Urinary Flashcards
0
Q
What other function does the urinary system have?
A
To excrete waste products
1
Q
What is the main function of the urinary system?
A
Control the concentration of the ECF
2
Q
How much water on average does a 70kg person contain?
A
40l:
25l intra cellular fluid
15l ECF: 12l interstitial, 3l plasma, lymph
3
Q
What can a failure to control ECF result in?
A
Raised bp, tissue fluid and function
Cell shrinks or swells
4
Q
What are the main functions of the kidney?
A
Control pH
Volume
Osmolarity
Excrete waste products
5
Q
How many litres a day of urine do we excrete?
A
~1.5l
6
Q
How much ECF does the kidney filter each day?
A
180l/day (refilters)
7
Q
How much blood flow does the kidney require?
How much of the CO is this?
A
4ml/g/min
25%
8
Q
Describe the anatomy of the kidneys
A
150g each Retroperitoneal T11-T13 Right is lower due to the liver Ribs 11th and 12th
9
Q
Name the structures of the kidney
A
Papilla (nipple) Medulla - inner Cortex - outer Minor calyx Major calyx Pelvic bladder Renal pyramid Renal column
10
Q
Name the 3 outside layers of the kidney
A
Fascia
Fat
Fibrous capsule
11
Q
Name some of the blood vessels and picture where they lay in the kidney
A
Segmental arteries and veins Interlobular artery and vein Interlobular arteries and veins Arcuate arteries and veins Renal artery and renal vein
12
Q
What is the place where things go in and out of the kidney called and in what order?
A
Renal hilum
Vein
Artery
Ureter
13
Q
What is the functional unit of the kidney?
A
Nephron
14
Q
Where does most of filtration take place?
A
Glomerulus
15
Q
What maintains the filtration pressure?
A
Afferent and efferent arterioles
16
Q
What is the glomerular filtration rate?
A
180l/day
17
Q
Where is the major site of reabsorption?
A
Proximal convoluted tubule
18
Q
What specialisation does the epithelial cells have for reabsorption?
A
Polarised
19
Q
What is the main role of the loop of henle?
A
Create a gradient of increasing osmolarity in the medulla by counter current multiplication which allows concentrated urine if water is to be preserved
20
Q
What function does the distal convoluted tubule perform?
A
Variable reabsorption of electrolytes and water
21
Q
Where is the collecting duct and what is its function?
A
Medulla
Produces either a high or low amount of concentration in the urine
22
Q
What is sodium recovery controlled by?
A
Renin angiotensin system
23
Q
What is water recovery controlled by?
A
Anti duiretic hormone
24
Where is the IVC and aorta?
IVC right
Aorta left
So left renal vein longer - important for transplant
Right renal artery is longer
25
Where does the IVC lie between?
Superior mesenteric artery and the aorta - can be compressed in an aneurysm
26
What are the 3 construction points of the ureter?
Junction at the renal pelvis
Where the common iliac divides into internal and external/pelvic birth
Where it pierces the bladder wall
27
What is the significance of the construction points of the ureter?
Stones can get trapped here as it narrows
28
What is renal colic?
Smooth muscle spasms at afferents to T11 and L2 presenting with flanx, loin and groin pain
29
What is the anatomical position of the bladder?
Rises into greater pelvis as it fills
| On the pubic symphysis
30
What is the anatomical position if the prostate gland?
Wraps around the male urethra at the neck of the bladder
31
What are the 4 sections of the male urethra?
Pre prostatic - passes through neck of bladder surrounded by internal urethral spinchter
Prostatic - descends through anterior prostate
Membranous - passes through perineal pouch
Spongy - courses through corpus spongiosum in the penis
32
How long is the male urethra?
18-22cm
33
How long is the female urethra and what is the significance of this?
4cm
| More prone to uti
34
For a respiratory problem, what are the changes?
Co2
35
For a metabollic problem, what are the changes with?
HCO3-
36
What if both metabollic and respiratory has changed?
Then you would need some form of compensation
37
If the pH is normal, what process has occurred after change?
Compensation
38
If the pH is abnormal, what changes have occurred?
Partial compensation
39
What is the normal pH in a healthy person?
7.38-7.42
40
Why is alkalaemia more dangerous than acidaemia?
Calcium concentration is affected causing tetany
41
What changes occur with acidaemia?
Increased potassium
42
What pHs are life threatening?
7.55
43
What does plasma pH depend on?
The 20:1 ratio of bicarbonate and carbon dioxide
Determined by respiration
Controlled by chemoreceptors
HCO3- is controlled by the kidneys
44
What occurs with respiratory acidaemia?
