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RENAL/UROLOGY Flashcards

1
Q

What tests should be performed in acute urinary retention?

A
  1. urinalysis for infection
  2. U+E - assess renal function
  3. FBC + CRP - infection?
  4. Bladder scan - more than 300cc confirms
  5. Renal USS if renal impairment
  6. PSA NOT required as will be raised in acute retention
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2
Q

How do you manage acute urinary retention?

A
  1. Catheterise - use 3-way catheter in clot retention
  2. Tamsulosin
  3. Record volume drained in first 15-mins
    - less than 200ml = no acute retention
  4. Further investigate based on likely cause
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3
Q

What is a sign of acute on chronic urinary retention?

A

Overflow urinary incontinence

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4
Q

What is the management of chronic urinary retention?

A
  1. Intermittent bladder catheterisation
  2. Long-term catheters (try avoid)
  3. Alpha-adrenoreceptor blocker try for 4-6wks
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5
Q

What are unilateral causes of hydronephrosis? (HINT: PACT)

A

P - pelvic ureteric obstruction
A - aberrant renal vessels
C - calculi
T - tumours of renal pelvis

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6
Q

What are bilateral causes of hydronephrosis? (HINT: SUPER)

A 
S - stenosis of urethra
U - urethral valve
P - prostatic enlargement
E - extensive bladder tumour
R - retroperitoneal fibrosis
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7
Q

What investigations should be performed in hydronephrosis?

A
  1. USS
  2. IV urogram assesses position of obstruction
  3. Antegrade or retrograde pyelography
  4. CT - if stones suspected
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8
Q

What is the most common cause of pyelonephritis?

A

E.coli

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9
Q

What investigations should be performed in suspected pyelonephritis?

A
  1. Urinalysis
  2. FBC
  3. U+E
  4. USS
  5. CT
  6. DMSA - indicates renal scarring
  7. Blood + urine cultures
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10
Q

What investigations should be performed in suspected renal stones?

A
  1. urinalysis
  2. U+E
  3. FBC ?infection
  4. Bone profile ?hypercalcaemia
  5. AXR
  6. spiral non-contrast CT KUB is gold standard
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11
Q

How do you manage renal stones?

A
  1. Diclofenac + fluids (IV or oral)
  2. If infection = cefuroxime + gentamicin
  3. 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

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12
Q

What are the symptoms + signs of ADPKD? Include extra-renal manifestations.

A

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

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13
Q

What investigations should be performed in ADPKD?

A
  1. Renal USS
  2. CT abdo + pelvis
  3. U+E
  4. Genetic testing
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14
Q

How do you manage ADPKD?

A
  1. monitor U+E, BP + USS regularly
  2. Treat HTN aggressively - ACEi first
  3. Analgesia for renal colic (avoid NSAIDs)
  4. Abx for infections (drainage of cysts may be req)
  5. Genetic counselling
  6. Lifestyle modifications - increase water + decrease salt intake, avoid caffeine
  7. Nephrectomy
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15
Q

What are the (i) pre-renal (ii) renal (iii) post-renal causes of AKI?

A

(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

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16
Q

How do patients tend to present with an AKI?

A
  • vomiting
  • dizziness
  • orthopnoea
  • reduced urine output
  • fluid overload (oedema, high or low BP, raised JVP, S3 gallop)
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17
Q

What investigations should be performed in pts with AKI?

A
  1. Bloods - FBC, U+E, LFT, glucose, clotting, Ca, ESR
  2. ABG - hypoxia (oedema), acidosis, hyperkaelamia
  3. Urine - dipstick, MC+S, chemistry (U+E, PCR, osmolality, BJP)
  4. ECG - hyperkalaemia
  5. CXR - pulmonary oedema
  6. Autoantibodies - ANCA, ANA, anti-GBM
  7. Consider blood film + renal immunology if systemic cause suspected
  8. Renal USS - size? obstruction? hydronephrosis?
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18
Q

How do you manage hyperkalaemia?

