Nephrology & Systemic Medicine: Kidney Stones & More
Table of Contents
- Kidney stones
- Tumor lysis
- Incontinence
- UTI
- Chronic prostatitis
- Hypertension at home
- Hematuria
- Glucocorticoids & nephrotic syndrome
- Monoclonal gammopathy of renal significance
- IGA nephropathy
- Polydipsia, DI
- Multiple myeloma & AKI
- Blood pressure escalation strategy
- Miscellaneous nephrology topics
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Kidney stones
- Thiazides will decrease urine calcium, helpful in calcium kidney stones, bad in gout bc uric acid excretion decreases too
- Thiazides can increase serum uric acid
- Give citrate supplements if pH is acidic and if theres a lot of oxalate in the urine
- Cholexestyramine will decrease oxalate absorption (binds to oxalate and bile salts in the gut)
- Manage uric acid stones by increasing urine pH, increase urine volume, and xanathine oxidase inhibitors
- Medical management of stones less than 1.5 cm, lithotripsy if stone greater than 1.5 cm
- HCTZ causes increase in serum Ca, and decrease urine Ca,
i. Loop diuretic increases Ca in the urine and decreases Ca in the serum
ii. Treat Ca phosphate stones with potassium citrate and HCTZ
- Topamax- decreases urine citrate- more prone to form stones
- Potassium citrate can be used to help prevent calcium oxalate stones in patients with chronic diarrhea and malabsorption.
Tumor lysis
- rasburicase if allopurinol doesn't work or if theres underlying kidney disease or signs of acute kidney disease
Incontinence
- urge : use tolterodine - antispasmodic (first can try voiding diary)
UTI
- bactrim for simple UT, if recurs within 6 mo then change abx
Chronic prostatitis
- 6 week cipro
- Alpha 1 blocker
- NSAID
Hypertension at home
- HTN with elevated BP at home next step to evaluate- 24 BP monitoring
Hematuria
- cystoscopy if negative but suspect malignancy then CT urography without contrast
Glucocorticoids & nephrotic syndrome
- Glucocorticoids are first-line therapy for primary minimal change glomerulopathy; standard treatment of the nephrotic syndrome (ACE inhibitors or ARBs, diuretics for edema, and cholesterol-lowering medication if total cholesterol >200 mg/dL [5.1 mmol/L]) is also indicated as needed.
Monoclonal gammopathy of renal significance
- Monoclonal gammopathy of renal significance is diagnosed in patients who would otherwise meet the criteria for monoclonal gammopathy of undetermined significance but have an abnormal urinalysis and kidney insufficiency; kidney biopsy confirms the diagnosis.
IGA nephropathy
- This patient currently has preserved kidney function and proteinuria <1000 mg/24 h; therefore, continuing conservative therapy with the ACE inhibitor lisinopril is appropriate.
Polydipsia & nephrogenic DI
- Polydipsia- low Na
- Diabetes insipidus- sodium levels: Diabetes insipidus, due to either a lack of antidiuretic hormone (ADH) secretion from the posterior pituitary gland or kidney resistance to ADH (nephrogenic diabetes insipidus), will result in low urine osmolality as seen in this patient. In the absence of ADH, excessive water is excreted by the kidneys. Serum sodium is typically normal but may be elevated in patients who do not have access to water. Although lithium can cause nephrogenic diabetes insipidus, the fact that she is hyponatremic rules out this diagnosis.
- Polydipsia- low Na
Multiple myeloma & AKI
- A diagnosis of multiple myeloma is suggested by the constellation of anemia, hypercalcemia, normal anion gap metabolic acidosis, and acute kidney injury.
Blood pressure escalation strategy
- If blood pressure control requires an additional >5–mm Hg reduction, it is unlikely to be achieved by increasing the single agent from 50% to 100% maximal dose. The better strategy is to add a second drug or a third drug to a two-drug regimen, as seen in this patient.
Miscellaneous nephrology topics
- Think methanol toxicity when high serum osm and low sodium (high osmolal gap bc 2XNa + gluc/18 + bun 2.8)
- Non anion gap acidosis
- Nephrotic syndrome- Anti-PLA2R antibodies are detected in approximately 75% of primary cases and rarely found in secondary forms
- Diabetes insipidus (DI) is diagnosed with simultaneous laboratory evidence of inability to concentrate urine in the face of elevated serum sodium and osmolality; a water deprivation test can confirm the diagnosis, and response to exogenous antidiuretic hormone supports central DI.
- Edema management in nephrotic syndrome: adding a second diuretic (thiazide) after loop diuretics is uptitrated, such as metolazone in this patient
- Extras: chronic RTA, hyperaldosteronism, metabolic alkalosis, and other electrolyte disturbances appear across the notes but are not fully delineated here.
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Neurology
- Nystagmus: Lasts less than 1 min with dix hallpike peripheral; lasts greater than 1 min central; Epply+ in BPPV; vestibular neuronitis and labyrinthitis similar in presentation.
- Haloperidol contraindicated in dementia with Lewy bodies; donepezil safer.
- Deep brain stimulation for Parkinson disease with carbidopa-levodopa response issues.
- Fever control in severe head injury; acetaminophen recommended.
- etc.
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Heme/Onc
- Multiple bullet notes on coagulopathy, transfusion thresholds, infectious risks, vaccines, cancer management, HIV management, and other oncology-related issues.
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Cardiology
- High intensity statins indicated for primary prevention in selected adults; NSTEMI/PCI guidelines; arrhythmia management; device therapy; valve disease management; and perioperative considerations.
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Infectious Disease
- Toxoplasma, Candida, latent TB (INH 9 months), travel vaccines, HIV prophylaxis, antibiotic stewardship, and numerous infectious disease guidelines.
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GI
- Diarrhea etiologies, diverticulitis, ulcers, Crohn's vs UC, H. pylori management, colon cancer screening, and liver disease guidelines across multiple topics.
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Endocrinology
- Diabetes mellitus types (MODY, LADA, autoimmune), thyroid disorders, adrenal disorders, osteoporosis, vitamin D, calcium, PTH management, and hormone replacement therapy.
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Rheumatology
- Systemic sclerosis, GCA, PMR, lupus nephritis, RA, psoriatic arthritis, myositis, sarcoidosis, and related autoimmune diseases with treatment strategies.
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Pulmonology/Critical Care
- COPD management, asthma, pneumonias, ARDS, pulmonary hypertension, thoracic interventions, and sleep medicine.
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General Medicine
- Screening guidelines, preventive medicine, vaccination, cardiovascular risk, GI bleeding, GI diseases, and metabolic syndromes.
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Dermatology
- Psoriasis, eczema, fungal infections, dermatitis, bacterial infections, viral infections, and systemic associations with dermatologic disease.
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