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UKMLA Prep > Renal 2 🫘 > Flashcards

Renal 2 🫘 Flashcards

1
Q

What is the terminology change for microscopic or dipstick positive haematuria?

A

Non-visible haematuria

Previously known as microscopic or dipstick positive haematuria, now termed non-visible haematuria.

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2
Q

What is visible haematuria?

A

Macroscopic haematuria

Visible haematuria is the term now used for what was previously known as macroscopic haematuria.

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3
Q

What percentage of the population is affected by non-visible haematuria?

A

Approximately 2.5%

Non-visible haematuria is found in around 2.5% of the population.

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4
Q

List four causes of transient or spurious non-visible haematuria.

A
  • Urinary tract infection
  • Menstruation
  • Vigorous exercise
  • Sexual intercourse

Transient or spurious non-visible haematuria usually settles after about 3 days.

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5
Q

What are the causes of persistent non-visible haematuria?

A
  • Cancer (bladder, renal, prostate)
  • Stones
  • Benign prostatic hyperplasia
  • Prostatitis
  • Urethritis (e.g., Chlamydia)
  • Renal causes (IgA nephropathy, thin basement membrane disease)

Persistent non-visible haematuria requires further investigation.

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6
Q

What foods can cause spurious red/orange urine?

A
  • Beetroot
  • Rhubarb

These foods can lead to a false positive for blood in urine.

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7
Q

What is the test of choice for detecting haematuria?

A

Urine dipstick

Urine dipstick is the preferred method for detecting haematuria.

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8
Q

Define persistent non-visible haematuria.

A

Blood present in 2 out of 3 samples tested 2-3 weeks apart

This definition helps in identifying cases that require further investigation.

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9
Q

What are the NICE urgent cancer referral guidelines for patients aged 45 years or older?

A
  • Unexplained visible haematuria without urinary tract infection
  • Visible haematuria that persists or recurs after successful treatment of urinary tract infection

These guidelines were updated in 2015.

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10
Q

What is nephrotic syndrome characterized by?

A
  • Proteinuria (> 3g/24hr)
  • Hypoalbuminaemia (< 30g/L)
  • Oedema

Nephrotic syndrome can arise from various glomerular diseases.

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11
Q

What are common primary causes of nephrotic syndrome?

A
  • Minimal change disease
  • Focal segmental glomerulosclerosis (FSGS)
  • Membranous nephropathy

These are key primary causes of nephrotic syndrome.

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12
Q

List the secondary causes of nephrotic syndrome.

A
  • Diabetes mellitus
  • Systemic lupus erythematosus (SLE)
  • Amyloidosis
  • Infections (HIV, hepatitis B and C)
  • Drugs (NSAIDs, gold therapy)

Secondary causes often relate to systemic diseases.

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13
Q

What is the pathophysiological mechanism of nephrotic syndrome?

A

Damage to the glomerular basement membrane and podocytes leading to increased permeability to proteins

This mechanism results in proteinuria, hypoalbuminaemia, and subsequent oedema.

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14
Q

What initial investigations are done for nephrotic syndrome?

A
  • Urine dipstick for proteinuria
  • MSU to exclude urinary tract infection
  • Early morning urinary protein:creatinine ratio or albumin:creatinine ratio
  • FBC and coagulation screen
  • Urea and electrolytes

These investigations help in confirming the diagnosis.

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15
Q

What is the frequency of calcium oxalate stones?

A

40%

Calcium oxalate stones are the most common type of renal stone.

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16
Q

What are the clinical features of a urinary tract infection?

A
  • Dysuria
  • Urinary frequency
  • Urinary urgency
  • Cloudy/offensive smelling urine
  • Lower abdominal pain
  • Fever (typically low-grade)
  • Malaise

Symptoms can vary in severity and presentation.

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17
Q

What is the role of urine dipstick in diagnosing UTI in women under 65 years?

A

Aid diagnosis

Urine dipsticks can help confirm UTI likelihood but should not be used in women over 65 years, men, or catheterised patients.

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18
Q

What is acute interstitial nephritis primarily caused by?

A

Drugs (most common cause), particularly antibiotics

Common drugs include penicillin, rifampicin, NSAIDs, allopurinol, and furosemide.

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19
Q

List symptoms associated with tubulointerstitial nephritis with uveitis (TINU).

A
  • Fever
  • Weight loss
  • Painful, red eyes

TINU typically occurs in young females.

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20
Q

What are the three traditional classifications of acute kidney injury (AKI) causes?

A
  • Prerenal
  • Intrinsic
  • Postrenal

These classifications help in identifying the underlying issues causing AKI.

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21
Q

What is a common prerenal cause of AKI?

A

Hypovolaemia secondary to diarrhoea/vomiting

Prerenal causes are often due to reduced blood flow to the kidneys.

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22
Q

What is a common intrinsic cause of AKI?

A

Acute tubular necrosis (ATN)

Intrinsic causes involve direct damage to the kidney tissue.

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23
Q

What is a postrenal cause of AKI?

A

Kidney stone in ureter or bladder

Postrenal causes relate to obstructions affecting urine flow from the kidneys.

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24
Q

What are the risk factors for AKI?

A
  • Chronic kidney disease
  • Other organ failure/chronic disease
  • History of acute kidney injury
  • Use of nephrotoxic drugs
  • Age 65 years or over
  • Oliguria
  • Neurological or cognitive impairment

Identifying these risk factors can help in prevention strategies.

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25
Q

What happens when kidneys stop working?

A
  • Reduced urine output (oliguria)
  • Fluid overload
  • Rise in molecules like potassium, urea, and creatinine

These changes indicate renal dysfunction and the need for intervention.

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26
Q

What are common symptoms of progressing AKI?

A
  • Reduced urine output
  • Pulmonary and peripheral oedema
  • Arrhythmias
  • Features of uraemia (e.g., pericarditis, encephalopathy)

Symptoms can vary based on the severity of renal failure.

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27
Q

What is the recommended method to detect AKI?

A

Urea and electrolytes (U&Es) blood test

This test provides key markers for renal function.

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28
Q

What criteria can be used to diagnose AKI according to NICE?

A
  • Rise in serum creatinine of 26 micromol/litre within 48 hours
  • 50% or greater rise in serum creatinine within the past 7 days
  • Fall in urine output to less than 0.5 ml/kg/hour for more than 6 hours

These criteria help in defining acute kidney injury.

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29
Q

What is the management approach for AKI?

A

Supportive care and careful fluid balance

Management focuses on ensuring kidney perfusion while avoiding fluid overload.

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30
Q

What is the role of renal replacement therapy in AKI?

A

Used when medical treatment fails for complications like hyperkalaemia, pulmonary oedema, acidosis, or uraemia

Haemodialysis is a common form of renal replacement therapy.

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31
Q

What is the urine sodium level in pre-renal uraemia?

