Renal USMLE
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| 3 categories of ARF, what's MC? | prerenal (MC), renal, postrenal (least common)
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| biggest risk ARF | infxn
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| T/F urine output is decrsd in ARF | F, can be oliguric, anuric, nonoliguric
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| 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
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| how urine sediment is difft bw pre-renal and renal ARF | pre-renal: hyaline casts, ATN: granular casts w epithelial cells
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| proteinuria (3/4+) suggests pre-renal or renal ARF? | renal ARF (specifically glomerular)
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| Causes ATN: MC, other causes | MC=ischemia, other: Abs ie aminoglycosides, radiocontrast, NSAID esp in CHF, mscl damage, hemoglobulinuria, MM Ig chains, chemo Rx
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| 2 main causes of ARF due to renal dzs | 1) ATN, 2) glomerular
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| causes of postrenal ARF | MC=BPH, also stones (but would need to be bilateral)
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| RBC casts suggests what ARF etiology | glomerular
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| WBC casts suggests what ARF etiology | acute interstitial nephritis or pyelonephritis
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| fatty casts suggests what ARF etiology | nephrotic syndome (glomerular cause ARF)
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| key causes of prerenal ARF | anything hypovolemia, incl decrsd CO and systemic vasodilate (ie sepsis)
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| if renal perfusion is already compromised, what Rx can ppt ARF | NSAIDs, ACEI, cyclosporin
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| metabolic changes seen in ARF | metabolic acidosis w incrsd anion gap, hi K and P, low Ca and Na + uremia
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| at what level correct acidosis w bicarb | <16
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| when start dialysis for ARF | symptomatic uremia, intractable acidemia, hyperK, or vol overload
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| causes of CRF |
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| cut offs for severity of CRF | (all in GFR) mild=70-120; mod=30-70; severe=<30; ESRD=<10
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| at what pt does uremia usu become symptomatic | BUN>60
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| 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]
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| 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
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| summary of lytes in CRF | hi K, Mg, P and metabolic acidosis
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| define renal osteodystrophy | bone pain, fractures from incrsd P leading to low Ca++ and 2ry hyperparathyroidism
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| 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
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| 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
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| in ARF which diuretic give | furosemide, if pul edema or oliguric
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| absolute indications for dialysis | AEIOU, A=acidosis, E=electrolytes (hi K), I=intoxications, O=overload (hypervol), U=uremia
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| which intoxications use dialysis for | MELA=MetOH, ethylene glycol, Li, aspirin
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| what symptoms of uremia, which symptom is absolute indication for dialysis? | N/V, CNS: changes in mental status, seizures, **absolute indication=uremic pericarditis
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| 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
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| what deficit of renal failure can't be corrected w dialysis | renal synthesis of EPO and vit D
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| 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
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| complications/limitations of peritoneal dialysis | hi glu soln leads to hyperglycemia, incrsd triglycerides; fluid maintained at waist; abd/inguinal hernia; peritonitis risk
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| what dialysis membrane is used in peritoneal dialysis | the peritoneum
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| proteinuria defined by lab value? Nephrotic level of proteinuria? | proteinuria= >150mg/d; nephrotic level= >3.5g/d
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| key features of nephrotic syn | proteinuria >3.5g/d, hypoalbumin, hyperlipid, edema, hypecoag (losing anti-coag), infxn (losing Ig)
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| 3 categories of proteinuria | 1) glomerular (more protein loss than other categories), 2) tubular, 3) other (UTI, fever, heavy exertion/stress, CHF, preg, orthostatic)
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| 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
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| key features of nephritic syn | hematuria, HTN, incrsd BUN (can also see edema and proteinuria (but not in range of nephrotic))
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| MC cause of nephritic syndrome | Post Strep
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| which glomerular dzs have tx | min change=steroids, FSGS ? Combo--not clear effective, HIV nephropathy=prednisone, ACEI, HAART
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| MC causes of nephrotic in kids, adults | kids=min change; adults=membranous, then FSGS, then membranoprolifer
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| FSGS nephrotic or nephritic? | nephrotic, but often hematuria and HTN are present
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| which glomerul dz shows thickening of capillary walls | membranous
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| what dz: asx mild hematuria/proteinuria that becomes gross hematuria after URI or exercise | IgA (bergers)
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| hematuria w hi freq hearing loss | Alports (hereditary nephritis), complete picture includes: hematuria, pyuria, proteinuria + hi freq hearing loss w/o deafness
