renal Flashcards
1
Q
classification of CKD
A
2
Q
proteinuria?
A
3
Q
earliest expression of diabetic nephropathy?
A
microalbuminuria
4
Q
how to differentiate between pre-renal failure and intrinsic renal damage
A
5
Q
functions of kindey
A
maintain water + electoclyte balance
acid-base balance
excrete waste products (urea + creatinine)
produces erythropoetin adn renin
6
Q
function of proximal covoluted tubule?
loop of henle?
distal convoluted tubule?
A
PCT = reabsorbs 100% glucose, proteins, carbohydrates
* 70% Na+ and H2O
Loop of Henle = creates hypeosmotic environment in medulla
DCT = reabsorbs water, Na+ and bicarbnate, excretes K+ and H+
7
Q
epithelial cells lining glomerular capallaries?
glomerular filter?
A
podocytes
glomerular filter = enodthelium of capillary + basement membrane + pedicels of podocytes
8
Q
blood supply to renal medulla?
A
vasa recta
9
Q
hormone that acts on DCT?
A
ALDOSTERONE
increases reabsorption of Na+ thus water, increasing BP
10
Q
what hormone acts on collecting ducts?
A
ADH - increases water reabsoprtion
11
Q
structures lined by transitional epihtelium (urothelium)?
features
A
mior calyx, major calyx, ureter, bladder
cells of luminal surface called umbrella cells because domed
12
Q
urethra of female vs male
A
female 3-5cm
* lined by trnasitional epithelium which transitions to stratified squamous
male 20cm
* prostatic urethra (from bladder through prostate) - transitional epithelium
* membranous (from prostate to bulb of penis) - transitional changes to straified columnar
* penile urethra - changes to stratified squamous
13
Q
osmolarity of body fluids
A
300 mosmol/l
14
Q
body water components
A
ICF = 70%
ECF = 30%
* ECF = plasma (20%), interstitial fluid (80%), lymph
15
Q
how to calculate body fluid compartments
A
TBW = ICF + ECF
tracer for ECF = inulin
TBW = H2O
ICF = TBW - ECF
16
Q
ionic concentrations of ICF vs ECF
A
17
Q
osmotic concentratiosn of ECF vs ICF
A
IDENTICAL 300 mosmol/l
18
Q
extracellular K+?
A
>95% of K+ is intracellular
leakages can cause
* muscle weakness + paralysis
* arrhythmias and cardaic arrest
19
Q
regulation of renal blood flow thus GFR
A
extrinsic = sympathetic via baroreceptor reflex
intrinsic = myogenic + tubuloglomerular feedback
20
Q
if capillary blood pressure falls…
A
GFR will decrease
21
Q
kidney response to haemorrhage
A
22
Q
mucula densa cell function?
A
sense NaCl content of tubular fluid
high levels = constriction of afferent arterioles
23
Q
other determinants of glomerular filtration rate
A
24
Q
plasma clearance of inulin? - what is used instead
glucose?
what is used to calculate renal plasma flow?
A
inulin = GFR (creatinine used clinically)
glucose = 0
para-amino hippuric acid (PAH) used to calculate renal plasma flow
25
accelerated hypertension?
medical emergency
diastolic BP \>120 mmHg
papilloedema
encephalopathy, fits, cardiac failure, acute renal failure
26
leukonychia?
splinter haemorrhages?
leukonychia seen in nephrotic syndrome - low albumin
splinter haemorrhages - CKD, vasculitis
27
UTI urinalysis
leukocytes + nitrites
28
normal 24 hour urine?
normal P:CR
grading proteinuria
normal 24 hour = \<150mg/24 hours
urine protein:creatinine = 0.5g/24 hours
asymptomatic low grade = PCR \<1g/day
heavy proteinuria = PCR 1-3 g/day
nephrotic = PCR \>3g/day
ACR \>30 = proteinuria
29
what does this show?
LVH!!
| (probably severe hypertension)
30
what does this show?
hyperkalaemia - tall teneted T waves
31
Acute kidney injury?
classifcation?
An abrupt (\<48 hrs) reduction in kidney function defined as:
* Increase in serum creatinine by \>26.4umol/l (50%)
* Reduction in UO
32
nephrotic syndrome triad?
proteinuria \>3g/day
hypoaluminaemia
oedema
33
nephritic syndrome symptoms?
AKI
oliguria
oedema/fluid retention
hypertension
active urinary sediment - RBCs (haematuria), leukocytes
34
risk factors AKI?
older age
CKD
Diabetes
Cardiac failure
Liver disease
PVD
Previous AKI
Also – hypotension, hypovolaemia, sepsis, deteriorating NEWS, **recent contrast**, exposure to certain medications
35
Ax pre-renal AKI?
Tx?
pre-renal AKI (commonest cause of AKI in hopsital - **sepsis + severe dehydration**)
* hypovolaemia = haemorrhage, burns
* hypotension = cardiogenic shock, sepsis, anapylaxis
* renal hypoperfusion = NSAIDs, ACEI, hepatorenal syndrome, **rhadbomyolysis**
Tx = fluid challenge for hypovolaemia (NaCL, NOT dextrose)
36
Ax AKI?
pre-renal
renal
post-renal
37
untreated pre-renal AKI?
leads to tubular necrosis
38
Ax renal AKI?
Vascular
* Vasculitis, renovascular disease
Glomerular
* Glomerulonephritis
Interstitial nephritis
* Drugs - antibiotics e.g. penicillin
* Infection (TB)
* Systemic (sarcoid)
Tubular injury
* Ischaemia
* Drugs (gentamicin)
* Contrast
* Rhabdomyolysis
39
s/s renal AKI?
Anorexia, weight loss, fatigue
N + V
Itch
Fluid overload – oedema, SOB
Signs
* Fluid overload – hypertension, oedema, pul oedema, effusions
* Uraemia – itch, pericarditis
* Oliguria
40
clues to cause of renal AKI?
History e.g. sore throat (antibiotics), rash (vasculitis), joint pains, D + V, haemoptysis
Recent contrast
Drugs
Bloods – eosinophilia, CK
Vascular bruits
41
Dx renal AKI?
obviously increase in serum creatinine \>26.4 (50%)
+ reduction in UO
in addition:
* U + Es (hyperkalaemia)
* FBC + coagulation (abnormal clotting, anaemia, CK)
* urinalysis (haematoproteinuria)
* USS (?obstruction)
* immunology - ANA, ANCA, GBM
42
Tx renal AKI?
