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Renal Flashcards

1
Q

Differences between AKI and CKD

A

Renal US = patients with CKD have bilateral small kidneys
Hypocalcaemia suggests CKD

Exceptions
* Autosomal dominant polycystic kidney disease
* Diabetic nephropathy
* Amyloidosis
* HIV-associated nephropathy

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2
Q

Differentials for haematuria

A
  • Trauma
  • Infection
  • Malignancy = RCC, SCC and adenocarcinoma, prostate cancer, urothelial cancer
  • Glomerulonephritis
  • Stones
  • BPH
  • PCKD
  • Vascular malformations
  • Renal vein thrombosis
  • Coagulopathy
  • Drugs = aminoglycosides, chemo, penicillin, sulphonamides, NSAIDs, anticoagulants
  • Exercise
  • Endometriosis
  • Catheterisation
  • Radiotherapy
  • Pseudohaematuria
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3
Q

Pre-renal causes of AKI

A

inadequate blood supply to kidneys reducing filtration
o Hypovolaemia = Dehydration (D+V), haemorrhage
o Hypotension (shock, sepsis, cardiac failure)
o Oedematous states = cirrhosis, nephrotic syndrome
o Renal artery stenosis/occlusion
o Drugs = antihypertensives, diuretics

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4
Q

Renal causes of AKI

A

o Peripheral vascular disease
o Disseminated intravascular coagulation
o Malignant hypertension
o Thromboembolic disease
o Glomerulonephritis
o Interstitial nephritis
o Acute tubular necrosis
o Rhabdomyolysis
o Tumour lysis syndrome
o Drugs  NSAIDs, PPIs, penicillins, radiological contrast

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5
Q

Post-renal causes of AKI

A

o Kidney stones
o Masses/cancer in abdo or pelvis
o Ureter or urethral strictures
o BPH or prostate cancer

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6
Q

Presentation of AKI

A
  • Symptoms of high urea
    o Fatigue, weakness, anorexia, nausea and vomiting
    o Followed by confusion, seizures and coma
  • Breathlessness
  • Thirst
  • Diarrhoea
  • Haematuria
  • Haemoptysis
  • Reduced urine output/Urine retention = oliguria
  • Palpable bladder, palpable kidneys, abdominal/pelvic masses, rashes
  • Postural hypotension
  • Pulmonary and peripheral oedema
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7
Q

Investigations for AKI

A
  • Urinalysis for protein, blood, leucocytes, nitrates, glucose
    o Leucocytes + nitrates = infection
    o Protein + blood = acute nephritis
    o Glucose = diabetes
  • Bloods  Anaemia, Hypocalcaemia, Hyponatraemia, Hyperphosphataemia, Hyperkalaemia, High creatinine/low GFR
  • US of urinary tract/kidneys within 24 hrs if no identifiable cause or risk of UTI
  • ECG = arrhythmias due to hyperkalaemia
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8
Q

Diagnosis criteria for AKI

A

KDIGO classification
- Rise in creatinine of >/= 25 micromol/L in 48 hrs
- Rise in creatinine of >/= 50% in 7 days
- Urine output of <0.5ml/kg/hour for >6 hrs (8hrs in children)
- >25% fall in eGFR in children/young adults in 7 days

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9
Q

Management of AKI

A
  • Prevention and treat cause
  • IV Fluid rehydration
  • Stop nephrotoxic medications = NSAIDs, ACEi, gentamicin, metformin, spironolactone
  • Relieve obstruction = catheter
  • Reverse hyperkalaemia with insulin and dextrose
  • Haemofiltration/haemodialysis if patient not responding to medical treatment of complications
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10
Q

Referral criteria for AKI

A
  • Renal transplant
  • ITU patient with unknown cause of AKI
  • Vasculitis/ glomerulonephritis/ tubulointerstitial nephritis/ myeloma
  • AKI with no known cause
  • Inadequate response to treatment
  • Complications of AKI
  • Stage 3 AKI
  • CKD stage 4/5
  • Qualify for renal replacement = hyperkalaemia/metabolic acidosis/ complications of uraemia/fluid overload
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11
Q

Complications of AKI

A
  • Hyperkalaemia
  • Fluid overload, heart failure, pulmonary oedema
  • Metabolic acidosis
  • Uraemia = encephalopathy or pericarditis
  • CKD
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12
Q

Risk factors for CKD

A
  • Smoking
  • Family history
  • Diabetes (T2>T1)
  • Hypertension
  • Glomerulonephritis
  • Polycystic kidneys disease
  • Medications = NSAIDs, PPIs, lithium
  • More common in African, Afro-Caribbean or Asian origin
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13
Q

Presentation of CKD

A
  • Asymptomatic
  • Itching
  • Loss of appetite
  • Nausea
  • Muscle cramps
  • Nocturia and polyuria
  • Amenorrhea in women and erectile dysfunction in men
  • Oedema
  • Peripheral neuropathy
  • Pallor
  • Hypertension
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14
Q

