nephrology
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IgANephropathy:MCCofGNinadults
‐ 1‐3daysafteranUPTI‐ Recurrentepisodesofgrosshematuria
‐ Serumcompliment:NORMAL
Post‐streptococcalGN:
‐ 1‐3wksafterpharyngitis(10days)andImpetigo(21days)
CRF:(knowallthefactorsthatdelaytheprogressionofdisease)
Factorsimprovingprognosis:
‐ Aceinhibitors(canworsenRFifCr>3‐3.5mg/dl)‐ Proteinrestriction(readcloselyESRDinKaplan)
End‐stagerenaldisease:
‐ Normochromicnormocyticanemiad/tEPdeficiency.‐ Allpts.withCRFandHct<30%(Hb<10g/dl)RecombinantEPtherapyAFTERIrondeficiency
hasbeenruledout.
S/EofEPtherapy:
• WorsensHTN(Intravenous:20‐50%ptswillhavea10mmhgriseinDBP,S/Croute:lessriseinBP)MayevenleadtoHTNencephalopathyd/trapidincreaseinBP
Tx:
‐ Fluidremoval(Dialysis)‐ Anti‐HTNdrugs(b‐blockersandVasodilators)
Prevention:
‐ SlowlyraisetheHctwithagoalhctof30‐35%
• Headaches(15%pts.)• Flu‐likesyndrome:(5%pts)LesscommonwithS/CEP,TxwithNSAIDs
• Redcellaplasia:rare
Options:
1.Transplant:
‐ Bettersurvivalandqualityoflife‐ Relateddonorlivingnon‐relatedlivingDead‐ 5‐yrsurvival:88%
Post‐opcx:
PresentsasOliguria,HTN,azotemia
‐ Acuterejection(grafttenderness,biopsyheavylymphocyticinfiltrateandvascularinvolvementTx:IVsteroids)
‐ Cyclosporinetoxicity‐ Ureteralobstruction‐ Vascularobstruction
‐ ATN
Dx:Inordertoconductad/d
‐ RenalUSG‐ MRI‐ Biopsy
‐ Radioisotopescanning
2.Dialysis:
‐ Aut.Neuropathypersistsorworsensindiabetics‐ Anemia,bonediseaseandHTNpersist.‐ 5‐yrsurvival:DM20%,Non‐DM30‐40%
Renalarterystenosis:
‐ Headache
‐ HTN‐ Renalbruit
Fibromusculardysplasiayoungadults
Atherosclerosiselderly
TxforbothAngioplastywithstenting
LOWERURINARYSYSTEM:
Irritativevoidingsymptoms:
‐ Frequency
‐ Urgency‐ Dysuria‐ Suprapubicorperinealdiscomfort
Obstructivesymptoms:
‐ Hesitancy‐ Weakstream
‐ Nocturia‐ Dribbling‐ Postvoidresidual>50cc
‐ Senseofincompleteemptying
Hematuria:
Initial(streambeginsred) urethraldamage
Terminal(streamendsred) BladderorProstaticdamage
Totalhematuria Kidneyorureterdamage
Prostatodynia:NohxofUTIbutvoidingabnormalitiespresent
s/s:
‐ Afebrile‐ Irritativevoidingsymptoms
Dx:
‐ UANormal‐ ExpressedprostaticsecretionsNormalnumberofWBCs.
‐ Culture–ive
Non‐bacterialprostatitis:(Maybecausedbymycoplasmaorureaplasma)
‐ Afebrile‐ Irritativevoidings/s
Dx:
‐ UANormal
‐ Expressedprostaticsecretions>10wbcs/HPF‐ Culture–ive
D/D:RuleoutbladderCAinanelderlypt.presentingwiththispicture.
