Benign Prostatic Hyperplasia

• Obstructive or irritative voiding symptoms.

• May have enlarged prostate on rectal examination.

• Absence of urinary tract infection, neurologic disorder, stricture disease, prostatic or bladder malignancy.

Benign Prostatic Hyperplasia 

• Most common benign tumor in men

• Incidence is age related

  • Poorly understood risk factors

Obstructive void symptoms

• Hesitancy

• Decreased force

• Decreased caliber of stream

• Sensation of incomplete bladder emptying

• Double voiding (going twice in 2 hours)

• Straining to urinate

• Postvoid dribbling

• Urgency

• Frequency

• Nocturia

With BPH...a detailed history focusing on the urinary tract should be obtained to exclude other possible causes of symptoms such as prostate cancer or disorders unrelated to the prostate such as?

• Physical exam (note size of prostate)

• DRE

• Focused neurological exam

• On exam, BPH noted with induration must alert the clinician to the possibility of 

• UA

  Creatinine

• PSA is optional

  Upper track CT or ultrasound

• Watchful waiting- Risk of progression is uncertain and is not inevitable. Some men undergo spontaneous improvement or resolutions
• Medical Therapy
• Conventional Surgical Therapy
• Minimally Evasive Therapy

1. -Blockers

• (The human prostate and bladder base contains ₁-adrenoceptors, and the prostate will show a contractile response to such agonists.)

  • Phenoxybenzamine (1 & 2 blockers)

  • Prazosin

  • Terazosin

  • Doxazosin

  • Alfuzosin

  • Tamsulosin (1a blocker) 

2.   5-Reductase Inhibitors

(Blocks the conversion of testosterone to dihydrotestosterone. This drug impacts upon the epithelial component of the prostate, resulting in reduction in size of the gland and improvement in symptoms. 

• Finasteride

3. Combination Therapy 

• Finasteride + Terazosin 

 4. Phytotherapy (Use of plants/plant extracts for medicine)

1. Transurethral resection of the prostate (TURP)

2. Transurethral incision of the prostate (TUIP)

3. Open simple prostatectomy

1. Laser therapy

2. Transurethral needle ablation of the prostate (TUNA)

3. Transurethral electrovaporization of the prostate

4. Hyperthermia

Cryptorchidism

Inability of testicle to descend into scrotum

• Cosmetic

• Undescended testes increases risk of cancer therefore can be more easily palpated in the scrotum

• Fertility is improved

Rationale for Treatment for Cryptorchidism

• Surgery prior to the age of 2 or during that year

• Surgery – Orchiopexy placement of the testes in scrotum

Tx for Cryptorchidism 

Erectile Dysfunction 

• can have organic and psychogenic etiologies.

•  may be an early sign of cardiovascular disease and requires evaluation.

• Incidence increases with age

Erectile Dysfunction 

• Occasional inability to obtain a full erection

• Inability to maintain an erection throughout intercourse

• Complete inability to achieve an erection

• Approximately 25% of all men older than age 65 years suffer from this disorder

• Most cases have an organic rather than a psychogenic cause

• Vast majority is organic secondary to lack of arterial blood supply (atheroma) involving the common or internal iliac arteries or their more distal branches

• Venous leakage: veno-occlusive mechanisms don’t work

• Secondary sexual characteristics should be assessed

• Neurologic and peripheral vascular examination should be performed

• Motor and sensory examination

• Palpation of peripheral pulses

• Genitalia examined noting the presence of penile scarring or plaque formation (peyronie’s disease) and any abnormalities in size or consistency of the testicles

• Prostate exam essential

• If normal erections in early morning or during sleep occur an____ cause is unlikely

The gradual loss of erections over time is more suggestive of an ___ cause

• _________ may occur as a result of mechanical disruption of the bladder neck especially after prostate resection or from sympathetic denervation from meds, diabetes, pelvic or retroperitoneal surgery

• If libido and erection are intact, lack of orgasm is usually of _______ origin

• ______ deficiency decreases prostate and seminal vesicle secretions

• ___________ is usually an anxiety-related disorder and rarely has an organic cause

• Patients with abnormalities of prolactin or testosterone require further evaluation with measurement of _______ & ________. Endocrinologic consultation is advised

Treatment

1. Hormonal Replacement

   • Testosterone replacement therapy (for hypogonadism)

2. Vasoactive Therapy

   • Sexual stimulation with subsequent nitric oxide release from the parasympathetic nerves and endothelium initiates penile erection.
   • Nitric oxide enters smooth muscles cells, increases cyclic guanosine monophosphate (cGMP) production, which mediates calcium sequestration and cellular hyperpolarization.

