Renal Flashcards
1
Q
Who does UTI affect?
A
Young, sexually active women
Menopausal women
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
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)
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
5
Q
What are the symptoms of an Upper UTI?
A
Acute pyelonephritis ➡️
High fever, rigours, vomiting, loin pain/tenderness, oliguria (AKI)
6
Q
What are the signs of a UTI on examination?
A
Fever Abdomen/loin tenderness Foul smelling urine Distended bladder Enlarged prostate
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
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
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
10
Q
How common is pyelonephritis?
A
Prevalence: 4 in 100,000 asymptomatic adults
11
Q
Who is pyelonephritis most likely to present in?
A
Most common in young women
>65 men and women equal
12
Q
What is pyelonephritis?
A
Pyelonephritis is an upper UTI that causes inflammation of the renal pelvis
caused by infections.
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
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
15
Q
What are the chronic risk factors for pyelonephritis?
A
Renal tract abnormalities/obstruction/calculi
Children➡️ vesicourethral reflux
Neonates➡️ intrarenal reflux
Recurrent UTI
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
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
18
Q
What are the possible differential diagnoses of pyelonephritis?
A
- interstitial cystitis
- PID
- appendicitis
- ectopic pregnancy
- urethritis
- STIs
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)
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
21
Q
How common is hydronephrosis?
A
Unilateral - 1/300 people in UK per year
Bilateral -1/600 people in UK per year
22
Q
Who does hydronephrosis affect?
A
Men and women at any age
Congenital causes common
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
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
25
What are the risk factors of hydronephrosis?
- Pregnancy
- Cancer of cervix, prostate, ovaries
- Previous calculi/obstruction
26
What are the symptoms of hydronephrosis?
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
27
What are the signs of hydronephrosis on examination?
Enlarged kidney-tender on palpation
Septicaemia signs
Anuria = bilateral complete obstruction
Distended bladder
28
What are the possible differential diagnoses of hydronephrosis?
- Renal cyst
- Renal mass
- AKI
- Polycystic kidney disease
29
What investigations are necessary to diagnose hydronephrosis?
- 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**
30
How would you treat hydronephrosis?
- 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
31
How common is AKI?
- 18% of hospital pts
| - 1% in community
32
Who does AKI affect?
- Most common in elderly
- ICU
- CKD
33
What is acute kidney injury (AKI)?
```
- creatinine rise >26 umol/L
OR
- creatinine 1.5 x baseline
OR
- urine output 6 consecutive hrs
```
34
What are the causes of AKI? (Pre renal, renal, post renal)
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)
35
What are the risk factors for AKI?
```
>75 years
CKD
Heart failure
Peripheral vascular disease
Chronic liver disease
Diabetes mellitus
Drugs
Sepsis
⬇️intake/⬆️loss
```
36
What are the symptoms of AKI?
Dysuria/oliguria
Nausea/vomiting
Dehydration
Confusion
37
What are the signs of AKI on examination?
⬆️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
38
What are the possible differential diagnoses of AKI?
CKD
39
What are the necessary investigations to diagnose AKI?
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
What are the treatments for AKI?
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
How common is chronic kidney injury (CKD)?
8.5% of population
42
What is CKD?
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
What are the causes of CKD?
```
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
What are the risk factors for CKD?
```
Recurrent UTIs
Systemic disorders (SLE)
Family History of renal problems
Diabetes
Hypertension
Cardiovascular disease
Structural renal disease (stones)
Haematuria/proteinuria
```
45
What are the symptoms of stage 4 CKD?
Uraemic symptoms - anorexia, vomiting, restless legs, fatigue, weakness, pruritus, bone pain
Women - amenorrhea
Men - impotence
Oliguria
Dyspnoea
Ankle swelling
46
What are the signs of CKD on examination?
```
Pallor
Yellow tinge to skin
Purpura
Excoriations
⬆️BP
Cardiomegaly
Fluid overload signs
Palpable kidneys
Severe - hyperkalaemia, arrhythmias, uraemia, encephalopathy, seizures, coma
```
47
What are the possible differential diagnoses for CKD?
AKI
| Acute on chronic CKD
48
What investigations are necessary to diagnose CKD?
```
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
What are the treatments of CKD?
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
How common is Benign Prostatic Hypertrophy (BPH)?
Common
24% of 40-64 year olds
40% of >64 year olds
51
Who does BPH affect?
Elderly men
52
Pathogenesis of benign prostatic hypertrophy?
Benign nodular/diffuse proliferation of musculofibrous and glandular layers of prostate
Inner (transitional) zone enlarges instead of outer as in cancer
53
What are the risk factors for Benign prostatic hypertrophy?
⬆️ age
| Being male
54
What are the symptoms of BPH?
```
Lower Urinary Tract Symptoms:
Nocturia
Frequency
Urgency
Post- micrurition dribbling (post weeing)
Poor stream/flow
Hesitancy
Overflow incontinence
```
55
What are the signs of BPH on examination?
Haematuria
Bladder stones
UTI
56
What are the potential differential diagnoses of BPH?
