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Renal tract conditions Flashcards

1
Q

What is bacteriuria?

A

The presence of bacteria in the urine

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2
Q

Define UTI

A

The presence of characteristic symptoms and significant bacteriuria from kidneys to bladder

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3
Q

What is the laboratory threshold for diagnosing significant bacteriuria?

A

10 to the power of 5 colony-forming units per millilitre (cfu/ml)

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4
Q

What is infection of the bladder called?

A

Cystitis

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5
Q

What is an uncomplicated urinary tract infection?

A

An infection of the urinary tract by a usual pathogen in a person with a normal urinary tract and with normal kidney function

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6
Q

What is a complicated UTI?

A

This occurs where anatomical, functional or pharmacological factors predispose the person to persistent infection

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7
Q

What are the three most common microorganisms to cause UTI?

A

Escherichia coli (75-95% in the community)
Staphylococcus saprophyticus
Proteus mirabilis

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8
Q

Are UTIs more common in men or women?

A

women

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9
Q

Risk factors associated with UTI are?

A 
Recent sexual activity
New sexual partner
Use of spermicide
Diabetes
Presence of catheter
Institutionalisation
Pregnancy
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10
Q

How does acute pyelonephritis present?

A 
High fevers
rigors
vomiting
loin pain and tenderness
oliguria
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11
Q

What is oliguria?

A

Passing a reduced amount of urine (less than 400mL/day in adults)

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12
Q

What are the symptoms of cystitis?

A 
Frequency
dysuria
urgency
haematuria
suprapubic pain
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13
Q

What are the symptoms of prostatitis?

A

Flu-like symptoms
Low backache
Few urinary symptoms
Swollen or tender prostate on PR

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14
Q

What is dysuria?

A

Painful urination

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15
Q

What are the sings of UTI?

A 
Fever
Abdominal or loin Tenderness
Foul smelling urine
Distended bladder
Enlarged prostate
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16
Q

Investigations for UTI?

A

Urine dipstick test (check for nitrites and/or leukocytes)

MSU

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17
Q

What is an MSU?

A

Midstream specimen of urine

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18
Q

What is sterile pyuria?

A

The presence of elevated numbers of white cells in urine which appears sterile

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19
Q

When should MSU be asked for?

A 
If symptomatic but dipstick is -ve
Or if:
Male
a child
pregnant
immuno-compromised
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20
Q

When should patients be referred for imaging or cytoscopy?

A

Patients who:
have persistently not responded to treatment
have a history of renal tract disease or anomaly
have haematuria
women with >3 confirmed infection in the last year
men with >2 confirmed infections in the last year

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21
Q

What is the drug of first choice for the empirical treatment of uncomplicated UTI?

A

Trimethoprim or nitrofurantroin

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22
Q

Causes of sterile pyuria?

A 
TB
Inadequately treated UTI
Appendicitis
Calculi; prostatitis
Bladder tumour
Polycystic kidney
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23
Q

Prevention of UTI?

A

Drink more water
Antibiotic prophylaxis (continuously or post coital)
Cranberry juice

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24
Q

What is the management for UTI?

