Renal (from MCQBank) Flashcards
Urinalysis findings of UTI
Nitrites (due to presence of nitrate reductase which convert nitrate to nitrite) - PPV 96% (ie if patient has UTI, the test will be positive)
Leucocyte - suggesting pyuria
Leucocyte esterase (can only be detected with relatively high WBC count in urine - so low test sensitivity).
PHIMOSIS vs PARAPHIMOSIS
What is phimosis?
PARAPHIMOSIS: cannot move the retracted foreskin bact to cover the penis tip
PHIMOSIS: cannot retract the foreskin from the penis tip
Inability to retract the foreskin due to narrow preputial ring.
If cannot clean under the foreskin, increase risk of stones forming and leading to cancer of penis.
Causes: primary/physiological (without scarring), secondary (due to scarring from conditions such as recurrent balanitis, traumatic retraction of foreskin, balanitis xerotica et obliterans)
Treatment (depends on cause!)
If primary/physiological (ie foreskin is retractable): conservative tx. topical steroids can be applied.
If pathological/secondary: circumcision, short course of topical steroids can be beneficial in mild scarring
Common organisms of UTI
E.coli (80%)
Staph saprophyticus (4%) in sexually active young women
Klebsiella pneumoniae (4%)
Proteus mirabilis (4%)
Enterobacter
Candida
Enterococci
If there are abnormalities of urinary tract- pseudomonas aeruginosa OR staph epidermidis
Complicated VS Uncomplicated UTI - what are the criteria?
Complicated: increase risk of complications such as persistent infection, treatment failure or recurrent infection. Associated with >=1 risk factor:
- abnormal urinary tract anatomy (eg calculus, vesicoureteric reflux, indwelling catheter, obstruction etc)
- virulent organism (eg Staph. aureus)
- immunosuppression (eg poorly controlled diabetes)
- impaired renal function
Uncomplicated: typical organisms, normal urinary tract and kidney function, no predisposing/comorbidities
What is recurrent UTI?
> =2 in 6 months OR >=3 in 12 months
Treatment of UTI
Women:
1st line:
- nitrofurantoin for 3 days (if eGFR>=45. cannot be used for G6PD deficiency or acute prophyria).
- Trimethoprim for 3 days (cannot use for blood dyscrasias)
2nd line:
- Nitrofurantoin for 3 days (if this is not used).
- Pivmecillinam for 3 days.
- Fosfomycin single dose sachet.
Pregnant:
- Nitrofurantoin for 7 days (avoid at term due to risk of neonatal haemolysis).
2nd choice:
- amoxicillin (if cultures support this) for 7 days or cefalexin for 7 days.
- AVOID TRIMETHOPRIM DUE TO FOLATE ANTAGONIST.
Men:
Trimethoprim or nitrofurantoin for 7 days
What is cryptoorchidism?
undescended testis
Greek kryptos (hidden), orchis (testicle)
Hallmark of genitourinary TB?
Sterile pyuria
Which side is more likely to be affected in testicular torsion?
Left side
What disease would mean that pain be relieved when elevated the scrotum?
Epididymitis
This is called the Prehn’s sign
What is priapism?
disorder in which the penis maintains a prolonged, rigid erection in the absence of appropriate stimulation.
Causes of high PSA
Old Age
Acute retention
Urinary catheter
Prostatitis
Prostate cancer
TURP
BPH
Before PSA test, make sure that they dont have active UTI, ejaculated in the last 48 hours, exercised vigorously in the last 48 hours, have a prostate biopsy in the last 6 weeks. CONTROVERSIAL: delay PSA test by 1 week post PR examination.
