Renal & GU Flashcards

1
Q

Tx of BPH

A

Tamsulosin
Finasteride

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2
Q

Action of tamsulosin
& what class of drug is it?

A

Relax smooth muscle of bladder and prostate
∴ ↑ Urine flow rate

(selective alpha-1-adernergic receptor antagonists)

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3
Q

S/E of tamsulosin

A

Postural instability, retrograde ejaculation

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4
Q

Findings on DPE of BPH

A

Smooth, enlarged prostate

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5
Q

Findings of DPE of Prostate cancer

A

Hard and irregular

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6
Q

Ix for BPH
(incl values if measuring any antigens cough cough)

A

Digital Rectal Examination
Prostate-Specific antigen > 1.5ng/mL
GS (?) : Trans-rectal US

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7
Q

Ix for Prostate cancer
(no abbrv)

A

Digital Rectal Exam
Prostate Specific Antigen
Trans-rectal US
Prostate biopsy

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8
Q

What’s the grading thing called for prostate cancer?

A

Gleason grading score

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9
Q

Most common pathogens for UTIs

A

E.Coli
Proteus

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10
Q

Why is creatinine used as a marker of GFR?

A

Freely filterised
Not metabolised
Not secreted
Not reabsorbed

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11
Q

Mechanism of loop diuretics
Where do they act upon?

A

Act of ascending limb of loop of Henle

Inhibit Na+/K+/2Cl- co-transporter
(bc if it transports ions, water will follow)

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12
Q

Examples of loop diuretics

A

Furosemide
Bumetanide

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13
Q

S/E Loop diuretics

A

Dehydration
Hypotension
Hypokalaemia
& Metabolic alkalosis can occur !

If v high doses, can cause ototoxicity

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14
Q

Give an example of K+ sparing diuretic

A

Amiloride
Spironolactone

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15
Q

Mechanism of K+ sparing diuretics
Where do they act upon?

A

Act on the distal convoluted tubule

Inhibits reabsorption of sodium (and ∴ water) by epithelial sodium channels
∴ Na+ and H2O excretion
(and K+ retention)

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16
Q

S/E K+ sparing diuretics

A

GI upset
Hyperkalaemia
Metabolic acidosis
Gynecomastia

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17
Q

Example of a thiazide diuretic

A

Bendroflumethiazide

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18
Q

Mechanism of Thiazide diuretic
Where does it act upon?

A

Acts on sodium/chloride transporter
Prevents it from functioning properly

∴ Sodium is NOT retained

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19
Q

Compare thiazide and loop diuretics
(In terms of length and efficacy)

A

Thiazide diuretics are longer acting
But not as effective as loop

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20
Q

S/E Thiazide diuretics

A

Hypokalaemia
Metabolic alkalosis
Hypovolaemia
Hyponatraemia

Hyperglycaemia in DM

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21
Q

Where does Angiotensin II act on?

A

PCT

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22
Q

What does Angiotensin II do?

A

Causes thirst
↑ SNS activity
ADH release (by stimulating post. pituitary)
Aldosterone release (by stimulating adrenal glands)
↑Proximal tubule reabsorption which ↑Na+ reabsorption
Causes vasoconstriction to ↑BP

ESSENTIALLY, ↑BP

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23
Q

Where does Aldosterone act?

A

On DCT and collecting ducts

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24
Q

What does Aldosterone do?

A

↑Na+ reabsorption
↑K+ secretion
Binds to cytoplasmic receptors - transported to nucleus
↑Epithelial Na channels
↑Na+/K+ ATPase
↑Effective circulating vol

