Nephrology & Urology 🫘 Flashcards
Patient needs fluids
No symptoms, except mild ortho static hypotension
How much?
2-4 L within 24 hours
Patient needs fluids
Patient is in pre shock
How much?
4-6 L within 24 hours
Patient needs fluids
Patient in shock
How much?
6-10L in 24 hours (1-2 L given at first and continue until stable)
When is HCO3 given
Severe acidosis (pH < 7.2) or (<7 in DKA)
Dextrose use?
To hydrate not resus
Hypernatremia algorithm, first question.
Urine Osmolality (<300 or >600)
Main DDX for patients with low urine osm and hypernatremia
DI (central and Nephrogenic)
How to Diff against central and nephrogenic DI
Give desmopressin
Next thing to check if hypernatremic patient has high urine osmolality
Check urine Na (high when taking in hypertonic saline, low when patient just losing fluids)
Rather than hyperNa algorithm, if patient presents with polyuria, how to do we invx
Water deprivation then desmopressin (DDX polydipsia, DI)
Central DI Mx
Desmopressin
Nephrogenic DI mx
Thiazide
When treating hyperna, what is the main thing we need to know
Volume status
Hypvolemic patient with hyperna, regardless of stability. How to Mx
Isotonic NaCl
Euvolemic patient with hyperna. How to Mx
D5W, or 0.45% NaCl
Hypervolemic hypernatremia Mx
D5W and diuretic combo
How to determine how much fluids needed in 24 hours in hyperna
(0.5 * weight) * (Na/140 - 1)
Second part of equation is sort of “excess Na”
Hyponatremia causing coma, siezure, usually occurs at what number
<120
Hyponatremia patient. Best initial test?
Serum osmolality
Hyponatremia and hypertonic serum osm. What’s going on here? What should we measure?
Likely another osmole. Measure glucose to rule out hyperglycaemia
Hyponatremia and isotonic serum osm. What’s going on here? What should we measure?
Like a pseudohyponatremia. Where lipids and proteins shift water in EC space. Measure lipids, Proteins. Don’t give Na
Hyponatremia and hypotonic serum osm. Assess what next
Volume status
Hyponatremia and hypotonic serum osm. And hypovolemic. Assess what?
FeNa
Hyponatremia and hypotonic serum osm. And hypovolemic. FeNa <1%. Causes
Losses of Na and water, not from kidney. Diahrrea, burns, third spacing (rarely as more hypervolemia)
Hyponatremia and hypotonic serum osm. And hypovolemic. FeNa >2%. Causes
Na and water loss renally. Diuretics, RTA, adrenal insuff
Hyponatremia and hypotonic serum osm. And euvolemic. Assess what?
Urine osmolality
Hyponatremia and hypotonic serum osm. And euvolemic. Urine osmolality above 100
SIADH (or hypothyroidism or GC deficiency = both cause high ADH)
Hyponatremia and hypotonic serum osm. And euvolemic. Urine osmolality below 100
Primary polydipsia, beer drinker
Hyponatremia and hypotonic serum osm. And hypervolemic. Measure what?
FeNa
Hyponatremia and hypotonic serum osm. And hypervolemic. FeNa < 1%. Causes and explanation
Proper low IV volume patients, will have higher ADH which causes low Na. Cirrhosis, CHF, nephrotic
Hyponatremia and hypotonic serum osm. And hypervolemic. FeNa > 2%. Causes
AKI and CKD
Main Tx of hyponatremia
0.9% NaCl
When consider hypertonic fluids for hyponatremia
If Na < 120/has seizures
Tx for hypovolemic hyponatremia.
0.9% NaCl
Risk of hypernatremia when treating hypovolemic hyponatremia. Tx of it?
As the patient becomes euvolemic, ADH rises and excretes free water only, causing hypernatremia. Give a little desmo if this occurs
Euvolemic hyponatremia Tx
Fluid restriction (usually an increased ADH case). Can do NaCl tablets/hypertonic fluids, loops if doesn’t work
Hypervolemic hyponatremia Tx
Fluid restriction (+- loops, ACEi). Cause of hyponat is likely due to fluids
SIADH specific Mx
Democlocylcine (NS worsens it)
Causes of hyperK
Hemolysis, ACEi, any kidney injury, TIV RTA, spirinolactone, insulin def, Beta blocker, DKA, digoxin, foods
Careful when correcting chronic hyponatremia?
Do > 72 hour duration. To avoid osmotic demyelination
Invx for suspected hyperkalemia
Repeat blood draw. Then ECG
If K above 6.5 or ECG changes. Initial Tx, and other follow up?
Ca Gluconate. Give insulin and glucose, B agonist, +- bicarb.
