nephrology/urology Flashcards

1
Q

causes of urinary retention

A
  • obstruction of the urethra
  • nerve problems
  • medications
  • weakened bladder muscles
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2
Q

history of acute urinary retention

A
  • gradual worsening voiding symptoms
  • UTI symptoms
  • clot formation (tumour)
  • back pain (cauda equina)
  • MS presentation
  • gynea symptoms
  • new meds
  • bowel habit
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3
Q

examination for acute urinary retention

A
  • uncomfortable, tachycardia, palpable bladder
  • neuro: perineal + perianal sensation + anal sphincter tone , lower limb tone, sensation and reflexes
  • prostate exam
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4
Q

management for acute urinary retention

A
  • catherisation + note residual urine volume + dipstick for UTI
  • PSA
  • ultrasound pelvis for masses (women)
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5
Q

common causes of haematuria

A
  • malignancy (upper tract urothelial cancer, bladder cancer, prostate cancer)
  • renal calculi
  • UTI
  • nephrological causes
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6
Q

investigations of painless visible haematuria

A
  • 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)
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7
Q

what else can can cause positive dipstick for haematuria or red coloured urine

A

pos dipstick: myoglobin

red coloured urine: beetroot, rifampicin, porphyrins

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8
Q

pain and urology

A

kidney pain: fixed constant flank pain/ colicky pain superimposed on a constant dull pain

ureteric distention: loin to groin pain, colicky pain

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9
Q

investigations of urology/kidney problems

A
  • 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
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10
Q

why do you use KUB X ray

A

calcification (renal and urinary tract stones)

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11
Q

why do you use IV pyelography

A

assess: anatomy (nb of kidneys, ureters), drainage, function (of kidneys), access (for surgery)

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12
Q

when do you use USS in urology/nephrology

A

assess kidney architecture

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13
Q

when do you use CT scan in urology/nephrology

A

stones

after USS: staging of malignancy, kidney disease that was visible

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14
Q

causes of urological stones

A
  • metabolic 50% (type 1 renal tubular acidosis, hyperparathyroidism, cystinuria, sarcoidosis, Crohns disease)
  • urological (outflow obstruction and lesions)
  • infection
  • immobilisation (resorption of bone)
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15
Q

types of urological stones

A
  • 75% calcium oxalate
  • 10% struvite ‘staghorn’ (magnesium ammonium phosphate)
  • 10% urate (radiolucent)
  • 5% mixed calcium phosphate and calcium oxalate
  • 1-2% cysteine stones
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16
Q

management of urological stones

A
  • 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

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17
Q

types of kidney tumours

A

benign: angiomyolipomas, oncocytoma
malignant: renal cell carcinoma, transitional cell carcinoma

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18
Q

renal cell carcinoma

  • aetiology/ presentation
  • clinical features
A
  • male:female 2:1, ‘th-6th decades
  • clinical features: triad haematuria, pain, mass + paraneoplastic syndromes + metastatic disease
  • management: surgical for resectable disease or immunotherapy
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19
Q

papillary necrosis

  • risk factors
  • complications
  • management
A
  • risk factors: paracetamol/NSAIDs, DM, sickle cell disease, infection
  • complications: obstruction and pyelonephrosis
    management: urgent drainage and antibiotic treatment
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20
Q

ADPKD

  • aetiology
  • symptoms
  • diagnosis
A

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

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21
Q

von Hippel-Lindau disease

  • aetiology
  • clinical manifestations
  • screening
A

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

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22
Q

renal colic differentials

A
renal stones
pyelonephritis
ectopic pregnancy, sorted ovarian cyst
appendicitis, diverticulitis
pancreatitis, cholecystitis
ruptured AAA
musculo-skeletal pain
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23
Q

haematuria investigations protocols

A

> 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)
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24
Q

name of upper urinary tract infection

A

pyelonephritis (kidney)

