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What is diabetic nephropathy?

Microvascular complication of diabetes
1. Glomerular + tubular Hypertrophy- Inc GFR
2. Glomerular Hyperfiltration (mesangial Hyperexpansion)
3. Microalbuminuria
4. Clinical Nephropathy (Dec GFR, proteinuria)
= end stage renal failure


Why can diabetic nephropathy be difficult to pick up via GFR?

GFR actually increases in early stages of diabetic nephropathy due to hypertrophy of glomerular + tubular cells (+mesangial cells at a later stage)
+ GRF dysfunction is hard to detect as an issue till drops to below 60%


What is the cardiac link with chronic kidney disease?

LVH/ Renal vascular disease
Investigate- Abdominal Aortic Angiogram (look for stenosis)
Atheromebolic Disease- Eosinophilia + peripheral skin lesion (purpuric rash) common in Its on warfrin


What is vasculitis?

Inflammed reaction in wall of any blood vessel- can be in single/ multiple organs and defined by size of vessel involved
Aortic/Large- Takaysu, Giant Cell
Medium- Polyartritis nodosa, kawasaki disease
Small- granulomatous polyarteritis (wegners), microscopic polyarteritis (pulmonary), eosioniphilic polyarteritis


What is granulomatous polyarteritis (wegners)?

Small vessel inflammatory vasculitis of the respiratory tract
Upper- epistaxis, sinusitis, deafness, nasal deformity
Lower- cough, dyspnoea, haemoptysis, pulmonary haemorrhage
+ pericarditis, scleritis, myalgia
Vasculitis rash


How do you diagnose and treat vasculitis?

Urine- blood, protein, urea/ creatinine
Bloods- Inc CRP, Inc AlkPh (Biliary,liver)
Hyperglobulaemias, +ve ANCA(PANCA microscopio, CANCAwegners)
Renal Biopsy
Treats- steroids + immunosuppressants


What is the link between renal disease and infective endocarditis?

Bacterial/ Fungal Infection of Cardiac Valves (step viridians, staph aureus, enterococci, HIV-IVdrugs) the immune complexes stick in kidneys - glomerulonephritis + small cell vasculitis
Do echo, CXR (cardiomegaly) and 3 sets of blood for infection
Give vancomycin + gentamicin + rifampicin (general) till know cause
Strep- penicillin/ vancomycin (if allergic)
Staph- flucoxacilin/ flucoxaciliin + rifampicin + gentamicin (if prosthetic)
Treat Endocarditis will treat renal disease


What stops urine coming up from the bladder back into the kidney?

Pressure of urine in bladder and muscle of bladder and ureters stops urine flowing back up


Where are the 3 constrictions of the ureter? Why are these clinically important?

Pelvic-Ureteric Junction
Crossing of ureter with common iliac artery
Vesico-ureteric junction- into bladder


What angle do ureters enter the bladder at?

Acute angle


Where is the urinary tract sterile from?

Kidney- internal urethral orifice (upper urthera)


How do you take a urinary specimen? What must you be careful of?

Void- stop midstream- disguard-take more= Mid Stream Specimen of Urine (MSSU) stop contamination via bacteria from terminal urethera (gut +skin)


How do you diagnose a urinary tract infection?

MSSU bacterial count of >104 + symptoms (fever, tachycardia, suprapubic pain/tenderness, inc frequency and urgency, dysuria)


What can a UTI lead to if infection spreads?

Uretheritis- Urethra
Bladder- Cystitis
Ureterritis- ureters
Acute Pylonephritis- Kidney (if recurrent/ prolonged- chronic pyelonephritis)


What predisposed someone to a UTI?

1. Urine Stasis- obstruction (vesicoureteric-congential, benign prostatic hyperplasia, uterine prolapse, tumours/ calculi)
2. Pushing bacteria up urethra- sex (uncomplicated UTI- short urethra, pregnancy), elderly, poor voiding (MS, stroke)
3. General- catheterisation, ureteric stent, diabetes, abnormal tract, oestrogen deficiency, bowel-bladder fistula, immunosuppression/steroids


What are the signs and symptoms of a UTI?