Tx if hyperkalemia, mild and no ECG changes
Patiromer, polysterene (kayexalate), loops, IV saline (if hypovolemic)
Tx for patients with CKD and hyperkalemia
Dialysis
Causers of hypokalemia
Insulin, B agonist, alkalosis, GI losses, loop, thiazide, 2° hyperaldosteronism, Barter/Gitelman, TII & I RTA, hypoMg, DKA Tx
Some stuff to Invx in hypokalemia
24 hour urine potassium and Cl. ABG. ECG. If HTN check aldosterone. Mg too
Mx for Barter and Gitelman
NaCl, KCl, Mg, spirinolactone for life,
Tx for hypokalemia
Oral potassium. IV potassium can cause phlebitis, only give for symptomatic hypokalaemia for ECG changes
Consider which other electrolyte when treating hypokalaemia
Magnesium
Main causes of hypercalcaemia
Primary and tertiary hyper parathyroidism, malignancy, milk alkali, high vitamin D, granulomatous diseases, supplementation, thiazides
I’m Best initial tests for high calcium.
Total and ionised calcium, albumin, phosphate, PTH
Other tests to order when determining hypercalcaemia
Vitamin D, PTHRP, ACE, ECG, protein electrophoresis
Treatment of calcium should be done in what circumstances
If more than 14 and or symptomatic
Calcium of more than 14, how to treat
Isotonic IV fluids plus or furosemide. And calcitonin. Bisphosphonate can also be given
Causes of hypocalcaemia
Hypo parathyroidism, secondary hyperparathyroidism, vitamin D deficiency, malnutrition, pancreatitis, blood products (Citrate 💪), hypomagnesaemia
Best tests for hypocalcaemia
Calcium and PTH
Aside from calcium and PTH, which of the tests should be ordered for hypocalcaemia
Magnesium albumin vitamin D buen and creatinine and ALP (depending on the circumstance)
Common scenario in patients with thyroid surgery, relating to calcium
Post thyroidectomy patient getting hypocalcaemia signs, from iatrogenic removal of the parathyroid gland
Treatment of hypocalcaemia
Treat underline disorder, oral calcium supplement, or IV if severe symptoms. Ensure magnesium repletion
Common populations to have low magnesium
Alcoholics, PPI patience, diuretics, malnutrition, TPN, diarrhoea and vomiting
How does low low magnesium affect calcium and potassium
Causes low calcium and potassium
Treatment for low magnesium
Oral or IV supplements depending on severity.
Timeframe for AKI Dx
Renal function decreasing in less than three months
Type A versus type B lactic acidosis
Type A: Tissue hypoxia
Type B: Decrease lactate clearance,
Bicarb is given to patients with metabolic acidosis, except which cause
Lactic acidosis
Guess the RTA.
A high urine pH, patient has history of SLE, patient has nephrolithiasis and a metabolic acidosis. Potassium is low
Type one (distal)
Guess the RTA.
Patient has metabolic acidosis, low potassium previously high urinary pH now becoming low.
Type two (Proximal
Guess the RTA.
Patient with Ricketts, severe low phosphate, High urinary pH, low serum potassium.
Patient has type two RTA, seen in Fanconi syndrome
Guess the RTA.
A metabolic acidosis, high potassium, patient is on spironolactone, urinary pH high or low
Type four
How to treat type one RTA
Potassium bicarb
How to treat type 2RTA
Sodium and potassium bicarb
Best treatment for chronic kidney disease patients to decrease the progression of the disease
ACE inhibitors or ARB
General treatment and management for chronic kidney disease patients
ACEI, EPO, phosphate binders, calcitriol, potassium restriction, supportive dietary management for fluids sodium potassium and phosphate
AKI. Stage one?

Creatinine up 50%, GFR down 25%, urine output less than 0.5 and six hours
AKI. Stage two?
Creatinine up 100%, GFR down 50%, urine output less than 0.5 in 12 hours
AKI . Stage three?
Creatinine up 200 percent, GFR down 75%, anuria for less than 12 hours
AKI. Stage four?
Complete loss of kidney function for more than a month
AKI. Stage five?
Complete loss of kidney function for less than three months
Treatment for prerenal AKI, and exceptions to this?
Fluid replacement, except for a hepato Renal, nephrotic syndrome, congestive heart failure
Treatment and management for post renal AKI
Urgent BladderScan and catheter to relieve any obstruction
Acute tubular necrosis, patient is asymptomatic with mild orthostatic hypotension. What is the management
Patient has mild fluid depletion, and is in oliguric phase of ATN. Replace 2 to 4 L within 24 hours
Patient with acute tubular necrosis. Patient has high heart rate normal blood pressure, and moderate high lactic acid. How to manage
Patient is in pre-shock, in oliguric phase of acute tubular necrosis. Replace 4-5 L within 24 hours
Patient with acute tubular necrosis has cool clammy hands, tachycardia, hypotension, lactic acidosis, mental status impairment. How to manage
Patient is in shock, secondary to the oliguric phase of acute tubular necrosis. Give 8 L within 24 hours. 1 to 2 of the litres should be given ASAP
Acute kidney injury, indications for dialysis
AEIOU
Long-term follow-up for AKI.
