Kidney Flashcards
Patient presents with
- acute onset of pain in one/both loins which radiates to iliac fossa and supra public area
- associated lumbar tenderness and guarding
- dysuria due to associated cystitis
- fever with/ without rigors , vomiting and hypotension
- neutrophils , organisms , RBC and tubular epithelial cells in urine
What is the diagnosis ?
Acute renal infection ( pyelonephritis )
Classic triad of loin pain, fever, and tenderness over the kidneys is the presentation of
Acute renal infection ( pyelonephritis )
What are the DDx of acute pyelonephritis ?
Acute appendicitis
Diverticulitis
Cholecystitis
Salpingitis
Patient presents with marked tenderness and bulging of the loin on affected side
Patient is extremely ill with fever
Leukocytosis and positive blood cultures
Urinary symptoms are absent
Urine doesn’t contain pus cells or organisms
What is the diagnosis ?
Perinephric abscess
What are the investigations that should be done in a patient with acute pyelonephritis ?
Urine routine : bacteria and neutrophils with typical clinical features confirms the diagnosis
Renal tract USS: excludes Perinephric collection and obstruction
How do you manage an acute pyelonephritis patient ?
Adequate fluid intake , i.v if necessary
Antibiotics for 7-14 days
Severe cases require initial i.v therapy with cephalosporin , quinolone and gentamicin
Urine should be cultured before and after treatment
What is acute pyelonephritis ?
Kidneys infected with UTI or bacteriuria
What is renal colic ?
Acute loin pain radiating to the groin , testis or labium , in the first dermatome
Intensity steadily increases to reach a peak in few minutes
The patient may groan in agony
Patient presents with acute loin pain radiating to the groin
With haematuria
What is the diagnosis ?
Typical features of ureteric obstruction most commonly due to calculi
Most common type of renal stones contain ?
Calcium salts
Second common renal stone is ?
Magnesium ammonium phosphate
What type of renal stones are found in fairly small number ?
Pure cystine or Uric acid stones
What is the most common location of stones , found in developing countries ?
Bladder stones
Patient presents with renal colic , pallor , sweating , restlessness and often vomiting
Frequency , dysuria , and haematuria
Intense pain that usually subsides within 2 hrs but may continue for hours or days
Usually constant during attacks although slight fluctuations in severity may occur
Dull loin ache may follow
What is the diagnosis ?
Impacted ureteric stone
What are the investigations done for impacted ureteric stone patient ?
Urinalysis — shows red cells
Abdominal x-Ray — 90% stones are opaque
IVU — delayed excretion of contrast from kidney and dilated ureter down to the stone
USS and CT — more radiolucent stones
How do you manage an impacted ureteric stone ?
Bed rest and apply warmth to site of pain
Powerful analgesia — morphine 10-20 mg, pethidine 100 mg i.m , Diclofenac 100 mg
Fluid intake of 2 L / day
Indications for active intervention in impacted ureteric stone ?
More than 6 mm
Immediate action if Anuria or severe infection is present in the stagnant urine proximal to the stone (pyonephrosis)
Most stones are fragmented by extracorporeal shock wave lithotripsy
What is Polyuria ?
Inappropriately high urine volume of more than 3L/day
What is nocturia ?
Waking up at night to void urine
It maybe consequence of Polyuria
May also result from fluid intake or diuretic use in late evening
Also occurs in chronic kidney disease and in prostatic enlargement — associated with hesitancy , poor stream , incomplete bladder emptying , terminal dribbling and urinary frequency
What is the frequency ?
Micturition more often than patient expects
Maybe consequence of Polyuria
Often due to diuretic therapy
Also symptom of UTI when urine volume is low — associated with dysuria, urgency and feeling of incomplete emptying
What is urinary incontinence ?
Involuntary leakage of urine
Diuretics worsen incontinence
How do you assess and what investigations should be done for excessive micturition ?
Voiding diary
Assess cognitive function and mobility
Neurological assessment
Examine perineal sensation and anal sphincter tone — same sacral root supplies bladder and urethral sphincter
Inspect lumbar spine for spina bifida occulta features
Rectal examination to assess prostate in men
Urinalysis and culture in all patients
Assess post micturition volume
What is stress incontinence ?
