Nephrology 2,09


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Nephrology 2,09

  1. 1. Pete A. Gutierrez MD, MMS, PA-C Miami Dade College Physician Assistant Program March 2009
  2. 2. Nephrology <ul><li>Urine Analysis: </li></ul><ul><ul><li>Dip stick testing: </li></ul></ul><ul><ul><ul><li>Problems: </li></ul></ul></ul><ul><ul><ul><ul><li>Urine Ph may change with time </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Contamination may cause bacteria to multiply and convert nitrate to nitrite causing a false positive. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>At low specific gravity (Less than 1.010), cells lyse and casts from less readily. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Cast also dissolve in alkaline Urine. </li></ul></ul></ul></ul>
  3. 3. Nephrology <ul><li>Midstream Urine Collection </li></ul><ul><ul><li>Contamination more common in women than in men. </li></ul></ul><ul><ul><li>Suprapubic aspiration is the more secure method of getting an Uncontaminated Urine </li></ul></ul><ul><ul><li>Hematuria </li></ul></ul><ul><ul><ul><li>Flank </li></ul></ul></ul><ul><ul><ul><li>Microscopic </li></ul></ul></ul>
  4. 4. Nephrology <ul><li>Urine Casts. Are formed from Tamm-Horsfall glycoprotein which is synthesized and secreted in the ascending limb of the loop of Henle and distal convoluted tubules. </li></ul><ul><li>Physiologic Casts Hyaline are transparent and cylindrical and are seen in urine of normal subjects. </li></ul><ul><li>Both can be increased by fever, exercise and volume depletion </li></ul>
  5. 5. Nephrology <ul><li>Pathologic casts: this may contain cellular material (erythrocytes, leukocytes, tubular cells, bacteria, or fungi) , fibrin, lipids, bile, and crystals. </li></ul><ul><li>The most important is the erythrocytes, because it indicates glomerular bleeding. </li></ul><ul><li>Those composed of polymorphonuclear leukocytes usually indicate renal parenchyma infection. </li></ul>
  6. 6. Nephrology <ul><li>Leukocytes in the urine means infection </li></ul><ul><li>Renal tubular cells are found in the urine in acute tubular necrosis and acute interstitial nephritis </li></ul><ul><li>Crystals of calcium oxalate and uric acid may be seen in normal urine however large bizarre crystals of any type including calcium oxalate and uric acid indicate calculus disease. </li></ul>
  7. 7. Nephrology <ul><li>IGA nephropathy: </li></ul><ul><ul><li>The most common form of primary glomerular disease in the world. </li></ul></ul><ul><ul><li>It is particular prevalent in Asia, and Australia, and rare in African Americans. </li></ul></ul><ul><ul><li>It originally thought to be benign. </li></ul></ul><ul><ul><li>Now understood it will progress to renal failure in 20 to 40% of patients affected. </li></ul></ul>
  8. 8. Nephrology <ul><li>Primary gross hematuria, </li></ul><ul><li>No therapeutic regimen has been shown to clearly affect the outcome in IgA disease. </li></ul><ul><li>However warfarin and dipyridamole with or without cyclophosphamide have been suggested as worthy of further investigation </li></ul><ul><li>Also omega 3 fatty acids, ACE, and long term steroids are also on trial. </li></ul>
  9. 9. Nephrology <ul><li>Membranous nephropathy: </li></ul><ul><ul><li>Two thirds of patients with this disorder either have a spontaneous remission or have stable or very slow progressive renal insufficiency. </li></ul></ul><ul><ul><li>Those with heavy proteinuria greater than 10 gram per day, hypertension, diminished GFR, male gender, don’t do well. </li></ul></ul>
