renal and urology incorrects Flashcards
40 yo man. 4 days of flank pain on the left. fever nausea vomiting
temp is 39.6. pulse rate 118 bpm and BP 90/40. imaging shows obstructed left ureteric stone with severe hydronephrosis.
treated with IV antibiotics and fluids.
next step in management?
Nephrostomy! -> renal pelvis needs to be urgently decompressed w nephrostomy . ureteric stent is more definitive, nephrostomy quicker
septic type picture
obstructed infected stone -> medical emergency
nephrostomy is tube letting urine drain from kidney through back
A 63 year old man attends his GP for review following addition of chlortalidone to maximal-dose ramipril for BP control. He also has type 2 diabetes
mellitus and chronic kidney disease, and takes metformin. His creatinine 1 month ago was 115 μmol/L (60–120).His BP is 133/85 mmHg.Investigations:Sodium 135 mmol/L (135–146)
Potassium 4.6 mmol/L (3.5–5.3) Urea 9.0 mmol/L (2.5–7.8) Creatinine 150 μmol/L >148 μmol/L eGFR 44 mL/min/1.73 m2 (>60)
Most appropriate management?
UKMLA ppq
Repeat urea and electrolytes in 2 weeks.
The patient has had a <30% increase in serum creatinine. At this level there is no indication to change treatment, repeat of renal function in 2-4 weeks is reasonable
renal stones first line imaging?
non contrast ct of renal tract/KUB
red cells and leukocytes seen
what is oral duloxetine used to treat?
STRESS urinary incontinence
man due for a ct scan with contrast. has a history of CKD
most appropriate treatment beforehand?
0.9% saline
to expand volume and prevent contrast nephropathy
IN a patient collapsed on the floor overnight. AKI diagnosed. most likely cause in the setting of a normal CK?
hypovolemia !!!
IgA nephropathy vs PSGN timeline?
Iga - days after eg 2
PSGN = 2 weeks!
56 woman. HTN and diabetes. signs of kidney damage
which type of antihypertensive is most appropriate?
Ace inhibitor!!!
Ace inhibitors protect renal function in diabetic nephropathy!! in addition to their antihypertensive effects
An 82 year old woman has constipation and passes infrequent, hard stools.
She has hypertension, overactive bladder symptoms and type 2 diabetes
mellitus. She takes amlodipine, doxazosin, gliclazide, metformin and
oxybutynin.
most likely drug causing constipation?
oxybutynin -is an anticholinergic and a frequent cause of constipation
You are reviewing the blood results for a 79-year-old man who was admitted to the geriatric ward from his care home yesterday evening having fallen. Urine dip showed no abnormalities on admission.
hypernatremia
raised urea and creatinine. but rise in urea is proportionally higher than rise in creatinine!!!
most likely cause?
dehydration
what medications should be avoided in AKI?
ace inhibitors - eg elenapril
NSAIDs except aspirin at cardiac dose
aminoglycosides - gentamicin!!
diuretics
angiotensin 2 receptor antagonists
may have to stop due to increased risk of toxicity:
metformin
lithium
digoxin
if you get a question stating digoxin and elenapril for example, elenapril is the one you withhold!!!
CKD first line treatment, what can be added on?
name another drug that all patients with CKD should be started on
most important test in diagnosis CKD?
Ace Inhibitor or arb - if ACR greater than 3mg/mmol
can add sglt2 inhibitor
all started on statin
albumin: creatinine ratio
may be measured on a spot sample if a first-pass early morn sample is not provided (but should be repeated on a first-pass specimen if abnormal)
Renal stones management? less than 5mm? less than 20? greater than 20?
less than 5 mm = watchful waiting
5-10mm shockwave lithotripsy
10-20 mm shockwave lithotripsy OR ureteroscopy
> 20 mm percutaneous nephrolithotomy
ureteric!!! stone management?
shockwave lithotripsy +/- alpha blockers>< 10mm shockwave lithotripsy +/- alpha blockers
10-20 mm ureteroscopy
not if uyltrasound shows dilatation of renal pelvis, then that is obstruction -> urgent surgical decompression via nephrostomy
patient presents with oliguria, fever, joint pain, and a rash (usually maculopapular) after taking co-amoxicalv. and blood tests reveal eosinophilia
most likely diagnosis?
name some other drugs that cause this diagnosis
acute interstitial nephritis
penicillin
rifampicin
NSAIDs!! eg aceclofenac. notttt paracetamol or codeine
allopurinol
furosemide
nephrogenic diabetes insipidus treatment?
chlorthiazide
A 73-year-old woman weighing 60kg admitted to the respiratory ward with CURB-4 pneumonia was initially improving on antibiotics. After two days she began to deteriorate and exhibited increased confusion. You note that in the past 8 hours, she has produced 180mL of urine.
urea from 4.6 on admission to 8.5 now
creatinine from 114 to 137
What feature is mot consistent with diagnosis of aki
decreased urine output!!
