Nephrology & Urology Flashcards
Normal PaCO2
35-45 mmHg
Normal PaO2
85%
Normal HCO3
22-32 mmol/L
Normal PH
7.40-7.45
urinary urgency + urinary frequency + nocturia
Overactive bladder
Peaked T-waves are seen in lead V2,V3,V4 and V5 + widening of QRS, decreased amplitude of P waves
hyperkalaemia
ACE inhibitors + spironolactone
Increased risk of hyperkalaemia
The combination of ACE inhibitors and spironolactone increases the risk of hyperkalemia due to their complementary mechanisms of action on the renin-angiotensin-aldosterone system (RAAS), both leading to reduced potassium excretion.
1. ACE Inhibitors: • ACE inhibitors (e.g., lisinopril, enalapril) block the conversion of angiotensin I to angiotensin II. • Angiotensin II normally stimulates the release of aldosterone from the adrenal glands. • Aldosterone promotes sodium and water reabsorption in the kidneys and potassium excretion. • By inhibiting this pathway, ACE inhibitors lead to reduced aldosterone levels, resulting in decreased potassium excretion and potential hyperkalemia. 2. Spironolactone: • Spironolactone is an aldosterone antagonist, meaning it directly blocks the action of aldosterone on its receptors in the kidneys. • This further reduces sodium reabsorption and potassium excretion. • Since aldosterone’s effect is to promote potassium excretion, blocking it with spironolactone leads to retention of potassium.
Causes of hyperkalaemia
RAAMUN
– Renal failure.
– Metabolic acidosis.
– Addison’s disease.
– Use of aldosterone antagonists like spironolactone.
– ACEi.
– NSAIDs.
Renal stone recurrence management
- Increase water intake about 2.5 to 3 litres/day
- calcium-rich foods
- thiazide diuretics
- lewer oxalate-rich foods (Oxalate stones)
- Allopurinol
- urinary alkaliniser (potassium citrate)
Renal stones initial investigation
1st case: CT KUB
2nd recurrent: ultrasound + X-ray KUB
Renal stones diagnostic investigation
spiral CT KUB non-contrast
alkaline urine + “Staghorn calculi”
Struvite stones
Proteus pathogen renal stone
Struvite
-magnesium ammonium phosphate
Uric acid stone treatment
- Allopurinol
- urine alkalinization
Oxalate stone treatment
Renal stones in renal pelvis management
< 2.5cm: Extracorporeal lithotripsy
< 2.5cm: Percutaneous lithotripsy
Renal stones in ureter
Upper half < 1cm: Lithotripsy
Upper half: >1 cm: Lithotripsy or nephrolithotomy
Lower half < 1cm: Lithotripsy
Lower half > 1cm: Lithotripsy or endoscopy
Renal stones in bladder
< 3cm: Transurethral lithotomy
> 3cm: Cystotomy
Low potassium + hypertension
Investigations
Investigate serum aldosterone
Most common complication of radical prostatectomy
Erectile Dysfunction (ED)
Premature ejaculation treatment
1st line: SSRI (raises orgasm threshold)
main complication of retroperitoneal lymph node dissection (RPLND)
Retrograde ejaculation
most common complication of TURP
Urinary tract infection (UTI)
UTI requiring hospitalisation
any infant < than 3 months
- increased risk of urosepsis
Infant UTi treatment
- IV trimethoprim/gentamicin, benzyl penicillin
Erectile Dysfunction (ED) management
Initial :
- Optimise modifiable risk factors / related comorbidities (HTN, DM, diet/exercise etc)
- Treat reversible causes
(Low testosterone, Medication-induced erectile dysfunction, Psychogenic erectile dysfunction – consider referral to a therapist)
- Pharmacological/Surgical treatment
- 1st line: phosphodiesterase type 5 inhibitor (sildenafil)
- 2nd line: penile injections, vacuum erection devices, external shock wave lithotripsy
3rd line: penile prosthesis
polycystic kidney disease features
- Polyuria and nocturia
– Renal failure
– Hypertension
– Abdominal wall and inguinal hernias
– Colonic diverticulosis
– Hepatic cysts
– Subarachnoid or cerebral haemorrhage
– Cardiac anomalies including mitral valve prolapse
albuminuria in diabetes
first void spot specimen Urinary albumin to creatinine (ACR) ratio
URTI + proteinuria + haematuria + immediate onset
IgA nephropathy
IgA nephropathy treatment
Asymptomatic microscopic haematuria: 2 positive
UAs out of 3 in 2-3 weeks
Symptomatic: corticosteroids
URTI + proteinuria + haematuria + onset within weeks + facial oedema
Poststreptococcal glomerulonephritis (PSGN)
HIV px + taking indinavir + haematuria + loin pain
Indinavir induced nephrolithiasis
- Only detectable on US
- Remove/Change indinavir
onset within weeks + HIV hx + haematuria + proteinuria
Focal segmental glomerulosclerosis (FSGS)
HIV-associated nephropathy (HIVAN)
-Nephrotic range proteinuria
-Azotaemia
-Normal to large kidneys on ultrasound images
-Focal segmental glomerulosclerosis (FSGS)
shortened QTc interval on ECG
Severe hypercalcaemia
Dialysis indications
- Pericarditis or pleuritis (urgent indication).
