Presentation of Kidney and Urinary Tract Diseases Flashcards
(100 cards)
1
Q
Name for infection of renal system
A
Pyelonephritis
2
Q
Name for inflammation of glomerulus
A
Glomerulonephritis
3
Q
What hereditary syndromes can be found to do with renal diseases?
A
Polycystic kidney disease
Nephrotic syndrome
4
Q
What is infection/inflammation of the ureter called?
A
Ureteritis
5
Q
When can the ureter be cut accidentally?
A
Hysterectomy
Colon resection
6
Q
Types of ureteric obstruction
A
Intra luminal (stone, blood clot)
Intra-mural (scar tissue, TCC)
Extra-luminal (pelvic mass, lymph nodes)
7
Q
What is inflammation of the bladder called?
A
Cystitis
8
Q
What is balanitis?
A
Skin irritation of head of penis
9
Q
Presentation of renal diseases
A
Pain Pyrexia Haematuria Proteinuria Pyuria Mass on palpation Renal failure
10
Q
Definition of oliguira
A
The production of abnormally small amounts of urine (urine output <0.5ml/kg/hr)
11
Q
Definition of anuria
A
Failure of the kidneys to produce urine
12
Q
Types of anuria
A
Absaloute - no urine output
Relative - <100ml/24 hours
13
Q
Definition of polyuria
A
Abnormally large production/passage of urine
Urine output > 3L/24 hours
14
Q
Definition of nocturia
A
Waking up at night > 1 occasion to micturate
15
Q
Definition of nocturnal polyuria
A
Nocturnal urine output >1/3rd total urine output in 24 hours
16
Q
What should be done when a patient has polyuria and polydipsia?
A
- Exclude CRF, hypokalaemia, hyperglycaemia, hypercalcaemia and thyrotoxicosis
- Urine osmolarity
- If > 750mOsm/kg
a. Check plasma osmolarity. If
I) >300mOsm/kg, test for Diabetes insipidus - DDAVP - Check the urine osmolality. If no urine concentration; nephrogenic DI, if urine concentrates; cranial diabetes Inspidius
I) > 300mOsm/kg, do a water deprivation test. If positive; think DI. If no increase or fluctuating urine osmolality; psychogenic polydipsia. If equivocal WDT, do a hypertonic saline infusion. If -ve (psychogenic polydipsia); but if +ve then cranial DI
b) If urine osmolality > 750mOsm/kg; no abnormality in urine concentrating ability
17
Q
What does AKI stand for?
A
Acute Kidney Injury
18
Q
What is the definition of AKI done in terms of? Explain these
A
Staging RIFLE R - Risk I - injury F - failure L - Loss E - end stage kidney disease
19
Q
What counts as risk in staging of AKI?
A
Increase in serum creatinine level (1.5x) or decrease in GFR by 25%, or UO < 0.5mL/kg/h for 6 hours
20
Q
What counts as injury in staging for AKI?
A
Increase in serum creatinine level (2.0x) or decrease in GFR by 50% or UO <0.5mL/kg/h for 12 hours
21
Q
What counts as failure in staging for AKI?
A
Increase in serum creatinine (3x) or decrease in GFR by 75%, or serum creatinine level >355 umol/L with acute increase of > 44umol/L; or UO < 0.3mL/kg/h for 24 hours or anuria for 12 hours
22
Q
What counts as loss in the staging for AKI?
A
Persistent ARF or complete loss of kidney function > 4 weeks
23
Q
What counts as end stage kidney disease in the staging for AKI?
A
Complete loss of kidney function > 3 months
24
Q
Functions of the kidney
A
Erythropoietin production Vit D metabolism Renin Body fluid homeostasis Electrolyte homeostasis Acid base homeostasis Regulation of vascular tone (i.e. BP) Excretory functions
25
Presentation of chronic renal failure
```
Asymptomatic
Tiredness
Anaemia
Peripheral oedema
High BP
Bone pain due to renal bone disease
Endocrine abnormalities (erythropoietin, vit D metabolism, renin)
Congestive cardiac failure
Pulmonary oedema
Electrolyte abnormalities (Na, K, Cl)
Acid base homeostasis abnormalities
Pruitis (in advanced renal failure)
Nausea vomiting (advanced)
Dyspnoea (advanced)
Pericarditis (advanced)
Neuropathy (advanced)
Coma (untreated advanced)
```
26
Presentation of ureteric diseases
```
Pain
Pyrexia
Haematuria
Palpable mass i.e. hydronephrosis
Renal failure (only if bilateral obstruction or single functioning kidney)
```
27
Presentation of bladder diseases
```
Suprapubic pain
Pyrexia
Haematuria
LUTS
Recurrent UTIs
Chronic urinary retention (due to bladder underactivity)
Urinary leak from vagina (i.e. vesico-vaginal fistula)
Pneumaturia (i.e. colo-vesical fistula)
```
28
What does LUTS stand for?
Lower urinary tract symptoms
29
What are the LUTS?
