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YOU BETTER WERK > UROLOGY/CKD > Flashcards

UROLOGY/CKD Flashcards

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1
Q

What is the most common composition of kidney stones?

A

Calcium oxalate

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2
Q

Investigation of renal calculi

A
  • urine analysis
  • renal function
  • CT KUB and XR KUB should be performed on the same day
  • approx ~50% of stones are radio-opaque
  • US KUB can be used when avoidance of radiation is necessar (young patients, females) but CT is preferred imaging modality

-

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3
Q

Which renal stones can pass conservatively?

A
  • majority of stones will pass within 6 weeks
  • 60% of stones 5-7mm will pass spontaneously
  • conservative mx: NSAIDs provide the most effective pain relief
  • consider 400mcg dose tamsulosin
  • dietary advice: low protein, low sodium may help reduce recurrence
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4
Q

Which subsets of patients need to be kidney stone free?-

A

Single kidney patients

Airline pilots

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5
Q

Definition of CKD

A
  • GFR <60 which is present for > 3 momths with or without evidence of kidney damage

OR

  • evidence of kidney damage with or without a decreased GFR present for > 3 months (evidenced by: albuminuria, haematurial, structural abnormalities, abnormal renal biopsy)

Risk factors: diabetes, HTN, established CVD, family history, obesity, smoker, > 60, ATSI, history of AKI

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6
Q

What are the 3 main points of screening for patients at risk of CKD?

A
  1. BP
  2. Urine ACR
  3. Blood test: creat/GFR
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7
Q

Algorithm for detection of CKD

A
  1. Screen at risk individuals, if urine ACR and eGFR are normal repeat in 1-2 years time (annually in pts with HTN or diabetes)

ABNORMAL GFR: if < 60 repeat in 7 days, if stable repeat GFR twice in 3 months
GFR > 20% REDUCTION: consider AKI, discuss with nephrologist

URINE ACR: if elevated repeat twice within next 3 months (preferably first morning void)

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8
Q

Describe the stages of renal function

A

Stage 1: GFR > 90

Stage 2: 60-90

Stage 3a: 45-60

Stage 3b: 30-45

Stage 4: 25-30

Stage 5: GFR <15 or on dialysis

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9
Q

Diet and nutrition goals in CKD

A
  • varied diet richen in vegetables, fruits, multigrain cereals, lean meat, chicke, fish, eggs, buts, seeds and low fat dairy products
  • limit salt to <6g/day
  • limit intake of foods containing added sugars and saturated/trans fats
  • avoid high calorie sweetened carbonated beverages
  • dietary protein no lower then 0.75g/kg
  • maintain albumin > 35
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10
Q

Obesity and CKD

A

Ideal BMI <25

WC <94cm in men and <80cm in women

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11
Q

Physical activity in CKD

A

Accumulate 150 to 300 minutes (2 ½ to 5 hours) of moderate intensity physical activity or 75 to 150 minutes (1 ¼ to 2 ½ hours) of vigorous intensity physical activity, or an equivalent combination of both moderate and vigorous activities, each week.

Do muscle strengthening activities on at least 2 days each week.

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12
Q

BP target in CKD

A

<130/80

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13
Q

Drug choice in management for cholesterol in patients >50 with CKD

A

Statin/ezetimibe combination

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14
Q

Immunisation in CKD

A
  • influenza and pneumococcal disease is recommended for all with diabetes or ESKD
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15
Q

ACEI/ARBs and eGFR decline

A
  • ACEI/ARBs cause reversible reduction in GFR
  • provided reduction is <25% within 2 months of starting therapy you should continue ACEI/ARB therapy
  • cease if reduction > 25%
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16
Q

What are the most common causes of ESRF in Australia?

