Conference Notes 1/8/2024

Nephritis/Nephrosis – Dr. Samuels
- Nephritic vs Nephrotic
  - Nephritic Syndromes
    - Hypertension
    - Decreased Urine Output
    - Proteinuria +/-
    - RBC casts
    - Examples:
      - PSGN
      - Rapidly Progressive Glomerulonephritis
      - IgA Nephropathy
  - Nephrotic
    - >3.5 grams protein excreted per 24h
    - Hypoalbuminemia >lipid formation
    - Edema/anasarca
    - Hypercoagulable state (loss of antithrombin III, protein C & S)
    - Examples:
      - FSGS (focal segmental glomerulosclerosis)
      - Membranous Nephropathy
      - Diabetic Nephropathy

Urinary Infections – Dr. Stanforth
- Urinary Tract Infections
  - Pathophys
    - Bacteria ascend through the urethra
    - Complicated vs uncomplicated
    - Relapse = recurrence of symptoms within 1 month despite treatment (typically same organism)
    - Reinfection = symptoms develop 1-6 months after treatment (typically different organs mim)
  - Risk factors
    - Anatomical abnormalities
    - Advanced age (men)
    - Nursing home residency
    - Neonatal
    - Diabetes, sickle cell disease
    - Pregnancy
    - Immunosuppression
    - Advanced neurologic disease
  - General workup
    - UA
      - WBC >5 w/ symptoms is diagnostic
    - Urine culture
    - Consider labs: CBC, CMP, lactic
    - Blood cultures not always indicated as cultured organsmi will typically match urine culture (97%)
  - Types
    - Renal
      - Pyelonephritis
        
        Flank pain, fevers, chills, nausea, vomiting
        
        CVA tenderness alone could be referred pain from cystitis
        
        Complications
        
        Bacterial Nephritis
        
        Renal/perinephric abscess
        
        Emphysematous pyelonephritis
    - Ureteral
      - Infected stone (8-15% of stones have co-infection)
      - Systemic symptoms: urology consult, close follow-up
      - Obstruction with infectious symptoms -> urologic emergency
      - Imaging considerations
    - Cystitis
      - Infection of bladder
      - Complicated
        
        Symptoms >7 days
        
        DM
        
        UTI in previous 4 weeks
        
        Men
        
        > 65years old
        
        Women using spermicides or diaphragm
        
        Relapse
        
        Pregnancy
      - Treatment
        
        Refer to system/community based antibiogram
    - Urethritis
      - UA, Urine GC/Chlamydia, M. genitalium and trichomonas testing
      - Treatment: Empirically cover gonorrhea and chlamydia
      - Partner treatment
    - Prostatitis
      - E. coli makes up about 80% of cases
      - Enterococcus, Staph. N. gonorrhoeae, Chlamydia
      - Prostate manipulation: increased risk of pseudomonas infections
    - Management:
      - Prolonged antibiotic course
  - Asymptomatic bacteriuria
    - Do not treat unless immunocompromised or pregnant