Nice have a set criteria to define AKI =
↑ creatinine > 26µmol/L!!!!! in 48 hours
↑ creatinine > 50% in 7 days
↓ urine output < 0.5ml/kg/hr for more than 6 hours
A 23-year-old male is admitted with left sided loin pain and fever. His investigations demonstrate a left sided ureteric calculi that measures 0.7cm in diameter and associated hydronephrosis.
management?
nephrostomy!!
An obstructed, infected system is an indication for urgent decompression. This may be achieved by ureteroscopy or nephrostomy. In addition to this the patient should also receive broad spectrum, intravenous antibiotics!
elderly 50kg
left hemicolectomy
finished 24 hours ago
passed 240 ml of urine since then
based on the urine output, what stage of aki does this patient have?
Stage 1 Increase in creatinine to 1.5-1.9 times baseline (greater than 1.5 x baseline!!!)
or
Increase in creatinine by ≥26.5 !!!!µmol/L, or
Reduction in urine output to <0.5 mL/kg/hour for ≥ 6 hours
Stage 2 Increase in creatinine to 2.0 to 2.9 times baseline (greater than 2x baseline!!) or
Reduction in urine output to <0.5 mL/kg/hour for ≥12 hours
Stage 3 Increase in creatinine to ≥ 3.0 times baseline!!!, or
Increase in creatinine to ≥353.6 µmol/L or
Reduction in urine output to <0.3 mL/kg/hour for ≥24 hours, or
The initiation of kidney replacement therapy, or,
In patients <18 years, decrease in eGFR to <35 mL/min/1.73 m2
A 51-year-old man presents to his GP with groin swelling and burning on urination. He also complains of groin pain and penile discharge. He is sexually active with his wife of 6 years.
On examination, his heart rate is 91/min, respiratory rate is 15/min, blood pressure is 129/84 mmHg, and temperature is 38.3ºC. The right testicle is painful, but this is relieved by elevating the scrotum.
What organism is most likely responsible for his symptoms?
e coli!!!
chlamydia is the most common but in this case patient is married in 50s with wife as only partner
patient with history of calcium oxalate kidney stones. what drug can be used as prophylaxis?
what else may also be useful?
bendroflumethiazide, indapamide
thiazide diuretics
potassium citrate may be useful
patient with AKI
urine osmolality = 1000 (50-1200)
urine Na+ = 10 ( 40-250)
most likely class of aki?
prerenal disease!!
Prerenal causes include anything that may lead to hypoperfusion of the kidney, such as dehydration, shock or haemorrhage. In a hypovolaemic state, whereby prerenal AKI can occur, the physiological response of the renal system is to retain salt and water in an effort to replenish the deplete circulatory volume. With this concept in mind, urine becomes concentrated (high osmolality) due to the reabsorption of water, and low in sodium, as the mechanism of fluid reabsorption relies on the retention of sodium. Further, prerenal AKI typically responds well to a fluid bolus as this is directly treating the underlying cause of the problem.
A 45-year-old man has recently been diagnosed with stage 5 chronic kidney disease (CKD) by a nephrologist. He started taking a new medication 6 weeks ago to treat symptoms that have developed because of his CKD. Over the last 3 weeks, he has developed abdominal pain, back pain, muscle weakness and is feeling quite anxious.
name a medication that would explain this.
calcium acetate
Calcium acetate is a calcium-based binder used to treat hyperphosphataemia. This patient is suffering from symptoms of hypercalcaemia as a result of a side effect of using a calcium-based binder.
man undergoes appendicitis. He weighs 75 kg. He initially does not feel able to drink as he is nauseated from the anaesthetic. His pre-operative bloods were normal. What fluid should initially be prescribed to initiate a maintenance regime and how fast should it be given?
Maintenance fluids should be prescribed at a rate of 30 ml/kg/24hr.
Amount: 75 kg X 30 ml = 2250 mL in a 24 hour period
Rate: 2500 / 24 = 93.75 ml/hr.
Initially prescribe 500 ml and then reassess the patients fluid status and ability to drink. So prescribe 500 ml at a rate of 100 ml/hr.
