Renal + UG Flashcards
Acute kidney injury
syndrome of abrupt decreased renal function
AKI patho/ dx
Criteria for dx
- Rise in creatinine >26umol/L in 48hrs
- Rise in creatinine 1.5x baseline
- Urine output <0.5ml/kg/h for 6+ hrs
3 stages in AKI
May cause sudden life-threatening biochem disturbances
Associated with - diarrhoea, haematuria, haemoptysis, hypotension, urine retention
AKI causes
Pre-renal (decreased perfusion/drop in BP/flow obstruction)
haemorrhage, burns, D+V, sepsis (systemic vasodilation), NSAIDs, ACEi/ARB - renal hypoperfusion, atherosclerosis - flow obstruction
Renal (intrinsic renal disease)
glomerulonephritis, ATN, drug reaction, infiltration, vasculitis, DIC
Post renal
in renal tract - stone, malignancy, clot, prostatic hypertrophy
AKI Px
depends on underlying cause
signs maybe palpable bladder, kidneys arrhythmias (hyperkalaemia) pericarditis - with uraemia impaired platelet function - bruising infection - immune suppression postural hypotension oedema
symptoms
oliguria
symptoms of uraemia - fatigue, weakness, anorexia, N+V, confusion, seizures, coma
SOB - anaemia and PO secondary to volume overload
Thirst
AKI DDx
AAA, alcohol toxicity, alcoholic and DKA, chronic renal failure, dehydration, GI bleed, HF, metabolic acidosis, CKD
AKI Ix
Bloods - FBC, U+E, creatinine, Ca, phosphate, anaemia and ESR high suggests myeloma/vasculitis
Urine dipstick - can suggest infection (leukocytes, nitrates), glomerular disease (blood, protein)
Urine (mid-stream) and blood cultures - ?infection
USS
CT-KUB
ECG, CXR, renal biopsy
AKI Mx
Treat cause
Stop nephrotoxic drugs - NSAIDs, ACEi, gentamicin, amphotericin
Optimise fluid balance - crystalloid
Tx hyperkalaemia - calcium gluconate, insulin and glucose
Tx acidosis - sodium bicarb
Tx PO - diuretics, furosemide
Renal replacement therapy (RRT) - haemofiltration, haemodialysis
Benign prostatic hyperplasia
increase in size of prostate
BPH patho
benign proliferation of muculofibrous and glandular layers
Inner (transitional) zone enlarges (prostate carcinoma sees peripheral layer expansion)
Narrows urethra
BPH Px
signs
abdo exam - enlarged bladder
symptoms
LUTS - frequency, urgency, hesitancy, incomplete bladder emptying, need to push/strain, nocturia, poor stream/flow, post-micturition dribbling, UTI, haematuria,
BPH DDx
bladder tumour, stones, trauma, prostate cancer, chronic prostatitis, UTI
BPH Ix
DRE - prostate enlarged, smooth
Serum electrolytes, renal USS - exclude renal damage
Transrectal USS - see prostate
PSA may be raised in large BPH
Biopsy, endoscopy
Low flow rate
Frequency vol chart - nocturia
BPH Mx
avoid caffeine, alcohol, void twice in a row
Alpha 1 antagonist - oral tamsulosin - relaxes SM in bladder neck. S/E drowsiness, dizziness, ejaculatory failure. CI postural hypotension
5-alpha-reductase inhibitor - oral finasteride - blocks testosterone -> dihydrotestosterone (active form, responsible for prostatic growth). S/E impotence, decreased libido
Surgery - TURP, TUIP, open prostatectomy
Chronic kidney disease
abnormal kidney structure/function, present for 3+ months
CKD patho
progressive impairment in renal function
classification based on decreased kidney function (GFR), or kidney damage (presence of albuminuria) and the cause of kidney disease (glomerular, tubulointerstitial, blood flow…)
tends to progress to end stage renal failure
CKD causes