Medications: PDE 5 Inhibitors

• Sildenafil (Viagra)

• Vardenafil (Levitra)

• Tadalafil (Cialis)

3. Vacuum Erection Devices

4. Penile Prostheses

5. Vascular Reconstuction

Hydrocele 

Fluid accumulation in scrotum between tunica albuginea and tunica vaginalis of testes

• Congenital lack of obliteration of process vaginalis

  • Most infant hydroceles should resolve by 2 years of age

• Infectious

• Traumatic

• Physical - located superior and anterior to the testis

• Bilateral in 7-10%

• Often associated with hernia (often right sided)

• Becomes smaller and softer after lying down

• Scrotal ultrasound

• Transilluminates brightly

• Adult onset secondary to orchitis or epididymitis, tuberculosis or some tropical infections

• Testicular torsion can cause a _____20% of the time

• Testicular tumors can cause 

• Traumatic nature are common

• Observation

• Hydrocelectomy may recur < 5%

Dilation of vein of pampiniform venous plexus and the internal spermatic vein

• 15% of male population

• Most common cause of male factor infertility resulting in reduced motility and stress pattern on semen analysis

• I. Palpable by valsalva maneuver

• III. Bag of “worm” visible through scrotal sac

• Variolcele has Grade I, II, III

• Which grade is Palpable by valsalva maneuver?

• Which grade is Bag of “worm” visible through scrotal sac

transscrotal doppler 

Varicocelectomy

• anatomic

Diagnosed by 

• H & P

• Focused neurological exam

• Post void residual

• UA

1. Kegel exercises

2. Medical therapy

   • Detrol

   • Enablex

   • Ditropan

   • Sanctura

   • Vesicare

     • All may cause confusion in the elderly

3. Surgical treatment

   • Midurethral slings

   • Periurethral bulking agents

   • Male sling

   • Artificial urinary sphincter

Nephro/urolithiasis 

• Most 90% are calcium oxalate

• 10% are uric acid

• Iatrogenic

• Hypercalcuria

• Hyperuricuria

Nephro/urolithiasis (BPH Lecture) 

• Flank pain

• Pain is colicky in nature

• Sudden

• Lasting 30 minutes, rarely lasting more than 6 hours

• Not related to movement

Nephro/urolithiasis  

• Infection and obstruction may cause loss of kidney or life in 24-48 hours

Most stones _______ greater than 90% will pass spontaneously

In Nephro/urolithiasis:

May have complete obstruction with no renal damage for up to____ weeks

In Nephro/urolithiasis:

• If hydronephrosis was present _________ should be done following passage of the stone

Nephro/urolithiasis Treatment

Surgical Treatment

• ESWL (Extracororeal shock wave lithotripsy) uses sound waves to break 

• Ureteroscopy (visualization;  grabbed by forceps or basket device)

• Percutaneous Nephrolithotomy: 1 cm incision made in the back ; a tube is inserted into the kidney, through which removed

• Either removed whole or after breaking up with laser or shock wave

• Increase fluid intake

• Reduce salt intake

• Reduce protein intake

• 
  

Nephro/urolithiasis Prevention

Paraphimosis

• Occurs when the foreskin of an uncircumcised male canot be pulled back over the head of the penis

• Causes: direct trauma to the area

  
  

Paraphimosis

• Failure to return the foreskin to its normal location after urination of washing (common in hospitals and nursing homes)

• Infection, which may be due to poor personal hygiene

Paraphimosis

• Inability to pull the retracted foreskin over the head of the penis

• Painful swelling at the end of the penis

• Pain in the penis

• A physical examination confirms the diagnosis; the health care provier will usually find a “doughnut” around the shaft near the head of the penis

• Pressing on (compression of) the head of the penis while pushing the foreskin forward may reduce the swelling.

• If it cannot be pushed back into place, prompt circumcision is needed

Tx of Paraphimosis

Damage to the penis tip, gangrene, loss the the penis tip

Complications of Paraphimosis

Phimosis

• hysiologic phimosis occurs naturally in newborn males, usually resolves by age 3.

• Pathologic phimosis defines an inability to retract the foreskin after it was previously retractible or after puberty, usually secondary to distal scarring of the foreskin.

Phimosis S/S

• S/S The foreskin may be red, swollen and tender

• If the cause is from an underlying condition, treat the condition.

• Circumcision may be needed

 twisting of the spermatic cord, wich cuts off the blood supply to the testicle and surrounding structures within the scrotum.

Can result from trauma to the scrotum, especially is significant swelling occurs.

