Renal and urology Flashcards
What parameter is measured when determining if a patient has an AKI ?
Serum creatinine.
What are the NICE guidelines for the diagnosis of an AKI ?
- Rise in creatinine more than 25 micomol/L in 48 hours.
- Rise in creatinine more than 50 percent from baseline in 7 days
- Urine output < 0.5ml/kg/hr for more than 6 hours.
What are the risk factors for the development of an AKI ?
Consider in any patient that is suffering from an acute illness like infection or having a surgical operation.
- CKD
- HF
- Diabetes
- Liver disease
- Older age
- Cognitive impairment
- Nephrotoxic medications
- Use of a contrast medium like during CT scans
What are some examples of pre renal causes of AKI ?
-Usually due to inadequate blood supply to the kidneys.
- Hypo-tension, heart failure and dehydration.
What are some examples of renal causes of AKI ?
Intrinsic disease causes reduced filtration of the blood
- Glomerulonephritis, interstitial nephritis and tubular necrosis.
What are some examples of post renal causes of AKI ?
Usually caused by obstruction to the outflow of urine from the kidneys (obstructive neuropathy)
- Kidney stones, Tumour in abdomen/pelvis, enlarged prostate or prostate cancer
What will be present on U+E, lFT, urinalysis (cause) in AKI ?
Deranged Us and Es
Raised urea
Urinalysis will show different things depending on the cause of the AKI
- Infection - Leukocytes and nitrites
- Protein and blood - Acute nephritis/infection
Glucose - Diabetes, nephritis. - FBC - hyperkalaemia
How should patients with an AKI be managed (stepwise) ?
- The underlying cause should be treated (e.g kidney stones, obstruction, fluid resus)
- Stop renotoxic drugs
- Iv fluids
- Treat any complications
- Prevention - avoid renotoxic drugs in acutley unwell patients,
What drugs are renotoxic and can increase risk of AKI ?
NSAIDS/spirinolactone/Diuretics/gentamycin/ACE
What electrolyte abnormality can occur in an AKI and what can it cause ?
Hyperkalaemia, can cause arrhythmias and tall tented T waves on ECG.
How is hyperkalaemia with heart involvement treated ?
IV calcium gluconate.
Apart from hyperkalaemia, what are some of the other possible complications of AKI ?
- Hyperkalaemia - Tall tented T waves and treated with calcium gluconate.
- Fluid overload, HF and pul odema
- Metabolic acidosis
- Uraemia can lead to encephalopathy or pericarditis.
What are some of the indications for dialysis in an AKI ?
- Persistently high potassium that is refractory to medical treatment
- Severe acidosis (pH<7.2)
- Refractory pulmonary oedema
- Symptomatic uraemia (pericarditis, encephalopathy)
- Drug overdose (e.g. aspirin)
What is BPH ?
Caused by hyperplasia of the stromal and epithelial cells and presents with lower urinary tract symptoms.
What are the typical symptoms of BPH ?
- Hesitancy
- Weak flow
- Urgency
- Increased frequency
- Intermittency (stops/starts ect)
- Straining to pass urine
- Terminal dribbling
- Incomplete emptying
- Nocturia.
How would you assess a patient with suspected BPH ?
- PR
- Abdominal examination
- Urinary frequency volume chart (fluid intake and output)
- Urine dipstick (infection/haematuria)
- PSA for prostate cancer, depending on patient preference
How would a prostate feel in BPH ?
Normal character and feeling, enlarged.
What is PSA testing and why is it not always used ?
PSA testing is used to determine the presence of prostate cancer. Known to be very unreliable with a high rate of false positives (75) and false negatives (15 percent). It can be raised in a number of conditions other than malignancy
What conditions can PSA be raised in ?
- Prostate cancer
- BPH
- Prostatitis
- UTI
- Vigorous exercise like cycling
- Recent ejaculation or prostate stimulation.
What are the two methods (basic not names) of management of BpH.
One to reduce symptoms and another to reduce the size of the prostate.
What medication can be used for symptom control in BPH ?
Tamulosin to relax the smooth muscle
What is one of the notable side effects of tamulosin used to treat BPH ?
Can cause postural hypotension.
What medication can be used to reduce the size of the prostate in BPH ?
5-A reductase inhibitors like finasteride. Can take up to 6 months to treat
What are the notable side effects of finasteride in treating BPH ?
Sexual dysfunction due to reduced testosterone
What is the most common surgical option in the treatment of BPH ?
TURP. Removal of the prostate via the urethra. The aim is to create a bigger space for urine to move through hence improving symptoms.
Major complications include sexual dysfunction, infection, retrograde ejaculation.
What are the other surgical options for treating BPH apart from TERP ?
- Transurethreal resection of the prostate TURP. Most common surgical management of BPH. Removal of part of the prostate via the urethra. The aim it to create a bigger space for urine to move through, therefore improving symptoms. Major complications include sexual dysfunction, infection, retrograde ejaculation.
- Transurethral electrovapourisation of the prostate TEVP
- Holmium laser enucleation of the prostate
- Open prostatectomy.
The creatinine is 200 mmol/L, compared to a baseline of 70 mmol/L. If this is mentioned in a exam question, what should you be considering in the answer ?
AKI
If a patient is presenting with symptoms of an AKI, but not a UTI, what should be the first line of investigation ?
Serum urea and creatinine
What does painless intermittent haematuria indicate in a male smoker ?
Transitional cell carcinoma of the bladder
What is a uraemic tinge ?
