for the diagnosis of renal artery stenosis?
    MRI
  32. What are some indications for a Renal Biopsy?
    • Unexplained acute or chronic kidney disaseas
    • acute nephritic syndrome
    • Unexplained hematuria and protinuria
    • Previously identified and treated lesion to plan future treatment
    • Systemic disease with kidney dysfunction (SLE)
    • Suspected organ rejection
  33. What are some Relative contraindications to performing a renal biopsy?
    • Solitary or ectopic kidney
    • Horseshoe kidney
    • Uncorrected bleeding disorder
    • Severe uncontrolled HTN
    • Renal infection
    • Renal neoplasm
    • Hyronephrosis
    • ESRD
    • Congenital anomalies
    • multiple cysts
    • uncooperative pt
  34. Can you re-administer anticogulation therapy to a pt directly after a renal biopsy?
    no you should wait 5-7 days
  35. What are the treatments for uncomplicated protinuria?
    • ACE inhibitors: decrease efferent arteriolar resistance (via a dilated efferetn arteriole) in comparison to afferetn arteriolar resistance leading to a decreased glomerular capillary pressure and decreased uriary protein excretion
    • ARBS: Decreased proteinuria and derease progressive renal disese
  36. ___ is a sudden decrease in renal function leading to the inability to maintain fluid and electrolyte balance and to excrete nitrogenous wastes (as evident by a marked increase in creatinine)
    Acute Renal failure
  37. What are the 3 main types of acute renal failure?
    • Prerenal azotemia
    • Postrenal azotemia
    • Intrinsic renal failure
  38. What is the most common cause of Acute renal failure?
    prerenal azotemia
  39. What is the pathophysiology of prerenal azotemia?
    • Hypoperfusion: can be reversed with restoration of renal blood flow if there is no parenchymal damage
    • if hypoperfusion persists it leads to ischemia and intrinsic renal failure
  40. What are some eitiologies of hypoperfusion that may lead to prerenal azotemia?
    • Decreased intravascular volume: hemorrhage, GI losses, dehydration, excessive diuresis, burns and trauma
    • Change in vascular resistance: sepsis, anaphylaxis, ACEI, renal artery stenosis
    • Decreased cardiac output: leading to decreased renal perfusion, cardiac shock, CHF, PE arrhythmias and valvular disaease
    • Decreased delivery to the Kidney: renal artery stenosis
  41. A really high BUN say of maybe something like... 20:1 would indicate what type of acute renal failure? (even though all ARF increases BUN ratio)
    Prerenal azotemia
  42. Does prerenal azotemia cause an increased or decreased GFR?
    decreased
  43. Pts with prerenal failure have a low fractional excretion of what ion?
    sodium
  44. What is the least common cause of acute renal failure?
    Post renal azotemia
  45. In this type of acute renal failure, obstructed urinary flow from both kidneys or a single functioning kidney is present. Obstruction can be constant or intermittent, partial or complete and is a reversible cause of renal failure
    Post renal azotemia
  46. What are some causes of post renal azotemia?
    Urethral obstruction, bladder dysfunction or obstruction, obstruction of both ureters or renal pelvises, BPH, bladder, prostate or cervical cancer mets
  47. What are some sx of Post renal azotemia?
    • Anuria (with complete obstruction)
    • polyuria (as in frequency) oligouria (with amnt)
    • abdominal pain
  48. Pts with post renal azotemia will have an (increased or decreased) urine osmolality, a (increased or decreased) urine Na and an (Increased or decresed) creatinine ratio
    • Increased urine osmolaity
    • Decreased urine Na
    • Increased BUN:Cre
    • NOTE: if it has been a few days then the kidneys get tired of concentrating the urine and have to let sodium out causing an increase in sodium
  49. What is the treatment for post renal azotemia?
    • Remove the obstruction (surgery, lithotripsy, etc)
    • Ultrasound
    • Bladder catherterization (if hydronephrosis and bladder enlargement
    • Monitor lytes and keept the pt hydrated
  50. With this type of ARF the parenchyma of the kidney is affected by definition
    Intrinsic Renal failure
  51. The majority of intrinsic acute renal failure caused by what?
    Acute tubular necrosis 85% of cases
  52. What are some causes of acute tubular necrosis?
    • Ischemia
    • Nephrotoxin exposure: toxins can be exogenous like drugs or endogenous like myoglobinuria from rhabdomyolysis
  53. Acute tubular necrosis due to ____ is caused by prolonged hypotension ro hypoxemia secondary to dehydration shock or sepsis
    Ischemia
  54. Which of the following drugs is NOT nephrotoxic?
    A. Amphotericin B
    B. Aminoglycosides
    C. Gentamycin
    D. cephalosporin
    D. Cephalosporin
    (this multiple choice question has been scrambled)
  55. What are some risk factors for a pt to be more sensitive to exogenous nephrotoxic drugs?
    • Underyling renal damage
    • Dehydration
    • Advanced age
    • Diabetes Mellitus
    • CHF
    • multiple myeloma
    • repeated contrast exposure
  56. A pt comes to you b/c they were found in a coma (still breathing) it is thought that they may have been there for some time because they were very dehydrated and slightly emaciated secondary to muscle wasting. They were found next to a bottle of jack daniels and an empty baggy with traces of cocaine. What is the most likely type of intrinisc renal failure?
    A. Ishcemia from the cocaine?
    B. Radiographic contrast media exposure
    C. Muscle necrosis from prolonged inactivity and cocaine/alcohol use
    D. diabetic nephropathy with dehydration compounded with NSAID use
    BONUS: what would their urine look like?
