Renal, Urogenital, Endocrine Flashcards
What are the criteria to diagnose an AKI?
Rise in creatinine of >25 micromol/L in 48 hours
Rise in creatinine of >50% in 7 days
Urine output <0.5ml/kg/hr for >6 hours
Risk factors for AKI?
CKD
HF
T2DM
Liver disease
>65 years
Cognitive impairment
Nephrotoxic medications e.g. NSAIDS, ACEi
Contrast in CT
Three generic causes of AKI?
Pre renal
Renal
Post renal
Pre renal causes of AKI?
Most common cause
Due to inadequate blood supply
Can be due to:
Dehydration
Hypotension/ shock
Heart failure
What are some renal causes of AKI?
Glomerulonephritis
Interstitial nephritis
Acute tubular necrosis
Post renal causes of AKI?
Due to obstruction of outflow
Kidney stones
Masses in abdomen or pelvis e.g cancer
Ureter strictures
Enlarged prostate e.g cancer or BPH
Investigations for AKI?
Urinalysis
Leucocytes—> ?infection
Nitrites —>?infection
Protein —> ?acute nephritis
Blood —> ?acute nephritis
Glucose —> ?diabetes
Potential consequences of AKI?
Hyperkalaemia
Fluid overload, heart failure, pulmonary oedema
Metabolic acidosis
Uraemia (high urea) —> encephalopathy or pericarditis
Causes of CKD?
Diabetes
Hypertension
Age related decline
Glomerulonephritis
Pyelonephritis
PKD
Medications e.g. NSAIDS, PPIs and lithium
How is CKD diagnosed?
eGFR- two tests required 3 months apart
Proteinuria… Urine albumin:creatinine ratio >3mg/mmol significant
Diagnosis requires an eGFR <60 and/or proteinuria in both tests 3 months apart.
Stages of kidney function?
G score based on eGFR
G1- eGFR >90
G2 - 60-89
G3a 45-59
G3b 30-44
G4 15-29
G5 <15 - end stage renal failure
What stage of CKD would an eGFR with…
89
17
61
37
89 —> G2
17 —> G4
61 —> G2
37 —> G3b
What eGFR is required to diagnose CKD
eGFR <60
(Or proteinuria)
Management of CKD?
Slow progression of disease
Reduce risk of CVD
Treating complications
Features of ADPKD?
Autosomal dominant polycystic kidney disease
Hypertension
Recurrent UTIs
Flank pain
Haematuria
Palpable kidneys
Renal impairment
Renal stones
Extra Renal manifestations
- Liver cysts- 70% can cause hepatomegaly
- Berry aneurysms- 8% can rupture and cause SAH
- CVD: mitral valve prolapse, aortic dissection, mitral/tricuspid incompetence, aortic root dilation
- cysts in other organs e.g. pancreas, spleen,
2nd line for stress incontinence?
Duloxetine
If 1st line pelvic floor, reduction in caffeine and alcohol tried and not for surgery
Urge incontinence management?
1st- Bladder retraining
2nd- bladder stabilising drugs e.g. oxybutinin, tolterodine or darifenacin (immediate release oxybutinin should be avoided in frail older women)
- mirabegron, a beta 3 agonist- if concerned about anti-cholinergic SEs in frail old ladies
What are the two pharmacological management options for stress and urge incontinence?
Stress- duloxetine
Urge- oxybutinin (urge-oxy, both begin with vowels)
Hypertension and hypokalaemia and lethargy. Likely cause?
Primary hyperaldosteronism
Can be caused by bilateral idiopathic adrenal hyperplasia- 70%
Adrenal adenoma secreting aldosterone- Conn’s syndrome
First line investigation for primary hyperaldosteroneism?
Serum aldosterone/renin ratio
Patient presents with acute renal failure and haemoptysis, what are the two most likely causes?
Goodpasture syndrome- associated with anti-GBM antibodies
Granulomatisis with polyangitis aka Wegeners granulomatosis- vascularised associated with ANCA antibodies
Patient with haemoptysis, deranged electrolytes, raised creatinine, reduced urine output, a wheeze, sinusitis and a saddle shaped nose. What’s going on?