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25
Where does ADH act on?
Distal tubule Collecting ducts
26
What does ADH do?
Acts on V1 receptors on blood vessels to cause vasoconstriction Acts on V2 receptors in basolateral side of collecting ducts ↑ Insertion of aquaporin 2 on apical membrane of collecting ducts ∴ ↑ Water reabsorption Also, helps maintain hypertonicity of medulla by ↑urea permeability of collecting ducts
27
What is ADH produced by?
Hypothalamus
28
Where is ADH released?
Post. pituitary
29
What triggers ADH release?
Increased plasma osmolality (↓ water)
30
What detects decreased water in the body? How?
Hypothalamic osmoreceptors Detects bc H2O diffuses out post. pituitary in response to ↑Na+ pulling it out
31
What is ANP?
Atrial Natriuretic Peptide
32
What is the aim of ANP?
To decrease BP (inhibits renin secretion)
33
When is ANP released ?
When atria are stretched (due to high BP), it causes ANP to be released
34
What are the actions of ANP?
Dilates aff glomerular arterioles Constricts eff glomerular arteriole Relaxes mesangial cells (to ↑GFR) - so excretion can be increased "Blocks" NCC in DCT and ENaC in CT ∴ prevents reabsorption and ↑Na+ excretion ↑Vasa recta blood flow - leads to less reabsorption SYSTEMIC VASODILATOR
35
Where is parathyroid hormone released from? In response to what?
Parathyroid glands In response to ↓Ca2+ plasma levels
36
What does PTH do?
↑ Ca2+ reabsorption ↑ HPO4^3- excretion Stimulates formation of Vit D
37
Describe the activation of Vitamin D
38
Where can kidney stones be deposited?
Anywhere from renal pelvis to ureter
39
Where are kidney stones formed?
Collecting ducts
40
RF Renal Colic
Male (M:F 2:1) Middle East - due to higher oxalate, lower Ca2+ diet and ↑dehydration
41
What is renal colic also known as?
Nephrolithiasis
42
Where the most common sites for renal stones to get stuck?
Pelviureteric junction (PUJ) - MC ! Pelvic brim Vesicoureteric junction (VUJ)
43
Causes Renal Colic
**ANATOMICAL ABNORMALITIES** Congenital - horseshoe, duplex, PUJ, spina bifida Acquired - obstruction, trauma, reflux **URINARY** Metastable urine Ca2+, oxalate, urate, cystine Dehydration **INFECTION-INDUCED STONES (struvite)** - UTI w organisms that produce urease, is assoc/ with struvite stones Proteus, klebsiella, pseudomonas **HYPERCALCIRURIA** In turn, caused by: Hyperparathyroidism - MC !!! Hypercalcaemia XS dietary calcium XS resorption of calcium from bone (immobilisation) Idiopathic hypercalciuria **HYPEROXALURIA** ↑ dietary intake of oxalate rich foods e.g. spinach, rhubarb, tea ALSO, ↓dietary calcium intake (bc means decreased binding of oxalate w/ Ca2+)
44
Signs / Symptoms Renal Colic
Can be asymptomatic **Loin to groin colicky pain** - peristaltic waves Severe, unilateral, worse than labour! Rapid onset (mins-hours) Unable to get comfy - writhing in agony Worse w fluid loading N+V Sweating Fever UTI Sx !! - Dysuria, burning when urinating, urgency, frequency Haematuria (visible and non-visible) Recurrent UTIs Rigors Bladder/urethral stones
45
Ix Renal Coli
Detailed history - might reveal cause of stone e.g. lots of tea = high oxalate **1st line** - XR KUB (easy and cheap) **GS!!!** NON-CONTRAST CT KUB vvv spec (99%) US - useful for pregnancies and young (no radiation) Sens for hydronephrosis Urine dipstick - traces of blood Mid-stream specimen follow up with MSU if pos Bloods - FBC, U&E, calciu, uric acid
46
What benefits does Non-Contrast CT have over CT w contrast?
Good for allergies (doesnt trigger) and no renal damage
47
Tx Renal Colic
Essentially the same for Ureteric and Kidney stones but kidney stones is more conservative i think -- Hydration STRONG ANALGESIC - IV diclofenac NSAIDs, IV paracetamol, +/- opiates! Anti-emetics - metoclopramide +/- IV fluids - might make pain worse as diuresis happens Conservative - allow 2 weeks to pass Abx if UTI Medical expulsive therapy? Not much evidence if it works Extracorpeal Shock Wave Lithotripsy (ESWL) - if <1 cm Surgery - Ureteroscopy, Percutaneous Nephrolithotomy (PCNL), Nephrectomy ADMIT IF SHOCK, FEVER, SEPSIS, PREGNANCY ETC
48
Types of Stones
Calcium oxalate - form in acidic urine, MC !!!! Calcium phosphate - alkali urine Calcium carbonate Struvite - proteus, Klebsiella, pseudomonas bacteria Uric acid Cystine Drug precipitants
49
Why are Kidney stones treated more conservatively?
Small, safe location More asymptomatic Static size
50
Lifestyle changes for prevention Renal Colic
↓Dietary salt Normal dairy intake Lose weight Active lifestyle Overhydration Stop smoking More citrus fruit
51
With renal colic, when might a stone pass spontaneously?
If small <5mm
52
How might you treat renal colic if it's a large stone?
ESWL Ureteroscopy PCNL
53
Comps Renal Colic
HYDRONEPHROSIS - requires surgical drainage
54
AKI Criteria for diagnosis
↑ Creatinine > 26 mmol/L in 48 hours above baseline ↑ Creatinine > 50% (best fig in last 6 months) Urine output < 0.5ml/kg/hour for > 6 consec hours
55
Define AKI
Abrupt deterioration (hours to days) in renal function Due to rapid decline in GFR Leading to a failure to maintain fluid, electrolyte, acid-base homeostasis Usually but not always reversible Decreased in function < 3 months?
56
What is AKI assoc with?
