Systems - Nephro - Urology
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What are two drugs you should never combine WRT the kidney? Why?
- -Anything that blocks ANG II (e.g. ACE i) and an NSAID
- -NSAID blocks prostaglandins, the effect of this is constriction of the afferent arteriole
- -blocking ANG II wil cause vasodilation of the efferent arteriole
- -result is decreased blood flow to the kidney and death
What are the EKG changes you see in hyperkalemia? (9)
- -peaked T waves
- -increased PR
- -flat or no p wave
- -shortened QT
- -AV blocks
- -wide QRS
- -sine wave
- -V fib
A patient presents with hyponatremia, low serum osmoles, and hypo-osmolar urine (<100 mosm/L). What is on your DDx? (3)
polydipsia (drank lots of water), poor solute intake, or a reset osmostat
What are the 6 D's of HYPERnatremia?
- Diabetes insipidus
- Docs (iatrogenic)
What is the maximum rate you should correct sodium imbalance at? What are the big concerns for a) hypernatremia and b) hyponatremia
12mmol/L per day
a) cerebral edema
b) central pontine myelinolysis
What are the normal physiological ranges for Na, K, Cl, HCO3
- Na: 135-145 mmol/L
- K: 3.5-5 mmol/L
- Cl: 95-105 mmol/L
- Bicarb: 18-23 mmol/L
How do you treat hyperkalema?
- C BIG K Drop
- Calcium: stabalize cardiac myocyte membrane
- Beta agonist: reuptake K; Bicarb: correct the metabolic acidosis, reuptake K
- Insulin: shifts K into the cell
- Glucose: to compensate for the insulin administration
- Kayexalate: binds K in the GIT and you then excrete in your feces
What is azotemia?
abnormally high levels of nitrogenous wastes in the (elevated BUN)
In what two cases would you correct hyponatremia with hypertonic saline? What is usually the best replacement fluid?
- 1) neurological sx due to hypoNa
- 2) serum Na is <120
otherwise, normal saline is usually the best choice.
What are the ECG findings in hyperkalemia (4)? what can it progress to?
- -peaked T waves, QRS prolongation, PR prolongation, low P waves
- - can progress to sine waves and then death
What is the DDx of metabolic acidosis? treatments for some
- Methanol: fomepiloz
- Uremia: dialysis
- Diabetic ketoacidosis (also eTOH and starvation: insulin and fluids
- Iron/isoniazide: GI lavage, charcoal
- Lactic acidosis
- Ethylene glycol: fomepizole
- Salicylates: alkanize urine
Describe the appropriate compensation you expect to see in metabolic/respiratory acidosis/alkalosis
- met acidosis: 1 decreased HCO3 = 1 dec pCO2
- met alkalosis: 1 inc. HCO3 = 1 inc pCO2
- acute resp acidosis: 10 inc pCO2 = 1 inc HCO3
- chron resp acidosis: 10 inc pCO2 = 3 inc HCO3
- acute resp alk: 10 dec pCO2 = 2 dec HCO3
- chron resp alk: 10 dec pCO2 = 4 dec HCO3
DDx for normal anion gap acidosis (2). describe two of the subtypes of the second one
- -Renal tubular acidosis
- -Type I (distal): problem with low H+ secretion, low serum K, pH > 5.3
- - Type IV (distal): aldosterone deficiency/resistance, high serum K, pH < 5.3
Describe the three anatomical categories of Acute Kidney Injury.
- Prerenal: hypovolemia
- Renal: Glomerular, tubulointerstitial, small/large BV
- postrenal: obstruction
What are the indications for dialysis?
- KAPPEL! as in Dr. Kappel
- -Pulmonary Edema (fluid overload)
- -"Looped" out on drugs
With regards to the FENa, UNa, Uosm; how do pre-renal azotemia and acute tubular necrosis differ?
- PRA vs ATN
- FENa: <1%, >1%
- Urine sodium: <20, >20
- Urine osm: >500, <300 -high in pre-renal azotemia because low volume status of patient
What does aldosterone do? How does a deficiency cause hyperK
secretes K into the lumen, reabsorbs Na, both Via the ENAC channels.
