nephrology/urology Flashcards
causes of urinary retention
- obstruction of the urethra
- nerve problems
- medications
- weakened bladder muscles
history of acute urinary retention
- gradual worsening voiding symptoms
- UTI symptoms
- clot formation (tumour)
- back pain (cauda equina)
- MS presentation
- gynea symptoms
- new meds
- bowel habit
examination for acute urinary retention
- uncomfortable, tachycardia, palpable bladder
- neuro: perineal + perianal sensation + anal sphincter tone , lower limb tone, sensation and reflexes
- prostate exam
management for acute urinary retention
- catherisation + note residual urine volume + dipstick for UTI
- PSA
- ultrasound pelvis for masses (women)
common causes of haematuria
- malignancy (upper tract urothelial cancer, bladder cancer, prostate cancer)
- renal calculi
- UTI
- nephrological causes
investigations of painless visible haematuria
- MSU (rule out infection )
- U&E (renal disease)
- flexible cystoscopy (bladder tumour)
- CT urogram (renal and ureteric tumours + kidney stones)
- serum PSA (rule out prostate cancer)
what else can can cause positive dipstick for haematuria or red coloured urine
pos dipstick: myoglobin
red coloured urine: beetroot, rifampicin, porphyrins
pain and urology
kidney pain: fixed constant flank pain/ colicky pain superimposed on a constant dull pain
ureteric distention: loin to groin pain, colicky pain
investigations of urology/kidney problems
- urine analysis: dipstick (protein:renal disorder, nitrites and leucocytes: infection), microscopy, culture, cytology
- blood tests, FBC, biochemistry, culture
- imagine: KUB, IV pyelogram, USS, MRI, angiography
why do you use KUB X ray
calcification (renal and urinary tract stones)
why do you use IV pyelography
assess: anatomy (nb of kidneys, ureters), drainage, function (of kidneys), access (for surgery)
when do you use USS in urology/nephrology
assess kidney architecture
when do you use CT scan in urology/nephrology
stones
after USS: staging of malignancy, kidney disease that was visible
causes of urological stones
- metabolic 50% (type 1 renal tubular acidosis, hyperparathyroidism, cystinuria, sarcoidosis, Crohns disease)
- urological (outflow obstruction and lesions)
- infection
- immobilisation (resorption of bone)
types of urological stones
- 75% calcium oxalate
- 10% struvite ‘staghorn’ (magnesium ammonium phosphate)
- 10% urate (radiolucent)
- 5% mixed calcium phosphate and calcium oxalate
- 1-2% cysteine stones
management of urological stones
- increase fluid intake
- diet: reduce animal protein, sugar, Na, oxalate
- treat infection
- for urate stones: alkalinise urine
- medications (bendroflumethazide, allopurinol, penicillamine)
surgery:
- no need < 5 mm, lower ureter, no obstruction
- ESWL -> ureteroscopic -> percutaneous -> laparoscopu -> open operation
types of kidney tumours
benign: angiomyolipomas, oncocytoma
malignant: renal cell carcinoma, transitional cell carcinoma
renal cell carcinoma
- aetiology/ presentation
- clinical features
- male:female 2:1, ‘th-6th decades
- clinical features: triad haematuria, pain, mass + paraneoplastic syndromes + metastatic disease
- management: surgical for resectable disease or immunotherapy
papillary necrosis
- risk factors
- complications
- management
- risk factors: paracetamol/NSAIDs, DM, sickle cell disease, infection
- complications: obstruction and pyelonephrosis
management: urgent drainage and antibiotic treatment
ADPKD
- aetiology
- symptoms
- diagnosis
aetiology:
-autosomal dominant (PKD1, PKD2)
symptoms:
- loin pain/haematuria (cyst haemorrhage)
- loin/abdominal discomfort (size)
- subarachnoid haemorrhages (Berry aneurysm)
- hypertension, uraemia, anaemia
- liver, pancreas and spleen cysts
- mitral valve prolapse
diagnosis:
-ultrasound/ CT scan
management:
- BP control
- renal function monitoring
von Hippel-Lindau disease
- aetiology
- clinical manifestations
- screening
aetiology:
- autosomal dominant, present within 2-3rd decade
clinical manifestations: cortical renal cyst, renal cell carcinoma, renal haemangioblastoma, renal cell adenoma, renal hemangioma, retinal angioma, CNS haemangioblastoma
