Renal Medicine and Urology Flashcards
Define Microalbuminuria
Define Proteinuria
Microalbuminuria: Protein in urine >2.5mg/mmol in males and >3.5 in females
Proteinuria: Protein in urine >30mg/mmol
ACR should be used over PCR in almost all cases. In what cases would you prefer PCR?
1) High levels of proteinuria
2) Pregnant women
3) Children (<18)
What are the 2 main ways to assess renal function
1) Urine ACR/PCR
2) eGFR/GFR
How is eGFR measured? Give 3 methods
Creatinine:
1) Cockcroft Gault Formula (CG)
2) CKD EPI Formula
Cystatin C
eGFR is not reliable in certain cases. Give 2 cases
Give 2 cases where eGFR may be each over and underestimated.
Unreliable if:
Rapidly changing
AKI
Drugs (Trimethoprim)
Overestimated if
Elderly (use CG formula)
Muscle wasting disorder e.g. Myasthenia Gravis (use CG)
Underestimated if
High muscle mass (CG)
Muscle wasting disorder (CG)
High protein diet
How is CKD diagnosed?
CKD is diagnosed if eGFR <45 (3b)on 2 readings, 90 days apart
or eGFR 45-59 and ACR >3/albumin conc. >30
or eGFR 60-90 + ACR>30 or Albumin conc. >300
What eGFR is an indication for RRT
<10 (oxford)
What eGFR would indicate end-stage renal failure?
eGFR<15
How would you grade/classify CKD? Go through it
Based on eGFR
G1 >90 -> Normal
G2 60-90 -> Does not indicate CKD unless ACR >30/albumin conc >300
G3a 45-59 does not indicate CKD unless ACR>3/Albumin conc. >30
G3b 30-44 - CKD if 2 readings, 90 days apart
G4 15-29 - Referral for renal
G5 <15 - Kidney failure
Define CKD
Slow decline in renal function over months/years defined by increased ACR and reduced eGFR
Give 8 causes of CKD
1) DM
2) HTN/CVD
3) Urinary tract obstruction
4) Hypercalcaemia
5) Nephrotoxic medication (Furosemide, Gentamicin, platinum…)
6) Glomerulonephritis
7) ADPKD (polycystic kidneys)
8) Interstitial nephritis
9) Amyloid
10) SLE
11) AKI
Same answer for RF of CKD
When should a patient presenting with reduced renal function be referred for Renal or urology?
eGFR<30 (G4)
Urology: outflow obstruction, reduced urine output
What are the options for renal replacement therapy?
1) Haemodialysis
2) Peritoneal dialysis
3) Renal transplant (best)
Haemodialysis can be performed at home or at the dialysis unit. How often should this be performed?
How is it performed?
What are the main complications?
Haemodialysis involves ultrafiltration through a semi-permeable membrane via an AV fistula 2-3 times per week.
Complications:
1) Fluid shift
2) Pulmonary oedema
3-5) AV fistula: AVF thrombosis, line sepsis, Steal syndrome (Ischaemia of the hand due to AVF)
Peritoneal dialysis is performed at home=> they are not tied to a dialysis machine. How often should this be performed?
How is it performed?
What are the main complications?
Permanent Tenchkoff catheter is inserted into the peritoneum. In peritoneal dialysis, the peritoneum acts as a filer. This needs to be changed 4x/day or 8-10 hours overnight
Complications:
1) Peritonitis
2) Abdominal wall hernia
3) Line sepsis
4) Line blockage
How would you manage CKD?
1) Treat reversible causes
a) Stop/avoid/reduce dosages of nephrotoxic drugs or those that are dependent on renal elimination
b) Control DM (glycemic control)
c) Treat BP (ACEi/ARBS or CCB/Thiazide)
d) Annual CVD check
e) Folic acid and B12 vitamin supplementation
2) RRT: Refer when eGFR<30 but commence RRT at <10
a) Haemodialysis
b) Peritoneal dialysis
c) Renal transplant
When a patient goes through kidney transplantation, what medications should they be put on?
where is the kidney likely sited?
Immunosuppressants (Tacrolimus or ciclosporin) or steroids (prednisolone)
Typically sited at the right iliac fossa
Give 5 RF for nephrolithiasis
1) Family history of nephrolithiasis, cystinuria, hypoxaluria
2) Anatomical/congenital abnormal kidney (Medullary sponge, Horseshoe kidney)
3) Dehydration
4) Immobilisation
5) Metabolic bone disease (Hypercalcemia, cystinuria, renal tubular acidosis)
6) Chronic/recurrent UTI
7) Drugs: Allopurinol (gout), Acetazolamide, loop diuretic (furosemide), Thiazides, Calcium, Vitamin supplements
Define Strangury
Symptoms associated with UTI including urgency, frequency, dysuria, and incomplete emptying
Define renal colic
Severe wavy pain of increasing severity
How does Nephrolithiasis present?
1) Renal colic => Severe wavy pain of increasing severity.
