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A2 ME3031 URINARY > W06: UTI, GLOMERULAR DISESE, Benign Prostate Disease, The Kidneys in Systemic Disease > Flashcards

W06: UTI, GLOMERULAR DISESE, Benign Prostate Disease, The Kidneys in Systemic Disease Flashcards

1
Q

Discuss the clinical presentation and principles of management of patients with renal pain and ureteric colic.

A

a

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2
Q

Describe the presentation, investigations of urinary tract infections.

A

INVESTIGATIONS:

MSU: urinalysis @ ward

MSU: microbiology, baacteruria 10^5

if UTI frequent: USS or IVU or isotope studies

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3
Q

Levels of infection within the urinary tract

A

Kidney

  • Acute Pyelonephritis
  • Chronic Pyelonephritis

Bladder
* Cystitis

Urethra
*Urethritis

Prostate
*Prostatitis

Epididymis/Testis
*Epididymo-orchitis

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4
Q

RF to UTI

A

Immunosuppression
Steroids
Malnutrition
Diabetes

Sexual intercourse and poor voiding habits
Congenital abnormalities e.g. duplex kidney
Stasis of urine e.g. due to poor bladder emptying
Foreign bodies eg catheters, stones
Oestrogen deficiency in postmenopausal women
Fistula between bladder & bowel

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5
Q

Common aetiological agents of UTI

A

gram -ve

  • e. coli
  • proteus mirabilis
  • klebsiella

gram+ve

  • cog -ve staph.
  • enterococci
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6
Q

Presentation of UTI

A

children: diarrhoea, systemic, n/v, nil eating, crying
adults: flank pain, dysuria, turbid offensive urine, urgency,

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7
Q

Presentation of pyelonephritis

A

systemic, loin tenderness at renal angle, dehydration, turbid urine

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8
Q

Presentation of pyelonephritis

A

systemic, loin tenderness at renal angle, dehydration, turbid urine

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9
Q

Describe the treatment of urinary tract infections.

A
  • Fluids
  • Antibiotics
    Amoxicillin (3-5 day course or 3g x 2), cephalosporin, Trimethoprim
  • Severe infections
    Intravenous antibiotics
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10
Q

Normally functionning UTract Vs Abnormal

A

normal = seldom renal dmg, produce normal IVU
* radiographic study of the renal parenchyma, pelvicalyceal system, ureters and the urinary bladder. This exam has been largely replaced by CT urography.

abnormal = anatomical/neuro, DM, stones,

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11
Q

Reflux Nephropathy

A

chronic in nature, childhood recurrent infection association
reflux + infection

*USS and biochem to assess progression
= findings of patchy interstitial scarring, tubular atrophy, and loss of nephron mass. It is often detected during a routine evaluation in early adulthood or during pregnancy

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12
Q

Quantification of Bacteriuria

A

≥ 10^5

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13
Q

Chronic Pyelonephritis

A

Radiological diagnosis
Scarring & clubbing
Hypertension / CRF

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14
Q

Explain the approach to diagnosis and management of patients with haematuria and proteinuria.

A

d/t inflammation of the kidneys (nephritic state)

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15
Q

Explain the diagnosis, pathological, and clinical manifestations of glomerulonephritis.

A

Glomerulonephritis is primarily diagnosed via biopsy

=
Haematuria (non-visible or visible)
Proteinuria (low grade or nephrotic)
Hypertension
Renal impairment

PROLIFERATIVE GLOMERULONEPHRITIS: presence of immune cells
= more nephritic in nature

NON-PROFILIEFRATIVE GLOMERULONEPHRITIS: normal/scarring but normal number of cells
= more nephrotic in nature

• diffuse or focal, global or segmental

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16
Q

State the management principles of glomerulonephritis.

