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Terms in this set (53)

acute onset of hematuria (usually gross),
urine sediment containing dysmorphic RBCs and RBC casts,
mild to moderate proteinuria values below
impaired renal function (azotemia),
oliguria (decreased urine output), and hypertension.

Nephrotic-range proteinuria
• >3.5 g protein/24 hours (nonpregnant adults)
• >3 mg protein/mg creatinine (children)
Hypoalbuminemia
• Serum albumin <3 g/dL (normal 3.5-4.5 g/dL)

Edema, is associated with nephrotic syndrome due to glomerular diseases. Hypoalbuminemia present b/c albumin lost in urine. Decreased plasma albumin concentration lowers plasma oncotic pressure, which favors filtration of fluid from capillaries into the interstitium. Pitting edema may be present

Other Clinical Characteristics of Nephrotic Syndrome
Hyperlipidemia
↑ liver synthesis, ↓ catabolism
↑ cholesterol (LDL, VLDL), ↑ triglycerides
Hypercoagulability
Loss of antithrombotic factors in urine
↑ liver synthesis of fibrinogen
↑ platelet number and increased platelet activation & aggregation
The most commonly encountered thromboembolic complications in children with nephrotic syndrome are renal vein thrombosis, deep vein thrombosis.
Increased risk for infection
Cellulitis
Peritonitis
Septicemia

In patients with nephrotic syndrome, abnormal filtration of macromolecules may permit lipoproteins to enter the urine (lipiduria). Some lipoproteins may be taken up by tubular epithelial cells. Such fat-laden tubular cells may degenerate and may be shed in the urine as oval fat bodies. (these would appear as "Maltese crosses" if viewed under polarized light).

CBC for nephrotic syndrome
platelet count often increased
If hemoglobin and hematocrit are increased, it suggests hemoconcentration and intravascular volume depletion.
Tubular dysfunction may causes urine to be the same osmolality as blood (1.010)
Tubules can be damaged by ischemia, toxins nephrotoxic drugs, or contrast agents.
Drugs that can causes inflammation are penicillins, cephalosporins, NSAIDS, and sulfonamides.
Endogenous Nephrotoxins
Myoglobinuria in rhabdomyolysis
Hemoglobinuria in hemolysis
filtered hemoglobin precipitates within tubules after combining with uromodulin (a normal urinary protein also called Tamm-Horsfall protein).
Light chains cast nephropathy in multiple myeloma
characterized by overproduction of abnormal immunoglobulin fragments (immunoglobulin light chains also known as Bence-Jones proteins) that are low molecular weight and readily filtered by kidney glomeruli. Bence-Jones proteins are directly toxic to tubule cells and can combine with Tamm-Horsfall protein (uromodulin) to form large casts that obstruct urine flow.
Uric acid crystals in tumor lysis syndrome
If chemo rapidly destroys a tumor, large quantities of uric acid can be released. Uric acid precipitates in the tubule lumen and causes inflam. The crystals can also obstruct flow. Tumor cells lysis also releases potassium and phosphate causing hyperkalemia and calcium phosphate crystals that enhance uric acid deposition in the kidney. All of this can cause oliguric or anuric acute kidney injury that may require dialysis.
Calcium crystals in hypercalcemia
impairs tubule functions reducing ability to concentrate urine; increased risk of calcium-containing calculi; possible nephrocalcinosis.
Acute pyelonephritis
(usually ascending bacterial infection from lower urinary tract infection) causes inflammation of the tubules and interstitium.

kidney blood vessels: thrombosis, stenosis, damage related to hypertension
What meds are they taking? Do they having any medication allergies? Have they ever needed to use contrast?
Initial laboratory tests should include the following:
• Urinalysis (dipstick plus microscopic examination of urine sediment)
• Urine protein quantification (24-hour urine collection preferred)
• Complete metabolic profile (provides BUN, creatinine, electrolytes, and albumin)
• Lipid panel (total cholesterol, LDL cholesterol, triglycerides, HDL cholesterol)
• Complete blood count (CBC and differential)
Serum Na may be low in nephrotic syndrome b/c of hyperlipidemia
Total calcium is decreased because of hypoalbuminemia (a large portion of circulating calcium is bound to albumin). Ionized calcium (not bound to albumin) remains normal.

Tests to narrow dx
Complement studies C3. C4
• Testing for HIV
• Testing for hepatitis B and C
• antinuclear antibody (ANA) and anti-double-stranded DNA antibody
• anti-neutrophil cytoplasmic antibodies (ANCA)
• anti-glomerular basement membrane antibodies
• anti-phospholipase A2 receptor (PLA2R)
• anti-streptolysin O (ASO)
• anti-deoxyribonuclease B (DNaseB)

History of:
• kidney disease
• hypertension
• diabetes
• infections, including hepatitis B or C, HIV, others
• cardiovascular disease, heart failure
• liver disease, jaundice, cirrhosis
• bleeding disorders or hematologic disorders (sickle cell, etc.)
• rheumatologic, inflammatory, or autoimmune diseases
• gout
• kidney stones (urolithiasis may cause urinary tract obstruction)
• hypercalcemia
• cancer (multiple myeloma, genitourinary system cancers, pelvic cancers, others)
• hospitalizations
• surgeries
• medical procedures

