RENAL + GU Flashcards
(339 cards)
1
Q
BPH
Define benign prostatic hyperplasia (BPH)
A
Increase in cell number and size in transitional/peri-urethral prostate area WITHOUT the presence of malignancy
2
Q
BPH
Describe the pathophysiology of Benign prostatic hyperplasia
A
Epithelial and stomal cell increase
Increased A1 adrenoreceptors –> smooth muscle contraction and mass effect of prostate size = obstruction
3
Q
BPH
what are the clinical features of BPH?
A
SYMPTOMS
- voiding (hesitancy, weak stream, straining, incomplete emptying, terminal dribbling)
- storage (urgency, frequency, nocturia, urgency incontinence)
- lower abdominal pain (indiactes urianry retention)
SIGNS
- DRE findings (smooth, enlarged + non-tender)
- lower abdominal tenderness + palpable bladder (indicates acute urinary retention)
4
Q
BPH
What investigations might you do in someone who you suspect has BPH?
A
- Digital rectal exam - show smooth but enlarged prostate
- PSA - not overly accurate but usually done for completion (remember you can’t do this at the same time as DRE)
- urinalysis
- U&Es
- international prostate symptoms score questionnaire
- Bladder diaries etc.
to consider
- renal tract USS
- urodynamics
- flexible cystoscopy
5
Q
BPH
What lifestyle changes can be made to manage symptoms of BPH?
A
- reduce caffeine intake
- treat constipation
- reduce fluid intake
- bladder retraining
6
Q
BPH
Describe the treatment for BPH
A
1st line = Alpha-1-antagonists (A-blockers) e.g. tamulosin
- relaxes smooth muscle in bladder neck & prostate
2nd line = 5-alpha-reductase inhibitors e.g. finasteride
- blocks conversion of testosterone to dihydrotestosterone -> decreases prostate size
TURP = gold standard
7
Q
BPH
Give the surgical treatment for BPH
A
Transurethral resection of prostate (TURP)
8
Q
BPH
What are the indications in someone with BPH to do a TURP?
A
RUSHES
- Retention
- UTI’s
- Stones (in bladder)
- Haematuria (refractory to medical therapy)
- Elevated creatinine
- Symptom deterioration (despite maximal medical therapy)
9
Q
BPH
What is the function of the prostate?
A
Secretes proteolytic enzymes into the semen which breaks down clotting factors in the ejaculate
10
Q
PROSTATE CANCER
Define prostate cancer
A
Adenocarcinoma in the peripheral zone of the prostate gland
11
Q
PROSTATE CANCER
Where can prostate cancer metastasise to?
A
Lymph nodes and bone
Rarely = brain, liver, lung
12
Q
PROSTATE CANCER
By what routes can prostate cancer spread?
A
- Lymphatic - to external iliac and internal iliac and presacral node
- Haematogenous - to bone, lung. liver, kidneys
- Direct - within in the prostate capsule
13
Q
PROSTATE CANCER
What can cause prostate cancer?
A
- High testosterone levels
- Family history - 2/3x increased risk if 1st degree relative is affected
14
Q
PROSTATE CANCER
what are the clinical features of prostate cancer?
A
SYMPTOMS
- common LUTS (frequency, hesitancy, terminal dribbling, nocturia)
- haematuria or haematospermia
- dysuria
- bone pain (suggests metastatic disease)
- weight loss
SIGNS
- asymmetrical, hard, nodular prostate
- palpable lymphadenopathy
- urinary retention (abdominal pain/tenderness, inability to urinate + palpable bladder)
15
Q
PROSTATE CANCER
What investigations might you do in someone who you suspect has prostate cancer?
A
- PSA = raised
- digital rectal exam = asymmetrical, hard, nodular prostate
- bone profile = hypercalcaemia + raised ALP in metastatic disease
- liver profile (assess for liver mets)
- U&Es (assess renal function)
- multiparametric MRI = first line imaging
- transrectal ultrasound (TRUS) - guided needle biopsy = gold standard
to consider
- bone scan
- CT abdomen + pelvis/MRI
16
Q
PROSTATE CANCER
What grading system is used in prostate cancer?
A
Gleason grading = higher the score, the more aggressive the cancer
17
Q
PROSTATE CANCER
What is the management for prostate cancer?
A
LOW/IMTERMEDIATE RISK LOCALISED
- option 1 = active surveillance/observation
- option 2 = radical prostatectomy
- option 3 = radical radiotherapy or brachytherapy +/- androgen therapy (e.g. flutamide)
HIGH RISK LOCALISED
- option 1 = radical prostatectomy
- option 2 = radical radiotherapy + anti-androgen therapy (e.g. flutamide)
- option 3 = radical radiotherapy with brachytherapy
- option 4 = docetaxel chemotherapy with anti-androgen therapy
METASTATIC DISEASE
- docetaxel chemotherapy and anti-androgen therapy
- bilateral orchidectomy
18
Q
PROSTATE CANCER
Give 2 advantages and 1 disadvantage of radical treatment for localised prostate cancer
A
Advantages:
- Curative
- Reduced patient anxiety
Disadvantages:
1. Can have adverse effects
19
Q
PROSTATE CANCER
How do LH antagonists work in treating prostate cancer?
A
First stimulate and then inhibit pituitary gonadotrophin E.g. Leuprolide
20
Q
PROSTATE CANCER
Is a raised PSA confirmatory of prostate cancer?
A
NO
Prostate cancer indication
it can also be raised in other conditions e.g. BPH
21
Q
PROSTATE CANCER
Other than prostate cancer, what can cause an elevated PSA?
A
- Benign prostate enlargement
- UTI
- Prostatitis
22
Q
PROSTATE CANCER
Give 2 advantages and 2 disadvantages of screening in prostate cancer
A
Advantages:
- Early diagnosis of localised disease (cure)
- Early treatment of advanced disease (effective palliation)
Disadvantages:
- Over diagnosis of insignificant disease
- Harm caused by investigation/treatment
23
Q
PROSTATE CANCER
What is PSA?
A
A glycoprotein secreted by the prostate into the blood stream
24
Q
TESTICULAR CANCER
Name the 2 types of testicular cancers that arise from germ cells
A
- Seminoma = most common, slow growing
2. Non-seminoma = yolk sac carcinoma/teratoma, rapid growth
25
TESTICULAR CANCER
Where does testicular cancer spread?
Locally into epididymis, spermatic cord and scortal wall Pelvic and inguinal Metastasises
26
TESTICULAR CANCER
what are the risk factors for testicular cancer?
1. Cryptorchidism (undescended testes)
2. Family history
3. previous testicular cancer
4. HIV
5. age 20-45
6. Caucasian
7. infant hernia
8. intersex conditions e.g. kleinfelters syndrome
9. mumps orchitis
27
TESTICULAR CANCER
what are the clinical features of testicular cancer?
SYMPTOMS
- painless testicular lump
- hyperthyroidism
- gynaecomastia
- bone pain (indicates metastasis)
- breathlessness (indicates lung metastasis)
SIGNS
- firm, non-tender testicular mass (does not transluminate, hydrocele may be present)
- supraclavicular lymphadenopathy
28
TESTICULAR CANCER
What investigations might you do on someone you suspect to have testicular cancer?
- ultrasound testicular doppler = first line
- tumour markers (beta-HCG, AFP and LDH)
to consider:
- CT chest, abdomen and pelvis (used for staging)
NOTE: fine needle aspiration or needle biopsy must NOT be used due to risk of seeding
29
TESTICULAR CANCER
How is testicular cancer staged?
1 = no mets
2 = nodes under diaphragm
3 = above diaphragm
4 = lungs
30
TESTICULAR CANCER
What is the treatment for testicular cancer?
SEMINOMA - LOCALISED
- radical orchidectomy
- post-orchidectomy active surveillance
- post-orchidectomy radiotherapy or chemotherapy
NON-SEMINOMA - LOCALISED
- radical orchidectomy
- post-orchidectomy active surveillance
- post-orchidectomy combination chemotherapy
ADVANCED OR METASTATIC DISEASE
- radical orchidectomy
- seminoma = adjuvant combination chemotherapy or radiotherapy
- non-seminoma = combination chemotherapy
31
EPIDIDYMAL CYST
What is an epididymal cyst?
Smooth extra-testicular, spherical cyst in the head of the epididymus
32
HYDROCELE
What is hydrocele?
Scrotal swelling as a result of excessive fluid in the tunica vaginalis
33
HYDROCELE
what is primary hydrocele?
In absence of disease in testis
Large and tense testis
Young boys mainly effected
Associated with a patent processus vaginalis, which typically resolves during the 1st year of life
34
HYDROCELE
Name 3 causes of secondary hydrocele
1. Testicular tumours
2. Infection
3. Testicular torsion
4. TB
5. trauma - is rarer and present in older boys and men
35
VARICOCELE
What is varicocele?
An abnormal enlargement of the pampiniform venous plexus in the scrotum
Caused by venous reflux
36
VARICOCELE
Why might renal cell carcinoma cause left sided varicocele?
If the renal tumour obstructs where the gonadal vein drains into the renal vein blood can back up and so you may see left sided varicocele
37
TESTICULAR TORSION
What is testicular torsion?
