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Renal Flashcards

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1
Q

Differences between AKI and CKD

A

Renal US = patients with CKD have bilateral small kidneys
Hypocalcaemia suggests CKD

Exceptions
* Autosomal dominant polycystic kidney disease
* Diabetic nephropathy
* Amyloidosis
* HIV-associated nephropathy

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2
Q

Differentials for haematuria

A
  • Trauma
  • Infection
  • Malignancy = RCC, SCC and adenocarcinoma, prostate cancer, urothelial cancer
  • Glomerulonephritis
  • Stones
  • BPH
  • PCKD
  • Vascular malformations
  • Renal vein thrombosis
  • Coagulopathy
  • Drugs = aminoglycosides, chemo, penicillin, sulphonamides, NSAIDs, anticoagulants
  • Exercise
  • Endometriosis
  • Catheterisation
  • Radiotherapy
  • Pseudohaematuria
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3
Q

Pre-renal causes of AKI

A

inadequate blood supply to kidneys reducing filtration
o Hypovolaemia = Dehydration (D+V), haemorrhage
o Hypotension (shock, sepsis, cardiac failure)
o Oedematous states = cirrhosis, nephrotic syndrome
o Renal artery stenosis/occlusion
o Drugs = antihypertensives, diuretics

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4
Q

Renal causes of AKI

A

o Peripheral vascular disease
o Disseminated intravascular coagulation
o Malignant hypertension
o Thromboembolic disease
o Glomerulonephritis
o Interstitial nephritis
o Acute tubular necrosis
o Rhabdomyolysis
o Tumour lysis syndrome
o Drugs  NSAIDs, PPIs, penicillins, radiological contrast

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5
Q

Post-renal causes of AKI

A

o Kidney stones
o Masses/cancer in abdo or pelvis
o Ureter or urethral strictures
o BPH or prostate cancer

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6
Q

Presentation of AKI

A
  • Symptoms of high urea
    o Fatigue, weakness, anorexia, nausea and vomiting
    o Followed by confusion, seizures and coma
  • Breathlessness
  • Thirst
  • Diarrhoea
  • Haematuria
  • Haemoptysis
  • Reduced urine output/Urine retention = oliguria
  • Palpable bladder, palpable kidneys, abdominal/pelvic masses, rashes
  • Postural hypotension
  • Pulmonary and peripheral oedema
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7
Q

Investigations for AKI

A
  • Urinalysis for protein, blood, leucocytes, nitrates, glucose
    o Leucocytes + nitrates = infection
    o Protein + blood = acute nephritis
    o Glucose = diabetes
  • Bloods  Anaemia, Hypocalcaemia, Hyponatraemia, Hyperphosphataemia, Hyperkalaemia, High creatinine/low GFR
  • US of urinary tract/kidneys within 24 hrs if no identifiable cause or risk of UTI
  • ECG = arrhythmias due to hyperkalaemia
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8
Q

Diagnosis criteria for AKI

A

KDIGO classification
- Rise in creatinine of >/= 25 micromol/L in 48 hrs
- Rise in creatinine of >/= 50% in 7 days
- Urine output of <0.5ml/kg/hour for >6 hrs (8hrs in children)
- >25% fall in eGFR in children/young adults in 7 days

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9
Q

Management of AKI

A
  • Prevention and treat cause
  • IV Fluid rehydration
  • Stop nephrotoxic medications = NSAIDs, ACEi, gentamicin, metformin, spironolactone
  • Relieve obstruction = catheter
  • Reverse hyperkalaemia with insulin and dextrose
  • Haemofiltration/haemodialysis if patient not responding to medical treatment of complications
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10
Q

Referral criteria for AKI

A
  • 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
  • CKD stage 4/5
  • Qualify for renal replacement = hyperkalaemia/metabolic acidosis/ complications of uraemia/fluid overload
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11
Q

Complications of AKI

A
  • Hyperkalaemia
  • Fluid overload, heart failure, pulmonary oedema
  • Metabolic acidosis
  • Uraemia = encephalopathy or pericarditis
  • CKD
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12
Q

Risk factors for CKD

A
  • Smoking
  • Family history
  • Diabetes (T2>T1)
  • Hypertension
  • Glomerulonephritis
  • Polycystic kidneys disease
  • Medications = NSAIDs, PPIs, lithium
  • More common in African, Afro-Caribbean or Asian origin
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13
Q

