RENAL, UROLOGY AND HAEMATOLOGY

Question 1

Why is furosemide given to patients assymetrically?

Answer 1

You don’t want take it too late in the day as it would cause diuresis during the night - onsets within 5 minutes but can last up to 8 hours

Question 2

What does postural drop, prolonged cap refill and tachycardia all suggest?

Answer 2

Hypovolaemia

Question 3

How do diuretics usually affect potassium levels?

Answer 3

They cause hypokalaemia - unless potassium sparing

Question 4

What fluid do you use for fluid resuscitation after an AKI?

Answer 4

0.9% sodium chloride or hartmanns but be aware hartmanns has potassium in it so is contraindicated if the patient is hyperkalaemic

Question 5

How do you prescribe appropriately in AKI?

Answer 5

DAMN
Diuretics, ACEi/ARB, metformin, NSAIDs

Question 6

Why should you not give metformin in an AKI?

Answer 6

It’s not nephrotoxic but is 90% excreted by the kidneys and so accumulates in AKI and causes lactic acidosis

Question 7

Outline why ACEi/ARB and NSAIDs are nephrotoxic especially when used together?

Answer 7

ACEi/ARBs block the effects of angiotensin 2 causing efferent arterioles dilation which reduces the pressure in the glomerulus
NSAIDs block the vasodilators effects of prostaglandins in the afferent arterioles so it cannot compensate for the efferent dilation and GFR reduces more

Question 8

What drugs need close monitoring in AKI?

Answer 8

Warfarin
Aminoglycosides
Lithium

Question 9

What drugs require dose reduction in AKI?

Answer 9

Meds that are metabolised and excreted by the kidneys should be dose adjusted for an assumed eGFR of <10
LMWH, opiates, penicillins, sulfonylureas, aciclovir and metformin

Question 10

What drugs can aggravate hyperkalaemia?

Answer 10

Trimethoprim
Spironolactone
Amiloride

Question 11

What’s the most common cause of acquired nephrogenic diabetes insipidus

Question 12

When do we use creatinine clearance instead of using eGFR?

Answer 12

For very toxic drugs, very elderly patients and those of extreme muscle mass (if in doubt use CrCl)

Question 13

Why is creatinine clearance more accurate than eGFR?

Answer 13

Because it includes adjustment for weight
Creatinine is used as a substrate for insulin so is nearly as accurate as an insulin measurement

Question 14

Why do extremes of muscle mass affect eGFR measurements? And how do we fix this?

Answer 14

EGFR uses average surface area of an adult so if you have a BMI <18 or >40 then you should adjust your eGFR for increased accuracy

Question 15

What can you do if there is impaired renal excretion and the half life has increased?

Answer 15

You can reduce the dose or extend the dosing interval

Question 16

What’s the problem with gentamicin? And why do we still use it regardless?

Answer 16

It has a narrow therapeutic index, ototoxic, vestibulotoxic and nephrotoxic
Because its the least likely antibiotic to cause clostridium difficil diarrhoea

Question 17

How is gentamicin given?

Answer 17

IV or IM as its not readily absorbed from the GIT

Question 18

How do you calculate an appropriate dose for gentamicin?

Answer 18

Consider the patients lean mass (mass without excess fat) because the total body water of everyone is very similar and is hardly affected by body mass
Do use ideal body weight for the patients height

Question 19

Outline why we say gentamicin follows first order kinetics?

Answer 19

It’s excreted unmodified buy the kidneys - drug is cleared from the blood at a rate proportional to its concentration

Question 20

What are the 2 regimens used in the UK to give gentamicin?

Answer 20

Pharmacokinetic
Extended interval

Question 21

What is extended interval dosing regimen?

Answer 21

Aka Hartford dosing
It’s the regimen that maximises bacterial killing whilst minimising toxicity
Give first infusion and then take a blood sample between 6 and 14 hours after. Instead of changing the dose you change the time between giving. The next dose

Question 22

What is urgency urinary incontinence?

Answer 22

When you feel a sudden/intense need to pass urine and your unable to delay going to the toilet - there are usually only a few seconds between the need to urinate and the release of urine. It’s often associated with overactive bladder syndrome

Question 23

What is stress urinary incontinence?

Answer 23

When urine leaks out with sudden pressure on the bladder and urethra, causing the sphincter muscles to open briefly eg. Sneezing laughing or coughing

Question 24

What is mixed urinary incontinence?

Answer 24

Stress and urgency urinary incontinence

Question 25

What is overflow urinary incontinence?

Answer 25

Continuous urine leakage resulting from a hypotonic bladder or bladder outlet obstruction producing urinary retention

Question 26

What’s stinylates the bladder?

Answer 26

Hypogastric nerve (sympathetic) - NA acts on beta 3 receptor to relax bladder and acts on alpha receptor to contract internal urethral sphincter Pelvic nerve (parasympathetic) - ACh acts on M3 receptor to contract bladder Pudendal nerve (somatic) - ACh acts on nicotinic except or to contract external urethral sphincter

Question 27

What drugs are available for overactive bladder syndrome?

