Systems - Nephro - Urology

• -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

• -peaked T waves
• -increased PR
• -flat or no p wave
• -shortened QT
• -AV blocks
• -wide QRS
• -sine wave
• -V fib
• -asystole

polydipsia (drank lots of water), poor solute intake, or a reset osmostat

• Diuresis
• Dehydration
• Diabetes insipidus
• Docs (iatrogenic)
• Diarrhea
• Disease

12mmol/L per day

a) cerebral edema

b) central pontine myelinolysis

• Na: 135-145 mmol/L
• K: 3.5-5 mmol/L
• Cl: 95-105 mmol/L
• Bicarb: 18-23 mmol/L

• 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
• Dialysis/diuresis

abnormally high levels of nitrogenous wastes in the  (elevated BUN)

• 1) neurological sx due to hypoNa
• 2) serum Na is <120

otherwise, normal saline is usually the best choice.

• -peaked T waves, QRS prolongation, PR prolongation, low P waves
• - can progress to sine waves and then death

• MUDPILES
• Methanol: fomepiloz
• Uremia: dialysis
• Diabetic ketoacidosis (also eTOH and starvation: insulin and fluids
• Paraldehyde
• Iron/isoniazide: GI lavage, charcoal
• Lactic acidosis
• Ethylene glycol: fomepizole
• Salicylates: alkanize urine

• 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

• -Diarrhea
• -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

• Prerenal: hypovolemia
• Renal: Glomerular, tubulointerstitial, small/large BV
• postrenal: obstruction

• KAPPEL! as in Dr. Kappel
• -hyperKalemia
• -acidosis
• -Pulmonary Edema (fluid overload)
• -Pericarditis
• -Encephalopathy
• -"Looped" out on drugs

• 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

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

• rule out thyroid
• rule out adrenal insufficiency
• if not these: SIADH

give water

3 weeks

• vessels: HTN crisis (scleroderma), TTP-HUS
• glomerulus: nephritic and nephrotic syndromes
• tubules: ATN
• interstitium: Acute interstitial nephritis

• >3g/day proteinuria (albuminuria)
• low serum albumin (duh!)
• generalized edema
• hyperlipidemia

Nephritic syndrome: proteinuria <1.5g/day, HTN, hematuria, rising Cr, mild edema

diabetes, diabetes, diabetes

• 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: Minimal change disease, focal segmental glomerulosclerosis, membranous nephropathy (IVDU's), membranoproliferative GN

Secondary: Diabetes, lupus, amyloidosis, multiple myeloma

Ischemic, nephrotoxic, septic

fever, rash, eosinophilia

• kidney damage > 3 months and one of the following
• -GFR<60 ml/min
• -structural or functional (urinary) abnormalities of the kindey

• -congestive heart failure
• -liver cirrhosis
• -hypothyroidism
• -history of being a kidney donor

• 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

• ADPKD
• Fabry's disease
• Alport;s syndrom

CKD

generally normal in AKI and small in CKD

exceptions (big kidneys in chronic): DM, MM, lymphoma, hydronephrosis, PKD

GN

• -unexplained glomerular hematuria
• -unexplained glomerular proteinuria
• -nephrotic syndrome
• -acute nephritic syndrome (RBC casts and dysmorphic RBC's)
• -unexplained acute kidney failure

• -eGFR < 30
• -progressive decline in eGFR
• -persistent significant proteinuria
• -failure to reach treatment goals

• aplasia (no/small kidney)
• hypoplasia (not enough)

>5 RBCs/microL in uncentrifuged midstream urine

3+ RBCs/HPF in HPF

• glom: brown, RBC casts, dysmorphic RBCs
• non-glom: pink/red

• Preceeding GAS infection
• supportive tmt with diuretic to prevent fluid overload, usually a complete recovery

• Is it blood?
• What is the clinical story?
• Where is the blood from?

Proteinuria!

