MLA > Renal > Flashcards

Renal Flashcards

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1
Q

What is chronic kidney disease?

A
  • chronic reduction in function sustained over 3 months
  • permanent and progressive
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2
Q

What is the presentation of chronic kidney disease?
fippan

A
  • fatigue
  • insomnia
  • polyuria
  • pruritus
  • anorexia
  • nausea + vomiting
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3
Q

When does CKD present?

A
  • primarily asymptomatic
  • presents when advanced (stages 4-5)
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4
Q

What may be seen on examination of CKD?

A
  • uraemic fetor (breath)
  • pallor (anaemia)
  • hypertension
  • oedema (peripheral + pulmonary)
  • peripheral neuropathy
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5
Q

What are risk factors for chronic kidney disease?

A
  • older age
  • diabetes
  • hypertension
  • smoking
  • nephrotoxic medication
  • male
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6
Q

What are common causes of CKD?

A
  • diabetes (nephropathy)
  • hypertension
  • age
  • glomerulonephritis
  • pyelonephritis
  • PKD
  • meds: NSAIDs, PPIs, lithium
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7
Q

What is the pathophysiology behind chronic kidney disease?

A
  • damaged nephrons > reduced GFR
  • inc burden on remaining nephrons
  • compensatory RAAS to inc GFR causes inc transglomerular pressure and damages basement membrane selectiveness
  • leads to proteinuria and haematuria
  • mesangial scarring
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8
Q

What investigations are done in chronic kidney disease?

A
  • urine dip for haematuria
  • eGFR with U&E: 2 tests 3 months apart
  • albumin:creatinine (ACR)
    >3mg/mmol is significant
  • BP, HbA1c and lipids
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9
Q

How is CKD managed?

A
  • exercise + healthy weight
  • ACEi and SGLT2
  • atorvastatin to prevent CVD
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10
Q

How is hypertension in CKD treated?

A
  • ACE inhibitors
  • Furosemide if GFR <45
  • dapagliflozin (SGLT2) if diabetic
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11
Q

With CKD, what decrease in eGFR or rise in creatinine is accepted?

A
  • eGFR: decrease up to 25%
  • creatinine: rise up to 30%
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12
Q

If a patient with CKD is dehydrated, what should be done with their hypertension drugs?

A
  • temporarily stop
  • e.g. gastroenteritis
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13
Q

What eGFR is the criteria for chronic kidney disease?

A

eGFR <60mL/min/1.73m^2

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14
Q

What are the eGFR values for the stages of chronic kidney disease?

A
  • 1 = >90
  • 2 = 60-89
  • 3a = 45-59 (moderate)
  • 3b = 30-44
  • 4 = 15-29 (severe)
  • 5 = <15 (end-stage renal failure)
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15
Q

What is the most significant factor causing anaemia in CKD?

A
  • lower erythropoietin
  • less RBC production
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16
Q

How does reduced iron absorption contribute to anaemia in CKD?

A
  • hepcidin levels increased due to inflammation and lower renal clearance
  • leads to decreased iron absorption in gut and impaired storage
  • less available for RBC production
  • less Fe3 to Fe2 conversion > less absorption
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17
Q

What is the target Hb for anaemia in CKD and how is it managed?

A
  • target Hb of 100-120g/L
  • oral iron if not on erythropoesis stimulation or haemodialysis
  • if on either above, use IV iron
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18
Q

What type of anaemia is seen in CKD and at what GFR?

A
  • normochromic normocytic
  • eGFR <35ml/min
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19
Q

What cardiac complication can occur due to anaemia in CKD?

A
  • left ventricular hypertrophy
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20
Q

What bloods are seen in renal bone disease in CKD?

A
  • high phosphate
  • low vit D
  • low calcium
  • 2º hyperparathyroid
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21
Q

What is the pathophysiology of renal osteodystrophy in CKD?

