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Renal Tract Conditions Flashcards

1
Q

What is a urinary tract infection

A

Infection of the urinary tract system (bladder, urethra, kidneys), generally caused by bacteria (especially E. coli)

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2
Q

How common are UTIs

A

Lifetime incidence of UTIs in adult women is 50% to 60%

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3
Q

Who are affected by UTIs

A

Women are at high risk due to a shorter urethra and the proximity of the anal and genital regions

Prevalence increases with age with women over 65 x2 as likely as rest of female population

Children with chronic constipation

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4
Q

What causes UTIs

A

Bacteria:
Infection ascends from the urethra to the bladder and can ascend further to the ureters and the renal pelvises (pyelonephritis)
E. coli is usually the causative organism
Staph Saprophyticus is 2nd

Viral:
Immunocompromised ptx and children most susceptible
Adenovirus, cytomegalovirus and BK virus are commonly involved in haemorrhagic cystitis

Yeast:
Rare (usually Candida species)

Abacterial:
Intersitial cystitis

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5
Q

What are the risk factors for UTIs

A 
Sexual intercourse
Indwelling urinary catheres
Pregnancy
Abnormalities of the urinary tract
- prevent bladder emptying 
- resulting in urinary stasis
- EG Urinary bladder diverticulum, Benign prostatic hyperplasia, congenital malformations causeing vesicoureteral reflux
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6
Q

How do UTIs present

A

Clinical findings depend on which part of the tract is affected and who is presenting

Lower:

  • Dysuria
  • Haematutia
  • Suprapubic pain
  • Urinary urgency
  • Increased urinary frequency

Upper:

  • Same symptoms as above plus the following
  • Fever
  • Flank pain
  • Fatigue/malaise
  • Nausea and vomiting

In males they may have prostatic/perineal area pain

In children:

  • Urinary incontinence
  • Malodorous urine
  • Irritability
  • Poor feeding
  • Failure to thrive

In elderly:
- Delirium/ acute confusion

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7
Q

What are potential signs on examination of those with suspected UTI

A

Pyuria (white blood cells can cause cloudiness)
Bacteriuria
Positive leukocyte esterase and nitrites on urinalysis

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8
Q

What are the differentials of UTi

A

If experiencing the fever and flank pain then take this as a sign of more serious infection eg pyelonephritis

Interstitial cystitis (painful bladder syndrome)

Asymptomatic bacteriuria

Vaginitis

Pelvic inflammatory disease

Prostatitis

Trauma

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9
Q

How would a patient with suspected UTI be investigated

A 
Urinalysis
Urine culture
Imaging:
- CT without contrast
- Ultrasound
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10
Q

How would UTI be explained to the patient and what would be discussed

A

Infection of the urinary tract system (bladder, urethra, kidneys), generally caused by bacteria (especially E. coli)

Easily treatable

Pregnant women need immediate antibiotics no matter severity of symptoms

Non-pregnant women can be given antibiotics if sever symptoms or a back up prescription to take if symptoms do not start to improve within 48 hours or if they worsen

Self-care:

  • Drink enough fluids to not feel thirsty
  • Take paracetamol or ibuprofen for pain relief

Safety net:

  • Call healthcare services if
    • Shivering, chills muscle pain
    • Confusion, or drowsiness
    • No urine passed in 24hrs
    • Vomitting
    • Blood in urine
    • Temp high (>38) or low (<36)
    • Kidney pain in back or under ribs
    • Worsening UTI symptoms
    • No improvement after 48hours of antibiotics
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11
Q

What is the treatment for a UTI

A

First-line empiric antibiotic therapy for uncomplicated UTIs includes outpatient therapy with oral trimethoprim-sulfamethoxazole, nitrofurantoin or fosfomycin for up to 7 days

For complicated UTIs antibiotic therapy should be extended for 7-14 days

Pregnant women with cystitis should be screened and treated if positive for asymptomatic bacteriuria

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12
Q

What is pyelonephritis

A

A severe infectious inflammatory disease of the renal parenchyma, calcices and pelvis that can be acute, recurrent or chronic.

Refers specificaly to infections in the kidney

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13
Q

Who is affected by pyelonephritis

A

Hospitalisation as a result of acute is 5x more common in women than men however women show a much lower mortality rate.

Complicated acute pyelonephritis tends to occur in med, older people, pregnant women and those with underlying anatomical or physiological abnormalities, immunosuppression, obstruction, catheteriation, incorrect abx selection and usage and resistant organisms

Slightly more than 20% of renal transplant patients suffer from acute pyelonephritis within 2 months of surgery.