Presentation of CKD

A
  • Asymptomatic
  • Itching
  • Loss of appetite
  • Nausea
  • Muscle cramps
  • Nocturia and polyuria
  • Amenorrhea in women and erectile dysfunction in men
  • Oedema
  • Peripheral neuropathy
  • Pallor
  • Hypertension
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14
Q

Investigations of CKD

A
  • Estimated GFR = 2 tests 3 months apart for diagnosis
    o eGFR <60 or proteinuria
  • Urine albumin: creatinine ratio >/= 3mg/mmol
  • Urine dipstick = haematuria
    o Check for bladder cancer
  • Renal ultrasound
  • Urine microscopy = UTI, glomerulonephritis
  • Biopsy and histology = Diagnose condition causing renal failure
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15
Q

Bloods in CKD

A

o Raised urea and creatinine
o Raised ALP
o Raised PTH if CKD stage 3+
o Raised phosphate
o Low Ca2+
o Hb low = normochromic normocytic anaemia

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16
Q

Stages of CKD

A
  • G score eGFR
    o G1 = eGFR >90
    o G2 = eGFR 60-89
    o G3a = 45-59
    o G3b = 30-44
    o G4 = 15-29
    o G5 = <15
  • A score = Albumin: creatinine ratio
    o A1 <3mg/mmol
    o A2 3-30mg/mmol
    o A3 >30 mg/mmol
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17
Q

Slow progression of CKD

A

o Diabetic control
o Hypertensive control = ACEi
o Treat glomerulonephritis

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18
Q

Complications of CKD

A
  • Anaemia
  • Renal bone disease
  • CVD
  • Peripheral neuropathy
  • Dialysis related problems
  • Hyperkalaemia
  • Peptic ulceration
  • Acute pancreatitis
  • Malignancy
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19
Q

Reduce risk of complications of CKD

A

o Exercise, maintain healthy weight and stop smoking
o Dietary advice on phosphate, sodium, potassium and water intake
o Atorvastatin 20mg = prevention of CVD

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20
Q

Treat complications of CKD

A

o Oral sodium bicarbonate = metabolic acidosis
o Iron supplementation and erythropoietin = anaemia
o Vit D = renal bone disease
o Proteinuria  ACE-I, SGLT-2 inhibitors
o Dialysis = haemofiltration, haemodialysis, peritoneal dialysis
o Renal transplant = end stage renal failure

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21
Q

Risk factors for renal cell carcinoma

A
  • Von Hippel Lindau syndrome
  • Inherited disease = neurofibromatosis, tuberous sclerosis
  • Cystic disease = AD polycystic kidneys, horseshoe kidneys
  • Toxins = Smoking, industrial exposure to carcinogens
  • Obesity
  • Renal failure and haemodialysis
  • HYpertension
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22
Q

Types of RCC

A

Clear cell carcinoma, papillary or chromophobe

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23
Q

Spread of RCC

A

Spread may be direct (renal vein), via lymph or haematogenous (bone, liver, lung, brain)