Also antiports 3Na/2K on the basal membrane
Also secretes H+ into the lumen via the Na/H antiporter
In a hyponatremia case where the ADH is working, but patient is euvolemic what is on your DDx?
- rule out thyroid
- rule out adrenal insufficiency
- if not these: SIADH
What is always the treatment in hypernatremia?
How do you calculate water deficit in hypernatremia?
What is the threshold for acuve vs chronic kidney injuries
What are the 4 general renal (intrinsic) causes of AKI? some prototypical disorders of each.
- vessels: HTN crisis (scleroderma), TTP-HUS
- glomerulus: nephritic and nephrotic syndromes
- tubules: ATN
- interstitium: Acute interstitial nephritis
Classical 4 findings in nephrotic syndrome (which three are NEEDED!). How does this compare to nephritic syndrome?
- >3g/day proteinuria (albuminuria)
- low serum albumin (duh!)
- generalized edema
Nephritic syndrome: proteinuria <1.5g/day, HTN, hematuria, rising Cr, mild edema
what is the MOST COMMON cause of secondary nephrotic syndrome?
diabetes, diabetes, diabetes
what are the three categories of nephritic syndrome? Examples of each
- Type I - Anti-GBM disease: Goodpasture's syndrome, Alport's syndrome
- Type II - Immune Complex: post-infectious GN (GAS usually), IgA nephropathy (Berger's disease)
- Type III - Pauci immune: Wegener's gran.,
Primary and secondary causes of nephrotic syndrome
Primary: Minimal change disease, focal segmental glomerulosclerosis, membranous nephropathy (IVDU's), membranoproliferative GN
Secondary: Diabetes, lupus, amyloidosis, multiple myeloma
three causes of ATN
Ischemic, nephrotoxic, septic
What is the triad of acute interstitial nephritis?
fever, rash, eosinophilia
What is the definition of CKD?
- kidney damage > 3 months and one of the following
- -GFR<60 ml/min
- -structural or functional (urinary) abnormalities of the kindey
what are 4 conditions that can give decreased GFR, but no structural or functional kidney abnormalities
- -congestive heart failure
- -liver cirrhosis
- -history of being a kidney donor
Classification of CKD (3 categories)
- Cause: GN, tubulointerstitial, vascular, congenital (these are pretty much the same as AKI)
- GFR category: stage increases as GFR decreases
- albuminuria level: can combine with GFR to get a prognostic score
three congenital causes of AKI
- Fabry's disease
- Alport;s syndrom
When someone has a vascular disease, what do you need to be concerned about?
What happens generally to kidney size in AKI and CKD. 5 exceptions
generally normal in AKI and small in CKD
exceptions (big kidneys in chronic): DM, MM, lymphoma, hydronephrosis, PKD
what is RBC cast's and dysmorphic RBC's pathognomonic for?
What are the indications for renal biopsy (5)
- -unexplained glomerular hematuria
- -unexplained glomerular proteinuria
- -nephrotic syndrome
- -acute nephritic syndrome (RBC casts and dysmorphic RBC's)
- -unexplained acute kidney failure
When should you refer CKD patients to a nephrologist?
- -eGFR < 30
- -progressive decline in eGFR
- -persistent significant proteinuria
- -failure to reach treatment goals
top two causes of ESRD in kids
- aplasia (no/small kidney)
- hypoplasia (not enough)
What is the definition of hematuria?
>5 RBCs/microL in uncentrifuged midstream urine
3+ RBCs/HPF in HPF
How can you differentiate glomerular and non-glomerular hematuria
- glom: brown, RBC casts, dysmorphic RBCs
- non-glom: pink/red
What usually causes postinfectious GN? treatment/prognosis
- Preceeding GAS infection
- supportive tmt with diuretic to prevent fluid overload, usually a complete recovery
Three steps when approaching hematuria
- Is it blood?
- What is the clinical story?
- Where is the blood from?
Proteinuria and hematuria...which is worse?
What are the 4 mechanisms of proteinuria?
- Increased glom permeability (glomerular)
- Decreased tubular reabsorption (tubular)
- Increased renal protein secretion (secretory)
- Overproduction of plasma proteins (overflow)
When measuring protein (24 hr void) in kids, what is:
What is a more humane way to measure this in a kid?