Leakage occurs because passive bladder pressure exceeds the urethral pressure , due to either poor pelvic floor support or a weak urethral sphincter , often both
Common in women specially following child birth
Rare in men , following prostate surgery
What kind of therapy is best responded to , by women having incontinence?
physiotherapy
In women with incontinence, what do you see on perineal inspection?
leakage of urine with coughs and sometimes also prolapse
If incontinence persists, what should be the management ?
Surgical treatment is indicated
What is urge incontinence?
Leakage usually occurs because of detrusor over-activity producing an increased bladder pressure which overcomes the urethral sphincter (motor urgency)
Urgency with or without incontinence may also be due to ?
hypersensitive bladder (sensory urgency) resulting from UTI or bladder stone
Diagnosis of urge incontinence is made by ?
Basis of symptoms after exclusion of urinary retention by bladder USS.
Confirmed by urodynamic testing.
How do you manage a patient with urge incontinence?
Bladder retraining, teaching patients to hold more urine voluntarily in their bladder, assisted by anticholinergic medication.
What is overflow incontinence?
Occurs when the bladder becomes chronically over-distended
Which kind of patients would present with overflow incontinence?
Most common in men with benign prostatic hyperplasia or bladder neck obstruction
May occur in both sex, due to detrusor muscle failure (atonic bladder)
Maybe idiopathic but more commonly as a result of pelvic nerve damage from surgery, trauma, or infection or from compression of the cauda equine from disc prolapse , trauma or tumor
In a patient with urge incontinence, what will be seen on the USS?
It reveals a significant post micturition volume (>100 ml)
How do you manage a patient with urge incontinence?
Obstructed bladders should be treated surgically
Unobstructed bladders need to be drained, preferably by intermittent self catheterization
Urodynamic testing helps in the clarification of the aetiology
What is post micturition dribble?
Commonly found in men
Due to small amount of urine becoming trapped in the U-bend of the bulbar urethra which leaks out when the patient moves
More pronounced if associated with urethral diverticulum or urethral stricture
May occur in females with urethral diverticulum, and mimics stress incontinence.
What is oliguria?
Excretion of urine less than 300-500ml/day while the patient is on a normal diet.
What is anuria?
Almost total absence of urine (<50ml/day)
What is the significance of low measured urine volume?
Consequence of reduced production, obstruction to urine flow or both
What is haematuria?
This indicates bleeding anywhere within the urinary tract and it maybe visible (macroscopic) or only detectable on urinalysis (microscopic)
What is the most likely cause of macroscopic haematuria?
Tumors, severe infections and renal infarction
How should you manage a patient with haematuria?
Haematuria on repeated dipsticks — exclude menstruation, infection and trauma — RBC confirmed on urine microscopy with infection absent on culture — do Renal imagine to exclude anatomical bleeder (renal USS, cystoscopy) — if anatomical lesion present then refer to urologist for full assessment, if no anatomical lesion then check for features of significant renal disease—- if present then consider renal biopsy, if absent keep for observation and do urine test, BP, creatine every 6-24 months
What is proteinuria ?
Usually asymptomatic.
Proteinuria is >2.5 g/day of protein in the Urine and indicates a glomerular source
While over 3.5 g/day is considered as nephrotic range.
Large amounts of protein in the urine make urine froth easily
What is the normal amount of low molecular weight protein found in the urine ?
< 150mg/day
Minor leakage of albumin could occur transiently following some conditions, what are they ? And how should it be dealt with ?
After vigorous exercise, during fever or UTI, and in heart failure , minor leakage of albumin is seen
Quantities do not reach nephrotic level and tests should be repeated once the stimulus is no longer present
What is the presentation of orthostatic proteinuria?
Positive daytime samples and negative morning samples
It is usually benign
What is the significance of low molecular weight proteins appearing in the urine in larger quantities than 150mg/day (rarely exceeding 1.5-2 g/24 hrs)?
Indicates failure of reabsorption by damaged tubular cells (tubular proteinuria)
What is the significance of heavy proteinuria ? And how do you manage it ?
Denotes an increase risk of progressive renal failure
Treating with drugs used to lower proteinuria such as ACE inhibitors also lowers this risk
How do you investigate proteinuria?
