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Year 4 > Genitourinary > Flashcards

Genitourinary Flashcards

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1
Q

Define AKI

A

Rapid decline in renal excretory function over hours or days recognised by a rise in urea and creatinine

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2
Q

What is the KDIGO grading for AKI?

A

Stage 1 - Increase by >/=1.5 but < 2 X baseline creatinine or an increase >26micromol/L in 48 hours
Stage 2 - Serum creatinine > 2 - 2.9 X baseline
Stage 3 - Serum creatinine > 3 X baseline or > 354 micromols/L

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3
Q

Give some examples of causes of pre-renal, renal and post-renal disease?

A

Pre-renal: Circulatory failure and hypo perfusion (Renal artery stenosis, hypovolaemia due to blood loss or inadequate fluids, cirrhosis or heart failure)
Renal: Gentamicin, ischaemic ATN, nephrotoxic ATN, glomerulonephritis, interstitial nephritis
Post-renal: Renal papillary necrosis, LN compression, prostate Ca, cervical Ca, urethral strictures, kidney stones

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4
Q

What are the absolute indications for dialysis?

A

Refractory potassium >/=6.5

Refractory pulmonary oedema

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5
Q

What are some management options in patients with anaemia in CKD?

A

Darbepoietin alfa - EPO
Alfacalcidol - Inc vit D to inc Ca
Phosphate binders (due to hyperphosphataemia)
Cincacalcet - to reduce PTH due to 2ndary HPTH

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6
Q

How would you classify CKD?

A

Stage 1 - > 90ml/min/1.73m^2 (normal or increased eGFR with evidence of some renal damage)
Stage 2 - 60-89 (slight decrease in eGFR with other evidence of kidney damage)
Stage 3 - 30-59 (moderate kidney disease)
Stage 4 - 15-29 (severe renal disease)
Stage 5 - < 15 (established renal failure)

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7
Q

What are some complications of CKD?

A

Anaemia
Renal bone disease (renal osteodystrophy)
CVD
Peripheral neuropathy

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8
Q

What characterises nephrItic syndrome?

A

GMB damage
HTN
Protein and blood in urine
Rapidly declining kidney function

Urinary sediment shows RED CELL CASTS, leucocytes, sub-nephrotic range proteinuria and dysmorphic red cells.

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9
Q

What triad characterises nephrOtic syndrome?

A 
Proteinuria >3g/day
Serum albumin < 25g/L
Peripheral oedema 
Dyslipidaemia
Loss of Ig - risk of infections. 
Loss of antithrombin III - risk of VTE
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10
Q

What is IgA nephropathy?

A

AKA Berger’s disease
Mesangial cell disease
Presents in 20s
Heavy proteinuria, visible haematura. HTN
Precipitated by synpharyngitis (upper respiratory tract infection)
May be secondary to coeliac or cirrhosis

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11
Q

What is the most common GN?

A

FSGN commonets in adults
Membranous
Mostly idiopathic, 10% secondary to malignancy
Nephrotic syndrome
Anti-phospholipase A2 receptor
Prone to thrombosis due to loss of anti-thrombin III in urine
IgG complexes and complement depositions on GBM

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12
Q

What is the commonest GN in children?

A

Minimal change disease I
Nephrotic syndrome
Fusion of foot processes

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13
Q

What causes rapidly progressive GN/ crescentic GN?

A

Lupus nephritis
HSP nephritis
ANCA vasculitis
Good pastures syndrome (anti-GBM)

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14
Q

What is transplant rejection?

A

When the body recognises cell surface proteins as ‘non-self’, blood group incompatibility, HLA incompatibility. T cell mediated or antibody mediated rejection.

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15
Q

How can you prevent transplant rejection?

A 
Immunosuppression: 
Basiliximab - anti-IL-2
Tacrolimus - Calcineurin inhibitor 
Mycophenolate mofetil - inhibits T and B cell proliferation 
± steroids - azathioprine, cyclosporin
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16
Q

What are the indications for renal replacement therapy?

A

AEIOU
Acidosis - severe and not responding to treatment
Electrolyte imbalance - severe and nor responding hypERkalaemia
Intoxication - overdose
Oedema - severe and not responding pulmonary oedema
Uraemia - seizures, reduced consciousness, uraemic pericarditis, encephalopathy

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17
Q

What symptoms characterise uraemic syndrome?

A

Itch, metallic taste, vomiting, restless legs, anorexia , weight loss

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18
Q

How does haemo-dialysis work?

A

Diffusion and pressure
Diffusion of solutes into dialyte solution - K and Urea
Filtration of fluid by hydrostatic pressure

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19
Q

What are some complications of haemodialysis?

A 
Crash 'acute hypotension'
Access problems
Fatigue 
Air embolism 
Blood loss
Hypokalaemia 
Cramps
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20
Q

How does Peritoneal dialysis work?

