GENITOURINARY TIKI TAKA

_________________________

. GLOMERULONEPHRITIS common criteria:

_____________________________________
1- RBCs in urine.
2- Red cell casts in urine.
3- Mild degree of proteinuria (< 2 g. / 24 hs.).
4- Edema.
5- May lead to nephrotic $.
6- Most accurate diagnosis by --> RENAL BIOPSY.

* GOOD PASTURE's $YNDROME:

___________________________
. Cough, hemoptysis, shortness of breath & lung findings.
. Dx: Best initial test: Anti-basement membrane Abs.
. Dx: Most accurate test: Renal biopsy -> Linear deposits.
. Tx: PLASMAPHARESIS & steroids.

* CHURG STRAUSS $YNDROME:

__________________________
. ASTHMA, cough, EOSINOPHILIA + Renal abnormalities.
. Dx: Best initial test: CBC for eosinophil count.
. Dx: Most accurate test: Renal biopsy.
. Tx: Glucocorticoids "prednisone".

* WEGENER's GRANULOMATOSIS:
____________________________
. URT infections + LRT infections.
. URT infections -> sinusitis & otitis.
. LRT infections -> cough, hemoptysis, Abnormal CXR.
. It is a systemic vasculitis so it may involve the joint, skin, eye.
. Dx: Best initial test: C-ANCA "Anti-neutrophil cytoplasmic Ab".
. Dx: Most accurate test: Renal biopsy.
. Tx: Steroids & cyclophosphamide.

* POLYARTERITIS NODOSA:
________________________
. Systemic vasculitis.
. Involvement of all organs EXCEPT LUNGS !!!!!
. Renal - myalgia - GI bleeding - purpura - stroke - uveitis - neuropathy.
. MULTIPLE MOTOR & SENSORY NEUROPATHY + PAIN.
. Dx: Best initial test: ESR & inflammation markers.
. Dx: Most accurate test: Renal biopsy or SURAL N. biopsy.
. Test for HEPATITIS B & C (Ass. e' PAN).
. ANGIOGRAPHY showing BEADING can spare the need for biopsy.
. Tx: Steroids & cyclophosphamide.

* IgA NEPHROPATHY = BERGER's DISEASE:

______________________________________
. Painless recurrent hematuria.
. ASIAN pt.
. H/O of very recent viral upper RTI.
. Dx: Best initial test: ++ IgA !
. Dx: Most accurate test: RENAL BIOPSY IS ESSENTIAL !
. Normal complement levels.
. Tx: Steroids.
 * HENOCH - SCONLEIN PURPURA:
_____________________________
. Adolescent or child.
. Raised, non-tender purpuric skin lesions "buttocks".
. Abdominal pain.
. Possible bleeding.
. Joint pain.
. Renal involvement.
. Dx: Best initial test: CLINICAL SUSPENSE !
. Dx: Most accurate test: R. biopsy "Not necessary".
. Tx: No ttt - Resolves spontaneously.

* POST-STREPTOCOCCAL GLOMERULONEPHRITIS = PSGN:

________________________________________________
. Dark urine "Tea-colored or cola-colored".
. Periorbital edema & hypertension.
. H/O of Throat or skin infections 10 - 20 days ago.
. Dx: Best initial test: Anti-streptolysin O test "ASLO",
. Anti-DNase & Antihyaluronidase.
. Low complement levels.
. Dx: Most accurate test: R. biopsy sh'd n't be done bec. blood tests r
suffecient.
. Tx: Antibiotics e.g. PENICILLIN.
. CONTROL HYPERTENSION & FLUID OVERLOAD with diuretics.

* CRYOGLOBULINEMIA:
____________________
. H/O of HEPATITIS "C" with renal involvement.
. Joint pain & pruritic skin lesions & Hepatosplenomegaly.
. Dx: Best initial test: Serum cryoglobulin componet levels,
. immunoglobulins & light chains, IgM.
. Low complement levels esp. "C4".
. Dx: Most accurate test: R. biopsy.
. Tx: Treat HEPATITIS C with INTERFERON + RIBAVIRIN.