- 1) <4 mg/m^2/hr
- 2) >4
- 3) >40
Do a Pr:Cr ratio
First line tmt for nephrotic syndrome
If you use a BP cuff that is too small, will the BP be too high or low?
too high. you will need to pump it up way more in order to occlude the artery
Describe how to define prehypertension and hypertension in peds patients?
pHTN: 90%tile<SBP or DBP<95%tile, OR any adolescent 12+ yo with BP >120/80
HTN: SBP or DBP>95th %tile for
both need to be measured at least 3 times and averaged
What are the 3 categories of peds HTN?
- stage1: 95-99th percentile plus 5 mmHg
- Stage 2: >99th percentile plus 5 mmHg
- Emergency: Stage 2 plus Sx
How do you treat peds HTN?
treat underlying cause
if it is not known what the cause is, treat like adult HTN
What is the #1 cause of ESRD?
What is the hallmark of glomerular disease?
What is are the thresholds for proteinuria and albuminuria (micro and macro) in diabetics?
- proteinuria: 150+ mg/day
- albuminuria: 30+ mg/day
- -microalb. 30-300 mg/day
- -macroalb. 300+ mg/day
Describe the progression of diabetic nephropathy
- hyperfiltration (elevated GFR)
- progressive nephropathy (decreased GFR)
- ESRD (GFR<15)
Remember that proteinuria in a diabetic is NOT always what?
What are the targets for controlling diabetes?
2hrs post prandial
- HbA1c: < 7
- fasting glucose: 4-7 mmol/L
- 2hrs post prandial: 5-10 mmol/L
- BP: 130/80
What is the single most effective measure to prevent the progression to diabetic nephropathy? How?
BP control. Usually requires 3+ medications.
- -RAAS blockade
- -CV protection (happy heart = happy kidneys)
What is the pathophysiological char's of diabetic nephropathy? (3)
- Mesangial expansion
- GBM thickening
Why do ACEi's cause increased serum Cr?
They impair alpha2-mediated efferent arteriole vasoconstriction (less GFR)
What is malignant hypertension (hypertensive emergency)?
BP>= 180/120 WITH end organ damage
end organs are: brain, heart, kidneys, eyes
How do you treat a hypertensive emergency?
IV meds to decrease DBP to about 100 mg over 6 hours. Any more may cause ischemic events
then use oral meds to decrease BP over several weeks
What is hypertensive urgency? What to do?
asymptomatic (no acute end organ damage)
oral meds to decrease BP slowly
Describe the long-term complications of HTN (4 categories)
- Brain: ischemic stroke, hemorrhage
- Heart: CHF, LVH
- -hypertensive nephhroslerosis -> CKD-> ESRD
- -accelerate other renal diseases -> ESRD
- Eyes: retinopathy
How many cases are primary (essential) HTN? secondary? 4 categories of secondary. When should you screen for secondary?
95% are essential HTN and don't need further investigation
Secondary: renal, endocrine, drugs, other
no need to screen for secondary unless there are clues
What are the 4 major drugs used to treat HTN?
- -thiazide diuretics
- -ACE inhibitors/ARB's
- -beta blockers (last line)
What are the indications (1) and contraindications (5) to renal transplant?
- indications: ESRD (CKD stage 5)
- contraindications: cancer, infection, systemic disease, psychiatric disease, obesity
How do you take a history for obstructive and irritative LUTS.
- FUN(irritative, filling) WISE (obstructive, voiding)
- Frequency increased (>8 times in 24 hours)
- Urgency (need to go immediately)
- Nocturia (2+ times per night)
- Weak stream
- Intermittent flow
- Straining to empty
- Emptying is incomplete
Describe the typical presentation of prostate cancer
non-specific. May have elevated PSA +/- nodules on DRE +/- BPH symptoms
Do you want to screen with PSA levels or DRE? When is PSA the most informative? When should you stop routine screening?
- both! higher sens and spec if you do both tests. When you have previous PSA tests to compare to, you can see if the PSA is elevated in that patient.
