Urology and Renal Medicine Flashcards
What is chronic kidney disease?
Abnormalities in kidney structure or function present for ≥3 months (GFR <60 mL/minute/1.73 m²) or other markers of kidney damage, e.g. proteinuria
What are the key diagnostic factors of chronic kidney disease?
Patients typically asymptomatic until stage 4 or 5 CKD
Fatigue
Oedema (salt and water retention)
Nausea with or without vomiting (accumulation of urea)
Pruritus
Restless legs
Anorexia
Foamy cola-coloured urine
Rashes (ecchymosis and purpura)
Dyspnoea and orthopnoea
Seizures
Hypertensive retinopathy
Apart from GFR, what other evidence suggests CKD?
Persistent microalbuminuria
Persistent proteinuria
Persistent haematuria (after exclusion of other causes, e.g. urological disease)
Structural abnormalities of kidney seen on imaging (e.g. polycystic kidney disease, reflux nephropathy)
Biopsy-proven chronic glomerulonephritis
What are the risk factors for CKD?
Diabetes mellitus
Hypertension
Age >50 years
Smoking
Obesity
Black or Hispanic ethnicity
Family history
Immune disorders, e.g. SLE, RA
Male sex
Long term use of NSAIDs
How is CKD investigated?
U&Es
eGFR
Urinalysis (haematuria and proteinuria)
Urinary albumin
Renal ultrasound (small kidneys, polycystic kidneys)
Kidney biopsy
How is GFR category G1-G2 w/o uraemia treated?
ACEi or ARB (ramipril or losartan) - CCB is second line
Dapagliflozin (SGLT2)
Statin (simvastatin)
Consider atenolol, amlodipine, spiranolactone
How is GFR category G5 or with uraemia treated?
1st line is dialysis
2nd line is kidney transplant
What are the diagnostic criteria for AKI?
Rise in creatinine of ≥ 25 micromol/L in 48 hours
Rise in creatinine of ≥ 50% in 7 days
Urine output of < 0.5ml/kg/hour for > 6 hours
What are the risk factors for AKI?
CKD
Heart failure
Diabetes
Liver disease
>65 years
Cognitive impairment
Nephrotoxic medications, e.g. NSAIDs or ACEi
Use of contrast mediums, e.g. CT scans
What are pre-renal causes of AKI?
Inadequate blood supply to kidneys reducing the filtration of blood, i.e. due to:
Dehydration
Hypotension (shock)
Heart failure
What are some renal causes of AKI?
Intrinsic disease in kidney reduces filtration of blood
Glomerulonephritis
Interstitial nephritis
Acute tubular necrosis
What are some post-renal causes of AKI?
Obstruction to the outflow of urine from the kidney, causing back-pressure into the kidney and reduced kidney function
Kidney stones
Masses such as cancer in the abdomen or pelvis
Ureter or uretral strictures
Enlarged prostate or prostate cancer
What are the symptoms of AKI?
Nausea or vomiting
Diarrhoea
Dehydration
Decreased urine output
Confusion
Drowsiness
Can often be asymptomatic
How is AKI investigated?
Urea and creatinine
Serum potassium (hyperkalaemia is complication of AKI)
Urinalysis
Ultrasound of urinary tract to look for obstruction
How is AKI managed?
Treat underlying cause
Fluid rehydration with IV fluids in pre-renal cause
Stop nephrotoxic medications, e.g. ACEi or NSAIDs
Relieve obstruction in post-renal AKI, e.g. with catheter
What are the features of nephrotic syndrome?
Low serum albumin (<25g/L)
High urine protein content (foamy urine)
Oedema
Deranged lipid profile (high cholesterol, triglycerides, LDLs)
High blood pressure
Hyper-coagulability
MOST COMMONLY SEEN IN 2-5 YEAR OLDS
What are the causes of nephrotic syndrome?
Minimal change disease (most common cause)
Intrinsic kidney disease (membranoproliferative glomerulonephritis, focal segmental glomerulosclerosis)
Secondary to underlying illness (diabetes, henoch schonlein purpura, infection - HIV, hepatitis, malaria)
How is minimal change disease diagnosed?
Urinalysis (small molecular weight proteins and hyaline casts)
Serum albumin (low)
Serum lipid profile (high cholesterol)
Urine dipstick (proteinuria)
Renal biopsy (for steroid-resistant patients)
How is nephrotic syndrome managed?
High dose steroids (prednisolone) - given for 4 weeks and gradually weaned over 8 weeks
ACEi (ramipril) and immunosuppressants (cyclosporine, rituximab) in steroid-resistant children
Low salt diet
Diuretics to treat oedema (furosemide)
Albumin infusions in severe hypoalbuminaemia
Antibiotic prophylaxis in severe cases
Prophylactic anticoagulation (low molecular weight heparin or warfarin)
What are complications of nephrotic syndrome?
Hypovolaemia
Thrombosis (anti-clotting factors lost in kidneys, liver produces pro-thrombotic factors in response to low albumin)
Infections (kidneys leak immunoglobulins)
Acute or chronic renal failure
Relapse
What is testicular torsion?
Twisting of the spermatic cord resulting in constriction of vascular supply and ischemia of testicular tissue
What are the risk factors for testicular torsion?
Age <25 years
Bell clapper deformity (allows testicles to rotate freely within tunica vaginalis)
What are the symptoms of testicular torsion?
Acute onset of unilateral testicular pain - trigger such as playing sports
Abdominal pain and vomiting
Firm swollen testicle (oedema)
Elevated testicle - no pain relief upon elevation of scrotum
Absent cremasteric reflex
Abnormal testicular lie (often horizontal)
Rotation, so that epididymis is not in normal posterior position
USUALLY TEENAGE BOYS
How is testicular torsion investigated?
Scrotal ultrasound (whirlpool sign) - will delay treatment, but confirms diagnosis
Surgical exploration is first line
How is testicular torsion treated?
Bilateral orchiopexy (correcting the position of the testicles and fixing them in place)
Orchidectomy (removing the testicle) if the surgery is delayed or there is necrosis
What are the symptoms of benign prostatic hyperplasia?
Storage symptoms: frequency, urgency, nocturia
Voiding symptoms: weak stream, hesitancy, intermittency, straining, incomplete emptying, post-void dribbling
What are the risk factors for BPH?
Age >50 years
Family history
How is BPH investigated?
DRE (assess size, shape and characteristics of prostate)
Urinalysis (normal in uncomplicated BPH, may show UTI, haematuria suggests bladder cancer)
PSA (false positives and negatives high)
Urinary frequency volume chart (show fluid intake and output)