Renal and Urology Flashcards
CKD
Symptoms/ signs
Investigations
Management
Proteinuria/hematuria and or GFR = <60ml/min
Fatigue(anemia/uremia), nausea, oedema and pruritus common
Urea builds up in the blood -> nausea, if severe you get encephalopathy which causes asterixis (tremor of the hand), pericarditis and platelet dysfunction (bleeding)
Potassium buildup = hyperkalemia which can cause cardiac arrhythmias
Na retention = HF, pulmonary oedema
Metabolic acidosis
High phosphate levels can cause osteomalacia - treat with bisphosphonates e.g alendronic acid. Sevalamer
ACE inhibitor “prils” or ARBS “sartan” + statin.
Dialysis or transplant for stage G5
AKI symptoms/ signs
Management
acute decline in kidney function, leading to a rise in serum creatinine and BUN/or a fall in urine output.
Hypotension, reduced urinary output
When dehydration causes AKI- rise in urea is proportionally higher than rise in creatinine
Uremia(encephalopathy or pericarditis) in AKI is an indication for dialysis
Pre renal - low urine sodium, high urine osmolality. Raised serum urea:creatinine ratio
Infra renal - high urine sodium, low urine osmolality
Nephrotoxic drugs: DAMN AKI Diuretics Aminoglycosides and ACE inhibitors Metformin NSAIDS(only aspirin can be continued at cardio protective dose) \+ Lithium
Complications of AKI = pulmonary oedema = haemodialysis
Diabetes insipidus Symptoms/signs
Investigations
Mangement
polydipsia, polyuria, and formation of inappropriately hypotonic (dilute) urine.
Hypernatremia may occur
Water deprivation test - failure to concentrate urine in response to dehydration, such that urine remains inappropriately dilute (urine osmolality <300 mmol/kg )
AVP stimulation test - distinguish between CDI and NDI
Central DI - desmopressin
Nephrogenic DI - adequate fluid intake; hydrochlorothiazide, indometacin
Multiple myeloma
Symptoms/signs
Investigations
Management
Cancer caused by proliferation of plasma cells in the bone marrow
Bone pain(typically localised to the back) and anemia - most common CRAB = Hypercalcemia, renal involvement, anemia, back pain Hypercalcemia signs- abdominal pain, urinary frequency, constipation
serum and urine protein electrophoresis = 1st line = IgG or IgA spikes
Confirm with bone marrow biopsy = increase in plasma cells
Under 65: Induction therapy (thalidomide + dexamethasone) + DVT prophylaxis(aspirin) + stem cell transplant. + bisphosphonates/denosumab for bone disease
Differentials: MGUS(Ig production of any type ASYMPTOMATIC so no CRAB symptoms) , amyloidosis
Nephrotic syndrome
Symptoms/signs
Investigations
Management
proteinuria (>3.5 g/24 hours), hypoalbuminemia (<30 g/L), and peripheral oedema.
Oedema
Foamy urine
Hyperlipidemia signs
Investigation = urinalysis
Renal biopsy is diagnostic of cause
Complications: infections, hypercoagulability, hypertension
- treat underlying cause - ACE inhibitors, diuretics, cholesterol medication, anticoagulants
BPH symptoms/signs
Investigations
Management
storage symptoms (frequency, urgency, nocturia, and incontinence) voiding symptoms (weak stream, dribbling, dysuria, straining).
Alpha-blocker - e.g. tamsulosin - 1st line
5-alpha-reductase inhibitors - e.g. finasteride - in patients with larger prostate (over 30 grams)
PDE-5 - e.g. sildenafil - consider if you have LUTS or erectile dysfunction
Last resort = TURP. Side effect = hyponatremia, retrogade ejaculation
Prostate cancer
Symptoms
Investigations
Asymptomatic
DRE - asymmetric or nodular prostate
PSA - Elevated. >10 highly suggestive
psa can also be elevated in BPH
Testicular cancer
Symptoms
Investigations
Management
hard, usually painless nodule on one testis
RFs; cryptorchidism, gonadal dysgenesis
Ultrasound with colour doppler or testis = 1st line
Germ Cell tumours: PALP in seminoma(most common) AFP in yolk sac tumour bHCG in choriocarcinoma No markers in teratoma. Mix of cells Embryonal carcinoma only painful one
Inguinal orchiectomy, testis sparing surgery
Kidney stone
Symptoms
Investigation
Management
Acute severe flank pain, usually radiating to the groin
Nausea and vomiting, urinary frequency/urgency, hematuria may occur
Non-contrast CT. pregnant or under 16 = ultrasound
Urinalysis
<5mm = Hydration and analgesia, wait to pass
<10mm = Tamsulsosin, if not passed after 4-6 hours = surgery
> 10mm = ESWL (surgical removal)
Staghorn = percutaneous nephrolithotomy.
