Renal/urology Flashcards
What is the definition of AKI?
Rise in creatinine of >25 micromol/l in 48 hours
Rise in creatinine of more than 50% in 7 days
Urine output of <0.5ml/kg/hour
Name some risk factors for AKI
Older age, sepsis, CKD, heart failure, diabetes, liver disease, medications
Name some common medications that can increase the risk of AKI
NSAIDs, gentamicin, diuretics, ACE inhibitors, contrast agents
Name some pre-renal causes of AKI
Dehydration, shock, heart failure, sepsis
Name some renal causes of AKI
Acute tubular necrosis, glomerulonephritis, acute interstitial nephritis, haemolytic uraemic syndrome, rhabdomyolysis
Name some post renal causes of AKI
Kidney stones, tumours, BPH, neurogenic bladder, strictures in urethra etc.
What is acute tubular necrosis?
Damage and death of the epithelial cells in the renal tubules due to ischaemia/hypoperfusion/nephrotoxins
What is seen in urinalysis of someone with acute tubular necrosis?
Muddy brown casts on urinalysis
How can you prevent AKI?
Avoid nephrotoxic drugs where appropriate, ensure adequate fluid intake, additional fluids before contrast
How do you manage AKI?
Reverse the underlying cause, IV fluids, withhold medication that may worsen condition, dialysis may be required in severe cases
What is CKD?
Progressive and permanent decrease in kidney function
What are the causes of CKD?
Diabetes, hypertension, age related decline, glomerulonephritis, polycystic kidneys, medications, renal artery stenosis
What are the symptoms associated with high urea/poor kidney function
Itching, loss of appetite, nausea, oedema, muscle cramps, peripheral neuropathy, pallor, hypertension
How do you confirm the diagnosis of CKD?
eGFR - two tests are required 3 months apart to confirm diagnosis
What are the stages and associated eGFRs?
Stage 1 = eGFR >90
Stage 2 = eGFR 60-89
Stage 3a = eGFR 45-59
Stage 3b = eGFR 30-44
Stage 4 = eGFR 15-29
Stage 5 = eGFR <15 (end stage)
How do you treat hypertension in those with CKD?
ACE inhibitors are 1st line
What is a significant result in urine albumin:creatinine?
> 3mg/mmol
What supportive management can be offered to those with CKD?
Optimise hypertensive/diabetic control, dietary advice regarding water and electrolyte intake, iron supplementation and EPO to treat anaemia
Why is CKD associated with anaemia?
Healthy kidneys produce EPO which stimulate production of RBC, in CKD this process does not occur as well –> anaemia
Why with CKD associated with bone disease?
High serum phosphate occurs due to reduced phosphate excretion
There is low vitamin D as the kidneys are essential in metabolising vitamin D
Active vitamin D is essential in calcium absorption from intestines and kidneys
How do you treat renal related bone disease?
Active vitamin D
Low phosphate diet
Bisphosphonates for osteoporosis
What is the preferred method for delivering long term dialysis?
Haemodialysis via AV fistula
What are the symptoms of nephritic syndrome?
Haematuria, oliguria, proteinuria (<3g), fluid retention
Why does nephrotic syndrome occur?
The basement membrane in the glomerulus becomes highly permeable resulting in significant proteinuria
What are the symptoms of nephrotic syndrome?
Proteinuria, low serum albumin, peripheral oedema, high cholesterol, frothy urine
What is the most common cause of nephrotic syndrome in children and adults?
Children = minimal change disease
Adults = membranous nephropathy
What is IgA nephropathy?
Nephritic syndrome that can occur 1-2 days after URTI
What is post-strep glomerulonephritis?
Nephritic syndrome that occurs 1-3 weeks following a strep infection
What is the pathology of anti-GBM?
Anti-GBM antibodies attack the glomerulus and pulmonary basement membranes causing pulmonary haemorrhage and glomerulonephritis
What systemic disease can cause glomerulonephritis?
HSP, vasculitis, lupus nephritis
What is renal tubular acidosis?
Metabolic acidosis due to imbalance of the hydrogen and bicarbonate ions
What is the pathology of type 4 renal tubular acidosis (most common)?
Caused by reduced aldosterone which leads to insufficient potassium and hydrogen ion excretion in the distal tubules (diabetes is most common cause)
What is the pathology of HUS?
