1
Q
Definition of bacteriuria?
A
o presence of bacteria in the urine. This may be symptomatic or asymptomatic. Asymptomatic bacteriuria should be confirmed by two consecutive urine samples
2
Q
Definition of UTI?
A
o presence of characteristic symptoms and significant bacteriuria from kidneys to bladder
o >105 (cfu/ml)
3
Q
Types of UTI?
A
o Lower UTI = infection of the bladder (cystitis)
o Upper UTI = infection of kidney and ureters (acute pyelonephritis)
4
Q
Classifications of UTI?
A
o Uncomplicated – normal renal tract/function
o Complicated – abnormal renal tract, obstruction, decreased renal function, immunocompromised
5
Q
Epidemiology of UTIs?
A
- Incidence is 5% in UK
- More common in females due to short urethra
- 40% have genitourinary anomalies
6
Q
Risk factors of UTIs?
A
o Women o Sexual intercourse o Catheter o Abnormality of renal tract o Antibiotic use o Pregnancy o Immunocompromise o Diabetes Mellitus o Spermide
7
Q
Causative organisms of UTIs?
A
o E. coli in 90% of cases
o Proteus (present under prepuce)
o Klebsiella
o Enterococcus faecalis
o Saprophytic staphylococci (young women)
o Pseudomonas (may indicate structural damage in urinary tract)
8
Q
Symptoms of lower UTIs?
A
o Dysuria o Frequency o Urgency o Haematuria o Suprapubic discomfort o Burning o Cloudy urine with offensive smell
9
Q
Investigations in lower UTI?
A
- Urine dipstick MSU
o Leukocytes and nitrites, haematuria and proteinuria - Urine M, C&S
o Male, child under 16, pregnant, very ill
o May show leukocytes, RBC commonly seen, renal pathology if crystals or granular casts found - Renal USS (KUB)
o If recurrent or complicated - Bloods
o FBC, U&Es, CRP, cultures if unwell
10
Q
Management of lower UTI - referral?
A
- Referral to hospital if sepsis suspected
11
Q
Management of lower UTI - general advice?
A
o Paracetamol for pain
o Hygiene: clean perineum front to back
o Increase fluid intake
o Voiding after intercourse
12
Q
Management of lower UTI - in non-pregnant women?
A
o Back-up antibiotic or immediate prescription, depending on clinical picture
Back-up prescription should be used if no improvement in 48 hours of taking antibiotic or worsens
13
Q
Management of lower UTI - non-pregnant women - antibiotics - first & second choice?
A
First Choice
• Nitrofurantoin (if eGFR>45) 100mg MR BD for 3 days
• Trimethoprim 200mg BD for 3 days
Second Choice (worsening UTI on first choice for >48 hours) • Nitrofurantoin (if eGFR>45 and not first choice) 100mg MR BD for 3 days • Pivmecillinam 400mg initial dose then 200mg TDS for 3 days • Fosfomycin 3g single dose sachet
14
Q
Management of lower UTI - pregnant women, men and children - investigations?
A
Midstream urine for M, C & S in pregnant women, men and children <16
15
Q
Management of lower UTI - antibiotics children <16 years old - under 3 months?
A
• Under 3 months – refer to paediatric specialist
16
Q
Management of lower UTI - antibiotics children <16 years old - over 3 months?
A
o First Choice
Nitrofurantoin (if eGFR>45) for 3 days
Trimethoprim for 3 days
o Second choice
Nitrofurantoin (if eGFR>45) for 3 days
Amoxicillin for 3 days
Cefalexin for 3 days
17
Q
Management of lower UTI - antibiotics men first choice?
A
o Nitrofurantoin (if eGFR>45) 100mg MR BD for 7 days o Trimethoprim 200mg BD for 7 days
Follow up in 48 hours
If not working consider alternative diagnosis
18
Q
Management of lower UTI - antibiotics - pregnant women - first & second choice?
A
• First choice o Nitrofurantoin (if eGFR >45) 100mg MR BDS for 7 days
Second choice
o Amoxicillin (only if cultures results available) 500mg TDS for 7 days
o Cefalexin 500mg BDS for 7 days
19
Q
Management of lower UTI - antibiotics - in asymptomatic bacteriuria?
A
• Nitrofurantoin, amoxicillin or cefalexin
20
Q
Management of lower UTI - catheterised patients - general management?
A
o Remove catheter or changing as soon as possible if been in place for >7 days
o Obtain urine sample via sampling port
21
Q
Management of lower UTI - catheterised patients - non-pregnant women and men >16 - antibiotics if lower symptoms?
A
o First choice
Nitrofurantoin, trimethoprim, amoxicillin (only if cultures available)
o Second choice
Pivmecillinam
22
Q
Management of lower UTI - catheterised patients - non-pregnant women and men >16 - antibiotics if upper symptoms?
A
o First choice
Cefalexin, ciprofloxacin, co-amoxiclav, trimethoprim
o First choice IV
Co-amoxiclav, cefuroxime, ceftriaxone, gentamicin, amikacin
23
Q
Management of lower UTI - catheterised patients - pregnant women - antibiotics?
A
- First choice oral – cefalexin
* First choice IV - cefuroxime
24
Q
Management of lower UTI - catheterised patients - children <16 - antibiotics?
A
Under 3 months – refer to paediatrics
Over 3 months
o First choice oral
Trimethoprim, amoxicillin, cefalexin, co-amoxiclav
o First choice IV
Co-amoxiclav, cefuroxime, ceftriaxone, gentamicin, amikacin
25
Management of recurrent UTIs - definiton of recurrent?
at least 2 episodes within 6 months, or 3 or more within 12 months
26
Management of recurrent UTIs - when to refer?
Men >16
People with recurrent upper UTI
People with recurrent lower UTI when underlying cause unknown
Pregnant women
27
Management of recurrent UTIs - general measures?
Non-pregnant women may wish to try D-mannose or cranberry products
Avoid douching
Wipe from front to back after defaecation
Avoid delay in post-coital urination
Hydration important
28
Management of recurrent UTIs - antibiotic prophylaxis - men and pregnant women?
First choice
o Trimethoprim 200mg when exposed to trigger or 100mg at night
o Nitrofurantoin 100mg when exposed to trigger or 50mg at night
Second choice
o Amoxicillin 500mg when exposed to trigger or 250mg at night
o Cefalexin 500mg when exposed to trigger or 125mg at night
• Review in 6 months
29
Management of recurrent UTIs - antibiotic prophylaxis - non-pregnant women?
* Vaginal oestrogen (estriol cream) for postmenopausal women with recurrent UTI if behavioural and personal hygiene measures are not effective
* Can consider single-dose antibiotic prophylaxis or daily antibiotic prophylaxis if needed
30
When to refer lower UTI to specialist - in women?
Recurrent lower UTI when cause unknown
31
When to refer lower UTI to specialist - in men?
Ongoing symptoms despite antibiotic treatment
Suspected bladder outlet obstruction, Hx of pyelonephritis, urinary calculi or previous GU surgery
Recurrent episodes of UTI (2 or more in 6 months)
32
Further investigations needed in children with UTI - When to arrange US of UT?
During acute infection in all children with atypical infection:
• Poor urine flow, abdominal/bladder mass, raised creatinine, sepsis, failure to respond to antibiotics within 48 hours, non-E.coli organism
During acute infection if child <6 months with recurrent UTI
Within 6 weeks if child >6 months with recurrent UTI
Within 6 weeks if <6 months with first-time UTI that responds to treatment
33
Further investigations needed in children with UTI - other tests needed and when?
o Dimercaptosuccinic acid scintigraphy (DMSA) carried out within 4-6 months of acute infection if:
All children <3 years with atypical or recurrent UTI
All children >3 years or over with recurrent UTIs
34
Definition of recurrent UTI in children?
* 2 or more UTI with acute pyelonephritis or,
* 1 episode of acute pyelonephritis + one or more lower UTI with cystitis or,
* 3 or more UTI with cystitis
35
When referred to secondary care for UTI - what further tests can be performed?
o US KUB
o CT KUB
o Cystoscopy
o Urodynamic studies
36
Risk factors for pyelonephritis?
```
o Women
o Sexual intercourse
o Catheter
o Abnormality of renal tract
o Antibiotic use
o Pregnancy
o Immunocompromise
o Diabetes Mellitus
o Spermide
```
37
Causative organisms of pyelonephritis?
o E. coli in 90% of cases
o Proteus (present under prepuce)
o Klebsiella
o Enterococcus faecalis
o Saprophytic staphylococci (young women)
o Pseudomonas (may indicate structural damage in urinary tract)
38
Symptoms of acute pyelonephritis?
```
o UTI symptoms (dysuria, frequency, urgency)
o Malaise
o Fever
o Loin pain +/- back pain
o Vomiting
o Rigors
```
39
Investigations in pyelonephritis?
- Urine dipstick MSU
o Leukocytes and nitrites, haematuria and proteinuria
- Urine M, C&S
o Obtain before starting antibiotics
40
When to refer to hospital - with suspected pyelonephritis?
o Septic signs
o Significantly dehydrated or unable to take oral fluids
o Pregnant
o Structural or functional abnormality of GU tract
o Immunosuppression
o Diabetes
41
Management of pyelonephritis - general measures?
Paracetamol for pain
Increase fluid intake
Seek medical advice if worsens or does not improve within 48 hours, or person systemically unwell
o Midstream urine sample for M, C & S
42
Management of pyelonephritis - antibiotics - non-pregnant women and men - oral antibiotics?
o Oral cefalexin 500mg BD/TD for 7-10 days
o Oral ciprofloxacin 500mg BD for 7 days
o If culture results known:
Oral Co-amoxiclav 500/125mg TDS for 7-10 days
Oral trimethoprim 200mg BD for 14 days
43
Management of pyelonephritis - antibiotics - non-pregnant women and men - IV antibiotics?
```
o Ceftriaxone
o Cefuroxime
o Ciprofloxacin
o Gentamicin
o Amikacin
o Co-amoxiclav (in combination or if culture results known)
```
44
Management of pyelonephritis - antibiotics - pregnant women - oral antibiotics?
o Cefalexin 500mg BD/TD for 7-10 days
45
Management of pyelonephritis - antibiotics - pregnant women - IV antibiotics?
o Cefuroxime 750mg to 1.5g TDS/QDS
46
Management of pyelonephritis - antibiotics - children <16 - oral antibiotics?
• Under 3 months – refer to paediatric specialist
Over 3 months
Cefalexin
Co-amoxiclav (only if culture results available and sensitive)
47
Management of pyelonephritis - antibiotics - children <16 - IV antibiotics?
