Week 14 Renal Flashcards

Question

UTI management for children

Answer 1

Test urine when infant or child presents with unexplained fever, symptoms/signs suggestive UTI Oral antibiotcs unless severely ill, vomiting, infants\<3 months **Oral:** trimethoprim, nitrofurantoin **IV antibiotics:** IV Ceftriaxone IV Gentamicin **Antibiotic prophylaxis:** Consider for CAKUT (congenital abnormalties of kidney and urinary tract) - Prophylaxis reduces risk of febrile UTI in vesico-ureteric reflux

Answer 2

Bacterial infection of lower uriSavenary tract (cystitis) or upper urinary tract (pyelonephritis), or both. Cystitis (type of UTI due to infection of lower urinary tract) Bacteriruria with symptoms of UTi, not systemic: Symptoms: Dysuria, frequnecy, urgency Pyelonephritis (type of UTI due to infection upper urinary tract (due to ascending bacteria)) Bacteriruia with fever \>38 Symptoms: systemic - fever, malaise, flank pain + symptoms of cystitis

Answer 3

Renal scarring HTN CKD

Answer 4

Vesico-ureterical reflux Anatomical obstruction Dysfunctional voiding

Answer 5

Congenital abnormalities of kidneys and urinary tract Vesico-ureterical reflux (valve defect) Obstruction of urinary drainage tracts Both assoc. with congenital renal dysplasia

Answer 6

Disorder characterised by renal cysts and systemic manifestations. Commonest inherited disorder in kidneys AD Causes: Mutations in PK1 (85%) and PK2 (15%) which are encode polycystin 1 and 2 (present in renal tubule epithelium (and liver/pancreas) - Leading to overexpression in cyst cells - cyst formation. PK1 more severe 25% pts no family history

Answer 7

Presents with family history Symptoms: HTN, abdo pain, renal cysts Signs: Palpable renal mass Diagnosis: If have family history, US when they are 21yrs, if negative, US at 30 yrs \<30 yrs: 2 cysts 30-59: 2 cysts each kidney \>60: 4 cysts each kidney If no family history: \>10 cysts in both kidneys CT/MRI pelvis/abdomen

Answer 8

Renal: End stage renal disease, cyst problems e.g. bleeding, pain, replaces normal tissue Other: HTN, intracranial aneurysms, liver/pancreatic cysts

Answer 9

Supportive Manage HTN Tolvaptan (Vasopressin V2 receptor antagonist) - decreaes cyst formation, delays decline in renal function SE: hypernatraemia (increased Na+) and hepatotoxicity

Answer 10

X-linked Mutations in COL4A3, 4, 5, which encodes alpha 3, 4, 5 chains of collagen 4 (main component in GBM). Leads to lamination and splitting of GBM. Clinical consequences: Microscopic haematuria, proteinuria, ESRF Sensorineural deafness (childhood)

Answer 11

AR PKD - children Von Hippel Lindau (AD) - malignant, benign tumours Tuberosclerosis (AD) - benign brain tumours, learning difficulties Medullary cystic disease (AD) - cysts in medulla, gout

Answer 12

X-linked storage disease Mutation leading to decreased enzyme, alpha galactosidase A which causes increased Gb3 (globotriaosylceramide) in podocytes Causes proteinuria, ESRF Symtpoms: cutanoues lesions - angiokeratoma Diagnosis: alpha-Gal A in leukocytes Renal biospy: inclusion bodies of Gb3 Treatment: enzyme replacement

Answer 13

Macroalbuminuria or microalbuminuria, assoc. with retinopathy (TMD1/2) Pathophysiology: Hyerpglycaemia - increased pressure in glomerulus - hyperfiltration - proteinuria - HTN and renal failure (20 years) Structural changes: BM thickening, loss of podocytes, mesangial expansion Histology: Wilson nodule (areas of mesangial expansion) Treatment: Glycaemic control, ACEi, SGLT2 inhibitors (as causes glucose excretion, and natriuresis (due to Na+ reabsorption with glucose, leading to activation RAAS)

Answer 14

DD: Obstruction, interstitial nephritis Renal artery stenosis: narrowing of renal artery. Clinical diagnosis. Pathophysiology: Atheroma - progressive narrowing - decreased GFR - hypoxia in renal cortex - microvascular damage - parenchyma inflammation - fibrosis

