1
Q
Blood urea nitrogen
A
Tells amount of urea nitrogen in blood that is made by liver when protein is broken down
Nitrogen then excreted into urine
2
Q
What does a BUN/Creatinine ratio greater than 20/1 indicate
A
Decreased blood flow to kidneyes
3
Q
Creatinine
A
Produced from muscle breakdown
Produced at constant rate and filtered through kidneys
Not the best test of kidney function because muscle mass needs to be considered (amputees, muscle wasting, malnutrition)
4
Q
What does doubling of creatinine represent
A
50% decrease in GFR
5
Q
Glomerular filtration rate (GFR)
A
Blood filter by glomeruli per minute
BEST way to measure kidney function and monitor progression
6
Q
Best lab to measure kidney function and and monitor progression
A
GFR
7
Q
What all is considered in GFR calculation
A
Serum creatinine, age, sex, race
8
Q
What GFR indicated chronic kidney disease
A
GFR<60 for over 3 months
9
Q
What GFR shows pt should be referred to nephrologist
A
GFR<30 chronically
10
Q
Do healthy kidneys excrete albumin into urine
A
No
11
Q
Microalbuminuria lab value
A
Albumin 30-300mg/L of urine
12
Q
Albuminuria
A
> 300mg/L of urine
13
Q
Abnormal albumin/creatinine ratio
A
30 or higer shows albumin is leaving at an accelerated rate (can be used because creatinine excreted at steady state)
14
Q
Whats tested on urine dipstick
A
Specific gravity
pH
Protein (albumin)Glucose
Ketones
Blood
Leukocyte esterase
Nitrates
Bilirubin
Urobilinogen
15
Q
Specific gravity definition
A
Ration of weight of urine to equal quantitiy of weight in water
16
Q
Normal specific gravity
A
1.003-1.030
Varies depending on hydration and kidneys ability to maximally dilate
17
Q
Normal pH of urine
A
4.5-8
18
Q
Albumin scoring on dipstick
A
Trace - 5-30
1+ - 30-100
2+ - 100-300
3+ - 300-1000
4+ - >1000
19
Q
What can cause false positive of albumin on dipstick
A
Alkaline (pH>7) urine
20
Q
What plasma glucose concenctration do you start seeing glycosuria
A
180
21
Q
What complications cause you to have ketones in urine
A
Diabetic ketoacidosis
Salicylate toxicity
Isopropyl alcohol poisoning
Starvation
22
Q
What can cause false positive ketones
A
Sulfhdryl group drugs (captopril or levodopa)
23
Q
What parts of blood are sensed on urine dipstick and how
A
Free hemoglobin and intact erythrocytes via peroxidase activity
24
Q
What can cause false positive for blood on urine dipstick
A
Ascorbic acid
Myoglobin
Bacteria expressing peroxidase activity
Rifampin
Chloroquine
Other iodine forms
25
Leukocyte esterase
Enzyme in leukocytes seen on dipstick
26
Nitrites
Seen on dipstick
Converted from nitrates in UTIs caused by gram negative organisms
27
What does bilirubin in urine indicate
liver disease
Obstructive jaundice
28
WHat can cause false positive of bilirubin on urine dipstick
Chlorpromazine
Ascorbic acid
29
Urobilinogen
Made in gut from metabolism of bilirubin --> reabsorbed --> Excreted in urine
30
What causes positive urobilinogen on dipstick
hemolytic anemia or hepatic necrosis but not from obstructive casuses
31
What would lead you to do urine microscopy
Abnormalities on dipstick
Acute kidney injury
Suspicion for glomerulonephritis
Newly diagnosed CKD
32
What can be seen on urine microscopy
WBC
RBC
Bacteria
Epithelial cells (shows urine wasn't properly gotten)
33
What do dysmorphic RBC on urine microscopy indicate
Glomerular disease
Called cast
34
Pyuria
Excess leukocytes in urine
4 or more leukocytes/HPF
35
Most common cause of pyuria
UTI
36
Cause of hyaline cast
Hypovolemia
37
What does hypovolemia cause in kidneys
Low urine output an dhyaline casts
38
What does tubular injury casue
Pigmented epithetical tubular debris and muddy brown casts
39
What does glomerular injury cause
Erythrocyte casts with lomerulonephritis
40
What does tubulointerstitial injury of the kidney cause
Leukocyte cast with pyelonephritis
41
What will be urine sodium if there are prerenal problems
<20
42
Normal urine sodium
Around 20
43
What will be urine sodium if ther eare problems with the kidney itself
>40
44
Urine osmolality definition and normal
500-850
Number of dissolved particles or concentration of all particles per unit of water in urine
45
What does a high urine osmolality indicate
>850
Problems before kidney
46
What does low urine osmolality indicate
300-500
Problems within the kidney
47
What level of protein in urine is considered proteinuria
>300
48
What lab values define acute kidney injury
Creatinine: 0.3 or more increase in last 48 hrs
49
Oliguric
urine production 400-500mL/day
50
Anuria
Urine production <100/day
51
CKD findings on imaging
Kidneys could be smaller
52
Acute Kidney disease complications non-renal complications
Uremia causing nausea vomiting, malaise, ams, encephalopathy
Pericardia effusions causing cardiac tamponade
53
AKI lab findings
Elevated BUN an creatinin
Metabolic acidosis with increased aniion gap
Hyperkalemia
Hyperphosphatemia
Hypermagnesemia
Hypocalcemia
Anemia
54
AKI ECG findings
Long QT segment (from hypocalcemia)\
Peaked T waves (from hyperkalmia)
PR prolongation
QRS widening
55
Three types of AKI
Prerenal
intrinsic - in kidney itself
Postrenal
56
How can decreased profusion cause AKI
Decrease in intravascular volume
Changes in vascular resistance
Low CO
57
Prerenal AKI lab findings
BUN/Creatinine ratio >20:1 due to decreased urea
Urinary sediment shows benign or hyaline casts
Urine osmolarity high (>500)
Fractional excretion of Na (FENa) low (<1%)
58
Prerenal AKI treatment
Treat heart failure or
infection (abx)
IV hydration or blood transfusion to get euvolemia
Watch electrolytes
Avoid nephrotoxic drugs
59
Most common type of intrinsic AKI
