FULL PRIMARY CARE STUDY GUIDE (also good for step)

What are some causes of terminal hematuria?

Urothelial cancer, cystitis, urolithiasis, benign prostatic hyperplasia, prostate cancer.

What could initial hematuria indicate?

Urethritis or trauma (e.g., catheterization).

What conditions can cause hematuria throughout the urinary stream?

Renal mass (benign/malignant), glomerulonephritis, urolithiasis, polycystic kidney disease, pyelonephritis, urothelial cancer, trauma, renal papillary necrosis.

What initial evaluations are done for hematuria in children?

Symptomatic trauma history, urinary tract infection, perineal/meatal irritation, and kidney stones.

What findings are associated with glomerular disease?

Brown urine, edema, hypertension, proteinuria, and RBC casts.

What diagnostic tests are used for hematuria?

Renal ultrasonography and urine culture.

How do you manage symptomatic ureteral stones?

Initial symptom control with analgesics and antiemetics, IV fluids, and assessing for urinary tract infection or acute kidney injury.

What is the treatment for complete obstruction due to ureteral stones?

Inpatient admission, urgent urology consultation, IV medications, and potential use of an alpha blocker.

What indicates glomerular hematuria?

Dysmorphic erythrocytes and erythrocyte casts.

What lab findings suggest immune complex mediated glomerulonephritis? Give examples of immune complex mediated glomerulonephritis.

Low serum complement levels. Examples: lupus nephritis, MPGN, PSGN, Staph-associated GN, endocarditis-associated GN

What are the complications of glomerular disease related to bleeding?

RBC casts and dysmorphic RBCs.

What is a common cause of acute tubular necrosis?

Prolonged hypotension and sepsis.

What is indicated for the treatment of prerenal acute kidney injury?

Restoration of renal perfusion.

What is the blood urea nitrogen/creatinine ratio in prerenal acute kidney injury?

Greater than 20:1.

What are some clinical features of diabetic kidney disease?

Persistent albuminuria, initial hyperfiltration, and progressive decline in GFR.

How do you manage diabetic nephropathy?

Intensive glycemic control and blood pressure control.

What is the goal for hemoglobin A1c in most diabetic patients?

Target hemoglobin A1c ≤7%.

What are the key histopathological findings in acute tubular necrosis?

Tubular epithelial cell necrosis with cell detachment, cast formation, and tubular lumen obstruction.

What are some common nephrotoxic agents?

Cisplatin, aminoglycosides, NSAIDs, and heavy metals.

What findings would you expect in the urine sediment of prerenal acute kidney injury?

Unremarkable (bland) urine sediment.

What signifies acute kidney injury from nephrotoxins?

Increased serum creatinine and lower urine output.

How is hyponatremia managed in hypervolemic patients?

Address underlying cause (HF, cirrhosis), fluid restriction (< 1.25 L/day), use of diuretics (loop diuretics).

What is the significance of a urine spot albumin to creatinine ratio?

It helps in the diagnosis of diabetic kidney disease and nephropathy.

What is a hallmark of the natural history of diabetic nephropathy?

Progressive decline in GFR and increasing albuminuria.

What is the role of acetazolamide in high-altitude illness?

It accelerates HCO3 excretion to improve pulmonary ventilation.

What is the primary treatment for glomerular diseases with low complement levels?

Supportive care, including RAAS blockade.

In membranous nephropathy, what is the most common primary etiology?

PLA2R autoantibodies.

What secondary factors can contribute to membranous nephropathy?

Infections, malignancy, autoimmune disease, and medications like NSAIDs.

What are Kimmelstiel-Wilson lesions associated with?

Overt diabetic nephropathy.

What is a typical management strategy for patients with ESRD?

Control of blood pressure, blood sugar, and consideration of dialysis.

What symptoms indicate the need for urgent urology consultation in ureteral stones?

Intractable pain, nausea, vomiting, or complete obstruction.

What are common signs of hematuria?

Dark red or brown urine, potentially with clots.

What is a key difference between glomerular and nonglomerular hematuria?

Glomerular hematuria features RBC casts and dysmorphic RBCs.

What is often the first step in evaluating unexplained hematuria?

Urinalysis to assess for RBCs and other abnormalities.

What role does the fractional excretion of sodium play?

Helps differentiate prerenal from intrinsic renal causes of acute kidney injury. FeNa < 1% = prerenal AKI

What is the significance of proteinuria in glomerular disease?

Typically ≥1+ (>500 mg/day), indicating glomerular involvement.

What are the next steps if initial therapeutic interventions for kidney stones fail?

Outpatient urology consultation for stones >10 mm or if no stone passage occurs in 4-6 weeks.

What are symptoms of renal papillary necrosis?

Hematuria and possibly flank pain.

What conditions are associated with renal papillary necrosis?

Sickle cell disease, acute pyelonephritis, NSAID use, and diabetes mellitus.

