Renal Flashcards
What score is used to measure impact of LUTS on QOL? Scores?
International prostate symptoms score
20-35: severely symptomatic
8-19: moderately symptomatic
0-7: mildly symptomatic
What can cause a raised PSA?
- 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)
Examples of alpha-blockers
- Tamsulosin
- Doxasocin
Example of 5-alpha reductase inhibitor
- Finasteride
SEs of alpha-blockers
- POSTURAL HYPOTENSION
- Dizziness
- Drowsiness
- Depression
- Dyspnoea and cough
SEs of 5-alpha reductase inhibitors
- Impotence
- Low libido
- Gynaecomastia
- Decreased prostate size
- Causes low levels of PSA
When should you refer to urology for prostate issues?
Men aged 50-69 years should be referred if the PSA is >= 3.0 ng/ml OR there is an abnormal DRE
Tx of prostate cancer
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)
1st line investigation for prostate cancer
Multiparametric MRI
What scoring system is used to assess MRI in prostate cancer?
Likert Scale
> 3 = do biopsy
1-2 = weigh up pros/cons of doing biopsy
What scoring system is used to assess the biopsy in prostate cancer?
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
Complications of radical prostatectomy
- ERECTILE DYSFUNCTION
- incontinence
Complications of radiotherapy/brachytherapy for prostate cancer
- Proctitis (rectum inflammation) - pred suppositories can help
- Cystitis
- Increased risk of bladder/colon/rectal cancer
- Erectile dysfunction
- Incontinence
Complications of hormone therapy for prostate cancer
- Hot flushes
- Sexual dysfunction
- Gynaecomastia
- Fatigue
- Osteoporosis
Types of bladder cancer
- Transitional cell carcinoma (90%)
- Squamous cell carcinoma (5% - higher in areas of schistosomiasis)
- Adenocarcinoma, sarcoma, small-cell carincoma (rare)
Bladder cancer
Risk factors
- Smoking (x3 risk)
- Aromatic amines (dye factory - aniline dyes)
- Rubber manufacturing
- Paraplegia (x20 risk due to long term catheterisation)
- Cyclophosphamides
- Schistosomiasis - SQUAMOUS CELL
Two-week referral for bladder cancer
- 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.
Presentation of renal cell carcinoma
- Haematuria
- Flank pain
- Palpable mass
Patho of renal cell carcinoma
- 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
Types of renal cell carcinoma
- CLEAR CELL (80%)
- Papillary
- Chromophobe
Renal cell carcinoma risk factors
- Smoking
- Obesity
- Hypertension
- End-stage renal failure
- VON HIPPEL-LINDAU DISEASE
- Tuberous sclerosis
- Only slightly increased in patients with ADPKD
Two-week wait for renal cancer
Aged over 45 with unexplained visible haematuria, either without a UTI or persisting after treatment for a UTI
Paraneoplastic features of RCC
- 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
RCC mets in lungs
CANNONBALL METS (clearly-defined circular opacities )
Staging of renal cell carcinoma
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
Mx of renal cell carcinoma
- 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)
Ix for RCC
- 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
Define AKI (criteria)
- 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
AKI Stage 1
- 1.5x - 1.9x baseline creatinine
- < 0.5 ml/kg/hr UO for 6-12 hours
AKI Stage 2
- 2.0x - 2.9x baseline creatinine
- < 0.5ml/kg/hr UO for 12hrs
AKI Stage 3
- > 3x baseline creatinine
- < 0.3 ml/kg/hr UO for > 24hrs
- or anuria > 12 hrs
Risk factors for AKI
- Emergency surgery (sepsis, hypovolaemia)
- Intraperitoneal surgery
- Pre-existing CKD (eGFR < 60)
- Diabetes
- HF
- Age > 65 yrs
- Liver disease
- Nephrotoxic drugs
- Cognitive impairment
- Contrast medium
Pre-renal causes of AKI
- Reduced vascular volume (hypotension - shock, dehydration, burns, D&V, renal artery stenosis)
- Reduced cardiac output (HF, MI, cardiogenic shock)
- Systemic vasodilation (sepsis, drugs)
Renal causes of AKI
- 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)
Post-renal causes of AKI
- Within renal tract: kidney stone, malignancy, ureter or urethral strictures, clot
- Extrinsic compression: BPH/prostate malignancy, pelvic malignancy, retroperitoneal fibrosis
Presentation of AKI
- 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
Urinalysis in AKI
- Leucocytes and nitrites –> infection
- Protein and blood suggest acute nephritis (but can also be present in infection)
- Glucose suggests diabetes
AKI
Investigation if no obvious cause?
