1. Relaxation of internal sphincter with increased volume and reduced SNS input 2. Voluntary relaxation of external sphincter 3. Suprapontine and pontine centres withdraw inhibition to detrusor muscle 4. Detrusor contracts 5. Voluntary contraction of abdominal muscles

Renal review Flashcards by Rosie Brewster

What innervates the detrusor muscle?

Pelvic nerve (parasympathetic, S2-4 –> Ach on muscarinic receptors causes contraction)

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What innervates the internal sphincter?

Hypogastric nerve (sympathetic, T10-L2) –> acts on alpha receptor

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Effects of hypogastric nerve?

Contraction of internal sphincter (a receptors)

Relaxation of bladder wall (b2 receptors)

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Potential effect of a-inhibitors (eg. prazosin)

Incontinence

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What innervates the external urethral sphincter?

Pudendal nerve (somatic, S2-4)

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Voiding physiology

Relaxation of internal sphincter with increased volume and reduced SNS input
Voluntary relaxation of external sphincter
Suprapontine and pontine centres withdraw inhibition to detrusor muscle
Detrusor contracts
Voluntary contraction of abdominal muscles

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PNS involvement in micturition

Bladder contraction

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SNS involvement in micturition

Internal sphincter contraction at low volumes
Maintains tone during filling
Innervates blood vessels

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Micturition reflex

Bladder fills –> stimulates stretch receptors –> excites PNS in bladder and inhibits motor neuron to external sphincter (overridden by voluntary control) –> bladder contraction and relaxation of external sphincter –> urination

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Common types of kidney stones

Calcium oxalate 75-80%
Uric acid 15%
Cystine <5%

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Which types of kidney stones are radiopaque/can be seen on X-ray?

Calcium oxalate

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Conservative Mx of kidney stones

Analgesia (NSAIDs –> diclofenac or indomethacin per rectum)

Wait for stone to pass (if pain controlled and no sepsis)

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Stone prevention

Diet - normal calcium, high fibre, low salt, low protein

Increased fluid intake

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OAB conservative Mx

Fluid intake, caffeine, alcohol
Weight loss
Stop smoking
Pelvic floor (30/day for 3 months)
Bladder retraining

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OAB drugs

Antimuscarinics –> side effects include dry mouth, dry eyes, constipation
B3-adrenergic agonist –> can increase BP

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SUI conservative Mx

Weight loss
Stop smoking
Pelvic floor (30/day for 3 months)

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Acute urinary retention Mx

Catheterization
A blockers (Tamsulosin) for males
Treatment of cause --> UTI, constipation, BPH, neurological cause, medication related

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BPH conservative Mx

Fluid intake
Stop smoking
Limit caffeine, alcohol
Timing of diuretics
Restriction of fluids at night
Bladder retraining
Reassurance

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BPH medical Rx

Alpha blockers (tamsulosin)
5-alpha reductase inhibitors
Combination of both

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Alpha blockers mechanism

Smooth muscle relaxation in bladder neck and prostate therefore improved flow of urine

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5-alpha reductase inhibitor mechanism

Blocks testosterone –> DHT

Prostate no longer grows and may shrink

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BPH surgical gold standard

TURP

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What type of genetic abnormality is congenital cystinosis?

Autosomal recessive defect

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Immunosuppressants post transplant

Tacrolimus (monitor levels)
Presnisone
Mycophenolate
Cyclosporin

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Nephrotoxins

Aminoglycosides (gentamicin) ACEi/NSAIDs/diuretic Contrast dyes Myoglobin (rhabdomyolysis, statins)

