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Renal USMLE

QuestionAnswer
3 categories of ARF, what's MC? prerenal (MC), renal, postrenal (least common)
biggest risk ARF infxn
T/F urine output is decrsd in ARF F, can be oliguric, anuric, nonoliguric
key lab values use to difft pre-renal v ATN (renal) causes of ARF [Pre-renal value always listed 1st, then ATN] U_osmol: >500 v >350; U_Na: <20 v >40; FE_Na: <1% v >1%; BUN:serum_Cr : >20 v <20
how urine sediment is difft bw pre-renal and renal ARF pre-renal: hyaline casts, ATN: granular casts w epithelial cells
proteinuria (3/4+) suggests pre-renal or renal ARF? renal ARF (specifically glomerular)
Causes ATN: MC, other causes MC=ischemia, other: Abs ie aminoglycosides, radiocontrast, NSAID esp in CHF, mscl damage, hemoglobulinuria, MM Ig chains, chemo Rx
2 main causes of ARF due to renal dzs 1) ATN, 2) glomerular
causes of postrenal ARF MC=BPH, also stones (but would need to be bilateral)
RBC casts suggests what ARF etiology glomerular
WBC casts suggests what ARF etiology acute interstitial nephritis or pyelonephritis
fatty casts suggests what ARF etiology nephrotic syndome (glomerular cause ARF)
key causes of prerenal ARF anything hypovolemia, incl decrsd CO and systemic vasodilate (ie sepsis)
if renal perfusion is already compromised, what Rx can ppt ARF NSAIDs, ACEI, cyclosporin
metabolic changes seen in ARF metabolic acidosis w incrsd anion gap, hi K and P, low Ca and Na + uremia
at what level correct acidosis w bicarb <16
when start dialysis for ARF symptomatic uremia, intractable acidemia, hyperK, or vol overload
causes of CRF
cut offs for severity of CRF (all in GFR) mild=70-120; mod=30-70; severe=<30; ESRD=<10
at what pt does uremia usu become symptomatic BUN>60
what level of Serum Cr is considered chronic renal insuffic; what does that term mean? 1.5-3 [kidneys are irrev compromised, but not failed]
clinical features of CRF by organ system (HTN, GI, CNS, Heme, Lytes, hormone, ID) HTN=decrsd GFR->aldos; GI=uremia->N/V; CNS=confusion, periph neuro; Heme=normocytic anemia (low EPO), uremia inihibits plts (bldg); Lytes=hi P->low vit D, low Ca++ -> incrsd PTH; hormone: low testost, amenorrhea, hi prolactin; ID=uremia inhibits immune
summary of lytes in CRF hi K, Mg, P and metabolic acidosis
define renal osteodystrophy bone pain, fractures from incrsd P leading to low Ca++ and 2ry hyperparathyroidism
Tx CRF: diet, Rx Diet: low protein, K, Mg, P (and low Na if CHF, HTN, oliguria); Rx: ACEI to decrs proteinuria and progression to ESRD, BP control w ACEI +/- diuretics, Rx control of glycemia
Tx CRF: lytes, heme Lytes: hyperP: Ca++ citrate which binds P, prevent 2ry hyperparathyroid by Ca++ and vitD, for acidosis give bicarb; heme: give EPO
in ARF which diuretic give furosemide, if pul edema or oliguric
absolute indications for dialysis AEIOU, A=acidosis, E=electrolytes (hi K), I=intoxications, O=overload (hypervol), U=uremia
which intoxications use dialysis for MELA=MetOH, ethylene glycol, Li, aspirin
what symptoms of uremia, which symptom is absolute indication for dialysis? N/V, CNS: changes in mental status, seizures, **absolute indication=uremic pericarditis
Access options for hemodialysis 1) central catheter to subclavian, 2) A-V fistula, best for permanent access, needs time to mature, listen for bruits to make sure open, 3) implantable graft **Note: blood must be heparinized
what deficit of renal failure can't be corrected w dialysis renal synthesis of EPO and vit D
