Renal (Urology) Flashcards
(140 cards)
1
Q
What is the difference between complicated/uncomplicated UTIs?
A
Uncomplicated = normal urinary tract structure, function; normal immune system; non-pregnant
Complicated = structural/functional abnormality of genitourinary tract e.g. obstruction, catheter, stones, renal transplant, neurogenic bladder; pregnancy; immunocompromised
2
Q
What are the main risk factors for developing a UTI?
A
Bacterial inoculation
- Sexual activity
- Urinary incontinence
- Faecal incontinence
- Constipation
Binding of uropathogenic bacteria
- Spermicide use
- Decreased oestrogen
- Menopause
Decreased urine flow
- Dehydration
- Obstruction
Increased bacterial growth
- Diabetes
- Immunosuppression
- Obstruction
- Stones
- Catheter
- Pregnancy
3
Q
What are the most common organisms to cause a UTI?
A
E. Coli = most common (80% in community)
- Staphyloccous saprophyticus (skin commensal)
- Proteus mirabilis
- Klebsiella pneumonia
- Pseudomonas
4
Q
What are the symptoms of cystitis?
A
- Frequency
- Dysuria
- Urgency
- Suprapubic pain
- Haematuria
5
Q
What are the symptoms of pyelonephritis?
A
- Lower UTI symptoms
- Fevers and rigors
- Nausea and vomiting
- Loin tenderness
- Fatigue and malaise
6
Q
What are the symptoms of prostatitis?
A
- Pain in perineum, rectum, scrotum, penis, bladder, lower back
- Fever
- Malaise
- Nausea
- Urinary symptoms
- Swollen/tender prostate on PR
7
Q
What tests are done for UTI?
A
MSU urinalysis - best initial test
- Leukocytes
- Nitrites
- will always be positive in catheterised patients
MSU MC&S
Bloods
- FBC
- U&Es
- Cultures
- Glucose (diabetes)
8
Q
What are some infection-related causes of sterile pyuria?
A
- TB
- Recently treated UTI
- Inadequately treated UTI
- Appendicitis
- Prostatitis
- Chlamydia
9
Q
What are some non-infection-related causes of sterile pyuria?
A
- Calculi
- Renal tract tumour
- Papillary necrosis
- Tubulointerstitial nephritis
- Polycystic kidneys
- Pregnancy
- SLE
- Steroids
10
Q
What is the treatment for non-pregnant women with a UTI?
A
3 day course of trimethoprim (or nitrofurantoin but only if eGFR > 30)
Upper UTI
- 7-10 day course of ciprofloxacin
- Co-amoxiclav can be used
11
Q
What is the treatment for pregnant women with a UTI? Which antibiotics must be avoided?
A
Penicillins/cephalosporins
Avoid:
- Trimethoprim (1st trimester)
- Nitrofurantoin (term)
- Quinolones e.g. ciprofloxacin (all pregnancy)
- Sulphonamides (all pregnancy)
12
Q
How do you treat men with UTI?
A
7 day course of trimethoprim/nitrofurantoin
Prostatitis - 4 week course of ciprofloxacin because it penetrates prostatic fluid
13
Q
Which antibiotics are best for long-term treatment or prophylaxis of UTIs?
A
Trimethoprim
Nitrofurantoin
Cefalexin
14
Q
What is the treatment for urinary tract tuberculosis?
A
Rifampicin + isoniazid for 6 months with pyrazinamide + ethambutol for 2 months
15
Q
What are some complications of urinary tract tuberculosis?
A
Interstitial nephritis
Renal amyloidosis
Glomerulonephritis (rare)
16
Q
What can cause urinary tract obstruction within the lumen?
A
- Calculus
- Blood clot
- Sloughed papilla
- Tumour
17
Q
What can cause urinary tract obstruction within the wall?
A
- Neuromuscular dysfunction - congenital, MS, spinal trauma
- Ureteric stricture - TB, post-surgery
- Congenital megaureter
- Bladder neck obstruction
- Pinhole meatus
18
Q
What can cause urinary tract obstruction from outside the tract?
