Renal CA

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Bowman's capsule

Bowman's capsule: renal structure consisting of glomeruli and extended opening of proximal tubule

Creatinine

Creatinine: spontaneous breakdown product of muscle creatine. normal cr cannot rule out kidney disease. Use GFR or can do 24hr urine to do cr clearance. the GFR can be low despite a normal CR.

creatinine clearance

Creatinine clearance: an estimate of GFR obtained by measurement of serum creatinine and urine creatinine excretion rate

GFR

Glomerular filtration rate (GFR): the rate in ml/min that substances (e.g., creatinine) are filtered through the glomeruli; reflects number of functioning nephrons

Glomerulus

Glomerulus: a tuft of blood vessels found in the renal nephron that are involved in the blood filtration

Nephron

Nephron: the anatomical and functional unit of the kidney, consisting of the renal corpuscle, proximal convoluted tubule, descending and ascending limbs of Henle's loop, distal convoluted tubule, and collecting tubule

Renal Threshold

Renal threshold: the plasma concentration of a substance above which it will be excreted into the urine

Tamm-Horsfall Protein

Tamm-Horsfall protein: a mucoprotein produced by the ascending limb of the loop of Henle that is a normal constituent of urine and is the major protein constituent of urinary casts

UREA

Urea: major nitrogen containing product of protein metabolism

Albuminuria

Albuminuria: the presence of albumin in urine

Anuria

Anuria : lack of urine output (< 50 mL per day)

CASTS

Casts : protein aggregates, outlined in the shape of renal tubules and excreted into the urine; the matrix is the Tamm-Horsfall protein

Hematuria

Hematuria: blood in the urine

ISOSTHENURIA

Isosthenuria: urine with a fixed specific gravity in range of 1.008 to 1.012

Microalbuminuria

Microalbuminuria: low-grade, dipstick-negative increase in urine albumin excretion, useful in monitoring renal status of individuals prone to renal impairment from diseases (e.g., hypertension, diabetes)

Oliguria

Oliguria: decreased urine output (< 400 mL per day)

Pyuria

Pyuria: the presence of pus (an inflammation fluid with leukocytes and dead cells) in the urine

Azotemia

Azotemia: an excess of urea, creatinine and other nitrogenous end products of amino acid metabolism in blood

Glomerulonephritis

Glomerulonephritis: nephritis accompanied by inflammation of the capillary loops in the glomeruli of the kidney; occurs in acute, subacute, and chronic forms and may be secondary to hemolytic streptococcal infection; evidence suggesting possible immune or autoimmune mechanisms

Hemodialysis

Hemodialysis: the exogenous removal of certain elements from the blood by virtue of the difference in the rates of their diffusion through a semipermeable membrane (for example, by means of a hemodialysis filter)

Nephritis

Nephritis: inflammation of the kidney with focal or diffuse proliferation or destructive processes that may involve the glomerulus, tubule, or interstitial renal tissue

Nephrotic syndrome

Nephrotic syndrome: general name for a group of diseases involving increased glomerular permeability, characterized by massive proteinuria and lipiduria with varying degrees of edema, hypoalbuminemia, and hyperlipidemia

Peritoneal dialysis:

Peritoneal dialysis: hemodialysis through the peritoneum, the dialyzing solution being introduced into and removed from the peritoneal cavity as either a continuous or an intermittent procedure

Uremia

Uremia: an excess in serum urea, creatinine, and other nitrogenous end products of protein and amino acid metabolism; more correctly referred to as azotemia

UA

Good screening tool.
Comprised of: Macroscopic examination, dipstick, microscopic evaluation, and specialty testing.
Collection technique is important - clean catch preferable but not always necessary (e.g., necessary for UTI but not for protein screen)
Should be tested within 2 hours of collection
- Microscopic is really important, frequently send urine out. Get a lot of info from a non invasive sample. 2hr after to collection needs to be tested, up to 4hrs if refridgerated

-collection:
•First select and label collection container
-Write 2 patient identifiers on container prior to collection
-Best to use sterile container with lid but not always necessary
•First morning collection (i.e., most concentrated) preferred, particularly for protein and SG
-However, random collection suitable for most tests
•Best sample is clean-catch, midstream sample
-Exernal genitalia wiped with antiseptic pad
-First portion of voided urine in toilet, next portion collected in sterile container, remainder voided in toilet
•Urine best tested within one hours of collection but maximum limit of two hours usually acceptable
-If refrigerated, may be tested within four hours
-Elements (e.g., casts, RBCs, WBCs, Bilirubin) quickly deteriorate at room temperature
-Bacteria may overgrow - bacteria may metabolize glucose present in urine - bacteria may interact with urine urea resulting in amonia formation and elevated pH
- 1st morning is best espc for protein, not always possible though.

Macroscopic UA

Macroscopic:
- •Color: Normal = light yellow to amber
•Abnormal colors include red, beer-brown, black, orange and blue-green.
-Red urine: Often seen with gross hematuria, porphyrins, pyridium, food colorings, beets
-Yellow-brown urine: Often seen when bilirubin present
-Brown-Black urine: Melanin, methyldopa
-Bright Orange: Rifampin
-Blue or Green urine: Often related to ingested dyes or some medications
-Amber/orange = bilirubin, urobilinogen
•Clarity (Turbidity)
-Normal = clear
-Abnormal = Hazy, Cloudy
•Artifact or cellular elements
- 1)Color on top and turbidity on the bottom.
-porphyrins- put it in the sun and it changes the color, or turns brown after a while.
-not clear=CELLS

UA Dipstick

UA dipstick:
•Wear Gloves
•Invert sample several times to mix the urine
•Insert reagent strip into container, completely, but only briefly, immersing all reagent areas.
•Remove excess urine by tapping edge of strip against side of urine container and drawing strip across top of container. May also blot strep edge against paper towel.
•Hold test strip horizontally (holding vertically allows colors to bleed from one test pad to another) and close to color chart on bottle label: Compare test areas on strip with corresponding color charts on the bottle label at the manufacturer specified times
•Record the results according to facility protocol
Don't forget about quality control. Reagent strips need to be tested with manufacturer supplied quality control solutions to assure appropriate reagent strip reactivity. Ideally, test controls to be performed daily, but, at a minimum, must be completed every time new bottle is opened
- Invert to mix sample 1st, get all pads wet with urine, hold strip horizontally so they don't bleed. (dip sticks are air sensitive, keep them closed, quality control.)
- 1.Mix: Invert sample
2.Insert reagent strip
3.Remove excess urine
4.Hold test strip horizontally
5.Record the results

-•Don't forget about quality control
- Semiquantitative Tests
•Protein
•pH
•Specific Gravity
•Bilirubin
•Urobilinogen
•Blood
•Leukocyte Esterase
•Nitrite
•Glucose
•Ketones

Protein-UA

- •Protein: Usually in form of albumin or globulins.
-Small amounts (i.e., microalbumin) in DM and HTN may be first signal of Chronic Kidney Disease (CKD)
-Globulins (Bence-Jones) associated with multiple myeloma
Large amounts in nephrotic syndrome and advanced kidney dise
- Urine dipstick, neg urine protein doesn't rule out small amounts. If you get a positive then it moderate to severe disease already. Send diabetics to the lab.
Trace amounts of larger proteins will show up but smaller molecules like albumin won't

PH UA

- •pH: Normal 5-9, usually around 6. Acidotic or alkalotic can be due to diet, medication, disease or metabolic changes. Some bacteria incr. pH
•Specific Gravity: Normal 1.010-1.025. Weight of particles in solution, correlates with osmolality.

Bilirubin UA

- •Bilirubin: Increased in obstructive biliary disease, hepatocellular injury. Not increased in hemolytic jaundice.
•Urobilinogen: Formed by bacterial conversion of conjugated bilirubin in intestine. Increased in hepatocellular injury and jaundice, not obstructive biliary disease. Also increased in CHF with liver congestion, cirrhosis, hepatitis.

Blood UA

- •Blood: Detects blood & hemoglobin.
•Can cross react with myoglobin.
•Increased in hemolysis, GU tract cancer, UTI, calculi, coagulopathies, glomerulonephritis.
- Quant analysis and to validate that there is in fact blood in the sample.

Ct for pts

- Ct for pts. with kidney stones, not IVP anymore. Miss a lot of stones with IVP. Order "CT of abdomen, stone protocol." include your suspicion and what they present w/ on the order form for imaging studies, lets the radiologist do other studies to figure out what is going on.

Glucose/ketones UA

Glucose: Present if serum glucose is > 180 mg/dL. Increased in DM.
•Ketones: Screening for ketoacidosis in diabetics. Increased in starvation, fever, pregnancy.

Leukocyte Esterase

•Leukocyte Esterase: Enzyme released by WBCs. Marker of infection or inflammation

Nitrate

Nitrite: Urine nitrates are converted to nitrite by some bacteria (E. coli, Klebsiella, Proteus, etc.).
-- Positive leuk and positive bacteria be suspicious of bacteria infection, be sure to treat to prevent pylo

UA Microscopic

UA MICROSCOPIC:
- •Urine is spun in a centrifuge, liquid is decanted and cellular elements are examined under a microscope.
•Some elements are reported in LPF (low power field), some in HPF (high power field).
•Detects cellular elements
-WBC
-RBC
-Bacteria
-Epithelial cells
-Casts, crystals

- The lab techs will look at all this stuff under the scope, pretty quick.
- •Theoretically, no cells should be found, but some cells are normal in small amounts.
•RBC: 0-3/HPF. Normal after exertion, trauma, fever. Persistent RBC's should be investigated. Seen in: UTI, glomerulonephritis, necrosis, tumors, stones, coagulopathies.
- •WBC: 0-2/HPF. UTI or inflammation.
•Squamous epithelial cells: usually means skin contamination.
•Renal tubular epis: 0-1/LPF. Acute tubular necrosis, nephrotic syndrome.
•Bacteria: Urine usually sterile. May contain rare bacteria depending on collection method, incr. in UTI

UA Microscopy Crystals

UA MICROSCOPY CRYSTALS:
- •Certain crystals are only seen in acidic or basic urine.
•Crystals can be normal, abnormal, or can mean a predisposition to form certain stones.
•Normal: calcium oxalate, triple phosphate, amorphous phosphates (basic), amorphous urates (acidic).
•Abnormal Crystals:
-Cystine: neonates with congenital cystinuria or severe liver disease.
-Tyrosine: congenital tyrosinosis or marked liver impairment
-Leucine crystals: severe liver disease or with maple syrup urine disease.

GFR DF: & equation info

-A similar relationship exists between BUN and GFR
-As urea is primarily excreted via glomerular filtration, changes in the GFR can change plasma urea levels.
-However, this, too, is not linear - the GFR must be significantly reduced to result in an increase BUN as urea excretion not determined solely by glomerular filtration (Up to 50% of filtered urea is normally reabsorbed from the tubules, passively following water and sodium).
-BUN alone is not a reliable indicator of changes in the GFR
-Urea production not always constant (formed by hepatic metabolism of amino acids - BUN increases with increased hepatic metabolism of amino acids) Can occur with dietary changes (e.g., increased protein intake), greater tissue breakdown (e.g., trauma), and medication use leading to decreased protein synthesis (e.g., tetracyclines).
-GFR THE BEST OVERALL index of kidney FX!!!!!!!!!!!!!!!!!!
-estimating equations for the GFR incorporate association w/ age, sex, race, and body size as surrogates fro creatinine generation.
-Estimating equations: 4 variable original MDRD Study equation
-"re-expressed" MDRD Study equation for standardized serum CR
- COCKROFT-GAULT equation
-CKD-EPI ( chronic kidney disease epidemiology collaberation ; MDRD = modification of diet in renal disease
-GFR equation calculators are available
-many labs regularly report eGFR when CR is ordered
- Calculate eGFR in order to determine CKD stage and appropriate clinical action plan.
- Most labs will provide the GFR, we won't be asked to calculate the values on a test. ******GFR is the best overall index of kidney function

UA Culture

UA CULTURE:
- •Semi-quantitative
•>100,000 colonies/ml indicative of infection
•>10,000 colonies/ml in symptomatic,immunosuppressed or abx treated patients
•Lower numbers if suprapubic (>150)
- Cultures are good to determine the susceptibility. Best antibots to tx pt

Casts, Urinalysis Casts

URINALYSIS CASTS:
- Urine casts represent molds (i.e., casts) of the renal tubule from which they arise. They are generally cylindrical, cigar-shaped entities found on urine sediment examination.
-- Casts help you determine the type of renal failure. Collections of cells that clumped together in the distal tubule. Take the shape of where they collected. Casts can take different shape. Different types of casts some are begin and some are very suspicious, depends on the type.
- Urine casts represent molds of the renal tubule from which they arise. They are generally cylindrical, cigar-shaped entities found on urine sediment examination.

