Nephrology Flashcards

Question

Describe the diagnosis and management of ADPKD

Answer 1

Diagnosis - Family history > Age 15-30: 2 unilateral or bilateral cysts > Age 30-59: 2 cysts in each kidney > Over age 60: 4 cysts in each kidney - No family history > 10 or more cysts in both kidneys > Renal enlargement > Liver cysts - Ultrasound > Differentiate between simple renal cysts - CT or MRI more sensitive - Genetic testing Management > Supportive > Early detection and management of blood pressure > Treat complications > Manage extra-renal associations > Prepare for renal replacement therapy Tolvaptan > Vasopressor antagonist, acts at V2 receptor - counteracts vasopressin > Delays onset of RRT by 4-5 years > Side-effects: hepatotoxicity, hypernatraemia

Answer 2

Inherited progressive glomerular disease Second most common inherited kidney disease Caused by an inherited defect in type IV collagen (basement membrane) - found in ears, eyes and kidney Usually X-linked - more severe presentation in males Collagen IV abnormalities > Alpha 3 gene mutation > Alpha 4 gene (COL3A4) mutation > Alpha 5 (COL3A5) mutation Deafness and renal failure – can affect other organs including eyes Presentation > Asymptomatic persistent non-visible haematuria from early childhood > Proteinuria, hypertension and progressive renal impairment > ESRD – 90% on dialysis or transplanted by age 40 > Sensorineural hearing loss in late childhood > Ocular defects >> Lens – anterior lenticonus >> Retina – bilateral white or yellow granulations >> Cornea – posterior polymorphous dystrophy, recurrent corneal erosion Management > Supportive – BP control > Prepare for dialysis or transplant

Answer 3

Rare X-linked lysosomal storage disorder Alpha galactosidase A deficiency resulting in accumulation of globotriaosylceramide (Gb3) Also causes neuropathy, cardiac and skin features GB3 accumulates in glomeruli, particularly in podocytes causing proteinuria and ESRF > Pro-inflammatory and pro-fibrotic Clinical presentation > Intermittent episodes of burning pain in extremities > Cutaneous vascular lesions – angiokeratomas > Diminished perspiration > Characteristic corneal and lenticular opacities > Abdominal pain, nausea and/or diarrhoea > Left ventricular hypertrophy > Arrythmia > Stroke > CKD and proteinuria Diagnosis > Measure alpha-Gal A activity in leukocytes (unreliable in females) > Renal biopsy >> Inclusion bodies of G3b aka zebra bodies Management > Enzyme replacement therapy; prevents progression to irreversible tissue damage

Answer 4

Pronephros Mesonephros Metanephros Nephrogenesis commences in week 10 No new nephrons after 36 weeks Approximately 1 million nephrons per kidney GFR > 120mls/min/1.73m2 > At birth: 40-65 mls/min/1.73m2

Answer 5

Pronephros Mesonephros Metanephros Nephrogenesis commences in week 10 No new nephrons after 36 weeks Approximately 1 million nephrons per kidney GFR > 120mls/min/1.73m2 > At birth: 40-65 mls/min/1.73m2

Answer 6

Renal hypoplasia – reduction in number of nephrons but normal architecture Renal dysplasia – malformed renal tissue Renal hypodysplasia – congenital small kidneys with dysplastic features Presentation > Antenatal:US growth > Neonate: >> Lung issues >> IUGR >> Acidosis >> Raised creatinine > Children >> FTT >> Anorexia >> Vomiting >> Proteinuria Management - supportive

Answer 7

Congenital absence of renal parenchymal tissue: metanephric stage Male:female preponderance Unilateral or bilateral (mostly sporadic) Associated with increased risk of other anomalies

Answer 8

- Multicystic dysplastic kidney (MCDK) - ADPKD - ARPKD

Answer 9

Abdominal mass detected antenatally or neonatally Involution: 35-65% Risks > Hypertension > Malignancy

Answer 10

Congenital hepatic fibrosis: subclinical to liver disease > Portal hypertension > Ascending cholangitis

Answer 11

Presentation > Haematuria > Hypertension > Flank pain > UTIs Associated anomalies > Mitral valve prolapse > Cerebral aneurysm > AVM > Hepatic / pancreatic cysts > Colonic diverticula / hernia

Answer 12

Male preponderance Bilateral in some cases Associated with renal injury and renal impairment Postnatal US – renal pelvic diameter >10mm Causes > Vesico-ureteric reflux > Obstruction of urinary tract

