Renal Flashcards
Benign prostatic hyperplasia Px
Old Age
Nocturia
Hesistancy
Weak stream
Testicular torsion presentation
MEDICAL EMERGENCY
Typically teenage male
Acute, severe pain in groin area
Red and swollen scrotum (unilateral)
Cremasteric reflex ABSENT on affected side
Prehns sign NEGATIVE
Epididymitis and testicular torsion differential
Prehn’s sign is positive in epididymitis (relief of pain) and negative in testicular torsion (exacerbation of pain)
Cremasteric reflex (stroke thigh = testicle contracts and rises) is negative in testicular torsion
Kidney stone presentation and gold standard investigation
Unilateral severe pain down the side of abdomen
Episodic with episodes not lasting too long
“worst pain ever felt”
Nausea with pain
GOLD STANDARD investigation: non-contrast CT of the kidneys, ureter and bladder (NCCT-KUB)
CKD GFR stages
G1: >90 (normal) G2: 60-90 G3a: 45-59 G3b: 30-44 G4 (severe): 15-29 G5: <15 = dialysis or kidney transplant
IgA nephropathy
Haematuria
Hypertension
Urinalysis: mild proteinuria with RBC casts (nephritic)
Nephritic syndrome causes
Renal:
IgA nephropathy
Systemic:
Post-streptococcal glomerulonephritis
Goodpasture’s
SLE
Nephrotic syndrome causes
Renal disease disrupting kidney function:
Minimal change disease
Focal segmental glomerulosclerosis
Membranous nephropathy
Secondary causes: DDANI (Diabetes, Drugs, Autoimmune, Neoplasia, Infection)
Pyelonephritis (summary)
Fever, nausea (systemically unwell)
Unilateral back pain
Dipstick urinalysis: positive for leukocytes, nitrites, blood
Empirical Abx: Ciprofloxacin
AKI secondary to sepsis Tx
Insulin + dextrose (HYPERKALAEMIA)
Stop aspirin
Give fluids (dehydration)
Sodium citrate (acidosis)
Gonorrhoea
Organism: Neisseria gonorrhoea
Gram stain appearance: Gram negative (pink) diplococci
Presentation: dysuria, discharge
Treatment: ceftriaxone IM
Nephrotoxic drugs contraindicated in AKI
NSAIDs: reduce prostaglandin production = vasoconstriction of afferent arteriole = reduced perfusion = decreased GFR
ACEi/ARB: Blood pressure drops = less blood forced into bowman’s capsule = decreased GFR
Aminoglycosides
Loop diuretics
Renal AKI
Glomerulonephritis
Small vessel vasculitis
Acute tubular necrosis
Acute interstitial nephritis
Post-renal AKI
BPH
Kidney stones
Ureter strictures
Bladder cancer Px and Ix
Haematuria
Frequency
Weight loss without pain
Investigation: cytoscopy
Bladder cancer
Px: painless haematuria, frequency, weight loss
Ix: flexible cystoscopy
Mx:
surgical: TURBT (low grade, non-muscular), radical cystectomy (severe, muscular)
medical: chemotherapy
Most common cause of glomerulonephritis
IgA nephropathy (Berger’s disease)
Oxybutynin in urge incontinence
Anti-muscarinic/cholinergic drug
Inhibits PNS - decreases detrusor excitability, preventing symptoms of urgency
Side effects of oxybutynin
SNS: Constipation Dry mouth Dry eyes Dilated pupils/blurred vision Tachycardia
Prostate cancer Px and Ix
Urgency, nocturia, weight loss, pain
GOLD STANDARD investigation: Transrectal US guided biopsy (Gleason grading)
PSA screening: positives and negatives
Non-specific (false positives), over-treatment
Inexpensive, convenient, early detection
Grading vs staging in cancer
Grade: microscopic appearance
Staging: size and spread of tumour
Four functions of the kidney
Water/hormone homeostasis
Removal of waste/toxins
RBC production (erythropoietin)
Activate Vitamin D
AKI Diagnostic criteria
Any one:
- rise in creatinine of >26 in 48 hours
- > 50% rise in creatinine in 7 days
- fall in urine output to less than 0.5 for more than 6 hours (stage 1) or 12 hours (stage 2)
Px: T2DM, HTN, low urine osmolality, high urine Na, hyperkalaemia
Pre-renal, renal, post-renal?