```
Co-amoxiclav (only in combination or if culture result known)
Cefuroxime
Ceftriaxone
Gentamicin
Amikacin
```
48
When to review antibiotics in acute pyelonephritis?
o Review antibiotics at 48 hours if IV and when cultures available
49
Definition of acute urinary retention?
- Inability to voluntarily urinate
50
Mechanism of acute urinary retention?
o Increased resistence to flow
o Inappropriate detrusor muscle innervation
o Bladder over-distention
o Drugs
51
Epidemiology of acute urinary retention?
- Medical emergency, abrupt development of inability to pass urine
- Common 0.3%
- Men 10x
52
Causes of acute urinary retention - anatomical?
```
BPH (most common)
Urethral strictures
Prostate carcinoma
Prostate haematoma
Urethral stone
Foreign body
Urinary stent occlusion
Constipation
Meatal stenosis
```
53
Causes of acute urinary retention - functional?
```
Neurogenic bladder
MS, Parkinsons, Alzheimer’s, cauda equina syndrome
SCI
CVA
Tumour
Spinal anaesthesia
Alcohol
Pain
UTI
Acute prostatitis (E.coli, proteus)
```
54
Causes of acute urinary retention - drugs?
Anticholinergics, antihistamines, amphetamines, morphine, hyoscine, TCAs
55
Symptoms of acute urinary retention?
o Severe pain
o Unable to pass urine
o Previous episodes
56
Signs of acute urinary retention?
Tender, distended bladder – dull to percuss above pubic symphysis
57
Initial investigations of acute urinary retention?
Rule out cauda equina
Bladder US scan
Calculates bladder volume
DRE of prostate – after catheterisation
Check anal tone, prostatic size, nodules, tenderness and exclude faecal impaction
Urinalysis - MSU
Bloods – FBC, U&E, glucose
58
Investigations to perform on ward of acute urinary retention?
o Renal US if any renal impairment
59
Immediate management of acute urinary retention?
o Catheterisation immediately
Document post-catheterisation residual volume, type of catheter (14/16G)
o Alpha-blocker given before catheter (tamsulosin)
60
Subsequent management of acute urinary retention?
o Treat cause
If BPH – tamsulosin with finasteride as an adjunct can be used
o Trial without catheter (TWOC) in men with BPH
61
Follow up of acute urinary retention?
o If secondary to BPH, constipation, UTI with no previous UT symptoms – no follow up
o Referral to urology clinic
62
Complications of acute urinary retention?
- UTIs
- AKI
- Post-retention diuresis, haematuria
63
Physiology of potassium?
- Potassium is mostly intracellular and thus serum potassium is poor indicator of total potassium
- Concentrations of H and K tend to vary together
- Insulin and catecholamines stimulate K into cells via Na/K/ATPase pump
64
Normal values of potassium?
- Normal values – 3.5-5mmol/L
65
Classifications of hyperkalaemia?
o Mild 5.5-6mmol/L
o Moderate 6.1-6.9mmol/L
o Severe >7.0mmol/L
66
Causes of hyperkalaemia?
o Spurious – Haemolysed sample
o Decreased renal excretion – AKI, CKD, K+ sparing diuretics
o Hypoaldosteronism – Addison’s disease, NSAIDs, ACEi
o Cell injury – Crush injury, rhabdomyolysis, burns, incompatible blood transfusion
o K+ cellular shifts – Metabolic acidosis, suxamethonium
67
Symptoms of hyperkalaemia?
o Muscle weakness/cramps
o Paraesthesia
o Focal neurological deficits
o Fast, irregular pulse with palpitations
68
ECG changes of hyperkalaemia?
o Peaked (tall, tented) T waves
o Small, flat P waves
o Widening QRS complexes (becomes sinusoidal)
o VF
69
When to treat hyperkalaemia immediately?
(>6.5 or >6 with ECG changes needs immediate treatment
70
Management of hyperkalaemia - immediate drug management?
o 10mL 10% calcium gluconate IVI to stabilise cardiac membrane (up to 30ml if no improvement in ECG)
o 10U soluble insulin (Actrarapid) in 50mL 50% glucose given over 5-15 minutes
o 5mg NEB Salbutamol, repeated once as necessary
o Calcium Resonium 15g orally every 6-8 hours (removes K from GI tract)
Co-prescribe with lactulose
o Review potassium intake, medications
o Contact renal team – may need dialysis if intractable
71
Definition of hypokalaemia?
- Potassium <2.5 needs urgent treatment but any value under 3.5 considered hypokalaemic
- Hypokalaemia exacerbates digoxin toxicity
72
Causes of hypokalaemia?
```
o Diuretics
o D&V
o Cushing’s/Steroids/ACTH
o Alkalosis
o Conn’s syndrome
o Renal tubular failure
o Pyloric stenosis
o Intestinal fistula
```
73
Symptoms and signs of hypokalaemia?
```
o Muscle weakness
o Hypotonia
o Hyporeflexia
o Cramps
o Tetany
o Palpitations
o Light-headedness
o Constipatio
```
74
ECG changes of hypokalaemia?
o Small/Inverted T waves
o Prominent U waves (after T wave)
o Long PR interval
o Depressed ST segments
75
Management of hypokalaemia - mild?
Oral K+ supplement (Sando K tablets) and U&Es daily
76
Management of hypokalaemia - severe?
IV potassium (normal max rate if 10mmol/hr but if severe 20mmol/h) and ensure continuous cardiac monitoring
77
Physiology of sodium regulation?
- Sodium controlled by aldosterone on DCT and collecting duct to increase Na reabsorption from urine
- Natriuretic peptides ANP, BNP, CNP reduce resorption from DCT and inhibit renin
- Derangement can occur with hypervolaemia, euvolaemia, hypovolaemia
78
Normal range of sodium?
- Normal ranges – 135-145mmol/L
79
Causes of hypernatraemia?
o Diabetes insipidus (lack of ADH or renal response)
o Fluid loss without replacement – Diarrhoea, vomiting
o Osmotic diuretics (mannitol, isosorbide)
o Hypertonic saline
o Cushing’s syndrome
80
Symptoms and signs of hypernatraemia?
o Lethargy, thirst, weakness, irritability, confusion and coma
o Signs of dehydration
81
Blood tests of hypernatraemia?
o High Na, PCV, albumin, urea
82
Management of hypernatraemia?
o Water orally if possible
o If hypovolaemia, 0.9% saline to correct
o Dextrose 5% IV (1L/6h) guided by urine output and serum Na (check every 2-3 hours)
83
Complications of hypernatraemia?
o Seizures
o Cerebral/subdural haemorrhages
o Dural sinus thrombosis
o Cerebral oedema
84
Causes of hyponatraemia - if dehydrated?
High urine Na – Addison’s disease, renal failure, diuretic excess, osmolar diuresis
Low urine Na – Diarrhoea, vomiting, burns, small bowel obstruction, CF
85
Causes of hyponatraemia - if not dehydrated?
Oedematous – Nephrotic syndrome, cardiac failure, liver failure, renal failure
Not oedematous – SIADH, water overload, hypothyroidism, glucocorticoid insufficiency
86
Symptoms of hyponatraemia?
Anorexia, nausea, malaise, headache, irritability, confusion, weakness and seizures
87
Management of hyponatraemia - acute (<24 hours)?
Assess volume status
Urine osmolarity
<100 - primary polydipsia or low solute intake
>100 and urine sodium >30 & hypovolaemic - vomiting, Addison's, diuretics, salt wasting
>100 and urine sodium >30 & euvolaemic - SIADH, secondary adrenal insufficiency, hypothyroid, diuretics
>100 and urine sodium <30 - heart failure, liver failure, nephrotic syndrome, D&V
Mild
If hypervolaemic - fluid restriction
If hypovolaemic - 0.9% saline IV slowly
• Rapid change can lead to central pontine myelinolysis
Na <120mmol/L associated with risk of cerebral herniation
In emergency consider hypertonic saline (1.8/3%)
88
Management of hyponatraemia - chronic?
Slowly increase Na <10mmol/L per day
Treat cause
May need hypertonic saline
89
Definition of hyponatraemia?
Mild hyponatraemia — serum sodium 130–135 mmol/L.
Moderate hyponatraemia — serum sodium 125–129 mmol/L.
Severe hyponatraemia — serum sodium less than 125 mmol/L.
90
Classes of hyponatraemia?
Acute — hyponatraemia duration for less than 48 hours.
Chronic — hyponatraemia duration for 48 hours or more
91
Complications of hyponatraemia?
Life-threatening if severe and/or of acute onset
Swelling of brain cells, cerebral oedema and raised intracranial pressure can lead to seizures, coma, or cardio-respiratory arrest
Increased mortality and longer hospital admission
Chronic hyponatraemia can cause falls, gait disturbances, concentration and cognitive deficits
92
Definition of CKD?
- Abnormal kidney function or structure present for >3 months or eGFR <60
93
Normal functions of kidney?
Excretory –
inorganic substances (e.g. potassium, phosphate)
organic (urea, creatinine)
clinically “uraemic toxicity”
Homeostasis – fluid balance, blood pressure, acid-base
Endocrine – erythropoietin, bone metabolism
94
Epidemiology of CKD?
- Over 70% due to DM, hypertension
- Prevalence increases with age
- 8.5% Stage 3-5 CKD
95
Causes of CKD - intrinsic?
o Hypertension
o DM (Type 2 most common)
o Glomerulonephritis
o Renal artery stenosis
96
Causes of CKD - nephrotoxic?
o NSAIDs, Lithium, Ciclosporin, Tacrolimus, Aminoglycosides, Mesalazine
97
Causes of CKD - obstructive?
o Bladder voiding dysfunction
o Urinary diversion surgery
o Recurrent urinary stones
98
Causes of CKD - multi-system disease?
o SLE, vasculitis, myeloma, polycystic kidney disease, Alport’s syndrome
99
Symptoms of CKD?
- Asymptomatic at first
- Anaemia – Low EPO – Pallor, SOB
- Renal osteodystrophy – osteomalacia, bone pain
- Epistaxis/bruising
- Uraemic symptoms
- Anorexia/nausea/vomiting
- Restless legs, weakness, pruritus and bone pain
100
Signs of CKD?
- Pallor, uraemic tinge, purpura, increased BP, signs of fluid overload, ballotable kidneys
101
When to test people for CKD?
