Urology/nephrology Flashcards
What are the 2 types of peritoneal dialysis?
CAPD=Continuous ambulatory peritoneal dialysis
APD= Automated peritoneal dialysis
Types of bladder outlet obstruction
Posterior urethral valve, prostatic hypertrophy, fucntional eg. nruogenic bladder- spina bifida, transverse myseltiis, trauma etc. Prune belly syndrome
Posterior urethral valve
Commonest congenital cause of bladder obstruction in male infants. Presents with antenatal hydropnephrosis, UTI, poor urinary stream, renal dysfunction. Management- valve resection, antibiotic prophylaxis, CKD care.
PKD1 and 2 gene mutaitons
Genes code for polycystin 1 and 2. Polycystins are located in renal tubular epithelia. Overexpressed in cyst cell.
How does VUR present?
Antenatal hydro-uretero-nephrosis. UTI and pyelonephritis. VUR in 30-40%. UTI + VUR= 30% renal scarring.
Pathology of bladder cancer
- 90% is transitional cell carcinoma
- 5% squamous cell carcinoma
- 2% adenocarcinoma
- other secondaries
What can you use to diagnose prostate cancer?
- Digital rectal examination
- Prostate specific antigen
- Transrectal ultrasound guided needle biopsy
What causes membranous glomerulonephritis?
Immune complex deposition, which results in complement activation against glomerular basement membrane proteins. Prognosis follows rule of thirds.
What patients are not suitable for peritoneal dialysis?
Grossly obese, intra-abdominal adhesions, frail, home not suitable.
What is Henoch-Schonlein purpura?
A systemic vasculitis- leads to deposition of IgA in skin and kidneys. A cause of nephritic syndrome.
What problems are not helped by dialysis?
Anaemia, renal bone disease, neuropathy, endocrine disturbances.
Why do you get oedema in nephrotic syndrome?
Hypoalbuminaemia results in decreased intravascular oncotic pressure. As a result, fluid moves out of the intravascular compartment and into the surrounding tissues causing oedema.
Adult polycystic kidney disease
Commonest inherited kidney disorder- autosomal dominant. In 5-10% of patients with end stage renal failure. PKD1 gene mutation 85%. PKD2 mutation 15%.
What is a complicated UTI?
Upper urinary tract infection +/- systemic signs and symptoms. Catheter-associated UTI.
How do you slow the progression of chronic kidney disease?
Aggressive BP control, good diabetic control, diet, smoking cessation, lowering cholesterol, treat acidosis.
What is Glomerulonephritis?
A renal disease characterised by inflammation and damage to the glomeruli. This allows protein (+/- blood) to leak out into the urine.
What is the treatment of metastatic bladder cancer?
Chemo: M-VAC: Methotrexate Vinblastine Doxorubicin Cisplatin
How do you diagnose UTI?
Multistix (leucoyctes and nitrites- positive for L+F= UTI in 90%) , microscopy/flow cytometry (negative for pus cells and bacteria= no UTI), urine culture.
What is involved in being ‘clinically uraemic’?
Anorexia, vomiting, itch, restless less, weight loss, metallic taste and more. It is an indication in CKD patients that we need to start dialysis.
What is acute bacterial prostatitis?
An acute infection of the prostate gland that causes pelvic pain and urinary tract symptoms, such as dysuria, urinary frequency, and urinary retention, and may lead to systemic symptoms, such as fevers, chills, nausea, emesis, and malaise.
What is TURP?
Transurethral resection of the prostate.
Minimal change disease
Commonest form of GN in children. Podocytes fuse together- leads to leakage of protein. Acute presentation, may follow URTI. Idiopathic but may be secondary to malignancy.
When might you have multiple organisms causing UTI?
-Long term catheters
-Recurrent infection
-Structural/ neurological abnormalities
>95% caused by single organism.
What are the paraneoplastic syndromes associated with renal cancer?
Polycythaemia (increased Epo), hypercalcaemia, hypertension (renin secretion), deranged LTFs.
What are urinary cast cells?
Microscopic cylindrical structures produced by the kidney in certain disease states. RBC casts are always pathological.
Symptoms of advanced chronic kidney disease
Pruritus, nausea, anorexia, weight loss, fatigue, leg swelling, breathlessness, nocturia, joint/bone pain.
