Endocrine and Nephrology Flashcards
aldosterone job
fluid and salt retention
K excretion
inhibited by spironalactone/ amiloride
deficient in addisons
- hypotention, low Na, high K
too much in conns
- htn, hypo K, alkalosis
secondary htn
RENAL 80%
gn, pyelo, cystic, stenosis
ENDOCRINE cush (cortisol), conn (aldosterone), congen adren hyp, phaeo, acromeg hyperparathyroid PREGNANCY
VASCULAR
- coarctation
- renal artery stenosis
alcohol
rare: MAO-i (depression) with cheese
ADH job
fluid retention
cushing syndorme vs disease
sydrome
- HTN,
- hirsuit, acne, thin hair
- ihd, infection
- central obesity, striae, thin/bruised skin
- osteoporosis, proximal myopathy
- impotence/dysmenorrh
= can be
1) iatrogenic
2) adrenal tumour/hyperplasia
3) ectopic acth producing tumour
4) pituitary tumour
disease = pituitary tumour
- produce acth -> casue adrenal hyperplasia
cushings test
48 hr low dose DEXOMETHASONE test
24hr urinary cortisol
also renin increased
ACTH helps diagnosis
- inc in ectopic/pituitary tumour
- dec in adrenal tumour/hyperplasia
do CT
cushings treatment
pre-surgery
- metyrapone
- ketoconazole
surgery
conns
primary hyperaldosteronism
- ademona or hyperplasia on adrenal
HTN HYPOKAL ALKALOSIS
weakness, polyuria/dipsia
low renin
high aldosterone
CT scan
T
(spironalactone/amiloride)
–> surgery
phaeo
adrenal tumour producing adrenaline/noradrenaline
SWEAT, PALP, TACHY, ANXIETY
HTN, HEADACHE,
othostatic hypo
cafe au lait
inc urinary adrenaline
T:
alpha blocker
b blocker
–> surgery
addisons
tired tanned tearful
GI
adrenocorticol insufficiency
low cortisol and aldost
= autoimmune
= or after stopping steroids
hypotension
GI upset
fatigue, depress
hypopigmentation
low Na, high K, acidosis,
hyperpigment, dehydration
synACTHhen test (short acth) autoantibodies
T: hydrocort and fludrocort
also in crisis –> fluid
acromegaly
pit tumour –> GH
DIAG: ogtt w GH meas
- IGF1 will also be raised
htn sweating heaaches visual field (temporal)
spade hands, big jaw/brow, coarse skin, sweaty
big lips, tongue, goitre, organomegaly, low voice
OA/arthropathy, carpal tunnel, pseudogout
prox myopthy, mononeuropathy
cv disease
htn, dm
polyps, crc
T:
somatostatin analogue (octreotide)
GH receptor antag
- sugery + radio
congenital adrenal hyperplasia
HTN
high acth
female virilisation at birth
renal cell carcinoma (adenocarcinoma)
renal cell adenocarcinoma -HAEMAT -LOIN PAIN -ABDO MASS may have fever, varicocoele
paraneoplastic:
hypercalcaemia, polycythaemia, htn
US, IV pyelogram
bladder cancer
painless frank haematuria
risk: smoking, industrial toxins (dyes), age>50
Hyperthyroid
60% graves
- autantibodies
- 30% have eyes (proptosis, exop, lid lag)
- painless goitre
- 50% cured by 18m carbimazole
toxic multinod (Painless G) toxic adenoma (no G) - these two may require surgery or radioiodine rather than carbimazole
subacute thyrotoxicosis (de Q) -PAINFUL GOITRE -low isotope uptake -self limiting -raised esr (often post viral) treat w nsaids
drugs amiodarone, lithium
hypothyroid types/causes
