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5thyr > Renal > Flashcards

Renal Flashcards

1
Q

What is the pathology of benign prostatic hypertrophy?

how does it differ from prostate carcinoma?

A
  • 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

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2
Q

What symptoms do you get with BPH? (think before, during, after)

A

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)

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3
Q

What symptoms would suggest acute obstruction?

A
  • suprapubic pain/tenderness
  • palpable bladder
  • change from Nocturia/Polyuria → Oliguria/Anuria
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4
Q

What investigations would you do for BPH? (bedside, bloods, imaging )

A

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
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5
Q

What would you feel in BPH on PR?

A

Smooth, symmetrically enlarged prostate with loss of the sulcus

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6
Q

Contraindications for PR?

A
  • 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
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7
Q

What are the drug treatments for BPH?

A
  1. Alpha-blockers e.g. tamsulosin, doxazosin

2. 5-alpha-reductase inhibitors e.g. finasteride

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8
Q

What is the mechanism of alpha blockers?

A

Alpha blockers

-block alpha1-adrenoreceptors in the smooth muscle→ vasodilation → decreased resistance

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9
Q

What are the main side effects of alpha blockers?

A

Postural hypotension

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10
Q

What is another indication for alpha blockers?

A

Resistant hypertension (because it causes postural hypotension as a SE)

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11
Q

What drug should not be prescribed with alpha blockers?

A

Beta-blockers - they inhibit reflex tachycardia needed in response to vasodilation/hypotension

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12
Q

What is the mechanism of finasteride?

A

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)
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13
Q

What are the side effects of 5-alpha-reductase inhibitors? Who should you not give it to?

A

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)

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14
Q

What is hydronephrosis?

A

The swelling of a kidney (dilation of renal pelvis and calyces)
-Due to build up of urine usually caused by an obstruction

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15
Q

How does hydronephrosis present?

A

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

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16
Q

What investigations are useful in hydronephrosis?

bedside, bloods and imaging

A

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
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17
Q

How do you treat a partial urinary obstruction?

A

Partial urinary obstruction

  • Hydration
  • Analgesia
  • Prophylactic antibiotics to prevent infection
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18
Q

Treatment of hydronephrosis?

A
  1. 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
  1. Treat the cause
    - infection, BPH, stones, cancer, retroperitoneal fibrosis
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19
Q

What are the different types of calculi in order of how common they are?

A
  1. Calcium oxalate (75%)
  2. Struvite - magnesium ammonium phosphate (15%)
  3. Urate
  4. Hydroxyapatite (usually due to UTI)
  5. Cysteine (usually due to renal tubular defect)
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20
Q

Risk factors for renal stones?

A

Renal stones risk factors

  • Gout (urate)
  • Hypercalcaemia (hyperthyroidism, hyperparathyroidism, neoplasia, sarcoidosis, lithium)
  • Urinary stasis (bladder stones)
  • Dehydratoin (including diuretics)
  • Anatomical abnormality (horseshoe, urethral stricture)
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21
Q

What is the appearance of each type of calculus on X-ray?(which one cant you seen X-ray)

A
  1. Calcium oxalate - silky, radio-opaque (white)
  2. Struvite - large, staghorn, radio-opaque (white)
  3. Urate - brown, radiolucent (CANT SEE on X-ray)
  4. Hydroxyapatite - smooth, large, radio-opaque (white)
  5. Cysteine - yellow, crystal, semi-opaque
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22
Q

Presentation of renal stones?

A

Renal stones

  1. Renal colic pain - fast onset/excruciating/loin to groin
    - Writhing around in agony! (if peritonitis-would be still)
    - Worse on micturition (dysuria)
  2. Urinary retention if obstruction (anuria)
  3. Systemic- fevers, rigors, N+V
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23
Q

Examination of renal stones?

What would you want to exclude?

A

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

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24
Q

Investigations of renal stones? (bedside, bloods, imaging)

A 
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)

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25
Q

1st line imaging for renal colic?

A

Non-contrast CT (99% visible, whilst excluding other causes of acute abdomen)

26
Q

How do you treat renal stones <5mm

A

Increase fluid intake - 90% pass spontaneously
Analgesia - diclofenac IV/PR/IM (opioids if CI)
Anti emetic- metoclopramide
Antibiotics - penicillin/gentamicin if infection

27
Q

How do you treat renal stones >5mm

A

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

28
Q

What can cause a urethral stricture?

A

Urethral stricture

  • Iatrogenic eg traumatic catheter
  • STI
  • Lichen sclerosus
  • Hypospadias
29
Q

Investigation and treatment of urethral stricture ?

