Renal & Genitourinary Flashcards
1
Q
Difference in presentation between lower UTI and upper UTI
A
- Lower UTI: Dysuria (painful urination) + frequency
- Upper UTI: Haematuria + fever
- Difference: Upper UTI patients are more unwell - lower is more localised symptoms
2
Q
Signs of cystitis
A
- Dysuria (pain, stinging or burning when passing urine)
- Suprapubic pain or discomfort
- Frequency
- Urgency
- Incontinence
- Confusion is commonly the only symptom in older + frail patients
3
Q
What will urinalysis show in a lower UTI
A
- Leukocytes
- Nitrates
- Haemogloblin
4
Q
What type of urine sample is best to give for testing for a lower UTI?
A
Midstream urine
(MSU)
5
Q
What plate do you use for a urine culture + sensitivity?
A
CLED plate (lactose fermenting bacteria)
6
Q
What are the causative bacteria for cystitis?
Nmeumonic
A
KEEPS
* Klebsiella spp
* E. coli
* Enterococcus spp
* Proteus mirabilis/pseudomonas aeruginosa
* Stapylcoccus aureus
7
Q
What antibobiotic should you avoid in pregnancy?
Cystitis and pregnancy
A
Nitrofurantoin
(in the third trimester)
8
Q
Which and what duration of antibiotic should be prescribed for cystitis in pregnancy?
A
Amoxicillin (after sensitivies are known)
7 days (complicated)
9
Q
What type of UTIs is nitrofurantoin useful in?
A
Lower UTIs (cystistis)
Nitrofurantoin = useless in upper UTIs
10
Q
Contraindications in nitrofurantoin
A
- Pregnancy (third trimester)
- Renal function eGFR <45
- Side effects (nausea, vomiting, liver problems, neuropathy etc)
11
Q
What is a problem with trimethoprim?
A
High rates of bacterial resistance
12
Q
What group of people should you not treat for cystitis?
A
Above 65yrs that are asymptomatic
13
Q
How long do you give someone (uncomplicated) with cystitis antibiotics for?
Un-complicated = non-pregnant women
A
3 day course of antibiotics
14
Q
Define ‘complicated’ with UTIs
A
- Any UTI in the presence of a structurally or functionally abnormal urinary tract - with or without host compromise
- Pregnant
15
Q
Ix and Mx for a complicated lower UTI
A
- Always send a sample for culture
- 7 days (longer) antibiotics
16
Q
Notes: Duration of antibiotics for Lower UTIs
A
- 3 daysof antibiotics for simple lower urinary tract infections in women
- 5-10 daysof antibiotics for immunosuppressed women, abnormal anatomy or impaired kidney function
- 7 daysof antibiotics for men, pregnant women or catheter-related UTIs
17
Q
Complications of cystitis
A
- Pyelonephritis
- Urosepsis
- Septic shock
18
Q
Complicating factors for UTIs
Complicated
A
- Anatomical or functional abnormalities within the urinary tract
- Male sex
- Pregnancy
- Immunosuppression (e.g., renal transplant),
- Diabetes
- incomplete voiding,
- indwelling urinary catheter,
- recent instrumentation,
- healthcare-associated infection,
- History of infection with extended-spectrum beta-lactamase-producing organisms or other multi-drug resistant organisms.
19
Q
Who are classed as ‘uncomplicated’ for lower UTIs?
A
Non-pregnant women
That’s it
20
Q
Causes of pyleonephritis
A
****KEEPS C******
- Klebsiella pneumoniae(gram-negative anaerobic rod)
-
****Escherichia coli**** (gram-neg, anaerobic rod)
- Most common cause
- Part of the normal lower intestinal microbiome → found in faeces + can easily spread to the bladder
- Enterococcus
- Pseudomonas aeruginosa
- Staphylococcus saprophyticus
- Candida albicans(fungal)
21
Q
Name the routes of infection for pyelonephritis
A
-
**Ascending**
- Urethra colonised with bacteria
- Massage of urethra during intercourse can force bacteria into the female bladder
- Urethra colonised with bacteria
-
Haematogenous
- S. aureus/Candida
- ****Lymphatic spread****
22
Q
Presentating Sx for pyeolnephritis
A
Lower UTI + triad of symptoms:
* Loin or back pain (bilateral or unilateral)
* N+V
* Pyuria (fever)
- Haematuria
- Renal angle tenderness O/E
- Systemic illness
23
Q
Ix for pyelonephritis
A
- Urine dipstick - signs of infection
- Nitrates
- Leukocytes
- Non-visible haematuria
- WBC casts (indicate pyuria of renal origin)
- Midstream urine (MSU) - for microscopy, culture, sensitivity
- Essential to establish the causative organism
- Collect before starting antibiotics
- Blood tests
- Raised WBC count (leukocytosis)
- Raised inflammatory markers (CRP, ESR)
- Creatinine (elevated with impaired kidney function)
- Abdominal examination
- Tender loin
- Renal angle tenderness
24
Q
Mx for pyelonephritis
A
- Fluid replacement
- IV antibiotics (7-10days) - broad spectrum e.g. co-amoxiclav +/- gentamicin, trimethoprim
- Drain obstructed kidney
- Catheter
25
Complications of pyelonephritis
* Scarring of the parenchyma
* CKD
* End-stage renal failure
* Renal abscess
26
Most common cause of non-gonococcal urethritis?
Chlamydia
27
Young male patient presents with dysruria, discharge and pus from urethra with pain. Possible diagnosis?
