RENAL/UROLOGY Flashcards
What tests should be performed in acute urinary retention?
- urinalysis for infection
- U+E - assess renal function
- FBC + CRP - infection?
- Bladder scan - more than 300cc confirms
- Renal USS if renal impairment
- PSA NOT required as will be raised in acute retention
How do you manage acute urinary retention?
- Catheterise - use 3-way catheter in clot retention
- Tamsulosin
- Record volume drained in first 15-mins
- less than 200ml = no acute retention - Further investigate based on likely cause
What is a sign of acute on chronic urinary retention?
Overflow urinary incontinence
What is the management of chronic urinary retention?
- Intermittent bladder catheterisation
- Long-term catheters (try avoid)
- Alpha-adrenoreceptor blocker try for 4-6wks
What are unilateral causes of hydronephrosis? (HINT: PACT)
P - pelvic ureteric obstruction
A - aberrant renal vessels
C - calculi
T - tumours of renal pelvis
What are bilateral causes of hydronephrosis? (HINT: SUPER)
S - stenosis of urethra U - urethral valve P - prostatic enlargement E - extensive bladder tumour R - retroperitoneal fibrosis
What investigations should be performed in hydronephrosis?
- USS
- IV urogram assesses position of obstruction
- Antegrade or retrograde pyelography
- CT - if stones suspected
What is the most common cause of pyelonephritis?
E.coli
What investigations should be performed in suspected pyelonephritis?
- Urinalysis
- FBC
- U+E
- USS
- CT
- DMSA - indicates renal scarring
- Blood + urine cultures
What investigations should be performed in suspected renal stones?
- urinalysis
- U+E
- FBC ?infection
- Bone profile ?hypercalcaemia
- AXR
- spiral non-contrast CT KUB is gold standard
How do you manage renal stones?
- Diclofenac + fluids (IV or oral)
- If infection = cefuroxime + gentamicin
- Anti-emetic if vomiting
If less than 5mm = let pass spontaneously with increased fluid intake
If over 5mm or pain NOT improving = expulsion therapy with nifedipine/tamsulosin
Stones that do not pass
= Extracorporeal shockwave lithotripsy
What are the symptoms + signs of ADPKD? Include extra-renal manifestations.
SYMPTOMS
- abdominal pain, haematuria, symptoms of UTI, headaches
SIGNS:
- renal enlargement with cysts, HTN, progressive renal failure, palpable kidneys
EXTRA-RENAL:
- cerebral aneurysms
- hepatic, splenic, pancreatic, ovarian + prostatic cysts
- cardiac valve disease (MR)
- colonic diverticula
- aortic root dilatation
What investigations should be performed in ADPKD?
- Renal USS
- CT abdo + pelvis
- U+E
- Genetic testing
How do you manage ADPKD?
- monitor U+E, BP + USS regularly
- Treat HTN aggressively - ACEi first
- Analgesia for renal colic (avoid NSAIDs)
- Abx for infections (drainage of cysts may be req)
- Genetic counselling
- Lifestyle modifications - increase water + decrease salt intake, avoid caffeine
- Nephrectomy
What are the (i) pre-renal (ii) renal (iii) post-renal causes of AKI?
(i) shock - dehydration, hypotension
- NSAIDs, ACEi
- HF
- renal artery stenosis
(ii) ATN
- nephritic syndrome
- nephritis
- vasculitis
(iii) Stone
Neoplasm
Inflammation/stricture
Prostatic hypertrophy
Posterior urethral valves
Infection
Neuro = post-op or neuropathy
How do patients tend to present with an AKI?
- vomiting
- dizziness
- orthopnoea
- reduced urine output
- fluid overload (oedema, high or low BP, raised JVP, S3 gallop)
What investigations should be performed in pts with AKI?
- Bloods - FBC, U+E, LFT, glucose, clotting, Ca, ESR
- ABG - hypoxia (oedema), acidosis, hyperkaelamia
- Urine - dipstick, MC+S, chemistry (U+E, PCR, osmolality, BJP)
- ECG - hyperkalaemia
- CXR - pulmonary oedema
- Autoantibodies - ANCA, ANA, anti-GBM
- Consider blood film + renal immunology if systemic cause suspected
- Renal USS - size? obstruction? hydronephrosis?
How do you manage hyperkalaemia?
