1
Q
causes of CKD
A
HTN Diabetes Melitius Glomeronephritis Pylonephritis Obstructive nephropathy
2
Q
explain process of haemodialysis
A
AV fistula made –> 2 months
vein: cephalic / basilic
artery: brachial
- blood filtered against a semi-permable membrane
- toxic concentrations filter across
- blood becomes more like the dialsis fluid
- filtered back
3
Q
complications of dialysis
A
bacterial peritonitis
sclerosing peritonitis
constipation
4
Q
what time period determines whether the organ rejection is acute or chronic?
A
6 months
5
Q
if on immunosuppressants - what are you concerned about?
A
Squamous cell carcinoma
6
Q
what is the term called for bone disease in patients with renal failure
A
renal osteodystropy
also known as uraemic osteopathy
- osteomalacia / rickets
- hyperparathyroidism
7
Q
action of PTH
A
- increases osteoclast activity –> Ca / Phos
- vitamin D hydroxylation - liver + kidneys
- Ca / Phos reabsorption via kidneys
8
Q
How does teritary hyperPTH develop?
A
due to untreated secondary hyperparathyroidism
results in parathyroid gland to act autonomously / undergo hyperplastic change
9
Q
complications of CKD
A
anaemia - due to reduced EPO responsible for RBC production
renal osteodystrophy - elevated PTH
cardiovascular disease
10
Q
pre-renal causes of AKI
A
hypovolaemia (sepsis, liver cirrhosis)
renal artery stenosis (ACE-i)
congestive heart failure
11
Q
renal causes of AKI
A
acute tubular necrosis nephrotoxic (rhabdomyolysis, contrast) glomerulonephritis malignant HTN vasculitis
12
Q
post-renal causes of AKI
A
renal calculi
BPH
strictures / ureteric tumours
prostate cancer
13
Q
indications for dialysis
A
chronic hyperkalaemia metabolic acidosis intractable fluid overload uraemic pericarditis uraemic encephalopathy
14
Q
in rhabdomyolysis what is the urinary test?
what is seen in it?
A
urinary myoblobin
muddy brown/granular clasts
15
Q
other than prolonged immobility - what else causes rhabdo?
A
excessive exercise burns epilepsy neuroepiletic malignant syndrome drugs (statins, ecstasy, heroin)
16
Q
define nephrotic syndrome
A
oedema
hypoalbuminia
proteinuria
hyperlipidimia
17
Q
complications of nephrotic syndrome + their Mx
A
hyperlipidaemia - statin
thromboembolism - anticoagulation
infections - pneumococcal vac
18
Q
dietary requirements for nephrotic syndrome
A
low salt intake
normal protein intake
19
Q
concerns of correcting sodium too quickly
hypo / hyper
A
hyper - cerebral oedema
hypo - central pontine myelinolysis
20
Q
Pathology of SIADH
Ix / Mx
A
oversecretion of ADH from posterior pituitary
ADH acts on aqua-porin 2 channels to reabsorb water molecules
Serum / urine osmolaity
- fluid restriction
- furosemide
- hypertonic saline
- conivapton / tolvapton - vasopressin receptor antagonist - competes at the collecting ducts
21
Q
conivapton / tolvapton - class of drug
A
vasopression receptor antagonist
22
Q
name 2 markers of infection urine
A
nitrates
leucocyte esterases
23
Q
things to reduce risk of developing UTI in females
A
well hydrated
post-coital voiding
wipe front to back
avoid spermcide
24
Q
types of renal replacement therapy
A
haemodialysis
- filtering of blood via AV fistula
- 3 to 5 hour sessions
perioneal dialysis
- flitration occurs inside the patient’s abdomen
- high dextrose concentration draws waste products out
- several hours of ‘dwelling time’
renal transplant
- donor kidney connected to external iliac vessels
- 10-12 year
25
what is diagnostic criteria for in diabetic nephropathy?
albumin: creatinine ratio (ACR)
- early morning sample
ACR > 2.5 microalbuminuria
BP aim <130/80
26
what is henoch-schonlein purpura?
IgA mediated small vessel vascultitis
- commonly seen in children after infection
(slight overlap with IgA nephropathy - Berger's Disease)
palpable purpuric rash
abdo pain
polyarthritis
renal failure - IgA
Prognosis
- self-limiting, good outcome
- especially in children w/o renal involvement
27
what qualifies for urgent referral regarding haematuria?