complications/limitations of hemodialysis hypotension; CNS: hyposmol of ECF wrt brain causes N/V, headache; heparin complications; vascular access infxn; amyloidosis b2 microglobulin in bones and joints
complications/limitations of peritoneal dialysis hi glu soln leads to hyperglycemia, incrsd triglycerides; fluid maintained at waist; abd/inguinal hernia; peritonitis risk
what dialysis membrane is used in peritoneal dialysis the peritoneum
proteinuria defined by lab value? Nephrotic level of proteinuria? proteinuria= >150mg/d; nephrotic level= >3.5g/d
key features of nephrotic syn proteinuria >3.5g/d, hypoalbumin, hyperlipid, edema, hypecoag (losing anti-coag), infxn (losing Ig)
3 categories of proteinuria 1) glomerular (more protein loss than other categories), 2) tubular, 3) other (UTI, fever, heavy exertion/stress, CHF, preg, orthostatic)
tx nephrotic syndrome (general, not etiology specific) 1) underlying dz (can incl steroids for some glomerul), 2)ACEI decrs albumin loss, esstl for DM w HTN, 3) diuretics for edema, 4) limit protein intake, 5) tx incrsd chol, 6) vaccine flu and PNA
key features of nephritic syn hematuria, HTN, incrsd BUN (can also see edema and proteinuria (but not in range of nephrotic))
MC cause of nephritic syndrome Post Strep
which glomerular dzs have tx min change=steroids, FSGS ? Combo--not clear effective, HIV nephropathy=prednisone, ACEI, HAART
MC causes of nephrotic in kids, adults kids=min change; adults=membranous, then FSGS, then membranoprolifer
FSGS nephrotic or nephritic? nephrotic, but often hematuria and HTN are present
which glomerul dz shows thickening of capillary walls membranous
what dz: asx mild hematuria/proteinuria that becomes gross hematuria after URI or exercise IgA (bergers)
hematuria w hi freq hearing loss Alports (hereditary nephritis), complete picture includes: hematuria, pyuria, proteinuria + hi freq hearing loss w/o deafness
which glomerular dz assoc w HepC and cryoglobulinemia Membranoprolifer
characteristics, tx of Post Strep GN 10-14d after infxn, nephritic but also see proteinuria, edema and low complement; usu children, usu self-limited [tx anti-HTN, loop diuretics]
which vascular dzs can cause GN, how difft Wegeners, Goodpasteurs, PAN (+ Scleroderma): Goodpasteurs usu see hemoptysis first; Wegeners has nasal involvement/bldg; PAN has no pul component
tx Wegeners GN? Goodpasteur GN? both steroids and cyclophosphamide
MC cause acute interstitial nephritis? In children other causes? MC=Rx, but can be after infxn esp in children (ie Strep, Legionella), + sarcoid
key features acute interstitial nephritis ARF, rash, fever, eosinophilia (so seeing eosinophils in urine suggests dx)--note can't always difft from ATN w/o bx but usu don't need bx
how are acute and chronic interstitial nephritis difft chronic doesn't have hypersensitivity component w eos; a progressive fibrosis/scarring process [+/- pap necrosis
MC cause of pap necrosis? How dx? MC=overuse OTC painkillers, (also DM, sickle cell, EtOH, UTI/UTO); dx=excretory urogram
how can analgesic nephropathy present either interstitial nephritis or pap necrosis and ARF or CRF
cxns of pap nerosis sloughed pap can obstruct ureter
name 5 tubulointerstitial dzs 1) acute/chronic interstitial nephritis, 2) renal pap necrosis, 3) renal tub acidosis, 4) hatnup syndrome, 5) fanconis
describe acid-base state of 3 renal tubular acidosis (RTA) dzs RTA1&2=low K, hi Cl, non AG metab acid w alk urine; RTA4=hi K, non AG met acidosis w acidic urine