- 10ml 10% calcium gluconate
- 10U actrapid, 50ml 50% glucose IV
- Salbutamol neb 5mg
- Recheck K+ in 2h by VBG, U+E, ECG
What are the complications of AKI?
- Hyperkalaemia
- Fluid overload, HF, pulmonary oedema
- Metabolic acidosis
- Uraemia (azotaemia) - can lead to encephalopathy or pericarditis
What are the indications for acute dialysis? (AEIOU)
A - acidosis (severe + not responding to treatment)
E - Electrolyte imbalance (severe + unresponsive hyperK+)
I - intoxication (acute drug OD)
O - Oedema (severe + unresponsive pulmonary oedema)
U - Uraemia symptoms e.g. seizures or reduced GCS
In what condition do you see muddy brown casts on urinalysis?
Acute tubular necrosis
- manage as for AKI
How do you manage acute pulmonary oedema?
Pour = stop fluids S - sit up O - high flow O2 D - diuretics = IV furosemide over 1hr Morphine + metoclopramide GTN spray
What is the criteria to diagnose AKI?
- Rise creatinine of at least 25 micromols/L
OR - Rise in creatinine of 50% in 7 days
OR - Urine output less than 0.5ml/kg/hr for more than 6h
When would you suspect chronic renal failure rather than acute?
- Small kidneys (less than 9cm)
- Anaemia
- Low calcium
- High phosphate
What is the triad of nephrotic syndrome?
- Proteinuria more than 3g in 24h
- Hypoalbuminaemia less than 25g/L
- Peripheral oedema
What are some other complications which occur as a result of nephrotic syndrome?
Infections - decreased IgG + complement
VTE
Hyperlipidaemia
What are the (i) primary + (ii) secondary causes of nephrotic syndrome?
PRIMARY - minimal change disease (most common in kids) - membranous nephropathy - FSGS - mesangiocapillary GN SECONDARY - Hep B+C - SLE, amyloidosis, paraneoplastic - diabetic nephropathy, HSP - Drugs (penicillamine, NSAIDs, anti-TNF, gold)
How do you manage minimal change disease?
Do not biopsy
- trial steroids high dose for 4 weeks, then wean over 8 wks
What is the triad of nephritic syndrome?
- Haematuria + red cell casts
- Moderate to severe HTN
- Moderate to severe drop in GFR (AKI)
What are the primary + secondary causes of nephritic syndrome?
PRIMARY: - IgA nephropathy (most common) - post-strep GN - mesangiocapillary GN SECONDARY: - anti-GBM - GPA, EGPA, MPA - SLE, HSP
How does IgA nephropathy tend to present? How is it diagnosed + managed?
Haematuria 1-3 days post URTI/gastroenteritis
- Biopsy to diagnose
- ACEi to control BP
How/when does post-streptococcal GN tend to present?
Usually affects kids 1-2 weeks after a sore throat/skin infection
- 1-3wk hx of strep infection (tonsilitis or impetigo)
How is post-streptococcal GN managed?
Usually resolves within 1 month so supportive management
- 95% resolve
What condition presents with coughing up blood + an AKI?
Anti-GBM (goodpastures)
- glomerulonephritis
- pulmonary haemorrhage
How do you treat anti-GBM?
Plasmapheresis
Immunosuppression = steroids + cytotoxics
How does rapidly progressive GN present?
AKI +systemic features e.g. weight loss, fever, myalgia, haemoptysis
- often 2ndary to GPA
How do you treat RPGN?
- Aggressive immunosuppression
- High dose IV steroids
- Plasmapheresis
What is the most common glomerulonephritis?
Membranous gomerulonephritis
What are the stages of chronic kidney disease?
eGFR values: G1 = 90 or greater G2 = 60-89 (only CKD in G1 or 2 if evidence of kidney damage e.g. blood/protein in urine) G3a = 45-59 G3b = 30-44 G4 = 15-29 G5 = less than 15 = ESRF - need RRT
What investigations are required to diagnose CKD?
- eGFR - 2 samples, 3 months apart to diagnose
- ACR - ?proteinuria
- FBC - ?anaemia of chronic disease
- Blood glucose - ?DM
- Bone profile - low calcium, high phosphate, ALP, PTH
- Renal USS - may be small or large if PKD
- CXR - cardiomegaly, pleural/pericardial effusion
- AXR - calcification from stones
- Bone X-rays - ?renal osteodystrophy
What complications can occur as a result of CKD? (CRF HEALS)
C - CVD R - Renal osteodystrophy F - Fluid (oedema) H - HTN E - electrolyte disturbance (K+, H+) A - Anaemia L - Leg restlessness S - Sensory neuropathy
How do you manage CKD?
