NRNP 6550 Final | UPDATED Questions with 100% Verified
Answers
Q1: Urine culture with UTI
A: 100.000 colonies in asymptomatic: bacteruria 10 - 10.000 colonies in symptomatic patients but also pyuria pyuria:
more than 10 leukocytes elevated erythrocytes with pyelonephritis WBC in urine false positive with tumor, urethritis
and poor collection technique Repeat in pregnant women
Q2: Lower urinary tract UTI and upper urinary tract UTI
A: bladder and urethra: cystitis/ urethritis/ prostatitis kidney and ureters: pyelonephritis/ renal abcess
Q3: Uncomplicated and complicated uti
A: Uncomplicated: in normal working urinary tract Complicated: defects in urinary tract or with other health problems
Q4: Common pathogens for UTI
A: E.coli (elderly women) Staphylococcus proteus mirabilis (elderly men) Klebsiella enterecoccus pseudomonas
Providencia (institutionalized) Fungus: candida
Q5: Risk factors for UTI
A: Female critically ill elderly catheter (caused by biofilm) DM calculi, tumor, stricture neurogenic bladder Women:
sexual intercourse or new sex partner pregnancy previous UTI Men: prostate enlargement prostatitis lack of
circumcision gay HIV
Q6: Findings UTI
A: Lower: Dysuria/ urgency/ frequency/ incontinence suprapubic pain hematuria fever/ chills uncommon No flank pain
Upper: flank pain fever and chills hematuria n/v ams (in elderly) malaise tachycardia/ tachypnea
Q7: Testing and results for UTI
A: Gold standard: urine culture and sensitivity: detection of bacteria. Start with POC: urine analysis. UA: pos for nitrite or
leukocyte or blood CBC: leukocyte with left shift in pyelonephritis For recurrent UTI in women or UTI in men rule out
obstruction, calculi, or necrosis with: xr voiding CT abdomen US pelvis MRI pelvis
Q8: Management acute cystitis
A: First line: - Single dose Fosfomycin (monurol) - 3 day: sulfa: trimethoprim/ sulfa (bactrim) (do not give near delivery of
baby, give cephalexin instead) or sulfa - 5 days: nitrofurantoin, caution in elderly Second line: - qiunolones:
ciprofloxain or levofloxacin for 3 days (not for pregnant women!) - B-lactams: amoxi-clav, cefdinir for 3 - 7 days
,Q9: Management uncomplicated upper UTI
A: Outpt: quinolone: ciprofloxacin for 7 days or levofloxacin for 5 days Sulfa: trimethoprim/ sulfa (bactrim) for 14 days
Inpt: Ceftriaxone or cefotaxime Ampicillin CAUTI: bacterial: treat with AB for 7 days Candiduria: fluconazole for 14
days Discomfort: Pyridium
Q10: Management acute complicated bacterial pyelonephritis
A: - Admit - Aminoglycosides: gentamicin/ tobramycin (not for monotherapy), based on renal function (trough less than 2
and peak level 5-10mg/L) and do not give for CKD - Ampicillin - Cefazolin - Cefotaxime and Ceftriaxon based on
obesity and pulm disease
Q11: Urine analysis: glucose and ketones
A: Serum glucose at least 180mg/dl for glucose to appear in urine Glucose in ua caused by: - Fancone Syndrome (bad
wall: caused by ahminoglycosides for example) - DM - Cushing's - Vit C can give false negative Ketones in urine: -
Alcohol - Diabetic - Starvation
Q12: Acute Kidney Injury
A: -Acute renal function loss with inability to excrete metabolic waste products (urea nitrogen and creatinine) to inability
to maintain fluid and electrolyte balance. - Resolves within 3mo - classified with RIFLE or etiology
Q13: RIFLE
A: Risk: creatinine up x 1.5 from baseline, GFR decrease more than 25% and UO less than 0.5ml/kg/hr for 6hr Injury:
creatinine up x 2 from baseline, GFR decrease more than 50% and UO less than 0.5ml/kg/hr for 12hr Failure:
creatinine up x 1.5 from baseline, GFR decrease more than 25% and UO less than 0.3ml/kg/hr for 12hr or anuria for
12hr Loss: Complete loss of renal function for more than 4 weeks End-stage Kidney Disease: RRT need for more
than 3mo
Q14: Prerenal renal failure
A: Most often the cause of RF - Decreased blood supply; intravascular volume depletion, vasodilatory states - Increased
tubular sodium and water reabsorption, causing: oliguria, decreased urine sodium, high urine osmolality, increased
urine specific gravity caused by: 1. Low CO 2. Hypovolemia 3. RAS (renal artery stenosis) 4. aminoglycosides,
NSAIDS Result: - low urine volume - increased urine creatinine with normal serum creatinine - minimal proteinuria -
serum K moderately increased - serum phos moderately increased - serum calcium normal - normal renal size on US