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24
Q

Presentation of RCC

A
  • Often asymptomatic
  • Haematuria
  • Vague loin pain
  • Abdominal mass
  • Systemic: Anorexia, malaise, fever (of unknown origin), night sweats and weight loss
  • Polycythaemia, anaemia, hypercalcaemia
  • Hypertension
  • Varicocele (caused by tumour compressing veins)
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25
Investigations for RCC
- Ultrasound = distinguish simple cyst from complex cyst or tumour - Renal biopsy = Get histology to identify tumour - CT chest and abdomen with contrast o Renal mass and involvement of renal vein of inferior vena cava o Cannon ball metastases in lungs - MRI = Tumour staging (Robertson) - Bloods o FBC = detect polycythaemia and anaemia due to EPO decrease o ESR may be raised o LFTs abnormal = obstructive jaundice (Stauffer syndrome) o Hypercalcaemia
26
Management of RCC
- Radical or Partial nephrectomy - Radiotherapy and chemotherapy - Ablative techniques = Cryoablation and radiotherapy - Alpha-interferon and interleukin-2 to reduce tumour size
27
Complication of RCC
Stauffer syndrome
28
Risk factors for pyelonephritis
- Structural renal/urological abnormalities - Diabetes - Calculi - Catherisation - Pregnancy
29
Causes of pyelonephritis
- E. coli - Klebsiella - Enterococcus - Pseudomonas
30
Presentation of pyelonephritis
- High fever and rigors - Loin to groin pain - Nausea and Vomiting - Dysuria and urinary frequency - Haematuria - Severe headache - Pain on bimanual palpation of renal angle
31
Investigations of pyelonephritis
- Urine dipstick = blood, protein, leukocyte esterase, nitrite - Midstream urine microscopy, culture and sensitivity before starting Abx - Blood cultures - Raised WCC and ESR/CRP - CT scan (adults) and ultrasound scan (children) - Dimercaptosuccinic acid = indication of renal scarring
32
Management of pyelonephritis
- Broad spectrum cephalosporin or quinolone for 7-10 days - Consider hospital admission - Surgery = Drain abscess or relieve calculi causing infection
33
Complications of pyelonephritis
- Recurrent kidney infections - Leads to scarring renal parenchyma - CKD - Abscess/pus around kidney
34
Risk factors for kidney stones
- Anatomical abnormalities that predispose to stone formation - Diet = Chocolate, tea, strawberries, rhubarb (all increase oxalate levels) - Gout - Family history - Ileostomy - Dehydration - Primary renal disease = Polycystic kidneys, Renal tubular acidosis - Drugs = diuretics, antacids, acetazolamide, corticosteroids, aspirin, allopurinol, vit C and D - High calcium
35
Location of kidney stones
Pelviureteric junction, Pelvic brim, Vesicoureteric junction
36
Presentation of kidney stones
- Most asymptomatic - Renal colic o Rapid onset = woken from sleep o Excruciating ureteric spasms = patient writhing in pain and cannot lie still o Pain radiates from loin to groin and comes and goes in waves as ureters peristalise o Worse with fluid loading - Oliguria and Dysuria - Haematuria - Nausea and vomiting - Sepsis - Recurrent UTIs = increased risk if voiding impaired - Bowel sounds may be reduced - Hypotension
37
Investigations of kidney stones
- Urine dipstick = haematuria, protein, glucose - Mid-stream urine  MCS - Bloods = Serum urea, electrolyte, creatinine and calcium, FBC - Non-contrast CTKUB (CT Kidney Ureter Bladder) - Ultrasound = Shows kidney stones and renal pelvis dilatation well but ureteric stones can be missed
38
Management of kidney stones
- Strong analgesic for renal colic = IM Diclofenac - Antibiotics if infection = IV cefuroxime or IV gentamicin - Antiemetics to prevent vomiting - Fluids - Stones <5mm in lower ureter 90% pass spontaneously - Medical expulsive therapy o Oral nifedipine or alpha blocker (oral tamsulosin) = promote expulsion - If still not passing, then surgery o Extracorporeal shockwave lithotripsy (10-20mm) o Ureteroscopy and laser lithotripsy o Percutaneous nephrolithotomy (>20mm)
39
Prevention of kidney stones
