NRNP 6550 Final Exam 2022, Complete
Solution (Answered)
Urine culture with UTI
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
Lower urinary tract UTI and upper urinary tract UTI
bladder and urethra: cystitis/ urethritis/ prostatitis
kidney and ureters: pyelonephritis/ renal abcess
Uncomplicated and complicated uti
Uncomplicated: in normal working urinary tract
Complicated: defects in urinary tract or with other health problems
Common pathogens for UTI
E.coli (elderly women)
Staphylococcus
proteus mirabilis (elderly men)
Klebsiella
enterecoccus
pseudomonas
Providencia (institutionalized)
Fungus: candida
Risk factors for UTI
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
Findings UTI
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
Testing and results for UTI
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
Management acute cystitis
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
Management uncomplicated upper UTI
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
Management acute complicated bacterial pyelonephritis
- 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
Urine analysis: glucose and ketones
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
Acute Kidney Injury
-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
RIFLE
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
Prerenal renal failure
, 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
Intrarenal
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)
Solution (Answered)
Urine culture with UTI
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
Lower urinary tract UTI and upper urinary tract UTI
bladder and urethra: cystitis/ urethritis/ prostatitis
kidney and ureters: pyelonephritis/ renal abcess
Uncomplicated and complicated uti
Uncomplicated: in normal working urinary tract
Complicated: defects in urinary tract or with other health problems
Common pathogens for UTI
E.coli (elderly women)
Staphylococcus
proteus mirabilis (elderly men)
Klebsiella
enterecoccus
pseudomonas
Providencia (institutionalized)
Fungus: candida
Risk factors for UTI
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
Findings UTI
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
Testing and results for UTI
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
Management acute cystitis
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
Management uncomplicated upper UTI
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
Management acute complicated bacterial pyelonephritis
- 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
Urine analysis: glucose and ketones
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
Acute Kidney Injury
-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
RIFLE
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
Prerenal renal failure
, 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
Intrarenal
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)