Investigations of CKD

A
  • Estimated GFR = 2 tests 3 months apart for diagnosis
    o eGFR <60 or proteinuria
  • Urine albumin: creatinine ratio >/= 3mg/mmol
  • Urine dipstick = haematuria
    o Check for bladder cancer
  • Renal ultrasound
  • Urine microscopy = UTI, glomerulonephritis
  • Biopsy and histology = Diagnose condition causing renal failure
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15
Q

Bloods in CKD

A

o Raised urea and creatinine
o Raised ALP
o Raised PTH if CKD stage 3+
o Raised phosphate
o Low Ca2+
o Hb low = normochromic normocytic anaemia

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16
Q

Stages of CKD

A
  • G score eGFR
    o G1 = eGFR >90
    o G2 = eGFR 60-89
    o G3a = 45-59
    o G3b = 30-44
    o G4 = 15-29
    o G5 = <15
  • A score = Albumin: creatinine ratio
    o A1 <3mg/mmol
    o A2 3-30mg/mmol
    o A3 >30 mg/mmol
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17
Q

Slow progression of CKD

A

o Diabetic control
o Hypertensive control = ACEi
o Treat glomerulonephritis

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18
Q

Complications of CKD

A
  • Anaemia
  • Renal bone disease
  • CVD
  • Peripheral neuropathy
  • Dialysis related problems
  • Hyperkalaemia
  • Peptic ulceration
  • Acute pancreatitis
  • Malignancy
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19
Q

Reduce risk of complications of CKD

A

o Exercise, maintain healthy weight and stop smoking
o Dietary advice on phosphate, sodium, potassium and water intake
o Atorvastatin 20mg = prevention of CVD

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20
Q

Treat complications of CKD

A

o Oral sodium bicarbonate = metabolic acidosis
o Iron supplementation and erythropoietin = anaemia
o Vit D = renal bone disease
o Proteinuria  ACE-I, SGLT-2 inhibitors
o Dialysis = haemofiltration, haemodialysis, peritoneal dialysis
o Renal transplant = end stage renal failure

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21
Q

Risk factors for renal cell carcinoma

A
  • Von Hippel Lindau syndrome
  • Inherited disease = neurofibromatosis, tuberous sclerosis
  • Cystic disease = AD polycystic kidneys, horseshoe kidneys
  • Toxins = Smoking, industrial exposure to carcinogens
  • Obesity
  • Renal failure and haemodialysis
  • HYpertension
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22
Q

Types of RCC

A

Clear cell carcinoma, papillary or chromophobe

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23
Q

Spread of RCC

A

Spread may be direct (renal vein), via lymph or haematogenous (bone, liver, lung, brain)

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24
Q

Presentation of RCC

A
  • Often asymptomatic
  • Haematuria
  • Vague loin pain
  • Abdominal mass
  • Systemic: Anorexia, malaise, fever (of unknown origin), night sweats and weight loss
  • Polycythaemia, anaemia, hypercalcaemia
  • Hypertension
  • Varicocele (caused by tumour compressing veins)
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25
Q

Investigations for RCC

A
  • Ultrasound = distinguish simple cyst from complex cyst or tumour
  • Renal biopsy = Get histology to identify tumour
  • CT chest and abdomen with contrast
    o Renal mass and involvement of renal vein of inferior vena cava
    o Cannon ball metastases in lungs
  • MRI = Tumour staging (Robertson)
  • Bloods
    o FBC = detect polycythaemia and anaemia due to EPO decrease
    o ESR may be raised
    o LFTs abnormal = obstructive jaundice (Stauffer syndrome)
    o Hypercalcaemia
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26
Q

Management of RCC

A
  • Radical or Partial nephrectomy
  • Radiotherapy and chemotherapy
  • Ablative techniques = Cryoablation and radiotherapy
  • Alpha-interferon and interleukin-2 to reduce tumour size
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27
Q

Complication of RCC

A

Stauffer syndrome

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28
Q

Risk factors for pyelonephritis

A
  • Structural renal/urological abnormalities
  • Diabetes
  • Calculi
  • Catherisation
  • Pregnancy
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29
Q

Causes of pyelonephritis

A
  • E. coli
  • Klebsiella
  • Enterococcus
  • Pseudomonas
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30
Q

Presentation of pyelonephritis

A
  • High fever and rigors
  • Loin to groin pain
  • Nausea and Vomiting
  • Dysuria and urinary frequency
  • Haematuria
  • Severe headache
  • Pain on bimanual palpation of renal angle
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31
Q

Investigations of pyelonephritis

A
  • Urine dipstick = blood, protein, leukocyte esterase, nitrite
  • Midstream urine microscopy, culture and sensitivity before starting Abx
  • Blood cultures
  • Raised WCC and ESR/CRP
  • CT scan (adults) and ultrasound scan (children)
  • Dimercaptosuccinic acid = indication of renal scarring
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32
Q

