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
Describe prognosis of acute kidney injury
- Overall mortality of 23.8%
- Community acquired lower mortality
- 90 mortality 25.6%
26
Define chronic kidney disease
- 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
List investigations in chronic kidney disease
- 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
Describe epidemiology of chronic kidney disease
- Stage 3 4% population
| - 40% people over age 45
29
List risk factors for chronic kidney disease
- Age
- Hypertension (15%)
Diabetes (30%)
- IHD
- Family history CKD
- African American (ApoL1 gene)
- Obesity
- Glomerulonephritis
- Hypertension
- Polycystic kidney disease
30
List causes of proteinuria
- Diabetes
- Minimal change (glomerular) disease
- Membranous nephropathy
- Amyloid
- SLE
31
List investigations of proteinurea
- Quantitate protein: creatinine
- Albumin and cholesterol
- Creatinine, eGFR
- Glucose, SLE, virology, myeloma screen
32
Describe management of proteinuria
- Control oedema with low salt and diuretics
- ACEi/ARB
- Treat cause
- Steroids or immunosuppression
- Risk of CKD or ESKD
33
Describe investigation of haematuria
- 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
List symptoms of chronic kidney disease
- 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
List signs of chronic kidney disease
- 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
List different causes of hyponatraemia
- 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
Describe nephrotic and nephritic syndrome
- 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
Define renal artery stenosis, ischaemic nephropathy and renovascular hypertension
- 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
Describe epidemiology of renal artery stenosis
- 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
Describe aetiology of renal artery stenosis
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
List risk factors for renal artery stenosis
- Dyslipidaemia
- Smoking
- Diabetes
- Female
- Hypertension age 55 or over
- Unexplained kidney dysfunction, peripheral vascular disease
42
List symptoms and signs of renal artery stenosis
- 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
List investigations for renal artery stenosis
- 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
Define prostate cancer
A malignant tumour of glandular origin, situated in the prostate. It is most commonly seen in older men.
45
Describe epidemiology of prostate cancer
- 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
Describe aetiology of prostate cancer
- High fat diet
| - Genetic factors
47
List risk factors for prostate cancer
- Age over 50
- Black ethnicity
- North american or northwest european descent
- Family history
- High levels of dietary fat
- BRCA2 gene
48
List symptoms of prostate cancer
- Asymptomatic until late
- Nocuria
- Urinary frequency
- Urinary hesitancy
- Dysuria
- Haematuria (transitional cell carcinoma)
- Weight loss
- Lethargy
- Bone pain
- Anorexia
49
List signs of prostate cancer
- Abnormal DRE
| - Palpable lymph nodes
50
List investigations for prostate cancer
- 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
Define benign prostatic hyperplasia
- 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
Describe epidemiology of benign prostatic hyperplasia
- Increases with age
- 42% men age 50-60 and 82% men age 70-80
- Global prevalence 25%
53
Describe aetiology of BPH
- 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
List risk factors for BPH
- Age over 50
- Family history
- Afro-Carribbean
- Cigarette smoking
- Male pattern baldness (androgens)
- Metabolic syndrome (obesity, diabetes)
55
List symptoms and signs and BPH
- 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
List investigations of BPH
- 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
Describe treatment of BPH
- 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
List complications of BPH
- Progression
- UTI
- Renal insufficiency
- Bladder stones
- Haematuria
- Sexual dysfunction
- Acute urinary retention
- Overactive bladder
59
Describe prognosis of BPH
- Most patients require ongoing therapy
- Progression occurs in 20% patients
- Risk for progression is reduced by use of finasteride and tamsulosin
60
Define polycystic kidney disease
- 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
Describe epidemiology of polycystic kidney disease
- 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
Describe aetiology of polycystic kidney disease
- 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
List signs and symptoms of polycystic kidney disease
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
List risk factors for polycystic kidney disease
- Family history of autosomal dominant PKD
| - Family history of cerebrovascular event
65
Describe investigation of polycystic kidney disease
- Renal ultrasound (under 30 at least 2 cysts, 20-59 2 cysts on each kidney, over 60 4 cysts on each kidney)
- CT abdo/pelvis (no family history over 10 cysts, presence of family history same as above)
- MRI abdomen/pelvis
- Urinalysis/urine culture, haematuria
- Serum electrolytes, urea, creatinine (normal or elevated)
- Fasting lipid profile (normal or elevated)
- ECG
- CT scan of brain (intracranial bleed)
- 24hr urine collection (high citrate, uric acid, or oxalate in setting of stones)
- KUB X ray, dual energy CT
66
Define nephrotic syndrome
Triad of
- Proteinuria (over 3g/24h, A:CR >250mg/mmol)
- Hypoalbuminaemia (<30g/L)
- Oedema
67
Describe aetiology and risks of nephrotic syndrome
Primary renal disease
- Minimal change disease (90% in children)
- Membranous nephropathy (most common cause in adults)
- Focal segmental glomerulosclerosis (35-50% in adults)
- Membranoproliferative GN
Secondary
- DM
- SLE
- Myeloma
- Amyloid (10%)
- Pre-eclampsia
68
Describe epidemiology of nephrotic syndrome
- 3 cases per 100000 per year
- More common in adults
- More common in women (2:1)
69
List symptoms and signs of nephrotic syndrome
- Generalised pitting oedema, may be rapid and severe, including peri-orbital oedema
- Systemic symptoms
- White banding on the nails from low albumin (Muerhkes)
- Rash (consistent with SLE), easy bruising and neuropathy (consistent with amyloidosis), haem-positive stool (consistent with GI malignancy), or fundoscopic examination that reveals evidence of diabetic retinopathy.
