Renal & Urology Flashcards

Question

What are Arteriovenous fistulas How are they made Time to develop Potential complications

Answer 1

Arteriovenous fistulas are direct connections between arteries and veins. They may occur pathologically but are generally formed surgically to allow access for haemodialysis. They are now regarded as the preferred method of access for haemodialysis due to the lower rates of complications. The time taken for an arteriovenous fistula to develop is 6 to 8 weeks. ``` Potential complications include: Infection Thrombosis May be detected by the absence of a bruit Stenosis May present with acute limb pain Steal syndrome ```

Answer 2

Causes of a normal anion gap or hyperchloraemic metabolic acidosis ``` GI bicarbonate loss: diarrhoea, ureterosigmoidostomy, fistula Renal tubular acidosis Drugs: e.g. acetazolamide ammonium chloride injection Addison's disease ``` A normal anion gap is 8-14 mmol/L Calculation: (sodium + potassium) - (bicarbonate + chloride)

Answer 3

Causes of a raised anion gap metabolic acidosis ``` Lactate: shock, hypoxia Ketones: diabetic ketoacidosis, alcohol Urate: renal failure Acid poisoning: salicylates, methanol 5-oxoproline: chronic paracetamol use ``` A normal anion gap is 8-14 mmol/L

Answer 4

Rare condition associated with both pulmonary haemorrhage and rapidly progressive glomerulonephritis. It is caused by anti-glomerular basement membrane (anti-GBM) antibodies against type IV collagen. Goodpasture's syndrome is more common in men (sex ratio 2:1) and has a bimodal age distribution (peaks in 20-30 and 60-70 age bracket). It is associated with HLA DR2. Features pulmonary haemorrhage followed by rapidly progressive glomerulonephritis ``` Factors which increase the likelihood of pulmonary haemorrhage smoking lower respiratory tract infection pulmonary oedema inhalation of hydrocarbons young males ``` Investigations renal biopsy: linear IgG deposits along the basement membrane raised transfer factor secondary to pulmonary haemorrhages Management plasma exchange (plasmapheresis) steroids cyclophosphamide

Answer 5

Aged >= 45 years AND: unexplained visible haematuria without urinary tract infection, or visible haematuria that persists or recurs after successful treatment of urinary tract infection Aged >= 60 years AND have unexplained nonvisible haematuria and either dysuria or a raised white cell count on a blood test

Answer 6

The maximum rate of potassium infusion via a peripheral line is 10 mmol/hour on a standard ward. rates above 20 mmol/hour require cardiac monitoring