Renal
Px: Normal Na, raised urea, raised creatinine, responds well to fluid therapy
Pre-renal, renal, post-renal?
Renal
Px: Loin to groin acute colicky pain, microscopic haematuria
Pre-renal, renal, post-renal?
Post-renal
AKI Mx
Fluid balance
Treat HYPERKALAEMIA
Treat underlying cause
CKD Mx
Slow the progression
- DM Tx
- HTN Tx
- Glomerulonephritis Tx
Reduce CVD risk
- Atorvastatin
Manage complications e.g.
- Mineral bone disease (low Vit D)
- HTN
- Proteinuria
- Anaemia
Lower urinary tract symptoms
Storage: frequency, urgency, nocturia, incontinence
Voiding: hesitancy, poor stream, straining, terminal dribble
Haematuria
DDx: UTI, BPH, prostate cancer
BPH Ix
DRE (SMOOTH enlarged prostate)
PSA
Mid stream sample (exclude infection)
Biopsy (exclude malignancy)
Prostate cancer treatment
Localised: radical prostatectomy
Advanced: GnRh agonist (Zoladex)
Most common type of prostate cancer
Adenocarcinoma
Hydrocele
Abnormal collection of fluid in the tunica vaginalis
Soft, non-tender swelling
Mx = Conservative (most resolve by 2 years old)
Varicocele
Abnormal enlargement of the testicular veins “bag of worms”
Ix: US and Doppler
Mx: Conservative
Note: left testicular vein drains into left renal vein, right testicular vein drains into inferior vena cava
Testicular torsion complication
Infarction of the testicle
Ratio used to calculate renal function
Urea:creatinine
CKD dietary changes
Low protein (ammonia excretion) Low potassium (cardiac arrythmias) Low sodium (hypertension)
CKD risk factors
Older age DM HTN Progressive AKI FHx
BPH Tx
1st line: Tamsulosin (alpha blocker)
2nd line: Finasteride (5 alpha reductase inhibitor)
Epididymal cyst (summary)
Most common cause of scrotal swelling
Lump found in posterior aspect of testicle
Ix: US
Mx: dissolve in 10 days
Testicular cancer (summary)
Painless lump
Hydrocele
Gynacomastia
Ix: US
Tx: chemo
Nephritic syndrome
INFLAMMATION within the kidney
Defining features:
- Haematuria
- Oliguria (due to reduced GFR)
- Hypertension (due to fluid overload)
- Proteinuria (but less than nephrotic)
Nephrotic syndrome
Issue with the filtration barrier (pOdOcytes = nephrOtic) = leaking of proteins into the urine
Triad of characteristics:
- Proteinuria
- Hypoalbuminaemia (due to loss in urine)
- Oedema (due to loss of oncotic pressure)
Px of nephrotic syndrome
Oedema Frothy urine (proteinuria)
Nephrotic syndrome Ix
Urinalysis
Urine protein:creatinine ratio (degree of proteinuria)
Blood tests (renal function, elevated lipids)
Renal biopsy (to look for cause)
Nephrotic syndrome Mx
Fluid and salt restriction Loop diuretics (oedema) Treat cause ACEi/ARB (reduce protein loss) Manage complications
Complications of nephrotic syndrome
Hyperlipidaemia: loss of albumin = increased cholesterol formation (Tx = statins)
VTE: due to increased clotting factors (Tx = heparin)
Nephritic syndrome Ix
Diagnostic test: kidney biopsy
Urinalysis (haematuria)
Bloods (elevated ESR and CRP; anaemia reflecting systemic disease)
Nephritic syndrome Mx
Treat underlying cause
ACEi/ARB (reduces proteinuria and preserves renal function)
Corticosteroids (reduce inflammation causing damage)
Causes of glomerulonephritis
IgA nephropathy
Goodpastures disease
Post-streptococcal glomerulonephritis
Henoch Schoenlein purpura
IgA nephropathy (summary)
Deposition of IgA into the mesangium of the kidney = activates complement pathway = glomerular injury
Develops during infection of mucosal lining (IgA mediated)