70
Describe investigations of nephrotic syndrome
- Proteinuria should be quantified by either 24-hour urine collection or spot urine protein-to-creatinine ratio (mg/micromol). A result of >3.5 g/24 hours, or PCR >300 mg/micromol, is diagnostic for nephrotic-range proteinuria.
- Serum free light chains and urine protein electrophoresis
- HIV test
- Serum complement level, syphilis test (RPR)
- Hepatitis serologies, complement (C3, C4, and total haemolytic complement)
- Cryoglobulins
- Antinuclear antibodies (ANA) screening
- Imaging if concerned about cancerous cause. Renal ultrasound
- Biopsy
71
Define nephritic syndrome
- Nephritic syndrome is an inflammatory process that is defined as the presence of one or more of the following:
- Hematuria with acanthocytes
- RBC casts in urine
Proteinuria (< 3.5 g/24 h)
- Hypertension
- Mild to moderate edema
- Sterile pyuria
- Oliguria
- Azotemia
72
List causes of nephritic syndrome
- Poststreptococcal glomerulonephritis
- IgA nephropathy
- Small vessel vasculitis
- Goodpasture syndrome (autoimmune, anti-GBM)
- Thin basement membrane nephropathy
- Alport syndrome (genetic, affects hearing and vision too)
- Diffuse proliferative glomerulonephritis
- Rapidly progressive glomerulonephritis
- Membranoproliferative glomerulonephritis
73
List risks for acute kidney injury
- Pre existing CKD
- Hypovolaemia
- Age over 75
- Male
- Comorbidity (diabetes, cardiovascular disease, malignancy, chronic liver disease, complex surgery)
- Contrast administration
74
Defien glomerulonephritis
- Glomerular injury
- A group of diseases that are characterised by inflammatory changes in the glomerular capillaries and basemenet membrane
75
Describe epidemiology of glomerulonephritis
- For every patient with clinically apparent GN, approx 5-10 patients have subclinical disease
- Focal segmental glomerulosclerosis most common cause
- Membranous nephropathy used to be most common
- Membranous most common in white men over 40, associated with lupus in young women and hep B in children
- Worldwide, most common cause of end stage renal disease (3rd most common in western world)
76
Describe aetiology of glomerulonephritis
- SLE and vasculitis
- Inflammation due to leukocyte infiltration, antibody deposition, and compliment activation
- Infections, drugs (anabolic stermoids, NSAIDS, heroin and cocoaine), metabolic disorders (diabetes mellitus, hypertension, thyroiditis), malignancy, hereditary disorders and deposition diseases (eg. amyloidosis)
77
List risk factors for glomerulonephritis
- Group A beta-haemolytic Streptococcus
- Respiratory infections
- Gastrointestinal infections
- Hepatitis B
- Hepatitis C
- Infective endocarditis
- HIV
- Systemic lupus erythematosus (SLE)
- Systemic vasculitis
- Hodgkin's lymphoma
- Lung cancer
- Colorectal cancer
- Non-Hodgkin's lymphoma
- Leukaemia
- Thymoma
- Haemolytic uraemic syndrome
- Drugs
78
List symptoms of glomerulonephritis
- Haematuria
- Oedema
- Oligouria
- Anorexia
- Nausea
- Malaise
- Weight loss
- Fever
- Skin rash
- Arthralgia
- Haemoptysis
- Abdo pain
- Sore throat
79
List signs of glomerulonephritis
- Hypervolaemia
- Oedema
- Hypertension
80
List investigations for glomerulonephritis
- Urinalysis and urine microscopy (haematuria, proteinuria, dysmorphic RBCs, leukocytes, and RBC casts)
- Metabolic profile (hypoalbuminaemia, elevated LFTs)
- GFR (may be reduced)
- FBC (anaemia)
- Lipid profile
- Urine ACR (normal)
- Ultrasound of kidneys (small or normal kidneys)
- ESR/CRP
- Complement
- Rheumatoid factor
- Anti-neutrophil cytoplasmic antibody, anti GBM, antistreptolysin O antibody, anti ANase, anti dsDNA, antinuclear
- Biopsy showing immune complex deposition GOLD STANDARD
81
Define amyloidosis
- Any histological tissue specimen that binds the cotton wool dye, Congo red, and demonstrates green birefringence when viewed under polarised light is, by definition, an amyloid deposit.
