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2012-08-13 14:55:11

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  1. Def of ARF
    • Rapidly deteriorating GFR with accumulation of nitrogenous wastes (azotemia)
    • Serum Cr increases b more than 0.5 mg or more than 50% over baseline levels
  2. Sx of ARF
    • N/V/D
    • Pruritus
    • Drowsiness, dizziness, hiccups, SOB, anorexia, hematochezia
  3. Signs of ARF
    • Tachycardia and hypotension in prerenal
    • Distended bladder, CVA tenderness, enlarged prostate in postrenal
    • Anuria or oliguria, change in volume status, change in MS, edema, weakness, dehydration, rashes, JVD, urinerferous odor, ecchymosis
  4. Best way to measure renal function
  5. Best way to monitor renal insufficiency
  6. What can affect BUN?
    • dehydration
    • catabolism
    • diet
    • renal perfusion
    • liver disease
  7. UA in prerenal ARF
    nl with few hyaline casts
  8. UA in post renal ARF
    NL with few hyaline casts
  9. Prerenal ARF labs
    • Urine Na < 20
    • FENa < 1%
    • Urine osmolality 500 mOsm
    • Elevated BUN/Cr ratio (20:1)
  10. Kidney size in CRF
    < 10 cm
  11. Intrinsic ARF labs
    • Increased urine Na > 40 mEq/L
    • FENa > 1-2%
    • Urine mOsm 250-300
    • Decreased BUN/CR ratio
  12. When to do short term dialysis in ARF
    When CR exceeds 5-10 mg
  13. Indications for dialysis
    • AEIOU
    • Acidosis
    • Electrolyte imbalance
    • Increase Cr
    • Overload fluid
    • Uremia
  14. Stages of CKD
    • Stage 1: GFR > 90; asx
    • Stage 2: GFR 60-89; asx
    • Stage 3: GFR 30-59; asx, BUN/Cr increase
    • Stage 4: GFR 15-29; sx (anemia, acidosis, ^K, vCa, ^phosphatemia)
    • Stage 5: GFR < 15; candidate for kidney transplant
  15. m/c causes of chronic renal failure
    DM (m/c), HTN, GN, PCKD
  16. Sx of uremia
    • Fatigue, malaise, anorexia
    • N/V
    • metallic taste, hiccups
    • dyspnea, orthopnea, impaired mentation
    • insomnia, irritability, muscle cramps, restless legs
    • weakness, pruritus, easy bruising, altered consciousness
  17. Kussmaul respirations
    Deep forced, labored breathing with increasing intensity
  18. goldstandard of dx CKD
    GFR via Cockcroft-Gault formula
  19. Lab findings in CKD
    • Proteinuria if kidney damage, microalbuminuria early
    • increased BUN/Cr
    • Hgb, Hct, electrolytes, and UA are abnl
  20. Tx of CKD
    • ACE-Is and ARBs to slow progerssion of renal dysfucntion
    • tight HTN and glycemic control
    • LDL < 100, tobacco cessation, weight control
    • EPO, iron supplements, antiplatelet therapy
    • Restrict protein intake, adequate caloric intake, Ca and Vit D supplements, limitation of water, Na, K, and phos
  21. GN
    damage of the renal glomeruli by deposition of inflammatory proteins in the glomerular membranes as the result of an immunologic response
  22. Major causes of GN
    Children: benign hematuria, HSP, mild post-infectious GN, IgA nephropathy, hereditary nephritis, membranoproliferative GN

    Adults: IgA nephropathy, hereditary nephritis, SLE, post infectious GN, vasculitis
  23. Difference b/w focal and diffuse GN
    diffuse > 50% of glomeruli affected
  24. Clinical features of GN
    • Hematuria, tea or cola colored urine
    • Oliguria or anuria
    • Edema of face and ees in the morning, feet and ankles in the afternoon and evening
    • HTN is common
  25. Labs in GN
    • Antistreptolysin O titer increased in 60-80%
    • UA shows hematuria, with misshaped RBCs (acanthocytes); RBC casts, and proteinuria (1-2g/24 hours)