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| which glomerular dz assoc w HepC and cryoglobulinemia | Membranoprolifer
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| 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]
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| 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
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| tx Wegeners GN? Goodpasteur GN? | both steroids and cyclophosphamide
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| MC cause acute interstitial nephritis? In children other causes? | MC=Rx, but can be after infxn esp in children (ie Strep, Legionella), + sarcoid
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| 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
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| how are acute and chronic interstitial nephritis difft | chronic doesn't have hypersensitivity component w eos; a progressive fibrosis/scarring process [+/- pap necrosis
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| MC cause of pap necrosis? How dx? | MC=overuse OTC painkillers, (also DM, sickle cell, EtOH, UTI/UTO); dx=excretory urogram
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| how can analgesic nephropathy present | either interstitial nephritis or pap necrosis and ARF or CRF
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| cxns of pap nerosis | sloughed pap can obstruct ureter
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| name 5 tubulointerstitial dzs | 1) acute/chronic interstitial nephritis, 2) renal pap necrosis, 3) renal tub acidosis, 4) hatnup syndrome, 5) fanconis
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| 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
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| cxns of ea RTA | RTA1=renal stones, rickets/osteomalacia; RTA2&4=no stones
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| 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
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| tx of RTA1, 2 | RTA1=bicarb to prevent stones, P to help acid sxn; RTA2=no bicarb (would just be excreted), Na restriction
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| 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]
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| tx Hartnup syndrome | suppl nicotinamide if symptomatic
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| 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++
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| clinical cxns of Fanconis | low P leads to rickets, impaired growth, osteomalacia, and path fx bones
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| tx Fanconis | P, K, alkali, salt, hydration
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| what lab value suggests myoglobulinuria or rhabdomyolysis | very high CPK value
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| 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
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| dx, tx adult polycystic kid dz | dx: US, tx: none (50% ESRD, course variable)
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| define medullary sponge kidney | cystic dilation of collecting ducts, thgt assoc w hyperparathyroid and parathyroid carcinoma
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| dx, presentation, tx medullary sponge kidney | dx: IVP; presentation: hematuria, UTI, stones; tx:none [stone prevention, tx UTIs]
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| define, tx of simple renal cyst | common (1/2 pts>50), no tx (Asx)
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| name 4 renal vascular dzs | 1) renal artery stenosis, 2) renal vein thrombosis, 3) HTN nephrosclerosis, 4) sickle cell nephropathy
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| 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
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| 3 clinical features suggesting renal artery stenosis | 1) sudden onset of HTN w/o fam hx, 2) refractory HTN, 3) abd bruit
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| 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
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| tx renal arter stenosis | revascul w percut translum angio (PRTA), success fibromusc>athero; surgery if PRTA is not successful
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| can see renal vein thrombosis w | nephrotic syn, preg, OCP
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| 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
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| 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
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| 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]
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| 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
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| bipyramidal or biconcave oval stone on radiograph=what type? | Ca++
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| flat sq plate kidney stone=what type? See on radiograph? | uric, can't see on plain radiograph
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| rectangular prism kidney stone=what type? See on radio? | struvite, can see
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| hexagon kidney stone=what type? See on radiograph? | cystine, can't see on plain radiograph
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| what incrses risk of uric acid kidney stones | gout, chemo of leuk and lymph
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| what incrses risk of Ca++ kidney stones | inrs Ca++=hyperparathyroid, sarcoid, cancer, vitD; incrs oxaloate=steatorrhea, B6 defic, Crohns
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| what incrs risk of struvite stones | alk urine, UTI w urease bug PESK=proteus, enterobac, serratia, klebsiella
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| tx/prevention Ca++ stones | limit Ca++ intake, thiazide diuretic [for all stones: hydration, pain manage]
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| tx/prevention cystine stones | limit protein, allopurinol [for all stones: hydration, pain manage]
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| if urine acidic w stones, what type? Alk? | acid think uric acid stone, alk think struvite
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| pyuria w stones, think what type | struvite (UTI w urease bug)
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| 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
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| 2 procedures for stones won't pass | 1) extracorpeal shock wave lithotripsy (breaks up stones 0.5-2cm), 2) percut nphrolithotomy (>2cm)