cxns of ea RTA RTA1=renal stones, rickets/osteomalacia; RTA2&4=no stones
name defect in ea RTA RTA1=can't secrete H+ in distal tub; RTA2=can't reabsorb HCO3 in prox tub; RTA4=hypoaldost, distal tb decrsd Na absorb and Na, K sxn
tx of RTA1, 2 RTA1=bicarb to prevent stones, P to help acid sxn; RTA2=no bicarb (would just be excreted), Na restriction
describe defect and clinical pic of Hartnup syn defect: AR aa transporter can't transport Tryp, causing nicotinamide defic; clinical like pellagra dermatitis, diarrhea, + ataxia, psych dz [dementia in pellagra]
tx Hartnup syndrome suppl nicotinamide if symptomatic
describe defect, clinical pic of Fanconis prox tub has defective transport of numerous substances; has proteinuria, polyuria, dehydration, RTA2, low K; urine contains hi glu, P, and Ca++
clinical cxns of Fanconis low P leads to rickets, impaired growth, osteomalacia, and path fx bones
tx Fanconis P, K, alkali, salt, hydration
what lab value suggests myoglobulinuria or rhabdomyolysis very high CPK value
key features of adult polycystic kidney dz hematuria, abd pain, abd mass, HTN, berry aneurysms, cysts in other organs, MVP, colon diverticuli, abd/inguinal hernias
dx, tx adult polycystic kid dz dx: US, tx: none (50% ESRD, course variable)
define medullary sponge kidney cystic dilation of collecting ducts, thgt assoc w hyperparathyroid and parathyroid carcinoma
dx, presentation, tx medullary sponge kidney dx: IVP; presentation: hematuria, UTI, stones; tx:none [stone prevention, tx UTIs]
define, tx of simple renal cyst common (1/2 pts>50), no tx (Asx)
name 4 renal vascular dzs 1) renal artery stenosis, 2) renal vein thrombosis, 3) HTN nephrosclerosis, 4) sickle cell nephropathy
2 types of renal artery stenosis, seen in which pts 1) atheroscl, 2/3, see in older men w hi chol and smoking; 2) fibromuscular dyspl
3 clinical features suggesting renal artery stenosis 1) sudden onset of HTN w/o fam hx, 2) refractory HTN, 3) abd bruit
dx of renal artery stenosis (3) 1) renal arteriogram w contrast if no RF, 2) MRA if RF, 3) captopril renal scintigram scan if nml renal fxn
tx renal arter stenosis revascul w percut translum angio (PRTA), success fibromusc>athero; surgery if PRTA is not successful
can see renal vein thrombosis w nephrotic syn, preg, OCP
2 types o f HTN nephrosclerosis and pts 1) benign, thickening of arterioles in long-standing HTN; 2) malignant: rapid decrs renal fxn and incrs HTN in AA men; grtly incrsd BP (papilloedema, cardiac decomp, CNS); rapid incrs Cr, proteinuria, RBC/WBC +/- nephrotic +/- microangiopathic hemo anemia
describe sickle cell nephropathy presentation, progression, tx nephrotic, often pap necrosis incrsd UTI, if tubules damaged can't concentrate urine leading to dehydration and more sickle events; ACEI can help
risk factors for stones, incl MC, dzs, Rx, ID MC=low fluid intake; dzs=RTA1, hyperparathyroid, gout, Crohns; Rx=loop, acetazolamide (carbonic anhydrase), antacids, chemo; male; ID=UTI w urease org [PESK=Proteus, Enterobac, Serratia, Kleb]
types of stones, which seen in radiography, and which most common 1) Ca++ (MC)=can see, 2) uric=can't see, 3) struvite (ammonium Mg PO4)=can see; 4) cystine=can't see
bipyramidal or biconcave oval stone on radiograph=what type? Ca++
flat sq plate kidney stone=what type? See on radiograph? uric, can't see on plain radiograph
rectangular prism kidney stone=what type? See on radio? struvite, can see
hexagon kidney stone=what type? See on radiograph? cystine, can't see on plain radiograph