    • C. muscle necrosis from prolonged inactivity and cocain/alcohol use.
    • Their urine would appear dark with increased phosphatemai and increased uricemia
  57. "Muddy brown Casts"
    Actue tubular necrosis
  58. What should you avoid when treating a pt with acute tubular necrosis?
    fluid overload and hyperkalemia
  59. What are the 3 phases of acute tubular necrosis?
    • Initial injury
    • Maintenance: 1-3 wks to several months of cellular repair and removal of tubular debris oliguric or non oliguric
    • Recovery: GFR rises, BUN and creatinine decrease
  60. This type of intrinsic renal failure is characterized by interstitial inflammatory response with edema and possible tubular cell damage
    Interstitial nephritis
  61. What are some drugs that can cause interstitial nephritis
    Penicillin, cephalosporins, sulphonamides, NSAIDs, rifampin, phenytoin, allopurinol, PPIs
  62. What are some infectious causes of interstitial nephritis?
    streptococcal, leptospirosis, CMV, histoplasmosis, Rocky mountain spotted fever
  63. What are some immunologic causes of intrinsic nephritis
    • Systemic lupus erythmatosus
    • Sjogren's syndrome
    • Sarcoidosis
    • cryoglobulinemia
  64. Pt presents with acute renal failure. They have a fever, transient maculopapular rash, arthralgias and eosinophilia. Their urinalysis reveals RBC, WBC, WBC casts and protinuria. They state that they have sig recent PMH of streptococcal infection which they have?
    Interstitial nephritis is causing their acute renal failure
  65. What is Berger's disease what type of acute renal failure is it associated?
    It is an IgA nephropathy and is associated with glomerulonephritis
  66. What is Wegner's granulomatosis and what type of renal disesae does it cause?
    It is a sytemic necrotizing vasculitis of small vessels affecting the upper airway, pulmonary and skin vessels, immune complexes are depositited on these tissues basement membranes leading to destruction. Glomerulonephritis
  67. What are some causes of glomerulonephritis?
    • IgA nephropathy (Berger's disease)
    • Endocarditis
    • Lupus
    • cryoglobulinemic glomerulonephritis (assiciated with hep C)
    • Membranoproliferative glomerulonephritis (if associated with pulmonary hemorrhage = good pastures syndrome)
    • Wegner's granulomatosus= systemic necrotizing vasculitis of small vessels affecting the upper airway and pumonary and skin vessels
  68. What are two signs/sx of glomerulonephritis?
    HTN and edema (periorbital and scrotal)
  69. What are some labs you should order if you suspect a glomerulonephritis?
    • Urine: moderate protein <3g/d, RBC, RBC casts, WBC
    • Compliment levels
    • ASO titer
    • AntiGBM antibody levels
    • ANCAs
    • Antinuclear antibody titers
    • Cryoglobulins
    • Hepatitis serologies
    • Blood
    • Consider ordering renal ultrasound or biopsy
  70. What is the treatment for glomerulonephritis?
    • High dose corticosteroids
    • cytotoxic agents such as cyclophosphamide
    • Plasma exchange in goodpasture disease until chemotherapy takes effect
  71. What are some clinical manifestations of acute renal failure?
    • N, V malaise
    • AMS
    • pericardial effusion with friction rub
    • arrhythmias secondary to hyperkalemia
    • rales on lung exam secondary to hypervolemia
    • abdominal pain and ileus
    • platelet dysfuntion
    • encephalopathic changes like asterixis confusion seizures
  72. What labs should you order for a pt is acute renal failure?
    • Increased BUN creatinine
    • hyperkalemia, hyperphosphatemia
    • EKG: peaked T waves, PR prolongation and QRS widening
    • QT prolongation secondary to decreased calcium
    • Anemia secondary to decreased erythropoetin production
    • Platelet dysfunction secondary to uremic toxins- intrinsic platelet abnormalities and impairement of the platelet vessel wall interaction
  73. ____ is a progressive loss in renal function over a period of months to years
    Chronic kidney disease or chronic renal disease
  74. Name some glomerularnephropathies that can cause chronic renal failure
    • Primary glomerular disease (IgA nephropathy)
    • Secondary glomerular nephropathy (Diabetic nephropathy)
    • Tubulointerstitial nephritis (drug hypersensitivity)
    • Hereditary disease (polycystic kidney disease)
    • Obstructive nephropathies (nephrolithiasis)
    • Vascular disease (HTN, renal artery stenosis)
  75. What is the most common tumor found in men?
    Benign prostatic hyperplasia (BPH)
  76. 56 y.o. M reports that his urine stream has weakend. He also complains of nocturia, decreased force of stream and hesitancy. He also states he is having post void dribbling. On the basis of the pt's history what do you expect to find on his examination?
    In most cases of BPH the prostate will have a smooth symmetric and firm elastic consistency. If you detect an irregular, harder nodule or lesion cancer must be supected.
  77. What percentage of men with BPH are afflicted with occult prostate cancer?
    10-30%
  78. How well does the size of the prostate corrolate with the symptoms in BPH?
    not well. symptoms can arise because of small fibrous prostate as well as a large one. Addintonal symptoms can also develop as a result of median bar hypertrophy of the posterior vesicle neck, detrusor muscle decompensation or instability
  79. Name 3 tests that can be used to determine the presence of BPH
    • Intravenous urography IVU
    • CT scan
    • Ultrasound
  80. What class of drugs is sued as first line treatment of BPH?
    alpha blockers
  81. Name the most common surgical proceedure for the treatment of BPH
    Transuretheral resection of the prostate (TURP)
  82. Why is surgical correction of cryptorchism important/?
    Surgical correctin is required to preserve fertility, but the procedure has not bearing on the future developement of testicular cancer. Surgery must be perfomed before age 5 to preserve fertility
  83. What children have a high risk for cryptorchism?
    Premature births have up to 20%prevalence
  84. what is the most common cause of sytemic ED?