Tx:Oralerythromycin(Macrolideformycoandureaplasma)
Acutebacterialprostatitis:
Causativeorganisms:
‐ YoungChlamydia,Gonorrhea
‐ ElderlyE.coli
S/S:
‐ Febrile‐ Irritativevoidings/s
‐ DREVerytenderprostate
Dx:(obtainmid‐streamurinesample)
‐ UANormal‐ Expressedprostaticsecretions>10wbcs/HPF(pyuria)‐ DogramstainandCulture(+ive)
Cx:
‐ Abscess
‐ Septicemia
Tx:I/Vantibiotics(hospitalizationrequiredb/coffearedCx)
Chronicbacterialprostatitis:
‐ Afebrile‐ Irritativevoidings/s‐ DRENormalorinduratedprostate
Dx:
‐ UANormal
‐ Expressedprostaticsecretions>10wbcs/HPF‐ Culture+ive
BPH:(Startsinthecenter,ProstateCAstartsintheperiphery)
• Mostpts.areASYMPTOMATICwithanenlargedprostateonDRE
• Irritativeandobstructivevoidingsymptoms• Usuallynohematuria,suprapubicpainandsystemicfeatures.• Elderlypt.withARFandobstructivevoidingsymptomsFIRSTstepinMxFoleycatheter.
• InchronicsevereBPH,foleycathwon’tpassd/thypertrophyLASTresort:suprapubiccath.• Pt.mayneedtovalsalvainordertopee(generatingenoughintraabdominalpressure)Maynot
beabletodoitifinseverepain.
• Allpts.withirritativeandobstructivesymptomsDoUA(rulesoutUTI)andCrIfCrraisedDoUSGofKUB
• MildBPHwillnotcauserenalinsuffiencyunlesscompletebladderoutletobstructionispresent.
Dx:
‐ DREenlarged,firmprostate‐ Post‐voidurinesampleIncreasedvol.
‐ AlwaysdoUAandSerumcreatininefirsttoruleoutothercauses.‐ CystoscopyVisualizesthebladderobstructiondonewheninvasivetxbeingconsidered(before
surgery)
‐ Cystometrogramseebelow‐ USGandIVPwhenCxBPHORcoexistentUTI‐ SerumPSAisonlyoptional(PSAplusDREincreasestheprob.TodetectprostateCA)
Mx:
‐ Mildsymptomswatchfulwaiting
‐ Moderatesymptoms:
Finasteride(actsonepithelialcomponents)or
Alphablockers(initialTOC,actsonthesmoothmusclesofprostateandbladderbase)
‐ SeveresymptomsTURPIffailsdoCYSTOMETROGRAM(alsodonewhenneurologiccauseisbeingconsidered)
BladderCA:
Riskfactors:
‐ Chronicanalgesicuse‐ Cigarettesmoking
S/S:
• Hematuria
• Irritativeandobstructives/s• Suprapubicpain(advancedCAPerivesicalnervesinvolvedorincreasedoutletobstruction)
• SystemicfeaturesMets
Acutecystitis:(MCroute:ascendinginfection)
Mech:UTisgenerallysterileexceptfordistalendofurethraandmeatus.Still,nocolonizationwithgram‐ivebacilliunless:
‐ Poorhygiene‐ Contraceptives
‐ Genitalinfections‐ Alterationofthenormalflorawithantibiotics
Oncethishascolonized,anyfactorcancausetheascentofbacteriaupintotheUTsuchasurethralmassageduringintercourse.
• UncomplicatedcystitiscanbeMxwithfindingsonlyonUAnoneedforculturestartoralTMP‐SMXIfpt.allergicOralciproorNitrofurantoin
• Urineculturecolonies>1000/ml(Pyelonephritis>10,000/ml)
Urethritis:
ChlamydiaMUCOpurulentdischarge,culture<100colonies/mlmeaningcultureNEGATIVE
GonorrheaPurulentdischarge,Gram+ive
Detrusorinstability:
Causesurgeincontinence(Spontaneouscontractionsofbladderunresponsivetocorticalinhibition)
Hypertonicbladder:
• Constanturinedribbling(Bladderhypertonic,urethralsphincterhypotonic)• Post‐voidurinevol.?