Flank pain
Dysuria (painful micturition)
Smelly. cloudy Urine
Suprapubic Pain (affecting bladder)
Kids- failure to thrive, fever, nausea, vomit, not eating (reflux nephropathy- cystogram)


How do you investigate and treat a UTI?

Investigate- MSSU + microscopy (>104), urinalysis (blood, leukocytes, protein)
US (kids + men)
Treat- Fluids, Antibiotics (amoxycillin) if severe use IV and advice on predisposing factors (eg./ void before and after sex)


What are the complications of UTI?

Actue- sepsis
Chronic- chronic pylenephritis= hypertension + Chronic renal failure
Bladder- squamous cell carcinoma, retension


What is nephrolithiasis? What is the most common type?

Kidney stones- calcium most common component- calcium oxalate most common stone- best seen on x-ray
Triple Phosphate- Infective via chronic infection, cant see these/ gallstones on X-ray


A Pt presents with-
Renal Pain- fixed in loin
Repeated UTI
Loin Tenderness (pain radiates to genitals)
What is the most likely diagnosis? How would you investigate this?

Nephrolithiasis (kidney stones)
Constant pain with mild fluctuations (not colic unless in hollow organ)
Investigate via
Bloods- FBC, creatinine, calcium, phosphate
MSSU + microscopy
CT KUB best
KUB xray- calcium stones
(US can miss stones so complimentary use)


How do you treat nephrolithiasis?

Kidney Stone- Surgical
1. Extracorporeal shock wave lithotripsy (<2cm sized stones, cant give if pregnant/ anticoagulants)
2. Percutaneous Nephrolithotomy, open surgery (rare- simple/ partial/ total nephrectomy least reassurance rate)
3. Open ureterolithotomy- flexible uretero-renal scope + stent
4.Endoscopic- is severe


A Pt presents with
Supra pubic/ groin/ penile pain
Sudden interrupted stream
persistent Uti
What is your most likely clinical diagnosis and how do you treat this?

Bladder stones
Treat via transurethral cystolitholapaxy- camera, US waves to crush


What is AKI? How is it staged?

Rapid loss of glomerular filtration and tubular function over hours- days (lose fluid balance, electrolyte homeostasis, acidosis,
AKI 1- urine output <0.5mL over 6-12hrs
AKI 2- urine output <0.5 over >12hrs
AKI 3- urine output <0.3mL >24hrs/ anuria for 12hrs


What are the main causes of acute kidney injury?

1. Pre-Renal- Blood flow to kidney eg./ haemorrhage, dehydration, vomiting, diarrhoea, diuretics, laxatives, hypotension, congestive cardiac failure, liver failure, arterial occlusion, NSAIDS, Ace Inhibitors, OCP, Intrinsic (damage to renal parenchyma), acute tubular necrosis (drugs, radio contrast), acute glomerulonephritis (autoimmune, drugs, infection), acute intersitiual nephritis, vasculitis, Inc BP.
2. Post-Renal- urine obstruction, intraluminal , intramural (stricture, malignancy, prostatic disease), extramural (retroperitoneal fibrosis, malignancy)


How does hypotension/ hypovolemia tie into AKI?

Results in acute tubular necrosis kidney is susceptible to hypo perfusion due to heterogeneity of blood supply


How are myelomas involved in renal disease?

Monoclonal proliferation of plasma cells
presents as anemia, back pain, chord compression, hypercalcaemia- diagnose via bone marrow aspiration, urinary bence jones protein, serum paraprotein


How would you investigate a suspected case of AKI?

Urine- dipstix for blood + protein, PCR (albumin- creatinine ratio)
Renal USS
Renal Biopsy


How do you prevent an onset of AKI from risk groups?

