WEEK 13 EXAM 5
chlamydia treatment
Chlamydia is the most common bacterial STI and while doxycycline is also acceptable, azithromycin is preferred because it is one-time dosing.
BV discharge slide
Clue cells, cant see nucleus or borders Greater than 20% of vaginal epithelium is considered clue cells than it is BV
HPV can result in
hyperplasia koilocytes Abnormal cell growth=wart
stages of Hep B
CPE-cytopolic effect (?), direction lysis, or other kinds of destruction of the cell Hep B e antigen
what is normal Cr level?
0.6-1.2 mg/dL
if the Confidence interval includes what number, the HR is not significant
1
tell me about primary syphilis symptoms and pathogenesis
1-3 months PAINLESS LESION enlarged lymph nodes healing proliferation in lymph nodes
what is renin
1. Enzyme produced by juxtaglomerular apparatus 2. Catalyzes formation angiotensinogen à angiotensin 3. Potent vasoconstrictor, salt balance & BP regulation
the causes of AKI are divided into 3 broad pathophysiologic categories
1. Prerenal AKI—diseases characterized by effective hypoperfusion of the kidneys in which there is no parenchymal damage to the kidney 2. Intrinsic AKI—diseases involving the renal parenchyma 3. Postrenal (obstructive) AKI—diseases associated with acute obstruction of the urinary tract
what 3 things are characteristic of nephrotic syndrome patients
1. edema 2. hypoalbuminemia 3. hyperlipidemia
ATN clinical course
1. initiation (period of exposure to hypotension, ischemia, sepsis, nephrotoxins) 2. Maintenance (typically 1-2 weeks, overy tubule injury, abrupt GFR fall) 3. recovery (cellular regeneration and repair)
why is using contrast dye bad for the kidney, potentially causing injury?
1. nephrotoxic 2. causes vasoconstruction AKI happens QUICKLY if this is the cause
2 components of renal autoregulation
1.Myogenic response 2.Tubuloglomerular feedback mechanism Together they work to maintain a constant GFR and renal blood flow (RBF) over a range of mean arterial pressures (~70-160 mm Hg)
wet mount trich specificity /sensitivity
100% if you see it you have it specificity sensitivie-50%
guidlines for ART meds for HIV say you should avoid what class, what drug
Avoid NNRTI regimens, avoid abacavir, requires genetic test before using (could cause SJS) avoid dolutegravir using in pregnancy/ childbearing= risk of neural tube defects
what are the 2 viral STIs that can be asymptomatic? How common is asymptomatic carriage for each? Do rates vary in males and females?
2 most common 1. HPV 2. genital herpes Most men who have HPV do not show symptoms, you can still spread virus This is a reason this is such a common infection You can shed the virus before signs and symptoms Typically most infectious during active breakout HSV1 and 2 can both do oral and genital properties HPV is the most common viral STI, and overall most common STI, and Chlamydia is the most common bacterial
HSV 1 vs HSV 2
2 subtypes general-HSV1 occurs above the waist HSV2-genital USUALLY^
tell me about initial contact of symphillis symptoms and pathogenesis
2-10 weeks primary chancre bacterial multiplication and inflammatory response
tell me about secondary syphilis symptoms and pathogenesis
2-6 weeks flu-like, rash, fever, spontaneous resolution proliferation in lymph nodes, liver, joints and skin Bacteria are proliferating within rashes on skin
Regardless of the virus, all viruses must go through a series of steps to complete replication process, what are those steps?
Attachment Penetration Uncoating Replication of nucleic acid Synthesis of necessary structural and non structural Assembly of particle Release-budding or lysis
recurrent UTI is defined as having ___ or more symptomatic infections within a single calendar year.
3
tell me about latent syphilis symptoms and pathogenesis
3-30 years dormant in bacteria in liver or spleen NO SYMPTOMS!!!!
Creatinine
35 y/o that works out will have a higher creatinine due to higher muscle mass Creatinine blood (Range is 0.6-1.0)
normal albumin level is
4
complications of chlamydia
80% of women asymptomatic, important for screening and epidemiology Newborns exposed during birthing process High rate of asymptotic=unknown carriers
renal ultrasound
95% accuracy May be falsely negative early, with ATN, or with retroperitoneal fibrosis
What is the most important risk factor for AKI?
: D; Chronic kidney disease is the most important risk factor for AKI; important because in many cases, like heart catheterization, use of a nephrotoxic contrast is needed. For open heart surgery, history of underlying kidney disease is the most important risk factor and the risk goes higher with severity of underlying kidney disease.
BUN: Cr Ratio <10:1 (low BUN with normal creatinine)
=intrinsic AKI
Albumin to creatine ratio
=less than 30
What is lupus nephritis?
A connective tissue disorder that affect females more than males. Symptoms include hematuria, proteinuria, hypertension, RV thrombosis and renal insufficiency. The kidney appears hyperechoic and small.
what is ATN?
A sudden decline in kidney function resulting from ischemic or toxin related damage Diagnosis is made by HISTORY Disease tubule Cannot retain Na FeNa is greater than 1, meaning the urine Na is elevated, kidneys are just DUMPing Na Muddy brown cast-classic finding 1-3 weeks Most pts recover
RBC casts (maybe few wbc)
AGN
WBC casts (maybe a few rbc)
AIN, Acute interstitial nephritis (AIN)
Acute non-obstructive pyelonephritis:
AKA acute uncomplicated pyelonephritis, is a kidney infection that occurs in healthy women (renal or upper urinary tract infection) E. Coli is isolated from 85-90% episodes. This is due to another adhesin virulence factor, P. Fimbria, aerobactin (scavenges for iron), and hemolysin (lyses host cells). P. Fimbria: Attaches to glycosphingolipid receptor Gal(alpha1-4) Gal-Beta disaccharide. Allows for attachment to renal cells and enhances bacterial persistence and inflammation in the urinary tract. WBC is high
AKI categories
AKI Break down into 3 main categories Prerenal- good kidney in bad environment Prior to kidney Dehydration Sepsis CV failure renal -everything in kidney, blood vessels, glom, tubules, interstitium postrenal -obstruction anywhere alone urinary tract Stones, cancers, fibrosis, big prostate pushing on plumbing
criteria for acute kidney injury-RIFLE?
AKI-rise in creatinine or decrease in urine output over short period of time risk injury, failure, loss, end stage Acute kidney injury network Kidney disease improving global outcomes Akin and kdigo are used most commonly .3 is the number to keep in mind
differnces between acute and chronic kidney disease
AKI-short time, not usually anemic, normal size chronic=3 months, anemic, kidneys atrophy and size reduced
What is the current ART
ART continued to evolve as new drugs were developed, with all recommended treatment regimens during this time consisting of 2 NRTIs + a third agent (PI, NNRTI, or INSTI now use STR (single tablet regimen), 1 pill once a day with 2-3 active agents. As drugs have become more and more potent, we may not need 3 active drugs. 2 active drugs will probably be more main stream. we never use 2 of the same nucleoside or nucleotides in 1 regimen. They have to all be different analogues from each other Will not use 2 adenosine or 2 cytosine analogues in the same regimen
muddy brown casts
ATN
what is the most common form of intrinsic acute renal failure
ATN
causes of AKI in hospital setting
ATN makes up almost half of all AKI In the icu ATN is the most common Prerenal makes up a big chunk As well as prerenal ATN and prerenal are the big dogs for causes of AKI in hospital
muddy, brown cast immediately think
ATN!
FENa above 2% or 3% is
ATN, postrenal
What is Goodpasture's syndrome?
Autoimmune disease that attacks the basement membranes of the lungs, alevoli, and glomerulus - it is caused by viral infections and surgery of the lung or kidneys.
Angiotensin 2 causes kidney to retain salt and water 2 ways
Acts directly on kidneys to cause salt and water retention Angiotensin 2 causes adrenal glands to secrete aldosterone (conserves salt through kidney) Both the direct effect of AII on the kidney and its effect acting through aldosteron are important in long term arterial pressure control Role of RAS in maintaining a normal MAP despite wide variation in salt intake Increased salt intake Increased extracellular volume (water follows salt) Increased arterial pressure Decreased renin and angiotensin because pressure is increased because of JG Decreased renal retention of salt and water-pee more Extracellular fluids to normal
what is the most common cause of chronic diabetes?
Adding an ACE or ARB is most important treatment
what parts of a persons hx could suggest postrenal AKI?
Age, history of BPH and suprapubic pain suggest post renal. History of over-the-counter cold medications which have anticholinergics could also precipitate acute obstruction
normal albumin excretion rate
Albumin excretion rate less than 30
Which lab finding indicates intrinsic AKI? A.FENa <1% B.BUN/SCr 10:1 C.Urine Na+ <10 meq/L D.Urine Osmolality 600 mOsm/L
Answer B. BUN/SCr 10:1 indicates intrinsic, the rest indicate pre-renal; in prerenal case, there is no tubular damage and kidneys are able to absorb Na so it will be low, fraction excretion will be low as well, and BUN:Cr ratio will be high (>20). In pre renal AKI, tubular function is typically normal, renal reabsorption of sodium and water is increased, and consequently the urine exhibits low sodium concentration (<20 mmol/l) and high osmolality (>500 mOsm/kg), presuming a diuretic has not been administered.
proteinuria
As proteinuria increase, mortality increases
uremia ppt.
