Urinary Flashcards

Question

Management of complications of CKD?

Answer 1

**Bone Metabolism/Osteoporosis/Secondary Hyperparathyroidism** * Measure serum calcium, phosphate and PTH if GFR less than 30 * Bisphosphonates if indicated in people with a GFR of 30 or more * Colecalciferol or ergocalciferol to treat vitamin D deficiency * Dietary restriction of phosphate, phosphate binder medications **Anaemia** * Recombinant human EPO **Metabolic Acidosis** * Consider oral bicarbonate if GFR less than 30 and a serum bicarbonate concentration of less than 20 mmol/litre (advice from renal)

Answer 2

1. **Haemodialysis** * 4 hours 3x per week * Access via AV fistula 2. **Peritoneal Dialysis** * CAPD (continuous ambulatory PD) - 4x 2-3 litre exchanges per day * APD (automated PD) - exchanges whilst asleep at night 3. **Kidney Transplantation** * Best rehabiliation and patient survival * Requires life-long immunosuppression, may fail after a time * Some may not be suitable * Donor = deceased, live (related, altruistic)

Answer 3

* Age (menopause) * Vaginal delivery * Prolapse * Previous bladder neck surgery Caused by weakness of pelvic floor muscles

Answer 4

* Urine dipstick +/- MSU * Frequency/volume chart * Urodynamics * Urine leaks with no change in pressure in the bladder, provoked by increased pressure in the abdomen

Answer 5

**_Conservative_** * Physio (pelvic floor exercises) * Vaginal cones * Electrical stimulation * Optimise BMI **_Medical_** * Duloxetine (SE = hesitancy when initiating) **_Surgical_** * TVT * Colposuspension * Injectables (collagen, botulinum etc)

Answer 6

1. Proteinuria (ACR \>200mg/mmol) 2. Hypoalbuminaemia (\<25 g/L) 3. Oedema (particularly periorbital) Commonly with hyperlipidaemia

Answer 7

* Minimal Change Disease * 80% cause in children, 25% in adults * Relapse common (75%) * Minimal change glomerulonephritis * Membranoproliferative glomerulonephritis * Membranous glomerulonephritis * Focal segmental glomerulonephritis Rare = SLE, HSP, amyloidosis, drug reactions

Answer 8

**_Signs_** * Periorbital, genital, dependent oedema (worse in the face in morning, swelling descends with gravity later in the day), ascites, pleural effusions **_Symptoms_** * Abdominal discomfort (hypovolaemia, ascites, peritonitis), diarrhoea and/or vomiting. Frothy urine * In children: upper resp. tract infection with oedema, lethargy, irritability and decreased appetite

Answer 9

* Thromboembolism (loss of anti-thrombotic proteins) * Infection (loss of Ig - pneumococcal, offer vaccination) * Hypovolemia and renal failure * Hyper-cholesterolaemia * Loss of specific proteins

Answer 10

* Urine dip: 3+ or 4+ protein * Urine PCR: \>200mg/mmol * Microscopy of urine: red cells, casts * Bloods * U&Es, creatinine, eGFR, * LFTs (albumin \<25g/L), * Cholesterol * ESR, FBC Must exclude primary cardiac failure, with raised JVP, pulmonary oedema and mild proteinuria. Exclude liver disease (possible cause of hypoalbuminaemia).

Answer 11

**_Conservative_** * Low sodium diet **_Medical_** * Diuretics (furosemide 80-160mg PO) * ACEi or ARB for BP reduction * LMWH for VTE prophylaxis or warfarin if symptomatic of VTE * Penicillin prophylactically * Oral prednisolone for 12-16 weeks (tapered down - if minimal change disease)

Answer 12

Age, high caffeine intake, smoking

Answer 13

* Miscroscopic haematuria (if age \>50) * Visible haematuria * Recurrent or persistant UTI with haematuria (\>40 yrs) * Suspected malignant mass rising from urinary tract

Answer 14

Involuntary bladder muscle activity causes increase in pressure and leads to leakage of urine

Answer 15

**_Conservative_** * Reduce tea/coffee intake * Stop smoking * Bladder retraining **_Medical_** * Anticholinergics (oxybutinin) * TCA/desmopressin **_Surgical_** * Intra-vesical botox * Sacral nerve stimulation * Other more complex things - clam cystoplasty, neuromodulator implant, detrusor myomectomy.

