Urology/Nephrology Flashcards
What can cause a raised PSA?
Prostate cancer
Prostatitis
Benign prostatic hyperplasia
Which is the most common cancer in men in the U.K.?
Prostate
What is the classic triad of clinical features of hypernephroma/clear cell adenocarcinoma of renal tubular epithelium?
Haematuria
Loin pain
Abdominal mass
What are features of hypernephroma?
Haematuria Loin pain Abdominal mass Anaemia Polycythemia Hypercalcaemia Left varicocoele
What is the treatment of choice for hypernephroma?
Nephrectomy
What are treatment options for benign prostatic hypertrophy?
TURP/prostatectomy
Alpha blockers
5 alpha reductase inhibitors
What are clinical features of benign prostatic hypertrophy?
Hesitancy
Poor urine flow (less than 18ml/sec)
Frequency
Urgency
What investigations should be done in a patient presenting with symptoms of benign prostatic hypertrophy?
Urine microscopy and culture
Rectal examination
Biopsy
PSA
What are risk factors for renal calculi?
Low urine output Hypercalciuria Hyperoxaluria Hyperuricuria Hypercitraturia
What percent of renal calculi are radio opaque?
90%
What does exposure to schistosoma haematobium increase the risk of?
Squamous cell carcinoma of the bladder
What are symptoms of gonococcal urethritis?
Purulent discharge
Dysuria
Proctitis
Pharyngitis
What are some complications of gonococcal urethritis?
Prostatitis Bartholinitis Epididymitis Arthritis Septicaemia
What is the treatment of gonococcal urethritis?
Ceftriaxone 500mg IM stat
Azithromycin 1g orally stat
What are causes of uric acid stone renal calculi?
Gout Myeloproliferative disorders Chronic diarrhoea Ileostomy Excessive meat eating
What is cystinuria? What is the treatment?
Defect in tubular reabsorption of cystine, orthinine, arginine and lysine
Autosomal recessive
Urinary alkalinisation and penicillamine
A 22 year old man presents with a hard lump in his right testicle. What is the likely diagnosis? What are useful tumour markers for this?
Teratoma of the testis
LDH and bHCG
How do you make a diagnosis of ureteric colic caused by a renal stone?
Plain abdominal X-ray KUB
Renal tract USS
IV urogram / unenhanced CT
What are obstructive and irritative symptoms of prostatism?
Obstructive: poor stream, hesitancy, terminal dribbling
Irritative: dysuria, urgency
How does acute epididymitis present?
Sub acute onset (1-3 days) of testicular pain accompanied by febrile illness
Affected testis is swollen, painful and tender
What is the likely cause of epididymitits in differing age groups?
Children: viral
Teenagers/young men: STI
Middle aged/elderly: complicates UTI
How do you treat epididymitits?
Antibiotics
Analgesics
Scrotal support
What are risk factors for renal stone formation?
Dehydration Hypercalciuria Hyperparathyroidism Hypercalcaemia Cystinuria High dietary oxalate Renal tubular acidosis Medullary sponge kidney Polycystic kidney disease Beryllium or cadmium exposure
What are risk factors for urate stone formation?
Gout
Ileostomy: loss of bicarbonate and fluid results in acidic urine, causing the precipitation of uric acid
What drugs can promote calcium stone formation?
Loop diuretics, steroids, acetazolamide, theophylline
What is the acute management of renal colic?
Diclofenac: intramuscular/oral
Alpha-adrenergic blockers to aid stone passing
Ultrasound initial imaging modality of choice. Complications such as hydronephrosis can also be quickly identified
Non-contrast CT (NCCT) to confirm the diagnosis. 99% of stones are identifiable
What size of renal stone will likely pass spontaneously?
Less than 5 mm will usually pass spontaneously. Lithotripsy and nephrolithotomy may be for severe cases
What are options to treat ureteric colic when there is an infection present?
Nephrostomy tube placement, insertion of ureteric catheters and ureteric stent placement
What different therapeutic options are available treat renal stones and which would you select for different indications?
Lithotripsy: Stone burden of less than 2cm in aggregate
Ureteroscopy: Stone burden of less than 2cm in pregnant females
Percutaneous nephrolithotomy: Complex renal calculi and staghorn calculi
Expectant management: ureteric calculi less than 5mm
A 63 year old man attends GP stating he has had 2 episodes of visible blood in his urine. There was not any pain. He denies lower urinary tract symptoms. A urinalysis shows +++ blood but is negative for all other markers. What investigation should be ordered?
Cystoscopy due to frank haematuria and his age
What are the symptoms of benign prostatic hyperplasia?
LUTS
Voiding: weak or intermittent flow, straining, hesitancy, terminal dribbling, incomplete emptying
Storage: urgency, frequency, urge incontinence, nocturia
What are complications of benign prostatic hyperplasia?
Urinary tract infection
Retention
Obstructive uropathy
What are management options for benign prostatic hyperplasia?
Watchful waiting
Medication: alpha 1 antagonist, 5 alpha reductase inhibitor
Surgery: transurethral resection of prostate (TURP)
What are possible side effects of tamulosin and alfuzosin?
Dizziness
Postural hypotension
Dry mouth
Depression
What are possible side effects of finasteride?
Erectile dysfunction
Reduced libido
Ejaculation problems
Gynaecomastia
What is the mechanism of action of finasteride?
5 alpha reductase inhibitor
Block conversion of testosterone to DHT which is known to induce BPH
Causes a reduction in prostate volume so slows disease progression but this takes time and might not improve symptoms for 6 months
What is the most common cause of scrotal swelling seen in primary care?
