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Year 3 > nephrology/urology > Flashcards

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
Q

name of lower urinary tract infection

A

cystitis (bladder)

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26
Q

lower UTI presentation

A 
dysuria
increase frequency, urgency
haematuria
suprapubic discomfort
burning pain
cloudy, smelly urine
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27
Q

upper UTI presentation

A

triad: vomiting, flank loin pain (usually unilateral), fever

symptoms of Lowe UTI
malaise
fever
rigs
loin/back pain 
signs of septicaemia
vomiting
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28
Q

risk factors for UTI

A

female, sex, condoms, menopause, urinary stones, urinary tract malformation, catheter

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29
Q

investigations for UTI

A
  • 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)
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30
Q

management of UTIs

A
  • 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)
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31
Q

risk factor bladder cancer

A

increasing age, smoking, exposure to chemical (i.e. dye industry and rubber manufacture), analgesic misuse

32
Q

bladder cancer presentation

A
  • visible painless haematuria (but can also be microscopic)

- irritative urinary symptoms/UTI that doesn’t resolve w/ antibiotics

33
Q

bladder cancer staging

A
  • 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
Q

bladder cancer grading

A

1: least aggressive/most well differentiated histologically
2: intermediate
3: most aggressive/least well differentiated

35
Q

bladder cancer treatment

A
  • 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
Q

types of cells that line the bladder

A

transitional epithelium

37
Q

what does international prostate symptoms score measure

A

measures severity of urinary symptoms:

  • incomplete voiding
  • frequency
  • intermittency
  • urgency
  • weak stream
  • straining
  • nocturia

+quality of life due to urinary symptoms

38
Q

BPH

  • symptoms/signs
  • treatment
A

-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
Q

prostate red flags

A 
overflow incontinence
renal impairement 
haematuria 
recurrent UTI 
raised PSA
40
Q

storage/irritative LUTS

A

frequency, urgency, nocturne, incontinence (urge), enuresis

41
Q

voiding/obstructive LUTS

A

poor flow, hesitancy, intermittency, incomplete voiding, straining, dribbling, incontinence (overflow)

42
Q

prostate cancer symptoms and signs

A

symptoms:
LUTS (obstructive and irritated)
pain (back, skeletal from metastasis)
fatigue, weight loss

signs:
-hard irregular gland in DRE

43
Q

investigations for prostate cancer

A
  • trans-urethral US + sampling prostatic biopsy/ template biopsy
  • PSA> 10 ng/ml?
44
Q

tumour grade prostate cancer

A

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
Q

def pyuria

A

pus in the urine

46
Q

functions of the kidney

A 
A WET BED
Acid base balance
water removal 
erythropoiesis 
toxin removal 
BP control
electrolyte balance
vit D activation
47
Q

what criteria do you use for KDIGO guidelines for AKI staging

A

serum creatinine

urine output

48
Q

KDIGO guidelines for AKI staging

A

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
Q

pre renal causes of AKI

A

(reduced renal perfusion)
dehydration, sepsis, hypotension, shock, hepatorenal syndrome, severe HF, intra abdominal hypertension/compartment syndrome

50
Q

renal causes of AKI

A

NSAIDS, ACEi, ARBs, gentamicin, GN/vasculitis, contrast, interstitial nephritis, myeloma, rhabdomyolysis

51
Q

post renal causes of AKI

A

(obstruction)

prostate enlargemen, renal stones, pelvic cancer

52
Q

risk factors for AKI

A 
>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
Q

ECG changes in hyperkalemia

A

peaked T waves
low flat P waves
broad QRS > 3 ss

54
Q

hyperkalemia treatment

A
  • protect the heart: IV calcium chloride or calcium gluconate
  • shift K+ into cells: IV infusion of insulin-glucose + nebuliser salbutamol
55
Q

diagnosis of AKI

A

-rise in serum creatinine
-fall in urine output
(try and measure against baseline)

56
Q

what tests to do if you suspect an AKI

A 
urine dipstick
urine cultures (UTI)
stool culture (for pathogens causing diarrhoea)
serum creatinine, eGFR
CXR
ECG
KUB ultrasound
57
Q

management of AKI

A
  • manage the cause
  • maintain appropriate hydration

ONLY consider dialysis if:

  • hyperkalaemia
  • pulmonary oedema
  • metabolic acidosis
  • uraemic encephalopathy

is there anything else?

58
Q

causes of acute tubular necrosis

A
  • sustained under perfusion and reduced renal blood flow of renal tubules
  • nephrotoxins
59
Q

what are the 3 phases of ATN

A

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
Q

SEPSIS 6

A

in: antibiotics, oxygen, fluids
out: urine output, lactate, blood cultures

61
Q

what are daily requirements of:

  • water
  • sodium
  • potassium
  • calcium
  • magnesium
  • chloride
  • phosphate
  • glucose
A
  • 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
Q

why is it important to do an early morning midstream urine sample when testing for CKD?

A

due to orthostatic proteinuria: benign condition caused by periods of prolonged standing

63
Q

what conditions can you have proteinuria?

A 
after physical exercise
pregnancy
fever
abnormal high BP
UTI 
nephrotic/nephritic syndrome
64
Q

def pruritus

A

itchy skin

65
Q

def of CKD

A

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
Q

def eGFR

A

creatinine based estimated of GFR

67
Q

what are the metabolic complications of CKD

A
  • CKD mineral bone disease (hypocalcaemia, hyperparathyroidism)
  • renal anaemia
  • metabolic acidosis
  • hyperkalaemia
68
Q

what are the treatments for the metabolic complications of CKD

A
  • calcitriol/alphacalcidol
  • EPO and IV iron
  • oral alkali (ie sodium bicarb)
  • dietary restrictions of potassium + reduce ACEi
69
Q

what are the physical complications of CKD

A

fluid overload

70
Q

what increases risk of CKD

A 
-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
Q

what are the criteria for referral to renal services:

CKD 1-2

A

referral not required

72
Q

what are the criteria for referral to renal services:

CKD 3

A

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
Q

what are the criteria for referral to renal services:

CKD 4

A

urgent referral

74
Q

what are the criteria for referral to renal services:

CKD 5

A

immediate referral

75
Q

which drug should you avoid in diabetes and CKD

A

metformin if eGFR <30

76
Q

what are indications to start renal replacement therapy

A

fluid overload
refractory hyperkalaemia
uraemia symptoms (nausea, confusion, weight loss, vomiting)

Year 3 (7 decks)

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