* LUPUS (SLE) NEPHRITIS:

_________________________
. H/O of SLE !!
. N.B. Drug induced lupus spares the kidneys & the brain "V.V.V. imp.".
. Dx: Best initial test: ANA & Anti-Ds DNA.
. Dx: Most accurate test: RENAL BIOPSY.
. R. biopsy is v. imp. in cases of SLE to determine the extent of the disease &
ttt.
. Tx:
----- Sclerosis only -------------------------------> No ttt.
----- Mild dis., early stage, NON proliferative ----> Steroids.
----- Severe dis. late stage, PROLIFERATIVE --------> MYCOPHENOLATE.

* ALPORT $YNDROME:
___________________
. CONGENITAL with family H/O of renal failure.
. Recurrent episodes of hematuria.
. Eye & ear problems e.g. deafness.
. No specific therapy.

* HEMOLYTIC UREMIC $YNDROME:

____________________________
. H/O of E-coli 0157:H7
 . Intra-vascular hemolysis (fragmented cells on smear).
. ++ Creatinine.
. -- platelets.

* THROMBOTIC THROMBOCYTOPENIC PURPURA "TTP":

_____________________________________________
. HU$ +
. Fever +
. Neurological abnormalities.
. Tx: Plasmapharesis in severe cases.

___________________________
. ARF : PRE-RENAL AZOTEMIA:
___________________________

.. Presentation:
_________________
... Elderly pt with poor oral intake living in nursing homes taking medications
e.g.,
... NSAIDs, ACE Is & diuretics causing intravascular volume depletion.
... leading to renal glomerular vasoconstriction.

.. Causes:
___________
. 1- Hypotension "SBP <90 mmHg".
. 2- Hypovolemia "dehydration or blood loss".
. 3- Low oncotic pressure " -- Albumin".
. 4- Congestive heart failure.
. 5- Constrictive pericarditis.
. 6- Renal artery stenosis.

.. Dx:
_______
... BUN:Creatinine ratio > 20:1.
... Urinary Na is low < 20.
... Fe Na < 1.
... Urine osmolality > 500.

___________________________________________________
. ARF : POST-RENAL AZOTEMIA = OBSTRUCTIVE UROPATHY:
___________________________________________________

.. Causes:
___________
. 1- Stone in the bladder or ureter.
. 2- Strictures.
. 3- Cancer of the bladder, prostate or cervix.
. 4- Neurogenic bladder "Atonic or non-contracting due to MS or DM".

.. Dx:
_______
... Similar to pre-renal azotemia.
... Distended bladder on exam.
... Large volume diuresis after passing a urinary catheter.
... Bilateral hydronephrosis on U/$.

______________________________________________________
. ARF : INTRA-RENAL AZOTEMIA = ACUTE TUBULAR NECROSIS:
______________________________________________________
 .. Dx:
_______
... BUN/Creatinine ratio 10:1.
... Urinary Na > 40.
... Urine osmolality < 350.

* TOXIN INDUCED RENAL INSUFFECIENCY:

_____________________________________
. Aminoglycosides: Gentamycin, tobramycin, Amikacin (--Mg is suggestive).
. Amphotericin.
. Contrast agents (--Mg is suggestive).
. Chemotherapy e.g Cisplatin.
. Urinalysis: MUDDY BROWN or GRANULAR CASTS.

* ALLERGIC INTERSTITIAL NEPHRITIS:

___________________________________
. Hypersensitivity reaction to medications e.g. Penicillin or Sulfa drugs.
. Phenytoin, Allopurinol, Cyclosporin, Quinidine & Rifampin.
. FEVER & RASH & ARTHRALGIA.
. Dx: WRIGHT stain or HANSEL's STAIN of the urine ---> EOSINOPHILIA.
. WBCs casts are common but RBCs cast are rare.
. Tx: Discontinue the offending drug.