  10. 10. Nephrology <ul><li>Bacteria: </li></ul><ul><ul><li>Gram Negative </li></ul></ul><ul><ul><ul><li>E-Coli </li></ul></ul></ul><ul><ul><ul><li>Klesbsiella Pneumoniae </li></ul></ul></ul><ul><ul><ul><li>Proteus </li></ul></ul></ul><ul><ul><ul><li>Enterobacter </li></ul></ul></ul><ul><ul><ul><li>Pseudomonas </li></ul></ul></ul>
  11. 11. Nephrology <ul><li>Gram Positive </li></ul><ul><ul><li>Staphylococcus saprophyticus </li></ul></ul><ul><ul><li>Staphylococcus aureus </li></ul></ul><ul><ul><li>Staphylococcus not aureus </li></ul></ul><ul><ul><li>Enterococci </li></ul></ul><ul><ul><li>Other bacteria mixed </li></ul></ul><ul><ul><li>Yeast </li></ul></ul>
  12. 12. Nephrology <ul><li>Symptomatic UTI’s: </li></ul><ul><ul><li>Obstruction to urine flow. </li></ul></ul><ul><ul><ul><li>Congenital anomalies </li></ul></ul></ul><ul><ul><ul><li>Renal Calculi </li></ul></ul></ul><ul><ul><ul><li>Ureteral occlusion (partial or total). </li></ul></ul></ul><ul><ul><ul><li>Vesicoureteral reflux </li></ul></ul></ul><ul><ul><ul><li>Residual urine in bladder </li></ul></ul></ul><ul><ul><ul><li>Neurogenic bladder </li></ul></ul></ul><ul><ul><ul><li>Urethral stricture </li></ul></ul></ul><ul><ul><ul><li>Prostatic hypertrophy </li></ul></ul></ul>
  13. 13. Nephrology <ul><li>Instrumentation of urinary tract; </li></ul><ul><li>Indwelling urinary catheter </li></ul><ul><li>Catheterization </li></ul><ul><li>Urethral dilation </li></ul><ul><li>cystoscopy </li></ul>
  14. 14. Nephrology <ul><li>Acute Urethral syndrome: </li></ul><ul><ul><li>Vaginitis approximately 20% of women in the United States have an episode of dysuria each year. (Candida is the most common cause). </li></ul></ul><ul><ul><li>Urethritis most commonly cause by Chlamydia trachomatis </li></ul></ul><ul><ul><li>Prostatitis The most common addiction in men causes dysuria and urinary frequency. (E. Coli). </li></ul></ul>
  15. 15. Nephrology <ul><li>Pregnancy and the increases risk of UTI: </li></ul><ul><ul><li>20-40% of which develop pyelonephritis. </li></ul></ul><ul><ul><li>Either short acting sulfonamides or amoxicillin for 7 days usually suffices. </li></ul></ul><ul><ul><li>Avoid Tetracycline, trimethropin and fluoroquinolones. </li></ul></ul>
  16. 16. Nephrology <ul><li>Hypertensive disorders of pregnancy: </li></ul><ul><ul><li>Preeclampsia is characterized by, 1. Hypertension, proteinuria, edema, and at time coagulation and liver abnormalities usually occurring at about the (20) weeks of pregnancy. Primarily in nulliparas. Pressure of 140/90. </li></ul></ul><ul><ul><li>Patient will go into convulsions and diet condition called eclampsia. </li></ul></ul>
  17. 17. Nephrology <ul><li>Kidney function and morphology in preeclampsia: </li></ul><ul><ul><li>Both GFR and RPF decrease in preeclampsia. </li></ul></ul><ul><ul><li>Uric acid increases in blood. </li></ul></ul><ul><ul><li>Increased proteinuria. </li></ul></ul><ul><ul><li>Calcium develop hypocalciuria </li></ul></ul><ul><ul><li>Lesion at the glomerular capillary endotheliosis. </li></ul></ul>
  18. 18. Nephrology <ul><li>Management of preeclampsia: </li></ul><ul><ul><li>Hospitalization rest and if signs of impeding eclampsia(hyperreflexia, headache, epigastric pain) develop termination of pregnancy should be considered. </li></ul></ul><ul><ul><li>The drug of choice for impeding convulsion is parenteral magnesium sulfate. </li></ul></ul>