Azotemia and uremia are two different types of kidney conditions. Azotemia is when there's nitrogen in your blood. Uremia occurs when there's urea in your blood If BUN is 150 and you are fine, not uremic, you are azotemic BUN is 150 and you have GI symptoms, vomitings, then patient is uremic
what diseases do we wet mount to diagnose?
BV trich yeast
Asymptomatic bacteriuria:
Bacteria present in the urine without symptoms or signs attributable to UTI E. coli is the most common. Gram positive organisms of low virulence such as enterococcus species and coagulase negative staphylococci are also frequently isolated from patients with asymptomatic UTI. Urinary tract infections typically occur when bacteria enter the urinary tract through the urethra and begin to multiply in the bladder. Although the urinary system is designed to keep out such microscopic invaders, these defenses sometimes fail. When that happens, bacteria may take hold and grow into a full-blown infection in the urinary tract.
BUN
Because it is affected by so many things, by itself it is not a great measure of kidney function
•26 y/o man is evaluated during a follow-up visit after presenting to an urgent care clinic for back pain 1 week ago. He is a personal trainer and lifts weights daily Which of the following is the most appropriate management? A: Avoid all NSAID medication B: Measure the serum creatine kinase level C: Measure the cystatin C level D: Schedule a kidney biopsy
C. Measure the cystatin C level Reason is the pt is a muscular person and eGFR by using creatinine formulas will not be as accurate due to increased muscle mass
if we have decreased GFR in the presence of NSAIDS and ACE or ARB, what intrarenal mechanisms for autoregulation are in place to recover from this?
C. Reduced perfusion pressure with a nonsteroidal anti-inflammatory drug (NSAID). Loss of vasodilatory prostaglandins increases afferent resistance; this causes the glomerular capillary pressure to drop below normal values and the GFR to decrease. D. Reduced perfusion pressure with an angiotensin-converting enzyme inhibitor (ACE-I) or an angiotensin receptor blocker (ARB). Loss of angiotensin II action reduces efferent resistance; this causes the glomerular capillary pressure to drop below normal values and the GFR to decrease
HPV characteristics
DOES NOT HAVE ENVELOPE, DOES NOT BUD 100 serotypes= a particular virus, once you are infected with it, you produce neutralizing antibodies, which are antibodies that are produced against the virus that bind specifically to the viral receptor, creating steric hindrance= preventing viral attachment. For every stereotype, it means that there is a different antibody because there is a different viral receptor. Replication requires growing cells, cells that are actively dividing
symptoms of ATN
Dehydration or excessive thirst A small amount of urine output Swelling and fluid retention Nausea and vomiting Trouble waking up/drowsiness Feeling sluggish Confusion
etiology of gonorrhea
Do not find it outside human host Facultative intracellular- can live inside or outside eukaryotic cell (unlike chlamydia)
indications for kidney biopsy
Don't know what is going on Over 1 month duration Cant leave them on dialysis, need to know why they are on it Systemic symptoms, treatments are usually immunosuppression- need to know diagnose this before doing this
When performing a sacral rock for a patient, which of the following is true?
During exhalation, the sacral base moves anterior The respiratory motion of the sacrum occurs on the superior transverse axis. As a patient inhales, the sacral base moves posterior and apex anterior. During exhalation, the sacral base moves anterior, and the apex posterior.
What is the difference between a bacterial spore and the elementary body formed by Chlamydia?
EB BODY OF CHLAMYDIA IS infectious,SPORES ARE NOT INFECTIOUS Spores are resilient, EB is not SPORES=BACTERIA GOING INTO DORMANCY BECAUSE ENVIRONMENTAL CONDITIONS ARE NOT CONDUCIVE TO ITS GROWN
descovy
Emtricitabine + tenofovir alafenamide, it is a type of PrEP
management of prerenal AKI
FLUID REPLACEMENT!!! •Restore euvolemia •Once euvolemia achieved: •Fluid replacement must match total output (UOP previous 24 hrs plus insensible loss) •May not need IV if oral intake matches output •Hypervolemic and oligouric ARF •Fluid restriction to prevent pulmonary edema •Hemodialysis if fluid overload does not respond to IV furosemide (Lasix)
RBC cast
Glomerulonephritis
what is the difference between FeNa and Fe Urea
Fractional Excretion of Urea (FEUrea) Determines the cause of renal failure. Similar to the FENa, but can be used on patients on diuretics. While lesser known than FENa, the FEUrea can be used in patients on diuretics, since urea excretion is not significantly affected by diuretics. FeNA will be affected by loop diuretics because more Na is excreted with loop diuretics
if you have AKI are u screwed? what is the recover?
Full recovery is most common 2-8 % have AKI that leads to end stage renal disease 8-22% lead to chronic kidney disease that is ongoing
GFR
GFR is sum filtration of all nephrons (all 1 million) Not correlation of loss of renal mass and nephron function, because remaining nephrons work harder to drive creatine down We only let healthy people donate kidney GFR goes from 100% to 50%, remaining kidney filters harder and GFR can go between 70-80% Loss an exact correlation between loss of renal mass and creatinine •Widely accepted as the best overall index of kidney function -Generally reduced after widespread structural damage -Most other kidney functions decline in parallel with GFR • •Sum of the filtration rates in all of the functioning nephrons • •Not an exact correlation between the loss of renal mass and the loss of renal function -Compensatory hyperfiltration in the remaining normal nephrons -Kidney donor -Kidney transplant recipient •True GFR is measured when: -A substance is filtered through the glomerulus and not secreted or reabsorbed in the renal tubules (INULIN) GFR is true measure when substance is filtered Inulin is not practical in clinical practices, so we use eGFR They are not as precise when GRF is better, become more accurate when GFR is worse cells +tubular reabsorption-tubular secretions-excretion over the plasma number
Describe the most common complications/sequelae of HIV infection if not treated early.
HIV attacks the body's immune system, specifically the CD4 cells, often called T cells. Over time, HIV can destroy so many of these cells that the body can't fight off infections and disease. Untreated, HIV reduces the number of CD4 cells (T cells) in the body. This damage to the immune system makes it harder and harder for the body to fight off infections and some other diseases. Opportunistic infections or cancers take advantage of a very weak immune system and signal that the person has AIDS. When people get HIV and don't receive treatment, they will typically progress through three stages of disease. Medicine to treat HIV, known as antiretroviral therapy (ART), helps people at all stages of the disease if taken as prescribed. Treatment can slow or prevent progression from one stage to the next. Also, people with HIV who take HIV medicine as prescribed and get and keep an undetectable viral load have effectively no risk of transmitting HIV to an HIV-negative partner through sex.
why is having comorbidities so bad for people with HIV?
HIV creates inflammation, higher risk for those already vulnerable Inflammation is the key reason that so many negative effects happen to this disease Inflammation to brian, gut, affect cytokine mobilization, affects heart Due to persistent inflammation we recommend adequate viral suppression, quit smoking, healthy eating and exercising, diabetes, hyperlipidemia, HTN, HIV disease is equivalent to smoking a pack a day as well as adding 10 years onto chronological age Inflammation has long term effects Areas we focus-CV disease, liver disease Gut Bone renal Mental health 2nd generation integrase issues Weight gain Increased risk of nontraumatic factors/mineral bone loss Overtime, the increase bone mineral density loss and bone marrow loss is greater in HIV pt Bone density scans to monitor in all HIV persons over 50 ruins GI mucosa, affects histology
HIV resistance summary
HIV drug resistance can be transmitted or treatment emergent, which can limit our treatment options If someone has resistance to multiple drugs, and only 1 drug works, hesitant to give it to them unless it is life saving Resistance occurs when u have replicating virus in the presence of suboptimal ART therapy, chose barrier with high drugs to resistance to avoid mutation, this is the protease inhibitors when boosted and 2nd generation integrase inhibitors Resistant testing can help inform treatment decision Genotypes (and phenotypes) to determine resistance
Identify HIV incidence and prevalence and undiagnosed infections in the MSM population; and identify other high-risk populations.
HIV incidence in MSM 26,200 ? HIV prevalence total 632,300 ? Gay Bisexual All racial and ethnic groups of MSM Injected Drug users Younger age groups
if we use abacivir we need to test pts
HLAb51 status
pink, varruculous papules around the gland penis and perirectal area
HPV
what is the most common STI
HPV
what factor can decrease the potential of acquisition of HPV
HPV vaccination
What are the most common indications for dialysis in acute kidney injury
HYPERkalemia ACIDosis and FLUID OVERLOAD
what is the hazard ratio
Hazard ratio can be used to compare 2 kaplan curves The hazard ratio is a comparison between the probability of events in a treatment group, compared to the probability of events in a control group. ... A hazard ratio of 1 means that both groups (treatment and control) are experiencing an equal number of events at any point in time HR less than 1 means that the treatment is working Research of new and improved drugs want to see hazard ratio less than 1 hazard treatment (risk in treatment group)/hazard control (risk in control group)
what is an important lab test for patients who want to get prep?