screening:
-anual USS, CT abdo every 3 years
renal colic differentials
renal stones pyelonephritis ectopic pregnancy, sorted ovarian cyst appendicitis, diverticulitis pancreatitis, cholecystitis ruptured AAA musculo-skeletal pain
haematuria investigations protocols
> 45yo macroscopic haematuria w/out infection:
- blood tests (FBC, U&Es, PSA)
- flexible cystoscopy
- CT urogram or renal USS
> 45yo microscopic haematuria
- cystoscopy
- renal USS
<45yo macroscopic haematuria w/out infection
- cystoscopy
- upper tract imaging
<45 yo microscopic haematuria: nothing unless:
- increase urinary frequency and urgency: cystoscopy (+ renal function, BP, urine protein excretion)
- loin pain: non contrast CT (+ renal function, BP, urine protein excretion)
name of upper urinary tract infection
pyelonephritis (kidney)
name of lower urinary tract infection
cystitis (bladder)
lower UTI presentation
dysuria increase frequency, urgency haematuria suprapubic discomfort burning pain cloudy, smelly urine
upper UTI presentation
triad: vomiting, flank loin pain (usually unilateral), fever
symptoms of Lowe UTI malaise fever rigs loin/back pain signs of septicaemia vomiting
risk factors for UTI
female, sex, condoms, menopause, urinary stones, urinary tract malformation, catheter
investigations for UTI
- urine dipstick (presence of proteins, leucocytes, nitrites and blood)
- MSU sent for microscopy, culture and sensitivity analysis
- FBC
- CRP
- CT or USS (to exclude pyonephrosis with loin pain and pyrexia)
management of UTIs
- 3 day course of antibiotics (trimethoprim, cephalexin or nitrofurantoin)
- if pyelonephritis and pyrexia: 24-48h IV gentamicin or temocillin + 10 day course oral antibiotics
If recurrent UTIs (more than 3 episodes/year):
- treat with long term low dose prophylactic antibiotics OR
- post-coidal antibiotic tablet OR
- self start 3 day course antibiotic at onset of symptoms OR
- topical oestrogen cream (in postmenopausal women)
risk factor bladder cancer
increasing age, smoking, exposure to chemical (i.e. dye industry and rubber manufacture), analgesic misuse
bladder cancer presentation
- visible painless haematuria (but can also be microscopic)
- irritative urinary symptoms/UTI that doesn’t resolve w/ antibiotics
bladder cancer staging
- pta: tumour cells confined to epithelium
- cis (carcinoma in situ): aggressive cells confined to epithelium (flat tumour)
- T1: tumour cells in sub-epithelium connective tissue
- T2/3 tumour cells in bladder wall muscle
- T4: tumour cells in adjacent organs (prostate/uterus)
bladder cancer grading
1: least aggressive/most well differentiated histologically
2: intermediate
3: most aggressive/least well differentiated
bladder cancer treatment
- stage Cis, pTa: TURBT
- stage 1 + grade 3: BCG, may require radical cystectomy
- stage 2-4: radical cystectomy or radiotherapy
- metastatic disease: systemic chemotherapy
types of cells that line the bladder
transitional epithelium
what does international prostate symptoms score measure
measures severity of urinary symptoms:
- incomplete voiding
- frequency
- intermittency
- urgency
- weak stream
- straining
- nocturia
+quality of life due to urinary symptoms
BPH
- symptoms/signs
- treatment
-symptoms/signs: obstructive LUTS (hesitancy poor stream, postmicturition dribbling, frequency and nocturia), enlarged bladder, (overflow incontinence) enlarged smooth, firm, rubber prostate
treatment:
- alpha 1 blockers (tamsolisin, alfuzosin, doxazosin)
- 5 alpha reductase inhibitors (finastride, dutasteride)
- TURP
prostate red flags
overflow incontinence renal impairement haematuria recurrent UTI raised PSA
storage/irritative LUTS
frequency, urgency, nocturne, incontinence (urge), enuresis
voiding/obstructive LUTS
poor flow, hesitancy, intermittency, incomplete voiding, straining, dribbling, incontinence (overflow)
prostate cancer symptoms and signs
symptoms:
LUTS (obstructive and irritated)
pain (back, skeletal from metastasis)
fatigue, weight loss
signs:
-hard irregular gland in DRE
investigations for prostate cancer
- trans-urethral US + sampling prostatic biopsy/ template biopsy
- PSA> 10 ng/ml?
