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.