PEM: Renal Disorders – Dr. Lund
- Pediatric Renal/GU
  - UTI
  - UTI: Diagnosis
    - Culture showing leukocyte esterase or pyuria AND …
      - 1,000 CFU SPA
      - 50,000 CFU catheterized specimen
      - 100,000 CFU clean catch
    - 2-24 months first febrile UTI or recurrent UTI in older child needs RBUS
  - UTI: Treatment
    - Cephalexin 25 mg/dose TID (max 1000mg/dose)
    - https://uticalc.pitt.edu/
- PIGN
  - One of the most common causes of acute glomerulonephritis in children
  - PSGN: Clinical features
    - M>F
    - 4-14 y/o, rare before 2 y/o
    - Latency 1-2 weeks for pharyngeal infections and 3-5mfor skin infection
  - Acute nephritic syndrome
    - Hematuria
    - Hypertension
    - Edema
    - Oliguria
  - PSGN: Treatment
    - Treat underlying infection
    - Treat nephritic syndrome, if needed
      - Diuretics
      - Antihypertensives
      - RRT
- Hemolytic Uremic Syndrome
  - Triad of microangiopathic hemolytic anemia, thrombocytopenia and acute kidney injury
  - Many etiologies with most common being shiga-toxin producing E. coli (STEC)
  - Treatment
    - pRBC
    - Fluid/electrolyte anagment
    - Dialysis
    - Platelets
- Henoch Schonlein purpura
  - IgA depositions in blood vessel walls – kidneys, GI tract, skin, joints
  - Clinical manifestation
    - Palpable purpura
    - Joint pain
    - GI complaints
    - Renal involvement
    - Cerebral vasculitis
    - Testicular hemorrhage
    - Interstitial pulmonary hemorrhage
  - Pathogenesis
    - Preceding URI
    - IgA complexes deposit in the small vessels in the skin joints, kidneys and GI tract.
  - Diagnosis
    - Mandatory criterium:
      - Purpura or petechiae with lower limb predominance
    - Minimum Criteria(1 of 4)
      - Diffuse abdominal pain with acute onset
      - Arthritis or arthralgia of acute onesie
      - Renal involvement in the form of proteinuria or hematuria
      - Histopathology showing leukocytoclastic vasculitis or proliferative glomerulonephritis, with predominant immunoglobulin A deposits
  - Treatment
    - Non renal involvement -> symptomatic treatment
    - No consensus on HSP nephritis/severe complications
      - Steroids
      - Cyclosporine, mycophenolate, cyclophosphamide, rituximab, dapsone
  - Approach to Hematuria
    - Pathophysiology
      - Glomerular
        
        Disruption of the glomerular basement membrane with leakage of RBS and protein
        
        RBC casts
        
        Brown, smoky coca-cola colored
      - Non-glomerular
        
        Renal papillae
        
        Sickle cell disease, trait
        
        Tubules are site inflammation caused by NSAIDs and antibiotics
        
        Pink, bright red with ot without clots more likely lower in urinary tract
        
        Increased vascularity from infection or chemical irritation
    - Evaluation
      - Confirm blood in urine
      - Detailed patient and family history
      - Life Threatening causes
        
        Trauma
        
        Acute glomerulonephritis
        
        HUS
        
        Renal stones with obstruction
        
        Tumor
        
        Hematologic disorders
        
        toxin/xenobiotic
    - Trauma
      - Hematuria is “cardinal marker of renal injury, with magnitude of hematuria paralleling the severity of renal injury (except renal pedicle injuries, which may have no associated hematuria
      - Presence of gross hematuria or significant microscopic hematuria (>50 RBCs/HPF) along with mechanism point to emergent imaging

Testicular Infections/STI – Dr. Scott
- Sexually Transmitted Infections
  - Ulcerative
    - Painful Ulcers
      - HSV
        
        HSV-2
        
        Multiple painful lesions
        
        Starts as blisters
        
        Clinical Dx
        
        Acyclovir 400 mg q8h x7-10 days or valacyclovir 1 g q12h x 7-10 days
      - Chancroid
        
        H. ducreyi
        
        Begins as chancre -> unilateral painful inguinal lymphadenopathy forms (buboes)
        
        Can form abscess
        
        Azithro 1 g PO x1 dose
    - Painless
      - Syphilis
        
        Chancre painless
        
        Secondary
        
        Maculopapular ras on trunk and extremities
        
        CSF involvement (40%)
        
        Late
        
        Most commonly neuro, associated with HIV
        
        Gummas
        
        Cardiovascular
        
        Diagnosis
        
        RPR or VDRL -> antibody if reactive
        
        Antibody test -> RPR or VDRL
        
        Tx:
        