A

Drink plenty of fluids
Urinate often
Emperical antibiotic treatment

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25
What are the risk factors for pyelonephritis?
``` Structural renal abnormalities Calculi and urinary tract catheterisation Stents or drainage procedures Pregnancy Diabetes Primary biliary cirrhosis Immunocompromised patients Neuropathic bladder ```
26
How does pyelonephritis present?
``` Rapid onset (appears over a day or two) Unilateral/ bilateral loin pain, suprapubic or back pain Fever (variable) Malaise Nausea Vomiting Anorexia Diarrhoea (occasionally) ```
27
What investigations could be undertaken for pyelonephritis?
``` Urinalysis Inflammatory markers FBC Blood cultures Imaging Renal biopsy Fairley test ```
28
What will urinalysis show in pyelonephritis?
Urine is often cloudy with an offensive smell | May be positive for blood, protein, leukocyte esterase and nitrite
29
What is the fairley test?
Rarely used today A bladder washout is performed. Urine cultures are taken immediately and at 10, 20 and 30 mins Isolated bladder infection: bacteriuria take time Kidney infection: bacteriuria returns rapidly
30
What supportive management is there for pyelonephritis?
Rest Adequate fluid intake Analgesia
31
What is the first line empirical antibiotic treatment for pyelonephritis?
Ciprofloxacin
32
Which patients are more at risk of pyelonephritis complications?
``` Diabetes mellitus Chronic renal failure sickle cell disease Renal transplant AIDs (and other immunocompromised states) ```
33
What are the potential complications of pyelonephritis?
``` Septicaemia Perinephric abscess Renal abscess Acute papillary necrosis Pregnancy (risk of premature labour) ```
34
Risk factors for chronic pyelonephritis?
Structural renal tract anomolies, obstruction or calculi Children with vesicoureteral reflux Intrarenal reflux in neonates Genetic predisposition Any factors predisposing to recurrent urinary infection
35
How does chronic pyelonephritis present?
``` Fever Malaise Loin pain Nausea Vomiting Dysuria Hypertension Failure to thrive ```
36
Management of chronic pyelonephritis?
Blood pressure control (ACE-i) Surgical re-implantation of the ureters may be needed in severe cases Renal failure may eventually require renal transplantation
37
What should all patients with chronic kidney disease be monitored for?
Hyperlipidaemia Hypertension Diabetes Deteriorating renal function
38
What is acute kidney injury?
A rapid deterioration of renal function as measured by serum urea and creatinine, resulting in inability to maintain fluid, electrolyte and acid-base balance
39
What are 3 criteria for diagnosing AKI?
Rise in creatinine >26umol/L in 48 hours Rise in creatinine >1.5x baseline Urine output 6 consecutive hours
40
In how many hospital patients does AKI occur?
18%
41
Risk factors for AKI?
``` Age >75 Chronic kidney disease Cardiac failure Peripheral vascular disease Chronic liver disease Diabetes Drugs Sepsis Poor fluid intake/increased losses History of urinary symptoms ```
42
What are the most common causes of AKI?
Ischaemia Sepsis Nephrotoxins Prostatic disease
43
What are the pre-renal causes of AKI?
``` (40-70%) renal hypoperfusion eg hypotension hypovolaemia sepsis renal artery stenosis ```
44
What medications can cause renal hypoperfusion?
NSAIDS selective COX-2 inhibitors ACE inhibitors ARBs
45
What are the causes of Intrinsic renal problems?
Glomerular disease Tubular injury Acute interstitial nephritis due to drugs, infection or autoimmune diseases Vascular disease
46
What are the post-renal causes of AKI?
(10-25%) caused by urinary tract obstruction Luminal (stones, clots, sloughed papillae) Mural (malignancy, BPH, Strictures) Extrinsic compression (malignancy, retroperitoneal fibrosis)
47
Hows does AKI present?
Present differently depending on the underlying cause and severity of AKI.
48
If symptomatic what are the symptoms of AKI?
``` Oliguria/anuria Nausea Vomiting Dehydration Confusion ```
49
Signs of AKI?