Hep B status because meds may suppress B Know other STIs Pregnancy test Only provide 90 day supply of either med Don't want a person becoming HIV positive and taking the meds, these drugs would not work to suppress virus
explain RAAS
Here are the components of RAS Decreased arterial pressure Causes kidney (through JG cells) to release renin Renin gets formed into angiotensin 1 Gets converted by an enzyme to angiotensin 2 Can be in inactive or active form Active form causes vasoconstriction Angiotensin causes renal retention of salt and water Angiotensin 2 can constrict VERY quicky, within seconds
HIV stats
Highest lifetime risk HIV group-African American MSM (1 in 2) Overall, average American regardless of gender, race, ethnicity, sexual orientation, lifetime risk is 1 in 99 In general hispanic MSM lifetime risk 1 in 4 Caucasion msm 1 in 11 African american men 1 in 20 regardless of sexual orientation Risk is based on geography and sexual network
indications for dialysis
Hyperkalemia Ethylene glycol Not urinating Ventilator CHF Sick from build up of nitrogenous waste products A - Acidosis E - Electrolyte disturbances I - Intoxications O - Overload (volume) U - Uremia
Serum Creatinine - Cr
If you are an average person, your kidneys stop working completely you are still producing creatinine, the plasma increases at that rate for an average sized person, but if u have a lost of muscle your creatinei might increase several folds per day
HIV prevention and treatment
If you are exposed, there is a prophylactic regimen that helps to cut down on virus
can you pass on HIV if you are undetectable?
If you are undetectable, you are not able to transmit the virus to your sexual partner If you have less than 200 viral particles you cannot transmit the virus to other people You are adequately virologically suppressed Decreases the stigma of HIV
albumin/creatinine ratio
Microalbumin test that measures creatinine also - Random urine specimen - Convenient and accurate - Calculates albumin-to-creatinine ratio (mg/g) - Ratio correlates closely with daily protein excretion - If spot albumin and creatinine concentrations are 200 mg/dl and 50 mg/dL - Ratio 4.0 represents a daily albumin excretion of approximately 4.0 g/day. Meant for screening Detects only albumin Will not pick up light chains proteinuria associated with cancers ***urine concentration will influence it **** Very accurate Urine protein/urine creatinine =grams of protein per day
Maintenance of Relatively Constant Intraglomerular Pressure by Renal Autoregulation despite Variations in Mean Arterial Pressure
In chronic hypertension, the curve showing the relation of the intraglomerular pressure to the renal perfusion pressure (or mean arterial pressure) is shifted to the right. With the development of chronic renal failure, renal autoregulation changes in such a way that the intraglomerular pressure begins to vary more directly with changes in the mean arterial blood pressure. When this change occurs, the normal sigmoidal relation becomes progressively more linear. As a result, increases in the mean arterial pressure cause exaggerated increases in the intraglomerular pressure, whereas declines in the mean arterial pressure cause exaggerated decreases. Because of the rightward shift in the lower end of the curve, antihypertensive therapy may be accompanied by a decline in the glomerular filtration rate at a level of blood pressure that would not affect a normal person. Renal dysfunction in this setting is hemodynamic in origin and reflects a lower intraglomerular pressure.
urethritis
Infection of the urethra (urethritis). This type of UTI can occur when GI bacteria spread from the anus to the urethra. Also, because the female urethra is close to the vagina, sexually transmitted infections, such as herpes, gonorrhea, chlamydia and mycoplasma, can cause urethritis.
WBC cast
Interstitial nephritis
if we have decreased GFR, what intrarenal mechanisms for autoregulation are in place to recover from this?
Intrarenal mechanisms for autoregulation of the glomerular filtration rate (GFR) under decreased perfusion pressure and reduction of the GFR by drugs. A. Normal conditions and a normal GFR. B. Reduced perfusion pressure within the autoregulatory range. Normal glomerular capillary pressure is maintained by afferent vasodilatation and efferent vasoconstriction.
Diagnosing AKI, need to consider
Is his AKI from prerenal state hypoperfusion, or interrenal state like ATN? What type is it??? Figure this out. Do US to see if there is ab obstruction. Do sediment to see if there are casts.
to do the whiff test what chemical do u add to the test tube
KOH
granuloma inguinale
Klebsiella granulomatis chronic, relapsing granulomatous anogenital infectinon appearance of relatively painless nodules that break down into shallow, sharply demarcataed ulcers diagnosis requires visualization of Donovan bodies
treatment of chlamydia
Know with confidence that pt did the whole course,
lag in getting ART in US
Lag in diagnosis and treatment initiation depending on what your insurance is Medicaid patients take A LONG TIME to get them to start treatment, We want to get them on ART that same day as diagnosis. This does not happen in every case
when to give IV lasix (furosemide) in patient to restore kidney function
Lasix will be indicated for a patient with volume or fluid overload
diagnostic testing of acute interstitial nephritis
Leaking glucose Bicarb Trouble concentrating urine
characteristics of chlamydia trachomatis
Obligate intracellular is underlined because it is important, it differentiates chlamydia from many of the other bacterial pathogens discussed D-k include the bacterial groups that cause STIs Has different structures throughout life cycle called elementary body and reticulate body needs to survive on a human!!!
A 27 year old male presents to the clinic with nonspecific back pain. He denies numbness, weakness, or tingling to the lower extremities, bowel or bladder incontinence, and muscle weakness. Orthopedic testing is negative. On exam he is found to have a left unilateral sacral flexion dysfunction and you decide to treat with respiratory assisted muscle energy. Which of the following regarding the treatment for this case is true?
Left leg should be abducted ~15 degrees and internally rotated The steps for respiratory assisted muscle energy for a left unilateral sacral flexion are as follows: patient lies prone, physician palpates left sacral sulcus while abducting the left leg ~15 degrees while internally rotating the leg to lose pack the SI joint. Hypothenar eminence of cephalad hand is placed on the left ILA with an anterior force (restriction). The patient inhales while the physician maintains anterior pressure on the left ILA. On exhalation, the physician maintains anterior pressure on the left ILA to prevent sacral flexion. The process is repeated as needed.
what is the log-rank test
Log-rank statistic measures whether the data in the two groups are statistically "different," do not need to know how to calculate the log-rank statistics, do need to know how to interpret p-values
prerenal causes of AKI
Low perfusion Volume depletion- hypotension Cardio problems causes decreases effective blood volume Hemodynamic insult
What is the GISP and why is it important?
MONITOR ANTIBIOTIC RESISTANCE TRENDS, MAKE NEW RECOMMENDATIONS ON TREATMENT
contraindications for P/C (percutaneous) renal biopsy
Main risk- bleeding. You are sticking a needle into highly vascular thing. Don't want high BP because they will bleed more If you have a problem in single kidney they will end up on dialysis Small kidney is scarred up and more likely to bleed
Lab workup for HIV new pt
Male and female and age make difference This is general Do own screen HIV to validate lab findings HIV RNA by PCR to get viral load, some labs do branch DNA CD4 and CD8 ratio Heb B and C status Hep A status Heb B is the most important ot know, drugs can suppress hep B Want to know other STIs Blood for syphilis Maybe herpes pr mycoplasma in genetic testing Trich-urine PCR HIV genotype Kidney and liver status HLAb51 status, in case we need to use abacavir G6pd enzymes, to know if dapsone is in the option Anal and cervical pap smear STI screens Pregnancy tests Vaccinations important Avoid live vaccines until pt has 2 consecutive CD4 counts Know kidney and liver function
kidney functions
Many functions, maintenance of body composition, mainly get rid of waste, 1.5% of what is filtered comes out, metabolic end products, fluid in body, pH of blood and lungs, urine (4-7) is acidic to blood (7.4), you can become acidotic with kidney failure, produce activated vitamin D Maturation of bone barrow, kidneys say produce red blood cells, can see anemia with kidney damage
Unlike Neisseria gonorrhoeae, Chlamydia trachomatis is a
Obligate intracellular pathogen, both are gram neg
minimal change disease
Minimal Change Disease (MCD for short) is a kidney disease in which large amounts of protein is lost in the urine. It is one of the most common causes of the Nephrotic Syndrome
primary glomerular causes of nephrotic syndrome (differential diagnoses) and secondary
Minimal change nephropathy-kids Focal glomerulosclerosis-AA Membranous nephropathy-adults by looking at their demographic (kid, adult, AA) you can try to see what they are more likely to get DM lupus
replication cycle of HPV
Most viruses like to have host cells that are actively dividing. If cells in host are in "S" phase, thats when you have all of the components: nucleotides, subunits, aa, needed for synthesis are prevalent. E6 and E7 are genes that help to push the cell into active synthesis stage. E6 and E7 therefore are considered viral antigens
how does HIV resistance happne?
