Urinary System - Level 2 Flashcards
1
Q
Definition of CKD?
A
- Abnormal kidney function or structure present for >3 months or eGFR <60
2
Q
Normal functions of kidney?
A
Excretory –
inorganic substances (e.g. potassium, phosphate)
organic (urea, creatinine)
clinically “uraemic toxicity”
Homeostasis – fluid balance, blood pressure, acid-base
Endocrine – erythropoietin, bone metabolism
3
Q
Epidemiology of CKD?
A
- Over 70% due to DM, hypertension
- Prevalence increases with age
- 8.5% Stage 3-5 CKD
4
Q
Causes of CKD - intrinsic?
A
o Hypertension
o DM (Type 2 most common)
o Glomerulonephritis
o Renal artery stenosis
5
Q
Causes of CKD - nephrotoxic?
A
o NSAIDs, Lithium, Ciclosporin, Tacrolimus, Aminoglycosides, Mesalazine
6
Q
Causes of CKD - obstructive?
A
o Bladder voiding dysfunction
o Urinary diversion surgery
o Recurrent urinary stones
7
Q
Causes of CKD - multi-system disease?
A
o SLE, vasculitis, myeloma, polycystic kidney disease, Alport’s syndrome
8
Q
Symptoms of CKD?
A
- Asymptomatic at first
- Anaemia – Low EPO – Pallor, SOB
- Renal osteodystrophy – osteomalacia, bone pain
- Epistaxis/bruising
- Uraemic symptoms
- Anorexia/nausea/vomiting
- Restless legs, weakness, pruritus and bone pain
9
Q
Signs of CKD?
A
- Pallor, uraemic tinge, purpura, increased BP, signs of fluid overload, ballotable kidneys
10
Q
When to test people for CKD?
A
Test people with risk factors for CKD:
o Diabetes, hypertension, AKI, CVD, SLE, structural renal tract disease, recurrent calculi, BPH
o Family history of CKD stage 5
o Taking nephrotoxic drugs (ciclosporin, tacrolimus, lithium, NSAIDs)
Test people with incidental findings:
o Proteinuria or persistent haematuria (2/3 with 1+) after exclusion of UTI
o eGFR of <60
11
Q
What tests to perform in people suspecting CKD?
A
- Serum creatinine (eGFR)
- Early Morning Urine – Albumin Creatinine Ratio (ACR)
- Urine dipstick for haematuria
12
Q
Specific advice for testing eGFR in CKD?
A
o No meat in 12 hours before, caution if extreme muscle mass
o Confirm result if <60 with test 2 weeks later
o If stable but same, repeat 3 months
13
Q
Specific advice for testing EMU ACR in CKD?
A
- Early Morning Urine – Albumin Creatinine Ratio (ACR)
o Repeat if 3-70mg/mmol within 3 months, no need if >70
o >3 is clinically proteinuria
14
Q
Specific advice for testing urine dipstick in CKD?
A
o Significant haematuria if 1+ or more, exclude UTI by sending MSU
15
Q
Specific advice for testing renal USS in CKD?
A
o If accelerated progression of CKD, visible or persistent invisible haematuria, symptoms of UT obstruction, FHx of PKD and >20 years, eGFR <30
16
Q
Other tests to find cause of CKD?
A
- Bloods (low Hb, Ca, high PO4 and ALP and PTH, glucose, U&Es)
- Urine – ACR, dipstick
- USS to check kidneys size and anatomy
- Renal biopsy if rapid decline and cause unclear
- Immunology – Goodpasture’s syndrome, IgA nephropathy
17
Q
Diagnosis of CKD can be made when?
A
- EGFR <60 and/or ACR >3 after 3 months
- If repeat eGFR 45-59 and urine ACR <3 and no proteinuria:
o Use eGFRcystatinC test
Hypothyroidism elevates, hyperthyroidism reduces
18
Q
Classification of CKD stages?
A
- Stage 1 - >90 No impairment
- Stage 2 – 89-60 Slight
- Stage 3A – 59-45 Moderate
- Stage 3B – 44-30 Severe
- Stage 4 – 29-15 Severe
- Stage 5 - <15 Renal Failure
- ACR classified in each stage as A1 - <3, A2 – 3-30, A3 - >30
19
Q
When to refer CKD to nephrologist?
