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2017/2018

2017/2018. Nephrology & Genitourinary. Phase 2a Revision Session Callum Leng & Karmay Phoon 22/2/2018. The Peer Teaching Society is not liable for false or misleading information…. What we will cover… . Physiology recap Renal colic Acute kidney injury

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2017/2018

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  1. 2017/2018

  2. Nephrology & Genitourinary Phase 2a Revision Session Callum Leng & KarmayPhoon 22/2/2018 The Peer Teaching Society is not liable for false or misleading information…

  3. What we will cover… • Physiology recap • Renal colic • Acute kidney injury • Glomerular diseases (nephritic syndrome, nephrotic syndrome and specific glomerular diseases e.g. minimal change disease) • Chronic renal failure • Polycystic kidney disease • Non-malignant scrotal disease (e.g. epididymal cyst, hydrocoele, varicocoele) • Testicular torsion • Prostatic hyperplasia • Malignant tumours of the GU tract (e.g. kidney, bladder, prostate, testis) • Infection (e.g. pyelonephritis, cystitis, prostatitis, urethritis, epididymo-orchitis) The Peer Teaching Society is not liable for false or misleading information…

  4. Renal physiology The Peer Teaching Society is not liable for false or misleading information…

  5. Diuretics The Peer Teaching Society is not liable for false or misleading information…

  6. Diuretics The Peer Teaching Society is not liable for false or misleading information…

  7. Renal Colic • A symptom – usually causedby renal calculi (kidney stones) • 3 common sites where stones get stuck • Pelvi-ureteric junction • Pelvic brim • Vesico-ureteric junction • Different compositions: • Calcium oxalate 75%, Struvite, Uric acid, Cystine • Caused by supersaturation of urine with salt/minerals Epidemiology Men 3:1 Women The Peer Teaching Society is not liable for false or misleading information…

  8. Renal Colic Presentation • Many stones asymptomatic and discovered by chance • Sudden severe pain (unilateral) • Pain starts in the loin and moves to the groin, sometimes with haematuria • Pain radiated down to the testis, labia • Pain of renal colic is quite constant but often periods of relief or dull ache before it returns • Other symptoms • Rigors, Dysuria, Haematuria, Urinary retention, Nausea and vomiting • Patient writhes around in agony • Normally apyrexial in uncomplicated renal colic Risk factors • Anatomical anomalies • FH • Hypertension • Gout • Hyperparathyroidism • Immobilisation • Dehydration Differentials • Ruptured AAA • Diverticulitis, appendicitis • Pyelonephritis • Acute pancreatitis • Testicular torsion • MSK The Peer Teaching Society is not liable for false or misleading information…

  9. Renal Colic Investigations • Bloods including calcium, phosphate and urate • Urinalysis, MSU if +ve • CT scan picks up 99% of stones • KUB XR picks up between 60-70% Management • Pain relief e.g. diclofenac or opioids; abx if infection suspected • Stones <5mm diameter: 90%+ pass spontaneously • Stones >5mm diameter: medical therapy (nifedipine or tamsulosin); Extracorporeal shockwave lithotripsy, percutaneous nephrolithotomy • If obstruction + infection - ureteric stent may be needed • Prevention: drink plenty The Peer Teaching Society is not liable for false or misleading information…

  10. Acute kidney injury • Rapid reduction in kidney function over hours to days • 3 criteria often used: • Rise in creatinine >26μmol/l in 48hrs • Rise in creatinine >1.5 × baseline • Urine output <0.5ml/kg/h for >6 consecutive hrs • RF’s: age, CKD, cardiac failure, peripheral vascular disease, diabetes, drugs, sepsis, poor fluid intake/fluid loss The Peer Teaching Society is not liable for false or misleading information…

  11. Acute kidney injury Causes • Pre-renal – hypoperfusion: hypotension, renal artery stenosis, drugs • Renal – acute tubular necrosis (commonest), autoimmune disease, glomerulonephritis, drugs, vasculitis • Post-renal – caused by urinary tract obstruction: stones, malignancy, extrinsic compression • Always check medications (especially new) Presentation • Depends on underlying cause and severity • Oliguria or anuria • Polyuria may occur due to reduced fluid reabsorption • Nausea, vomiting • Dehydration • Confusion • Hypertension • Urinary retention (large painless bladder) • Dehydration • Postural hypotension The Peer Teaching Society is not liable for false or misleading information…

