Nephrology Flashcards
Define oliguria
Reduced urine output, usually less than 0.5 ml/kg/h
What does specific gravity on urinalysis measure?
Osmolality of urine
Increased osmolality in diabetes, dehydration, adrenal insufficiency
Decreased osmolality in diabetes insipidus, renal failure
What are casts (found on urinary microscopy)?
Cylindrical bodies formed in lumen of distal tubules, usually due to breakdown/inflammatory processes
List indications for renal biopsy
Unexplained renal failure Acute nephritic syndrome Unexplained proteinuria/haematuria Planning therapy Autoimmunity (SLE, Goodpasture's, GPA)
List contraindications to renal biopsy
Abnormal clotting Hypertension over 160/90 Single kidney Chronic renal failure with small kidney Abnormal anatomy
UTI is highly suspected if there is bacteriuria with greater than how many organisms per mL of fresh mid-stream urine?
Greater than 10^5 organisms
List the main conditions for upper and lower UTI
Upper: pyelonephritis
Lower: urethritis, cystitis, prostatitis
List aetiology/risk factors for UTI
Females (short, wide urethra) Sexual intercourse Spermicide use Pregnancy Menopause Immunosuppression Catheterisation UT obstruction (stones)
List the main organisms that cause UTI’s
E. coli Klebsiella Enterococci Proteus Pseudomonas (esp catheters) Staph saphrophyticus in women of child-bearing age
List clinical features of upper UTI
Loin pain Tender Fever Rigors Vomiting Oliguria
List clinical features of lower UTI
Frequency Dysuria Haematuria Suprapubic pain Backache Urgency Strangury
What investigations would you do for suspected UTI?
Mid-stream urine sample Urinalysis Microscopy/culture Bloods: FBC, U+E, CRP US scan, IV urogram, cystoscopy
Outline management of UTI
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
What is glomerulonephritis?
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%
What is the commonest type of glomerulonephritis worldwide?
IgA nephropathy
List clinical features of IgA nephropathy
Episodic macroscopic haematuria
Post-URTI
Proteinuria
What investigations would you do for IgA nephropathy?
Renal biopsy
Immunofluorescence shows IgA and C3 deposits
Outline management of IgA nephropathy?
Prednisolone
Cyclophosphamide if progressively worsening renal function
What is Goodpasture’s disease?
Anti-glomerular-basement-membrane antibodies destroy type IV collagen of the glomerulus
List clinical features of Goodpasture’s syndrome
Macroscopic haematuria
Oliguria
Haemoptysis
Renal failure
What investigations would you do for Goodpasture’s syndrome?
Antibody screen
Urine output
IgG detection
Presence of crescents on renal biopsy
Outline management of Goodpasture’s syndrome
Plasmapharesis
Steroids
Cytotoxics
List aetiology/risk factors for rapidly progressive glomerulonephritis
Immune complex -mediated Post-infection Henoch-Schonlein purpura IgA nephropathy Vasculitis (GPA, EGPA) Goodpasture's syndrome Drugs
List clinical features of rapidly progressive glomerulonephritis
Systemic upset
Fever
Haemoptysis
Pulmonary haemorrhage
What investigations would you do for rapidly progressive glomerulonephritis?
Renal biopsy shows crescents Antibody screen (ANCA)
Outline management of rapidly progressive glomerulonephritis
High dose (IV) methylprednisolone + cyclophosphamide Plasmapharesis
What is nephrotic syndrome?
Protein leakage into urine due to non-proliferative damage to the glomerular basement membrane
List the core triad of features of nephrotic syndrome
More than 3g of protein in urine in 24h
Hypoalbuminaemia
Oedema
What are the principles of management of nephrotic syndrome?
Restrict sodium (reduce oedema)
Diuretic
ACE inhibitor
What is the commonest cause of nephrotic syndrome in children?
Minimal change nephropathy
What type of cancer is minimal change nephropathy particularly associated with?
Hodgkin’s lymphoma
What investigations would you do for minimal change nephropathy?
Selective proteinuria - check albumin
Normal light microscopy
Electron microscopy shows fused podocytes
Outline management of minimal change nephropathy
Steroids
Cyclophosphamide/ciclosporin if relapses
What is the commonest cause of nephrotic syndrome in adults?