Mutations such as M184V may make the virus less susceptible to ARVs, ARV cannot bind Mutations cause conformational changes in a viral enzyme's binding site
what is Light Chain Cast Nephropathy
Myeloma cast nephropathy, also referred to as light-chain cast nephropathy, is the formation of plugs (urinary casts) in the kidney tubules from free immunoglobulin light chains leading to kidney failure in the context of multiple myeloma. It is the most common cause of kidney injury in myeloma. •Cast nephropathy is characterized by intratublular obstruction with light chain casts -> ATN •Clinical clue: •Elevated urine P:C ratio (detects all urine proteins) with minimal proteinuria on dipstick (only detects albuminuria) if you see major differences between these 2, think of a light chain •Anemia, hypercalcemia (corrected for hypoalbuminemia), peeing out albumin,
when to use NNRTI
NNRTI only need 1 pt mutation to develop resistance, only use in patients who are highly adherent to taking medication in certain situations
if a patient is taking an __________ med, and they are showing Cr increases, always discontinue
NSAID
drug classes that should not be used in acute renal failure settings
NSAIDS or COX-2 inhibitors ACE inhibitors ARBs demerol (Meperidine)
nephritic vs nephrotic
Nephritic -Almost always has blood in urine -Amt of proteinuria is much less than 3.5 g per day -HTN -Red blood cell casts is hallmark of nephritic!!! Nephrotic -When someone has heavy proteinuria -Because losing so much protein in urine they lose albumin in the blood -This reduces the oncotic pressure and leads to third spacing of the fluids into interstitial fluids and causes edema -Due to low serum albumin, your body cranks up protein production including lipids Nephrotic range proteinuria (more than 3.5 g per day) vs nephrotic syndrome (more than 3.5 g per day along with edema, hypoalbuminemia, and hyperlipidemia)
nephrotic syndrome explained
Nephrotic syndrome is characterized by a massive renal loss of protein (> 3.5 g/day) resulting in edema, hypercoagulability (antithrombin III deficiency), and an increased risk of infection (loss of immunoglobulins). Typical laboratory findings of nephrotic syndrome include hyperlipidemia and fatty casts on urinalysis. The most common causes of nephrotic syndrome in adults are focal segmental glomerulosclerosis and membranous nephropathy. Both diseases usually require immunosuppressive therapy. In children, nephrotic syndrome is most commonly caused by minimal change disease, a benign condition that responds well to corticosteroids. However, nephrotic syndrome can also be a manifestation of advanced renal disease (e.g., diabetic nephropathy, amyloidosis). These diseases are associated with a worse prognosis and are more difficult to treat.
Cystatin C
Newer measure of kidney function Produced by all nucleated cells More accurate, can pick up small changes better than creatinine
acute renal failure vs AKI
No longer use ARF because term is not as accurate, function is not 0 It is a spectrum of kidney injury Mild or severe injury to the point of failure
Nonoliguria
Nonoliguria: UOP > 500 ml/24 hr
When to start ART
Normal cd4 was 500-1500 For many years 350 was used as cutoff for when to initiate Drugs are more and more tolerated, less side effects, less resistant Now, every patient who is HIV positive, no matter what
if a patient is dehydrated, what is the treatment to restore kidney function
Normal saline 500 cc (cubic centimeter or ml) over 30 minutes
pathophys of gonorrhea
Note in top left diplococci, pilli sticking out for attachment Attaches and is endocytosed Transmitted through the human host and released into basal lateral surface out the basal lateral membrane Engulfed by phagocyte or PMN cell, phagocytes kill n. Gonorrhea but in doing so would reinforce inflammatory response, recruit additional host immune factors, and release cytokines and inflammatory factors that would result in eukaryotic cell damage PMN cells that take in gonorrhea will not kill them. THey will carry them through the cell damage and take them to the exudate that is seen upon infections It is this pmn cell with bacteria in it that will go on to infect next host
Complicated Urinary tract infection:
Occurs in individuals with underlying structural or functional abnormalities of the GU tract. Can be limited to the bladder or involve both the bladder and kidneys E. coli is the most common but not by a as large of a margin than uncomplicated infections. Requires a smaller amount of virulence factors due to the abnormalities in the urinary tract. There are several other causative agents: Enterobacteriaceae: Klebsiella spp, Enterobacter spp, Citrobacter spp Nonfermenting Gram Negative: Pseudomonas aeruginosa Urease producing: Proteus mirabilis, Morganella morganii, and Providencia spp Urease metabolizes urea to ammonia and damages the kidneys directly and facilitates stone formation. Enterococcus species and coagulase negative staphylococci are the most common gram positive organisms Yeast species are seen occasionally, most common are Candida albicans, C. tropicalis, C. glabarata, and C. parapsilosis
clinical findings of ATN
Oliguria with brown, granular casts Elevated BUN and creatinine Hyperkalemia w/ metabolic acidosis
chancroid clinical presentation
PAINFUL ulcer
what drugs are at risk for causing acute interstitial nephritis
PCN Cephalosporins cipro Furosemide Thiazides Fenoprofen PPI phenytonin, allopurinol
virulence factors of gonorrhea
Pathophysiology is enhanced by these virulence factors LOS is endotoxin Not a good choice to use B-lactam to treat
Which of the following is true regarding the FABER orthopedic test?
Patient lies supine while hip is flexed and abducted with knee bent The FABER test is an orthopedic exam to test for hip joint, SI joint, or iliopsoas pain. The name stands for the positioning: Flex, ABduct, Externally Rotate the hip into a figure four position with the lateral malleolus resting above the contralateral knee. Pain with positioning is more indicative of hip pain. Pain with compression of the knee after positioning is more likely SI pain.
PrEP vs PEP
PrEP (pre-exposure prophylaxis) is only for people who are at risk of getting HIV. But PEP (post-exposure prophylaxis) is an option for someone who thinks they've recently been exposed to HIV during sex or through injection drug use.
major risk factors of AKI
Pt risk factors- preexisting chronic kidney disease, sepsis, older people, diabetics, chronic HTN, renal artery stenosis Meds-NSAIDS, Cox-2 inhibitors Cyclosporine or tac- transplant meds Contrast for cat scan studies Aces and arbs- decrease efferent flow Any procedures like bypass surgery, anything involving aortic cross clamps, have to temporarily stop flow
what happens if u remove a kidney? how will pressure be affected?
Reduction of kidney mass to 30% greatly reduced the ability of the kidneys to excrete salt. In order to accommodate this, the kidney has to have MAP increase in order to excrete salt at the same level.
postrenal causes of AKI
Renal dysfunction due to impediments in the flow of urine Causes of post-renal AKI can be further defined anatomically Intra-ureteral Stones, clots, tumors Extra-ureteral BPH, neurogenic bladder Retroperitoneal fibrosis Bladder, cervical tumors
Most herpes infections are transmitted by people who have never had any symptoms. Please address this phenomenon and why it is important when you counsel a patient who is newly diagnosed with a genital herpes infection.
SYMPTOMS ADJUST WHEN BODY GETS SO OVERWHELMED WITH VIRUS THAT YOU SHOW PHYSICAL SIGNS asymptomatic infections are common in herpes asymptomatic shedding is a significant factor in that it is a source of infection
pathophysiology of chlamydia infection
Shown above is eukaryotic cell with nucleus Here is single EB- this is chlamydia attaching to the surface of eukaryotic cell Invades cell and replicates Within the eukaryotic cell, the EB differentiates into RB, reticulate body. RB is metabolically active and duplicates and increases in number, this is the growing form of the bacteria That RB form of the bacteria fills the cell in vesicle until signal is received Signal is likely space confinement or nutrient limitation At that point, RBs differentiate into the EBs Eukaryotic cell is lysed EBs released into environment to infect next eukaryotic cell Note that 1 single EB enters the cell, and a bunch of EBs are released EB is infectious agent, it does the binding, but it is not metabolically active RBs are not infectious, and they are metabolically active Antibiotic treatment will be targeting the RBs!!!!! Note the side path The RBs are replicating to a certain point and then hanging out dormant , not continuing to replicate and not transition back to EB, this is how we see persistence of chlamydia
what are some test findings of HIV and low labs?
Skin test delayed-type hypersensitivity (DTH) responses are absent, natural killer (NK) cell and cytotoxic T-cell (Tc) activity is reduced, and there are various other immunological abnormalities, including polyclonal activation of B cells.
stages of HIV
Stage 1: Acute HIV infection Within 2 to 4 weeks after infection with HIV, people may experience a flu-like illness, which may last for a few weeks. people with acute infection are often unaware that they're infected because they may not feel sick right away or at all. To know whether someone has acute infection, either an antigen/antibody test or a nucleic acid (NAT) test is necessary. Stage 2: Clinical latency (HIV inactivity or dormancy) This period is sometimes called asymptomatic HIV infection or chronic HIV infection. HIV is still active but reproduces at very low levels. People may not have any symptoms or get sick during this time. People who are taking medicine to treat HIV (ART) as prescribed may be in this stage for several decades. people can still transmit HIV to others during this phase. people who take HIV medicine as prescribed and get and keep an undetectable viral load (or stay virally suppressed) have effectively no risk of transmitting HIV to their HIV-negative sexual partners. At the end of this phase, a person's viral load starts to go up and the CD4 cell count begins to go down.. Stage 3: Acquired immunodeficiency syndrome (AIDS) AIDS is the most severe phase of HIV infection. People with AIDS have such badly damaged immune systems that they get an increasing number of severe illnesses, called opportunistic illnesses. Without treatment, people with AIDS typically survive about 3 years. Common symptoms of AIDS include chills, fever, sweats, swollen lymph glands, weakness, and weight loss. People with AIDS can have a high viral load and be very infectious.
how to diagnose postrenal AKI?
renal ultrasound!!! need to see if there is an abstruction
how will pts with postrenal AKI present?