Management of pyelonephritis

A
  • Broad spectrum cephalosporin or quinolone for 7-10 days
  • Consider hospital admission
  • Surgery = Drain abscess or relieve calculi causing infection
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33
Q

Complications of pyelonephritis

A
  • Recurrent kidney infections
  • Leads to scarring renal parenchyma
  • CKD
  • Abscess/pus around kidney
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34
Q

Risk factors for kidney stones

A
  • Anatomical abnormalities that predispose to stone formation
  • Diet = Chocolate, tea, strawberries, rhubarb (all increase oxalate levels)
  • Gout
  • Family history
  • Ileostomy
  • Dehydration
  • Primary renal disease = Polycystic kidneys, Renal tubular acidosis
  • Drugs = diuretics, antacids, acetazolamide, corticosteroids, aspirin, allopurinol, vit C and D
  • High calcium
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35
Q

Location of kidney stones

A

Pelviureteric junction, Pelvic brim, Vesicoureteric junction

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36
Q

Presentation of kidney stones

A
  • Most asymptomatic
  • Renal colic
    o Rapid onset = woken from sleep
    o Excruciating ureteric spasms = patient writhing in pain and cannot lie still
    o Pain radiates from loin to groin and comes and goes in waves as ureters peristalise
    o Worse with fluid loading
  • Oliguria and Dysuria
  • Haematuria
  • Nausea and vomiting
  • Sepsis
  • Recurrent UTIs = increased risk if voiding impaired
  • Bowel sounds may be reduced
  • Hypotension
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37
Q

Investigations of kidney stones

A
  • Urine dipstick = haematuria, protein, glucose
  • Mid-stream urine  MCS
  • Bloods = Serum urea, electrolyte, creatinine and calcium, FBC
  • Non-contrast CTKUB (CT Kidney Ureter Bladder)
  • Ultrasound = Shows kidney stones and renal pelvis dilatation well but ureteric stones can be missed
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38
Q

Management of kidney stones

A
  • Strong analgesic for renal colic = IM Diclofenac
  • Antibiotics if infection = IV cefuroxime or IV gentamicin
  • Antiemetics to prevent vomiting
  • Fluids
  • Stones <5mm in lower ureter 90% pass spontaneously
  • Medical expulsive therapy
    o Oral nifedipine or alpha blocker (oral tamsulosin) = promote expulsion
  • If still not passing, then surgery
    o Extracorporeal shockwave lithotripsy (10-20mm)
    o Ureteroscopy and laser lithotripsy
    o Percutaneous nephrolithotomy (>20mm)
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39
Q

Prevention of kidney stones

A
  • Overhydration
  • Diet = low Ca2+, low salt, low animal protein
  • Reduce BMI
  • Active lifestyle
  • Cholestyramine and pyridoxine reduced urinary oxalate secretion
  • Allopurinol and oral bicarbonate prevents uric acid stones
  • Cysteine binder = captopril
  • If hypercalciuria then thiazide diuretic (Oral Bendroflumethiazide)
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40
Q

Complications of kidney stones

A
  • > 50% lifetime risk of recurrence once you’ve had them
  • Acute pyelonephritis
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41
Q

Causes of glomerulonephritis

A
  • Primary
  • Secondary = infection, autoimmunity or malignancy
  • Nephrotic and nephritic syndromes
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42
Q

Causes of acute urinary retention

A
  • BPH
  • Urethral strictures
  • Calculi
  • Cystocele
  • Constipation
  • Masses
  • Drugs: anticholinergic, TCA, antihistamines, opioids, benzos
  • Neurological cause
  • UTI
  • Post-op or postpartum
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43
Q

Presentation of acute urinary retention

A
  • Inability to pass urine
  • Lower abdominal discomfort/tenderness
  • Considerable pain or distress (chronic retention will be painless)
  • Acute Confusional state (elderly)
  • Palpable distended urinary bladder
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44
Q

Investigations for acute urinary retention

A
  • Fluid status assessment
    VBG for K+
    Rectal, neurological ± pelvic exam
  • Urinalysis and culture (after catheterisation)
  • Serum U&Es and creatinine, FBC, CRP
  • US bladder = volume >300
    Accurately measure urine output
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45
Q

Management of acute urinary retention

A
  • Decompression via catheterisation
    o Volume <200 indicates not urinary retention
    o Volume >400 indicates catheter should be left in place
  • Further investigation into causes
  • Trial of IV fluids unless in heart failure
  • Flush catheter if catheter not draining
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46
Q

Complications of acute urinary retention

A
  • Post-obstructive diuresis
  • AKI
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47
Q

Risk factors for nephritis syndrome

A
  • Hep B/C
  • Malaria
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48
Q