What is Alport’s syndrome?
Usually X-linked. Collagen 4 abnoralities. Deafness and renal failure. Can lead to microscopic haematuria, proteinuria and end stage renal filure. 90% on dialysis or transplant by age 40.
Problems with eGFR
- Only validated in whites and African-Americans
- Mean age 50- not validated in elderly
- Drug dosing- doesn’t take weight into account
- AKI- not valid
- Pregnancy
Problems with creatinine for use in kidney function
- Creatine and phopshocreatine are muscle breakdown products
- Affected slightly by diet
- Up to 15% secreted by tubule
- Concentration affected by plasma volume (if dehydrated, increase in creatinine)
Medical castration vs. surgical castration.
Potential treatment for advanced prostate cancer. LHRH analogue vs. orchidectomy.
Management of VUR and UTI
Medical- antibiotic prophylaxis for high grade VUR (III to V) until toile trained by day.
Surgical- ‘STING procedure’, open ureteric implantation. Role of circumcision.
Epididymitis
Inflammation of epididymis- ascending infection from urethra. Pain, fever, swelling , penile discharge. Common organisms: GNB, enterococci, streptococci. In sexually active men rule out chlamydia and N. gonorrhoea.
What is crescentic GN/ rapidly progressive GN?
Group of conditions which demonstrate glomerular crescents on kidney biopsy. Aggressive disease- 90% progress to ESRF.
Renal clearance of a substance=
volume of plasma which would be cleared of the substance per unit of time. urine conc. of substance x urine volume/ plasma conc. of substance. Usually described as ml/min. Glomerular filtration rate.
IgA nephropathy
Commonest primary glomerulonephritis. Mesangial IgA/C3 deposition. Haematruira and hypertension. No specific therapy- antihypertensive, ACE inhibitors. Can be synpharyngitic.
What is Fabry’s disease?
X-linked storage disorder. Alpha galactosidase A deficiency resulting in accumulation of Gb3. Leads to proteinuria and ESRF. Managed with enzyme replacement therapy.
What is a perinephric abscess?
Uncommon. Risk factors: untreated LUTI, anatomical abnormalities, renal calculi, bacteraemia, haematogenous spread. Common organisms: E. Coli, proteus, S. aureus, Streptococci, candida.
Renal artery stenosis
Clinical diagnosis. Unlike narrowed coronary arteries, there is evidence that angioplasty/stenting is rarely effective in renal vessels.
What is an uncomplicated UTI?
Lower UTI, normal structure and neurology.
Risk factors for bladder cancer
Age >50, caucasians, environmental carcinogens, chronic inflammation (stones, infection, long term catheters), drugs (phenacitin, cyclophosphamide), pelvic radiotherapy. Smoking (30-50% of bladder cancers). Hydrocarbons.
How to we measure function of the kidneys?
Measure what is going out in the urine or what is left in the blood. 24 hour urine collection (grams/24hr) or total protein:creatinine ratio on morning spot sample (mg/mmol).
What are indications for nephron sparing surgery?
- Single kidney
- CKD
- CV risk factors
- pT1a tumours
What is amyloidosis?
Deposition of highly stable insoluble proteinous material in extracellular space- 7.5-10nm linear aggregated fibrils of variable length forming a felt like structure made of beta-pleated sheets. Numerous H-bonds thro’ peptide amide groups make them highly stable. Can occur in kidney, lover, heart, gut. 2 classes- AA and AL.
What is a renal abscess?
Complication of pyelonephritis. Normally caused by gram negative bacilli.
Membranous glomerulonephritis
Common in adults. Present with nephrotic syndrome. Anti-phospholipase A2 receptor antibody in 70%. Treat underlying secondary cause, supportive non-immunological or specific immunotherapy treatment. Can lead to complete remission, partial remission, ESRD, relapse or death.
What is a cyst?
Sac like structure containing fluid. In the kidneys, these arise from the tubules. Cause problems by compressing other structures, replacing useful tissue, becoming infected, bleeding , pain.
Define ‘Chronic Kidney Disease’
Kidney damage or GFR <60ml/min per 1.73m2 for 3 months or more.
Presenting features of pyelonephritis (infection of the kidney- upper UTI)?
