Weakness
Oliguria
Dizziness
Loss of systemic vascular resistance ( SVR)
Tachycardia
Orthostatic blood pressure changes
Gold standard:
To distinguish preener failure is the return of renal function to baseline with volume repletion
Tx: replace volume with IV Fluids
Rhabdomyolysis
SSX: presents same as preener
DX: FENa is greater than 2%
**Muddy casts and renal tubular cells on UA
Tx: remove offending agent
** Just like prerenal: think post dye using procedure, use of ahminoglycosides or muscle breakdown( marathon runner or cocaine use)
SSX:
Hematuria
Edema
HTN
Oliguria
UA: RBC Casts***
Antibodies:
**ASO: Post streptococcal ( most common)***
SSX:
Massive edema**
urine 3.5+ grams protein( proteinuria)**
hypoalbuminemia
hyperlipidemia and lipiduria
Diabetic neuropathy**
**Oval fat bodies found in urine
DX: Biopsy
Tx: Steroids
Heroin and HIV black male
– elective surgery
– Uncircumcised men= risk for penile cancer
– Can cause tourniquet effect
– Can be emergent and need surgery
-Typically applied to patients with GFR; 60 mL/min
– Uremia: advanced stage of renal failure with symptoms affect multiple oran systems
Major causes:
Diabetes
Glomerulonephrtis
HTN
Tx: Diet modification
Restrict protein, Na+, K+ and fluid intake
Treat hypertension
Treat anemia with erythropoietin
CV: HTN, CHF,
Heme: anemia
CNS: decrease mental acuity
Neuromuscular: restless leg syndrome
Bone: osteodystrophy
Endocrine: mild glucose intolerance
Skin: sallow, pale,
GFR;90
Kidney damage with normal/increased GFR
Stage 2:
GFR 60-89
Kidney damage with mildly decreased GFR
Stage 3:
GFR 30-59
Moderately decreased GFR
Stage 4:
GFR 15-29
Severely decreased GFR
Stage 5:
GFR ; 15 or dialysis
Kidney Failure
Classic Triad:
1. Low grade fever ( ; 70% of cases)
2. Rash ( ; 30% of cases)
3. Arthralgia ( ; 15% of cases)
DX:
Eosinophiluria
Central Diabetes Insipidus: lack of ADH production
SSX:
Polyuria (; 3 literas a day)
Polydipsia
Unquenchable thirst
Irritability
lethargy
muscle twitching
Hypereflexia
Mental status changes
* Hypernatremia occurs when thirst is impaired
– AMS, Elderly, baby
Treatment:
NDI- The urine output can be lowered with thirst awareness, low salt, low protein diet, thiazides, and NSAIDS
Hypovolemic Hypernatremia
Due to renal diuretics, osmotic diuresis due to glycosuria
Isovolemic hypernatremia
Caused by diabetes insidious( central and nephrogenic) excess skin losses, respiratory loss, others
Hypervolemic Hypernatremia
Caused by iatrogenic Na+ administration ( e.g. hypertonic dialysis, hypertonic saline enema, Na- containing medications) and other exogenous sources( seawater ingestion, salt tablets) or adrenal hyper fusion (Cushing syndrome) hyperaldosteronism
Usually with Na+ ; 125mEq/L
SSX:
Severity of symptoms correlates with rate of decrease in Na+
Lethargy, confusion, coma, muscle twitches and irritability, seizures, N/V
Signs:
Hyporeflexia
Mental status changes
Tx:
Fluid restriction
IV replacement NS
Hypertonic Na+ replacement in severe cases
Demecycline and lithium
** Osmotic demyelination syndrome occurs if Na+ is replaced too quickly ( pontine crenation)
Prevents water diuresis= holding onto water and leads to hyponatremia
Causes:
Brain trauma
Tumors
Drugs
Post surgery
Medications
Water retention:
Cirrhosis
CHF
Primary
polydipsia
Psychogenic
polydipsia
*Psychogenic polydipsia may be truly psychological or related to side effects from psychotropic agents
Tx: is fluid restriction
Caused by water intoxication ( urine osmolality ; 80 most), SIADH, hypothyroidism, hypoadrenalism, thiazide diuretics, beer ptomaine
Due to renal loss ( urinary Na; 20 mEq/L)
– due to diuretics, post obstructive diuresis, mineralocorticoid deficiency
Seen with CHF
Nephrosis
renal failure
liver disease
SIADH:
increase serum water= decrease Na