A
- Tumours e.g. colon carcinoma
- Diverticulitis
- AAA
- Retroperitoneal fibrosis
- BPH
19
Q
What is hydronephrosis?
A
The swelling of a kidney (dilation of renal pelvis and calyces) due to build up of urine usually caused by an obstruction
20
Q
How does hydronephrosis present?
A
Isolated hydronephrosis is almost always asymptomatic - the UTI/stone causing it is what causes symptoms
Pain
- Loin pain provoked by increasing urine volume e.g. fluid intake, diuretics, alcohol
- The pain radiates to inguinal region
Anuria = complete bilateral obstruction Polyuria = partial obstruction (increased urine due to poor tubular concentrating capacity)
N+V in acute obstruction
21
Q
What investigations are useful in hydronephrosis?
A
- U+Es + eGFR
- Ultrasound to show dilation of renal pelvis - first-line
- Non-contrast helical CT scan if renal colic - high sensitivity for renal stones
- IV urography - visualises upper urinary tract to assess position of the obstruction
22
Q
How do you treat a partial urinary obstruction?
A
Hydration
Analgesia
Prophylactic antibiotics
23
Q
How do you treat a complete urinary tract obstruction depending on whether its lower/upper/acute/chronic?
A
Catheterisation - lower urinary tract obstruction
Nephrostomy - acute obstruction of upper urinary tract
Stenting of ureter - chronic obstruction
May need dialysis
24
Q
What are the limitations of measuring serum creatinine for diagnosing an AKI? But why is serum creatinine superior to urea?
A
Limitations:
- Muscle mass
- Dilution
- eGFR can fall to half before creatinine rises past upper limit
Superior:
- Urea is easily influenced by protein turnover (diet, etc) and hydration status
25
What are some risk factors for developing an AKI?
- Pre-existing CKD (eGFR < 60)
- Co-morbidity
- Increasing age > 65 years
- Males
26
Name the commonest causes of AKI
1. Sepsis
2. Major surgery
3. Cardiogenic shock
4. Other hypovolaemia
5. Drugs - NSAIDs, ACE inhibitors
6. Hepatorenal syndrome (renal deterioration secondary to cirrhosis)
7. Obstruction - BPH, tumours, stones, strictures
27
What are some pre-renal causes of AKI?
Decreased perfusion to the kidney
Hypovolaemia
- Haemorrhage
- Burns
- Diarrhoea + vomiting
- Pancreatitis
Decreased cardiac output
- Cardiogenic shock
- MI
Systemic vasodilation
- Sepsis
- Drugs
Renal vasoconstriction
- Renal artery stenosis
- NSAIDs
- ACEi
- Hepatorenal syndrome
28
What are some renal causes of AKI?
Direct damage to kidney
Glomerular
- Acute tubular necrosis - sepsis, infection, ischaemia, nephrotoxins
- Glomerulonephritis
Interstitial
- Drugs
- Sarcoidosis
- Infection
Vessels
- Vasculitis
- HUS
- TTP
- DIC
- Malignant hypertension
29
What are some post-renal causes of AKI?
Bilateral obstruction of urinary flow out of the kidneys
Within renal tract
- Stone
- Malignancy
- Stricture
- Clot
Extrinsic compression
- Pelvic malignancy
- BPH
- Retroperitoneal fibrosis
Neurologenic bladder
Congenital malformation e.g. posterior urethral valves
30
What are some symptoms and signs of advanced uraemia?
* Anorexia, nausea, vomiting
* Reduced mental state, reduced GCS, seizures
* Myoclonic twitching
* Increased photosensitive pigmentation – which may make the patient appear misleadingly healthy
* Brown discolouration of the nails
* Excoriations from pruritis
* Signs of fluid overload – peripheral oedema, pulmonary oedema (crackles at the lung bases on auscultation)
* Pericardial friction rub
* Glove and stocking sensory loss – rare
31
What is the diagnosis criteria for AKI?