- The patient with this deposit has amyloidosis.
- Deposits of amyloid may be localised in tissue or part of a systemic process.
- Progressive deposition of amyloid is disruptive to tissue and organ function and manifests its clinical sequelae by the dysfunction of those organs in which it deposits.
82
Describe epidemiology of amyloidosis
- In the UK, 5.1-12.8 per 1 million per year, 60 new cases annually
- More common in males
- Mean age at diagnosis 63
- Lower in Asian populations
83
Describe aetiology of amyloidosis
- Primary amyloidosis (AL - immunoglobulin light chain, unknown aetiology, no underlying risks but can be multiple myeloma)
- Non-familial secondary (AA inflammatory polyarthropathies eg. rheumatoid, chronic infections, IBD, castlemans)
- Secondary amyloidosis (AA serum amyloid A, acute phase reactant released in inflammation - famillial mediterranean fever, TNFa receptor associated, Muckle wells, hyper IgD)
- Also inherited forms (AF)
- Localised affects one organ (eg. Alzheimers, familial amyloid cardiomyopathy)
84
List risk factors for amyloidosis
- Monoclonal gammopathy of undetermined significance (MGUS)
- Inflammatory polyarthropathy
- Chronic infections
- Inflammatory bowel disease
- Familial periodic fever syndromes
- Castleman's disease
85
List symptoms of amyloidosis
- Oedema
- Fatigue
- Palpitations and SOB
- Claudication
- Nausea
- Abdo cramps
- Weight loss (malabsorption)
- Macroglossia can interfere with speech and swallowing and cause noisy breathing at night
- Alternating bowel habit (due to intestinal villi damage)
- Light headed/orthostatic hypotension (PNS)
- Diffuse muscular weakness
- Sensory neuropathy (paraesthesia)
86
List signs of amyloidosis
- JVP raised, lower extremity oedema (due to nephrotic syndrome + congestive heart failure)
- Periorbital purpura (haematological)
- Macroglossia, hepatomegaly and splenomegaly (deposits in the organs)
- Submandibular salivary gland enlargement
- Distal, symmetrical sensory neuropathy (pain and temp, later proprioception)
- Tinels sign (tapping on carpal nerve at the wrist produces tingling)
- Phalens manoeuvre (patient holds hands in forced flexion. Carpal nerve compression when 1-4 fingers tingle)
- Associated with alzhiemers dementia (A beta peptides collect in the brain)
87
Describe investigations for amyloidosis
- Serum immunofixation (presence of monoclonal protein in light chain amyloidosis AL)
- Urine immunofixation (monoclonal protein presence AL)
- Immunoglobulin free light chain assay (abnormal kappa to lambda ratio AL)
- Bone marrow biopsy (clonal plasma cells)
- Tissue biopsy (positive green birefringence when stained with congo red) most important diagnostic method
- Proteinuria and hypoalbuminaemia
- T2DM (due to pancreas involvement)
88
Define hydrocele
- A collection of serous fluid between the layers of the membrane (tunica vaginalis) that surrounds the testis or along the spermatic cord.
