Renal Flashcards
What is normal GFR
over 90ml/min and over 60 in elderly
Kidney extra functions other than excretion
EPO Ca and PO3 Acid base control BP Electrolyte management
What is a cystogram
Used to view bladder by giving contrast people urinate out
Symptoms people may describe alongside renal syndromes
Symptoms of UTI Pain Oligouria, anuria, polyuria, nocturia Oedema, SOB Fatigue Pain from bone breaks Headaches from HTN Muscle weakness Itching and nausea etc
Where are prostaglandins and bradykinins made
Kidney
What is wrong with serum creatinine
People with same creatinine can have very different clearing functions
What 2 substances do we use to measure GFR
Cystatin C
Creatinine
What is eGFR
Equation using serum creatinine that also uses body weight sex etc
Limitations for eGFR
Only useful in stable patients so AKI not useful and dependant on muscle mass
What is simplest kidney function test
Urine dipstick
What un pathological sources can make urine go red
Beetroot
Dyes
Porphyria
Rifampicin
What pathological sources make urine go red
Myoglobin
Blood
What does proteinuria normally indicate about site of problem
Glomerular problem
What must you always do if dispstick positive
Quantitate it- work out protein creatinine ratio
Define AKI- old
Rapid decline in renal function over hours or days with accumulation of waste productions with or without change in urine output
AKI research definition
Serum creatinine rise by 26umol/L within 24 hrs
Or
Serum creatinine rise by x1.5 from reference value which is presumed to have happened within a week
Or
Urine output of less than 0.5ml/kg/hr for 6 consecutive hours
How are AKI staged
1-3
Stage 1 AKI criteria
Definition for AKI
Stage 2 AKI criteria
SCr increase of 2-3 from baseline or less than 0.5mL/kg/hr for 12 hours
Stage 3 AKI criteria
SCr increase of over 3 from baseline or less than 0.3mL/kg/hr for 24 hours, anuria for 12 hours
Or been started on RRT
Why is even slight AKI critical
Minor changes in serum creatinine shown to have massive prognostic implications
What is important to do in patients at risk of AKI
Ensure hydration
Take off nephrotoxic drugs
More frequent monitoring
Who is at risk of AKI
Recent major surgery
Acutely ill
Risk factors for AKI
CKD Previous AKI Diabetes Low BP Over 75 HF Liver disease
Categorising cause of AKI
Pre renal
Intrinsic
Post renal
How to exclude post renal cause of AKI
US
What sort of things cause pre renal AKI
Low CO
Hypovolaemia
Renal artery thrombosis
Hypotension
What sort of things cause post renal AKI
Bladder tumour
Uereteric or urethral obstruction
Blocked urinary catheter
What sort of things cause renal AKI
ATN Glomerulonephritis Vasculitis Myeloma Toxins- rhabdomyolysis Malignant HTN TTP Interstitital nephritis
What is ATN
Acute tubular nephritis
Difference between AKI and CKD
AKI reversible
What is first thing to do when see rediced eGFR or SCr raised
Is it acute or chronic
Questions to ask when faced with AKI
What is cause and is it treatable
Questions to ask when faced with CKD
Cause?
Can we slow progression
How to control and treat complications
Make plan for RRT
How does AKI present
Non specific Uraemia symptoms Underlying disease sx Reduced output Systemic features like myalgia, rash, arthralgia Change in electrolytes, volume pH
Uraemia Sx
Anorexia
Nausea
Vomiting
AKI history
Duration Systemic featurs PMH- vascular, UTIs, diabetes Fx- strokes, sudden death Dx- anything new including herbal, over the counter, recreational drugs
AKI examination
BP, volume status Systemic disease features Bladder Palpable kidneys? Urinalysis and dispstick
What would you see in urine of someone with glomerular disease
Red cells
Red cell casts
Proteinuria
What would you see in urine of someone with tubular disease
Minimal blood
Small protein
White cell casts
What would you see in urine of someone with pre renal disease
No blood or protein
Investigations for someone with AKI
Previous renal baseline Electrolytes US CXR to see if fluid overload Urinalysis CK Autoimmune screen
Difference in size of kidney between AKI and CKD
CKD a lot smaller
What are main complications of AKI
Pulmonary oedema Potassium variations Acidosis HTN Uraemia affect brain, nerves and heart
What would cause CKD in childhood
Congenitally abnormal kidneys
Childhood reflux nephropathy
How is CKD staged
1-5 based on GFR
Who is at risk of CKD
Elderly HTN Black people IHD Diabetes Obesity
Causes of CKD
Diabetes
Chronic glomerulonephritis
Vacular diseases
Polycystic kidney disease
Preventing CKD progression
BP control- ACEi, ARBS
SGLTi drugs
Minimising CVS risk factors- hard to do when have no sx
Encourage hydration
What do you get with nephrotic syndrome
Heavy proteinuria
Oedema
Hypoalbuminaemia
Sx of nephrotic syndrome
Swollen legs
Limited walking
Painful legs
Normal protein in urine
Up to 300mg/day
What is nephrotic syndrome threshold for proteinuria
Over 3g/day
What is main indication of proteinuria
Glomerular disease
What are common glomerular pathologies
Diabetes
Membranous nephropathy
