Nephrology & Urology Flashcards
Indications for IV fluids?
Resuscitation
Maintenance
Replacement
Management of fluid resuscitation?
500mL 0.9% NaCl or Hartmann’s STAT
→ 250mL if at risk of fluid overload
250-500mL boluses up to 2000mL if needed
Daily water vs Na/K/Cl vs glucose requirement?
Water = 25-30mL/kg/day
Na/K/Cl = 1mmol/kg/day
Glucose = 50-100g/day
A 1L bag of IV fluid e.g. 0.9% NaCl contains how much water?
1L (you dumbass)
Caution with 0.9% NaCl vs Hartmann’s vs dextrose 5%?
0.9% NaCl = risk of hypernatraemia and hyperchloraemic metabolic acidosis
Hartmann’s = risk of hyperkalaemia
Dextrose 5% = do not use for fluid resuscitation
Maximum rate of K infusion?
No more than 10mmol/kg/hour
Features and most common cause of nephrotic vs nephritic syndrome?
Nephrotic = oedema, proteinuria (“frothy urine”), hypoalbuminaemia, hypercholesterolaemia,
→ minimal change disease (kids), FSGS (adults)
Nephritic = haematuria, hypertension, mild proteinuria, oliguria
→ IgA nephropathy
What causes hypercoagulability in nephrotic syndrome?
Antithrombin III loss via urine
Definition of AKI?
Rapid onset reduction in renal function causing oliguria and elevated serum urea + creatinine
Cause of pre-renal vs intrinsic vs post-renal causes AKI?
Pre-renal (most common) = ischaemia
Intrinsic = kidney damage
Post-renal = obstruction
Urine osmolality and urine sodium in pre-renal vs intrinsic AKI and explain?
Pre-renal = urine osmolality high, urine sodium low
→ kidneys concentrate urine and retain sodium to increase blood pressure
Intrinsic = urine osmolality low, urine sodium high
→ damaged kidneys fail to concentrate urine or retain sodium
Investigations for AKI?
U&Es
Urinalysis
Renal tract USS (if no cause found)
Biochemical features of AKI?
Hyperkalaemia
Hyperphosphataemia
Hyperuricaemia
High creatinine
Metabolic acidosis
Staging of AKI?
I = 1.5x creatinine baseline or reduction in urine output to < 0.5mL/kg/hour for ≥ 6 hours
II = 2.5x creatinine baseline or reduction in urine output to < 0.5mL/kg/hour for ≥ 12 hours
III = ≥ 3 x creatinine baseline or reduction in urine output to < 0.3mL/kg/hour for ≥ 24 hours
Management of AKI?
Stop nephrotoxic drugs!
Treat hyperkalaemia (if present)
Pre-renal = IV fluid challenge
Intrinsic = treat underlying cause, nephrology referral
Post-renal = catheterise, urology referral
Drugs which should be stopped in AKI?
NSAIDs (except aspirin at cardioprotective dose)
Aminoglycosides
ACEi/ARBs
Diuretics
Drugs which may become toxic in AKI?
Metformin
Digoxin
Lithium
Opioids
Management of hyperkalaemia?
< 6mmol/L = supportive, adjust medication
> 6mmol/L = ECG then treat if abnormal
≥ 6.5mmol/L = urgent treatment
→ IV calcium gluconate + IV insulin/dextrose or + nebulised salbutamol
Most common intrinsic AKI and causes?
Acute tubular necrosis
→ ischaemia or nephrotoxins
Urinalysis features of acute tubular necrosis?
Muddy brown casts
Renal epithelial cell casts
Most common cause of acute interstitial nephritis?
Drugs (especially antibiotics)
Features of acute interstitial nephritis?
AKI
Hypertension
Rash, fever
Eosinophilia
Most common type of glomerulonephritis?
IgA nephropathy
Outline management of glomerulonephritis?
1st line = supportive management
2nd line = ACEi/ARB
3rd line = steroid
Features of IgA nephropathy?
12-72 hours post-URTI
Nephritic syndrome (haematuria dominant)
Features of post-streptococcal glomerulonephritis?
7-14 days post-URTI
Nephritic syndrome (proteinuria dominant)
Investigation for IgA nephropathy vs post-streptococcal glomerulonephritis?
IgA nephropathy = renal biopsy
Post-strep = anti-streptolysin O titre
Biopsy features of membranous glomerulonephritis?
Thickened basement membrane
IgG and complement deposits
“Spike and dome” appearance
Biopsy feature of minimal change disease?
Fusion of podocytes
Biopsy feature of rapidly progressive glomerulonephritis?
Epithelial crescents
Biopsy features of FSGS?
Focal and segmental sclerosis
Features of Henoch-Schönlein purpura (HSP)?
Post-URTI
Vasculitis → purpuric rash
Abdominal pain
Arthralgia/Arthritis
IgA nephropathy
Monitoring of Henoch-Schönlein purpura (HSP)?
BP and urinalysis for 6-12 months
Features of rhabdomyolysis?
