Finals > Renal > Flashcards

Renal Flashcards

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1
Q

What score is used to measure impact of LUTS on QOL? Scores?

A

International prostate symptoms score

20-35: severely symptomatic
8-19: moderately symptomatic
0-7: mildly symptomatic

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2
Q

What can cause a raised PSA?

A
  • Prostate cancer
  • BPH
  • Recent ejaculation or prostate stimulation (ideally not in past 48 hrs)
  • Prostatitis
  • UTI
  • Vigorous exercise (notably cycling, ideally not in past 48 hrs)
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3
Q

Examples of alpha-blockers

A
  • Tamsulosin

- Doxasocin

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4
Q

Example of 5-alpha reductase inhibitor

A
  • Finasteride
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5
Q

SEs of alpha-blockers

A
  • POSTURAL HYPOTENSION
  • Dizziness
  • Drowsiness
  • Depression
  • Dyspnoea and cough
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6
Q

SEs of 5-alpha reductase inhibitors

A
  • Impotence
  • Low libido
  • Gynaecomastia
  • Decreased prostate size
  • Causes low levels of PSA
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7
Q

When should you refer to urology for prostate issues?

A

Men aged 50-69 years should be referred if the PSA is >= 3.0 ng/ml OR there is an abnormal DRE

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8
Q

Tx of prostate cancer

A

Localised (T1/T2):

  • Surveillance/watchful waiting in early, multiple co-morbs, low Gleason score
  • Radical prostatectomy
  • External beam radiotherapy
  • Brachytherapy (modification allowing internal radiotherapy)

Localized advanced (T3/T4):

  • Hormone therapy (androgen-deprivation)
  • Radical prostatectomy
  • Radiotherapy

Hormone therapy includes:

  • GnRH agonists, e.g. Goserelin
  • Bicalutamide (blocks androgen receptor)
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9
Q

1st line investigation for prostate cancer

A

Multiparametric MRI

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10
Q

What scoring system is used to assess MRI in prostate cancer?

A

Likert Scale
> 3 = do biopsy
1-2 = weigh up pros/cons of doing biopsy

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11
Q

What scoring system is used to assess the biopsy in prostate cancer?

A

Gleason Score

  • First number = grade most prevalent in sample
  • Second number = 2nd most prevalent grade in sample
  • Grades = 1-5 (5= worse)
  • Add two number together (2= best, 10 = worst)
  • > 8 = severe
  • 6-8 = mod
  • <6 = low risk
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12
Q

Complications of radical prostatectomy

A
  • ERECTILE DYSFUNCTION

- incontinence

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13
Q

Complications of radiotherapy/brachytherapy for prostate cancer

A
  • Proctitis (rectum inflammation) - pred suppositories can help
  • Cystitis
  • Increased risk of bladder/colon/rectal cancer
  • Erectile dysfunction
  • Incontinence
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14
Q

Complications of hormone therapy for prostate cancer

A
  • Hot flushes
  • Sexual dysfunction
  • Gynaecomastia
  • Fatigue
  • Osteoporosis
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15
Q

Types of bladder cancer

A
  • Transitional cell carcinoma (90%)
  • Squamous cell carcinoma (5% - higher in areas of schistosomiasis)
  • Adenocarcinoma, sarcoma, small-cell carincoma (rare)
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16
Q

Bladder cancer

Risk factors

A
  • Smoking (x3 risk)
  • Aromatic amines (dye factory - aniline dyes)
  • Rubber manufacturing
  • Paraplegia (x20 risk due to long term catheterisation)
  • Cyclophosphamides
  • Schistosomiasis - SQUAMOUS CELL
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17
Q

Two-week referral for bladder cancer

A
  • Aged over 45 with unexplained visible haematuria, either without a UTI or persisting after treatment for a UTI
  • Aged over 60 with microscopic haematuria (not visible but positive on a urine dipstick) PLUS:
    • Dysuria or;
    • Raised white blood cells on a full blood count

Consider a non-urgent referral in people over 60 with recurrent unexplained UTIs.