A

> Lifestyle
BP Control

> Steroids
Imm Supp: Rituximab
Cyclophosphamide

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17
Q

Nephritic vs Nephrotic

A 
NEPHROTIC: 
massive proteinuria (≥3.5 g/day) resulting in significant hypoalbuminaemia (serum albumin ≤30 g/L).
  • associated with oedema (due to reduced oncotic pressure), hyperlipidaemia and hypercoagulability.
  • Oedema (e.g. peri-orbital, lower limb, ascites)
  • Xanthelasma and/or xanthoma
  • Leukonychia
  • Shortness of breath (with associated chest signs of pleural effusion – e.g. stony dullness in lung bases)

NEPHRITIC (more immune/inflamm in nature):
haematuria, mild to moderate proteinuria (typically less than 3.5g/L/day), hypertension, oliguria and red cell casts in the urine.

    • dysmorphic rbcs sidement
  • HT
  • renal impairment
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18
Q

IgA NEPHROPATHY

A

common cause, M>F,

IgA deposition in the mesangium and mesangial proliferation.

  • haematuria + proteinuria
  • crescent deposition
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19
Q

Post Infectious Glomerulonephritis

A

Follows 10-21 days after infection typically of throat or skin; genetic predisposition

Most commonly with Lancefield group A Streptococci.

> diuretics for oedema
antihypertensives

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20
Q

Crescentic glomerulonephritis

A

d/t
1) ANCA

2) anti-glomerular basement membrane (GBM)
nephritis +/- resp. haemorrhage (goodpasture’s syndrome)

3) IgA vasculitis; SLE; post-infectious

= immune nature

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21
Q

GBM disease tx

A

anti-GBM

> aggressive immunesuppression: steroid, plasma exchange, and cyclophosphamide

22
Q

NON-PROLIFERATIVE GLOMERULONEPHRITIS

A

Focal and segmental glomerulonephritis
Membranous Nephropathy

> Treat oedema: salt and fluid restriction and loop diuretics.
Hypertension: use Renin-Angiotensin-Aldosterone-blockade.
Reduce risk of thrombosis: Heparin or Warfarin.
Reduce risk of infection e.g. pneumococcal vaccine.
Treat dyslipidemia e.g. statins.

23
Q

Significance of MINIMAL CHANGE DISEASE

A

commonest in children; sudden onset of oedema/days

> steroids for remission but relapse common
PREDNISOLONE then TAPER.
+ ?thromboprophylaxis

> relpse tx: (imm-suppr.)
Cyclophosphamide
Cyclosporin
Tacrolimus
Mycophenolate mofetil
Rituximab

end-staage kidney disease risk is low

24
Q

Focal and segmental glomerulosclerosis

A

(nephrotic)
Pathology reveals focal and segmental sclerosis with distinctive patterns e.g.
tip lesion, collapsing, cellular, perihilar, and not otherwise specified.

• steroid resistant; high risk end stage progression

> Trial of steroids, positive response , even partial remission, carries better prognosis.
Alternative options: cyclosporin, cyclophosphamide, and Rituximab.

25
Q

Membranous Nephropathy

A

Commonest cause of nephrotic syndrome in adults; idiopathic

*serum markers

2º: Malignancies, SLE, Rheumatoid arthritis., Drugs: NSAIDs, gold, penicillamine.

> usual steroid/ imm supp

26
Q

List the common benign diseases of the prostate and state the principles of their clinical presentation, investigation

A

Investigations: MSU, flow rate study, post-void residual USS, bloods (PSA),

  • renal tract USS
  • cystoscopy for HAEMTURIA
  • ⇧PSA or abn DRE = prostate biopsy
27
Q

Recognise and understand the complications associated with benign prostatic obstruction, and the indications for surgical treatment

A

a

28
Q

Benign Prostatic Hyperplasia

A

fibromuscular and glandular hyperplasia; primarily affects transition zone; disordered dihydrotestosterone

⇧age

  • moderat to severe LUTS
  • progression to BOObstr.
29
Q

LUTS

A

symptoms indicative of nature of syndrome

OBSTRUCTIVE = VOIDING: hesistancy, poor stream, terminal dribbling, incomplete emptying