Casts, Hyaline

Hyaline casts: Consist only of Tamm-Horsfall protein. Small amount normal - likely due to relatively concentrated urine at time of collection, numerous hyaline casts associated with all renal diseases, essential hypertension, and nephrotic syndrome.

casts, WBC-

White blood cell casts: Formed when WBC's incorporated within protein matrix - enter the urine stream by ameboid movement through and between tubular epithelial cells and sometimes across the glomerular capillary lumen; associated with diseases with leukocytic exudation and interstitial inflammation (e.g., pyelonephritis.

- Red cell casts: Formed from RBC's packed in fibrin meshwork within cast matrix occurring as a result from severe injury to the glomerular basement membrane; associated with acute glomerulonephritis (most common), lupus nephritis, Goodpasture's syndrome, and subacute bacterial endocarditis.
Renal epithelial casts: Result from constant desquamation and renewal of the renal epithelium - pathological process resulting in damage to the tubular portion of the nephron (tubular damage); associated with nephrotoxic agents and exposure to some viruses.

- Granular casts: Formed from breakdown products of cellular casts and immunoglobulins - include coarsely granular and finely granular casts. Deeply pigmented (i.e., muddy brown) granular cast are characteristic for acute tubular necrosis!

Waxy casts: Result of progressive degenerative changes in cellular casts; associated with severe chronic renal disease and amyloidosis.

Fatty casts: Commonly attributed to leakage of lipoproteins through glomerular filter; associated with nephrotic syndrome, diabetes mellitus, and damaged renal tubular epithelial cells.
- *know what deeply pigmented/muddy brown granular casts are characteristic of!!!!!!!!!!!!!= ACUTE TUBULAR NECROSIS!!!

Oval Fat Bodies and Fatty Casts:
- Transitional Epithelial Cells

B: Oval Fat Body (note lipid drops within body)
- Oval Fat Bodies and Fatty Casts: Renal tubular cell or cast containing fat globules suggestive of nephrotic syndrome. Under polarized light fat bodies reveal "maltese cross" appearance. Lipid deposits can appear as isolated fat deposits, oval fat bodies, and fatty casts, and can be seen together on same urine sample.
- Oval fat bodies hovering around the urine sample along with the fatty cast and fat droplets as well, often see all 3. the fat in the cells tells us elevated lipids

Casts, RBC

Red cell casts: Formed from RBC's packed in fibrin meshwork within cast matrix occurring as a result from severe injury to the glomerular basement membrane; associated with acute glomerulonephritis (most common), lupus nephritis, Goodpasture's syndrome, and subacute bacterial endocarditis.

Casts, Renal epithelial casts

Renal epithelial casts: Result from constant desquamation and renewal of the renal epithelium - pathological process resulting in damage to the tubular portion of the nephron (tubular damage); associated with nephrotoxic agents and exposure to some viruses.

Casts, Granular

- Granular casts: Formed from breakdown products of cellular casts and immunoglobulins - include coarsely granular and finely granular casts. Deeply pigmented (i.e., muddy brown) granular cast are characteristic for acute tubular necrosis!

Casts, waxy

Waxy casts: Result of progressive degenerative changes in cellular casts; associated with severe chronic renal disease and amyloidosis.

Casts, Fatty

Fatty casts: Commonly attributed to leakage of lipoproteins through glomerular filter; associated with nephrotic syndrome, diabetes mellitus, and damaged renal tubular epithelial cells.
- *know what deeply pigmented/muddy brown granular casts are characteristic of!!!!!!!!!!!!!= ACUTE TUBULAR NECROSIS!!!

casts, fatty/oval bodies

Oval Fat Bodies and Fatty Casts:
- Transitional Epithelial Cells

B: Oval Fat Body (note lipid drops within body)
- Oval Fat Bodies and Fatty Casts: Renal tubular cell or cast containing fat globules suggestive of nephrotic syndrome. Under polarized light fat bodies reveal "maltese cross" appearance. Lipid deposits can appear as isolated fat deposits, oval fat bodies, and fatty casts, and can be seen together on same urine sample.
- Oval fat bodies hovering around the urine sample along with the fatty cast and fat droplets as well, often see all 3. the fat in the cells tells us elevated lipids

UA Special Tests

UA SPECIAL TESTS:
•Microalbuminuria represents a small increase in urinary excretion of albumin that is too small to be detected on conventional urinalysis protein assay.

•As kidney damage progresses, the amount of urinary albumin increases

•Urine microalbumin is used as screening tool to assess risk of diabetic nephropathy and/or hypertensive nephropathy

•Most frequently, an albumin to creatinine ratio (ACR)is used for assessement and staging of renal disease
- Only order for pts that you're suspicious renal disease, microalbuminuria. Like diabetic pts. and severe HTN pts. ACR- helpful for staging of renal disease. Helps to estimate the GFR, you can find disease at an earlier stage with this test.

24HR-Urine

24 HOUR URINE:
•Indications for a 24-Hour Urine Test
-Determination of creatinine clearance
-Quantification of proteinuria in renal disease

-Stone analysis after recurrence of nephrolithiasis (generally not performed for first episode)
-Hormonal diseases and tumors of the adrenal glands
-Quantification of proteinuria in chronic renal diseases
•24 hour urine for Creatinine Clearance and Protein
-Both urine and serum creatinine checked
-Good indication of GFR.
-Creatine Clearance = Ucr x Total Volume/Scr (Can be corrected for BSA)
- GFR- assessment. Often you get an incomplete sample from the lab. Very high error rate. Now we assess the GFR with the ACR.
-don't use this for GFR anymore b/c of error rate, even though its says it on the slide.

renal labs: Importance

IMPORTANCE OF RENAL LABS:
•Renal impairment most commonly identified first by laboratory tests: Most patients, even with significant renal disease, will not have symptoms until &gt; 50-75% of renal failure.

•Even slight renal impairment signals need to better treat/control underlying medical conditions (e.g., diabetes, hyperlipidemia, hypertension).

•Many drugs cleared by kidneys and, therefore, level of renal function necessary to determine proper dosage and risk of toxicity.
- Kidneys do a lot of ****, break down drugs clean out blood, blah blah. No kidneys then toxicity.

BUN TEST

BUN TEST:
Blood Urea Nitrogen (BUN)
(also known as Serum Urea Nitrogen - SUN)

•Major nitrogen-containing metabolic product of protein catabolism

•Primarily synthesized by hepatocytes and filtered by glomeruli with 40-70% reabsorbed by passive diffusion across renal tubular epithelium, depending on urine flow

•If GFR significantly reduced, BUN increased

•Level greatly influenced by diet: Higher protein in diet = higher BUN

•Not as sensitive an indicator of renal function/dysfunction as creatinine (>50% renal function decrease necessary to elevate BUN)
- Kidneys aren't filtering well then you get an elevated BUN and creatinine. Not linear. For acute renal failure this is important but not in chronic kidney disease. The creatinine test is more sensitive for kidney disease than BUN test.

Creatinine / CR

Creatinine /CR:
•Derived from conversion of muscle creatine

•Patients with conditions resulting in decreased production my have reduced creatinine excretion and creatinine level (e.g. Amputees, Children, Elderly, Hepatic Disease, Muscular Dystrophy, Paraplegia/Qudraplegia, Poliomyelitis)

•Creatinine level in high normal range may signal significant renal dysfunction in patients expected to have low creatinine level

Creatinine level must be compared to previous labs to determine stability and significance - a creatinine level in moderate to high normal range may still signal significant kidney disease in all patients
- Can still have disease without pathologic levels. Be careful. Even if they're WNL doesn't let you know, want to compare even normal results with the pts. previous tests, look for jumps from old tests even if their results are still in normal range.

BUN: CREATININE RATIO

BUN:Creatinine RATIO: Interpretation :

BUN:Creatinine Ratio = >15:1 (Increased formation of Urea)

•High Protein Intake
•Catabolic States
-e.g., Fever, tissue necrosis, Corticosteroid Use, Tetracycline Use, Sepsis
•Decreased Elimination of Urea (increased BUN)
-Volume Loss (volume depletion increases concentration)
-Decreased Cardiac Output : C0 = amount of blood ejected by left ventricle/minute [calculated by Stroke Volume (i.e., amt ejected by LV /contraction) x Heart Rate
•e.g., via Arrythmias, Cardiogenic Shock, CHF, Pericarditis
Obstructive Uropathy (e.
- WNL BUN 10 creatinine 1- when that ration changes you look for conditions. I
- BUN:Creatinine Ratio = <15:1 (Decreased formation of Urea)

•Starvation
•Advanced Liver Disease
•Hereditary Deficiency of Urea-Cycle Enzymes
•Relative Increased urea removal (e.g., post dialysis)
•Increased creatinine formation (e.g., rhabdomylosis)
•Decreased excretion of creatinine
-Meds (Cimetidine, Trimethoprim, Pyrimethamine)
•Assay Interference
-Meds (Cefoxitin, Ascorbic Acid, Methyldopa, Barbituates, Flucytosine)

GFR

Glomerular Filtration Rate (GFR) :
- Rate of glomerular filtration (i.e., GFR) is major determinant in creatinine excretion and, therefore, renal function. The lower the GFR, the lower the creatinine excretion, and the higher the plasma creatinine.

