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YOU BETTER WERK > UROLOGY/CKD > Flashcards

UROLOGY/CKD Flashcards

1
Q

What is the most common composition of kidney stones?

A

Calcium oxalate

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2
Q

Investigation of renal calculi

A
  • urine analysis
  • renal function
  • CT KUB and XR KUB should be performed on the same day
  • approx ~50% of stones are radio-opaque
  • US KUB can be used when avoidance of radiation is necessar (young patients, females) but CT is preferred imaging modality

-

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3
Q

Which renal stones can pass conservatively?

A
  • majority of stones will pass within 6 weeks
  • 60% of stones 5-7mm will pass spontaneously
  • conservative mx: NSAIDs provide the most effective pain relief
  • consider 400mcg dose tamsulosin
  • dietary advice: low protein, low sodium may help reduce recurrence
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4
Q

Which subsets of patients need to be kidney stone free?-

A

Single kidney patients

Airline pilots

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5
Q

Definition of CKD

A
  • GFR <60 which is present for > 3 momths with or without evidence of kidney damage

OR

  • evidence of kidney damage with or without a decreased GFR present for > 3 months (evidenced by: albuminuria, haematurial, structural abnormalities, abnormal renal biopsy)

Risk factors: diabetes, HTN, established CVD, family history, obesity, smoker, > 60, ATSI, history of AKI

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6
Q

What are the 3 main points of screening for patients at risk of CKD?

A
  1. BP
  2. Urine ACR
  3. Blood test: creat/GFR
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7
Q

Algorithm for detection of CKD

A
  1. Screen at risk individuals, if urine ACR and eGFR are normal repeat in 1-2 years time (annually in pts with HTN or diabetes)

ABNORMAL GFR: if < 60 repeat in 7 days, if stable repeat GFR twice in 3 months
GFR > 20% REDUCTION: consider AKI, discuss with nephrologist

URINE ACR: if elevated repeat twice within next 3 months (preferably first morning void)

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8
Q

Describe the stages of renal function

A

Stage 1: GFR > 90

Stage 2: 60-90

Stage 3a: 45-60

Stage 3b: 30-45

Stage 4: 25-30

Stage 5: GFR <15 or on dialysis

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9
Q

Diet and nutrition goals in CKD

A
  • varied diet richen in vegetables, fruits, multigrain cereals, lean meat, chicke, fish, eggs, buts, seeds and low fat dairy products
  • limit salt to <6g/day
  • limit intake of foods containing added sugars and saturated/trans fats
  • avoid high calorie sweetened carbonated beverages
  • dietary protein no lower then 0.75g/kg
  • maintain albumin > 35
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10
Q

Obesity and CKD

A

Ideal BMI <25

WC <94cm in men and <80cm in women

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11
Q

Physical activity in CKD

A

Accumulate 150 to 300 minutes (2 ½ to 5 hours) of moderate intensity physical activity or 75 to 150 minutes (1 ¼ to 2 ½ hours) of vigorous intensity physical activity, or an equivalent combination of both moderate and vigorous activities, each week.

Do muscle strengthening activities on at least 2 days each week.

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12
Q

BP target in CKD

A

<130/80

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13
Q

Drug choice in management for cholesterol in patients >50 with CKD

A

Statin/ezetimibe combination

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14
Q

Immunisation in CKD

A
  • influenza and pneumococcal disease is recommended for all with diabetes or ESKD
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15
Q

ACEI/ARBs and eGFR decline

A
  • ACEI/ARBs cause reversible reduction in GFR
  • provided reduction is <25% within 2 months of starting therapy you should continue ACEI/ARB therapy
  • cease if reduction > 25%
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16
Q

What are the most common causes of ESRF in Australia?

A

DIABETES # 1

Glomerulonephritis # 2

Hypertension # 3

Polcystic kidneys # 4

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17
Q

Screening for CKD in ATSI population

A
  • all patients >30 should have urine ACR, eGFR and BP done every 2 years
  • or if 18-29 with one or more CKD risk factors
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18
Q

Once CKD is diagnosed through GFR/urine ACR what further diagnostic evaluation is required?