Diarrhoea Haematuria Haemoptysis Hypotension Urine retention
57
Causes AKI
**PRE-RENAL** - ↓blood flow to kidney ∴ ↓ GFR Shock Hypovolaemia ! - diarrhoea, vomiting, trauma, bleeding, diuretics, burns Hypotension - cardiogenic shock, sepsis, anaphylaxis Cardiovascular - HF, severe arrhythmias Sepsis Renal hypoperfusion - NSAIDs, ACEi, ARBs **RENAL** - cells damaged so kidney can't filer blood properly Acute tubular necrosis Nephrotoxins - NSAIDs, Methotrexate Glomerulonephritis Acute interstitial nephritis Infection Vasculitis Malignant HTN Autoimmune disease **POST-RENAL** - anything that causes blockage of kidney BPH Kidney stones Cancer Blood clot
58
RF AKI
Age > 75 years DM HF Sepsis Peripheral vascular disease Drugs FHx Poor fluid intake/loss
59
DDx Nephrolithiasis
Aortic abdo aneurysm Diverticulitis - L sided Appendicitis - R sided Pyelonephritis Acute pancreatitis Ectopic preg Testicular torsion Peritonitis
60
Signs / Symptoms AKI
Often asymptomatic!! Esp early stages Fluid overload - oliguria/anuria, pulmonary/peripheral oedema, palpable bladder, hypovolaemic shock, ↑JVP, Hyperkalaemia - arrhythmias, muscle weakness, tachycardia Hyperuraemia - N+V, weakness, tremor, pericarditis, platelet dysfunction (bleeding), confusion and seizures if severe Metabolic acidosis Postural hypotension Thirst Poor tissue turgor
61
When is AKI a medical emergency?
Hyperkalaemia!!
62
What ECG signs are associated with hyperkalaemia?
Tall peaked T waves Wide QRS Small P waves
63
Ix AKI
Needs to meet the diagnostic criteria!! -- Urine dipstick - blood, nitrites, leukocytes, glucose, protein Bloods - FBC, U&Es, creatinine, liver enzymes Renal US - for obstruction Renal biopsy - for intra renal cause Monitor urine output Non-contrast CT KUB KUB CR Autoantibodies - Anti-GBM, ANCA
64
Tx AKI
**Treat underlying cause** Pre-renal - correct vol depletion w fluids, treat sepsis w Abx Intra-renal - maybe refer if concern over glomerular/interstitial pathology Post-renal - catherise, CT KUB, maybe retrograde stents (to clear obstruction) -- **STOP NEPHROTOXIC DRUGS !** - NSAIDs, ACEi, ARBs, lithium, digoxin Treat underlying comps - hyperkalaemia, pulmonary oedema etc IF severe - dialysis
65
What is refractory pulmonary oedema?
When AKI is esp bad, kidneys stop producing urine That fluid can end up in lungs!
66
Describe some differences between AKI and CKD
**AKI** Normal sized kidneys No anaemia No DM ↓ BP Rapid change Oliguria usually Not often CNS symptoms Presents more like shock **CKD** Small kidneys! Anaemia DM ↑BP Gradual onset Oliguria only in later stages CNS symptoms in later disease Presents like serious extensive disease
67
Chronic Kidney Disease Definition
Long-standing and progressive pathological abnormality of the kidney FOR AT LEAST 3 MONTHS
68
Pathophysiology Renal Colic
**Stones form from crystals in supersaturated urine** Occurs when solute is too conc - increase in solute or decrease in solvent (dehydration)
69
Causes CKD
HTN DM (more T2 than T1) Polycystic kidney disease SLE Nephrotoxic drugs, chronic NSAID use Obstructive uropathy - kidney stones, enlarged prostate Progression from AKI Glomerular disease / Chronic glomerulonephritis SLE Atherosclerotic renal vascular disease Tuberous sclerosis Malignancy - myeloma
70
CKD Diagnostic Criteria
eGFR < 60 ml/min/1.73m2 eGFR < 90ml/min/1.73m2 + signs of renal damage Albuminuria > 30mg/24hours (albumin:creatinine > 3mg/mmol)
71
RF CKD
DM HTN Female? Age Smoking Polycystic kidney disease NSAIDs Cardiovascular disease - IHD, LV hypertrophy FHx
72
Signs / Symptoms CKD
Early stages = Asymptomatic Arise as GFR declines -- **Urinary** - oliguria! haematuria, proteinuria, nocturia, polyuria **Bone disease!** - Osteomalacia, osteoporosis **Anaemia!** **Bilaterally small kidneys!!** Increased skin pigmentation! (yellow tinge) HYPERKALAEMIA N+V, fatigue, malaise, anorexia, itching, hiccups, convulsions, tremors, pallor CVD - Uraemic pericarditis Neuro - confusion, coma, fits **Vol overload** - SOB (pulmonary oedema, dyspnoea, ankle oedema) Sexual dysfunction
73
Describe the mechanism of HTN as a cause for CKD
Walls thicken in order to withstand pressure ∴ narrow lumen ∴ less blood and O2 to kidney ∴ ischaemic injury Immune cells travel into damaged glomerulus and release TGF-B1 Then, mesangial cells regress to immature cells + excrete extracellular matrix ∴ GLOMERULOSCLEROSIS (kidney is scarred) ∴ ↓ ability for nephron to filter blood
74
Describe the mechanism of DM as a cause for CKD
Type 2 > Type 1 XS glucose in blood sticks to proteins - esp effects efferent arteriole making it stiff and narrow ∴ obstruction for blood leaving glomerulus ∴ hyperfiltration ∴ mesangial cells secrete more structural matrix ∴ ↑ size of glomerulus ∴ Glomerulosclerosis Eventually becomes CKD
75
Quick!!!! Presentation CKD
Early asympto Normochromic, normocytic anemia Bone disease ! - osteomalacia HTN Fluid overload - oedema CVD - cardiomyopathy Malaise, loss of appetite, oliguria, haematuria
76
Ix CKD
**FBC** - shows anaemia, ↑ creatinine and urea levels + ↓ Ca2+ , ↑ phosphate, PTH, K+ **Urinalysis** Dipstick (haematuria and proteinuria ~ GN, leukocytes and nitrites ~ infection) Urine & blood culture - to exclude infection White cells - bacterial UTI Eoisinophilia - allergic tubulointerstitial nephritis Granular casts - active renal disease Blood - glomerulonephritis Renal US - excludes obstruction, see kidney size! CT - useful to diagnose retroperitoneal fibrosis and other causes of obstruction Biopsy Cystoscopy ECG - hyperkalaemia
77
