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CP1 revision > Deck 7 > Flashcards

Deck 7 Flashcards

1
Q

Renal corpuscle info

A

Bowman’s capsule, inner (visceral) podyctres), outer (parietal) simple squamous

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2
Q

DCT absorption

A

Na/K/Ca

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3
Q

AKI

A

Rapid decline in kidney function (hours/days) as measured by urea and creatinine

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4
Q

AKI RF

A

65+, hypovolaemia, sepsis, diabetes, chronic liver disease, HF, chronic kidney disease

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5
Q

Pre-renal AKI

A

Reduced perfusion.
Hypovolaemia, hypotension, fluid overload, reduced CO, vascular causes (renal artery stenosis/occlusion, NSAIDs, ACEi, renal vein thrombosis, AAA)

Gives ATN
Initially get high urine osmolarity (>500), then isotonic urine with high sodium as concentrating power lost

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6
Q

Intrinsic renal damage causes

A

Glomerular problems (glomerulonephritis, HUS, IgA)
AIN (drug induced, infection, autoimmune or lymphoma)
ATN (most common, ischaemia, rhabdomyolysis, radiocontrast agent)
Vascular (vasculitis, thrombosis/embolii)
HUS (post elcoli or URTI)

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7
Q

Post renal aki causes

A

luminal (stones, clots, sloughed papillae)
Mural (malignancy, BPH, stricture)
Extrinsic compression (pelvic malignancy, retroperitoneal fibrosis)

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8
Q

AKI S+S

A 
Can be asymptomatic
Oliguria, N&V, dehydration, thirst, confusion, fatigue
Signs of fluid imbalance.
May have vasculitis features. 
May have palpable abdominal mass
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9
Q

AKI diagnosis

A

RIFLE (risk, injury, failure, loss, ESRD)
AKIN is like rifle but uses time as well
KDIGO uses serum creatinine and/or urine output

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10
Q

KDIGO 1

A

1.5-1.9x baseline or >0.3mg/dl increase in sCR

OR <0.5mL/kg/h urine over 6-12 hours (~35mL/ hour)

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11
Q

KDIGO2

A

2.0-2.9x baseline,

OR <0.5kg/kg/h over 12+h (~35mL/h)

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12
Q

KDIGO3

A

3+x baseline, or 4mg/dl increase
OR
<0.3mL/kg/h (~21mL/h) for 24h or anuria for over 12 hours

Can also be RRT start or below 18 years with eGFR <35

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13
Q

AKI investigations

A

FBC (?eosinophilia in acute interstitial nephritis or vasculitis)
Creatinine kinase if ?rhabdomyolysis
Immunology (myeloma screen, lupus screen, vasculitis screen)
Imaging (renal USS to rule out obstruction), CXR is pulmonary oedema), CY KUB in obstruction)

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14
Q

Metformin in AKI

A

caution. High renal excretion, can lead to lactic acidosis.

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15
Q

AKI complications

A 
Hyperkalaemia
Hyperphosphataemia
Hyponatraemia
Hypermagnesaemia
hypocalcaemia
Metabolic acidosis
Fluid overload
Uraemia
CKD
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16
Q

Secondary causes of glomerunephritis

A 
N: neoplasm
S: SLE
A: amyloid
I: infection
D: diabetes
HSP: henoch Schonlein purpura
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17
Q

Features of glomerulonephritis

A

Immunological attack by Ab or T cell attacking antigen.
Capillary -endothelial proliferation (bigger fenestra) with capillary wall necrosis and mesangial scaring (glomerulosclerosis), thickened BM (more permeable) and cell deposition in Bowman’s space)

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18
Q

Nephrotic basics

A 
BM damaged, allows protein through. 
Protein loss >3.5g/day
Ig loss, hyprecholesterolaemia, oedema (oncotic pressure loss and sodium retention via RAAS), thombosis due to clotting imbalance. 
May have haematuria
Non proliferative histologically.
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19
Q

Nephrotic signs and symptoms

A

xanthalasma, xanthoma, fatigue, leukonychia, oedema, dyspnoea (can be pleural effusion or pulmonary oedema), may have frothy urine

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20
Q

Nephrotic investigation

A

MSU, dipstick, FBC, LFT, calcium, U&E, CRP, glucose, Ig (serum, urine), autoimmune screen, hepatitis screen, HIV screen, CXR, renal biopsy

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21
Q

Minimal change

A

Most common childhood nephrotic
No LM, but podocyte effacement on EM. IF shows IgM in mesangium.

