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Core Conditions > Renal > Flashcards

Renal Flashcards

1
Q

Who does UTI affect?

A

Young, sexually active women

Menopausal women

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2
Q

What causes UTI?

A

E. Coli

  • main organism
  • 75-95% in community; >41% in hospital

Enterobacteriaceae

Classification:

  • uncomplicated = normal renal tract + function
  • complicated = abnormal tract, voiding difficulty/obstruction, ⬇️renal function, ⬇️immunity, virulent organism (staph aureus)

Sterile pyuria ➡️ no organisms

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3
Q

What are the risk factors for UTI?

A 
Sexual intercourse
Gender (F>M)
Exposure to spermicide
Pregnancy
Menopause
Immunosuppression
DM
Urinary tract ➡️ obstruction, stones, malformation
Catheter ➡️ urine always infected, only treat if ill
Antibiotics (changes vaginal flora)
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4
Q

What are the symptoms of a Lower UTI?

A

Cystitis ➡️
Frequency, dysuria, urgency, haematuria, suprapubic pain

Prostatitis ➡️
Flu- like symptoms, low backache, few urinary symptoms, swollen/tender prostate

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5
Q

What are the symptoms of an Upper UTI?

A

Acute pyelonephritis ➡️

High fever, rigours, vomiting, loin pain/tenderness, oliguria (AKI)

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6
Q

What are the signs of a UTI on examination?

A 
Fever
Abdomen/loin tenderness
Foul smelling urine
Distended bladder
Enlarged prostate
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7
Q

What are the differential diagnoses of a UTI?

A

Women:
Urethral syndrome (no bacterial infection)
Postmenopause with atrophic vaginitis and urethritis
Genital tract infection eg thrush, herpes simplex, chlamydia, gardnerella

Men:
Enlarged/inflamed prostate

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8
Q

What are the necessary investigations to diagnose a UTI?

A

Urine dipstick ➡️ looking for nitrites, leukocytes and blood

Mid-stream Urine ➡️ if dipstick positive, symptomatic, male, pregnant, child, immunosuppressed
- pure growth of 1 000 000 organism/mL = diagnosis

Bloods ➡️ FBC, U&Es, CRP, cultures (check for sepsis), PSA, fasting glucose

Imaging ➡️ ultrasound, bladder scan

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9
Q

What are the treatments for a UTI?

A

Cranberry juice
Fluids
Frequent urination

Pharmacological: 
LUTI: 
Trimethoprim ➡️ 200mg/12h
Nitrofurantoin ➡️ 50mg/6h
- uncomplicated female 3-6 days
- male/complicated female 7 days
Amoxicillin ➡️ 500mg/8h
Alternatives = Cefalexin (if eGFR>40)
                       Co-amoxiclav (7d)

UUTI:
Co-amoxiclav ➡️ 1.2g/8h IV, oral switch when afebrile
Men ➡️ may need 2/52 quinolone eg levofloxacin

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10
Q

How common is pyelonephritis?

A

Prevalence: 4 in 100,000 asymptomatic adults

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11
Q

Who is pyelonephritis most likely to present in?

A

Most common in young women

>65 men and women equal

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12
Q

What is pyelonephritis?

A

Pyelonephritis is an upper UTI that causes inflammation of the renal pelvis

caused by infections.

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13
Q

What are the causative organisms of infective pyelonephritis?

A
  • E. coli, klebsiella spp, proteus spp, enterococcus spp

Rare) mycobacteria, fungi, yeasts and corynebacterium urealyticum (rare

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14
Q

What are the acute risk factors for pyelonephritis?

A 
Catheter
Calculi
Structural abnormality
Renal tract ablation
Stents/drainage procedures
Pregnancy
DM
Primary biliary cirrhosis
Immunocompromised
Neuropathic bladder
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15
Q

What are the chronic risk factors for pyelonephritis?