- Stop when they are 75, unless there is a clinical indication to test
Describe how to assess risk in prostate cancer using the PSA, Gleason, and clinical staging
Describe the tmts for prostate cancer (4)
- Radical prostatectomy (laproscopic removal)
- Radiotherapy (external beam or brachytherapy)
- androgen deprivation (only for metastatic disease, it is palliative)
- Palliative radiotherapy
What is normal urinary frequency and amount?
5-8 times (300-400 mls per time)
What is the normal prostate size?
walnut size (25-30 mm)
In BPH, size does not correlate to what?
symptoms or degree of obstruction
What zone of the prostate do you usually see cancer? BPH?
- cancer: peripheral zone
- BPH: central
Describe the tmt progression in BPH.
- -alpha blockers (terazosin, relax SM)
- -5-alpha reductase inhib (inhibit the production of DHT)
- -transurethral resection of the prostate (TURP, basically hollowing it out from the inside out)
Complications of BPH (6)
- -overflow incontinence
- -renal insufficiency
- -bladder stones
- -bladder distension
- -recurrent UTI
What is the cornerstone of medical tmt in OAB? optical contraindication
antimuscanarics such as oxybutynin. narrow angle glaucoma
What can cause an elevated PSA (5)?
- -prostatic trauma
What is the pain that you classically see in renal colic (acute UUT obstruction). What is the main etiology?
flank/abdomen pain, radiates to groin, labia, testicles, the patient CANT get comfortable!
main cause is stones.
What is the most common cause of chronic UUT obstruction
3 most common locations for UUT obstruction
- uretopelvic junction (UPJ)
- pelvic brim (iliac vessels)
- uretovesicle junction (UVJ)
two most common causes of urethral strictures
- iatrogenic (operations, catheters)
Most common cause of bladder stones. most common make-up of stones
infection stones. Usually made up of CaOx (usually due to hypercalcemia)
What is the best diagnostic technique in urolithiasis?
CT is the gold standard
What medical treatments are used for stones? (3)
- -Hydration DOES NOT facilitate expulsion and may increase renal capsular distension.
- -analgesics (NSAIDS -> narcotics)
- -relax smooth muscles (alpha-blockers, CCB's)
When should you urgently and emergently refer stones to urology
-Urgent: intractable pain and/or intractable N/V
-Emergent: fever (urosepsis) is most urgent, solitary kidney, or bilateral obstructing stones
Urological (surgical) tmts for stones (3)
- -extracorporeal lithotripsy
- -uretorenoscopy laser lithotripsy
- -percutaneous nephrolithotomy (definitive tmt for the biggest stones)
What ANS components are responsible for ejaculation and eretion?
- Point and Shoot
- Para is erection
- Symp is ejaculation
Describe reflex and psychogenic erections
- reflex: somatic sensation vi pudendal nerve increases parasymp outflow via cavernosal nerves
- psychogenic: erotic stimuli increases BOTH symp and parasymp outflow
Describe the 4 steps in the physiology of an erection
- 1) dilation of arteries
- 2) enlargement of sinusoidal spaces
- 3) compression of subtunical veins
- 4) increase in cavernosal pressure
What drugs are an absolute contraindication to PDE5 inhibitors (e.g. sildenafil, aka viagra)? why?
nitroglycerine, because the combined effects lead to a severe HYPOtension.
how many men suffer from ED by age 50?
50% by age 50
describe the functional classification of ED
- 1) arterial: same RF's in CAD
- 2) cavernosal: Peyronie's disease (ED, painful plaque, curvature)
- 3) hormonal: libido is the first thing to go in testosterone deficiency
- 4) neurological: CNS, PNS, demyelinating, surg
- 5, but is involved in all) psychological
Big things to ask in and ED Hx and look for in an ED PE?
- Hx: nocturnal erections, masturbation erections mean pshycogenic etiology
- PE: groin pulses, neuro (including anal tone), scrotal and penile exam
Why is tadalifil (cialis) better than viagra and levitra?