Acute tubular necrosis
60
Major causes of acute tubular necrosis
Ischemia
Nephrotoxin exposure
61
Sites of injury of intrinsic renal disorders
Tubules
Interstitium
Vasculature
Glomeruli
62
Acute tubular necrosis causes
Exposure to nephrotoxins (mostly exogenous):
Antimicrobial agents (aminoglycosides, amphotericin B, Vancomycin, Acyclovir, Cephalosporins)
CT contrast
Calcinerin inhibitor
Rhabdomyolysis
63
How to prevent acute tubular necrosis caused by CT contrast
500-1000mL of normal salline over six hours before and after contrast is given
Avoid nephrotoxic agent s the day before and after contrast is given (metformin, ACEi, ARB)
64
Acute tubular necrosis lab findings
Hyperkalemia
Hyperphosphatemia
BUN and creatininen ration <20:1
Urine osmolality is low (<350)
Microscopy shows a
Pigmented epithetical tubular debris and muddy brown casts
65
Acute tubular necrosis treatment
Speeding up recovery and avoiding complications
Avoid volume overload and hyperkalemia
Furosemide infusion, thiazide diuretics
66
What is rhabdomyolysis
Muscle fibers break down and leak contets into blood stream
67
What is found in labs for rhabdomyoliysis
Myoglobinuria (causes false positive of blood on dipstick)
Elevated creatine kinase levels (>20,000)
Elevated AST, ALT< and lactate dehydrogenase
68
Rhabdomyolysis causes
Distance runnng
Crush injuries
Seizures
Substance abuse
Cocaine
Meds (statins)
69
Rhabdomyolysis treatment
Aggressive volume repletion with normal saline
Remove offending agents
70
Intrinsic AKI (acute interstitial nephritis) causes
Drugs
Infection
Immunologic disorders
Idiopathic conditions
71
Most common drugs to causes acute interstitial nephritis
Penicillins
Cephalosporins
Sulfonamides
NSAIDs
72
Acute interstitial nephritis presentation
Fever
Rash
Arthralgias
Nausea
VOmiting
malaise
HTN
Flank/lumbar pain
Mild edema
Can be asymptomatic
Triad of fever, rash, arthralgias
73
Acute interstitial nephritis lab findings
Peripheral blood eosinophila
Urine eosinophils
Serum BUN/Cr ratio <20:1
WBC. RBC, Casts on UA
74
Acute interstitial nephritis treatment
Supportive and remove offending agent
If persist, hygih dose methylprednisone or prednisone orally for 1-2 weeks then steroid taper for more severe cases of drug-induced interstitial nephritis
75
Postrenal causes of AKI
Urethral obstruction
Bladder dysfunction
Obstruction of both ureters or renal pelvises
Anticholinergic drugs
Neurogenc bladder due to injury, diabetes, or drugs
76
Lab findings in postrenal AKI
Initially high urine osmolality, low urine Na, high BUN/creatinine ration, low FENa, Decreased pH and bicarb
Urine Na increaseds several day slater
urine sediment generally bland
77
Postrenal AKI treatment
Bladder catheterization and ultrasonography to check for hydroureter, hydronephrosis, large baldder volume with no sensation to void.
Monitor I&O
78
Hydronephrosis
Postrenal AKI
Distension of renal calyces and pelvis of one or both kidneys by urine
Obstruction can occur at any level of urinarty tract
79
What causes bilateral hydronephrosis
Obstruction of urinary flow at or bleow level of bladder or urethra
80
How to diagnosis hydronephrosis
Bladder catheterization, if diuresis occurs, obstruction is below bladder neck.
81
Hydronephrosis presentatoin
Pain Caused by distention of collecting system or renal capsule that can radiate to lower abdomen, testicles, or labia
Diff voiding with oliguria or anuria in complete obstruction
Polyuria/nocturia can occur with partial obstruction
82
Hydronephrosis lab findings
UA shows hematuria, pyuria, proteinuria, or bacteriuria with normal sediment
Check BUN/creatinine
Urodynamic testing if suspect bladder causes
83
Hydronephrosis imaging
Ultrasound preferred
IV urogram (aka IV pyelogram)
CT
84
Hydronephrosis treatment
Abx for 3-4 weeks if infection
Catheters, stents, or surgery to fix blockage
85
When to start dialysis in AKI
Serum creatinine > 5mg/dl
Unresponsive acidosis
Electrolyte disorders
Fluid overload
Uremic complications
86
First step in treatment for proteinuria
Max out ACEi (-pril) or ARB (-sartan)
87
What to do if you put them on ACEi/ARB and still have proteinuria
SGLT2 (-flozin)
88
What to do if you give them ACEi/ARB and SGLT2 and still have proteinuria
MRA (spironolactone)
89
What puts someone at highest risk for CKD
Previous acute kidney injury
90
CKD
Abormal kidney function >3 months
Usually asymptomatic until near end stage
91
CKD risk factors
Diabetes mellitus
HTN
Chronic NSAID use
Glomerulonephritis
Polycystic kidney disease
Systemic upus erythamatous
92
CKD presentation
Fatigue
Malaise
Anorexia
Nausea
Vomiting
Metallic taste
Hiccups
DOE
Irritability
Muscle cramps
Restless legs
Weakenss
Pruritis
Easy bruising
Altered mentation
muscle waisting
Pallor
Edema
Ecchymosis
Bruit
Weight loss
93
Symptoms of CKD stages I-IV
Asymptomatic
94
CKD labs
BMP to get GFR
Urinalysis: proteinuria,, albuminuria, UACR
Urine microscopy: waxy casts
CBC: anemia
95
Who to give Statin in CKD
>49 yo
ASCVD
DM
Hx of TIA/CVA
10 year risk>10%
96
Who to give RAS inhibitor (ACEi/ARB) in CKD and how to go about that
BP >120/80
Proteinuria
Use highest dose tolerated
Recheck BMP 2-4 weeks after initiation
97
Who to give SGLT2 inhibitor in CKD
Diabetes
HF
Refractory proteinuria on max RAS agent
98
When to give MRA (spironolactone) in CKD
Proteinuria despite RAS agent and SGLT2
99
Who to screen for CKD
Diabetes
HTN
CAD
Age>50
Obesity
Fam hx CKD
Polycystic kidney disease
Systemic lupus erythematous
100
When to refer CKD to nephrology
GFR<30
UAVR>300
Urine output declines
Protein/creatinine ratio >500
HTN refractory to 4 meds