You are reviewing a 65-year-old in the renal clinic. He has been on haemodialysis for chronic kidney disease for the past 6 years. What is he most likely to die from?
ischemic heart disease!!!
dialysis = RF
In a patient with suspected anaemia of chronic disease secondary to CKD what should be checked before starting epo?
iron status
if the ferritin is low -> suggests iron deficiency so replace with oral iron first!!!
if ferritin is normal -> EPO
recommened water requirement when prescribing maintenance fluids?
25-30 ml/kg/day of water
A 73-year-old man undergoes an emergency laparotomy for a perforated bowel. Due to persistent hypotension intra-operatively he receives fluid resuscitation and is started on an infusion of noradrenaline. He is transferred to the intensive care unit post-operatively for ongoing vasopressor support and fluid resuscitation. In total he receives 6 litres of normal saline.
arterial blood gas shows metabolic acidosis with raised chloride
most likley cause?
fluid resuscitation
use of sodium chloride carries this risk!!
CKD is linked to what type of hyperparathyroidism?
secondary
minimal change disease management?
oral prednisolone!! hh
A 56-year-old woman presents to the emergency department with 2 weeks of worsening lethargy and malaise. Her partner notes she has been very confused over the past 24 hours as well. She has a history of type 2 diabetes mellitus and chronic kidney disease (CKD) stage 4. On examination, she has pitting oedema to her mid-thigh and nil else of note. Her blood tests
show raised urea and creatinine
most appropriate management?
dialysis!
haemodialysis) is used when a patient is not responding to medical treatment of complications, for example hyperkalaemia, pulmonary oedema, acidosis or uraemia (e.g. pericarditis, encephalopathy).
patient here has uremic encephalopathy
CKD is not diagnoses by low egfr alone, there needs to be evidence of end organ damage -> proteinuria or abnormal urea and electrolytes, which are further markers of kidney damage
A 72-year-old man is having an elective trans-urethral resection of prostate (TURP) for benign prostatic hyperplasia under spinal anaesthesia. Forty minutes into the procedure he develops headache and visual disturbances. A venous blood gas is sent off, and the main abnormality noted is severe hyponatremia.
What is the cause of this presentation?
irrigation with glycine!
patient is experiencing TURP syndrome
CNS, respiratory and systemic symptoms
mechansim of action of desmopressin?
vassopresin v2 receptor AGONIST
if a patient weighs 60kg and you need to precribe potassium over 12 hours, what will you give
30mmol
potassium is prescribed at a rate of
1 mmol/kg/day
A 28 kg 7-year-old boy has to fast for an elective surgery.
On examination, he is clinically well and there are no signs of dehydration. His vital signs are normal.
What is the amount of maintenance intravenous fluid needed by this patient in 24 hours?
as the patient is a child you use the holiday segar formula
First 10!! kg x 100!!! ml/kg = 1000 ml
Second 10!!! kg x 50!!! ml/kg = 500 ml
subsequent kg (Last 8 kg x 20!!! ml/kg) = 160 ml
= 1,660 in total
test for adult polycystic kidney disease?
ultrasound abdomen!!!
NOT PKD1 gene testing as not recommended routinely
A 84-year-old woman admitted for the treatment of a lower respiratory tract infection becomes anuric on the ward for the last 6 hours. Blood tests taken show:
Urea 11mmol/L (baseline 5mmol/L)
Creatinine 156umol/L (baseline 78umol/L)
According to the acute kidney injury (AKI) staging, which stage of AKI is this woman at?
AKI stage stage 2!!!
increase in creatining 2x baseline
in a pregnant woman, is urteroscopy or lithotripsy preferred for stone removal?
uteroscopy
A 39-year-old man presents with six months of polyuria and polydipsia. He has also been experiencing fleeting episodes of arthralgia and lethargy. Past medical history is unremarkable and he is not on any medications. When asked about family history, he states that his parents are okay but remembers his grandma had to have regular removal of her blood throughout her life. He is not sure why as she died from heart disease when he was a child.
investigations point to cranial diabetes insipidus
what other test is needed to confirm diagnosis?
serum ferritin!!!
hereditary hemochromatosis is a cause of cranial diabetes insipidus
if it was nephrogenic diabetes insipidus instead:
- anti ro and anti la if suspecting sjogrens as cause
- short synacten test if suspecting adrenocortical insufficiency as cause
A 23-year-old man presents to his GP with testicular pain. He reports pain in the left testicle, with associated swelling that has come on over the course of the day. He reports feeling generally unwell and a little nauseous.
On examination, the left testicle is swollen and erythematous. It is tender to palpation, particularly over the top of the testicle, but the pain eases when the testicle is lifted.
What management is most appropriate at this stage?
IM ceftriaxone single dose + 10-14 days oral doxycyline
pain that eases with lifting points to epidiymo-orchitis!! and torsion would be more acute pain