Risk Groups- previous, elderly, heart failure, liver disease, DM, vascular disease
S-sepsis 6 treatment
T-Toxins-gentamycin, NSAIDS, IV contrast
O- Optimise Bp and volume (fluids + remove diuretic meds)
P- Prevent harm- u+e, medication and fluid balance


How do you treat sepsis?

Sepsis 6
1. Blood Cultures
2. Urine + U+E monitoring
3. Fluids
4. Antibiotics
5. Lactate Levels
6. 02 stats


What are the 5Rs for IV prescribing?

Routine Maintenance


What are the stages of chronic kidney disease?

1- GFR >90 some damage
2- GFR 60-89
3- GFR A(45-59), B (30-44)
4- 15-29
5- <15 (dialysis)


Why is creatine not a good marker of kidney function?

Creatinine will be in normal range until 60% of total kidney function is lost
Also affected by muscle mass (more muscle mass= higher serum creatinine)


What would you find in urine is GBM is damaged?

WBC< RBC, high molecular weight proteins (globulin, albumin) eg./ good pastures disease


What is CKD?

Presence of kidney damage (abnormal blood, urine, xray findings) OR GFR <60ml/min
caused by Diabetes, glomerulonephritis (IgA, vasculitis), hypertension, renovascular disease (eg./ renal artery stenosis, atherosclerosis) and all causes of acute over 3months


A Pt presents with-
Polyuria, oliguria, nocturne
Peripheral oedema
Vomit, anorexia, ureic odour
congnitive dysfunction.
What is your most likely diagnosis? How do you confirm this and how would you go about treating it?

Chronic Kidney Disease
Bloods- anemia, glucose, LFTs, bicarb, creatine kinase
Urine dipstick- blood and proteins
Us kidney
Biopsy (if large/ unclear diagnosis)
Cause- obstruction/ drugs/ Ca/ glucose control
BP control- ACE Inhibitors, Angiotensin Receptor Blockers,
statins (CV risk of atheroma) + anticoagulants
anemia (b12, folate, iron)
acidosis- sodium bicarb
loop diuretics (oedema)


What do you have to be careful of when treating a Pt with acidosis?

If they are hypertensive as sodium bicarbonate increases blood volume
this can occur in chronic kidney injury due to acidosis (result of kidney failure) and hypertension (causing kidney failure)


What is the treatment for someone in stage 5 chronic kidney disease?

Stage 5 GRF <15= dialysis (haemodiaylisis, peritoneal), transplant


What are the signs and symptoms of glomerulonephritis?

Inflammation of glomeruli and nephrons
Heavy Protenuria (nephrotic syndrome)
Acute Renal Failure
Hypertension (malignant)


What are the main causes of haematuria?

Urinary Tract Stones
Urinary Tract Tumour


What is the difference between and nephrotic and nephritic presentation?

Nephrotic- Mild Inc in BP, proteinuria (>3.5mg/day), GFR normal or slightly decrease
Nephritic- Malignant hypertension, haematuria (mild, macro), GFR big drop


What is IgA glomerulonephritis (most common)?

Antibody (IgA) stuck in mesangium - proliferation- mesangium + matrix expansion- End Stage Renal Failure
Test: Diptick (haematuria)- US- Biopsy- Immunoflourescence
Treat: self limiting


How do you treat glomerulonephritis?

BP control- 130/ 80 OR <125/75 if protenuria
Angiotensin Converting Enzymes, ARBs (reduce protenuria and preserve renal function)


What is membranous glomerulonephritis?

IgG deposits between basal lamina and podrocytes (not into urine)- membrane thickens and leaky- compliment activated and punches holes in filter- albumin filtered into urine= protenuria, nephrotic syndrome- End stage renal failure
Can be linked to an underlying malignancy, NO immune link so investigate via clotting factors + renal biopsy


How is diabetic nephropathy linked to glomerulonephritis?

