Renal Flashcards
Differences between AKI and CKD
Renal US = patients with CKD have bilateral small kidneys
Hypocalcaemia suggests CKD
Exceptions
* Autosomal dominant polycystic kidney disease
* Diabetic nephropathy
* Amyloidosis
* HIV-associated nephropathy
Differentials for haematuria
- Trauma
- Infection
- Malignancy = RCC, SCC and adenocarcinoma, prostate cancer, urothelial cancer
- Glomerulonephritis
- Stones
- BPH
- PCKD
- Vascular malformations
- Renal vein thrombosis
- Coagulopathy
- Drugs = aminoglycosides, chemo, penicillin, sulphonamides, NSAIDs, anticoagulants
- Exercise
- Endometriosis
- Catheterisation
- Radiotherapy
- Pseudohaematuria
Pre-renal causes of AKI
inadequate blood supply to kidneys reducing filtration
o Hypovolaemia = Dehydration (D+V), haemorrhage
o Hypotension (shock, sepsis, cardiac failure)
o Oedematous states = cirrhosis, nephrotic syndrome
o Renal artery stenosis/occlusion
o Drugs = antihypertensives, diuretics
Renal causes of AKI
o Peripheral vascular disease
o Disseminated intravascular coagulation
o Malignant hypertension
o Thromboembolic disease
o Glomerulonephritis
o Interstitial nephritis
o Acute tubular necrosis
o Rhabdomyolysis
o Tumour lysis syndrome
o Drugs NSAIDs, PPIs, penicillins, radiological contrast
Post-renal causes of AKI
o Kidney stones
o Masses/cancer in abdo or pelvis
o Ureter or urethral strictures
o BPH or prostate cancer
Presentation of AKI
- Symptoms of high urea
o Fatigue, weakness, anorexia, nausea and vomiting
o Followed by confusion, seizures and coma - Breathlessness
- Thirst
- Diarrhoea
- Haematuria
- Haemoptysis
- Reduced urine output/Urine retention = oliguria
- Palpable bladder, palpable kidneys, abdominal/pelvic masses, rashes
- Postural hypotension
- Pulmonary and peripheral oedema
Investigations for AKI
- Urinalysis for protein, blood, leucocytes, nitrates, glucose
o Leucocytes + nitrates = infection
o Protein + blood = acute nephritis
o Glucose = diabetes - Bloods Anaemia, Hypocalcaemia, Hyponatraemia, Hyperphosphataemia, Hyperkalaemia, High creatinine/low GFR
- US of urinary tract/kidneys within 24 hrs if no identifiable cause or risk of UTI
- ECG = arrhythmias due to hyperkalaemia
Diagnosis criteria for AKI
KDIGO classification
- Rise in creatinine of >/= 25 micromol/L in 48 hrs
- Rise in creatinine of >/= 50% in 7 days
- Urine output of <0.5ml/kg/hour for >6 hrs (8hrs in children)
- >25% fall in eGFR in children/young adults in 7 days
Management of AKI
- Prevention and treat cause
- IV Fluid rehydration
- Stop nephrotoxic medications = NSAIDs, ACEi, gentamicin, metformin, spironolactone
- Relieve obstruction = catheter
- Reverse hyperkalaemia with insulin and dextrose
- Haemofiltration/haemodialysis if patient not responding to medical treatment of complications
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
- CKD stage 4/5
- Qualify for renal replacement = hyperkalaemia/metabolic acidosis/ complications of uraemia/fluid overload
Complications of AKI
- Hyperkalaemia
- Fluid overload, heart failure, pulmonary oedema
- Metabolic acidosis
- Uraemia = encephalopathy or pericarditis
- CKD
Risk factors for CKD
- Smoking
- Family history
- Diabetes (T2>T1)
- Hypertension
- Glomerulonephritis
- Polycystic kidneys disease
- Medications = NSAIDs, PPIs, lithium
- More common in African, Afro-Caribbean or Asian origin
Presentation of CKD
- Asymptomatic
- Itching
- Loss of appetite
- Nausea
- Muscle cramps
- Nocturia and polyuria
- Amenorrhea in women and erectile dysfunction in men
- Oedema
- Peripheral neuropathy
- Pallor
- Hypertension
Investigations of CKD
- Estimated GFR = 2 tests 3 months apart for diagnosis
o eGFR <60 or proteinuria - Urine albumin: creatinine ratio >/= 3mg/mmol