A
- eGFR <30
- ACR >70mg/mmol
- ACR >30mg/mmol with haematuria
- Decrease by >25% in year or decrease GFR >15ml/min/1.73 in year
- Poorly controlled BP on 4 antihypertensives
- Suspected genetic causes or renal artery stenosis
20
Q
Monitoring of CKD?
A
- Annual eGFR and ACR if no CKD and risk factors
- eGFR, ACR (stage 1-3a annually, stage 3b-4 biannually, stage 5 quarterly)
- FBC (Stage 3b, 4, 5)
- Serum calcium, phosphate, vitamin D and PTH in (stage 4, 5)
21
Q
Management of CKD - self-management?
A
- Stop smoking
- Regular exercise and healthy body weight
- Eat healthy diet – low sodium, Vit D analogues and Ca supplements
- Avoid NSAIDs, nephrotoxics
- Manage and minimise risk factors
22
Q
Management of CKD - antihypertensives?
A
o If hypertensive and ACR <30 – follow guidelines
o If hypertension and ACR >30 – ACEi/ARB
o If ACR >70 and normotensive OR CKD and diabetic – ACEi/ARB (aim <130/80)
23
Q
Management of CKD -aim of antihypertensives?
A
Aim <140/90 in hypertensive + CKD + ACR <70
Aim <130/80 in ACR>70 + normotensive or CKD + diabetes
24
Q
Management of CKD -monitoring of antihypertensives?
A
Measure serum potassium and eGFR before ACEi, 1-2 weeks later and at any dose change (before starting K<5, otherwise don’t start ACE/ARB, stop if K>6 after 1-2 weeks)
If eGFR decreased by >25% then repeat test 1-2 weeks – if <25% then continue and repeat test in 1-2 weeks, if >25% investigate causes and stop drug
25
Management of CKD - statin therapy?
- Atorvastatin 20mg daily (if eGFR <60 and ACR >3)
o Baseline lipids, CK, LFTs
o Can increase dose if not >40% reduction in non-HDL cholesterol and eGFR >30 in 3 months
o Repeat lipids at 3 months
26
Management of CKD -antiplatelets and anticoagulants?
- Antiplatelets
o Secondary prevention only
- Anticoagulant
o Secondary prevention of CVD – Apixaban used if eGFR 30-50 and non-valvular AF and 1 of: Hx of TIA/stroke, >75, HTN, DM, HF
27
Management of CKD - complications - anaemia?
o Check Hb in people with eGFR <45
o Offer iron tablet if deficient – if Hb level not reached within 3 months, offer IV therapy
o If on dialysis – offer IV iron first
o EPO may be needed
28
Management of CKD - complications - bone complications?
o Measure serum Ca, phosphate, PTH and Vit D when eGFR <30
If needed – cholecalciferol
o Bisphosphonates for prevention of osteoporosis when eGFR >30, if indicated only
29
Management of CKD - complications - bicarbonate level?
- Oral sodium bicarbonate
| o eGFR<30 or sodium bicarbonate <20
30
Definition of deterioration of CKD?
- Decrease by >25% or 15ml/min/1.73 in year
- Repeat eGFR 3x over 90 days
- Refer to nephrologist as before
31
When to discuss RRT in CKD?
- Discuss when eGFR <20
- Dialysis started when impact of symptoms of uraemia on daily living, biochemical measures or uncontrollable fluid overload or at eGFR around 5-7 if no symptoms
32
Options of RRT in CKD?
- Haemodialysis
o Diffusion solutes between blood and dialysis fluid – access via fistula inserted 6 months before start
- Peritoneal dialysis
o Diffusion solutes between blood in peritoneal capillaries and dialysis fluid in peritoneal cavity
o Continuous ambulatory peritoneal dialysis (4x a day)
o Automated PD (several exchanges per night)
- Kidney transplant
o From deceased donor or live donor
o Lifelong immunosuppression
o Must be medically fit for surgery
33
Prognosis of CKD?