Urethritis
28
Ix for urethritis
Nucleic acid amplification test (NAAT)
| High specifity and sensitivity
29
Treatment for chlamydia and gonnorrhoea
Azithromycin
30
Two main causative organisms of urethritis
* Neisseria gonorrhoae
* Chlamydia trachomatis
31
Sx for epidydimo-orchitis
* Palpable swelling of testicles + epididymis (tenderness)
* Subacute onset of unilateral scrotal pain + swelling
* STI epidydimo-orchitis (urethritis + urethral discharge)
32
Causes of prostatitis
E. coli
Chlamydia
33
Rx for prostatitis
* STI
* UTI
* Indwelling catheter
34
Presentation of prostatitis
* Extreme lower abdominal, ejaculatory, rectal and perineal pain
* LUTS (dysuria, hesitancy frequency, retention)
* Sexual dysfunction
* Pain and bowel movements
* Tender + enlarged prostate (on DRE)
* Systemic symptoms: Fever, chill, malaise
35
Differentials for prostatitis
* BPH
* Cystsitis
* Prostate cancer
* Epidydimo/orchitis
36
Antibiotic for acute and chronic prostasitis
Acute: Trimethoprim
Chronic: Tamulosin (alpha-blockers)
37
Define testicular torsion
Twisting of the testicular on the spermatic cord → constriction pf the vascular supply → time-sensitive ischaemia → necrosis of testicular tissue → sub-infertility or infertility
38
8 y/o patient presents with unilateral testicular pain, firm swollen (erythematous) and elevated (retracted) testicle. Possible diagnosis?
Testicular torsion
39
Gold standard Ix for testicular torsion
Colour doppler ultrasound/ scrotal ultrasound
(Whirlpool sign - absent or decreased blood flow in the affected testicle)
40
Surgical options for testicular torsion
* Orchiopexy (correct position)
* Orchidectomy (removal of testicle)
41
What is testicular appendage torsion presentation?
Blue dot sign
Hard tender nodule - may be palpable on the upper pole of the testicle
42
What is a varicocele
Abnormal dilation of the internal spermatic veins + pampiform venous plexus - that drain from the testis
(caused by venous reflux)
43
What side does 90% of varicoceles occur?
Left testis
| Left testicular vein - left renal vein, right testicular - IVC
44
What is the condition in which the testis can be described as a 'bag of worms'
Varicocele
| Dull ache, scrotal heaviness
45
What is an epidydimal cyst that contains sperm called?
Spermatocele
46
Where do epiydimal cysts lie?
Above and behind testis
47
What does a epidydimal cysts feel like O/E?
Soft round lump
(typically at the top of the testicle)
| May be able to transilluminate
48
Difference O/E between an epidydimal cyst and a hydrocele
* Epidydmial cyst - testis palpable quite separately from cyst
* Hydrocele - testis palpable within the fluid swelling
49
Symptoms a patient may feel with an epidydimal cysts
Often asymptomatic
(Painful once they get large)
50
Ix for epidydimal cyst
Scrotal ultrasound
51
Management for an epidydimal cyst
* Management = usually not necessary
* Surgical excision if painful or symptomatic
52
What is a hydrocele?
Abnormal collection of fluid within the tunica vaginalis (fluid surrounds the testes)
(Soft scrotal swelling + usually painless)
53
Hydroceles can be idiopathic and secondary to what?
* Testicular cancer
* Testicular torsion
* Epididymo-orchitis
* Trauma
54
What does a hydrocele of the testis look like O/E?
* Soft, non-tender, smooth, cystic swelling
* Irreducible
* Transilluminated (testicle floats within the fluid)
* Painless
55
Ix for a hydrocele
* Clinical diagnosis
* Scrotal ultrasound (exclude serious causes e.g. cancer)
* Serum AFP + hCG (exclude malignant teratoma or other germ cell tumours)
56
How do you treat a hydrocele?
* Idiopathic hydrocele = managed conservatively
- Resolve spontaneously
* Large + symptomatic cases
- Surgery (surgical removal)
- Aspiration
- Sclerotherapy
57
Underlying pathology of BPH
Hyperplasia of the stromal + epithelial cells of the prostate
| Testosterine + dihydrotestosterone (DHT) = most significant contributers
58
How does BPH cause LUT symptoms
Prostate gets bigger → squeezes or partially blocks:
* The bladder → urine retnetion → bladder dilation + hypertrophy → urine statsis → UTIs
* The urethra → urination problems
59
What is the scoring system for LUTS?
International Prostate Symptoms Score (IPSS)
60
Signs of BPH
* Bladder stones
* Acute urinary retention
* UTIS (stagnation of urine)
61
Mneumonic for LUTS
FUNI SHIT PM
* Storage (FUNI): Think pregnant women
* Voiding (SHIT): Think BPH
* PM = post-micturition
62
3 categories for LUTS
* Storage
* Voiding
* Post-micturition
63
Name storage LUTS
FUNI:
* F - Frequency
* U - Urgency
* N - Nocturia
* I - Incontinence (urgency)
| Think pregnant women
64
Name the voiding LUTS
S - Straining
H - Hestitancy
I - Incomplete emptying/Intermittent stream
T - Terminal dribbling
65
Ix for BPH
* DRE
* Abdo examination
* Bladder diary
* Internation Prostate Symptoms Score (IPSS)
* Prostate-specific antigen (PSA) - UNRELIABLE (75% FP, 15% FN) - Patient counselling
* Urinalysis
66
What does a benign prostate feel like O/E?
* Smooth
* Symmetrical
* Slightly soft
* Maintained central sulcus
67
What does a cancerous prostate fell like O/E?
* Firm/hard
* Asymmetrical
* Craggy or irregular
* Loss of central suclus
68
Other Ix for BPH
* Ultrasound of prostate
* CT abdomen/pelvis
* Cystoscopy (prostate size + shape)
* Assessment of renal function
69
Differentials for BPH
* Prostate cancer
* UTI
* Bladder cancer
* Urethral stricture
* Overactive bladder
* Prostatitis
70
Lifestyle advice for mild + manageable symptoms of BPH
* Avoid caffeine + alcohol
* Void twice in a row to aid emptying
71
Name medications to treat BPH and their class
* Alpha-blockers → tamulosin
* 5-alpha reductase inhibitors → finasteride
| Tamulosin can cause postural hypotension
72
Gold standard treatment of BPH (surgical)
Transurethral resection of the prostate (TURP)
| Old men use turps!
73
Complications of BPH
* UTIs
* Bladder stones
* Haematuria
* Sexual dysfunction
* Acute urinary retention
74
Aetiology of BPH
Smooth muscle hyperplasia + bladder dysfunction
75
What symptoms does someone with BPH present with?
LUTS
* Storage (freq, urgency, nocturia, incontinence)
* Voiding (weak stream, dribbling, dysuria, straining)
76
BPH
Evaluation includes history and examination including an abdominal examination for a palpable bladder, a digital rectal exam, and a neurological assessment.
