Renal Flashcards
AKI
- criteria
- Sx, conditions, urinalysis and Mx for Pre-renal, renal and post-renal
Criteria needed for diagnosis:
* A rise in serum creatinine of ≥26 µmol/L within 48 hours
* A rise in serum creatinine to ≥1.5 times baseline in the last 7 days
* Urine volume <0.5 mL/kg/hr for >6 hours
PRE-RENAL:
Sx - signs of volume depletion (e.g., hypotension, tachycardia, reduced skin turgor)
Conditions - hypoperfusion, renovasc disease
Urinalysis - hyaline casts
Mx - fluid resus
RENAL:
Sx - oliguria, eosinophiluria, fever, rash, haematuria, flank pain
Conditions - glomerulonephritis,
vasculitis (PAN, TTP),
acute tubular necrosis (ATN),
acute interstitial nephritis (AIN)
Urinalysis - proteinuria, haematuria and RBC casts
Mx - corticosteroids, IV fluids, and cessation of offending drugs (such as gentamicin)
POST-RENAL:
Sx - signs of renal obstruction (distended bladder, incomplete voiding)
Conditions - outflow obstruction (tumours, clots, strictures)
Urinalysis - if kidney stones, haematuria
Mx - remove blockage
Indications for dialysis
Dialysis indications (“AEIOU”):
* Acidosis
* Electrolyte abnormalities (hyperkalaemia)
* Intoxication (e.g., ethylene glycol, lithium)
* Overload (volume)
* Uraemia (pericarditis, encephalopathy, platelet dysfunction)*
Drugs in AKI:
Safe
Worsen renal fucntion
Increased risk of toxicity (but do not worsen AKI)
**Safe: **
* paracetamol
* warfarin
* statins
* aspirin (cardioprotective 75mg)
* clopidogrel
* BBs
should be stopped:*
* NSAIDs
* Aminoglycosides
* ACEi
* ARBs
* Diuretics **
**May be stopped: **
* metformin
* digoxin
* lithium
Nephrotic syndrome
- features
- causes
- risk of thrombosis
- Mx
Clinical features:
* Massive proteinuria (>3.5 g/24 hr)
* Hypoalbuminaemia (<30 g/L)
* Oedema
* Hyperlipidaemia (accelerated atherosclerosis)
Common causes of nephrotic syndrome:
* Minimal change disease (most common in children, associated with recent infections)
* Focal segmental glomerulosclerosis (most common in Afro-Caribbean adults, presents with hypertension)
* Membranous nephropathy (associated with malignancies, autoimmune diseases, hepatitis B/C)
* Diabetic nephropathy (complication of diabetes)
* Lupus nephritis (with haematuria and proteinura)
* Amyloidosis (associated with multiple myeloma or chronic inflammatory disease)
Thrombosis risk is increased due to the loss of antithrombin III, protein C, and protein S in urine.
Treatment approach includes treatment of underlying disease and symptoms:
* Lifestyle—Fluid restriction
* Medical—Steroids and immunosuppressant, diuretic, ACEI, statin, antibiotic (infection risk), hypercoagulability treatment.
**Renal artery stenosis **
- causes
- Sx
- examinations
- investigations
- Mx
Most common causes:
* Atherosclerotic disease (90% of cases)
* Fibromuscular dysplasia (10% of cases) is angiopathy of medium-sized vessels resulting in areas of stenosis and aneurysm (in carotid, vertebral, and renal arteries)
* Takayasu’s arteritis in Southeast Asia/East Asia
Common presenting symptoms:
* >55 years old
* Accelerated or difficult-to-control secondary hypertension due to RAAS activation
* Decrease in renal function with ACEI or ARBs
* Flash pulmonary oedema in absence of decreased cardiac output
Examination findings: Abdominal bruit heard over the epigastrium or flank
Initial investigation:
* Duplex ultrasound should be ordered to assess the velocity and severity of stenosis (>50% reduction in vessel diameter)
* Ultrasound, however, cannot confirm diagnosis.