Glycated molecules stick to each other- ito endothelium and mesangial matrix- compress capillaries + fill bowman space (adhesion to glomerular tuft)- Inc mesangial matrix (kimmelstelt Wilson Lesion)


What is crescentic glomerulonephritis?

Acute-Chronic RF (systemic unwell)
US + renal biopsy + clotting factors
Bowmans space filled with macrophages (inflammation- crescent shaped) caused by granulomatous polyarteritis (wegners)/ microscopic polyarteritis- ANCA (c)


What is diffuse proliferative-post infective nephritis?

Post streptococcal infection (10-21 days after) get streptococcal antigen in glomerulus- PROLIFERATIVE
Presents as nephritic syndrome (haematuria, malignant hypertension, decrease GFR, puffy face)
Treat- antibiotics, loop diuretics, vasodilatory drugs (hypertensive ACE-I, ARB)


What is focal necrotising anti-glomerular basement membrane disease?

Goodpastures disease (autoantibodies to TIV collagen, also in lung- pulmonary haemorrhage) PROLIFERATIVE of epithelial cells and macrophages ruptures bowman capsule
Presents as nephritic syndrome
Treat via- corticosteroids + immunosuppressants (eg./ B cell therapy, complement inhibitors)


What is non-proliferative, minimal change syndrome?

Kids- lose high amount of protein, oedema
Can get recurrences but prognosis good and chances of ESRF are low
Treat via- prednisolone (steriods) and then further course eg./cyclosporin if recurrent episodes (beware of toxicity in recurrent episodes)


What is focal, segmental glomerulonephritis?

Nephrotic syndrome + sclerosis + steroid resistance (high risk of end stage disease)


What renal presentations would be suitable for imaging?

Renal Colic/ Renal Stone
Suspected Renal Mass
UTI (males, kids, repeated, non-clearing)
Hypertension- essential, secondary to renal pathology eg./ glomerulonephritis (nephritic syndrome), polycystic kidneys, atheroma


What urinary type problems would a KUB x-ray be used to see/diagnose?

Urinary tract stones (calcium shows up well)
Filling defect (intravenous urogram)


What type of urinary problems can a pyelography be used to diagnose?

Injection of contrast into ureters (xray)- can be used to see shapes and stores (phasing out)


What can a micturating cystourethrography be used be diagnose?

Vesico-urteric reflux, paediatric imaging


What type of urinary disorders can an ultrasound be used to diagnose?

NOT stones (is complementary only)
contrast not nephrotic, cheap, no radiation
No functional info
can be used to see megaureter - dilated ureter, renal tumour (colour doppler- vascularity), bladder tumour, renal artery stenosis (hypertension)


What type of urinary disorders can a CT be used to diagnose?

Renal Stones, Staging, Renal tumours, Investigating haematuria
Contrast is nephrotoxic


What type of urinary disorders can an MRI be used to diagnose?

Duplex collecting system (double ureter), Horseshoes kidney, renal TCC/ urothelial carcinoma
NOTE: cant looks for mets in hollow organs eg./ lungs and contraindicated in pacemakers, claustrophobia, hip replacements, prosthetic valves etc


What type of urinary disorders can a PET CT be used to diagnose?

Extra-urologicals mets (limited due to urinary uptake)


What can isotope scans be used to diagnose?

DMSA- renal scaring/stones/UTI
MAG3- Renal function + drainage
Bone Scan- mets


Where is common metastatic spread from the kidney?

Bones, liver, lung, brain, suprarenal, other kidney


What is hydronephrosis?

Swelling of kidney due to urine build up


A Pt presents with-
Painful inability to void with palpable and perusable bladder
What is your clinical diagnosis? How could this have occurred? How do you treat this?

Acute Urinary Retension
Cause- Benign prostatic obstruction (worsened by constipation, alcohol etc), alcohol, UTI, urethral stricture
Treat: Catheterisation, alpha blocker (if no renal failure)


A Pt presents with-
Painless palpable and precussible bladder after voiding
What is your clinical diagnosis? How could this have occurred? How do you treat this?