Associated complications
101
CKD stages I-IV management
Yearly BMP, UACR, lupuds
BP<120/80
Statin in pts >50yo
<1.5g Na daily
102
CKD stages III and IV management
Yearly BMP
UACR
Lipids
PTH
Ca
Vitamin D
CBC
Phosphorus
103
CKD complications
Anemia from decreased erythropoietin production
Hyperkalemia
Acidemia
Secondary hyperthyroid
Elevated phosphorus
Hypocalcemia
Low vitamin D
Renal osteodystrophy
Vascular calcifications
104
Anemia in CKD treatment
Check iron levels first
Consider erythropoietin if possible (lowest possible dose)
Maintain hgb>11
Ferrous sulfate for low iron
105
Hyperkalemia in CKD treatment
Avoid ACEi/ARB and spironolactone
Potassium binding agents (sodium polysytrene sulfonate, sodium zirconium cyclosilicate, patiromer)
106
Acidemia in CKD treatment
Consistent serum bicarbonate <20
Oral bicarbonate solution/tablets
107
Secondary hyperparathyroid in CKD treametn
Calcitriol, paricalcitol, deoxercalciferol
Goal PTH 150-300
108
Elevated phosphorus in CKD treatment
Dietary mods
Renal osteodystrophy
109
Electrolyte changes in CKD
Hyperkalemia
Hyperphosphatemia
Hypocalcemia
Hypomagnesium
110
Meds to avoid when GFR<30
Metformin
Sulfonylurea
ACEi/ARB
HCTZ
DOAC
Fenofibrates
Lovenox
111
End stage renal disease presentation
Fatigue
Malaise
Anorexia
Nausea
Uremic frost
Kussmaul respirations
Pruritis
Easy bruising
Chachexia
HTN
112
End stage renal disease uremic syndrome complications
Pericarditis
Delirium
Pericardial effusion
Uremic encephalopathy
113
Types of hemodialysis access
Synthetic AV graft
Central venous catheter
AV fistula
114
What GFR to refer to hemodialysis
15-29
115
Arteriovenous fistula dialysis
Preferred
Takes 2-6 months to form
Less risk of clots or infections
Lasts for years
Connect artery to vein
116
Arterovenous graft dialysis
If pt has small or weak feins that won't make fistula
usually needs 2-4 weeks to develop
Bruit and thrill on physical exam
Causes increased risk of clotting and infection
No venipuncture, taking BP, or heavvy lifting
Don't last as long as fistula
117
Central venous catheter dialysis
Used for more temporary dialysis (ACUTE)
High infection rate
Veins can develop stenosis or clot
Usually changes every 4 weeks
Swimming/bathing not recommended
118
Peritoneal dialysis
Does not require vascular access
LEss stressful
Decreased side effects
Can be done at home
Causes increased risk of peritonitis bc of intraabdominal catheter
119
Polycystic kidney disease treatment
RAAS
Tulbactam if progresses
DO NOT Use statins, sglt2, GLP-1, or MRA
120
Polycystic kidney disease pathophys
>5 cysts on kidney overwhelms and replaces mass of kidney reducing kidney function leading to kidney failure
121
What gene is associated with polycystic kidney disease
APKD
Can be born with or acquired with long term CKD/ESRD
122
Polycystic kidney disease presentation
Flank/back pain from kidney stones
Cyst rupture/hemorrhage or infection
HTN
Recurrent UTI
Weight loss
HA
Nocturia
Nodular and tender kidney
Cysts on pancreas and liver
123
Polycystic kidney disease extrarenal manifestations
Cerebral "berry" aneurisms
Hepatic cysts
Pancreatic cysts
Mitral valve prolapse
Diverticulosis
124
]polycystic kidney disease imaging
Renal ultrasound showing fluid filled cyst
CT showing enlarged kidneys and cysts
Angiography with bending of small vessels around cysts
125
Polycystic kidney disease labs
CBC showing anemia
126
Supportive treatment for polycystic kidney
BP <110/75
Pain management
Normal BMI
Drink more water
Treat infections with abx
Dialysis
Transplant
Tolvaptan
Screening for cerebral aneurisms
127
Renal cell carcinoma presentation
Usually asymptomatic until advance
Metastasis in lymph, lungs, liver, bone brian
Flank pain
Palpable renal mass
Hematuria
Abd pain and mass
Weight loss
HTN
128
Renal cell carcinoma risk factors
Smoking
Obesity
HTN
129
Renal cell carcinoma increased risk population
Family Hx
ESRD on HD >3 years before kidney radiation
130
Renal cell carcinoma labs
Anemia
Hypercalcemia
Hematuria
131
Renal cell carcinoma imaging
CT biopsy usually done at time of nephrectomy
132
Renal cell carcinoma treatment
Nephrectomy
Surveilance for 5 years post-cure
133
Renovascular hypertension
High bp that develops into renal artery disease either stenosis or fibromuscular dysplasia
134
Renal artery stenosis risk factors
Older pt with ASCVD
Smoking
ASCVD risk factors
135
Gold standard to confirm renal artery stenosis
Renal angiography
136
Renal artery stenosis treatment
ACEi/ARB
Statin
PCTA or bypass if 70% lesion
137
What is a sign of fibromuscular displacia on imaging
String of pearls sign (squiggly renal artery)on renal angiography
138
Fibromuscular diysplasia risk factors
<50
Women
Refractory to HTN treatment
139
Fibromuscular dysplacia treatment
PTCA/stent/bypass
140
Nephrotic syndrome features
Proteinuria from damage to glomerulus
Hypoalbuminemia since albumin is being dumped into urine causing low oncotic pressure
Edema from low oncotic pressure
Hyperlipidemia from hepatic lipoproteins being made in response to decrease in oncotic pressure
141
Four criteria for nephrotic syndrome
Proteinuria >3.5
Low albumin
Edema
Hyperlipidemia
142
Nephrotic syndrome symptoms
Foamy/frothy urine
Edema of lower extremities, eyelids, face, abd
Weight gain
Fatigue
143
Diagnostic tests used for nephrotic syndrome
BMP
Lipids
24 hr urine
Albumin creatinine ratio
Kidney ultrasound
Kidney biopsy
144
Nephrotic syndrome causes
Focal segmental glomerulosclerosis
Minimal change disease
Membraneous nephropathy
Diabetic nephropathy
Amyloidosis
145
Focal segmental glomerulosclerosis pathophys
Filtration issue from podocyte damage.