- Urine dipstick = haematuria
o Check for bladder cancer - Renal ultrasound
- Urine microscopy = UTI, glomerulonephritis
- Biopsy and histology = Diagnose condition causing renal failure
Bloods in CKD
o Raised urea and creatinine
o Raised ALP
o Raised PTH if CKD stage 3+
o Raised phosphate
o Low Ca2+
o Hb low = normochromic normocytic anaemia
Stages of CKD
- G score eGFR
o G1 = eGFR >90
o G2 = eGFR 60-89
o G3a = 45-59
o G3b = 30-44
o G4 = 15-29
o G5 = <15 - A score = Albumin: creatinine ratio
o A1 <3mg/mmol
o A2 3-30mg/mmol
o A3 >30 mg/mmol
Slow progression of CKD
o Diabetic control
o Hypertensive control = ACEi
o Treat glomerulonephritis
Complications of CKD
- Anaemia
- Renal bone disease
- CVD
- Peripheral neuropathy
- Dialysis related problems
- Hyperkalaemia
- Peptic ulceration
- Acute pancreatitis
- Malignancy
Reduce risk of complications of CKD
o Exercise, maintain healthy weight and stop smoking
o Dietary advice on phosphate, sodium, potassium and water intake
o Atorvastatin 20mg = prevention of CVD
Treat complications of CKD
o Oral sodium bicarbonate = metabolic acidosis
o Iron supplementation and erythropoietin = anaemia
o Vit D = renal bone disease
o Proteinuria ACE-I, SGLT-2 inhibitors
o Dialysis = haemofiltration, haemodialysis, peritoneal dialysis
o Renal transplant = end stage renal failure
Risk factors for renal cell carcinoma
- Von Hippel Lindau syndrome
- Inherited disease = neurofibromatosis, tuberous sclerosis
- Cystic disease = AD polycystic kidneys, horseshoe kidneys
- Toxins = Smoking, industrial exposure to carcinogens
- Obesity
- Renal failure and haemodialysis
- HYpertension
Types of RCC
Clear cell carcinoma, papillary or chromophobe
Spread of RCC
Spread may be direct (renal vein), via lymph or haematogenous (bone, liver, lung, brain)
Presentation of RCC
- Often asymptomatic
- Haematuria
- Vague loin pain
- Abdominal mass
- Systemic: Anorexia, malaise, fever (of unknown origin), night sweats and weight loss
- Polycythaemia, anaemia, hypercalcaemia
- Hypertension
- Varicocele (caused by tumour compressing veins)
Investigations for RCC
- Ultrasound = distinguish simple cyst from complex cyst or tumour
- Renal biopsy = Get histology to identify tumour
- CT chest and abdomen with contrast
o Renal mass and involvement of renal vein of inferior vena cava
o Cannon ball metastases in lungs - MRI = Tumour staging (Robertson)
- Bloods
o FBC = detect polycythaemia and anaemia due to EPO decrease
o ESR may be raised
o LFTs abnormal = obstructive jaundice (Stauffer syndrome)
o Hypercalcaemia
Management of RCC
- Radical or Partial nephrectomy
- Radiotherapy and chemotherapy
- Ablative techniques = Cryoablation and radiotherapy
- Alpha-interferon and interleukin-2 to reduce tumour size
Complication of RCC
Stauffer syndrome
Risk factors for pyelonephritis
- Structural renal/urological abnormalities
- Diabetes
- Calculi
- Catherisation
- Pregnancy
Causes of pyelonephritis
- E. coli
- Klebsiella
- Enterococcus
- Pseudomonas
Presentation of pyelonephritis
- High fever and rigors
- Loin to groin pain
- Nausea and Vomiting
- Dysuria and urinary frequency
- Haematuria
- Severe headache
- Pain on bimanual palpation of renal angle
Investigations of pyelonephritis
- Urine dipstick = blood, protein, leukocyte esterase, nitrite
- Midstream urine microscopy, culture and sensitivity before starting Abx
- Blood cultures
- Raised WCC and ESR/CRP
- CT scan (adults) and ultrasound scan (children)
- Dimercaptosuccinic acid = indication of renal scarring
Management of pyelonephritis
- Broad spectrum cephalosporin or quinolone for 7-10 days
- Consider hospital admission
- Surgery = Drain abscess or relieve calculi causing infection
Complications of pyelonephritis
