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MRCS Critical care > Renal > Flashcards

Renal Flashcards

1
Q
A
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2
Q

Describe mechanism of TURP syndrome

A

-Irrigation fluid for TURP is hypo-osmolar
-Hyposmolar solution used to avoid diathermy injury to pt from resectoscope
-If absorbed via prostatic venous sinuses: can result in hyponatraemia and hypervolaemia

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3
Q

Why does TURP syndrome cause change in bp?

A
  1. Volume overload initially causes hypertension
  2. Subsequently causes cardiac insufficiency and hypotension
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4
Q

What is TURP syndrome?

A

-Caused by absorbtion of large amounts of irrigation fluid into prostatic venous sinuses
-Syndrome can be caused by hyponatraemia (<125mmol/L) or hyperammonaemia (metabolite of glycine)

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5
Q

What are signs and symptoms of TURP syndrome?

A

-Hypertension and then hypotension
-Tachycardia
-Hypoxia (overload)
-Dyspnoea (overload)
-neurological: confusion, disorientation, convulsions, coma

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6
Q

What is the mechanism behind neurological symptoms in TURP syndrome?

A

Hyponatreamia causes osmotic gradient in the brain resulting in cerebral oedema and raised ICP

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7
Q

What are the most appropriate irrigation fluids for use in TURP syndrome?

A

Hypoosmar solutes (Glycine, Sorbitol, Manitol)

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8
Q

How would you manage hypotensive patient with TURP syndrome?

A

Resuscitate according to Ccrisp protocol
Identify bleeding, take bloods including osmolality
Stop IVI
Inform ITU/HDU and operating surgeon

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9
Q

Where should hypotensive pt with TURP syndrome be managed?

A

in ITU/HDU
Risk of developing cerebral/pulmonary oedema

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10
Q

What precautions can be taken to minimise risk of TURP?

A

Minimise operating time
Close monitoring of observations during surgery
Keep fluid bag low to reduce pressure
Minimise operative bleeding

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11
Q

How is hyponatraemia classified?

A

Hypervolaemic: Excess water dilutes sodium
Euvolaemic: Hyponatraemia in presence of normal water levels
Hypovolaemic: water and sodium levels are both low

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12
Q

What are causes of hypervolaemic hyponatraemia?

A

Renal failure, liver failure, heart faliure, iatrogenic fluid overload

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13
Q

What are causes of euvolaemic hyponatraemia?

A

SIADH
Hypothyroidism

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14
Q

What are causes of SIADH?

A

-CNS causes: mass/bleed (trauma, sah), infection (meningitis)
-Pulmonary causes (pneumonia, asthma
-Cancer: gi, lung, genitourinary
-Drugs: (SSRI)

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15
Q

What are causes of hypovolaemic hyponatraemia?

A

-Marked blood loss
-Inadequate replacement of fluid and electrolytes
-sepsis

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16
Q

How is sodium reabsorbed by the kidneys?

A

Majory (60%) of filtered sodium is reabsorbed in the PCT via an ATP dependent pump
-20% loop of henle: passive due to countercurrent mechanism
-remainder dct and collecting ducts under control of aldosterone (active)

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17
Q

What is absorbed in proximal convoluted tubule?

A

Sodium reabsorption (60%) via ATP dependent pump
Passive reabsorption of chloride ions
Water reabsorption down osmotic gradient

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18
Q

What is absorbed in loop of henle?

A

Loop of henle reabsorbs 25% filtered sodium
Passive reabsorption of chloride ions
Ascending limb impermeable to water
Reabsorption of water in descending limb down osmotic gradient

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19
Q

What is absorbed in loop of henle?

A

Sodium reabsorption (25%)
Passive reabsorption of chloride ions
Ascending limb impermeable to water
Loop of henle reabsorbs 25% of filtered sodium

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20
Q

What is absorbed in distal convoluted tubule?

A

-Sodium reabsorption (8%). This process is energy dependent.
-Reabsorption of sodium in dct and collecting duct is partially under control of aldosterone
-Low osmolality of ultrafiltrate entering dct leads to passive reabsorption of water, which continues in collecting ducts

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21
Q

Explain the countercurrent mechanism

A

-formed by two parallel limbs in loop of henle
-Ascending limb is highly impermeable to water but permeable to solutes (Na, Cl)
-Reabsorption of solutes creates osmotic gradient in medullary interstitium and raises osmolality of this compartment
-Leads to reabsorption of water from descending limb

22
Q

Define acute renal failure

A

Sudden impairment of the kidney’s ability to excrete nigtrogenous waste products of metabolism

23
Q

Causes of pre-renal failure

A

Dehydration
Sepsis
Heart failure
Blood loss

24
Q

Causes renal AKI

A

-ATN
-Glomerulonephritis
-Hepatorenal syndrome
-Vasculitis
-Nephrotoxic medications

25
Q

Causes Post renal AKI

A

Obstruction from calculi
Prostatic obstruction (BPH, Cancer)
Renal/bladder tumour
Extrinsic compression from pelvic tumours

26
Q

What is the pathogenesis of acute renal failure?

