Renal and urology Flashcards
1
Q
Define UTI, and list the types
A
- Infection of any part of the urinary tract, usually by bacteria.
- Lower UTI is infection of the bladder.
- Upper UTI includes pyelitis (infection of the proximal part of the ureters) and pyelonephritis (infection of the kidneys and the proximal part of the ureters).
- Uncomplicated UTI is infection of the urinary tract by a usual pathogen in a person with a normal urinary tract and normal kidney function.
- Complicated UTI is when one or more risk factors are present that predisposes the person to persistent infection, recurrent infection, or treatment failure.
- Recurrent UTI is repeated UTI, which may be due to relapse or reinfection, and may be defined as 3 or more UTIs in the last 12 months, or 2 or more episodes of confirmed UTI in the last 6 months.
- Relapse is a recurrent UTI with the same strain of micro-organism. Relapse is the likely cause if infection recurs within a short period after treatment (for example within 2 weeks).
- Reinfection is a recurrent UTI with a different strain or species of micro-organism. Reinfection is the likely cause if UTI recurs more than 2 weeks after treatment.
- Asymptomatic bacteriuria is the presence of significant bacteria in the urine, as a result of colonisation of the urinary tract, without symptoms or signs of infection.
2
Q
Describe aetiology of UTI
A
- Urinary tract infection (UTI) is usually caused by bacteria from the gastrointestinal tract, most common E.coli
- The spectrum of micro-organisms which cause UTI is similar in men and women. The most common causative micro-organisms are E.coli, staphylococcus saprophticus, klebsiella, proteus mirabilis
- Less common micro-organisms causing UTI include Enterobacter Enterococcus, Serratia marcescens, Pseudomonas species, and S aureus.
- Candida albicans — rare in the community, but may be seen in people with risk factors such as indwelling catheters, or men who are immunocompromised.
- Entry of bacteria into the urinary tract may be direct, for example, from insertion of a catheter into the bladder, instrumentation, or surgery, indirect via the blood stream (more likely in immunocompromised people), or retrograde, ascending through the urethra into the bladder.
3
Q
List risk factors for recurrent UTI in women
A
In young and pre-menopausal women include:
- Sexual intercourse.
- Past medical history of UTI in childhood.
- Having a mother with history of UTI.
In post-menopausal and elderly women include:
- History of UTI before menopause.
- Urinary incontinence.
- Atrophic vaginitis.
- Cystocele.
- Increased post-void urine volume.
- Urine catheterisation and reduced functional status in elderly institutionalised women.
4
Q
Describe epidemiology of UTI in men
A
- UTI is much less common in men than in women — this is is attributed to the shorter urethra in women.
- Rarely develops in men under 50
- Hospital-acquired UTIs are associated with catheter use, and catheter-associated UTIs are the source of 8% of hospital-acquired bacteraemia.
- Asymptomatic bacteriuria prevalence in men older than 70 years of age ranges from approximately 4–7%.
- Prevalence in institutionalized older people ranges from 19–37%.
5
Q
Describe epidemiology of UTI in women
A
- Acute UTI occurs in up to 50% of women and estimates suggest that by the age of 24 years nearly one third of females will have had at least one episode of cystitis
- 20-30% recurrence
- UTIs are common in older women
- Bacteriuria — bacteriuria develops within days of catheter insertion and over time all people with a catheter have bacteriuria
- The prevalence of CA-UTI is estimated to be 8.5%
- Approximately half of healthcare-acquired infections are due to an indwelling urinary catheter
- CA-UTIs are one of the main causes of secondary health care-associated bacteraemia
- Asymptomatic bacteriuria is more common in elderly and people with spinal injury
6
Q
List risk factors for UTIs in men
A
- Age over 50
- Co-existing illness.
- Institutional care — residence in a long-term care facility correlates with the likelihood of men developing bacteriuria and UTI.
- An indwelling urinary catheter.
- Previous UTI
- BPH
7
Q
List symptoms and signs of lower UTI
A
- Dysuria — discomfort, pain, burning, tingling or stinging associated with urination.
- Frequency — passing urine more often than usual.
- Urgency — a strong desire to empty the bladder, which may lead to urinary incontinence.
- Urine may appear cloudy to the naked eye, or change colour or odour.
- Haematuria may present as red/brown discolouration of urine or as frank blood.
- Nocturia — passing urine more often than usual at night.
- Suprapubic discomfort/tenderness.
- Generalised features in elderly women
8
Q
List symptoms and signs of pyelonephritis
A
- Kidney pain/tenderness in back under ribs.
- Flank pain, or costovertebral angle tenderness is present in 86% of people with pyelonephritis.