4. Low Na+ 5. Low H2O 6. High osmolality (500 and up) 7. High uric acid 8. Specific gravity: greater than 1,010 9.
Urinary sodium: less than 20 10. Sediment*: 0 (hyaline casts) 11. BUN/ creat ratio: greater than 10/1
Q15: Intrarenal
A: Cause: - Ischemia or nephrotixic injury (rhabdo, multiple myeloma, aminoglycosides, chemo, contrast) - Necrosis
(acute tubular necrosis ATN) (prolonged hypotension, low CO, liver disease) - Acute tubulointerstitial nephritis from
bacterial pyelonephritis, drug-induced, immunologic disorders - oliguric/ anuric - decreased urine creatinine - no
proteinuria - serum creatinine increased - serum K increased - serum phos increased - serum Calcium decreased
Low Na+ High H2O Low osmolality (350 and less) Specific gravity: 1,010 Urinary sodium: greater than 20 Sediment:
+ BUN/ creat ratio: less than 20/1 FEna: greater than 2% Treat: stop offending drug. Contrast: fluid administration,
pre- and post. Hold metformin before contrast, for 48hrs.
, Q16: Postrenal
A: Cause: Urinary flow obstruction: Enlarged prostate Cervical cancer Tumors Kidney stones Neurogenic bladder,
diabetic neuropathy, spinal cord disease - urine creatinine decreased - no proteinuria - no sediment or hematuria with
stones - BUN increased - serum creatinine increased - serum phos increased - serum calcium decreased Anuria/
polyuria Urine osmolality less than 350 Fixed urine specific gravity (1.0008- 1.012) Urine Na greater than 40 BUN to
creatinine ratio: greater than 20:1 Treat with catheter drainage, urethral stents, percutaneous nephrostomy
Q17: treatment of ARF/AKI
A: -· Therapy for ARF: o Treat underlying cause o Correct fluid, electrolyte, uremic abnormalities o Prevent
complications o Lasix can be given for volume overload (due to oliguria) o Patient can become nutritionally deficient
as ARF is a catabolic state. Total caloric intake: 30 - 45 kcal/kg/day. Protein restricted when not on dialysis: 0.6g/
kg/day. If on dialysis protein should be 1-1.5g/kg/day. Diet should be low protein/ Na/ K o Dialysis, often needed.
