Renal and Urology Flashcards
What are the classic symptoms of pyelonephritis?
What imaging would you want to do on someone with suspected pyelonephritis?
What are some complications?
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
When is UTIs as common in males as females?
1st year of life
It becomes more common as we age due to bladder outlet difficulties
What is the diagnostic investigation to diagnose glomerulonephritis?
Renal Biopsy with:
- light microscopy
- electorn microscopy
- Immunofluroence
In suspected glomerulinephritis, what invesitgations should be done?
- *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
If there is haematuria, how can the source be isolated?
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
What are the key symptoms of nephritc syndrome?
Peripheral oedema
Periorbital oedema
Hypertension
Oligouria
Urine analysis:
Haematuria
- RBC cast
Proteinuria
- moderate amount (1-3g - so not as much as a nephrotic syndrome)
Post Streptococcal glomeruonephritis:
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
IgA Nephropathy:
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
What are the general treatments for nephritic syndrome?
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)
What are the common causes of Rapidly progressive Glomerulinephritis?
- *Good Pastures disease**
- Anti GBM antibodies
- *Granlumoatosis with polyangitiis**
- c - ANCA
Microscopic polyangitis
- p - ANCA
- *Lupus nephritis**
- dsDNA
- ANA
**all require a renal biopsy
How is granulomatosis polyangitiis treated?
If evidence of Renal disease or pulmonary disease:
- IV methpredisolone
+
Cyclophosphamide
+/-
Plasmaphresis
No eivdence of renal disease:
- oral predisolone
or
- rituxmab
What are the types of primary diseases that can cause nephrotic syndrome?
Minimal change disease
- children
Membraneous nephropathy
- Adults
- anti - phospholipid A2 antibodies
Focal Segmental Glomerulosclerosis
- Coloured people
Membranoproliferative glomerunephritis
- type I
- Type II
- Type III
What are some complications of nephrotic syndrome?
- *Hypercoagulable**
- DVT
- P.E
Hypovolaemia
Protein Malnourishment
- *Immunocompromised**
- loss of IgG in urine
What is the general treatment for nephrotic syndrome?
Reducing protein loss
- ACE hibitors
Control of oedema:
- redued Na2+ intake
- Furesimide
Anticoagulation:
- Heparin
What is the treatment for membraneous nephropathy?
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
List some examples of complicated UTIs and pyleonephritis:
Male
Pregnancy
Indwelling catheter
Poorly controlled Diabetes melitus
Previous Urogenital surgery
uroligcal conditions
- BPH
What are some risk factors for developing a UTI?
Sexual activity
Urinary incontinence
Spermicide use
Obstruction of urine
Immunospuression
catherter
Renal tract malformations
Diabetic Meliitus
What investigations should be done in suspected UTI?
*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
How does Pyelonephritis appear on ultrasound?
Hypoechoic mass
- usually unilateral
How does pyleonephritis appear on CT?
Hypotense regions of the kidneys
What is the recommended treatment for pyleonephritis in pregnant women?
Ceftriaxone
When should asymptomatic bacturia be treated?
In pregnant women
Renal transplant patients
Those about to have a urological intervention
- TURB
What are the complications of Pyelonephritis?
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
What is the mangement of renal abcesses?
Antibiotic management
Renal Abcess >5cm = percutaneous drainage
Perirenal abcess >3cm = Percutaneous drainage
if these can’t be drained then surgery is recommended
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?
Chlaymadia
What is first line for hyper PTH in kidney disease?
Phosphate binders
What is the best investigations for establishing between acute and chronic kidney disease and what is the characteristic finding?
Ultra sound.
Chronic kidney disease will tend to have bilaterally small kidneys
*exceptions include:
- diabetic nephropathy
- Sarcoidosis
- HIV nephropathy
Which drugs during an AKI should potentially be stopped, not because they worsen the AKI, but can lead to toxic build up?
Metaformin
Lithium
Digoxin
How is diabetic kidney nephropathy monitored?
Early morning Albumin:creatinine ratio
What is the classification of CKD:
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
What are the biggest factors associated with prognosis in CKD?
Low GFR
Albuminuria
What investigations would you want to do into suspected CKD?
- *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
What are the general management stratagies for CKD?
Referral to nephrology
Slow progression of the disease
Management of complications
Preperation for renal replacement therapy
What are some of the complications of CKD and how are they managed?
- *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
If Renal replacment is going to be required, and you make a referral, when should this be done by?
What else should be done?
> 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.
What drugs inparticular need careful consideration with regards to dosing in CKD due to their renal excretion?