Evaluate patient at least yearly
Difference between ACR and PCR For protein collection
Albumin creatinine ratio has high sensitivity and can be done as a spot test. PCR is less sensitive and requires 24 hour collection
Patient has urine protein on urinalysis. Do what next
Repeat qualitative proteinuria testing
What is orthostatic proteinuria
An adolescent condition with benign proteinuria. Monitor periodically
After quantifying proteinuria, you find it’s more than 3 g. What does this point towards and what should we do
Points towards the glomerular disease, consider a biopsy
After quantifying proteins in proteinuria patience, you find it’s less than 3 g, it’s not pure albuminuria, and the monoclonal light chains on normal. What is a likely diagnosis
 Tubulointerstitial nephritis, explore autoimmune, allergy, medication et cetera
After quantifying proteinuria in proteinuria patient, you find it’s less than 3 g, and a protein immuno electrophoresis shows you it’s mainly albumin, what is a likely diagnosis
Glomerulosclerosis, for example diabetic nephropathy. Or could be a minimal change
What is overflow proteinuria
From too many proteins in the blood, seen in myeloma, HEMOLYSIS, rhabdomyolysis
What type of proteinuria is caused by UTIs, bladder cancer, nephrolithiasis
A post renal proteinuria, usually less than 1 g a day
Out of overflow, glomerular, tubulointerstitial, post renal, proteinuria Which usually have more than 3 g a day
Usually glomerular and overflow
Treatments for renal osteodystrophy in chronic kidney disease
 phosphate binders and calciminetics
How to treat metabolic acidosis in chronic kidney disease
Sodium bicarb
Treatment for anaemia in chronic kidney Disease
EPO
Diabetes patient, yearly exam shows GFR less than 60, dipstick haematuria negative. Patient reevaluated over three months later, GFR still less than 60, and ACR more than three. What’s your diagnosis
Chronic kidney disease
KDIGO, two categories to determine CKD
GFR and albuminuria
Ranges for A1 A2 A3, in the KDIGO staging of CKD
A1 = less than 30 mg
A2 = between 30 and 300 mg
A3 = above 300 mg
G1 to G5 Ranges, in the KDIGO staging of CKD (recall rule of 30, 15, 15, 15)
G1 = above 90
G2 = 60–89
G3A = 45–59
G3B = 30–44
G4 = 15–29
G5 = less than 15
Risk stratification for a patient with chronic kidney disease with G5 A2
Very high risk
Risk stratification in a patient with chronic kidney disease with G2 A2
Moderate-risk
Risk stratification for a chronic kidney disease patient with G4 A1
Very high
I risk stratification for a chronic kidney disease patient with G2 A1
Low risk
Risk stratification for a chronic kidney disease patient with G3A A2
High risk
Risk stratification for a chronic kidney disease patient with G2 A2
Moderate risk
Risk stratification for a chronic kidney disease patient with G1 A2
Moderate risk
Risk stratification for a chronic kidney disease patient with G1 A3
High risk
Risk stratification for a chronic kidney disease patient with G3B A1
High risk
Risk stratification for a chronic kidney disease patient with G3B A2
Very high risk
Risk stratification for a chronic kidney disease patient with G3A A3
Very high risk
Hypertensive patient with chronic kidney disease, first line treatment
ACE inhibitor
Patient with pruritus from uraemia, treatment
Antihistamine first generation
First line treatment for renal artery stenosis (medically and lifestyle)
Ace inhibitor and healthy eating/diet
 What is diabetic nephropathy screening
ACR, detecting micro albuminuria, Between 30 and 300 mg. Usually asymptomatic
Treatment for diabetic nephropathy
ACE inhibitors at first, then eventually may need dialysis/kidney transplant
Diagnosis Invx of nephritic syndrome
Do urinanalysis and renal biopsy
Treatment of post strep GN
Supportive, diuretics
Treatment of IGA GN
ACEI, glucocorticoids
Treatment of Wegners renal disease
High-dose corticosteroids, cytotoxic’s, or rituximab.
Treatment of microscopic polyangiitis
High-dose corticosteroids, cytotoxic’s, or rituximab.
Treatment of churg Strauss
High-dose corticosteroids, cytotoxic’s, or rituximab.
