Urinary Flashcards
What drugs have a narrow therapeutic index?
Gentamicin renal/ototoxicity
Digoxin
Lithium
Tacrolimus - renal/CNS toxcity
How are drugs nephrotoxic?
Water/sodium reabsorbed after filtered
Concentration goes up
Starts to damage nephron
How do you avoid damage with drugs?
REDUCE DOSAGE
Increase dose interval
TDM Monitor blood levels for toxic drugs like gentamicin, lithium, digoxin, vancomycin
What does renal impairment lead to?
Increase half-life of drugs
Build up of drugs
Decrease in protein binding, more free drug available
Increased sensitivity to pharmacological action
Increased sensitivity to toxicity and ADRs
How should you prescribe drugs if patient has renal failure?
Use drugs totally metabolised by liver
Reduce dose with longer dosage periods
What drugs induce renal failure?
Water and electrolyte abnormalities diuretics, laxatives, lithium, NSAIDs Increased catabolism Steroids, tertracyclines Vascular occlusion Oestrogens/ OCP
What drugs can cause acute tubular necrosis?
aminoglycoside antibiotics,
amphotericin B,
cisplatin (causes renal failure in up to 25% of patients after a single dose), radiocontrast agents
statin drugs given in combination with immunosuppressive agents such as cyclosporin
When does incontinence occur in men?
Intrinsic urethral sphincter well developed in men, poor in women
Incontinence in men when prostate removed
Poor pelvic floor muscles
What is oliguria?
Low urine output
Less than 0.5ml/kg/hour
What is anuria?
No urine output
What is polyuria?
Urine output greater than 3l/day
What is nocturia?
Waking up at night at least one time to go to the toilet
What is nocturnal polyuria?
Nocturnal urine output greater than a 1/3 of total urine output
What is RIFLE?
Pneumonic for kidney disease: Risk Injury Failure Loss of function End stage kidney disease
What is the Risk phase of RIFLE?
Risk - Increase in serum creatinine level (1.5x) or decrease in GFR by 25%, or UO <0.5 mL/kg/h for 6 hours
What is the injury stage of rifle?
Injury - Increase in serum creatinine level (2.0x) or decrease in GFR by 50%, or UO <0.5 mL/kg/h for 12 hours function >3 months
What is the failure stage of RIFLE?
Failure - Increase in serum creatinine level (3.0x), or decrease in GFR by 75%, or serum creatinine level >355μmol/L with acute increase of >44μmol/L; or UO <0.3 mL/kg/h for 24 hours, or anuria for 12 hours
What is the loss phase of RIFLE?
Loss - Persistent ARF or complete loss of kidney function >4 weeks
What is the end stage of RIFLE?
End-stage kidney disease - complete loss of kidney
What are the three types of haematuria?
Microscopic
Visible
Dipstick
How does chronic renal failure present?
Asymptomatic (found on blood and urine testing) Tiredness Anaemia Oedema High blood pressure Bone pain due to renal bone disease
How does advanced chronic renal failure present?
Pruritus Nausea/vomiting Dyspnoea Pericarditis Neuropathy Coma (untreated advanced renal failure)
How do ureteric diseaes present?
Pain (eg. renal colic) Pyrexia Haematuria Palpable mass (ie. hydronephrosis) Renal failure (only if bilateral obstruction or single functioning kidney)
How do bladder diseases present?
Pain (suprapubic) Pyrexia Haematuria Lower urinary tract symptoms (LUTS) Recurrent UTIs Chronic urinary retention (due to bladder underactivity) Urinary leak from vagina (i.e. vesico-vaginal fistula) Pneumaturia (i.e. colo-vesical fistula)
What are the types of lower urinary tract symptoms?
Storage
Voiding
Incontinence
What are storage LUTS?
frequency,
nocturia,
urgency,
urge incontinence
What are voiding LUTS?
poor flow,
intermittency,
terminal dribbling
What are incontinence LUTS?
stress, urge, mixed, overflow, neurogenic, dribbling
What is acute urinary retention?