tumour grade prostate cancer
Gleason score (addition of 2 most common scores): scores of 3-5 are considered cancerous
Grade
1: Gleason score 6
2: Gleason score 7 (3 +4)
3: Gleason score 7 (4+3)
4: Gleason score 8
5: Gleason score 9/10
def pyuria
pus in the urine
functions of the kidney
A WET BED Acid base balance water removal erythropoiesis toxin removal BP control electrolyte balance vit D activation
what criteria do you use for KDIGO guidelines for AKI staging
serum creatinine
urine output
KDIGO guidelines for AKI staging
1: - SCr: 1.5-1.9x baseline Or >3.0 mg/dL increase
- urine output<0.5 ml/Kg/hr for 6-12h
2: -SCr 2-2.9 x baseline
- UO: <0.5 mL/Kg/hr for >12h
3: -SCr: >3.0x baseline OR >4.0 mg/dL OR initiation for RRT or <18 yo, eGFR <35 ml/min/1.73m2
- UO: <0.3 ml/KG/hr for >24h or anuria for >12h
pre renal causes of AKI
(reduced renal perfusion)
dehydration, sepsis, hypotension, shock, hepatorenal syndrome, severe HF, intra abdominal hypertension/compartment syndrome
renal causes of AKI
NSAIDS, ACEi, ARBs, gentamicin, GN/vasculitis, contrast, interstitial nephritis, myeloma, rhabdomyolysis
post renal causes of AKI
(obstruction)
prostate enlargemen, renal stones, pelvic cancer
risk factors for AKI
>65 yo history of AKI CKD (eGFR <60) symptoms/history of urological obstruction diabetes, HF, liver disease sepsis hypovolaemia oliguria nephrotoxic drugs exposure to iodinated contrast agents
ECG changes in hyperkalemia
peaked T waves
low flat P waves
broad QRS > 3 ss
hyperkalemia treatment
- protect the heart: IV calcium chloride or calcium gluconate
- shift K+ into cells: IV infusion of insulin-glucose + nebuliser salbutamol
diagnosis of AKI
-rise in serum creatinine
-fall in urine output
(try and measure against baseline)
what tests to do if you suspect an AKI
urine dipstick urine cultures (UTI) stool culture (for pathogens causing diarrhoea) serum creatinine, eGFR CXR ECG KUB ultrasound
management of AKI
- manage the cause
- maintain appropriate hydration
ONLY consider dialysis if:
- hyperkalaemia
- pulmonary oedema
- metabolic acidosis
- uraemic encephalopathy
is there anything else?
causes of acute tubular necrosis
- sustained under perfusion and reduced renal blood flow of renal tubules
- nephrotoxins
what are the 3 phases of ATN
oligouric phase: kidneys produce <500mls urin/day (patients vulnerable to fluid overload and electrolyte imbalance + creatinine levels rise rapidly)
maintenance phase: increased urinary output (helps maintain fluid and electrolyte balance + creatinine stabilises)
polyuric recovery phase: polyuria (can cause hypovolaemia + electrolyte loss + creatinine levels fall)
SEPSIS 6
in: antibiotics, oxygen, fluids
out: urine output, lactate, blood cultures
what are daily requirements of:
- water
- sodium
- potassium
- calcium
- magnesium
- chloride
- phosphate
- glucose
- water: 1.5 ml/kg/hr
- sodium/pottassium: 1 mmol/kg/24h
- calcium: 1000mg
- magnesium: 350 mg
- chloride: 750-900mg
- phosphate: 700mg
- glucose: 50g/day
why is it important to do an early morning midstream urine sample when testing for CKD?
due to orthostatic proteinuria: benign condition caused by periods of prolonged standing
what conditions can you have proteinuria?
after physical exercise pregnancy fever abnormal high BP UTI nephrotic/nephritic syndrome
def pruritus
itchy skin
def of CKD
abnormalities of kidney function or structure > 3 months with implications to health :
-markers of kidney damage
-GFR <60 ml/min/1.73 m2
(on at least 2 occasions separated by period of 90 days)
def eGFR
creatinine based estimated of GFR
what are the metabolic complications of CKD
- CKD mineral bone disease (hypocalcaemia, hyperparathyroidism)
- renal anaemia
- metabolic acidosis
- hyperkalaemia
what are the treatments for the metabolic complications of CKD
- calcitriol/alphacalcidol
- EPO and IV iron
- oral alkali (ie sodium bicarb)
- dietary restrictions of potassium + reduce ACEi
what are the physical complications of CKD
fluid overload
what increases risk of CKD
-increases susceptibility: age family history reduced kidney mass low birth weight ethnic minorities low income
-direct kidney damage: diabetes high BP autoimmune disease systemic sepsis UTI urinary stones urinary obstruction drug toxicity
what are the criteria for referral to renal services:
CKD 1-2
referral not required
what are the criteria for referral to renal services:
CKD 3
routine referral if:
- microscopic hamaturia
- urinary PCR >45 mg/mmol
- unexplained anaemia
- abnormal K+, Ca, Pi
- systemic illness (ie SLE)
- uncontrolled BP
- fall in GFR > 5ml/min in 12/12
- fall in GFR >15% after ACEi/ARB
what are the criteria for referral to renal services:
CKD 4
urgent referral
what are the criteria for referral to renal services:
CKD 5
immediate referral
which drug should you avoid in diabetes and CKD
metformin if eGFR <30
what are indications to start renal replacement therapy
fluid overload
refractory hyperkalaemia
uraemia symptoms (nausea, confusion, weight loss, vomiting)
