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Y3 - Cs - renal > condition part 1 > Flashcards

condition part 1 Flashcards

1
Q

definition for AKI

A

a significant deterioration in renal function occurring over hours-days

KDIGo definition

  • inc in SCr by > 03.mg within 48 hours
  • inc in SCr to >1.5 times baseline
  • urine volume <0.5ml/Kg for 6 hours
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2
Q

what are the different stages of AKi

A

Stage 1

  • SCr 1.5-1.9 times baseline or >0.3mh inc
  • Urine - <0.54ml/kg for 6-12 hrs

Stage 2

  • SCr 2-2.9 times baseline
  • urine < 0.5ml/kg for > 12hrs

Stage 3

  • 3 times baseline or inc >4.0mg or initiation of renal replacement therapy
  • urine - <0.3ml/kg for > 24hrs or anuria for > 12hrs
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3
Q

how common is AKI

A

affect 18% of hospital patients in the UK
incidence of hospital-acquired AKI has Inc
incidence of commnity-acquired AKI on admission to hospital is 3-5% in the UK

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4
Q

who is affected the most by AKi

A

elderly and hospitalised pt

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5
Q

causes of AKI

A

pre-renal (40-70% of cases)

  • due to renal hypotensions
  • hypovolaemia
  • hypotension
  • sepsis (systemic vasodilation)
  • congestive cardiac failure
  • liver cirrhosis
  • renal artery stenosis
  • NSAIDs
  • ACEi (interfere with blood flow)

Intrinsic ( 10-50%)

  • due to damages in the kidney
  • tubular - acute tubular necrosis, nephrotoxins eg drugs, radiological contrasts, heavy metal poisoning, HB in haemolysis, myoglubinuria in rhabdomyolysis, crystal and protein (Ig)
  • glomerular - glomerulonephritis, autoimmune conditions (SLE, HSP)
  • interstitial - acute interstitial nephritis (drugs, infection, autoimmune)
  • vascular - vasculitis, malignant hypertension, thrombus, cholesterol emboli, large vessels occlusion

post-renal (10-25%)

  • due to urinary tract obstruction
  • luminal - stones, clots, sloughed papillae
  • mural - malignancy ( ureteric, bladder, prostate)
  • extra-luminal - malignancy in the pelvic
  • retroperitoneal fibrosis
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6
Q

RF for AKi

A 
>65yrs 
HF
Liver disease 
CKD
past history of AKI
diabetes 
poor fluid intake 
inc fluid loss -diarrhoea, bleeding 
Oliguria (production of abnormal small amount of urine) 
haematological malignanacy
- urinary symtoms 
spesis
nephrotoxic drugs
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7
Q

symptoms of AKI

A

usually result of underlying causes, but could be

  • oliguria/anuria
  • polyuria
  • N+V
  • dehydration
  • confusion
  • palpitations - cardiac arrhythmia due to altered K+ level
  • rash/bruising - vascular disease
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8
Q

signs on exam for AKI

A 
HTN
skin turgor - dec with dehydration and inc in oedema 
raised JVP 
palpable bladder 
postural hypotension 
pulmonary and peripheral oedema
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9
Q

differenital for AKI

A

CKD

acute on chronic renal failure

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10
Q

investigation for AKI

A

ABCDE - C - check BP, JVP, skin turgor, cap refill, urine poutput, check urgent K+ and ECG

history - looking for RF

examination - full systemic examination, abdo masses, renal bruits, rashes

urinalysis - leukocytes and nitrites indicating infection, blood and protein indicating glomerular disease, send culture for infection

bloods - FBC, U+E, creatinine, LFT, clotting, ESR, CRP
- creatine kinase - (rhabdomyolysis), ABG, blood film and renal immunology

imaging - renal USS, CTKUB, CXR

need to variefy if pt has CKD or actually AKI

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11
Q

mangement for AKI

A

general measure

  • euvolaemia - correct any fluid imbalance (avoid potassium containing fluids unless hypokalaemic
  • stop nephrotoxic drugs
  • stop exacerbating factors - hypovolaemia, sepsis, high BP

monitor

  • consider transfer to ICU.HDU
  • hourly obs
  • daily fluid balance and weight chart
  • daily U+Es

nutrition - aim for normal calorie intake, consider NG tube if intake is poor

treating underlying causes

  • pre-renal - fluids for volume depletion, antibiotics for sepsis, ICU referral if in shock
  • intrinsic - refere to nephrology
  • post-renal - cather for obstruction
  • refer to urology for cystoscopy/stents/nephrostomy

managing complications

  • hyperkalaemia - IV calcium gluconate over 2 mins for cardioprotectivity, IV insulin and glucose stimulates intracellular uptake of K+ to buy time to lower K+
  • pulmonary oedema - high flow O2, IV flurosemide, venous vasodilator
  • uraemia - dialysis maybe if severe of complication eg encephalopathy
  • acidaemia - dialysis maybe or IV bicarb