- Overhydration - Diet = low Ca2+, low salt, low animal protein - Reduce BMI - Active lifestyle - Cholestyramine and pyridoxine reduced urinary oxalate secretion - Allopurinol and oral bicarbonate prevents uric acid stones - Cysteine binder = captopril - If hypercalciuria then thiazide diuretic (Oral Bendroflumethiazide)
40
Complications of kidney stones
- >50% lifetime risk of recurrence once you’ve had them - Acute pyelonephritis
41
Causes of glomerulonephritis
- Primary - Secondary = infection, autoimmunity or malignancy - Nephrotic and nephritic syndromes
42
Causes of acute urinary retention
- BPH - Urethral strictures - Calculi - Cystocele - Constipation - Masses - Drugs: anticholinergic, TCA, antihistamines, opioids, benzos - Neurological cause - UTI - Post-op or postpartum
43
Presentation of acute urinary retention
- Inability to pass urine - Lower abdominal discomfort/tenderness - Considerable pain or distress (chronic retention will be painless) - Acute Confusional state (elderly) - Palpable distended urinary bladder
44
Investigations for acute urinary retention
- Fluid status assessment VBG for K+ Rectal, neurological ± pelvic exam - Urinalysis and culture (after catheterisation) - Serum U&Es and creatinine, FBC, CRP - US bladder = volume >300 Accurately measure urine output
45
Management of acute urinary retention
- Decompression via catheterisation o Volume <200 indicates not urinary retention o Volume >400 indicates catheter should be left in place - Further investigation into causes - Trial of IV fluids unless in heart failure - Flush catheter if catheter not draining
46
Complications of acute urinary retention
- Post-obstructive diuresis - AKI
47
Risk factors for nephritis syndrome
- Hep B/C - Malaria
48
Causes of nephritic syndrome
- IgA nephropathy  Macroscopic haematuria in young people 1-2 days following URTI - Henoch-Schoenlein purpura  Children following infection - Post-streptococcal  1-2 wks after throat or skin infection - Anti-glomerular basement membrane disease - Rapidly progressive GN - Good-pasture’s disease - Systemic sclerosis - SLE
49
Presentation of nephritic syndrome
- Haematuria - Oliguria - Proteinuria = <3g/24 hours - Fluid retention (oedema) - Uraemia = anorexia, pruritus, lethargy, nausea - Hypertension - Moderate to severe decrease in GFR - HSP = palpable purpuric rash over buttocks and extensor surfaces
50
Investigations for nephritic syndrome
- Bloods = eGFR, serum urea and electrolytes and albumin - Culture = Swab from throat or infected skin - Urine dipstick = proteinuria and haematuria - Renal biopsy
51
Management of nephritic syndrome
- Treat causes - Salt and water restriction - Hypertension = ACE-I or CCBs (amlodipine) if AKI - Diuretics - Immunosuppression with corticosteroids for SLE, ANCA vasculitis, anti-GBM, IgA vasculitis - Antibiotics for endocarditis - Monitor blood pressure and urinalysis
52
Causes of nephrotic syndrome
- Primary o Minimal change disease (children) o Membranous nephropathy o Focal segmental glomerulosclerosis (adults) o Membranoproliferative GN - Secondary o Diabetes o Lupus nephritis, SLE, RA o Myeloma o Amyloid o Pre-eclampsia o HIV, HBV, HCV o Drugs = NSAIDS and ACEi
53
Presentation of nephrotic syndrome
- Peripheral pitting oedema - Proteinuria >3g/24 hours - Hypoalbuminemia <30g/L - Frothy urine - Hypercholesterolaemia >10mmol/l
54
Investigations for nephrotic syndrome
- Renal biopsy in adults - Urine dipstick = proteinuria - Bloods = low albumin, high creatinine, low eGFR, high lipids - Immunology/serology testing
55
Management of nephrotic syndrome
- Treat underlying cause and treat symptoms - Minimal change disease  oral corticosteroids or cyclophosphamide if steroid resistant - IV furosemide = oedema - Ramipril/candesartan = reduce proteinuria - Prophylactic anticoagulation with warfarin - Simvastatin = reduce cholesterol
56
Complications of nephrotic syndrome
- Venous Thromboembolism - Hypertension - Hyperlipidaemia - AKI - Infection  cellulitis, strep, peritonitis
57
What is autosomal dominant polycystic kidney disease (ADPKD)
- Genetic condition where kidneys develop multiple fluid filled cysts - Family history of ADPKD, ESRF or hypertension - Mutations in PKD1 (85%) gene on chromosome 16 - Mutations in PKD2 (15%) gene on chromosome