Amyloid
SLE
How to control oedema
Low salt diet
Diuretics
Proteinuria management
Control odema
ACEi/ARB
Treat cause
Haematuria with pain investigations
Stones and cancer likely so imagining
Haematuria age considerations
Over 40 must rule out cancer
Under 40 most likely IgA nephropathy
Investigation for renal stones
CT KUB
What is a CT KUB
Kidney
Findings of nephrotic syndrome
Hypoalbuminaemia
Oedema
Proteinuria
What is nephrotic syndrome
Increased permeability of GBM
What is active urinary sediment
Protein and blood in urine
Categories of AKI
Pre renal
Renal
Post renal
Pre renal causes of AKI
Hypovolaemia
Sepsis
Renal causes of AKI
Drugs
Glomerulonephritis
Post renal causes of AKI
Obstruction
How to diagnose renal artery stenosis
Magnetic Resonance Angiogram and will see unequal perfusion bilaterally
What is treatment of hyperkalaemia
Calcium chloride (calcium gluconate also) followed by insulin and dextrose- calcium chloride stabilises the myocardium and glucose important to open cellular trasnporters to shift potassium into cells
What are 4 indications for urgent haemodialysis
Uraemic encepaholopathy(over40)
Hyperkalaemia resistant to treatment after 4 hours of insulin/dextrose
Metabolic acidosis that doesnt respond to IV fluids
Pulmonary oedema with oligouria
Can be drugs
Treatment for metabolic acidosis
IV NaCl
IV sodium bicarb
Why can pulmonary oedema occur with oligouria
After fluid resus post AKI it is possible to not regain urine output ability leading to fluid overload
What presents with shortness of breath, haemoptysis and renal issues
Goodpastures
What is goodpastures syndrome
Presence of autoantibodies to the alpha-3 chain of type IV collagen
What causes pulmonary renal syndrome with rapid degeneration of glomerulonepthritis
Goodpastures
ANCA vasculitis
What does pulmonary renal syndrome consist of
Haemoptysis and glomerulnephritis
What blood findings suggest chronic renal failure as opposed to AKI
Low Hb
Elevated phosphate
Low calcium
Differences between chronic and acute presentation of bladder outflow obstruction
Bladder smaller in acute- chronic obstruction gives time for bladder to grow
Acute very painful
Treatment of bladder outflow obstruction
Put in a catheter
What cant be done before checking PSA
Catheter be put in
Important investigations in outflow obstruction
US
Then CT to see if ant mets
What causes itching from kidney pathology
Hyperphosphataemia
How does high phosphate from kidney failure lead to hypocalcaemia and hypoparathyroidism
Negative feedback directly on PT gland
Additional treatments of hyperkalaemia
Salbutamol nebs
Haemodialysis if required
Haemofiltration
What does epistaxis, skin rash and unilateral deafness imply
Vasculitis
How does nephrotic syndrome present
Leg oedema
Facial swelling
Scrotal swelling
Ascites
When does nephrotic syndrome only cause pulmonary oedema and raised JVP
Renal or cardiac failure is present
What gives frothy urine
Proteinuria
What is most common cause of nephrotic syndrome in men
Membranous glomerulonephritis
Can diabetes cause nephrotic syndrome
Yes but only after a few years of disease
What tends to cause nephrotic syndrome in women
SLE
Causes of nephrotic syndrome
Membranous glomerulonephritis
Minimal change glomerulonephritis- common in children
SLE
Diabetes
Why must avoid contrast CT in renal patients
Contrast can be nephrotoxic
Symptoms of chronic renal disease
Impotence Pruritus Weight loss Pleural effusion Bone pain
Why do you check PTH in kidney patients
Can get secondary hyperparathyroidism due to renal failure
What are US findings of outflow obstruction
Smaller kidneys with cortical thickness
Thick walled bladder
Why get bone pain in renal failure
Osteodystrophy
Bloods to look out for in chronic kidney disease
Phosphate
Calcium
Potassium
PTH
Nephrotic syndrome triad
Oedema
Hypoalbuminaemia(less than 30)
Heavy protein loss (more than 3g/24hrs urine collection or PCR over 300)
Different ways to determine protein loss
PCR
24hr urine collection
What is normally associated with heavy protein loss
Hypercholesterolaemia due to increased hepatic synthesis
Most common cause of nephrotic syndrome
Diabetes
What happens to INR in nephrotic syndrome
Clotting factors are protein bound so these are lost into urine making patient hypercoagulable
What are people with nephrotic syndrome more susceptible to
DVT due to loss of clotting factors
Infection due to loss of Ig
Differentials for elevated urea
Dehydration
Upper GI bleed
High protein diet
Pre renal causes of AKI
Hypoperfusion from: Sepsis Hypovolaemia HF Renal artery stenosis
Renal causes of AKI
Glomerulonephritis Acute intersitial nephritis Nephrotoxic drugs Vasculitis Nephrotoxic drugs Rhabdomyolysis
Post renal causes of AKI
Stone
Protastatic hypertrophy
Cancer
Management of renal problems according to the renal pathology
Modify risk factors such as antihypertensives
Fluid balance with salt and fluid restriction
EPO stimulating agents for anaemia
Phosphate binders and vit d supplements for hypocalcaemia