Tx CKD
Irreversible so aim is to prevent progression and symptom control! If eGFR < 30 OR A:C > 70 = stage 4. Refer to nephrology Lifestyle changes! Treat underlying cause! HTN - treat w ABCD etc Oedema - fluid and sodium restriction, loop diuretic DM - metform etc CVD - aspirin, atorvastatin (statins if GFR < 60) If all else fails - Renal replacement therapy (haemo/peritoneal dialysis, kidney replacement, haemofiltration)
78
Describe the stages of CKD
**Stage 1** - eGFR ≥ 90 (mild damage, kidneys work as normal) **Stage 2** - eGFR 60 - 89 (mild damage, kidneys still work well) **Stage 3a** - eGFR 45 - 59 (mild-mod damage, kidneys don't work as well as they should) **Stage 3b** - eGFR 30 - 44 (Mod-severe damage, kidneys don't work as well as they should) **Stage 4** - eGFR 15 - 29 (Severe damage, close to not working at all) **Stage 5** - eGFR is less than 15! (close to not working at all or have failed, most severe damage)
79
What are some indications for dialysis?
Symptomatic uraemic - pericarditis or tamponade Hyperkalaemia - when not controlled by conservative means Metabolic acidosis Fluid overload - resistant to diuretics
80
Comps CKD
Hyperkalaemia Osteoporosis ! Vit D def Anaemia Metabolic acidosis Pruritus - bc nitrogenous waste products of urea Pericarditis HTN
81
Quick! Loin pain, Fever, Pyuria What is it?
Pyelonephritis
82
Ix ALL UTIs
**1st line** - Urine dipstick Will be **+**leucocytes, **+** nitrites, **+**haematuria **GS!!!** Midstream microscopy, culture and sensitivity
83
Pathophysiology Benign Prostate Hyperplasia
_Benign_ proliferation of _transitional_ zone of prostate! After 30 - men produce 1% less testosterone every year but 5a-reductase increases ∴ ↑ dihydrotestosterone levels ∴ prostate cell hypertrophy As prostate grows, can squeeze/block bladder ∴ urine retention ∴ bladder dilation and hypertrophy ∴ urine stasis ∴ bacteria ∴ UTI !
84
Cause BPH
Dihydrotestosterone
85
RF BPH
Age FHx Heart disease Obesity DM
86
What is protective against BPH?
Castration!
87
Signs / Symptoms BPH
**STORAGE** Frequency ↑ Urgency Nocturia Urgency incontinence **VOIDING** - SHIPP **S**training **H**esitancy **I**ncomplete emptying **P**oor/intermittent stream **P**ost-micturition dribbling -- Bladder stones Acute urinary retention UTIs
88
Red flags for prostate cancer
Dysuria - painful/difficult urination Haematuria
89
Painless haematuria What are you instantly assuming it is?
Malignancy Until proven otherwise
90
DDx BPH
Overactive bladder syndrome! Bladder tumour Bladder stones Trauma Prostate/Bladder cancer UTI Prostatitis
91
Ix BPH
International prostate symptom score (IPSS) Digital rectal exam - smooth, enlarged prostate PSA - may be raised Urine dipstick Biopsy Abdo exam = enlarged bladder To exclude renal damage - U&E and renal US Also to rule out obstruction - US
92
Tx BPH
Lifestyle advice - avoid caffeine and alcohol Void twice in a row to aid emptying **1st line** - oral tamsulosin **2nd line** - oral finasteride, dutasteride Surgery - **GS!** Trans-urethral resection of prostate (TURP) or Trans-urethral incision of prostate (less destruction, best for small prostates)
93
What are some indications BPH should be treated with surgery?
**RUSHES** **R**etention **U**TIs **S**tones **H**aematuria (resistant to 5-alpha reductase-inhibitors i.e. FInasteride) **E**levated creatinine **S**ymptom deterioration
94
Comps TURP
Risk of ED
95
Comps BPH
Bladder calculi UTI Haematuria Acute retention
96
Causes UTI
**KEEPS** **K**lebsiella **E**.Coli **E**nterobacter **P**roteus / Psuedomonas aeruginosa **S**taph spp
97
What is Klebsiella often assoc with?
Hospitals Catheters
98
Which KEEPS bacteria for UTIs is most common?
E.Coli !
99
What is Proteus assoc with?
Renal stones
100
What is Pseudomonas aeruginosa assoc w?
Recurrent UTIs
101
A young, sexually active female has a UTI. Which bacteria is it most likely to be?
Staphylococcus spp
102
Name Lower UTIs
Cystitis Prostatitis Urethritis Epidydymo-orchiditis
103
Name Upper UTIs
Pyelonephritis
104
What causes a UTI to be complicated?
Pregnancy Males Catheterised patients Children Recurrent or Persistent infection Immunocomp If acquired in hospital (Nosocomial) Urosepsis
105
Signs / Symptoms Lower UTI
**HD FUSS** **H**aematuria **D**ysuria **F**requency **U**rgency **S**uprapubic pain **S**melly urine
106
Signs / Symptoms Upper UTI
Systemic symptoms -- Loin/Abdo pain Tenderness N+V Fever Costovertebral angle pain
107
Why do you do midstream urine sample?
Bc first sample of urine has first shedding of epithelial cells Want to void bacteria away to get fresh part
108
Why might you get a urine sample first thing in the morning?
Because bacilli accumulate in urine and after a period of dehydration, you will tend to get the highest conc
109
Signs / Symptoms Pyelonephritis
**TRIAD OF :** Loin pain, fever, pyuria Usually unilateral pain + Back pain Headaches N+V Rigors Costovertebral angle pain Assoc cystitis symptoms
110
What is Pyelonephritis?
