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Nephrotic syndrome - facts
- Triad: HoAlb, edema, HChol
- Path: abnl glomerular permeability
- Causes: many
- Membranous glomerulonephritis
- DM (MC cause ESRD in USA)
- SLE, Drugs, Infection
- Focal segm glomerulosclerosis
- Membranous nephropathy
- Membranoproliferative GN
- Minimal chg dz (kids), prednisone
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Nephrotic syndrome - S/Sx
- Edema: periph, LE -> gen (periorbital)
- HCoag state: loss of anticoag factors
- /risk of infection: .
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Nephrotic syndrome - Labs
- Urine prot excr: >3g/day
- HoAlb: <3g/dL
- HLipid: .
- ?Oval fat bodies: in urine
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Nephritic syndrome - facts
- Ind: inflam proc causing renal dysfn
- Path: inflam of glomeruli due to GN
- Etiol: post-strep(MC),post-inf(GAS)GN
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Nephritic syndrome - S/Sx
- HTN: .
- Edema: low-press tissue(periorb,scrot)
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Nephritic syndrome - labs
- Blood: hemat,RBC casts,dysmorph RBC
- AKI: azotemia, oliguria
- Mild proteinuria: <3g/day
- /Cr: .
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Nephritic syndrome - types
- Asymp glom hematuria: prot<1g/d
- Nephrit syn: AKI, prot 1-3g/d, hemat,
- RBC casts, edema, HTN
- Rapidly prog GN: AKI,prot 1-3g/d,hemat
- RBC casts,sys sxs,GFR50%/d-m
- extensive glom crescent form'n
- Post-inf GN: ", /ASO, IgG&C3 basement
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AKI - general
- Def: rapid renal-fn, /Cr .5-1(50%)
- Urine: ?oliguric, anuric, ~oliguric
- S/Sx: wt gain, edema
- Lab: azotemia (/BUN,Cr)
- Etiol: prerenal, intrinsic, postrenal
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AKI - general Tx
- Avoid: meds blood flow(NSAIDs), N-tox
- Dosage: adjust for renal fn level
- Fluids: correct. HoVol<-IVF, HVol<-diur,
- mon I/O, wt
- Lytes: Correct disturb
- CO: BP 120-140/80-90
- Dialysis: A,E,I,O,U
- Acidosis: signif, intract metabolic
- Electrolytes: severe, persist HK
- Intox: methanol, ethyl glyc, lith, ASA
- Overload: HVol not managed
- Uremia: sev(clin), uremic pericarditis
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AKI, prerenal - facts
- MC cause of AKI (60-70%)
- Potentially reversible
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AKI, prerenal - causes
- syst art blood vol or renal perfus'n
- HoVol: dehyd,//diur,in,V/D,burn,bleed
- CHF: .
- HoTN: sepsis,//~HTNmeds,bleed,dehyd
- Renal a obstr: .
- Liver: cirrhosis, hepatorenal syndrome
- Drugs: NSAIDs, ACEIs, cyclosporin
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AKI, prerenal - S/Sx
- Signs of vol deplete: .
- Dry mucous membranes
- HoTN
- Tachycardia
- Tissue turgor
- Oliguria/anuria
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AKI, prerenal - Labs
- Oliguria: always
- /BUN:Cr ratio: >20:1
- /urine osm: >500
- urine Na: <20mEq/L
- FENa<1%: Na avidly reabsorbed
- /urine:plasma Na: >40:1
- Urine sediment: bland
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AKI, prerenal - Tx
- Treat underlying d/o
- NS->euvol & BP (~edema/ascites)
- X ~HTN meds
- X ACEIs, NSAIDs
- If unstable, Swan-Ganz monitoring
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AKI, intrinsic - facts
- Tissue damage->glom filtr & tube fn
- Kid unable to eff concentrate urine
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AKI, intrinsic - causes
- ATN(MC): Isch(shock,bleed,sep,DIC,HF)
- Tox(aminogly,vanc,contr,NSAIDs,pois
- myo/hemoglobinurea,cispl,MM-κγ)
- AGN: Goodpast,Wegen,post-strepGN,lup
- Vasc: renal a. occl/sten, TTP, HUS
- Interstit: allerg IN (med hypersens)
- Malig HTN: .
