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Phase 4 > Renal and Urology > Flashcards

Renal and Urology Flashcards

1
Q

What are the classic symptoms of pyelonephritis?

What imaging would you want to do on someone with suspected pyelonephritis?

What are some complications?

A

Classic triad of:

  • loin pain
  • Fever
  • tenderness over the kidneys

Officially can be diagnosed with:
Bacturia + Fever

or

Bacturia + Loin Pain

Imaging:

  • Ultrasound of kidneys
  • CT KUB

The US should also check for any obstructions which may be contributing to the infection. These will show renal pelvis inflammation and small abcesses
CT is the investigation of choice when trying to assess for complications

Complications:

Sepsis

Renal Scarring - causing CKD

Emphysematous Plyeonephritis
- severe necrotising infection of the kidney parachyma

  • seen on CT with gas around the kidneys

Hydronephrosis
- would require catherisation to improve flow

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2
Q

When is UTIs as common in males as females?

A

1st year of life

It becomes more common as we age due to bladder outlet difficulties

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3
Q

What is the diagnostic investigation to diagnose glomerulonephritis?

A

Renal Biopsy with:

  • light microscopy
  • electorn microscopy
  • Immunofluroence
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4
Q

In suspected glomerulinephritis, what invesitgations should be done?

A
  • *Urine analysis:**
  • Dipstick
  • Microscopy
  • 24 hour protien collection
  • Protein/ Creatinine ratio

FBC:
- Anaemia

Coagulation Studies

Serology:

  • c-ANCA
  • dsDNA
  • Anti - GBM
  • IgA

Electrophresis

Imaging
- Ultrasound of kidneys

Biopsy

  • Light Microscopy
  • electron microscropy
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5
Q

If there is haematuria, how can the source be isolated?

A

RBC casts - which are dysmorphic RBCs would suggest from the glomeruli

Non - dysmorphic would suggest from lower down from the glomeruli i.e kidney stone

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6
Q

What are the key symptoms of nephritc syndrome?

A

Peripheral oedema

Periorbital oedema

Hypertension

Oligouria

Urine analysis:

Haematuria
- RBC cast

Proteinuria
- moderate amount (1-3g - so not as much as a nephrotic syndrome)

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7
Q

Post Streptococcal glomeruonephritis:

A

Caused by a skin infection 1-6 weeks ago
or
URTI 1-3 weeks ago

Investigations:

Anti- streptolysin O test

Complement studies C3/4 (reduced)

*usually biopsy is not needed.

Treatment:

- furisemide

  • antibiotics
  • supportive management
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8
Q

IgA Nephropathy:

A

Usually occurs 12-72 hours following an infection

Symptoms:

  • pupura of lower body
  • arthritis
  • G.I pain
  • Symmetrical rashes

Investigations:

Need to rule out ITP and TTP therefore

  • coagulation studies are done and
  • platelets

Skin biopsy of rash:

  • Leukocytoclasic vasculitis
  • IgA depositation

Renal Biopsy
- IgA deposits within mesangium

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9
Q

What are the general treatments for nephritic syndrome?

A

Blood pressure control
- ACE inhibitor
or
- Angiotensin Receptor Blocker

Immunosupressive:

  • corticosteroids for immune complex supression
    (IgA nephropathy)
    (rapidly progressive glomerulinephritis)

Antibiotics:

  • for on going infections that may be triggering
    (post strep infection)

Pain:

(IgA nephropathy for G.I pain)

Renal Dialysis
(for ESRD)

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10
Q

What are the common causes of Rapidly progressive Glomerulinephritis?

A
  • *Good Pastures disease**
  • Anti GBM antibodies
  • *Granlumoatosis with polyangitiis**
  • c - ANCA

Microscopic polyangitis

  • p - ANCA
  • *Lupus nephritis**
  • dsDNA
  • ANA

**all require a renal biopsy

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11
Q

How is granulomatosis polyangitiis treated?

A

If evidence of Renal disease or pulmonary disease:

  • IV methpredisolone
    +

Cyclophosphamide

+/-

Plasmaphresis

No eivdence of renal disease:

  • oral predisolone

or
- rituxmab

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12
Q

What are the types of primary diseases that can cause nephrotic syndrome?