Fix too fast= pontine crenation
Treat with 3% saline
Symptoms: AMS, seizures
Hypo-reflexia
Hypernatremia
Diabetes insipidus:
decrease serum water= increase sodium
Fix too fast= cerebral edema
Treat with increase free water or D5-W
Symptoms: AMS, seizures
Hyper-reflexia
Mechanisms:
Most often due to iatrogenic or inadequate renal exrection of potassium
Spironolactone, ACE inhibitors
SSX:
Weakness
flaccid paralysis
confusion
Signs:
Hyperactive deep tendon reflexes, decrease motor strength
ECG changes: peaked T waves, wide QRS, loss of P wave, sine wave, systole
Tx:
Get ECG
Repeat stat K+ to confirm
* Confirm hyperkalemia
*Look for medications
*Peaked T waves
calcium chloride: only protects heart from effects of hyperkalemia
Alkalinize: Na bicarbonate
D50 and insulin: drive K+ back into cells
Albuterol inhalation:
@4x-8x normal dose
Kayexalate
Diuresis ( Lasix)
Mechanisms:
Due to inadequate intake, loss or intracellular shifts
Inadequate intake ( oral or IV)
Gi tract loss
renal loss
SSX:
Muscle weakness, cramps, tetany, polyuria, polydipsia
Signs:
Flattening T waves**
U wave becoming obvious
***Hypokalemia potentiates the cardiac toxicity of digitalis ( V tach)
Potassium is reabsorbed in the renal tubules, the cellular pumps that reabsorb potassium are activated by magnesium
Therefore, low magnesium will not allow reasorption of potassium until magnesium is corrected
Mechanisms
Excess administration
Management of preeclampsia with magnesium sulfate
Renal insufficiency
Exacerbated by ingestion of magnesium containing antacids
Signs and symptoms:
Tx:
Calcium gluconate
Stop magnesium – containing medications
** Magnesium containing antacid over dose or over use
**Post magnesium therapy in preeclampsia
Mechanisms:
Decreased intake or absorption, malabsorption, chronic GI losses, alcoholics
SSX:
Weakness, muscle twitches, asterixis, vertigo
Symptoms of hypocalcemia and hypokalemia:
Signs:
Tachycardia
Tremor
hyperactive reflexes
tetany
seizures
ECG: may show prolongation of PR, QT, and QRS intervals as well as ventricular ecotype and sinus tachycardia
Tx: Replace Mg+2 IV severe, orally if mild
** Malabsorption, ETOH, diuretics
** Watch K+ and Ca++
Symptoms:******
bones( osteoltits fibrous cystic)
stones( renal colic)
groans( constipation)
Psychiatric overtones( neuropsychiatric symptoms- confusion)
Polyuria,polydipsia, fatigue, anorexia, nausea, vomiting****
Signs:
HTN
Hyporeflexia
Mental status changes
Shortening of the QT interval on the ECG
-Increased frequency of urination, nocturia, hesitancy, urgency, and weak urinay stream
Dx:
rule out prostate cancer
Digital rectal exam and PSA
Tx:
Alpha blockers ( urethral relaxation)
(Terazosin)
(Doxazosin)
** Tamsulosin is more selective for the smooth muscle in the neck of bladder and prostate
-Can be used for HTN
5 alpha reductase inhibitors( shrink prostate)
Finasteride
Dutasteride
TURP if refractory to meds
** Nocturia, polyuria
Normal PSA with increases should be evaluated further
PSA; 4
BPH
Prostate CA
Prostatitis
Mechanisms:
Hypoparathyroidism
Critical illness, sepsis, pancreatitis
Vitamin D deficiency
SX:
HTN
Peripheral and premolar paresthesis
Abdominal pain
cramps
lethargy
irritability in infants
Signs:
Hyperactive DTRs
*Carpopedal spasm ( Trousseasu’s sign)
* Presence of Chvostek sign ( facial nerve twitch)
Generalized seizures, tetany, laryngospasm
Prolonged QT interval on ECG
decrease PTH= decrease Ca+2
Increase PTH= increase Ca+2
Mechanisms:
Increased intake and absorption
Decreased excretion (MOST COMMON CAUSE)
Renal failure
Rhabdomyolysis
Symptoms and signs
Mostly related to tetany as a result of hypocalcemia
Tx:
Low phosphate diet
** Renal failure patient is most common!!!
2. If its below 7.4
a. PaCO2 too high – Resp
b. HCO3 to low- Metab.