* Angiography is the GOLD STANDARD
Most appropriate management:
* Optimising vascular risk factors (smoking cessation, diabetes control, statins, and adequate antihypertensive therapy)
* Avoid nephrotoxic agents (e.g., ACEI, ARBs, NSAIDs)
* Angioplasty (stenting) for flash pulmonary oedema or hypertension refractory to medical management
ADPKD
- investigation
- Mx
investigation:
* Renal ultrasound to detectrenal cysts
* However, it is usually limited to detected cysts ≥10 mm
* screening relatives
* FBC may show raised Hb due to excess erythropoietin.
Management:
* Lifestyle—Renoprotective measures (e.g., diet, exercise, cessation of smoking)
* Medical—Tolvaptan (slows cyst growth and delays ESRF), ACEI/ARB, antibiotics (UTI and infected cysts)
Management of end-stage/severe ADPKD:
* Dialysis
* Kidney transplant
Acute interstitial nephritis
- Sx
- Drug causes
- Investigations
- Investigation for definitive diagnosis
- Mx
Sx:
fever, rash, arthralgia
eosinophilia
mild renal impairment
hypertension
Drug causes:
* Antibiotics, especially beta-lactams
* Diuretics
* NSAIDs
* PPIs, H2 antagonists (cimetidine and ranitidine)
* Allopurinol
* Phenytoin
Investigations:
*U&E may show AKI with elevated serum creatinine.
* FBC: Raised eosinophils
* Urinalysis: Sterile pyuria (absence of RBCs excludes acute glomerulonephritis), heavy proteinuria with nephrotic syndrome
* Kidney ultrasound may show large swollen kidneys, to exclude hydronephrosis from post-renal cause.
Investigation to confirm diagnosis: A biopsy of the kidney is needed to provide information on the severity of disease, clues to possible aetiology, and prognosis.
Mx:
* Lifestyle—Discontinue the triggering medication and provide supportive care.
* Medical—Corticosteroids may be associated with greater recovery of kidney function.
Anti-GBM disease (Goodpastures)
- Sx
- Investigations
- Management
**Symptoms: **
* pulmonary haemorrhage
* glomerulonephritis (proteinuria + haematuria)
**Investigations: **
* renal biopsy shows IgG deposits
* raised transfer factor secondary to pul haemorrhage
**Management: **
* plasma exchange
* steroids
* cyclophosphamide
Focal segmental glomerulosclerosis (FSGS)
- causes
- symptoms
- investigation
- management
Causes: idiopathic,HIV, heroin, Alports, sickle-cell
Sx:
- oedema
- ascites
- proteinuria
Investigation:
- renal biopsy shoes effacement of foot processes
Mx:
- steroids +/- immunosurpressants
What is the fluid maintenance in children?
AKI vs CKD
Most patients with CKD have bilaterally small kidneys
Hypocalcaemia is also suggestive of CKD over AKI
Chronic kidney disease
- stages
Maintenance fluids:
- water
- potassium, sodium & chloride
- glucose
- water: 25-30ml/kg/day
- K+: 1mmol/kg/day
- glucose: 50-100g/day
Alports syndrome:
* Sx
* Diagnosis
Results in an abnormal GBM mutation (X-linked dominant)
Sx:
* microscopic haematuria
* progressive renal failure
* bilateral sensorineural deafness
* lenticonus: protrusion of the lens surface into the anterior chamber
* retinitis pigmentosa
* renal biopsy: splitting of lamina densa seen on electron microscopy
Diagnosis:
* renal biopsy - basket weave
Renal transplant: causes of reaction
- hyperacute (minutes to hours)
- acute graft failure (<6 months)
- chronic (>6 months)
- hyperacute: pre-existing antibodies against ABO or HLA antigents
- acute: mismatched HLA. cytotoxic T cells.