Aminoglycosides
- gentamcin
Penicillins
Cephalosporins
Heparin
Lithium
Opiates
Digoxin
What are some complications of polycyctic kidney disease?
Liver/ pancreatic cyst formation
Cyst rupture
SAH
Renal failure
Mitral valve prolaspe
Diverticulitis
What is the diagnostic criteria for polycycstic kidney disease? and what is the diagnostic test of choice?
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.
What is the management of polycystic kidney disease?
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
What are some causes of congenital chronic kidney disease?
- *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
What is the general management for nephrotic syndrome?
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
If someone is breathless, with hepatosplenomeglay but normal LFTs, what should you immediately think?
Amyloidosis
How often is haemodialysis usually needed to be done?
3 x weekly for 3-5 hours
What is a major complication of haemodialysis that presents with:
- focal neurological deficits
- reduced GCS
- Papiloedema
- headache
Dialysis disequilibrium syndrome
Where there is a reverse osmosis in the brain leading to cerebral oedema
What are the features of acute interstitial nephritis?
25% of AKI is caused by this.
*Eosinophilia
*sterile pyuria
Classic triad of:
- fever
- Arthralgia
- maculopapular rash
Typically caused by:
- Antibiotics
- Allopurinol
- NSAIDs
Following a kidney transplant, what cancer are people more at risk of?
Skin Cancer
- sqaumous and basal cell
What is a biological marker on U&Es of dehydration and not an AKI?
Disproportionally high urea to creatinine
What does leukocytes in the urine tell you?
That there is inflammation. it is not specific to infection.
Nitrites on top would suggest infection
What can tumour lysis syndrome lead to with regards tot he kidneys?
AKI
- induces tubular necrosis
How can urine osmolarity help determine the the cause of an AKI?
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.
In an AKI situation, what would protein in the urine be suggestive off?
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
What is the most common extra-renal manifestation of polycycstic kidney disease?
Liver cysts
What is the assessments that should be done in AKI?
RENAL
R - Rule out Sepsis
E - Exclude obstruction
N - Note urinalysis
A - Assess Fluid balance
L - Look at drugs
What is the antibiotics used for epidymitimitis and orchitis?
<35 years - doxycycline
+ /-
- ceftriaxone + referral
>35 years:
- ciprofloxacin
What are the types of dialysis used?
Haemdialysis
- *-** diffusion
- hydrostatic pressure
- *Peritoneal Dialysis**
- Continuous Ambulatory
- Autonomic peritoneal dialysis
Haemofiltration
- Hydrostatic pressure
What are some complications of haemodialysis?
Hypotensive Crash
Dialysis Disequalibrium Syndrome
Steel syndrome
Cramps
Fatigue
What are some complications of Peritoneal dialysis?
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
What are some absolute condraindications to peritoneal dialysis?
Stoma
Intra-abdominal sepsis
Visual impairement - patients need to be able to see what they are doing
Abdominal hernia
What are some investigations that should be done into CKD?
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
What is the generalised treatment for CKD?
- Appropraite referral to Nephrology
- >25% drop in eGFR
- increased Proteinuria >30g
- Slow down progression of CKD
- Lifestyle factors
- ACE inhibitors
- Glycaemia control - Treat renal complications
- Anemia
- Acidosis
- Renal Osteodystrophy
- Treat non renal complication
- heart failure - BP
- <140/90
- 130/80 (DM) - Preperation for RRT
- 1 year in advance
What is the biggest cause of death on RRT?
Ischemic Heart disease
What is a good test to estbalish the difference between pre-renal and intra-renal AKI?
Urine sodium
- in prerenal the urinary sodium will be low as the kidneys try to hold onto fuild
Name some causes of non - visiable haematuria:
Renal Calculi
Prostatitis
Renal cell carcinoma
Bladder Carcinoma
Renal IgA nephropathy
What investigations do you want in someone who presents with an AKI?
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?
What is the management for Pyelonephritis?
Sepsis 6
- Aggressive Fluids
- IV antibiotics
(gentamicin)
(Ceftrixaone or co-amoxiclav for pregnant women)
Where are Haemodialysis lines placed in on a AKI who doesn’t have a fistula in situ?
Femoral Vein
Internal Jugular
What is requried prior to starting dialysis treatment?
Hepatitis Screen
HIV screen
Hepatitis vaccine
What are the indications for starting dialysis therpay in AKI?
Refractory pulmonary oedema
Refractory K+
Hyperuarcaemia causing:
- pericarditis
- Encephalopathy
What are the signs and symptoms of Good pastures?
