Evaluation of Renal Disease • Incidental discovery • ‘Renal’ presentation: HTN/EDEMA/NAUSEA/HEMATUREA • Evaluation: ?Duration (acute/Chronic)/ Urinalysis/GFR • Anatomical location of disease: Pre-renal/ Post Renal/ Intrinsic -
Imaging studies • Radionuclide perfusion scan • Ultrasonogrphy • IVP-? • CT scan- stones 95% • MRI-adrenals well imaged • Renal biopsy
Acute Renal Failure • Sudden increase in BUN or serum creatinine. • Oliguria often associated. • Symptoms and signs depend on cause. • Serum creatinine concentration will typically increase by 1–1.5 mg/dL daily
Features • Azotemia (Uremia) can cause nausea, vomiting, malaise, and altered sensorium. • Pericardial effusion and a pericardial friction rub • Elevated BUN and creatinine • Hyperkalemia • ECG can reveal peaked T waves, PR prolongation, and QRS widening • Metabolic acidosis • Anemia (EPO), platelet dysfunction
Acute Renal Failure Features • Pre-renal most common- mostly due to hypotension and decreased kidney perfusion • Post- renal – least common/ due to obstruction- prostate/ drugs/stones/
Glomerulonephritis • Hematuria, red cell casts, and mild proteinuria. • Dependent edema and hypertension. • Acute renal insufficiency • Immune complex deposition • SLE(35% to 90%)/HCV(8% ESRD) • Hypertensive and edematous, and have an abnormal urinary sediment.
Glomerulonephritis • Dipstick and microscopic evaluation: hematuria, moderate proteinuria (usually < 2 g/d), cellular elements such as red cells, red cell casts, and white cells. Red cell casts are specific for glomerulonephritis • Therapy- High-dose corticosteroids and cytotoxic agents such as cyclophosphamide
HIV Associated Nephropathy • Can present as the nephrotic syndrome in patients with HIV infection. • Mostly young black men. • More common mode of acquisition of HIV is through injection drug use.(IVDU)
Chronic Renal Failure • Progressive azotemia over months to years. • 20 million Americans, or one in nine adults • Symptoms and signs of uremia when nearing end-stage disease. • Hypertension in the majority. • Isosthenuria (fixed specific gravity) and broad casts in urinary sediment are common. • Bilateral small kidneys on ultrasound are diagnostic.
Chronic Renal Failure 70% due to diabetes/hypertension
Complications • Hyperkalemia • Metabolic acidosis • Hypertension • Pericarditis • CHF • Anemia/petichiae/purpura • Uremic encephalopathy
Treatment • Protein restriction 1g/kg/day • Sodium and water restriction • Potassium restriction • Phosphorus restriction • Magnesium restriction • Peritoneal/Hemo dialysis • Renal transplant 50% eligible
Nephrotic Syndrome • Proteinurea > 3.5 g/1.73 m2 per 24 hours. • Low albumin (albumin < 3 g/dL). 3.2-4.5 is normal. • Hyperlipidemia occurs in over 50% • Peripheral edema. • Systemic disease: diabetes mellitus, amyloidosis, or SLE • Type 2 DM proportion is slowly increasingSingle most common cause • Deficiency: vitamin D, zinc, and copper from loss of binding proteins in the urine; they are prone to infection, in part from urinary losses of immunoglobulins. • Increased risk of coagulationClotting problems due to liver involvement – worse with heavy metal exposure – cadmium, gold, lead, zinc, nickel, mercury, etc.
Analgesic Nephropathy • Large quantities of- acetaminophen (Tylenol), Aspirin-NSAIDs(>1g/day for >3 years) • Aminoglycosides, gentamicin antibiotics, cancer meds Urinalysis- • Hematurea • Proteinurea • Anemia • PMN
Heavy Metals Nephropathy • Lead, Cadmium (welders/ moonshiners) • Increased SUA-GoutDamaged ki uric acid levels up • Mercury and Bismuth can do the samePeptobismol contains bismuth – too much can cause increased bismuth levels. • Complain of polyuriaCan’t concentrate urine, so flows out quickly
Renal artery stenosis • Atherosclerosis/ (67-95%)/ • Fibromuscular dysplasia (young women ) • Risk factors include- • renal insufficiency • diabetes mellitus • tobacco use • hypertension • Doppler ultrasonography, captopril renography, and magnetic resonance angiography (MRA ) • Therapy-?Angioplasty/Stenting/Bypass/MedicinesAlso drugs to keep the blood thin and flowing.
