Renal Flashcards
1
Q
What is the NICE criteria for AKI?
A
- Rise in creatinine of >25 micromol/L in 48 hrs
- Rise in creatinine >50% in 7 days
- Urine output of <0.5 ml/kg/hr for >6 hrs
2
Q
What is acute kidney injury?
A
An acute drop in kidney function. Diagnosed by measuring creatinine
3
Q
How can causes of AKI be classified? Which is most common?
A
- Pre-renal (most common)
- Renal
- Post-renal
4
Q
What are pre-renal causes of AKI?
A
Due to inadequate blood supply to the kidneys
- Dehydration
- Hypotension
- HF
5
Q
What are renal causes of AKI?
A
Intrinsic disease leading to reduced filtration of blood
- Glomerulonephritis
- Interstital nephritis
- Acute tubular necrosis
6
Q
What are post-renal causes of AKI?
A
Obstruction to the outflow of urine causing back-pressure into the kidney
- Kidney stones
- Massess
- Ureter or uretral strictures
- Enlarged prostate or prostate cancer
7
Q
What is the first step of treating AKI?
A
Correcting the underlying cause:
- IV fluids in pre-renal AKI
- Stop nephrotoxic meds and antihypertensives that reduce filtration pressure
- Relieve obstruction in post-renal AKI
8
Q
What are complications of AKI?
A
- Hyperkalaemia
- Fluid overload
- Metabolic acidosis
- Uraemia -> encephalopathy/pericarditis
9
Q
What are causes of CKD?
A
- Age related decline
- Diabetes
- Chronic HTN
- Chronic glomerulonephritis
- PKD
- Meds
10
Q
What is required to confirm a diagnosis of CKD?
A
2 eGFR tests 3 months apart
11
Q
What eGFR would indicate end stage renal failure?
A
eGFR <15
12
Q
Possible complications of CKD?
A
- Anaemia
- Renal bone disease
- CVD
- Peripheral neuropathy
- Dialysis related problems
13
Q
Why can you get anaemia in CKD?
A
Healthy kidney cells produces erythropoietin which stimulates the production of RBC
14
Q
General principles of CKD management?
A
- Manage cause
- General measures - fluid restriction, dietary protein restriction, ACE-In
- Treat complications
- Dialysis (regular dialysis when GFR <15ml/min and symp/complications of kidney disease)
15
Q
What are indications for short term dialysis?
A
AEIOU:
- Acidosis (severe and not responding to tx)
- Electrolyte abnormalities (tx resistant Hyperkalaemia)
- Intoxication
- Oedema (severe/unresponsive pulmonary oedema)
- Uraemia (symptoms such as seizures/reduced consciousness)
16
Q
What is the main indication for long term dialysis?
A
End-stage renal failure (CKD stage 5)
17
Q
What are the options for long term dialysis?
A
- Haemodialysis
- Peritoneal dialysis
18
Q
How do renal stones present?
A
- Asymptomatic
- Renal colic - unilateral loin to groin pain, colicky
- Haematuria
- N+V
- Reduced UO
- Symptoms of sepsis if infection present
19
Q
What are the types of renal stones
A
- Calcium based stones (most common) - hypercalcaemia and low UO are RF, calcium oxalate stones are most common
- Uric acid - not visible on XR
- Struvite - produced by bacteria (associated w infection)
- Cystine
20
Q
What are two complications of renal stones?
A
- Obstruction -> AKI
- Infection -> obstructive pyelonephritis
21
Q
What is the investigation of choice for renal stones?
A
Non-contrast CT KUB
22
Q
What is the management of renal stones?
A
- NSAIDs for pain - IM diclofenac
- Antiemetics for N+V
- Abx if infection
- WW if stone <5mm
- Tamsulosin - can help aid spontaneous passage of stones
- Surgical interventions for larger stones/complete obstruction/infection
23
Q
What advice can you give pts to reduce the risk of recurrent renal stones?
A
- Increase fluid intake
- Add fresh lemon juice to water
- Reduce salt intake
- Avoid carbonated drinks
- For calcium stones - reduce intake of oxalate-rich foods (spinach, beetroot, nuts, black tea, rhubarb)
24
Q
What meds can be used to reduce the risk of recurrence of renal stones?
A
- Potassium citrate
- Thiazide diuretics (indapamide)
Both in pts with calcium oxalate stones and raised serum calcium
25
How do you investigate a man presenting with LUTS?
- Abdo examination
- DRE
- Urine dipstick
- PSA
26
What is BPH?
Hyperplasia of the stromal and epithelial cells of the prostate
27
What are medical options for managing BPH? What do they do?
- Alpha blockers (tamsulosin) - relax smooth muscle, improving symptoms
- 5-alpha-reductase-inhibitors (finasteride) - shrink the prostate
Can be used in conjunction, alpha blockers provide more immediate relief
28
What are side effects of the medications used to manage BPH?
- Tamsulosin = postural hypotension
- Finasteride = sexual dysfunction (due to reduced testosterone)
29
What is the most common surgical treatment of BPH?
