Renal & Urinary Flashcards
3 risk factors for developing kidney stone?
metastable urine - high calcium/oxalate/urate/cysteine - high PTH -- high calcium - dehydration - Dents disease -- high cysteine anatomical abnormality eg horseshoe kidney, trauma renal tubule acidosis
what 2 types of stones are the most common? in what kind of urine do they develop?
calcium stones – oxalate or phosphate – most common
ca oxalate in acidic urine
ca phosphate in alkaline urine
what are struvite stones associated with? how do they form?
infection
bacteria make ammonia
= alkaline urine
= precipitation of magnesium + phosphate
what is kidney stone pain like?
severe unilateral loin to groin colicky sudden onset
apart from pain, 3 other features of kidney stone?
urgency frequency writhing frank or microscopic haematuria nausea/vom
what is the gold standard imaging for ?kidney stones? what would you see? 3
CT kidneys, ureter, bladder - without contrast
stone is bright white
fat stranding in perinephric tissues
inflammation
hydronephrosis
cortical thickening
best analgaesia for acute kidney stone?
paracetamol or diclofenac
3 surgical managements for kidney/ureter stones?
lithotripsy
percutaneous nephrolithotomy
ureteral stent
a treatment for uric acid stones?
alkalise the urine eg sodium bicarb
treatment for cysteine stones?
captopril (cysteine binder)
give 5 risk factors for AKI?
Infection dehydration peripheral vascular disease NSAIDS diabetes heart failure liver disease - causes decreased blood to kidney age over 65 contrast dyes hypovolaemia
3 pre-renal causes of AKI?
Dehydration / diarrhoea bleeding shock sepsis heart failure
Renal causes of AKI?
glomerular nephritis - nephritic/nephrotic syndromes acute tubular necrosis acute interstitial nephritis - infection/ischaemia/connective tiss dis infection NSAID TTP vasculitis henoch-scholein purpura
3 post renal causes of AKI?
kidney stone mass in ureter urethral stricture - post surgery benign prostate hyperplasia prostate cancer problem with nerves so cannot urinate
what is the criteria for AKI?
increase in serum creatinine, more than 25mmol/l over 48 hrs or a 50% rise in last week
or less than 0.5ml/kg/hr urine output
3 complications of AKI?
hyperkalaemia, causes arrythmia
fluid overload, causes pulm hypertension
metabolic acidosis
uraemia, causes encephalopathy
what is a normal GFR?
60ml/min/1.73m2 +
what staging system is used for AKI?
KDIGO
renal cell carcinoma is what kind of cancer?
adenocarcinoma
risk factors for renal cell carcinoma?
male black smoking haemodialysis von hippel lindau
what is the most common type of RCC?
clear cell
4 places RCC commonly metastasises to?
lungs - cannonball
brain
bone
adrenals
local fat
renal vein
clinical presentation of RCC? - 5
haematuria loin pain palpable mass fever weight loss varicocele enlarged lymph nodes
3 common paraneoplastic syndromes related to RCC?
renin = hypertension
EPO = polycythaemia
PTH-like molecule = hypercalcaemia
stauffers syndrome is a triad of:
deranged LFT
hypoglycaemia
fever
(stauffers syndrome is a paraneoplastic syndrome associated with renal cell carcinoma)
what is oncocytoma?
benign kidney mass
in the collecting duct
what is the most common bladder cancer?
transitional cell carcinoma
what is the epidemiology of transitional cell carcinoma?
smoking
PAH - hairdressers, rubber factory
when does squamous cell carcinoma in the bladder develop, give some risk factors?
irritation of the bladder – transitional epithelium becomes squamous
schistosomiasis
catheter
kidney stones
investigations for bladder cancers?
flexible cystoscopy
clinical presentation of bladder cancer? 3
painless haematuria
dysuria
raised WCC
recurrent inf
surgery for bladder cancer?
TURBT - BCG + chemo
cystectomy
what is the actual function of the prostate?
produces seminal fluid
to sustain semen
what kind of cancer is prostate cancer normally?
adenocarcinoma
5 LUTS?
frequency urgency nocturia terminal dribbling haematuria dysuria/pain
presentation of prostate cancer?
urine retention lower abdo pain LUTs eg frequency, dribbling asymetrical hard, lumpy prostate with loss of median sulcus weight loss, etc
investigations for prostate cancer?