Causes of nephritic syndrome

A
  • IgA nephropathy  Macroscopic haematuria in young people 1-2 days following URTI
  • Henoch-Schoenlein purpura  Children following infection
  • Post-streptococcal  1-2 wks after throat or skin infection
  • Anti-glomerular basement membrane disease
  • Rapidly progressive GN
  • Good-pasture’s disease
  • Systemic sclerosis
  • SLE
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49
Q

Presentation of nephritic syndrome

A
  • Haematuria
  • Oliguria
  • Proteinuria = <3g/24 hours
  • Fluid retention (oedema)
  • Uraemia = anorexia, pruritus, lethargy, nausea
  • Hypertension
  • Moderate to severe decrease in GFR
  • HSP = palpable purpuric rash over buttocks and extensor surfaces
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50
Q

Investigations for nephritic syndrome

A
  • Bloods = eGFR, serum urea and electrolytes and albumin
  • Culture = Swab from throat or infected skin
  • Urine dipstick = proteinuria and haematuria
  • Renal biopsy
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51
Q

Management of nephritic syndrome

A
  • Treat causes
  • Salt and water restriction
  • Hypertension = ACE-I or CCBs (amlodipine) if AKI
  • Diuretics
  • Immunosuppression with corticosteroids for SLE, ANCA vasculitis, anti-GBM, IgA vasculitis
  • Antibiotics for endocarditis
  • Monitor blood pressure and urinalysis
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52
Q

Causes of nephrotic syndrome

A
  • Primary
    o Minimal change disease (children)
    o Membranous nephropathy
    o Focal segmental glomerulosclerosis (adults)
    o Membranoproliferative GN
  • Secondary
    o Diabetes
    o Lupus nephritis, SLE, RA
    o Myeloma
    o Amyloid
    o Pre-eclampsia
    o HIV, HBV, HCV
    o Drugs = NSAIDS and ACEi
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53
Q

Presentation of nephrotic syndrome

A
  • Peripheral pitting oedema
  • Proteinuria >3g/24 hours
  • Hypoalbuminemia <30g/L
  • Frothy urine
  • Hypercholesterolaemia >10mmol/l
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54
Q

Investigations for nephrotic syndrome

A
  • Renal biopsy in adults
  • Urine dipstick = proteinuria
  • Bloods = low albumin, high creatinine, low eGFR, high lipids
  • Immunology/serology testing
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55
Q

Management of nephrotic syndrome

A
  • Treat underlying cause and treat symptoms
  • Minimal change disease  oral corticosteroids or cyclophosphamide if steroid resistant
  • IV furosemide = oedema
  • Ramipril/candesartan = reduce proteinuria
  • Prophylactic anticoagulation with warfarin
  • Simvastatin = reduce cholesterol
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56
Q

Complications of nephrotic syndrome

A
  • Venous Thromboembolism
  • Hypertension
  • Hyperlipidaemia
  • AKI
  • Infection  cellulitis, strep, peritonitis
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57
Q

What is autosomal dominant polycystic kidney disease (ADPKD)

A
  • Genetic condition where kidneys develop multiple fluid filled cysts
  • Family history of ADPKD, ESRF or hypertension
  • Mutations in PKD1 (85%) gene on chromosome 16
  • Mutations in PKD2 (15%) gene on chromosome
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58
Q

Presentation of ADPKD

A
  • Nocturia
  • Loin pain
  • Haematuria
  • Excessive water and salt loss
  • Bilateral kidney enlargement
  • Renal colic due to clots
  • Hypertension
  • Recurrent UTIs
  • Renal stones = mainly uric acid stones
  • Progressive renal failure
59
Q

Investigations for ADPKD

A
  • Ultrasound
    o 15-39 yrs >/= 3 cysts (uni/bilateral)
    o 40-59 yrs >/= 2 cysts (each kidney)
    o >60 yrs >/= 4 cysts (each kidney)
  • Genetic testing for PKD1 and PKD2
  • Screening for relative with abdo US
60
Q

Management of ADPKD

A
  • Tolvaptan (vasopressin receptor antagonist) = slow development of cysts and progression of renal failure
  • Laparoscopic removal of cysts to help with pain/nephrectomy (remove entire kidney)
  • Antihypertensives
  • Analgesia
  • Abx for infection
  • Drainage of infected cysts
  • Dialysis/transplant = end stage renal failure
  • Genetic counselling and support
    o Screening for relatives with US
  • Avoid contact sports = cyst rupture
  • Avoid anti-inflammatory meds and anticoagulants
  • Regular USS, bloods, BP
61
Q

Complications of ADPKD

A
  • Hepatic, splenic, pancreatic, ovarian, prostatic cysts
  • Cerebral berry aneurysms
  • Cardiac valve disease (mitral regurg)
  • Colonic diverticula
  • Aortic root dilatation
62
Q