NSAID, allergy and hodgkin lymphoma associations

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22
Q

Membranous glomerulonephritis

A 
30% of adult nephrotic. 
LM: mesangium expansion and capillary thickening
IF shows IgG and C3
EM shows GBM thickening
PLA2R antibodies

Penicillin, NSAIDs, malignancy (lung, colon melanoma), SLE, HBV, HVC, syphilis, scistomiasis, malaria

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23
Q

FSGS

A

Most common adult nephrotic
Often has azotaemia and haematuria
IgM and C3 can be present in sclerotic areas/mesangium
Can be secondary to HIV, heroin, sickle cell

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24
Q

Other nephrotics

A

Diabetes (most common cause), amyloidosis, HBV,HCV,

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25
Q

Nephrotic management

A

Diuretics, fluid management, ACEi, anticoagulation, Tx cause

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26
Q

Nephritic basics

A

Endothelial or mesanglial damage. Proliferative plus GBM thickening.
HTN, haematuria, casts in urine, proteinuria, oliguria, oedema, C3/C4 reduction (overuse)
May have ANA, anti-dsDNA, ANCA, antiGBM
Often abrupt onset

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27
Q

Acute post infectious

A

Most common nephritic globally.

Group A beta haemolytic streptococcus

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28
Q

IgA disease

A

Often macroscopic haematuria (often cola coloured). Can occur post URTI or HVB
Most common nephritic.
IgA/C3 deposits

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29
Q

Henoch scholein purpura

A

Systemic IgA vasculitis.

Typically get cola urine, widespread rash (esp extensors), arthalgia, abdominal pain, haematochezia

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30
Q

Rapidly progressing glomerulonephritis

A

Crescents, rapid loss of renal function.
Can be anti GBM (goodpastures if lung too)
Immune complex disease (IgA, post strep, SLE)
Pauci immune (very few Igs on staining)
Polyangitis
Churg strauss vasculitis

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31
Q

Poor prognostic indicators in nephritic

Sequalae

A

Severe renal impairment at presentation, persistent heavy proteinuria, HTN.

Adults often has long term complications
(can be HTN encephalopathy, HF, uraemia (dialysis))

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32
Q

PRGN nephritic screen

A

ANCA/anti GBM

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33
Q

SLE nephritic screen

A

ana, DS-dna, COMPLEMENT

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34
Q

myeloma nephritic screen

A

Igs, serum electrophoresis

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35
Q

RA associated GN screen

A

Rheumatoid factor

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36
Q

membranoproliferative glomerulonephritis (MCGN)

A

HBV/HBC screen

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37
Q

Post streptococcal nephritic screen

A

ASA

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38
Q

SLE associated diseases

A

Can be mix of nephrotic and nephritis. May see membranous, membranoproliferative and FSFN

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39
Q

CKD

A

Irreversible progressive renal function decline. Can be diagnosed if EGFR decreases over 3 months

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40
Q

CKD S+S

A

HTN, proteinuria, anaemia, nocturia (loss of concentrating), fatigue, dyspnoea, ED, oedema (peripheral/pulmonary)
Late shows pruritus, anorexia, N&V
Very late: hiccups, Kussmaul’s resp (met acid), muscle twitch, drowsiness, coma, fits

May have pericardial rub

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41
Q

CKD investigation

A
  • Bloods (U&E - can show hyperkalaemia, increased urea, creatinine)
    • FBC (?haemanitinics)
    • Calcium, phosphate, PTH
    • Lipid profile
    • Glucose, HBa1C
    • Albumin
    • Bicarb
    • Myeloma screen
    • HIV/HEP serology if transplant needed
    • ECG
    • Urinalysis (can quantify protein with PCR
      Renal US to exclude obstruction ans assess kidney size and any asymmetry (small kidney in CKD, asymmetry suggests renovascular/developmental disease. Polycystic kidney?)
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42
Q

CKD stagings

A

1 is mild with normal eGFR

2) 60-90
3a) 45-60
3b) 30-45 (anaemia present)
4) 15-30 (electrolytes)
5) <15 (dialysis once <10)

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43
Q

Management of CKD`

A

ACEi/ARB are key for BP control. Diabetes control.