A

Diffusion and osmotic filtration
Uses the peritoneum to filter fluid. Dialysis solution is put into the peritoneum, it is high in glucose, it absorbs waste and extra fluid and then is removed.
Called Exchange

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21
Q

What are some complications of peritoneal dialysis?

A 
Infections - peritonitis
Development or worsening control of diabetes 
Hernia, dislodged catheter 
Encapsulating peritoneal sclerosis 
Hypoalbuminaemia 
Psychological effects
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22
Q

What other treatment would you need to give if a patient with kidney failure who is receiving dialysis?

A

Anaemia - EPO and iron
Renal bone disease - Phosphate binders, Vit D
Neuropathy
Endocrine

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23
Q

What are the types of Adult polycystic kidney disease?

A

PKD 1 - on chromosome 16 - rapidly progressive and leads to ESRD
PKD - on chromosome 4 - slowly progresses and will not usually reach ESRD

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24
Q

What causes PKD?

A

Polycyctins are over expressed in cysts
They are found in the renal tubular epithelium
They usually regulate IC calcium
Cysts gradually enlarge - increased pressure - normal kidney tissue replaced, kidney volume increased. eGFR drops.

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25
How can PKD present?
Loin pain, HTN, impaired renal function, haematuria Extra-renal: Hepatic and pancreatic cysts, abdominal hernia, diverticular disease, bronchiectasis, LVH
26
What drug could you give in PKD before you eventually need to start RRT?
Tolvaptan - Vasopressin V2 receptor antagonist to increase urine output by blocking reabsorption of water SE - hepatotoxic (monitor LFTs), hypernatraemia
27
What is Alport's syndrome?
X-linked. Collagen 4 abnormalities Deafness, eye problems and renal failure. microscopic proteinuria, haematuria and ESRF Sensorineural hearing loss in late childhood. 90% on dialysis or transplant by 40
28
What disease is due to alpha galactosidase 4 deficiency?
Fabry's disease. X-linked Accumulation of Gb3 in glomeruli and podocytes - proteinuria and ESRD Check alpha-gal4 activity in leukocytes and renal biopsy for inclusion bodies of gb3 Replace enzyme
29
How might renal artery stenosis present?
Resistant to treatment Flash pulmonary oedema Worsened renal function with ACEi/ARB in bilateral stenosis Increased bp
30
Give the pathogenesis of renovascular disease.
Progressive narrowing of the renal artery with atheroma 20% stenosis - GFR falls but oxygenation of cortex and medulla maintained Stenosis at 70% and there is cortical hypoxia - microvascular damage and inflammation and oxidative pathways Parenchymal inflammation and fibrosis progresses and becomes irreversible. Give statin AVOID ACEi/ARB
31
What is amyloidosis? | Nephrotic syndrome
A group of disorders characterised by EC deposits of insoluble proteins in abnormal fibrillar form and are resistant to degradation 8-10nm linear aggregated fibrils
32
What is primary amyloidosis?
AL amyloidosis. Ig fragments from haematological conditions such as myeloma or monoclonal gammopathy of undetermined significance Light chain can break off or bone marrow can produce excess light chain.
33
What organs can be damaged in AL amyloidosis? (amyloid light chain)
GI- malabsorption, hepatomegaly, N&V, diarrhoea Purpura Renal - proteinuria (frothy urine) and nephrotic syndrome CV - restrictive cardiomyopathy, arrhythmias Carpal tunnel and peripheral and autonomic neuropathy
34
What is secondary amyloidosis?
AA amyloid. Serum amyloid precursor protein An acute phase reactant protein raised in chronic inflammation or infection - Crohns, RA, TB Hepatospenomegaly, nephrotic syndrome
35
What is systemic lupus erythromatous?
A multisystem, inflammatory AI connective tissue disease where autoantibodies are formed agains a variety of autoantigens causing tissue damage.
36
What immunology is involved in SLE?
``` >95% ANA positive high dsDNA - renal involvement C3 and C4 low Anti-ribosomal - CNS involement Anti-phospholipid antibodies ```
37
What symptoms may be seen in SLE?
Butterfly rash, Photosensitive rash Arthritis, pain and tenderness in prox IPJ, Pericartitis Reynaud's Dry mouth and eyes Seizures Haemolytic anaemia, thrombocytopenia, PEs Miscarriage, pre-eclampsia - antiphospholipid Ab
38
What treatment is used in mild SLE?
DMARD - Hydroxychloroquine NSAIDs Low dose corticosteroids - prednisolone Aspirin
39
What treatment would you use for severe SLE?