Wegeners granulomatosis aka granulomatosis with polyamgitis
How are most types of Glomerulonephritis treated?
Immunosuppression ie steroids
Blood pressure control through ACEi or ARBs
23yo man presents with dark urine, reduced urine output, some ankle swelling, had a cold 2-3 weeks ago but otherwise no PMH. What’s going on?
Signs of nephritic syndrome- haematuria, oligourea, fluid retention, AND proteinurea
Likely: post streptococcal Glomerulonephritis
What is nephritic syndrome?
Nephritic syndrome/nephritis describes a group of symptoms, not a disease
Has features of (but these aren’t a criteria to be classed as nephritic sx)
Haematuria
Oliguria
Proteinuria- less than 3g/24hrs- more will be NEPHROTIC syndrome
Fluid retention
What is nephrotic syndrome?
Group of sx without specific cause. But have a criteria to be classed as nephrotic sx (unlike nephritic sx)
Criteria
- peripheral oedema
- PROTEINUREA >3g/24hours
- serum albumin under 25g/L
- hypercholesterolaemia
Signs of CKD?
Usually asymptomatic until stage 4 (eGFR 15-29) but can have:
- pruritis- itching
- loss of appetite
- nausea
- oedema
- muscle cramps
- perioheral neuropathy
- pallor
- hypertension
What is required to diagnose CKD?
eGFR < 60
OR
proteinuria
How is proteinuria measured, what result is significant?
Urine albumin : creatinine ratio
Significant >3 mg/mmol
What is the G score and the A score?
G score is the eGFR score
A score is based on the albumin:creatinine ratio
High calcium, high PTH. What type of hyperparathyroidism is this? Cause?
Primary
Parathyroid gland tumour
What causes secondary hyperparathyroidism? Would Ca and PTH be raised or low?
CKD
Low vit D
Ca would be low
PTH would be raised
What causes tertiary parathyroidosm?
Result of long term secondary. Parathyroid gland undergoes hyperplasia to maintain the high release of PTH. If cause is treated, still releases high PTH
Management of tertiary hyperparathyroidism?
Surgical resection of hyperplased area
3 actions of PTH
To raise calcium by:
Increases gut reabsorption of calcium
Increased reabsorption of calcium and phosphate from the kidney
Increased osteoclast activity to release calcium and phosphate from bones
AKI complications
Hyperkalaemia
Haemorrhage
Pulmonary oedema
What’s released into the blood when rhabdomyalysis occurs?
Creatinine kinase
Myoglobin
How can rhabdomyolysis cause an AKI?
Myoglobin released filter through the glomerulus and precipitate, obstructing the tubules
What common drugs should be stopped if someone has an AKI?
NSAIDs
ACEi
Metformin
Furosemide
Management of AKI caused by rhabdomyolysis?
IV fluid rehydration
Acute renal failure and suspecting an intrinsic renal cause, other than the usual blood workup, what blood tests would you want?
ANCA- ?Wegeners granulomatosis
anti-GBM- ?Goodpastures?
Define nephrotic syndrome
Proteinuria >3g/24hours
Hypoalbuminaemia <30g/L
Oedema
Most common cause of nephrotic syndrome in children, adults and elderly?
Other causes?
Children- minimal change disease
Adults- membranous nephropathy
Elderly- focal segmental glomerulosclerosis
Other causes
- diabetes
- amyloidosis
- SLE
- drugs
Complications of nephrotic syndrome?
Increased susceptibility to infections- lose immunoglobulins in urine and tx is immunosuppressive e.g. steroids
Increased risk of VTE- loss of clotting factors in urine and increased fibrinogen
Hyperlipidaemia- increased synthesis of lipoproteins in liver due to hypoalbunaemia
What do you do to determine cause in hypovolaemic hyponatraemia?
Measure urinary sodium- indicates if sodium is lost renally or extra-renally
Renally if urinary Na >20
Extra-Renally if Na<20
Hypovolaemic hyponatraemia renal loss causes?