Test people with risk factors for CKD:
o Diabetes, hypertension, AKI, CVD, SLE, structural renal tract disease, recurrent calculi, BPH
o Family history of CKD stage 5
o Taking nephrotoxic drugs (ciclosporin, tacrolimus, lithium, NSAIDs)
Test people with incidental findings:
o Proteinuria or persistent haematuria (2/3 with 1+) after exclusion of UTI
o eGFR of <60
102
What tests to perform in people suspecting CKD?
- Serum creatinine (eGFR)
- Early Morning Urine – Albumin Creatinine Ratio (ACR)
- Urine dipstick for haematuria
103
Specific advice for testing eGFR in CKD?
o No meat in 12 hours before, caution if extreme muscle mass
o Confirm result if <60 with test 2 weeks later
o If stable but same, repeat 3 months
104
Specific advice for testing EMU ACR in CKD?
- Early Morning Urine – Albumin Creatinine Ratio (ACR)
o Repeat if 3-70mg/mmol within 3 months, no need if >70
o >3 is clinically proteinuria
105
Specific advice for testing urine dipstick in CKD?
o Significant haematuria if 1+ or more, exclude UTI by sending MSU
106
Specific advice for testing renal USS in CKD?
o If accelerated progression of CKD, visible or persistent invisible haematuria, symptoms of UT obstruction, FHx of PKD and >20 years, eGFR <30
107
Other tests to find cause of CKD?
- Bloods (low Hb, Ca, high PO4 and ALP and PTH, glucose, U&Es)
- Urine – ACR, dipstick
- USS to check kidneys size and anatomy
- Renal biopsy if rapid decline and cause unclear
- Immunology – Goodpasture’s syndrome, IgA nephropathy
108
Diagnosis of CKD can be made when?
- EGFR <60 and/or ACR >3 after 3 months
- If repeat eGFR 45-59 and urine ACR <3 and no proteinuria:
o Use eGFRcystatinC test
Hypothyroidism elevates, hyperthyroidism reduces
109
Classification of CKD stages?
- Stage 1 - >90 No impairment
- Stage 2 – 89-60 Slight
- Stage 3A – 59-45 Moderate
- Stage 3B – 44-30 Severe
- Stage 4 – 29-15 Severe
- Stage 5 - <15 Renal Failure
- ACR classified in each stage as A1 - <3, A2 – 3-30, A3 - >30
110
When to refer CKD to nephrologist?
- eGFR <30
- ACR >70mg/mmol
- ACR >30mg/mmol with haematuria
- Decrease by >25% in year or decrease GFR >15ml/min/1.73 in year
- Poorly controlled BP on 4 antihypertensives
- Suspected genetic causes or renal artery stenosis
111
Monitoring of CKD?
- Annual eGFR and ACR if no CKD and risk factors
- eGFR, ACR (stage 1-3a annually, stage 3b-4 biannually, stage 5 quarterly)
- FBC (Stage 3b, 4, 5)
- Serum calcium, phosphate, vitamin D and PTH in (stage 4, 5)
112
Management of CKD - self-management?
- Stop smoking
- Regular exercise and healthy body weight
- Eat healthy diet – low sodium, Vit D analogues and Ca supplements
- Avoid NSAIDs, nephrotoxics
- Manage and minimise risk factors
113
Management of CKD - antihypertensives?
o If hypertensive and ACR <30 – follow guidelines
o If hypertension and ACR >30 – ACEi/ARB
o If ACR >70 and normotensive OR CKD and diabetic – ACEi/ARB (aim <130/80)
114
Management of CKD -aim of antihypertensives?
Aim <140/90 in hypertensive + CKD + ACR <70
Aim <130/80 in ACR>70 + normotensive or CKD + diabetes
115
Management of CKD -monitoring of antihypertensives?
Measure serum potassium and eGFR before ACEi, 1-2 weeks later and at any dose change (before starting K<5, otherwise don’t start ACE/ARB, stop if K>6 after 1-2 weeks)
If eGFR decreased by >25% then repeat test 1-2 weeks – if <25% then continue and repeat test in 1-2 weeks, if >25% investigate causes and stop drug
116
Management of CKD - statin therapy?
- Atorvastatin 20mg daily (if eGFR <60 and ACR >3)
o Baseline lipids, CK, LFTs
o Can increase dose if not >40% reduction in non-HDL cholesterol and eGFR >30 in 3 months
o Repeat lipids at 3 months
117
Management of CKD -antiplatelets and anticoagulants?
- Antiplatelets
o Secondary prevention only
- Anticoagulant
o Secondary prevention of CVD – Apixaban used if eGFR 30-50 and non-valvular AF and 1 of: Hx of TIA/stroke, >75, HTN, DM, HF
118
Management of CKD - complications - anaemia?
o Check Hb in people with eGFR <45
o Offer iron tablet if deficient – if Hb level not reached within 3 months, offer IV therapy
o If on dialysis – offer IV iron first
o EPO may be needed
119
Management of CKD - complications - bone complications?
o Measure serum Ca, phosphate, PTH and Vit D when eGFR <30
If needed – cholecalciferol
o Bisphosphonates for prevention of osteoporosis when eGFR >30, if indicated only
120
Management of CKD - complications - bicarbonate level?
- Oral sodium bicarbonate
| o eGFR<30 or sodium bicarbonate <20
121
Definition of deterioration of CKD?
- Decrease by >25% or 15ml/min/1.73 in year
- Repeat eGFR 3x over 90 days
- Refer to nephrologist as before
122
When to discuss RRT in CKD?
- Discuss when eGFR <20
- Dialysis started when impact of symptoms of uraemia on daily living, biochemical measures or uncontrollable fluid overload or at eGFR around 5-7 if no symptoms
123
Options of RRT in CKD?
- Haemodialysis
o Diffusion solutes between blood and dialysis fluid – access via fistula inserted 6 months before start
- Peritoneal dialysis
o Diffusion solutes between blood in peritoneal capillaries and dialysis fluid in peritoneal cavity
o Continuous ambulatory peritoneal dialysis (4x a day)
o Automated PD (several exchanges per night)
- Kidney transplant
o From deceased donor or live donor
o Lifelong immunosuppression
o Must be medically fit for surgery
124
Prognosis of CKD?
- CKD progresses to End-stage KD in 2% of people
| - 20x more likely to die of CVD then to progress to End-stage KD
125
Complications of CKD?
- Renal replacement therapy
- CVD and events
- Renal anaemia, bone disease (low Ca, high PO4 and PTH)
- Malnutrition
- Neuropathy
- Lipid abnormalities
126
Definition of AKI?
- Rapid reduction in kidney function over hours to days, as measured by serum urea and creatinine – leading to failure to maintain fluid, electrolyte and acid-base homeostasis
127
Epidemiology of AKI?
- Occurs in 18% of hospital patients
128
Risk factors of AKI?
- Age>75
- CKD
- Cardiac failure
- PVD
- Liver failure
- Diabetes
- Drugs
- Sepsis
- Poor fluid intake
129
Causes of AKI - pre-renal?
Most common
o Renal hypoperfusion due to hypotension (hypovolaemia, D&V, sepsis), renal artery stenosis +/- ACEi
o Reduced cardiac output (cardiac and liver failure)
130
Causes of AKI -intrinsic?
10-50%
```
o Acute tubular necrosis
Due to drugs, aminoglycosides, radiological contrast, rhabdomyolysis
o Glomerulonephritis
o Vasculitis, thrombosis
o Interstitial nephritis, lymphoma
```
131
Causes of AKI - post-renal?
10-25%
Urinary tract obstruction
Luminal – stones, clots
Mural – malignancy, BPH, strictures
Extrinsic compression – malignancy, retroperitoneal fibrosis
132
Symptoms and signs of AKI?
- May be none
- Fatigue, malaise, rash
- Joint pains, nausea and vomiting
- Chest pain, palpitations, SOB, fluid overload
- Oliguria, hypo/hypertension
133
When to measure U&Es to identify AKI?
CKD, HF, liver disease, Hx of AKI, oliguria (<0.5ml/kg/hour), hypovolaemic, NSAIDs, ACEi/ARBs, diuretics, urinary obstruction, sepsis, severe diarrhoea, nephritis, hypotension, >65
134
When to detect AKI in hosptial patients?
Rise in serum creatinine >26 within 48 hours
50% or greater rise in serum creatinine within 7 days
Fall in urine output to <0.5ml/kg/hour for >6 hours in adults and >8 hours in children
25% or greater fall in eGFR in children and young people within 7 days
135
KDIGO staging of AKI - Stage 1?
* Rise in creatinine >26umol/L in 48h OR >1.5-1.9x baseline (best figure in last 3 months)
* Urine output <0.5ml/kg/h for >6 consecutive hours
136
KDIGO staging of AKI - Stage 2?
* Increase in creatinine 2-2.9x baseline
| * Urine output <0.5ml/kg/h for >12h
137
KDIGO staging of AKI - Stage 3?
* Increase in creatinine >3x baseline OR >354umol/L OR commenced on RRT
* Urine output <0.3ml/kg/h for >24h OR anuria for >12h
138
Tests to identify cause of AKI?
Bloods
• FBC, U&E, LFTs, Ca, Phosphate
• Cultures if signs of infection
Urinalysis
• Test for blood, protein, leucocytes, nitrites and glucose as soon as suspected
• If haematuria and proteinuria and no obvious cause/UTI/trauma – think acute nephritis
Ultrasound
• Do not offer if cause of AKI identified
• If pyonephrosis suspected – US within 6 hours
• If no cause of AKI found – urgent US within 24 hours
139
Management of AKI - if urinary obstruction suspected/identified?
Refer immediately when one or more of following is present:
Pyonephrosis
Obstructed solitary kidney
Bilateral upper urinary tract obstruction
Complications of AKI caused by urological obstruction
Nephrostomy or stenting performed within 12 hours of diagnosis if needed
140
Management of AKI -investigations to perform?
o ABG/VBG
o ECG
o Catheterisation and urine output
141
Management of AKI - initial management - STOP AKI?
Sepsis
Complete sepsis 6 if sepsis suspected
Toxins
Stop/avoid nephrotoxics (Gentamicin, NSAIDs, ACE/ARBs, diuretics, contrast)
Optimise BP
If low BP – fluid bolus (0.9% saline 500ml IV 15-20 minutes)
Assess volume status
BP, JVP, skin turgor, fluid balance sheet, weight
IV fluids
• If low BP – fluid bolus (0.9% saline 500ml IV 15-20 minutes)
• IV fluids maintenance if not hypovolaemic
```
Prevent Harm
Treat complications
• Hyperkalaemia
• Pulmonary oedema
• Acidosis
• Pericarditis
Review all medications
Identify cause
```
Refer to renal team early for opinion
142
Management of AKI - monitoring?
o Check pulse, BP, JVP, urine output hourly
o CVP line if on HDU/ICU
o Daily U&Es, fluid balance chart and daily weight
143
Management of AKI - when to discuss with nephrology?
