Renal Flashcards
Hydronephrosis
Urine back pressure into calyces compresses the nephrons within the medullary pyramids
- can lead to renal failure
- kidneys are enlarged and palpable
Treat causes:
Upper tract:
- Acute: insertion of a nephrostomy tube
- Chronic: insertion of a ureteric stent or a pyeloplasty
Lower tract: insertion of a urinary catheter or a suprapubic catheter
Pyelonephritis
Pyelonephritis is a kidney infection that occurs when bacteria from a urinary tract infection spreads to the kidney.
Amoxicillin (IV) + Gentamicin (IV)
Penicillin allergic: Switch Amoxicillin with Co-trimaxazole (IV)
Step down to: Co-trimaxazole (IV)
Chronic Kidney Disease
- reduced GFR
Stage 1: GFR >90 + evidence of kidney damage
Stage 2: GFR 60-90 + evidence of kidney damage
Stage 3: GFR 30-60
Stage 4: GFR 15-30
Stage 5: <15 or on RRT
Slow progression and reduce cardio risk:
- Reduce BP (ACEis/ ARBs)
- Statins
- Stop smoking
Nephrotic Syndrome
Non-proliferative process affecting podocytes
Symptoms: Oedema
Increased protein in the urine and decreased protein (albumin) in the blood, with increased fat in the blood.
Fluid restriction Salt restriction ACEi/ ARBs Anticoagulants IV Albumin
Glomerulonephritis
Immune mediated disease of the kidneys affecting glomeruli
Non-proliferative: Minimal change, FSGS, Membranous
- can cause Nephrotic syndrome
Proliferative: IgA, Rapidly progressive, post-infective
- can cause Nephritis syndrome
All GNs: Dietary changes Stop smoking ACEs/ARBs Statins
Treat underlying type
Severe: RRT
Minimal change GN
Non-proliferative
Nephrotic
- Oedema
- Proteinuria
- Decrease in blood protein
- Increase in blood lipids
Corticosteroids
Does not lead to CKD
Minimal change GN
Non-proliferative
Nephrotic
- Oedema
- Proteinuria
- Decrease in blood protein
- Increase in blood lipids
Corticosteroids
Cyclophosphamide
Does not lead to CKD
Focal segmental glomerulosclerosis (FSGN)
Non-proliferative
Nephrotic
Characterised by a sclerosis of segments of some glomerules, associated with conditions such as HIV and heroin abuse, or inherited as Alport syndrome.
Increase in hyalin and lipids. Low albumin.
Corticosteroids
Leads to CKD
Membranous (MGN)
Non-proliferative
Nephrotic/ nephritic
Associated with auto-antibodies to phospholipase A2 receptor, cancer, Hep B/c, Malaria, Syphilis, and SLE.
Corticosteroids
1/3 lead to CKD
IgA Nephropathy GN
Proliferative
Nephritic
The most common type of glomerulonephritis
- several days after a respiratory infection
- characterised by deposits of IgA in the space between glomerular capillaries
- Haematuria
- Low grade proteinuria
Self resolving
Omega 3 oil
Leads to CKD
Henoch–Schönlein purpura
A form of IgA nephropathy, typically affecting children, characterised by a rash of small bruises affecting the buttocks and lower legs, with joint pain and abdominal pain
Analgesia
Self sesolving
Post-infectious GN
Proliferative
Nephritic
Classically occurs after infection with the bacteria Streptococcus pyogenes. 1–4 weeks after a pharyngeal infection.
Presents with malaise, a slight fever, nausea and increased blood pressure, gross haematuria, and smoky-brown urine
Steroids
Rapidly progressive (PRGN)
Proliferative
Nephritis
Characterised by a rapid, progressive deterioration in kidney function.
Type 1: Goodpastures syndrome. IgG antibodies directed against the glomerular basement membrane trigger an inflammatory reaction. Haemoptysis.
Type 2: immune-complex-mediated damage, and may be associated with systemic lupus erythematosus, post-infective glomerulonephritis, IgA nephropathy, and IgA vasculitis
Type 3: associated with causes of vascular inflammation including granulomatosis with polyangiitis (GPA) and microscopic polyangiitis. ANCA antibody.
Steroids
Cyclophasphamide, azathioprine, mycophenolate
Plasmaphoresis
Diabetic Nephropathy
Protein loss in the urine due to damage to the glomeruli may become severe, and cause a low serum albumin with resulting oedema resulting in nephrotic syndrome. GFR may progressively fall to less than 15.
Damage to the glomerular basement membrane allows proteins in the blood to leak through, leading to proteinuria. Deposition of abnormally large amounts of mesangial matrix causes periodic-acid schiff positive nodules called Kimmelstiel–Wilson nodules.
