Renal Flashcards
UTI
inflammatory reaction of the urinary tract epithelium in response to pathogenic micro-organisms most commonly bacteria (e.g. E.coli)
• Infectious cystitis is the most common type of UTI which is caused by a bacterial infection of the bladder
• Complicated UTI: LUTI pts with tract abnormality or systemic disease involving the kidney (DM, sickle cell)
how common is UTI
Second most common infection among non-institutionalised patients
causes of UTI
- UTI results from pathogenic organisms gaining access to the urinary tract and not being effectively eliminated
- • The bacteria ascend the urethra and generally have an intestinal origin – e.coli cause most utis in men and women (70%) and proteus mirabilis (10%)
• In hospitals it is usually klebsiella aerogenes and enteroccus faecalis
risk factors for UTI
- MEN: BPH, urinary tract stones, urological surgery, urethral strictures, age>50, previous UTI, catheterisation
- WOMEN: sexual activity, spermicide use, post-menopuase, positive Fx of UTIs, Hx of recurrent UTIs, presence of a foreign body
symptoms/ signs for UTI
- MEN: presence of risk factors, dysuria, urinary frequency and urgency, suprapubic pain, hesistancy, nocturia, enlarged prostate
- WOMEN: presence of risk factors, dysuria, urinary frequency, haematuria, back/flank pain, costovertebral angle tenderness
DDx for UTI
- MEN: BPH, prostatitis, pyelonephritis, urinary tract stones, gonococcal urethritis, chlamydia urethritis, bladder or prostate or renal cancer, epididymitis
- WOMEN: over-active bladder, urothelial carcinoma of the bladder or upper urinary tract non-infetious urethritis, foreign body in bladder, vaginitis due to candidia or trichomonas
investigations for UTI
• MEN:
• 1ST LINE:
o Urine dipstick positive leukocyte esterase and/or nitrite
o Urine microscopy leukocytes and/or bacteria
o Urine culture >10^2 CFU/mL, do this when pt is over 65, pregnant or Abxs are ineffective
o Gram stain bacteria
o US if suspect obstruction
• WOMEN:
• 1ST LINE:
o Urine dipstick positive leukocyte esterase and/or nitrite
o Urine microscopy leukocytes and/or bacteria
o Urine culture and sensitivity growth of >10^5 CFU/mL
management of UTI
- MEN: tends to be complicated uti
- 1ST LINE: ciprofloxacin
- 2nd LINE: trimethoprim
• WOMEN: • UNCOMPLICATED: o 1ST LINE: oral abx therapy – nitrofurantoin (oral) o 2nd LINE: trimethoprim o IF PREGNANT amoxicillin • COMPLICATED: o 1ST LINE: ciprofloxacin (oral) o IF PREGNANT cephalexin (oral)
prognosis and complications for UTI
prognosis:
• MEN: younger men have better prognosis
• WOMEN: excellent prognosis with appropriate antimicrobial treatment
complications: sepsis, AKI, pyelonephritis, prostatitis (men)
Acute pyelonephritis definition
• Severe infectious inflammatory disease of the renal parenchyma, calicles and pelvis that can be acute, recurrent or chronic
how common is Acute pyelonephritis
• Estimated to account for at least 250,000 surgery consultations and 200,000 hospitalisations
risk factors for Acute pyelonephritis
- Frequent sexual intercourse
- UTI
- Diabetes mellitus
- Stress incontinence
- Foreign body in urinary tract
- Anatomical/functional urinary abnormality
- Pregnancy
symptoms / signs for Acute pyelonephritis
- Presence of risk factors
- Fever
- Nausea and vomiting
- Dysuria, frequency or urgency
- Flank pain or costovertebral angle tenderness
Ddx for Acute pyelonephritis
- Chronic pyelonephritis
- Pelvic inflammatory disease
- Pelvic pain syndrome
- Cystitis
- Acute prostatitis
- Lower lobe pnuemonia
Igx for Acute pyelonephritis
- 1st LINE:
- Urinalysis WBC >10/HPF, RBCs >5/HPF
- Gram stain typically gram negative rods, less typically gram-positive cocci
- Urine culture bacteria > 100,000 colony-forming units (CFU)/mL
- FBC leucocytosis
- ESR and CRP elevated
- Procalcitonin elevated
- Blood culture any bacterial growth is considered abnormal
Management for Acute pyelonephritis
- MILD-TO-MODERATE SYMTPOMS:
- 1ST LINE: empiric oral abx therapy cefixime or ciprofloxacin (oral)
- 2nd LINE: levofloxacin or trimethoprim/sulfamethoxazole (oral)
- SEVERE SYMPTOMS:
- 1ST LINE: gentamicin IV
prognosis and complications of Acute pyelonephritis
good prognosis
complications - • Need for catheterisation, renal failure, abx failure, allergic reaction to abx, sepsis, renal abscess formation