It can be cuased from strenuous exercise or may not have an obvious cause

• S/S sudden onset of severe pain in one testicle with or without a previous predisposing event

  • Swelling within one side of the scrotum

  • Nausea or vomiting

  • Light-headedness

  • Affected testicle will be higher than unaffected testicle

  • Testicle lump

  • Blood in semen

• Physical exam will reveal tenderness and usually extreme swelling (it is more common on the right side)

• • Doppler ultrasound of the testicle can show blood flow

• surgery as soon as possible, if preformed within 6 hours most testicles can be saved (if blood supply has been cut off for too long the testicle may atrophy days to weeks after the event.  

• During surgery the other testicle will be anchored to prevent a further occurrenc

Tx testicular torsion

• Infection of the bladder that is most commonly due to the coliform bacteria E. Coli and enterococi.

• The route of infection is typically ascending from the urethra.

• Rare in men and implies a pathological process such as infected stones, prostatitis, or chronic urinary retention requiring further investigation.

coliform bacteria E. Coli and enterococi.  

Essentials of Diagnosis: 

• Irritative voiding symptoms

• Pt usually afebrile

• Positive urine culture; blood cultures may also be positive 

• Irritative voiding (frequency, urgency, dysuria)

• Suprapubic discomfort

• Women may experience gross hematuria and s/s following sexual intercourse

• Physical exam may exhibit suprapubic tenderness, but physical exam is often unremarkable

• Systemic toxicity is absent.

• Urinalysis shows pyuria (pus in urine) and bacteruria and varying degrees of hematuria.

• The degree of pyuria and bacteruria does not necessarily correlate with the severity of the symptoms.

• Urine culture is positive for the offending organism, but colony counts exceeding (10)5/mL are not essential for the diagnosis

• Ultrasonography or cystoscopy (especially in males)

• Short term antimicrobial therapy

• Fluoroquinolones and nitrofurnation are drugs of choice in uncomplicated cases

• Trimethoprim-sulfamethoxazole can be ineffective b/c of the emergence of resistant organisms.  

• Pain with a full bladder or urinary urgency – relief when emptied

• Submucosal petechiae or ulcers on cytoscopic exam

• Diagnosis of exclusion

Pt must have a negative urine culture and cytology and no other obvious cause such as radiation cystitis, chemical cystitis, vaginitis, uretheral diverticulum or genital herpes.

Unknown etiology 

• No cure

• Most pts achieve symptomatic relief with hydrodistension

• Amitriptyline

• Nifedipine

• Elmiron

• Other treatment options: transcutaneous electic nerve stimulation

Epididymitis Essentials of Diagnosis

• S/S

  Fever

• Irritative voiding symptoms

• Painful enlargement of epididymis

In Epididymitis, most cases are infectious and are either _____ or _______ sexually transmitted from , or non-sexually transmitted forms, usually in older men with urinary tract infections and prostatitis.   

_____has been associated with self-limited epididymis, which is a dose dependent phenomenon. 

• May follow acute physical strain, trauma, or sexual activity

• Urethritis (pain at the tip of the penis and uretheral discharge)

• Cystitis (irritative voiding s/s)

• Pain develops in the scrotum and may radiate along the spermatic cord or the the flank.

• Fever

• Scrotal swelling

• Early may be distinguished from the testis, however later it may appear as one swollen mass.

• Prostate may be tender on rectal exam

• Prehn sign- elevation of the scrotum above the pubic symphysis improves the pain. (not in every case) 

• CBC shows leukocytosis and a left shift

• In a sexully transmitted variety urethral discharge may be gram stained

• In non-sexually transmitted, urinalysis shows pyuria, bacteruria and varying degrees of hematuria.

• Urine cultures will show offending pathogen

Orchitis

swelling of one or both of the testicles

• Blood in the semen

• Discharge from penis

• Fever

• Groin pain

• Pain with intercourse or ejaculation

• Pain with urination

• Scrotal swelling

• Tender, swollen groin on affected side

• Heavy feeling in the testicle

• Pain is made worse by bowel movement or straining

• On physical exam; enlarged, tender testicle or prostate, tender and enlarged lymph nodes in the groin area on the affected side

• nfections from bacteria or viruses

• Most common virus is mumps

• Can occur with infections of the prostate of epididymis

• STD’s such as gonorrhea or chlamydia

• Long term use of a foley catheter

• Congenital birth defects

• Regular UTIs

• Surgery of the urinary tract 

• Treat the underlying cause

• Pain meds

• Best rest with scrotum elevated and ice the scrotum

• Fever

• Irritative voiding symptoms

• Perineal or suprapubic pain; exqusite tenderness common on rectal exam

• Positive urine culture

• Usually caused by E coli and pseudomonas

• The most likely routes of infection ascent up the urethra and reflux of infected urine into the prostatic ducts.

Acute Bacterial Prostatitis most common organisms? 