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18
Q

Presentation of renal cell carcinoma

A
  • Haematuria
  • Flank pain
  • Palpable mass
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19
Q

Patho of renal cell carcinoma

A
  • Adenocarcinoma
  • In proximal convoluted tubules
  • Solid lesions
  • Up to 20% may be multifocal, 20% may be calcified and 20% may have either a cystic component or be wholly cystic
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20
Q

Types of renal cell carcinoma

A
  • CLEAR CELL (80%)
  • Papillary
  • Chromophobe
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21
Q

Renal cell carcinoma risk factors

A
  • Smoking
  • Obesity
  • Hypertension
  • End-stage renal failure
  • VON HIPPEL-LINDAU DISEASE
  • Tuberous sclerosis
  • Only slightly increased in patients with ADPKD
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22
Q

Two-week wait for renal cancer

A

Aged over 45 with unexplained visible haematuria, either without a UTI or persisting after treatment for a UTI

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23
Q

Paraneoplastic features of RCC

A
  • Polycythaemia (secretion of unregulated erythropoeitin)
  • Hypercalcaemia (secretion of hormone that mimics action of PTH)
  • Hypertension (increased renin secretion, polycythaemia and physical compression)
  • Stauffer syndrome - abnormal liver function tests (ALT/AST/ALP/bilirubin raised) without liver mets
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24
Q

RCC mets in lungs

A

CANNONBALL METS (clearly-defined circular opacities )