Chronic Urinary Retension
Cause- Detrusor inactivity- Primary (primary bladder failure), Long Standing (bladder outlet obstruction eg./ benign prostatic enlargement
Presents as multiple UTIs, bladder stones, outflow incontenece
Treat: IMMEDIATE catheterisation possible TURP (resect prostate)


What are the possible complications of Chronic Urinary Retension?

UTI, haematuria, electrolyte abnormalities
Diuresis- physiological/ pathological


What is the difference between physiological and pathological diuresis?

Physiological- <200ml/hr
Pathological >200ml/hr


What is the red flag sign for impaired urinary retension?

New onset bed wetting


A Pt presents with-
Colicky Pain
Frank Haematuria
Palpable Mass
What is your likely diagnosis? How would you investigate and treat this?

(upper) urinary tract obstruction
Non-contrast CT (nephrotoxcitiy)
Percutaneous Nephrotomy insertion/ retrograde stent instertion / treat underlying cause eg./ shock wave litripsy is urinary stone, laparoscopic pyeloplasty if PUJ obstruction


A Pt presents with-
Acute/ Chronic Urinary Retension
Recurrent UTI + Sepsis
Frank Haematuria
Bladder stones
Renal Failure
What is your likely diagnosis? How would you investigate and treat this?

Lower Urinary Tract Obstruction
Urinary Retension- catheterise immediatley
Treat- ABC, USS of renal tract, BPE-TURP, optical urethrectomy (urethral stricture), circumcision (phimosis)


2 Pst present to A+E
1. Painless peeing, in content, inc creatinine
2. Painful retension, slightly decreased creatinine
How do you treat them both? Why?

1. Chronic Kidney Retension- risk of diuresis- drop BP- hypovolemia
2. Acute retension- catheterise and go home


What are the 3 types of haematuria?

1. Microscopic (>=3 blood cells per high power field)
2. Macroscopic/ Frank ( biggest malignancy risk)-flexible cystaurethroscopy, CTU, USS
3. Dipstick


What is proteinuria?

Urinary protein excretion >150mg/day
Shouldn't be any as basement membrane keeps large molecular weight proteins eg./ albumin in and proximal tubule catches the low molecular weight ones


A Pt presents with-
Unexplained visible haematuria
What investigation is required? What is this to rule out?

Cytoscopy- up urethra to look at bladder to rule out bladder and renal cancer (TCC, SCC)
Treat via cystectomy- remove bladder


What is colon diverticulosis?

Colon-vesicle fistula


What is the function of the prostate? Where is it?

Under bladder- secondary sexual organ without which can ejaculate but sperm won't work


Where are most prostate cancers found? What investigation confirms this?

Posterior Zone- Digital Rectal Examination


What 3 things make up the HALD diagram?

1. Lower Urinary Tract Symptoms- voiding (hesitancy, poor stream, dribbling, incomplete emptying), Storage (frequency, nocturia, urgency)
2. Benign Prostatic Enlargement- fibromusclar and glandular hyperplasia, affects transitional zone
3. Bladder Outflow Obstruction


How do you investigate a suspected Benign Prostatic

Penis- phimosis
Digital Rectal Examination, MSSU, flow rate, dipstick (blood- flexible cystoscopy)
Bloods- PSA (marker of benign disease/ treatment response of malignant disease)
Renal Tract US (if obstruction/ stones suspected)
TRUS (guided prostate biopsy if PSA Inc/ abnormal DRE)


How do you treat benign prostatic obstruction (due to glandular hyperplasia)

1. Uncomplicated BPO- Watch and Wait +Alpha blockers (smooth muscle relaxes) +5⍺reductase inhibitors (break down testosterone (decrease prostate size and decreases cancer of medium grade cancer but possibly increases change of high grade) + TURP (gold standard)
2. Complicated(medical therapy not sufficient)- Cystolitholapaxy (remove ureteric stone), TURP, catheterisation


What is the most common type of bladder cancer?