UK - diabetes, glomerulonephritis, HTN, renovascular disease
PKD, infective, obstructive, reflux nephropathies, SLE, amyloidosis, myeloma, hypercalcaemia, vasculitis, drugs
RFs - FHx, CVD, proteinuria, smoking, ethnicity (african, Afro-Caribbean, Asian)
CKD Px
signs
increased skin pigmentation, pallor, HTN, peripheral oedema, LVH, pleural effusions
CKD cx - anaemia, pericarditis
Underlying disease - eg SLE
symptoms malaise anorexia, wt loss insomnia nocturia, polyuria (impaired concentrating ability) itching N+V+D amenorrhoea, erectile dysfunction
CKD DDx
AKI (CKD - normochromic anaemia, small kidneys on USS, renal osteodystrophy)
acute on chronic kidney disease
CKD Ix
ECG - hyperkalaemia
Urinalysis - haematuria, proteinuria, mid-stream to MC&S, albumin:creatinine ratio, protein:creatinine ratio
Urine microscopy
Serum biochem - U+E, bicarb, creatinine (high urea, creatinine), low eGFR, raised ALP, raised PTH if CKD stage 3+
Bloods - raised phosphate, low Ca, low Hb
Auto-AB screening for disease, eg SLE, scleroderma. Viral antigen tests
USS - small kidneys
CT
Biopsy, histology
CKD Mx
Treat BP
Treat bone disease, tx PTH if raised - vit D, calcitriol
Control diabetes
CVD - simvastatin, aspirin
Anaemia - iron/folate/folic acid
Acidosis - sodium bicarb
Oedema - furosemide
RRT - haemofiltration, haemodialysis, peritoneal dialysis
Kidney transplant
CKD Cx
Anaemia - due to reduced EPO production by kidney
Bone disease - renal osteodystrophy - renal phosphate retention, impaired 1,25-diOH vit D production -> fall in Ca, PTH increases to compensate, skeletal decalcification
Neurological - dysfunction, polyneuropathy
CVD - higher risk
Skin disease - pruritus, brown discolouration of nails
Glomerulonephritis
inflammation of glomeruli and nephrons
can cause
- damage to filtration mechanism - haematuria, proteinuria
- glomerular damage constricts blood flow - compensatory HTN
- loss of filtration capacity - AKI
Nephritic syndrome
inflammation - may involve glomerulus, tubule, interstitial renal tissue
Nephritic syndrome causes
often immune response triggered by infection
IgA nephropathy post-strep infection IE, SLE, bacterial infection Systemic sclerosis ANCA vasculitis Goodpasture's
Nephritic syndrome Px
GFR decrease haematuria proteinuria HTN oedema from salt and water retention oliguria uraemia - anorexia, pruritus, lethargy, nausea
Nephritic syndrome Ix
measure eGFR, proteinuria, U+E, albumin
Culture - from throat/infected skin
Urine dipstick - proteinuria, haematuria
Renal biopsy if needed
Nephritic syndrome Mx
Tx cause
HTN - salt restriction, loop diuretics, CCB
Nephrotic syndrome
Due to podocyte damage
Nephrotic syndrome patho
triad of proteinuria, hypoalbuminaemia, oedema
Podocyte pathology - abnormal structure/function, immune damage, injury, death - proteins leak out
Hyperlipidaemia often present - liver goes into overdrive due to albumin and protein loss - increased clot risk, raised cholesterol
Causes - primary renal disease (eg minimal change disease, membranous nephropathy), secondary (eg DM, lupus, myeloma)
Nephrotic syndrome Px
mild BP increase Proteinuria >3.5g/24hr mild decrease in GFR hypoalbuminaemia oedema - ankles, genital, abdo wall frothy urine
Nephrotic syndrome DDx
CCF - oedema, but has raised JVP
Liver disease, eg cirrhosis - hypoalbuminaemia and oedema, but signs of chronic liver failure
