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Acute urinary problems Flashcards

1
Q

What two things are measured in AKI and help to define AKI? What is the main clinical clue?

A
  • Serum urea and CREATININE

- REDUCED URINE OUTPUT is the main clinical clue (consider AKI in anyone with reduced urine output)

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2
Q

What are the magic numbers in AKI

What patients does this not really work for?

A

STAGE 1: Creatinine increased by 26umol (or more) from baseline within 48 hours or 150% in 7 days (risk)

STAGE 2: 200% (injury)

STAGE 3: Creatinine rise to 354umol or increase of 300% (failure)

**CKD patients have higher creatinine, so these values are for healthy patients

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3
Q

What is creatinine?

Limitations of creatinine?

A

-Creatinine is a breakdown of skeletal muscle that is excreted by the kidneys (majority glomerulus so good estimate of filtration)

Creatinine=most useful marker, however affected by:
• Muscle mass
•eGFR can fall to half before creatinine rises past upper limit
• Dilution

  • Urea is easily influenced by protein turnover (diet, etc) and hydration status
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4
Q

What are the most common pre-renal causes of AKI?

What can hypo perfusion lead to?

A

PRE RENAL CAUSES AKI (the most common-70%)
-Nearly always due to HYPOPERFUSION of the kidney
•Hypovolaemia (burns, heamorrgae, D+V, pancreatitis)
•Reduced cardiac output (heart failure/MI)
•Distributive shock sepsis (vasodilation) or anaphylaxis
•Altered blood flow to kidneys (NSAIDs/ACEis/renal artery stenosis/hepatorenal syndrome)

*Hypoperfusion can lead to acute tubular necrosis (ATN) (which is an intra-renal cause)

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5
Q

What are some common intra-renal causes of AKI?

remember they can e split up into 3 parts

A 
INTRA-RENAL CAUSES AKI  (20%) 
1) Glomerulus 
  •Glomerulonephridities (e.g. SLE/HSP)
  •ATN (Acute tubular necrosis-often from pre renal)
2) Interstitial 
  •Nephrotoxic drugs/infection/infiltration (e.g. sarcoid/myeloma free light chains) 
3) Vessels
  •Vasculitis/HUS/TTP/DIC/malignant HTN
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6
Q

What are some common post-renal causes of AKI?

can either have within renal tract or extrinsic

A

POST-RENAL CAUSES AKI
-Bilateral obstruction of urinary flow out of the kidneys (leading to hydronephrosis)

Within renal tract

  • Stone
  • Malignancy
  • Stricture
  • Infection

Extrinsic compression

  • Pelvic malignancy
  • BPH
  • Retroperitoneal fibrosis
  • Congenital (posterior urethral valves)
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7
Q

What are some risk factors for developing AKI?

A

Risk factors for AKI

  • Age >75
  • CKD (eGFR < 60)
  • Drugs (always look for newly started medications)
  • Dehydration
  • Cardiac failure
  • Peripheral vascular disease
  • Diabetes
  • Chronic liver disease
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8
Q

History, Examination, Investigations for AKI?

A

AKI
History
-have you been ill recently
-have you had any recent scans

Examination

  • Palpable bladder? (retention)
  • Palpable kidneys/renal bruits?
  • SKIN (rashes)
  • JOINTS (arthritis)
  • fever
  • systemically unwell?

Investigations

  • URINALYSIS: (blood/protein/infection)
  • BLOODS: FBC/UsEs (Serum creatinine, K+)/CK/LFT (hepato renal syndrome)/CRP/clotting/ABG (metabolic acidosis)/ blood film (HUS)
  • IMAGING: Renal USS and bladder scan
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9
Q

How should you initially manage a patient with AKI?