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25
Staging of renal cell carcinoma
Stage 1: < 7cm, confined to kidney Stage 2: > 7cm but confined to kidney Stage 3: Local spread to nearby tissues or veins, but not beyond Gerota's fascia Stage 4: Spread beyond Gerota's fascia, including mets
26
Mx of renal cell carcinoma
- Partial or radical nephrectomy (may include surrounding tissue, lymph nodes and even adrenalectomy) - Arterial embolisation (cut off blood supply to kidney) - Percutaneous cryotherapy (freeze and kill tumour cells) - Radiofrequency ablation - Chemo or radiotherapy (BUT RCC usually resistant) - IL-2 and alpha-interferon - Tyrosine kinase inhibitors (sorafenib, sunitinib)
27
Ix for RCC
- CT - Biopsy should not be performed when a nephrectomy is planned but is mandatory before any ablative therapies are undertaken - Assessment of the functioning of the contralateral kidney
28
Define AKI (criteria)
- Rise in creatinine > 26 micromol/L in 48 hours - Rise in creatinine of >50% (1.5x) in 7 days - Urine output of < 0.5ml/kg/hr for > 6 hours
29
AKI Stage 1
- 1.5x - 1.9x baseline creatinine | - < 0.5 ml/kg/hr UO for 6-12 hours
30
AKI Stage 2
- 2.0x - 2.9x baseline creatinine | - < 0.5ml/kg/hr UO for 12hrs
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AKI Stage 3
- > 3x baseline creatinine - < 0.3 ml/kg/hr UO for > 24hrs - or anuria > 12 hrs
32
Risk factors for AKI
- Emergency surgery (sepsis, hypovolaemia) - Intraperitoneal surgery - Pre-existing CKD (eGFR < 60) - Diabetes - HF - Age > 65 yrs - Liver disease - Nephrotoxic drugs - Cognitive impairment - Contrast medium
33
Pre-renal causes of AKI
- Reduced vascular volume (hypotension - shock, dehydration, burns, D&V, renal artery stenosis) - Reduced cardiac output (HF, MI, cardiogenic shock) - Systemic vasodilation (sepsis, drugs)
34
Renal causes of AKI
- Glomerular: glomerulonephritis, acute tubular necrosis - Interstitial nephritis - Rhabdomyolysis - Tumour lysis syndrome (high phosphate, high potassiu, low calcium, should be given IV allopurinol or IV rasburicase with chemo to prevent)
35
Post-renal causes of AKI
- Within renal tract: kidney stone, malignancy, ureter or urethral strictures, clot - Extrinsic compression: BPH/prostate malignancy, pelvic malignancy, retroperitoneal fibrosis
36
Presentation of AKI
- Initially: asymptomatic - Reduced urine output - Pulmonary and peripheral oedema - Arrhythmias (secondary to changes in potassium and acid-base) - Features of uraemia, e.g. pericarditis, encephalopathy
37
Urinalysis in AKI
- Leucocytes and nitrites --> infection - Protein and blood suggest acute nephritis (but can also be present in infection) - Glucose suggests diabetes
38
AKI Investigation if no obvious cause?
USS within 24 hrs
39
AKI Management
- Fluid rehydration (IV fluids) - Med review: stop nephrotoxic drugs - Relieve obstruction if present, e.g. insert catheter - If obstruction suspected --> urology review - Treat any hyperkalaemia - Renal replacement therapy if complications
40
Complications of AKI
- Hyperkalaemia - Fluid overload, HF, pulmonary oedema - Metabolic acidosis - Uraemia (high urea) --> encephalopathy, pericarditis
41
Referral criteria for AKI
- Renal transplant - ITU patient with unknown cause of AKI - Vasculitis/ glomerulonephritis/ tubulointerstitial nephritis/ myeloma - AKI with no known cause - Inadequate response to treatment - Complications of AKI - Stage 3 AKI (see guideline for details) - CKD stage 4 or 5 - Qualify for renal replacement hyperkalaemia / metabolic acidosis/ complications of uraemia/ fluid overload (pulmonary oedema)
42
Difference between acute tubular necrosis and prerenal uraemia
ATN: - Urine sodium > 40 mmol/L - Low urine osmolality (< 350) - Poor response to fluid challenge - Normal urea:creatinine ratio - Urine: brown granular casts Prerenal uraemia: - Urine sodium < 20 mmol/L (holds on to sodium to preserve volume) - High urine osmolality (> 500) - Good response to fluid challenge - Raised urea:creatinine ratio - Urine: normal sediment
43
Differentiating AKI and CKD?
US: CKD usually have bilateral small kidneys | CKD also usually has hypocalcaemia (due to lack of Vit D)
44
Exceptions to small kidneys in CKD?
- Diabetic nephropathy in early stages - PCKD - Amyloidosis - HIV-associated nephropathy
45
Drugs that may worsen AKI
``` - NSAIDs (except if aspirin at cardiac dose e.g. 75mg od) • Aminoglycosides • ACE inhibitors • Angiotensin II receptor antagonists • Diuretics ```
46
Drugs that may need to be stopped in AKI due to toxicity risk?
- Lithium - Metformin - Digoxin
47
Causes of CKD?
- Diabetic nephropathy - Chronic glomerulonephritis - Chronic pyelonephritis - Hypertension - Adult polycystic kidney disease - Age-related decline - Meds: NSAIDs, PPIs, Lithium
48
Risk factors for CKD
- Older age - Hypertension - Diabetes - Smoking - Use of meds that affect kidney
49
Features of CKD
