Renal and Urology Flashcards
AKI
Criteria?
1) Rise in creatinine of > 25 umol/L in 48hrs
2) Rise in creatinine of >50% in 7 days
3) Urine output of <0.5ml/kg/hr for >6hrs
AKI
Stages?
STAGE 1
- >1.5-1.9x baseline OR <0.5ml/kg/hr for 6-12hrs
STAGE 2
- >2.0-2.9x baseline OR <05ml/kg/hr for 12+hrs
STAGE 3
- 3x baseline or >353umol/L OR <0.3ml/kg/hr for 24hrs OR anuria for >12hrs
AKI
Risk factors?
HANDS C
Heart failure / Hypovolaemia/ Hx of AKI Age >65 Nephrotoxic drugs (NSAIDs/ ACEi) Diabetes Sepsis
CKD/ CLD / contrast agents
AKI
What is Acute Tubular Necrosis?
How does Necrosis occur?
damage and death (necrosis) of the epithelial cells of the renal tubules and most common cause of AKI
Necrosis occurs due to ischaemia or toxins (drugs)
AKI
Pathognomonic finding of ATN?
“Muddy brown casts” found on urinalysis
AKI
How does ATN cause a reduction in eGFR?
Reduced blood supply
AND
dead cells slough off into lumen causing further obstruction
AKI
Pre-renal causes?
Secondary to renal hypoperfusion
- reduced circulating volume (e.g. hypovolaemia)
- reduced cardiac output (e.g. cardiac failure),
- systemic vasodilatation (e.g. sepsis)
- arteriolar changes (e.g. secondary to ACE-inhibitor or NSAID use)
AKI
Intrinsic causes?
(structural damage)
Glomerulonephritis
ATN and Interstitial Nephritis
Rhabdomyolysis
AKI
Post-renal causes?
Obstructive causes (10%)
- Renal stones
- Prostatitis/ cancer / BPH
- Urinary stones
AKI
Investigations?
Urinalysis - Infection (leucocytes), glucose, protein, blood
Ultrasound - if looking for obstruction
AKI
Clinical features?
Pre-renal - dehydration and hypovolaemia or hypervolaemia for cardiac failure (oedema etc)
Intrinsic - Nephrotic / nephritic syndromes
Post renal- loin to groin pain, haematuria, N+V, LUTS
AKI
Clinical features of Acute Interstitial Nephritis and most common cause?
drugs are the most common cause, particularly antibiotics - penicillin / rifampicin
NSAIDs
allopurinol
furosemide
Features - fever, rash, arthralgia
eosinophilia
AKI
Management?
RENAL DRS 26
Record baseline creatinine Exclude Obstruction (US) Nephrotoxic drugs stopped Assess and correct fluids and electrolytes Losses recorded +/- cathether
Dipstick (blood/protein/infection/glucose)
Review meds
Screen
26 creatinine rise for AKI diagnosis
HYPERKALAEMIA
Causes?
CKD
Rhabdomyolysis
AKI / Addison’s
Metabolic Acidosis
drugs*: potassium sparing diuretics, ACE inhibitors, angiotensin 2 receptor blockers, spironolactone, ciclosporin, heparin
HYPERKALAEMIA
Signs on ECG and cardiac complications?
- Tall T
- Absent P
- Broad QRS
- Sinusoidal wave pattern
COMPLICATIONS - VF / arrhythmias
HYPERKALAEMIA
Management?
Cardiac protection = IV calcium gluconate
Shift extracellular K+ intracellular =
• Combined insulin/dextrose infusion
• Nebulised salbutamol
Removal of potassium from body =
• Calcium resonium (orally or enema)
• Loop diuretics
• Dialysis
Causes of Hydronephrosis?
Various obstructions e.g
Unilateral - calculi, ureteric obstruction and tumours
Bilateral - stenosis of urethra/ prostatic enlargement
RHABDOMYOLYSIS
Classic presentation?
Patient fell and prolonged seizure found to have AKI
RHABDOMYOLYSIS
What does muscle cell apoptosis release?
Myoglobin
Potassium
Phosphate
Creatine Kinase
ALL filtered by kidney and myoglobin TOXIC to kidney = AKI
RHABDOMYOLYSIS
Investigations?
Raised CK
Myoglobinuria (red-brown urine)
U+E (AKI and hyperkalaemia)
ECG (hyperkalaemia)
RHABDOMYOLYSIS
Causes?
CCSSEE
Crush injury Collapse Seizure Statin + Clarithromycin Ecstasy excessive exercise
RHABDOMYOLYSIS
Management?