1. aged 45 +
2. unexplained haematuria (no UTI)
3. visible haematuria that persists after treatment
1. aged 60 +
2. unexplained non-visible haematuria + raised WCC / dysuria
28
define triad for haemolytic uraemic syndrome
1. acute kidney injury
2. microangiopathic haemolytic anaemia
3. thrombocytopenia
29
what is haemolytic uraemia syndrome classfied into?
primary - atypical
complement dysregulation
secondary - following infection
E.coli
Pneumococcal infection
HIV
30
what is desmopressin?
synthetic ADH
used to treat cranial diabetes insipidus
NOT nephrogenic DI
31
what is chlorothiazide?
thiazide
- allows sodium to be released into the urine --> hence lowering the serum osmolarity
used to treat nephrogenic DI
32
what is the acceptable amount of glucose for a patient to be given daily?
50-100g irrespective of weight
33
how do you detemine between pre/renal/post causes of AKI?
presence of protein in urine dip - confirms renal cause
34
after 2 episodes of painless frank haematuria - what is the investigation?
cystoscopy
gold standard for bladder cancer
35
what is the mechanism of renal failure by rhabdomyelosis?
myoglobinuria causes renal failure by tubular cell necrosis
--> toxicity of myoglobin on the tubular cells
36
patients on haemodialysis for CKD --> what are they most likely to die from? Why
ischaemic heart disease
due to increased calcification in dialysis
37
why is the hypercoagulopathy in nephrotic syndrome?
loss of anti-thrombin 3 via the kidneys
38
what is the screenin test for adult polycystic kidney disease?
Abdo USS
39
what would you find on a membranous glomerulonephritis renal biopsy?
- thickened basement membrane
- subepithelial spikes on silver stain
- PLA2
40
on abdominal USS - what difference would you see between diabetic nephropathy + CKD?
Chronic diabetic nephropathy
- bilateral enlarged kidneys / normal
CKD - bilateral small kidneys
41
causes of renal artery stenosis
```
atherosclerosis (90%)
fibromusclar dysplasia (10%)
```
42
why would you choose to use contrast on a CT ?
if checking for malignancy - look for blood supply
43
indications for NIV? (4)
1. COPD with resp acidosis (pH 7.25-7.35)
2. Cardiogenic pulmonary oedema unresponsive to CPAP
3. T2RF with chest wall deformity / obstructive sleep apnoea
4. weaning off tracheal intubation
44
when investigating a pleural effusion - how do you determine the cause
fluid / serum protein ratio
if >0.5 exudate
if <0.5 transudate
45
define ARDS
increased permeability of alveolar capillaries leading to fluid accumulation in the alveoli
- acute onset
- bilateral pulmonary oedema
- non-cardiogenic
- low oxygen sat (in site of high ox)
46
what are to 2 management outcomes of CURB65?
moderate / outpatient
- amox (macrolide if pen allergic)
severe / admit
- amox + macrolide
47
explain the biochem of conn's
high aldosterone secretion
acts on Na/k channels - resulting NA reabsorption + K excretion
H ions are also in competition with K ions
As H ions are excreted HCO3 is being reabsorbed with Na --> high HCO3 --> metabolic alkalosis
48
what does urine potassium >20 mmol/l in the presence of hypokalaemia tell you?
pathology is a renal cause
49
drugs influencing renin/aldosterone measures
spironolactone
ostrogens
ACE-i
50
how do you work out anion gap?
what is normal value?
(Na + K) - (HCO3 + Cl)
8-14 mmol/L
51
causes of hypercalcaemia
bone mets
thiazide diuretics - reduced calcium reabsorb (stimulate sodium/calcium exchange intracellularly)
1 + 3 hyperPTH
PTHrP - squamous cell
52
difference on imaging between acute renal failure vs CKD?
