Renal and GU Flashcards
What is glomerulonephritis?
How are most cases treated in general?
-Umbrella term applied to conditions that cause inflammation of or around the glomerulus and the nephrons.
- Most cases Tx w steroids
- Can need blood pressure control w ACEi or ARB
What is nephritic syndrome?
What are the common features?
-Simply means they fit a clinical picture of having inflammation of their kidney and it does not represent a specific diagnosis or give the underlying cause.
- Proteinuria <3g/24 hours
- Haematuria - visible or non visible
- Oliguria - signif reduced urine frequency
- Fluid retention
What is a common condition that causes nephritic syndrome?
What is another condition that presents similarly but is in the middle of nephritic v nephrotic?
IgA nephrotic
- Peak presentation in young around 20.
- Presents 2-3 days following URTI w macroscopic haematuria
- THINK when presenting w recurrent haematuria
- Tx w steroids
- Histology - IgA deposits and glomerular mesangial proliferation
SIMILAR - POST STREP GLOMERULONEPHRITIS/ diffuse proliferative glomerulonephritis
- Presents 2-3 weeks following strep infection e.g tonsilitis, impetigo
- Typically <30
- Develop nephritic syndrome
What is nephrotic syndrome?
What is the most common cause in children?
What is the most common cause in adults?
-Nephrotic syndrome is not a disease, but is a way of saying “the patient has these symptoms” –> indicates there is an underlying disease present but doesn’t specify the disease.
To have nephrotic syndrome a patient must fulfil the following criteria
- Peripheral oedema –> THINK WHEN PRESENTING W PERIORBITAL OEDEMA - DO URINE DIP
- Proteinuria more than 3g / 24 hours (frothy urine)
- Serum albumin less than 25g / L
- Hypercholesterolaemia
Children - minimal change disease
Adults - focal segmental glomerulosclerosis.
What is membranous glomerulonephritis?
- Most common type of glomerulonephritis overall
- There is a bimodal peak in age in the 20s and 60s
- The majority (~70%) are idiopathic
- Can be secondary to malignancy, rheumatoid disorders e.g SLE and drugs (e.g. NSAIDS)
- Histology shows “IgG and complement deposits on the basement membrane”
- Oedema (especially facial)
What is goodpastures syndrome?
- Anti-GBM (glomerular basement membrane) antibodies attack glomerulus and pulmonary basement membranes.
- This causes glomerulonephritis and pulmonary haemorrhage.
- Acute kidney failiure –> rapid onset AKI w proteinuria, haematuria and haemoptysis.
- Anti GBM Ab
Either goodpastures or granulomatosis w polyangitis (wegners|) –> ANCA. Also w wegners ave wheeze, sinusitis, saddle shape nose.
What is UTI?
What is the most common cause?
What is a uncomplicated v complicated UTI?
What are the RF?
- Lower UTI –> cystitis (infection of bladder). Upper UTI –> pyelonephritis.
- Commonly caused by bacteria in GI tract – g-ve bacteria from bowel and vaginal flora –> e coli (80%), kleibsella, proteus mirabilis
- Uncomplicated UTI – in non pregnant women
- Complcatied UTI –> all others –> men, children, pregnant women, recurrent UTIs, structural abnormality
- RF –> female, pregnancy, diabetes, sexual intercourse, catheter.
What is the typical presentation of a lower UTI?
- Dysuria, urinary frequency, urinary urgency, cloudy/offensive smelling urine, lower abdominal pain, fever typically low-grade in lower UTI, malaise.
- In elderly –> acute confusion is a common feature.
- Catheter –> not always classic symptoms and signs.
What are the investigations in an uncomplicated v complicated UTI?
Non complicated UTI –> NON PREGNANT WOMEN
- URINE DIPSTICK w leukocytes and nitrite
- Technically diagnosis can be w/o further tests when <65 w >3 symps or one severe of cystitis and no vaginal discharge.
- <3 symps and <65 –> urine dipstick –> +ve nitrite or leukocyte and RBC –> likely. -ve nitrite and positive for leukocyte –> UTI equally likely to other diagnosis.
- Send culture when –> >65, or visible/non visible haematuria, not responding to Tx.
- When non complicated UTI not responding to Tx –> urine sample w culture.
Complicated UTI –> men, pregnant women, children
-Urine sample for MSU culture and sensitivity . GOLD STANDARD –> microbiological culture of a correctly collected midstream urine specimen. Pure growth >10(little 5) microorganisms/ml urine –> diagnostic.
What is the management for an uncomplicated v complicated UTI?
Uncomplicated
- Trimethoprim or nitrofurantoin for 3 days. Nitrofurantoin only if eGFR >30.
- If doesn’t work –> culture for sensitivity.
- Advice –> increase fluid intake, void post intercourse, hygiene.
Complicated - Pregnant women
-Symptomatic –> urine culture. Ab 1st line nitrofurantoin. 2nd line amoxicillin or cefalexin.
-AVOID trimethoprim –> teratogenic in 1st trimester, should be avoided in pregnancy.
-Asymptomatic bacteriuria –> urine culture routine at 1st antenatal visit. Immediate Ab as above for 7 days. Tx as signif risk progression to pyelonephritis. Further culture when completion of treatment.
Complicated - Men
-1st line –> Immediate trimethoprim or nitrofurantoin for 7 days unless prostatitis is suspected.
-Alternatives amoxicillin. Or pivemecillinam if 1st line unsuitable.
-‘Referral to urology is not routinely required for men who have had one uncomplicated lower urinary tract infection (UTI).’
Complicated - catheter
- Don’t treat asymptomatic bacteria in catheterised patients
- If the patient is symptomatic –> 7 day course Ab.
What is pyelonephritis and its typical presentation?
When should you suspect pyelonephritis?
-Infection of kidney
-Predominantly affects women <35
-Is most commonly caused by ascending infection (typically E. coli from the lower urinary tract although it may also be due to bloodstream spread of infection (e.g. sepsis).
Presentation
Classic triad –> loin pain/tenderness, fever (rigors), pyuria.
-Vomiting.
-Pyuria –> white cell casts (leukocytes) in urine
SUSPECT when –> signs and symps of UTI e.g dysuria, frequency, urgency AND new signs pyelonephritis including fever, nausea, vomiting, flank pain.
-Abdo examination –> renal angle tenderness. R/o appendicitis, ectopic pregnancy.
What are the investigations and management for pyelonephritis?
When should you consider referring someone to hospital?
When should you advise someone to seek further advice?
Investigations
-Mid stream urine culture
-Blood culture
-US ? –> r/o obstruction
-Non pregnant women, men, catheter –> ciprofloxacin (quinolone) 500mg BD 7 days, trimethoprim, coamoxcilav or cefalexin.
-Pregnant women not needing admission –> cefalexin 500mg BD/X3D for 7-10 days.
- Advise seek help –> if symptoms worsen at any time, do not start to improve within 48 hours of taking the antibiotic, or if they become systemically very unwell.
- Referral should be considered for people if they –> significantly dehydrated or unable to take oral fluids and medicines, pregnant, have recurrent episodes of UTI (for example two or more episodes in a 6-month period). Or higher risk of developing complications — people with known or suspected structural or functional abnormality of the genitourinary tract or underlying disease (such as diabetes mellitus, or immunosuppression).
-Renal abscess –> more common in diabetics
-Emphysaematous pyelonephritis –> gas accumulation. Life threatening.
For patients with sign of acute pyelonephritis hospital admission should be considered
