Week 14 - Nephrology/Urology

Question 1

List the 6 functions of the kidney?

Answer 1

1. Metabolic waste excretion (urea, creatinine)
2. Endocrine functions (vit D, EPO, PTH)
3. Drug metabolism / excretion
4. Acid / base
5. Blood pressure control
6. Control of solutes and fluid status (sodium, potassium, fluid)

Question 2

What is the primary role of the kidneys?

Answer 2

Maintain fluid & electrolyte homeostasis in response to blood pressure and hormones

Question 3

List the 6 structures of the kidney nephron?

Answer 3

1. Glomerulus
2. Bowman’s capsule
3. Proximal convoluted tubule
4. Loop of Henle
5. Collecting tubule (to ureter)

Question 4

Describe the glomerular filtration barrier?

Answer 4

Filters plasma & are not supposed to let through protein/cells/big molecules

Question 5

What are the 2 structures of the glomerular filtration barrier?

Answer 5

1. Podocyte foot processes

2. Capillary fenestrated endothelium

Question 6

What 4 things control the glomerular filtration rate?

Answer 6

1. Blood flow
2. Intraglomerular pressure
3. Transmembrane pressure- filtration barrier
4. Oncotic pressure

Question 7

What 4 things happen to the filtrate passing through the kidney tubules?

Answer 7

1. Filtration
2. Reabsorption
3. Secretion
4. Excretion

Question 8

Where does filtrate reabsorption occur?

Answer 8

Peritubular capillaries

Question 9

Where does filtrate filtration occur?

Answer 9

Bowan’s capsule

Question 10

What is urinary excretion equal to?

Answer 10

Filtration - Reabsorption + Secretion

Question 11

What is the normal amount of protein in the urine?

Answer 11

Less than 150mg protein / 24h

Question 12

What makes up 15% of proteinuria?

Answer 12

Albumin

Question 13

What makes up 85% of proteinuria?

Answer 13

Other proteins ie. Tamm, Horsfall, Immunoglobulin

Question 14

What does urinalysis detect?

Answer 14

Albumin

Question 15

What are 3 ways to measure urinary protein excretion?

Answer 15

1. 24hr urine collection (grams / 24h)
2. Protein:creatinine ratio (PCR) on morning spot sample (mg/mmol)
3. Albumin:creatinine ratio (mg/mmol)

Question 16

What is the normal range for male/female albuminuria?

Answer 16

• Male: <2.5

- Female: <3.5

Question 17

What is the microalbuminuria range for male/females?

Answer 17

• Male: 2.5-35

- Female: 3.5-35

Question 18

What is the macroalbuminuria range for male/females?

Answer 18

• Male: >25

- Female: >35

Question 19

What is haematuria?

Answer 19

• Can be blood detectable on dipstick (non-visible haematuria)
• Visible haematuria- can come from anywhere in the urinary tract (kidneys, stones, infection, malignancy, cysts, inflammation)

Question 20

What are the 7 things measured in a U&Es blood test?

Answer 20

1. Sodium
2. Potassium
3. Chloride
4. Urea
5. Creatinine
6. eGFR
7. +/- bicarbonate

Question 21

What 3 things would a substance to test U&Es ideally be?

Answer 21

1. Freely filtered at glomerulus
2. Not secreted
3. Not reabsorbed

Question 22

What is creatinine?

Answer 22

Creatine and phosphocreatine breakdown product

Question 23

What is creatinine levels affected by?

Answer 23

• Slightly by diet

- Concentration affected by plasma volume

Question 24

What % of creatinine is secreted by tubules?

Answer 24

Up to 15%

Question 25

What 4 things affect urea levels in the body?

Answer 25

1. Diet- high protein or GI bleed 2. Tissue breakdown- corticosteroid 3. Dehydration- passive reabsorption proximal tubule 4. Liver failure (lowers urea)

Question 26

What % of urea is reabsorbed?

Answer 26

Up to 40%

Question 27

What is the renal clearance of a substance?

Answer 27

Volume of plasma which would be cleared of the substance per unit of time

Question 28

What is the renal clearance equation?

Answer 28

Urine concentration of substance X Urine volume / Plasma concentration of substance (ml/min)

Question 29

How is renal clearance usually described?

Answer 29

As Glomerular Filtration Rate

Question 30

What 4 factors is the modification of diet in renal disease (MDRD) based on?

Answer 30

1. Plasma creatinine concentration 2. Age (adults only) 3. Gender 4. Race

Question 31

What does the modification of diet in renal disease (MDRD) give values as?

Answer 31

ml/min per 1.73m2 body surface area

Question 32

What 3 factors increase an individuals creatinine?

Answer 32

1. Younger 2. Males 3. Races

Question 33

What is the relationship between serum creatinine and GFR?

Answer 33

Inversely proportional & also depends on muscle mass

Question 34

eGFR assumes _____ renal function?

Answer 34

Stable

Question 35

What is the GFR value if the plasma creatinine concentration= 100micromols/l, but the patient has no kidneys or is making no urine?

Answer 35

GFR= 0

Question 36

What is eGFR value important for?

Answer 36

Drug dosing

Question 37

Who is the eGFR value not suitable for?

Answer 37

Acute kidney injury as it takes 3-4 days to build up

Question 38

What are the 5 stages of chronic kidney disease?

Answer 38

- Stage 1: with another abnormality, otherwise regard as normal (eGFR => 90) - Stage 2: with another abnormality, others regard as normal (eGFR 60-89) - Stage 3: moderate impairment (eGFR 30-59) - Stage 4: severe impairment (eGFR 15-29) - Stage 5: advanced renal failure (eGFR <15)

Question 39

What does CKD-EPI stand for?

Answer 39

Chronic Kidney Disease Epidemiology Collaboration (for patients with higher levels of eGFR)

Question 40

What eGFR should be regarded as normal?

Answer 40

=>60 ml/min/1,73m2 - Unless they have evidence of kidney disease (persistent proteinuria/haematuria or both, microalbuminuria in patients with diabetes, structural kidney disease in adults or reflux nephropathy)

Question 41

What 3 tests establish basic kidney function?

Answer 41

1. Blood creatinine 2. Calculating eGFR if patient is stable 3. Urinalysis

Question 42

What is glomerulonephritis?

Answer 42

Inflammatory diseases involving the glomerulus & tubules, categorised by biopsy findings

Question 43

What are the 4 main targets for injury in glomerulonephritis?

Answer 43

1. Podocytes 2. Basement membrane 3. Mesangial cells 4. Glomerular capillaries

Question 44

What are the 2 pathophysiological mechanisms of glomerulonephritis?

Answer 44

1. Extrinsic: antibodies, immune complexes, complement | 2. Intrinsic: cytokines, growth factors, proteinuria

Question 45

List 8 secondary causes of glomerulonephritis?

Answer 45

1. CV: SBE 2. Resp: bronchiectasis, lung cancer, TB 3. ID: Hepatitis, HIV, chronic infections 4. Rheum: RA, lupus, amyloid 5. Drugs: NSAIDS, bisphosphates, heroin 6. Gastro: ALD, IBD, coeliacs disease 7. Diabetes 8. Haem: myeloma, CLL, PRV

Question 46

List the 3 approaches to glomerulonephritis?

Answer 46

1. Presentation, history 2. Kidney biopsy findings 3. Likely cause & specific management

Question 47

What are 3 ways to examine a biopsy of the kidney cortex?

Answer 47

1. Light microscopy (glomerular and tubular structure) 2. Immunofluorescence (looking for Ig and complement) 3. Electron microscopy (glomerular basement membrane and deposits)

Question 48

Give 8 examples of kidney disease?

Answer 48

1. Minimal change nephropathy 2. Rapidly progressive glomerulonephritis (RPGN) 3. Membranoproliferative 4. Membranous nephropathy 5. Crescentic glomerulonephritis/vasculitis 6. Post-infectious 7. Diabetic nephropathy 8. Lupus nephropathy

Question 49

How does a disruption of glomerular filtration barrier present clinically?

Answer 49

ABNORMAL URINE

Question 50

Describe Rapidly progressive glomerulonephritis (RPGN)?

Answer 50

- Rapid rise in serum creatinine - Crescentic damage - Vasculitis/lupus/IgA: often have other clinical features

Question 51

Describe nephritis?

Answer 51

- Blood and protein in urine, high blood pressure, rising sCr - Proliferative / acute inflammation - IgA / lupus / post-infectious

Question 52

Describe nephrotic?

Answer 52

- >3.5g/d proteinuria, low sAlb, oedema - Non-proliferative, podocyte damage (scarring) - Minimal change / FSGS / Membranous

Question 53

Describe overlap glomerulonephritis?

Answer 53

- Blood / heavy proteinuria | - IgA / MCGN / lupus

Question 54

Describe 2 other presentations of glomerulonephritis?

Answer 54

1. Urinary abnormalities alone | 2. Hypertension

Question 55

What are the 4 factors of nephrotic syndrome?

Answer 55

1. 3.5g proteinuria per 24h (urine PCR >300) 2. Serum albumin <30 3. Oedema 4. Hyperlipidaemia

Question 56

What are the 2 complications of nephrotic syndrome?

Answer 56

1. Risk of venous thromboembolism | 2. Increased risk of infection

Question 57

List the 4 stages in the glomerulonephritis model?

Answer 57

1. Insult precipitant 2. Injury 3. Response to injury --> disease 4. Outcome

Question 58

What are the possible therapeutic strategies for glomerulonephritis stage 1: Insult precipitant (infection, antibody)?

Answer 58

Control infection & connective tissue disease

Question 59

What are the 2 possible therapeutic strategies for glomerulonephritis stage 2: Injury?

Answer 59

1. Remove antibody/immune complex | 2. Block antibody

Question 60

What are the 3 possible therapeutic strategies for glomerulonephritis stage 3: response to injury?

Answer 60

1. Steroids 2. Cytotoxics 3. Anti-hypertensives

Question 61

What are the possible therapeutic strategies for glomerulonephritis stage 3: response to injury?

Answer 61

1. Dialysis 2. Transplantation 3. Slow progression 4. Resolution

Question 62

List the 4 aspects of IgA nephropathy from mild --> severe (spectrum of disease)?

Answer 62

1. Minor Urinary abnormalities 2. Hypertension 3. Renal impairment & heavy proteinuria 4. Rapidly progressie glomerulonephritis

Question 63

Describe the epidemiology of IgA nephropathy (mesangial disease)?

Answer 63

- The most common primary glomerular disease - Up to 1% of the “normal” population - Precipitated by infection? Synpharyngitic - May be secondary to HSP, cirrhosis, coeliac disease

Question 64

List the 3 pathophysiological abnormalities in IgA nephropathy (mesangial disease)?

Answer 64

1. Abnormal/ over-production of IgA1, IgA I/C 2. Mesangial IgA, C3 deposition 3. Mesangial proliferation

Question 65

What are the 3 clinical signs of IgA nephropathy (mesangial disease)?

Answer 65

1. Haematuria 2. Hypertension 3. Proteinuria (varies with prognosis)

Question 66

What do almost 1/3rd of IgA nephropathy (mesangial disease) progress to?

Answer 66

End stage renal failure (ESRF)

Question 67

What is the treatment for IgA nephropathy (mesangial disease)?

Answer 67

- No specific therapy - Antihypertensive - ACE inhibitors

Question 68

Describe the epidemiology of Membraneous glomerulonephritis?

Answer 68

- A disease of adults | - 10% secondary to malignancy, CTD, drugs

Question 69

Describe the pathophysiology of membraneous glomerulonephritis?

Answer 69

- Anti-phospholipase A2 receptor antibody in 70% | - Immune complexes in basement membrane/ sub-epithelial space

Question 70

How does Membraneous glomerulonephritis typically present?

Answer 70

Presents with the nephrotic syndrome: commonest primary cause, often chronic

Question 71

Describe the variable natural history/prognosis of Membraneous glomerulonephritis?

Answer 71

- A 1/3rd spontaneously remit - A 1/3rd progress to ESRF over 1-2 years - A 1/3rd persistent proteinuria, maintain GFR

Question 72

What are 3 ways to treat membraneous nephropathy?

Answer 72

1. Treat underlying disease if secondary 2. Supportive non-immunological: ACEi, statin, diuretics, salt restriction 3. Specific immunotherapy: Steroids, Alkylating agents (cyclophosphamide), Cyclosporin

Question 73

List the 2 alternative agents used to treat membraneous nephropathy?

Answer 73

1. Rituximab | 2. Anti-CD20 MAb

Question 74

What are the 5 possible outcomes for membraneous nephropathy?

Answer 74

1. Complete remission 2. Partial remission 3. End Stage Renal Disease (ESRD) 4. Relapse 5. Death

Question 75

What is the commonest form of glomerulonephritis in children?

Answer 75

Minimal change disease

Question 76

What does minimal change disease cause?

Answer 76

Nephrotic syndrome

Question 77

What are the 2 causes of minimal change disease?

Answer 77

1. Idiopathic | 2. Secondary to malignancy

Question 78

What s the pathophysiology of minimal change disease?

Answer 78

- Foot process fusion - T cell, cytokine mediated - Target glomerular epithelial cell, basement membrane charge

Question 79

Describe the presentation of minimal change disease?

Answer 79

- Acute presentation may follow URTI - GFR - normal, or reduced due to intravascular depletion - Relapsing course (50% will relapse)

Question 80

What does minimal change disease early cause?

Answer 80

Renal failure

Question 81

What % of minimal change disease will relapse?

Answer 81

50%

Question 82

What is the treatment for minimal change disease?

Answer 82

High dose steroids: Prednisolone 1mg/Kg for up to 8 weeks

Question 83

What is crescentic glomerulonephritis/ rapidly progressive glomerulonephritis?

Answer 83

- Group of conditions which demonstrate glomerular crescents on kidney biopsy - Aggressive disease: progress to ESRF

Question 84

List the 5 common causes of crescentic glomerulonephritis/ rapidly progressive glomerulonephritis?

Answer 84

1. ANCA vasculitis (MPO / PR3) 2. Goodpasture’s syndrome (anti-GBM) 3. Lupus nephritis 4. Infection associated 5. HSP nephritis

Question 85

What are the 7 basics for approaching a patient with potential glomerulonephritis?

Answer 85

1. A full medical and drug (including recreational) history 2. UEs 3. Dip urine for blood 4. Quantify proteinuria 5. Check albumin 6. Check USS 7. Glomerulonephritis screen

Question 86

What are the 5 tests in the Glomerulonephritis screen?

Answer 86

1. HbA1c / random glucose 2. ANCA / anti-GBM 3. ANA / PLA2R / virology 4. Complement / ANA / dsDNA 5. Complement / virology (hep B, C, HIV) / Igs / RF

Question 87

What disease can be detected when measuring HbA1c / random glucose in the Glomerulonephritis screen?

Answer 87

Diabetic nephropathy

Question 88

What disease can be detected when measuring ANCA / anti-GBM in the Glomerulonephritis screen?