Transurethral resection of the prostate (TURP)
30
What are risk factors for bladder cancer?
- Smoking
- Increasing age
- Aromatic amines exposure in dye and rubber industries (now heavily regulated)
- Schistosomiasis
31
What symptom is a red flag for bladder cancer?
Painless haematuria
32
What is used to diagnose bladder cancer?
Cystoscopy
33
What are management options for bladder cancer?
- Transurethral resection of bladder tumour (TURBT)
- Intravesical chemotherapy - chemo given into bladder via a catheter, after ^ to prevent reoccurrence
- Intravesical BCG - giving the BCG vaccine into the bladder is thought to stimulate the immune system -> attacks bladder tumours
- Radical cystectomy
34
What's the most common type of bladder cancer?
Transitional cell carcinoma
35
What's the most common type of renal cell carcinoma?
Clear cell
36
How does renal cell carcinoma present?
Triad of:
- Haematuria
- Flank pain
- Palpable mass
37
Renal cell carcinoma often spreads to the renal vein and then the inferior vena cava. Whats a classic feature of metastatic renal cell carcinoma?
' Cannonball metastases' in the lungs
38
What are management options for renal cell carcinoma?
First line = removal of the tumour:
- Partial nephrectomy
- Radical nephrectomy
Less invasive procedures:
- Arterial embolisation - cutting off blood supply to affected kidney
- Percutaneous cryotherapy - injecting liquid nitrogen to kill tumour cells
- Radiofrequency ablation - putting a needle in the tumour and using an electrical current to kill tumour cells
39
What are risk factors for prostate cancer?
- Increasing age
- FHx
- Black African or Caribbean origin
- Tall stature
- Anabolic steroids
40
Where does prostate cancer commonly metastasise?
- Bone
- Lymph nodes
41
What is the issue with PSA testing?
- It is unreliable
- High rate of false positives and false negatives
42
How does a cancerous prostate feel?
- Firm or hard
- Asymmetrical
- Craggy
- Loss of central sulcus
43
What is the first line investigation for suspected localised prostate cancer?
Multiparametric MRI
44
How is prostate cancer diagnosed?
Prostate biopsy
45
What is used to look for bony metastases in prostate cancer?
Isotope bone scan
46
What grading system is specific to prostate cancer? What does a higher score indicate?
- Gleason Grading System - based on histology from biopsies
- A higher score indicates the tumour is more poorly differentiate -> worse prognosis
47
What are management options for prostate cancer?
- Watch and wait
- External beam radiotherapy - directed at prostate
- Brachytherapy - radioactive seeds implanted into prostate -? delivers targeted continuous radiotherapy
- Hormone therapy - to reduce level of androgens (prostate cancer is almost androgen dependant)
- Radial prostatectomy
48
What do most testicular cancers arise from?
Germ cells in the testes
49
What age group is testicular cancer most prevalent?
15-35
50
What are risk factors for testicular cancer?
- Undescended testes
- Male infertility
- FHx
- Increased height
51
How does testicular cancer present?
Painless lump on the testicle
52
What investigation is used to diagnose testicular cancer?
Scrotal ultrasound
53
What staging system is used to stage testicular cancer?
Royal Marsden Staging System
54
What are management options for testicular cancer?
- Radical orchidectomy +/- prosthesis insertion
- Chemo
- Radiotherapy
- Sperm banking as treatment can cause infertility
55
How can the types of testicular cancer be categorised?
- Seminomas
- Non-seminomas (mostly teratomas)
56
What are tumour markers for testicular cancer?
- Alpha-fetoprotein (not raised in seminomas)
- Beta-hCG - may be raised in both types
- Lactate dehydrogenase (LDH) - non-specific tumour marker
57
What are causes of epididymo-orchitis?
- E. Coli
- Chlamydia trachomatis
- Neisseria gonorrhoea
- Mumps
58
How does epididymo-orchitis present?
- Testicular pain
- Dragging/heavy sensation
- Swelling of testicle and epididymis
- Tenderness on palpation
- Urethral discharge (think STI cause)
- Systemic symptoms
59
What is the management of epididymo-orchitis?
- Acutely unwell -> hosp for IV abx
- Local guidelines for choice of abx
- If likely enteric organism (e.g. E. coli) -> quinolone abx (e.g. oflaxacin)
60
What are complications of epididymo-orchitis?
- Chronic pain
- Chronic epididymitis
- Testicular atrophy
- Sub-fertility
- Scrotal abscess
61
What are the most common causes of UTIs?
- E. coli (most common) - found in faeces and spread to the bladder
- Klebsiella pneumoniae
- Enterococcus
- Pseudomonas aeruginosa
62
What at RF for UTIs?
- Sexual activity - spread bacteria around the perineum
- Incontinence
- Poor hygiene
- Urinary catheters
63
What should you look at on urine dipstick if suspecting a UTI?
- Nitrates
- Leukocytes
- RBCs
Nitrates are a better indication of infection than leukocytes. NICE indicate nitrates or leukocytes AND RBCs suggest a UTI
64
Which pts with a UTI require a MSU?