A
  1. 10ml 10% calcium gluconate
  2. 10U actrapid, 50ml 50% glucose IV
  3. Salbutamol neb 5mg
  4. Recheck K+ in 2h by VBG, U+E, ECG
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19
Q

What are the complications of AKI?

A
  1. Hyperkalaemia
  2. Fluid overload, HF, pulmonary oedema
  3. Metabolic acidosis
  4. Uraemia (azotaemia) - can lead to encephalopathy or pericarditis
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20
Q

What are the indications for acute dialysis? (AEIOU)

A

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

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21
Q

In what condition do you see muddy brown casts on urinalysis?

A

Acute tubular necrosis

- manage as for AKI

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22
Q

How do you manage acute pulmonary oedema?

A 
Pour = stop fluids
S - sit up 
O - high flow O2
D - diuretics = IV furosemide over 1hr
Morphine + metoclopramide
GTN spray
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23
Q

What is the criteria to diagnose AKI?

A
  1. Rise creatinine of at least 25 micromols/L
    OR
  2. Rise in creatinine of 50% in 7 days
    OR
  3. Urine output less than 0.5ml/kg/hr for more than 6h
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24
Q

When would you suspect chronic renal failure rather than acute?

A
  1. Small kidneys (less than 9cm)
  2. Anaemia
  3. Low calcium
  4. High phosphate
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25
Q

What is the triad of nephrotic syndrome?

A
  1. Proteinuria more than 3g in 24h
  2. Hypoalbuminaemia less than 25g/L
  3. Peripheral oedema
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26
Q

What are some other complications which occur as a result of nephrotic syndrome?

A

Infections - decreased IgG + complement
VTE
Hyperlipidaemia

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27
Q

What are the (i) primary + (ii) secondary causes of nephrotic syndrome?

A 
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)
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28
Q

How do you manage minimal change disease?

A

Do not biopsy

- trial steroids high dose for 4 weeks, then wean over 8 wks

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29
Q

What is the triad of nephritic syndrome?

A
  1. Haematuria + red cell casts
  2. Moderate to severe HTN
  3. Moderate to severe drop in GFR (AKI)
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30
Q

What are the primary + secondary causes of nephritic syndrome?

A 
PRIMARY:
- IgA nephropathy (most common)
- post-strep GN
- mesangiocapillary GN
SECONDARY:
- anti-GBM
- GPA, EGPA, MPA
- SLE, HSP
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31
Q

How does IgA nephropathy tend to present? How is it diagnosed + managed?

A

Haematuria 1-3 days post URTI/gastroenteritis

  • Biopsy to diagnose
  • ACEi to control BP
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32
Q

How/when does post-streptococcal GN tend to present?

A

Usually affects kids 1-2 weeks after a sore throat/skin infection
- 1-3wk hx of strep infection (tonsilitis or impetigo)

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33
Q

How is post-streptococcal GN managed?

A

Usually resolves within 1 month so supportive management

- 95% resolve

34
Q

What condition presents with coughing up blood + an AKI?

A

Anti-GBM (goodpastures)

  • glomerulonephritis
  • pulmonary haemorrhage
35
Q

How do you treat anti-GBM?

A

Plasmapheresis

Immunosuppression = steroids + cytotoxics

36
Q

How does rapidly progressive GN present?

A

AKI +systemic features e.g. weight loss, fever, myalgia, haemoptysis
- often 2ndary to GPA

37
Q

How do you treat RPGN?

A
  1. Aggressive immunosuppression
  2. High dose IV steroids
  3. Plasmapheresis
38
Q

What is the most common glomerulonephritis?

A

Membranous gomerulonephritis

39
Q

What are the stages of chronic kidney disease?

A 
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
40
Q

What investigations are required to diagnose CKD?