Answer 15

Decline in renal excretory function over hours/days and increased in serum creatinine and urea **Assessment:** KDIGO Stage 1: serum creatinine \>1.5, \<2 Stage 2: serum creatinine \>2, \<3 Stage 3: serum creatinine \> 3 x increase AKI baseline **Management:** Airway Breathing Circulation - restore renal perfusion - correct hyperkalaemia, pulmonary oedema Remove causes e.g. drugs, sepsis Exclude obstruction **Hyperkalaemia treatment:** 6-6.4: risk of arrythmia \>6.5 is medical emergency Causes ECG changes: ventricular tacycardia - loss of P wave, peaked T wave - IV calcium gluconate - Insulin/dextrose (drives K+ into cells) Oral calcium resonium (reduce absorption) Bicarbonate (if high K+, and HCO3 \<16) Dialysis (if refractory hyperkalaemia, pulmonary oedema, acidotic, toxins)

Answer 16

**Pre-renal (decresaed perfusion)** - Hypotension - Sepsis (cause vasodilation causing drop in perfusion pressure) - Cardiac failure - ACEi - Renal artery stenosis **Renal** Acute tubular necrosis (most common) Obstructive GN Vasculitis Gentamicin Rhabdomyolysis **Post-renal (obstruction)** - Calculi - Tumours e.g. prostate - Lymph nodes

Answer 17

Most reversible Necrosis of tubular cells causing obstruction of tubules Symptoms: hypotension, tachycardia **Causes:** Ischaemia - hypotension, sepsis Toxins: Endogenous - myoglobin (due to rhabdomyolysis. Presents with coca-cola urine), Ca2+ Exogenous - NSAIDs, gentamicin, ACEi, radiocontrast Complications: polyuric phase (up to 72 hrs), inability to concentrate urine in tubules

Answer 18

Kidney damage or eGFR \<60ml/min for 3 months or more **Causes:** Diabetic nephropathy, chronic glomerulonephritis, APKD, reflux nephropathy **Symptoms:** Itch, rotten taste in mouth (due to uraemia), fatigue (due to anaemia), weight loss, SOB, joint/bone pain **Signs:** Pulmonary oedema, HTN, increased HR, yellow tinge skin (uraemic frost) **Investigations:** FBC: Anaemia Ca2+ (decreased), PTH (incresead), phosphate (increased) - Kidney's can't excrete phosphate, and 1a hydroxylate Vit D causing decreased Ca2+. PTH increaesd to compensate (resorbs bone, also increases phosphate) Serum creatinine (increased) Urinalysis (proteinuria, haematuria) eGFR (decreased) Renal US (kidneys smaller than normal if chronic, and to see if there is obstruction) **Staging:** Stage 1: \>90 Stage 2: 60-89 Stage 3: 30-59 Stage 4: 15-29 Stage 5: \<15 Stage 1 and 2 normal, unless urine or structural abnormality e.g. proteinuria, APKD

Answer 19

**P**rostaglandins **d**ilate **a**fferent arterioles (to increase flow) **A**ng II constricts **e**fferent **a**rteriole NSAIDs inhibit prostaglandins, ACEi inhibits Ang II, so contra-indicated for AKI

Answer 20

BP control Glycaemic control Diet Smoking Lowering cholesterol Treat acidosis

Answer 21

1st line treatment ACEi e.g. Ramipril - Can be used as 25% GFR reduction in first few weeks is a good thing 2nd line: Ca+ channel blockers e.g. verapimil Activated Vit D (Alfacalcidol) Phosphate binders e.g. calcium carbonate Cinalcalcet (calcimimetic) - to decrease production of PTH

Answer 22

Regulates total body water Regulates electrolytes Makes EPO Makes renin

Answer 23

Medically resistant HTN Medically resistant pulmonary oedema Medically resistant acidosis Uraemic pericarditis Uraemic encephalopathy No rule for eGFR, but usually 5-10

