nephro-urology Flashcards
primary causes of glomerulonephritis
- IgA nephropathy - few days after URTI
- post strep glomerulonephritis - 1-3 weeks after strep throat/ 3-6 weeks after skin infection
- goodpastures
- focal segmental glomerulonephritis
type of reaction post strep glomerulonephritis
type 3 hypersensitivity reaction
secondary causes of glomerulonephritis
- lupus nephritis
- wegeners glomerulonephritis
- HSP
- HUS
presentation of glomerulonephritis
- haematuria/ proteinuria
- acute nephritic syndrome
- nephrotic syndrome
- rapidly progressing crescenteric glomerulonephritis
describe features of nephritic syndrome
- haematuria
- reduced renal function
- oliguria
- hypertension
diagnostic indicators of post strep glomerulonephritus
- low C3 , normal C4, low CH50
- biopsy - granular deposits of IgG and C3 in capillary loops
- ASOT titres +ve
diagnostic indicators of lupus nephritis
low C3 and low C4
When is a biopsy indicated in glomerulonephritis
- creatinine abnormal at 6 weeks
- low C3 beyond 3 months
- proteinuria beyond 6 months
biopsy of IgA nephropathy
IgA deposits in glomerular mesangium
management of glomerulonephritis
depends on cause…
1. penicillin if post strep
2. diuretics
3. ACE-I
4. dialysis - if severe overload hyperkalaemia ologuria
Primary causes of nephrotic syndrome
- minimal change disease ** (90%) - steroid sensitive
- focal segmental glomerulosclerosis (10%) - poorer prognosis, not steroid sensitive
triad of nephrotic syndrome
- proteinuria >1g/m2/day
- hypoalbuminaemia <25 g/L
- oedema
symptoms of nephrotic syndrome
- low albumin - causes oedema + proteinuria
- loss of anti thrombin 3, protein C&s - risk of thrombosis by renal blood vessels or sagitall sinus vessels
- loss of immunoglobulin s- increased risk of pneumococcal/ cellulitis/ peritonitis
- hyperlipidaemia
1st line investigations for nephrotic syndrome
- urinanalysis
- protein: creatinine ratdio
- FBC, Bone, albumin, LFT, U&e
- Height and weight
- BP
atypical features of nephrotic syndrome
- age <1 y/o or >12 y/o
- macroscopic haematuria
- HTN
- low C3
- Raised creatinine
- family history
- unresponsive to steroids after 6 weeks
- systemic features
2nd line investigations in atypical features of nephrotic syndrome
- complement C3/C4
- dsDNA, ANA, ANCA
- RENAL USS
- renal biopsy
management of 1st presentation of nephrotic syndrome
- prednisolone 60mg/m2/day for 16 weeks and then 40mgs for further 4 weeks
- penicillin prophlaxis
- pPI
- weight monitoring and fluid intake
- pneumococcal vaccination
if not responding to steroids after 4 weeks in nephrotic syndrome
- tacrolimus
- ACE-I
- ritixumab
if relapsing (>2 relapses in 6 months) of nephrotic syndrome…
- alternate day prednisolone
- wean over 6 months
relapse: >3 proteinuria on dipstick for 3 consecutive days
triad of haemolytic uraemic syndrome
- microscopic haemolytic anaemia
- AKI
- thrombocytopenia
causes of haemolytic uraemic syndrome
- shiga toxin producing E.coli - e.coli 0157 ** from contaminated food or fary yard animal faeces
- strep pneumoniae
- HIV
- SLE
- medications e.g. cytotoxins calcineurin inhibitors
- hereditary mutations
diagnosis of HUS
- stool sample
- FBC - anaemia , thrombocytopenia
- blood film * - fragmented RBC (shistocytes)
- u&e - raised urea and creat
- CRP - raised
complications of HUS
1.pancreatitis
2. myocarditis
3. encephalopathy
management of HUS
- IV fluids (0.9% saline)
- dialysis / haemofiltration
5% mortality
30-40% chronic renal injury
definition of AKI
- urine < 0.5ml/hr/kg for 6 hours
- increased serum creatinine to 1.5 x baseline
- rise in serum creatinine by 26.5 umol in 48 hours
pre renal causes of AKI
- extracellular fluid deficiency e.g. DKA, burns, diarrhoea, haemorrhage