- Recurrent kidney infections
- Leads to scarring renal parenchyma
- CKD
- Abscess/pus around kidney
Risk factors for kidney stones
- Anatomical abnormalities that predispose to stone formation
- Diet = Chocolate, tea, strawberries, rhubarb (all increase oxalate levels)
- Gout
- Family history
- Ileostomy
- Dehydration
- Primary renal disease = Polycystic kidneys, Renal tubular acidosis
- Drugs = diuretics, antacids, acetazolamide, corticosteroids, aspirin, allopurinol, vit C and D
- High calcium
Location of kidney stones
Pelviureteric junction, Pelvic brim, Vesicoureteric junction
Presentation of kidney stones
- Most asymptomatic
- Renal colic
o Rapid onset = woken from sleep
o Excruciating ureteric spasms = patient writhing in pain and cannot lie still
o Pain radiates from loin to groin and comes and goes in waves as ureters peristalise
o Worse with fluid loading - Oliguria and Dysuria
- Haematuria
- Nausea and vomiting
- Sepsis
- Recurrent UTIs = increased risk if voiding impaired
- Bowel sounds may be reduced
- Hypotension
Investigations of kidney stones
- Urine dipstick = haematuria, protein, glucose
- Mid-stream urine MCS
- Bloods = Serum urea, electrolyte, creatinine and calcium, FBC
- Non-contrast CTKUB (CT Kidney Ureter Bladder)
- Ultrasound = Shows kidney stones and renal pelvis dilatation well but ureteric stones can be missed
Management of kidney stones
- Strong analgesic for renal colic = IM Diclofenac
- Antibiotics if infection = IV cefuroxime or IV gentamicin
- Antiemetics to prevent vomiting
- Fluids
- Stones <5mm in lower ureter 90% pass spontaneously
- Medical expulsive therapy
o Oral nifedipine or alpha blocker (oral tamsulosin) = promote expulsion - If still not passing, then surgery
o Extracorporeal shockwave lithotripsy (10-20mm)
o Ureteroscopy and laser lithotripsy
o Percutaneous nephrolithotomy (>20mm)
Prevention of kidney stones
- Overhydration
- Diet = low Ca2+, low salt, low animal protein
- Reduce BMI
- Active lifestyle
- Cholestyramine and pyridoxine reduced urinary oxalate secretion
- Allopurinol and oral bicarbonate prevents uric acid stones
- Cysteine binder = captopril
- If hypercalciuria then thiazide diuretic (Oral Bendroflumethiazide)
Complications of kidney stones
- > 50% lifetime risk of recurrence once you’ve had them
- Acute pyelonephritis
Causes of glomerulonephritis
- Primary
- Secondary = infection, autoimmunity or malignancy
- Nephrotic and nephritic syndromes
Causes of acute urinary retention
- BPH
- Urethral strictures
- Calculi
- Cystocele
- Constipation
- Masses
- Drugs: anticholinergic, TCA, antihistamines, opioids, benzos
- Neurological cause
- UTI
- Post-op or postpartum
Presentation of acute urinary retention
- Inability to pass urine
- Lower abdominal discomfort/tenderness
- Considerable pain or distress (chronic retention will be painless)
- Acute Confusional state (elderly)
- Palpable distended urinary bladder
Investigations for acute urinary retention
- Fluid status assessment
VBG for K+
Rectal, neurological ± pelvic exam - Urinalysis and culture (after catheterisation)
- Serum U&Es and creatinine, FBC, CRP
- US bladder = volume >300
Accurately measure urine output
Management of acute urinary retention
- Decompression via catheterisation
o Volume <200 indicates not urinary retention
o Volume >400 indicates catheter should be left in place - Further investigation into causes
- Trial of IV fluids unless in heart failure
- Flush catheter if catheter not draining
Complications of acute urinary retention
- Post-obstructive diuresis
- AKI
Risk factors for nephritis syndrome
- Hep B/C
- Malaria
Causes of nephritic syndrome
- IgA nephropathy Macroscopic haematuria in young people 1-2 days following URTI
