Urinary Flashcards
1
Q
What drugs have a narrow therapeutic index?
A
Gentamicin renal/ototoxicity
Digoxin
Lithium
Tacrolimus - renal/CNS toxcity
2
Q
How are drugs nephrotoxic?
A
Water/sodium reabsorbed after filtered
Concentration goes up
Starts to damage nephron
3
Q
How do you avoid damage with drugs?
A
REDUCE DOSAGE
Increase dose interval
TDM Monitor blood levels for toxic drugs like gentamicin, lithium, digoxin, vancomycin
4
Q
What does renal impairment lead to?
A
Increase half-life of drugs
Build up of drugs
Decrease in protein binding, more free drug available
Increased sensitivity to pharmacological action
Increased sensitivity to toxicity and ADRs
5
Q
How should you prescribe drugs if patient has renal failure?
A
Use drugs totally metabolised by liver
Reduce dose with longer dosage periods
6
Q
What drugs induce renal failure?
A
Water and electrolyte abnormalities diuretics, laxatives, lithium, NSAIDs Increased catabolism Steroids, tertracyclines Vascular occlusion Oestrogens/ OCP
7
Q
What drugs can cause acute tubular necrosis?
A
aminoglycoside antibiotics,
amphotericin B,
cisplatin (causes renal failure in up to 25% of patients after a single dose), radiocontrast agents
statin drugs given in combination with immunosuppressive agents such as cyclosporin
8
Q
When does incontinence occur in men?
A
Intrinsic urethral sphincter well developed in men, poor in women
Incontinence in men when prostate removed
Poor pelvic floor muscles
9
Q
What is oliguria?
A
Low urine output
Less than 0.5ml/kg/hour
10
Q
What is anuria?
A
No urine output
11
Q
What is polyuria?
A
Urine output greater than 3l/day
12
Q
What is nocturia?
A
Waking up at night at least one time to go to the toilet
13
Q
What is nocturnal polyuria?
A
Nocturnal urine output greater than a 1/3 of total urine output
14
Q
What is RIFLE?
A
Pneumonic for kidney disease: Risk Injury Failure Loss of function End stage kidney disease
15
Q
What is the Risk phase of RIFLE?
A
Risk - Increase in serum creatinine level (1.5x) or decrease in GFR by 25%, or UO <0.5 mL/kg/h for 6 hours
16
Q
What is the injury stage of rifle?
A
Injury - Increase in serum creatinine level (2.0x) or decrease in GFR by 50%, or UO <0.5 mL/kg/h for 12 hours function >3 months
17
Q
What is the failure stage of RIFLE?
A
Failure - Increase in serum creatinine level (3.0x), or decrease in GFR by 75%, or serum creatinine level >355μmol/L with acute increase of >44μmol/L; or UO <0.3 mL/kg/h for 24 hours, or anuria for 12 hours
18
Q
What is the loss phase of RIFLE?
A
Loss - Persistent ARF or complete loss of kidney function >4 weeks
19
Q
What is the end stage of RIFLE?
A
End-stage kidney disease - complete loss of kidney
20
Q
What are the three types of haematuria?
A
Microscopic
Visible
Dipstick
21
Q
How does chronic renal failure present?
A
Asymptomatic (found on blood and urine testing) Tiredness Anaemia Oedema High blood pressure Bone pain due to renal bone disease
22
Q
How does advanced chronic renal failure present?
A
Pruritus Nausea/vomiting Dyspnoea Pericarditis Neuropathy Coma (untreated advanced renal failure)
23
Q
How do ureteric diseaes present?
A
Pain (eg. renal colic) Pyrexia Haematuria Palpable mass (ie. hydronephrosis) Renal failure (only if bilateral obstruction or single functioning kidney)
24
Q
How do bladder diseases present?
A
Pain (suprapubic) Pyrexia Haematuria Lower urinary tract symptoms (LUTS) Recurrent UTIs Chronic urinary retention (due to bladder underactivity) Urinary leak from vagina (i.e. vesico-vaginal fistula) Pneumaturia (i.e. colo-vesical fistula)
25
What are the types of lower urinary tract symptoms?
Storage
Voiding
Incontinence
26
What are storage LUTS?
frequency,
nocturia,
urgency,
urge incontinence
27
What are voiding LUTS?
poor flow,
intermittency,
terminal dribbling
28
What are incontinence LUTS?