Therefore, and generally speaking, there is an inverse relationship between GFR and plasma creatinine values such that:

↓GFR=↑Creatinine Level
↑GFR=↓Creatinine Level
-However, given variance in muscle mass and food intake (both affect creatinine) and normal variances in creatinine level the relationship between reduced GFR and creatinine level is not linear.
1 : Rise in serum creatinine from 1-2 mg/dl = 50% reduction in GFR
2 : Rise in serum creatinine from 4.7-6mg/dl = ≈5% reduction in GFR
- A similar relationship exists between BUN and GFR
-As urea is primarily excreted via glomerular filtration, changes in the GFR can change plasma urea levels.
-However, this, too, is not linear - the GFR must be significantly reduced to result in an increase BUN as urea excretion not determined solely by glomerular filtration (Up to 50% of filtered urea is normally reabsorbed from the tubules, passively following water and sodium).
-BUN alone is not a reliable indicator of changes in the GFR
-Urea production not always constant (formed by hepatic metabolism of amino acids - BUN increases with increased hepatic metabolism of amino acids) Can occur with dietary changes (e.g., increased protein intake), greater tissue breakdown (e.g., trauma), and medication use leading to decreased protein synthesis (e.g., tetracyclines).

alternative labs for CR clear/GFR- Cystatin C-radioisotope-

Alternative Laboratory Markers for Creatinine Clearance/GFR Determination:
•Cystatin C------
-Endogenous cysteine protease inhibitor that is freely filertered by the kidneys and unaffected by the renal tubules
-An alternative serum marker of GFR in CKD
-Not useful with ARF due to unstable association between creatinine production and renal excretion on basis of acutely changing renal function
-More variable than serum creatinine
-Can be affected by acute disease (e.g., malignancy, HIV)
•Radioisotope and short clearance studies using infused substances-------
-Inulin (used in many research studies)
-Iothalamate
•Alternative markers not very useful in primary care practice due to complexity and lack of value over eGFR in primary care settings
- Nephrologist will order these types of tests. These are special labs that you won't ever really use

AFR-Acute Renal Failure

ACUTE RENAL FAILURE:
-Creatinine: rise of 0.5mg/dL or 50% increase above baseline
-GFR: 50% decrease in baseline GFR
-Subjective: ROS, including systemic sx; PMH; Meds
-Objective: Vitals, Skin, Cardiac, Lung, GI, GU (including pelvic and/or rectal)
-Labs: BMP, UA with microscopic, FENa
-Imaging: Renal Ultrasound with Doppler (resistive indices)
- Diagnosis. These pts present with sx. Do pelvic and rectal exam to look for pelvic masses causing obstruction, then order metabolic panel, then renal ultrasound

ARF causes

CAUSE OF ACUTE:
1.Prerenal: decreased perfusion from shock, injury, illness
2.Intrarenal: Kidney damage via inflam., toxins, medications, infection, or reduced blood supply
3.Postrenal: Obstruction of urine flow secondary to prostatic inflammation/ enlargement, calculi, bladder tumor, injury.

FENa

FENa (Fractional Excretion of Sodium)
- FENa = (Urinary Na x Plasma Creatinine)/(Plasma Na x Urine Creatinine) x 100
-Calculated as part of initial evaluation of ARF
-Calculated to determine if hypovolemia or decreased effective circulating plasma volume contributing to renal failure: Reflects integrity of tubular reabsorptive function - low concentration represents intact reabsortive function
-Simple random urine collected for urinary sodium near same time as blood tests (creatinine and sodium)

ARF-Prerenal

ACUTE RENAL FAILURE:
•Prerenal
•BUN:Creatinine Ratio >20:1
•FENa <1 %
•Urine Specific Gravity >1.020
•Urine Osmolality >500 mOsm/kg
•Hyaline Casts
•No evidence of obstruction
•No evidence of intrarenal causes
-Prerenal -low NA

AFR-Intrarenal

•Intrarenal
•BUN:Creatinine Ratio 10:1 to 20:1
•FENa >1%
•Urine Specific Gravity 1.010 to 1.020
•Urine Osmolality 300-500 mOsm/kg
•Tubular or Granular Casts
•No evidence of obstruction
•US evidencing medical kidney disease
•(Consider Biopsy)

AFR- Postrenal

•Postrenal:
•Serum tests similar to Intrarenal
•Urine Tests similar to Intrarenal
•Ultrasound evidences hydronephrosis
•(CT without contrast if obstruction suspected but not clear on US - if bladder distended or pelvic/rectal mass appreciated on physical exam)
•(Consider Urology Consultation)
-Postrenal—think of obstructive process that are blocking the flow

AFR-Labs

Acute Renal Failure: Lab/Exam Findings :
•Decreased urine output
-Oliguria (<400 ml/24 hours)
-Anuria (absence of urine output)
-Most cases of ARF are non-oliguric
•Urine output correlates strongly with residual glomerular filtration and poorly with renal tubular function
-Oliguric ARF = more severe renal failure and increased mortality
•Electrolyte and Metabolic Abnormalities
-Hyperkalaemia, Hypocalcaemia, Hyperphosphataemia, Hypermagnesaemia
•Clinical Findings that are secondary to ARF
-e.g., fluid overload, altered mental status, nausea, anorexia, pericarditis

Kidney Disease-labs

KIDNEY DISEASE: Laboratory Evaluation
Diagnostic Test Results Associated Causes
Elevated Creatine Kinase and Myoglobin Rhabdomyolysis
Elevated Uric Acid Gouty Neprhopathy, Malignancy
Elevated Calcium Malignancy
Monocolonal Spike on Serum Protein Electrophoresis Multiple Myeloma
Hemoglobin SS on Hgb electrophoresis Sickle Cell nephropathy
Positive HIV Testing HIV Nephropathy
Elevated Antistreptolysin-O titer Poststreptococcal Glomerulonephritis
Evidence of Hemolysis (schistocytes on peripheral blood smear, decreased haptoglobin, elevated indirect bilirubin, elevated lactate dehydrogenase, thrombocytopenia) Hemolytic Uremic Syndrome, Thrombocytic Thrombocytopenic Purpura, SLE, other autoimmune diseases
Positive ANA Autoimmune Diseases
- - Do Ck b/c-...
ASO- make sure that its not from strep, also check psych pts with OCD
- Diagnostic Test Results Associated Causes
Low complement level SLE, endocarditis, postinfectious glomerulonephritis
Positive antibasement membrane antibody Good pasture's Syndrome
Positive cytoplasmic antineutrophil cytoplasmic antibody Wegener's Granulomatosis
Increased anion gap with increased osmolar gap Ethylene Glycol or Methanol Poisoning
Eosinophilia Allergic Interstitial Nephritis
Positive blood cultures and new cardiac murmur Endocarditis
Elevated Prostate-Specific Antigen Prostatic Hypertrophy, Prostate Cancer
Abdominal Calcifications on Plain-Film Radiograph Nephrolithisis, Ureterolithiasis
Mass or Calcifications on Abdominal or Pelvic CT and Hydronephrosis on Ultrasound Malignancy, Prostatic Hypertrophy, Uterine Fibroids, Nephrolithiasis, Ureterolithiasis

Kidney Disease: labs

KIDNEY DISEASE:
Laboratory Evaluation
- •All Patients
•CBC
•Serum BUN and Creatinine
•Estimation of GFR
•Serum Electrolytes
•FENa (for ARF)
•Urinalysis
•Gross, Dipstick, and Microscopic Analysis
•Urine Microalbumin for patient with predisposing risks (e.g., DM, HTN) whose urinalysis is negative for protein
•If UA positive for protein order Protein-to-Creatinine ratio
•If UA negative for protein but microalbumin positive order Microalbumin-to-Creatinine (or Albumin-to-Creatinine) ratio
•Renal Ultrasound with Doppler
- Basic Metabolic Panel (BMP; aka Chem 7) includes BUN, Creatinine, Sodium, Potassium, CO2, Chloride, and Glucose. Some labs now incorporate eGFR when BMP, CMP, or BUN & Creatinine ordered
-Standard Urine negative for protein & pt. at ↑risk
- Albumin -Specific Dipstick Test (i.e., microalbumin)
-Recheck at periodic health evaluation and consider diagnostic evaluation and intervention to maximize HTN and BG control to prevent worsening
- Urinary albumin can vary (on basis of exercise within last 24 hours, infection, fever, CHF, significant hyperglycemia, pregnancy, significant HTN, UTI, hematuria - all can increase urinary albumin level over baseline values). Dx of albuminuria best made after at least 2 specimen collected within 3-6 month period of time.
- If pt is already spilling protein, then you don't need to check microalbumin
If ACR is under 30, considered normal. Over 30 is serious, considered renal disease,

CASTS, UA abnls FAST chart

NOM-INFLAMMATORY GLOMERULAR DISEASE, NON-INFLAMMATORY TUBULOINTERSTITIAL DISEASE, OR DISEASES AFFECTING MEDIUM-SIZED ARTERIES: RBC-, RBC CASTS -, WBC -, WBC CASTS -, TUBULAR CASTS -, CELLULAR CASTS -, GRANULAR CASTS -, FAT * - , TOTAL PROTEIN TO CR RATIO 200-1,000 MG/G

MAY BE PRESENT IN ALL OTHER TYPES OF KIDNEY DISEASE, BUT MOST ABUNDANT IN ACUTE TUBULAR NECROSIS (THE MOAT COMMON KIDNEY DISEASE CAUSING KIDNEY FAILURE): TUBULAR CASTS +, GRANULAR CASTS +, CELLULAR CASTS.

DIABETIC KIDNEY DISEASE AND NON-INFLAMMATORY GLOMERULAR DISEASES: RBC-, RBC CASTS - FAT* +, >1,000 MG/G TOTAL PROTEIN TO CR RATIO.


PROLIFTERATIVE GLOMERULONEPHRITIS OR HEREDITARY NEPHRITIS: + RBC, +RBC CASTS*

HEREDITARY NEPHRITIS, or DISEASE of SMALL VESSELS (MICROANGIOPATHY): RBC +, RBC CASTS * -, TUBULAR Cells +, GRANULAR CASTS +

CYSTIC KIDNEY DISEASE, KIDNEY NEOPLASMS OR URINARY TRACT LESIONS OTHER THAN KIDNEY DISEASE: +/- RBC, RBC CASTS* -, TUBULAR CASTS -, GRANULAR CASTS -

AFR vs. CKD LABS

Acute vs. Chronic Kidney Disease: Laboratory Evaluation :
- Differentiating Between ARF and CKD
•Past records invaluable
-Increased creatinine and decreased GFR may be stable based on past values indicating CRF
-No records available, no hx suggestive of CRF - then assume acute and urgently treatable
•Renal imaging - small kidney size (<10 cm) suggests chronic renal disease (Normal kidney size does not rule-out CKD)
•Timing: ≥ 3 months consistent with CKD

CHRONIC KIDNEY DISEASE: Definition
•Two Independent Criteria for CKD
- •Kidney damage for ≥ 3 months as defined by structural or functional abnormalities of the kidney (with or without decreased GFR) evidenced by either:
•Pathologic abnormalities - or -
•Markers of renal damage including laboratory or imaging abnormalities
•GFR <60 mL/min/1.73 m2 for ≥3 months
- Chronic kidney disease, do ultrasound, they will often get smaller with the disease because they have deteriorating over time.

nephrOtic

NephrOtic Think O !!! for prOtein, rOund -edema , fat and rotund high lipids.