58
Presentation of ADPKD
- Nocturia - Loin pain - Haematuria - Excessive water and salt loss - Bilateral kidney enlargement - Renal colic due to clots - Hypertension - Recurrent UTIs - Renal stones = mainly uric acid stones - Progressive renal failure
59
Investigations for ADPKD
- Ultrasound o 15-39 yrs >/= 3 cysts (uni/bilateral) o 40-59 yrs >/= 2 cysts (each kidney) o >60 yrs >/= 4 cysts (each kidney) - Genetic testing for PKD1 and PKD2 - Screening for relative with abdo US
60
Management of ADPKD
- Tolvaptan (vasopressin receptor antagonist) = slow development of cysts and progression of renal failure - Laparoscopic removal of cysts to help with pain/nephrectomy (remove entire kidney) - Antihypertensives - Analgesia - Abx for infection - Drainage of infected cysts - Dialysis/transplant = end stage renal failure - Genetic counselling and support o Screening for relatives with US - Avoid contact sports = cyst rupture - Avoid anti-inflammatory meds and anticoagulants - Regular USS, bloods, BP
61
Complications of ADPKD
- Hepatic, splenic, pancreatic, ovarian, prostatic cysts - Cerebral berry aneurysms - Cardiac valve disease (mitral regurg) - Colonic diverticula - Aortic root dilatation
62
Presentation of autosomal recessive polycystic kidney disease
- Many present in infancy with multiple renal cysts and congenital hepatic fibrosis - Enlarged polycystic kidneys
63
Investigations for ARPKD
- Ultrasound - Genetic testing  PKHD1 mutation on long arm of chromosome 6
64
Management of ARPKD
- Genetic counselling for family members - Laparoscopic removal of cysts to help with pain/nephrectomy - Blood pressure control with ACE-inhibitor = ramipril - Treat stones and give analgesia - Renal replacement therapy for ESRF
65
Von Hippel-Lindau syndrome
- Autosomal dominant - Multisystem cancer syndrome  renal cysts and clear cell renal carcinoma in 40s - Mx : screen for tumours
66
Alport syndrome
- X-linked - Haematuria, proteinuria and progressive renal insufficiency - High tone sensorineural hearing loss
67
Types of diabetic nephropathy
- Diabetic kidney disease  any kidney disease in patient with diabetes - Diabetic nephropathy  any kidney disease presumed to be caused by diabetes - Diabetic glomerulopathy  biopsy proven diabetes related changes in glomerulus
68
Risk factors for diabetic nephropathy
- Modifiable  glycaemic control, hypertension control, salt intake, smoking, RAS blockage - Non-modifiable  age, sex, duration of diabetes, ethnicity
69
Diagnosis of diabetic nephropathy
- >10 years diabetes - Other microvascular complications - Progressive increase in urine protein excretion over years - No evidence of other probable cause
70
Management of diabetic nephropathy
- Optimise diabetic control - Optimise blood pressure control - Treatment of microalbuminuria/proteinuria  ACEi/ARB - Smoking cessation - Statins
71
Types of UTI
- Cystitis  bladder infection - Prostatitis  prostate infection - Pyelonephritis  kidney/renal pelvis infection
72
Risk factors for UTI
- Sexual activity - Urinary/faecal incontinence - Constipation - Spermicide use - Low oestrogen - Menopause - Dehydration - Obstructed urinary tract - Diabetes - Immunosuppression - Catheter - Pregnancy - Kidney/bladder stones
73
Causes of UTI
- Klebsiella pneumoniae - E. coli (MOST COMMON) - Enterococcus - Proteus mirabilis/ pseudomonas - Staphylococcus saprophyticus
74
Presentation of UTI
- Cystitis = frequency, dysuria, urgency, suprapubic pain, polyuria, haematuria, cloudy/smelly urine - Acute pyelonephritis = fever, rigors, vomiting, loin pain, costovertebral pain, septic shock
75
Classification of UTI
- Uncomplicated = normal renal tract structure and function - Complicated = presence of factors that increase risk of Tx failure
76
Investigation for UTI
- Dipstick for haematuria, nitrites, leukocytes - MSU culture - Bloods to assess for development of AKI - Sepsis 6 if indicated - Radiology for complicated pyelonephritis/UTI
77
Management of UTI