Focal segemental glomerulosclerosis
List aetiology/risk factors for focal segmental glomerulosclerosis
Primary (idiopathic) Secondary to Alport's syndrome IgA nephropathy Vasculitis Obesity Reflux disease Heroin use
What investigations would you do for focal segmental glomerulosclerosis?
Segmental glomerulosclerosis on light microscopy
IgM and C3 levels
Outline management of focal segmental glomerulosclerosis
Steroids
Cyclophosphamide/ciclosporin if resistant
List aetiology/risk factors for membranous nephropathy
Malignancy
Drugs - gold, penicillamine, captopril
Autoimmunity
Infection (hepatitis B)
What investigations would you do for membranous nephropathy?
Diffuse thickened glomerular basement membrane on microscopy
IgG, C3 deposits
Anti-PLA2r antibody
Outline management of membranious nephropathy
Steroid
Cyclophosphamide if worsening renal function
What is nephritic syndrome?
Proliferative damage to glomerular endothelium, causing blood to leak through into urine
List aetiology/risk factors for nephritic syndrome
Post-Strep glomerulonephritis
IgA nephropathy
Rapidly progressive glomerulonephritis
List clinical features of nephritic syndrome
Haematuria Proteinuria Oliguria Oedema Mild hypertension
What would you see on microscopy in nephritic syndrome?
Red cell casts
How is nephritic syndrome treated?
Treat the underlying cause
List clinical features of renal vein thrombosis
Asymptomatic Loin pain Haematuria Palpable kidney Reduced renal function Pulmonary embolism
What investigations would you do for renal vein thrombosis?
Doppler USS
CT/MRI angiography
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
List pre-renal aetiology for acute renal failure
Mainly hypoperfusion caused by Haemorrhage Sepsis Heart failure Renal artery stenosis ACE inhibitors NSAIDs
List intra-renal aetiology for acute renal failure
Acute tubular necrosis caused by ischaemia/nephrotoxins Vasculitis Malignant hypertension Haemolytic uraemic syndrome Glomerulonephritis
List post-renal aetiology for acute renal failure
Mainly urinary tract obstruction due to
Stones
Tumour
Compression
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
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
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
Define chronic renal disease
Kidney damage lasting more than 3 months
Based on abnormal physical findings or GFR less than 60 +- kidney damage
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
List aetiology/risk factors for chronic kidney disease
Hypertension Diabetes Chronic glomerulonephritis Vasculitis Polycystic kidney disease Stones Haemolytic uraemic syndrome
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
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
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
List problems/complications of haemodialysis
Hypotension Arrhythmia Time-consuming (3-4x a week) Thrombosis Stenosis Infection
List problems/complications of peritoneal dialysis
Peritonitis Malfunction Hernia Back pain Anaemia Bleeding Infection
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
Give examples of exogenous nephrotoxins
NSAID’s
Antimicrobials (gentamicin, vancomycin, tetracycline, aciclovir)
Radiocontrast (IV)
Anaesthetic agents
Cisplatin chemotherapy
ACEi
Immunosuppressants (ciclosporin, methotrexate)
Give examples of endogenous nephrotoxins
Excess haemolysis causing haemoglobinuria
Myoglobin (rhabdomyolysis)
Urate crystals
Ig chains e.g. in myeloma
What is tubelointerstitial nephritis?
Inflammation of renal interstitium
List aetiology/risk factors for tubelointerstitial nephritis
Drugs Infection (Staph, Strep, Brucella) Glomerulonephritis Chronc pyelonephritis Sickle cell disease Fibrosis
What is rhabdomylosis?
Skeletal muscle breakdown causes myoglobin, PO4, urate and Cr release which is nephrotoxic
List aetiology/risk factors for rhabdomyolyisis
Post-ischaemia Infection Embolism Immobilisation Trauma Drugs (statins, fibrates, alcoohl, ecstasy, heroin)
List clinical features of rhabdomyolysis
Red-brown urine
Muscle pain
Swelling
What investigations would you do for rhabdomyolysis?
Grossly elevated CK
Myoglobinuria
No red cells on microscopy
Hyperkalaemia
Outline management of rhabdomyolysis
Urgently treat hyperkalaemia
IV fluids
Maintain urine output
What is polycystic kidney disease?
