Kidney

Question 0

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 ?

Answer 0

Acute renal infection ( pyelonephritis )

Question 1

Classic triad of loin pain, fever, and tenderness over the kidneys is the presentation of

Answer 1

Acute renal infection ( pyelonephritis )

Question 2

What are the DDx of acute pyelonephritis ?

Answer 2

Acute appendicitis
Diverticulitis
Cholecystitis
Salpingitis

Question 3

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 ?

Answer 3

Perinephric abscess

Question 4

What are the investigations that should be done in a patient with acute pyelonephritis ?

Answer 4

Urine routine : bacteria and neutrophils with typical clinical features confirms the diagnosis

Renal tract USS: excludes Perinephric collection and obstruction

Question 5

How do you manage an acute pyelonephritis patient ?

Answer 5

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

Question 6

What is acute pyelonephritis ?

Answer 6

Kidneys infected with UTI or bacteriuria

Question 7

What is renal colic ?

Answer 7

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

Question 8

Patient presents with acute loin pain radiating to the groin
With haematuria

What is the diagnosis ?

Answer 8

Typical features of ureteric obstruction most commonly due to calculi

Question 9

Most common type of renal stones contain ?

Answer 9

Calcium salts

Question 10

Second common renal stone is ?

Answer 10

Magnesium ammonium phosphate

Question 11

What type of renal stones are found in fairly small number ?

Answer 11

Pure cystine or Uric acid stones

Question 12

What is the most common location of stones , found in developing countries ?

Answer 12

Bladder stones

Question 13

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 ?

Answer 13

Impacted ureteric stone

Question 14

What are the investigations done for impacted ureteric stone patient ?

Answer 14

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

Question 15

How do you manage an impacted ureteric stone ?

Answer 15

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

Question 16

Indications for active intervention in impacted ureteric stone ?

Answer 16

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

Question 17

What is Polyuria ?

Answer 17

Inappropriately high urine volume of more than 3L/day

Question 18

What is nocturia ?

Answer 18

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

Question 19

What is the frequency ?

Answer 19

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

Question 20

What is urinary incontinence ?

Answer 20

Involuntary leakage of urine

Diuretics worsen incontinence

Question 21

How do you assess and what investigations should be done for excessive micturition ?

Answer 21

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

Question 22

What is stress incontinence ?

Answer 22

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

Question 23

What kind of therapy is best responded to , by women having incontinence?

Answer 23

physiotherapy

Question 24

In women with incontinence, what do you see on perineal inspection?

Answer 24

leakage of urine with coughs and sometimes also prolapse

Question 25

If incontinence persists, what should be the management ?

Answer 25

Surgical treatment is indicated

Question 26

What is urge incontinence?

Answer 26

Leakage usually occurs because of detrusor over-activity producing an increased bladder pressure which overcomes the urethral sphincter (motor urgency)

Question 27

Urgency with or without incontinence may also be due to ?

Answer 27

hypersensitive bladder (sensory urgency) resulting from UTI or bladder stone

Question 28

Diagnosis of urge incontinence is made by ?

Answer 28

Basis of symptoms after exclusion of urinary retention by bladder USS. Confirmed by urodynamic testing.

Question 29

How do you manage a patient with urge incontinence?

Answer 29

Bladder retraining, teaching patients to hold more urine voluntarily in their bladder, assisted by anticholinergic medication.

Question 30

What is overflow incontinence?

Answer 30

Occurs when the bladder becomes chronically over-distended

Question 31

Which kind of patients would present with overflow incontinence?

Answer 31

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

Question 32

In a patient with urge incontinence, what will be seen on the USS?

Answer 32

It reveals a significant post micturition volume (>100 ml)

Question 33

How do you manage a patient with urge incontinence?

Answer 33

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

Question 34

What is post micturition dribble?

Answer 34

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.

Question 35

What is oliguria?

Answer 35

Excretion of urine less than 300-500ml/day while the patient is on a normal diet.

Question 36

What is anuria?

Answer 36

Almost total absence of urine (<50ml/day)

Question 37

What is the significance of low measured urine volume?

Answer 37

Consequence of reduced production, obstruction to urine flow or both

Question 38

What is haematuria?

Answer 38

This indicates bleeding anywhere within the urinary tract and it maybe visible (macroscopic) or only detectable on urinalysis (microscopic)

Question 39

What is the most likely cause of macroscopic haematuria?

Answer 39

Tumors, severe infections and renal infarction

Question 40

How should you manage a patient with haematuria?

Answer 40

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

Question 41

What is proteinuria ?

Answer 41

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

Question 42

What is the normal amount of low molecular weight protein found in the urine ?

Answer 42

< 150mg/day

Question 43

Minor leakage of albumin could occur transiently following some conditions, what are they ? And how should it be dealt with ?

Answer 43

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

Question 44

What is the presentation of orthostatic proteinuria?

Answer 44

Positive daytime samples and negative morning samples | It is usually benign

Question 45

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)?

Answer 45

Indicates failure of reabsorption by damaged tubular cells (tubular proteinuria)

Question 46

What is the significance of heavy proteinuria ? And how do you manage it ?

Answer 46

Denotes an increase risk of progressive renal failure | Treating with drugs used to lower proteinuria such as ACE inhibitors also lowers this risk

Question 47

How do you investigate proteinuria?

Answer 47

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

Question 48

What is microalbuminuria?

Answer 48

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

Question 49

What is nephrotic syndrome?

Answer 49

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

Question 50

A patient presents with overt proteinuria (usually > 3.5 g/24 hrs - urine maybe frothy), Hypoalbuminaemia (

Answer 50

Nephrotic syndrome

Question 51

How will you manage a patient with nephrotic syndrome ?

Answer 51

``` Diuretics Low - Sodium diet Statins Anticoagulation Vaccination against infection ```

Question 52

What are the causes of Oedema?

Answer 52

Low plasma oncotic pressure Increased capillary permeability Increased hydrostatic pressure

Question 53

What are the possible reasons that can cause low plasma oncotic pressure?

Answer 53

Hypoalbuminaemia as seen in nephrotic syndrome Liver failure Malabsorption

Question 54

What are the possible reasons that can cause increased capillary permeability?

Answer 54

``` Infection Drug related (calcium channel blockers) ```

Question 55

What are the possible reasons that can cause increased hydrostatic pressure ?

Answer 55

``` high venous pressure/obstruction (CHF, DVT, Pelvic tumor) lymphatic obstruction (malignancy, radiation injury, congenital abnormality) ```

Question 56

What are the investigations in Oedema?

Answer 56

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

Question 57

How do you manage a patient with Oedema ?

Answer 57

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

Question 58

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?

Answer 58

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

Question 59

What is Acute renal failure?

Answer 59

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

Question 60

What are the causes of ARF?

Answer 60

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

Question 61

What is reversible pre-renal ARF?

Answer 61

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

Question 62

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?

Answer 62

Reversible pre-renal ARF

Question 63

What is the management of Reversible Pre-Renal ARF?

Answer 63

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