- Acute uncomplicated cystitis o Nitrofurantoin 3 days (women) or 7 days (men) o Trimethoprim (not in pregnancy) - Acute uncomplicated pyelonephritis o Oral ciprofloxacin 14 days - Acute complicated cystitis o Oral ciprofloxacin - Urosepsis or acute severe pyelonephritis o IV co-amoxiclav o Analgesia o IV fluids
78
Complications of UTI
- Urosepsis - Recurrent UTI (>3 in 1 year or >2 in 6m) - Chronic pyelonephritis - Abscess formation - Pyelonephrosis
79
Risk factors for BPH
- African-Caribbean more than white men - Older men - High testosterone
80
Presentation of BPH
- Voiding Sx (obstructive)  weak or intermittent urinary flow, straining, hestitancy, terminal dribbling, incomplete emptying, delay in initiation of micturition - Storage Sx (irritative)  urgency, frequency, overflow/urgency incontinence, nocturia - Haematuria - Enlarged bladder - Occluded bladder = anuria
81
Investigations for BPH
- Urine dipstick + MSU - DRE = enlarged and smooth prostate - Serum PSA = may be raised - Flow rates and residual volume - Frequency volume chart - U+Es and renal ultrasound = exclude renal damage - Transrectal ultrasound = size of prostate - International Prostate Symptom Score (IPSS)
82
Conservative management of BPH
- Reassurance and monitoring if manageable symptoms - Lifestyle = avoid caffeine, alcohol, relax when voiding
83
Medical management of BPH
- 1st line = alpha 1 antagonist (oral tamsulosin) o Relax smooth muscle - 2nd line = 5-alpha-reductase inhibitor (oral finasteride) o Block testosterone and helps reduced size of prostate
84
Surgical management for BPH
o Transurethral resection of prostate (TURP) o Transurethral electrovaporisation of prostate (TUVP) o Holmium laser enucleation of prostate (HoLEP) o Open prostatectomy via abdominal or perineal incision
85
Complications for BPH
- Bladder calculi - UTI - Acute urinary retention - Kidney damage
86
Risk factors for prostate cancer
- Family history - Genetic = HOXB13, BRCA 2 - Increased testosterone - Tall - Anabolic steroids
87
Pathophysiology of prostate cancer
- Majority adenocarcinomas arising is peripheral zone of prostate gland - Most common site of metastases is bone and lymph nodes - Locally spread to seminal vesicles, bladder and rectum
88
Presentation of prostate cancer
- LUTS if local disease = nocturia, hesitancy, poor stream, terminal dribbling, retention - Weight loss, fatigue and bone pain - Haematuria - Erectile dysfunction - Anaemia
89
Investigations for prostate cancer
- DRE = hard irregular prostate - Raised PSA = false positive and negatives - Trans-rectal ultrasound and biopsy
90
Scoring system for prostate cancer
Gleason
91
Management of prostate cancer
- Watch and wait - Radiotherapy - Brachytherapy = implantation of radioactive material targeted at tumour - Hormonal treatment o Bilateral orchidectomy o LHRH agonists (goserelin) o Androgen receptor blockers (bicalutamide) - Surgery = total prostatectomy
92
Complications of prostate cancer
- Erectile dysfunction - Urinary incontinence - Radiation induce enteropathy = PR bleeding, pain, incontinence - Urethral strictures
93
Risk factors for prostatitis
- STI - UTI - Indwelling catheter/ intermittent bladder catheterisation - Post-prostate biopsy - Increasing age
94
Causes of prostatitis
- Streptococcus faecalis - E.coli - Chlamydia
95
Presentation of prostatitis
- Fevers, rigors, malaise - Pain on ejaculation - Pain in perineum, penis, rectum or back - Significant voiding LUTs = poor intermittent stream, hesitancy, incomplete emptying, post micturition dribbling, straining, dysuria
96
Investigations for prostatitis
- DRE = prostate tender, hard and hot, boggy - Urine dipstick = positive for leucocytes and nitrites - Urine and blood cultures - STI screen = chlamydia - Trans-urethral ultrasound scan
97
Management of prostatitis
- 14 day course of quinolone (ciprofloxacin) - Acute o IV gentamicin + IV co-amoxiclav o 2-4 weeks on quinolone = ciprofloxacin o 2nd line = trimethoprim o TRUSS guided abscess drainage if necessary - Chronic o 4-6 week course of quinolone = ciprofloxacin o +/- alpha blocker = tamsulosin o NSAIDs = ibuprofen
98
Risk factors for bladder cancer
- Smoking - Occupation = industrial paint, motor, leather and rubber workers, blacksmiths, hair dye - Indwelling catheter - Bladder stones - Family history - Schistomiasis = SCC - Previous radiation to pelvis - Drinking water is protective