Presentation of autosomal recessive polycystic kidney disease

A
  • Many present in infancy with multiple renal cysts and congenital hepatic fibrosis
  • Enlarged polycystic kidneys
63
Q

Investigations for ARPKD

A
  • Ultrasound
  • Genetic testing  PKHD1 mutation on long arm of chromosome 6
64
Q

Management of ARPKD

A
  • Genetic counselling for family members
  • Laparoscopic removal of cysts to help with pain/nephrectomy
  • Blood pressure control with ACE-inhibitor = ramipril
  • Treat stones and give analgesia
  • Renal replacement therapy for ESRF
65
Q

Von Hippel-Lindau syndrome

A
  • Autosomal dominant
  • Multisystem cancer syndrome  renal cysts and clear cell renal carcinoma in 40s
  • Mx : screen for tumours
66
Q

Alport syndrome

A
  • X-linked
  • Haematuria, proteinuria and progressive renal insufficiency
  • High tone sensorineural hearing loss
67
Q

Types of diabetic nephropathy

A
  • Diabetic kidney disease  any kidney disease in patient with diabetes
  • Diabetic nephropathy  any kidney disease presumed to be caused by diabetes
  • Diabetic glomerulopathy  biopsy proven diabetes related changes in glomerulus
68
Q

Risk factors for diabetic nephropathy

A
  • Modifiable  glycaemic control, hypertension control, salt intake, smoking, RAS blockage
  • Non-modifiable  age, sex, duration of diabetes, ethnicity
69
Q

Diagnosis of diabetic nephropathy

A
  • > 10 years diabetes
  • Other microvascular complications
  • Progressive increase in urine protein excretion over years
  • No evidence of other probable cause
70
Q

Management of diabetic nephropathy

A
  • Optimise diabetic control
  • Optimise blood pressure control
  • Treatment of microalbuminuria/proteinuria  ACEi/ARB
  • Smoking cessation
  • Statins
71
Q

Types of UTI

A
  • Cystitis  bladder infection
  • Prostatitis  prostate infection
  • Pyelonephritis  kidney/renal pelvis infection
72
Q

Risk factors for UTI

A
  • Sexual activity
  • Urinary/faecal incontinence
  • Constipation
  • Spermicide use
  • Low oestrogen
  • Menopause
  • Dehydration
  • Obstructed urinary tract
  • Diabetes
  • Immunosuppression
  • Catheter
  • Pregnancy
  • Kidney/bladder stones
73
Q

Causes of UTI

A
  • Klebsiella pneumoniae
  • E. coli (MOST COMMON)
  • Enterococcus
  • Proteus mirabilis/ pseudomonas
  • Staphylococcus saprophyticus
74
Q

Presentation of UTI

A
  • Cystitis = frequency, dysuria, urgency, suprapubic pain, polyuria, haematuria, cloudy/smelly urine
  • Acute pyelonephritis = fever, rigors, vomiting, loin pain, costovertebral pain, septic shock
75
Q

Classification of UTI

A
  • Uncomplicated = normal renal tract structure and function
  • Complicated = presence of factors that increase risk of Tx failure
76
Q

Investigation for UTI

A
  • Dipstick for haematuria, nitrites, leukocytes
  • MSU culture
  • Bloods to assess for development of AKI
  • Sepsis 6 if indicated
  • Radiology for complicated pyelonephritis/UTI
77
Q

Management of UTI

A
  • Acute uncomplicated cystitis
    o Nitrofurantoin 3 days (women) or 7 days (men)
    o Trimethoprim (not in pregnancy)
  • Acute uncomplicated pyelonephritis
    o Oral ciprofloxacin 14 days
  • Acute complicated cystitis
    o Oral ciprofloxacin
  • Urosepsis or acute severe pyelonephritis
    o IV co-amoxiclav
    o Analgesia
    o IV fluids
78
Q

Complications of UTI

A
  • Urosepsis
  • Recurrent UTI (>3 in 1 year or >2 in 6m)
  • Chronic pyelonephritis
  • Abscess formation
  • Pyelonephrosis
79
Q

Risk factors for BPH

A
  • African-Caribbean more than white men
  • Older men
  • High testosterone
80
Q

Presentation of BPH

A
  • Voiding Sx (obstructive)  weak or intermittent urinary flow, straining, hestitancy, terminal dribbling, incomplete emptying, delay in initiation of micturition
  • Storage Sx (irritative)  urgency, frequency, overflow/urgency incontinence, nocturia
  • Haematuria
  • Enlarged bladder
  • Occluded bladder = anuria
81
Q

Investigations for BPH

A
  • Urine dipstick + MSU
  • DRE = enlarged and smooth prostate
  • Serum PSA = may be raised
  • Flow rates and residual volume
  • Frequency volume chart
  • U+Es and renal ultrasound = exclude renal damage
  • Transrectal ultrasound = size of prostate
  • International Prostate Symptom Score (IPSS)
82
Q

