nephrology 2,09

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  • 1.Pete A. Gutierrez MD, MMS, PA-C Miami Dade College Physician Assistant ProgramMarch 2009

2. Nephrology

  • Urine Analysis:
    • Dip stick testing:
      • Problems:
        • Urine Ph may change with time
        • Contamination may cause bacteria to multiply and convert nitrate to nitrite causing a false positive.
        • At low specific gravity (Less than 1.010), cells lyse and casts from less readily.
        • Cast also dissolve in alkaline Urine.

3. Nephrology

  • Midstream Urine Collection
    • Contamination more common in women than in men.
    • Suprapubic aspiration is the more secure method of getting an Uncontaminated Urine
    • Hematuria
      • Flank
      • Microscopic

4. Nephrology

  • 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.
  • Physiologic CastsHyaline are transparent and cylindrical and are seen in urine of normal subjects.
  • Both can be increased by fever, exercise and volume depletion

5. Nephrology

  • Pathologic casts: this may contain cellular material (erythrocytes, leukocytes, tubular cells, bacteria, or fungi) , fibrin, lipids, bile, and crystals.
  • The most important is the erythrocytes, because it indicates glomerular bleeding.
  • Those composed of polymorphonuclear leukocytes usually indicate renal parenchyma infection.

6. Nephrology

  • Leukocytes in the urine means infection
  • Renal tubular cells are found in the urine in acute tubular necrosis and acute interstitial nephritis
  • 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.

7. Nephrology

  • IGA nephropathy:
    • The most common form of primary glomerular disease in the world.
    • It is particular prevalent in Asia, and Australia, and rare in African Americans.
    • It originally thought to be benign.
    • Now understood it will progress to renal failure in 20 to 40% of patients affected.

8. Nephrology

  • Primary gross hematuria,
  • No therapeutic regimen has been shown to clearly affect the outcome in IgA disease.
  • However warfarin and dipyridamole with or without cyclophosphamide have been suggested as worthy of further investigation
  • Also omega 3 fatty acids, ACE, and long term steroids are also on trial.

9. Nephrology

  • Membranous nephropathy:
    • Two thirds of patients with this disorder either have a spontaneous remission or have stable or very slow progressive renal insufficiency.
    • Those with heavy proteinuria greater than 10 gram per day, hypertension, diminished GFR, male gender, dont do well.

10. Nephrology

  • Bacteria:
    • Gram Negative
      • E-Coli
      • Klesbsiella Pneumoniae
      • Proteus
      • Enterobacter
      • Pseudomonas

11. Nephrology

  • Gram Positive
    • Staphylococcus saprophyticus
    • Staphylococcus aureus
    • Staphylococcus not aureus
    • Enterococci
    • Other bacteria mixed
    • Yeast

12. Nephrology

  • Symptomatic UTIs:
    • Obstruction to urine flow.
      • Congenital anomalies
      • Renal Calculi
      • Ureteral occlusion (partial or total).
      • Vesicoureteral reflux
      • Residual urine in bladder
      • Neurogenic bladder
      • Urethral stricture
      • Prostatic hypertrophy

13. Nephrology

  • Instrumentation of urinary tract;
  • Indwelling urinary catheter
  • Catheterization
  • Urethral dilation
  • cystoscopy

14. Nephrology

  • Acute Urethral syndrome:
    • Vaginitis approximately 20% of women in the United States have an episode of dysuria each year.(Candida is the most common cause).
    • Urethritis most commonly cause by Chlamydia trachomatis
    • Prostatitis The most common addiction in men causes dysuria and urinary frequency. (E. Coli).

15. Nephrology

  • Pregnancy and the increases risk of UTI:
    • 20-40% of which develop pyelonephritis.
    • Either short acting sulfonamides or amoxicillin for 7 days usually suffices.
    • Avoid Tetracycline, trimethropin and fluoroquinolones.

16. Nephrology

  • Hypertensive disorders of pregnancy:
    • 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.
    • Patient will go into convulsions and diet condition called eclampsia.

17. Nephrology

  • Kidney function and morphology in preeclampsia:
    • Both GFR and RPF decrease in preeclampsia.
    • Uric acid increases in blood.
    • Increased proteinuria.
    • Calcium develop hypocalciuria
    • Lesion at the glomerular capillary endotheliosis.

18. Nephrology

  • Management of preeclampsia:
    • Hospitalization rest and if signs of impeding eclampsia(hyperreflexia, headache, epigastric pain) develop termination of pregnancy should be considered.
    • The drug of choice for impeding convulsion is parenteral magnesium sulfate.

19. Nephrology

  • Regulation of blood pressure:
    • Hydralazine administered intravenously is the drug of choice. (5mg as a bolus follow by 5-10mg every 20-30 minutes.
    • Labetalol intravenously 20mg and repeat the dose every 20 minutes, up to 200 mg.
    • Refrain from using nitroprusside.

20. Nephrology

  • Use of Radiologic Techniques:
    • KUB
    • Intravenous pyelography (IVP) Stone, obstruction.(allergic reactions).
    • Cystography(Bladder).
    • Ultrasound
    • Ct evaluation of renal disease
    • MRI

21. Nephrology

  • Renal angiography provides definitive diagnosis of renal arterial pathology

22. Nephrology

  • Algorithm for treatment of hypertension:
    • First line of therapy should be diuretic (thiazide).
    • In patients with type I diabetes and proteinuria (Diabetic nephropathy) the treatment is with an ACE inhibitor.
    • In patients with heart failure (Systolic dysfunction), ACE inhibitor or diuretic is indicated
    • Beta blockers or Ca Channels blocker can them be use.

23. Nephrology

  • Causes of resistant Hypertension:
    • White coat
    • Pseudohypertension in elderly persons
    • Use of improper size blood pressure cuff.
    • Patient non compliant
    • Failure due to cost, side effects, or ignorance
    • Dietary noncompliance
    • Excess salts.

24. Nephrology

  • Causes of resistant Hypertension:
    • Excess ethanol intake
    • Volume overload