Grey/blue colour to the skin
A patient is found with an AKI following a fall on the floor. What is the most likley cause of his AKi ?
Rhabdomyolysis. Myoglobin breakdown, is nephrotoxic.
What should you think in patients that present with a painless testis lump with no transillumination ?
Testicular tumour untill proven otherwise
What is the common epidemiology in patients with suspected testicular cancer ?
Common in younger men under 45, with the highest incidence between 15 and 35 years.
What type of testicular cancer does gynaecomastia indicate ?
Presentation of a rare tumour type called a leydig cell tumour
What are the risk factors for developing testicular cancer ?
- Undescended testes
- HIV
- PMHx of testicular cancer
- Caucasian
- Under 45
- Male infertility
- Family history
- Increased height.
What is the main presenting symptoms of testicular cancer ?
Painless lump on the testical.
Apart from a painless lump on the testicle, what are some of the other symptoms of testicular cancer ?
- Painless lump on the testicle. Can sometimes present with pain.
- Arise from the testis.
- Irregular
- Hard
- NO transillumination
- Non tender
- Non fluctuant.
What is the initial investigation in patients presenting with a painless scrotal lump ?
Scrotal USS
Then a staging CT scan.
What are the three tumour markers involved in identifying testicular cancer ?
- Alpha fetoprotein
- Beta hCg
- LDH
What type of tumour is alpha fetoprotein raised in ?
Raised in teratomas.
What type of tumour can beta hCg be raised in ?
Can be raised in teratomas and seminomas.
Choriocarcinomas.
What type of tumour can LDH be raised in ?
Very non specific tumour marker. Most common type of testicular cancer occuring in undescended testes in seminoma.
What are some common sites of metastasis in testicular cancer ?
- Lymphatics (make sure to undergo a lymphatic examination). Para aortic lymph nodes.
- Lungs
- Liver
- Brain
What are the stages of the royal marsden staging system (used in staging testicular cancer)
- Stage 1 – isolated to the testicle
- Stage 2 – spread to the retroperitoneal lymph nodes
- Stage 3 – spread to the lymph nodes above the diaphragm
- Stage 4 – metastasised to other organs
How is testicular cancer managed ?
Surgery to remove the affected testicle (radical orchidectomy) – a prosthesis can be inserted
Chemotherapy
Radiotherapy
Sperm banking to save sperm for future use, as treatment may cause infertility
What are some of the possible long term side effects of testicular cancer ?
- Infertility
- Hypogonadism
- Peripheral neuropathy
- Hearing loss
- Lasting kidney, liver or heart disease
- Increased risk of cancer in the future.
Prostate cancer is __________________ dependent ????
Androgen dependent and relies on androgen hormones to grow. Majority are adenocarcinomas.
What are some of the common sites of metastasis for the prostate cancer ?
Lymph nodes and the bones.
What are the risk factors for developing prostate cancer ?
- Increasing age
- Fhx
- Black African or Caribbean origin
- Tall stature
- Anabolic steroids.
How does prostate cancer present ?
Can be asymptomatic but may also present with LUTS
- Hesitancy
- Frequency
- Weak flow
- Terminal dribbling
- Nocturia
May be other symptoms such as haematuria, erectile dysfunction and symptoms of advanced disease or metastasis like weight loss, bone pain or cauda equina.
What is a PSA and why must patients be counselled on its use ?
PSA may lead to the early detection of prostate cancer and lead to effective treatment and prevent significant problems. PSA has a high rate of false positives (75) and false negatives (15 percent). PSA can be raised in the following conditions …..
False positives may lead to further investigations including invasive prostate biopsies which can have complications and may be unnecessary. May also lead to a unnecessary diagnosis and treatment of prostate cancer.
False negatives may lead to false reassurance.
What other conditions can cause an isolated rise in PSA ?
- Prostate cancer
- BPH
- Prostatitis
- UTI
- Vigorous excersise
- Recent ejaculation or prostate stimulation.
What does a benign prostate feel like ?
smooth, symmetrical and slightly soft with a central sulcus.
What does a prostate in BPH feel like ?
General enlargement
What does a prostate in prostatitis feel like ?
May feel enlarged, asymmetrical and warm
What does a cancerous prostate feel like ?
Firm, hard, asymmetrical, craggy or irregular with loss of the central sulcus. May be a hard nodule. Any features in primary care may require a 2WW.
What is the first line imaging investigation for localised prostate cancer ?
Multiparametric MRI
What is the likert scale ?
Used to diagnose prostate cancer
1 – very low suspicion
- 2 – low suspicion
- 3 – equivocal
- 4 – probable cancer
- 5 – definite cancer
Used after multiparametric MRI
When is a prostate biopsy conducted ?
Depends on likert scale and is usually done on a score 3 or above and clinical suspicion (examination and psa levels).
Why are multiple needles and multiple different sites used in prostate biopsy ?
- Risk of false negatives if the biopsy misses the cancerous area. Multiple needles are used to take samples from different areas of the prostate.
- MRI scan results can guide the biopsy to decide the best target for the needles
What are the two methods of biopsy in prostate cancer ?
- Transrectal USS guided biopsy - involves an ultrasound probe inserted into the rectum, providing a good indication of the size and the shape of the prostate.
- Transperineal biopsy - Needles inserted through the perineum and it is usually under local anaesthetic.
What are some of the possible complications or prostate biopsy ?
Pain, bleeding, infection, urinary retention and erectile dysfunction.
How is an isotope bone scan used in prostate cancer ?
