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GP - General Practice > Renal Medicine and Urology > Flashcards

Renal Medicine and Urology Flashcards

1
Q

Define Microalbuminuria
Define Proteinuria

A

Microalbuminuria: Protein in urine >2.5mg/mmol in males and >3.5 in females

Proteinuria: Protein in urine >30mg/mmol

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2
Q

ACR should be used over PCR in almost all cases. In what cases would you prefer PCR?

A

1) High levels of proteinuria
2) Pregnant women
3) Children (<18)

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3
Q

What are the 2 main ways to assess renal function

A

1) Urine ACR/PCR
2) eGFR/GFR

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4
Q

How is eGFR measured? Give 3 methods

A

Creatinine:
1) Cockcroft Gault Formula (CG)
2) CKD EPI Formula

Cystatin C

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5
Q

eGFR is not reliable in certain cases. Give 2 cases

Give 2 cases where eGFR may be each over and underestimated.

A

Unreliable if:
Rapidly changing
AKI
Drugs (Trimethoprim)

Overestimated if
Elderly (use CG formula)
Muscle wasting disorder e.g. Myasthenia Gravis (use CG)

Underestimated if
High muscle mass (CG)
Muscle wasting disorder (CG)
High protein diet

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6
Q

How is CKD diagnosed?

A

CKD is diagnosed if eGFR <45 (3b)on 2 readings, 90 days apart
or eGFR 45-59 and ACR >3/albumin conc. >30
or eGFR 60-90 + ACR>30 or Albumin conc. >300

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7
Q

What eGFR is an indication for RRT

A

<10 (oxford)

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8
Q

What eGFR would indicate end-stage renal failure?

A

eGFR<15

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9
Q

How would you grade/classify CKD? Go through it

A

Based on eGFR
G1 >90 -> Normal
G2 60-90 -> Does not indicate CKD unless ACR >30/albumin conc >300
G3a 45-59 does not indicate CKD unless ACR>3/Albumin conc. >30
G3b 30-44 - CKD if 2 readings, 90 days apart
G4 15-29 - Referral for renal
G5 <15 - Kidney failure

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10
Q

Define CKD

A

Slow decline in renal function over months/years defined by increased ACR and reduced eGFR

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11
Q

Give 8 causes of CKD

A

1) DM
2) HTN/CVD
3) Urinary tract obstruction
4) Hypercalcaemia
5) Nephrotoxic medication (Furosemide, Gentamicin, platinum…)
6) Glomerulonephritis
7) ADPKD (polycystic kidneys)
8) Interstitial nephritis
9) Amyloid
10) SLE
11) AKI

Same answer for RF of CKD

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12
Q

When should a patient presenting with reduced renal function be referred for Renal or urology?

A

eGFR<30 (G4)
Urology: outflow obstruction, reduced urine output

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13
Q

What are the options for renal replacement therapy?

A

1) Haemodialysis
2) Peritoneal dialysis
3) Renal transplant (best)

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14
Q

Haemodialysis can be performed at home or at the dialysis unit. How often should this be performed?

How is it performed?

What are the main complications?

A

Haemodialysis involves ultrafiltration through a semi-permeable membrane via an AV fistula 2-3 times per week.

Complications:
1) Fluid shift
2) Pulmonary oedema
3-5) AV fistula: AVF thrombosis, line sepsis, Steal syndrome (Ischaemia of the hand due to AVF)

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15
Q

Peritoneal dialysis is performed at home=> they are not tied to a dialysis machine. How often should this be performed?

How is it performed?

What are the main complications?

A

Permanent Tenchkoff catheter is inserted into the peritoneum. In peritoneal dialysis, the peritoneum acts as a filer. This needs to be changed 4x/day or 8-10 hours overnight

Complications:
1) Peritonitis
2) Abdominal wall hernia
3) Line sepsis
4) Line blockage

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16
Q

How would you manage CKD?