Straining to urinate, with little success Pain - especially if acute obstruction Hematuria Abnormal urinary flow
24 hr urine collection
The 24-hour urine protein test consists of multiple samples of urine taken over a 24-hour period. It's different from a protein-to-creatinine ratio test, which uses just one sample of urine. The 24-hour urine protein test may be given as a follow-up to a positive protein-to-creatinine ratio test. Need to have actual total collection for it to be accurate
how does Tubuloglomerular Feedback work?
The juxtaglomerular cells on the afferent and efferent arterioles and the macula densa cells of the distal tubule are anatomically right next to each other. The macula densa cells (called that because they are dense and appear darker under the microscope).The macula densa cells are stimulated by low NaCl. They send a signal to the JG cells to release renin. Renin results in the formation of angiotensin II (AII). All constrict the efferent arteriole preferentially. Thus, increase in intraglomerular pressure to favor filtration so kidney can keep good things in the blood and secrete bad wastes out for urination.
Home Access HIV-1 Test System
The Home Access HIV-1 Test System is a laboratory test sold over-the-counter (OTC) that uses fingerstick blood mailed to the testing laboratory. The test kit consists of multiple components, including materials for specimen self-collection, prepaid materials for mailing the specimen to a laboratory for testing, testing directions, an information booklet ("Things you Should Know About HIV and AIDS"), an anonymous registration system and a call center to receive your test results and follow-up counseling by telephone. uses a finger prick process for home blood collection which results in dried blood spots on special paper. The dried blood spots are mailed to a laboratory with a confidential and anonymous unique personal identification number (PIN), and are analyzed by trained clinicians in a laboratory using the same tests that are used for samples taken in a doctor's office or clinic. Test results are obtained through a toll free telephone number using the PIN, and post-test counseling is provided by telephone when results are obtained. sensitivity (i.e., the percentage of results that will be positive when HIV is present) was estimated to be greater than 99.9%. The specificity (i.e., the percentage of results that will be negative when HIV is not present) was also estimated to be greater than 99.9%. 80 bucks???? MORE EXPENSIVE TAKES TIME, HAVE TO MAIL IN SAMPLE REALLY REALLY SENSITIVE AND SPECIFIC
Describe the principles of survival analysis including interpretations of Kaplan-Meier curve.
The Kaplan-Meier estimator is used to estimate the survival function. The visual representation of this function is usually called the Kaplan-Meier curve, and it shows what the probability of an event (for example, survival) is at a certain time interval. What percent of the group survived after 5 years? Because it is hard to follow people for years and years ,they may drop out of the study. This is seen on the curves as a "tick" mark, study is now technically less precise but it is ok we "censored them" out of the study mainly descriptive commonly used to compare 2 study populations intuitive graphical presentation
oraquick
The OraQuick® InHome HIV Test is an invitro diagnostic home use test for HIV (HIV1 and HIV2) in oral fluid. works by looking for your body's response (antibodies) to fighting the HIV virus. Swab stick thingy against patients outer gums and place in solution This test detects HIV infection if used 3 months after a risk event. If you want to be tested before 3 months, you should go to your doctor or local healthcare provider. When you have been infected with the HIV virus, your body tries to defend against the HIV virus by producing antibodies to it. These antibodies can be found in your blood or oral fluid. It takes your body up to 3 months to produce these antibodies at levels that can be detected by this test. A negative result means that the test has not detected HIV antibodies (your body's way of fighting the virus). If it has been at least 3 months since you have had a risk event and you followed the directions carefully, you likely do not have HIV. However, as with any test, there is a chance for false results. Specificity: 99.9% of people (4,902 out of 4,903) correctly reported a negative test result. Sensitivity: 91.7 % of HIV positive people tested reported a correct test result. OraQuick In-Home HIV Test typically costs around $35.00 - $45.00. CHEAPER, BUT LESS SENSITIVE GET THE RESULTS RIGHT AT HOME WITHOUT WAITING TO SEE MAILED IN RESULTS
causitive agent of syphilis and characteristics
The causative agent of syphilis is Treponema pallidum, a Gram-negative motile spirochete This pathogen is spread only by sexual contact (A) and is intracellular (D), corkscrew shaped
describe the relationship between changes in GFR and how it changes serum Cr
The change in serum creatinine that occurs lags behind the change in GFR that is seen with acute renal failure. Here you see the abrupt drop in GFR in a patient with acute renal failure, but the serum creatinine lags behind so that it may not start going up until 24 or 36 hours after the acute insult. When we see a patient with aggressively rising serum creatinine, that does not mean that the renal function is continuing to deteriorate. The GFR may be close to 0 and be maintained at that level close to 0 during that period of time. The creatinine has not come back into a steady state at this new very low GFR.
The likelihood of developing resistance is highly dependent on the level of ARVs in the plasma. Why?
The likelihood of developing resistance is highly dependent on the level of ARVs in the plasma How ARV drug resistance develops Antiviral drug levels through resistance Drug levels low, on the right, person is optimally adherent, viral suppression occurs, little likelihood of virus resistance because there is not a lot of virus to make mistakes Middle suboptimal drug range=where mutation occur, sweet spot, allows for high likelihood of Antiviral resistance to occur
what is the first treatment in a patient with rhabdomyolysis to prevent AKI
The main step in preventing AKI in a patient with rhabdomyolysis is early and aggressive fluid therapy. Intravenous isotonic saline should be initiated to prevent precipitation of the pigment in the tubular lumen. Fluid should be administered aiming to target urine output of 200 to 300 ml/h. If patient develops evidence of fluid overload (over hydration - peripheral edema, pleural effusion, pulmonary edema, etc) IV Lasix can be administered . If IV Lasix, dialysis could be initiated and continued until kidney function recovers. In most patients, recovery of AKI is the norm, but chances are lower in elderly or patient with multiple underling medical conditions, chronic kidney disease, diabetes.
A patient presents with the following findings: a positive seated flexion test on the left, negative standing flexion test, right sacral sulcus deep, left ILA posterior. Based on the diagnosis, how would you position the patient to perform sacral muscle energy?
The sacral diagram would be drawn with a positive seated flexion on the left, right sacral sulcus and ILA deep, left sacral sulcus and ILA shallow, and an oblique axis on the right. This would be a Left on Right backward torsion. For sacral muscle energy, physician instructs patient to lay on the side of the axis (in this case right), and then turn so their back is on the table.
Membranous nephropathy
Thick glomerular basement membrane on H&E, due to immune complex deposition. , Immune complexes deposit SUBEPITHELIALLY. They have a granular immunofluorescence and a ________ appearance on EM. This is because epithelial cells lay down basement membrane when they get pushed off by immune complexes. cause nephrotic syndrome
what is the most common cause of AKI
renal-60% prerenal-30% post-10%
when to use continuous renal replacement therapy
This is another type of dialysis Used for very sick pts Low BP On ventilator In ICU, slow continuous dialysis
HIV route of transmission
This virus can "lay dormant"
Rhabdomyolysis
Toxin exposure Muscle necrosis/breakdown releases myoglobin into the blood Too much blood myoglobin can cause kidney damage causes ATN? causes direct tubular toxicity of myoglobin to renal tubular cells; urine analysis positive for heme with no RBC suggests AKI is due to myoglobin, not hemoglobin, since there are no RBCs in urine. High CPK goes with rhabdo. With muscle breakdown, potassium, phosphorous and uric acid will be high as well. Rhabdomyolysis is commonly seen in patients with seizures, excessive exercise, alcohol or drug abuse (Cocaine), treatment with statins, prolonged immobilization, limb ischemia, crush injury
transmission of syphilis is based on
Transmission based on what stage of syphilis the person transmitting the disease is in Latent-no lesions no rashes , will NOT transmit the disease Primary and secondary are most likely to spread Syphillis can cross the placenta
what causes syphillis
Treponema pallidum
Detail the basic characteristics, of Trichomonas vaginalis as well as the pathophysiology associated with infection
Trichomonas Vaginalis is a common protozoan inhabitant of the vagina and is found in 15% of or more of women, in whom it occasionally causes vaginitis. Entry, Multiplication, and Damage: T. vaginalis infection is transmitted by sexual intercourse. Vaginitis is typically associated with a frothy creamy discharge. Most male partners of symptomatic women become infected, however, the majority of infections in men are asymptomatic, can cause mild urethritis, epididymitis, or prostatitis. Diagnosis and Treatment: It is usually possible to see these flagellates moving vigorously in wet preparations of vaginal secretions from infected women. Infection of male partners can be assumed. Single dose metronidazole or tinidazole is recommended. Trichomoniasis is associated with adverse outcomes in pregnant patients. Male partners should be treated as well to prevent reinfection.
Describe HIV replication and know the roles of each of the following: receptors, reverse transcriptase, protease, integrase, and provirus.