- New/different myalgia, flu-like illness.
- Shaking chills (rigors) or temperature 37.9°C or above (or below 36°C in people aged over 65 years).
- Nausea/vomiting.
9
Q
Describe diagnosis of lower UTI
A
- History (exclude STI causes especially in men)
- MSU dipstick and culture and sensitivity testing
- Dipstick not usually done in men or women over 65/ have risk factors
- Cytoscopy or USS in secondary care if underlying issue
10
Q
Describe diagnosis of pyelonephritis
A
- Loin pain/fever
- MSU culture and sensitivity testing
- CT KUB
11
Q
Describe management of UTI
A
- Antibiotics (nitrofurantoin or trimethoprim - 3 day treatment)
- If recurrent/indwelling catheter then refer
- Refer for cancer if suspected
- Hospital treatment if risk factors, systemic upset risk of sepsis
- If pyelonephritis/ urosepsis co-amoxiclav +/- amikacin/gentamicin
12
Q
List possible complications of lower UTI
A
- Renal function impairment
- Prostatitis in men
- Pyelonephritis — 75% of people with pyelonephritis will have had UTI previously.
- Sepsis
- Urinary stones — more likely with Proteus mirabilis infection which is associated with stone formation in the renal collecting ducts.
- Pre-term delivery and low birth weight if occurs in pregnancy
13
Q
List complications of pyelonephritis
A
- Sepsis.
- Parenchyma renal scarring.
- Recurrent urinary tract infections.
- Renal abscess formation.
- Preterm labour in pregnancy.
- Emphysematous pyelonephritis.
14
Q
Describe prognosis of pyelonephritis
A
- Acute pyelonephritis usually responds well to antibiotic therapy — time to resolution of symptoms depends largely on the initial severity of disease.
- In the majority of cases, prompt diagnosis and appropriate treatment result in a complete and uncomplicated recovery within days to weeks.
- The prognosis is less favourable for older people and those with complicating factors or underlying renal disease.
15
Q
Describe prognosis of lower UTI
A
Acute, uncomplicated urinary tract infection (UTI) usually resolves within a few days. A UK primary care-based study found that in women with mild to moderately severe UTI symptoms resolved after an average of
- 3.32 days when treated with an antibiotic to which the pathogen was sensitive.
- 4.73 days when treated with an antibiotic to which the pathogen was resistant.
- 4.94 days when not treated with an antibiotic.
- Approximately 25–35% of women with UTI have a recurrent infection within 3 to 6 months and approximately 44% within 12 months
16
Q
How is renal function measured?
A
- Normal GFR 120-130ml/min/1.73m^2
- eGFR - age and creatinine to estimate GFR. Reported when serum creatinine measured.
- Urine dip (haematuria)
- If proteinurea detected on dipstick measure protein: creatinine ratio or albumin: creatinine ratio
17
Q
Define acute kidney injury
A
- A rapid decline in renal function over a period of hours or days
- Accumulation of waste, pro-dugs and potentially life threatening metabolic consequences with or without urine changes
- Stage 1, 2 or 3 based on serum creatinine increase (1 increase 1.5-1.9 fold, 2 2-2.9 fold, 3 more than 3 fold from baseline)
18
Q
Describe investigations into acute kidney injury and their results
A
- Serum creatinine rise by greater than 26 within 48 hours
OR - Urine output less than 0.5ml/kg/hr for 6 hours
OR - Serum creatinine rise 1.5 times reference value which occurred within 1 week
- Ultrasound (small kidneys sugest CKD), CXR for chest infection, electrolytes, lactate for sepsis
- SLE immunology (ANA, dsDNA, complements), anti-GBM
- Liver function, platelets
Urine
- Red cells, red cell casts and protein urea in glomerular disease
- Minimal blood, small protein, white cell casts if tubular disease
- Pre-renal no blood or protein or casts
19
Q
Describe aetiology for acute kidney injury
A
Pre renal (perfusion to kidney decreased)
- Hypovolaemia (renal loss, extrarenal loss)
- Systemic vasodilation (sepsis, neurogenic shock)
- Decreased cardiac output
- Intrarenal vasoconstriction
Renal (intrinsic disease)
- Acute tubular necrosis (ischaemia, drugs, toxins - most common cause)
- Glomerular (glomerulonephiritis)
- Interstitial nephritis (drugs, infections, infiltration)
- Vascular (vessel obstruction)
Post-renal (obstruction to urine)
- Stones
- Renal tract malignancy
- Stricture
- Clot
- Pelvic malignancy
- Prostatic hypertrophy
- Retroperitoneal fibrosis
20
Q
Describe management of acute kidney injury
A
- Ensure hydration (IV fluids), monitor fluid balance
- Potassium
- Dialysis
- Avoid unnecessary drugs (eg. NSAIDs, ACEI, ARB, aminoglycosides)