CKD-Pts likely to have
CKD?

patients is likely to have
CKD?a. A 55-year-old woman with a serum creatinine level
of 1.2 mg/dL
b. A 45-year-old man with bilateral below-the-knee
amputations and a serum creatinine level of
1.1 mg/dL
c. An 80-year-old woman with a serum creatinine level
of 1.0 mg/dL
d. A 70-year-old man with some muscle wasting who
weighs 65 kg and has a serum creatinine level of
1.1 mg/dL
e. All of the above

DX * tests & associated causes:

1. Elevated Uric Acid- Gouty Neprhopathy, Malignancy
2. Creatine Kinase and Myoglobin-Rhabdomyolosis
3. Elevated Calcium-Malignancy
4. Monocolonal Spike on Serum Protein Electrophoresis
-Multiple Myeloma
5. Hemoglobin SS on Hgb electrophoresis- Sickle Cell nephropathy
6. Positive HIV Testing- HIV Nephropathy
7. Elevated Antistreptolysin ~ O titer-Poststreptococcal Glomerulonephritis
8. Evidence of Hemolysis (schistocytes on peripheral blood smear, decreased haptoglobin, elevated indirect bilirubin, elevated lactate dehydrogenase, thrombocytopenia)- Hemolytic Uremic Syndrome, Thrombocytic Thrombocytopenic Purpura, SLE, other autoimmune diseases
9. Positive ANA- Autoimmune Diseases

(note---Do Ck b/c-...
ASO- make sure that its not from strep, also check psych pts with OCD)
10. Low complement level-SLE, endocarditis, postinfectious glomerulonephritis
11.Positive antibasement membrane antibody-Good pasture's Syndrome
12.Positive cytoplasmic antineutrophil cytoplasmic antibody-Wegener's Granulomatosis
13.Increased anion gap with increased osmolar gap-Ethylene Glycol or Methanol Poisoning
14.Eosinophilia- Allergic Interstitial Nephritis
15.Positive blood cultures and new cardiac murmur-Endocarditis
16.Elevated ProstateSpecific Antigen (PSA)- Prostatic Hypertrophy, Prostate Cancer
17.Abdominal Calcifications on Plain-Film Radiograph-Nephrolithisis, Ureterolithiasis
18.Mass or Calcifications on Abdominal or Pelvic CT and Hydronephrosis on Ultrasound-Malignancy, Prostatic Hypertrophy, Uterine Fibroids, Nephrolithiasis, Ureterolithiasis

KD-lab eval

All pts:All Patients
CBC
Serum BUN and Creatinine
Estimation of GFR
Serum Electrolytes
FENa (for ARF)
Urinalysis
Gross, Dipstick, and Microscopic Analysis
Urine Microalbumin for patient with predisposing risks (e.g., DM, HTN) whose urinalysis is negative for protein
If UA positive for protein order Protein-to-Creatinine ratio
If UA negative for protein but microalbumin positive order Microalbumin-to-Creatinine (or Albumin-to-Creatinine) ratio
Renal Ultrasound with Doppler
-Basic Metabolic Panel (BMP; aka Chem 7) includes BUN, Creatinine, Sodium, Potassium, CO2, Chloride, and Glucose. Some labs now incorporate eGFR when BMP, CMP, or BUN & Creatinine ordered

AcuteVs.Chronic labs

Past records invaluable
Increased creatinine and decreased GFR may be stable based on past values indicating CRF
No records available, no hx suggestive of CRF - then assume acute and urgently treatable
Renal imaging - small kidney size (<10 cm) suggests chronic renal disease (Normal kidney size does not rule-out CKD)
Timing: ≥ 3 months consistent with CKD

CHRONIC KIDNEY DISEASE: Definition

Two Independent Criteria for CKD
Kidney damage for ≥ 3 months as defined by structural or functional abnormalities of the kidney (with or without decreased GFR) evidenced by either:
Pathologic abnormalities - or -
Markers of renal damage including laboratory or imaging abnormalities
GFR <60 mL/min/1.73 m2 for ≥3 months
-Chronic kidney disease, do ultrasound, they will often get smaller with the disease because they have deteriorating over time.
120 -90 normal GFR.

DETECTION:Microalbuminuria
First morning or random urine microalbumin
Urine Albumin/Creatinine Ratio (ACR)
Creatinine and/or GFR Changes (small seemingly insignificant increases in serum creatinine can represent very significant kidney damage - even if creatinine is in normal range)
-Kidney failure = stage 5. do dialysis or transplant.
CKD= any condition that causes slow, irreversible damage to normal kidney tissue
CKD- has NO cure. Most people are asymptomatic until their kidney disease is advanced
CKD- has 5 stages (6 if you include stage 0)
CKD stages 1-4 could be tx'ed to delay progression to kidney failure (all stages warrant TX!!!
CKD/kidney disease can progress to kidney failure and death if left untreated
Kidney failure or end stage renal disease (ESRD) is called stage 5
Kidney replacement therapy includes dialysis or transplantation
-Urine test for protein and blood test to est the GFR, Cr alone is not dx'ic (? in notes but be careful)

Microalbuminuria-CKD detection

Microalbuminuria
First morning or random urine microalbumin
Urine Albumin/Creatinine Ratio (ACR)
Creatinine and/or GFR Changes (small seemingly insignificant increases in serum creatinine can represent very significant kidney damage - even if creatinine is in normal range)

CKD-stages

Stage #-Description-GFR range (mL/min/1.73m2)

Stage 0: At Increased Risk= ≥90.
Stage 1: Kidney Damage with normal or increased GFR
=≥90.
Stage 2: Kidney Damage with mildly reduced GFR(GFR starts dropping) = 60-89.
Stage 3: Moderately reduced GFR = 30-59
Stage 4: Severely reduced GFR (plan for dialysis)
= 15-29
Stage 5: Overt renal failure -start dialysis = <15

-Stage 0 great predictor for later disease, stage 0-indicates need to be aggressive, doing fine but at risk for developing renal disease later on. Keeps you alert and monitoring the pt. can help prevent the development of the disease. LDL below 100 for cardiac
-Adapted from National Kidney Foundation Kidney Disease Outcomes Quality Initiative Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification. http://www.kidney.org/professionals/kdoqi/guidelines_ckd/p9_approach.htm
- On dialysis makes your GFR appear to go up.

Stage 1: kidney damange and normal or increased GFR
Stage 2: Kidney damage and mild decreased GFR
Stage 3: moderate decrease in GFR
Stage 4: Severe decrease in GFR
Stage 5: KIDNEY FAILURE - dialysis!

STAGE ACTION PLAN/ CKD Clinical action plan:
Stage 1= DX & TX, Tx of comorbid conditions, Slowing the progression, Cardiovascular risk reduction.
- Stage 2 Estimating progression
Stage 3- Evaluate & TX complications
Stage 4 - preparation of kidney replacement therapy ( pt and family education, dialyisis access, preemptive transplant
Preemptive transplant is stage 4 prophylactic alive kidney!!!
- Stage 5- Kidney replacement therapy (if clinically indicated)

CKD LDL goal

100 or lower! 130 is the upper limit of normal for your average person but needs to be kept within a very strict range for pts with cardiac issues the ideal LDL range is 70-100!!!!

CKD-stage0

-Use of the Diagnostic Descriptor "CKD Stage 0"
-Many practitioners/specialists/organizations argue for the formal use of CKD Stage 0 as part of a patients medical record of diagnoses to raise attention for present risk factors of future CKD (e.g., DM II, moderate to severe HTN)
--- Pts with diabetes and HTN

CKD-causes, most common

Common Causes of CRF:
1. Diabetic Nephropathy (most common cause)
2. Hypertensive Nephrosclerosis,(second leading cause - increased frequency among African Americans)
3. Chronic Glomeruloneprhitis
4. Chronic Interstitial Nephritis (associated with progressive scarring of the interstitium)
5. Renovascular Disease (associated with large artery narrowing reducing blood supply to kidneys - e.g., renal artery stenosis)
6. Vasculitis (associated with small blood vessel inflammation)
7. Polycystic Kidney Disease
Hereditary Kidney Diseases of the kidney, (e.g., hereditary nephritis - Alport's syndrome)

- NOTE: Most pts. get dx at stage 3 in the office. ACR can help you find these pts at stage 1 or 2. Increased ACR- preprotinurea, at least in stage 1. so they will eventually progress to other stages, haven't started spilling protein at this point in their disease. Age related kidney disease rarely ends up on dialysis. Most pts. with kidney disease don't end up on kidney disease. Ace inhibitors have greatly decreased the progression of disease so fewer people need to go on dialysis. Some drugs with need to be adjusted for pts with renal disease, adjust rx based on the pts. GFR.

CKD&CVD

Cardiovascular risks and Chronic Kidney Disease:
- Mortality in patients with CKD more likely due to CVD than renal failure. 1, 2
Reduce risk of CVD events in patients with CKD stages 1-4 by lowering LDL to 100 mg/dL or below. 3
Reduce CVD risk factors for all patients with CRF (e.g., diabetes control, BP control, lipid control) to slow progression of renal failure

CASE-CKD#1(EX

CKD case #1: 63yo white male.
MHX: DM2 X 10yrs, HTN (138/86), hyperlipidemia
SHX: smoker, vet, semi-retired, divorced 2 supportive kids
RX's: Glipizide-10 mg/qd
Ramipril - 20mg/qd
Losartan- 25mg / qd
Atrovastatin - 20 mg/qd
(random note: Liposide reduces blood sugars)

LABS:
HbA1c- 8.1%
Pre-prandial glucose- 135mg/dL
Peak Post-prandial glucose- 185 mg/dL
Total Cholesterol- 222 mg/dL
LDL-C~ 143
HDL-C~ 30
Triglycerides- 246
Hg- 11.1 g/dL
Bicarb- 25 mg/dL
BUN - 22
Creatinine- 1.6 mg/dL
eGRF - 87 mL/min/1.73m^2

*~Which modifiable risk factors put John at risk for CKD?
Diabetes
HTN
Hyperlipidemia
All of the above ****** D = correct
(stress and smoking are also risk factors)
- Kidney failure = stage 5. do dialysis or transplant.
CKD= any condition that causes slow, irreversible damage to normal kidney tissue
CKD- has NO cure. Most people are asymptomatic until their kidney disease is advanced
CKD- has 5 stages (6 if you include stage 0)
CKD stages 1-4 could be tx'ed to delay progression to kidney failure (all stages warrant TX!!!
CKD/kidney disease can progress to kidney failure and death if left untreated
Kidney failure or end stage renal disease (ESRD) is called stage 5
Kidney replacement therapy includes dialysis or transplantation

CKD pop #'s 26 million

2007 JAMA from AMA US chronic kidney disease population is estimated at 26 million

CKD case#2-

MARY: 70yo black female
MHX: HTN ( 141/85), osteoarthritis, DM2 & hyperlipidemia. Experiencing fatigue, evening cramping, and difficulty urinating, worsening GFR recently noted!
SHX: nursing home resident, non-smoker, experiences decreased mobility from arthritis, daughter lives out of state
RX's: Lisinopril (decreases sugars) 5 mg po BID
Hydrochlorothiazide 25 mg qd
Clonidine 0.1 mg po BID
Glipizide 5mg qd
Simvastatin 20mg qd
Ibuprofen
- ddx- acute renal failure, worsening chronic condition, renal calcilie, CV disease, *70 yr should not be on an NSAID.
-LABS:
HbA1c- 7.9%
Pre-Prandial glucose- 141
Peak post-prandial glucose - 191
Total cholesterol - 214
LDL- C 164
HDL-C 51
Triglycerides 171
HG - 11.5
Bicarb- 25 mmol/L
BUN 35
Spot Urine Protein/ Creatinine ration = 320 mg/g
Creatinine - 1.3
eGFR - 51
-Increased BUN and Creatinine, what stage is this pt in? !!!!!!!!! A normal serum creatinine does not rule out kidney disease, a very hammered pt. !!!!!!!
Spot urine and protein are tests of chronic kidney disease, wouldn't test these for acute.
-WHAT ARE MARY"S CKD RISK FACTORS?
A) Older Age
B) HTN
C) Use of NSAIDS
D) All of the Above ****************!!! D= correct

-What would indicate that Mary has clinical proteinuria?
A)<20mg/dL spot urine dipstick
B) >300mg/d total protein (24hr excretion)
C)<200 mg/g spot urine protein-creatinine ratio
D) None of the above
=== Correct = B !!***** >300 mg/d total protein (24 hr excretion) would indicate that Mary has clinical proteinuria
Difference btw spot and 24hr collection and the albumin to cr ratio!

