Renal Flashcards
Tx of AKI
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
Indications for acute dialysis with AKI
refractory hyperkalaemia pulmonary oedema acidosis uraemic pericarditis/encephalopathy complete anuria drug OD
what is a good indicator of AKI severity
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
what are common electrolyte abnormalities in AKI
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)
Tx of Hyperkalaemia
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
Tx of CKD
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
Tx of renal bone disese
Restrict dietary phosophate
Giving phosphate binders
Adcal supplementation
whats the difference between haemodialysis and haemofiltration
Hameofiltration differs from haemodialysis by not transfering solutes via diffusion but via filtration
what are the 2 peritoneal dialysis regimes
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
what is the major risk of peritoneal dialysis
peritonitis
dialysis complications
Annual mortality is 20%
Infection
Cardiovascular disease
Renal bone disease
Anaemia
Bleeding tendencies
Increased risk of renal malignancy
what assessments are required prior to transplantation
Virology/TB assessment
Active infection contraindicated due to risks of immunosuppression
Blood group/HLA matching
Full systemic examination – comorbid disease is a contraindication
operative complications of renal transplantation
Bleed
Thrombosis
Infection
Urinary leaks
post-surgical complications of transplant
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
prognosis of a transplant
5 year 80-95% graft survival rate depending on how good the HLA match is
what drugs need adjusting in renal impairment
Gentamicin
Cephalosporins
Heparin
Lithium
Opiates
Digoxin
How do you manage minimal change disease in children
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
most common cause of glomerulonephritis in adults
beurgers disease (IgA nephropathy)
Tx of Beurgers disease/IgA nepropathy
supportive therapy
prognosis of beurgers disease
20% progress to ESRD in 20 years
prognosis of minimal change disease
1% progress to ESRD
Tx of HSP
Attacks are usually self limiting but if there are relapses and evidence of progressive renal involvement then corticosteroids are inidicated
Tx of goodpastures disease
plasma exchange and corticosteroids +/- cytotoxics
Tx of RPGN
Aggressive immunosuppression (high dose steroid and cyclophosphamide)
Prognosis depends on how early treatment is initiated
Tx of cystitis (empirical)
3 days of Nitrofurantoin (100mg BD) /Trimethoprim
Tx of pyelonephritis
IV tazocin 4.5g TDS
At least 7 days
Tx of asymptomatic UTI in pregnant women
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
Tx of recurrent UTI
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
Tx of hydronephrosis secondary to ureteric obstruction
Nephrostomy
If there is significant enough hydronephrosis
Prevents fluid accumulation and damage
Surgical stenting, depending on cause
Acute Tx of renal calculi
A-E assessment
75mg IM diclofenac unless contraindicated
Beware post renal AKI
IM metclopramide if severe vomiting
IV Abx if there is infection
admission requirements for renal calculi
Still pain after 1 hour
Risk of AKI
Signs of shock/infection
Uncertainty over diagnosis
indications for active treatment of renal calculi
Low chance of spontaneous passage (>10mm)
Persistent pain
Ongoing obstruction
Signs of infection
Renal insufficiency
options for active treatment of renal calculi
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
conservative management of renal calculi
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
Tx of bladder stones
same as renal stones
complications of bladder stones
increased risk of TCC
Tx of wilms tumour
nephrectomy and pre-operative chemotherapy
Tx of renal cell carcinoma
Radical nephrectomy
Partial nephrectomy
If peripheral tumour <5cm
If bilateral tumours or contralateral poor kidney function
Post-op chemo
prognosis of Renal cell carcinoma
65% 5 year survival if N0, 25% if there is nodal involvement, 5% if there are distant mets
Tx of bladder cancer
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
Tx of bladder rupture
Intraperitoneal bladder rupture
Treated with laporotomy and suturing of the bladder
Extraperitoneal bladder rupture
Treated conservatively with prolonged urethral or suprapubic catheterisation
Tx of bladder outlet obstruction
Catheterisation
Beware of large diuresis following relief of obstruction
Find and treat underlying cause
Tx of acute retention secondary to BPH
urethral catheterisation
suprapubic catheterisation if not possible
lifestyle advice in BPH
Avoid alcohol/caffeine
Relax when voiding
Void twice in a row to help voiding
Bladder retraining
medical management of BPH
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
when is conservative management advised for BPH
when symptoms are mild/not bothersome
side effects of finasteride
Impotence
Reduced libido
It is excreted in semen so condoms should be used
surgical management of BPH
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
indications for surgical management of BPH
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.
what is the gleason grade and D’amico risk stratification
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
Tx of prostate cancer
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
Tx of gonorrhea
IM ceftriaxone
Follow up and repeat cultures in 3 days
Trace and treat all sexual contacts
Tx of Chlamydia
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
Tx of urethral tears
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
Tx of urethral strictures
First-line = optical urethrotomy
Urethroplasty for recurring injury (50%)
Tx of phimosis
Circumcision is the treatment of choice for troubling symptoms
Tx of paraphimosis
Emergency treatment
Anaesthesia
Applying pressure to glans
Slitting of the foreskin dorsally (if required)
Circumcision
Offered after a paraphimosis to prevent recurrence
Tx of priapism
Ice packs
Alpha agonists
Selective embolisation
Aspiration of the corpus cavernosum
Surgical intervention
tx of Peyronies
Managing associated depression if present
Surgical intervention may help penetration
Tx of maldescent of the testes
if ectopic or undescended = orchidoplexy at 6 months if not descended
if merely retractile testes (can be coaxed down from external ring) - normal
complications of maldescent of the testes
Defective spermatogenesis
Increased risk of torsion
Increased risk of malignancy
Increased risk of indirect inguinal hernia
Tx of epididymal cysts
usually left alone
if causing troublesome symptoms they can be excised
Tx of hydrocele
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
Tx of varicocele
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
Tx of testicular tumours
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
prognosis of testicular cancer
Node negative cases have nearly 100% 5 years survival
Overall >90%
Tx of testicular torsion
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
prognosis of testicular torsion
Salvage rate of 80% is achievable if the patient is operated on within 6 hours of event
Tx of epididymo-orchitis
6 weeks ciprofloxacin
+ doxycycline if suspecting chlamydia
Analgesia and scrotal support may provide relief
Tx of acute prostatitis
6 weeks of ciprofloxacin
medical Tx of male erectile dysfunction
Sildenafil – viagra
Induces vasodilation
Fills corpus cavernosa with blood
Intracavernosal prostaglandin injections
vacuum condoms or inflatable intrapenile prostheses if these treatments fail
when is siladefinil contraindicated for erectile dysfunction
patients on hypotensives
lifestyle advice for erectile dysfunction
Treat reversible medical causes
Correct hormonal disturbances
Stop smoking
Reduce alcohol intake
Treat diabetes