- -longer half life (17 hours as opposed to 2 hours)
- -no interaction with alcohol
What is the DDx for PainFUL scrotal masses? (6)
- -testicular torsion
- -torsion of appendix epididymis
- -testicular abscess
- -hematocele (usually from trauma)
- -testicular tumor with hemorrhage
What is the DDx for painLESS scrotal masses (5)
- -testicular or paratesticular tumor
If you see a sexually active young man in your office with scrotal pain what should you think?
chlamydia and gonorrhea
If you clinically suspect testicular torsion what should you do? how long do you have?
urgently refer to a urologist for an emergent right detorsion and bilateral orchidopexy (fixation of testes to scrotum). salvage rates are 100% if you get at it in the first 6 hours
What are the 4 key clinical findings for testicular torsion?
- -ipsilateral loss of kremasteric reflex
- -high riding testicle
What is the most important RF for testicular cancer. Etiology of 95% of testicular cancers. route of metastatic spread
- cryptorchidism (undescended testicle)
- 95% are primary germ cell tumors (not mets).
- retroperitoneal LNs->lungs->liver->brain
What are the 2 types of primary testicular tumors. What are the tumor markers for testicular cancer?
- seminoma is hCG only
- non-seminoma is AFP +/- hCG
painless scrotal masses are what until proven otherwise
So you have someone coming in with a NAGMA, what are the 2 common etiologies? how do you differentiate?
either renal tubular acidosis or diarrhea
- RTA has a positive urine anion gap
- diarrhea has a strongly NeGUTive urine anion gap.
If you see a patient come in with ADPKD and a headache, what is the first thing that you MUST rule out? most common cause of death in ADPKD?
- an aneurysm in the circle of willis
- renal failure is the most common cause of death
What is the most common congenital urethral obstruction? Classic findings?
- -posterior urethral valves
- -male infant with distended, palpable bladder with low urine output.
DDx of hematuria
- I PEE RBCS
- Infection (UTI)
- External Trauma
- Renal glomerular disease
If someone has a dipstick test positive for blood, what should you do?
Urinalysis. hematuria is defined as >2-3 RBC's per HPF
When should you refer hematuria to urology? (4)
- -anyone with gross hematuria (unless UTI)
- -anyone over 40
- -anyone who smokes (high risk of bladder cancer)
- -abnormal cytology/ultrasound
2 key concepts for family docs evaluation hematuria
- -don't investigate +ve dipstick, confirm with microscopic analysis first
- -rule out serious disease, not always necessary to make a diagnosis (we usually dont)
What is the most common cause of dysuria? who gets it most often? why?
infection, 3F:1M, they have a short urethra
describe the history and initial investigations with someone coming in with dysuria? PE?
- Hx: sexually active?, vaginal/urethral discharge?, fever?
- urine culture
- PE: not in women with classic signs, always in men because it is less common
When can you give an appropriate empirical abx in suspected UTI? (3) when to refer?
- abx if:
- -classic symptoms in young women
- -abnormal urinalysis
- -vaginal urethral discahrge
refer if it not clearly an infection
When should you do an intravenous urogram?
NEVER! Just refer them on for CT
How do you manage renal trauma?
Usually just watch and wait. The renal capsule will hold the kidney together and the tamponade pressure will limit bleeding. If you surgically incise the parenchyma you will lose this pressure. You save more renal tissue this way
If there is suspected urethral trauma what should you NEVER do? Why? What should you do instead?
DONT INSERT A FOLEY CATHETER!! you can turn a partial urethral injury into a full injury and then they need surgery! use a suprapubic catheter
How do you investigate suspected urethral injury?
retrograde urethrogram (xray contrast up the urethra)
Describe 5 things you typically see in primary nocturnal enuresis histories
- bedwetting since toilet training
- FAMILY HISTORY
- no daytime Sx
- no bowel Sx
- developmental stages are normal
80% of children achieve night time control of urination by what age?
What is the definition of a UTI?
When should you do a voiding cystourethrogram? what is it looking for?
- -recurrent febrile UTI
- -U/S or nuclear renal scan (which you would do first) is abnormal.
looking for vesicouretral reflux
If you have UTI and a high fever what does this suggest?
