Renal Flashcards
What is the pathology of benign prostatic hypertrophy?
how does it differ from prostate carcinoma?
- Benign nodular or diffuse proliferation of prostate (fibrous and glandular layers)
- Transitional (inner) zone enlarges more than peripheral (whereas in prostatic carcinoma the peripheral layer enlarges more)
The likely cause is failure of apoptosis
What symptoms do you get with BPH? (think before, during, after)
Before: ‘FUNI’
- ↑frequency
- ↑urgency
- nocturia
- hesitency (takes time to initiate micturition )
- incontinence
During:
- poor stream
- haematuria (rupture of prostatic veins)
- terminal tribbling
After:
-Incomplete emptying (sensation of still having urine in bladder)
What symptoms would suggest acute obstruction?
- suprapubic pain/tenderness
- palpable bladder
- change from Nocturia/Polyuria → Oliguria/Anuria
What investigations would you do for BPH? (bedside, bloods, imaging )
BPH investigations
Bedside
- PR!
- Mid stream urine dip
Bloods
- U&Es
- PSA
Imaging
- Bladder scan will show large residual volume/possibly hydronephrosis
- Transrectal ultrasound + biopsy
What would you feel in BPH on PR?
Smooth, symmetrically enlarged prostate with loss of the sulcus
Contraindications for PR?
- No informed consent
- Fistulae
- Excessive rectal bleeding
- History of 3rd degree heart block
- Autonomic dysreflexia
- Patient is a child
- History of abuse
- Presence of foreign body
What are the drug treatments for BPH?
- Alpha-blockers e.g. tamsulosin, doxazosin
2. 5-alpha-reductase inhibitors e.g. finasteride
What is the mechanism of alpha blockers?
Alpha blockers
-block alpha1-adrenoreceptors in the smooth muscle→ vasodilation → decreased resistance
What are the main side effects of alpha blockers?
Postural hypotension
What is another indication for alpha blockers?
Resistant hypertension (because it causes postural hypotension as a SE)
What drug should not be prescribed with alpha blockers?
Beta-blockers - they inhibit reflex tachycardia needed in response to vasodilation/hypotension
What is the mechanism of finasteride?
Finasteride
- 5-alpha-reductase inhibitors
- Inhibits conversion of testosterone to active dihydrotestosterone (which normally stimulates prostatic growth)
- Therefore it reduces the size of the prostate gland, (but it can take months)
What are the side effects of 5-alpha-reductase inhibitors? Who should you not give it to?
SIDE EFFECTS 5-alpha-reductase inhibitors (Finesteride)
- Impotence
- Reduced libido
- Gynaecomastia
- Hair growth (used off license for treatment of male pattern baldness)
- Breast cancer
DO NOT give to pregnant women or men who are having unproductive sex with pregnant woman (causes abnormal development of external genitalia)
What is hydronephrosis?
The swelling of a kidney (dilation of renal pelvis and calyces)
-Due to build up of urine usually caused by an obstruction
How does hydronephrosis present?
Isolated hydronephrosis is almost always asymptomatic - the UTI/stone causing it is what causes symptoms (colicky pain or signs of infection)
Upper urinary obstruction
- Loin to groin pain – dull, sharp or colicky (intermittent)
- Patient restless, unable to lie still
- Provoked by alcohol, diuretics, ↑fluid intake
- I/L back pain
- Oliguria or Anuria (suggests B/L disease)
Lower urinary obstruction
-symptoms of LUTI > acute urinary retention> suprapubic pain and distended bladder
Both: N+V in acute obstruction
What investigations are useful in hydronephrosis?
bedside, bloods and imaging
Hydronephrosis
Bedside
-24 hr urine collection – monitor creatinine clearance
-Urinalysis MCS – screen for infection
Bloods
- Us and Es and egfr ↓Na+, ↓K+ (think about it being diluted)
- Creatinine (deranged because back flow=damage)
- FBC - evidence of anaemia due to CKD or infection
- Serum Ca2+, phosphate, urate
- Serum PSA (if LUT obstruction)
- Cultures if signs of sepsis
Imaging
- 1st line: USS KUB to show dilation of renal pelvis - first-line
- 2nd line: CT KUB if neg or to see extent of abnormality
- IV urography - visualises upper urinary tract to assess position of the obstruction
How do you treat a partial urinary obstruction?