Answer 88

Vasculitis

Question 89

What disease can be detected when measuring ANA / PLA2R / virology in the Glomerulonephritis screen?

Answer 89

Membraneous

Question 90

What disease can be detected when measuring Complement / ANA / dsDNA in the Glomerulonephritis screen?

Answer 90

Lupus

Question 91

What 2 diseases can be detected when measuring Complement / virology (hep B, C, HIV) / Igs / RF in the Glomerulonephritis screen?

Answer 91

1. Membranoproliferative glomerulonephritis (MPGN) | 2. Focal segmental glomerulosclerosis (FSGS)

Question 92

List 4 systemic diseases that are associated with renal dysfunction?

Answer 92

1. Diabetes mellitus 2. Atheromatous vascular disease 3. Amyloidosis 4. Systemic lupus erythematosis

Question 93

List 5 ways that systemic diseases manifest in the kidneys?

Answer 93

1. Acute kidney injury (AKI) 2. Chronic kidney disease (CKD) 3. Nephritic syndrome 4. Proteinuria 5. Nephrotic syndrome

Question 94

What 4 questions should you ask when suspecting systemic diseases are affecting the kidneys?

Answer 94

1. Renal impairment old or new?- previous U&E 2. Proteinuria?- Urinalysis & quantitative proteinuria (uPCR) 3. Which is it?- AKI/CKD/nephritis/nephrotic syndrome/proteinuria 4. Clues to systemic disease?- history and examination

Question 95

What are 3 other tests to confirm a diagnosis of systemic disease affecting the kidneys?

Answer 95

1. Special antibodies, complement, eosinophils, 2. Imaging 3. Renal biopsy

Question 96

What do 30-40% of diabetics develop?

Answer 96

Kidney problems

Question 97

What are 26% of people starting renal replacement therapy?

Answer 97

Diabetic

Question 98

Why is nephropathy important?

Answer 98

As the stage of diabetic nephropathy increases so does the % mortality rates per annum

Question 99

What are the 2 main features of diabetic nephropathy?

Answer 99

1. Proteinuria is hallmark | 2. Associated with retinopathy

Question 100

What is the chain reaction than hyperglycaemia causes in the kidney nephron?

Answer 100

Volume expansion --> Intra-glomerular hypetension --> Proteinuria --> Hypertension & renal failure

Question 101

List the 5 structural changes associated with the diabetic kidney glomerulus?

Answer 101

1. Thickening of the glomerular basement membrane 2. Fusion of foot processes 3. Loss of podocytes 4. Denuding of glomerular basement membrane 5. Mesangial matrix expansion

Question 102

List 4 kidney complications associated with diabetic kidney disease?

Answer 102

1. Anaemia 2. Bone & mineral metabolism 3. Retinopathy 4. Neuropathy

Question 103

What 2 things reduce the risk of diabetic nephropathy?

Answer 103

1. Tight glycaemic control | 2. Good BP control: ACEi/ARB/SGLT-2 inhibitors

Question 104

Describe the effect of diabetes on the kidney nephron?

Answer 104

- Afferent arteriole vasodilation - Efferent arteriole vasoconstriction - Increased intraglomerular pressure - Increased GFR - Increased glucose & sodium reabsorption - Increased glucose excretion in urine

Question 105

What affect do SGLT-2 inhibitors have on the diabetic kidney?

Answer 105

- Afferent arteriole vasoconstriction - Efferent arteriole unaffected - Decreased intraglomerular pressure & normalisation of GFR

Question 106

Give an example of an SGLT-2 inhibitors?

Answer 106

Empagliflozin

Question 107

What are the 3 main effects of SGLT-2 Inhibitors?

Answer 107

1. Glycosuria 2. Natriuresis 3. Cardiac & Renal protection

Question 108

What is crucial about diagnosing diabetic nephropathy?

Answer 108

If no protein in urine & no retinopathy then it isn't diabetic nephropathy

Question 109

Describe the diagnosis of renal artery stenosis?

Answer 109

- Clinical diagnosis - No angiogram/CT angiogram/MRI - Unlike narrowed coronary arteries, there is evidence that angioplasty/stenting is rarely effective in renal vessels

Question 110

Describe the 4 steps of pathogenesis of renovascular disease?

Answer 110

1. Progressive narrowing of renal arteries with atheroma 2. Perfusion falls 20%. GFR falls but tissue oxygenation of cortex & medulla maintained 3. RA stenosis progresses to 70%. Cortical hypoxia causes microvascular damage & activation of inflammatory & oxidative pathways 4. Parenchymal inflammation & fibrosis progress & become irrreversible. Restoration of blood flow provides no benefit

Question 111

Describe the medical management of renal artery stenosis?

Answer 111

- BP control (not ACEi/ARB) - Statin - If diabetic, good glycaemic control

Question 112

Describe the lifestyle management of renal artery stenosis?

Answer 112

- Smoking cessation - Exercise - Low sodium diet

Question 113

Describe the angioplasty management of renal artery stenosis?

Answer 113

- Rapidly deteriorating renal failure - Uncontrolled ↑BP on multiple agents - Flash pulmonary oedema

Question 114

List 6 differential diagnosis for nephrotic syndrome?

Answer 114

1. Various GNs (IgA, minimal change, membranous, FSGS) 2. Diabetic nephropathy 3. Lupus nephritis 4. Viral infections (HBV, HCV, HIV) 5. Amyloidosis 6. Myeloma

Question 115

List 3 investigations you would do for nephrotic syndrome?

Answer 115

1. Blood tests: glucose, ANA, HBV/HCV/HIV PCR 2. Protein electrophoresis/urinary Bence Jones proteins 3. Kidney biopsy

Question 116

What is amyloidosis?

Answer 116

Deposition of highly stable insoluble proteineous material in extracellular space (felt-like substance made of beta-pleated sheets) i.e. in the kidney, heart, liver gut

Question 117

Describe 2 features of amyloidosis?

Answer 117

1. Specific ultrastructural features (8-10nm fibrils) | 2. High affinity for the constituents of the capillary wall

Question 118

Describe the light microscopy of amyloidosis?

Answer 118

Congo red stain: Apple green birefringence

Question 119

Describe the electron microscopy of amyloidosis?

Answer 119

Amyloid fibrils 9-11nm cause mesangial expansion

Question 120

What are the 2 classes of amyloidosis?

Answer 120

1. AA = systemic amyloidosis (inflammation/infection) | 2. AL = immunoglobulin fragments from haematological condition eg myeloma

Question 121

Describe the treatment of AA amyloid?

Answer 121

Treat the underlying source of inflammation/infection

Question 122

Describe the treatment of AL amyloid?

Answer 122

Treat the underlying haematological condition

Question 123

What is glomerular disease?

Answer 123

Nephritic syndrome: AKI with blood and protein on dipstick

Question 124

List 4 differential diagnosis for nephritic syndrome?

Answer 124

1. Vasculitis: ANCA- associated 2. Vasculitis: anti-GBM disease 3. Vasculitis: lupus nephritis 4. IgA nephropathy (crescentic variety)

Question 125

What is systemic lupus erythematosis (SLE)?

Answer 125

Auto-immune disease: immune complex mediated glomerular disease, serious but treatable!

Question 126

Describe the pathophysiology of systemic lupus erythematosis (SLE)?

Answer 126

Multiple auto- antibodies directed against DNA, histones, snRNPs, transcriptional/translational machinery

Question 127

Describe the epidemiology of systemic lupus erythematosis (SLE)?

Answer 127

- Female>>male (2-12:1) - African > Asian > Caucasian - Genetic predisposition (12+ genes identified) & environmental trigger

Question 128

Describe the 4 stages of lupus nephritis pathophysiology?

Answer 128

1. Auto-antibodies produced against dsDNA or nucleosomes (anti-dsDNA, anti-histone) 2. Form intravascular immune complexes or attach to GBM 3. Activate complement (low C4) 4. Renal damage

Question 129

How do you confirm a diagnosis of systemic lupus erythematosis (SLE)?

Answer 129

Renal biopsy (stages the disease)

Question 130

What is the treatment for systemic lupus erythematosis (SLE)?

Answer 130

Immunosuppression: steroids/MMF/cyclophosphamide/rituximab

Question 131

What does renal involvement in systemic disease confer?

Answer 131

Worse prognosis

Question 132

What are the 5 clinical signs of cystitis (infection of the bladder)?

Answer 132

1. Dysuria 2. Frequency 3. Urgency 4. Suprapubic pain 5. Haematuria

Question 133

What are the 5 specific clinical signs of pyelonephritis (infection of the kidney)?

Answer 133

1. Fever (>38ºC) 2. Chills/rigors 3. Flank pain 4. Costo-vertebral angle tenderness 5. Nausea/vomiting

Question 134

List the 8 risk factors for a UTI?

Answer 134

1. Infancy: boys and girls under 1 year 2. Abnormal urinary tract: congenital or other abnormalities 3. Females 4. Bladder dysfunction/incomplete emptying 5. ‘Foreign' body 6. Diabetes mellitus 7. Renal transplant 8. Immunosuppression

Question 135

What 3 factors in females makes UTI's more common?

Answer 135

1. Anatomy 2. Sexual intercourse 3. Pregnancy

Question 136

What 3 factors in bladder dysfunction/incomplete emptying makes UTI's more common?

Answer 136

1. Constipation (‘dysfunctional elimination syndrome’) 2. Neurogenic bladder 3. Prostate enlargement in men

Question 137

What 2 "foreign" bodies can make UTI's more common?

Answer 137

1. Catheters | 2. Stones

Question 138

Why does diabetes mellitus make UTI's more common?

Answer 138

Glycosuria promotes bacterial growth

Question 139

Describe the gender shift with age associated with UTI's in childhood?

Answer 139

- Much more common in childhood for F > M - M > F within first 6 months - 50% of males present < 1 year - 80% of females present > 1 year

Question 140

What is the relevance of treating a UTI in childhood?

Answer 140

- Identifying structural abnormality | - Reducing risk of further damage

Question 141

Describe the structural abnormalities associated with UTI's in childhood?

Answer 141

- Congenital renal tract abnormality in up to 50% | - Vesico-Ureteric Reflux (VUR) in 30-40%

Question 142

What are the 3 consequences of UTI's in childhood?

Answer 142

1. Renal Scarring in 10 - 15% (irreversible) 2. Chronic Kidney Disease (CKD) 3. Hypertension risk increases with burden of scarring: 10-20%

Question 143

What are 5 "upper tract" UTI' symptoms?

Answer 143

1. Fever 2. Lethargy 3. General malaise 4. Vomiting 5. Loin pain

Question 144

What are 5 "lower tract" UTI symptoms?

Answer 144

1. Non specific abdo. pain 2. Urgency 3. Frequency 4. Wetting 5. Frank haematuria

Question 145

When are non-specific UTI symptoms more likely in children?

Answer 145

<2 years

Question 146

What signs are needed for a diagnosis of acute pyelonephritis/ upper urinary tract infection?

Answer 146

- Bacteriuria and fever > 38°C | - Bacteriuria, loin pain/tenderness and fever of less than 38°C

Question 147

What signs are needed for a diagnosis of cystitis/ lower urinary tract infection?

Answer 147

Bacteriuria and symptoms or signs of UTI that are not systemic

Question 148

What are 3 investigations used to diagnose urinary tract infections?

Answer 148

1. Multistix (leucocyte esterase + nitrite) 2. Microscopy/flow cytometry 3. Urine culture

Question 149

Describe the use of Multistix (leucocyte esterase + nitrite) for UTI diagnosis?

Answer 149

- Useful for child >3 years - Positive LE & nitrite → UTI in 90% - Negative for LE & nitrite → No UTI

Question 150

Describe the use of microscopy/flow cytometry for UTI diagnosis?

Answer 150

Flow cytometry negative for pus cells and bacteria → No UTI

Question 151

How would you culture urine in all children <3 years with clinical suspicion?

Answer 151

- Obtain urine before starting antibiotics | - “Clean catch”; supra pubic aspiration; catheter specimen

Question 152

What is the definition of a UTI on urine culture?

Answer 152

- Single organism => 105 CFU/ml (contamination risks) | - Any growth of single organism if SPA

Question 153

What are the 2 rules of UTI management?

Answer 153

1. Prompt identification | 2. Antibiotic treatment

Question 154

When would you teat urine in an infant or child?

Answer 154

Presenting with unexplained fever of 38ºC or higher OR | symptoms and signs suggestive of UTI

Question 155

Describe the antibiotic treatment for UTIs?

Answer 155

- “Best guess” while awaiting culture and sensitivities | - Oral antibiotic unless severely ill, vomiting, infant <3 months (in practice often < 6 months)

Question 156

What are the 2 types of IV antibiotic treatment for UTIs?

Answer 156

1. 3rd generation cephalosporin: Cefotaxime, Ceftriaxone | 2. Aminoglycoside: Gentamicin (monitor levels and renal function)

Question 157

What are the 5 oral antibiotics given to treat UTIs?

Answer 157

1. Co-amoxiclav 2. Nitrofurantoin 3. Trimethoprim 4. Cephalosporin 5. Quinolone

Question 158

Describe when you would image for UTI's in childhood?

Answer 158

- Age: < 6 months, 6 mo-3 years, > 3 years - Presentation: pyelonephritis v. cystitis - Infection: atypical or recurrent - Family history: Vesico-ureteric reflux - Imaging abnormalities found: ultrasound, nuclear medicine

Question 159

Describe when you would give antibiotic prophylaxis for UTIs in childhood?

Answer 159

- Not routinely in ‘simple’ UTI | - Consider for CAKUT

Question 160

What are 3 antibiotics which can be given prophylactically for UTIs in childhood?

Answer 160

1. Trimethoprim 2. Nitrofurantoin 3. Co-amoxiclav

Question 161

What are the 3 PROS of ultrasound imaging for UTIs?

Answer 161

1. Radiation free 2. Readily available 3. Good for filleted drainage tracts & cysts

Question 162

What are 2 CONS of ultrasound imaging for UTIs?

Answer 162

1. Operator dependent | 2. Less sensitive for scarring, parenchymal change

Question 163

What is the PRO for Micturating Cystourethrogram (MCUG) for UTIs?

Answer 163

Gold standard for VUR & PUV

Question 164

What are the 2 CONS for Micturating Cystourethrogram (MCUG) for UTIs?

Answer 164

1. Radiation | 2. Invasive: UTI risk

Question 165

What are the 3 types of nuclear medicine imaging scans for UTIs?

Answer 165

1. DMSA (static) 2. MAG3 indirect cystogram 3. MAG3 diuresis renogram

Question 166

What is the gold standard imaging for scars in UTIs?

Answer 166

DMSA (static) nuclear medicine scan

Question 167

What is the gold standard imaging for obstruction in UTIs?

Answer 167

MAG3 Diuresis venogram nuclear medicine scan

Question 168

What indicates renal fixed scarring on a Renal Isotope Imaging (DMSA scan)?

