Lectures - URGENT Flashcards
Give 4 kidney functions
Production of EPO, activation of 25(OH)2 vitamin D (into 1,25 dihydroxyvitamin D), renin production (BP control), secrete toxic substances, blood pH homeostasis
How much cardiac output do the kidneys receive?
20%
What are the stages of CKD in terms of eGFR?
1 (>90), 2 ( to help, all are multiples of 15
Why do you get anaemia and bone disease in renal failure?
Because there is reduced functioning of the kidney - i.e. reduced vitamin D activation
What does eGFR use in its calculation?
serum creatinine (+ height, age, gender, race)
why is serum creatinine used in eGFR calculations?
It is excreted by the liver fully
What drug affects creatinine excretion?
Trimethoprim
What are the causes of coloured urine?
Jaundice (haemoglobinuria), beeturia, myoglobinuria, drugs (rifampicin - orange wee)
What are normal physiological causes of haematuria?
Strenuous exercise and menstruation
What should you ask a patient in their history concerning haematuria?
Whether the blood is early on or late in their stream? pain? unilateral loin pain? bilateral loin pain? FHx of bladder cancer? occupation?
What does MSSU and MC&S stand for?
Mid-stream sample of urine and microscopy, culture and sensitivity
give causes of haematuria
Bladder cancer, BPH, prostate cancer, post TURP, UTI,
What is the total body water? What does this split into in the compartments?
42L: i.c. fluid (28L), interstitial fluid (11L) and plasma (3L)
What occurs to potassium in renal failure?
It isn’t excreted - it is retained –> hyperkalaemia
What 3 things should you look out for in a patient with renal failure?
Hyperkalaemia, acidosis and volume overload (salt and water retention)
Give 3 pre-renal causes of oliguria
dehydration, HF + shock, blood loss
Give a renal causes of oliguria
Acute tubular necrosis
Give a post-renal cause of oliguria
Obstruction (prostate cancer, BPH, stones)
How do shock and HF lead to oliguria?
Reduced kidney perfusion
Why does someone with volume overload become hypoxic?
Pulmonary oedema
What two signs might suggest a patient is fluid overloaded?
raised JVP and pitting oedema (+ ascites)
Give 5 causes of fluid loss
Burns, surgery + blood loss, nephropathy, diarrhoea, bowel obstruction, vomiting
What is the criteria for SIRS?
2 of:
- > 38 or 20
- pCO2 12000 or
What is the definition of sepsis?
SIRS + confirmed or suspected infection
What defines septic shock?
infection/sepsis with persistent hypotension
What is the most likely source of sepsis?
UTI
What is the treatment for sepsis?
SEPSIS 6: High flow 100% O2, IV fluid resuss, blood culture, IV Abx, serum lactate (+FBC + U+E), monitor urine output by putting in a catheter
When should you treat asymptomatic bacteruria?
If the patient is PREGNANT
Give 6 causes of urinary tract obstruction
Within the lumen: calculus, tumour (renal pelvis or ureter), blood clot, sloughed renal papillae
Within the wall: congenital abnormalities, stricture, neuropathic bladder
Outside: BPH, prostatic tumour, pelvic tumours, AAA
What is hydronephrosis?
Dilatation of renal pelvis + calyces
What does urinary tract obstruction lead to?
Inflammation, haemodynamic and functional changes to the kidney
What happens to the size of the kidney after prolonged obstruction of the urinary tract?
Enlarges? or shrinks?
What are the symptoms of an upper urinary tract obstruction?
Pain in the flank region, anuria (if bilateral obstruction)
What are the symptoms of lower urinary tract obstruction? (LUTS)
Terminal dribbling, hesitancy, poor stream , frequency, sense of incomplete emptying, retention with overflow, UTI
What signs might you find on examination for urinary tract obstruction?
Pelvic tumour, rectal exam (BPH or tumour), enlarged bladder, enlarged liver
What investigations might you order to investigate urinary tract obstruction?
Urine: dipstick, MC&S
Blood tests: FBC, U+E
Imaging: US, CT, XR
What might USS show in urinary tract obstruction?
Hydronephrosis
What is the 1st line treatment usually for urinary tract obstruction?
surgery
What is the 2nd line treatment usually for urinary tract obstruction?
Catheter
Who should you avoid NSAIDs in?
Renal insufficiency or GI bleeds
Why should NSAIDs be avoided in patient’s with renal insufficiency?
Because NSAIDs vasoconstrict the afferent arteriole of the nephron (they prevent the production of PG needed to dilate the afferent arteriole)
What is a risk after re-establishing urinary flow in patient with
Post-obstructive diuresis
What else might you do in the management of urinary obstruction?
Fluid resuscitation
What is the definition of haematuria?
> 3 RBCs/hpf (high powered field)
What bacteria can induce kidney stones?
proteus mirabilis
What predisposes to testicular torsion?
Bell clapper deformity (congenital)
What is the pathophysiology of testicular torsion?