- 2 types: communicating and non-communicating
- Communicating patent processus vaginalis
- Non-communicating closed processus vaginalis and more fluid is produced by the tunica vaginalis than is being absorbed
89
Describe aetiology of hydrocele
- Congenital in paediatrics
- Adult acquired
- Non-communicating secondary to minor trauma, infection, testicular torsion, operation, or testicular tumour
- Reactive inflammatory response
- Communicating increased intra abdominal pressure with patent processus vaginalis
90
Describe epidemiology of hydrocele
- Predominantly affect males
- Common in infants and children, often associated with indirect inguinal hernia
- 1-3% of full term infants have a hydrocele or hernia
- More prevalent in premature infants and those whose testes descend late
- Patent processus vaginalis common autopsy finding
- 15-22% chance if patent
- Often patent processus vaginalis closes within first year of life
- Incidence unknown in adults, occur in 10% of testicular malignancies
91
List risks for hydrocele
- Male sex
- Prematurity and low birth weight
- Infants <6 months of age
- Infants whose testes descend relatively late
- Increased intraperitoneal fluid or pressure
- Inflammation or injury within the scrotum
- Testicular cancer
- Connective tissue disorders
- Varicocelectomy
- Filariasis
- Maternal exposure to polybrominated biphenyl
92
List signs and symptoms of hydrocele
- Scrotal mass
- Easily transilluminated
- Enlarges following activity (due to increasing intra abdo pressure)
- Can get above the swelling
- Not separate from the testes
93
List investigations for hydrocele
- Clinical diagnosis
| - Can do ultrasound, tumour markers, urine dip
94
Define varicocele
The abnormal dilation of the internal spermatic veins and pampiniform plexus that drain blood from the testis
95
Describe aetiology of variocele
- Increased hydrostatic pressure in the left renal vein
- Incompetent or congenitally absent valves
- Rarely retroperitoneal or abdo compressive mass
- Abnormal collection of pertoneal fluid
96
Describe epidemiology of varicocele
- 10-15% of men and adolescent boys in the general population
- 40% of men with infertility have varicocele
- Rare pre-puberty
- 90% left side, 10% bilateral.
97
List risk factors for varicocele
- Somatometric parameters (tall/low BMI)
| - FHx of varicocele
98
List signs and symptoms of varicocele
- Painless scrotal mass
- Left sided
- Small testicle
- Uncommonly groin pain
- Feels like a bag of worms, enhanced by Valsalva
- May disappear when laying flat
99
Describe investigations for varicocele
- Clinical diagnosis
| - Consider ultrasound, semen analysis, FSH and testosterone (infertility), CT abdo/pelvis (exclude mass)
100
Define epididymitis and orchitis
- Epididimitis is inflammation of the epididymous
| - Orchitis is inflammation of the testes
101
Describe aetiology of epididymitis and orchitis
- Orchitis rare in isolation, main cause is mumps
- Epididymitis is commonly bacterial, either STI related in younger males (eg. chlamydia, gonorrhoea) or enteric organisms in older males (eg. E.coli, pseudomonas)
- Chronic is recurrent and/or untreated acute epididymitis, or TB.
- Post-op
102
Describe epidemiology of epididymitis and orchitis
- Epididymitis is one of the most common causes of scrotal pain in adults
- Epididymitis most common in patients 15-30 and over 60
- Mumps orchitis in 40% postpubertal males with mumps
103
List signs and symptoms of epididymitis and orchitis
- Unilateral acute onset scrotal pain (bilateral 5-10%)
- Swelling, erythematous skin, systemic symptoms such as fever
- Epididymis is tender, pain may be relieved on elevation of the testes.
- Symptoms of lower UTI
- Orchitis - mumps (fatigue, headache, parotid swelling)
- Nausea and vomiting
- Malaise
104
Describe investigations for epididymitis and orchitis
- Urinalysis and culture if UTI suspected
- Urethral smear for STI
- Urethral swab for gonorrhoea
- HIV testing
- Colour doppler ultrasound to ensure no torsion
- Mumps IgM/IgG serology
105
List risk factors for epididymitis and orchitis
- Previous N.gonorroeae, or known contact
- Presence of purulent urethral discharge, MSM, black ethnicity
- Indwelling catheters
- Abnormalities of urinary tract (eg. stricture or obstruction)
- Anal intercourse
106
Describe management of epididymitis and orchitis
- Urgent urology opinion if torsion possibility
- STI GUM for full UTI screen, treatment and contact tracing
- Rest, analgesia, scrotal support
- Abstain from intercourse if STI
- Antibiotics - if sexually transmitted ceftriaxone plus doxycycline, if enteric ofloaxcin or ciprofloxacin
- If severe, fluid and electrolyte management and IV broad spectrum
- If chronic, surgery
107
List complications of epididymitis and orchitis
- More often if uro-pathogen related
- Reactive hydrocele
- Abscess formation and infarction of the testicle
- Infertility
- Mumps can lead to testicular atrophy, sub-fertility and infertility
108
Describe prognosis of epididymitis and orchitis
- Discomfort may last weeks or even months
| - Most patients feel better after 3 days of antibiotics, and dont have any long term problems
109
Define testicular cancer
- Malignant neoplasm of the testes
- The most common malignancy in young adult men (20 to 34 years of age), and highly curable when diagnosed early.
