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Renal and Urology Flashcards

1
Q

What are the classic symptoms of pyelonephritis?

What imaging would you want to do on someone with suspected pyelonephritis?

What are some complications?

A

Classic triad of:

  • loin pain
  • Fever
  • tenderness over the kidneys

Officially can be diagnosed with:
Bacturia + Fever

or

Bacturia + Loin Pain

Imaging:

  • Ultrasound of kidneys
  • CT KUB

The US should also check for any obstructions which may be contributing to the infection. These will show renal pelvis inflammation and small abcesses
CT is the investigation of choice when trying to assess for complications

Complications:

Sepsis

Renal Scarring - causing CKD

Emphysematous Plyeonephritis
- severe necrotising infection of the kidney parachyma

  • seen on CT with gas around the kidneys

Hydronephrosis
- would require catherisation to improve flow

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2
Q

When is UTIs as common in males as females?

A

1st year of life

It becomes more common as we age due to bladder outlet difficulties

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3
Q

What is the diagnostic investigation to diagnose glomerulonephritis?

A

Renal Biopsy with:

  • light microscopy
  • electorn microscopy
  • Immunofluroence
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4
Q

In suspected glomerulinephritis, what invesitgations should be done?

A
  • *Urine analysis:**
  • Dipstick
  • Microscopy
  • 24 hour protien collection
  • Protein/ Creatinine ratio

FBC:
- Anaemia

Coagulation Studies

Serology:

  • c-ANCA
  • dsDNA
  • Anti - GBM
  • IgA

Electrophresis

Imaging
- Ultrasound of kidneys

Biopsy

  • Light Microscopy
  • electron microscropy
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5
Q

If there is haematuria, how can the source be isolated?

A

RBC casts - which are dysmorphic RBCs would suggest from the glomeruli

Non - dysmorphic would suggest from lower down from the glomeruli i.e kidney stone

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6
Q

What are the key symptoms of nephritc syndrome?

A

Peripheral oedema

Periorbital oedema

Hypertension

Oligouria

Urine analysis:

Haematuria
- RBC cast

Proteinuria
- moderate amount (1-3g - so not as much as a nephrotic syndrome)

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7
Q

Post Streptococcal glomeruonephritis:

A

Caused by a skin infection 1-6 weeks ago
or
URTI 1-3 weeks ago

Investigations:

Anti- streptolysin O test

Complement studies C3/4 (reduced)

*usually biopsy is not needed.

Treatment:

- furisemide

  • antibiotics
  • supportive management
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8
Q

IgA Nephropathy:

A

Usually occurs 12-72 hours following an infection

Symptoms:

  • pupura of lower body
  • arthritis
  • G.I pain
  • Symmetrical rashes

Investigations:

Need to rule out ITP and TTP therefore

  • coagulation studies are done and
  • platelets

Skin biopsy of rash:

  • Leukocytoclasic vasculitis
  • IgA depositation

Renal Biopsy
- IgA deposits within mesangium

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9
Q

What are the general treatments for nephritic syndrome?

A

Blood pressure control
- ACE inhibitor
or
- Angiotensin Receptor Blocker

Immunosupressive:

  • corticosteroids for immune complex supression
    (IgA nephropathy)
    (rapidly progressive glomerulinephritis)

Antibiotics:

  • for on going infections that may be triggering
    (post strep infection)

Pain:

(IgA nephropathy for G.I pain)

Renal Dialysis
(for ESRD)

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10
Q

What are the common causes of Rapidly progressive Glomerulinephritis?

A
  • *Good Pastures disease**
  • Anti GBM antibodies
  • *Granlumoatosis with polyangitiis**
  • c - ANCA

Microscopic polyangitis

  • p - ANCA
  • *Lupus nephritis**
  • dsDNA
  • ANA

**all require a renal biopsy

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11
Q

How is granulomatosis polyangitiis treated?