Kidney Diseases: Improving Global Outcomes
One of:
- Serum creatinine rises by >26 umol/L from baseline value within 48 hours
- Serum creatinine rises > 1.5 times from the baseline value within one week
- Urine output is less than 0.5ml/kg/hr for >6 consecutive hours
32
What investigations can be done in AKI to identify the cause?
Urgent VBG to check K+
Bloods
- U+Es - serum creatinine
- LFTs - hepatorenal syndrome
- FBC - platelets (if low do blood film)
- Blood film - HUS
- Antibody screen if autoimmune cause suspected
Urine dipstick and MC&S
- Proteinuria
- Haematuria
Bladder scan if retention suspected
Ultrasound scan within 24 hours unless cause obvious
Monitor urine output
33
Which medications are nephrotoxic?
A DIAMOND + Li
Aminoglycosides
```
Diuretics (especially potassium sparing)
Iodine contrasts/immunosuppressants
Antihypertensives e.g. ACEi, ARB
Metformin
Opioids
NSAIDs
Digoxin
```
Lithium
34
How do you treat AKI?
STOP AKI
1. Sepsis - BUFALO
2. Toxins - stop nephrotoxins
3. Optimise blood pressure - 500ml 0.9% sodium chloride given over 15 min (if hypovolaemic)
4. Prevent harm
- Treat complications e.g. hyperkalaemia, pulmonary oedema, pericarditis
- Identify cause
- Review drug chart
- Renal replacement therapy?
- Monitor fluids and U+Es
35
What ECG changes would you see in hyperkalaemia in order of severity?
1. Tall tented T-waves
2. Flattened P-waves
3. Prolonged PR interval
4. Widened QRS complexes
5. Idioventricular rhythms (slow regular ventricular rhythm, typically with a rate of less than 50, absence of P waves, and a prolonged QRS interval)
6. Sine wave patterns
7. VF/asystole
36
When is renal replacement therapy indicated for AKI?
- Persistently high potassium that is refractory to medical treatment
- Severe acidosis (pH<7.2)
- Refractory pulmonary oedema
- Symptomatic uraemia (pericarditis, encephalopathy)
- Drug overdose (e.g. aspirin)
37
What is the definition of chronic kidney disease?
Abnormal kidney structure or function present for >3 months with implications for health
38
What is the classification of kidney disease based on?
eGFR (ml/min/1.73^2)
```
G1: >90 - normal
G2: 60-89 - only CKD if other evidence of kidney damage e.g. proteinuria, tubule disorder
G3a: 45-59 - mild to moderate
G3b: 30-44 - moderate to severe
G4: 15-29 - severe
G5: <15 - kidney failure
```
39
What are some risk factors for a decline in eGFR?
- Hypertension
- Diabetes mellitus
- Chronic NSAID use
- Smoking
- Increasing age
- Obesity
40
What are some congenital causes of CKD?
Renal dysplasia
Alport syndrome
Fabry disease
41
What are the most common causes of CKD in the UK?
1. Diabetes mellitus
2. Glomerulonephritis
3. Hypertension
42
CKD may be symptomatic if eGFR < 30. What are some symptoms of CKD?
- Fluid overload: SOB, oedema, polyuria (salt retention)
- Anorexia, nausea, vomiting
- Pruritis (raised urea)
- Bone pain (renal osteodystrophy)
- Insomnia
- Restless legs
43
What would the blood results look like in CKD?
FBC - Normochromic normocytic anaemia
U+Es
- Low calcium, high phosphate (renal osteodystrophy)
- Low sodium, high potassium
- Low bicarb
44
What is the most common cause of renal artery stenosis in patients over 50?
Atherosclerosis
45
What imaging would you do in CKD? What would you see?
Ultrasound scan of kidneys for size, symmetry, anatomy, corticomedullary differentiation and to exlude obstruction
- Small kidneys (<9cm) except in amyloid, myeloma, diabetes
- Asymmetrical = renovascular disease
46
What is the gold standard investigation for CKD?