A

DIABETES # 1

Glomerulonephritis # 2

Hypertension # 3

Polcystic kidneys # 4

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17
Q

Screening for CKD in ATSI population

A
  • all patients >30 should have urine ACR, eGFR and BP done every 2 years
  • or if 18-29 with one or more CKD risk factors
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18
Q

Once CKD is diagnosed through GFR/urine ACR what further diagnostic evaluation is required?

A
  • renal USS
  • repeat serum biochemistry
  • FBC, CRP, ESR
  • fasting glucose/lipids
  • urine microscopy
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19
Q

What further investigation should be performed in patients with CKD and signs of systemic disease (rash, arthritis, features of connective tissue disease, pulmonary symptoms)?

A

Anti-glomerular basement membrane antibody

Anti-neutrophil cytoplasmic antibody

Anti-nuclear antibody

Extractable nuclear antigens

Complement studies

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20
Q

What further testing should be sought in patients > 40 with CKD and possible myeloma?

A
  • serum and urine protein electrophoresis
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21
Q

YELLOW CLINICAL ACTION PLAN: CKD

A

GFR >60 + microalbuminuria or GFR 45-60 w/ normoalbuminuria

Goals: investigate cause, reduce progression, assess cardiovascular risk

Frequency of review: every 12 months

Clinical assessment: GP, weight, smoking

Labs: urine ACR, eGFR, biochemical profile, HbAqc, fasting lipids

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22
Q

ORANGE CLINICAL ACTION PLAN: CKD

A
  • GFR 30-50 with microalbuminuria or GFR 35-40 norrmoalbuminuria

Goals: early detection and management of complications, adjustement of regular medications, referral when indicated

Frequency of review: every 3-6 months

Additional labs: FBC, calcium, phosphate, parathyroid homrone (6-12 monthly if GFR <45)