* RHABDOMYOLYSIS:
__________________
. Large volume muscular necrosis.
. causes direct toxic effect of myoglobin on the kidney tubule.
. H/O of crush injury or seizure.
. H/O of prolonged immobility.
. H/O of recent start of STATIN for hyperlipidemia.
. Best initial test: Urinalysis -> Large amounts of blood with no cells.
. Relative absence of RBCs on urine microscopy.
. ++ CPK (MOST SPECIFIC FINDING).
. Most accurate test: Urine myoglobin > 20000.
. Rhabdomyolysis --> ++ K & -- Ca.
. In case of hyperkalemia .. Do EKG to exclude arrhythmia.
. Tx hyperkalemia with IV Ca gluconate, insulin & glucose.
. Tx: BOLUS OF NORMAL SALINE, MANNITOL.
. ALKALINIZATION OF URINE.

* OXALATE CRYSTAL INDUCED RENAL FAILURE:

_________________________________________
. H/O of suicide trial by anti-freeze ingestion "ethylene glycol".
. intoxication due to metabolic acidosis & ++ in anion gap.
. Best initial Dx: Urinalysis --> ENVELOPE SHAPED OXALATE CRYSTALS.
. Best initial Tx: ETHANOL or FOMEPIZOLE with immediate dialysis.

* URIC ACID CRYSTAL INDUCED RENAL FAILURE:

___________________________________________
. H/O of chemotherapy for lymphoma causing tumor lysis $.

* CONTRAST INDUCED RENAL FAILURE:

__________________________________
. H/O of radiological procedure with contrast.
. H/O of elderly pt with DM or HTN.
. CREATININE just above normal 1.5 - 2.5.
. Tx: HYDRATION with Normal saline & Bicarbonate & N-Acetyl cysteine.
 . NON-IONIC contrast agent is associated with less severity of nephropathy.

* NSAIDs INDUCED NEPHROPATHY Mechanism:

________________________________________
. Direct toxicity & ATN.
. Allergic interstitial nephritis with eosinophils in the urine.
. Nephrotic $.
. Afferent arteriolar VC.

. NEPHROTIC $YNDROMES & THEIR ASSOCIATIONS:

___________________________________________
. CHILDREN -------------------------------> Minimal change disease.
. ADULTS & CANCERS "LYMPHOMA" ------------> MEMBRANOUS.
. HEPATITIS C ----------------------------> MEMBRANOPROLIFERATIVE.
. HIV, HEROIN USE ------------------------> FOCAL SEGMENTAL.
. UN-CLEAR -------------------------------> MESANGIAL.

. STEPS FOR PROTEINURIA EVALUATION:

___________________________________
. Repeat the urine analysis.
. Evaluate for orthostatic proteinuria.
. Get a protein/creatinine ratio.
. Perform a renal biopsy.

. INDICATIONS OF DIALYSIS:
__________________________
. Hyperkalemia.
. Metabolic acidosis.
. Uremia with encephalopathy.
. Fluid overload.
. Uremia with pericarditis.
. Toxicity with a dialyzable drug e.g. Lithium , ethylene glycol or Aspirin.

. URGE INCONTINENCE:
____________________
. Pain followed by urge to urinate.
. Not related to coughing, laughing or standing.
. Dx: Urodynamic pressure monitoring.
. Tx: Behaviour modification + Anti-cholinergics.

. STRESS INCONTINENCE:
______________________
. NO PAIN.
. Follow coughing or laughing.
. Dx: Observe leakage with coughing.
. Tx: KEGEL exercise + Estrogen cream.

. SEVERE HYPERKALEMIA:
______________________
. Denoted by PEAKED T waves on EKG.
. Tx: I.V. CALCIUM GLUCONATE.

. NEPHROLITHIASIS:
__________________
. Sudden onset flank pain.
. Colicky, may be referred to the scrotum.
. Nause, vomiting.
. Cola colored urine.
. Dx: Non contrast CT Abdomen (Preferred to X-ray as it detects Radio-lucent
stones).
. Tx: Relieve the pain by NSAIDs.
. Tx: Stones < 5 mm -> pass spontaneously with conservative ttt.
. Best conservative ttt is FLUID INTAKE > 2 LITERS / day.