Indications for dialysis

``` Acidosis <7.1 Electrolyte (>6 K+, elevated T wave ECG) Ingestion Overload Uremic ```

cANCA

Wegener granulomatosis

pANCA

Not Wegeners (Microscopic polyangitis, Churg Strauss syndrome)

anti-GBM

Goodpastures

ANA

Negative excludes SLE

Infection risks post transplant

CMV Urosepsis Influenza EBV negative recipient with EBV donor

UTI rx for non-pregnant women

Trimethoprim | Nitrofurantoin

UTI rx for pregnant women

Cefalexin

Hyperacute transplant rejection

Minutes to hours Mediated by pre-existing antibodies to ABO and MHC antigens Unresponsive to immunosuppressive treatment

Acute transplant rejection

1-3 weeks post-transplant Caused by T cells Immunosuppressive therapy may help

Chronic rejection

Months or years post-transplant Hard to detect Cell-mediated and Ab-mediated Immunosuppressive therapy often fails

Side effect of statins

Myalgia --> look at LFTs on r/v

Are creatinine levels a reliable indicator of AKI?

No - they only increase 48hrs post injury

What results from prolonged pre-renal AKI?

Acute tubular necrosis

What 4 structures can be damaged in intra-renal AKI?

Tubules Glomerulus Vascular structures Interstitial tissue

Causes of ATN

Hypoperfusion | Nephrotoxins

Pre-renal AKI Rx

Fluid resus Blood transfusion Stop ACE-i/NSAIDs

Intra-renal AKI Rx

Dialysis Nutrition Avoid further nephrotoxins Review

Post-renal AKI Rx

Bladder catheter Ureteric stents Percutaneous nephrostomy

RTA type I

Distal tubules Can't secrete H+ Stones

RTA type II

Proximal tubules Can't absorb HCO3 Bone problems

RTA type IV

Low aldosterone Increased K+ Decreased Na+

Normal anion gap

Base loss: diarrhoea, RTA, CA inhibitor

Increased anion gap

Acid load: renal failure, toxins, DKA, shock

RCC risk factors

Men 50-70yo Smoking Obesity

TCC risk factors

Phenacetin Smoking Aniline dyes Cyclophosphamide

CKD risk factors

``` Diabetes Hypertension Established CVD Family hx of kidney failure Obesity Smoker Aboriginal or Torres Strait Islander >30 years Hx of AKI ```

CKD Screen

Blood test - eGFR Urine test - albumin/creatinine ratio BP check

Albuminuria BP goal

<130/80

CKD BP goal

<140/90

BP Mx in CKD

Lifestyle modifications | ACE-i or ARB

Albuminuria mx in CKD

ACE-i or ARB

CKD hyperparathyroidism pathway

CKD --> PO4 retention --> increased FGF23 --> decreased calcitriol --> decreased serum Ca, increased serum PO4 --> 2˚ hyperparathyroidism

Polycystic KD I

younger presentation, faster progression

Polycystic KD II

older presentation, slower progression

PKD renal manifestations

``` Impaired urinary concentration Hypertension (precedes GFR decline) Proteinuria Cyst haemorrhage UTI Nephrolithiasis ```

PKD extra-renal manifestations

Liver cysts Intracranial aneurysms Mitral valve prolapse Seminal vesical cysts

PKD Mx

Manage HTN and proteinuria | ACE-i

Alport syndrome

X-linked basement membrane disorder arising from mutations in genes coding for type IV collagen proteins

AD Tubulointerstitial disease

Suspect in teenage pt with progressive kidney disease with bland urinary sediment in the setting of strong family history

Arthralgia / fever / weight loss with loss of kidney function?

SLE, ANCA-associated vasculitis

Nosebleeds / hearing loss with loss of kidney function?

ANCA-associated vasculitis

Petechial rash with loss of kidney function?

ANCA-associated vasculitis, IgA vasculitis (Henoch-Schönlein purpura), cryoglobulinaemia

Haemoptysis with loss of kidney function?

Anti-GBM disease (Goodpastures), ANCA-associated vasculitis

``` Which GN? Peak incidence is young men Haemoptysis Active urine sediment Usually abrupt presentation ```

Anti-GBM disease (Goodpastures disease)

Which GN? Haematuria, proteinuria, renal impairment Fever, malaise, anorexia, weight loss, myalgias, arthralgias Purpura most common on legs and occurs in ‘crops

ANCA-associated vasculitis

Which GN? Peak incidence in 20-40’s Male predominance 2:1 Most common cause of GN in Australia

IgA nephropathy

``` Which GN? Nephrotic 30% adults with NS 80-90% >30yrs may have microscopic but not macroscopic haematuria HTN, CKD ```

Membranous GN

``` Which GN? 35% of nephrotic syndrome in adults more likely to have mild haematuria, hypertension and impaired renal function afroamericans with HIV ```

FSGS

Which GN? usually sudden onset usually normal kidney function commonest cause NS children (80%)

Minimal change disease

How to control proteinuria?

ACE-i Non-dihydropyridine CCBs Reduce salt intake Reduce protein intake

MCD Rx

Steroids

Primary FSGS Rx

Corticosteroids | Immunosuppressives

Secondary FSGS Rx

Manage BP | ACE-is and ATRA

Membranous nephropathy Rx

Immunosuppression

IgA nephropathy Rx

Controversial - ACEis, corticosteroids, fish oil

ANCA - associated disease Rx

Immunosuppression

Goodpastures Rx

Plasma exchange Immunosuppression Corticosteroids and cyclophosphamide

Alpha blockers side effects

postural hypotension and retrograde ejaculation