IM renal

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Author:
TerryZ
ID:
249480
Filename:
IM renal
Updated:
2013-11-29 14:13:56
Tags:
internal medicine IM renal
Folders:
IM
Description:
Internal medicine - renal
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  1. Nephrotic syndrome - facts
    • Triad: HoAlb, edema, HChol
    • Path: abnl glomerular permeability
    • Causes: many
    •         Membranous glomerulonephritis
    •         DM (MC cause ESRD in USA)
    •         SLE, Drugs, Infection
    •         Focal segm glomerulosclerosis
    •         Membranous nephropathy
    •         Membranoproliferative GN
    •         Minimal chg dz (kids), prednisone
  2. Nephrotic syndrome - S/Sx
    • Edema: periph, LE -> gen (periorbital)
    • HCoag state: loss of anticoag factors
    • /risk of infection: .
  3. Nephrotic syndrome - Labs
    • Urine prot excr: >3g/day
    • HoAlb: <3g/dL
    • HLipid: .
    • ?Oval fat bodies: in urine
  4. Nephritic syndrome - facts
    • Ind: inflam proc causing renal dysfn
    • Path: inflam of glomeruli due to GN
    • Etiol: post-strep(MC),post-inf(GAS)GN
  5. Nephritic syndrome - S/Sx
    • HTN: .
    • Edema: low-press tissue(periorb,scrot)
  6. Nephritic syndrome - labs
    • Blood: hemat,RBC casts,dysmorph RBC
    • AKI: azotemia, oliguria
    • Mild proteinuria: <3g/day
    • /Cr: .
  7. Nephritic syndrome - types
    • Asymp glom hematuria: prot<1g/d
    • Nephrit syn: AKI, prot 1-3g/d, hemat,
    •             RBC casts, edema, HTN
    • Rapidly prog GN: AKI,prot 1-3g/d,hemat
    •             RBC casts,sys sxs,GFR50%/d-m
    •             extensive glom crescent form'n
    • Post-inf GN: ", /ASO, IgG&C3 basement
  8. AKI - general
    • Def: rapid renal-fn, /Cr .5-1(50%)
    • Urine: ?oliguric, anuric, ~oliguric
    • S/Sx: wt gain, edema
    • Lab: azotemia (/BUN,Cr)
    • Etiol: prerenal, intrinsic, postrenal
  9. AKI - general Tx
    • Avoid: meds blood flow(NSAIDs), N-tox
    • Dosage: adjust for renal fn level
    • Fluids: correct. HoVol<-IVF, HVol<-diur,
    •          mon I/O, wt
    • Lytes: Correct disturb
    • CO: BP 120-140/80-90
    • Dialysis: A,E,I,O,U
    •    Acidosis: signif, intract metabolic
    •    Electrolytes: severe, persist HK
    •    Intox: methanol, ethyl glyc, lith, ASA
    •    Overload: HVol not managed
    •    Uremia: sev(clin), uremic pericarditis
  10. AKI, prerenal - facts
    • MC cause of AKI (60-70%)
    • Potentially reversible
  11. AKI, prerenal - causes
    • syst art blood vol or renal perfus'n
    • HoVol: dehyd,//diur,in,V/D,burn,bleed
    • CHF: .
    • HoTN: sepsis,//~HTNmeds,bleed,dehyd
    • Renal a obstr: .
    • Liver: cirrhosis, hepatorenal syndrome
    • Drugs: NSAIDs, ACEIs, cyclosporin
  12. AKI, prerenal - S/Sx
    • Signs of vol deplete: .
    •    Dry mucous membranes
    •    HoTN
    •    Tachycardia
    •    Tissue turgor
    •    Oliguria/anuria
  13. AKI, prerenal - Labs
    • Oliguria: always
    • /BUN:Cr ratio: >20:1
    • /urine osm: >500
    • urine Na: <20mEq/L
    • FENa<1%: Na avidly reabsorbed
    • /urine:plasma Na: >40:1
    • Urine sediment: bland
  14. AKI, prerenal - Tx
    • Treat underlying d/o
    • NS->euvol & BP (~edema/ascites)
    • X ~HTN meds
    • X ACEIs, NSAIDs
    • If unstable, Swan-Ganz monitoring
  15. AKI, intrinsic - facts
    • Tissue damage->glom filtr & tube fn
    • Kid unable to eff concentrate urine
  16. AKI, intrinsic - causes
    • ATN(MC): Isch(shock,bleed,sep,DIC,HF)
    •   Tox(aminogly,vanc,contr,NSAIDs,pois
    •         myo/hemoglobinurea,cispl,MM-κγ)
    • AGN: Goodpast,Wegen,post-strepGN,lup
    • Vasc: renal a. occl/sten, TTP, HUS
    • Interstit: allerg IN (med hypersens)
    • Malig HTN: .