A

< 20 mmol/L

This indicates that kidneys are attempting to conserve sodium.

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32
Q

What is the urine sodium level in acute tubular necrosis?

A

> 40 mmol/L

In ATN, kidneys lose the ability to conserve sodium.

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33
Q

What is a fluid challenge in relation to kidney function?

A

Good or Poor response based on fluid retention

A good response indicates the kidneys are functioning properly, while a poor response suggests potential kidney issues.

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34
Q

What fractional urea excretion percentage indicates poor kidney function?

A

> 35%

A fractional urea excretion above 35% suggests renal impairment.

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35
Q

What urine:plasma osmolality ratio indicates poor kidney function?

A

< 1.1

A low urine:plasma osmolality indicates a dilutional state, often seen in renal failure.

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36
Q

What specific gravity value indicates poor kidney function?

A

< 1010

A specific gravity below 1010 suggests dilute urine, often linked to renal impairment.

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37
Q

What are the features of AKI? (4)

A
  • Raised urea
  • Raised creatinine
  • Raised potassium
  • Muddy brown casts in urine

These features help in diagnosing acute kidney injury.

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38
Q

What are the diagnostic criteria for AKI?

A
  • Rise in creatinine of 26µmol/L or more in 48 hours
  • > = 50% rise in creatinine over 7 days
  • Fall in urine output to < 0.5ml/kg/hour for over 6 hours in adults
  • > = 25% fall in eGFR in children/young adults in 7 days

These criteria are essential for the diagnosis of AKI.

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39
Q

What are the KDIGO staging criteria for AKI Stage 1?

A
  • Increase in creatinine to 1.5-1.9 times baseline
  • Increase in creatinine by ≥26.5 µmol/L
  • Reduction in urine output to <0.5 mL/kg/hour for ≥ 6 hours

Stage 1 indicates a mild degree of AKI.

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40
Q

What are the referral criteria for a nephrologist? (7)

A
  • 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

These criteria help determine when to refer for specialized care.

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41
Q

What are the two main causes of acute tubular necrosis (ATN)?

A
  • Ischaemia
  • Nephrotoxins

Ischaemia may result from shock or sepsis, while nephrotoxins can include drugs like aminoglycosides.

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42
Q

What is the most common cause of acute kidney injury (AKI)?

A

Acute tubular necrosis (ATN)

ATN is frequently seen in clinical practice as a cause for AKI.

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43
Q

What are the features of rhabdomyolysis? (7)

A
  • Acute kidney injury with disproportionately raised creatinine
  • Elevated creatine kinase (CK)
  • Myoglobinuria
  • Hypocalcaemia
  • Elevated phosphate
  • Hyperkalaemia
  • Metabolic acidosis

These features are critical for diagnosis and management.

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44
Q

What management is recommended for rhabdomyolysis?

A

IV fluids to maintain good urine output

This is essential to prevent further kidney damage.

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45
Q

What are the risk factors for benign prostatic hyperplasia (BPH)?

A
  • Age
  • Ethnicity
  • Family history

Age is the primary risk factor, with prevalence increasing significantly in older men.

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46
Q

What are the voiding symptoms associated with BPH?

A
  • Weak or intermittent urinary flow
  • Straining
  • Hesitancy
  • Terminal dribbling
  • Incomplete emptying

These obstructive symptoms are common in BPH.

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47
Q

What is the International Prostate Symptom Score (IPSS) used for?

A

Classifying the severity of lower urinary tract symptoms (LUTS)

It assesses the impact of LUTS on quality of life.

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48
Q

What is the first-line treatment for moderate-to-severe voiding symptoms in BPH?

A

Alpha-1 antagonists (e.g., tamsulosin)

These medications improve symptoms in about 70% of men.

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49
Q

What characterizes urinary incontinence (UI)?

A

Involuntary leakage of urine

UI is a common issue, particularly in older females.

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50
Q

What initial investigation is recommended for urinary incontinence?

A

Bladder diaries for a minimum of 3 days

This helps track patterns and inform treatment.

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51
Q

What is the mnemonic CRABBI used for in multiple myeloma?

A
  • Calcium
  • Renal
  • Anaemia
  • Bleeding
  • Bone

This mnemonic helps remember key features of multiple myeloma.

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52
Q

What is nephrotic syndrome characterized by?

A
  • Proteinuria (> 3g/24hr)
  • Hypoalbuminaemia (< 30g/L)
  • Oedema

This triad is crucial for diagnosing nephrotic syndrome.

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53
Q

What are the primary causes of nephrotic syndrome?

A
  • Minimal change disease
  • Focal segmental glomerulosclerosis
  • Membranous nephropathy

These are common primary causes of nephrotic syndrome.

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54
Q

What is the first-line diagnostic tool for testicular cancer?

A

Ultrasound

Ultrasound is essential for evaluating suspected testicular masses.

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55
Q

What are the common types of germ-cell tumours?

A
  • Seminomas
  • Non-seminomas (embryonal, yolk sac, teratoma, choriocarcinoma)

Germ-cell tumours account for 95% of testicular cancer cases.

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56
Q

What are common symptoms of elevated PTH-rP levels in multiple myeloma?

A

Constipation, nausea, anorexia, confusion

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57
Q

What causes renal damage in multiple myeloma?

A

Monoclonal production of immunoglobulins leads to light chain deposition within the renal tubules

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58
Q

What are other causes of renal impairment in myeloma?

A
  • Amyloidosis
  • Nephrocalcinosis
  • Nephrolithiasis
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59
Q

How does bone marrow crowding affect erythropoiesis?

A

It suppresses erythropoiesis, leading to anaemia

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60
Q

What condition results from bone marrow crowding and increases the risk of bleeding?

A

Thrombocytopenia

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61
Q

What causes lytic bone lesions in multiple myeloma?

A

Bone marrow infiltration by plasma cells and cytokine-mediated osteoclast overactivity

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62
Q

What is a significant risk associated with the lytic bone lesions in multiple myeloma?

A

Pathological fractures

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63
Q

What leads to increased susceptibility to infection in multiple myeloma patients?

A

Reduction in the production of normal immunoglobulins

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64
Q

What are some other features associated with multiple myeloma? (4)

A
  • Amyloidosis (e.g. macroglossia)
  • Carpal tunnel syndrome
  • Neuropathy
  • Hyperviscosity
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65
Q

What does a full blood count typically show in multiple myeloma?

A

Anaemia

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66
Q

What is indicated by rouleaux formation in a peripheral blood film?

A

Multiple myeloma

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67
Q

What is the significance of elevated levels of M protein in the diagnosis of multiple myeloma?

A

It indicates monoclonal gammopathy

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68
Q

What is the purpose of a bone marrow aspiration in multiple myeloma?

A

To confirm the diagnosis if the number of plasma cells is significantly raised

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69
Q

What imaging technique is increasingly recommended for detecting bone lesions in multiple myeloma?