Ask whether the patient had any of the following symptoms:
• Recent fever, upper respiratory infection, pharyngitis
• Change in urine appearance (change in color, hematuria, blood clots) or change in
volume of urine
• Pain suggesting renal or ureteral colic: Flank pain (due to kidney edema associated with
inflammation, infection, obstruction), abdominal pain, or groin pain
• Shortness of breath, difficulty breathing, cough, pleuritic chest pain, hemoptysis
• Weight loss or weight gain
• Skin rash or joint discomfort
• Pain on urination (dysuria), urinary frequency, or urgency
• Difficulty starting urine stream or emptying bladder
• Diarrhea
• Increased Thirst
Check for RBC cast, WBC cast, Granular muddy/dirty casts, hyaline casts (can be normal) broad waxy casts. Do Complete metabolic profile.
Calculate Clearance
where U = urine creatinine concentration in mg/dL; P = serum creatinine concentration in mg/dL; V = volume of urine in mL/min.





Is there any family history of kidney disease?
Does the patient's past medical history includes any of the following diseases?
• kidney disease
• hypertension
• diabetes
• infections, including hepatitis B or C, HIV, others
• cardiovascular disease, heart failure
• liver disease, jaundice, cirrhosis
• bleeding disorders or hematologic disorders (sickle cell, etc.)
• rheumatologic, inflammatory, or autoimmune diseases
• gout
• kidney stones (urolithiasis may cause urinary tract obstruction)
• hypercalcemia
• cancer (multiple myeloma, genitourinary system cancers, pelvic cancers, others)
• hospitalizations
• surgeries
• medical procedures
Is the patient taking any medications, including OTC or herbal supplements? Any known allergies to medications?
Has the patient ever had any radiographic contrast media ("dye") for procedures such as CT scan (may cause contrast-induced nephropathy), angiography (may cause atheroemboli), etc.
Has the patient had any recent diagnostic tests (are there baseline kidney function tests, etc.)?
Sometimes AKI is asymptomatic in early stages.
Ask whether the patient had any of the following symptoms:
• Recent fever, upper respiratory infection, pharyngitis
• Change in urine appearance (change in color, hematuria, blood clots) or change in volume of urine,
• Flank pain (due to kidney edema associated with inflammation, infection, obstruction), abdominal pain, groin pain (renal or ureteral "colic"?)
• Shortness of breath, difficulty breathing, cough, pleuritic chest pain, hemoptysis
• Weight loss or weight gain
• Skin rash or joint discomfort
• Pain on urination (dysuria), difficulty starting urine stream or emptying bladder
• Diarrhea
• Increased Thirst

Physical Examination
In addition to a complete physical exam, consider the following:
• Signs of volume depletion: orthostatic hypotension, dry mucous membranes, dry axillae, skin tenting
• Signs of volume overload (heart failure, liver cirrhosis): edema, ascites, rales, jugular venous distention (JVD)
• Signs of Systemic Disease: infection or sepsis (septic shock), autoimmune diseases
• Signs of atheroemboli: check the toes for evidence of ischemia or gangrene
• Signs associated with urinary tract obstruction: bladder size, prostate exam




27B, Chronic Kidney Disease (CKD)
Check 6
Complete metabolic profile (CMP) with normal range in parentheses
(Normal range will vary for different laboratories, depending on the assay methods being used)
Glucose (70-99 mg/dL)
BUN (blood urea nitrogen) (8-21 mg/dL)
Creatinine (0.6-1.3 mg/dL adult; 0.3-0.7 mg/dL child) Calcium (8.0-10.5 mg/dL)
Sodium (135-145 mEq/L)
Potassium (3.5-5.0 mEq/L)
Chloride (99-108 mEq/L)
CO2, total (aka bicarbonate) (22-29 mEq/L)
Albumin (3.6-5.0 g/dL)
Bilirubin, Total (0.2-1.2 mg/dL)
Alkaline phosphatase (0-120 U/L)
Protein, total (6.0-8.0 g/dL)
ALT (alanine transaminase) (3-45 U/L)
AST (aspartate transaminase) (10-40 U/L)
Serum phosphorus and magnesium Intact PTH (parathyroid hormone)
Calculate estimated GFR (eGFR) using serum creatinine and the Cockcroft-Gault equation or other equation. Usually the laboratory provides the eGFR whenever serum creatinine is measured.
Complete Blood Count (CBC) and differential Urinalysis
Assess degree of proteinuria by measuring urinary creatinine and either albumin or protein for calculation of a ratio. Expressing protein excretion as a ratio of urine protein-to-creatinine corrects for variability in urine volume and approximates the 24-hour protein excretion rate.
Urine albumin-to-creatinine ratio:
• normal < 30 mg/g
• moderate albuminuria (a.k.a. "microalbuminuria") = 30-300 mg/g
• macroalbuminuria > 300 mg/g
• nephrotic range proteinuria > 3.5 g/day (usually albumin represents a large proportion of the urine protein)
Urine protein-to-creatinine ratio:
• normal < 150 mg/g
• moderate proteinuria 150-500 mg/g
• severe proteinuria > 500 mg/g
• nephrotic range > 3500 mg/g (> 3.5 g/day)