Hyperventillation
| Hypercapnia
45
What occurs with respiratory alkalaemia?
Hypoventillation
| Hypocapnia
46
What detects the changes in pCO2?
Central medulla chemoreceptors
47
What is correction?
When you change the disturbances in pH and the cause is corrected for so pH is normal
48
What is compensation?
When the pH has changed due to a cause, the pH is compensated back to normal but the cause is not removed
49
How can pCO2 (resp) changes be compensated for (get pH back to normal)?
Altering the HCO3- in the kidneys
50
How is respiratory acidaemia compensated for?
Kidneys increase HCO3- reabsorption
51
How is respiratory alkalaemia compensated for?
Kidneys decrease HCO3- reabsorption
52
What is metabollic acidosis?
When too much acid is produced and there is a fall in HCO3- which decreases the pH
53
How is metabollic acidosis compensated for?
Increase ventilation which means more carbon dioxide is expelled and the pH is restored
54
What is metabolic alkalosis?
Plasma HCO3- rises too much
55
How is metabolic alkalosis compensated for?
An increase in ventilation
56
What is the problem when compensating for metabolic alkalosis?
You cannot increase ventilation too much or the decrease in oxygen will be far too low - therefore it can only be partially compensated for
57
Why do you get metabolic alkalosis?
Persistent vomiting which leads to a loss of too much acid
| You need to treat the dehydration and then the alkalosis will correct itself
58
How much HCO3- is filtered every day?
4500mmol
59
Is 4500mmol enough HCO3-?
No, the body has to make more by reacting with co2 and water
OR
amino acid breakdown into ammonia plus a hydrogen ion to make ammonium so the ureters and urethras are not damaged.
60
Where is HCO3- recovered in the kidney?
80-90% in PCT
| Remainder in TAL
61
Where is HCO3- made in the kidney?
Distal tubule
62
What is the minimum urine pH?
4.5 mmol of H+
63
How much H+ do we excrete every day?
50-100 mmol
| Controlled by HCO3- concentration
64
What is the anion gap?
(Na+k) - (Cl - HCO3)
| The gap is usually 10-15 mmol but changes can be accounted for if different acids have replaced HCO3-
65
Give examples of other metabollic acids created that displace HCO3-
Lactic acid
| Ketone bodies
66
What K+ condition is associated with metabolic acidosis?
Hyperkalaemia
67
What K+ condition is associated with metabolic alkalosis?
Hypokalaemia
68
Where is most of the potassium in the body and how much?
ICF 98% ~ 120-150mmol
| ECF 2% ~ 3-3.5mmol
69
Where is the resting membrane potential?
90 mmol - due to potassium
Increase in K+ depolarises membrane
Decrease in K+ hyper polarises the membrane
70
What 2 processes keep potassium regulated?
Internal balance
| External balance
71
Explain external balance
```
The kidneys balance the k+
5-10% is lost in the GI tract
It takes 6-12 hours to excrete a load of K+
LONG TERM
TOTAL BODY K+ content
```
72
Explain internal balance
Regulates k+ in the ECF
Immediate
If ECF K+ increases - K+ moves into cells
If ECF K+ decreases - K+ moves out of cells
73
How much of ingested K+ moves into cells within minutes?
| How long does excretion take?
4/5
| 6-12 hours
74
What factors promote K+ intake into cells?
Hormones - insulin, aldosterone, catecholamines
Alkalosis
Acidosis
75
How does insulin increase uptake of K+?
K+ in splanchnic blood stimulates insulin secretion from pancreas and this stimulates K+ uptake into liver and muscle cells via a Na-K-ATPase pump
76
How does aldosterone increase K+ uptake into cells?
K+ in bold stimulates aldosterone release which stimulates K+ uptake into cells via Na-K-ATPase
77
How do catecholamines increase K+ uptake?
Acts via beta 2 adrenoreceptors which in turn stimulate Na-K-ATPase
78
What promotes K+ out of cells?
```
Low ECF concentration
Exercise (produces K+ but immediately put into cells and then exercise releases catecholamines, stopping exercise leads to low K+)
Cell lysis
Increase in ECF osmolatity
Acidosis to balance charges
```
79
Give some conditions that can give rise to hyperkalaemia
Addison's disease
Diabetic ketoacidosis
Kidney failure
ACE inhibitors
80
Give some conditions that give rise to hypokalaemia
Cushings disease
Increased RAAS
Glucose and insulin
81
Define hyperkalaemia
Increase in K+ above 5mmol/L
82
Why do you get hyperkalaemia?