Renal replacement therapy
- haemodialysis - requires patient to be haemodynamically stable, allows good clearance of solutes in short periods
haemofiltration - slower at clearing solutes, less significant shift so BP likely to drop
indication for acute dialysis - refractory pulmonary oedema, perisistnet hyperkalaemia, severe meabolic acidosis, uraemic encephalopathy, uraemic pericarditis

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12
Q

definition of CKD

A

presence of kidney damage or dec in kidney function for 3 months or more or

GFR <60 for 3 months or more with or without evidence of kidney damage or

GFR > 60 for 3 months or more together with evidence of kidney damage

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13
Q

what are the different stage of CKD

A

1 - >90, normal or inc GFR with other evidence of renal damages

2 - 60-89, slight dec GFR with other evidence of renal damage

3A&B - A(45-59) & B (30-44) with moderate dec GFR +/- evidence of renal damage

4- 15-29, severe dec GFR +/- evidence of renal damage

5 - <15, established renal failure (ERF)/End stage renal disease (ESRD)

evidence of renal damage = proteinuria, haematuria, evidence of disease

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14
Q

how common is CKD

A

8.8% of UK population have symtpomatic CKD

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15
Q

who is affected the most by CKD

A

4x more common in African-American deut to increase prevalence of HTN
CKD due to atherosclerotic renal disease more common in elderly
>70% of all CKD are due to DM, atherosclerosis and HTN

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16
Q

what are some screening questions for CKD

A

duration of symptoms
drugs eg NSAIDs, analgesia, herbal remedies
previous medial and surgical history -chemo, multisystem disease such as SLE, malaria
previous occasions on which urinalysis (urea and creatinine) might have been performed

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17
Q

causes for CKD

A

congenital and inherited - PCKD, medullary cystic disease, tuberous sclerosis, oxalosis, cystinosis, congenital obstructive uropathy

glomerular disease - primary glomerulonephritis incl focal glmoerulosclerosis, secondary glomerular disease ((systemic lupus, polyangitis, Wegener’s granulomatosis, amyloidosis, diabetic glomerulosclerosis, accelerated HTN, haemolytic uraemic syndrome,

vascular disease - hypertensive nephrosclerosis (inc BP), reno-vascular disease, smale and medium-sized vessel vasculitis, DM

tubulointersitial disease - Tubulointerstitial nephritis – idiopathic, due to drugs (especially nephrotoxic analgesics), immunology related, reflux nephropathy, tuberculosis

Urinary tract obstruction - calculus disease, prostatic disease, pelvic tumours, retroperitoneal fibrosis

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18
Q

RF for CKD

A

DM, age > 60, recurrent UTIs, urinary obstruction, systemic illness that affects the kidneys

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19
Q

symptoms for CKD

A

early CKD often asymptomatic

when urea is >40ml
- malaise, loss of energy
loss appetite/anorexia
insomnia
nocturia/polyuria (loss of concentrating ability)
-N+V and diarrhoea
- metallic taste
- paraesthesiae due to neuropathy
-restless legs snydrome (overwhelming need to frequently alter position of lower limbs)
bone pain due to metabolic bone disease
paraesthesiae and tetany due to hypocalcaemia
symptoms due to salt and water retention - peripheral or pulmonary oedema
symptoms due to anaemia
amenorrhoea in women, erectile dysfunction in men
oliguria

[urea] > 60mmol/L = more severe uraemic symptoms and CNS involvement eg mental slowing, confusion, clouding of consciousness, seizures, myoclonic twitching, encephalopathy, coma
Urine output is not a useful guide to kidney function as though GFR decreases => oliguria; tubular resorption is also less so high vols of urine may still result