When is renal replacement therapy used
Stage 5 kidney disease
Problems for patients with haemodialysis
Have to go into hopsital 4/7
Complications include infection, cardiovascular disease, fluid balance irregularities
Problem for patients with peritoneal dialysis
Massive risk of infection
Benefit of peritoneal dialysis for patients
Done at home
Benefit of renal transplant for patients
Lasts 10-20 years no hospital trips
Problems of renal transplant for patients
Rejection
Massive operation
Immunosuppression
Recurrence
Difference between nephrotic and nephritic
In nephritic get blood and protein in urine but in nephrotic just protein
Definition of nephritic
Related to inflammation of glomerulus and nephrons
Definition of nephrotic syndrome
Definition of nephrotic syndrome
Urinary protein loss of over 3.5g/day
Causes of nephritic syndromes
IgA nephropathy Post streptococcal glomerulonephritis Henoch-schonlein purpura Haemolytic uraemic syndrome SLE Goodpastures syndrome
Causes of nephrotic syndrome
Minimal change disease
Focal segment glomerulosclerosis
Membranous glomerulonephritis
Diabetes nephropathy
When do you get IgA nephropathy
Few days post URTI
When do you get post streptococcal glomerulonephritis
4-6 weeks post strep infection
When do you get HUS
Post E coli infection (0157)
What is henoch-schonlein purpura
IgA vasculitis that commonly affects children
Triad of symptoms for henoch schonlein purpura
Purpura on buttocks
Abdo pain
Arthritis
Way to remember Sx of SLE
SOAP BRAIN MD
What is an urinary tract calculi
Crystal deposition within UT
Presentation of UTC
Severe loin to groin pain
What are 4 types of UTC stones
Calcium oxalate- most common!! Calcium phosphate Magnesium ammonium phosophate Uric acid Cysteine
Bedside investigations for UTC
Urine dispstick
Bloods for U&Es
Urine dipstick finding of UTC
Haematuria
Gold standard diagnosis for UTC
CT KUB
Management of UTC
First determine if its infected or obstructed- nephrostomy
Then determine if stone smaller or greater than 5mm.
If smaller allow to pass spontaneously and retain it for analysis. If larger intervention needed
Interventional methods for UTC
Uteroscopic lithotripsy
Extracorporeal shockwave lithotripsy
Percutaneous nephrolitomy
What happens in uteroscopic lithotripsy
Camera put through urethra and stone is crushed
What happens in extracorporeal shockwave lithotripsy
Ultrasound shockwaves used to break up stone
What happens in percutaneous nephrolitomy
Hole made in back under general anaesthetic and stone removed or cut up
What happens in nephrostomy
Drain put in to drain urine that cant pass
What is way to remember symptoms relating to lower UT
FUND- to do with storage
HIPS- to do with voiding
FUND symptoms of LUT
Frequency
Urgency
Nocturia
Dsyuria
HIPS symptoms relating to LUT
Hesitancy
Incomplete emptying
Poor stream
Straining
What is benign prostatic hyperplasia
Slowly progressive hyperplasia of periurethral zone of prostate gland
Management of benign prostatic hyperplasia
If in acute retention immediately catheterise
Then have conservative, medical and surgical options
Conservative management of benign prostatic hyperplasia
Watchful waiting
Medical management of BPH
Alpha blocker- tamsulosin
5a-reductase inhibitor- finasteride
Anti-cholinergic
Surgical management of BPH
TURP
Incision into prostate
Open prostatectomy
What is TURP
Transurethral resection of prostate
When feeling scrotal mass first question ask
Can you feel above the mass- no then is inguinal hernia
If can feel above a scrotal mass what is next question to ask
Can the swelling be separated from the testicle
What is implied if mass can be separated from the testicle
Epididymal cyst
Varicocele
If cant separate testicle from mass what is next thing to ask
Is it tender
What does tender scrotal mass suggest
Epididymitis
Orchitis
What does non tender mass that cant be separated from testicle suggest
Hydrocele
Tumour
How to differentiate between tumour and hydrocele
Is it transilluminable
What is a hydrocele
Collection of serous fluid in tunica vaginalis
Investigations for scrotal mass
Consider secondary causes
US
Testicular tumour markers
Urine cultures
Causes of hydrocele
Primary- congenital patent vaginalis
Secondary- trauma, malignancy, infection/inflammation
What is a varicocele
Distended veins of pampiniform plexus
Where are varicoceles normally found
Left testicle
What complications are there for varicocele
Renal cancer risk
Infertility risk
What does swelling on lying down suggest with scrotal mass
Varicocele
What re the tumour markers for testicular cancer
Afp
B-hCG
LDH
Important investigations for testicular cancer
CT for staging
What is most common malignancy in males aged 20-40
Testicular
Where does testicular cancer normally metastasize
Para-aortic nodes
What can hydrocele be a sign of
Cancer in testicle
Epididymo orchiditis
What testicular mass will transilluminate
Hydrocele
Epididymal cyst
Where would pain be in LUT infection
Suprapubic
Management of renal colic
IV fluids and anti-emetics
