Disease Flashcards
1
Q
What do the symptoms of kidney disease come from?
A
- local effects
- underlying disease
- effects of loss of kidney function (advanced disease)
2
Q
What are the important systemic enquiry questions for the kidneys?
A
- appetite and weight loss
- nausea and vomiting
- dyspepsia
- dyspnoea
- urinary symptoms ie frequency, hesitancy, polyuria and nocturia
- joint pain and arthralgia
- skin rashes
3
Q
What are the possible examination signs with a kidney issue?
A
- pyrexia
- skin rash
- heart murmurs
- retinopathy
- neuropathy
- arterial bruits
- pallor
- raised JVP
- lung creps
- oedema
- gout
- palpable kidneys
- arrhythmias
4
Q
What is accelerated hypertension?
A
this is a medical emergency
- diastolic BP>120mmHg
- papilloedema
- end-organ decompensation
5
Q
How is urine protein tested?
A
- 24hr urine collection
- urine protein to creatinine ratio
6
Q
What are urinary casts?
A
form by precipitation of Tamm-Horsfall mucoprotein and formation is pronounced in low urine flow and low pH
7
Q
What are the main types of urinary casts?
A
- hyaline: usually benign
- red cell: always pathological, associated with nephritis syndrome
- leukocyte: infection/inflammation
- granular: chronic disease
8
Q
What is the best measure of kidney function?
A
GFR
9
Q
What are the stages of kidney failure with GFR?
A
G1= >90- kidney damage with normal/ increased GFR G2= 60-89- kidney damage with mild decrease in GFR
^These are only CKD if there are markers of kidney damage too
G3= 30-59- moderate decrease in GFR G4= 15-29- severe decrease in GFR G5= <15 or dialysis- kidney failure
10
Q
What is acute kidney injury?
A
decline in GFR over 48h with or without oliguria where there is an absolute increase in serum creatinine by >26.4 or increase in creatinine by >50% or reduction in urinary output
11
Q
What is involved in nephrotic syndrome?
A
this is often normal renal function
- proteinuria >3g/day
- hypoalbuminaemia
- oedema
12
Q
What is involved in nephritic syndrome?
A
this is signs and symptoms of glomerulonephritis
- acute kidney injury
- oliguria
- oedema/fluid retention
- HTN
- active urinary sediment
13
Q
What are the patient risk factors for AKI?
A
- old
- CKD
- diabetes
- cardiac failure
- liver disease
- PVD
- previous AKI
14
Q
What are the exposure risk factors for AKI?
A
- hypotension
- hypovolaemia
- sepsis
- decreasing NEWS score
- recent contrast
- exposure to certain medications
15
Q
What are the main classes of causes of AKI?
A
- pre-renal/functional
- renal/structural
- post-renal/obstruction
16
Q
What are the pre-renal/functional causes of AKI?
A
- hypovolaemia (haemorrhage and volume depletion eg D+V or burns)
- hypotension (cariogenic, distributive shock)
- renal hypoperfusion (NSAIDs, ACEI, hepatorenal syndrome)
17
Q
What is pre-renal AKI?
A
reversible volume depletion leading to oliguria (<0.5mls/kg/hr) and an increase in creatinine
18
Q
What is nausea/vomiting and weight loss caused by in renal?
A
uraemia
acidosis
19
Q
What is itch caused by in renal?
A
uraemia
hyperphosphataemia
acidosis
20
Q
What is SOB caused by in renal?
A
anaemia
acidosis
21
Q
What are the two main groups of symptoms of bladder outflow obstruction?
A
Storage-
- frequency
- nocturia
- urgency
Voiding
- hesitancy
- poor flow
- intermittent flow
- sensation of incomplete emptying
- post-micturition dribbling
22
Q
What are the red flags symptoms for bladder and prostate cancer?
A
– Haematuria – Suprapubic pain – Recurrent Urinary Tract Infections – Bone pain – Weight loss
23
Q
What is the treatment for hyperkalaemia?
A
- calcium gluconate to protect against arrhythmias
- insulin (with glucose) to move K into cells
- salbutamol which moves K into cells too
will need haemodialysis eventually
24
Q
If there is both proteinuria and haematuria where is the issue most likely to be?
A
kidneys
25
What is the most likely cause of haematuria without proteinuria?
- in young is kidneys <45
| - in old is bladder >45
26
What can metformin do to the kidneys?
when there is a reduced GFR there is an increased risk of lactic acidosis
27
Which class of drug is proven to slow progression of diabetic nephropathy?
ACEi or ARB
28
Which classes of medications are stopped on sick days?
- ACEi/ARB
- NSAIDs
- Diuretics
- Diabetic medication ie gliclazides and metformin
29
What is the mnemonic for indications for dialysis?