A

1) Treat reversible causes
a) Stop/avoid/reduce dosages of nephrotoxic drugs or those that are dependent on renal elimination
b) Control DM (glycemic control)
c) Treat BP (ACEi/ARBS or CCB/Thiazide)
d) Annual CVD check
e) Folic acid and B12 vitamin supplementation

2) RRT: Refer when eGFR<30 but commence RRT at <10
a) Haemodialysis
b) Peritoneal dialysis
c) Renal transplant

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17
Q

When a patient goes through kidney transplantation, what medications should they be put on?

where is the kidney likely sited?

A

Immunosuppressants (Tacrolimus or ciclosporin) or steroids (prednisolone)

Typically sited at the right iliac fossa

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18
Q

Give 5 RF for nephrolithiasis

A

1) Family history of nephrolithiasis, cystinuria, hypoxaluria
2) Anatomical/congenital abnormal kidney (Medullary sponge, Horseshoe kidney)
3) Dehydration
4) Immobilisation
5) Metabolic bone disease (Hypercalcemia, cystinuria, renal tubular acidosis)
6) Chronic/recurrent UTI
7) Drugs: Allopurinol (gout), Acetazolamide, loop diuretic (furosemide), Thiazides, Calcium, Vitamin supplements

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19
Q

Define Strangury

A

Symptoms associated with UTI including urgency, frequency, dysuria, and incomplete emptying

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20
Q

Define renal colic

A

Severe wavy pain of increasing severity

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21
Q

How does Nephrolithiasis present?

A

1) Renal colic => Severe wavy pain of increasing severity.
+ Abrupt onset flank pain radiating to the abdomen
Radiates to the groin as it progresses down the ureter
2) Recurrent UTIs
3) Urinary retention

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22
Q

You are asked to examine a patient with renal colic. What will you be looking for?

A

Inspection: Unable to sit still, pale, clammy (sweaty)

Palpation: Loin, flank tenderness

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23
Q

How would you differentiate peritonitis from renal colic on exam?

A

Peritonitis will remain still to avoid pain
Renal colic will constantly be shifting position to help ease the pain

24
Q

A patient presents with acute onset abdominal pain. They appear clammy. Give 6 differentials.

What investigations will you perform?

A

Nephrolithiasis
Pyelonephritis
Cholecystitis
Pancreatitis
Appendicitis
Diverticulitis
Peritonitis
Bowel obstruction
Strangulated hernia
Testicular torsion

Investigations:
Bedside: Urine dipstick, vitals
Bloods: FBC, U&E, Creatinine, eGFR, Ca2+, PO4, LFTs (Why? Alk phos to rule out obstructive jaundice via gallstones), uric acid
Urine: Midstream culture and sensitivity, RBC, Urine cysteine “spot test”, ACR, Ca2+, PO4, Uric acid, Na
Imaging: X-ray kidney ureter, bladder + Renal tract US

25
Q

give 4 types of Renal stones

A

1) Calcium Oxalate
2) Calcium phosphate
3) Staghorn (triple phosphate a/w proteus)
4) Urate (caused by allopurinol and alcohol)
5) Cysteine (metabolic)
6) Xanthine (metabolic)

26
Q

What lab test is an indication that the stone is Calcium Oxolate?
Same for calcium phosphate

A

Hypercalciuria => Calcium oxalate
Hypercalcemia => Calcium Phosphate

27
Q

Which stones are radio-opaque and which are radio-transluscent?

A

All are radioopaque except Xanthine and Urate crystals

28
Q

How would you manage a patient with suspected Renal stones?

A

1) Stones typically pass spontaneously => only treat analgesia (IM Diclofenac - NSAID-)

2) Admit if fever, oliguria, symptoms >24 hr, or pregnant

29
Q

What would you advise the patient as preventative measures to the recurrence of kidney stoes?

A

1) Increase fluid intake (8-10 cups)
2) increase intake of fruits and veg
3) weight loss
4) Animal protein
5) reduced salt intake

30
Q

An 18 year old patient presents with widespread stones distributed throughout the body. What are your top 2 diagnoses

A

hyperoxaluria Type 1
Cystinuria

80% of those with Hyperoxaluria have chronic renal failure. It is divided into type 1 and 2, 1 being the more severe.