```
Storage
- frequency
- nocturia
- urgency
- urge incontinence
Voiding
- poor flow
- intermittency
- terminal dribbling
Incontinence
- stress
- urge
- mixed
- overflow
- neurogenic
- dribbling
```
30
Causes of LUTS
```
OAB
UTI
Interstitial cystitis
Bladder cancer
BOO
Pelvic floor dysfunction
Neurological causes
Chronic renal failure
Cardiac failure
DM
DI
```
31
What does OAB stand for?
Over active bladder
32
What does UTI stand for?
Urinary tract infection
33
What neurological causes can cause LUTS?
Supra-pontine lesions (e.g. stroke, alzheimers, parkinsons)
Intra-pontine, suprasacral lesions (e.g. spinal cord injury, disc prolapse, spina bifida)
Infra-sacral (e.g. MS, DM, Cauda equina compression, surgery to retroperitoneum)
34
What does DM stand for?
Diabetes mellitus
35
What does DI stand for?
Diabetes inspidius
36
What controls micturition?
1. Cortical centre (bladder sensation and conscious inhibition of micturition)
2. Pons (micturition centre)
3. Sacral segments (S2-S4) - micturition reflex
37
What is the micturition reflex?
Relaxation of internal urethral sphincter (autonomic - sympathetic)
Relaxation of external urethral sphincter (somatic)
Contraction of detrusor muscle (autonomic - parasympathetic)
38
What is the micturition cycle?
1. Storage (or filling) phase
| 2. Voiding phase
39
What does BOO stand for?
Bladder outflow obstruction
40
Presentation of bladder outflow tract diseases
```
Pain
- suprapubic
- perineal
Pyrexia
Haematuria
LUTS
Overflow incontinence
Recurrent UTIs
Acute urinary retention
Chronic urinary retention
```
41
What LUTS are caused by BOO?
```
Hesitancy
Intermittency
Poor flow
Terminal dribbling
Incomplete bladder emptying
```
42
Definition of acute urinary retention
Painful inability to void with a palpable and percusable bladder
43
Residuals in acute urinary retention
Vary from 500ml to 1 litre depending on time lag in seeking medical attention
44
What is the main risk factor for acute urinary retention?
BPO
45
Causes of acute urinary retention
```
BPO
UTI
Urethral stricture
Alcohol excess
Post op causes
Acute surgical or medical problems
```
46
What does BPO stand for?
Benign prostatic obstruction
47
Causes of BPO causing acute urinary retention
```
Spontaneously (I.e. natural progression of BPO)
Triggers
- constipation
- alcohol excess
- post op cases
- urological procedure
```
48
Treatment of acute urinary retention
Immediate catheterisation (either urethral or suprapubic)
Treat underlying trigger if present
If due to BPE
- alpha blocker immediately then remove catheter in 2 days
- if fail to void; recatheterise and organise TURP (after 6 weeks)
49
Complications of acute urinary retention
```
UTI
Post decompression haematuria
Pathological diuresis
Renal failure
Electrolyte abnormalities
```
50
What is diuresis?
Increased or excessive production of urine
51
What does TURP stand for?
Transurethral resection of the prostate
52
Definition of chronic urinary retention
Painless, palpable and percusable bladder after voiding
53
Residuals in chronic urinary retention
Varies from 400ml to > 2 litres depending on the stage of condition (i.e. wide spectrum)
54
Main cause of chronic urinary retention
Detrusor underactivity
55
Types of detrusor underactivity
Primary i.e. primary bladder failure
| Secondary i.e. due to longstanding BOO, such as BPO or urethral stricture
56
Presentation of chronic urinary retention
LUTS
Complications
Incidental finding
57
Complications of chronic urinary retention
```
UTI
Bladder stones
Post decompression haematuria
Pathological diuresis
Electrolyte abnormalities
Persistent renal dysfunction due to acute tubular necrosis
Overflow incontinence
Post renal or obstructive renal failure
```
58
When does overflow incontinence and renal failure occur in chronic urinary retention?
At the severe end of the spectrum, when bladder capacity is reached and bladder pressure is in excess of 25cm water (i.e. chronic high pressure urinary retention)
59
Who needs treatment in chronic urinary retention?
Asymptomatic patients with low residuals do not necessarily need treatment
Patients with symptoms or complications need treatment but no role for medical therapy
60
Treatment of chronic urinary retention
Immediate catheterisation
- either urethral or suprapubic initially
- then CISC if appropriate
IV fluids
Long term urethral or suprapubic catheter, CISC or TURP if due to BPE
61
What electrolyte abnormalities as a complication would be seen in a patient with chronic urinary retention?
Hyponatraemia
Hyperkalaemia
Metabolic acidosis
62
Features of pathological diuresis
```
Urine output > 200ml/hr
+
Postural hypotension (systolic differential > 20mmHg between lying and standing)
+
Weight loss
+
Electrolyte abnormalities
```
63
Treatment of pathological diuresis
IV fluids (total input = 90% of output) and monitor closely
64
Which of acute or chronic retention does TURP have a more successful outcome in?