Reference range of PSA
50-59y/o: >=3ng/ml
60-69y/o: >=4ng/ml
>=70y/o: >5ng/ml
Cause of bacterial vaginosis
Gardnerella vaginalis (MOST COMMON)
Prevotella spp
Mycoplasma hominis
Mobiluncus spp
(they replace lactobacilli and cause increase in pH)
Classification of testicular cancer
Germ cell tumours: 45%seminomas, 50%non-seminomas (ie teratoma)
Non-germ cell tumour: Leydig cell, Sertoli, sarcomas
Extragonadal tumours
Risk factor of testicular cancer
cryptoorchidism
malignancy in contralateral testis
Klinefelter’s syndrome
FHx
Male infertility
Low birth weight
Young maternal age
Young paternal age
Multiparity
Breech delivery
Infantile hernia
Testicular microlithiasis (small intratesticular calcification seen on USS)
Most common type of ureteric stone
Calcium oxalate
Hallmark investigative finding for diabetes insipidus
urine specific gravity 1.005 or less
urine osmolality less than 200mOsm/kg
random plasma osmolality is usually >287mOsm/kg
Treatment of diabetes insipidus
Desmopressin (ADH analogue)
Thiazide diuretic - inhibit reabsorption of NaCl in the distal renal tubule
NSAIDs (eg indamethacin)
Sodium restriction
invasive treatment options for urge incontinence (aka detrusor overactivity / detrusor instability)
Botulinum toxin A - 1st line
Sacral nerve stimulation
Surgery - only indicated for intractable and severe detrusor overactivity
Examples of drugs causing infertility for women
NSAIDs (?reversible inhibit ovulation)
Cyclo-oxygenase inhibitors (negative local effect on ovulation)
Spironolactone (menstrual irregularities)
Cytotoxic drugs (induce ovarian failure)
Neuroleptic drugs (amenorrhoea)
Marijuana/Coccaine (impaired ovulation and tubal function)
Bacterial causes of epididymo-orchitis
- Less than 35y/o
- More than 35y/o
<35y/o - chlamydia trachomatis & neisseria gonorrhoea
>35y/o - non-sexual Gram negative organism such as E.coli & pseudomonas
Treatment of epididymo-orchitis
Uncomplicated gonorrhoea: cefiximine / ciprofloxacin
Uncomplicated genital chlamydia, non-gonorrhoeal urethritis & non-specific genital infection: doxycycline / azithromycin
if urine dip positive - treat as complicated UTI - trimethoprim or ofloxacin for 14 days
Urethral injuries - how many types?
2 types:
- Posterior (membranous and prostatic part) - due to major blunt trauma ie RTA & pelvic fractures
- Anterior (distal to the membranous part - ie bulbar and penile urethra) - due to blunt trauma to perineum
Apart from smoking, other exposures that increases risk of bladder cancer?
Aromatic amines in dyes, paints, solvents, leather dust, inks, combustion products, rubber & textiles
Arsenic contaminated wells
Radiation to pelvis
Cyclophosphamide
Chronic infection - HIV, Herpes simplex
Coffee (by 20%? but disputed by some papers)
?artificial sweeteners
Radiological investigation for colovesical fistula
CT-AP
Minimally invasive procedures for BPH
TUMT (transurethral microwave thermotherapy)
TUNA (transurethral needle ablation)
Invasive: TURP (transurethral resection of prostate)
Classification of CKD
- GFR category
- ACR category
GFR category (1-5)
ACR category (1-3): <3, 3-30, >30
Ethnic risk factors for progression of CKD?
Black / Asian
Findings from cystoscopy for interstitial cystitis (bladder pain syndrome)
Diffuse erythematous bladder epithelium & ulcerative patches (Hunner’s ulcers) surrounded by mucosal congestion
end-stage fibrotic bladder as cannot fill more than 300ml of urine
after over-distension, there may be glomerulations (discrete tiny raspberry-like lesions appearing as miniscule mucosal tears and haemorrhages)
Complex invasive treatment for interstitial cystitis (bladder pain syndrome)
pelvic floor trigger point injections
pelvic floor botox injections
surgery: bladder augmentation, cystectomy with urinary diversion
Tx nephrogenic diabetes insipidua
Chlorothiazide
common kidney transplant post-op problems
Post-op problems
ATN of graft
vascular thrombosis
urine leakage
UTI
Hyperacute rejection (minutes to hours)
due to pre-existing antibodies against ABO or HLA antigens
an example of a type II hypersensitivity reaction
leads to widespread thrombosis of graft vessels → ischaemia and necrosis of the transplanted organ
no treatment is possible and the graft must be removed
Acute graft failure (< 6 months)
usually due to mismatched HLA. Cell-mediated (cytotoxic T cells)
usually asymptomatic and is picked up by a rising creatinine, pyuria and proteinuria
other causes include cytomegalovirus infection
may be reversible with steroids and immunosuppressants
Causes of chronic graft failure (> 6 months)
both antibody and cell-mediated mechanisms cause fibrosis to the transplanted kidney (chronic allograft nephropathy)
recurrence of original renal disease (MCGN > IgA > FSGS
causes of minimal change glomerulonephritis
idiopathic majority
10-20% :
- drugs: NSAIDs, rifampicin
- Hodgkin’s lymphoma, thyomoma
- infectious mononucleosis
difference between pre-renal uraemia and acute tubular necrosis in terms of:
- urine sodium
- urine osmolality
- fractional sodium excretion
- response to fluid challenge
CHECK PPT slides!
