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Finals > Renal > Flashcards

Renal Flashcards

1
Q

What score is used to measure impact of LUTS on QOL? Scores?

A

International prostate symptoms score

20-35: severely symptomatic
8-19: moderately symptomatic
0-7: mildly symptomatic

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2
Q

What can cause a raised PSA?

A
  • Prostate cancer
  • BPH
  • Recent ejaculation or prostate stimulation (ideally not in past 48 hrs)
  • Prostatitis
  • UTI
  • Vigorous exercise (notably cycling, ideally not in past 48 hrs)
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3
Q

Examples of alpha-blockers

A
  • Tamsulosin

- Doxasocin

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4
Q

Example of 5-alpha reductase inhibitor

A
  • Finasteride
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5
Q

SEs of alpha-blockers

A
  • POSTURAL HYPOTENSION
  • Dizziness
  • Drowsiness
  • Depression
  • Dyspnoea and cough
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6
Q

SEs of 5-alpha reductase inhibitors

A
  • Impotence
  • Low libido
  • Gynaecomastia
  • Decreased prostate size
  • Causes low levels of PSA
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7
Q

When should you refer to urology for prostate issues?

A

Men aged 50-69 years should be referred if the PSA is >= 3.0 ng/ml OR there is an abnormal DRE

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8
Q

Tx of prostate cancer

A

Localised (T1/T2):

  • Surveillance/watchful waiting in early, multiple co-morbs, low Gleason score
  • Radical prostatectomy
  • External beam radiotherapy
  • Brachytherapy (modification allowing internal radiotherapy)

Localized advanced (T3/T4):

  • Hormone therapy (androgen-deprivation)
  • Radical prostatectomy
  • Radiotherapy

Hormone therapy includes:

  • GnRH agonists, e.g. Goserelin
  • Bicalutamide (blocks androgen receptor)
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9
Q

1st line investigation for prostate cancer

A

Multiparametric MRI

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10
Q

What scoring system is used to assess MRI in prostate cancer?

A

Likert Scale
> 3 = do biopsy
1-2 = weigh up pros/cons of doing biopsy

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11
Q

What scoring system is used to assess the biopsy in prostate cancer?

A

Gleason Score

  • First number = grade most prevalent in sample
  • Second number = 2nd most prevalent grade in sample
  • Grades = 1-5 (5= worse)
  • Add two number together (2= best, 10 = worst)
  • > 8 = severe
  • 6-8 = mod
  • <6 = low risk
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12
Q

Complications of radical prostatectomy

A
  • ERECTILE DYSFUNCTION

- incontinence

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13
Q

Complications of radiotherapy/brachytherapy for prostate cancer

A
  • Proctitis (rectum inflammation) - pred suppositories can help
  • Cystitis
  • Increased risk of bladder/colon/rectal cancer
  • Erectile dysfunction
  • Incontinence
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14
Q

Complications of hormone therapy for prostate cancer

A
  • Hot flushes
  • Sexual dysfunction
  • Gynaecomastia
  • Fatigue
  • Osteoporosis
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15
Q

Types of bladder cancer

A
  • Transitional cell carcinoma (90%)
  • Squamous cell carcinoma (5% - higher in areas of schistosomiasis)
  • Adenocarcinoma, sarcoma, small-cell carincoma (rare)
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16
Q

Bladder cancer

Risk factors

A
  • Smoking (x3 risk)
  • Aromatic amines (dye factory - aniline dyes)
  • Rubber manufacturing
  • Paraplegia (x20 risk due to long term catheterisation)
  • Cyclophosphamides
  • Schistosomiasis - SQUAMOUS CELL
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17
Q

Two-week referral for bladder cancer

A
  • Aged over 45 with unexplained visible haematuria, either without a UTI or persisting after treatment for a UTI
  • Aged over 60 with microscopic haematuria (not visible but positive on a urine dipstick) PLUS:
    • Dysuria or;
    • Raised white blood cells on a full blood count

Consider a non-urgent referral in people over 60 with recurrent unexplained UTIs.