    • Decreased C3
  26. Tx of GN
    • Steroids and immunosuppressive drugs
    • Decrease salt and fluid intake
    • Dialysis if symptomatic azotemia is present
    • Medical therapy: ACE Is in chronic GN; tx other sx as necessary
  27. Nephrotic syndrome
    • Excretion of more than 3.5g protein¬† in 24 hours
    • manifests with hypoalbuminemia, lipiduria, hypercholesterolemia, and edema
  28. How does nephrotic syndrome predispose someone to thrombosis?
    secondary to loss of proteins S and C and antithrombin III
  29. Sx of nephrotic syndrome
    malaise, abdominal distention, anorexia, facial edema/puffy eyelids, oliguria, scrotal swelling, SOB, weight gain
  30. Signs of nephrotic syndrome
    ascites, edema, HTN, orthostatic hypotension, retinal sheen, skin striae
  31. Lab findings in nephrotic syndrome
    • UA shows proteinuria, lipiduria, glycosuria, hematuria, and foamy urine
    • UA also shows RBC casts, granular casts, hyaline casts, fatty casts, oval fat body **** (renal tubular cell that has reabsorbed some of the excess lipids in urine)
    • Blood shows: hypoalbuminemia, azotemia, HL
  32. What causes HL in nephrotic syndrome?
    liver producing increased lipoproteins d/t hypovolemia from the loss of intravascular volume
  33. Causes of nephrotic syndrome
    • Any sort of glomerular disease state
    • SLE
    • malignancy
    • toxemia of pregnancy
    • drugs and nephrotoxins
    • lymphomas and leukemias
    • DM
    • amyloidosis
  34. Tx of nephrotic syndrome
    • ACE-Is early
    • diurectics to reduce fluid
    • restrict Na and fluid intake
    • Nl protein and K, but not excessive
    • Tx infections
    • anticoagulants if thromboses are present
    • some pts need steroids
  35. Nephrotoxic drugs
    • aminoglycosides
    • NSAIDs
  36. PKD
    growth of cysts made of epithelial cells from the renal tubules and collecting system, that replace the mass of the kidneys, reducing function and leading to kidney failure
  37. m/c type of PCKD
    autosomal dominant, B/L
  38. m/c sx of PCKD
    other sx
    • back and flank pain, HA
    • Hematuria, HTN, recurrent UTI, weight loss, renal colic, N/V
  39. Lab findings in PCKD
    • anemia
    • UA shows protienuria, hematuria, pyuria, bacteriruia
  40. Dx of PCKD
  41. tx of PCKD
    • supportive
    • manage pain, control HTN, intake of fluids, low-protein diet
    • Tx infections vigorously with abx (bactrim, quinolones, chloramphenicol, vanco)
    • dialysis or transplant when needed
  42. m/c type of kidney stone
    calcium, they are radiopaque
  43. How do uric acid stones appear on xray
  44. How do cystine stones appear on xray
  45. struvite stones
    formed by combo of Ca, ammonium, amd magnesium and are radiopaque
  46. Tx of kidney stones
    • < 5 mm: may pass spontaneously, manage on an outpt basis, drink plenty of fluids, strain urine
    • 5-10mm: elective lithotripsy or uteroscopy with stone basket extraction
    • >10mm: tx on inpt basis, vigorous hydration, ureteral stent or percutaneous nephrostomy, analgesics, lithotripsy