    Diabetes
  85. What are some sytemic conditions that can cause erectile dysfunction
    Diabetes, hypercholesterolemia, heart disease, depression, renal failure, adrenal and thyroid dysfunction
  86. Name some treatment for improving erectile dysfunction
    Hormonal replacement, vacuum constriction device, vascular surgery, vasoactive thrapy, and penile prosthesis
  87. 33 y.o. male pt presents with a history of sudden onset right flank pain that was sharp and doubled the pt over. This was also assciated wtih nausea and vomiting and radiation of pain around the flank to the lower quadrant of the abdomen and scrotum. based on this history what is the likely diagnosis?
    Kidney stone
  88. What is the test of choice for ruling out a kidney stone?
    Spiral CT scan
  89. What is one of the greatest factors in the prevention of kidney stones?
    the amount of fluid intake by the pt. The more a pt is able to take in fluid the less likely he or she will develop a stone. If the pt has a history of a stone the recommendation is to try to double the amnt of fluids.
  90. What percentage of renal calculi are radiopaque?
    85% with 75% of calcium composed stones being opaque
  91. What are the admission criteria for pts with renal calculi?
    Infection with current obstruction, a solitary kidney and a complete obstruction, uncontrolled pain, intractable emesis, large stones. Only 10% of stones >6 mm pass spontaneously. Other indications include renal insufficency and a complete obstruction or urinary extravasation as demonstrated by IVP.
  92. A urinary pH of 7.3 is conducive for the formation of what kind of stones?
    struvite and phosphorus stones. Alkalotic ruin actually inhibits the fromation of uric acid and cystine stones. Conversly struvite and phosphate stones are inhibited by more acidic urine
  93. What type of renal stone is caused by a genetic error?
    cystine stones. These stones are produced becasue there is an error in the transport of amino acids that results in cystinuria
  94. Whate is kidney stone formation most likely to occur?
    the proximal portion of the collecting system
  95. Name the 3 most common anatomical sites where kidney stones like to get stuck?
    • uterovesicular junction
    • crossing over the iliac vascular structures
    • opening of the urethrovesicular junction
  96. What are some symptoms of Chronic renal failure?
    • Fatigue, weakness, malaise
    • Anorexia, N/V, metallic taste, hiccups
    • Irritability, difficulty concentrating, insomnia, memory deficit
    • Pruritis, yellow skin, easily bruising
    • decresaed libido, menstrual irregularities
    • CP from pericarditis
    • Note: symptoms develop slowly, are nonspecific and continue until renal failure is far advanced
  97. 54 y.o. M with diabetes presents with fatigue, wekaness and malaise. He states that it has been getting worse over the last 6-8 months although it has been going on for about a year. He said that he is just not as hungry as he was and that his wife has complained in his marked decrease in sexual interest in her (she thinks he is having an affair). He has a pertinent PMH of Intrinsic acute renal failure X2 once due to diabetes and NSAIDs and once due to diabetes and aminoglycosides. What does he have now and how would you treat? how would your treatment plan change if his creatinine clearance was 6mg/dL?
    • He is in Chronic renal failure
    • to start potassium restriction and sodium polystyrene sulfonate
    • protein restriction
    • phosphorus restriction
    • magnesium restriction
    • Dialysis when GFR is 10mL/min or creatinine is 8mg/dl OR 15ml/min or 6mg/dL if diabetic which our pt is so if his creatine was 6mg/dL we would have to have a conversation with him about geting on a transplant list and the initiation of dialysis.
  98. ___ is a fishy breath odor assiciated with chronic renal failure
    uremic fetor
  99. ___ is a pale white frost deposit found on the skin secondary to kidney failure and inability to excrete waste. Compounds and waste products excreted through small capillaries throught the skin.
    Uremic frost
  100. What are some cardiovascular and pulmonary symptoms of chronic renal failure?
    HTN, rales, cardiomegally, edema and peircardial friction rub
  101. What are some labs you might find abnormal in chronic renal failure?
    • Increases BUN creatinine
    • Anemia (secondary to decresed erythropoiten)
    • Metabolic acidosis (inability to secrete bicarb)
    • Increased phosphatemia
    • Hypocalcemia
    • Hyperkalemia
    • Urine with BROAD WAXY CASTS
    • US: small bilateral echogenic kidneys
  102. What electrolyte imbalence is the chronic renal failure pt at risk for if their GFR drops below 10-20ml/min?
    • Hyperkalemia
    • it can cause occur with cellular destruction (hemolysis or trauma)
    • Dietary K (citris, fruit, salt substitutes containing K)
    • Drugs that decrease K secretion (amiloride, triamterene, spironolactone, NSAIDs, ACEIs)
  103. In CRF if the damaged kidney is unable to excrte the 1 mEq/kg/d of acid generated by dietary protein metabolism this condition ensues....
    Metabolic acidosis
  104. The majority of chronic kidney disease pts die of ____
    cardiovascular disease
  105. Pericarditis in chronic renal failure is believed to be secondary to the retention of metabolic toxins and is an absolute indication to what treatment modality?
    hemodialysis
  106. In chronic renal failure, CHF causes extracellular fluid overload, anemia and HTN which all increase the work of the myocardium and increase Oxygen demand and accelerate atherosclerosis The treatment to prevent this is ....