A

Renal tract abnormalities/obstruction/calculi
Children➡️ vesicourethral reflux
Neonates➡️ intrarenal reflux
Recurrent UTI

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16
Q

What are the symptoms of pyelonephritis?

A

Acute: rapid onset:

  • Loin to groin/suprapubic pain
  • Fever and rigors
  • Malaise
  • Nausea/vomiting/Anorexia/Diarrhoea
  • UTI symptoms (frequency, dysuria, haematuria, hesitancy), Gross haematuria (30% young women)

Chronic:

  • Fever
  • Malaise
  • Loin pain
  • Nausea/vomiting
  • Dysuria
  • failure to thrive in children
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17
Q

What are the signs of pyelonephritis on examination?

A
  • patient looks ill
  • pain on palpation of 1/2 kidneys
  • moderate suprapubic tenderness without guarding
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18
Q

What are the possible differential diagnoses of pyelonephritis?

A
  • interstitial cystitis
  • PID
  • appendicitis
  • ectopic pregnancy
  • urethritis
  • STIs
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19
Q

What investigations are necessary to diagnose pyelonephritis?

A

Urinalysis:
- dipstick = protein, leukocytes, nitrites, blood
MSU microscopy:
- pyuria

Bloods:
CRP ESR, plasma viscosity
FBC ➡️ elevated WCC with neutrophilia
Cultures

Imaging: (uncertain clinical picture)
Contrast-enhanced CT
Ultrasound
MRI for scarring

Renal biopsy (suspected cancer)

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20
Q

Management of acute pyelonephritis?

A

Acute:
Support, rest analgesia, fluids

Antibiotics: (empiric)
Ciprofloxacin 250-500mg BD (7-10days)

Surgery to drain abscess/relieve obstruction causing infection

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21
Q

How common is hydronephrosis?

A

Unilateral - 1/300 people in UK per year

Bilateral -1/600 people in UK per year

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22
Q

Who does hydronephrosis affect?

A

Men and women at any age

Congenital causes common

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23
Q

What is hydronephrosis?

A

Condition where one or both kidneys become stretched or swollen as a result of a build-up of urine inside the kidneys

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24
Q

What causes hydronephrosis?

A

Ureter obstruction:

  • tumour, blood clot, calculi, sloughed papillae
  • stricture, congenital megaureter, bladder neck obstruction, neurogenic bladder, bladder carcinoma
  • outside lumen: pelvic-ureteric junction compression e.g. tumours & prostatic hyperplasia, retroperitoneal fibrosis
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25
Q

What are the risk factors of hydronephrosis?

A
  • Pregnancy
  • Cancer of cervix, prostate, ovaries
  • Previous calculi/obstruction
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26
Q

What are the symptoms of hydronephrosis?

A

Acute:

  • Quick onset (~3hrs)
  • Severe, colicky pain in back/flank (worse when drinking fluid)
  • palpable mass
  • Nausea/vomiting
  • Systemic symptoms ➡️ Fever/rigors
  • Haematuria

Chronic:

  • Same as acute
  • Asymptomatic
  • Dull ache in flank
  • Decreased frequency of urination
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27
Q

What are the signs of hydronephrosis on examination?

A

Enlarged kidney-tender on palpation
Septicaemia signs
Anuria = bilateral complete obstruction
Distended bladder

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28
Q

What are the possible differential diagnoses of hydronephrosis?

A
  • Renal cyst
  • Renal mass
  • AKI
  • Polycystic kidney disease
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29
Q

What investigations are necessary to diagnose hydronephrosis?

A
  • Ultrasound ➡️ swollen, fluid filled kidney
  • AXR - radiolucent stones
  • Cytoscopy
  • Bloods ➡️ U&Es (Na+/K+⬇️ after chronic obstruction), check urate, phosphate, calcium wtc if stones suspected
  • eGFR
  • PR looking for enlarged prostate, in enlarged maybe PSA
  • Blood cultures
  • Urinalysis**
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30
Q

How would you treat hydronephrosis?