- Gastroprotection (PPI) and nutritional support
- More frequent monitoring
- Reverse anything underlying
- Referral if not responding/complications such as fluid overload or hyperkalaemia
21
Q
Describe epidemiology of acute kidney injury
A
- 48% hospital acquired
- 45% acute tubular necrosis
- 21% pre renal
- 13% obstruction
- Stage 1 occurs in 15% of hospital admissions
22
Q
List symptoms of acute kidney injury
A
- Uraemia (nausea, vomiting anorexia)
- Features of underlying disease
- Decreased urine output, changes to urine colour
- Systemic features (rash, myalgia, arthralgia, headaches)
- Confusion, fatigue, drowsiness
23
Q
List signs of acute kidney injury
A
- Volume status (dry mucous membranes, dry skin, JVP, CVP, oedema - depends if overload of underload)
- BP
- Systemic disease
- Palpable kidney
- Bladder distended (post-renal)
24
Q
List complications of acute kidney injury
A
- Hyperkalaemia causing muscle weakness, paralysis, cardiac arrythmias or arrest (treat with IV calcium, insulin and dextrose, salbutamol, calcium, dialysis)
- Pulmonary oedema
- Hyperphosphataemia
- Hypertension
- Metabolic acidosis
- Uraemia
- CKD
25
Q
Describe prognosis of acute kidney injury
A
- Overall mortality of 23.8%
- Community acquired lower mortality
- 90 mortality 25.6%
26
Q
Define chronic kidney disease
A
- Reduction in kidney function present for more than 3 months with associated health implications
- A syndrome for which there is a cause
- Often presents late
- Irreversible
- Stage 1-5 (GFR over 90 stage 1, 60-90 stage 2, 30-60 stage 3, 15-30 stage 4, less than 15 stage 5.)
- A1 <30mg/24h albumin excretion, <3 ACR. A2 30-300 3-30ACR, A3 >300 and >30
27
Q
List investigations in chronic kidney disease
A
- Blood test (creatinine, eGFR, albumin:creatinine ratio, Hb normocytic normochromic anaemia, glucose, low Ca, raised PTH, raised phosphate ie. osteodystrophy)
- ANA, ANCA, antiphopspholipid antibodies, paraprotein, complement, cryoglobin, anti GBM, hepatitis serologyanti-PLA2R)
- Urine dipstick (MC&S, A:CR)
- Ultrasound (small, scarred kidneys except in infiltrive disorders ie. APKD and DM)
- Renal biopsy
28
Q
Describe epidemiology of chronic kidney disease
A
- Stage 3 4% population
- 40% people over age 45
29
Q
List risk factors for chronic kidney disease
A
- Age
- Hypertension (15%)
Diabetes (30%) - IHD
- Family history CKD
- African American (ApoL1 gene)
- Obesity
- Glomerulonephritis
- Hypertension
- Polycystic kidney disease
30
Q
List causes of proteinuria
A
- Diabetes
- Minimal change (glomerular) disease
- Membranous nephropathy
- Amyloid
- SLE
31
Q
List investigations of proteinurea
A
- Quantitate protein: creatinine
- Albumin and cholesterol
- Creatinine, eGFR
- Glucose, SLE, virology, myeloma screen
32
Q
Describe management of proteinuria
A
- Control oedema with low salt and diuretics
- ACEi/ARB
- Treat cause
- Steroids or immunosuppression
- Risk of CKD or ESKD
33
Q
Describe investigation of haematuria
A
- Cytoscopy if age over 40
- Urine dip
- CT scan for stones or cancers if pain (KUB)
- If under 40, suspect glomerular disease, may need kidney biopsy
34
Q
List symptoms of chronic kidney disease
A
- Haematuria
- Lethargy
- Itch
- Breathlessness
- Cramps
- Sleep disturbance
- Bone pain
- Loss of appetite, vomiting, weight loss, taste disturbance
- Polyuria, oligouria, anuria, nocuria
- SOB, peripheral oedema (fluid overload)
- Fatigue, restless legs
- Impotence
35
Q
List signs of chronic kidney disease
A
- Uraemic odour
- Pallor
- Ureamic frost (skin deposits, shiny skin)
- Cachexia
- Cognitive impairment
- Dehydration or hypovolaemia
- Tachypnoea
- Hypertension
- Hepatomegaly, palpable kidneys
- Distended bladder
- Peripheral oedema (fluid overload), JVP
- Peripheral neuropathy
- Frothy urine
- Pulmonary oedema
- Asterixis (uraemic encephalopathy)
- Half and half nails
36
Q
List different causes of hyponatraemia
A
- Hypovolaemia (diarrhoea, vomiting, diuretics - low urine sodium as trying to retain sodium in blood)
- Euvolaemia (hypothyroidism, adrenal insufficiency, SIADH - TFTs, synacthen test, plasma and urine osmolality, high urine sodium)
- Hypervolaemia (low urine sodium due to reduced renal perfusion, caused by cardiac failure, cirrhosis and nephrotic syndrome - fluid overload and low urine sodium)
37
Q
Describe nephrotic and nephritic syndrome
A
- Nephrotic syndrome is a condition involving the loss of significant volumes of protein via the kidneys (proteinuria >3g/day) due to increased permiability of GBM to protein which results in hypoalbuminaemia, and oedema. Due to podocyte damage.