What is the most common cause of hematuria in children?
glomerulonephritis (think especially if they are post GAS-infection) and there are RBC casts and proteinuria
If testicles dont come down by this age, they are NOT going to come down on their own
In crytptorchidism. Why should you do orchidopexy by year one?
because of worry about infertility (starts decreasing at this point). Cancer risk does not change with surgery
If you see a child with hypospadius (large urethral opening on the underside of the penis) what should you never do? why?
circumcise him, because you will need the skin later on for reconstruction.
Prostate cancer is a dietary disease. three dietary things for reducing prostate cancer?
green tea, soy products, cooked tomato products
According to dee dee what drink should you suggest for preventing UTI?
What are reasonable hippie choices for treating nonbacterial prostatitis (2)
If a patient has elevated kidney function tests what should you not forget to ask about?
supplements and botanical therapies
Describe the clinical classification of urinary incontinency (5)
-urgency: strong desire to pee, but can't wait long enough for the toilet
-stress urinary: caused by increased intraabdominal pressure (e.g. cough)
-mixed urinary: combo of stress and urge
-overflow: retention, void small amounts with large residual volume
-total: complete loss of control
Describe the common lesions than can cause neurogenic bladder
spinal cord (2)
- Brain: stroke, concussion, tumor, parkinson's
- SC: MS, acute lesions
- peripheral: sensory (diabetes), motor (polio, herpes, etc)
Describe what the following measure:
- -cystometrogram: intrabladder pressure changes in response to gradual filling.
- -persistent flatline: atonic bladder
- -early spike: overactive bladder
- -uroflowmetry: pattern of urination
Absolute indications for catheter drainage/urinary diversion (3)
- -UUT deterioration or persistently poor emptying despite optimal treatment
- -Unmanageable vesicouretral reflux with infection causing UUTI
- -temp diversion for an abscess or fistula makes LUT unusable as a reservoir or conduit
DDx of Pre renal causes of AKI (5)
- -renal artery stenosis
Vascular causes of AKI (2)
Key urine findings in these AKI types
- -pre-renal: empty (hyaline) casts
- -glom: RBC casts
- -tubular: granular "muddy brown" casts
- -interstitial: WBC casts
- -vascular: "bland" urine
compare and contrast pre-renal AKI and ATN
- They are both different end of the same spectrum:
- pre-renal: hyaline casts, reversible, Urine Na is low
- ATN: granular casts, irreversible, urine Na is not low
What are the non-glomerular renal causes of hematuria (4+)
definition of proteinuria and albuminuria
- >150 mg/day protein
- >30 mg/day albuminuria
Describe the 5 causes of proteinuria
- Transient (benign: exercise, illness, etc)
- glomerular (nephrotic, nephritic)
- tubular (tubes secreting)
- overflow (too much monoclonal protein, e.g. MM)
- Orthostatic (benign, young people, split urine test)
What are the top 5 causes of nephrotic syndrome?
- 1) minimal change disease
- 2) focal segmental glomerular sclerosis
- 3) membranous
- 4) amyloidosis
- 5) DM
What is the clinical triad of nephritic syndrome?
- -elevated BP
- -dysmorphic RBC's/casts
- -AKI - subacute increase in Cr
list some examples of the three types (based on path stain) of nephritic syndrome
- pauci: ANCA
- linear: anti-GBM (goodpasture's)
- granular (low C3, C4): IgA nephropathy, lupus nephritis, membranoproliferative GN, post infectious GN
What is a Normal Anion Gap Metabolic Acidosis (NAGMA)? How do you differentiate the causes
Basically if the ion gap is normal OR if the change in bicarb is greater than the change in anion gap (which basically means that there is something else causing the bicarb to dip) then there is NAGMA as well. Either RTA or Diarrhea
- Urine ion gap = Na+K-Cl
- -If it is neGUTive, bicarb is being made (and putting lots of Cl in the urine) and this is due to diarrhea
- -If it is positive, there is low Cl meaning that bicarb is not being made because of some problem in the tubules (RTA)
Describe the 3 types of RTA
- Type I (distal) - decreased acid secretion into DT
- Type II (proximal) - decreased bicarb reabsorption in proximal tubule
- Type IV (aldosterone) - not enough aldo production, decreases acid secretion in distal tubule and cause hyperkalemia
What would you like to do?
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