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Renal 14 Tubulo. Dz

Ryan: Tubulointerstital Disease

What are the different types of tubulointerstitial disease? Acute interstitial nephritis Chronic interstitial nephritis Acute tubular necrosis Renal tubular acidosis Multiple myeloma
List the general features of tubulointerstitial disease. Proteinuria <1g/day Anemia Acidosis Hypertension WBCs and WBC casts on UA Na and K abnormalities
List the general features of glomerular disease. Proteinuria >3-3.5 g/day Anemia is uncommon Acidosis is uncommon Hypertension Oval fat bodies on UA May see low Na
Acute interstitial nephritis (AIN) is also known as what? Drug-induced hypersensitivity
What may be seen on UA? Eosinophils, RBCs, WBCs, and WBC casts NO RBC casts or fat bodies
Which drugs normally cause AIN? Antibiotics NSAIDS Cimetidine Thiazides Allopurinol
What infections can cause AIN? CMV Legionella Leptospiosis Streptococcus
What clinical features will you see in a pt with AIN? Rash Fever Azotemia (RF) Malaise Arthalgias
How soon after starting a new medication can these symptoms be seen? 7-10 days after starting a new medication
What would you expect to see in a pts lab? Eosinophilia Elevated sed rate Low C3&C4 WBCs and WBC casts
What stain is associated with AIN? *Hansel's stain* ---BUZZWORD---
Which antibiotics most commonly cause AIN? Beta-lactams TMP/SMX (sulfa) Ripfampin Fluoroquinolones (rarely in kids)
What is the classic triad of AIN? Fever Rash Eosinophils
What is this response related to? No clue, not related to dose or duration
How long do you have to be taking NSAIDs before you start to see symptoms? Several months
Why might the AIN triad not occur? Anti-inflammatory drugs block the inflammatory response
What systemic diseases can cause AIN? Sarcoidosis SLE Any infection (pyelonephritis) Transplant rejection (drugs)
Tx of AIN STOP THE DRUG!!! Usually brings about an improvement of renal fxn
Chronic Interstitial Nephritis (CIN) Chronic condition involving fibrosis of the interstitium and tubular destruction
What pts should this be on your DDx for? Hx of frequent pain who present with proteinuria & elevated creatintine Glucosuria with normal serum glucose
Check for _____ in kids *lead toxicity*
What drug class may be responsible? NSAIDs Can cause acute or chronic IN
Name the post renal causes of CIN. Chronic Obstructive Uropathy (urethral reflux) Chronic Pyelonephritis Chronic Renal Lithiasis
List the other causes of CIN Medications Post acute Tubular Necrosis Autoimmune- Sjogren's syndrome Raditaion
The hallmark of CIN **Sterile Pyuria** Inflammatory response to something
Clinical features of CIN Usually asymptomatic Anemia Acidosis RTA Minimal Proteinuria Hypertension
Tx of CIN BP control is the MOST IMPORTANT ACEI/ARB are DoC Anemia control Acidosis control Phosphorus control
Do you give a pt with CIN pyuria antibiotics? NO Not unless there is bacteria present It's inflammatory, NOT an infxn
Acute Tubular Necrosis (ATN) Most common RENAL ARF Necrosis due to microthrombi Frequently due to prolonged hypotension and augmentation of the immune system from sepsis.