Conservative management of BPH

A
  • Reassurance and monitoring if manageable symptoms
  • Lifestyle = avoid caffeine, alcohol, relax when voiding
83
Q

Medical management of BPH

A
  • 1st line = alpha 1 antagonist (oral tamsulosin)
    o Relax smooth muscle
  • 2nd line = 5-alpha-reductase inhibitor (oral finasteride)
    o Block testosterone and helps reduced size of prostate
84
Q

Surgical management for BPH

A

o Transurethral resection of prostate (TURP)
o Transurethral electrovaporisation of prostate (TUVP)
o Holmium laser enucleation of prostate (HoLEP)
o Open prostatectomy via abdominal or perineal incision

85
Q

Complications for BPH

A
  • Bladder calculi
  • UTI
  • Acute urinary retention
  • Kidney damage
86
Q

Risk factors for prostate cancer

A
  • Family history
  • Genetic = HOXB13, BRCA 2
  • Increased testosterone
  • Tall
  • Anabolic steroids
87
Q

Pathophysiology of prostate cancer

A
  • Majority adenocarcinomas arising is peripheral zone of prostate gland
  • Most common site of metastases is bone and lymph nodes
  • Locally spread to seminal vesicles, bladder and rectum
88
Q

Presentation of prostate cancer

A
  • LUTS if local disease = nocturia, hesitancy, poor stream, terminal dribbling, retention
  • Weight loss, fatigue and bone pain
  • Haematuria
  • Erectile dysfunction
  • Anaemia
89
Q

Investigations for prostate cancer

A
  • DRE = hard irregular prostate
  • Raised PSA = false positive and negatives
  • Trans-rectal ultrasound and biopsy
90
Q

Scoring system for prostate cancer

A

Gleason

91
Q

Management of prostate cancer

A
  • Watch and wait
  • Radiotherapy
  • Brachytherapy = implantation of radioactive material targeted at tumour
  • Hormonal treatment
    o Bilateral orchidectomy
    o LHRH agonists (goserelin)
    o Androgen receptor blockers (bicalutamide)
  • Surgery = total prostatectomy
92
Q

Complications of prostate cancer

A
  • Erectile dysfunction
  • Urinary incontinence
  • Radiation induce enteropathy = PR bleeding, pain, incontinence
  • Urethral strictures
93
Q

Risk factors for prostatitis

A
  • STI
  • UTI
  • Indwelling catheter/ intermittent bladder catheterisation
  • Post-prostate biopsy
  • Increasing age
94
Q

Causes of prostatitis

A
  • Streptococcus faecalis
  • E.coli
  • Chlamydia
95
Q

Presentation of prostatitis

A
  • Fevers, rigors, malaise
  • Pain on ejaculation
  • Pain in perineum, penis, rectum or back
  • Significant voiding LUTs = poor intermittent stream, hesitancy, incomplete emptying, post micturition dribbling, straining, dysuria
96
Q

Investigations for prostatitis

A
  • DRE = prostate tender, hard and hot, boggy
  • Urine dipstick = positive for leucocytes and nitrites
  • Urine and blood cultures
  • STI screen = chlamydia
  • Trans-urethral ultrasound scan
97
Q

Management of prostatitis

A
  • 14 day course of quinolone (ciprofloxacin)
  • Acute
    o IV gentamicin + IV co-amoxiclav
    o 2-4 weeks on quinolone = ciprofloxacin
    o 2nd line = trimethoprim
    o TRUSS guided abscess drainage if necessary
  • Chronic
    o 4-6 week course of quinolone = ciprofloxacin
    o +/- alpha blocker = tamsulosin
    o NSAIDs = ibuprofen
98
Q

Risk factors for bladder cancer

A
  • Smoking
  • Occupation = industrial paint, motor, leather and rubber workers, blacksmiths, hair dye
  • Indwelling catheter
  • Bladder stones
  • Family history
  • Schistomiasis = SCC
  • Previous radiation to pelvis
  • Drinking water is protective
99
Q

Pathophysiology of bladder cancer

A
  • Transitional cell carcinoma (>90%) or squamous cell carcinoma
  • Tumour spread to pelvic structures (local), iliac and para-aortic nodes (lymphatic), liver and lungs (blood)
100
Q

Presentation of bladder cancer

A
  • Painless macroscopic haematuria
  • Recurrent UTIs
  • Voiding irritability
  • LUTS
  • Painful clot retention
  • If advanced  mass, lymphadenopathy, pelvic/flank pain
  • Systemic: weight loss, lethargy
101
Q

Investigations of bladder cancer

A
  • Flexible Cystoscopy and biopsy under 2WW
  • CT urogram
  • Urinary tumour markers
102
Q