Answer 13

Level of obstruction - Pelvis/ureter (PUJ) > Partial/total blockage of urine at ureter junction with kidney > Males > females > Bilateral in some > Antenatal diagnosis >> Abdominal mass, UTI, failure to thrive (FTT) >> Abdominal or flank pain >> Ureter - Ureter/bladder (VUJ) > Vesico-ureteric junction obstruction > Functional or anatomical abnormality >> Megaureter >>> Primary: reflux / obstruction >>> Secondary: bladder issues >> Ureteric dilation >7mm - Bladder > Posterior urethral valves >> Most common obstructive uropathy >> Antenatal detection >> Investigations: US, MCUG >> Bilateral hydronephrosis; UTI >> Management – cystoscopy, ablation of valve >> Risk of CKD and bladder dysfunction - Urethra

Answer 14

Decline of renal excretory function over hours or days > Avoid eGFR – not reliable in AKI > Serum creatinine more reliable Severity of AKI – KDIGO - Stage 1 > Serum creatinine >1.5 and <2x AKI baseline or >26 micromol/l increase above AKI baseline - Stage 2 > Serum creatinine >2.0 and <3x AKI baseline - Stage 3 > Serum creatinine 3x AKI baseline or > >354 micromol/l increase above AKI baseline Oliguria <1mL/kg/h in infants <0.5mL/kg/h in children <400-500mL/24h in adults

Answer 15

Pre-renal > Hypovolaemia + hypotension > Reduced effective circulating volume > Drugs > Renal artery stenosis Renal > Glomerular >> Glomerulonephritis > Tubular >> Ischaemic ATN >> Nephrotoxic ATN >> Myeloma cast nephropathy > Tubulointerstitial >> Drugs >> Myeloma >> Sarcoid Post-renal > Renal papillary necrosis > Kidney stones > Retroperitoneal fibrosis > Carcinoma of the cervix > Prostatic hypertrophy/malignancy > Urethral strictures

Answer 16

Hypotension Hypovolaemia > Blood loss > Diarrhoea/vomiting > Burns Reduced effective circulating volume - hypoperfusion > Cardiac failure > Septic shock > Cirrhosis Hypoxia Drugs > ACEi > NSAIDs Toxins Renal artery stenosis

Answer 17

Large blood vessels > Polyarthritis nodosa Glomeruli and small blood vessels > Glomerulonephritis > Vasculitis Tubular > Ischaemic acute tubular necrosis (ATN) >> Unresolved pre-renal causes: >>> hypoperfusion or direct toxicity >>> Hypotension >>> Sepsis Toxins Exogenous > Drugs > NSAIDS, gentamicin, ACEi > Contrast > Poisons (metals, antifreeze) Endogenous > Myoglobin (rhabdomyolysis) > Haemoglobin > Immunoglobulins (myeloma) > Calcium > Urate Nephrotoxic ATN > Toxins (ethylene glycol, lithium), contrast, gentamicin > Myeloma cast nephropathy Tubulointerstitial > Acute tubulointerstitial nephritis > Rhabdomyolysis > Drugs > Myeloma > Sarcoid

Answer 18

Hypovolaemia leads to a fall in glomerular filtration pressure Prostaglandins dilate afferent arteriole to increase flow as MAP falls towards 80 mmHg > Blocked by NSAIDs Efferent arteriole can vasoconstrict, increasing glomerular pressure > Blocked by ACEi

Answer 19

Acute or chronic Bloods – both urea and creatinine elevated Potassium must be controlled as it can cause heart problems > <6.0 is abnormal but no immediate concern > 6.0-6.4 risk of arrhythmia > >6.5 is a medical emergency Urine output Clinical assessment of fluid status > BP, JVP, oedema, heart sounds Underlying diagnosis – history, exam, meds

Answer 20

- Circulation - restore renal perfusion - Treat hyperkalaemia - Treat pulmonary oedema if present - Remove causes: drugs, sepsis... - Exclude obstruction and consider renal causes - Refer to ICU or renal unit

Answer 21

Protect the heart > IV calcium gluconate 10ml 10% as cardiac membrane stabiliser Drive K+ into cells > Insulin 10-15 units actrapid + 50ml dextrose – moves potassium into cells > If raised potassium and low bicarb, supplementation of bicarb – IV NaBicarb 1.26% > Beta agonists – nebulised salbutamol Remove K+ from body > Acute >> Haemodialysis >>> Refractory potassium >6.5 mmol/l >>> Refractory pulmonary oedema >>> May be considered for >>>> Acidosis (pH < 7.1) >>>> Uraemia (pericarditis, encephalopathy) >>>> Toxins (lithium, ethylene glycol...) >> Loop diuretic - furosemide > Long-term >> Reduce absorption from gut – calcium resonium 15g/day orally or enema