146
Focal segmental glomerulosclerosis causes
Immunologic
Genetic (APOL1 gene)
Overwork injuries (obesity, solitary kidney, HTN)
147
Focal segmentsal glomerulosclerosis diagnostic tests
Kidney biopsy required shwoing hyalinosis and segmental sclerosis
Immunofluorescence with entrapment of IgM and C3
Light mcroscopy showing sclerosis of glomeruli
Electron microscopy showing podocyte effacement
148
Primary Focal segmental glomeruloscelrosis treatment
ACEi/ARB and Na restriction
CCS
Calcineurin inibitor (cyclosporine and tacrolimus)
149
Secondary Focal segmental glomeruloscelrosis treatment
Treat underlying cause
150
What patients is focal segmental glomerulosclerosis commonly found in
Sickle cell
HIV
Black
Hispanic
151
Most common nephrotic syndrome in children
Minimal change disease
152
Minimal change disease causes
MOSTLY IDIOPATHIC
Infections
NSAIDs
Allergies
mallignancy
153
Minimal change disease diagnostic testing
Most not good
Biopsy only if refractory
Glomeruli normal on light microscopy
Effacement (thinning) of podocytes on microscopy
154
Minimal change disease pathophys
Idiopathic podocyte dysfunction
T cell disorder impairs glomelrular filtration
Sudden onset in children
155
Minimal change disease treatment in children
Empiric treatment preferred instead of getting biopsy
Predinsone
ACE/ARB if prednisone doesn't solve
156
Minimal change disease treatment in adults
Prednisone
ACE/ARB
Diuretics
Na restricted diet
Refractory may need to add immunosuppressive agents
157
Membranous nephropathy pathophys
deposits of antigen antibody complexes between glomerular basement membrane and podocytes
158
Membranous nephropathy causes
Idiopathic but associated with phospholipase A2 receptor (PLA2R) on podocytes
159
Membranous nephropathy diagnostic testing
Kidney biopsy gold standard.
If anti-PLA2R positive biopsy not needed
Light microscopy shows glomerular basement membrane thickening
Electron microscopy shows spike and dome appearance
160
Membranous nephropathy treatment
A. Manage symptoms with diuretics, statins, ACEi/ARB, anticoag, Na restriction
B. Immunosuppresive therapy: Corticosteroids alternating with cyclophosphamide, or give rituximab, or give tacrolimus or cyclosporine
C. Dialysis or transplant
D. treat underlying cause in secondary
161
Membranous nephropathy complications
Hypercoag (embolism, dvt)
Increased risk fo bleeding
Hyperlipidemia
Progression to CKD
Immunotherapy side affects
162
Leading cause of CKD and ESKD
Diabetic nephropathy
163
Diabetic nephropathy
Leading cause of CKD and ESKD worldwide
Affects 30% of diabetics
Usually present before T2DM diagnosis
Highly associated with presence of retinopathy
164
Who should be screened for diabetic nephropathy
Anyone >5yo with T2DM
165
What is looked at in diabetic nephropathy screening
EGFR
Urinary albumin:creatinine rati
Random (spot) collection
166
Who should be monitored twice annually for diabetic nephropathy
Pt with diabetes and urinary albumin >300 or EGFR 30-60
167
Diabetic nephropathy diagnosis
Albuminuria and/or reduced eGFR in presence of high A1C and absence of other causes
Retinopathy and diabetes often seen with it
168
Diabetic nephropathy treatment
Glucose control (A1C<6.5)
BP control (<130/80) with ACEi/ARB
Use SGLT2 or GLP1 maybe
169
Amyloidosis pathogenesis
TIssue deposition of abnormally folded proteins calle amyloid fibrils from bone marrow making amyloid light chains (primary)
Or fibrils from circulating inflammatory protein in infammatory disease (secondary)
170
Renal amyloidosis diagnosis
Biopsy GOLD congo red stain with apple green birefringence under polarized light
171
Renal amyloidosis treatment
Corticosteroids reduce inflammation
Melphalan and stem cell transplant is standard of care
Also use cyclophosphamide, bortezomib, and dexmethazone plus daratumumab
Hemodialysis or transplant if not responsive
172
Nephritic syndrome characteristics
INFLAMMATORY
RBC casts
Proteinuria <3.5
Hematuria
HTN Edema
173
Nephritic syndrome symptoms
Edema of face, eyes, legs, abd
Proteinuria
Cola colored frothy urine
RBC casts (acanthocytosis)
HTN
Decreased urine output
174
Acanthocytes
Found in nephritic syndrome
RBCs damaged when filtered through glomerulus
Sign of glomerulonephritis
175
Nephritic syndrome pathophys
Antigen either bacterial or autoantibody causes inflammatory response leading to tissue damage
Complement overactivation can also cause it
176
Glomerulonephritis (nephritic syndrome) causes
IgA/Berger's most common in adults
Goodpasture syndrome
Granulomatosis
Membranoproliferative glomerulonephritis
Lupus
Infection (strep in kids)
177
Nephretic syndrome imaging
Renal ultrasound
CXR showing pulmonary edema
178
Nephritic syndrome lab findings
Elevated creatinine
UA shows hematuria and proteinuria with dysmorphic red cells, red cell casts, and white cells
Spot urine albumin/creatinine ratio or 24 hr urine collection to quantify proteinuria
179
What does finding red cell casts on UA suggest
Glomerulonephritis
180