Bladder cancer
Symptoms
Investigations
Management
Gross or microscopic haematuria - usually gross, painless and present through the entire urinary stream. Occurs intermittently
Dysuria
Cystoscopy and urinary cytology = 1st line
Non invasive = transurethral resection + chemo + immunotherapy
Invasive = cystectomy
Diabetic nephropathy
Symptoms
Investigation
Management
clinical diagnosis in a patient with long-standing diabetes (>10 years) with albuminuria and/or reduced estimated glomerular filtration rate (eGFR)
Hypertension, retinopathy, oedema
Signs of uremia
Other signs of diabetes
Urinalysis = proteinuria - this indicates nephropathy
Albumin to creatinine ratio - increased
Glycemic control, ACE inhibitor/ARB + smoking cessation
What medications are used for urge incontinence?
Kegel exercises. 2nd line = oxybutynin, mirabegron
Treatment for stress incontinence?
Treatment = kegel exercises, weight loss
Overflow incontinence treatment?
Catheterization, alpha blocker for BPH
Epidiymo-orchitis
Symptoms/signs
Investigations
Management
Unilateral scrotal pain and swelling of gradual onset. Urinary symptoms
+Prehns sign (pain relief when scrotum is elevated
- Children - congenital abnormality + ecoli
- Young men - chlamydia most common
Urine dipstick to check for UTIS
Elevated CRP = distinguishing feature
IM ceftriaxone and PO Doxycycline if due to chlamydia and gonorrhoea
treat underlying cause if due to TB
UTI subtypes
Symptoms and signs
Investigations
Management
Infectious cystitis (most common)
Urethritis
Pyelonephritis
Dysuria
Urgency
Frequency
Cloudy urine in women, urethral discharge may occur in men
Suprapubic pain
Flank pain and costovertebral angle tenderness= pyelonephritis
Urine dipstick = first line = +ve leukocyte esterase and + nitrites (indicates gram negative organisms). Sterile pyuria may suggest urethritis by gonorrhea or chlamydia
Confirmed with MSU
Pyelonephritis = Cefalexin
Cystitis = nitrofurantoin women, trimethoprim men
State the complications of AKI and how you would treat them.
What investigations do you do for AKI?
fluid overload -> IV furosemide
Uremia -> haemodyalisis
Metabolic acidosis -> IV PO sodium bicarbonate
Hyperkalemia -> FIRST do an ECG, if ECG shows changes or if K+ above 6.5 give calcium gluconate 10% 30mls IV
AKI investigations
- fluid assessment
- ABG/VBG, potassium and bicarb
- U&Es, ECG
State and describe some infra-renal causes of AKI
- acute tubular necrosis. Caused by ischemia and toxins. Granular muddy brown casts on urinalysis. Stop insult.
- Acute interstitial Necrosis (AIN). Immune mediated hypersensitivity reaction, usually to medication. Presents with rashes, fever, arthralgia, eosinophilia (signs of allergy). White cell casts on urinalysis. Stop insult.
- Haemolytic ureamic syndrome - hemolytic anaemia, AKI, thrombocytopenia. Give ABx as usually secondary to EHEC infection
- Thrombotic thrombocytopenic purpura - hemolytic anaemia, AKI, thrombocytopenia AND FEVER (+neurological symptoms). Plasmapheresis
- Glomerulonephritis - nephrotic and nephritic syndrome
5 causes of Nephrotic syndrome?
How do they present?
Investigations for nephrotic syndrome?
- Minimal change disease - most common cause in children. Periorbital oedema. Hodgkin’s lymphoma. Podocyte foot effacement on electron microscopy.
- Membranous GN - light microscopy BM thickening, Electron microscopy shows spike and dome appearance. Darker spots in between basement membrane shows immune complex deposition. Associated with SLE, HepB/C syphilis
- FSGS - caused by injury to podocytes. Renal biopsy shows focal segmental areas of mesangial collapse and sclerosis . Associated with HIV, heroin abuse, sickle cell disease, anabolic steroids
- Diabetic nephropathy - characteristic Kimmelstiel-Wilson nodules on light microscopy (huge empty circles)
- Amyloid nephropathy - apple green birefringence
Adults = renal biopsy
In children = clinical diagnosis of minimal change disease
Renal cell carcinoma symptoms?
Causes of RCC?
Investigation and management?
- flank pain
- palpable mass
- hematuria
- varicocele on left - RED FLAG
- paraneoplastic syndrome
- cannonball mets in lungs
- Sporadic
- Inherited e.g. Von Hipple Lindau Disease - Retinal and CNS (headaches, etc) hemangioblastomas, renal cell carcinoma, phaeo
CT or MRI!!!! If CKD/RENAL FAILURE
1st line = surgical resection
