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4MB Medicine > Nephrology > Flashcards

Nephrology Flashcards

1
Q

Define oliguria

A

Reduced urine output, usually less than 0.5 ml/kg/h

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2
Q

What does specific gravity on urinalysis measure?

A

Osmolality of urine
Increased osmolality in diabetes, dehydration, adrenal insufficiency
Decreased osmolality in diabetes insipidus, renal failure

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3
Q

What are casts (found on urinary microscopy)?

A

Cylindrical bodies formed in lumen of distal tubules, usually due to breakdown/inflammatory processes

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4
Q

List indications for renal biopsy

A 
Unexplained renal failure
Acute nephritic syndrome
Unexplained proteinuria/haematuria
Planning therapy
Autoimmunity (SLE, Goodpasture's, GPA)
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5
Q

List contraindications to renal biopsy

A 
Abnormal clotting
Hypertension over 160/90
Single kidney
Chronic renal failure with small kidney
Abnormal anatomy
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6
Q

UTI is highly suspected if there is bacteriuria with greater than how many organisms per mL of fresh mid-stream urine?

A

Greater than 10^5 organisms

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7
Q

List the main conditions for upper and lower UTI

A

Upper: pyelonephritis
Lower: urethritis, cystitis, prostatitis

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8
Q

List aetiology/risk factors for UTI

A 
Females (short, wide urethra)
Sexual intercourse
Spermicide use
Pregnancy
Menopause
Immunosuppression
Catheterisation
UT obstruction (stones)
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9
Q

List the main organisms that cause UTI’s

A 
E. coli
Klebsiella
Enterococci
Proteus
Pseudomonas (esp catheters)
Staph saphrophyticus in women of child-bearing age
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10
Q

List clinical features of upper UTI

A 
Loin pain
Tender
Fever
Rigors
Vomiting
Oliguria
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11
Q

List clinical features of lower UTI

A 
Frequency
Dysuria
Haematuria
Suprapubic pain
Backache
Urgency
Strangury
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12
Q

What investigations would you do for suspected UTI?

A 
Mid-stream urine sample
Urinalysis
Microscopy/culture
Bloods: FBC, U+E, CRP
US scan, IV urogram, cystoscopy
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13
Q

Outline management of UTI

A 
Drink lots of fluids and pee often
Cranberry juice
Empirical therapy: trimethoprim/nitrofurantoin
Hospital therapy: gentamicin
GP therapy: co-amoxiclav/co-trimoxazole
Levofloxacin in men may be needed
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14
Q

What is glomerulonephritis?

A

Immune-mediated damage to glomerulus and podocytes, causing leakage of blood +/- protein in urine
Focal if less than 50% affected, diffuse if more than 50%

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15
Q

What is the commonest type of glomerulonephritis worldwide?

A

IgA nephropathy

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16
Q

List clinical features of IgA nephropathy

A

Episodic macroscopic haematuria
Post-URTI
Proteinuria

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17
Q

What investigations would you do for IgA nephropathy?

A

Renal biopsy

Immunofluorescence shows IgA and C3 deposits

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18
Q

Outline management of IgA nephropathy?

A

Prednisolone

Cyclophosphamide if progressively worsening renal function

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19
Q

What is Goodpasture’s disease?

A

Anti-glomerular-basement-membrane antibodies destroy type IV collagen of the glomerulus

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20
Q

List clinical features of Goodpasture’s syndrome

A

Macroscopic haematuria
Oliguria
Haemoptysis
Renal failure

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21
Q

What investigations would you do for Goodpasture’s syndrome?