Isotopic eGFR
47
What further investigations should you consider for progressive CKD or AKI without recovery?
Renal biopsy
48
How can you slow renal disease progression?
- Target BP < 130/80
- ACE inhibitors - first line
- Target HbA1C < 53mmol/mol
- Lifestyle advice: reduce salt intake, smoking cessation, exercise
- Statins to reduce CVD risk
49
What are some complications of CKD and how can they be managed?
Anaemia
- Treat any iron, folate, b12 deficiencies
- Give erythropoietic stimulating agent if Hb<11g/dL
Acidosis
- Sodium bicarbonate supplements if eGFR < 30
Oedema
- High dose loop diuretics (can be combined with thiazide)
Secondary hyperparathyrodism and renal osteodystrophy
- Vitamin D supplements
Restless legs/cramps
- iron deficiency may be cause
- sleep hygiene advice
- gabapentin
50
What should you when starting any patient on ACE inhibitors?
Check their U+Es (particularly potassium, eGFR and creatinine) before starting, 2 weeks after and 2 weeks after any dose changes
Expect rise in creatinine of 30% (but no more than double)
51
What is the pathology of benign prostatic hypertrophy?
Benign nodular or diffuse proliferation of musculofibrous and glandular layers of prostate.
Transitional (inner) zone enlarges more than peripheral (whereas in prostatic carcinoma the peripheral layer enlarges more)
The likely cause is failure of apoptosis
52
What symptoms would you get with BPH?
Before: urgency, hesitancy, incontinence, frequency, nocturia
During: poor stream, haematuria (rupture of prostatic veins), terminal tribbling
After: sensation of incomplete emptying
53
What would you feel on a PR in BPH?
Smooth, symmetrically enlarged prostate with loss of the sulcus
54
Talk through how you would do a PR osce station
'I need to perform a rectal examination, which will involve me inserting a finger into your back passage. It might be a little bit uncomfortable but shouldn't be painful and won't take long. Is that alright?'
'It is normal practice to have a chaperone present, is that ok with you?'
'Roll onto your side and bring your knees to your chest'
Inspection: skin excoriation, skin tags, rashes, haemorrhoids, fissures, bleeding, abscesses
Palpation: lubricate finger, warn the patient, insert finger half way and ask patient to cough to assess anal tone, insert finger further, do posterior sweep then anterior sweep, palpate prostate for location size shape tenderness symmetry sulcus
Slowly withdraw finger and look for blood, faeces, mucus
55
What are some contraindications for PR exam?
- No informed consent
- Fistulae
- Excessive rectal bleeding
- History of 3rd degree heart block
- Autonomic dysreflexia
- Patient is a child
- History of abuse
- Presence of foreign body
56
Aside from PR, what investigations can you do for BPH?
- Mid stream urine dip
- U&Es
- Ultrasound - will show large residual volume/possibly hydronephrosis
- PSA
- Transrectal ultrasound + biopsy
57
What are the drug treatments for BPH?
1. Alpha-blockers e.g. tamsulosin, doxazosin
| 2. 5-alpha-reductase inhibitors e.g. finasteride
58
What is the mechanism of alpha blockers?
They block alpha1-adrenoreceptors in the smooth muscle, which leads to vasodilation and decreased resistance to bladder outflow
59
What are the main side effects of alpha blockers?
Postural hypotension
60
What is another indication for alpha blockers?
Resistant hypertension
61
What drug should not be prescribed with alpha blockers?
Beta-blockers - they inhibit reflex tachycardia needed in response to vasodilation
62
What is the mechanism of finasteride?
Inhibits conversion of testosterone to active dihydrotestosterone (which normally stimulates prostatic growth)
Therefore it reduces the side of the prostate gland, but it can take months
63
What are the side effects of 5-alpha-reductase inhibitors? Who should you not give it to?