A
  • dec phosphate excretion > high serum phosphate
  • low vit D and low calcium (no hydroxylation of vit D to calcitriol)
  • more parathyroid hormone excreted > 2º hyperparathyroidism
  • stimulates osteoclasts > inc Ca absorption from bone
  • osteomalacia and osteosclerosis
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22
Q

What is a key finding on spinal X-Ray of renal bone disease in CKD?

A
  • rugger jersey spine
  • sclerosis of vertebral body and osteomalacia in centre
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23
Q

How is renal bone disease in CKD managed?

A
  • low phosphate diet
  • phosphate binders
  • active vit D
  • adequate calcium intake
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24
Q

When are calcium-based phosphate binders used in mineral bone disease in CKD?

A
  • normal or low serum calcium
  • no risk of vascular calcification
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25
Sevelamer is a non calcium-based phosphate binder used in mineral bone disease in CKD. Give: 1. its mechanism 2. its risks
- binds to dietary phosphate and prevents absorption - reduced uric acid levels - hypercalcaemia or vascular calcification risk
26
Give two other non-calcium based phosphate binders
- lanthanum carbonate - ferric citrate
27
What bone complications may occur with CKD?
- osteitis fibrosa cystica - adynamic bone disease - osteomalacia - osteosclerosis - osteoporosis
28
When are vitamin D analogues used in renal bone disease in CKD?
- 2º hyperparathyroidism - titrate dose to minimise hypercalcaemia and adynamic bone disease risk
29
Why might parathyroidectomy be needed in CKD?
- refractory 2º hyperpth despite medical management
30
What is adynamic bone disease in CKD? - 2 causes - PPx - Calcium?
- oversuppressed parathyroid - overtreatment with vit D analogues/ Ca based phosphate binders - osteoblasts and clasts become inactive - no bone remodelling, low turnover - Ca goes to vessels > vascular calcification
31
What factors may affect an eGFR result?
- pregnancy - muscle mass - eating red meat 12h prior
32
How can AKI and CKD be differentiated on renal USS and bloods?
- CKD pts have bilateral small kidneys - CKD likely hypocalcaemic
33
Does albumin:creatinine ratio (ACR) or protein:creatinine ratio (PCR) have greater sensitivity?
- ACR - recommended in diabetics
34
How is an ACR sample collected?
- first pass morning urine specimen - if 3-70mg/mmol: confirm with repeat sample - if >70, no repeat
35
How is proteinuria in CKD managed?
- ACEi or ARB 1st line if htn + CKD, with ACR >30mg/mmol - if ACR >70, give treatment even if no htn
36
How do SGLT-2 inhibitors treat proteinuria?
- block glucose reabsorption - reduced Na reabsorption - reduces BP
37
What additional evidence of renal disease is needed to diagnose CKD stages 1-2?
- Proteinuria - Urine sediment abnormalities: RBC, casts, or WBC - Electrolyte abnormalities - Structural or histological abnormalities - History of kidney transplantation
38
What is accelerated CKD?
- within 12 mo: - persistent decrease in eGFR of 25% or more and a change in CKD category - persistent decrease in eGFR of 15
39
How often should different risk levels of CKD be monitored?
- low-moderate: annually - high: every 6mo - very high: every 3-4mo
40
What GFR defines renal failure?
- <15ml/min
41
What is haemodialysis?
- pump blood through dialyser - 4hrs 3x per week - solutes diffuse into dialysate and are removed - needs arterio-venous fistula (takes 8 weeks to become usable)
42
What is peritoneal dialysis?
- infusing dialysate into peritoneal cavity through permanent catheter - drained after several hrs dwell time
43
What is continuous ambulatory peritoneal dialysis?
- manual exchanges performed 4x daily - exchanges last 30 mins - dwell time 4-8hrs - can do normal activities
44
What is automated peritoneal dialysis?