Treatment of good pastures
Plasma exchange, steroids, cyclo phosphide
Minimal change treatment
Steroids
Focal segmental glomerulosclerosis Tx
Prednisone, ACEI,
Treatment of membranous nephropathy
RAAS inhibition
Treatment for lupus Nephritis
Prednisone, or immuno surpression 
Treatment of membranoproliferative GN
Prednisone plus or minus immuno suppressant
Investigations for nephrotic syndrome
Urinanalysis, spot PCR, albumin and lipid blood test, renal biopsy
Which vaccine is needed in nephrotic syndrome and why
23 polyvalent pneumococcal vaccine, due to loss of Ig
After urinanalysis, what is the gold standard investigation to diagnose kidney stones
Non-contrast abdomen CT (KUB)
Aside from abdomen CT, which imaging is helpful to see progression/treatment of larger stones
X-ray
Medical therapy for calcium stones
Hydration, sodium restriction, thiazide diuretics. Consider citrate supplementation
Ethylene glycol and RTA type one cause what stone type
Calcium stones
Treatment (medically) for struvite stones
Hydration, antibiotics, but will most likely need surgical removal
Medical therapy for uric acid stone
Hydration, Alkalinise urine, Allopurinol
Medical therapy for cysteine stones
Hydration, sodium restriction, alkalinise urine, penicillinamine
Child or pregnant woman with kidney stones. First line imaging
Ultrasound
General medical therapy for all stones
Hydration, sodium restriction, analgesia, very often citrate
Kidney stone below 5 mm, treatment
Pain control and medical therapy, no other intervention
Kidney stone between 5–10 mm, therapy
The usuals. Alpha blocker or calcium channel blocker
When do we do shockwave lithotripsy for kidney stones
Between 10–20 mm, and stone is in the kidney, not in ureter. Not for very hard stones or patients on anticoagulation
When do we do semirigid ureteroscopy with laser fragmentation and basket extraction 
Usually stones between 10 to 20 mm, that are in the ureter, and patient can go home the same day
When do we do Flexible ureteroscopy with laser fragmentation
When kidney stone is between 10 to 20 mm, and stone is in the kidney/renal pelvis. Likely when lithotripsy cannot be done
When do we do percutaneous nephrolithotomy
Four stones above 20 mm, hard stones that cannot be accessed via flexible ureteroscopy, for staghorn calculi, or emergency cases
First investigation for PKD
Ultrasound or CT
Confirmatory investigation for PKD
Genetic testing, Although not necessary
Blood pressure control in PKD
Ace inhibitor
Why is tolvaptan used in PKD
ADH stimulates Cyst growth
Investigations for hydronephrosis
Ultrasound first, CT to find potential cause
Easiest and first test for UTI
Urine dipstick. Look for white blood cells and nitrates and leukocyte esterase
You have just done a urine dipstick and you see leucocytes and nitrates, what is the next step
Is midstream urine sample, to identify pathogen
If a patient has recurrent complicated UTIs, what is two investigations can we do
Ultrasound, x-ray KUB,
In UTI investigation, if you suspect con commitment malignancy what investigation do you do
CT urogram
When do we do a flexible cystoscopy in UTIs
Patients over 50 years old with haematuria
Diagnosis/investigations/initial Mx for acute pyelonephritis (kinda the same for acute and chronic)
Midstream urine sample and culture, empirical antibiotics (3rd gen ceph), ultrasound, blood tests and cultures
When do we worry about upper UTIs
Men, pregnant women, any child, any elderly, Frequent In women
Management of acute pyelonephritis, say as much as you can
I admit the patient (if signs of sepsis or systemic symptoms). ABC approach. Gain IV access, collect blood samples, IV fluids and resus, Do urinanalysis, MSU. Give empiric Comoxiclav and IV aminoglycoside if severe. Antibiotics should be given for at least 24 hours and then converted to oral for two weeks.
Investigation for vesicoureteral reflux
Micturating cystourethrogram, biopsy if evidence of scarring
Grade 1–5, of vesicoureteral reflux
Grade one – reflux into ureter
Grade 2 – reflux into renal pelvis
Grade 3 – mild to moderate dilation of ureter, pelvis, calyx
Grade 4– Dilation of pelvis, and calyx with ureteral tortuosity
Grade 5 – gross dilation of whole calycal system and severe tortuosity
Any prophylaxis we give to VUR patients?
Give prophylactic antibiotics.
What indications are there for VUR surgery
If a patient on prophylactic antibiotics has a breakthrough febrile UTI. All patients can be considered for surgery anyway
Follow-up management an investigation for VUR (given case when not doing surgical correction)
Monitor proteinuria, MSU, full blood count, blood pressure, ultrasound of kidney and bladder, cystogram every 1 to 2 years.