- CKD progresses to End-stage KD in 2% of people
| - 20x more likely to die of CVD then to progress to End-stage KD
34
Complications of CKD?
- Renal replacement therapy
- CVD and events
- Renal anaemia, bone disease (low Ca, high PO4 and PTH)
- Malnutrition
- Neuropathy
- Lipid abnormalities
35
Definition of AKI?
- Rapid reduction in kidney function over hours to days, as measured by serum urea and creatinine – leading to failure to maintain fluid, electrolyte and acid-base homeostasis
36
Epidemiology of AKI?
- Occurs in 18% of hospital patients
37
Risk factors of AKI?
- Age>75
- CKD
- Cardiac failure
- PVD
- Liver failure
- Diabetes
- Drugs
- Sepsis
- Poor fluid intake
38
Causes of AKI - pre-renal?
Most common
o Renal hypoperfusion due to hypotension (hypovolaemia, D&V, sepsis), renal artery stenosis +/- ACEi
o Reduced cardiac output (cardiac and liver failure)
39
Causes of AKI -intrinsic?
10-50%
```
o Acute tubular necrosis
Due to drugs, aminoglycosides, radiological contrast, rhabdomyolysis
o Glomerulonephritis
o Vasculitis, thrombosis
o Interstitial nephritis, lymphoma
```
40
Causes of AKI - post-renal?
10-25%
Urinary tract obstruction
Luminal – stones, clots
Mural – malignancy, BPH, strictures
Extrinsic compression – malignancy, retroperitoneal fibrosis
41
Symptoms and signs of AKI?
- May be none
- Fatigue, malaise, rash
- Joint pains, nausea and vomiting
- Chest pain, palpitations, SOB, fluid overload
- Oliguria, hypo/hypertension
42
When to measure U&Es to identify AKI?
CKD, HF, liver disease, Hx of AKI, oliguria (<0.5ml/kg/hour), hypovolaemic, NSAIDs, ACEi/ARBs, diuretics, urinary obstruction, sepsis, severe diarrhoea, nephritis, hypotension, >65
43
When to detect AKI in hosptial patients?
Rise in serum creatinine >26 within 48 hours
50% or greater rise in serum creatinine within 7 days
Fall in urine output to <0.5ml/kg/hour for >6 hours in adults and >8 hours in children
25% or greater fall in eGFR in children and young people within 7 days
44
KDIGO staging of AKI - Stage 1?
* Rise in creatinine >26umol/L in 48h OR >1.5-1.9x baseline (best figure in last 3 months)
* Urine output <0.5ml/kg/h for >6 consecutive hours
45
KDIGO staging of AKI - Stage 2?
* Increase in creatinine 2-2.9x baseline
| * Urine output <0.5ml/kg/h for >12h
46
KDIGO staging of AKI - Stage 3?
* Increase in creatinine >3x baseline OR >354umol/L OR commenced on RRT
* Urine output <0.3ml/kg/h for >24h OR anuria for >12h
47
Tests to identify cause of AKI?
Bloods
• FBC, U&E, LFTs, Ca, Phosphate
• Cultures if signs of infection
Urinalysis
• Test for blood, protein, leucocytes, nitrites and glucose as soon as suspected
• If haematuria and proteinuria and no obvious cause/UTI/trauma – think acute nephritis
Ultrasound
• Do not offer if cause of AKI identified
• If pyonephrosis suspected – US within 6 hours
• If no cause of AKI found – urgent US within 24 hours
48
Management of AKI - if urinary obstruction suspected/identified?
Refer immediately when one or more of following is present:
Pyonephrosis
Obstructed solitary kidney
Bilateral upper urinary tract obstruction
Complications of AKI caused by urological obstruction
Nephrostomy or stenting performed within 12 hours of diagnosis if needed
49
Management of AKI -investigations to perform?
o ABG/VBG
o ECG
o Catheterisation and urine output
50
Management of AKI - initial management - STOP AKI?