Answer 7

``` Common (>1 in 10) diuretics, caffeine & alcohol diabetes mellitus lithium heart failure ``` Infrequent (1 in 100) hypercalcaemia hyperthyroidism Rare (1 in 1000) chronic renal failure primary polydipsia hypokalaemia ``` Very rare (<1 in 10 000) diabetes insipidus ```

Answer 8

Causes of transient or spurious non-visible haematuria urinary tract infection menstruation vigorous exercise (this normally settles after around 3 days) sexual intercourse Causes of persistent non-visible haematuria cancer (bladder, renal, prostate) stones benign prostatic hyperplasia prostatitis urethritis e.g. Chlamydia renal causes: IgA nephropathy, thin basement membrane disease Spurious causes - red/orange urine, where blood is not present on dipstick foods: beetroot, rhubarb drugs: rifampicin, doxorubicin

Answer 9

IV 0.9% sodium chloride at a rate of 1 mL/kg/hour for 12 hours pre- and post- procedure. There is also evidence to support the use of isotonic sodium bicarbonate

Answer 10

Screening all patients should be screened annually using urinary albumin:creatinine ratio (ACR) - should be an early morning specimen ACR > 2.5 = microalbuminuria in men, >3.5 in women ``` Management dietary protein restriction tight glycaemic control BP control: aim for < 130/80 mmHg benefits independent of blood pressure control have been demonstrated for ACE inhibitors (ACE-i) and angiotensin II receptor blockers (A2RB). Combinations of ACE-i and A2RB are not commonly used anymore following the ON-TARGET trial which showed worse outcomes for patients on dual blockade control dyslipidaemia e.g. Statins ```

Answer 11

Focal segmental glomerulosclerosis (FSGS) is a cause of nephrotic syndrome and chronic kidney disease. It generally presents in young adults. ``` Causes idiopathic secondary to other renal pathology e.g. IgA nephropathy, reflux nephropathy HIV heroin Alport's syndrome sickle-cell ``` Focal segmental glomerulosclerosis is noted for having a high recurrence rate in renal transplants. Investigations renal biopsy focal and segmental sclerosis and hyalinosis on light microscopy effacement of foot processes on electron microscopy Management steroids +/- immunosuppressants Prognosis untreated FSGS has a < 10% chance of spontaneous remission

Answer 12

Urgent referral (i.e. within 2 weeks) Aged >= 45 years AND: - unexplained visible haematuria without urinary tract infection, or - visible haematuria that persists or recurs after successful treatment of urinary tract infection Aged >= 60 years AND have unexplained nonvisible haematuria and either dysuria or a raised white cell count on a blood test Non-urgent referral Aged 60 >= 60 years with recurrent or persistent unexplained urinary tract infection Since the investigation (or not) of non-visible haematuria is such as a common dilemma a number of guidelines have been published. They generally agree with NICE guidance, of note: patients under the age of 40 years with normal renal function, no proteinuria and who are normotensive do not need to be referred and may be managed in primary care

Answer 13

Metabolic alkalosis may be caused by a loss of hydrogen ions or a gain of bicarbonate. It is due mainly to problems of the kidney or gastrointestinal tract ``` Causes vomiting / aspiration (e.g. peptic ulcer leading to pyloric stenos, nasogastric suction) diuretics liquorice, carbenoxolone hypokalaemia primary hyperaldosteronism Cushing's syndrome Bartter's syndrome congenital adrenal hyperplasia ```

Answer 14

Hyperacute acute rejection (minutes to hours) due to pre-existent antibodies against donor HLA type 1 antigens (a type II hypersensitivity reaction) rarely seen due to HLA matching Acute graft failure (< 6 months) usually due to mismatched HLA. Cell-mediated (cytotoxic T cells) other causes include cytomegalovirus infection may be reversible with steroids and immunosuppressants Causes of chronic graft failure (> 6 months) both antibody and cell mediated mechanisms cause fibrosis to the transplanted kidney (chronic allograft nephropathy) recurrence of original renal disease (MCGN > IgA > FSGS

Answer 15

The aim is to reduce phosphate and parathyroid hormone levels. Overview reduced dietary intake of phosphate is the first-line management phosphate binders vitamin D: alfacalcidol, calcitriol parathyroidectomy may be needed in some cases Phosphate binders Aluminium-based binders are less commonly used now Calcium-based binders - problems include hypercalcemia and vascular calcification Sevelamer - a non-calcium based binder that is now increasingly used binds to dietary phosphate and prevents its absorption also appears to have other beneficial effects including reducing uric acid levels and improving the lipid profiles of patients with chronic kidney disease

Answer 16

V v rare - aka don't worry about Most common in Far East and Africa Aetiology V VV rare if circumcised Pathology - Erythroplasia of Querat: Penilce CIS - SCC Presentation - Chronic fumigating ulcer - Bloody purulent discharge - 50% have inguinal nodes at presentation Management Medical - If early and no uretheral involvement. Radiotherapy and iridium wires Surgical - Amputation and lymph node dissection if late

