Nephro and uro Flashcards
Methods of removing potassium from the body? [3]
calcium resonium (orally or enema)
loop diuretics
dialysis
which method of potassium removal is most effective?
calcium resonium enemas are more effective than oral as potassium is secreted by the rectum
what is the serum creatinine increase in stage 1 AKI?
Increase 1.5-1.9x baseline
what is the serum creatinine increase in stage 2 AKI?
Increase 2.0-2.9x baseline
what is the serum creatinine increase in stage 3 AKI? [2]
Increase > 3x baseline or >354 µmol/L
what is the urine production in stage 1 AKI?
< 0.5ml/kg/h for >6 consecutive hours
what is the urine production in stage 2 AKI?
< 0.5ml/kg/h for >12 consecutive hours
what is the urine production in stage 3 AKI?
< 0.3ml/kg/h for > 24h or anuric for 12h
which condition presents with a triad of fever, arthralgia and rash
acute interstitial nephritis
drug causes of acute interstitial nephritis [5]
penicillin
rifampicin
NSAIDs
allopurinol
furosemide
how much water is replaced in maintenance fluids? adults
25-30 ml/kg/day of water
how much potassium, sodium and chloride is replaced in maintenance fluids?
approximately 1 mmol/kg/day of potassium, sodium and chloride
how much glucose is replaced in maintenance fluids?
approximately 50-100 g/day of glucose to limit starvation ketosis
in which patients should Hartmann’s not be used?
Hyperkalaemic patients
time frame for hyper acute graft rejection
how is this managed?
minutes to hours
removal of the graft
key investigation in acute interstitial nephritis
urinary white cell casts/eosinophils
how is maintenance fluid calculated for a child?
over 24 hours:
100ml/kg for first 10
50ml/kg for next 10
20ml/kg for every kg after
or 4/2/1 rule in ml/kg/hour
main investigation for APKD
USS
first line bloods in AKI caused by rhabdomyolysis
plasma creatine kinase
electrolyte abnormalities in rhabdomyolysis
high phosphate
low calcium
high potassium
what is the first line treatment of rhabdomyolysis
IV normal saline
not Hartmann’s as they are hyperkalaemic
which drug may be beneficial for a select patients of ADPCKD to slow down CKD disease progression?
Tolvaptan
V2 receptor antagonist
most sensitivity investigation for myasthenia gravis
single fibre electromyography
what is the tensilon test?
IV edrophonium reduces muscle weakness temporarily
- not commonly used any more due to the risk of cardiac arrhythmia
first line treatment for myasthenia gravis
pyridostigmine
(Acetylcholinesterase inhibitor)
eventually immunosuppression: prednisolone, azathioprine, cyclosporin
how high is CK compared to the upper limit in rhabdomyolysis
> 5 times i.e. significant elevation
Creatinine increase to diagnose AKI
> 26 in 48 hours
Creatinine increase in 7 days to diagnosis AKI
> 50%
describe the myoglobinuria
tea coloured, dark or reddish-brown
drugs to stop in AKI
Diuretics
Aminoglycosides, ACEi, ARBs
Metformin
NSAIDs
aspirin that is not a cardio protective dose i.e. 75mg
what is the urgent referral criteria for haematuria
Aged >= 45 years AND:
unexplained visible haematuria without urinary tract infection, or
visible haematuria that persists or recurs after successful treatment of urinary tract infection
Aged >= 60 years AND have unexplained nonvisible haematuria and either dysuria or a raised white cell count on a blood test
which blood test is used to find the cause of post streptococcal glomerulonephritis? [2]
anti streptolysin O titre
alongside a low C3
mechanism behind hyperacute graft rejection
due to pre-existing antibodies against ABO or HLA antigens
mechanism behind acute graft failure (<6m)
usually due to mismatched HLA. Cell-mediated (cytotoxic T cells)
mechanism behind chronic graft rejection
both antibody and cell-mediated mechanisms cause fibrosis to the transplanted kidney (chronic allograft nephropathy)
most common and important viral infection in solid organ transplant recipients
cytomegalovirus
reasons for failing to respond to EPO replacement
iron deficiency
inadequate dose
concurrent infection/inflammation
hyperparathyroid bone disease
aluminium toxicity
first line treatment of minimal change disease
prednisolone
causes of normal anion gap metabolic acidosis
Hyperalimentation
Addisons
RTA
Diarrhoea
Acetozolamide
Spironolactone
Saline
causes of raised anion gap metabolic acidosis
Methanol
Uraemia
DKA
Propylene glycol
Isoniazid
Lactic acidosis (sepsis, tissue isch.)