Tropism- the fact that the virus likes a particular cell HIV is for CD4+ cells Actually enters into cell using gp41 Once in cell, the reverse transcriptase takes single stranded RNA and copies it into single stranded DNA. Destroys RNA and uses single stranded DNA as a template to synthesize the whole molecular strand, which is how you get double stranded RNA, integrase inserts it into the host genome. **once a virus is assembled, it is not infectious at that point. It will use a single polypeptide which is clipped into individual proteins, polyprotein. Virus encodes a protease, en enzyme, which then clips it into several proteins. Only when the parts are clipped is virus capable of infecting cells. This is why protease is a target for antiretroviral drugs. Virus cannot mature.
management of AKI
Trying to find cause and reverse that Want to fix the obstruction If they have prerenal azotemia you want to volume resuscitate them and improve blood pressure If it is intraglomerular process you want to find diagnosis- May just be supportive care Good pressure Good volume Remove nephrotoxic drugs Give kidneys time to heal
glomerular causers of AKI
Typically see funny red cells, get distorted as they pass through glom, get mickey mouse ears All must be diagnosed by kidney biopsy
anuria
UOP < 100 ml/24 hr, absence of urine
oliguria
UOP < 500 ml/24 hr
polyuria
UOP > 3000 ml/24 hr
Acute uncomplicated urinary tract infection:
UTI presenting as acute cystitis (bladder or lower urinary tract infection) in otherwise healthy women Acute uncomplicated Cystitis: E. Coli is isolated from 80-85% of cases of acute uncomplicated cystitis. Staphylococcus saprophyticus is found in 5-15% of cases. The remaining infections are due to organisms like Klebsiella spp, Proteus spp, or group B streptococcus. Escherichia coli: Essential virulence factor for acute cystitis is expression of the man-nose-sensitive fimbria or FimH. This is a protein receptor that facilitates adherence of E. coli to bladder uroepithelial cells through mannosylated glycoproteins that line the bladder mucosa. Present in 80% of E. coli strains, including fecal strains. Staphylococcus saprophyticus: Gram positive organism found in 5-15% of the remaining acute episodes of cystitis. Found more often in the fall than any other time of year. urine shows WBC normal positive leukocyte esterase positive nitrites
what is end stage renal disease
Uremic Acidotic Hyperkalemia Hyperphosphatemia Volume overloaded Hypertensive Anemia Secondary Hyperparathyroid Bilateral atrophic kidneys . End stage renal disease. All of normal functions are abnormal. Uremia-waste products building up, acidotic, can't get rid of K and p, volume over load, CHF, increase in BP, anemia, secondary hyperparathyroidism trying to get rid of P, shrivel up and become small or atrophic
What kind of urine findings would you expect in prerenal AKI? A.FENa > 1% B.Urine osmolality 100 mOsm/kg H2O C.Urine sodium <20 meq/L D.Urine specific gravity 1.01
Urine sodium <20 meq/L; in prerenal azotemia, the renal parenchyma ( is not damaged, so with severe dehydration, the renal tubules are still able to effectively absorb sodium; urine sodium will be low and urine will be concentrated with high urine osmolality or specific gravity.
what drugs should be used for ART?
Use boosted protease inhibitor regimen including drug darunavir, along with its nucleoside backbone of tenofovir and FTC, or dolutegravir along with nuc backbone of tenofovir and FTC •The DHHS Guidelines recommend a darunavir-based regimen in a rapid initiation scenario
Which of the following best describes the nerve fibers carrying sensation from of the body of the uterus?
Visceral sensory - travel with sympathetics -cell bodies in T10-L1 DRGs The body and fundus of the uterus lie above the pelvic pain line. Thus, the visceral sensory afferent fibers travel with the sympathetic fibers descending into the pelvis in the hypograstric plexus. These are sensory fibers, so the cell bodies reside in dorsal root ganglia (DRGs) as do the cell bodies of all afferent nerves. The cell bodies of second order sympathetic neurons and their glial cells reside in peripheral ganglia like the inferior mesenteric ganglion. Visceral sensory fibers innervating structures below the pelvic pain line travel with parasympathetic fibers to the S2, 3 and 4 DRGs. The perineum (including the lower 1/3 of the vagina) is innervated by somatic sensory fibers that are part of the pudendal nerve and also travel to the S2,3 and 4 DRGs
What types of bacterial STIs can be asymptomatic? How common is asymptomatic carriage for each? Do these rates vary in males and females?
WHY NOT GOOD NUMBERS IN MEN CHLAMYDIA? WE ROUTINE RECOMMEND SCREENING FOR WOMEN IN REPRODUCTIVE AGE, WE HAVE GREAT DATA IN WOMEN, UNTREATED IT CAN LEAVE TO INFERTILITY WE DON'T ROUTINELY RECOMMEND SCREENING MEN chlamydia, gonorrhea, syphilis
vaginal candidiasis discharge slide
Where mouse is is showing yeast buds, little guy and big guy, looks like snowmen See a pseudohyphae-buds and joints in "hair" looking thing
graph of arterial pressure control in essential hypertension
X axis= arterial pressure Salt intake on Y Normal person, doesn't matter the salt intake, our kidneys have ways to get rid of it In other 2 curves we have patients with essential hypertension Non salt sensitive hypertension in middle curve In salt sensitive, see how dotted line curves over to the right
what is the most common cause of AKI?
acute tubular necrosis
how to treat diabetic nephropathy
add on an ACE or ARB •Improved glucose control HgA1C <7 •RAAS blockers: ACE, ARB, Aldactone/eplerenone
Urine protein:Cr ratio picks up
all proteins in the urine, not just albumin, will pick up light chain proteins too
types of interstitial nephritis
allergic infectious immunologic toxin neoplastic
Lymphogranuloma venereum (LGV)
an infection of the lymphatic system caused by three strains of the bacterium Chlamydia trachomatis, transmitted sexually tender inguinal and or femoral lymphadenopathy self limited ulcer sometimes
Hep B characteristics of virus
antigens -proteins produced that are needed for virus assembly, help us detect if it is an acute infection, chronic, etc. Once strand of circle is complete, the other strand is incomplete circle. See half a circle
renal scans are used to
assess kidney size and echogenicity, which helps determine if it is AKI or CKD
A 25yo female presents with a complaint of increased malodorous discharge. She declines a physical exam but provides you with a self-collected vaginal swab. On testing, pH is 4.5, whiff test is positive, and microscopically you see 75% of vaginal epithelial cells with borders obscured by cocci. Her diagnosis is:
bacterial vaginosis
A patient presents to the clinic for LBP. A standing flexion test and seated flexion test are negative. A classic spring test is positive. Which of the following is the most likely sacral diagnosis?
bilateral extension A negative seated flexion test should clue you in to a bilaterally flexed or extended sacrum. A positive spring test means there is "no spring" at the lumbosacral junction, indicating the base is posterior or extended.
What is multiple myeloma?
cancer of plasma cells
bacterial vaginosis common symptoms
change in discharge odor itching burning +/- dysuria
Focal glomerulonephritis
changes in only some glomeruli; others remain normal, causes nephrotic syndrome
what is the number 1 cause of bacterial STIs in the US?
chlamydia
what common bacterial STIs present with vaginal/penile discharge
chlamydia gonorrhea
A 16yo male presents with painful urination and yellow penile discharge. Your differential diagnosis should include
chlamydia gonorrhea herpes? this is not usual presentation, it should be on your differential trich
What immune mechanism(s) will play the largest role in clearing a Chlamydia infection? How is this different than the immune mechanisms mediating clearance of an infection with Neisseria gonorrhea?
chlamydia is CELL MEDIATED IMMUNITY neisseria is HUMORAL IMMUNITY
if you have nephrotic syndrome, you are at risk for
clotting, DVT, PEs Why? •Nephrotic Syndrome can be complicated by clotting manifestations due to a secondary hypercoaguable state •Membranous glomerulopathy greatest risk of thrombosis •Up to 35% MGN •Risk greatest when serum albumin <2.8 •In response to hypoalbumenia-> liver overproduces proteins •Hyperlipidemia •Procoagulant proteins: factor 5/8 & fibrinogen •Urinary loss of low-molecular-wt anticoagulants •Antithrombin III, protein C, protein S
we have what types of cells on the microscope with BV
clue cells
describe the juxtaglomerular apparatus
darker= macula densa, sense the amt of NaCl in tubule fluid that is going through them Low NaCl= low flow=low blood flow= need to maintain flow, send signal to adjacent juxtaglomerular cells, JG cells JG secrete renin, renin eventually become angiotensin II Angiotensin II does constrict both afferent and efferent arterioles, but is MORE constrictive on the efferent side Helps to build up intraglomerular pressure within the glomerulus which promotes filtration Distal tubule efferent =exit afferent = coming in
when bp increases, renin will
decrease
as GFR increases, Cr
decreases Using creatinines alone are not accurate, they mean different GFRs in different patient populations
are patients mandated to disclose their STI status with partners
depends state by state
azotemia
elevated BUN
what is cytopathology
destruction of CD4 T helper cells common with HIV When CD4 count goes down, it is a measure of infection Overtime, as virus replicates, presents mature particles, they attack new CD4 cells, so you become susceptible to other infections
HPV complications
development of carcinomas, remember E6 and E7 genes are interrupting the cell cycle causing abnormal growth, causing tumors/carcinomas
Does dialysis "jumpstart" / "rest" / "help" the kidneys ???