    • H20 and Na restrictions
    • Loop diuretics
    • Ofthen in combo with thiazides (if the pts kidneys can tolerate)
  107. What are the neurologic complications of chronic renal failure?
    • When GFR is less than 10-15 mL/min
    • Possibly secondary to aggregation of uremic toxins
    • Sx: Lethargy, confusion and coma
    • PE: Nystagmus, weakness, asterixis, hyperreflexia, stocking and glove neuropathy
  108. What are some Dietery modifications that should be recommended/imposed upon a pt with chronic renal failure?
    • Protein restriction: decreased albumin at the start of dialysis is strong predictor of mortality
    • Na and H20 restriction: Recomended 2gNa/day with 1-2L H2O/day, Na intake >3-4 g/d or else edema HTN and CHF can ensue and it should be less than 1g/d b/c of volume depleteion and hypotension i.e you cant win muahahahaha
    • K restriction: less than 50-60mEq/d
    • Phosporus restriction: limit cola (no coca cola classic ne more) eggs, dairy, meat, add a phosphorus binder if GFR is less than 20-30 mgL/min
    • Magnesium restriction: all laxatives (so if all these new diet changes give them constipation it is the finger and not the bottle) any acids with mg are contraindicated
  109. What is the clinical indication for the initiation of dialysis in a pt with chronic renal failure?
    • GFR 10mL/min or creatinine 8mg/dL
    • if diabetic then: 15ml/min or creatinine 6mg/dL
  110. Other than the GFR and creatinine what are some other indications for the initiation of dialysis in a chronic renal failure pt?
    • Refractory hyperkalemia
    • Fluid overload unresponsive to diuresis
    • Severe metabolic acidosis (pH less than 7.2)
    • Uremic syndrome (encephalopathy, pericarditis, coagulopathy)
    • Neurologic symptoms (seizure or neuropathy)
  111. Explain how peritoneal dialysis works
    • Dialysate enters the peritoneal cavity through a catheter
    • Fluids and solutes move across the capillary bed and between the viseral and parietal layers of the peritoneal membrane
    • can have CAPD- continuous ambulatory peritoneal dialysis (pt exchanges dialysate 4-6X/day)
    • Or CCPD- continuous ambulatory peritoneal dialysis (machine automatically performs exhange at night)
    • This gives pts more autonomy
    • Monitor nutritonal status frequently since large amnts of albmumin are removed
    • Peritonitis with S. aureus is most common complication
  112. What is the most common complicatin to peritoneal dialysis?
    S. aureus peritonitis
  113. Other than dialysis what is the other difinitive treatment for end stage renal disease?
    Kidney transplant
  114. If a pt who needs dialysis declines treatment what is their prognosis?
    death within days to weeks
  115. What are the 3 types of glomerulonephropathies
    • Nepritic syndome
    • Nephrotic syndrome
    • Asymptomatic renal disease
  116. 36 y.o. M pt presents with periorbital and scrotal edema. on UA he is found to have dysmorphic RBCs, RBC casts and some protein. What does he have and what is the treatment?
    • Acute glomerulonephritis
    • Tx: BP and fluid overload control. salt and water restrictions
    • diuresis
    • dialysis PRN
  117. 30 y.o. F pt presents with oliguria and edema with mild hypertension. She works in a daycare and recently had impetigo and pharyngitis simultaneously about 2wks ago. Her UA shows coke colored urine, RBC, and RBC casts, and 1.3 g/d of protein. What is the next diagnostic study you would like to do and what do you think is her diagnosis?
    • Dx: immunoflorescence shows IgE and C3 granular pattern along capillary basement membranes
    • She has post infectious Glomerulonephritis
  118. What is the treatment for post infectious glomerulonephritis?
    • Supportive
    • Abx
    • Na restrictions
    • diuresis
  119. 40 y.o. F pt presents with peripheral edema, and salt retention their bloodwork shows a decreased serum albumin and total protein. Their UA shows 4.0 g/day of protein excretion with some epithelial cell casts and over fat bodies. What does she have?
    Glomerulonephropathy. specifically Nephrotic syndrome
  120. You have a pt with Nephrotic syndrome who is not hypercoaguable, but is having protein loss Edema and hyperlipidemia what treatments would you recommend?
    • Protein loss: protein restriction (may decrease glomerulosclerosis) ACEI (reduce glomerular capillary pressure and proteinuria by decreasing effereten arterioloar resistance)
    • Edema: Na restriction, Diuretics (dependant on the protein this large doses may be nessisary combo of loop diuretics and thiazides are best)
    • Hyperlipidemia: dietary modification and exercise
  121. How would you manage the hypercoaguable state associated with Neprhotic syndrome?
    Anticoagulation for 3-6 months if it is recurrent then treat with anticoag indeffinitly
  122. What causes a hypercoaguable state in pts with neprhotic syndrome?
    losses of antithrombin 3, protein C and S in the urine and increased platelet activation this often leads to renal vein thrombosis
  123. Red blood cell casts are pathopneumonic for
    Glmoerulonephritis
  124. Hematuria with dysmorphic RBCs, RBC casts and protein
    Glomerulonephritis
  125. Proteins and lipids
    Nephrotic syndrome
  126. Pigmented granular casts, renal tubular epithelial cells
    Acute tubular necrosis
  127. WBC (neutrophils or eosinophils) WBC casts, and RBC and some protein
    Interstitial nephritsi or pyelonephritis
  128. proteinuria >3.5g/24 hrs is chracteristic of what?