Ethylene glycol
Salicyclates
or KULT
Causes of transient or spurious non-visible haematuria [4]
exercise
sex
UTI
menstruation
leading cause of death in CKD patients
IHD
investigations for urethral stricture [2]
uroflowmetry
ultrasound postvoid residual (PVR) measurement
treatment for urethral stricture [2]
dilation
endoscopic urethrotomy
key feature in history of a young man with urethral stricture
STI e.g. gonorrhoea
features of urethral stricture [4]
weak stream
dribbling/incomplete emptying
dysuria
spraying
first line medications for overactive bladder [3]
oxybutynin (immediate release), tolterodine (immediate release), or darifenacin (once daily preparation)
second line med for overactive bladder
mirabegron
LUTS: voiding symptoms [5]
hesistancy
Poor or intermittent stream
Straining
Incomplete emptying
Terminal dribbling
LUTS: storage symptoms [4]
Urgency
Frequency
Nocturia
Urinary incontinence
treatment for moderate to severe voiding symptoms
alpha blocker e.g. tamsulosin
treatment for enlarged prostate with voiding symptoms
alpha blocker and alpha reductase inhibitor
treatment for renal stones < 5mm
watch and wait
treatment for renal stones 5-10mm
shockwave lithotripsy
treatment for renal stones 10-20 mm
shockwave lithotripsy OR ureteroscopy
treatment for renal stones >20mm
percutaneous nephrolithotomy
how are bladder voiding symptoms of an overactive bladder best investigated?
urodynamic studies
infection of stag horn calculi is most commonly by
proteus mirabilis
how should a patient with mixed symptoms of voiding and storage be treated?
alpha blocker with anti muscarinic
IPSS score grades
Score 20–35: severely symptomatic
Score 8–19: moderately symptomatic
Score 0–7: mildly symptomatic
which two stones are radiolucent
urate and xanthine
what are staghorn calculi made of?
struvite (ammonium magnesium phosphate, triple phosphate
main investigation for kidney stones
CT KUB
main investigation for kidney stones in the pregnant and children
USS
how are renal stones removed in the pregnant
ureteroscopy
as lithotripsy is contraindicated
what are 4 medical indications for circumcision
phimosis
recurrent balanitis
balanitis xerotica obliterans
paraphimosis
what GUM anatomy tends to be affected in pelvis fracture due to trauma [2]
urethra or bladder
how do you investigate urethral injury
ascending urethrogram
how do you investigate bladder injury
IV urogram or cystogram
what are communicating hydroceles
caused by patency of the processus vaginalis allowing peritoneal fluid to drain down into the scrotum. Communicating hydroceles are common in newborn males (clinically apparent in 5-10%) and usually resolve within the first few months of life
what are non communicating hydroceles
caused by excessive fluid production within the tunica vaginalis
when do infantile hydroceles resolve by
1-2 years
contraindication for circumcision
hypospadias
complications of vasectomy [5]
bruising
haematoma
infection
sperm granuloma
chronic testicular pain (affects between 5-30% men)
what a proportionally larger increase urea compared to creatinine indicate
a pre renal cause to AKI
how is acute clot retention causing bladder retention initially treated
bladder irrigation via 3 way catheter
what does electron microscopy show in minimal change disease renal biopsy
fusion of podocytes and effacement of foot processes
how is steroid resistant minimal change disease treated
cyclophosphamide
what is the triad in Haemolytic uraemic syndrome
haemolytic anaemia
thrombocytopenia
AKI
most common cause of HUS
e.coli O157:H7
treatment of HUS
supportive
when is plasma exchange used in HUS treatment
in severe cases of HUS with no associated diarrhoea
which 3 conditions cause nephrotic syndrome
Minimal change disease
focal segmental glomerulosclerosis membranous glomerulonephritis
Post-streptococcal glomerulonephritis is caused by which organism usually
group A beta-haemolytic Streptococcus infection (usually Streptococcus pyogenes)
which cancer are renal transplant patients at risk of
squamous cell carcinoma of the skin due to the immunosuppression
what three things do patients on immunosuppression post renal transplant need to be monitored for
which immunosuppressive medication are the main causes
cardiovascular disease
renal failure
malignancy
tacrolimus and ciclosporin- Tacrolimus and ciclosporin can cause hypertension and hyperglycaemia. Tacrolimus can also cause hyperlipidaemia.
