Renal Disease

Renal Disease

1. Acute Renal Injury

   • Pre-renal Azotemia
     • Reduced perfusion or oxygenation
       • Volume depletion
         • GI loss/bleeding/diruetics
       • Reduced effective circulating volume
         • Sepsis/HF/Cirrhosis/Hepatorenal/meds
           • NSAIDS/Lithium
     • normal urine sediment
   • Post-renal Azotemia
     • Urinary tract obstruction
   • Intra-renal Azotemia
     • Renal Parenchymal disease
       • Tubular Causes
         • Acute Tubular Necrosis
           • Ischemic ATN
             • 2* Shock/burn/dehydration/CHF
             • 1* Hypotension/ischemia
           • Nephrotoxic ATN
             • 2* drugs
               • Aminoglycoside most common
               • Radiocontrast
             • Rhabdomyolysis
               • ^ myoglobin
           • Pigmented casts
           • FENa >2% / FEurea >50%
             • FEx=(Ux/Sx)/(Ucrea/Screa) * 100
         • Tubular obstruction/cast nephropathy
           • Crystal intratubular obstruction
             • 2* drugs
             • Uric acid following cancer tx
             • CaOxalate due to ethylene glycol
           • light chain cast
             • Multiple Myeloma
               • Kappa
                 • more common
               • Lambda
       • Interstitial causes
         • Pyelonephritis
           • Leukocyte cast
           • infection
           • PMN
         • Allergic interstitial nephritis
           • Drugs
             • NSAIDS/Diruetics/Beta lactam
           • eosinophilia
           • white cell cast
           • leukocyte
       • Vascular causes
         • Cholesterol Emboli
           • long term HTN
           • abd Aorta emboli post anticoag
           • Livedo reticularis
           • Eosinophil
           • low C3
         • Thrombotic Microangiopathy (HUS)
           • other organ involvement
           • Livedo reticularis
           • normal complement
           • Schistocytes
           • could be secondary to infection
           • Hemolytic Uremic Syndrome
             • hemolytic anemia
             • thrombocytopenia
             • uremia
             • post E.coli infection in children
       • Glomerular causes
         • Severe glomerulonephritis
           • Pauci-immune
             • ANCA (PR3/MPO)
               • GPA
               • MPA
               • EGPA (Churg Strauss)
           • + immune
             • Anti GMB
               • Good pasture's if lung
           • SLE
         • Less severe GN
           • Postinfectious
             • low C3/C4
               • 1-3 weeks post infection
                 • StrepO/anti DNAse B
           • IgA/HS purpura
             • normal complement
               • IgA +immune
                 • with infection
           • Cryoglobulinemia
           • low C3/C4
             • ANA/dsDNA/Smith
         • Nephorotic
           • 1* cause
             • Minimal change
               • children
             • FSGS
               • Blacks
               • HIV/Heroin/Sickle cell
             • SLE
               • low complement
             • Membranous
               • antiPLA2
               • HepB/Syphilis/drug
               • White/Asian adults
           • 2* cause
             • Diabetic kidney
               • KW nodule sclerosis
               • thick GBM
             • Amyloidosis
               • AL / AA
                 • associated with plasma cell disorder
         • Nephritic and Nephrotic
           • Membranoproliferative GN
             • Low C3 and/or C4
             • C3 glomerulopathy
               • immune + for only C3
             • HepC, Cryoglobulins, SPEP
             • Immune complex type
               • immune+ IgG and C3

2. Chronic Kidney Disease

3. Genetic

   • AD Polycystic Kidney Disease
     • Auto Dominant
     • adult
     • Extrarenal cysts
     • Type 1 more severe
     • multiple cysts
   • AR Polycystic Kidney Disease
     • Children
     • Auto Recessive
     • 2/3 die perinatal
     • Enlarged smooth kidney
     • dilation of collecting system
   • Alport's
     • X-linked: alpha 5 chain
     • collagen 4 synthesis disorder
     • similar to thin basement membrane disease
     • UBlood+ Uprotein+
     • Sensory loss
     • Visual: Lenticonus
     • Leiomyomas
     • alternate thin and thick membrane
       • lamellation (break)
   • Fabry
     • x-linked lysosomal storage
       • lack alpha-galactosidase A
         • GL-3 accumulate
       • women symptomatic
         • genetic test
       • man check GLA level
     • Angiokeratomas
     • Corneal Whorl
     • GI/Cardiac
     • Neuro
     • Renal
       • Proteinuria