Answer 16

1. **S**epsis - treat with BUFALO 2. **T**oxins - stop nephrotoxic drugs 3. **O**ptimise BP * IV access and fluids if hypovolaemic * Volume status assessment * Consider holding anti-hypertensives * Consider vasopressors 4. **P**revent Harm * Treat complications (hyperkalaemia, pulmonary oedema, acidosis) * Identify cause * Review medication and doses * Refer for RRT if necessary **_Monitor_** * Daily volume assessment * Fluid balance * U+Es, bicarbonate

Answer 17

90% = transitional cell carcinoma 5-8% = SCC 1-2% = adenocarcinoma

Answer 18

* Male * Smoking * Aromatic amine exposure (textiles) * Schistosomiasis (for SCC) * Chronic UTI * Stasis of urine

Answer 19

**_Signs_** * Microscopic haemautria * Sterile pyuria * Palpable suprapubic mass **_Symptoms_** * Painless haematuria * Uterine colic due to clots from upper tract lesion * Malignant cystitis (frequency, dysuria, infection) * UTI in men or recurrent UTI in women * Loin pain * General **_FAWR_** symptoms - fever, weight loss, anorexia/anaemia, reduced energy

Answer 20

Outflow obstruction Ureteric obstruction Enlarged pelvic lymph nodes Metastasis (liver, bone)

Answer 21

**_Urine_** * Urine dip and MC&S * Cytology for malignant cells **_Bloods_** * FBC, U+E **_Imaging_** * USS KUB * Cystoscopy to visualise tumour * CXR

Answer 22

T1 - transurethral resection of tumour (TURBT) and single dose of intra- vesical chemo. Follow up with regular cystoscopy. T2 - TURBT and radiotherapy. Follow up with regular cystoscopy. T3 - Radical cystectomy +/- radiotherapy. T4 - TURBT for local symptoms. Palliative radiotherapy +/- chemo. Palliative care involvement.

Answer 23

* Age (85% \>65) * First degree relative affected * Black afro-carribean population * Dietary (low fruit, high fat and meat diet)

Answer 24

LNs, seminal vesicles Bone, liver, brain

Answer 25

**_Symptoms_** * **Early**: symptomless, usually detected on PSA * **Local** : protastism, urinary retention, haematuria, lower extremity oedema * **Metastatic**: Malaise, weight loss, bone pain, pathological fractures, spinal cord compression, ureteric obstruction leading to renal failure **_Signs_** * On DRE * Local: hard nodule in prostate * Local advanced: prostate hard, non-tender, loss of sulci * Metastatic signs

Answer 26

**DRE** **Bloods** * **PSA** - \>40 = high chance of nodal spread, \>100 = metastatic spread very likely. **Imaging** * Transrectal ultrasound and biopsy * MRI, CT, X-ray, bone scan

Answer 27

**_Early Disease_** * Active surveillance - PSA and regular DRE * Radical prostatectomy * Radiotherapy/Brachytherapy * Hormone treatment not beneficial in early disease **_Symptomatic Disease_** * LHRH Analgoues * e.g. Goserulin, SC injection every 4-12 weeks. Decreases testosterone levels to levels of castration in \<2 months. * SE: impotence, hot flushes, gynaecomastia, local bruising/infection * Anti-androgens * Flutamide, bicalutamide * Prevent side effects of testosterone flare when giving LHRH analogues * Surgical castration * Rarely used **_Metastatic Disease_** * Local radiotherapy and corticosteroids

Answer 28

From epithelium of the proximal convoluted tubule. Known as clear cell carcinomas. Invasion of renal vein is common.

