Renal, Urology & Electrolytes Flashcards
What is a normal daily urine output?
1000-2800ml/day
What is a normal voiding frequency/ day?
3-7x daily
What is a normal volume of voiding?
250-500ml
Name 3 features of hypernatraemic dehydration?
Drowsiness/ coma Jittery movements Increased muscle tone Hyperreflexia Convulsions
What is the defintion of CKD?
GFR < 60 for more than 3 months
or structural/ functional impairment for < 3 months
2 most common causes of CKD?
Hypertension
Diabetes
What is cinacalcet and what is it used for?
Reduces levels of PTH
Often for patients with CKD
What are the main extracellular ions?
Na
Cl
What is normal requirements of K, Na and Cl ions per day?
1mmol/kg
What are the 5 Rs of fluid prescribing?
Resuscitate < acute
Routine maintenance
Replacement (sodium, potassium, chloride)
Redistribution (if passing lots of urine do they need k+)
Reassessment
What antibiotic should be used for an inpatient with a UTI and an eGFR of 14?
Cefalexin (nitro and trimethoprim not in severe RI)
How much maintenance fluid should a 75kg person have over a day?
Roughly 2l over 24hours
Give NaCl 0.18% Glucose 4% with/without KCl
What is a normal anion gap?
4-12 mmol
Metabolic acidosis can be split into those with a high or low anion gap
What are the causes of a) high anion gap and b) low anion gap metabolic acidosis?
High: DKA/ lactic acidosis (sepsis)
Low: Diarrhoea/ addisons/ renal tubular acidosis
Name 3 causes of a hyperkalaemia?
ACEI
Spironolactone
AKI
How do you treat hyperkalaemia? (3)
Nebulised salbutamol
IV insulin/ dextrose
Calcium gluconate
What are the ECG features of hyperkalaemia (3)?
Tall ‘tented’ T waves
Wide QRS
Short PR
Small P waves
Name three causes of a hypokalaemia?
Vomiting
Diuretics
Cushings
Conn’s
Name three ECG features of hypokalaemia?
Flat T waves
U waves
Long PR
ST depression
How do you treat hypokalaemia?
Add K+ into fluids
What is the key feature of the relationship between K+ and H+ relevant to hyper/hypokalaemia?
H+ and K+ follow each other
So hyperkalaemia = acidosis
Hypokalaemia = Alkalosis
What are the general features of potassium imbalance?
Weakness, fatigue, palpitations are common to both hyper and hypo
Name 3 causes of a hypercalcemia?
Primary hyperparathyroid
Bone mets
Severe dehydration
How do you manage hypercalacemia?
1) Rehydrate with normal saline
Once fluid status sorted give calcitonin and bisphosphonates
What is the role of calcitonin?
Opposes the action of PTH (so lowers blood Ca2+)
Name 3 causes of a hypocalcaemia?
Hypoparathyroid
CKD (will also cause secondary hyperparathyroid)
Vit D deficiency (will also cause secondary hyperparathyroid)
What is the difference between primary and secondary hyperparathyroid?
Primary = Too much PTH from parathyroid glands Secondary = High PTH in response to a low blood calcium/ vit D (often due to CKD)
How do you treat hypocalacemia? (1)
IV calcium gluconate
10ml of 10% over 10mins
Name three causes of a hypernatraemia?
Dehyrdration (low intake, D+V, burns etc)
Diabetes insipidus
Diuretic use
How do you treat hypernatraemia?
Fluids
Don’t correct too fast - 0.5mmol/L/hr tops if chronic
What are the two most common causes of hyponatremia?
Euvolemic = SIADH Hypervolemic = CCF/ renal failure/ hepatic failure
How do you treat hyponatremia?
If hypovolemia = Fluids
If euvolemic = Treat cause
If hypervolemic = Fluid restrict
Recognition diagnosis:
Epistaxis + sinusitis + nephritic syndrome
Wegners granulomatosis
c-ANCA on bloods
Recognition diagnosis:
Haemoptysis + nephritic syndrome
Goodpastures syndrome
Anti-GBM on bloods
Recognition diagnosis:
Sensory-neural deafness + nephritic syndrome
Alports syndrome
What history feature unites IgA nephropathy and post-streptococcal glomerulonephritis and what distinguishes them?