AEIOU
- A-acidosis that is not medically improved
- E-electrolyte disturbance eg hyperkalaemia
- I-intoxication ie drug overdose
- O-verload ie pulmonary oedema
- U-uraemia >40
30
What is the physiological response in the body to a decrease in renal perfusion?
- renin released
- renin causes angiotensin 2 to cause vasoconstriction of the efferent arteriole
- GFR is maintained
31
What do ACEI do?
cause a reduction in GFR by inhibiting angiotensin 2 from vasoconstricting the efferent arteriole
32
What happens if there is a decrease in renal perfusion in a patient who takes an ACEI?
there is a severe drop in GFR
33
What does untreated pre-renal AKI lead to?
acute tubular necrosis
34
What are the causes of acute tubular necrosis?
- sepsis
- severe dehydration
- rhabdomyolysis
- drug toxicity
35
What is the treatment of pre-renal AKI?
- assess for hydration: BP, HR, UO, JVP, cap refill, pul oedema
- fluid challenge for hypovolaemia using crystalloid
36
What is renal AKI caused by?
inflammation or damage to cells
- vascular eg vasculitis
- glomerular eg glomerulonephritis
- interstitial eg drugs, sarcoid, TB
- tubular eg ischaemia, drugs, contrast
37
What are the symptoms of renal AKI?
- anorexia
- weight loss
- fatigue
- N and V
- itch
- fluid overload
38
What are the signs of renal AKI?
- fluid overload: HTN, oedema, pulmonary oedema, effusions
- uraemia: itch, pericarditis
- oliguria
39
What is the treatment and diagnosis for renal AKI?
Diagnosis: U and E, FBC, crag, urinalysis, USS, immunology
Treatment: fluids, ?inotropes if fluid doesn't increase BP, treat underlying cause, stop nephrotoxic drugs, ?dialysis
40
What are the main life threatening complications of AKI?
- hyperkalaemia
- fluid overload
- severe acidosis
- uraemia pericardial effusion
- severe uraemia
41
What is post-renal AKI?
obstruction of urine flow leading to hydronephrosis
42
What are the causes of post-renal AKI?
- stones
- cancer
- strictures
- extrinsic pressure
43
What is the treatment for post-renal AKI?
relieve the obstruction with a catheter or a nephrostomy
44
What are the signs of hyperkalaemia on an ECG?
- tall, peaked T waves with a narrow base (best seen in precordial leads)
- shortened QT interval
- ST-segment depression
45
What are the main drugs to avoid in a patient with AKI?
- NSAIDs
- ACEI/ARB
- Diuretics
- Gentamicin
- Contrast
- Trimethoprim
- Potassium sparing diuretics
46
What is needed ideally for a diagnosis of CKD?
two samples at least 90 days apart using eGFR of less than 60
47
What is classed as accelerated progression of CKD?
- 25% decrease in GFR and change in category in 12m
| - decrease in GFR of 15ml/min per year
48
What are the RF for CKD?
- chronic NSAID use
- smoking
- African/ Caribbean/ Asian
- proteinuria (more likely to progress)
- diabetes
- hypertension
- acute kidney injury
49
What is the definition of CKD?
decreased GFR and/or evidence of kidney damage present for more than 3 months
50
What are the BP aims for CKD and also with diabetes?
for CKD= <140/90
| for CKD and diabetes= <130/80
51
What is the prevention of CVD in CKD?
huge risk
- atorvastatin and ?aspirin
- smoking cessation, weight loss, aerobic exercise, limit salt
- control HTN
52
What are the causes of CKD?
- diabetes
- HTN
- small vessel vasculitis
- chronic glomerulonephritis
- reflex nephropathy
- PKD
- obstructive post-renal disease eg calculi, prostatic or bladder
53
What are the clinical signs of CKD?
- anaemia
- weight loss
- advanced uraemia (lemon yellow, twitch, confusion, pericardial rub/effusion)
54
What are the symptoms of CKD?
- Uraemia: confusion, N and V, weight loss, itch, muscle twitch, altered taste and fatigue
- Pain: neuropathic, ischaemic, bony and visceral
- Anaemia: fatigue and muscle weakness
55
What are the renal consequences of CKD?
- local pain and infection
- haematuria and proteinuria
- HTN
- acid-base disturbances
leading to end-stage renal disease
56
What are the extra-renal consequences of CKD?
- CVD
- mineral and bone disease
- anaemia
- nutrition
57
What happens in mineral bone disease?
Vit D is normally hydroxylated in the kidneys but it isn't so there is calcium imbalance and high PTH
58
What is the treatment for CKD with mineral bone disease?
