Renal + urology Flashcards by cole roberts

What are the causes of CKD?

Diabetic nephropathy

Hypertension

Chronic glomerulonephritis

Chronic pyelonephritis

Adult PCKD

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What constitutes stages 1-5 of CKD?

1: >90ml/min + evidence of renal damage*
2: 60-90ml/min + evidence of renal damage
3a: 45-59
3b: 30-44
4: 15-29
5: <15

*Renal damage: Deranged electrolytes, U+Es

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Outline the diagnosis process of CKD

eGFR < 60ml/min, repeat in 2 weeks to exclude AKI

if eGFR <60ml/min OR ACR >=3mg, repeat in 3 months

if 3 month repeats as above, diagnose CKD

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When should referral to nephrology be made for
Symptoms
eGFR
Proteinuria

Clinical:

Persistent haematuria + cancer symptoms
Uncontrolled HTN on 4 drugs
Features of PCKD, RAS

eGFR:
- >25%/15 point decrease in 12 months
>25% decrease in 3 months of starting RAAS
- Increased CKD category

ACR
- >70 alone OR >30 with persistent haematuria

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How do you manage anaemia in CKD?

Check iron status
Correct iron levels first
Then Erythropoetin if benefit likely

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What is an important side effect of erythropoetin therapy

Accelerated Hypertension
Can lead to encephalopathy and seizures

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How do you manage proteinuria in CKD if you are…

Non-Diabetic

Diabetic

Offer ARB/ACEI if ACR

Non-diabetic:

>70mg/mmol

30-70 with hypertension

Diabetic:

3mg/mmol

+ SGLT2i if ACR 3-30mg/mmol

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How to protect bones in CKD

Reduce phosphate intake (phsophate pulls Ca2+ from bones)

If CKD 4-5 Give phosphate binders: calcium acetate, sevelamer

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When is sevelamer favoured over calcium acetate?

Hypercalcaemia and vascular calcification

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When should a CKD patient be dialysed?

eGFR < 15 (stage 5)

Renal transplant

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What are the two main forms of dialysis?

Peritoneal

Haemodialysis

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Patient reports pain distal to AV fistula, what could be occuring

STEAL syndrome

Fistula removes arterial blood, causing ischaemia of distal limb

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What are the two commonest causes of peritonitis in dialysis?

How does NICE recommend you treat it?

Coag -ve staph eg Staph epidermidis

Staph aureus another cause

Vanc + ceftazidime added to fluid

Vanc orally + Ceftazidime in fluid

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How do you manage hyperkalaemia on bloods?

ECG

Stop drugs eg ACEIs

IV calcium gluconate for cardiac protection

Insulin/dextrose or neb salbutamol to shift K+ into cells

Calcium resonium to remove K+ from body

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What are the causes for non visible haematuria that is

Spurious

Persistent

Spurious:

UTI, Menstruation, vigorous exercise, sexual intercourse

Persistent

Urogen cancer, stones, BPH, inflammation, nephritic syndromes

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What infection can cause haematuria?

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Who gets referred for haematuria

Urgently

Non-urgently

Urgent

>=45 years + visible haematuria that is unexplained/persistent after UTI

>=60 years + unexplained NON-visible haematuria + dysuria/raised WCC

Non-urgent

>=60yrs + recurrent/persistent unexplained urinary tract infection

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What features would make you suspect prostate cancer

LUTS, bloody/painful urination in an older man, especially if black

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Who gets referred for prostate cancer?

2 week referral for

Malignant features on PR exam

Raised PSA

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What is the first line and GS investigation for prostate cancer?

1st: Multiparametric MRI

GS: TRUS biopsy if Likert scale >3/5

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What scoring system aids diagnosis of prostate cancer?

Gleason scoring

>=6 indicates cancer

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What are the treatment options for bladder cancer?

Localised (T1/2): Radical prostatectomy + radiotherapy

Localised advanced (T3/4): Above + hormonal therapy

Metastatic

Anti-androgen therapy: Gosrelin to downregulate/bicalutamide to block

Bilateral orchidectomy

Docetaxel chemotherapy

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What features raise suspicion of bladder cancer?

