Renal
Dr T Jenyon
Plan
•
•
•
•
•
•
•

Background
Symptoms and Signs
Renal medicine
Renal failure
Rare renal
UTI and calculi
Surgical renal
Background
•
•
•
•

Kidney is retroperitoneal
11-14cm in length
Has a high proportion of cardiac output
Central role in fl...
Background
• Other roles:
– Erythropoetin
– Vitamin D metabolism
– Caltabolism of small proteins (insulin)
– Drug excretio...
Background - Fluid and electrolytes
• ADH (posterior pituitary) controls Osmolality
• Renin-angiotensin-aldosterone contro...
Background – Urea and creatinine
• Urea – nitrogenous waste due to breakdown of
amino acids
• Raised in
•
•
•
•

Renal fai...
Notes
• Alcoholics tend to have a very low urea as poor diet
and knackered liver
• Sudden increase in Urea but not creatin...
Renal anatomy
Symptoms and signs
•
•
•
•
•
•
•
•

Frequency/Polyuria
Oliguria
Dysuria/pain
Incontinence
Palpable kidneys
Glycosuria
Haem...
Frequency / Polyuria
• Frequency implies increaed frequency voiding –
different from polyuria (increased volume)
• Frequen...
Oliguria
• Urine output <0.5ml/kg/hr or less than 400mls per
day
• Causes (basically causes of ARF)
– Pre-renal - Decrease...
Dysuria/Pain
• Dysuria – pain on urination
– Think of UTI/STI
– Can get sterile urethritis

• Renal stones classically cau...
Incontinence
• Involuntary voiding of urine
• If new onset suspect UTI, in men suspect protatism and overflow – check
for ...
Palpable kidneys
• Bilateral palpable kidneys
–
–
–
–
–

ADPKD
Bilateral hydronephrosis
Amyloid
Bilateral RCC
Tuberous scl...
Kidney Vs Spleen
• Kidney
– Moves late on
inspiration
– Possible to get above
– Smooth shape
– Resonant to percussion

• S...
Glycosuira
• Blood glucose of >10mmol will spill over into
urine
• Think DM
• Can have congenital low renal threshold for
...
Haematuria
• Is it Blood?
– Rifampicin, beetroot, myoglobinuria
(rhabdomyolysis)

• Is it from urological tract
– DD Vagin...
Haematuria
• Generalised disorder
– IBE, coagulopathy, sickle cell, vasculitis

• Specific disorder
– Kidneys or Ureter/bl...
Proteinuria
• Urine Dipstix react to albumin but not Bence Jones Protein (myeloma)
• ‘microalbuminuria’ is proteinuria in ...
Proteinuria
• Benign
– Orthostatic proteinuria
– Exercise/febrile illness

• Excess circulating protein
– Myeloma

• Renal...
Renal Medicine
Nephrotic syndrome
Nephritic syndrome
GN
TIN
Renal Medicine
• Appears complex no definitive relationship
between syndromes/symptoms and
pathology/biopsy
• But

– Some ...
Nephrotic Syndrome
•
•
•
•

Massive proteinuria (>3.5g/day)
Hypoalbuminaemia (<30g/L)
Oedema
Hyperlipdaema

•
•

Increased...
Nephrotic syndrome
• Commonest cause in kids:
– Minimal change glomerulonephritis
• Not much to see on microscopy (minimal...
Nephrotic syndrome
• Other causes of Nephrotic syndrome:
– Focal Segmental Glomerulosclerosis
• Only some (focal) glomerul...
Nephritic Syndrome
• Symptomatic haematuria and proteinuria
–
–
–
–
–

Haematuria with red cell casts
Proteinuria (<3.5g/d...
Nephritic Syndrome
• Commonest cause:
– IgA nephropathy (Bergers disease)
• 3-4 days post infection – usually URTI
• 16-35...
Nephritic syndrome
• Other causes:
– HSP (Henoch Schonlein Purpura)
• Systemic variant of IgA nephropathy
• Usually 3-10yr...
Asymptomatic haematuria and proteinuria
• Alports syndrome
– (inherited renal failure and deafness)

• Thin basement membr...
Parts of Kidney
• Simplified
– Glomerulus
– Blood vessels
– Tubules
– Interstitium
Glomerulonephritis
• Inflammation of glomerulus
• Usually present with:
– Haematuria with red cell casts
– +/- Proteinuria...
GN
• IgA (bergers disease)
– IgA, young girl, 3-4 days post URTI