A

Antibody screen
Urine output
IgG detection
Presence of crescents on renal biopsy

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22
Q

Outline management of Goodpasture’s syndrome

A

Plasmapharesis
Steroids
Cytotoxics

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23
Q

List aetiology/risk factors for rapidly progressive glomerulonephritis

A 
Immune complex -mediated
Post-infection
Henoch-Schonlein purpura
IgA nephropathy
Vasculitis (GPA, EGPA)
Goodpasture's syndrome
Drugs
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24
Q

List clinical features of rapidly progressive glomerulonephritis

A

Systemic upset
Fever
Haemoptysis
Pulmonary haemorrhage

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25
Q

What investigations would you do for rapidly progressive glomerulonephritis?

A 
Renal biopsy shows crescents
Antibody screen (ANCA)
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26
Q

Outline management of rapidly progressive glomerulonephritis

A 
High dose (IV) methylprednisolone + cyclophosphamide
Plasmapharesis
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27
Q

What is nephrotic syndrome?

A

Protein leakage into urine due to non-proliferative damage to the glomerular basement membrane

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28
Q

List the core triad of features of nephrotic syndrome

A

More than 3g of protein in urine in 24h
Hypoalbuminaemia
Oedema

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29
Q

What are the principles of management of nephrotic syndrome?

A

Restrict sodium (reduce oedema)
Diuretic
ACE inhibitor

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30
Q

What is the commonest cause of nephrotic syndrome in children?

A

Minimal change nephropathy

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31
Q

What type of cancer is minimal change nephropathy particularly associated with?

A

Hodgkin’s lymphoma

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32
Q

What investigations would you do for minimal change nephropathy?

A

Selective proteinuria - check albumin
Normal light microscopy
Electron microscopy shows fused podocytes

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33
Q

Outline management of minimal change nephropathy

A

Steroids

Cyclophosphamide/ciclosporin if relapses

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34
Q

What is the commonest cause of nephrotic syndrome in adults?

A

Focal segemental glomerulosclerosis

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35
Q

List aetiology/risk factors for focal segmental glomerulosclerosis

A 
Primary (idiopathic)
Secondary to
Alport's syndrome
IgA nephropathy
Vasculitis
Obesity
Reflux disease
Heroin use
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36
Q

What investigations would you do for focal segmental glomerulosclerosis?

A

Segmental glomerulosclerosis on light microscopy

IgM and C3 levels

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37
Q

Outline management of focal segmental glomerulosclerosis

A

Steroids

Cyclophosphamide/ciclosporin if resistant

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38
Q

List aetiology/risk factors for membranous nephropathy

A

Malignancy
Drugs - gold, penicillamine, captopril
Autoimmunity
Infection (hepatitis B)

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39
Q

What investigations would you do for membranous nephropathy?

A

Diffuse thickened glomerular basement membrane on microscopy
IgG, C3 deposits
Anti-PLA2r antibody

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40
Q

Outline management of membranious nephropathy

A

Steroid

Cyclophosphamide if worsening renal function

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41
Q

What is nephritic syndrome?

A

Proliferative damage to glomerular endothelium, causing blood to leak through into urine

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42
Q

List aetiology/risk factors for nephritic syndrome

A

Post-Strep glomerulonephritis
IgA nephropathy
Rapidly progressive glomerulonephritis

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43
Q

List clinical features of nephritic syndrome

A 
Haematuria
Proteinuria
Oliguria
Oedema
Mild hypertension
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44
Q

What would you see on microscopy in nephritic syndrome?

A

Red cell casts

45
Q

How is nephritic syndrome treated?

A

Treat the underlying cause

46
Q

List clinical features of renal vein thrombosis

A 
Asymptomatic
Loin pain
Haematuria
Palpable kidney
Reduced renal function
Pulmonary embolism
47
Q

What investigations would you do for renal vein thrombosis?