- dialysis machine works while the patient is sleeping - 3-5 exchanges over 8-10 hours each night
45
How does transplantation work in CKD?
- transplanted into groin - renal vessels connected to the external iliac vessels - failing kidneys are not removed - take life-long immunosuppressants to prevent rejection
46
What are complications of CKD? PAUNCHR
P – Pulmonary oedema A – Acidosis U – Uraemic encephalopathy N – aNaemia C – Cardiovascular disease H – Hyperkalaemia R – Renal bone disease
47
What are key complications of haemodialysis?
- infection - haemodynamic instability - hypotension - cramps, n+v
48
What are key complications of peritoneal dialysis?
- peritonitis - catheter infection or blockage - hyperglycaemia - hernia - encapsulating peritoneal sclerosis
49
What is acute kidney injury?
- acute drop in kidney function over hours or days - diagnosed by measuring serum creatinine
50
What are the NICE criteria for AKI?
- rise in creatinine of ≥25µmol/L in 48h - rise in creatinine of ≥50% in 7 days - urine output of < 0.5ml/kg/hr for > 6hrs
51
What are pre-renal causes of renal failure?
- due to inadequate blood supply to the kidneys, reducing filtration of blood - hypovolaemia - reduced CO - drugs that reduce BP - renal artery stenosis
52
What are causes of intrinsic renal failure?
- intrinsic disease leads to reduced filtration of blood - Glomerulonephritis - Interstitial nephritis - Acute tubular necrosis - rhabdomyolysis: CK in skeletal muscle is nephrotoxic - nephrotoxic drugs and antibiotics
53
What are post-renal causes of AKI?
- caused by obstruction to the outflow of urine causing back pressure and reduced kidney function - renal stones - cancer - enlarged prostate - blocked catheter
54
How is AKI investigated?
- urinalysis - leucocytes and nitrites: infection - protein and blood: acute nephritis - glucose: diabetes
55
How is AKI managed?
- fluid rehydration if pre-renal - stop nephrotoxic medication - relieve obstruction if post renal - dialysis if serious
56
What are symptoms of AKI?
- nausea - dehydration and less urination - oedema - diarrhoea - confusion and drowsiness
57
What are risk factors for AKI?
- CKD - heart failure - diabetes - liver disease - older age - oliguria
58
When should renal USS be done in AKI?
- no identifiable cause - within 24hrs
59
Which drugs may cause toxicity in AKI (but do not worsen the AKI themselves)? 3 drugs
- metformin - lithium - digoxin
60
Which drug classes are nephrotoxic by altering GFR?
- ACEi - ARBs - NSAIDs - cyclosporin
61
Which drugs are toxic to tubular cells?
- aminoglycosides (gentamicin) - cisplatin
62
Which drugs cause crystal nephropathy?
- aciclovir - ampicillin
63
Define stage 1 AKI by creatinine vs baseline and urine output reduction
- inc in creatinine 1.5-1.9x baseline - reduction in output <0.5mL/kg/hr for ≥6hrs
64
Define stage 2 AKI by creatinine vs baseline and urine output reduction
- inc in creatinine 2.0-2.9x baseline - reduction in output <0.5mL/kg/hr for ≥12hrs
65
Define stage 3 AKI by creatinine vs baseline and urine output reduction
- inc in creatinine ≥3.0 baseline - reduction in output <0.3mL/kg/hr for ≥24hrs - eGFR <35 if under 18y/o
66
What is Goodpasture's syndrome?
- rare, genetic, autoimmune condition - glomerulonephritis and alveolar haemorrhage with circulating anti-GBM antibodies
67
What is post streptococcal glomerulonephritis?
- patients under 30 y/o - occurs 1-3 weeks after streptococcal (S. pyogenes) infection - patients develop a nephritic syndrome and usually have a full recovery
68
What is nephritic syndrome?
- a group of symptoms - haematuria (smoky coloured urine) - oliguria - proteinuria - fluid retention
69
What is an epididymal cyst?
- occur at head of epididymis - on top of but posterior to testicle - fluid filled sac - soft, round lump - separate from testicle - harmless - may be able to transilluminate