  47. Tx of hypernatremia
    • inpt
    • administer free water
    • dialysis if Na > 200
  48. rapid correction of hypernatremia
    can cause pulmonary or cerebral edema, esp. in pts with DM
  49. When do s/sx of hyponatremia show up?
  50. m/c electrolyte disorder in hospital
  51. Causes of hyponatremia with hypervolemia
    • CHF
    • nephrotic syndrome
    • renal failure
    • hepatic cirrhosis
  52. causes of hyponatremia with euvolemia
    • hypothyroidism
    • glucocorticoid excess
    • SIADH release
  53. DIADH
    hypotonic hyponatermia, urine osmolality > 100 mOsm, nl cardiac, hepatic, thyroid, adrenal, and renal funciton; absence of extracellular fluid volume deficit (Urine Na > 40 mEq/L)
  54. hyponatremia with hypovolemia
    occurs with renal or nonrenal Na loss
  55. SIADH workup
    CT to r/o CNS disorder; CXR to r/o lung pathology
  56. tx of hyponatremia
    • tx hyponatremia on inpt basis
    • tx underlying cause
    • monitor volume status
  57. central pontine myelosis
    overly rapid correction of hyponatremia with hypertonic saline
  58. Central DI
    caused by deficienct secrtion of arginine vasopressin (ADH) from posterior pituitary
  59. Nephrogenic DI
    Caused by kidneys unresponsive to nl vasopressin levels; may be inherited x-linked disorder or acquired as a result of lithium therapy, hypokalemia, hypercalcemia, or renal dz
  60. Tx of neurogenic (central) DI
    parenteral or intranasal desmopressin
  61. Nephrogenic DI tx
    HCTZ or amiloride diuretics or indomethacin
  62. m/c causes of hyperkalemia
    • renal failure, ACE-Is, hyporeninemic hypoaldosteronism, cell death, and metabolic acidosis
    • also hemolysis or thrombocytosis
  63. Neurologic sx of hyperkalemia
    numbness, tingling, weakness, flaccid paralysis
  64. Lab findings in ^K
    • K > 5
    • measure BUN and Cr
    • decreased FE-K
  65. EKG changes in ^K
    • >6.0
    • earliest manifestation is peaking of the T waves
    • flattening of the p wave, prolongation of PR interval, widening of QRS in > 7
    • Final event is sine-wave pattern with cardiac arrest (8.0 to 10)
  66. Tx of ^K
    • Stop K sparing drugs and K supplements, low K diet
    • If severe with EKG changes, calcium gluconate via IV to antagonize the effects of ^K on the heart
    • Sodium bicarb, glucose (D50), and insulin to drive K back into the intracellular compartment
    • Kayexalate to remove K when levels are extremely high
    • dialysis if everything fails
  67. Hypokalemia causes
    • shift of K into intracellular compartment, of from K losses of extrarenal or renal origin
    • m/c caused by diuretics, renal tubular acidosis, or GI loss
  68. Lab findings in hypokalemia
    • K < 3.5
    • EKG shows flattened or inverted T waves, increased prominence of U waves, depression of ST segment, and ventricular ectopy
  69. Tx of hypokalemia
    • no tx needed unless cardiac manifestations are present
    • PO KCl therapy
    • aggressive K replacement in cardiac glycosides, as it can lead to dig intoxication
  70. m/c causes of disorders of calcium and phosphorus
    • parathyroid disorders
    • chronic renal failure
    • malignancy
  71. Causes of hypercalcemia
    malignancy (lung cancer, squamous cell carcinoma of head and neck, esophagus) vit D intoxication, hyperparathyroidism, and sarcoidosis
  72. clinical features of hypercalcemia
    asx until > 12
  73. elevated urine calcium
    malignant neoplastic or paraneoplastic process or hyperparathyroidism
  74. Decreased urine calcium
    primary hyperparathyroidism
  75. Tx for hypercalcemia
    isotonic saline, loop diuretics, manage underlying cause
  76. m/c cause hypocalcemia
  77. lab findings in hypocalcemia
  78. tx hypocalcemia
    • tx any emergent cardiovascular states
    • replace severe deficiency with clacium gluconate or calcium chloride
  79. m/c cause of hyperphosphatemia
  80. S/sx of hypermagnesemia
    • initially reduced DTRs
    • muscle weakness, hypotension, respiratory depression, then cardiac arrest
    • N/V/flushing
  81. hypermagnesemia EKG changes
    widened QRS complex, prolonged PR interval, prolonged QT interval
  82. hypermagnesemia tx
    • 10-20 mL of 10% calcium gluconate IV over ten minutes
    • saline diuresis and IV furosemide may increase excretion of magnesium
    • dialysis if severe
  83. m/c causes of hypomagnesemia
    • chronic alcoholism
    • chronic diarrhea
    • hypoparathyroidism
    • hyperaldosteronism
    • diuretic therapy
    • osmotic diuresis
    • nutritional deficiencies
  84. severe acidemia vs severe alkemia
    <7.2, > 7.6
  85. Respiratory acidosis
    primary increase in pp of CO2 i the blood and decreased blood pH; the kidneys therefore slowly increase bicarb
  86. Pathophysiology of respiratory acidosis
    • failure of lung to excrete CO2
    • result of alveolar hypoventilation leading to pulm CO2 retention or of overproduction of CO2 or a combo of both