Nephrotic syndrome Ix
renal biopsy urine dipstick CXR/USS serum albumin low serum creatinine, eGFR, lipids, glucose tests for underlying cause
Nephrotic syndrome Mx
Tx cause
reduce oedema - diuretics, fluid and salt restriction
reduce proteinuria - ACEi/ARB
Reduce cx risk - warfarin, simvastatin
Nephrotic syndrome Cx
susceptible to infection
thromboembolism
hyperlipidaemia
Renal cell carcinoma
Kidney cancer, arises from PCT epithelium
may spread (renal vein, via lymph, bone, liver, lung)
RCC RFs
smoking, obesity, HTN, renal failure, PKD, FHx
RCC Px
often asym
signs abdo mass varicocele - invasion of left renal vein, compression of left testicular vein polycythaemia - EPO production HTN - from renin secretion by tumour Iron deficient anaemia - from haematuria fever
symptoms
haematuria
loin/left flank pain
wt loss
RCC Ix
USS, CT chest abdo, MRI
Bloods - polycythaemia/anaemia, ESR raised, abnormal liver biochem
Renal biopsy
Bone scan if signs, or serum Ca raised
RCC Mx
Localised - surgery - nephrectomy, ablative (cryoablation, radiotherapy)
Metastatic - immunotherapy, molecular therapy
Bladder cancer
type of transitional cell carcinoma
can spread to pelvic structures, lymph nodes, liver, lungs
Bladder cancer Px
painless haematuria
recurrent UTIs
void irritability
Bladder cancer Ix
cystoscopy (bladder endoscopy), biopsy
Urine microscopy - sterile pyuria
CT/MRI/ image lymph nodes
Bladder cancer Mx
surgical resection, chemo
cystectomy (bladder removal)
chemo and radio
Prostate cancer
most are adenocarcinomas arising from peripheral zone
can spread to seminal vesicles, bladder, rectum, via lymph, bone, brain, liver, lung
A hormone-sensitive malignancy (testosterone)
Prostate cancer Px
LUTS nocturia hesitancy poor stream terminal dribbling obstruction wt loss, bone pain, anaemia
Prostate cancer DDx
BPH, prostatitis, bladder tumours
Prostate cancer Ix
DRE - hard, irregular prostate
Raised PSA
Trans-rectal ultrasound scan (TRUSS), biopsy
Urine biomarkers, MRI
Prostate cancer Mx
no spread
prostatectomy, radiotherapy, hormone therapy
metastatic
orchidectomy
LHRH agonist - goserelin/leuprorelin
Androgen receptor blockers - bicalutamide
for symptoms - analgesia, tx metastases, radiotherapy
Testicular tumours
tumour of testes
mostly from germ cells - seminomas, teratomas
Testicular tumour RFs
undescended testes, infant hernia, infertility, FHx
Testicular tumours Px
signs
hydrocele
abdo mass
symptoms painless lump in testicle testicular pain/abdo pain cough, SOB - lung metastases back pain - para-aortic lymph node metastases
Testicular tumour DDx
testicular torsion, lymphoma, hydrocele, epididymal cyst
Testicular tumour Ix
USS
biopsy, histology
Serum tumour markers - alpha-fetoprotein, b-hCG
CXR, CT - staging
Testicular tumour Mx
Orchidectomy
Radiotherapy
Chemo
offer sperm storage
UTIs
inflammatory response of urothelium to bacterial invasion - associated with bacteriuria, pyuria
5 pathogens in primary care - KEEPS Klebsiella E coli Enterococci Proteus spp Staph (coagulase -ve) (broader range in hospital/catheterised)
Upper tract - pyelonephritis
Lower tract - cystitis, prostatitis, epididymo-orchitis, urethritis
Uncomplicated - normal renal tract structure, function
Complicated - structural/functional abnormality, eg stones, obstruction
RFs female - shorter urethra sex pregnancy, menopause catheter tract obstruction - urine stasis