```
Specialist treatment needed (vasculitis, glomerulonephritis, nephritis, myeloma)
AKI with no clear cause
Inadequate response to treatment
Complications associated
Stage 3 AKI
Renal transplant
CKD Stage 4/5
```
144
Management of AKI -indications for RRT?
o Refractory pulmonary oedema
o Persistent hyperkalaemia
o Severe metabolic acidosis (7.15)
o Ureamic complications (pericarditis, encephalopathy)
o Drug overdose – Barbituates, lithium, alcohol, salicylates, theophylline
145
Options for RRT in AKI?
Haemodialysis
Blood passed over semi-permeable membrane against dialysis fluid flowing in opposite direction
Hemofiltration
Water is cleared across dialysis membrane using positive pressure to drag small and larger size solutes into waste by convection
Peritoneal Dialysis
Uses peritoneum as semi-permeable membrane and allows solutes to diffuse slowly
Can be performed continuously and at home so allows more freedom
146
Follow up after AKI?
o Monitor U&Es for 2-3 years after AKI
147
Complications of AKI?
- Hyperkalaemia
- Metabolic acidosis
- Volume overload
- Uraemia
- CKD
148
Symptoms in urinary incontinence?
Stress - leakage of urine on sneezing, coughing, exercise, rising from sitting or lifting
Urge - urgency and failure to reach toilet, frequency and nocturia possible
Other symptoms to ask:
Frequency during day/night, dysuria, haematuria,, dribbling of urine after leaving toilet, feeling incomplete bladder emptying
149
Gynaecological history important in urinary incontinence?
```
Uterus or not
Pre/Postmenopausal
Problems with intercourse
How many babies - delivery method
Smear tests up to date
```
150
PMH important in urinary incontinence?
```
Uterus or not
Pre/Postmenopausal
Problems with intercourse
How many babies - delivery method
Smear tests up to date
```
151
DH important in urinary incontinence?
Diuretics
Laxatives
Medications for urinary symptoms in past
152
SH for urinary incontinence?
```
Caffeine intake
Carbonated drinks
Alcohol
Smoking
Ketamine
Occupation - heavy lifting?
```
153
Examination performed in incontinence?
```
History including obstetric, sexual and functional status
BMI and Urine dipstick & MSU
Abdominal and pelvic examination
Cough - any leakage?
Assess for prolapse
Assess for vaginal atrophy
VE
Smear
```
154
Investigations in urinary incontinence?
- Urinalysis and MSU microscopy (culture and sensitivity)
o Exclude UTI
- OGTT if diabetes suspected
- Frequency/volume chart
o Should be filled in for 72h and give idea off fluid intake and voiding problems
155
When should a cystoscopy be performed in urinary incontinence?
o Used to visualise urinary tract
| o Indicated if recurrent UTI, haematuria, bladder pain, suspected fistula, tumour
156
What are the specialist tests performed for urinary incontinence?How do they work?
Urodynamics
o Uroflowmetry
Ability of bladder to store and void urine
Patient voids in private onto commode with urinary flow meter, measuring voided volume over time and plotting graph
o Cystometry
Invasive and involves measuring pressure and volume in bladder during filling and voiding
Bladder filled with saline and intravesical & vaginal/rectal probe measure differences in pressure to give detrusor pressure
Patient first desire to void, strong desire to void and cough
Diagnoses stress incontinence
157
Initial management of stress urinary incontinence?
```
Lifestyle interventions
• Weight reduction if BMI >30
• Smoking cessation
• Reduce caffeine and fizzy drinks
• Treatment of chronic cough and constipation
```
Pelvic floor muscle training
• For at least 3 months
• Exercises continued long-term.
• 8-12 slow maximal contractions sustained for 6-8 seconds each, 3x per day
Follow up 3 months
158
Follow up management of stress urinary incontinence?
Urodynamics
MDT Meeting
Duloxetine
• SNRI enhances urethral striated sphincter activity via a centrally mediated pathway.
• Dose-dependent decreases in frequency of incontinence episodes
Transvaginal tape
159
Pharmacological management of stress urinary incontinence?
Duloxetine
• SNRI enhances urethral striated sphincter activity via a centrally mediated pathway.
• Dose-dependent decreases in frequency of incontinence episodes
160
Surgical management of stress urinary incontinence ? When considered and what types?
Considered when other measures failed
Transvaginal Tape
• Polypropylene mesh tape placed under mid-urethra via small vaginal incision
• Risks – bladder injury, voiding difficulty, tape erosion
Periuretheral injections
• Bulking agents, better for older, frail or young women
161
Initial management of urge urinary incontinence?
Lifestyle advice
• Weight reduction if BMI >30, smoking cessation, reduce caffeine and fizzy drinks, treatment chronic cough and constipation
Pelvic floor muscle training
• 3 months, exercises continued long-term, 8-12 slow maximal contractions sustained for 6-8 seconds each, 3x per day
Bladder diary (>3 days) - idea of fluid intake and bladder voiding problems
Bladder drills
• Ability to suppress urinary urge and extend the intervals between voiding
Anticholinergics - Oxybutynin (+/- vaginal oestrogen if vaginal atrophy)
Follow up 3 months
162
Describe properties of initial pharmacological management of urge urinary incontinence? SE? CI?
When is botox used?
Anticholinergic (antimuscarinic) agents (oxybutynin)
• Block the sympathetic nerves thereby relaxing the detrusor muscle
• Side effects = dry mouth (up to 30%), constipation, nausea, dyspepsia, flatulence, blurred vision, dizziness, insomnia, palpitation, arrhythmias.
• Contraindications = acute (narrow angle) glaucoma, myaesthenia gravis, urinary retention or outflow obstruction, severe UC, GI obstruction.
Oestrogens
• In women with vaginal atrophy, intravaginal oestrogens may be tried
Botulinum Toxin A
• Blocks neuromuscular transmission – causing the muscle to become weak.
• Used in follow up and injected cystoscopically into the detrusor, usually under local anaesthetic.
163
Follow up management of urge urinary incontinence?
Try 2nd anticholinergic (tolterodine)
Urodynamic study (increased detrusor pressure upon voiding)
MDT meeting
Cystoscopy & Botox (botulinum toxin A)
Nerve stimulation - percutaneous posterior nerve/percutaneous sacral nerve
Augmentation cystoplasty - if small bladder
Urinary diversion
164
Management of overflow incontinence?
o Treat with catheter
• Can cause urinary retention in 5-20% of cases, in which intermittent self catherterisation may be required.
o Surgical
Reserved as last resort for debilitating symptoms, failed therapies
Bladder distension, sacral neuromodulation, detrusor myomectomy have limited efficacy
165
How common is urogenital prolapse?
* Occurs in 40-60% of parous women
| * Most common reason postmenopausal women have hysterectomy
166
Definition of urogenital prolapse?
o Weakness of supporting structures (levator ani muscles and endopelvic fascia) allows the pelvic organs to protrude within the vagina
o Can be bladder, urethra, rectum, and bowel
167
Risk factors of urogenital prolapse?
```
o Increasing age
o Vaginal delivery
o Increasing parity
o Obesity
o FHx of prolapse
o Constipation/Chronic cough
```
168
Types of urogenital prolapse?
o Can occur in anterior, middle or posterior compartments of pelvis
169
Anterior types of urogenital prolapse?
```
Cystocele
• Prolapse of bladder into the vagina
Urethrocele
• Prolapse of urethra into the vagina, associated with USI
Cysto-urethrocele when both (MC)
```
170
Middle types of of urogenital prolapse?
Uterine prolapse
• Descent of uterus into vagina
• Baden-Walker Graded
Vaginal vault prolapse
• Descent of vaginal vault post-hysterectomy, associated cystocele, rectocele and enterocele common
Enterocele
• Herniation of pouch of Douglas into vagina
• Pouch usually contains loops of small bowel
171
Posterior types of urogenital prolapse?
Rectocele
| • Prolapse of rectum into vagina
172
POPQ staging of urogenital prolapse?
o 0 = No prolapse
o 1 = >1cm above hymen
o 2 = At level of hymen
o 3 = >1cm below hymen but protrudes <2cm total length of vagina
o 4 = Complete eversion of vagina (complete procidentia)
173
General symptoms of urogenital prolapse?
- Dragging sensation discomfort, and heaviness within the pelvis.
Usually worse at the end of the day or when standing up.
- Feeling of ‘a lump coming down’
- Dyspareunia or difficulty in inserting tampons.
- Discomfort and backache.
174
Cysto-urethrocele symptoms of urogenital prolapse?
- Urinary urgency and frequency.
- Incontinence
- Incomplete bladder emptying
o Urinary retention or reduced flow where the urethra kinked
175
Rectocele symptoms of urogenital prolapse?
- Constipation
| - Difficulty with defecation (may digitally reduce it to defecate).
176
Other symptoms of urogenital prolapse?
* Symptoms tend to become worse with prolonged standing and towards the end of the day.
* Grade 3 or 4 prolapse, there may be mucosal ulceration and lichenification, resulting in vaginal bleeding and discharge.
* Symptoms can affect quality of life, causing social, psychological, occupational or sexual limitations to a woman’s lifestyle.
177
Examinations performed in urogenital prolapse?
• Examine patient in both standing and left lateral position
o Ask woman to strain and observe
• Bimanual examination (exclude pelvic masses)
• Sims speculum examination
o Inspect anterior and posterior walls, ask to strain
178
Investigations of urogenital prolapse?
* USS to exclude pelvic or abdominal masses.
* Urodynamics are required if urinary incontinence is present
* Assess fitness for surgery – ECG, CXR, FBC, U&Es
179
Prevention of urogenital prolapse?
| Conservative management of urogenital prolapse?
Prevention
- Reduction of prolonged labour, trauma caused by instrumental delivery
- Encouraging persistence with post-natal pelvic floor exercises.
General Advice
- Weight reduction
- Avoid heavy lifting
- Treatment of chronic constipation and cough (including smoking cessation)
- Pelvic floor muscle exercises
180
Further management of urogenital prolapse - Intravaginal (pessary) devices? When used? What is it? Instructions?
- Conservative line of therapy for women who decline surgery, who are unfit for surgery, or for whom surgery is contraindicated.
o Artificial pelvic floor placed in the vagina to stay behind the symphysis pubic and in front of the sacrum.
o Sexually active women can use ring pessaries, either have sex with it in place or take it out and replace after
o They should be changed 6 monthly and if post-menopausal, topical oestrogen may be given to decrease risk of vaginal erosion.