Especially when BUN greater than 100 and serum creatinine greater than 5 - 10, acidosis/ alkalosis, hyperkalemia o
Metabolic acidosis: treat with IV (or oral) bicarb when serum HCO3 is less than 15, or PH less than 7.2 o Renal
transplant
Q18: Treat renal failure complications: which and how
A: Hyperkalemia: - Kayelxalate 15-30 g with 100 ml sorbitol: enema - IV calcium: cardioprotective - Insulin (10units) with
25 g glucose - IV sodium Bicarb (150 mEq in 1 lt) - dialysis in significantly elevated K (greater than 7)
Hyperphosphatemia: - Keep below 4.6 - Restrict phos (cola, eggs, dairy, meat) - Give calcium carbonate (650mg
TID) - Renvela (Sevelamir) - Calcium acetate - Dialysis Hypocalcemia (ion Ca less than 1.12): - Calcium carbonate
supplements - maintain phos at 6 Hypermagnesemia Avoid mag. laxatives Fluid overload: - Decrease Na and fluid
intake and give lasix HTN: Goal: 140/80 unless proteinuria than 125/75 ACE-inhib, calcium blockers if proteinuria
present, hydralazine, B-blocker Protein catabolism: - Limit protein intake: less than 8gr/kg.day, avoid stress and not
too much physical activity Acidosis Give sodium citrate when HCO3 below 20 Anemia - give iron - give erythropoietin
injection
Q19: RRT option in AKI and CKD
A: - Hemodialysis (intermittent (MAP of at least 60mmHg), continuously venous or arterial) - Peritoneal dialysis - for long
term use. Does not achieve adequate creatinine clearance (may be switched to hemodialysis in acute care situations)
and high risk for infection
Q20: chronic kidney disease
A: · Chronic kidney disease: GFR 60ml/ min or less for longer than 3mo. o HTN common o US with show bilat small
kidneys o Cause: § HTN nephropathy § Diabetic nephropathy § Renal artery stenosis § Glomerular disease o When
GFR between 5 - 10: dialysis o Creatinine clearance: age and gender-dependent. Males: 97-137, Females: 88-128 o
Signs/ Symptoms: - Fatigue/ weakness - Pruritis - bruising - dyspnea on exertion - HTN - Metallic taste - SOB/ pleural
effusion - n/v with anorexia - impotence/ nocturia - peripheral neuropathy - anemia (due to erythropoietin deficiency)
Q21: Stages of CKD
A: o Stages - 5 stages 80 - 120 ml/min § 1: GFR greater than 90 § 2: GFR 60 - 89 § 3: GFR 30 - 59 § 4: GFR 15 - 29 §
5: ESRD GFR less than 15, uremia, cardiovascular disease.
Answers
Q1: Urine culture with UTI
A: 100.000 colonies in asymptomatic: bacteruria 10 - 10.000 colonies in symptomatic patients but also pyuria pyuria:
more than 10 leukocytes elevated erythrocytes with pyelonephritis WBC in urine false positive with tumor, urethritis
and poor collection technique Repeat in pregnant women
Q2: Lower urinary tract UTI and upper urinary tract UTI
A: bladder and urethra: cystitis/ urethritis/ prostatitis kidney and ureters: pyelonephritis/ renal abcess
Q3: Uncomplicated and complicated uti
A: Uncomplicated: in normal working urinary tract Complicated: defects in urinary tract or with other health problems
Q4: Common pathogens for UTI
A: E.coli (elderly women) Staphylococcus proteus mirabilis (elderly men) Klebsiella enterecoccus pseudomonas
Providencia (institutionalized) Fungus: candida
Q5: Risk factors for UTI
A: Female critically ill elderly catheter (caused by biofilm) DM calculi, tumor, stricture neurogenic bladder Women:
sexual intercourse or new sex partner pregnancy previous UTI Men: prostate enlargement prostatitis lack of
circumcision gay HIV
Q6: Findings UTI
A: Lower: Dysuria/ urgency/ frequency/ incontinence suprapubic pain hematuria fever/ chills uncommon No flank pain
Upper: flank pain fever and chills hematuria n/v ams (in elderly) malaise tachycardia/ tachypnea
Q7: Testing and results for UTI
A: Gold standard: urine culture and sensitivity: detection of bacteria. Start with POC: urine analysis. UA: pos for nitrite or