ACEis
Manage Diabetes
Leads to ESKD
- RRT
Ischaemic Nephropathy
Decrease in GFR and kidney perfusion.
Caused by: HTN, artherosclerosis, Vascular disease, fibromusclular dysplasia
Symptoms:
- Flash pulmonary oedema
- Abdominal bruits
- Artherosclerosis
ACEi
Angioplasty/ stent
Statin
Anti-platelets
Lupus Nephritis Class I
Minimal mesangial GN
Mesangial deposits are visible under an electron microscope
Hydroxychloroquine
KF rare
Lupus Nephritis Class II
Mesangial proliferative GN
Mesangial hypercellularity and matrix expansion. Microscopic haematuria with or without proteinuria may be seen.
Hydroxychloroquine
Corticosteroids
Tacrolimus
KF rare
Lupus Nephritis Class III
Focal glomerulonephritis
Indicated by sclerotic lesions involving less than 50% of the glomeruli.
Immunofluorescence reveals positively for IgG, IgA, IgM, C3, and C1q.
Haematuria and proteinuria are present.
Hydroxychloroquine
Corticosteroids
Acute: Cyclophosphamide / MMF (mycophenolate mofetil)
Chronic: Azathioprine/ MMF
KF rare
Lupus Nephritis Class IV
Diffuse proliferative nephritis
Most severe, and the most common subtype. More than 50% of glomeruli are involved.
Haematuria and proteinuria are present, frequently with nephrotic syndrome, hypertension, hypocomplementemia, elevated anti-dsDNA titres and elevated serum creatinine.
Hydroxychloroquine
Corticosteroids
Acute: Cyclophosphamide / MMF (mycophenolate mofetil)
Chronic: Azathioprine/ MMF
KF rare
Lupus Nephritis Class V
Membranous (MGN)
Diffuse thickening of the glomerular capillary wall and membrane thickening. Signs of nephrotic syndrome. Microscopic haematuria and hypertension.
Hydroxychloroquine
Corticosteroids
Cyclophosphamide + Tacrolimus/ MMF/ Azathioprine
KF rare
Lupus Nephritis Class VI
Advanced sclerosing lupus nephritis
Sclerosis involving more than 90% of glomeruli.
Hydroxychloroquine
Poor response to therapy.
They’re fucked.
Acute Kidney Injury
A decrease in urine output
Stage 1: <0.5 ml/kg/h for >6hrs
Stage 2: <0.5 ml/kg/h for >12hrs
Stage 3: <0.3 ml/kg/h for >24hrs, or 12hrs of anuria
Due to:
- blood vessel damage (vasculitis, renovascular diseases)
- glomerular disease
- interstitial injury (infection, TB, Sarcoid, SLE)
- tubular injury (ischaemia, rhabdomyolysis, gentamicin)
Fluid Resuscitation (0.9% crystalloid bolus, then repeat if necessary)
If low BP then use inotropes/ vasopressors
Treat underlying causes
RRT
Hyperkalaemia
Muscle weakness and abnormal heart rhythms
Normal: 3.5-5
Hyper: >5.5
Life threatening: >6.5
Protect myocardium: 10ml 10% calcium gluconate IV
Influx of K into cells: Insulin (Actrapid) with 50ml 50% dextrose Salbutamol Neb (90 mins)
Long-term: Calcium resonium (prevents absorption from GI tract)
Autosomal Dominant Polycystic Disease
Small, fluid-filled sacs called cysts to develop in the kidney
Symptoms:
- abdominal pain, HTN, haematuria, UTIs, kidney stones
HTN control
Tolvaptan
RRT
Alport’s Syndrome
- thickening of glomerular BM
HTN control
RRT
Anderson Fabry’s Disease
- deficiency in a-galactosidase A that causes a build of of fat
Fabrazyme (enzyme replacement)
Medullary Cystic Kindey
Small, fluid-filled sacs called cysts form in the center of the kidneys. These cysts scar the kidneys and cause them to malfunction
Transplant
Medullary Spongy Kidney
Congenital disorder of the kidneys characterized by cystic dilatation of the collecting tubules in one or both kidneys. Individuals with medullary sponge kidney are at increased risk for kidney stones and urinary tract infection (UTI)
Maintaining adequate fluid intake, with the goal of decreasing the risk of developing kidney stones
Pain management:
ureteroscopic laser papillotomy
Cystitis
Inflammation of the bladder
Antibiotics
Phenazopyridine
Urinary retention
Inability to urinate, with increased pain
Due to obstruction
Catheter
Alfuzosin/ Tamulosin - relaxes muscles in bladder/prostate
Acute Loin Pain
- colic pain mediated by prostiglandins in ureter
Mild: Analgesia (NSAIDs
Severe: Ureteric stent/ stone removal/ fragmentation
Epididymitis
Inflammation of the epididymis
- Common in chlamydia
Analgesia + bed rest
Send MSSU, gonorrhoea & chlamydia tests.