Stop nephrotoxics
Establish good perfusion pressure – fluid resuscitiate (if no improvement = **inotropes, vasopressors**)
Treat underlying cause
Dialysis if no urine passage
43
life threatening complications AKI?
Hyperkalaemia
Fluid overload (pulmonary oedema)
Severe acidosis (pH \<7.15)
uraemic pericardial effusion
severe uraemia (\>40)
44
post-renal AKI Ax?
Tx?
Obstruction of urine flow leading to back pressure (**hydronephrosis**)
Ax = Stones, cancer, strictures, BPH
Tx = relieve obstruction, catheter/nephrostomy
45
life threatening hyperkalaemia?
signs?
Tx?
Life threatening hyperkalemia = \>6.5
signs = muscle weakness, T waves on ECG
Tx = **calicum gluconate** (to protect myocardium), then insulin with 50% dextrose (move K+ back into cells), then calcium resonium (to stop GI absoprtion)
46
urgent indications for dialysis?
Hyperkalaemia \>7 ( or \>6.5 unresponsive to therapy)
Sever acidosis pH \<7.15
Fluid overload
Urea \>40, pericardial rub/effusion
47
ECG changes hyperkalaemia?
48
medicines to stop on sick days?
ACE-I and ARBS
NSAIDs
diuretics
metformin + empagliflozin
49
1 = goodpasture's syndrome
2 = rhabdomyolysis?
3 = acute tubular necrosis?
4 = obstructive uropathy
50
furosemide
51
calcium gluconate
52
elevated creatinine
53
kidneys reabsorb....
99% of fluid
99% of salt
100% of glucose
100% of amino acids
50% of urea
0% creatinine
54
proximal tubule absoprtion + secretion?
fluid is?
Reabsorbed in PT
* 70% Na (via K+ATPase) + water
* 100% glucose + amino acid
* phosphate, sulphate, lactate
Secreted in PT
* H+, neurotransmitters, bile pigments, uric acid, drugs, toxins
fluid is **iso-osmitic (~300)** in PT
55
Loop of Henle function?
physiology
formation of **hypertonic urine**
## Footnote
entire loop functions as **countercurrent multiplier**
together the loop and vasa recta establish a **hyper-osmotic medullary interstitial fluid**
56
ascending vs descending limb loop of henle?
57
CKD Dx?
complications?
CKD requires 2 samples at least 90 days apart
comps = AKI, falls, fragility
58
stages CKD?
59
ACR CKD?
60
golden rules of CKD?
Monitor people for development/progression of CKD for at least **2-3 years after AKI**, EVEN IF serum creatinine has returned to baseline
Advise people who have had AKI that they are at increased risk of CKD
61
accelerated progression CKD?
risk factors associated wtih CKD progression?
Sustained decrease in GFR of \>25% within 12 months
OR
Sustained decrease in GFR of 15/ml/min per year
risk factors = CVD, AKI, hypertension, **diabetes, smoking**, chronic use of NSAIDs, untreated urinary outflow obstruction, African/Asian origin
62
people with CKD who should be referred for specialist assessment?
GFR \<30 (G4 + 5)
ACR \>70
ACR \>30 with haematuria
sustained decrease of GFR by 25% in 12 months
poorly controlled hypertension
suspected renal artery stenosis
63
blood pressure targets CKD?
In people with CKD, aim to keep **\<140/90**
In people with CKD and diabetes, keep **\<130/80**
64
CKD Tx?
ACE-I/ARB
atorvastatin 20mg
alfacalcidol, phosphate binders, calcimimetic for CKD-MBD
iron therapy for anaemia
65
Ax CKD?
66
clinical signs CKD?
Anaemia – conjunctival + palmar pallor
Weight loss
Advanced uraemia
* Lemon yellow
* Uraemic frost
* Twitching
* Encephalopathic flap
* Confusion
* Pericardial rub/effusion
* Kussmaul breathing (metabolic acidosis)
67
symptoms CKD?
Uraemic
* N + V
* Anorexia
* Weight loss
* Fatigue
* Itch
* Altered taste
* Restless legs
* Muscle twitching
* Difficulties concentrating
* Confusion
Thirst
Anaemia = fatigue, muscle weakness
Pain = bony, neuropathic, ischaemic, visceral
68
consequences CKD?
Renal
* Pain, haemorrhage, infection
* Haematuria, proteinuria
* Impaired salt and water handling
* Hypertension
* Electrolyte abnormalities
* Acid-base disturbance (metabolic acidosis)
* **ESRD**
Extra-renal
* CVD
* Mineral and bone disease (extra PTH, calcium moved from inside bones)
* Anaemia
* Malnutrition
69
ESRD Tx?
dialysis
transplant
70
CVD in CKD?
Starts early – **eGFR \<50**
Risk increases with **microalbuminuria** even if eGFR normal
71
Tx CKD-mineral bone disease
Phosphate restriction
Salt reduction
Potassium restriction
Fluid restriction
meds = alfacalcidol, phosphate binders (aluminium), calcimimetic (Cinacalcet)
72
renal anaemia?
Target?
**renal anemia = HB \<100 despite no iron deficiencies**
target Hb = 100-120g/l
73
autosomal dominant polycystic renal disease Ax?
significance?
S/s?
extra-renal features?
Mutation in PKD1 gene
**Important cause of ESRD!!**
s/s = chronic pain (back), hypertension, haematuria (cyst rupture etc), cyst infection, **renal failure**
extra-renal:
* **hepatic cysts**
* **intra-cranial aneurysms!!**
* cardiac valvular disease
* abdominal/inguinal hernias
74
Dx ADPKD?
USS = cysts + renal **enlargement**
CT/MRI
genetics - PKD1
75
ADPKD genetic counselling?
Offspring of affected individual 50% risk of having disease
76
Tx ADPKD?
**Tolvaptan!**
control BP
if progressed to renal failure = dialysis + transplant
77
autosomal recessive PKD affects?
gene?
cysts where?