Answer 22

Polyuric phase 48-72h Up to 6L urine/day Often subsequent low K, Ca, Mg Tubules fail to concentrate urine

Answer 23

Kidney damage or GFR <60ml/min per 1.73m2 for 3 months or more Aetiology - Diabetic nephropathy - Glomerular sclerosis - Nodular lesions - Proteinuria and deterioration of renal function - Renovascular disease / ischaemic nephropathy - Chronic glomerulonephritis - Membranous glomerulonephritis - IgA nephropathy - Reflux nephropathy / chronic pyelonephritis - ADPKD - Obstructive uropathy

Answer 24

- Pruritus - Nausea, anorexia, weight loss - Fatigue - Leg swelling - Breathlessness - Nocturia - Joint/bone pain - Confusion Advanced CKD - Peripheral and pulmonary oedema - Pericardial rub - Rash/excoriation - Hypertension - Tachypnoea - Cachexia - Pallor & lemon yellow tinge

Answer 25

eGFR <30 Iron absorption and utilisation are suboptimal Replace iron, B12 and folate if low Treatment > ESA (erythropoiesis stimulating agent) e.g. darbepoietin alfa 30 micrograms every 2 weeks > Trigger usually Hb < 100g/L > Target Hb is 100-120g/L

Answer 26

Reduced 1-alpha hydroxylation of 25-hydroxycholecalciferol - low vitamin D, low calcium Reduced phosphate excretion - high phosphate High PTH – can lead to osteitis fibrosa cystica, left ventricular hypertrophy... Treatment > Activated vitamin D: alfacalcidol > Mg supplements > Phosphate binders > Calcium-based: calcium carbonate/acetate > Non-calcium: sevelamer, lanthanum, aluminium > Calcimimetic: cinacalcet > Parathyroidectomy

Answer 27

Slowing progression > Aggressive BP control - ACEi/ARB > Good diabetic control > Diet > Smoking cessation > Lowering cholesterol > Treating acidosis Renal replacement therapy (RRT) > Conservative care > Home-based therapies >> Home haemodialysis >>> Most start with eGFR 6-8ml/min >>> Side-effects >>>> Weight loss and persistent nausea >>>> Persistent hyperkalaemia >>>> Acidosis >>>> Severe hyperphosphataemia >>>> Pruritus >>>> Problematic fluid overload >> Peritoneal dialysis > Hospital-based therapies >> Hospital haemodialysis >> Self-care unit > Transplant

Answer 28

Medically resistant hyperkalaemia Medically resistant pulmonary oedema Medically resistant acidosis Uraemic pericarditis Uraemic encephalopathy

Answer 29

Anorexia Vomiting Itch Restless legs Weight loss Metallic taste

Answer 30

> Hospital or home > Daily or nocturnal Mechanism > Blood is removed using a blood pump > Passed through arterial circuit into dialysis filter > Blood flows countercurrent to dialysis fluid > Dialysis fluid is lower in concentration of solutes such as potassium, phosphate... > Removal of solutes from blood e.g. potassium, urea occurs via diffusion down a concentration gradient > Removal of fluid or "ultrafiltration" occurs through hydrostatic filtration > Filtration removes fluid and dialysate is discarded > Passes through dialysis filter into an air detector and back into patient > Continuous loop for 4 hours Access > AVF access >> Arteriovenous fistula – connection between artery and vein If veins not suitable for procedure, graft can be used > TCVC (tunneled central venous catheter)

Answer 31

CAPD (continuous ambulatory peritoneal dialysis) or APD (automated peritoneal dialysis) Daily or nocturnal

Answer 32

Donor kidney placed in right or left iliac fossa Ureter is shorter Stent placed from donor kidney to bladder, removed a few weeks after transplantation Native kidneys are left in body unless causing infection

Answer 33

Fatigue Fluid restriction Restricted diet – potassium, phosphate Women are infertile Reduced life expectancy

Answer 34

Reduced life expectancy > Older age > Comorbidity Surgical contraindications > No bladder > Calcified blood vessels Medical contraindications > Hypertension > Hypotension > Diseases that will recur in the transplant