A

Minimal change disease
- children

Membraneous nephropathy

  • Adults
  • anti - phospholipid A2 antibodies

Focal Segmental Glomerulosclerosis
- Coloured people

Membranoproliferative glomerunephritis

  • type I
  • Type II
  • Type III
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13
Q

What are some complications of nephrotic syndrome?

A
  • *Hypercoagulable**
  • DVT
  • P.E

Hypovolaemia

Protein Malnourishment

  • *Immunocompromised**
  • loss of IgG in urine
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14
Q

What is the general treatment for nephrotic syndrome?

A

Reducing protein loss

  • ACE hibitors

Control of oedema:

  • redued Na2+ intake
  • Furesimide

Anticoagulation:

  • Heparin
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15
Q

What is the treatment for membraneous nephropathy?

A

this depends of the severity. Remeber 1/3rd will spontaneously get better, 1/3rd will maintain eGFR and 1/3rd will progress to ESRF.

therefore management depends how at risk they are:

Low risk: - monitor
Medium risk: Predisilone
High risk: Predisilone + Cyclophosphamide

+ ACE

+ Salt restriction
+/- Diuretics

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16
Q

List some examples of complicated UTIs and pyleonephritis:

A

Male

Pregnancy

Indwelling catheter

Poorly controlled Diabetes melitus

Previous Urogenital surgery

uroligcal conditions
- BPH

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17
Q

What are some risk factors for developing a UTI?

A

Sexual activity

Urinary incontinence

Spermicide use

Obstruction of urine

Immunospuression

catherter

Renal tract malformations

Diabetic Meliitus

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18
Q

What investigations should be done in suspected UTI?

A

*in non - pregnant women <65, if they have >3 or more symptoms in keeping with UTI then treat empirically.

  • **Diptick**
  • females
  • *Mid-stream Urinary/ MSU culture:**
  • men
  • Pregnany women
  • Children
  • previous failure to repsond oral antibiotics

Blood tests:

  • do if systemically un well

Imaging:

Conisder in

  • pyleonephritis
  • failure to respond to treatment
  • unusual organisms
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19
Q

How does Pyelonephritis appear on ultrasound?

A

Hypoechoic mass
- usually unilateral

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20
Q

How does pyleonephritis appear on CT?

A

Hypotense regions of the kidneys

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21
Q

What is the recommended treatment for pyleonephritis in pregnant women?

A

Ceftriaxone

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22
Q

When should asymptomatic bacturia be treated?

A

In pregnant women

Renal transplant patients

Those about to have a urological intervention
- TURB

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23
Q

What are the complications of Pyelonephritis?

A

AKI

  • Septic shock
  • Papillary necrosis - post obstructive

Emphysematous plyeonephritis

  • Gas producing
  • usually staph aureus

Abscess:

Continual loin pain + fever

Renal Abcess
- Pus within the kidney Parachymal tissue

Perirenal Abcess
- pus between the renal capsule and Gerota’s fascia

Renal Scarring

  • risk of chronic renal failure
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24
Q

What is the mangement of renal abcesses?

A

Antibiotic management

Renal Abcess >5cm = percutaneous drainage

Perirenal abcess >3cm = Percutaneous drainage

if these can’t be drained then surgery is recommended

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25
Q

If a young patient has symptoms of a UTI and on dipstick there blood and leukocytes, however on MSU there is nothing, what is a likely diagnosis?

A

Chlaymadia

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26
Q

What is first line for hyper PTH in kidney disease?

A

Phosphate binders

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27
Q

What is the best investigations for establishing between acute and chronic kidney disease and what is the characteristic finding?

A

Ultra sound.

Chronic kidney disease will tend to have bilaterally small kidneys

*exceptions include:

  • diabetic nephropathy
  • Sarcoidosis
  • HIV nephropathy
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28
Q

Which drugs during an AKI should potentially be stopped, not because they worsen the AKI, but can lead to toxic build up?

A

Metaformin

Lithium

Digoxin

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29
Q

How is diabetic kidney nephropathy monitored?

A

Early morning Albumin:creatinine ratio

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30
Q

What is the classification of CKD:

A

Abmormal Kidney structure or function for >3 months with implications towards health.

G1 - >90
- with evidence of underlying kidney disease

G2 - 60-90

G3 - 30 -60

G4 - 15 - 30

G5 <15

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31
Q

What are the biggest factors associated with prognosis in CKD?