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25
name of lower urinary tract infection
cystitis (bladder)
26
lower UTI presentation
``` dysuria increase frequency, urgency haematuria suprapubic discomfort burning pain cloudy, smelly urine ```
27
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 ```
28
risk factors for UTI
female, sex, condoms, menopause, urinary stones, urinary tract malformation, catheter
29
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)
30
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)
31
risk factor bladder cancer
increasing age, smoking, exposure to chemical (i.e. dye industry and rubber manufacture), analgesic misuse
32
bladder cancer presentation
- visible painless haematuria (but can also be microscopic) | - irritative urinary symptoms/UTI that doesn't resolve w/ antibiotics
33
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)
34
bladder cancer grading
1: least aggressive/most well differentiated histologically 2: intermediate 3: most aggressive/least well differentiated
35
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
36
types of cells that line the bladder
transitional epithelium
37
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
38
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
39
prostate red flags
``` overflow incontinence renal impairement haematuria recurrent UTI raised PSA ```
40
storage/irritative LUTS
frequency, urgency, nocturne, incontinence (urge), enuresis
41
voiding/obstructive LUTS
poor flow, hesitancy, intermittency, incomplete voiding, straining, dribbling, incontinence (overflow)
42
prostate cancer symptoms and signs
symptoms: LUTS (obstructive and irritated) pain (back, skeletal from metastasis) fatigue, weight loss signs: -hard irregular gland in DRE
43
investigations for prostate cancer
- trans-urethral US + sampling prostatic biopsy/ template biopsy - PSA> 10 ng/ml?
44
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
45
def pyuria
pus in the urine
46
functions of the kidney
``` A WET BED Acid base balance water removal erythropoiesis toxin removal BP control electrolyte balance vit D activation ```
47
what criteria do you use for KDIGO guidelines for AKI staging
serum creatinine | urine output
48
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
49
pre renal causes of AKI
(reduced renal perfusion) dehydration, sepsis, hypotension, shock, hepatorenal syndrome, severe HF, intra abdominal hypertension/compartment syndrome
50
renal causes of AKI
NSAIDS, ACEi, ARBs, gentamicin, GN/vasculitis, contrast, interstitial nephritis, myeloma, rhabdomyolysis
51
post renal causes of AKI
(obstruction) | prostate enlargemen, renal stones, pelvic cancer
52
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 ```
53
ECG changes in hyperkalemia
peaked T waves low flat P waves broad QRS > 3 ss
54
hyperkalemia treatment
- protect the heart: IV calcium chloride or calcium gluconate - shift K+ into cells: IV infusion of insulin-glucose + nebuliser salbutamol
55
diagnosis of AKI
-rise in serum creatinine -fall in urine output (try and measure against baseline)
56
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 ```
57
management of AKI
- manage the cause - maintain appropriate hydration ONLY consider dialysis if: - hyperkalaemia - pulmonary oedema - metabolic acidosis - uraemic encephalopathy is there anything else?
58
causes of acute tubular necrosis
- sustained under perfusion and reduced renal blood flow of renal tubules - nephrotoxins
59
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)
60
SEPSIS 6
in: antibiotics, oxygen, fluids out: urine output, lactate, blood cultures
61
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
62
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
63
what conditions can you have proteinuria?
``` after physical exercise pregnancy fever abnormal high BP UTI nephrotic/nephritic syndrome ```
64
def pruritus
itchy skin
65
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)
66
def eGFR
creatinine based estimated of GFR
67
what are the metabolic complications of CKD
- CKD mineral bone disease (hypocalcaemia, hyperparathyroidism) - renal anaemia - metabolic acidosis - hyperkalaemia
68
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
69
what are the physical complications of CKD
fluid overload
70
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 ```
71
what are the criteria for referral to renal services: | CKD 1-2
referral not required
72
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
73
what are the criteria for referral to renal services: | CKD 4
urgent referral
74
what are the criteria for referral to renal services: | CKD 5
immediate referral
75
which drug should you avoid in diabetes and CKD
metformin if eGFR <30
76
what are indications to start renal replacement therapy
fluid overload refractory hyperkalaemia uraemia symptoms (nausea, confusion, weight loss, vomiting)