- 3rd space fluid loss e.g. sepsis
- heart failure
intrinsic causes of AKI
- renal tubular acidosis
- congenital e.g. lupus nephritis
- vascular e.g. renal vein thrombosis, HUS ***
- toxins e.g. NSAIDs, gent, contrast, furosemide
- acute glomerulonephritis
post renal causes of AKI
- neuropathic e.g. transverse myelitis, spinal tumour
- obstruction e.g. stones, tumour
- posterior urethral valves
causes of chronic kidney disease
- chronic glomerulonephritis
- HUS
- polycystic kidney disease
- systemic e.g. HSP, SLE
- hereditary e.g. alport, nephronophthisis , reflux, obstructions
presentation of chronic kidney disease
- fatigue, lethargy
- anaemia
- vit D deficiency (increased PTH - low vit D, low calcium and increased phosphate)
- hypertension
- faltering growth
indications for acute dialysis
- persistent severe hyperkalaemia
- severe symptomatic uraemia
- severe ECF volume overload
- hyponatraemia <120 or hypernatraemia >155
- severe metabolic acidosis
- removal of toxins
complications of haemodialysis
- depression
- anaphylaxis
- hypotension
- catheter sepsis
- thrombosis
complications of peritoneal dialysis
- peritonitis
- weight gain
- blocked catheters
- hyperglycaemia
- hernia
management of renal transplant patients
- calcineurin inhibitors e.g. tacrolimus
- mycophenolate/ azathioprine
- corticosteroids
- infection prophylaxis e.g. co-trimoxazole
- enoxaparin -> aspirin
complications of renal transplant
- acute rejection
- hypertension
- infection
- vascular thrombosis
- malignancy
describe type 1 distal renal tubular acidosis
- usually inherited
- defects in H+ secretion causing acidosis
- ph >5.5
describe type 2 proximal renal tubular acidosis
- usually secondary to metabolic disease e.g. cystinosis, wilsons, galactosaemia
- defect in bicarb reabsorption
- ph <5.5
features of fanconi syndrome
- polyuria
- glycosuria
- hypokalaemia
- low phosphate
presentation of type 1 distal renal tubular acidosis
- faltering growth
- renal stones
- vomiting
- polyuria, polydipsia
- muscle weakness
what is bartter syndrome
defective functioning of Na/K/Cl cotransporter in the thick acsending loop of henle.
causes hyperplasia of juxtaglomerular apparatus
presentation of bartter syndrome
- severe salt wasting - dehydration
- dysmorphic - triangular face, protruding ears, large eyes
- faltering growth
- fatigue
- polyuria
diagnosis of bartter syndrome
- hypokalaemia
- hypochloraemia
- metabolic alkalosis
- hypercalcuria
+ raised renin/aldosterone (with normal BP), hyponatraemia, hypocalcaemia
describe gitelman syndrome
loss of Na and Cl and excess K via NaCL channel in the distal convulate dtubule
diagnosis of gitelman syndrome
- low magnesium **
- reduced calcium in urine
- hyponatraemia
- hypochloraemia
- hypokalaemia
- hypercalcaemia
describe goodpastures disease
autoantibodies against alpha3 chain of type IV collagen in alveolar and glomerular basement membranes
presentation of goodpastures disease
- renal - rapidly progressing glomerulonephritis
- pulmonary - cough, dyspnoea, haemoptysis
diagnosis of goodpastures disease
- anti GBM antibodies *
- ANCA +ve
- Renal biopsy
- CXR - pulmonary haemorrhage
risk factors for UTIs
- boys < 6 months and girls >6 months
- VUR
- renal calculi
- spinal lesions
- constipation
diagnosis of UTI
- clean catch mid stream urine microscopy **
- need LP if <1 month old
atypical UTI features
- non E.coli organism
- seriously ill or sepsis
- poor urine flow
- failure to respond to abx in 48 hours
- abdomen/ bladder mass
- raised creatinine
investigations for <6 months old with UTI
NON COMPLICATED - USS within 6 weeks
ATYPICAL/ RECURRENT - USS in acute infection, DMSA and MCUG in 6 weeks
investigations for 6 months- 3 years old with UTI