Addisons disease
Diuretics
Diuretic phase of renal failure
Hypovolaemic hyponatraemia extra-renal loss causes?
Diarrhoea
Vomiting
Burns
Fistula
Euvolaemic hyponatraemia what investigation to determine cause?
Urine osmolality
If low (<500mmol/kg)- ?hypothyroidism, ?psychogenic polydipsia
If high (>500mmol/kg)- SIADH
What changes occur to the urine in SIADH? What type of hyponatraemia is caused by SIADH?
High urine osmolality/ high urine sodium
Euvolaemic hyponatraemia- the increased ADH causes blood dilution and reduced Na but not enough to cause a fluid overload
Are the following intracellular or extracellular?
- sodium
- potassium
Sodium is extracellular- hence the higher (compared to K) conc in blood
Potassium is intracellular
How do you calculate serum osmolality?
(2x Na) + glucose + urea
Sometimes include K in the (2x Na+K)
All in mmol/L
How do you test for adrenal insufficiency?
Short synacthen test
When correcting hyponatraemia, how quickly should you aim to correct the Na deficit?
Less than 10mmol/l per 24 hours
What happens if severe hyponatraemia is corrected too quickly?
Severe is below 120 mmol/l
Central pontine myelinolysis
What’s a normal osmolality of serum and urine?
Plasma- 275-295 mOsm/kg
Urine- around 100
A patient presents with dysuria and urinary frequency, what are you looking for on urine dipstick to confirm the diagnosis?
Nitrites- suggest bacteria present as they break down nitrates into nitrites
Leukocyte esterase- indicates leukocyte level (ie WBCs)- raised indicates infection
Nitrites are better indication of a UTI.
If both present, treat as UTI
If only nitrites- treat as UTI
If only leukocytes raised- don’t treat unless clinical evidence of UTI
If only one raised, send to microbiology
How does aldosterone act on the body?
Aldosterone is a mineralocorticoid steroid hormone
Acts on kidney
Causes/increases:
Na reabsorption from distal tubule
K secretion from distal tubule —> can get hypokalaemia
H secretion from collecting ducts
What would you expect to see in the ix of choice in primary hyperaldosteronism?
High aldosterone and low renin
What would you expect to see in the ix of choice in secondary hyperaldosteronism?
High aldosterone and high renin
Most common cause of secondary hypertension?
Hyperaldosteroneism
Cause and pathophysiology of primary hyperaldosteronism?
Adrenal glands directly produce too much aldosterone
Causes- most common
- b/l adrenal hyperplasia
- an adrenal adenoma secreting aldosterone- aka Conn’s syndrome
Serum renin will be low as negative feedback causes it to decrease
Causes and pathophysiology of secondary hyperaldosteronism?
Secondary so overstimulated from elsewhere!
Excess renin stimulating adrenal gland to release aldosterone
Causes
- renal artery stenosis
- renal artery obstruction
- HF
What is diabetes insipidus?
A condition where either secretion or response to ADH is impaired.
I.e. decreased secretion or an insensitivity to it
Features of diabetes insipidus?
Polyuria
Polydipsia
Hypernatraemia
Investigations for diabetes insipidus?
High plasma osmolality with low urine osmolality
- a urine osmolality >700 mOsm/kg excludes diabetes insipidus
Water deprivation test
What test can exclude diabetes insipidus?
If urine osmolality is above 700
As DI leads to a high plasma osmolality and a low urine osmolality
What are the two types of diabetes insipidus?
Cranial or nephrogenic
Cranial is where not enough ADH is produced by the hypothalamus
Nephrogenic is where the kidneys don’t respond to ADH
What is the water deprivation test? What is it aka?
How does it work?
Aka: desmopressin stimulation test
Tests for diabetes insipidus
Method
- avoid fluids for 8 hours- fluid deprivation
- urine osmolality is measured
- synthetic ADH (desmopressin) is given
- 8 hours later urine osmolality is measured again
In cranial DI, the urine osmolality will go from low to high as the kidneys are able to respond to the desmopressin
So, in nephrogenic DI, urine osmolality will be low and stay low
Desmopressin test. What will the urine osmolality after desmopressin deprivation and after desmopressin administration in….
