kidney disorders - renal 4 Flashcards
what is obstructive uropathy?
Obstructive uropathy is blockage of urinary flow
It can affect one or both kidneys depending on the level of obstruction
The obstruction may occur suddenly or develop slowly over days, weeks or even months
An “upper” obstruction i.e. ureter or above e.g. kidney stones
A “lower” obstruction i.e. ureter or below e.g. BPH
Obstruction to the kidneys can result in a condition called hydronephrosis which can cause renal failure.
what is hydronephrosis?
obstruction of urine flow (upper and lower)
Obstruction: urine backs eventually reaching the small tubes of the kidney and collecting in the renal pelvis
This results in swelling of the kidney and appear distended = hydronephrosis
how can infection in the kidney occur?
An infection may develop in the kidneys as the bacteria are not being flushed out
if both kidneys are obstructed what can it cause?
If both kidneys are obstructed it may lead to AKI or even CKD
what are the causes of obstructive uropathy? (children and young adults and older adults)
The most common causes of obstructive uropathy differ by age:
Children: structural abnormalities
Young adults: stones in the kidney, ureter or elsewhere in the urinary tract
Older adults: benign prostatic hyperplasia, prostate cancer, retroperitoneal or pelvic tumours and calculi
Other possible causes include:
Polyps in the ureter
Tumour in or near the ureter
Disorders of the muscles/nerves in the ureter or bladder
Formation of scar tissue in or around ureter
what is the symptoms of obstructive uropathy?
Depends on the cause, location and duration of the obstruction
If kidney distended, renal colic can develop
If obstruction related to BPH: hesitancy, frequency, nocturia, terminal dribbling or bladder discomfort occur (voiding and storage problems)
If a urinary tract infection has developed patients may have pus or blood in urine, fever and discomfort in the area of the bladder of kidneys
what is the diagnosis method for obstructive uropathy?
Imaging tests
- ultrasound of the bladder will tell us the volume of urine retained in the bladder. If
patient is in severe retention then a catheter will be inserted
- ultrasound of the kidneys will tell us if hydronephrosis is present
- CT scan can pick up renal stones
Endoscopy
- a camera can be used to examine the urethra, prostate, bladder, ureters or kidneys to
identify sites of obstruction
Blood and urine tests
- bloods may reveal high urea or creatinine levels - urine may reveal high WBCs
what is the treatment for obstructive uropathy?
Aim is to relieve the cause of the obstruction
BPH or prostate cancer: medications or surgery
Hydronephrosis: nephrostomy tube or ureteral stent
Renal calculi (stones): removal
what is renal calculi?
stone
Stones are common among middle-aged/older adults (aged 20-40)
More common amongst men (15% men and 5% women)
Vary in size
Staghorn!
Begin to form in a kidney and may enlarge in a ureter or the bladder
Kidney or ureteral or bladder stone
what are the types of renal calculi?
Calcium oxalate
- Most common (70%) - Made up of calcium and oxalate - Oxalate = waste product of food; sticks to calcium - Dehydration/high protein diet/high oxalate diet/medical conditions
Urate/uric acid stones
- Result of hyperuricaemia and/or when urine is too acidic - High protein diet but not the only cause
Cystine stones
- Made up of cystine (naturally occurring) - Rare - Genetic disorder that causes cysteine to leak from kidneys to urine
Infection stones
- AKA struvite stones - Made up of minerals e.g. magnesium, ammonium and phosphate - Happens when there is a urinary tract infection
what are the causes of stones?
May form if the urine is too saturated with salts or if the urine lacks the normal inhibitors for stone formation e.g. citrate Hyperparathyroidism Dehydration Renal tubular acidosis Diet high in animal-source protein or vitamin C Family history of stone formation Bariatric surgery Rarely drugs
what is the symptoms of stone?
Tiny stones may not cause any symptoms
Bladder stones may cause lower abdomen pain
Ureter or renal pelvis stones may cause back pain or renal colic
Nausea and vomiting
Sweating
Blood or a stone/piece of stone in the urine
Infection signs e.g. chills, fever, dysuria, cloudy urine, foul-smelling urine and abdominal swelling
what is the diagnosis methods for stones?
Symptoms (as above)
Urinalysis will pick up on the presence of blood or pus in the urine
X-ray not very accurate and will only pick up calcium stones
Intravenous urogram the dye will be able to determine the degree of blockage and the
location BUT risky due to the dye’s potential to worsen kidney failure or cause an allergic reaction. Not preferred
CT scan can locate the stone and indicate the degree to which the stone is blocking the urinary tract. Preferred.
what is the treatment for stones?
Manage the symptoms
- paracetamol is a safe option - NSAIDs or opioids but be careful of both due to potentially reduced renal function - anti-emetics e.g. cyclizine or metoclopramide
Remove the stones
- non-invasive removal - invasive removal
what are nin invasive management for stones?
Increase fluid intake (orally or IV) to encourage the smaller stones to be flush out
Alpha-adrenergic blockers e.g. tamsulosin can be used to relax the smooth muscle of the ureter and allow stones to pass
Penicillamine can be used to dissolve cystine stones
Extracorporeal shock wave lithotripsy (ESWL) use of sound waves to shatter the stones into tiny so that they can then be flushed out
what are invasive managment for stones?
Ureteroscope small viewing telescope inserted into the urethra and through the bladder to remove small stones in the lower part of the ureter
Percutaneous nephrolithotomy (PCNL) small incision into the back and a probe is inserted through the nephroscope to break the stone into smaller pieces
Open surgery rare and only used if there’s a very large stone or abnormal anatomy
what are infections ?