primary atrophic
- no goitre
hashimotos
- can be initially hyperth
- GOITRE
- autoantibodies
in subacute (dq) get hyperthyroid, then hypothyroid
- self limiting post viral
- painful goitre, low isotope uptake, high ESR
also amiod, lithium, iodine defic (G)
hyperthyroid sx
anxiety, hot, sweaty
```
palpitation, tachycardia, af
cardiomyopathy
tremor
diarrhoea
menstrual
proximal myopathy
pretibial myxoedema
~~~
Hyperthyroid treat
b block vs Sx
Anti-thyroid: carbimazole
?block and replace
!!! risk of agranulocytosis —> neutropenia
(watch for sore throat/fever)
radioiodine
surgery
leaves pt hypothyroid - levothyroxine
thyroid storm
can complicate hyperthyroidism
+++ anxiety, tremor, tachy, fever, sweat, confusion
fluid
steroid
b block
carbimazole
Hypothyroid symptoms
Sx
- depress, loss of energy, cold
- hairloss (frontal), loss of eyebrows
- puffy dry skin, complexion
- hoarse voice
- cardiomyopathy, bradycardia
- wg, constip, menorrhagia
- carpal tunnel
- myalgia, cramps, weakness, slow reflexes
hypothyroid association
turners, downs, CF
pbc
treatment - levothyroxine
- titrate dose vs symptoms and blood levels
- high dose may trigger angina
NB AMIODARONE CAUSES THYROID PROBLEMS - both hypo and hyper
acute kidney injury definition
creat rise by 26 micromols/l in 48hrs
creat rise by 50% of baseline in a week (baseline from 3m)
oliguria (less than 0.5ml/kg/hr)
Acute renal failure causes and approach
Pre-renal
- hypovol, sepsis,
Renal
- T.I.D (tubulointerstitial disease)
- from nsaids, gentamycin, ace, ciclosporin
- from ischaemia
- from gn
- also haemolytic uraemic syndrome
Post renal (us shows hydronephrosis)
- stones
- prostate
- retroperitoneal fibrosis
—> Manage pulm oedema and hyperkalaemia
If pulm oed, hyperkal, acidosis, encephalop, pericarditis
—> dialysis
acute renal failure
prerenal (50%) vs atn (30%)
prerenal
- hypoperfusion (hypovol, sepsis)
- tubules still working so Na is resorbed
(low urine Na, high serum Na) and urine is concentrated (high osmol)
atn (tin)
- ischaemia
- nephrotoxins (nsaid, abx)
- hepatorenal syndrome
- GN, vasculitis, myeloma, HUS
- –> high Na in urine and dilute
nephrotoxic drugs
gentamycin, streptamycin (aminoglycosides)
radiocontrast
nsaids
ace/arb
immunosuppress (cyclosporin, methotrexate)
chemotherapy
serious comps of acute renal fail
hyperkalaemia (tall t, small p, wide qrs, pr)
- give ca gluconate
- give insulin glucose
- give calcium resonium/salbutamol
pulmonary oedema - sit up, high flow o2 - furosemide 120mg IV over 1 hr - morphine 2.5 IV (cause venous dilation) (+metoclopramide) -- HAEMODIALYSIS -- CPAP
acute renal failure management
often occurs w illness, sepsis, nephrotoxic drugs
- is cause pre, intra, or post renal?
oliguria raised urea (7) and creat (120)
nausea/vom
bleeding, htn
- –> risk high K and met acidosis
- –> risk vol overload - pulm oedema
Mx:
- o2 sats, listen to chest - ?pulm oedema
- ?give fluid, catheterise
- test urine (pre vs atn)
- stop nephrotoxins
- watch bloods - hyperkalaemia?
- US abdo/kidney - obstruction?
