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
