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CP3 Management > Renal > Flashcards

Renal Flashcards

1
Q

Tx of AKI

A

A-E assessment

Correction of any hypoxia

Halt any potentially damaging drugs

Restrict potassium intake

Pre-renal causes
Treat shock

Post-renal causes
Refer to urology

Renal causes
Assess fluid status with volume replacement to match known insensible losses
CVP measurement may be necessary
If there is urine output after fluid replacement continue large quantities of fluids +/- diuretics

If there is no urine output or complications are present nephrologist intervention is required

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2
Q

Indications for acute dialysis with AKI

A 
refractory hyperkalaemia
pulmonary oedema
acidosis
uraemic pericarditis/encephalopathy
complete anuria 
drug OD
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3
Q

what is a good indicator of AKI severity

A

furosemide stress test

Furosemide 1mg/kg is give after fluid resus, and urine output over 2 hours is measured and replaced

Volume of fluid output at 2 hours can then be used to demonstrate likelihood of progression to AKI stage III

Generally after a week of oliguria, if the AKI is improving there will be one week of polyuria before return to normal kidney function at week 3

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4
Q

what are common electrolyte abnormalities in AKI

A

Rapidly progressive uraemia
Symptoms progress from anorexia, pruitis, vomiting to encephalopathy (confusion, drowsiness, fitting) and haemorrhagic episodes

Hyperkalaemia

Hypernatraemia (unless pre-renal)

Metabolic acidosis

Hypocalcaemia/hypophosphataemia (more common in CKD)

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5
Q

Tx of Hyperkalaemia

A

Start continuous ECG monitoring

10ml 10% calcium gluconate IV
Repeat at 5 minute intervals to a max of 3 doses until ECG stabilises

50ml of 50% glucose with 10U ACTRAPID insulin into a large vein over 30 mins to decrease K+ concentration

Consider 10mg salbutamol neb (also lowers potassium)

If pH <7.2 consider sodium bicarbonate IV if advised by renal registrar

Recheck K+ after 2 hours

Calcium resonin can then be given orally/rectally, however this is a long term management option

Tackle underlying issue

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6
Q

Tx of CKD

A

Treat reversible causes

First line is blood pressure/diabetic control
<130/80
If proteinuric BP should be <125/75
ACE inhibitors first line

Primary CV prevention is also important
Statin + low dose aspirin

Second line is control of complications
Recombinant EPO for those with anaemia
Calcium/Vit D supplementation
K+ restriction is there is any suggestion of hyperkalaemia

Renal replacement therapy is indicated in those with ESRD
Guidelines suggest this should be for any symptomatic CKD 5 patient however many consultants will delay starting dialysis

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7
Q

Tx of renal bone disese

A

Restrict dietary phosophate

Giving phosphate binders

Adcal supplementation

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8
Q

whats the difference between haemodialysis and haemofiltration

A

Hameofiltration differs from haemodialysis by not transfering solutes via diffusion but via filtration

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9
Q

what are the 2 peritoneal dialysis regimes

A

Continuous ambulatory peritoneal dialysis (CAPD) or continuous cycling peritoneal dialysis (CCPD)

CAPD = every 2 hours up to 3-4 times a day 2L of peritoneal fluid is drained out and a fresh 2L is reinserted into the peritoneal cavity

CCPD = over a 12 hour period fluid is continuously pumped through the abdomen

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10
Q

what is the major risk of peritoneal dialysis

A

peritonitis

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11
Q

dialysis complications

A

Annual mortality is 20%

Infection

Cardiovascular disease

Renal bone disease

Anaemia

Bleeding tendencies

Increased risk of renal malignancy

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12
Q

what assessments are required prior to transplantation

A

Virology/TB assessment
Active infection contraindicated due to risks of immunosuppression

Blood group/HLA matching

Full systemic examination – comorbid disease is a contraindication

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13
Q

operative complications of renal transplantation

A

Bleed

Thrombosis

Infection

Urinary leaks

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14
Q

post-surgical complications of transplant

A

Rejection
Risk highest in the first 3 months
Lifelong immunosuppression because of this
Most episodes of rejection are reversible and in most cases immunological tolerance develops