Twisting of the spermatic cord resulting in occlusion of testicular blood vessels
Leads to ischaemia and postnatal loss of testis
38
GLOMERULONEPHITIS
Define glomerular disease
= Glomerulonephritis
| Group of parenchymal kidney diseases that all result in the inflammation of the glomeruli and nephrons
39
GLOMERULONEPHRITIS
Give 3 consequences of glomerulonephritis
1. Damage to filtration mechanism --> haematuria and proteinuria
2. Damage to glomerulus restricts blood flow --> hypertension
3. Loss of usual filtration capacity --> AKI
40
GLOMERULONEPHRITIS
Briefly describe the pathophysiology of glomerulonephritis
Immunologically mediated --> immunoglobulin deposits and inflammatory cells
41
GLOMERULONEPHRITIS
How can glomerulonephritis present?
1. Nephritic syndrome
2. Nephrotic syndrome
3. Asymptomatic haematuria
42
URINARY STONES
Where can urinary tract stones be found?
Upper = renal and ureteric
Lower = bladder, prostatic and urethral
They most commonly are deposited at the pelviureteric junction, pelvic brim and vesicouretertic junction
43
URINRY STONES
What are urinary tract stones composed of?
80-85% = calcium oxalate (radio-opaque),
44
URINARY STONES
Describe the pathophysiology of stone formation in the upper urinary tract?
Stones form from crystals in supersaturated urine
45
URINARY STONES
Describe the epidemiology of stones in the urinary tract
10-15% lifetime risk
Males > females (2:1)
Higher prevalence in Middle East due to higher oxalate and lower calcium, containing diet
Peak prevalence 20-40yrs
50% risk of recurrence
46
URINARY STONES
what are the risk factors?
- dehydration
- previous kidney stones
- stone-forming foods (chocolate, rhubarb, spinach, tea, most nuts)
- genetic
- crohns disease
- hypercalcaemia
- hyperparathyroidism
- kidney related disease (polycystic kidney)
- drugs (loop diuretics, acetazolamide, protease inhibitors)
- gout
47
URINARY STONES
Give 5 potential causes of urinary tract stones
1. Congenital abnormalities - horseshoe kidney, spina bifida
2. Hypercalcaemia/high urate/high oxalate
3. Hyperuricaemia
4. Infection
5. Trauma
48
URINARY STONES
what is the clinical presentation of urinary tract stones?
SYMPTOMS
- acute, severe flank pain (classically loin to groin pain)
- pain lasts minutes to hours and occurs in spasms
- nausea + vomiting
- haematuria (microscopic or macroscopic)
- fever
SIGNS
- flank or renal angle tenderness
- hypotension + tachycardia (indicates urosepsis)
49
URINARY STONES
Give 3 differential diagnosis of urinary tract stones
1. AAA (until proven otherwise)
2. Diverticulitis
3. Appendicitis
4. Ectopic pregnancy
5. Testicular torsion
50
URINARY STONES
What investigations might you do on some who you suspect has a urinary tract stone?
- urinalysis = microscopic haematuria +/- pyuria (culture if septic)
- CRP = elevated
- U&Es = raised creatinine
- bone profile + urate = elevated calcium
- non-contrast CT KUB = GOLD STANDARD, to be performed within 14hrs
to consider
- 24hr urine monitoring
- renal tract USS
- x-ray KUB
- blood cultures
- coagulation profile
51
URINARY STONES
Give 5 ways in which urinary tract stones can be prevented
thiazide diuretics - reduce Ca levels
1. Stay well hydrated
2. Low salt diet
3. Healthy protein intake
4. Reduced BMI
5. Active lifestyle
6. Urine alkalisation
52
URINARY STONES
what is the management?
ACUTE
- IV fluids + anti-emetics
- analgesia (NSAID (PR diclofenac), IV paracetamol if NSAID is contraindicated)
CONSERVATIVE + MEDICAL MANAGEMENT
- watchful waiting (if <5mm)
- medical expulsive therapy (tamsulosin) for ureteric stones 5-10mm, NOT for renal stones
SURGICAL (within 48hrs of dx / admission)
- uteroscopy
- extracorporeal shock wave lithotripsy (ESWL)
- percutaneous nephrolithotomy (PCNL)
- ureteral stenting
- percutaneous nephrostomy
53
URINARY TRACT STONES
what are the complications?
- obstruction + hydronephrosis
- urosepsis
54
RENAL COLIC
What is renal colic?
Pain due to obstruction in the urinary tract
55
RENAL COLIC
What investigations might you do to find out what is causing someone's renal colic?
1. Bloods - including calcium, phosphate, urate
2. Urinalysis
3. MSU MCS (mid-stream urine microscopy, culture & specificity)
4. NCCT-KUB (non-contrast CT scan of kidney, ureter and bladder) = gold standard
56
RENAL COLIC
Describe the treatment for renal colic
1. Analgesia - NSAIDS (diclofenac)
2. Anti-emetics
3. Check for sepsis
57
RENAL COLIC
Give 3 causes of renal colic
1. Urinary tract stones
2. UTI
3. Pyelonephritis
58
URINARY STONES
Give 3 places where urinary tract stones are likely to get stuck
1. Ureteropelvic junction
2. Pelvic brim
3. Vesoureteric junction
59
RENAL PHYSIOLOGY
Give 5 functions of the kidney
1. Filters and secretes waste/excess substances
2. Blood volume/fluid management (BP control)
3. Synthesises Erythropoietin
4. Acid base regulation (reabsorption go Na, Cl, K, glucose, H2O, AA's)
5. Converts 1-hydroxyvitamin D --> 1,25-dihydroxyvitamin D (active)
60
RENAL PHYSIOLOGY
What is the GFR?
Volume of fluid filtered from the glomeruli into Bowman's space pre unit time
61
RENAL PHYSIOLOGY
What would you expect a typical GFR to be?
120 ml/min
62
RENAL PHYSIOLOGY
Write an equations for GFR
(Um X urine flow rate) / Pm
```
Um = conc of marker substance in urine
Pm = conc of marker substance in plasma
```
63
RENAL PHYSIOLOGY
Give an example of a marker substance for estimating GFR
Creatinine
64
RENAL PHYSIOLOGY
Give 3 essential features of a marker substance for estimating GFR
1. Not metabolised
2. Freely filtered
3. Not reabsorbed/secreted
65
RENAL PHYSIOLOGY
Name a drug that can inhibit creatinine secretion and what is the affect of this on GFR?
Trimethoprim (antibiotic to treat UTIs)
| Serum creatinine rises and so kidney function (GFR) appears worse
66
RENAL PHYSIOLOGY
What is the affect on GFR of afferent arteriole vasoconstriction?
Decreased GFR
67
RENAL PHYSIOLOGY
What is the affect on GFR of efferent arteriole vasoconstriction?
Increased GFR
68
RENAL PHYSIOLOGY
What does the eGFR require to be calculated?
Steady state
69
RENAL PHYSIOLOGY
What is the effect of NSAIDs on the afferent arteriole of glomeruli?
NSAIDs inhibit prostaglandins and so lead to afferent arteriole vasoconstriction = reduced GFR
70
RENAL PHYSIOLOGY
What is the effect of AECi on the efferent arteriole of glomeruli?
ACEi cause efferent arteriole vasodilation = reduced GFR
71
CKD
Define chronic kidney disease
Long standing, usually progressive, impairment in renal function for more than 3 months
72
CKD
How is CKD diagnosed?
- eGFR < 60mL/min/1.73m2,
or:
- eGFR < 90mL/min/1.73m2 + signs of renal damage,
or:
- Albuminuria > 30mg/24hrs (Albumin:Creatinine > 3mg/mmol)
73
CKD
Briefly describe the pathophysiology causes CKD
Hyper-filtration for nephrons that work --> glomerular hypertrophy and reduced arteriolar resistance --> raised intraglomerular capillary pressure and strain --> accelerates remnant nephron failure (progressive)
74
CKD
Name 4 cause of CKD
1. DM - 24% of patients
2. Hypertension
3. Glomerulonephritis
4. Congenital - polycystic kidney disease
5. Urinary tract obstruction
6. drugs - NSAIDs, ACEi, antidepressants, many antibiotics
75
CKD
what are the clinical features of CKD?
SYMPTOMS
- lethargy
- pruritus
- nausea
- anorexia
- frothy urine
- swollen ankles
SIGNS
- HTN
- fluid overload
- uraemic sallow (yellow/pale brown colour to skin)
- evidence of underlying cause (e.g. butterfly rash in lupus)
76
CKD
What investigations might be done in someone who has CKD?
- urine dip = proteinuria and haematuria
- urine albumin:creatinine ratio(ACR) = >3
- U&Es
- FBC = normocytic, normochromic anaemia
- bone profile + PTH
- renal USS
to consider
- CT KUB
- renal biopsy
- investigate underlying cause
77
CKD
Describe the management of CKD
Slow progression of disease
- DM treatment
- HTN treatment
- Glumeronephritis treatment
Reduce risk of CVD
- Atorvastatin- 20mg
Manage complications
- Mineral bone disease- low Vit D
- HTN
- Anaemia = iron replacement, EPO
- RRT- haemodialysis, peritoneal dialysis, transplant
78
DIALYSIS
What is renal replacement therapy?