A

If evidence of Renal disease or pulmonary disease:

  • IV methpredisolone
    +

Cyclophosphamide

+/-

Plasmaphresis

No eivdence of renal disease:

  • oral predisolone

or
- rituxmab

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12
Q

What are the types of primary diseases that can cause nephrotic syndrome?

A

Minimal change disease
- children

Membraneous nephropathy

  • Adults
  • anti - phospholipid A2 antibodies

Focal Segmental Glomerulosclerosis
- Coloured people

Membranoproliferative glomerunephritis

  • type I
  • Type II
  • Type III
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13
Q

What are some complications of nephrotic syndrome?

A
  • *Hypercoagulable**
  • DVT
  • P.E

Hypovolaemia

Protein Malnourishment

  • *Immunocompromised**
  • loss of IgG in urine
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14
Q

What is the general treatment for nephrotic syndrome?

A

Reducing protein loss

  • ACE hibitors

Control of oedema:

  • redued Na2+ intake
  • Furesimide

Anticoagulation:

  • Heparin
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15
Q

What is the treatment for membraneous nephropathy?

A

this depends of the severity. Remeber 1/3rd will spontaneously get better, 1/3rd will maintain eGFR and 1/3rd will progress to ESRF.

therefore management depends how at risk they are:

Low risk: - monitor
Medium risk: Predisilone
High risk: Predisilone + Cyclophosphamide

+ ACE

+ Salt restriction
+/- Diuretics

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16
Q

List some examples of complicated UTIs and pyleonephritis:

A

Male

Pregnancy

Indwelling catheter

Poorly controlled Diabetes melitus

Previous Urogenital surgery

uroligcal conditions
- BPH

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17
Q

What are some risk factors for developing a UTI?

A

Sexual activity

Urinary incontinence

Spermicide use

Obstruction of urine

Immunospuression

catherter

Renal tract malformations

Diabetic Meliitus

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18
Q

What investigations should be done in suspected UTI?

A

*in non - pregnant women <65, if they have >3 or more symptoms in keeping with UTI then treat empirically.

  • **Diptick**
  • females
  • *Mid-stream Urinary/ MSU culture:**
  • men
  • Pregnany women
  • Children
  • previous failure to repsond oral antibiotics

Blood tests:

  • do if systemically un well

Imaging:

Conisder in

  • pyleonephritis
  • failure to respond to treatment
  • unusual organisms
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19
Q

How does Pyelonephritis appear on ultrasound?

A

Hypoechoic mass
- usually unilateral

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20
Q

How does pyleonephritis appear on CT?

A

Hypotense regions of the kidneys

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21
Q

What is the recommended treatment for pyleonephritis in pregnant women?

A

Ceftriaxone

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22
Q

When should asymptomatic bacturia be treated?

A

In pregnant women

Renal transplant patients

Those about to have a urological intervention
- TURB

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23
Q

What are the complications of Pyelonephritis?

A

AKI

  • Septic shock
  • Papillary necrosis - post obstructive

Emphysematous plyeonephritis

  • Gas producing
  • usually staph aureus

Abscess:

Continual loin pain + fever

Renal Abcess
- Pus within the kidney Parachymal tissue

Perirenal Abcess
- pus between the renal capsule and Gerota’s fascia

Renal Scarring

  • risk of chronic renal failure
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24
Q

What is the mangement of renal abcesses?