1. Transitional cell carcinoma- smoking, genetic (TSG), pelvic radiotherapy
2. Squamous Cell Carcinoma- schistosomiasis (subsuharian), chronic cysts
3. Adenocarcinoma- urachal (rare, embryological)


How does bladder cancer present?

Painless, visible haematuria, recurrent UTi (SCC), Storage (dysuria, frequency, nocturne, urgency/incontence, bladder pain)


How do you diagnose and stage bladder cancer? What are the treatment options?

1. Cystoscopy + Endoscopic Resection
2. Endoscopic US of Abdomen to asses bladder mass/ thickening (before + after)
3.CT + bone scan for mets
TREAT- 1. Low grade non muscle invasive (Tis/Ta/T1) endoscopic resection + intravesicle chemo, follow up with IV chemo if recurrence
2. High Grade (no muscle invasion) intravesicle BCG therapy/ radical surgery (aggressive so endoscopic resection not enough)
3. Muscle Invasive (T2a/b,3a/b + 4a)- Neoadjuvant chemo, radical radiotherapy/ cystoprostatectomy


How is TCC graded?

1. Well differentiated (commonly undifferentiated)
2. Moderately differentiated (often non-invasive)
3. Poorly Differentiated (often invasive)


How does an upper urinary tract cancer present? How do you investigate and treat this?

Transitional Cell Carcinoma
presents- frank haematuria, unilateral ureteric obstruction, flank/loin pain, (bone pain, hypocalcaemia is mets)
Diagnose- CT, Intravenous Urogram, urine cytology, stereoscopy + biopsy
Treat- nephrourectomy, nephrosparing endoscopic treatment's (bilateral/unfit), endoscopic (unfit/low grade)


How does renal cell carcinoma present? What investigations would you carry out? How do you treat it?

Triad- Haematuria, flank pain + mass
Paraneoplastic syndrome- anorexia, pyrexia, anemia, abnormal LFTs
Investigate- CT(abdo + chest), Bloods-u+E, FBC, LFT, IVU, US (cyst/tumour), DMSA/MAG3 urogram
Treat- surgical- laparoscopic radical nephrectomy/pallative cytoreductive nephrectomy


What is prostate cancer?

Commonest male malignancy
Adenocarcinoma (FH + Inc testosterone)
Locally Invasive- haematuria, suprapubic pain, incontenece, renal failure, haemospermia- watch + wait/ radiotherapy/ radical prosectomy/cryotherapy/thermotherapy. If advanced cant do active surveillance, androgen therapy (limit testosterone levels), castration (chemical/surgical), anti-androgens, oestrogen
Distant Mets- Bone pain, sciatica, paraplegic,
Widespread Mets- Lethargy, weight loss, cachexia (wasting)
Diagnosis- PSA (kallikerein Serinci Protease) leads to over diagnosis and over treatment + age specific


What is the difference in location by benign prostatic hyperplasia and prostate adenocarcinoma?

BPH- Transitional Zone
AC- Peripheral Zone


How is TNM staging used to grade cancers?

T-local spread (1+2 close to normal cells, 3 outside capsule, 4 adjacent organs)
N- regional spread
M-distant spread


Where does testicular cancer spread to?

para-aortic lymph nodes


Where does penile cancer spread to?

Inguinal lymph nodes


How does testicular cancer present? How do you investigate and treat it?

Lump- tender, swollen. Could be infection eg./ epidydimal orchitis, epididymal cyst, testicular torsion)
Investigate- MSSU, testicular US and CxR, biomarkers
treat- radical orchidectomy
+ surveillance/ adj radiotherapy (low stage)
+ chemo + lymph node resection (nodal)
+ chemo (mets)


What are the markers for different types of tesicualr cancer?

AFP- teratoma
BHCG- seminoma
LDH- unspecific