• Minimal change
– Commonest cause of nephrotic syndrome...
GN
• Membranoproliferative/mesangiocapillary
– Mesangial proliferation with double BM
– Two types
• I - assoc Cryoglobulin...
Parts of kidney
– Glomerulus
– Blood vessels
– Tubules
– Interstitium

Act as one
Tubulointerstitial Nephritis
• A cause of a Nephritic type picture due to damage to
the tubules or interstitium
• Almost a...
Renal Failure
Acute Renal Failure
Chronic renal failure
Acute renal failure
• Suddenly and usually reversible loss in renal
function occurring over hours or days.
• Usually assoc...
Causes ARF
– Pre-renal - Decreased perfusion of kidneys
• shock/hypovolaemia
• (usually reversible but may progress to ATN...
Acute tubular necrosis - ATN
• Tubular cells have a very high oxygen
requirement.
• If deprived of oxygen they die
• Take ...
Uraemia
• (a term loosely applied to describe the symptoms that accompany renal
failure, presumably due to build up of tox...
Approach to ARF
• Rule out or treat hypovolaemia
• Insert catheter (rules out obstruction and allows
close monitoring of f...
Dialysis in ARF
• 4 main indications
– Hyperkalaemia not responding to medical
treatment
– Pulmonary oedema not responding...
Chronic Renal Failure
• Substantial and irreversible deterioration of
renal function, classically develops over a
period o...
Chronic renal failure - Problems
• Fluid retention
• Anaemia (Burr cell)
• Metabolic bone disease
– (low Ca, high phosphat...
Approach to CRF
• Identify cause
• Prevent further progression if possible
• Once creatinine hits 300 there is usually
pro...
Dialysis in CRF
• This should be started when patient has
advanced renal failure, but before they
develop complications
• ...
Dialysis
• 2 main types
• Intermittent haemodialysis
– AV fistula
– Better filtration

• Continuous peritoneal dialysis

–...
Transplant
• Refer to transplant team early
• Transplant nurse, transplant coordinator etc
• Needs ABO and HLA compatibili...
Transplant drugs
•
•
•
•
•

Steriods
Azathioprine
Ciclosporin
Tacrolimus/Sirolimus
Mycophenolate
Complication of transplant
• Graft failure
– Acute – usually preventable with
immunosuppressant's
– Chronic – Slow decline...
Diseases which can reoccur in a graft
•
•
•
•

IgA Nephropathy
Goodpastures
Focal Segmental Glomerulosclerosis
Metabolic d...
Rare Renal
Goodpastures
• Autoantibodies against type IV collagen in
lung and kidney basement membrane (anti –
GBM)
– Haemoptysis
– H...
Wegners
• A vasculitis with granulomas
• Get sinusitis, nose bleeds, nasal deformities,
arthritis, cavitating lung lesions...
SLE and Scleroderma
• Kidneys often involved
• No renal involvement in drug induced SLE
• SLE renal involvement graded I-V...
DM
• Diabetics often have kidney damage
• It is a microvascular complication
– (due to ischemia, glycosilation)

• Get Kim...
Tumour Lysis Syndrome
• When cells die they release contents into
blood
• When large number of cells die all at once,
ofte...
ADPKD
• Autosomal dominant polycystic renal disease
• PKD1 (chromo 16) PKD2 (chromo 4)
• Multiple cysts in kidneys cause:
...
Multiple Myeloma
• ARF is common in myeloma
– Immunoglobulins can block tubules – get
‘fractured casts with giant cell rea...
Renal Tubular Acidosis
• Rare cause of metabolic acidosis due to renal
issues
• “If patient is acidotic and urine is not t...
RTA
• Type I
– Don’t get rid of H+ in distal tubule
– Assoc stones and hypokalaemia

• Type II
– Leak bicarbonate
– No sto...
Fanconi syndrome
• Generalised disturbance of renal function
• Can be inherited or acquired
• A cause of RTA II
Hepatorenal Failure
• Renal failure as a consequence of liver failure
• Very poor prognosis unless liver sorted out
Amyloid
• ‘Extracellular deposition of protein which form
B-pleated sheets’
• Tissues/organs become larger and firmer
• On...
Renal artery stenosis
• A cause of hypertension
• Narrowing in artery to kidney (e.g.
athersclerosis, NF) decreases perfus...
UTI
UTI
• Mostly E-Coli (70% E-coli)
– Can use
•
•
•
•