- Progressive uraemic encephalopathy or neuropathy (confusion,
asterixis, myoclonus, wrist or foot drop, or, in severe cases, seizures (urgent indication). - A clinically significant bleeding diathesis attributable to uraemia (immediate indication).
- Persistent metabolic disturbances that are refractory to medical therapy (hyperkalemia, metabolic acidosis, hypercalcemia,hypocalcemia,
hyperphosphatemia) - Fluid overload refractory to diuretics
Dialysis metabolic abnormalities
- hyperphosphatemia
- Vitamin D deficiency
- hypocalcaemia
- secondary hyperparathyroidism
- hyperphosphataemia
Dialysis skeletal abnormalities
renal osteodystrophy:
- Osteomalacia
- osteosclerosis
- osteitis fibrosa cystica
Most common acute complication of haemodialysis
Hypotension
Paradoxical hypertension
Increase dialysis duration
Over dialysis cause paradoxical high bp and hypotension
Acute renal failure risk
- Advanced liver cirrhosis
- Ascites medication
Chronic renal failure risk
- Ischemic heart disease
- Type 2 DM
Most common neurologic complication of chronic renal failure
Peripheral neuropathy
Hypercalcaemia manifestations
Hypercalcemia, which is too much calcium in the blood, can cause a variety of symptoms. Here’s an easy way to remember the key manifestations:
-
Stones:
- Kidney Stones: High calcium levels can lead to the formation of kidney stones, which can cause pain in the back or sides and sometimes blood in the urine.
-
Bones:
- Bone Pain: Excess calcium can be pulled from the bones, leading to bone pain, aches, or even fractures.
-
Groans:
- Abdominal Pain: Hypercalcemia can cause digestive issues, including abdominal pain, nausea, constipation, and sometimes peptic ulcers (stomach ulcers).
-
Thrones:
- Frequent Urination and Dehydration: High calcium levels can make you pee a lot, leading to dehydration. This can also cause increased thirst.
-
Psychiatric Overtones:
- Mental Symptoms: High calcium can affect the brain, causing confusion, lethargy, fatigue, memory problems, depression, and in severe cases, hallucinations or even coma.
- Stones (kidney stones), Bones (bone pain), Groans (abdominal issues), Thrones (frequent urination), and Psychiatric Overtones (mental changes) are the main symptoms of hypercalcemia. These clues can help you remember the broad range of effects high calcium levels can have on the body.
- constipation
- anorexia
- nausea and vomiting
- abdominal pain
- ileus
– Bone pain.
– Muscular weakness - Peptic ulceration.
– Pancreatitis.
– Neurological - Short QT interval on ECG
renal impairment:
- polyuria, nocturia, and
polydipsia
> Ca 3mmol/L:
- emotional labiality
- confusion,
- delirium
- depression/psychosis
- stupor
- coma
Hypercalcaemia risk factors
Paraneoplastic syndromes:
- squamous cell carcinoma of the head and neck
- Renal cell carcinoma
- Carcinoma of lung
- Multiple myeloma
Hypocalcaemia manifestations
- Paraesthesia and numbness of the fingertips and perioral area.
-Chvostek’s sign: Twitching of the ipsilateral facial musculature (perioral, nasal, and eye muscles) by tapping over cranial nerve VII at the ear.