181
Types of pessary and when used?
Ring pessary = most commonly used
o Placed between the posterior aspect of the symphysis pubis and posterior fornix of the vagina.
Shelf pessary = used when a correctly sized ring pessary will not sit in the vagina and/or where the perineum is deficient
Others: Hodge pessary, cube and doughnut pessaries (very rarely used).
182
Indications for surgical management of urogenital prolapse?
- Failure of conservative treatment
- Voiding or defaecation problems
- Recurrent prolapse after surgery
- Ulceration
- Irreducible prolapse
- Preference
183
Surgical management of anterior compartment of urogenital prolapse?
• Anterior colporrhaphy (anterior repair)
| - Appropriate for repair of a cysto-urethrocele.
184
Surgical management of posterior compartment of urogenital prolapse?
```
Posterior colporrhaphy (posterior repair)
- Appropriate for correction of a rectocele and deficient perineum
```
185
Surgical management of uterovaginal (apical) compartment of urogenital prolapse?
* Vaginal hysterectomy (most common)
* Sacrohysteropexy
- Preserve the uterus.
- Attaches the prolapsed uterus to the sacrum
186
Surgical management of vaginal vault of urogenital prolapse?
• Sacrospinous ligament fixation
| - Suturing vaginal vault to sacrospinous ligaments using a vaginal approach.
187
Surgical management of recurrent compartment of urogenital prolapse?
* ~1/3 of prolapse surgery is for recurrent prolapse.
* Vaginal epithelium may be scarred and atrophic (makes surgery harder and gives increased risk of damage to bladder and bowel)
188
Surgical management of recurrent compartment of urogenital prolapse?
* ~1/3 of prolapse surgery is for recurrent prolapse.
* Vaginal epithelium may be scarred and atrophic (makes surgery harder and gives increased risk of damage to bladder and bowel)
189
Definition of nephrotic syndrome?
```
- Clinical syndrome defined as:
o Proteinuria (>3.5g/24h (ACR>250))
o Oedema
o Hypoalbuminemia (<30g/L)
```
- It is caused by injury to podocyte which increase permeability of serum protein through the damaged basement membrane in the renal glomerulus
190
Classes of nephrotic syndrome?
- Classified as steroid sensitive, steroid resistant or steroid dependent
191
Aetiology of nephrotic syndrome - primary?
Minimal change disease – 85% in children
• Idiopathic, NSAIDs, Hodgkin’s lymphoma
• Biopsy – normal under light microscopy
• Steroids usual course of treatment
Focal segmental glomerulonephritis (FSGN) – most common in adults
• Segmental areas of mesangial collapse and sclerosis
• Due idiopathic, HIV, SCD, Alport’s, obesity, reflux nephropathy
Membranous nephropathy – common in older adults
• Due to – malignancy, hepatitis B, gold, penicillamine, NSAIDs, thyroid, SLE
• Thickened GBM
Membranoproliferative glomerulonephritis
192
Aetiology of nephrotic syndrome - secondary?
Infection – HIV, HepB/C, syphilis, malaria
SLE, HSP, Lupus
Diabetes – MC secondary cause
Alport’s syndrome
Malignancies
Toxins (snake bites, bee stings) and heavy metals
193
Symptoms and signs of nephrotic syndrome?
- Periorbital oedema, leg/ankle oedema, ascites and breathlessness
- Oliguria
- Proteinuria, oedema, hypoalbuminemia
- Dyslipidaemia, abnormalities in coagulation/fibrinolysis, reduced renal function
194
Investigations of nephrotic syndrome?
Urine dipstick
o Check for protein & microscopic haematuria
Urine MSU
o Microscopy, culture and sensitivities to exclude UTI
Red cell casts, protein electrophoresis
Urine ACR
Bloods
o FBC, CRP, ESR, U&E’s (creatinine, low albumin)
o Complement levels
o Autoimmune screen – ANA, ANCA, anti-DNA, anti-GBM, complement)
o Syphilis/HepB/C screen
CXR and renal USS
Renal biopsy
195
Management of nephrotic syndrome - general advice?
- Sodium and fluid restriction
- High-dose loop diuretics (furosemide)
- Daily weight & U&Es
- Pneumococcal and influenza vaccination
196
Management of nephrotic syndrome - minimal change disease
Steroid-sensitive nephrotic syndrome
Oral prednisolone for 4 weeks then wean over 4 months
• If steroid toxicity, use cyclophosphamide
Steroid-resistant nephrotic syndrome
Management of oedema with diuretics, salt restriction and ACE inhibitors (enalapril)
197
Management of nephrotic syndrome - focal segmental glomerulonephritis?
o Corticosteroids
| o Cyclophosphamide if steroid-resistant
198
Management of nephrotic syndrome - membranous nephropathy?
o Secondary – treat cause
| o ACEi and diuretics
199
Management of nephrotic syndrome - mesangiocapillary GN?
o ACEi
| o Steroids and cyclophosphamide if rapid deterioration
200
Complications of nephrotic syndrome ?
- Susceptible to infections
- Risk of VTE – urinary excretion of antithrombin 3
- Hyperlipidaemia
- AKI/CKD
201
Pathology of bladder cancer?
o Calyces, renal pelvis, ureter, bladder and urethras lined by transitional epithelium
o 50% in bladder
202
Spread of bladder cancer?
o Local – pelvic structures
o Lymph – iliac and para-aortic nodes
o Bloods – liver and lungs
203
Epidemiology of bladder cancer?
- Men > Women
| - Age >40
204
Cell types of bladder cancer?
o 90% transitional cell carcinoma
| o Rare – adenocarcinoma, SCC (from schistosomiasis)
205
Aetiology of bladder cancer?
```
o Cigarette smoking
o Aromatic amines (rubber industry)
o Chronic cystitis
o Drugs – cyclophosphamide
o Schistosomiasis (SCC)
```
206
Symptoms of bladder cancer?
```
o Painless haematuria
o UTI symptoms without bacteriuria
o Pain
o Voiding irritability
o If in ureters, pelvis – flank pain due to obstruction
```
207
When to refer on 2 week pathway of bladder cancer?
Over 45 with:
• Unexplained visible haematuria without UTI OR
• Visible haematuria persisting or recurring after treatment of UTI
Over 60 with unexplained non-visible haematuria and either:
• Dysuria OR
• Raised WCC
208
When to refer non-urgently of bladder cancer?
o Non-urgent referral in over 60 with recurrent or persistent UTIs
209
Diagnostic investigations performed in secondary care of bladder cancer?
US KUB
Cystoscopy with biopsy
If invasive – CT/MRI
Transurethral Resection of bladder tumour
• With photodynamic diagnosis, narrow-band imaging, cytology or urinary biomarker test
• Obtain detrusor muscle
• Record size and number of tumours
• Offer single dose of intravesical mitomycin C
210
Staging investigations of bladder cancer?
TURBT within 6 weeks if no detrusor muscle
CT scan
• If diagnosed with muscle-invasive or high-risk and being assessed for radical treatment
CT urography
CT thorax
PET scan – if indeterminate findings on CT or high risk of metastatic disease
211
Management of bladder cancer - general advice?
o Clinical nurse specialist – support
| o Smoking cessation
212
Management of bladder cancer - non-muscle invasive - risk classification?
o Risk Classification – determined on size, number, histology, type, grade, stage
213
Management of bladder cancer - non-muscle invasive - low risk?
White-light guided TURBT
o With photodynamic diagnosis, narrow-band imaging, cytology or urinary biomarker test
o Obtain detrusor muscle
o Record size and number of tumours
o Offer single dose of intravesical mitomycin C
o TURBT within 6 weeks if no detrusor muscle
Follow-Up
o Cystoscopy at 3 months and 12 months after diagnosis
o Discharge if no recurrence
214
Management of bladder cancer - non-muscle invasive - medium risk?
6 doses of intravesical mitomycin C
o If recurs, specialist MDT
Follow Up
o Cystoscopy follow up at 3, 9 and 18 months and annually after
215
Management of bladder cancer - non-muscle invasive - high risk?
TURBT before 6 weeks – if 1st TURBT shows high risk
Intravesical BCG or
o Induction and maintenance
Radical cystectomy
o Urinary stoma or urinary diversion (unless cognitive impairment, impaired renal function or bowel disease)
```
Follow Up
o Cystoscopy every 3 months for 2 years, every 6 months for 2 years and then annually
o CT every 6 months for 2 years
o Annually
Measure eGFR
US of KUB
B12 and folate level
Urethral washing for cytology
```
216
Management of bladder cancer - muscle invasive?
Neoadjuvant Chemotherapy – cisplatin then:
Radical Cystectomy OR
• Urinary stoma or urinary diversion (unless cognitive impairment, impaired renal function or bowel disease)
• Adjuvant chemotherapy - cisplatin
Radiotherapy with Radiosensitiser
• Mitomycin in combo with 5-FU
• Over 6.5 or 4 weeks
```
Follow up
Cystoscopy every 3 months for 2 years, every 6 months for 2 years and then annually
CT every 6 months for 2 years
Annually
• Measure eGFR
• US of KUB
• B12 and folate level
• Urethral washing for cytology
```
217
Management of bladder cancer - locally advance or metastatic cancer?
Chemotherapy
MVAC with G-CSF (if ECOG 0,1 and GFR >60)
• Carboplatin with gemcitabine (if ECOG 2 or GFR<60)
• Pembrolizumab if cisplatin unsuitable
Gemcitabine with MVAC and G-CSF
218
Management of bladder cancer - symptoms management?
Bladder (haematuria, dysuria, frequency, nocturia)
• Radiotherapy
Loin Pain or Renal Failure
• Percutaneous nephrostomy or retrograde stenting
Bleeding
• Radiotherapy or embolization
Pelvic Pain
• Radiotherapy
• Nerve block
• Palliative chemotherapy
219
Type of prostate cancer?
- Malignant tumour of the prostate
o >95% are adenocarcinomas, developing in glandular tissue in posterior or peripheral parts of prostate
- BPH more common in centre of gland
220
Spread of prostate cancer?
- Spread may be local (seminal vesicles, bladder, rectum), via lymph or haematogenous (sclerotic bony lesions)
221
Epidemiology of prostate cancer?
- Commonest cancer in males
- 1 in 8 men will get prostate cancer in lives
- Older men - >50% occur after 75 years
222
Risk factors of prostate cancer?