Answer 35

> Body recognises cell surface proteins as "non-self" > Blood group or HLA incompatibility Pathogenesis of transplant rejection > Foreign antigenic peptide recognised and bound by APC > APC presents foreign antigenic peptide to T cell receptor and binds > T cell activated, produces IL-2 > Leads to cascade of events and results in activation of T and B cells, as well as antibody production Cell-mediated rejection > Interstitial inflammation and tubulitis > Treated with steroids > Diagnosis – biopsy > Does not present with proteinuria Antibody-mediated rejection > Endothelial swelling, glomerulitis and peritubular capillaritis > Donor specific antibodies > May present with proteinuria

Answer 36

Basiliximab > Chimeric mouse-human monoclonal antibody directed against IL-2 receptor Tacrolimus > Calcineurin inhibitor Mycophenolate mofetil > Inhibitor of inosine-5'-monophosphate dehydrogenase – depletes guanosine nucleotides in T and B lymphocytes, inhibits proliferation Steroids

Answer 37

Rejection Infection Common organisms in common sites > Chest infection > Skin/wound infections > Urine infection Re-activation infections > CMV disease – pneumonitis, colitis, hepatitis, renal disease > BK nephropathy Uncommon organisms > Pneumocystis jirovecii Malignancy > Kaposi sarcoma > Skin: non-melanoma, non-epithelial; melanoma > Non-Hodgkin & Hodgkin lymphoma > Lung > Kidney > Colon and rectum > Pancreas

Answer 38

Bacteria in urine Asymptomatic Affects preschool age (girls > boys), adults (females > boys) Other risk factors > Urinary catheterisation > Diabetes > Anatomical abnormalities of urinary tract > Pregnancy Management > Treat asymptomatic bacteriuria only in >> Preschool children >> Pregnancy >> Renal transplant >> Immunocompromised > Treatment in other asymptomatic patients not indicated

Answer 39

>95% caused by single organism > Gram negative bacilli >> E. coli >> Klebsiella species >> Proteus species >> Pseudomonas species > Gram positive bacteria >> Streptococcus species >>> Enterococcus species >>> S. Agalactiae (Group B streptococcus) >> Staphylococcus species >>> S. saprophyticus >>> S. aureus > Candida species >> Fungal balls >> Renal / peri-nephric abscesses > Anaerobes >> Associated with bladder malignancies Multiple organisms in > Long-term catheteres > Recurrent infections > Structural / neurological abnormalities Multi-drug resistant organisms > Anatomical/neurological abnormalities > Frequent infections > Multiple antibiotic courses > Prophylactic antibiotic use

Answer 40

Suprapubic discomfort Dysuria Urgency Frequency Cloudy, blood-stained, smelly urine Low-grade fever Sepsis Failure to thrive or jaundice in neonates Abdominal pain and vomiting in children Nocturia, incontinence and delirium in the elderly

Answer 41

Non-pregnant women > First presentation, culture not mandatory > Dipstick – high false positive rate > Check previous culture results Empirical antibiotic > Amoxicillin, trimethoprim, nitrofurantoin > Pivmecillinam, fosfomycin No response to treatment > Urine culture > Change antibiotic Children and men > Send urine for every presentation > Treat appropriately (empirical > targeted) Pregnancy > Send urine and treat each episode > Check previous sensitivities > Amoxicillin and cefalexin relatively safe > Avoid trimethoprim 1st trimester; avoid nitrofurantoin near term Recurrent UTI > Send sample from each episode > Encourage hydration, urge-initiated and post-coital voiding > Urology investigation > Intravaginal/ oral oestrogen > Antibiotic therapy as per symptoms Catheter-associated UTI > Colonisation common > Biofilm production by bacteria > Send CSU > Start antibiotic – initially empirical based on previous microbiology > Drug resistant and polymicrobial infections > Remove / replace catheter

Answer 42

Upper urinary tract infection > Moderate to severe infection > Flank pain +/- systemic infection > Enlarged kidney > Abscesses on surface of kidney (severe) Management > Urine > Blood culture > Imaging Community > Co-amoxiclav > Ciprofloxacin > Trimethoprim Hospital > IV antibiotics >> Amoxicillin / vancomycin >> Gentamicin / aztreonam / temocillin > Uncomplicated pyelonephritis > 7 day antibiotic course Complicated pyelonephritis > At least 2 weeks of antibiotics +/- radiological/surgical intervention (drainage of abscesses)