A

Antibiotic management

Renal Abcess >5cm = percutaneous drainage

Perirenal abcess >3cm = Percutaneous drainage

if these can’t be drained then surgery is recommended

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25
If a young patient has symptoms of a UTI and on dipstick there blood and leukocytes, however on MSU there is nothing, what is a likely diagnosis?
Chlaymadia
26
What is first line for hyper PTH in kidney disease?
Phosphate binders
27
What is the best investigations for establishing between acute and chronic kidney disease and what is the characteristic finding?
Ultra sound. Chronic kidney disease will tend to have bilaterally small kidneys \*exceptions include: - diabetic nephropathy - Sarcoidosis - HIV nephropathy
28
Which drugs during an AKI should potentially be stopped, not because they worsen the AKI, but can lead to toxic build up?
Metaformin Lithium Digoxin
29
How is diabetic kidney nephropathy monitored?
Early morning Albumin:creatinine ratio
30
What is the classification of CKD:
Abmormal Kidney structure or function for \>3 months with implications towards health. G1 - \>90 - with evidence of underlying kidney disease G2 - 60-90 G3 - 30 -60 G4 - 15 - 30 G5 \<15
31
What are the biggest factors associated with prognosis in CKD?
Low GFR Albuminuria
32
What investigations would you want to do into suspected CKD?
* *U&Es** - compare with previous * *FBC** - Normocytic anaemia * *Bone profile** - low Ca2+ - High PTH * *Immunology** - glomerulinephritic causes * *Urine analysis:** - A:Cr - P:Cr - Dipstick * *Imaging of Kidneys** - size (small, unless polycystic, amyoid and myeloma) - Symmetry (stenosis) **Histology**
33
What are the general management stratagies for CKD?
Referral to nephrology Slow progression of the disease Management of complications Preperation for renal replacement therapy
34
What are some of the complications of CKD and how are they managed?
* *Anaemia**: - EPO when \<110Hb * *Hypertension:** - ACE Inhibitor (monitor closely * *Acidosis**: - Sodium bicarbonate * *Oedema**: - Na2+ restriction - Duiretics (needs careful monitoring) * *Bone mineral Disoders** - Phosphate binders - Vitamin D supplements * *Cardiovascular Risks** - Aspirin - Statin
35
If Renal replacment is going to be required, and you make a referral, when should this be done by? What else should be done?
\> 1 year. within 1 year of referral and starting renal replacement therapy is considered a late referral. All should be registered for donation within 6months of transplant.
36
What drugs inparticular need careful consideration with regards to dosing in CKD due to their renal excretion?
Aminoglycosides - gentamcin Penicillins Cephalosporins Heparin Lithium Opiates Digoxin
37
What are some complications of polycyctic kidney disease?
Liver/ pancreatic cyst formation Cyst rupture SAH Renal failure Mitral valve prolaspe Diverticulitis
38
What is the diagnostic criteria for polycycstic kidney disease? and what is the diagnostic test of choice?
Family history: 15 - 30: \>2 cysts present, TWO unilateral or bilateral cysts 30 - 59: \>4 cysts ,TWO Cysts bilaterally \>60: \>8 cysts, FOUR Cysts Bilaterally No family history: \>10 more cysts in both kidney Liver cysts Renal enlargement \*a CT or MRI can be used which are more sensitive.
39
What is the management of polycystic kidney disease?
**Blood pressure control** 1st line: ACE 2nd line: Thiazide 3rd line: Beta blocker * *Manage extra-renal complications** - anaemia etc **Renal replacement therapy** Preparation **Tolvaptan -\*\*\*** Vasopressin receptor antagonist \*\* - reduces production of cysts **Surgical:** Surgical excision if compression is needed for pain or obstruction
40
What are some causes of congenital chronic kidney disease?
* *Adult Polycystic kidney disease** - PKD -1 - PKD -2 * *Autosomal reciessive Polycystic kidney disease** - begins as neonate * *Renal Phakomatoses** - tuberous sclerosis - Von Hippel Lindau disease **Alport Syndrome:** Collagen Type IV defect * *Fabry Disease** - Lymosomal disorder