AKI
PMH trauma e.g. long lie
Muscle pain and swelling
Red/brown “tea coloured” urine
Biochemical features of rhabdomyolysis?
Severely raised CK
Raised LDH
Hypocalcaemia (Ca absorbed by muscle)
Hyperkalaemia/phosphataemia/uricaemia
Features of haemolytic uraemic syndrome (HUS)?
Triad of:
→ AKI
→ microangiopathic haemolytic anaemia
→ thrombocytopaenia
Blood film features of HUS?
Reticulocytes
Schistocytes
Most common causes of CKD?
Diabetes
Hypertension
Chronic glomerulonephritis
Polycystic kidney disease
Staging of CKD?
I = GFR > 90ml/min with evidence of kidney damage
II = GFR 60-90ml/min with evidence of kidney damage
III = GFR 30-59ml/min
IV = GFR 15-29ml/min
V = GFR < 15ml/min
N.B. patients are usually asymptomatic until IV or V
eGFR variables?
CAGE:
Creatinine
Age
Gender
Ethnicity
Investigation and management of CKD proteinuria?
Albumin:creatinine ratio
Management = ACEi/ARB
Complications of CKD?
Fluid overload → hypertension, oedema
Hyperkalaemia → arrhythmias
Hyperuricaemia → itch, pericarditis, encephalopathy
Low EPO → anaemia → LVH
Low vitamin D → hypocalcaemia/hyperphosphataemia → bone disease, secondary/tertiary hypoparathyroidism
Management of CKD anaemia?
1st line = correct iron deficiency (oral or IV)
2nd line = EPO injections
Management of CKD bone disease?
1st line = low phosphate diet
2nd line = phosphate-binders (sevelamer) + vitamin D analogue (alfacalcidol)
Total parathyroidectomy for tertiary hyperpathyroidism
Renal USS feature of CKD and exception?
Bilateral small kidneys
Enlarged in early diabetic nephropathy
Renal failure definition?
eGFR < 15mL/min (stage V CKD)
Management of renal failure and options?
Renal replacement therapy (RRT)
→ haemodialysis
→ peritoneal dialysis
→ renal transplant
Indications for dialysis?
AEIOU:
Acidosis (pH <7.2)
Electrolyte (hyperkalaemia >7)
Intoxication (poisoning)
Oedema (pulmonary)
Uraemia (uraemic pericarditis, encephalopathy)
Surgery required prior to haemodialysis and timescale?
Creation of arteriovenous fistula
At least 8 weeks before
Most common cause of peritoneal dialysis peritonitis?
Staphylococcus epidermidis
Management of hyperacute (minutes) vs acute (<6 months) renal transplant rejection?
Hyperacute = removal of graft
Acute = steroids/immunosuppressants
Post-surgical infection vs malignancy linked to renal transplant?
Infection = CMV
Malignancy = SCC
Features of ADPKD?
Renal failure
Haematuria
Flank pain
Hypertension
Palpable kidneys
Extra-renal manifestations of ADPKD?
Liver cysts (most common)
Berry aneurysms
Heart valve disease
Investigation and management of ADPKD?
Investigation = renal USS
Management = anti-hypertensives, tolvaptan (slows cyst formation)
Most common renal malignancy?
Renal cell carcinoma (clear cell)
Features and management of renal cell carcinoma?
Frank haematuria
Flank/loin pain
Palpable abdominal mass
Left-sided varicocele
Management = partial or total nephrectomy
Paraneoplastic features of renal cell carcinoma?
Polycythaemia
Hypertension
Hypercalcaemia
Stauffer syndrome (deranged LFTs)
Renal malignancy seen in children?
Nephroblastoma (Wilm’s tumour)
Features and investigation of renal colic?
Loin to groin pain
Haematuria
N&V
Investigation = non-contrast CT KUB
Most common composition of renal stone?
Calcium oxalate
Investigation and management of renal stone?
Investigation = non-contrast CT KUB
Management = NSAID (e.g. diclofenac), < 5mm should pass on their own, medical management (e.g. tamsulosin) or shockwave lithotripsy/nephrolithotomy
Invasive management of choice for renal stone in pregnancy?
Ureteroscopy
Management of ureteric obstruction?
Urgent surgical decompression e.g. stent
Most common causes of UTI?
E.Coli (most common)
Klebsiella
Enterococcus
Pseudomonas
Staphylococcus saprophyticus
Features of a UTI?
Dysuria
Smelly urine
Urinary frequency/urgency/hesitancy
Suprabubic/back pain or discomfort
Urine dipstick features of UTI?
Leukocytes
Nitrites
Haematuria
Who needs a urinalysis to confirm UTI?
Children
Pregnant
Men
Catheterised
Management of UTI in women?
Non-pregnant = nitrofurantoin or trimethoprim 3 days
Pregnant = nitrofurantoin (1st line), amoxicillin or cefalexin (2nd line)
Management of UTI in men?
Nitrofurantoin or trimethoprim 7 days
Management of UTI in catheterised patients?
Only treat if symptomatic
Remove or change the catheter
Features, investigation and management of pyelonephritis?