Acute Bacterial Prostatitis

• Perianal, sacral or supra pubic pain

• Irritative voiding complaints

• Urinary retention from prostate swelling

• Warm and tender prostate 

• Possible hospitalization

• Ampicillin and aminoglycoside depending on the pathogen

• After the pt is afebrile for 24-48 hours the ABX are continued for 4-6 weeks

• If urinary rentention, suprapubic tube is required

Tx of acute bacterial prostatits

Chronic Bacterial Prostatitis 

• Irritative voiding symptoms

• Perianal or suprapubic discomfort, often dull and poorly localized

• Positive expressed prostatic secretions and culture

• May evolve from acute prostatitis or have no history of acute infection 

• some pts are asymptomatic

• low back pain

• perianal pain

• history of UTIs

Chronic Bacterial Prostatitis 

• urinalysis is usually normal

• expressed prostatic secretions demonstrate increased leukocytes, especially macrophages – the count does not correlate with severity

Nonbacterial Prostatitis

• Irritative voiding symptoms

• Perianal or suprapubic discomfort, similar to that of chronic condition

• Positive expressed prostatic secretions, but culture is negative

• Most common cause of symptoms

• The cause is unknown, diagnosis is one of exclusion

  Same symptoms as chronic condition without history of UTI's

• Because the etiology is unknown a trial of antibiotics against ureaplasma, mycoplasma and Chlamydia is tired. Erythromycin for 14 days and then continued for 3-6 weeks if there is a favorable response.

• Symptomatic relief with NSAIDs 

• Treatment Nonbacterial Prostatitis 

PYELONEPHRITIS 

Essentials of diagnosis:

*FEVER ** FLANK PAIN ** IRRITATIVE VOIDING SX ** POSITIVE URINE CULTURE*

PYELONEPHRITIS 

• Infectious inflammatory disease involving the kidney parenchyma and renal pelvis

• Gram negative bacteria most common (E. coli, proteus, klebsiella, enterobacter and pseudomonas); gram positive less common)

• The infection usually ascends from the lower urinary tract (except for the gm positive staph aureus which is usually spread by the blood).

PYELONEPHRITIS S/S

• Fever, flank pain, shaking chills (rigors), and irritative voiding sx (urgency, frequency and dysuria)

• Can have associated nausea, vomiting, diarrhea

• Tachycardia

• Costovertebral angle tenderness

PYELONEPHRITIS LABS

• CBC: leukocytosis and a left shift (high WBCs with high neutrophils)

• UA shows pyuria, bacteriuria, and varying degrees of hematuria; white cell casts may be seen

• Urine culture will show heavy growth of the bacteria responsible

• Blood cultures may be positive

• renal US may show hydronephrosis from a stone or other source of obstruction 

• Admit to hospital if severe or there are complicating factors

• Obtain urine and blood culture to identify organism

• Start with IV ampicillin and an aminoglycoside prior to getting sensitivity results; continue IV ABX for 24 hours after fever resolves and then switch to oral for a complete 14 day course.

• Outpatient treatment—quinolones or nitrofurantoin (macrobid)

• Adjust ABX for sensitivities

• Fever may last up to 72 hours; if longer, do CT or US to exclude other issues

• Obtain repeat urine cultures after treatment is complete

Tx of PYELONEPHRITIS

URETHRITIS 

• Noninfectious causes of urethritis include _____ .

URETHRITIS 

pain at the tip of the penis and urethral discharge

 dysuria

• Good hx, including sexual hx

• Do exam, looking for evidence of discharge

• Take samples from urethra

• Treat for gonnorhea and chlamydia if urethral Gram stain is positive for Gram negative intracellular diplococci

• Give tmt for Chlamydia if the urethral smear shows 5 or > wbcs per high power field and if Gram stain does not suggest gonorrhea

• Explain dx, tmt and methods of prevention

• Tell pt to avoid sex until tmt and follow-up are completed

• Advise treatment of partners

• Retest for gonorrhea after all tmt completed

• Symptomatic gonorrhea usually develops within a few days ofexposure

• Chlamydial infections take slightly longer

• Mild infections may cause urethral discomfort and dysuria without discharge and may be confused with cystitis.