List some investigations in a haematuria case
Urine dipstick (to detect the haematuria), renal function to get GFR, ACR or PCR, urine microscopy
How to manage this patient? Less than 40 years old, hematuria, normal renal function no proteinuria and normotensive
No referral, just manage in primary care
How to manage this patient? A patient who is above 60 with haematuria, and the background of UTI
Non-urgent referral
Patient above 45, with unexplained haematuria (without UTI or persistent after treatment of UTI). How do you manage that patient
Urgent referral, within two weeks
Patient above 60 with hematuria, and no UTI
Urgent referral, within two weeks
Diagnosis of varicocoel
Doppler
Management overview of varicocoel
Conservative, but do surgery if painful or big enough for fertility affected. Surgery includes surgical debride meant and embolisation
Treatment of cryptorchidism
Orchidopexy at 6 to 18 months. If intra-abdominal, maybe do laparoscopy
Diagnosis of hydrocele
Clinical diagnosis. Ultrasound done if there is doubt
Management of infantile hydrocele
Watch and wait for the first two years, surgical correction after
Management of adult hydrocele
Conservative approach if small and asymptomatic
hematocele mx
Drainage or excision
Investigations for epididymitis/orchitis
STI screening, MSU, urinanalysis, blood tests for mumps and HIV, urgent Doppler to rule out torsion
Treatment of epididymitis/orchitis if secondary to STI
Doxy foxy
Treatment of epididymitis/orchitis if secondary to UTI
Fluoroquinolone
First investigation for testicular torsion
Ultrasound with Doppler
Management for testicular torsion
Emergency orchidectomy and orchidopexy. Do orchidopexy on other testy to
Paraphimosis management
Attempt manual retraction within three weeks, giving antibiotics and analgesics. If this fails do circumcision
If a child has penile lichen sclerosis, how to manage:
If assymp
If symp
Step up
If therapy doesn’t work
No treatment
Topical steroids
Tacrolimus
Circumcision
If urethra is involved in lichen sclerosis, what investigation must be done, and what treatments can be offered given that strictures have occurred
Cystourethroscopy to identify severity and location. If stricture has occurred must do dilation and direct visual internal urethrotomies
Any follow-up needed for a patient with lichen sclerosus
Yes, yearly follow-up to check for squamous cell carcinoma
Only treatment for phimosis
Circumcision
Some investigations ideas for BPH
Urinanalysis, and culture to rule out infections and he materia. PSA. Bloods to rule out obstructive uropathy. And bladder ultrasound scan to assess hydronephrosis.
Best initial therapy for BPH
Alpha blockers
After alpha blockers, what is the next best treatment for BPH
Five alpha reductase inhibitors
When do we do transurethral resection of the prostate
In patients with severe symptoms of BPH (renal problems, stones, UTI).
Not responsive to medical therapy
When do we do a transrectal ultrasound in BPH
Before starting finasteride or TURP, we need to know the prostate volume
PSA less than 4 versus PSA more than 10. What do we do?
Less than four do not biopsy. More than 10 biopsy
Patient has PSA between 4–10, you calculate the free : total PSA, which is less than 25%. What do you do
Biopsy
Most accurate test to diagnose prostate cancer
Ultrasound – guided transrectal biopsy
Once diagnosed prostate cancer, which of the investigations do we need to do
CT abdomen pelvis, and bone scan. MRI also good (shereen)
When do we watch and wait in prostate cancer
And if patients are low risk, Gleeson is 3+3, PSA less than 0.15, cancer is less than 50% of the biopsy,
Patients are elderly
Patients with prostate cancer who have watch and wait/active surveillance, what is this
Core biopsies taken, and re-biopsy, with yearly DRE and imaging and 6 monthly PSA
Treatment for bone pain in metastasis from prostate cancer
Radiation therapy
List five conditions which you should wait at least seven days after the resolution of, before testing PSA
BPH, prostatitis, UTI, DRC, sexual intercourse, catheterisation
Name a couple of therapies for prostate cancer
Brachyherapy (radioactive pellets injected into prostate), radiotherapy, da Vinci robotic prostatectomy
Do we screen for Bladder cancer
No
How to diagnose bladder cancer
Cystoscopy with biopsy
What imaging is needed for staging of bladder cancer
CT, or MRI
Treatment for bladder carcinoma in situ
Intravesicular chemo therapy
Treatment for non-muscle invading bladder cancer, that is low risk
Transurethral resection, then mitomycin and surveillance for six months
Treatment for non-muscle invading bladder cancer, that is intermediate risk
Transurethral resection, mitomycin and BCG and surveillance for three months
Treatment for non-muscle invading bladder cancer, that is high risk
Resect and BCG, and considered radical cystectomy
Treatment for muscle invading bladder cancer
Radical cystectomy, or radiotherapy alone for patients who are poor candidates for surgery, note this is the worst survival
Treatment for invasive bladder cancer with distant metastasis
Chemotherapy alone, consider this palliative
Use of Bosniak classification
To assess if a renal cyst needs a CT to rule out cancer.