A
  1. eGFR - 2 samples, 3 months apart to diagnose
  2. ACR - ?proteinuria
  3. FBC - ?anaemia of chronic disease
  4. Blood glucose - ?DM
  5. Bone profile - low calcium, high phosphate, ALP, PTH
  6. Renal USS - may be small or large if PKD
  7. CXR - cardiomegaly, pleural/pericardial effusion
  8. AXR - calcification from stones
  9. Bone X-rays - ?renal osteodystrophy
41
Q

What complications can occur as a result of CKD? (CRF HEALS)

A 
C - CVD
R - Renal osteodystrophy
F - Fluid (oedema)
H - HTN
E - electrolyte disturbance (K+, H+)
A - Anaemia
L - Leg restlessness
S - Sensory neuropathy
42
Q

How do you manage CKD?

A
  1. 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
  2. PREVENT COMPLICATIONS
    - Lifestyle = exercise, weight loss, stop smoking
    - Diet = re phosphate, sodium, potassium + water
    - primary prevention CVD = 20mg atorvastatin
  3. 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
43
Q

What are the features of renal osetodystrophy?

A
  1. Osteoporosis
  2. Osteomalacia
  3. 2ndary/teritary HPT = osteofibrosa cystica (pepper pot skull)
44
Q

Describe the pathophysiology behind why renal bone disease occurs.

A
  • 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
45
Q

What is the treatment for renal bone disease?

A
  1. Active vitamin D = alfacalcidol, calcitrol
  2. Low phosphate diet
  3. Bisphosphonates
46
Q

What are the causes/types of primary hyperaldosteronism?

A
  1. Bilateral adrenal hyperplasia (70%)

2. Solitary aldosterone-producing adenoma = CONN’s

47
Q

What are the clinical features of primary hyperaldosteronism?

A
  1. Features of hypokalaemia (muscle weakness)
  2. Paraesthesias
  3. HTN
  4. Polyuria, polydipsia
48
Q

What investigations should be performed in primary hyperaldosteronism?

A
  1. Aldosterone: renin ratio = raised!!!
  2. U+E = hypokalaemia, normal/high sdium
  3. Blood gas = metabolic alkalosis
  4. ECG
  5. Fludrocortisone suppression test
    High-res CT abdo + adrenal vein sampling is used to differentiate between unilateral and bilateral sources of aldosterone excess
49
Q

How do you manage primary hyperaldosteronism?

A

CONN’S:

  1. laparoscopic adrenalectomy
  2. Spironolactone for 4wks pre-op to control BP + K+

HYPERPLASIA:
1. Spironolactone or eplerenone

50
Q

What is the most common type of renal tubular acidosis?

A

TYPE 4 - caused by reduced aldosterone

51
Q

What type of renal tubular acidosis can cause renal stones?

A

TYPE 1

  • metabolic acidosis + hypoK+
  • high urinary pH (over 5.5)
52
Q

What biochemical abnormalities occur in type 4 RTA? How is it managed?

A

Hyperkalaemia, high Cl-, metabolic acidosis, low urinary pH

Manage with Fludrocortisone
- sodium bicarb + treatment of hyperK+ may also be required

53
Q

What are the clinical features of renal cancer?

A

Triad of:

  1. Haematuria
  2. Loin pain
  3. Abdominal mass

Also:

  • clot retention
  • Left varicocele (invasion of left renal vein)
  • cannonball metastases in lungs (SOB)
  • systemic = anorexia, malaise, weight loss
54
Q

What is the most common primary renal cell cancer?

A

clear cell

55
Q

What are the 2ww guidelines for suspected renal/bladder cancer?

A

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

56
Q

What is the most common primary bladder cancer?

A

transitional cell carcinoma

57
Q

What is the diagnostic test for bladder cancer?

A

Flexible cystoscopy with biopsy

58
Q

How do you manage bladder cancer?

A

TURBT

- urostomies are right side of abdomen + are spouted, not flush

59
Q

How does BPH tend to present?