signs in someone over filled [4]
Ascites
Crackles
Tachypnoea
Elevated JVP
signs in someone underfilled [4]
Tachycardia
Hypotension
Oliguria
Sunken eyes and reduced skin turgor
fluid balance and values for underfilled and over filled
input-output
too +ve –> overfilled
too -ve –> under filled
what is the earliest, clinically detectable manifestation of classic diabetic kidney disease
microalbuminuria
how is diabetic nephropathy tested for
measure albumin:creatinine ratio (ACR) on a first pass urine sample
if a first pass sample is not available, repeat the test on a first pass sample the next day
management of diabetic nephropathy
- dietary protein restriction
- tight glycaemic control
- BP control: aim for < 130/80 mmHg
ACE inhibitor or angiotensin-II receptor antagonist - control dyslipidaemia e.g. Statins
what drugs are used in the control of BP in diabetic nephropathy
ACEi or ARB
never together
what albumin:creatinine ratio defines microalbuminuria
> 2.5
high lactate post triple AAA repair cause
mesenteric ischaemia
first line management of phosphataemia
reduce dietary phosphate
which abx causes an isolated increase in creatinine
trimethoprim
treatment of choice for UTI in renal dysfunction
trimethoprim
nitrofurantoin not given to those with a eGFR <45
side effects of EPO [3]
bone aches
flu like sx
skin rash
prevention of calcium stones
high fluid intake
add lemon juice to drinking water
avoid carbonated drinks
limit salt intake
potassium citrate may be beneficial NICE
thiazides diuretics (increase distal tubular calcium resorption)
GOLD STANDARD investigation for bladder cancer
cystoscopy
In a patient with suspected anaemia of chronic disease secondary to CKD, what must be checked before starting EPO
iron studies
level of serum haptoglobin in HUS
low
3 things that can alter eGFR reading
pregnancy –> increased
muscle mass (e.g. amputees, body-builders) –> decreased
eating red meat 12 hours prior to the sample being taken –> decreased
anion gap calculation
(Na+ + K+) – (Cl- + HCO3-) = Anion Gap
what type of metabolic acidosis does renal tubular acidosis cause
hyperchloraemic normal anion gap metabolic acidosis
which nephrotic syndrome shows:
basement membrane thickening on light microscopy
subepithelial spikes on silverr stain
positive immunohistochemistry for PLA2
membranous glomerulonephritis
which nephrotic syndrome has a spike and dome appearance on electron microscopy
membranous glomerulonephritis
management of membranous glomerulonephritis
all patients should receive an ACE inhibitor or an angiotensin II receptor blocker (ARB):
immunosuppression: A combination of corticosteroid + another agent such as cyclophosphamide is often used
consider anticoagulation for high-risk patients
indications of haemdialysis
Acidosis
Electrolyte imbalance
Intoxication (overdose)
Oedema
Uraemia (confusion, pericarditis, encephalopathy, seizures, decreased consciousness).
management of proteinuria in CKD [2 lines]
1st line: ACEi/ARB
2nd: SGLT-2 inhibitor
prognosis of minimal change disease
1/3 have just one episode
1/3 have infrequent relapses
1/3 have frequent relapses which stop before adulthood
contraindications to fluid challenge in patient with AKI [2]
signs of fluid overload
haemorrhage
key finding in rapidly progressive glomerulonephritis on microscopy
which vasculitis can lead to this
epithelial crescents
Wegener’s
microscopy finding in the kidney in diabetic nephropathy
Kimmelstiel-Wilson nodules
patients with non-visible haematuria and taking warfarin. Who do they need to be referred to
<40 –>nephrology
> 40/older –> urology for cystoscopy
how is acute graft failure picked up in renal transplant
picked up by a rising creatinine, pyuria and proteinuria
Which post op complication is responsible for around 90% acute renal failure episodes in the first few weeks after a renal transplant.
acute tubular necrosis of graft
esp cadaver donor
1st line investigation of hydronephrosis
USS
metabolic change in diarrhoea vs vomiting
diarrhoea- acidosis
vomiting -alkalosis
treatment of metastatic prostate cancer
hormonal e.g. GnRH agonists like goserelin
which electrolyte abnormality may prolonged diarrhoea cause
hypokalaemia
extra renal manifestation of ADPKD
- liver cysts (70% - the commonest extra-renal manifestation): may cause hepatomegaly
- berry aneurysms (8%): rupture can cause subarachnoid haemorrhage
- cardiovascular system: mitral valve prolapse, mitral/tricuspid incompetence, aortic root dilation, aortic dissection
- cysts in other organs: pancreas, spleen; very rarely: thyroid, oesophagus, ovary
how does TURP syndrome present
what causes it
TURP syndrome typically presents with CNS, respiratory and systemic symptoms
It is caused by irrigation with large volumes of glycine during TURP, which is hypo-osmolar and is systemically absorbed when prostatic venous sinuses are opened up during prostate resection. This results in hyponatremia, and when glycine is broken down by the liver into ammonia, hyper-ammonia and visual disturbances.