A

AKI MANAGMENT
ABCDEG> treat sepsis if found then USTOP

USTOP

  1. Us and Es (creatinine and POTASSIUM)
    - Treat hyperkaleamia if present
  2. Sepsis - screen and treat with BUFALO
  3. Toxins - stop nephrotoxins
  4. Optimise blood pressure
    -mucous membranes/HR/BP/CRT/JVP/oedema and crackles
    •hypovolemic>give IV 0.9% saline. Inotropic support if volume not regularising (ICU)
    •Overloaded>restrict fluids and talk to senior-diuretics
  5. Prevent harm
    - Treat COMPLICATIONS e.g. hyperkalaemia (ECG), pulmonary oedema, pericarditis
    - Identify CAUSE (dipstick, USS-obstruction)
    - Renal replacement therapy?
    - Review drug chart
    - Monitor fluids (catheter) and U+Es
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10
Q

What common drugs are nephrotoxic?

A

AL DIAMOND

Antihypertensives e.g. ACEi, ARB, BB, CCB, AB
Lithium
Diuretics (especially potassium sparing)
Intravenous contrast /immunosupresants
Antibiotics - gentamicin (aminoglycosides) + nitrofurantoin
Metformin
Opioids
NSAIDs
Digoxin (aggravates hyperkaleamia)

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11
Q

What are drugs may increase risk of urinary retention?

A

Drugs that increase risk of urinary retention

  • Anticholinergics
  • Opioids
  • Benzodiazepines
  • NSAIDs
  • Calcium channel blockers
  • Antihistamines
  • Alcohol
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12
Q

How would a patient in urinary retention present?

What investigations should you do for someone having urinary retention?

A

Urinary retention

  • An enlarged, tender bladder that is dull to percussion
  • Anuria
  • Possible associated delirium

Investigations:
Bloods: FBC, UsEs, Glucose, PSA
Imaging: USS renal, CT pelvis/abdo/ MRI/CT head look for neuro cause if unexplained

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13
Q

Who is acute urinary retention more common in and why?

A
  • MEN
  • Due to prostatic hypertrophy
  • Also common post-operatively and due to urethral stricture
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14
Q

What are some common causes of acute urinary retention?

What are some causes of urinary retention in women?

A

Urinary retention

  • Bladder calculi
  • Bladder cancer
  • Faecal impaction
  • Urethral strictures

Urinary retention in women

  • Retroverted gravid uterus
  • Atrophic urethritis
  • MS (multiple sclerosis)
  • Prolapse
  • Pelvic mass
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15
Q

What are some specific things you’d want to check on history and examination in urinary retention?

A

URINARY RETENTION

  • *ALWAYS SUSPECT SPINAL PATHOLOGY**
  • History-ask about caudal equine syndrome (saddle anaesthesia/change in sensation, incontinence, lower back pain, changes in movement or sensation in legs)

-Exam- do PNS exam, PR (anal tone and also prostate) and pre/post BLADDER SCAN

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16
Q

How should acute urinary retention be managed?

A

Urinary retention

  • Urethral catheterisation (if no CI) or consider supra-pubic if urethral not possible
  • Use 3 way catheter if clots
  • Alpha blocker (Tamsulosin) given to prepare for TWOC

Testing urine
-Once urine has been passed then DIP IT for infection and treat that

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17
Q

How will renal colic present?

A

Intermittent flank or loin pain that might also travel down to the groin
SEVERE PAIN that comes and goes in waves - this pattern of pain is due to ureteric peristalsis
Might also have urinary symptoms of:
- Anuria, dysuria, increased frequency, urgency, suprapubic tenderness, changes in smell or colour of urine, haematuria, sweating, fever, N&V

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18
Q

What is a common cause of renal colic?

A

KIDNEY STONES (Sweaty, N&V, and excruciating pain will predominate)

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19
Q

How should you investigate someone with renal colic pain?

A 
KUB USS
Urine dip - blood leucocytes 
Pregnancy test in women
CT
Bloods: FBC, U&amp;E, WCC, CRP
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20
Q

How should someone with renal colic be managed initially?