A

Doppler USS

CT/MRI angiography

48
Q

Define acute renal failure

A

Deterioration in GFR/abrupt increase in urea and Cr over a short period of time
Occurs in a patient with previously normal renal function

49
Q

List pre-renal aetiology for acute renal failure

A 
Mainly hypoperfusion caused by
Haemorrhage
Sepsis
Heart failure
Renal artery stenosis
ACE inhibitors
NSAIDs
50
Q

List intra-renal aetiology for acute renal failure

A 
Acute tubular necrosis caused by ischaemia/nephrotoxins
Vasculitis
Malignant hypertension
Haemolytic uraemic syndrome
Glomerulonephritis
51
Q

List post-renal aetiology for acute renal failure

A

Mainly urinary tract obstruction due to
Stones
Tumour
Compression

52
Q

List clinical features of acute renal failure

A 
May be asymptomatic until GFR very low
Oliguria
Loin pain
Tenderness
Palpable bladder/kidney
Enlarged prostate
Proteinuria
Haematuria
Dysuria
53
Q

What investigations would you do for acute renal failure?

A

Bloods: hyperkalaemia, uraemia, FBC, coagulation
Consider immunology screen (antibody, complement)
Urinalysis
Urine microscopy (casts, culture)
Ultrasound

54
Q

Outline management of acute renal failure

A

Stop nephrotoxins (NSAID, ACEi, gentamicin, gold, penicillamine, meformin)
Catheterise to monitor urine output
Fluid balance and weight monitoring, IV fluids
Antibiotics if sepsis
Treat hyperkalaemia (Ca gluconate, insulin + glucose, neb salbutamol)
Acute dialysis if persistent

55
Q

Define chronic renal disease

A

Kidney damage lasting more than 3 months

Based on abnormal physical findings or GFR less than 60 +- kidney damage

56
Q

Define the different stages of chronic kidney disease

A

1: GFR greater than 90, kidney damage
2: GFR 60-89, kidney damage
3: GFR 30-59
4: GFR 15-29
5: GFR less than 15

57
Q

List aetiology/risk factors for chronic kidney disease

A 
Hypertension
Diabetes
Chronic glomerulonephritis
Vasculitis
Polycystic kidney disease
Stones
Haemolytic uraemic syndrome
58
Q

List clinical features of chronic kidney disease

A 
Asymptomatic until GFR less than 20
Oedema
Fatigue, lethargy, malaise
Anorexia
Vomiting
Dyspnoea
Bone pain
Yellow skin
Brown nails
Myopathy
59
Q

What investigations would you do for chronic kidney disease?

A 
Bloods: decreased Hb, increased urea/Cr
Urinalysis
Urine microscopy for casts
Ultrasound scan
EGFR
Antibody screen
Renal biopsy if unexplained
60
Q

Outline management of chronic kidney disease

A 
Treat reversible causes
Stop nephrotoxins
Sodium and protein restriction
EPO injection/IV iron if anaemia
Phosphate binder/vit D/Ca supplement for bone disease
Dialysis
Transplant
61
Q

List problems/complications of haemodialysis

A 
Hypotension
Arrhythmia
Time-consuming (3-4x a week)
Thrombosis
Stenosis
Infection
62
Q

List problems/complications of peritoneal dialysis

A 
Peritonitis
Malfunction
Hernia
Back pain
Anaemia
Bleeding
Infection
63
Q

Why is creatinine a good measure of renal function?

A

It is excreted unchanged and very little is reabsorbed, so if renal function deteriorates, Cr levels in the body will rise
Cr levels in blood and urine can be compared to produce creatinine clearance, which correlates with GFR

64
Q

Give examples of exogenous nephrotoxins

A

NSAID’s
Antimicrobials (gentamicin, vancomycin, tetracycline, aciclovir)
Radiocontrast (IV)
Anaesthetic agents
Cisplatin chemotherapy
ACEi
Immunosuppressants (ciclosporin, methotrexate)

65
Q

Give examples of endogenous nephrotoxins

A

Excess haemolysis causing haemoglobinuria
Myoglobin (rhabdomyolysis)
Urate crystals
Ig chains e.g. in myeloma

66
Q

What is tubelointerstitial nephritis?

