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Renal Flashcards

1
Q

What are the key homeostatic functions of the kidney?

A

Regulation of BP, fluid and electrolyte balance
Acid base homeostasis
Removal of drugs and toxins
Waste elimination

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2
Q

At what point in an AKI are the homeostatic functions of the kidney disturbed?

A

Early in AKI

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3
Q

At what point in CKD are the homeostatic functions of the kidney disturbed?

A

Late in CKD

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4
Q

What are the endocrine functions of the kidney?

A 
EPO synthesis
Renin synthesis
Gluconeogenesis
Degradation of peptide hormones
Hydroxylation of Vitamin D
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5
Q

What are the pre-renal causes of AKi?

A
  1. Hypovolamia (hypotension, haemorrhage, trauma, surgery, GI bleed)
  2. Sepsis (vasodilation)
  3. Renal artery stenosis
  4. Heart failure
  5. Drugs which affect BP eg NSAIDs
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6
Q

What is the most common cause of AKI?

A

Pre-renal: Usually hypovolaemia

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7
Q

Which drugs should be avoided in renal impairment?

A 
Metronidazole
Aminoglycosides (Gentamycin)
NSAIDs
Potassium sparing diuretics
Lithium
Nitrofurantoin
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8
Q

What are the renal causes of AKI?

A
  1. Infection/ inflammation: pyelonephritis.glomerulonephritis
  2. Trauma
  3. Ischemia
  4. Drug toxicity eg. Gentamicin, NSAIDs
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9
Q

What are the post renal causes of AKI?

A
  1. BPH
  2. Renal stones
  3. Cancer
  4. Fibrosis
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10
Q

How many stages of AKI are there?

A

3

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11
Q

What measurements are used to diagnose AKI?

A

Serum creatinine
Urine output
eGFR

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12
Q

What is Stage 1 AKI?

A

Serum creatinine 1.5-2 x baseline or increase in 26umol/l in 48 hours

Urine output <0.5ml/kg/hr for 6-12 hours

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13
Q

What is Stage 2 AKI?

A

Serum creatinine 2-3x baseline

Urine output <0.5 for >12 hours

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14
Q

What is Stage 3 AKI?

A

Serum creatinine >3x baseline

Urine output <0.3 for >24 hours or ANURIA

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15
Q

Compare the following for pre-renal vs renal AKI:

  • Urine output
  • Urine Na+
  • Serum Na+
  • Serum urea vs creatinine
A

PRE-RENAL:
Urine output LOW, Urine Na LOW
Serum Na HIGH, Serum Urea>Creatinine

RENAL:
Urine output initially HIGH, Urine Na HIGH
Serum Na LOW, Serum Urea=Creatinine

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16
Q

How should pre-renal AKI be treated in general?

A

FLUIDS

As renal perfusion and urine output is LOW

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17
Q

How should renal AKI not be treated in general?

A

DO NOT GIVE FLUIDS

Kidneys can’t concentrate urine, Na is lost in urine

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18
Q

In intrinsic causes of AKI what electrolyte disturbances are seen?

A

Loss of Na in urine, so Hyponatraemia
Hyperkalaemia

Leads to metabolic acidosis

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19
Q

How should AKI be managed?

A
  1. Determine cause (drugs? volume loss? infection?)
  2. Stop or avoid nephrotoxic drugs (NSAIDs, ACE/ARBS)
  3. Restore renal perfusion in pre-renal AKI
  4. Correct electrolyte disturbances
  5. If life threatening intrinsic AKI, may need haemofiltration or dialysis
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20
Q

What will the serum and urine sodium levels be in PRE-RENAL AKI?

A

Serum sodium HIGH

Urine sodium LOW (<15)

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21
Q

What will the serum and urine sodium levels be in RENAL AKI?

A

Serum sodium LOW

Urine sodium HIGH (>40)

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22
Q

What are the causes of CKD? (chronic kidney damage over >3 months, causing gradual irreversible changes in renal function)

A 
Hypertension
Atherosclerosis
Diabetes
Polycystic kidney disease
Long term NSAID use
Recurrent pyelonephritis/ glomerulonephritis
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23
Q

What symptoms/signs may a patient with CKD have?