Epididymal cysts
What are features of epididymal cysts?
Separate from the body of the testicle
Found posterior to the testicle
What conditions are associated with epididymal cysts?
Polycystic kidney disease
Cystic fibrosis
Von Hippel Lindau syndrome
How is a diagnosis of epididymal cyst confirmed?
USS
What is the management for epididymal cysts?
Supportive
Surgical removal or sclerotherapy if large or symptomatic
What is the difference between communicating and non communicating hydrocoele?
Communicating: patency of processus vaginalis allowing peritoneal fluid to drain down into scrotum. Seen in newborn males and usually revolve in first few months of life
Non communicating: excessive fluid production in tunica vaginalis
What may be some causes of a hydrocoele?
Epididymo-orchitis
Testicular torsion
Testicular tumour
What are features of a hydrocoele?
Soft non tender swelling of the hemi scrotum usually anterior and below the testicle
Swelling confined to the scrotum, can get above it
Transilluminates
Testis difficult to palpate
What is the management for hydrocoele?
Infantile hydrocoele repaired if they do not resolve spontaneously by age of 1-2 years
Adults: depends on severity of presentation
USS usually warranted to exclude underlying causes
Why are varicocoeles important to recognise even if they are asymptomatic?
Associated with infertility
On which side are varicocoeles more common?
Much more common on the left (>80%)
What are features of a varicocoele?
Bag of worms
Subfertility
How is a diagnosis of a varicocoele made?
USS with Doppler
What should be done before commencing a patient on goserelin for prostate cancer? Why?
Pretreatment with flutamide (synthetic antiandrogen)
Goserelin may cause transient increase in symptoms - flare effect due to increase in leutenising hormone production prior to down regulation
What are treatment options for localised prostate cancer (T1/2)?
Conservative: active monitoring and watchful waiting
Radical prostatectomy
Radiotherapy: external beam and brachytherapy
What are treatment options for localised advanced prostate cancer (T3/4)?
Hormonal therapy
Radical prostatectomy
Radiotherapy: external beam and brachytherapy
What are treatment options for metastatic prostate cancer?
Synthetic GnRH agonist: goserelin. Cover initially with anti androgen: flutamide
Anti androgen: cyproterone acetate prevents DHT binding
Orchidectomy
A 23 year old male is admitted with loin pain and fever. He has a ureteric calculi that measures 0.7cm in diameter and is associated with hydronephrosis. What do you do?
Urgent decompression
Either ureteroscopy or nephrostomy
Broad spectrum IV antibiotics
What size renal stones can be considered for extracorporeal shock wave lithotripsy?
Less than 2cm
What should be done to treat large proximal renal stones?
Percutaneous nephrolithotomy
What is the most sensitive and specific diagnostic test for renal stones?
Non contrast CT
When is intensive and urgent treatment required for renal stones?
Ureteric obstruction
Renal developmental abnormality - horseshoe kidney
Previous renal transplant
What cancer is histologically graded using a Gleason score?
Prostate
How is a diagnosis of prostate cancer made?
PSA measurement
Digital rectal examination
Trans rectal USS +/- biopsy
MRI/CT and bone scan for staging
What is the normal upper limit of PSA?
4 ng/ml
What may cause false positive raised PSA results?
Prostatitis
UTI
BPH
Vigorous DRE
What type of cancer mainly causes prostate cancer?
Adenocarcinoma
Where do the majority of prostate cancers lie?
Peripheral zone
How does the Gleason score work?
Two grades awarded 1-5
1 for most dominant grade 1-5
2 for second most dominant grade 1-5
2 has best prognosis, 10 the worst
Where does prostate cancer spread first?
Obturator nodes
What is the management for prostate cancer?
Watchful waiting - elderly, multiple comorbidities, low Gleason score
External radiotherapy/brachytherapy
Surgery - radical prostatectomy including obturator nodes
Hormonal therapy - LHRH analogues and anti androgens
In which patient group is active surveillance the preferred management for prostate cancer?
Low risk men Clinical stage T1c Gleason score 3+3 PSA density <0.15 Cancer in less than 50% cores <10 mm of any core involved
What is a common side effect of radical prostatectomy?
Erectile dysfunction
What are some late problems of using radiotherapy to treat prostate cancer?
Radiation proctitis
Rectal malignancy
A 34 year old man presents to emergency surgery with abdominal pain located in his left flank and radiating to his groin. What is the most suitable initial management?
IM Diclofenac 75mg
What can be done to prevent renal stones?
High fluid intake Low animal protein, low salt diet Thiazide diuretics (increase distal tubular calcium resorption)
A 22 year old woman presents with macroscopic haematuria. She is sexually active. She is known to have renal calculi and had a berry aneurysm clipped. What is the likely diagnosis?
Adult Polycystic kidney disease - liver cysts, berry aneurysms, pancreatic cysts, renal calculi, HTN
A 45 year old woman presents with haematuria and loin pain. She has a temp of 37 and is found to have a Hb of 180 and a creatinine of 156. Her urine shows 3+ blood. Blood and urine cultures are negative. What is the diagnosis?
Renal vein thrombosis - renal cell carcinoma
What are feature of renal cell carcinoma?
Renal vein thrombosis
Pyrexia of unknown origin
Left varicocoele
Paraneoplastic endocrine effects - EPO, renin, ACTH, PTHrP
A 62 year old man presents with nocturia, hesitancy and terminal dribbling. Prostate exam reveals moderately enlarged prostate with no irregular features and a well defined median sulcus. Blood tests show PSA of 1.3. What is the most appropriate management?