Infection of renal parenchyma and soft tissues of renal pelvis and upper ureter
111
Route of infection for Pyelonephritis
Infection usually bc E.Coli (UPEC) Usually via ascending transurethral route BUT can be via bloodstream or lymphatics (L = rare) -- Haematogenous - Aureus, Candida
112
DDx Pyelonephritis
Diverticulitis Abdo aortic aneurysm Kidney stones Cystitis Prostatitis
113
Tx Pyelonephritis
Hydration / Fluid replacement Analgesia! Co-amoxiclav for 7 days / Trimethoprim for 14 days +/- Gentamicin if severe IF PREGNANT, cefalexin for 7 days IV if severe Drain obstructed kidney
114
Who does Cystitis occur in?
Children Females Pregnant Catheterised
115
Why are women more susceptible to UTIs?
Shorter urethra Short proximity to anus - allows bacteria transfer
116
Signs / Symptoms Cystitis
**HD FUSS** **H**aematuria **D**ysuria **F**requency **U**rgency **S**uprapubic pain **S**melly urine + Incontinence + Confusion in elderly
117
What drugs are Nephrotoxic?
ACEi ARBs NSAIDs Digoxin Lithium
118
What is cystitis?
Urinary infection of the bladder
119
Causes Cystitis
KEEPS Mostly E.Coli
120
Tx Cystitis
**1st line** - Nitrofurantoin or Trimethoprim If pregnant! Trimethoprim CANNOT be used in 1st trimester and Nitrofurantoin CANNOT be used in 3rd trimer ∴ use cefalexin (or amoxicillin) instead **2nd line** - Ciprofloxacin or co-amoxiclav
121
What is Prostatitis?
Infection and inflammation of prostate gland
122
Causes Prostatitis
Acute - Strep. Faecalis, E.Coli, Chlamydia Chronic : Bacterial - Strep. Faecalis, E. Coli, Chlamydia Non-Bacterial - Elevated prostatic pressure, pelvic flood myalgia
123
RF Prostatitis
STI UTI Indwelling catheter Post-biopsy Age ↑
124
Signs / Symptoms Prostatitis
ACUTE : Systemic symptoms Fevers, rigors, malaise Painful ejaculation Pelvic pain HD FUSS CHRONIC : Acute symptoms > 3 months Recurrent UTIs
125
DDx Prostatitis
Cystitis BPH Calculi Prostatic abscess Malignancy
126
Ix Prostatitis
the normal PLUS DRE - prostate = tender, hard from calcification Blood cultures STI screen - esp chlamydia Trans-urethral US scan (TRUSS)
127
Tx Prostatitis
ACUTE : **1st line** - IV gentamycin + IV co-amoxiclav **2nd line** - Trimethoprim TRUSS abscess drainage if necessary 4-6 weeks quinolone etc once well -- CHRONIC : 4 - 6 weeks of quinolone e.g. ciprofloxacin +/- alpha-blocker (tamsulosin)
128
Comps Prostatitis
Urinary retention
129
What is urethritis?
Urethral inflammation
130
Causes of Urethritis
GONOCOCCAL - Neisseria gonorrhoea NON-GONOCOCCAL - **Chlamydia** MC ! Mycoplasma genitalium Trichomonas vaginalis NON-INFECTIVE - Trauma Urethral stricture Irritation Urinary calculi
131
RF Urethritis
Sexually active Unprotected sex Male 2 Male sex
132
Signs / Symptoms Urethritis
May be asymptomatic Systemic Sx - malaise, fatigue etc Dysuria Discharge, blood, pus Urethral pain Penile discomfort Skin lesions
133
DDx Urethritis
Candida balanitis Epididymitis Cystitis Acute prostatitis Urethral malignancy
134
Ix Urethritis
Normal UTI Ix PLUS Nucleic Acid Amplification Test (NAAT) high spec, high sens F - self-collected vaginal swab, endo-cervical swab, first void urine M - first void urine Urine dipstick - to exclude UTI (bc primarily a SEXUALLY ACQ DISEASE) Urethral smear
135
Tx Urethritis
**Chlamydia :** PO azithromycin or 1week doxycycline PO IF PREGNANT - PO erythromycin (14days) or PO azithromycin **Gonorrhoea** IM ceftriaxone w/ PO azithromycin Partner notification -- Patient ed Contact tracing
136
What do you need to keep in mind with urethritis?
Reactive arthritis - can't see, can't pee, can't climb a tree
137
When is Epididymo-Orchitis most common?
15 - 30 years > 60 years
138
Causes Epididymo-Orchitis
STIs : **< 35 years** Chlamydia trachomatis Neisseria gonorrhoea **> 35 years** KEEPS -- Mumps Trauma Elderly - usually catheter related
139
Signs / Symptoms Epididymo-Orchitis
Scrotal pain and swelling! - subacute onset, unilateral Tenderness Sweats/fevers If STI cause : Urethritis, Urethral discharge If Mumps cause : Headache, fever, unilateral or bilateral parotid swelling
140
Ix Epididymo-Orchitis
Same as Urethritis -- Normal UTI Ix PLUS Nucleic Acid Amplification Test (NAAT) high spec, high sens F - self-collected vaginal swab, endo-cervical swab, first void urine M - first void urine Urine dipstick - to exclude UTI (bc primarily a SEXUALLY ACQ DISEASE) Urethral smear
141
Quick! Genital ulcer, what is the disease?
ANY GENITAL ULCER IS SYPHILIS UNTIL PROVEN OTHERWISE
142
Quick! Testicular lump, what is it?
Cancer until proven otherwise
143
Quick! Acute and tender lump, what is it?
Testicular torsion until proven otherwise
144
Big 3 Qs to ask about scrotal masses
1. Can you get above it? 2. Is it separate from testis? 3. Cystic or solid?
145
Scrotal mass : Cannot get above What is it?
Inguinoscrotal hernia OR Proximally extending hydrocele
146
Scrotal mass : Separate AND cystic What is it?
Epididymal cyst
147
Scrotal mass : Separate AND solid What is it?
Epididymitis OR Varicocele
148
Scrotal mass : Testicular AND cystic What is it?
Hydrocele
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Scrotal mass : Testicular AND solid What is it?
Tumour, haematocele
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Describe an Epididymal cyst