A 
Swollen ankles
SOB
Tiredness
Nausea
Haematuria
Bleeding tendency
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24
Q

Which waste products will accumulate in the blood of CKD patients?

A

Urea
Creatinine
Phosphate

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25
Q

What tests are used to monitor CKD?

A

eGFR
Creatinine for end stage
Albumin:creatinine ratio to look for protein leakage

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26
Q

How many stages of CKD are there?

A

1,2,3a,3b,4,5

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27
Q

What is the eGFR in stage 1 CKD?

A

> 90

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28
Q

What is the eGFR in stage 2 CKD?

A

60-90

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29
Q

What is the eGFR in stage 3a CKD?

A

45-60

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30
Q

What is the eGFR in stage 3b CKD?

A

30-45

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31
Q

What is the eGFR in stage 4 CKD?

A

15-30

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32
Q

What is the eGFR in stage 5 CKD?

A

<15

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33
Q

How are serum potassium and calcium levels affected in CKD?

A

K+ increases leading to metabolic acidosis

Ca2+ decreases leading to secondary hyperparathyroidism

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34
Q

What are the biochemical changes in Stage 3-4 CKD?

A

Raised serum creatinine, raised albumin:creatinine ratio
Raised cholesterol and trigylceride
Decrease eGFR
Hypocalcaemia (leading to secondary hyperparathyroidism)

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35
Q

What are the biochemical changes in Stage 4-5 CKD?

A

Raised serum creatinine and urea
Raised serum phosphate
Hyperkalaemia

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36
Q

Which treatments do patients with stage 3b-4 CKD require?

A

EPO injections
Calcidiol
Phosphate binders (reduces risk of metastatic calcification)
Bicarbonate (corrects acid-bas disturbances)

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37
Q

Which treatments do patients with stage 5 CKD require?

A

Dialysis

Transplant

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38
Q

How would GLOMERULAR damage affect urine output in CKD?

A

Low urine output (oliguria)

Due to little glomerular filtrate

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39
Q

How would TUBULAR damage affect urine output in CKD?

A

High urine output (polyuria)

Due to poor reabsorption

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40
Q

What is renal bone disease?

A
  1. Increased bone reabsorption
  2. Osteitis fibrosa
  3. Metastatic calcification (arteries, skin)
  4. Oesteoporosis
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41
Q

What management do patients with Stage 2-3a CKD require?

A

Management in GP
Monitoring of eGFR, bone profile, PTH
Treat cause (HTN, diabetes)
Drugs eg. statins, antihypertensives

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42
Q

What are renal tubular disorders?

A

Defects in transporting glucose, AAs, phopshate etc.

Cause electrolyte disturbances but do NOT cause renal failure

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43
Q

What are TYPE 1 renal tubular disorders?

A

Defect in the DCT; failure to excrete H+ ions and acidify urine.
Leads to acidosis, kidney stones.

44
Q

What are TYPE 2 renal tubular disorders?

A

Defect in PCT (Eg. Part of Fanconi syndrome)

Leads to alkalosis

45
Q

What is a NON-RENAL cause of increased serum creatinine?

A

Muscle breakdown

46
Q

What is a NON-RENAL cause of decreased serum creatinine?

A

Low muscle mass eg. Duchenne muscular dystrophy

47
Q

What is a NON-RENAL cause of increased serum urea?

A

Raised protein load eg. upper GI bleed

48
Q

What is a NON-RENAL cause of decreased serum urea?

A

Low protein load eg. malnutrition, anorexia

49
Q

What are the 7 steps to diagnosis in urology?

A
  1. History
  2. Examination
  3. Basic Investigations
  4. Specialist investigations
  5. Imaging
  6. Endoscopy
  7. Biopsy
50
Q

What are examples of Irritative/storage LUTS?

A
  1. Increased daytime freq (>7)
  2. Increased nighttime freq (>1)
  3. Urgency
  4. Incontinence
51
Q

What are examples of obstructive/ voiding LUTS?