-An e GFR of 51 ml/min/1.73m would indicate that mary has ____?
A) Stage 1
B) stage 2
C) Stage 3******* c=correct1
D) Stage 4

CKD 2 test(NKF)*

DETECTING CKD National Kidney Foundation: 2 simple tests
Urine test for detecting proteinuria and or hematuria
Blood test for eGFR

-serum cr alone should not be used to assess the level of kidney function
-Usefulness of serum CR alone to detect kidney disease is limited b/c of variation among labs in assays & b/c its level is also affected by physiological processes other than GFR, including generation (largely dependant on muscle mass and meat intake), proximal tubular secretion, and extrarenal elimination. This can lead to different interpretations of assay results

CKD Albumin excretion

CKD ABNORMALITIES in ALBUMIN EXCERTION :
Category- spot collection (mg/g creatinine) - 24 hr collection (mg/24h) - Timed Collection (Ug/min)

1) Normoalbuminuria: <30 = spot collection; <30 = 24hr ; timed collect = <20
2) Microalbuminuria: spot = 30-300; 24 hr= 30- 300; timed = 20-200
3) Macroalbuminuria: spot = > 300; 24hr = >300 ; timed = > 200

-B/c of variability in urinary albumin excretion, @ least 2 specimines, preferably 1st thing in the morning void, collected w/I 3-6 months should be abnormal before considering a pt to have crossed 1 of these dx thresholds. Exercise w/I 24 hrs, infection, fever, congestive heart failure, marked hyperglycemia, pregnancy, marked HTN, UTI, and hematuria may increase URINARY albumin over baseline values.
-A 1st moring void sample is best b/c it is thought to closely mirrow 24 hr collection result; however, if not possible, a random collection sample is acceptable (& pro'ly most commonly used in day-to- day practice.

CKD-ALBUMIN-NORMAL-MICRO-MACRO

CKD ABNORMALITIES in ALBUMIN EXCERTION :
Category- spot collection (mg/g creatinine) - 24 hr collection (mg/24h) - Timed Collection (Ug/min)

1) Normoalbuminuria: <30 = spot collection; <30 = 24hr ; timed collect = <20
2) Microalbuminuria: spot = 30-300; 24 hr= 30- 300; timed = 20-200
3) Macroalbuminuria: spot = > 300; 24hr = >300 ; timed = > 200

24HR COLLECTION SAMPLE BEST TIME OF DAY?

1ST MORNING VOID!!!!!!!!!
- 1st moring void sample is best b/c it is thought to closely mirrow 24 hr collection result; however, if not possible, a random collection sample is acceptable (& pro'ly most commonly used in day-to- day practice.

-CKD ABNORMALITIES in ALBUMIN EXCERTION :
Category- spot collection (mg/g creatinine) - 24 hr collection (mg/24h) - Timed Collection (Ug/min)

1) Normoalbuminuria: <30 = spot collection; <30 = 24hr ; timed collect = <20
2) Microalbuminuria: spot = 30-300; 24 hr= 30- 300; timed = 20-200
3) Macroalbuminuria: spot = > 300; 24hr = >300 ; timed = > 200

ALBUMIN -CRITERIA FOR URINARY ALBUMIN EXCRETION

B/c of variability in urinary albumin excretion, @ least 2 specimines, preferably 1st thing in the morning void, collected w/I 3-6 months should be abnormal before considering a pt to have crossed 1 of these dx thresholds. Exercise w/I 24 hrs, infection, fever, congestive heart failure, marked hyperglycemia, pregnancy, marked HTN, UTI, and hematuria may increase URINARY albumin over baseline values.

ALBUMIN, FACTORS THAT MESS UP THE UA BASELINE LEVEL!

Exercise w/I 24 hrs, infection, fever, congestive heart failure, marked hyperglycemia, pregnancy, marked HTN, UTI, and hematuria may increase URINARY albumin over baseline values.

CKD lab(V) proteinuria& Albuminuria

URINE COLLECTION METHOD:
Total protein :
24-hr excretion (varies w/ method)~ Normal = <300 mg/d ; Microalbuminuria = NA ; Macroalbuminuria or Clinical Proteinuria : 300 mg/ g
Spot Urine Dipstick ~ Normal = <30 mg/dL ; microalb = NA ; Macroalb/clincal proteinuria = >30 mg/dL
Spot Urine Protein-Creatinine Ratio (varie w/ method ~ Normal = <200 mg/g ; Microalb = NA ; Macro/ proteinuria = >200 mg/g

Albumin:
24-HR excretion ~ Normal = <30 mg/ d ; Microalbuminuria = 30-300 mg/d ; Macroalbuminuria/clinical proteinuria = >300 mg/d
Spot Urine Albumin-Specific Dipstick ~ Normal = < 3 mg/dL ; Microalbuminuria = > 3 mg/d/L ; macroalbuminuria/proteinuria = NA
**Spot Urine Albumin- Creatiinine Ration (varies by seX) ~ Normal = < 17 mg/g (MEN) < 25 mg/g (WOMEN) ; Microalbuminura = 17-250 mg/g (MEN) 25-355 mg/g (WOMEN) = Macroalbuminuria/proteinuria = > 250 mg/g (MEN) & > 355 mg/g ( WOMEN)

-Notice the difference in cut off values between the NKF and the ADA. Lab values for "normal" range/cutoff may vary from lab to lab and depending on criteria used. Generally, an albumin:creatinine ratio <30 mg/g is considered "normal", although some consider much lower values to be representative of kidney disease, and a ratio >300 is considered macroalbuminuria or proteinura.

ProteinuriaVs.Albuminuria-Labs- micro-macro, 24hr spot...

URINE COLLECTION METHOD:
Total protein :
24-hr excretion (varies w/ method)~ Normal = <300 mg/d ; Microalbuminuria = NA ; Macroalbuminuria or Clinical Proteinuria : 300 mg/ g
Spot Urine Dipstick ~ Normal = <30 mg/dL ; microalb = NA ; Macroalb/clincal proteinuria = >30 mg/dL
Spot Urine Protein-Creatinine Ratio (varie w/ method ~ Normal = <200 mg/g ; Microalb = NA ; Macro/ proteinuria = >200 mg/g

Albumin:
24-HR excretion ~ Normal = <30 mg/ d ; Microalbuminuria = 30-300 mg/d ; Macroalbuminuria/clinical proteinuria = >300 mg/d
Spot Urine Albumin-Specific Dipstick ~ Normal = < 3 mg/dL ; Microalbuminuria = > 3 mg/d/L ; macroalbuminuria/proteinuria = NA
**Spot Urine Albumin- Creatiinine Ration (varies by seX) ~ Normal = < 17 mg/g (MEN) < 25 mg/g (WOMEN) ; Microalbuminura = 17-250 mg/g (MEN) 25-355 mg/g (WOMEN) = Macroalbuminuria/proteinuria = > 250 mg/g (MEN) & > 355 mg/g ( WOMEN)

CKD-total proteinVSalbumin

URINE COLLECTION METHOD:
Total protein :
24-hr excretion (varies w/ method)~ Normal = <300 mg/d ; Microalbuminuria = NA ; Macroalbuminuria or Clinical Proteinuria : 300 mg/ g
Spot Urine Dipstick ~ Normal = <30 mg/dL ; microalb = NA ; Macroalb/clincal proteinuria = >30 mg/dL
Spot Urine Protein-Creatinine Ratio (varie w/ method ~ Normal = <200 mg/g ; Microalb = NA ; Macro/ proteinuria = >200 mg/g

Albumin:
24-HR excretion ~ Normal = <30 mg/ d ; Microalbuminuria = 30-300 mg/d ; Macroalbuminuria/clinical proteinuria = >300 mg/d
Spot Urine Albumin-Specific Dipstick ~ Normal = < 3 mg/dL ; Microalbuminuria = > 3 mg/d/L ; macroalbuminuria/proteinuria = NA
**Spot Urine Albumin- Creatiinine Ration (varies by seX) ~ Normal = < 17 mg/g (MEN) < 25 mg/g (WOMEN) ; Microalbuminura = 17-250 mg/g (MEN) 25-355 mg/g (WOMEN) = Macroalbuminuria/proteinuria = > 250 mg/g (MEN) & > 355 mg/g ( WOMEN)

-Notice the difference in cut off values between the NKF and the ADA. Lab values for "normal" range/cutoff may vary from lab to lab and depending on criteria used. Generally, an albumin:creatinine ratio <30 mg/g is considered "normal", although some consider much lower values to be representative of kidney disease, and a ratio >300 is considered macroalbuminuria or proteinura.

CKD 1-5: ACTION PLAN

CKD Clinical action plan:
Stage 1= DX & TX, Tx of comorbid conditions, Slowing the progression, Cardiovascular risk reduction.
- Stage 2 Estimating progression
Stage 3- Evaluate & TX complications
Stage 4 - preparation of kidney replacement therapy ( pt and family education, dialyisis access, preemptive transplant
Preemptive transplant is stage 4 prophylactic alive kidney!!!
- Stage 5- Kidney replacement therapy (if clinically indicated)

Albumin-CKD-DKD Dx

CKD ALBUMIN - TO CREATININE RATION IN SCREENING AND DX OF DKD
SCREEN; diabetes pts annually for DKD
WHO AND WHEN: type 1DM= after 5yrs, then annuallly. Type 2 DM: @ DX1!!, then annually
WHAT AND HOW: urinary albumin - to -creatinine ration (ACR) in a spot urine sample
-eGFR FROMSERUM CREATININE: MICROalbuminuria-ARC btw 30-300 mg/g; MACROalbuminuria= ARC > 300 mg/g
-- albumin to CR ration screen and dx for type 1= 5yrs after then annually!!!! No co-morbid lack beta islet cells
-type 2 at dx and then annually - do it at dx bc they are usually pretty far along by the time they're dx'ed as having DM2.
There is a ? About this -know this slide.

DKD-CKD DX: Albumin

CKD ALBUMIN - TO CREATININE RATION IN SCREENING AND DX OF DKD
SCREEN; diabetes pts annually for DKD
WHO AND WHEN: type 1DM= after 5yrs, then annuallly. Type 2 DM: @ DX1!!, then annually
WHAT AND HOW: urinary albumin - to -creatinine ration (ACR) in a spot urine sample
-eGFR FROMSERUM CREATININE: MICROalbuminuria-ARC btw 30-300 mg/g; MACROalbuminuria= ARC > 300 mg/g
-- albumin to CR ration screen and dx for type 1= 5yrs after then annually!!!! No co-morbid lack beta islet cells
-type 2 at dx and then annually - do it at dx bc they are usually pretty far along by the time they're dx'ed as having DM2.

CKD-Case#3-GEorge-MI

CASE # CKD
GEORGE: 45 yohispanic Male
MHX: 4yr hx HTN (162/92), 3yr hx DM tpye 2, MYOCARDIAL INFARCTION 2yrs ago, Kidney fx remained stable at follow-up. However, worsening GFR & increasing microalbuinuria are now noted
SHX: Accountatnt, married, smoker, drinks 3-5 qd
RX's:
-Lisinopril 20mg qd
Amlodipine 10 mg qd
-Furosemide 20 mg qd
-Glipizide 5 mg qd

LABS:
HbA1c = 8.3%
Total cholesterol = 195
LDL = 125
Triglycerides = 154
Pre-prandial glucose = 135
Peak post- prandial glucose = 192
Spot Urine to Albumin -to -Creatinine ratio = 315
BUN = 23
Creatinine = 1.6
eGFR = 62

Albumin to creatinine ration of 315 means that George has ?
A)Normoalbuminuria
B)Microalbuminuria
C)Macroalbuminuria
D) all of the above
-C = Correct Macroalbuminuria! DF = ACR> 300 MG/G

CKD-Dyslipidemia

DYSLIPIDEMIA AND CKD
-strong evidence that general population that dyslipidemias cause atherosclerotic cardiovascular disease (ACVD)
- Lipid profiles can vary widely depending on the level of kidney FX and presence of NEPHROTIC SYNDROME
- Dyslipidemias are prevalent among pts from the earliest stages of CKD. The prevalence of dyslipidemias in kidney transplant recipients is also VERY HIGH
- Dyslipidemias are associated w/ decrease kidney fx in the general pop and in pts w. CKD. = a Modifiable RISK Factor for CVD in pts w/ CDK!!!!
--many factors can influence the occurance of dyslipidemias in CKD: diet, lifestyle choices, other medical conditions, certain rx's
-different aspects of CKD can also alter liprotein levels: Changes in proteinuria, GFR, and TX of CKD
-evaluate pts for dyslipidemias if they CKD, to detect abnormalities that may be tx'd to reduce the risk of CVD

dyslipidemia guidelines

Dyslipidemias guidelines/values: Df'ed in the Adult TX panel 3 guidelines-

Total Cholesterol:
-Desirable= <200
-Borderling High = 200-229
High ~ = > 240

LDL:
-Optimal = <100
Near optimal = 100- 129
-Borderline = 130- 159
- High = 160- 169
-Very High ~ => 190