Most common inherited nephropathy, usually presents in adulthood
Abnormality in PKD1 (c16) or PKD2 (c4)
List clinical features of polycystic kidney disease
Loin pain Haematuria Abdo pain Hypertension Subarachnoid haemorrage Mitral prolapse Infection
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
Where does renal cell carcinoma typically arise?
Proximal tubular epithelium
List clinical features of renal cell carcinoma
Asymptomatic Haematuria Loin pain Flank mass Anorexia Malaise Weight loss Polycythaemia Varicocele if left renal vein affected
Outline management of renal cell carcinoma
Partial nephrectomy if bilateral
Full if unilateral
Which parts of the urinary tract does transitional cell carcinoma typically affect?
Bladder
Ureter
Renal pelvis
List aetiology/risk factors for transitional cell carcinoma
Smoking
Rubber industry
Chronic cystitis
Schistosomiasis
List clinical features of transitional cell carcinoma
Painless haematuria Frequency Urgency Dysuria UT obstruction Irritation
What investigations would you do for transitional cell carcinoma?
Urine cytology
Cystoscopy + biopsy
CT/MRI
IV urogram
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
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
List clinical features of benign prostatic hyperplasia
Difficulty starting Poor flow Nocturia Acute retention Overflow incontinence
What investigations would you do for benign prostatic hyperplasia?
PR exam
Abdo USS
Mid-stream urine
USS-guided biopsy
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
Prostatic adenocarcinoma arises peripherally. True/False?
True
So symptoms occur later
List clinical features of prostatic adenocarcinoma
Asymptomatic Nocturia Back pain Weight loss Anaemia Hesitancy Poor stream UT obstruction symptoms
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
Outline management of prostatic adenocarcinoma
Radiotherapy Hormone therapy Transurethral resection if obstructed Orchidectomy if mets GNRH analogue (goserelin) Anti-androgen (flutamide)
List luminal aetiology of urinary tract obstruction
Calculus
Clot
Slough
Cancer
List mural aetiology of urinary tract obstruction
Neuromuscular dysfunction
Stricture
Schistosomiasis
List extra-mural aetiology of urinary tract obstruction
Tumour
Diverticulae
Aneurysm
Fibrosis
List clinical features of urinary tract obstruction
Loin pain, radiating to groin Anuria, polyuria Infection (fever, malaise) Dribbling Incompleteness Palpable kidney/bladder Distention
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)
Outline management of urinary tract obstruction
Upper tract - nephrostomy, stent, pyeloplasty
Lower tract - urethral/suprapubic catheter
What are renal calculi?
Consist of crystal aggregates and form in collecting ducts
Ca oxalate stones (spiky)
Ca phosphate stones (smooth)
What are the 3 main parts of the urinary tract susceptible to being blocked by stones?
Pelvio-ureteric junction
Pelvic brim
Vesico-ureteric junction
List aetiology/risk factors for renal stones
Dehydration Gout Hypercalcaemia UTI PKD Poor diet High vitamin D Drugs (loop diuretics, antacids, steroid, theophylline, aspirin)
List clinical features of renal stones
Renal colic Increased urine volume Haematuria Pallor, sweaty Vomiting Bladder irritation Scrotal pain
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
Outline management of renal stones
Analgesia - diclofenac IV Fluids Alpha blocker Antibiotic if infection Medical expulsion - nifedipine Shockwave lithotripsy Keyhole surgery (rare)
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
List aetiology/risk factors for urinary incontinence
Prostate enlargement (overflow) Pelvic surgery, child birth (stress) Ageing Obesity Overactive bladder (urge) Caffeine Neuro disorder
What investigations would you do for urinary incontinence?
Standing-supine stress test
Urodynamic studies
Outline management of stress urinary incontinene
Pelvic floor exercises Electrical stimulation Pessary Duloxetine Colposuspension/sling surgery Taping
Outline management of urge urinary incontinence
Bladder diary Oestrogen for atrophic vaginitis Bladder training Absorbant pads Anti-muscarinic (oxybutynin) B3-agonist (mirabegron) Neuromodulation surgery