CKD - bilateral small kidneys
HIV-related nephropathy - bilateral large kidneys
53
what class of diuretic is used to prevent reaccumulation os ascites?
aldosterone antagonist - spironolactone
54
extra-renal manifestations of ADPKD
liver cysts - hepatomegaly (most common)
| berry aneurysms - SAH
55
iatrogenic cause for nephrogenic diabetes inspidus
lithium
56
what does a greater increase in urea over creatinine signify?
and vice versa?
urea > creatinine = dehydration
creatinine > urea = AKI
57
What are the features of diabeteic nephropathy?
microalbuminuria - 1st indicator
urinary albumin:creatinine ratio (ACR) used for screening
ACR > 2.5 = microalbuminuria
58
Mx of diabetic nephropathy
1. dietary protein restriction
2. tight glycaemic control
3. BP control
4. ACE -I & ARB
5. statins
59
electrolyte imbalance seen in adrenal insuffiiency
hyperkalaemia metabolic acidosis
- loss of adrenal function
- low aldosterone = low sodium / high pot
- sodium excretion = Hion retention
60
what are the variables used to calculate eGFR?
Creatinine
Age
Gender
Ethinicity
61
what is henoch schonlein purpura
IgA mediated small vessel vasculitis
overlap with IgA nephropathy (berger's disease)
HSP - children usually get this after infection
62
Features of HSP
abdo pain
polyarthritis
haematuria
palpable purpuric rash
63
Mx for HSP
supportive - disease is self-limiting
| analgesia
64
what do eosinophillic cast seen in urine signfiy?
tubulointerstitial nephritis
reaction to penicillin
65
when is EPO secreted?
in response to cellular hypoxia
used to treat anaemia associated with CKD
66
how to determine between renal artery stenosis + bilateral adrenal hyperplasia?
why?
RAS - high renin levels, signifiying a secondary cause
BAH - low renin levels
in RAS - kidney thinks BP is low so triggers RAAS = high renin
in BAH - high BP due to water retention, kidneys trying to lower it hence low renin produced
67
what is haemolytic uraemic syndrome?
disease of endothelial injury, classified by:
- classically after e.coli releasing toxin (90% cases)
- pneunococal
- HIV
1. AKI
2. microangiopathic haematuria
3. thrombocytopenia
Mx - supportive, abx have no role
68
post-catheterising care
1. sample
2. document residual volume
3. retract foreskin over glans penis
69
causes of acute urinary retention
UTI
constipation
BPH
Pelvic nerve damage
Meds - anti-cholinergics / opioids
70
how to determine if retention is acute or chronic ?
acute:
- smaller volumes drained
chronic:
- larger volume + painless
- incontinence due to overload pressure
71
draining urinary retention - what is the patient at risk from?
post-obstructive diuresis
- triggered by acute drainage
- at risk of dehydration
generally self-limiting to 24 hrs
72
Mx for BPH
alpha 1 receptor antagonist
- tamulosin
- doxazosin
5-alpha reductase
- finesteride
PDE-5 inhibitor
- sidenifil
Anti-cholinergics
- oxybutynin
73
risk factors for bladder ca
```
smoking
aromatic amine exposure
males
schistosomiasis
chronic cysitis
```
74
investigations for macroscopic haematuria
renal USS
flexible cystoscopy
x-ray KUB
75
most common type of bladder ca
other types;
transitional
squamous
adeno
76
Mx bladder Cancer
trans-urethral resection of bladder tumour (TURBT)
77
bladder cancer mets (3 - systems)
local:
- pelvic structures (uterus, rectum)
lymphatic:
- iliac + paraaortic LN
haematological:
- liver
- lung
- bone
78
why is abx cover given for prostate biopsy?
minimise infection associated with transrectal biopsy
moving flora into the prostate
79
what score is used to grade prostate cancer?
gleason's
80
causes for testicular pain
```
testicular torsion
epididymo-orchitis
testicular tumour
varicocele
hydrococele
inguino-scrotal hernia
```
81
clinical signs of testicular torsion
- swollen hot testis
- high lying transverse
- unilateral pain
loss of cremasteric reflex
prehn's sign - pain does not ease
82
renal tumour for:
55yr old:
5yr old:
renal cell carcinoma
wilm's tumour / nephroblastoma
83
common complication of renal tumour in males + pathophysiology?