Poststreptococcal glomerulonephritis presentation
MC in children
1-3 weeks after throat infection or 3-6 weeks after impetigo
Group A strep
HTN
Decreased GFR
181
What causes poststreptococcal glomerulonephritis
Group A strep
182
Poststreptococcal glomerulonephritis diagnostic testing
Streptozyme test shwoing 5 antibodies including antistreptolysin-O
UA has RBC casts (acanthocytes) and maybe proteinuria
Reduced C3
183
Poststreptococcal glomerulonephritis treatment
Loop diuretics (fluorosemide) and Na and water restriction to treat HTN and edema
Abx if strep infection still present
184
Most common cause of primary nephritic syndrome (glomerulonephritis)
IgA (Berger's syndrome)
185
IGA nephropathy (Berger's disease) presentation
MC cause of acute glomer
Men 1-2 days after URI or GI infection
HTN
Fecre
Dark urine
Edema
Hematuria
186
IGA nephropathy (Berger's disease) lab findings
Hematuria
RBC casts
Proeinuria
Specific gravity >1.02
Elevated BUN and creatinine
Normal complement
187
IGA nephropathy (Berger's disease) diagnostic testing
Renal biopsy shows IGA deposits
188
IGA nephropathy (Berger's disease) treatment
ACEi
Loop diuretics
CCS if rapid progression
189
Anti-glomerular basement membrane disease pathophys
Autoimmune against glomerular and alveolar basement membranes
190
Anti-glomerular basement membrane disease presentation
Younger
Develop pulmonary hemorrhage (hemoptysis) and glomerulonephritis
Critically ill
Older
Isolated glomerulonephritis
Less severe course
Malaise, fever, chills, arthralgia, weight loss
191
Anti-glomerular basement membrane disease Diagnostic testing
UA shows low-grade proteinuria, Gross or microscopic hematuria, and RBC and granular casts
Increased BUN and creatinine
ANTI-GBM antibodies in serum confirms
CXR or CT shows bilateral, diffuse Ground glass or consolidative opacities
192
Membranoproliferative glomerulonephritis causes
Hep B or C
193
Membranoproliferative glomerulonephritis presentation
Nephritic syndrome
194
Membranoproliferative glomerulonephritis daignostic testing
Biopsy showing enlarged hypercellular glomeruli with thickened glomerular membrane
195
Membranoproliferative glomerulonephritis treatment
Supportive and immunosuppressant
196
Granulomatosis with polyanagitis pathophys
Vasculitis causing necrotizing granulomas
197
Granulomatosis with polyangitis presentation
Cough
Dyspnea
Flu-like
joint pain
198
Granulomatosis with polyangitis diagnostic tests
ANCA in blood
Kidney biopsy with pauci-immune crescentic glomerulonephritis with necrotizing vasculitis
199
Pauci-immune
Lacking immune complexes on biopsy
200
Rapidly progressive glomerulonephritis diagnostiv tests
Kidney biopsy shows cellular cescent formation in glomeruli
201
Rapidly progressive glomerulonephritis treatment
Immmunosuppresion (CCS or cyclophosphamide)
Plasmapheresis if immunosuppression contraindicated)
202
Nephrolithiasis
Stones located in kidney
203
Urolithiasis
Stones formed in kidney exit renal pelvis into urinary collection system
204
Most common type of kidney stones
Calcium oxalate
205
Calcium oxalate stone causes
Hyperoxaluria (urinary oxylate >40mg/day)
Ingestion of foods with oxalate (spinach, cocoa, nuts, pepper, tea, beets, rhubarb)
Intestinal disease can effect oxalate metaobolism
206
Calcium phosphate stones causes
Urine pH > 7.2
Too much Ca and P
Too little citrate
Hyperparathyroidism
Renal tubular acidosis
207
Uric acid stones cause
Elevated urinary uric acid from breakdown of purines in meat
Low urine pH and low urine volumes
208
Uric acid stones risk factors
Gout
Diarrhea
Diabetes
Metabolic syndrome
209
Cystine stones cause
Genetic metabolic disorder on SLC3A1 or SLC7A
Kidneys not reabsorbing cystine
210
Strutvite (staghorn) kidney stones causes
Infection stones (aka magnesium ammonium phosphate stones)
More commonly seen in women with UTI
211
What diet modifications can prevent kidney stones
Less animal protein
DASH diet
Mediterranian diet
DO NOT decrease Ca intake
Drink more water
212
What meds are linked to causing kidney stones
Carb anhydrase inhibitors (Acetazolamide)
Systemic corticosteroids
Antiretroviral
Gout meds
Diuretics (loop)
Decongestants
Abx
Laxatives
213
Kidney stone symptoms
Renal colic pain
Sx start when stons pass from renal pelvis into ureter
Pain waxes and wanes with severe spasms
Unilateral
Hematura
NV
Penile or testicular pain
Dysuria, urinary urgency, suprapubic pain
CVA tenderness
214
Where is the stone when it causes urinary frequecy and urgency
Ureterovesicular junction
215
Common places for stone to be lodged
Ureteropelvic junction
Distal ureter at level of iliac vessels
Uterovesical junction
215
how is the pain when kidney stone is passed into bladder
Relieved
216
Kidney stone diagnostic imaging
CT without contrast (most reliable)
US of kidneys and bladder (first in pregnant)
Plain radiographs
217
Hydronephrosis
Kidney stretched and swollen from build up of urine inside (could be form stone blockage)
Seen on US
218