Dialysis or renal transplantation
79
DIALYSIS
Name 2 types of dialysis?
1. Haemodialysis
| 2. Peritoneal dialysis
80
DIALYSIS
What is the access point in haemodialysis?
AV fistula or tunelled catheter
81
DIALYSIS
How does haemodialysis work?
Exchange of waste solutes through diffusion into dialysate most common (40%), typically 3x4hrs per week
82
DIALYSIS
Give 3 examples of waste products that are removed from the blood in dialysis
1. Urea
2. Creatinine
3. Potassium
4. Phosphate
83
DIALYSIS
Give 5 potential complications of haemodialysis
1. Hypotension
2. Cramps
3. Nausea
4. Chest pain
5. Fever
6. Blocked or infected dialysis catheter
84
DIALYSIS
Give 3 groups of people who haemodialysis is good for?
1. People who live alone/frail/elderly
2. People who fear operating machines
3. People who are unsuitable for peritoneal dialysis (abdominal surgery/hernia)
85
DIALYSIS
What is the access point for peritoneal dialysis?
A peritoneal catheter is placed into the peritoneal cavity through a SC tunnel
86
DIALYSIS
DIALYSIS
what is peritoneal dialysis?
peritoneal catheter inserted
Glucose solution pumped in to peritoneum for exchange of solutes across peritoneal membrane
removal of dialysis solution
Continuous or overnight typically
87
DIALYSIS
Give 4 potential complications of peritoneal dialysis
1. Infection (peritonitis/catheter exit site infection)
2. Peri-catheter leak
3. Abdominal wall herniation
4. Intestinal perforation
88
DIALYSIS
Give 3 groups of people who peritoneal dialysis is good for
1. Young people/those in full time work
2. People who want control/responsibility of their care
3. People with severe HF
89
DIALYSIS
what is the most common causative organism of peritonitis secondary to peritoneal dialysis?
staphylococcus epidermidis
s.aureus is another common cause
90
DIALYSIS
what is the management of peritonitis secondary to peritoneal dialysis?
vancomycin + ceftazidime added to dialysis fluid
OR
vancomycin added to dialysis fluid + oral ciprofloxacin
91
RENAL TRANSPLANT
Where in the abdomen does a transplanted kidney lie?
In the iliac fossa
92
RENAL TRANSPLANT
What has to be assessed for a renal transplant to occur?
Virology status = CMV, hepatitis, EBV
CVD
TB
ABO and HLA haplotype
93
RENAL TRANSPLANT
What tests can be done to evaluate kidney function in a potential kidney donor?
1. Serum creatinine
2. Creatinine clearance
3. Urinalysis
4. Urine culture
5. GFR
94
RENAL TRANSPLANT
Give 3 contraindications for renal transplant
1. ABO incompatibility
2. Active infection
3. Recent malignancy
4. Morbid obesity
5. Age >70
6. AIDS
95
RENAL TRANSPANT
What are the 2 main causes of death after a kidney transplant?
1. CV disease
| 2. Infection
96
RENAL TRANSPLANT
Name 4 potential complications of a kidney transplant
1. Thrombosis
2. Obstruction
3. Infections - URTI, chest
4. Rejection (12% in 1st year)
97
RENAL TRANSPLANT FAILURE
what is the cause of hyperacute rejection?
- due to pre-existing antibodies against ABO or HLA antigens
- occurs in minutes to hours
- is a type II hypersensitivity reaction
98
RENAL TRANSPLANT FAILURE
what is the management of hyperacute rejection?
remove the transplanted kidney
99
RENAL TRANSPLANT FAILURE
what is the cause of acute graft rejection?
- usually due to mismatched HLA
- cell mediated (cytotoxic T cells)
- other causes = CMV
- occurs <6 months after transplant
100
RENAL TRANSPLANT FAILURE
what are the clinical features of acute graft failure?
- usually asymptomatic
- rising creatinine
- pyuria
- proteinuria
101
RENAL TRANSPLANT FAILURE
what is the management of acute graft failure?
may be reversible with steroids and immunosuppressants
102
RENAL TRANSPLANT FAILURE
what are the causes of chronic graft failure?
- both antibody and cell-mediated mechanisms cause fibrosis to transplanted kidney (chronic allograft nephropathy)
- recurrence of original renal disease (MCGN > IgA > FSGS)
103
CKD
Why do advanced CKD patients need regular fluid assessment?
They may be oliguric or anuric
104
DIURETICS
Name a loop diuretic
Furosemide - acts on NKCC2 transporter
105
DIURETICS
Give 3 potential side effect of furosemide
1. Hypokalaemia
2. Hypotension
3. Dehydration
106
DIURETICS
What other drug might you prescribe with furosemide in someone with poorly controlled potassium?
A potassium sparing diuretic e.g. spironolactone
| Work on RAAS not ion channels so help control potassium levels in the blood
107
DIURETICS
On which part of the nephron do thiazides act?
The distal tubule Act on NCC channels
108
DIURETICS
On which part of the nephron do aldosterone antagonists act on?
Collecting ducts
109
AKI
Define Acute Kidney Injury (AKI)
Sudden decline in renal function determined by increased serum creatinine +/- ↓ urine output.
Results in imbalance in electrolytes and azotaemia (↑ creatinine / nitrates)
110
AKI
what are the different types of AKI?
1. Pre-renal = decreased blood flow to kidneys --> decreased GFR
2. Renal = kidney damage
3. Post-renal = Urinary tract obstruction
111
AKI
what are the risk factors for AKI?
1. Increasing age
2. CKD
3. HF
4. DM
5. Nephrotoxic drugs - NSAIDs, ACEi
6. hypertension
7. sepsis
8. organ failure e.g. heart failure + liver failure
112
AKI
what are the pre-renal causes of AKI?
- hypovolaemia (reduced oral intake, haemorrhage, GI loss, renal loss, burns)
- reduced cardiac output (heart failure, liver failure, sepsis, drugs)
- drugs that reduce BP, circulating volume or renal blood flow
113
AKI
What are the renal (intrinsic) causes of AKI?
- toxins + drugs (antibiotics, contrast, chemotherapy)
- vascular (vasculitis, theromboembolism)
- tubular (acute tubular necrosis, rhabdomyolysis, myeloma)
- interstitial causes (interstitial nephritis, lymphoma infiltration)
114
AKI
what are the post-renal causes of AKI?
- renal stones
- blocked urinary catheter
- enlarged prostate
- GU tract tumours
- retroperitoneal fibrosis
- neurogenic bladder
115
AKI
How does AKI present?
SYMPTOMS
- reduced urine output +/- change in colour
- confusion/drowsiness
- dyspnoea +/- swollen legs
- suprapubic pain (e.g. urinary retention)
- haematuria (e.g. if caused by glomerulonephritis)
SIGNS
- hypovolaemia (dry mucus membranes, decreased skin turgor, reduced BP)
- uraemic skin changes (uraemic frost if severe)
- signs of volume overload (bibasal crackles, raised JVP, peripheral oedema)
- palpable bladder
116
AKI
What investigations might you do to determine whether someone has AKI?
- U&Es = check potassium (hyperkalaemia)
- FBC + CRP (for evidence of infection)
- venous blood gas (to assess for metabolic acidosis)
- CXR (to assess for pulmonary oedema)
- USS urinary tract (to investigate obstruction or hydronephrosis)
to consider
- urine dipstick +/- culture + sensitivity (if glomerulonephritis or UTI suspected)
- CK (if rhabdomyolysis suspected)
- autoimmune screen
117
AKI
What is the affect of AKI on creatinine and urine output?
Creatinine = raised
Urine output = reduced
118
AKI
What is the diagnostic criteria for AKI?
1/3 = diagnostic
1. Rise in CR >26 mmol/L in 48 hours
2. Rise in Cr >50% in last 7 days
3. Urine output fall to < 0.5 ml/kg/h for more than 6 hours
119
AKI
what are the different stages of AKI?
STAGE 1
- Cr rise to 1.5-1.9 x baseline
- Cr rise by 26umol/L
- fall in urine to <0.5ml/kg/hr for >6hrs
STAGE 2
- Cr rise to 2.0-2.9 x baseline
- fall in urine output to 0.5ml/kg/hr for >12 hrs
STAGE 3
- Cr rise to >3.0 x baseline
- Cr rise to >353.6umol/L
- fall in urine to <0.3ml/kg/hr for >24hrs
- in patients <18yr, fall in eGFR to <35ml/min/1.73m2
120
AKI
How do you treat AKI?
1st line
- treat complications (e.g. hyperkalaemia)
- IV fluids
- fluid-balance chart +/- catheter
- treat underlying cause (start abx, stop offending drug, remove obstruction etc)
(may use loop diuretics if patient is severely overloaded)
2nd line
- renal replacement therapy (if refractory hyperkalaemia, severe metabolic acidosis, volume overload or uraemic)
121
AKI
What is the major complication someone with AKI might develop?
Hyperkalaemia
Can lead to arrhythmias ECG = tall tented T waves, increase PR interval and wide QRS complex
122
AKI
How can hyperkalaemia be prevented in someone with AKI?