Atonic/acontractilebladder:
Causes:
‐ Diabeticautonomicneuropathy‐ MS
‐ Anestheticblocks‐ Anticholinergics‐ Caudaequinesyndrome
‐ Antipsychotics‐ H1‐antihistaminics(doxepin,hydroxyzine,diphen.,chlor.)‐ TCAs
‐ Sedatives
s/s:
• OverflowincontinenceConstanturinedribbling• Post‐voidurinehighvol.
Tx:
‐ Intermittentcath.
‐ Cholinergicsbethanecol‐ Avoidalcoholanddotightglycemiccontrol(onlyifDM)
Stressincontinence:
• Pelvicfloorweaknessinwomen
• Afterradicalortransurethralprostatectomyinmen• Post‐voidurineNORMAL
Detrusor‐sphicterdyssynergia:
‐ Occursd/tneurologicalproblem.
‐ Bothdetrusorandsphinctercontractcausingdifficultyininitiatingurinationandinterruptionofthestream.
Urinaryfistula:
‐ Hxofpelvicsurgeryorirradiation‐ Constanturineleakingthroughfistula
‐ DxIVP
Acuteepididymitis:
s/s:
‐ Fever‐ Painfulenlargementoftestes‐ Irritativevoidingsymptoms
*Sexuallytransmitted(chlamydiaandgonorrhea)Adultsepididymitis+urethritis(painatthetipof
penisandurethraldischarge)
*Non‐sexuallytransmitted(E.coli,pseudomonas)Elderlyepididymitis+UTI
ObstructiveUropathy:(postrenalazotemia)mightbed/tstonescausingunilateralobstruction,
s/s:
‐ Flankpain‐ Lowvol.voids(oliguria)withorwithoutoccasionalhighvol.voids(obstructionisbeingovercome
byalargevol.ofretainedurine)‐ Azotemia(pressureatrophyanddecreasedGFR)
*Voidingcystourethrogram donewhenpthasrecoveredfrominfectionandyouneedtolookforsomestructuralabnormalitiesintheurinarytract(morecommoninchildren)
DRUGS:
NSAIDs,ACE‐,diureticsblunttherenalresponsetolowintravascularvol.(wouldpredisposetopre‐
renalazotemiainasusceptibleelderlyperson)
Rifampin:
‐ DiscolorsALLbodilysecretions‐ Discolorssoftcontactlenses
Acycloviranacuteriseincreatinine
‐ I/Vdrugcausescrystallinenephropathy(tubularobstructionanddamage)in5‐10%pts.usually
indehydration‐ Txandprevention:Hydrationanddoseadjustment(slowingI/Vinfusion)
Vancomycin:Nephrotoxicinhighdoses
Azithromycin:Givenin
‐ Comm.acquiredpneumonia‐ Sinusinfections
‐ Strep.pharyngitis‐ Chlamydia
Cyclosporine:(InhibitstranscriptionofIL‐2andothercytokinesmainlythehelperT‐cells)
S/E:HyperMING
Hypertension:
‐ seenin1stfewwksoftherapy‐ DOCCCBs
Malignancy:increasedriskof
‐ SCCifskin
‐ Lymphoproliferativediseases
Infections
Neurotoxicity:Oftenreversible
‐ Headache‐ Visaualdisturbances
‐ Tremors‐ Seizure‐ Mutismetc
Nephrotoxicity:MCandseriousS/E
‐ Reversible:Acuteazotemia
‐ Irreversible:progressiverenaldisease‐ Hyperuricemia,hyperkalimia,hypophosphatemia,hypomagnesemia
‐ HUSmayoccurrarely
Gingivalhypertrophyandhirsuitism
Glucoseintolerance:Concommitantuseofpresdnisonesignificanthyperglycemia
GImanifestations:
‐ Anorexia‐ NVD
TACROLIMUS:
‐ SameMOAandS/Eascyclosporine
‐ NOgingivalhypertrophyandhirsuitism‐ MOREneurotoxicity,GIs/s,glu.Intolerance
AZATHIOPRINE:metabolizedto6‐MP(inhibitorofpurinepathway)
‐ Doserelateddiarrhea‐ Leukopenia
‐ Hepatotoxicity
MYCOPHENOLATE:InhibitorofIMPDHinhibitingpurinepathway
‐ Myelosuppression
KAYEXALATESodiumpolystyrenesulfonate
METFORMINcase:Pt.withprerenalazotemianeedstostopmetforminifhe’salreadytakingitb/clacticacidosisispotentiatedbyrenalfailure.Pt.hadhighHb(17g/dld/trelativepolycythemiaindehydration)
LONG‐ACTINGHYPOGLYCEMICSe.gGLYBURIDEusedwithcautioninRFptsb/ctheycanaccumulate
andcausehypoglycemia(shorter‐actinglikeglipizidecanbeusedsafelyastheyareprimarilymet.Byliver)
MCCofnephroticsyndromeinhodgkin’slymphomaisMinimalchangedisease.