70
What conditions are associated with epididymal cysts?
- polycystic kidney disease - cystic fibrosis - von Hippel-Lindau syndrome
71
What is a hydrocele?
- collection of fluid in tunica vaginalis - can be idiopathic - cause: cancer, torsion, epididymo-orchitis, trauma
72
What is a communicating hydrocele?
- caused by processus vaginalis allowing peritoneal fluid to drain into scrotum
73
What is a non-communicating hydrocele?
- excess fluid production in tunica vaginalis
74
How does a hydrocele present?
- testicle palpable within hydrocele - painless and soft scrotal swelling anterior to and below testicle - irreducible and no bowel sounds - transilluminated by torch
75
How is a hydrocele managed?
- infantile repaired if no spontaneous resolve by age 1-2 - adults: conservative, may USS to exclude tumour - surgical repair if causing discomfort
76
What is a varicocele?
- veins in pampiniform plexus become swollen - veins drain into testicular vein and regulate temp in testes - 90% occur in LHS - associated with subfertility
77
How does a varicocele present?
- throbbing pain, dragging sensation - more prominent on standing and disappears when lying down - scrotal mass that feels like bag of worms - does NOT transilluminate
78
How are varicoceles investigated?
- US with doppler imaging - semen analysis - hormonal tests
79
How are varicoceles managed?
- usually conservative - surgical if extreme pain
80
What complications can arise from varicoceles?
- testicular atrophy - reduction in size and function of testicle - infertility/impaired fertility due to temperature disruption
81
What is a spermatocele?
- benign, smooth, extra-testicular - cyst fluid contains sperm - develops commonly post vasectomy - no way to differentiate from varicocele on examination
82
What is epididymo-orchitis and what are the causes?
- inflammation of the epididymis ± testicle on one side - commonly caused by spread of infection from genital tract or bladder
83
What are the causes of epididymo-orchitis?
- E. coli (common >35) - chlamydia trachomatis (common <35) - neisseria gonorrhoea - mumps
84
What is the presentation of epididymo-orchitis?
- gradual onset of pain - unilateral testicular pain and swelling - may have urethral discharge - Prehn's sign positive: pain relief on elevation of testicle
85
What is the investigation of epididymo-orchitis?
- rule out testicular torsion - assess for STI in younger pts - MSU for MC&S in older pts
86
How is epididymo-orchitis managed?
- refer to STI clinic if appropriate - ceftriaxone 500mg IM, plus oral doxycycline 100mg BD for 10-14 days - if sending MSU, treat empirically with oral quinolone for 2 weeks
87
What is testicular torsion?
- twisting of the spermatic cord and rotation of the testicle - can lead to ischaemia, necrosis and infertility
88
What is the epidemiology and aetiology of testicular torsion?
- males aged 10-30 - typically occurs in teenage boys - triggered by activity e.g. sport - Bell-clapper deformity: absence of fixation between testicle and tunica vaginalis
89
What is the presentation of testicular torsion?
- acute, rapid onset of severe unilateral testicular pain - abdo pain and vomiting - firm, swollen testicle - testicle lying high and horizontal
90
What is seen on examination in testicular torsion?
- absent cremasteric reflex - Prehn's sign negative - swollen testis retracted upwards - reddened skin
91
How is testicular torsion investigated?
- doppler ultrasound to rule out epididymitis (but can delay surgery) - absent cremasteric reflex - surgical exploration mandatory as urological emergency
92
How is testicular torsion managed?
- surgery - surgical exploration of scrotum - orchidectomy (removal) if necrosis
93
What occurs after successful detorsion in testicular torsion?