S/s?
children - associated with **hepatic lesions**
gene = PKDH1 on chromosome 6
cysts bilateral + symmetrical, **collecting ducts!**
**S/s**
* kidneys always palpable
* hypertension
* recurrent UTI
78
Alport's syndrome?
S/s?
Dx?
Tx?
X-linked herediatary nephritis
S/s = **haematuria,** sensorineural deafness, anterior lenticonus, leiomyoma of oesophagus/genitalia
Dx = **suspect in haematuria + hearing loss**
renal biopsy characteristic feature = variable GMB thickness
Tx = no specific treatment, treat BP, maybe dialysis/transplant
79
Anderson Farby's disease clinical features?
Dx?
Tx?
features = **renal failure, angiokeratomas**, cardiomyopathy + valve disease, stroke, acroparaesthesia
Dx = plasma a-GAL, renal biopsy
Tx = enzyme replacement - **fabryzyme**
80
medullary cystic kidney?
difference from ADPKD?
Dx?
Tx?
autosomal dominant
difference from ADPKD = **normal sized/small kindeys** (in ARPKD and ADPKD kidneys are **enlarged + palpable**)
Dx = family history + CT scan
Tx = renal transplant
81
medullary sponge kidney?
sporadic inheritance - medulla looks like a sponge
82
fluid in loop of henle?
Tubular fluid leaving loop of Henle entering distal convoluted tubule is hypo-osmotic to plasma
83
hormones controlling fluid + electolyte balance?
ADH = increased water reabsorption (collecting duct)
Aldosterone = increased **Na reabsorption**, increased **H+/K+ secretion** (DCT)
Atrial natriuretic hormone = **decreased** Na reabsorption
Parathyroid hormone (PTH) = **increased** calcium reabsorption, **decreased** phosphate reabsorption
84
distal tubule fluid?
permeability?
segments?
Tubular fluid is **hypo-osmotic** to plasma
Distal tubule has **LOW** permeability to water and urea
Distal tubule can be described as 2 segments (early + late)
* Early = **NaCl reabsorption**
* Late = Ca, Na, K reabsorption (except **K+ is secreted in presence of aldosterone**) + H+ secretion
85
high ADH?
low ADH?
High ADH = high water permability + hypertonic urine
Low ADH = low water permeability + hypotonic urine
86
diabetes insipidus s/s?
Tx?
s/s = large volumes of dilute urine + constant thirst
Tx = **ADH replacement**
87
ADH release?
**hypothalamic osmoreceptors!!! = most important**
also stimulated by decreased left atrial pressure = increased ADH
GI stretch receptors = inhibits ADH
nicotine **stimulates** ADH, alcohol **inhibits**
88
aldosterone released by?
when?
function?
aldosterone secreted by **adrenal cortex**
secreted in response to **rising K+** or **falling Na+** in the blood
OR **activation of RAAS**
stimulates Na+ reabsorption and K+ secretion in DCT
89
effect of aldosterone?
Normally **90% of K+** is reabsorbed in **proximal tubule**
When aldosterone absent, the rest is reabsorbed in the distal tubule (therefore, no K+ excreted in urine)
An increase in [k+] **directly** stimulates adrenal cortex
**Aldosterone stimulates** **secretion of K+ in distal tubule**
A decrease in plasma [Na+] promotes **indirect** secretion of aldosterone
90
triggers for renin release from JGA?
reduced pressure in afferent arteriole
macula densa cells (decreased NaCl)
reduced arterial blood pressure
91
what is responsible for fluid retention in congestive heart failure?
Tx?
RAAS
Tx = low salt diet, loop diuretics + **ACE-I**
92
Atrial natriuretic peptide?
Heart produces ANP which is stored in atrial muscle cells
ANP released when cells mechanically stretched due to increase in circulating plasma volume
ANP promotes excretion of Na+ and diuresis
Lowers BP :))
93
micturation controlled by?
Micturition reflex
* Stretch receptors in bladder wall initiate micturition reflex
* Bladder contraction and opening of internal and external urethral sphincters
Voluntary control
* Tightening of external sphincter and surrounding pelvic diaphragm
94
aldosterone summary
95
pH of artrial vs venous blood?
increase in [H+]?
pH of arterial blood = 7.45
pH of venous blood = 7.35
An increase in H+ REDUCES pH
96
complication of acidosis?
alkalosis?
acidosis = depression of CNS
alkalosis = overexcitability of PNS and then CNS
97
most important physiological buffer
98
what is the most common cause of ESRD?
2nd most common?
most common = diabetes
2nd most common = chronic glomerulonephritis
99
what is glomerulonephritis?
Immune-mediated disease affecting glomeruli
100
clinical presentation glomerulonephritis?
Damage to endothelial or mesangial cells leads to proliferative lesion + red cells in urine
Damage to podocytes leads to non-proliferative lesion and protein in urine
101
Ix glomerulonephritis?
Clinical presentation
Blood tests
Urinalysis – haematuria, proteinuria
Urine protein:creatinine ratio
Kidney biopsy
102
S/s glomerulonephritis?
nephritic syndrome/nephrotic syndrome/mixed
impaired renal function (can lead to ESRD)
hypertension
103
s/s nephritic syndrome?
indicative of?
Acute renal failure
Oliguria
Oedema/fluid retention
Hypertension
RBCs, RBC and granular casts in urine
Indicative of a proliferative process affecting **endothelial cells**
104
nephrotic syndrome s/s?
indicative of?
Proteinuria \>3g/day
Hypoalbuminemia (\<30)
Oedema
Hypercholesterolaemia
Usually normal renal function
Indicative of a non-proliferative process affecting podocytes
105
nephrotic syndrome complications?
Infections – loss of antibodies
Renal vein thrombosis - loss of anticoagulants
Pulmonary emboli
Volume depletion – overuse of diuretics may lead to ARF (pre-renal)
Vit D deficiency - also lost in urine
Subclinical hypothyroidism - urinary loss protein-bound thyroid hormones
106
Ax glomerulonephritis?
idiopathic GN (types discussed later)
secondary = infections, drugs, malignancy, systemic disease (ANCA, lupus, goodpastures, HSP)
107
crescenteric glomerulonephritis?