Ingeneral:Membranousnephropathyisassoc.withothermalignancies(lung,breast,stomach,
colon,non‐hodgkin’s)
Uremiccoagulopathy:
MajoruremictoxicinvolvedGuanidinosuccinicacid(Defectinplatelet‐vesselandplatelet‐plateletadhesion)
‐ Nowadays,onlypresentsasepistaxisandecchymosesb/cofdialysis.
‐ Majorbleedingoccursinthosenotondialysis.
Labs:aPTT,PTT,TTgenerallynormal
BTisusuallyprolonged.
Plateletcountnormal(There’splateletDYSFUNCTIONnotthrombocytopenia,that’swhyaplatelettransfusionwon’tdob/ctheyquicklywillbecomeinactivatedbythetoxins)
Tx:
‐ DDVP(TOC)
‐ CanalsogiveCryopptandestrogenconjugates.
Dialysis:
‐ MCCofdeathinapt.withdialysisCardiac(60%dieofsuddencardiacdeath,20%acuteMI)‐ ApartfrommanyriskfactorsforcardiacdiseaseIncreasedhomocysteinelevelsinESRDand
DialysisandInhibitionofNOcausesvasoconstrictionsandHTN
‐ Withdrawalfromdialysisaccountsforonly20%deathsinadialysispt.
Youngblackmalewithisolatedpainlesshematuriathatresolvesrapidly.(d/tpapillaryischemia sickledcellsd/thypoxia)
RenalcellCA:
s/s:
‐ Mostlyasymptomatic‐ Hematuria40%pts.
‐ Fever,nightsweats,anorexia,wt.lss20%pts.‐ Classictriad:Flankpain,hematuria,palpableabd.Massstronglysuggests
metastatic/advanceddisease)Onlyin10%pts.
‐ Scrotal‐varicocele(majorityonleft)<10%ptsDon’temptywhenptrecumbent.
Lab:Polycythemiaandthrombocytosis
Dx:CTabdomen(TOC)
Cystinuria:
‐ Defectivetransportofcystine,lysine,arginine,ornithinebytherenaltubularbrushborder.‐ Cysteineformshard,radioopaquestones
s/s:
‐ Recurrentstonessincechildhood
‐ PositivefamilyHx.
Dx:
‐ UAtypicalhexagonalcrystals‐ Urinarycyanidenitroprussidetest(candetectelevatedcysteinelevels)+ive.Itisalsoawidely
usedscreeningtest.
Hyperkalimia:
‐ Amongothercauses,canbeapseudohyperkalimialabsamplecanbecomehemolysedduringvenipuncture.
‐ Drugscausing:NSAIDs,ACE‐,K+sparingdiuretics(spirono,amiloride,triamtrene)
‐ EKGchanges:PeakedtwavesProlongedPRintervalandQRSdurationEventuallossofP
wavesprogressivewideningoftheQRSandmergingwiththeTwaveproducesaSINE‐WAVEpatternprogressestoV.fiborasystole.