Management of bladder cancer

A
  • Not invading muscle
    o TURBT
    o Chemo into bladder after surgery
    o Weekly Tx for 6 weeks with BCG vaccine squirted into bladder via catheter
  • Muscle invasive
    o Radical cystectomy with ileal conduit
    o Radiotherapy
    o IV chemo
  • Metastatic = palliative chemo and radio
103
Q

Complications of bladder cancer

A
  • Cystectomy = sexual and urinary malfunction
  • Clot retention
  • B12/folate deficiency
104
Q

Risk factors for testicular cancer

A
  • Infant hernia
  • Infertility
  • Family history
  • Previous testicular tumour
  • Cryptorchidism  Undescended testis
  • Klinefelter’s syndrome
105
Q

Pathophysiology of testicular cancer

A
  • Germ cell cancer = seminoma (older), teratoma (child)
  • Metastasise to lung, liver, brain, para-ortic lymph nodes, cervical nodes
106
Q

Presentation of testicular cancer

A
  • Painless lump in testicle
  • Testicular pain and/or abdominal pain
  • Cough and dyspnoea = indicative of lung metastases
  • Back pain = para-aortic lymph node metastasis
  • Hydrocele = May contain bloodstained fluid
  • Abdominal mass
107
Q

Investigations for testicular cancer

A
  • Ultrasound and biopsy
  • Tumour markers
    o Alpha-fetoprotein raised in teratomas
    o Beta-hCG raised in teratomas and seminomas
    o Lactate dehydrogenase
  • CXR and CT = staging and metastases
108
Q

Management of testicular cancer

A
  • Orchidectomy
  • Chemo/radiotherapy
  • Monitoring post treatment with tumour markers and imaging
  • Sperm storage offered
109
Q

Cause of hydronephrosis

A
  • Unilateral (PACT)
    o Pelvic-ureteric obstruction (congenital or acquired)
    o Aberrant renal vessels
    o Calculi
    o Tumours of renal pelvis
  • Bilateral (SUPER)
    o Stenosis of urethra
    o Urethral valve
    o Prostatic enlargement
    o Extensive bladder tumour
    o Retro-peritoneal fibrosis
110
Q

Investigations of hydronephrosis

A
  • US  hydronephrosis
  • IVU  assess position of obstruction
  • Antegrade or retrograde pyelography
  • If suspect renal colic do CT scan
111
Q

Management of hydronephrosis

A
  • Remove obstruction and drainage of urine
  • Acute upper urinary tract obstruction  nephrostomy tube
  • Chronic upper urinary tract obstruction  ureteric stent or pyeloplasty
112
Q

Associations of epididymal cyst

A
  • Polycystic kidney disease
  • Cystic fibrosis
  • Von Hippel-Lindau syndrome
113
Q

Presentation of epididymal cyst

A
  • Small cysts may remain undetected and asymptomatic
    o Well defined and will transilluminate since fluid-filled
  • Testis is palpable quite separately from cyst and lies posterior (Unlike hydrocele)
  • Once cysts get large, may be painful
114
Q

Management of epididymal cyst

A

Scrotal US
- If painful and symptomatic then surgical excision

115
Q

Causes of acute tubular necrosis

A
  • Ishcaemia  shock, sepsis
  • Nephrotoxins  aminoglycosides, myoglobin (secondary to rhabdomyolysis), radiocontrast agents, lead
116
Q

Presentation of acute tubular necrosis

A
  • Features of AKI  raised urea, creatinine, potassium
  • Muddy brown cast in urine
117
Q

Phases of acute tubular necrosis

A
  • Oliguric phase
  • Polyuric phase
  • Recovery phase
118
Q

Histology of acute tubular necrosis

A

o Tubular epithelium necrosis
o Dilatation of tubules
o Necrotic cells obstructing tubule lumen

119
Q

Causes of rhabdomyolysis

A
  • Seizure
  • Collapse/coma
  • Ecstasy
  • Crush injury
  • McArdle’s syndrome
  • Drugs: statins
120
Q

Investigations for rhabdomyolysis

A
  • AKI with disproportionately raised creatinine
  • Elevated creatine kinase (at least 5x upper limit)
  • Myoglobinuria: dark/ reddish-brown colour
  • Hypocalcaemia
  • Elevated phosphate
  • Hyperkalaemia
  • Metabolic acidosis
121
Q

Management of rhabdomyolysis

A
  • IV fluids to maintain good urine output
  • Urinary alkalinisation
122
Q

Causes of hyperkalaemia

A
  • AKI
  • CKD
  • Adrenal insufficiency
  • Rhabdomyolysis
  • Tumour lysis syndrome
  • Drugs: spironolactone, ACEi/ARB, NSAIDs, ciclosporin, heparin
  • Potassium supplements: bananas, kiwi, salt substitues
  • Massive blood transfusion
123
Q