PSA - non specific
multiparametric MRI
biopsy
transrectal USS
how is prostate cancer graded & staged?
Gleasson score to grade (higher is worse)
TMN to stage
treatment options for prostate cancer?
prostatectomy
radiotherapy
brachytherapy - radioactive beads into prostate
flutamide - anti testosterone
3 times when PSA may be high?
cancer BPH exercise post ejaculation infection
5 risk factors for CKD?
smoking hypertension SLE infection eg HIV ACEi nephrotic/nephritic syndromes polycystic kidney vesicourethral reflux
4 pathophysiological effects of declining kidney function?
fluid balance/BP regulation disrupted – hypervolaemia/hypertension
vit D metabolism poor – bone resorbed
hyperkalaemia, uraemia
decreased EPO = normocytic anaemia
metabolic acidosis - as less H+ excretion and less bicarb production
5 clinical presentations of CKD?
HTN oedema uraemia = sallow/frost anaemia -- lethargy, pallor frothy urine muscle cramps (hyperK) nausea anorexia
what is ACR and what does it show/mean?
albumin/creatinine ratio
more than 3 means proteinuria
how is GFR calculated?
eGFR - creatinine
gold standard - inulin - but v invasive
end stage renal failure is what GFR?
15 or less
what does FBC show in CKD?
normocytic anaemia
2 types of dialysis?
haemodialysis - more effective
peritoneal dialysis - easier for pt
why is BPH more common with age?
5a reductase converts testosterone to dihydrotestosterone
5a reductase increases with age
dihydrotestosterone is more active
presentation of BPH?
LUTS eg frequency, straining, hesitancy, weak stream, urgency, incontinence, nocturia
enlarged but smooth prostate
tests for BPH?
PSA slightly raised
urinalysis to exclude infection
transurethral biopsy to exclude cancer
urodynamics/flow studies
what scoring system is used for BPH?
IPSS
2 drugs for BPH?
a1 antagonists eg tamsulosin - relax smooth muscle - 1st line
5a reductase inhibitors eg finasteride - shrink prostate - 2nd line/for severe
2 lifestyle changes/conservative management in BPH?
reduce fluid intake/caffeine
urethral milking
incontinence pads
bladder training
3 Complications of BPH?
UTI
urine retention
stones
nephropathy
5 risk factors for UTI?
sexually active catheterised enlarged prostate renal tract tumour renal stones urinary retention woman incontinence poor hygeine dehydration
what does pyuria mean?
neutrophils in the urine
what is cystitis?
inflammation of the bladder
associated with UTI
uncomplicated vs complicated UTI?
uncomplicated - healthy non pregnant women
everyone else - complicated
4 bacteria that commonly cause UTI? Which is most common?
e.coli most common staph saphrophyticus klebsiella pneumoniae pseuddomonas aeruginosa proteus - stones as they increase the pH of urine
what is pyelonephritis?
infection in the kidney
inflammation of upper urinary tract, renal pelvis, parenchyma, upper ureter
5 clinical presentations of UTI?
frequency dysuria urgency incontinence confusion suprapubic pain
3 features that suggest pyelonephritis over UTI?
loin pain
fever
haematuria
what do nitrates suggest?
gram neg bacteria eg e coli
what do urine casts suggest?
damage to epithelium/tubular necrosis/glomerulus
what does epithelium in MSU suggest?
poorly taken sample, may be contaminated
what number of bacteria in an MSU is significant?
10^5
10^4 may be contamination
what samples do you need, to test for TB in urine?
3 early morning samples
how to treat uncomplicated UTIs in young women?
3 days abx
eg nitrofurantoin or trimethoprim
how to manage ‘complicated’ UTI?
MSU for culture
7 days abx
what about abx for UTI in pregnancy?
nitrofurantoin = 1st line
2nd line = cefalexin or amoxicillin
(not trimethoprim)
3 things about UTI in pregnancy?
urinalysis is an unreliable test, always send for culture
asymptomatic bacteriuria is common
always treat, they are at much higher risk of pyelonephritis
when would/wouldn’t you treat or test a ?UTI?
