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Renal Flashcards

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1
Q

Tx of AKI

A

A-E assessment

Correction of any hypoxia

Halt any potentially damaging drugs

Restrict potassium intake

Pre-renal causes
Treat shock

Post-renal causes
Refer to urology

Renal causes
Assess fluid status with volume replacement to match known insensible losses
CVP measurement may be necessary
If there is urine output after fluid replacement continue large quantities of fluids +/- diuretics

If there is no urine output or complications are present nephrologist intervention is required

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2
Q

Indications for acute dialysis with AKI

A 
refractory hyperkalaemia
pulmonary oedema
acidosis
uraemic pericarditis/encephalopathy
complete anuria 
drug OD
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3
Q

what is a good indicator of AKI severity

A

furosemide stress test

Furosemide 1mg/kg is give after fluid resus, and urine output over 2 hours is measured and replaced

Volume of fluid output at 2 hours can then be used to demonstrate likelihood of progression to AKI stage III

Generally after a week of oliguria, if the AKI is improving there will be one week of polyuria before return to normal kidney function at week 3

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4
Q

what are common electrolyte abnormalities in AKI

A

Rapidly progressive uraemia
Symptoms progress from anorexia, pruitis, vomiting to encephalopathy (confusion, drowsiness, fitting) and haemorrhagic episodes

Hyperkalaemia

Hypernatraemia (unless pre-renal)

Metabolic acidosis

Hypocalcaemia/hypophosphataemia (more common in CKD)

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5
Q

Tx of Hyperkalaemia

A

Start continuous ECG monitoring

10ml 10% calcium gluconate IV
Repeat at 5 minute intervals to a max of 3 doses until ECG stabilises

50ml of 50% glucose with 10U ACTRAPID insulin into a large vein over 30 mins to decrease K+ concentration

Consider 10mg salbutamol neb (also lowers potassium)

If pH <7.2 consider sodium bicarbonate IV if advised by renal registrar

Recheck K+ after 2 hours

Calcium resonin can then be given orally/rectally, however this is a long term management option

Tackle underlying issue

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6
Q

Tx of CKD

A

Treat reversible causes

First line is blood pressure/diabetic control
<130/80
If proteinuric BP should be <125/75
ACE inhibitors first line

Primary CV prevention is also important
Statin + low dose aspirin

Second line is control of complications
Recombinant EPO for those with anaemia
Calcium/Vit D supplementation
K+ restriction is there is any suggestion of hyperkalaemia

Renal replacement therapy is indicated in those with ESRD
Guidelines suggest this should be for any symptomatic CKD 5 patient however many consultants will delay starting dialysis

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7
Q

Tx of renal bone disese

A

Restrict dietary phosophate

Giving phosphate binders

Adcal supplementation

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8
Q

whats the difference between haemodialysis and haemofiltration

A

Hameofiltration differs from haemodialysis by not transfering solutes via diffusion but via filtration

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9
Q

what are the 2 peritoneal dialysis regimes

A

Continuous ambulatory peritoneal dialysis (CAPD) or continuous cycling peritoneal dialysis (CCPD)

CAPD = every 2 hours up to 3-4 times a day 2L of peritoneal fluid is drained out and a fresh 2L is reinserted into the peritoneal cavity

CCPD = over a 12 hour period fluid is continuously pumped through the abdomen

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10
Q

what is the major risk of peritoneal dialysis

A

peritonitis

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11
Q

dialysis complications

A

Annual mortality is 20%

Infection

Cardiovascular disease

Renal bone disease

Anaemia

Bleeding tendencies

Increased risk of renal malignancy

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12
Q

what assessments are required prior to transplantation

A

Virology/TB assessment
Active infection contraindicated due to risks of immunosuppression

Blood group/HLA matching

Full systemic examination – comorbid disease is a contraindication

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13
Q

operative complications of renal transplantation

A

Bleed

Thrombosis

Infection

Urinary leaks

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14
Q

post-surgical complications of transplant

A

Rejection
Risk highest in the first 3 months
Lifelong immunosuppression because of this
Most episodes of rejection are reversible and in most cases immunological tolerance develops

Ciclosporin/tacrolimus toxicity

Infection/malignancy due to immuosuppression
Skin cancer
Anal cancer
Lymphoma

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15
Q

prognosis of a transplant

A

5 year 80-95% graft survival rate depending on how good the HLA match is

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16
Q

what drugs need adjusting in renal impairment

A

Gentamicin

Cephalosporins

Heparin

Lithium

Opiates

Digoxin

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17
Q

How do you manage minimal change disease in children

A

try steroids and if the child responds within a month biopsy is not required, otherwise biopsy is indicated

steroids tend to resolve it in 4-6 weeks

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18
Q

most common cause of glomerulonephritis in adults

A

beurgers disease (IgA nephropathy)