99
Pathophysiology of bladder cancer
- Transitional cell carcinoma (>90%) or squamous cell carcinoma - Tumour spread to pelvic structures (local), iliac and para-aortic nodes (lymphatic), liver and lungs (blood)
100
Presentation of bladder cancer
- Painless macroscopic haematuria - Recurrent UTIs - Voiding irritability - LUTS - Painful clot retention - If advanced  mass, lymphadenopathy, pelvic/flank pain - Systemic: weight loss, lethargy
101
Investigations of bladder cancer
- Flexible Cystoscopy and biopsy under 2WW - CT urogram - Urinary tumour markers
102
Management of bladder cancer
- Not invading muscle o TURBT o Chemo into bladder after surgery o Weekly Tx for 6 weeks with BCG vaccine squirted into bladder via catheter - Muscle invasive o Radical cystectomy with ileal conduit o Radiotherapy o IV chemo - Metastatic = palliative chemo and radio
103
Complications of bladder cancer
- Cystectomy = sexual and urinary malfunction - Clot retention - B12/folate deficiency
104
Risk factors for testicular cancer
- Infant hernia - Infertility - Family history - Previous testicular tumour - Cryptorchidism  Undescended testis - Klinefelter’s syndrome
105
Pathophysiology of testicular cancer
- Germ cell cancer = seminoma (older), teratoma (child) - Metastasise to lung, liver, brain, para-ortic lymph nodes, cervical nodes
106
Presentation of testicular cancer
- Painless lump in testicle - Testicular pain and/or abdominal pain - Cough and dyspnoea = indicative of lung metastases - Back pain = para-aortic lymph node metastasis - Hydrocele = May contain bloodstained fluid - Abdominal mass
107
Investigations for testicular cancer
- Ultrasound and biopsy - Tumour markers o Alpha-fetoprotein raised in teratomas o Beta-hCG raised in teratomas and seminomas o Lactate dehydrogenase - CXR and CT = staging and metastases
108
Management of testicular cancer
- Orchidectomy - Chemo/radiotherapy - Monitoring post treatment with tumour markers and imaging - Sperm storage offered
109
Cause of hydronephrosis
- Unilateral (PACT) o Pelvic-ureteric obstruction (congenital or acquired) o Aberrant renal vessels o Calculi o Tumours of renal pelvis - Bilateral (SUPER) o Stenosis of urethra o Urethral valve o Prostatic enlargement o Extensive bladder tumour o Retro-peritoneal fibrosis
110
Investigations of hydronephrosis
- US  hydronephrosis - IVU  assess position of obstruction - Antegrade or retrograde pyelography - If suspect renal colic do CT scan
111
Management of hydronephrosis
- Remove obstruction and drainage of urine - Acute upper urinary tract obstruction  nephrostomy tube - Chronic upper urinary tract obstruction  ureteric stent or pyeloplasty
112
Associations of epididymal cyst
- Polycystic kidney disease - Cystic fibrosis - Von Hippel-Lindau syndrome
113
Presentation of epididymal cyst
- Small cysts may remain undetected and asymptomatic o Well defined and will transilluminate since fluid-filled - Testis is palpable quite separately from cyst and lies posterior (Unlike hydrocele) - Once cysts get large, may be painful
114
Management of epididymal cyst
Scrotal US - If painful and symptomatic then surgical excision
115
Causes of acute tubular necrosis
- Ishcaemia  shock, sepsis - Nephrotoxins  aminoglycosides, myoglobin (secondary to rhabdomyolysis), radiocontrast agents, lead
116
Presentation of acute tubular necrosis
- Features of AKI  raised urea, creatinine, potassium - Muddy brown cast in urine
117
Phases of acute tubular necrosis
- Oliguric phase - Polyuric phase - Recovery phase
118
Histology of acute tubular necrosis
o Tubular epithelium necrosis o Dilatation of tubules o Necrotic cells obstructing tubule lumen
119
Causes of rhabdomyolysis
- Seizure - Collapse/coma - Ecstasy - Crush injury - McArdle’s syndrome - Drugs: statins
120
Investigations for rhabdomyolysis
- AKI with disproportionately raised creatinine - Elevated creatine kinase (at least 5x upper limit) - Myoglobinuria: dark/ reddish-brown colour - Hypocalcaemia - Elevated phosphate - Hyperkalaemia - Metabolic acidosis