uncomplicated kidney stone treatment
Pain management
Increase fluid intake
Dietary mod
24 hr urinalysis
Routine followup
Unnula imaging with ultrasound
Surgery if can't be passed
219
Kidney stone <5mm treatment
Pass spontaneously
Fluids and analgesics
220
Kidney stone 5-10mm treatment
Might pass spontaneously
Fluids
Analgesia
Medical expulsino therapy (alpha one antagonist or calcium channel blocker) (tamsulosin or nifedipine) (only give for 4 weeks then we need surgery if still there)
221
Kidney stone >10mm
Probably won't pass to bladder
Need scope and stent if distal to kidney
Lithropasty if proximal or near kidney
222
When to urgent consult for kidney stone
Associated with infection
Urosepsis
Acute kidney injury
renal failure
Unstable
Stone not passing after 4 weeks treatment
>10mm
223
Procedural options in kidney stones
Ureteroscoy with laser lithotripsy
Extracorporeal shock wave lithotripsy
Percutaneous nephrolithotomy
224
When to use percutaneous nephrostomy
Pt with infection and obstructing stone, ureteral stent, or percutaneous nephros
225
What diuretic to give someone with high urine calcium
THiazides
226
High urine oxalate level treatment
Calcium carbonate
227
What to give for uric acid stone prevention
Potassium bicarbonate/citrate
Can also bring down uric acid levels with allopurinol
228
What to give for struvite stone prevention
Acetohydroxamic acid to stop bacteria from making ammonia
229
Bladder calculi and cause
Stones formed in bladder from pt not being able to empty bladder completely
Dehydration
230
Bladder calculi presentation
Irritated bladder
SEvere suprapubic pain
Bleeding
DYsuria
Increased urine freq
Cloudy, dark, bloody urine
231
Bladder calculi diagnostic studies
UA shows UTI and blood
CT scan DIAGNOSTIC
Radiographs and US
Cystoscopy to see stones in bladder
232
Acute simple cystitis
Begins with colonization of vaginal introitus with pathogens from fecal flora (usually e. coli) and ascension into urethra and bladder
233
Most common pathogen of acute simple cystitis
E. coli
234
Acute simple cystitis presentation
Increased urine freq and urgency
Hematuria
Suprapubic pain
Foul smelling urine
AMS and nocturia in elderly
NO fever
235
Acute simple cystitis risk factors
Sex
Spermicide
Prev UTI
New sexual partners in past year
Diabetes
Structural abnormalities
236
acute simple cystitis diagnostic testing
Leukocyte esterase
Nitrites
WBC on microscopy
Hematuria
Don't always need urine culture but should be done to specify pathogen
237
Who can we start treating in acute simple cystitis before UA results come back
Dysuria with or without change in urinary freq
No vaginal discharge
238
Treatment for cystitis with high risk aabx resistant bacteria
in patient
Fluoroquinolone, bactrim, third gen cephalosporin
239
Acute simple cystitis treatment
Nitrofurantoin
FOsfomycin
Trimethoprim-sulfamethoxazole
240
Recurrent cystitis treatment
Change abx and get culture
241
Most common UTI in pregnancy
E. coli
242
UTI in preg treatment
Beta-lactam
Nitrofurantoin
Fosfomycin
DO NOT give bactrim
243
UTI in preg diagnostic studies
UA and culture
244
Male cystitis diagnostic tests
Positive nitrates and leukocyte esterase
Urine culture usually with E. coli
245
Do you give abx for asymptomatic UTI
Only if preg
246
Complicated UTI presentatoin
Fever
Chills, rigors, fatigue, malaise
Flank pain
CVA tenderness
NV
247
Complicated UTI complications
Shock
Sepsis
Multi-organ failure
Acute-renal failure
248
Comlicated UTI diagnostic studies
UA with pyruia
hematuria
Leukocyte esteraase
Nitrites
Preg test
249
COmplicated UTI imaging
Only for severely ill even after antimicrobial theray
CT scan with no contrast
250
Complicated UTI treatment
Outpatient: Fluoroquinolones
Inpatient: 3rd or 4th gen cephalosporin, fluoroquinolones, aminglycosides 14 days
251
EABV
Effective arterial blood volume
252
How does your body regulate blood volume
RAAS
Sympathetics
ADH
253
Is osmoregulation or volume regulationo more important
Volume
254
Oncotic pressure
Pressure effect of proteins on movement of water
255
Osmotic pressure
Pressure effect of solutes on movement of water
256
Where is osmolality monitored
Hypothalamus
257
Where is osmolality controlled
Hypothalamus
258
Do we have more water in intracellular or extracellular space
Intracellular
259
Hypovolemia clinical findings
Dry mucus membranes
Decreased skin turgor
Tachycardia
Cool extremeties
Edema
Ascites
Pleural efussions
260
Hypovolemia treatment
Treat underlying cause
Fluid resuscitation
261
Hypervolemia presentation
Edema
Pulmonary crackles
Ascites
Anasarca
Weight gain
Increased JVP
Electrolyte probs
Kidney injury
262
Hypervolemia treatment
Treat underlying condition
Diuresis
Salt restriction
263
Most common electrolyte to have problems with
Sodium
264
When is hyponatremia considered severe
<125
265
What to check if Na is low
osmolality
If also hyposmolar it is bad.
If normal or high osmolality, its not right
266
How fast should you correct sodium
Within 48 hrs if acute and severe.