+ Abrupt onset flank pain radiating to the abdomen
Radiates to the groin as it progresses down the ureter
2) Recurrent UTIs
3) Urinary retention
You are asked to examine a patient with renal colic. What will you be looking for?
Inspection: Unable to sit still, pale, clammy (sweaty)
Palpation: Loin, flank tenderness
How would you differentiate peritonitis from renal colic on exam?
Peritonitis will remain still to avoid pain
Renal colic will constantly be shifting position to help ease the pain
A patient presents with acute onset abdominal pain. They appear clammy. Give 6 differentials.
What investigations will you perform?
Nephrolithiasis
Pyelonephritis
Cholecystitis
Pancreatitis
Appendicitis
Diverticulitis
Peritonitis
Bowel obstruction
Strangulated hernia
Testicular torsion
Investigations:
Bedside: Urine dipstick, vitals
Bloods: FBC, U&E, Creatinine, eGFR, Ca2+, PO4, LFTs (Why? Alk phos to rule out obstructive jaundice via gallstones), uric acid
Urine: Midstream culture and sensitivity, RBC, Urine cysteine “spot test”, ACR, Ca2+, PO4, Uric acid, Na
Imaging: X-ray kidney ureter, bladder + Renal tract US
give 4 types of Renal stones
1) Calcium Oxalate
2) Calcium phosphate
3) Staghorn (triple phosphate a/w proteus)
4) Urate (caused by allopurinol and alcohol)
5) Cysteine (metabolic)
6) Xanthine (metabolic)
What lab test is an indication that the stone is Calcium Oxolate?
Same for calcium phosphate
Hypercalciuria => Calcium oxalate
Hypercalcemia => Calcium Phosphate
Which stones are radio-opaque and which are radio-transluscent?
All are radioopaque except Xanthine and Urate crystals
How would you manage a patient with suspected Renal stones?
1) Stones typically pass spontaneously => only treat analgesia (IM Diclofenac - NSAID-)
2) Admit if fever, oliguria, symptoms >24 hr, or pregnant
What would you advise the patient as preventative measures to the recurrence of kidney stoes?
1) Increase fluid intake (8-10 cups)
2) increase intake of fruits and veg
3) weight loss
4) Animal protein
5) reduced salt intake
An 18 year old patient presents with widespread stones distributed throughout the body. What are your top 2 diagnoses
hyperoxaluria Type 1
Cystinuria
80% of those with Hyperoxaluria have chronic renal failure. It is divided into type 1 and 2, 1 being the more severe.
Type 1: Calcium oxalate stones widely distributed throughout the body, presents as nephrocalcaemia in children
Type 2: More benign and also rarer. Nephrocalcinosis but no CKD
Cysteinuria is also familial and presents early.
Give 10 causes of Haematuria
Infection: !UTI, Urethritis, !bacterial prostatitis, TB, schistosomiasis
Tumour: Bladder, prostate, renal, endometrial Ca
Inflammation: Glomerulonephritis, HSP (vasculitis with IgA deposition), IgA nephropathy, Good pasture’s syndrome
Structural: !Stones (Renal, ureter, bladder), !!!Cysts (ADPKD), !!!BPH, Congenital
Trauma: Sexual intercourse, foreign body, !!Iatrogenic (surgery/catheter)
Drugs: Warfarin, NSAIDs
Coagulation disorders
Any presence of blood on urine dipstick is significant, requiring investigation. What investigations should be done in the presence of haematuria?
FBC
BP
Renal function: ACR and eGFR
Abdominal palpation
Urine for M, C&S
PSA for males
Pelvic USS for female
Renal USS for recurrent haematuria
What is Urine M, C&S
Urine microscopy, culture & sensitivity
Beatroot ingestion and hyperbilirubinemia in obstructive jaundice may lead to discolouration of the urine. What may cause a false +ve for blood on urine dipstick? (2)
Free Hb or myoglobin
A patient presents with raised WCC but no nitrites or blood. Everything else is normal on the dipstick. What is this called?
Give 5 causes that can lead to this
Sterile Pyuria
Causes:
1) Appendicitis
2) Calculi
3) Prostatitis
4) Bladder tumour
5) ADPKD
6) Interstitial nephritis
7) Interstitial cystitis
8) Renal TB
What is interstitial nephritis?
kidney condition characterized by inflammation of the spaces between the kidney tubules.
What is interstitial cystitis?
How is it different from cystitis?
Typically presents in middle-aged women
Inflammation of the tissues lining the bladder (interstitial) leading to fibrosis of the bladder wall => incomplete emptying => stasis and increased risk of UTI.
Presents the same way as cystitis. There is no tx as it is just “ Bladder pain syndrome”. Refer to urology if needed
What are the 2 main types of bladder cancer?
Transitional cell Ca
Squamous cell Ca
What are some RFs for Bladder cancer?