  19. 19. Nephrology <ul><li>Regulation of blood pressure: </li></ul><ul><ul><li>Hydralazine administered intravenously is the drug of choice. (5mg as a bolus follow by 5-10mg every 20-30 minutes. </li></ul></ul><ul><ul><li>Labetalol intravenously 20mg and repeat the dose every 20 minutes, up to 200 mg. </li></ul></ul><ul><ul><li>Refrain from using nitroprusside. </li></ul></ul>
  20. 20. Nephrology <ul><li>Use of Radiologic Techniques: </li></ul><ul><ul><li>KUB </li></ul></ul><ul><ul><li>Intravenous pyelography (IVP) Stone, obstruction. (allergic reactions). </li></ul></ul><ul><ul><li>Cystography (Bladder). </li></ul></ul><ul><ul><li>Ultrasound </li></ul></ul><ul><ul><li>Ct evaluation of renal disease </li></ul></ul><ul><ul><li>MRI </li></ul></ul>
  21. 21. Nephrology <ul><li>Renal angiography provides definitive diagnosis of renal arterial pathology </li></ul>
  22. 22. Nephrology <ul><li>Algorithm for treatment of hypertension: </li></ul><ul><ul><li>First line of therapy should be diuretic (thiazide). </li></ul></ul><ul><ul><li>In patients with type I diabetes and proteinuria (Diabetic nephropathy) the treatment is with an ACE inhibitor. </li></ul></ul><ul><ul><li>In patients with heart failure (Systolic dysfunction), ACE inhibitor or diuretic is indicated </li></ul></ul><ul><ul><li>Beta blockers or Ca Channels blocker can them be use. </li></ul></ul>
  23. 23. Nephrology <ul><li>Causes of resistant Hypertension: </li></ul><ul><ul><li>White coat </li></ul></ul><ul><ul><li>Pseudohypertension in elderly persons </li></ul></ul><ul><ul><li>Use of improper size blood pressure cuff. </li></ul></ul><ul><ul><li>Patient non compliant </li></ul></ul><ul><ul><li>Failure due to cost, side effects, or ignorance </li></ul></ul><ul><ul><li>Dietary noncompliance </li></ul></ul><ul><ul><li>Excess salts. </li></ul></ul>
  24. 24. Nephrology <ul><li>Causes of resistant Hypertension: </li></ul><ul><ul><li>Excess ethanol intake </li></ul></ul><ul><ul><li>Volume overload </li></ul></ul><ul><ul><li>Failure to include diuretic </li></ul></ul><ul><ul><li>Inadequate treatment </li></ul></ul><ul><ul><li>Medication interactions. </li></ul></ul><ul><ul><li>Nonsteroidal meds. </li></ul></ul><ul><ul><li>Trycyclic antidepressants </li></ul></ul><ul><ul><li>Cocaine or other illicit drugs </li></ul></ul>
  25. 25. Nephrology <ul><li>Causes of resistant Hypertension: </li></ul><ul><ul><li>Associated co morbid conditions </li></ul></ul><ul><ul><li>Obstructive sleep apnea </li></ul></ul><ul><ul><li>Increasing obesity </li></ul></ul><ul><ul><li>Anxiety induced hyperventilation or panic attacks. </li></ul></ul>
  26. 26. Nephrology <ul><li>Causes of resistant Hypertension: </li></ul><ul><ul><li>Underlying secondary hypertension </li></ul></ul><ul><ul><ul><li>Reno vascular hypertension </li></ul></ul></ul><ul><ul><ul><li>Primary renal parenchyma disease </li></ul></ul></ul><ul><ul><ul><li>Primary Hyperaldosteronism </li></ul></ul></ul><ul><ul><ul><li>Pheochromocytoma </li></ul></ul></ul>
  27. 27. Nephrology <ul><li>Evaluation of suspected renovascular hypertension: </li></ul><ul><ul><li>The principal cause is atheromatous narrowing of one or both main renal arteries, which occurs in older individuals, with a peak incidence in the sixth decade. </li></ul></ul><ul><ul><li>Men are affected twice as often as women. </li></ul></ul>