Give calcium gluconate to protect myocardium
| Give insulin and dextrose (insulins drives K+ into cells and dextrose is to rebalance the blood sugar)
123
UTI
Define urinary tract infection
Inflammatory response of the urothelium to bacterial invasion, usually associated with bacteriuria and pyuria
124
UTI
What determines if a UTI is complicated or uncomplicated?
A UTI is deemed complicated if it affects:
- Someone with an abnormal urinary tract
- A man
- Pregnant lady
- Children
- Immunocompromised
- If it is recurrent
125
UTI
Describe the pathophysiology of UTI's
Organisms colonise the urethral meatus --> bacterial sent --> bacteriuria
126
UTI
Name 3 UTI causative organisms
The 5 most common pathogens can remembered with KEEPS:
- Klebsiella
- E coli- most common causing >50% of cases
- Enterococci
- Proteus
- Staphylococcus coagulase negative
127
UTI
Describe the epidemiology of UTI's
More common in women due to short urethra and its proximity to the anus
128
UTI
Give 4 risk factors of UTI's
1. Catheter
2. Female
3. Prostatic hypertrophy (obstructs)
4. Low urine volume
5. Urinary tract stones
6. Pregnancy
129
UTI
The vagina is heavily colonised with lactobacilli, what is the function of this?
Helps maintain a low pH = host defence mechanism
130
UTI
Give 2 reasons why a post-menopausal women is more susceptible to a UTI
1. pH rises --> increased colonisation by colonic flora
| 2. Reduced mucus secretion
131
UTI
Define pyuria
Presence of pus in urine
132
UTI
Name 3 lower urinary tract infections
1. Cystitis
2. Prostatitis
3. Urethritis
133
UTI
Name a upper urinary tract infection
Pyelonephritis
134
UTI
what are the classic UTI symptoms
```
FUNDS:
frequency,
urgency,
nocturia,
dysuria
```
Haematuria
Abdominal pain
Malaise
Confusion (old patients)
135
UTI
What investigations might you do in someone who you suspect has a UTI?
urine dipstick
- positive nitrite or leukocyte + positive RBCs = UTI likely
- negative nitrite + positive leukocyte = UTI equally likely as other causes
urine MC&S
- bacteria, WBCs +/- RBCs
to consider
- bladder scan
- renal tract USS
- cystoscopy
136
UTI
when would you request urine microscopy + culture?
- request in all women with positive dipstick
- request in women >65, catheterised, pregnant or non-visible haematuria regardless of dipstick
137
UTI
What is the first line treatment for an uncomplicated UTI?
NON-PREGNANT FEMALE
- 1st line = NITROFURANTOIN (if eGFR>45) or TRIMETHOPRIM for 3 days
- 2nd line = NITROFURANTOIN (if not used 1st line + eGFR>45) or PIVIMECILLINAM or FOSFOMYCIN for 3 days
PREGNANT FEMALE
- 1st line = NITROFURANTOIN (if eGFR>45 + avoid near term) for 7 days
- 2nd line = AMOXICILLIN (only if culture-sensitive) or CEFALEXIN for 7 days
CATHETERISED FEMALE
- 1st line = NITROFURANTOIN or TRIMETHOPRIM for 7 days
MALE
- 1st line = TRIMETHOPRIM or NITROFURANTOIN for 7 days
- 2nd line = AMOXICILLIN (only if culture sensitive) or CEFALEXIN for 7 days
138
UTI
How does trimethoprim work?
It affects folic acid metabolism
139
UTI
Describe the management for a complicated UTI
Culture sample --> Abx for 7 days
140
UTI
Define recurrent UTI
>2 episodes in 6 months or >3 in 12 months
141
UTI
Describe the management for someone who is having recurrent UTIs
1. Increase fluid intake
2. Regular voiding
3. Void pre and post intercourse
4. Abx prophylaxis
5. Vaginal oestrogen replacement
142
CYSTITIS
What is cystitis?
Inflammation of the bladder secondary to infection
143
CYSTITIS
what are the risk factors for cystitis?
1. Urinary obstruction
2. Previous damage to bladder epithelium
3. Poor bladder emptying
4. bladder stones
144
CYSTITIS
what are the symptoms of cystitis?
1. Dysuria
2. Frequency and urgency
3. Suprapubic pain
4. Offensive smelling/cloudy urine
5. Haematuria
145
CYSTITIS
What is the treatment for cystitis?
1st line = Trimethoprim or nitrofurantoin (avoid trimethoprim in pregnancy -> teratogenic)
2nd line = ciprofloxacin or Co-amoxiclav
146
PROSTATITIS
what are the causes of prostatitis?
acute:
- streptococcus faecalis
- e.coli (most common)
- chlamydia
chronic:
- bacterial (as above)
- non-bacterial - elevated prostatic pressure, pelvic floor myalgia
147
PROSTATITIS
what are the different types?
- acute bacterial prostatitis
- chronic bacterial prostatitis
- chronic non-bacterial prostatitis (chronic pelvic pain syndrome)
148
PROSTATITIS
what are the clinical features of prostatitis?
SYMPTOMS
- dysuria
- urinary frequency
- urinary urgency
- lower back pain
- perineal discomfort
- pain during ejaculation
- acute symptoms (fever, myalgia, nausea, fatigue, sepsis)
SIGNS
- fever (in acute prostatitis)
- prostate tenderness on DRE
149
PROSTATITIS
What investigations might you do in someone with prostatitis?
- urinalysis = to detect UTI
- urine MC + S = to detect causative organism
- chlamydia + gonorrhoea NAAT testing (on first pass urine)
to consider
- PSA = may be elevated
- post-prostatic massage urine sample (for chronic prostatitis)
- imaging (TRUS) or MRI
150
PROSTATITIS
How would you treat prostatitis?
1st line
- fluoroquinolone antibiotic (CIPROFLOXACIN), alternatives are trimethoprim + ofloxacin
- acute = 2-4 weeks
- chronic = 12 weeks
other treatment
- alpha blockers (TAMSULOSIN)
- NSAIDs
- stool softeners
151
URETHRITIS
URETHRITIS
what are the causes of urethritis?
- N. gonorrhoea
- chlamydia
- trauma
- urethral stricture
- irritation
- urinary calculi
152
URETHRTITIS
what are the symptoms of urethritis?
- skin lesion
- dysuria +/- discharge (blood/pus)
- urethral pain
- penile discomfort/Pruritis
153
URETHRITIS
what is the treatment for urethritis?
oral doxycycline for 7 days of single dose of azithromycin
154
PYELONEPHRITIS
Define pyelonephritis
Infection of the renal pelvis and upper ureter, most commonly acquired by ascending transurethral spread, but can be via blood or lymphatics
155
PYELONEPHRITIS
What can cause pyelonephritis?
- majority caused by UPEC (uropathogenic E.coli)
- main organisms = KEEPS
- Klebsiella
- E.coli - most common
- Enterococcus
- Proteus
- Staphylococcus
156
PYELONEPHRITIS
what is the clinical presentation of pyelonephritis?
SYMPTOMS
- flank pain
- myalgia
- rigors
- dysuria
- haematuria
- confusion
SIGNS
- renal angle tenderness
- suprapubic tenderness
- fever
- tachycardia
- hypotension
- altered mental status
157
PYELONEPHRITIS
What investigations might you do in someone with pyelonephritis?
- urinalysis = WBCs + nitrites present
- urine MC + S = to quide antibiotic treatment
- FBC = leukocytosis
- CRP = elevated
- U&Es = to assess renal function
to consider
- US KUB = to assess for hydronephrosis
- CT KUB = if renal colic suspected
- CT abdomen with contract = to rule out renal abscess
158
PYELONEPHRITIS
Describe the treatment for pyelonephritis
MILD DISEASE - ORAL ANTIBIOTICS
- oral cefalexin - 500mg BD or TDS for 7-10 days
- oral ciprofloxacin - 500mg BD for 7 days
SEVERE DISEASE - IV ANTIBIOTICS
- IV gentamicin (dosage based of body weight + renal function)
- IV ciprofloxacin 400mg TDS
ADJUNCT THERAPY
- hydration = oral or IV
- analgesia = PR DICLOFENAC
159
PYELONEPHRITIS
What can a prolonged pyelonephritis infection cause?
Renal abscess
Treatment = drainage
160
URINARY STONES
what is the management for urinary tract stones?
- Strong analgesia- diclofenac
- Antibiotics
- Tamsulosin/nifedipine- relaxes smooth muscle and helps expulsion
- Percutaneous nephrolithotomy- used to expulse stones over 10mm
161
URINARY STONES
what are the risk factors for urinary tract stones?
- chronic dehydration
- obesity
- high protein/salt diet
- recurrent UTIs
- hyperparathyroidism (hypercalcaemia)
- congenital abnormalities
162
URINARY STONES
what are the signs for treatment of urinary tract stones?
- intolerable pain/vomiting
- signs of obstruction/infection
- AKI (and hyperkalaemia)
163
AKI
what is the pathophysiology of pre-renal AKI?