Slowly if it has slowly come on
267
What does hyponatremic with normal osmolality indicate
Lab arttifact (hyperlipidemia or hyperproteinemia)
268
What does Hyponatremia with high osmolality indicate
Na effectively low due to H2O movement bc of stuff like glucose or mannitol
269
What can excess water intake more than kidneys can take result in
Hyponatremia
270
Hypovolemic hyponatremia causes
Fluid loss (diarrhea, vomiting, burns, diuretics)
271
How to differentiate between renal and extra-renal losses of water
Urine sodium
Extrarenal: <20
Renal: >20
272
Hypovolemic hyponatremia treatment
Restore colume with Normal saline
ADH secretion will stop once volume restored
273
Euvolemic hyponatremia causes
SIADH
Hypothyroidism
Adrenal insufficiency
Psychogenic polydipsia
274
Euvolemic hyponatreamia with increased urine sodium and osmolality workup
TSH, cortisol, ACTH tests
If thyroid normal suspect SIADH
275
SIADH lab findings
Hyponatremia (<135)
Hypoosmolality (<285)
Urine Na > 20
276
SIADH treatment
Fluid restriction
Increase Na intake
urea tablets
Diuretics (loop, SGLT-2)
Vasopressin
277
SIADH presentation
Dizziness, fatigue, headache, vomiting
Confusion, seizure, coma, brainstem herniation
278
ADH independent causes of hyponatremia
Psychogenic polydipsia
Beer potomania (only drink beer)
Tea and toast diet (low protein leads to less solutes)
Renal impairment (GFR<15)
278
Hypervolemic hyponatremia causes
Cirrhosis and HF
279
Primary response to hypernatremia
Increased thirst
Increased ADH
280
Hypervolemic hyponatremia treatment
Diuretics (no thiazides)
Fluid restriction
Hypertonic salene
Paracentesis
281
Hypernatremia presentation
Cerebral dehydration
ethargy
Irritability
Weakness
hyperthermia
Delirium
Seizure
Coma
282
What can be caused by fixing hyponatremia too fast
Osmotic demyelnation
283
Non-oliguric hypernatremia causes
Diabetes insipidus
Osmotic diuresis
284
Oliguric hypernatremia causes
Reduced water intake
Diarrhes, sweat, hyperventilation
Rhabdomyolysis
284
Hypernatremia treatmen
Rate of fixing electrolytes depends on severity and acuity
ACute 1.5-2/hr
Chronic or asymptomatic 0.5/hr
Normal saline for hypovolemic until euvolemia reached then D5W
Euvolemic needs D5W
Hypervolemic needs diuretics and D5W
285
Hypokalemia treatment
Treat underlying
Stop diuretics, beta blockers, insulin
Correct Mg deficiency
PO dietary or supplementation of K (20-40/day)
IV K in severee
285
Hypokalemia ECG changes
Inverted T wave
Just flat T wave early on
285
What can be caused by fixing hyernatremia too fast
Cerebral edema
285
Hyperkalemia ECG abnormalities
Peaked T waves
Long PR segment
Wide and bizarre WRS
286
Hyperkalemia causes
Kidney failure
Shift from ICC to ECF
286
Hypomagnesemia presentation
Tremors
Cramps
Confusion
Disorientation
Weakness
HTN
Tachycardia
Arrhythmia
Difficult to distinguish from Hypo-K and hypo-Ca
287
Hyperkalemia presentation
Muscel weakness and spasms
Cardiac conductoin abnormalities reducing myocardial excitability
Impaired amonium excretion and may lead to metabolic acidosis
288
Hypomagnesemia ECG findings
V-Tach (Torsades de Pointes)
Prolonged PR
Peaked T waves
Prolonged QRS and QT
288
Hyperkalemia treatment
Confrm laab vale to rule out pseudohyperkalemia
IV calcium gluconates
Insulin, beta agoniast, Na bicarbonate
Loop diuretics, K binders, Hemodialysis
289
Hypomagnesium treatment
Magnesium oxide PO daily
IV mag if symptomatic
290
Hypermagnesemia presentation
Muscle weakness
Decreased reflexes
Mental obtundation
Confusion
Hypotension
Paralysis
Heart block
Cardiac arrest
291
Hypermagnesemia treatment
Remove magnesium sources
IV calcium chloride
Hemodialysis maybe
292
Hypermagnesemia ECG findings
INcreased PR interval
Widened QRS
QT proongation
293
Hypocalcemia clincical findings
Tetany
Laryngospasm
Convulsions
Paresthesia
Abd pain
Chovstek sign
Trousseau sign
294
Hypocalcemia treatment
IV calcium gluconate with D5W for symptomatic
Asymptomatic: Oral calcium, vitamin D., Mg if thats low too
No treatment if low albumin is the cauee
295
Hypercalcemia causes
Hyperparathyroidism
Malignancy
296
Hypercalcemia presentation
Anxiety
Lethargy
Constipation
ANorexia
Cognitive changes
Kidney stones
297
Hypercalcemia management
Treat underlying
no therapy for asymptomatic and still <12
Normal saline
Calcitonin
Bisphosphonates
298
Hyperphosphatemia clinical findings
Asymptomatic
Similar to hypocalcemia
298
Hyperphosphatemia treatment
IV calcium gluconate for acute
Hemodialysis for impaired kidney function
In chronic decrease dietary intake and add phosphate binders
299
Hypophosphatemia clinical findings
Related to ATP deficiency
Weakness, paresthesia, encephalopathy
299
Hypophosphatemia treatment
PO phosphate for moderate and asymptomatic
IV phosphate for severe or unable to tolerate PO
Monitor phosphate and calcium levels every 6 hrs
299
Contraindications to phosphate replacement
Advanced CKD
Tissue damage/necrosis
Hypercalcemia
300
Hyperphosphatemia clinical findings
Asymptomatic
Similar to hypocalcemia
300
Hyperphosphatemia treatment
Acute and symptomatic: IV calcium gluconate
Impaired kidneys: Hemodialysis
Chronic: Decrease dietary intake and add oral phaosphate binders
301
Hypophosphatemia presentation
Related to ATP deficiency
Weakness
Paresthesia
Encephalopathy
302
Hypophosphatemia lab tests
Urine phosphate (24 hrs) distinguishes between renal and non-renal causes
CBC, CMP, ABG to see other causes
303
