Renalsz Flashcards
Bladder cancer types and ix
Transitional cell cancer -95%- smoking and dyes
SCC- schistomyasis ix
present- Painless frank hematuria
Over 65, heamaturia always should be ix–cystoscopy
ddx- renal stones, RCC, prostate cancer
Renal cancer mx
TURBT for isolated lesions surface lesions (t1/2)
Locoregional spread is best determined using pelvic MRI and distant disease CT scanning. Nodes of uncertain significance may be investigated using PET CT.
Intravesical chemo if risk of recurrence
surgery ( surgery (radical cystectomy and ileal conduit) or radical radiotherapy) over t2
CKD types
Its base one eGFR calculations, which can be affected by–
Factors which may affect the result
pregnancy
muscle mass (e.g. amputees, body-builders)
eating red meat 12 hours prior to the sample being taken
Stage 1- >90 with signs of kidney damage (abnormal UE, Dipstick, ACR/PCR)
Stage 2 60-90 with signs of kidney damage
DONT DIAGNOSE CKD t1/2 without signs of damage
Stage 3a- 60-45
3b -45-30
4-30-15
5-<15 –need dyalisis and probably renal transplant
The urinary albumin:creatinine ratio (ACR) is a key investigation in diagnosing early CKD -early morning sample
AKI VS CKD renal ultrasound - most patients with CKD have bilateral small kidneys. Exceptions to this rule include:
autosomal dominant polycystic kidney disease
diabetic nephropathy (early stages)
amyloidosis
HIV-associated nephropathy
Consequences of CKD-
HTN
hypocalcaemia (due to lack of vitamin D), hyperphosphatemia
Aneamia-lack of erythropoetin
normochromic normocytic anaemia and becomes apparent when the GFR is less than 35 ml/min
CKD management
Issues- Calcium metabolism, Aneamia,
calcium -phosphate not extreted, Vit D not produced
2nd ary and tertiary hyperprathyroidism
mx- diet- reduce intake of phoisphate
Phosphate binders (eg selvamer)
Oral vit D
Parathyroidectomy can be used
Anemia-lack of eryhtropoetin -normocytic
First optimise iron/folate/b12 and others- give oral replacement, and if needed IV iron
Then can consider EPO replacements
patients on ESAs/EPO replacement or haemodialysis generally require IV iron
Circumcision uk requirements
Circumcision for religious or cultural reasons is not available on the NHS
Medical indications for circumcision
phimosis
recurrent balanitis
balanitis xerotica obliterans
paraphimosis
It is important to exclude hypospadias prior to circumcision as the foreskin may be used in surgical repair. Circumcision may be performed under a local or general anaesthetic.
Dyalisis and renal replacement why
Types
haemodialysis
peritoneal dialysis
renal transplant
indications for emergency-hyperkalemia, ureamic encelopathy, acidosis, drug overdoses
Haemodialysis is the most common form of renal replacement therapy.
Filtration of the blood through a dialysis machine in hospital.
dialysis 3 times per week, with each session lasting 3-5 hours.
At least 8 weeks before the commencement of treatment, create an arteriovenous fistula
Site infection, endocarditis, Hypotension -safest
. Dialysis solution is injected into the abdominal cavity through a permanent catheter. The high dextrose concentration of the solution draws waste products from the blood into the abdominal cavity across the peritoneum. After several hours of dwell time, the dialysis solution is then drained, removing the waste products from the body, and exchanged for new dialysis solution
Continuous ambulatory peritoneal dialysis (CAPD) - as described above, with each exchange lasting 30-40 minutes and each dwell time lasting 4-8 hours. The patient may go about their normal activities with the dialysis solution inside their abdomen
Automated peritoneal dialysis (APD) - a dialysis machine fills and drains the abdomen while the patient is sleeping, performing 3-5 exchanges over 8-10 hours each night
–>Peritonitis, Catheter blockage, fluid retention, hernia
Renal transplantation involves the receipt of a kidney from either a live or deceased donor. The average wait for a kidney in the UK is 3 years,–
Life long immunosupression -CMV inf
DVT / PE, GvHD, Malignancies (particularly lymphoma and skin cancer), reccurence of kidney disease
does not receive renal replacement therapy is 6 months. The symptoms of renal failure that is not being adequately managed with RRT are:
breathlessness
fatigue
insomnia
pruritus
hyperkalemia, ureamic encelopathy, acidosis
Glomerulonephritis
Many types
Post Step Glomerulo-7-14d after usually Streptococcus pyogenes)
visible haematuria, proteinuria, hypertension
this may result in oedema, low C3 on Ix
acute, diffuse proliferative glomerulonephritis -starry sky appearance
IgA nephro- 1/2 days post URTI-commonest glomerulo WORLDWIDE-Frank heamaturia in young adult
No bad signs- no follow up except UE after
If active proteinuria-initial treatment is with ACE inhibitors
Bad- Steroids
(henoch-schelein is a IgA vasculitis- very similar but usually more arthritis, rash + signs of nephropathy (heamaturia, htn etc)–supportive mx—blood pressure and urinanalysis should be monitored to detect progressive renal involvement
Membrenous- most common in adults-nephrotic type
infections: hepatitis B, malaria, syphilis
malignancy (in 5-20%): prostate, lung, lymphoma, leukaemia
all patients get ACE/ARB
1/3 get better on own
1/3 remain proteinuric
1/3 get bad CKD- steroids + other immunosupressor (eg cyclophosphamide)
remember-bad nephrotic is very pro-coag as lose Prot C- consider anticoag
Focal segmenting-young adult–
secondary to other renal pathology e.g. IgA nephropathy, reflux nephropathy
HIV
heroin
Mx– steroids +/- immunosuppressants
rarely remits
Rapidly progressing–
rapid loss of renal function associated with the formation of epithelial crescents
causes-Goodpasture’s syndrome
Wegener’s granulomatosis
nephritic syndrome: haematuria with red cell casts, proteinuria, hypertension, oliguria
GBM mx- plasma exchange (plasmapheresis)
steroids
cyclophosphamide
Wegners mx (cAnca) —steroids
cyclophosphamide (90% response)
plasma exchange
Scrotal lumps ddx
Inguinal hernia—-direct
inguinoscrotal swelling; cannot ‘get above it’ on examination
Cough impulse may be present
May be reducible
mx- surgery
Varicocele
Varicosities of the pampiniform plexus
Typically occur on left (because testicular vein drains into renal vein)
May be presenting feature of renal cell carcinoma
Affected testis may be smaller and bilateral varicoceles may affect fertility
mx-conservative, if there are concerns about testicular function of infertility then surgery or radiological management can be considered.