  87. causes of respiratory acidosis
    • primary pulm dz
    • myasthenia gravis
    • primary CNS dysfunction
    • drug induced hypoventilation
  88. When do kidneys start compensating for respiratory acidosis?
    2-5 days, when they increase H+ secretion and bicarb production in the distal nephron, after which the plasma bicarb level steadily increases
  89. tx of respiratory acidosis
    • tx underlying causes
    • ventilation if CNS or pulm depression is severe
  90. respiratory alkalosis
    decreased blood pCO2 and increased blood pH
  91. Respiratory alkalosis pathophys
    • resulve of excessive elimination of CO2 d/t increased ventilatory drive
    • kidneys respond to eliminate bicarb
  92. causes of respiratory alkalosis
    • anxiety m/c
    • ASA intoxication
    • hypoxia
    • intrathoracic disorders
    • primary CNS dysfunction
    • GM (-) septicemia
    • liver insufficiency
    • pregnancy
  93. s/sx of respiratory alkalosis
    • frequent, deep, sighing respirations to stustained and obvious rapid, deep breathing
    • circomoral paresthesias, acropharesthesias, giddiness or lightheadedness
  94. lab findings in resp alkalosis
    • loss of CO2 via lungs, increase in pH
    • within hours H+ secretion in distal nephron decreases, Cl increases
  95. tx of resp alkalosis
    correct underlying disorder
  96. S/sx of respiratory acidosis
    metabolic encephalopathy (aka hypercapnic encephalopathy) with HA and drowsiness is m/c change
  97. metabolic acidosis
    • elevation in nl serum concentration of H ions that is initiated by either the loss of bicarb from or by the addition of H+ ions to the serum
    • presiratory response is imemdiate with compensatory increase in respiration
  98. Causes of metabolic acidosis
    • Anything that can cause increased H+ in the blood
    • lactic acidosis
    • diabetic keotacidosis
    • starvation ketosis
    • ethlene glcol
    • metahol
    • salicylate intoxication
    • renal tubular acidosis
    • renal insufficiency
    • adrenal insufficiency
  99. earliest sign of metabolic acidosis
    other s/sx
    • hyperventilation is earliest
    • ventricular arrhythmias
    • neurologic sx ranging from lethargy to frank coma)
  100. Lab studies of metabolic acidosis
    • bicarb follws the bPh in metabolic acid0base disorders; in acidosis the pH and bicarb both go down
    • pH < 7.38m decreased plasma bicarb, decreased pCO2
  101. Tx of metabolic acidosis
    • tx the cause
    • insulin therapy and volume repletion for diabetic ketoacidosis
    • Bicarb therapy if pH <7.2
  102. metabolic alkalosis
    • increase in serum bicarb with no change in PCO2
    • kidneys fail to excrete excess HCO3, thereby maintaining the alkalosis
  103. causes of metabolic alklaosis
    • vomiting
    • hyperalimentation therapy
    • disproportionate loss of chloride
    • ¬†(diarrhea)
    • ng tube suciton
    • villous adenoma
    • chloride diarrhea
    • diuretics
    • hypercalcemia
    • milk-alkali syndrome
  104. Clinical features of metabolic alkalosis
    • neurologic abnormalities (paresthesias, carpopedal spasm, light headedness)
    • volume depletion sx
  105. tx of metabolic alkalosis
    • interventions to increase renal excretion of bicarb most effecitve
    • chloride-responsive conditions (gastric fluid loss, diuretic) tx with solutations containing sodium chloride
    • chloride resistant )eg, mineralcorticoid excess) can be tx by removing an adrenal adenoma, or by using spirinolactone
  106. Tx of pyelo
    • immunocompetent: tx with quinolones or Bactrim for 1-2 weeks
    • hospitalize if severe infections or complicating factors
    • f/u urine cultures mandatory 1-2 weeks following treatment