Alpha 1 antagonist
What are features of hypospadias?
Ventral urethral meatus
Hooded prepuce
Chordee (ventral curvature of the penis) in more severe forms urethral meatus may open more proximally in the more severe variants However, 75% of the openings are distally located
When and how is hypospadias corrected?
Corrective surgery is performed before 2 years of age. It is essential that the child is not circumcised prior to the surgery as the foreskin may be used in the corrective procedure. In boys with very distal disease no treatment may be needed
What is a retractile testis?
A testis that appears in warm conditions or which can be brought down on clinical examination and does not immediately retract
What is a congenital undescended testis?
Failed to reach the bottom of the scrotum by 3 months of age
What defects are associated with undescended testis?
Patent processus vaginalis Abnormal epididymis Cerebral palsy Mental retardation Wilms tumour Abdominal wall defects: gastroschisis, prune belly syndrome
What are reasons for correction of cryptorchidism?
Reduce risk of infertility
Allows the testes to be examined for testicular cancer
Avoid testicular torsion
Cosmetic appearance
What is the treatment for cryptorchidism?
Orchidopexy at 6- 18 months of age. The operation usually consists of inguinal exploration, mobilisation of the testis and implantation into dartos pouch
Intra-abdominal testis should be evaluated laparoscopically and mobilised. Whether this is a single stage or two stage procedure depends upon the exact location
After the age of 2 years in untreated individuals the Sertoli cells will degrade and those presenting late in teenage years may be better served by orchidectomy than to try and salvage a non functioning testis with an increased risk of malignancy
What are features of renal cell carcinoma?
Triad: haematuria, loin pain, abdominal mass
Pyrexia of unknown origin
Left varicocele (due to occlusion of left testicular vein)
Endocrine effects: erythropoietin (polycythaemia), parathyroid hormone (hypercalcaemia), renin, ACTH
25% have metastases at presentation
What are some causes of transient non visible haematuria?
Urinary tract infection
Menstruation
Vigorous exercise (normally settles after around 3 days)
Sexual intercourse
What are some causes of persistent non visible haematuria?
Cancer (bladder, renal, prostate) Stones Benign prostatic hyperplasia Prostatitis Urethritis e.g. Chlamydia Renal causes: IgA nephropathy, thin basement membrane disease
What are some causes of red urine where blood is not present?
Foods: beetroot, rhubarb
Drugs: rifampicin, doxorubicin
What is the definition of persistent non visible haematuria?
Blood being present in 2 out of 3 samples tested 2-3 weeks apart
What features of haematuria presentation require a 2 week wait referral?
Aged 45 or more and: Unexplained visible haematuria without urinary tract infection, visible haematuria that persists or recurs after successful treatment of urinary tract infection
Aged 60 or more and: unexplained nonvisible haematuria and either dysuria or a raised white cell count on a blood test
What is the most common malignancy in men aged 20-30?
Testicular cancer
What is the average age of onset of seminomas?
40
What tumour marker results would you expect with a seminoma?
Normal AFP, HCG and LDH in most
What are risk factors for testicular cancer?
Cryptorchidism Infertility Family history Klinefelters syndrome Mumps orchitis
How might a testicular cancer present?
Painless lump
Pain
Hydrocoele
Gynaecomastia
How do you diagnose testicular cancer?
USS
CT chest abdo pelvis for staging
Tumour markers - AFP, HCG, LDH
What is the management of testicular cancer?
Orchidectomy - inguinal approach
Chemo and radiotherapy depending on staging
Abdo lesions >1cm following chemo need retroperitoneal lymph node dissection
What are the infections which usually cause epididymo-orchitis in men <35?
Gonorrhoea or chlamydia
What drug is a recognised non infective cause of epididymitis?
Amiodarone
Who gets seminomas and teratomas?
Seminoma - usually over 30
Teratoma - 18-25
What is Peyronie’s disease?
Fibrotic process in tunica albuginea related to penile trauma and scarring during intercourse
Associated with penile curvature and pain
May be associated with dupuytrens contracture
What is the most common presenting feature in transitional cell carcinoma?
Haematuria
What type of surveillance is performed for patients following a diagnosis of transitional cell carcinoma?
Cystoscopic
How long after treating a UTI should you wait before taking a PSA measurement?
2 weeks
What can happen if urinary retention is not treated promptly?
Hydronephrosis and acute renal failure
What can be a complication of prostate surgery which can lead to urinary retention?
Bladder neck stenosis
Where are suprapubic catheters inserted? And how?
Approximately 2 finger breadths above symphysis pubis under USS guidance
How does sildenafil work?
Inhibits phosphodiesterase type 5 producing cavernous sinus venodilation and erection in appropriately stimulated patients
What are side effects of sildenafil?
Flushing
Nasal congestion
Blue visual discolouration
Why is sildenafil still effective in patients who have developed impotence following prostate surgery?
It acts directly on corpus cavernosa rather than via a neural effect
What are some causes of a neurogenic bladder?
Multiple sclerosis
Spinal injury
Parkinson’s disease
What is Bergers disease?
IgA nephropathy/mesangioproliferative glomerulonephritis
Haematuria
Mesangial IgA deposits
What is Alports syndrome?