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14
Q

What causes pyelonephritis

A

Acute:
- Enteric bacteria (eg E coli) that ascend from the lower urinary tract or that spread haematogenously to the kidney

Complicated infections can result from:

  • Underlying medical problems (eg diabetes, HIV)
  • Genitourinary anatomical abnormalities
  • Obstruction (eg benign prostatic hypertrophy, calculi)
  • Multi-drug-resistant pathogens
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15
Q

What are the risk factors for pyelonephritis

A

Strong:

  • UTI
  • Diabetes
  • Stress incontinence
  • Foreign body in urinary tract (eg calculus, catheter)
  • Anatomical/ functional urinary abnormality
  • Immunosuppressive state
  • Pregnancy
  • Frequent sexual intercourse

Weak:

  • Maternal family history of UTI
  • New sex partner
  • Spermicide use
  • Age between 18 and 50 years
  • Age >60years
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16
Q

How does pyelonephritis present

A 
Fever
Presence of risk factors 
Nausea and vomiting
Dysuria, frequency, or urgency
Flank pain or costovertebral angle tenderness
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17
Q

Which other conditions present similarly to pyelonephritis

A

Chronic vs acute pyelonphritis

Pelvic inflammatory disease

Pelvic pain syndrome

Cystitis

Acute prostatitis

Lower lobe pneumonia

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18
Q

How is suspected pyelonephritis investigated

A

1st line investigations:

  • urinalysis
  • gram stain
  • urine culture
  • full blood count
  • erythrocyte sedimentation rate
  • CRP
  • procalcitonin
  • blood culture

Investigations to consider:

  • renal ultrasound
  • contrast enhanced spiral computed tomography
  • magnetic resonance imaging

Emerrging tests:

  • interleukin
  • copeptin
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19
Q

How would pyelonephritis be discussed with patient

A

If taken abx then follow and complete regimen so recurrent infection is prevented

Should be aware and alert their doctor of concerning symproms such as fever or flank pain

If pregnant, UTI may ascend to the kidney and may be sever so important to seek routine antenatal testing and treatment in such situations

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20
Q

How is pyelonephritis treated

A

Goals of treatment are infection control and symptom reduction

Indications for hospitalisation:

  • Inability to maintain oral hydration or adherence to meds regimen
  • Hypotension
  • Vomiting
  • Dehydration
  • Sepsis
  • High WBC count
  • Temp >39
  • Severly ill with multiple comorbidities
  • Pregnancy
  • Uncertain about diagnosis
  • Older and/or immunocompromised

Start abx before results of blood or urine cultures are returned in order to prevent ptx deterioration

Mild to moderate and uncomplicated pyelonephritis:

  • Oral antibiotics:
    • Fluoroquinolones
    • Cephalosporins
    • Sulphonamides

Severe and complicated pyelonephritis and pregnant ptx:

  • hospitalisation and treatment with IV agents
  • Choice of abx regimen based on blood/urine cultures and localised resistence patterns
  • Possible regimens:
    • Fluoroquinolones
    • Extended spectrum cephalosporins
    • Aminoglycosides with or without ampicillin
    • Aminopenicillins
    • Antipseudomonal penicillins
    • Carbapenems
  • Two week course of IV abx often sufficient
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21
Q

What is the prognosis of pyelonephritis

A

Complications:

  • obstruction requiring catheterisation
  • spesis
  • renal failure
  • abscess formation
  • antibiotic failure

Recurrence:

  • Usually occurs within 1-2 weeks
  • Most likely cause is insufficient duration of initial treatment
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22
Q

What is hydronephrosis

A

Swelling of a kidney due to a build up of urine. It happens when urine cannot drain out from the kidney to the bladder froma blockage or obstruction. Can occur in one or both kidneys

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23
Q

How common is hydronephrosis

A

Prevalence in general population is 0.15% to 0.67%

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24
Q

What causes hydronephrosis

A

Usually caused by another underlying illness or risk factor:

  • Kidney stone
  • Congenital blockage
  • Blood clot
  • Scarring of tissue due to injury or previous surgery
  • Tumor or cancer (bladder, cervical, colon, or prostate)
  • BPH
  • Pregnancy
  • UTI
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25
What are the risk factors for hydronephrosis
Renal calculi External compression from abdominal and pelvic masses and tumors Diabetes Neurogenic bladder Congenital anomalies of kidneys and urinary tract
26
How does hydronephrosis present
Pain in back or side (may be sudden and sever or may be a dull ache that comes and goes over time) (may get worse after drinking lots of fluid) UTI symptoms Haematuria Decrease in urinary frequency or with a weaker stream Does not tend to cause symptoms in babies
27
What are the differential diagnoses for hydronephrosis
Renal sinus cysts Extrarenal pelvis Pseudohydronephrosis
28
How is suspected hydronephrosis investigated
``` Ultrasound usualling confirms diagnosis Can also use Xray, CT or MRI Cystoscopy FBC U and E CRP LFT Urinalysis ```
29
How is hydronephrosis treated
Address underlying cause Abx for any infection cause May require surgery to remove any kidney stones Catheterisation in cases of sever blockage or nephrostomy bag to drain urine directly from kidney Key to treatment is address issue asap to avoid any permanent damage to kidneys Can lead to kidney failure in severe cases in which case will need dialysis or kidney transplant, however most people recover from hydronephrosis if treated promptly.
30
What is acute kidney injury
An acute decline in kideny function, leading to a rise in serum creatinine and/or a fall in urine output It is a specturm from milf kidney injury to severe kidney failure
31
How common is acute kidney injury
Estimated to be 10400 per million population in UK | Seen in 10-20% people admitted to hospital as emergencies with an inpatient mortality of >20%
32
What are the causes of AKI for each type
Prerenal: Any condition leading to decreased renal perfusion - Hypovolaemia - Hypotension - Renal artery stenosis - Drugs affecting glomerular perfusion (NSAIDs, ACE inhibitors, cyclosporin) Intrinsic: Any disease that leads to sever direct kidney damage - Acute tubular necrosis (most comonly caused by sepsis, infection, ischemia or nephrotoxins) - Glomerulonephritis - Vascular (haemolytic uremic syndrome, vasculitis, malignant hypertension, thrombotic thrombocytopenic purpura) - Acute tubulointerstitial nephritis (drug-induced, infectious, immunologica) Postrenal: Any condition that results in bilateral obstruction of urinary flow from the renal pelvis to the urethra -Congenital malformations -Acquired obstructions (benign prostatic hyperplasia, Tumors, stones, catheter associated injuries) -Neurogenic bladder
33
What are the risk factors for AKI
``` Strong: Advanced age Underlying kidney disease Diabetes mellitus Sepsis Iodinated contrast Exposure to nephrotoxins Excessive fluid loss Surgery Haemorrhage Recent vascular intervention Cardiac arrest Pancreatitis Trauma Malignant hypertension Myeloproliferative disorders (eg multiple myeloma) Connective tissue disease Sodium-retaining states (eg congestive heart failure, cirrhosis, nephrotic syndrome) Drug overdose Nephrolithiasis ``` ``` Weak: Drug abuse Alcohol abuse Excessive exercise Recent blood transfusion Malignancy Genetic susceptibility Use of renin-angiotensin system inhibitors Proton pump inhibitors Herbal therapy ```
34
How does AKI present
Usually occurs in patients with intercurrent illness, without symptoms or signs specific to the kidneys and is only diagnosed when kidney function tests are performed May present in many different ways: - sepsis - hypotension - decreased urine output - lower UTI symptoms - oedema
35
What are the differentials in suspected AKI
Chronic kidney disease Increase muscle mass Drug side effect
36
How is suspected AKI investigated
1st investigation: - basic metabolic profile (U and E, LFT) - serum potassium - FBC - Bicrabonate - CRP - Blood culture - Urinalysis - Urine culture - Urine output monitoring - Fluid challenge (good response supports diagnosis of pre-renal AKI) - Venous blood gas - Chest X ray - ECG
37
What should be discussed with AKI patients
Inform patient of episode of AKI, giving cause and prevention measures needed to avoid further episode Discuss immediate treatment options, monitoring and prognosis; and long term treatment options, monitoring, self-management and support in collaboration with MDT Info to those needing renal replacement therapy after discharge (fistula, peritoneal catheter, frequency and length of dialysis) Discuss risk of future AKI
38
How is AKI treated