A
  1. STORAGE SYMPTOMS
    - nocturia
    - frequency
    - incontinence
    - incomplete emptying
  2. VOIDING SYMPTOMS
    - hesitancy
    - straining
    - weak stream + terminal dribbling
    - incomplete emptying
60
Q

What investigations should be performed in suspected BPH?

A
  1. Urine dipstick - r/o infection
  2. Bloods - U+E, PSA (do prior to DRE)
  3. DRE
  4. Imaging
61
Q

What are the management options for BPH? (conservative, medical + surgical)

A
  1. CONSERVATIVE
    - avoid caffeine, reduce alcohol
    - double voiding, relax when voiding
    - bladder training
  2. 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
  3. SURGERY
    - TURP if symptoms affecting QoL + failed medical treatment
62
Q

Why does prostate cancer tend to be asymptomatic?

A

As it tends to occur in the periphery so does not press or urethra

63
Q

What is the 1st line test for suspected prostate cancer?

A

Multiparametric MRI

- results reported using 5-point scale and if 3 or above, offer TRUS biopsy

64
Q

How do you manage acute bacterial prostatitis?

A
  1. 14-day course of quinolone e.g. ciprofloxacin
  2. Consider STI screen
  3. Analgesia
65
Q

What are the 3 main types of incontinence?

A
  1. Stress incontinence
  2. Urge incontinence
  3. Overflow incontinence
66
Q

What are risk factors for stress incontinence?

A
  • childbirth
  • post-menopause
  • oestrogen loss
  • CTDs
  • obesity
  • prostatectomy in men
67
Q

What are some causes/risk factors for urge incontinence?

A
  • idiopathic
  • infection (UTI)
  • DM
  • vaginitis
  • diuretics
  • stroke, PD, dementia
  • neurogenic = MS, UMN lesion, spina bifida
68
Q

What investigations should be performed to diagnose stress incontinence?

A

Must r/o DM + infection!

  1. MSU sample r/o glycosuria + infection
  2. Frequency/volume chart - normal frequency + bladder capacity
  3. Urodynamic studies - if surgery is indicated
69
Q

How do you manage stress incontinence?

A 
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)
70
Q

What investigations should be performed in suspected overactive bladder syndrome?

A

Must R/O:
- DM, hypercalcaemia, prolapse, UTI
- USS to r/o retention
Urodynamic studies to confirm diagnosis

71
Q

How do you manage overactive bladder syndrome?

A

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

72
Q

What are the side effects of antimuscarinics? E.g. solfenacin, tolterodine, oxybutynin.

A 
Dry mouth
Constipation 
Nausea
Dyspepsia
Flatulence
Blurred vision
Dizzy
Insomnia
73
Q

What Abx are given to men with UTI? What duration is the course of treatment?

A

Nitrofurantoin or trimethoprim for 7 days

74
Q

What treatment is given for pregnant women with UTI?

A

Nitrofurantoin for 7 days
- avoid near-term as risk of neonatal haemolysis
2nd line = amoxicillin or cefalexin

75
Q

What are indications for urine culture in a suspected paediatric UTI?

A
  • 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
76
Q

What is the definition of a recurrent UTI in children?

A 
- 2 or more upper UTIs
OR
- 1 upper + 1 lower UTI
OR
- 3 or more lower UTIs
77
Q

What Abx is used in children with suspected upper UTI?

A

cefalexin

78
Q

What symptoms/signs are indicative of an atypical UTI in children?

A
  • extremely ill
  • poor urine flow
  • abdo/bladder mass
  • fails to respond to treatment w/in 48h
  • non E.coli
  • raised creatinine
  • septicaemia
79
Q

What will a renal USS show in relation to paeds UTI? When is it indicated?

A

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
80
Q

What does a DMSA scan show? When is it performed?

A

Assesses renal function + identifies any scarring

Performed 4-6 months post-UTI in:

  • all with recurrent UTIs
  • children under 3y with atypical UTI
81
Q

What is a MCUG used for? When is it indicated?

A

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

FINALS (14 decks)

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