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20
Q

signs on exam for CKD

A

short stature (if CKD in childhood)
pallor due to anaemia or yellow pigmentation (uraemic syndrome)
bruising or purpura
inc photosensitivity prigmentation
brown discolouration of nails
scratch marks due to uraemic puritis
signs of fluid overload eg pleural effusion
pericardial friction rub
mitral regurgitation due to overload or annular calcification
glove and stocking peripheral sensory loss
high BP

impalpable kidneys unless enlarged due to PCKD, tumours or obstruction

signs of an underlying condition that has lead to CKD

  • cutaneous vasculitis lesion in systemic vasculitides
  • retinopathy in DM
  • evidence of peripheral vascular disease
  • evidence of spina bifida or other causes of neruogenic bladder
  • should assess hydration status (JVP and skin turgor, BP lying and standing)
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21
Q

differential for CKD

A

AKI

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22
Q

investigation for CKD

A

bloods - FBC (Hb dec), eosinophilia (vasculitis, allergic tubulointerstitial nephritis), fragmented RBC +/- thrombocytopenia (accelerated HTN, haemolytic uraemic syndrome)
ESR inc
Uand E inc - inc PTH
immnunology - autoantibody screening in SLE, antibodies to HBV,HCV,HIV

urinalysis

urine microscpy, culture and sensitivity

  • WCC (infection)
  • eosinophiluria 0 allergic tubulointersititial nephritis
  • casts - Granular casts formed from abnormal cells within the tubular lumen, and indicate active renal disease. Red-cell casts are highly suggestive of glomerulonephritis.

radiology - USSm AXR, CT (retroperitoneal fibrosis), MRI and IV urography

renal biopsy

bone scan and DXR

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23
Q

treatment for CKD

A

transplant ultimate choice, RRT

monitoring - ultimately need ed dialysis
reduce use of drug that are excreted in the kidney - heparin, lithium, digoxin, ehtnambutol, cephalosporins, sulfmethoxazole, procainaminde, tetracycline, opiates

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24
Q

definition of hydronephrosis

A

aseptic distension and dilation of the renal pelvis and calyces usually caused by urinary tract obstruction