STOP AKI anogram: Sepsis: - Perform urgent screening and implement local guidelines within 1 hour of suspected sepsis Toxins: - identify and stop any nephrotoxic drugs and nephrotoxins Optimise volume status and blood pressure: - if hypovolaemic give immediate IV bolus of crystalloid - Withhold drugs that may exacerbate AKI (ACE inhibitors or angiotensin-II receptor antagonists - Consider withholding diuretics and other antihypertensive medications - Escalate to critical care for consideration of vasopressors if pt remains severly hypotensive Prevent harm: - Identify and treat reversible causes (eg UTI) - Treat life threatening compliactions (hyperkalaemia and acidosis) - Review and modify doses of all meds in line with degree of kidney injury
39
What is chronic renal failure
Abnormality in kidney function or structure for at least three months
40
How common is chronic renal failure
9-13% of adults worldwide
41
Who is most affected by chronic renal failure
Black people, Hispanic people and FH of kidney disease have higher prevalence. Those with an episode of AKI are most likely to be at risk of CKD and end-stage kidney disease in the future.
42
What causes CKD
Diabetic nephropathy: most common, cause accounts for 44% of cases Hypertensive nephropathy: 28% Glomerulonephritis: 8% Polycystic kidney disease/ hereditary: 2% Urological disease: 0.5% Other causes: Amyloidosis Toxins Chronic inflammation
43
What are the risk factors for CKD
Strong: - Diabetes - Hypertension - Age > 50yo - Childhood kidney disease Weak: - Smoking - Obesity - Black or Hispanic ethnicity - Family history of CKD - Autoimmune disorders - Male - Long term use of NSAIDs - High uric acid levels
44
How does CKD present
``` Often asymptomatic until later stages Common: Fatigue Oedema Nausea w/ or without vomiting Pruritus Restless legs Anorexia ``` ``` Uncommon: Foamy-appearing urine Cola coloured urine Rashes Dyspnoea Orthopnoea Seizures Retinopathy ```
45
What signs may be a CKD patient have no examination
``` Hypertension Peripheral oedema Pulmonary oedema Clinical features of uremia Pigmented spots Pruritus Anemia Uremic pericarditis Pleuritis Asterixis Encephalopathy Peripheral neuropathy GI symptoms (nausea, vomiting) ```
46
What other conditions present similarly to CKD
``` Diabetic kidney disease Hypertensive nephrosclerosis Ischemic nephropathy Obstructive uropathy Nephrotic syndrome Glomerulonephritis ```
47
How is suspected CKD investigated
Blood tests: - FBC - U and E (compare trend of eGFR and creatinine) - CRP - Bicarbonate - Urine tests (dipstick, urinalysis - Protein creatinine ratio and albumin creatinine ratio to accurately measure levels of protein leakage from kidneys) Ultrasound (size- shrunken in chronic presentation) ECG (electrocardiogram) Echocardiogram Vit D is activated by kidneys and this is needed for calcium absorption so if kidneys aren't functioning then there will be low calcium levels and therefore high parathyroid hormone Renal biopsy to determine underlying cause Classification based on glomerular filtration rate Stage GFR) (mL/min/1.73 m2) Description 1 > 90 Normal or high 2 60 to 89 Mildly decreased 3 30 to 59 Moderately decreased 4 15 to 29 Severely decreased 5 < 15 Kidney failure Classification based on albuminuria Stage Urinary albumin excretion (mg/day) Description A1 < 30 Normal A2 30 to 300 Mildly increased (microalbuminuria) A3 > 300 Severely increased (macroalbuminuria)
48
What should be discussed with CKD patients
Patients must be proactive in the management of their disease and monitor their progression. Dietary therapy is indicated from stage 3 onwards. Lifestyle changes are the leading factors in delaying progression of CKD. From stage 4, they will be trained in types of dialysis and may be evaluated for transplant and the referral made for this. It is a chronic lifelong condition which they will suffer with long term. When they go on to dialysis, this can be incredibly limiting for the patient and their quality of life due to either regular hospital attendance (haemodialysis) or regular dialysis 3-4 times a day (CAPD) or overnight (APD)
49
What are the consequences of CKD
MAD HUNGER - Metabolic Acidosis - Dyslipidaemia - High potassium - Uraemia - Na+/H2O retention - Growth retardation - Erythropoietin failure (anaemia) - Renal osteodystrophy
50
How is CKD managed
Conservative: - Diet: salt restriction, potassium restriction, fluid restriction Medical: - Nephrotoxic substance avoidance: NSAIDs, Nicotine, Sulfonamide antibiotics, aminoglycosides, vancomycin, acyclovir, cisplatin - Blood pressyre control - Vaccinations: Pneumococcal every 5 years, Flu jab, hep B If eGFR of 17 then start education on dialysis and transplant Starting dialysis is a decision based on how the patient feels not purely on numbers from tests
51
What is benign prostatic hyperplasia
Lower urinary tract symptoms caused by bladder outlet obstruction due to benign prostatic hyperplasia, also known as benign due to benign prostatic enlargement, are due to two components: - a static component related to increase in beign prostatic tissue narrowing the urethral lumen - a dynamic component related to an increase in prostatic smooth muscle tone mediated by alpha-adrenergic receptors Symtoms related to bladder outlet obstruction may also be contributed to by bladder over-activity