causes of Acute pyelonephritis
- Acute uncomplicated pyelonephtiritis most often develops as a result of an ascending urinary tract infection
- Pathogenesis may involve haematogenous seeding of the kidneys in patients with bacteraemia
chronic pyelonephritis definition
• Chronic pyelonephritis is a complex renal disorder characterised by chronic tubulointerstitial inflammation and deep segmental cortical renal scarring and clubbing of the pelvic calyces as the papillae retract into the scars
how common is chronic pyelonephritis
- More common in children
- More common in caucasians than in people of African descent
- More common in women
causes of chronic pyelonephritis
- Renal damage occurs slowly over a long-period of time in responde to a chronic inflammatory process or infections
- Results in thinning of the renal cortex along with deep, segmental, coarse cortical scarring
- Obstruction predisposes the kidney to infection and chronic obstruction contributes to parenchymal atrophy
- Obstruction can be bilateral, resulting in renal insufficiency or unilateral
- Recurrent infections superimposed on diffuse or localised obstructive lesions lead to recurrent bouts of renal inflammation and scarring
risk factors for chronic pyelonephritis
- Acute pyelonephritis
- VUR
- Obstruction
- Renal calculi
- Diabetes mellitus
symptoms/signs for chronic pyelonephritis
- Hx of vesicoureteral reflux, acute pyelonephritis or renal obstruction
- Female
- Nausea
- Elevated
- Children and infants (risk of VUR)
DDx of chronic pyelonephritis
- Acute pyelonephritis
- Renal calculi
- Renal cancer
Investigations for chronic pyelonephritis
- 1st LINE:
- Urinalysis may be normal, dipstick positive for leukocytes, nitries, blood
- Renal function elevated creatinine and estimated GFRm reduced creatinine clearance
- Urine culture positive or may be sterile
- Electrolyte panel hyponatraemia, hyperkalaemia, acidosis
- FBC anaemia, leucocytosis
- Renal USS small, irregular, scarred kdineys with echogenic parenchyma
- UB X-Ray renal stones, small or large kidneys, air in renal collecting/parenchymal system
- CT Abdomen
prognosis and complications of chronic pyelonephritis
prognosis varies on cause
complications- Acute renal failure, hyperparathyroidism, acute pyelonephritis, obstruction, CKD
Hydronephrosis (obstructive uropathy) definition
- Blockage of urinary flow, which can affect one or both kidneys depending on the level of obstruction
- If only one kidney is affected, urinary output may be unchanged and serum creatinine can be normal
- When kidney function is affected this is termed obstructive nephropathy
- Hydronephrosis refers to dilation of the renal pelvis and can be present with or without obstruction
How common is Hydronephrosis (obstructive uropathy)
- Unilateral obstructive uropathy is most commonly due to ureteral stones
- Stones are more common in hot and dry climates and obesity appears to increase the incidence
- BPH is a common cause of acute and chronic bilateral obstruction
Causes of Hydronephrosis (obstructive uropathy)
- Obstructive uropathy, regardless of the specific cause, can cause back pressure on the kidney by preventing urinary flow
- Can result in decreased renal blood flow, decreased glomerular filtration rate and up-regulation of the RAAS system
- This can in turn cause atrophy and apoptosis of the renal tubules and interstitial fibrosis with infiltration of the interstitial spaces by macrophages
- These changes may lead to decreased re-absoprtion of solutes and water, inability to concentrate the urine and impaired excretion of hydrogen and potassium
- If left untreated, obstructive nephropathy can cause irreversible renal damage, obstruction can ultimately cause tubulointerstitial fibrosis and tubular atrophy and interstitial inflammation
risk factors for Hydronephrosis (obstructive uropathy)
- BPH
- Constipation
- Medication anticholinergic agents, narcotic analgesia, alpha receptor antagonists
- Urolithiasis (ureteric calculi)
- Spinal cord injury, parkinson’s disease, or MS
- Malignancy
- Posterior urethral valves
- Meatal stenosis
symptoms/signs for Hydronephrosis (obstructive uropathy)
- Flank pain
- Fever
- Lower urinary tract symptoms
- Distended abdomen/palpable bladder
- Inability to urinate
- Enlarged or hard nodular prostate on rectal examination