    nephrotic syndrome
  129. "muddy brown casts"
    tubular necrosis
  130. Who is more likely to get renal cancer men or women?
    men
  131. Medullary cell type kidney cancer is associated exclusively with ___
    Sickle cell trait
  132. What are the risk factors for renal cell carcinoma?
    • Smoking!!!!! number 1 risk factor
    • Obesity in women
    • HTN due to chronic cellular damage at the kidney level
    • End stage renal disease
    • Acquired renal cystic disease
  133. What are some condtions associated with renal cell cancer? Hint: they are all zebras.
    • Von Hippel lindau: predispostion to multiple cancers cystic disease of the kidney and pancreas
    • Tuberous sclerosis: can affect kidneys, GI tract, pancreas, skin
    • Sickle cell trait: causes renal medullary tumor
    • Hoseshoe kidney: congenital malformation that is usuallyu functioning but will rapidly cause renal failure
  134. What is the classic triad of Renal cell carcinoma?
    • Hematuria, flank pain and abdominal mass
    • may lead to a diagnosis of cystitis but if associated with B symptoms CANCER untill proven otherwise
  135. A varicocele on the right in a young man or a new onset varicocele on the left in an older man is a suspicious symptom for what?
    Renal cell carcinoma
  136. What are some paraneoplastic symptoms of renal cell carcinoma?
    • Fever
    • Abnormal liver function (stauffers syndrome- abnormal liver enzyme dysfunction)
    • Cachexia (wasting)
    • Cushing's syndrome - too much cortisol usually peripheral, leads to wt gain fluid retention and fat redistribution
  137. Pt has a flank tenderness that is not colicky in nature but is tender to palpation/manipulation is this characteristic of
    A. RCC
    B. wilms
    C. Renal stone
    D. finicky pt
    A. renal cell carcinoma
    (this multiple choice question has been scrambled)
  138. What is Stauffer's Syndrome
    abnormal liver function associated with Renal cell carcinoma
  139. Where will there be lymphadenopathy in a pt with renal cell carcinoma?
    Inguinal lymphadenopathy and supraclavicular lymphadenopathy
  140. What are some lab findings for Renal cell carcinoma?
    • Hematuria: often have frank RBCs
    • Urinary neoplastic cells (on cytology, where pathology sees cancer and picks up 40% of incidentaloma RCC)
    • Anemia- b/c EPO is not being produced and pt is peeing blood
    • polycythemia
    • hypercalcemia
    • hepatic dysfunction
    • elevated alk phos
    • increased renin
  141. What is the INITIAL test for abnormal UA with suspicion of RCC?
    • Ultrasound
    • Initial test for most kidney issues able to see size degree of volume in kidneys
    • cystic or solid?
    • if cystic take some of that... in other words "tap that ooooooo"
  142. What is the Imaging study of choice for a suspected renal cell carcinoma that is solid?
    • CT with oral and IV contrast
    • Oral contrast for bowel mets
  143. What is the gold standard diagnostic study for renal cell carcinoma?
    • Recection of mass and histological specimin confirmation
    • Histology
    • Clear cell: single kidney affected one tumor
    • Papillary renal cell: bilateral kidneys with multiple tumors
    • Chromophobic: 3-5% rare but best prognosis
    • Medullary: occurs in sickel cell pts
    • Collecting duct
  144. Why is IVP not usually used in the diagnosis of renal cell carcinoma?
    dye load is tremendous and the kidneys need to process it as the kidney fills up with dye it burdens the kidney. However it is an excellent test b/c it will outline the mass in teh kidney since the mass witll not fill with dye
  145. When would you use an MRI as the imaging study of choice Dx of Renal cell carcinoma
    • If the pt has a contrast contraindication.
    • Those include: renal insufficiency, metforman, high dose ACEI, allergies to dye
  146. Why would you do a CXR in a pt with RCC?
    RCC likes to mets to lungs and so if you have any suspicion of that then do a CXR
  147. If a pt with RCC has an abnormal alk phos or bone pain what diagnostic test should you do?
    Bone scan for mets to bone
  148. Surgery is curative in pts with renal cell carcinoma that have stages _____
    stage I and II
  149. What is a partial nephrectomy and when is it used?
    • "wedge resection"
    • Resect tumor and boarders and do if a pt has only one kidney or if there is bilateral kidney involvement or if the pt has a low functioning kidney
    • Tumors need to be less than 4cm
  150. Radical nephrectomy is the removal of....
    • Kidney
    • Nodes associated with kidney/ all diseased nodes
    • Perirenal fascia
  151. For RCC tumors less than 2cm what is another therapy option other than wedge resection?
    • Ablative therapy
    • cryotherapy and RF ablation
  152. What is a helpful proceedure for VERY large RCC tumors pre-op
    • Angioembolization
    • a gel or sponge in renal artery to infarct the kidney it aids the surgeon to take out the kidney in a safe manner
  153. What are some non surgical/adjuvent therapies for RCC?
    • RCC dose not respond to cytotoxic chemotherapy!!!