Answer 168

Poor uptake of isotope and irregular kidney outline

Question 169

What are 3 mechanisms of renal scarring?

Answer 169

1. Immunology 2. Genetics 3. Dysplasia

Question 170

What are 10 risk factors for renal scarring?

Answer 170

1. Age 2. High grade VUR 3. Anatomical obstruction 4. Dysfunctional voiding 5. Frequent episodes of APN 6. Therapeutic delay 7. Bacterial virulence factors 8. Host response 9. Low birth weight 10. Prenatal dysplasia

Question 171

What are 2 congenital abnormalities of kidney and urinary tract (CAKUT)?

Answer 171

1. Vesico-Ureteric Reflux (VUR) 2. Obstruction of urinary drainage tracts - Both may be associated with congenital renal dysplasia

Question 172

What 3 things are indicated on antenatal alerts- ultrasound?

Answer 172

1. Dilated drainage tract 2. Renal parenchyma: ‘bright kidneys’ 3. Oligohydramnios

Question 173

What are 3 post-natal confirmations for kidney injury?

Answer 173

1. Ultrasound 2. MCUG 3. NM studies: DMSA, MAG-3

Question 174

What is Vesico-ureteric reflux (VUR)?

Answer 174

Retrograde passage of urine from the bladder into the upper urinary tract

Question 175

Describe the prevalence of vesico-ureteric reflux (VUR)?

Answer 175

Most common urologic finding in children: - ~1 percent of newborns - 30-40% of young children with UTI

Question 176

Describe the 5 grades of Vesico-ureteric Reflux?

Answer 176

- Grade I: reflux into a non-dilated ureter only - Grade II: reflux into the renal pelvis & calyces without dilatation - Grade III: reflux into a mildly to moderately dilated ureter & renal pelvis with no or only slight blunting of fornices - Grade IV: moderate dilatation & tortuosity of the ureter & renal pelvis, with obliteration of the sharp angle of the fornices but maintenance of papillary impressions in most calyces - Grade V: gross dilatation & tortuosity of the ureter, renal pelvis, & calyces with loss of papillary impressions

Question 177

What does MCUG stand for?

Answer 177

Micturating cysto-urethrogram

Question 178

What does Bilateral vesico-ureteric reflux appear like on a MCUG?

Answer 178

- Dye refluxing into both ureters & renal pelvi-calyceal systems - Dye filled bladder

Question 179

Describe the presentation of Vesico-ureteric reflux (VUR)?

Answer 179

- Antenatal hydro-uretero-nephrosis | - UTI & Pyelonephritis: VUR in 30-40%

Question 180

Describe briefly the grading of vesico-ureteric reflux (VUR)?

Answer 180

- ‘Low grade’: I-II | - ‘High grade’: III-V

Question 181

Describe the association between vesico-ureteric reflux (VUR) and spontaneous resolution?

Answer 181

- 90% of low grade reflux | - 30-40% of high grade reflux

Question 182

What does a UTI + vesico-ureteric reflux (VUR) equal?

Answer 182

- 30% ‘renal scarring’ | - Much damage due to VUR is prenatal = dysplasia

Question 183

Describe the medical management of UTI + vesico-ureteric reflux (VUR)?

Answer 183

Antibiotic prophylaxis for high grade VUR (III-V) until toilet trained by day

Question 184

Describe the surgical management of UTI + vesico-ureteric reflux (VUR)?

Answer 184

- 'STING’ procedure: Submucosal Teflon INJection - Open ureteric re-implantation - Role of circumcision

Question 185

When would you consider surgical management for a UTI + vesico-ureteric reflux (VUR)?

Answer 185

‘Failed’ medical management: - Recurrent, proven febrile UTI - New scarring

Question 186

What are the 2 commonest complications of circumcision?

Answer 186

1. Haemorrhage | 2. Infection

Question 187

What are 5 potential renal areas of obstruction?

Answer 187

1. Pelvis/ureter (PUJ) 2. Ureter 3. Ureter/Bladder (VUJ) 4. Bladder 5. Urethra

Question 188

What are the 3 factors to defining an obstruction?

Answer 188

1. Identification of the level of obstruction 2. Severity 3. Duration

Question 189

What are the 3 types of bladder outlet obstruction?

Answer 189

1. Posterior Urethral Valve 2. Prostatic Hypertrophy 3. Functional obstruction

Question 190

What is Posterior Urethral Valve the commonest cause of?

Answer 190

Commonest congenital cause of bladder outlet obstruction in male infants

Question 191

What is prostatic hypertrophy the commonest cause of?

Answer 191

Commonest acquired cause of bladder outlet obstruction in world

Question 192

What are the 2 types of function bladder outlet obstruction?

Answer 192

1. Neurogenic Bladder: Spina Bifida, Sacral agenesis, Spinal Dysraphism, Transverse Myelitis, Trauma 2. Prune Belly Syndrome

Question 193

List the 4 presentations of posterior urethral valve obstruction?

Answer 193

1. Antenatal hydronephrosis 2. Urinary tract infection 3. Poor urinary stream 4. Renal dysfunction

Question 194

What are the 2 potential posterior urethral valve structures affected leading to obstruction?

Answer 194

Valve leaflets or circumferential diaphragm

Question 195

What are the 3 means of management for posterior urethral valve obstruction?

Answer 195

1. Valve resection 2. Antibiotic prophylaxis 3. CKD care

Question 196

What are the two % outcomes for posterior urethral valve obstruction?

Answer 196

1. Chronic Renal Failure: 7% | 2. Mortality: 7%

Question 197

Describe the presentation of Pelvi-ureteric junction obstruction?

Answer 197

- Commonest cause of hydronephrosis in children - Frequently noted on antenatal ultrasound - Abdominal mass, pain, haematuria, UTI

Question 198

Describe the presentation of Vesico-ureteric junction obstruction?

Answer 198

- Anatomical narrowing v. functional obstruction | - Antenatal dilatation, UTI, Abdominal mass, pain, haematuria

Question 199

Describe the observant management of Pelvi-ureteric junction obstruction?

Answer 199

- USS & DMSA | - MAG 3 diuresis renogram

Question 200

Describe the surgical management of Pelvi-ureteric junction obstruction?

Answer 200

Pyeloplasty

Question 201

Describe the observant management of Vesico-ureteric junction obstruction?

Answer 201

- 50%-90% improve or resolve - USS & DMSA - MAG 3 diuresis renogram

Question 202

Describe the surgical management of Vesico-ureteric junction obstruction?

Answer 202

- Temporary: stent insertion | - Definitive: resection & re-implantation

Question 203

When would you consider surgical management for Vesico-ureteric junction obstruction?

Answer 203

For symptoms or increasing dilatation up to 30% require surgery

Question 204

What are the 3 main consequences of renal scarring from pyelonephritis?

Answer 204

1. Hypertension 2. Chronic kidney disease 3. Mortality

Question 205

What is a cyst?

Answer 205

Sac like structure containing fluid

Question 206

Where do cysts arise in the kidneys?

Answer 206

Arise from the tubules

Question 207

How do cysts cause problems?

Answer 207

Compressing other structures, replacing useful tissue, becoming infected, bleeding, pain

Question 208

What is the inheritance of adult polycystic kidney disease?

Answer 208

Autosomal dominant

Question 209

Describe the prevalence of adult polycystic kidney disease (APKD)?

Answer 209

- Commonest inherited kidney disorder | - 5-10% of patients with end stage renal failure

Question 210

Describe the 2 mutations in adult polycystic kidney disease (APKD)?

Answer 210

- PKD 1 gene mutation (chromosome 16) = 85% (1270 mutations) | - PKD 2 gene mutation (chromosome 4) = 15% (200 mutations)

Question 211

What are polycystins?

Answer 211

Membrane proteins involved in intracellular calcium regulation

Question 212

What is overexpressed in cyst cells?

Answer 212

Polycystins

Question 213

Where are polycystins located?

Answer 213

In renal tubular epithelia (and liver and pancreas ducts)

Question 214

Describe the 4 natural history steps of adult polycystic kidney disease?

Answer 214

1. Cysts gradually enlarge 2. Kidney volume increases 3. Some compensation 4. eGFR falls, usually 10y before kidneys fail

Question 215

What are the 3 factors when diagnosing polycystic kidney disease via ultrasound?

Answer 215

1. Differentiate between ‘simple renal cysts’ 2. Family history: ultrasound at age 21 (if negative, should be repeated age 30 or will miss 14%) 3. No family history: 10 or more cysts in both kidneys, renal enlargement, liver cysts

Question 216

What imaging tests are more sensitive for polycystic kidney disease diagnosis?

Answer 216

CT or MRI better than ultrasound

Question 217

List the 2 adult polycystic kidney disease renal complications?

Answer 217

1. 50% risk ESRD by age 50y | 2. Cyst ‘accidents’ 60%

Question 218

List 7 other complications of adult polycystic kidney disease?

Answer 218

1. Hypertension 2. Intracranial aneurysms (3%) 3. Mitral valve prolapse 25% 4. Aortic incompetence 10% 5. Colonic diverticular disease 6. Liver / pancreas cysts 7. Hernias

Question 219

Describe the 5 factors to managing adult polycystic kidney disease?

Answer 219

1. Management is supportive 2. Early detection and management of blood pressure 3. Treat complications 4. Manage extra-renal associations 5. Renal replacement therapy

Question 220

What is Tolvaptan treatment for adult polycystic kidney disease?

Answer 220

Vasopressin V2 receptor antagonist

Question 221

List the 5 consequences of Tolvaptan treatment for adult polycystic kidney disease?

Answer 221

1. Delay onset of RRT by around 4-5 years 2. Heavy monitoring 3. Hepatotoxicity 4. Hypernatraemia 5. Very expensive

Question 222

What 2 situations do the Scottish medicines consortium (SMC) recommend the use of Tolvaptan treatment?

Answer 222

CKD3 & declining renal function

Question 223

List 4 other rare cystic diseases?

Answer 223

1. Von Hippel Lindau 2. Tuberous sclerosis 3. Medullary cystic disease 4. Autosomal recessive PKD

Question 224

Describe Von Hippel Lindau?

Answer 224

- Multiple benign and malignant tumours | - Autosomal dominant

Question 225

Describe Tuberous sclerosis?

Answer 225

- Multiple benign tumours brain, eyes, heart, kidney, skin - Epilepsy and learning difficulties - Autosomal dominant

Question 226

Describe Medullary cystic disease?

Answer 226

- Medulla not cortex, small to normal sized kidneys; gout | - Autosomal dominant

Question 227

Describe autosomal recessive PKD?

Answer 227

- Children | - Hepatic fibrosis

Question 228

Describe the inheritance of Alport's Syndrome?

Answer 228

Usually X-linked: if inherited, affected or carrier

Question 229

Describe the prevalence of Alport's Syndrome?

Answer 229

Second most common inherited kidney disease (1/5000 prevalence)

Question 230

Describe the 4 collagen abnormalities associated with Alport's syndrome?

Answer 230

- Alpha 3 gene mutation - Alpha 4 gene (COL3A4) mutation OR - Alpha 5 (COL3A5) gene mutation

Question 231

List the 2 signs of Alport's syndrome?

Answer 231

Deafness & renal failure (can affect other organs including eyes)

Question 232

Where is collagen 4 found?

Answer 232

Basement membranes

Question 233

Describe the abnormal glomerular basement membrane in Alport's syndrome?

Answer 233

- Initially thin | - Becomes split & laminated with many different layers

Question 234

List the 4 clinical consequences of Alport's syndrome?

Answer 234

1. Microscopic haematuria, proteinuria and end stage renal failure (ESRF) 2. 90% on dialysis or transplant by age 40y, 50% by age 25y 3. Sensorineural hearing loss late childhood 4. Female Alport’s carriers: 12% ESRF by age 40y

Question 235

Describe the inheritance of Fabry's disease?

Answer 235

Rare X-linked storage disorder

Question 236

Describe the abnormality in Fabry's disease?

Answer 236

- Alpha galactosidase A deficiency resulting in accumulation of globotriaosylceramide (Gb3 - Gb3 accumulates in glomeruli, particularly podocytes causing proteinuria and ESRF

Question 237

What are 3 other consequences of Gb3 accumulating in the glomeruli?

Answer 237

1. Neuropathy 2. Cardiac 3. Skin features (Angiokeratoma)

Question 238

How do you diagnose Fabry's disease?

Answer 238

- Measure alpha-Gal A activity in leukocytes | - Renal biopsy: inclusion bodies of G3b

Question 239

How do you manage Fabry's disease?

Answer 239

Enzyme replacement therapy

Question 240

What do dialysed patients have a 5% risk of?

Answer 240

End stage renal failure

Question 241

Why does acute kidney injury confer an additional mortality?

Answer 241

Due to sepsis, bleeding, respiratory failure etc

Question 242

What is the definition of acute kidney injury (severity)?

Answer 242

- No agreed definitions | - “Decline of renal excretory function over hours or days …recognized by the rise in serum urea and creatinine”

Question 243

What is AKI e-alerts?

Answer 243

Uses an algorithm to highlight when creatinine changed to indicate patient has AKI

Question 244

What are the 3 scenarios when an AKI e-alert would go off?

Answer 244

1. Serum creatinine ≥1.5 times higher than the median of all creatinine values 8–365 days ago 2. Serum creatinine ≥1.5 times higher than the lowest creatinine within 7 days 3. Serum creatinine >26 µmol/L higher than the lowest creatinine within 48 h

Question 245

What is the KDIGO definition of stage 1 acute kidney injury?

Answer 245

Serum creatinine ≥1.5 and < 2.0 times AKI baseline or >=26.0 µmol/l increase above AKI baseline

Question 246

What is the KDIGO definition of stage 2 acute kidney injury?

Answer 246

Serum creatinine >=2.0 and < 3.0 times AKI baseline

Question 247

What is the KDIGO definition of stage 3 acute kidney injury?

Answer 247

Serum creatinine 3.0 times AKI baseline or >=354 µmol/l increase above AKI baseline

Question 248

What are the 3 classifications for acute renal failure?

Answer 248

1. Pre-renal= circulatory failure "shock" 2. Renal= the cells of the kidney 3. Post Renal= Obstruction

Question 249

What are the 3 types of renal (intrinsic) disease?

Answer 249

1. Glomerular: glomerulonephritis 2. Tubular (obsruction & dysfunction): ischaemic cute tubular necrosis, nephrotoxic cute tubular necrosis, myeloma cast nephropathy 3. Tubulointerstitial: drugs, myeloma sarcoid

Question 250

What are 4 types of pre-renal (reduced renal perfusion) diseases?

Answer 250

1. Hypovolaemia & hypotension: diarrhoea/vomiting/burns, inadequate fluid intake, blood loss through trauma 2. Reduced effective circulating volume: cardiac failure, septic shock, cirrhosis 3. Drugs: ACE1, NSAIDS 4. Renal artery stenosis

Question 251

What are 6 types of post-renal diseases?