Ciclosporin/tacrolimus toxicity

Infection/malignancy due to immuosuppression
Skin cancer
Anal cancer
Lymphoma

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15
Q

prognosis of a transplant

A

5 year 80-95% graft survival rate depending on how good the HLA match is

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16
Q

what drugs need adjusting in renal impairment

A

Gentamicin

Cephalosporins

Heparin

Lithium

Opiates

Digoxin

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17
Q

How do you manage minimal change disease in children

A

try steroids and if the child responds within a month biopsy is not required, otherwise biopsy is indicated

steroids tend to resolve it in 4-6 weeks

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18
Q

most common cause of glomerulonephritis in adults

A

beurgers disease (IgA nephropathy)

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19
Q

Tx of Beurgers disease/IgA nepropathy

A

supportive therapy

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20
Q

prognosis of beurgers disease

A

20% progress to ESRD in 20 years

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21
Q

prognosis of minimal change disease

A

1% progress to ESRD

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22
Q

Tx of HSP

A

Attacks are usually self limiting but if there are relapses and evidence of progressive renal involvement then corticosteroids are inidicated

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23
Q

Tx of goodpastures disease

A

plasma exchange and corticosteroids +/- cytotoxics

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24
Q

Tx of RPGN

A

Aggressive immunosuppression (high dose steroid and cyclophosphamide)

Prognosis depends on how early treatment is initiated

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25
Q

Tx of cystitis (empirical)

A

3 days of Nitrofurantoin (100mg BD) /Trimethoprim

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26
Q

Tx of pyelonephritis

A

IV tazocin 4.5g TDS

At least 7 days

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27
Q

Tx of asymptomatic UTI in pregnant women

A

Always treat, for at least 7 days

avoid nitrofurantoin at term due to neonatal haemolysis risk + avoid trimethoprim in first trimester as it is teratogenic

consult local guidelines but generally nitrofurantoin/amoxicillin/cefalexin advised by NICE

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28
Q

Tx of recurrent UTI

A

Advice on high fluid intake , frequent voiding (specifically after sex), avoidance of spermicidal jellies and avoidance of constipation

If this fails trimethoprim/nitrofurantoin prophylaxis may be started

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29
Q

Tx of hydronephrosis secondary to ureteric obstruction

A

Nephrostomy
If there is significant enough hydronephrosis
Prevents fluid accumulation and damage

Surgical stenting, depending on cause

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30
Q

Acute Tx of renal calculi

A

A-E assessment

75mg IM diclofenac unless contraindicated

Beware post renal AKI

IM metclopramide if severe vomiting

IV Abx if there is infection

31
Q

admission requirements for renal calculi

A

Still pain after 1 hour

Risk of AKI

Signs of shock/infection

Uncertainty over diagnosis

32
Q

indications for active treatment of renal calculi

A

Low chance of spontaneous passage (>10mm)

Persistent pain

Ongoing obstruction

Signs of infection

Renal insufficiency

33
Q

options for active treatment of renal calculi

A

Extracorporeal shockwave lithiotripsy (ESWL)
Outpatient procedure that focuses shockwaves on stones to break them up and then it can be passsed spontaneously

If there is hydronephrosis present there may need to be a nephrostomy first to decompress the pelvicalyceal system

Uretoscopy

Various energy sources e.g. laser can be used to break up a stone

Percutaneous nephrolithotomy
Used for renal, (not ureteric) calculi that do not respond to ESWL

34
Q

conservative management of renal calculi

A

Tamsulosin/nifedipine increase the rate of spontaneous expulsion

Advice if sending home
80% pass naturally
Maintain a high fluid intake
Advise to return if there is an increase in pain or signs of infection

First time stone formers should be advised to urinate into a seive to collect the stone for analysis