TRIGLYERIDES:
- Normal = <150
-Borderline High = 150- 199
- Hign = 200-499
- Very High ~ => 500

HDL:
- Low = <40

Dyslipidemia TX w/ CKD levels

Management of Dyslipidemias in Adults w/ CKD
Dyslipidemia:
-TG=> 500 mg/dL ; goal TG <500 ; initiate TLC ; Increase- TLC + Fibrate or Niacin ; Alternative - Fibrate or Niacin

-LDL 100-129: Goal - LDL <100 ; Initiate- TLC ; Increase- TLC + low dose statin ; Alt- Bole acid seq or Niacin

LDL => 130: Goal - < 100 ; initiate- TLC + low dose stating ; increase TLC max dose Statin ; Alt- Bile acid seq or Niacin

- TG=> 200 & non HDL- => 130: Goal- non HDL < 130 ; Initiate- TLC + low dose Statin ; Increase- TLC + max dose Statin ; Alt- Fibrate or Niacin

Encourage THERAPUETIC LIFESTYLE CHANGES (TLC)
LDL targets for CKD 1-2 are < 100 ; < 70 for those w/ coronary artery disease
- statins have been shown to be effective in lowering LDL in pts w/ CKD stages 1-4 and could reduce cardiovascular events! However, the benificial evidence for statin use in pts receiving dialysis stage 5) is lacking based on 2 basic large studes

CKD-anemia DX levels

DX of amenia should be made and further evaluation should be undertaken at the following HG concentration
-<13.5 g/dL in M & < 12.0 F
-<13.5 g/dL F & <12.0 M
<15.0 M & <13.0 F
-<15.0 F & <12.0 M

A: dx of anemia should be made and further eval should be undertaken at the following hemoglobin concentrations : < 13.5 g M & <12.0 F

Anemia&CKD

ANEMIA AND CKD: -often occurs early in CKD and commonly contributes to poor quality of life
Severity of anemia in pts w/ CKD Is related to A) degree of loss of GFR and B) the cause of kidney disease
--the lowest Hb levels are found in ptws w/ very low levels of kidney FX (anephric &/or dialysis pts)
-The lowest levels of HB are found in anephric pts and in those who commence dialysis therapy at very low levels of kidney fx
- Further evalutation to ID the source of anemia is undertaken @ the following Hb levels: <13.5 in males & 12.0 in females

Anemia assessment w/ CKD

Initial Anemia assessment:
CBC
-Absolute reticulocyte count (ARC)
-serum ferritin
-serum transferrin saturation(TSAT) or content of Hb in reticulocytes (cHr)

-Erythropoisis-stimulating agents (ESAs) are used to achieve and maintain target Hb levels
-Iron therapy may serve as a primary therapy for selected pts (particularly those with nondialysis CKD) or as adjunct therapy for those people also undergoing tx w/ and ESA

CKD-Mineral Bone Disorder

- CKD Mineral Bone disprder (CKD-MBD) :
-the processes causing disorders of mineral metabolism and bone may have their onset as early as CKD Stage # 2!!!!!!! When GFR is 60-89
- disturbances in ca, phosphorus, vit D, and Parathyroid hormone (PTH) levels that occur as CKD develops can lead to abnls in bone and soft tissues, including blood vessels, and are thought to contribute significantly to the increase risk for CVD!!!!!! And Mortality in CKD !!!!!!!!
Prevention and early detection are very importanbt in improving quality of life and longevity of CKD in pts
-Can start early. Phosphorus, parathyroid and vit D and ca problems associated. Bones and soft tissue issues. Big problem for people w/ kidney disorders. Metabolism is kinda messed up, stim parathyroid when you don't need it, renal osteodystrophy changes in people with renal disease your whole pth system is ****ed once in stage 3 up the frequency - ca and phosphorus gets pulled out of the bones, alkaline phosphotase will be elevated in the serum levels (also in bone disease and if you mets to the bone as well). Osteoblastic lesions = elevated alkaline phosphotase level, comes out of the bone. Become disregulated 2ndary hypoarathyroid feedback system gets disgregulated with this. Anemia and bone disease start early in the kidney disease process the malnutricion is as their disease develops and they get sicker.

CKD-MBD monitoring

CKD-MBD: Df, frequency of monitoring:

CKD-MBD- systematic disorder of mineral and bone metabolism d/t CKD manifest either by or a combo of:-abnls of ca, phosphorus, PTH, vit D mtabolism
-ablns in bone turnover, mineralization, volume, linear growth or strength
Vasculat or other soft tissue calcification

Renal Osteodystrophy:
-renal osteodystrophy is an alteration of bone morphology in pts w/ CKD
It is 1 measurement of the skeletal coponent of the systematic disorder of CKD-MBD that is quantifiable by histomorphometry of bone biopsy.

Suggested frequency of serum cal, phosphorus, and PTH measurements According to CKD stages:
Ca & Phosphorus - progressive CKD stage 3 = 6-12 months ; CKD stage 4 = 3-6months ; CKD stage 5 = 1-3months
PTH & Alkaline phosphatases - CKD Stage 3 = Baseline ; CKD stage 4 = 6-12months ; CKD 5 = 3-6months
-Calcidiol - CKD 3 = baseline ; CKD 4 = baseline ; ckd 5 baseline

Renal Osteodystrophy:

Renal Osteodystrophy:
-renal osteodystrophy is an alteration of bone morphology in pts w/ CKD
It is 1 measurement of the skeletal coponent of the systematic disorder of CKD-MBD that is quantifiable by histomorphometry of bone biopsy.

CKD-Malnutricion& PEW& nutricion

Malnutricion and CKD:
Malnutricion or protein energy wasting (PEW) is common on CKD associated w/ poor pt outcomes!
Malnut in CKD begins as early as stage 3 and 4 !!!!!!. Risk increases w/disease progression.
- preventing PEW or malnutricion may require clinical intervention to assess nutricional status, individualize strategies for prevention and tx and to provide pt instruction and to promotes pt adherence
- special trained registered dietician can help address the nutricional aspects so that protein wasting can be avoided or diminished
-People with CKD often have high phosphorus and high K, often start diaylsis when you can no longer control these levels and keep them down, you try to keep people w/ CKD at lower levels K normal is 4 but people w/ CKD keep them around 2 when they're in stages 3-4. rxs given to leach these out of your blood. If phos is high then your ca is usually lower... Phosphorus and K and GFR and the 3 main thing that determine when you have to start someone one dialysis. Gfr >15, elevated K >4 if stages 1-2 or 3-4 >2.4. phos is : ( for kidneys. Dairy phos and Ca watch out.

- -A balanced approach to nutrition in CKD: Macronutrient Composition and Mineral content stages 1-4
Nutrient :
Na - stage 1-4= <2-3
Total fat (% of calories) stage 1-4 = <30
Saturated fat stage 1-4 = <10
Cholesterol stage 1-4 = <200
Carbohydrates stage 1-4 50-60

Protein (g/kg/d, % of calories):
-No diabetes stage 1-2 = 1.4 (~18) ; Stage 3-4 = 0.6-0.8 (~8*10)
-Diabetes stage 1-2 = 0.8 (~10) ; stages 3-4 = 0.6-0.8 (~8*10)

Phosphorus (g/d) stage 1-2 = 1.7 ; stages 3-4 = 0.8-1.0

Potassium (g/d) stages 1-2 = >4 ; stages 3-4 = 2.4

DASH diet = dietary approach to stop HTN diet.
-adjust total calories from protein, fat, carbs, are 100%. Emphasize whole food sources= veggies, whole grains, nuts, legumes, low fat or non fat dairy canola oil olive oil cold water fish and poultry

CKD Nutrition

-A balanced approach to nutrition in CKD: Macronutrient Composition and Mineral content stages 1-4
Nutrient :
Na - stage 1-4= <2-3
Total fat (% of calories) stage 1-4 = <30
Saturated fat stage 1-4 = <10
Cholesterol stage 1-4 = <200
Carbohydrates stage 1-4 50-60

Protein (g/kg/d, % of calories):
-No diabetes stage 1-2 = 1.4 (~18) ; Stage 3-4 = 0.6-0.8 (~8*10)
-Diabetes stage 1-2 = 0.8 (~10) ; stages 3-4 = 0.6-0.8 (~8*10)

Phosphorus (g/d) stage 1-2 = 1.7 ; stages 3-4 = 0.8-1.0

Potassium (g/d) stages 1-2 = >4 ; stages 3-4 = 2.4

DASH diet = dietary approach to stop HTN diet.
-adjust total calories from protein, fat, carbs, are 100%. Emphasize whole food sources= veggies, whole grains, nuts, legumes, low fat or non fat dairy canola oil olive oil cold water fish and poultry

CKD-pt education

Pt family education
-educate pts and their family when they're ready
-ID Barriers or limitations to learning before Ed session
-allow for ?'s and answwrs
Put special emphasis on the care needs of pts after discharge
-clearly initiate the pts teaching plan in the medical recodrd

modified morinsky scale

Modified morisky scale: therapuetic regimine for quick placement in the adherence intention quadrants plan improvement

Adherence intention quads-moroinsky scale

Adherence intention quadreants:

Quad #1: knowledge LOW and motivation LOW, adherence intention = low
- Quad 1 interventions:
-motivational interviewing
-disease specific ED
-medication regime ED
teach-back (ask pt to repeat instructions)
-Family ED

Quad #2 knowledge LOW, motivation HIGH, adherence= variable
- Interventions quad #2:
-motivational support
-reinforce/praise pts efforts to adhere to prescribed therapy
-disease specific ED and potential consequence of non-adherence
Discuss action to take before the present prescription runs out
-teach-back
-family ED

Quad #3 - knowledge HIGH, motivation LOW, adherence = variable.
- Interventions Quad #3:
Motivatioal support
-pt reminder systems
- social support plan
- family motivation assessment

Quad #4 - knowledge HIGH, motivation HIGH, adherence intention = high
- Interventions quad 4:
Continued knowledge & motivastion reinforcement support
- open-ended discussions to uncover emerging concerns

CKD facts

CKD:
1. Does GFR decline as we age?
- yes!
2. A GFR <? Is indicative of CKD ?
-60
3.CKD is a structural or fx abnlality of the kidney that lasts more than ?
- 3months
4. What is the most common stage of the CKD stages?
-
5. DF CKD stage 0:
-
6. What action would be appropriate in a pt w/ CKD stage 0?
-
7. DF CKD stage 1?
-
8. What would be the appropriate action for a pt w/ CKD stage 1?
-
9. Df CKD stage 2?
-
10. DF CKD stage 3
-
11. Df CKD stage 4?
-
12. At what stage is it noted that you should prepare for renal replacement therapy?
-
13. Dialysis is required for ____ this GFR?
- dialysis required for this GFR < 15

answers
- GFR>90 w/only increased risk
-screening w/risk rreduction
-GFR >90 w/DAMAGE to kidney
-Dx& TX to slow progression of damages Tx any co-morbinds
-GFR 60-89, milf=d decrease in GFR
GFR 30-59, moderate decrease in GFR
-GFR 15-29, SEVERE decrease in GFR
- stage 4

top5thingsnephroligists wish PCPs knew

A "Normal" Serum Creatinine Level May Not Be Normal
Know the Medications That Spuriously Elevate the Serum Creatinine Level
Patients With Decreased GFR or Proteinuria Should Be Evaluated to Determine the Cause; Positive Urine Dipstick Test Results for Protein Should Be Followed Up With a Spot Urine Protein to Urine Creatinine Ratio
In Patients With Early-Stage CKD, Periodic Evaluation and Intervention Are Appropriate to Slow the Progression of Renal Disease and Avoid Its Complications
Do Not Automatically Discontinue an ACEI or ARB Solely Because of a Small Increase in the Serum Creatinine or Potassium Level******