Proteinuria on repeated urine dipsticks —- quantity proteinuria —- substantial if more than 1.5 g/day —- consider renal biopsy
Proteinuria on repeated urine dipsticks — quantity proteinuria — insubstantial if < 1.5g/day — check for features of significant renal disease — if present then consider renal biopsy, if absent then keep under observation —- and do urine test, BP , creatinine every 6-24 months
What is microalbuminuria?
0.03 -0.3 g/day
Clear sign of glomerular abnormality and can identify very early glomerular disease (diabetic nephropathy)
Persistent microalbuminuria has also been associated with increased risk of atherosclerosis and cardiovascular mortality
What is nephrotic syndrome?
Describes the clinical consequences that occur when substantial amounts of protein are lost in the urine
Diseases that cause nephrotic syndrome always affects the glomerulus and tend to be non-inflammatory or subacute examples of glomerulonephritis
DM and amyloidosis also cause nephrotic syndrome
A patient presents with overt proteinuria (usually > 3.5 g/24 hrs - urine maybe frothy), Hypoalbuminaemia (
Nephrotic syndrome
How will you manage a patient with nephrotic syndrome ?
Diuretics Low - Sodium diet Statins Anticoagulation Vaccination against infection
What are the causes of Oedema?
Low plasma oncotic pressure
Increased capillary permeability
Increased hydrostatic pressure
What are the possible reasons that can cause low plasma oncotic pressure?
Hypoalbuminaemia as seen in nephrotic syndrome
Liver failure
Malabsorption
What are the possible reasons that can cause increased capillary permeability?
Infection Drug related (calcium channel blockers)
What are the possible reasons that can cause increased hydrostatic pressure ?
high venous pressure/obstruction (CHF, DVT, Pelvic tumor) lymphatic obstruction (malignancy, radiation injury, congenital abnormality)
What are the investigations in Oedema?
Cause is usually apparent from the history and examination of CVS and Abdomen combined with measurement of urinary protein and serum albumin level
If ascites or pleural effusion is present and diagnosis is difficult, then take the aspiration fluid and measure protein and glucose and microscopy for cells to clarify diagnosis
How do you manage a patient with Oedema ?
Treat specific causes
Restrict sodium in generalized oedema
Mild fluid retention responds to a diuretic such as thiazide or low dose furosemide or bumetanide
In nephrotic syndrome , renal failure and severe cardiac failure, very large doses of diuretics sometimes in combination maybe required
Hypertension is a very common feature of what kind of kidney diseases and why is it very important to control in these kind of patients?
Renal parenchymal and vascular disease and is an early feature of glomerular disorders.
As GFR declines, hypertension becomes increasingly regardless of renal diagnosis
Control of hypertension is very important due to further decline leading to adverse cardiovascular risk in renal disease
What is Acute renal failure?
ARF refers to sudden and usually reversible loss of renal function
Develops over a period of days or weeks and is usually accompanied by a reduction in urine volume
Frequently multifactorial
If cause cannot be rapidly corrected and renal function restored, then temporary renal replacement therapy maybe required
What are the causes of ARF?
Pre-renal causes such as systemic blood or fluid loss, or local diseases affecting arterioles
Intrinsic renal disease such as Acute tubular necrosis , Glomerular disease , Interstitial disease
Post-renal causes such as Obstruction
What is reversible pre-renal ARF?
Due to hemodynamic disturbances , it can initialy produce acute renal dysfunction that has the potential to be rapidly reversed, prompt recognition and treatment are important
A patient presents with hypotension (with signs of poor peripheral perfusion which maybe absent if taking NSAIDs or ACEI), Postural hypotension (>20/10 mmHg from lying to standing — useful early sign of hypovolemia), Metabolic acidosis and hyperkalemia are present, The person doesn’t show any obvious cause of renal hypoperfusion (may have concealed blood loss following trauma or into pregnant uterus, also large volume of intravascular fluid maybe lost following injuries and burns and in severe inflammatory skin diseases or sepsis)
What is the diagnosis?
Reversible pre-renal ARF
What is the management of Reversible Pre-Renal ARF?
Establish and correct underlying cause
If hypovolaemia is present , then restore blood volume as rapidly as possible with blood , plasma or isotonic saline 0.9% depending on what was lost
Optimise systemic haemodynamics
Correct metabolic acidosis - restoration of blood volume will correct acidosis by restoring kidney function — Isotonic Sodium Bicarbonate maybe used