Pyelonephritis
infection of renal parenchyma and soft tissues of renal pelvis and upper ureter
E coli commonly
Pyelonephritis Px
loin pain
fever
pyuria
oliguria if causes AKI
bacteriuria
rigors
headache, malaise, N+V
Pyelonephritis Ix
Urine dipstick - foul smelling, cloudy - nitrites, leucocytes, protein
Mid-stream urine sample - MC&S
Bloods - WCC elevated, CRP, ESR
USS - ?calculi, obstruction
Pyelonephritis Mx
Rest, fluids, analgesia
ABs - oral ciprofloxacin/co-amoxiclav
severe - IV gentamicin/IV co-amoxiclav
Surgery - drain abscesses, relieve calculi
Cystitis
urinary infection of bladder
E coli commonly
Cystitis Px
signs
offensive smelling/cloudy urine
abdo/loin tenderness
symptoms dysuria frequency urgency suprapubic pain haematuria
Cystitis Ix
Mid-stream urine sample
Dipstick urinalysis - positive leucocytes, blood nitrites
Cystoscopy to exclude cancer
Cystitis Mx
ABs
trimethroprim/cefalexin
ciprofloxacin/co-amoxiclav
Prostatitis
infection or inflammation of the prostate gland
Acute - strep faecalis, E coli, chlamydia
Chronic - bacterial/non-bacterial
Prostatitis Px
acute systemic unwellness fever, rigors, malaise pain on ejaculation voiding LUTS - poor stream, hesitancy, incomplete emptying, terminal dribbling, straining, dysuria pelvic pain
chronic
acute for >3 months
recurrent UTIs
pelvic pain
Prostatitis Ix
DRE - tender, hot to touch, hard from calcification
Urine dipstick - leucocytes, nitrites
Mid-stream MC&S
STI screen
TRUSS - transurethral USS
Prostatitis Mx
acute IV gentamicin, IV co-amoxiclav 2-4wks ciprofloxacin 2nd line - trimethroprim TRUSS guided abscess drainage if needed
chronic
4-6 wks ciprofloxacin
tamsulosin
NSAIDs, ibuprofen
Urethritis
urethral inflammation due to infectious/non-infectious cause
Primarily a sexually acquired disease
Urethritis causes
N.gonorrhoea
Chlamydia (most common)
Trichomonas vaginalis
Trauma, stricture, irritation, urinary calculi
Urethritis Px
may be asym
signs
skin lesions
symptoms dysuria +/- discharge, blood/pus urethral pain penile discomfort systemic symptoms
Urethritis Ix
NAAT (nucleic acid amplification test)
female - vaginal swab, endocervical swab, first void urine
Male - first void urine
Microscopy of genital secretions
Blood cultures
Urine dipstick, urethral smear
Urethritis Mx
chlamydia
oral azithromycin, or 1wk oral doxycycline
pregnant - oral erythromycin / oral azithromycin
gonorrhoea
IM ceftriaxone, oral azithromycin
patient education, contact tracing
Epididymal cyst
Smooth, extratesticular, spherical cyst in head of epididymis
Lies above, behind testis, contains clear and milky fluid
Px lump, often multiple, maybe bilateral painful once large well defined, will transluminate (since fluid filled) testes palpable separate to cyst
DDx
spermatocele - fluid and sperm filled cyst in epididymis
hydrocele - fluid collection surrounds whole testis
varicocele
Ix
scrotal USS
Mx
surgical excision if painful
Hydrocele
abnormal collection of fluid in tunica vaginalis
Primary /secondary
Px
scrotal enlargement - non-tender, smooth, cystic swelling
not usually painful unless infected
testis palpable within cyst
lies anterior, below testis, will transluminate
Ix
USS
serum alpha-fetoprotein and hCG to exclude cancer
Mx
resolve spontaneously
therapeutic aspiration, surgical removal
Varicocele