Both following URTI
IgA nephropathy = 1-2 days after, nephritic syndrome
Post-streptococcal = 1-2 weeks after, nephritic and nephrotic picture
What are the three most common causes of nephrotic syndrome?
Minimal change disease (kids) Membraneous glomerulonephritis (adults - commonly cause by drugs) Diabetic nephropathy
What is the most common cause of nephritic syndrome?
IgA nephropathy
What is the triad which characterises nephrotic syndrome?
Proteinuria (<3g/24hrs)
Hypoalbuinaemia (<30)
Oedema
How do you manage renal stones <5mm?
Expectantly
How do you manage renal stones 5mm-2cm?
Lithotripsy
or ureteroscopy if pregnant
How do you manage renal stones where hydronephrosis is present?
Percutaneous nephrostomy
How do you manage a staghorn calculus?
Percutaenous nephrolithotomy
Name three risk factors for renal stones?
Previous stone Dehydration FHx Hypertension Hyperparathyroid Gout
What are the three most common types of kidney stones?
Calcium oxylate (75%) - Radio-opaque (white) Calcium phosphate (10%) Uric acid (5%)
What are you first investigations for suspected renal stones?
Obs B- (Urine dip) B- (FBC, U+E, Calcium, phosphate, urate) I- CT KUB S- (none)
What is the definition of AKI?
Urine output <30ml/hr (0.5ml/kg/hr) for greater than 6 hours
+
Rise in creatinine 1.5x baseline in <7days
Name 5 common causes of AKI?
Pre-renal - Hypovolemia (sepsis, volume loss, shock) Renal - Nephrotoxic drugs or scan contrast media - Glomerulonephritis Post-renal - UTI - Stones
Name 3 investigations you would do in suspect AKI?
Urine dip Fluid balance FBC U+E (beware high K+) LFT's Clotting
What are the three most common complications of AKI?
Hyperkalaemia
Acidosis
Pulmonary oedema
How is AKI managed?
Sepsis etc screen (pre-renal cause) Toxins (stop NSAID/ ACEI/ gentamycin) Optimise BP (fluids) Prevent harm - Look for cause - Monitor for hyperkalaemia etc
Bladder cancers are most commonly what type?
TCC (90%)
10% are SCC (which is caused by schistosomiasis so common in developing countries)
How does bladder cancer present? What additional investigations should you do?
Painless haematuria
(Always 2ww if over 45)
- Urinanylsis (exclude infection)
- FBC/ U+E
- Cystoscopy (done from 2ww)
How are bladder cancers managed?
If non invasive:
- Macroscopic transurethral resection (TUR) + single dose intra-vesicle Mitomycin C
If invasive:
- Neoadjuvant chemo and radical cystectomy
How should patients be followed up following topical tx for non-invasive bladder cancer?
Cystoscopy at 3/9/18 months then yearly afterwards
What is the most common kidney cancer in a) adults and b) children
a) Renal Cell Carcinoma
b) Wilm’s tumour
When does kidney cancer most commonly occur and what is the classic presentation triad?
After age 40 (peak 60-70)
Haematuria, loin pain and loin mass
25% present with mets (most commonly lung)
What investigations would you do for suspected RCC?
Urinalysis + culture
FBC (anaemia or raised EPO causing high RBC)
U+E (often normal)
GOLD = CT urogram
CXR for cannon ball bets
How do you manage RCC?
Localised:
- Partial nephrectomy (with or without chemo)
- Radical if not possible
Advanced
- Nephrectomy +/- interferon alpha
How is polycystic kidney disease inherited?
Autosomal dominant
How does ADPKD usually present?
Loin pain, haematuria, renal mass (same as renal CA)
> Raised BP (EPO)
How should suspected ADPKD be investigated?