Hereditary glomerulonephritis caused by mutation of COL4A genes that contribute to the basement membrane
Chronic nephritis progresses via uraemic syndrome to end stage renal disease treatable by dialysis or kidney transplant
Can be associated with hearing loss and lenticonus and other eye disorders
Which infectious agent is most commonly associated with acute pyelonephritis?
E. coli
How does IgA nephropathy typically present?
Young male
Recurrent macroscopic haematuria
Associated with URTIs
Renal failure
How do you differentiate between IgA nephropathy and post streptococcal glomerulonephritis?
Post strep is associated with low complement levels
Main symptom in post strep is proteinuria, IgA is mainly haematuria
Post strep interval between URTI and onset of renal problems (1-2 weeks), IgA onset sooner (1-2 days)
What are markers of poor prognosis with IgA nephropathy?
Male Proteinuria, especially >2g/day HTN Smoking Hyperlipidaemia ACE genotype DD
Why are patients with nephrotic syndrome at increased risk of renal vein thrombosis, DVT or PE?
Loss of antithrombin III in the urine
Increased plasma concentrations of fibrinogen
Increased plasma concentrations of factors V, VII, VIII and X
What is the best option for haemodialysis access?
Permanent connection between artery and vein allowing it to dilate so it can be needled each time they attend
Usually radio-cephalic in non dominant arm
If this isn’t possible then brachio-cephalic
What is PTFE graft?
Polytetrafluoroethylene used as a communication medium between artery and vein - prosthetic haemodialysis access arteriovenous grafts (AVGs)
What is a good choice of access for patients who need urgent dialysis?
Tunnelled internal jugular dialysis catheter
How long does a fistula take to mature?
6-8 weeks
What type of dialysis are tenckhoff catheters used for?
Peritoneal
Which variables are used in the modification of diet in renal disease equation for calculating eGFR?
Serum creatinine
Age
Gender
Ethnicity
How can you tell the difference between pre renal uraemia and acute tubular necrosis?
Pre renal uraemia: urinary sodium low, urine:plasma osmolality raised, specific gravity raised, bland sediment, response to fluid challenge
Acute tubular necrosis: raised urinary sodium, brown granular casts, no response to fluid
What are the triad of features associated with haemolytic uraemic syndrome?
Acute renal failure
Microangiopathic haemolytic anaemia
Thrombocytopenia
What are causes of haemolytic uraemic syndrome?
Post dysentery: Ecoli 0157:H7 Tumours Pregnancy Ciclosporin COCP SLE HIV
What investigations should be done for haemolytic uraemic syndrome?
FBC: anaemia, thrombocytopenia, fragmented blood film
U and E: acute renal failure
Stool culture
What is the management for haemolytic uraemic syndrome?
Supportive: fluids, transfusion, dialysis
Which findings on renal biopsy are associated with granulomatosis with polyangiitis?
Crescentic glomerulonephritis
Which pathology is associated with Kimmelstiel-Wilson nodules on renal biopsy?
Diabetes mellitus
What are causes of glomerular proteinuria?
Primary glomerular disease: glomerulonephritis, anti GBM disease (goodpastures), immune complex deposition, inherited conditions (alports)
Secondary: diabetes, HTN
What are mechanisms of proteinuria?
Overflow - excessive serum concentration Increased glomerular permeability Impaired tubular reabsorption Secretion into renal tract Haematuria
What are pros and cons of peritoneal dialysis?
Flexibility
Self care
Need to be able to manage connections or have someone at home to help them
Why is peritoneal dialysis not good for diabetic patients?
Glucose in the peritoneal dialysis fluid which can worsen diabetes
More prone to infection - PD peritonitis, exit site infections
How does reflux nephropathy lead to renal failure? What can this result in?
Renal scarring due to urine flowing backwards towards the kidneys
Can lead to high blood pressure, excessive protein loss in urine
How is reflux nephropathy managed?
Investigation in childhood
Early intervention with antibiotics
Referral to urologist for identification and correction of anatomical abnormalities
A 25 year old male smoker complains of painful breasts. He is noted to have mild tender gyaecomastia. He has a normal right testis but the left is not palpable. What is the likely diagnosis?
Testicular carcinoma in an undescended testis - Teratoma
What is Bartters syndrome?
Defect in thick ascending limb of loop of henle - NaKCl cotransporter
Hypokalaemia
Alkalosis
What is Gitelman syndrome?
Autosomal recessive kidney disorder - NaCl symporter mutation
Hypokalaemia and hypomagnesaemia
What is delayed graft function in renal transplant?
Need for dialysis after transplant
What are risk factors for delayed graft function after renal transplant?
Renal disease in donor: donor age >60, HTN, serum creatinine >130
Retrieval process: cerebrovascular cause of death, inotropes prior to death, deceased cardiac donor
Prolonged cold ischaemic time >18/24h
Higher risk from recipient: obese, HLA sensitisation, haemodialysis within 24h of operation, difficult surgery, poor perfusion of graft
How does Bartters syndrome usually present?
Polyuria
Nocturnal enuresis
Growth retardation
What is the management for nephrogenic diabetes insipidus?
Chlorothiazide: thiazide diuretic
What are causes of urinary incontinence?
Overactive bladder/urge incontinence
Stress incontinence
Mixed stress and urge
Overflow due to bladder outlet obstruction
How should urinary incontinence be initially investigated?
Bladder diaries for minimum 3 days
Vaginal examination to exclude cystocoele
Urine dipstick and culture
What is the management for urge incontinence?