Hydrocele
Non painful, soft fluctuant swelling
Often possible to ‘get above it’ on examination
Usually contain clear fluid
Will often transilluminate
testicular cancer
epidermitis–
Often history of dysuria and urethral discharge
Swelling may be tender and eased by elevating testis
Most cases due to Chlamydia
Epidymal cyst-
Lie above and behind testis
can get above
Single or multiple cysts
May contain clear or opalescent fluid (spermatoceles)
Usually occur over 40 years of age
Painless
Testicular torsion
Severe, sudden onset testicular pain
Risk factors include abnormal testicular lie
Typically affects adolescents and young males
On examination testis is tender and pain not eased by elevation
varicocele
A varicocele is an abnormal enlargement of the testicular veins. They are usually asymptomatic but may be important as they are associated with infertility.
Varicoceles are much more common on the left side (> 80%). Features:
classically described as a ‘bag of worms’
subfertility
Diagnosis
ultrasound with Doppler studies
can be presentation of RCC
Management
usually conservative
occasionally surgery is required if the patient is troubled by pain. There is ongoing debate regarding the effectiveness of surgery to treat infertility
Hydrocele
A hydrocele describes the accumulation of fluid within the tunica vaginalis. They can be divided into communicating and non-communicating:
communicating: caused by patency of the processus vaginalis allowing peritoneal fluid to drain down into the scrotum. Communicating hydroceles are common in newborn males (clinically apparent in 5-10%) and usually resolve within the first few months of life
non-communicating: caused by excessive fluid production within the tunica vaginalis
Hydroceles may develop secondary to:
epididymo-orchitis
testicular torsion
testicular tumours
Features
soft, non-tender swelling of the hemi-scrotum. Usually anterior to and below the testicle
the swelling is confined to the scrotum, you can get ‘above’ the mass on examination
transilluminates with a pen torch
the testis may be difficult to palpate if the hydrocele is large
Diagnosis may be clinical but ultrasound is required if there is any doubt about the diagnosis or if the underlying testis cannot be palpated.
Management
infantile hydroceles are generally repaired if they do not resolve spontaneously by the age of 1-2 years
in adults a conservative approach may be taken depending on the severity of the presentation. Further investigation (e.g. ultrasound) is usually warranted however to exclude any underlying cause such as a tumour
Testicular cancer
Inguinal hernias
groin lump
superior and medial to the pubic tubercle
disappears on pressure or when the patient lies down
discomfort and ache: often worse with activity, severe pain is uncommon
strangulation is rare
indirect (hernia through the inguinal canal) and direct hernias (through the posterior wall of the inguinal canal)
the clinical consensus is currently to treat medically fit patients even if they are asymptomatic
mesh repair is associated with the lowest recurrence rate
unilateral inguinal hernias are generally repaired with an open approach
bilateral and recurrent inguinal hernias are generally repaired laparoscopically
no manual work after 2-3 weeks
Abdominal hernias
Risk factors for abdominal wall hernias include:
obesity
ascites
increasing age
surgical wounds
palpable lump
cough impulse
pain
obstruction: more common in femoral hernias
strangulation: may compromise the bowel blood supply leading to infarction
Femoral–(F»M)
Below and lateral to the pubic tubercle
More common in women, particularly multiparous ones
High risk of obstruction and strangulation –ALWAYS SURGERY
PKD
Autosomal dominant polycystic kidney disease (ADPKD) is the most common inherited cause of kidney disease,
2 types- pkd 1 presents earlier
tolvaptan (vasopressin receptor 2 antagonist) may be an option
slow the progression of cyst development and renal insufficiency only if:
they have chronic kidney disease stage 2 or 3 at the start of treatment, rapidely progress
heamorhagic stroke
Autosomal recessive polycystic kidney disease (ARPKD) is much less common than autosomal dominant disease (ADPKD)
Patients also typically have liver involvement, for example portal and interlobular fibrosis.
RAS
Renal artery stenosis secondary to atherosclerosis accounts for around 90% of renal vascular disease, with fibromuscular dysplasia being the most common cause of the remaining 10%.
Features
hypertension
chronic kidney disease
‘flash pulmonary oedema’
care with ACE in significant renal impairment may occur in patients who have undiagnosed bilateral renal artery stenosissds