Extensiveevidenceofhyperkalemia,notelossofPwavevoltage,anddramaticincreaseinwidthofQRScomplex
Tx:Dependsonthedegreeofhyperkalimia
ImmediateTxif:
‐ EKGchanges‐ Muscleparalysis
‐ K+>6.5
Give:
‐ 10%Calciumgluconateforheart(stabilizinfmyocardialmemb.)‐ IVdextrose+Insulinand/orB2agonists/NaHCO3fortranscellularshift‐ Givediuretics(loopandthiazides)andcation‐exchangeresins(kayexalate)onlyifrenalfunction
ok.‐ DialysisRenalfailurept.orlife‐threateninghyperkalimia.
Pt.withrenalcolic:
X‐rayabdomenpelvisifnostonesseenconsiderfollowingpossibilities:
‐ Uricacidstones(radiolucent)‐ Calciumstones<1‐3mm
‐ Non‐stonecause(e.g.Obstructionbyabloodclotortumor)
Generalguidelinesforstones:
‐ Recurrentrenalstones:Do24‐hrurinecollectionforcalcium,citrate,urate,oxalate,sodiumandpHlevels)
‐ Hydration>2L/day
‐ PainMx:Narcotics(mayexacerbatenausea,vomiting)andNSAIDs(onlypreferredinthosewithnormalrenalfunction)
Uricacidstones:
Dx:USGorCTwithoutcontrast(TOC)
Tx:
‐ Hydration(>2L/day)
‐ Alkalinizationofurine(sodiumbicarborsodiumcitrate)‐ Lowpurinedietwith/withoutallopurinol
Calciumoxalatestones:
Mx:(Inorderofrelativeimportance)
1‐ Hydration>3L/day2‐ Normalorincreasedcalciumdiet(RDA1000mg/dL)
3‐ Na+restriction(<100mEq/dL)4‐ Oxalaterestriction(chocolate,vitC)5‐ Decreasedproteinintake
*IfapersononHCTZdevelopsrecurrentcalciumstonesCheckurinesodiumlevels(toseeifpt.iscompliantwiththesodiumrestricteddietb/csaodiumincreasescalciumexcretionandhence
increasingstoneformation)
UTI:
Evenifdipstickcomesoutnegative(Negativeleukocyteesteraseandnitrites),dourinecultureifpt.presentswiths/slikeUTI
Acutepericarditis:
MCCviralinfection
EKGchanges:
‐ DiffuseSTelevationthatistypicallyconcaveup(asopposedtoinacuteMIwherewehaveSTelevationinonlyspecificleads)
‐ ElevationofPRsegmentinleadaVR‐ DepressionofthePRsegmentinotherlimbleads
MajorityofGNareImmunecomplex–mediatedexceptafew:
1‐ MPGN:
TypeII:Densedepositdisease
M/S:
• DenseINTRAmembranousdepositsthatsatinforC3(IgGAbcalledC3nephriticfactordirectedagainstC3convertaseofthealternativecomplementpathwayleadingtopersistentactivation
andkidneydamage2‐ CresentericGN:
M/S:
• Cell‐mediatedinjuryTypeIVHSreaction
3‐ DiffuseproliferativeGN SLE4‐ Memb.Nephropathy Hep.Cassociationandpt.increasedforrenalveinthrombosis,pul.
Edema
5‐ Alport’ssyndrome:
M/S:
• AlternateareasofthickandthincapillaryloopswithGBMsplitting6‐ Thinbasementmembranedisease:M/ShematuriaandNOproteinuria
M/S:
• Markedlythinnedbasementmemb.
Contrast‐inducednephropathy:
‐ MCpresentation:Creatininespikewithin24hrsofcontrastadministrationwithreturntonormalrenalfunctionwithin5‐7days.
‐ Mechanism:Renalvasoconstrictionandtubulardamage‐ Moreatrisk:DiabeticandChronicrenalinsufficiency(Lookatcreatinine)Trytodo
alternativestudysuchasUSGbutifCTisamust,usenon‐ioniccontrastagents.