A
  • fluid balance
  • Analgesics
  • Blockage removal ➡️ urethral/suprapubic catheter
    Stenting of ureter
  • Nephrostomy (incision in kidney- emergency)
  • Lithotripsy ➡️ using shockwaves to break up stones

*Most stones pass spontaneously

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31
Q

How common is AKI?

A
  • 18% of hospital pts

- 1% in community

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32
Q

Who does AKI affect?

A
  • Most common in elderly
  • ICU
  • CKD
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33
Q

What is acute kidney injury (AKI)?

A 
- creatinine rise >26 umol/L
OR
- creatinine 1.5 x baseline
OR
- urine output 6 consecutive hrs
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34
Q

What are the causes of AKI? (Pre renal, renal, post renal)

A

Pre- renal:

  • 40-70% of renal hypoperfusion (hypotension/sepsis/hypovolaemia)
  • renal artery stenosis
  • ACE inhibitors

Renal/Intrinsic:

  • tubular necrosis due to nephrotoxins, pre-renal damage, radiological contrast, crystal damage (Uris acid), myeloma, ⬆️Ca
  • glomerular- autoimmune (SLE), drugs, infection
  • interstitial - drugs
  • vascular- vasculitis, malignant hypertension, thrombus, cholesterol emboli

Post renal:
- 10-25% UT obstruction (stones, clots, sloughed papillae, malignancy, BPH, strictures, retroperitoneal fibrosis)

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35
Q

What are the risk factors for AKI?

A 
>75 years
CKD
Heart failure
Peripheral vascular disease
Chronic liver disease
Diabetes mellitus
Drugs
Sepsis
⬇️intake/⬆️loss
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36
Q

What are the symptoms of AKI?

A

Dysuria/oliguria
Nausea/vomiting
Dehydration
Confusion

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37
Q

What are the signs of AKI on examination?

A

⬆️creatinine >26umol/L in 48h
⬆️ creatinine >1.5xbaseline (best figure in 3/12)
Urine output 6h

Palpable bladder
Palpable kidneys (polycystic kidney disease)
Abdomen/pelvic mass
Renal bruits
Rashes (signs of vasculitis)
Hypertension
Fluid overload (raised JVP, pulmonary oedema, peripheral oedema)
Pericardial Rub
Crispy-clearly dehydrated, poor skin turgor

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38
Q

What are the possible differential diagnoses of AKI?

A

CKD

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39
Q

What are the necessary investigations to diagnose AKI?

A

Urine Dipstick

  • infection (leukocytes, nitrites)
  • glomerular disease (blood, protein)
  • MC&S

Bloods

  • U&Es, FBC, LFTs, clotting, CK, ESR, CRP
  • ABG for acid base assessment
  • blood cultures
  • blood film and renal immunology if systemic cause suspected

Imaging
- renal ultrasound (distinguish between obstruction/hydronephrosis, look for cysts/small kidneys/masses)
- chest X-Ray if fluid overload signs
-

40
Q

What are the treatments for AKI?

A

Stop nephrotoxic drugs ➡️ (NSAIDs/ACE inhibitors/gentamicin/amphotericin/metformin)

Fluids (avoiding potassium containing fluids)

Antibiotics for sepsis

Catheterise/stent

Dialysis

Renal replacement therapy ➡️ haemodialysis (intermittent and need to be haemodynamically stable) or haemofiltration (continuous, slower). Both require access through internal jugular line

41
Q

How common is chronic kidney injury (CKD)?

A

8.5% of population

42
Q

What is CKD?

A

Impaired renal function for longer than 3 months due to abnormal function/structure

OR

GFR 3 months with or without evidence of kidney damage

43
Q

What are the causes of CKD?

A 
Diabetes Mellitus
Glomerulonephritis
Hypertension or renal vascular disease
Pyelonephritis and reflux nephropathy
Rare (obstructive uropathy, chronic interstitial nephritis, polycystic kidney disease (inherited))
20% of cases unknown
44
Q

What are the risk factors for CKD?