    • Targeted therapies: anti VEGF and mTOR inhibitors
    • Immunotherapies: Stage IV
    • Radiation therapy: Palliative, shrinks tumor and may make it amenable for resection, sometimes will induce spontaneous regression of CA
  154. What are the most common places for RCC to mets?
    • Lung
    • Bone
    • Regional nodes
    • Brain
    • Adjacent organs
  155. Stage I RCC has a ___ survial rate
    95%
  156. Stage II RCC has a __ survival rate
    75%
  157. State III RCC has a __ survival rate
    40-70%
  158. Stage IV RCC has a _ survial rate
    less than 10%
  159. What is the Karnofsky preformance status?
    • Was originally used for hospice care in determining how likely a pt was to need hospice. also used in evaluation of prognosis of pt with RCC. under 80% is a worse prognosis
    • 100%: normal, no complaints, no signs of disease
    • 90%: capable of normal activity few sx or signs of disease
    • 80%: normal activity with some difficulty some signs or sx
    • 70%: caring for self but not capable of normal activity or work
    • 60%: requriring some help can take care of most personal requriements
    • 50%: requries help often requries frequent medical care
    • 40%: diabled, requires special care and help
    • 30%: severely disabled, hospital admission indicated but no risk of death
    • 20%: very ill urgently requiring hospital admission, reqruies supportive measure or treatmetn
    • 10% morbid, rapidly progressive fatal disease process
    • 0% death
  160. What are two emergent complications to worry about with RCC and how do you treat each?
    • Acute Renal failure: can lead to hyperkalemia so you need to treat and stabilize the heart emergently, hydrate but diurese in worst case
    • Actue Adrenal insufficency: decreased steroid production from adrenal involvement leads to hypotension and shock
  161. How often does an RCC pt need a CT scan post surgery?
    every 3-6 months
  162. What is another name for nephroblatoma?
    Wilms tumor
  163. ___ is a pediatric kidney cancer tht is a malignant tumor arising from embryonal cells
    Wilm's tumor
  164. __ is the most common renal maligancy in childhood
    wilms tumor
  165. Familial wilms tumor is most often (unilateral or bilateral?)
    Bilateral
  166. What are some conditions associated with wilms tumor?
    • Aniridia (no iris)
    • Hemiphypertrophy (all organs and limbs are bigger on one side)
    • cryptorchidism
    • Hypospadias
    • Duplicated renal collecting system
    • WAGR: anridia, genitourinary anomalies and MR
    • Denys- Dash syndrome
    • Klippel Trenaunay syndrome
    • Beckwith- weidemann syndrome
  167. Asymptomatic abdominal mass in a 2-5 y.o. child
    wilms tumor! 90% present with asymptomatic abdominal mass.
  168. What are some symptoms of a wilms tumor?
    • asymptomatic abdominal mass
    • abdominal pain
    • anorexia
    • vomiting
    • malaise
    • gross hematuria
    • constipation
  169. What are some PE findings of a wilms tumor?
    • abdominal mass: will feel retroperitoneal flank mass with a large kidney that can take up 1/2 of the abdomen
    • Prominent abdominal veins
    • Increased abdominal girth
    • microscopic hematuria
    • HTN
    • Anemia
    • other congenital anomalies
  170. An elderly couple adopted a child from Africa and when they saw that the child has no iris they rushed the child to you for evaluation. What are you concerned about?
    Wilms tumor
  171. Where to wilms tumors tend to mets to?
    • Lungs
    • liver
    • contralateral kidney
    • Intra-abdominal sites
  172. What lab studies should you order if you suspect a wilms tumor?
    • CBC, CMP with calcium
    • Urinalysis
    • Coagulation studies (check bleeding, worry if liver dysfunction or von Willibrand dz)
    • Catecholamine metabolites (check for pheochromocytoma)
    • May require a bone marrow biopsy
  173. Best imaging technique for wilms tumor extenstion into the IVC
    Renal ultrasound
  174. ___ confirms diagnosis of a wilms tumor
    percutaneous biopsy
  175. What kind of CT to you order for a child whom you suspect has a wilms tumor
    CT scan of the abdomen and chest with oral and IV contrast
  176. What are favorable findings on biopsy of a wilms tumor
    epithelial, stromal and blastemal elements
  177. What are unfavorable findings on wilms tumor histology
    anaplastic
  178. What is the treatment for a wilms tumor
    • Surgery: pediatric urologist should perform the surgery, it is a radical nephrouterectomy
    • they will also need lymph node dissection
    • do wedge resection if it is bilateral
  179. What are the non-surgical/adjuvant treatment options for wilms tumor
    • Chemotherapy: stage I and II vincristine + pulse dose dactinomycin
    • External beam radiation: Stage III and IV for tx of lung mets
  180. What are some paraneoplastic syndromes associated with wilms tumor
    • polycythemia
    • hypercalcemia
    • von willibrands dz
    • ruputure of wilms tumor
  181. What pt population is most likely to develop bladder cancer?
    Men, african americans 69y.o. + who smoke
  182. What are some risk factors for developing Bladder cancer?
    • Smoking!!!!!!
    • Occupational exposures
    • Schistosomiasis
    • Hx of pelvic irradiation, mostly for gyn tumors
    • Chronic UTI
    • Chronic indwelling catheter
    • Cyclophosphamide exposure
    • High fat diet
    • Chronic dehydration
  183. What r some conditions associated with bladder cancer
    • Spinal cord injury with neurogenic bladder
    • metastasis from other primary malignancy
    • bladder diverticula
    • urachaal remnant
  184. What are some sx of Bladder cancer
    • may be asymptomatic
    • hematuria
    • urinary voiding sx (freqency, urgency, dysruia)
    • Abdominal or pelvic pain similar to UTI
    • Anorexia or wt loss
    • Flank pain
    • hematuria
    • abdominal mass
    • anorexia
    • cachexia
  185. Where does bladder cancer like to mets
    • first invades bladder wall then mets locally to the uterus vagina
    • next the abdominal or pelvic wall
    • finally distal to bone and soft tissue of the abdomen
  186. 70 y.o. M Pt presents with hematuria and pain like a UTI with some frequency and urgency. He has only every had one UTI before and you think it might be bladder cancer. What diagnostic studies should you order?
