Renal Flashcards
Features of renal failure
Inability to remove metabolic waste –> Uraemia
Inability to control acid-base –> Metabolic acidosis, Hyperkalaemia
Inability to control Na+ and fluid –> Oedema, SOB
Loss of Erythropoietin and activated Vit D –> Anaemia, Osteomalacia
Drugs which cause ATN
Paracetamol
Aminoglycosides
Contrast
NSAIDs
ACE inhibitors
Lithium
Myoglobin (Rhabdomyolysis)
Drugs which cause AIN
NSAIDS
Penicillin
Sulphonamides
Phenytoin
Definition of Oliguria
Oliguria = urine output < 0.5ml/kg/hr
Muddy brown urinary casts
Diagnosis?
Acute Tubular Necrosis
Red cell casts in urine
Diagnosis?
Nephritic syndrome
Tx of Hyperkalaemia
10ml 10% IV Calcium gluconate
100ml 20% IV Dextrose with 10 units of Actrapid (over 30min)
Nebulised salbutamol 10-20mg
+/- Calcium resonium
+/- Dialysis
Treatment of AKI
Fluid balanace assessment
Stop nephrotoxic drugs (ACEi, NSAIDs, K+ sparing diuretics)
Treat compilcations (Hyperkalaemia, Met Acidosis, Pulmonary oedema)
Treat underlying cause
-
Pre-renal failure or Intrinsic renal failiure
- If volume depleted –> IV Fluids
- If volume overload –> Furosemide +/- RRT (haemodialysis)
-
Post-renal failure
- Urinary catherisation
- Remove obstruction
Causes of renal failure
Pre-renal failure (hypovolaemia)
- Hypovolaemia (blood loss, shock, 3rd spacing)
- Heart failure (cardiogenic shock)
Intrinsic renal failure
- Acute Tubular Necrosis (ATN)
- Acute Interstitial Nephritis (AIN)
- Acute glomerulonephritis
- Vasculitis
Post-renal failure (obstruction)
- Renal calculi
- BPH
- Tumour
- Ascending UTI
Fall
Dark urine (coca cola urine / tea coloured)
Blood +++ (but no RBC on microscopy)
Microscopy: Muddy brown casts
Hyperkalaemia
Raised CK
Rhabdomyolysis
Blood ++ is Myoglobulin ++
Rash
Arthralgia
Eosinophilia
Raised Creatinine and Urea
Diagnosis?
Acute interstitial nephritis
Indications for RRT
Acute (Tip: AEIOU)
- Acidosis (pH < 7.2)
- Electrolytes (persistent K > 7.0)
- Intoxication
- Overload of fluid (refractory to treatment)
- Uremic pericarditis / encephalopathy
Chronic
- CKD Stage 5
Stages of CKD
Causes of CKD
Tx of CKD
Conservative
- Diet (low K+ diet)
-
Modify cardiovascular risk factors
- Diet and Exercise
- Smoking cessation
- Weight loss
Medical
- Anti-hypertensives
- +/- Statin
- +/- Low-dose aspirin
- Optimise Diabetes control
- Treat compilcations
- Anaemia –> Iron or Erythropoietin
- Fluid overload –> Fluid restriction +/- Furosemide
- Secondary hyperPTH –> Vitamin D +/- Bisphosphonates
Surgical
- RRT (Haemodialysis, Peritoneal dialysis, Renal transplant)
Flank pain
UTI symptoms
Haematuria
Early-onset Hypertension
Hepatomegaly
Palpable enlarged kidneys
Diagnosis? Treatment?
Polycystic kidney disease
Autosomal dominant (most commonly) ==> ADPKD
Tx:
- Anti-hypertensives
- Cyst aspiration
- Manage CKD
- 50% progress to CKD
- ADPKD accounts for 10% of CKD Stage 5
Presentation of glomerulonephritis
Asymptomatic haematuria
Nephrotic syndrome
Nephritic syndrome
Definitions
Glomerulonephritis
Nephrotic syndrome
Nephritis syndrome
Glomerulonephritis = immune complex formation or deposition in glomeruli –> inflammation
Nephrotic syndrome = proteinuria, hypoalbuminaemia, oedema
Nephritis syndrome = proteinuria + haematuria, oedema
Anti-phospholipase 2A antibodies
Membranous nephropathy
Glomerulonephritis and Hepatitis C
Membranoproliferative glomerulonephritis (MPGN)
Types of Rapidly progressive GN (Cresecentic GN)
Type 1
- Goodpastures (Anti-GBM)
Types 2 (immune complex deposition)
- IgA
- HSP
- SLE
Type 3 (Pauci-immune / ANCA +ve) ==> Nephritic syndrome
- Wegner’s
- Charg-Strauss
- Microscopic polyangiitiis
IgA nephropathy vs Post-streptococcal glomerulonephritis
IgA nephropathy = post-strep 2-3 days
Short “IgA” ==> Days
Post-streptococcal glomerulonephritis = post-strep 2-3 weeks
Longer word ==> Weeks
Features of HSP
Tetrad (PAAG)
-
Palpable purpuric rash
- On buttocks and extensor surfaces of arms and legs
- Arthralgia / Arthritis
- Abdominal pain
- Glomerulonephritis
Most common cause of asymptomatic haematuria
Thin basement membrane
Glomerulonephritis
Haemoptysis
Goodpasture’s syndrome
Anti-GBM antibodies
(against Type IV Collagen in kidneys and lungs)
Causes of nephrotic syndrome
Primary
- Glomerulonephritis (all types)
Secondary
- Diabetic nephropathy (most common)
- Deposition of immune complexes
- SLE
- Hepatitis B and C
- Amyloidosis
Tx of nephrotic syndrome
Fluid restriction +/- Furosemide
Proteinuria ==> ACE inhibitor
Lipids ==> Statin