Answer 27

Muscarinic receptor antagonists e.g. oxybutinin and tolterodine Beta 3 adrenoreceptor agonist e.g. mirabegron Both - relax bladder

Question 28

What side effects do anticholinergic have?

Answer 28

BCDU Blurred vision Constipation Dry mouth Urinary retention

Question 29

How is stress incontinence managed?

Answer 29

Pelvic floor exercises for at least 3 months Surgery e.g. urinary sling Vaginal oestrogens in peri-menopausal women Duloxetine in those averse to surgery

Question 30

Who is most likely to experience stress incontinence?

Answer 30

Women after childbirth due to damaged pelvic floor

Question 31

Why do vaginal oestrogens help stress incontinence?

Answer 31

Because the vaginal mucosa will become atrophied after a lack of oestrogen in perimenopausal periods which can make stress incontinence worse

Question 32

How do you assess the severity of BPH?

Answer 32

Using international prostate severity score 0-7 mildly symptomatic 8-19 moderately symptomatic 20-35 severely symptomatic

Question 33

How do you manage LUTS in men?

Answer 33

Conservative measures e.g. pads, bladder training, urethral milking, catheterisation, Drugs - alpha blockers for moderate to severe LUTS, anticholinergic for overactive bladder, 5-alpha reductive inhibitor to men with PSA >1.4, diuretics Surgery

Question 34

What’s the first line treatment for BPH LUTS symptoms?

Answer 34

Alpha blockers e.g. tamsulosin

Question 35

What are the adverse effects of alpha blockers?

Answer 35

Othrostatic hypotension Headache Dizziness Oedema Erectile dysfunction Rhinitis

Question 36

What are the contraindications for alpha blockers?

Answer 36

History of postural hypotension History of micturition syncope

Question 37

Which drugs do alpha blockers reac with?

Answer 37

Other hypotensive agents PDE5 inhibitors as can cause significant hypotension

Question 38

What’s second line drug treatment for BPH?

Answer 38

5 alpha reductase inhibitors

Question 39

What are the adverse side effect of 5 alpha reductase inhibitors?

Answer 39

Sexual dysfunction Depression Breast enlargement, breast tenderness impotence - affects testosterone levels

Question 40

Which drugs do 5 alpha reductase inhibitors interact with?

Answer 40

Calcium channel blockers

Question 41

What’s a contraindication of 5 alpha reductase inhibitors

Answer 41

Pregnanct women shouldn’t even expose themselves to them as it may cause abnormal development of the external genitalia

Question 42

How do we manage prostate cancer?

Answer 42

Radiotherapy Surgical prostatectomy Anti androgens GnRH analogues e.g. goserelin

Question 43

How do GnRH analogues work for prostate cancer?

Answer 43

They cause an initial increase in LH and FSH but chronic administration results in the sustained suppression of pituitary gonadotropins so serum testosterone levels fall

Question 44

What’s the treatment of choice for bladder cancer

Answer 44

Cisplatin based combination chemotherapy

Question 45

How do we treat renal cell carcinomas?

Answer 45

Tyrosine kinase inhibitors e.g. sorafenib and sunitinib Or mTOR inhibitor

Question 46

Where do renal cell carcinomas metastasise to and why?

Answer 46

Lungs because they tend to grow down the renal vein which runs directly to the heart - can cause cannon ball tumours in lungs

Question 47

What are the 2 ways in which iron salts can be given for iron deficient anaemia?

Answer 47

Oral and parenteral but only when oral therapy is unsuccessful or intolerable

Question 48

What are examples of oral iron salts?

Answer 48

Ferrous sulphate Ferrous fumarate Ferrous gluconate

Question 49

Why is iron from meat better than iron from plants?

Answer 49

Because iron from meat is heme iron which is Fe2+ and can be used directly whereas non-heme iron from plants is Fe3+ is oxygenation status need to change before being absorbed

Question 50

What are the main adverse drug efefcts of iron

Answer 50

constipation Black stools Diarrhoea Epigastric pain GI irritation Nausea

Question 51

What drugs does iron react with and how?

Answer 51

Levothyroxine Bisphosphonates Ciprofloxacin Tetracyclines Calcium and zinc salts They work by reducing gut absorption so should be taken at least 2 hours before oral iron

Question 52

Why should you take iron with vitamin C?

Answer 52

It helps absorb it because it cotransports with iron

Question 53

What’s the recommended duration of iron treatment?

Answer 53

Take it until Hb levels are normal and then continue for 3 months as you need to replenish bone marrow stores too

Question 54

What drugs can be used for transplant immunosuppression?

Answer 54

Calcineurin inhibitors e,g, Ciclosporin and tacrolimus Anti-proliferative agents e.g. azathioprine and cyclophosphamide

Question 55

What’s the MOA of calcineurin inhibitors?

Answer 55

Inhibit calcineurin which is a key protein allowing transcription of IL-2 which inhibits T lymphocytes activation