Referral to nephrologist if young, CK4, rapid deterioration), significant proteinuria/haematuria

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44
Q

CKD complications

A

anaemia (Target 100-120 with EPO to avoid HTN and thrombosis)
Renal osteodystrophy (lack of 1 alpha hydroxylase, hyperphosphataemia cause lack of calcium) - can get tertiary hyperparathyroidism
Fluid overload (needs water/salt restriction)
Electrolyte disturbances (often hyperkalaemia, acidosis)
Myopathy (poor nutrition, hyperparathyroidism, vit D deficiency, electrolyte derangement)
Peripheral neuropathy
Anorexia
Immunocompromise
N&V
Peptic ulcer disease
Depression
CV issues (pericarditis, atherosclerosis, HTN, hyperlipidaemia)

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45
Q

Dialysis needed if

A

intractable acidosis, intoxicants (methanol, ethylene glycol, lithium), too much fluid and anuric), uraemic symptoms (N&V, pericarditis, seizures, bleeding, encephalopathy), severe electrolyte derangement

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46
Q

CKD causes

A

Most common diabetes, then interstitial disease, idiopathic, HTN, systemic inflammation, renal artery stenosis, congenital and drug induced

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47
Q

Diabetic nephropathy

Causes and management

A

Mediated by HTN, hyperglycaemia (extent and duration) as well as glomerular hyperfiltration, smoking, obesity, physical inactivity, dyslipidaemia, proteinuria, dietary factors, genetic susceptibility
Managed as per CKD (reduce proteinuria, control BP, modify CV risk, BM control)

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48
Q

PCKD

S+S

Investigation

A

ADPKD more common (autosomal dominant)
ARPKD is recessive and less common - earlier renal failure
Renal cyst, extra renal cyst, IC aneurysm, dolichoectasias, aortic root dilatation/aneurysm, mitral valve prolapse, abdominal wall herniae

HTN, CKD, abdo swelling +/- ruptured IC aneurysm
FHx is key. echo and MRI brain if suspected

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49
Q

Chronic pyelonephritis

A

interstitial nephritis/reflux nephropathy/chronic atrophic pyelonephritis

Chronic vesico ureteric reflux (congenital) or obstruction related (prostate, retroperitoneal fibrosis, stones)

Chronic tubulointerstitial inflammation, deep segmental cortical renal scarring, calyx clubbing.
Chronic inflammation.

HTN, proteinuria CKD features. Rule out UTI.
Micturating cystogram to diagnose UT abnormalities.
Irreversible, no specific treatment

50
Q

Obstructive uropathy
RF

S+S

Tx

A

Urine flow block (kidney(s), or any level).
Commonly stones or BPH

RF are BPH, constipation, medication (anticholinergics, alpha receptor agonist), urolithiasis, advanced age, recurrent UTI

Flank pain, LUT symptoms, distended abdo/bladder, haematuria, Hx of meatal narrowing, pelvic/abdo malignancy, neurological disease, pyrexia, rigors, HTN

Must relieve pressure
.

51
Q

HTN urological effects

A

arteriolosclerosis (thickening arterioles, afferent inelastic and rigid causing ischaemia - > glomeruli loss).
Atherosclerosis causes renal artery stenosis

52
Q

urolithiasis RF

A

Male 3:1, anatomical abnormalities (horseshoe kidney, stricture), HTN, gout, hyperparathyroidism, immobilisation, dehydration, metabolic disorder

53
Q

Renal stone composition

A 
Normally calcium (80% calcium oxalate, 20% calcium phosphate).
15% uric acid (purine diet, haematological issue, klebsiella, proteus

4% struvite (ammonium mg, phosph - staghorn)

Cysteine stones are rare (familial cysteine met disorder)

54
Q

Renal stone constriction sites

A

PUJ, pelvic brin, VUJ

55
Q

renal stone symptoms

Urine dip

A

sudden onset, severe loin to groin pain, N&V, haematuria. if infection too, rigors, fever, lethargy.