. DEHYDRATION:
______________
. Altered mental status.
. Dry oral mucosa.
. ++ Na & ++ K.
. BUN / Creatinine > 20 "Pre-renal azotemia".
. More common in old age due to -- thirst response to dehydration.
. Tx: I.V. sodium containing CTYSTALLOIDS = NORMAL SALINE = 0.9 % NaCl.

. HERNIATED INTERVERTEBRAL DISK may cause URINE RTENTION due to SEVERE PAIN:
____________________________________________________________________________
. Unilateral radicular pain in a dermatomal distribution.
. Bk tendrness due to spasm of the paraspinous muscles.
. Cauda Equina $ can be excluded by absence of saddle anesthesia & intact
sphincter tone.
. There will be pain on coughing or chest movement.
. So, severe pain in a pt.with a mild urinary obstruction, such as BPH,
. may cause urinary retention due to inability to Valsalva.

. CHLAMYDIAL URETHRITIS:
________________________
. Middle aged female.
. H/O of mutliple sex parteners.
. Dysuria & urinary frequency.
. Urinalysis: Absent bacteriuria.
. Urine culture < 100 colonies.

. HONEYMOON CYSTITIS:
_____________________
. Urinary infection most commonly arises by an ascending route.
. Sexual intercourse is one of the most imp. risk factors of un-complicated UTIs.
. due to its mechanical effect of introducing uropathogens into the bladder.

. RENAL CELL CARCINOMA:

_______________________
. Triad of flank pain, hematuria & palpable abdominal renal mass.
. Scrotal varicoceles "Lt sided" r seen in 10 % of pts.
. Varicoceles typically fail to empty when the pt is recumbent due to tumor
obstruction.
. So presence of non emptying varicocele make you suspect mass obstruction by a
tumor !
. Para-neoplastic symptoms e.g. Thrombocytosis, hypercalcemia & cachexia.
. Dx: Abd. CT .

. BENIGN PROSTATIC HYPERPLASIA = BPH:

_____________________________________
. Lower urinary tract symptoms e.g. frequency. nocturia, hesitancy & weak stream.
. Hypertrophy usually starts at the CENTRAL part of the prostate.
. Rectal exam: Smooth & firm enlargement of the prostate.
. N.B. prostate cancer rectal ex: (prostate nodules - induration - asymmetry).
. 1st initial step of management is placement of a FOLEY's catheter.
. Tx of BPH: Alpha blockers.
. Tx of severe cases: Surgery TURP.
. Current recommendations: All BPH pts sh'd have urinalysis & serum creatinine,
 . to assess for urinary infection, obstruction or hematuria.
. If there is woresening of creatinine,
. Abdomial ULTRA$OUND is the initial test of choice to assess for HYDRONEPHROSIS.
. Hydronephrosis is caused by urinary obstruction & renal failure.

. HYPERKALEMIA (++ K > 5):

__________________________
. Drugs ++ K (ACE Is - NSAIDs - K sparing diuretics e.g. spironolcatone &
Amiloride).
. Pseudohyperkalemia (Hemolyzed sample during venipuncture).
. Hyperkalemia (K > 6.5) may cause cardiac toxicity .
. EKG -> Peaked T waves & progressive widening of the QRS complex.
. Tx: IV CALCIUM GUCONATE.
. Tx: Insulin - B2 agonists.
. Tx: Na HCO3.
. Dialysis in severe cases.
. REMOVAL OF K FROM THE BODY -----> KAYEXALATE !

. The most common cause of death in RENAL DALYSIS & TRANSPLANTATION:

____________________________________________________________________
. is CARDIOVASCULAR complications.

. ANALGESIC NEPHROPATHY:
________________________
. Woman with chronic headaches on NSAIDs.
. Presenting with painless hematuria.
. NSAIDs -> VC of renal medulla vessels -> RENAL PAPILLARY NECROSIS.
. CHRONIC TUBULO-INTERSTITIAL NEPHRITIS.

. AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE (ADPCKD):

________________________________________________________
. HYPERTENSION + PALPABLE kidneys "BILATERALLY".
. Multiple renal cysts & intermittent flank pain.
. Liver enlargement due to cystic involvement "Most common extra-renal
manifestation".
. Hematuria, UTIs & nephrolithiasis.
. Death may occur due to intracranial bleeding caused by rupture of berry anurysm.

. GLOMERULOPATHY associated diseases:

_____________________________________
. Lymphoma ---------------------------->
. Lymphoma complicated by nephrotic $ ->
. HIV --------------------------------->
. AFRICAN AMERICANS ------------------->
. OBESE ------------------------------->
. HEROIN ADDICTS ---------------------->
Membranous nephropathy.
Minimal change nephropathy.
Focal & segmental glomerulosclerosis.
Focal & segmental glomerulosclerosis.
Focal & segmental glomerulosclerosis.
Focal & segmental glomerulosclerosis.

. MULTIPLE MYELOMA:
___________________
. Old age pt 65 ys with anemia, fatigue & bony pains (back & chest).
. Renal insuffeciency due to obstruction of the distal & collecting tubules by,
. BENCE JONES PROTEINS "PARA-PROTEINS".
. Old pt + bony pain + renal failure + Hypercalcemia = Multiple myeloma.

. AMITRIPTYLINE INDUCED URINE RETENTION:

________________________________________
. Amitriptyline is TCA with anticholinergic properties,
. it will lead to -- dterusor ms contraction & prevent urethral sphincter
relaxation.
 . leading to urine retention.
. Tx: Discontinue Amitriptyline + urinary catheterization.

. OVER-FLOW IN-CONTINENCE:
__________________________
. May be due to DM autonomic neuropathy causing a denervated bladder -> urine
retention.
. The a-contractile hypotonic bladder gradually overdistends,
. When the bladder pressure rises above the urethral pressure,
. Urine is lost until the pressure equalizes !
. These events occur in a cyclic manner occuring at day & night.
. Exam may reveal a distended bladder.
. post-voidal residual urine volume is high.
. Associated other D.M. manifestations e.g. gastropathy, nephropathy &
retinopathy.

. D.M. is the 1st leading cause of nephropathy, kidney biopsy will show:
________________________________________________________________________
. GLOMERULAR HYPERFILTRATION is the EARLIEST renal abnormality detected. (UW Q!).
. ++ extracellular matrix, basement membrane thickening, mesangial expansion &
fibrosis.
. DIABETIC MICRO-ANGIOPATHY. (UW Q!)
. Proteinuria & progressive -- in GFR.
. Glomerulosclerosis. (UW Q!).

. HTN is the 2nd leading cause of nephropathy, kidney biopsy will show:
_______________________________________________________________________
. Arterio-sclerotic lesions of the afferent & efferent renal arterioles &
capillaries.
. NO proteinuria.

. HEMATURIA:
____________
. Initial "Beginning of urination" -----> Urethral lesion e.g. Urethritis.
. Terminal "At the end of voiding" -----> Prostatic or Bladder lesion e.g.
cystitis.
. Total "during the entire process" ------> Ureters or kidneys lesion.

. The presence of clots in urine is more consistent with bladder not renal lesion.

_______________________
. URINARY TRACT STONES:
_______________________

1.CALCIUM OXALATE STONES:

__________________________
. Radio-opaque.
. envelope shaped on microscopy.
. Small bowel disease, surgical resection or chronic diarrhea,
. may lead to malabsorption of fatty acids & bile salts,
. which are important for chelating calcium,
. so, when Calcium is free, it binds with oxalic acid,
. forming Ca Oxalate stones.

2.CALCIUM PHOSPHATE STONES:

____________________________
. common in primary hyperparathyroidism.
 3.URIC ACID STONES:
____________________
. When urine is acidic.
. When there is ++ cell turnover.
. Radio-lucent on X-ray.
. Tx: Hydration.
. Tx: Alkalinization of urine to pH > 6.5 by oral POTASSIUM CITRATE.