Partial urinary obstruction
- Hydration
- Analgesia
- Prophylactic antibiotics to prevent infection
Treatment of hydronephrosis?
- Decrease pressure
Upper UTO
-Ureteral stenting or percutaneous NEPHROSTOMY
(nephrostomy 1st line if infection)
-Alpha blocker (tamsulosin) to reduce stent-related pain
Lower UTO (e.g. prostate)
- Foley Catheter (suprapubic if unable)
- Alpha blocker for 2 days before TWOC
- Treat the cause
- infection, BPH, stones, cancer, retroperitoneal fibrosis
What are the different types of calculi in order of how common they are?
- Calcium oxalate (75%)
- Struvite - magnesium ammonium phosphate (15%)
- Urate
- Hydroxyapatite (usually due to UTI)
- Cysteine (usually due to renal tubular defect)
Risk factors for renal stones?
Renal stones risk factors
- Gout (urate)
- Hypercalcaemia (hyperthyroidism, hyperparathyroidism, neoplasia, sarcoidosis, lithium)
- Urinary stasis (bladder stones)
- Dehydratoin (including diuretics)
- Anatomical abnormality (horseshoe, urethral stricture)
What is the appearance of each type of calculus on X-ray?(which one cant you seen X-ray)
- Calcium oxalate - silky, radio-opaque (white)
- Struvite - large, staghorn, radio-opaque (white)
- Urate - brown, radiolucent (CANT SEE on X-ray)
- Hydroxyapatite - smooth, large, radio-opaque (white)
- Cysteine - yellow, crystal, semi-opaque
Presentation of renal stones?
Renal stones
- Renal colic pain - fast onset/excruciating/loin to groin
- Writhing around in agony! (if peritonitis-would be still)
- Worse on micturition (dysuria) - Urinary retention if obstruction (anuria)
- Systemic- fevers, rigors, N+V
Examination of renal stones?
What would you want to exclude?
Examination of renal stones
- Renal angle tenderness - especially on percussion if there is retroperitoneal inflammation
- Palpable kidney = indicates hydronephrosis
- Reduced bowel sounds (as in any severe pain)
- Severe pain in testis but NOT tender on palpation
**Ensure abdominal exam excludes appendicitis, ectopic preg, AAA
Investigations of renal stones? (bedside, bloods, imaging)
Bedside -urine dip \+ Blood (suggestive of stones) \+ Leucocyt, + Nitrates (both suggest infection – independent or concomitant to stones) \+Protein
-MSU sent for MCS
Pyuria – suggests infection (consider pyelonephritis)
Bloods
↑CRP ↑ESR, U+Es (Urea, Creat – assess renal function)
Imaging
1st line: NON CONTRAST helical CT scan!! best for seeing kidney stones
(if pregnant or child do USS)
1st line imaging for renal colic?
Non-contrast CT (99% visible, whilst excluding other causes of acute abdomen)
How do you treat renal stones <5mm
Increase fluid intake - 90% pass spontaneously
Analgesia - diclofenac IV/PR/IM (opioids if CI)
Anti emetic- metoclopramide
Antibiotics - penicillin/gentamicin if infection
How do you treat renal stones >5mm
Medical expulsive therapy
- Nifedipine (calcium-channel blocker) or tamsulosin (alpha blocker) allows stone to pass
If don’t pass within 48 hours:
- Extracorporeal shockwave lithotripsy (SLW)(ultrasound waves shatter the stone)
- Uteroscopy (tube passed up to stone)
*Percutaneous nephrolithotomy = keyhole surgery to remove stones if complex/large
What can cause a urethral stricture?
Urethral stricture
- Iatrogenic eg traumatic catheter
- STI
- Lichen sclerosus
- Hypospadias
Investigation and treatment of urethral stricture ?