—> DIALYSIS
(acidotic, hyperkal, p.oed, pericard, enceph)
indication for dialysis in acute renal fail
pulmonary oedema persistant hyperkal severe met acidosis uraemic encephalopathy uraemic pericarditis
Nephritic syndrome
type of acute kidney diysfunction
HAEMATURIA w RED CASTS
mild proteinuria
HTN (fluid retention)
urea and creat, low gfr
may be seen 2/3 weeks post strep pyog
mx: ace vs htn and prot diuretic if oedema ?dialysis if ureamic ? biopsy
Chronic renal failure features
tiredness
anaemia (take EPO)
bone probs: low Ca, high PO4, high PTH
lose sex drive
renal bone disease
2dry hyperparathyroid
see high PTH but low/norm Ca
due to failure of vit D metab by kidneys
- > low Ca abs
- -> inc PTH release
- also phosphate retention by kidneys
= causes bone disease (demin) - ALP+
T: vit D, phosphate binders
Systemic renal probs
DM myeloma renovascular disease goodpasture vasculitides (weg, mp, pan, HSch) SLE, SSc
amyloid
haemolytic uraemic syndrome (diar, haemolysis, thrombocyto, renal)
cryoglobinaemia (cold, renal, urticaria)
Polycystic Kidney
autosomal dominant (95% type 1 chrom 16, 5% chrom 4) 25% cases are spontaneous
screening if FH by US
-need more cysts if older
ie 2 30, 4 bilat>60
prog growth of cysts
- haemat, pain, renal imp, htn
associated with berry aneurysm (SAH in 10%)
renovascular disease
mainly due to atheroma
see htn resistant to treatment
US - asymmet kidneys
angiography
risk - smoking, cholest etc
tx: stenting/plasty
Reflux nephropathy
Kidneys can become scarred and shrunken due to chronic tubulo interstitial disease/nephritis
Assoc w recurrent UTI’s (pyelonephritis)
Ix:
IV urogram
DMSA (radio scan of kidney tissue - shows scarring)
Micturating cystogram (uses xray)
Treat uti, htn, ?steroids, dialysis
SLE
kidney impairment - GN
also facial rash
Tubulo interstital disease
Interstitial nephritis
Intrinsic renal failure
Accounts for 20% of dialysis
Can present w proteinuria, haematuria or in renal failure
- do UE’s, urine protein and mc+s, us and ?biopsy
May be acute -renal fail (?+ fever, rash, eosinophilia)
- often due to drugs
- -abx (gentamycin), nsaids
- also infection, sjogrens
Chronic
- presents with crap renal function, htn, polyuria
- small kidneys on us
- often due to REFLUX - rec pyelonephritis
- also long term analgesia, gn, ischaemia, metabolic (uric acid, myeloma, high ca), toxins (heavy metals), sarcoid
T: identify and correct cause
- corticosteroids
- dialysis
renal vein thrombosis treat
warfarin 3-6months (inr 2-3)
eGFR
variables:CAGE
creatinine, age, gender, ethnicity
if over 60 need other evidence of kidney disease
under 15 is end stage renal failure
need for dialysis
30% GN 20% TIN (tubulo-interstitial nephritis) 10% PKD 10% DM 10% HTN/RV
Glomerulonephritis
type of intrinsic renal injury
- may be chronic or rapid deter
- can present w nephrotic, nephritic, AKI,
- or just solitary protein/haemat
- nephritic/acute renal fail - IgA, post infec, vasculit, goodpast
- nephrotic synd - minimal ch, membranous, fsgs, mesangio
may be multisystem illness
diag by biopsy
ANCA (weg), C3/4, ANF (sle), antiBM (goodpast)
tx: steroid and immuno supp ace vs bp diuretic vs oedema statin, anticoag 30% of dialysis patients
Types of glomerularnephritis
Non proliferative (generally nephrotic)
- minimal change
- FSGS
- membranous (can also be nephritic)
- thin basement (just micro haemat)
Proliferative
- IgA
- post infectious
- rapid progressive
- membranoprolif / mesangiocapil (can be nephrotic)
comps of diabetes