A 
Recurrent UTIs
Systemic disorders (SLE) 
Family History of renal problems
Diabetes
Hypertension
Cardiovascular disease
Structural renal disease (stones)
Haematuria/proteinuria
45
Q

What are the symptoms of stage 4 CKD?

A

Uraemic symptoms - anorexia, vomiting, restless legs, fatigue, weakness, pruritus, bone pain

Women - amenorrhea
Men - impotence

Oliguria
Dyspnoea
Ankle swelling

46
Q

What are the signs of CKD on examination?

A 
Pallor
Yellow tinge to skin
Purpura
Excoriations
⬆️BP
Cardiomegaly
Fluid overload signs
Palpable kidneys
Severe - hyperkalaemia, arrhythmias, uraemia, encephalopathy, seizures, coma
47
Q

What are the possible differential diagnoses for CKD?

A

AKI

Acute on chronic CKD

48
Q

What investigations are necessary to diagnose CKD?

A 
Bloods:
Hb (normochromic, normocytic anaemia)
ESR, U&Es, ⬇️Ca, ⬆️Phosphates, ⬆️alkaline phosphatase (renal osteodystrophy)
⬆️PTH if stage 3+
Glucose (DM)

Urine - dipstick, MC&S, albumin, creatinine:protein ratio

imaging - ultrasound (check size, anatomy - usually small

49
Q

What are the treatments of CKD?

A

Limiting progression/complications:

  • reduce BP
  • cardiovascular - statins, aspirin
  • diet - moderated protein intake, K+ restriction if hyperkalaemic, avoid high phosphate foods
  • renal bone disease - treat PTH if raised, reduce phosphate in blood and diet, Calcium binds to phosphate and decreases absorption therefore Ca2+ supplements

Symptom control:

  • anaemia - iron/folate/b12 replacement, EPO
  • acidosis - sodium bicarbonate supplements but caution in hypertension
  • oedema - diuretics, fluid restriction
  • restless legs/cramps - ferritin levels checked

Renal replacement therapy

  • dialysis
  • transplant
50
Q

How common is Benign Prostatic Hypertrophy (BPH)?

A

Common
24% of 40-64 year olds
40% of >64 year olds

51
Q

Who does BPH affect?

A

Elderly men

52
Q

Pathogenesis of benign prostatic hypertrophy?

A

Benign nodular/diffuse proliferation of musculofibrous and glandular layers of prostate

Inner (transitional) zone enlarges instead of outer as in cancer

53
Q

What are the risk factors for Benign prostatic hypertrophy?

A

⬆️ age

Being male

54
Q

What are the symptoms of BPH?

A 
Lower Urinary Tract Symptoms:
Nocturia
Frequency
Urgency
Post- micrurition dribbling (post weeing)
Poor stream/flow
Hesitancy
Overflow incontinence
55
Q

What are the signs of BPH on examination?

A

Haematuria
Bladder stones
UTI

56
Q

What are the potential differential diagnoses of BPH?

A

Prostatic carcinoma

57
Q

What investigations are necessary to diagnose BPH?

A 
PR exam
Urine ➡️ MSU
Blood ➡️ U&Es, PSA (to rule out cancer)
Ultrasound
Biopsy
58
Q

What are the treatments for BPH?

A

LIFESTYLE:

  • no caffeine/alcohol (decreases urgency/nocturia)
  • relax when voiding/void twice

DRUGS:
- alpha blockers ➡️ Tamsulosin 400ug/d PO
(or alfuzosin/doxazosin/terazosin)
They decrease smooth muscle tone, but can cause side effects
- 5alpha-reductive inhibitors ➡️ finasteride 5mg/d PO
They decrease testosterone conversion to dihydrotestosterone, and are excreted in semen, can cause impotence and reduced libido

SURGERY:

  • transurethral resection
  • transurethral incision
  • retropubic prostatectomy
  • transurethral laser-induced prostatectomy
59
Q

How common is Prostate Carcinoma?