- Nephritic syndrome is a condition involving haematuria, mild to moderate proteinuria (typically less than 3.5g/L/day), hypertension, oliguria and red cell casts in the urine. Due to inflammatory response within the glomeruli leading to GBM disruption.
38
Q
Define renal artery stenosis, ischaemic nephropathy and renovascular hypertension
A
- A narrowing of the renal artery lumen. It is considered angiographically significant if more than a 50% reduction in vessel diameter is present.
- Ischaemic nephropathy is a chronic reduction in glomerular filtration rate that occurs from a narrowing in the renal artery.
- Renovascular hypertension is hypertension mediated by high levels of renin and angiotensin II, produced by an underperfused kidney supplied by a stenosed renal artery.
39
Q
Describe epidemiology of renal artery stenosis
A
- 0.2-5% of all hypertensive patients
- Depends on the underlying cause (atherosclerotic 90% of all RAS, fibromuscular cases 10% of RAS)
- Females more likely than males to have fibromuscular displasia
40
Q
Describe aetiology of renal artery stenosis
A
Atherosclerotic RAS
- Atherosclerosis (80%)
- Diabetes mellitus
- Dyslipidaemia
- Smoking
Fibromuscular dysplasia
- Medial fibroplasia
- Intimal and adventitial fibroplasia
- Smoking
Other
- Post transplant
- Aneurysm
- Embolus
- Malformations
- Trauma
41
Q
List risk factors for renal artery stenosis
A
- Dyslipidaemia
- Smoking
- Diabetes
- Female
- Hypertension age 55 or over
- Unexplained kidney dysfunction, peripheral vascular disease
42
Q
List symptoms and signs of renal artery stenosis
A
- Abdominal bruit/ other bruits, weak leg pulses
- Sudden or unexplained recurrent pulmonary oedema
- Kidney injury after ACEi and ARB use
- Unexplained heart failure
- Refractory angina
- Hypokalaemia
- Hypertension
43
Q
List investigations for renal artery stenosis
A
- Serum creatinine (normal or high)
- Serum potassium (normal or low)
- Renin high, aldosterone high (secondary hypertension as the JCA detects a low bp reaching the glomerulus through the stenosed artery despite a high BP)
- Urinalysis and sediment evaluation (normal)
- Aldosterone to renin ratio (<20)
- Duplex ultrasound (reduction in vessel diameter)
- Gadolinium enhanced MR angiography
- CT angiography
- Conventional angiography/ CO2 angiography
- MR angiography
- Digital subtraction renal angiography GOLD STANDARD
- Captopril radionuclide renal scan
44
Q
Define prostate cancer
A
A malignant tumour of glandular origin, situated in the prostate. It is most commonly seen in older men.
45
Q
Describe epidemiology of prostate cancer
A
- 6th leading cause of cancer mortality in the UK, 2nd leading among men
- Adenocarcinoma of the prostate most commonly diagnosed
- Median age of diagnosis 66 years old
- Australia and New Zealand have the highest rates
46
Q
Describe aetiology of prostate cancer
A
- High fat diet
- Genetic factors
47
Q
List risk factors for prostate cancer
A
- Age over 50
- Black ethnicity
- North american or northwest european descent
- Family history
- High levels of dietary fat
- BRCA2 gene
48
Q
List symptoms of prostate cancer
A
- Asymptomatic until late
- Nocuria
- Urinary frequency
- Urinary hesitancy
- Dysuria
- Haematuria (transitional cell carcinoma)
- Weight loss
- Lethargy
- Bone pain
- Anorexia
49
Q
List signs of prostate cancer
A
- Abnormal DRE
- Palpable lymph nodes
50
Q
List investigations for prostate cancer
A
- DRE
- PSA
- Testosterone
- LFTs, FBC, renal function
- Prostate biopsy,
transperineal (gleason score, sum of 2 highest samples added together). Diagnostic for adenocarcinoma. - Bone scan, x-rays, pelvic CT/ MRI
- MRI gold standard, good at differentiating between high risk and low risk cancer. Normal prostate MRI - may have low risk, low grade cancer.
