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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
What investigations would you do for rapidly progressive glomerulonephritis?
``` Renal biopsy shows crescents Antibody screen (ANCA) ```
26
Outline management of rapidly progressive glomerulonephritis
``` High dose (IV) methylprednisolone + cyclophosphamide Plasmapharesis ```
27
What is nephrotic syndrome?
Protein leakage into urine due to non-proliferative damage to the glomerular basement membrane
28
List the core triad of features of nephrotic syndrome
More than 3g of protein in urine in 24h Hypoalbuminaemia Oedema
29
What are the principles of management of nephrotic syndrome?
Restrict sodium (reduce oedema) Diuretic ACE inhibitor
30
What is the commonest cause of nephrotic syndrome in children?
Minimal change nephropathy
31
What type of cancer is minimal change nephropathy particularly associated with?
Hodgkin's lymphoma
32
What investigations would you do for minimal change nephropathy?
Selective proteinuria - check albumin Normal light microscopy Electron microscopy shows fused podocytes
33
Outline management of minimal change nephropathy
Steroids | Cyclophosphamide/ciclosporin if relapses
34
What is the commonest cause of nephrotic syndrome in adults?
Focal segemental glomerulosclerosis
35
List aetiology/risk factors for focal segmental glomerulosclerosis
``` Primary (idiopathic) Secondary to Alport's syndrome IgA nephropathy Vasculitis Obesity Reflux disease Heroin use ```
36
What investigations would you do for focal segmental glomerulosclerosis?
Segmental glomerulosclerosis on light microscopy | IgM and C3 levels
37
Outline management of focal segmental glomerulosclerosis
Steroids | Cyclophosphamide/ciclosporin if resistant
38
List aetiology/risk factors for membranous nephropathy
Malignancy Drugs - gold, penicillamine, captopril Autoimmunity Infection (hepatitis B)
39
What investigations would you do for membranous nephropathy?
Diffuse thickened glomerular basement membrane on microscopy IgG, C3 deposits Anti-PLA2r antibody
40
Outline management of membranious nephropathy
Steroid | Cyclophosphamide if worsening renal function
41
What is nephritic syndrome?
Proliferative damage to glomerular endothelium, causing blood to leak through into urine
42
List aetiology/risk factors for nephritic syndrome
Post-Strep glomerulonephritis IgA nephropathy Rapidly progressive glomerulonephritis
43
List clinical features of nephritic syndrome
``` Haematuria Proteinuria Oliguria Oedema Mild hypertension ```
44
What would you see on microscopy in nephritic syndrome?
Red cell casts
45
How is nephritic syndrome treated?
Treat the underlying cause
46
List clinical features of renal vein thrombosis
``` Asymptomatic Loin pain Haematuria Palpable kidney Reduced renal function Pulmonary embolism ```
47
What investigations would you do for renal vein thrombosis?
Doppler USS | CT/MRI angiography
48
Define acute renal failure
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
List pre-renal aetiology for acute renal failure
``` Mainly hypoperfusion caused by Haemorrhage Sepsis Heart failure Renal artery stenosis ACE inhibitors NSAIDs ```
50
List intra-renal aetiology for acute renal failure
``` Acute tubular necrosis caused by ischaemia/nephrotoxins Vasculitis Malignant hypertension Haemolytic uraemic syndrome Glomerulonephritis ```
51
List post-renal aetiology for acute renal failure
Mainly urinary tract obstruction due to Stones Tumour Compression
52
List clinical features of acute renal failure
``` May be asymptomatic until GFR very low Oliguria Loin pain Tenderness Palpable bladder/kidney Enlarged prostate Proteinuria Haematuria Dysuria ```
53
What investigations would you do for acute renal failure?
Bloods: hyperkalaemia, uraemia, FBC, coagulation Consider immunology screen (antibody, complement) Urinalysis Urine microscopy (casts, culture) Ultrasound
54
Outline management of acute renal failure
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
Define chronic renal disease
Kidney damage lasting more than 3 months | Based on abnormal physical findings or GFR less than 60 +- kidney damage
56
Define the different stages of chronic kidney disease
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
List aetiology/risk factors for chronic kidney disease
``` Hypertension Diabetes Chronic glomerulonephritis Vasculitis Polycystic kidney disease Stones Haemolytic uraemic syndrome ```
58
List clinical features of chronic kidney disease
``` Asymptomatic until GFR less than 20 Oedema Fatigue, lethargy, malaise Anorexia Vomiting Dyspnoea Bone pain Yellow skin Brown nails Myopathy ```
59
What investigations would you do for chronic kidney disease?
