Renal + urology Flashcards
What are the causes of CKD?
Diabetic nephropathy
Hypertension
Chronic glomerulonephritis
Chronic pyelonephritis
Adult PCKD
What constitutes stages 1-5 of CKD?
1: >90ml/min + evidence of renal damage*
2: 60-90ml/min + evidence of renal damage
3a: 45-59
3b: 30-44
4: 15-29
5: <15
*Renal damage: Deranged electrolytes, U+Es
Outline the diagnosis process of CKD
eGFR < 60ml/min, repeat in 2 weeks to exclude AKI
if eGFR <60ml/min OR ACR >=3mg, repeat in 3 months
if 3 month repeats as above, diagnose CKD
When should referral to nephrology be made for
Symptoms
eGFR
Proteinuria
Clinical:
- Persistent haematuria + cancer symptoms
- Uncontrolled HTN on 4 drugs
- Features of PCKD, RAS
eGFR:
- >25%/15 point decrease in 12 months
>25% decrease in 3 months of starting RAAS
- Increased CKD category
ACR
- >70 alone OR >30 with persistent haematuria
How do you manage anaemia in CKD?
Check iron status
Correct iron levels first
Then Erythropoetin if benefit likely
What is an important side effect of erythropoetin therapy
Accelerated Hypertension
Can lead to encephalopathy and seizures
How do you manage proteinuria in CKD if you are…
Non-Diabetic
Diabetic
Offer ARB/ACEI if ACR
Non-diabetic:
>70mg/mmol
30-70 with hypertension
Diabetic:
3mg/mmol
+ SGLT2i if ACR 3-30mg/mmol
How to protect bones in CKD
Reduce phosphate intake (phsophate pulls Ca2+ from bones)
If CKD 4-5 Give phosphate binders: calcium acetate, sevelamer
When is sevelamer favoured over calcium acetate?
Hypercalcaemia and vascular calcification
When should a CKD patient be dialysed?
eGFR < 15 (stage 5)
Renal transplant
What are the two main forms of dialysis?
Peritoneal
Haemodialysis
Patient reports pain distal to AV fistula, what could be occuring
STEAL syndrome
Fistula removes arterial blood, causing ischaemia of distal limb
What are the two commonest causes of peritonitis in dialysis?
How does NICE recommend you treat it?
Coag -ve staph eg Staph epidermidis
Staph aureus another cause
Vanc + ceftazidime added to fluid
OR
Vanc orally + Ceftazidime in fluid
How do you manage hyperkalaemia on bloods?
ECG
Stop drugs eg ACEIs
IV calcium gluconate for cardiac protection
Insulin/dextrose or neb salbutamol to shift K+ into cells
Calcium resonium to remove K+ from body
What are the causes for non visible haematuria that is
Spurious
Persistent
Spurious:
UTI, Menstruation, vigorous exercise, sexual intercourse
Persistent
Urogen cancer, stones, BPH, inflammation, nephritic syndromes
What infection can cause haematuria?
TB
Who gets referred for haematuria
Urgently
Non-urgently
Urgent
>=45 years + visible haematuria that is unexplained/persistent after UTI
>=60 years + unexplained NON-visible haematuria + dysuria/raised WCC
Non-urgent
>=60yrs + recurrent/persistent unexplained urinary tract infection
What features would make you suspect prostate cancer
LUTS, bloody/painful urination in an older man, especially if black
Who gets referred for prostate cancer?
2 week referral for
Malignant features on PR exam
Raised PSA
What is the first line and GS investigation for prostate cancer?
1st: Multiparametric MRI
GS: TRUS biopsy if Likert scale >3/5
What scoring system aids diagnosis of prostate cancer?
Gleason scoring
>=6 indicates cancer
What are the treatment options for bladder cancer?
Localised (T1/2): Radical prostatectomy + radiotherapy
Localised advanced (T3/4): Above + hormonal therapy
Metastatic
Anti-androgen therapy: Gosrelin to downregulate/bicalutamide to block
Bilateral orchidectomy
Docetaxel chemotherapy
What features raise suspicion of bladder cancer?