- Cytoscopy with biopsy for translational cell carcinoma
51
Q
Define benign prostatic hyperplasia
A
- Benign enlargement of the prostate gland, which is normal and occurs with age.
- Histological diagnosis made by biopsy of the prostate.
- Occurs at the transition zone of the prostate.
52
Q
Describe epidemiology of benign prostatic hyperplasia
A
- Increases with age
- 42% men age 50-60 and 82% men age 70-80
- Global prevalence 25%
53
Q
Describe aetiology of BPH
A
- Hyperplasia of the epithelial and stromal compartments, particularly in the transitional zone, may be attributed to various factors including shifts in age-related hormonal changes creating androgen/oestrogen imbalances.
- Changes in prostatic stromal-epithelial interactions that occur with ageing and increases in prostatic stem cell numbers are also aetiological considerations.
- Progression from pathological BPH to clinical BPH (i.e., the presence of symptoms) may require additional factors such as prostatitis, vascular effects, and changes in the glandular capsule
54
Q
List risk factors for BPH
A
- Age over 50
- Family history
- Afro-Carribbean
- Cigarette smoking
- Male pattern baldness (androgens)
- Metabolic syndrome (obesity, diabetes)
55
Q
List symptoms and signs and BPH
A
- Frequency, urgency and nocuria (storage symptoms)
- Weak stream, hesitancy, intermittency, straining, incomplete emptying, post void dribbling (voiding symptoms)
- Fever with dysuria (UTI)
- Urinary retention
- Smoothly enlarged prostate on DRE
56
Q
List investigations of BPH
A
- International prostate scoring system (LUTS+ QOL), frequency volume chart
- Urinalysis
- PSA, U and E
- DRE (smoothly enlarged)
- Flow rate + post void residual bladder scan
- ?Renal tract ultrasound
- ?Flexible cystoscopy (strictures)
57
Q
Describe treatment of BPH
A
- Watchful waiting (self monitor symptoms and yearly check up)
- Behavioural management (eg. bladder training, fluid intake advice, avoid alcohol and caffeine)
- If no indication for surgery but symptoms are bad, tamsulosin or alfuzosin (a blocker), OR finasteride or dutasteride (5-a reductase inhibitor) are first line
- Alternative medicine: saw palmetto
- Surgery may be used if very large prostate volume (over 30g) - transurethral resection of the prostate. Alternatives laser, rezum/steam, urolift, embolisation, catheter options
58
Q
List complications of BPH
A
- Progression
- UTI
- Renal insufficiency
- Bladder stones
- Haematuria
- Sexual dysfunction
- Acute urinary retention
- Overactive bladder
59
Q
Describe prognosis of BPH
A
- Most patients require ongoing therapy
- Progression occurs in 20% patients
- Risk for progression is reduced by use of finasteride and tamsulosin
60
Q
Define polycystic kidney disease
A
- Part of a heterogeneous group of disorders characterised by renal cysts and numerous systemic and extrarenal manifestations.
- There are 2 types: autosomal-dominant PKD (ADPKD) and autosomal-recessive PKD (ARPKD).
61
Q
Describe epidemiology of polycystic kidney disease
A
- Autosomal dominant worldwide and all races. Less common in black people, 1 in 400-1 in 1000 prevalence in america
- 1 in 10000-1 in 40000 autosomal recessive
62
Q
Describe aetiology of polycystic kidney disease
A
- Autosomal dominant PKD1 and PKD2 (wild type copy develops an inactivating mutation leading to loss of polycystin function)
- PC1, PC2 and autosomal recessive PKD gene in autosomal recessive.
63
Q
List signs and symptoms of polycystic kidney disease
A
Clinically silent for many years
- Hypertension
- Abdo/flank pain (stones)
- Haematuria
- Palpable kidneys/abdo mass
- Headaches
- Dysuria, urgency, suprapubic pain, fever (UTI of cysts)
- Cardiac murmur
- Abdo hernia or rectus abdominis diastasis
- Hepatomegaly
- Chest pain
- Sub arachnoid haemorrhage (berry aneurysm)
64
Q
List risk factors for polycystic kidney disease
A
- Family history of autosomal dominant PKD
- Family history of cerebrovascular event