Answer 251

1. Renal papillary necrosis 2. Kidney stones (at any level) 3. Retroperitoneal fibrosis 4. Carcinoma of the cervix 5. Prostatic hypertrophy/malignancy 6. Urethral strictures

Question 252

What are the 2 key facts of the kidneys?

Answer 252

1. Kidneys need a blood supply to make urine | 2. And need an unobstructed collecting system to ensure that urine can be excrete

Question 253

What are all post renal causes of kidney disease?

Answer 253

Obstructive- Anything between renal pelvis and urethral meatus which obstructs flow of urine

Question 254

What are the 4 broad categories of intrinsic acute kidney injury?

Answer 254

1. Large blood vessels 2. Small blood vessels & glomeruli 3. Tubulointerstitium 4. Acute tubular necrosis (ischaemic/toxic)

Question 255

What are the 3 most common causes of intrinsic acute kidney injury?

Answer 255

1. Acute tubular necrosis- 80% 2. Obstructive- 10% 3. Glomerulonephritis (primary & secondary)- 3%

Question 256

What drug specifically can cause renal acute kidney injury?

Answer 256

Gentamicin

Question 257

Give 1 example of a glomeruli (vasculitis) cause of acute kidney injury?

Answer 257

Glomerulonephritis

Question 258

Give 2 examples of a tubular cause of acute kidney injury?

Answer 258

1. Tubulo-interstitial nephritis | 2. Rhabdomyolysis

Question 259

What is Acute tubular necrosis generally?

Answer 259

Any pre-renal cause of AKI if severe/of sufficent duration

Question 260

Describe the prognosis of Acute tubular necrosis?

Answer 260

- Usually reversible - ~10-15% will never recover renal function - A further 10-15% will have chronic renal impairment

Question 261

What is Acute tubular necrosis always due to?

Answer 261

Under perfusion of the tubules and/or direct toxicity

Question 262

Give 4 examples of acute tubular necrosis causes?

Answer 262

1. Hypotension 2. Sepsis 3. Toxins 4. Or often, all three

Question 263

List 3 exogenous toxins which can cause acute tubular necrosis?

Answer 263

1. Drugs (eg, NSAID’s gentamicin,ACEinh) 2. Contrast 3. Poisons (eg, metals, antifreeze)

Question 264

List 5 endogenous toxins which can cause acute tubular necrosis?

Answer 264

1. Myoglobin 2. Haemoglobin 3. Immunoglobins 4. Calcium 5. Urate

Question 265

What happens to the glomerular filtration as pressure falls?

Answer 265

Prostaglandins dilate afferent arteriole to increase flow as MAP falls towards 80mmHg

Question 266

What are the 5 things to target when managing acute kidney injury?

Answer 266

1. Acute or chronic? 2. Bloods: both urea and creatinine ↑ 3. Potassium (biggest thing to kill the patient) 4. Urine output (usually <400ml/day) 5. Clinical assessment of fluid status (BP, JVP, oedema, heart sounds) 6. Underlying diagnosis (history, exam, meds)

Question 267

What are the 6 steps to treatment of acute kidney injury?

Answer 267

1. Immediate 2. Airway & breathing 3. Circulation: shock- restore renal perfusion 4. Remove causes: drugs, sepsis 5. Exclude obstruction & consider ‘renal’ causes 6. Ask for help: ICU or renal unit

Question 268

What are the 7 steps in the diagnostic process of acute kidney injury?

Answer 268

1. AKI or CKD? 2. History and exam (e.g. septic, rashes, haemoptysis, rhabomyolysis etc) 3. Drugs (prescribed, OTC, supplements, radio-contrast and abuse) 4. Urinalysis 5. Renal ultrasound 6. ‘GN’ screen: ANCA, ANA, Immunoglobulins + EP, complement, aGBM, Urine Bence Jones protein 7. Others blood film, LDH, CK etc

Question 269

How do you exclude obstruction in kidney disease?

Answer 269

Renal ultrasound

Question 270

What does renal ultrasound give information on?

Answer 270

- Size (chronic kidney disease has small kidneys) | - Loss of cortico-medullary differentiation suggests CKD

Question 271

What can be apart on an ECG of someone with renal disease?

Answer 271

Tachycardia due to hyperkalaemia

Question 272

What is the immediate problem with acute kidney injury

Answer 272

Abnormal potassium levels

Question 273

What is a potassium (K) of <6.0?

Answer 273

Abnormal but no immediate concern

Question 274

What is a potassium (K) of 6.0-6.4?

Answer 274

Risk of arrhythmia: needs treatment esp if ECG changes

Question 275

What level of potassium is a medical emergency?

Answer 275

K>6.5

Question 276

What are the 3 ways of treating hyperkalaemia?

Answer 276

1. Reduce absorption from gut: Calcium Resonium 15g 4x day orally (or enema) 2. Insulin 10-15units actrapid+ 50ml 50% dextrose moves potassium into cells (watch Blood Glucose) 3. Calcium gluconate 10ml 10% as cardiac membrane stabiliser

Question 277

When is it worth a bicarbonate supplementation for acute kidney injury?

Answer 277

If raised potassium and HCO3 <16

Question 278

What type of Bicarbonate supplementation would you give for acidosis in acute kidney injury?

Answer 278

NaBicarb 1.26% intravenously

Question 279

What are the 2 absolute indications for dialysis?

Answer 279

1. Refractory potassium ≥6.5 mmol/l | 2. Refractory pulmonary oedema

Question 280

What are 3 relative indications for dialysis?

Answer 280

1. Acidosis (pH <7.1) 2. Uraemia (esp if urea >40): pericarditis, encephalopathy 3. Toxins (lithium, ethylene glycol etc)

Question 281

Describe the outcomes for acute kidney injury?

Answer 281

- 85% return to baseline kidney function - 10% are left with some renal impairment - 5% do not recover kidney function i.e. need long term dialysis or transplant

Question 282

Describe the recovery from an acute tubular necrosis?

Answer 282

- May be up to 6L urine/day - Often subsequent low K, Ca, Mg as ‘low quality urine - Tubules fail to concentrate urine

Question 283

How long is the polyuric phase in acute tubular necrosis recovery?

Answer 283

48-72hr

Question 284

What is the definition of chronic kidney disease?

Answer 284

Kidney damage or GFR<60ml/min per 1.73m2 for 3 months or more

Question 285

What os serum creatinine a product of?

Answer 285

Muscle metabolism

Question 286

Describe Creatinine & Creatinine Clearance?

Answer 286

- Fairly constant production and constant serum levels - 24h urine creatinine clearance – often inaccurate - Freely filtered but tubular secretion

Question 287

What 2 things does the exponential relationship between serum creatinine and GFR lead to?

Answer 287

1. Slow recognition of loss of the first 70% of renal function ie LAG TIME 2. Surprise at the sudden rise in creatinine with late renal referral

Question 288

What 3 things does the effect of muscle mass on serum creatinine lead to?

Answer 288

1. Overestimation of function in women 2. Overestimation of function in the elderly 3. Overestimation in other low muscle mass groups e.g. amputees, para/quadriplegics, rheumatoid arthritis

Question 289

What are the 6 problems with eGFR?

Answer 289

1. Only validated in whites and African-Americans 2. Mean age 50: not validated in elderly 3. Values above 60ml/min not distinguishable so reported as eGFR >59ml/min 4. Drug dosing: doesn’t take weight into account 5. AKI: not valid 6. Pregnancy

Question 290

Describe the stage 1 classification of kidney failure?

Answer 290

- eGFR: >90 ml/min/1.73m2 | - Normal or increased eGFR, with other evidence of kidney damage

Question 291

Describe the stage 2 classification of kidney failure?

Answer 291

- eGFR: 60-89 ml/min/1.73m2 | - Slight decrease in eGFR, with other evidence of kidney damage

Question 292

Describe the stage 3a classification of kidney failure?

Answer 292

- eGFR: 45-59 ml/min/1.73m2 | - Moderate decrease in eGFR

Question 293

Describe the stage 3b classification of kidney failure?

Answer 293

- eGFR: 30-44 ml/min/1.73m2 | - Moderate decrease in eGFR

Question 294

Describe the stage 4 classification of kidney failure?

Answer 294

- eGFR: 15-29 ml/min/1.73m2 | - Severe decrease in eGFR

Question 295

Describe the stage 5 classification of kidney failure?

Answer 295

- eGFR: <15 ml/min/1.73m2 | - Established renal failure

Question 296

What could stage 1&2 kidney damage be?

Answer 296

- Structural: APKD, pyelonephritis, OR | - Urine abnormality: proteinuria, haematuria

Question 297

How much protein in the urine is seen as being normal?

Answer 297

<150mg/day

Question 298

How much of proteinuria is albumin?

Answer 298

2/3rds

Question 299

How can you test for albumin in urine?

Answer 299

Dipstick (not very accurate)

Question 300

What are 3 situations of proteinuria?

Answer 300

1. Fever 2. Exercise 3. Normal

Question 301

What are 2 more accurate measurements of proteinuria?

Answer 301

1. 24h collection gold standard but not used now in routine practice 2. PCR and ACR useful and correlate with 24h

Question 302

What is a normal ACR?

Answer 302

<2.5

Question 303

What is a normal PCR?

Answer 303

<20

Question 304

What ACR indicates albuminuria?

Answer 304

>30

Question 305

What PCR indicates nephrotic range proteinuria?

Answer 305

> 300 (3g/24hr)

Question 306

What should you do if heavy albuminuria?

Answer 306

Use PCR to follow progress

Question 307

What are the 6 aetiologies of chronic kidney disease?

Answer 307

1. Diabetic nephropathy (nodular lesions) 2. Renovascular disease/ischaemic nephropathy 3. Chronic glomerulonephritis (membranous/IgA nephropahthy) 4. Reflux nephropathy/chronic pyelonephritis 5. ADPKD 6. Obstructive uropathy

Question 308

List 8 symptoms of advanced chronic kidney disease?

Answer 308

1. Pruritus 2. Nausea, anorexia, weight loss 3. Fatigue 4. Leg swelling 5. Breathlessness 6. Nocturia 7. Joint/bone pain 8. Confusion

Question 309

List the 7 signs of advanced chronic kidney disease?

Answer 309

1. Peripheral and pulmonary oedema 2. Pericardial rub 3. Rash/excoriation 4. Hypertension 5. Tachypnoea 6. Cachexia 7. Pallor &/or lemon yellow tinge

Question 310

What are the 5 general principles for chronic kidney disease management?

Answer 310

1. Targeted screening 2. Slow the rate of progression & reduce cardiovascular risk 3. Replace impaired individual functions of the kidney 4. Advanced planning for future renal replacement therapy (RRT) 5. Renal replacement therapy

Question 311

What are 6 ways to slow the progression of chronic kidney disease?

Answer 311

1. Aggressive BP control 2. Good diabetic control 3. Diet 4. Smoking cessation 5. Lowering cholesterol 6. Treat acidosis

Question 312

What are the drugs of choice for hypertension in chronic kidney disease?

Answer 312

ACE-I/ARB if BP lowering will reduce rate of progression

Question 313

What does ACE-I/ARB do to the kidney nephron?

Answer 313

Decreases perfusion pressure therefore decreasing BP

Question 314

What reduction in eGFR with ACEI/ARB is good?

Answer 314

Upto 25% in first few weeks

Question 315

When will you get more of a reduction in eGFR using ACEI/ARB in chronic kidney disease?

Answer 315

If critically reduced renal perfusion (volume depletion, sepsis, RAS)

Question 316

What makes anaemia especially common in chronic kidney disease?

Answer 316

eGFR <30

Question 317

Describe why anaemia is prevalent in chronic kidney disease?

Answer 317

Iron absorption & utilisation suboptimal

Question 318

What is the triggered haemoglobin for anaemia in chronic kidney disease?

Answer 318

<100 g/l

Question 319

What is the target haemoglobin for anaemia in chronic kidney disease?

Answer 319

100-120g/l

Question 320

Why is anaemia bad in chronic kidney disease?

Answer 320

Higher associated with adverse CV events

Question 321

Describe the treatment/management of anaemia in chronic kidney disease?

Answer 321

- Replace iron, B12, folate first if low | - ESA eg Darbepoietin alfa 30microg every 2 weeks

Question 322

Describe the pathophysiology of secondary hyperparathyroidism?

Answer 322

Increased PTH leads to bone disease & chronic kidney disease which then leads to a decrease in calcium causing more PTH to be released by the parathyroid

Question 323

List the 5 treatments for Chronic Kidney Disease–Mineral and Bone Disorder (CKD–MBD)?

Answer 323

1. Activated vitamin D : Alfacalcidol 2. Occasionally Magnesium supplements 3. Phosphate binders: target phosphate 0.9-1.5 mmol/l 4. Calcimimetic: cinacalcet 5. Parathyroidectomy

Question 324

What are 2 calcium based phosphate binders?

Answer 324

Calcium carbonate/acetate

Question 325

What are 3 non-calcium phosphate binders?

Answer 325

1. Sevelamer 2. Lanthanum 3. Aluminium

Question 326

What are the 4 managements for renal replacement therapy?

Answer 326

1. Conservative care 2. Transplant 3. Hospital Based Therapies: haemodialysis, self care unit 4. Home Based Therapies: haemodialysis, peritoneal dialysis

Question 327

What are 6 times that you would start dialysis?

Answer 327

1. Individual approach based on symptoms 2. Most start with eGFR 6-8ml/min 3. Weight loss and persistent nausea 4. Peristent hyperkalaemia, acidosis, severe hyper-phosphataemia or pruritis 5. Problematic fluid overload

Question 328

What is the best time for starting dialysis?

Answer 328

- No benefit to early start | - Best to have permanent access

Question 329

List the 4 hormonal functions of the kidney?

Answer 329

1. Mineral Metabolism 2. Production of Renin 3. Production of EPO 4. Glucose Metabolism

Question 330

List the 4 "water & waste" functions of the kidney?

Answer 330

1. Regulation of total body water 2. Waste excretion e.g. Urea/Creatinine 3. Regulation of body electrolytes 4. Regulation of acid-base balance

Question 331

List 5 indications for when to start renal replacement therapy?

Answer 331

1. Medically resistant hyperkalaemia 2. Medically resistant pulmonary oedema 3. Medically resistant acidosis 4. Uraemic pericarditis 5. Uraemic encephalopathy

Question 332

List the 6 clinical signs of uraemia?

Answer 332

1. Metallic taste 2. Weight loss 3. Restless legs 4. Itch 5. Vomiting 6. Anorexia

Question 333

What is the level of GFR that you'd start renal replacement therapy?

Answer 333

- No absolute rule - Generally between 5-10ml/min/1.73m2 - Assessed on an individual patient basis

Question 334

List the 3 renal replacement modalities?

