Genitourinary Flashcards
Define AKI
Rapid decline in renal excretory function over hours or days recognised by a rise in urea and creatinine
What is the KDIGO grading for AKI?
Stage 1 - Increase by >/=1.5 but < 2 X baseline creatinine or an increase >26micromol/L in 48 hours
Stage 2 - Serum creatinine > 2 - 2.9 X baseline
Stage 3 - Serum creatinine > 3 X baseline or > 354 micromols/L
Give some examples of causes of pre-renal, renal and post-renal disease?
Pre-renal: Circulatory failure and hypo perfusion (Renal artery stenosis, hypovolaemia due to blood loss or inadequate fluids, cirrhosis or heart failure)
Renal: Gentamicin, ischaemic ATN, nephrotoxic ATN, glomerulonephritis, interstitial nephritis
Post-renal: Renal papillary necrosis, LN compression, prostate Ca, cervical Ca, urethral strictures, kidney stones
What are the absolute indications for dialysis?
Refractory potassium >/=6.5
Refractory pulmonary oedema
What are some management options in patients with anaemia in CKD?
Darbepoietin alfa - EPO
Alfacalcidol - Inc vit D to inc Ca
Phosphate binders (due to hyperphosphataemia)
Cincacalcet - to reduce PTH due to 2ndary HPTH
How would you classify CKD?
Stage 1 - > 90ml/min/1.73m^2 (normal or increased eGFR with evidence of some renal damage)
Stage 2 - 60-89 (slight decrease in eGFR with other evidence of kidney damage)
Stage 3 - 30-59 (moderate kidney disease)
Stage 4 - 15-29 (severe renal disease)
Stage 5 - < 15 (established renal failure)
What are some complications of CKD?
Anaemia
Renal bone disease (renal osteodystrophy)
CVD
Peripheral neuropathy
What characterises nephrItic syndrome?
GMB damage
HTN
Protein and blood in urine
Rapidly declining kidney function
Urinary sediment shows RED CELL CASTS, leucocytes, sub-nephrotic range proteinuria and dysmorphic red cells.
What triad characterises nephrOtic syndrome?
Proteinuria >3g/day Serum albumin < 25g/L Peripheral oedema Dyslipidaemia Loss of Ig - risk of infections. Loss of antithrombin III - risk of VTE
What is IgA nephropathy?
AKA Berger’s disease
Mesangial cell disease
Presents in 20s
Heavy proteinuria, visible haematura. HTN
Precipitated by synpharyngitis (upper respiratory tract infection)
May be secondary to coeliac or cirrhosis
What is the most common GN?
FSGN commonets in adults
Membranous
Mostly idiopathic, 10% secondary to malignancy
Nephrotic syndrome
Anti-phospholipase A2 receptor
Prone to thrombosis due to loss of anti-thrombin III in urine
IgG complexes and complement depositions on GBM
What is the commonest GN in children?
Minimal change disease I
Nephrotic syndrome
Fusion of foot processes
What causes rapidly progressive GN/ crescentic GN?
Lupus nephritis
HSP nephritis
ANCA vasculitis
Good pastures syndrome (anti-GBM)
What is transplant rejection?
When the body recognises cell surface proteins as ‘non-self’, blood group incompatibility, HLA incompatibility. T cell mediated or antibody mediated rejection.
How can you prevent transplant rejection?
Immunosuppression: Basiliximab - anti-IL-2 Tacrolimus - Calcineurin inhibitor Mycophenolate mofetil - inhibits T and B cell proliferation ± steroids - azathioprine, cyclosporin
What are the indications for renal replacement therapy?
AEIOU
Acidosis - severe and not responding to treatment
Electrolyte imbalance - severe and nor responding hypERkalaemia
Intoxication - overdose
Oedema - severe and not responding pulmonary oedema
Uraemia - seizures, reduced consciousness, uraemic pericarditis, encephalopathy
What symptoms characterise uraemic syndrome?
Itch, metallic taste, vomiting, restless legs, anorexia , weight loss
How does haemo-dialysis work?
Diffusion and pressure
Diffusion of solutes into dialyte solution - K and Urea
Filtration of fluid by hydrostatic pressure
What are some complications of haemodialysis?
Crash 'acute hypotension' Access problems Fatigue Air embolism Blood loss Hypokalaemia Cramps
How does Peritoneal dialysis work?
Diffusion and osmotic filtration
Uses the peritoneum to filter fluid. Dialysis solution is put into the peritoneum, it is high in glucose, it absorbs waste and extra fluid and then is removed.
Called Exchange
What are some complications of peritoneal dialysis?