- Henoch-Schoenlein purpura Children following infection
- Post-streptococcal 1-2 wks after throat or skin infection
- Anti-glomerular basement membrane disease
- Rapidly progressive GN
- Good-pasture’s disease
- Systemic sclerosis
- SLE
Presentation of nephritic syndrome
- Haematuria
- Oliguria
- Proteinuria = <3g/24 hours
- Fluid retention (oedema)
- Uraemia = anorexia, pruritus, lethargy, nausea
- Hypertension
- Moderate to severe decrease in GFR
- HSP = palpable purpuric rash over buttocks and extensor surfaces
Investigations for nephritic syndrome
- Bloods = eGFR, serum urea and electrolytes and albumin
- Culture = Swab from throat or infected skin
- Urine dipstick = proteinuria and haematuria
- Renal biopsy
Management of nephritic syndrome
- Treat causes
- Salt and water restriction
- Hypertension = ACE-I or CCBs (amlodipine) if AKI
- Diuretics
- Immunosuppression with corticosteroids for SLE, ANCA vasculitis, anti-GBM, IgA vasculitis
- Antibiotics for endocarditis
- Monitor blood pressure and urinalysis
Causes of nephrotic syndrome
- Primary
o Minimal change disease (children)
o Membranous nephropathy
o Focal segmental glomerulosclerosis (adults)
o Membranoproliferative GN - Secondary
o Diabetes
o Lupus nephritis, SLE, RA
o Myeloma
o Amyloid
o Pre-eclampsia
o HIV, HBV, HCV
o Drugs = NSAIDS and ACEi
Presentation of nephrotic syndrome
- Peripheral pitting oedema
- Proteinuria >3g/24 hours
- Hypoalbuminemia <30g/L
- Frothy urine
- Hypercholesterolaemia >10mmol/l
Investigations for nephrotic syndrome
- Renal biopsy in adults
- Urine dipstick = proteinuria
- Bloods = low albumin, high creatinine, low eGFR, high lipids
- Immunology/serology testing
Management of nephrotic syndrome
- Treat underlying cause and treat symptoms
- Minimal change disease oral corticosteroids or cyclophosphamide if steroid resistant
- IV furosemide = oedema
- Ramipril/candesartan = reduce proteinuria
- Prophylactic anticoagulation with warfarin
- Simvastatin = reduce cholesterol
Complications of nephrotic syndrome
- Venous Thromboembolism
- Hypertension
- Hyperlipidaemia
- AKI
- Infection cellulitis, strep, peritonitis
What is autosomal dominant polycystic kidney disease (ADPKD)
- Genetic condition where kidneys develop multiple fluid filled cysts
- Family history of ADPKD, ESRF or hypertension
- Mutations in PKD1 (85%) gene on chromosome 16
- Mutations in PKD2 (15%) gene on chromosome
Presentation of ADPKD
- Nocturia
- Loin pain
- Haematuria
- Excessive water and salt loss
- Bilateral kidney enlargement
- Renal colic due to clots
- Hypertension
- Recurrent UTIs
- Renal stones = mainly uric acid stones
- Progressive renal failure
Investigations for ADPKD
- Ultrasound
o 15-39 yrs >/= 3 cysts (uni/bilateral)
o 40-59 yrs >/= 2 cysts (each kidney)
o >60 yrs >/= 4 cysts (each kidney) - Genetic testing for PKD1 and PKD2
- Screening for relative with abdo US
Management of ADPKD
- Tolvaptan (vasopressin receptor antagonist) = slow development of cysts and progression of renal failure
- Laparoscopic removal of cysts to help with pain/nephrectomy (remove entire kidney)
- Antihypertensives
- Analgesia
- Abx for infection
- Drainage of infected cysts
- Dialysis/transplant = end stage renal failure
- Genetic counselling and support
o Screening for relatives with US - Avoid contact sports = cyst rupture
- Avoid anti-inflammatory meds and anticoagulants
- Regular USS, bloods, BP
Complications of ADPKD
- Hepatic, splenic, pancreatic, ovarian, prostatic cysts
- Cerebral berry aneurysms
- Cardiac valve disease (mitral regurg)
- Colonic diverticula
- Aortic root dilatation
Presentation of autosomal recessive polycystic kidney disease