• Defined as reduced total body water

   

• Occurs when rate of salt water intake is less than the combined rates of renal and extrarenal losses

Volume Depletion Due to Increased Fluid Loss (2 types) 

• Decreased fluid intake

• Increased fluid loss

• Signs and symptoms vary with degree 

• Orthostatic hypotension and tachycardia are common

  • Orthostatic hypotension with have a 20-mmHg drop in systolic or 10 mmHg drop in diastolic pressure

• PE: decreased skin turgor and dry mucosa membranes

• Positive response to a fluid challenge

• Fluid replacement with normal saline

• Most potent fluid replacement substance is blood

  • Used typically in cases of hemorrhage

• Increase in total body water

• 
  

• • Right-sided heart failure

  • Constrictive pericarditis

• Left-sided heart failure

• Vena cava obstruction

• Local increase in venous pressure includes:

• Nephrotic syndrome

• Hypoabuminemia

• Reduced oncotic pressure includes: 

• Systemic increase in venous pressure

• Local increase in venous pressure

• Reduced oncotic pressure

• Cirrhosis

Primary Aldosteronism

Cushing's Syndrome

Syndrome of Inappropriate Antidiuretic hormone

Renal failure

• Symptoms related to cause of volume excess

• Cases due to reduced effective circulating volume will have edema

Diuretics are the treatment of choice for volume excess:

• Proximal diuretic (acetazolamide)

• Loop diuretic

• Early distal diuretic (thiazide)

• Late distal diuretic (spironolactone)

Proximal diuretic (acetazolamide)

 tx: volume excess

• Primary effect: ↓ Na+/H+

• SE: hypokalemic, hyperchloremic acidosis

Loop Diuretic

 tx: volume excess

• Primary effect: ↓Na+/K+:2 Cl- absorption

• SE: hypokalemic alkalosis (furosemide)

• SE: hearing deficit (bumetanide)

• Early distal diuretic (thiazide)

   tx: volume excess
  

• Primary effect: ↓NaCl absorption

• SE: hypokalemic alkalosis, hyperglycemia

• Late distal diuretic (spironolactone)

   tx: volume excess
  

• Primary effect: ↓ Na+ absorption

• SE: hyperkalemic acidosis

Acute Renal Failure (Acute Kidney Injury)

• Sudden increase in BUN or serum creatinine

• Oliguria often associated

• Symptoms and signs depend on cause

Acute Renal Failure (Acute Kidney Injury)

• Rapid deterioration of renal function

• Abrupt decrease in Glomerular Filtration rate (GFR)

• Can’t maintain fluid and electrolyte balance

• Causes AZOTEMIA (elevated BUN and creatinine)

• Possibly oliguria (< 400 mL output in 24 hrs)

• Occurs in hours to days in people who had previously normal kidney function or In people with chronic renal disease (Acute on chronic)

• Defined as a sudden decrease in kidney function, resulting in an inability to maintain acid-base, fluid, and electrolyte balance, and to excrete nitrogenous wastes

• Serum creatinine is a convenient marker

• Uremic milieu can cause nonspecific symptoms

• When present, often due to azotemia or its underlying cause

  • Azotemia can cause nausea, vomiting, malaise, and altered sensorium.

• Hypertension is rare, but fluid homeostasis is often altered

• Hypovolemia can cause prerenal dz, whereas hypervolemia result from intrinsic/postrenal dz

• Pericardial effusions can occur with azotemia, and a pericardial friction rub

  • Effusions may result in cardiac tamponade

• Arrhythmias occur especially with hyperkalemia

• Lung examination may show rales in the presence of hypervolemia

• Nonspecific diffuse abdominal pain and ileus as well as platelet dysfunction; thus, bleeding and clotting disorders are more common

• Neurologic exam reveals encephalopathic changes with asterixis and confusion; seizures

• Elevated BUN and creatinine are present (Do not in themselves distinguish acute from chronic kidney disease)

• Hyperkalemia from impaired renal potassium excretion

• ECG can reveal peaked T waves, PR prolongation, and QRS widening

  • Long QT segment can occur with hypocalcemia

• Anion gap metabolic acidosis (due to decreased organic acid clearance)

• Hyperphosphatemia occurs when phosphorus cannot be secreted by damaged tubules either with or without increased cell catabolism

• Hypocalcemia with metastatic calcium phosphate deposition may be observed when the product of calcium and phosphorus exceeds 70 mg²/dL²

• Anemia can occur as a result of decreased erythropoietin production over weeks, and associated platelet dysfunction is typical

Arrhythmias occur especially with

Lung examination may show rales in the presence of 

Long QT segment can occur with

• ECG can reveal peaked T waves, PR prolongation, and QRS widening

Hyperphosphatemia

occurs when phosphorus cannot be secreted by damaged tubules either with or without increased cell catabolism

Hypocalcemia (d/t acute renal failure)

metastatic calcium phosphate deposition may be observed when the product of calcium and phosphorus exceeds 70 mg²/dL²

can occur as a result of decreased erythropoietin production over weeks, and associated platelet dysfunction is typical

• Prerenal causes of Kidney Disease

   