Answer 43

Renal abscess > Complication of pyelonephritis – similar symptoms > Positive urine and blood culture > Usually gram negative bacilli Can become life-threatening > Emphysematous pyelonephritis > Bubblewrap appearance > Poor response to antibiotic therapy alone Perinephric abscess > Uncommon > Often from haematogenous spread > Common organisms >> Gram negative bacilli – E. coli, proteus species >> Gram positive cocci – S. aureus, streptococci >> Candida species > Symptoms >> Similar to pyelonephritis >> Localised signs, local invasion > Investigations >> Urine and blood cultures usually positive >> Pyuria +/- bacterial growth > Poor response to antibiotic therapy – surgical management

Answer 44

Usually spontaneous; may follow urethral instrumentation Signs and symptoms > Diffuse oedema > Microabscesses > Perineal / back pain > UTI symptoms > Urinary retention > Pyrexia Complications > Prostatic abscess > Spontaneous rupture – urethra, rectum > Epididymitis > Ascending infection > Systemic sepsis Investigations > Urine and blood culture > Transrectal US > CT/MRI > Do not obtain prostatic secretions Likely organisms > Gram negative bacilli – E. coli, proteus species > S. aureus – MSSA, MRSA > Neisseria gonnorhoea Management > Empirically ciprofloxacin / ofloxacin

Answer 45

Rarely associated with acute prostatitis > May follow Chlamydia urethritis Signs and symptoms > Recurrent UTI symptoms > Perineal discomfort > Back pain > Low grade fever Relapse common Common organisms > Gram negative bacilli – E. coli, proteus species > Enterococcus species > S. aureus – MSSA, MRSA

Answer 46

Inflammatory reaction of the epididymis Cause > Ascending infection from urethra > Urethral instrumentation Symptoms > Symptoms of UTI / urethritis > Pain > Fever > Swelling > Penile discharge Common organisms > GNB, enterococci, staphylococci > TB in high risk areas and individuals > Rule out Chlamydia and N. gonorrhoea in sexually active men

Answer 47

Inflammation of one or both testicles Signs and symptoms > Testicular pain and swelling > Dysuria > Fever > Penile discharge Aetiology > Usually viral – mumps > Bacterial >> Pyogenic >> Complication of epididymitis >> IV antibiotics as per complicated UTI + surgical drainage Complications > Testicular infarction > Abscess formation

Answer 48

Form of necrotising fasciitis Usually >50 years of age Rapid onset and spreading infection Systemic sepsis Risk factors > UTI > Complications of IBD > Trauma > Recent surgery Common organisms > Mixed infections – mainly GNB and anaerobes Investigations > Blood cultures > Urine > Tissue / pus Management > Surgical debridement > Broad spectrum / combination antibiotics > Piperacillin-tazobactam + gentamicin + metronidazole +/- clindamycin

Answer 49

Age >65 Familial and genetic risk factors > Especially first degree relatives > Abnormalities on chromosomes 1q, 8p and Xp > BRCA2 gene mutations > PTEN and TP53 TSGs mutations Hormones Racial factors - increased risk in black population Geographic variation - highest incidence in westernised nations

Answer 50

Often asymptomatic Painful or slow micturition Urinary tract infection Haematuria – blood in urine Urinary retention – may cause anuria, uraemia Lymphoedema

Answer 51

Bone pain – most common symptom of metastases Renal failure – ureteric obstruction > Anorexia > Weight loss > Raised creatinine > Stent or nephrostomy Spinal cord compression > Urological emergency – urgent MRI > Severe pain > Off legs > Retention > Constipation > Radiotherapy v spinal decompression surgery

Answer 52

PSA is a serine protease (33kD) secreted into seminal fluid Responsible for liquefaction of seminal coagulation Efficiently hydrolyses semenogelins causing release of sperm Small proportion leaks into circulation > Tends to rise with age > Depends on prostate size > Is influenced by inflammation and infection

Answer 53

Digital rectal examination PSA – prostate specific antigen TRUS (trans-rectal ultrasound) – guided needle biopsy

Answer 54

Majority is primary adenocarcinoma Usually arises in peripheral zone of prostate Gleason grading 6 – well-differentiated, 25% likelihood of local progression 7– moderately differentiated, 50% likelihood of local progression >7 – poorly differentiated, 75% likelihood of local progression