Type 1: Calcium oxalate stones widely distributed throughout the body, presents as nephrocalcaemia in children

Type 2: More benign and also rarer. Nephrocalcinosis but no CKD

Cysteinuria is also familial and presents early.

31
Q

Give 10 causes of Haematuria

A

Infection: !UTI, Urethritis, !bacterial prostatitis, TB, schistosomiasis
Tumour: Bladder, prostate, renal, endometrial Ca
Inflammation: Glomerulonephritis, HSP (vasculitis with IgA deposition), IgA nephropathy, Good pasture’s syndrome
Structural: !Stones (Renal, ureter, bladder), !!!Cysts (ADPKD), !!!BPH, Congenital
Trauma: Sexual intercourse, foreign body, !!Iatrogenic (surgery/catheter)
Drugs: Warfarin, NSAIDs
Coagulation disorders

32
Q

Any presence of blood on urine dipstick is significant, requiring investigation. What investigations should be done in the presence of haematuria?

A

FBC
BP
Renal function: ACR and eGFR
Abdominal palpation
Urine for M, C&S
PSA for males
Pelvic USS for female
Renal USS for recurrent haematuria

33
Q

What is Urine M, C&S

A

Urine microscopy, culture & sensitivity

34
Q

Beatroot ingestion and hyperbilirubinemia in obstructive jaundice may lead to discolouration of the urine. What may cause a false +ve for blood on urine dipstick? (2)

A

Free Hb or myoglobin

35
Q

A patient presents with raised WCC but no nitrites or blood. Everything else is normal on the dipstick. What is this called?

Give 5 causes that can lead to this

A

Sterile Pyuria

Causes:
1) Appendicitis
2) Calculi
3) Prostatitis
4) Bladder tumour
5) ADPKD
6) Interstitial nephritis
7) Interstitial cystitis
8) Renal TB

36
Q

What is interstitial nephritis?

A

kidney condition characterized by inflammation of the spaces between the kidney tubules.

37
Q

What is interstitial cystitis?
How is it different from cystitis?

A

Typically presents in middle-aged women
Inflammation of the tissues lining the bladder (interstitial) leading to fibrosis of the bladder wall => incomplete emptying => stasis and increased risk of UTI.

Presents the same way as cystitis. There is no tx as it is just “ Bladder pain syndrome”. Refer to urology if needed

38
Q

What are the 2 main types of bladder cancer?

A

Transitional cell Ca
Squamous cell Ca

39
Q

What are some RFs for Bladder cancer?

A

Smoking
Urinary stasis
Chronic UTI
Aromatic amine exposure (due to textile industry or rubber)
Schistosomiasis

40
Q

How does bladder cancer present?

A

Haematuria,
pelvic/loin pain,
!recurrent UTI,
!bladder outflow obstruction,
increased frequency, anemia
+ B symptoms.

41
Q

What investigations would you perform for bladder Ca?

A

Urine Dipstick for Haematuria => do those investigations
FBC
BP
Renal function: ACR and eGFR
Abdominal palpation
Urine for M, C&S
PSA for males
Pelvic USS for female
Renal, ureter, bladder USS for recurrent haematuria

42
Q

How would you manage Bladder Ca in primary care?
Management in secondary care is dependent on the stage of the Ca. Go through it with tx

A

Refer to Urology
T1 = Confined to mucosa/submucosa => TURBT +/- Single intravesical chemotherapy

T2 = invasion into connective tissue around bladder => TURBT +/- Radiotherapy

T3 = Invasion through muscle and fat => Radical cystectomy +/- Radiotherapy

T4 = Beyond Bladder => TURBT for sx relief + Palliative radio and chemo

43
Q

What is TURBT

A

Transurethral resection of bladder tumour

44
Q

Renal Cell Carcinoma/Hypernephroma is the most common type of renal cancer accounting for >90% of renal cancers. What type of cancer is that?