- Many present in infancy with multiple renal cysts and congenital hepatic fibrosis
- Enlarged polycystic kidneys
Investigations for ARPKD
- Ultrasound
- Genetic testing PKHD1 mutation on long arm of chromosome 6
Management of ARPKD
- Genetic counselling for family members
- Laparoscopic removal of cysts to help with pain/nephrectomy
- Blood pressure control with ACE-inhibitor = ramipril
- Treat stones and give analgesia
- Renal replacement therapy for ESRF
Von Hippel-Lindau syndrome
- Autosomal dominant
- Multisystem cancer syndrome renal cysts and clear cell renal carcinoma in 40s
- Mx : screen for tumours
Alport syndrome
- X-linked
- Haematuria, proteinuria and progressive renal insufficiency
- High tone sensorineural hearing loss
Types of diabetic nephropathy
- Diabetic kidney disease any kidney disease in patient with diabetes
- Diabetic nephropathy any kidney disease presumed to be caused by diabetes
- Diabetic glomerulopathy biopsy proven diabetes related changes in glomerulus
Risk factors for diabetic nephropathy
- Modifiable glycaemic control, hypertension control, salt intake, smoking, RAS blockage
- Non-modifiable age, sex, duration of diabetes, ethnicity
Diagnosis of diabetic nephropathy
- > 10 years diabetes
- Other microvascular complications
- Progressive increase in urine protein excretion over years
- No evidence of other probable cause
Management of diabetic nephropathy
- Optimise diabetic control
- Optimise blood pressure control
- Treatment of microalbuminuria/proteinuria ACEi/ARB
- Smoking cessation
- Statins
Types of UTI
- Cystitis bladder infection
- Prostatitis prostate infection
- Pyelonephritis kidney/renal pelvis infection
Risk factors for UTI
- Sexual activity
- Urinary/faecal incontinence
- Constipation
- Spermicide use
- Low oestrogen
- Menopause
- Dehydration
- Obstructed urinary tract
- Diabetes
- Immunosuppression
- Catheter
- Pregnancy
- Kidney/bladder stones
Causes of UTI
- Klebsiella pneumoniae
- E. coli (MOST COMMON)
- Enterococcus
- Proteus mirabilis/ pseudomonas
- Staphylococcus saprophyticus
Presentation of UTI
- Cystitis = frequency, dysuria, urgency, suprapubic pain, polyuria, haematuria, cloudy/smelly urine
- Acute pyelonephritis = fever, rigors, vomiting, loin pain, costovertebral pain, septic shock
Classification of UTI
- Uncomplicated = normal renal tract structure and function
- Complicated = presence of factors that increase risk of Tx failure
Investigation for UTI
- Dipstick for haematuria, nitrites, leukocytes
- MSU culture
- Bloods to assess for development of AKI
- Sepsis 6 if indicated
- Radiology for complicated pyelonephritis/UTI
Management of UTI
- Acute uncomplicated cystitis
o Nitrofurantoin 3 days (women) or 7 days (men)
o Trimethoprim (not in pregnancy) - Acute uncomplicated pyelonephritis
o Oral ciprofloxacin 14 days - Acute complicated cystitis
o Oral ciprofloxacin - Urosepsis or acute severe pyelonephritis
o IV co-amoxiclav
o Analgesia
o IV fluids
Complications of UTI
- Urosepsis
- Recurrent UTI (>3 in 1 year or >2 in 6m)
- Chronic pyelonephritis
- Abscess formation
- Pyelonephrosis
Risk factors for BPH
- African-Caribbean more than white men
- Older men
- High testosterone
Presentation of BPH
- Voiding Sx (obstructive) weak or intermittent urinary flow, straining, hestitancy, terminal dribbling, incomplete emptying, delay in initiation of micturition
- Storage Sx (irritative) urgency, frequency, overflow/urgency incontinence, nocturia
- Haematuria
- Enlarged bladder
- Occluded bladder = anuria
Investigations for BPH
- Urine dipstick + MSU
- DRE = enlarged and smooth prostate
- Serum PSA = may be raised
- Flow rates and residual volume
- Frequency volume chart
- U+Es and renal ultrasound = exclude renal damage