41
What is the general management for nephrotic syndrome?
**Reduce Oedema:** - Fluid restriction - loop duiretics \*consider IV loop diuretics if oral does not work due to gut odema \*add thiazides if not working with just loop diuretics **Treat underlying cause:** Steroids and immunospuressive therapies are usually needed * *Reduce Proteinuria:** - ACE inhibitors * *Thromboembolism:** - treat with Heparin - LMWH **Infection control** these people are immunocompromised and thus must be monitored carefully - Pneumoccocal vaccine should be given. patients are very susceptible to it * *Hyperlipidaemia:** - statins
42
If someone is breathless, with hepatosplenomeglay but normal LFTs, what should you immediately think?
Amyloidosis
43
How often is haemodialysis usually needed to be done?
3 x weekly for 3-5 hours
44
What is a major complication of haemodialysis that presents with: - focal neurological deficits - reduced GCS - Papiloedema - headache
**Dialysis disequilibrium syndrome** Where there is a reverse osmosis in the brain leading to cerebral oedema
45
What are the features of acute interstitial nephritis?
25% of AKI is caused by this. \*Eosinophilia \*sterile pyuria _Classic triad of:_ - fever - Arthralgia - maculopapular rash Typically caused by: - Antibiotics - Allopurinol - NSAIDs
46
Following a kidney transplant, what cancer are people more at risk of?
Skin Cancer - sqaumous and basal cell
47
What is a biological marker on U&Es of dehydration and not an AKI?
Disproportionally high urea to creatinine
48
What does leukocytes in the urine tell you?
That there is inflammation. it is not specific to infection. Nitrites on top would suggest infection
49
What can tumour lysis syndrome lead to with regards tot he kidneys?
AKI - induces tubular necrosis
50
How can urine osmolarity help determine the the cause of an AKI?
High osmolarity suggests pre-renal - because the kidneys are able concentrate and reabsobe more salt. - thus a low urinary Na2+ and high osmolarity in the urine suggest pre-renal Low osmolarity suggests intra-renal as the kidney is unale to concentrate.
51
In an AKI situation, what would protein in the urine be suggestive off?
It would suggest an intra-renal aetiology as the proteins pre-renally should sitll not be filtered and post renally should not off been filtered
52
What is the most common extra-renal manifestation of polycycstic kidney disease?
Liver cysts
53
What is the assessments that should be done in AKI?
RENAL R - Rule out Sepsis E - Exclude obstruction N - Note urinalysis A - Assess Fluid balance L - Look at drugs
54
What is the antibiotics used for epidymitimitis and orchitis?
\<35 years - doxycycline + /- - ceftriaxone + referral \>35 years: - ciprofloxacin
55
What are the types of dialysis used?
**Haemdialysis** * *-** diffusion - hydrostatic pressure * *Peritoneal Dialysis** - Continuous Ambulatory - Autonomic peritoneal dialysis **Haemofiltration** **-** Hydrostatic pressure
56
What are some complications of haemodialysis?
Hypotensive Crash Dialysis Disequalibrium Syndrome Steel syndrome Cramps Fatigue
57
What are some complications of Peritoneal dialysis?
SBP Sclerosis Peritonitis - potentially fatal as it causes thickening of the peritoneal membrane Pleural effusion - can be tested for via the Hypertonic solution - or blue colour as the dialysate is often blue Glucose overload Herniation
58
What are some absolute condraindications to peritoneal dialysis?
Stoma Intra-abdominal sepsis Visual impairement - patients need to be able to see what they are doing Abdominal hernia
59
What are some investigations that should be done into CKD?
**_Bloods:_** FBC - Signs of anaemia U&Es - High creatinine - High urea - Checking for other electrolyte imbalances eGFR LFTs - Albumin Albumin can be lost/ also consider malnutrition Bone profile - Ca2+ - Phosphate levels - PTH Glucose levels (diabetic screen) Lipids **_Orifices:_** Urine analysis Protein: creatinine ratio **_X-rays:_** Renal ultrasound Small kidneys is in keeping with chronic \*if there is asymmetry then consider renal stenosis Joint x-rays: Renal osteodystrophy DEXA scan **_ECG:_** Risk of hyperkaliaemia, especially true in \>40 **_Special tests:_** Antibody testing - ANA - ANCA - GBM Renal biopsy
60