Due to the high risk of metastasis. Can be used to look for bony metastasis. A radioactive isotope can be given by IV injection followed by a short wait. Metastatic bone lesions take up the isotope.
What does a PIRADS score of more than indicate ?
Need for biopsy as there is a high index of suspicion for prostate cancer
What is the Gleason grading system ?
Based on the histology from the prostate biopsies. Specific to prostate cancer and helps to determine the most appropriate treatment options.
What is the gleason grading system made up of ?
Used in prostate cancer
The Gleason score will be made up oftwo numbersadded together for the total score (for example, 3 + 4 = 7):
- The first number is the grade of the most prevalent pattern in the biopsy
- The second number is the grade of the second most prevalent pattern in the biopsy
What are the three sub categories of the gleason grading system and what do they indicate ?
- 6 is considered low risk
- 7 is intermediate risk (3 + 4 is lower risk than 4 + 3)
- 8 or above is deemed to be high risk
- TNM staging system can also be used in the staging of prostate cancer
An 89 year old gentleman presents with weight loss, back pain and frequency. A digital rectal exam is suspicious therefore he is referred to urology under a two week wait referral criteria. A urologist diagnoses high-grade prostate cancer after investigations. What scoring criteria is likely to have been used to make this diagnosis?
Gleason scoring system
What is smoking and painless haematuria consistent with ?
Transitional cell carcinoma of the bladder.
What type of cancer are die workers likley to get ?
Transitional cell carcinoma of the bladder
What are the risk factors for bladder cancer ?
- smoking
- increased age
- Aromatic amines like used to make dye and rubber. Also cigarettes
- schistosomaiasis causes Scc of the bladder in countries with a high prevalence of infection.
What is the most common type of bladder cancer and what are the risk factors for development ?
- transitional cell.
- smoking, aromatic amines and dyes
What are the risk factors for scc of the bladder ?
- Higher in areas of schistosomiasis infection
- Long term catheterisation
What is the key symptom of bladder cancer ?
Painless haematuria
Bladder cancer until
proven otherwise.
What are some of the systemic features of bladder cancer ?
General B symptoms like weight loss and night sweats
What are some of the common local features of bladder cancers ?
- Painless haematuria
- UTI
- Hydronephrosis
What are some of the common sites of metastasis for bladder cancer ?
Lungs
Liver
Bone
What are some of the imaging modalities for suspected bladder cancer ?
- Ct urogram (contrast is injected into a vein which is then filtered by the kidney and excreted )
- Flex or rigid sig and biopsy
- Ct bone isotope scan or MRI to stage malignancy
What are some of the 2ww guidelines for bladder cancer ?
Aged over 45 with unexplained visible haematuria, either without a UTI or persisting after treatment for a UTI
Aged over 60 with microscopic haematuria (not visible but positive on a urine dipstick) PLUS:
Dysuria or;
Raised white blood cells on a full blood count
What are guidelines for non urgent referral 2ww guidelines ?
Non urgent referral in patients over 60 with recurrent unexplained UTI.
What imaging method can be used to visualise bladder cancers and stage them ?
Cytoscopy.
What qualifies for non invasive bladder cancer via the TNM staging system ?
- Tis/carcinoma in situ: cancer cells only affect the urothelium and are flat
- Ta: cancer only affecting the urothelium and projecting into the bladder
- T1: cancer invading the connective tissue layer beyond the urothelium, but not the muscle layer
What is the gold standard of treatment for non invasive bladder cancer ?
TURBT - trans urethral resection of the bladder cancer
Chemotherapy can be used alongside the TURBT either during or after
What other modality of treatment can be used in treating non invasive bladder malignancy (other than TRUS) ?
BcG (immunotherapy) - Usually in intermediate grade cancer.
What is the gold standard of treatment of patients with metastatic lymph node spread bladder cancer (T2-T4) e.g local bladder cancer with muscle invasion?
Cystectomy with urinary diversion.
T2N0M0 likely to be the staging of tumour. Unlikley to be offered if metastatic or nodular spread.
Unlikely to be considered if the patient has significant co-morbidity.
Radiotherapy and chemotherapy can be trialled before radical cystectomy.
What is the single biggest risk factor for the development of bladder cancer ?
Smoking
What are the first line investigations for patients before histologist investigations in bladder cancer ?
Ct urogram and flexible cystoscopy.
What are some common causes of CKD ?
- Diabetics
- Age
- Glomerulonephritis
- PkD
- Medications like NSAIDS, PPI, lithium
- Hypertension
What is the common causes of CKD ?
Diabetic neuropathy
How does diabeties cause CKD ?
Diabetic neuropathy can cause microalbuminuria. Progression can lead to nephropathy and CKD.
All patients over the age of 12 should undergo regular UACR testing to screen for microalbuminuria.
What levels of UACR indicate microalbuminuria ?
Over 2.5 in men and over 3.5 in women.
How should diabetics presenting with CKD as a result of diabetic nephropathy be managed ?
ACE inhib
What is frothy urine a sign of ?
- Protein in the urine and kidney injury.
- Nephrotic syndrome
What are some risk factors for CKD ?
- Old age
- hypertension
- Diabetes
- Smoking
- Use of nephritic medications.
What are some examples of nephrotoxic medications ?
- NSAIDS
- Lithium
- spirnolactone
- Some antibiotics
How does CKD present ?
Often asymptomatic but can present with
- Pruritus
- Loss of appetite
- Nausea
- Oedema
- Muscle cramps
- Peripheral neuropathy
- Pallor
- Hypertension.