PR diclofenac or IV paracetamol
In which sex are renal colics more common
Men
Are AXR good for renal stones
80% picked up
Which renal stones are radio-opaque on AXR
Calcium oxalate
Calcium phosphate
URATE IS NOT
Specifity of CT KUB for stones
97%
AXR findings of renal colic
Pelvicalcyeal dilation
Dilation of ureter
Where are common points for renal stone to be stuck
Pelvi-uteric junction (at start of ureter)
Vesicourteric junction (where ureter enters bladder or ureter inside bladder)
Where urter crosses iliac vessels
What is pyonenephrosis
Backing up of septic pus and sediment into kidney
Management of pyonephrosis
IV paracetamol
IV abx
IV fluids
Why is stone removal not indicated in pyonephrosis
Uretal wall very fragile
What are staghorn renal stones
Branched stones that fill the renal pelvis
What is urgency urinary continence
Pressing desires to go to toilet and can lead to leakage of urine if dont make it in time
What is overactive bladder syndrome
Urinary urgency without or without urinary incontinence associated withincreased frequency and nocturia
What is stress urinary incontinence
Leaking or dribbling of urine post sneeze or cough that arises from increased abdo pressure
What is post-micturition dribble
When small amounts of urine in bulbar urethra pass leak out when moving post urination
Who is post-micturition dribble very common in
Elderly men
How is diagnosis of overactive bladder syndrome made
Bladder diary
What is treatment of OAB
Fluid advice
Bladder training
Anti-cholinergics like oxybutinin
What can happen to inguinal hernia when patient lies down
Will disappear
Features of testicular torsion
Excruciating sudden onset pain
High lying testicles
What normally causes epididymo orchiditis
UTI
Medical instruments
What are 2 most common testicular cancers
Seminoma
Testicular teratoma
What do seminomas produce
Placental ALP
What does raised PALP suggest
Seminoma
What do only teratomas produce
AFP
Peak age differences between seminoma and teratoma
Teratoma- 20-30
Seminoma 30-40
Differences between teratoma and seminoma in preferred met route
Seminoma- lymphatics
Teratoma- blood
What metastases do seminomas often cause
Cannonball lung mets
In a young man what is a testicular mass until proven otherwise
Tumour
If diagnosis of testicular tumour is made what further investigations should be made
CT abdo
CXR
What do germ cell tumours of testes produce
hCG
What HcG is measured for testicular cancer marker
Beta as the alpha chain is very similar to that of pituitary hormones
Tumour markers for testicular cancer
AFP
LDH
Beta HCG
PALP
Side effect of ectopic HCG production
Gynaecomastia
Gold standard diagnosis for kidney cancers
CT urogram
Most common group for testicular torsion
11-30
Management of testicular torsion
Analgesia then surgery immediately with potential orchidectomy
What can be done to further engorge the veins in varicocele
Valsalva
What can make varicocele disappear
Lying supine
Gold standard investigation for varicocele
Scrotal US
What is rare association of varicocele
Renal carcinoma
Associations of renal cell carcinoma
Smoking
Von-hippel Lindau disease
Industrial dyes
What happens to magnesium in CKD
Elevated as reduced excretion
What are 5 types of incontinence
Stress Overflow Urge Neuropathic Mixed
What is most common cause of stress incontinence in men
BPH
What is most common cause of stress incontinence in women
Hypermobility of sphincter
What causes hypermobility of sphincter in women
Pregnancy and labour can cause damage to connective tissue surrounding bladder that doesnt support them in cases of extreme pressure
Or damage to nerve affects sphincter control
Investigations you would do for stress incontinence
Stress test where ask to cough
PAD test
Urodynamics
What happens in pad test
Person wheres pad then weigh how much it is after from how much urine has been leaked into it
What are 2 categories causing overflow incontinence aand examples
Outflow obstruction- BPH, cystocele, organ prolapse, urethral stricture
Reduced detrusor action- medication, long standing distension
Investigation for overflow obstruction
Post voiding US
What are 2 categories causing neuropathic incontinence
Spasticity of detrusor muscle- stroke, MS
Inability to control external sphincter- cauda equina or anything affecting S2-S4
Main symptoms of BPH
Hesitancy
Poor flow
Post micturition drip
Pis en deux
What is pis en deux
Incomplete voiding so need to go again just after have been
Investigations for BPH in order
Take blood for PSA
Then do DRE
Dipstick
Cystoscopy
Why are UTIs more common in women
Their urethra is much shorter so less distance for bacteria to travel
What does acute urinary retention lead to increased risk of
Hydronephrosis
UTI
Renal stones
How does rhabdomyolysis present
Muscle pain and weakness
Dark urine
What does nephrtic syndrome consist of
HTN
Haematuria
Proteinurea
Oedema
Extreme signs of nephritic syndrome
Oligouria
Uraemia
Presentation of renal cell carcinoma
Pain
Haematuria
Mass in flank
FLAWS
Where do renal cell carcinomas originate from