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18
Q

Presentation of renal cell carcinoma

A
  • Haematuria
  • Flank pain
  • Palpable mass
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19
Q

Patho of renal cell carcinoma

A
  • Adenocarcinoma
  • In proximal convoluted tubules
  • Solid lesions
  • Up to 20% may be multifocal, 20% may be calcified and 20% may have either a cystic component or be wholly cystic
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20
Q

Types of renal cell carcinoma

A
  • CLEAR CELL (80%)
  • Papillary
  • Chromophobe
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21
Q

Renal cell carcinoma risk factors

A
  • Smoking
  • Obesity
  • Hypertension
  • End-stage renal failure
  • VON HIPPEL-LINDAU DISEASE
  • Tuberous sclerosis
  • Only slightly increased in patients with ADPKD
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22
Q

Two-week wait for renal cancer

A

Aged over 45 with unexplained visible haematuria, either without a UTI or persisting after treatment for a UTI

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23
Q

Paraneoplastic features of RCC

A
  • Polycythaemia (secretion of unregulated erythropoeitin)
  • Hypercalcaemia (secretion of hormone that mimics action of PTH)
  • Hypertension (increased renin secretion, polycythaemia and physical compression)
  • Stauffer syndrome - abnormal liver function tests (ALT/AST/ALP/bilirubin raised) without liver mets
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24
Q

RCC mets in lungs

A

CANNONBALL METS (clearly-defined circular opacities )

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25
Q

Staging of renal cell carcinoma

A

Stage 1: < 7cm, confined to kidney
Stage 2: > 7cm but confined to kidney
Stage 3: Local spread to nearby tissues or veins, but not beyond Gerota’s fascia
Stage 4: Spread beyond Gerota’s fascia, including mets

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26
Q

Mx of renal cell carcinoma

A
  • Partial or radical nephrectomy (may include surrounding tissue, lymph nodes and even adrenalectomy)
  • Arterial embolisation (cut off blood supply to kidney)
  • Percutaneous cryotherapy (freeze and kill tumour cells)
  • Radiofrequency ablation
  • Chemo or radiotherapy (BUT RCC usually resistant)
  • IL-2 and alpha-interferon
  • Tyrosine kinase inhibitors (sorafenib, sunitinib)
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27
Q

Ix for RCC

A
  • CT
  • Biopsy should not be performed when a nephrectomy is planned but is mandatory before any ablative therapies are undertaken
  • Assessment of the functioning of the contralateral kidney
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28
Q

Define AKI (criteria)

A
  • Rise in creatinine > 26 micromol/L in 48 hours
  • Rise in creatinine of >50% (1.5x) in 7 days
  • Urine output of < 0.5ml/kg/hr for > 6 hours
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29
Q

AKI Stage 1

A
  • 1.5x - 1.9x baseline creatinine

- < 0.5 ml/kg/hr UO for 6-12 hours

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30
Q

AKI Stage 2

A
  • 2.0x - 2.9x baseline creatinine

- < 0.5ml/kg/hr UO for 12hrs

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31
Q

AKI Stage 3

A
  • > 3x baseline creatinine
  • < 0.3 ml/kg/hr UO for > 24hrs
  • or anuria > 12 hrs
32
Q

Risk factors for AKI

A
  • Emergency surgery (sepsis, hypovolaemia)
  • Intraperitoneal surgery
  • Pre-existing CKD (eGFR < 60)
  • Diabetes
  • HF
  • Age > 65 yrs
  • Liver disease
  • Nephrotoxic drugs
  • Cognitive impairment
  • Contrast medium
33
Q

Pre-renal causes of AKI

A
  • Reduced vascular volume (hypotension - shock, dehydration, burns, D&V, renal artery stenosis)
  • Reduced cardiac output (HF, MI, cardiogenic shock)
  • Systemic vasodilation (sepsis, drugs)
34
Q

Renal causes of AKI

A
  • Glomerular: glomerulonephritis, acute tubular necrosis
  • Interstitial nephritis
  • Rhabdomyolysis
  • Tumour lysis syndrome (high phosphate, high potassiu, low calcium, should be given IV allopurinol or IV rasburicase with chemo to prevent)
35
Q

Post-renal causes of AKI

A
  • Within renal tract: kidney stone, malignancy, ureter or urethral strictures, clot
  • Extrinsic compression: BPH/prostate malignancy, pelvic malignancy, retroperitoneal fibrosis
36
Q

Presentation of AKI

A
  • Initially: asymptomatic
  • Reduced urine output
  • Pulmonary and peripheral oedema
  • Arrhythmias (secondary to changes in potassium and acid-base)
  • Features of uraemia, e.g. pericarditis, encephalopathy
37
Q

Urinalysis in AKI

A
  • Leucocytes and nitrites –> infection
  • Protein and blood suggest acute nephritis (but can also be present in infection)
  • Glucose suggests diabetes
38
Q

AKI

Investigation if no obvious cause?