Answer 24

Haemodialysis Peritoneal dialysis Renal transplant Conservative treatment

Answer 25

Removal of solutes through diffusion Removal of fluid through pressure: hydrostatic filtration Uses external semi-permeable membrane Requires AVF (arterial venous fistula) - artery and vein connected Pros: Hospital or home 4h, 3 times a wk Home based more flexibile, but requires carer, space Cons: Acute hypotension "crash" Access problems Cramps

Answer 26

Diffusion and osmotic filtration Across peritoneal membrane as filter Dialysis fluid goes in via catheter (contains high amounts of glucose - hyperosmolality) causing osmotic filtration Types: CAPD (continuous ambulatory peritoneal dialysis) - occurs during day APD (automated peritoneal dialysis) - occurs during night **Pros:** Home based Maintain independence **Cons:** Infection - peritonitis Glucose load - develop/worsen diabetes Obese pts, intra-abdominal adhesions not suitiable

Answer 27

EPO, iron supplements needed Renal bone disease - need phosphate binders, vit D Neuropathy

Answer 28

Preschool children Pregnancy Immuncompromised Renal transplant

Answer 29

90% caused by single organism E.coli, Klebsiella, Proteus, Enterococcus Multiple in: Catheters, recurrent infection Multi-drug resistant bacteria: Frequent infections, mutiple antibiotic courses

Answer 30

Types: Living or cadaveric (after brainstem, cardiac death) Average wait 3 years Pros: No dialysis More independence Better renal function Cons: Requires immunosuppressants after e.g. ciclosporin, tacrolimus Increased cardiovascular risk Increased infection Contraindications: Malignancy Active infection

Answer 31

Suprapubic discomfort, dysuria, frequency, urgency, low grade fever Nocturia, incontinece in elderly

Answer 32

If first time presenation in non-pregnant women: urine dipstick, culture not mandatory Children and men require urine culture always

Answer 33

Amoxillcin or Cefalexin

Answer 34

2 or more episodes in 6 months 3 or more in 1 years Management: Oral hydration Post-coital voiding oral estrogen Short course antibiotics Single post coital antibiotics Prophylactic abx - if other measure failed

Answer 35

IV Ciprofloxacin **Catheter assoc. UTI** Organisms usually pts flora or healthcare environment Complications CAUTI: - chronic renal inflammation - Risk of bladder Ca Treatment: IV Gent **Renal pyelonephritis** Upper UTI infection, ascending infection involving pelvis of kidney Complication: renal abscess (usually gram -ve) - Can lead to emphysematous pyelonephritis (severe infection that causes gas accumulation in tissue) **Perinephric abscess** Pus in perinephric space Pts usually septic Causes: Untreated lower UTI, anatomical abnormalities Organisms: E.coli, S. aureus **Management:** FBC, UEs, CRP, urine sample, blood culture, renal US, abx

Answer 36

Inflammation of prostate due to bacterial infection Symptoms: Fever, back pain, acute lower UTI symptoms e.g. dysuria, frequency, uregency Organisms: E.coli, S.aureus, N.gonnorhoea Complications: Prostate abscess, rupture Treatment: IV Ciprofloxacin

Answer 37

Prolonged prostate infection lasting \>3 months Asymptomatic, fever, back pain, UTI symptoms Organisms: E.coli, Enterococcus, S.aureus

Answer 38

**Orchitis** Inflammation of one/both testicles Symptoms: testicular pain, fever, dysuria Causes: bacterial or viral e.g. mumps Bacterial orchitis: complication of epididymitis **Epididymitis** Inflammation of epididymis Ascending infection from urethra Causes: Gram neg, TB

Answer 39

Type of nec fas affecting genital, perineum Rapid onset, systemic sepsis Organisms: E.coli, anaerobes Risk factors: UTI, IBD complications Treatment: surgical debridement

Answer 40

Epithelial cells: contamination Bacteria no WBC: contamination Bacteria + WBCs, with catheter: assess clinically Bacteria + WBCs + no catheter: infection Pyuria (pus in urine) with no bacteria: TB, urethritis (chlamydia), previous antibiotcs

Answer 41

Colicky pain, haematuria, unilateral flank tenderness **Calcium oxalate/phosphate** (most common) Cause: Idiopathic, hypercalciuria Infection stones: **struvite** (Magneusium, ammonium, phospate) - proteus **Uric acid stone** (not seen on XR) - most common seen in gout, hyperuricaemia Others: **cystiene** (not seen on CT) - mostly in children