- Costovertebral angle tenderness
- Haematuria
- Increasing age
- Meatal narrowing
DDx for Hydronephrosis (obstructive uropathy)
- Parapelvic cysts
- Hydronephrosis of pregnancy
- AAA
- Appendicitis
- Gynaecological disorders e.g. ovarian torsion, cyst
- Ectopic pregnancy
- Renal failure
- Bowel obstruction
investigations for Hydronephrosis (obstructive uropathy)
- 1st LINE:
- Urinary dipstick nomrla or positive nitrites, leukocyte esterase and/or blood in presence of infection, microscopic haematuria in renal colic
- Renal ultrasound hydronephorsis affecting the upper urinary tract
- Urea and creatinine normal or elevated
- FBC normal or elevated WBC if infection present, low haemoglobin and haematocrit if bleeding
- CT pyelogram stones in the urinary tract identified as causing obstruction
- IV pyelohram (excretory urography) delayed nephrogram and drainage if obstruction present
- CONSIDER: PSA, tumour markers, CT scan abdomen and pelvis, bladder ultrasound, MRU (urography)
prognosis and complications for Hydronephrosis (obstructive uropathy)
prognosis - can result in permanent renal damage if left untreated but the majority of patient recover fully
complications - renal failure, severe sepsis, post-obstructive diuresis, septic shock
management of Hydronephrosis (obstructive uropathy)
- SIGNS OF SEPSIS: 1ST LINE – analgesia and rehydration, nephrostomy or ureteric sten and abx - gentamicin
- RENAL STONES:
- SMALL: 1ST LINE – trial of passge with analgesia and rehydration – ketorolac IM, 2nd LINE – active stone removal
- LARGE: 1ST LINE - trial of passge with analgesia and rehydration – ketorolac IM
- NOT DUE TO STONES: 1ST LINE – ureteric stent + paracetamol + gentamicin (1st) or meropenem (2nd) both IV, 2nd LINE: nephrostomy
acute renal failure - pre renal (aka Pre-Renal Azotaemia) definition
• Acute kidney injury (AKI), previously known as acute renal failure (ARF), is an acute decline in renal function, leading to a rise in serum creatinine and/or a fall in urine output
how common is acute renal failure - pre renal (aka Pre-Renal Azotaemia)
- Very common in acute illness
- Stage 1 AKI is found in more than 15% of emergency hospital admissions
- AKI with plasma creatinine >500micromol/L is diagnosed in 2 to 7.5 per 10,000 adult population per year in the UK
- Injury counts when serum creatinine is 2X increased from the baseline
causes of acute renal failure - pre renal (aka Pre-Renal Azotaemia)
- Impaired perfusion of the kidneys with blood due to one or more of hypovolaemia, hypotension, impaired cardiac pump efficiency or vascular disease limiting renal blood flow
- The kidneys can normally cope with a variety of blood pressure but they need to autoregulate
- This is dependent on the intrarenal production of prostaflandins and angiotensin II
- With severe or prolonged hypovolaemia there is eventually a drop in GFR (pre-renal failure)
- Drugs that impair renal autoregulation such as ACEi and NSAIDs increase the tendency to develop prerenal uraemia
- Is characterised in the early stages by lack of structural damage and rapid reversibility once normal renal perfusion has been restored
- However, all causes of prerenal uraemia may, if sustained, lead to ischaemic tubule cell injury (ischaemic intrinsic AKI) form which recovery will be delayed
risk factors for acute renal failure - pre renal (aka Pre-Renal Azotaemia)
- General:
- > 65 Hx of AKI
- CKD (eGFR <60mL/min/1.73m2)
- Symptoms or Hx of urological obstruction or conditions which may lead to obstruction
- Chronic conditions such as HF, liver disease and diabetes mellitus
- Neurological or cognitive impairment or disability (which may limit fluid intake)
- Sepsis
- Hypovolaemia
- Oliguria (urine output <0.5mL/kg/hour)
- Nephrotoxic drug use within the last week (e.g. ACEi and NSAID, ARBS, and diuretics)
- Exposure to iodinated contrast agents within the last week
symptoms of acute renal failure - pre renal (aka Pre-Renal Azotaemia)
- Suspect AKI if presented with an acute illness and any of the risk factors above
- Also new onset or significantly worsening urological symptoms
- Symptoms or signs of a multi-sysem disease affecting the kidneys and other organ systems
- Alteration of urine volume: oliguria usually occurs in the early stages, recovery of renal function typically occurs after 7-21 days and in the recovery phase which may last some weeks, often passage of large amounts of dilute urine