- A precancerous condition termed carcinoma in situ is highly specific early in the natural history of the disease.
- Germ cell (seminomatous and non-seminomatous) or non-germ cell
110
Describe aetiology of testicular cancer
- All germ cell tumours start during fetal development, and progress through non-invasive carcinoma in situ stage
- Congenital abnormalities leading to distorted differentiation of germ cells and arrest of normal development are considered an important aetiological factor
- Environmental factors (trauma, hormones, atrophy) and genetic predisposition play a role
111
Describe epidemiology of testicular cancer
- 1% of all incident cancers, less than 1% cancers in men
- Among men age 15-44 most common cancer diagnosed
- Median age at diagnosis is 33
- Highest incidence in northern european countries, lowst in asian and african countries
- In the UK, 1400 cases each year with highest incidence age 25-35
112
List risks for testicular cancer
- Cryptorchidism
- Gonadal dysgenesis
- Family history of testicular cancer
- Personal history of testicular cancer
- Testicular atrophy
- White ethnicity
- HIV infection
- Chemical carcinogens and low sperm count
- Rural residence
- Higher socioeconomic status
- Inguinal hernia
- Genetic abnormality
113
List signs and symptoms of testicular cancer
- 55% cases on the RHS, 2% bilateral
- Usually painless hard, irregular mass, 10% acute pain
- Extratesticular manifestations include bone pain, lower extremity swelling, supraclavicular lymph nodes, hyperthyroidism, gynaecomastia.
- Mets to lungs may cause large pleural effusion in young men
- Leydic can cause hormonal symptoms eg. gynaecomastia
114
Describe investigations for testicular cancer
- Ultrasound with colour doppler of testes. Testicular mass
- CXR, CTAP for mets
- beta-hCG (elevated in all choriocarcinoma, 5-10% of patients with pure seminoma)
- Serum alpha fetoprotein (elevated in teratoma)
- Serum lactate dehydrogenase elevated in 50% cases, HCG
- Biopsy, confirm histology
115
Describe management of hyperkalaemia
- Calcium gluconate can be used acutely, given IV as 10mls 10% solution, to provide cardiac protection in hyperkalaemia.
- Salbutamol nebulisers and insulin treatments will help to move potassium back into the cells.
- Severe hyperkalaemia especially with anuria, will usually need haemodialysis/haemofiltration.
- 50mls 50% dextrose
- Long term use valtessa
116
Define urinary tract calculi
- Nephrolithiasis refers to the presence of crystalline stones (calculi) within the urinary system (kidneys and ureter).
- Such renal stones are composed of varying amounts of crystalloid and organic matrix.
- Ureteric stones almost always originate in the kidney but then pass down into the ureter.