- restrict phosphate
- consider lower salt, restrict potassium and fluid
- medication= Alfacalidol (active Vit D), phosphate binders, calcimimetic
59
What is the treatment for renal anaemia?
common esp in DM due to low production fo erythropoietin (target is 100-120Hb)
- Ferinject/Venofer which is iron therapy, give IV iron if this is unsuccessful
- check for B12 and folate deficiency too
60
What are the physical effects of CKD?
- thirst
- malnutrition
- anaemia
- loss of interest in food
- vitamin/mineral imbalance
there is a high depression rate in ESRD
61
What are the adverse affects of the post renal transplant drugs?
- infections
- cancer
- GI upsets
- hirsutism
- weight changes
62
What main areas does vasculitis affect?
kidneys, skin and lungs
63
What are the types of ANCA antibodies?
cANCA is GPA (anti-PR3)
| pANCA is MPA (anti-MPO)
64
What are the features of lupus nephritis?
- proteinuria is observed
- classification ranges from minimal to advanced sclerosis
- biopsy of kidneys is needed
65
What are the zones of the prostate?
- transitional zone
- central zone
- peripheral zone- most prostate adenocarcinomas come from here
- fibromuscular zone
66
What is the role of PSA?
it is involved in liquefaction of semen and is increased in prostate cancer and other conditions
aka glycoprotein enzyme kallikrein 3
67
What are the three parts to dialysis?
diffusion, convection and adsorption
68
What is involved in the diffusion part of dialysis?
creating an equilibrium which removes urea, potassium and sodium and allows bicarbonate infusion
69
What is involved in the convection part of dialysis?
water and dissolved solutes move across a membrane in response to a pressure gradient aka ultrafiltration
70
What is involved in the adsorption part of dialysis?
plasma proteins stick to the membrane surface and are removed by membrane binding
high flux membrane do this more than low flux
71
What is haemodiafiltration?
this is more convective than HD with a large solute drag so is a better treatment
72
How often is haemodialysis done?
4 hours a week three times a week
73
What are the lifestyle changes for someone on dialysis?
- 1l a day of fluid
- low salt, potassium and phosphate diet
- give phosphate binders with meals
74
What are the two types of access for dialysis?
- tunneled venous catheter= easy, infection with S.aureus, vein damage
- fistula= gold standard, can't be used immediately. needs surgery, less infections, surgical connection between artery and vein
75
What are the problems with dialysis?
- hypotension leading to under-filing of intravascular space
- haemorrhage
- loss of vascular access
- arrhythmia
- cardiac arrest
76
What is peritoneal dialysis?
- solute removal by diffusion of solutes across peritoneal membrane
- water removal by osmosis driven by high glucose conc in dialysate fluid
77
What are the issues with peritoneal dialysis?
- infection ie peritonitis or exit site
- peritoneal membrane failure so can't remove enough water or solutes
- hernias due to high intra-abdominal pressure
78
What are the reasons for starting dialysis?
- resistant hyperkalaemia
- eGFR<7
- urea<40
- unresponsive metabolic acidosis
- N+V, anorexia, fatigue, itch and unresponsive fluid overload
79
What is disequilibrium syndrome?
the correcting of urea levels too fast
80
What are the three types of renal transplant?
- deceased heart beating donor
- non-heart beating donor
- live donation
81
What are the contraindications for renal transplant?
```
malignancy
active HIV
untreated TB
severe heart/airways disease
acute vasculitis
severe PVD
hostile bladder
```
82
What is desensitisation in relation to renal transplant?
active removal of blood group or donor specific antibody by plasma exchange or B cell antibody (rituximab)
83
Where is the new kidney attached?
to the external iliac artery and vein in the iliac fossa
84
What are the types of rejection?
- hyperacute: preformed antibodies, transplant needed
- acute: cellular/antibody mediated, increase immunosuppression
- chronic: antibody mediated slow progression decline which has no treatment
85
What is involved in anti-rejection therapy?
decreased activation of T cells
86
What happens if the anti-rejection therapy becomes too much?
- infection so UTI or LRTI
- cytomegalovirus causes death in first 3 months and causes renal dysfunction, give IV ganciclovir
- BK virus can cause nephropathy
- EBV infection can lead to lymphoma due to immunoproliferation
87
What are the types of anti- rejection drugs?
- monoclonal antibodies: prevent activation fo CD4 T cells so no rejection
- glucocorticoids: inhibit lymphocytes action and suppress cytokines
- calcineurin inhibitors =: inhibit T cell activation and prevent cytokine release
- anti-metabolites: block purine synthesis so suppress lymphocyte proliferation
88
What are the features of acute urinary retention?