Trimethoprium
Nitrofurantoin
Amoxicillin
(Cefalexin a favourite if pre...
UTI
• Remember STIs as a cause of dysuria
• Can get sterile urethritis
• Can get asymptomatic Bacteriuria – treat if
pregn...
Pyelonephritis
• Infection of the kidney
• Usually due to ascending infection
• Fever/Rigors
• Loin pain
• Needs admisison...
Renal stones (nephrolithiasis)
• Pain – loin to groin, can’t get comfortable, rolling
around
• 95% have haematuria on dips...
Renal stones
• Treat:
– Diclofenac, esp PR is excellent
– May need antiemetic

• Check U&Es to ensure no renal failure fro...
BPH
• Benign prostatic hyperplasia
• Protate gets uniformly enlarged – smooth on
pr
• PSA may be slightly raised
• May get...
BPH
• Treatment
– Drugs
• Tamsulosin – a-blocker relaxes smooth muscle
particular in urogenital tract and eases some of th...
Prostate cancer
• 2nd commonest malignancy of men
• Adenocacinoma that arises in peripheral
prostate
• PSA tumour marker
•...
Prostate cancer
•
•
•
•

Craggy prostate on PR
Raised PSA (>4ug/l)
Do Transrectal ultrasound and biopsy
Bone scan/CT/MRI p...
Torsion
• Urological emergency
– Testis twists and cuts off blood supply
– Will die in hours
– Sudden onset of pain
– Test...
Testicular lumps
• Can you get above it – ie is it a hernia
• Cold, hard, attached to testis – Cancer
• Whole testis swoll...
Testicular tumours
• Painless hard lump on testis
• Germ cell
– Teratomas, 20-30s, secrete BHCG and aFP
– Seminomas, 30-40...
RCC
• Renal cell carcinoma, aka clear cell
• Classic triad of
– Pain
– Haematuria
– Renal mass

• Assoc smoking and von Hi...
TCC
• Transitional cell carcinoma
• Can arise from Bladder, Ureter or renal pelvis
• Assoc smoking and analine dies
• Thin...
Paeds Urology
• Phimosis – narrowing of opening of foreskin
• Paraphimosis – swelling of glans due to tight
foreskin being...
Notes
•
•
•
•
•

Hyaline casts in normal individuals
Granular casts in renal damage
Dysmorphic RBCs indicate glomerular di...
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Renal revision

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Renal: The important stuff!!!