  12. Acute kidney injury • Nephrotoxic drugs • ACE inhibitors/ ARBs • Results in dilated efferent arterioles decreasing GFR • NSAIDs • Inhibits cyclooxygenase which causes excess vasoconstriction of the afferent arteriole • Aminoglycosides (10-15% incidence of Acute Tubular Necrosis) • And many others… The Peer Teaching Society is not liable for false or misleading information…

  13. Acute kidney injury • Investigations: full examination, creatinine, urea, electrolytes, liver enzymes, clotting, glucose, urine dipstick, autoantibodies (anti-GBM, ANCA), renal USS, ?CT-KUB • Management: aim for euvolaemia, stop nephrotoxic drugs, treat underlying cause, manage complications Complications: hyperkalaemia. Give insulin/dextrose or salbutamol neb with calcium gluconate (cardio-protective) The Peer Teaching Society is not liable for false or misleading information…

  14. Chronic kidney disease • Chronic renal failure involves a long-standing and often deteriorating reduction in renal function. It is irreversible and generally appears over a period of years. Initially, CRF begins as only biochemical abnormalities, but eventually it will result in clinical symptoms.  • Although irreversible it can be slowed down • Once reaching a stage where death is imminent without renal replacement therapy, it is referred to as ESRF, i.e. end-stage renal failure.  The Peer Teaching Society is not liable for false or misleading information…

  15. Chronic kidney disease

  16. Chronic kidney disease • Presentation • One of the most useful signs is bilaterally small kidneys on USS. • Malaise, loss of appetite, insomnia, nocturia and polyuria due to inability to concentrate urine, itching due to high levels of urea, N/V/D, symptoms of anaemia, peripheral and pulmonary oedema, bruising, bone pain due to metabolic bone disease. • In more advanced disease symptoms tend to be more severe, and there may be CNS symptoms such as mental slowing, seizures, or myoclonus. • Eventually there may also be oliguria, which tends to occur in ARF and in the very late stages of CRF. The Peer Teaching Society is not liable for false or misleading information…

  17. Chronic kidney disease The Peer Teaching Society is not liable for false or misleading information…

  18. Chronic kidney disease The Peer Teaching Society is not liable for false or misleading information…

  19. Nephrotic syndrome A syndrome, not a disease • Triad of: • Proteinuria • Hypoalbuminaemia • Oedema • Causes: • Primary: minimal change disease, membranous nephropathy, focal segmental glomerulosclerosis • Secondary: hepatitis, diabetic nephropathy, drug-related • Anything which injures podocyte foot processes can be a cause The Peer Teaching Society is not liable for false or misleading information…

  20. Nephrotic syndrome • Investigations: urine dip (protein +++), bloods (show low albumin), biopsy (adults) • Management: steroids in children, diuretics for oedema, ACE-i for proteinuria, treat underlying cause • Complications: infections, thromboembolism, hypercholesterolaemia The Peer Teaching Society is not liable for false or misleading information…

  21. Nephritic syndrome A syndrome, not a disease • Haematuria • +++ blood on urine dipstick (macro/microscopic) • Red cell casts (distinguishing feature) • Podocytes develop large pores so blood and protein can escape through into urine • Proteinuria • ++ protein on urine dipstick • Hypertension • Low urine volume (<300ml/day) The Peer Teaching Society is not liable for false or misleading information…

  22. Nephritic syndrome • Causes: post-streptococcal glomerulonephritis, IgA nephropathy, rapidly progressive glomerulonephritis (Goodpasture’s syndrome/vasculitic disorders) • Often appears days-weeks after URTI • IgA nephropathy – days after URTI • Post-streptococcal glomerulonephritis – weeks after URTI • Treat underlying cause The Peer Teaching Society is not liable for false or misleading information…

  23. Polycystic kidney disease • Autosomal dominant • 85% have mutation in PKD1 – reach ESRF by 50s • 15% have mutation in PKD2 – reach ESRF by 70s • Family screening important - MRI • Autosomal recessive • Rarer • Variable signs, may present in infancy with multiple renal cysts and congenital hepatic fibrosis • No specific treatment The Peer Teaching Society is not liable for false or misleading information…