Answer 334

1. Haemodialysis- hospital/home 2. Peritoneal dialysis- CAPD APD, daily nocturnal 3. Renal transplant- cadaveric living

Question 335

What are the 2 aims of haemodialysis?

Answer 335

1. Removal of solutes- potassium, urea: DIFFUSION | 2. Removal of fluid: CONVECTION (osmotic pressure)

Question 336

Describe the mechanisms by which haemodialysis replaces the functions of the kidney?

Answer 336

Blood in --> blood out --> diffusion removes solutes --> filtration removes fluid --> dialysate discarded

Question 337

What does haemodialysis involve?

Answer 337

Diffusion & filtration

Question 338

What does haemofiltration involve?

Answer 338

Convection

Question 339

What drug is added to the haemodialysis machine?

Answer 339

Heparin

Question 340

What are the 2 places to get haemodialysis access?

Answer 340

1. Tunneled cuffed venous catheter (TCVC)- catheter goes into the right atrium of the heart 2. Atriovenous fistula (AVF) access- surgeon connects an artery to a vein, usually in your arm, to make vessel strong enough for dialysis needle

Question 341

What are the two ways to receive haemodialysis?

Answer 341

Hospital or home based, hospital is much more common

Question 342

List the 4 possible durations for haemodialysis treatment?

Answer 342

- Standard: 4h, 3 times a week - 6h 3 times a week - Short daily dialysis - Daily overnight

Question 343

What are the PROS & CONS for home based haemodialysis?

Answer 343

- PROS: greater flexibility and empowerment | - CONS: need carer, space and capital investment

Question 344

List the 8 haemodialysis complications?

Answer 344

1. ‘Crash’ (acute hypotension) 2. Access problems 3. Cramps 4. Fatigue 5. Hypokalaemia 6. Blood loss 7. Dialysis disequilibrium 8. Air embolism

Question 345

Describe peritoneal dialysis?

Answer 345

A cleansing fluid flows through a tube (catheter) into abdomen & filters waste products from your blood. After a prescribed period of time, the fluid with filtered waste products flows out abdomen and is discarded

Question 346

What are the 2 different types of peritoneal dialysis?

Answer 346

1. Continuous Ambulatory Peritoneal Dialysis (CAPD) | 2. Automated Peritoneal Dialysis (APD)

Question 347

Describe Continuous Ambulatory Peritoneal Dialysis (CAPD)?

Answer 347

- Machine-free & done while you go about your normal activities - You do the treatment by placing about two quarts of cleansing fluid into your belly and later draining it - This is done by hooking up a plastic bag of cleansing fluid to the tube in your belly - Raising the plastic bag to shoulder level causes gravity to pull the fluid into your belly - When empty, the plastic bag is removed and thrown away

Question 348

How does Automated Peritoneal Dialysis (APD) differ from Continuous Ambulatory Peritoneal Dialysis (CAPD)?

Answer 348

- Machine (cycler) delivers and then drains the cleansing fluid for you - The treatment usually is done at night while you sleep.

Question 349

List the 7 practicality of peritoneal dialysis?

Answer 349

1. Home based therapy 2. Better with some residual renal function 3. Different glucose concentrations of dialysate to provide more or less ultrafiltration 4. Dialysate contains other electrolytes like in HD 5. Gradual treatment- no good for AKI 6. Simple procedure once taught 7. Maintain independence

Question 350

List the 6 complications of peritoneal dialysis?

Answer 350

1. Infection- peritonitis 2. Glucose load- development or worsening control of diabetes 3. Mechanical- hernia, diaphragmatic leak, dislodged catheter 4. Peritoneal membrane failure 5. Hypoalbuminaemia 6. Encapsulating peritoneal sclerosis

Question 351

List the 4 types of patients that are not suitable for peritoneal dialysis?

Answer 351

1. Grossly obese 2. Intra-abdominal adhesions 3. Frail 4. Home not suitable

Question 352

Describe conservative care for kidney disease?

Answer 352

- Increasingly frail and elderly population - Recognition that survival may be slightly better on RRT but quality may not - Symptom based management

Question 353

What are the 6 renal replacement modalities of choice considerations?

Answer 353

1. Lifestyle 2. Frailty 3. Vascular access 4. Time- travel to and from hospital 5. Carer 6. Physical- concurrent medical problems e.g. disseminated malignancy, severe dementia, severe psychiatric disease

Question 354

List 4 problems which are not helped by dialysis?

Answer 354

1. Anaemia- need erythropoesis supplementing agents and iron 2. Renal bone disease- need phosphate binders and vitamin D 3. Neuropathy 4. Endocrine disturbances

Question 355

Dialysis only gives around ______ eGFR, not as good as transplant?

Answer 355

10ml/min

Question 356

What are the 2 transplantation practicalities?

Answer 356

1. Cadaveric waiting list- Kidney after brainstem/cardiac death 2. Not all patients suitable for transplant

Question 357

What is the average wait on the kidney transplant list?

Answer 357

3 years

Question 358

List the 5 PROS of transplantation?

Answer 358

1. No dialysis 2. Better level of renal function 3. Can live much more independently 4. Better life expectancy 5. Fertility better

Question 359

List the 5 CONS of transplantation?

Answer 359

1. Immunosuppressive medication for duration of transplant 2. Increased cardiovascular risk 3. Increased infection 4. Post transplant diabetes 5. Skin malignancies and others

Question 360

What 2 things does peritoneal dialysis involve?

Answer 360

Diffusion & osmosis

Question 361

What is the definition of an upper urinary tract infection?

Answer 361

- Pyelonephritis | - Renal abscess

Question 362

What is the definition of an uncomplicated UTI?

Answer 362

- Lower UTI | - Normal structure & neurology

Question 363

What is the definition of a complicated UTI?

Answer 363

- Upper UTI +/- systemic signs and symptoms | - Catheter associated UTI

Question 364

What is the definition of relapse?

Answer 364

Infection with the same organism

Question 365

What is the definition of recurrent infection?

Answer 365

Infection with same or different organism

Question 366

What is the definition of urosepsis, complicated UTI?

Answer 366

- Temp >38ºC - HR>90/min - RR>20/min - WBC >15.0 or <4.0

Question 367

List 6 at risk groups for bacteriruia?

Answer 367

1. Females 2. Hospitalised 3. Catheterised 4. Diabetics 5. Anatomical abnormalities 6. Pregnant patients

Question 368

What are the 4 situations that you would treat asymptomatic bacteriuria?

Answer 368

1. Preschool children 2. Pregnancy 3. Renal transplant 4. Immunocompromised

Question 369

Describe ascending urinary tract infections?

Answer 369

- Urethral colonisation - Female>male - Multiplication in bladder - Ureteric involvement

Question 370

Describe descending/haematogenous urinary tract infections?

Answer 370

- Blood-born infections | - Involvement of renal parenchyma

Question 371

What are >95% of urinary tract infections cause by?

Answer 371

Single organism

Question 372

What are 3 types of UTI's that have multiple organisms?

Answer 372

1. Long term catheters 2. Recurrent infection 3. Structural/ neurological abnormalities

Question 373

What are 4 types of UTI's that have multi-drug resistant organisms?

Answer 373

1. Anatomical/neurological abnormalities 2. Frequent infections 3. Multiple antibiotic courses 4. Prophylactic antibiotic use

Question 374

List the 7 clinical features of UTI's?

Answer 374

1. Suprapubic discomfort 2. Dysuria 3. Urgency 4. Frequency 5. Cloudy, blood stained, smelly urine 6. Low-grade fever 7. Sepsis

Question 375

List the 2 special clinical features of UTI's in neonates?

Answer 375

1. Failure to thrive | 2. Jaundice

Question 376

List the 2 special clinical features of UTI's in children?

Answer 376

1. Abdominal pain | 2. Vomiting

Question 377

List the 3 speical clinical features of UTI's in the elderly?

Answer 377

1. Nocturia 2. Incontinence 3. Confusion

Question 378

List the 4 common gram negative bacilli organisms causing UTI's?

Answer 378

1. E.coli 2. Klebsiella sp. 3. Proteus sp. 4. Pesudomonas sp.

Question 379

List the 4 common gram positive bacteria causing UTI's?

Answer 379

1. Streptococcus sp. - Enterococcus sp., S. agalactiae (Group B streptococcus) 2. Staphylococcus sp. (S.saprophyticus, S.aureus) 3. Anaerobes 4. Candida sp.

Question 380

Describe the investigations for the 1st presentation of uncomplicated UTI's in non-pregnant women?

Answer 380

- Culture not mandatory - Dipstick, high false positive rate - Check previous culture results - Antibiotic 3-7/7

Question 381

List the 2 investigations for an uncomplicated UTI in non-pregnant women with no response to treatment?

Answer 381

1. Urine culture | 2. Change antibiotic

Question 382

Describe the investigations for children and men with uncomplicated UTI's?

Answer 382

- Send urine for each and every presentation | - Treat appropriately

Question 383

Describe the treatment for UTI's in pregnancy (common)?

Answer 383

- Treat for 7-10 days - Amoxicillin and cefalexin relatively safe - Avoid Trimethoprim in 1st trimester - Avoid Nitrofurantoin near term

Question 384

What treatment may be needed in severe UTI's during pregnancy?

Answer 384

May need hospital admission for IVs

Question 385

What may a UTI in pregnancy develop into?

Answer 385

Pyelonephritis (~30%)

Question 386

What is the definition of a recurrent UTI?

Answer 386

- ≥2 episodes in six months | - ≥3 episodes/year

Question 387

What is the recommended for a recurrent UTI?

Answer 387

- Send sample with each episode - Hydration - Urge initiated & post coital voiding - Intravaginal/oral oestrogen - Urology investigation

Question 388

Describe the treatment for recurrent UTI's?

Answer 388

- Self administered single dose/short course therapy - Single dose post coital antibiotics - Prophylactic antibiotics

Question 389

What 2 antibiotics can be used prophylactically for recurrent UTI's?

Answer 389

1. Trimethoprim | 2. Nitrofurantoin

Question 390

What is the risk of prophylactic antibiotics for recurrent UTIs?

Answer 390

- Antimicrobial resistance | - Increasing prevalence of Carbapenem Resistant Organisms (CRO)s-Meropenem (R)

Question 391

What is common in catheter associated UTI (CAUTI)?

Answer 391

Colonisation, treatment is not required

Question 392

Describe catheter associated UTI (CAUTI)?

Answer 392

- HAI: 35% - Disturbance of the flushing system - Colonisation of the urinary catheter - Biofilm production by bacteria

Question 393

What are the 2 likely types of organisms for catheter associated UTI (CAUTI)?

Answer 393

- HAI: 35% | - Patient’s flora

Question 394

List the 5 complications of catheters?

Answer 394

1. CAUTI 2. Obstruction-hydronephrosis 3. Chronic renal inflammation 4. Urinary tract stones 5. Long term risk of bladder cancer

Question 395

What are 5 ways to prevent catheter infections?

Answer 395

1, Catheterise only if necessary 2. Remove when no longer needed 3. Remove/replace if causing infection 4. Catheter care (bundles) 5. Hand hygiene

Question 396

What are the 4 steps to treatment of catheter related UTI?

Answer 396

1. Check recent /previous microbiology 2. Start empirical antibiotics 3. Remove catheter if not needed 4. Replace catheter under antibiotic cover

Question 397

What type of antibiotics would you give for catheter related UTI?

Answer 397

- Gentamicin/ Ciprofloxacin | - May need to use broad spectrum antibiotics

Question 398

Describe acute pyelonephritis?

Answer 398

- Moderate to severe infection - Ascending infection involving pelvis of kidney - Enlarged kidney - Abscesses on surface of kidney

Question 399

What are the 2 steps to managing acute pyelonephritis?

Answer 399

1. Check previous/recent microbiology results | 2. Send urine +/- blood culture+/- imaging

Question 400

What are 3 reasons why acute pyelonephirits management may be limited?

Answer 400

1. Allergy 2. Drug interaction 3. Antimicrobial resistance

Question 401

What are 3 antibiotics given for community acute pyelonephritis?

Answer 401

1. Co-amoxiclav 2. Ciprofloxacin 3. Trimethoprim

Question 402

What type of antibiotvs are given for hospital acute pyelonephritis?

Answer 402

Often broad spectrum antibiotics

Question 403

What is the treatment for uncomplicated pyelonephritis?

Answer 403

7-14/7 antibiotic

Question 404

What is the treatment for complicated pyelonephritis?

Answer 404

≥ 14/7 therapy +/- radiological/surgical intervention

Question 405

What can be a complication of pyelonephritis?

Answer 405

Renal abscess

Question 406

Describe a renal abscess?

Answer 406

- Similar symptoms to pyelonephritis - Usually positive urine and blood culture - Can become life-threatening - Poor response to antibiotics

Question 407

What type of organism is likely to cause a renal abscess?

Answer 407

Gram negative bacilli

Question 408

What are 3 ways that a renal abscess can become life threatening?

Answer 408

- Emphysematous pyelonephritis - Urgent urology review - High mortality rate

Question 409

What are 3 risk factors for perinepric abscess (uncommon)?

Answer 409

1. Untreated LUTI, anatomical abnormalities 2. Renal calculi 3. Bacteraemia, haematogenous spread

Question 410

List 3 types of common organisms causing a perinephric abscess?

Answer 410

1. Gram negative bacilli- E.coli, Proteus sp. 2. Gram positive cocci- S.aureus, Streptococci 3. Candida sp.

Question 411

Describe the symptoms of a perinephric abscess?

Answer 411

- Similar to pyelonephritis - Localised signs/symptoms - Pyuria +/- bacterial growth

Question 412

What type of cultures are perinephric abscesses usually?

Answer 412

Positive blood cultures

Question 413

How do you treat a perinephric abscess?

Answer 413

- Empirically as complicated UTI - Poor response to antibiotic therapy - Surgical management

Question 414

List the 6 management techniques of complicated UTI's?

Answer 414

1. FBC, U+Es, CRP 2. Urine sample- Urethral, CSU, Suprapubic, Nephrostomy 3. Blood culture if pyrexia or hypothermic 4. Renal ultrasound 5. CT KUB 6. Antibiotic therapy14/7 or more

Question 415

What are 2 ways to tell a urine microscopy has been contaminated?

Answer 415

1. Epithelial cells | 2. Bacteria with no WBC

Question 416

What urine microscopy interpretation means there is an infection?

Answer 416

Bacteria with WBC and no catheter

Question 417

What urine microscopy interpretation means you should assess it further clinically?

Answer 417

Bacteria with WBC + catheter

Question 418

What are 5 reasons as to why someone would have pyuria with no bacteria?

Answer 418

1. Previous/recent antibiotic 2. Tumour 3. Calculi 4. Urethritis (check for Chlamydia) 5. Tuberculosis

Question 419

List the 5 possible oral antibiotics that you would give for an uncomplicated UTI?