```
Impotence
Reduced libido
Gynaecomastia
Hair growth - used off license for treatment of male pattern baldness
Breast cancer
```
Pregnant women must avoid as it causes abnormal development of external genitalia
64
What surgical treatments can men with BPH have?
Transurethral resection of prostate
Transurethral incision of prostate - relieves pressure on urethra
Transurethral laser-induced prostatectomy
Retropubic prostatectomy - open operation for v large prostates
65
What is the commonest male malignancy?
Prostate carcinoma - 1/4 of male cancers. 80% of over 80s
66
What are the main risk factors for prostatic carcinoma?
Family history
Increased testosterone
African and Caribbean ethnicity
67
What type of carcinoma are most prostatic carcinomas?
Adenocarcinomas of peripheral zone
68
Where do prostatic carcinomas mostly metastasise to?
Bone
| Lymph nodes
69
What would DRE of a prostatic carcinoma feel like?
Hard, irregular, nodular prostate that is immobile
| Potentially palpable seminal vesicles
70
What staging score is used for prostate cancer?
Gleason score - pathologist looks at prostatic tissue under microscope and grades the morphology of the cells from 1 to 5
1. Normal tissue, well differentiated cells that are small and uniform
2. Increased stroma between glands
3. Distinctly infiltrative margins, moderately differentiated cells
4. Irregular masses of neoplastic glands. Poorly differentiated
5. Occasional gland formation seen. Very poorly differentiated
71
What is the main surgical treatment for prostatic carcinoma?
Radical prostatectomy
72
What is the most common bladder cancer?
Transitional cell carcinoma (90%)
| Squamous cell carcinoma (10%)
73
What are the main risk factors for bladder cancer?
```
Smoking - 50%
Aromatic amines (rubber industry)
Chronic cystitis
Schistosomiasis (SCC)
Pelvic irradiation
```
74
What is the presentation for bladder cancer?
Painless haematuria - treat as malignancy until proven otherwise
Recurrent UTIs
Voiding irritability
Weight loss
75
What are the diagnostic investigation for bladder cancer?
Cystoscopy with biopsy
| CT urogram
76
What would urinalysis show in bladder cancer?
Sterile pyuria
| Haematuria
77
How do you treat transitional cell carcinoma of bladder?
T1 - transurethral resection of bladder tumour +/- chemotherapy +/- intravesical BCG immunotherapy
T2/T3 - radical cystectomy (or radiotherapy if > 70 years)
T4 - palliative care, chronic catheterisation
78
Where do renal cell carcinomas arise from?
Epithelial cells of proximal convoluted tubules in the renal cortex
79
What is the triad for renal cell carcinoma presentation?
Haematuria - most common presenting symptom
Loin pain
Loin mass
80
What are the most common sites of metastases from renal cell carcinoma?
Lungs - cannon ball mets
Bone
Liver
81
What is the best initial investigation for suspected renal cell carcinoma?
CT abdo with contrast - best initial test
Shows renal lesion with thickened irregular walls, variable enhancement and calcification
82
What is the treatment for renal cell carcinoma?
Radical nephrectomy
| It is generally chemo and radio resistant
83
Where do urinary tract calculi usually deposit?
1. Pelviureteric junction
2. Pelvic brim
3. Vesicoureteric junction
84
What are the different types of calculi in order of how common they are?
1. Calcium oxalate (75%)
2. Struvite - magnesium ammonium phosphate (15%)
3. Urate
4. Hydroxyapatite (usually do to UTI)
5. Cysteine (usually due to renal tubular defect)
85
What metabolic disorders predispose you to urinary tract calculi?
Hypercalcaemia (hyperthyroidism, hyperparathyroidism, neoplasia, sarcoidosis, lithium)
Renal tubular acidosis
Gout
Cysteinuria
86
Which foods are high in oxalate levels and hence increase your risk of kidney stones?
```
Chocolate
Tea
Rhubarb
Strawberries
Nuts
Spinach
```
87
What medications precipitate renal stones?