- low blood volume or low effective circulating volume causes decreased perfusion
- this decreases GFR and creatine clearance which activates RAAS- this increases Na+, urea and BP
164
AKI
what is the pathophysiology of post-renal AKI?
obstruction
- stones, prostate enlargement or infection causes back pressure into tubules
- this decreases hydrostatic pressure which decreases GFR`
165
AKI
what is the pathophysiology of intra-renal AKI?
- glomerular - glomerulonephritis
o this causes barrier damage and protein leakage
o this decreases oncotic pressure which decreases GFR- tubular
- necrosis
o complex blood supply causes cells to infarct, break away and plug tubules
o this decreases hydrostatic pressure and decreases GFR
- vascular - vasculitis
o damaged vasculature decreases O2 which causes necrosis
- interstitial - acute interstitial nephritis
o inflammation and immune cells cause damage
166
PROSTATE CANCER
what are the risk factors for prostate cancer?
- family history
- increasing age
- black
- genetic
- HOXB13, BRCA2
167
PROSTATE CANCER
what is the epidemiology of prostate cancer?
- commonest male malignancy
- 7% of all cancer
- by age of 80, 80% have malignant prostatic change
- in most cases malignant foci remain dormant
168
TESTICULAR CANCER
what is the epidemiology of testicular cancer?
● Most common cancer in young men
● More than 96% arise from germ cells
● 10% occur in undescended testes
● Main types are seminomas and teratomas
169
BPH
what is the epidemiology of benign prostate hyperplasia (BPH)?
- common
- affects 24% of men 40-60 and 40% of over 60
- afro-Caribbean men affected more
170
VARICOCELE
what is the pathophysiology of varicocele?
● Abnormal dilation of the testicular veins in the pampiniform venomous plexus caused by venous reflux
● Increased reflux from compression of the renal vein
● Lack of effective valves between testicular and renal veins
171
VARICOCELE
what is the clinical presentation of varicocele?
SYMPTOMS
- throbbing/dull pain or discomfort, worse on standing
- a dragging sensation
- sub-fertility or infertility
SIGNS
- 'bag of worms'
- scrotal mass more prominent on standing
- disappears when lying down
- asymmetry in testicular size
172
VARICOCELE
what are the investigations for varicocele?
- USS with doppler imaging
- semen analysis (if there are concerns about fertility)
- hormone tests (FSH + testosterone if they are concerned about function
173
VARICOCELE
what is the management for varicocele?
- usually managed conservatively
- surgery may be indicated for pain, testicular atrophy or infertility
174
VARICOCELE
what is the epidemiology of varicocele?
● Left side more commonly affected
● Unusual in boys under 10
● Incidence increases after puberty
● Associated with sub fertility
175
TESTICUAR TORSION
what are the causes of testicular torsion?
Underlying congenital malformation
- belt-clapper deformity - where the testis is not fixed to the scrotum completely, allowing for free movement leading to twisting
176
TESTICULAR TORSION
what is the epidemiology of testicular torsion?
- common urological emergency in adolescent boys
- most common 11-30yrs
- left side is more commonly affected
177
TESTICULAR TORSION
what is the clinical presentation of testicular torsion?
SYMPTOMS
- testicular (usually unilateral, sudden onset, excruciating, can be intermittent)
- Nausea + vomiting
- lower abdominal pain (referred)
SIGNS
- swollen, high-riding and tender testicle
- skin may be erythematous
- prehn's negative (pain NOT relieved on lifting ipsilateral testicle)
- absent cremasteric reflex
178
TESTICULAR TORSION
what are the investigations for testicular torsion?
If history/exam is suggestive of torsion, imaging should not be performed as it may delay treatment
- surgical exploration
to consider
- testicular USS = whirlpool sign, decreased blood flow
- urinalysis (may suggest another cause)
179
TESTICULAR TORSION
what is the treatment for testicular torsion?
VIABLE TESTICLE
- bilateral orchiopexy (testicle untwisted + both testicles fixed to scrotal sac)
NON-VIABLE TESTICLE
- ipsilateral orchidectomy + contralateral orchiopexy
IF SURGICAL DELAY
- manual detorsion (only if surgery is not available within 6hrs)
180
TESTICULAR TORSION
what are the complications?
- recurrent torsion
- infertility
- pubertal delay
181
CYSTITIS
what are the investigations for cystitis?
- dipstick urinalysis = positive leucocytes, blood and nitrites
- microscopy and sensitivity of mid-stream urine = GOLD STANDARD
182
PYELONEPHRITIS
what are the risk factors for pyelonephritis?
- female sex
- structural urological abnormalities
- vesico-ureteric reflux
- UTIs
- uncontrolled DM
- urinary tract outlet obstruction (stricture, blocked catheter)
- immunocompromised
- pregnancy
- end stage renal failure
183
PYELONEPHRITIS
what is the pathophysiology of pyelonephritis?
- infection mostly due to bacteria from patients bowel flora
- most common via ascending transurethral route but can be blood stream or lymphatics
184
PYELONEPHRITIS
what is the epidemiology of pyelonephritis?
- predominantly females under 35
- unusual in men
185
PROSTATITIS
what is prostatitis?
infection and inflammation of the prostate gland
can be acute or chronic
186
PROSTATITIS
what are the risk factors for prostatitis?
- STI
- history of UTI
- indwelling catheter
- post-biopsy
- HIV infection
- increasing age
187
HYDROCELE
what is communicating hydrocele?
processus vaginalis fails to close, allowing peritoneal fluid to communicate with the scrotal portion
188
HYDROCELE
what is the clinical presentation of hydrocele?
- soft, non-tender, smooth cystic swelling
- no pain unless infected
- transluminates (testicle floats within the fluid)
- irreducible + has no bowel sounds
189
HYDROCELE
what are the investigations for hydrocele?
- USS
- serum alpha-fetoprotein and hCG to exclude malignant teratomas and germ cell tumours
190
HYDORCELE
what is the treatment for hydrocele?
- most resolve spontaneously
- therapeutic aspiration or surgical removal
191
EPIDIDYMAL CYST
what is the epidemiology of epididymal cyst?
- usually develop around 40yrs
- rare in children
- not uncommon
192
EPIDIDYMAL CYST
what is the pathophysiology of epididymal cyst?
contain clear and milky fluid - spermatocele
- lie above and behind the testis
193
EPIDIDYMAL CYST
what conditions are associated with epididymal cysts?
- polycystic kidney disease
- cystic fibrosis
- von Hippel-Lindau syndrome
194
EPIDIDYMAL CYST
what is the clinical presentation of epididymal cyst?
- soft, round lump
- typically at the top of the testicle, posteriorly
- may be multiple/bilateral (may be painful)
- transluminate (for large cysts, appearing separate from the testicle)
- testis is palpable separately from cyst
195
EPIDIDYMAL CYST
what are the investigations for epididymal cyst?
USS
196
EPIDIDYMAL CYST
what is the treatment for epididymal cyst?
- treatment is usually not required as they are entirely harmless and are not associated with infertility or cancer
- if painful/symptomatic or torsion of cyst, then surgical excision
197
UTI
what is a complicated UTI?
- infection in patients with abnormal urinary tract
- pregnant women
- most UTIs in men
- treatment is more likely to fail and complications are more likely
198
UTI
what is an uncomplicated UTI?
UTI in a healthy non-pregnant women with normally functioning urinary tract
199
URETHRITIS
what is urethritis?
urethral inflammation due to infectious or non-infectious cause
non-gonococcal > gonococcal
200
URETHRITIS
what are the investigations for urethritis?
- STI testing
- microscopy and culture of urethral discharge
- urine dipstick
- urethral smear
- ?flexible cystoscopy
201
POLYCYSTIC KIDNEY
what is the epidemiology of autosomal dominant polycystic kidney disease?
- most common inherited kidney disease
- autosomal dominant inheritance with high penetrance
- male > female
202
POLYCYSTIC KIDNEY
if 1 parent is affected by autosomal dominant polycystic kidney disease what is the chance of transmission?
50% chance
203
POLYCYSTIC KIDNEY
if both parents are affects by autosomal dominant polycystic kidney disease, what is the chance of transmission to offspring?
50% chance of being affected
25% = normal
25% = homozygous for disease (die in the womb)
204
POLYCYSTIC KIDNEY
what are the causes of autosomal dominant polycystic kidney disease?
- mutations in PKD1 gene on chromosome 16 = 85%
| - mutations in PKD2 gene on chromosome 4
205
POLYCYSTIC KIDNEY
what are the risk factor for autosomal dominant polycystic kidney disease?
- family history of ADPKD- ESRF
| - hypertension
206
POLYCYSTIC KIDNEY
what is the pathophysiology of autosomal dominant polycystic kidney disease?
Cysts develop and grow over time in the tubular portion of the nephron
Compression of renal architecture and vasculature
Progressive impairment - gets bigger and worse with age
207
POLYCYSTIC KIDNEY
what is the clinical presentation of autosomal dominant polycystic kidney disease?
- hypertension
- abdo/flank pain (haemorrhage)
- LUTS (dysuria, urgency, pain)
- palpable
208
POLYCYSTIC KIDNEY
what are the investigations for autosomal dominant polycystic kidney disease?