Crescentic = presence of crescents in e.g. **RPGN in vasculitis**
108
Tx glomerulonephritis?
immunosuppression - corticosteroids, azathioprine, cyclophosphamide/chlorambucil
anti-hypertensives (target \<130/80 or \<120/75 if proteinuria)
ACE-I/ARBs
statins
?anticoagulants
109
Tx nephrotic patients?
remission?
Fluid + salt restriction
Diuretics
ACEI/ARBS
Anticoagulation
IV albumin (**only if volume depletion**)
**Immunosuppression**
* Complete remission = proteinuria \<300mg/day
* Partial remission = proteinuria \<3g/day
110
idiopathic GN main types?
Minimal change
Focal segmental glomerulosclerosis (FSGS)
Membranous
Membranoproliferative
IgA nephropathy
111
minimal change nephropathy?
Dx?
Tx?
ESRD?
COMMONEST cause of **nephrotic syndrome** in children!!
Dx = normal renal biopsy!!
Tx = 94% complete remission with **oral steroids**
* second-line drugs = cyclophosphamide
**does NOT cause progressive renal failure**
112
focal segmental glomerulosclerosis?
Ax?
Dx?
Tx?
Complication?
COMMONEST cause of nephrotic syndrome in **adults!!**
1\* or 2\* (HIV, heroin use, obesity, reflux nephropathy)
Dx renal biopsy = **minimal immune deposition**
Tx = **steroids** (60% remission)
**50% progress to ESRF after 10 years**
113
membranous nephropathy?
Ax?
Dx?
Tx?
Complication?
**2nd** commonest cause of nephrotic syndrome in adults
1\* or 2\* - **important** secondary causes:
* infections (hep B/parasites)
* connective tissue disease **(lupus)**
* **malignancies!!! (lung, colon + melanoma)**
* drugs (gold/penicillamine, NSAIDs)
Dx renal biopsy = **subepithelial immune complexes in basement membrane**
Tx = steroids, alkylating agents (cyclophosphamide + chlorambucil), monoclonal Ab
**30% progress to ESRF in 10 years**
114
PLA2r antibody?
present in \>70% of primary membranous nephropathy
115
IgA nephropathy clinical features?
Ax?
Associated with?
Dx?
Tx?
complication?
Asymptomatic microhaematuria + non-nephrotic proteinuria
**Classic presentation = macroscopic haematuria after resp/GI infection**
**Associated with HSP**
Dx renal biopsy = mesangial cell proliferation and IgA deposits
Tx = **ACEI/ARB + fish oil**
25% lead to ESRF in 10-30 years
116
rapidly progressive glomerulonephritis?
Clinical features?
Ax?
characteristic feature?
rapid deterioration in renal function over days/weeks
clinical features = RBCs, red blood cell clasts + granular clasts in urine
Ax = pic
characteristic feature = **glomerulr crescents on biopsy**
117
goodpasture's syndrome can cause?
Dx?
Tx?
goodpasture's syndrome can cause rapidly progressive glomerulonephritis (pulmonary-renal syndrome)
Dx = anti-GBM antibody (IgG)
Tx = **steroids, cyclophosphamide, plasmapheresis**
118
Ax nephritis?
infective = pyelonephritis
non-infective = glomerulonephritis
119
acute urinary retention?
Ax?
S/s?
triggering events?
Tx?
**renal emergency!!**
Ax = **BPH**, prostatitis, anticholinergic medication
S/s = inability to urinate resulting in increasing pain
triggering events = surgery, catheter, anaesthesia
Tx = catheter, alpha blocker, 5-alpha reductase inhibitor
120
Acute loin pain DDx?
Tx?
if stone hasn't passed within a month?
ureteric colic secondary to calculus (renal stone)
**DDx = AAA**
Tx renal stone = NSAIDs + opiate, **tamsulosin** (alpha-blocker) for small stones that are expected to pass
if stone hasn't passed in a month = ureteric stent, stone fragmentation
**for infected hydroneprhosis = nephrostomy**
121
indications to treat renal stone urgently?
Tx?
pain unrelieved
pyrexia
persistent nausea/vom
high-grade obstruction
Tx
* Ureteric stent
* Stone fragmentation
* **Nephrostomy for infected hydronephrosis**
122
Causes of frank haematuria?
Ix?
Ax
* cystitis/pyelonephritis
* Stones
* bladder cancer
* BPH
* Polycystic kidneys
* Trauma
* Coagulation/platelet deficiencies
Ix = CT urogram + cystoscopy
123
acute scrotum Ax
Torsion of spermatic cord
Epididymitis
Inguinal hernia
Hydrocele
Trauma/insect bite
Inflammatory vasculitis
Tumour
124
Torsion of spermatic cord epidemiology?
S/s?
O/E?
Ix?
Tx?
teenage boys - puberty
S/s = severe pain (often woken from sleep), nausea + vomiting, sometimes referal of pain to lower abdomen
O/E = testis high in scrotum, **absence of cremasteric reflex**
Ix = doppler USS
Tx = emergency surgery (within 4 hours)!!!!
**NB - fix contralteral side otherwise bell-clapper deformity**
125
torsion of appendage symptoms?
clinical features?
dinstinguish from testicular torsion?
Tx?
s/s = variable, may be same as spermatic cord torsion
clinical features = localised tenderness at upper pole + **blue dot sign**
difference from cord torsion = testis mobile + cremasteric reflex present
Tx = resolves on its own
126
epididymitis s/s?
Ax?
when to suspect?
Dx?
Tx?
(how to diff. from testicular torsion)
s/s = dysuria + pyrexia
Ax = UTI, urethritis, catheterisation
**suspect if pyuria (pus in urine)**
Dx = doppler (swollen epididymis) + urine culture
Tx = **ofloxacin 400mg** for 14 days
(NB - can differentiate from TT = cremasteric reflex is present)
127
idiopathic scrotal oedema?
self-limiting, unknown cause, usually associated with scrotal erythema
no fever, minimal tenderness, may be pruritus
128
paraphimosis?
Ax?
Tx?
Painful swelling of foreskin distal to a phimotic ring
Often happens after foreskin retracted for catheterisation and staff member forgets to replace it in natural position
Tx
* Iced glove, granulated sugar 1-2hrs, multiple punctures in oedematous skin
* Manual compression of glans with distal traction on oedematous foreskin
* Dorsal slit
129
Fournier's gangrene?