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25
how common is hydronephrosis
1 in 300 in the uk per year 1 in 600 have bilateral hydronephrosis 1 in 100 pregnanacies affected by antenatal hydornephrosis and is one of the most common abrno detected on antenatal screening
26
causes of hydronephrosis
unilateral hydronephrosis - intraluminal - calculi, embolus, congenital PUJ onstruction - intrinsic/mural - ureteric stricture, BPH, malignancy (Kidney, prostate, bladder), ureterocele (ongenital abnormality found in the ureter. In this condition the distal ureter balloons at its opening into the bladder, forming a sac-like pouch), neurogenic bladder - extraluminal - pregnancy, malignancy in the pelvic organs, lymphadenopathy bilaterial - congenital - strictures, Primary vesicoureteral reflux – dysfunctional valves between ureter and bladder allowing retrograde flow of urine, posterior urthral valves, phimosis (non retractibility of the foreskin) - acquired - bladder neck hypertrophy, BPH, prostate cancer, malignancy, urinary strictures
27
symptoms of hydronephrosis
vary depending whether the obstruction being acute or chronic and the severity of the blockage acute - pain in flank (intense, often caused by renal stone), suprapubic pain, haematuria, N+V, palpable kidney chronic - not much symptoms
28
differentials for hydronephrosis
renal stones, BPH
29
investigation for hydronephrosis
bloods - U+E, creatinine imaging- USS, CT pr IVU urine dipstick, MSU MC+S, bladder scan
30
management for hydronephrosis
nephrostomy (an artificial opening created between the kidney and the skin which allows for the urinary diversion directly from the upper part of the urinary system (renal pelvis) ureteric stent pyeloplasty uretheral or suprabubic catheter Weight, fluid balance and U+Es must be closely monitored as a temporary salt-losing nephropathy may occur due to large diuresis after relief of obstruction.
31
definition for Benign prostatic hyperplasia
non-malignant inc in size of the prostate gland which happens with ages
32
how commons is BPH
<45s - unusual 50s - 40% 90s - 90%
33
who is affected the most by BPH
men over 50s less common in asians
34
pathology of BPH
both glandular epithelial cells, muscle fibres and stromal cells undergo hyperplasia. stromal hyperplasia predominates Majority of the growth occurs in the transitional zone and also the posterior urethral glands but the peripheral zone is less involved
35
causes to BPH
aetiology unknown suggested that it might be mediated by testosterone and oestrogen. Dihydrotestosterone which is a metabolite of testosterone is thought to have a role in this inc oestrogen with age and also inc DTH and so mediate prostatic growth
36
RF for BPH
DM | HTN
37
symptoms of BPH
LUTS - lower urinary tract symptoms - without haematurai and dysuria unless presenting with other problems
38
signs of BPH on examination
PR exam - smooth, symmetrical, flattened sulcus palpable bladder dec urinary outflow
39
differenital diagnosis of BPH
prostate cancer - prostate might feel bumpy/asymmetrrical on PR, raised PSA UTI - dysuria, systemic symptoms, resolves urinary tract stones - haematuria, pain detrusor muscle weakenss - no pain/dysuria. incontinence chronic prostatitis - abdo/plvice/perineal pain, post-ejaulatory pain
40
what are some questions for asking for BPH
``` incomplete emptying? frequency? intermittency urgency weak stream straining nocturia ```
41
treatment for BPH
watchful waiting medical therapy - tamsulosin (alpha blockers) - 1st line - finasteride (5alpha-reducatase inhibitors) surgical treatment - transurethal resectino of the prostate - transurethal incision of the prostate - retropubic prostatectomy - transurethral lasser-induced prostatectomy
42
what are lower urinary tract symptoms
storage symptoms - frequency - urgency - nocturia - overflow incontinence voiding symptoms - hesitancy - intermittency - poor stream - incomplete voiding - dysuria Post-micturition symptoms - terminal dribling - haematuria
43
how common is prostatic carcinoma
7% of all cancer affecting men and most common cancer in men in the UK
44
who is affected the most by prostatic carcinoma
80% of men >80 yrs, risk inc with age
45
pathogenesis of prostatic carcinoma
most of the prostate cancers are adenocarcinomas which are usually well-differentiated Mostly this occur in the peripheral zone begins as carcinoma in situ or PIN (prostate intraepithelial neoplasia) - clumps of cancer cells remain confined to otherwise normal prostate glands ZIP1 is a tumour suppressor gene whcih codes for a protein that actively transport zinc into the prostate glands for production of semen and when this is silence by carcinoma, the cancer cells can save all this energy on active transport to grow and proliferate instead spread maybe local to seminal vesicles, bladder or rectum via lymph or haematogenously into sclerotic bone lesions
46
RF for prostatic carcinoma
age FH - 2-3x higher risk with 1st degree relateive FH of breast cancer - BRCA1 and BRCA2 found to have been implicated in some cases - highest incidence inAfrican Americans, lowest incidence in aisan and Oriental men smoking - inc risk of fatal prostate cancer
47
symptoms of prostatic carcinoma
``` 2/3 asymptomatic 1/3 LUTS erectile dysfunction painful ejaculation metastatic spread - back pain, bone pain, weight loss, anaemia, lymph node enlargement ```
48
signs of prostatic cancer
PR exam - asymmetry, nodules, adhesion to surrounding tissue, hard gland, palpable seminal vesicles, obliteration of median sulcus
49
differential for prostate cancer
BPH UTI/UT stones chronic prostatitis
50
investigations for prostate cancer
urinalysis - to rule out bladder/renal patholgy MSU MC+S - to rule out infection bloods - U+Es, creatinine - to rule our renal disease PSA Biopsy CT Bone scan - if metastases suspected
51
management for prostate cancer
``` watchful waiting active surveillance radial prostatectomy radiotherapy brachytherapy - transperineal implantation of radioactive seeds into the prostate High-Intensity Focused Ultrasound (HIFU) hormone therapy ```
52
definition for urinary tract calculi
renal stones consisting of crystal aggregates
53
what is pyelonephritis
infection within the renal pelvis (with or without infection of the renal parenchyma)
54
what are the most common pathogens that cause pyelonephritis
EKPPE ``` E.coli Klebsiella pneumoniae Proteus Pseudomonas enterococcus ```
55
RF for pyelonephritis
female, FH sexual intercourse, exposure to spermicide, menopause, pregnancy, uncircumsized immunosuppression, urinary tract obstruction/stone/malformation, prostate enlargement, DM, catheter, fistulas, spinal cord/nerve damages
56
presentation of pyelonephritis
``` rigors fever N+V rapid onset loin pain - radiate to groin suprapubic pain diarrhoea ``` may have lower UTI infection symptoms eg frequency, dysuria, gross haematuria, hesitancy
57
signs of pyelonephritis
tender to palpaite general ill fever
58
differentials for pyelonephritis
``` UTI MSK renal calculi ectopic pregnancy endometriosis prostatitis appendicitis AAA abdo abscess diverticulitis ```
59
investigation for pyelonephritis
FBC, U+Es, ESR, CRP urinalysis - nitriles, WBC MSU culture and sensitivity CTKUB - if renal calculi suspected
60
treatment for pyelonephritis
ciprofloxacin, co-amoxiclav paracetamol fluids

Y3 - Cs - renal (2 decks)

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