Answer 55

TNM classification > T1 – within prostate > T2 – felt on DRE > T3 – cancer invades wall into seminal vesicles > T4 – cancer invades adjacent organ i.e. bladder, bowel, pelvic floor Localised prostate cancer > Watchful waiting > Active surveillance > Radiotherapy (with or without LHRH analogue) >> External beam >> Conformal >> Brachytherapy > Radical prostatectomy > Cryotherapy / HIFU > TURP if symptomatic Advanced prostate cancer > Androgen ablation therapy >> Medical castration – LHRH analogue >> Surgical castration – orchidectomy Chemotherapy TURP for relief of symptoms (transurethral resection of the prostate) Radiotherapy

Answer 56

Age >50 Race – more common in Caucasians Environmental carcinogens Chronic inflammation > Stones > Infection – schistosomiasis > Long-term catheters Drugs – phenacitin, cyclophosphamide Pelvic radiotherapy Occupation Smoking – especially from 4-ABP and naphythylamines

Answer 57

Presentation / diagnosis > Classically painless frank haematuria Investigations > Cystoscopy > Renal US > CT KUB

Answer 58

Transitional cell carcinoma (90%) > Superficial – 75% > Invasive – 25% Squamous carcinoma (5%) Adenocarcinoma (2%) Other secondaries Muscle invasive bladder cancer is highly aggressive

Answer 59

> Diagnosed at flexible cystoscopy > Urgent TURBT (trans-urethral resection of bladder tumour) > CT IVU > Bimanual examination carried out at TURBT > Intravesical mitomycin reduces risk of recurrence Low-grade superficial TCC > Flexible check cystoscopy 3 months > 30% chance of recurrence > Course of 6 weekly mitomycin treatment given for persistent Ta tumours High-grade non-muscle-invasive bladder cancer (HG NMIBC) > 80% recurrence risk; 50% chance of progressing to muscle invasive disease > Do early check cystoscopy and rebiopsy > Treat with intravesical BCG immunotherapy – effective in 50% > Course of 6 weekly instillations then further cystoscopy/biopsy > Cystectomy if treatment fails MIBC > Requires radical therapy > Radical cystectomy or radiotherapy > Bladder and prostate/uterus removed > Urine diverted into an ileal conduit or rarely an orthotopic neobladder > Neo-adjuvant chemotherapy Metastatic disease > Often pulmonary > Treat with chemotherapy > Classic M-VAC >> Methotrexate >> Vinblastine >> Doxorubicin >> Cisplatin > Gemicitobine / docetaxel

Answer 60

85% of all renal tumours Others > Transitional cell carcinoma > Sarcoma > Metastases Risk factors > Smoking > Obesity > Hypertension > Acquired renal cystic disease > Haemodialysis Genetics > VHL (Von Hippel Lindau) > HPRCC – hereditary papillary renal carcinoma > HLRCC – hereditary leiomyomatosis and renal cell cancer > Birt-Hogg-Dube > Tuberous sclerosis

Answer 61

Incidental Systemic symptoms > Night sweats > Fever > Fatigue > Weight loss > Haemoptysis Classic triad > Mass > Pain > Haematuria > Varicocoele > Lower limb oedema > Paraneoplastic syndrome >> Polycythaemia due to increased EPO >> Hypercalcaemia due to PTHrP or from osteolytic hypercalcaemia >> Hypertension due to renin secretion >> Deranged LFTs – Stauffer's syndrome – due to hepatotoxic tumour products

Answer 62

Histology > Clear cell (80%) >> Vascular, granular and clear (lipids) > Papillary > Chromophobe – large polygonal > Collecting duct – rare > Medullary cell – rare Staging - TNM staging > T3a – invasion into renal vein > T3B – IVC below diaphragm > T3c – IVC above diaphragm > T4 – beyond Gerota's and adrenal gland

Answer 63

Radical nephrectomy (includes Gerota's fascia, spares adrenal gland) > Large renal mass > If no absolute indication for nephron-sparing surgery (NSS) Indications for NSS > Single kidney > CKD > CV risk factors > pT1a tumours Small renal mass > Biopsy > Treatment >> NSS >>> Partial nephrectomy >>> Cryotherapy >> Radical nephrectomy >> Surveillance > Metastatic disease - tyrosine kinase inhibitors

Answer 64

Most common solid cancer in younger men (20-45) Most curable cancer Risk factors > Age 20-45 > Cryptorchidism > HIV > Caucasian population Clinical presentation > Painless lump