Renal USS then renal biopsy for genes
<30yrs – at least 2 unilateral or bilateral cysts
30-59yrs – 2 cysts in each kidney
>60yrs – 4 cysts in each kidney
209
POLYCYSTIC KIDNEY
what is the treatment for autosomal dominant polycystic kidney disease?
- Treat hypertension – lifestyle, ACEi (ramipril)
- Infected – Abx or drain
- Surgical – removal (nephrectomy)
- Chronic – dialysis or transplant
210
POLYCYSTIC KIDNEY
what are the complications of polycystic kidney disease?
berry aneurysms
cysts on other organs
50% have ventricular hypertrophy
pre-malignant
211
POLYCYSTIC KIDNEY
what is the epidemiology of autosomal recessive polycystic kidney disease?
- rarer than autosomal dominant
- autosomal recessive inheritance
- disease of infancy
212
POLYCYSTIC KIDNEY
what are the causes of autosomal recessive polycystic kidney disease?
PKHD1 mutation on long arm (q) of chromosome 6
213
POLYCYSTIC KIDNEY
what is the clinical presentation of autosomal recessive polycystic kidney disease?
- variable
- many present in infancy with multiple renal cysts and congenital hepatic fibrosis
- enlarged polycystic kidneys
- 30% develop kidney failure
214
POLYCYSTIC KIDNEY
what are the investigations for autosomal recessive polycystic kidney disease?
- Diagnosed antenatally or neonatally
- Ultrasound - to see cysts
- CT & MRI to monitor liver disease
- Genetic testing
215
POLYCYSTIC KIDNEY
what are the treatments for autosomal recessive polycystic kidney disease?
- Currently no treatment available
- Genetic counselling for family members
- Laparoscopic removal of cysts to help with pain/nephrectomy (remove entire kidney)
- Blood pressure control with ACE-inhibitor e.g. RAMIPRIL
- Treat stones and give analgesia
- Renal replacement therapy for ESRF
- Counselling and support
216
AKI
what is the specific clinical presentation of pre-renal AKI?
- hypotension (D&V, syncope, pre-syncope)
| - signs of liver or heart failure (oedema)
217
AKI
what is the specific clinical presentation of intra-renal AKI?
infection, signs of underlying disease (vasculitis, glomerulonephritis, DM)
218
AKI
what is the specific clinical presentation of post-renal AKI?
LUTS (BPH)
219
AKI
what are the complications of AKI?
end stage renal failure
metabolic acidosis
uraemia
CKD
220
CKD
how does diabetes cause CKD?
Glycation of glomerular endothelium and efferent arteriole leading to fibrosis (diabetic nephropathy)
221
CKD
how does hypertension cause CKD?
thickening of afferent arteriole leading to ischaemia. Further fluid overloading due to activation of RAAS
222
URINARY STONES
what is the treatment for urinary tract stones?
- strong analgesic (IV diclofenac)
- antibiotics if infection (IV cefuroxime or IV gentomycin)
- antiemetics
- stone removal
223
CKD
what is stage 1 CKD?
eGFR > 90ml/min
224
CKD
what is stage 2 CKD?
eGFR 60-89ml/min
225
CKD
what is stage 3a CKD?
eGFR 45-59ml/min
226
CKD
what is stage 4 CKD?
eGFR 29-15ml/min
227
CKD
what is stage 5 CKD?
eGFR < 15ml/min
228
PHARMACOLOGY
which drugs are classed as nephrotoxic?
- NSAIDs
- aminoglycosides
- ACEi
- ARB
- loop diuretics
- metformin
- digoxin
- lithium
229
GOODPASTURES
what is goodpastures disease?
Caused by autoantibodies to Type IV collagen in glomerular and alveolar membrane
230
GOODPASTURES
what is the clinical presentation of goodpastures disease?
Presents with SOB and oliguria due to respiratory and renal damage
231
GOODPASTURES
what are the investigations for goodpasture's disease?
Diagnose with anti-GBM antibodies in bloods and biopsy
232
GOODPASTURES
what is the management for goodpasture's disease?
plasma exchange
steroids
cyclophosphamide (for immune suppression)
233
POST STREP GLOMERULONEPHRITIS
what is the most common cause of post strep glomerulonephritis?
- most common = strep pyogenes (lancefield group A beta haemolytic)
234
POST STREP GLOMERULONEPHRITIS
what is the clinical presentation of post strep glomerulonephritis?
Presents with haematuria. Can present with acute nephritis
235
POST STREP GLOMERULONEPHRITIS
what are the investigations for post strep glomerulonephritis?
Diagnosed by evidence of strep infection
236
POST STREP GLOMERULONEPHRITIS
what is the management for post strep glomerulonephritis?
Treated with antibiotics to clear the strep, and supportive care.
237
NEPHRITIC VS NEPHROTIC
what is the difference between nephritic syndrome vs nephrotic syndrome?
NEPHRITIC
- proteinuria +
- hypertension
- haematuria
- very reduced GFR
- oedema +
NEPHROTIC
- proteinuria ++++++
- hypoalbuminaemia
- oedema ++++
- slightly reduced/normal GFR
- hyperlipidaemia
238
BLADDER CANCER
what is it?
transitional cell carcinoma that arises in the bladder
239
BLADDER CANCER
what are the different types?
papillary = majority of cases, finger-like projections, often non-invasive + better prognosis
flat = lie flat against bladder tissue, more prone to invasion, poorer prognosis
240
BLADDER CANCER
where does bladder cancer spread to?
spreads to the iliac and para-aortic nodes, and to the liver and lungs
241
BLADDER CANCER
what are the risk factors of bladder cancer?
- increasing age (50-80)
- male
- family history
- smoking (2-4 x increased risk)
OCCUPATIONAL EXPOSURE
- aromatic amines (rubber, dye and textile industries)
- polycyclic aromatic hydrocarbons (aluminium, coal + roofing industries)
- painter + hairdressers
242
BLADDER CANCER
what is the presentation of bladder cancer?
SYMPTOMS
- painless haematuria
- dysuria
- frequency
- weight loss
SIGNS
- palpable suprapubic mass
- anaemia (if chronic bleeding)
243
BLADDER CANCER
what are the 2WW referral criteria?
>45 + unexplained visible haematuria without UTI
>45 + visible haematuria that persists/recurs after successful treatment of UTI
>60 + unexplained microscopic haematuria + dysuria or raised WCC
244
BLADDER CANCER
what are the investigations for bladder cancer?
- urinalysis = haematuria
- urinary cytology = cancer cells
- FBC = anaemia (in chronic bleeding)
- U&Es (assess renal failure)
- bone profile = hypercalcaemia + raised ALP with bone mets
- LFTs + coagulation screen = deranged in liver mets
- flexible cystoscopy = to confirm tumour
further staging
- CT abdomen + pelvis
- CT urogram
- Pelvic MRI
- PET scan
- bone scan
245
BLADDER CANCER
what is the management for bladder cancer?
SUPERFICIAL/NON-MUSCLE INVASIVE
- trans-urethral resection of bladder tumour with post-op dose of intravesical mitomycin C
- low risk = no further treatment
- intermediate risk = 6 doses intravesical mitomycin C
- high risk = intravesical BCG or radical cystectomy
MUSCLE-INVASIVE
- radical cystectomy (with neoadjuvant chemo) - will require urostomy
- radical radiotherapy (with neoadjuvant chemo)
LOCALLY ADVANCED OR METASTATIC
- chemotherapy (cis-platin based)
- palliative treatment (radiotherapy for symptom control)
246
URINARY STONES
what is urolithiasis?
presence of stones in urinary tract
247
RENAL PHYSIOLOGY
what is the equation for net filtration pressure for the glomerulus?
NFP = GHP - (GCOP + CHP)
```
NFP = net filtration pressure
GHP = glomerular hydrostatic pressure
GCOP = glomerular colloid oncotic pressure
CHP = capsular hydrostatic pressure
```
248
RENAL PHYSIOLOGY
what is the gold standard for measuring GFR?
inulin
249
RENAL PHYSIOLOGY
which part of the loop of henle is permeable to water?
descending limb
250
RENAL PHYSIOLOGY
what is the innervation of the external urinary sphincter?
pudendal nerve S2-S4
251
RENAL PHYSIOLOGY
what is the innervation of internal urinary sphincter?
pelvic splanchnic nerve S2-S4
252
RENAL PHYSIOLOGY
what is the innervation of the bladder?
```
sympathetic = sympathetic chain T11-L2
parasympathetic = pelvic splanchnic S2-S4
```
253
RENAL PHYSIOLOGY
what is the role of intercalated cells of the collecting duct?
Intercalated cells are responsible for acid/base balance
Alpha = acid
Beta = basic
254
RENAL PHYSIOLOGY
what cells line the collecting duct?
principal cells and intercalated cells
255
RENAL PHYSIOLOGY
what is the physiology of micturation?
Pontine micturition centre promotes micturition by activating parasympathetic and deactivating sympathetic and somatic motor activity
Detrusor muscle contracts and sphincters open
256
CKD
what is stage 3b CKD?
eGFR 30-44ml/min
257
EPIDIDYMO-ORCHITIS
what is it?
acute inflammation of the epididymis (epididymitis) that may affect the testicle (orchitis)
258
EPIDIDYMO-ORCHITIS
what are the causes?