vascular eg cvd, pvd nephropathy -microalbuminaemia indicates early disease -ace or arb good retinopathy neuropathy
diabetic retinopathy
aspirin good
- cap changes
- microaneurysm (dots)
- occlusion (cotton wool spots)
- ischaemia
neoproliferation of vessels - bleeding and fibrosis
- hemorrahge (blots)
- risk of detachment
Nephrotic Syndrome
TRIADS
proteinuria
hypoalbumin
oedema (due to low protein and high sodium)
HYPERLIPID (check cholesterol)
INFECTION (IgG loss)
CLOTTING (lose antithrombin iii, protein c and protein s)
- sudden deterio in renal func, pain, haemat - think renal ven thrombosis
cause: GN 75%
- also DM, amyloid,
proteinuria
shown by dipstick
can be raised in exercise, fever etc
follow up
- 24 hr urine collection
- Bence Jones test if rel
- biopsy if heavy
microalbunaemia: early DM nephro
RBC casts: GN –> biopsy
ANF, ANCA: wegen, SLE
Nephritic syndrome
triad of
- haematuria, casts
- oliguria
- htn
often overlapping w acute renal failure
associated w proliferative types of GN
- IgA, post-infec, rapid Prog
Minimal Change GN
Nephrotic synd in kids/young adults
Minimal change on biopsy, immunology
(foot processes fused)
Doesn’t progress
Membranous GN
Mainly nephrotic but can be nephritic
diffuse thickening w IgG C3
2/3 autoimmune
Otherwise
- malignancy
- penicillamine
- malaria
- hep b
- sle
1/3 remit
1/3 stable CKD
1/3 progress to ESRF
focal segment glomerulosclerosis
scarring
generally progresses to ESFR
secondary to
- alports
- heroin
- HIV
- sickle
- reflux
Alports
x linked dominant
20% spontaneous
childhood GN (due to abn BM) - haemat, failure
DEAFNESS and eye probs
renal transplant failure
need dialysis by 20’s
Thin basement GN
Genetic - autosomal dominant
Often no nephritic or nephrotic
- just microscopic haematuria
Benign course - good prognosis
Nephrotic syndrome treatments
low Na intake (vs oedema)
diuretic vs oedema
ACE vs proteinuria
statin vs hyperlipid
anticoag if immobile
steroid + immunosupp
IgA nephropathy
aka BERGERS
Most common type of GN
Proliferative, w IgA deposits
Nephritic
Self resolving, benign course
Young adults within days of resp infection
Can devel Henoch Schonlein in kids
- see purpuric rash
Henoch Schonlein (IgA)
purp rash
polyarthritis
abdo pain
nephropathy
Post-infectious
1-4 weeks post infection
- classical strep pyog throat
‘Smoky brown urine’
Good prognosis in kids
In adults can progress
Mesangiocap GN (aka membranoproliferative)
Unlike most proliferative gn this is more nephrotic
Tramline, large glomerular membrane
Causes include SLE and hepatitis
Rapid progressive GN
Also called crescenteric
Poor prognosis - devel quickly to ESRF
Can devel from
- IgA, post infectious
- goodpastures
- sle
- wegeners
Goodpastures
= anti BM disease
renal failure and pulmonary hemorrhage (haemoptysis)
system unwell
antiBM antibodies
t: plasmaphoresis (remove ab’s)
pred, cyclophosph
Vasculitides
wegeners (small vessel)
- lungs and kidneys
- haemop and nosebleeds
- GN/ renal fail
- ANCA (cANCA)
microscopic polyangitis (small vessel)
- kidneys, skin, neuro (myalgia)
- ANCA (pANCA)
- t: pred and cyclophosph
pan (medium vessel)
- non specific - wl, fever, malaise
- then skin, heart, kidney, neuro
- pANCA
- t: immunosupp
churg-strauss doesnt affect kidney
- asthma
henoch scholein
- ?post infection
- malaise, arthralg, abdo pain
- purpuric rash on extensors
- some renal involve
Wegeners
GN - renal failure
saddle nose
haemoptysis, nosebleeds
ANCA (esp cANCA)
t: steroid, cyclophosphamide
T1DM
juvenile onset generally