dialysis does NOT treat renal failure, but rather the complications of renal failure Ultimately if they don't improve and are getting sick, offer dialysis Does dialysis jump start rest or help the kidneys? NO!! IT does not mean that kidneys will get better! Just takes over some of the functions of the kidneys while kidney is healing, but it does not improve those functions
In setting of diuretics, the fractional excretion of urea is more accurate than fractional excretion of Na, because
diuretics are forcing Na into the urine
what is the most common form of censoring in medical studies
right censoring
HIV characteristics
enveloped=exits cell by budding (not lysis) Single stranded RNA genome RNA virus, and one of the first steps of its replication is that it has a polymerase that we refer to as reverse transcriptase, sometimes referred to as RNA dependent DNA polymerase, because the template it uses is RNA, it uses the template and copies it into double stranded DNA, and that double stranded DNA is then inserted into the host genome, at this point, that viral DNA is inserted into the host genome and known as a provirus Provirus is any viral genome inserted into the host genome.
herpres simplex virus characteristics
enveloped=has a capsid (protein shell that surrounds DNA or RNA, never both) with a modified cell membrane=envelope HSV=double stranded DNA neurovirulence=the only receptors that the virus can attach to are found in neural tissue, this is how they attach and enter cells latency= once the antiviral response of the immune system has kicked in, it does not completely clear that virus, some of the virus hangs along, lying dormant and can be reactivated
true or false, HPV will be stopped from transmission if u just wear a condom
false!! Barriers lower the chances but it can infect areas not covered by condoms
if AKI is caused from a vascular problem, what are symptoms you may see?
flank pain decreased UO fever hematuria high LDH
what is a normal microscopic discharge evaluation?
fried eggs more lactobacilli than cocci less than 10 WBC
HSV 2 presentation
genital ulcers
how to know if it is acute or chronic AKI?
get old Cr values to look at to compare do a renal US- small kidneys are CHRONIC do they have DM? HTN? Anemia, secondary hyperparathyroidism=chronic
HSV 1 Presentation
gingivostomatitis
what is the second most common cause of bacteria STI in the US>?
gonorrhea
characteristics of haemophilus ducreyi
gram neg bacillus
BUN/Cr in prerenal
greater than 20
what % of FE urea is ATN
greater than 50%
tell me about tertiary syphilis symptoms and pathogenesis
gumma in skins, bones, liver, brain, and testis, VV syphilis, neurosyphilis
what is the bacteria that causes chancroid
haemophilus ducreyi
Which of the following diseases is a risk factor for the development of hepatocellular carcinoma?
hep B
if there is watery discharge what diagnosis are likely
herpes and foreign body
What lab findings suggest ATN?
high urine Na and high osmolality- this will damage the tubules muddy, brown granular casts
Chancroid
highly infectious nonsyphilitic venereal ulcer associated with inguinal lymphadenopathy, causivive agent is haemophilus ducreyi
HIV replication
https://www.youtube.com/watch?v=8sipX86JfUw
water and salt increases, what does MAP do?
increases, the decreases Increase in extracellular fluid volume Leads to increase blood volume Increase mean arterial pressure Increase venous return of blood to heart Increase in CO Will have some autoregulation Vasodilation because MAP is high Decreasing arterial pressure to normal
when to give dialysis
indicated patient with acute renal failure not responding to IV Fluids or if patient has volume overload or refractory hyperkalemia, metabolic acidosis or uremia.
cystitis
inflammation of the bladder, usually caused from e. coli
glomerulonephritis
inflammation of the glomeruli of the kidney •Glomerular hematuria typically features brown or tea colored urine with dysmorphic erythrocytes and/or erythrocyte casts on urine sediment •Erythrocyte casts are cylindrical or tubular structure and inclusion of small agranular spherocytes •DM nephropathy- do not see red cell casts, usually a clinical Dx, rarely kidney biopsy
cytopathology, interaction of the immune system and the virus for Hep b
interaction of the immune system and the virus As immune system tries to combat virus, the cells and tissues around are getting damaged Immunopathology, as a result of, rather than the direct lysis of the cell due to the viral infection
Which of the following provides blood to the erectile tissue of the corpora cavernosa of the clitoris and the bulbs of the vestibule?
internal pudendal The vaginal aa. provide blood to the vagina, but not the external genitalia. There is no pudendal a. (only a pudendal nn.). The internal pudendal aa. is a branch of the internal iliac a. and travels with the pudendal n. to the perineum. The external pudendal aa. arise from the femoral a. and provide blood to superficial structures of the perineum. The inferior and superior vesicle aa. provide blood to the urinary bladder only
what type of ATN is the most common?
ischemic Ischemic ATN is most common Inner and outer medulla is sensitive to hypoxia with low flow, tubules start to necrosis from Sepsis, Shock, post surgery Generally reversible
tubular ATN types
ischemic, obstructuve, nephrotoxic
the most common estimator of the survival function is the
kaplan meier estimator
as mean arterial pressure _____ urine out put _______
rises , rises Try to get fluid out to bring down mean arterial pressure
what does the hazard ratio represent
risk of event (death in survival analysis) in the treatment group compared to the control represents the instantaneous event rate
will u have a large or small kidney in CKD
large
complications of syphils
late stage syphilis
total protein excretion rate
less than 150
what % of FE urea is prerenal?
less than 35%
complications of Heb B
liver cirrhosis hepatocellular carcinoma
Creatinine Clearance
measurement of the rate at which creatinine is cleared from the blood by the kidney
the narrower the confidence interval the More/less precise the estimate
more
U(Na) in prerenal ARF
more than 15 meg/L
hep B portal of infection
mucosal surfaces of genitalia skin-blood contact
HPV portal of infection
mucus membranes abrasions, cracks in skin
HSV portals of entry
mucus membranes abrasions, cracks in skin
Which of the following best describes the arterial blood supply to the female reproductive tract?
multiple branches of the internal iliac a. and branches of the abdominal aorta The female reproductive tract receives blood from 4 pairs of arteries. The ovarian arteries branch directly from the abdominal aorta just below therenal arteries and descend to the ovaries and fallopian tubes in the suspensory ligament of the ovary. It is the left ovarian vein that usually branches from the left renal vein. The uterine, vaginal and internal pudendal aa. are branches of the internal iliac aa. The ovarian and uterine arteries form a substantial anastomosis. The uterine aa. are normally the largest of these vessels and they hypertrophy dramatically during pregnancy
Renal Artery Stenosis (RAS) how to diagnose
narrowing of the renal artery Renal artery- usually presents in CKD (chronic kidney disease), someone with hemodynamic compromise, typically tight lesion in the renal artery, low flow, it will clot off Classically question stem will have Diastolic ab bruit is clue to RAS Also if you give some ACE or ARB cr level increases because they are dependent on efferent tone to maintain GPP, ACEs and ARBS decrease that Can't compensate due to stenotic fixed lesion, not allowing higher blood flows to come in Diagnosed by Ct with dye or MRI Angiography is Gold standard- diagnostic and can perform stent placement if needed
how to treat postrenal AKI
need to get the obstruction OUT to do this, need to inservt foley cath
is a person infectious in latent syphilis?
no
what is the biggest/ most prevalent symptom of chylamidia
no symptoms!! 80% are asymptomatic
is yellow, purulent discharge a symptom of BV?
no, it is usually gray. IT will not cause burning with urination
is there a test for HPV?
no, there is only a test for detecting HPC in cervical cancer. In order to confirm STI HPV it is just a clinical diagnosis
chancriod symptoms
painful genital ulcer, tender suppurative lymphadenopathy
genital herpes presentation
painful ulcers/vesivles, fever, regional lymphadenopathy
characteristics of granuloma inguinale
painless, slowly progressing ulcers, beefy red, no regional lymphadenopathy, travel to an endemic country
In assessing a patient's sexual history, your patient discloses that they've had one male partner in the past 3 months. When you inquire about whether that partner has used injection drugs, you are assessing which aspect of the sexual history?
partners
urine Na initially low then becomes normal
postrenal
FENa below 1% is
pre-renal
bland to hyaline casts
prerenal
high BUN/Cr ratio
prerenal
high urine SG, more than 1.020
prerenal
high urine osmolality (above 500 osm/kg)
prerenal
lab differences between prerenal and ATN
prerenal -normal sediment -can handle salt -urine Na is low -FeNa is low ATN -muddy brown -can't handle salt -urine salt is HIGH -FeNa is high
hyaline cast
prerenal azotemia
what is the cause of AKI if pt comes in with complaints of nausea vomiting diarrhea hypotension low urine Na high osmolality
prerenal azotemia this is pointing to dehydration or volume depletion , the low urine sodium and high urine osmolality suggest normal renal parenchymal cells which are doing their job. At this point the renal dysfunction should be reversible with administration of IV fluids and stopping nephrotoxic medications- NSAIDS or ACEI or ARB. If hypotension is severe or if left untreated for long period of time, it can result in tubular damage/necrosis and result in intrinsic AKI. Once the tubules are damaged they cannot absorb sodium or concentrate urine to higher than 300 mOsm. Acute tubular necrosis affects the outer layer of medulla, which includes distal straight portion of proximal tubule involved in sodium reabsorption and medullary thick ascending limb (mTAL) which is involved in urine concentration.
kidneys respond to increase renal perfusion, which is done by getting pt bp up
prerenal indication, this is most important
low urine sodium, less than 20 meq/l
prerenal, you are not peeing out Na
hematuria
presence of blood in the urine
uremia
presence of urinary waste in the blood clinically sick from elevation of nitrogenous waste products, typically seen with elevated BUN
What drives glomerular filtration?
pressure GLOBULAR PROFUSION PRESSURE AND ULTIMATE URINE PRODUCTION.