Smooth, extratesticular, spherical cyst in head of epididymis
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What does an epididymal cyst contain?
Clear and milky (spermatocele) fluid
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Signs / Symptoms Epididymal cyst
Can be painful once large Lump - often multiple and bilateral Well defined Will transluminate Testis palpable SEPARATE from cyst
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How do differentiate between epididymal cyst and spermatocele?
You cannot clinically differentiate Only way is to aspirate bc sperm present in fluid if spermatocele
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Ix Epididymal Cyst
Scrotal US Transilumination - to eliminate hydrocele
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What is a Hydrocele?
Abnormal collection of fluid within tunica vaginalis aka fluid surrounds testes
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Describe a 1º Hydrocele
More common and larger Usually in young men Assoc w/ patent processus vaginalis - which usually resolves in 1st year of life
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What can a 2º Hydrocele be secondary to?
Testis tumour Trauma Infection TB Testicular torsion Generalised oedema
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Signs / Symptoms Hydrocele
Unless infected, shouldn't be painful! Non-tender, smooth, cystic swelling Testis usually palpable but if large, might be difficult Will transluminate
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DDx Hydrocele
Testicular torsion Strangulated hernia
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Ix Hydrocele
Scrotal US Serum AFP and HCG - exclude malignancy FBC - to check for infection Transillumination
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Tx Hydrocele
Resolve spontaneously Esp in infancy - resolves by 2 years Therapeutic aspiration or surgical removal
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What is a varicocele?
Abnormal dilation of testicular veins in pampiniform venomous plexus
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Pathophysiology Varicocele
Left renal vein invades L testicular vein ∴ compression ∴ impaired venous drainage (venous reflux) ∴ ↑ venous pressure ∴ vein dilation ∴ causes varicocele
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Signs / Symptoms Varicocele
Dull ache Scrotal heaviness "Bag of worms" - distended scrotal blood vessels
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Ix Varicocele
Venography Colour doppler US - to see blood flow
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Tx Varicocele
Surgery ! If pain, infertility or testicular atrophy
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What is Haemotocele?
Blood in tunica vaginalis
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Cause Haemotocele
Trauma
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Tx Haematocele
Aspiration or surgery
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In testicular torsion, which cells are the most susceptible to ischaemia?
Germ cells
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What age is testicular torsion most common?
11-30 years
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What side is more commonly affected in testicular torsion?
Left
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Causes Testicular Torsion
Teens/Neonates : Bell-clapper deformity When testis isn't fixed fully to scrotum ∴ can move freely on axis Adults - testicular malignancy
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RF Testicular Torsion
FHx - Genetics
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Signs / Symptoms Testicular Torsion
Sudden onset testicular pain! Makes walking difficult Comes on during sports and physical activity Inflamed & tender testicle Abdo pain N+V Unilateral pain High riding testicle Absent cremasteric reflex NEG Prehn's sign
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DDx Testicular torsion
Epididymo-Orchitis Tumour, trauma, acute hydrocele Idiopathic scrotal oedema
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Ix Testicular Torsion
Emergency!!!! QUICK!! Don't delay surgical exploration! **Doppler US** - shows decreased blood flow!! Urinalysis - to exclude infection and epididymis
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Tx Testicular Torsion
Surgery within 6 hours!!!! Salvage rate = 90-100% but if > 24 hours = 1-10% ! Orchidectomy and bilateral fixation
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What is a positive Prehn's sign?
When lifting testicle lessens pain / provides relief
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When is Prehn's sign POSITIVE?
Epididymitis NEG IN TESTICULAR TORSION
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Typical case of Post-Streptococcus Glomerulonephritis
Child had a strep infection (pharyngitis, cellulitis, tonsilitis) 1-3 weeks later, they present with haematuria, oliguria, proteinuria etc
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Cause Post-Strep Glomerulonephritis
Lancefield Group A beta haemolytic streptococcus e.g. STREP PYOGENS
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Pathophysiology Post-Strep Glomerulonephritis
