8a Nephrology and Urology

Interstitial Cystitis (IC)

• chronic inflammation of urinary bladder of unknown causes

• aka painful bladder syndrome

• F>M, 20-30 y/o

• possibly autoimmune bc it is sometimes seen with systemic lupus erythematosus

Pathophysiology of interstitial cystitis

• chronic inflammation → damaged bladder tissue → fibrosis

• mast cell overactivity → increase histamine → bladder wall edema → obstruction / decrease volume

signs and symptoms of interstitial cystitis

• urgency, frequency, small urine output

• irritation of bladder wall → bleeding (hematuria) and pain (dysuria) during urination

• chronic inflammation can cause:

  • fibrosis

  • hemorrhagic ulcers - Hunner’s ulcers

• urinary frequency (up to 60x day/night)

testing for interstitial cystitis

• frequency, urgency, dysuria without infection

• UA: WNL + APF (anti-proliferative factor)

treatment for interstitial cystitis

• no cure

• current pharmacologic treatments are not very effective

• elmiron, botulinum toxin (BTX-A), possible cystectomy

Urinary Tract Infection (UTI)

• urethritis, cystitis ± pyelonephritis

• MC nosocomial infection

• common cause of confusion in elderly

causes of UTI

• E.coli

• many other bactera

increased risk of UTI

• females, DM, urinary catheters

• poor hygiene

• dehydration

• compromised immune system

signs and symptoms of urethritis and cystitis

• dysuria, frequency, urgency

• fever, n/v, hematuria

testing for UTI

• urine analysis (UA)- best intital test

  • bacteria

  • nitrites

  • leukocyte

  • esterase

  • WBCs

• urine culture and sensitivity

• Xray, CT scan

• leukocytes

• costovertebral tenderness (murphy’s punch)

treatment for UTI

• oral antibiotics if only urethritis and cystitis

• IV antibiotics with fever and pyelonephritis

stress incontinence

• MC in women < 60

• incontinence with laughing, coughing, sneezing, lifting

• decreased pelvic floor muscle strength

urge incontinence

• MC in “older adults”

• detrusor hyperreflexia (aka reflex bladder)

• involuntary loss of urine

• constant dripping, nocturia

• neurological disorders → parkinson’s disease, MS, CNS, or peripheral nerve damage

overflow incontinence

• blockage of the bladder outlet (BPH, prostate cancer, urethra narrowing)

• bladder is always full, frequently leaks urine, urgency

signs and symptoms of urinary incontinence

• urgency

• frequency

• dysuria

• suprapubic pain

testing for urinary incontinence

• clinical

• pelvic U/S

• R/O UTI

Nephrolithiasis

• aka kidney stones or renal calculi

• M 10% > F 7%

causes of nephrolithiasis

diet, dehydration, sedentary lifestyle, medication side effects

types of nephrolithiasis

• calcium stones → MCC

• struvite stones → kidney infections

• uric acid stones → gouty arthritis

Calcium Stones (70-80%)

• MC: calcium oxalate (80%)

• calcium phosphate (15%)

• risk factors: hypercalciuria, hyperoxaluria, alkaline urine

uric acid stones (7%)

• gouty arthritis (Gout)

• acidic urine

struvite stones (15%)

• magnesium - ammonium - phosphate

• f >M

• staghorn caliculi (large)

• risk factors

  • alkaline urine

  • infection with urease producing bacteria

    • proteus, klebsiella, pseudomonas

Where are Staghorn Calculi located and the size

• large

• fill the minor and major calyces

Where are Non-Staghorn Calculi located and the size

• located in calyces, renal pelvis or in the ureter

If stone is <5mm

50% chance of spontaneous passgae

If stone >1cm

0% chance of spontaneous passage

Nephrolithiasis signs and symptoms

• moderate to severe pain

• renal colic

  • flank pain radiating to the groin

  • signs of renal pelvis obstruction or upper ureter obstruction

• n/v, dysuria, hematuria

testing for nephrolithiasis

• UA

• CT

• renal function tests

• calcium, pth

Ureterscope

surgical treatment that is required for nephrolithiasis if it is in the ureter

Nephroscope

surgical treatment that is required for nephrolithiasis if it is in the kidney

shock wave lithotripsy

surgical treatment that is required for nephrolithiasis using sound waves to pulverize stones