``` Bloods: decreased Hb, increased urea/Cr Urinalysis Urine microscopy for casts Ultrasound scan EGFR Antibody screen Renal biopsy if unexplained ```
60
Outline management of chronic kidney disease
``` 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
List problems/complications of haemodialysis
``` Hypotension Arrhythmia Time-consuming (3-4x a week) Thrombosis Stenosis Infection ```
62
List problems/complications of peritoneal dialysis
``` Peritonitis Malfunction Hernia Back pain Anaemia Bleeding Infection ```
63
Why is creatinine a good measure of renal function?
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
Give examples of exogenous nephrotoxins
NSAID's Antimicrobials (gentamicin, vancomycin, tetracycline, aciclovir) Radiocontrast (IV) Anaesthetic agents Cisplatin chemotherapy ACEi Immunosuppressants (ciclosporin, methotrexate)
65
Give examples of endogenous nephrotoxins
Excess haemolysis causing haemoglobinuria Myoglobin (rhabdomyolysis) Urate crystals Ig chains e.g. in myeloma
66
What is tubelointerstitial nephritis?
Inflammation of renal interstitium
67
List aetiology/risk factors for tubelointerstitial nephritis
``` Drugs Infection (Staph, Strep, Brucella) Glomerulonephritis Chronc pyelonephritis Sickle cell disease Fibrosis ```
68
What is rhabdomylosis?
Skeletal muscle breakdown causes myoglobin, PO4, urate and Cr release which is nephrotoxic
69
List aetiology/risk factors for rhabdomyolyisis
``` Post-ischaemia Infection Embolism Immobilisation Trauma Drugs (statins, fibrates, alcoohl, ecstasy, heroin) ```
70
List clinical features of rhabdomyolysis
Red-brown urine Muscle pain Swelling
71
What investigations would you do for rhabdomyolysis?
Grossly elevated CK Myoglobinuria No red cells on microscopy Hyperkalaemia
72
Outline management of rhabdomyolysis
Urgently treat hyperkalaemia IV fluids Maintain urine output
73
What is polycystic kidney disease?
Most common inherited nephropathy, usually presents in adulthood Abnormality in PKD1 (c16) or PKD2 (c4)
74
List clinical features of polycystic kidney disease
``` Loin pain Haematuria Abdo pain Hypertension Subarachnoid haemorrage Mitral prolapse Infection ```
75
Outline management of polycystic kidney disease
``` Target BP of 130/80 Adenyl cyclase agonist/cAMP inhibitor Octreotide halts cyst growth Increase caffeine intake Laparoscopic removal, nephrectomy ```
76
Where does renal cell carcinoma typically arise?
Proximal tubular epithelium
77
List clinical features of renal cell carcinoma
``` Asymptomatic Haematuria Loin pain Flank mass Anorexia Malaise Weight loss Polycythaemia Varicocele if left renal vein affected ```
78
Outline management of renal cell carcinoma
Partial nephrectomy if bilateral | Full if unilateral
79
Which parts of the urinary tract does transitional cell carcinoma typically affect?
Bladder Ureter Renal pelvis
80
List aetiology/risk factors for transitional cell carcinoma
Smoking Rubber industry Chronic cystitis Schistosomiasis
81
List clinical features of transitional cell carcinoma
``` Painless haematuria Frequency Urgency Dysuria UT obstruction Irritation ```
82
What investigations would you do for transitional cell carcinoma?
Urine cytology Cystoscopy + biopsy CT/MRI IV urogram
83
Outline management of transitional cell carcinoma
Diathermy via transurethral cystoscopy/resection Intravesical chemotherapy if small multiple/high-grade Radical cystectomy if T2-T3 Palliation if T4
84
What is benign prostatic hyperplasia?