A

Whole-body MRI

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70
Q

What major diagnostic criteria are used for multiple myeloma?

A
  • Plasmacytoma
  • 30% plasma cells in a bone marrow sample
  • Elevated levels of M protein
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71
Q

What are the minor diagnostic criteria for multiple myeloma? (4)

A
  • 10% to 30% plasma cells in a bone marrow sample
  • Minor elevations in the level of M protein
  • Osteolytic lesions
  • Low levels of antibodies in the blood
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72
Q

What is the primary goal of managing multiple myeloma?

A

To control symptoms, reduce complications, and prolong survival

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73
Q

What is ‘induction therapy’ in the context of multiple myeloma treatment?

A

A combination of drugs used to treat myeloma

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74
Q

What type of transplantation is commonly used in multiple myeloma treatment?

A

Autologous hematopoietic cell transplantation

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75
Q

What is the role of zoledronic acid in multiple myeloma management?

A

To prevent and manage osteoporosis and fragility fractures

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76
Q

What is the most common cause of epididymo-orchitis in sexually active younger adults?

A

Chlamydia trachomatis and Neisseria gonorrhoeae

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77
Q

What are the clinical features of epididymo-orchitis?

A
  • Unilateral testicular pain
  • Swelling
  • Urethral discharge (may be present)
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78
Q

What is the most important differential diagnosis to exclude in cases of epididymo-orchitis?

A

Testicular torsion

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79
Q

What is the recommended management for epididymo-orchitis caused by an STI?

A

Urgent referral to a local specialist sexual health clinic

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80
Q

What is the standard maintenance fluid requirement for an 80kg patient?

A

2 litres of water, 80mmol potassium

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81
Q

What is a hyperosmolar hyperglycaemic state (HHS)?

A

A medical emergency characterized by severe hyperglycaemia and dehydration

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82
Q

What are the typical clinical features of HHS?

A
  • Polyuria
  • Polydipsia
  • Lethargy
  • Nausea and vomiting
  • Altered level of consciousness
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83
Q

What is the recommended initial management for HHS?

A

Fluid replacement with IV 0.9% sodium chloride solution

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84
Q

What are the major risk factors for erectile dysfunction?

A
  • Cardiovascular disease
  • Obesity
  • Diabetes mellitus
  • Smoking
  • Alcohol use
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85
Q

What is the first-line treatment for erectile dysfunction?

A

PDE-5 inhibitors (e.g., sildenafil)

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86
Q

What are common side effects of PDE-5 inhibitors?

A
  • Visual disturbances
  • Headache
  • Flushing
  • Gastrointestinal side effects
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87
Q

What does the presence of blue discolouration of vision indicate?

A

Use of sildenafil (Viagra)

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88
Q

What is the most common inherited cause of kidney disease?

A

Autosomal dominant polycystic kidney disease (ADPKD)

Affects 1 in 1,000 Caucasians.

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89
Q

What are the two disease loci identified in ADPKD?

A

PKD1 and PKD2

Code for polycystin-1 and polycystin-2 respectively.

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90
Q

What percentage of ADPKD cases are type 1?

A

85% of cases.

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91
Q

What chromosome is associated with ADPKD type 1?

A

Chromosome 16.

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92
Q

What is the screening investigation for relatives of ADPKD patients?

A

Abdominal ultrasound.

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93
Q

Fill in the blank: Ultrasound diagnostic criteria for patients aged < 30 years with positive family history of ADPKD is _______.

A

two cysts, unilateral or bilateral.

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94
Q

What treatment option is available for select patients with ADPKD?

A

Tolvaptan (vasopressin receptor 2 antagonist).

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95
Q

What are the criteria for using tolvaptan in ADPKD treatment?

A
  • Chronic kidney disease stage 2 or 3 at the start of treatment
  • Evidence of rapidly progressing disease
  • Company provides it with the discount agreed in the patient access scheme.
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96
Q

What is the most significant factor causing anaemia in chronic kidney disease (CKD)?

A

Reduced erythropoietin levels.

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97
Q

At what GFR level does anaemia usually become apparent in CKD?

A

Less than 35 ml/min.

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98
Q

What is the target haemoglobin level suggested by NICE guidelines for CKD management?

A

10 - 12 g/dl.

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99
Q

What is the common cause of anaemia in renal failure?

A

Reduced erythropoietin levels, reduced absorption of iron, reduced erythropoiesis, and stress ulceration.

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100
Q

What are the basic problems in chronic kidney disease?

A
  • Low vitamin D
  • High phosphate
  • Low calcium
  • Secondary hyperparathyroidism.
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101
Q

What is the most commonly used formula to estimate glomerular filtration rate (eGFR)?

A

Modification of Diet in Renal Disease (MDRD) equation.

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102
Q

What variables are used in the MDRD equation?

A
  • Serum creatinine
  • Age
  • Gender
  • Ethnicity.
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103
Q

What are the stages of chronic kidney disease based on GFR?

A
  • Stage 1: > 90 ml/min
  • Stage 2: 60-90 ml/min
  • Stage 3a: 45-59 ml/min
  • Stage 3b: 30-44 ml/min
  • Stage 4: 15-29 ml/min
  • Stage 5: < 15 ml/min.
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104
Q

Name three common causes of chronic kidney disease.

A
  • Diabetic nephropathy
  • Chronic glomerulonephritis
  • Hypertension.
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105
Q

What is osteitis fibrosa cystica?

A

Also known as hyperparathyroid bone disease.

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106
Q

What are the possible features of chronic kidney disease?

A
  • Oedema
  • Polyuria
  • Lethargy
  • Pruritus
  • Anorexia
  • Insomnia
  • Nausea and vomiting
  • Hypertension.
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107
Q

True or False: ACE inhibitors are first-line treatment for hypertension in CKD.

A

True.

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108
Q

What is the function of furosemide in CKD?

A

Useful as an anti-hypertensive, particularly when GFR falls below 45 ml/min.

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109
Q

What dietary management is suggested for high phosphate levels in CKD?

A

Reduced dietary intake of phosphate.

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110
Q

How should phosphate binders be managed?

A
  • Calcium-based binders
  • Sevelamer (non-calcium based binder).
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111
Q

What is the preferred method for quantifying proteinuria in CKD?

A

Albumin:creatinine ratio (ACR).

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112
Q

What does a confirmed ACR of 3 mg/mmol or more indicate?

A

Clinically important proteinuria.

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113
Q

What is the management for proteinuria in CKD?

A
  • ACE inhibitors or ARBs
  • SGLT-2 inhibitors.
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114
Q

What is minimal change disease often associated with?

A

Nephrotic syndrome.

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115
Q

What is the primary treatment for minimal change disease?

A

Oral corticosteroids.

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116
Q

What defines nocturnal enuresis?