Answer 42

Volume in which the amount of drug needed to distribute uniformly to produce observed blood conc (tells you how extensively the drug distributes to rest of body compared to plasma) Vd increased in lipid soluble drugs e.g. diazepam If Vd near the plasma drug conc, shows drug stays in vascular space e.g. warfarin

Answer 43

PK: what body does to drug - Absorption - Distribution - Metabolism - Excretion PD: what drug does to body - MOA of drug - Efficacy - Safety profile

Answer 44

Volume of plasma needed to clear substance per unit time

Answer 45

Time required for serum plasma conc of the drug to decrease by half Long half life required loading dose 4-5 half lives to reach steady state Depends on clearence and Vd Used to determine: Time it takes for drug to be eliminated Time to reach steady state Dosing interval

Answer 46

**Linear:** dose proportional to conc of drug e.g. double dose, double conc Rate of elimiation proportional to conc **Non linear:** dose non-proportional to conc Rate of elimiation constant regardless of drug conc.

Answer 47

Age Renal impairment Hepatic impairement Congestive HF GI disease

Answer 48

Decreased total body water and increased fat - affects Vd Water soluble drugs e.g. lithium, gentamicin - Serum levels may increaese due to decreased Vd Fat soluble drugs e.g. diazepam - Half life may increase with increaesd body fat B-blockers effect reduced in age

Answer 49

Creatinine clearence Depends on age, weight, sex, creatinine conc

Answer 50

PD pts have increased risk of drug induced confusion NSAIDs can exacerbate CHF

Answer 51

Statins and erythromycin Verapamil and B-blockers

Answer 52

NSAIDs - HTN - antihypertensives Ca channel anatagonists - oedema - furosemide

Answer 53

Gentamicin Lithium Digoxin Methotrexate Penicillins

Answer 54

Renal failure can lead to acidosis Acidic drugs less bound to albumin (ionised) leading to more free (active) drug in plasma E.g. phenytoin (acidic)

Answer 55

Reduce dose

Answer 56

Renal: Same/Increased Vd, decreased rate of excretion (t1/2 increased) Increase dosing interval Hepatic: Same/incresed Vd, slower rate of metaoblism (t1/2 and F increases) Reduce dose, increase dosing interval

Answer 57

High extraction: metabolised at high rate by liver. Affected by changes in blood flow. E.g. Morphine Low extraction: metabolised at low rate by liver. Not changed by blood flow. But changes with liver enzyme activity. E.g. theophylline

Answer 58

Increased sensitvity to oral anticoagulants Fluid retention Hepatorenal syndrome

Answer 59

Abnormal urine (e.g. too much salt) Urinary obstruction e.g. pelviureteric junction obstriction, medullary sponge kidney UTI (proteus mirablis splits urea into ammonia, causing alkaline pH leading to struvite stones)

Answer 60

Too much salt - Salt can lead to increaesd acid (metabolic syndrome), hypercalciuria Not enough water Lack of inhibitors e.g citrate, magnesium

Answer 61

Calcium oxalate or phosphate (most common) Struvite Uric acid Others e.g. Cysteine

Answer 62

Observation Medical: **NSAIDs** (reduces pain, GFR and renal pressure) Surgical: **ESWL** (extracorporeal shockwave lithotripsy) - shockwaves to break up stones - proximal utreteric stones \<10mm, or renal stones \<2cm **Laproscopy/open surgery** - treat huge ureteric stones, non functioning kidney

Answer 63

Medical emergency Implement sepsis 6 Invstigations: Bloods, CRP, Coag USS or CT Treatment: Nephrostomy (tube placed into kidney to drain urine out) or ureteric stent

Answer 64

**Maintenance:** 0.18% NaCl 5% glucose Hartmann's **Replacement:** Hartmann's Alternative balanced solutions for resus **Resusication:** Hartmann's Alternative balanced solutions for resus

Answer 65

Not physiological Can cause hyperchloraemia acidosis Increaesd Cl+ leads to renal vasoconstriction leading to poor UO Kidney's can't excrete Na+ load So leads to hyperchloraemia, hypernatraemia, acidosis