What indicates an infection-related glomerulonephritis?

Positive ASO antibodies, especially after streptococcal infection.

What is a critical indication for hospitalization in patients with ureteral stones?

Complete obstruction or acute kidney injury.

How is chronic kidney disease often characterized?

Declining GFR and progressive loss of kidney function over time.

What diagnostic imaging is useful in assessing kidney stones?

CT scan of the abdomen.

What laboratory tests are indicated in glomerular disease evaluation?

Serum complement levels, renal ultrasound, and urine albumin-to-creatinine ratio.

What do muddy brown casts in urine suggest?

Acute tubular necrosis.

What is the recommended target for blood pressure management in diabetic patients?

Target blood pressure <130/80 mm Hg.

What therapy is preferred in diabetic nephropathy for controlling hypertension?

ACE inhibitors or angiotensin II receptor blockers.

What defines overt diabetic nephropathy?

Severe proteinuria and reduced glomerular filtration rate (GFR).

What mechanisms underlie diabetic kidney disease progression?

Hyperfiltration, hypertension, and glomerulosclerosis.

How should blood pressure be managed in end-stage renal disease patients?

Control with medications, diet, and physical activity.

What is indicated if a patient presents with symptomatic polyuria and hematuria?

A thorough evaluation for underlying causes like kidney stones or urinary tract infection.

What are common complications of diabetic nephropathy?

Increased cardiovascular risk and progression to end-stage renal disease.

What is the management goal for patients with symptomatic ureteral stones?

Effectively control pain and manage urinary blockage.

What is the clinical feature of acute kidney injury due to ischemia?

Decreased urine output.

How is urinary tract infection assessed in children presenting with hematuria?

Urine culture and symptom evaluation.

What does acute kidney injury due to nephrotoxicity commonly present with?

Elevated creatinine levels and specific urine sediment changes.

What condition can dysmorphic RBCs indicate in urinalysis?

Glomerular disease.

When do we give patients hypertonic 3% saline if they are hyponatremic?

Consider treatment when symptomatic or if sodium <120 mEq/L.

What role does urinalysis play in diagnosing kidney disorders?

Helps identify abnormalities in blood, protein, and specific cells.

What are the risks associated with untreated membranous nephropathy?

Nephrotic syndrome and thromboembolic events.

What are the potential outcomes of severe diabetic nephropathy?

Progression to end-stage renal disease and increased cardiovascular events.

How is glomerular hematuria differentiated from nonglomerular hematuria?

Through the presence of RBC casts and dysmorphic RBCs.

What key tests facilitate the diagnosis of diabetic nephropathy?

Serum creatinine, urine albumin-to-creatinine ratio, and urinalysis.

What is the significance of albuminuria in diabetic patients?

It is indicative of renal impairment and a risk factor for cardiovascular disease.

What is the essential goal of managing hypervolemic hyponatremia?

Minimizing hypotension to decrease ADH and water reabsorption.

What is the mnemonic for causes of ATN?

C3ANADA: Cisplatin, Contrast, Calcineurin inhibitors (ciclosporin, tacrolimus), Aminoglycosides (gentamicin), NSAIDs, Amphotericin B, Diuretics, Antivirals

What is the mnemonic for causes of AIN/TIN?

DRAINS: Diuretics, Rifampin, Allopurinol and Antibiotics (penicillin), PPIs, NSAIDs, Sulfa drugs

What is the mnemonic for causes of Renal Papillary Necrosis?

SAND: Sickle cell, Acute pyelonephritis, NSAIDs, DM

What is the diagnosis of microscopy showing diffuse glomerular basement membrane thickening, spikes on light microscopy, granular IgG and C3 on immunofluorescence, subepithelial deposits and podocyte effacement on electromicroscopy?

Membranous nephropathy (nephrotic syndrome)

What is the treatment for membranous nephropathy?

supportive care (RAAS blockers, loop diuretics), therapy for underlying cause

What are the ESRD-specific CV risk factors in ESRD patients?

anemia of CKD, vascular calcifications, oxidative stress related to uremia and dialysis

How does sickle cell trait affect the kidney?

Usually asymptomatic, but can lead to hematuria, renal papillary necrosis, and hyposthenuria due to microinfarctions and impaired concentrating ability.

Screening guidelines for diabetic kidney disease? When do we screen and what do we screen with?

Screen at time of dx for type 2 DM. Screen 5 years after dx for type 1 DM. Screening with: serum Cr, urine microalbumin-to-creatinine ratio (if > 300 mcg, bad), OR 24-hour urine protein, urine microscopy

Lupus nephritis - what are the antibodies to order? And what type of kidney syndrome? And what level of complement?

ANA, anti-dsDNA antibodies. Glomerulonephritis/Nephritic Syndrome (Immune Complex Mediated). Complement levels will be low.

MPGN - what are the antibodies to order? And what type of kidney syndrome? And what level of complement?