A
  • renal USS
  • repeat serum biochemistry
  • FBC, CRP, ESR
  • fasting glucose/lipids
  • urine microscopy
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19
Q

What further investigation should be performed in patients with CKD and signs of systemic disease (rash, arthritis, features of connective tissue disease, pulmonary symptoms)?

A

Anti-glomerular basement membrane antibody

Anti-neutrophil cytoplasmic antibody

Anti-nuclear antibody

Extractable nuclear antigens

Complement studies

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20
Q

What further testing should be sought in patients > 40 with CKD and possible myeloma?

A
  • serum and urine protein electrophoresis
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21
Q

YELLOW CLINICAL ACTION PLAN: CKD

A

GFR >60 + microalbuminuria or GFR 45-60 w/ normoalbuminuria

Goals: investigate cause, reduce progression, assess cardiovascular risk

Frequency of review: every 12 months

Clinical assessment: GP, weight, smoking

Labs: urine ACR, eGFR, biochemical profile, HbAqc, fasting lipids

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22
Q

ORANGE CLINICAL ACTION PLAN: CKD

A
  • GFR 30-50 with microalbuminuria or GFR 35-40 norrmoalbuminuria

Goals: early detection and management of complications, adjustement of regular medications, referral when indicated

Frequency of review: every 3-6 months

Additional labs: FBC, calcium, phosphate, parathyroid homrone (6-12 monthly if GFR <45)

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23
Q

At what GFR should parathyroid hormone be checked and how frequently

A

GFR <45

  • every 6 -12 months
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24
Q

RED CLINICAL ACTION PLAN: CKD

A

Goals: prepare for renal replacement if necessary

Frequency of review: 1-3 monthly

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25
Q

What are the 5 As?

A

Ask

Assess

Advise

Assist

Arrange

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26
Q

Which 2 groups of patients should have their CVD risk assessed?

A

Adults > 45

ATSI people > 35

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27
Q

CVD risk and CKD

A
  • any patient with moderate to severe CKD is KNOWN to be at increased CVD risk
  • > macroalbuminuria, eGFR <45
  • > diabetes and age > 60
  • > diabetes with microalbuminuria
  • > familiar hypercholesterolaemia
  • > SBP > 180, DBP >110
  • > serum total cholesterol > 7.5

High risk = > 15% CVD risk

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28
Q

Diabetes targets in CKD

A
  • BGL: 6-8 fasting or 8-10 post prandial
  • HbA1c generally <7 (6.5-7.5)
29
Q

Diabetic medications and CKD

A

Metformin: reduce dose GFR 30-60, contraindicated if GFR <30 (cease when unwell)

SGLT2 inhibitors: contraindicated in moderate renal impairment (GFR <45) (significant renal and CVD benefits in people with CKD and diabetes)

Gliptins (DPP4I): safe in CKD with dose adjustment

Sulphonyurea: dose reduction required GFR <30

GLP1 agonist: contraindicated GFR <30 (potential CVD benefits)

30
Q

Which class of anti-hyperglycaemia may cause UTI?

A

SGLT2 inhibitors

  • Increase urinary glucose excretion
31
Q

HTN management in CKD

A
  1. ACEI/ARB (monitor GFR and K)

Consider adding

  • CCB, diuretic or beta blocker
  • refer to nephrologist if not consistently below target with atleast 3 anti-hypertensive agents
32
Q

What rise in serum potassium is expected in CKD when ACEI are started?

A

>0.5mmol/L

Hence need to caution in patients with baseline potassium of >5.5

33
Q

Diuretics in CKD

A

GFR >45 = non-loop diuretic (i.e. thiazides)

GFR <45 = loop diuretic (frusemide)

Frusemide can be safely used for management of fluid overload in all stages of CKD, including when GFR <30

-

34
Q

Commonly prescribed drugs that adversely affect renal function in CKD

A
  • aminoglycosides
  • calcineurin inhibitors (cyclosporine, tacrolimus)
  • gadolinium
  • lithium
  • NSAIDs, COX 2 inhibitors
  • contrast
35
Q

Prevention of AKI in CKD patients who are sick or dehydrated: medications to withhold