Answer 419

1. Amoxicillin 2. Trimethoprim 3. Nitrofurantoin 4. Pivmecillinam 5. Fosfomycin

Question 420

List the 5 possible IV antibiotics that you would give for a complicated UTI?

Answer 420

1. Amoxicillin 2. Vancomycin 3. Gentamicin 4. Aztreonam 5. Temocillin

Question 421

Give 2 examples of resistance organisms causing complicated UTI's?

Answer 421

1. ESBL | 2. Amp C

Question 422

Describe the antibiotic guidelines for complicated UTI's?

Answer 422

- Contraindications, e.g. renal failure - Drug monitoring may be needed, e.g. Gentamicin - Do not omit an antibiotic without finding an alternative

Question 423

What is amoxicillin effective for?

Answer 423

Some Gram negatives (~ 25%)- Streptococci

Question 424

What is co-amoxiclav effective for?

Answer 424

Good Gram negative cover- Streptococci, Anaerobes

Question 425

What is ciprofloxacin effective for?

Answer 425

- Gram negatives including Pseudomonas sp. | - Poor Gram positive cover

Question 426

What is Trimethoprim & Cefalexin effective for?

Answer 426

Gram positive and Gram negatives (except Pseudomonas sp.)- uncomplicated UTI

Question 427

What is Gentamicin effective for?

Answer 427

Gram negatives (inc. Pseudomonas sp.) & most Staphylococci, no streptococcal cover

Question 428

What is vancomycin effective for?

Answer 428

Gram positive cover only (inc. MRSA)

Question 429

List the 9 problems surrounding multi-drug resistant bacteria?

Answer 429

1. Selection pressure of antibiotic use 2. Development of resistant bacteria 3. Simple UTIs unmanageable in community 4. Out-Patient Parenteral Antimicrobial Therapy (OPAT) 5. For some patients, very little left 6. Hospital admission and risk of HAIs 7. Morbidity/mortality 8. Bed occupancy 9. Cost

Question 430

What is acute bacterial prostatitis?

Answer 430

- Localised infection - Usually spontaneous - May follow urethral instrumentation

Question 431

List the 3 likely organism for acute bacterial prostatitis?

Answer 431

1. Gram negative bacilli, e.g. E.coli, Proteus sp. 2. S.aureus (MSSA, MRSA) 3. N.gonorrhoea (less common)

Question 432

List 5 investigations for acute bacterial prostatitis?

Answer 432

1. Urine culture, usually positive 2. Blood culture 3. Trans-rectal U/S 4. CT/ MRI

Question 433

What is not advised for acute bacterial prostatitis?

Answer 433

Obtaining prostatic secretions NOT advisable

Question 434

List 5 complications for acute bacterial prostatitis?

Answer 434

1. Prostatic abscess 2. Spontaneous rupture- Urethra, rectum 3. Epididymitis 4. Pyelonephritis 5. Systemic sepsis

Question 435

What are 2 antibiotics for acute bacterial prostatitis?

Answer 435

1. Ciprofloxacin | 2. Ofloxacin (no streptococcus cover)

Question 436

Describe chronic prostatitis?

Answer 436

- Rarely associated with acute prostatitis - May follow Chlamydia urethritis - Recurrent UTIs - Diagnosis difficult - Relapse common - Most asymptomatic

Question 437

List the 3 symptoms for chronic prostatitis?

Answer 437

1. Perineal discomfort/ back pain 2. +/- low grade fever 3. UTI symptoms

Question 438

List 3 common organisms for chronic prostatitis?

Answer 438

1. Gram negative bacilli, e.g. E.coli, Proteus sp. 2. Enterococcus sp. 3. S.aureus MSAA, MRSA)

Question 439

What is the aetiology of epididymitis?

Answer 439

- Ascending infection from urethra | - Urethral instrumentation

Question 440

List the symptoms of epididymitis?

Answer 440

1. Pain 2. Fever 3. Swelling 4. Penile discharge 5. Symptoms of UTI/ urethritis

Question 441

List the common organism of epididymitis?

Answer 441

1. Gram Negative Bacteria 2. Enterococci 3. Staphylococci 4. TB in high risk areas and individuals

Question 442

What should you rule out in sexually active men?

Answer 442

Chlamydia & N.gonorrhoea (urethritis)

Question 443

What is orchitis?

Answer 443

Inflammation of one or both testicles

Question 444

List the 4 clinical signs of orchitis?

Answer 444

1. Testicular pain and swelling 2. Dysuria 3. Fever 4. Penile discharge

Question 445

What are the 2 aetiologies of orchitis?

Answer 445

1. Usually viral- mumps | 2. Bacterial

Question 446

Describe pyogenic (production of pus) bacterial orchitis?

Answer 446

- Complication of epididymitis - Acutely unwell - Rule out sexually transmitted bacteria - IV antibiotics - Urgent urological review

Question 447

List 2 complications of bacterial orchitis?

Answer 447

1. Testicular infarction | 2. Abscess formation

Question 448

Describe Fournier's Gangrene?

Answer 448

- Form of necrotising fasciitis - Usually > 50 yrs of age - Rapid onset and spreading infection - Systemic sepsis

Question 449

List 4 risk factors for Fournier's gangrene?

Answer 449

1. UTI 2. Complications of IBD 3. Trauma 4. Recent Surgery

Question 450

What are the common pathogens for Fournier's gangrene?

Answer 450

Mixed infections, mainly GNB and anaerobes

Question 451

List the 3 investigations for Fournier's gangrene?

Answer 451

1. Blood cultures 2. Urine 3. Tissue/pus

Question 452

What is the 1st line management for Fournier's gangrene?

Answer 452

Surgical debridement

Question 453

List the 4 broad spectrum/combination antibiotics that you would give for Fournier's gangrene initially?

Answer 453

Pip-tazobactam+ Gentamicin+ Metronidazole+/- Clindamycin

Question 454

What is the definition of pharmacokinetics?

Answer 454

- The science of the rate of movement of drugs within biological systems, as affected by the absorption, distribution, metabolism, and elimination of medications - “What your body does to the drug”

Question 455

What is the definition of pharmacodynamics?

Answer 455

- Study of the biochemical and physiologic processes underlying drug action - “What the drug does to your body”

Question 456

What is the definition of bioavailability?

Answer 456

- Fraction of the administered dose of drug that reaches the systemic circulation - Expressed as letter F

Question 457

List the 3 potential factors which can affect bioavailbility?

Answer 457

1. Drug factors- molecular weight/ionisation 2. Absorption- gastric pH, health of GI tract 3. First pass metabolism (hepatic)- phenytoin may reduce, grapefruit may increase

Question 458

What is the equation for the apparent volume of distribution?

Answer 458

VD= amount of drug in the body/ plasma drug concentration

Question 459

What is the definition of clearance?

Answer 459

Volume of plasma (blood etc.) “cleared” of drug per unit time (e.g. mlmin-1 or Lh-1)

Question 460

What is the half life equal to?

Answer 460

Time required for serum plasma concentration to decrease by half

Question 461

What is the half life determined by?

Answer 461

Clearance and volume of distribution

Question 462

What is the apparent volume of distribution?

Answer 462

The volume in which the amount of drug would need to be uniformly distributed to produce observed blood concentration

Question 463

What is loading doses often used for?

Answer 463

Drugs with long half-life

Question 464

What is the definition of an elimination half life?

Answer 464

Time for the concentration to fall to half

Question 465

What does an elimination half life depend on?

Answer 465

Clearance and Volume of distribution: - T1/2 = -Ln 0.5 x V/CL - T1/2 = 0.693 x V/CL

Question 466

What 3 things is an elimination half life used to determine?

Answer 466

1. Time to eliminate drug 2. Time to reach steady state 3. Dosage interval

Question 467

What is the definition of linear pharmacokinetics?

Answer 467

- Concentration that results from a dose is proportional to the dose (double the dose, double the concentration) - Rate of elimination is proportional to the concentration (50% of drug will be eliminated in a given time frame)

Question 468

What is the definition of non-linear pharmacokinetics?

Answer 468

- Concentration that results is not proportional to dose - Rate of elimination is constant regardless of amount of drug present - Dosage increases can saturate binding sites & result in non- proportional increase in drug levels (or opposite)

Question 469

List the 5 influences of disease on pharmacokinetics/pharmacodynamics?

Answer 469

1. Influence of age 2. Impaired renal function 3. Impaired hepatic function 4. Congestive cardiac failure 5. Gastrointestinal disease

Question 470

Describe how body fat/water influences the volume of distribution?

Answer 470

Decrease in total body water (due to decrease in muscle mass) & increase in total body fat affects volume of distribution

Question 471

Give 4 examples of water soluble drugs?

Answer 471

1. Lithium 2. Aminoglycosides 3. Alcohol 4. Digoxin - Serum levels may go up due to decreased volume of distribution

Question 472

Give 3 examples of fat soluble drugs?

Answer 472

1. Diazepam 2. Thiopental 3. Trazadone - Half life increased with increase in body fat

Question 473

What factor of pharmacokinetics is not highly impacted by ageing?

Answer 473

Absorption

Question 474

What factor of pharmacokinetics is typically reduced with age but variable?

Answer 474

Variable changes in first pass metabolism due to variable decline in hepatic blood flow

Question 475

Descirbe how age influences liver function?

Answer 475

- Oxidative metabolism through cytochrome P450 system does decrease with aging, resulting in a decreased clearance of drugs - Hepatic blood flow variable

Question 476

What does not change in the liver due to the influence of ageing?

Answer 476

Acetylation & conjugation do not change appreciably with age

Question 477

Describe ageing affect on GFR?

Answer 477

Generally declines, but is extremely variable: - 30% have little change - 30% have moderate decrease - 30% have severe decrease

Question 478

What is an unrealible market of GFR in ageing?

Answer 478

Serum creatinine (do Cr Cl instead)

Question 479

What is the Cockroft and Gault Equation?

Answer 479

Cr Cl = 140-age(yrs) x wt (kg) x.85 for women / Cr (mg/100ml) x 72

Question 480

List 4 drug effects (pharmacodynamics) that are increased due to ageing?

Answer 480

1. Alcohol 2. Opiates 3. Sedatives 4. Theophylline

Question 481

Describe some drug effects (pharmacodynamics) that are decreased due to ageing?

Answer 481

Diminished HR response to isoproterenol & beta -blockers

Question 482

What are 15% of hospitalizations in the elderly related to?

Answer 482

Adverse drug reactions

Question 483

What are 2 problems when a person is on more medications?

Answer 483

1. Higher the risk of drug-drug interactions or adverse drug reactions 2. Higher risk of non-adherence

Question 484

What do do patients with parkinson's disease have an increased risk of?

Answer 484

Drug induced confusion

Question 485

What drugs can exacerbate chronic heart failure?

Answer 485

NSAIDS & COX-2's

Question 486

What 2 drugs lower the seizure threshold?

Answer 486

Neuroleptics and quinolones

Question 487

What 3 drug worsen constipation?

Answer 487

1. Calcium 2. Anticholinergics 3. Calcium channel blockers

Question 488

What 2 drugs cause urinary retention in benign prostatic hyperplasia (BPH) patients?

Answer 488

1. Decongestants | 2. Anticholinergics

Question 489

What are drug-drug interactions a common cause of?

Answer 489

Adverse drug reactions in elderly

Question 490

Give 4 common examples of drug-drug interactions?

Answer 490

1. Statins and erythromycin and other antibiotics 2. Verapamil and beta-blockers 3. Warfarin and multiple drugs (incl aspirin) 4. ACE inhibitors increase hypoglycemic effect of sulfonylureas

Question 491

Give 4 examples of conditions that are under-treated in the elderly?

Answer 491

1. Coronary artery disease 2. Anticoagulation in AF 3. Hypertension, especially systolic hypertension 4. Pain

Question 492

What is a common cause of polypharmacy in the elderly?

Answer 492

The "prescribing cascade"

Question 493

Give 4 common examples of the "prescribing cascade"?

Answer 493

1. NSAID ->HTN->antihypertensive therapy 2. Metoclopromide ->parkinsonism ->Sinemet 3. Dihydropyridine -> oedema ->frusemide 4. HCTZ ->gout->NSAID ->2nd antihypertensive

Question 494

List 3 pharmacokinetic problems with renal disease?

Answer 494

1. Decreased elimination 2. Decreased protein binding 3. Decreased hepatic metabolism

Question 495

List 2 pharmacodynamic problems with renal disease?

Answer 495

1. Altered sensitivity to drug effect | 2. Adverse effects

Question 496

Give 5 examples of drugs that have a decreased elimination in renal disease?

Answer 496

1. Aminoglycosides 2. Lithium 3. Digoxin 4. Methotrexate 5. Penicillins

Question 497

What are the 3 management steps for decreased elimination in renal disease?

Answer 497

1. Determination of renal function 2. Alteration of dosing schedule 3. Monitoring drug concentrations

Question 498

What does renal failure lead to?

Answer 498

Acid retention

Question 499

Describe protein binding in renal disease?

Answer 499

- “Acidic” drugs less bound to albumin: Conformational change in albumin, less ionised drug to bind - Increased free (active) drug in plasma

Question 500

Describe hepatic metabolism in renal failure?

Answer 500

- Hepatic metabolism of some drugs is slower in renal failure: Endogenous inhibitor in uraemic plasma

Question 501

What normalises slow hepatic metabolism in renal failure?

Answer 501

Haemodialysis

Question 502

What effect does renal failure have on pharmacodynamics?

Answer 502

- Increased sensitivity to sedatives | - BBB permeability

Question 503

What are 7 important examples of drugs to watch out for in renal disease?

Answer 503

1. Antibiotics (reduce dose) 2. LMWH (reduce dose) 3. Metformin (avoid) 4. NSAIDs (avoid) 5. Digoxin (reduce dose) 6. Phenytoin (reduce dose) 7. ACE Inhibitors (caution)

Question 504

Summaries the 3 rules of prescribing in renal disease?

Answer 504

1. Same hepatic metabolism 2. Same/increased VD and prolonged elimination (t1/2 increased) 3. Thus, increased dosing interval

Question 505

List the 4 effects hepatic impairment has on pharmacokinetics?

Answer 505

1. First pass metabolism 2. Activation of prodrugs 3. Decreased protein binding 4. Decreased elimination

Question 506

What effect does hepatic impairment have on pharmacodynamics?

Answer 506

Altered sensitivity to drugs

Question 507

Give 3 examples of how hepatic impairment has profound changes in bioavailability?

Answer 507

1. Chlormethiazole (1000% increase) 2. Verapamil (140% increase) 3. Paracetamol (50% increase)

Question 508

Give 2 examples of drugs that hepatic impairment reduces their first pass activation?

Answer 508

1. Enalapril | 2. Perindopril

Question 509

What dose it mean to be a high extraction drug?

Answer 509

- Metabolised at high rate by liver - Rate varies with delivery - Affected by changes in blood flow

Question 510

Give 3 examples of high extraction drugs?