A

Painkillers (might need IV)
FLUIDS - really important to keep patient hydrated.
Shock therapy can break down stones to make them easier to pass

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21
Q

How will testicular torsion present?

What will appear like on examination?

A
  • Sudden onset SEVERE PAIN in the testicles, upper thigh, groin or lower abdomen
  • Vomitig

O/E:

  • Red, Swollen, tender testis
  • ABSENCE of cremasteric reflex
  • Testicle lies higher
  • might lie more horizontally than vertically
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22
Q

Who is testicular torsion most common in?

A
  • Boys in neonatal period and then again between the ages of 11-30 (peak during puberty)
  • Bell clapper deformity
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23
Q

How should testicular torsion be investigated?

A
  • It shouldn’t. If you suspect torsion you need to contact uro-surgery immediately because it is time sensitive
  • Emergency surgery within 6-12 hours to preserve the testicle
24
Q

How do we define a UTI?

A

UTI

  • Infection of either lower urinary system i.e. urethra (urethritis), bladder urinary system (cystitis), prostate (prostatitis)
  • Or upper (anything above bladder) i.e. renal pelvis (pyelonephritis)
25
Q

What are some symptoms of UTI? (8)

A

UTI

  • ↑Frequency
  • ↑Urgency
  • Dysuria (pain on urination)
  • Blood in urine (cystitis)
  • Supra pubic tenderness (bladder may be distended)
  • Foul smelling ± Cloudy urine
  • Confusion (elderly)
  • Systemic features uncommon but can happen (sweating, fever, N+V)
26
Q

What sort of symptoms would make you concerned that the LUTI had become an UUTI?

What is the treatment for upper UTI

A

Upper UTI

  • MORE SYSTEMIC SYMPTOMS OF UNWELL
  • Fever and rigors
  • Sweating
  • Malaise
  • Vomiting and loss of appetite
  • Loin/back pain

Treatment of UPPER UTI (pyelonephritis)

  • 7-10 day course of CIPROFLOXACIN
  • Co-amoxiclav can be used
27
Q

What is the most common cause of UTI?

A

E. Coli = most common (80% in community)

  • Staphyloccous saprophyticus (skin commensal)
  • Proteus mirabilis
  • Klebsiella pneumonia
  • Pseudomonas
28
Q

How do we investigate a UTI

A 
Urine dip (look for nitrites - sensitive, leucocytes, protein, blood)
Urine microscopy and culture
  1. Urine dipstick (MSU)
    -look for +Nitrites +Leucocytes (+Blood)
    -will always be +ve in catheter
    •if +ve then just treat empirically and send off MC+S
    •if -ve but symptomatic → MSU
  2. Also send for MC&S
    > 105 organisms/ml = diagnostic
    if <105 organisms/ml and pyuria e.g. > 20 WBCS/mm = may still be significant
  3. Sexual history + swabs if appropriate –
    - VVS
    - ECS w/ NAATS
    - Urethral swab
29
Q

Initial management of UTI for MEN
(what and how long for)

What do you give if acute prostitis?

A

UTI treatment MEN
7 day course of trimethoprim/nitrofurantoin (if egfr >30)

Prostatitis - 4 week course of ciprofloxacin because quinolines penetrate prostatic fluid

30
Q

Initial management of UTI for WOMEN? (uncomplicated vs complicated)

A

UTI management for WOMEN

  • 3 day course of trimethoprim (or nitrofurantoin but only if eGFR > 30)
  • Symptoms should resolve in 48hrs

Complicated (e.g. impaired renal function, abnormal urinary tract, immunosuppressed) longer e.g. 7 days

31
Q

What is the treatment for pregnant women with a UTI?
1st line
2nd line

Which antibiotics must be avoided in pregnancy?

A

UTI in pregnancy
1st line: oral Nitrofurantoin (unless at term)
2nd line (no improvement or unsuitable): oral amoxicillin (only if culture susceptible), or cefalexin.