- Biochemical abnormalities: hyperkalaemia, metabolic acidosis, hyponatraemia (due to water overload as a result of continued drinking), hypoglycaemia due to reduced production of Vit D and hyperphosphataemia due to phosphate reduction
signs of acute renal failure - pre renal (aka Pre-Renal Azotaemia)
- Symptoms are very non-specific symptoms in AKI are usually related to the underlying causes rather than the AKI itself
- N & V
- Drowsiness
- SOB – due to pulmonary oedema or metabolic acidosis
- Arrhythmias
- Orthopnea
- Paroxysmal nocturnal dyspnoea
- Peripheral odema
- Hypotension
- Tachycardia
- Dizziness
- All patients with AKI should be examined for evidenc of obstruction (enlarged palpable kidneys or bladder, large prostate on rectal exam, pelvic masses on vaginal exam in women)
DDx for acute renal failure - pre renal (aka Pre-Renal Azotaemia)
• Intrinsic and post-renal AKI
Investigations for acute renal failure - pre renal (aka Pre-Renal Azotaemia)
- 1st LINE:
- Basic metabolic profile (inc urea and creatinine) – acutely evelated serum creatinine, high serum potassium, metabolic acidosis
- Ratio of serum urea and creatinine – serum urea to creatinine ratio >20:1 supports pre-renal azotaemia
- Urinalysis – RBCs, WBCs, cellular casts, proteinuria, bacteria, positive nitrite and leukocyte esterase (in cases iof infection)
- Urine culture – bacterial or fungal growth may occur
- FBC – anaemia, leucocytosis, thrombocytopenia
- Fractional excretion of sodium - <1% supports pre-renal azotaemia
- Fractional excretion of urea - <35% supports pre-renal azotaemia
- Urinary eosinophil count - >5% to 7% supports a diagnosis of interstitial nephritis
- VBG – diagnostic for metabolic acidosis and certain intoxications
- Fluid challenge – renal function improves rapidly in pre-renal azotaemia
- Bladder catheterisation – significant urine volume released after catheter placement (in cases of bladder outlet obstruction), minimal residual urine after catheter placement (in cases of impaired urine production or higher level obstruction)
- Urine osmolality – high in pre-renal azotaemia, close to serum osmolality in acute tubular necrosis
- Renal ultrasound – dikated renal calyces (suggesting obstruction)
- CXR and ECG
Management for acute renal failure - pre renal (aka Pre-Renal Azotaemia)
• 1st LINE:
• Volume expansion and/or RBC transfusion – crystalloid (normal saline or lactated Ringer’s), colloid might be used if there is significant hypoalbuminaemia
o + severe hy: potension vasopresser e.g. dopamine IV
o + volume overload diuretic e.g. furosemide
Prognosis and complications for acute renal failure - pre renal (aka Pre-Renal Azotaemia)
Prognosis is variable and depends on cause of injury and the severity and duration of AKI
Complications include hyperphosphatemia, volume overload, hyperkalaemia, metabolic acidosis
Acute Renal Failure – Intrinsic (Acute Tubular Necrosis) definition
• Acute kidney injury (AKI), previously known as acute renal failure (ARF), is an acute decline in renal function, leading to a rise in serum creatinine and/or a fall in urine output
how common is Acute Renal Failure – Intrinsic (Acute Tubular Necrosis)
- Very common in acute illness
- Stage 1 AKI is found in more than 15% of emergency hospital admissions
- AKI with plasma creatinine >500micromol/L is diagnosed in 2 to 7.5 per 10,000 adult population per year in the UK
- Injury counts when serum creatinine is 2X increased from the baseline
causes of Acute Renal Failure – Intrinsic (Acute Tubular Necrosis)
- Most commonly due to acute tubular necrosis as a result of renal ischaemia or direct renal toxins
- Other causes include disease affecting the interstitium (drug hypersensitivities, infections) the renal vasculature (vasculitis, accelerate hypertension, cholesterol embolism, HUS, thrombotic thrombocytopenic purpura) and acute glomerulonephritis
- CAUSES:
- Haemorrhage, burns, diarrhoea, vomiting and fluid loss from fistula
- Acute pancreatitis, diurectics, MI, CHF, endotoxic shock, snake bite
- Myoglobinaemia, haemoglobinaemia, hepatorenal syndrome
- Radiological contrast agents
- Drugs aminoglycosides, NSAIDs, ACEis, platinum derivatives
- Abruptio placentae, pre-exlampsia and eclampsia