• Increased glom permeability (glomerular)
• Decreased tubular reabsorption (tubular)
• Increased renal protein secretion (secretory)
• Overproduction of plasma proteins (overflow)

• 1) <4 mg/m^2/hr
• 2) >4
• 3) >40

Do a Pr:Cr ratio

steroids

too high. you will need to pump it up way more in order to occlude the artery

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

• stage1: 95-99th percentile plus 5 mmHg
• Stage 2: >99th percentile plus 5 mmHg
• Emergency: Stage 2 plus Sx

treat underlying cause

if it is not known what the cause is, treat like adult HTN

diabetic nephropathy

proteinuria

• proteinuria: 150+ mg/day
• albuminuria: 30+ mg/day
•   -microalb. 30-300 mg/day
•   -macroalb. 300+ mg/day

• hyperfiltration (elevated GFR)
• microalb
• macroalb
• progressive nephropathy (decreased GFR)
• ESRD (GFR<15)

diabetic nephropathy

• HbA1c: < 7
• fasting glucose: 4-7 mmol/L
• 2hrs post prandial: 5-10 mmol/L
• BP: 130/80

BP control. Usually requires 3+ medications.

• -RAAS blockade
• -CV protection (happy heart = happy kidneys)
• -lifestyle

• Mesangial expansion
• GBM thickening
• Glomerulosclerosis

They impair alpha2-mediated efferent arteriole vasoconstriction (less GFR)

BP>= 180/120 WITH end organ damage

end organs are: brain, heart, kidneys, eyes

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

BP>=180/120

asymptomatic (no acute end organ damage)

oral meds to decrease BP slowly

• Brain: ischemic stroke, hemorrhage
• Heart: CHF, LVH
• Kidneys:
• -hypertensive nephhroslerosis -> CKD-> ESRD
• -accelerate other renal diseases -> ESRD
• Eyes: retinopathy

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

• -thiazide diuretics
• -ACE inhibitors/ARB's
• -CCB's
• -beta blockers (last line)

• indications: ESRD (CKD stage 5)
• contraindications: cancer, infection, systemic disease, psychiatric disease, obesity

• 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

non-specific. May have elevated PSA +/- nodules on DRE +/- BPH symptoms

• 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

• Radical prostatectomy (laproscopic removal)
• Radiotherapy (external beam or brachytherapy)
• androgen deprivation (only for metastatic disease, it is palliative)
• Palliative radiotherapy

5-8 times (300-400 mls per time)

walnut size (25-30 mm)

symptoms or degree of obstruction

• cancer: peripheral zone
• BPH: central

• -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)

• -overflow incontinence
• -renal insufficiency
• -bladder stones
• -bladder distension
• -recurrent UTI
• -hematuria

antimuscanarics such as oxybutynin. narrow angle glaucoma

• -Ca
• -BPH
• -UTI
• -prostatic trauma
• -prostatitis

flank/abdomen pain, radiates to groin, labia, testicles, the patient CANT get comfortable!

main cause is stones.

UPJ obstruction

• uretopelvic junction (UPJ)
• pelvic brim (iliac vessels)
• uretovesicle junction (UVJ)

• trauma
• iatrogenic (operations, catheters)

infection stones. Usually made up of CaOx (usually due to hypercalcemia)

CT is the gold standard

• -Hydration DOES NOT facilitate expulsion and may increase renal capsular distension.
• -analgesics (NSAIDS -> narcotics)
• -relax smooth muscles (alpha-blockers, CCB's)

-Urgent: intractable pain and/or intractable N/V

-Emergent: fever (urosepsis) is most urgent, solitary kidney, or bilateral obstructing stones

• -extracorporeal lithotripsy
• -uretorenoscopy laser lithotripsy
• -percutaneous nephrolithotomy (definitive tmt for the biggest stones)

• Point and Shoot
• Para is erection
• Symp is ejaculation

• reflex: somatic sensation vi pudendal nerve increases parasymp outflow via cavernosal nerves
• psychogenic: erotic stimuli increases BOTH symp and parasymp outflow

• 1) dilation of arteries
• 2) enlargement of sinusoidal spaces
• 3) compression of subtunical veins
• 4) increase in cavernosal pressure

nitroglycerine, because the combined effects lead to a severe HYPOtension.