A

Inflammation of renal interstitium

67
Q

List aetiology/risk factors for tubelointerstitial nephritis

A 
Drugs
Infection (Staph, Strep, Brucella)
Glomerulonephritis
Chronc pyelonephritis
Sickle cell disease
Fibrosis
68
Q

What is rhabdomylosis?

A

Skeletal muscle breakdown causes myoglobin, PO4, urate and Cr release which is nephrotoxic

69
Q

List aetiology/risk factors for rhabdomyolyisis

A 
Post-ischaemia
Infection
Embolism
Immobilisation
Trauma
Drugs (statins, fibrates, alcoohl, ecstasy, heroin)
70
Q

List clinical features of rhabdomyolysis

A

Red-brown urine
Muscle pain
Swelling

71
Q

What investigations would you do for rhabdomyolysis?

A

Grossly elevated CK
Myoglobinuria
No red cells on microscopy
Hyperkalaemia

72
Q

Outline management of rhabdomyolysis

A

Urgently treat hyperkalaemia
IV fluids
Maintain urine output

73
Q

What is polycystic kidney disease?

A

Most common inherited nephropathy, usually presents in adulthood
Abnormality in PKD1 (c16) or PKD2 (c4)

74
Q

List clinical features of polycystic kidney disease

A 
Loin pain
Haematuria
Abdo pain
Hypertension
Subarachnoid haemorrage
Mitral prolapse
Infection
75
Q

Outline management of polycystic kidney disease

A 
Target BP of 130/80
Adenyl cyclase agonist/cAMP inhibitor
Octreotide halts cyst growth
Increase caffeine intake
Laparoscopic removal, nephrectomy
76
Q

Where does renal cell carcinoma typically arise?

A

Proximal tubular epithelium

77
Q

List clinical features of renal cell carcinoma

A 
Asymptomatic
Haematuria
Loin pain
Flank mass
Anorexia
Malaise
Weight loss
Polycythaemia
Varicocele if left renal vein affected
78
Q

Outline management of renal cell carcinoma

A

Partial nephrectomy if bilateral

Full if unilateral

79
Q

Which parts of the urinary tract does transitional cell carcinoma typically affect?

A

Bladder
Ureter
Renal pelvis

80
Q

List aetiology/risk factors for transitional cell carcinoma

A

Smoking
Rubber industry
Chronic cystitis
Schistosomiasis

81
Q

List clinical features of transitional cell carcinoma

A 
Painless haematuria
Frequency
Urgency
Dysuria
UT obstruction
Irritation
82
Q

What investigations would you do for transitional cell carcinoma?

A

Urine cytology
Cystoscopy + biopsy
CT/MRI
IV urogram

83
Q

Outline management of transitional cell carcinoma

A

Diathermy via transurethral cystoscopy/resection
Intravesical chemotherapy if small multiple/high-grade
Radical cystectomy if T2-T3
Palliation if T4

84
Q

What is benign prostatic hyperplasia?

A

Proliferation of musculofibrous and glandular layers of prostae, supposedly due to hormone imbalance (oestrogen : reduced androgen)
Inner transitional zone of prostate enlarges

85
Q

List clinical features of benign prostatic hyperplasia

A 
Difficulty starting
Poor flow
Nocturia
Acute retention
Overflow incontinence
86
Q

What investigations would you do for benign prostatic hyperplasia?

A

PR exam
Abdo USS
Mid-stream urine
USS-guided biopsy

87
Q

Outline management of benign prostatic hyperplasia

A

Watchful-waiting if moderate, reduce caffeine and alcohol
Bladder training
Catheterisation
Alpha-blocker - tamsulosin, doxazosin
Finasteride (decreases size through inhibiting testosterone breakdown)
Transurethral resection/incision
Prostatectomy

88
Q

Prostatic adenocarcinoma arises peripherally. True/False?