A

Involuntary discharge of urine at night in a child aged 5 years or older.

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117
Q

What is the first-line management for enuresis?

A

Enuresis alarm.

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118
Q

Name a common cause of polyuria.

A
  • Diabetes mellitus
  • Diuretics
  • Caffeine and alcohol.
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119
Q

What does diabetes insipidus (DI) refer to?

A

A condition characterized by excessive urination due to inadequate vasopressin.

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120
Q

What are the common causes of polyuria?

A

Diuretics, caffeine & alcohol, diabetes mellitus, lithium, heart failure

Common causes occur in more than 1 in 10 patients.

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121
Q

What are the infrequent causes of polyuria?

A

Hypercalcaemia, hyperthyroidism

Infrequent causes occur in 1 in 100 patients.

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122
Q

What are the rare causes of polyuria?

A

Chronic renal failure, primary polydipsia, hypokalaemia

Rare causes occur in 1 in 1000 patients.

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123
Q

What is the very rare cause of polyuria?

A

Diabetes insipidus

Very rare causes occur in less than 1 in 10,000 patients.

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124
Q

What is diabetes insipidus (DI)?

A

A condition characterized by decreased secretion of antidiuretic hormone (ADH) or insensitivity to ADH

Cranial DI and nephrogenic DI are the two main types.

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125
Q

What are the causes of cranial diabetes insipidus?

A

Idiopathic, post head injury, pituitary surgery, craniopharyngiomas, infiltrative diseases (histiocytosis X, sarcoidosis), DIDMOAD syndrome, haemochromatosis

DIDMOAD is an association of cranial DI, diabetes mellitus, optic atrophy, and deafness.

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126
Q

What are the causes of nephrogenic diabetes insipidus?

A

Genetic mutations, hypercalcaemia, hypokalaemia, lithium, demeclocycline, tubulo-interstitial disease

The more common form affects the vasopressin receptor.

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127
Q

What are the main features of diabetes insipidus?

A

Polyuria, polydipsia

These symptoms are due to the lack of water reabsorption.

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128
Q

How is diabetes insipidus investigated?

A

High plasma osmolality, low urine osmolality, water deprivation test

A urine osmolality of >700 mOsm/kg excludes diabetes insipidus.

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129
Q

What is the management for nephrogenic diabetes insipidus?

A

Thiazides, low salt/protein diet

Central diabetes insipidus can be treated with desmopressin.

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130
Q

What is the most common urological cancer?

A

Bladder cancer

It most commonly affects males aged between 50 and 80 years.

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131
Q

What increases the risk of bladder cancer?

A

Smoking, exposure to hydrocarbons, chronic bladder inflammation from Schistosomiasis

Smokers have a 2-5 fold increased risk.

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132
Q

What are the types of bladder malignancies?

A

Urothelial carcinoma (>90%), squamous cell carcinoma (1-7%), adenocarcinoma (2%)

Urothelial carcinomas may be solitary or multifocal.

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133
Q

What does TNM staging stand for?

A

Tumor, Node, Metastasis

It is a classification system for cancer staging.

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134
Q

What is the prognosis for T1 bladder cancer?

A

90%

Prognosis decreases as the stage increases.

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135
Q

What are common risk factors for urothelial carcinoma?

A

Smoking, exposure to aniline dyes, rubber manufacture, cyclophosphamide

Smoking is the most important risk factor in western countries.

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136
Q

What are the presenting symptoms of bladder cancer?

A

Painless macroscopic haematuria

Up to 10% of females over 50 with microscopic haematuria may have malignancy.

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137
Q

What is benign prostatic hyperplasia (BPH)?

A

A common condition seen in older men characterized by lower urinary tract symptoms

Around 50% of 50-year-old men will have evidence of BPH.

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138
Q

What are the risk factors for BPH?

A

Age, ethnicity (black > white > Asian)

BPH symptoms increase with age.

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139
Q

What are the voiding symptoms of BPH?

A

Weak flow, straining, hesitancy, terminal dribbling, incomplete emptying

These are obstructive symptoms.

140
Q

What are the storage symptoms of BPH?

A

Urgency, frequency, nocturia, post-micturition dribbling

These are irritative symptoms.

141
Q

What is the International Prostate Symptom Score (IPSS)?

A

A tool for classifying the severity of lower urinary tract symptoms

Scores range from 0-35, indicating mild to severe symptoms.

142
Q

What are the management options for BPH?

A

Watchful waiting, alpha-1 antagonists, 5 alpha-reductase inhibitors, surgery (TURP)

Combination therapy may be considered for moderate-to-severe symptoms.

143
Q

What is TURP syndrome?

A

A rare complication of transurethral resection of the prostate caused by irrigation with glycine

It results in hyponatremia and can present with CNS symptoms.

144
Q

What are the risk factors for developing TURP syndrome?

A

Surgical time > 1 hr, height of bag > 70cm, resected > 60g, large blood loss

These factors increase the likelihood of systemic absorption of glycine.

145
Q

What are the fluid requirements for maintenance in adults according to NICE?

A

25-30 ml/kg/day of water, 1 mmol/kg/day of potassium, sodium, chloride, 50-100 g/day of glucose

Adjustments may be needed based on medical history.

146
Q

What is the commonest cause of end-stage renal disease (ESRD) in the western world?

A

Diabetic nephropathy

33% of patients with type 1 diabetes mellitus have diabetic nephropathy by age 40.

147
Q

What are the stages of diabetic nephropathy?

A

Stage 1: Hyperfiltration, Stage 2: Silent phase, Stage 3: Incipient nephropathy, Stage 4: Overt nephropathy, Stage 5: End-stage renal disease

Progression occurs at different rates in type 1 and type 2 diabetes.

148
Q

What is the management for diabetic nephropathy?

A

Dietary protein restriction, tight glycaemic control, BP control, ACE inhibitors, control dyslipidaemia

Annual screening with urinary albumin:creatinine ratio is recommended.

149
Q

What is persistent proteinuria in the context of nephropathy?

A

Albumin excretion > 300 mg/day, dipstick positive

Persistent proteinuria is a key indicator in evaluating kidney function in nephropathy.

150
Q

What is the typical GFR in Stage 5 end-stage renal disease?

A

Typically < 10 ml/min

At this stage, renal replacement therapy is needed.

151
Q

How do the progression timelines of type 1 and type 2 diabetes mellitus differ?

A

Type 1 progresses through stages typically, while type 2 may progress quickly to later stages

Some patients with type 2 diabetes mellitus (T2DM) may experience rapid progression.

152
Q

What are the first-line treatments for venous thromboembolism (VTE) according to the 2020 NICE guidelines?

A

Direct oral anticoagulants (DOACs)

This includes their use as interim anticoagulants before a definite diagnosis.

153
Q

What is the two-level DVT Wells score used for?