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23
Q

At what GFR should parathyroid hormone be checked and how frequently

A

GFR <45

  • every 6 -12 months
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24
Q

RED CLINICAL ACTION PLAN: CKD

A

Goals: prepare for renal replacement if necessary

Frequency of review: 1-3 monthly

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25
What are the 5 As?
Ask Assess Advise Assist Arrange
26
Which 2 groups of patients should have their CVD risk assessed?
Adults \> 45 ATSI people \> 35
27
CVD risk and CKD
- any patient with moderate to severe CKD is KNOWN to be at increased CVD risk - \> macroalbuminuria, eGFR \<45 - \> diabetes and age \> 60 - \> diabetes with microalbuminuria - \> familiar hypercholesterolaemia - \> SBP \> 180, DBP \>110 - \> serum total cholesterol \> 7.5 High risk = \> 15% CVD risk
28
Diabetes targets in CKD
- BGL: 6-8 fasting or 8-10 post prandial - HbA1c generally \<7 (6.5-7.5)
29
Diabetic medications and CKD
Metformin: reduce dose GFR 30-60, contraindicated if GFR \<30 (cease when unwell) SGLT2 inhibitors: contraindicated in moderate renal impairment (GFR \<45) (significant renal and CVD benefits in people with CKD and diabetes) Gliptins (DPP4I): safe in CKD with dose adjustment Sulphonyurea: dose reduction required GFR \<30 GLP1 agonist: contraindicated GFR \<30 (potential CVD benefits)
30
Which class of anti-hyperglycaemia may cause UTI?
SGLT2 inhibitors - Increase urinary glucose excretion
31
HTN management in CKD
1. ACEI/ARB (monitor GFR and K) Consider adding - CCB, diuretic or beta blocker - refer to nephrologist if not consistently below target with atleast 3 anti-hypertensive agents
32
What rise in serum potassium is expected in CKD when ACEI are started?
\>0.5mmol/L Hence need to caution in patients with baseline potassium of \>5.5
33
Diuretics in CKD
GFR \>45 = non-loop diuretic (i.e. thiazides) GFR \<45 = loop diuretic (frusemide) Frusemide can be safely used for management of fluid overload in all stages of CKD, including when GFR \<30 -
34
Commonly prescribed drugs that adversely affect renal function in CKD
- aminoglycosides - calcineurin inhibitors (cyclosporine, tacrolimus) - gadolinium - lithium - NSAIDs, COX 2 inhibitors - contrast
35
Prevention of AKI in CKD patients who are sick or dehydrated: medications to withhold
ACEI ARB NSAIDs Diuretics SGLT2 inhibitors Increased risk of adverse effects due to reduce clearance: metformin, sulfonyluria, atenolol SADMANS Sulfonyluria, ACE, diuretics, metformin, ASRB, NSAIDs, SGLT2
36
Polycystic kidney disease
3 total cysts if \< 40, 2 in each kidney if 50-60 or 4 in each kidney if \> 60 - treatment: tolvaptan
37
Indications for referral to nephrologist in CKD
- GFR \<30 (stage 4 and 5 of any cause) - persistent albuminuria - sustained GFR decrease of \>25% within 12 months or sustained decrease of 15ml/min per year - CKD with hypertension that is hard to control despite 3 anti-hypertensive agents Not indicated if stable GFR \> 30, urine ACR \<30, controlled blood pressure
38
Signs and symptoms of acute nephritis
- oliguria - haematuria - acute HTN - oedema
39
Acidosis in CKD
- GFR \<30 = increased risk of metabolic acidosis TreatmentL sodiBic: with aim to keep HCO3 \> 22
40
Management of albuminuria in CKD
- degree of albuminuria relates to severity of disease - target = 50% reduction in urine ACR - management: ACEI/ARB, reduction of salt intake, spironolactone (with caution!)
41
Anaemia in CKD
- target Hb 100-115 - due to reduced EPOI, resistance to action of ESA, reduced iron absorption - starts to develop when GFR \<60 - aims of ESA therapy are ferritin 200-500 and TSAT 20-30% - exclude other causes: b12/folate, IDA, GIT blood loss, TSH, hyperparathyroidism
42
Depression in CKD
- Common: 1/5 CKD and 1/3 on dialysis - SSRIs safe in CKD
43
Microscopic haematuria in CKD
- r/o infection - if there is associated reduction in GFR --\> consider glomerulonephritis, urinary tract US, referral to nephrologist - nil reduction of GFR --\> consider urological malignancy, refer for cytolic and ultrasound + urological review
44
Management of hyperkalaemia
Target K \< 6 - impaired urinary excretion of potassium - may rise with ACEI/ARB - K 6-6.5: low K diet, correct acidosis (HCO3 \>22), thiazides, consider resonium, cease ACEI/ARB/spironolactone if K persistently \> 6 and not responsigve - K \> 6.5 --\> refer to ED due to risk of arrythmia
45
Target albumin in CKD
\>35
46
CKD pruritis
- evening primrose oil - skin emollients - avoid soap and detergent - topical capsaicin - if pruritis and restless legs consider gabapentin - can refer to dermatologist for UBV therapy
47