Urine dip shows WCC, haematuria, ketone but no glucose (dehydration)

56
Q

Renal stone management

A

Abx in infection
Diclofenac/opiates/buscopan for pain
Large stones/hydronephrosis need ECPW, endoscopic removal, percutaneous removal or open surgery

Focus on admission in AKI, uncontrolled pain, ninfection, stones >5mm
May want to fit stent or use nephrostomy (USS guidance)

57
Q

Renal stone complications

A

AKI.

Can give CKD and scarring. sepsis in infected

58
Q

Recurrent stone advice

A

Avoid dehydrations
In calcium stones, check PTH and avoid excess salt
Oxalate stones - avoid purine and oxalate foods (nuts, rhubarb, sesame)
Urate stones - avoid purine food and consider allopurinol
Cysteine stones need genetic testing
Struvite stones may need UTI treatment

59
Q

Bladder stone causes

A

outflow obstruction, prolonged catheterisation, upper UT stone passing down
Infection (e.g. schistosomiasis)

60
Q

Bladder stone symptoms

A

UTI symptoms (frequency, pain, haematuria) - pain typically at end of micturation when bladder contracts.
Males may also feel pain at tip of penis.
May get perineal pain
May have anuria or retention if obstructing outflow

61
Q

Things to exclude in ?ureteric obstruction

A

acute scrotum (as loin to groin pain), AAA (may be causing obstruction and pregnancy.

62
Q

Renal cell carcinoma

A

Adenocarcinoma (can be clear cell, pink cell and papillary renal cell)

63
Q

Renal cell cancer S+S

A

60% have haematuria. may have mild loin discomfort and mass. May have pathological fracture (PTH-like protein produced). May have varicoele if left renal vein involved. May have polycythaemia.

Renal vein allows haematological spread to IVC, so may have lung symptoms

64
Q

RF for renal cancer

A

smoking, obesity, HTN, renal disease, Fhx, asbestos, heavy metals, oestrogen therapy exposure, CKD, acquired cystic kidney disease, hevy NSAID/aspirin/diuretic use

Peak age is 50+

65
Q

Diagnosis of renal cell cancer

A

USS shows solid mass. can do CT scan.
Raised ALP, ESR.
Cannonball lung mets.

66
Q

Tx of renal cell carcinoma

A

Radical nephrectomy (can do partial but need to do renal angiography first).
TK inhibitors. Poor prognosis (mets<2 years).
If spread to perinephric fat then already T3

67
Q

Wilms tumour

A

Nephroblastoma (primative embyonic tumour). Blood spread. Peak age is 2 years. Excellent prognosis, unless mets

68
Q

Bladder stone investigation

A

urine dip, MSU, FBC, U&E, imaging

69
Q

Bladder stone management

A

Cytoscopy, stone drainage, lithotripsy

70
Q

Bladder cancer

S+S

A

Painless haematuria, recurrent UTI symptoms, pain from local strictures.

71
Q

Bladder cancer RF

A

male, smoker, 50+, dye/rubber workers, schistosomiasis infection, chronic cystitis, bladder stones, vesicular diverticulum, leukoplakia

72
Q

Diagnosis of bladder cancer

A

Urine MCS/cytology (often shows sterile pyuria), flex cystoscopy with biopsy (GSTD) - CT/MRI can miss if carcinoma in situ.

73
Q

Bladder cancer types

A

Generally urothelium (TCC), but can get true squamous cell and squamoid transformation of TCC)

Can also get benign (papillomas, leuimyoma, hemiangiooma, neurofibroma) or malginant non-epithelial tumour (rhabdomyosarcoma)

74
Q

Bladder cancer Tx

A

Cytoscopic tumour removal, intravesical BCG (immune response can shrink early stage cancer), radical cystectomy.