What criteria leads to a diagnosis of CKD ?
eGFR < 60 on two blood tests three months apart or proteinuria.
Proteinuria via UACR > 3
What imaging can be used in diagnosing and investigating CKD ?
eGFR more than 60
When is renal biopsy indicated in chronic renal disease ?
In order to diagnose patients. Indicated in patients with progressive worsening of symptoms and symptomatic CKD.
What are some of the possible complications of CKD ?
- Anaemia
- Renal bone disease
- CV disease
- Peripheral neuropathy
- Dialysis related problems.
What criteria in context of CKD indicates the need for specialist refferal ?
- eGFR < 30
- ACR ≥ 70 mg/mmol
- Accelerated progression defined as a decrease in eGFR of 15or25%or15 ml/min in 1 year
- Uncontrolled hypertension despite ≥ 4 anti-hypertensives
How is CKD managed overall ?
Slow the progression of the disease, reduce CV risk, reduce risk of complications and treating complications.
How is disease progression managed in CKD ?
Optimise diabetic and hypertensive control. Treat pyelonephritis
How are CV risk factors managed in CKD ?
Exercise, weight control, special electrolyte dietary control and atorvastatin 20mg for primary prevention of CV disease.
How is metabolic acidosis treated in CKD ?
IV sodium bicarbonate
How is anaemia treated in CKD ?
EPO - CKD reduces the amount of EPO. Make sure they have no iron deficiency anaemia, if they do treat with iron first.
How does anaemia present in CKD ?
-Normocytic normochromic anaemia.
What is renal bone disease in CKD ?
Due to deranged kidney function - Sclerosis (whitening of ends of vertebrae) on x-ray and osteomalacia and less white in the centre of the vertebra.
Can also have osteoporosis.
How to manage renal bone disease in CKD ?
Vit D (e.g calcitriol), low phosphate diet and biphosphates in osteoporosis in renal bone disease
How is End stage CKD managed ?
- Dialysis in end stage renal disease
- Renal transplant in end stage.
How is hypertension managed in CKD ?
- First line = ACE inhib with the aim to keep blood pressure less than 140/90.
- Diabetes plus ACR (patients will often be on metformin) > 3mg/mmol
- Hypertension plus ACR > 30mg/mmol
- All patients with ACR > 70mg/mmol
What is it important to monitor in CKD ?
Hyperkalaemia - as kidney function and ACE inhib can cause hyperkalaemia.
More common in AKi rather than CKD
What causes raised urea but normal creatinine ?
- Upper GI bleed
- Bodybuilders and people with high protein diet.
This is because of urea is a major waste product of protein digestion.
What is a possible electrolyte complication of CKD ?
Hypocalcaemia can cause secondary hyperparathyroidism.
What is prostate cancer dependent on (hormone) ?
Androgen dependent and relies on testosterone to grow (majority are adenocarcinomas)
What are the risk factors for prostate cancer ?
- Increasing age
- Fhx
- Black African or Caribbean origin
- Tall stature
- Anabolic steroids.
How does prostate cancer present ?
Can be asymptomatic but may also present with LUTS
- Hesitancy
- Frequency
- Weak flow
- Terminal dribbling
- Nocturia
Maybe other symptoms such as haematuria, erectile dysfunction and symptoms of advanced disease or metastasis like weight loss, bone pain or cauda equina.
What are the three golden rules for diagnosing prostate cancer ?
- Abnormal PR
- Abnormal PSA
- Symptomatic
Why must patients be counselled on PSA test ?
PSA may lead to the early detection of prostate cancer and lead to effective treatment and prevent significant problems. PSA has a high rate of false positives (75) and false negatives (15 percent).
What are the other causes of raised PSA ?
- Prostate cancer
- BPH
- Prostatitis
- UTI
- Vigorous excersise
- Recent ejaculation or prostate stimulation.
What does a cancerous prostate feel like ?
Firm, hard, asymmetrical, craggy or irregular with loss of the central sulcus. May be a hard nodule.
What does a prostate in BPH feel like ?
Normal texture, generalised enlargement
What is the first line investigation for prostate cancer ?
Multiparametric MRI
When is a biopsy indicated in prostate cancer ?
Likert more than 3
How are Biopsys taken in prostate cancer ?
- Transrectal USS guided biopsy - involves an ultrasound probe inserted into the rectum, providing a good indication of the size and the shape of the prostate.
- Transperineal biopsy - Needles inserted through the perineum and it is usually under local anaesthetic.
Why are isotope bone scans used in prostate cancer ?
Can be used to look for bony metastasis. A radioactive isotope can be given by IV injection followed by a short wait. Metastatic bone lesions take up the isotope.
What is the gleason grading system ?
Based on the histology from the prostate biopsies. Specific to prostate cancer and helps to determine the most appropriate treatment options.
- The first number is the grade of the most prevalent pattern in the biopsy
- The second number is the grade of the second most prevalent pattern in the biopsy
What gleason score is considered high risk ?
8 or more
How are small prostate cancers managed ?
watch and wait/surveillance
How can prostate cancer be treated >?
- External beam radiotherapy - directed at the prostate. Key complication is proctitis (inflammation of the rectum). Proctitis can cause pain, altered bowel habit, rectal bleeding and discharge. Prednisone suppositories can be used to help reduce inflammation.
- Brachytherapy - Implantation of radioactive metal seeds into the prostate, resulting in targeted, continuous radiotherapy to the prostate. The radiation can cause inflammation of the nearby organs like the bladder and the rectum
- Hormone therapy - Reduce the level of androgen that stimulate the cancer to grow.