Ureteral

Bladder Outlet

Neurogenic Bladder

Foley Cath

Postobstructive

1. Glomeruli (capillary membrane)

• Immune

  • IgA nephropathy (Berger’s disease)

  • Lupus

  • Wegener’s

  • Goodpastures

• Infectious

  • Hepatitis B/C

  • Post-strep (Glomerulonephritis): Common in kids

  • HIV

  • Endocarditis

• Toxic
• Heroin

1. Interstitium (interstitial nephritis)
2. Tubules (Acute tubular necrosis/ ATN)

• Intra-renal Kidney Dz due to 

• Interstitium (interstitial nephritis)

• Inflammation in interstitial space caused by allergies to meds or infectious dz

• Either asymptomatic, or may have fever, rash, joint pain

• Nonspecific, Due to accumulation of nitrogenous wastes or volume overload

• N/V

• Anorexia

• Cardiopulmonary sxs

  • Chest pain (pericarditis): Due to fluid buildup

  • Dyspnea (pulmonary edema)

• Fatigue

• Confusion

• Pruritis

• Signs of volume overload

  • Elevated jugular venous pressure

  • Cardiac murmur

  • Cardiac gallop

• Bladder obstruction

  • Abdominal mass

  • Suprapubic dullness (distended bladder)

• Chronic renal failure

  • Pallor from anemia

  • Skin excoriations from pruritis

• Bleeding

• Diarrhea

• Diuretics

• Third Spacing

• Decreased effective circulating volume

• CHF

• Cirrhosis

  SIGNS OF??

• Sepsis

• Cardiogenic shock

• Anaphylaxis

• Anesthesia and medication induced

• Relative hypotension

  SIGNS OF??

renal artery failure

afferent arteriolar narrowing

• Don’t give NSAIDs to a patient with renal artery stenosis because it will cause ______ due to the renal afferent artery losing its ability to autoregulate

• NSAIDs block prostaglandins, causing ___________

NSAIDs

COX-2s

ACEI: ACEIs dilate efferent arterioles

1. Acute oliguric renal failure

• Foley catheter (r/o obstruction)

   

• U/S :look for hydronephrosis
• Use fluid challenge or diuretics to establish urine output

• Review meds and remove nephrotoxins

• Collect fresh urine sample

  • Check urine sediment

    • Cells or casts in a fresh, centrifuged urine

    • Indicates presence of intrinsic renal disease

    • Urine sediment in prerenal and postrenal injury does NOT usually have cells or casts

• Get BUN and Creatinine

  • Ratio > 20:1: prerenal state (urea reabsorbed because of conservation)

• FeNa

  • If FeNa is < 1, nephron working hard to retain salt and water: prerenal

  • If FeNa> 2, nephron cannot retain Na: intrinsic

  • Diuretics falsely increase FeNa

Diagnostic Steps

Acute Renal Failure

 Chronic

• Anemia (descreased erythropoeitin)

• Low calcium

• Small kidneys on ultrasound

  WHICH TYPE OF RENAL FAILURE?

WHAT TYPE OF RENAL FAILURE?

• Anemia less likely

• Kidneys not small

If FeNa is < 1, nephron working hard to retain salt and water:

• If FeNa> 2, nephron cannot retain Na:

• Cells or casts in a fresh, centrifuged urine, Indicates presence of: 

• Urine sediment in prerenal and postrenal injury usually 

• Hospitalize (for dx and management)

• Volume depletion or volume overload?

  • Get daily weights

  • Ins and outs including free water losses (~ 10 mL/kg/d)

  • Examine pts

  • Decide on volume repletion or diuresis

• Watch for infection (increase risk)

• Nutrition priority (anorexia common)

• Do a renal dose for all meds based on calculated creatinine clearance:

• Lab tests to follow:

  • In oliguric ARF: expect daily increases in creatinine (Cr) of 0.5 to 1.0 mg/dL and BUN of 10-20 mg/dL

  • Get electrolytes at least daily (acidemia and hyperkalemia common)

  • CBC, uric acid, Ca++, Mg, Phosphate at admission and during illness

  • Check ABGs as needed to monitor pH and acidosis

• Dialysis

  • When symptomatic renal failure present

  • Severe volume overload

Treatment/management acute renal failure

0.5 to 1.0(Cr)

10-20 (BUN)

In oliguric ARF: expect daily increases in creatinine (Cr) of  _______mg/dL and BUN of ______ mg/dL

• Check CBC, uric acid, Ca++, Mg, Phosphate at admission and during illness

• Check ABGs as needed to monitor pH and acidosis

• When symptomatic renal failure present

• Severe volume overload

• Life-threatening acidosis

• Severe electrolyte abnormalities (esp. hyperkalemia)

