Renal

Question 1

What are the key features of nephritic syndrome?

Answer 1

• Haematuria → visible or non-visible
• Oliguria
• Proteinuria → <3g
• Fluid & salt retention → hypertension
• Pyuria → sterile leukocytes

Question 2

What is the most common cause of nephritic syndrome in adults?

Answer 2

IgA nephropathy - Berger’s Disease

Question 3

How does IgA Nephropathy typically present?

Answer 3

Young patient (20s), macroscopic haematuria 24-48hrs after an upper respiratory tract infection.

Other features:
- Oliguria
- Proteinuria → <3g
- Fluid & salt retention → hypertension
- Pyuria → sterile leukocytes

Question 4

What condition will have the following result on renal biopsy: IgA deposits in mesangial proliferation ?

Answer 4

IgA Nephropathy - Berger’s Disease.

Question 5

How is IgA Nephropathy managed?

Answer 5

• High-dose prednisolone → reduce proteinuria & delay renal impairment
• Other immunosuppressive drugs can be used in patients with deteriorating renal function.

Question 6

What is the typical presentation of Post-Streptococcal Glomerulonephritis?

Answer 6

2 weeks after infection with nephritic syndrome → haematuria, oliguria, oedema, hypertension

Question 7

What investigation is key when diagnosing Post-Streptococcal Glomerulonephritis?

Answer 7

Raised anti-streptolysin O titre - this confirms recent strep infection

Question 8

How is post-streptococcal glomerulonephritis managed?

Answer 8

• Supportive, careful monitoring of fluid balance
• Usually self-limiting, particularly in children

Question 9

What is the diagnostic criteria for an AKI?

Answer 9

• Rise in creatinine of >25 in 48hrs
• Rise in creatinine of >50% from baseline in 7 days
• Urine output <0.5ml/kg/hour

Question 10

What 2 drugs are given to slow progression of CKD?

Answer 10

• ACE inhibitors → need to monitor potassium & this plus CKD can cause hyperkalaemia
• SGLT2 inhibitors (dapagliflozin) → slow rate of progression, reduce incidence of CVD

Question 11

What are the 3 key complications of CKD, and how are they managed?

Answer 11

• Anaemia:
  
  • Due to decreased EPO production
  • Iron first, then EPO-stimulating agents
• Renal bone disease:
  
  • Decreased activated vitamin D (reduced calcium), PTH stimulating osteoclast activity
  • Low phosphate diet (avoid fizzy drinks)
  • Phosphate binders
  • Active forms of vitamin D (cicitriol)
  • Increased calcium intake
  • Bisphosphonates if osteoporosis
• Metabolic acidosis → sodium bicarbonate

Question 12

What is the medical management of benign prostatic hyperplasia?

Answer 12

• Alpha agonists → tamsulosin
  
  • Relaxes smooth muscle of the urethra & prostate
  • Causes a rapid improvement of symptoms
  • Side effects → headaches, postural hypotension, ejaculation problems, nasal congestion
• 5-alpha reductase inhibitors → finasteride
  
  • Essentially reduces the amount of dihydrotestosterone in the tissues, leading to a reduction in prostate size.
  • Takes up to 6 months of treatment for the effects to result in improved symptoms
  • Side effects → erectile dysfunction, loss of libido

Question 13

What surgical management is considered for BPH?

Answer 13

• TURP → transurethral resection of the prostate
  
  • Most common surgical treatment of BPH
  • Side-effects → bleeding, infection, incontinence, ED, retrograde dysfunction

Question 14

What investigations are done for suspected bladder cancer?

Answer 14

Cystoscopy → used to visualise bladder cancers.

CT CAP → if they are suspected to have muscle-invasive bladder cancer after cystoscopy

Question 15

How is bladder cancer managed?

Answer 15

• TURBT → for NMIBlCa
  
  • Trans-Urethral Resection of Bladder Tumour
• Intravesical chemotherapy → often used after TURBT through a catheter to reduce the risk of recurrence.
• Radical cystectomy → removal of the entire bladder
  
  • There are several options for urine following this, most commonly being urostomy with an ileal conduit

Question 16

How does testicular cancer present?