77
Define nephrits
Inflammation of the kidneys
78
Features of Nephritic syndrome?
HOOP:
* Haematuria
* Oliguria (reduced urine output)
* Oedema (fluid retention)
* Proteinuria
79
What are the levels of proteinuria in nephritic and nephrotic syndrome?
* Nephritic: less than 3g/24 hours
* Nephrotic: more than 3g/24 hours
80
What is the brief pathology of nephritic syndrome?
* Nephr**i**tic → **i**nflammation → haematuria
* Diseases caused by **inflammation** → damage to the kidney → become more permeable → allows RBCs into urine → haematuria
* Signs, symptoms, pathology:
- Damage → permeable glomeruli → haematuria + proteinuria
- Decreased glomerular filtration rate → oedema + hypertension
- Less waste product excreted → uraemia
81
What are the causes of nephritic syndrome in children + adults?
Children/adolescents:
* IgA nephropathy
* Post-streptococcal glomerulonephritis
Adults:
* Systemic Lupus Erythematosus (SLE)
* Goodpasture's syndrome (anti-glomerular basement membrane disease)
* Rapidly progressive glomerulonephritis
82
Name the major complication of nephritic syndrome
Acute kidney failure
83
Brief underlying pathology for nephrotic syndrome
Collection of diseases caused by inflammation → damage to glomeruli → more permeable → allow proteins from blood into urine → proteinuria
84
Features of nephrotic syndrome
| Mneumonic
Protein LACE:
* **Protein**uria (more than 3g/24 hours)
* **L**ipid up
* **A**lbumin down (serum less than 25g/L)
* **C**hlosterol up (hypercholesterolaemia)
* **E**dema (peripheral oedema)
85
What are most types of glomerulonephritis treated with?
* Immunosuppresion (e.g. steroids)
* Blood pressure control - by blocking RAAS (ACEi or ARBs)
86
What does frothy urine indicate?
Protenuria
87
How do most nephrotic patients present?
* Oedema
* Frothy urine (proteinuria)
88
What does nephrotic sundrome predispose a patient to?
* Thrombosis
* Hypertension
* High cholesterol
89
What is the most common cause of nephrotic syndrome in children and adults?
* Children: Minimal change disease
* Adults: Focal segmental glomerulosclerosis
90
If a patient presents with acute renal failure and haemoptysis - what two conditions should you think of?
* Goodpasture syndrome
* Granulomatosis with polyangiitis (Wegener's granulomatosis)
* **Goodpasture syndromes** = associated with **anti-GBM antibodies**
* **Wegener’s granulomatosis** = a type of **vasculitis** associated with anti-neutrophil cytoplasmic antibodies (**ANCA**).
- Patients with Wegener’s granulomatosis may also have a wheeze, sinusitis and a saddle-shaped nose.
91
What histological feature is characteristic of rapidly progressive glomerulonephritis?
Cresent glomerulonephritis
92
What is the main differentiator between nephritic and nephrotic syndrome?
Nephritic: Hameaturia
Nephrotic: Proteinuria (more than 3g/24 hours)
93
What type of hypersensitivity reaction underpins nephritic syndrome?
Type III hypersensitivity
94
Low does nephritic syndrome lead to hypertension?
Low filtration → low perfusion to the kidney → activation of RAAS → hypertension
95
Pathology underlying IgA nephropathy (Berger's disease)
* Abnormal IgA forms → deposits in kidney → kidney inflammation (nephritis) → kidney damage
96
What is associated with IgA nephropathy (Berger's disease) - that can make it a differentiating factor in diagnosis?
* Associated with **GI** + respiratory tract infections
* Very short duration between (1-3 days)
97
First line and gold standard investigations for IgA nephropathy
* First line: Urinalysis (haematuira, proteinuria); eGFR (reduced); CT KUB (normal)
* Gold standard: Kidney biopsy (diffuse mesangial IgA deposition)
98
What is the positive histological feature of IgA nephropathy (Berger's disease)
Diffuse mesangial IgA deposition
99
Treatment for IgA nephropathy (Berger's disease)
* Immunosuppressants (prednisolone + cyclophoshamide)
* ACEi for hypertension
100
What is post-streptococcal glomulerilonephritis?
* Inflammation of the glomeruli as a complication of a bacterial infection
* Occurs 1-3 weeks after a Group A β-haemolytic streptococcus infection, such as tonsillitis caused by Streptococcus pyogenes.
101
A patient presents with haematuria after having tonsilits 2 weeks before. Possible diagnosis?
Post-streptococcal glomerulonephritis
102
What causes post-streptococcal glomerulonephritis?
Group A beta-haemolytic streptococcal pyogenes infection
(1-2 weeks after throat infection)
(6 weeks after skin infection (impetigo))
103
Underlying pathology of post-streptococcal glomerulonephritis
* Group A β-haemolytic streptococcus pyogenes infection (e.g. tonsillitis)
* 1-3 weeks after immune complexes (strep antigens + antibodies + complement proteins) = get stuck in the glomeruli of the kidneys
* Inflammation → acute deterioration in renal function → acute kidney injury (AKI)
104
Symptoms that a patient may experience with post-streptococcal glomerulonephritis
* Fever
* Headache
* Malaise
* Anorexia
* Nausea
105
Ix for post-streptococcal glomerulonephritis
* Urinalysis: Proteinuira, haematuria
* Tonsilitis-related: Throat swab (charcoal. positive for strep).
* Kidney biopsy: Subepithelial humps
106
What type of microscopy is used to look at the histology for kidney biopsies?
Mainly electron microscopy (not light microscopy)
107
Treatment for post-streptococcal glomerulonephritis
Supportive (80% recovery)
Complications:
* Antihypertensive (hypertension)
* Diuretics (oedema)
108
What two major presentations does Goodpasture's syndrome consist of?
* Glomerulonephrtis
* Pulmonary haemorrhage
109
Genetic risk factors for Goodpasture's syndrome
HLA-DR4 or B1
110
Which antibodies are involved in Goodpasture's syndrome?
Anti-GMB (glomerular basement membrane)
(They attack the glomerulus + pulmonary basement membranes → CAUSING GLOMERULONEPHRITIS + PULMONARY HAEMORRHAGE)
111
If a patient presents with an AKI and haemoptysis, what glomerulonephritis are we going to test for?