PREVENTION(allofthefollowingarepre‐CTi.e.pre‐contrasttreatments)
1‐ I/VHydration(ISOTONICBICARBONATEistheIVfluidofchoice)
2‐ Non‐ioniccontrastagents(low‐osmolality)3‐ Limittheamountofcontrast4‐ N‐Acetylcysteine(preventsdamaged/titsvasodilatoryandantioxidantproperties)inpts.with
borderlineRF.5‐ FenoldopamForuseinpts.withborderlineRF6‐ DiscontinueNSAIDs(Causerenalvasoconstriction)
7‐ Prednsione:Onlyinthosewithknownallergytocontrastmaterial(doesn’tpreventcontrast‐inducednephropathyONLYtakescareoftheallergicaspect)
Priapism:Anypt.presentingwithpriapismcheckhismedications
Commoncauses:
• SicklecelldiseaseandleukemiaChildrenandadolescents• Perinealorgenitaltraumaresultsinlacerationofcavernousartery
• NeurogeniclesionsSCinjury,Caudaequinesynd.• DrugsTrazodoneandPrazocin(MCcausativedrug)
AcuteinterstitialNephritis:
Commoncausativedrugs:
MnemonicCATNAP
1‐ Phenytoin
2‐ Allopurinol3‐ Antibiotics(MethicillinMC)cephs,sulfa,rifampicin4‐ NSAIDs
5‐ Thiazides6‐ Captopril
s/s:
‐ Rash(maculopapular)‐ Arthralgias
‐ ARF‐ UA:
*Eosinophiluria
*WBCcastsmademostlyofeosinophils
*Hematuria
*Sterilepyuria
TxDiscontinuecausativedrug
Medullarycystickidney:
• AdultformAut.Dominant• JuvenileformAut.Recessive(Callednephronophthisis)
s/s:
• InitiallyasymptomaticlaterdevelopUTIandstonespresentwithflankpainandhematuria
• NOrenalfailure• NOHTN(asopposedtoAPKD)
Dx:
• KUB:Nephrocalcinosis• USG:NORMAL(asopposedtoAPKD)
• IVP:Radiallyarrangedcontrastfilledcysts
Mx:
• Notherapytopreventdiseaseprogression(usuallynoharmfuleffects)• Periodicscreeningforstones,UTIandhematuria.
• Pts.withmedullarycystickidney+hemi‐hypertrophySCREENFORCANCER• Renalfailure+systemiceosinophilia:‐ AIN
‐ PAN‐ AtheroembolicDisease‐
Hydration:
‐ CrystalloidsNormalsaline,Ringer’slactateetc‐ ColloidsAlbuminetcGiveninburnsorhypoproteinemicstates
*Rehydrationtherapyinelderlyptsshouldbeundertakenwithcautionb/cNa+loadingcanunmask
Subclinicalheartfailure
Atheroembolicdisease:(Cholesterolembolization) Elderlypts.withatheroscleroticdisease
Causes:
‐ Arterialintervention‐ Anticoagulantsorthrombolytics
S/S:Anyorganexceptlungscanbeinvolved
‐ SkinLivedoreticularis,petechiae,gangrene,ulcersandmottlingoftoes.‐ RenalfailureRiseinCr.overseveralwks
‐ GIandCNSs/s
Labs:
• UAeosinophiluria,mildproteinuria,hematuria• Normocyticnormochromicanemia• Increasedleukocytes
• IncreasedESR• IncreasedCRP• Decreasedcomplement
DxTissuebiosyisdefinitive
TxConservative(anticoagulationshouldbestoppedasitmaypreventhealingofruptured
plaques)
Diabeticnephropathy:ACE–effectiveastheyreduceintraglomerularHTN,decreasingglomerulardamage.
1‐ Within1styrofDMGlomerularhyperperfusionandrenalhypertrophywithincreasein
GFR(hyperfiltration)2‐ First5yrsGBMthickening,Glomerularhypertrophy,mesangialvol.expansionwithGFR
returningtonormal.
