renal tract Flashcards
UTI
- risk factors? 10
- commonest causative organism?
- female
- sexual intercourse
- exposure to spermicide for women (on condoms)
- pregnancy
- menopause
- immunosuppression
- diabetes
- catheter
- abnormality of tract (incl past surgery)
- kidney stones
- E. coli
lower UTI:
- urinary symptoms? 4
- systemic symptoms? 6
- frequency
- urgency
- dysuria
- foul-smelling urine (+ cloudy +/or blood)
- suprapubic ache/pain ( can get back pain in men)
- non-specific malaise
- nausea
- fatigue
- fever
- delirium (esp in elderly)
lower UTI
- tests? 2
- when to do each?
dipstick (leucocytes + nitrates)
- everyone (though if repeated in women just go on history)
midstream urine sample (MSU)
- male
- pregnant
- child
- immunosuppressed
- very ill
- not improving after empirical Abx
lower UTI:
- 1st line treatment? (incl length)
- 1st line treatment in pregnancy?
- when to treat in pregnant women?
- when to treat in catheterised people?
nitrofurantoin
- women = 3 days
- men = 7 days
cefalexin (or other cephalosporin)
screen for + treat any bacteruria in pregnancy (whether symptomatic or not)
catheterised people always have bacteruria - only treat if symptomatic
don’t forget analgesia!!
lower UTI:
- prevention advice? 2
- differential diagnoses? 5
- drink plenty of water
- drink cranberry juice (not if on warfarin)
- urinary TB (esp if MSU is negative)
- STIs (incl chlamydia)
- thrush
- urethral syndrome
- BPH (in men)
pyelonephritis:
- symptoms? (in addition to lower UTI ones) 3
- most common cause?
- lower UTI symptoms
+ fever
+ loin/back pain
+ nausea/vomitting
nb can get oliguria if AKI
ascending from lower UTI (norm e coli)
- same risk factors as lower UTI
pyelonephritis:
- investigations?
- Abx management? 1
- other treatment? 2
- MSU (mainly for sensitivities)
if uncomplicated give oral Abx (ciprofloxacin or co-amoxiclav, cefalexin if pregnant)
- review in 24hrs, if not better admit
if any significant co-morbidity or lots of vomiting etc then admit immediately
- maintain full hydration
- analgesia
follow buffalo if develop sepsis
pyelonephritis differential diagnoses of flank pain:
- renal? 3
- GI? 6
- resp? 3
- ob/gyn? 4
- cardiovascular? 2
nb for DD of urinary symptoms see lower UTI
- kidney stone
- AKI
- renal/peri-renal access
- pancreatitis
- acute cholecystitis
- ischaemic colitis
- perforated gastric ulcer
- appendicitis
- diverticulitis
- basal pneumonia
- pleuritis
- PE
- ectopic pregnancy
- eclampsia
- ovarian torsion
- pelvic inflammatory disease
- ruptured AAA
- MI (esp in diabetics)
basically an acute abdomen
loads of other causes!! differentiate most of them away due to urinary symptoms/Hx of UTI
hydronephrosis:
- causes? 6
- kidney stone
- BPH
- pregnancy
- cancer (bladder, cervical, prostate, colon etc)
- congenital blockage
- scarring (injury or previous surgery)
nb this is present in 1% of foetuses, is often picked up on prenatal scans, many self-resolve
hydronephrosis:
- symptoms? 4
nb these depend on where the blockage is
- loin or back pain (often a dull ache)
- incomplete bladder emptying (also swollen bladder)
- haematuria
- change in urinary patterns (norm less, but can be more if partial obstruction)
nb often get UTIs secondary to hydronephrosis so this may be the initial presentation
hydronephrosis:
- things to look for on clinical exam? 3
- investigations? (incl bloods)
- imaging?
- treatment? 4
- enlarged kidneys
- do PR to assess prostate
- do good palpation to identify any pelvic mass which may be cause of obstruction
- Urine dipstick (looking for blood)
- U+Es
- ultrasound is first line (though CT more sensitive)
- analgesia
- treat underlying cause
- can drain urine direct from kidneys to prevent further damage
- surgery may be required (incl stunting etc)
AKI:
- definition?