It takes into account wall septation, calcification and enhancement
Best imaging investigation for renal cell carcinoma. How to confirm diagnosis
CT, then Histology on nephrectomy specimen
Stage one renal cancer
Less than 7 cm
Stage two renal cancer
More than 7 cm
Stage three renal carcinoma
Tumour spread into renal vein/IVC
Stage 4 renal cell carcinoma
Haematogenous spread
Small RCC Mx (and when to do active surveillance)
Active surveillance if: elderly/frail (CI for Sx), <4cm (stage 1 only), slow growth
Cryotherapy if above not applicable
Indications for when to do Partial nephrectomy for RCC
Mass less than 4-6 cm, patient has one kidney, or diseased kidneys, if tumour bilateral, (all makes sense )
Indication for radical nephrectomy for RCC
Large tumours, or inaccessible tumours
Aside from surgery, good Tx for RCC
Tyr kinase inhibitors, (not radio or chemo)
First invx for testicular mass
US (don’t biopsy!)
Seminoma localised to teste. Mx!
sperm bank visit. radical orchiectomy and Radiotherapy!
Non seminoma CA localised to teste, mx
Sperm bank visit. Radical orchiectomy, LN dissec and BEP
What is testicular microlithiasis
Calcified stones on teste, can mimic cancer
Who should have a contralateral teste biopsy, if germ cell CA diagnosed
If <40, and small contralateral teste
LDH is not sensitive or specific for any teste cancer, but does indicate what
Px
Teste cancer with abdominal mets. Mx?
Radical inguinal orchidectomy and chemo. BEP too
Pulmonary mets in Teste CA. Mx?
Chemo prior to radical inguinal orchidectomy
Invx for acute urinary retention syndrome
UA, urea/Cr, FBC, bladder US to confirm. Not PSA (falsely elevated)
Mx and for acute retention syndrome. What confirms the Dx (ml wise)
Catheter to decompress.
Vol > 400ml confirms Dx. <200 means not ARS. Between = clinical judgment
Mx for ureteral stenosis. And specifically at the UPJ
Stenting, and pyeloplasty if at UPJ
Time to appreciate KDIGO
Polycystic kidney disease diagnostic requirement in a less than 30-year-old
Two cysts total can be on the same kidney or on each kidney
Polycystic kidney disease, diagnostic requirement for patients aged 30 to 59
Need to do more cysts on each kidney. So four or more cysts in total
Diagnostic requirement for polycystic kidney disease, in patients 60 years or above
At least four cysts on each kidney. So a total of eight cysts or more
Management for most cases of HUS
Support of management; fluids, antihypertensives.
Plasma exchange only in severe cases with no diarrhoea
Haemodialysis impatience with AKI
The nice guidelines for fluid. How many mils per kilogram per day of water does a patient need
25 to 30 mls
According to nice, how much potassium, sodium, chloride is needed a day
1 MMOL/kg/day… Not what the doctor said
When does a patient have to stop taking Metformin in chronic kidney disease
When the GFR is below 30. But below 45 you should be cautious
Which screening test is used for polycystic kidney disease suspicion
Ultrasound
Patient 45 or above with unexplained hematuria without a UTI, or persistent after UTI treatment. What referral do we do
Urgent referral
Patient with chronic kidney disease, I want to do a contrast enhanced CT (of the lungs for example) what measures can we take to protect this patient
IV hydration before an after contrast infusion
Management off mild/moderate hypokalaemia (2.5–3.4) And no ECG findings
Oral potassium
Severe hypokalaemia management (less than 2.5) or symptomatic and ECG changes
Cardiac monitoring, potassium chloride in saline IV
2 variations of fluid therapy
Replacement and maintenance
Maintenance therapy requirements
2 L of fluid, 2 mmol per kilogram of sodium, 0.5 mmol per kilogram of potassium, 50 to 100 g of glucose
Example of good maintenance fluid regime
1 L saline, 1 L 5% dextrose, 20 minimal potassium chloride
When considering fluid replacement therapy what is the most important question to ask
Volume status
case of testicular torsion. how to Mx
book for surgical exploration… dont do US with doppler if it would delay time. (time is gonad)
Renal replacement indications
- Uraemic pericarditis
- Pulmonary oedema unresponsive to diuretic treatment
- Severe Hyperkalaemia
- Severe Acidosis
- Uraemic encephalopathy
Definition of AKI
Rise in serum creatinine >0.3mg/dl from
baseline within 48hrs. Or ↑ serum creatinine 1.5x from baseline, or urine output <0.5ml/kg for >6 hours
How much Na and K does a patient need per day?
150 of Na, 40 of K
Max decrease in Na per day in a hypernatremic patient?
around 10mmol
how to calculate fluid admin per day in chronic hypernat
first calc water deficit (like acute). Then calculate how much Na needs to be decreased by. (patient Na - 140). Since Na can only be decreased by 10 max, per day, you can calc how many days it takes to get to 140. Then calc volume/no. of days
Two Mx options for patient with renal stone who get hydronephrosis?