Bladder retraining for minimum 6 weeks, gradually increase intervals between voiding
Bladder stabilising drugs: antimuscarinic - oxybutynin, tolterodine, darifenacin
What is the management for stress incontinence?
Pelvic floor muscle training: at least 8 contractions 3 times a day for 3 months
Surgical: retropubic mid urethral tape
What are side effects of erythropoietin?
Accelerated HTN Bone aches Flu like symptoms Skin rashes Urticaria Pure red cell aplasia Iron deficiency Risk of thrombosis
How is versico ureteric reflux usually diagnosed?
Following a micturating cystourethrogram
DMSA scan can be done to look for scarring
What are phosphate binders used for?
Reduce absorption of phosphate taken with meals and snacks
Typically used in CKD with bone pathology
Which treatment option is best for differing presentation of renal stones? Eg pregnant woman, staghorn, calculi less than 5mm, stone burden less than 2cm aggregate
Stone burden less than 2cm: lithotripsy
Less than 2cm, pregnancy: ureteroscopy
Complex calculi/staghorn: percutaneous nephrolithotomy
Calculi less than 5mm: manage expectantly
What is rhabdomyolysis? How does it cause AKI?
Clinical syndrome associated with breakdown of skeletal muscle fibres and myocyte cell membrane leading to release of muscle contents into the circulation
Damage to membrane causes increase in intracellular calcium which leads to apoptosis
Release of myoglobin, potassium, phosphate, CK and urate
Calcium release leads to further uptake into cells and further necrosis/apoptosis, Hyperphosphataemia leads to hypocalcaemia
Leads to AKI by combination of vasoconstriction and formation of casts
How is acute kidney injury classified?
Pre-renal: Impaired perfusion of the kidneys e.g. hypovolaemia, hypotension
Intrinsic: Acute Tubular Necrosis, Disease affecting interstitium (infections), renal vasculature (vasculitis) or glomerulonephritis, Nephrotoxic drugs
Post-renal, Obstruction: Within lumen (calculi), Within the wall (stricture), Pressure from outside (tumours)
Which medications can contribute to AKI?
C – contrast A – ACEi/ ARBs N – NSAIDs D – Diuretics A – Aminoglycosides (gentamicin)
What is the NICE definition of AKI?
Rise in serum creatinine of >26mmol/L in 48 hours
50% rise in serum creatinine in past 7 days
Fall in urine output to less than 0.5 ml/kg/hour for more than 6 hours in adults (more than 8 hours in children and young people)
25% fall in eGFR in children and young people in past 7 days
What is the management of AKI?
Conservative: Stop nephrotoxic medications
Medical: Treat cause – infection/ hypovolvaemia, Rehydrate / fluid management, Treat electrolyte abnormalities – phosphate/calcium should return to normal with rehydration
Surgical: Remove occlusion / obstruction, Catheterisation, Percutaneous nephrostomy
What are complications of AKI?
Fluid overload
Hyperkalaemia
Severe metabolic acidosis
Uraemic pericarditis: pericardial effusion and tamponade
Need for renal replacement therapy (dialysis)
What are indications for renal replacement therapy with AKI?
Fluid overload / pulmonary oedema (refractory to medical management)
Hyperkalaemia (refractory to medical management)
Evidence of uraemia (pericarditis, altered mental state)
Severe metabolic acidosis (pH <7.1)
Removal of drugs precipitating AKI (gentamicin, lithium, severe aspirin overdose)
What are the different severities of AKI?
<6.0mmol/L – mild
6.1-6.4mmol/L – moderate
>6.5 mmol/L - severe
What are causes of Hyperkalaemia?
Decrease excretion (AKI, drugs) Redistribution (DKA, metabolic acidosis) Increased extraneous load (transfusion)
What ECG changes are seen with Hyperkalaemia?
Absent P wave Prolonged PR Broad bizarre QRS complex Tall tented T waves Sine wave
What is the management of AKI?
Stop accumulation: Stop potassium supplements / any other drug resulting in accumulation
Protect cardiac membrane: 10ml 10% calcium gluconate – improve ECG changes in 1-3 mins but only last 30-60 mins
Shift potassium into cells: Insulin-glucose infusion – 10 units Actrapid in 50ml of 50% glucose over 30 mins, Salbutamol – 10-20mg nebulised
Remove potassium: Calcium resonium– slow onset
What is chronic kidney disease?
Evidence of kidney damage (albuminuria) or decrease in kidney function (eGFR <60 ml/min per 1.73m2) for 3 months
What are some causes of CKD?
Congenital: Polycystic kidneys Glomerular disease: Glomerulonephritis, DM, amyloidosis Vascular disease: HTN, Vasculitis Tubular / interstitium disease Chronic obstruction
What are signs and symptoms of CKD?
Anaemia Polyuria Nocturia Haematuria Proteinuria Bruising Dyspnoea Pruritis Leuconychia Flapping tremor Muscle weakness Bone pain Peripheral neuropathy Heart failure Pericarditis Anorexia Diarrhoea
What are complications of CKD?
Anaemia: Reduced erythropoietin production
Renal osteodystrophy (includes osteomalacia/porosis, 2o and 3ohyperparathyroidism): Raised phosphate, low calcium, Impaired (active) Vitamin D
Neurological: Peripheral neuropathy - uraemia
What is the biggest cause of mortality in CKD?
Cardiovascular disease
How are complications of CKD managed?
Conservative: Lifestyle changes and improvement in risk factors, Dietary restriction of potassium, phosphate
Medical: Phosphate binders (calcium acetate), EPO / iron supplements for anaemia, Vaccinations – increased risk of infections
Surgical: Dialysis
How does peritoneal dialysis work?