Cryoglobulins, anti-HCV. Glomerulonephritis/Nephritic Syndrome (Immune Complex Mediated). Complement levels will be low.

PSGN - what are the antibodies to order? And what type of kidney syndrome? And what level of complement?

ASO antibodies. Glomerulonephritis/Nephritic Syndrome (Immune Complex Mediated). Complement levels will be low.

Staph-associated GN - what are the antibodies to order? And what type of kidney syndrome? And what level of complement?

+tissue/blood culture. Glomerulonephritis/Nephritic Syndrome (Immune Complex Mediated). Complement levels will be low.

Endocarditis-associated GN - what are the antibodies to order? And what type of kidney syndrome? And what level of complement?

+blood culture. Glomerulonephritis/Nephritic Syndrome (Immune Complex Mediated). Complement levels will be low.

Goodpasture disease - what are the antibodies to order? And what type of kidney syndrome? And what level of complement?

Anti-GBM antibodies. Glomerulonephritis/Nephritic Syndrome (Autoimmune, Antibody Mediated). Complement levels will be normal.

Pauci-immune GN (GPA, MPA, EGPA) - what are the antibodies to order? And what type of kidney syndrome? And what level of complement?

ANCA antibodies. Glomerulonephritis/Nephritic Syndrome (Vasculitis, Antibody Mediated). Complement levels will be normal.

GPA - what are the antibodies to order? And what type of kidney syndrome? And what level of complement?

ANCA antibodies. Glomerulonephritis/Nephritic Syndrome (Vasculitis, Antibody Mediated). Complement levels will be normal.

MPA - what are the antibodies to order? And what type of kidney syndrome? And what level of complement?

ANCA antibodies. Glomerulonephritis/Nephritic Syndrome (Vasculitis, Antibody Mediated). Complement levels will be normal.

EGPA - what are the antibodies to order? And what type of kidney syndrome? And what level of complement?

ANCA antibodies. Glomerulonephritis/Nephritic Syndrome (Vasculitis, Antibody Mediated). Complement levels will be normal.

What is the screening recommendation for abdominal aortic aneurysm?

1-time screening with abdominal U/S in men aged 65-75 yo who have ever smoked.

What is the screening recommendation for anxiety disorders in adults?

For patients 64 yo and younger, screen for anxiety using GAD-7.

What is the screening recommendation for breast cancer?

Screening mammography every 1-2 years for women aged 40-74 years.

What is the screening recommendation for cervical cancer?

Pap test/cervical cytology every 3 years from ages 21-29 yo. For women 30-65 yo, screen every 3 years with Pap test/cervical cytology alone, every 5 years with high-risk HPV testing alone, or every 5 years with hrHPV testing in combination with cytology (co-testing).

What is the screening recommendation for STI screening?

Screen for chlamydia, gonorrhea, and syphilis in sexually active women under 25 years and in higher-risk populations.

What is the screening recommendation for colorectal cancer?

Screening with fecal occult blood testing, sigmoidoscopy, or colonoscopy starting at age 45 and continuing until age 75. Colonoscopy is every 10 years.

If IBD, 8 years after diagnosis if earlier than 37 yo at time of diagnosis.

If first-degree relative, 10 years before they got diagnosed OR at 40, whichever comes first.

What is the screening recommendation for depression and suicide?

Screen for depression in adolescents and adults using standardized instruments in primary care settings. Assess suicide risk in patients with depressive symptoms.

What is the screening recommendation for Hepatitis B virus?

Screen high-risk populations (liver disease) and pregnant women for Hepatitis B virus. Routine screening is recommended for individuals born in areas where Hepatitis B is endemic.

What is the screening recommendation for Hepatitis C virus?

Screen once in lifetime from age 18-79 years old.

What is the screening recommendation for HIV?

Screen once in lifetime from age 15-65 years old. Also all pregnant women.

What is the screening recommendation for lung cancer?

Annual low dose CT for adults aged 50-80 years old who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years.

What is the screening recommendation for osteoporosis?

Screen women with DEXA scan aged 65 and older and younger women with 1 or more risk factors for osteoporosis.

What is the screening recommendation for prediabetes and type 2 diabetes?

Screen adults aged 35-70 years who are overweight or obese, and screen those with risk factors, such as a family history of diabetes.

What is the recommendation for statin use?

Prescribe statins for adults aged 40-75 years with a 10-year cardiovascular disease risk of 10% or higher, and for those with a history of cardiovascular disease.

1. History of CAD.

2. LDL > 190.

3. 40-75 years old with DM.

4. 40-75 with 10-year CV of 10%+.

What is the screening recommendation for falls prevention?

Screen for fall risk in older adults > 65 yo and implement exercise or physical therapy interventions as needed.

What are common symptoms of anterior uveitis?

Ocular pain, photophobia, decreased acuity.

What is a common examination finding in anterior uveitis?

Ciliary flush, pupillary constriction, hypopyon.