primary secondary tertiary prevention
primary = before have it secondary = asymptomatic but you have it tertiary = reduce complications once symptomatic or long term effects (chemo, etc.) quartenary = PREVENT HARM and UNNECESSARY tests/procedures, etc.
trich is a bacteria, virus, protozoa, or fungus?
protozoa
common hx in someone with ATN
recent surgery hypotension sepsis muscle necrosis volume depletion exposure to nephrotoxic agents
clinical presentation of gonorrhea
rectal-purulent discharge pharyngitis purulent conjuctivitis bilateral in opthalmia nenatorum disseminated gonoccal infection-fever, rash, etc bad eye infection
What is the difference between SCREENING and TESTING when it comes to sexually transmitted infections? How do they change the labs you would order for a particular patient?
screening-test on asymptomatic patient testing-doing a test for symptomatic patient Need at least 1 diagnostic code to order test In STI, use symptoms that we use to order test STI screening (if person is just worried about their partners, would not get tested) Reason for the difference is for insurance coverage
BV wet mount s/s
sen-60% spec-98%
yeast wet mount s/s/
sen-61% spec-89%
HPV route of transmission
sexual contact
what is censoring
something outside of the event at interest occurred, we know longer have data to track What happens to all of our previous data on a patient if they drop out at year 5 of a 10 year study? Should we throw out all of their previous data? New data will be less precise because you decrease sample size. Remove new patient from the number at risk if they are censored •They are lost to follow up or drop out of the study •The study ends before they die or have an outcome of interest. •They are counted as alive or disease-free for the time they were enrolled in the study. •We say that the survival time is censored. •These are examples of right censoring, which is the most common form of censoring in medical studies. •For these patients, the complete time-to-event measure is unknown; we only know that the true time-to-event measure is greater than the observed measurement. •If dropout is related to both outcome and treatment, dropouts may bias the results In general, assume that censoring is non-informative, that is to say, censoring should not convey information about the patients outcome (event vs non-event)
most appropriate treatment of acute interstitial nephritis
stop the med that is causing it. If that doesn't work, then give steroid.
when do you change HIV therapy regimen?
the Goal is to be HIV undetectable, unlike to get resistance, when you are undetectable, low level viremia between 48 and 200 copies, RNA pt may be suboptimally inherent, may not transmit virus to others, cants transmit virus, unlike to develop resistance, over 200=resistance or nonadherence or virologic failure, some other intervention is necessary drug resistance does not appear to occur below 48 RNA copies
things that affect Cr
things that affect creatinine generation= Extremes of muscle mass Body size Creatine supplements Drugs that reduce creatinine secretion and make your serum creatinine higher Dialysis-creatinine is removed from the blood after dialysis. GFR did not improve, creatine was removed by dialysis
characteristics of treponema pallidum
this causes syphillis
A 40yo female presents with papules at the vaginal introitus. They are pink, fleshy and moist. Your differential diagnosis should include
this is a classic description of the "condyloma lata" lesions of secondary syphilis. Other conditions that should be on your differential are granuloma inguinale hpv molluscum
Venereal-
transmitted by sexual contact
ARV drug resistance can be classified as either
treatment-emergent or transmitted-Suboptimal retroviral med creates resistance Could pass on to next partner giving them resistance
An 18yo female presents with a complaint of malodorous discharge and burning in her vagina during and after sex. On physical exam she has thin, yellow-green vaginal discharge. On testing, pH is 4.9, whiff test is positive, and microscopically you see motile ciliated organisms. Her diagnosis is:
trich
LGV presentation
unilateral tender femoral or inguinal lymph node, protocolitis if rectal exposure
urine analysis in pre and post renal causes
unremarkable
what are absolute indications/conditions for renal replacement therapy?
uremic complications like encephalopathy, pericarditis, and bleeding a BUN greater than 100 K+ greater than 6, ECG abnormalities severe acidosis urine output less than 200 ml in 12 hrs, or anuria diuretic resistant pulmonary edema
types of UTIs
urethritis, cystitis, pyelonephritis
what lab values help to differentiate between pre-renal vs intrinsic AKI
urine Na and urine Cr
what lab values are used to diagnose AKI
urine output and serum Cr AKI is defined by an elevation in the serum creatinine concentration (a rise from baseline at least 0.3mg/dl within 48 hours or at least 50% higher than baseline in one week) or reduction in urine output to < 0.5ml/kg/hr. Leads to accumulation of waste products, BUN and Creatinine, acid base disturbance, electrolytes disorders and fluid retention.
syphilis
usually painless, may have palm/sole rash
A 25yo female presents with a complaint of vaginal burning and increased discharge. On physical exam she has thick, white clumps adherent to vaginal walls and cervix. On testing, pH is 3.6, whiff test is negative, and microscopically you see buds. Her diagnosis is
vag. candidiasis
What is the definition of a tertiary chorionic villus and when do they first appear (fetal age -not gestational age)
villus with fetal blood vessels -week 3 The chorionic villae of the placenta are composed of fetal tissue bathed in maternal blood in trophoblastic lacunae/intervillous spaces. They are designated as primary, secondary and tertiary depending on their stage of development. At first the villae (primary villi) appear late in the second week and only consist of a layer of syncytiotrophoblast (giant multinucleated cell formed by fusion of cytotrophoblast cells) with a chord of cytotrophoblast cells in the core. Early in the third week, the primary villi acquire an additional internal layer of extraembryonic mesenchyme (from extra- embryonic mesoderm) and are then termed secondary villi. Later in the third week, fetal blood vessels start to invade some of the secondary villi, which are then termed tertiary villi.
what is the receptor that HIV uses to bind to cells
viral gp120, which interacts with the gp41 transmembrane protein and leads to a conformational change that produces a fusion pore for viral entry CCR5 receptor is important in establishing the infection , also CXCR4
Acute interstitial nephritis
which is usually seen with antibiotics like cephalosporins, etc. It is associated with rash, peripheral eosinophilia and urine with WBC, eosinophils and mild proteinuria. Urine culture would be negative. interstitial nephritis is a kidney condition characterized by swelling in between the kidney tubules.
eGFR
•Estimated eGFR equations are: -Less precise at higher GFR levels than lower levels because of physiologic and statistical considerations in developing GFR estimating equations. •Creatinine based formulas are used to estimate GFR by adjusting for factors that affect serum Cr and CrCl •These formulas take into account the effects of age, race, sex and muscle mass (estimated by weight) on serum Cr levels •Modification of Diet in Renal Disease (MDRD) equation (1999)- uses serum Cr, age, sex, and race to estimate the GFR (NOT weight) •CKD-EPI Creatinine Equation (2009) -Uses the same 4 variables (Serum Cr, age, sex, and race) as MDRD to estimate the GFR -Concern MDRD may be overdiagnosing Stage 3 CKD, especially in elderly -Less bias than MDRD especially at GFR > 60 ml/min, improvement in precision and greater accuracy Applying an estimating formula implies that you are in a steady state
if you display nephrotic syndrome symptmos. what is the best next step test to diagnose
•Kidney biopsy is the most appropriate next step for the patient who has nephrotic syndrome most likely caused by minimal change glomerulopathy (MCG). •MCG is cause of NS in 10-15% of adults (increased elderly) •Most cases are idiopathic •Secondary causes: NSAIDS, lymphoma •1st line treatment = steroids Almost all nephrotics you have to biopsy Exceptions- children with minimal change (give steroids first) The patient in the case has minimal change If it is primary minimal change you give steroids secondary cause stop NSAIDS, treat lymphoma duh
ANCA-associated glomerulonephritis
•Nephritic syndrome characterized by hematuria, proteinuria, & leukocytes in urine sediment •Hallmark is dysmorphic erythrocytes, with/without RBC casts •Systemic findings may include edema, HTN & AKI What is ANCA vasculitis? ANCA vasculitis is an autoimmune disease affecting small blood vessels in the body. It is caused by autoantibodies called ANCAs, or Anti-Neutrophilic Cytoplasmic Autoantibodies. ANCAs target and attack a certain kind of white blood cells called neutrophils.
Biochemical Markers of Kidney Function
•Serum Creatinine •Serum Cystatin C •Blood Urea Nitrogen (BUN)-BUN is not so accurate but usable
UA dipstick and protein detection
•Simple and inexpensive •Semi-quantitative estimate •Detect only albumin •Greatly influenced by urinary concentration Meant for screening Detects only albumin Will not pick up light chains proteinuria associated with cancers ***urine concentration will influence it ****
What is survival (time-to-event) analysis?
•Time-to-event data are generated when the measure of interest is the amount of time to occurrence of an event of interest. •Statistical methods for analyzing longitudinal data on the occurrence of events. •Events may include death, injury, onset of illness, recovery from illness (binary variables) or transition above or below the clinical threshold of a meaningful continuous variable (e.g. CD4 counts). •Accommodates data from randomized clinical trial or cohort study design. (Study designs listed below) For Example: - Time from randomization to death in clinical trial - Time from HIV infection to AIDS - Time from exposure to injectable drug to incidence of HIV in an epidemiological cohort study •Time-to-event: The time from entry into a study until a subject has a particular outcome
urine sediment in prerenal ARF
•usually normal, without cellular elements or abnormal casts