Dialysate infused into peritoneal cavity, blood sourced from peritoneal capillaries Filtration of water achieved by addition of glucose to dialysate ( poor diabetes control) 4 exchanges (20 mins) spaced throughout day or automated overnight only requiring one or two in daytime
What are contraindications to peritoneal dialysis?
Abdominal adhesions Obesity Intestinal disease Respiratory disease Hernias
What are complications of peritoneal dialysis?
Access – catheter problems
Dialysis – peritonitis, constipation, hernias
Poor diabetes control
What are features of nephrotic syndrome?
Hypoalbuminaemia
Oedema
Proteinuria (>3.5g in 24 hours)
Hyperlipidaemia
What are features of nephritic syndrome?
Hypertension Haematuria Oliguria Oedema Proteinuria (<2g in 24 hours) Uraemia
What are causes of nephrotic syndrome?
Primary (idiopathic) glomerular disease: Focal segmental glomerulosclerosis (adults), Minimal change (children)
Secondary glomerular disease: Infection, Metabolic (DM), Drugs, Malignancy (multiple myeloma)
Why does proteinuria occur in nephrotic syndrome?
Increased filtration of macromolecules across glomerular capillary wall
Podocyte damage
Primarily albumin loss, Other proteins including clotting factors
Why does hypoalbuminaemia occur in nephrotic syndrome?
Reduced oncotic pressure
Production of lipids (lipoproteins)
Why does oedema occur in nephrotic syndrome?
Reduced oncotic pressure
Renal sodium retention / sodium reabsorption leads to volume expansion
What is the management of nephrotic syndrome?
Conservative: Salt and fluid restriction, Nutrition – maintain normal protein intake
Medical: ACEi – reduces proteinuria, Diuretic therapy, Management of complications, DVT, Hypovolaemia, Corticosteroids/ immunosuppression
Surgical: Renal transplant if progresses to ESRF
What are complications of transurethral resection of the prostate?
TUR syndrome
Urethral stricture/UTI
Retrograde ejaculation
Perforation of the prostate
What is TUR syndrome?
When irrigation fluid enters systemic circulation
Dilutional hyponatraemia
Fluid overload
Glycine toxicity
What are causes of nephritic syndrome?
Post infection (Group A beta-haemolytic strep)
Viral infections
Systemic disease (SLE, HSP, vasculitis)
Primary glomerular disease (IgA nephropathy)
What is an easy way to calculate corrected calcium?
Add 0.1mmol/L calcium for every 4g/dL that albumin is below 40
What are medical benefits to male circumcision?
Reduced risk penile cancer
Reduced risk UTI
Reduced risk STI including HIV
What are medical indications for male circumcision?
Phimosis
Recurrent balanitis
Balanitis xerotica obliterans
Paraphimosis
In which patients would hormonal therapy be recommended for men with prostate cancer who have had a biochemical relapse?
Symptomatic local disease or progression
Proven mets
PSA doubling time <3 months
What is fibromuscular dysplasia and why does it cause HTN?
Abnormal collagen deposition in renal artery vascular wall which leads to string of beads appearance
Multiple obstructions and dilatations causes obstructed flow to kidneys and therefore compensatory RAAS activation
How can primary polydipsia be distinguished from diabetes insipidus?
Lack of water consumption at night
No nocturia
What are features of goodpastures syndrome?
Pulmonary haemorrhage
Rapidly progressive glomerulonephritis
Which factors increase risk of pulmonary haemorrhage in goodpastures syndrome?
Smoking Lower respiratory tract infection Pulmonary oedema Inhalation of hydrocarbons Young males
What would renal biopsy show in goodpastures syndrome?
Linear IgG deposits along basement membrane
What is the management of goodpastures syndrome?
Plasma exchange
Steroids
Cyclophosphamide
Why does urinary obstruction lead to a proportionately greater increase in urea compared to creatinine?
Urinary stasis in the renal tract permits reabsorption of urea in the blood stream
Why does hepato renal syndrome occur?
Deranged liver function causes changes in circulation that supplies intestines. This changes blood flow and tone in vessels supplying kidney which leads to hepato renal syndrome
What is the treatment for hepato renal syndrome?
Liver transplant
Which bugs commonly cause infective epididymal-orchitis?
Gonorrhoea or Chlamydia in younger men
E. coli, klebsiella, proteus in older men
When should PSA testing not be performed?
Within 6 weeks of prostate biopsy
Within 4 weeks of UTI
Within 1 week of DRE
Within 48 hours of vigorous exercise or ejaculation
What are causes of unilateral hydronephrosis?
PACT Pelvic ureteric obstruction Aberrant renal vessels Calculi Tumours of renal pelvis
What are causes of bilateral hydronephrosis?
SUPER Stenosis of urethra Urethral valve Prostatic enlargement Extensive bladder tumour Retroperitoneal fibrosis
What level of rise in creatinine is worrying after starting ACE inhibitors?
Greater than 20%
What are the grades of vesicoureteric reflux?
1: reflux into ureter only
2: reflux into renal pelvis on micturition
3: mild/moderate dilatation of ureter, pelvis and calyces
4: dilation of renal pelvis and calyces with moderate ureteral tortuosity
5: gross dilatation of ureter, pelvis and calyces with ureteral tortuosity
How should vesicoureteric reflux investigated?
Micturating cystourethrogram
DMSA can be performed to look for scarring
Which drugs can precipitate urinary retention?