Avoid:

  • Trimethoprim (1st trimester)
  • Nitrofurantoin (term)
  • Quinolones e.g. ciprofloxacin (all pregnancy)
  • Sulphonamides (all pregnancy)
32
Q

How can you tell the difference between AKI and someone with chronic kidney problems?

A

CKD patients will have high phosphate and low calcium

33
Q

What is the definition of bacteriuria?

Whats it called if there is no bacterial growth?

A

UTI bacteriuria
-defined as 10^5 organisms/ml of fresh MSU (mid stream urine)

-Symptoms but no bacterial growth = Abacterial cystitis (otherwise known as urethral syndrome)

34
Q

What is it called when you find bacteria on MSU but there are no symptoms of UTI?

A

ASYMPTOMATIC BACTERURIA

  • bacteria >10^5 in urine but with no UTI symtptoms
  • don’t always need treatment
  • PREGNANT WOMEN NEED TREATMENT
35
Q

When would you do imaging for UTI?

What is the imaging of choice?

A 
Imaging for UTI 
Do an USS + referral to urology CTKUB if: 
-men with upper UTI 
-recurrent (more than 2 in one year) 
-failure to respond to treatment 
-pyelonephritis
-abn. organism (immunocompromised) 
-persistent haematuria
36
Q

In an elderly patient that comes in confused, what two urinary problems should you always consider?

A

UTI

ACUTE URINARY RETENTION (post void bladder scan) <200ml unlikely

37
Q

What is a complication of catheterisation after acute urinary retention?

A

Post obstructive diuresis can occur after catheterisation -prolonged polyuria
- excessive salt and water loss

38
Q

How do you treat catheter sample UTI?

A

Catheter sample bacteria

  • all will have bacteria, send MSU only if symptomatic
  • change catheter before starting antibiotics per local guidelines
39
Q

What are symptoms of prostatitis

A
  • Pain in perineum, rectum, scrotum, penis, bladder, lower back
  • Fever
  • Malaise
  • Nausea
  • Urinary symptoms
  • Swollen/tender prostate on PR
40
Q

What is sterile pyuria?

A

Sterile pyuria

  • mid-stream urine specimen has 10 or more white blood cells per cubic millimeter or +ve leukocytes on dip stick
  • with negetive urinary culture
41
Q

What are some infective causes of sterile pyuria?

A

Sterile pyuria (infective causes)

  • TB (persistant)
  • Recently treated UTI
  • Inadequately treated UTI
  • Appendicitis
  • Prostatitis
  • Chlamydia
42
Q

What are some non infective causes of sterile pyuria?

A

Sterile pyuria (non-infective causes)

  • Calculi
  • Renal tract tumour
  • Papillary necrosis
  • Tubulointerstitial nephritis
  • Polycystic kidneys
  • Pregnancy
  • SLE
  • Steroids
43
Q

How do you treat asymptomatic bacteria in pregnancy?

A

Asx Bacteriuria

  • should be confirmed on 2nd sample
  • ALWYS TREAT PREGNANT PEOPLE WITH ASX BACT
  • Nitrofurantoin (avoid at term)
44
Q

Complicated vs uncomplicated UTI?

A

Uncomplicated = normal urinary tract structure, function; normal immune system; non-pregnant

Complicated = structural/functional abnormality of genitourinary tract e.g. obstruction, catheter, stones, renal transplant, neurogenic bladder; pregnancy; immunocompromised

45
Q

Main risk factors for UTI?

A

Bacterial inoculation

  • Sexual activity
  • Urinary incontinence
  • Faecal incontinence
  • Constipation

Binding of uropathogenic bacteria

  • Spermicide use
  • Decreased oestrogen
  • Menopause

Decreased urine flow

  • Dehydration
  • Obstruction

Increased bacterial growth

  • Diabetes
  • Immunosuppression
  • Obstruction
  • Stones
  • Catheter
  • Pregnancy
46
Q

Commonest causes of AKI?