Kidney failure
Metabolic acidosis
Reduced aldosterone
Cell lysis
83
What effects do hyperkalaemia cause?
```
Bradycardia
Heart block
Arrhythmia
Smooth gut in GI paralysed
Acidosis
```
84
What changes would you see in an ECG of someone with hyperkalaemia?
Widened QRS
Absent p wave
Prolonged PR interval
VF
85
What emergency treatment would you give for hyperkalaemia?
Calcium gluconate to reduce K+ effect on heart
Glucose, insulin
Salbutamol
Dialysis
86
What long term treatment would you use for hyperkalaemia?
Treat cause
Reduce intake
Dialysis
Oral K+ binding resins
87
Define hypokalaemia
K+ concentration of <3.5 mmol/L
88
Give some common causes of hypokalaemia
```
Vomiting
Diarrhoea
Kidney diuretic drugs
High aldosterone
Metabollic alkalosis
```
89
Give some effects of hypokalaemia
```
Increased excitability of the heart
Arrhythmia
Smooth muscle paralysis
Muscle weakness
Diabetes insipidus
```
90
What would you expect to see on an ECG for hypokalaemia?
U wave
T wave flatter
Further from QRS complex
91
How would you treat hypokalaemia?
Cause
| IV K+(BE CAREFUL)
92
When does plasma osmolarity increase?
If water intake is less than excretion
93
When does plasma osmolarity decrease?
If water intake is more than water excretion
94
On average, how much urine does someone excrete every day?
1-1.5l/day
95
What do disorders of water balance manifest as?
Changes in body fluid osmolarity
96
What do disorders of sodium balance manifest as?
Changes in body volume
97
What are changes in plasma osmolarity detected by?
OVLT in the hypothalamus
Anterior and ventral to the third ventricle
Fenestrated epithelium
98
What two pathways maintain osmolarity?
Thirst and ADH
99
Describe the role of ADH
If plasma osmolarity increases by 1% then OVLT cause release of ADH from posterior pituitary
This causes low volumes of concentrated urine to be produced
Affects water and urea reabsorption
100
What changes does ADH make in the collecting duct?
Addition of aquaporin 2 channels which increase water absorption
When body is normal, aquaporin 2 is removed via endocytosis
101
How does the ADH effect on urea cause body osmolarity to decrease?
I'm dehydration, urea is reabsorped as it acts as an osmole so water will follow it
102
Explain/draw the counter current multiplication system
At the bottom of the loop of Henle the concentration is high. Above this descends in concentration the higher you get on both sides. Na Cl is pumped out of the ascending loop and is impermeable to water. Water is pumped out of the descending loop causing an increase in conc the further you of down the loop of Henle. This is maintained by vasa recta which move in the opposite direction.
103
Name some functions of calcium
Nerve conduction
Muscle contraction
Hormone and enzyme release
Exocytosis
104
How much free calcium do we have in our body?
1-1.3 mmol/L
105
What is the total calcium range in plasma?
2.1-2.6mmol/L
106
What 3 forms does calcium exist as in the plasma and in what proportions?
Free ionised - 45%
Bound to albumin - 45%
Caught up in phosphates etc - 10%
107
How much calcium is in our whole body? How does it exist?
25-30mol but 99% is in skeleton
| 0.1% in ECF
108
Discuss the handling of calcium in the intestines
Calcium is absorbed in the intestines by the help of calcitriol binding
109
Discuss renal handling of calcium
Filter 250mmol per day
98-99% is reabsorbed
Calcium excretion <10mmol per day
65% reabsorped in PCT
20-25% in loop of Henle
10% in the DCT by control of PTH
110
What do you give patients if they need to lose calcium?
NaCl
111
Where do patients with calcium deficiency get their calcium from and what problems can this cause?
Bone
| Brittle bones
112
How much vitamin D does a healthy adult need a day?
800-1000units
113
Why do you get vitamin D deficiency?
```
Lack of sunlight
Pigmentation
Breast feeding
Multiple pregnancies
Vegetarians
Anorexia
```
114
What are the actions of 1,25(OH)2D?
Increases calcium and phosphate availability in intestines
Promotes osteoblasts
Promotes active form
Synthesis of renal-1-alpha-hydroxylase
115
What are the actions of PTH?
Calciferol to calcitriol
Aids bone remodelling
Increases plasma calcium and phosphate plasma conc
Increases calcium reabsorption
Decreases phosphate and HCO3- reabsorption
Increase ca release from bone
116
How is PTH controlled?
Negative feedback of calcium levels
117
What are the causes of hypercalcaemia?
Primary Hyperparathyroidism
Haematological malignancy- due to action of PTHrp
Non haematological malignancy - "
118
What are the symptoms of hypercalcaemia?