Dysuria, frequency, urgency, suprapubic pain, haematuria PLUS fever (>38), chills/rigor, flank pain, costo-vertebral angle tenderness, nausea/vomiting.
What is a recurrent UTI?
Over 2 episodes in 6 months or 3 in one year. Mostly women. Encourage hydration, encourage urge initiated and post coital voiding.
Why do you sometimes get hyperlipidaemia in nephrotic syndrome?
Due to hypoalbuminaemia, the liver compensates and increases production, however this has the side effect of also increasing the production of lipids, hence causing hyperlipidaemia.
Treatment options for advanced prostate cancer
Androgen ablation therapy- Medical castration (LHRH analogue) or surgical castration (orchidectomy), chemotherapy, TURP, radiotherapy.
Normally, how often do people get haemodialysis?
Standard 4 hour, 3 times a week. Normally in a hospital.
What is Granulomatosis with Polyangitis?
Systemic vasculitis that affects small and medium vessels. Lower and upper respiratory syndrome and renal syndrome. Positive for c-ANCA. treatment is glucocorticoids plus methotrexate, rituximab and cyclophosphamide.
What is VUR?
Vesico-ureteric reflux, a type of CAKUT. Retrograde passage of urine from the bladder into the upper urinary tract. Grade 1 and 2= low grade. Grade 3-5= high grade. Most common urologic finding in children. 30-40% of young children with a UTI.
What is Tolvaptan and what is it used to treat?
Vasopressin in V2 receptor antagonist. Used to treat APKD. Heavy monitoring required. Side effects of hepatotoxicity and hypernatraemia. Very expensive. High discontinuation rate. Can delay onset of renal replacement therapy by 4-5 years.
Goodpasture’s syndrome
Immune-mediated disease. Antibodies directed against glomerular basement membrane antigens (anti-GBM antibodies). Patients present with renal failure (nephritic syndrome) and haemoptysis (as antigens found in glomeruli and alveoli of lungs). High dose immunosuppression required: IV prednisolone and cyclophosphamide.
How do you manage renal artery stenosis?
BP control (not ACEi/ARB), statin, if diabetic good glycaemic control.
Smoking cessation, exercise, low sodium diet.
Angioplasty only in rapidly deteriorating renal failure, uncontrolled rising BP on multiple agents and flash pulmonary oedema.
Complications of catheter associated UTI?
- Obstruction-hydronephrosis
- Chronic renal inflammation
- Urinary tract stones
- Long term risk of bladder cancer
Why might you consider anticoagulation and lipid-lowering medication in nephrotic syndrome?
Because of the hypercoagulable state and hyperlipidaemia associated with nephrotic syndrome.
What are the secondary causes of nephrotic syndrome?
SLE, Hep B and C, HIV, Diabetes mellitus, malignancy.
Nephritic syndrome- associated diseases?
- Post-streptococcal glomerulonephritis
- IgA nephroapthy
- Rapidly progressive GN (Goodpasture’ syndrome, vasculitis disorder)
- Membranoproliferative GN
- HSP
What are primary causes of nephrotic syndrome?
- Minimal change glomerulonephritis
- Focal segmental glomerulosclerosis
- Membranous glomerulonephritis
Risk factors for testicular cancer
Age 20-45. Cryptorchidism. HIV. Caucasian population.
What are the aims of haemodialysis?
1) Removal of solutes: DIFFUSION
2) Removal of fluid, ‘ultrafiltration’ pressure: HYDROSTATIC FILTRATION.
Wegner’s granulomatosis
Vasculitis affecting lungs, kidney and other organs. Disease caused by anti-neutrophilic cytoplasmic antibodies (c-ANCA). Treatment IV steroids and cyclophosphamide.
What is the grading system for prostate cancer?
Gleason grading. <4= well differentiated. >7= poorly differentiated.
What are the potential modes of haemodialysis access?
- Arterial venous fistula
- Arterial venous graft
- Tunneled central venous catheter
What are the tumour markers in testicular cancer?
- Alpha-fetoprotein
- Beta hCG
- LDH
What is an ‘SPK’?
Simultaneous pancreas-kidney transplant. Offered to T1DM.
What is the gold standard imaging technique to look for scars?
DMSA (static). Nuclear medicine.
Potential complications of peritoneal dialysis?