Answer 17

Acute inflammation of the foreskin and glans. Associated with strep and staph infections. More common in diabetics. Often seen in young children with tight foreskins ℞: Antibiotics, circumcision, hygiene advice.

Answer 18

The foreskin occludes the meatus. In young boys this causes recurrent balanitis and ballooning, but time (+ trials of gentle retraction) may obviate the need for circumcision. In adulthood presents with painful intercourse, infection, ulceration, and is associated with BALANITIS XEROTICA OBLITERANS (thickening of foreskin and glans) Management <2: expectant, gentle retratction, steroid creams >2 Circumcision

Answer 19

Occurs when a tight foreskin is retracted and becomes irreplaceable, preventing venous return leading to OEDEMA and even ischaemia of the glans. Causes If foreskin is not replaced after catheterization. Masturbation Intercourse Surgery℞: Ask patient to squeeze glans. Try applying a 50% glucose-soaked swab (oedema may follow osmotic gradient). Ice packs and lidocaine gel may also help. May require aspiration/dorsal slit/circumcision.

Answer 20

Development abnormality of the position of the urethral opening Hypospadias: Opening on ventral surface Epispadias: Opening on dorsal surface

Answer 21

Fluid within the tunica vaginalis Causes 1) Primary (associated with a patent processus vaginalis, which typically resolves during the 1st year of life) 2) Secondary to testis tumour/trauma/infection. Primary hydroceles are more common, larger, and usually in younger men. Can resolve spontaneously ℞: Aspiration (may need repeating) or surgery: plicating the tunica vaginalis (Lord’s repair)/inverting the sac (Jaboulay’s repair). SurgeryIs the testis normal after aspiration? If any doubt, do us.

Answer 22

Blood within tunica vaginalis Trauma May need drainage or excision

Answer 23

Dilated veins of the pampniform plexus ``` Feels like a bag of worms in scrotum May be visible dilated veins Reduce in size lying down May be a dull ache May lead to oligospermia (REDUCED FERTILITY) ``` Pathology] 1) Primary: L sided commoner as L testicular v drains to Renal vein, whereas R drains to IVC 2) Left RCC has tracked down renal vein --> testicular vein obstruction Management - Scrotal support - Surgical: Clipping the testicular vein (open or lap)

Answer 24

Causes Chlamydia (eg if <35yrs); E. coli; mumps; N. gonorrhoeae; tb. Features: Sudden-onset tender swelling, dysuria, sweats/fever. May have secondary hydrocele Urethral discharge ``` Investigations Urine dip + MCS ( ‘1st catch’ urine sample) Blood: FBC, CRP Urethral swab AND STI SCREEN US: May be needed to exclude abscess ``` Complications: May lead to infertility Management Bed rest, analgesia, scrotal support, drainage of any abscess + If <35yrs; doxycycline 100mg/12h (covers chlamydia; treat sexual partners). If gonorrhoea suspected add ceftriaxone 500mg im stat. If >35yrs (mostly non-sti), associated uti is common so try ciprofloxacin 500mg/12h or ofloxacin 200mg/12h. Antibiotics should be used for 2–4wks.

Answer 25

Seminoma, 55% (30–65yrs); 1) Germ cell tumours = 95% - Pure seminoma - Non seminomas - Mixed = commonest NSGCT - Teratoma - Yolk sac - Choriocarcinoma 2) Sex cord Stromal - Leydig cell - Sertoli cell 3) Lymphoma/Leukaemia - NHL: Commonest malignant testicular mass >60y - ALL: Commonest malignant testicular mass <5y

Answer 26

Germ cell - divided into 1) Pure seminomas (40%) - Commonest single type - 30-40y - High betaHCG in 15% - High ALP in some - V radiosensitive 2) Non seminomas a) Mixed = commonest NSGCT b) Teratoma - arise from all 3 germ cell layes - common and benign in children - rare and malignant in adults - secrete beta hcg and/or AFT - Chemosensitive c) Yolk sac - commonest testicular tumour in children d) Choriocarcinoma - high high betahcg - Choriocarcinoma

Answer 27

Tumour markers - High AFP and HCG in 90% teratomas - High HCG in 15% seminomas - Normal AFP in pure seminomas Scrotal US = 1st line Staging - CX - CT DO NOT BIOPSY as --> seeding along needle tract Management - Radical orchidectomy (INGUINAL incision; occlude the spermatic cord before mobilization to ↓risk of intra-operative spread). Options are constantly updated (surgery, radiotherapy, chemotherapy). Seminomas are exquisitely radiosensitive. - Stage 1 seminomas: orchidectomy + radiotherapy cures ~95%. Do close follow-up to detect relapse. Cure of nsgct, even if metastases are present, is achieved by 3 cycles of BLeomycin + Etoposide + cisPlatin. Non-seminomas/Teratomas - Orchidectomy + chemo + para-aortic LN dissection 5yr survival >90% in all groups. Surgery Encourage regular self-examination (prevents late presentation).

Answer 28

1 No evidence of metastasis. 2 Infradiaphragmatic node involvement (spread via the para-aortic nodes not inguinal nodes). 3 Supradiaphragmatic node involvement. 4 Lung involvement (haematogenous).

Answer 29