75
Q

BPH

A

Transitional zone expansion

Very common in 70+

76
Q

BPH s+S

A

Hesitancy, UTIs, poor flow, terminal drippling, may have retention, overflow incontinence, haematuria if veins rupture

On PR: sulcus generally palpable. Globally enlarged. Smooth. Non tender

77
Q

BPH investigation

A

FBC, U&E, PSA (<4 normal,>10 raised), urnialysis/MCS, uroflowmetry, bladder USS, transrectal USS (rule out carcinoma - may have iopsy)

78
Q

BPH complications

A

UTI, overflow incontinence, bladder calculi, bladder diverticulae, bilateral hydronephritis, renal failure

79
Q

UTI RF

A

Female, pregnancy (progesterone mediated vesicoureteric reflux, stasis), post menopausal (less lactobacilli), strutural abnormality, sex (first time, long time without), catheter use)

80
Q

Most common UTI pathogen

A

E. coli

81
Q

Most common UTI pathogen in young, sexually active females

A

Staphylococcus saprophyticus

82
Q

Pseudomonas UTI

A

linked to catheterisation

83
Q

Less common UTI

A

enterococci, proteus, klebsiella, pseudomonas

84
Q

UTI found more in hospital

A

klebsiella, s epidermidis, enterococci and pseudomonas

85
Q

Boundary for upper UTI

A

Above VUJ - pyelonephritis

86
Q

Boundary for lower UTI

A

below VUJ. cystitis

87
Q

Cystitis S+S

A

Dysuria, haematuria, frequency/urgency, suprapubic pain, foul smelling/cloudy urine, strangury (dysuria with small volume only expelled by straining despite urgency), confusion/lethargy/fatigue (urosepsis)

88
Q

Cystitis investigations

A

Urine dipstick for women <65. Everyone else gets MSU (all men, pregnant women and over 65 women get one - as well as if persistent symptoms, recurrent UTIs, recent catheterisation, RF for complications, haematuria).
Renal tract imaging (US/CT) if persistent, recurrent, ?obstruction or septic shock

89
Q

Sterile pyuria

A

Leukocytes but no organisms grown) then consider recently treated UTI, appendicitis, TB, chlamydia, bladder cancer

90
Q

UTI Tx

A

trimethoprim or nitrofurantoin. NSAIDs/paracetamol. Hydration. Hygiene measures

91
Q

pyelonephritis S+S

A

Dysuria, frequency, flank pain (or suprapubic pain), haematuria, high grade fever, N&V, rigors. Usually acute onset, systemically unwell. Generally occurs in incompetent vesicoureteric valve

92
Q

Pyelonephritis investigations

A

Urine dip/MSU
Bloods (look for AKI)
Blood culture (?sepsis)
USS KUB (often FL - look for obstruction, inflammatory change, hydronephritis)
CT (reserved for cases where not improving. avoid in children/pregnancy)
Dimercaptosuccinic acid (DMSA scan) - detailed imaging of renal cortices to see scarring and poor function. Requires IV dye and monitoring of kidneys to see filtration

93
Q

DMSA scan

A

Uses IV dye to look at kidney scarring and function

94
Q

Pyelonephritis Tx

A

Abx (ciprofloxacin, trimethroprim, co-amox). If severe then admit for IV abx (cefuroxime or ciprofloxacin). Hydration is key.
FU USS may be needed

95
Q

pyelonephritis complications

A

sepsis, AKI, perinephric abscess, renal papillary necrosis

96
Q

Comparison of pyelonnephritis/cystitis

A

Both have dysuria, frequency and can have haematuria
LUTI tends to have urgerncy, suprapubic pain, cloudy/smelly urine - can have confusion, lethargy and fatigue if urosepsis
UUTI tends towards flank pain, high grade dever and N&V

97
Q

Asymptomatic bacteruria

A

More common in the elderly and with catheters. No Tx unless pregnant or awaiting invasive urological procedure.