Goodpasture's syndrome
(presence of anti-GBM antibodies)
| Kidney + lung → Goodpasture's
112
Sx for Goodpasture's syndrome
* HOOP
* Crackles on lung eximation
* Cough
* Dyspnoea
* Nausea
113
What are the diagnostic tests for Goodpasture's syndrome?
* Anti-GBM serologies
* Renal biopsy (cresent glomerulonephritis + IgG immunofluorescence)
114
Management for Goodpasture's syndrome
* Oral corticosteroid (prednisolone)
* Plasmapheresis (remove the pathogenic antibody (anti-GBM)
* Cyclophosphamide
115
What antibodies cause nephritic syndrome in SLE?
Anti-dsDNA
They form antibody complexes → initiate inflammatory response → Type III hypersensitivity reaction
116
Is SLE nephropathy nephritic or nephrotic?
Both
117
Mx for SLE nephropathy
Immunosuppression
(prednisolone + cyclophosamide)
118
Complications of SLE nephropathy
* Rein vein thrombosis
* Pulmonary embolism
* Rapidly progressive glomerulonephritis
119
What is minimal change disease?
* Most common nephrotic syndrome in children
* T cells release cytokines = cause effacement (flattened) of podocytes
* Lose albumin in urine
120
Signs of minimal change disease
More rapid onset (days to weeks) - compared to others.
Nephrotic (Protein LACE)
* **Proteinuria** (frothy urine)
* Lipid up (**hyperlipidaemia**)
* **Albumin down (less than 25g/L)**
* Cholesterol up (**hypercholesterolaemia**)
* **Edema** (facial or generalised)
* **Hypercoagulablity** (risk of DVT, thrombosis)
121
Why do you get high triglycerides + cholesterol in nephrotic syndrome?
Compensation, as there is a loss of protein in the urine + low albumin in serum
(Serum albumin level and total cholesterol level are inversely related: the lower the serum albumin level, the higher the cholesterol level)
122
First and gold standard Ix for minimal change disease
First: Urinalysis (proteinuria); 24-hour urine protein; serum albumin level (low)
Gold standard: Renal biopsy (podocyte effacement - electron microscopy)
123
Mx of minimal change disease
* **Corticosteroid (prednisolone)**
* Fluid restriction + low sodium diet
* **Albumin + furosemide (IV)**
124
Complications of nephrotic syndrome (2)
* Hypertension (?fluid retention)
* Thrombosis (hypercoagulability)
125
What is the most common nephrotic syndrome in adullts?
Focal segmental glomulerosclerosis
| Mainly men
126
What conditions can focal segmental glomerulosclerosis be secondary to?
* HIV
* Obesity
* Medications
* Maladaptive response to decreased renal mass
127
Rx for focal segmental glomerulosclerosis
- **Male sex**
- **Black race**
- Family history of focal segmental glomerulosclerosis
- **Heroin abuse**
- Presumed mechanism = direct toxic effect on the podocyte
- Use of known **causative medications**
- Interferon alfa, **lithium**, sirolimus, and pamidronate
- Chronic viral infections
- **HIV**-1, parvovirus B19, and cytomegalovirus
- **Solitary kidney**
128
Ix for focal segmental glomerulosclerosis
* **Serum urea ** (elevated - suggests renal dysfunction)
* **Creatinine** (elevated - suggests renal dysfunction)
* **eGFR** (decreased)
* **Urine protein-to-creatine ratio** (asymptomatic <1; symptomatic >3)
* **Serum albumin** (hypoalbuminaemia)
* **Serum lipid profile** (increased total cholesterol + LDL)
* **Renal biopsy + histology**
129
What histological features show on a renal biopsy for focal segmental glomerulosclerosis
* **Light microscopy: Focal segmental sclerosis**
* Electron microscopy: Effacement of podocyte foot processes
* Immunofluroscence: Non-specific focal deposits of IgM and C3
130
First and second line management for focal segmental glomerulosclerosis
First line: Treat underlying cause; **ACEi** (lisinopril) or **ARB** + sodium; restriction, **corticosteroid (pred)**
Second line:
- **Furosemide** ± thiazide diuretic
- Treat oedema
- Statin (**atorvastatin**)
- High serum cholesterol and low-density lipoprotein produced by nephrotic syndrome
- **Ciclosporin** ± corticosteroid (prednisolone)
- Ciclosporin = induce remission + preserve renal function
131
Name some causes of membranous nephropathy
Primary:
* Idiopathic (most common)
* Associated with HLA alleles
Secondary:
- Auto-antibodies generated in response to underlying conditions
- Infections
- Hep B
- Hep C
- Syphilis
- Medications
- NSAIDs, penicillamine
- Autoimmune
- Systemic lupus erythematosus (SLE)
- Malignancy
132
Rx for membranous nephropathy
- Male sex
- Age>40 years
- **HLA-DR3**
- **Autoimmune disease**
- Hepatitis B and C
- Syphilis
- Solid organ carcinoma
- Medication
133
Underlying pathology of membranous nephropathy
Inflammation of glomerular basement membrane triggered by immune complex deposits → increased permeability → proteinuria → nephrotic syndrome
134
Px of membranous nephropathy
* Oedema
* Hypertension
* Xanthelasma (yellow growths on or near eyelids - hypercholesteraemia)
* Foamy urine (proteinuria)
* Fatigue/malaise
* Anorexia
135
What histological feature is characteristic of membranous nephropathy?
Diffuse thickening of glomerular basement membrane
136
Mx for membraneous nephropathy
- Low salt + low protein diet
- Hypertension → ACEi or ARB
- Hyperlipidaemia → simvastatin or atorvastatin
- Oedema → furosemide ± hydrochlorothiazide
- Moderate to high risk pf progressive kidney injury → corticosteroid (prednisolone) + cytotoxic or immunosuppressive therapy (cyclophosphamide)
137
Define an AKI
* Acute drop in kidney function → leading to a rise in serum creatinine and/or fall in urine output
* Decrease in function LESS THAN 3 MONTHS
138
What is the diagnostic criteria for an AKI
Ix: Urea and electrolytes - CREATININE
- Rise in creatinine of ≥ 25 micromol/L in 48 hours
- Rise in creatinine of ≥ 50% in 7 days
- Urine output of < 0.5ml/kg/hour for > 6 hours
139
What population are AKIs most common in?