Kidney Blood tests

• BUN - Blood urea nitrogen

• CR - Creatinine

• GFR - glomerular filtration rate

• sodium and potassium levels

• vit D / Ca 2+

• albumin/protein

• RBCs

Kidney Urine Tests

• urine output

• albumin/protein

• casts

Urine Casts

• tubular casts

• tubule shaped particles

Glomerulonephritis

group of conditions that injure the glomeruli (filtration) in the nephron

• may be acute or chronic

causes of glomerulonephritis

• berger’s disease, PIGN

• SLE, AI, bacterial endocarditis, HTN, DM

signs and symptoms of glomerulonephritis

• proteinuria, oliguria

• hematuria

• HTN, edema

testing for glomeruloephritis

BUN, creatinine, CT, biopsy

Azotemia

high BUN and/or Cr

Uremia

high BUN with symptoms

Oliguria

Urine Output <500ml/day

Anuria

no urine output

Acute Renal Failure (ARF) aka Acute Kidney Injury (AKI)

Acute renal insufficiency

Chronic Renal Failure (CRF)

Chronic Kidney Disease (CKD)

Glomerulonephritis

Anigen-Ab complex → Inflammation → decrease GFR

Post infectious Glomerulonephritis (PIGN)

• immune complex deposition → inflammation and glomerular injury

• age 5-15years

• will present 1-2 weeks after a sore throat OR up to 6 weeks after impetigo

signs and symptoms of PIGN

fever + periorbital edema + flank pain

diagnosis of PIGN

• anti-streptolysin O antibodies (ASO)

• hematuria, proteinuria, RBC casts in urine, cola colored urine

• azotemia (decreased GFR, increased BUN, increase Cr)

• Periorbital edema (around the eyes)

IgA Nephropathy aka Berger’s Disease

• IgA deposition in glomeruli

• MCC of glomerulonephritis worldwide

• M > F

• 20-30 yo

causes of Berger’s Disease

usually starts within a day or two after a non-specific respiratory tract infection or GI infection

signs and symptoms of Berger’s Disease

• dark brown/bloody/rust color urine

• 25% of cases progress to CKD in 20-30 years

testing for Berger’s Disease

• increase BUN, increase Cr, decrease GFR

• U/A: proteinuria, hematuria

• HTN, Edema, decreased urinary output

• MAT: biopsy (IgA deposits)

treatment for Berger’s Disease

• no cure but meds can slow progress

• 20% eventually need dialysis and transplantation (recurrence is possible even after kidney transplant)

Acute Kidney Injury

• loss of kidney function (increase BUN and increase Cr, decrease GFR)

• may be acute or chronic

causes of Acute Kidney Infection

• prerenal azotemia (before the kidney)

• intrarenal azotemia (in the kidney)

• postrenal azotemia (after the kidney)

Prerenal Azotemia

• BUN: Cr> 15:1

• decrease blood flow into the kidney

• hypotension, dehydration

Intrarenal Azotemia

• BUN: Cr < 15:1

• acute kidney injury

• kidney damage → inflammation

Postrenal azotemia

• urine outflow obstruction

• BPH, bilateral nephrolithiasis, bladder tumor

• BUN: Cr is variable

signs and symptoms of acute kidney injury

• decrease urine output → edema

• fatigue, confusion, dyspnea

• AMS, seizures

testing for acute kidney injury

• daily urine output <500mL

• BUN and Cr , GFR

• electrolytes

• KUB ultrasound

• abd/pelvic CT scan

Chronic Kidney Disease aka Chronic Renal Failure

• decreased GFR

  • <60mL/min/1.73.m² for 3+ months

• acute may become chronic

• when a particular amount of nephrons are affected/destroyed, the remaining nephrons begin a process of irreversible sclerosis that leads to a progressive decline in the GFR

signs and symptoms of chronic kidney disease

• headaches

• decreased ability to concentrate urine

• polyuria → oliguria

• increase BUN and serum creatinine

• edema

• GFR

• mild anemia

• increase BP weakness and fatigue

tests for chronic kidney disease

• increase BUN

• increase Cr

• decreased GFR

treatment for chronic kidney disease

dialysis or kidney transplant

Stages 1-3b of CKD

asymptomatic

Stages 4-5 of CKD

• symptomatic

• anemia

• hyperkalemia

• HTN, edema

• decreased albumin

• dyslipidemia

Stage 5 CKD

• end stage renal disease

• requires dialysis or kidney transplant