Presents asymptomatically with microscopic haematuria
Diagnosis: biopsy
Minimal change disease
Makes up 25% of adult cases of nephrotic syndrome
Most common type seen in children
Normal appearance on microscopy but abnormal function
Diagnosis: biopsy
Tx: high dose steroids (prednisolone)
Focal segmental glomerulosclerosis (summary)
Aetiology: can be idiopathic or secondary to HIV, heroin, lithium
Diagnosis: biopsy (presence of scarring of the glomeruli i.e. focal sclerosis)
Tx: steroids in idiopathic, ACEi/ARB for BP control
Membranous nephropathy
25% of adult nephrotic syndrome
Immunologically mediated (IgG)
Diagnosis: renal biopsy (thickened glomerular basement membrane)
- Antiphospholipase A2 receptor antibody found in 70-80% of patients
Tx: ACEi/ARB, in patients with high risk of progression: prednisolone and cyclophosphamide
Bladder cancer risk factors
Smoking (increases risk 2-4 times) - accounts for HALF of male cases
Age >55
Pelvic radiation
Exposure to occupational carcinogens
Bladder stone (due to chronic inflammation)
Most common cause of nephritic syndrome in high income countries
IgA nephropathy
Henoch Schoenlein purpura
Small vessel vasculitis that affects the kidney and joints due to IgA deposition
More common in males post upper resp tract infection
PURPURIC RASH on legs, NEPHRITIC symptoms, and joint pain
Diagnosis: kidney biopsy
Mx: corticosteroids and ACEi/ARB
Post-streptococcal glomerulonephritis
Nephritic syndrome following an infection (3-6 weeks prior, impetigo or strep throat)
Usually affects children
Deposition of strep antigen complexes in the glomeruli = inflammation and damage
Dx: evidence of strep infection + haematuria
Tx: Abx and supportive care
Bladder cancer Px
PAINLESS HAEMATURIA
Pelvic mass
UTI symptoms without bacteriuria
Bladder cancer Ix
Urinalysis (sterile pyuria)
Diagnostic: cystoscopy and biopsy
CTT urogram: allows staging
1st line Tx bladder cancer
Transurethral resection or local diathermy
Renal cancer
90% = proximal tubular epithelium (renal cell carcinomas)
Age 55, F > M
Spread to bone, liver, lungs
RF Renal Cell Carcinoma
Haemodialysis
Smoking
Hypertension
Px Renal Cell Carcinoma
Haematuria
Flank pain
Palpable abdominal mass
Renal Cell Carcinoma Ix
CT/MRI
Bloods: polycythaemia (erythropoietin secretion)
Raised BP (increased renin secretion)
Ultrasound
Bladder cancer parasite
Schistosomiasis
Score to predict survival in RCC
Mayo score
stage 1: partial or radical nephrectomy
stage 3: radical nephrectomy and adrenalectomy
5 most common pathogens in UTIs
KEEPS: Klebsiella (PREGNANT WOMEN) E. coli (MOST COMMON CAUSE) Enterococci Proteus Staphylococcus coagulase -ve
UTI Px
Voiding: FUND
- Frequency, Urgency, Nocturia, Dysuria
Pyelonephritis
Infection and inflammation of the kidney
Most often due to ASCENDING UTI
Pyelonephritis Px
Triad:
Loin pain
Fever
Polyuria
Gold standard for Dx of causative agent in UTIs
Mid stream urine and culture
Pyelonephritis Ix
Urinalysis (WCC and microscopic haematuria)
Mid stream urine and culture
Bloods (elevated CRP)
Renal USS (rule out urinary tract obstruction/stones)
Pyelonephritis Tx
Cefalexin (7-10 days)
Trimethoprim or amoxicillin if sensitive
Cystitis Tx
Trimethoprim or nitrofurantoin (3 days)
AVOID trimethoprim in pregnancy
- Avoid nitrofurantoin at term in pregnancy
Cystitis
Urinary bladder infection
Most common in young sexually active women
Cystitis RFs
History of UTI
Diabetes
Frequent sexual intercourse
Pregnancy
Prostatitis