Elderly
140
What are the 3 categories for the causes of an AKI?
* Pre-renal
* Renal
* Post-renal
141
Name some pre-renal causes of an AKI
| Inadequate blood supply to the kidney → ↓filtration of blood
* Hypotension (shock)
* Heart failure
* Dehydration
- Hypovolaemia (fluid loss)
- GI losses → diarrhoea + vomiting
- Acute haemorrhage → trauma + bleeding
- Renal losses → diuretics or osmotic diuresis
- Dermal losses → burns
142
Name some renal causes of an AKI
| Intrinsic disease in the kideny → ↓filtration of blood
* Glomerulonephritis
* Interstitial nephritis
* Nephrotoxic drugs
- NSAIDs → inhibits COX → causes excess vasoconstriction of afferent arteriole
- ACEi/ARBs → results in dilated efferent arterioles → decreasing GFR
- Methotrexate
* Malignant hypertension
* Autoimmune disease
143
How do NSAIDs effect the kidney?
inhibits COX → causes excess vasoconstriction of afferent arteriole
144
How do ACEi/ARBs effect the kidney?
Dilation of efferent arterioles → decreasing GFR
| **A**CEi.**A**RBs → **a**fter efferent
145
Name some post-renal causes for an AKI
Caused by obstruction to outflow of urine from the kidney → causing back-pressure into the kidney → ↓kidney function = OBSTRUCTIVE UROPATHY
* **Kidney stones (nephrolithiasis)**
* Masses (cancer in abdomen or pelvis)
* Ureter or uretheral strictures
* **Enlarged prostate or prostate cancer**
* Blood clot
| Anything blocking the outflow of the kidney reducing outflow
146
Rx question: When should you consider the possibility of an AKI in patients?
Patients with an **acute illness (e.g. infection)** or **having a surgery**
* Chronic kidney disease
* Heart failure
* Diabetes
* Older age (above 65 years)
* Nephrotoxic medications (NSAIDs and ACEi)
* Malignant hypertension
* Trauma
* Sepsis
147
Signs of an AKI
* **Tachycardia**
* **Peripheral oedema**
* **Poor tissue turgor**
* Postural hypotension (dehydration)
* Hypotension (pre-renal cause of AKI)
- Fluid overload + increased JVP, pulmonary oedema (CXR)
- Abdomen: large, painless bladder (chronic retention)
148
Symptoms of an AKI
* Early stages = asymptomatic
* **Oliguria** (decreased urine output)
- **Anuria**
- **Dehydration**
- **Nausea + vomiting**
- **Confusion**
- Fever (sepsis)
- Uraemia - weakness, tremor, fatigue, nausea, vomiting, mental confusion, seizures, coma
- LUTS
- Prostatic hyperplasia = an obstructive post-renal cause of AKI
149
What are the NICE criteria for an AKI?
* Urine output less than 0.**5**ml/kg/hr for >6 hours
* Rise in creatinine of ≥ 2**5** micromol/L in 48 hours
* Rise in creatinine of ≥ **5**0% in 7 days
150
Ix for an AKI
First line:
- **Urinalysis**:
- Leucocytes + nitrates → suggest infection
- Protein + blood → suggest acute nephritis (but can be positive in infection)
- Glucose → suggests diabetes
- Urine + blood cultures → look for infection
- KUB Ultrasound → look for obstruction
Other:
* Monitor urine output - catheter
* KUB XR (non-contrast)
* Autoantibodies (Anti-GBM, ANCA)
151
Differential diagnosis for an AKI
* Chronic kideny disease (>3 months of creatinine rise)
* Drug side effect (cimetidine or trimethoprim)
* Increased muscle mass
152
How can you prevent an AKI?
* Avoid nephrotoxic medications (NSAIDs and ACEis)
* Adequate fluid input (IV fluids if not oral)
153
What are the treatments of an AKI? For the 3 categories
* Pre-renal: Fluid rehydration (IV fluids)
* Renal: Stop nephrotoxic medications e.g. NSAIDS and antihypertensives that reduce the filtration pressure (i.e. ACE inhibitors)
- NSAIDs e.g. aspirin, ibuprofen
- ACEi e.g. ramipril
- Gentamicin
- Amphotericin
* Post-renal obstruction: Catheterise and consider CT KUB
- E.g. insert catheter for a patient in retention from an enlarged prostate
154
What are the major complications of an AKI?
* **Hyperkalaemia**
* Fluid overload, heart failure, pulmonary oedema
* Metabolic acidosis
* Uraemia (high urea) → encephalopathy or pericarditis
155
Why is hyperkalaemia a complication of kideny failure?
When the kidneys are failing → they cannot excrete potassium → cardiac arrest
156
How does hyperkalaemia present on an ECG?
* Tall peaked T waves
* Wide QRS complex
* Small P waves
157
What is the management for hyperkalaemia?
* **Calcium gluconate** (membrane stabiliser → protects heart)
** * Insulin + dextrose** (insulin drives K+ into cells)
* **IV fluid **
* Salbutamol
158
Name some causes of chronic kidney disease (CKD)
* Diabetes
* Hypertension
* Age-related decline
* Glomerulonephritis
* Polycystic kidney disease
* Nephrotoxic medications (NSAIDs, PPIs, Lithium)
159
Pathology of chronic kidney disease (CKD)
Damaged nephrons → blood diverted to healthy nephrons → increased flow + stress to these nephrons → these nephrons start to fail → detection as new/increasing proteinuria
160
What does CKD often progress to?
End-stage kidney disease
161
Symptoms of CKD
* Asymptomatic (unless advanced stages)
* Pruritus (itching)
* Loss of appetite
* Nausea
* Muscle cramps
162
Signs of chronic kidney disease (CKD)
* Oedema
* Hypertension
* Peripheral neuropathy
* Pallor
163
What is the diagnostic criteria for CKD?