hypophosphatemia treatment
Moderate and asymptomatic: PO phosphate
Severe and symptomatic: IV phosphate
Monitor every 6 hrs
304
High anion gap metabolc acidosis causes
Ketoacidosis (uncontrolled diabetes)
Uremia (kidney failure)
Lactic acidosis (tissue damage)
Toxic ingestion (antifreeze, aspirin, pesticides, ethylene glycol, methanol, salicylates)
305
Ketoacidosis pathophys
Not enough insulin so blood glucose not used causing
Muscle, adipose, and glucagon breakdown
306
Lactic acidosis values
Lactate>2
307
Lactic ac
308
Lactic acidosis causes
Sepsis shock
Mesenteric ischemia
Resp failure
Carbon monoxide poisoning
Intense exercise
Seizures
Alcoholism
HIV infection
309
Normal anionic gap acidosis causes
DIarrhea
Renal tubular acidosis
both losses of HCO3
310
Metabolic acidosis clinical findings
Kussmaul respirations (deep and labored)
headache
Lethargy
Stupor
Coma
311
Chloride responsive alkalosis causes
Vomiting
NG tube suction
Diuretics
312
Chloride unresponsive alkalosis causes
Hyperaldosteronism
Antacids
313
Metabolic alkalosis lab findings
High blood pH
High HCO3
Low Cl
Low K
314
Respiratory acidosis presentation
Somnolence
Confusion
Asterixis
Myoclonus
Pursed lip breathing
Barrel chest
315
Respiratory alkalosis cause
Hyperventilation leading to hypocapnea
316
Second most common urologic cancer
Bladder (mostly urothelial cell aka transitional cell carcinoma)
317
Bladder cancer symptoms
Hematuria
Can have change in urine freq and consistancy
Abd masses
hepatomegaly
Lymphadenopathy
Lymphedema of lower extremeties
318
Bladder cancer lab findings
Hematuria
Pyuria and azotemia maybe
Anemia
cytology maybe positive
319
Bladder cancer imagin
Confirmed with cytoscopy and biopsy
US
CT
MRI
320
What is looked at in Bladder cancer staging
Size
Pleomorphism
Mitotic rate
Hyperchromatism staining
Extent of bladder wall penetration and presence of metastasis
321
Bladder cancer screening levels
T- primary
N- regional lymph nodes
M- Distant metastasis
322
Bladder cancer treatment
Surgery (transurethral resction is FIRST LINE)
Partial cystectomy for muscle invasive
Give chemo on top of surgery to prevent recurrence
INtravesical therapy
Chemotherapy
Radiotherapy
Immunotherapy (anti-PDL-1)
323
What treatment option for T2 bladder cancer
Chemo first
Then radical cystectomy
324
Interstitial cystitis (interstitial pain syndrome) symptoms
pain with bladder filling relieved with emptying
Urine freq and urgency
Dramatic exaggeration of normal sensation
325
Interstitial cystitis diagnosis
Exclusion
Lots of times presents with IBS/IBD or allergies
326
Interstitial cystitis treatment
Hydrodistension (stretching our bladder every couple months)
Amitriptyline
Nifedipune
Pentosan
DMSO + heparin
Nerve stimulation
Remove bladder is last resort
No cure
327
Urinary incontinence transienct causes
Infection most common
Delirium
Infection
Atrophic urethritis and vaginitis
Pharmeceuticals
Stool impaction
Restricted mobility
328
Urinary incontinence established causes
Detrusor overactivity
Urethral inocmpetence (stress incontinence)
Overflow incompetence
329
What meds can cause urinary incompetence
Diuretics
Anticholinergics
Psychotropics
Opioid analgesics
Alpha blockers
Alpha antagonists
Ca channel blockers
330
Detrusor overactivity/urge incontinence physical exam
Fill bladder with water and have them cough vigorously
Delayed leakage shows urge incontinence
331
Detrusor overactivity/urge incontinence treatment
Piss schedule
Weight loss if obese
Pelvic floor muscle (Kegel) exercises
If that doesn't work, put on antimuscarinci/anticholinergic (tolterodine or oxybutynin)
Boxtox
Beta-3-agonists (mirabegron)
332
Stress incontinence pathophys
Hypermobility of bladder (displacement of bladder neck and urethra) during increased abd pressure (coughing or valsalva maneuver)
333
Stress incompetence treatment
Limit caffeine and fluid intake
Weight loss in obese
Pelvic floor muscle exercises
Vaginial cones or pessaries
Surgery last resort
334
Overflow incontinence presentation
Dribbling
Urge incontinence due to detrusor overactivity
Nocturia
Can't fully empty bladder
335
Overflow incontinence causes
Meds
Sacral lower motor neuron dysfunction
336
Overflow incontinence treatment
Bladder decompression with catheter first
Then Alpha blocking agent (tamsulosin and finnasteride)
Double voiding
Press on bladder
Straight cath before bed
337
Cystocele
Bladder prolapse
Occurs when pt stands or strains
Usually from pelvic floor injury in childbirth
338
Dyspareunia
Painful intercourse
339
Cystocele is located at what aspect of vaginal wall
Anterior
340
Cystocele symptoms
Vaginal heaviness
Sensation of sitting on ball
Straining or coughing
Urinary freq changes
Sensation of incomplete emptying
Constipation
Dyspareunia
341
Cystocele imaging
Sonography or MRI
342
Cystocele treatment
Pessary
pelvic floor muscle exercises
Estrogen for some
Surgery maybe
Weight loss in obese
High fiber diet and laxatives to improve constipation
343
Diabetic autonomic neuropathy
Poor glucose control causes bladder dysfunction
344
Diabetic autonomic neuropathy treatment
Bethanechol to improve emptying
Stirct urine schedule and Crede maneuver
Advanced need catheterization
345
Female urethritis causes
Gonorrhea
Chlamydia
Mycoplasma
Ureaplasma
Trichomonas
346
Female urethritis presentation
Urethral discharge
Tenderness
Congested mucosa
Induration of urethra
347
Female urethritis treatment
Estrogen cream