3 UTI symptoms – empirical abx
2 UTI symptoms + nitrates – empirical abx
2 UTI symptoms + leucocytes – send MSU
symptoms but no leuco/nitr in dipstick or it looks clear - unlikely to be a UTI
2 bacteria that are yellow on a CLED?
yellow on CLED = lactose fermenting
e.coli
staph saprophyticus
2 organisms that are blue on a CLED?
blue on cled = non lactose fermenting
salmonella
shigella
pseudomonas
pink colonies on a MacConkey plate are_____
lactose fermenting
e coli
staph saprophyticus
pyelonephritis is most common in ___
females under 35
esp pregnant
3 ways infection can spread to the upper urinary tract and cause pyelonephritis?
ascending from urethra, common in intercourse
haematogenous, in sepsis
lymphatic
presentation of pyelonephritis?
fever rigors unilateral loin (-- groin) pain pyuria nausea haematuria dysuria/frequency
investigations for pyelonephritis?
urine dip -- leuco and nitrates MSU shows white cell casts CRP USS DMSA scan if recurrent
treatment for pyelonephritis?
broad spec abx - coamoxiclav, gentamycin analgaesia antipyretics fluid drain kidney
5 bacteria that can cause prostatitis, which is most common?
e coli - most common pseudomonas klebsiella proteus mirabilis chlamydia gonorrhoea staph aureus (disseminated from somewhere else)
5 clinical signs/symptoms of prostatitis?
pain - perineal/rectal/pelvic/back hesitance, straining, dribbling dysuria, frequency, urgency tachycardia, pyrexia malaise, myalgia palpable bladder prostate feels hot/swolen/tender
investigations for prostatitis?
urinalysis/MSU Blood/semen culture trans urethral ultrasound - TRUSS MRI of prostate DRE CRP
management for prostatitis?
ciprofloxacin 14 days
if abscess - TRUSS guided drainage
treatment for chronic prostatitis?
analgaesia
tamsulosin
stool softener - docusate
most common cause of urethritis?
STI
eg chlamydia
presentation of urethritis? - 5
dysuria haematuria/pus in urine discharge urethral pain / itching inflammation skin lesion reactive arthritis conjunctivitis epididymitis
management of chlamydia?
doxycycline
azithromycin - if preg
management for gonorrhoea?
ceftriaxone + azithromycin
does chlamydia infect the vagina?
no, chlamydia and gonorrhoea cannot infect squamous epithelium
what is the incubation period for chlamydia and gonorrhoea?
chlamydia = 1-3 weeks
gon: 10 days for women, 1-5 days in men
presentation of gonorrhoea & chlamydia in women?
asymptomatic
change in vaginal discharge
menstrual irregularity
dysuria
3 complications of GC/ chlamydia in women?
PID
neonatal transmission
fitz-hugh-curtis: diagnose at nephrostomy, similar to gallbladder dis
what does gonorrhoea look like on a gram stain?
gram neg
diplococci
in the cytoplasm of polymorphs
what organism causes syphilis?
treponema pallidum
what are the features of primary syphilis?
chancre
macule - papule - non tender solitary ulcer
5 features of secondary syphilis?
may or may not follow chancre rash mucous membrane lesions generalised lymphadenopathy alopecia bone pain hepatitis nephrotic syndrome deafness iritis meningitis CN palsy
treatment for syphilis?
penicillin
how is CKD defined?
GFR less than 60
GFR less than 90 with renal damage
albuminuria - more than 30mg/24hr or ACR more than 3
what is the most common cause of CKD?
diabetes
-damage to efferent arteriole
what is nephritis? what are the two types?
nephritis = general inflammation of the kidney
glomerulonephritis
interstitial nephritis
3 conditions that cause glomerulonephritis and lead to a nephritic syndrome?
goodpastures
rapidly progressive glomerulonephritis (can come from goodpastures)
IgA nephropathy
Henloch-schonlein purpura - essentially this is like a sstemic version of IgA nephropathy
post streptococcal glomerulonephritis
membranoproliferative glomerulonephritis
SLE
post streptococcal glomerulonephritis develops in who following what kind of conditions?
tonsilitis
impetigo
under 30s
immune complexes are deposited in glomerulus, causing inflammatory damage to podocytes
goodpastures syndrome is caused by
antibodies to glomerular basement membrane
3 conditions that cause glomerulonephritis leading to nephrotic syndrome?
minimal change focal segmental glomerular sclerosis diabetes membranous glomerulonephritis amyloidosis
membranous glomerulonephritis is caused by
igG deposition in the glomerular membrane
minimal change disease is commonest in
children
nephritic & nephrotic syndrome?
nephritic: haematuria (cola), mild proteinuria,, HTN, peripheral oedema
nephrotic: severe/frothy proteinuria, central oedema, hypoalbuminuria, lipid/clot
epidemiology, aetiology and investigations for IgA nephropathy?
in the 20s
following GI or URT infection
dipstick
mesangial proliferation ang IgA at biopsy
aetiology, epidemiology of membranoproliferative glomerulonephritis?