- comorbidities that increase risk? 6
- other risk factors? 4
acute decline in renal function over hours/days, shown by:
- rise in createnine
- rise in blod urea
- decrease in urine output
- sepsis
- CKD
- heart failure
- peripheral vascular disease
- chronic liver disease
- diabetes
- age >75
- nephrotoxic drugs (esp newly started)
- poor fluid intake/increased losses
- history of urinary symptoms
nephrotoxic drugs
- causing pre-renal damage? 4
- causing intra-renal damage? 8
- need dose reduction in renal failure to avoid toxicity? 2
PRE-RENAL
- NSAIDs
- ACEi (but good for CKD)
- ARBs
- any drug that causes excess GI loss (diarrhoea/vomiting) -> hypoperfusion
INTRA-RENAL
- x-ray contrast
- diuretics*
- lithium
- methotrexate
- aminoglycosides (gentamicin)
- cephalosporins
- vancomycin
- most Abx*
NEED DOSE REDUCITON
- digoxin
- anti epileptics
basically just check BNF when prescribing for someone with CKD!
nb many infrarenal toxicity is due to inflammation following a hypersensitivity reaction to the drug
nb I may have missed some…
Causes of AKI:
- pre-renal? 4
- intra-renal?
- post renal?
which are commonest causes?
PRE-RENAL (40-70%)
- shock (incl sepsis) - very common
- drug toxicity (NSAIDs + ACEi) - very common
- hypovolemia (secondary to haemorrhage, burns, dehydration)- renal artery stenosis (or emboli)
INTRA-RENAL
- acute tubular necrosis (most common intra-renal cause)
- — ischaemia (secondary to pre renal) - common
- — drug toxicity (gentamicin, methotrexate, contrast etc)
- — toxins (produced by some bacterial sepsis)
- — myoglobinuria (secondary to rhabdomyolysis)
- acute interstitial nephritis
- — drugs, infections, hypercalcaemia, multiple myeloma
- glomerular disease
- — acute glomerulonephritis (often autoimmune, SLE etc)
- vascular disease
- — vasculitis
- — malignant hypertension
- — thrombotic microangiopathies
POST-RENAL
- BPH
- urethral strictures
- tumours (prostate, bladder, gynae)
- stone (need to be bilateral -> AKI)
- retroperitoneal fibrosis
nb obstruction must occur in both kidneys (or in single functioning kidney) for renal failure to occur
AKI:
- symptoms? 5
- signs? 4 (regardless of cause)
- nausea + vomiting
- fatigue
- confusion
- SOB
- abdo pain +/or back ache
(- can get seizures or coma if severe)
nb can present without any symptoms
- OLIGURIA
- peripheral oedema
- dry mucous membranes
- cost-vertebral angle tenderness
- cap refill (may be low if hypo perfused)
nb may find renal bruits if vascular cause
depending on cause can find other findings (e.g. pelvic mass if obstructive etc)
AKI:
- bloods for all? 4
- bloods to consider? 4
- other investigations? 2
- imaging? 1
- treatment? 3
- U&Es (use to find eGFR)
- FBC
- LFTs
- CRP + ESR
- consider ABG
- consider blood culture
- consider autoimmune screen
- consider blood film
- measure urine output
- urine dipstick
- ultrasound is first line (CT if needed)
- stop nephrotoxic drugs
- fluid replacement (if needed)
- treat underlying cause (dialysis if needed)
nb if caused by BPH then catheterise
CKD:
- what conditions predispose to CKD? 7 (commonest 4?)
- other risk factors? 3
- diabetes (common)
- HTN (common)
- Cardiovascular disease
- polycystic kidney disease (common)
- structural renal tract disease, renal calculi or prostatic hypertrophy (common)
- multi system disease with possible kidney involvement (e.g. SLE, myeloma)
- PMH of AKI
- FH of stage 5 CKD or hereditary renal disease
- patients on known nephrotoxic drugs
- increasing age
CKD symptoms:
- neuro? 3
- systemic? 3
- urinary? 2
- skin? 2
- GI tract? 2
- peripheral? 2
nb early stage has no symptoms (but can still be picked up on bloods etc)
- decreased mental sharpness
- insomnia
- headaches
- lethargy (anaemia)
- muscles cramps (low vit D)
- exertion breathlessness (anaemia)
- blood in urine
- nocturia
- abnormally pale (anaemia) or pigmented (dt retained urochromes and hemosiderin deposition) skin
- pruritis
- poor appetite + weight loss
- nausea
- peripheral oedema
- erectile dysfunction
CKD:
- clinical signs?