Infections - peritonitis Development or worsening control of diabetes Hernia, dislodged catheter Encapsulating peritoneal sclerosis Hypoalbuminaemia Psychological effects
What other treatment would you need to give if a patient with kidney failure who is receiving dialysis?
Anaemia - EPO and iron
Renal bone disease - Phosphate binders, Vit D
Neuropathy
Endocrine
What are the types of Adult polycystic kidney disease?
PKD 1 - on chromosome 16 - rapidly progressive and leads to ESRD
PKD - on chromosome 4 - slowly progresses and will not usually reach ESRD
What causes PKD?
Polycyctins are over expressed in cysts
They are found in the renal tubular epithelium
They usually regulate IC calcium
Cysts gradually enlarge - increased pressure - normal kidney tissue replaced, kidney volume increased. eGFR drops.
How can PKD present?
Loin pain, HTN, impaired renal function, haematuria
Extra-renal:
Hepatic and pancreatic cysts, abdominal hernia, diverticular disease, bronchiectasis, LVH
What drug could you give in PKD before you eventually need to start RRT?
Tolvaptan - Vasopressin V2 receptor antagonist to increase urine output by blocking reabsorption of water
SE - hepatotoxic (monitor LFTs), hypernatraemia
What is Alport’s syndrome?
X-linked. Collagen 4 abnormalities
Deafness, eye problems and renal failure.
microscopic proteinuria, haematuria and ESRF
Sensorineural hearing loss in late childhood.
90% on dialysis or transplant by 40
What disease is due to alpha galactosidase 4 deficiency?
Fabry’s disease. X-linked
Accumulation of Gb3 in glomeruli and podocytes - proteinuria and ESRD
Check alpha-gal4 activity in leukocytes and renal biopsy for inclusion bodies of gb3
Replace enzyme
How might renal artery stenosis present?
Resistant to treatment
Flash pulmonary oedema
Worsened renal function with ACEi/ARB in bilateral stenosis
Increased bp
Give the pathogenesis of renovascular disease.
Progressive narrowing of the renal artery with atheroma
20% stenosis - GFR falls but oxygenation of cortex and medulla maintained
Stenosis at 70% and there is cortical hypoxia - microvascular damage and inflammation and oxidative pathways
Parenchymal inflammation and fibrosis progresses and becomes irreversible.
Give statin
AVOID ACEi/ARB
What is amyloidosis?
Nephrotic syndrome
A group of disorders characterised by EC deposits of insoluble proteins in abnormal fibrillar form and are resistant to degradation
8-10nm linear aggregated fibrils
What is primary amyloidosis?
AL amyloidosis.
Ig fragments from haematological conditions such as myeloma or monoclonal gammopathy of undetermined significance
Light chain can break off or bone marrow can produce excess light chain.
What organs can be damaged in AL amyloidosis? (amyloid light chain)
GI- malabsorption, hepatomegaly, N&V, diarrhoea
Purpura
Renal - proteinuria (frothy urine) and nephrotic syndrome
CV - restrictive cardiomyopathy, arrhythmias
Carpal tunnel and peripheral and autonomic neuropathy
What is secondary amyloidosis?
AA amyloid. Serum amyloid precursor protein
An acute phase reactant protein raised in chronic inflammation or infection - Crohns, RA, TB
Hepatospenomegaly, nephrotic syndrome
What is systemic lupus erythromatous?
A multisystem, inflammatory AI connective tissue disease where autoantibodies are formed agains a variety of autoantigens causing tissue damage.
What immunology is involved in SLE?
>95% ANA positive high dsDNA - renal involvement C3 and C4 low Anti-ribosomal - CNS involement Anti-phospholipid antibodies
What symptoms may be seen in SLE?
Butterfly rash, Photosensitive rash
Arthritis, pain and tenderness in prox IPJ, Pericartitis
Reynaud’s
Dry mouth and eyes
Seizures
Haemolytic anaemia, thrombocytopenia, PEs
Miscarriage, pre-eclampsia - antiphospholipid Ab
What treatment is used in mild SLE?
DMARD - Hydroxychloroquine
NSAIDs
Low dose corticosteroids - prednisolone
Aspirin
What treatment would you use for severe SLE?
DMARDs- Azathioprine, cyclophosphamide High dose corticosteroids Immunosuppressants Omeprazole Aspirin
What is Acute tubular necrosis?
Damage and necrosis of the epithelial cells of the renal tubules.
Due to hypo perfusion of the tubules ± direct toxicity
What might Acute tubular necrosis show on urinalysis?
Muddy brown casts
What is renal agenesis?