- wrapped in warm saline gauze - viable if pink colour returns - if viable, both testis should be fixed (bilateral orchidopexy)
94
What is benign prostatic hyperplasia?
- hyperplasia of the stromal and epithelial cells of the prostate
95
What is the epidemiology of BPH?
- older men - 80% of aged 80 have evidence - black > white > Asian
96
What are the symptoms of BPH?
- LUTS - complications: UTI, retention, obstructive uropathy
97
How is BPH investigated?
- international prostate symptom score (IPSS) - DRE - PSA - urine dipstick and bladder diary
98
What can cause a raised PSA?
- prostate cancer - BPH - prostatitis - UTI - vigorous exercise - recent ejaculation or prostate stimulation
99
How is BPH treated?
- α blockers e.g. tamsulosin relaxes smooth muscle - 5-α reductase inhibitors reduce size of prostate: convert testosterone to DHT e.g. finasteride - can be used in combination if needed
100
How do α-1 antagonists work in BPH and what are some adverse effects?
- first line and recommended for voiding symptoms - decrease smooth muscle tone of prostate and bladder - adverse: dizziness, postural hypotension, dry mouth, depression
101
How do 5 α reductase inhibitors work in BPH?
- block conversion of testosterone to dihydrotestosterone - indicated if significantly enlarged prostate or high progression risk - causes reduction in prostate volume - may take up to 6 mo to work
102
What are adverse effects of 5 α reductase inhibitors?
- erectile dysfunction - reduced libido - ejaculation problems - gynaecomastia
103
What is felt in a prostate exam that differentiates BPH and cancer?
- BPH: smooth, symmetrical, slightly soft with central sulcus - cancer: hard, asymmetrical, irregular, loss of central sulcus
104
Which LUTS fall into storage?
- frequency - urgency - nocturia - incontinence
105
Which LUTS fall into voiding?
- poor flow (weak/intermittent) - incomplete emptying - straining - terminal dribbling - hesitancy
106
Which LUTS fall into post micturition?
- sensation of incomplete voiding - post-micturition dribbling
107
What drugs may be used in BPH if there is a mix of storage and voiding symptoms?
- anticholinergic - tolterodine or darifenacin
108
What is surgical management of BPH?
transurethral resection of prostate
109
What is hydronephrosis?
- swelling of the kidney due to obstructive uropathy
110
What are the unilateral causes of hydronephrosis? (PACT)
- Pelvic-ureteric junction obstruction - Aberrant renal vessels > extrinsic compression - Calculi - Tumour of renal pelvis or ureter
111
What are bilateral causes of hydronephrosis? (SUPER)
- Stenosis of urethra - Urethral valve - Prostatic enlargement - Extensive bladder tumour - Retroperitoneal fibrosis
112
How is hydronephrosis investigated?
- 1st line: USS - IV urogram: site and degree of obstruction - anterograde/retrograde pyelography - if renal colic: non-contrast CT KUB: calculi
113
How is hydronephrosis managed?
- relieve obstruction + drain urine - unilateral: nephrostomy to decompress - bilateral: nephrostomies - chronic: stenting
114
What are risk factors for renal stones?
- dehydration - Hx or FHx - obesity - hypercalciuria, hyperpth, hypercalcaemia - renal tubular acidosis - polycystic kidney disease
115
What are risk factors for urate stones?
- gout - ileostomy: loss of bicard and fluid > acidic urine > uric acid precipitation
116
Which drugs cause/prevent renal stones?
- cause: loop diuretics, steroids, acetazolamide, theophylline - prevent: thiazide diuretics
117
What is the presentation of renal stones?
- sudden onset, severe loin to groin pain: colicky - nausea - systemic: fever (infection)
118
What bloods should be done in renal colic and what is seen?
- FBC: neutrophilia - check eGFR - CRP: raised - lactate: consider infection
119
What bedside investigations may be done in renal stones and what is seen?
- ECG: sinus tachycardia - urine dip: microscopic haematuria - urine MC&S: for infection
