Prerenal Failure
Volume loss, heart failure
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

Prerenal Failure( most common cause)
Most common cause of preener failure is dehydration
Urinanlysis RBC Casts
Glomerulonephritis
Urinanlysis WBC Casts
Pyelonephritis
Urinanlysis Muddy Casts
Acute tubular necrosis
Urinanlysis Hyaline Casts
Normal
Urinanlysis Waxy Casts
Chronic renal disease
Urinanlysis Increase osmolality FENa> 2%
Acute tubular necrosis
Acute Tubular necrosis
Damage to tubules- can’t concentrate urine
Acute Tubular necrosis Cause
Prerenal is # 1 cause
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)

Nephritic Syndrome
-Autoimmune problem

SSX:
Hematuria
Edema
HTN
Oliguria

UA: RBC Casts***

Antibodies:
**ASO: Post streptococcal ( most common)***

Nephrotic Syndrome( Types)
T cell mediated problem

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

Nephrotic syndrome ( membranous)
most common in NON DIABETIC adults, associated with malignancies
Nephrotic syndrome ( Minimal change)
Most common cause of nephrotic syndrome in KIDS
Nephrotic syndrome ( Focal segmental Glomerulosclerosis) ( FSGS)
Obese
Heroin and HIV black male
Nephrotic syndrome ( Lupus)
noticed in both nephritic and nephrotic
Nephrotic syndrome ( most common)
DIABETES- Most common cause of nephrotic syndrome and subsequent renal failure
Phimosis
Foreskin that cannot be retracted to expose the glans penis

– elective surgery
– Uncircumcised men= risk for penile cancer

Paraphimosis
retracted foreskin that cannot be returned to normal position

– Can cause tourniquet effect
– Can be emergent and need surgery

Chronic Kidney Disease
Evidence of kidney damage, even with normal or increase GFR

-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

Chronic kidney disease SSX
GI: anorexia, N/V, hiccups, metallic taste, bleeding

CV: HTN, CHF,
Heme: anemia
CNS: decrease mental acuity
Neuromuscular: restless leg syndrome
Bone: osteodystrophy
Endocrine: mild glucose intolerance
Skin: sallow, pale,

Stages of Renal Failure
Stage 1:
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

Interstitial Nephritis
Caused by allergic reaction or pyelonephritis

Classic Triad:
1. Low grade fever ( ; 70% of cases)
2. Rash ( ; 30% of cases)
3. Arthralgia ( ; 15% of cases)

DX:
Eosinophiluria

Hypernatremia
Nephrogenic Diabetes Insipidus (MOST COMMON) resistance to ADH, also low Ca+, K+ or lithium

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

Hypernatremia correction
** CAUTION: Rapid correction of the Na+ level using free water ( D5-W) can cause cerebral edema and seizures
Combined sodium and water losses
Hypovolemic Hypernatremia
Water loss in excess of Na+ loss results in low total body sodium

Due to renal diuretics, osmotic diuresis due to glycosuria

Excess Water loss
Isovolemic hypernatremia
Total body sodium remains normal, but total body water is decreased

Caused by diabetes insidious( central and nephrogenic) excess skin losses, respiratory loss, others

Excess sodium
Hypervolemic Hypernatremia
Total body sodium increased

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

Hyponatremia
Multiple etiologies

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)

Hyponatremia Cause
Too much ADH

Prevents water diuresis= holding onto water and leads to hyponatremia

Causes:
Brain trauma
Tumors
Drugs
Post surgery

Hyponatremia Cause
Other Causes:

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

Classification of hypotonic hypnatremia
Low osmolality.
Isovolemic Hyponatremia
No evidence of edema, normal BP
Caused by water intoxication ( urine osmolality ; 80 most), SIADH, hypothyroidism, hypoadrenalism, thiazide diuretics, beer ptomaine
Hypovolemic Hyponatremia
Evidence of decreased skin turgor and an increase in heart rate and decease in BP after going from lying to standing position

Due to renal loss ( urinary Na; 20 mEq/L)
– due to diuretics, post obstructive diuresis, mineralocorticoid deficiency

Hypervolemic Hyponatemia
Evidence of edema( urinay Na ; 10 mEq/L)
Seen with CHF
Nephrosis
renal failure
liver disease
Isovolumetric Natremic Comparison
Hyponatremia

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

Hyperkalemia
K+ ; 5.2 mEq/L
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

Hyperkalemia correctoin( rapid)
Rapid correction:
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

Hyperkalemia correction( slow)
Slow correction:
Kayexalate
Diuresis ( Lasix)
Hypokalemia
K+ ;3.6 mEq/L

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

Hypermagnesemia
Mg+2 ;2.1 mEq/L

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

Hypomagnesemia
Mg+2 ; 1.5 mEq/L

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++

Hypercalcemia
Ca+2; 10.2 mg/dL

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

BPH
Men older than 50 y/o
-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

PSA Values
Normal ;4
Normal PSA with increases should be evaluated further

PSA; 4
BPH
Prostate CA
Prostatitis

Hypocalcemia
Ca+2; 8.4 mg/dL

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

Hypocalcemia
PTH is responsible for the immediate regulation of Ca+2 levels

decrease PTH= decrease Ca+2
Increase PTH= increase Ca+2

Hyperphosphatemia
PO4 >4.5 mg/dL
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!!!