STIs
- gonorrhoea
- chlamydia
non-STI
- e.coli
- candida
- mumps
- TB
non-infectious
- Behcet's disease
- amiodarone induced
259
EPIDIDYMO-ORCHITIS
what are the clinical features?
SYMPTOMS
- testicular pain
- N+V
- fever
- dysuria
SIGNS
- testicular swelling
- palpable swollen, tender epididymis
- testicular erythema
- reactive hydrocele
- urethral discharge
260
EPIDIDYMO-ORCHITIS
what are the investigations?
- STI screen
bloods - FBC, U&Es, CRP, syphilis screen bloodborne virus screen, mumps serology,
blood cultures (if fever)
USS
261
EPIDIDYMO-ORCHITIS
what is the management?
ANTIBIOTICS
- STI related = ceftriaxone 500mg-1g IM single dose + doxycycine 100mg BD for 10-14 days
- UTI related = oflaxacin 200mg BD for 14 days or levofoxacin 500mg OD for 10 days
SUPPORTIVE CARE
- analgesia (paracetamol + NSAIDS)
- safety net
- referral
262
EPIDIDYMO-ORCHITIS
what are the complications?
testicular abscess
testicular torsion
subfertility
263
RENAL CELL CARCINOMA
what is it?
most common type of kidney tumour
it is a type of adenocarcinoma that arises from renal tubules
264
RENAL CELL CARCINOMA
what are the different types?
- clear cell (80%)
- papillary (15%)
- chromoprobe (5%)
wilms tumour is a type of tumour that affects children, typically under the age of 5
265
RENAL CELL CARCINOMA
what are the risk factors?
- increasing age
- male
- black ethnicity
- smoking
- obesity
- hypertension
- end-stage renal failure
- Von Hippel-Lindau disease
- Tuberous sclerosis
266
RENAL CELL CARCINOMA
what are the clinical features?
over 50% are asymptomatic and are diagnosed incidentally
SYMPTOMS
- haematuria
- flank pain
- abdominal mass
- weight loss
- fatigue
- fever of unknown origin
SIGNS
- flank mass
- left-sided varicocele
- hypertension
- evidence of metastatic disease (SOB, chronic liver disease, bone pain)
267
RENAL CELL CARCINOMA
how does a left-sided renal cell carcinoma cause a varicocele whereas a right sided carcinoma does not?
- left testicular vein drains into the left renal vein
- a left RCC can invade the renal vein causing back pressure + varicocele formation
- right testicular vein drains directly into the IVC so a right sided RCC does NOT cause a varicocele
268
RENAL CELL CARCINOMA
what are the investigations?
- urinalysis = microscopic haematuria or proteinuria
- U&Es (assess for renal dysfunction)
- LFTs and coagulation profile = derangement indicates liver mets
- bone profile = elevated calcium indicates bone mets
- LDH = elevated indicates poorer prognosis
- CT abdomen/pelvis with contrast (definitive test)
to consider
- CT chest (required to complete staging)
- bone scan (if evidence of bony mets)
- renal biopsy ( not routinely done due to risk of seeding)
269
RENAL CELL CARCINOMA
what is the management?
LOCALISED DISEASE
- partial nephrectomy (standard for T1 tumours)
- radical nephrectomy (standard for T2-4) +/- lymph node dissection + adenalectomy if involved
- minimally invasive procedures (radiofrequency ablation or embolisation) if unfit for surgery
METASTATIC DISEASE
- molecular therapy (sunitinib or pazopanib)
- radiotherapy
- cytoreductive surgery
270
RENAL CELL CARCINOMA
what are the complications?
- metastasis (adrenal, liver, bone, lung, brain)
- paraneoplastic syndrome (polycythaemia, hypercalcaemia, cushings syndrome)
- Stauffer syndrome
271
RENAL CELL CARCINOMA
what are the endocrine associations?
EPO = polycythaemia
PTH hormone-related peptide (PTHrP) = hypercalcaemia
ACTH = cushings syndrome
renin
272
NEPHRITIC SYNDROME
what is it?
caused by a variety of diseases and is characterised by haematuria, hypertension and oliguria
273
NEPHRITIC SYNDROME
what is the predominant symptom in nephritic syndrome?
haematuria
274
NEPHRITIC SYNDROME
what are the causes?
- IgA nephropathy
- post-streptococcal GN
- anti-GBM antibody disease (goodpastures syndrome)
- alport's syndrome
- lupus nephritis
- granulomatosis with polyangiitis (GPA)
- microscopic polyangiitis (MPA)
- eosinophilic granulomatosis with polyangiitis (eGPA)
- MPGN
275
NEPHRITIC SYNDROME
what are the general clinical features?
SYMPTOMS
- pink, red or 'coke' tinged urine (haematuria)
- foamy urine (proteinuria)
SIGNS
- oliguria (urine output <0.5ml/kg/hr)
- hypertension
- haematuria
276
NEPHRITIC SYNDROME
what are the investigations?
- urinalysis = haematuria (red cast cells), proteinuria (haematuria>proteinuria)
- urine albumin-creatinine ratio (ACR) = raised
- FBC = low Hb
- U&Es (to monitor eGFR)
- LFTs = albumin may be low
- renal USS
to consider
- renal biopsy (light + electron microscopy)
- assess for underlying cause
277
NEPHRITIC SYNDROME
what is the general management?
LIFESTYLE
- low salt, protein + fat diet
- improve CVD risk factors
ADJUNCTIVE THERAPIES
- diuretics (for fluid overload)
- ACEi (to reduce proteinuria)
278
NEPHRITIC SYNDROME
what are the features of IgA nephropathy?
- IgA levels rise secondary to recent (in last 7 days) GI/resp infection
- associated with coeliac disease
- most common glomerulonephritis worldwide
279
NEPHRITIC SYNDROME
what are the findings for IgA nephropathy?
- normal/low C3 levels
- light microscopy = mesangial hypercellularity
- immunofluorescence staining for IgA and C3
280
NEPHRITIC SYNDROME
what is the management for IgA nephropathy?
- trial ACEi or ARB for 3-6 months
- offer 6 month trial of corticosteroids if persistent proteinuria
281
NEPHRITIC SYNDROME
what are the features of post-streptococcal GN?
- delayed consequence of infection with strep pyogenes
- usually develops 2-6 weeks after infection (pharyngitis/skin infection)
282
NEPHRITIC SYNDROME
what are the findings for post-streptococcal GN?
- low C3
- raised anti-DNase B
- raised anti-streptolysin O
- immunofluorescence for IgG, IgM and C3
283
NEPHRITIC SYNDROME
what is the management of post-streptococcal GN?
symptomatic management only
284
NEPHRITIC SYNDROME
what are the features of Anti-GBM antibody disease (goodpasture syndrome)?
- autoimmune disease targeting lungs and kidneys
- causes pulmonary haemorrhage and glomerulonephritis
285
NEPHRITIC SYNDROME
what are the findings for anti-GBM antibody disease (goodpasture syndrome)?
- light microscopy shows crescentic glomerulonephritis
- immunofluorescence = linear deposition of IgG along glomerular capillaries
286
NEPHRITIC SYNDROME
what is the management of anti-GBM antibody disease (goodpasture syndrome)?
- plasmapheresis
- steroids
- cyclophosphamide
287
NEPHRITIC SYNDROME
what are the features of alport's syndrome?
comprises of triad of ophthalmological issues, auditory issues and nephritic syndrome
x-linked dominant inheritance
288
NEPHRITIC SYNDROME
what are the findings for Alport's syndrome?
- renal biopsy = gold standard (basket-weave appearance under electron microscope)
- genetic testing = mutation in alpha chain of type IV collagen
289
NEPHRITIC SYNDROME
what are the features of lupus nephritis?
- deposition of SLE antibody-antigen complexes
- most common form is diffuse proliferative glomerulonephritis
290
NEPHRITIC SYNDROME
what are the findings for lupus nephritis?
- loop wire appearance
291
NEPHRITIC SYNDROME
what is the management for lupus nephritis?
corticosteroids + immunosuppressants
292
NEPHRITIC SYNDROME
what are the features of granulomatosis with polyangiitis (Wegener's granulomatosis)?
- small vessel vasculitis
- affects lungs, nasopharynx and kidneys
- saddle nose deformity
293
NEPHRITIC SYNDROME
what are the findings for granulomatosis with polyangiitis?
c-ANCA positive
renal biopsy = segmental necrotising glomerulonephritis
294
NEPHRITIC SYNDROME
what are the features of microscopic polyangiitis?
small vessel vasculitis
affects lungs and kidneys
295
NEPHRITIC SYNDROME
what are the findings for microscopic polyangiitis?
p-ANCA positive
296
NEPHRITIC SYNDROME
what are the features of eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)?
characterised by:
- asthma
- allergic rhinitis
- nasal polyps
- eosinophilia
- small vessel vasculitis
297
NEPHRITIC SYNDROME
what are the findings for eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)?
- p-ANCA positive
- eosinophilia
298
NEPHROTIC SYNDROME
what is the classic triad for nephrotic syndrome?