Nausea and vomitting/depression/lethargy/decreased cognitive abilities/constipation/anorexia/pancreatitis/polyurea and polydypsia/hypertension
119
What is classed as a high calcium and what kind of importance is it?
>3.5 mmol/L
| Medical emergency
120
How do you manage hypercalcaemia?
```
Bisphosphonates
Calcitonin
Hydration
Loop duiretics
Treat underlying condition
```
121
Name the 3 types of Hyperparathyroidism
Primary - renal plasma calcium
Secondary - low or normal plasma calcium
Tertiary - raised plasma calcium
122
Discuss calcium stone formation
Due to increased levels of calcium in the urine
Low urine volume
Low urine pH (<5.47)
123
How do you diagnose renal stone formation?
History
Urine
Blood screen
Radiograph
124
How do you manage renal stone formation?
Increasing fluid intake, reducing dietary calcium, dietary restriction of calcium and animal protein
125
What controls the short term measure of blood pressure?
Baroreceptors in the carotid sinus and arch of aorta - they detect the stretching of the vessels and send a signal to the medulla
126
What controls the medium and long term blood pressure?
RAAS
ANP
ADH
Sympathetic nervous system
127
Explain the RAAS
```
Renin converts angiotensinogen to angiotensin I
Ace converts angiotensin I to angiotensin II
causes: release of aldosterone
Sympathetic stimulation
Vasoconstriction
ADH release
Na reabsorption
Noradrenaline release
```
128
What is the function of aldosterone?
Acts on principle cells of the collecting duct to activate ENaC and apical K+ channels
Increases Na extrusion via Na-K-ATPaae
129
What is the adverse effect of ace inhibitors?
Breaks down bradykinin into peptides
130
What does the sympathetic nervous system do in enters of blood pressure?
Vasoconstriction
Decreases renal blood flow and therefore decreases GFR and Na excretion
Stimulates renin
Activates Na-K-ATPase
131
What does ADH do in terms of blood pressure?
Forms concentrated urine
| Acts on thick ascending limb to stimulate NaKCC2 transporter and increase urea absorption
132
What does ANP do?
```
Promotes sodium excretion
Released by atrial myocytes in response to stretching
Vasodilation
Increase blood flow
Decrease sodium reabsorption
```
133
What is the function of prostaglandins?
Decrease sodium reabsorption
Enhance GFR
Vasodilators
134
What is the adverse effect of NSAID's?
Inhibit prostaglandins
135
What is hypertension?
Blood pressure over 140/90 mmHg
136
What are the 2 forms of hypertension?
Essential hypertension which has an unknown cause and is 95% of cases
Secondary hypertension where there is a known cause
137
Name some causes of secondary hypertension
```
Conns syndrome
Cushings disease
Pheochromocytoma
Renal vascular disease
Aldosteronism
```
138
What are some outcomes of hypertension?
```
MI
Stroke
Aneurysm
Renal failure
Retinopathy
Heart failure
```
139
How do you treat hypertension?
```
ACE inhibitors
Diuretics
Vasodilators
Beta blockers
Diet
Exercise
Stop smoking and drinking
Decrease salt intake
```
140
Define isosmotic
Same concentration as plasma
141
Define hyposmotic
Lower concentration than plasma
142
Define hyper osmotic
Higher concentration than the plasma
143
What happens with auto regulation when you increase BP?
Afferent arteriole constriction - adenosine released
144
What happens with auto regulation when you decrease blood pressure?
Afferent arteriole dilation - prostaglandins released
145
Describe the common organisms that cause UTI
```
Enterococci faecalis
E. coli
Coliforms
Proteus spp
Coag negative staphs
```
146
Which of the bacteria is common in hospital UTI?
Coagulase negative staphylococcus
147
What would you do for an uncomplicated UTI?
Urine dipstick test
| See for nitrates, leukocyte esterase, blood, proteins
148
Who is likely to get an uncomplicated UTI?
Young, healthy women with no abnormalities
149
Who is likely to get a complicated UTI?
Pregnant, males, young children, elderly patients, catheterised, urinary tract abnormalities, poly nephritis,
150
Do you need to culture the urine with an uncomplicated UTI?
No
151
What sample collection method would you use for a complicated UTI? (Adults, children, catheterised, supra pubic)
Mid stream specimen for adults
Adhesive bag over genitals for children
Catheter samples taken with a needle in the catheter tube for catheterised patients
Supra pubic aspiration
152
How are urine samples stored/transported?
4 degrees
| Boric acid
153
What is the purpose of boric acid?