Thrombosis in small vessels throughout the body triggered by shiga toxins for shigella or E.coli 0157
What is the triad of findings in HUS?
And what symptoms does that cause?
Haemolytic anaemia, AKI, thrombocytopenia
–>
Fever, abdo pain, lethargy, pallor, reduced urine output, haematuria, hypertension, bruising, jaundice, confusion
What is the management for HUS?
Supportive care - IV fluids, treat hypertension, blood transfusions, haemodialysis
What is released in rhabdomyolysis?
Myoglobin, potassium, phosphate and CK
CK >10000
What are the causes of rhabdomyolysis?
Prolonged immobility, extremely vigorous exercise, crush injuries, seizures, statins
What are the symptoms associated with rhabdomyolysis?
Muscle pain, muscle weakness, reduced urine output, red brown urine, fatigue, confusion
What is the management of rhabdomyolysis?
IV fluids, treat any hyperkalaemia
What extra-renal manifestations are associated with PKD?
Cerebral aneurysms, cysts on liver/spleen/pancreas/ovaries, mitral regurg, colonic diverticula
Which type of PKD is worse?
Autosomal recessive is more severe and often leads to renal failure before adulthood
What treatment is done for people with PKD?
Antihypertensives, analgesia, antibiotics, drainage of cysts, dialysis, renal transplant, screen for complications
What symptoms are associated with BPH?
Hesitancy, weak flow, urgency, frequency, intermittency, straining, terminal dribbling, incomplete emptying, nocturia
What is done to assess someone with/for BPH?
International prostate scoring system, DRE (large but smooth with intact central sulcus), urinary frequency volume chart, urine dip, bloods including PSA
What lifestyle advice can be given to someone with BPH?
Reduce caffeine/alcohol, avoid large fluid intakes in evening, avoid constipation, bladder retraining
What medications can be given to men with BPH?
Alpha blockers - tamsulosin (fast acting)
5-alpha reductase inhibitors - finasteride (can take up to 6 months)
What surgical options are available for men with BPH?
TURP is main one and most common
Which zone of the prostate are the majority of prostate cancers found?
Peripheral zone
What would a prostate feel like in someone with prostate cancer?
May feel firm, hard, asymmetrical, craggy, loss of central sulcus
What are the 1st line and definitive investigations for prostate cancer?
1st line = mutliparametric MRI
Definitive = prostate biopsy
Where does prostate cancer spread to?
Lymph nodes, bones, lungs, liver
What options are there for managing prostate cancer?
Active surveillance, watchful waiting, radiotherapy, brachytherapy, hormone therapy (used in non-local disease), surgery
What are the two types of testicular cancer?
Seminomas
Non-seminomas (usually teratomas)
What are the risk factors for testicular cancer?
Undescended testes
Male infertility
Family history
Low birth weight
Infantile hernia
Kleinfelter’s syndrome
What are the features of testicular cancer lumps?
Painless, arising from testicle, hard, irregular, no transillumination
What tumour markers are used for testicular cancer?
Alpha fetoprotein
Beta-hCG
LDH - non-specific
What is the management for testicular cancer?
Surgery to remove testicle, chemotherapy (if advanced or adjuvant to prevent recurrence), radiotherapy
What is the most common type of bladder cancer in the UK?
Transitional cell carcinomas (95%)
SCC (5%)
What are the main risk factors for bladder cancer?
Smoking and increased age, aromatic amines found in dye and cigarette smoke
What symptoms are associated with bladder cancer?
Painless haematuria
>45 with visible haematuria =2ww
>60 with microscopic haematuria plus dysuria or raised WCC =2ww
What investigations are used in bladder cancer?
Flexible cystoscopy + biopsy and CT urogram
What is the management for bladder cancer?
TURB, intravesical chemotherapy/BCG, radical cystectomy
Chemo + radiotherapy may be used
What is the triad of symptoms associated with RCC?
Haematuria, flank/loin pain, palpable mass
What risk factors are there for RCC?
Smoking, obesity, hypertension, end-stage renal failure, male
What is the classical metastasis for RCC?
Cannonball mets in the lung (spreads via inferior vena cava)
What paraneoplastic features are associated with RCC?
Polycythaemia = due to secretion of unregulated EPO
Hypercalcaemia - due to secretion of a hormone that mimics action of PTH
Hypertension - due to increased renin
Stauffer’s syndrome - abnormal LFTs without liver mets
What investigations are done in RCC?