Prostatic carcinoma
57
What investigations are necessary to diagnose BPH?
```
PR exam
Urine ➡️ MSU
Blood ➡️ U&Es, PSA (to rule out cancer)
Ultrasound
Biopsy
```
58
What are the treatments for BPH?
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
How common is Prostate Carcinoma?
80% in >80 year olds
| Most common male malignancy
60
What causes Prostatic Carcinoma?
Adenocarcinoma of peripheral prostate ➡️ spread locally to seminal vesicles, bladder and rectum via lymph
Spreads to bone via the blood
61
What are the risk factors of Prostate Carcinoma?
Family History increases risk by 2-3x
⬆️ testosterone
⬆️ age
Male
62
What are the symptoms of Prostate Carcinoma?
```
Asymptomatic
Nocturia
Hesitancy
Poor stream
Terminal dribbling
Obstruction
Weight loss
Bone pain (metastasis)
```
63
What are the signs of Prostate Carcinoma on examination?
PR EXAM: hard irregular prostate
64
What are the possible differential diagnoses of Prostate Carcinoma?
Benign prostatic Hypertrophy
| Urartians tract obstruction
65
What investigations are necessary to diagnose Prostate Carcinoma?
```
PSA - increased (70% of cancers)
Transrectal ultrasound and biopsy
X-Ray
Bone scan
CT/MRI ➡️ can use to stage the disease
```
66
What is the prognosis of Prostate Carcinoma?
10% mortality in 6m
| 90% mortality in >10 years
67
What are the treatment options for Prostate Carcinoma?
```
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
How common is Bladder Carcinoma?
Transitional Cell Carcinoma is most common bladder cancer (>90%)
69
Who does it affect?
Male:Female
5:2
70
What are the risk factors for Bladder Carcinoma?
```
Smoking
Aromatic Amines
Chronic Cystitis
Schistomiasis (⬆️ SCC)
Pelvic irradiation
```
71
What are the symptoms of Bladder Carcinoma?
Painless haematuria
72
What are the signs of Bladder Carcinoma on examination?
Recurrent UTI
| Voiding irritability
73
What investigations are necessary to diagnose Bladder Carcinoma?
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
What is the treatment for bladder carcinoma?
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
How common is Renal Carcinoma?
90% of all renal cancers
76
Who does Renal Carcinoma affect?
Mean age = 55years
Male:Female
2:1
77
What are the causes of Renal Carcinoma?
From proximal renal tubular epithelium
| 15% of haemodialysis patients develop Renal Carcinoma?
78
What are the risk factors for Renal Carcinoma?
Haemodialysis
79
What are the symptoms of Renal Carcinoma?
```
Haematuria
Anorexia
Loin Pain
Malaise
Weight loss
```
80
What are the signs of Renal Carcinoma on examination?
Abdominal mass
81
What investigations are necessary to diagnose Renal Carcinoma?
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
What is the prognosis of Renal Carcinoma?
10 year survival = 20%-96.5%
| Depending on Mayo prognostic risk score (size, stage, grade, necrosis)
83
What's the treatment for Renal Carcinoma?
```
Radical nephrectomy (RCC generally radio/chemo resistant)
Mets/Unresectable➡️ angiogenesis- targeting agents
```
84
How common is Urinary Tract Stones (nephrolithiasis)?
Common
| Lifetime incidence = 15%
85
Who does Urinary Tract Stones affect?
20-40 year olds
Male:Female
3:1
86
What are the causes of Urinary Tract Stones?
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
What are the risk factors for Urinary Tract Stones?
```
Recurrent UTIs
Metabolic abnormalities (increased crystals in blood/urine
Urinary tract abnormalities
Foreign bodies (stents, catheters)
Family history
```
88
What are the symptoms of Urinary Tract Stones?
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
What are the signs of Urinary tract stones on examination?
```
UTI
Pyelonephritis
Pyonephritis
Haematuria
Proteinuria
Sterile pyuria
Anuria
```
90
What investigations are necessary to diagnose Urinary tract stones?
Bloods
Urine Dip - 90% haematuria
MSU - MC&S
Imaging
91
What is the treatment for Urinary tract stones?
```
Analgesia
Fluids
Antibiotics
Small stones pass spontaneously
Bigger stones:
Extracorporeal shockwave lithotripsy
Uteroscopy
Keyhole surgery to remove stones
```
92
How common is UTI?
1-3% GP appointments
~50% women have 1 in their lifetime
20-30% have recurrence
93
When is hospital admission required in pyelonephritis ?
- pregnant
- comorbidities
- severe symptoms
- sepsis
- obstruction
- obstruction
94
Management of chronic pyelonephritis
- ACEi to control BP
- Abx prophylaxis
- renal transplant if causing failure
95
What is the function of aldosterone ?
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
What does angiotensin II do ?
Causes blood vessels to constrict, hence increasing blood pressure
97
Causes of CKD?
- diabetes
- glomerulonephritis
- unknown
- hypertension/renovascular disease
- pyelonephritis / reflux nephropathy