A

ACEI

ARB

NSAIDs

Diuretics

SGLT2 inhibitors

Increased risk of adverse effects due to reduce clearance: metformin, sulfonyluria, atenolol

SADMANS

Sulfonyluria, ACE, diuretics, metformin, ASRB, NSAIDs, SGLT2

36
Q

Polycystic kidney disease

A

3 total cysts if < 40, 2 in each kidney if 50-60 or 4 in each kidney if > 60

  • treatment: tolvaptan
37
Q

Indications for referral to nephrologist in CKD

A
  • GFR <30 (stage 4 and 5 of any cause)
  • persistent albuminuria
  • sustained GFR decrease of >25% within 12 months or sustained decrease of 15ml/min per year
  • CKD with hypertension that is hard to control despite 3 anti-hypertensive agents

Not indicated if stable GFR > 30, urine ACR <30, controlled blood pressure

38
Q

Signs and symptoms of acute nephritis

A
  • oliguria
  • haematuria
  • acute HTN
  • oedema
39
Q

Acidosis in CKD

A
  • GFR <30 = increased risk of metabolic acidosis

TreatmentL sodiBic: with aim to keep HCO3 > 22

40
Q

Management of albuminuria in CKD

A
  • degree of albuminuria relates to severity of disease
  • target = 50% reduction in urine ACR
  • management: ACEI/ARB, reduction of salt intake, spironolactone (with caution!)
41
Q

Anaemia in CKD

A
  • target Hb 100-115
  • due to reduced EPOI, resistance to action of ESA, reduced iron absorption
  • starts to develop when GFR <60
  • aims of ESA therapy are ferritin 200-500 and TSAT 20-30%
  • exclude other causes: b12/folate, IDA, GIT blood loss, TSH, hyperparathyroidism
42
Q

Depression in CKD

A
  • Common: 1/5 CKD and 1/3 on dialysis
  • SSRIs safe in CKD
43
Q

Microscopic haematuria in CKD

A
  • r/o infection
  • if there is associated reduction in GFR –> consider glomerulonephritis, urinary tract US, referral to nephrologist
  • nil reduction of GFR –> consider urological malignancy, refer for cytolic and ultrasound + urological review
44
Q

Management of hyperkalaemia

A

Target K < 6

  • impaired urinary excretion of potassium
  • may rise with ACEI/ARB
  • K 6-6.5: low K diet, correct acidosis (HCO3 >22), thiazides, consider resonium, cease ACEI/ARB/spironolactone if K persistently > 6 and not responsigve
  • K > 6.5 –> refer to ED due to risk of arrythmia
45
Q

Target albumin in CKD

A

>35

46
Q

CKD pruritis

A
  • evening primrose oil
  • skin emollients
  • avoid soap and detergent
  • topical capsaicin
  • if pruritis and restless legs consider gabapentin
  • can refer to dermatologist for UBV therapy
47
Q

Management of restless legsin CKD

A

Check iron status and replace if deficient.

Home therapies such as massage, warm baths, warm/cool compresses, relaxation techniques, exercise.

Low dose dopaminergic agents or dopamine agonists.

Benzodiazepine

48
Q

Stages of CKD and yellow/orange/red classification

A
49
Q

CKD risk factors: who should be screened?

A
  • smokers
  • obesity, BMI > 30
  • FHx
  • Diabetes
  • HTN
  • ATSI > 30
  • Established CVD
  • History of AKI
50
Q

Common presentations of glomerulonephritis

A
  • nephritic syndrome:
  • nephrotic syndrome
  • GN and infection
  • GN and drugs
  • GN and purpuric skin rash
  • GN and cancer
51
Q

Causes of nephrotic syndrome

A
  • minimal change disease
  • membranous GN (HbsAg, CXR, mammogram)
  • FSGS
  • SLE (ANA, anti-ds SNA, C3, C4)
  • Diabetes (FGL)
  • Amyloid (urinary bence jones, serum and urine protein electrolphoresis)
52
Q

Causes of nephritic syndrome

A

IgA nephropathy

Poststrep GN

SLE

Anti-GBM disease

ANCA vasculitis

Mesangiocapillary GN

53
Q

Presentation of nephritic syndrome

A
  • macroscopic haematuria (cola coloured urine)
  • severe hypertension
  • progressive oliguria and renal impairment
  • unwell patient, often abrupt onset
54
Q

Nephrotic syndrome triad

A
  • oedema
  • hypoalbuminaemia
  • heavy proteinuria > 3.5g/day due to disruption of glomerula filtration barrier
55
Q

What is the most common cause of GN?