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Renal revision

  1. 1. Renal Dr T Jenyon
  2. 2. Plan • • • • • • • Background Symptoms and Signs Renal medicine Renal failure Rare renal UTI and calculi Surgical renal
  3. 3. Background • • • • Kidney is retroperitoneal 11-14cm in length Has a high proportion of cardiac output Central role in fluid and electrolyte balance
  4. 4. Background • Other roles: – Erythropoetin – Vitamin D metabolism – Caltabolism of small proteins (insulin) – Drug excretion
  5. 5. Background - Fluid and electrolytes • ADH (posterior pituitary) controls Osmolality • Renin-angiotensin-aldosterone controls Extracellular volume (via Na)
  6. 6. Background – Urea and creatinine • Urea – nitrogenous waste due to breakdown of amino acids • Raised in • • • • Renal failure High protein intake GI bleed (acts as high protein meal) Dehydration • Creatinine • Raised in • Renal failure • Large muscle mass • Acute muscle damage
  7. 7. Notes • Alcoholics tend to have a very low urea as poor diet and knackered liver • Sudden increase in Urea but not creatinine think dehydration or GI bleed • Ratio should be around 1:20 • Altered ratio (1:5) suggests acute renal failure, GI bleed etc • Low Hb, high urea, think GI bleed
  8. 8. Renal anatomy
  9. 9. Symptoms and signs • • • • • • • • Frequency/Polyuria Oliguria Dysuria/pain Incontinence Palpable kidneys Glycosuria Haematuria Proteinuria
  10. 10. Frequency / Polyuria • Frequency implies increaed frequency voiding – different from polyuria (increased volume) • Frequency – Think UTI • Polyuria • Excess intake • Osmotic diuresis (DM) • Defective concentrating ability of kidney • Diuretics • CRF • Diabetes insipidus
  11. 11. Oliguria • Urine output <0.5ml/kg/hr or less than 400mls per day • Causes (basically causes of ARF) – Pre-renal - Decreased perfusion of kidneys • shock/hypovolaemia – Renal • ATN/GN – Post renal - Obstruction of urine flow • Intra-lumen – stone • In the wall – stricture/tumour • Compressing wall – prostate/tumour/AAA • Remember blocked catheter if catherised
  12. 12. Dysuria/Pain • Dysuria – pain on urination – Think of UTI/STI – Can get sterile urethritis • Renal stones classically cause ‘renal colic’ – loin to groin pain coming in waves, makes patient roll around
  13. 13. Incontinence • Involuntary voiding of urine • If new onset suspect UTI, in men suspect protatism and overflow – check for bladder • Types: – Functional, i.e. caught short – Stress, weak pelvic floor, small amounts leak when coughing or laughing • Do pelvic floor exercises, can try Duloxeteine, TFVT or colposuspension is surgical option – Urge, uncontrolled emptying of bladder, e.g. brain damage. • Find cause, try timed voiding, oxybutynin/tolterodine can help
  14. 14. Palpable kidneys • Bilateral palpable kidneys – – – – – ADPKD Bilateral hydronephrosis Amyloid Bilateral RCC Tuberous sclerosis • Unilateral palpable kidneys – RCC – Hydronephrosis – Bilateral cause with only one palpable • (In chronic renal failure kidneys tend to be small and shrunken)
  15. 15. Kidney Vs Spleen • Kidney – Moves late on inspiration – Possible to get above – Smooth shape – Resonant to percussion • Spleen – Moves early on inspiration – Can’t get above – Notched leading edge – Dull to percussion – Enlarges towards RIF
  16. 16. Glycosuira • Blood glucose of >10mmol will spill over into urine • Think DM • Can have congenital low renal threshold for glucose
  17. 17. Haematuria • Is it Blood? – Rifampicin, beetroot, myoglobinuria (rhabdomyolysis) • Is it from urological tract – DD Vagina/rectum • Is it from kidney – Look for red cell casts • Is it painless – Think cancer
  18. 18. Haematuria • Generalised disorder – IBE, coagulopathy, sickle cell, vasculitis • Specific disorder – Kidneys or Ureter/bladder/Urethra • Medical – GN – IgA or thin BM disease – Infection - UTI/prostatitis/schistosomiasis • Surgical – Stone, tumour, trauma
  19. 19. Proteinuria • Urine Dipstix react to albumin but not Bence Jones Protein (myeloma) • ‘microalbuminuria’ is proteinuria in the range of 30-300mg/L (e.g. DM) • Quantify proteinuria with 24hr urine of protein/creatinine ratio (PCR) or albumin creatinine ratio (ACR) • >3.5g/day suggests nephrotic syndrome this may make the urine frothy • Proteinuria and heamaturia with red cell casts suggests Nephritic syndrome
  20. 20. Proteinuria • Benign – Orthostatic proteinuria – Exercise/febrile illness • Excess circulating protein – Myeloma • Renal damage – DM/GN/nephritic/nephrotic syndrome • UTI
  21. 21. Renal Medicine Nephrotic syndrome Nephritic syndrome GN TIN