  28. 28. Nephrology <ul><li>A second type of lesion is the fibro muscular dysplasia (Hyperplasia) the lesion appears as a multifocal “string of beads,” beginning in the middle of the renal artery. </li></ul><ul><li>Test of choice is the renal angiography. </li></ul><ul><li>Treatment must be aggressive. </li></ul>
  29. 29. Nephrology <ul><li>Diuretics: </li></ul><ul><ul><li>Loop </li></ul></ul><ul><ul><li>K-sparing </li></ul></ul><ul><ul><li>Osmotic </li></ul></ul><ul><ul><li>Carbonic anhydrase inhibitors </li></ul></ul>
  30. 30. Nephrology <ul><li>Nephritis vs. Nephrotic: </li></ul><ul><li>In Nephritis syndrome there is variable proteinuria and active urine sediment; dysmorphic RBC’s and WBC’s and casts of RBC, WBC, and granular material. (Remember that CASTS always originate in the renal tubules). </li></ul><ul><li>Common causes of Nephritis syndrome are post infections GN, IgA Nephropathy, and Lupus Nephritis. </li></ul>
  31. 31. Nephrology <ul><li>Nephrotic Syndrome: </li></ul><ul><ul><li>Always heavy proteinuria, and urine fat. </li></ul></ul><ul><ul><li>Nephrotic range proteinuria is >2.5-3.5gm/day. </li></ul></ul><ul><ul><li>(Free fat droplets, oval fat bodies, fatty/waxy casts and renal tubular cells with lipid droplets). </li></ul></ul><ul><ul><li>Nephrotic patients tend to get hypoalbuminemia (with 2 nd edema) and they develop tendency for more infections, especially with H. Influenza, and S. Pneumonia. </li></ul></ul><ul><ul><li>Also low thyroid binding protein so low total thyroxine and iron levels. </li></ul></ul>
  32. 32. Nephrology <ul><li>The Nephrotic patient also have severe hyperlipidemia. </li></ul><ul><li>IgA Nephropathy most common >25%, also know as Berger Disease. </li></ul><ul><li>It can present from hematuria alone Berger disease to Schonlein Henoch Purpura, which is found in children's, affecting the skin the kidneys and the joints. </li></ul><ul><li>The Hematuria is usually present secondary to an infection or exercise. </li></ul>
  33. 33. Nephrology <ul><li>Membranoproliferative AGN: </li></ul><ul><li>This presentation has both basement membrane and changes in cells proliferation. </li></ul><ul><li>Presentation is similar to IgA with Hematuria with nephrotic range proteinuria and rapidly progressive glomerulonephritis, and may lead to renal failure. </li></ul><ul><li>Rapidly Progressive AGN: </li></ul><ul><ul><li>Starts with azotemia, oliguria followed by diuresis in days to weeks after which the GFR usually returns to normal. Rapid progression to renal failure </li></ul></ul>
  34. 34. Nephrology <ul><li>Diabetic Nephropathy: </li></ul><ul><ul><li>Is the second commonest cause of nephrotic range proteinuria. </li></ul></ul><ul><ul><li>In develops in 30% of the adult population with type I Diabetes. </li></ul></ul><ul><ul><li>First change in renal problems is micro albuminuria. </li></ul></ul><ul><ul><li>Patients progress to full renal failure within 5-7 years. </li></ul></ul><ul><ul><li>Need to control tight control of blood sugar level in order to prolong the disease process. </li></ul></ul>
  35. 35. Nephrology <ul><li>Acute Intestitial diseases: </li></ul><ul><ul><li>They present with slight proteinuria < 2mg/d. </li></ul></ul><ul><ul><li>Acute allergic interstitial nephritis (AIN) is a drug induced hypersensitivity problem and often presents with eosinophils. </li></ul></ul><ul><ul><li>The most common drug is cimetidine, thiazides, phenytoin, and allopurinol. </li></ul></ul><ul><ul><li>The most common antibiotics culprits are: </li></ul></ul><ul><ul><ul><li>Beta-Lactams like methicillin, TMP/SMX, and Rimfapin, also fluoroquinolones. </li></ul></ul></ul>