Refer the patient to urology within a week

35
Q

Tx of bladder stones

A

same as renal stones

36
Q

complications of bladder stones

A

increased risk of TCC

37
Q

Tx of wilms tumour

A

nephrectomy and pre-operative chemotherapy

38
Q

Tx of renal cell carcinoma

A

Radical nephrectomy

Partial nephrectomy
If peripheral tumour <5cm
If bilateral tumours or contralateral poor kidney function

Post-op chemo

39
Q

prognosis of Renal cell carcinoma

A

65% 5 year survival if N0, 25% if there is nodal involvement, 5% if there are distant mets

40
Q

Tx of bladder cancer

A

Carcinoma in situ or T1 bladder carcinomas
Transurethral resection of bladder tumour ay systoscopy with intravesical chemotherapy

5 year survival = 95%

T2 – T3 or high grade tumours
Radical cystectomy + pre-op chemo
Ileal conduit is used to leave an urostoma

T4 (invasion beyond the bladder)
Treated palliatively

Long term follow up with cystoscopy is then required

41
Q

Tx of bladder rupture

A

Intraperitoneal bladder rupture
Treated with laporotomy and suturing of the bladder

Extraperitoneal bladder rupture
Treated conservatively with prolonged urethral or suprapubic catheterisation

42
Q

Tx of bladder outlet obstruction

A

Catheterisation
Beware of large diuresis following relief of obstruction

Find and treat underlying cause

43
Q

Tx of acute retention secondary to BPH

A

urethral catheterisation

suprapubic catheterisation if not possible

44
Q

lifestyle advice in BPH

A

Avoid alcohol/caffeine

Relax when voiding

Void twice in a row to help voiding

Bladder retraining

45
Q

medical management of BPH

A

Alpha blockers + behavioural management programme
e.g. Tamsulosin, Doxasocin

5-alpha reductase inhibiotors + behavioural management programme
e.g. Finasteride
indicated in prostate >30 grams over alpha blockers
Stops testosterone conversion to dihydrotestosterone reducing enlargement

PDE-5 inhibitors

anticholinergic agents

46
Q

when is conservative management advised for BPH

A

when symptoms are mild/not bothersome

47
Q

side effects of finasteride

A

Impotence

Reduced libido

It is excreted in semen so condoms should be used

48
Q

surgical management of BPH

A

Transurethral resection of the prostate (TURP)
10% risk of impotence, 20% need a repeat within 10 years
Retrograde ejaculation is almost universal after the procedure
Other risks are bleeding and TURP syndrome
Absorption of fluid washout leads to hyponatraemia and fits

Holmium laser prostatectomy (HoLEP)
Endoscopic increasingly used for larger prostates
Urinary incontinence may occur if too much of a gland is removed
In general morbidity from TURP/HoLEP procedures is low

49
Q

indications for surgical management of BPH

A

refractory responses to medication

complications attributed to BPH such as renal insufficiency, bladder stones, recurrent haematuria or urinary tract infections

development of urinary tract retention.

50
Q

what is the gleason grade and D’amico risk stratification

A

Done after biopsy, two different biopsies are given a ‘score’ out of 5 based on grade and then they are added together

Vital for prognosis

<6 = low risk

> 8 = high risk

d’amico = Combines gleason score with clinical stage and PSA give a more accurate prognostic score than gleason alone

51
Q

Tx of prostate cancer

A

Generally depends on surgical fitness of the patient along with the stage/grade of the disaese

T1/T2 (local disease) - patient has a choice between:
Active surveillance - Regular PR, PSA, biopsies
Radiotherapy/Brachytherapy (Brachytherapy = radioactive pellets in prostate)
Surgery - Radical prostatectomy

Advanced disease (T3/4)  
Active surveillance not recommended

Choice between radiotherapy or surgery – treatment outcomes the same

Metastatic disease
Hormonal therapy
GnRH agonists - Gosrelin/buserelin
Can be palliative or an adjunct to curative treatment
An antiandrogen such as cyproterone acetate is co-prescribed initially to prevent an early rise in testosterone