1. renal mass causing compression of L renal vein
2. resulting in testicular vein compression
3. resulting in variocele (bag of worms)
84
RF for renal cell carcinoma
```
age
smoking
male
obesity
hereditary papillary RCC
long term dialysis
```
85
what are you concerned about administering vancomycin ?
too fast - red man syndrome
redness / pruritus / burning sensation
- upper body
patho - excess release of histamine from mast cells
86
what drugs should be stopped in AKI
```
NSAIDs
aminoglycosides
ACE-i
ARBs
Diuretics
metformin
```
87
what rate should fluids be prescribed?
30ml/kg/24hr
88
bedside test for renal colic?
following investigation
urinanalysis
CT KUB
89
Why is there referred pain to the groin in renal colic?
visceral nerve supply to the ureters + kidneys follow the same somatic pathway as the gonads and the flank
--> ureteric pain is referred to these regions
90
why is there pain in renal colic?
peristalisis attempting to push the stone and relieve obstruction
- results in local ischaemia and hence pain
91
locations of stone obstuction (3)
- pelvic-ureteric junction
- crosses the bifuraction of the common iliac artery
- vesico-ureteric junction
92
what is contraindicated in a patient w/ renal colic with infection
retrograde ureterogram + stent insertion
- don't put foreign body in an KNOWN infected space
93
Ix for patient admitted with renal colic
Analgesia
CT KUB within 14 hrs
NSAID - diclofenac
94
Mx of renal stones
<5mm pass spontaneously
>5mm:;
- lithtripsy = high energy shock waves, crushing stones into smaller pieces
- nephrolithotomy / tripsy = used if there is infection / irregular stones / post lithotripsy
--> enter kidney at the back either taken out via tube (-tomy) or crushed and vaccumed up (-tripsy)
>2cm:
ureteroscopy
- -> involves a flexible telescope, to looking into the ureter
- -> outpatient procedure with or w/o a tent inserted
95
where does a hydrocele arise from?
accumulation of fluid in the tunica vaginalis
96
how is a varicocele described?
abnormal enlargement of the testicular veins
'bag of worms'
associated with RCC
- renal tumour obstructs the L testicular vein
97
what is a triple diagnosis ?
Adopt a holistic approach:
- physical
- psychological
- social
98
types of hydrocele
communicating
- channel from the peritoneum into the tunica vaginalis
- patent process vaginalis
(common in new borns)
non-communicating
- caused by excessive fluid production in the tunica vaginalis
99
pathophysiology of TURP syndrome
1. irrigation fluid (glycine - hypo-osmolar) enters via the prostate bed/sinuses
2. fluid enters the intravascular space -- resulting in expansion
3. A state of fluid overload develops
- hyponatraemia
- fluid overload
4. Glycine is metbolised by the liver --> producing ammonia --> visual disturbances
100
list general operation risks
```
infection
bleeding
atelectasis
VTE
MI
Reaction to anaesthia
```
101
what is TURP?
op risks
transurethral resection of the prostate
- removing portion of the prostate to improve urinary symptoms
```
impotence
retrograde ejaculation
bladder wall injury
clot retention
bladder neck stenosis
TURP syndrome
```
102
spinal > GA
- short post op recovery time
- lower risk of resp infections
- reduced risk of atelactasis
- decreased bleeding (less vasodilation)
103
describe stress incon
rise in intra-abdominal pressure overwhelms the pelvic floor and pelvic fascia
--> forces urine out of the urethral closure
laughing / coughing
104
describe urge incon
overactive innveration of the detrusor activity
sudden urge to micturate
105
RFs for stress incon
child birth
surgery to pelvic floor
chronic cough
obesity
106
Mx for urge
1 - bladder retraining
2 - antimuscuarinics (oxybutylin - avoid in old frail ladies)
3 - mirabegron (a beta-3 agonist - use for old ladies)
107
anti-cholingeric SE
```
dry mouth
urinary retention
constipation
blurred vision
dizziness / drowiness
acute closed angle glaucoma
hyperthermia
confusion
```
108
Mx for stress incon
1. pelvis floor exercises
| 2. surgery - retropubic mid-urethral tape procedures
109
common bacteria in UTI
```
E.coli
klebsiella
proteus
enterococuss
staph. saprophyitucs
```
110
causes of ureathral stricture
foreign body insertion (catheter)
gonnhorra / chlamydia
pelvic trauma
111
causes of recurrante UTI in men
bladder overflow obstruction
- BPH
- indwelling catheter
- ureathral stricture
neuropathic bladder
uretheral tract surgery
112
what is bladder diverticulum?