Answer 510

1. Morphine 2. Verapamil 3. Lignocaine

Question 511

What dose it mean to be a low extraction drug?

Answer 511

- Metabolised at low rate by liver - Independent of blood flow - Sensitive to changes in liver enzyme activity

Question 512

Give 2 examples of low extraction drugs?

Answer 512

1. Chloramphenicol | 2. Theophylline

Question 513

What are the 4 factors of hepatic impairment on pharmacokinetics?

Answer 513

1. Difficult to predict 2. Many factors involved 3. No simple test (cf renal impairment) 4. Start with low dose

Question 514

What are the 5 factors of hepatic impairment on pharmacodynamics?

Answer 514

1. Sensitivity to sedatives 2. Sensitivity to oral anticoagulants 3. Precipitation of encephalopathy 4. Fluid retention 5. Hepatorenal syndrome

Question 515

Give 5 important examples of drugs to watch out for in liver disease?

Answer 515

1. Some antibiotics 2. Valproate 3. Warfarin 4. Sedatives 5. Verapamil

Question 516

Summarise the 3 rules of prescribing in hepatic disease?

Answer 516

1. Same renal elimination 2. Same/increased VD and slower rate of enzyme metabolism (t1/2 / F increase) 3. Thus decrease dosage, increase dosing interval

Question 517

What 3 pharmacokinetic factors are affected in congestive heart failure?

Answer 517

1. Absorption 2. Hepatic elimination 3. Renal elimination

Question 518

What are 3 gastrointestinal disease which affect drugs pharmacodynamics/ pharmacokinetics?

Answer 518

1. Achlorhydria 2. Crohn’s disease 3. Post-operative issues

Question 519

Describe the epidemiology of prostate cancer?

Answer 519

- Commonest Urological Malignancy | - Now commonest cause of male cancer death

Question 520

Describe the age risk factor for prostate cancer?

Answer 520

- 85% diagnosed in over 65yrs old - Microscopic foci 30% 50yo and 70% >80yo - Strongest factor linked to prostate cancer

Question 521

Describe the familial & genetic risk factors for prostate cancer?

Answer 521

- 2x risk if 1st degree relative <60yo - 4x risk if two 1st degree relatives (any age) - Abnormalities on chromosomes- 1q, 8p & Xp - BRCA2 gene mutations reported - PTEN & TP53

Question 522

Describe the racial risk factors for prostate cancer?

Answer 522

African american 1.6 x risk of white american

Question 523

Describe the geographical variations for prostate cancer?

Answer 523

- Highest incidence in westernized nations, least in Asia and Far East - US migrants from Japan & Asia 20x increase

Question 524

Describe the hormonal risk factors for prostate cancer?

Answer 524

- Men castrated before puberty almost never develop prostate cancer - Higher incidence of the disease may be associated with elevated 5alpha-reductase levels

Question 525

Describe the diet risk factors for prostate cancer?

Answer 525

- Link between total fat consumption & prostate cancer deaths - A positive association between serum levels of alpha-linolenic, palmitoleic & palmitic acid & risk of prostate cancer

Question 526

List the 6 symptoms of local/locally advanced prostate cancer?

Answer 526

1. Often asymptomatic (PSA) 2. Painful or slow micturition 3. Urinary tract infection 4. Haematuria - blood in urine 5. Urinary retention (may cause anuria, uraemia) 6. Lymphoedema

Question 527

List 2 symptoms of metastatic prostate cancer?

Answer 527

1. Bone pain- most common symptom of metastases | 2. Renal failure- ureteric obstruction

Question 528

What is the main sign of prostate cancer?

Answer 528

Raised PSA level - on suspicion or screening

Question 529

What are the 3 ways to diagnose/screen for prostate cancer?

Answer 529

1. DRE - digital rectal examination 2. PSA - prostate-specific antigen 3. TRUS - guided needle biopsy

Question 530

Describe the pathology of prostate cancer?

Answer 530

- Majority is primary adenocarcinoma | - Usually arises in peripheral zone of prostate

Question 531

How is prostate cancer graded?

Answer 531

Gleason grading system showing the 10-year likelihood of local progression

Question 532

Describe the TNM classification staging for prostate cancer?

Answer 532

- Clinical tumour staging (T) - Lymph node involvement (N) - Metastases (M)

Question 533

What is prostate specific antigen (PSA)?

Answer 533

Serine protease (33kD) secreted into seminal fluid (not tumour specific)

Question 534

What is prostate specific antigen (PSA) responsible for?

Answer 534

- Liquefaction of seminal coagulation - Efficiently hydrolyses semenogelins causing release of sperm - Small proportion leaks into circulation

Question 535

What 3 things influence PSA levels?

Answer 535

1. Tends to rise with age 2. Depends on prostate size 3. Other influences (eg inflammation, infection)

Question 536

What 2 things can PSA measurements provide?

Answer 536

1. Information about prostate cancer from the initial screening 2. Early detection through to the staging of the disease

Question 537

List the 6 treatment options for a localised prostate cancer?

Answer 537

1. Watchful waiting 2. Active Surveillance 3. Radiotherapy (with or without LHRH analogue) 4. Radical prostatectomy 5. Cryotherapy/HIFU 6. TURP if symptomatic

Question 538

What are the 3 types of radiotherapy appropriate for a localised prostate cancer?

Answer 538

1. External beam 2. Conformal 3. Brachytherapy

Question 539

What are the 2 prostate metastatic complications?

Answer 539

1. Spinal cord compression | 2. Ureteric obstruction

Question 540

List the 7 factors of spinal cord compression from a metastatic prostate cancer?

Answer 540

1. Urological emergency 2. Severe pain 3. Off legs 4. Retention 5. Constipation 6. Urgent MRI 7. Radiotherapy vs spinal decompression surgery

Question 541

List the 3 factors of ureteric obstruction from a metastatic prostate cancer?

Answer 541

1. Anorexia, weight loss, raised creatinine 2. To nephrostomize or not and then to stent or not 3. Temporary measure will not improve cancer progression

Question 542

What are the 4 treatment options for advanced prostate cancer?

Answer 542

1. Androgen ablation therapy: medical castration (LHRH analogue) or surgical castration (orchidectomy) 2. Chemotherapy 3. TURP for relief of symptoms 4. Radiotherapy

Question 543

Describe the epidemiology of bladder cancer?

Answer 543

- Male:female= 2.5:1 | - More common in the elderly

Question 544

List the 6 risk factors for bladder cancer?

Answer 544

1. Age: rare <50yrs 2. Race: common in caucasians 3. Environmental Carcinogens 4. Chronic inflammation: stones, infection (schistosamiasis), long term catheters 5. Drugs: phenacitin, cyclophosphamide 6. Pelvic radiotherapy 7. Occupation

Question 545

Describe hydrocarbons?

Answer 545

- 25-45 year latency | - Liver metabolism but excretion in urine

Question 546

What is an aromatic hydrocarbon?

Answer 546

Anilines

Question 547

What accounts for 30-50% of all bladder cancers?

Answer 547

Smoking

Question 548

How many years of smoking cessation does the bladder cancer risk return to normal?

Answer 548

20 years

Question 549

What 2 things does smoking release in the body resulting in an increased bladder cancer risk?

Answer 549

4-ABP & naphythylamines

Question 550

How does bladder cancer present?

Answer 550

- Classically painless frank haematuria | - Some present with microscopic haematuria (5% serious causes)

Question 551

What should all people presenting with painless frank haematuria have?

Answer 551

Cystoscopy, renal USS/KUB

Question 552

What are the 3 different pathologies for bladder cancer?

Answer 552

1. Transitional cell carcinoma: 90% (Superficial 75% & Invasive 25%) 2. Squamous carcinoma: 5% 3. Adenocarcinoma: 2%

Question 553

Describe the 4 grades of bladder cancer?

Answer 553

1. Grade 1: well differentiated- good prognosis 2. Grade 2: moderately differentiated 3. Grade 3: poorly differentiated 4. Carcinoma in situ

Question 554

What grade of bladder cancer is least common?

Answer 554

Grade 3 (most likely to progress to invasive disease)

Question 555

How is bladder cancer diagnosed?

Answer 555

At flexible cystoscopy

Question 556

What is the treatment of bladder cancer?

Answer 556

Urgent TURBT (trans-urethral resection of bladder tumour) booked

Question 557

What are 2 investigations you can do for bladder cancer?

Answer 557

1. CT intravenous urogram (CT IVU)- 5% chance upper tract involvement 2. Bimanual examination carried out at TURBT

Question 558

What reduced the risk of bladder cancer recurrence?

Answer 558

Intravesical mitomycin

Question 559

Describe the good prognosis of low grade superficial transitional cell carcinoma of the bladder (TCC)?

Answer 559

- 10% risk of progression | - 30% chance recurrence

Question 560

What is the management for low grade superficial transitional cell carcinoma of the bladder (TCC)?

Answer 560

- Flexible check cystoscopy 3 months | - Course of 6 weekly mitomycin treatments given for persistent Ta tumours

Question 561

Describe the bad prognosis of high grade non-muscle invasive bladder cancer (HGNMIBC), pT1, Cis?

Answer 561

- 80% recurrence risk | - 50% chance of progressing to muscle invasive disease

Question 562

What is the management for high grade non-muscle invasive bladder cancer (HGNMIBC), pT1, Cis?

Answer 562

- Early check cystoscopy & rebiopsy - Treat with intravesical BCG immunotherapy: effective in 50% - Course of 6 weekly instillations then further cystoscopy/biopsy - Cystectomy of treatment fails

Question 563

What is the management for muscle invasive bladder cancer (MIBC) T2-4?

Answer 563

- Require radical cystectomy or radiotherapy | - Neo-adjuvant chemotherapy

Question 564

What is a radical cystectomy?

Answer 564

- Bladder & prostate/uterus removed | - Urine diverted into an ileal conduit or (rarely) an orthotopic neobladder

Question 565

When is a radical cystectomy sometimes required?

Answer 565

After radiotherapy failure “salvage cystectomy”

Question 566

What is metastatic disease often?

Answer 566

Pulmonary

Question 567

What is the M-VAC chemotherapy treatment for metastatic disease?

Answer 567

- Methotrexate, vinblastine, doxorubicin, cisplatin | - Highly toxic

Question 568

What combination treatment is given for metastatic disease?

Answer 568

Gemicitobine/Docetaxel

Question 569

Describe the % 5 year survival for stage Ta --> T4a bladder cancer?

Answer 569

- Ta: 94% - T1: >90% - T2: 75% - T3: 40-60% - T4a: 10%

Question 570

Describe the epidemiology of renal cell carcinoma?

Answer 570

- 85% of all renal tumours - Age peak of 40-70 years old - Males outnumber females 2:1

Question 571

Give 4 examples of renal cancer?

Answer 571

1. Renal cell carcinoma 2. Transitional Cell Carcinoma 3. Sarcoma 4. Metastases

Question 572

List the 6 risk factors for renal cancer?

Answer 572

1. Smoking 2. Obesity 3. Hypertension 4. Acquired renal cystic disease 5. Haemodialysis 6. Genetics

Question 573

List the 5 systemic symptoms (<25%) seen in renal cancer?

Answer 573

1. Night sweats 2. Fever 3. Fatigue 4. Weight loss 5. Haemoptysis

Question 574

What is the classic triad seen in 10% of renal cancer presentations?

Answer 574

1. Mass 2. Pain 3. Haematuria Varicocele

Question 575

What 2 presentations can be seen in renal cancer?

Answer 575

1. Lower limb oedema | 2. Paraneoplastic syndrome

Question 576

List 5 paraneoplastic syndromes associated with renal cancer?

Answer 576

1. Polycythaemia (3-10%) 2. Hypercalcaemia (3-13%) 3. Hypertension (Up to 40%) 4. Deranged LFT’s: Stauffer’s syndrome 5. Rarely produces ACTH (Cushing’s syndrome), enteroglucagon (protein enteropathy), prolactin (galactorrhoea), insulin (hypoglycaemia) & gonadotropins

Question 577

List the 5 initial investigations to diagnose renal cancer?

Answer 577

1. Usually on USS 2. FBC, UE, LFT, CRP, bone profile, LDH 3. CT kidneys +/- MRI RV 4. Renal Biopsy 5. CT Chest

Question 578

Describe the 3 histology types of renal cancer?

Answer 578

1. Conventional or clear cell (80%)- vascular, granular & clear (lipids) 2. Papillary (10%)- solid & 40% multi-focal 3. Chromophobe (5%)- large polygonal

Question 579

What are 2 rare histology types of renal cancer?

Answer 579

1. Collecting duct | 2. Medullary cell

Question 580

Describe the T1a --> T4 staging of renal cancer?

Answer 580

- T1a: <4cm - T1b: 4-7cm - T2: >7cm - T3a: into renal vein - T3b: IVC below diaphragm - T3c: IVC above diaphragm - T4: beyond Gerota’s &/or adrenal gland

Question 581

How do you treat a large renal mass?

Answer 581

- Radical Nephrectomy | - If no absolute indication for NSS

Question 582

How do you treat a radical nephrectomy?

Answer 582

- Removal of kidney & Gerota’s fascia | - Sparing adrenal gland

Question 583

How do you treat a small renal mass?

Answer 583

- Biopsy - Nephron sparing surgery - Partial Nephrectomy - Cryotherapy - Radical Nephrectomy - Surveillance

Question 584

What are the 4 indications for Nephron Sparing Surgery (NSS)?

Answer 584

1. Single kidney 2. Chronic Kidney Disease 3. CV risk factors 4. pT1a tumours

Question 585

What is the treatment for renal metastatic disease?

Answer 585

Tyrosine Kinase Inhibitors

Question 586

Describe the epidemiology of testicular cancer?

Answer 586

- Most Common solid cancer in men 20-45 - Most curable cancer - Increasing Incidence

Question 587

List the 4 risk factors for testicular cancer?

Answer 587

1. Age 20-45yo 2. Cryptorchidism 3. HIV 4. Caucasian population

Question 588

How do the majority of testicular cancers present?

Answer 588

Painless lump

Question 589

What are the 4 investigations for a testicular cancer?

Answer 589

1. Scrotal ultrasound 2. Alpha-fetoprotein 3. Beta hCG 4. LDH

Question 590

Give 4 examples of testicular germ cell tumours (most common)?

Answer 590

1. Seminoma 2. Teratoma 3. Mixed 4. Yolk Sac

Question 591

Give 2 examples of testicular stromal tumours (10% malignant)?

Answer 591

1. Leydig | 2. Sertoli

Question 592

Give 2 examples of other testicular tumours?

Answer 592

1. Lymphoma | 2. Metastasis

Question 593

List the 4 treatments for testicular cancer?

Answer 593

1. Radical Orchidectomy 2. Chemotherapy 3. Para-aortic nodal radiotherapy 4. Retroperitoneal Lymph Node Dissection

Question 594

Describe the epidemiology of penile cancer?

