Renal and GU investigations and treatments Flashcards
AKI
INVESTIGATIONS
1st - Urinalysis
Establish cause via urea:creatinine ratio (pre-renal, renal, post-renal) + diagnose with KDIGO classification (stage 1,2,3):
Reduced urine output - <0.5ml/kg/hr for at least 6 consecutive hours)
Serum creatinine - an increase >26 micromol/L within 48 hours or an increase >1.5 times baseline in 7 days
Urea:creatinine
>100:1 - Pre-renal (due to increased absorption of BUN due to reduced perfusion)
40:1 Post renal
<40:1 - Intra renal
U and E → K+, H+, urea, creatinine
FBC and CRP - check for infection
Ultrasound - to assess for obstruction (post-renal cause)
Biopsy - to confirm intra-renal cause
TREATMENT
Treat complications and underlying cause.
COMPLICATIONS
Hyperkalemia - Calcium gluconate
Fluid overload - diuretics
Hypovolemic patients - IV fluids
UNDERLYING CAUSE
Stop nephrotoxic medication e.g. gentamicin, NSAIDS
Last resort: Renal replacement therapy (haemodialysis) (depending on haemodynamic stability, severity of electrolyte imbalance)
In post-renal AKI - relieve obstruction (catheter)
Nephrolithiasis
INVESTIGATIONS
First line - Urinalysis - haematuria,
Urine dipstick
Ultrasound KUB (but this is GS for children and pregnant women)
GS
(Suspected kidney stones) → within 24 hours perform Non-contrast CT scan (KUB) of the kidney, ureters and bladder - NCCT KUB
CONTRAINDICATED in children and pregnant women
X-ray may show calcium based stones but does not show uric acid stones.
TREATMENT
For stones <5mm
1st line - Watch and wait as they may be passed spontaneously
Symptomatic
Hydrate + give nsaid (DICLOFENAC) IM
If UTI confirmed –> Antibiotics e.g. Gentamycin
For larger stones
Surgical intervention
Extracorporeal shock wave lithotripsy (ESWL) - where shock waves are directed at the stones to break them into smaller pieces
Percutaneous nephrolithotomy (PCNL) - keyhole removal of stones - through the patient’s back.
Ureteroscopy
CKD
- What complications to manage?
INVESTIGATIONS
1st line
Urine dipstick - proteinuria
FBC - Anaemia of chronic disease
Ultrasound - bilateral renal atrophy
GS
eGFR - <60
And eGFR function staging (G score 1-5)
G1 >90
G2 60-89
G3 30-59
G4 15-29
G5 <15
Serum creatinine - elevated
Diagnosis made when eGFR is sustained <60 over 3 months
TREATMENT
First line - really managing the complications
eGFR stage 1-4 →Ace inhibitors - Ramipril, (Angiotensin 2 receptor 2 blocker - telmisartan) + statins (to protect patients from cardioascular complications)
eGFR stage 5 → Dialysis
If End stage renal failure → Renal transplant
(For managing complications:
Anaemia → iron and erythropoietin
Renal osteodystrophy → vitamin D
Oedema → diuretics
Cardiovascular → ace inhibitors and statins
BPH
INVESTIGATIONS
1st and GS
Digital rectal examination (to assess size, shape and characteristics of the prostate - SMOOTH AND ENLARGED, soft) - hard, irregular and enlarged could be prostate cancer
Urine dipstick - to assess for infection (leukocytes and nitrites)
Prostate specific antigen (PSA) test for prostate cancer
(may ask them to do a bladder diary)
TREATMENT
Lifestyle - decreasing caffeine (may need catheter acutely)
1st line - Alpha blockers (tamsulosin) - reduce muscle tone in bladder neck (but is CI in patients with postural hypotension)
2nd line - 5 alpha reductase inhibitor (finasteride) - blocks the synthesis of dihydrotestosterone from testosterone - which usually can lead to prostate growth
Can lead to sexual dysfunction
Last resort - Surgery (TURP) - Transurethral resection of the prostate (complication - retrograde ejaculation
Pyelonephritis
INVESTIGATIONS
First line - Urine dipstick (positive for leukocytes and nitrites) - pyuria
FBC - increased WBC
(There would also be gas in the renal parenchyma)
GS - Midstream urine culture and sensitivity test
TREATMENT
1st line - Empirical antibiotics
Ciprofloxacin/co-amoxiclav, CEFALEXIN if pregnant
For pain management - Paracetamol (Analgesia)
Cystitis
INVESTIGATIONS
First line - midstream urine dipstick
FBC - mostly normal WBC (only increased if WBC spread to upper urinary tract)
GS - Midstream urine culture and sensitivity test
TREATMENT
Antibiotics –> Trimethoprim or nitrofurantoin
(Amoxicillin if pregnant)
Urethritis
INVESTIGATIONS
1st -
Nucleic acid amplification test (NAAT) → may detect N.gonorrhoeae or C.trachomatis
Urine dipstick + Urine culture and sensitivity test - to identify the pathogen in the case of a UTI
TREATMENT
Neisseria gonorrhoea - IM Ceftriaxone + azithromycin (if chlamydia not ruled out)
Chlamydia trachomatis - Azithromycin (doxycycline)
Epididymo orchitis
INVESTIGATIONS
First line - Urine dipstick
GS - Urine Culture, microscopy and sensitivity test
Nucleic acid amplification test (NAAT) - for C.trachomatis and N.gonorrhoeae.