USS - can differentiate cyst from tumour
CT scan - senstitive for small tumours
Excretion uropathy
What is the management of someone with RCC?
Surgery - partial or total nephrectomy
Arterial embolisation, ablation, percutaneous cryotherapy
Where do renal stones most commonly get stuck?
Vesico-ureteric junction
What is the most common type of renal stone and what are the other types?
Calcium stones (80%)
Uric acid
Struvite (associated with staghorn calculus)
Cystine (associated wtih geentic condition that leads to high cystine levels in urine –> recurrent renal stones)
What are the symptoms of renal stones?
Renal colic - unilateral loin to groin pain, fluctuates in severity as the stone moves and settles
May also have haematuria, N+V, sepsis
What is the first line investigation in someone with renal colic?
Non-contrast CT KUB (within 24 hours)
What type of analgesia is given in renal colic?
IM/PR diclofenac (if renal function allows)
IV paracetamol if not suitable for NSAIDs
When are surgical interventions required for renal stones?
10mm or larger or do not pass spontaneously or where there is complete obstruction or infection
What findings would you see on a urine dipstick that indicate UTI?
Nitrites (best indicator), leukocytes, microscopic haematuria
What bacteria cause UTIs?
E.coli, klebsiella, enterococcus, pseudomonas aeruginosa, staph aureus, candida albicans
What antibiotics are used for UTIs?
And what length course is used for different types of people
1st line = trimethoprim/nitrofurantoin
2nd line = fosfomycin
Pregnancy = amoxicillin, cefalexin
3 days in simple lower UTIs
5-10 days for immunosuppressed, abnormal anatomy or impaired renal function
7 days for men, pregnant women or catheter related UTI
What are the risk factors for pyelonephritis?
Female, structural urological abnormalities, vesico-ureteric reflux, diabetes
What symptoms are associated with pyelonephritis?
Fever, loin/back pain, N+V, haematuria, dysuria, renal angle tenderness
What antibiotics are used in pyelonephritis?
Cefalexin, co-amox, trimethoprim, ciprofloxacin
What are the typical findings on testicular examination in someone with hydrocele?
Testicle is palpable within hydrocele
Soft, fluctuant, transilluminated
Irreducible and has no bowel sounds
When do hydroceles require surgery/aspiration?
If large or symptomatic
In babies need surgery if not corrected by 1-2years of age
What are the symptoms and examination findings of someone with varicocele?
Symptoms = throbbing/dull pain or discomfort worse on standing, dragging sensation, infertility
Examination = bag of worms, disappears when lying down, asymmetry in testicle size
What examination findings are present in those with epididymal cyst?
Soft round lump typically at top of testicle, separate from testicle, may transilluminate if large
Do epididymal cysts need removing?
Usually harmless so no but can be removed if causing pain
What are the causes of epididymo-orchitis?
E.coli, chlamydia trachomatis, neisseria gonorrhoea, mumps
What are the symptoms of epidiymo-orchitis?
Gradual onset (hours) of unilateral testicular pain, heavy dragging sensation, swelling of testicle and epididymis, tenderness on palpation
What antibiotics are typically used for epidydmo-orchitis?
If enteric cause - ofloxacin, levofloxacin, co-amoxiclav
If STI - IM ceftriaxone, doxycyline
What are the causes of ED?
Spinal cord disease, diabetes, vascular disease, trauma, hypertension, drugs, psychological causes
What medications can be used to treat ED?
Phosphodiesterase-5-inhibitors = sildenafil
Intracavernosal injections of alprostadil
What are the causes of acute urinary retention?
BPH, urethral obstruction, medications, UTI, postoperatively
What symptoms are common in acute urinary retention?
Inability to pass urine, lower abdominal pain, considerable pain or distress, acute confusional state
What investigations and management are done in acute urinary retention?
Bladder USS
Bloods - U+Es, creatinine, FBC, CRP
Catheterisation
What is a complication of treating acute urinary retention?
Post-obstructive diuresis - requires IV fluids
When is the PSA blood test very useful?
In monitoring response to treatment in those with prostate cancer
What investigation is required in a child/adult with nephrotic syndrome?
Child - none as likely minimal change disease
Adult - renal biopsy to determine cause
What is required before contrast in someone with CKD?
IV fluids