Management of restless legsin CKD
Check iron status and replace if deficient. Home therapies such as massage, warm baths, warm/cool compresses, relaxation techniques, exercise. Low dose dopaminergic agents or dopamine agonists. Benzodiazepine
48
Stages of CKD and yellow/orange/red classification
49
CKD risk factors: who should be screened?
- smokers - obesity, BMI \> 30 - FHx - Diabetes - HTN - ATSI \> 30 - Established CVD - History of AKI
50
Common presentations of glomerulonephritis
- nephritic syndrome: - nephrotic syndrome - GN and infection - GN and drugs - GN and purpuric skin rash - GN and cancer
51
Causes of nephrotic syndrome
- minimal change disease - membranous GN (HbsAg, CXR, mammogram) - FSGS - SLE (ANA, anti-ds SNA, C3, C4) - Diabetes (FGL) - Amyloid (urinary bence jones, serum and urine protein electrolphoresis)
52
Causes of nephritic syndrome
IgA nephropathy Poststrep GN SLE Anti-GBM disease ANCA vasculitis Mesangiocapillary GN
53
Presentation of nephritic syndrome
- macroscopic haematuria (cola coloured urine) - severe hypertension - progressive oliguria and renal impairment - unwell patient, often abrupt onset
54
Nephrotic syndrome triad
- oedema - hypoalbuminaemia - heavy proteinuria \> 3.5g/day due to disruption of glomerula filtration barrier
55
What is the most common cause of GN?
IgA Nephropathy
56
Management of APSGN outbreaks
- occassionally outbreaks occur due to specific GAS strains - management is to treat all children in community with any evidence of school sores with IM penicillin
57
Diagnostic criteria for PSGN a) clinical b) lab
CLINICALLY: at least of 2 of the following: - facial oedema and/or peripheral oedema - hypertension - moderate haematuria on dipstick (2+ RBC) LAB - haematuria on microscopy - evidence of recent strep infection: positive GAS culture or elevated ASO titre or anti-DNase B - reduced C3 complement level
58
Management of PSGN
- IM benzathine penicillin regardless of whether skin sores or pharyngitis arte present at time of presentation - admission!
59
Contact tracing with PSGN
- need names of family and household/close contacts of supsected case including adults and children who have been stating in the household 2 weeks prior to onset of symptoms - need to examine skin for sores/scabies, BP to checked, urine to be checked and if sore present should be swabbed - any child **12 months to 16 years** are to be given LA bicillin whether skin sores a present or not - if \> 17 treat with Abx if infected skin sores present - if scabies presenty treat with 5% permethrin or ivermectin if \> 15kg for heavy or recurrent infections
60
Which class of CCB causes peripheral oedema?
Dihydropyridines (felodipine, amlodipine) - causes peripheral oedema due to redistribution of extracellular fluid (rather than fluid retention) - will not respond to diuretics - may put patient at risk of volume depletion
61
When is urinary protein excretion highest?
In the afternoon!
62
Three initial investigations for men with LUTS
Urinalysis Urinary tract ultrasound Serum creatinine/estimated glomerular filtration rate
63
Common drugs whch may need to be reduced or ceased in CKD
- apixaban, dabigatran, rivaroxaban - gabapentin, lithium, pregabalin - opioids, benzos - spironolactone, digoxin - allopurinol, cochicine - fenofibrate - NSAIDs
64
Relative anatomy: haematospermia
- testes --\> epididymis --\> vas deference --\> ejaculatory duct - fluid from sminal vesciles, prostate and Cowper's glands the mixes with the sperm to form ejaculate
65
Causes of haematospermia
- Infection: bacterial (STI, entococcus, TB), viral (HIV, CMV, HSV) - Iatrogenic: post TRUS, radiation, post vasectomy - Malignancy: prostate, bladder, testicular, urethral - Trauma: coital trauma, pernieal trauma - Prolonged abstinence - Obstruction: duct obstruction, cysts or calculi - Systemic disorders: HTN, CLD, lymphoma, leukaemia, amyloidosis, bleeding disorders
66
Red flags: haematospermia
Age \> 40 Recurrent or persistent Prostate cancer risk factors: family hx of African heritage Constitutional symptoms (weight loss, anorexia, bone pain)
67
Approach to haematospermia
- screen for red flags (malignancy) - common aetiologies: UTI/prostatitis/STI - examination: BP, temperature, genital examination, DRE - systems review: feature of CLD, lymphoma or leukaemia - investigation: urine MCS, urine cytology, FBC, coags - if STI suspected --\> NAAT for chlamydia and gonorrhoea - PSA in men \> 40 or if abnormal DRE
68
Indications for urology referral: haematospermia
- Men \> 40 - persistent or recurrent - suspicious DRE fidning - abnormal PSA - suspicion of malignancy - concurrent haematuria
69

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