- Androgen-receptor blockers - such as bicalutamide
- GnRH agonistssuch as goserelin(Zoladex) orleuprorelin(Prostap). Dregarelix has metastaic prostate cancer with bony involvement that would not be curative with surgery. GnRH is good as symptom management. Anti androgen therapy is the mainstay of treatment for metastatic prostate cancer e.g back pain regardless of if you think it should be palliative ect
-Bilateral orchidectomy-to remove the testicles (rarely used)
What are the side effects of androgen therapy ?
- Hot flushes
- Sexual dysfunction
- Gynaecomastia
- Fatigue
- Osteoporosis
What is the surgical management of prostate cancer ?
Radical prostatectomy involves the surgical operation to remove the entire prostate. Cure cancer that is confined to the prostate. The key complications are erectile dysfunction and urinary incontinence.
What is nephrotic syndrome ?
Occurs when the basement membrane of the glomerulus becomes highly permeable to protein allowing proteins to leak from the blood into the urine and is common in ages 2-5.
What are the triad of symptoms associated with nephrotic syndrome ?
- Low serum albumin
- High urine protein content (+3 on dipstick)
- Oedema
What are the other symptoms of nephrotic syndrome ?
- Frothy urine
- May have facial odema and peripheral odema
- Pallor
- Hypercholesterolaemia
- Deranged lipid profile
- Hypertension
- Hypercoagulability
- Hypoalbuminaemia
- Hyperlipidaemia
What is the most common cause of nephrotic syndrome in children ?
Minimal change disease
What is the most common cause of nephrotic syndrome in adults ?
Membranous glomerulonephritis
What are some of the other causes of nephrotic syndrome ?
- Most common cause in children is minimal change disease
- Most common cause in adults is membraneous golmerulonephritis
- Systemic disease - DM, SLE and amyloidosis
How does minimal change disease present on biopsy ?
- Urinalysis will show SMWP and hyaline casts.
- Fusion of podocytes on electron microscope
How is minimal change disease treated ?
Corticosteroids like prednisolone
A 4 year old child presents with oedema, proteinuria and low albumin. What is the most likley cause and underlying pathophysiology ?
Minimal change disease causing nephrotic syndrome.
What is the most common cause of nephrotic syndrome in adults ?
Membranous glomerulonephritis
What can cause membranous glomerulonephritis ?
Associated with cancer (lung/colon/breast), infections (Hep B, SLE. thyroid disease) and drugs like penicillamine used to treat wilsons disease
What groups is FSG most prevalent in ?
More common in afro caribbean population
- Associated with burgers, HIV and sc
- Focal scarring and igM deposition
What is FSG treated with ?
Steroids like prednisolone
What will be present on investigation in nephrotic syndrome ?
- Urine dipstick - Proteinurea
- Urine analysis - Raised albumin creatinine ratio. Next step after dipstick (raised serum albumin)
- Renal biopsy in all adults, only in children who have an atypical presentation (steroid resistant, under 1 and over 12, haematuria ect)
How is nephrotic syndrome generally managed ?
high dose steroids like prednisolone.
What are patients who are steroid resistant in nephrotic syndrome treated ?
Patients that do not respond to steroids should be treated with ACE inhib and immunosuppressants like rituximab.
What are some of the complications of nephrotic syndrome ?
- Hypovolaemia and oedema/hypotension
- Thrombosis (DVT)
- Infection AKI/CKD
- Relapse.
- Hyperlipidaemia.
What is used to definitivley diagnose nephrotic syndrome ?
Renal biopsy
What is the difference between nephrotic and nephritic syndrome ?
in nephritic syndrome (haematuria), hypertension and RBC casts
What should the presence of peripheral odema in a child prompt a suspicion of ?
Nephrotic syndrome.
What bacteria is routinely screened for in patients undrgoing renal transplant surgery ?
Mycoplasma TB
What is nephritic syndrome ?
Not a diagnosis, based on if the patient fits the clinical picture of …
- Haematuria
- Oliguria
- Proteinuria (less than 3g/24 hours)
- Fluid retention
What is the clinical criteria for nephrotic syndrome ?
- Peripheral odema
- Proteinuria (<3g/24 hours)
- serum albumin less than 25g
- Hypercholesterolemia
What is glomerulonephritis ?
Conditions that cause inflammation of or around the glomerulus and nephron.
What is glomerulosclerosis ?
Scarring of the tissue of the glomerulus
What is the most common cause of nephrotic syndrome in children ?
Glomerulonephritis - Minimal change disease
What is the most common cause of nephrotic syndrome in adults ?
Glomerulonephritis - FSG
What complications does nephrotic syndrome predispose people to ?
thrombosis, hypertension and high cholesterol.
How is glomerulonephritis treated generally (for most subtypes) ?
- Immunosupression (steroids)
- Blood pressure control with an ACE/ARB
What are some of the specific types of glomerulonephritis ?
- Minimal change disease ( most common cause of nephrotic syndrome in children, usually idiopathic and is treated successfully with steroids).
- Focal segmental glomerulosclerosis - Most common cause of nephrotic syndrome in adults.
- Membranous glomerulonephritis
- IgA nephropathy (burgers disease)
- Post strep glomerulonephritis
- Meningiocapillary glomerulonephritis
- Rapidly progressive glomerulonephritis
- Good pasture syndrome.
How does IgA nephropathy present (bergers disease ?)
- Usually develops 1-2 days after a URTI in young men
- Key symptoms is intermittent gross haematuria
-may be none or small amounts of proteinuria.