Presentation of hyperkalaemia

A
  • Asymptomatic until K+ is high enough to cause cardiac arrest
  • Chest pain
  • Weakness
  • Palpitations
  • Light headedness
  • Muscle weakness and fatigue
  • Kussmaul’s respiration = low, deep, sighing inspiration/expiration
  • Fast irregular pulse
  • Metabolic acidosis
124
Q

Bloods for hyperkalaemia

A
  • Serum K+ > 5.5mmol/L
    o If >6.5mmol/L = Medical emergency
125
Q

ECG for hyperkalaemia

A

Tall tented T waves, Flattening or absence of P waves, Broad QRS complexes
o Usually only ECG changes if K+ >6.0

126
Q

Management of hyperkalaemia

A
  1. IV calcium gluconate for cardiac stability
  2. 50ml 50% dextrose infusion with 10 units of ActRapid over 15 mins
    - Nebulised salbutamol
    - Calcium Resonium or sodium zirconium cyclosilicate  remove K+ from body
    - Repeat VBG/U+Es to Monitor for response and rebound
    - Monitor glucose
    - Review medication = ACEi, NSAIDs, spironolactone
    - Sodium bicarbonate = correct acidosis
    - Dialysis
127
Q

Causes of hypokalaemia

A
  • Vomiting and diarrhoea
  • Thiazide and loop diuretics
  • Cushing’s and Conn’s syndrome
  • Corticosteroids
128
Q

Presentation of hypokalaemia

A
  • Usually asymptomatic
  • Muscle weakness
  • Cramps
  • Tetany
  • Palpitations
  • Light-headedness
  • Constipation
  • Hypotonia
  • Hyporeflexia
  • Arrhythmias
129
Q

Bloods for hypokalaemia

A
  • Serum K+ <3.5 mmol/L
    o <2.5 mmol/L = urgent treatment
130
Q

ECG for hypokalaemia

A

o Small or inverted T waves
o Prominent U waves
o Long PR interval
o Depressed ST segments

131
Q

Management for hypokalaemia

A
  • Identify and treat underlying cause
  • Withdrawal from diuretics/laxatives
  • Oral/IV K+ supplements = oral sando-k
  • If on thiazide diuretic, switch to K+ sparing diuretic (spironolactone)
132
Q

Causes of hypernatraemia

A
  • Dehydration
  • Osmotic diuresis
  • Diabetes insipidus
  • Excess IV saline
133
Q

Management of hypernatraemia

A
  • Manage underlying cause
  • Replace deficit plus maintenance slowly at uniform rate over 48 hrs
134
Q

Complications of hypernatraemia

A

Rapid infusion = cerebral oedema

135
Q

Causes of metabolic acidosis with normal anion gap

A

o Gastrointestinal bicarbonate loss: diarrhoea, ureterosigmoidostomy, fistula
o Renal tubular acidosis
o Drugs: acetazolamide
o Ammonium chloride injection
o Addison’s disease

136
Q

Causes of metabolic acidosis with raised anion gap

A

o Lactate: shock, hypoxia
o Ketones: diabetic ketoacidosis, alcohol
o Urate: renal failure
o Acid poisoning: salicylates, methanol

137
Q

Metabolic alkalosis causes

A
  • Vomiting/aspiration
  • Diuretics
  • Liquorice, carbenoxolone
  • Hypokalaemia
  • Primary hyperaldosteronism
  • Cushing’s syndrome
  • Bartter’s syndrome
  • Congenital adrenal hyperplasia
138
Q

Maintenance fluids for adult

A

25-30ml/kg/day
1mmol/kg/day K+, Na+, Cl
50-100g/day glucose

139
Q

Causes of hyponatraemia

A
  • Hypovolaemic hyponatraemia  diuretic stage of renal failure, diuretics, Addisonian crisis
  • Euvolaemic hyponatraemia  SIADH
  • Hypervolaemic hyponatraemia  heart failure, liver failure, nephrotic syndrome
140
Q

Presentation of hyponatraemia

A
  • Early Sx
    o Headache
    o Lethargy
    o Nausea
    o Vomiting
    o Dizziness
    o Confusion
    o Muscle cramps
  • Late Sx
    o Seizures
    o Coma
    o Respiratory arrest
141
Q

Severity of hyponatraemia

A
  • Mild:130-134
  • Moderate: 120-129
  • Severe: <120
142
Q

Management of hyponatraemia

A
  • Exclude spurinous result
  • Review medications
  • Chronic hyponatraemia without severe Sx
    o Hypovolaemic  isotonic saline
    o Euvolaemic  fluid restrict to 500-1000ml/day, consider demeclocycline/vaptans
    o Hypervolaemic  fluid restrict to 500-1000ml/day + consider loop diuretics/vaptans
  • Acute hyponatraemia with severe Sx
    o Hypertonic saline (3% NaCl)
143
Q

Complications of hyponatraemia

A
  • Cerebral oedema  brain herniation
  • Of Tx  osmotic demyelination syndrome
    o Locked-in syndrome

Finals (23 decks)

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