Answer 29

Smoking, high BMI, HTN **_Other_** * Occupational exposure (asbestos, trichloroethylene) * Polycystic kidney disease * Chronic hep C infection * Genetics: 2-3% hereditary e.g von Hippel-Lindau, 2.5x higher with a first degree relative

Answer 30

**_Symptoms_** * Triad of haematuria, flank pain, palpable flank mass (in order of how common) **_Signs_** * Local extension into IVC = bilateral leg oedema and collateral venous circulation **_Metastasis_** * Bone pain, persistent cough, upper GI bleed, neuro deficits * Varicocele if extends into left renal vein

Answer 31

* Polcythaemia due to EPO secretion * Hypercalcaemia due to PTH related peptide * Hypertension due to renin secretion * Neuromyopathy

Answer 32

**_Urine_** * Urine dip + Microscopy (haematuria) **_Bloods_** * FBC, U+E, LFTs **_Imaging_** * Renal USS * Plain abdo Xray, CXR (cannonball mets) * Abdo CT - function of contralateral kidney, primary tumour extension, venous involvement

Answer 33

**_Local Disease_** * Partial nephrectomy - tumours \<7cm, if limited renal funciton or 1 kidney * Radical nephrectomy * Ablative - Radiofrequency ablation for small masses in frail patients/poor renal function **_Metastatic Disease_** * Cytoreductive nephrectomy and chemotherapy * Largely resistant to chemo, radio and hormonal therapy * Aim to relieve symptoms and maintain function with IFN alpha or interleukin 2 immunotherapy

Answer 34

Aseptic distention of renal pelvic and calyces of the kidney with urine due to obstruction of urine outflow

Answer 35

**_Unilateral_** * Lumen - calculi * Wall - ureterocoele, stricture, malignancy * External - blood vessel, lymphadenopathy **_Bilateral_** * Congenital - strictures, valves * Acquired - bladder neck hypertrophy, prostatic hypertrophy or malignancy, urethral stricture, phimosis

Answer 36

**_Symptoms_** * Pain in back or side, may be acute or gradual onset. * Haematuria, oliguria * UTI symptoms (inc. rigors, nausea, vomiting) **_Signs_** * Temperature, rigors, may have visibly swollen kidneys

Answer 37

Atrophy of the kidney parenchyma, leading to decrease in renal function

Answer 38

**_Urine_** * Urine dip and microscopy **_Bloods_** * FBC, U&Es, LFTs, CRP **_Imaging_** * USS KUB/CT KUB

Answer 39

Drain urine from bladder using catheter - if unable to obtain large volume of urine, blockage may be in ureter or bladder. If blocked ureter... * Urethral stent * Nephrostomy tube (drain urine through back) * Abx to control infection May require **surgery** if caused by *scar/clot* **Endoscopic surgery** if caused by *stone*

Answer 40

* **Gonococcal urethritis** * Non-gonococcal urethritis (Reiter's) * Persistent/recurrent urethritis * 30-90 days after treatment of acute NGU * Most likely to be multifactorial, mycoplasma genitalium, t. vaginalis

Answer 41

Most ***idiopathic*** Hypercalciuria, hyperoxaluria, hyperuricaemia, cystinuria, schistosomiasis **_Risk Factors_** * Hyperparathyroidism, gout, chemo for leukaemia, enlarged prostate, hydronephrosis, UTI, catheter

Answer 42

**_Symptoms_** * Acute onset severe unilateral colickly pain from loin to groin (testicle pain) * N+V, sweating * Haematuria, dysuria * Frequent painful passage of small volumes of urine with feeling of incomplete emptying **_Signs_** * High HR, sweating, restlessness * Some tenderness over affected loin

Answer 43

**_Urine_** * Urine dip (blood) - nitrites = UTI * PT if female **_Bloods_** * U+E, FBC, calcium, urate **_Imaging_** * CT KUB (99% of stones), KUB X-ray (60%)

Answer 44

Always exclude other causes of abdominal pain such as AAA rupture, especially if no prior renal disease. **_Male_** * Testicular tumour, epididymitis or prostatitis **_Female_** * Gynae cause inc. torsion, cyst and ectopic pregnancy.