4.CYSTEINE STONES:
___________________
. ++ cysteine "Inborn error of metabolism".
. +ve family H/O.
. Recurrent stones since childhood.
. HARD & RADIO-OPAQUE stones.
. HEXAGONAL CRYSTALS on urine analysis.
. +ve Urinary cyanide nitroprusside test.

5.STRUVITE STONES:
___________________
. Formed when urine is ALKALINE.
. Bec. of infection with urease producing bacteria e.g. PROTEUS.
. H/O of recurrent UTI.

. NEPHROTIC $YNDROME:
______________________
. Proteinuria ( > 3- 3.5 g/day - most imp. criterion).
. Hypoalbuminemia.
. Edema.
. Hyperlipidemia & lipiduria.
. Pathology: Altered permeability of the glomerular membrane.
. Children : Minimal change disease.
. Adults : Membranous glomerulopathy.
. Complicated by HYPERCOAGULABILITY -> Thrombo-embolic manifestations.
. Accelerated atherosclerosis.
. Venous or arterial thrombosis & even pulmonary embolism.
. Other complications: Ptn malnutrition - iron resistant microcytic hypochromic
anemia.
. Other complications: ++ susceptibility to infections & vitamin D defeciency.

. POST-OPERATIVE OLIGURIA:
__________________________
. Low urine out-put volume with lower abdominal pain.
. Most common cause is post-renal i.e. bladder out-let obstruction.
. Placement of a bladder catheter can rapidly improve symptoms "1st step done".
. Never to start fluids before catheterization as it may worsen the condition.

. BLUE TOE $YNDROME = CHOLESTEROL EMBOLIZATION:

_______________________________________________
. H/O of cardiovascular disease with recent surgical intervention or angiography.
. Atherosclerotic plaque may break off & enter the circulation.
. Abdominal pain & nausea.
. Livedo reticularis = cyanotic dicolouration of the skin
. ARF may occur due to renal artery embolization.
. ++ urea & creatinine levels.
. -- complement levels.
. ++ eosinophils.

. N.B. BLUE TOE $ sh'd n't be mis-diagnosed with CONTRAST INDUCED NEPHROPATHY:
______________________________________________________________________________
 . Absence of livedo reticularis, abd. symptoms, high eosinophils & -- complement.

. ACUTE PYELONEPHRITIS:
_______________________
. Acute febrile illness.
. Costo-vertebral angle tendrness.
. Pyuria & bacteriuria.
. Initial ttt -> Blood cultures followed by Empirical I.V. Antibiotics.
. No response within 72 hours -> Do imaging e.g. U/$ or CT,
. to search for underlying pathologies (e.g.obstruction) or complications
(e.g.abscess).

. Prazosin & TRAZODONE cause PRIAPISM !

. Diabetic pts with renal failure on METFORMIN should stop it as it ++ lactic

acidosis.

. SIMPLE RENAL CYST:

____________________
. Age > 50 ys.
. Benign, don't require ttt.
. Reassurance.

. Both IgA Nephropathy & PSGN are major causes of hematuria after an upper RTI:
_______________________________________________________________________________
. IgA nephropathy: begins (1-5days) after URTI with normal serum complement.
. PSGN : begins 10-15 days after URTI with low serum complement.

. MEMBRANO-PROLIFERATIVE GLOMERULONEPHRITIS:
____________________________________________
. caused by persistent activation of the alternative complement pathway.
. Microscopy: Dense intra-membranous deposits that stain for C3.

. Dipsticks findings in case of UTI:

____________________________________
. Leukocyte esterase -> Pyuria.
. Positive nitrites -> Enterobacteriaceae.
. The most common culprit organism in UTIs is E-Coli.

. ERYTHROPOIETIN THERAPY in cases of ESKD:

__________________________________________
. ESKD presents with normocytic normochromic anemia due to -- erythropoietin.
. Tx of choice is recombinant erythropoietin.
. Started if Hb < 10 g/dl.
. Most common side effect is WORSENING OF HYPERTENSION.
. Other SE: Headaches & flu-like symptoms.

. ESKD ttt options:

___________________
. Dialysis or renal transplantation.
. Renal transplantation is more preferred due to better survival rate.
. A living related donor is always preferred.