117
Describe epidemiology of urinary tract calculi
- 12% lifetime prevalence
- More common in adult men than women (2:1)
- More common in white people
- Typically peaks age 40-50
- Higher prevalence in hot, arid or dry climate
- Correlated with T2DM, obesity, higher weight circumference
1% hspital admissions
- Lifetime risk 5-12%
118
Describe aetiology of urinary tract calculi
- Crystalline mineral depositions that form from microscopic crystals in the loop of henle, distal tubules, or the collecting duct
- Usually due to elevated calcium, uric acid, oxalate and sodium. Decreased stone inhibitors such as citrate and magnesium
- Struvate is infectious (magnesium or ammonium phosphate)
- Low urinary volume and abnormal pH also contribute
- Supersaturation of urine occurs
- Risks: low fluid intake, high salt, structural urinary tract abnormalities
119
List signs and symptoms of urinary tract calculi
- Acute severe flank pain, radiates from loin to groin
- Nausea and vomiting
- Urinary frequency or urgency
- Haematuria
- Testicular pain
- Tachycardia
- Hypotension
- Costovertebral angle and ipsilateral flank tenderness
120
List risk factors for urinary calculi
- Dehydration
- High salt intake
- White ancestry
- Male sex
- Obesity
- Crystalluria
- Medications (antacids, carbonic anhydrase inhibitors, sodium and calcium containing, protease inhibitors)
121
Describe investigations for urinary tract calculi
- Non-contrast helical CT KUB scan GOLD STANDARD, accurately determines size and location of stones, hydronephrosis and character, may be perinephric stranding (contrast is higher radiation)
- Renal ultrasound if pregnant or under 24 hours of presentation
- Urinalysis (microhaematuria)
- FBC
- Serum electrolytes, calcium, urea and creatinine
- Urine pregnancy test
- Stone analysis for composition
- KUB x-ray. Uric acid stone not visible on x ray but visible on CT. (10-20% not radioopaque)
- 6 week follow up - advise to go to hospital if fever, not passing urine, unable to keep fluids down
122
Describe management of urinary tract calculi
- Hydration and analgesia (NSAIDs, morphine)
- Symptoms of obstruction, antibiotics (if infection) and renal decompression (uteric stent, nephrostomy tube, delay stone removal until drainage complete and infection cleared)
- If no evidence of obstruction, watchful waiting consider surgical intervention for over 10 mm and stones that remain despite conservative therapies (shock wave lithotripsy 1cm, uteroscopy 1.5-2cm, percutaneous nephrolithotomy over 2cm)
- Medical expulsive therapy if 5-10mm- alpha blocker (tamsulosin, alfuzosin as they relax smooth muscle)
- Oral alkalinisation therapy (potassium citrate and sodium bicarb) to prevent supersaturation, ongoing therapy for some patients
NOTE: JJ stent can be used to prevent stricturing and oedema, and therefore prevent any further blockages
123
List complications of urinary tract calculi
- Recurrence (50-60% chance)
- Post-percutaneous nephrolithotomy bleeding, post shock wave lithotripsy haematoma, sepsis, uteric injury, stienstrasse (accumulation of stone fragments)
- Visceral organ injury
- Uteric stricture
- Pneumothorax
- Infection (obstructive pyonephritis, infection, ICU needed with nephrostomy, then determine cause and treat stones)
124
Describe prognosis of urinary tract calculi
- Lifelong disease process
- 50% recurrence at 5 years
- Higher risk if not following lifestyle modifications, or underlying metabolic abnormalities
- Residual fragments from surgery usually spontaneously pass as long as under 4mm
125
What is found in the urine in multiple myeloma?
Bence jones proteins
126
What causes renal damage in rhabdomyolysis?
Myoglobin is toxic - causes cocacola urine
127
Define bladder cancer
- A tumoour of the bladder
- Most common urothellial carcinoma (over 90%)
- Low grade papillary
- High grade flat or in situ, difficult to visualise
128
Describe epidemiology of bladder cancer
- 90% translational cell crcinomas in the UK
- 9th in worldwide cancer incidence
- 7th most common cancer in men, 17th most common cancer in women
- Globally, Egypt, West Europe and North America have the highest rates, and asia the lowest
- In the UK, 1:6000/year, male to female 5:2
- Women, black people and older people all experience higher mortality
129
Describe aetiology/risk factors of bladder cancer
- Age over 55
- Smoking increases risk 2-4 fold and causes 1/2 cases in men and 1/3 in women