```
Diuretics
Antacids
Corticosteroids
Theophylline
Aspirin
Allopurinol
Vitamin C + D
```
88
What is the appearance of each type of calculus on X-ray?
1. Calcium oxalate - silky, radio-opaque
2. Struvite - large, staghorn, radio-opaque
3. Urate - smooth, brown, radiolucent
4. Hydroxyapatite - smooth, large, radio-opaque
5. Cysteine - yellow, crystal, semi-opaque
89
How do renal stones present?
1. Pain - fast onset of excruciating colicky loin to groin pain causing them to roll around (if it was peritonitis they would stay still); N&V
2. Infection - fevers, rigors
3. Haematuria
4. Proteinuria
5. Sterile pyuria
6. Anuria
90
What signs might you find on examination of renal stones?
Renal angle tenderness - especially on percussion if there is retroperitoneal inflammation
Reduced bowel sounds (as in any severe pain)
Severe pain in testis but not tender on palpation
91
What is the investigation choice for imaging stones?
Non-contrast CT (99% visible, whilst excluding other causes of acute abdomen)
92
How do you treat stones <5mm?
Increase fluid intake - 90% pass spontaneously
Analgesia - diclofenac IV/PR
Antibiotics - penicillin/gentamicin if infection
93
How do you treat stones >5mm?
Medical expulsive therapy
- Nifedipine (calcium-channel blocker) or tamsulosin (alpha blocker)
- Extracorporeal shockwave lithotripsy (ultrasound waves shatter the stone)
- Uteroscopy
Percutaneous nephrolithotomy = keyhole surgery to remove stones if complex
94
What are the most common common cause of urinary retention?
13:1 M>F
Mechanical obstruction
- BPH = most common
- Urethral strictures
- Calculi
- Cystocele
- Constipation
- Masses
- UTI (in pt with predisposing causes)
Functional obstruction
- Neurological causes e.g. spinal cord compression, cauda equina
- Medications
- Post-operative
95
What is a cystocele?
Prolapsed bladder
Bulging of bladder into the vagina
96
What medications can cause urinary retention?
```
Anticholinergics
Tricyclic antidepressants
Antihistamines
Opioids
Benzodiazepine
Sympathomimetics
```
97
How does acute urinary retention present? How does this compare to chronic?
Inability to pass urine
Lower abdo discomfort
Pain and distress
vs chronic which is usually painless
98
Why is PSA not appropriate in acute urinary retenion?
Usually elevated
99
What volume on a bladder US confirms urinary retention?
Acute urinary retention = >400ml
Chronic urinary retention = post void volume of > 300ml
100
What is the management of acute urinary retention?
Urinary catheterisation and volume drained in 15 minutes measured
<200 ml = no urinary retention
>300 ml = leave catheter in place
101
Why is metabolic acidosis associated with hyperkalaemia?
Acidosis causes potassium to move from cells to extracellular compartment in exchange for hydrogen ions
102
List some causes of hyperkalaemia
Impaired excretion of potassium:
- AKI and CKD
- Addison's disease
- Hypoaldosteronism
- Drugs that impair excretion
Increased release of potassium from cells:
- Metabolic acidosis
- Rhabdomyolysis
- Massive haemolysis
- Tumour lysis syndrome
- Insulin deficiency
- Drugs that increase release
103
Which medications can cause hyperkalaemia?
```
Drugs that impair excretion:
- Potassium sparing diuretics (e.g. spironolactone)
- ACE inhibitors and ARBs
- Ciclosporin
- High dose trimethoprim
- NSAIDs
- Heparins (inhibit aldosterone release)
Heparin
```
Drugs that increase release:
- Beta blockers in renal failure pt
- Digoxin toxicity
104
Why does it make sense that beta blockers can cause hyperkalaemia? (ie opposite drug)
Beta blockers interfere with potassium transport into cells
Salbutamol (beta agonist) can be used as an emergency treatment
105
Causes of benign proteinuria?