``` DMARDs- Azathioprine, cyclophosphamide High dose corticosteroids Immunosuppressants Omeprazole Aspirin ```
40
What is Acute tubular necrosis?
Damage and necrosis of the epithelial cells of the renal tubules. Due to hypo perfusion of the tubules ± direct toxicity
41
What might Acute tubular necrosis show on urinalysis?
Muddy brown casts
42
What is renal agenesis?
Congenital absence of the renal parenchymal tissue that occurs during the metanephric stage.
43
What is renal hypoplasia?
Reduction in the number of nephrons but normal kidney architecture
44
What defines a recurrent UTI?
More than 2 infections in 6 months or more than 3 in 12 months
45
What organisms can cause complicated and uncomplicated UTIs?
Uncomplicated: E.coli, klebsiella, proteus mirabilis (PM forms staghorn stones) Complicated: E.coli, pseudomonas, klebsiella, staph, enterococci, proteus
46
What symptoms may indicate a lower UTI?
Increased frequency, urgency, dysuria, small voiding volume, feverish, suprapubic pain
47
What symptoms may indicate upper UTI?
Suprapubic tenderness, palpable bladder, renal angle tenderness, vomiting, rigors, fever
48
What antibiotics can you use in a UTI in a pregnant woman?
Fosfomycin 3g PO 1 dose Amxocillin 500mg PO tdd 7d Cefalexin 500mg PO bd 7d
49
What is Orchitis?
Inflammation of one or both testicles
50
What conditions are associated with urolithasis?
Gout, hyperparathyroidism
51
What is frank haematuria?
Dark red blood with clots
52
What is pseudo-haematuria?
Red or brown urine that is not secondary to the presence of Hb. Rifampicin, methyldopa, vaginal bleeding, dyes -beetroot, myoglobin (rhabdomyolysis), hyperbilirubinaemia
53
What is Virchow's triad? for renal cell Ca
Flank pain, haematuria, palpable abdominal mass
54
How might RCC present?
Respiratory symptoms if mets to lungs - Cannonball mets Left varicoele Lower limb oedema Paraneoplasric syndrome
55
What paraneoplastic syndrome can occur in RCC?
Polycythaemia - increased EPO Hypercalcaemia Hypertension - increased renin Stauffers syndrome - hepatotoxic tumour products
56
What are the types of RCC?
Clear cell - 85% papillary chromophobe
57
What is Von Hippel Lindau syndrome?
AD mutation inactivating the TSG on P53 Pheochromocytoma Renal and pancreatic cysts Cerebellar hemiangioma
58
What therapies can be used in bladder cancer?
NMIBC TURBT - transurethral resection of bladder tumour Mitomycin C - intravesicular chemotherapy - prevents recurrence BCG therapy - intravesicular immunotherapy - prevents T1 to T2 MIBC Radical cystectomy - removal of the bladder + prostate/uterus - ureters plugged into Neobladder (studier pouch from ileum) or ileal conduit Radiotherapy ± chemo
59
What is the most common type of prostate cancer?
Adenocarcinoma of the peripheral zone
60
What genetic factors put you at an increased risk of prostate cancer?
BRCA 2, PTEN, TP53 | Gleasons grading system
61
What are the red flags of prostate cancer that indicate mets?
Ureteric obstruction - May present with AKI Hypercalcaemia- *SCLEROTIC bony mets - may present with bone pain Spinal cord compression - may present off legs, severe pain, constipated, urinary retention
62
What are retractile testes?
Intermittent active cremasteric reflex retracts the testes most commonly into the external inguinal ring.
63
What complications can arise from undecided testes?
Reduced fertility Increased risk of testicular cancer Increased risk of testicular torsion Increased risk of indirect inguinal hernia
64
What is testicular torsion?
When mobile testes rotate on the spermatic cord, leading to a reduction in arterial blood flow. There is reduce venous return and so venous obstruction, venous congenstion, increased pressure, arterial compression, irreversible ischaemia, necrosis
65
What types of testicular tumours are there and what is the most common?
Germ cell tumours (most common) - Seminoma, Teratoma, yolk sac Non-germ cell - Interstitial/stromal cell tumours - leydig, sertoli. - other - lymphoma, metastatic
66
What tumour markers could indicate testicular cancer?
Alpha-fetoprotein - in yolk sac and teratoma (oncofoetal marker) bHCG - in seminoma and teratoma (oncofoetal marker) LDH - in seminoma
67
Where is AFP produced and what malignancies does it indicate?
Yolk sac Liver, pancreas, testes, stomach Benign hepatic disease
68
What produces bHCG and what malignancies is it associated with?
Syncitiotrophoblasts Nearly all choriocarcinomas, 20% seminomas Lung, pancreas, testes, stomach, breast, kidney, bladder Hypogonadism
69
What organisms commonly form epididymitis?
Neisseria gonorrhoea | Chlamydia trachomatis
70