3. If its higher than 7.4
a. HCO3 too high -Met
b. PaCO2 too low- Resp
CO2(35-45 ) normal
Bicarbonate (20-26) normal
Dx:
Breathing too slow
Cause:
Chronic obstructive pulmonary disease
Guillain Barre syndrome
Myasthenia gRAVIS
Muscular Dystrophy
** Respiratory depession
**COPD= retain CO2
Dx:
Breathing too fast
Cause:
Shock
lung causes:
pneumonia
Pneumothorax
CHF
Pulmonary embolism
**Hyperventilation
DX:
Due to loss of acid or the addition of alkali
Cause:
Loss of stomach acid( VOMITING)
Oral administration of alkalizing agents-antacids
Volume depletion ( ex: on diuretics)
Hypokalemia
**Bulimia
** OD of antacids
Otherwise detected by DRE or symptoms:
Asymmetric areas of induration
Frank nodules
New onset of erectile dysfunction
Hematospermia
Screening:
**PSA and DRE
White male with average risk at 50 years old
**Black males, + FMHX or + BRCA mutations start screening at 40 years old
**DX: Prostate biopsy
Tx: based on presence of metastasis
**Pelvis and spine most common site of mets
Chills
malaise
myalgia
dysuria
pelvic or perineal pain
cloudy urine
Older patient > 35 years old; E.coli
Younger with urethritis consider – chlamydia/gonorrhea
**Digital rectal exam- tender “pull patient off roof”
Tx: Fluoroquinolones
**Extreme tenderness on DRE
Prostatits which occurs post TURP or prostate biopsy has a high risk for sudden onset of severe sepsis
In men > 35 years old- E. coli most common
SSX:
Groin heaviness
aching discomfort and radiation
Epididymis is swollen and tender and can progress to a large warm mass
*** + Phren’s sign= relief with elevation
Tx:
Men; 35 years old ceftrioxone IM plus doxycyline for 10 days
**Men; 35 years old ciprofloxacin for 10-14 days
-Psychogenic:
Normal nightime erectile function using a Rigl Scan or similar device
tx: counseling
-Organic:
Vascular: look for CAD, DM, smoking, LeRiche syndrome
Tx:
PDE5 Inhibitors: sildenafil, tadalafil
Injectables or pumps
HRT, Weight loss
** PDE5+ Alpha blocker or nitrates= HYPOTENSION
Tx:
Ice/walk stairs
Orchitis without epididymitis is very uncommon in adults
-Treatment as per epididymitis
-Viral ( mumps, rubella, coxsackie, parovirus) and bacterial ( brucellosis) infection can cause orchitis in kids
Tx:
Bed rest
NSAIDS
Scrotal suppport and ice
**Mumps can cause orchitis in kids
** Brucellosis comes from unpasteurized milk
– Most descend by first few months not likely if not descended by 6 months
-Complications of undescended testes include testicular cancer, infertility and hernia
-Treatment: @ 6 months and before 2 years old
Surgery- orchlopexy
** Adults with cryptorchidism= increase cancer risk
Groin pain
hematuria
N/V
*Calcium oxalate is the most common
DX:
US
CT- gold standard
TX:
Pain meds
Lithotripsy
** Uric= low purine diet
**Struvite= UTI
** Cystine= genetic kids with stones
Anion gap= Na- (Cl +HCO3)= 10-16
High Anion gap; 16
Causes of normal anion gap
RAGE
R: Renal tubular acidosis, resp. acidosis
A: Acetazolamide, ammonium chloride
G: GI (Diarrhea, enteroenteric fistula)
E: Endocrine
MUDPILES
M: methanol
U: uremia
D: diabetes
P: paraldehyde
I: idiopathic
L: lactic acidosis
E: ethylene glycol
S: salicylates
Mechanisms:
Decreased dietary intake
Starvation
alcoholism
Renal losses
Symptoms/signs
;1 mg/dL
Weakness
Muscle pain and tenderness
Parasthesis
Cardiac and respiratory failure
Tx: replacement
Low or no urine output
Suprapubic pain
HTN
Sometimes obvious bladder enlargement
Tx:
Foley catheter
**Find the obstruction
Azotemia: Retention of nitrogenous wastes
Oliguria: Urine output less than 400ml/day
Acute renal failure: A rapid, but usually temporary, reduction in renal excretory function sufficient to cause azotemia
Patients can’t VOID RIGHT
Vasculitis
Obstruction
Infection
Drugs ( acute tubular necrosis)
Renal artery stenosis
Interstitial nephropathy
Glomerular nephropathy
Hypovolemia
Thromboembolism
Clues:
HTN before age 30
HTN with CAD or PVD history
Resistant HTN( > 3 drugs)
increase creatinine after start of ACE inhibitor therapy
*Gold standard for diagnosis renal artery stenosis is : renal angiography