leukocyte or blood CBC: leukocyte with left shift in pyelonephritis For recurrent UTI in women or UTI in men rule out
obstruction, calculi, or necrosis with: xr voiding CT abdomen US pelvis MRI pelvis
Q8: Management acute cystitis
A: First line: - Single dose Fosfomycin (monurol) - 3 day: sulfa: trimethoprim/ sulfa (bactrim) (do not give near delivery of
baby, give cephalexin instead) or sulfa - 5 days: nitrofurantoin, caution in elderly Second line: - qiunolones:
ciprofloxain or levofloxacin for 3 days (not for pregnant women!) - B-lactams: amoxi-clav, cefdinir for 3 - 7 days
,Q9: Management uncomplicated upper UTI
A: Outpt: quinolone: ciprofloxacin for 7 days or levofloxacin for 5 days Sulfa: trimethoprim/ sulfa (bactrim) for 14 days
Inpt: Ceftriaxone or cefotaxime Ampicillin CAUTI: bacterial: treat with AB for 7 days Candiduria: fluconazole for 14
days Discomfort: Pyridium
Q10: Management acute complicated bacterial pyelonephritis
A: - Admit - Aminoglycosides: gentamicin/ tobramycin (not for monotherapy), based on renal function (trough less than 2
and peak level 5-10mg/L) and do not give for CKD - Ampicillin - Cefazolin - Cefotaxime and Ceftriaxon based on
obesity and pulm disease
Q11: Urine analysis: glucose and ketones
A: Serum glucose at least 180mg/dl for glucose to appear in urine Glucose in ua caused by: - Fancone Syndrome (bad
wall: caused by ahminoglycosides for example) - DM - Cushing's - Vit C can give false negative Ketones in urine: -
Alcohol - Diabetic - Starvation
Q12: Acute Kidney Injury
A: -Acute renal function loss with inability to excrete metabolic waste products (urea nitrogen and creatinine) to inability
to maintain fluid and electrolyte balance. - Resolves within 3mo - classified with RIFLE or etiology
Q13: RIFLE
A: Risk: creatinine up x 1.5 from baseline, GFR decrease more than 25% and UO less than 0.5ml/kg/hr for 6hr Injury:
creatinine up x 2 from baseline, GFR decrease more than 50% and UO less than 0.5ml/kg/hr for 12hr Failure:
creatinine up x 1.5 from baseline, GFR decrease more than 25% and UO less than 0.3ml/kg/hr for 12hr or anuria for
12hr Loss: Complete loss of renal function for more than 4 weeks End-stage Kidney Disease: RRT need for more
than 3mo
Q14: Prerenal renal failure
A: Most often the cause of RF - Decreased blood supply; intravascular volume depletion, vasodilatory states - Increased
tubular sodium and water reabsorption, causing: oliguria, decreased urine sodium, high urine osmolality, increased
urine specific gravity caused by: 1. Low CO 2. Hypovolemia 3. RAS (renal artery stenosis) 4. aminoglycosides,
NSAIDS Result: - low urine volume - increased urine creatinine with normal serum creatinine - minimal proteinuria -
serum K moderately increased - serum phos moderately increased - serum calcium normal - normal renal size on US
4. Low Na+ 5. Low H2O 6. High osmolality (500 and up) 7. High uric acid 8. Specific gravity: greater than 1,010 9.
Urinary sodium: less than 20 10. Sediment*: 0 (hyaline casts) 11. BUN/ creat ratio: greater than 10/1
Q15: Intrarenal
A: Cause: - Ischemia or nephrotixic injury (rhabdo, multiple myeloma, aminoglycosides, chemo, contrast) - Necrosis
(acute tubular necrosis ATN) (prolonged hypotension, low CO, liver disease) - Acute tubulointerstitial nephritis from
bacterial pyelonephritis, drug-induced, immunologic disorders - oliguric/ anuric - decreased urine creatinine - no
proteinuria - serum creatinine increased - serum K increased - serum phos increased - serum Calcium decreased
Low Na+ High H2O Low osmolality (350 and less) Specific gravity: 1,010 Urinary sodium: greater than 20 Sediment:
+ BUN/ creat ratio: less than 20/1 FEna: greater than 2% Treat: stop offending drug. Contrast: fluid administration,
pre- and post. Hold metformin before contrast, for 48hrs.