A

USS within 24 hrs

39
Q

AKI

Management

A
  • Fluid rehydration (IV fluids)
  • Med review: stop nephrotoxic drugs
  • Relieve obstruction if present, e.g. insert catheter
  • If obstruction suspected –> urology review
  • Treat any hyperkalaemia
  • Renal replacement therapy if complications
40
Q

Complications of AKI

A
  • Hyperkalaemia
  • Fluid overload, HF, pulmonary oedema
  • Metabolic acidosis
  • Uraemia (high urea) –> encephalopathy, pericarditis
41
Q

Referral criteria for AKI

A
  • Renal transplant
  • ITU patient with unknown cause of AKI
  • Vasculitis/ glomerulonephritis/ tubulointerstitial nephritis/ myeloma
  • AKI with no known cause
  • Inadequate response to treatment
  • Complications of AKI
  • Stage 3 AKI (see guideline for details)
  • CKD stage 4 or 5
  • Qualify for renal replacement hyperkalaemia / metabolic acidosis/ complications of uraemia/ fluid overload (pulmonary oedema)
42
Q

Difference between acute tubular necrosis and prerenal uraemia

A

ATN:

  • Urine sodium > 40 mmol/L
  • Low urine osmolality (< 350)
  • Poor response to fluid challenge
  • Normal urea:creatinine ratio
  • Urine: brown granular casts

Prerenal uraemia:

  • Urine sodium < 20 mmol/L (holds on to sodium to preserve volume)
  • High urine osmolality (> 500)
  • Good response to fluid challenge
  • Raised urea:creatinine ratio
  • Urine: normal sediment
43
Q

Differentiating AKI and CKD?

A

US: CKD usually have bilateral small kidneys

CKD also usually has hypocalcaemia (due to lack of Vit D)

44
Q

Exceptions to small kidneys in CKD?

A
  • Diabetic nephropathy in early stages
  • PCKD
  • Amyloidosis
  • HIV-associated nephropathy
45
Q

Drugs that may worsen AKI

A 
- NSAIDs (except if aspirin at cardiac dose e.g. 75mg od)
• Aminoglycosides
• ACE inhibitors
• Angiotensin II receptor antagonists
• Diuretics
46
Q

Drugs that may need to be stopped in AKI due to toxicity risk?

A
  • Lithium
  • Metformin
  • Digoxin
47
Q

Causes of CKD?

A
  • Diabetic nephropathy
  • Chronic glomerulonephritis
  • Chronic pyelonephritis
  • Hypertension
  • Adult polycystic kidney disease
  • Age-related decline
  • Meds: NSAIDs, PPIs, Lithium
48
Q

Risk factors for CKD

A
  • Older age
  • Hypertension
  • Diabetes
  • Smoking
  • Use of meds that affect kidney
49
Q

Features of CKD

A
  • Oedema: ankle swelling, weight gain (low albumin)
  • Polyuria
  • Lethargy
  • Pruritus
  • Anorexia (weight loss)
  • Insomnia
  • Nausea and vomiting
  • Hypertension
  • Muscle cramps
50
Q

eGFR variables?

A

CAGE

  • Creatinine (serum)
  • Age
  • Gender
  • Ethnicity
51
Q

Factors that may affect eGFR result?

A
  • Pregnancy
  • Muscle mass (e.g. amputees, body-builders)
  • Eating red meat 12 hours prior to the sample being taken
52
Q

CKD Stage 1

A

eGFR > 90
- Some kind of kidney damage on other tests (if tests normal - no CKD)

The patient does not have CKD if they have a score of A1 combined with G1 or G2.
They need at least an eGFR of < 60 or proteinuria for a diagnosis of CKD.

53
Q

CKD Stage 2

A

eGFR 60-90
- With some kind of kidney damage (if tests normal - no CKD)

The patient does not have CKD if they have a score of A1 combined with G1 or G2.
They need at least an eGFR of < 60 or proteinuria for a diagnosis of CKD.

54
Q

CKD Stage 3a

A

eGFR 45-59

- Moderate reduction in kidney function

55
Q

CKD Stage 3b

A

eGFR 30-44

- Moderate reduction in kidney function

56
Q

CKD Stage 4

A

eGFR 15-29

- Severe reduction in kidney function

57
Q

CKD Stage 5

A

eGFR < 15

  • Established kidney failure
  • Dialysis or kidney transplant may be needed
58
Q

A Scores in CKD

A

Based on albumin:creatinine ratio
A1: < 3 mg/mmol
A2: 3-30 mg/mmol
A3: > 30 mg/mmol

The patient does not have CKD if they have a score of A1 combined with G1 or G2.
They need at least an eGFR of < 60 or proteinuria for a diagnosis of CKD.