VTE ==> TED stockings + LMWH
Treat underlying cause
Causes of Nephritic syndrome
Primary
- Glomerulonephritis
- IgA nephropathy (most common)
- Membranoproliferative glomerulonephritis
Secondary
- Glomerulonephritis
- Post-streptococcal glomerulonephritis
- Goodpasture’s
- Vasculitis
Definition of urinary retention on Bladder USS
Bladder volume > 300ml indicates urinary retention
Tx of renal stones
Most common locations for stones
Pelvic-ureteric junction (PUJ)
Vesico-ureteric junction (VUJ)
Sacroiliac joint
Types of renal calculi
Calcium (80%) - Calcium oxalate, Calcium phosphate
Uric acid
Magnesium ammonium phosphate
Cystine stones
Ix for renal calculi
CT KUB (non-contrast)
Definition of UTI
Urine culture grows
> 100,000 colony-forming units (CFU) / mL
of a single organism
LUTS symptoms
Storage symptoms (FUN)
– Frequency / Polyuria
– Urgency
– Nocturia
If underlying obstructive cause –> Emptying symptoms (WISE)
– Weak stream / Hesitancy
– Intermittent flow / Incontinence
– Straining to urinate
– Incomplete Emptying
Tx of UTI
(1) Nitrofurantoin
(2) Trimethoprim
In pregnancy
(1) Nitrofurantoin (avoid at term)
(2) Amoxicillin
Tx of overactive bladder
(1) Anti-muscarinic drugs (Oxybutynin, Tolterodine)
(2) Mirabegron
(3) Duloxetine
Causes of renal artery stenosis
Atherosclerosis (90%) - older patients
Fibromuscular dysplasia (10%) - young patients
Ix for Renal artery stenosis
Digital subtraction angiography
Tx for renal artery stenosis
Conservative –> Modify cardiovascular risk factors
Medical –> Anti-hypertensives (but avoid ACEi in bilateral RAS)
Surgical
- Renal artery stenting
- Renal artery balloon angioplasty
- Surgical revascularisation (aortorenal bypass)
Type 1-4 Renal tubular acidosis
Type 1 = excess H+ reabsorption in DCT
- Hypokalaemic, metabolic acidosis
Type 2 = low HCO3- reabsorption in PCT
- Hypokalaemic, metabolic acidosis
Type 3 = Type 1 + Type 2
Type 4 = Low Aldosterone
- Hyperkalaemia, metabolic acidosis
Tx of BPH
Mild BPH (IPSS 0-7)
- Urinary catherisation (self or long-term)
Moderate-to-Severe BPH (IPSS 8-35)
-
alpha-blocker (Tamsulosin, Doxazosin)
- Relaxes smooth muscle tone
- Requires dose titration
-
5a-reductase inhibitor (Finasteride)
- Decrease in prostate size
- Requires 3-6 months before improvement
- Phosphodiesterase-5 inhibitor (Sildenafil)
- Anti-cholinergic (oxybutynin)
Refractory to medical Tx
- If prostate < 80g
- Minimally invasive therapy (TUMT, TUNA, PUL)
- Moderatively invasive thearpy (TURP, TUVP, Laser)
- If prostate > 80g
- Laser enucleation (HoLEP, ThuLEP)
- Open prostatectomy
LUTS
Perineal pain
Fever
Painful ejaculation
(VERY) Tender, boggy prostate
Diagnosis? Treatment?
Prostatitis
Treated with Antibiotics + Analgesia
+/- Urinary catherisation
Cause of epididymo-orchitis
Age < 35 years old ==> STI organism
- Chlamydia trachmatis
- Neisseria gonorrhoeae
Age > 35 years old ==> Non-STI organism
- Enteric organisms
- E. coli (following UTI)
Unilateral scrotal pain
Fever
Scrotal swelling
Hot, red, swollen hemiscrotum
Prehn’s sign +ve
(elevation of testes relieves pain)
Diagnosis? Treatment?
Epididymo-orchitis
Antibiotics
Analgesia
Painless scrotal mass
NOT separate from testies
Able to get above mass
Variable size (bigger with activity and in evening)
Transillumination
Diagnosis? Treatment?
Hydrocele
(1) Conservative (scrotal support)
If large –> surgical excision and repair (or aspiration)
Ix for underlying cause (torsion, malignancy, varicoele operation)
Sudden onset testicular pain
Nausea and Vomiting
Loss of cremasteric reflex
High riding testis
Abnormal transverse lie
Prehn’s sign -ve
Diagnosis? Treatment?
Testicular torsion
Do NOT delay Tx for imaging
Surgical detorsion ASAP (within 4-8hr)
If torsion –> fix BOTH sides
If necrosis –> +/- Orchidectomy
Tx for undescended testis (cryptorchidism)
Complication?
Orchiopexy (move undescended testicle into scrotum)
Complications:
Testicular cancer
Infertility
Painless scrotal mass
Left sided
Infertility
Bag of worms appearance
Diagnosis? Treatment?
Varicocele
Supportive underwear
or Surgery (but does not improve fertility)
TURP syndrome - Sx, Tx
Body absorbs irritation fluid
Clinical features
- Dilutional hyponataremia –> Confusion, N&V, Changes in Vision
- Fluid overload
- Glycine toxicity
Management
- Fluid restriction
- Tx hyponatraemia
Complications of TURP
Early
- UTI
- TURP syndrome
Late
- Retrograde ejaculation
- Inferility
- Urinary incontinence (due to sphincter damage)
CK value in Rhabdomyolysis
CK > 10,000