Bacterial antigens are deposited in glomerulus TYPE III HYPERSENSITIVITY REACTION
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Ix Post-Strep Glomerulonephritis
Urine dipstick and microscopy - RED CLAST CELLS Proteinuria, ↓ GFR etc Combined with history of previous Strep infection
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Cause IgA Nephropathy
Abnormal IgA1
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Pathophysiology IgA Nephropathy
Abnormal IgA is deposited in the mesangium Kidney is then attacked by anti-glycan antibodies ∴ complement pathway is activated Type III HYPERSENSITIVTY REACTION !! (inflam occurs at site of deposition, not site of formation)
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Signs / Symptoms IgA Nephropathy
Usually in childhood, after a GI or resp infection Nephritis Sx + Uraemia - anorexia, rash, lethargy etc
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How does Henloch-Schonlein Purpura present?
Similar to IgA Nephropathy But also purpuric rash on legs, joint pain
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Ix IgA Nephropathy
History - to find cause Measure eGFR, proteinuria, serum urea etc **GS!!!** Biopsy!!! Diffuse mesangial IgA deposits Sub-endothelial and sub-epithelial deposits Light microscopy - mesangial proliferation Urine dipstick
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Tx IgA Nephropathy
Supportive !! Control BP (ACEi, ARBs etc) lower cholesterol etc Immunosuppression (to avoid immune complexes forming) Induction = steroids + cyclophosphamide Remission = steroids + azathioprine
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What is IgA Nephropathy also known as?
Berger disease
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What is Goodpasture's Syndrome?
Autoimmune condition that attacks the type **IV** collagen in the basement membrane of lungs and kidney
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What type of hypersensitivity reaction is Goodpasture's syndrome?
Type 2 - anti GBM antibodies
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Signs / Symptoms Goodpasture's syndrome
HAEMOPTYSIS + HAEMATURIA SOB + some resp signs ! Nephritic symptoms Rapid progressive kidney failure
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Ix Goodpasture's Syndrome
**GS!!** - anti-GBM and renal biopsy
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Tx Goodpasture's syndrome
Plasma exchange - to remove antibodies Steroids Cyclophosphamide
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What is testicular appendage torsion?
NOT a medical emergency (unlike appendage torsion) Twisting of the appendix of the testicle i think idk dont quote me on this look it up a bit more pls
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Types of Prostate Cancer
Adenocarcinomas - MC! arise from periph zone Transitional cell carcinomas - arise from transitional zone Small cell prostate cancer
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How can prostate cancer spread?
Local - to seminal vesicles, bladder, rectum Via Lymph Haematogenously - to bone, brain, liver, lung CAN METASTASISE - to bone, lung, adjacent structures
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RF Prostate Cancer
Age Obesity FHx - BRCA1, BRCA2 (HOXB13 predisposition gene) High fat, low fibre diet ↑ Testosterone Black skin tone
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Screening Prostate Cancer
Prostate specific antigen But not always reliable
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Signs / Symptoms Prostate Cancer
Asymptomatic at first LUTS symptoms - same as BPH **FUUN SHIPP** Haematuria Cancer B Sx - weight loss, anorexia, night sweats Anaemia Bone pain (metastases)
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Why is prostate cancer usually asymptomatic at first?
Bc most prostate malignancies arise from peripheral zone Which is far from urethra ∴ can grow large before starts to present
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DDx Prostate cancer
BPH Bladder cancer Prostatitis
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Ix Prostate Cancer
DRE - hard, irregular PSA - non specific Trans-urethral US scan (TRUSS) Prostate biopsy! - Gleason grading Imaging Bone Scan TMN staging!
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Describe how one would use Gleason grading
Histological grades for 2 most common patterns (1-5) Then add up together Higher score = ↑ aggressive Generally, 6 = low grade, 7 = mid grade 8 - 10 = high grade, v aggressive cancer
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Describe TNM staging for prostate cancer
T1 - no palpable tumour on DRE T2 - palpable tumour but confined to prostate T3 - palpable tumour that extends past prostate (There is T3a and T3b, also T4 = metastases) N stage - Nodes -> MRI scan, CT scan M stage - Metastases -> bone scan
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Tx Prostate Cancer
If low risk, watchful waiting Localised radical Tx = radical prostatectomy or radical radiotherapy Hormone therapy - slows tumour growth > GnRH agonist e.g. SC Goserelin, Leuprorelin > Androgen receptor blockers e.g. Bicalutamide If metastatic - Bilateral surgical orchidectomy (castration) or palliative care :( Treat hypercalcaemia with diuretics Bisphophonates - zolendronic acid