- proteinuria (>3.5g/day)
- hypoalbuminaemia (<30g/L) - leads to severe oedema
- hyperlipidaemia
299
NEPHROTIC SYNDROME
what is the predominant feature for nephrotic syndrome?
proteinuria
300
NEPHROTIC SYNDROME
what are the causes?
- minimal change disease
- focal segmental glomerulosclerosis
- membranous nephropathy
- membranoproliferative GN
- diabetes
- amyloidosis
301
NEPHROTIC SYNDROME
what are the general clinical features?
SYMPTOMS
- frothy urine
- facial and peripheral oedema
- recurrent infections (due to hypogammaglobinaemia)
- predisposition to VTE
SIGNS
- HTN (more common in nephritic)
- proteinuria
- limited/absent haematuria
-
302
NEPHROTIC SYNDROME
what are the investigations?
- urinalysis = proteinuria
- 24hr urine protein collection = >3.5g protein
- urine albumin-creatinine ratio (ACR) = raised
- U&Es (to monitor eGFR)
- LFTs = hypoalbuminaemia <25m/L
- lipid profile = hypercholesterolaemia
- renal USS
to consider
- renal biopsy (light + electron microscopy)
- assess for underlying cause
303
NEPHROTIC SYNDROME
what is the most common cause in children?
minimal change disease
304
NEPHROTIC SYNDROME
what is the most common cause in adults?
focal segmental glomerulosclerosis
305
NEPHROTIC SYNDROME
what are the features of minimal change disease?
- most common cause in children
- responds excellent to steroids
- may be preceded by URTI
- associated with hodgkins lymphoma
306
NEPHROTIC SYNDROME
what are the findings for minimal change disease?
- light microscopy = normal glomeruli
- electron microscopy = effacement of foot processes
307
NEPHROTIC SYNDROME
what are the features of focal segmental glomerulonephritis?
- most common cause in adults
- associated with HIV, heroin use, sickle cell disease and SLE
308
NEPHROTIC SYNDROME
what are the findings for focal segmental glomerulonephritis?
- light microscopy = focal + segmental glomerular sclerosis
- electron microscopy = effacement of foot processes
309
NEPHROTIC SYNDROME
what are the features of membranous nephropathy?
- most common cause in elderly
- associated with malignancy, Hep B, NSAIDs, SLE
310
NEPHROTIC SYNDROME
what are the findings in membranous nephropathy?
- light microsopy = thick glomerular basement membrane
- electron microscopy = subepithelial immune complex deposition (spike + dome pattern)
311
NEPHROTIC SYNDROME
what are the findings for amyloidosis?
- apple-green birefringence under polarise microscopy with congo red stain
312
NEPHROTIC SYNDROME
what is the management?
LIFESTYLE
- low salt, protein and fat diet
- improve CVD risk factors
ADJUNCTIVE THERAPIES
- diuretics (relief of fluid overload)
- ACEi (reduce proteinuria)
MINIMAL CHANGE DISEASE
- corticosteroids
FOCAL SEGMENTAL GLOMERULONEPHRITIS
- corticosteroids
- ciclosporin if not responsive to steroids
MEMBRANOUS NEPHROPATHY
- corticosteroids + cyclophosphamide
313
RENAL TUBULAR ACIDOSIS
what is it?
a group of conditions that all result in a hyperchloraemic metabolic acidosis with a normal anion gap
314
RENAL TUBULAR ACIDOSIS
what is the blood results for renal tubular acidosis?
hyperchloraemic metabolic acidosis with normal anion gap
315
RENAL TUBULAR ACIDOSIS
what are the different types?
- type I (distal)
- type II (proximal)
- type III (mixed)
- type IV (hyperkalaemic)
316
RENAL TUBULAR ACIDOSIS
what is type I RTA?
- defective H+ secretion in distal tubule
- causes hypokalaemia
317
RENAL TUBULAR ACIDOSIS
what are the causes of type I RTA?
- idiopathic
- RA
- SLE
- Sjogren's
- amphotericin B toxicity
- analgesic nephropathy
318
RENAL TUBULAR ACIDOSIS
what are the complications of type I RTA?
nephrocalcinosis
renal stones
319
RENAL TUBULAR ACIDOSIS
what is type II RTA?
- decreased HCO3- reabsorption in proximal tubule
- causes hypokalaemia
320
RENAL TUBULAR ACIDOSIS
what are the causes of type II RTA?
- idiopathic
- fanconi syndrome
- wilson's disease
- cystinosis
- outdated tetracyclines
- carbonic anhydrase inhibitors (acetazolamide, topiramate)
321
RENAL TUBULAR ACIDOSIS
what are the complications of type II RTA?
- osteomalacia
322
RENAL TUBULAR ACIDOSIS
what is type 3 RTA?
- extremely rare
- caused by carbonic anhydrase II deficiency
- results in hypokalaemia
323
RENAL TUBULAR ACIDOSIS
what is type IV RTA?
- reduction in aldosterone leads in turn to reduction in proximal tubular ammonium excretion
324
RENAL TUBULAR ACIDOSIS
what are the causes of type IV RTA?
- hyperaldosteronism
- diabetes
325
RENAL TUBULAR ACIDOSIS
does it cause hypo or hyperkalaemia?
Type 1 = hypokalaemia
Type 2 = hypokalaemia
Type 3 = hypokalaemia
Type 4 = hyperkalaemia
326
RENAL TUBULAR ACIDOSIS
what is the clinical presentation?
- often asymptomatic
- children may present with poor growth or rickets
- alkaline urine = recurrent UTIs
- osteomalacia (bone pain, # risk + weakness)
327
RENAL TUBULAR ACIDOSIS
what are the investigations?
- blood gas
- urinary pH + electrolytes
- ECG
- U&Es
- bone profile
- magnesium
- aldosterone + renin
- USS KUB
328
RENAL TUBULAR ACIDOSIS
what is the management?
- stop causative medications
- treat electrolyte imbalance
- Type 1 + 2 = bicarbonate (or potassium citrate)
- type 4 = lifelong mineralocorticoid + glucocorticoid replacement
329
ACUTE INTERSTITIAL NEPHRITIS
what is it?
A cause of intrinsic AKI where there is acute tubulo-interstitial inflammation
It most commonly occurs due to a hypersensitivity reaction to certain medications
330
ACUTE INTERSTITIAL NEPHRITIS
what are the causes?
MEDICIATIONS
- antibiotics (beta-lactams, cephalosporins, fluoroquinolones)
- NSAIDs
- diuretics
- rifampicin
- allopurinol
- PPIs
- ranitidine
- warfarin
- phenytoin
AUTOIMMUNE
- Sjogren
- SLE
- sarcoidosis
INFECTIONS
331
ACUTE INTERSTITIAL NEPHRITIS
what are the clinical features?
- rash (macular or maculopapular + fleeting)
- fevers (low grade)
- oliguria
- flank pain or sensation of fullness
- arthralgia
- peripheral oedema (esp in NSAIDs)
- hypertension
- eosinophilia
332
ACUTE INTERSTITIAL NEPHRITIS
what are the investigations?
URINE
- microscopy = pyuria + white cell casts
- culture = negative (sterile pyuria)
BLOODS
- FBC = eosinophilia
- U&Es
- autoimmune screen
IMAGING
- renal USS
333
ACUTE INTERSTITIAL NEPHRITIS
what is the management?
CONSERVATIVE
- stop any causative medications
- supportive fluid management
- refer to specialist renal services
MEDICAL
- if autoimmune = steroids
- fluid overload = furosemide
334
ACUTE TUBULAR NECROSIS/INJURY
what is it?
the most common cause of intrinsic AKI
renal tubular epithelial cells are damaged either due to nephrotoxic agent or ischaemic insult
335
ACUTE TUBULAR NECROSIS/INJURY
what are the risk factors?
- hypovolaemia
- older age
- CKD
- recent use of nephrotoxic drugs
336
ACUTE TUBULAR NECROSIS/INJURY
what are the causes?
ISCHAEMIC
- hypovolaemia
- diarrhoea/vomiting
- haemorrhage
- dehydration
- burns
- anaphylaxis
- sepsis
- surgery
NEPHROTOXIC CAUSES
- aminoglycosides (e.g. gentamicin)
- antifungals (e.g. amphotericin)
- chemotherapy
- antivirals
- NSAIDs
- contrast agents
- myoglobin
- haemoglobin
337
ACUTE TUBULAR NECROSIS/INJURY
what are the clinical features?
Lethargy and malaise
Nausea and vomiting
Oliguria or anuria (polyuria may be seen in the recovery phase)
Confusion
Drowsiness
Peripheral oedema
338
ACUTE TUBULAR NECROSIS/INJURY
what are the investigations?
URINE
- dipstick = may be false positive for blood
- microscopy = muddy brown granular casts and renal tubular epithelial cells
- osmolality = low
- urinary sodium = high
BLOODs
- blood gas
- U&Es
- urea:creatinine ratio
- FBC
IMAGING
- ECG
- USS KUB
339
ACUTE TUBULAR NECROSIS/INJURY
what is the management?
CONSERVATIVE
- identify + treat cause
- avoid nephrotoxic meds
- fluid balance monitoring
MEDICAL
- IV fluids
- blood if haemorrhage