* **Proteinuria** or **haematuria**
AND/OR
* **Reduction in eGFR** for more than 3 months
164
Ix for chronic kidney disease
* **U&E** (**eGFR** - 3 months apart to confirm diagnosis)
* **Proteinuria** (**urine albumin:creatinine ratio**, ≥ 3mg/mmol is significant)
* **Haematuria** (urine dipstick (1+))
* **Renal ultrasound**
165
What are the aims of management for CKD?
Slow progression + reduce complication risk
* Slow disease progression
* Reduce CVD risk
* Reduce complications risk
* Treat complications
166
How do you reduce the complications of CKD?
* Exercise, maintain a healthy weight and stop smoking
- Special dietary advice about phosphate, sodium, potassium and water intake
- **Offer atorvastatin 20mg for primary prevention of cardiovascular disease**
167
What is the treatment for metabolic acidosis in CKD?
Oral sodium bicarbonate
168
Name two treatments for end-stage renal failure
* Dialysis
* Renal transplant
169
What is the first line treatment for hypertension in CKD patients?
ACEi
(aim BP < 140/90 mmHg)
170
What electrolyte level needs to be monitored in CKD?
Serum potassium
* CKD + ACEis both cause hyperkalaemia
171
What are complications of CKD?
- Cardiovascular disease
- Peripheral neuropathy
- Anaemia
- Healthy kidneys produce erythropoietin (= the hormone that stimulates the production of RBCs)
- Renal bone disease
- Dialysis related problems
172
Where can renl calculi get deposited and irritate?
Anywhere from the **renal pelvis** to the **urethra**
(Most common place = the vesco-ureteric junction)
173
Which sex is more likely to develop kidney stones?
Male
174
Name some causes of kidney stones
* **Anatomic** deformity (horshoe, duplex)
* **Hypercalciuria** (from hyperparathyroidism)
* **Hypercalcaemia**
- Calcium supplementation
- Hyperparathyroidism
- Cancer (myeloma, breast or lung)
- **Infection-induced struvite** – **proteus**, klebsiella and pseudomonas
- Hyperoxaluria (high oxalate in the urine)
175
What is the most common form of renal calculi?
Calcium oxalate
176
What are the types of renal calculi?
* Calcium-based (80%)
* Uric acid (not visable on x-ray)
* Struvite (bacterial infection)
* Cystine
177
What are the risk factors of calcium-based kidney stones?
* Reduced urine output
* Hypercalcaemia
178
What does a staghorn calculus look like and when do they develop?
* Kidney stone in the **shape of the renal pelvis** → seen on **x-ray**
* Most commonly made out of **struvite** → **recurrent upper UTIs**
* Recurrent UTIs (bacteria hydrolyses the urea in the urine → ammonia → **solid struvite**)
179
What is the described as with kidney stones?
**Renal colic**
* **Unilateral loin to groin pain** (excruciating)
* **Colicky** (fluctuating in severity) as the stone moves and settles
* Unable to get comfortable
180
Patient presents with haematuria and reduced urine output. Patient is also feeling nauseous and has loin to groin pain that fluctuates in severity. Possible diagnosis?
| Kidney stones can also be asymptomatic!
Kidney stones
(renal calculi, urolithiasis, nephrolithiasis)
181
Name the UTI symptoms
* Dysuria (painful or difficulty urinating)
* Stangury (burning when urinating)
* Urgency
* Frequency
182
First line and gold standad Ix for kidney stones
First line:
* **Urine dipstick** (haematuria, exclude infection)
* **Blood test** (eGFR, infection, serium calcium (potential hypercalcaemia)
* **Abdominal x-ray** (calcium-based = show; uric acid stones = don't show (radiolucent))
Gold standard: **Non-contrast CT KUB (diagnostic) **
* KUB = kidneys, ureters, bladder
* Within 24 hours of presentation
183
First and second line management for kidney stones
First line:
** * Hydration + analgesia** (NSAIDs (ibuprofen) or IV paracetamol)
* **Antibiotics** (if bacteriuria)
* Watchful waiting (stones less than 5 mm)
Second line: Extracorporeal **shock wave lithotripsy**
184
Preventative treatment for recurrent infections?
* **Increase fluid intake** (2.5-3 litres per day)
** * Reduce dietary salt intake **
* **Maintain normal calcium intake** (low calcium may increase risk)
* **Thiazide diuretics (indapamide)** - in patients with calcium oxalate stones and raised urinary calcium
185
2 complications fo kidney stones
* **AKI** (caused by obstruction)
* **Infection** with **obstructive pyelonephritis**
186
Risk factors for developing kidney stones
* Chronic dehydration
* Diet
* Obesity
* Positive family history
* Metabolic abnormalities (hyperparathyroidism)
187
What is the presentation of hypercalcaemia mneumonic?
Renal stones, painful bones, abdominal groans and psychiatric moans
188
What are the 3 causes of hypercalcaemia?
* Calcium supplementation
* Hyperparathyroidism
* Cancer (myeloma, breast, lung cancer)
189
What is polycystic kidney disease?
**Genetic disease**
Kidneys fill with hundreds of cysts → become larger → kidenys unable to function
190
What are the two types of polycystic kidney diseasae (PKD)?
* Autosomal dominant (ADPKD) = adult PKD (more common)
* Autosomal recessive (ARPKD) = childood PKD
191
What are the gene mutations involved in autosomal dominant PKD (ADPKD)?
* Polycystin 1 (**PKD1**) = more severe - earlier onset
* Polycystin 2 (**PKD2**) = less severe - later onset
192
What is the genetic mutation associated with autosomal recessive PKD?
Polycystic kidney hepatic disease 1 (PKHD1)
| Both parents hasve to pass on the mutation
193
Pathology of polcytsic kidney disease
- Cysts in cortex + cysts in medulla
- Cysts become larger over time → compress blood vessels of neighbouring healthy nephrons → starve neighbouring nephrons of oxygen
- Poor perfusion of kidneys → activates renin-angiotensin-aldosterone system → retain fluid → hypertension
- Large cysts → compress collecting system → urinary stasis → kidney stones
194
Name some extra-renal manifestations of ADPKD
* **Hepatic**, splenic, pancreatic, ovarian and prostatic cysts
* Cardiac valve disease (mitral regurgitation)
* Aortic root dilation
* Cerebral aneurysms
195
Name come complications of ADPKD
* Chronic loin pain
* Hypertension
* Cardiovascular disease
* Kidney stones
* End-stage renal failure (mean age 50 yrs)
* Gross haematuria (occurs with cyst rupture - resolves within few days)
196
What are the symptoms of polycystic kidney diseasse?