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Why are hormone therapies esp used in prostate cancer?
Bc prostate malignancies are the malignancy most sensitive to hormone therapy
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How does Wilm's tumour present?
IN CHILDREN Abdo mass Haematuria
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What is the major abdo malignancy in children?
Wilm's tumour
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Wilm's tumour is a malignancy of ?
Renal tubules and mesenchymal cells
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When might PSA be raised?
BMI < 25 Black Africans Taller men Recent ejaculation Recent rectal examination Prostatitis BPH Prostate cancer UTI
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Indications for dialysis
**AEIOU** **A**cidosis - pH < 7.2 OR bicarbonate < 10mmol **E**lectrolyte imbalance - persistent hyperkalaemia 7mmol/L **I**ntoxication - BLAST (Barbiturates, Lithium, Alcohol, Salicylates, Theophylline) **O**edema (refractory pulmonary oedema) **U**raemia - encephalopathy or pericarditis, urea > 40
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Would the eGFR increase or decrease with Post-Strep glomerulonephritis? Why?
DECREASE bc deposition of immune complexes ∴ ↓ ability to filter toxins ∴ ↓ eGFR
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What drugs should be stopped in AKI?
_Stop the **DAMN** drugs_ **D**iuretics & digoxin **A**CEi / ARBs **M**etformin **N**SAIDs
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Big diff between IgA Nephropathy and Post-Strep
TIMELINE Post-strep is 1-2 weeks later IgA is days i think?
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Quick! Patho of NephrOtic syndrome?
Usually issue w filtration barrier - podocytes ∴ protein leaks into urine
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Causes Nephrotic Syndrome
**MFM** **M**inimal change disease **F**ocal Segmental Glomerulosclerosis *M**embranous Nephropathy
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General presentation of Nephrotic syndrome
PROTEINURIA > 3.5g/day Hypoalbuminaemia Oedema Hyperlipidaemia
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General presentation of Nephritic syndrome
HAEMATURIA ↓GFR Oliguria Proteinuria **<** 2g/day Oedema HTN
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Pathophysiology Minimal Change disease
Cytokines attack foot processes of podocytes ∴ Shrinkage/Blunting of podocytes ∴ Protein leakage
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What Nephrotic syndrome is most common in children?
MINIMAL CHANGE DISEASE
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Ix Minimal Change Disease
Renal biopsy Electron microscopy
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Tx Minimal Change Disease
Corticosteroids +/- Cyclophosphamide or Cyclosporine (if freq recurring)
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Pathophysiology Focal Segmental Glomerulosclerosis
Podocytes are damaged (how?? no clue) ∴ proteins + lipids go into urine Overtime, protein + lipids are trapped in glomerulus ∴ Hyalinosis (glassy appearance on histology) ∴ sclerosis
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RF Focal Segmental Glomerulosclerosis
African-American!!!
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2º Cause Focal Segmental Glomerulosclerosis
SCD HIV Heroin abuse Kidney hypoperfusion
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Ix Focal Segmental Glomerulosclerosis
Renal biopsy & Histology - hyalinosis, effacement of foot processes & segmental sclerosis Immunofluorescence - non-spec deposits of IgM and complement
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Tx Focal Segmental Glomerulosclerosis
Steroids
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Pathophysiology Membranous Glomerulonephritis
IgG deposition in sub-epithelial surgace ∴ thickening of glomerular capillary wall ∴ damaged glomerulus ∴ protein leaks out
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1º cause of Membranous Glomerulonephritis
PLA2R antigen targets glomerular podocyte membrane
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2º Membranous Glomerulonephritis
Autoimmune conditions Viruses Drugs Tumours
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Ix Membranous Glomerulonephritis
Renal biopsy Electron microscopy - thickened capillaries and GBM (spike and dome pattern!) Effacement of foot processes PLA2R antigen
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Tx Membranous Glomerulonephritis
Supportive - oedema, HTN, proteinuria etc Immunosuppression - steroids, cyclophosphamide RAAS blockade? Anti-Coag
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Signs / Symptoms SLE Nephropathy
Rash Arthralgia Kidney failure Pericarditis Pneumonia
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Ix SLE Nephropathy
Anti-Nucelar antibody pos Double stranded DNA pos Low complement C3 + C4
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Tx SLE Nephropathy
Immunosuppresion - Steroids Cyclophosphamide Rituximab