Smoking
Urinary stasis
Chronic UTI
Aromatic amine exposure (due to textile industry or rubber)
Schistosomiasis
How does bladder cancer present?
Haematuria,
pelvic/loin pain,
!recurrent UTI,
!bladder outflow obstruction,
increased frequency, anemia
+ B symptoms.
What investigations would you perform for bladder Ca?
Urine Dipstick for Haematuria => do those investigations
FBC
BP
Renal function: ACR and eGFR
Abdominal palpation
Urine for M, C&S
PSA for males
Pelvic USS for female
Renal, ureter, bladder USS for recurrent haematuria
How would you manage Bladder Ca in primary care?
Management in secondary care is dependent on the stage of the Ca. Go through it with tx
Refer to Urology
T1 = Confined to mucosa/submucosa => TURBT +/- Single intravesical chemotherapy
T2 = invasion into connective tissue around bladder => TURBT +/- Radiotherapy
T3 = Invasion through muscle and fat => Radical cystectomy +/- Radiotherapy
T4 = Beyond Bladder => TURBT for sx relief + Palliative radio and chemo
What is TURBT
Transurethral resection of bladder tumour
Renal Cell Carcinoma/Hypernephroma is the most common type of renal cancer accounting for >90% of renal cancers. What type of cancer is that?
How would it present?
Clear cell adenocarcinoma of the renal tubular epithelium
Presentaion: Haematuria, loin pain, anemia, left varicocele + B symptoms
What is the most common causative organism for a UTI?
Give 2 other examples
E.coli (70%)
Proteus
Pseudomonas
Staph
Strep
What are the RF for a UTI?
1) Female
2) DM
3) Stones
4) Pregnancy
5)Dehydration
6) Bladder Ca
7) Urinary stasis (from stones or obstruction due to anatomical causes)
8) GU instrumentation (catheter)
9) Menopause (bladder atrophy, increased pH)
10) Sexual intercourse
11) Delayed micturition
A patient presents with Dysuria and Urgency. Give 5 ddx
1) UTI
2) Urethral syndrome (pain syndrome)
3) Inflammation (interstitial cystitis, radiation-induced)
4) Intravesical lesion (tumour, stone, iatrogenic)
5) Atrophy -> Menopause
A patient presents with Urinary frequency, Give 10 ddx
1) Detrusor muscle instability (neuromuscular disorder, radiation-induced)
2) Neurogenic bladder (MS)
3) Enlarged prostate
4) Pregnancy
5) DM
6) Diuretics
7) Excessive fluid intake/habit
+ ddx of dysuria and urgency
1) UTI (cystitis and pyelonephritis)
2) Urethral syndrome (pain syndrome)
3) Inflammation (interstitial cystitis, radiation-induced)
4) Intravesical lesion (tumour, stone, iatrogenic)
5) Atrophy -> Menopause
How does cystitis present?
Dysuria, urgency, frequency, incomplete emptying
suprapubic pain
Cloudy/offensive urine
Haematuria
How does pyelonephritis present?
Flank pain, rigors, malaise, vomiting +/- haematuria
+ Sx or hx of cystitis
Dysuria, urgency, frequency, incomplete emptying
suprapubic pain
Cloudy/offensive urine
Haematuria
What investigations would you perform for Cystitis initially?
If it has progressed to pyelonephritis what further investigations would you perform?
Urine Dipstick for Haematuria => do those investigations
FBC
BP
Abdominal palpation
Urine for M, C&S
Further inv.
Renal function: ACR and eGFR
PSA for males
Pelvic USS for female
Renal, ureter, bladder USS for recurrent haematuria
What would be considered complicated cystitis?
Male
GU malformation
Immunosuppression
Recurrent UTI
What advice would you give a patient to prevent a UTI?
Hydration
Frequent urination
Double voiding
Voiding after intercourse
How would you manage Cystitis
How would you manage Pyelonephritis?
Paracetamol +/- NSAIDs for pain
Advice:
Hydration
Frequent urination
Double voiding
Voiding after intercourse
Cystitis: + Nitrifurantoin (3/7 if uncomplicated, 7-10/7 if complicated) or trimethoprim (teratogenic)
Pyelonephritis + Ciprofloxacin for 7/7
If a male presenting with recurrent UTIs on a background of BPH, what medication would you prescribe to improve?
Finasteride, Dutasteride
If a post-menopausal woman is presenting with recurrent UTIs, how would you prevent
Advice:
Hydration
Frequent urination
Double voiding
Voiding after intercourse
+ Topical oestrogen
What is urethral syndrome?
What is it associated with
How does it present?
How is this managed?
It is a pain syndrome of unknown cause a/w with the pain and discomfort of the urethra a/w cold, stress, nylon underwear and COCP
Presents with the same sx as cystitis but -ve Dipstick. Dysuria, urgency, frequency,
incomplete emptying, suprapubic pain
Only with advice
Hydration
Frequent urination
Double voiding
Voiding after intercourse
+ Cotton underwear
+ Changing/stopping COCP