Answer 65

Scrotal ultrasound Tumour markers > Alpha-fetoprotein – teratomas and yolk sac tumours > Beta hCG – teratoma, seminoma > LDH – seminoma Classification > Germ cell tumours > Seminoma > Teratoma > Mixed > Yolk sac Stromal tumours > Leydig > Sertoli Other > Lymphoma > Metastasis

Answer 66

Radical orchidectomy Chemotherapy Para-aortic nodal radiotherapy Retroperitoneal lymph node dissection

Answer 67

Rare Associated with HPV infection (16, 18, 21) and smoking Premalignant lesions – chronic changes Even rarer in males circumcised at birth Treatment > Circumcision > Topical treatment CO2/5FU > Penectomy +/- reconstruction > Lymphadenectomy > Chemo-radiotherapy

Answer 68

Paired retroperitoneal organs (T12-L3)) Right lies lower than left; normally 10-12cm in length, 5-7cm wide and 3cm thick Surrounded by Gerota's fascia Clinically important > For PCNL (percutaneous nephrolithotomy) >> Upper pole more posterior and medial >> Medial surface more anterior > Gerota's fascia deficient inferiorly >> Often where haemorrhage or haematoma can appear after trauma

Answer 69

25-30cm long, 4-5mm calibre 3 segments > Proximal: PUJ-pelvic brim > Mid: segment over sacral bone > Distal: lower sacral border to UO 4 layers > Urothelial mucosa > Lamina propria > Muscular layer > Adventitial layer 3 physiological narrowings > Pelviureteric junction (PUJ) > Ureters cross iliac vessels at pelvic brim (midureter) > Vesicoureteric junction (VUJ) >> Ureter joins bladder

Answer 70

Intrinsic > Sex (male:female 2:1) >> Testosterone increases production of oxalate >> Females produce more citrate (productive) > Age: peak 20-50 years > Family history >> More common in Caucasian, Asian >> Familial renal tubular acidosis >> Cystinuria > Comorbid factors Extrinsic > Fluid intake > Diet >> High animal protein >>> High oxalate, low pH, low citrate >> High salt – hypercalciuria >>Low calcium diets > Sedentary lifestyle > High incidence in hot climates > Country of residence

Answer 71

Calcium oxalate stones most common > Radio-opaque: seen on X-ray Uric acid > Form due to chronic dehydration > Increased risk with gout, genetic tendency, diet with excess protein Calcium phosphate + calcium oxalate Pure calcium phosphate > Rare > May be seen in renal tubular acidosis Struvite > Seen in UTIs > Consist of magnesium, ammonium and phosphate > Require aggressive treatment of UTI Cysteine > Rare, predominantly associated with cysteinuria (genetically inherited condition) Xanthine > Enzyme deficiency causes buildup of xanthine deposits Silica > Rare > Caused by medications or herbal supplements

Answer 72

Undersaturated Supersaturated but stable – metastable Supersaturated with spontaneous precipitation – unstable Saturation product > level at which no more solute will dissolve in a solution without a change in pH, temperature Formation product – level at which spontaneous formation occurs Free particle model of stone formation > Crystals growing and agglomerating > Critical particle trapped in tubule Fixed particle model of stone formation > Crystals growing and agglomerating > Particle adheres to a damaged site on the tubule wall and other crystals agglomerate with it

Answer 73

Incidental Pain > Colic > Radiates from loin to groin > In males can be testicular or penile pain > Cannot settle > Unable to stay still Haematuria > Visible or non-visible Sepsis/infection > Unknown source until imaged DDX > AAA > Appendicitis > Gynae pathology

Answer 74

History and examination Bloods > U&Es, CRP, FBC Urine > Dipstick MSSU > Calcium > Urate > Sodium nitroprusside – cystine Stone analysis Imaging > Gold standard – CT KUB >> Stone diameter >> Skin to stone distance > Ultrasound >> Especially young females > X-ray >> Better for follow-up of known radioopaque stone

Answer 75

Analgesia > NSAIDs – reduce pain due to reduced glomerular filtration, renal pressure and ureteric peristalsis Tamsulosin > Alpha blocker which blocks muscle contraction > Relaxes ureter and encourages stone passage Surgical options > Ureteroscopy and basket > Ureteroscopy and fragmentation > FURS – flexible ureteroscopy > ESWL – extracorporeal shockwave lithotripsy > PCNL – percutaneous nephrolithotomy Evidence of sepsis > Retrograde ureteric stent >> Inserted by urology under anaesthetic >> Connects bladder to kidney >Nephrostomy >> Inserted percutaneously by interventional radiology in an antegrade fashion