A

To assess the likelihood of deep vein thrombosis (DVT)

It includes various clinical features with assigned points.

154
Q

What score indicates a DVT is likely according to the two-level DVT Wells score?

A

2 points or more

This score helps determine further diagnostic steps.

155
Q

What should be done if a DVT is ‘likely’ based on the Wells score?

A

A proximal leg vein ultrasound scan within 4 hours

If positive, anticoagulant treatment should start immediately.

156
Q

What is the recommended action if a DVT is ‘unlikely’?

A

Perform a D-dimer test

If D-dimer is positive, follow up with a proximal leg vein ultrasound scan.

157
Q

What type of D-dimer tests does NICE recommend?

A

Either point-of-care (finger prick) or laboratory-based tests

Age-adjusted cut-offs should be used for patients > 50 years old.

158
Q

What was the historical method for VTE management before the introduction of DOACs?

A

Warfarin, often preceded by heparin until INR was stable

The emergence of DOACs has transformed modern management.

159
Q

According to the 2020 guidelines, what should be the first-line anticoagulant offered after a DVT diagnosis?

A

Apixaban or rivaroxaban

DOACs are now preferred over low-molecular weight heparin.

160
Q

What is the minimum duration for anticoagulation in VTE management?

A

At least 3 months

Duration may vary based on whether the VTE was provoked or unprovoked.

161
Q

What characterizes a provoked VTE?

A

Due to an obvious precipitating event

Example: immobilisation following major surgery.

162
Q

What is the ORBIT score used for?

A

To assess the risk of bleeding

This helps determine the duration of anticoagulant therapy.

163
Q

What are common clinical features of a DVT?

A

Lower limb pain, swelling, erythema, pitting oedema, distension of superficial veins

These symptoms are crucial for diagnosis.

164
Q

What is the common condition diagnosed in up to 30,000 men each year in the UK?

A

Prostate cancer

Prostate cancer is the most common cancer in adult males in the UK.

165
Q

What is a common symptom of metastatic prostate cancer?

166
Q

What are some symptoms of locally advanced prostate cancer?

A

Pelvic pain, urinary symptoms

167
Q

What diagnostic tests are used for prostate cancer?

A
  • Prostate specific antigen measurement
  • Digital rectal examination
  • Trans rectal ultrasound (+/- biopsy)
  • MRI/CT and bone scan for staging
168
Q

What is the normal upper limit for prostate specific antigen (PSA)?

169
Q

What may cause false positives in PSA testing?

A
  • Prostatitis
  • Urinary tract infection (UTI)
  • Benign prostatic hyperplasia (BPH)
  • Vigorous digital rectal examination (DRE)
170
Q

What percentage of free: total PSA suggests cancer?

171
Q

What is the most common pathology type found in prostate cancer?

A

Adenocarcinoma (95%)

172
Q

What grading system is used for prostate cancer and how is it calculated?

A

Gleason grading system; two grades are awarded, added together to give the Gleason score

173
Q

What does a Gleason score of 2 indicate?

A

Best prognosis

174
Q

What is the first site of lymphatic spread in prostate cancer?

A

Obturator nodes

175
Q

What treatment options are available for low-risk prostate cancer?

A
  • Watch and wait
  • Radiotherapy
  • Surgery (Radical prostatectomy)
  • Hormonal therapy
176
Q

What is the preferred option for low-risk men according to NICE?

A

Active surveillance

177
Q

What are the risk factors for developing prostate cancer? (4)

A
  • Increasing age
  • Obesity
  • Afro-Caribbean ethnicity
  • Family history (5-10%)
178
Q

What are potential symptoms of localized prostate cancer?

A
  • Bladder outlet obstruction
  • Hematuria
  • Hematospermia
  • Pain (back, perineal, testicular)
179
Q

What is the traditional investigation for suspected prostate cancer?

A

Transrectal ultrasound-guided biopsy (TRUS)

180
Q

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

A

Multiparametric MRI

181
Q

What complications can arise from TRUS biopsy?

A
  • Sepsis (1%)
  • Pain (lasting >= 2 weeks in 15%)
  • Fever (5%)
  • Hematuria and rectal bleeding
182
Q

What is the management for renal stones less than 5mm?

A

Watchful waiting

183
Q

What is the treatment for renal stones measuring 10-20 mm?

A
  • Shockwave lithotripsy
  • Ureteroscopy
184
Q

What percentage of men with a PSA of 4-10 ng/ml will have prostate cancer?

185
Q

What is a key aim of treating advanced prostate cancer?

A

Reducing androgen levels

186
Q

What is the role of GnRH agonists in prostate cancer treatment?

A

Initially increase testosterone levels before reducing them to castration levels

187
Q

What is a common side effect of radical prostatectomy?

A

Erectile dysfunction

188
Q

What is the function of bicalutamide in prostate cancer treatment?

A

Non-steroidal anti-androgen that blocks the androgen receptor

189
Q

What is the recommended PSA level threshold for men aged 50-59?

A

> 3.5 ng/ml

190
Q

What urinary condition may raise PSA levels?

A

Benign prostatic hyperplasia (BPH)

191
Q

What is the management for stones larger than 20 mm?

A

Percutaneous nephrolithotomy

192
Q

What is the typical management for patients with renal colic?

A

NSAID analgesia

193
Q

What does the Likert scale score of 3 or higher indicate?

A

Offer a multiparametric MRI-influenced prostate biopsy

194
Q

What is the composition of struvite stones?

A

Magnesium, ammonium, and phosphate

195
Q

What is the effect of urinary pH on stone formation?

A

Varies by stone type; e.g., uric acid stones form in acidic urine

196
Q

What is an important consideration when prescribing NSAIDs for renal colic?

A

Increased risk of cardiovascular events

197
Q

What are the potential complications of radiotherapy for prostate cancer?

A
  • Radiation proctitis
  • Rectal malignancy
  • Increased risk of bladder, colon, and rectal cancer
198
Q

What is the typical management for ureteric stones less than 10 mm?

A

Shockwave lithotripsy +/- alpha blockers

199
Q

What should be done if a patient with renal stones shows signs of infection?

A

Immediate CT KUB

200
Q

What is the significance of age-adjusted PSA levels?

A

Helps in determining the need for further investigation based on age

201
Q

What is the procedure of rolithotomy used for?

A

Access to the renal collecting system

Involves intra corporeal lithotripsy or stone fragmentation and removal of stone fragments.

202
Q

What percentage of the general population may experience hypercalciuria leading to calcium stones?

A

5-10%

This condition is a significant risk factor for the formation of calcium stones.

203
Q

List three prevention strategies for renal stones.

A
  • High fluid intake
  • Add lemon juice to drinking water
  • Limit salt intake
204
Q

Which substance may be beneficial in preventing calcium stones according to NICE?

A

Potassium citrate

It may help in managing calcium levels in urine.