Ax?
S/s?
Dx?
Tx?
Form of necrotising fasciitis occurring around male genitalia
Ax = diabetes, local trauma, urinary extravasation, perianal infection
S/s
* Starts as cellulitis – swollen, erythematous, tender, marked pain, fever, systemic toxicity
* swelling + crepitus of scrotum, dark purple areas
* marked toxicity out of proportion to local findings
Dx = x-ray or USS may confirm gas in tissues
Tx = **antibiotics + surgical debridement**
130
nephritic vs nephrotic syndrome
how to distinguish cause of glomerulonephritis?
Nephritic = haematuria, hypertension
Nephrotic = heavy proteinuria, non-dependent oedema, hyperlipidaemia
distinguish cause = renal biopsy
* Light microscopy
* Electron microscopy
* Immunofluorescence (**goodpasture's = linear IgG**)
131
s/s minimal change disease?
FSGS?
Membranous?
IgA?
minimal change = nephritic (haematuria + HTN)
FSGS = nephritic
membranous = nephrotic (proteinuria, oedema, hyperlipidaemia)
IgA = nephritic
132
membranoproliferative GN Ax?
Dx?
idiopathic primary or 2\* (infection, lupus, malignancy)
Dx = **tram tracks** on microscopy
133
diabetes kidney?
Nodules = kimmelstiel Wilson lesion
134
bosniak score?
predicts cancer risk in renal cysts
135
Xanthogranulomatous pyelonephritis?
infection creates kidney mass
136
renal tumours staging?
benign tumours?
malignant?
paediatric tumour?
1 = benign
4 = malignant
benign - oncocytoma
malignant = chromophobe, clear cell, papillary and collecting duct
paediatric = Wilm's tumour
137
oncoytoma features?
BENIGN
small, oval, well-circumscribed
brown with stellate star
138
chromophobe features?
Difficulty is histological similarity to oncocytomas (benign vs malignant)
Oncocytotic but with raison-like nuclei and perinuclear haloes
139
papillary tumour kindey features?
2nd most common malignant tumour
papillary = finger-like projections
140
collecting duct tumour kidney?
**least** common **malignant** tumour
very poor survival
141
clear cell tumour kidney?
risk factors?
s/s?
features?
**most** common **malignant** tumour
when people say renal cancer they normally mean clear cell
risk factors = **obesity** + genetics
S/s
* heamaturia
* mass
* hypertension
BRIGHT YELLOW TUMOUR SURFACE (histologically clear)
142
significance of clear cell renal cancer?
has potential for renal vein involvement and can even extend into vena cava and grow towards the heart!!!
143
genetics renal cancer?
Von Hippel Lindau
144
Von Hippel Lindau increases risk of?
Renal cell carcinoma
Cerebellar hemangioblastoma
Pancreatic tumours
Epididymal tumours
145
systemic causes of CKD?
Diabetes (most common)
Myeloma
Amyloidosis
Vasculitis
SLE
146
multiple myeloma?
S/s?
classic presentation?
Cancer of **plasma cells**
symptoms
* Bone pain
* Weakness + fatigue
* Weight loss
* Recurrent infections
Signs
* Anaemia
* **Hypercalcaemia**
* Renal failure
* Lytic bone lesions
**classic presentation = back pain and renal failure!!**
147
Dx multiple myeloma?
Tx?
Bloods = **serum protein electrophoresis,** serum free light chains
Urine = **bence jones protein**
Bone marrow biopsy
Skeletal survey (lytic lesions)
Renal biopsy
Tx = manage hypercalcaemia (saline + bisphosphonates), chemo, stem cell transplant, plasma exchange to remove light chains, dialysis (supportive)
148
amyloidosis?
types?
Deposition of amyloid in tissues or organs
## Footnote
Types:
primary/light chain amyloidosis (AL)
secondary/systemic/inflammatory (AA)
dialysis-related amyloidosis (DRA)
hereditary and old age amyloidosis
149
primary AL amyloidosis pathophys?
affects?
prognosis?
Production of abnormal immunoglobulin light chains from plasma cells
Light chains enter bloodstream and cause amyloid deposits
affects heart, bowel, skin, nerves + kidneys
prognosis = 6 months - 4 years untreated
150
AA amyloidosis associated with?
e.g.?
Dx?
Associated with systemic inflammation from either chronic inflammatory conditions (RA, IBD, psoriasis) or chronic infections (TB, osteomyelitis, bronchiectasis)
Dx = production of acute phase protein – **serum amyloid A protein (SAA)**
151
presentation amyloidosis?
Depends on organs or tissues involved:
* Renal (**nephrotic**) = proteinuria + impaired renal function
* Cardiac – cardiomyopathy
* Nerves – peripheral or autonomic neuropathy
* Hepatomegaly/splenomegaly
* GI – malabsorption
152
S/s renal amyloidosis?
Ix renal amyloidosis?
s/s = nephrotic syndrome (proteinuria + impaired renal function)
Ix
* urinalysis (protein)
* bloods - U+E, CRP, protein electrophoresis, **serum free light chain assay**
* renal biopsy (**congo red, apple green under polarised light**)
* SAP scan i.e. scintigraphy with radiolabelled serum amyloid, shows extent of disease
153
Tx amyloidosis?
**no cure**
AA – treat underlying condition
AL – immunosuppression (steroids, chemo, stem cell transplant)
154
summary amyloidosis
155
ANCA associated vasculitis general s/s?
Dx?
Fever, arthralgia, weight loss, anorexia, malaise
Dx
* Urinalysis – blood, protein
* Bloods – raised CRP, AKI i.e creatinine, anaemia
* Immunology – ANCA, MPO, PR3
* Renal biopsy
156
p-ANCA vs c-ANCA
p-ANCA = MPO
c-ANCA = PR3
157
tx vasculitis?
**Steroids!**
* Also cyclophosphamide + ritixumab
* plasma exchange
* dialysis (supportive)
158
malar rash of SLE
159
lupus diagnostic criteria
| (MD SOAP BRAIN)
160
SLE kidney disease s/s?
Dx?