Older men who smoke and worked in textiles
Reporting recurrent urinary symptoms or painless haematuria
What is the first-line and definitive investigation for bladder cancer?
1st: CT-KUB
GS: TURBT
Who gets referred for bladder cancer?
>45yrs + unexplained or persistent haematuria where UTI has been accounted for
>=60yrs + non-visible haematuria + dysuria/raised WCC
.’. urgent haematuria criteria
How do you treat bladder cancer that is
Non-muscle invasive
Muscle invasive
Locally advanced/metastatic
non-muscle: radical cystectomy + adjuvant chemo
muscle invasive: As above + urinary diversion
Locally advanced/metastatic: Chemotherapy
What is the prognosis of bladder cancer?
Good if superficial but recurrs
Declines to 15% if metastatic
A non-tender, hard, irregular and non-transilluminable lump in a young white guy with HIV suggests?
Testicular cancer
Who gets referred for testicular cancer?
Man with non-painful change in shape of testis
What is the first line and GS investigation for testicular cancer?
1st: Scrotal USS
+ CT staging and tumour markers
What are the tumour markers for testicular cancer?
B-HCG for both
AFP if non-seminomatous
What is the management of testicular cancer?
Orchidectomy
Elderly man with increased urgency and reduced flow on urination suggests what condition?
Benign prostatic hypertrophy
What are the investigations for BPH
PR exam
Dipstick urine
freq-volume chart 3 days
PSA if IPSS >=8
In BPH, what are the management options if
moderate symptoms
prostatatic enlargement
mixed storage + obstructive symptoms
Tamsulosin
Finasteride
Anti-muscarinics (tolteridone/darifenacin)
Elderly female with high BMI and parity has increased urinary frequency raises suspicion of?
Urinary incontience
How can you differ between the following types of incontinence?
Urge
Stress
Overflow
Stress worse on sneezing or coughing
Overflow: Dribbling due to obstruction
Urge: Increased need to urinate due to overactive bladder
What investigations should you perform for suspected incontinence?
Vaginal exam for prolapse and tone
Urine dipstick and culture
Bladder diary for 3 days
What is the treatment route for someone with incontience with increased urgency?
Bladder retraining for 6 weeks
Medical
1st: Anti-muscarinics (no oxybutinin for frail women)
2: Mirabegnon
How do you treat incontience that is worse on stressing?
Pelvic floor muscle retraining 3 months
Mid-urethral tape for surgery
Duloxetine if surgery declined
Old man with Parkinson’s and BPH becomes confused following UTI and has reduced urinary output, what is the suspected diagnosis?
Acute urinary retention
What is the investigation and management of acute urinary retention?
Urinalysis and culture for infection
U+Es for AKI
Admit if first presentation
Catheterise + alpha blockers 2-3 days
Severe loin to groin pain associated with haematuria, nausea and vomiting in a middle aged man suggests what diagnosis?
Renal colic/stones
What investigations should be performed for renal stones
Check routine bloods including eGFR
Non-Contrast CT-KUB
What is the management for renal stones where
<5mm
5-9mm
10-19mm
>=20mm
Watch and wait
Shock wave lithotripsy (US waves)
Urethroscopy (scope up the tract)
Percutaneous nephrolithotomy (direct removal from kidney)
What renal stone is most associated with the follwing
Most common
Gout
Proteus UTI
Recurrent stones and UTIs
Calcium
Uric acid
Struvite
Cysteine
How can you prevent recurrence of the following stones?
Calcium
Oxalate
Uric acid
High fluid, low animal protein diet
Cholestyramine
Allopurinol
What is the most common type of bladder cancer?
Transitional cell
What renal imaging is most useful for…
The renal cortex
glomerular filtration
imaging kidneys in renal impairment
Bladder reflux
Evaluate lesions when staging malignancy
DMSA scintigraphy
DTPA
MAG3 urography
MCUG scan
PET/CT
When prescribing treatment GnRH agonists for prostate cancer, what do you need to co-prescribe and why?
Anti-androgens (cyoproterone acetate)
Prevents flaring of symptoms when starting treatment
What is the most common cause of peritonitis in peritoneal dialysis?