59
Q

CKD

Investigations

A
  • eGFR: U&Es - two tests 3 months apart required for diagnosis
  • Proteinuria (> 3 (A2) = significant)
  • Haematuria - check with urine dipstick (1+ = significant, should prompt malignancy Ix’s)
  • Renal US for accelerate CKD, haematuria, Fx of PCKD, evidence of obstruction
60
Q

CKD

When to refer?

A
  • eGFR < 30
  • Urine albumin:creatinine ratio (ACR) > 70 mg/mmol
  • Accelerated progression (eGFR decrease of 15 or 25% or 15ml/min in 1 year)
  • Uncontrolled HTN despite >4 antihypertensives
61
Q

Define nephritis

A

Generic term for the inflammation of the kidneys

62
Q

Define nephritic syndrome

A

A group of symptoms (NOT a diagnosis)
- They fit the clinical picture of having inflammation of their kidney, but does not represent a specific diagnosis

Examples:

  • Haematuria
  • Oliguria
  • Proteinuria
  • Fluid retention
63
Q

Define nephrotic syndrome

A

Refers to a group of symptoms, without specifying the underlying cause. So, it is not a disease but is a way of saying ‘the patient has these symptoms’ inidcating an underlying disease present, but does not specify which disease.

MUST fulfill these criteria:

  • Peripheral oedema
  • Proteinuria > 3g/24 hrs
  • Serum albumin < 25g/L (hypoalbuminaemia)
  • Hypercholesterolaemia
64
Q

Define glomerulonephritis

A
  • Glomerulonephritis is an umbrella term applied to conditions that cause inflammation of or around the glomerulus and nephron
  • There are many conditions that can be described as glomerulonephritis
65
Q

Define interstitial nephritis

A
  • Inflammation of the space between cells and tubules (the interstitium) within the kidney
  • It is important not to confuse this with glomerulonephritis
  • Under the umbrella term of interstitial nephritis, there are two key specific diagnoses: acute interstitial nephritis and chronic tubulointerstitial nephritis
66
Q

Define glomerulosclerosis

A
  • Describes the pathological process of scarring of the tissue in the glomerulus
  • Can be caused by any time of glomerulonephritis, obstructive uropathy or by a specific disease called focal segmental glomerulosclerosis
67
Q

What does nephrotic syndrome predispose someone to?

A

Predisposes patients to thrombosis, hypertension and high cholesterol

68
Q

Polycystic kidney disease

Chromosome in ADPKD 1 and 2? What do 1 and 2 code for?

A
  • 1: Chromosome 16
  • 2: Chromosome 4

Codes for polycystin-1 and polycystin-2

69
Q

Extrarenal manifestations of ADPKD

A
  • Aortic root dilatation
  • Mitral regurgitation (due to mitral valve prolapse)
  • Diverticular disease
  • Hepatic, splenic, pancreatic, ovarian, prostatic cysts
  • Intracranial aneurysms (may lead to SAH)
70
Q

Metabolic acidosis

Normal anion gap

Causes

A
  • GI bicarbonate loss (diarrhoea)
  • Renal tubular acidosis
  • Drugs, acetazolamide
  • Ammonium chloride injection
  • Addison’s disease
  • Hyperchloraemia (excess NaCl fluid)
71
Q

Metabolic acidosis

Raised anion gap

Causes

A
  • Lactate: shock, sepsis, hypoxia
  • Ketones: DKA, alcohol
  • Urate: renal failure
  • Acid poisoning: salicylates, methanol
72
Q

Causes of sterile pyuria

A
  • Partially treated UTI
  • Urethritis e.g. Chlamydia
  • Renal tuberculosis
  • Renal stones
  • Appendicitis
  • Bladder/renal cell cancer
  • Adult polycystic kidney disease
  • Analgesic nephropathy
73
Q

Causes of polyuria

A
  • Diuretics, caffeine, alcohol
  • DM
  • LITHIUM
  • HF
  • Hypercalcaemia
  • Hyperthyroidism
  • Chronic renal failure
  • Primary polydipsia
  • Hypokalaemia
  • Diabetes insipidus
74
Q

How to calculate anion gap?

A

(Sodium + Potassium) - (Chloride + Bicarbonate)

75
Q

Normal anion gap?

A

10-18 mmol/L

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