  24. ADPKD Presentation • Excessive water and salt loss • Nocturia • Loin pain (due to renal haemorrhage, stones and UTIs) • Hypertension • Bilateral kidney enlargement • Gross haematuria following trauma • Renal colic due to clots • UTI and pyelonephritis may be presenting features • Renal stones are twice as common than in the general population Pathophysiology • PKD1 and 2 cause mutations in polycystin 1 and 2 respectively. • Polycystins regulate tubular and vascular development in the kidneys but also in other organs. • Cysts in the liver don’t affect function. • 25/30% have heart valve disorders. • 15% of ADPKD patients die from berry aneurysms rupturing causing SAH The Peer Teaching Society is not liable for false or misleading information…

  25. ADPKD Investigations • Ultrasound diagnostic criteria • At least two unilateral or bilateral renal cysts at age <30 years • At least two cysts in each kidney between the ages of 30-59 years • At least four cysts in each kidney at age >60 years • The diagnosis is supported by hepatic or pancreatic cysts Management • No cure • Counselling and support for patients & family members • Monitor for disease progression • Treat hypertension, UTIs, stones, give analgesia • Dialysis for end-stage renal failure The Peer Teaching Society is not liable for false or misleading information…

  26. Prostatic Hyperplasia Benign proliferation of musculofibrous/glandular tissue Transitional (inner) zone DIHYDROTESTOSTERONE = BAD GUY The Peer Teaching Society is not liable for false or misleading information…

  27. Prostatic Hyperplasia Know your LUTS! Investigations • DRE –smooth + enlarged • PSA • TRUSS • Renal US The Peer Teaching Society is not liable for false or misleading information…

  28. Prostatic Hyperplasia Management • Lifestyle advice • Caffeine • Alcohol • Bladder training • Medical • 1st line: α-blockers • 2nd line: 5α-reductase inhibitors • Surgical • TURP • TUIP • TULIP • Retropubic prostatectomy • Catheterisation The Peer Teaching Society is not liable for false or misleading information…

  29. Prostate Cancer Investigations • DRE –hard + irregular • PSA (CAUTION: non-specific) • Biopsy • TRUSS • Imaging • Bone scan Malignant adenocarcinoma Peripheral zone Risk factors: • Family history • High levels of testosterone Metastasis: • Adjacent structures • Bone • Lung The Peer Teaching Society is not liable for false or misleading information…

  30. Prostate Cancer Gleason score = most common grade + highest grade The Peer Teaching Society is not liable for false or misleading information…

  31. Prostate Cancer Management • Localised (low risk)  active surveillance • Localised (disease progressing/advanced)  radical treatment • Radical prostatectomy • Radical radiotherapy • Hormone therapy  LHRH agonists (goserelin) + anti-androgen (cyproterone acetate) • Hormone-refractory metastatic cancer  chemotherapy (docetaxel) • Metastatic  surgical castration + palliative care Side effects of hormone therapy: osteoporosis, gynaecomastia, sexual dysfunction Complications of cancer: bone mets, spinal cord compression The Peer Teaching Society is not liable for false or misleading information…

  32. Renal Cell Carcinoma (RCC) • Adenocarcinoma – proximal tubule epithelium • Highly vascular • Metastasis –bone, liver, lungs (‘cannon ball’ mets) Risk factors: • Poor lifestyle • Underlying medical conditions – HTN, CKD • Renal abnormalities – VHL, polycystic, horseshoe • Haemodialysis The Peer Teaching Society is not liable for false or misleading information…

  33. Renal Cell Carcinoma (RCC) Management • T1/localised radical nephrectomy • Metastatic/non-resectable  biological therapies • mTOR inhibitors (temsirolimus) • TKI (sunitinib, sorafenib) • Monoclonal antibodies (bevacizumab) *NOTE: RCC can be quite chemo/radio resistant • Investigations • Bloods • Urine • Imaging The Peer Teaching Society is not liable for false or misleading information…

  34. Bladder Cancer PAINLESS HAEMATURIA Risk factors: • Occupation – rubber, azo dyes • Schistosomiasis (squamous type) • Chronic cystitis • Pelvic irradiation • Lifestyle – smoking • Gender – male > female 3 types: • Transitional cell (>90%) • Squamous cell • Adenocarcinoma The Peer Teaching Society is not liable for false or misleading information…

  35. Bladder Cancer Investigations • Cystoscopy • Biopsy • CT urogram • Urine (dipstick, cytology, microscopy) • Bimanual examination under anaesthesia • MRI/lymphangiography Diagnostic The Peer Teaching Society is not liable for false or misleading information…