Acid Base
1. First look at pH (7.4)
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

Respiratory Acidosis
Ex: pH 7.30, PCO2 60, Bicarb 22

Dx:
Breathing too slow

Cause:
Chronic obstructive pulmonary disease
Guillain Barre syndrome
Myasthenia gRAVIS
Muscular Dystrophy

** Respiratory depession
**COPD= retain CO2

Respiratory Alkalosis
Ex: pH 7.52, PCO2 25, Bicarb 22

Dx:
Breathing too fast

Cause:
Shock
lung causes:
pneumonia
Pneumothorax
CHF
Pulmonary embolism

**Hyperventilation

Metabolic Alkalosis
Ex: pH 7.52, PCO2 40, Bicarb 35

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

Prostate Carcinoma
Asymptomatic cases found due to PSA
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

Prostatitis
Spiking fever
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

Urethritis/Epididymitis
In men< 35 years old – Chlamydia( clear discharge) and gonorrhea (prudent discharge) are the most common

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

Erectile Dysfunction
– Common in men over 40

-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

Priapism
Erection longer than 4 hours

Tx:

Ice/walk stairs

Orchitis
Scrotal swelling, pain, and tenderness with erythema and shininess of the overlying skin

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

Cryptorchidism
Failure of testes to descend one or both

– 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

Kidney Stones
– Presents as colicky flank pain
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

Metabolic Acidosis
Examples: pH 7.30, PCO2 40, Bicarb 16

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

Hypophosphatemia
PO4 ; 2.5 mg/dL

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

Postrenal Failure
Sx:
Low or no urine output
Suprapubic pain
HTN

Sometimes obvious bladder enlargement

Tx:
Foley catheter

**Find the obstruction

Acute Renal Failure ( AKI)
** Find the cause

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

Acute Renal Failure( AKI) Causes
Causes ofAcute Kidney Injury

Patients can’t VOID RIGHT

Vasculitis
Obstruction
Infection
Drugs ( acute tubular necrosis)
Renal artery stenosis
Interstitial nephropathy
Glomerular nephropathy
Hypovolemia
Thromboembolism

Renal Artery Stenosis
– Atherosclerosis of the renal arteries

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

Polycystic Kidney Disease
> 30 years old + FMHx and abdominal mass( flank)
-Flank or abdominal pain
Signs: HTN

Labs: urinalysis shows hematuria

Complications:
Renal failure -45%

** Family HX,
** HTN
** Flank mass

Wilms Tumor( nephroblastoma)
Most common renal cancer in children!!
– 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

Renal Cell Carcinoma
Renal cell carcinomas- 80% of primary renal cancer

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

Bladder Carcinoma
Urothelial (transitional cell) carcinoma

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

Hydronephrosis
Dilation and swelling of the kidney

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

Pyelonephritis
UTI usually precursor
-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

Cystitis
***Bacterial cystitis most common agent E.coli

-Dysuria
-frequency
-Urgency
-suprapubic pain
-hematuria

**Fever is rare!

” Honeymoon cystitis”
DX: urinalysis and culture

Tx: Quinolones or Bactrim

** Fever is rare in cystitis

Incontinence (Urge)
detrusor muscle is overactivity

** 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

Incontinence (Stress)
Weak detrusor muscle

** 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

Incontinence (Mixed)
Most common!!

** With both physical activity and urge

Dx:
History + rule out UTI/structural

Tx: Bladder training
Weight loss
Kegel exercises

Anti-muscarinic medications:
tolterodine
Oxybutynin

Testicular Cancer
Males 15 to 35 years old
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

Testicular Torsion
Testicular torsion is a urologic emergency

-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

Torsion of the appendix testis
Torsion of the appendix testis is usually benign and self resolving

-Pain is localized to superior testicle
-Normal cremasteric reflex

– ” Blue dot sign” paratesticular nodule superior aspect of testicle

Varicocele
A collection of dilated and tortuous veins surrounding the spermatic cord in the scrotum

-Veins of pampiniform plexus

-**** bag of worms*
*** Does NOT transilluminate*

Generallly non tender
Not medical emergency
Elevtive surgery

Hydrocele
A collection of peritoneal fluid between the parietal and visceral layers of the tunica vaginalis

-Common in newborns

-Physical exam:
Scrotum= cystic fluid collection
*** + Transillumination

-Non medical emergency
-Elective surgery

Electrolytes
Hyperkalemia- peaked T waves
Hypokalemia – Flattening of T waves, U wave

Hypocalcemia- Long QT
Hypercalcemia- Short QT
Hypermagnesemia- Prolonged PR interval, Widened QRS complex

Hypomagnesemia- Tall T wave

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