Answer 16

• Painless lump on the testicle → occasionally presents with pain.
  
  • Hard, irregular, not fluctuant, no Transillumination.
• Gynaecomastia

Question 17

What tumour markers are raised in testicular cancer?

Answer 17

AFP (raised in teratomas), β-HCG (teratomas & seminomas), LDH (non-specific)

Question 18

What investigation confirms a diagnosis of testicular cancer?

Answer 18

Scrotal USS

Question 19

What surgery is done for testicular cancer?

Answer 19

Inguinal orchidectomy → curative in 80% of patients

Question 20

What is the first-line investigation for suspected localised prostate cancer?

Answer 20

Multiparametric MRI

Question 21

What investigation is done to look for bony metastases in those with prostate cancer?

Answer 21

Isotope bone scan

Question 22

How is prostate cancer managed?

Answer 22

Depending on the grade & stage of prostate cancer, treatment can involve:

• Surveillance or watchful waiting
• External beam radiotherapy directed at the prostate.
  
  • Can cause proctitis (inflammation in the rectum), causing pain, altered bowel habit, rectal bleeding & discharge.
• Hormone therapy
  
  • Aims to reduce the level of androgens which stimulate the cancer growth.
  • Can be used in combination with radiotherapy, or alone in advanced disease where cure is not possible.
  • Options:
    
    • Androgen-receptor blockers → bicalutamide
    • GnRH agonists
  • Side effects → hot flushes, sexual dysfunction, gynaecomastia, fatigue, osteoporosis
• RALP →Robotic assisted laparoscopic prostatectomy
  
  • Can be curative in localised disease

Question 23

What are the 3 main types of urinary incontinence?

Answer 23

Overflow Incontinence

• Chronic urinary retention due to an obstruction to the outflow causes an overflow of urine without the urge to go.

Stress Incontinence

• Due to weakness of the pelvic floor & sphincter muscles, causing urine to leak at times of increased pressure on the bladder.
  
  • Laughing, coughing, surprise.

Urge Incontinence

• Due to overactivity of the detrusor muscle, causing people to have the sudden urge to pass urine, and sometimes not arriving before urination occurs.

Question 24

What causes overflow incontinence?

Answer 24

• Anticholinergic medications
• Fibroids
• Pelvic tumours
• Neurological conditions

Question 25

How is urge/stress incontinence managed with lifestyle changes?

Answer 25

• Pelvic floor muscle exercises
• Lifestyle advice
  
  • Reduce caffeine & alcohol intake
  • Smoking cessation
  • Weight loss
• Bladder training → gradually increasing the time between voiding

Question 26

What medications can be used for urge incontinence?

Answer 26

• Anticholinergic → oxybutynin
  
  • Side effects → dry mouth/eyes, urinary retention, worsening of cognition & dementia
• Mirabegron
  
  • Contraindicated in uncontrolled hypertension
• Intra-detrusor botulinum toxin therapy → if urodynamics show an overactive bladder

Question 27

What medication can be used for stress incontinence?

Answer 27

Duloxetine

Question 28

What antibiotics are used to treat a UTI in pregnancy?

Answer 28

• cefalexin
• amoxicillin
• nitrofurantoin (not in 3rd trimester)
• trimethoprim (not in 1st trimester)

Question 29

What is Anti-GBM disease? How does it present, and how is it managed?

Answer 29

= rare autoimmune disorder where antibodies target type 4 collagen (present in kidneys & alveoli), causing a rapidly progressing glomerulonephritis & often pulmonary haemorrhage.

• Severe & rapidly progressive AKI → leading to renal failure
  
  • Over a few weeks
• Haemoptysis & pulmonary haemorrhage
  
  • 50% of people have lung involvement

management:
- Plasma exchange to remove circulating antibodies
- High-dose oral prednisolone or cyclophosphamide