, Q16: Postrenal
A: Cause: Urinary flow obstruction: Enlarged prostate Cervical cancer Tumors Kidney stones Neurogenic bladder,
diabetic neuropathy, spinal cord disease - urine creatinine decreased - no proteinuria - no sediment or hematuria with
stones - BUN increased - serum creatinine increased - serum phos increased - serum calcium decreased Anuria/
polyuria Urine osmolality less than 350 Fixed urine specific gravity (1.0008- 1.012) Urine Na greater than 40 BUN to
creatinine ratio: greater than 20:1 Treat with catheter drainage, urethral stents, percutaneous nephrostomy
Q17: treatment of ARF/AKI
A: -· Therapy for ARF: o Treat underlying cause o Correct fluid, electrolyte, uremic abnormalities o Prevent
complications o Lasix can be given for volume overload (due to oliguria) o Patient can become nutritionally deficient
as ARF is a catabolic state. Total caloric intake: 30 - 45 kcal/kg/day. Protein restricted when not on dialysis: 0.6g/
kg/day. If on dialysis protein should be 1-1.5g/kg/day. Diet should be low protein/ Na/ K o Dialysis, often needed.
Especially when BUN greater than 100 and serum creatinine greater than 5 - 10, acidosis/ alkalosis, hyperkalemia o
Metabolic acidosis: treat with IV (or oral) bicarb when serum HCO3 is less than 15, or PH less than 7.2 o Renal
transplant
Q18: Treat renal failure complications: which and how
A: Hyperkalemia: - Kayelxalate 15-30 g with 100 ml sorbitol: enema - IV calcium: cardioprotective - Insulin (10units) with
25 g glucose - IV sodium Bicarb (150 mEq in 1 lt) - dialysis in significantly elevated K (greater than 7)
Hyperphosphatemia: - Keep below 4.6 - Restrict phos (cola, eggs, dairy, meat) - Give calcium carbonate (650mg
TID) - Renvela (Sevelamir) - Calcium acetate - Dialysis Hypocalcemia (ion Ca less than 1.12): - Calcium carbonate
supplements - maintain phos at 6 Hypermagnesemia Avoid mag. laxatives Fluid overload: - Decrease Na and fluid
intake and give lasix HTN: Goal: 140/80 unless proteinuria than 125/75 ACE-inhib, calcium blockers if proteinuria
present, hydralazine, B-blocker Protein catabolism: - Limit protein intake: less than 8gr/kg.day, avoid stress and not
too much physical activity Acidosis Give sodium citrate when HCO3 below 20 Anemia - give iron - give erythropoietin
injection
Q19: RRT option in AKI and CKD
A: - Hemodialysis (intermittent (MAP of at least 60mmHg), continuously venous or arterial) - Peritoneal dialysis - for long
term use. Does not achieve adequate creatinine clearance (may be switched to hemodialysis in acute care situations)
and high risk for infection
Q20: chronic kidney disease
A: · Chronic kidney disease: GFR 60ml/ min or less for longer than 3mo. o HTN common o US with show bilat small
kidneys o Cause: § HTN nephropathy § Diabetic nephropathy § Renal artery stenosis § Glomerular disease o When
GFR between 5 - 10: dialysis o Creatinine clearance: age and gender-dependent. Males: 97-137, Females: 88-128 o
Signs/ Symptoms: - Fatigue/ weakness - Pruritis - bruising - dyspnea on exertion - HTN - Metallic taste - SOB/ pleural
effusion - n/v with anorexia - impotence/ nocturia - peripheral neuropathy - anemia (due to erythropoietin deficiency)
Q21: Stages of CKD
A: o Stages - 5 stages 80 - 120 ml/min § 1: GFR greater than 90 § 2: GFR 60 - 89 § 3: GFR 30 - 59 § 4: GFR 15 - 29 §
5: ESRD GFR less than 15, uremia, cardiovascular disease.