120
What imaging is done in renal stones?
- non-contrast CT KUB (within 24h) - if pregnant/young: USS
121
How may pain be managed in renal colic/stones?
- NSAIDs: (PR) diclofenac - if CI: IV paracetamol - α blockers: promote smooth muscle relaxation > easing stone passage
122
How are calcium renal stones prevented?
- 2.5-3L fluid intake per day - add lemon juice to water - avoid carbonated drinks - <6g salt per day - NORMAL Ca intake - thiazide diuretics if recurring
123
In which patients should urine culture be sent for UTI?
- women aged > 65 years - recurrent UTI (2 episodes in 6 mo or 3 in 1y) - pregnant women - men - visible or non-visible haematuria
124
How likely is UTI in the following dipstick results? nitrite, leukocyte and RBC
- +ve for nitrite/leukocyte and RBC → UTI likely - -ve for nitrite and +ve for leukocyte → UTI is equally likely to other diagnoses - -ve for nitrite, leukocyte, RBCs → UTI is less likely
125
What Abx are given for an uncomplicated UTI?
- 3 days of trimethoprim or nitrofurantoin
126
How are UTIs treated in men?
- 7d of trimethoprim or nitrofurantoin - send urine culture before starting Abx
127
How is UTI treated in catheterised patients?
- don't treat asymptomatic bacteria - if symptomatic give 7d abx - change/remove catheter asap if been in for >7d
128
How are recurrent UTIs treated?
- Prophylactic oral abx (cephalexin, nitrofurantoin and trimethoprim) 1st line - take daily or postcoitally for 6-12 mo
129
What are the 3 common causes of non specific urethritis?
- Chlamydia trachomatis - Ureaplasma urealyticum - Mycoplasma genitalium
130
How is urethritis managed?
- oral doxycycline 7d - OR single dose azithromycin
131
How is urethritis investigated?
- gram stained urethral swab looking for leukocytes and Gram negative diplococci - Chlamydia urinary NAAT
132
What are risk factors for acute bacterial prostatitis?
- recent UTI - intermittent bladder catheterisation - recent prostate biopsy - BPH
133
What are the features of acute bacterial prostatitis?
- pain in perineum, penis, rectum, back, suprapubic - obstructive voiding symptoms - fever/rigors - DRE: tender, boggy prostate
134
How is acute bacterial prostatitis managed?
- 14d course of a quinolone e.g. ciprofloxacin - consider STI screen
135
What type of cancer is prostate cancer usually?
adenocarcinoma
136
How does prostate cancer spread?
- lymphatic spread to obturator nodes - local spread to seminal vesicles
137
What are risk factors for prostate cancer?
- age - obesity - Afro-Caribbean - FHx
138
What may be felt in prostate cancer on DRE?
- asymmetrical - hard - nodular enlargement - loss of median sulcus
139
What are presenting features of prostate cancer?
- bladder obstruction: hesitancy and retention - haematuria - back, perineal or testicular pain
140
What are the choices of investigation in prostate cancer?
- TRUS biopsy - multiparametric MRI
141
Within what timeframe does hyperacute rejection occur? Why does it occur?
- minutes to hours - pre-existing antibodies against ABO/HLA antigens - type II hypersensitivity reaction
142
What is the pathophysiology of hyperacute rejection and how is it managed?
- widespread thrombosis of vessels > ischaemia and necrosis of transplant - no treatment, graft removed
143
Within what timeframe does acute graft failure occur and why?
- <6 months - cell mediated (cytotoxic T cells) - mismatched HLA
144
How is acute graft failure identified?
- asymptomatic - rising creatinine, pyuria and proteinuria - USS guided renal allograft
145
How is acute graft failure managed?
- steroids and immunosuppressants
146
What are secondary causes of minimal change disease?
- Hodgkin's lymphoma - NSAID use
147
What are secondary causes of FSGS?
- HIV - obesity - reflux nephropathy - drugs: lithium, bisphosphonates
148
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