A

-reduced perfusion pressure -> efferent vasoconstriction -> reduced blood flow and cortical/medullary ischaemia -> shedding cells into lumen -> back leak fluid into insterstitium -> increased medullary hydrostatic pressure—> reduced re absorption

renal parenchyma ischaemia results from fall in perfusion pressure
-This leads to vasoconstriction of efferent arterioles which preserves capillary filtration pressure
-Contricted efferent arterioles have reduced blood flow, resulting in worsening cortical and medullary ischaemia
-Ischaemic cells are shed into tubular lumen causing obstruction, which promotes a ‘back leak’ of tubular fluid into interstitium
-This raises interstitial hydrostatic pressure, which reduces tubular fluid reabsorption and worsens oliguria

27
Q

Which part of nephron will be affected by acute renal failure first?

A

-thick ascending limb—> within medulla, most atp pumps

Cells of thick ascending limb are most susceptible to ischaemic injury
-This is because they are within medulla, which has poorer oxygenation than cortex
-Also, active ATP pumps at cell membrane have higher oxygen demand

28
Q

Where is renin released from in kidneys and what triggers its release?

A

-Renin is released from juxtaglomerular apparatus

Renin release is triggered by:
-Reduced renal perfusion
-Sympathetic nervous system stimulation
-Catecholamine release
-Hyponatraemia

Renin cleaves angiotensin 1 from angiotensinogen

29
Q

Name some nephrotoxic drugs

A

NSAIDS
ACE inhibitors
Gentamicin
Furosemide
Thiazide diuretics

30
Q

Name some important life-threatening complications of acute renal failure

A

-Fluid retention and hypervolaemia leading to acute pulmonary oedema
-Hyperkalaemia leading to metabolic acidosis and cardiac arrythmias

31
Q

How would you manage hypperkalaemia?

A

10ml 10% calcium gluconate
Insulin dextrose infusion
Salbutamol
Calcium resonium
Treat cause

32
Q

What are the indications for renal replacement therapy?

A

Acidosis
Refractory hyperkalaemia
Refractory pulmonary oedema and fluid overload
Uraemic encephalopathy
Removal of toxins

33
Q

Grade 1 kidney injury

A

Renal contusion, non-expanding subcapsular haematoma

34
Q

Grade 2 kidney injury

A

Laceration <1cm in depth not involving renal medulla and collecting system, non-expanding retroperitoneal haematoma

35
Q

grade 3 kidney injury

A

Laceration >1cm not involving collecting system

36
Q

grade 4 kidney injury

A

Laceration >1cm extending into collecting system, renal vessel injury with haemorrhage

37
Q

Grade 5 kidney injury

A

Shattered kidney or avulsed renal vessels

38
Q

What are the indications for surgical management of renal trauma?

A

Haemodynamically unstable patient indicating ongoing bleeding
Expanding perinephric haematoma
Avulsion of renal pedical

39
Q

When would you suspect urethral injury in a patient?

A

-Bleeding from urethra
-Perineal haematoma
-Scrotal haematoma
-High riding prostate on DRE in male

40
Q

What is the likely anatomical site of urethral injury in a male in pelvic ring fractures and in ‘saddle injuries’?

A

Pelvic ring fractures: membranous part of urethra
-Saddle injuries: bulbar urethra

41
Q

What investigation would you do to confirm urethral injuries?

A

Retrograde urethrogram

42
Q

How woulld you manage a patient with suspected urethral injury?

A

If there is no extravasation on retrograde urethrogram, urinary catheter

If there is extravasation, suprapubic

Formal surgical repair can be considered at later stage.

43
Q

What investigations would you perform for renal acolic?

A

Bloods: U + E, Bone profile, urate
Imaging: CTKUB, US if pregnant

44
Q

What are the common sites of stone impaction along the ureter?

A

-Pelvi-ureteric junction
-When the ureter crosses pelvic brim
-Vesico-ureteric junction

45
Q

What are the different types of renal stones?

A

Calcium oxalate stones
Calcium phosphate stones
Struvite stone: magnesium and ammonia (also known as infection stone)
Uric acid stone

46
Q

What is a staghorn calculus?

A

Stone occupying renal pelvis and at least one calyceal system

47
Q

Which stones can you manage conservatively?

A

Stones <4mm will almost always pass spontaenoiusly

48
Q

How would you manage pt with a stone >1cm and impaired renal function?

A

-Ureteric stent placement
-Percutaneous nephrostomy

49
Q

How would you manage renal stones?

A

-Conservative management
-Ureteroscopy and stone retrieval
-ESWL
-Percutaneous nephrolithotomy

50
Q

What are the causes of haematuria?

A

Infection:
-Cystitis
-Prostatitis

Autoimmune
-Glomerulonephritis
-Iga nephropathy

Tumours
Renal stones
Trauma

51
Q

What investigations would you consider in pt with haematuria?

A

-Bloods
-Renal US
-Flexible cystoscopy
-CT urogram

52
Q

What are the different types of renal tumours?

A

Benign
-Adenoma
-Angiomyolipoma
-Cysts

Malignant
-Wilm’s tumour
-RCC
-TCC

MRCS Critical care (11 decks)

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