Abdomina

Question 1

What is murphys sign

Answer 1

Hold over liver - deep breath

Pain on inspiration

Question 2

What may cause a Left flank scar?

If you found a readily ballotable mass on the right side that moves posteriorly with respiration what would the answer be?

Answer 2

adrenalectomy or nephrectomy

PCKD

Question 3

Young patient with bilaterally enlarged kidneys. You suspect polycystic kidney disease.

You notice that they also have a hemiparesis.

Answer 3

subarachnoid haemorrhage

Question 4

Partial vs complete nephrectomy pros and cons

Answer 4

Partial
Higher risk of recurrence
Preservation of renal function

Question 5

RCC gender?
age?
Type?

Answer 5

Male predominance
30-50

Clear cell RCC (up to 70%,
Papillary RCC (2nd most common)
Chromophobe RCC

Question 6

Where do clear cell RCC come from? Gene?

Answer 6

originating in the proximal tubule with a 3p deletion)

Question 7

Classic symptoms of a rcc

Answer 7

Haematuria
Flank mass
Loin tenderness

Note this triad only in 10%

Question 8

Investigations for suspected RCC

Answer 8

Full blood count - (Anaemia and polycythaemia)
Urea and electrolytes
Bone profile (especially calcium)
Liver function tests
Thyroid function tests
Clotting profile
Urine

Urine dip for haematuria and proteinuria
Culture to ensure no infection
Imaging

Staging computer tomography scan of the chest, abdomen and pelvis
If concerns about bone metastases, then magnetic resonance imaging of the brain and spine and/or nuclear medicine bone scan
Histopathology

Biopsy of identified mass

Question 9

Gold standard management of RCC?
Other options?

Answer 9

nephrectomy (total / partial)

Tyrosine kinase inhibitors (sunitinib and pazopanib)

Multikinase inhibitor (sorafenib)

Anti-vascular endothelial growth factor monoclonal antibody (bevacizumab)

Mammalian target of rapamycin inhibitors (temsirolimus and everolimus)

Answer 10

Staging
tumour Size (</> 7cm),
Nuclear Grade
the absence/presence of tumour Necrosis)

Question 11

Renal transplant exam

Answer 11

End of bed - diabetes

Hands - finger pricks
Tremor - Tacrolimus

Fistula in arm - check both
- Palpate and auscultate
- If no thrill / brui likely non functioning
- Raise up and see if collapses -> poor flow

Face
Eyes corneal arcus

Mouth
Gingival hypertophy - ciclosporin

Neck
JVP
CVC scar
Parathyroidectomy scar

Chest
Tunneled scar

Back
Scar - nephrectomy

Abdo
Scars
- Midline could be pancreas + kidney transplant
- Appendix
- Muliple transplants
-Port sites - Laproscopic / peritoneal dialysis scars
- Lipohypertrophy - diabetes
Palpation
- Dont forget spleen and liver exam + PKDs
Auscultate - bruis

Blood pressure
Urine dip
Full fluid assessment

Question 12

Why polycystic kidneys nephrectomy

Answer 12

Make room for donor kidney

Recurrent infections

Impact bowel - pressure reduces absorption

Question 13

Most common reasons for renal transplant

Answer 13

Diabetes - 50%

Young - reflux neuropathy

PCKD

Nephrotoxins

CKD of uncertain aetiology sometimes with multiple risk factors

Question 14

Present renal transplant exam

Answer 14

This patient has end stage renal disease as evidenced by…
Kidney transplant, dialysis line, fistulaetc

Then try and explain aetiology
This may be secondary to
- diabetes (finger prick marks, isulin marks.
- PCKD - balotable kidney

Previous forms of RRT - are they functioning

Any evidence of immunosupressive therapy
- Gingival hypertophy ?ciclosporin
- Tremor ? tacrolimus

Question 15

Investigations in renal tranplant?

Extra if suspicion of Tx failure?

Answer 15

U&Es / renal function
Bone profile - Ca Po4
Consider PTH/vit D if chronic
Diabetic HbA1C

Trough levels of immunosupression if on

Imaging
Transplant ultrasound (looking at blood suply)

If concerned about acute failure - biopsy of transplant

Question 16

Common viruses to worry about in renal transplant

Answer 16

CMV especially if donor positive

BK virus

EBV

Question 17

What are the principles of the management of people with CKD ?

Answer 17

CKD
- Follow up based on severity / progression
- Patient education
- Sick day rules
- Medications Eg ACEi for proteinuria
- Discussion on the aetiology eg diabetes

Managment of complications
- CV health, BP, Cholesterol, smoking
- Renal anaemia - IV iron / Epo
- Acidosis - oral bicarb
- Fluid balance - diruetics
- Uraemia once symotomatic eg effusions / apetite -> Dialysis
- HyperK - diet / binders
- Bone disease - phosphate binders
- Parathyroidism - vit D supplements

As they progress discussions around management of end stage.
- Pros and cons of Haemo/Peritoneal dialysis
- Transplant

Question 18

Drug for PCKD

Answer 18

Tolvaptan

Question 20

Renal tranplant drugs specific side effects
Steroids
Tacrolimus
Ciclosporin
Azathioprine
Mycophenolate

Answer 20

Steroids - diabetes, bone demineralisation

Tacrolimus - diabetes

Ciclosporin - Neurotoxicity
- Headaches, insomnia, hairloss

azathioprine
Pancytopenia
Pancreatitis

Mycophenolate
GI upset

Question 21

When refer CKD for RRT

Answer 21

Risk stratification tool
Kidney failure risk equation calculator
- 5 year risk over 5%

Other NICE guidance
- ACR of 70 mg/mmol or more, unless known to be caused by diabetes and already appropriately treated
- ACR of more than 30 mg/mmol (ACR category A3), together with haematuria
-a sustained decrease in eGFR of 25% or more and a change in eGFR category within 12 months
-a sustained decrease in eGFR of 15 ml/min/1.73 m2 or more per year
-hypertension that remains poorly controlled (above the person’s individual target) despite the use of at least 4 antihypertensive medicines at therapeutic doses
-known or suspected rare or genetic causes of CKD
-suspected renal artery stenosis.

Question 22

Haemodialysis and peritoneal dialysis pros and cons

Answer 22

“There are pros and cons of each and need to come to a shared decision together with the individual patient”

Haemo
- Intermittent therapy (not daily)
- Social interaction
Cons
- Travel time
- Infection of lines

Peritoneal
- Start treatment quickly (compared to fistula)
- Can do anywhere
Cons
-

Question 23

Biggest issues with AV fistula

Answer 23

Bleeding

Failure - up to 20% need extra op to work in first 6 months

Clotting

Decreased vasular supply to hand

Running out of access