- cranial DI
- nephrogenic DI
- primary polydipsia
Desmopressin is synthetic ADH
Cranial DI
- after deprivation- low (as not enough ADH to reabsorption water)
- after ADH- high- as kidneys respond
Nephrogenic DI
- after deprivation- low
- after ADH- stays low as kidneys can’t respond
Primary polydipsia
- urine osmolality is high after deprivation of water as there is no ADH problem and the body is not still secreted water when dehydrated. This is caused by excessive drinking
How do you calculate the anion gap?
(Na + K) - (Bicarb + Cl)
Normal anion gap
~3-12 mmol/L
Every source says something slightly different in range of 3 to 18
From the history, how would you differentiate between IgA nephropathy and post streptococcal glomerulonephritis?
PSGN usually develops 1-2weeks post strep infection e.g. sore throat
IgA is usually 1-2 days after URTI
They both usually present with haematuria
What bedside test can be done to differentiate between AKI and CKD?
Renal USS
Usually, CKD can lead to small kidneys.
Exceptions- PKD and early stages of diabetic nephropathy where they can increase in size before later shrinking
Management of IgA nephropathy
If isolated event with proteinuria <500 and normal eGFR- only follow up to check renal function
If persistent proteinuria >500- ACEi
If eGFR is falling and not responding to ACEi- immunosuppression with corticosteroids
What blood test can be done to confirm recent streptococcal infection?
Raised anti-streptolysin O titre
Low C3
Management of nephrogenic and cranial diabetes insipidus?
Cranial- synthetic ADH (desmopressin)
Nephrogenic- thiazide like diuretics and low salt/protein diet +/- NSAIDS
What is a pheochromocytoma?
A tumour of chromaffin cells in the adrenal medulla of adrenal glands
So, secretes unregulated amounts of adrenaline
How does a pheeochromocytoma usually present?
Bursts of a excessive sympathetic activity,
Adrenaline is released in bursts from the phaeochromocytoma
How do you diagnose/ investigate for a phaeochromocytoma?
24 hour catecholamines
Plasma free metanephrines
*metanephrines are breakdown products if adrenaline with a linger half life so have less dramatic fluctuations. 24 hour catecholamines are done do see the wider picture too
Symptoms and signs of a phaeochromocytoma?
Fluctuating symptoms of increased sympathetic activity
- anxiety
- sweating
- headache
- hypertension
- palpitations, tachycardia
And ‘paroxysmal AF’
Management of a phaeochromocytoma?
Alpha blockers e.g. phenoxybenzamine
Beta blockers once established on alpha blockers
Adrenalectomy- to remove tumour. Should be medically managed pre surgery to reduce anaesthetic and surgical risk
What medication can be given to patients with PKD and their disease is progressing rapidly or they’re in stage 2 or 3 CKD?
Tolvaptan- a vasopressin receptor 2 antagonist
Investigation for acromegaly?
Serum IGF-1 levels (insulin-like growth factor) is 1st line
OGTT is used to confirm with lack of GH suppression when given glucose
What is sick euthyroid syndrome?
In acute illness can occur
T3 and T4 are low and TSH doesn’t increase in response to this
Usually resolves with treatment of cause
For a patient who is newly diagnosed with T2DM and has a PMH of angina, what treatment should they be prescribed?
Metformin- titrated up as tolerated
Once metformin is established, start an SGLT-2 inhibitor (e.g. dapaglifozin) due to CVD disease (used as organ protection rather than glycemic control)
Should be given in addition to metformin in patients with:
- high risk of CVD, QRISK >10%
- established CVD e.g. angina
- chronic HF
Diabetes sick day rules?
If a diabetic becomes unwell
- Increase frequency of glucose monitoring to at least 4 hourly
- at least 3L of fluids /day
- if can’t eat, drink sugary drinks
- continue normal drugs- including insulin, to prevent DKA
How does Addisons disease usually present?