- Transrectal ultrasound = size of prostate
- International Prostate Symptom Score (IPSS)
Conservative management of BPH
- Reassurance and monitoring if manageable symptoms
- Lifestyle = avoid caffeine, alcohol, relax when voiding
Medical management of BPH
- 1st line = alpha 1 antagonist (oral tamsulosin)
o Relax smooth muscle - 2nd line = 5-alpha-reductase inhibitor (oral finasteride)
o Block testosterone and helps reduced size of prostate
Surgical management for BPH
o Transurethral resection of prostate (TURP)
o Transurethral electrovaporisation of prostate (TUVP)
o Holmium laser enucleation of prostate (HoLEP)
o Open prostatectomy via abdominal or perineal incision
Complications for BPH
- Bladder calculi
- UTI
- Acute urinary retention
- Kidney damage
Risk factors for prostate cancer
- Family history
- Genetic = HOXB13, BRCA 2
- Increased testosterone
- Tall
- Anabolic steroids
Pathophysiology of prostate cancer
- Majority adenocarcinomas arising is peripheral zone of prostate gland
- Most common site of metastases is bone and lymph nodes
- Locally spread to seminal vesicles, bladder and rectum
Presentation of prostate cancer
- LUTS if local disease = nocturia, hesitancy, poor stream, terminal dribbling, retention
- Weight loss, fatigue and bone pain
- Haematuria
- Erectile dysfunction
- Anaemia
Investigations for prostate cancer
- DRE = hard irregular prostate
- Raised PSA = false positive and negatives
- Trans-rectal ultrasound and biopsy
Scoring system for prostate cancer
Gleason
Management of prostate cancer
- Watch and wait
- Radiotherapy
- Brachytherapy = implantation of radioactive material targeted at tumour
- Hormonal treatment
o Bilateral orchidectomy
o LHRH agonists (goserelin)
o Androgen receptor blockers (bicalutamide) - Surgery = total prostatectomy
Complications of prostate cancer
- Erectile dysfunction
- Urinary incontinence
- Radiation induce enteropathy = PR bleeding, pain, incontinence
- Urethral strictures
Risk factors for prostatitis
- STI
- UTI
- Indwelling catheter/ intermittent bladder catheterisation
- Post-prostate biopsy
- Increasing age
Causes of prostatitis
- Streptococcus faecalis
- E.coli
- Chlamydia
Presentation of prostatitis
- Fevers, rigors, malaise
- Pain on ejaculation
- Pain in perineum, penis, rectum or back
- Significant voiding LUTs = poor intermittent stream, hesitancy, incomplete emptying, post micturition dribbling, straining, dysuria
Investigations for prostatitis
- DRE = prostate tender, hard and hot, boggy
- Urine dipstick = positive for leucocytes and nitrites
- Urine and blood cultures
- STI screen = chlamydia
- Trans-urethral ultrasound scan
Management of prostatitis
- 14 day course of quinolone (ciprofloxacin)
- Acute
o IV gentamicin + IV co-amoxiclav
o 2-4 weeks on quinolone = ciprofloxacin
o 2nd line = trimethoprim
o TRUSS guided abscess drainage if necessary - Chronic
o 4-6 week course of quinolone = ciprofloxacin
o +/- alpha blocker = tamsulosin
o NSAIDs = ibuprofen
Risk factors for bladder cancer
- Smoking
- Occupation = industrial paint, motor, leather and rubber workers, blacksmiths, hair dye
- Indwelling catheter
- Bladder stones
- Family history
- Schistomiasis = SCC
- Previous radiation to pelvis
- Drinking water is protective
Pathophysiology of bladder cancer
- Transitional cell carcinoma (>90%) or squamous cell carcinoma
- Tumour spread to pelvic structures (local), iliac and para-aortic nodes (lymphatic), liver and lungs (blood)
Presentation of bladder cancer
- Painless macroscopic haematuria
- Recurrent UTIs
- Voiding irritability
- LUTS
- Painful clot retention
- If advanced mass, lymphadenopathy, pelvic/flank pain
- Systemic: weight loss, lethargy
Investigations of bladder cancer