- Pregnant pts
- Pts w recurrent UTI
- Atypical symptoms
- No improvement with abx
65
What antibiotics are commonly used in community to treat UTIs?
- Trimethoprim
- Nitrofurantoin
66
What is the duration of abx for UTIs?
- 3 days - UTI in women
- 5-10 days - immunosuppressed women, impaired renal function
- 7 days - men , pregnant women, catheter-related UTIs
67
How does pyelonephritis present?
- Fever
- Loin pain
- N+V
- Systemic illness
- LOA
- HAematuria
- Renal angle tenderness
68
What is the management of pyelonephritis?
- 7-10 abx
- Cefalexin
- Co-amox if culture results avaliable
- Trimethoprim of culture results available
69
How can prostatitis be classified?
1. Acute bacterial
2. Chronic - >3 months
- Chronic prostatitis/chronic pelvic pain syndrome (no infection)
- Chronic bacterial prostatitis (infection)
70
How does prostatitis present?
- Pelvic pain
- LUTS
- Sexual dysfunction
- Pain with bowel movements
- Tender, enlarged prostate
71
What is the management of acute prostatitis?
- Hosp admission if systemically unwell
- Oral abx - typically for 2-4 weeks
- Analgesia
- Laxatives for pain during bowel movements
72
What is the management of chronic prostatitis?
- Alpha-blockers - relax smooth muscle, help with symptoms
- Analgesia
- Antibiotics - if <6 months of symptoms (e.g. trimethoprim/doxycycline for 4-6 wks)
- Laxatives for pain during bowel movements
73
What are complications of acute bacterial prostatitis?
- Sepsis
- Prostate abscess
- Acute urinary retention
- Chronic prostatitis
74
How does upper urinary tract obstruction present?
- Loin to groin pain
- Reduced/no UO
- Non specific symptoms e.g. vomiting
- Impaired renal function on bloods (raised creatinine)
75
How does lower urinary tract obstruction present?
- Difficulty/inability to pass urine
- Urinary retention (w an increasingly full bladder)
- Impaired renal function on bloods (raised creatinine)
76
What is neurogenic bladder?
Abnormal function of the nerve innervating the bladder and urethra
77
What are management options for urinary tract obstruction?
- Upper - nephrostomy
- Lower - urethral/suprapubic catheter
78
What is hydronephrosis? What is the cause?
- Swelling of the kidney (renal pelvis and calyces)
- Urinary tract obstruction -> back-pressure into the kidneys
79
What is renal tubular acidosis (RTA)?
Metabolic acidosis due to pathology in the tubules of the kidneys
80
What are the types of RTA?
- Type 1 - distal tubule cannot excrete H+
- Type 2 - proximal tubule cannot reabsorb HCO3
- Type 3 - mixed
- Type 4 - low aldosterone/impaired aldo function
Type 4 is most common. Know 1/4 for exams
81
What are the features of type 1 RTA?
- High urinary pH
- Metabolic acidosis
- Hypokalaemia (failure of H+/K+ exchange)
82
What is the treatment of type 1 RTA?
Oral bicarbonate - corrects acidosis and electrolyte imbalances
83
What are the features of type 4 RTA?
- Metabolic acidosi
- Hyperkalaemia
- Low urinary pH
84
Why is urinary pH low in types 4 RTA?
- Normally ammonia is produced in the distal tubules to buffer H+ ions and prevent the urine from becoming to acidotic
- Hyperkalaemia suppresses ammonia production -> urine becomes acidotic
85
What are causes of type 4 RTA?
Reduced aldosterone:
- Adrenal insufficiency
- Diabetic nephropathy
- Meds (ACE-In, spironolactone, eplerenone)
86
What is the management of type 4 RTA?
- Manage underlying cause
- Fludrocortisone for aldosterone deficiency
- Oral bicarbonate
- Treatment of hyperkalaemia
87
What is PKD?
A genetic condition where healthy kidney tissue is replaced with fluid-filled cysts
88
What are the two types of PKD? Which is more common?
- AD (more common)
- AR
89
What genes are affected in ADPKD?
- PKD1 gene on chromosome 16
- PKD2 gene on chromosome 4
90
What are complications of ADPKD?
- Chronic loin pain
- Hypertension
- Gross haematuria (when cyst rupture)
- Recurrent UTI
- Renal stones
- End-stage renal failure (occurs at mean age of 50)
91
What are extra-renal manifestations of ADPKD?
- Cerebral aneurysms
- Hepatic/splenic/pancreatic/ovarian/prostatic cysts
- MR
- Colonic diverticula
92
What is the management of PKD?
- Tolvaptan - slow the dev of cyst and progression of renal failure in ADPKD
- Treat complications e.g. HTN, pain, infections
- Drainage if symptomatic
- Dialysis/transplant for end-stage renal failure
Advice:
- Avoid contact sport (cyst rupture)
- Avoid NSAIDs and anticoagulants
- Genetic counselling