insulin defic due to autoimmune destruc of panc
Polyuria/dispia, infections, weight loss
Prone to ketoacidosis and wl
DISH
T2DM mgmt
lifestyle
statin, bp control
metformin (GI upset)
glicazide - sulfonyl (hypo, wg, siadh)
?insulin
?glitazone (fluid retention, liver, bone)
?exenatide GOOD FOR WEIGHT LOSS
t2dm
older onset asian men obesity etc strong genetic component - dec insulin secretion
comps of diabetes
vascular eg cvd, pvd nephropathy -microalbumin aemia indicates early disease -ace or arb good retinopathy neuropathy
HONK
hyperglycaemic crisis (may be >50) - sodium will aslo be raised (>160)
- do not see acidosis
precip by infection, mi etc
- > thirst, polurai
- -> hyperviscosity - thrombosis (ha, visual)
high mortality
T as per dka
- fluid + K
- insulin
MODY
type 2 under 25 years
autosomal dominant
dont see ketosis
diabetic retinopathy
aspirin good
- cap changes
- microaneurysm (dots)
- occlusion (cotton wool spots)
- ishcaemia
neoproliferation of vessels - bleeding and fibrosis
- hemorrahge (blots)
- risk of detachment
diabetic foot
NEUROPATHY low sensation in stocking distrib absent knee jerks deformity - charcot
ISCHAEMIA
?pulse
ulcers - painless and punched out
treat fungal infec
diab neuropathy
numbness pain tingle
glove and stocking
worse at night
duloxetine first line
amitriptyline
pregabalin
diabetes target blood pressure
no organ damage 140,80
end organ damge 130,80
ACE inhib
SIADH - retaining to much fluid
hyponatraemia
concentrated urine
drugs - ssri, tca, carbamez, cyclophosph
malig, pnaeumonia, tb, neuro
UTI
urethritis, prostatitis, cystitis
(frequency, dysuria, smelly, fever, ?abdo pain)
- may get haematuria in cystitis
-may get back ache, flu in prostatitis
–> pyelonephritis (see fever+, rigors, pain+, ?oliguria)
obstruction is big risk factor
are there voiding probs? retention?
test renal function, consider US
recurrent: do cystoscopy
preventing UTI
fluid intake
cranberry juice
urinate often
wiping, voiding post sex
preventing renal stones
good fluid intake
protein diet and thiazides increase Ca - so avoid
allopurinol if prone to urate stones
rhubbarb, spinach increase oxalate
vit B6 reduces oxalate
cystein - alkalinize urine
phosphate - acidify urine
secondary htn
RENAL 80%
gn, pyelo, cystic, stenosis
ENDOCRINE cush (cortisol), conn (aldosterone), congen adren hyp, phaeo, acromeg hyperparathyroid PREGNANCY
VASCULAR
- coarctation
- renal artery stenosis
alcohol
rare: MAO-i (depression) with cheese
renal stones
pain +++ loin to groin
haematuria
inc risk with
- low fluid intake high ca intake
- hyperparathyroid
- recurrent UTI’s (struvite)
Ix: abdo xray/ KUB xray IVU 24hr urine (for chemistry of stone) fbc and urine (UTI?) renal US and UE's
mx: analgesia (opioid) and fluid
? alpha blocker can help pass stone
?Abx
if >5mm need lithotripsy (ECWL or PCNL)
respiratory acid and alkalosis
Resp Acid
- hypoventilation
copd, nm, sedation
Resp Alk
- hyperventilation
panic, PE
types of renal stone
80% ca oxalate
15% struvite (infection, esp protease) - staghorn
10% uric acid (LUCENT)
rarer: cystein (semi-lucent), xanthine (lucent or semi)
Hypokalaemia <3.5
diuretic aldost excess (conns and cushings) vom, diarr insulin salbutamol
ecg: U (wave after T), flat T, tall P, long PR
tx: KCl (w/ or w/out fluid)
hyperkalaemia >5.5
low aldost - addison spironalactone/amiloride ace-i haemolysis acidosis
ecg: tall t, falt p, wide qrs
tx: ca gluconate, insulin glucose, calcium resonium
hyponatraemia <135
what is the volume status?