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19
Q

Tx of Beurgers disease/IgA nepropathy

A

supportive therapy

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20
Q

prognosis of beurgers disease

A

20% progress to ESRD in 20 years

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21
Q

prognosis of minimal change disease

A

1% progress to ESRD

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22
Q

Tx of HSP

A

Attacks are usually self limiting but if there are relapses and evidence of progressive renal involvement then corticosteroids are inidicated

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23
Q

Tx of goodpastures disease

A

plasma exchange and corticosteroids +/- cytotoxics

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24
Q

Tx of RPGN

A

Aggressive immunosuppression (high dose steroid and cyclophosphamide)

Prognosis depends on how early treatment is initiated

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25
Tx of cystitis (empirical)
3 days of Nitrofurantoin (100mg BD) /Trimethoprim
26
Tx of pyelonephritis
IV tazocin 4.5g TDS At least 7 days
27
Tx of asymptomatic UTI in pregnant women
Always treat, for at least 7 days avoid nitrofurantoin at term due to neonatal haemolysis risk + avoid trimethoprim in first trimester as it is teratogenic consult local guidelines but generally nitrofurantoin/amoxicillin/cefalexin advised by NICE
28
Tx of recurrent UTI
Advice on high fluid intake , frequent voiding (specifically after sex), avoidance of spermicidal jellies and avoidance of constipation If this fails trimethoprim/nitrofurantoin prophylaxis may be started
29
Tx of hydronephrosis secondary to ureteric obstruction
Nephrostomy If there is significant enough hydronephrosis Prevents fluid accumulation and damage Surgical stenting, depending on cause
30
Acute Tx of renal calculi
A-E assessment 75mg IM diclofenac unless contraindicated Beware post renal AKI IM metclopramide if severe vomiting IV Abx if there is infection
31
admission requirements for renal calculi
Still pain after 1 hour Risk of AKI Signs of shock/infection Uncertainty over diagnosis
32
indications for active treatment of renal calculi
Low chance of spontaneous passage (>10mm) Persistent pain Ongoing obstruction Signs of infection Renal insufficiency
33
options for active treatment of renal calculi
Extracorporeal shockwave lithiotripsy (ESWL) Outpatient procedure that focuses shockwaves on stones to break them up and then it can be passsed spontaneously If there is hydronephrosis present there may need to be a nephrostomy first to decompress the pelvicalyceal system Uretoscopy Various energy sources e.g. laser can be used to break up a stone Percutaneous nephrolithotomy Used for renal, (not ureteric) calculi that do not respond to ESWL
34
conservative management of renal calculi
Tamsulosin/nifedipine increase the rate of spontaneous expulsion Advice if sending home 80% pass naturally Maintain a high fluid intake Advise to return if there is an increase in pain or signs of infection First time stone formers should be advised to urinate into a seive to collect the stone for analysis Refer the patient to urology within a week
35
Tx of bladder stones
same as renal stones
36
complications of bladder stones
increased risk of TCC
37
Tx of wilms tumour
nephrectomy and pre-operative chemotherapy
38
Tx of renal cell carcinoma
Radical nephrectomy Partial nephrectomy If peripheral tumour <5cm If bilateral tumours or contralateral poor kidney function Post-op chemo
39
prognosis of Renal cell carcinoma
65% 5 year survival if N0, 25% if there is nodal involvement, 5% if there are distant mets
40
Tx of bladder cancer
Carcinoma in situ or T1 bladder carcinomas Transurethral resection of bladder tumour ay systoscopy with intravesical chemotherapy 5 year survival = 95% T2 – T3 or high grade tumours Radical cystectomy + pre-op chemo Ileal conduit is used to leave an urostoma T4 (invasion beyond the bladder) Treated palliatively Long term follow up with cystoscopy is then required
41
Tx of bladder rupture
Intraperitoneal bladder rupture Treated with laporotomy and suturing of the bladder Extraperitoneal bladder rupture Treated conservatively with prolonged urethral or suprapubic catheterisation
42
Tx of bladder outlet obstruction
Catheterisation Beware of large diuresis following relief of obstruction Find and treat underlying cause
43
Tx of acute retention secondary to BPH
urethral catheterisation suprapubic catheterisation if not possible
44
lifestyle advice in BPH
Avoid alcohol/caffeine Relax when voiding Void twice in a row to help voiding Bladder retraining
45
medical management of BPH
Alpha blockers + behavioural management programme e.g. Tamsulosin, Doxasocin 5-alpha reductase inhibiotors + behavioural management programme e.g. Finasteride indicated in prostate >30 grams over alpha blockers Stops testosterone conversion to dihydrotestosterone reducing enlargement PDE-5 inhibitors anticholinergic agents
46
when is conservative management advised for BPH
when symptoms are mild/not bothersome
47
side effects of finasteride
Impotence Reduced libido It is excreted in semen so condoms should be used
48
surgical management of BPH