It stops the division of bacteria to keep the sample representative of collection time
154
What investigations are you to do with a urine sample?
```
Look for turbidity (cloudiness)
Look for leukocyte esterase
Look for nitrates
Look for proteins
Look for blood
```
155
What does screening of urine in labs detect?
Blood
Bacteria
WBC
Casts
156
Why do we culture urine?
To investigate children, males and complicated infections
157
How predictive is a single urine specimen?
80% predictive
158
How can you interpret the culture of urine collected?
```
Qualify
Delays in culture
Organisms
Microscopy
Symptoms
Previous antibiotics
```
159
What is sterile pyuria?
When a UTI is present however unable to identify and culture an organism
160
What are the causes of sterile pyuria?
```
Previous antibiotics
Chlaymdia, gonorrhoea, tb
Appendicitis
Chemical inflammation
Vaginal inflammation
```
161
What percentage of women actually have a UTI?
50% significant bacteria
| 50% urethral syndrome
162
What are the non antibiotic treatments of a UTI?
Increase fluid intake
| Address underlying disorders
163
For an uncomplicated UTI, what antibiotics would you recommend and for how long?
3 day course
| Nitrofurantoin or trimethoprim
164
What antibiotics are not effective with UTI?
Amoxicillin
165
What antibiotics would you use for a complicated UTI and for how long?
```
5-7 days
Cephalexin
Nitrofuratoin
Trimethoprim
Ciprofloxacin
```
166
What antibiotics would you use for poly nephritis?
14 days
| Co amoxilav, ciprofloxacin, gentamicin IV
167
When is prophylaxis appropriate?
3 or more episodes of UTI in one year
No treatable or underlying condition
Single, low, nightly dose of antibiotics
Trimethoprim or nitrofurantoin used
168
What is the problem with diagnosing UTI with catheters?
No indication of pain passing urine or frequency
169
What percentage of GP consultations do urine infection take up?
1-3%
170
What are the host factors that make them susceptible to infection?
Short urethra
Valve incomplete
Incomplete bladder emptying, residual urine
Obstruction from stones, tumour, pregnancy, prostate
171
What bacterial factors can lead to an increased susceptibility to infection?
K antigens - polysaccharide capsule produced all
Adhesion - fimbriae and adhesins allow attachment to epithelia
Haemolysin - damage membranes
Urease - breaks down urea
Faecal flora - gets into the urinary tract
172
Define diuresis
Diuresis is the increased urine production
173
What is a diuretic?
A drug that increases urine production
174
Name some diseases causing diuresis
Diabetes mellitus because glucose acts as an osmole
Cranial diabetes insipidus as it inhibits ADH release
Nephrogenic diabetes insipidus inhibits ADH effect on collecting ducts
Psychogenic polydypsia increase thrist secondary effect
175
Name some substances that can cause diuresis other than diuretic drugs
Alcohol as it inhibits ADH release
Coffee as it increases GFR and decreases Na absorption
Demeclyocycline and lithium inhibit ADH release on collecting ducts
176
What are diuretics used to treat?
```
Congestive heart failure
Nephrotic syndrome
Cirrhosis and liver disease
Hypercalcaemia
Glaucoma
Kidney failure
Hypertension
Pulmonary oedema
Cerebral oedema
```
177
Explain oedema formation in congestive heart failure
Decrease in venous systemic pressure leads to oedema
OR
deceased CO, RAAS, sodium and water retention, ECF expansion and oedema
178
Explain oedema formation in nephrotic syndrome
Low plasma albumin, decreased oncotic pressure, oedema, reduced circulatory volume, RAS activated, water and sodium retention
179
Explain oedema formation in cirrhosis of the liver
Low plasma albumin, decreased oncotic pressure, oedema, reduced circulatory volume, RAS activated, water and sodium retention
180
Where do loop duiretics act?
Loop of Henle
181
What is the mechanism of loop duiretics?
Inhibits Na-K-2Cl
More sodium retained and potassium is lost in urine
Causes hypokalaemia
182
What are loop diuretics used for?
Heart failure
Hypercalcaemia as it inhibits ca reabsorption
Acute pulmonary oedema
Nephrotic syndrome
183
Name 2 examples of loop diuretics
Furosemide
| Bumetanide
184
Where do thiazide diuretics act?
DCT
185
What do thiazide diuretics do?
They inhibit Na Cl symporter
Increase calcium absorption
Decrease k absorption
186
When are thiazide diuretics ineffective?
Renal failure
187
How much sodium is inhibited with thiazide diuretics?
5%
188
How much sodium is inhibited with loop diuretics?