-Trousseau’s sign: carpal spasm induced by inflation of the blood pressure cuff around the arm.
-Spontaneous muscle cramps.
-Tetany is seen in severe hypocalcaemia
Causes of confusion in kidney disease
without spasm: uraemia
with spasms: hypercalcaemia
Treatment of urge incontinence
**1st line: Bladder retraining
2nd line: TCA/intravesical botulism
3rd line: Surgery
Haematuria+ hypertension + bilateral palpable
kidneys + abdomen and flank fullness
Polycystic kidney disease (PCKD)
autosomal dominant polycystic kidney disease (ADPKD) dx
Presence of 2 or more cysts in each kidney
autosomal dominant polycystic kidney disease (ADPKD) complications
cerebral aneurysms
Polycystic kidney disease (PCKD) high BP mechanism
increased activity of renin angiotensin system
Polycystic kidney disease (PCKD) risk factors
– Younger age dx
– Black Race.
– Male sex.
– Presence of polycystin-1 mutation.
– Hypertension.
Good cyst penetration medication
Fluoroquinolones
(lipid soluble)
Painless haematuria investigation protocol
- urine
microscopy and culture to rule out urinary tract infection - serum electrolytes, urinary proteins, red cell casts in the urine and check BP to rule out glomerulonephritis
- urinary tract US and
cystoscopy - CT abdomen non contrast
Painless
Haematuria+ Gross/macroscopic+55 year=
= Initial Urine analysis next? Cystoscopy
Haematuria+Gross/macroscopic+35 year=== initial Urine analysis next ?CT abdomen
shahriar cop
Haematuria +microscopict 55 years:
initial urine analysis next? USG/ cystoscpoy
Haematuria+microscopic+30 years=== initial urine analysis next? USG/Cystoscopic
Painful,
Haematuria +40 years
Initial urine analysis next? X ray next to confirm? Spiral CT
Haematuria,
Female,
Initial urine analysis(abnormal)=
> repeat the test
If you find clean catch urine reagarding UTI== choose this is as answer
Scrotal lumps investigation
malignant unless proven otherwise
initial: US
lab test for tumour markers:
1. The beta subunit of beta-hCG
2. AFP
3. actate dehydrogenase (LDH)
most common
cause of lower urinary tract symptoms (LUS)
Benign prostate hyperplasia (BPH)
Benign prostate hyperplasia (BPH) management
- 1st line: Finasteride that needs to be bridged with selective α-blocker such as doxazosin, terazosin, or pprazosin
- gold standard: Transurethral resection of the prostate (TURP)
Benign prostate hyperplasia (BPH) complications
To kidneys
hydronephrosis and kidney damage
Most common expected Longterm complication of TURP
Retrograde ejaculation 80-90%
lower urinary tract symptoms (LUS) symptoms
Filling:
-urinary frequency,
- urgency,
- dysuria,
- nocturia.
Voiding:
- poor stream
- hesitancy
- terminal dribbling,
- incomplete voiding
- overflow incontinence (occurs in chronic retention)
Lower Urinary Tract Symptoms (LUTS) refer to a group of symptoms related to problems with urination. Here’s a simple explanation:
LUTS are usually divided into two categories: storage symptoms and voiding symptoms.
- Urgency: A sudden, strong need to urinate, often with little warning.
- Frequency: Needing to urinate more often than usual, typically more than 8 times a day.
- Nocturia: Waking up at night to urinate one or more times.
- Urge Incontinence: Leaking urine before you can get to the toilet due to a sudden urge to urinate.
- Weak Stream: The flow of urine is slower or weaker than usual.
- Hesitancy: Difficulty starting urination, even when you feel the urge to go.
- Intermittency: Starting and stopping several times while urinating.
- Straining: Needing to push or strain to start urination or to continue urinating.
- Incomplete Emptying: Feeling like the bladder isn’t completely empty even after urinating.
- Post-void Dribbling: Leaking a small amount of urine after finishing urination.
- Storage symptoms involve issues with holding urine, like needing to go frequently or urgently.
- Voiding symptoms involve issues with emptying the bladder, like a weak stream or difficulty starting urination.