• Pericarditis

• Toxins that dialysis can remove

Prerenal Azotemia

Postrenal Azotemia

Normal or red cells, white cells, or crystals

Acute Tubular Necrosis

Granular (muddy brown) casts, renal tubular casts

Acute Glomerulonephritis

Red cells, dysmorphic red cells and red cell casts

Acute Interstitial Nephritis

White cells, white cell casts, with or without eosinophils

Acute Tubular Necrosis

Ischemia, nephrotoxins

Acute Glomerulonephritis

Immune complex-mediated, pauci-immune, anti-GBM related

Acute Interstitial Nephritis

Allergic rxn; drug rxn; infection, collagen vascular dz

• Progressive azotemia over months to years

• Symptoms and sings of uremia when nearing end-stage disease

• HTN in the majority

• Isosthenuria and broad casts in urinary sediment are common

• Bilateral small kidneys on ultrasound are diagnostic

• Most pts are unaware of this condition because they remain asymptomatic until the disease has progressed

• Rarely reversible and leads to progressive decline in kidney function even if inciting event has been removed

• Reduction in renal mass leads to hypertrophy of the remaining nephrons wih yperfiltration

• GFR is transiently supranormal

• Places a burden on the remaining nephrons and lead to progressive glomerular sclerosis and interstitial fibrosis, suggesting hyperfiltration may worsen kidney function

Stage #1- Kidney damage with normal or ↑GFR (≥90)

#2- Kidney damage with mildly ↓ GFR (60-89)

#3-Moderately ↓ GFR (30-59)

#4- Severely ↓GFR (15-29)

#5-Kidney failure (<15)

Diagnosis and treatment. Treatment of comorbid conditions. Slowing of progression. Cardiovascular disease risk education.

Diagnosis and treatment. Treatment of comorbid conditions. Slowing of progression. Cardiovascular disease risk education.

AND

estimating progresion

Diagnosis and treatment. Treatment of comorbid conditions. Slowing of progression. Cardiovascular disease risk education. Estimating Progression.

AND

Evaluating and treating complications

• Glomerulopathies

  • Primary glomerular diseases

    • Focal and segmental glomerulosclerosis

    • Membranoproliferative glomerulonephritis

    • IgA nephropathy

    • Membrane nephropathy

  • Secondary glomerular diseases

    • Diabetic nephropathy

    • Amyloidosis

    • Postinfectious glomerulonephritis

    • HIV-associated nephropathy

    • Collagen-vascular diseases

    • Sickle cell nephropathy

    • HIV-associated membranoproliferative glomerulonephritis

• Tubulointestinal nephritis

  • Drug hypersensitivity

  • Heavy metals

  • Analgesic nephropathy

  • Reflux/chronic pyelonephritis

  • Idiopathic

• Hereditary diseases

  • Polycystic kidney disease

  • Medullary cystic disease

  • Alport syndrome

• Obstructive nephropathies

  • Prostatic disease

  • Nephrolithiasis

  • Retroperitoneal fibrosis/tumor

  • Congenital

• Vascular diseases

  • Hypertensive nephrosclerosis

  • Renal artery stenosis

• Focal and segmental glomerulosclerosis

• Membranoproliferative glomerulonephritis

• IgA nephropathy

• Membrane nephropathy

  ALL ARE?

• Diabetic nephropathy

• Amyloidosis

• Postinfectious glomerulonephritis

• HIV-associated nephropathy

• Collagen-vascular diseases

• Sickle cell nephropathy

• HIV-associated membranoproliferative glomerulonephritis

  ALL ARE??

• Drug hypersensitivity

• Heavy metals

• Analgesic nephropathy

• Reflux/chronic pyelonephritis

• Idiopathic

  ALL ARE??

• Hereditary diseases

• • Polycystic kidney disease

  • Medullary cystic disease

  • Alport syndrome

    ALL ARE??

• • Prostatic disease

  • Nephrolithiasis

  • Retroperitoneal fibrosis/tumor

  • Congenital

    ALL ARE??

• Hypertensive nephrosclerosis

• Renal artery stenosis

  ALL ARE?