IV fluids
IV Sodium bicarbonate (make kidneys more alkaline)
IV Mannitol to increase GFR and reduce oedema
Triad of Haemolytic Uraemic Syndrome?
AKI
haemolytic Anaemia
thrombocytopenia
Common cause of HUS?
classically Shiga toxin-producing Escherichia coli (STEC) 0157:H7 (90%)
(secondary cause)
Classic presentation of HUS?
Bloody diarrhoea and then:
bruising (low platelets) abdo pain Confusion (uraemia) pallor (anaemia) Hypertension (renal failure)
Tx of HUS?
Supportive + antihypertensives
No role for antibiotics despite preceding diarrhoea
Acute Urinary Retention
Presentation and Investigation?
Male 13:1
Acute confused and inability to pass urine / lower discomfort
Bladder US!
Causes of Acute Urinary Retention?
most commonly secondary to BPH
Others include strictures, calculi, masses +
DRUGS - benzos, Anticholinergics, Opioids
DIABETIC NEPHROPATHY
What is it?
high levels of glucose passing through glomerulus causing glomerulosclerosis
Most common cause of CKD and glomerular pathology in the UK
DIABETIC NEPHROPATHY
key feature?
Proteinuria - diabetics needed screening by ACR and U+E
Tx - ACE-i BP control
CKD Risk factors / causes?
Smoking
Hypertension
Old age
Polycystic kidney disease
Diabetes
Medications (lithium, PPI, NSAIDs)
Dx of CKD?
Significant proteinuria?
Two U+Es 3 months apart (eGFR)
ACR of >3mg/mol
For CKD eGFR <60 or proteinuria needed for dx
Staging of CKD?
G score and A score
G score is based on eGFR - G1 - >90 G2 - 60-89 G3a 45-59 G3b 30-44 G4 - 15-29 G5 - <15 end stage RF
A score is based on ACR
A1 - <3mg/mmol
A2 - 3-30mg/mmol
A3 - >30mg/mmol
Complications of CKD?
Secondary hyperparathyroidism + high phosphate CVD Renal Bone disease (low Vit D and treat with Vit D) Anaemia (treat with iron) Peripheral Neuropathy
SCRAP
Presentation of Nephrotic Syndrome?
- Proteinuria (>3.5g day)
- Hypoalbuminaemia (<25g/L)
- Oedema
+ hyperlipidaemia
+ hypercoagulable state
Presentation of Nephritic Syndrome?
- haematuria
- Proteinuria
- Oliguria
- Hypertension
Causes of Nephrotic?
Minimal change disease
focal segemental glomerulonephritis
membranous GN
Causes of Nephritic?
Rapidly progressive GN (goodpastures / wegeners)
IgA nephropathy
Post strep GN
Alport syndrome
What is IgA nephropathy?
Classical presentation?
Most common glomerulonephritis worldwide
macroscopic haematuria in young people following an URTI.
Difference between post strep GN and IgA nephropathy presentation?
Post strep = 1-2 weeks after URTI + proteinuria
IgA nephropathy = 1-2 days after URTI
What conditions are we thinking if someone presents with Acute Renal Failure and Haemoptysis?
Either Anti GBM disease or Granulomatosis with Polyangiitis
Polycystic Kidney Disease
What is the Ultrasound diagnostic criteria?
<30 years - 2 cysts uni/bi
3-59 years - 2 cysts bilaterally
> 60 years - 4 cysts bilaterally
Features of PCKD?
Extra renal features?
Recurrent UTIs, stones, HTN, abdo pain, haematuria
EXTRA RENAL - liver cysts (70%) berry aneurysms (8%) rupture - SAH CV disease (mitral regurgitation)
Management of PCKD?
Tolvaptan
if end stage RF - dialysis and transplant
Types of PCKD?
Autosomal dominant 1 (85% - chromosome 16)
Autosomal dominant 2 (15% - chromosome 4)
Autosomal recessive - end stage RF before adulthood
Management and cause for Urge Incontinence?
Cause - Detrusor overactivity
1st - Bladder retraining (6 weeks)
2nd - oxybutynin/ tolterodine / darifenacin
3rd - Mirabegron if old and frail
Management and cause for Stress Incontinence?