LUTS can be caused by various conditions, such as an enlarged prostate in men, urinary tract infections, or bladder disorders, and may require different treatments depending on the underlying cause.
fever + perineal region pain + frequency, urgency, dysuria + oliguria + leukocytosis + prostate tenderness + with/o hypotension and tachycardia
Prostatitis
Prostatitis treatment
Borad spectrum antibiotics for 3 weeks
elderly patient + sclerotic changes in vertebrae and pelvis
Prostrate cancer
Prostate cancer T staging
T1 - impalpable
T2 - confined to one nodule
T3a - outside capsule
T3b - into seminal vesicle
Prostate cancer active surveillance criteria
- PSA ≤ 10.0 ng/mL
- clinical stage T1–2a
- Gleason score ≤ (3 + 4 = 7) and pattern 4 component < 10% after pathological review
Prostate cancer active surveillance protocol
- PSA measurements every 3 months
- PE + DRE every 6 months
- Repeat prostate biopsy within 6–12 months of starting protocol
Prostate PSA
40–49 years: <2.5 ng/mL
50–59 years: <3.5
60–69 years: <4.5
70+ years: <6.5
Gleason grade
1: mild - no intervention
2:-3 moderate - conservative measures
3-5: high - requiring surgical intervention
Gleason score
< 6: low risk
7 (3+4)
7 (4+3)
8
9-10
urethral injury initial investigation
retrograde urethrogram followed by Foley (bladder or urinary) catheter
indwelling catheter (Foley) contraindications
Pelvic injury with urethral meatus blood
suprapubic catheter contraindications
– Coagulopathy
– Urinary Bladder carcinoma
– Pregnancy
– Ascites
– Severe obesity
– Lower abdominal scar tissue, mesh or adhesions from previous surgeries, pelvic cancer or radiation treatment
testicular torsion management
Immediate surgery to prevent infarction
testicular tumour malignancy investigation
- scrotal ultrasound
with colour Doppler - CT abdomen and chest x-ray
- inguinal orchiectomy
testicular tumour lymphatic spread would indicate the worst prognosis
Cervical
young male+ low haemoglobin & haematocrit + hypertension + haematuria + proteinuria + with/o haemoptysis/SOB/cough/dyspnoea
Anti–glomerular basement membrane disease (Goodpasture’s)
Anti–glomerular basement membrane disease
Goodpasture’s disease:
- Young males most common
- development of autoantibodies against the non-collagenous domain of type IV collagen
- haemoptysis may also be a feature (smokers)
Anti–glomerular basement membrane disease treatment
- plasma exchange
- corticosteroids
- cytotoxic therapy
Sudden onset of severe testicular pain + nausea and vomiting + Asymmetric high riding testes + Absent cremasteric reflex + Negative Prehn’s sign
Testicular torsion
fever & rigors + tender upper pole of testes + positive Prehn’s sign + lower urinary tract symptoms
epididymitis
sudden onset + painless testicular swelling that decreases when supine + “ bag of worms” sensation
varicocele (renal tumour)
- mostly on the left side
Painless haematuria w/o other symptoms
bladder carcinoma
bladder carcinoma risk factors
- male
- smoking
- printing/leather dye industry work
Bladder carcinoma diagnostic investigation
Cystoscopy
Drug is associated with increased risk of bladder carcinoma
Pioglitazone
Hypertension post dialysis treatment
- Conservative: remove excess sodium and dry weight reduction
- 1st line: BB Atenolol
-2nd line: CCB amlodipine - ACEi or ARBs
-Diuretics (monitor for ototoxicity)
most common opportunistic pathogen in
transplant
Cytomegalovirus (CMV)
Graft rejection treatment
- steroid boost
- monoclonal antibodies to CD3 (OKT3)
- pooled antibodies against lymphocytes (ALGs)
Renal artery stenosis (RAS) treatment
Unilateral: ACEi
Bilateral: CCB, BB
Hyponatremia causing medication
- thiazide diuretics (indapamide)
Smoking cessation medication
– 1st line: Varenicline
– Nicotine replacement therapy
– Bupropion (1st line pregnancy)
stress incontinence management
- Pelvic floor exercises (Kuegels)
- Bladder neck suspension/sling
Partial nephrectomy
< 7 cm
- not centrally located
- expected to live > 5 years with/o other comorbidities
Total nephrectomy
- size > 7cm
- central location
- lymph node involvement
- associated with renal vein/IVC thrombus
- Direct extension into ipsilateral adrenal gland
Painless haematuria
Rule out malignancy