Causes of ATN Sepsis Drugs (NSAIDs) Post-operative-post CABG Pancreatitis Prolonged and Untreated prerenal conditions
Clinical features of ATN Oliguric or non-oliguric Azotemia Elevations in serum Creatinine may not reflect the degree of renal dysfxn Acidosis/hyperkalemia
ATN labs Uosm <350, Una >40, FeNa >2 Plasma BUN/Cr <10-15 Ucr/Pcr <20 **Muddy brown casts on Urine Sed.**
Tx of ATN Treat underlying condition Dopamine doesn't work ANP doesn't work High dose Loops: limited Dialysis MAY increase survival
Rental tubular acidosis (RTA) Met. acidosis usually caused by a defect in renal tubular fxn (genetic)
How many types of RTA exist? 3 types: 1 proximal (type 2) 2 distal (types 1 & 4)
What does the anion gap look like in RTA? Normal gap metabolic acidosis
Relate RTA types with serum K Type 1: Low K Type 2: Normal L Type 3: High K
Type 2 RTAs Mechanism similar to acetazolamide (decreased HCO3 reabsorption in the proximal tubule)
Causes Type 2 RTA in children Fanconi Syndrome
Fanconi syndrome Rare disorder of tubule fxn Results in excess glucose, HCO3, phosphates, uric acid, K, Na, and some amino acids in the urine May be hereditary
Etiologies of Type 2 RTA Drugs Heavy Metals Disorders or protein, carbs, or amino acid metabolism Multiple myeloma (adults)
Type 4 RTA Affects Na/K-H exchange in the DCT Similar to spirnolactone
Common etiologies of Type 4 RTA in kids Obstructive uropathy Interstitial renal dz Multicystic dysplastic kidneys
Etiologies of Type 4 RTA Type 1 pseudoaldosteronism Diabetic nephropathy 21-hydroxylase deficiency Renal transplant
RTA Type 4 Tx Tx aimed at treatingthe primary dz Try to give HCO3 but MUST restrict K
Type 1 RTA Distal defect in H secretion Pts become acidotic and hypokalemic Commonly causes renal stones
How do children with Type 1 RTA present? Commonly with failure to thrive
Etiologies of Type 1 RTA Amphotericin B Toluene Lithium SLE Sjogren's Syndrome Chronic active hepatitis
Multiple Myeloma Blood cancer in which plasma cells grow uncontrollably, usually in the bone marrow
Associated bone lesions Cause structural damage and/or fractures from overproduction of myeloma cells
Why is it referred to as Multiple Myeloma? Because 90% of patients have multiple bone lesions
Causes of renal failure in MM Cast nephropathy Light chain deposition dz Primary amyloidosis Hypercalcemia Renal tubular dysfunction Volume depletion
Myeloma Kidney mechanisms Intracellular cast formation Direct tubular toxicity by light chains
Cast nephropathy Most common pathological Dx on renal biopsy in MM
Light chains bind with this Tamm-Horsfall Mucoprotein
Where is the Tamm-Horsfall mucoprotein secreted? From tubular cells in the ascending loop on Henle
This will worsen cast nephropathy Dehydration Due to decreased flow and increase in [light chain]
Light chain deposition disease Most commonly presents with both renal insufficiency and nephrotic syndrome
Which Ig id responsible? Kappa Ig
What takes up/metabolizes the light chains? Macrophages
Amyloidosis Usually due to lambda light chains
What stain is used for amyloidosis? **Congo Red** Beta-pleated
Why does renal failure develop? From tubular injury Also presents as nephrotic syndrome
Hypercalcemia in MM Occurs from bone reabsorption 15% of pts with MM
Contributes to renal failure by... Renal vasoconstriction Leads to intratubular calcium deposition.
Acquired Fanconi syndrome Light chains cause tubular dysfunction w/o renal insufficiency Mostly kappa light chains
Light chains are resistant to ___ and form ___ Degradation Crystals
Two ways tubular damage is caused Light chain toxic effects Indirectly from the release of intracellular lysosomal enzymes
MM lab findings Elevated BUN and Creatinine Hypercalcemia, uricemia Low anion gap UA shows NO protein Elevations in the gamma fraction-Bence-Jones Protein
Tx of renal failure in MM Hydration with IV fluids Tx of hypercalcemia (Loops) Tx of myeloma (steroids) Possible plasmapheresis Dialysis
***MM Buzzwords*** Chronin back pain Males >50 African-American Hepatosplenomegaly Cardiomyopathy
Created by: bcriss