- Second-hand smoke; occupational exposure to chemical carcinogens, such as aromatic amines used in rubber and dye industries, and polycyclic aromatic hydrocarbons used in the aluminium, coal, and roofing industries; and exposure to arsenic in drinking water account for one quarter or more of cases
- Painters, hiardressessers, medical personel all at greater risk
- Pelvic radiation and chemo (cyclophosphamide) significantly increase risk of bladder cancer
- T2DM increases risk (pioglitazone)
- Chronic inflammation, Schistosoma infection, and chronic indwelling catheters all increase risk of SCC
- Familial cases
- Chronic cystitis
130
List signs and symptoms of bladder cancer
- Painless haematuria >80% patients. gross, painless haematuria is most common
- Typically intermittent episodes of haematuria (macro or microscopic)
- Dysuria - typical of carcinoma in situ but can be seen in high-grade urothelial carcinoma. Indicated aggressive bladder cancer
- Urinary frequency
- Recurrent UTIs
131
List investigations for bladder cancer
- RBC casts, crenated red cells seen with glomerular bleeding (80% gross or microscopic haematuria, may be pyuria)
- Urine cytology (90% patients positive if carcinoma in situ or high grade, <33% in low grade transitional)
- Renal and bladder ultrasound (bladder tumours and/or upper tract obstruction)
- CT urogram (bladder tumours, upper urinary tract tumours and or obstruction - staging)
- Cystoscopy (low grade papillary and readily visible, high grade flat and more difficult to see. carcinoma in situ frequently not visible - may use narrow beam imaging or fluorescence to white light) - cytoscopy+ biopsy diagnostic
- IV urogram for filling defects
- FBC (anaemia), urinary markers positive (bladder tumour antigen, nuclear matrix protein 22, immunoCyt/uCyt+, urovysion)
- Alk phos (elevated/bone pain indicated bone scan)
- CT/MRI abdo and pelvis
- CXR
132
Describe staging of bladder cancer
- Tis carcinoma in situ
- Ta tumour confined to epithelium
- T1 tumour in submucosa or lamina propria
- T2 invades muscle
- T3 extends into perivesical fat
- T4 invades adjacent organs
- NO no lymph nodes involve
- N1-3 progressive lymph node involvement
- M0 no mets
- M1 distant mets
133
List causes of voiding symptoms
- BPH
| - Strictures (younger men, post STI)
134
List causes of storage problems
- Strong flow often
- Detrusor overactivity
- Can be caused by BPH
135
Describe treatment of overactive bladder
- Reassure and treat UTI
- Dietary advice
- BAUS bladder training exercises
- Anticholinergics (oxybutinin, tolterodine, solifenacin), beta agonist (betmiga)
- Surgical management (intravesical botox injection, SNS, neuromodulation, bladder augmentation, urinary diversion/conduit)
136
Describe management/investigations of urinary retention
- Catheterise and measure residual volume
- DRE
- Urine cultre and treat UTI if cause
- FBC, U and E,admit if renal failure
- Neuro exam if cord compression suspected
- Prescribe Abx, laxatives, alpha blocker if necessary
- Consider ultrasound if abnormal renal function
- Admit and monitor urine output and fluid replace (obstructive nephropathy)
- If high pressure surgery or long term catheter
137
Define transurethral resection of the prostate
- A resectoscope (containing a light, camera and loop of wire) is passed along the urethra to the prostate. The wire is heated with an electric current, and this cuts away sections of the prostate
- A catheter is used to flush, and left in while in hospital
- General or spinal anaesthesia is used, with 1-3 days hospital stay.
138
List indications for transurethral resection of the prostate
- Urinary retention and renal insufficiency caused by BPO (benign prostatic obstruction)
- Failure of medical therapy, recurrent cystitis, persistant prostatic bleeding
139
List risks of transurethral resection of the prostate
- Failure to ejaculate (retrograde ejaculation - into the bladder instead of penis) 90%
- Urinary incontinence (usually temporary)
- ED
- Difficulty passing urine, urethral strictures
- UTI (5%)
- Bleeding (2%)
- Turp syndrome - too much fluid used to flush is absorbed into the bloodstream, causes n and v, dizziness, headache, confusion. SOB, seizures, fits, and coma if untreated
- Risk of death 1 in 1000
140
Describe KDIGO classification systmen
AKI
Stage 1
- 1.5x rise in Creatinine (Cr) compared to baseline OR
- Urine output <0.5mL/kg/hr for >6hrs
Stage 2
- 2x rise in Cr OR
- Urine output <0.5mL/kg/hr for >12hrs
Stage 3
- 3x rise in Cr OR