25%
189
What are thiazide diuretics used for?
Hypertension
| Hypercalcaemia
190
What is a side effect of thiazide diuretics?
Erectile dysfunction
Gout
Glucose intolerance
Hyperlipidaemias
191
Name 2 examples of diuretics
Metalazone
| Bendroflumethiazone
192
Give 2 examples of K+ sparing diuretics
Amiloride
| Triamtrene
193
Where does amiloride act?
Collecting ducts
194
How does amiloride function?
Inhibits ENaC
Decreases the Na channel
Causes hyperkalaemia as there is a decrease in K+ in the urine because more positive charge from sodium is lost
195
How do aldosterone antagonists act?
They block aldosterone by competitively inhibiting it
| Which blocks am reabsorption
196
What are aldosterone antagonists used to treat?
Best treatment for hypertension
Ascites and cirrhosis because it doesn't cause hypokalaemia
Used in heart failure with loop diuretics
197
How is hyperkalaemia caused with diuretics?
Block aldosterone -decreases Na absorption- K+ is kept in the cell
198
How can you minimise changes in K+ with diuretics?
Give a loop and thiazide with a k+ sparing or aldosterone antagonist
199
What 2 diuretics are not used?
Carbonic anhydrase inhibitors
| Osmotic diuretics
200
How do osmotic diuretics work?
Act as an osmole
201
What are osmotic diuretics used to treat?
Cerebral oedema
202
What are carbonic anhydrase inhibitors used to treat?
Glaucoma
203
Where do carbonic anhydrase inhibitors act?
PCT
| Interferes with Na and HCO3- reabsorption.
204
What can carbonic anhydrase inhibitors cause?
Metabolic acidosis
205
Name a carbonic anhydrase inhibitor
Acetazolamide
206
Name an osmotic diuresis
Mannitol
207
Give an example of an aldosterone antagonist
Spironolactone
208
Describe the anatomy of the detrusor muscle
Inner longitudinal, middle circular, outer longitudinal
Gives bladder strength to stretch
Rugae on inner folds to stretch
209
Describe the anatomy of the internal ureteral spinchter
Continuation of the detrusor
Smooth muscle
Physiological spinchter
210
Describe the anatomy of the external urethral spinchter
Anatomical spinchter
Derived from pelvic floor muscles
Skeletal muscle
Somatic
211
What is the innervation of the detrusor muscle?
S2-S4 parasympathetic pelvic nerve
Stimulated by Ach acting on M3
T10-L2 hypogastric nerve
Sympathetic
B3 receptors
212
What is the innervation of the internal urethral spinchter?
T10-L2 hypo gastric nerve
Sympathetic
Alpha 1 receptors
Sympathetic - relaxation
213
What is the innervation of ge external urethral spinchter?
Pudendal nerve
S2-S4
Acts on nicotinic receptors to cause contraction
214
What is the parasympathetic system responsible for in terms of micturation?
Peeing
Contraction of detrusor
Relaxing of internal spinchter
215
What is the sympathetic system responsible for in terms of micturation?
Storage of urine
Relaxing detrusor
Contracting internal spinchter
216
Describe voiding of urine
Relaxation of bladder allows for storage of urine
At about 500ml, temp and pain signals tell the brain voiding is necessary and also stretch receptors
Contraction of detrusor, relaxation of both spinchters, passage of urine
In males the bulbospongiosus muscle expels the last few drops of urine
217
Does the pressure increase when bladder is full?
No, bladder is relaxed and contraction of spinchters also help to reduce the pressure
218
What occurs when you need to store urine?
Bladder relaxes
Spinchter contracts
Bladder expands
Prevention of urine passing
219
Define stress urinary incontinence
This is when you leak urine when you cough or sneeze for example
220
Define urge urinary incontinence
This is leakage associated with urgency to urinate
221
Define mixed urinary incontinence
This is when a combination of involuntary leakage on urge and exertion such as sneezing or coughing causes leakage
222
Define overflow urinary incontinence
When the bladder is full there is leakage
223
Describe the prevalence of urinary incontinence with age
Increases
224
Describe the risk factors associated with urinary incontinence
```
Pregnancy
Obesity
Drugs
UTI
Familial
Pelvic prolapse
```
225
Describe the investigation of urinary in continence
```
Record amount of fluid they pass for 2 or 3 days
Number of pads patient wears
Pad test
Urine dipstick
Cystoscopy
```
226
Describe the examination of a patient with suspected incontinence
Height weight
Abdo exam
Digital rectal exam for males
Vaginal exam or external gentitalial exam for women
227
Explain how you would manage a patient with incontinence
```
Modify lifestyle - weight loss, fixed schedule, decrease caffeine
Catheter
Sheath device
Pads
Bladder training
Pelvic floor training
```
228
Describe the pharmaceutical management of incontinence
Duloxetine - only last resort - increases contraction of external urethral spinchter
Anticholinergics - act on m3 receptors to stop contraction of detrusor
Botulinum toxin - inhibits Ach, prevents detrusor contraction
229
Describe the surgical management of incontinence in women
Low tension vaginal tapes (not suitable for goes who want babies)
Correcting anatomical position of urethra
Sling
Intramural bulking agents such as collagen - for those who want babies
231
Describe the surgical management of incontinence in men
Artificial spinchter
| Male sling
232
How much of the cardiac output does the kidney recieve?