205
Q

What is the effect of cholestyramine on urinary oxalate secretion?

A

Reduces urinary oxalate secretion

This is particularly relevant for preventing oxalate stones.

206
Q

What medication is used to treat uric acid stones?

A

Allopurinol

It helps in reducing uric acid levels in the body.

207
Q

Identify two risk factors for the formation of renal stones.

A
  • Dehydration
  • Hypercalciuria
208
Q

Which condition is associated with urate stones due to loss of bicarbonate and fluid?

A

Ileostomy

This results in acidic urine, promoting uric acid precipitation.

209
Q

Name a drug that promotes the formation of calcium stones.

A

Loop diuretics

Other drugs include steroids, acetazolamide, and theophylline.

210
Q

What is the radiographic appearance of calcium oxalate stones?

A

Opaque

They account for 40% of renal stones.

211
Q

What type of renal stone has a ‘ground-glass’ appearance on X-ray?

A

Cystine stones

These stones constitute about 1% of renal stones.

212
Q

Fill in the blank: Stag-horn calculi develop in _______ urine.

A

Alkaline

They are composed of struvite and involve the renal pelvis.

213
Q

What is the frequency of occurrence for mixed calcium oxalate/phosphate stones?

A

25%

These stones are also opaque on radiographs.

214
Q

True or False: Urate stones are radio-lucent.

A

True

They account for 5-10% of renal stones.

215
Q

What are the components of stag-horn calculi?

A

Struvite (ammonium magnesium phosphate, triple phosphate)

They are often associated with infections by Ureaplasma urealyticum and Proteus.

216
Q

Which diuretic can prevent calcium stones by increasing distal tubular calcium resorption?

A

Thiazides

They help in reducing the risk of calcium stone formation.

217
Q

What are the two primary conditions that account for 90% of cases of hypercalcaemia?

A
  1. Primary hyperparathyroidism
  2. Malignancy
218
Q

What is the commonest cause of hypercalcaemia in non-hospitalised patients?

A

Primary hyperparathyroidism

219
Q

What is the commonest cause of hypercalcaemia in hospitalised patients?

A

Malignancy

220
Q

What are some processes by which malignancy can cause hypercalcaemia?

A
  • PTHrP from the tumour (e.g. squamous cell lung cancer)
  • Bone metastases
  • Myeloma (due to increased osteoclastic bone resorption)
221
Q

What is the key investigation for patients with hypercalcaemia?

A

Measuring parathyroid hormone levels

222
Q

List other causes of hypercalcaemia.(10)

A
  • Sarcoidosis
  • Vitamin D intoxication
  • Acromegaly
  • Thyrotoxicosis
  • Milk-alkali syndrome
  • Thiazides
  • Calcium-containing antacids
  • Dehydration
  • Addison’s disease
  • Paget’s disease of the bone
223
Q

What mnemonic is used to remember the features of hypercalcaemia?

A

‘Bones, stones, groans, and psychic moans’

224
Q

What are some ECG changes associated with hyperkalaemia?

A
  • Tall-tented T waves
  • Small P waves
  • Widened QRS leading to a sinusoidal pattern
  • Asystole
225
Q

What are the causes of hyperkalaemia? (6)

A
  • Acute kidney injury
  • Drugs (e.g. potassium-sparing diuretics, ACE inhibitors)
  • Metabolic acidosis
  • Addison’s disease
  • Rhabdomyolysis
  • Massive blood transfusion
226
Q

What foods are high in potassium?

A
  • Salt substitutes (contain potassium)
  • Bananas
  • Oranges
  • Kiwi fruit
  • Avocado
  • Spinach
  • Tomatoes
227
Q

True or False: IV calcium gluconate lowers serum potassium levels.

228
Q

What is the European Resuscitation Council’s classification of hyperkalaemia based on potassium levels?

A
  • Mild: 5.5 - 5.9 mmol/L
  • Moderate: 6.0 - 6.4 mmol/L
  • Severe: ≥ 6.5 mmol/L
229
Q

What is the preferred treatment for severe hypocalcaemia?

A

IV calcium replacement with calcium gluconate

230
Q

What are the features of hypocalcaemia?

A
  • Tetany
  • Perioral paraesthesia
  • Prolonged QT interval on ECG
231
Q

What signs are associated with hypocalcaemia?

A
  • Trousseau’s sign
  • Chvostek’s sign
232
Q

What can cause hypokalaemia with alkalosis?

A
  • Vomiting
  • Thiazide and loop diuretics
  • Cushing’s syndrome
  • Conn’s syndrome
233
Q

What is the treatment for magnesium deficiency?

A
  • <0.4 mmol/L or tetany, arrhythmias, seizures: IV magnesium replacement
  • > 0.4 mmol/L: Oral magnesium salts
234
Q

What are the causes of hyponatraemia?

A
  • Water excess
  • Sodium depletion
235
Q

What is the principle management for acute severe hyponatraemia?

A

Hypertonic saline (typically 3% NaCl)

236
Q

What are the complications of over-correction in hyponatraemia?

A

Osmotic demyelination syndrome (central pontine myelinolysis)

237
Q

What is the most common bladder cancer?

A

Urothelial (transitional cell) carcinoma

238
Q

What risk factors increase the likelihood of bladder cancer?

A
  • Smoking
  • Exposure to hydrocarbons
  • Chronic bladder inflammation (e.g. Schistosomiasis)
239
Q

What percentage of bladder malignancies are urothelial carcinomas?

240
Q

What is the typical age range for males affected by bladder cancer?

A

50 to 80 years

241
Q

What is the most common type of bladder cancer?

A

Transitional cell carcinoma (TCC)

TCC accounts for 90% of bladder cancers.

242
Q

What proportion of TCCs have a papillary growth pattern?

A

Up to 70%

Papillary growth patterns are typically associated with better prognosis.

243
Q

What is the prognosis for T3 bladder cancer?

A

30% (or higher) risk of regional or distant lymph node metastasis

244
Q

What does T0 in TNM staging indicate?

A

No evidence of tumour

245
Q

What is the definition of Ta in TNM staging?

A

Non invasive papillary carcinoma

246
Q

What is the most common presentation of bladder cancer?

A

Painless, macroscopic haematuria (85%)

247
Q

What is the recommended management for superficial bladder lesions?

A

TURBT in isolation

248
Q

What is the prognosis for T2 bladder cancer?

249
Q

What is the term for non-visible haematuria?

A

Non-visible haematuria

This term is used to describe microscopic or dipstick positive haematuria.

250
Q

List three causes of transient non-visible haematuria.

A
  • Urinary tract infection
  • Menstruation
  • Vigorous exercise
251
Q

What is the test of choice for detecting haematuria?

A

Urine dipstick

252
Q

What criteria define persistent non-visible haematuria?