IRRITATIVE = STORAGE: freq, nocturia, urgency, incontinnce

30
Q

BPO Tx

A

uncomplicated BPO (benign prost. obstr.)
* wait
* Alpha blockers = relax
* 5 alpha reductase inhibitors / 5ARI (Finasteride or Dutasteride) = testosterone to dihydrotestos.; ⇩prostate size
= Combination most effective in preventing progression; ⇩prostatic bleeding

  • Surgical intervention
    • TURP (prostate size <100cc) - prost. resection GOLD STANDARD; sfx: bleeds, infection, retro ejac., regrowth = recurrent haematuria or BOO (blad. outf. obstr.)

Open retropubic or transvesical prostatectomy (prostate size >100cc)
Endoscopic ablative procedures

complicated
> Sx

31
Q

BOO Tx

A

(blad. outf. obstr.)

> mostly sx = TURP

> alternatively: LT catheter but has issues such as catheter trauma, blockages, frank haematuria or recurrent UTI

32
Q

ACUTE URINARY RETENTION

A

painful inability to void with a palpable and percussible bladder; 500ml-1L+

> catheter
if no renal failure, alpha blocker and remove catheter

33
Q

CHRONIC URINARY RETENTION

A

painless, palpable and percussible bladder AFTER voiding; 400 to >2L residual and voiding possible

*detrusor underactivity, or longstanding BOO (BPO, stricture) = LUTS

> symptomatic = catheter, CISC, TURP

34
Q

CISC

A

Clean intermittent self-catheterisation (CISC) is the intermittent insertion of a catheter into the bladder by the patient in order to assist drainage of the urine when normal voiding is not possible.

35
Q

UPPER TRACT OBSTRUCTION & LOWER TRACT OBSTRUCTION presentation and complications

A

UPPER:
PAIN, frank haematuria
*palpable mass, microscopic haematuria
compl.: INFECTION, SEPSIS, RENAL FAILURE

acute: renal funct. ?normal
chronic: high pressure v low pressure, partial or complete obstruction

LOWER:
incontinence, retention, infection and sepsis, frank haematuria, stone formation, RFailure

high-p = painless, incontinent, ⇧cr., bilateral hydronephrosis

low-p = painless, dry, normal cr, normal kidneys

36
Q

UPPER OBSTRUCTION MGMT

A

RESUSCITATION: iv access, abg, cultures, fluid monitoring; analgesia
+abx?
+ HDU care? renal replacement rx?

*IMAGING

  • EMERGENCY TX OF OBSTRUCTION:
  • percutaneous nephrostomy insertion under LA
  • retrograde stent insertion via cystoscopy

> stone = ureteroscopy and laser lithotripsy +/- basketing or ESWL

> ureteric tumour = radical nephro-ureterectomy

> PUJ obstr. = laparoscopic pyeloplasty

37
Q

What is radical nephro-ureterectomy

A

Laparoscopic radical nephroureterectomy is a minimally invasive surgical procedure to remove the renal pelvis, kidney and entire ureter, along with the bladder cuff, in an attempt to provide the greatest likelihood of survival for patients with transitional cell cancer.

38
Q

LOWER OBSTRUCTION MGMT

A

> catheter

> foley cathater

  • EMERGENCY TX OF OBSTRUCTION:
  • urethral catheter
  • suprapubic catheter
underlying
> BPE = TURP
> stricture = optical urethrotomy
> meatal stenosis = meatal dilatation
> phimosis = circumcision
39
Q

Complications of obstruction

A

DECOMPRESSION HAEMATURIA: vascular shearing d/t compliance of tissue, self-limiting

POST-OBSTRUCTIVE DIURESIS: 200ml/hr++, osmotic diuresis = Na thus H2O depletion
> saline input

40
Q

The following are absolute indications for surgical intervention in patients with benign prostatic obstruction except:

a. refractory acute urinary retention
b. refractory chronic urinary retention
c. renal failure
d. recurrent UTI
e. bladder stones