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| UTO: clinical presentation of upper UTO v lower | upper UTO=renal colic; lower UTO=urination
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| causes of upper UTO | intrinsic renal=kidney stones, sloughed papillae, blood clots, tumor; extrinsic=preg, tumors, AAA
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| causes of lower UTO | BPH, prostate cancer, bladder cancer
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| dx of UTO (3) | renal US, IVP (but not in preg, CRF), voiding cystourethrography can be used for lower UTO
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| Prostate cancer: MC type, risk factors | 95% adeno; risk: ***age, AA, high fat diet, fam Hx, herbicides/pesticides
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| 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)
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| 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
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| what can incrs PSA other than cancer | BPH, age, prostatitis, needle bx, prostate massage (but not DRE)
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| stages of prostate cancer | A=nonpalp, confined to prostate, B=pap nodule, confined to prostate, C=beyond capsule w/o met, D=mets
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| 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))
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| classic triad of renal cell carcinoma presentation | (only 10%) hematuria, flank pain, abd mass
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| what dz has autosomal dominant transmission at risk renal cell carcinoma | VHL (but only 2% of RCC, most are sporadic cancers)
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| risks for renal cell carcinoma (5) | smoking, phenacetin analgesics, adult polycystic kidney dz, VHL, Hg&cadmium exposure
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| dx renal cell carcinoma | renal US, f/u CT for staging
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| tx renal cell carcinoma | radical nephrectomy, incl Gerota's fascia
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| MC genitourinary cancer | bladder cancer
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| MC type of bladder cancer | transitional cell (90%)
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| tx bladder cancer | local excision, but likely to recur
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| risks for bladder cancer | smoking, aniline and azo dyes, radiation, coffee, sweeteners, cyclophosphamide
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| how does bladder cancer nmlly present | hematuria (r/o infxn)
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| dx bladder cancer | cytoscopy+bx; CXR and CT for staging
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| 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)
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| types of germ cell testicular cancers | seminoma (MC, slow growth, late invasion, radiosensitive), nonseminomas usu containing 2 of: embryonal, choriocarcinoma, teratoma, yolk sac
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| qualities of embryonal testicular cancer; germ cell? Seminoma? | germ cell nonseminoma; hemorr/necrosis, mets abd lymph&lungs early, incrsd AFP
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| 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)
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| qualties of seminoma? Germ cell? | germ cell; MC, slow growth, late invasion, radiosensitive
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| qualities of teratoma? Germ cell? Seminoma? | germ cell, nonseminoma; rarely met
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| qualities of yolk sac testic cancer? Germ cell? Seminoma? | germ cell, nonseminoma; usu in young boys
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| name non germ cell testicular cancers | Leydig (sxn hormones causing precocious puberty or gynecomastia, if met poor px), Sertoli (usu benign)
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| which more common: germ cell or non germ cell testic cancers | germ cell (95%) and of those MC is seminoma
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| staging of testicular cancer | A=testicle/cord, B=retroperitoneal LN spread below diaphragm, C=distant mets
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| difftl for testicular cancer | varicocele (dilated veins in testicle), testicular torsion, spermatocele (testic cyst), hydrocele (fluid in testis)
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| incrsd risk testic cancer | cryptorchidism (even if surgical repair), Klinefelter
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| incrsd AFP in testicular cancer indicates | embyronal germ cell nonseminoma
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| risk penile cancer, age peaks | risk: circumcision may protect, HSV, HPV18; peak age 60
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| MC etiologies for epidimytis | in kids/old: E Coli, in young adult=Chlamydia or gonorrh
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| how difft testicular torsion and epidimytis | testicular torsion is sudden, testicle elevated in scrotum, no F, usu appears in adolescent
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| effects of Angio II | vasoconstrictor, rel ADH from P. Pit, rel aldosterone from adrenal, hypothal incrs thirst
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| 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
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| what's Conn's dz | primary hyperaldosteron
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| cause, signs/symptoms of primary hyperaldosteron | cause: adrenoma of adrenal cortex (Conn's dz), HTN, decrsd K, metabolic alkalosis, decrsd renin
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| tx primary hyperaldosteron | spironolactone (aldosterone antagonist)
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| signs, symptoms hypoaldoster | hypotension, skin pigment (from incrsd ACTH leading to MSH)
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| definition Addisons | primary hypoaldosteronism (of adrenal corrtex) MC infxs cause
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| when is aldosterone rel? | decrsd blood volume, incrsd K
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| what does aldosterone do? | incrsd Na reabsorb and incrsd K sxn
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| how does blocking aldosterone effect K? BP? | incrs K, decr BP