    • Lab studies: urinalysis, urine culture, urine cytology, CBC, BMP, LFT/alphos for mets to bones and liver
    • Cystoscopy with biopsy: makes diagnosis do a scraping with a fish hook and suction cells
    • Determination of extent and staging is based on imaging: IVP, retrograde pyelogram, cytology, CT of abdomen and pelvis with IV contrast, CXR for mets
    • Histology: transitional cell carcinoma, adenocarcinoma, small cell carcinoma, squamous cell carcinoma, in children its usually Rhabdomyosarcoma
  187. What is the treatment for bladder cancer that is superficial and has not penetrated into the muscular layer of the bladder
    • Transurethral resection of the bladder TURBT
    • or TURBT +BCG if non-muscle invading but deeper than plain superficial
  188. What s the Tx for bladder cancer that is muscle invasive
    • Radical cystectomy with lymph node dissection: en bloc resection of the prostate and hysterectomy prophylactic
    • bladder sparing cystecotmy is becomming more popular- if cut out bladder need to create ancillary tract like a peritoneal drain which can increase chance of infection or neurogenic problems
  189. What are the non-surgical/adjuvant therapy for Bladder cancer?
    • Chemotherapy: for all muscle invading tumors (M-VAC methotrexate, vinblastine, doxyrubicine, cisplatin) preoperatively, adjuvently for mets following cystectomy, for unresectable diseease or non surgical candidates
    • STOP SMOKING!
  190. ___ is the narrowing or complete occlusion of one or both renal arteries
    renal artery stenosis
  191. Cases of renal artery stenosis in older men are usually caused by ___ while cases of renal artery stenosis in young women are usually ___
    • Atherosclerosis
    • Fibromuscular dysplasia
  192. What causes renal artery stenosis in children
    intimal fibrodysplasia
  193. What are some comorbidities associated with renal artery stenosis
    • PAD
    • DM
    • AAA
    • SLE
    • RA
  194. What are some risk factors for renal artery stenosis
    • Atherosclerosis
    • old age
    • FMD
    • autoimmune Dz
    • Smoking
    • low socioeconomic status
    • men
    • white men
  195. is there a genetic component to renal artery stenosis
    no
  196. What are some associated conditions with renal artery stenosis
    • high grade retinopathy (cotton wool spots on fundoscopic exam)
    • Abdominal flank bruit
    • atherosclerotic disease
    • CAD
    • PAD
    • new onset HTN after 50
    • Extrinsic compression on a renal artery
    • Embolic disease
    • Dissection
    • Iatrogenic surgical mishap
  197. Any time there is acute decrease in renal function after giving ACE inhibitors you should evaluate the pt for
    renal artery stenosis (bilateral)
  198. If you start a pt on an ACEI when should you check a metbolic panel
    • 3wks
    • ACE I can cause acute renal failure by decreaseing efferent pressure meaning the kidney is not perfusing meaning cant pass solute meaning suddent dramatic increase in creatinine
  199. What is the tx for a pt who has acute renal failure following ACE I therapy
    • they have bilateral renal artery stenosis
    • discontinue the ACEI and hydrate treat with RAS
  200. What test can your pt do at home to test for erectile dysfunction
    postage stamp test
  201. What are the Signs and Sx of renal artery stenosis
    • Asymptomatic most of the time
    • May have sx of actue hypertensive urgency/emergency (mental changes, headache, shortness of breath, visual changes, papilledema)
    • HTN
    • Acute Renal failure
    • Abdominal bruit
    • Hypertensive retinopathy
    • Bruit on PE
  202. What lab studies would you do for renal artery stenosis
    • Repeat BP
    • Urinalysis: look for hematuria, protinuria, any sign of renal failure, casts
    • BMP
    • Plasmin Renin
    • Renal vein renin levels: perform during dye studies not commonly done unless you need to determine which kidney has RAS. Kidney with RAS will have increased renin production compared to nonaffected kidney
  203. Pt has elevated serum renin. One kidney is known to have renal arter stenosis one does not. Which kidney is producing the renin
    the affected kidney
  204. What imaging studies would you do for renal artery stensosis
    • Renal ultrasound with doppler
    • Captopril nuclear renogram
    • digital subtraction angiography (invasive) inject dye into arteries to look for FMD knotted ropy arteries gold standard
    • MRA not done as much as CT
  205. What is the gold standard test for fibromuscular displasia causing renal artery stenosis
    • Digital subtraction angiography
    • Inject dye into arteries to look for FMD
    • will find knotted or ropy renal arteries
  206. What is the treatment for renal artery stenosis?
    • ACEI is DOC for HTN unless bilateral RAS
    • control HTN
    • Manage lipids
    • Asprin or plavix
    • Wt loss
    • Smoking cessation
  207. What is the surgical managment for renal artery stenosis
    • PCTA: percutaneous transluminal coronary angioplasty with stenting, or surgical revascularization
    • Aortorenal bipass: alternative is splenorenal or hepatorenal bypass
  208. WHat is the follow up for stenting in renal artery stensosis
    • Lifelong follow up and therapy
    • At least every 6 mo BP renal function and UA provider must draw BMP 3-4 wks after starting ACEI
  209. What is the peak age range for neprholithiasis
    20-40 y.o.