Answer 45

**_Conservative_** * Analgeisa (NSAIDs, then opioids) * Antiemetic * Fluid replacement * Watch urine for stone **_Surgical_** * Endoscopic rather than open/Shockwave lithotripsy * Indications * Large stones (\>5mm), infection above site of obstruction, failure of conservative treatment, evidence of renal impairment, anatomical abnormality **_Prevention_** * Drink plenty of fluids, treat cause of stone

Answer 46

Autosomal dominant condition, cause of renal failure. Always bilateral, growth of cysts in the tubules throughout the nephrons

Answer 47

Function usually preserved until 40-50yrs. In adults: * Acute loin pain +/- haematuria * Vague abdominal/loin discomfort due to increasing size of kidneys * Hypertension * Features of uraemia

Answer 48

Fixed, abnormal narrowing of the urethra that causes obstruction to outflow and back pressure on the bladder, ureters and kidneys. Most commonly iatrogenic in origin, ask about trauma, infection or urethral instrumentation.

Answer 49

Progressive diminution in urine flow, with other features of bladder outflow obstruction. * Spraying or forking of urinary stream may be experienced. * Must examine external meatus and palpate urethra for areas of fibrosis in corpus spongiosum.

Answer 50

* Abnormal backflow of urine from the bladder into ureter and kidney. * Very common anatomical abnormality of renal tract * Predisposes to infection * Can lead to scarring and destruction of the kidney.

Answer 51

Urinary tract infection (raise concerns after 1 UTI in boys, 2 in girls) Incontinence, frequency, dysuria, abdominal pain

Answer 52

Glomerular injury by * Immunological component * Completement activation, platelet aggregation, neutrophil infiltration, activation of the kinin system. May occur in isolation or secondary to disease e.g. polyarteritis nodosa and SLE.

Answer 53

Nephrotic syndrome = proteinuria, low albumin, oedema Nephritic syndrome = haematuria, uraemia, facial oedema

Answer 54

Categorised by haematuria with red cell casts in the urine. May present clinically as: * Nephrotic syndrome (proteinuria, low albumin, oedema) * Nephritic syndrome (haematuria, uraemia, facial oedema) * Acute or chronic renal failure * Asymptomatic haematuria and/or proteinuria

Answer 55

* Proteinuria in the day which is absent from early morning urine samples. * Prognosis normal up to 40 years following diagnosis. * Common in young males. Significant renal abnormality more likely if haematuria and proteinuria are detected

Answer 56

* Dehydration * Advanced age * CKD * Cardiac disease * Diabetes * Myeloma * Nephrotoxic drugs

Answer 57

* Acute glomerulonephritis * Vasculitis, SLE * Myeloma (paraproteins can be toxic) * Rhabdomyolysis * Hepatorenal (haemodynamic changes in context of chronic liver disease) * Toxins – drugs, radiocontrast, chemicals * Tumour lysis * Thrombotic microangiopathy (HUS, TTP) * Pregnancy related * Accelerated hypertension

Answer 58

* Tubular damage – from pre-renal ischaemic/toxic insult * Manifests as AKI not immediately reversed by resuscitation – i.e. oliguria no longer a physiological response * Period of established reduced kidney function, followed by recovery/polyuric phase * Kidney function recovery may be incomplete

Answer 59

**_ABCDE_** * Assessment of hydration/haemodynamic status * Previous measure of kidney function * Evidence of sepsis * Any nephrotoxins?

Answer 60

* Urinalysis * Blood and protein = glomerulonephritis/vasculitis (RBC casts) * FBC, biochemistry, CRP * Sepsis screen * CK if rhabdo * Immune screen * (ANCA, ANA, Anti-GBM, ASO titres, C3, C4) * Myeloma screen * Serum electrophoresis and free light chains, urine electrophoresis (Bence Jones protein) * USS * Renal biopsy * If unexplained, no obstruction

Answer 61

* Urea increases * Creatinine increases (can be in normal range) * Increased urea/creatinine ration = pre-renal * eGFR not meaningful if rapid change creatinine * Hyperkalaemia * Metabolic acidosis * Calcium tends to fall but PO4 tends to rise * High Ca - can cause AKI, suspect myeloma