Haemoptysis and haematuria
develop RPGN
Treatment:
- plasmapheresis
- steroids
What is the most common cause of SBP in peritoneal dialysis?
Staph Epidermis
- from the insertion of the tubes
What GN are HIV paitents at risk of developing?
Focal segemental Glomerulnephritis
What are some long term complicatiosn of all dialysis?
Dialysis Amyloidosis
- Accumlation of amyloid proteins which are unable to be secreted.
- causes carpel tunnel syndrome.
*monitored by nuclear imaging
What are the most likely pathogens to cause peritonitis in Peritoneal dialysis and what is the management?
Staph Aureus/ Epidermis
E.Coli
Managemnt:
- send Blood cultures
- Send Peritoneal culutres
- Sepsis 6
**antibitoics can be given IV or peritoneal
What are the advantages of kidney transplant over dialysis?
More Freedom from:
- dialysis time
- Dietary and fluid restrictions
Correct electrolyte abnormalies
Anaemia is corrected
What are some complications of kidney transplant:
- *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
What investigations should be done into polycystic kidney disease?
Ultrasound
- Kidneys
CT
- Liver
- Pancreatic Cysts
ECG
- hypertension
- left ventricle strain
Head MRI
Genetic testing
*not before 15 years old
What is an alternative biological marker that can be used instead of creatinine?
Cystatin C
Advice on dialysis:
Reduce:
- Calcium
- Salt
- Caolrie intake
- monitor fluid intake
When starting someone with ACE inhibitors who has CKD, what lab valvues are allowed?
30% rise in creatinine
25% drop in eGFR
What are the ulcers called associatted with CKD?
Calciphylaxis ulcer
What is the best tranplant for diabetic patients?
Kidney
and
Pancrease
What is a significant albumin: creatiine ratio and when should immediate referral be made?
>3
immediate referral: >70
What is Fabry’s disease and how does it present?
X-linked condition of lipid storage defects.
causing podocyte damage.
Protein urea.
What is Alport’s syndrome?
Defect in the collagen 4 production.
- x-linked condition
Results in:
- Kidney failure (haematuria, proteinuria)
- Deafness
- Visual disturbance
Name the genetic tubular defects and where they occur:
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
If there is recurrent UTIs, what further investigations would you want to conduct after urine samples and potential blood cultures?
Ultrasound of Kidney
- *CT Abdo:**
- kidney mass
- Stone (differential)
- *Micturationg cytogram**
- anatomical abnormalities
- *Cystoscopy**
- malignancy
Diabetic screen
What are the symptoms of prostatisis and how is it treated?
Fever
N&V
Dysuria
Urgency
Painful micturation
Incomplete emptying
Strangulation
Back Pain
Painful ejaculation
*boggy prostate
Treatment:
- 4 weeks levofloxacin
+ - Analgesics
How often should people with proteinuria be monitored?
Every 6 months.
Increasing proteinuria and reducing eGFR require further investigation
What is an abnormal amount of RBCs in the urine?
>2 RBCs/mm3
What is the tumour marker for bladder cancer?
BTA
Why do you assess LFTs in bladder cancer? and what would you see?
For metastasis
- see increased ALP
What immunololgical therapy can be used for non-inassive bladder cancers?
BCG
**also reduces incidence
During a radial cystomy what else has to be removed?
Prostate in men
Uterus, fallopian tubes, urethera and vagina wall in women
What imaging investigations do you want into renal cell carcinoma?
- *Ultrasound**
- assess to see if it is cyst
Pre/ post IV contrast CT scan
- *Radioistopic Bone scan**
- for Mets
List some causes of AKI:
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
When should an AKI be referred to renal?
Stage 3.
Intra-renal causes
pH <7.2
Refractoary hypercalamia
Pre-renal with hypertension or fluid overload
Difficult fluid balance
How long does the fitula formation for dialysis need before it can be used?
8 weeks
Investigations into creatinine rise in renal transplant patient:
Ultrasound of kidney
ciclopsorin levels
Renal biopsy
Renal arteriogram
What is an important thing to test in the urine in an AKI?
Urine osmolality
If there is a patient with an AKI who is fluid overloaded, what is the definitive management?
Dialysis
How is a patient with an AKI going to be monitored?
hourly monitoring:
K+/ ECG
Urine output
U&Es - creatinine
Lactate
How is the hypocalcamia and phosphate treated in CKD?
Phosphate binders
and
1 alpha hydrooxycalciferol supplements