  17. AKI, intrinsic - S/Sx
    Depends on cause; usually edema
  18. AKI, intrinsic - Labs
    • BUN:Cr: <20:1, closer to 10:1, both /
    • /urine Na: >40mEq/L; FENa>2-3%
    • urine osm: <350
    • u:plasm Cr: <20:1
  19. AKI, intrinsic - Tx
    • Once ATN develops, support, elim agent
    • Oliguric - trial of furosemide
  20. AKI, post-renal - facts
    • Least common: (5-10%)
    • Etio: Obstr}/tube press}\GFR. B for /Cr
  21. AKI, post-renal - causes
    • OBSTRUCTION!
    • MC: Urethral 2/2 BPH 
    • loneK: .
    • Stones: .
    • Neoplasm: .
    • Retroperitonal fibrosis: .
    • Ureteral: B, rare
  22. AKI, post-renal - Dx
    • Key: /BUN,Cr
    • Lytes: CBCw/diff, Alb
    • UA dipstick: prot 3+/4+ (RF<-glom d/o)
    •          micro: casts
    •                   Hyaline: prerenal
    •                   RBC: glomerular dz
    •                   WBC: parenchymal infect
    •                   Fatty: nephrotic syndrome 
    •          chem: Na, Cr, Osm, FENa
    •             FENa=(UNa*PCr)/(UCr*PNa)
    •             <1 prerenal, 2-3+ parenchymal
    • Renal US: .
  23. AKI, post-renal - Tx
    • Bladder catheter for decompression
    • ?Urology consult
  24. AKI - Prerenal vs Intrinsic
    • _               Prerenal         Intrisic       _
    • UA:         hyaline casts       Abnl
    • BUN:Cr:       >20:1          <20:1
    • FENa:           <1%           >2-3%
    • U Osm:     >500mOsm  250-300mOsm
    • U Na:           <20            >40(>20)
  25. AKI - UA table
    • Cause       Sediment          Prot  Blood
    • Prerenal:  Benign,hyaline    neg   neg
    • ATN:        Mud,tube,gran    trace  neg
    • AGN:        Dysmorph RBC,    4+    3+
    •                R/W/fatty casts
    • AIN:         R/WBCs,Wcasts    1+    2+
    •                eosinophils
    • Postrenal: benign,?R/WBCs  neg   neg
  26. Uremia - facts
    • Uremic synd: assoc w/adv renal impair
    • Uremia: S/Sx assoc/w accum N wastes
    • Occurs: rarely if BUN>60mg/dL
    • Path: .
    •    Accum of toxins (prod port metal)
    •    X fluid/lyte homeo, hormone regul
    •    Progressive sys inflam(vasc/nutrit)
  27. Uremia - S/Sx
    • Skin: pruritis, yellow
    • Endo: HPThy,/ins res,amen,impot,HLipid
    • Lytes: AGacid,HK,HVol,HoCa,HPO4,HMg
    • Pulm: ~<3 edema,pnuemonitis,plueritis
    • CV: cardiomyop,arrhyth,pericard,//ather
    • GI: anorex,N/V,?taste,gastr,PU,bleed
    • Hem: anemia,bleed d/o,leukocyte d/o
    • MS: weak,(pseudo)gout,osteodystrophy
    • CNS: irrit,insom,leth,anorex,seiz,coma
    • PNS: glove-stock,restl leg,foot/wrs drp
  28. Polycystic kidney dz - facts
    • Inher: AD, MC genetic cause of CKD
    • Stat: 50% by 60s; RF<-pyleo, stones
  29. Polycystic kidney dz - S/Sx
    • UT: hematur, 
    • Abd: P, hernia(abd/inguinal)
    • Syst: HTN 75%
    • Kidn: palpable; stones, late RF
    • Brain: IC berry aneur(5-20%)
    • Cyst: infect, bleed into, ->BLOPS
    • Card: valve abnl (MVP, Aortic insuf)
    • GI: diverticula
  30. Polycystic kidney dz - Dx
    US - 305 cysts/kidney
  31. Polycystic kidney dz - Tx
    • Cure: none
    • Symp: drain
    • Inf: tx w/ abx
    • HTN: control
    • ACEI: preserve kidney fn

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