```
o Genetics
BRCAII & pTEN genes
o Radiation exposure
o Diet
o Anabolic Steroids (due to increased testosterone)
o Age
o African/Afro-Caribbean
o Family History
```
223
Symptoms of prostate cancer?
```
o Asymptomatic
o Poor stream
o Nocturia
o Terminal dribbling
o Polyuria
o Metastatic symptoms
Weight loss, anaemia, lower back pain, MSCC
```
224
Signs of prostate cancer?
o Rectal Examination
Enlarged, hard, craggy gland
Loss of median sulcus
225
Investigations in primary care of prostate cancer?
Prostate Specific Antigen (PSA) increased
• Test in men with:
o Lower UT symptoms
o Erectile dysfunction
o Visible haematuria
• Better prognosis if picked up, may be high or low falsely
• 75% of men with abnormal PSA do not have cancer
• Most men who have abnormal test will have biopsy which is invasive
Digital Rectal Examination
After PSA
226
Investigations in secondary care in suspected prostate cancer?
```
Transrectal USS and biopsy
If curative intent:
• MRI
If metastatic concerns:
• Radiolabelled technetium bone scan
```
227
Staging of prostate cancer?
TMN
228
Grading of prostate cancer?
Gleason grading 2-5 and then added together, scored on basis of histological patterns 2-10
• Low risk – GS<7, T1/2, PSA<10
• Moderate risk – GS=7, T2, PSA 10-20
• High risk – GS>7, PSA>20
229
When to refer for 2-week appointment of prostate cancer?
o DRE – prostate feels malignant
| o PSA raised
230
2-week referral assessment of prostate cancer?
o Urology clinic appointment
o Imaging MRI/USS/X-rays
o Trans-rectal Biopsy – 10 cores
Rectal discomfort, blood in urine or semen, 3% risk of sepsis
231
Management of prostate cancer - observational?
Asymptomatic prostate cancer confined to prostate, particularly in elderly and where other conditions limit length of survival
232
Management of prostate cancer - surgery?
Radical Prostatectomy with curative intent
• T2 or less
• Perineal or retroperineal routes
• May have temporary or lasting impotence and incontinence
Palliative surgery
• Used to relieve prostatic symptoms or urinary obstruction
233
Management of prostate cancer - radiotherapy?
Performed by external beam irradiation, interstitial implantation of radioisotopes or both
Radical radiotherapy
• Can be used in T1/T2 tumours or to control locally advanced tumours
Adjuvant radiotherapy
• Following radical surgery if concerns about residual disease
Palliative used to palliate primary tumour or treat complications
Side Effects: Dysuria, rectal bleeding, diarrhoea, impotence, incontinence
234
Management of prostate cancer - brachytherapy?
TRUS used and used in fit men with no-comorbidity
235
Management of prostate cancer - hormonal?
Treating advanced disease or in conjunction with radiotherapy for localised disease
LHRH agonists (leuprorelin, goserelin)
• Reduces level of testosterone
• Given monthly or 3-monthly via SC/IM depots
• Medical castration causes increased CVD, osteoporosis
Gonadotrophin-releasing hormone antagonist (degarelix)
• Castrate levels of testosterone within 3 days
• Monthly SC injection
Oestrogen Therapy
• Inhibit LHRH, rarely used
Anti-Androgens (bicalutamide)
• Slows progression and survival benefit combined with LHRH
236
Management of prostate cancer - chemotherapy?
Used in castrate-refractory metastatic disease
237
Follow up of prostate cancer?
Watchful waiting followed up in primary care according to MDT outcome
PSA measured once a year
Radical treatment
PSA 6 weeks after treatment, 6 monthly for 2 years, then yearly
238
Definition of urinary tract obstruction?
o Impaired urinary flow which results in proximal distention of urinary tract depending on location:
Urethra – bladder dilation, secondary hypertrophy and diverticulae formation
Ureter – megaureter and hydronephrosis
239
Points most susceptible to urinary tract obstruction?
Pelvi-ureteric junction
Where ureters cross pelvic brim, at level of iliac vessels
Vesico-ureteric junction
240
definition of hydronephrosis?
o Urine-filled dilation of renal pelvis and calyces due to obstruction
o Increased pressure being transmitted to kidney, leading to infection, stones and decreasing renal function
241
Epidemiology of urinary tract obstruction?
- In older men, BPH
- 1 in 100 foetuses have hydronephrosis on US
- Women – pelvic tumours, prolapse or pregnancy
242
Causes of urinary tract obstruction - within lumen?
Blood clot
Calculi
Sloughed papillae
Tumour of renal pelvis or ureter
243
Causes of urinary tract obstruction - within wall?
```
Ureteric, urethral strictur
Congenital megaureter
Bladder neck obstruction
Congenital urethral valves
Pinhole meatus
Neurogenic bladder
SCI or MS
```
244
Causes of urinary tract obstruction - pressure from outside?
```
PUJ compression
Tumours
BPH
Retroperitoneal fibrosis
• Present with dull abdominal pain, or complications of that
• 50% hypertension
• Anaemia, raised ESR/CRP
Pancreatitis
Crohn’s Disease
Phimosis
```
245
Symptoms of acute upper urinary tract obstruction?
o Flank pain
Dull, sharp or colicky, varies in severity
Unable to lie still
Radiates to iliac fossa, inguinal area, testis or labium
Provoked by alcohol, diuretics or high fluid intake
o Nausea & Vomiting
o Loin tenderness, enlarged kidney
o Anuria – bilateral
246
Symptoms of chronic upper urinary tract obstruction?
o Flank or abdominal pain
o Chronic kidney disease
o Polyuria
247
Symptoms of acute lower urinary tract obstruction?
```
o Severe suprapubic pain
o Distended bladder – abdominal distention, suprapubic dullness on percussion
o Urine hesitancy
o Narrow/Weak urine stream
o Terminal dribbling
o Incomplete bladder emptying
```
248
Symptoms of chronic lower urinary tract obstruction?
```
o Urine hesitancy
o Narrow/Weak urine stream
o Terminal dribbling
o Incomplete bladder emptying
o May have signs of UTI
o Distended bladder
```
249
Investigations in urinary tract obstruction?
DRE
```
Blood Tests
o FBC – anaemia, infection
o U&Es
o If stones – serum calcium, phosphate and urate levels
o If prostate enlarged - Serum PSA
```
Urinalysis – dipstick and M,C&S
Blood cultures if signs of sepsis
250
Imaging in urinary tract obstruction?
US KUB
If abnormal – CT KUB or XR KUB
If suspected calculi – non-contrast helical CT
If renal pathology – contrast CT
Renal scintigraphy – shows function and excretion
Retrograde urethrography – demonstrates structural abnormalities
Nephrostography
Urodynamic studies
251
Urological emergencies requiring urgent treatment in urinary tract obstruction?
```
o Complete UT obstruction
o Any obstruction in single kidney
o Obstruction with fever/infection
o CKD
o Suspicion of neurological dysfunction
o Uncontrolled pain
```
252
Management of urinary tract obstruction - general management?
```
o Analgesia
o Hydration
o Relieve blockage
Acute lower – catheter
Acute upper – nephrostomy or ureteric stent
```
253
Management of urinary tract obstruction - PUJ obstruction?
o Pyeloplasty – open, laparoscopic or robot-assisted
o Endopyelotomy – full-thickness incision through stenosis and leaving stent
o Ureteroscopic endoureterotomy – strictures
254
Management of urinary tract obstruction - malignancy?
o Treat cause
| o Percutaneous nephrostomy to relieve obstruction
255
Management of urinary tract obstruction - idiopathic retroperitoneal fibrosis?
o Ureterolysis or stent placement
o Corticosteroids and/or axathioprine, tamoxifen
o Biopsy to exclude malignancy
256
Management of urinary tract obstruction - BPH?
o Acute retention – catheterisation
o Mild symptoms – reduce fluid intake, avoid caffeine and alcoholic drinks
o Medical treatment – alpha blockers (tamsulosin, alfuzosin, doxazosin, terazosin) & 5-alpha reductase inhibitors (finasteride)
o Surgical treatment – Transurethral resection of the prostate
257
Complications of urinary tract obstruction?
```
o Infection
o Extravasation
o Fistula formation
o CKD
o Pain
```
258
Epidemiology of renal carcinoma?
- Mostly males
| - Mean age 55
259
Types of renal carcinoma?
o 90% are renal cell carcinoma (Grawitz tumour)
| Arise from proximal tubular epithelium – highly vascular with large cells with clear cytoplasm (clear cell carcinoma)
260
Risk factors of renal carcinoma?
```
o Smoking
o Males
o Older age
o Obesity
o FHx
o Von Hippal Lindau – bilateral RCC common
```
261
Spread of renal carcinoma?
o Direct – renal vein
o Lymph
o Haematogenous – bone, liver, lung
262
Symptoms of renal carcinoma?
```
o Asymptomatic
o Haematuria
o Loin pain
o UTI
o Mass in flank
o Anorexia, malaise, weight loss
```
263
Signs of renal carcinoma?
o Anaemia, PCV, high calcium
264
Investigations to perform if suspected of renal carcinoma?
```
- Bloods
o FBC – elevated RBC, reduced Hb
o LDH raised
o High Ca
o U&Es
```
- Urinalysis
o Haematuria
o Proteinuria
265
When to refer for 2 week appointment of renal carcinoma?
- Refer for 2-week appointment if >45 and have:
o Unexplained visible haematuria without UTI OR
o Visible haematuria that persists or recurs after treatment of UTI
266
Diagnostic investigations of renal carcinoma?
o US KUB
o CT scan
o Biopsy
267
Management of renal carcinoma - risk assessment?
```
o <1 year to systemic therapy
o Performance status
o Hb low
o Calcium high
o Neutrophils high
o Platelets high
```
268
Management of renal carcinoma - screening in VHL?
o Annual abdominal US at 11 years
| o CT every year after 20
269
Management of renal carcinoma - Stage 1/2?
```
o Surgical Procedures
Laparoscopic cryotherapy
Percutaneous cryotherapy
Percutaneous radiofrequency ablation
Laparoscopic partial nephrectomy
Laparoscopic nephrectomy
```
o Not fit for surgery
Surveillance
270
Management of renal carcinoma - Advanced or metastatic cancer?
o First-Line
Nivolumab + Ipilimumab
Cabozantinib
Tivozanib
o Second-Line
Lenvatinib + everolimus
Cabozantinib
Everolimus
271
Definition of renal stones/colic?