A
  1. Sepsis
  2. Major surgery
  3. Cardiogenic shock
  4. Other hypovolaemia
  5. Drugs - NSAIDs, ACE inhibitors
  6. Hepatorenal syndrome (renal deterioration secondary to cirrhosis)
  7. Obstruction - BPH, tumours, stones, strictures
47
Q

What from urninalysis would suggest intra renal?

A
  • Blood/protien in urine suggests intra renal cause (↑renal damage, infection, vasculitis/ SLE rhabdomyolysis)
  • Also recent throat infection
48
Q

What other symptoms would make you think of vasculitis?

A

Vascilitis

-achy joints/ skin rashes/ AKI is classic vascilitis

49
Q

What are some symptoms and signs of advanced uraemia?

A
  • Reduced mental state, reduced GCS, seizures
  • Myoclonic twitching
  • Anorexia, nausea, vomiting
  • Increased photosensitive pigmentation – which may make the patient appear misleadingly healthy
  • Brown discolouration of the nails
  • Excoriations from pruritis
  • Signs of fluid overload – peripheral oedema, pulmonary oedema (crackles at the lung bases on auscultation)
  • Pericardial friction rub
  • Glove and stocking sensory loss – rare
50
Q

What are some indications for dialysis/renal replacement therapy after AKI?

A

Dialysis indications (AEIOU)
A-Acidosis (pH <7.1)
E-Electrolytes (refractory hyperkalemia> 6.5mEq/L
I-Intoxications (SLIME neumonic-salicylates, lithium, isopropanol, methanol, ethylene glycol
O-Overload/pulmonary oedema despite diuretics
U-Ureamia >45 (elevated BUN with signs of uraemia (encephalopathy, seizures, coma, pericarditis)

51
Q

For AKI, apart from a Creatinine rise of 26 in 48hrs, what else can indicate AKI?

A

Diagnosiing AKI

  • Serum creatinine rises by >26 umol/L from baseline value within 48 hours
  • Serum creatinine rises > 1.5 times from the baseline value within one week
  • Urine output is less than 0.5ml/kg/hr for >6 consecutive hours
52
Q

What ECG changes would you see in hyperkalaemia in order of severity?

A
  1. Tall tented T-waves
  2. Flattened P-waves
  3. Prolonged PR interval
  4. Widened QRS complexes
  5. Idioventricular rhythms (slow regular ventricular rhythm, typically with a rate of less than 50, absence of P waves, and a prolonged QRS interval)
  6. Sine wave patterns
  7. VF/asystole
53
Q

Urine output for stage 1,2,3 AKI?

A

Urine output
stage 1 -<0.5ml/kg/hr for 6hours
stage 2 <0.5ml/kg/hr for 12hours
stage 3 <0.3ml/kg/hr for 24 hours

54
Q 
What do the following suggest in the context of AKI 
free light chains 
RBC casts 
Granular casts 
Eosinophils
A
  • Bence-jones protein (Free light chains) – myeloma (75%)
  • RBC casts (RBC from glomerulus) – Glomerulonephritis
  • Granular casts – Acute tubular necrosis
  • Eosinophils – Acute interstitial nephritis (drugs)
55
Q

How can you tell the difference between pre renal AKI and intra renal AKI using urine osmolality?

A

Differentiate between pre-renal and renal

  • Pre-renal e.g. hypovolaemia
  • Kidneys aim to retain Na+/water → concentrated urine
  • ↑Urine osmolality, ↓Na+

Renal e.g. ATN

  • kidney damaged → loses filtration ability to concentrate urine
  • ↓Urine Osmolality ↑Na+
56
Q

When do you treat hyperkaleamia?

A

Treat when potassium > 6.5 OR >6 with ECG changes!

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