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AKI, intrinsic - S/Sx
Depends on cause; usually edema
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AKI, intrinsic - Labs
- BUN:Cr: <20:1, closer to 10:1, both /
- /urine Na: >40mEq/L; FENa>2-3%
- urine osm: <350
- u:plasm Cr: <20:1
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AKI, intrinsic - Tx
- Once ATN develops, support, elim agent
- Oliguric - trial of furosemide
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AKI, post-renal - facts
- Least common: (5-10%)
- Etio: Obstr}/tube press}\GFR. B for /Cr
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AKI, post-renal - causes
- OBSTRUCTION!
- MC: Urethral 2/2 BPH
- loneK: .
- Stones: .
- Neoplasm: .
- Retroperitonal fibrosis: .
- Ureteral: B, rare
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AKI, post-renal - Dx
- Key: /BUN,Cr
- Lytes: CBCw/diff, Alb
- UA dipstick: prot 3+/4+ (RF<-glom d/o)
- micro: casts
- Hyaline: prerenal
- RBC: glomerular dz
- WBC: parenchymal infect
- Fatty: nephrotic syndrome
- chem: Na, Cr, Osm, FENa
- FENa=(UNa*PCr)/(UCr*PNa)
- <1 prerenal, 2-3+ parenchymal
- Renal US: .
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AKI, post-renal - Tx
- Bladder catheter for decompression
- ?Urology consult
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AKI - Prerenal vs Intrinsic
- _ Prerenal Intrisic _
- UA: hyaline casts Abnl
- BUN:Cr: >20:1 <20:1
- FENa: <1% >2-3%
- U Osm: >500mOsm 250-300mOsm
- U Na: <20 >40(>20)
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AKI - UA table
- Cause Sediment Prot Blood
- Prerenal: Benign,hyaline neg neg
- ATN: Mud,tube,gran trace neg
- AGN: Dysmorph RBC, 4+ 3+
- R/W/fatty casts
- AIN: R/WBCs,Wcasts 1+ 2+
- eosinophils
- Postrenal: benign,?R/WBCs neg neg
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Uremia - facts
- Uremic synd: assoc w/adv renal impair
- Uremia: S/Sx assoc/w accum N wastes
- Occurs: rarely if BUN>60mg/dL
- Path: .
- Accum of toxins (prod port metal)
- X fluid/lyte homeo, hormone regul
- Progressive sys inflam(vasc/nutrit)
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Uremia - S/Sx
- Skin: pruritis, yellow
- Endo: HPThy,/ins res,amen,impot,HLipid
- Lytes: AGacid,HK,HVol,HoCa,HPO4,HMg
- Pulm: ~<3 edema,pnuemonitis,plueritis
- CV: cardiomyop,arrhyth,pericard,//ather
- GI: anorex,N/V,?taste,gastr,PU,bleed
- Hem: anemia,bleed d/o,leukocyte d/o
- MS: weak,(pseudo)gout,osteodystrophy
- CNS: irrit,insom,leth,anorex,seiz,coma
- PNS: glove-stock,restl leg,foot/wrs drp
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Polycystic kidney dz - facts
- Inher: AD, MC genetic cause of CKD
- Stat: 50% by 60s; RF<-pyleo, stones
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Polycystic kidney dz - S/Sx
- UT: hematur,
- Abd: P, hernia(abd/inguinal)
- Syst: HTN 75%
- Kidn: palpable; stones, late RF
- Brain: IC berry aneur(5-20%)
- Cyst: infect, bleed into, ->BLOPS
- Card: valve abnl (MVP, Aortic insuf)
- GI: diverticula
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Polycystic kidney dz - Dx
US - 305 cysts/kidney
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Polycystic kidney dz - Tx
- Cure: none
- Symp: drain
- Inf: tx w/ abx
- HTN: control
- ACEI: preserve kidney fn
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