3‐ Within5‐10yrsMicroalbuminuriaprogressiontoovernephropathy4‐ Seequestion15block2INaadiabeticpt.Diabeticnephropathyfindingspresentafter
successfultxofUTI(glomerularbasementmemb.Changes)
Hypertensivenephropathy:
1‐ Nephrosclerosishypertrophyanintimalmedialfibrosisofrenalarterioles
2‐ GlomerulosclerosisLossofglomerularcap.SurfaceareawithglomerularandperitubularfibrosisM/Shematuriaandproteinuriaoccur
Hepatorenalsyndrome:
‐ CxofESLDoccurringin10%ptswithcirrhosis.
‐ DecreasedGFRintheabsenceofshock,proteinuriaorothercauseofrenaldysfunctiond/trenalvasoconstriction.Resultingd/tdecreasedvasodil.Substances.
‐ MCCofdeathInfectionandHemorrhage
TypeIHRSRapidlyprogressive.Pts.diewithin10wkswithouttx.
TypeIIHRSSlowlyprogressive.Averagesurvival3‐6months.
• KidneyBiopsyNORMAL
Tx:LIVERtransplantationistheonlytherapy(mortalitywithdialysisishigh)
Acutepyelonephritis:
‐ Multiresistantorganismlikegram‐iverodGiveAminoglycosides(e.g.amikacin)
‐ Aminoglycosidesusedlessinelderlyandthosewithrenaldysfunctiond/tneedforconstantmonitoring.
‐ Chronicallyill,institutionalizedorindwellingbladdercathetersMRSAcancausepylointhese.
CxsepsishencegetbloodandurineculturesBEFOREstartingantibioticsinanyptappearing
septic.
HypotensiveptaggressivetxwithIVcrystalloids,IVantibiotics,Sxvasopressors.
CTandUSGwhenpt.doesn’trespondtoantibiotics(within3days)ORwhenDxisindoubt
Painlessgrosshematuria:
• Inadultsconsidermalignancyunlessprovenotherwise• Initialpresentingsignin80%ofsuchtumors(kidney,ureterorbladdermalignancy)
• Assessment:‐ ContrastCTorIVP‐ Cystoscopy(Bladderandurethra)
Falsehematuria:
AlwaysconfirmerythrocytesM/Sb/coffaslepositivedipsticktestinginthecaseof:
‐ Myoglobinuria
‐ Hemoglobinuriaporphyria‐ Aftereatingbeets
‐ RifampinS/E
Isolatedproteinuria:Canoccurd/tanystress
‐ Theevaluationofpt.shouldbeginbytestingtheurineonatleast2otheroccasions.
Papillarynecrosis:
Causes:
‐ Analgesicoveruse(MC)
‐ DM‐ Infections‐ UTobstruction
‐ Hemoglobinopathies‐ Cirrhosis‐ CHF
‐ Shock‐ Hemophilia
Nephriticsyndrome:
Apartfromthetypicals/s,alsocauses:
‐ Rash‐ Low‐gradefevers
‐ Proteinuriamaybemildorprofounddependingontheunderlyingetiology‐
Nephroticsyndrome:(evenifit’sa12yroldwithNephrotic,thinkacceleratedatherogenesisb/cof
hyperlipidemia)
‐ MCD‐ MGN‐ MPGN
‐ MesangialproliferativeGN‐ FocalsegmentalGS(NEPHRITICrangeproteinuriawithrapiddevofRF,azotemiaandnormal
sizedkidneysoccursevenwhenCD4countsareNORMALinanHIVpatient)
Cxofnephroticsyndrome:
*Hypercoagulationd/t:
‐ LossofATIII,prCandS
‐ Plateletaggregation
‐ Hyperfibrinogenemia(d/tincreasedhepaticsynthesis)‐ Impairedfibrinolysis
Manifestsas:
‐ RVT
‐ Renalarterythrombosis‐ Pul.embolism
Renalveinthrombosis:
s/s:
‐ Suddenonsetofabdominalpain‐ Fever
‐ Grosshematuria
*proteinmalnutritiom
*Iron‐resistantmicrocyticanemia(transferrinloss)
*Vit‐Ddef.(Cholecalciferolbindingproteinloss)
*Thyroxindecrease(TBGloss)
*Increasedinfections
Multiplemyeloma:(plasmacellmyeloma,myelomatosis,kahler’sdisease)
‐ Fatigue‐ Bonepain(esp.backandchest)‐ Normochromicnormocyticanemia(HB<12)
‐ Electrophoresis:Monoclonalparaproteinspeak(clonalproliferationoftheplasmacellsproducingexcessproductionofasingleimmunoglobulintype)
‐ Bencejonesproteinurialeadingtorenalinsufficiencyd/tobstructionwithlargelaminatedcastscontainingparaproteins(mainlyBJP)
‐ Hyperuricemia,amyloiddepositionandpyelonephritisMAYoccur
InsolublecrystaldepositionresultinginARF:
‐ Hyperuricemia
‐ Indinavir‐ Acyclovir‐ Sulfonamide
Rhambdomyolysis:
‐ DipstickpositiveforhematuriabutMicroscopynegative
‐ Riskfactorsshouldbepresentlikealcoholism(MC),cocaineabuse(directlytoxictomyocytes),crushinjuries,statinuse,metabolicabnormalities,prolongedimmobilization)
‐ DisproportionateriseofCREATININEascomparedtoBUN(like3.4to36)
‐ Txaggressivehydration.Mannitolandalkalinizationofurinemaybeused
REMEMBER:
NormalurineRBCs4orless/HPF
NormalurineWBCs10orless/HPF
Analgesicnephropathy:
MCformofdrug‐inducedCRF
Presentation:womanwithchronicheadacheswithpainlesshematuria
MCpathologies:
‐ Papillarynecrosisd/tpap.Ischemiacausedbyintensevasoc.Ofmedullaryvasarecta
‐ Chronictubulointerstitialnephritis(chronicpyelonephritiscanalsocausethis)
Earlymanifestations:
‐ Polyuria‐ Sterilepyuria(WBCcastsmayalsobeseen)
Later:
‐ Hematuria
‐ Renalcolicmayoccurifhematuria(grosswithunchangedRBCs)isprominentandclotsareforming
Advanceddisease:
‐ HTN‐ Proteinuria(nephroticrangeseeninseverecases
ATN:ProlongedhypotensionfromanycausecanleadtoATN
‐ Urineosmolality 300‐350mosm/L(never<300)
‐ UrineNa+ >20mEq/L
‐ FeNa+>2%(fractionalexcretion)
WBCcastsAINandpyelonephritis
Crystals:
Uricacidclassicstellateorstar‐shaped
Ca‐oxalateenvelopeshaped
Cysteinehexagonal
Idiopathicanti‐GBMantibodymediatedGN:
‐ Involveskidneyalone‐ nopul.InvolvementlikeGoodpasture’s
‐
MicroscopicPolyangiitis:
‐ Feverandmalaise‐ Abd.Painandhematuria‐ purpura
‐ Glomerulonephritis‐ Pul.Hemorrhage‐ SerologyNormalcomplementbutpositiveANCA
Mixedcryoglobulinemia:
‐ PresentsjustlikeHSPexceptfor:
*lowcomplements
*NOGIbleedetc…
*HCVassociation
Solitaryrenalcyst:pt.maypresentwiths/sofatotallydifferentdiseasebutwhenulookattheCTKNOWhowthecystlookslike‐‐verycommon.Firstcheckifithas:
‐ Thickenedirregularwalls
‐ Multilocularmass‐ Thickseptaewithinmass
‐ Contrastenhancement
Ifitdoesn’treassurepatientandNOfurthertestingwithrepeatCTsetc.
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