Cystic Disease of Kidneys • Simple cysts -50% over the age of 50 yearsNot considered a problem if you find a couple over the age of 50. Over 5 cysts is bad.Blood leaking into the cysts causes a colicky type of pain. • Rarely symptomatic • No clinical significance • Generalized cysts scattered throughout the cortex and medulla of both kidneys and can progress to ESRD Produces KI failure
Simple cysts • 65–70% of all renal masses Painless hematuria is a marker for this • Differentiate them from malignancy, abscess, or polycystic kidney diseaseAbscess = fever, heat sx. • Sonographic criteria to be considered benign: • (1) echo free, • (2) sharply demarcated mass with smooth walls, and • (3) an enhanced back wall
ADPKD • Affects 500,000 individuals • 1 in 800 live births. • Fifty percent get ESRD by age 60 End Stage Renal Disease • ADPKD1 on the short arm of chromosome 16 (85–90% )Faster progression than chrom 4. • ADPKD2 on chromosome 4 (10–15%). Slower progression
APKD Features • Abdominal/Flank pain- ?infection/bleed • Hematuria • UTI/Stones 20%Repeat infections • FH (75%) • HTN(50%) • Palpable large kidneys • Cerebral aneurysms (10-15%) • MVP & aortic aneurysms (25%)Mitral valve prolapse – 2ndary reasons for this. • Colonic diverticula more common • U/S:2 or more cysts by age 30 diagnostic • CT scan highly sensitive Tx is symptomatic mgmt. Treat the above stuff and watch for other signs listed above. In other words, just throw more drugs at it. Pts often come for pain.
Analgesic Nephropathy:Renal Papillary Necrosis Kidney damage due to meds. Will eventually need dialysis, KI transplants.
Uric acid Stones • Stones consist of the following from most common to least common: • Calcium • Struvite • Uric Acid • Homocysteine
Renal Cancer Young children are likely to have – painless hematuria. Catch it early and can cure. Less commone for adults.
Chronic Glomerulonephritis (ESRD) No cortex left here.
Staghorn Calculus Colicky pain, UTI repeats. Will kill off the kidney in time.
Atrophy of Kidney You only need 1/8 of a kidney to keep living. atrophied kidney
Know this! RAAS
Ch.23-Urology UROLOGICAL CONDITIONS EVALUATIONS MANAGEMENT
Urology Evaluations Pain- major factor. Determine where it is, what it refers to: • Renal: ipsilateral, costovertebral angle, n/v • Ureteric: ‘colic’- dull ache Commonly related to tip of penis. • Bladder: Suprapubic discomfort or related to micturition • Prostatic: Perenial-radiates to-lumbosacral inguinal, or lower limbs and voiding irritation. • Penile: • STD related (dischg/pain) • phimosis (uncircumcised, narrowing of foreskin – can cause urinary retention, backs up when severe, can affect KI. Can also be common in diabetes. ) • Peyronie’s disease • Testicular: Trauma/torsion/epidydimitis- scrotal pain radiates to groinPainless swelling can often = cancer, esp age 15-35. Always do a belly exam. Listen to the aorta for aneurism, listen to the Lungs, look for heart/evidence of pericarditis, feet/face for edema, ascites for abdomen. Check breath for uremia. Check mental status for confusion (MMSI).
Hematuria • Initial- at beginning of urination and clears during the stream suggests anterior urethral source • Terminal- at the end of stream implies bladder neck/ prostatic sourcePenile fracture could cause this. • Total- Throughout Urination - bladder or upper tract source • Age: Young women –cystitis. Do gynecological review too. Older - ?renal cancer/ ?stones/GN/PKD
Irritative Voiding Symptoms: Something is irritating the plumbing Urgency Dysuria Frequency NocturiaShouldn’t have to get out of bed to pass urine! Obstructive Voiding Symptoms: Blockage of urethra Hesitancy Decreased force of streamStream should be parabolic in shape. Intermittency Post void dribbling All seen in patients with enlarged prostate. Rarer in women, but not during preggers when the bladder is squeezed.
Incontinence ‘Involuntary’ loss of urine • Total- all the time in all positionsUrine is irritating to the skin – can cause all kinds of irritative problems in the local area. • Stress- activity associated- coughing/lifting/sneezing/exercising • Urge-strong urge followed by loss of urine • Overflow- chronic retention results in overflow incontinenceWhat feels like a normal voiding, but isn’t emptying enough. Be able to describe incontenence with these types. Anticholinergic drugs are most popular to block relaxation of sphincter and deal with incontinence.