A

Low GFR

Albuminuria

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32
Q

What investigations would you want to do into suspected CKD?

A
  • *U&Es**
  • compare with previous
  • *FBC**
  • Normocytic anaemia
  • *Bone profile**
  • low Ca2+
  • High PTH
  • *Immunology**
  • glomerulinephritic causes
  • *Urine analysis:**
  • A:Cr
  • P:Cr
  • Dipstick
  • *Imaging of Kidneys**
  • size (small, unless polycystic, amyoid and myeloma)
  • Symmetry (stenosis)

Histology

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33
Q

What are the general management stratagies for CKD?

A

Referral to nephrology

Slow progression of the disease

Management of complications

Preperation for renal replacement therapy

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34
Q

What are some of the complications of CKD and how are they managed?

A
  • *Anaemia**:
  • EPO when <110Hb
  • *Hypertension:**
  • ACE Inhibitor (monitor closely
  • *Acidosis**:
  • Sodium bicarbonate
  • *Oedema**:
  • Na2+ restriction
  • Duiretics (needs careful monitoring)
  • *Bone mineral Disoders**
  • Phosphate binders
  • Vitamin D supplements
  • *Cardiovascular Risks**
  • Aspirin
  • Statin
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35
Q

If Renal replacment is going to be required, and you make a referral, when should this be done by?

What else should be done?

A

> 1 year.

within 1 year of referral and starting renal replacement therapy is considered a late referral.

All should be registered for donation within 6months of transplant.

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36
Q

What drugs inparticular need careful consideration with regards to dosing in CKD due to their renal excretion?

A

Aminoglycosides
- gentamcin

Penicillins

Cephalosporins

Heparin

Lithium

Opiates

Digoxin

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37
Q

What are some complications of polycyctic kidney disease?

A

Liver/ pancreatic cyst formation

Cyst rupture

SAH

Renal failure

Mitral valve prolaspe

Diverticulitis

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38
Q

What is the diagnostic criteria for polycycstic kidney disease? and what is the diagnostic test of choice?

A

Family history:

15 - 30: >2 cysts present, TWO unilateral or bilateral cysts

30 - 59: >4 cysts ,TWO Cysts bilaterally

>60: >8 cysts, FOUR Cysts Bilaterally

No family history:

>10 more cysts in both kidney

Liver cysts

Renal enlargement

*a CT or MRI can be used which are more sensitive.

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39
Q

What is the management of polycystic kidney disease?

A

Blood pressure control

1st line: ACE

2nd line: Thiazide

3rd line: Beta blocker

  • *Manage extra-renal complications**
  • anaemia etc

Renal replacement therapy

Preparation

Tolvaptan -***

Vasopressin receptor antagonist **
- reduces production of cysts

Surgical:

Surgical excision if compression is needed for pain or obstruction

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40
Q

What are some causes of congenital chronic kidney disease?

A
  • *Adult Polycystic kidney disease**
  • PKD -1
  • PKD -2
  • *Autosomal reciessive Polycystic kidney disease**
  • begins as neonate
  • *Renal Phakomatoses**
  • tuberous sclerosis
  • Von Hippel Lindau disease

Alport Syndrome:
Collagen Type IV defect

  • *Fabry Disease**
  • Lymosomal disorder
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41
Q

What is the general management for nephrotic syndrome?

A

Reduce Oedema:

  • Fluid restriction
  • loop duiretics *consider IV loop diuretics if oral does not work due to gut odema
    *add thiazides if not working with just loop diuretics

Treat underlying cause:

Steroids and immunospuressive therapies are usually needed

  • *Reduce Proteinuria:**
  • ACE inhibitors
  • *Thromboembolism:**
  • treat with Heparin - LMWH

Infection control
these people are immunocompromised and thus must be monitored carefully
- Pneumoccocal vaccine should be given. patients are very susceptible to it

  • *Hyperlipidaemia:**
  • statins
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42
Q

If someone is breathless, with hepatosplenomeglay but normal LFTs, what should you immediately think?

A

Amyloidosis

43
Q

How often is haemodialysis usually needed to be done?

A

3 x weekly for 3-5 hours

44
Q

What is a major complication of haemodialysis that presents with:

  • focal neurological deficits
  • reduced GCS
  • Papiloedema
  • headache
A

Dialysis disequilibrium syndrome

Where there is a reverse osmosis in the brain leading to cerebral oedema

45
Q

What are the features of acute interstitial nephritis?