  107. sudden onset of high fever, chills, and low back and perineal pain
    acute prostatitis
  108. tx of prostatitis
    • hospitalization for acute
    • IV amp and gent until cultures are available and pts are afebrile for 24-48 hours
    • Men < 35 yo, ofloxacin x 10 days or ceftriaxone 250 mg IM followed by 10 days of doxy is recommended
    • >35 yo,
    • NSAIDs for analgesia
  109. orchitis sx
    testicular swelling and tenderness, usually U/L, with fever and tachycardia
  110. orchitis cause
    ascending bacterial infection from urinary tract, or in males with mumps
  111. tx of orchitis
    • if mumps, sxmatic relief with ice and analgesia
    • bacteria: tx like epididymitis
  112. epididymitis m/c causes
    • <35: G+C
    • >35: E coli
  113. Epididymitis s/sx
    • heaviness, dull aching discomfort in the affected hemiscrotum radiating up into the ipsilateral flanks
    • markedly swollen and TTP epididymitis
    • fever and chills
  114. Prehn's sign
    relief of pain with scrotal elevation with epididymitis
  115. Tx of epididymitis
    • <35 yo: ceftriaxone 250 mg IM plus doxy 100 mg PO QD x 10 days
    • >35: cipro 500 mg PO QD x 10-14 days
  116. m/c location of prostate cancers
    peripheral zone
  117. hyperechoic lesions in prostate
    prostate Ca
  118. Tx of prostate Ca
    • Low grade tumors that are well differentiated may not need any therapy
    • stage A and B (tumor confined to prostate) tx with radical retropubic prostatectomy, brachytherapy, or external beam radiation therapy
    • Stage C disease (tumor with local invasion) tx as A and B, but with reduced effectiveness
    • Stage D disease (metastic) hormonal manipulation using orchiectomy, antiandrogens, luteinizing hormone-releasing agonists, or estrogens
  119. m/c type of kidney ca
  120. Hippel-Lindau disease
    hereditary RCC
  121. m/c sx of RCC
    other s/sx
    • gross or microscpoic hematuria
    • gross hematuria, flank pain, and palpable mass is classic triad
  122. RCC labs
    • normochromic anemia
    • elevated ESR
    • hematuria
    • dx with CT
  123. Tx of RCC
    • radial nephrectomy for localized dz (T1-T3a)
    • radiation therapyy for palliation in pts with disseminated disease
    • a-interferon and interluekin to stop growth
  124. m/c solid renal tumor of childhood
    Wilms' tumor
  125. nephroblastoma
    Wilms' tumor
  126. m/c sign of wilms
    • asx abdominal mass found by a family member or during PE
    • other sx: anorexia, N/V, fever, abdominal pain, hematuria
    • HTN can occur d/t elevated renin levels
  127. tx of wilms
    • multimodal: surgery, chemo, some radiation
    • chemo responsitive to vincristine, , doxorubicin, and dactinomycin
  128. m/c type of testicular ca
    • nonseminomatous
    • m/c tpe of nonseminomatous is mixed cell type
  129. tumor marker for testicular Ca
    AFP or aHCG
  130. hydrocele
    mass of fluid-filled congenital remnants of the tunica vaginalis, usually resulting from a patent processes vaginalis
  131. Spermatocele
    palpable, round, firm cystic mass with distinct borders, free floating above the testicle, which transilluminates, mass may be tender
  132. time period for saving testicular torsion
    6 hours
  133. dx of varicocele
    doppler sonography
  134. first sign of puberty in males
    scrotal/testicular development
  135. broad waxy casts
    chronic kidney disease
  136. paint-brush appearance of the papillae
    medullary sponge disease
  137. pt with struvite stones and UTI, has sx m/c caused by what bacteria?
  138. m/c cause of nephrotic syndrome in kids
    minimal change disease
  139. type of kidney stone associated with infectious cause
  140. m/c cause of peritonitis in pts getting dialysis