‘Systemic’ symptoms • ‘High’ fevers in women –acute pyelonephritisRepeat fevers, chills, occ flank tenderness. Urine tests w/presence of nitrities, leukocytes found. Both measured with dipstick. Suggests infection. May need antibiotics IV then oral antibiotics. • Men fevers- acute pyelonephritis/ acute prostatitis/epididymitis • Fevers with cancer kidney/bladder/testes • Weight lossPoints to cancer.
Other symptoms Hematopsermia- blood in ejaculation-?prostate/?seminal vesicle • Tests: urine/DRE/Cystoscopy • Pneumaturia- air in urine fistulas(diverticulitis/Crohn’s/radiationFistula is an unnatural connection between UB and other like rectum – causes air pockets in urine, might look like little soap bubbles. Fistulas can also cause urine to spill out of the wrong orifice. Fecal mix in urine can cause big bacterial problems. • Urethral discharge- STD/ elderly-cancer • Cloudy urine-UTI / Chyluria (filariasis/ tb)Rule out UTI first.
Scrotal Contents • Epidydimitis- tender testcilces • Hydrocele- collection of fluid in scrotal sac • Varicocele- retroperitoneal tumor/obstruction of spermatic vein • Torsion of testis- 10-20 yrs/ acute pain and swelling, testicle elevated
When to test for Hematuria Always a red flag! • Timing • Colic/voiding/constitutional • AnticoagulantsEven aspirin can do this • Drugs- analgesics/cyclophophamide • Diabetes Mellitus/Sickle Cell Disease/Stones • Urinalysis • Cystoscopy / Imaging/ MRI
Manage Acute Cystitis • Irritative voiding symptoms (frequency/urgency/dysuria/suprapubic pain/ postcoital dysuria-hematuria) • Afebrile/ no systemic symptomsMany docs won’t even do a test, just give antibio’s if this is the 1st time. • Positive urine culture • Most common E. coli • Urinalysis: pyuria/bacteriuria/hematuria • DD: F- vulvovaginitis/ PID M- prostatitis/ urethritis • Tx:Short-term abx (1-3 days) • Bactrim Ⓡ - most common treatment • Quinolones (TequinⓇ) • Pyridium
Symptoms Fever Flank pain Irritable voiding symptoms Positive urine culture Gram –ve: E.coli/ Proteus/ Klebsiella/ Enterobacter/ Pseudomonas Tests CBC: WBC Increased/ Renal u/s DD: Appendicitis/ Risks Lower Lobe pneumonia Sepsis/Shock/Abscess Treatment: IV abx- ampicillin Gentamicin quinolones Prompt diagnosis and treatment essential Fever, flank pain, positive urine test - pyelonephritis Manage Acute Pyelonephritis
Manage Acute prostatitis • Fever • Irritative voiding symptoms • Perineal/suprapubic pain • Tender DRE / + ve urine culture • E.coli/Pseudomonas • WBC increased/ Pyruria/ • Bacteriuria / Hematuria • TX: • IV abx- ampicillin / gentamicin • Oral quinolones-4-6 weeks
Manage Acute Epididymitis • Fever • Irritative voiding symptoms • Painful enlarged epidydimitis/ scrotal swellings • STD under 40 (Chlamydia/GC)Most common cause • Over 40- urethritis/cystitis • IMAGING- • Scrotal ultrasound • Treatment: Abx-10-21 days • Delayed or inadequate treatment may result in epididymo-orchitis, decreased fertility, or abscess formation.
Diabetic Nephropathy Issues And Management
Facts about Diabetic Nephropathy • Number one cause for ESRD • 45% of all dialysis patients • Early diagnosis of diabetes and proper therapy of diabetes helps prevention of renal issues • Diagnosed by proteinuria • Serum Creatininine progressively increases • More common in Type 1 Diabetes Mellitus • After 10-15 years of Type 1 Diabetes Mellitus • After 20 years of Type 2 Diabetes Mellitus
Etilogy of diabetic nephropathy • Angiotensin II (ATII) itself contributes to the progression • An inflammatory process with evidence of macrophage infiltration in glomeruli with early diabetic sclerosis • ACE inhibitors block this macrophage induced inflammation