Sepsis
Complete sepsis 6 if sepsis suspected
Toxins
Stop/avoid nephrotoxics (Gentamicin, NSAIDs, ACE/ARBs, diuretics, contrast)
Optimise BP
If low BP – fluid bolus (0.9% saline 500ml IV 15-20 minutes)
Assess volume status
BP, JVP, skin turgor, fluid balance sheet, weight
IV fluids
• If low BP – fluid bolus (0.9% saline 500ml IV 15-20 minutes)
• IV fluids maintenance if not hypovolaemic
```
Prevent Harm
Treat complications
• Hyperkalaemia
• Pulmonary oedema
• Acidosis
• Pericarditis
Review all medications
Identify cause
```
Refer to renal team early for opinion
51
Management of AKI - monitoring?
o Check pulse, BP, JVP, urine output hourly
o CVP line if on HDU/ICU
o Daily U&Es, fluid balance chart and daily weight
52
Management of AKI - when to discuss with nephrology?
```
Specialist treatment needed (vasculitis, glomerulonephritis, nephritis, myeloma)
AKI with no clear cause
Inadequate response to treatment
Complications associated
Stage 3 AKI
Renal transplant
CKD Stage 4/5
```
53
Management of AKI -indications for RRT?
o Refractory pulmonary oedema
o Persistent hyperkalaemia
o Severe metabolic acidosis (7.15)
o Ureamic complications (pericarditis, encephalopathy)
o Drug overdose – Barbituates, lithium, alcohol, salicylates, theophylline
54
Options for RRT in AKI?
Haemodialysis
Blood passed over semi-permeable membrane against dialysis fluid flowing in opposite direction
Hemofiltration
Water is cleared across dialysis membrane using positive pressure to drag small and larger size solutes into waste by convection
Peritoneal Dialysis
Uses peritoneum as semi-permeable membrane and allows solutes to diffuse slowly
Can be performed continuously and at home so allows more freedom
55
Follow up after AKI?
o Monitor U&Es for 2-3 years after AKI
56
Complications of AKI?
- Hyperkalaemia
- Metabolic acidosis
- Volume overload
- Uraemia
- CKD
57
Symptoms in urinary incontinence?
Stress - leakage of urine on sneezing, coughing, exercise, rising from sitting or lifting
Urge - urgency and failure to reach toilet, frequency and nocturia possible
Other symptoms to ask:
Frequency during day/night, dysuria, haematuria,, dribbling of urine after leaving toilet, feeling incomplete bladder emptying
58
Gynaecological history important in urinary incontinence?
```
Uterus or not
Pre/Postmenopausal
Problems with intercourse
How many babies - delivery method
Smear tests up to date
```
59
PMH important in urinary incontinence?
```
Uterus or not
Pre/Postmenopausal
Problems with intercourse
How many babies - delivery method
Smear tests up to date
```
60
DH important in urinary incontinence?
Diuretics
Laxatives
Medications for urinary symptoms in past
61
SH for urinary incontinence?
```
Caffeine intake
Carbonated drinks
Alcohol
Smoking
Ketamine
Occupation - heavy lifting?
```
62
Examination performed in incontinence?
```
History including obstetric, sexual and functional status
BMI and Urine dipstick & MSU
Abdominal and pelvic examination
Cough - any leakage?
Assess for prolapse
Assess for vaginal atrophy
VE
Smear
```
63
Investigations in urinary incontinence?
- Urinalysis and MSU microscopy (culture and sensitivity)
o Exclude UTI
- OGTT if diabetes suspected
- Frequency/volume chart
o Should be filled in for 72h and give idea off fluid intake and voiding problems
64
When should a cystoscopy be performed in urinary incontinence?
o Used to visualise urinary tract
| o Indicated if recurrent UTI, haematuria, bladder pain, suspected fistula, tumour
65
What are the specialist tests performed for urinary incontinence?How do they work?
Urodynamics
o Uroflowmetry
Ability of bladder to store and void urine
Patient voids in private onto commode with urinary flow meter, measuring voided volume over time and plotting graph
o Cystometry
Invasive and involves measuring pressure and volume in bladder during filling and voiding
Bladder filled with saline and intravesical & vaginal/rectal probe measure differences in pressure to give detrusor pressure
Patient first desire to void, strong desire to void and cough
Diagnoses stress incontinence
66
Initial management of stress urinary incontinence?