- SLOW PROGRESSION
- optimise DM control
- BP less than 140/90mmHg (ACEi/ARB) - id DM, less than 130/80. Monitor serum K (risk of hyperK+)
- treat GN - PREVENT COMPLICATIONS
- Lifestyle = exercise, weight loss, stop smoking
- Diet = re phosphate, sodium, potassium + water
- primary prevention CVD = 20mg atorvastatin - TREAT COMPLICATIONS
(i) oral sodium bicarbonate for metabolic acidosis
(ii) Iron + EPO for anaemia
(iii) vit D for renal bone disease
(iv) diuretics
(v) dialysis
What are the features of renal osetodystrophy?
- Osteoporosis
- Osteomalacia
- 2ndary/teritary HPT = osteofibrosa cystica (pepper pot skull)
Describe the pathophysiology behind why renal bone disease occurs.
- low 1-alpha-hydoxylase causes decreased vit D activation
- this causes low calcium + high PTH
- high serum phosphate due to decreased renal excretion also causes low calcium + high PTH
- raised PTH causes activation of bone reabsorption
What is the treatment for renal bone disease?
- Active vitamin D = alfacalcidol, calcitrol
- Low phosphate diet
- Bisphosphonates
What are the causes/types of primary hyperaldosteronism?
- Bilateral adrenal hyperplasia (70%)
2. Solitary aldosterone-producing adenoma = CONN’s
What are the clinical features of primary hyperaldosteronism?
- Features of hypokalaemia (muscle weakness)
- Paraesthesias
- HTN
- Polyuria, polydipsia
What investigations should be performed in primary hyperaldosteronism?
- Aldosterone: renin ratio = raised!!!
- U+E = hypokalaemia, normal/high sdium
- Blood gas = metabolic alkalosis
- ECG
- Fludrocortisone suppression test
High-res CT abdo + adrenal vein sampling is used to differentiate between unilateral and bilateral sources of aldosterone excess
How do you manage primary hyperaldosteronism?
CONN’S:
- laparoscopic adrenalectomy
- Spironolactone for 4wks pre-op to control BP + K+
HYPERPLASIA:
1. Spironolactone or eplerenone
What is the most common type of renal tubular acidosis?
TYPE 4 - caused by reduced aldosterone
What type of renal tubular acidosis can cause renal stones?
TYPE 1
- metabolic acidosis + hypoK+
- high urinary pH (over 5.5)
What biochemical abnormalities occur in type 4 RTA? How is it managed?
Hyperkalaemia, high Cl-, metabolic acidosis, low urinary pH
Manage with Fludrocortisone
- sodium bicarb + treatment of hyperK+ may also be required
What are the clinical features of renal cancer?
Triad of:
- Haematuria
- Loin pain
- Abdominal mass
Also:
- clot retention
- Left varicocele (invasion of left renal vein)
- cannonball metastases in lungs (SOB)
- systemic = anorexia, malaise, weight loss
What is the most common primary renal cell cancer?
clear cell
What are the 2ww guidelines for suspected renal/bladder cancer?
Aged 45y or over with:
1. Unexplained visible haematuria without UTI
OR
2. Visible haematuria which persists/recurs after successful UTI treatment
Aged 60y or over with unexplained non-visible haematuria + either dysuria OR raised WCC
What is the most common primary bladder cancer?
transitional cell carcinoma
What is the diagnostic test for bladder cancer?
Flexible cystoscopy with biopsy
How do you manage bladder cancer?
TURBT
- urostomies are right side of abdomen + are spouted, not flush
How does BPH tend to present?
- STORAGE SYMPTOMS
- nocturia
- frequency
- incontinence
- incomplete emptying - VOIDING SYMPTOMS
- hesitancy
- straining
- weak stream + terminal dribbling
- incomplete emptying
What investigations should be performed in suspected BPH?