Spermatic cord twists reducing the blood supply to the ipsilateral testis - ischaemia –> infarction (testicular loss)
What are the symptoms and signs of tesicular torsion>
Symptoms: sudden and severe pain, associated abdominal pain, nausea, vomiting, fever
Signs: 1 testis is swollen, tender, hot and has an absent cremesteric reflex
How would you treat testicular torsion?
Analgesia (morphine), anti-emetic (ondasetron)
Salvagable: surgerical detorsion
unsalvagable: orchidectomy
What is surgical removal of testis called?
Orchidectomy
What is an epididymal cyst?
A fluid filled sac of the epididymus
What are the symptoms and signs of an epididymal cyst?
Asymptomatic
signs: well defined + separate lump from the testis; transilluminates
How and why would you investigate a epididymal cyst?
USS - to rule out other lesions (e.g. cancer)
How would you treat an epididymal cyst?
No treatment
What differentiates epididymal cysts, hydrocoeale and varicocoeale from a testicular tumour?
Testicular tumour doesn’t transilluminate
What is a hydrocoeale?
Fluid within the TUNICA VAGINALIS
What are the causes of a hydrocoeale?
Primary: patent processus vaginalis
Secondary to: trauma, testicular cancer, infection (epididymo-orchitis), testicular torsion
What are the clinical features of a hydrocoeale?
scrotal swelling, pain only if infected, testis palpable within the hydrocoeale, transilluminates
What investigations would you carry out to diagnose a hydrocoeale and why?
To look for a cause:
- USS
- serum AFP and hCG
What is the treatment for a hydrocoaele?
aspiration or surgery
what is a varicocoaele?
Dilatation of pampiniform plexus veins
What side are varicocoaele more common on and why?
L side as the L testi drains into the L renal vein (backpressure from L renal vein)
What are the symptoms of a varicocoaele?
Dull ache, infertility
What would you feel on examination in someone with a varicocoaele?
“Bag of worms”
What complication is varicocoaele associated with?
Subfertility
What investigations might you carry out for a varicoale?
Sperm count
What is the treatment for varicocoeale?
If pain –> ablation/embolisation or surgery
Sperm bank
tight fitting + supportive underwear
If you’re unsure of a diagnosis of testicular torsion what investigation would you do?
Doppler USS - shows lack of blood flow to the testicle
What are the two types of lower urinary tract symptoms?
Storage and voiding symptoms
What are the storage lower urinary tract symptoms?
Frequency, urgency, nocturia, overflow incontinence
What are the voiding lower urinary tract symptoms?
Terminal dribbling, hesitancy, poor stream/flow, inadequate emptying, straining
What are lower urinary tract symptoms caused by?
Obstruction (BPH)
What is the differential diagnosis of BPH?
Prostatic cancer, stone, prostatitis, overactive bladder, bladder cancer…
Which part of the prostate does BPH first affect?
transitional zone
What are the red flag symptoms of prostatic tumour that distinguish it from BPH?
Back pain, haematuria, weight loss
What assessment is used to determine the impact symptoms of BPH have on someone’s quality of life?
IPSS - international prostate scoring system
What are the 3 zones in the prostate? Which does BPH and prostatic cancer affect more?
Transitional (inner) zone (BPH), central zone, peripheral zone (Cancer)
Describe the pathophysiology of BPH
5-alpha reductase converts testosterone into its active form: DHA. DHA stimulates hyperplasia of prostatic cells
What is the definition of hyperplasia?
Enlargement of a tissue due to increase in the number of cells
What are the symptoms of BPH?
LUTS (nocturia, hesitency, terminal dribbling, frequency, urgency, incomplete emptying of the bladder)
What examination would you perform on a patient (older male) who comes in with LUTS? What would you find if the cause was BPH and prostatic cancer?
DRE:
- BPH –> smooth enlarged prostate
- Prostatic cancer: craggy, hard and nodular enlarged prostate
What are the signs of BPH?
DRE –> smooth enlarged prostate
What investigations would you carry out to diagnose BPH?
PSA, MSU/dipstick, U+E (kidney function), cystoscopy (LUT endoscopy), TRUSS
What diseases are PSA levels raised in?
BPH, prostatic cancer, prostatitis
What is the conservative management for BPH?
Reduce coffee + alcohol intake
Change diuretic to another anti-hypertensive
What is the medical management of BPH
Alpha blockers
Give an example of an alpha blocker. What are the side effects of alpha blockers?
Doxazosin
SEs: dry mouth, hypotension, drowsy, ejaculatory failure
Give an example of a 5-alpha reductase inhibitor. What are the side effects?
Finasteride
SEs: decreased labido, ED
What are the surgical treatments for BPH?
TURP (TULIP + TUIP)
What are the complications of TURP?
TUR syndrome, haemorrhage, infection, sepsis, ED, incontinence
What are the indications for surgery to correct
RUSHES:
- Retention
- UTIs
- Stones
- Haematuria
- elevated creatinine