```
Lifestyle interventions
• Weight reduction if BMI >30
• Smoking cessation
• Reduce caffeine and fizzy drinks
• Treatment of chronic cough and constipation
```
Pelvic floor muscle training
• For at least 3 months
• Exercises continued long-term.
• 8-12 slow maximal contractions sustained for 6-8 seconds each, 3x per day
Follow up 3 months
67
Follow up management of stress urinary incontinence?
Urodynamics
MDT Meeting
Duloxetine
• SNRI enhances urethral striated sphincter activity via a centrally mediated pathway.
• Dose-dependent decreases in frequency of incontinence episodes
Transvaginal tape
68
Pharmacological management of stress urinary incontinence?
Duloxetine
• SNRI enhances urethral striated sphincter activity via a centrally mediated pathway.
• Dose-dependent decreases in frequency of incontinence episodes
69
Surgical management of stress urinary incontinence ? When considered and what types?
Considered when other measures failed
Transvaginal Tape
• Polypropylene mesh tape placed under mid-urethra via small vaginal incision
• Risks – bladder injury, voiding difficulty, tape erosion
Periuretheral injections
• Bulking agents, better for older, frail or young women
70
Initial management of urge urinary incontinence?
Lifestyle advice
• Weight reduction if BMI >30, smoking cessation, reduce caffeine and fizzy drinks, treatment chronic cough and constipation
Pelvic floor muscle training
• 3 months, exercises continued long-term, 8-12 slow maximal contractions sustained for 6-8 seconds each, 3x per day
Bladder diary (>3 days) - idea of fluid intake and bladder voiding problems
Bladder drills
• Ability to suppress urinary urge and extend the intervals between voiding
Anticholinergics - Oxybutynin (+/- vaginal oestrogen if vaginal atrophy)
Follow up 3 months
71
Describe properties of initial pharmacological management of urge urinary incontinence? SE? CI?
When is botox used?
Anticholinergic (antimuscarinic) agents (oxybutynin)
• Block the sympathetic nerves thereby relaxing the detrusor muscle
• Side effects = dry mouth (up to 30%), constipation, nausea, dyspepsia, flatulence, blurred vision, dizziness, insomnia, palpitation, arrhythmias.
• Contraindications = acute (narrow angle) glaucoma, myaesthenia gravis, urinary retention or outflow obstruction, severe UC, GI obstruction.
Oestrogens
• In women with vaginal atrophy, intravaginal oestrogens may be tried
Botulinum Toxin A
• Blocks neuromuscular transmission – causing the muscle to become weak.
• Used in follow up and injected cystoscopically into the detrusor, usually under local anaesthetic.
72
Follow up management of urge urinary incontinence?
Try 2nd anticholinergic (tolterodine)
Urodynamic study (increased detrusor pressure upon voiding)
MDT meeting
Cystoscopy & Botox (botulinum toxin A)
Nerve stimulation - percutaneous posterior nerve/percutaneous sacral nerve
Augmentation cystoplasty - if small bladder
Urinary diversion
73
Management of overflow incontinence?
o Treat with catheter
• Can cause urinary retention in 5-20% of cases, in which intermittent self catherterisation may be required.
o Surgical
Reserved as last resort for debilitating symptoms, failed therapies
Bladder distension, sacral neuromodulation, detrusor myomectomy have limited efficacy
74
How common is urogenital prolapse?
* Occurs in 40-60% of parous women
| * Most common reason postmenopausal women have hysterectomy
75
Definition of urogenital prolapse?
o Weakness of supporting structures (levator ani muscles and endopelvic fascia) allows the pelvic organs to protrude within the vagina
o Can be bladder, urethra, rectum, and bowel
76
Risk factors of urogenital prolapse?
```
o Increasing age
o Vaginal delivery
o Increasing parity
o Obesity
o FHx of prolapse
o Constipation/Chronic cough
```
77
Types of urogenital prolapse?
o Can occur in anterior, middle or posterior compartments of pelvis
78
Anterior types of urogenital prolapse?
```
Cystocele
• Prolapse of bladder into the vagina
Urethrocele
• Prolapse of urethra into the vagina, associated with USI
Cysto-urethrocele when both (MC)
```
79
Middle types of of urogenital prolapse?