- Urine dipstick - r/o infection
- Bloods - U+E, PSA (do prior to DRE)
- DRE
- Imaging
What are the management options for BPH? (conservative, medical + surgical)
- CONSERVATIVE
- avoid caffeine, reduce alcohol
- double voiding, relax when voiding
- bladder training - MEDICAL
1st = tamsulosin, doxasosin (alpha blocker)
- SE = postural hypotension, dizzy, dry mouth, depression
2nd = finasteride (5 alpha reductase)
- SE = erectile dysfunction, decreased libido, ejaculation problems, gynaecomastia - SURGERY
- TURP if symptoms affecting QoL + failed medical treatment
Why does prostate cancer tend to be asymptomatic?
As it tends to occur in the periphery so does not press or urethra
What is the 1st line test for suspected prostate cancer?
Multiparametric MRI
- results reported using 5-point scale and if 3 or above, offer TRUS biopsy
How do you manage acute bacterial prostatitis?
- 14-day course of quinolone e.g. ciprofloxacin
- Consider STI screen
- Analgesia
What are the 3 main types of incontinence?
- Stress incontinence
- Urge incontinence
- Overflow incontinence
What are risk factors for stress incontinence?
- childbirth
- post-menopause
- oestrogen loss
- CTDs
- obesity
- prostatectomy in men
What are some causes/risk factors for urge incontinence?
- idiopathic
- infection (UTI)
- DM
- vaginitis
- diuretics
- stroke, PD, dementia
- neurogenic = MS, UMN lesion, spina bifida
What investigations should be performed to diagnose stress incontinence?
Must r/o DM + infection!
- MSU sample r/o glycosuria + infection
- Frequency/volume chart - normal frequency + bladder capacity
- Urodynamic studies - if surgery is indicated
How do you manage stress incontinence?
CONSERVATIVE - lose weight, stop smoking, treat chronic cough - pelvic floor exercises trialed for 3 months - electrical stimulation, pessary PHARMACOLOGICAL - duloxetine (SE = N+V, abdo pain) SURGERY - sling procedure - tension free vaginal tape - cholposuspension (loss of fertility)
What investigations should be performed in suspected overactive bladder syndrome?
Must R/O:
- DM, hypercalcaemia, prolapse, UTI
- USS to r/o retention
Urodynamic studies to confirm diagnosis
How do you manage overactive bladder syndrome?
CONSERVATIVE
- limit fluids to 1-1.5L/day, AVOID caffeine + alcohol, lose weight
- R/V prescription e.g. diuretics
- bladder retraining
Test for vaginitis, if present treat with oestrogen cream
PHARMACOLOGICAL
- Anticholinergics = oxybutynin, tolterodine, solfenacin
- if CI (acute glaucoma, MG, retention, UC, GI obstruction) use mirabegron instead
What are the side effects of antimuscarinics? E.g. solfenacin, tolterodine, oxybutynin.
Dry mouth Constipation Nausea Dyspepsia Flatulence Blurred vision Dizzy Insomnia
What Abx are given to men with UTI? What duration is the course of treatment?
Nitrofurantoin or trimethoprim for 7 days
What treatment is given for pregnant women with UTI?
Nitrofurantoin for 7 days
- avoid near-term as risk of neonatal haemolysis
2nd line = amoxicillin or cefalexin
What are indications for urine culture in a suspected paediatric UTI?
- suspected pyelonephritis
- high risk of serious illness
- infant under 3 months
- +ve dipstick for leucocytes/nitrites
- recurrent UTI
- not responding to treatment in 24-48hrs
What is the definition of a recurrent UTI in children?
- 2 or more upper UTIs OR - 1 upper + 1 lower UTI OR - 3 or more lower UTIs
What Abx is used in children with suspected upper UTI?
cefalexin
What symptoms/signs are indicative of an atypical UTI in children?
- extremely ill
- poor urine flow
- abdo/bladder mass
- fails to respond to treatment w/in 48h
- non E.coli
- raised creatinine
- septicaemia
What will a renal USS show in relation to paeds UTI? When is it indicated?
Will identify hydronephrosis due to obstruction or VUR
- all those under 6 months with 1st UTI should have within 6wks of infection
- if recurrent UTIs perform within 6wks
- If atypical UTI do during illness
What does a DMSA scan show? When is it performed?
Assesses renal function + identifies any scarring
Performed 4-6 months post-UTI in:
- all with recurrent UTIs
- children under 3y with atypical UTI
What is a MCUG used for? When is it indicated?
Used to identify VUR, bladder abnormalities, posterior urethral valves
Indicated in:
- children under 6 months with recurrent/atypical UTI
- consider in those over 6 months with dilatation on USS, poor urine flow, non E. Coli or FHx of VUR