20s and 60s
igG and c3 deposition in basement membrane
idiopathic
secondary - NSAIDs, malignancy, rheumatoid
is the most common primary cause of nephrotic syndrome in adults (diabetes is most common secondary cause)
management of nephritic syndrome?
steroids
BP control
gold standard investigation for nephritic/nephrotic syndromes?
nephritic = biopsy - crescent shaped glomeruli
nephrotic - needle biopsy and microscopy - light, electron, fluroescence
pathophysiology in nephrotic syndrome?
damage to glomerulus = protein esp albumin leak into urine instead of being filtered and retained
loss of albumin = oedema
what happens in minimal change disease?
T cells release cytokines which damage podocytes
‘minimal change’ seen at microscopy, may see loss of podocytes
management for nephrotic syndrome?
steroids - mainstay ciclosporin diuretics ACEi albumin anticoagulant - apixaban, lmw heparin, warfarin (warfarin has a delayed effect)
the two forms of polycystic kidney disease?
autosomal dominant - develops in adulthood
PKD1 on chr 16 / PKD on chr 4
autosomal recessive - rarer but worse
develops in childhood
chr 6 PKDH1
what protein is mutated in polycystic disease, what is its normal function and what happens when its mutated?
polycystin protein
allows calcium influx to inhibit cell proliferation
mutation = cell overproliferation and overexpression of water channels
= fluid formed cysts
what are 3 pathophysiological effects of the cysts in polycystic kidney disease?
compress blood flow – hypoperfusion – RAAS activation – hypertension
block the collecting ducts – stasis of urine – kidney stones
renal failure
5 renal signs/symptoms of polycystic kidney disease?
pain palpable enlarged kidneys haematuria nocturia polyuria, polydipsia, hypertension
5 extra-renal complications of polycystic disease? caused by cysts forming elsewhere
hepatomegaly splenomegaly pancreatic dysfunction infertility mitral/aortic regurg berry anneurysm aortic root dilatation diverticulae
3 presentations of autosomal recessive polycystic kidney disease?
at birth: - olighydramosis (lack of amniotic fluid) underdeveloped lungs -- resp failure low ears, flat nasal bridge congenital liver fibrosis
investigations to diagnose PKD?
U & E
USS
genetic testing
management of polycystic kidney disease?
tolvaptan / v2 antagonist
cyst drainage
dialysis
avoid contact sports, nsaids, anticoagulants
where is an epidydimal cyst/ what does it feel like?
smooth
in the epidydimus, above the testicle
feels clearly separate from testicle
investigations for epidydimal cyst?
uss
transluminates on exam, as is fluid filled
a lump that’s separate from the testicle could be:
epidydimitis / varicocele if solid
epidydimal cyst if fluid filled
what is a hydrocele?
a collection of fluid within the tunica vaginalis - between the parietal and visceral layers
aetiology of hydrocele?
idiopathic most common esp in younger men
secondary - tumour, trauma, tb, torsion
what is a communicating hydrocele caused by?
failure of the tunica vaginalis to close at birth
what is a simple hydrocele caused by?
overproduction of serous fluid by the mesothelium
what does a hydrocele look/feel like?
painless soft swelling
in the scrotum, above and below testicle
not reducible
transluminates
3 management options for a large problematic hydrocele?
aspiration
remove it
sclerotherapy
what is a varicocele?
swelling of the veins in the pampiniform plexus
which side is it more common to have a varicocele, why?
left
as the left testicular vein flows into renal vein before vena cava
the right testicular vein flows straight into vena cava
left sided varicocele can be caused by
renal cell carcinoma
classically a varicocele feels like
a bag of worms
how does a varicocele change when lying down?
it should disappear
if it doesnt there could be a retroperitoneal tumour
if the left scrotum is smaller where is the varicocele?
left
what are the 5 gleasson stages?
