Renal surg Flashcards
Patient that has undergone several PCIs for CAD and also right carotid endarterectomy (diffuse atherosclerosis) plus episodes of pulmonary Edema where can’t lie flat and fluid overloaded and severe hypertension. But normal ejection fraction most likely has what condition? First step in management?
Renal artery stenosis
Renal ultrasound!! With Doppler
Associated findings are CKD and hypokalemia due to Raas activation
Medications used to aid passage of kidney stones between 5mm and less than or equal to 10mm
Tamsulosin!! And other alpha 1 antagonists!
Note less than 5 = expectant with fluid and pain control
Greater than 10 = lithotripsy/stent placement
Bladder rupture first line investigation?
Signs
Retrograde cystography
Hematuria, inability to void, ascites due to urine
CKD predisposes to secondary hyperparathyroidsm and can cause osteofibrosis cystica, if this is expected, check PTH levels
What type of kidney stone is associated with Chrons disease and what is the mechanism?
Calcium oxalate - increased enteric absorption of calcium oxalate
Renal stenosis can cause abdominal bruit and shrinking of kidney on affected size. Hypoperfusion cause increased renin and aldosterone on this side. On normal kidney side hyperperfusion on this side causes decreased renin secretion.
Blunt renal trauma diagnosed with?
CT AB
Mechanism of kidney stone formation i a patient with recurrent UTIs?
Increased urine ammonia production!
Struvite or magnesium ammonium phosphate stones
Management of simple renal cyst?
Signs of a malignant renal cyst.
Reassurance with no follow up needed!!!
Worried about malignancy if:
- thick irregular wall
- multilocular and septate
- contrast enhancement on CT/MRI
A normal anion gap metabolic acidosis is due to loss of bicarbonate. Give examples.
An elevated anion gap metabolic acidosis is due to accumulation of acidic compounds. Give examples.
Normal Anion gap metabolic acidosis
- severe diarrhoea, RTA, excess saline infusion, intestinal (high ileostomy output, fistula) and pancreatic fistula/pancreatic leak. CAI and MRA diuretics
Elevated anion gap
- lactic acidosis, DKA, kidney failure uraemia, methanol, ethylene glycol, salicylate toxicity.
Type of metabolic acidosis in pancreatic leak?
Non anion gap.
Bicarbonate is leaking out and decreased
Note - CO2 would be decreased due to compensatory respiratory alkalosis
Mechanism for high blood pressure in PCKD?
Increased renin activity!
Due to increased renal ischemia as cyst expands
Thus best treated with ace inhibitors
Flank pain, hematuria, enlarged kidney with no signs of hydronephrosis in a patient with a history of pancreatic cancer on chemo. Most likely diagnosis?
Management?
Other risk factors?
Renal vein thrombosis!!
CT/Mr angiography or renal
venography
Hypercoagulability is a risk factor - Malignancy!!, nephrotic syndrome, thrombophilias, OCP
Trauma/ external compression
Not nephrolithiasis as won’t cause an enlarged kidney without hydronephrosis. And pain would be colicky
Not renal infarction as history of cardioembolic disease would be present eg a fib. Incomplete or wedge shaped area of infarction would be seen on imaging and acute rise in BP due to renin common
59 YO man with dysuria urinary urgency and frequency. Suprapubic pain. Smoothly enlarged prostate no tenderness. Urinalysis shows moderate blood (hematuria)
Most likely diagnosis?
Bladder cancer!
Voiding symptoms + suprapubic OR flank pain + hematuria common + also hydronephrosis unliaterally or bilaterally due to obstructon by bladder!!.
Enlarged prostate normal in elderly man
hematuria with no evidence of infection, glomerulonephritis (RBC casts) or nephrolithiasis and over 40 = investigation for bladder cancer.
Renal transplant patient now having refractory hypertension. And declining renal function. Most likely diagnosis? First step in management?
Has developed renal artery stenosis!!
Renal Doppler ultrasonography!! (Renovascukar imaging)
Agitation and suprapubic tenderness 2 days following hip fracture. 82 year old with history of BPH. Most likely diagnosis? First line investigation?
Acute urinary retention
Bladder ultrasound!! Will show greater than 300ml of urine. - insert Foley catheter!
Abdominal surgery, pelvic surgery and joint arthroplasty are risk factors
Not bladder rupture as likely to be hematuria
29 YO decreased force of urinary stream, incomplete bladder emptying. post voidal residual volume high. nothing else of note. most likely diagnosis?
urethral stricture!! -> diagnosed using urethrography or cystourethroscopy. urethral dilation or surgical urethroplasty for treatmet
RF = male, trauma eg catheterization, radiotherapy
complications = acute retention, recurrent UTIs, badder stones
not abnormal detrusor overactivity -> this would cause urinary frequency, urgency, nocturia, incontinence
name an indication for urgent urological consultation for nephrolithiasis. management?
fevers and chills!!
points to infection and rapid progression to severe sepsis and shock can occur
IV antibiotics + urinary tract decompression!! (stent or nephrostomy)
other indications:
- refractory pain and vomiting, not just the presence of these
- anuria
- AKI
polycythemia with high EPO levels (aka secondary polycythemia). no evidence of hypoxia. first step to diagnose?
CT scan of abdomen!!! -> most likely a renal cell carcinoma
*secondary polycythemia usually due to renal or liver tumours producing EPO or chronic hypoxia (cardiopulmonary disease, Obstructive sleep apnea, high altitude)
*NOT bone marrow biopsy as that is done for primary polycythemia which has low EPO levels
few days post pituitary surgery. nausea malaise and intermittent dizziness. normal serum cortisol. best next step in diagnosis?
serum electrolytes!!
risk of cranial diabetes insipidus -> now known as arginine vasopressin deficiency and also SIADH post pituitary surgery so electrolytes to check for both!!!
AVP-D = polyuria, slightly elevated sodium
SIADH = normal/low urine output due to renal water retention with hyponatremia
*you can also check for secondary adrenal insuffiency characterized by low ACTH but patients cortisol levels were normal making this unlikely
blood at the urethral meatus and a high riding prostate, (inability to void) is concerning for posterior urethral injury. first line investigation?
retrograde urethrography
(dye through urethra and take xray pictures, xtravasation of contrast from urethra = diagnostic of urethral injury)
hemangioblastomas in the retina, cns and renal cysts. most likely diagnosis?
VHL syndrome
Post operative urinary retention is common. what are the symptoms?
suprapubic dysfunction and fullness, hypertension, tachycardia.
type of surgery also rf = eg hernia repair, joint arthroplasty
19 yo woman with history of headaches, hypertension pointing towards renal artery stenosis, and bruits heard behind left ear. most likely diagnosis?
fibromuscular dysplasia!!11
- Internal carotid artery stenosis = headaches, tinnitus, TIA so focal weakness vision loss /stroke, neck pain
- renal artery stenosis - flank pain, htn
abdominal bruit, subauricular bruit
treat with ace/arbs