Cause - leaking when cough/ laugh etc
1st - pelvic floor muscle training (8 - 3x day for 3 months)
2nd - Duloxetine
surgical procedures: e.g. retropubic mid-urethral tape procedures
Signs of Varicocele?
bag of worms. On the left is concern for Renal cell carcinoma
Signs of testicular torsion
Painful tender testes retracted upwards
Whirlpool sign on US
signs of Hydrocele
Transilluminate clear fluid and painless
Signs and cause of epididymo-orchitis
Local spreading of chlamydia / gonorrhoea
- dysuria and discharge
Management of epididymo-orchitis
if the organism is unknown BASHH recommend: ceftriaxone 500mg intramuscularly single dose,
plus doxycycline 100mg by mouth twice daily for 10-14 days
Lower urinary tract symptoms?
cant UNSHIFT the urine
Urgency Nocturia Straining Hesitancy Intermittent flow Frequency Terminal dribbling
weak flow and incomplete emptying
BPH / LUTS initial assessment?
DRE Abdo exam Dipstick Urinary frequency chart PSA
How does a cancerous prostate feel?
Hard, assymetrical craggy/ irregular and loss of central sulcus
Causes of increased PSA?
1) Prostate cancer
2) BPH
3) Prostatitis
4) UTIs
5) Vigorous exercise (cycling)
6) Recent stimulation e.g. ejaculation
Management of BPH and what the medication does?
Alpha blockers - Tamsulosin (relax smooth muscle)
5 - alpha reductase inhibitors - Finasteride (reduce size by blocking conversion of testosterone to DHT)
Acute Bacterial Prostatitis cause and treatment?
E.coli
Tx - Quinolones for 14 days
Surgical treatment of BPH?
Transurethral resection of the prostate (TURP)
removed by diathermy loop through resectoscope in urethra
Alport Syndrome signs?
Can’t see - Lenticonus
Can’t pee - CKD, hematuria
Can’t hear a high C - sensorineural deafness
An important marker to distinguish between pre-renal and renal causes of an acute kidney injury?
Assess urinary sodium
pre-renal (hypovolaemia) = kidney tries to preserve sodium to encourage water retention
renal = elevated levels of urinary sodium due to inability to preserve sodium levels through renal damage
PROSTATE CANCER
Likely tumour type?
Androgen dependant adenocarcinoma
(95%) - peripheral zone
PROSTATE CANCER
Most likely spread?
Bones and lymph nodes
PROSTATE CANCER
Risk factors?
Afro caribbean
Increasing age
Obesity
Family history
PROSTATE CANCER
What PSA result guides referral?
men aged 50-69 years should be referred if the PSA is >= 3.0 ng/ml
OR there is an abnormal DRE
PROSTATE CANCER
First line investigation?
Multiparametric MRI
2nd- prostate biopsy
PROSTATE CANCER
Features?
LUTS Haematuria ED Bone pain (bone mets) weight loss Abnormal DRE
PROSTATE CANCER
Medical management?
Reduce androgen levels
Goserelin
Bicalutamide
PROSTATE CANCER
Complication of of radical prostatectomy
Erectile dysfunction
PROSTATE CANCER
Risks with radiotherapy? (tx for types T3/4)
increased risk of bladder, colon, and rectal cancer following radiotherapy for prostate cancer
How is Prostate cancer graded?
Gleason Grading Score
Typical cause of Pyelonephritis?
E.coli
Features of Pyelonephritis?
LUTS Fever Loin pain vomiting white cell casts in urine
Treatment for Pyelonephritis?
broad-spectrum cephalosporin or a quinolone for 10 - 14 days
(cefalexin)
What type of tumour are 95% of testicular cancers
Germ cell tumours - seminomas and non seminomas
Tumour markers of testicular cancer?
seminomas: hCG may be elevated in around 20%
non-seminomas: AFP and/or beta-hCG are elevated in 80-85%
LDH is elevated in around 40% of germ cell tumours
Risk factors of testicular cancer?
Common age of incidence?
Infertlity
Klinefelters
20-30 years
Diagnosis and treatment of testicular cancer?
Ultrasound and Orchidectomy
features of testicular cancer?
Painless lump
Gynaecomastia due to an increased oestrogen:androgen ratio
Most likely mets from testicular cancer?
Brain, lung, lymph, liver
When should trimethoprim be avoided in pregnancy and why?
Avoid in first trimester due to folate antagonist properties which cause neural tube defects such as spina bifida
When should Nitrofurantoin be avoided in pregnancy and why?
Avoid close to term (3rd trimester) due to `neonatal haemolysis’
Risk factors for transitional cell carcinoma of the bladder include:
Smoking
Aromatic Amines
Exposure to aniline dyes in the printing and textile industry: examples are 2-naphthylamine and benzidine
Rubber manufacture
Cyclophosphamide
Risk factors for squamous cell carcinoma of the bladder include:
Schistosomiasis
Smoking
Most common type of bladder cancer?