- Flexible Cystoscopy and biopsy under 2WW
- CT urogram
- Urinary tumour markers
Management of bladder cancer
- Not invading muscle
o TURBT
o Chemo into bladder after surgery
o Weekly Tx for 6 weeks with BCG vaccine squirted into bladder via catheter - Muscle invasive
o Radical cystectomy with ileal conduit
o Radiotherapy
o IV chemo - Metastatic = palliative chemo and radio
Complications of bladder cancer
- Cystectomy = sexual and urinary malfunction
- Clot retention
- B12/folate deficiency
Risk factors for testicular cancer
- Infant hernia
- Infertility
- Family history
- Previous testicular tumour
- Cryptorchidism Undescended testis
- Klinefelter’s syndrome
Pathophysiology of testicular cancer
- Germ cell cancer = seminoma (older), teratoma (child)
- Metastasise to lung, liver, brain, para-ortic lymph nodes, cervical nodes
Presentation of testicular cancer
- Painless lump in testicle
- Testicular pain and/or abdominal pain
- Cough and dyspnoea = indicative of lung metastases
- Back pain = para-aortic lymph node metastasis
- Hydrocele = May contain bloodstained fluid
- Abdominal mass
Investigations for testicular cancer
- Ultrasound and biopsy
- Tumour markers
o Alpha-fetoprotein raised in teratomas
o Beta-hCG raised in teratomas and seminomas
o Lactate dehydrogenase - CXR and CT = staging and metastases
Management of testicular cancer
- Orchidectomy
- Chemo/radiotherapy
- Monitoring post treatment with tumour markers and imaging
- Sperm storage offered
Cause of hydronephrosis
- Unilateral (PACT)
o Pelvic-ureteric obstruction (congenital or acquired)
o Aberrant renal vessels
o Calculi
o Tumours of renal pelvis - Bilateral (SUPER)
o Stenosis of urethra
o Urethral valve
o Prostatic enlargement
o Extensive bladder tumour
o Retro-peritoneal fibrosis
Investigations of hydronephrosis
- US hydronephrosis
- IVU assess position of obstruction
- Antegrade or retrograde pyelography
- If suspect renal colic do CT scan
Management of hydronephrosis
- Remove obstruction and drainage of urine
- Acute upper urinary tract obstruction nephrostomy tube
- Chronic upper urinary tract obstruction ureteric stent or pyeloplasty
Associations of epididymal cyst
- Polycystic kidney disease
- Cystic fibrosis
- Von Hippel-Lindau syndrome
Presentation of epididymal cyst
- Small cysts may remain undetected and asymptomatic
o Well defined and will transilluminate since fluid-filled - Testis is palpable quite separately from cyst and lies posterior (Unlike hydrocele)
- Once cysts get large, may be painful
Management of epididymal cyst
Scrotal US
- If painful and symptomatic then surgical excision
Causes of acute tubular necrosis
- Ishcaemia shock, sepsis
- Nephrotoxins aminoglycosides, myoglobin (secondary to rhabdomyolysis), radiocontrast agents, lead
Presentation of acute tubular necrosis
- Features of AKI raised urea, creatinine, potassium
- Muddy brown cast in urine
Phases of acute tubular necrosis
- Oliguric phase
- Polyuric phase
- Recovery phase
Histology of acute tubular necrosis
o Tubular epithelium necrosis
o Dilatation of tubules
o Necrotic cells obstructing tubule lumen
Causes of rhabdomyolysis
- Seizure
- Collapse/coma
- Ecstasy
- Crush injury
- McArdle’s syndrome
- Drugs: statins
Investigations for rhabdomyolysis
- AKI with disproportionately raised creatinine
- Elevated creatine kinase (at least 5x upper limit)
- Myoglobinuria: dark/ reddish-brown colour
- Hypocalcaemia
- Elevated phosphate
- Hyperkalaemia
- Metabolic acidosis
Management of rhabdomyolysis
- IV fluids to maintain good urine output
- Urinary alkalinisation
Causes of hyperkalaemia
- AKI
- CKD
- Adrenal insufficiency
- Rhabdomyolysis
- Tumour lysis syndrome
- Drugs: spironolactone, ACEi/ARB, NSAIDs, ciclosporin, heparin