A
  1. Hesitancy
  2. Poor stream
  3. Terminal dribbling
  4. Post micturition dribbling
52
Q

What is sensory urgency?

A

Frequent urination due to a bladder issue eg. cystitis

53
Q

What is motor urgency?

A

Sudden urgency to urinate due to a nervous influence eg. Caffeine, MS

54
Q

What are the different types of incontinence?

A
  1. Stress - weakness of pelvis floor muscles when coughing etc. Does not happen in men unless they have had prostatic surgery
  2. Urge - due to detrusor overactivity eg. in stroke, alzheimer’s parkinsons
  3. Overflow - due to retention eg. in BPH
  4. Anatomical - incontinence due to a sphincter injury or congenital issue
55
Q

What happens to the detrusor muscle and sphincter during the storage stage of the micturition cycle?

A

Detrusor muscle is relaxed

Sphincter is contracted

56
Q

What happens to the detrusor muscle and sphincter during the voiding stage of the micturition cycle?

A

Detrusor muscle contracted

Sphincter relaxed

57
Q

Which nerves control the detrusor muscle?

A

Pelvic nerve (parasympathetic)

58
Q

Which nerves control the urethral sphincter?

A 
Pudendal nerve (voluntary)
Hypogastric nerve (sympathetic)
59
Q

What is a normal urine flow rate?

A

> 15mls/second

60
Q

What is an obstructed urine flow rate?

A

<10mls/second

61
Q

How can LUTS be managed? (conservative, medical, surgical)

A
  1. Conservative
  2. Medical
    Alpha blockers (eg. Terazosin, Doxazosin) relax the ureter/ prostate
    5 alpha reductase inhibitors-Finasterise Dutaseride
    Anticholinergics
  3. Surgical- TURP, laser prostatectomy
62
Q

What is the % chance a uroepithelial cancer is present if a patient has visible haematuria?

A

25%

Need a CT urogram

63
Q

What is the % chance a uroepithelial cancer is present if a patient has non-visible haematuria?

A

<5%

If symptomatic; need CT urogram
If non symptomatic; need USS and KUB Xray

64
Q

Why might a PSA value be high?

A

BPH
Prostatitis
Prostate cancer
Sports injury eg. cycling

65
Q

What is acute urine retention?

A

Short term painful retention, residual volume <1000mls, relief on catheterisation

66
Q

What is chronic urine retention?

A

Chronic painless retention, residual volume >1000mls

67
Q

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

A

Assessing severity of symptoms in BPH

Score <7 is mild
Score >20 is severe

68
Q

What are the risk factors for renal cancer?

A 
Men
Genetics
Smoking
Obesity
Hypertension
CKD
69
Q

What are the different types of renal cancer?

A
  1. Clear cell carcinoma (most common)
  2. Papillary carcinoma
  3. Chromophobe cell carcinoma
  4. Collecting duct carcinoma (rare and aggressive)
  5. Unclassified RCC
  6. Transitional cell carncinoma (kidney and ureter junction)
  7. Renal sarcoma
  8. Neuroblastoma (Wilm’s tumour)
70
Q

What are the types of benign renal tumour?

A

Oncocytoma

Adenoma

71
Q

What are the signs and symptoms of renal cancer?

A 
Haematuria
Lower back pain
Abdominal mass
Fatigue
Weight loss
Fever
72
Q

How can renal cancer be diagnosed?

A

USS

CT or MRI

73
Q

How can renal cancer be treated?

A

Radical or partial nephrectomy

Radical= whole kidney, adrenal gland and ureter

74
Q

What are the potential causes of haematuria?

A 
UTI
Trauma
Kidney stones
Cancer- renal/bladder
Drugs eg. Cyclophosphamide
Obstruction
75
Q

What should urine cytology normally appear like?

A

Few cells
Squamous cells = skin contamination
Urothelial cells= round and lots of cytoplasm

76
Q

Which cells should not be seen on normal urine cytology?