  36. Bladder Cancer Management The Peer Teaching Society is not liable for false or misleading information…

  37. Testicular Cancer Presentation: • Painless testicular lump • Haematospermia • Abdominal mass 5 types: • Seminoma (germ-cell) • Non-seminoma • Sex cord (stromal) • Mixed • Lymphoma Risk factors: • Undescended testes • Infant hernia • Infertility The Peer Teaching Society is not liable for false or misleading information…

  38. Testicular Cancer Investigations • Scrotal US • Biopsy • Serum tumour markers • CT/MRI (staging) • CXR (suspected lung mets) 3 important tumour markers • α-fetoprotein (αFP) • β-human chorionic gonadotrophin (β-hCG) • Lactate dehydrogenase (LDH) Staging: • No mets • Para-aortic –infradiaphragmatic • Supradiaphragmatic • In lungs The Peer Teaching Society is not liable for false or misleading information…

  39. Testicular Cancer Management • Seminomas  radical orchidectomy + radiotherapy • Non-seminomas  chemotherapy The Peer Teaching Society is not liable for false or misleading information…

  40. Other Urinary Tract Malignancies Transitional cell carcinoma (TCC): • Not all TCC are bladder cancers – can also occur in renal pelvic, calyx, ureter, urethra Nephroblastoma (Wilm’sTumour): • Childhood tumour (>3 years) – from primitive renal tubules & mesenchymal cells • Suspect if abdo mass + haematuria in children Penile cancer: • Caused by irradiation or virus • Presents with ulceration & discharge • Manage with 1) radiotherapy, 2) iridium wires, 3) amputation The Peer Teaching Society is not liable for false or misleading information…

  41. Non-Malignant Scrotal Disease The Peer Teaching Society is not liable for false or misleading information…

  42. Non-Malignant Scrotal Disease The Peer Teaching Society is not liable for false or misleading information…

  43. Testicular Torsion Twisted spermatic cord  cut off blood supply to testes  ischaemia EMERGENCY!! Presentation: • Sudden onset testicular pain • Inflammed & tender testicle • Unilateral • Abdo pain • N&V What to do? • Refer to urology ASAP • Surgery • Scrotal/Doppler US can be done but do not delay treatment The Peer Teaching Society is not liable for false or misleading information…

  44. Scrotal Problems General rule of thumb: • Testicular lump  CANCER until proven otherwise • Acute + tender lump  TORSION until proven otherwise The Peer Teaching Society is not liable for false or misleading information…

  45. Urinary Tract Infection (UTI) Definition: pure growth of >105 organisms per ml of fresh MSU Risk factors • Female • Intercourse • Pregnancy • Menopause • UT obstruction • Malformations • Immunosuppression • Catheterization The Peer Teaching Society is not liable for false or misleading information…

  46. Urinary Tract Infection (UTI) Signs & symptoms • Loin/abdo pain • Offensive-smelling urine • Haematuria • Fever Investigations • MC&S of MSU [GOLD] • Dipstick • Bloods The Peer Teaching Society is not liable for false or misleading information…

  47. Urinary Tract Infection (UTI) Management • Abx • Fluid intake • Pain relief How to prevent UTI? • Water • Water • Water • Prophylactic Abx The Peer Teaching Society is not liable for false or misleading information…

  48. Urinary Tract Infection (UTI) The Peer Teaching Society is not liable for false or misleading information…

  49. Quiz An 85-year-old woman is investigated by her general practitioner (GP) for increasing tiredness, which has developed over the past 12 months. She has lost her appetite and feels constantly nauseated. She has lost about 8kg in weight over the past 6 months. For the last 12 weeks she has also complained of generalized itching and cramps. She has been hypertensive for 20 years and has been on antihypertensive medication for that time. She has had two cerebrovascular accidents, which have le her with some le side weakness and reduced mobility. She is an African Caribbean, having emigrated to the United Kingdom in the 1960s. On US she has small kidneys. • What’s the diagnosis? • What is the most common cause? • What are the differences between the acute and chronic form of this disease?

  50. Quiz • What’s the diagnosis?Chronic kidney disease • What is the most common cause?Diabetes mellitus • What are the differences between the acute and chronic form of this disease? Key points • Patients often become symptomatic due to renal failure only when their glomerular filtration rate (GFR) is less than 15 mL/min and thus may present with end-stage renal failure. • Previous measurements of serum creatinine enable the rate of deterioration of renal function to be known. • Renal ultrasound is the key imaging investigation.

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