- Urine output <0.3mL/kg/hr for >24hrs or
anuria >12hrs
141
List features of acute tubular necrosis
- Urine muddy brown granular casts, myoglobulinaria, haemoglobinuria
- Raised AKI (urea, creatinine, potassium, metabolic acidosis)
- Urea:creatinine over 40:1 intrinsic renal
- Tubular epithelium necrosis (histological)
142
List features of minimal change disease
- Normal light microscopy
- Oedema, hypoalbuminaemia, proteinuria
- Podocyte effacement on EM
- More common in young males
- Normal BP/renal function
- Associated with hodgkin lymphoma
143
List features of membranous glomerulonephrosis
- Nephrotic syndrome
- Autoimmune (against PLA2R)
- Malignancy, drugs, infection (hep B/C, SLE - subepithelial deposition, spike and dome pattern)
144
List features of focal segmental glomerulosclerosis
- Focal scarring, IgM deposition
- Afro Carribeans
- Heroin, HIV
- Pamidronate
145
List features of diabetic nephropathy
- Nodular glomerulosclerosis and kimmelstiel wilson nodules
| - Negative congo red
146
Describe features of membranoproleferative flomerulonephrosis
- IC associated with deposition, 50% ESRF
- Type 1 hep C>Hep B
- Type 2 C3 nephritic factor
147
List post streptococcal causes of nephritic syndrome
- IgA nephropathy days after URTI infection, immuno complex, episodic macroscopic haematuria, normal serum complement
- HSP IgA, systemmic vasculitis, deposition in skins, joints, kidneys, purpuric rash/arthralgia
- Post streptococcal GN 1-2 weeks after throat or skin infection, low C3, smoky urine
148
List types of rapidly progressive glomerulonephritis
- Type 1 goodpastures, anti GBM, haemoptysis, haematuria, proteinuria, young males
- Immune complex deposition SLE, IgA,HSP
- Pauci immune negative stain, ANCA associated, cANCA granulomatosis polyangiitis, pANCA eosinophilic granulomatosis with polyangiitis
149
Describe features of acute interstitial nephritis
- Immune mediated hypersensitivity of either drugs or other ag
- Allergic triad of fever, rash, arthralgia, AKI
- High IgE, oesinophilia
- Biopsy shows inflammatory cell infiltrate
- Drug hypersensitiviy (70%): NSAID, ranitidine, anticonvulsants
- Infections (Strep, Pneumoooccus, Staph)
- Autoimmune (SLE, Sjogren’s)
150
Describe aetiology of CKD
- Glomerular (membranous, chronic glomerulonephritis, diabetes, amyloid)
- Tubulointersititial (UTI, pyelonephritis, stones, drugs, toxins, sarcoid)
- Blood flow vessles (renal limited vasculitis, atherosclerotic renal disease, HTN, HF, TTP)
- COngenital
- Transplant
151
List types of stone in urinary tract calculi
- Calcium oxalate– most common (80%)
- Magnesium ammonium phosphate “Struvite stones” ”Staghorn”
Related to Proteus sp. that can break down urea
- Uric acid – usually relate to low urine pH, radiolucent on AXR
- Cysteine (1%) – related to inborn errors of metabolism i.e. homocystinuria
152
List types of testicular cancer
Germ cell tumour
- Seminoma - 50% “fried egg appearance, radiosensitive, 3rd decade)
- Non-Seminoma (e.g. teratoma (non-rad sensitive), choriocarcinoma (HcG, blood spread), Yolk sac (high AFP), embryonal carcinoma (haem spread)) – 30% [20-30 years]
Sex cord cell tumour
- Sertoli tumour, Leydig cell tumours - hormone producing
153
List causes of hyperkalaemia
Reduced excretion
- Renal CKD
- Endocrine renin angiotensin aldosterone system
Release from cells
- Rhabdomyolysis
- Acidosis
154
List causes of hypokalaemia
- Increased excretion, diuretics, conns
- Renal tubular acidosis
- Burns, eczema, psoriasis, villous, adenoma
- Vomiting
- Redistribution into cells (insulin, salbutamol, metabolic alkalosis)
155
Describe management of hypokalaemia
- Give potassium
| - Monitor levels
156
List types of incontinence
- Stress (increased abdo pressure)
- Urge (involuntary contraction of urinary muscles)
- Overflow (blockage of urethra)
- Neurogenic
157
Describe characteristics of rapidly progressive glomerulonephitis
- Rapid loss of renal function
| - Glomerular crescent formation seen in at least 50% of glomeruli in biopsy
158
Describe goodpastures histology appearance
Crescent shaped glomeruli
159
Describe angiomyolipoma
- A benign renal tumour
- Associated with tuberous sclerosis (skin patches, learning disability, eczema) or sporadic lung lymphangioleiomyomatosis
- Mostly asymptomatic, detected incidentally. Can cause haemorrhage
- Hyperechoic lesions
- More common in men
160
Describe presentation of renal tuberculosis
Sterile pyuria on the background of an infective picture