what electrolyte changes can you see in a patient with rhabdomyolysis?
high creatine kinase
hypocalcaemia (calcium typically binds to myoglobin released from damaged muscle)
hyperphosphataemia (phosphate is released during necrosis and destruction of myocytes)
hyperuricaemia (due to cellular breakdown and leakage of cellular contents into circulation)
hyperkalaemia: develop before renal failure
myoglobinuris - dark/reddish brown colour
metabolic acidosis
what are the acceptable changes in renal function when you start ACEi?
decrease in eGFR by 25%
increase of creatinine by 30%
IgA vs post-streptococcal GN
IgA: visible haematuria following a recent URTI. AKA Berger’s disease. Presents in young maes and onset is very acute.
Post-strep: occurs 2 weeks post URTI/LRTI. main symptom is proteinuria. there is low complement levels. tx: ACEi or immunosuppression with corticosteroids
why do you get metabolic acidosis in a patient with chronic kidney disease?
fixed acids (lactic acid, phosphoric acid, sulphuric acid, acetoacetic acid and beta-hydroxybutyric acid) will be produced from protein catabolism.
they require alkali to buffer and be excreted.
this alkali is usually NH4+ & produced by the kidneys.
in CKD, the kidneys are not producing this -> hence metabolic acidosis.
> reduce HCO3-
>respiratory compensation (reduced pCO2)
membranous nephropathy is associated with what..?
stomach cancer
SLE
HepB/C
PS: drugs: captoril, gold, lithium, NSAIDs causes minimal change GN.
Fanconi syndrome
Generalised inherited or acquired disturbance of renal tubular transport.
Leads to aminoaciduria, glycosuria, phsophaturia, renal tubular acidosis type 2 (proximal) and hypopgosphataemic rickets (children) or osteomalacia (adults)
Autosomal dominant (chromosome 15) but can also be recessive or x-link.
Tax: replacement if substance lost in urine and specific treatment for underlying cause
Advise to reduce renal stone formation - what to take and what to avoid?
to consume less oxalate by reducing tea, chocolate, nuts, strawberries, rhubarb, spinach, beans & beetroot.
to drink plenty of fluids especially in the summer.
Treatment of nephrogenic diabetes insipidus
Desmopressin - Large doses (ADH analogue)
Thiazide diuretic
NSAIDS
Sodium retention
Balkan nephropathy - what is it?
Found in small communities along the Danube River.
Only in adults.
Lack of high blood pressure, xanthochromia on palms and soles (tanchev’s sign), early anaemia of hypochromous type, slow progressive renal failure
Due to chronic dietary exposure to aristolochic acid which grows as a weed in the wheat fields
What to do with the dose of these drugs in renal impairment?
Phenytoin
Cefuroxime
Furosemide
Phenytoin is metabolised in lover - so no change in dose for retail impairment,
Cefuroxime is a cephalosporin and this is excreted unchanged by the kidney. So, reduce dose frequency in renal impairment.
Furosemide acts on Na/K/Cl co-transporter. Higher doses needed if number of functioning nephrons are reduced.
Churn Strauss -what are the components?
Asthma
Eosinophilia
Vasculitis
P-ANCA
Difference in examination for :
- hydrocele
- varicocele
- epididymal cyst
- cancer
Hydrocele : firm lump in scrotum, testis cannot be felt as the hydrocele is located superior & anterior to testis, lump is transilluminable
Varicocele: scrotal swelling, like ‘bag of worms’ when standing
Epididymal cyst : transilluminable lump in scrotum, distinct from testis (palpable separately from testis)
Tumour : lump in scrotum, cannot palpate separately to testis
Spermatocele: located superior and posterior to testis
Incontinence - what is this:
- true incontinence
- overactive incontinence
- overflow incontinence
- functional incontinence
True: due to fistulous tract between the vagina and either ureter, bladder or urethra
Overactive: detrusor overactivity. can associate with dryness or incontinence.
Overflow: incomplete bladder emptying due to detrusor contractility or bladder outlet obstruction
Functional: when patients have mental or physical disabilities that keeps them from urinating normally although the urinary tract is intact.
Examples of drugs causing infertility in men
Sulfasalazine (reduce sperm count)
Androgens and anabolic steroids (reduce testicular volume and oligospermia/azoospermia)
Cytotoxic drugs (may cause permanent azoospermia)
Coccaine/Marjuana - affect quality of semen
Herbal remedies ie root extracts of Tripterygium wilfordii (reduce testicular volume and azoospermia/oligospermia)