A

Blood present in 2 out of 3 samples tested 2-3 weeks apart

253
Q

What are the NICE urgent cancer referral guidelines for patients aged >= 45 years?

A

Unexplained visible haematuria without urinary tract infection or visible haematuria that persists or recurs after successful treatment of urinary tract infection

254
Q

What is IgA nephropathy also known as?

A

Berger’s disease

255
Q

What is the classical presentation of IgA nephropathy?

A

Macroscopic haematuria in young people following an upper respiratory tract infection

256
Q

What is the common histological subtype of renal cell carcinoma?

A

Clear cell carcinoma (75-85% of tumours)

257
Q

What is the classical triad of renal cell carcinoma?

A
  • Haematuria
  • Loin pain
  • Abdominal mass
258
Q

What are the T category criteria for renal cell carcinoma?

A
  • T1: Tumour ≤ 7 cm and confined to the kidney
  • T2: Tumour > 7 cm and confined to the kidney
  • T3: Tumour extends into major veins or perinephric tissues
  • T4: Tumour invades beyond Gerota’s fascia
259
Q

What is the management for a T1 renal cell carcinoma?

A

Partial nephrectomy

260
Q

What is a hydrocele?

A

Accumulation of fluid within the tunica vaginalis

261
Q

What distinguishes a communicating hydrocele from a non-communicating hydrocele?

A

Communicating: patency of the processus vaginalis; Non-communicating: excessive fluid production

262
Q

What is a varicocele?

A

Abnormal enlargement of the testicular veins

263
Q

What is the most common cause of scrotal swellings seen in primary care?

A

Epididymal cysts

264
Q

What is the management for testicular malignancy?

A

Orchidectomy via an inguinal approach

265
Q

What is the commonest age group for testicular torsion?

A

Around puberty

266
Q

What is Stauffer syndrome associated with?

A

Renal cell cancer

Typically presents as cholestasis/hepatosplenomegaly.

267
Q

What are the features of a hydrocele?

A
  • Soft, non-tender swelling of the hemi-scrotum
  • Transilluminates with a pen torch
268
Q

What is the management for an infantile hydrocele that does not resolve spontaneously?

A

Repair by age of 1-2 years

269
Q

What is the typical location for varicoceles?

A

Typically occur on the left side

This is because the testicular vein drains into the renal vein.

270
Q

What is a potential presenting feature of renal cell carcinoma?

A

Varicoceles

Affected testis may be smaller, and bilateral varicoceles may affect fertility.

271
Q

What is the standard treatment for testicular malignancy?

A

Orchidectomy via an inguinal approach

This allows high ligation of the testicular vessels and avoids exposure of another lymphatic field to the tumour.

272
Q

What is the most common age group for testicular torsion?

A

Young teenagers

Most commonly occurs in males aged between 10 and 30 years, with peak incidence at 13-15 years.

273
Q

What is the treatment for testicular torsion?

A

Prompt surgical exploration and testicular fixation

Can be achieved using sutures or by placement of the testis in a Dartos pouch.

274
Q

How are varicoceles generally managed?

A

Usually managed conservatively

Surgery or radiological management may be considered if there are concerns about testicular function or infertility.

275
Q

How are epididymal cysts excised?

A

Using a scrotal approach

276
Q

What is the management approach for hydroceles in children?

A

Inguinal approach to ligate the processus vaginalis

The underlying pathology is a patent processus vaginalis.

277
Q

What is the most common malignancy in men aged 20-30 years?

A

Testicular cancer

278
Q

What percentage of testicular cancer cases are germ-cell tumours?

A

Around 95%

279
Q

What are the two main types of germ cell tumours?

A
  • Seminomas
  • Non-seminomas (including embryonal, yolk sac, teratoma, choriocarcinoma)
280
Q

What is the peak incidence age for teratomas and seminomas?

A
  • Teratomas: 25 years
  • Seminomas: 35 years
281
Q

What are some risk factors for testicular cancer?

A
  • Infertility
  • Cryptorchidism
  • Family history
  • Klinefelter’s syndrome
  • Mumps orchitis
282
Q

What is the most common presenting symptom of testicular cancer?

A

A painless lump

283
Q

What may occur due to an increased oestrogen:androgen ratio in testicular cancer?

A

Gynaecomastia

284
Q

What is the first-line diagnostic tool for testicular cancer?

A

Ultrasound

285
Q

What are the treatment options for testicular cancer?

A
  • Orchidectomy
  • Chemotherapy
  • Radiotherapy

Treatment depends on whether the tumour is a seminoma or a non-seminoma.

286
Q

What is the prognosis for seminomas at Stage I?

A

Around 95% 5-year survival

287
Q

What is the prognosis for teratomas at Stage I?

A

Around 85% 5-year survival

288
Q

What is acute epididymitis?

A

Acute inflammation of the epididymis, often involving the testis, usually caused by bacterial infection

289
Q

What are the usual infections causing epididymitis in men under 35?

A
  • Gonorrhoea
  • Chlamydia
290
Q

What is the typical symptom of testicular torsion?

A

Severe pain of sudden onset

291
Q

What sign is lost in testicular torsion?

A

Cremasteric reflex

292
Q

What is a hydrocele?

A

A mass that transilluminates, usually possible to ‘get above’ on examination

293
Q

What is the treatment for hydrocele in adults?

A

Lords or Jabouley procedure

294
Q

What are the small vestigial remnants associated with testicular torsion?

A
  • Appendix testis
  • Appendix epididymis
295
Q

What is the ‘blue-dot’ sign associated with?

A

Appendix testis torsion

296
Q

What is the usual age group for appendix testis torsion?

A

Boys aged 8-11 years

297
Q

What is the management approach for suspected appendix testis torsion?

A

Exploratory operation to exclude classic testicular torsion

298
Q

What is aortic dissection?

A

A rare but serious cause of chest pain

299
Q

What is the primary pathophysiological change in aortic dissection?

A

Tear in the tunica intima of the wall of the aorta

300
Q

What is the most important risk factor associated with aortic dissection?

A

Hypertension

301
Q

Name three associations of aortic dissection.

A
  • Trauma
  • Bicuspid aortic valve
  • Marfan’s syndrome
302
Q

What is a common symptom of aortic dissection?

A

Chest or back pain

303
Q

How is the pain in aortic dissection typically described?

A

Severe and ‘sharp’, ‘tearing’ in nature

304
Q

What is the difference in pain presentation between type A and type B aortic dissection?

A

Chest pain is more common in type A; upper back pain is more common in type B

305
Q

What are some physical exam findings in aortic dissection?

A
  • Pulse deficit
  • Variation in systolic blood pressure between arms
  • Aortic regurgitation
306
Q

What classification system is used for aortic dissection?

A

Stanford and DeBakey classification

307
Q

What is the difference between type A and type B in the Stanford classification?