Twist of the spermatic cord resulting in testicular ischaemia and necrosis. most common in males aged between 10 and 30 (peak incidence 13-15 years) Features Pain is usually severe and of sudden onset the pain may be referred to the lower abdomen nausea and vomiting may be present On examination, there is usually a swollen, tender testis retracted upwards. The skin may be reddened cremasteric reflex is lost elevation of the testis does not ease the pain (Prehn's sign) Management Treatment is with urgent surgical exploration If a torted testis is identified then both testis should be fixed as the condition of bell clapper testis is often bilateral.

Answer 30

Complete absence of the testis from the scrotum (anorchism is absence of both testes) Complications - Infertility 10x risk of malignancy (remains after surgery) Increased risk of torsion Associated with hernias or urinary tract abnormalities Management - Orchidopexy

Answer 31

Adenocarcinoma Peripheral zone of prostate Presentation - usually asymptomatic - Urinary: FUNHIPS - Systemic: wt loss, fatigue Examination - hard irregular prostate - loss of midline sulcus Diagnosis: - ↑psa (normal in 30% of small cancers); transrectal us & biopsy; bone scan; ct/mri. Staging: mri. Tumour grade—Gleason score. Gleason grading is from 1 to 5, with 5 being the highest grade, and carrying the poorest prognosis. Gleason grades are decided by analysing histology from two separate areas of tumour specimen, and adding them to get the total Gleason score for the tumour, from 2 to 10. Scores 8–10 suggest an aggressive tumour; 5–7: intermediate; 2–4: indolent. Treatment: • Radical prostatectomy if <70yrs gives excellent disease-free survival (laparoscopic surgery is as good). The role of adjuvant hormonal therapy is being explored. - ED common * Radical radiotherapy (± neoadjuvant & adjuvant hormonal therapy) is an alternative curative option that compares favourably with surgery (no rcts). It may be delivered as external beam or brachytherapy. * Hormone therapy alone temporarily delays tumour progression but refractory disease eventually develops. Consider in elderly, unfit patients with high-risk disease. * Active surveillance—particularly if >70yrs and low-risk Metastatic disease: • Hormonal drugs may give benefit for 1–2yrs. LHRH agonists, eg 12-weekly GOSERELIN (10.8mg sc) first stimulate, then inhibit pituitary gonadotrophin. nb: risks tumour ‘flare’ when first used—start anti-androgen, eg CYTOPROTERON ACETATE, or flutamide in susceptible patients. The lhrh antagonist degarelix is also used in advanced disease.

Answer 32

Causes of raised PSA Benign prostatic hyperplasia (BPH) NICE advise that, as PSA levels may be increased, testing should not be done within at least: 6 weeks of a prostate biopsy 4 weeks following a proven urinary infection/prostatitis 1 week of digital rectal examination 48 hours of vigorous exercise 48 hours of ejaculation

Answer 33

Benign prostatic hyperplasia (BPH) is a common condition seen in older men. Risk factors age: around 50% of 50-year-old men will have evidence of BPH and 30% will have symptoms. Around 80% of 80-year-old men have evidence of BPH ethnicity: black > white > Asian ``` BPH typically presents with lower urinary tract symptoms (LUTS), which may be categorised into: voiding symptoms (obstructive): weak or intermittent urinary flow, straining, hesitancy, terminal dribbling and incomplete emptying storage symptoms (irritative) urgency, frequency, urgency incontinence and nocturia post-micturition: dribbling ``` Complications: UTI (secondary to stasis), Bladder stones (secondary to stasis), retention, obstructive uropathy Management options Medication: alpha-1 antagonists, 5 alpha-reductase inhibitors. Surgery: transurethral resection of prostate (TURP = old), Enucleation of the prostate (HoLEP = laser ablation)

Answer 34

Alpha-1 antagonists e.g. tamsulosin, alfuzosin MOA: Decrease smooth muscle tone (prostate and bladder) (1st like) improve symptoms in around 70% of men SE: dizziness, postural hypotension, dry mouth, depression 5 alpha-reductase inhibitors e.g. finasteride MOA: Block the conversion of testosterone to dihydrotestosterone (DHT), which is known to induce BPH unlike alpha-1 antagonists causes a reduction in prostate volume and hence may slow disease progression. This however takes time and symptoms may not improve for 6 months. They may also decrease PSA concentrations by up to 50% SE: erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia ``` TURP 14% become impotent ~10% ED <10% Incontinence Beware bleeding, clot retention, and post turp syndrome: absorption of washout causing cns & cvs disturbance. ~12% need redoing within 8yrs. ``` HoLEP = Enucleation of the prostate

Answer 35

90% TCC SCC associated with schistosomiasis ``` Risk factors Smoking Amine exposure Rubber, Textiles, Leather, printing Previous renal TCC Chronic cystitis Schistosomiadid Pelvic irradiation ``` Presentation - Painless Haematuria - Voiding irritability - Recurrent UTIs - Renetnrion and obstructive renal failure Spread - Bones - Liver - Lungs

Answer 36