treat with fluid restriction
treatment of nephrogenic DI
thiazides and low salt diett
treatment of central DI
desmopressin
what are patients at increased risk of post radiotherapy for prostate cancer
Patients are at increased risk of bladder, colon, and rectal cancer following radiotherapy for prostate cancer
cause of epididymo-orchitis in:
- young sexually active
- older, low risk
- young sexually active: chlamydia and gonorrhoea
- older, low risk: E.coli
when are hyaline casts seen in the urine [4]
seen in normal urine, after exercise, during fever or with loop diuretics
In which condition are red cell casts seen in the urine
nephritic syndrome
in which condition are brown granular casts seen in the urine
acute tubular necrosis
in which condition are ‘bland’ urinary sediment seen in the urine
pre renal uraemia
swelling you can’t get over o/e
which ones can you get over
inguinal hernia
can get over hydrocele
which carcinoma can a varicocele be a presentation of
renal cell carcinoma
swelling separate from the testes and behind it
epididymal cyst
normal post void residual volume in someone < 65
< 50ml
normal post void residual volume in someone > 65
< 100 ml
how much urine in the bladder after voiding defines chronic urinary retention
> 500ml
Post-catheterisation urine volume of >_______ suggests acute-on-chronic urinary retention.
Post-catheterisation urine volume of >800 ml suggests acute-on-chronic urinary retention.
how much urine in the bladder after voiding defines acute urinary retention
> 300ml
Investigations for suspected epididymo-orchitis are guided by age:
- sexually active younger adults (<35)
- older adults with a low-risk sexual history (>35)
sexually active younger adults: NAAT for STIs
older adults with a low-risk sexual history: MSSU
treatment of epididymo-orchitis in:
- young sexually active (<35)
- older, low risk (>35)
- mx: send for NAAT and ceftriaxone 500mg intramuscularly single dose, plus doxycycline 100mg by mouth twice daily for 10-14 days
- mx: send an MSU and treating empirically with an oral quinolone for 2 weeks (e.g. ofloxacin)
on which side do varicoceles typically occur on
left side due to direct drainage to renal vein
in which conditions is Prehns sign positive
epididymis orchitis
pain relieved by lifting the testis
which renal stones are associated with an inherited metabolic condition
cystine
which stones form in alkaline urine
struvite
and sometimes calcium phosphate
difference in presentation between testicular torsion and epididymo-orchitis
Testicular torsion would typically cause more acute symptoms and more severe pain.
EO is gradual pain and swelling
what is the importance of cyproterone acetate (anti-androgen) in the hormonal treatment of prostate cancer
prevent ‘tumour flare’ when taking GnRH agonist like goserlin initially which increases symptoms
Initially, treatment of prostate cancer with GnRH agonists can cause a paradoxical increase in symptoms such as bone pain, bladder obstruction and other symptoms, this is referred to as a ‘tumour flare’.
This occurs because GnRH temporarily causes the pituitary to increase luteinizing hormone (LH) secretion before it begins to inhibit LH release. The increase in LH causes increased stimulation of Leydig cells in the testicles which in turn produce more testosterone. Testosterone stimulates the survival and growth of prostate cancer.
Therefore the initial increase in production of testosterone caused by GnRH agonists can cause paradoxical survival, growth and resultant symptoms of prostate cancer.
Anti-androgens act by blocking androgen receptors which prevent androgens such as testosterone from binding their receptors and suppressing luteinizing hormone, which in turn reduces testosterone levels.
chemotherapy used in prostate cancer
docetaxel
which hormones are non-seminoma germ cell testicular tumours associated with
AFP and b-hCG
hormone in seminomas
20% have elevated hCG, mostly normal
1st line investigation of testicular cancer
treatment
USS
orchidectomy, chemo, radio
types of testicular cancers
germ cell (95%)
within those are seminomas and non-seminomas
non seminomas include embryonal, yolk sac, teratoma and choriocarcinoma
3 features of testicular cancer
a painless lump is the most common presenting symptom (pain may also be present in a minority of men)
hydrocele
gynaecomastia
complications of TURP: TURP
T urp syndrome
U rethral stricture/UTI
R etrograde ejaculation
P erforation of the prostate
which testicular tumours have normal AFP and HCG
seminomas
treatment of prostatitis
14 days of quinolones e.g. cipro
how do you calculate serum osmolarity
2Na + glucose + urea