Painful inability to void with palpable + percussible bladder
Treat with catheterisation
What are the complications of acute urinary retention?
UTI Haematuria Diuresis Renal failure Elctrolyte disturbances
What are the complications of chronic urinary retention?
UTI,
post-decompression haematuria,
pathological diuresis,
electrolyte abnormalities
>(hyponatraemia, hyperkalaemia, metabolic acidosis),
persistent renal dysfunction due to acute tubular necrosis
What is chronic urinary retention?
painless, palpable and percussible bladder after voiding Able to void but residual volume Immediate treatment is catherisation Manage with IV fluids Can give long term catheter
What effects creatine?
Muscle mass Age Ethnicity Gender Weight
What is chronic kidney disease?
Chronic kidney disease (CKD) is defined by either the presence of kidney damage (abnormal blood, urine or x-ray findings) or GFR<60 ml/min/1.73m2 that is present for ≥3 months
How can you test GFR?
Inulin clearance
Isotope GFR
24 hr urine collection + blood test
GFR estimating equations
What is the GFR of the kidney diseases?
Stage 1, 2, 3a, 3b, 4, 5
Stage 1: >90 Stage 2: 60-89 Stage 3a: 45-59 Stage 3b: 30-44 Stage 4: 15-29 Stage 5: <15
What do the different chronic kidney diseases mean?
Stage 1: Kidney damage with normal/high GFR
Stage 2: Kidney damage with mild reduction
Stage 3a/b: Moderately impaired
Stage 4: Severely impaired
Stage 5: Advanced disease
What investigations should you do into kidney disease - what are you looking for?
Blood count/film - haemolytic uraemic syndrome
Serum/urine electrophoresis - myeloma
Urine protein/creatinine ratio - intrinisc renal disease
CK - rhabdomyloysis
Anti-GBM - anti-gbm disease
ANCA - ANCA associated vasculitis
How do you manage kidney disease?
BP control
Proteinuria control
Reverse contributing factors
Lipid lowering
What are the complications of chronic kidney disease?
Metabolic acidosis Anaemia Bone disease Low activation of Vit D Phosphate control + PTH Cardiovascular disease
What are the features of metabolic acidosis?
General symtpoms, worsens hyperkalaemia
Exacerbates renal bone disease
Treat with oral Na bicarbonate
What is glomerulonephritis?
Inflammatory disease of kidney
Presents with proteinuria, renal failure + hypertentsion
What are the types of glomerulanephritis?
Non-proliferative Proliferative >Diffuse proliferative - post infective >Focal preliferative (IgA) >Focal necrotising >Membrano-proliferative
What is non-proliferative glomerularnephritis?
Glomeruli look normal or have areas of scarring. They have normal numbers of cells
Tubules and interstitium may be damaged
What is proliferative glomerularnephritis?
Excessive cellsinside glomeruli
What is diffuse proliferative (post infective) nephritis?
Follows 10-21 days after infection, typically of throat/skin
Most commonly with streptococci
What is acute nephritis, how does it present?
Fluid retention with oedema Normal serum albumin Little proteinuria Hypertension Renal impairment Typical of post-infective glomerulonephritis
What is IgA nephropathy?
Commonest cause of glomerulonephritis Typically occurs in the young Presents with macroscopic haematuria Provoked by intercurrent infection Usually not hypertensive Laboratory tests reflect renal function No characteristic serology Diagnosed by renal biopsy
How do you treat IgA nephropathy?
ACEI/other hypotensives
How many people with IgA nephropathy go on to get renal failure?
25% go on to form renal failure
What is crescentic glomerulonephritis?