Symptoms and Signs

• Often develop slowly and are nonspecific

• Can remain asymptomatic until kidney disease is advanced (GFR<10-15 mL/min)

• Fatigue, weakness, and malaise

• GI complaints: anorexia, nausea, vomiting, a metallic taste in the mouth, and hiccups

• Neurologic problems: irritability, difficulty in concentrating, insomnia, subtle memory defects, restless legs, and twitching

• Pruritus

• As progresses, decreased libido, menstrual irregularities, chest pain from pericarditis, and paresthesias

• Sxs of drug toxicity (esp. those eliminated by the kidney) increase as renal clearance worsens

• Physical exam:

  • Pt appears chronically ill

  • HTN common

  • Skin may be yellow, with signs of easy bruisability

    • Uremic frost, a cutaneous reflection of ESRD, is rarely seen

  • Uremic fetor is the characteristic fishy odor of the breath

  • Cardiopulmonary signs: rales, cardiomegaly, edema, and a pericardial friction rub

  • Mental status: decreased concentration to confusion, stupor, and coma

  • Myoclonus and asterixis are signs of uremic effects on the CNS

• Term "uremia" is used for this clinical syndrome, but the exact cause remains unknown

• BUN and serum creatinine are considered markers for unknown toxins

• In any patient with kidney disease, it is important to identify and correct all possibly reversible causes

  • Urinary tract infections, obstruction, extracellular fluid volume depletion, nephrotoxins, hypertension, and CHF should be excluded. Any can worsen underlying chronic kidney disease

• Diagnosis made by documenting elevations of the BUN and serum creatinine concentrations

• Evidence of previously elevated BUN and creatinine, abnormal prior urinalyses, and stable but abnormal serum creatinine on successive days is most consistent with a chronic process

• Anemia, metabolic acidosis, hyperphosphatemia, hypocalcemia, and hyperkalemia can occur with both acute and chronic kidney disease

• Urinalysis shows isosthenuria if tubular concentrating and diluting ability are impaired

• Urinary sediment can show broad waxy casts as a result of dilated, hypertrophic nephron

• Small echogenic kidneys bilaterally (< 10 cm) by ultrasonography

  • Although normal or even large kidneys can be seen with adult polycystic kidney disease, diabetic nephropathy, HIV-associated nephropathy, multiple myeloma, amyloidosis, and obstructive uropathy

• Radiologic evidence of renal osteodystrophy is another helpful finding, since radiographic changes of secondary hyperparathyroidism do not appear unless parathyroid levels have been elevated for at least 1 year

• Evidence of subperiosteal reabsorption along the radial sides of the digital bones of the hand confirms hyperparathyroidism

GFR is < 10–20 mL/min

Potassium balance generally remains intact in chronic kidney disease until the

• Endogenous causes include any type of cellular destruction such as hemolysis and trauma, hyporeninemic hypoaldosteronism (type IV renal tubular acidosis, seen particularly in diabetes mellitus), and acidemic states 
• Exogenous causes include diet (eg, citrus fruits and salt substitutes containing potassium) and drugs that decrease K⁺ secretion (amiloride, triamterene, spironolactone, NSAIDs, ACE inhibitors) or block cellular uptake (B-blockers).

• Certain states pose an increased risk of hyperkalemia at higher GFRs

• Cardiac monitoring is indicated for any ECG changes seen with hyperkalemia, or a serum potassium level 

• Chronic hyperkalemia is best treated with 

Hyperkalemia

Acid Base d/o

cardio complications

hematologic complications

neruro complications

d/o of mineral metabolism

endocrine d/o

• Damaged kidneys are unable to excrete the ______ of acid generated by metabolism of dietary proteins

• Resultant metabolic acidosis in chronic renal dz is primarily due to loss of _____.

• Limits production of ammonia (NH₃) and limits buffering of H⁺ in the urine

• Although pts are in positive hydrogen ion balance, the arterial blood pH is maintained at 7.33–7.37 and serum bicarbonate concentration rarely falls below 15 mEq/L

• Excess hydrogen ions are buffered by the large ______ and ______.

• In chronic renal dz Serum bicarbonate level should be maintained at greater than 

• sodium bicarbonate, calcium bicarbonate, and sodium citrate
• Administration should begin with 20–30 mmol/d of oral alkali divided into two doses per day and titrated as needed

• HTN

• Pericarditis

• CHF

• Anemia

• Coagulopathy

• Encephalopathy

• Peripheral neuropathy

• Mineral bone disorders 

• Osteomalacia

• Adynamic bone disease

• Hyperglycemic or hypoglycemic depending on disturbance

• Decrease libido and impotence

• Dietary (Protein restriction, salt and water restriction, K+ and phosphorus restriction, magnesium restriction) 
• Dialysis
• Kidney Transplant

• Potassium restriction, Restriction is needed once the GFR has fallen below

• Protein restriction slows the progression to ESRD; however, this has not been consistently proved in clinical trials

• The benefits of protein restriction in slowing the rate of decline of GFR must be weighed against the risk of ________

1 g/kg/d, 

0.6–0.8 g/kg/d

• In advanced dz, the kidney is unable to adapt to large changes in sodium intake

• Intake >____ can lead to edema, hypertension, and congestive heart failure, 

2 g/d

1-2L