A

25% of AKI is caused by this.

*Eosinophilia

*sterile pyuria

Classic triad of:

  • fever
  • Arthralgia
  • maculopapular rash

Typically caused by:

  • Antibiotics
  • Allopurinol
  • NSAIDs
46
Q

Following a kidney transplant, what cancer are people more at risk of?

A

Skin Cancer
- sqaumous and basal cell

47
Q

What is a biological marker on U&Es of dehydration and not an AKI?

A

Disproportionally high urea to creatinine

48
Q

What does leukocytes in the urine tell you?

A

That there is inflammation. it is not specific to infection.

Nitrites on top would suggest infection

49
Q

What can tumour lysis syndrome lead to with regards tot he kidneys?

A

AKI

  • induces tubular necrosis
50
Q

How can urine osmolarity help determine the the cause of an AKI?

A

High osmolarity suggests pre-renal

  • because the kidneys are able concentrate and reabsobe more salt.
  • thus a low urinary Na2+ and high osmolarity in the urine suggest pre-renal

Low osmolarity suggests intra-renal as the kidney is unale to concentrate.

51
Q

In an AKI situation, what would protein in the urine be suggestive off?

A

It would suggest an intra-renal aetiology as the proteins pre-renally should sitll not be filtered and post renally should not off been filtered

52
Q

What is the most common extra-renal manifestation of polycycstic kidney disease?

A

Liver cysts

53
Q

What is the assessments that should be done in AKI?

A

RENAL

R - Rule out Sepsis
E - Exclude obstruction

N - Note urinalysis

A - Assess Fluid balance

L - Look at drugs

54
Q

What is the antibiotics used for epidymitimitis and orchitis?

A

<35 years - doxycycline

+ /-
- ceftriaxone + referral

>35 years:

  • ciprofloxacin
55
Q

What are the types of dialysis used?

A

Haemdialysis

  • *-** diffusion
  • hydrostatic pressure
  • *Peritoneal Dialysis**
  • Continuous Ambulatory
  • Autonomic peritoneal dialysis

Haemofiltration

- Hydrostatic pressure

56
Q

What are some complications of haemodialysis?

A

Hypotensive Crash

Dialysis Disequalibrium Syndrome

Steel syndrome

Cramps

Fatigue

57
Q

What are some complications of Peritoneal dialysis?

A

SBP

Sclerosis Peritonitis
- potentially fatal as it causes thickening of the peritoneal membrane

Pleural effusion

  • can be tested for via the Hypertonic solution
  • or blue colour as the dialysate is often blue

Glucose overload

Herniation

58
Q

What are some absolute condraindications to peritoneal dialysis?

A

Stoma

Intra-abdominal sepsis

Visual impairement - patients need to be able to see what they are doing

Abdominal hernia

59
Q

What are some investigations that should be done into CKD?

A

Bloods:

FBC

  • Signs of anaemia

U&Es

  • High creatinine
  • High urea
  • Checking for other electrolyte imbalances

eGFR

LFTs - Albumin

Albumin can be lost/ also consider malnutrition

Bone profile

  • Ca2+
  • Phosphate levels
  • PTH

Glucose levels (diabetic screen)

Lipids

Orifices:

Urine analysis

Protein: creatinine ratio

X-rays:

Renal ultrasound

Small kidneys is in keeping with chronic

*if there is asymmetry then consider renal stenosis

Joint x-rays:

Renal osteodystrophy

DEXA scan

ECG:

Risk of hyperkaliaemia, especially true in >40

Special tests:

Antibody testing

  • ANA
  • ANCA
  • GBM

Renal biopsy

60
Q

What is the generalised treatment for CKD?

A
  1. Appropraite referral to Nephrology
    - >25% drop in eGFR
  • increased Proteinuria >30g
  1. Slow down progression of CKD
    - Lifestyle factors
    - ACE inhibitors
    - Glycaemia control
  2. Treat renal complications
    - Anemia
  • Acidosis
  • Renal Osteodystrophy
  1. Treat non renal complication
    - heart failure - BP
    - <140/90
    - 130/80 (DM)
  2. Preperation for RRT
    - 1 year in advance
61
Q

What is the biggest cause of death on RRT?