JJ stent or percutaneous nephrostomy
VUR patient, less than 1 years old. When to give prophlx ABx?
Give when the patient has grade 3-5 hydroneph. Be careful to give Abx in this age
When to do Sx for VUR?
Best way to prevent UTI. Give in all patients who have breakthrough UTI despite ABx prophlx
Prior to prostate CA biopsy, what is the best invx?
MRI
After acute urinary retention…. Post obstructuve diuresis Mx?
IV fluids. Recall pathogenesis of the diuresis
If patient with paraphimosis comes in with evidence of strangulation…how to Mx?
Ice, needle decompression, and inject hyaluronidase, analgesia. Refer for circumcision
Initial tests for epidydmo-orchitis? Consider if above or below 35
US to rule out torsion. MSU and culture for above 35 (likely uti), and first void urine if below 35 (likely STD).
Tx of epidydmoorchitis (if uti or std)
Analgesia and scrotal support…
STD: doxy foxy (azythromycin if neisseria)
UTI: -floxacin
Followup in 2 weeks
Lord and Jaboulay repair are used for what
Hydrocele Tx (if large/symptomatic)
What is the rule for correcting sodium levels in a patient with hyperglycaemia above 200
For every 100 mg/dL Above 200 of glucose, add a 1.6 to the sodium. For example a patient with 133 sodium and 400 glucose, is actually around 136 sodium
When do you actually give hypertonic saline for a patient who has hyponatraemia
If the sodium is less than 120, and all the patient has seizures
What are the contraindications for giving potassium for hypokalaemia
Illyus, bowel obstruction, ischaemic gut or pancreatic transplant 
Can acromegaly, adrenal insufficiency, Zollinger Ellison cause hypercalcaemia
The answer is yes
How much does calcium full body for every one decrease in albumin below 4
0.8
Treatment of a patient with calcium above 14
IV fluids (isotonic). Can also give Luke diuretics to. Calcitonin and bisphosphonate should be considered
Patient has serum calcium between 12 and 14, and is asymptomatic. What kind of treatment regime are you doing
They don’t require emergency treatment, but can give fluids or loops if you want
Most accurate test for hypercalcaemia And other lab tests we can do
Ionised calcium and PTH. Other labs include magnesium, albumin, vitamin D, and consider LP, BUN, creatinine
How to prevent contrast nephropathy
IV fluids or a non-ionic contrast agent
Definition of chronic kidney disease
GFR less than 60 (less than 90 in children) for more than three months regardless of course
What is the unique GFR definition for chronic kidney disease in children. And what is the most common cause of chronic kidney disease in children
GFR must be less than 90. And congenital abnormalities is the most common cause
Went to give statins to patients with chronic kidney disease
If they are above 50. Or if they’re both 18 and they have a coronary artery disease, diabetes, prior stroke
Patience with GFR is less than 30 and chronic kidney disease, what should the nephrologist start doing
Education should be started regarding renal replacement therapy and an AV fistula should be considered
Can cholesterol emboli cause nephritic syndrome
Yes. And C3 and C4 is low
General treatment for nephritic syndrome
AAS blockade, salt restriction, treat any hypertension, often glucocorticoids with another immuno suppressant
What is the cut off from the nephrotic syndrome Regarding protein to creatinine ratio
Two
General overview of treatment for nephrotic syndrome
RAAS blockade, statins, steroids with another immuno suppressant, ace inhibitors, and vaccinate with 23 PPV
Gold standard for diagnosing kidney stones
Non-contrast abdominal CT
Best test for imaging for kidney stones in pregnant women and children
Ultrasound
First aid algorithm for kidney stone treatment (surgical/urological approach)
Why is it important to manage UTIs quickly in PCKD patience
To prevent renal cyst infection
What is an unusual vascular cause of hydronephrosis
Aortic
Neurogenic bladder treatment
Clean intermittent catheterisation regime
Urinary tract obstruction treatment
Stent. Percutaneous nephrostomy
In what hydrocele type with increasing Valsalva increase the size of it
Communicating hydrocele
How does chronic prostatitis or chronic pelvic pain syndrome present
Irritation avoiding. Culture is negative
Treatment for chronic prostatitis or chronic pelvic pain syndrome
Alpha blockers or five alpha reductase inhibitors
 Risk factors for erectile dysfunction
TCA SSRI hypertension heart disease prostate cancer treatment spinal cord injury diabetes atherosclerosis
What is the diagnosis for erectile dysfunction
Clinical diagnosis. But check for neurological cause or hypergonadism. And then do screening for risk factors
First line therapy for erectile dysfunction
Sildenafil. Testosterone if hypergonadism. Psychotherapy if psychogenic
Second line for erectile dysfunction if sildenafil does not work or is contra indicated
Vacuum pumps, intracavernosal injections, another inflatable prosthesis