Proximal tubular epithelium
What is other name for a renal cell carcinoma
Von Grawitz tumour
Which antibiotic should be especially avoided in pregnant women with UTI
Trimethoprin as a folic acid antagonist
Fluoroquinalones
Tetracyclines- these both teratogens
When would phosphate deficiency be suggested
Signs of osteoporosis
Anorexis
Weight loss
Signs of acute renal failure
Uraemia Hyperventilation Easy bruising SOB due to increased fluid Oligouria
How does uraemia present
Nausea and vomiting
Confusion in extreme cases
How does acidosis present in renal failure
Hyperventilation
How can a kidney patient be SOB
Fluid in lungs
Anaemia from EPO dysfunction
How do kidney patients present woth easy bruising
Haemostasis impaired
What is criteria used to determine whether kidney injury is chronic, acute or acute on chronic
RIFLE
How can teratomas be classified
Mature or immature
Difference in teratoma between men and women
Malignant in men but normally benign in women
Difference in malignancy between mature and immature teratomas
Mature normally benign
Immature malignant
What can see in immature teratomas
Immature nerual tissue containing skin and teeth etc
How are mature teratomas classified
Cystic and solid
What is different about solid teratomas
Can undergo transformation to carcinoma
Complications of renal colic that would make you consider fast tracking management
Infection
Cant keep fluids down where nauseous
AKI
Constant pain
Haematuria ddx
Kidney - cancer - glomerulonephritis - pyelonephritis Bladder - cancer Prostate - BPH - prostatits - cancer Ureter and urethra - UTI -stone
Physiological causes of microscopic haematuria
Vigorous exercises
Sex recently
Signs of bladder cancer urinalysis
Blood
WCC
Sx bladder cancer
Dysuria
Polyuria
Blood in urine
Investigations for bladder cancer
Urinalysis
Urine cytology
Cystoscopy
CT urogram
What does blood in urine throughout voiding suggest
Kidney or bladder problem
What does blood at end of urinating suggest
Prostate or distal bladder problem
What does blood at beginning of urinating suggest
Urethral problem
What can give fake positive for blood on dipstick
Hb
Myoglobin
What is another name for IgA nephropathy
Bergers disease
What is urine blood in Bergers
Macroscopic
In daibetic nephropathy what is proportions on dipstick
Protein> blood
Post surgery what is cause of hyponatraemia
Poor fluid control
What happens in diabetic nephropathy
Initially increased GFR and GBM hypertrophy -> glomerulosclerosis due to ECM buildup-> BM destruction so protein loss
What happens when give too much insulin in blood
Hypo
Hypokalaemia
How does excess insulin present
Sweating
Irritable
What tends to cause acute tubulointerstitial nephritis
Drug hypersensitivity from NSAIDS and penicillin commonly
How does acute tubulointerstitial nephritis present
Painful joint
Fever
Rash
Nephritic syndrome
Blood findings of acute tubulointerstitial nephritis
Eosinophilia
What is problem of using MRI for UTC
Cant differentiate between stones, tumours and clots
How does TB affecting kidney present
Pain in flank going to back
Nocturia
Polyuria
How is TB affecting kidney found
Pyuria that wont colonise
Main risk factor for bladder cancer
Dyes
Inks
Triad of renal cancer
Haeamturia
FLAWS
Flank pain and mass
Hypercalcaemia symptoms of kidney
Polyuria
Nocturia
Polydipsia
Vasculitides affecting kidney
Henoch schonlein purpura
Granulomatosis with polyangiitis
Microscopic polyangiitis
Eosinophilic granulomatosis with polyangiitis
What is BPE
Benign prostate enlargement that is common as grow older
What is BPH
Enlargement of prostate with histological diagnosis of hyperplasia
What is BOO
Bladder outflow obstruction
From the prostate where does BPH occur
Transition zone
From the prostate where does cancer occur
Peripheral zone
What is significance of prostate cancer growing from peripheral zone
Tumour is already quite big by time it reaches the urethra
Difference between voiding and storage problems
Strong flow in storage symptoms
What causes voiding symptoms
Obstruction
What causes storage symptoms
Detrusor overactivity
What investigations would do for BOO
DRE Dipstick Flow rate and post voiding scan PSA, U&Es bloods Renal US Flexi cystoscopy
Why do you always do bladder scan post flow rate test
Chronic urinary retention common in elderly
How can prostate cancer present
LUTS Haematuria Dysuria Pain Bone pain FLAWS
Grading scale for prostate cancer
Gleason
What is best imagine for prostate cancer
MRI
When person is doing urology history what should be filled out
IPSS
In DRE how do you describe size of prostate
According to objects- walnut, ping pong ball, golf ball, clementine
How does renal failure increase risk of heart problems
Long QT from hypocalcaemia
Hyperkalaemia
What can lead to orcitis or epididymitis
STI
UTI
Post op
What is concern of patient who has varicocele
Slight chance of kidney cancer
What gene is linked to prostate cancer
BRCA2
What is used to pick up uric acid stones
CTKUB
What is main danger of stones