A

Ischemic Heart disease

62
Q

What is a good test to estbalish the difference between pre-renal and intra-renal AKI?

A

Urine sodium

  • in prerenal the urinary sodium will be low as the kidneys try to hold onto fuild
63
Q

Name some causes of non - visiable haematuria:

A

Renal Calculi

Prostatitis

Renal cell carcinoma

Bladder Carcinoma

Renal IgA nephropathy

64
Q

What investigations do you want in someone who presents with an AKI?

A

Bloods:

FBC - infection

Coagulation screen - DIC?

CRP

U&ES - essential - and to compare against baseline. Check K+

Blood cultures

Bone profile - Ca2+ help establish between chronic

+/-

Myoglobin - is there justification

+/-

Serum creatinine

HIV and Hepatitis serology

Essential if there is likely hood of dialysis needed

Orifices:

Urine dipstick

Urine analysis

  • Microscopy
  • Cultures
  • Sensitives

Urine osmolality

This is really useful for establishing the cause. If there is a high urine osmolality then it is likely to be pre-renal, as opposed to intra-renal which is unable to concentrate

X-rays:

Kidney ultrasound

Bladder ultrasound

CXR - pulmonary oedema

ECG:

Hyperkalaemia

Tall tented T waves

Loss of P waves

Sinusoidal

Special tests:

Myeloma screen?

65
Q

What is the management for Pyelonephritis?

A

Sepsis 6

  • Aggressive Fluids
  • IV antibiotics

(gentamicin)

(Ceftrixaone or co-amoxiclav for pregnant women)

66
Q

Where are Haemodialysis lines placed in on a AKI who doesn’t have a fistula in situ?

A

Femoral Vein

Internal Jugular

67
Q

What is requried prior to starting dialysis treatment?

A

Hepatitis Screen

HIV screen

Hepatitis vaccine

68
Q
A
69
Q

What are the indications for starting dialysis therpay in AKI?

A

Refractory pulmonary oedema

Refractory K+

Hyperuarcaemia causing:

  • pericarditis
  • Encephalopathy
70
Q

What are the signs and symptoms of Good pastures?

A

Haemoptysis and haematuria

develop RPGN

Treatment:

  • plasmapheresis
  • steroids
71
Q

What is the most common cause of SBP in peritoneal dialysis?

A

Staph Epidermis

  • from the insertion of the tubes
72
Q

What GN are HIV paitents at risk of developing?

A

Focal segemental Glomerulnephritis

73
Q

What are some long term complicatiosn of all dialysis?

A

Dialysis Amyloidosis

  • Accumlation of amyloid proteins which are unable to be secreted.
  • causes carpel tunnel syndrome.

*monitored by nuclear imaging

74
Q

What are the most likely pathogens to cause peritonitis in Peritoneal dialysis and what is the management?

A

Staph Aureus/ Epidermis

E.Coli

Managemnt:

  • send Blood cultures
  • Send Peritoneal culutres
  • Sepsis 6

**antibitoics can be given IV or peritoneal

75
Q

What are the advantages of kidney transplant over dialysis?

A

More Freedom from:

  • dialysis time
  • Dietary and fluid restrictions

Correct electrolyte abnormalies

Anaemia is corrected

76
Q

What are some complications of kidney transplant:

A
  • *Acute tubular necrosis**
  • more common from deceased donation
  • >24 hours kidney has been out body
  • *Technical failures**
  • failed anastomosis
  • Ureter dysfunction
  • *Acute Rejection**
  • usually seen in first 3 months
  • high dose steroids can be used

**there is a subset of Acute rejeciton with Angiotensin Receptor antibody activation. Presents with hypertension and seizure.
- ACE inhibitors fix

Infection

Chronic Allograft nephropathy

  • *Malignancy:**
  • squamous cell carcinoma

Cardiovascualr disease

77
Q

What investigations should be done into polycystic kidney disease?

A

Ultrasound
- Kidneys

CT

  • Liver
  • Pancreatic Cysts

ECG

  • hypertension
  • left ventricle strain

Head MRI

Genetic testing
*not before 15 years old

78
Q

What is an alternative biological marker that can be used instead of creatinine?