A

refractory chronic retention bc can catheterise

41
Q

The following are causes of acute urinary retention in men except:

a. spinal cord compression
b. urinary tract infection
c. constipation
d. pain from laparotomy wound
e. cystoscopy under local anaesthetic

A

cystoscopy under local anaesthetic

42
Q

Long-term urethral catheters (e.g. silicone-based ones) should not be left in-situ for longer than:

a. 1 week 
b. 4 weeks
c. 8 weeks 
d. 12 weeks
e. 16 weeks
A

maximum duration of short term urethral catheters is 4 weeks

vs

long term catheters duration = min. of 4, up to 12w

43
Q

What is the ‘gold standard’ investigation for renal colic?

a. Renal ultrasound scan
b. MRI of renal tract 
c. IVU
       d. CT-KUB
e. Plain KUB X-ray
A

CT-KUB

44
Q

The following are common types of renal tract stones except:

a. Calcium phosphate
b. Calcium oxalate
c. Calcium bicarbonate
       d. Uric acid (urate)
e. Magnesium ammonium phosphate (struvite)
A

Calcium bicarb (teeth, bones)

*with Calcium oxalate being commonest, alongside calcium phosphate being common too

45
Q

Investigations of urinary tract obstructions

A

1) * CT-KUB *
non-contrast, low dose, no nephrotox., renal failure
+visualise stones and obstructions in emergency setting

  • not as useful if ureter/collecting system undilated
  • RENAL USS: upper tract hydronephrosis, hydroureter but cannot visualise cause of obstruction d/t obstruction of bowel gas
  • IVU (old)
  • CT Urogram - different phases; higher radiation, nephrotoxic, CI in RFailure, greater sensitivity for obstructing masses (carcinomas, pelvic mass)
  • MAG3 isotope study = split renal function (ideally 50/50) = used for chronic unilateral upper obstruction esp chronic PUJ obstruction
46
Q

DIABETIC NEPHROPATHY

A

hyperfiltration, altered glomerular composition, renal hypertrophy, and glomerular HT

= albuminuria + deposition of ECM

=> glomerulosclerosis, interstitial fibrosis

  • increasing proteinuria associated w/ declining GFR
  • commonest cause of ESRD
47
Q

LUPUS NEPHRITIS: common signs, and mgmt

A

F>M; systemic fever fatigue mouth ulcers rash joints, butterfly rash

common for Pt. to develop lupus nephritis; glomerulonephritis w/ immune deposits
+ proteinuria (nephrotic syndrome)
+ haematuria, RBC casts
+ creatinine+++

> corticost.
or imm suppr.

48
Q

MYELOMA: signs and dx

A

multiple myeloma = plasma cell profileration = XS Immunoglobulins

⇧ESR, anaemia, Wt loss, fractures, infections, backpain
LYTIC LESION; URINE DIP = HEAVY PROTEINURIA

  • bone aspirate
  • serum paraprotein
  • urinary BENCE-JONES PROTEIN
  • skeletal survey

Cast nephropathy, hypercalcaemia, hyperuricaemia, amyloidosis

49
Q

Signs of systemic disease with renal involvement

A

1) SPLINTER HAEMORRHAGES, PURPURA, RAYNAUD’S
2) SCLERITIS, UVEITIS, RETINAL VASCULITIS, HYPERTENSIVE RETINOPATHY
3) VASCULITIC RASH, SCLERODERMA

+hypertension, creps, joint swelling tenderness, stroke encephalopathy

50
Q

Investigations in systemic renal suspicions

A

URINE DIP

Bloods - ANCA (anti-MPO/anti-PR3 antibodies), ANA, dsDNA antibodies, Complement levels C3, C4, Blood cultures
Radiology – CXR, USS abdomen, CT thorax
Echocardiography
Kidney Biopsy

A2 ME3031 URINARY (14 decks)

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