```
stress,
urge,
mixed,
overflow,
neurogenic,
dribbling
```
29
What is acute urinary retention?
Painful inability to void with palpable + percussible bladder
Treat with catheterisation
30
What are the complications of acute urinary retention?
```
UTI
Haematuria
Diuresis
Renal failure
Elctrolyte disturbances
```
31
What are the complications of chronic urinary retention?
UTI,
post-decompression haematuria,
pathological diuresis,
electrolyte abnormalities
>(hyponatraemia, hyperkalaemia, metabolic acidosis),
persistent renal dysfunction due to acute tubular necrosis
32
What is chronic urinary retention?
```
painless, palpable and percussible bladder after voiding
Able to void but residual volume
Immediate treatment is catherisation
Manage with IV fluids
Can give long term catheter
```
33
What effects creatine?
```
Muscle mass
Age
Ethnicity
Gender
Weight
```
34
What is chronic kidney disease?
Chronic kidney disease (CKD) is defined by either the presence of kidney damage (abnormal blood, urine or x-ray findings) or GFR<60 ml/min/1.73m2 that is present for ≥3 months
35
How can you test GFR?
Inulin clearance
Isotope GFR
24 hr urine collection + blood test
GFR estimating equations
36
What is the GFR of the kidney diseases?
| Stage 1, 2, 3a, 3b, 4, 5
```
Stage 1: >90
Stage 2: 60-89
Stage 3a: 45-59
Stage 3b: 30-44
Stage 4: 15-29
Stage 5: <15
```
37
What do the different chronic kidney diseases mean?
Stage 1: Kidney damage with normal/high GFR
Stage 2: Kidney damage with mild reduction
Stage 3a/b: Moderately impaired
Stage 4: Severely impaired
Stage 5: Advanced disease
38
What investigations should you do into kidney disease - what are you looking for?
Blood count/film - haemolytic uraemic syndrome
Serum/urine electrophoresis - myeloma
Urine protein/creatinine ratio - intrinisc renal disease
CK - rhabdomyloysis
Anti-GBM - anti-gbm disease
ANCA - ANCA associated vasculitis
39
How do you manage kidney disease?
BP control
Proteinuria control
Reverse contributing factors
Lipid lowering
40
What are the complications of chronic kidney disease?
```
Metabolic acidosis
Anaemia
Bone disease
Low activation of Vit D
Phosphate control + PTH
Cardiovascular disease
```
41
What are the features of metabolic acidosis?
General symtpoms, worsens hyperkalaemia
Exacerbates renal bone disease
Treat with oral Na bicarbonate
42
What is glomerulonephritis?
Inflammatory disease of kidney
| Presents with proteinuria, renal failure + hypertentsion
43
What are the types of glomerulanephritis?
```
Non-proliferative
Proliferative
>Diffuse proliferative - post infective
>Focal preliferative (IgA)
>Focal necrotising
>Membrano-proliferative
```
44
What is non-proliferative glomerularnephritis?
Glomeruli look normal or have areas of scarring. They have normal numbers of cells
Tubules and interstitium may be damaged
45
What is proliferative glomerularnephritis?
Excessive cellsinside glomeruli
46
What is diffuse proliferative (post infective) nephritis?
Follows 10-21 days after infection, typically of throat/skin
| Most commonly with streptococci
47
What is acute nephritis, how does it present?
```
Fluid retention with oedema
Normal serum albumin
Little proteinuria
Hypertension
Renal impairment
Typical of post-infective glomerulonephritis
```
48
What is IgA nephropathy?
```
Commonest cause of glomerulonephritis
Typically occurs in the young
Presents with macroscopic haematuria
Provoked by intercurrent infection
Usually not hypertensive
Laboratory tests reflect renal function
No characteristic serology
Diagnosed by renal biopsy
```
49
How do you treat IgA nephropathy?
ACEI/other hypotensives
50
How many people with IgA nephropathy go on to get renal failure?
25% go on to form renal failure
51
What is crescentic glomerulonephritis?