Uterine prolapse
• Descent of uterus into vagina
• Baden-Walker Graded
Vaginal vault prolapse
• Descent of vaginal vault post-hysterectomy, associated cystocele, rectocele and enterocele common
Enterocele
• Herniation of pouch of Douglas into vagina
• Pouch usually contains loops of small bowel
80
Posterior types of urogenital prolapse?
Rectocele
| • Prolapse of rectum into vagina
81
POPQ staging of urogenital prolapse?
o 0 = No prolapse
o 1 = >1cm above hymen
o 2 = At level of hymen
o 3 = >1cm below hymen but protrudes <2cm total length of vagina
o 4 = Complete eversion of vagina (complete procidentia)
82
General symptoms of urogenital prolapse?
- Dragging sensation discomfort, and heaviness within the pelvis.
Usually worse at the end of the day or when standing up.
- Feeling of ‘a lump coming down’
- Dyspareunia or difficulty in inserting tampons.
- Discomfort and backache.
83
Cysto-urethrocele symptoms of urogenital prolapse?
- Urinary urgency and frequency.
- Incontinence
- Incomplete bladder emptying
o Urinary retention or reduced flow where the urethra kinked
84
Rectocele symptoms of urogenital prolapse?
- Constipation
| - Difficulty with defecation (may digitally reduce it to defecate).
85
Other symptoms of urogenital prolapse?
* Symptoms tend to become worse with prolonged standing and towards the end of the day.
* Grade 3 or 4 prolapse, there may be mucosal ulceration and lichenification, resulting in vaginal bleeding and discharge.
* Symptoms can affect quality of life, causing social, psychological, occupational or sexual limitations to a woman’s lifestyle.
86
Examinations performed in urogenital prolapse?
• Examine patient in both standing and left lateral position
o Ask woman to strain and observe
• Bimanual examination (exclude pelvic masses)
• Sims speculum examination
o Inspect anterior and posterior walls, ask to strain
87
Investigations of urogenital prolapse?
* USS to exclude pelvic or abdominal masses.
* Urodynamics are required if urinary incontinence is present
* Assess fitness for surgery – ECG, CXR, FBC, U&Es
88
Prevention of urogenital prolapse?
| Conservative management of urogenital prolapse?
Prevention
- Reduction of prolonged labour, trauma caused by instrumental delivery
- Encouraging persistence with post-natal pelvic floor exercises.
General Advice
- Weight reduction
- Avoid heavy lifting
- Treatment of chronic constipation and cough (including smoking cessation)
- Pelvic floor muscle exercises
89
Further management of urogenital prolapse - Intravaginal (pessary) devices? When used? What is it? Instructions?
- Conservative line of therapy for women who decline surgery, who are unfit for surgery, or for whom surgery is contraindicated.
o Artificial pelvic floor placed in the vagina to stay behind the symphysis pubic and in front of the sacrum.
o Sexually active women can use ring pessaries, either have sex with it in place or take it out and replace after
o They should be changed 6 monthly and if post-menopausal, topical oestrogen may be given to decrease risk of vaginal erosion.
90
Types of pessary and when used?
Ring pessary = most commonly used
o Placed between the posterior aspect of the symphysis pubis and posterior fornix of the vagina.
Shelf pessary = used when a correctly sized ring pessary will not sit in the vagina and/or where the perineum is deficient
Others: Hodge pessary, cube and doughnut pessaries (very rarely used).
91
Indications for surgical management of urogenital prolapse?
- Failure of conservative treatment
- Voiding or defaecation problems
- Recurrent prolapse after surgery
- Ulceration
- Irreducible prolapse
- Preference
92
Surgical management of anterior compartment of urogenital prolapse?
• Anterior colporrhaphy (anterior repair)
| - Appropriate for repair of a cysto-urethrocele.
93
Surgical management of posterior compartment of urogenital prolapse?
```
Posterior colporrhaphy (posterior repair)
- Appropriate for correction of a rectocele and deficient perineum
```
94
Surgical management of uterovaginal (apical) compartment of urogenital prolapse?