Benign = isolated benign proteinuria <3.5g/day
Orthostatic
Transient eg heavy exertion / stress, fever, seizures, exposure to cold temperatures
Woman can present with mild proteinuria due to vaginal discharge
106
What is orthostatic proteinura?
A type of benign proteinuria characterized by increased protein excretion only in the upright position
Typically presents with isolated proteinuria during the day and normal protein excretion at night when the individual is in a recumbent position
107
In which population does orthostatic proteinuria usually present? Does it need treatment?
Obese adolescents
No treatment needed
108
What is the most common cause of inherited kidney disease?
Autosomal dominant polycystic kidney disease (ADPKD)
109
What are the two types of adult polycystic kidney disease?
1) Autosomal recessive
- Short life expectancy that rarely surpasses childhood
2) Autosomal dominant
- Associated with a reduced life expectancy in adulthood
110
Which Chr are involved in PKD?
Autosomal recessive = Chr 6
Audosomal dominant = Chr 16 (85%) or 4 (15%)
111
How does autosomal recessive adult polycystic kidney disease present?
Chronic renal failure - haematuria, proteinuria
Protruding abdomen due to renal enlargement or hepatomegaly
Extra-renal manifestations
112
What extra-renal manifestations are associated with ARPKD?
Severe in utero renal impairment leads to maternal oligohydramnios (baby not making urine so insufficient amniotic fluid) this leads to a series of abnormalities associated with oligohydramnios (known as Potter sequence)
Liver involvement - portal fibrosis leads to portal HTN and progressive liver failure
HTN (unknown cause) can lead to CHF
113
What are the deformities described by Potter sequence?
Craniofacial abnormalities
- Retrognathia (posteriorly placed mandible)
- Low set ears
- Flat nose
Clubbed feat
Pulmonary hypoplasia
114
How does autosomal dominant adult polycystic disease present?
```
Chronic renal failure
Flank / abdo pain
- Sharp pain implies cyst rupture
Recurrent UTIs
Extrarenal manifestations
```
115
What extrarenal manifestations are associated with ADPKD?
Hepatic cysts
Also cysts in pancreas, spleen, ovary and testicles
CV:
- Arterial HTN (morning headaches)
- Valvular defects, especially mitral valve prolapse
- LVH
Diverticulosis
Abdo / inguinal hernias
Cerebral berry aneurysms
116
What does examination of PKD show?
Palpable abdo masses that are not tender to touch
| Usually bilateral
117
How is PKD diagnosed?
Renal US (diagnostic if positive FH):
- 2 cysts, unilateral or bilateral, if <30yrs
- 2 cysts in both kidneys if 30-59yrs
- 4 cysts in both kidneys if >60yrs
CT
Renal function
IV pyelogram can be used to evaluate presence of obstruction
118
What is the management of PKD?
Prevent renal dysfunction:
- ACEi or ARB to HTN and to slow proteinuria
Tolvaptan
- Slows growth of cysts
```
Early treatment of UTIs
Fluids
Avoid toxins
May need haemodyalisis / transplant
- Portosystemic shunting of liver transplant in ARPDK with severe hepatic involvement
```
119
What can cause a urethral stricture?
Iatrogenic eg traumatic placement of an indwelling catheter
STI
Lichen sclerosus
Hypospadias
120
What can cause "Pseudohyperkalaemia" / artefact hyperkalaemia that you should be aware of when interpreting K+?
* Haemolysis (traumatic venepucture, prolonged tourniquet use, fist clenching)
* Delayed analysis (K+ leaks out out of red blood cells)
* Contamination with potassium EDTA anticoagulant in FBC bottles
* Thrombocytopenia (K+ leaks out of platelets during clotting)
121
What is the management of hyperkalaemia?
1. 10ml of 10% calcium gluconate (or chloride) over 10 mins - this is cardioprotective
2. IV insulin (10u soluble insulin) in 25g glucose (50mL of 50% or 125ml of 20% glucose) - insulin causes intracellular K+ shift and glucose to required to prevent hypoglycaemia
3. Nebulised salbutamol - also causes intracellular K+ shift
122
Other than eGFR what else can be used to diagnose CKD?