What is the generalised treatment for CKD?
1. Appropraite referral to Nephrology - \>25% drop in eGFR - increased Proteinuria \>30g 2. Slow down progression of CKD - Lifestyle factors - ACE inhibitors - Glycaemia control 3. Treat renal complications - Anemia - Acidosis - Renal Osteodystrophy 4. Treat non renal complication - heart failure - BP - \<140/90 - 130/80 (DM) 5. Preperation for RRT - 1 year in advance
61
What is the biggest cause of death on RRT?
Ischemic Heart disease
62
What is a good test to estbalish the difference between pre-renal and intra-renal AKI?
Urine sodium - in prerenal the urinary sodium will be low as the kidneys try to hold onto fuild
63
Name some causes of non - visiable haematuria:
Renal Calculi Prostatitis Renal cell carcinoma Bladder Carcinoma Renal IgA nephropathy
64
What investigations do you want in someone who presents with an AKI?
**_Bloods:_** FBC - infection Coagulation screen - DIC? CRP U&ES - essential - and to compare against baseline. Check K+ Blood cultures Bone profile - Ca2+ help establish between chronic +/- Myoglobin - is there justification +/- Serum creatinine HIV and Hepatitis serology Essential if there is likely hood of dialysis needed **_Orifices:_** _Urine dipstick_ _Urine analysis_ - Microscopy - Cultures - Sensitives _Urine osmolality_ This is really useful for establishing the cause. If there is a high urine osmolality then it is likely to be pre-renal, as opposed to intra-renal which is unable to concentrate **_X-rays:_** Kidney ultrasound Bladder ultrasound CXR - pulmonary oedema **_ECG:_** Hyperkalaemia Tall tented T waves Loss of P waves Sinusoidal **_Special tests:_** Myeloma screen?
65
What is the management for Pyelonephritis?
Sepsis 6 - Aggressive Fluids - IV antibiotics (gentamicin) (Ceftrixaone or co-amoxiclav for pregnant women)
66
Where are Haemodialysis lines placed in on a AKI who doesn't have a fistula in situ?
Femoral Vein Internal Jugular
67
What is requried prior to starting dialysis treatment?
Hepatitis Screen HIV screen Hepatitis vaccine
68
69
What are the indications for starting dialysis therpay in AKI?
Refractory pulmonary oedema Refractory K+ Hyperuarcaemia causing: - pericarditis - Encephalopathy
70
What are the signs and symptoms of Good pastures?
Haemoptysis and haematuria develop RPGN Treatment: - plasmapheresis - steroids
71
What is the most common cause of SBP in peritoneal dialysis?
Staph Epidermis - from the insertion of the tubes
72
What GN are HIV paitents at risk of developing?
Focal segemental Glomerulnephritis
73
What are some long term complicatiosn of all dialysis?
Dialysis Amyloidosis - Accumlation of amyloid proteins which are unable to be secreted. - causes carpel tunnel syndrome. \*monitored by nuclear imaging
74
What are the most likely pathogens to cause peritonitis in Peritoneal dialysis and what is the management?
Staph Aureus/ Epidermis E.Coli Managemnt: - send Blood cultures - Send Peritoneal culutres - Sepsis 6 \*\*antibitoics can be given IV or peritoneal
75
What are the advantages of kidney transplant over dialysis?
More Freedom from: - dialysis time - Dietary and fluid restrictions Correct electrolyte abnormalies Anaemia is corrected
76
What are some complications of kidney transplant:
* *Acute tubular necrosis** - more common from deceased donation - \>24 hours kidney has been out body * *Technical failures** - failed anastomosis - Ureter dysfunction * *Acute Rejection** - usually seen in first 3 months - high dose steroids can be used \*\*there is a subset of Acute rejeciton with Angiotensin Receptor antibody activation. Presents with hypertension and seizure. - ACE inhibitors fix **Infection** **Chronic Allograft nephropathy** * *Malignancy:** - squamous cell carcinoma **Cardiovascualr disease**