Transurethral resection of the prostate (TURP) 10% risk of impotence, 20% need a repeat within 10 years Retrograde ejaculation is almost universal after the procedure Other risks are bleeding and TURP syndrome Absorption of fluid washout leads to hyponatraemia and fits Holmium laser prostatectomy (HoLEP) Endoscopic increasingly used for larger prostates Urinary incontinence may occur if too much of a gland is removed In general morbidity from TURP/HoLEP procedures is low
49
indications for surgical management of BPH
refractory responses to medication complications attributed to BPH such as renal insufficiency, bladder stones, recurrent haematuria or urinary tract infections development of urinary tract retention.
50
what is the gleason grade and D'amico risk stratification
Done after biopsy, two different biopsies are given a 'score' out of 5 based on grade and then they are added together Vital for prognosis <6 = low risk >8 = high risk d'amico = Combines gleason score with clinical stage and PSA give a more accurate prognostic score than gleason alone
51
Tx of prostate cancer
Generally depends on surgical fitness of the patient along with the stage/grade of the disaese T1/T2 (local disease) - patient has a choice between: Active surveillance - Regular PR, PSA, biopsies Radiotherapy/Brachytherapy (Brachytherapy = radioactive pellets in prostate) Surgery - Radical prostatectomy ``` Advanced disease (T3/4) Active surveillance not recommended ``` Choice between radiotherapy or surgery – treatment outcomes the same Metastatic disease Hormonal therapy GnRH agonists - Gosrelin/buserelin Can be palliative or an adjunct to curative treatment An antiandrogen such as cyproterone acetate is co-prescribed initially to prevent an early rise in testosterone
52
Tx of gonorrhea
IM ceftriaxone Follow up and repeat cultures in 3 days Trace and treat all sexual contacts
53
Tx of Chlamydia
1g azithromycin as a single dose, or 7 day course of doxyxycline/erythromycin Test of cure not required in a simple infection Trace sexual contacts
54
Tx of urethral tears
If the urethral wall is partially intact (determined by contrast urethrography) it can be treated conserviatively by prolonged catheterisation Complete tears require suprapubic catheterisation and formal repair
55
Tx of urethral strictures
First-line = optical urethrotomy Urethroplasty for recurring injury (50%)
56
Tx of phimosis
Circumcision is the treatment of choice for troubling symptoms
57
Tx of paraphimosis
Emergency treatment Anaesthesia Applying pressure to glans Slitting of the foreskin dorsally (if required) Circumcision Offered after a paraphimosis to prevent recurrence
58
Tx of priapism
Ice packs Alpha agonists Selective embolisation Aspiration of the corpus cavernosum Surgical intervention
59
tx of Peyronies
Managing associated depression if present Surgical intervention may help penetration
60
Tx of maldescent of the testes
if ectopic or undescended = orchidoplexy at 6 months if not descended if merely retractile testes (can be coaxed down from external ring) - normal
61
complications of maldescent of the testes
Defective spermatogenesis Increased risk of torsion Increased risk of malignancy Increased risk of indirect inguinal hernia
62
Tx of epididymal cysts
usually left alone if causing troublesome symptoms they can be excised
63
Tx of hydrocele
Most patients presenting with hydrocele should be scanned to rule out underlying causes Most hydroceles are benign and not troublesome If the swelling is causing a problem then the excision of the hydrocele sac is possible – aspiration leads to recurrence
64
Tx of varicocele
usually, reassurance is enough - surgical management does not ensure return of fertility Radiological embolisation of the left renal vein Surgical ligation and division of the testicular veins
65
Tx of testicular tumours
Testicular tumour suspected = early surgical exploration through inguinal incision indicated Orchidectomy for obvious/previously diagnosed tumours Biopsy and frozen section if diagnosis is unclear If diagnosis confirmed orchiectomy performed Retroperitoneal lymph node dissection may also be undertaken Post surgical radiotherapy Indicated for seminomas (highly radiosensitive) Post surgical chemotherapy for NSGCTs - (not radiosensitive) Sperm banking used due to risk of infertility
66
prognosis of testicular cancer
Node negative cases have nearly 100% 5 years survival Overall >90%
67
Tx of testicular torsion
Emergency Surgery If the testes is still viable it is untwisted and sutured to the tunica vaginalis with contralateral testicular fixation also (prevent future events) Non-viable = orchidectomy and fixation of the contralateral testes should occur
68
prognosis of testicular torsion
Salvage rate of 80% is achievable if the patient is operated on within 6 hours of event
69
Tx of epididymo-orchitis
6 weeks ciprofloxacin + doxycycline if suspecting chlamydia Analgesia and scrotal support may provide relief
70
Tx of acute prostatitis
6 weeks of ciprofloxacin
71
medical Tx of male erectile dysfunction
Sildenafil – viagra Induces vasodilation Fills corpus cavernosa with blood Intracavernosal prostaglandin injections vacuum condoms or inflatable intrapenile prostheses if these treatments fail
72
when is siladefinil contraindicated for erectile dysfunction
patients on hypotensives
73
lifestyle advice for erectile dysfunction
Treat reversible medical causes Correct hormonal disturbances Stop smoking Reduce alcohol intake Treat diabetes

CP3 Management (11 decks)

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