25%
233
What is the definition of AKI?
A decline in GFR that occurs during a period of less than 2 weeks
234
How is AKI measured?
By an increase in serum creatinine
235
Define oligouria
A decrease in urine production <500ml a day
236
Define anuria
No urine production, <100ml a day
237
Define uraemia
The clinical signs and symptoms of kidney failure leading to a lack of secretory and excretory function
238
Define azotaemia
An increase in urea in the blood
239
What are the 3 causes of AKI?
Pre-renal
Post-renal
Intrinsic
240
What is pre-renal AKI?
This is due to reduction in perfusion
60% of all AKI
Kidney unable to maintain bloodflow
REVERSIBLE as injury has not yet occurred
241
What is post-renal AKI?
This is due to an obstruction such as an enlarged prostate, stones, or at the bladder
242
What is intrinsic kidney disease?
This is damage to the interstitial kidney/glomerulus/tubules
243
What treatment is there available for AKI?
Volume correction for pre-renal
Urological intervention for post-renal
Supportive treatment
Dialysis
244
Define haematuria
Bleeding into the urinary tract from anywhere between the glomerulus to the urethra
245
Define nephrological haematuria
Glomerular inflammation and bleeding
| glomerulonephritis
246
Define urological haematuria
Renal stones, RCC, TCC
247
Define glomerulonephritis
Renal disease characterised by inflammation of the glomeruli or small blood vessels in the kidney
Can present with haematuria/proteinurea
248
Define nephrotic syndrome
Protein over 3.5g/day in the urine
249
Define nephritic syndrome
```
Haematuria
Proteinurea
Renal impairment
Salt and water retention
Hypertension
```
250
What are some glomerulonephritis giving haematuria?
IgA neuropathy
Mesangiocapillary glomerulonephritis
Post streptococcal glomerulonephritis
251
What are some systemic diseases causing glomerulonephritis?
SLE
Bacterial endocarditis
Vasculitis
Anti GBM disease
252
What are some investigations of haematuria?
```
Urine microscopy
Assessment of renal function
Qualification of 24 hour protein excretion
Immunological tests
Renal imaging
<45 then a renal biopsy
```
253
What are the investigations of proteinurea?
```
Assessment of renal function
Blood sugar/serum albumin/serum cholesterol
Immunological tests
Renal Imaging
Urine:Creatinine ratio
```
254
What is minimal change glomerulonephritis?
Need an electron microscope to see damage, will show epithelial cell foot process effacement
Light microscopy normal
255
What is membranous glomerulonephritis?
Increase in thickness of BM with sub epithelial depositation of electron dense deposits on electron microscopy
Gives silver spikes stain on microscopy
Little proliferation but mesangial sclerosis may occur in advanced cases
All glomeruli involved
256
What is focal segmental glomerularsclerosis?
Sclerosis of some glomeruli
| In early cases mostly juxtamedullary glomeruli involved
257
How does oedema occur in glomerular disease?
Hydrostatic pressure causes fluid to move into the interstitium
At the distal end fluid moves back in due to oncotic pressure
Proteinurea lowers oncotic pressure by lowering serum albumin so fluid does not reenter. Also activates RAAS
258
What is nephritic syndrome?
A collection of signs associated with disorders affecting the kidneys, characterised by having pores in the basement membrane large enough to permit proteins and red blood cells
259
What is rapidly progressive glomerular nephritis?
A clinical situation whereby glomerular injury is so severe that renal function deteriorates over days. Patient presents as a uraemic emergency
260
Define chronic kidney disease
Irreversible and sometimes progressive loss of renal function over months to years.
261
What happens in CKD?
Functioning renal tissue is replaced by ecf and scar tissue so sclerosis and fibrosis occurs. Excretory and hormone functions are both lost. Characterised by proteinurea and hypertension
262
What do most patients die of in CKD?