Can go into gram neg septicaemia
What would suggest uric acid stone on urinalysis
Low pH
Treatment for uric acid stones
Alkylysing the urine
What is NMP22 associated with in urine cytology
Bladder cancer
What is most commonl cause of PCKD
Mutation on PKD1 chromosome 16
How can PCKD present
Loin pain or diffuse abdo pain as kidneys hypertrophy
Symptoms of kidney failure as disease progresses
Bleeding or infection of cysts
What are some associations of PCKD
Mitral valve prolapse
Berry aneurysms
Best first line imaging for PCKD
US
Best imaging for PCKD
MRI
In question what is loin pain with mid systolic click
PCKD
Mainstay first line treatment of new onset proteinuria in daibetics
ACEi or ARBs
What are Kimmelstiel wilson nodules seen in
Diabetes nephropathy- nodular glomerulosclerosis
What is medullary sponge kidney
Congenital disorder of the kidneys that
is characterized by the formation of cystic sacs within the papillary zone of the kidney creating a sponge-like appearance
Presentation of medullary sponge kidney
Cysts obstruct the outflow predisposing to UTIs, stones and haematuria
Associations of medullary sponge kidney
Hypercalciurua
Hypertrophy
Renal tubular acidosis
Effects of excessive NSAID use
Papillary necrosis
Tubulointerstitial nephritis
What does papillary necrosis and tubulinterstitial nephritis from NSAID use lead to
Anaemia
UTIs
Haematuria
What is best way to visualise papillary necrosis and tubulinterstitial nephritis from NSAID use
MRI
How do calcium oxalate stones appear on urinalysis microscopy
Envelope shaped
What is a healthy adult urinary rate
1ml/kg/hour
What is defined as oligouria
Less than 0.5mL/kg/hour
What can cause reduced local perfusion of kidneys
Stenosis
Thrombosis
Aneurysm
How can renal causes of AKI be classified
Vascular Tubular Glomerular Interstitial Complex
Vascular causes of AKI
TTP HUS DIC Malignant HTN Vasculitides Scleroderma
Glomerular causes of AKI
Glomerulonephritis
Complex causes of kidney damage
Amyloid
Myeloma
Interstitial causes of AKI
Interstitial nephritis from drugs
Infectious causes of AKI
Malaria
Legionnaires
Leptospirosis
How can post renal causes of renal failure be classified
Ureter
Bladder
Urethra
Ureteric causes of renal failure
Abdominal mass
Bilateral stones
Pelvic surgery complication
Retroperitoneal fibrosis
Bladder causes of renal failure
Neuropathic bladder
Anticholinergic or sympathomimetic drugs
Bladder stones or tumour
Uterovaginal prolapse in women
Urethral causes of renal failure
BPH Prostate cancer Urethral stricture Infection meaning too painful to urinate Blocked catheter
What is rate of required fluid
30-50ml/kg/day
What is volume of fluid required each day by body
3L
How much more fluid is needed per day in febrile patients per degree of body temp
500ml/ 1^C
What class of abx cause interstitial nephritis
Aminoglycosides
Glycopeptides
What are things to assess on examination of oligouria
If catherised check bag
Signs of volume status- JVP, BP, lips, cap refill, narrow pulse pressure
Signs of heart failure
Palpable and dull on percussion bladder
What would cause post operative bilateral creps
Atelectasis
What is difference between acute and chronic retention on presentation
Chronic is painless
Management of acute urinary retention
Catheterise Measure how much is voided Fluids to replenish those lost in diuresis Assess renal function Assess cause of obstruction Do a TWOC if possible
What is a TWOC
Trial without catheter
What does over 1L being voided on catheterisation of acute retention
That it is an acute on chronic cause
What test cant you do when assessing cause of urinary retention
PSA as this will definetely be raised
When is only time people are eligible for TWOC following acute retention
If under 1L was voided upon catheterisation and has normal renal function
What happens in a TWOC
Given an alphablocker and a dose of ABx (to prevent UTI following catheterisation)
Wait to see if actually urinates
If patient fails TWOC what happens to them
Given finasteride too with an indwelling catheter and booked in for a TWOC outpatient clinic
If patient urinates more than 1L on presentation or their renal function was raised on presentation what is management
they are immediate candidates for TURP
What causes urethral strictures
Repeated trauma to urethra often after cystoscopies
How can surgery lead to AKI
Fluid loss during surgery may have caused hypovolaemic perfusion of kidney
Management of renal cause oligouria patient
Stop fluids Assess need for dialysis Check drug chart and stop any drugs Blood tests to assess U&Es, Ca and PO to determine if chronic Renal US Urinalysis
What causes focal segmented glomerulosclerosis
Heroine
HIV
What is gold standard measurement of GFR
Inulin
What influences blood urea levels
Nutritional state
Hepatic function
GI bleed
What is renal function a measure of
Flow from the glomerulus to the bowmans capsule
What causes nausea and vomiting in AKI
Uraemia
Difference in whats used to measure AKI vs CKD
Creatinine in AKI
eGFR in CKD