1 - well formed uniformly distributed
2 - mostly well formed with minor poorly formed
3 - mostly poorly formed with minor well formed
4 - poorly formed glands
5 - necrosis, cords, nests, sheets
risk factors for testicular torsion?
young trauma bell clapper deformity bicycle riding cryptorchidism large testicles
presentation of anti-glomerular basement membrane disease / goodpastures ?
oliguria nephritic haemoptysis SOB cough
what is Alports syndrome?
genetic problem with type 4 collagen
= renal failure, hearing loss, problems with eyesight - lenticonus
x linked recessive or autosomal recessive
what are the stages of CKD?
1 - kidney damage but GFR over 90 2. kidney damage GFR 60-90 3A - 45-60 3b - 30-45 4 - 15-30 5 - less than 15
what is first line for urgency incontinence?
oxybutynin - antimuscarinic
prevent parasympathetic contraction of detrusor
what is the treatment for stress incontinence?
1 - bladder training
2 - duloxetine (SNRI)
what are struvite stones made from?
magnesium ammonium phosphate
what is prehns sign for? what is a positive prehns sign?
to identify testicular torsion
pos when lifting the testicle = relief of pain
pos sign = epidydimitis NOT testicular torsion
what are kimmelstiel-wilson lesions?
when the mesangeal matrix invades glomerular capillaries
eg in diabetic hypertensive nephropathy
what diet is best for kidney disease?
low potassium, phosphate, sodium, protein
2 markers for testicular cancer?
alpha fetoprotein
beta hCG
tumour marker for bladder cancer?
fibrin
what are the stages of AKI?
1 - 150-200% increase in creatinine. less than 0.5ml/kg/hr for 6 hrs
2 - 200-300% increase in creatinine, less than 0.5mg/kg/hr for 12 hours
3 - less than 0.3ml/kg/hr
what are first medications for vasculitis?
steroids
rituximab
what investigation would you use to stage renal cancer?
CT or MRI
what is the surgery for testicular torsion?
manual detorsion (it is an emergency)
3 investigations for post streptococcal glomerulonephritis?
U&E
urinalysis
biopsy - dead bacterial cells and antibodies causing inflammation
3 common places for renal stones to get lodged?
ureteropelvic junction
pelvic brim
vesicoureteral junction
ureteral crossing of iliac vessels
presentation of CKD?
fatigue uraemic frost bone pain anorexia pruritis arrythmia
presentation of AKI?
encephalopathy due to uraemia arrythmia/muscle weakness oliguria creatinine if post renal cause - luts signs of cause eg infection, vasculitis, etc metabolic acidosis itchiness
in nephrotic syndrome, what happens to cholesterol and coagulability?
albumin is lost
so liver increases production of albumin
along with this the liver increases production of cholesterol (xanthelasma) and coagulation factors (coagulopathy)
what is focal segmental glomerulosclerosis? & what is it caused by?
focal segments of plaques
hiv, sickle cell, interferon drugs
what is von hippel lindau syndrome?
mutation in VHL which regulates HIF – mutation = cancer
cysts form all over - kidney, pancreas, adrenals, phaeochromocytoma, liver
dominant or de novo
what drugs should be stopped in AKI?
NSAIDS
ACEi
what stones can/can’t be seen on x ray?
uric acid and cysteine stones are radiolUCent (can’t see)
calcium and struvite stones can be seen
how is phosphate affected in CKD?
hyperphosphataemia
the kidnneys normally excrete phosphate, they can’t do that as well in CKD
what things might suggest acute tubulointerstitial nephritis?
rash recently started a drug pyuria eosinophils fever
yolk sac tumour?
most common testicular cancer in boys
schiller duval bodies
high ALP
what is the most common cause of epidydimitis?
gonorrhoea in young
e coli over 35
NSAIDs cause what kind of AKI?
intrarenal
what happens to calcium in CKD?
hypocalcaemia
what antibiotics commonly cause AKI?
macrolides eg gentamycin – causes tubular necrosis
IgA nephropathy and post strep glomerulonephritis are both nephritic conditions that develop after tonsilitis etc but what is the difference?
IgA - within a few days
post strep - within a few weeks
which part of the prostate is cancer usually in?
peripheral
transitional in BPH
what nerves innervate the bladder?
sympathetic - relax detrusor - inferior hypogastric
parasymp - contracts detrusor - pelvic
somatic - sphincter - pudendal