What can cause orchitis?
Mumps
71
What are risk factors for penile caner?
Smoking, HPV 16,18,21
72
What is erectile dysfunction?
The inability to achieve or maintain an erection satisfactory for sexual intercourse
73
What are some causes of erectile dysfunction?
Psychogenic - anxiety, depression Drugs - antihypertensives, recreational drugs, alcohol Vascular - atheroma, DM Neurological - Parkinson's disease, pelvic fracture
74
What treatment can you use in erectile dysfunction?
Oral phosphodiesterase - 5 inhibitors - Sildenafil (viagra)
75
What is priapism?
``` Abnormally sustained erection unrelated to sexual stimulation High flow (arterial) - Non-ischaemic Low flow (venous) - Ischaemic (EMERGENCY) ```
76
How might a fistula in ano present?
Knife like pain on defecation that feels like throbbing min-hours after. due to pelvic floor spasm Fresh blood on wiping.
77
How might an anal fissure present?
Sharp anal pain like cut glass, during and after (for ~45min) defecation. Some blood.
78
What is the most common cause of lower GI bleeding?
Diverticulosis
79
What are some causes of confusion?
Hypoxia, hypoglycaemia, bladder outflow obstruction - urinary retention, UTI, sepsis (infection), hepatic encephalopathy, stroke, hypercalcaemia, drugs/medication, dehydration, dementia, delirium
80
What triad may be seen in ulcerative colitis?
Abdominal pain, bloody diarrhoea, weight loss
81
What extra-intestinal signs can be seen in IBD?
``` A PIE SAC Apouthous ulcers Pyoderma gangrenous Iritis Erythema nodosum Sclerosing cholangitis Arhtritis Clubbing ```
82
What criteria is used to grade severity of ulcerative colitis?
Truelove and Witts Mild - <4 bowel movement per day, small amount of blood mixed in with stool. Moderate - 4-6 bowel movements per day with more blood mixed in Severe - >6 bowel movements per day, visible blood in stool, anaemia, ESR>30, Pyrexial, HR > 90 Fulminant - > 10 stools per day, continuous blood in stool, anaemia, pyrexial, ESR > 30, HR >90
83
What criteria is used to know if you need urgent hospital admission in UC?
Severe colitis Moderate disease that doesn't response to steroids within 2 weeks Partial treatment response should be seen urgently in OPS
84
List the possible complications of bowel dilation?
Toxic megacolon, Perforation, severe haemorrhage
85
What are the indications for surgery in UC?
Toxic megacolon, perforation, severe haemorrhage, failed medical therapy. Panproctocolectomy, left with ileostomy or J pouch
86
What treatment options are available in UC?
Mainting remission in Mild-mod 1st line Mesalazine or sulfasalazine 2nd line - IV prednisolone or budesonide 3rd line - azathioprine or 6-mercaptopurine 4th line - biological agents - Anti-TNF - influximab, golimumab 5th - surgery
87
How does Mesalazine work?
Anti-inflammatory effect on the colonic epithelium 500mg given to maintain remission SE - arthralgia, diarrhoea, cough, leucopenia
88
What are the side effects of immunomodulators azathioprine and 6-mercaptopurine?
Lymphoma, non-melanoma skin cancer
89
What are some Sx and signs of CKD?
Sx - Pruritis, breathlessness, Fatigue, joint/bone pain, leg swelling, confusion Signs - Peripheral & pulmonary oedema, rash, HTN, tachycardia, pallor or lemon yellow tinge
90
What are some differences between acute and chronic retention?
Acute <24hr, can be due to GA, Alcohol, UTI, constipation, usually painful urgency, Normal U&Es, no incontinence, ~400-1000ml, when drained clear urine, Chronic >24hr, painless, usually insidious, AKI with eGFR in single figures, strong Hx of LUTS and overflow incontinence, >1L, when drained haematuric due to decompression bleeding
91
What are some secondary causes of GN?
Myeloma, CLL, IBD, ALD, coeliac, amyloidosis. lupus, hepatitis, malaria, HIV, TB, NSAIDs, bisphosphonates
92
What is the staging in RCC?
``` T1a - <4cm, T1b - 4-7cm, T2 >7cm T3a - into renal vein T3b - into IVC below diaphragm T3c - IVC above diaphragm T4 - beyond gerotas fascia and/or adrenal gland ```
93
What is Prehns sign?
When you lift up the symptomatic side (testicle), if the pain is relieved then is shows a diagnosis of epididymitis, if the pain is worse or not relived is might be testicular torsion
94
What is the most common cause of nephrotic syndrome in adults?
Focal segmental glomerulosclerosis | Segmental scarring of certain glomeruli and fusion of podocyte foot processes
95
How might good pastures disease present?
Antibodies to GBM which is the same as in alveoli so nephritic syndrome and pulmonary haemorrhage - haemoptysis IgG along BM

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