A

Polylobar neutrophils- with large irregular nuclei

77
Q

What are the main types of bladder cancer?

A
  1. Urothelial/ transitional cell (90%)
  2. Squamous cell (5-10%) usually invasive. More common if schistomiasis is widespread
  3. Adenocarcinoma (1-2%) rare
78
Q

How is bladder cancer diagnosed?

A

Urine cytology
Cystoscopy
IV Pyelogram

79
Q

How is bladder cancer treated?

A 
Intravesicular BCG/ Mitomycin C
Transurethral resection of bladder tumour (TURBT)
Cystectomy 
Radiotherapy
Chemotherapy
80
Q

What is the main type of prostate cancer?

A

Acinar adenocarcinoma (peripheral zone)

81
Q

Compare a focal vs diffuse glomerular lesion?

A

Focal- <50% all glomerular involved

Diffuse- >50% all glomerular involved

82
Q

Compare a segmental vs global glomerular lesion?

A

Segmental <50% of individual glomerular involved

Global >50% individual glomerular involved

83
Q

Nephrotic syndrome is a triad of ___________

A
  1. Proteinuria
  2. Hypoalbuminaemia
  3. Oedema
84
Q

What are the main types of nephrItic glomerulonephritis?

A
  1. Post infection

2. Necrotising/ Crescenteric eg. Anti GBM, Immune Complex Mediated (eg. IgA nephropathy), ANCA asssociated.

85
Q

What are the main types of nephrOtic glomerulonephritis?

A
  1. Minimal change disease
  2. Membranous nephropathy
  3. FSGS Focal segmental glomerulosclerosis
86
Q

What is the commonest cause of end stage renal failure?

A

Diabetic nephropathy

87
Q

Which systemic disease leading to renal disease is diagnosed by a Congo red stain on biopsy?

A

Amyloidosis

88
Q

How does minimal change disease (nephrotic syndrome) appear on light and electron microscope?

A

Light microscope- normal glomeruli

EM- Fusion of podocyte foot processes

89
Q

Does minimal change disease respond to steroids?

90
Q

Does Focal segmental glomerulosclerosis respond to steroids?

A

No- poor response

91
Q

Which type of nephrotic syndrome has spikes on silver stain?

A

Membranous nephropathy

92
Q

Which type of nephrotic syndrome is usually idiopathic with Anti PLA2R?

A

Membranous nephropathy

93
Q

Which type of nephrotic syndrome is due to abnormal podocytes eg. the APOL1 gene?

94
Q

Fanconi syndrome usually affects which part of the renal tubule?

95
Q

Which diuretics work on the PCT?

A

Osmotic diuretics eg. Mannitol

Carbonic anhydrase inhibitors eg. Acetazolamide

96
Q

Which diuretics work on the DCT?

A

Thiazide diuretics eg. Bendroflumethiazide

Thiazide like diuretics eg. Indapamide

97
Q

Which diuretics work on the collecting duct?

A

Potassium sparing eg. Spironalactone

98
Q

What is nephritic syndrome?

A

Pathology of the glomerulus involving haematuria due to inflammation.

99
Q

What is pyelonephritis?

A

Kidney infection, which is usually bacterial due to an ascending UTI.

100
Q

Which area of the prostate is affected in BPH?

A

Transitional zone (inner)

101
Q

Which drugs can be used in BPH?

A
  1. Alpha blockers eg. Doxazosin, Tamsulosin- decrease smooth muscle tone
  2. 5aplha reductase inhibitors eg. Finasteride- decrease conversion of testosterone to Dihydrotestosteron
102
Q

What are the side effects of alpha blockers used for BPH?

A 
Drowsiness
Depression
Hypotension
Dry mouth
Extra pyramidal signs
Ejaculatory failure
103
Q

How is gonorrhoea treated?

A

Amoxicillin

Clarithromycin

104
Q

How is chlamydia treated?

A

Azithromycin

Doxycycline

105
Q

How is pyelonephritis treated?

A

Coamoxiclav
Clarithromycin
Gentamicin

Year 3 (22 decks)

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