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)