. Management of CALCIUM OXALATE STONES:

_______________________________________
. 1- ++ fluid intake.
. 2- -- Na intake.
. 3- THIAZIDE DIURETIC.
. 4- -- protein & oxalate intake.
 . GUESS WHAT ???!!------------> Calcium restriction is not required

. ACUTE EPIDIDYMITIS:
_____________________
. Fever.
. Painful enlargement of the testes.
. Irritative voiding symptoms.

. Two types of epididymitis: Sex-transmitted related & non-related.

. Sex-transmitted: more common in young pts & associated with urethritis.

. Sex-transmitted: pain at the tip of the penis & urethral discharge.
. Sex-transmitted: caused by Chlamydia trachomatis & Neisseria Gonorrhea.

. NON-sex-transm.: more common in elderly & associated with a UTI.

. NON-sex-transm.: No pain at the penile tip - No urethral discharge.
. NON-sex-transm.: caused by gram -ve rods e.g. E-coli.

. ACUTE PROSTATITIS:
____________________
. Fever, chills, ++ WBCs with bandemia.
. Urinary urgency, dysuria & +ve leukocyte esterase.
. Pain in the perineal region.
. Tender boggy prostate..
. Obtaining a mid-stream urine sample is the 1st step sh'd be done.
. Prostatic massage sh'd be avoided as it may lead to infectious spread.

. EXOGENOUS ANABOLIC STEROID USE can produce INFERTILITY in MEN:

________________________________________________________________
.By suppressing the production of GnRH, LH & FSH.

. ACYCLOVIR -> CRYSTALLURIA with RENAL TUBULAR OBSTRUCTION:

___________________________________________________________
. Acyclovir doesn't produce interstitial nephritis. (Take care - common mistake).
. Acyclovir is poorly soluble in urine & easily precipitates in renal tubules.
. It causes tubular obstruction with acute renal failure.
. It is due to large parenteral doses of Acyclovir.
. Inadequate hydration is a common predisposing factor.

. FIBROMUSCULAR DYSPLASIA -> RENAL ARTERY STENOSIS -> RENOVASCULAR HYPERTENSION:

________________________________________________________________________________
. Young adult.
. Headache, hypertension & renal bruit.
. Medical therapy only with ACEIs is NOT effective.
. Tx of choice is: Percutaneous ANGIOPLASTY + STENT.

. PERICARDITIS is a common complication of UREMIA (RF):

_______________________________________________________
. Chest pain (Non radiating - Retrosternal - Relieved by leaning forward).
. EKG (Diffuse ST elevation - PR segment depression).
. Pericardial friction rub.
. Tx: Hemodialysis.

. CASTS in NEPHROLOGY:
______________________
. Muddy brown granular casts ->
. Broad & waxy casts --------->
. RBCs casts ----------------->
. WBCs casts ----------------->
Acute tubular necrosis.
Chronic renal failure.
Glomerulonephritis.
Interstitial nephritis & pyelonephritis.
 . Fatty casts ----------------> Nephrotic $.

. RENAL AMYLOIDOSIS:
____________________
. H/O of Rheumatoid arthritis (predisposes to amyloidosis).
. Enlarged kidneys & hepatomegaly.
. Renal biopsy -> Amyloid deposits with APPLE GREEN BIREFRINGENCE under polarized
light.

. RENAL DISEASE -----> RENAL BIOPSY FINDING:

____________________________________________
. AMYLOIDOSIS -> Amyloid deposits with APPLE GREEN BIREFRINGENCE under polarized
light.
. RPGN "Rapid progressive GN" -> Crescent formation.
. GOOD PASTURE's $ -> Linear immunoglobulin deposits (Ani-glomerulat b. membrane
Abs).
. LUPUS NEPHRITIS -> Granular deposits.
. NEPHROTIC $ "MINIMAL CHANGE DISEASE" -> NORMAL LIGHT MICROSCOPY.