What is defined as CKD
An eGFR of less than 60 for more than 3 months
What is an AKI a failure to manage
Fluid- oligouria leading to hypervolaemia
Electrolytes- hyperkalaemia
Acid base- metabolic acidosis
What are common symptoms of an AKI
N&V Confusion from uraemia SOB Dehydration Oligouria/anuria
What does an abrupt anuria suggest
Post renal cause whereas insidious suggest renal
What causes ATN
Toxins: Paracetamol Contrast Rhabdomyolysis NSAIDS Abx Hypoperfusion
What is ATN
Death of epithelial cells but wis reversible as cells can regro
What is pathognomonic for ATN
Muddy brown casts
What is seen on urinalysis ATN
Muddy brown casts
Epithelial cells
What is different about AKI in acute interstitial nephritis
Non oligouric
Causes of AIN
Drugs- often Abx, NSAIDS, PPIs, diuretics
Infections- Ecoli, campylobacter, syphillis, measles, mumps, EBV, histoplasmosis
Infiltration- lupus, sarcoid, sjogrens
Urinalysis findings of AIN
WC casts
Sterile pyuria
Proteinuria
Categorising causes of pre renal AKI
Hypovolaemia
Systemic vasodilation
Reduced cardiac output
Intrarenal vasoconstriciton
How does myoglobin affect kidney
Acute tubular necrosis
Endogenous causes of ATN
Myoglobin
Uric acid crystals
Light chains in myeloma
Urine findings of rhabdomyolysis
Muddy brown casts
Myoglobinuria
What is urea:creatinine ratio in pre renal cause
Over 100:1
What is urea:creatinine ratio in post renal cause
40:1-100:1
What is urea:creatinine ratio in renal cause
Under 40:1
What is normal urea:creatinine ratio
40:1-100:1
Blood findings of rhabdomyolysis AKI
Hypocalcaemia
Hyperphosphataemia
Raised CK
Histopathological finding of ATN
Tubular necrosis
Primary causes of nephrotic syndrome
FSGS
Minimal change disease
Membranous nephropathy
Secondary causes of nephrotic syndrome
DM
Amyloid
SLE
What happens to renal function and complement levels in minimal change disease
Normal
What disease is associated with minimal change disease
Hodgkins lymphoma
What is primary cause of membranous nephrotic syndrome
Autoimmune
What are secondary causes of membranous nephrotic syndrome
Cancer- lung/colon adenoarcinoma
SLE
Hep B/C
Which ethnicity is normally affected by membranous nephrotic syndrome
Afro carribeans
Histopatholoical findings of diabetic nephropathy
Kimmelstiel wilson nodules
Nodular glomerulosclerosis
Histopathological findnigs of FSGS
Focal scarring
IgM deposits
Stain done for amyloid nephrotic syndrome and result
Congo red
Apple green birefringence
What is special about mesangiocapillary GN
A mix of both nephritic and nephrotic syndrome
Histopathological findings of MSCGN
Tram tracking
Mesangial proliferation
What conditions are assocaited with MSCGN
Hep C
End stage renal failure
C3 nephritic factor
What types of infection cause post strep GN
Lung
Skin- remember!!!
Blood findings of post strep GN
High anti-strep titres
Low C3
What is smoky urine seen in
Post streptococcal GN- described as cola like
What is primary cause of GN
Rapidly progressive glomerulonephritis
What are the 3 types of RPGN
Type 1- Anti- GBM
Type 2- immune coplex deposition
Type 3- Pauci immune
What causes type 1 anti GMN RPGN
Goodpastures
What causes type 2 immune complex deposition RPGN
SLE
IgA
Henoch schnolein purpura
What causes type 3 pauci immune RPGN
Wegners
Granulomatosis with microscopic polyangiitis
Churg strauss
Differnece in presentation of 3 causes of type 3 RPGN
Wegners- nose and lung
Churg strauss- eosinophilia, asthma, mononeuritis multiplex
Microscopic polyangiitis- purpuric rash
What would be done in renal workup of patient
Bedside- urinalysis with microscopy
Bloods- urea:creatinine ratio, complement levels, autoimmune screen (ANCA, GBM), EBV and hep C serology, serum free light chains
Imaging- renal USS and biopsy histology and immunofluorescence
Use of ACR vs PCR
Albumin creatinine ration used more for DM
PCR used more for nephrotic syndrome generally
Causes of proteinuria
Nephrotuc syndromes Amyloid HTN DM Myeloma
Causes of glucose in urine
DM
Pregnancy
Sepsis
Tubular damage
Most common causes of CKD
DM HTN Atherosclerosis Chronic glomerulonephritis Stones/infection
Most common congenital cause of CKD
PCKD
What do you see on examination of CKD patient
AV fistula Finger BM Half and half nails Tremor- on immunosuppresion tacrolimus Gum hypertrophy from ciclosporin Parathyroidectomy scar Dialysis line Kidney transplant scar and mass (hockey stick scar) Uraemic fetor Pruritus
What are half and half nails also called
Lindsay nails
What must do if see AV fistula on examination
Examine for thrills and bruits- if blood flowing through then is active bruit
Consequences of CKD
Anaemia from EPO deficiency Renal bone disease Acidosis Hyperkalaemia Vascular calcifcation Uraemic pericarditis
How are CKD patients at greater risk of pericarditis
Uraemia
What investigations will do for CKD patient