Hypertension Large painless bladder Dehydration with postural hypotension and no oedema Fluid overload (raised JVP, pulmonary and peripheral oedema) Pallor, rash, bruising (may suggest inflammatory or vascular disease, emboli or disseminated intravascular coagulation) Pericardial rub
50
Assessment of AKI?
Make sure you know all the renal effects of all drugs being taken All assessment should include basic ABCDE approach
51
When assessing ABCDE for AKI what parts of C are important to remember?
Assess volume status (BP, JVP, skin turgor, cap refill, urine output) Check an urgent K+ on a venous blood specimen and check ECG for life threatening hyperkalaemia
52
What blood tests should be undertaken for acute kidney injury?
``` U&E FBC LFT clotting ESR CRP consider ABG ```
53
What should be looked for in a AKI urinalysis?
Leukocytes and nitrites (infection) | Blood and protein (Glomerular disease)
54
What can a renal USS be used to distinguish between in an AKI?
Obstruction and hydronephritis. | Also used to look for cysts, small kidneys, masses as well as assess corticomedullary differentiation
55
When should chronic kidney disease be suspected?
Long duration of symptoms Nocturia Small kidneys (
56
Is there a specific treatment for AKI?
No. AKI management is largely supportive. Consists of treating the cause where possible, monitoring fluid and electrolyte balance closely and optimising haemodynamic status.
57
What are the general measures in AKI management?
``` Assess volume status Aim for euvolaemia Stop nephrotoxic drugs Monitoring Identify and treat infection Nutrition ```
58
Which drugs should one consider withholding in AKI?
``` CANDA Contrast media ACE inhibitors NSAIDs Diuretics Angiotensin receptor blocker ```
59
What are the acute complications of AKI?
Hyperkalaemia Metabolic Acidosis Pulmonary Oedema Bleeding
60
What are the ECG signs of hyperkalaemia?
Tall 'tented' T-waves small or absent p wave increased PR interval Widening QRS complex
61
What is the immediate treatment for hyperkalaemia?
``` 10mL 10% calcium gluconate IV (cardioprotective) IV insulin and glucose (insulin stimulates intracellular uptake of K+) Salbutamol nebulisers (work in the same way as insulin) ```
62
When should the patient be referred for renal replacement therapy?
``` If any of the following are not responding to medical management: Hyperkalaemia Metabolic acidosis Fluid overload Pulmonary oedema Uraemia ```
63
What is hydronephrosis?
Hydronephrosis is the swelling of a kidney due to a build-up of urine. It happens when urine cannot drain out from the kidney to the bladder from a blockage or obstruction. Hydronephrosis can occur in one or both kidneys.
64
What are the causes/risk factors for hydronephrosis?
``` Kidney stone UTI Congenital blockage Blood clot Scarring of tissue Tumor or cancer Enlarged prostate Pregnancy ```
65
What are the two mechanisms to cause hydronephrosis?
Obstruction of the outflow of urine | Reflux of urine into the renal pelvis
66
How is hydronephrosis diagnosed?
Ultrasound | Cytoscopy
67
What is the definition of Chronic kidney disease?
Impaired renal function for >3 months based on abnormal structure or function or GFR 3 months with or without evidence of kidney damage.
68
At what stage of CKD do symptoms normally occur
stage 4 (GFR
69
What is the definition of end stage renal failure? ESRF
GFR
70
What are the 5 primary causes of CKD?
``` Diabetes (20%) Glomerulonephiritis Unknown (20%) Hypertension/renovascular disease Pyelonephritis and reflux nephropathy ```
71
What conditions is CKD often associated with?
``` Old age Diabetes Hypertension Obesity CVD ```
72
Risk factors for CKD?
``` CVD Proteinuria AKI Hypertension Diabetes Smoking African, African-caribbean or asian family origin Chronic use of NSAIDs Untreated urinary outflow tract obstruction ```
73
Symptoms of CKD?
Usually asymptomatic and often unrecognised because there are no specific symptoms Specific symptoms usually develop only in severe CKD
74
What are the symptoms of severe CKD?
``` Anorexia Nausea Vomiting Fatigue Weakness Pruritus Lethargy Peripheral oedema Dyspnoea Insomnia Muscle cramps Pulmonary oedema Nocturia Polyuria Headache Sexual dysfunction ```