S. epidermidis
How do you treat rhabdomyolysis?
IV fluids
+ urinary alkalinisation
What is a common complication of prostate cancer?
Erectile dysfunction
What can throw off an eGFR?
Motherhood
Muscles
Meat (red, consumed 12hrs before)
What quotas are needed for maintenance fluid for…
Water
glucose
Na+, K+, Cl-
25-30ml/kg/day
50-100g/day (WEIGHT IRRELEVANT)
1mmol/kg/day
Who should Hartmann’s solution be avoided in?
Hyperkalaemics
What blood results do you see in HUS/
Reduced Hb, thrombocytes
Fragmented blood film
If a patient has gynaecomastia on spironolactone, what do you switch them to?
Eplernone
What investigations and treatment is done in priapism?
Cavernosal blood gas analysis or doppler US
1st line: Aspirate + saline flush
What is the US diagnostic criteria for polycystic kidney disease?
If + ve family history…
2 cysts, either side, <30yrs
2 cysts, bilateral 30-59
four cysts, bilateral, >60yrs
How can you differentiate between AKI and dehydration on U+Es
Dehydration: urea increase > creat increase proportionally
How is LUTS…
Investigated
Treated
Urinary freq-vol chart
International prostate symptom score >=8
If voiding prevalent: a-blocker
Prostatic enlargement: 5-a reductase (finasteride)
Mixed: Combo therapy
How is hydronephrosis…
Identified
Managed
1st line: US
if colic suspected: CT scan
Rx
relieve blockage…
Acute upper tract: Nephrostomy
Chronic upper: stent
High PLASMA osmolality and low URINE osmolality indicates what?
How do you…
Differentiate this from primary polydipsia
Differentiate the subtypes?
Diabetes insipidus
Urine osmolarity high after deprivation, DI low
Cranial: Desmopressin (ACTH) causes increased osmolarity
Nephrogenic: Desmopression does not change
For hypokalaemia, what are the…
Investigations
Treatment
If found, ECG for T wave flattening, U waves and ST segment changes
Mild-mod (>2.5): Oral potassium
Severe (<=2.5): IV replacement <10mmol/hr
How can you differentiate full torsion vs appendage only?
cremasteric reflex absent in true torsion
How does the size of the kidney change if the patient has
CKD
Diabetic
CKD: Smaller
Diabetic: Larger
How can dehydration be spotted as a cause of AKI?
Proportional raise in urea greater than that of creatinine
How do you treat hydronephrosis if the blockage is due to…
Urinary retention
Neprho-ureteric blockage
Urethral catheter
Nephrostomy
When do you dialyse an AKI patient?
If they are not responding to treatment…
Hyperkalaemia
Pulmonary oedema
Acidosis
Uraemia
How does the following direct the cause of hypertension and headache…
low renin, high aldosterone
high renin, high aldosterone
Helps differentiate where excess aldosterone is coming from
Renin low: Primary (as renin not stimulating release) eg adenomas
Renin high: Secondary (as renin stimulating increased release) eg renal artery blockages cause hypoperfusion causing more renin to bring BP back up
How can you prevent renal stones in a hypercalcaemic patient?
What is the most common cause of death in dialysis patients?
IHD
For prostatitis…
What is the most common organism
What antibiotic do you give
E.Coli
14 days quinilone
How do you determine if a renal transplant patient is experiencing
Hyperacute rejection
Acute graft failure
Chronic graft failure
Hyperacute: Within hours
Acute: <6 months, rising creat + pyuria + proteinuria
Chronic: >6 months, recurrence of original disease
Which renal condition causes ‘allergic’ picture, impaired renal function following drug therapy (particularly antibiotics)
Acute interstitial nephritis
How can you roughly estimate paeds maintenance fluids if small losses are not important?
1st 10kg: 100ml/kg
2nd 10kg: 50ml/kg
Subsequent: 20ml/kg
How long does it take for an AV fistula to work?
6-8 weeks
Painless haematuria, flank pain and mass in a child suggests what?
Wilms tumour
What cause of AKI has incresed urine sodium?
Acute tubular necrosis
Necrosis of tubules causes leakage