Ix: USS or urethrography
Tx: Dilatation (balloon dilation) or Endo-ureterotomy (cut through scope)
What is Vesico-Ureteric Reflux (VUR)?
Who normally gets it?
Vesico-Ureteric Reflux (VUR)
-Ureters are displaced laterally → abnormal backflow of urine from bladder into ureter and kidney → recurrent UTI → Renal scarring
Presentation
Recurrent UTIs – typically presentation at childhood
What is the diagnostic investigation for Vesico-Ureteric Reflux
- Micturating cystourethrogram – diagnostic for VUR
* can also do DMSA to look for scarring
What is Nephrotic syndrome?
Nephrotic syndrome
- Injury to podocytes wrapped around glomerular capillaries (normally maintain filtration barrier)
- Kidneys leak large amounts of protein into urine
What is the triad of nephrotic syndrome?
Nephrotic syndrome
- Triad of:
- PROTEINURA (> 3g/24 hours)
- HYPOALBUMINAEMIA (<25g/L)
- ODEMIA (low protein in blood>causes fluid to leak into peripheries)
What are the main causes of nephrotic syndrome (adults vs children) and what are the key features on microscopy
Nephrotic syndrome
Children=minimal change disease (light microscopy normal)
Adults
- Minimal change (normal)
- Membranous (spike and dome pattern)
- Focal segmental glomerulosclerosis (focal segments)
Mixed picture (slightly more nephritic): -Membranoproliferative (tram tacks)
What are some key secondary causes of:
Focal segmental glomerulosclerosis
Membranous
Membranoproliferative
- Focal segmental glomerulosclerosis=2ndry to heroin/HIV
- Membranous =2ndry to Lupus/malignancy
- Membranoproliferative =2ndry to Hep C-tram tracks
*also diabetes, amyloidosis, drugs (NSAIDs, penicillamine, anti-TNF)
Presentation of nephrotic syndrome?
Differentials?
Nephrotic syndrome
-Generalised pitting oedema (can be rapid and severe)
(periorbital/genital common)
-Oliguria + Frothy urine (all the protein)
- Differentials:
- congestive heart disease (raised JVP, pulmonary odema)
- liver disease (↓albumin)
Management of nephrotic syndrome?
Nephrotic syndrome
- Admit
- REDUCE ODEMA
- Fluid and salt restrict (1L/day)
- Loop diuretics (furosemide) oral at first IV if not working
- Aim for weight loss of 0.5-1kg/day
- Thiazides secondline - TREAT UNDERLYING CAUSE
- adults require biopsy (not required in children as minimal change is nearly always cause,unless steroids don’t work)
- give PO Prednisolone in adults/children with minimal change disease - REUDUCE PROTEINURIA
- ACEi or ARB (may not be needed in minimal change disease)
What are the complications of nephrotic syndrome
Nephrotic syndrome complications
Thromboembolism (DVT/PE/renal vein thrombosis because you lose antithrombin III)
-Prophylaxis
-Treat with heparin and warfarin if they occur
Hyperlipideamia (livers responce to loss of protein)
Infection (loss of immunoglobulins in urine)
- Give pneumococcal vaccination
- Treat any infection as normal
How would renal vein thrombosis present?
Renal vein thrombosis
- loin pain and heamaturia
- AKI if bilateral
What is a ‘nephritic’ picture?
Nephritis
- HAEMATURIA
- HYPERTENSION
- Protinuria/hypoalbimineamis/odema
Differentials for URTI and nephritic picture?
What markers would they both have?
How do they present differently?
2-3 weeks ago? Post-strep (post=gone) ↑ASOT ↓C3
-slightly mixed nephritic-nephrotic picture
2-3 days ago? IgA nephropathy/Bergers disease (I=immediatly) ↑IgA
- EPISODIC MACRO HEAMATURIA
- can cause chronic renal failure in 20% like HSP
How is the ADULT form of polycystic kidney disease present?