Older men who smoke and worked in textiles

Reporting recurrent urinary symptoms or painless haematuria

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What is the first-line and definitive investigation for bladder cancer?

1st: CT-KUB

GS: TURBT

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Who gets referred for bladder cancer?

\>45yrs + unexplained or persistent haematuria where UTI has been accounted for \>=60yrs + non-visible haematuria + dysuria/raised WCC .'. urgent haematuria criteria

How do you treat bladder cancer that is Non-muscle invasive Muscle invasive Locally advanced/metastatic

non-muscle: radical cystectomy + adjuvant chemo muscle invasive: As above + urinary diversion Locally advanced/metastatic: Chemotherapy

What is the prognosis of bladder cancer?

Good if superficial but recurrs Declines to 15% if metastatic

A non-tender, hard, irregular and non-transilluminable lump in a young white guy with HIV suggests?

Testicular cancer

Who gets referred for testicular cancer?

Man with non-painful change in shape of testis

What is the first line and GS investigation for testicular cancer?

1st: Scrotal USS + CT staging and tumour markers

What are the tumour markers for testicular cancer?

B-HCG for both AFP if non-seminomatous

What is the management of testicular cancer?

Orchidectomy

Elderly man with increased urgency and reduced flow on urination suggests what condition?

Benign prostatic hypertrophy

What are the investigations for BPH

PR exam Dipstick urine freq-volume chart 3 days PSA if IPSS \>=8

In BPH, what are the management options if moderate symptoms prostatatic enlargement mixed storage + obstructive symptoms

Tamsulosin Finasteride Anti-muscarinics (tolteridone/darifenacin)

Elderly female with high BMI and parity has increased urinary frequency raises suspicion of?

Urinary incontience

How can you differ between the following types of incontinence? Urge Stress Overflow

Stress worse on sneezing or coughing Overflow: Dribbling due to obstruction Urge: Increased need to urinate due to overactive bladder

What investigations should you perform for suspected incontinence?

Vaginal exam for prolapse and tone Urine dipstick and culture Bladder diary for 3 days

What is the treatment route for someone with incontience with increased urgency?

Bladder retraining for 6 weeks Medical 1st: Anti-muscarinics (no oxybutinin for frail women) 2: Mirabegnon

How do you treat incontience that is worse on stressing?

Pelvic floor muscle retraining 3 months Mid-urethral tape for surgery Duloxetine if surgery declined

Old man with Parkinson's and BPH becomes confused following UTI and has reduced urinary output, what is the suspected diagnosis?

Acute urinary retention

What is the investigation and management of acute urinary retention?

Urinalysis and culture for infection U+Es for AKI Admit if first presentation Catheterise + alpha blockers 2-3 days

Severe loin to groin pain associated with haematuria, nausea and vomiting in a middle aged man suggests what diagnosis?

Renal colic/stones

What investigations should be performed for renal stones

Check routine bloods including eGFR Non-Contrast CT-KUB

What is the management for renal stones where \<5mm 5-9mm 10-19mm \>=20mm

Watch and wait Shock wave lithotripsy (US waves) Urethroscopy (scope up the tract) Percutaneous nephrolithotomy (direct removal from kidney)

What renal stone is most associated with the follwing Most common Gout Proteus UTI Recurrent stones and UTIs

Calcium Uric acid Struvite Cysteine

How can you prevent recurrence of the following stones? Calcium Oxalate Uric acid

High fluid, low animal protein diet Cholestyramine Allopurinol

What is the most common type of bladder cancer?

Transitional cell

What renal imaging is most useful for... The renal cortex glomerular filtration imaging kidneys in renal impairment Bladder reflux Evaluate lesions when staging malignancy

DMSA scintigraphy DTPA MAG3 urography MCUG scan PET/CT

When prescribing treatment GnRH agonists for prostate cancer, what do you need to co-prescribe and why?

Anti-androgens (cyoproterone acetate) Prevents flaring of symptoms when starting treatment

What is the most common cause of peritonitis in peritoneal dialysis?