52
How common is benign prostatic hyperplasia
Approx 42% men aged 51-60 years 82% men aged 71-80 years Global lifetime prevalence is around 25%
53
Who is affected by BPH
Usually seen in older men
54
What causes BPH
Hyperplasia of the epithelial and stromal compartments, particularly in the transitional zone, may be attributed to various factors including shifts in age related hormal changes creating androgen/oestrogen imbalances. Changes in prostatic stromal-epithelial interactions that occur with ageing and increases in prostatic stem cell numbers are also potential causes. Progression from pathological BPH to clinical BPH (ie symptomatic) may require additional factors such as prostatitis, vascular effects and changes in the glandular capsule
55
What are the risk factors for BPH
Strong: Age >50 years ``` Weak: Family history Non-asian race Smoking Male pattern baldness Metabolic syndrome ```
56
How does BPH present
``` Frequency Urgency Nocturia Weak stream Hesitency Intermittency Straining Incomplete emptying Post void dribbling ```
57
What are the differentials in suspected BPH
``` Overactive bladder Prostatitis Prostate cancer UTI Bladder cancer Neurogenic bladder Urethral stricture ```
58
How is suspected BPH investigated
1st investigations: - Urinalysis - Prostate specific antigen - International prostate symptom score (pt questionaire) - Global bother score (pt questionaire) - Volume charting Investigations to consider: - Ultrasound - CT abdomen/pelvis - Cytoscopy - Uroflowmetry - Urodynamic study
59
What should be discussed with BPH patients
Openly discuss bother and treatment effects during regular follow-ups Caution pt on side effects of medications (dizziness, impotence) Acute progression of symptoms should alert patient to impending urinary retention for ehich catheterisation may be required Pt symptoms are key indicator for therapy need and should keep diary of voiding wherever possible
60
How is BPH managed
Goal is to improve LUTS, both voiding and storage issues, in order to improve QOL of pt Fluid limitations Watchful waiting Alpha-blockers 5-alpha-reductase inhibitors for those with prostate >30grams to reduce prostate size Anticholinergic therapy may benefit men with LUTS that are primarily irritative (frequency and urgency) without elevation to post-void residual volume. Drug therapy and response should be reassessed every 6 to 12 months Refer to urologist for therapeutic invasive therapy if: - chosen surgery as primary treatment - refactory response to medication or unwilling to use it - complications attributed to BPH
61
What is prostate carcinoma
A malignant tumour of glandular origin, situated in the prostate
62
How common is prostate carcinoma
6th leading cause of cancer mortality in US and second leading cause among men in US Lifetime risk of developing prostate cancer in the US is approximately 12%
63
Who is affected by prostate carcinoma
Most commonly seen in older men with median age at diagnosis being 66 years old Highest incidence seen among black men.
64
What causes prostate carcinoma
Exact cause is unknown Suggested factors: - High fat diet - Genetic factors
65
What are the risk factors of prostate carcinoma
``` Age >50 yo Black ethnicity North American or Northwest European descent Family History of prostate cancer High levels dietary fat ```
66
How does prostate carcinoma present
Common: - Nocturia - Urinary frequency - Urinary hesitancy - Dysuria Uncommon: - Haematuria - Weight loss - Lethargy - Bone pain
67
What signs will be on examination of prostate carcinoma
Common: - Abnormal digital rectal examination (asymmetrical, nodular prostate) - Elevated prostate specific sntigen (PSA) Uncommon: -Palpable lymph nodes
68
What are the differentials in suspected prostate carcinoma
Benign prostatic hyperplasia | Chronic prostatitis
69
How is suspected prostate carcinoma investigated
1st investigations: - Serum prostate specific antigen (PSA) - Testosterone - LFTs - FBC - Renal function - Prostate biopsy Investigations to consider: - Bone scan - Plain x-rays - Pelvic CT scan - Pelvic MRI/endorectal MRI Emerging tests: - Urinary biomarkers - Serum biomarkers - 18F-sodium fluoride PET/CT and 11C-choline PET/CT - Prostate cancer antigen 3 (PCA3) assay - TMPRSS2-ERG gene fusions - Prostate health index (PHI) - 4Kscore test
70
How is prostate carcinoma discussed with patient
It is a curable cancer Survival depend on initial stage of disease at the time of diagnosis Overall 5 year survival rate is around 100% for local and regional stage prostate cancer and around 30% for distant stage prostate cancer
71
How is prostate carcinoma treated
Treatment may consist of: - observation - active surveillance - androgen deprivation therapy - external beam radiotherapy - brachytherapy - radical prostatectomy - or a combination of 2 or more of these modalities

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