what incrses risk of uric acid kidney stones gout, chemo of leuk and lymph
what incrses risk of Ca++ kidney stones inrs Ca++=hyperparathyroid, sarcoid, cancer, vitD; incrs oxaloate=steatorrhea, B6 defic, Crohns
what incrs risk of struvite stones alk urine, UTI w urease bug PESK=proteus, enterobac, serratia, klebsiella
tx/prevention Ca++ stones limit Ca++ intake, thiazide diuretic [for all stones: hydration, pain manage]
tx/prevention cystine stones limit protein, allopurinol [for all stones: hydration, pain manage]
if urine acidic w stones, what type? Alk? acid think uric acid stone, alk think struvite
pyuria w stones, think what type struvite (UTI w urease bug)
when admit pt w kidney stone if cant control pain w oral meds, renal colic + UTI +/- F, stone >1cm which isn't likely to pass spontaneously
2 procedures for stones won't pass 1) extracorpeal shock wave lithotripsy (breaks up stones 0.5-2cm), 2) percut nphrolithotomy (>2cm)
UTO: clinical presentation of upper UTO v lower upper UTO=renal colic; lower UTO=urination
causes of upper UTO intrinsic renal=kidney stones, sloughed papillae, blood clots, tumor; extrinsic=preg, tumors, AAA
causes of lower UTO BPH, prostate cancer, bladder cancer
dx of UTO (3) renal US, IVP (but not in preg, CRF), voiding cystourethrography can be used for lower UTO
Prostate cancer: MC type, risk factors 95% adeno; risk: ***age, AA, high fat diet, fam Hx, herbicides/pesticides
progression of prostate cancer and when presents starts periphery, moves centrally, then obstructive but by this time often mets (can present bone pain, ie lower back)
dx prostate cancer 1) DRE (dig rectal exam): abnml -> TRUS (transrectal US) w bx regardless of PSA; 2) PSA>10 or velocity>0.75/yr -> TRUS w bx
what can incrs PSA other than cancer BPH, age, prostatitis, needle bx, prostate massage (but not DRE)
stages of prostate cancer A=nonpalp, confined to prostate, B=pap nodule, confined to prostate, C=beyond capsule w/o met, D=mets
tx for difft stages prostate cancer 1) localized to prostate (A, B)=radical prostatectomy (but older asx men <10yr survival might leave), 2) local invasive=radiation therapy&androgen deprivation; 3) mets=decrs testost (anti-androgen, remove testes, LHRH agonist (Leuprolide))
classic triad of renal cell carcinoma presentation (only 10%) hematuria, flank pain, abd mass
what dz has autosomal dominant transmission at risk renal cell carcinoma VHL (but only 2% of RCC, most are sporadic cancers)
risks for renal cell carcinoma (5) smoking, phenacetin analgesics, adult polycystic kidney dz, VHL, Hg&cadmium exposure
dx renal cell carcinoma renal US, f/u CT for staging
tx renal cell carcinoma radical nephrectomy, incl Gerota's fascia
MC genitourinary cancer bladder cancer
MC type of bladder cancer transitional cell (90%)
tx bladder cancer local excision, but likely to recur
risks for bladder cancer smoking, aniline and azo dyes, radiation, coffee, sweeteners, cyclophosphamide
how does bladder cancer nmlly present hematuria (r/o infxn)
dx bladder cancer cytoscopy+bx; CXR and CT for staging
staging of bladder cancer and treatments 0=mucosa (intravesicular chemo), A=lamina propria (transurethral resxn, but recur so rept cytoscopy), B=mscl invasion (radical cystectomy+LN disxn, urinary diversion), C=perivascular fat (same tx as B), D=mets to LN, other sites (cystectomy and chemo)
types of germ cell testicular cancers seminoma (MC, slow growth, late invasion, radiosensitive), nonseminomas usu containing 2 of: embryonal, choriocarcinoma, teratoma, yolk sac