S. epidermidis

How do you treat rhabdomyolysis?

IV fluids + urinary alkalinisation

What is a common complication of prostate cancer?

Erectile dysfunction

What can throw off an eGFR?

Motherhood Muscles Meat (red, consumed 12hrs before)

What quotas are needed for maintenance fluid for... Water glucose Na+, K+, Cl-

25-30ml/kg/day 50-100g/day (WEIGHT IRRELEVANT) 1mmol/kg/day

Who should Hartmann's solution be avoided in?

Hyperkalaemics

What blood results do you see in HUS/

Reduced Hb, thrombocytes Fragmented blood film

If a patient has gynaecomastia on spironolactone, what do you switch them to?

Eplernone

What investigations and treatment is done in priapism?

Cavernosal blood gas analysis or doppler US 1st line: Aspirate + saline flush

What is the US diagnostic criteria for polycystic kidney disease?

If + ve family history... 2 cysts, either side, \<30yrs 2 cysts, bilateral 30-59 four cysts, bilateral, \>60yrs

How can you differentiate between AKI and dehydration on U+Es

Dehydration: urea increase \> creat increase proportionally

How is LUTS... Investigated Treated

Urinary freq-vol chart International prostate symptom score \>=8 If voiding prevalent: a-blocker Prostatic enlargement: 5-a reductase (finasteride) Mixed: Combo therapy

How is hydronephrosis... Identified Managed

1st line: US if colic suspected: CT scan Rx relieve blockage... Acute upper tract: Nephrostomy Chronic upper: stent

High PLASMA osmolality and low URINE osmolality indicates what? How do you... Differentiate this from primary polydipsia Differentiate the subtypes?

Diabetes insipidus Urine osmolarity high after deprivation, DI low Cranial: Desmopressin (ACTH) causes increased osmolarity Nephrogenic: Desmopression does not change

For hypokalaemia, what are the... Investigations Treatment

If found, ECG for T wave flattening, U waves and ST segment changes Mild-mod (\>2.5): Oral potassium Severe (\<=2.5): IV replacement \<10mmol/hr

How can you differentiate full torsion vs appendage only?

cremasteric reflex absent in true torsion

How does the size of the kidney change if the patient has CKD Diabetic

CKD: Smaller Diabetic: Larger

How can dehydration be spotted as a cause of AKI?

Proportional raise in urea greater than that of creatinine

How do you treat hydronephrosis if the blockage is due to... Urinary retention Neprho-ureteric blockage

Urethral catheter Nephrostomy

When do you dialyse an AKI patient?

If they are not responding to treatment... Hyperkalaemia Pulmonary oedema Acidosis Uraemia

How does the following direct the cause of hypertension and headache... low renin, high aldosterone high renin, high aldosterone

Helps differentiate where excess aldosterone is coming from Renin low: Primary (as renin not stimulating release) eg adenomas Renin high: Secondary (as renin stimulating increased release) eg renal artery blockages cause hypoperfusion causing more renin to bring BP back up

How can you prevent renal stones in a hypercalcaemic patient?

What is the most common cause of death in dialysis patients?

IHD

For prostatitis... What is the most common organism What antibiotic do you give

E.Coli 14 days quinilone

How do you determine if a renal transplant patient is experiencing Hyperacute rejection Acute graft failure Chronic graft failure

Hyperacute: Within hours Acute: \<6 months, rising creat + pyuria + proteinuria Chronic: \>6 months, recurrence of original disease

Which renal condition causes 'allergic' picture, impaired renal function following drug therapy (particularly antibiotics)

Acute interstitial nephritis

How can you roughly estimate paeds maintenance fluids if small losses are not important?

1st 10kg: 100ml/kg 2nd 10kg: 50ml/kg Subsequent: 20ml/kg

How long does it take for an AV fistula to work?

6-8 weeks

Painless haematuria, flank pain and mass in a child suggests what?

Wilms tumour

What cause of AKI has incresed urine sodium?

Acute tubular necrosis Necrosis of tubules causes leakage