Answer 66

Damaged skeletal muscle breaks down, releasing myoglobin, intracellular ions Due to trauma, prolonged immobilisation (e.g. due to alcohol, drugs) Leads to: - electrolyte imbalance (high K+, Mg, phosphate, low Ca+) - DIC (increased PT, PTT and INR) - AKI (increaed urea, creatinine) Diagnosis: Increased serum creatinine kinase 5x ULN

Answer 67

Acute: US: Normal sized kidneys Electryolyte imbalance e.g. high K+ Chronic: US – small kidneys PTH elevated Phosphate elevated Anaemic

Answer 68

**Posterior urethral valve** **-** Obstructing membrane at posterior urethra due to abnormal development - Most common congenital cause of bladder obstruction - Presents as antenatal hydronephrosis, UTI Management: valve resection **Prostate hypertrophy** **Neurogenic bladder e.g. spinal bifida** **PUJO (pelvi-ureteric junction obstruction)** Between renal pelvis and ureter Common cause of hydronephrosis in children Commonly found on antenatal US Abdo mass, haematuria **VUJO (vesico ureteric junction obstruction)** Between ureter and bladder Anantomical narrowing or obstruction e.g. strictures Abdo mass, haematuria

Answer 69

Adenocarcinoma, usually arises in periphary of prostate **Risk factors:** Age, genetics e.g. BRAC2, p53, african american **Signs/symptoms:** Often asymptomatic, UTI, haematuria, bone pain (most common symptom of metastases) Complications: SC compression, ureteric obstruction **Diagnosis:** Digital rectal exam PSA (prostate specific antigen) TRUS (needle biopsy) Gleeson Grading (based on how differentiated they are) - provides prognostic information TNM staging **Treatment** Radiotherapy Androgen ablation - LHRH analogue, or orchidectomy (surgical castration) Chemotherapy Prostatectomy

Answer 70

Transitional cell carcinoma Risk factors: Age, caucasian, chronic inflammtion e.g. stones, long term catheters **Presents:** Painless, visible haematuria **Diagnosis:** Cystoscopy **Treatment:** TURBT (trans-urethral resection, of bladder tumour) Cystectomy (bladder and prostate/uterus removed) Mets: usually **pulmonary** M-VAC (Methotrexate, vinblastine, doxorubicin, cisplatin)

Answer 71

Renal cell carcinoma (most common) **Risk factors:** Smoking, obesity, HTN, renal cysts, haemodialysis Presents: triad: mass, pain, haematuria lower leg oedema, paraneoplastic syndrome: polycytheamia (increased EPO), HTN, (increased renin), **Investigations:** FBC, CRP, LFTs, bone profile, US, CT kidneys, renal biopsy **Histology:** Clear cell (most common) - vascular, granular and clear (due to lipids) Papillary - sold, multi-focal **Treatment:** Nephron sparing surgery (part of kidney removed) - if pt ahs one kidney, CKD Radical nephrectomy (remove kidney) Mets: Tyrosine kinase inhibitors

Answer 72

Germ cell tumours (most common), Stromal tumours Most curable ca. Risk factors: Age: 25-40, cryptochordism, HIV Presentation: painless lump, **Investigation**: Alpha-feta protein (also in HCC) Beta hCG LDH **Treatment:** Radical orchidectomy, chemo **Penile cancer:** Risk factors: HPV 16, 18, smoking Treatment: Circumcision, penectomy+/-reconstruction

Answer 73

**Renal US** Pros: Dilated ducts, no radiation Cons: Can't see kindey parenchyma **Micturating cystourethrogram** Dye given through cathether, X rays taken. Shows flow of urine Pros: GS for VUJ Cons: radiation **Nuclear**: **DMSA** Radiocontrast given, taken up by healthy tissues Pros: Scarring Cons: GS Radiation **MAG3 indirect cystogram** Radiocontrast injected, passed out into urine Pros: VUJ, no catheter required Cons: Continence and co-operation required **MAG3 diuresis renogram** Pros: GS for obstruction Cons: continence and co-operation

Week 14 Renal Flashcards

(100 cards)