- inability to urinate and increasing pain
- due to BPH or can be precipitated by catheter, anaesthesia or medication
- give catheter, uroselective alpha blocker and then remove catheter
89
What is post-obstructive diuresis?
present in patients with chronic bladder outflow obstruction associated with uraemia, oedema and HTN
90
What are the features of ureteric loin pain?
- caused by a stone with the pain caused by prostaglandins
- give NSAIDs and /opiate
- give alpha blocker (tamsulosin) for small stones
- treatment is ureteric stent or stone fragmentation and removal
91
When should stones in the ureter be treated urgently?
unrelieved pain
pyrexia
persistent nausea/vomiting
high-grade obstruction
92
What are the causes of frank haemturia?
- trauma
| - coagulation/platelet deficiencies
93
What is the best test for frank haematuria?
CT urogram and cytoscopy
94
What are the features of a spermatic cord torsion?
- adolescent, spontaneous, n and v, referred pain to lower abdomen
- do doppler US
- surgical fixation
95
What is the blue dot sign?
this is an appendage torsion in the testicle which has a spontaneous resolution
96
What is the presentation of epididymitis?
- dysuria and pyrexia in a child
| - history of UTI, urethritis and catheter
97
What is the diagnosis and treatment for epididymitis?
- do urine culture
- give analgesia and scrotal support
- give oflaxacin
98
What are the features of idiopathic scrotal oedema?
it is self-limiting and can cause itch
99
What is paraphimosis?
a painful swelling of the foreskin distal to the phimotic ring caused by foreskin not being replaced after a procedure
100
what is the treatment for paraphimosis?
puncture, compression and slit
101
What is Fournier's gangrene?
this is necrotising fasciitis of the testicles which starts as cellulitis but goes purple, swollen with crepitus
102
What is the treatment for Fournier's gangrene?
antibiotics and surgical debridement
103
What are the predisposing factors for Fournier's gangrene?
diabetes, local trauma and periurethral extravasation
104
What are the voiding symptoms of BOO?
- weak or intermittent urinary stream
- straining
- hesitancy
- terminal dribbling
- incomplete emptying
105
What are the storage symptoms of BOO?
- urgency
- frequency
- incontinence
- nocturia
106
What are the causes of urinary incontinence?
- urethral: urge, stress, mixed or overflow
| - fistula/ectopic ureter
107
What device is used to assess pressures in urinating?
cystomethograms show pressures of filling and voiding phases
108
What are the nerves involved in urination?
afferent= pelvic parasympathetic
efferent= pudendal
facilitation and inhibition is by S2-3
109
What is overflow incontinence?
bladder outflow obstruction so huge palpable bladder so there is chronic retention leading to wetness at night and renal impairment
110
What does urge incontinence consist of?
high daytime frequency with small voided volumes which can be due to detrusor overactivity so it contracts during inhibition of voiding
111
What are the causes of over excitation of the bladder?
- afferent overstimulation due to irritation of the bladder
- excess facilitation by S2-3
- loss of central inhibition due to paraplegia
112
What is stress incontinence?
urine leaks out due to increased intra-abdominal pressure with our detrusor contraction due to pelvic floor damage or urethral function issues
urodynamic diagnosis - USI
113
What is a painless palpable mass in pelvis on examination that is dull to percussion?
bladder
114
What is the treatment for overflow urinary incontinence?
assess renal function, treat obstruction, catheter, rehabilitate bladder, teach intermittent self catheterisation
115
What is the treatment for urge urinary incontinence?
bladder retraining, drugs (antimuscarinics and beta3 adrenergic), neuromodulation (pacemaker) or surgery
116
What is the treatment for stress urinary incontinence?
decrease weight, stop smoking, pelvic floor physiology, surgical correction eg tape procedure
117
What is the emergency management of haematuria?
- FBC, renal function, clotting
- 3 way catheter with bladder washout
- monitor output and haemoglobin
- remove catheter
- USS/CT and cystoscopy
118
What is the initial management of UT calculi?
- ABCDE
- analgesia- NSAIDs eg Diclofenac IM/PR
- bloods- FBC, U and E, CRP, urate and calcium
- CT KUB is gold standard
- treat sepsis
119
What is the elective treatment for UT stones?
ureteroscopy
shock wave lithotripsy
percutaneous nephrolithotomy
(stones up to 6mm don't need treatment)
120
What are the most common causes of retention of urine in men vs women?
- men= prostate cancer, BPH and urethral stricture
| - women= pelvic prolapse, post-surgery, pelvic mass due to gynae issue
121
What is the management for acute retention?
- catheter and record residual volume
- FBC, renal function and urine dip
- treat cause
- alpha blocker
122
What is the management for chronic retention?
catheter and monitor for post-obstructive diuresis and decompression haematuria
123
What are the main causes of CKD?
- hypertension
- diabetes
- glomerular disease