A

Ix: USS or urethrography

Tx: Dilatation (balloon dilation) or Endo-ureterotomy (cut through scope)

30
Q

What is Vesico-Ureteric Reflux (VUR)?

Who normally gets it?

A

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

31
Q

What is the diagnostic investigation for Vesico-Ureteric Reflux

A
  • Micturating cystourethrogram – diagnostic for VUR

* can also do DMSA to look for scarring

32
Q

What is Nephrotic syndrome?

A

Nephrotic syndrome

  • Injury to podocytes wrapped around glomerular capillaries (normally maintain filtration barrier)
  • Kidneys leak large amounts of protein into urine
33
Q

What is the triad of nephrotic syndrome?

A

Nephrotic syndrome

  • Triad of:
    1. PROTEINURA (> 3g/24 hours)
    2. HYPOALBUMINAEMIA (<25g/L)
    3. ODEMIA (low protein in blood>causes fluid to leak into peripheries)
34
Q

What are the main causes of nephrotic syndrome (adults vs children) and what are the key features on microscopy

A

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)
35
Q

What are some key secondary causes of:
Focal segmental glomerulosclerosis
Membranous
Membranoproliferative

A
  • 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)

36
Q

Presentation of nephrotic syndrome?

Differentials?

A

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)
37
Q

Management of nephrotic syndrome?

A

Nephrotic syndrome

  1. Admit
  2. 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
  3. 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
  4. REUDUCE PROTEINURIA
    - ACEi or ARB (may not be needed in minimal change disease)
38
Q

What are the complications of nephrotic syndrome

A

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
39
Q

How would renal vein thrombosis present?

A

Renal vein thrombosis

  • loin pain and heamaturia
  • AKI if bilateral
40
Q

What is a ‘nephritic’ picture?

A

Nephritis

  • HAEMATURIA
  • HYPERTENSION
  • Protinuria/hypoalbimineamis/odema
41
Q

Differentials for URTI and nephritic picture?
What markers would they both have?
How do they present differently?

A

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
42
Q

How is the ADULT form of polycystic kidney disease present?

What chromosomes? (2 different chromosomes)

A

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

43
Q

How does polycystic kidney disease present?

A

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)
44
Q

What extra renal manifestations are associated with PCKD?

A

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
45
Q

How id PCKD diagnosed?

A

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
46
Q

What does examination of PKD show?

A

Palpable abdo masses that are not tender to touch

Usually bilateral

47
Q

What is the managent for PCKD? (list both conservative and medical)

A 
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)
48
Q

What is orthostatic proteinura?

A
  • 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
49
Q

In which population does orthostatic proteinuria usually present? Does it need treatment?

A

Obese adolescents

No treatment needed

50
Q

What is the most common bladder cancer?

A

Transitional cell carcinoma (90%)

Squamous cell carcinoma (10%)

51
Q

What are the main risk factors for bladder cancer?

A 
Smoking!!!!!!!! - 50%
Aromatic amines (rubber industry) 
Chronic cystitis 
Schistosomiasis (SCC) 
Pelvic irradiation
52
Q

What is the presentation for bladder cancer?

A

Bladder cancer

  • Painless HAEMATURIA! - treat as malignancy until proven otherwise
  • Recurrent UTIs
  • Voiding irritability
  • Weight loss
53
Q

What are the diagnostic investigation for bladder cancer?

A

1st line: Flexible Cystoscopy with biopsy

can also do CT urogram (diagnostic and staging)

54
Q

What would urinalysis show in bladder cancer?

A

Sterile pyuria

Haematuria

55
Q

How do you treat transitional cell carcinoma of bladder?

A

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

56
Q

Where do renal cell carcinomas arise from?

A

Epithelial cells of proximal convoluted tubules in the renal cortex

57
Q

What is the triad for renal cell carcinoma presentation?

A

Renal carncer

  • Haematuria - most common presenting symptom
  • Loin pain
  • Loin mass
58
Q

What are the most common sites of metastases from renal cell carcinoma?

A

Lungs - cannon ball mets
Bone
Liver

59
Q

What is the best initial investigation for suspected renal cell carcinoma?

A

CT abdo WITH contrast - best initial test for renal cancer

Shows renal lesion with thickened irregular walls, variable enhancement and calcification

60
Q

What is the treatment for renal cell carcinoma?

A

Radical nephrectomy

It is generally chemo and radio resistant

61
Q

What type of carcinoma are most prostatic carcinomas?

A

Adenocarcinomas of peripheral zone

5thyr (18 decks)

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