  210. who is more likely to get renal stones males or females
    Male caucasian males
  211. If a stone moves into a ureter from the kidney what complications do you have to worry about
    hydronephrosis that dialtes and leads to symptoms of decresed renal function and renal parenchymal damage
  212. What are the risk factors for nephrolithiasis
    • genetic susceptitibilty
    • Obesity
    • Type II DM
    • Gout
    • Neurogenic bladder
    • Low urinary volume
    • Diet
    • Medications
    • work environment with high heat exposure
    • outdoor activities in teh summer
  213. What are some dietary contributors to nephrolithiasis?
    • Low dietary calcium intake: need calcium to decrease kidney stones but calcium supplments increase stones wierd
    • Calcium supplements
    • High animal protein intake
    • Low fluid intake
    • Hight vitamin C intake (but OJ decreases stones)
    • Low magnesium intake
    • Low potassium intake
    • Low vitamin B6 intake
  214. What are some medications that can lead to nephrolithiasis
    • Hypercalcemia: acetazolamine, CCBs, calcium supplements, phosphorus binding antacids, furosemide, corticosteroids, topiramate, triamterene, theophylline
    • Hypoditraturia: thiazides and furosemide
    • Hyperuricosuria: Probenecid, salicylates radio contrast dye and losartan
  215. What are some conditions associated with neprholithiasis
    • Gout
    • Inflammatory bowel disease
    • malignancy
    • hyperparathyroidism
    • hyperthyroidism
  216. 34 y.o. M landscaper presents with sudden very severe flank pain that makes tehm double over it radiated from his testicles throughout his abdomen as if he were kicked in teh balls. He also reports nausea.
    nephrolithiasis
  217. Sx of nephrolithiasis
    • may be asymptomatic
    • flank pain often severe (usally sudden onset, may radiate to back groin or genitalia, pt will often point to kidney)
    • urinary frequency or dysuria
    • nausea with or without vomiting
    • gross hematuria
  218. PE signs of nephrolithiasis
    • Pt is unable to sit still
    • diaphoresis
    • tachycardia
    • intestinal ilius
    • CVA tenderness
    • Occasional fever
    • Best to rule out other causes of abdominal pain
  219. What are some lab studies you would order for a suspected nephrolithiasis
    • CBC to ruleout infection
    • BMP plus calcium
    • urinalysis
    • stone analysis
    • 24 hour urine for metabolite abnormalities
    • serum parathyroid levels
    • urica acid levels
  220. Eitiologies of a calcium phosphate stone
    • Dehydration,
    • increased calcium absrobtion or excretion
    • RTA
    • hyperparathyroidism
    • chronic bowel disease
    • malabsorbtion
    • poor GI citrate absorbtion
    • Excess vitamin D or C
    • alkaline urine
    • calcium antacids
    • malignancy
    • hyperthyroidism
    • chronic corticosteroids
    • thiazide diuretics
  221. Stones associated with UTI that have staghorn calculi usually made of magnesium amonium and or phosphate they occur in alkaline urine
    struvite stones
  222. Infection with urease producing bacteria can cause what type of renal stone
    struvite
  223. These stones occur with familial gout, IBD, high purine diet, acidic urine, myeloprolivertive disorders malignancy and chemo
    uric acid stones
  224. these stones occur with hereditary cystinuria
    cystine stones
  225. What imaging studies would you do for nephrolithiasis
    • Non contrast helical CT is the test of choice
    • Plain abdominal X ray 70% of calcium stones show up
    • IVP but high dye load not optimal
    • US will not show stone but will show hydronephrosis
  226. What is the immediate treatment for a nephrolithiasis
    • Rehydration: 3mm stones can pass most stones 5mm and more will not pass but may with time over 1cm WONT
    • Pain control: NSAIDs tordol 30 mg IV 60 mg IM not PO, narcotics morphien dilaudid
    • antiemetics: zofran
    • Alpha antagonist blockers
  227. What are some indications for urgent admission and consult for a pt with nephrolithiasis
    • Urosepsis
    • Anuria (no pee, most likely urethral obstruction where 2 kidneys are blocked sometimes a catheter will pass the stone but if not then call surgery)
    • Renal failure
  228. Pain control nephrolithiasis can include
    • NSAIDs: toradol 30mg IV or 60mg IM not PO
    • Narcotics (morphine, dilaudid, fentynyl)
  229. Dispostion for a pt who has a small kidney stone less than 5mm and no hydronephrosis
    • can d/c home
    • continue hydration
    • pain control narcotic nsaid combo like vicopro
    • Expulsive therapy: alpha antagonist, CCB, corticosteroids
    • strain urine
    • avoid food triggers
    • frequent follow up
    • must pass stone within 4 wks
  230. Plan and disposition for a pt with a larger kidney stone more than 5mm, hydronephrosis or uncontrolled pain or infection
    • uruology intervention
    • depends on location
    • ESWL: uppper pol or renal pelvis less than 2cm
    • URS: uretral or kidney stones
    • Percutnatous nephrolithotripsy with loer pole large stone or UP junction
    • Open surgery no longer frequently used
  231. What f/u should you do on a pt with acute nephrolithiasis
    • must document stone passage
    • weekly or biweekly radiographs
    • lab monitoring
    • prevention
  232. What are some complications of acute nephrolithiasis
    • acute obstruction
    • spesis
    • renal failure

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