**Flank pain**
UTIs: Dysuria, subrapubic pain, fever
197
What are the key presentations of polycystic kidney disease?
* Flank pain
* Hypertension
* Palpable kidney mass
* Haematuria (upon cyst rupture)
* Renal insufficiency
198
Ix for polycystic kidney disease first line and gold-standard
First line:
* Renal ultrasound
* Genetic teasting (PKD1, PKD2, PKHD1)
Gold standard: Contrast-enhanced CT scan abdomen/pelvis, MRI of abdomen/pelvis
199
What investigation should be performed and what is seen when suspecting ARPKD?
Prenatal ultrasound
* Bilaterally large kidneys with cysts
* Oligohydramnios
200
What medication is used in ADPKD to slow the development of cysts and renal failure?
Tolvaptan
201
First line and second line management for ADPKD
First line:
* **Tolvaptan** orally
* Lifestyle measures (optimal weight, regular exercise, no smoking
* Hypertension: ACEi (**ramipril**) or ARB (**valsartan**)
* Infected renal cyst (**ciprofloxacin**)
Second line:
* Dialysis (**haemodialysis** - preferred over peritoneal dialysis)
* Renal transplant
202
Name some complications of PKD
* Hypertnesion (due to renal failure) - cardiac complications
* Liver failure (due to liver fibrosis)
* Portal hypertension (leading to oesophageal varices)
* Progerssive renal failure
* Chronic lung disease
203
What type of neoplasm is prostate cancer and where do they grow?
Adenocarcinoma
Grow in the peripheral zone of the prostate
204
What are some Rx for prostate cancer?
* Increasing age
* Family history
* **Black African or Caribbean origin**
* Tall stature
* **Anabolic steroids**
* **Peripheral obesity** (Waist circumference by 10cm - mortality increases by 18%)
205
What hormone is prostate cancer dependent on to grow?
Prostate cancer = androgen-dependent (rely on testosterone to grow)
206
What are the signs of prostate cancer?
* Haematuria
* Erectile dysfunction
* DRE: A cancerous prostate may feel firm or hard, asymmetrical, craggy or irregular, with loss of the central sulcus
207
What are the symptoms of prostate cancer?
* Asymptomatic
* Lower urinary tract symptoms (LUTS) - similar to BPH
- Hesitancy
- Frequency
- Weak flow
- Terminal dribbling
- Nocturia
* Symptoms of advanced disease or metastasis
- Weight loss
- Bone pain
- Cauda equina syndrome
208
What are the first line investigations for prostate cancer?
* **DRE** - prostate examination
- Cancerous prostate = firm/hard, asymmetrical, craggy/irregular with loss of central sulcus, may have a hard nodule
* **Multiparametric MRI - Likert scale**:
- 1 – very low suspicion
- 2 – low suspicion
- 3 – equivocal
- 4 – probable cancer
- 5 – definite cancer
* **Prostate-Specific Antigen (PSA)**:
- High rate of false positive
- Unreliable
209
What is the gold standard investigation for prostate cancer?
* Prostate biopsy (transrectal ultrasound-guided biopsy (TRUS))
210
What grading system is based on the histology from the prostate biopsies
| Helps to determine appropriate treatment
**Gleason Grading System**
* 6 = low risk
* 7 = intermediate risk
* 8 or above = high risk
(The greater the Gleason score, the more poorly differentiated the tumour is (the cells have mutated further from normal prostate tissue) and the worse the prognosis)
211
What staging system is used in prostate cancer?
TNM Staging
212
Name the grading and staging systems for prostate cancer
* Grading: **Gleason** Grading System
* Staging: **TNM** Staging System
213
2 differentials for prostate cancer?
* Benign prostatic hyperplasia
* Chronic prostatitis
214
How do you monitor a patient with prostate cancer?
'Watchful waiting' - with PSA
215
What's the difference between grade and stage of a cancer?
- Grade = how it might biologically behave
- Stage = The amount of tissue there is around (the extent)
216
Management of prostate cancer
- **Surveillance** or **watchful waiting** in early prostate cancer
- **External beam radiotherapy** directed at the prostate
- **Brachytherapy**
- Implanting radioactive metal ‘seeds’ into the prostate
- Delivers targeted radiotherapy to the prostate
- **Hormone therapy**
- Reduce level of androgens (e.g. testosterone that stimulate the cancer to grow
- **Androgen-receptor blockers** such as **bicalutamide**
- **GnRH agonists** such as goserelin (Zoladex) or leuprorelin (Prostap)
- **Surgery**
- **Radical prostatectomy** = removal of the entire prostate
- Aim = to cure prostate cancer confined to the prostate
217
What is the androgen-receptor blocker used in prostate cancer?
Bicalutamide
218
Complications of prostate cancer
Radiation-induced:
- Dysuria
- Urinary frequency
- Rectal bleeding
- Erectile dysfunction
- Hot flushes
Hormone-induced:
- Gynaecomastia
- Hot flushes
219
What is the staging process of prostate cancer?
**TNM Staging**
- **T stage**:
- T1 - no palpable tumour on **DRE**
- T2 - palpable tumour, confined to prostate
- T3 - palpable tumour extending beyond prostate capsule
- T4 – invading local structures (sphincter/rectum)
- **N stage**:** MRI scan, CT scan, (laparoscopy)**
- **M stage**: **Bone scan/ PET scan/MRI
220
What are the two types of testicular cancer?
* Seminomas
* Non-seminomas (mostly teratomas)
221
What age group is testicular cancer most common in?
Young men (15-34)
222
Rx for testicular cancer
* Undescended testes
* Male infertility
* Family history
* Increased height
223
What are is the key presentation of testicle cancer?
* Haematospermia
* Testicular lump (hard, irregular, non-tender, NOT FLUCTUANT, NO TRANSILLUMINATION)
(Gynaecomastia (breast enlargement - Leydig cell tumour)
224
Why might you develop symptoms with testicular cancer?