- Deposition of stones/blood clots within the urinary tract causing spasmodic pain
- Commonly deposited in pelvoureteric junction, pelvic brim, vesicoureteral junction
272
Types of renal stones/colic?
o Calcium Oxalate (65%)
o Struvite (15%)
o Urate (5%)
o Mixed
273
Pathology of renal stones/colic?
o Pressure necrosis causes direct damage to renal parenchyma
274
Epidemiology of renal stones/colic?
- Lifetime risk 10%
- Higher prevalence in Middle East
- Most occur in upper UT
- Male 2x and peak age 20-40 years
275
Aetiology of renal stones/colic?
o Dehydration
o Calcium stones – hypercalcaemia (primary, increased Vit D, sarcoidosis), renal disease (PKD tubular acidosis, medullary sponge kidney), hyperoxaluria
o Urate stones – diet, increased uric acid, gout
o Struvate stones – UTI, recurrent (staghorn calculi)
276
Symptoms of renal stones/colic?
Pain
Dull loin ache (renal pelvis stones), severe colicky pain often sudden onset
Radiating from loin to groin
Bladder stones cause suprapubic pain and perineal ache
Haematuria often frank
If obstructed then may have dysuria, inability to void
277
Signs of renal stones/colic?
o Restless, sweaty, pale, nauseated
| o Fever, loin tenderness, palpable kidneys
278
Investigations of renal stones/colic?
- Bloods – FBC, U&E, Ca, PO4, urate, glucose
- Urinalysis
- Urine M, C&S if infection
279
Immediate admission when in renal stones/colic?
o Sepsis
o CKD, solitary kidney, bilateral obstructing stones
o Dehydrated and cannot take oral fluids due to N&V
280
Diagnostic imaging of renal stones/colic?
```
o Urgent (within 24 hours) non-contrast helical CT scan in adults
o Urgent USS in children, or pregnant women
```
281
Tests to find cause of renal stones/colic?
o Serum Ca and urate, 24-hour calcium urine, phosphate, oxalate, urate
282
Management of renal stones/colic - initial management?
o Analgesia
Diclofenac 75mg IM repeated after 30 mins
If NSAIDS CI or not sufficient – give IV paracetamol
Opioids used if both NSAIDs and paracetamol not sufficient
o Antiemetic if opioid
o High fluid intake/IV fluids
283
Management of renal stones/colic - watchful waiting?
- Watchful Waiting for asymptomatic renal stones
| o Stone <5mm OR stone >5mm and person wishes for watchful waiting
284
Management of renal stones/colic - when to refer to urology?
- Refer to urology if >5mm stones
285
Management of renal stones/colic - medical treatment?
o Medical expulsion if <10mm
| Give alpha-blocker – tamsulosin, alfuzosin
286
Management of renal stones/colic - surgical treatment - when?
• Offer within 48 hours if pain is ongoing and not tolerated OR stone unlikely to pass
Pre-treatment stenting
• Only considered in children having shockwave lithotripsy for renal staghorn stones
287
Management of renal stones/colic - surgical treatment of renal - what - if stone <10mm?
o Shockwave Lithotripsy
o Ureteroscopy extraction if SWL CI, previous failed SWL
o If SWL and URS failed – consider percutaneous nephrolithotomy
288
Management of renal stones/colic - surgical treatment of renal - what - if stone 10-20mm?
o Ureteroscopy or Shockwave lithotripsy
| o IF SWL and URS failed – percutaneous nephrolithotomy
289
Management of renal stones/colic - surgical treatment of renal - what - if stone >20mm?
• Renal Stone >20mm, including staghorn stones
o Percutaneous nephrolithotomy
o URS if PCNL not an option
290
Management of renal stones/colic - surgical treatment of ureteric - if stone <10mm?
o Shockwave Lithotripsy
| o Ureteroscopy if stones not cleared within 4 weeks of SWL, SWL CI or previous course failed
291
Management of renal stones/colic - surgical treatment of ureteric - if stone 10-20mm?
o Ureteroscopy extraction
| o Percutaneous nephrolithotomy if URS failed
292
Ongoing management in renal colic/stones?
Stone analysis
| Serum calcium
293
General advice in renal colic/stones?
```
Avoid rhubarb, spinach
High fluid intake 2.5-3L/day
Add fresh lemon juice to water
Avoid carbonated drinks
Restrict sodium intake to <6g/day
Maintain normal calcium intake
Medications for recurrent stones
• Calcium Oxalate – potassium citrate + thiazide (after restricting sodium to <6d/day)
```
294
Type of polycystic kidney disease - autosomal dominant?
o 85% mutations in PKD1 (c16), 15% have PKD2 (c4) with slower course, PKD3 also described
o Mutations in polycystin 1/2/3 which regulate tubular and vascular development in kidneys and other organs
295
Type of polycystic kidney disease - autosomal recessive?
o Chromosome 6 encoding fibrocystin
| o Less common than ADPKD
296
Epidemiology of polycystic kidney disease?
- AD – 1 in 1000 individuals, 10% of people on dialysis
297
Symptoms of autosomal dominant polycystic kidney disease?
Loin pain
Hypertension
Haematuria
298
Signs of autosomal dominant polycystic kidney disease?
```
Renal enlargement with cysts
Haematuria
Cyst infection
Renal calculi
Hypertension
Progressive renal failure
```
299
Extra-renal signs of autosomal dominant polycystic kidney disease?
```
Liver cysts
Subarachnoid haemorrhage (SAH)
Mitral valve prolapse
Ovarian cysts
Diverticular disease
```
300
Symptoms of autosomal recessive polycystic kidney disease - category 1 - perinatal?
Large abdomen, renal enlargement
Severe renal impairment in utero – oligohydramnios and pulmonary hypoplasia
75% result in death within a week of birth
301
Symptoms of autosomal recessive polycystic kidney disease - category 2 - neonate?
Palpable kidneys at birth and kidney disease progresses
Liver involvement
Usually causes death within few months
302
Symptoms of autosomal recessive polycystic kidney disease - category 3 - infancy?
Enlarged kidneys, hepatosplenomegaly
| Develop ESKD
303
Symptoms of autosomal recessive polycystic kidney disease - category 4 - childhood?
Marked liver disease
<10% develop ESKD
Renal enlargement and hepatosplenomegaly
Mortality is lowest in this category
304
Investigations in autosomal dominant polycystic kidney disease - screening for people with family affected?
Abdominal USS
Diagnosis when FHx &:
<30 - at least 2 unilateral or bilateral cysts
30 to 59 - 2 cysts in each kidney
>60 - 4 cysts in each kidney
305
Investigations in autosomal dominant polycystic kidney disease - other investigations?
Bloods
• FBC (high Hb)
• U&E
• Bone profile
Imaging
• USS & CT
306
Investigations in autosomal dominant polycystic kidney disease - screening for SAH?
MR angiography
| 1st degree relatives with SAH + ADPKD
307
Investigations for autosomal recessive polycystic kidney disease?
o USS in perinatal period
o CT and MRI in older children
o Genetic Testing if one diagnosed case in family
308
Management of polycystic kidney disease - general advice?
o Advise against contact sport
o Avoid smoking
o Maintain healthy diet and BMI
o Regular exercise
309
Management of polycystic kidney disease - monitoring?
Annual
o BP
o U&E
o USS
310
Management of polycystic kidney disease - BP?
o Target BP <130/80
| o Use ACEi/ARBs
311
Management of polycystic kidney disease - drug treatment?
Tolvaptan
o Slow progression of cysts development and renal insufficiency if CKD stage 2/3 at start of treatment and evidence of rapidly progressing disease
312
Management of polycystic kidney disease - in end-stage renal failure?
Dialysis or transplant
313
Prognosis of polycystic kidney disease?
o 50% will be in ESRD requiring dialysis or transplant by age of 60 in PKD1 and 75 in PKD2
314
Definition of polycystic ovary disease?
o Hyperandrogenism, oligomenorrhoea and polycystic ovaries on US without other causes of polycystic ovaries
315
Epidemiology of polycystic ovary disease?
- Prevalence = 10% of women at childbearing age.
| - Responsible for ~80% of anovulatory subfertility.
316
Pathogenesis of polycystic ovary disease?
- Excess androgens
o Hypersecretion of LH (increased frequency and amplitude of LH pulses).
o LH stimulates androgen secretion from ovarian thecal cells
- Androgens are steroid hormones (e.g. testosterone) that stimulates or controls the development and maintenance of male characteristics
o Increased androgens in the ovary disrupt folliculogenesis lead to excess small ovarian follicles (hence the cysts) and irregular/absent ovulation.
o peripheral androgens cause hirsutism (acne/body hair).
- Insulin resistance leads to hyperinsulinemia:
o Reduced sex hormone binding globulin (SHBG) in liver so increased free testosterone
o Increased androgen production
317
Aetiology of polycystic ovary disease?
* Unknown
| * Genetic (there is familial clustering of PCOS)
318
Symptoms of polycystic ovary disease?
o Asymptomatic
o Oligomenorrhoea (irregular periods, <9 per year) or amenorrhoea (no periods)
o Signs of hyperaldosteronism: acne, hirsutism, alopecia.
o Obesity
o Psychological: mood swings, depression, anxiety
o Sub/infertility
o Recurrent miscarriage
319
Signs of polycystic ovary disease?
o Male-pattern baldness, alopecia
o Obesity (usually central)
o Acanthosis nigricans (areas of increased velvety skin pigmentation which occur in the axillae and other flexures)
o Clitoromegaly, increased muscle mass, deep voice - severe
320
Investigations of polycystic ovary disease - bloods?
```
Total testosterone (normal or slightly raised)
Free testosterone (may be raised if >5nmol/L – exclude androgen-secreting tumours and CAH – 17-hydroxyprogesterone)
SHBG (normal or low in PCOS)
LH (elevated)
FSH (normal)
TFTs
Prolactin
• To exclude a prolactinoma
```
321
Investigations of polycystic ovary disease - imaging and screening?
o USS
o Screen for diabetes (OGTT) and abnormal lipids
o BMI
322
What is the Rotterdam criteria for diagnosing polycystic ovary disease?
Requires the presence of 2 out of 3 of:
• Polycystic ovaries on US (12 or more follicles or ovarian volume >10 on USS)
• Oligo-ovulation or anovulation
• Clinical/biochemical features of hyperandrogenism (Acne, excess body hair, alopecia OR raised serum testosterone)
323
Management of PCOS - general advice?
```
o Weight loss
o Diet
o Exercise
o Stop smoking
o Sleep apnoea advice
```
324
Management of PCOS - women not planning pregnancy - improving insulin resistance?