Rapidly progressive glomeulonephritis
Medical emergency
Occurs in three settings
>Prescence of anti-glomerular basement membrane antibodies
>Associated with systemic vasculitis
>Complication of other types of glomerulonephritis
52
What is good pasture's disease?
rare disease caused by autoimmunity to glomerular basement membrane (anti-GBM)
presents as nephritis with or without lung haemorrhage
diagnosed with anti-GBM antibodies in serum/kidney
>A cause of crescnetic glomerulonephritis
53
What is non-proliferative glomerulonephritis?
minimal change
| focal membranous nephropathy
54
What is nephrotic syndrome?
clinical triad of
>pitting oedema
>proteinuria
>hypoalbuminaemia
Also has hyperlipidaemia
hyper coagulable state
increased risk of infection
55
What are the differentials to nephrotic syndrome?
Congestive heart failure
| Hepatic disease
56
What is minimal change glomerulanephritis?
commonest in children
sudden onset of oedema
complete loss of proteinuria with steroids
57
What are the complications of minimal change glomerulonephritis?
bacterial infection
| Thrombosis
58
How do you treat minimal change glomerulonephritis?
Prednisolone - for maximum of 8 weeks
59
What is focal glomerulonephritis?
```
Severe nephrotic syndrome
very disabling
at best incomplete response to steroids
progresses to renal failure over 2 to 3 years
it can recur in renal transplants
```
60
How do you treat focal glomerulonephritis?
treat with steroids and continue if clinically useful
try cyclosporine if steroids fail
non-specific drugs to reduce proteinuria (ACEI)
non-specific treatment for nephrotic oedema
61
What are the features of membranous glomerulonephritis?
commonest cause in adults
| half isolated half with other diseases
62
What is the management for membranous glomerulonephritis?
immunosuppression for those with deteriorating renal function
prednisolone and chrorambucil for six months
can recurring renal transplants
prognosis is generally good
63
What are the clinica features of CKD?
Until CKD stage 4 or 5 the patient may be asymtomatic
The syndrome of advanced CKD is called uraemia
Uraemic symptoms can involve almost every organ system but the earliest and cardinal symptom is malaise and fatigue
64
What are the types of renal replacement?
Haemodialysis
Peritoneal dialysis
>Continous
>Intermittent
Renal transplant
65
What are the types of access for haemodyalysis?
Arteriovenous fistula
AV prosthetic graft
Tunnelled venous catheter
Temporary venous catheter
66
What are the restrictions for dialysis?
```
Fluid restriction
>Dictated by residual urine output
>Interdialytic weight gain
Dietary restriction
>Potassium
>Sodium
>Phosphate
```
67
What are the restrictions on dialysis for fluid?
Haemodialysis
>Usually restricted to 500-800 ml/24 hours
>intake allowed = urine output +insensible loss
Peritoneal dialysis
>Usually more liberal intake as continuous ultrafiltration is often achieved
68
What are the complications of haemodialysis?
```
Clotting of vascular access
Hypotension and cramps
Cardiovascular problems
Heparin related problems
Allergic reactions to dialysers and tubing
Catastrophic dialysis accidents (rare)
```
69
What are the complications of peritoneal dialysis?
```
Peritonitis
Exit site infection
Tunnel infection
Ultrafiltration problems
Abdominal wall herniae
```
70
What are the types of acute kidney injury?
Pre-renal - blood flow
Renal - damage to renal parenchyma
Post-renal - obstruction to urine exit
71
What causes pre-renal injury?
Reduces circulatory volume
Arterial occlusion
Vasomotor
72
What causes renal injury?
```
Acute tubular necrosis
>Ischaemia
>Toxic
Acute interstitial nephritis
Acute glomerulonephritis
Intra renal vascular obstruction
>Vasculitis
>Thrombocitic microangiopathy
```
73
What causes post-renal injury?
Obstruction
>Intraluminal
>Intramural
>Extramural
74
What are the risk factors for radiocontrast necropathy?
```
AKI following administrated iodine contrast agent
Diabetes mellitus
Renovascular disease
Impaired renal function
Paraprotein
High volume of radiocontrast
```
75
What are teh clinical features of myeloma of the kidneys?
```
Proliferation of plasma cells producing excess of immunoglobulin + light chains
Anaemia
Back pain
Weight loss
Fractures
Infections
Cord compression
Markedly elevated ESR
Hypercalcaemia
```
76
What are the consequences of an AKI?
```
Acidosis
Electrolyte disturbance
Intoxication
Overload
Uraemic complications
```
77
How do you treat a AKI?
Fluid balance
Optimise BP
Stop nephrotoxic drugs
Treat sepsis
78
What are the ECG changes of a AKI?