What is present on histology in IgA nephropathy ?
IgA deposits and glomerular mesangial proliferation.
What is the first line INVESTIGATION in patients with nephrotic syndrome ?
Urinalysis/microscopy and MC and S
What is the gold standard of diagnosis in glomerulonephritis ?
Renal biopsy
How does post strep glomerulonephritis present (TIME FRAME)
?
Occurs 1-3 weeks after a strep throat infection or up to 6 weeks after a strep skin infection
- Presnts with nephritic syndrome symptoms.
What will be present on renal biopsy/electron microscopy in post strep glomerulonephritis ?
Subepithelial humps in the glomeruli and immune complex formation
Released serum levels of C3
IgG and C3 subepithelial deposition
(management is supportive)
What will be present on histology on membranous glomerulonephritis ?
IgG and complement deposits on the basement membrane.
What is goodpasture syndrome ?
Anti - GBM antibodies attack the glomerulus and the primary basement membranes. This causes glomerulonephritis and pulmonary haemorrhage.
How will a patient with good pasture syndrome present ?
Acute kidney failure and haemoptysis
What are the possible differentials for a patient presenting with haemoptysis and acute kidney failure ?
- Good pasture syndrome
- Wegeners syndrome (granulomatosis with polyangiitis)
What is rapidly progressive glomerulonephritis ?
- Histology will show Crescentic glomerulonephritis.
- Presents with a very acute illness with sick patients but responds well to treatment
- Often secondary to good-pasture syndrome.
What is epidiymo-orchitis ?
Infection of the epididymis and/or the testes resulting in pain and swelling and is commonly caused by local spread of infections from the genital tract or the bladder.
What are the common causative organisms of epididymo-orchitis ?
- Chlamydia trachomatis
- Neisseria gonorrhoeae - above typically seen in sexually active adults
- E.coli - typically in adults with a low risk sexual history.
- Mumps - Patient with parotid gland swelling and orchitis. Tends to only affect the testicle and not the epididymis. Can also cause pancreatitis
What are the symptoms of epididymo-orchitis ?
- Unilateral testicular pain and swelling
- May be urethral discharge (sti)
- Swelling of the testicle and epidiymis
- Acute onset of pain/
- Pain on palpation, particularly over the epididymis.
What is an important differential to rule out in epididymo-orchitis ?
Testicular torsion
Which would more likely present in a patient under 20, with severe pain and an acute onset and there would be an absent cresentaric reflex.
What are the important investigations when investigating epididymorchitis ?
- In younger adults, make sure to assess for STIs.
- In older adults with low risk sexual history, send a mid stream MSU for microsopy and culture
What are the important investigations when investigating epididymorchitis ?
- In younger adults, make sure to assess for STIs.
- In older adults with low risk sexual history, send a mid stream MSU for microsopy and culture
What is the general criteria for a STI cause of epididymorchitis ?
discharge, under 35 and increased number of sexual partners in the last 12 months.
What is the general management of a patient with STI induced epidiymo-orchitis ?
urgent refferal to specialist STI clinic and if the organism is unknown, ceftriaxone 500mg IM single dose + doxycycline 100mg PO twice daily for up to 2 weeks.
What is the general management of a patient with bacterial cause of epidymorchitis ?
MSU and oral quinolone (ofloxacin)/levofloxacin or co-amoxiclav when CI for two weeks
Quniolones are powerful BSA with good gram negative cover. What side effects is it important to infrom patients of that are taking them in conditions like prostatits, UTI, pyelonephritis and epidiymo-orchitis ?
- Tendon damage and tendon rupture (achillies)
- Lower seizure threshold so caution patients with epilepsy.
What is the treatment of asymptomatic bacteria in catheterised patients ?
No treatment is needed. Long term catheterisation results in colonisation of the catheter and is not reflective of an ongoing UTI.
What is the treatment of symptomatic patients with long term catheterisation ?
7 day course of antibiotics.
Consider removing or changing the catheter if it has been in place for more than 7 days.
What is the treatment of patients with acute pyelonephritis ?
the BNF currently recommends a broad-spectrum cephalosporin or a quinolone (for non-pregnant women) for 10-14 days
What is the treatment of a non pregnant woman with a UTI ?
recommendtrimethoprim or nitrofurantoinfor3 days
When should a urine culture be sent in terms of UTI ?
- aged > 65 years
- visible or non-visible haematuria
What antibiotic should be avoided to treat UTI in the first trimester of pregnancy ?
Trimethoprim as it is a tetarogenic
What is the first/second line treatment of symptomatic UTI in a pregnant woman ?
- first-line: nitrofurantoin(should be avoided near term)
- second-line:amoxicillin or cefalexin
How should asymptomatic bacteruria be managed in pregnant women ?
- Urine culture at first antenatal visit
- Nitrofurantoin (avoided near term, amoxicillin or cefalexin) 7 day course
- Due to risk of acute pyelonephritis
- Further urine culture after treatment
How is a UTI managed in a male ?
- Immediate 7 day course of antibiotics
- Trimethoprim/nitrofurantoin unless prostatitis is suspected
- Urine culture should be sent in all cases before antibiotics are started .
What are the common symptoms of an lower UTI ?
Dysuria (pain, stinging or burning when passing urine)
Suprapubic pain or discomfort
Frequency
Urgency
Incontinence
Confusion is commonly the only symptom in older more frail patients
What is the most common only symptom of UTI in older patients ?
Confusion
What are the symptoms of pyelonephritis ?