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| name 4 types of diuretics | thiazide, loop, K+ sparing, carbonic anhydrase
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| describe thiazide mech of action, SE | inhibit Na reabsorb in distal (decrs Na, decrs K); SE: GLUC (incrs glu, lipid, uric, Ca++), sulfa allergy
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| 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
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| 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
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| describe carbonic anhydrase diuretic mech of action, SE | works on prox convul tubule (PCT); SE acidosis, neuropathy, sulfa
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| how does EtOH act as a diuretic | inhibits ADH
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| what diuretic use if hi uric? | ethacrynic acid (+allopurinol)
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| what diuretic use if sulfa allergy? | ethacrynic acid
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| what's the name of a carbonic anhydrase diuretic | acetazolamide
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| which diuretics can't be used if sulfa allergy | acetazolamide (carbonic anhydrase inhib), loop, HCTZ
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| which diuretic works on PCT? Distal tubule? TAL? | PCT: carbonic anhydrase, DT: HCTZ, TAL: loop
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| which diuretic works on cortical collecting duct | K+ sparing (where aldosterone acts)
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| 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)
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| what diuretic can ppt gout? | HCTZ (and loop)
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| don't use loop diuretic with what antibiotic? | aminoglycoside (incrsd ototoxicity)
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| what's the name of a K= sparing diuretic | spironolactone (aldosterone antagonist)
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| what's the name of a loop diuretic | furosemide
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| what diuretic use in nephrogenic diabetes | HCTZ
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| if pt on digoxin, which diuretic? | K sparing (sprionolactone)--low K incrs digoxin toxicity
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| in CHF use what diuretics | loop and thiazide (+/- K sparing for digoxin pts)
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| what happens to electrolytes in RF | hypoCa (not making 1,25 vitD), Hyper K, Mg, and P, Hypovol Hypotonic HyperNa
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| 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
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| 5 nephritic syn | post infxn, IgA, Wegeners, Goodpasture, Alports
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| What's Berger's | IgA nephropathy (nephritic)
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| What IgA nephropathy assoc w | s/p URI and GI infxn in young men
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| renal bx: lumpy bumpy | postinfectious nephritic dz
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| C3 is decrsd in which nephropathy? Nml in which? | decrsd in postinfectious nephritic dz; nml in IgA (Berger's)
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| tx for Wegeners? Goodpastures? | Wegeners: hi dose corticosteroids, Goodpastures: plasmaphoresis, pulse steroids
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| what Alports? (ie age, other assoc anomalies) | hereditary nephritic syndrome seen in boys 5-20; assoc nerve deafness and eye disorders
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| Alports bx findings? | GBM splitting on electron microscopy
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| tx IgA nephritic syndrome | glucocorticosteroids for some pts, ACEI for proteinuria
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| MC cause nephrotic in kids? | min change dz
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| bx min change dz | light microscopy nml, electron micro: fusion of epithelial foot processes
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| tx min change dz (nephrotic)? Post infxs nephritic? | min change: steroids, excellent px; post infxs: supportive
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| demographics assoc focal segmental nephrotic | HIV, IV drug use, obesity, young black male w HTN
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| bx findings: sclerosis of capillary tufts | focal segmental nephrotic syndrome (also see segmental sclerosis)
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| membranous nephropathy: nephritic? | no, nephrotic
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| MC cause nephrotic in caucasian adults? | membranous
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| bx membranous | spike and dome granular deposits of IgG and C3
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| bx DM nephropathy | BM thickened, nodular Kimmelstiel-Wilson
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| is Lupus nephropathy nephrotic or nephritic? | both
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| bx Lupus nephropathy | wire loop lesion, subendothel deposit iC
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| what dz has Congo red stain on renal bx | renal amyloidosis
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| what dz assoc with renal amyloidosis | mltpl myeloma or chronic inflamm (I.e., RA, TB)
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| what 2 dzs can cause nephrotic and nephritic? | Lupus and membranoprolifer
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| bx membranoprolifer nephrop | tram track BM
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| what dz assoc with membranoprolifer nephrop | Hep C, Lupus, cryoglobulin, SBE
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| lab findings of nephrotic | proteinuria >3.5g/d, decrsd albumin, edema (classically periorbital in the am), incrsd lipid
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| lab findings of nephritic | HTN, hematuria, oliguria, incsd BUN
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| 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
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| renal bx: GBM spliting in what? Tram track in what dz? | GBM splitting=Alports; tram track=membranoprolifer
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