Bedside Obs- looking at HTN in particular Urinalysis- haematuria and proteinuria Fundoscopy for HTN changes ECG for hyperkalaemia and LVH Bloods FBC- normocytic anaemia LFTs- albumin U&Es- eGFR, potassium, urea creatinine ratio VBG- metabolic acidosis from retention of acid or loss of bicarb Hba1c- likely to be on steroids Bone profile Blood tacrolimus Imaging CXR- pulmonary oedema or pericardial effusion USS check perfused Histology to check disease progression if getting worse
Limiting complications management of CKD
Control BP and glucose strongly- ACEi ideal
Diet- avoid high phosophate foods mainly dairy
Symptoms control CKD
Human EPO
Sodium bicarb if acidotic
Loop diuretics and restrict fluid for oedema
Phosphate binders for hyperphosophataemia
Vit D supplements
Parathyroidectomy if tertiary parathyroidectomy
What is management of tertiary hyperparathyroidism
Parathyroidectomy
Why is BP control important if recently had renal transplant
Affects grafts ability to hold
Why is peritoneal dialysis not good for diabetics
Fluid used is full of glucose
Who is peritoneal dialysis contraindicated in
Diabetics
What bacteria is indicated in UTI from catheters
Proteus as very good at swimming up
Atypical organisms causing UTI typically in immunocompromised
Candida albicans
Pseudomonas
Klebsiella
What is presentation of PCKD
Often clincally silent for many years
Acute loin pain
Haematuria
Stone formation
Examination findings of PCKD
Enlarged kidney
HTN
Haematuria
Investigations for PCKD
Obs
FBC- raised Hb
Deranged U&Es
USS or could do MRI if positive fx or SAH or PCKD
What causes varicocele in renal cancer
Invasion of renal vein
Investigations for renal cancer
BP-obs showing HTN from increased renin FBC- polycythaemia sometimes ALP- bone mets Urinalysis- haematuria CXR- canonball mets CT/MRI IVU
What is IVU
Intravenous urogram
What flank pain can radiate to back
Pyelonephritis
AIN
TB affecting kidney
What presents following abx for CAP with pain radiating to back
AIN
Differentials for haematuria and a rash
SLE
Vasculitide
HSP
Rfs for UTC
Idiopathic Hypercalcaemia Hyperuricaemia Low water Lots of meat Structural kidney defects- medullary sponge kidney, PCKD
Which kidney stones can especially be seen on AXR
Uric acid
What forms staghorn kidney stones
Struvite
Which infection is often linked to struvite staghorn stones
Proteus
What tends to cause cysteine stones
Congenital defects- homocyteinuria
Investigations going to do for UTC
Bloods- renal damage
Urine dip/MSU- blood
Non contrast CT-KUB
What looking for on CT KUB for UTC
Where are stones
How big
Evidence of obstruction leading to hydronephrosis
When do you do US KUB instead of CT KUB for UTC
Pregnant
Under 16
Which stone gives microscopy shows crystals having a “coffin-lid” shaped appearance
Struvite
When do you do AXR for UTC
To track recovery
Conservative management of UTC
Lifestyle advice- more water
Modify RFs
Medical management of UTC
Diclofenac
Anti-emetics
Tamsulosin
What is done if UTC stone 5-10mm
Medical management using tamsulosin
What are indications for surgical management of UTC
Renal dysfunction Previous renal disease Infection Pain for over 48hrs Bilateral stones
What to do if stone 10-20mm
Uteroscopy lithotripsy
What to do if stone over 20mm
Percutaneous nephrolithotomy
Management of infected stone leading to pyonephrosis
Sepsis 6- co amox and gent
Nephrostomy
What is seen on US of varicocele
Dilated pampiniform plexus
Investigations for varicocele
US
Colour doppler
CT
Causes of epidiymitis and orchitis
In sexually active people is normally gonorrhoea or chlamydia
In over 35s tends to be klebsiella or enterococcus from UTI
In children is mumps orchitis
What causes orchitis in sexually active people
gonorrhoea or chlamydia
What causes orchitis in over 35s
klebsiella or enterococcus from UTI
What causes orchitis in very young
Mumps
What age group is orchitis mainly found in
Male 20-30
Symptoms of orchitis
Slow onset testicular pain
Tender to touch
LUTS sx
Discharge from penis
O/E epididymitis
Testicular tenderness
Positive prehns sign
Investigations for orchitis and epididymitis
Urinalysis- mc&s
Bloods- WBC, CRP
Mumps serology
Management of orchitis
Abx and analgesia
Scrotal support pants
GUM referral with tracing of partners
Complications of orchitis
Reactive hydrocele
Abscess
Infertility
Risk factors for testicular cancer
Cryptorchidism, Klinefelter syndrome, hypospadias
What is cryptochordism
When one or two of testicles fail to descend
Symptoms of testicular cancer
Dullness in testes
Ache
Back ache from met spread
Inguinal lymph nodes
How are testicular cancers classified
Germ cell tumour
Non germ cell
Examples of germ cell testicular cancer
Seminoma Teratoma Choriocarcinoma Yolk sac Embryonal carcinoma
Examples of non germ cell testicular cancer
Sertoli cell tumours
Leydig cell tumours
What is the marker very raised in choriocarcinoma
bHcG
What marker is very raised in yolk sac tumours
AFP
What testicular cancer has fried egg appearnce
Seminoma
What is most common testicular cancer
Seminoma
Management of testicular torsion
Analgesia
Antiemetics
Urgent orchidectomy and contralateral fixation
DDx for testicular torsion
Epididymo orchitis
Incarcerated inguinal hernia