CVS causes
263
What is the classification used for CKregD?
```
5 stages
1 - GFR >90 - early
2 - GFR 60-89
3 - GFR 30-59
4 - GFR 15-29
5 - GFR <15 established renal failure
```
264
At what stage do most patients present with CKD?
Stage 3 present to GP
Generally asymptomatic
85% of CKD patients are found from regisries of IHD, diabetes and hypertension
265
What makes CKD develop quicker?
Badly controlled BP
266
What are the chances of death with stages 2 3 and 4 of CKD after 5 years?
2 - 20%
3 - 25%
4 - 45%
267
How would you investigate CKD?
24 hour creatinine clearance
Inulin
51CR EDTA or Iohexol
268
What is the problem with measuring creatinine for CKD?
It can be normal when GFR is <60%
| Depends upon age, sex and ethncitiy - black patients, young, males tend to have higher muscle bulk
269
How can you assess CKD?
```
Cause
Diagnosis and Prognosis
Degree of renal impairment
Imaging
Compliment/immunoglobulins/antibodies/ANCA
CRP
SPEP/UPEP
```
270
What are the cardiovascular complications of CKD?
Cardiomyopathy
Atheroscerosis
Pericarditis
271
What are the causes of CKD?
```
Immunological - glomerulonephritis
Idiopathic
Genetic - alports or PKD
Infection - pyelonephritis
Obstruction
Systemic - myeloma/diabetes
Vascular
Hypertension
```
272
What are the haematological complications of CKD? And how does it occur?
```
Anaemia
Decreased RBC survival
Resistance to erythropoeitin
Decreased erythropoeitin
Blood loss
(Eryhropoeitin stimulates bone marrow for rbc production)
```
273
What are the bone complications of CKD?
Renal bone disease
Decreased Vitamin D - lowers calcium - secondary hyperparathyroidism - osteomalacia
Increase in phosphate which lowers free calcium levels which causes secondary hyperparathyroidism, osteitis fibrosis cystica
Non bone calcification
274
What are the CNS complications of CKD?
Coma
Seizures
Neuropathy
275
What are the general symptoms of CKD?
```
Tired
Breathless
Nausea and vomitting
Restess legs
Aches and Pains
Itching
Chest pain
```
276
How can you conservatively manage CKD?
```
Diet
Exercise
Stop smoking
ACE inhibitors/Angiotensin receptor blockers
Treat diabetes
Statins
Treat blood pressure
```
277
What does RRT (renal replacement therapy) consist of?
Either renal transplant or dialysis
| Peritoneal dialysis or haemodialysis
278
What are the indications for dialysis?
```
Uraemic symptoms
Acidosis
Pericarditis
Fluid overload
GR <10ml/min
```
279
What is required for haemodialysis?
```
Artificial kidney
Logistics
Purified water supply
Anti-coagulation
Vascular access
HD machine
```
280
What procedure do you need to perform to allow haemodialysis as often as 3 times a week?
Create an arterio-venous fistula between radial artery and cephalic vein so blood flows from artery to vein and the vein builds up smooth muscle, allows cannulation 3x a week as a normal vessel would not be strong enough for this.
281
What are the advantages of haemodialysis?
High survival rate
4/7 days free of treatment
Dialysis dose is easily prescribed
282
What are the disadvantages of haemodialysis?
```
Expensive
Can't travel
CVS instability
Fluid and diet restrictions
Can't pass urine
Access problems
```
283
What is peritoneal dialysis?
This is where dialysis occurs across the peritoneal membrane and the waste products are also excreted across the peritoneal membrane. Requires peritoneal blood flow, membrane and peritoneal dialysis fluid.
284
What are the advantages of peritoneal dialysis?
```
Can be done at home
Low technology
Easily learned
CVS stability
Better for elderly and diabetics possibly
Allows mobility
```
285
What are the disadvantages of peritoneal dialysis?
```
No long term survivors as of yet
High revenue costs
Frequent exchanges - 4 a day roughly
Peritonitis
Treatment failures
Limited dialysis dose range
```
286
What are the sources for kidney transplant?
```
Emotional relation
Relative
Alturistic donor
Non-heart beating donor
Deceased donor
```
287
Where is the kidney put in the patient?
Into the iliac fossa and connected via the iliac vessels and into the bladder
288
What are the advantages for renal transplant?
```
Near normal renal function
High survival rate
Allows mobility
Cheaper
Long term good results
```
289
What are the disadvantages about renal transplantation?
```
Hard to find donors or a match
CKD still in patient
Operation - morbidity and mortality
Life long immunosuppression
Not all are suitable - eg malignancy
```