Rapidly progressive glomeulonephritis
Medical emergency
Occurs in three settings
>Prescence of anti-glomerular basement membrane antibodies
>Associated with systemic vasculitis
>Complication of other types of glomerulonephritis
What is good pasture’s disease?
rare disease caused by autoimmunity to glomerular basement membrane (anti-GBM)
presents as nephritis with or without lung haemorrhage
diagnosed with anti-GBM antibodies in serum/kidney
>A cause of crescnetic glomerulonephritis
What is non-proliferative glomerulonephritis?
minimal change
focal membranous nephropathy
What is nephrotic syndrome?
clinical triad of
>pitting oedema
>proteinuria
>hypoalbuminaemia
Also has hyperlipidaemia
hyper coagulable state
increased risk of infection
What are the differentials to nephrotic syndrome?
Congestive heart failure
Hepatic disease
What is minimal change glomerulanephritis?
commonest in children
sudden onset of oedema
complete loss of proteinuria with steroids
What are the complications of minimal change glomerulonephritis?
bacterial infection
Thrombosis
How do you treat minimal change glomerulonephritis?
Prednisolone - for maximum of 8 weeks
What is focal glomerulonephritis?
Severe nephrotic syndrome very disabling at best incomplete response to steroids progresses to renal failure over 2 to 3 years it can recur in renal transplants
How do you treat focal glomerulonephritis?
treat with steroids and continue if clinically useful
try cyclosporine if steroids fail
non-specific drugs to reduce proteinuria (ACEI)
non-specific treatment for nephrotic oedema
What are the features of membranous glomerulonephritis?
commonest cause in adults
half isolated half with other diseases
What is the management for membranous glomerulonephritis?
immunosuppression for those with deteriorating renal function
prednisolone and chrorambucil for six months
can recurring renal transplants
prognosis is generally good
What are the clinica features of CKD?
Until CKD stage 4 or 5 the patient may be asymtomatic
The syndrome of advanced CKD is called uraemia
Uraemic symptoms can involve almost every organ system but the earliest and cardinal symptom is malaise and fatigue
What are the types of renal replacement?
Haemodialysis
Peritoneal dialysis
>Continous
>Intermittent
Renal transplant
What are the types of access for haemodyalysis?
Arteriovenous fistula
AV prosthetic graft
Tunnelled venous catheter
Temporary venous catheter
What are the restrictions for dialysis?
Fluid restriction >Dictated by residual urine output >Interdialytic weight gain Dietary restriction >Potassium >Sodium >Phosphate
What are the restrictions on dialysis for fluid?
Haemodialysis
>Usually restricted to 500-800 ml/24 hours
>intake allowed = urine output +insensible loss
Peritoneal dialysis
>Usually more liberal intake as continuous ultrafiltration is often achieved
What are the complications of haemodialysis?
Clotting of vascular access Hypotension and cramps Cardiovascular problems Heparin related problems Allergic reactions to dialysers and tubing Catastrophic dialysis accidents (rare)
What are the complications of peritoneal dialysis?
Peritonitis Exit site infection Tunnel infection Ultrafiltration problems Abdominal wall herniae
What are the types of acute kidney injury?
Pre-renal - blood flow
Renal - damage to renal parenchyma
Post-renal - obstruction to urine exit
What causes pre-renal injury?
Reduces circulatory volume
Arterial occlusion
Vasomotor
What causes renal injury?
Acute tubular necrosis >Ischaemia >Toxic Acute interstitial nephritis Acute glomerulonephritis Intra renal vascular obstruction >Vasculitis >Thrombocitic microangiopathy
What causes post-renal injury?
Obstruction
>Intraluminal
>Intramural
>Extramural
What are the risk factors for radiocontrast necropathy?
AKI following administrated iodine contrast agent Diabetes mellitus Renovascular disease Impaired renal function Paraprotein High volume of radiocontrast
What are teh clinical features of myeloma of the kidneys?
Proliferation of plasma cells producing excess of immunoglobulin + light chains Anaemia Back pain Weight loss Fractures Infections Cord compression Markedly elevated ESR Hypercalcaemia
What are the consequences of an AKI?
Acidosis Electrolyte disturbance Intoxication Overload Uraemic complications
How do you treat a AKI?
Fluid balance
Optimise BP
Stop nephrotoxic drugs
Treat sepsis
What are the ECG changes of a AKI?