* Nephrotic!!! – **proteinuria**
* **Red-cell clasts!!**
* Microhaematuria
* Reduced renal function
* Hypertension
* Hyperkalaemia
Dx
* bloods - raised CRP, ANA + anti-dsDNA, complement proteins
* urinalysis - **proteins** + microhaematuria
161
most frequently observed abnormality in lupus nephritis?
proteinuria
162
most common cancer in men in UK?
Dx?
Tx?
prostate cancer
Dx
* bloods (**PSA**) + biopsy
Tx
* Surgery
* Radiotherapy
* Brachytherapy
* Anti-androgens
* LHRH-agonists
163
staging prostate cancer
gleasons plus...
164
most common bladder cancer?
presentation?
Dx?
transitional cell carcinoma
presentation = **80%** **with visible haematuria**
Dx = **CT urogram + cystoscopy!!**
165
Tx bladder cancer?
Surgery
If muscle invasion = radiotherapy
If metastatic = cisplatin based chemotherapy
166
urothelium lines?
Bladder, ureters and collecting ducts
also significant proportion of urethra
167
cystitis important subtypes?
* bacterial
* parasites and mycotic (fungal) infection
* aseptic
* reactive to catheters
168
parasitic Ax cystitis?
where?
complication?
**Schistosomiasis** – swims up urethra
**found in lake Malawi**
if untreated = persistent inflammation = squamous metaplasia = **squamous cell carcinoma**
169
aseptic cystitis?
presents with?
Tx?
Used to be called interstitial cystitis (painful bladder syndrome)
presents with **dysuria** but with persistently **negative** cultures + urinalysis
Tx = **NSAIDs + tricyclics**
170
urothelial neoplasia risk factors?
**SMOKING+++** (almost as strong an association as lung cancer)
beta-napthylamine (dye industry) - regulated now
171
transitional cell carcinoma appearance?
papillary - finger-like projections
172
other types of bladder cancer?
Adenocarcinoma (can occur due to metaplasia - difficult to distinguish from colon cancer that has metastasised)
Squamous cell carcinoma – catheters + schistosomiasis
173
prostate cancer usually occurs where?
risk factors?
Usually occurs in periphery of gland
Risk factors = cadmium battery workers
174
when is PSA unreliable for diagnosing prostate cancer?
unreliable in:
* big prostates
* prostatitis
* immediately following PR exam
* bike-riding
* **spironolactone**
175
Ax bladder outflow obstruction (BOO)?
Benign prostatic hyperplasia (BPH)
Urethral stricture
Prostate cancer
Bladder stones
Extrinsic – cystocele, cancers
drugs like **anticholinergics** and **nasal decongestants** - ASK ABOUT MEDICATIONS
176
symptoms of BOO
storage – when bladder is filling with urine
* frequency
* urgency
* nocturia
voiding – when patient is trying to pass urine
* hesitancy
* poor flow
* intermittent flow
* sensation of incomplete emptying
* post-micturition dribbling
177
red flag signs bladder cancer?
Haematuria
Suprapubic pain
Recurrent urinary tract infections
178
Ix BOO?
Ix
* Frequency-volume chart
* Urinalysis
* Serum creatinine
* PSA
* renal USS if - loin pain, haematuria
* cystoscopy if - haematuria, pain, recurrent UTIs
179
Tx for LUTS (storage vs voiding)
alpha blocker = tamsulosin
5-alpha reducstase inhibitor = finasteride
180
benign renal tumours?
malignant?
Benign
* Simple cysts
* Angiomyolipoma
* Oncocytoma
Malignant
* Renal cell carcinoma
* Transitional cell carcinoma
* Lymphoma
181
s/s oncocytoma?
difficulty?
Dx?
Tx?
S/s = asymptomatic (85%), loin pain, haematuria
radiologically very difficult to distinguish from renal cell carcinoma
Dx
* CT scan - spoke wheel pattern
* biopsy
Tx - depends on size
* \<3cm = surveillance (unfit) or ablation (fit)
* \>3cm = partial nephrectomy
* large tumours = **laparoscopic (gold standard) radical nephrectomy**
182
angiomyolipoma?
Ax?
s/s?
Dx?
Tx?
most common benign renal tumor
Ax = 80% sporadic in middle ages females, 20% associated with **tuberous sclerosis**
s/s = asymptomatic, loin pain, haematuria, mass
**10% Wunderlich's syndrome - massive retroperitoneal bleed**
Dx
* USS + CT (fatty tumour of low density)
Tx
* elective = embolisation + partial nephroctomy
* emergency = embolisation + emergency nephrectomy
183
Wunderlich’s syndrome?
associated with?
emergency - massive retroperitoneal bleed
associated with **angiomyolipoma of the kidney**
184
renal cell carcinoma?
types?
**Adenocarcinoma** of renal cortex
types
* clear cell (80%)
* papillary
* chromophobe
* collecting duct (rare - young patients, v poor prognosis)
* medullary cell = **sickle cell patients**
185
medullary cell renal carcinoma associated with?
SICKLE CELL
186
staging renal cancer?
T1 - \<7cm
T2 - \>7cm confined to kidney
T3 – extends beyond kidney into renal vein, perinephric fat, renal sinus, IVC
T4 – beyond Gerota's fascia into surrounding structures
187
s/s renal cancer?
Dx?
Haematuria, loin pain, mass
Pyrexia of unknown origin
Varicocele (appears suddenly)
Paraneoplastic syndrome (30%)
Dx
* USS
* CT chest, abdomen, pelvis for staging
* FBC
* renal and liver functions
188
Tx renal cell carcinoma?
follow-up?
Small tumours \<3cm = surveillance (unfit) + ablation (fit)
\>3cm = partial nephrectomy
large tumours
* radical nephrectomy
* **laparoscopic approach gold standard**
**Followup**
* FBC/renal and liver functions
* CT/USS + CXR
* **5-10 years**
189
testicular cancer epidemiology?
risk factors?
Epidemiology
* Men 20-45
* Seminomatous 35-45 y/o
* Non-seminomatous \<35 y/o
risk factors = previous TC (increased risk in contralateral testi), **cryptochordism**, HIV, family history
190
types testicular cancer?
seminoma is same as dysgerminoma in females
191
clinical presentation testicular cancer?