Fever is a more prominent feature than lower urinary tract infections.
Loin, suprapubic or back pain. This may be bilateral or unilateral.
Looking and feeling generally unwell
Vomiting
Loss of appetite
Haematuria
Renal angle tenderness on examination
What does the presence of nitrates in urine demonstrate ?
UTI - bacteria
Should a patient with only leukocytes present on dipstick, should they be treated for a UTI ?
No, only if there is clinical evidence of a UTI
What is the best indication of infection in a dipstick ?
Nitrites, leukocytes can be raised not in a UTI
What drugs should be avoided in an AKI ?
- NSAIDS, ACE, diuretics and ARBS
What is the first line of treatment in BPH in patients with postural hypotension/hypotension ?
Finasteride (tamulosin causes hypotension)
What medication is safe to use in patients with end stage renal failure ?
Tramadol
What is a possible complication of acute urinary retention ?
Post obstructive diuresis
What causes post obstructive diuresis (complication for urinary retention ? )
the kidneys may increase diuresis due to the loss of their medullary concentration gradient.
This can be due to catheter insertion
This can take time re-equilibrate
this can lead to volume depletion and worsening of any acute kidney injury
some patients may therefore require IV fluids to correct this temporary over-diuresis
What is the first line investigation for a patient with acute urinary retention ?
To confirm the diagnosis of acute urinary retention a bladder ultrasound should be performed. A volume of >300 cc confirms the diagnosis, but if the history and examination are consistent, with an inconsistent bladder scan, there are causes of bladder scan inaccuracies and hence the patient can still have acute urinary retention.
How is urinary retention managed ?
Acute urinary retention is managed by decompressing the bladder via catheterisation
What are the symptoms of acute urinary retention ?
Inability to pass urine
Lower abdominal discomfort
Considerable pain or distress
an acute confusional state may also be present in elderly patients
Distended bladder and lower abdominal tenderness
How can a UTI or acute urinary retention present in elderly patients ?
Acute confusional state
What is the most common cause of acute urinary retention in men ?
Secondary to BPH
What medications can cause acute urinary retention ?
- Anticholinergics (Atropine)
- Tricyclic antidepressants
- Antihistamines
-opiods
-Benzodiasepines.
AV block can occur secondary to …..
Inferior MI (ST elevation in leads 2 3 and aVF
What are the indications for dialysis in a patient with an AKI ?
Acidosis (severe metabolic acidosis with pH of less than 7.20)
Electrolyte imbalance (persistent hyperkalaemia of more than 7 mmol
Intoxication (poisoning)
Oedema (refractory pulmonary oedema)
Uraemia (encephalopathy or pericarditis).
What is nephritic syndrome ?
The patient fits a clinical picture of inflammation of the kidneys (oliguria, proteinuria (less than 3) and fluid retention)
Most likely to present as haematuria and non nephritic range proteinuria.
What is the criteria for nephrotic syndrome ?
- Peripheral odema
- Proteinuria (< 3g/24 hours)
- Serum albumin less than 25g
- Hypercholesterolaemia.
What is the most common cause nephrotic syndrome in children ?
Minimal change disease
Treates with steroids
What is the most common cause of nephrotic syndrome in adults ?
FSG
How are most cases of glomerulonephritis managed ?
-Steroids
-ACE inhib/ARB for BP control if needed
What are the features of IgA nephropathy ?
- Usually develops 1-2 days after URTI/GI infection
-Patients present with gross microscopic haematuria.
What are the first line investigation vs gold standard diagnosis in glomerulonephritis ?
- Urinalysis and microscopy (MCnS) - urinalysis will be positive for blood and protein.
- Gold standard biopsy will be renal biopsy.
What are the features of post strep glomerulonephritis ?
- Occurs 1-3 weeks after strep throat infections
- presents with typical nephrotic syndrome symptoms.
What is goodpasture syndrome ?
Anti-GBM antibodies attack the glomerulus and the primary basement membrane causing glomerulonephritis and pulmonary haemorrhage
How will good-pasture syndrome present?
A patient will present with acute kidney failure and haemoptysis
What is the treatment of goodpasture syndrome ?
High dose corticosteroids, cyclophosphamide and plasmapheresis
What is priapism ?
Prolonged and painful erection which persists for more than 2 hours after sexual activity
What is the management of priapism (prolonged erection)?
First line is aspiration of blood in the corpus cavernosa and irrigation with normal saline
Broadly, when is a contrast CT used ?
Contrast for anything with vascular supply like in cancer (angiogenesis)
What can tri-methoprim cause an isolated rise of ?
Creatinine
A 50-year-old woman presents to the GP clinic complaining of headache and nasal discharge. She further mentioned that similar episodes had occurred many times before, for which she is taking antibiotics. She also complains that her urine has become unusually dark. On examination, a saddle nose deformity is observed. Urinalysis shows significant blood with red blood cell casts.
What is the most likely diagnosis?
Granulomatosis with polyangiitis
What is granulomatosis with polyangiitis ?
Small vessel vasculitis that presents with rapidly progressive sinusitis, haemoptysis and rapidly progressive glomerulonephritis
What is granulomatosis with polyangiitis ?
Small vessel vasculitis that presents with rapidly progressive sinusitis, haemoptysis and rapidly progressive glomerulonephritis
What marker is used to confirm a diagnosis of granulomatosis with polyangiiitis
c-ANCA
What is the difference in the time frame between post strep glomerulonephritis vs IgA nephropathy ?