How would it present?

A

Clear cell adenocarcinoma of the renal tubular epithelium

Presentaion: Haematuria, loin pain, anemia, left varicocele + B symptoms

45
Q

What is the most common causative organism for a UTI?
Give 2 other examples

A

E.coli (70%)
Proteus
Pseudomonas
Staph
Strep

46
Q

What are the RF for a UTI?

A

1) Female
2) DM
3) Stones
4) Pregnancy
5)Dehydration
6) Bladder Ca
7) Urinary stasis (from stones or obstruction due to anatomical causes)
8) GU instrumentation (catheter)
9) Menopause (bladder atrophy, increased pH)
10) Sexual intercourse
11) Delayed micturition

47
Q

A patient presents with Dysuria and Urgency. Give 5 ddx

A

1) UTI
2) Urethral syndrome (pain syndrome)
3) Inflammation (interstitial cystitis, radiation-induced)
4) Intravesical lesion (tumour, stone, iatrogenic)
5) Atrophy -> Menopause

48
Q

A patient presents with Urinary frequency, Give 10 ddx

A

1) Detrusor muscle instability (neuromuscular disorder, radiation-induced)
2) Neurogenic bladder (MS)
3) Enlarged prostate
4) Pregnancy
5) DM
6) Diuretics
7) Excessive fluid intake/habit

+ ddx of dysuria and urgency
1) UTI (cystitis and pyelonephritis)
2) Urethral syndrome (pain syndrome)
3) Inflammation (interstitial cystitis, radiation-induced)
4) Intravesical lesion (tumour, stone, iatrogenic)
5) Atrophy -> Menopause

49
Q

How does cystitis present?

A

Dysuria, urgency, frequency, incomplete emptying
suprapubic pain
Cloudy/offensive urine
Haematuria

50
Q

How does pyelonephritis present?

A

Flank pain, rigors, malaise, vomiting +/- haematuria
+ Sx or hx of cystitis
Dysuria, urgency, frequency, incomplete emptying
suprapubic pain
Cloudy/offensive urine
Haematuria

51
Q

What investigations would you perform for Cystitis initially?
If it has progressed to pyelonephritis what further investigations would you perform?

A

Urine Dipstick for Haematuria => do those investigations
FBC
BP
Abdominal palpation
Urine for M, C&S

Further inv.
Renal function: ACR and eGFR
PSA for males
Pelvic USS for female
Renal, ureter, bladder USS for recurrent haematuria

52
Q

What would be considered complicated cystitis?

A

Male
GU malformation
Immunosuppression
Recurrent UTI

53
Q

What advice would you give a patient to prevent a UTI?

A

Hydration
Frequent urination
Double voiding
Voiding after intercourse

54
Q

How would you manage Cystitis
How would you manage Pyelonephritis?

A

Paracetamol +/- NSAIDs for pain
Advice:
Hydration
Frequent urination
Double voiding
Voiding after intercourse

Cystitis: + Nitrifurantoin (3/7 if uncomplicated, 7-10/7 if complicated) or trimethoprim (teratogenic)

Pyelonephritis + Ciprofloxacin for 7/7

55
Q

If a male presenting with recurrent UTIs on a background of BPH, what medication would you prescribe to improve?

A

Finasteride, Dutasteride

56
Q

If a post-menopausal woman is presenting with recurrent UTIs, how would you prevent

A

Advice:
Hydration
Frequent urination
Double voiding
Voiding after intercourse

+ Topical oestrogen

57
Q

What is urethral syndrome?

What is it associated with

How does it present?

How is this managed?

A

It is a pain syndrome of unknown cause a/w with the pain and discomfort of the urethra a/w cold, stress, nylon underwear and COCP

Presents with the same sx as cystitis but -ve Dipstick. Dysuria, urgency, frequency,
incomplete emptying, suprapubic pain

Only with advice
Hydration
Frequent urination
Double voiding
Voiding after intercourse
+ Cotton underwear
+ Changing/stopping COCP

GP - General Practice (15 decks)

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