A

True

So symptoms occur later

89
Q

List clinical features of prostatic adenocarcinoma

A 
Asymptomatic
Nocturia
Back pain
Weight loss
Anaemia
Hesitancy
Poor stream
UT obstruction symptoms
90
Q

What investigations would you do for prostatic adenocarcinoma?

A

Hard irregular mass on PR exam
Increased PSA
US-guided biopsy
Bone XR to check for osteosclerosis/mets

91
Q

Outline management of prostatic adenocarcinoma

A 
Radiotherapy
Hormone therapy
Transurethral resection if obstructed
Orchidectomy if mets
GNRH analogue (goserelin)
Anti-androgen (flutamide)
92
Q

List luminal aetiology of urinary tract obstruction

A

Calculus
Clot
Slough
Cancer

93
Q

List mural aetiology of urinary tract obstruction

A

Neuromuscular dysfunction
Stricture
Schistosomiasis

94
Q

List extra-mural aetiology of urinary tract obstruction

A

Tumour
Diverticulae
Aneurysm
Fibrosis

95
Q

List clinical features of urinary tract obstruction

A 
Loin pain, radiating to groin
Anuria, polyuria
Infection (fever, malaise)
Dribbling
Incompleteness
Palpable kidney/bladder
Distention
96
Q

What investigations would you do for urinary tract obstruction?

A

Bloods: Cr, U+E, urine : Cr ratio
Urine microscopy
US scan
Ureterogram if hydronephrosis (can use to drain)

97
Q

Outline management of urinary tract obstruction

A

Upper tract - nephrostomy, stent, pyeloplasty

Lower tract - urethral/suprapubic catheter

98
Q

What are renal calculi?

A

Consist of crystal aggregates and form in collecting ducts
Ca oxalate stones (spiky)
Ca phosphate stones (smooth)

99
Q

What are the 3 main parts of the urinary tract susceptible to being blocked by stones?

A

Pelvio-ureteric junction
Pelvic brim
Vesico-ureteric junction

100
Q

List aetiology/risk factors for renal stones

A 
Dehydration
Gout
Hypercalcaemia
UTI
PKD
Poor diet
High vitamin D
Drugs (loop diuretics, antacids, steroid, theophylline, aspirin)
101
Q

List clinical features of renal stones

A 
Renal colic
Increased urine volume
Haematuria
Pallor, sweaty
Vomiting
Bladder irritation
Scrotal pain
102
Q

What investigations would you do for renal stones?

A

Bloods: FBC, U+E, Ca, PO4, glucose, bicarbonate, urate
Mid-stream urine dipstick
CT-KUB is diagnostic
IV urogram, spiral CT

103
Q

Outline management of renal stones

A 
Analgesia - diclofenac IV
Fluids
Alpha blocker
Antibiotic if infection
Medical expulsion - nifedipine
Shockwave lithotripsy
Keyhole surgery (rare)
104
Q

What are the 3 main types of urinary incontinence?

A

Stress: increased intraabdominal pressure causes leak from weak sphincter
Urge: detrusor overactivity produces urgent desire to void
Overflow: fully distended bladder causes leakage

105
Q

List aetiology/risk factors for urinary incontinence

A 
Prostate enlargement (overflow)
Pelvic surgery, child birth (stress)
Ageing
Obesity
Overactive bladder (urge)
Caffeine
Neuro disorder
106
Q

What investigations would you do for urinary incontinence?

A

Standing-supine stress test

Urodynamic studies

107
Q

Outline management of stress urinary incontinene

A 
Pelvic floor exercises
Electrical stimulation
Pessary
Duloxetine
Colposuspension/sling surgery
Taping
108
Q

Outline management of urge urinary incontinence

A 
Bladder diary
Oestrogen for atrophic vaginitis
Bladder training
Absorbant pads
Anti-muscarinic (oxybutynin)
B3-agonist (mirabegron)
Neuromodulation surgery

4MB Medicine (19 decks)

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