- Oedema: ankle swelling, weight gain (low albumin) - Polyuria - Lethargy - Pruritus - Anorexia (weight loss) - Insomnia - Nausea and vomiting - Hypertension - Muscle cramps
50
eGFR variables?
CAGE - Creatinine (serum) - Age - Gender - Ethnicity
51
Factors that may affect eGFR result?
- Pregnancy - Muscle mass (e.g. amputees, body-builders) - Eating red meat 12 hours prior to the sample being taken
52
CKD Stage 1
eGFR > 90 - Some kind of kidney damage on other tests (if tests normal - no CKD) The patient does not have CKD if they have a score of A1 combined with G1 or G2. They need at least an eGFR of < 60 or proteinuria for a diagnosis of CKD.
53
CKD Stage 2
eGFR 60-90 - With some kind of kidney damage (if tests normal - no CKD) The patient does not have CKD if they have a score of A1 combined with G1 or G2. They need at least an eGFR of < 60 or proteinuria for a diagnosis of CKD.
54
CKD Stage 3a
eGFR 45-59 | - Moderate reduction in kidney function
55
CKD Stage 3b
eGFR 30-44 | - Moderate reduction in kidney function
56
CKD Stage 4
eGFR 15-29 | - Severe reduction in kidney function
57
CKD Stage 5
eGFR < 15 - Established kidney failure - Dialysis or kidney transplant may be needed
58
A Scores in CKD
Based on albumin:creatinine ratio A1: < 3 mg/mmol A2: 3-30 mg/mmol A3: > 30 mg/mmol The patient does not have CKD if they have a score of A1 combined with G1 or G2. They need at least an eGFR of < 60 or proteinuria for a diagnosis of CKD.
59
CKD Investigations
- eGFR: U&Es - two tests 3 months apart required for diagnosis - Proteinuria (> 3 (A2) = significant) - Haematuria - check with urine dipstick (1+ = significant, should prompt malignancy Ix's) - Renal US for accelerate CKD, haematuria, Fx of PCKD, evidence of obstruction
60
CKD When to refer?
- eGFR < 30 - Urine albumin:creatinine ratio (ACR) > 70 mg/mmol - Accelerated progression (eGFR decrease of 15 or 25% or 15ml/min in 1 year) - Uncontrolled HTN despite >4 antihypertensives
61
Define nephritis
Generic term for the inflammation of the kidneys
62
Define nephritic syndrome
A group of symptoms (NOT a diagnosis) - They fit the clinical picture of having inflammation of their kidney, but does not represent a specific diagnosis Examples: - Haematuria - Oliguria - Proteinuria - Fluid retention
63
Define nephrotic syndrome
Refers to a group of symptoms, without specifying the underlying cause. So, it is not a disease but is a way of saying 'the patient has these symptoms' inidcating an underlying disease present, but does not specify which disease. MUST fulfill these criteria: - Peripheral oedema - Proteinuria > 3g/24 hrs - Serum albumin < 25g/L (hypoalbuminaemia) - Hypercholesterolaemia
64
Define glomerulonephritis
- Glomerulonephritis is an umbrella term applied to conditions that cause inflammation of or around the glomerulus and nephron - There are many conditions that can be described as glomerulonephritis
65
Define interstitial nephritis
- Inflammation of the space between cells and tubules (the interstitium) within the kidney - It is important not to confuse this with glomerulonephritis - Under the umbrella term of interstitial nephritis, there are two key specific diagnoses: acute interstitial nephritis and chronic tubulointerstitial nephritis
66
Define glomerulosclerosis
- Describes the pathological process of scarring of the tissue in the glomerulus - Can be caused by any time of glomerulonephritis, obstructive uropathy or by a specific disease called focal segmental glomerulosclerosis
67
What does nephrotic syndrome predispose someone to?
Predisposes patients to thrombosis, hypertension and high cholesterol
68
Polycystic kidney disease Chromosome in ADPKD 1 and 2? What do 1 and 2 code for?
- 1: Chromosome 16 - 2: Chromosome 4 Codes for polycystin-1 and polycystin-2
69
Extrarenal manifestations of ADPKD
- Aortic root dilatation - Mitral regurgitation (due to mitral valve prolapse) - Diverticular disease - Hepatic, splenic, pancreatic, ovarian, prostatic cysts - Intracranial aneurysms (may lead to SAH)
70
Metabolic acidosis Normal anion gap Causes
- GI bicarbonate loss (diarrhoea) - Renal tubular acidosis - Drugs, acetazolamide - Ammonium chloride injection - Addison's disease - Hyperchloraemia (excess NaCl fluid)
71
Metabolic acidosis Raised anion gap Causes
- Lactate: shock, sepsis, hypoxia - Ketones: DKA, alcohol - Urate: renal failure - Acid poisoning: salicylates, methanol
72
Causes of sterile pyuria
- Partially treated UTI - Urethritis e.g. Chlamydia - Renal tuberculosis - Renal stones - Appendicitis - Bladder/renal cell cancer - Adult polycystic kidney disease - Analgesic nephropathy
73
Causes of polyuria
- Diuretics, caffeine, alcohol - DM - LITHIUM - HF - Hypercalcaemia - Hyperthyroidism - Chronic renal failure - Primary polydipsia - Hypokalaemia - Diabetes insipidus
74
How to calculate anion gap?
(Sodium + Potassium) - (Chloride + Bicarbonate)
75
Normal anion gap?
10-18 mmol/L
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