What is the first important investigation impatience with BPH symptoms
After digital rectal exam you should do your analysis and urine culture just to rule out infection and haematuria
Most accurate test to diagnose prostate cancer
Transrectal ultrasound guided biopsy
How to manage bone pain in prostate cancer met
Radiation therapy
When should screening for prostate cancer be earlier and more strongly indicated
In black men and first-degree relatives with prostate cancer. Normal screening can start at 50 years old
Diagnostic investigation for patients with bladder cancer suspect
Cystoscopy and biopsy
Best initial test and then confirmatory test for renal cell carcinoma
CT. Then Histology on nephrectomy specimen
Main treatment for localised renal cell carcinoma
Surgical resection of thermal ablation
Since response rates to radiation and chemo are low what is the best medication for renal cell carcinoma
Tyrosine kinase inhibitor is
Most common cancer in men Between 15 and 34
Testicular cancer
General treatment for seminoma testicular cancer 
Radical orchiectomy and chemo or radiotherapy
General treatment for nonseminomatous germ cell tumour
Retro peritoneal lymph node dissection with the radical orchiectomy
What can be added to the treatment regime of testicular cancer in advance cases
Platinum based chemo
A few possible regimes for uncomplicated UTI treatment
TNT SMX for three days or nitrofurantoin for 5 to 7 days
Do you need cultures for uncomplicated UTI
No it’s a clinical diagnosis. You culture only if treatment fails
What’s examples of complicated UTIs
Pregnant, co mobs like diabetes, infants, man, Immuno compromised, stance, catheter, systemic symptoms
Take me through some choices for treatment for complicated UTI
Fluoroquinolones, 3rd/4th gen Catholics foreign, TMP SMX.
Two antibiotic choices for a symptomatic bacteruria pregnant women
Amoxicillin or nitrofurantoin
When are prophylactic antibiotics given for UTIs
If a patient has two or more UTIs in six months. Or three or more infections in one year
Clinical suspicion for pyelonephritis, how to investigate
Blood cultures and urine cultures and urine analysis
If a patient with pyelonephritis has a high complication risk, how do you Further investigate
Do imaging (CTO ultrasound) to assess for anatomical causes
Haemodynamically stable patience. Treatment for pyelonephritis 
Outpatient care. Quinolones or 3rd/4th generation Catholics foreign OTMPS max
Haemodynamically unstable patients with pyelonephritis. How to treat
Inpatient care. Parental antibiotics including Kev trioxane, ampicillin, piperacillin, fluoroquinolone
Why 10 nitrofurantoin only be used for cystitis and not pyelonephritis
It cannot penetrate renal parenchyma only the bladder,
Severe Acute prostatitis treatment
Hospitalisation, IV antibiotics like a fluoroquinolone plus or minus Catholics foreign.
Mild acute prostatitis treatment
Patient, give TMP SMX or fluoroquinolone.
Treatment for prostatitis usually takes how long and why
4 to 6 weeks for acute, 6 to 8 for chronic. Take this long to achieve therapeutic levels in the prostate
Management of pyelonephritis associated abscess
Drain and continue antibiotics
How to confirm the diagnosis of acute prostatitis
 Your analysis and urine culture, blood cultures if haemodynamically unstable
10 days of increasing unilateral flank pain/tenderness. UTI symptoms (eg, dysuria, urinary urgency) are absent. urinalysis results often include pyuria. Hx of UTI month ago. Fever and chills present. Little weight loss.
Renal,abscess
AKI in patient who is older. And the Ca is high… sus?
Should be low most of the time. Consider myeloma
Cyclical hematuria and dysuria…. (Days before mense). UTI tests negative
consider endometriosis
If a hydro seal increases during Valsalva what does this tell us
That is his a communicating type
Describe some of the symptoms of interstitial cystitis
Pain when filling bladder, exercise, sexual intercourse, alcohol consumption, prolonged sitting. Pain is relieved and voiding. Diagnosis of exclusion. At least six weeks of LUTS
BPH patients who get recurrent UTIs or bladder stones or signs of renal insufficiency , this would be an indication to do what
This would be an indication to do some form of surgery (TURP or prostatectomy
AP essay above which level is heavily indicative of prostate cancer
10
What is bicalutamide
Androgen receptor blocker (decent for prostate cancer metastasis disease
Usual prostate cancer screening can start around 50 (this is quite flexible). But which to patient types would you consider doing earlier screening in
Positive family history, and first-degree relative
What age and above patient with haematuria, unexplained buy anything else, would you do a cystoscopy
35.
What is the most common malignancy and 15 to 34-year-olds
Testicular cancer
Although testicular cancer is more common in the 15 to 30-year-old range, what is the incidence mainly for seminomas
40 to 50. They have a bimodal age distribution