A

80% in >80 year olds

Most common male malignancy

60
Q

What causes Prostatic Carcinoma?

A

Adenocarcinoma of peripheral prostate ➡️ spread locally to seminal vesicles, bladder and rectum via lymph
Spreads to bone via the blood

61
Q

What are the risk factors of Prostate Carcinoma?

A

Family History increases risk by 2-3x
⬆️ testosterone
⬆️ age
Male

62
Q

What are the symptoms of Prostate Carcinoma?

A 
Asymptomatic
Nocturia
Hesitancy
Poor stream
Terminal dribbling
Obstruction
Weight loss
Bone pain (metastasis)
63
Q

What are the signs of Prostate Carcinoma on examination?

A

PR EXAM: hard irregular prostate

64
Q

What are the possible differential diagnoses of Prostate Carcinoma?

A

Benign prostatic Hypertrophy

Urartians tract obstruction

65
Q

What investigations are necessary to diagnose Prostate Carcinoma?

A 
PSA - increased (70% of cancers)
Transrectal ultrasound and biopsy
X-Ray 
Bone scan
CT/MRI ➡️ can use to stage the disease
66
Q

What is the prognosis of Prostate Carcinoma?

A

10% mortality in 6m

90% mortality in >10 years

67
Q

What are the treatment options for Prostate Carcinoma?

A 
PROSTATE ONLY:
Radical prostectomy
Radical radiotherapy 
Hormone therapy - delays tumour progression temporarily but refractory disease occurs, for elderly pts with increase risk disease
Active surveillance

METASTATIC DISEASE
Hormones- give benefits for 1-2years
➡️ LHRH agonists stimulate then inhibit pituitary gonadotrophin (risk tumour flares when first started)
➡️ anti-androgen to prevent flares

SYMPTOMATIC:
Analgesia
Hypercalcaemia treatment
Radiotherapy for bone mets/spinal cord compression

68
Q

How common is Bladder Carcinoma?

A

Transitional Cell Carcinoma is most common bladder cancer (>90%)

69
Q

Who does it affect?

A

Male:Female
5:2

70
Q

What are the risk factors for Bladder Carcinoma?

A 
Smoking
Aromatic Amines
Chronic Cystitis
Schistomiasis (⬆️ SCC)
Pelvic irradiation
71
Q

What are the symptoms of Bladder Carcinoma?

A

Painless haematuria

72
Q

What are the signs of Bladder Carcinoma on examination?

A

Recurrent UTI

Voiding irritability

73
Q

What investigations are necessary to diagnose Bladder Carcinoma?

A

Diagnostic Cytoscopy with biopsy
Urine microscopy and cytology
CT urogram = diagnostic and staging
Bimanual Exam Under Anaesthetic assesses spread
MRI Lymphangiography = pelvic node involvement

74
Q

What is the treatment for bladder carcinoma?

A

T(in situ)/Ta(confined to epithelium)/T1(in lamina propria) ➡️ 80% = transurethral Cytoscopy/resection of bladder + drug therapy = 95% 5yr survival

T2-3 (muscle involved) ➡️ radical cystectomy or radiotherapy and post op chemo

T4 (beyond bladder) ➡️ palliative chemo/radio and catheterisation

Follow up ➡️ 3monthly for 2years then 6monthly = high risk
➡️ 9montly then yearly = low risk

75
Q

How common is Renal Carcinoma?

A

90% of all renal cancers

76
Q

Who does Renal Carcinoma affect?

A

Mean age = 55years
Male:Female
2:1

77
Q

What are the causes of Renal Carcinoma?

A

From proximal renal tubular epithelium

15% of haemodialysis patients develop Renal Carcinoma?

78
Q

What are the risk factors for Renal Carcinoma?