Peaked T waves
>Usually earliest sign of hyperkalaemia
P wave widens + flattens
PR lengthens
P waves then disappear
79
How do you treat hyperkalaemia?
```
Stabilise
>Calcium gluconate
Shift
>Salbutamol
>Inslin dextrose
Remove
>Diuresis
>Dialysis
>Anion exchange resins
```
80
What are the benign diseaes of the prostate?
```
Benign prostatic enlargement (BPE)
Benign prostatic hyperplasia (BPH)
Benign prostatic obstruction (BPO)
Bladder outflow obstruction (BOO)
Lower urinary tract symptoms (LUTS)
```
81
What is benign prostatic hyperplasia?
Characterised by fibromuscular and glandular hyperplasia
Affects transition zone
Part of aging process in men
Can progress to bladder
82
What are the signs of prostatic hyperplasia?
```
Palpable abdo
Phimosis
Asses prostate size
Suspicious nodules?
Blood/UTI in urine?
```
83
How do you treat benign prostatic hyperplasia?
```
Medical therapy
>Alpha blockers
>5 alpha reductase inhibs
Surgical
>Remove
```
84
What are the effects of alpha blockers on the prostate?
Main treatment
Smooth muscle of bladder neck + prostate innervated
Relaxation + antagonise dynamic element
All types equally effective varying side effects
85
What are the effects of 5ARIs on the prostate?
Convert testosterone to dihydrotesterone
Reudce prostate size
Can reduce haematuria
86
What is TURP?
Transurethral resection of prostate
Effective in relieving symtoms
Can lead to bleeding, infection, retrograde ejeaculation
87
What are the complications of BPO?
```
Progression of LUTS
Acute urinary retention
Chronic urinary retention
Urinary incontinence
UTI
Bladder stones
Renal failure
```
88
How do you treat complicated benign prostatic hyperplasia?
Surgery
| Long term catheter
89
Where can be obstructed in the upper urinary tract?
- PUJ
- ureter
- VUJ
90
Where can be obstructed in the lower urinary tract?
- bladder neck
- prostate
- urethra
- urethral meatus
- foreskin (e.g. phimosis)
91
What are the symptoms of upper urinary obstruction?
- Pain
- Frank haematuria
- Symptoms of complications
92
What are the signs of upper urinary obstruction?
- Palpable mass
- Microscopic haematuria
- Signs of complications
93
What are the complications of upper urinary obstruction?
- Infection and sepsis
| - Renal failure
94
How do you manage upper urinary obstruction?
```
Resus
Investigate
Emergency treatment if required
>Retrograde stent, percutaneous nephrostomy insertion
Treat underlying
```
95
How does lower unrinary obstruction present?
```
Lower urinary tract symptoms
> including urinary incontinence
Acute urinary retention
Chronic urinary retention
Recurrent urinary tract infection and sepsis
Frank haematuria
Formation of bladder stones
Renal failure
```
96
How do you treat lower urinary tract obstruction?
```
Resus
Investigate
Emergency
>Catheter - urethral/suprapubic
Treat underlying cause
```
97
Where is a kidney transplant placed?
In iliac fossa + anastomosed t iliac veins
98
What are the complications of a renal transplant?
```
Rejection
Infective
Malignancy
Hypertension
Hyperlipidaemia
CRF (chronic renal failure)
```
99
What can cause acute rejection of a transplant?
```
Hyperacute - pre-existing alloreactivity to donor
Acute T mediate
>Lymphocytic infiltrate
>Tubulitis
Acute antibody mediated
>Endarteritis
>Endothelialitis
Humoral
>Neutrophil infiltration
```
100
What is CMV?
```
Most common infection after transplant -
>cytomegalovirus
Causes
>Gastroenteritis
>Nephritis
>Hepatitis
>Pneumonitis
>Retinitis
```
101
What are the risk factors of BKAN?
Immunosuppresion
Old age, male, white
Mismatch, urethral stents
102
How do you manage BKAN?
Modify immunosuppresion
| Antiviral therapy
103
What are the types of immunosuppresion you can get?
```
Non-specific
T cell activation specific
mTOR inhibitors
Anti-IL2 receptor antibodies
T cell antibodies
```
104
What are the non-specific immunosuppresion drugs?
Predisolone
| Azathioprine
105
What is the main T cell activation specific drug?
Cyclosporin