qualities of embryonal testicular cancer; germ cell? Seminoma? germ cell nonseminoma; hemorr/necrosis, mets abd lymph&lungs early, incrsd AFP
qualities of choriocarcinoma testicular cancer; germ cell? Seminoma? germ cell nonseminoma; most aggressive, usu met by time dx, but rare; incrsd bHCG (but also seen in other testic cancers)
qualties of seminoma? Germ cell? germ cell; MC, slow growth, late invasion, radiosensitive
qualities of teratoma? Germ cell? Seminoma? germ cell, nonseminoma; rarely met
qualities of yolk sac testic cancer? Germ cell? Seminoma? germ cell, nonseminoma; usu in young boys
name non germ cell testicular cancers Leydig (sxn hormones causing precocious puberty or gynecomastia, if met poor px), Sertoli (usu benign)
which more common: germ cell or non germ cell testic cancers germ cell (95%) and of those MC is seminoma
staging of testicular cancer A=testicle/cord, B=retroperitoneal LN spread below diaphragm, C=distant mets
difftl for testicular cancer varicocele (dilated veins in testicle), testicular torsion, spermatocele (testic cyst), hydrocele (fluid in testis)
incrsd risk testic cancer cryptorchidism (even if surgical repair), Klinefelter
incrsd AFP in testicular cancer indicates embyronal germ cell nonseminoma
risk penile cancer, age peaks risk: circumcision may protect, HSV, HPV18; peak age 60
MC etiologies for epidimytis in kids/old: E Coli, in young adult=Chlamydia or gonorrh
how difft testicular torsion and epidimytis testicular torsion is sudden, testicle elevated in scrotum, no F, usu appears in adolescent
effects of Angio II vasoconstrictor, rel ADH from P. Pit, rel aldosterone from adrenal, hypothal incrs thirst
what happens when kidneys detect decrsd BP JGA rel renin, which cleaves angiotensin (from liver) making AngioI, ACE in lung capillaries cleaves Angio I to make Angio II
what's Conn's dz primary hyperaldosteron
cause, signs/symptoms of primary hyperaldosteron cause: adrenoma of adrenal cortex (Conn's dz), HTN, decrsd K, metabolic alkalosis, decrsd renin
tx primary hyperaldosteron spironolactone (aldosterone antagonist)
signs, symptoms hypoaldoster hypotension, skin pigment (from incrsd ACTH leading to MSH)
definition Addisons primary hypoaldosteronism (of adrenal corrtex) MC infxs cause
when is aldosterone rel? decrsd blood volume, incrsd K
what does aldosterone do? incrsd Na reabsorb and incrsd K sxn
how does blocking aldosterone effect K? BP? incrs K, decr BP
name 4 types of diuretics thiazide, loop, K+ sparing, carbonic anhydrase
describe thiazide mech of action, SE inhibit Na reabsorb in distal (decrs Na, decrs K); SE: GLUC (incrs glu, lipid, uric, Ca++), sulfa allergy
describe loop diuretic mech of action, SE works on cotransport of TAL, inhibits tonicity of medulla; SE: loose Ca++, ototoxic, decrs K, nephritis, sulfa allergy, gout
describe K sparing diuretic mech of action, SE works on cortical collecting; SE: incrs K, decrs aldosterone, gynecomastia, hirsutism, sexual dysfxn **don't use in RF
describe carbonic anhydrase diuretic mech of action, SE works on prox convul tubule (PCT); SE acidosis, neuropathy, sulfa
how does EtOH act as a diuretic inhibits ADH
what diuretic use if hi uric? ethacrynic acid (+allopurinol)
what diuretic use if sulfa allergy? ethacrynic acid
what's the name of a carbonic anhydrase diuretic acetazolamide
which diuretics can't be used if sulfa allergy acetazolamide (carbonic anhydrase inhib), loop, HCTZ