O/E?
s/s
* **Scrotal lump!!!**
* 5% acute pain due to bleeding
* 10% symptoms of advanced disease: weight loss, neck lumps, chest symptoms or bone pain
O/E
* Asymmetry or slight scrotal discolouration
* Hard, **non-tender**, irregular mass
* Secondary hydrocele
* Abdominal mass = advanced disease
192
Ix testicular cancer?
Imaging – USS testicle, CT abdomen + chest for staging
Bloods – serum tumour markers
* Alpha fetoprotein - yolk sac
* B-HCG - choriocarcinoma
* LDH - seminoma
FBC
LFTs + renal function tests
193
Tx testicular cancer?
**Radical inguinal orchidectomy – offer sperm preservation**
* re-check tumour markers 1 week post-op
**Chemo as adjuvant even in non-metastatic cases**
194
penile cancer types?
**Squamous cell carcinoma (95%)** – i.e. skin cancer
Kaposi’s sarcoma
BCC, malignant melanoma, sarcoma
195
risk factors penile cancer?
Age (50-60)
Phimosis – chronic inflammation
Geography – Asia, Africa, South America
HPV types 16 + 18
Smoking
Immunocompromised patients
196
most common site of penile cancer?
glans
197
presentation penile cancer?
Ix?
Hard **painless** lump
Ix
* MRI to assess tumour depth
* CT scan abdomen, pelvis, chest in advanced disease
198
Tx penile cancer?
Prepucal lesions = circumcision
Glans lesions
* **Superficial = glans resurfacing**
* **Deep = glansectomy**
More advanced disease
* total penile amputation with formation of perineal urethrostomy
Inguinal lymphadenectomy if involved
199
micturation reflex?
S2-S3 – pelvic parasympathetic nerves (pudendal)
200
overflow incontinence s/s?
Huge palpable bladder
Chronic retention
Often wet at night
Renal impairment
201
detrusor overactivity?
Ax?
can be a cause of urge incontinence
Ax
* irritation of bladder - afferent overstimulation
* paraplegia (loss of central inhibition)
* idiopathic
202
extraurethral causes of incontinence?
ectopic ureter (rare, congenital)
vesico-vaginal fistula
203
BXO?
**Balantitis xerotic obliterans i.e. lichen sclerosis of the penis**
204
testicular lumps differential?
Hernia
Cystocele
Hydrocele
Spermatocele
testicular cancer
205
hydrocele?
features?
Accumulation of fluid around testes
* between 2 layers of tunica vaginalis
Unicystic, smooth and fluid filled - **transilluminates!!**
206
spermatocele?
Ax?
presentation?
Cystic change within vas deferens (epididymis)
Unknown cause and usually **asymptomatic**
(normally present after self-examination)
207
Varicocele?
Varicose venous plexus that drains testis
May present having felt a lump “bag of worms”
remember sudden variocele can be symptom of RCC
208
potato tumour?
prognosis?
seminoma
excellent cure rate
209
respiratory alkalosis Ax?
excessive removal of CO2 from body
* Altitude hypoxia
* Hyperventilation (fever, brainstem damage)
* Hysterical overbreathing
210
urine alkaline when?
metabolic compensation for respiratory alkalosis
211
metabolic acidosis Ax?
ingestion of acids
excessive metabolic production of H+ (lactic acid during exercise or ketoacidosis)
excessive loss of base from the body (e.g. diarrhoea – loss of HCO3-)
212
metabolic alkalosis Ax?
Loss of HCL from stomach (vomiting)
Ingestion of alkali or alkali-producing foods (used to be a problem with old antacids!!)
Aldosterone hypersecretion (causes stimulation of **Na+/H+** exchange at apical membrane of tubule = acid secretion)
213
....
214
loop diuretics e.g.?
mechanism?
used for?
containdications?
furosemide + bumetanide
mechanism = inhibit Na/K/2Cl- co-transporter in loop of henle
used in = acute pulmonary oedema, heart failure, CKD, ascites, nephrotic syndrome, to reduce acute hypercalcaemia
containdications
* severe hypovolaemia or dehydration
* severe hypokalaemia/hyponatraemia
* hepatic encephalopathy
* **GOUT**
215
adverse effects loop diuretics?
hypokalaemia
metabolic alkalosis – increased H+ secretion
hypocalcaemia/hypomagnesaemia
hypovolemia and hypotension (especially in the elderly)
hyperuricemia – **may precipitate acute gout attack!!**
Dose-related loss of hearing
216
thiazide + thiazide-like diuretics e.g.?
mechanism?
benefits?
thiazide = bendroflumethiazide
thiazide-like = chlorthalidone, indapamide and metolazone (thiazide-like)
mechanism = inhibits **Na/Cl** co-transporter in DCT
benefit = has vasodilator action which is effective for hypertension
* also no hypocalcaemia like loop diuretics (advantage in elderly patients with osteoporosis)
217
clinical uses thiazide diuretics?
contraindications?
uses:
* heart failure
* Hypertension
* Severe resistant oedema
* Renal stone disease (nephrolithiasis) – **reduced** urinary excretion of Ca++ discourages Ca++ stone formation
* Nephrogenic diabetes insipidus (mechanism not clearly understood)
Contraindications
* Hypokalaemia
* Hyponatraemia
* Gout
218
adverse effects thiazide diuretics?
Hypokalaemia
Metabolic alkalosis
Hypovolemia and hypotension (esp in elderly)
Hypomagnaesmia (**not** hypocalcaemia – advantage in elderly patients with osteoporosis)
Hyperuricemia – **may precipitate gout**
Erectile dysfunction
Impaired glucose tolerance in diabetics
219
potassium sparing diuretics?
mechanism?
Spironolactone and eplerenone
## Footnote
mechanism = aldosterone antagonists
220
drugs to avoid with potassium-sparing diuretics?
clinical uses?
containdications
do not use with ace-inhibitors = **SEVERE HYPERKALAAEMIA**
clinical uses of aldosterone antagonists:
* Heart failure
* Primary hyperaldosteronism (**conn’s syndrome**)
* Resistant essential hypertension
* Secondary hyperaldosteronism (due to hepatic cirrhosis with ascites)
contraindications
* severe renal impairment
* hyperkalaemia
* Addison's disease
221
carbonic anhydrase inhibitor e.g.?
clinical use
acetazolamide
use:
* glaucoma
* altitude sickness prophylaxis
222
diabetes insipidus Ax?