98
Q

Catheters and bacteruria

A

Catheters always have bacteria, only need to investigate or Tx of symptomatic

99
Q

Pyuria DDx

A

Pus in urine
UTI (including TB), interstitial nephropathy (e.g. diabetes), acute glomerulonephritis, tumours, post surery, catheters, contamination from vagina

100
Q

Diabetic urinary tract complications

A 
Vascular issue (atherosclerosis and hyaline arteriolosclerosis - > ischaemic glomerular damage)
Direct flomerular damage via BM thickening (proteinuria) and abnormal mesangium (glomerulosclerosis) - KW lesions
Infection risk (pyelonephritis and renal papillary necrosis)
101
Q

Non blood haematuria

A

haemolysis, rhabdomyolysis (myoglobin), food dyes, drugs (metronidazole, nitrodurantoin, doxorubicin, rifampicin), porphoryia, tyrosinaemia

Note that haemolysis and rhabdomyolysis would show as “blood” on urine dip

102
Q

Most common causes of haematuria

A

Macroscopic - ?malignancy, but can be stones, BPH, UTI etc

microscopic is more commonly UTI, BPH and stones, but can be malignancy

103
Q

Investigations for haematuria

A

Urine dip, FBC, U&E, clotting screen, urine red cell morphology (dysmorphic suggests renal origin), cytological examination of urine, imagina (xray, urogram, CT, USS, MRI)

104
Q

FLT haematuria imaging

A

USS of kidney and bladder
AXR
Cytoscopy

105
Q

Hyperkalaemia

A

Can be pseudohyperkalaemia, AKI, CKD, K sparing diuretics, ACEi, NSAIDs, acidosis, Addison’s disease, tumour lysis syndrome, burns

106
Q

ECG with hyperkalaemia

A

Tall T wave, wide QRS, flattened P wave, prolonged PR interval
Can lead to VF/VT

107
Q

Tx of hyperkalaemia

A

if >6.5 then 10mL 10% calcium gluconate IV (repeat at 5 minutes until ECG stabilises)
50mL 50% glucose with 10 units Actrapid insulin /30 minutes
Consider 10mg salbutamol neb and sodium bicarb

108
Q

Phimosis

A

foreskin wont retract. Can be congenital, chronic balanitis, traumatic). May present as poor stream and ballooning foreskin in children, in adults as pain during sex. Circumcision resolves

109
Q

paraphimosis

A

Tight foreskin over glans, obstructing venous return, Can occur following erection or catheterisation. Manually reduce, or circumcision

110
Q

Penis cancer

A

Rare. SCC. Associated with HPV 16 and 18. Presents as red patch on penis which then ulcerates. No urethral symptoms or involvement. Diagnosis is punch biopsy. Can be cured if early with radiotherapy, or surgery if late

111
Q

Priapism

A

Hours long erection (corpora cavernosa only - spongiosum remains flaccid). Can be idiopathic, trauma induced, sickle cell crisis or intracevernosal infections for impotence. Can treat with ice packs, alpha agonist, selective embolisation, aspiration or surgery.

112
Q

Peyronies disease

A

upward curvature. Idiopathic, but scarring following trauma is potential aetiology - Tx may include managing depression and could have surgical intervention).

113
Q

Transilluminating scrotal mass

A

hyrocoele, epididymal cyst or varcocoele

114
Q

Solid scrotal mass

A

cancer, orchitis, gumma - needs USS

115
Q

Scrotal lump separate to testes

A

chronic epidymitis

116
Q

Can’t get above scrotal swelling

A

inguinal hernia or proximally extending hydrocoele - check by illuminating

117
Q

If can get above scrotal swelling

A

primary scotal swelling

118
Q

Phren’s sign

A

Pain relief on lifting testicle, can rule our torsion in favour of epdidymiitis

119
Q

Testicular torsion

A

Absent cremasteric reflex, negative phren’s sign

120
Q

Epidymal cyst

A

Common, occur due to cystic degeneration of epididymal structures. Associated with PKD and CF. Almost always at the upper pole. Transillulimates. May or may not contain sperm. Can be painful or uncomfortable, may be excised (drainage often doesn’t resolve)

121
Q

Hydrocoele

A

Most common cause. Fluctulant, transilluminates. Can be congenital (generally resolves within 1 year), primary (idiopathic - ‘vaginal hydrocoele’) or secondary (due to inflammation/cancer). USS should be undertaken to rule out underlying patohlogy. Excision of hydrocoele sac can be done if problematic

122
Q

Varicocoele

A

Paminiform plexus varicosity, generally on the left. Presents as dragging sensation and ache. May only be palpable in standing position. Associated with reduced fertility, but surgical correction often doesn’t correct. Can be valvular incompetence at junction of left renal vein, but can be due to left renal tumour.

CP1 revision (16 decks)

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