Answer 62

* **Renal** * Oligrua (can be polyuria) * **CVS/Resp** * Fluid overload, pericarditis * **GI** * Anorexia, nausea, vomiting, peptic ulceration * **CNS** * Drowsiness, encephalopathy, fits * **Haem** * Bleeding tendency, drop in Hb (\< compared to CKD)

Answer 63

* Fluid Management * Resus - then careful assessment/monitoring and fluid input according to need * Diuretics and fluid restriction for fluid overload * Vasopressors/Inotropes * Restrict potassium intake - only give if potassium is low * Avoid nephrotoxins * Nutrition - because they are catabolic * Consider ulcer prophylaxis - at risk of GI bleeding * Monitoring renal function (bloods, urine output) * Treat underlying cause

Answer 64

Because it dilates the efferent arteriole --\> less back pressure leads to less glomerular pressure --\> the pressure is what creates flow of urine --\> worsens AKI

Answer 65

DONT TAKE - can precipitate AKI

Answer 66

1. Acute intermittent haemodialysis (quite intensive changes in hydration and chemistry over short periods of time) 2. Continuous haemofiltration - unstable patients requiring inotropes 3. Peritoneal diaylsis - not usually in AKI

Answer 67

* Fluid status assessment and resuscitation * Bloods - U+Es * Assessment for compartment syndrome * Pressure of body weight and hard floor below may exceed perfusion pressure Causes = crush injury, long lie, drugs (MDMA, statins, phenothiazines), arterial ischaemia, myositis (infection, autoimmune)

Answer 68

Muscle damae with release of intracellular contents including myoglobin - toxic to tubules Urine dark in colour, positive haematuria (myoglobin) **_Bloods_** * V.high CK (tens of thousands) * Hyperkalaemia * High PO4, low Ca

Answer 69

Confirm diagnosis - examination, bladder scan or formal USS Catheter Fluid replacement - monitor hydration, fluid balance and electrolytes (post-obstructive diuresis)

Answer 70

**_Investigations_** * Haematoproteinuria - suggests glomerular disease - red cell cast (RBCs stuck together - glomerular) * Immunology screen * CRP or plasma viscosity * Renal USS and biopsy

Answer 71

* DM * HTN * CVD * Structural renal disease * Mutlisystem illness (SLE) * Nephrotoxic drugs

Answer 72

Raised urea and creatinine in blood Hyperkalaemia Metabolic acidosis (reduced serum bicarb) Bone biochemistry Raised serum urate (renally excreted --\> gout)

Answer 73

**_Renal_** * Fluid retention, inability to concentrate urine (polyuria, nocturia) **_Cardiovascular_** * HTN, pulmonary oedema * LVF, vascular disease, dyslipidaemia, vascular calcification, pericarditis **_GI_** * Anorexia, nausea, vomiting, malnutrition, peptic ulceration Neuro, derm, endocrine features too.

Answer 74

* **More advanced CKD (lower GFR)** * **BP control** * **Proteinura/albuminuria** * Race, gender * Smoking * Hyperglycaemia, hyperlipidaemia * Obesity * CVS disease * Nephrotoxic drugs

Answer 75

**Renoprotective Effect (even if normal BP) --\> need to be on the maximum tolerated dose, may cause further decrease in proteinuria.** * May cause transient decrease in GFR (\<20% is fine) * Profound drop in GFR in RA stenosis * Risk of hyperkalaemia * Monitoring U+Es baseline and at 1 week

Answer 76

Phosphate is thought to increase vascular calcification --\> development of CV disease

Answer 77

BP U+E Urine dipstick Urine albumin/creatinine ratio

Answer 78

* Increased urinary albumin excretion, but below the level that registers on protein dipstick * Normally small amount of protein (small molecules) in urine, but very little albumin (large protein) - increase suggests 'glomerular leakiness' * In diabetes, the risk of progression to established diabetic nephropathy (persistent proteinuria) - CVS risk and increased diabetes complications ## Footnote **Way of picking them up early**

Answer 79

Stop metformin when eGFR \<30 (lactic acidosis) Drug dose alterations for oral drugs Reducing insulin requirements/hypoglycaemia with worsening kidney function (low appetite, intake etc).

Urinary Flashcards

(108 cards)