- bloods? 6
- other investigations? 2
- imaging?
often none!
- may be signs of cause, e.g. diabetes
To be counted as CHRONIC must be shown to be long-standing - look at old eGFRs
- FBC (anaemia)
- U+Es (calculate eGFR)
- glucose (diabetes)
- Vit D
- calcium
- phosphate
- PTH
(- autoantibody screen) - BP
- urine (protein, blood)
- USS
nb consider renal biopsy only if kidneys are normal size + cause of CKD is not clear from other investigations
CKD:
- stages? 6
incl eGFR values
stage 1) >90
stage 2) 60-89
stage 3A) 45-59
stage 3B) 30-44
stage 4) 15-29
stage 5) <15
nb to diagnose stage 1 or 2, must be haematuria, proteinuria or known renal structural abnormality
CKD:
- recommended dietary changes? 4
- other lifestyle advice? 4
- other drug management? 6
- treatment for end-stage disease? 2
- sodium restriction
- fluid restriction
- phosphate restriction (certain foods)
- potassium restriction (certain foods)
- stop smoking
- do regular exercise
- moderate alcohol intake
- loose weight (if overweight)
- stop nephrotoxic drugs (incl ibuprofen)
- give vit D + calcium
- treat HTN (with ACEi or ARBs)
- treat high cholesterol (with statins)
- control diabetes
- treat any other underlying cause
- dialysis (blood or peritoneum)
- renal transplant
Benign prostatic hyperplasia/hypertrophy (BPH):
- who is affected?
- symptoms? 9
- men >50
- nocturia
- frequency
- urgency
- hesitancy
- poor stream/flow
- post-micturition dribbling
- overflow incontinence
- haematuria
- UTIs
BPH:
- clinical investigation? 1
- bloods? 2
- other investigation? 1
- imaging? 1
- PR (enlarged smooth prostate)
- U+Es
- PSA (BEFORE do PR exam)
- mid-stream urine (MSU)
- trans-rectal USS +/-biopsy
BPH:
- lifestyle advice? 2
- peeing advice? 3
- pharm management? 2 (incl examples)
- surgical management?
- avoid caffeine
- avoid alcohol
- relax when voiding
- void twice in a row to aid emptying
- ‘train’ bladder by holding on/distracting to increase time between voiding
selective a1 blockers
- e.g. tamsulosin, doxazosin)
- reduces smooth muscle tone
5a-reductase inhibitors
- finasteride
- decreases conversion of testosterone to more potent type (which promotes prostate growth)
lots of different options
- most common is TURP (transurethral resection of the prostate
prostate cancer:
- risk factors? 4
- where in prostate is majority found?
- age
- ‘western diet’
- African/afrocarribean ethnicity
- FH (incl BRCA gene)
- peripheral zone (75%)
prostate cancer:
- urinary symptoms? 9
- systemic symptoms? 4
often is asymptomatic until quite late (as is in periphery so has to be quite big to cause LUTS)
basically very similar to BPH
- nocturia
- frequency
- urgency
- hesitancy
- poor stream/flow
- post-micturition dribbling
- overflow incontinence
- haematuria
- BLOOD IN SPERM
- bone + back pain (rarely LL near symptoms dt spinal compression)
- pain in testicles
- loss of appetite
- unexplained weight loss
prostate cancer:
- clinical exam? 1
- other bedside test? 1
- bloods? 1
- invasive investigation?
- digital rectal exam (hard, irregular gland)
- MSU (check for infective cause)
- PSA (not very specific!!)
- transrectal USS with biopsy
prostate cancer:
- curative treatment options? 3
- palliative treatment options? 4
- watchful waiting (PR + PSA every 6 months)
- radical prostatectomy
- radiotherapy (EBRT) +/- hormone therapy
you’re way more likely to die WITH prostate cancer than OF it!
palliative:
- radiotherapy
- hormone therapy
- chemotherapy
- TURP
nb hormone therapy blocks testosterone transforming to more potent form (so side effects are dt effectively taking away testosterone)
- it can’t cure cancer on it’s own but slows down the growth