- Potassium supplements: bananas, kiwi, salt substitues
- Massive blood transfusion
Presentation of hyperkalaemia
- Asymptomatic until K+ is high enough to cause cardiac arrest
- Chest pain
- Weakness
- Palpitations
- Light headedness
- Muscle weakness and fatigue
- Kussmaul’s respiration = low, deep, sighing inspiration/expiration
- Fast irregular pulse
- Metabolic acidosis
Bloods for hyperkalaemia
- Serum K+ > 5.5mmol/L
o If >6.5mmol/L = Medical emergency
ECG for hyperkalaemia
Tall tented T waves, Flattening or absence of P waves, Broad QRS complexes
o Usually only ECG changes if K+ >6.0
Management of hyperkalaemia
- IV calcium gluconate for cardiac stability
- 50ml 50% dextrose infusion with 10 units of ActRapid over 15 mins
- Nebulised salbutamol
- Calcium Resonium or sodium zirconium cyclosilicate remove K+ from body
- Repeat VBG/U+Es to Monitor for response and rebound
- Monitor glucose
- Review medication = ACEi, NSAIDs, spironolactone
- Sodium bicarbonate = correct acidosis
- Dialysis
Causes of hypokalaemia
- Vomiting and diarrhoea
- Thiazide and loop diuretics
- Cushing’s and Conn’s syndrome
- Corticosteroids
Presentation of hypokalaemia
- Usually asymptomatic
- Muscle weakness
- Cramps
- Tetany
- Palpitations
- Light-headedness
- Constipation
- Hypotonia
- Hyporeflexia
- Arrhythmias
Bloods for hypokalaemia
- Serum K+ <3.5 mmol/L
o <2.5 mmol/L = urgent treatment
ECG for hypokalaemia
o Small or inverted T waves
o Prominent U waves
o Long PR interval
o Depressed ST segments
Management for hypokalaemia
- Identify and treat underlying cause
- Withdrawal from diuretics/laxatives
- Oral/IV K+ supplements = oral sando-k
- If on thiazide diuretic, switch to K+ sparing diuretic (spironolactone)
Causes of hypernatraemia
- Dehydration
- Osmotic diuresis
- Diabetes insipidus
- Excess IV saline
Management of hypernatraemia
- Manage underlying cause
- Replace deficit plus maintenance slowly at uniform rate over 48 hrs
Complications of hypernatraemia
Rapid infusion = cerebral oedema
Causes of metabolic acidosis with normal anion gap
o Gastrointestinal bicarbonate loss: diarrhoea, ureterosigmoidostomy, fistula
o Renal tubular acidosis
o Drugs: acetazolamide
o Ammonium chloride injection
o Addison’s disease
Causes of metabolic acidosis with raised anion gap
o Lactate: shock, hypoxia
o Ketones: diabetic ketoacidosis, alcohol
o Urate: renal failure
o Acid poisoning: salicylates, methanol
Metabolic alkalosis causes
- Vomiting/aspiration
- Diuretics
- Liquorice, carbenoxolone
- Hypokalaemia
- Primary hyperaldosteronism
- Cushing’s syndrome
- Bartter’s syndrome
- Congenital adrenal hyperplasia
Maintenance fluids for adult
25-30ml/kg/day
1mmol/kg/day K+, Na+, Cl
50-100g/day glucose
Causes of hyponatraemia
- Hypovolaemic hyponatraemia diuretic stage of renal failure, diuretics, Addisonian crisis
- Euvolaemic hyponatraemia SIADH
- Hypervolaemic hyponatraemia heart failure, liver failure, nephrotic syndrome
Presentation of hyponatraemia
- Early Sx
o Headache
o Lethargy
o Nausea
o Vomiting
o Dizziness
o Confusion
o Muscle cramps - Late Sx
o Seizures
o Coma
o Respiratory arrest
Severity of hyponatraemia
- Mild:130-134
- Moderate: 120-129
- Severe: <120
Management of hyponatraemia
- Exclude spurinous result
- Review medications
- Chronic hyponatraemia without severe Sx
o Hypovolaemic isotonic saline
o Euvolaemic fluid restrict to 500-1000ml/day, consider demeclocycline/vaptans
o Hypervolaemic fluid restrict to 500-1000ml/day + consider loop diuretics/vaptans - Acute hyponatraemia with severe Sx
o Hypertonic saline (3% NaCl)
Complications of hyponatraemia
- Cerebral oedema brain herniation
- Of Tx osmotic demyelination syndrome
o Locked-in syndrome