Urine albumin:creatinine ratio > 30
123
What factors can affect eGFR and so are examples of when you shouldn't rely on their eGFR reading?
* Very high protein diet
* Extremes of body size
* High or low muscle mass e.g. MS
* Severe liver disease
* Drugs – particularly fenofibrate and trimethoprim
* Pregnancy
* Patient is on dialysis
124
What are some non-CKD factors that can cause albuminuria?
* UTI
* High dietary protein intake
* Heart failure
* Acute febrile illness
* Heavy exercise within the last 24 hours
* Menstruation
* Genital infection
* Drugs – especially NSAIDs
125
When should you consider renal replacement therapy for CKD patients?
Refer patients to a renal specialist when eGFR < 30 to consider their options
eGFR < 10 OR eGFR < 15 in diabetes
126
What are the different options of renal replacement therapy?
Peritoneal dialysis – can be performed either in a hospital environment, or at home
Haemodialysis
Renal transplant
127
What can cause a raised PSA?
```
Prostatic carcinoma
Age
UTI
Prostatitis
BPH
Ejaculation
DRE
Vigorous exercise
```
128
What kind of carcinoma are most prostatic carcinomas?
Adenocarciomas of the peripheral zone
129
How does prostate cancer present?
Prostate cancer may cause no signs or symptoms in its early stages
Prostate cancer that's more advanced may cause signs and symptoms such as:
- Problems urinating
- Poor stream of urine
- Blood in semen
- Discomfort in the pelvic area
- Bone pain due to metastases
- Erectile dysfunction
130
What is the appropriate management for asymptomatic patients with prostate cancer?
Watchful waiting - no active management, just repeat PSA and DRE at regular intervals
131
Which prostate cancer patients is a radical prostatectomy appropriate for?
Appropriate for patients with no evidence of metastatic disease but are symptomatic and have >10 years life expectancy
132
What type of management is suitable for elderly patients with symptomatic prostate cancer?
Radiotherapy
133
What are the two different types of radiotherapy for prostate cancer? What is the benefit of one over the other?
External beam radiotherapy (high energy Xrays from outside body) - risk of impotence and proctitis
Brachytherapy (radioactive seeds planted in prostate) - less risk of impotence and bladder problems
134
What is the main treatment for non-localised prostate cancer? Give examples
Androgen suppression - main treatment for non-localised disease
- Androgen suppression drugs e.g. bicalutamide
- LH-releasing hormone antagonists (aka GnRH analogues) e.g. goserelin, leuprorelin, triptorelin
- Castration - offer to all men with metastatic disease
135
What genetic disease is associated with renal cell carcinoma?
Von Hippel-Lindau disease - deletion of short arm of chromosome 3
136
What paraneoplastic syndromes can occur in renal cell carcinoma?
* Hypertension due to release of renin
* Hypercalcaemia due to release of PTH-related protein
* Polycythaemia due to erythropoietin release
* Secondary hypercortisolism due to ACTH release
* Stauffer's syndrome - non-metastatic hepatic dysfunction with raised ALP and clotting abnormalities
* Limbic encephalitis - memory loss, psychosis, depression
137
When would you do an ultrasound in a UTI?
Ultrasound scan
- Men with upper UTI
- Persistent haematuria
- Recurrent UTI
138
How are diabetic patients screened for diabetic nephropathy?
All patients should be screened annually using urinary albumin:creatinine ratio (ACR)
Should be an early morning specimen
ACR > 2.5 = microalbuminuria
139
What are some causes of unilateral hydronephrosis?
PACT
* Pelvic-ureteric obstruction
* Aberrant (abnormal) renal vessels
* Calculi
* Tumours or renal pelvis
140
What are some causes of bilateral hydronephrosis?
```
SUPER
• Stenosis of the urethra
• Urethral valve
• Prostatic enlargement
• Extensive bladder tumour
• Retro-peritoneal fibrosis
```