B- Urinanlysis
B- FBC (Hb/ EPO), U+E
I- USS is 1st line but may also need CT urogram to exclude Renal Ca
What are the diagnosis criteria for ADPKD?
If under 30: At least two cysts
30-59years: At least two cysts in each kidney
Over 60: At least 4 cysts in each kidney
Note: At age 30-49 almost 2% of people will have at least one cyst, this rises to 11% of those age 50-70
How is ADPKD managed?
C- Avoid contact sports, advise on CVS risk factors (most mortality0
M- Control BP, analgesia, manage compliations
What is a common complication of ADPKD?
Secondary hyperparathyroid
- Kidneys not converting vitD to active form
Shows low Ca and high PTH (high phosphate = renal disease, low phosphate = primary vitD deficiency)
How common is BPH?
40% of people in 50’s
90% of people in 90’s
Name 4 common symptoms of BPH?
Weak stream Frequency Urgency Hesitancy Incomplete voidance
All male patients presenting with LUTS should complete what?
International prostate symptom score (0-35)
How should LUTS in an elderly male be investigated?
B- Abdo exam, DRE, urine dip and culture
B- FBC, LFT (bone), consider PSA but rarely useful (only if ?DRE findings)
I- USS of bladder for post void volume
S- Flow studies
How is BPH treated?
Mild syx - Watch and wait Moderate symptoms (IPPS >8) = Tamulosin If severe = Tamulosin and Finasteride
Surgical (TURP)
What is tamulosin, what are it’s common SE?
Alpha blocker (reduces muscle tone in neck of bladder)
SE: Dizziness, postural hypotension, dry mouth
What is finasteride and what are it’s common SE?
5-alpha-reductase blocker
SE: Erectile dysfunction, reduced libido, retrograde ejaculation
What are management options in prostate Ca?
C- Watchful waiting, monitor PSA 3mthly
M- Goserelin (GnRH antagonist) or radiotherapy
S- Radical prostatectomy
What is your DDx for a scrotal swelling (5)?
Inguinal hernia < can’t get above it
Epidiymal cyst < Painless lump, often young
Hydrocele < Painless swelling, transilluminates
Testicular tumour < Discrete nodule
Varicocele < Usually on left
(R/o torsion)
- Also consider epididymo-orchitis
What is epididymo-orchitis and how does it present?
Infection (commonly Chlamydia or honorrhoeae)
- Unilateral pain and swelling
(+ Possible urethral discharge and urinary syx)
How is epididymo-orchitis treated?
Ceftriaxone 500mg IM
Doxycycline 100mg Oral BD (10-14days)
What is the most common testicular cancer and how should it be investigated?
Germ-cell tumours (95%), most common subtype is seminoma
Painless lump = USS
What is the mainstay of treatment for testicular cancer?
Orchidectomy
Who is affected by acute urinary retention and what is the most common cause?
M13:1F
Most common cause is BPH
(Can also be caused by constipation, neurological etc)
How does acute urinary retention present and how does this differ to chronic urinary retention?
Acute:
- Lower abdo discomfort and considerable pain (plus no urine)
Chronic:
- Often no pain
A patient presents with acute urinary retention, what investigations should be performed?
Obs
B- Urine dip, urinanlysis + culture (after catheter), bladder USS
B- Serum U+E’s, FBC and CRP (infection)
What volume of fluid in the bladder confirms a diagnosis of retention?
> 300mls
What volume of fluid drained from a catheter excludes urinary retention?
<200mls in 15mins
Over 400mls means catheter should be left in place
How long should patients be treated for a UTI?
Women = 3 days Preg women = 7 days Men = 7 days Children = 3 days Children <3mths = Immediate paediatrican referal
Name two features in a patient with dysuria and frequency which would raise suspicion of an upper UTI?
Fever
Loin pain or tenderness
How is a TURP performed?
Under general or spinal
Takes up to an hour
1-3days to recover in hospital (needs catheter to stay in place for a few days, then can go home)
Name the three main complications of a TURP?