* Vaginal hysterectomy (most common)
* Sacrohysteropexy
- Preserve the uterus.
- Attaches the prolapsed uterus to the sacrum
95
Surgical management of vaginal vault of urogenital prolapse?
• Sacrospinous ligament fixation
| - Suturing vaginal vault to sacrospinous ligaments using a vaginal approach.
96
Surgical management of recurrent compartment of urogenital prolapse?
* ~1/3 of prolapse surgery is for recurrent prolapse.
* Vaginal epithelium may be scarred and atrophic (makes surgery harder and gives increased risk of damage to bladder and bowel)
97
Surgical management of recurrent compartment of urogenital prolapse?
* ~1/3 of prolapse surgery is for recurrent prolapse.
* Vaginal epithelium may be scarred and atrophic (makes surgery harder and gives increased risk of damage to bladder and bowel)
98
Definition of nephrotic syndrome?
```
- Clinical syndrome defined as:
o Proteinuria (>3.5g/24h (ACR>250))
o Oedema
o Hypoalbuminemia (<30g/L)
```
- It is caused by injury to podocyte which increase permeability of serum protein through the damaged basement membrane in the renal glomerulus
99
Classes of nephrotic syndrome?
- Classified as steroid sensitive, steroid resistant or steroid dependent
100
Aetiology of nephrotic syndrome - primary?
Minimal change disease – 85% in children
• Idiopathic, NSAIDs, Hodgkin’s lymphoma
• Biopsy – normal under light microscopy
• Steroids usual course of treatment
Focal segmental glomerulonephritis (FSGN) – most common in adults
• Segmental areas of mesangial collapse and sclerosis
• Due idiopathic, HIV, SCD, Alport’s, obesity, reflux nephropathy
Membranous nephropathy – common in older adults
• Due to – malignancy, hepatitis B, gold, penicillamine, NSAIDs, thyroid, SLE
• Thickened GBM
Membranoproliferative glomerulonephritis
101
Aetiology of nephrotic syndrome - secondary?
Infection – HIV, HepB/C, syphilis, malaria
SLE, HSP, Lupus
Diabetes – MC secondary cause
Alport’s syndrome
Malignancies
Toxins (snake bites, bee stings) and heavy metals
102
Symptoms and signs of nephrotic syndrome?
- Periorbital oedema, leg/ankle oedema, ascites and breathlessness
- Oliguria
- Proteinuria, oedema, hypoalbuminemia
- Dyslipidaemia, abnormalities in coagulation/fibrinolysis, reduced renal function
103
Investigations of nephrotic syndrome?
Urine dipstick
o Check for protein & microscopic haematuria
Urine MSU
o Microscopy, culture and sensitivities to exclude UTI
Red cell casts, protein electrophoresis
Urine ACR
Bloods
o FBC, CRP, ESR, U&E’s (creatinine, low albumin)
o Complement levels
o Autoimmune screen – ANA, ANCA, anti-DNA, anti-GBM, complement)
o Syphilis/HepB/C screen
CXR and renal USS
Renal biopsy
104
Management of nephrotic syndrome - general advice?
- Sodium and fluid restriction
- High-dose loop diuretics (furosemide)
- Daily weight & U&Es
- Pneumococcal and influenza vaccination
105
Management of nephrotic syndrome - minimal change disease
Steroid-sensitive nephrotic syndrome
Oral prednisolone for 4 weeks then wean over 4 months
• If steroid toxicity, use cyclophosphamide
Steroid-resistant nephrotic syndrome
Management of oedema with diuretics, salt restriction and ACE inhibitors (enalapril)
106
Management of nephrotic syndrome - focal segmental glomerulonephritis?
o Corticosteroids
| o Cyclophosphamide if steroid-resistant
107
Management of nephrotic syndrome - membranous nephropathy?
o Secondary – treat cause
| o ACEi and diuretics
108
Management of nephrotic syndrome - mesangiocapillary GN?
o ACEi
| o Steroids and cyclophosphamide if rapid deterioration
109
Complications of nephrotic syndrome ?
- Susceptible to infections
- Risk of VTE – urinary excretion of antithrombin 3
- Hyperlipidaemia
- AKI/CKD