Caused by the presence and multiplication of microorganisms in the urinary tract
Incidence increases with age for both genders
Incidence higher in women due to shorter urethra
Incidence increases in men over the age of 40 years due to BPH
Most infections in adult men are complicated and related to abnormalities of the urinary tract
Bacteria usually enter via the urethra and will ascend up the urinary tract
Bacteria can enter via bloodstream
Main organism from bowel flora
A urinary tract infection (UTI) is an infection in any part of your urinary system
- what are the 5 ?
- acute and chronic pyelonephritis
- cystitis
- urethritis
- epididymitis
- prostatitis
what is the most common bacteria which causes UTI?
UTIs are usually caused by bacteria from the GIT
Escherichia coli responsible for 80-90% of infections in the community
Choice of antibiotic is determined by the organism and sensitivity data
what are the symptoms of UTI?
Increase in urinary frequency, urgency and/or strangury Dysuria Offensive smelling & cloudy urine Haematuria and/or pus in the urine Constant lower abdominal ache Nausea, tiredness and cold sweats Urge incontinence Asymptomatic UTI only needs treatment in pregnant women as it can lead to developmental delay, cerebral palsy or foetal death.
what are the complications of UTI?
Ascending infection can lead to pyelonephritis
Renal failure, especially in the elderly
Sepsis (medical emergency)
Can lead to permanent damage to the kidneys (especially if patient develops hydronephrosis)
Can lead to infection stones
What are the treatment for uti?
Hydrate or rehydrate patient
Primary care will often suggest treatments to alkalinise the urine e.g. potassium citrate solution or cranberry juice
Ensure all patients are advised to seek medical attention if a high fever develops or patient becomes systemically unwell
Antibiotics prescribed only if patient is symptomatic
Acute cystitis: usually trimethoprim or nitrofurantoin for 3 day
Prostatitis: usually trimethoprim, doxycycline or ciprofloxacin for 2-4 weeks
Treatment dictated by antimicrobial sensitivities (not always available in primary care)
what is acute pyelonephritis
Sudden and severe infection
Can result in the kidneys swelling causing permanent damage
Can be life-threatening
Infection within the renal pelvis, usually accompanied by infection within the renal parenchyma
Any problem that interrupts the normal flow of urine causes a greater risk of acute pyelonephritis
More common in women due to shorter urethra
Main antimicrobial = E. coli point of entry being the urethra
Antibiotics co-amoxiclav but may differ depending on local resistance pattern
what is the risk factors for acute pyelonphritis?
Chronic kidney stones Older adults Immunocompromised patients Vesicoureteral reflux BPH Diabetes Pregnancy Catheter use Urinary tract surgery Nerve or spinal cord damage
what is chronic pyenlophritis?
Recurrent acute pyelonephritis
Often asymptomatic
Infection within the renal pelvis, usually accompanied by infection within the renal parenchyma
Renal pelvis has no natural defence against bacteria
Main antimicrobial = Pseudomonas
Patients may present with proteinuria, hypertension or UTI
These patients need regular monitoring
May be due to structural abnormalities in children so they may require surgery
If a patient is symptomatic antibiotics as per sensitivities
what is the compications with chronic pyenolophritis?
Progressive renal scarring Hydronephrosis CKD Secondary hypertension Pyonephrosis Focal Segmental Glomerulosclerosis (FSGS)
what is polycystic kidney disease?
Mainly inherited kidney disorder
Most common inherited renal disease and the fourth leading cause of kidney failure
Can be acquired in patients who already have kidney failure or are on dialysis
Causes fluid-filled cysts to form in the kidneys
May impair kidney function and eventually cause kidney failure
People with PKD may also develop cysts in the liver and other complications
Kidneys can become 2-3 times enlarged
what are the symptoms of PKD?
Many people live with PKD for year without experiencing symptoms Symptoms include: - pain or tenderness in abdomen and/or back - haematuria - frequent urination - UTIs and/or kidney stones - fatigue - joint pain - skin that bruises easily - pale skin colour
what are the treatments for PKD ?
Tolvaptan
- NICE approved Oct 2015
- slows the progression of cyst development and helps protect renal function
- significantly delays the need for dialysis or a kidney transplant
- patients need regular review and prescriber need specialist training prior to
prescribing
what is autoimmune disease?
Autoimmune diseases is when the immune system creates antibodies or immunoglobulins that attack the body itself
Systemic lupus erythematosus (SLE) affects many parts of the body, including the kidneys = lupus nephritis
Goodpasture Syndrome results from antibodies that specifically target the lungs and kidneys Immunoglobulin A (IgA) nephropathy results when IgA forms deposits in the glomeruli causing inflammation
= GLOMERULONEPHRITIS
what is Glomerulonephritis
treatment
Inflammation of the glomeruli
Caused by autoimmune or non-autoimmune diseases
Can lead to kidney failure
ACEIs or ARBs needed to manage the high blood pressure
Most patients will be on high dose immunosuppressants such as corticosteroids, mycophenolate or cyclophosphamide
A lot of patients will undergo plasma exchange which involves replacing their plasma with donated plasma that contains no antibodies
If kidney failure occurs a lot of patients will need to have dialysis and eventually will be added to the kidney transplant list
what is nephrotic syndrome?
treatment
Nephrotic is the result of glomerulonephritis
Damage to the glomeruli causes proteins to leave the blood, be passed into the tubules with the filtrate and enter the urine
More than 3g of protein can leak through per day
Characterised by proteinuria, low levels of protein in blood and oedema, particularly around the eyes/feet/hands
Treatment = diet modification, blood pressure control and immunosuppressants for the glomerulonephritis Outcome = dialysis and eventually transplant