Inflammation and swelling of the prostate gland
Most common causative agent: E. Coli
Prostatitis Px
DRE: VERY TENDER prostate
Systemic Sx: fever, chills, malaise
VOIDING symptoms
Prostatitis Ix
Urinalysis and culture (blood, WBCs, bacteria)
Prostatitis Tx
Ciprofloxacin or levofloxacin (14 days)
Most common bacterial STI and causative organism
Chlamydia trachomatis
Chlamydia symptom in men
Testicular pain
50% are ASx
Chlamydia symptom in women
Vaginal discharge and dysuria
70% are ASx
Chlamydia diagnostic test
Nucleic acid amplification testing
Chlamydia Mx
1st line: DOXYCYCLINE
Breastfeeding, pregnancy, allergy: AZITHROMYCIN
Avoid sex until Tx finished
Contact tracing
Second most common STI in UK and causative organism
Neisseria gonorrhoea (Gram -ve diplococci)
Gonorrhoea Ix
Nucleic acid amplification testing (NAAT)
Microscopy and culture (G-ve diplococci)
Gonorrhoea Tx
1st line: Ceftriaxone IM dose
2nd line: azithromycin
Syphilis Tx
Benzanthine penicillin + azithromycin
Urolithiasis
The presence of crystalline stones in the urinary tract
OKA: renal calculi, nephrolithiasis
Three places where you find renal stones
Where the ureter narrows:
- Pelvicoureteric junction
- Pelvic brim
- Vesicoureteral junction
Composition of renal stones
Crystals in supersaturated urine = CALCIUM oxylate (80% of cases)
Renal stones RFs
Think anything that increases calcium, oxalate or phosphates
Dehydration High salt intake Hypercalcaemia Obesity (lowers pH) Oxalate rich diet Gout (Uric acid stones) Thiazide (Uric acid reabsorption)
Diclofenac
NSAID
Adrenal gland layers
Renal stones Px
Most are asymptomatic SEVERE COLICKY UNILATERAL PAIN from LOIN to GROIN Writhing around in pain Associated with nausea and vomiting ASSUME AAA until proven otherwise!
Renal stone 1st line diagnostic imaging technique
KUB X-Ray (diagnostic for 80% of cases)
Renal stone Gold standard imaging technique
Non-contrast CT KUB
Renal stones Mx
STRONG analgesia: diclofenac
Antibiotics
Tamsulosin: relaxes smooth muscle and helps expulsion
Percutaneous nephrolithotomy: used to expel stones over 10mm
Prevention:
- thiazide diuretics (helps with recurrent stones by reducing calcium levels)
- hydration, reduce salt and oxalate intake
AKI stages
Stage 1: risk Stage 2: injury Stage 3: failure Loss ESKD
CKD Px
Pruritis
Fatigue
Oedema
Polyuria
2nd line to ACEi due to cough SE
Angiotensin II receptor blockers E.g. candesartan
Post-strep glomerulonephritis Ix
Blood tests (renal function + eGFR)
Urinalysis (blood + protein)
Biopsy (dead bacterial cell + antibodies)
USS
Granulomatosis with polyangiitis Px
Nasopharynx: saddle nose
Lung: Dyspnoea, Haemoptysis
Kidneys: decreased urine output
Goodpastures Px
Reduced urine output
Haemoptysis
Oedema
Dyspnoea
Testicular seminoma
Germ cell tumour
Seminoma cancers NEVER secrete alpha-fetoprotein (AFP)
Radiolucent vs radiopaque
Radiolucent: allow X-Rays to penetrate through them and expose the receptor
Radiopaque: bony in origin (absorb/stop the penetration of the X-Rays and therefore do not reach the receptor)
Uric acid stones on X-Ray
Radiolucent
Treatment with prognostic benefit in prostate cancer
Finasteride: inhibits conversion of testosterone to dihydrotestosterone
Uncomplicated UTI
Non-pregnant women
Children over 3 months
Autosomal dominant polycystic kidney disease mutations
PKD1 mutation
PKD2 mutation
ADPKD complications
Kidney stones
Renal insufficiency
Berry aneurysms
Heart failure (aortic root dilation)