A
  • Type A: Involves ascending aorta
  • Type B: Involves descending aorta
308
Q

What are the three types of aortic dissection in the DeBakey classification?

A
  • Type I: Originates in ascending aorta, propagates distally
  • Type II: Confined to ascending aorta
  • Type III: Originates in descending aorta
309
Q

What is a common presentation of chronic kidney disease?

A

Usually asymptomatic, diagnosed via abnormal urea and electrolyte results

310
Q

List some possible symptoms of late-stage chronic kidney disease. (8)

A
  • Oedema
  • Polyuria
  • Lethargy
  • Pruritus
  • Anorexia
  • Insomnia
  • Nausea and vomiting
  • Hypertension
311
Q

What defines hypertension?

A

Chronically raised blood pressure, typically above 140/90 mmHg

312
Q

What is the normal blood pressure range for healthy individuals?

A

Between 90/60 mmHg and 140/90 mmHg

313
Q

What percentage of hypertension cases are classified as primary or essential?

A

Around 90-95%

314
Q

Name three causes of secondary hypertension.

A
  • Renal disease
  • Endocrine disorders
  • Other causes (e.g., pregnancy, medications)
315
Q

What symptoms may indicate very high blood pressure?

A
  • Headaches
  • Visual disturbance
  • Seizures
316
Q

What is the recommended method for diagnosing longstanding hypertension?

A

Using 24-hour blood pressure monitors

317
Q

What should be checked to assess for end-organ damage in hypertension?

A
  • Fundoscopy
  • Urine dipstick
  • ECG
318
Q

What are the common drug classes used to treat hypertension?

A
  • ACE inhibitors
  • Calcium channel blockers
  • Thiazide-type diuretics
  • Angiotensin II receptor blockers (A2RB)
319
Q

What is a common side effect of ACE inhibitors?

320
Q

What is the first-line treatment for patients under 55 years with hypertension?

A

ACE inhibitor or angiotensin receptor blocker

321
Q

What lifestyle changes are recommended for managing hypertension? (7)

A
  • Low salt diet
  • Reduced caffeine intake
  • Stop smoking
  • Drink less alcohol
  • Eat a balanced diet
  • Exercise more
  • Lose weight
322
Q

What is the criteria for Stage 1 hypertension according to NICE?

A

Clinic BP >= 140/90 mmHg and subsequent ABPM or HBPM average >= 135/85 mmHg

323
Q

What is the criteria for Stage 2 hypertension according to NICE?

A

Clinic BP >= 160/100 mmHg and subsequent ABPM or HBPM average >= 150/95 mmHg

324
Q

What is the recommended action if a patient’s blood pressure is >= 180/120 mmHg?

A

Admit for specialist assessment

325
Q

What is the protocol for home blood pressure monitoring (HBPM)?

A
  • Two consecutive measurements at least 1 minute apart
  • Record twice daily for at least 4 days
326
Q

True or False: Blood pressure readings in both arms should be measured when diagnosing hypertension.

327
Q

Fill in the blank: NICE recommends that antihypertensive drug treatment should be considered for adults under 60 with stage 1 hypertension and an estimated 10-year risk below _______.

328
Q

What is the first-line treatment for hypertension in patients with diabetes mellitus?

A

ACE inhibitor or Angiotensin receptor blocker (ACE-i or ARB)

ACE inhibitors are preferred unless contraindicated.

329
Q

When should angiotensin receptor blockers be used instead of ACE inhibitors?

A

When ACE inhibitors are not tolerated (e.g., due to cough)

This indicates a patient-specific response to medication.

330
Q

What is the recommended first-line treatment for patients aged 55 or of black African or African-Caribbean origin?

A

Calcium channel blocker (C)

ACE inhibitors have reduced efficacy in these populations.

331
Q

If a patient is already taking an ACE-i or ARB, what should be added next for hypertension treatment?

A

Calcium channel blocker or a thiazide-like diuretic

This is part of step 2 treatment.

332
Q

What is the third step in hypertension treatment if a patient is already on (A + C)?

A

Add a thiazide-like diuretic (D)

This completes the (A + C + D) regimen.

333
Q

What defines step 4 treatment in hypertension management according to NICE?

A

Resistant hypertension

It involves adding a fourth drug or seeking specialist advice.

334
Q

What should be confirmed before proceeding to step 4 treatment?

A

Elevated clinic BP with ABPM or HBPM and assess for postural hypotension

This ensures accurate diagnosis before further treatment.

335
Q

What is the blood pressure target for patients under 80 years using clinic BP?

A

140/90 mmHg

This is the guideline target for managing hypertension.

336
Q

What is the most common cause of secondary hypertension?

A

Primary hyperaldosteronism (including Conn’s syndrome)

This condition affects 5-10% of patients diagnosed with hypertension.

337
Q

What renal conditions may increase blood pressure?

A
  • Glomerulonephritis
  • Pyelonephritis
  • Adult polycystic kidney disease
  • Renal artery stenosis

These conditions are significant contributors to secondary hypertension.

338
Q

Name an endocrine disorder that can lead to increased blood pressure.

A

Phaeochromocytoma

Other disorders include Cushing’s syndrome, Liddle’s syndrome, congenital adrenal hyperplasia, and acromegaly.

339
Q

List some drug causes of secondary hypertension.

A
  • Steroids
  • Monoamine oxidase inhibitors
  • Combined oral contraceptive pill
  • NSAIDs
  • Leflunomide

These medications can contribute to elevated blood pressure.

340
Q

What are the causes of primary hyperparathyroidism?

A
  • Solitary adenoma (85%)
  • Hyperplasia (10%)
  • Multiple adenoma (4%)
  • Carcinoma (1%)

Most cases are due to a solitary adenoma.

341
Q

What mnemonic helps remember the symptomatic features of primary hyperparathyroidism?

A

‘Bones, stones, abdominal groans and psychic moans’

This includes polydipsia, depression, nausea, and more.

342
Q

What are common associations with primary hyperparathyroidism?

A
  • Hypertension
  • Multiple endocrine neoplasia: MEN I and II

These associations are important for diagnosis and management.

343
Q

What investigations are used for primary hyperparathyroidism?

A
  • Blood tests (raised calcium, low phosphate)
  • PTH levels
  • Technetium-MIBI subtraction scan
  • X-ray findings (pepperpot skull, osteitis fibrosa cystica)

These tests help confirm the diagnosis.

344
Q

What is the definitive management for primary hyperparathyroidism?

A

Total parathyroidectomy

This is the surgical treatment of choice.

345
Q

Under what conditions can conservative management be offered for primary hyperparathyroidism?

A

If calcium level is < 0.25 mmol/L above normal, patient is > 50 years, and no end-organ damage

Conservative management may delay surgery.

346
Q

What is cinacalcet?

A

A calcimimetic used for patients not suitable for surgery

It mimics calcium’s action on tissues.

UKMLA Prep (48 decks)

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