Retrograde ejaculation (90%) Erectile dysfunction (10%) Urinary incontience (common) Urethral stricture (4%)
Name three management options for erectile dysfunction?
C- Lower BP + cholesterol
M- Sildenafil (Viagra)
(+ Assess for urinary symptoms, may have BPH)
Name 3 common features of pyelonephritis?
UTI symptoms
Loin pain
Fever and rigors
Vomiting
(White cell casts in urine)
How should pyelonephritis be treated?
ABCDE
R- Admission
CMS
(IV Cephalosporins)
What is treatment for stress incontinence?
1) Pelvic floor exercises TDS for 3 months
2) Surgery
What is treatment for urge incontience?
1) Bladder retraining for min of 6 weeks
2) Oxybutynin (antimuscarinic)
A patient presents with incontience, what are the initial investigations?
Bladder diaries
Vaginal examination
Urine dip and culture
Name 3 RF’s for urinary incontinence?
Advancing age Previous childbirth + pregnancy Obesity Hysterectomy FHx
What is the peak incidence of testicular torsion?
13-15yrs
Name 3 presenting features of testicular torsion?
Sudden, severe onset pain
Pain may be referred to lower abdo
N+V possible
Swollen, tender testis which is retracted upwards, possible red skin
Elevation of the testis does not relieve pain
How should testicular torsion be investigated?
Obs Bedside - Doppler USS Bloods - FBC, U+E, LFT I- / S- Surgical exploration
(Note doppler first but if high clinical suspicion and -ve doppler straight to surgical exploration)
How should testicular torsion be managed?
R- Early immediate referral to emergency urology
C- Try reducing (outward rotation) - don’t do if pain increases, should have immediate syx relief
M- Analgesia
S- Surgical reduction and bilateral orchiopexy
What are the two options when considering dialysis?
Peritoneal
1) Continous ambulatory (CAPD) - exhange 2L QDS
2) APD (automated PD) = Done overnight
Haemodialysis - 3x a day in hospital
What variables are used to calculate eGFR?
Serum creatinine
Age
Gender
Ethnicity
Name 3 factors which could affect an eGFR result?
Pregnancy
Muscle mass (bodybuilders, amputees)
Eating red meat within 12 hrs before sample
What are the stages of CKD?
Stage 1 - eGFR >90 but some signs kidney damage Stage 2 - eGFR = 60-90 Stage 3a - eGFR = 45-59 Stage 3b- eGFR = 30-44 Stage 4- eGFR = 15-29 Stage 5- eGFR = <15
Name 5 possible features of symptomatic CKD
- Nocturia and polyuria (can’t concentrate urine)
- Oedema (salt and water retention)
- Bone pain (hypocalcemia due to not enough VitD converted)
- Anaemia (low EPO)
- Anorexia, weight loss, fatigue, weakness
How should CKD be managed?
R- Stop smoking, control weight and exercise
- Restrict sodium
- Moderate protein intake only
M- Consider effect of medications
Also:
- Annual assessment of CVS risk
How is CKD diagnosed?
Based off at least two eGFR results, 90 days apart
Name 5 common CKD complications and their treatments?
Hyperphosphataemia (Ca + vit D suppliments) Oedema (furosemide) Restless legs (Clonazepam) Anaemia (give EPO) Acidosis (give Bicarb) Uremia
When is a patient with CKD referred to assess the need for dialysis?
When CKD 4/5
What is the classic triad of haemolytic uraemic syndrome?
Acute renal failure
Haemolytic anaemia
Thrombocytopenia
What is the main cause of haemolytic uraemic syndrome?
E coli
How is haemolytic uraemic syndrome managed?
Fluids
(Blood transfusion and dialysis also if required)
No AB’s
How is hydronephrosis investigated?
USS renal tract
What are the causes of a unilateral hydronephrosis?
PACT Pelvic-ureteric obstruction (congenital or acquired) Aberrant renal vessels Calculi Tumours of renal pelvis