52
Q

Tx of gonorrhea

A

IM ceftriaxone

Follow up and repeat cultures in 3 days

Trace and treat all sexual contacts

53
Q

Tx of Chlamydia

A

1g azithromycin as a single dose, or 7 day course of doxyxycline/erythromycin

Test of cure not required in a simple infection

Trace sexual contacts

54
Q

Tx of urethral tears

A

If the urethral wall is partially intact (determined by contrast urethrography) it can be treated conserviatively by prolonged catheterisation

Complete tears require suprapubic catheterisation and formal repair

55
Q

Tx of urethral strictures

A

First-line = optical urethrotomy

Urethroplasty for recurring injury (50%)

56
Q

Tx of phimosis

A

Circumcision is the treatment of choice for troubling symptoms

57
Q

Tx of paraphimosis

A

Emergency treatment
Anaesthesia
Applying pressure to glans
Slitting of the foreskin dorsally (if required)

Circumcision
Offered after a paraphimosis to prevent recurrence

58
Q

Tx of priapism

A

Ice packs

Alpha agonists

Selective embolisation

Aspiration of the corpus cavernosum

Surgical intervention

59
Q

tx of Peyronies

A

Managing associated depression if present

Surgical intervention may help penetration

60
Q

Tx of maldescent of the testes

A

if ectopic or undescended = orchidoplexy at 6 months if not descended

if merely retractile testes (can be coaxed down from external ring) - normal

61
Q

complications of maldescent of the testes

A

Defective spermatogenesis

Increased risk of torsion

Increased risk of malignancy

Increased risk of indirect inguinal hernia

62
Q

Tx of epididymal cysts

A

usually left alone

if causing troublesome symptoms they can be excised

63
Q

Tx of hydrocele

A

Most patients presenting with hydrocele should be scanned to rule out underlying causes

Most hydroceles are benign and not troublesome

If the swelling is causing a problem then the excision of the hydrocele sac is possible – aspiration leads to recurrence

64
Q

Tx of varicocele

A

usually, reassurance is enough - surgical management does not ensure return of fertility

Radiological embolisation of the left renal vein

Surgical ligation and division of the testicular veins

65
Q

Tx of testicular tumours

A

Testicular tumour suspected = early surgical exploration through inguinal incision indicated

Orchidectomy for obvious/previously diagnosed tumours

Biopsy and frozen section if diagnosis is unclear

If diagnosis confirmed orchiectomy performed

Retroperitoneal lymph node dissection may also be undertaken

Post surgical radiotherapy Indicated for seminomas (highly radiosensitive)

Post surgical chemotherapy for NSGCTs - (not radiosensitive)

Sperm banking used due to risk of infertility

66
Q

prognosis of testicular cancer

A

Node negative cases have nearly 100% 5 years survival

Overall >90%

67
Q

Tx of testicular torsion

A

Emergency Surgery

If the testes is still viable it is untwisted and sutured to the tunica vaginalis with contralateral testicular fixation also (prevent future events)

Non-viable = orchidectomy and fixation of the contralateral testes should occur

68
Q

prognosis of testicular torsion

A

Salvage rate of 80% is achievable if the patient is operated on within 6 hours of event

69
Q

Tx of epididymo-orchitis

A

6 weeks ciprofloxacin
+ doxycycline if suspecting chlamydia

Analgesia and scrotal support may provide relief

70
Q

Tx of acute prostatitis

A

6 weeks of ciprofloxacin

71
Q

medical Tx of male erectile dysfunction

A

Sildenafil – viagra
Induces vasodilation
Fills corpus cavernosa with blood

Intracavernosal prostaglandin injections

vacuum condoms or inflatable intrapenile prostheses if these treatments fail

72
Q

when is siladefinil contraindicated for erectile dysfunction

A

patients on hypotensives

73
Q

lifestyle advice for erectile dysfunction

A

Treat reversible medical causes

Correct hormonal disturbances

Stop smoking

Reduce alcohol intake

Treat diabetes

CP3 Management (11 decks)

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