. IMPORTANT DRUG SIDE EFFECTS:

______________________________
. TACROLIMUS: Nephrotoxicity - hyperkalemia - hypertension - tremors.
. CYCLOSPORINE: Same as Tacrolimus + Hirsutism & Gum hypertrophy.
. AZATHIOPORINE: Diarrhea - leukopenia - hepatotoxicity.
. "M"YCOPHENOLATE -> Bone "M"arrow depression.

. RENAL VEIN THROMBOSIS:

________________________
. Important complication of Nephrotic $.
. caused by MEMBRANOUS GLOMERULONEPHRITIS (Not minimal change dis.).
. Due to loss of ANTITHROMBIN 3 in urine.
. Sudden onset of abdominal pain, fever & hematuria.

. ACUTE CYSTITIS:
_________________
. Healthy, young, non-pregnant woman. " Un-complicated".
. Pregnant, v.young, v.old, D.M.,immunocompromized,anatomical abnormality.
"Complicated".
. Dysuria, frequency, supra-pubic pain & or hematuria (Hemorrhagic cystitis).
. Tx of un-complicated cystitis: NITROFURANTOIN or Oral TMP-SMX.
. Tx of complicated cystitis: Levofloxacin or ciprofloxacin.

. RENAL TRANSPLANT DYSFUNCTION:

_______________________________
. Oliguria - hypertension - ++ creatinine/urea.
. Causes:
_________
1- Ureteral obstruction.
2- Acute rejection.
3- Cyclosporine toxicity.
4- Vascular obstruction.
5- Acute tubular necrosis.

. Acute rejection is best treated with INTRAVENOUS STEROIDS.

. NON-INFLAMMATORY CHRONIC PROSTATITIS:

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. Afebrile pts.
. Irritative voiding symptoms (frequency, urgency, suprapubic or perineal
discomfort).
. Normal physical exam.
. Normal urine analysis.
. Expressed prostatic secretions show NORMAL number of leukocytes.
. culture of the expressed secretionsis NEGATIVE for bacteria.
. No past H/O of UTIs.

. HEPATO-RENAL $YNDROME:
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. Complication of end stage LIVER disease (e.g. Cirrhosis).
. -- GFR in absence of shock, proteinuria or other causes of renal dysfunction.
. Failure to respond to 1.5 liters of normal saline.
. Most common causes of death are infection & hemorrhage.
. Tx: LIVER "NOT KIDNEY" TRANSPLANTATION.

. RIRFAMPICIN (Anti-Tuberculous drug):

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. Reddish discolouration of urine, saliva, sweat & tears.
. Benign drug effect.
. Reassure the patient.

. UREMIC COAGULOPATHY:
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. Complication of CRF.
. Echymosis & epistaxis are the most common presentations.
. The main cause is PLATELET DYSFUNCTION.
. PT,PTT,Platelet count -> NORMAL.
. Bleeding time is prolonged.
. Tx: DDAVP ++ the release of factor 8 (Von Willebrand f) from endothelial storage
sites.
. PLATELET TRENSFUSION has NOOOOOO EFFECT as they quickly become INACTIVE.

. SICKLE CELL TRAIT:

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. YOUNG BLACK MALE with PAINLESS HEMATURIA.
. Painless hematuria in EPISODES !
. Caused by PAPILLARY ISCHEMIA.
. Reassurance.

. DETRUSOR MUSCLE INACTIVITY:

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. May be caused by 1st generation ANTI-HISTAMINICs due to their ANTI-CHOLINERGIC
effects.
. They inhibit the action of Acetyl-choline on Muscarinic receptors.
. Urine retention occurs due to detrusor ms. failure of contraction.
. Other SEs: Dryness of eyes, oral mucosa & rspiratory passags.

. GROSS PAINLESS HEMATURIA in an ADULT = BLADDER MASS TUMOR:

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. Do a contrast CT abominal scan or IVP to detect the mass.
. The presence of erythrocytes in urine sh'd be confirmed microscopically,
. to exclude myoglobinuria, hemoglobinuria or porphyria.
. Other causes: BEETS large amounts ingestion or Rifampicin ttt.

Dr. Wael Tawfic Mohamed

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