75
Signs of CKD?
``` Increased skin pigmentation Pallor Hypertension Postural hypotension Peripheral oedema Left ventricular hypertrophy peripheral vascular disease pleural effusion peripheral neuropathy restless legs syndrome ```
76
What is assessment of CKD focused on?
Assessment of renal function (stage of CKD) and identification of the underlying cause
77
Define the GFR 5 stages of CKD
``` Stage 1: GFR >90 Stage 2: GFR 60-89 Stage 3: GFR 45-59 Stage 4: GFR 15-29 Stage 5 GFR ```
78
Signs of renal damage?
Proteinuria Haematuria Evidence of abnormal anatomy or systemic disease
79
When should a patient with CKD be referred to a nephrologist?
``` Stage 4 and 5 CKD Moderate proteinuria Proteunuria with haematuria Rapidly falling GFR Increasinh BP poorly controlled despite >4 antihypertensive drugs Rare or genetic causes of CKD Suspected renal artery stenosis ```
80
Management of CKD patients is split into four main approaches. These are?
Investigation (identifying and treating reversible causes) Limiting progression/complications Symptom control Preperation for renal replacement therapy
81
What does limiting progression/complication of CKD involve?
BP Renal bone disease Cardiovascular modification Diet
82
What does symptom control of CKD involve?
Anaemia Acidosis Oedema Restless leg/cramps
83
For which drugs is is important to modify dosage in relation to GFR?
``` Aminoglycosides (gentamicin) Cephalosporins Heparin Lithium Opiates Digoxin ```
84
What is benign prostatic Hyperplasia?
BPH is an increase in the size of the prostate gland without malignancy. Benign nodular or diffuse proliferation of musculofibrous and glandular layers of the prostate
85
What is LUTS?
lower urinary tract symptoms
86
How is the pathology of BPH different to that of prostate carcinoma?
In BPH the inner (transitional) zone enlarges in contrast to peripheral layer expansion seen in prostate carcinoma.
87
How common is BPH?
24% if aged 40-64 | 40% if older
88
How does BPH present?
``` Nocturia Frequency Urgency Post-micturition dribbling Poor stream/flow Hesitancy Overflow incontinence Haematuria Bladder stones UTI ```
89
Tests/assessment of BPH
Assess severity of symptoms and impact on life PR exam MSU U&E Ultrasound 'Rule out' cancer: PSA, transrectal USS and biopsy
90
What lifestyle changes should be recommended in BPH?
Avoid caffeine and alcohol (to reduce urgency and nocturia) Relax when voiding Void twice in a row to aid emptying Train the bladder (holding on)
91
What drug treatments are there for BPH?
Alpha blockers are first line (tamsulosin, alfuzosin). They decrease prostate and bladder smooth muscle tone 5alpha-reductase inhibitors (finasteride). Reduce testosterone
92
What are the surgical options of BPH?
Transurethral resection of prostate Transurethral incision of prostate Retropubic prostatectomy Transurethral laser-induced prostatectomy
93
How common is prostate cancer?
Commonest male malignancy. | 80% in men >80years
94
What is the most common pathology of prostate cancer?
Most prostate cancers are adenocarcinomas arising in the peripheral zone of the prostate.
95
Risk factors for Prostate carcinoma
Increasing age Family history High testosterone levels
96
Symptoms of prostate cancer?
``` Can be asymptomatic Nocturia Hesitancy Poor stream Terminal dribbling or obstruction Weight loss and bone pain suggests metastates ```
97
How would prostate cancer present in a DRE?
``` A hard irregular gland. Asymmetry Nodule with one lobe Induration Lack of mobility Palpable seminal vesicles ```
98
Diagnosis of Prostate cancer?
``` Increased PSA Transrectal USS and biopsy X rays Bone scan CT/MRI ```
99
Treatment for prostate cancer confined to the prostate?
Radical prostatectomy Radical radiotherapy Hormone therapy Active surveillance
100
Treatment for metastatic prostate cancer?
Hormonal drugs (LHRH agonists) reduce testosterone. eg goserelin
101
Side effects of Hormone therapy?
``` Flare phenomenon Sexual dysfunction Hot flushes Osteoporosis Gynaecomastia Fatigue ```

3rd Year (18 decks)

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