        Penicillins
        
        Doxycycline
        
        Ceftriaxone if neurosyphilis
        
        Jarish-Herxmeier reaction: fever. Chills, myalgias, headache
      - LGV
        
        Chlamydia trachomatis
        
        Associated with HIV
        
        Primary: painless ulcer x2-3 days
        
        Secondary: painful ulcer 2*6 weeks later
        
        Fever, mylagia, malaise
      - Gonorrhea chlamydia/chlamydia
        
        Arthritic, PID
        
        Urine culture
        
        Ceftriaxone/doxy
      - Epididymitis
        
        <35, GC/chlamydia
        
        >35 (or anal intercours): e. Coli, pseudomanas, TB, enterovacrer, syph
        
        Scrotal elevation
        
        Pain relief
        
        GC/Chlamydia treatment
      - Orchitis
        
        Testes inflammation
        
        Most commonly mumps
        
        GC, chlamydia, E. coli

Torsion – Dr. Gosser
- Ovarian torsion
  - Most common in reproductive-aged females but is found in females of any age
  - Risk factors
    - Ovary > 4cm
    - Pregnancy
    - Patients undergoing IVF, patients after tubal ligation
  - Mechanism: enlarged ovary rotates on the axis of its ligaments leading to twisting of the ligaments restricting lymphatic outflow, swelling that will inhibit venous return that in-turn compromises arterial blood flow.
  - Requires emergent OB/Gyn consult for operative management
- Testicular torsion
  - Bimodal incidence
    - Peaks in first year of life and in puberty
  - Risk Factors
    - Mechanical: exertional/exercise, trauma
    - Testicular masses
    - Undescended testicle
    - Bell-clapper deformity
  - Evaluation
    - Emergent urology consult
    - UA
    - US for equivocal cases
    - TWIST Score
  - Mechanism
    - Twisting of the testis on its blood supply
    - Tunica vaginalis is secured to the scrotal wall on the posterolateral side, prevents movement of the testis
      - If this attachment occurs too superiorly, this can lead to torsion
  - Treatment
    - Manual detorsion (temporizing measure)
      - Medial to lateral rotation (open book)
    - Urological consultation for detorsion and orchipexy
    - Salvage rates
      - 100% at 6 hours
      - 20% at 12 hours
      - Little to no salvageability at >24 hours
ITE Tox Review – Dr. Eisenstat
- Toxicology ITE Prep
  - self-review
Renal Emergencies – Dr. Thomas
- Hyperkalemia and Emergent Hemodialysis
  - Causes of hyperkalemia
    - The Kidney
      - Renal insufficiency
      - ARF
      - Addison’s Disease, Adrenal insufficiency
      - ACEs
      - ARBs
    - Intake
      - Excessive K+ supplementation
      - Excessive K+ in diet
      - Dehydration
        
        Prerenal cause of insufficiency
        
        Causes shift in electrolytes with more K+ now extracellular
    - Tissue Damage
    - Endocrine
    - The Lab/Phlebotomy
  - Hyperkalemia
    - Generally >5 or 5.5
    - The serum concentration of K+ is important
    - The rate of change in the concentration of serum K+ is MORE important
    - EKG changes
      - Mild 5.5-6.5 – Peaked T Waves and or Prolonged PR segment
      - Moderate 6.5-8 – Loss of P Wave, Prolonged QRS complex, ST-Segment elevation, Ectopic beats
      - Severe >8.0 – Progressive widening of the QRS, Sine wave morphology, V-fib, Asystole, axis deviations, BBB, Fascicular blocks
  - Therapy
    - Calcium
    - Insulin/dextrose
    - Albuterol
    - Bicarb
      - Only really worthy of consideration in setting of metabolic acidosis
    - Diuretics
    - GI elimination
      - NOT RAPID
      - NOT FOR EMERGENCY TREATMENT
    - Hemodialysis
  - Emergent Hemodialysis
    - AEIOU
      - Acidosis
        
        pH ,7.1
      - Electrolytes
        
        Refractory hyperkalemia
      - Intoxication/Ingestions
        
        Toxic alcohols, salicylates, lithium, etc
      - Overload
        
        Congestive Heart Failure
      - Uremia
        
        Uremic pericarditis, uremic encephalopathy
    - I STUMBLED (Toxins removed by HD)
      - I – INH, Isopropyl alcohol
      - S – Salicylates
      - T – Theophylline, Tenormin (atenolol)
      - U – Uremia
      - M – Methanol
      - B – Barbiturates
      - L – Lithium
      - E – Ethylene glycol
      - D – Dabigatran, Depakote

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The sickest patients, who receive world-class care in the trauma/critical care bay of University of Louisville Department of Emergency Medicine

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