abnormal dilation of testicular veins in pampiniform venous plexus, caused by venous reflux (lack of effective valves, increased reflux from compression of renal vein)
left side more commonly affected - angle at which left testicular vein enters left renal vein
Px
distended scrotal blood vessels
dull ache, scrotal heaviness
scrotum hangs lower on that side
DDx
secondary to other pathological processes blocking testicular vein, eg kidney tumours, retroperitoneal tumours
Ix
venography, colour doppler USS
Mx
surgery if pain, infertility, testicular atrophy
Polycystic kidney disease
multiple cysts develop in kidney -> renal enlargement, kidney tissue destruction
loss of function - mechanical compression, apoptosis of healthy tissue, reactive fibrosis
autosomal dominant/recessive
PKD Px
signs bilateral kidney enlargement HTN renal stones (uric acid) progressive renal failure
symptoms loin pain haematuria renal colic due to clots excessive water and salt loss nocturia
extrarenal
SAH, polycystic liver disease, pancreatitis, ovarian cysts
PKD DDx
acquired, simple kidney cysts, dominant/recessive, medullary sponge kidney
PKD Ix
USS
Genetic testing
PKD Mx
BP control
Treat stones, give analgesia
Laparoscopic removal of cysts / nephrectomy (whole kidney)
RRT for ESRF
screen family, counselling
Renal calculi
renal stones - crystal aggregates, form in CDs
Renal calculi patho
classically get stuck:
- pelviureteric junction
- pelvic brim
- vesicoureteric junction
stones form when solute conc exceeds saturation
obstruction -> hydronephrosis - obstruction and dilation of renal pelvis
stone types
- calcium oxalate (75%)
- magnesium ammonium phosphate
- also urate, hydroxyapatite, cystine, others
Renal calculi causes
hypercalciuria
high PTH, excessive diet Ca intake, renal disease (eg PKD)
hyperoxaluria
high diet intake, low dietary Ca, increased intestinal absorption due to GI disease, eg Crohn’s
uric acid stones
hyperuricaemia, dehydration, ileostomies
infection induced stones
usually UTI - Ca/Mg mixed
cystine stones
from cystinuria - genetic condition
Renal calculi RFs
anatomical abnormalities, eg duplex, obstruction dehydration infection hypercalcaemia, hyperoxaluria, hypercalciuria, hyperuricaemia renal disease drugs diet gout FHx
Renal calculi Px
signs
pain - loin to groin, in waves (ureter peristalsis), rapid onset, spasmodic
dysuria/anuria, strangury (burning when peeing), frequency
haematuria
infection
proteinuria
sterile pyuria
symptoms
N+V
Renal calculi DDx
vascular damage, bowel pathology, ectopic pregnancy, ovarian cyst torsion
Renal calculi Ix
Urine dipstick - haematuria
Mid-stream specimen to MC&S
KUBXR - kidney, ureter, bladder x ray
NCCT-KUB - non-contrast CT
USS
Renal calculi Mx
Analgesic for renal colic - diclofenac IV fluids ABs - IV cefuroxime, gentamicin Antiemetics Oral nifedipine (CCB) or oral tamsulosin
Surgical
extracorporeal shockwave lithotripsy (ESWL)
Endoscopy with YAG laser
Percutaneous nephrolithotomy (PCNL) - keyhole surgery
Renal calculi Cx
hydronephrosis, blockage of urinary flow, renal damage, infection
Testicular torsion
twisting of spermatic cord
perhaps after sport
Px inflammation of one testis - tender, hot, swollen sudden onset pain in one testis abdo pain N+V
DDx
epididymo-orchitis, tumour, trauma, hydrocele
Ix
doppler USS, urinalysis to rule out infection
Mx
surgery - bilateral fixation of testes
Cx
infertility, infection, infarction of testes