A

Haemodialysis

79
Q

What are the symptoms of Renal Carcinoma?

A 
Haematuria
Anorexia
Loin Pain
Malaise
Weight loss
80
Q

What are the signs of Renal Carcinoma on examination?

A

Abdominal mass

81
Q

What investigations are necessary to diagnose Renal Carcinoma?

A

BP ➡️ increases due to increased renin
Blood tests ➡️ FBC (⬆️EPO), ESR, U&Es, ALP (bony mets)
Urine ➡️ blood cytology
Imaging ➡️ Utrasound, CT/MRI, Intravenous Urogram (filling defect +/- calcification) CXR (cannon ball mets)

82
Q

What is the prognosis of Renal Carcinoma?

A

10 year survival = 20%-96.5%

Depending on Mayo prognostic risk score (size, stage, grade, necrosis)

83
Q

What’s the treatment for Renal Carcinoma?

A 
Radical nephrectomy (RCC generally radio/chemo resistant)
Mets/Unresectable➡️ angiogenesis- targeting agents
84
Q

How common is Urinary Tract Stones (nephrolithiasis)?

A

Common

Lifetime incidence = 15%

85
Q

Who does Urinary Tract Stones affect?

A

20-40 year olds
Male:Female
3:1

86
Q

What are the causes of Urinary Tract Stones?

A

They are crystal aggregates ➡️ 75% calcium oxelate
➡️ Mg ammonium phosphate 15%
➡️ urate; hydroxyapatite; cysteine; mixed

Causes:
Diet 
Season
Dehydration
Drugs➡️ diuretics, aspirin, antacids, corticosteroids, Vit C&D
87
Q

What are the risk factors for Urinary Tract Stones?

A 
Recurrent UTIs
Metabolic abnormalities (increased crystals in blood/urine 
Urinary tract abnormalities
Foreign bodies (stents, catheters)
Family history
88
Q

What are the symptoms of Urinary Tract Stones?

A

Asymptomatic

Renal colic - severe pain loin to groin
- nausea vomiting, can’t lie still
Renal obstruction - loin pain; worse on movement/pressure
Mid-ureter obstruction - mimics appendicitis/diverticulitis
Lower ureter obstruction - bladder irritability; scrotal/penile/labia majora pain
Bladder/Urethra obstruction - pelvic pain, dysuria, inability to void; interrupted flow

89
Q

What are the signs of Urinary tract stones on examination?

A 
UTI
Pyelonephritis
Pyonephritis
Haematuria
Proteinuria
Sterile pyuria
Anuria
90
Q

What investigations are necessary to diagnose Urinary tract stones?

A

Bloods
Urine Dip - 90% haematuria
MSU - MC&S
Imaging

91
Q

What is the treatment for Urinary tract stones?

A 
Analgesia
Fluids
Antibiotics
Small stones pass spontaneously
Bigger stones:
Extracorporeal shockwave lithotripsy
Uteroscopy
Keyhole surgery to remove stones
92
Q

How common is UTI?

A

1-3% GP appointments
~50% women have 1 in their lifetime
20-30% have recurrence

93
Q

When is hospital admission required in pyelonephritis ?

A
  • pregnant
  • comorbidities
  • severe symptoms
  • sepsis
  • obstruction
  • obstruction
94
Q

Management of chronic pyelonephritis

A
  • ACEi to control BP
  • Abx prophylaxis
  • renal transplant if causing failure
95
Q

What is the function of aldosterone ?

A

Causes the tubules of the kidneys to increase reabsorption of sodium and water, therefore increasing extracellular fluid, and hence an increase in blood pressure

96
Q

What does angiotensin II do ?

A

Causes blood vessels to constrict, hence increasing blood pressure

97
Q

Causes of CKD?

A
  • diabetes
  • glomerulonephritis
  • unknown
  • hypertension/renovascular disease
  • pyelonephritis / reflux nephropathy

Core Conditions (15 decks)

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