Metastases!
- Cough/dyspnoea → indicative of lung metastases
- Back pain → indicative of para-aortic lymph node metastasis
225
What are the first line investigations for testicular cancer?
* Scrotal ultrasound (colour Doppler of testis) (diagnostic)
* Bloods for tummour markers
- Lactate dehydrogenase (LDH) = non-specific tumour marker
- Beta-hCG (may be raised in teratomas + seminomas)
226
What is the staging system for testicular cancer?
Royal Marsden Staging
227
Where are the most likely metastases sites for testicular cancer?
* Lymphatics
* Brain
* Liver
* Lungs
228
Differentials for testicular cancer?
* Epidydimal cyst
* Hydrocele
* Epididymo-orchitis
229
Treatment of prostate cancer?
* **Radical orchidectomy** - via inguinal approach
* Chemotherapy
* Radiotherapy
230
What type of neoplasm is bladder cancer and where does it arise from?
* Arises from the endothelium lining (urothelium)
* **Transitional cell carcinoma (90%)**
* Squamous cell carcinoma (5%)
231
A patient is a retired dye factory worker with painless haematuria. Possible diagnosis?
Transitional cell carcinoma (bladder cancer)
232
Rx for bladder cancer
* Snoking
* Increasing age
* Aromatic dyes (**dye + rubber industries**)
* **S**chistosomiasis (= causes **s**quamous cell carcinoma of the bladder)
233
What are the key presentations of bladder cancer?
* Painless haematuria
* UTI symptoms (absence of infection): **Dysuria**, frequency, urgency
234
What are the cancer B symptoms
* Unexplained weight loss
* Night sweats
* Loss of appetite
235
When do you use a two week wait referral 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
236
What is the first line and gold standard Ix for bladder cancer?
* First line: Urinalysis (haematuria)
* Gold standard: Flexible cystoscopy + biopsy
237
What is the staging system for bladder cancer?
TNM
238
Differentials for bladder cancer?
* BPH
* Prostatitis
* UTI
* Nephrolithiasis
* Renal cell carcinoma
239
What is the managment for non-muscle invading bladder cancer?
Transurethral resection of bladder tumour (TURBT)
240
What is the managment for muscle invading bladder cancer?
Radical cystoscopy
(Removal of the entire bladder)
241
What is the classic triad of Px for renal cell carcinoma?
* Flank pain
* Haematuria
* Palpable mass
| DDx - PKD only has haematuria when cyst ruptures
242
What is the most common type of renal cell adenocarcinoma?
Clear cell
243
Rx for renal cell adenocarcinoma
* Renal abnormalities (PKD, horseshoe kidneys)
* Hypertension
* Smoking
* Emd-stage renal failure
244
Where does renal cell carcinoma arise from?
Proximal tubular epithelium
245
Patient present with vague loin pain, weight loss, and complains that he is sweating a lot in the night. O/E you palpate a renal mass and haematuria. Possible diagnosis?
Renal cell carcinoma
246
What are the first line and gold-standard Ix for renal cell carcinoma?
First line:
* Abdome/pelvis ultrasound (differentiate benign cyst from solid tumour)
* Blood (paraneoplastic syndrome - reduced Hb; eGFR may be reduced)
* Urinalysis (haematuria and/or proteinuria)
Gold standard:
* CT scan (abdomen/pelvis) = more sensitive
247
Management of renal cell carcinoma
* Stage 1 or 2: Surveillance, local ablation therapy (radiofrequency ablation (RFA))
* Stage 3: Radical nephrectomy
* Stage 4: Partial nephrectomy, chemotherapy, palliative radiation
248
Complications of renal cell carcinoma
- Anaemia
- Adverse effects from targeted therapies
- Paraneoplastic syndromes - production of hormones
- EPO - more RBCs → polycythaemia
- PTHrP → hypercalcaemia
- ACTH - more cortisol → Cushing’s
249
What is the staging system for renal cell carcinoma?
TNM staging system
250
Is Chlamydia trachomatis gram-positive or gram-negative bacteria?
Gram-negative
251
What are the serovars of Chlamydia?
D-K
Urogenital infection, conjuctivitis
252
What STI results in yellow, cloudy vaginal discharge?
Chlamydia
253
What anorectal symptoms does chlamydia cause?
* Discomfort
* Discharge
* Bleeding
* Change in bowel habbit
254
What are the key presentations of chlamydia in men and women?
Female:
* Asymptomatic (majority)
* **Abnormal vaginal discharge**
* **Dysuria (painful urination)**
* Painful sex
* Abnormal vaginal bleeding
Male:
* **Urethral discharge or discomfort**
* **Painful urination (dysuria)**
* Epididymo-orchitis
O/E
* Pelvic or abdominal tenderness
* Inflamed cervix
255
Key Ix for chlamydia
* Nucleic acid amplification test (NAAT)
* Swab (men = urethral; women = vulvovaginal)
* First-catch urine sample (men + women)
256
First line treatment for chlamydia (and alteranative)
Uncomplicated: Doxycycline BD (7 days)
Pregnant + breastfeeding: Azithromycin (2/3 days)
257
Complications of chlamydia
* Pelvic inflammatory disease
* Infertility
* Ectopic pregnancy
* Conjunctivitis
* Reactive arthriris
Pregnancy-related complications:
* Preterm delivery
* Low birth weight
* Neonatal infection (conjunctivitis and pneumonia)
258
What is the bacteria that causes gonorrhoea?
Neisseria gonorrhoea
(Gram-negative diplococcus)
259
Which STI is more likely to be symptomatic, chlamydia or gonorrhoea?
Gonorrhoea
260
What are they presentations of gonorrhoea?
* Odourless purulent discharge - green or yellow
* Dysuria
* Pelvic pain
* Testicular pain or swelling (epididymo-orchitis)
261
Ix for gonorrhoea
* Endocervival, vulvovaginal or urethral **swabs** OR **first-catch urine sample **
* **NAAT** (detects the RNA or DNA of gonorrhoea)
* **CHARCOAL SWAB** - for culture + **sensitivities** (gonorrhoea has a high level of antibiotic resistance)
262
Treatment for gonorrhoea
Intramusclular **ceftriaxone**