Tx?
neurogenic (lack of ADH from post. pituitary)
* Tx = desmopressin
nephrogenic (inability of kidney to respond to ADH)
* genetic
* drugs - lithium, demecloclycine, vaptans
* Tx = **thiazides + NSAIDs**
223
what drugs are of use in hypervolaemic hyponatraemia (i.e. SIADH)?
vaptans e.g. Tolvaptan
224
complicated UTI?
**complicated UTI** = a UTI complicated by **systemic symptoms** OR urinary **structural abnormality/stones**
225
does bacteriuria mean UTI?
no - esp in elderly patients or patients with catheter
226
bacteria Ax UTI?
**E.Coli**
Klebsiella
enterobacter
proteus
pseudomonas aeruginosa
227
what makes E.coli dangerous?
endotoxin in LPS layer
228
proetus UTI?
produces urease which breaks down urea to form **amonia**
increases urinary pH which causes formation of **phosphate stones**
229
pseudomonas aeruginosa?
Ax UTI?
Tx?
**Gram negative bacillus** but **not** a coliform
Associated with **catheters**
Tx = **ciprofloxacin**
230
staph aureus UTI?
uncommon - usually from bacteraemia rather than urinary tract
231
s/s UTI?
Dx?
S/s
* Dysuria (pain passing urine)
* Frequency
* Nocturia
* Haematuria
* Fever
* Loin pain (suggests involvement of kidneys, complicated)
* Rigors (complicated)
Dx = MSU sample
* can also do dipstick but **NOT in elderly or catheter patients**
* nitrites + leukocytes indicate UTI
232
Kass's criteria?
\>10^5 organisms/ml = probable UTI (significant bacteriuria)
\<10^3 organisms/ml = not significant bacteriuria
10^4 organisms/ml – contaminated? Infection? Repeat specimen
233
asymptomatic bacteriuria?
Significant bacteriuria (\>10^5 orgs/ml)
No pus cells in urine
Antibiotic treatment often not required **EXCEPT in pregnancy**
234
asymptomatic bacteriuria in pregnancy?
Tx?
**MUST TREAT**
## Footnote
if untreated can cause sepsis, IUGR
Tx = nitrofurantoin 7 days
235
UTI catheterised patients?
Catheterised patients with \>10^5 orgs/ml should ONLY be given antibiotics if there is supporting evidence of UTI (fever, symptoms)
236
UTI Tx?
female uncomplicated = nitrofurantoin or trimethoprim 3 days
male UTI = nitrofurantoin or trimethoprim 7 days
complicated UTI/pyelonephritis = co-amoxiclav or co-trimoxazole 7 days
* hospital = IV gentamicin + amoxicillin 7 days
* if penicillin allergic = co-trimox + gentamicin
237
complicated UTI pregnancy?
AVOID gentamicin !!!!
238
ESBL bacteria?
Tx?
resistant to ALL cephalosporins and to almost all penicillins
Tx
* Nitrofurantoin (oral), pivmecillinam (oral)
* Fosfomycin (oral), temocillin (IV)
* Meropenem (IV), ertapenem (IV)
239
trimethoprim pregnancy?
forms?
avoid in 1st trimester (3 months) of pregnancy
can be given on its own or as co-trimoxazole
240
nitrofurantoin pregnancy?
Avoid in late pregnancy (can cause neonatal haemolysis), breastfeeding and children \<3 months old
so 1st and 2nd trimester = nitrfurantoin
3rd trimester = trimethoprim
241
drugs implicated in AKI?
1 – pre-renal failure – hypotension, hypovolemia
* e.g. diuretics, ACEI/ARBs
2 – renal – AIN/tubular necrosis (ATN)
* e.g. gentamicin, sulphonamides (trimethoprim), aspirin (NSAIDs)
3 – post renal – retroperitoneal fibrosis, crystalluria, urinary calculi
* e.g. methysergide or chemotherapy
242
drug reactions to know about
Theophylline and macrolide antibiotics
Statins and macrolides/fibrates
Warfarin and multiple drugs (aspirin, antibiotics)
ACE and sulphonylureas (hypoglycaemia)
Clopidogrel and PPIs
243
drug-disease interactions
Urinary retention in BPH patients on decongestants or anticholinergics
Constipation worsened by calcium, anticholinergics, CCB
Neuroleptics, tramadol and quinolones = worsen epilepsy
Beta blockers and asthma
244
drug-food interactions
Bananas, oranges, green leafy vegetables (K+ rich) interact with ACEI, ARBS, K-sparing diuretics
Apples, chickpeas, spinach, nuts, broccoli, **cranberry juice** interact with warfarin
Chicken, turkey, milk, soy, cheese, yoghurt = antibiotics, thyroid meds, digoxin, diuretics
**Grapefruit**, apple, orange and cranberry = statins + antihistamines
245
type B drug reaction examples?
drug rashes
bone marrow aplasia (chloramphenicol)
hepatic necrosis (halothane)
HIGH MORTALITY
246
long term effect of steriods?
B-blockers?
NSAIDs?
steroids = cushings
b-blockers = diabetes
NSAIDs = hypertension
247
type E (end of treatment) drug reaction examples?
Beta-blocker withdrawal and angina
steroid withdrawal and Addison crisis
anticonvulsant withdrawal and changes in epilepsy frequency
248
haematuria?
regarded as urologic malignancy until proven otherwise
249
inflammatory causes of haematuria?
Urethritis
Prostatitis
Cystitis
Ureteritis
Pyelonephritis
Glomerulonephritis
250
jogger's haematuria?
Tx?
due to renal/bladder trauma
Tx = self-limiting (lasts 7 days)
251
red diaper syndrome?
serratia marcescens infection
252
referal to urology vs nephrology
urology
* all patients with visible haematuria
* all patients with symptomatic miscroscopic haematuria
* \>40 years with asymptomatic microscopic haematuria
nephrology
* evidence of declining renal function
* CKD eGFR \<30
* significant proteinuria
* isolated haematuria with hypertension in \<40 y/o
* visible haematuria coinciding with infection