Metformin (not licensed so risks and benefits weighed up)
325
Management of PCOS - women not planning pregnancy - hormonal control?
COCP cyclical
IUS
If not taking pill (norethisterone 5mg TDS PO for 10 days)
326
Management of PCOS - women not planning pregnancy - hirsutism control?
```
Co-cyprindol 2mg/d
Waxing, shaving
Eflornithine facial cream
Spironolactone
• Avoid in pregnancy, teratogenic
```
327
Management of PCOS - women presenting with subfertility and wishing to conceive?
Clomifene citrate
Induces ovulation
Use for <6 cycles
Need US monitoring
Metformin added on
Laparoscopic Ovarian Drilling
Needlepoint diathermy in 4 places per ovary to reduce steroid production
When clomifene not working
328
Complications of PCOS?
* Infertility
* Endometrial hyperplasia and cancer
* CVD risk
* T2DM – screening offered if obese, FHx, >40
* GDM – screen in pregnancy 24-28 weeks
329
Definition of urethral stricture?
- Narrowing of urethra due to scar tissue developing in tissues
- Men common
330
Causes of urethral stricture?
o Iatrogenic (catheter, endoscope, prostatectomy, TURP)
o BPH
o Trauma (pelvic fracture, straddle injury)
o Infection (UTIs, gonorrhoea, chlamydia)
o Congenital
o Cancer (rare)
331
Symptoms and signs of urethral stricture?
- Reduced urine flow
- Straining to pass urine
- Spraying of urine or double stream
- Incomplete bladder emptying
- UTIs
- Reduced force of ejaculation
332
Investigations of urethral stricture?
- Post-void bladder US
- Urine flow tests
- Retrograde urethrogram (antegrade cystourethrogram if suprapubic catheter in place)
333
Management of urethral stricture?
- Dilating and stretching
- Stenting (work best for short strictures)
- Internal urethrotomy (endoscopic)
- Urethroplasty
334
Definition of vesicoureteric reflux?
- Reflux of urine from bladder into ureter
- Usually due to primary maturation abnormality of vesicoureteral junction which leads to impairment of normal pinch-cock action of VUJ in micturition
- Can be unilateral or bilateral
335
Epidemiology of vesicoureteric reflux?
Females common
- 25% of children <6 with first-time URI have VUR and 25% have significant VUR
- 1-3% prevalence in general population
- Most common cause of chronic pyelonephritis
336
Associated conditions of vesicoureteric reflux?
o Congenital obstructive posterior urethral membrane (COPUM)
o Bulbar urethral obstruction (Cobb collar)
o Ureteral partial obstruction
o Duplex collecting system
337
Symptoms of vesicoureteric reflux?
```
- Recurrent UTIs
o Dysuria
o Frequency
o Offensive smelling urine
o Abdominal pain
o Fever
```
338
Investigations of vesicoureteric reflux?
- US KUB
| - Micturating cysto-urethrogram (MCUG)
339
What is MCUG and how is it graded in vesicoureteric reflux?
Micturating cysto-urethrogram (MCUG)
o Bladder catheterised, then filled with dye and x-ray
o Graded:
1 – limited to ureters
2 – renal pelvis
3 – mild dilatation of ureter and pelvicalyceal system
4 – tortuous ureter with moderate dilatations, blunt fornices
5 - severe dilatation of ureter and pelvicalyceal system, loss of fornices
340
Further testing of vesicoureteric reflux?
- Mercapto acetyl tri-glycine reflux test (MAG3)
o Injection of special dye is given and pictures taken when passing urine
- Dimercapto succinic acid (DMSA) to assess kidneys
341
Management of vesicoureteric reflux - general measures?
o Ensure good fluid intake
o Pass urine regularly (women after sexual intercourse)
o Avoid constipation
342
Management of vesicoureteric reflux - medication?
o Low-dose prophylactic antibiotics at night
| Trimethoprim/Nitrofurantoin/Amoxcillin
343
Management of vesicoureteric reflux - surgery?
o Cystoscopy and injection of Deflux
| o Open/Keyhole ureteric re-implantation
344
Complications of vesicoureteric reflux?
- Renal scarring
- Recurrent UTIs
- Acute pyelonephritis
345
Definition of glomerulonephritis?
- Increased glomerular cellularity restricts glomerular blood flow and therefore filtration is decreased
- Leads to:
o Decreased urine output and volume overload
o Hypertension
o Oedema
o Haematuria and proteinuria
346
Epidemiology of glomerulonephritis?
- Peak age 7 years
347
Aetiology of nephritic syndrome - primary causes?
IgA Nephropathy
o Visible haematuria
o Most common glomerulonephritis
Mesangiocapillary glomerulonephritis
o Episodes of macroscopic haematuria, commonly associated with URTIs
348
Aetiology of nephritic syndrome - secondary causes?
Post-infectious (streptococcal most common, staph aureus)
o Usually presents 7-21 days to streptococcal throat infection
o Cola-coloured urine
o High anti-DNAse
Vasculitis (HSP, SLE, Wegeners granulomatosis)
o HSP is vasculitis disease, see HSP
o SLE mainly affect adolescent girls and presents with multiple antibodies and haematuria/proteinuria
SLE
Goodpasture syndrome
o Anti-GBM positive
o Auto-antibodies to type 1 collagen – renal and lung disease
349
Aetiology of nephrotic syndrome - primary causes?
Minimal change disease – 85% in children
o Idiopathic, NSAIDs, Hodgkin’s lymphoma
o Biopsy – normal under light microscopy
o Steroids usual course of treatment
Focal segmental glomerulonephritis (FSGN) – most common in adults
o Segmental areas of mesangial collapse and sclerosis
o Due idiopathic, HIV, SCD, Alport’s, obesity, reflux nephropathy
Membranous nephropathy – common in older adults
o Due to – malignancy, hepatitis B, gold, penicillamine, NSAIDs, thyroid, SLE
o Thickened GBM
Membranoproliferative glomerulonephritis
350
Aetiology of nephrotic syndrome - secondary causes?
* Infection – HIV, HepB/C, syphilis, malaria
* SLE, HSP, Lupus
* Diabetes – MC secondary cause
* Alport’s syndrome
* Malignancies
* Toxins (snake bites, bee stings) and heavy metals
351
Symptoms of nephritic syndrome?
o Haematuria, raised BP, oliguria, reduced EGFR
352
Symptoms of nephrotic syndrome?
o Proteinuria, oedema, hypoalbuminaemia
353
Symptoms of uraemia?
o Malaise, anorexia, fever
354
Investigations in glomerulonephritis - what bloods to do to find cause??
o FBC, CRP, U&Es (creatinine, K, bicarbonate, calcium, phosphate, albumin)
o Complement (low C3, normal C4)
o ANA and anti-DNA antibodies (SLE suspected), Anti-GBM (Goodpastures), ANCA (if vasculitis suspected – Wegeners, polyangiitis)
o Blood cultures
o Glucose
o Viral Serology (HepB/HepC)
355
Investigations in glomerulonephritis - other investigations?
Mid-stream urine M, C & S
o Count RBCs, WBCs, hyaline, granular casts, red cell casts means glomerular bleeding in post-infectious glomerulonephritis
o Urine culture and specific gravity
Urine dipstick
Urine PCR
Renal US
Renal biopsy
356
Management of glomerulonephritis?
Early referral to nephrologist
Supportive treatment
o Attention to fluid balance
o Keep BP <130/80 or <125/75 if proteinuria >1g/d
ACEi/ARB – useful as reduce proteinuria and preserve renal function
o Treat Oedema
Loop diuretics
Nitroprusside for encephalopathy
HSP and IgA nephropathy require long term follow-up
SLE needs immunosupression
357
What is normal daily urine protein excretion in a day?
- Average daily urine protein excretion in adults is 80mg/day
- Normal <150mg/day
358
Definition of orthostatic proteinuria?
o Normal urinary protein excretion during night but increased excretion during the day, associated with activity and upright posture
o Due to increased renal dynamics
o Mostly albumin
359
Epidemiology of orthostatic proteinuria?
- Most common in children and young adults, males more
| - 22% of school males
360
Symptoms of orthostatic proteinuria?
- Transient symptoms – recent strenuous exercise
361
Other causes of proteinuria?
o Physical Exercise, fever, pregnancy, UTI, Nephrotic syndrome, renal tubular disease, CKD
o Nutcracker Phenomenon – compression of left renal vein between aorta and superior mesenteric artery
362
Investigations of orthostatic proteinuria?
- Urinalysis
- Bloods
- Urine ACR/PCR EMU (first-void) & random sample in day
- 24-hour urine collection
363
Investigations of orthostatic proteinuria -urinalysis findings?
o Positive protein dipstick during day
o Negative EMU protein sample
o Exclude UTI, diabetes
364
Investigations of orthostatic proteinuria -bloods findings?
o U&Es normal
| o Glucose normal
365
Investigations of orthostatic proteinuria -urine ACR/PCR findings?
o Absence of proteinuria in morning sample and presence in daytime confirms orthostatic proteinuria
366
Investigations of orthostatic proteinuria -24-hour urine collection findings?
Protein, creatinine clearance – split into day and night collections
367
Investigations of orthostatic proteinuria -diagnosing nutcracker phenomenon?
o US KUB normal
| o CT
368
Management of orthostatic proteinuria?
- Rule out other causes – may require referral to nephrologist
- No specific treatment – may persist but no clinical significance
AKT Flashcards
flashcards
Decks in class (37)
# Cards
-
Last Minute . com146
-
DVLA Advice63
-
Statistics86
-
Organisation and Management152
-
Developmental Milestones44
-
School Exclusion Illnesses11
-
Immunisation Programme44
-
2-Week Cancer Pathways34
-
Questions I Got Wrong243
-
Learning Points from Questions96
-
Notifiable Diseases5
-
BP & Diabetes Targets9
-
CYP450 DRUGS5
-
DRUGS IN PREGNANCY AND BREASTFEEDING3
-
Haematology273
-
Cardiovascular516
-
Endocrine454
-
ENT313
-
Gastrointestinal 1402
-
Gastrointestinal 2513
-
Infectious Diseases335
-
MSK370
-
Neurology 1250
-
Neurology 2242
-
Ophthalmology & Skin353
-
Psychiatry345
-
Reproductive System 1232
-
Reproductive System 2280
-
Respiratory411
-
Urinary System368
-
Gynaecology357
-
Fertility72
-
Antenatal Obstetrics399
-
Postnatal Obstetrics75
-
Contraception Drugs212
-
General Paediatrics424
-
General Paediatrics 2530