Post strep = presents with acute illness several weeks prior
IgA = presents with acute illness a couple of days after
When is renal replacement therapy indicated in patients with an AKI ?
- Hyperkalaemia
- Metabolic acidosis
- Symptoms or signs of uraemia (pericarditis or encephalopathy)
- Pulmonary odema
What organism can cause peritoneal dialysis peritonitis ?
S.epidermidis
What can left sided variceales be suggestive of ?
renal cell carcinoma
caused by obstruction of the left renal vein by an invasive tumour.
Patient should have an USS abdomen
What are the common causes of membranous glomerulonephritis ?
- Malignancy
- Infections (HEP B, SLE and thyroid disease)
What is an electrolyte complication of CKD ?
Hypocalcaemia
What medications have renotoxic potential ?
NSAIDs
Metformin
Digoxin
Ca channel blockers
ARBS
What is the anticoagulant of choice in an AKI ?
Warfarin
What can cause a decrease in eGFR (false negative) ?
Eating red meat the night before the test
In aspirin/salicylate positioning, there is a raised anion gap acidosis. What is the appropriate treatment option for a patient in this situation ?
IV sodium bicarbonate.
What is used in the prevention of contrast induced nephropathy ?
IV 0.9 percent sodium chloride pre and post procedure
How does acute interstitial nephritis present ?
- Allergic type picture ( fever, joint pains and pruritic macular rash has formed on the torso)
- Usually arises due to drug toxicity like amoxicillin post CAP
-Raised urinary WCC, IgE and eosinophils - Impaired renal function.0
How does acute interstitial nephritis present ?
- Allergic type picture ( fever, joint pains and pruritic macular rash has formed on the torso)
-Raised urinary WCC, IgE and eosinophils - Impaired renal function.
Compartment syndrome/rhabdomyolysis can cause acute tubular necrosis. How does this present ?
- Worsening renal function
- Muddy brown casts
How is anaemia corrected in CKD ?
-1st line correct the iron deficiciency
- Then start on EPO stimulating agents.
What is the mainstay of treatment for renal cell carcinoma (adenocarcinoma) ?
- Insensitive to chemotherapy and radiotherapy making surgery the main treatment
- T1 lesions may be managed as a partial nephrectomy and gives equivolent oncological outcomes to radical nephrectomies.
- T2 lesions are managed by radical nephrectomies
What is the mainstay of treatment of transitional cell carcinoma (renal) ?
- Surgery - Radical nephroureterectomy (only offered if there is no metastatic disease)
- Laser therapy - Patients that have one kidney, poor combined renal function and are not fit enough for GA and a major operation.
Chemotherapy and radiotherapy used in a more palliative setting.
What are the clinical features of renal cancer ?
- Haematuria
- Loin pain
- Flank mass
- Metastatic disease
- A left sided varicoceal can be the presenting feature of a RCC.
What is a left sided varicoceal indicative of ?
Can be a presenting feature of RCC
What are the investigation choices in RCC ?
- USS
- CT kidneys
- IV urogram
- Flex cystoscopy
- CXR (classic cannon ball secondaries can be seen in the lung)
What is the treatment escalation of urge incontinence ?
- 1st line = bladder retraining
- 2nd line is anti-muscarinics like oxybutyn (avoided in older women) or tolterodine
What is the treatment of stress incontinence ?
- Duloxetine (pelvic muscle exercises)
What investigations are used in monitoring bladder activity in a patient presenting with incontinence ?
- Bladder diaries for 3 days
- Vaginal examination to rule out prolapse and ability to initiate contraction of pelvic floor excersises.
- Urodynamic studies
- urine dipstick and cultures
How does renal colic present ?
- Severe, intermittent loin pain that can radiate to the groin
- Pain is often restless
- Haematuria - However negative would not rule out a renal stone.
- Nausea and vomiting
- Secondary infection may cause sepsis
What is the most common type of renal stone and what increases risk of these ?
Calcium stones make up 80 percent of stones (calcium oxalate most common) or calcium phosphate (less common)
Uric acid - Gout can increase risk of these types of stones.
What stones are responsible for large staghorn calculi and what are the predisposing factors ?
Struvite - Often lead to large staghorn calculi
- Predisposing factors = recurrent URTI
- Most common organism is proteus infection
What is the most common investigation in patients with renal stones ?
Investigations - Bloods and renal function
Non contrast CTKUB
What are the different management options for renal stones ?
- Stones <5 with no signs obstruction = Watchful waiting
- Tamsulosin can be used in those with stones less than 5mm in the distal ureter
- Percutaneous nephrolithotomy - Used for patients with large stones or complex calculi like staghorn calculi.
- Uterosocpy - choice in pregnancy, distal or middle uteric stones.
- SWL
- Prevention - Thiazides for hypercalciuria and allopurinol in uric acid stones.
Proteinuria and haematuria (with casts) should prompt what investigation ?
Percutaneous renal biopsy
What are the electrolyte abnormalities seen in CKD ?
Hyperkalaemia, hypocalcaemia and hyperphosphataemia.
What is a dangerous complication of E.coli infection (raw veg, undercooked veg, dairy products ) ?
Haemolytic uraemic syndrome
What is one of the side effects of spirinolactone ?
Gynecomastia
What is the most common/important viral infection to consider in patients who are organ transplant recipients ?
Cytomegalovirus.
What is the imaging modality used in PKD ?
USS
How do kidneys present in diabetic nephropathy ?
Bilaterally enlarged kidneys.
What electrolyte abnormality indicates chronic CKD rather than acute ?
Hypocalcaemia.