4. Congenital

   • Vesicoureteral Reflux
     • Retrograde flow
     • risk for pyelonephritis and scarring
       • low dose antibiotics
     • Blunted calyx 20%
     • hypertension
     • Bilateral is worse
     • can be self limited
     • Medical: antibiotics to keep urine sterile
       • compliance problem
     • Surgical
       • Intraluminal tunnel
       • Ureteral injection
   • Posterior Urethral Valves
     • obstruction of bladder/kidney
     • severe vesicoureteral reflux
     • risk for urosepsis
     • Renal dysplasia
     • hydronephrosis
     • Thick wall bladder
     • Oligohydramnios
     • FOLEY FOLEY FOLEY
     • antibiotics/fluids
   • Renal Dysplasia
     • undifferentiated / muscle/ cartilage
       • Multicystic
         • usually unilateral
         • Most common abdominal mass in new borns
       • aplastic and diffuse cystic
         • might be hereditary
   • Oligohydramnios
     • placental pathology
     • Potter sequence
       • facial abnormality
       • limb deformity
       • Renal agenesis
       • pulmonary hypoplasia
   • Horseshoe kidney
     • trapped by inferior mesenteric artery, cannot ascend
     • usually normal function
   • Polyhydramnios
     • idiopathic

5. Obstructions

   • Calcium Oxalate
     • Shuriken-like
       • common
         • Randall's plaque (CaPhos)
       • idiopathic hypercalciuria
       • hyperparathyroid/sarcoidosis
       • hyperuricosuria
   • Calcium Phosphate
     • mixed with calcium ox
     • pH>7.5
     • Stars
     • Type 1 Distal RTA
     • UTI
   • Struvite
     • Infection PROTEUS
       • antibiotics
     • other urease organism
     • screw like
       • giant stones
     • Acetohydroxamic acid treat
   • Uric Acid
     • more soluble at higher pH
     • can pass by alkalization
   • Cystine
     • AR in dibasic amino acid transport
       • soluble at pH>9.6
       • Thiols for chelation
       • COLA
       • Hexagonal
   • Drug induced

6. Malignancies

   • Kidney
     • Renal Cell Carcinoma
       • Adenocarcinoma
         • Clear cell
           • Ch 3
         • Papilloma
           • Ch7/17
         • nephrosectomy based on size
       • Hematuria/Flank pain/abd mass
   • Bladder
     • Urothelial carcinoma
       • invasive (Ch7)
       • non invasive (Ch3)
       • Field affect
     • Squamous cell caricinoma
       • Schistosomiasis

7. UTI

   • Pyeronephritis
     • altered in older pt
     • outpatient
       • Fluroquinolone 7 days or TMZ 14d
     • inpatient
       • IV fluoroquionolone/aminoglycoside +/- ampi
   • Cystitis
     • Uncomplicated
       • Acute
         • Nitrofurantoin 5days
         • TMP-SMZ 3days
         • Fluoroquinolone 3days
       • Recurring
         • TMP/SMZ or nitrofurantoin 6-12 months
         • self-start therapy
     • Complicated
       • Empiric antibiotics
       • Fluoroquinolone 7-14 days
         • Imaging if not responsive
   • prostatitis
     • Acute bacterial
       • tender, boggy prostate
         • Fluoroquinolone 3-4 wks
     • Chronic Bacterial
       • no fever/no obstruction
         • massage culture
           • Fluoroquinolone 4-8wks
     • Chronic non bacterial
       • NSAIDS
     • Asymptomatic inflammatory