Infection- PD related peritonitis, glucose load- make diabetes worse, mechanical- hernia, dislodged catheter, peritoneal membrane failure, hypoalbuminaemia.
How do you prevent catheter infections?
Catheterise only if necessary, remove when no longer needed, remove/replace if causing infection, hand hygiene.
AA Amyloidosis
AA = systemic amyloidosis- seen with TB and osteomyeltitis (historically). Now see it with IBD. (inflammation/infection). Treat the underlying source of inflammation/infection.
What are the potential metastatic complications of prostate cancer?
- Spinal cord compression
- Ureteric obstruction
Natural history of APKD
- Cysts gradually enlarge
- Kidney volume increases
- Some compensation
- EGFR falls, usually 10y before kidneys fail
What is a radical nephrectomy?
Removal of kidney and Gerota’s fascia. Sparing adrenal gland.
Haematuria
Blood detectable on urine dipstick (non-visible haematuria). Or visible haematuria which can come from anywhere in the urinary tract (kidneys, stones, infection, malignancy, cysts, inflammation). ‘Coca cola’ urine- blood but not bright red, normally a kidney problem.
What are the features of nephritic syndrome?
Haematuria (microscopic or macroscopic), proteinuria, hypertension (normally mild) and low urine volume <300ml.day.
Penile cancer risk factors and treatment
Rare (0.2% male cancers). Associated with HPV infection (16, 18, 21) and smoking. Treatment: circumcision, topical treatment CO2/5FU. Penectomy +/- reconstruction. Lymphadenectomy. Chemo-radiotherapy.
Presenting features of cystitis (infection of the bladder- lower UTI)?
Dysuria, frequency, urgency, suprapubic pain and haematuria (visible).
What are the potential haemodialysis complications?
‘Crash’ (acute hypotension). Access problems, cramps, fatigue, hypokalamia, blood loss, dialysis disequilbrium, air embolism.
Renal scarring risk factors
Age, high grade VUR and anatomical obstruction), dysfunctional voiding, low birth weight, prenatal dysplasia.
What is a paraneoplastic syndrome?
A syndrome (a set of signs and symptoms) that is the consequence of cancer in the body, but unlike mass effect, is not due to the local presence of cancer cells.
What are the risk factors for Fournier’s gangrene?
UTI, complications of IBD, trauma, recent surgery.
Triad of nephrotic syndrome
1) 3.5g proteinuria per 24hr (urine PCR >300).
2) Serum albumin <30
3) Oedema
4)Hyperlipidaemia
What is the primary role of the kidneys?
To maintain fluid and electrolyte homeostasis in response to blood pressure and hormones.
What are the common causes of crescentic GN/ rapidly progressive GN?
ANCA vasculitis, Goodpasture’s syndrome, lupus nephritis, infection associated, Henoch Schonlein Purpura nephritis.
Signs and symptoms of prostate cancer
Painful or slow micturition, UTI, haematuria, urinary retention, lymphoedema.
Signs of advanced chronic kidney disease
Peripheral and pulmonary oedema, pericardial rub, rash/excoriation, hypertension, tachypnoea, cachexia, pallor and/or lemon yellow tinge.
What are the 3 renal replacement modality?
1) Haemodialysis
2) Peritoneal dialysis
3) Renal transplant
What is a radial cystectomy?
Bladder and prostate/uterus removed. Normally urine diverted into an ileal conduit.
What is PSA?
Prostate specific antigen. Serine protease secreted into seminal fluid- responsible for liquefaction of seminal coagulation. Tends to rise with age, depends on prostate size, other influences eg. inflammation, infection.
Presentation of bladder cancer
Classically painless frank haematuria. Should then have a cystoscopy.
AL Amyloidosis
AL = immunoglobulin fragments from haematological condition eg myeloma
Ig LC λ >κ (12:1 if renal impairment) 12ααs.
Treat the underlying haematological condition.
What are the indications for renal replacement therapy?
- Medically resistant hyperkalaemia
- Medically resistant pulmonary oedema
- Medically resistant acidosis
- Uraemic pericarditis
- Uraemic encephalopathy
CAKUT
Congenital abnormalities of the kidneys and urinary tract.
What is Fournier’s gangrene?
A type of necrotizing fasciitis or gangrene affecting the external genitalia and/or perineum. It commonly occurs in older men, but it can also occur in women and children. It is more likely to occur in diabetics, alcoholics, or those who are immunocompromised.