What chromosomes? (2 different chromosomes)
Polycystic kidney disease
-Adults is autosomal dominant
PKD1 chr.16 (85%) → rapid end stage renal failure (ESRF) by 50
PKD2 chr.4 (15%) → slow progress to ESRF by 70
Often latent presentation, so screening is essential
How does polycystic kidney disease present?
Polycysic kidney disease
- Loin pain (most common 60%) due to:
- ↑Formation of stones = Renal colic
- Haemorrhage (heamaturia)
- Recurrent UTIs
- Sharp pain indicates rupture
- Progressive renal failure (↓UO, ↑ACR, ↓eGFR etc.)
- ↑HYPERTENSTION (→ LVH)
What extra renal manifestations are associated with PCKD?
PCKD-extra renal manifestations
- CYSTS
- hepatic!
- also in pancreas (pancreatitis) spleen, ovary and testicles (infertility)
- CARDIOVASCULAR
- Arterial HTN (morning headaches) > leading to LVH
- Valvular defects, especially MITRAL VALVE PROLAPSE
- Cerebral berry aneurysms (SAH)
- GI
- Diverticulosis
- Abdo / inguinal hernias
How id PCKD diagnosed?
Renal US (diagnostic if positive FH):
- 2 cysts, unilateral or bilateral, if <30yrs
- 2 cysts in both kidneys if 30-59yrs
- 4 cysts in both kidneys if >60yrs
What does examination of PKD show?
Palpable abdo masses that are not tender to touch
Usually bilateral
What is the managent for PCKD? (list both conservative and medical)
Management of PCKD Conservative -Treat any infections/stone/pain -Increase fluids (3-4L/day) -No contact sport → ↑risk of haemorrhage
Medical
- CONTROL BP 1st line ACEi or ARB to HTN (aim <130/80) and to slow proteinuria
- Tolvaptan - Slows growth of cysts
- Pre-empt plan for RRT (heamodialysis/transplant)
What is orthostatic proteinura?
- A type of benign proteinuria characterized by increased protein excretion only in the upright position
- Typically presents with isolated proteinuria during the day and normal protein excretion at night when the individual is in a recumbent position
In which population does orthostatic proteinuria usually present? Does it need treatment?
Obese adolescents
No treatment needed
What is the most common bladder cancer?
Transitional cell carcinoma (90%)
Squamous cell carcinoma (10%)
What are the main risk factors for bladder cancer?
Smoking!!!!!!!! - 50% Aromatic amines (rubber industry) Chronic cystitis Schistosomiasis (SCC) Pelvic irradiation
What is the presentation for bladder cancer?
Bladder cancer
- Painless HAEMATURIA! - treat as malignancy until proven otherwise
- Recurrent UTIs
- Voiding irritability
- Weight loss
What are the diagnostic investigation for bladder cancer?
1st line: Flexible Cystoscopy with biopsy
can also do CT urogram (diagnostic and staging)
What would urinalysis show in bladder cancer?
Sterile pyuria
Haematuria
How do you treat transitional cell carcinoma of bladder?
T1 - transurethral resection of bladder tumour TURBT
+/- chemotherapy +/- intravesical BCG immunotherapy
T2/T3 - radical cystectomy (or radiotherapy if > 70 years)
T4 - palliative care, chronic catheterisation
Where do renal cell carcinomas arise from?
Epithelial cells of proximal convoluted tubules in the renal cortex
What is the triad for renal cell carcinoma presentation?
Renal carncer
- Haematuria - most common presenting symptom
- Loin pain
- Loin mass
What are the most common sites of metastases from renal cell carcinoma?
Lungs - cannon ball mets
Bone
Liver
What is the best initial investigation for suspected renal cell carcinoma?
CT abdo WITH contrast - best initial test for renal cancer
Shows renal lesion with thickened irregular walls, variable enhancement and calcification
What is the treatment for renal cell carcinoma?
Radical nephrectomy
It is generally chemo and radio resistant
What type of carcinoma are most prostatic carcinomas?
Adenocarcinomas of peripheral zone