Renal ultrasound: indications to order

Indications for Ordering

Workup of ARF or CKD
Determination of Size (Small Size suggests CKD)
Assessment for Hydronephrosis
Assessment for polycystic kidney disease
Assessment for structural abnormalities (e.g., collecting system abnormalities, horseshoe kidney, masses)
Assessment for renovascular disease (Doppler)

-Advantages
Can be performed at bedside if need be No radiation No IV contrast Easily Repeatable Fast

Disadvantages
Does not directly assess renal function
(e.g., in comparison to IVP)
Cannot typically identify renal or ureteral stone
Must F/U with CT if mass discovered

Ultrasound findings: WNL

Normal Renal Ultrasound Findings:
Length: 100-115mm
Width: 50-70 mm
Depth: 30-50 mm
-Renal Parenchyma (i.e., functional tissue of the kidneys) , Measured from the convex outer edge to the tip of a papilla, Normal value = 13-18 mm.
- Kidney Volume calculation (length x width x depth x 0.5). Normal volume = 110-200
- Renal Parenchyma Pyelon Index
(relationship between dorsal parenchyma to pyelon to ventral parenchyma). Normally 1:1:1
Increasing age, renal atrophy results in an index of 1:2:1
- Anatomy
Bean shaped organ with smooth convex lateral organ boundary. Homogeneously hypoechoic renal parenchyma. Hyperechoic surrounding fat tissue and pyeloliceal system with parapelvic fat
- Kidneys have significant anatomical variations - can lead to confusion in US imaging
Tumor-like lesions need F/U with CT
-Polycystic kidney disease, usually large kidney. Small size usually/suggestive of CKD, cells die and kidney shrinks (can be large too). Poly cystic kidney cysts can be ill defined and indeterminable from masses, malignancy, stones, want to see the density. Want to order a helical CT to evaluate.

Normal Sonographic Appearance:
- Bean shaped organ with smooth convex lateral organ boundary
Depending on imaged axis, sonographic shape differs
Longitundinal: Football-shaped
Transverse View: C-shaped
Bright area surrounding kidney: Gerota's fascia and perinephric fat
Grainy gray periphery: Renal cortex and pyramids (pyramids not always identifiable
Echogenic (bright) central area: Renal sinus (calyces, pelvis, renal sinus fat)
Tubular structure extending inferiorly: Ureters (visualized when distended; not always visible when not distended)
-Always scan both kidneys for comparison and correlation to clinical presentation
-Kidneys have significant anatomical variations - can lead to confusion in imaging
-Tumor-like lesions need F/U with CT

Scan both kidneys to compare symmetry and size, congenital abnormalities, assess hydronephrosis (both, rarer but better prognosis)

Ultrasound w/ doppler: renal

Renal ultrasonography with arterial Doppler studies is the single most important test for evaluating all patients with an elevated creatinine level. First and most importantly, it is the least invasive method for identifying obstructive uropathy, the most reversible form of renal failure. Second, it provides information on renal size (Graves, 2008, pg 1067)."
- Kidneys < 7-8 cm: suggests CKD and very low likelihood of reversible form or renal failure
Kidneys >12-13cm: suggests obstruction, malignancy, polycystic kidney disease
Abnormal Doppler: suggests renovascular disease
-One test that can tell you if you have a quick intervention like in obstructive kidney disease, the best test for kidneys for this reason, followed by the GFR but that is really a calculation. Pt will present sx 1st- urinary signs, sick pts. ultrasound w/ doppler for acute kidney disease, CKD w/ vascular disease and severe hypertension. Don't order need to order ultrasound w/ dopler for follow ups. Obstructive will present a AKD, so you'd order utrasound with doppler.

ureter/renal stones-Ultrasound

Although often difficult to identify, renal and ureteral stones may be seen on ultrasonography as bright objects casting a shadow

Doppler with Resistive Indices

Renal Ultrasound -Doppler with Resistive Indices:
-Resistive Index (RI)

Standard Flow Rates of the Renal Artery
Peak Systolic Velocity (PSV): 80-150 cm/s End Diastolic Velocity (EDV): 20-50 cm/s

Formula for RI: = (PSV-EDV)/PSV
Standard value = 0.5-0.7

RI >0.7 or side variance of > 0.1
Hydronephrosis
Intrinsic Renal Disease
Renal Transplant Graft Rejection

RI <0.5
Renal Artery Stenosis

Magnetic Resonance Angiography: Renovascular Disease

Indications for Ordering

Work-Up for nonessential hypertension and suspected renal artery stenosis

Renovascular hypertension (RVHT): represents a condition of nonessential hypertension due to renovascular arterial occlusive disease promoting renal ischemia and resulting renin-angiotensin-aldosterone activation.

Renal artery stenosis (RAS): represents a major cause of RVHT, accounting for up to 10% of the 50 million cases of hypertension in the United States; and represents important cause of CRF with atherosclerosis being most common cause of RAS in elderly patients.

Arterial dysplasias (AD) - (e.g., medial fibroplasia; MFP) - represent uncommon vascular disorders related to heterogeneous histologic changes affecting carotid circulation and visceral and peripheral arteries. Up to 30% of 30-40 year-old patients with RAS have MFP (MFP is the most common type of fibromuscular displasia); RAS related to MFP most commonly affects young to middle-aged adults, predominantly females. However, MFP also affects children and represents important cause of pediatric RVHT. Textbook finding on imaging includes string of beads appearance related to areas of stenotic narrowing alternating with small aneurysms.
-AD common in younger women.
- Can correct the stenosis with a stent.

Renal Artery Stenosis

Renal artery stenosis (RAS) is commonly associated with hypertension and renal failure; however, a causal relationship may not always present - signaled by lack of improvement on correction of stenosis.

Atherosclerosis accounts for >90% of all patients with RAS in Western populations with Fibromuscular Disease (FMD) seen in most of the remaining Caucasian patients with RAS. However, non-Westerners may have different pathologic process (e.g., Takayasu's arteritis is responsible for up to 60% of all RAS cases in the Indian subcontinent).

FMD relatively common condition in the West, with prevalence of 1-2% (uncommon in Africans and Asians), mostly females, with the renal arteries affected in 60-75% of all cases of FMD (right > Left) in addition to other major arteries (e.g., carotids - 15% of cases).

Pathogenesis is uncertain - familial autosomal dominant pattern, α1 antitrypsin deficiency, mural ischaemia induced by vasoconstriction of the vasa vasorum, and smoking have all been linked to the disorder.

-The different things that cause FMD and things that change the renal blood flow. Other disorders than renal artery stenosis that can cause renal blood flow issues

MRA renal arteries

Renal angiogram showing the typical 'string of beads' appearance of fibromuscular dysplasia (FMD).
-FMD not renal artery stenosis, has a characteristic finding of string of beads appearance. Ultrasound tells you whether you need MRA (increased indices', need MRA not CT) tells us if need to order angiogram...
-when you order anything with contrast need to have pt go for BUN/Creatinine 1st so that the radiologist can tell what type of contrast to order. BUN/Creat ratio elevated, do a CK (to see if it is rabdo), then possibly a 24hr urine.

Renovascular Disease:Clinical features that suggest it

Hypertension:
Abrupt onset of HTN in patients <30 years (suggestive of FMD) or >50 years (suggestive of atherosclerotic renal vascular disease)
No FH of HTN hypertension
Severe or malignant HTN
Medication resistance (≥3 drugs)

Renal abnormalities:
Unexplained renal failure in patients >50 years
Increased serum creatinine after ACE-I or ARB initiation
Asymmetrical kidneys on sonography

Other:
Unexplained acute pulmonary edema or CHF
Femoral, renal, aortic or carotid bruits
History of extra-renal vascular disease
Hypokalaemia
Neurofibromatosis

Renalvascular disease interventions

Intervention: Percutaneous Renal Angioplasty (PTRA)
What determines level of significance for intervention? Controversial
Significant: >60 stenosis - some interventional radiologist would perform PTRA for significant stenosis
Critical (i.e., >90% stenosis) - some interventional radiologist would perform PTRA only for critical stenosis
Intervention depends on level of stenosis and clinical presentation!
-Renal artery stenosis even if it is signif, is not always the cause of sx. Angio does not always fix the problem rough guess 40% failure rate.

Renal Ultrasound: Pearls and Pitfalls

Multiple renal cysts may be misinterpreted as hydronephrosis
Extrarenal pelvis (collecting system located outside the kidney) can be misinterpreted as early hydronephrosis but is actually a normal variant.
Overhydration may result in mild bilateral hydronephrosis without obstruction
Regardless of the presence of obstruction, underhydration may result in the absence of hydronephrosis on initial scanning - rescan after hydration
In pregnancy or in a patient with a full bladder, mild bilateral hydronephrosis may be evident despite lack of obstruction
The kidneys in a patient with CKD may not have any sonographic abnormalities: A normal ultrasound does not rule out CKD.
Adjacent structures such as the gallbladder may be misinterpreted as a renal mass/cyst
A patient with multiple renal cysts may also have hepatic cysts: Image the liver while performing renal ultrasound to check for hepatic cysts
Some types of polycystic kidney disease associated with intracerebral aneurysms: Appropriate F/U is necessary
In the clinical setting of acute renal colic with unremarkable renal sonogram, check the aorta for AAA.

Creatinine inaccurate readings

In which of the following pts, can a creatinine reading be inaccurate as a measure of kidney function?

A) Pts with paraplegia
B) Pts who have a skeletal muscle disease
C) Pts who are severely malnourished
D) Pts whose kidney function is rapidly deteriorating
E) Pts who are pregnant

F= correct !!!
F) All of the above
-Creatinine is a product of muscle breakdown that is filtered by the kidney. Remember that any disease where the muscles are not working properly or the pt is in a unique metabolic state (starvation, pregnant, etc) or pts whose kidneys are failing fast - the creatinine will not be as accurate as a measure of kidney function and a clearance study should be performed

normal GFR in 'healthy people'?

a) > 150 mL/min/1.73 m2
B) > 120 mL/min/1.73 m2

**** correct= c
C) > 90 mL/min/1.73 m2
-GFR is a measure of how well the nephrons are working. Cannot be directly measured
-GFR declines with age in general
D) 60 mL/min/1.73 m2
E) 15 mL/min/1.73 m2

Remember that GFR is different then creatinine clearance.
Creatinine clearance exceeds GFR because creatinine is secreted by the proximal tubule as well as filtered by the glomerulus.
Creatinine clearance can be measured from serum creatinine and creatinineexcretion, or estimated from serum creatinine using estimating equations (like Cockcroft-Gault formula and a few others).

Which of the following pts would have a higher 'normal' GFR?