What do polycystin proteins do?
Membrane proteins involved in intracellular calcium regulation.
Common organisms that cause UTI
gram -ve= E. coli, Klebsiella, proteus, pseudomonas.
gram +ve= streptococcus, enterococcus, staohylococcus, Anaerobes
What are the functions of the kidney?
- Metabolic waste excretion (urea, creatinine)
- Endocrine functions (vit. D, EPO, PTH)
- Drug metabolism/excretion
- Control of solutes and fluid status
- Blood pressure control
- Acid/base
Treating UTI in pregnancy
Send urine sample with each presentation. Treat for 7-10 days. Amoxicillin and cefalexin relatively safe. Avoid trimethoprim in 1st semester and nitrofuratonin near term.
UTI risk factors
Infancy (boys and girls under 1 year), abnormal urinary tract (congenital or other abnormalities), females, bladder dysfunction/incomplete empyting, ‘foreign’ body (catheter, stones), diabetes mellitus, renal transplant, immunosuppression.
How can 0.9% saline affect the kidneys?
Can cause hyperchloraemic acidosis. This leads to renal vasoconstriction and poor urine output.
What are the options for fluid maintenance?
- Sodium chloride 0.18%/4% glucose
- 5% glucose
- Hartmann’s
What are the options for fluid replacement?
Work out losses and replace with Hartmann’s/ plasmalyte. May use 0.9% NaCl for vomiting/large NG losses.
Name some stone inhibitors
Citrate, magnesium, pyrophosphate, glycoproteins.
What factors affect stone formation?
- Low volume
- Low pH
- Low citrate
- Low magnesium
- High uric acid
- High calcium
- High oxalate
How do stones present?
Incidental, pain, haematuria, UTI or sepsis.
Where are the 3 places stones cause pain?
- Pelvicureteric junction
- Vesicoureteric junction
- Crossing iliacs
How do NSAIDs reduce pain in kidney stones?
They reduce pain due to reduced glomerular filtration, renal pressure and ureteric peristalsis.
Define ‘Acute Kidney Injury’
Decline of renal excretory function over hours or days. recognised by the rise in serum urea and creatinine. RIFLE criteria (risk, injury, failure, loss, ESKD).
How to classify AKI severity
Stage 1: serum creatinine 1.5-2 times AKI baseline
Stage 2: serum creatinine 2-3 times AKI baseline
Stage 3: serum creatinine 3.0 times above AKI baseline
What are the diagnostic classifications of AKI
Pre-renal (often circulatory failure “shock”)
Renal (cells of the kidney)
Post renal (obstruction)
What are pre-renal causes of AKI?
Anything that impairs renal perfusion eg. hypotension, hypovolaemia, hypoxia, sepsis, drugs etc.
What are post-renal causes of AKI?
Obstructive causes- anything between renal pelvis and uretheral meatus which obstructs flow of urine eg. calculi, tumours, lymph nodes, prostate.
What is rhabdomyolysis?
A serious syndrome due to a direct or indirect muscle injury. It results from the death of muscle fibers and release of their contents into the bloodstream. This can lead to serious complications such as renal (kidney) failure. This means the kidneys cannot remove waste and concentrated urine.
What is acute tubular necrosis?
Reversible or irreversible type of renal failure caused by ischaemic or toxic injury to the renal tubular epithelial cells. The injury results in cell death or detachment from basement membrane causing tubular dysfunction.
Causes of acute tubular necrosis?
Always due to under perfusion of the tubules and/or direct toxicity: -hypotension -sepsis -toxins Or often, all 3
ATN exogenous toxins
- Drugs eg. NSAIDs, gentamicin, ACE inhibitors
- Contrast
- Poisons eg. metals, anti-freeze
ATN endogenous toxins
- Myoglobin
- Haemoglobin
- Immunoglobins
- Calcium
- Urate
How do you treat hyperkalaemia?
If K+>6.5= medical emergency. Calcium gluconate 10% as cardiac membrane stabiliser. Insulin dextrose moves potassium into cells. Reduce absorption from gut
Recovery from acute tubular necrosis
Often a polyuric phase for 48-72hrs. May be up to 6l urine/day. Tubules fail to concentrate urine.