Answer 594

- Rare (0.2% male cancers in the west) - Premalignant lesions: chronic changes - Even rarer in males circumcised at birth

Question 595

List the 5 treatments for penile cancers?

Answer 595

1. Circumcision 2. Topical treatment CO2/5FU 4. Penectomy +/- reconstruction 5. Lymphadenectomy 6. Chemo-radiotherapy

Question 596

What are the 2 associated factors for penile cancer?

Answer 596

HPV infection (16,18,21) & smoking

Question 597

Describe the epidemiology of stone disease?

Answer 597

- 10-15% lifetime risk - 30-50 years - Males>females - Caucasian>Asian>Black>Hispanic - Commoner in hot, dry climates

Question 598

Describe the risk of a further stone?

Answer 598

- 50% at 10 years | - 90% at 30 years

Question 599

What are 3 reasons why stones form?

Answer 599

1. Abnormal urine 2. Urinary obstruction 3. Urinary Infection

Question 600

What are 5 reasons why stones form abnormal urine?

Answer 600

1. Under-saturated 2. Too much salt 3. Not enough water 4. Lack of inhibitors 5. Abnormal proteins

Question 601

What 4 things happen when the body has too much salt?

Answer 601

1. Abnormal blood: too much calcium & acid 2. Abnormal urine 3. Hypercalciruia 4. Hyperoxaluria

Question 602

What are 4 stone inhibitors?

Answer 602

1. Citrate 2. Magnesium 3. Pyrophosphate 4. Glycoproteins

Question 603

What are 2 stone promoters?

Answer 603

1. THP(abnormal) | 2. Matrix substance A

Question 604

List 7 factors that affect stone formation?

Answer 604

1. Low volume 2. Low pH (acidic) 3. Low citrate 4. Low magnesium 5. High uric acid 6. High calcium 7. High oxalate

Question 605

Give 4 examples of congenital urinary obstruction?

Answer 605

1. Medullary sponge kidney 2. PUJ obstruction 3. Mega ureter 4. Ureterocele

Question 606

Give 2 examples of acquired urinary obstruction?

Answer 606

1. Ureteric stricture | 2. Anastamotic stricture

Question 607

Describe proteus mirablis urinary infection?

Answer 607

- Splits urea --> ammonium - Raises urine pH - Struvite (magnesium, ammonium phosphate & some Capo4)

Question 608

List 4 different types of stones?

Answer 608

1. Calcium stones: 80% (mixed) 2. Infection stones: 10% 3. Uric acid stone: 5% 4. Others: 1%

Question 609

Describe a calcium stone?

Answer 609

- Calcium oxalate monohydrate or dihydrate | - Calcium phosphate

Question 610

Describe an infection stone?

Answer 610

Struvite (proteus)

Question 611

What is special about a uric acid stone?

Answer 611

Not seen on xray (metabolic syndromes)

Question 612

Give 4 examples of other stones?

Answer 612

1. Cystine (genetic) 2. Xanthine 3. Silica 4. Drug stones: indinavir (not seen on CT)

Question 613

What are 4 ways for a stone to present?

Answer 613

1. Incidental 2. Pain: colic, radiates from loin to groin, cannot settle, unable to stay still 3. Haematuria: visible or non visible 4. UTI or Sepsis: unknown source until imaged

Question 614

List the 4 initial investigations for a stone?

Answer 614

1. History & exam 2. Bloods: U&E, CRP, FBC 3. Urine: non visible haematuria= 85% 4. Imaging: gold standard = CT KUB (non contrast)

Question 615

What 6 biochemical tests should you do for the first stone?

Answer 615

1. U&E 2. Calcium 3. Urate 4. Urine dip (pH , blood etc) 5. Sodium nitroprusside: Cystine 6. Stone analysis

Question 616

What 5 biochemical gets should you do for recurrent (multiple) stones?

Answer 616

1. U&E 2. Calcium 3. Urate 4. Venous bicarbonate 5. 2x24 hour urine analysis

Question 617

What are the 4 ways to manage a stone?

Answer 617

1. Observation: asymptomatic, small 2. Medical therapy: dissolution therapy 3. Non invasive therapy 4. Invasive therapy: Minimal => maximal

Question 618

Where do stones cause pain?

Answer 618

- Renal: asymptomatic | - 3 points: PUJ, VUJ, crossing iliacs

Question 619

What is the % chance of a <4mm stone passing?

Answer 619

75%

Question 620

What is the % chance of a <7mm stone passing?

Answer 620

- 25% proximal - 45% mid - 64% distal ureter

Question 621

What are the 2 types of medical therapy for stones?

Answer 621

1. Analgesia (NSAIDs or opiates) | 2. Medical Expulsive Therapy

Question 622

What is the purpose of NSAIDS for stones?

Answer 622

Reduce pain due to reduced glomerular filtration, renal pressure & ureteric peristalsis

Question 623

List 5 surgical options for managing stones?

Answer 623

1. ESWL: extracorporeal shockwave lithotripsy 2. Rigid ureteroscopy & fragmentation/ basket extraction 3. FURS: flexible ureteroscopy 4. PCNL: percutaneous nephrolithotomy 5. Emergency stent or nephrostomy

Question 624

What is ESWL (extracorporeal shockwave lithotripsy) best for?

Answer 624

Proximal ureteric stones <10mm or renal stones <2cm depending on location

Question 625

Describe ESWL (extracorporeal shockwave lithotripsy)?

Answer 625

- Generate shockwaves externally to break up stones - Needs analgesia - Stone density - Skin stone depth

Question 626

What is Ureteroscopy best for?

Answer 626

Ureteric stones or renal <2cm

Question 627

Describe Ureteroscopy?

Answer 627

- Rigid or flexible - Basket + laser - Needs anaesthetic

Question 628

What is PCNL (percutaneous nephrolithotomy) best for?

Answer 628

Stones >2cm in kidney

Question 629

Describe PCNL (percutaneous nephrolithotomy)?

Answer 629

- Direct access to kidney via the skin to fragment or extract stones - Needs general anaesthetic

Question 630

What is laparoscopic + open surgery best for?

Answer 630

Huge ureteric stones

Question 631

Describe laparoscopic + open surgery?

Answer 631

- Non functioning kidney | - Reconstruction needed

Question 632

What is a urological emergency?

Answer 632

A patient with sepsis & obstructing stone

Question 633

What will a patient with sepsis & obstructing stone need?

Answer 633

Urgent decompression of an obstructed infected collecting system by nephrostomy or retrograde ureteric stenting

Question 634

Describe the body fluid compartments?

Answer 634

- Total body water= 40L - Intracellular fluid volume= 25L - Interstitial fluid volume (ECF)= 12L - Plasma fluid volume (ECF)= 3L

Question 635

What are 5 things that can happen in hospital to alter someones fluid balance?

Answer 635

1. Bowel prep 2. Medications 3. Fluid intake pre-op 4. Fluid input in theatre 5. Blood loss in theatre

Question 636

What are 6 fluid output post-op that can alter someones fluid balance?

Answer 636

1. Vomiting 2. Diarrhoea 3. Drains 4. NG losses 5. Pyrexia 6. Blood loss

Question 637

List 9 general things you would examine to check for a patients fluid balance?

Answer 637

1. ‘End of the bed’ look 2. ABCD 3. AVPU / GCS 4. Peripheral temp 5. CRT 6. Mucous membranes 7. Chest auscultation 8. Peripheral / sacral oedema 9. JVP 10. Colour of urine 12. Weight

Question 638

What 6 basic observations would you do to check a patients fluid balance?

Answer 638

1. HR 2. NIBP 3. RR 4. SpO2 5. Temp 6. UOP / fluid balance

Question 639

What 5 things should you check in a patients blood results for fluid balance?

Answer 639

1. Check not anaemic 2. Haematocrit 3. U+Es 4. Lactate 5. Acid base status

Question 640

What are 2 ways to monitor cardiac output?

Answer 640

1. Trans-oesophageal doppler | 2. Pulse contour analysis

Question 641

What is oliguria a normal response to?

Answer 641

Surgery

Question 642

What are the 7 key questions when prescribing fluids?

Answer 642

1. Does my patient need fluid? 2. Why? 3. Which fluid? 4. How much? 5. Any additives eg K+, Mg2+, PO42- 6. What route? 7. Are there any comorbidities which will influence management? (eg CCF, CKD)

Question 643

What can occur as a result of infusion of too much or too little fluid by inexperienced staff?

Answer 643

Mortality/morbidity

Question 644

What are the 3 types of fluids?

Answer 644

1. Maintenance- water & electrolytes: daily fluid requirements + insensible loss 3. Replacement: replace ongoing losses (vomit, diarrhoea, fistulae, stoma output etc) 4. Resuscitation: correct an intravascular or extracellular volume deficit

Question 645

Give 7 examples for things that can happen in hypovolaemia?

Answer 645

1. Reduced circulating blood volume 2. Increased cardiopulmonary complications 3. Multiple organ failure 4. Mitochondrial dysfunction 5. Endothelial dysfunction 6. Hypoxaemia 7. Altered coagulation

Question 646

Give 7 examples for things that can happen in hypervolaemia?

Answer 646

1. Pulmonary oedema & decreased gas exchange 2. Splanchnic oedema 3. Raised intra-abdominal pressure 4. Decreased tissue oxygenation 5. Impaired wound healing 6. Reactive oxygen species 7. Multiple organ failure

Question 647

What is the sodium & water retention phase mediated by?

Answer 647

RAAS, ADH + catecholamines acting on the kidney

Question 648

Describe the catabolic response to injury/illness?

Answer 648

- Impaired capacity of kidneys to excrete water & Na+ (worsened by hyperchloraemia & hypokalaemia) - Decreased urinary output - Poor concentrating ability: poor excretion of Na+ & Cl- load in a small volume of urine - Vulnerable to fluid / Na+ / Cl- retention

Question 649

What does leaky capillary cause in injury/illness?

Answer 649

Albumin + fluid move to interstitial space –> oedema

Question 650

Overall what does excess fluids cause?

Answer 650

Major cause of morbidity / mortality

Question 651

Give 6 examples of commonly used crystalloid fluids?

Answer 651

1. Plasma 2. Sodium chloride 0.9% (saline) 3. Sodium chloride 0/18%/4% glucose 4. 0.45% NaCl/4% glucose 5. 5% glucose 6. Hartmann's

Question 652

Describe crystalloid fluids?

Answer 652

- Electrolytes & water (saline, hartmanns etc) - Iso / hypo / hypertonic - "Balanced”: electrolyte concentrations similar to plasma with addition of buffer (usually lactate): Eg Hartmanns / Plasmalyte

Question 653

When are crystalloid fluids commonly used?

Answer 653

Periop setting

Question 654

Describe colloid fluids?

Answer 654

- Plasma derivatives (eg albumin / FFP) or synthetic (eg gelatins / HES) - Stay in systemic circulation longer BUT may cause more interstitial fluid retention when they eventually leak out -Effects on coag, anaphylaxis, AKI (HES)

Question 655

What does 0.9% saline cause?

Answer 655

- Can cause hyperchloraemic acidosis which causes renal vasoconstriction & poor urine output - Kidneys can’t excrete Na+ load - K+ depletion also reduces ability to excrete Na+

Question 656

What are the 3 results of 0.9% saline?

Answer 656

1. Hypernatraemia 2. Hyperchloraemia 3. Acidosis

Question 657

What happens when patients receive less chloride?

Answer 657

- Significant reduction in renal dysfunction, creatinine levels & RRT (0.9% NaCl vs Hartmann’s or Plasmalyte 148) - No effect on mortality

Question 658

What is the daily maintenance requirement for water?

Answer 658

25-30 ml/kg

Question 659

What is the daily maintenance requirement for sodium & potassium?

Answer 659

Approx 1 mmol/kg each

Question 660

What is the daily maintenance requirement for calories?

Answer 660

Minimum 400 Calories (i.e. 100 g dextrose)

Question 661

What is the GIFTASUP recommendation for meeting maintenance requirements?

Answer 661

- Receive Na+ 50-100 mmol/day, K+ 40-80 mmol/day in 1.5-2.5 litres of water by the oral, enteral or parenteral route - Additional amounts given to correct deficit or continuing losses - Careful monitoring: clinical examination, fluid balance charts & regular weighing

Question 662

What are solutions such as 4%/0.18% dextrose/saline & 5% dextrose important sources of?

Answer 662

- Free water for maintenance, used with caution as excessive amounts may cause dangerous hyponatraemia, esp in the elderly - Not appropriate for resuscitation or replacement therapy except in significant free water deficit e.g. diabetes insipidus

Question 663

Describe how to prescribe replacement fluids?

Answer 663

- Work out losses & replace with Hartmann’s / Plasmalyte - May use 0.9%NaCl for vomiting / large NG losses - Review patient’s clinical status & blood results regularly

Question 664

What is GIFTASUP recommendation for giving crystalloid replacement/resuscitation fluids?

Answer 664

Because the risk of inducing hyperchloraemic acidosis, balanced salt solutions e.g. Ringer’s lactate/acetate or Hartmann’s solution should replace 0.9% saline, except in cases of hypochloraemia e.g. from vomiting or gastric drainage.

Question 665

What is the algorithm for fluid challenges?

Answer 665

200-250ml bolus in <15mins then review / reassess via clinical picture, obs

Question 666

What should you do when giving resuscitation fluids in heart failure?

Answer 666

Reduce volume / caution

Question 667

What are the 2 types of resuscitation fluids?

Answer 667

1. Plasmaltye | 2. Hartmanns

Question 668

What should you do when giving resuscitation fluids with evidence of bleeding?

Answer 668

- GET HELP - ABC assessment - Large IV access x 2 - Bloods & Xmatch - Give blood if ongoing bleed (O neg may be used in emergencies)

Question 669

What should you do if haemodynamic status is not improving despite fluid boluses?

Answer 669

- Call for more senior help | - May need critical care / vasopressors

Question 670

What are the 2 types of replacement fluids?

Answer 670

1. Hartmanns | 2. Alternative balanced solutions for resuscitation

Question 671

What are the 4 types of maintenance fluids?

Answer 671

1. Sodium chloride 0.18%/4% dextrose 2. 5% Glucose 3. Hartmann's 4. Alternative balanced solutions for resuscitation

Question 672

What is GIFTASUP recommendation for when patients patients leave theatre for the ward, HDU or ICU?

Answer 672

- Volume status should be assessed - The volume & type of fluids given perioperatively should be reviewed and compared with fluid losses in theatre including urine & insensible losses

Question 673

What is GIFTASUP recommendation for patients who are euvolaemic and haemodynamically stable?

Answer 673

Return to oral fluid administration should be achieved as soon as possible

Question 674

What is GIFTASUP recommendation for patients requiring IV maintenance fluids?

Answer 674

- Should be sodium poor & of low enough volume until the patient has returned their sodium & fluid balance over the peri operative period to zero - When this has been achieved the IV fluid volume & content should be those required for daily maintenance & replacement of any on-going additional losses