Which of the following pts would have a higher 'normal' GFR?
A= correct

A) African american man
B)African american female
C)Caucasian female
-Remember that GFR is usually estimated using creatinine. Creatinine will be higher in people with more muscle mass ( african americans, men, not eldery people)

Serum creatinine: GFR: KF

-Serum creatinine does not tell the whole story - need to look at previous results and the pt
-Take home pt is that creatinine alone is not that useful in measuring kidney function, the same number can mean different things for different people. The equations usually take into account a persons age and weight.
-Cockcroft-Gault formula CCr={((140-age) x weight)/(72 SCr)} x 0.85 if female

EX:

Creatinine:
1) 22yo black man= 1.2 mg/dL ----- 2) 58yo whit man = 1.2 mg/dL -----3) 80 yp white woman

GFR:
1) 98 mL/min/1.73m 2) 66mL/min/1.73 3) 46mL/min/1.73

Kidney Function:
1) Normal GFR or stage 1 CKD if kidney damage is also present
2) Stage 2 CKD if kidney dx is also present
3) Stage 3CKD

Cockcroft-Gault formula

Cockcroft-Gault formula CCr={((140-age) x weight)/(72 SCr)} x 0.85 if female

Azotemia

term that describes an excess of urea, creatinine and other nitrogenous end products of amino acid metabolism in blood?

A)Asterixis
B)Azotemia
C) Nephrotic syndrome
D) Microalbuminuria

b= correct - Azotemia (sometimes also referred to as uremia but the correct term is azotemia

A patient presents with waxy casts in the urine. What are you concerned about?

A patient presents with waxy casts in the urine. What are you concerned about?

A) Acute tubular necrosis
B)Normal variant
C)Chronic renal disease
D) Nephrotic syndrome


C = Correct

Casts - molds of the tubule - can represent certain diseases

Casts - molds of the tubule - can represent certain diseases

-Granular or muddy casts = Acute Tubular necrosis**
Hyaline casts (made of the tamm-horsfall protein) = certain amt normal or can be seen with kidney dx
Waxy casts = Chronic renal disease or amyloidosis**
Fat bodies or casts = nephrotic syndrome (remember that nephrotic syndrome lets proteins and fat through the cells)
Red blood cell casts = glomerulonephritis
Epithelial casts = damage to tubules

red urine?

Which of the following can lead to red urine?

A)Pyridium - taken for UTIs
-also hematuria (duh), porphyrins, beets, food coloring
B)Melanin or methyldopa - turn urine dark
C)Rifampin - turn urine orange
D)Bilirubin - brown to orange color

A= correct

low urine output. BUN = 60 and creatinine = 4. What does this ratio tell you?

A patient presents to the ED with low urine output. The first labs to come back are BUN and creatinine. BUN is 60 and creatinine is 4. What does this ratio tell you?

A) pre-renal azotemia = Correct A!
-Bun/CR ratio of >20
-body does not have enough fluid so
-urine output will be low (but concentrated b/c the kidneys work fine they just aren't getting the blood flow they need)
-the fractional excretion of sodium will be low (body is hanging on to all it can)
B) Post renal failure
C) Infrarenal failure

What is the definition of chronic kidney disease

2 independent criteria
-kidney damage for 3=> months as defined by structural or functional abnls of the kidney (w/ or w/o decreased GFR) evidenced by either:
-pathologic abnormalities - or-
-markers of renal damage including lab or imaging abnls
-GFR <60 m/Lmin/1,73 for +> 3 momths

GFR of 55 and evidence of kidney damage. What stage of CKD would they fall into?

A patient has a GFR of 55 and evidence of kidney damage. What stage of CKD would they fall into?

A) Stage 0
B) Stage 1
C) Stage 2
D) Stage 3 Correct answer!
-Moderately reduced GFR: 30-59
stage 4
Stage 5

At which stage is dialysis necessary? Stage 5

clinical proteinuria

Which of the following would indicate that a pt has clinical proteinuria? - B=CORRECT!

A) < 20 mg /dl spot urine dipstick
B) > 300 mg /d total protein (24 hour excretion)
-Remember there is a total protein value and a urine protein-creatinine value
-for total protein: < 30 is normal, 30-300 is microalbuminuria and > 300 is macroalbuminuria
-for urine albumin - creatinine: < 17 (men) and < 25 for women is normal. Clinical proteinurina (macroproteinuria) is seen when levels are above 255 for men and 250 for women
Just remember these are two different tests but the numbers are about the same
C)< 200 mg/g spot urine protein-creatinine ratio
D)None of the above

type 2 diabetes, when should you check their first urine albumin-creatinine ratio?

type 2 diabetes, when should you check their first urine albumin-creatinine ratio?
-Should screen annually
Type 1: after 5 years and then annually
Type 2: at diagnosis and then annually

Take home pt is that diabetes severely affects the kidneys!

testicular cancer most common 3

Which age group is testicular cancer most common in?
B= correct!

A) 8-12 months
B) 15-30 years - think of lance armstrong
C) 40-50 years
D) >50 years old

1% all cancers in men.
Most common cancer in men 15-30 years of age.
90% present as asymptomatic masses.
If detected early, cure rate approaches 90%.
Early detection by PE and self examination is crucial to prognosis.

Gleason Score

Gleason Score, what is it used for?
-The Gleason Grading system is used to help evaluate the prognosis of men with prostate cancer. Together with other parameters, it is incorporated into a strategy of prostate cancer staging which predicts prognosis and helps guide therapy. A Gleason score is given to prostate cancer based upon its microscopic appearance. Cancers with a higher Gleason score are more aggressive and have a worse prognosis.

Prostate Cancer - adenocarcinoma

Prostate Cancer - adenocarcinoma
-From your lecture

Male, Age > 50
Black > Whites > Asian, Native Americans
1st Degree relative
Autopsy reveals 30% males age 30-49 have
Almost 100% males >65
10 year Survival rate:
75% stage B; 55% stage C; 15% stage D
Debate as to Cost and Morbidity of
Test - Tx - Watch in Asymptomatic (one of the articles is about this)

***33% of cancers in men; 10% of all cancer deaths in men.
>230,000 new cases annually; 29,000 annual deaths.
Appx. one in 6 men by age of 80.
90% are detectable by rectal exam
Prostate Cancer usually involves posterior lobe of prostate

Urine dipstick testing is considered a CLIA waived test. A Clinical Laboratory Improvement Amendments (CLIA) certificate of waiver for a specific laboratory test indicates:

Urine dipstick testing is considered a CLIA waived test. A Clinical Laboratory Improvement Amendments (CLIA) certificate of waiver for a specific laboratory test indicates: A =correct!

A)mThe test is has been determined so simple and accurate that there is little risk of error if performed incorrectly.
B) The test has been determined so vital to non-hospital medical care settings that it can be done outside of a laboratory setting
C) The test is automated and chance of error is extremely low
D) It is among a small group of tests very commonly performed in practice settings, including basic chemistries and serum lipids, such that a waiver has been granted
E) The test can be performed outside of a laboratory setting as long as it is collected and performed by a certified Laboratory Technologist.

You receive a urine microscopy report that is positive for Hyaline Casts. A small amount of Hyaline casts on urine microscopy is most often associated with:

You receive a urine microscopy report that is positive for Hyaline Casts. A small amount of Hyaline casts on urine microscopy is most often associated with:

-Pathologic findings of renal disease with interstitial inflammation - WBC CASTS (insterstitial means within the cells so think of an infection like pyelo)
Benign findings of a relatively concentrated urine at time of collection
Pathologic findings of subacute bacterial endocarditis or Good pasture's syndrome RBC Casts - any kind of condition that damages the basement membrane (also lists lupus and glomerulonephritis on slides)
Finding suggestive of damage to the tubular portion of the nephron RENAL Epithelial casts - toxins and viruses
Result of breakdown products of cellular casts and immunoglobulin Granular CASTS - remember muddy brown granular casts are pathognomic for acute tubular necrosis

One of the criteria for determining the presence of Chronic Kidney Disease is the presence of kidney damage for > 3 months as evidenced by structural or functional abnormalities. Another independent criteria for CKD is:

One of the criteria for determining the presence of Chronic Kidney Disease is the presence of kidney damage for > 3 months as evidenced by structural or functional abnormalities. Another independent criteria for CKD is:C= correct!

A) GFR < 90 ml/min/1.73 m2 for > 3 months
B) GFR < 80 ml/min/1.73 m2 for > 3 months
C) GFR < 60 ml/min/1.73 m2 for > 3 months
D) GFR < 40 ml/min/1.73 m2 for > 3 months
E) GFR < 20 ml/min/1.73 m2 for > 3 months

You have a patient whose presentation and blood tests suggest acute kidney failure. The patient's urine microscopy results reveal tubular cells, cellular casts, and granular casts. These findings are most abundant in:

You have a patient whose presentation and blood tests suggest acute kidney failure. The patient's urine microscopy results reveal tubular cells, cellular casts, and granular casts. These findings are most abundant in: E= correct

-Proliferative glomerulonephritis and hereditary nephritis
Hereditary nephrititis and microangiopathy
Cystic kidney disease and kidney neoplasms
Diabetic kidney disease and non-inflammatory glomerular disease
Acute Tubular Necrosis - muddy granular casts are pathognomic for ATN.
One of the other keys to this question is the acute renal failure as many of the other options are more chronic diseases too

How does renal carcinoma often present?

How does renal carcinoma often present? B= correct

A) Severe abdominal pain
B) Gross hematuria and weight loss (or asymptomatic)
-solitary renal mass
-40% metastatic at diagnosis
-more common in men and smokers (same for bladder cancer which also can present with hematuria)
-any solid renal mass should be evaluated for RCC
-tx with surgery first
C) Jaundice
D) Obstructive nephropathy

nephrolithiasis, best test?

What is the best test to evaluate for nephrolithiasis?
C =correct!

A) IVP
B) Cystogram
C) Non contrast CT
Mainstay of imaging non-contrast CT scan
contrast obscures stones
10% of all people will have stone in lifetime
Most common calcium oxalate
15% struvite
1-2% cystine
Complications
obstruction
stricture
infection
renal failure
Flank pain, microscopic hematuria

A) Contrast CT

What is the most common malignancy of the bladder?

What is the most common malignancy of the bladder?
B = correct


A) Adenocarcinoma

B) Transitional cell carcinoma
- smoking, chemical exposure, chronic infection
Imaging includes
IVP
CT
MRI
all will show irregular filling defects
4% squamous cell CA
< 1% Adenocarcinoma
urachal remnant
Benign tumors - smooth filling defects seen
leiomyoma
hemangioma

C) Squamous cell carcinoma
D) Angiomyolipoma - this is a mass that can be seen in females in the kidney - its benign. Can see a fatty area (lipoma part)

How does benign prostatic hypertrophy present on physical exam?

How does benign prostatic hypertrophy present on physical exam?
B= correct

A) Hard nodule on DRE - prostate cancer
B) Boggy, enlarged throughout gland on DRE
-symptoms of having to pee a lot and can't get it all out ( think of dad)
-treated with meds (that dad wont take  )
C) No findings
D) 3Blood on DRE

alternative marker to measure GFR?

alternative marker to measure GFR?
B= correct


A) Insulin
B) Cystatin C (inulin not insulin is another one)
-Endogenous cysteine protease inhibitor that is freely filertered by the kidneys and unaffected by the renal tubules
An alternative serum marker of GFR in CKD
Not useful with ARF due to unstable association between creatinine production and renal excretion on basis of acutely changing renal function
More variable than serum creatinine
Can be affected by acute disease (e.g., malignancy, HIV)
C) Albumin
D) BUN

How do most patients with kidney disease present initially?

How do most patients with kidney disease present initially? = 3

1) Hematuria
2) Abdominal pain
3) Asymptomatic
Renal impairment most commonly identified first by laboratory tests: Most patients, even with significant renal disease, will not have symptoms until > 50-75% of renal failure.
Even slight renal impairment signals need to better treat/control underlying medical conditions (e.g., diabetes, hyperlipidemia, hypertension).
Many drugs cleared by kidneys and, therefore, level of renal function necessary to determine proper dosage and risk of toxicity.

4)Flank pain

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