Fever
N&V
Flank/loin/back pain
UTI symptoms e.g. dysuria
Investigation = MSU
Management = broad-spectrum antibiotics
Investigation and management of hydronephrosis?
Investigation = renal tract USS
Management = nephrostomy tube
Most common bladder cancer?
Transitional cell carcinoma
Risk factors for transitional cell carcinoma?
Smoking
Aniline dye exposure
Cyclophosphamide
Investigation and management of bladder cancer?
Investigation = cystoscopy
Low grade = TURBT +/- chemotherapy
High grade = surgery e.g. cystectomy
Features of acute vs chronic urinary retention?
Acute = anuria, suprapubic pain, confusion
Chronic = typically painless
Investigation and management of acute urinary retention?
Investigation = bladder USS
Management = treat underlying cause, catheterise
Complication after relieving urinary retention?
Post-obstruction diuresis
Voiding vs storage symptoms?
Voiding = hestitancy, straining, spraying, weak or intermittent flow, terminal dribbling, incomplete emptying
Storage = frequency, urgency, nocturia, incontinence
Investigation for lower urinary tracy symptoms (LUTS) in men?
Urodynamic studies
Drug options for overactive bladder?
1st line = antimuscarinic e.g. oxybutynin, tolterodine
2nd line = mirabegron
Features of BPH?
Voiding symptoms
Storage symptoms
Complications e.g. UTI
Investigations of BPH?
PSA
Urinary dipstick
Urine frequency-volume chart
International prostate symptom score (IPSS)
Management of BPH?
1st line = alpha-agonist (e.g. tamsulosin)
2nd line = 5-alpha-reductase inhibitor (e.g. finasteride)
3rd line = combination therapy of above
4th line = surgery e.g. TURP
Alpha-agonist example, mechanism of action and side effects?
Example = tamsulosin
Mechanism of action = reduces smooth muscle tone of the bladder and prostate
Side effects = postural hypotension
5-alpha-reductase inhibitor example, mechanism of action and side effects?
Example = finasteride
Mechanism of action = decreases prostate size by inhibiting conversion of testosterone to dihydrotestosterone
Side effects = erectile dysfunction, gynaecomastia
Advice on starting finasteride?
Can take up to 6 months for improvement
Counselling on PSA test?
- PSA is a protein made by prostate cells
- High levels may indicate prostate cancer
- Disadvantages: raised PSA does not mean cancer, low PSA does not exclude cancer
- If elevated, may indicate need for biopsy +/- treatment which may not be necessary
Factors which can elevate PSA?
Acute urinary retention
Benign Prosthetic Hypertrophy
Recent ejaculation
PR examination
Urethral instrumentation
Urinary tract infection
Prostatitis
Prostate cancer
Investigations for prostate cancer?
Multiparametric MRI
Prostate biopsy
Management of prostate cancer?
Low grade = watch and wait
High grade = radiotherapy, prostatectomy, hormonal therapy
Posterior scrotal lump separate to the body of the testicle?
Epididymal cyst
Soft, non tender swelling of the hemi-scrotum which transilluminates?
Hydrocele
Patient with fertility issues with scrotum that feels like a bag of worms?
Varcicocele
Investigation for scrotal/testicular lumps?
USS or USS + doppler (varicocele)
Red, swollen testicle that has retracted upwards?
Testicular torsion
Management of testicular torsion?
Bilateral orchidopexy
Swollen testicle with dysuria and urethral discharge?
Epididymo-orchitis
Most common causes of epididymo-orchitis?
Young = STIs e.g. chlamydia
Older = E.Coli
Investigation and managament of epididymi-orchitis?
Investigation = NAAT for STIs, MSU
Management = treat underlying cause
Features to differenciate testicular torsion vs epididymo-orchitis?
Pain will ease on elevation of testis in epididymo-orchitis, not in testicular torsion
Cremasteric reflex is lost in testiclar torsion
Features and management of acute bacterial prostatitis?
Generally unwell e.g. fever
Penis/perineum/rectum/back pain
Voiding symptoms
Management = quinolone for 14 days
Management of balantitis?
Saline wash
Topical steroid/antifungal/antibiotic
Circumcision if recurrent
Phimosis vs paraphimosis?
Phimosis = tight foreskin can’t be retracted
Paraphimosis = foreskin stuck behind glans penis, medical emergency!!
What needs to be ruled out before circumcision?
Hypospadias
Investigations and management of erectile dysfunction?
Free testosterone (between 9am-11am)
If low, repeat with FSH, LH and PRL
Management = sildenafil
Prevention of contrast-induced nephropathy?
IV 0.9% NaCl infusion
Anion gap calculation and causes of normal vs raised?
(Na + K) - (Cl + HCO3)
Normal = HCO3 loss e.g. diarrhoea, renal tubular acidosis, Addison’s disease
Raised = high lactate, high ketones, high urate, acid poisoning e.g. salicylate
Cause of type 1 vs type 2 RTA and biochemical complication?
Type 1 = poor H+ excretion
Type 2 (Fanconi) = poor HCO3- reabsorption
Hyperchloraemic metbaolic acidosis