Answer 76

Produces a shockwave > Electrohydraulic > Electromagnetic > Piezoelectric Direct effect > Shearing > Spalling Cavitation effect > Shockwave in fluid causes a microbubble > Dissolved gas in fluid around bubble expands into bubble > Bubble collapses > Microjets enter stone causing fragmentation

Answer 77

Branched stones that fill all or a part of the renal pelvis and branch into several or all of the calyces Most often composed of struvite > Bacteria produce urease, breaks down urea into ammonia > Causes alkalinisation of urine and formation of magnesium ammonium phosphate crystals

Answer 78

Creates a percutaneous tract from skin to kidney Able to clear larger volumes of stone e.g. struvite Increased risk as it is an invasive procedure

Answer 79

Intracellular > 2/3 of fluid > Composition: potassium Extracellular > 1/3 of fluid > Composition >> Interstitium: sodium, chloride >> Plasma (intravascular)

Answer 80

Third space losses > More fluid in extracellular compartment than there should be e.g. low albumin in intravascular space – fluid taken into interstitium > Interstitial space becomes overexpanded Risk of osmolar problems > Cerebral oedema >> Acute hyponatraemia > Osmotic demyelination syndrome >> Sodium corrected too quickly

Answer 81

Relevant history > Fluid depletion – diuretics, abnormal losses > Fluid overload - heart failure, renal failure Symptoms > Fluid depletion – postural hypotension, thirst, dry mouth > Fluid overload – breathlessness, swollen ankles Signs > Fluid depletion – reduced skin turgor, CRT >2 secs, tachycardia > Fluid overload – hypertension, increased JVP, 3rd heart sound, pulmonary oedema Lab tests > Fluid depletion - U&Es, especially high urea > Fluid overload – serum albumin

Answer 82

Resuscitation > Restore circulation to vital organs following loss of intravascular volume Clinical signs of hypovolaemia > Hypotension > Tachycardia > Peripherally cool > CRT > 2 secs > NEWS > 5 Passive leg raising suggests fluid responsiveness Fluid bolus, usually saline or Hartmann's Routine maintenance > Patients not drinking / unable to drink / having to fast for over 8-12h > Calculate requirement based on >> Projected losses >> Intake e.g. IV drug volumes / NG feed Replacement > Treat deficits or ongoing losses not needed urgently for resus Redistribution Reassessment > Daily U&Es and fluid balance > Consider daily bicarbonate or magnesium if abnormal GI or renal losses

Answer 83

Crystalloids > Saline (various, 0.9% is standard) >> Distributes between extracellular compartments > Dextrose (various, 5% is standard) >> goes straight into intracellular compartments > Balanced solutions e.g. Hartmann's or Ringer's lactate >> Distributes between extracellular compartments > Sodium bicarbonate (1.26%) - expert advice only Colloids > E.g. Gelofusion or starch-based fluid > Stay in intravascular space Blood products > Packed red cells > Platelets or fresh frozen plasma (clotting factors) > Human albumin solution

Answer 84

Severity of AKI – KDIGO Stage 1 > Serum creatinine >1.5 and <2x AKI baseline or >26 micromol/l increase above AKI baseline Stage 2 > Serum creatinine >2.0 and <3x AKI baseline Stage 3 > Serum creatinine 3x AKI baseline or >354 micromol/l increase above AKI baseline

Answer 85

The dialysate contains dextrose. Absorbing some of the dialysate might cause the consumption of hundreds of extra calories daily, leading to hyperglycaemia and weight gain.

Answer 86

Antithrombin II deficiency can be inherited or acquired. The patient has nephrotic syndrome, which is associated with a loss of antithrombin III from the kidneys resulting in an acquired deficiency and a hypercoagulable state and thus puts this patient at risk of the development of deep vein thrombosis.

Answer 87

Painless flank mass, haematuria, and paraneoplastic features including hypertension, polycythaemia, hypercalcaemia, and Cushing's syndrome Localised renal cancer (that is 7 cm or larger) is definitively treated with a radical nephrectomy. Adjuvant treatment does not help completely resected disease

Answer 88

elevated serum creatinine level sinusitis hematuria pleural effusions positive result of antineutrophil cytoplasmic antibody test

Answer 89

staphylococcus epidermis

Answer 90

IgA nephropathy would occur a few days after the respiratory infection rather than weeks.

Answer 91

IM diclofena

Nephrology Flashcards

(117 cards)