  36. 36. Nephrology <ul><li>Hereditary Kidney diseases: </li></ul><ul><ul><li>Alport Syndrome= nephritis can be either X-linked or AD with variable expression, men are affected more than females. </li></ul></ul><ul><ul><li>Is a connective tissue defect(type IV collagen) which affect the basement membrane. </li></ul></ul><ul><ul><li>Target is the same as Goodpasture syndrome with occasional deafness and lens problems. </li></ul></ul><ul><ul><li>The female X l;inked had usually microscopic hematuria. </li></ul></ul><ul><ul><li>Males have renal failure before age 50. </li></ul></ul>
  37. 37. Nephrology <ul><li>Polycystic kidney disease: </li></ul><ul><ul><li>Autosomal dominant. Is the commonest genetic disease of the kidney. Usually associated with a mutation on the short arm of 16. </li></ul></ul><ul><ul><li>Patients develop cysts in the kidneys, liver and pancreas and associated with recurrent hematuria. </li></ul></ul><ul><ul><li>Progressive renal failure and HTN are the norm. </li></ul></ul><ul><ul><li>Cerebral aneurism is a very small percent 1-5%. </li></ul></ul><ul><ul><li>For kidneys infections use the lipid soluble antibiotics like trimethroprim, erythromycin, chloramphenicol, tetracycline, ciprofloxin and clindamycin. </li></ul></ul>
  38. 38. Nephrology <ul><li>DKA: </li></ul><ul><ul><li>Occurs in 5% of patients with Type I DM. </li></ul></ul><ul><ul><ul><li>Laboratory shows increased ion gap. Metabolic acidosis, and positive serum ketones in the urine., with plasma glucose usually elevated. Hyonatremia, hyperkalemia, azotemia, and hyperosmolality are other findings. </li></ul></ul></ul><ul><ul><ul><li>Clinical features: </li></ul></ul></ul><ul><ul><ul><ul><li>Nausea </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Vomiting </li></ul></ul></ul></ul><ul><ul><ul><ul><li>And vaguely localized abdominal pain. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Dehydration </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Respiratory shock </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Coma </li></ul></ul></ul></ul>
  39. 39. Nephrology <ul><li>Management: </li></ul><ul><ul><li>ICU </li></ul></ul><ul><ul><li>Replacement of fluids deficits of several liters. (subtracting present weight with known recent weight). </li></ul></ul><ul><ul><li>At least one liter an hour </li></ul></ul><ul><ul><li>Insulin therapy </li></ul></ul><ul><ul><li>IV bolus of regular insulin at 10-15 units follow by an infusion of 10-15 units/hour. </li></ul></ul><ul><ul><li>A decrease of 50-75 mg/dl/hour is an appropriate response. </li></ul></ul>
  40. 40. Nephrology <ul><li>DKA continued: </li></ul><ul><ul><li>When serum bicarbonate rises to 15 mEq/L 1-2 units/hour of insulin is the goal. </li></ul></ul><ul><ul><li>Start Dextrose %% should be infused once plasma glucose degreases to 250 mg/dl in order to prevent hypoglycemia. </li></ul></ul><ul><ul><li>Potassium deficits can be restore by adding 10-20 mEq/hour in the IV fluids. </li></ul></ul><ul><ul><li>Monitoring of blood glucose every 1-2 hours and arterial blood gases as often as necessary. </li></ul></ul>
  41. 41. Nephrology <ul><li>Complications of DKA: </li></ul><ul><ul><li>Lactic acidosis </li></ul></ul><ul><ul><li>Arterial thrombosis </li></ul></ul><ul><ul><li>Cerebral Edema </li></ul></ul>