NON COMPLICATED - Nil
ATYPICAL - USS in acute or 6/52 if well but atypical bug, DMSA in 4-6 months
RECURRENT - USS in 6/52 and DMSA 4-6 months
investigations > 3 years old
NON COMPLICATED - nil
ATYPICAL - USS in acute infection
RECURRENT - USS within 6 /52 and DMSA in 4-6 months
management of UTI
- simple - oral trimeoprim 3/7
- upper UTI - oral cefalexin 10 days
- <3 months - IV abx
- unwell - IV abx
definition of nocturnal enuresis
involuntary wetting during sleep (>5 y/o) at least twice a week with no congenital/acquired defect
risk factors for nocturnal enuresis
- boys
- developmental delay
- autism, ADHD, anxiety
- psychological stress
- obesity
- constipation
- family history
primary causes of nocturnal enuresis
- sleep arousal difficulties
- polyuria
- bladder dysfunction
secondary causes of nocturnal enuresis (previously dry at night for >6 months)
- psychological ** - stress, trauma, family change
- UTI
- diabetes
- constipation
management of primary causes of nocturnal enuresis
- reassurance
- behavioural therapy **
- conditioning therapy / enuresis alarm
management of primary causes of nocturnal enuresis with daytime symptoms
- refer to clinic
- desmopressin ** - oral 200 ug at bed and fluid restrict for 1 hour before bed.
- oxybutynin - if detrusor instability
stages of vesico-ureteric reflux
1 - urine tracks into non dilated ureter
2 - urine tracks into renal pelvis without dilatation
3 - mid-moderate dilatation of ureter
4 - ureteral tortuoisuty with pelvicalcayeal dilatation
5- gross dilatation and ureteral torturosity with blunted fornices
investigations for suspected VUR
- MCUG - if antenatal or UTI 6 months old or USS hydronephrosis
- DMSA - assess for renal scarring
management of VUR
- prophylactic abx
- anti cholinergic agenets e.g. oxybutynin
- surgical correction at 2-3 y/o
presentation of posterior urethral valves
- antenatal diagnosis - oligihydramnios +/- b/l hydronephrosis
- urinary tract obstruction - urinary retention, poor stream, UTIs
investigations for posterior urethral valves
- MCUG *
- USS renal within 48 hours *** - shows hydronephrosis and bladder distension
- renal function
management of undescended testes
if not descended after 3 months for surgical correction >`6 months old (no surgery >18 months)
presentation of testicular torsion
- acute testicular pain - red hot swollen testes
- nausea and vomiting
- negative prehns signs
- absent cremasteric reflex
management of testicular torsion
surgery within 6 hours of presentation
PAIN RELIEF
Cause of polycystic kidney disease
autosomal recessive
autosomal dominent - PKD1 gene on chromosome 16
presentation of AR polycystic kidney disease
- antenatal diagnosis - large echogenic kidney , resp distress due to pulmonary hypoplasia
- renal failure
- systemic hypertension
presentation of AD polycystic kidney disease
- present older
- renal cysts
- liver cysts
- berry aneurysm -> SAH
- aortic root dilatation and mitral valve prolapse
causes of calcium containing renal stones
MOST COMMON
- hyperparathyroid/ hypercalcaemia
- Bartter syndrome
- renal tubular acidosis
- TB, sarcoidosis
- drugs - thiazide diuretics, furosemide, steroids
causes of struvite containing renal stones
proteus infection
causes of uric acid containing stones
gout
lesch nyhan syndorme
malignancy - tumour lysis
drugs - aspirin, thiazine diuretics
causes of cystine stones
cystinuria
‘staghorn appearance’
yellow hexagonal crystals in urine
features of acute interstitial nephritis
- hyperkalaemia
- metabolic acidosis
-Hypertension - vomiting, haematuria, dysuria, abdo pain
causes of acute interstitial nephritis
- infections
- reaction to medications e.g. ciprofloxacin, trimethoprim, erythromycin