USS within 24 hrs
AKI
Management
- 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
Complications of AKI
- Hyperkalaemia
- Fluid overload, HF, pulmonary oedema
- Metabolic acidosis
- Uraemia (high urea) –> encephalopathy, pericarditis
Referral criteria for AKI
- 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)
Difference between acute tubular necrosis and prerenal uraemia
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
Differentiating AKI and CKD?
US: CKD usually have bilateral small kidneys
CKD also usually has hypocalcaemia (due to lack of Vit D)
Exceptions to small kidneys in CKD?
- Diabetic nephropathy in early stages
- PCKD
- Amyloidosis
- HIV-associated nephropathy
Drugs that may worsen AKI
- NSAIDs (except if aspirin at cardiac dose e.g. 75mg od) • Aminoglycosides • ACE inhibitors • Angiotensin II receptor antagonists • Diuretics
Drugs that may need to be stopped in AKI due to toxicity risk?
- Lithium
- Metformin
- Digoxin
Causes of CKD?
- Diabetic nephropathy
- Chronic glomerulonephritis
- Chronic pyelonephritis
- Hypertension
- Adult polycystic kidney disease
- Age-related decline
- Meds: NSAIDs, PPIs, Lithium
Risk factors for CKD
- Older age
- Hypertension
- Diabetes
- Smoking
- Use of meds that affect kidney
Features of CKD
- Oedema: ankle swelling, weight gain (low albumin)
- Polyuria
- Lethargy
- Pruritus
- Anorexia (weight loss)
- Insomnia
- Nausea and vomiting
- Hypertension
- Muscle cramps
eGFR variables?
CAGE
- Creatinine (serum)
- Age
- Gender
- Ethnicity
Factors that may affect eGFR result?
- Pregnancy
- Muscle mass (e.g. amputees, body-builders)
- Eating red meat 12 hours prior to the sample being taken
CKD Stage 1
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.
CKD Stage 2
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.
CKD Stage 3a
eGFR 45-59
- Moderate reduction in kidney function
CKD Stage 3b
eGFR 30-44
- Moderate reduction in kidney function
CKD Stage 4
eGFR 15-29
- Severe reduction in kidney function
CKD Stage 5
eGFR < 15
- Established kidney failure
- Dialysis or kidney transplant may be needed
A Scores in CKD
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.
CKD
Investigations
- 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
CKD
When to refer?
- 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
Define nephritis
Generic term for the inflammation of the kidneys
Define nephritic syndrome
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
Define nephrotic syndrome
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
Define glomerulonephritis
- 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
Define interstitial nephritis
- 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
Define glomerulosclerosis
- 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
What does nephrotic syndrome predispose someone to?
Predisposes patients to thrombosis, hypertension and high cholesterol
Polycystic kidney disease
Chromosome in ADPKD 1 and 2? What do 1 and 2 code for?
- 1: Chromosome 16
- 2: Chromosome 4
Codes for polycystin-1 and polycystin-2
Extrarenal manifestations of ADPKD
- Aortic root dilatation
- Mitral regurgitation (due to mitral valve prolapse)
- Diverticular disease
- Hepatic, splenic, pancreatic, ovarian, prostatic cysts
- Intracranial aneurysms (may lead to SAH)
Metabolic acidosis
Normal anion gap
Causes
- GI bicarbonate loss (diarrhoea)
- Renal tubular acidosis
- Drugs, acetazolamide
- Ammonium chloride injection
- Addison’s disease
- Hyperchloraemia (excess NaCl fluid)
Metabolic acidosis
Raised anion gap
Causes
- Lactate: shock, sepsis, hypoxia
- Ketones: DKA, alcohol
- Urate: renal failure
- Acid poisoning: salicylates, methanol
Causes of sterile pyuria
- Partially treated UTI
- Urethritis e.g. Chlamydia
- Renal tuberculosis
- Renal stones
- Appendicitis
- Bladder/renal cell cancer
- Adult polycystic kidney disease
- Analgesic nephropathy
Causes of polyuria
- Diuretics, caffeine, alcohol
- DM
- LITHIUM
- HF
- Hypercalcaemia
- Hyperthyroidism
- Chronic renal failure
- Primary polydipsia
- Hypokalaemia
- Diabetes insipidus
How to calculate anion gap?
(Sodium + Potassium) - (Chloride + Bicarbonate)
Normal anion gap?
10-18 mmol/L