Reduced cortisol and aldosterone produced from adrenal glands
Lethargy, weakness, anorexia, n&v, weight loss, salt-craving
Hyperpigmentation of palmar creases
Vitiligo- loss of skin pigment
Loss of oubic hair in women
Hypotension
Hypoglycaemia
Hyponatraemia and hyperkalaemia
Severe: collapse, shock, pyrexia
What is addisons disease?
A for Adrenal
Addisons is primary hypoadrenalism. Ie the adrenal glands aren’t functioning properly
This leads to low cortisol and aldosterone
T2DM diagnostic criteria?
Either plasma glucose or HBA1c
If symptomatic
- fasting glucose >7 mmol/l
- random glucose >11.1 mmol/l
*if asymptomatic, these must be repeated to diagnose
HBA1c >48 (6.5%) mmol/mol
Which diabetic drugs are higher risk of causing hypoglycaemia?
Insulin
Sulfonylureas e.g. gliclazide
What electrolyte abnormalities do you often see in Conn’s syndrome?
Hypokalaemia
Hypernatraemia (or higher in normal range)—> hypertension
Conn’s is specifically an adrenal adenoma that secreted excess aldosterone. The most common cause of hyperaldosteronism is now recognised as bilateral hyperplasia of adrenal glands
Conns is caused by increased aldosterone release from adrenal glands —> causes Na reabsorption and K and H secretion in kidneys. Can also get alkalosis due to loss of H
What vision abnormality can be seen in acromegaly?
Bitemporal hemianopia- due to compression of optic chiasm from pituitary adenoma
How would you test for a phaeochromocytoma?
Plasma metanephrines OR 24 hour urine catecholamines
What is Conn’s syndrome?
Conn’ syndrome- an adrenal adenoma secreting excessive aldosterone ( causing a Primary hyperaldosteroneism)
What is Cushing’s disease?
What is Cushing’s syndrome?
Cushing’s syndrome reflects the clinical picture of prolonged elevation of cortisol.
Cushing’s disease is the specific condition where a pituitary adenoma secretes excess ACTH which leads to Cushing’s syndrome
Brief overview of the adrenal axis?
Hypothalamus releases CRH in response to low cortisol
CRH stimulates anterior pituitary to release ACTH
ACTH stimulates adrenal glands to release cortisol
Cortisol is a steroid hormone that:
- suppresses the immune system
- inhibits bone formation
- raises blood glucose
- increases metabolism
- increases alertness
What does CRH and ACTH stand for?
CRH- Corticotrophin Releasing Hormone
ACTH- Adrenocorticotrophic hormone
What medications are aldosterone antagonists?
Eplerenone
Spironolactone
What medication can be used if hyponatraemia in SIADH is not alone corrected by fluid restriction?
Vaptans e.g. Tolvaptan
- they’re ADH receptor blockers
T2DM diagnosis
Plasma glucose for
- fasting
- random
- OGTT
HbA1c
Fasting > 7 mmol/l
Random > 11 mmol/l
OGTT- give 75g glucose drink, 2 hours later >11 mmol/l
HbA1c > 48 mmol/mol (>42 is prediabetes)
Sweating, increased alertness, tremour, always hot with neck stiffness, recent illness, what is it?
Hyperthyroidism
De quervains thyroidistis- post illness, usually resolves
What is hydroxychloroquine used to treat and what do patients need to be monitored for?
SLE- discoid and systemic
Rheumatoid arthritis
Eye function as higher risk of severe retinopathy. Visual acuity testing every 6-12 months (standard reading chart)
Can be used in pregnancy
Incubation period for gonorrhoea and chlamydia?
Gonorrhoea 2-5 days
Chlamydia 7-21 days but often asymptomatic
19yo male with dysuria and penile discharge, key differentiating question to differentiate between chlamydia and gonorrhoea?
When did they have unprotected sex
Both present with dysuria and penile discharge but chlamydia presents 7-21 days after unprotected sex, gonorrhoea is 2-5 days
Gonorrhoea tx?
IM ceftriaxone 1g (used to also give Azithromycin, not anymore)
Management of chlamydia
Doxycycline 7 days
Used to be Azithromycin. Azithromycin still used 2nd line and in pregnancy(or erythromycin or amoxicillin)