77
What investigations should be done into polycystic kidney disease?
Ultrasound - Kidneys CT - Liver - Pancreatic Cysts ECG - hypertension - left ventricle strain Head MRI Genetic testing \*not before 15 years old
78
What is an alternative biological marker that can be used instead of creatinine?
Cystatin C
79
Advice on dialysis:
Reduce: - Calcium - Salt - Caolrie intake - monitor fluid intake
80
When starting someone with ACE inhibitors who has CKD, what lab valvues are allowed?
30% rise in creatinine 25% drop in eGFR
81
What are the ulcers called associatted with CKD?
Calciphylaxis ulcer
82
What is the best tranplant for diabetic patients?
Kidney and Pancrease
83
What is a significant albumin: creatiine ratio and when should immediate referral be made?
\>3 immediate referral: \>70
84
What is Fabry's disease and how does it present?
X-linked condition of lipid storage defects. causing podocyte damage. Protein urea.
85
What is Alport's syndrome?
Defect in the collagen 4 production. - x-linked condition Results in: - Kidney failure (haematuria, proteinuria) - Deafness - Visual disturbance
86
Name the genetic tubular defects and where they occur:
Fanconi syndrome: PCT - defective absorption. - causes metabolic acidosis due to loss of HCO3 Bartter syndrome: Thick Ascending Loop - Metabolic alkalosis due to increased reabsorption later on Gitelman Syndrome: DCT - Mimics thiazides
87
If there is recurrent UTIs, what further investigations would you want to conduct after urine samples and potential blood cultures?
**Ultrasound of Kidney** * *CT Abdo:** - kidney mass - Stone (differential) * *Micturationg cytogram** - anatomical abnormalities * *Cystoscopy** - malignancy **Diabetic screen**
88
What are the symptoms of prostatisis and how is it treated?
Fever N&V Dysuria Urgency Painful micturation Incomplete emptying Strangulation Back Pain Painful ejaculation \*boggy prostate Treatment: - 4 weeks levofloxacin + - Analgesics
89
How often should people with proteinuria be monitored?
Every 6 months. Increasing proteinuria and reducing eGFR require further investigation
90
What is an abnormal amount of RBCs in the urine?
\>2 RBCs/mm3
91
What is the tumour marker for bladder cancer?
BTA
92
Why do you assess LFTs in bladder cancer? and what would you see?
For metastasis - see increased ALP
93
What immunololgical therapy can be used for non-inassive bladder cancers?
BCG \*\*also reduces incidence
94
During a radial cystomy what else has to be removed?
Prostate in men Uterus, fallopian tubes, urethera and vagina wall in women
95
What imaging investigations do you want into renal cell carcinoma?
* *Ultrasound** - assess to see if it is cyst **Pre/ post IV contrast CT scan** * *Radioistopic Bone scan** - for Mets
96
List some causes of AKI:
**_Pre-renal:_** - Sepsis - Renal artery occulusion - Hypovolamia - M.I - NSAIDs **_Renal_** - Glomerulinephritis - Acute tubular necrosis (Rhabdomylisis, Constrast) - Acute interstilial nephritisi (Drug reaction, pyelonephritis) - Capillary damage (HUS, TTP) - myeloma **_Post Renal:_** - Strictures - Stones - Tumours - catherter block
97
When should an AKI be referred to renal?
Stage 3. Intra-renal causes pH \<7.2 Refractoary hypercalamia Pre-renal with hypertension or fluid overload Difficult fluid balance
98
How long does the fitula formation for dialysis need before it can be used?
8 weeks
99
Investigations into creatinine rise in renal transplant patient:
Ultrasound of kidney ciclopsorin levels Renal biopsy Renal arteriogram
100
What is an important thing to test in the urine in an AKI?
Urine osmolality
101
If there is a patient with an AKI who is fluid overloaded, what is the definitive management?
Dialysis
102
How is a patient with an AKI going to be monitored?
hourly monitoring: K+/ ECG Urine output U&Es - creatinine Lactate
103
How is the hypocalcamia and phosphate treated in CKD?
Phosphate binders and 1 alpha hydrooxycalciferol supplements

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