121
Management of rhabdomyolysis
- IV fluids to maintain good urine output - Urinary alkalinisation
122
Causes of hyperkalaemia
- AKI - CKD - Adrenal insufficiency - Rhabdomyolysis - Tumour lysis syndrome - Drugs: spironolactone, ACEi/ARB, NSAIDs, ciclosporin, heparin - Potassium supplements: bananas, kiwi, salt substitues - Massive blood transfusion
123
Presentation of hyperkalaemia
- Asymptomatic until K+ is high enough to cause cardiac arrest - Chest pain - Weakness - Palpitations - Light headedness - Muscle weakness and fatigue - Kussmaul’s respiration = low, deep, sighing inspiration/expiration - Fast irregular pulse - Metabolic acidosis
124
Bloods for hyperkalaemia
- Serum K+ > 5.5mmol/L o If >6.5mmol/L = Medical emergency
125
ECG for hyperkalaemia
Tall tented T waves, Flattening or absence of P waves, Broad QRS complexes o Usually only ECG changes if K+ >6.0
126
Management of hyperkalaemia
1. IV calcium gluconate for cardiac stability 2. 50ml 50% dextrose infusion with 10 units of ActRapid over 15 mins - Nebulised salbutamol - Calcium Resonium or sodium zirconium cyclosilicate  remove K+ from body - Repeat VBG/U+Es to Monitor for response and rebound - Monitor glucose - Review medication = ACEi, NSAIDs, spironolactone - Sodium bicarbonate = correct acidosis - Dialysis
127
Causes of hypokalaemia
- Vomiting and diarrhoea - Thiazide and loop diuretics - Cushing’s and Conn’s syndrome - Corticosteroids
128
Presentation of hypokalaemia
- Usually asymptomatic - Muscle weakness - Cramps - Tetany - Palpitations - Light-headedness - Constipation - Hypotonia - Hyporeflexia - Arrhythmias
129
Bloods for hypokalaemia
- Serum K+ <3.5 mmol/L o <2.5 mmol/L = urgent treatment
130
ECG for hypokalaemia
o Small or inverted T waves o Prominent U waves o Long PR interval o Depressed ST segments
131
Management for hypokalaemia
- Identify and treat underlying cause - Withdrawal from diuretics/laxatives - Oral/IV K+ supplements = oral sando-k - If on thiazide diuretic, switch to K+ sparing diuretic (spironolactone)
132
Causes of hypernatraemia
- Dehydration - Osmotic diuresis - Diabetes insipidus - Excess IV saline
133
Management of hypernatraemia
- Manage underlying cause - Replace deficit plus maintenance slowly at uniform rate over 48 hrs
134
Complications of hypernatraemia
Rapid infusion = cerebral oedema
135
Causes of metabolic acidosis with normal anion gap
o Gastrointestinal bicarbonate loss: diarrhoea, ureterosigmoidostomy, fistula o Renal tubular acidosis o Drugs: acetazolamide o Ammonium chloride injection o Addison’s disease
136
Causes of metabolic acidosis with raised anion gap
o Lactate: shock, hypoxia o Ketones: diabetic ketoacidosis, alcohol o Urate: renal failure o Acid poisoning: salicylates, methanol
137
Metabolic alkalosis causes
- Vomiting/aspiration - Diuretics - Liquorice, carbenoxolone - Hypokalaemia - Primary hyperaldosteronism - Cushing’s syndrome - Bartter’s syndrome - Congenital adrenal hyperplasia
138
Maintenance fluids for adult
25-30ml/kg/day 1mmol/kg/day K+, Na+, Cl 50-100g/day glucose
139
Causes of hyponatraemia
- Hypovolaemic hyponatraemia  diuretic stage of renal failure, diuretics, Addisonian crisis - Euvolaemic hyponatraemia  SIADH - Hypervolaemic hyponatraemia  heart failure, liver failure, nephrotic syndrome
140
Presentation of hyponatraemia
- Early Sx o Headache o Lethargy o Nausea o Vomiting o Dizziness o Confusion o Muscle cramps - Late Sx o Seizures o Coma o Respiratory arrest
141
Severity of hyponatraemia
- Mild:130-134 - Moderate: 120-129 - Severe: <120
142
Management of hyponatraemia
- Exclude spurinous result - Review medications - Chronic hyponatraemia without severe Sx o Hypovolaemic  isotonic saline o Euvolaemic  fluid restrict to 500-1000ml/day, consider demeclocycline/vaptans o Hypervolaemic  fluid restrict to 500-1000ml/day + consider loop diuretics/vaptans - Acute hyponatraemia with severe Sx o Hypertonic saline (3% NaCl)
143
Complications of hyponatraemia
- Cerebral oedema  brain herniation - Of Tx  osmotic demyelination syndrome o Locked-in syndrome
Finals
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