Peaked T waves
>Usually earliest sign of hyperkalaemia
P wave widens + flattens
PR lengthens
P waves then disappear
How do you treat hyperkalaemia?
Stabilise >Calcium gluconate Shift >Salbutamol >Inslin dextrose Remove >Diuresis >Dialysis >Anion exchange resins
What are the benign diseaes of the prostate?
Benign prostatic enlargement (BPE) Benign prostatic hyperplasia (BPH) Benign prostatic obstruction (BPO) Bladder outflow obstruction (BOO) Lower urinary tract symptoms (LUTS)
What is benign prostatic hyperplasia?
Characterised by fibromuscular and glandular hyperplasia
Affects transition zone
Part of aging process in men
Can progress to bladder
What are the signs of prostatic hyperplasia?
Palpable abdo Phimosis Asses prostate size Suspicious nodules? Blood/UTI in urine?
How do you treat benign prostatic hyperplasia?
Medical therapy >Alpha blockers >5 alpha reductase inhibs Surgical >Remove
What are the effects of alpha blockers on the prostate?
Main treatment
Smooth muscle of bladder neck + prostate innervated
Relaxation + antagonise dynamic element
All types equally effective varying side effects
What are the effects of 5ARIs on the prostate?
Convert testosterone to dihydrotesterone
Reudce prostate size
Can reduce haematuria
What is TURP?
Transurethral resection of prostate
Effective in relieving symtoms
Can lead to bleeding, infection, retrograde ejeaculation
What are the complications of BPO?
Progression of LUTS Acute urinary retention Chronic urinary retention Urinary incontinence UTI Bladder stones Renal failure
How do you treat complicated benign prostatic hyperplasia?
Surgery
Long term catheter
Where can be obstructed in the upper urinary tract?
- PUJ
- ureter
- VUJ
Where can be obstructed in the lower urinary tract?
- bladder neck
- prostate
- urethra
- urethral meatus
- foreskin (e.g. phimosis)
What are the symptoms of upper urinary obstruction?
- Pain
- Frank haematuria
- Symptoms of complications
What are the signs of upper urinary obstruction?
- Palpable mass
- Microscopic haematuria
- Signs of complications
What are the complications of upper urinary obstruction?
- Infection and sepsis
- Renal failure
How do you manage upper urinary obstruction?
Resus Investigate Emergency treatment if required >Retrograde stent, percutaneous nephrostomy insertion Treat underlying
How does lower unrinary obstruction present?
Lower urinary tract symptoms > including urinary incontinence Acute urinary retention Chronic urinary retention Recurrent urinary tract infection and sepsis Frank haematuria Formation of bladder stones Renal failure
How do you treat lower urinary tract obstruction?
Resus Investigate Emergency >Catheter - urethral/suprapubic Treat underlying cause
Where is a kidney transplant placed?
In iliac fossa + anastomosed t iliac veins
What are the complications of a renal transplant?
Rejection Infective Malignancy Hypertension Hyperlipidaemia CRF (chronic renal failure)
What can cause acute rejection of a transplant?
Hyperacute - pre-existing alloreactivity to donor Acute T mediate >Lymphocytic infiltrate >Tubulitis Acute antibody mediated >Endarteritis >Endothelialitis Humoral >Neutrophil infiltration
What is CMV?
Most common infection after transplant - >cytomegalovirus Causes >Gastroenteritis >Nephritis >Hepatitis >Pneumonitis >Retinitis
What are the risk factors of BKAN?
Immunosuppresion
Old age, male, white
Mismatch, urethral stents
How do you manage BKAN?
Modify immunosuppresion
Antiviral therapy
What are the types of immunosuppresion you can get?
Non-specific T cell activation specific mTOR inhibitors Anti-IL2 receptor antibodies T cell antibodies
What are the non-specific immunosuppresion drugs?
Predisolone
Azathioprine
What is the main T cell activation specific drug?
Cyclosporin