A

Cystatin C

79
Q

Advice on dialysis:

A

Reduce:

  • Calcium
  • Salt
  • Caolrie intake
  • monitor fluid intake
80
Q

When starting someone with ACE inhibitors who has CKD, what lab valvues are allowed?

A

30% rise in creatinine

25% drop in eGFR

81
Q

What are the ulcers called associatted with CKD?

A

Calciphylaxis ulcer

82
Q

What is the best tranplant for diabetic patients?

A

Kidney

and

Pancrease

83
Q

What is a significant albumin: creatiine ratio and when should immediate referral be made?

A

>3

immediate referral: >70

84
Q

What is Fabry’s disease and how does it present?

A

X-linked condition of lipid storage defects.

causing podocyte damage.

Protein urea.

85
Q

What is Alport’s syndrome?

A

Defect in the collagen 4 production.

  • x-linked condition

Results in:

  • Kidney failure (haematuria, proteinuria)
  • Deafness
  • Visual disturbance
86
Q

Name the genetic tubular defects and where they occur:

A

Fanconi syndrome: PCT

  • defective absorption.
  • causes metabolic acidosis due to loss of HCO3

Bartter syndrome: Thick Ascending Loop
- Metabolic alkalosis due to increased reabsorption later on

Gitelman Syndrome: DCT
- Mimics thiazides

87
Q

If there is recurrent UTIs, what further investigations would you want to conduct after urine samples and potential blood cultures?

A

Ultrasound of Kidney

  • *CT Abdo:**
  • kidney mass
  • Stone (differential)
  • *Micturationg cytogram**
  • anatomical abnormalities
  • *Cystoscopy**
  • malignancy

Diabetic screen

88
Q

What are the symptoms of prostatisis and how is it treated?

A

Fever
N&V

Dysuria
Urgency
Painful micturation
Incomplete emptying
Strangulation

Back Pain
Painful ejaculation

*boggy prostate

Treatment:

  • 4 weeks levofloxacin
    +
  • Analgesics
89
Q

How often should people with proteinuria be monitored?

A

Every 6 months.

Increasing proteinuria and reducing eGFR require further investigation

90
Q

What is an abnormal amount of RBCs in the urine?

A

>2 RBCs/mm3

91
Q

What is the tumour marker for bladder cancer?

A

BTA

92
Q

Why do you assess LFTs in bladder cancer? and what would you see?

A

For metastasis

  • see increased ALP
93
Q

What immunololgical therapy can be used for non-inassive bladder cancers?

A

BCG

**also reduces incidence

94
Q

During a radial cystomy what else has to be removed?

A

Prostate in men

Uterus, fallopian tubes, urethera and vagina wall in women

95
Q

What imaging investigations do you want into renal cell carcinoma?

A
  • *Ultrasound**
  • assess to see if it is cyst

Pre/ post IV contrast CT scan

  • *Radioistopic Bone scan**
  • for Mets
96
Q

List some causes of AKI:

A

Pre-renal:

  • Sepsis
  • Renal artery occulusion
  • Hypovolamia
  • M.I
  • NSAIDs

Renal

  • Glomerulinephritis
  • Acute tubular necrosis (Rhabdomylisis, Constrast)
  • Acute interstilial nephritisi (Drug reaction, pyelonephritis)
  • Capillary damage (HUS, TTP)
  • myeloma

Post Renal:

  • Strictures
  • Stones
  • Tumours
  • catherter block
97
Q

When should an AKI be referred to renal?

A

Stage 3.

Intra-renal causes

pH <7.2

Refractoary hypercalamia

Pre-renal with hypertension or fluid overload

Difficult fluid balance

98
Q

How long does the fitula formation for dialysis need before it can be used?

A

8 weeks

99
Q

Investigations into creatinine rise in renal transplant patient:

A

Ultrasound of kidney

ciclopsorin levels

Renal biopsy

Renal arteriogram

100
Q

What is an important thing to test in the urine in an AKI?

A

Urine osmolality

101
Q

If there is a patient with an AKI who is fluid overloaded, what is the definitive management?

A

Dialysis

102
Q

How is a patient with an AKI going to be monitored?

A

hourly monitoring:

K+/ ECG

Urine output

U&Es - creatinine

Lactate

103
Q

How is the hypocalcamia and phosphate treated in CKD?

A

Phosphate binders

and

1 alpha hydrooxycalciferol supplements

Phase 4 (49 decks)

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