``` Tis: Carcinoma in situ Ta: Confined to epithelium T1: Tumour in submucosa T2: Deep uscle involved (muscular propria) T3: In the perivesical fat T4: In the perivesical fat ``` Management T1: Intravesical BCG - once a week for 6 weeks (close cystoscopic surveillance after 6 weeks of rest after the course) - Ultimately may need radical cystectomy ( + ileal conduit) T2-3 Radical cystectomy = gold standard - with ileal conduit T4 Usually palliative chemo/radiotherapy

Answer 37

``` EPO --> Polycythaemia PTHrP --> High Calcium Renin --> HTN ACTH --> Cushings syndrome Amyloidosis ``` Spread - Bone - Liver - Lung Presentation - 50% incidental - Triad: Haematuria, Loin pain, Loin mass - Systemic - Clot retention - Invasion of L vein --> L varicocele - Cannon ball mets --> SOB Staging - CT T1: Tumour confined to kidney <7 cm T2: limited to kidney >7 cm T3: Tumour extension into the renal/ IVC or Gerota's fascia (perinephric fat) T4: Spread to lymph nodes or other organs e.g. ipsilateral adrenal gland or invades beyond Gerota's fascia

Answer 38

``` Bilateral = Super Stenosis of the urethra Urethral valve Prostatic enlargement Extensive bladder tumour Retro-peritoneal fibrosis ``` ``` Unilateral = PACT Pelvic-ureteric obstruction (congenital or acquired) Aberrant renal vessels Calculi Tumours of renal pelvis ``` Investigation - Ultrasound - first-line: identifies presence of hydronephrosis and can assess the kidneys - IVU- assess the position of the obstruction - Antegrade or retrograde pyelography- allows treatment - if suspect renal colic: CT scan (majority of stones are detected this way)

Answer 39

The presence of protein effectively rules out a pre-renal or post-renal cause and the lack of nitrites rules out infection. = Both are intrinsic renal cause When trying to differentiate between the two intrinsic renal causes, it helps to understand how each of them affect the kidney. - Acute interstitial nephritis is an inflammatory process so there is a higher white cell content in the urine, while acute tubular necrosis is not so the urine has no cellular component. NB: A glomerulonephritis would induce a nephritic syndrome with blood present in the urine.

Answer 40

Damage to tubular cells due to prolonged ischaemia or toxins = MUDDY BROWN CASTS Kidneys can no longer concentrate urine or retain sodium - = urine osmolality low = urine sodium high Rarer causes = acute glomerulonephritis, acute interstitial nephritis

Answer 41

1) Goodpastures (+ haemoptysis) 2) GPA (c-anca, saddle nose aka Werner's) 3) SLE, microscopic polyarteritis

Answer 42

Nausea, vomiting, tinnitus and headache. In more severe overdoses, hyperventilation and a secondary respiratory alkalosis develops. Over ~24 hours, this progresses to a metabolic acidosis and hypokalaemia, both of which indicate a severe overdose. Confusion, coma, seizures, hypoglycaemia and fever may also develop. Management If overdoses are recent, administer activated charcoal. Management of minor overdoses is otherwise largely supportive. However, more significant overdoses may require alkalinisation with IV sodium bicarbonate in order to maintain blood pH at 7.5-8.0 , and enhance salicylate excretion.

Answer 43

Features Bilateral symptoms conjunctival erythema, conjunctival swelling (chemosis) Itch is prominent the eyelids may also be swollen May be a history of atopy May be seasonal (due to pollen) or perennial (due to dust mite, washing powder or other allergens Management of allergic conjunctivitis first-line: topical or systemic antihistamines e.g. emadestine second-line: topical mast-cell stabilisers, e.g. Sodium cromoglicate and nedocromil

Answer 44

CAG trinucleotide repeat | Genetic anticipation

Renal & Urology Flashcards

(68 cards)