Congenital absence of the renal parenchymal tissue that occurs during the metanephric stage.
What is renal hypoplasia?
Reduction in the number of nephrons but normal kidney architecture
What defines a recurrent UTI?
More than 2 infections in 6 months or more than 3 in 12 months
What organisms can cause complicated and uncomplicated UTIs?
Uncomplicated: E.coli, klebsiella, proteus mirabilis (PM forms staghorn stones)
Complicated: E.coli, pseudomonas, klebsiella, staph, enterococci, proteus
What symptoms may indicate a lower UTI?
Increased frequency, urgency, dysuria, small voiding volume, feverish, suprapubic pain
What symptoms may indicate upper UTI?
Suprapubic tenderness, palpable bladder, renal angle tenderness, vomiting, rigors, fever
What antibiotics can you use in a UTI in a pregnant woman?
Fosfomycin 3g PO 1 dose
Amxocillin 500mg PO tdd 7d
Cefalexin 500mg PO bd 7d
What is Orchitis?
Inflammation of one or both testicles
What conditions are associated with urolithasis?
Gout, hyperparathyroidism
What is frank haematuria?
Dark red blood with clots
What is pseudo-haematuria?
Red or brown urine that is not secondary to the presence of Hb.
Rifampicin, methyldopa, vaginal bleeding, dyes -beetroot, myoglobin (rhabdomyolysis), hyperbilirubinaemia
What is Virchow’s triad? for renal cell Ca
Flank pain, haematuria, palpable abdominal mass
How might RCC present?
Respiratory symptoms if mets to lungs - Cannonball mets
Left varicoele
Lower limb oedema
Paraneoplasric syndrome
What paraneoplastic syndrome can occur in RCC?
Polycythaemia - increased EPO
Hypercalcaemia
Hypertension - increased renin
Stauffers syndrome - hepatotoxic tumour products
What are the types of RCC?
Clear cell - 85%
papillary
chromophobe
What is Von Hippel Lindau syndrome?
AD mutation inactivating the TSG on P53
Pheochromocytoma
Renal and pancreatic cysts
Cerebellar hemiangioma
What therapies can be used in bladder cancer?
NMIBC
TURBT - transurethral resection of bladder tumour
Mitomycin C - intravesicular chemotherapy - prevents recurrence
BCG therapy - intravesicular immunotherapy - prevents T1 to T2
MIBC
Radical cystectomy - removal of the bladder + prostate/uterus - ureters plugged into Neobladder (studier pouch from ileum) or ileal conduit
Radiotherapy ± chemo
What is the most common type of prostate cancer?
Adenocarcinoma of the peripheral zone
What genetic factors put you at an increased risk of prostate cancer?
BRCA 2, PTEN, TP53
Gleasons grading system
What are the red flags of prostate cancer that indicate mets?
Ureteric obstruction - May present with AKI
Hypercalcaemia- *SCLEROTIC bony mets - may present with bone pain
Spinal cord compression - may present off legs, severe pain, constipated, urinary retention
What are retractile testes?
Intermittent active cremasteric reflex retracts the testes most commonly into the external inguinal ring.
What complications can arise from undecided testes?
Reduced fertility
Increased risk of testicular cancer
Increased risk of testicular torsion
Increased risk of indirect inguinal hernia
What is testicular torsion?
When mobile testes rotate on the spermatic cord, leading to a reduction in arterial blood flow. There is reduce venous return and so venous obstruction, venous congenstion, increased pressure, arterial compression, irreversible ischaemia, necrosis
What types of testicular tumours are there and what is the most common?
Germ cell tumours (most common) - Seminoma, Teratoma, yolk sac
Non-germ cell - Interstitial/stromal cell tumours - leydig, sertoli. - other - lymphoma, metastatic
What tumour markers could indicate testicular cancer?
Alpha-fetoprotein - in yolk sac and teratoma (oncofoetal marker)
bHCG - in seminoma and teratoma (oncofoetal marker)
LDH - in seminoma
Where is AFP produced and what malignancies does it indicate?
Yolk sac
Liver, pancreas, testes, stomach
Benign hepatic disease
What produces bHCG and what malignancies is it associated with?
Syncitiotrophoblasts
Nearly all choriocarcinomas, 20% seminomas
Lung, pancreas, testes, stomach, breast, kidney, bladder
Hypogonadism
What organisms commonly form epididymitis?
Neisseria gonorrhoea
Chlamydia trachomatis
What can cause orchitis?
Mumps
What are risk factors for penile caner?
Smoking, HPV 16,18,21
What is erectile dysfunction?