If STI likely (<35 or new partner in last 3mth): Doxycycline
If UTI likely (>35 and no new partner): Ofloxacin or Ciprofloxacin
Paraphimosis
Swelling of glans of penis while the foreskin is retracted
- Common in cathetirisation / cystoscopy
Manual compression of glans (with iced glove if necessary)
Dorsal slit
Priapism
Erection lasting longer than 4hrs
Aspiration
Phenylephrine injection (1 mL injections made every 3 to 5 minutes for approximately one hour)
Surgical shunt
Spontanous resolvement
Fournier Gangrene
Necrotising fasciitis around male genitals
Antibiotics
Debridement
Emphysematous pyelonephritis (EPN)
Is a severe infection of the renal parenchyma that causes gas accumulation in the tissues. EPN most often occurs in persons with diabetes mellitus, especially women.
Nephrectomy
Perinephric Abscess
Rupture of acute cortical abscess into the perinephric space
Antibiotics and drainage
Bladder Injury
- due to pelvic fracture
Large bore catheter
Antibiotics
Urethral injury
- ## fracture of pubic rami
Sub pubic catheter
Reconstruction
Penile Fracture
- popping sound
- 20% urethral injury
Exploration and repair
Testicular Injury
- pain and nausea
Exploration and repair
Benign prostatic hypertrophy
Alpha blockers
Finasteride (5 alpha reductase inhibitor)
Transurethral resection of the prostate (TURP)
Urethra Stricture
Urethrotomy
Meatal urethral stenosis
Dilation
Prostate Cancer
- 95% adenocarcinoma
- sclerotic bone lesions on XR
- haematuria/haematospermia
- 70ish
- peripheral zones
Metastatic:
- Androgen deprivation
- Goserelin (Zoladex): GnRH agonist
- Cyproterone acetate
- Diethylstilbestrol
- Cytotoxic chemotherapy
Organ confined:
- Prostatectomy
- Radiotherapy
Renal Cell Carcinoma
- loin pain, haematuria, renal mass
Radial nephrectomy Partial nephrectomy Radio frequency ablation IL-2 (Aldesleukin) IFN-Alpha Sunitinib
Penis Cancer
- squamous cell carcinoma
- association with HPV,
Bowen’s Disease and Erythroplasia of Queyrat: In situ SCC
Topical 5 flouracil Circumcision Radiotherapy Surgery Amputation :(
Testicular Tumours
Germ cell tumours:
- 40% Seminomas (most common, pale macroscopic potatoe appearance, 30-50 years)
- 40% Teratomas (solid cysts, necrosis, haemorrhage)
Radiotherapy
Orchidectomy
Infection of catheterised adult
Do not treat unless signs and symptoms of infection.
Do not use urinalysis.
If you must: treat as complicated UTI
Complicated UTI
Amoxicillin (IV) + Gentamicin (IV)
Penicillin allergic: Switch Amoxicillin with Co-trimaxazole (IV)
Step down to: Co-trimaxazole (IV)
Female UTI
Nitrofurantoin or Trimethoprim for 3 days
Male UTI
Nitrofurantoin or Trimethoprim for 7 days
UTI or bacteriuria in pregnancy
1st-2nd trimester: Nitrofurantoin
3rd trimester: Trimethoprim
2nd line: Cefalexin
Prostatitis
Inflamed prostate gland
Ofloxacin or Ciprofloxacin
High risk of C. difficile: Trimethoprim
Renal Calculi <5mm
Diclofenac - Analgesia
Alpha blockers to aid ureteric stone passage
Stones < 5 mm will usually pass spontaneously. Lithotripsy and nephrolithotomy may be for severe cases.
Stone burden of less than 2cm in pregnant females
Ureteroscopy
Stone burden of less than 2cm in aggregate
Lithotripsy
Complex renal calculi and staghorn calculi
- Proteus sp.
Percutaneous nephrolithotomy
Oxalate stones
Cholestyramine reduces urinary oxalate secretion
Pyridoxine reduces urinary oxalate secretion
Uric acid stones
Allopurinol
Urinary alkalinization e.g. oral bicarbonate
Nephrogenic diabetes Insipidus
Thiazide diuretics
DI leads to the production of vast amounts of dilute urine which is dehydrating and raises the plasma osmolarity, stimulating thirst. The effect of the thiazide causes more sodium to be released into the urine. This lowers the serum osmolarity which helps to break the polyuria-polydipsia cycle.
Overactive Bladder
Antimuscarinic drugs (oxybutynin, tolterodine and darifenacin)
Nephroblastoma (Wilms Tumour)
Age <4
Haematuria
nephrectomy
Hyperkalaemia causing Myeloma
NaCl Volume resus
IV Pamidronate