Treatment
Neisseria gonorrhoea - IM Ceftriaxone + azithromycin (if chlamydia not ruled out)
Chlamydia trachomatis - Azithromycin (doxycycline)
If its a UTI cause
Ciprofloxacin (wide spec)
Nephrotic syndrome
- Pallor
INVESTIGATIONS
First line - urinalysis → proteinuria
For young patients (minimal change disease)
Biopsy + electron microscopy → podocyte effacement (and fusion)
No changes on light microscopy
In adults (focal segmental glomerulosclerosis)
Biopsy + light microscopy → Segmented sclerosis in <50% of the glomeruli (scarring of glomeruli - resulting in proteinuria)
In adults (membranous nephropathy)
Biopsy + light microscopy - thickened glomerular basement membrane
Biopsy + electron microscopy - Spike + dome appearance and subepithelial immune complex deposition (on thickened basement membrane)
TREATMENT
Steroids - Prednisolone
Minimal change - responds well
FSG and MN - responds less well
(Diuretics for oedema)
(Albumin infusion for severe hypoalbuminemia)
IgA Nephropathy
INVESTIGATIONS
First line - Urine dipstick and urinalysis - haematuria and possible albuminemia
GS - Kidney biopsy with immunofluorescence microscopy - shows mesangial IgA deposition
TREATMENT
Non curative (30% progress to ESRF)
But supportive treatment for hypertension with ACE-I –> RAMIPRIL
Post strep glomerulonephritis
INVESTIGATIONS
1st - urinalysis - haematuria, proteinuria
GS -
Kidney biopsy + light microscope (hypercellular glomeruli)
+ electron microscope+ immunofluorescence (hump shaped subepithelial immune complex deposits) –> shows starry sky appearance
Serology for S pyogenes (as self limiting)
TREATMENT
Usually self limiting
Supportive treatment for hypertension with Ace-inhibitor (ramipril)
Good pasture’s syndrome
INVESTIGATIONS
First line - Anti GBM antibodies
GS - Renal biopsy which shows damage and immunoglobulin deposition. (Necrosis with epithelial cell crescents)
Treatment
Prednisolone + plasma exchange (to remove pathogenic antibody)
Lupus nephritis
INVESTIGATIONS
Serology for ANA and anti double stranded DNA antibodies
Presents with WIRE LOOP glomerulonephritis - on biopsy
TREATMENT
Prednisolone, hydroxychloroquine
Methotrexate (immunosuppressant)
Causes of rapidly progressing glomerulonephritis
Caused by: Wegener’s granulomatosis (C-ANCA positive), Microscopic polyangitis (P-ANCA positive + autoantibodies against myeloperoxidase90), Good pastures (Anti GBM antibodise)
INVESTIGATION
Biopsy would show inflammatory crescents in Bowman’s space.
Renal cell carcinoma
INVESTIGATIONS
1st line - Ultrasound (abnormal renal mass/cyst)
GS - Contrast CT scan of chest/abdomen/pelvis
(Use robson staging or TNM staging)
TREATMENT
1st line - surgery –> Nephrectomy