Anticholinergics: TCA
Antipsychotics: chlorpromazine
Opiate analgesics
What does Hartmanns contain?
Na: 131 (135-145)
Cl: 111 (100-120)
K: 5 (3.5-5.0)
HCO3- 29 (22-26) as lactate
What is the most common cause of catheter outflow obstruction in someone on peritoneal dialysis for a long time?
Constipation
Why are people on dialysis prone to constipation?
Renal diet low in fibre - low in fruit and veg to avoid potassium and phosphate excess
What are the diagnostic criteria for nephrotic syndrome?
Serum albumin <25
Urinary protein >3-3.5g in 24 hours
Marked pitting oedema
What does 0.9% normal saline contain?
Na: 154 mmol/L (135-145)
Cl- 154 mmol/L (100-120)
Acidotic (pH 5.5)
What does dextrose saline 4%/0.18% contain?
Na: 30 mmol/L
Cl- 30 mmol/L
What is TURP syndrome?
Absorption into prostatic venous sinuses of fluids used to irrigate bladder during a TURP
Manifestations of fluid overload
What are the 3 main symptomatic features of obstruction of the urinary tract?
Hesitancy
Poor stream
Post void dribble
(Frequency and urgency occur due to bladder irritation secondary to obstruction)
Infection with which organism increases the likelihood of staghorn calculus formation in the kidney? Why?
Proteus mirabilis - has a urease producing enzyme which favours urinary alkalinisation which leads to staghorn calculi formation
What advice should be given to a patient with regards to performing 24 hour urinary collection?
Get the correct bottle for the test
Read leaflet about dietary requirements during test
If small amount of liquid already in bottle, do not throw away
Start collection after first void of day
Collect all urine for 24 hours including first void following day
What are risk factors for developing TURP syndrome?
Survival time >1 hour Height of bag >70cm Resected >60g Large blood loss Perforation Large amount of fluid used Poorly controlled chronic heart failure
What are risk factors for urinary retention?
Removal of urinary catheter Constipation Immobility Opiate analgesia Infection Haematuria BPH
What are features of urethral injury?
Urinary retention
Blood at urethral meatus
High riding prostate on DRE
What is a jarisch herxheimer reaction?
Fever rash tachycardia after first dose of antibiotic when treating syphilis
Due to release of endotoxins following bacterial death, occurs within a few hours of treatment
Which drugs should be stopped in AKI?
ACEi/ARBs NSAIDs Diuretics HMG-CoA Reductase inhibitors (statins) Metformin Other anti-hypertensives
What are risk factors for drug induced AKI?
Patient-related factors: Age, sex, race
Pre-existent renal disease (CKD)
Specific disease (diabetes mellitus, multiple myeloma, proteinuric
patients)
Sodium-retaining states (cirrhosis, heart failure, nephrosis)
Hypovolaemia and Sepsis
Acidosis, potassium and magnesium depletion
Hyperuricemia, hyperuricosuria (acute neoplasia)
Renal transplantation
What are causes of drug induced AKI and which part of the kidney do they effect?
Pre-renal: Haemodynamically mediated (ACE/ARB, NSAIDs)
Hypovolaemia (Diuretics), osmotic nephrosis (Mannitol)
Renal: Acute tubular necrosis (consequence of pre-renal), Uncertain (Aminoglycoside), Acute allergic interstitial nephritis (Penicillins, NSAIDs), Rhabdomyolysis (HMG CoA Reductase Inhibitors), Glomerulonephritis (Endocarditis), Vasculitis (Hydralazine)
Renal (renovascular): Thrombosis (HUS/TTP eg Ciclosporin and Tacrolimus), Cholesterol emboli (Warfarin)
Post-renal (obstructive nephropathy): Intratubular obstruction (Tumour Lysis Syndrome), Nephrolithiasis (Acute Urate Nephropathy), Papillary necrosis (NSAIDs)
Where do NSAIDs and ACE ihibitors exert their effects on the kidney?
NSAIDs: block PGE production, so less afferent arteriole vasodilation
ACE inhibitors: block production of Ang II, so less efferent vasoconstriction
Both lead to reduced GFR
When do gentamicin levels need to be checked?
Pre-dose levels on day 3
Which drugs can cause acute interstitial nephritis?
Abx: Penicillins/Cephalosporins, Rifampicin, Sulphonamides PPIs NSAIDS Allopurinol Phenytoin Quinolones: ciprofloxacin Cimetidine Chinese herbs
What are some non drug causes of acute interstitial nephritis?
SLE, Sjögren’s, sarcoidosis
What are blood pressure targets for patients with CKD?
CKD without proteinuria: 120-139/<90 mmHg
CKD and significant proteinuria (urine albumin:creatinine ratio >70 mg/mmol) or diabetes mellitus: 120-129/<80 mmHg
What is the Cockcroft gault equation?
140-age(yrs) X weight(kg)x constant/Serum creatinine
Constant: x 1.23 for male, x 1.04 for female
Which drugs should definitely be avoided in renal failure?
Antibiotics: tetracycline, nitrofurantoin
NSAIDs
Lithium
Metformin
What is the most common cause of nephrotic syndrome in a 30 year old?
Focal glomerulosclerosis
In which patients is post op renal failure more likely?
Elderly Peripheral vascular disease High BMI COPD Need vasopressors Nephrotoxic medication Emergency surgery
What are predisposing factors for developing renal calculus?