Proliferation of musculofibrous and glandular layers of prostae, supposedly due to hormone imbalance (oestrogen : reduced androgen) Inner transitional zone of prostate enlarges
85
List clinical features of benign prostatic hyperplasia
``` Difficulty starting Poor flow Nocturia Acute retention Overflow incontinence ```
86
What investigations would you do for benign prostatic hyperplasia?
PR exam Abdo USS Mid-stream urine USS-guided biopsy
87
Outline management of benign prostatic hyperplasia
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
Prostatic adenocarcinoma arises peripherally. True/False?
True | So symptoms occur later
89
List clinical features of prostatic adenocarcinoma
``` Asymptomatic Nocturia Back pain Weight loss Anaemia Hesitancy Poor stream UT obstruction symptoms ```
90
What investigations would you do for prostatic adenocarcinoma?
Hard irregular mass on PR exam Increased PSA US-guided biopsy Bone XR to check for osteosclerosis/mets
91
Outline management of prostatic adenocarcinoma
``` Radiotherapy Hormone therapy Transurethral resection if obstructed Orchidectomy if mets GNRH analogue (goserelin) Anti-androgen (flutamide) ```
92
List luminal aetiology of urinary tract obstruction
Calculus Clot Slough Cancer
93
List mural aetiology of urinary tract obstruction
Neuromuscular dysfunction Stricture Schistosomiasis
94
List extra-mural aetiology of urinary tract obstruction
Tumour Diverticulae Aneurysm Fibrosis
95
List clinical features of urinary tract obstruction
``` Loin pain, radiating to groin Anuria, polyuria Infection (fever, malaise) Dribbling Incompleteness Palpable kidney/bladder Distention ```
96
What investigations would you do for urinary tract obstruction?
Bloods: Cr, U+E, urine : Cr ratio Urine microscopy US scan Ureterogram if hydronephrosis (can use to drain)
97
Outline management of urinary tract obstruction
Upper tract - nephrostomy, stent, pyeloplasty | Lower tract - urethral/suprapubic catheter
98
What are renal calculi?
Consist of crystal aggregates and form in collecting ducts Ca oxalate stones (spiky) Ca phosphate stones (smooth)
99
What are the 3 main parts of the urinary tract susceptible to being blocked by stones?
Pelvio-ureteric junction Pelvic brim Vesico-ureteric junction
100
List aetiology/risk factors for renal stones
``` Dehydration Gout Hypercalcaemia UTI PKD Poor diet High vitamin D Drugs (loop diuretics, antacids, steroid, theophylline, aspirin) ```
101
List clinical features of renal stones
``` Renal colic Increased urine volume Haematuria Pallor, sweaty Vomiting Bladder irritation Scrotal pain ```
102
What investigations would you do for renal stones?
Bloods: FBC, U+E, Ca, PO4, glucose, bicarbonate, urate Mid-stream urine dipstick CT-KUB is diagnostic IV urogram, spiral CT
103
Outline management of renal stones
``` Analgesia - diclofenac IV Fluids Alpha blocker Antibiotic if infection Medical expulsion - nifedipine Shockwave lithotripsy Keyhole surgery (rare) ```
104
What are the 3 main types of urinary incontinence?
Stress: increased intraabdominal pressure causes leak from weak sphincter Urge: detrusor overactivity produces urgent desire to void Overflow: fully distended bladder causes leakage
105
List aetiology/risk factors for urinary incontinence
``` Prostate enlargement (overflow) Pelvic surgery, child birth (stress) Ageing Obesity Overactive bladder (urge) Caffeine Neuro disorder ```
106
What investigations would you do for urinary incontinence?
Standing-supine stress test | Urodynamic studies
107
Outline management of stress urinary incontinene
``` Pelvic floor exercises Electrical stimulation Pessary Duloxetine Colposuspension/sling surgery Taping ```
108
Outline management of urge urinary incontinence
``` Bladder diary Oestrogen for atrophic vaginitis Bladder training Absorbant pads Anti-muscarinic (oxybutynin) B3-agonist (mirabegron) Neuromodulation surgery ```

4MB Medicine (My version) (19 decks)

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