hypervolaemic
- hf, liver, kidney fail
normovol
- SIADH - fluid reten (high urinary Na)
(SqLC, pneumonia etc, CNS trauma/infec)
hypovol
- dehydr, vom, diarr, burns (low urinary Na)
- these can also cause hypernat
- fluid lost from diuretics, addisons (high urinary Na)
hypernatraemia >145
give dextrose fluid
hypervol
- aldost excess (cushings, conns)
(give diuretics)
normovol
- diabetes insipidus - fluid loss, dilute urine
(adh defic or nephrogenic - Ca, Li)
hypovol
- burns, sweat, vom, diarr
- diuretics
- hyperglycaemia
Hypercalcaemia >2.6
bones moans (depres) groans (constip) stones
peptic ulcers
—> nephrogenic diabetes insipidus
80% primary hyperparathyroidism - PTH may be normal/rasied w Ca high - polyuria, polydip, weakness, vom - low phosphate = adnoma or hyperplasia of gland = can also be due to LITHIUM
20& malig
- consider if Ca high but PTH low
= myeloma of bone 2dry
= squam cell lc producing PTH-like protein
diabetes insipidus - pissing too much fluid
inappropriately dilute urine, large vol
cranial = ADH deficiency
nephrogenic
= hypercalcaemia
= lithium
T: desmopressin (also used in von willebrands, haemophilia)
Hypocalcaemia <2.1
tetany, seizures, qt elong
chvosteck (tap on facial nerve)
trousseau (bp cuff -> carpopedal spasm)
Urge incontinence
Overactive bladder
Anticholinergic tablet
Bladder retraining
tuberous sclerosis
rare auto dom
- intellect, epilepsy
- facial angiofibroma
- renal angiomyolipoma, malig
- harmartoma
VON HIPPEL LINDAU
autosomal dominant renal disorder
renal tumours
brain tumour - haemangioblastoma
adrenal tumou
- phaeo (htn, ha/sweat/tachy, trem,anxiety)
bph
v common over 60
smooth enlarged prostate
psa normal <4 ideally
do msu to rule out UTI
complications
- retention - may need self catheterisation
- infection
- stones
treatment
- ? self catheterise
1) alpha blocker - tamsulosin
2) 5alpha red inh - finasteride (anti androgen - causes erectile/libido probs)
2) surgery - resection or stenting/dilate
hyperprolactinaemia
galactorrhoea
bitemporal hemianopia
w: menstual prob, infertility
m: erectile dys
C: prolactinoma
- also stress, renal fail, PCOS
T of prolactinoma
1) dopamine agonists (shrink)
2) surgery and radio
prostatism history
voiding probs
- hesitancy/strian, poor flow, terminal dribble, pis en deux
storage probs
- urgency, frequency, nocturia, incontinence
any red flags - weight loss, bone pain, blood in urine
family history
medications
cause
- bph
- prostate cancer
bph
v common over 60
smooth enlarged prostate
psa normal <4 ideally
complications
- retention - may need self catheterisation
- infection
- stones
treatment 1) alpha blocker - tamsulosin 2) 5alpha red inh - finasteride (anti androgen - causes erectile/libido probs) Catheteristion Surgery - turp
prostate cancer
psa raised - over 10 is suspicious
- do TR US
- do TR punch biopsies
gives gleason score “3+4” means mainly stage 3 some 4 (5 is worst)
also use tnm staging - do ct
do cxr, bonescan and renal us to look for mets
treatment
- wait
- surgery - turp of total prostatectomy
- radio - external beam or brachytherapy
- gnrh analogue - goserelin - “zolidex 3m injections”
- newer anti androgen drugs