> 75% stenosis in one or both renal arteries suggests probably renal cause of HTN
Tx: stunting of renal arteries
**Resistant HTN
** Renal artery bruit
**Acute renal failure after start of ACE inhibitor
-Flank or abdominal pain
Signs: HTN
Labs: urinalysis shows hematuria
Complications:
Renal failure -45%
** Family HX,
** HTN
** Flank mass
– Abdominal mass or swelling
PE:
revelas a firm, non-tender, smooth mass that rarely crosses the midline
CT or US
-biopsy or resection then chemotherapy
***Unilateral painless abdominal mass in child
Asymptomatic until the disease is advanced
Classic triad of RCC:
Flank pain
Hematuria
Palpable abdominal/renal mass
Hematuria= cancer advanced to tubules
DX:
US or CT then biopsy
** Surgical radical nephrectomy usually curative
** Flank pain
** Hematuria
** Palpable abdominal renal mass
Painless hematuria
Pain= advanced or metastatic
-Voiding symptoms are most common in patients with carcinoma in situ
**Cystoscopy is the gold standard for the initial diagnosis
TURBT + Neoadjuvant chemotherapy
****Painless hematuria
**** Smoker
Unilateral
– Urine output maintained by other kidney
Bilateral
– Post renal failure
Causes:
Obstruction
-Stones
-Tumor
-Sclerosis
-Increased pressure of extra fluid within the kidney causes damage to kidney cells and decreased kidney function
– Reversible if the underlying condition is corrected
-Fever > 38C
-chills
-flank pain
-costovertebral angle tenderness
-N/V
Hospitalize
-Severe symptoms
-Patient is unable to self hydrate
-DX:
UA
WBC casts in the urine
CT or ultrasound show edema, perinephric stranding
TX: IV antibiotics and IV fluids until can take orally and fever resolves for 24 hours
** CVA tenderness
** WBC casts
tx:
** First line:
Ciprofloxacin 400 mg IV and
Levofloxacin 750 mg IV
-Dysuria
-frequency
-Urgency
-suprapubic pain
-hematuria
**Fever is rare!
” Honeymoon cystitis”
DX: urinalysis and culture
Tx: Quinolones or Bactrim
** Fever is rare in cystitis
** Urge to empty bladder
-Frequent small amounts of urine
– Commonly associated with cystitis
Dx:
History + rule out UTI/structural
Tx: Bladder training
Weight loss
Kegel exercises
Anti-muscarinic medications:
tolterodine
Oxybutynin
** Physical Activity
-Coughing
-Laughing
-Bending over
-Running
– Changing position
Dx:
History + rule out UTI/structural
Tx: Bladder training
Weight loss
Kegel exercises
Anti-muscarinic medications:
tolterodine
Oxybutynin
** With both physical activity and urge
Dx:
History + rule out UTI/structural
Tx: Bladder training
Weight loss
Kegel exercises
Anti-muscarinic medications:
tolterodine
Oxybutynin
Germ cell tumors
Intrascrotal malignancies usually are firm
Nontender masses that do not trans illuminate
Labs:
Beta hCG
AFP
LDH
Scrotal US look for metastasis
-Radical inguinal orchiectomy is used both to provide the histologic diagnosis and local tumor control
-Common metastasis:
abdomen
brain
lung
Radiation and chemotherapy
******* Painless testicular mass that does not trans illuminate
-Common in neonates and post pubertal boys
-Sudden onset pain after vigorous activity or minor trauma
PE:
Asymmetrically high riding testicle.
“Bell clapper deformity”
Negative paren’s sign
Cremasteric reflex is absent with torsion!
Ultrasound with doppler for diagnosis
Can attempt to manually turn the testicle and relieve pain, ” open book procedure”
-Successful manipulation still needs surgery
-Urgent surery
** Pain is acute ( hours) and patients will NOT be able to get comfortable ” bell clapper deformity”
** Elevation of testicle does NOT alleviate pain
-Pain is localized to superior testicle
-Normal cremasteric reflex
– ” Blue dot sign” paratesticular nodule superior aspect of testicle
-Veins of pampiniform plexus
-**** bag of worms*
*** Does NOT transilluminate*
Generallly non tender
Not medical emergency
Elevtive surgery
-Common in newborns
-Physical exam:
Scrotum= cystic fluid collection
*** + Transillumination
-Non medical emergency
-Elective surgery
Hypokalemia – Flattening of T waves, U wave
Hypocalcemia- Long QT
Hypercalcemia- Short QT
Hypermagnesemia- Prolonged PR interval, Widened QRS complex
Hypomagnesemia- Tall T wave