outpouching of the bladder (congenital / acquired)
acquired - increased intravesicular pressure, forcing the mucosa through the muscle layer
113
what bacteria can colonise bladder diverticulum?
pseudomonas
| e.coli
114
what is nephritic syndrome
hypertension
| haematuria
115
types of renal stone
calcium oxalate - 85%
calcium phosphate - 10%
struvite (magnesium) - 2-20%
116
triad for TURP
hyponatriaemia - dilution
fluid overload
glycine toxicity - confusion / hallucinations
117
stag horn calculi seen on AXR - what does this signify?
struvite composition
- develops in alkaline
- proteus infection potentiate this environemnt
- convert urea to ammonia
118
voiding symptoms
SH-EDF
straining
hestitancy
emptying
dribble
flow (poor)
119
causes of a raised PSA
```
rigorous exercise
recent ejaculation
BPH
prostate cancer
prostate exam
```
120
erectile dysfunction Ix
1. QRISK - cvd risk
2. morning testosterone test
- -> if low / borderline = check FSH/LH
121
difference between acute interstitial nephritis vs acute tubular nephritis
acute interstitial nephritis - commonly after abx/amino use
triad:
1. rash
2. fever
3. eosinphillia
acute tubular necrosis
2 main causes:
- ischaemia (shock, sepsis)
- nephrotoxins (rhab, contrast, aminoglycosides)
- muddy brown clasts / unresolving renal dysfunction
122
varicocele Mx
asymptomatic
- no action
- semen analysis every 1-2 yrs
symptomatic
- surgery
123
what is priapism
persistent penile erecton > 4hrs
not associated with sexual stimulation
1. ischaemic
2. non-ischaemic
124
hydronephrosis causes
unilateral:
- Pelvic-ureteric obstruction
- Abberant renal artery (supplies both superior/inferior pole of kidney)
- Calculi
- Tumours of the renal pelvis
bilateral:
- Stenosis of urethra
- Urethral valve
- Prostatic enlargement
- Extensive bladder tumour
- Retro-perioneal fibrosis
125
hydronephrosis
Ix / Mx
1. USS - identify presence of hydronephrosis
Mx
if small stone (<10mm) - let it pass
if large obstruction (>10mm)
- Remove obstruction
- stent
acute - nephrostomy tube
chronic - ureteric stent / pl
126
when to urgently refer after prostate exam
felt hard
irregular
PSA doesnt always have to be elevated
127
if renal stones suspected - what specific test would you request?
calcium
urate
oxlate
in blood + urine
128
abx used to treat UTIs in community
trimethoprim
nitrofuratoin
amoxicillin
129
female advice forn UTI reoccurance
post coital voiding
front to back wiping
stay hydrated
drink cranberry juice
130
LUTS
```
VOIDING
straining
hesitancy
emptying
dribbling
flow
```
```
STORAGE
nocturia
urgency
incontinence
frequency
```
131
polcystic kidney disease genetic trait?
pathophysio
autosomal dominant / PKD1 - 85%
- development of renal cysts w/ chronic kidney disease
- kidney enlargement
- compression of renal vasculature / interstital fibrosis
132
ADPKD screening
+ diagnostic criteria
USS abdo
CT / MRI
2 cysts in pt < 30yrs
2 cysts, both kidneys in pt 30-59yrs
4 cysts, both kidneys in pt >60yrs
133
ADPKD Mx
vasopressin receptor antagonist (same as SIADH)
| - act on aquaporins to prevent water absorption
134
Location of other cysts
mainly liver cysts (70%)
cardiovascular disease (10%)
- left ventricular hypertrophy
- mitral value prolapse / regurg
135
ADPKD complications
renal carcinoma
| ovarian cysts
136
minimal change disease pathophysiology
1. damage to basement membrane - by t cell / cytokine
2. glomerular permability to serum albumin --> hence hypoalbumin
doesn't cause end-stage renal failure
137
minimal change disease - what is seen on microscopy?
light microscopy - normal
electron microscopy - podcyte fusion + effacement of foot processes
138
minimal change disease Mx
steroids (resolves 80% of the time)
immunosuppressants
small portion have recurrant episodes
