Core Presentations

Question 1

Examples of core presentations

Answer 1

-Fever
-Oedema
-Oligoanuria
-Microscopic and Macroscopic Haematuria
-Proteinuria
-Non-specific malaise
-Associated systemic symptoms (e.g. arthralgia, sinusitis, rash)

Question 2

Causes of fever in renal

Answer 2

-Pyelonephritis

Question 3

Causes of oedema

Answer 3

-Increased total extracellular fluid: raised JVP and pulmonary oedema
=Congestive heart failure
=Renal failure
=Liver disease

-High local venous pressure
=Deep venous thrombosis or venous insufficiency
=Pregnancy
=Pelvic tumour

-Low plasma oncotic pressure/serum albumin (no raised JVP/ pulmonary oedema)
=Nephrotic syndrome
=Liver failure
=Malnutrition/malabsorption

-Increased capillary permeability
=Local infection/inflammation
=Severe sepsis
=Calcium channel blockers

-Lymphatic obstruction (non-pitting)
=Infection: filariasis, lymphogranuloma venereum
=Malignancy
=Radiation injury
=Congenital abnormality

Question 4

Causes of Oligoanuria

Answer 4

Oliguria and anuria are defined as a urine output of less than 400 mL/day or 100 mL/day, respectively.
=urinary output <0.5 mL/kg/hr should prompt assessment of fluid status and correction of volume depletion where present

-Complete urinary obstruction
=Prostatic enlargement
=Urethral stenosis
=Bladder tumour
=Bilateral ureteric obstruction due to retroperitoneal fibrosis, cancer, bilateral ureteric stones, radiation injury
=Bilateral renal stones

-Lack of renal perfusion (bilateral)
=Aortic dissection involving renal arteries
=Severe ATN
=Severe functional hypo perfusion

-Rapidly progressive glomerulonephritis
=Anti-GBM
=ANCA vasculitis

Question 5

Causes of haematuria

Answer 5

1. Exclude infection, menstruation and causes of a positive urinary dipstick in the absence of red cells (haemoglobinuria/myoglobinuria)

-Vascular
=Polyarteritis nodosa
=Small-vessel vasculitis
=Vascular malformation
=Renal infarction
=Coagulation disorders

-Intrinsic
=Glomerulonephritis
=SLE
=Interstitial nephritis

-Tumour
=Renal
=Ureteric
=Bladder
=Prostate

-Infection
=Pyelonephritis
=Cystitis
=Urethritis

-Other
=Cysts
=Trauma
=Calculus
=Benign prostatic enlargement

Question 6

Interpretation and management of non-visible haematuria

Answer 6

-WBC: infection
-Abnormal epithelial cells: tumour
-Red cell casts, dysmorphic erythrocytes: glomerular
-No red cells, haemoglobinuria: intravascular haemolysis
-No red cells, myoglobinuria (brown urine): rhabdomyolysis

-Assess BP, eGFR, ACR
=If abnormal or FH of renal disease/ evidence of systemic disease: refer to nephrology, renal biopsy
=If normal and under 60, observation (annual urinalysis, BP, ACR and eGFR)
=If normal and above 60/ symptomatic: refer to urology (USS/ CT renal tracts, cystoscopy

Question 7

Causes of visible haematuria

Answer 7

-Malignancy
-UTI
-Stones
-IgA nephropathy (following URTI)

Question 8

Causes of proteinuria

Answer 8

-greater than 1g/day indicative of glomerular pathology.
-Transient proteinuria can occur after vigorous exercise, during fever, in heart failure and in people with urinary tract infection. Patients should be assessed for the presence of these conditions and urine testing repeated once the potential trigger has been treated or resolved.

-Minimal change disease
-Primary focal segmental glomerulosclerosis
-Membranous nephropathy
-Amyloid
-Diabetic nephropathy

Question 9

Consequences of nephrotic syndrome

Answer 9

-Hypoalbuminaemia: oedema
-Sodium retention: oedema, treat with diuretics and low-sodium diet
-Hypercholesterolaemia: atherosclerosis, statins
-Hypercoagulability: VTE, prophylaxis if severe or chronic
-Infection: pneumococcal and meningococcal, vaccination?