The inability to achieve or maintain an erection satisfactory for sexual intercourse
What are some causes of erectile dysfunction?
Psychogenic - anxiety, depression
Drugs - antihypertensives, recreational drugs, alcohol
Vascular - atheroma, DM
Neurological - Parkinson’s disease, pelvic fracture
What treatment can you use in erectile dysfunction?
Oral phosphodiesterase - 5 inhibitors - Sildenafil (viagra)
What is priapism?
Abnormally sustained erection unrelated to sexual stimulation High flow (arterial) - Non-ischaemic Low flow (venous) - Ischaemic (EMERGENCY)
How might a fistula in ano present?
Knife like pain on defecation that feels like throbbing min-hours after. due to pelvic floor spasm Fresh blood on wiping.
How might an anal fissure present?
Sharp anal pain like cut glass, during and after (for ~45min) defecation. Some blood.
What is the most common cause of lower GI bleeding?
Diverticulosis
What are some causes of confusion?
Hypoxia, hypoglycaemia, bladder outflow obstruction - urinary retention, UTI, sepsis (infection), hepatic encephalopathy, stroke, hypercalcaemia, drugs/medication, dehydration, dementia, delirium
What triad may be seen in ulcerative colitis?
Abdominal pain, bloody diarrhoea, weight loss
What extra-intestinal signs can be seen in IBD?
A PIE SAC Apouthous ulcers Pyoderma gangrenous Iritis Erythema nodosum Sclerosing cholangitis Arhtritis Clubbing
What criteria is used to grade severity of ulcerative colitis?
Truelove and Witts
Mild - <4 bowel movement per day, small amount of blood mixed in with stool.
Moderate - 4-6 bowel movements per day with more blood mixed in
Severe - >6 bowel movements per day, visible blood in stool, anaemia, ESR>30, Pyrexial, HR > 90
Fulminant - > 10 stools per day, continuous blood in stool, anaemia, pyrexial, ESR > 30, HR >90
What criteria is used to know if you need urgent hospital admission in UC?
Severe colitis
Moderate disease that doesn’t response to steroids within 2 weeks
Partial treatment response should be seen urgently in OPS
List the possible complications of bowel dilation?
Toxic megacolon, Perforation, severe haemorrhage
What are the indications for surgery in UC?
Toxic megacolon, perforation, severe haemorrhage, failed medical therapy.
Panproctocolectomy, left with ileostomy or J pouch
What treatment options are available in UC?
Mainting remission in Mild-mod
1st line Mesalazine or sulfasalazine
2nd line - IV prednisolone or budesonide
3rd line - azathioprine or 6-mercaptopurine
4th line - biological agents - Anti-TNF - influximab, golimumab
5th - surgery
How does Mesalazine work?
Anti-inflammatory effect on the colonic epithelium
500mg given to maintain remission
SE - arthralgia, diarrhoea, cough, leucopenia
What are the side effects of immunomodulators azathioprine and 6-mercaptopurine?
Lymphoma, non-melanoma skin cancer
What are some Sx and signs of CKD?
Sx - Pruritis, breathlessness, Fatigue, joint/bone pain, leg swelling, confusion
Signs - Peripheral & pulmonary oedema, rash, HTN, tachycardia, pallor or lemon yellow tinge
What are some differences between acute and chronic retention?
Acute <24hr, can be due to GA, Alcohol, UTI, constipation, usually painful urgency, Normal U&Es, no incontinence, ~400-1000ml, when drained clear urine,
Chronic >24hr, painless, usually insidious, AKI with eGFR in single figures, strong Hx of LUTS and overflow incontinence, >1L, when drained haematuric due to decompression bleeding
What are some secondary causes of GN?
Myeloma, CLL, IBD, ALD, coeliac, amyloidosis. lupus, hepatitis, malaria, HIV, TB, NSAIDs, bisphosphonates
What is the staging in RCC?
T1a - <4cm, T1b - 4-7cm, T2 >7cm T3a - into renal vein T3b - into IVC below diaphragm T3c - IVC above diaphragm T4 - beyond gerotas fascia and/or adrenal gland
What is Prehns sign?
When you lift up the symptomatic side (testicle), if the pain is relieved then is shows a diagnosis of epididymitis, if the pain is worse or not relived is might be testicular torsion
What is the most common cause of nephrotic syndrome in adults?
Focal segmental glomerulosclerosis
Segmental scarring of certain glomeruli and fusion of podocyte foot processes
How might good pastures disease present?
Antibodies to GBM which is the same as in alveoli so nephritic syndrome and pulmonary haemorrhage - haemoptysis
IgG along BM