Acute retention
| HOWEVER in low pressure chronic retention better outcomes
65
If there is high pressure chronic urinary retention, what are the two types of diuresis that may occur?
Physiological (<200ml/hour usually)
| Pathological (>200ml/hour usually)
66
Definition of UTI
An infection affecting the urinary tract (including kidneys, bladder, prostate, testis and epididymis)
67
What does a diagnosis of a UTI require?
Microbiological evidence
AND
Symptoms/signs
68
What is the microbiological evidence required to diagnose a UTI?
Bacterial count of 10^4 cfu/ml from MSSU specimen with no more than two species of microorganisms
69
What symptoms/signs are required to diagnose a UTI?
At least one of the following
- fever > 38C
- Loin/flank pain or tenderness
- Suprapubic pain or tenderness
- urinary frequency
- urinary urgency
- dysuria
70
Types of UTI
Uncomplicated
| Complicated
71
What is an uncomplicated UTI? What is a complicated UTI?
Uncomplicated - Young sexually active females only with clear relation to sexual activity
Complicated - everyone else
72
What type of UTI always needs to be investigated?
Complicated
73
What factors should be considered in differentiating between complicated and uncomplicated UTIs?
Age
Sexual activity (females)
Gender
Co-morbidities (e.g. immunosuppression, renal failure, medications)
Abnormal renal tract (e.g. stones, renal outflow obstruction, BOO, horseshoe kidney, VU reflux, renal scarring, bladder tumour)
Foreign body (e.g. catheter, ureteric stent)
Type of organism
74
What is inflammation of the bladder called?
Cystitis
75
What is inflammation of the prostate called?
Prostatitis
76
What is inflammation of the kidney called?
Pyelonephritis
77
What is inflammation of the testis called?
Orchitis
78
Complications of UTI
Infective; sepsis (especially pyelonephritis), perinephric abscess
Renal failure (scarring)
Bladder malignancy (squamous cell carcinoma)
Acute urinary retention
Frank haematuria
Bladder or renal stones
79
Investigations for UTI
```
MSSU/CSU
Lower tract;
- flow studies
- residual bladder scan
- cystoscopy
Upper tract;
- USS kidneys
- IVU/CT-KUB
- MAG-3 renogram
- DMSA scan
```
80
What is a CT KUB?
A CT scan of the kidneys, ureters and bladder
81
Emergencies related to urinary tract diseases
Acute renal failure
Sepsis due to UTI +/- upper or lower urinary tract obstruction
Renal colic
Severe haematuria causing haemorrhagic shock
Metastatic disease causing metabolic derangements (e.g. hypercalcaemia from bony mets), spinal cord compression from vertebral mets etc
Acute urinary retention
Chronic high pressure urinary retention
Iatrogenic injury/trauma to upper or lower urinary tracts, penis and testis
Testicular torsion
Paraphimosis
Priapism
82
What is testicular torsion?
The spermatic cord rotates and becomes twisted
83
What is paraphimosis?
The foreskin is pulled back behind the tip of the penis and becomes stuck there. The retracted foreskin and the penis become swollen and fluid build up
84
What is priapism?
Persistent and painful erection of the penis
85
Treatment of nephrogenic DI
Chlorothiazide
86
What drug is a recognised cause of nephrogenic DI?
Lithium
87
What is a known cause of cranial DI?
Hereditary haemachromatosis
88
Who is eGFR often inaccurate in?
People with extremes of muscle mass e.g. bodybuilders
89
Inheritance of Alport syndrome
```
X linked dominant (85%)
Autosomal recessive (10-15%)
```
90
Pathology of Alport syndrome
Defect in the gene which codes for type IV collagen resulting in an abnormal GBM
91
Who does Alport syndrome effect?
More severe disease in males
Females rarely develop renal failure
Presents in childhood usually
92
Presentation of Alport syndrome
```
Microscopic haematuria
Progressive renal failure
Bilateral sensorineural deafness
Lenticonus
Retinitis pigmentosa
```
93
Definition of lenticonus
Protrusion of the lens surface into the anterior chamber
94
Diagnosis of Alport syndrome
Molecular genetic testing
Renal biopsy
- longitudinal splitting of lamina densa of the GBM resulting in a basket weave appearance
95
When prescribing maintenance fluids, what is usually required?
25 - 30 ml/kg/day
96
What is the recommended fluid challenge in a patient who is dehydrated who does not have clinical signs or documentation of HF?
500ml normal saline STAT
97
What is the recommended fluid challenge in a patient who is dehydrated who has HF?
250ml normal saline STAT
98
Symptoms of mild - moderate hypokalaemia
Asymptomatic
99
Symptoms of severe hypokalaemia (< 2.5)
Weakness
Leg cramps
Palpitations secondary to cardiac arrhythmias
Ascending paralysis
100
ECG changes seen in hypokalaemia
U waves
T wave flattening
ST segment changes
