: pyelonephritis, tubulointerstitial dz, or txp rejection Granular casts : acute tubular necrosis (ATN) Broad waxy casts : CRF w/ dilated ducts Fatty casts : nephrotic syndrome Hyaline casts : nonspecific R ENAL FAILURE BUN : normally reabsorbed, can’t be reabsorbed if kidney is damaged Azotemia : ↑ BUN Uremia : ↑ BUN w/ sx (usually BUN >60) Cr : freely filtered and not reabsorbed, measure of GFR Acute renal failure : rapid decline in renal fxn → ↑ BUN, ↑ creatinine Oliguric phase : UOP <500 mL/day, lasts 10-14 days Diuretic phase : UOP >500 mL/day, due to diuresis of retained fluids/electrolytes Recovery phase : recovery of tubular function Prerenal ARF Intrinsic ARF Postrenal ARF Etiology ↓ renal blood flow → ↓ GFR (hypotension, CHF, etc.) damage to renal parenchyma (ATN, toxins, glomerulo- nephritis, etc.) bilateral urinary tract obstruction (stones, BPH, cancer, etc.) Urine osm >500 <350 <350 Urine Na + <10 >20 >40 FENa <1% >2% >4% BUN/Cr >20:1 <15:1 >15:1 Ischemic ATN : ↓ renal blood flow → proximal/distal tubules don’t enough O 2 for Na/K pump → cell death → ARF Nephrotoxic ATN : toxin-mediated damage to proximal tubules → cell death → ARF (e.g. IV dye, gentamycin, Hb/Mb) Chronic renal failure : irreversible, progressive reduction in GFR Etiology : DM (#1), HTN (#2), chronic glomerulonephritis (#3) Stages : stage 1 GFR 90-100 stage 2 GFR 60-89 stage 3 GFR 30-59 stage 4 GFR 15-29 stage 5 GFR <15 or dialysis (aka ESRD) ARF/CRF complications : ↓ GFR → electrolyte retention → ↑ Na, ↑ K, ↑ H → HTN, CHF uremia → n/v, pericarditis, asterixis, encephalopathy, platelet dysfxn ↓ EPO → normocytic anemia ↓ vit D → renal osteodystrophy, 2° HPTH, calciphylaxis D IALYSIS Dialysis : artifical removal of electrolytes/toxins from blood Dialysate : articifial solution that resembles human plasma Indications : AEIOU – Acidosis (severe metabolic acidosis) Electrolytes (severe hyperkalemia) Intoxication (methanol, ethylene glycol, lithium, aspirin) Overload (severe hypervolemia) Uremia (severe uremia, pericarditis, BUN >150) Limitations : doesn’t help w/ kidney synthetic functions (e.g. EPO, vitamin D) Hemodialysis Peritoneal dialysis Method blood from AV fistula pumped through dialyzer, filtrated, then sent back into pt body high-glucose dialysate infused into peritoneal cavity, then drained from abdomen Frequency MWF or TuThSa q 4-8 hrs Advantages faster/more efficienct can be initiated quickly mimics normal kidney fxn self-dialysis Disadvantages risk of removing too much fluid or electrolytes requires vascular access “first - use syndrome” – chest and back pain, rare anaphylaxis w/ new machine risk of hyperglycemia risk of peritonitis increased abdominal girth
M EDICINE × R ENAL P ROTEINURIA AND Dz Presentation Management Other HEMATURIA Proteinuria >150 mg protein/24 hr • Dx screen w/ dipstick and UA, then get 24 hr • urine collection • asx/transient → reassurance • asx/persistent → Dx check BP and examine • urine sediment; Tx underlying cause • sx → Tx underlying cause + ACE inhibitors Hematuria
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