which diuretic works on PCT? Distal tubule? TAL? PCT: carbonic anhydrase, DT: HCTZ, TAL: loop
which diuretic works on cortical collecting duct K+ sparing (where aldosterone acts)
what's the order of the portions of the tubules that diuretics act? prox convol tubul (carbonic anhyd), TAL (loop), distal tubule(HCTZ), cortical collecting duct (K+ sparing)
what diuretic can ppt gout? HCTZ (and loop)
don't use loop diuretic with what antibiotic? aminoglycoside (incrsd ototoxicity)
what's the name of a K= sparing diuretic spironolactone (aldosterone antagonist)
what's the name of a loop diuretic furosemide
what diuretic use in nephrogenic diabetes HCTZ
if pt on digoxin, which diuretic? K sparing (sprionolactone)--low K incrs digoxin toxicity
in CHF use what diuretics loop and thiazide (+/- K sparing for digoxin pts)
what happens to electrolytes in RF hypoCa (not making 1,25 vitD), Hyper K, Mg, and P, Hypovol Hypotonic HyperNa
how treat electrolyte abnmlties in CRF 1) hyper P-give calcium citrate (binds phosphate), 2) prevent 2ry hyperparathyroid by Ca and vit D (also helps uremic osteodystrophy), 3) acidosis-oral bicarb
5 nephritic syn post infxn, IgA, Wegeners, Goodpasture, Alports
What's Berger's IgA nephropathy (nephritic)
What IgA nephropathy assoc w s/p URI and GI infxn in young men
renal bx: lumpy bumpy postinfectious nephritic dz
C3 is decrsd in which nephropathy? Nml in which? decrsd in postinfectious nephritic dz; nml in IgA (Berger's)
tx for Wegeners? Goodpastures? Wegeners: hi dose corticosteroids, Goodpastures: plasmaphoresis, pulse steroids
what Alports? (ie age, other assoc anomalies) hereditary nephritic syndrome seen in boys 5-20; assoc nerve deafness and eye disorders
Alports bx findings? GBM splitting on electron microscopy
tx IgA nephritic syndrome glucocorticosteroids for some pts, ACEI for proteinuria
MC cause nephrotic in kids? min change dz
bx min change dz light microscopy nml, electron micro: fusion of epithelial foot processes
tx min change dz (nephrotic)? Post infxs nephritic? min change: steroids, excellent px; post infxs: supportive
demographics assoc focal segmental nephrotic HIV, IV drug use, obesity, young black male w HTN
bx findings: sclerosis of capillary tufts focal segmental nephrotic syndrome (also see segmental sclerosis)
membranous nephropathy: nephritic? no, nephrotic
MC cause nephrotic in caucasian adults? membranous
bx membranous spike and dome granular deposits of IgG and C3
bx DM nephropathy BM thickened, nodular Kimmelstiel-Wilson
is Lupus nephropathy nephrotic or nephritic? both
bx Lupus nephropathy wire loop lesion, subendothel deposit iC
what dz has Congo red stain on renal bx renal amyloidosis
what dz assoc with renal amyloidosis mltpl myeloma or chronic inflamm (I.e., RA, TB)
what 2 dzs can cause nephrotic and nephritic? Lupus and membranoprolifer
bx membranoprolifer nephrop tram track BM
what dz assoc with membranoprolifer nephrop Hep C, Lupus, cryoglobulin, SBE
lab findings of nephrotic proteinuria >3.5g/d, decrsd albumin, edema (classically periorbital in the am), incrsd lipid
lab findings of nephritic HTN, hematuria, oliguria, incsd BUN
difft patterns of deposits on bx subendo=Lupus; mesangial IgA=IgA (Berger's); linear=Goodpasture; lumpy/bumpy=postinfxs;spike and dome=membranous; membranoprolifer: subendo and mesangial deposits
renal bx: GBM spliting in what? Tram track in what dz? GBM splitting=Alports; tram track=membranoprolifer
Created by: ehstephns on 2010-12-06



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