- chronic: antibody and cell mediated mechanisms cause fibrosis to the transplanted kidney
How long do AV fistulas take to be fully functioning?
6 - 8 weeks
Benign prostatic hyperplasia
- symptoms
- assessment
- Mx
Symptoms:
- Obstructive voiding Sx: weak or intermittent flow, straining, hesitancy, dribbling
- Storage Sx: urgency, frequency, nocturia
- post-micturation: dribbling
- complications: UTI, retention
Assessment:
- urine dipstick
- U&Es
- PSA: if obstructive Sx or worries about prostate Ca
- urinary freq-volume chart
- Internal Prostate Symptom Score (IPSS)
Mx
- watchful waiting
- alpha-1-antagonist e.g. tamsulosin, alfuzosin (decrease smooth muscle tone in bladder)
- 5 alpha-reductase inhibitors e.g. finasteride
- combination therapies
Bladder Cancer:
- features
- referral criteria
- investigations
- management
Sx: haematuria, dysuria, frequency, suprapubic pain & sysemic Sx
Referral criteria: 2ww
45+ and:
- unexplained haematuria without UTI
- visible haematuria which persists post UTI Mx
60+ and: unexplained non‑visible haematuria and either dysuria or a raised white cell count on a blood test
Investigation: cystoscopy and biopsies
Management: resection, chemo & radiotherapy
Epididymitis and orchitis
- what is it?
- what is the most common cause for epididymitis?
- investigations
- management
Epididymitis - inflammation of the epididymis
Orchitis - inflammation of the testes
Most common cause is STIs in males 14-35 (chlamydia, gonorrhoea)
In older men it is enteric organisms e.g. E.coli or Enterococcus faecalis
Can get mumps orchitis
Investigations:
- Prehn sign - elevating and supporting scrotum reduces pain (differentiate from torsion)
- Investigate for underlying pathology
Management: treat underlying cause
Prostate cancer:
- features
- referral criteria
- investigations
- management
Prostate cancer is now the most common cancer in adult males in the UK and is the second most common cause of death due to cancer in men after lung cancer.
Features:
- often asymptomatic
- bladder outlet obstruction: hesitancy, urinary retention
- haematuria, haematospermia
- pain: back, perineal or testicular
- digital rectal examination: asymmetrical, hard, nodular enlargement with loss of median sulcus
Referral criteria: 2WW if prostate feels malignant on PR exam
PSA if: lower UTI Sx, erectile dysfunction, visible haematuria THEN 2ww
Investigation: MRI
Mx:
radiotherapy, hormonal therapy
Testicular cancer:
- subtypes
- features
- tumour markers
- diagnosis
- management
Subtypes: seminomas & non-seminomas (teratoma, yolk sac)
Features
- painless lump
- hydrocele
- gynaecomastia
Tumour markers:
- seminomas: hCG
- non-seminomas: AFP & hCG
- LDH
Diagnosis: USS
Mx:
- treatment depends on whether the tumour is a seminoma or a non-seminoma
- orchidectomy
- chemotherapy and radiotherapy may be given depending on staging and tumour type
Urinary tract calculi
- features
- ureteric colic
- investigation
- management
Features
* Ureteric/renal colic (most common presentation)
* UTIs
* Haematuria
* Incidental findings (during imaging for other symptoms).
Ureteric colic: this is the result of a stone impacting in the urinary tract and causing obstruction behind it.
Diagnosis:
- CT KUB
- IV urography
- ultrasonography
Management:
Acute - diclofenac via rectal suppositary, antispasmodic and tamsulosin if stones <10mm
Preventing -
- potassium citrate if stones >50% calcium oxalate
- thiazide diuretics
Surgical:
- drainage if signs of sepsis
- Extracorporeal shock wave lithotripsy: stones <2cm (contra in pregnancy, AAA, urosepssi and coagulopathy)
- Uteroscopy: lower uterteric stones