Urothelium - transitional cell carcinoma (95%)
Presentation of bladder cancer?
painless, macroscopic haematuria
How is bladder cancer diagnosed and staged?
Cystoscopy and Biopsies and staged by TNM
Treatment of bladder cancer?
TURBT if superficial (not invading muscle)
T2 disease = surgery (cystectomy + urostomy)
Referral guidance for bladder cancer?
Over 45 with unexplained visible haematuria, persisting after UTI treatment
Over 60 with microscopic haematuria plus dysuria or Raised WCC
RENAL STONES
symptoms?
Unilateral loin to groin pain
Colicky
Haematuria
N+V
RENAL STONES
Types of stones?
Drugs that can cause stones?
Calcium oxalate (oaque on radiograph) Urate (Radio-lucent)
Loop diuretics
steroids
acetazolamide
theophylline
RENAL STONES
How to prevent renal stones?
High fluid intake Avoid carbonated drinks citric acid reduce salt thiazide diuretics
RENAL STONES
Risk factors?
Hypercalcaemia Hyperparathyroid Dehydration High dietary oxalate PCKD Renal tubular acidosis
urate stones : GOUT
RENAL STONES
Medical treatment?
Best imaging?
Pain - Diclofenac (NSAID)
Tamsulosin (Alpha blocker)
Non contrast CT-KUB
RENAL STONES
Surgical treatment?
Extracorpeal shock wave lithotripsy (ESWL)
Ureteroscopy
RENAL CELL CARCINOMA
Common type?
Adenocarcinoma
- Clear cell (80%)
- Papillary
- chromophobe
RENAL CELL CARCINOMA
Risks?
Smoking obesity hypertension end stage renal failure von hippel-lindau tuberous sclerosis
RENAL CELL CARCINOMA
Features?
classical triad: haematuria, loin pain, abdominal mass
RENAL CELL CARCINOMA
Associations with other organs?
Left varicocele (due to occlusion of left testicular vein)
cannonball mets (mets to liver due to RCC)
RENAL CELL CARCINOMA
Paraneoplastic features?
EPO - Polycythaemia
mimic PTH - hypercalcaemia
HTN - renin
Abnormal LFTs - Stauffer syndrome
RENAL CELL CARCINOMA
Stages?
1 - <7cm confined to kidney
2 - >7cm confined to kidney
3 - local spread (within gerotas fascia)
4 - spread beyond (lung, bone, brain)
RENAL CELL CARCINOMA
Management?
Total nephrectomy unless T1 could be partial
examples of quinolones?
Ciprofloxacin
Ofloxacin
Levofloxacin
what are quinolones mainly used for
UTIs
Prostatitis
Epididymo orchitis
Pyelonephritis
Key side effects of Quinolones?
1) Tendon damage/ rupture (Achilles)
2) Lower seizure threshold (in epilepsy)
3) lengthens QT interval
Avoid in breastfeeding and pregnant
Causes of NAGMA?
HARDUPS
Hyperalimentation (XS saline) Acetazolamide Renal tubular acidosis Diarrhoea Ureterostomy (new outlet) Post hypocapnic state Spironolactone (hypoadrenalism)
Causes of HAGMA?
MUDPILES
Methanol Uraemia (AKI/CKD) DKA Propylene glycol Isoniazid / Iron Lactic Acidosis Ethanol / Ethylene Glycol Salicylates (aspirin)
Why does raised anion gap acidosis occur?
Accumulation of an unmeasured anion that consumes bicarbonate with no reciprocal increase in Cl-
how to calculate anion gap?
What is a normal anion gap
(sodium + potassium) - (bicarbonate + chloride)
A normal anion gap is 8-14 mmol/L
Complications of Peritoneal Dialysis and likely cause?
peritonitis:
coagulase-negative staphylococci such as Staphylococcus epidermidis is the most common cause
RENAL TUBULAR ACIDOSIS
Where the different types found on the glomerulus
2 - proximal CT
1 - distal CT
4 - Collecting duct
RENAL TUBULAR ACIDOSIS
Potassium changes?
2 LOW - hypokal
1 LOW - hypokal
4 MORE - hyperkal
RENAL TUBULAR ACIDOSIS
Calcium changes?
2 - normal
1 - high
4 - normal
1 is odd therefore odd one out
RENAL TUBULAR ACIDOSIS
pH changes?
2 - <5.5
1 - OVER 5.5
4 - <5.5
1 is odd therefore odd one out
RENAL TUBULAR ACIDOSIS
kidney stones?
2 - No
1 - YES (high calcium)
4 - No
1 is odd therefore odd one out