50% by age 50

• 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

• Hx: nocturnal erections, masturbation erections mean pshycogenic etiology
• PE: groin pulses, neuro (including anal tone), scrotal and penile exam

• -longer half life (17 hours as opposed to 2 hours)
• -no interaction with alcohol

• -testicular torsion
• -torsion of appendix epididymis
• -Epididymitis
• -testicular abscess
• -hematocele (usually from trauma)
• -testicular tumor with hemorrhage

• -hydrocele
• -spermatocele
• -variocele
• -hernia
• -testicular or paratesticular tumor

chlamydia and gonorrhea

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

• -ipsilateral loss of kremasteric reflex
• -high riding testicle
• -pain
• -erythema

• cryptorchidism (undescended testicle)
• 95% are primary germ cell tumors (not mets).  
• retroperitoneal LNs->lungs->liver->brain

• hCG
• Alpha feto protein
• LDH

• seminoma is hCG only
• non-seminoma is AFP +/- hCG

testicular cancer

either renal tubular acidosis or diarrhea

• RTA has a positive urine anion gap
• diarrhea has a strongly NeGUTive urine anion gap.

• an aneurysm in the circle of willis
• renal failure is the most common cause of death

• -posterior urethral valves
• -male infant with distended, palpable bladder with low urine output.

• I PEE RBCS
• Infection (UTI)
• PKD
• Exercise
• External Trauma
• Renal glomerular disease
• BPH
• Cancer
• Stones

Urinalysis. hematuria is defined as >2-3 RBC's per HPF

• -anyone with gross hematuria (unless UTI)
• -anyone over 40
• -anyone who smokes (high risk of bladder cancer)
• -abnormal cytology/ultrasound

• -don't investigate +ve dipstick, confirm with microscopic analysis first
• -rule out serious disease, not always necessary to make a diagnosis (we usually dont)

infection, 3F:1M, they have a short urethra

• Hx: sexually active?, vaginal/urethral discharge?, fever?
• urinalysis
• urine culture
• PE: not in women with classic signs, always in men because it is less common

• abx if:
• -classic symptoms in young women
• -abnormal urinalysis
• -vaginal urethral discahrge

refer if it not clearly an infection

NEVER! Just refer them on for CT

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

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

retrograde urethrogram (xray contrast up the urethra)

• bedwetting since toilet training
• FAMILY HISTORY
• no daytime Sx
• no bowel Sx
• developmental stages are normal

5

>10^5 microbes/ml

• -recurrent febrile UTI
• -U/S or nuclear renal scan (which you would do first) is abnormal. 

looking for vesicouretral reflux

pylonephritis

glomerulonephritis (think especially if they are post GAS-infection) and there are RBC casts and proteinuria

6 months

because of worry about infertility (starts decreasing at this point). Cancer risk does not change with surgery

circumcise him, because you will need the skin later on for reconstruction.

green tea, soy products, cooked tomato products

cranberry juice

quercetin, cernilton

supplements and botanical therapies

-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

• Brain: stroke, concussion, tumor, parkinson's
• SC: MS, acute lesions
• peripheral: sensory (diabetes), motor (polio, herpes, etc)

• -cystometrogram: intrabladder pressure changes in response to gradual filling. 
•   -persistent flatline: atonic bladder
•   -early spike: overactive bladder
• -uroflowmetry: pattern of urination

• -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

• -hypovol
• -renal artery stenosis
• -CHF
• -cirrhosis
• -sepsis

• TTP-HUS
• scleroderma

• -pre-renal: empty (hyaline) casts
• -glom: RBC casts
• -tubular: granular "muddy brown" casts
• -interstitial: WBC casts
• -vascular: "bland" urine

• 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

• pyelonephritis
• stones
• PKD
• trauma
• others

• >150 mg/day protein
• >30 mg/day albuminuria

• 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)

• 1) minimal change disease
• 2) focal segmental glomerular sclerosis
• 3) membranous
• 4) amyloidosis
• 5) DM

• -elevated BP
• -dysmorphic RBC's/casts
• -AKI - subacute increase in Cr

• pauci: ANCA
• linear: anti-GBM (goodpasture's)
• granular (low C3, C4): IgA nephropathy, lupus nephritis, membranoproliferative GN, post infectious GN

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)

• 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