Female gender Hot climate Poor fluid intake Protein rich diet Immobility Occupational factors Metabolic disorders Urinary stasis/obstruction Urinary infection Acidic urine increases urate stone formation
What are complications of nephrotic syndrome?
Risk of thrombosis
Infection (loss of complement proteins and immunoglobulins) particularly pneumococcal pneumonia
Hyperlipidaemia
Why does hypercalcaemia lead to polyuria?
High calcium levels impair the renal tubules ability to concentrate urine as the NaKCl pump is less active due to Ca ions sitting in the tubular lumen
Why is cholesterol high in nephrotic syndrome?
Increased hepatic lipoprotein synthesis triggered by low oncotic pressures
Hypoalbuminaemia upregulates HMG CoA reductase and downregulates lipoprotein lipase
What are common causes of nephritic syndrome?
Post step glomerulonephritis
IgA nephropathy
What are some causes of acute renal failure?
Renal ischaemia Vasculitis Connective tissue disease Drug therapies: gentamicin, cephalosporins Infections: pyelonephritis
What is a Gleason score?
Used to predict prognosis in patients with prostate cancer
Based on glandular architecture seen on histology following hollow needle biopsy
Score of 2-10. 6 is lowest cancer score
What size of renal calculus can be managed with lithotripsy?
Total volume less than 2cm
What is the management of large renal calculi (over 2cm)?
Percutanous nephrolithotomy
How does bacterial prostatitis present?
Dysuria Urinary frequency Perineal pain Urine dipstick positive for leukocytes and nitrites Tender prostate on examination
Which drug is useful for post operative urinary retention?
Bethanechol
What are risk factors for post operative urinary retention?
Peri operative anticholinergic use Peri operative opiate use Age >50 Operation over 2 hours Abdo surgery IV fluids >750ml during operation
Which drug can be used to prevent the flare effect in using goserelin to treat prostate cancer?
Flutamide: synthetic antiandrogen
What are indications for renal transplant?
Diabetic nephropathy
PKD
Glomerulonephritis
What are complications of renal transplant?
Rejection leading to renal failure
Cushing syndrome
Skin malignancy due to immunosuppression
Ciclosporin leading to gum hypertrophy and HTN
What are signs of renal failure in a transplant patient?
Cachexia
Pulmonary and peripheral oedema
Pallor
How common is ADPKD?
1 in 1000
What are associated features of ADPKD?
Liver cysts
Berry aneurysms
Mitral valve prolapse (weakness in extracellular matrix)
What are differentials for bilateral renal masses?
ADPKD Bilateral renal cysts Bilateral renal cell carcinoma Bilateral hydronephrosis Amyloidosis Tuberous sclerosis
How do you calculate serum osmolality?
2(Na + K) + urea + glucose
What is the treatment for SIADH?
Fluid restriction
Demeclocycline
Tolvaptan (vasopressin antagonist)
What are treatments for bladder tumours?
TURBT
Intravesicular BCG or mitomycin c
What are complications of TURP?
Urinary incontinence Erectile dysfunction Clot retention Bladder neck stenosis Bladder wall injury Retrograde ejaculation Haematospermia TURP syndrome
What are causes of recurrent UTI in men?
Bladder outflow obstruction: prostate enlargement, indwelling catheter, urethral stricture Neurpathic bladder Urinary tract surgery Colovesical fistula Immunosuppression
Which bugs cause uti?
E. coli Staph saprophyticus Klebsiella Enterococcus Proteus
What are causes of urethral stricture formation?
Pelvic trauma Perineal trauma Urethral instrumentation Urethral insertion of foreign bodies Gonorrhoea Chlamydia Long term catheter Lichen sclerosus et atrophicus
How might a urethral stricture present?
Recurrent UTI LUTS Divergent stream Chronic retention Overflow incontinence
How should you investigate urethral stricture?
Cystoscopy Urinalysis Renal function Urodynamics with flow cystometry and residual volume Endoluminal USS
What are complications of urethral stricture?
Calculus Chronic infection Prostatitis Epididymitis Fourniers gangrene Renal impairment Bladder diverticula
What are management options for urethral stricture?
Internal urethrotomy
Urethroplasty
Graft reconstruction
Perineal urethrostomy
How do you stage CKD?
GFR
Proteinuria/albuminuria
What are the functions of the kidney?
Homeostasis: fluid and electrolyte balance, acid base
Excretion: drugs, metabolites
Hormone: renin, EPO, activation of Vit D
What are complications of kidney failure?
Hyperkalaemia Pulmonary oedema Metabolic acidosis Uraemia Anaemia HTN Hypercalcaemia
What are important HPC questions in a renal patient?
Fluid overload: SOB, orthopnoea, PND, ankle swelling, weight gain
Urinary symptoms: frothy urine, Haematuria, LUTS, UTIs, retention, loin pain
Uraemia: itching, nausea, weight loss
Vasculitis: arthralgia, rashes, ENT
What are differences between primary and secondary GN?
Primary: intrinsic kidney problem, minimal change, membranous nephropathy
Secondary: systemic disease, SLE, vasculitis
What is a renal screen?
Urine dip Urine PCR Blood: U and Es, FBC, C3/C4, protein electrophoresis, ANCA, MPO, PR3, anti GBM, ANA, anti DsSNA, ASOT, ACE, RhF Renal USS Renal biopsy
What can cause membranous nephropathy?
Primary: idiopathic
Secondary: cancer, drugs, infection, SLE, hep B/C
What can cause non nephrotic range proteinuria?
HTN
Diabetes