A

IgA Nephropathy

56
Q

Management of APSGN outbreaks

A
  • occassionally outbreaks occur due to specific GAS strains
  • management is to treat all children in community with any evidence of school sores with IM penicillin
57
Q

Diagnostic criteria for PSGN

a) clinical
b) lab

A

CLINICALLY: at least of 2 of the following:

  • facial oedema and/or peripheral oedema
  • hypertension
  • moderate haematuria on dipstick (2+ RBC)

LAB

  • haematuria on microscopy
  • evidence of recent strep infection: positive GAS culture or elevated ASO titre or anti-DNase B
  • reduced C3 complement level
58
Q

Management of PSGN

A
  • IM benzathine penicillin regardless of whether skin sores or pharyngitis arte present at time of presentation
  • admission!
59
Q

Contact tracing with PSGN

A
  • need names of family and household/close contacts of supsected case including adults and children who have been stating in the household 2 weeks prior to onset of symptoms
  • need to examine skin for sores/scabies, BP to checked, urine to be checked and if sore present should be swabbed
  • any child 12 months to 16 years are to be given LA bicillin whether skin sores a present or not
  • if > 17 treat with Abx if infected skin sores present
  • if scabies presenty treat with 5% permethrin or ivermectin if > 15kg for heavy or recurrent infections
60
Q

Which class of CCB causes peripheral oedema?

A

Dihydropyridines (felodipine, amlodipine)

  • causes peripheral oedema due to redistribution of extracellular fluid (rather than fluid retention)
  • will not respond to diuretics
  • may put patient at risk of volume depletion
61
Q

When is urinary protein excretion highest?

A

In the afternoon!

62
Q

Three initial investigations for men with LUTS

A

Urinalysis

Urinary tract ultrasound

Serum creatinine/estimated glomerular filtration rate

63
Q

Common drugs whch may need to be reduced or ceased in CKD

A
  • apixaban, dabigatran, rivaroxaban
  • gabapentin, lithium, pregabalin
  • opioids, benzos
  • spironolactone, digoxin
  • allopurinol, cochicine
  • fenofibrate
  • NSAIDs
64
Q

Relative anatomy: haematospermia

A
  • testes –> epididymis –> vas deference –> ejaculatory duct
  • fluid from sminal vesciles, prostate and Cowper’s glands the mixes with the sperm to form ejaculate
65
Q

Causes of haematospermia

A
  • Infection: bacterial (STI, entococcus, TB), viral (HIV, CMV, HSV)
  • Iatrogenic: post TRUS, radiation, post vasectomy
  • Malignancy: prostate, bladder, testicular, urethral
  • Trauma: coital trauma, pernieal trauma
  • Prolonged abstinence
  • Obstruction: duct obstruction, cysts or calculi
  • Systemic disorders: HTN, CLD, lymphoma, leukaemia, amyloidosis, bleeding disorders
66
Q

Red flags: haematospermia

A

Age > 40

Recurrent or persistent

Prostate cancer risk factors: family hx of African heritage

Constitutional symptoms (weight loss, anorexia, bone pain)

67
Q

Approach to haematospermia

A
  • screen for red flags (malignancy)
  • common aetiologies: UTI/prostatitis/STI
  • examination: BP, temperature, genital examination, DRE
  • systems review: feature of CLD, lymphoma or leukaemia
  • investigation: urine MCS, urine cytology, FBC, coags
  • if STI suspected –> NAAT for chlamydia and gonorrhoea
  • PSA in men > 40 or if abnormal DRE
68
Q

Indications for urology referral: haematospermia

A
  • Men > 40
  • persistent or recurrent
  • suspicious DRE fidning
  • abnormal PSA
  • suspicion of malignancy
  • concurrent haematuria
69
Q
A

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