  22. 22. Renal Medicine • Appears complex no definitive relationship between syndromes/symptoms and pathology/biopsy • But – Some patterns are present – Results from biopsy can help guide treatment • E.g. kid presents with nephrotic syndrome: – They are assumed to have minimal change GN. – Treat with Steroids. – If they do not respond to steroids they will have a biopsy that might reveal a different cause that might need a different treatment
  23. 23. Nephrotic Syndrome • • • • Massive proteinuria (>3.5g/day) Hypoalbuminaemia (<30g/L) Oedema Hyperlipdaema • • Increased thrombotic tendency (loose antithrombin III and protein S) Increased susceptibility to infection (loose immunoglobulins)
  24. 24. Nephrotic syndrome • Commonest cause in kids: – Minimal change glomerulonephritis • Not much to see on microscopy (minimal change), get fusion of podocytes on electron microscopy • Benign (only 1% progress to ESRF), treat high dose (60mg) Prednisolone, only biopsy if not responding • Commonest in adults – Membranous nephropathy • Thickened BM with spikes on silver staining (IgG) • 1/3 better,1/3 same, 1/3 ESRF • Idiopathic, or assoc Malignancy, drugs, SLE (V), Hep B
  25. 25. Nephrotic syndrome • Other causes of Nephrotic syndrome: – Focal Segmental Glomerulosclerosis • Only some (focal) glomeruli have some (segmental) sclerosis. Idiopathic or assoc HIV • High recurrence in transplant – DM – Amyloid – SLE
  26. 26. Nephritic Syndrome • Symptomatic haematuria and proteinuria – – – – – Haematuria with red cell casts Proteinuria (<3.5g/day) Oliguria Hypertension Oedema – (remember UTI can give you haematuria and proteinuria)
  27. 27. Nephritic Syndrome • Commonest cause: – IgA nephropathy (Bergers disease) • 3-4 days post infection – usually URTI • 16-35 yr olds with episodic macroscopic haematuria • IgA and C3 on biopsy with mesangial hypercellularity • 2nd commonest: – Proliferative GN / Post Strep GN – 1-3 weeks post strep infection • IgG and C3 on biopsy • ASOT (anti streptolysin-O-Titre)
  28. 28. Nephritic syndrome • Other causes: – HSP (Henoch Schonlein Purpura) • Systemic variant of IgA nephropathy • Usually 3-10yrs old – Plus fever, rash (purpura on legs and buttocks), joint pain, abdo pain – SLE – Cryoglobulinaemia – Infective endocarditis – Tubulointerstitial nephritis
  29. 29. Asymptomatic haematuria and proteinuria • Alports syndrome – (inherited renal failure and deafness) • Thin basement membrane disease – (inherited AD, BP and renal function normal) • Remember UTI – But often plus frequency, dysuria, temperature
  30. 30. Parts of Kidney • Simplified – Glomerulus – Blood vessels – Tubules – Interstitium
  31. 31. Glomerulonephritis • Inflammation of glomerulus • Usually present with: – Haematuria with red cell casts – +/- Proteinuria – May present as ARF, nephritic or nephrotic syndrome
  32. 32. GN • IgA (bergers disease) – IgA, young girl, 3-4 days post URTI • Minimal change – Commonest cause of nephrotic syndrome in kids, fusion of podocytes, treat high dose Prednisolone, excellent prognosis • Membranous – Commonest cause of nephrotic syndrome in adults, thickened BM with spikes (IgG), idiopathic, or malignancy, SLE, Drugs or Hep B • Proliferative (post strep) – Post Strep, 1-3 weeks post infection, IgG on biopsy, ASOT and low C3 • Focal Segmental Glomerulosclerosis – Only some glomeruli have segmental sclerosis, assoc HIV, high recurrence in transplants • Thin BM disease – AD – family history, heamaturia without renal failure or hypertension
  33. 33. GN • Membranoproliferative/mesangiocapillary – Mesangial proliferation with double BM – Two types • I - assoc Cryoglobulinaemia/Hepatitis C • II - assoc Partial lipodystophy • Rapidly progressive GN – ESRF in weeks – Focal necrotising GN with cresentic changes – Assoc: • • • • Vasculitis – Wegners/Churg-Strauss Goodpastures SLE/ RA Other GN (eg IgA)
  34. 34. Parts of kidney – Glomerulus – Blood vessels – Tubules – Interstitium Act as one
  35. 35. Tubulointerstitial Nephritis • A cause of a Nephritic type picture due to damage to the tubules or interstitium • Almost all due to hypersensitivity reactions to drugs – Penicillins or NSAIDS – Also Cadmodium, mercury, reflux, sickle cell or urate nephropathy • • • • Often get Eosinophilia May have fever, arthralgia and rash ‘Non-oliguric renal failure’ (No red cell casts – signifies glomerular damage)
  36. 36. Renal Failure Acute Renal Failure Chronic renal failure
  37. 37. Acute renal failure • Suddenly and usually reversible loss in renal function occurring over hours or days. • Usually associated with a reduced urine volume
  38. 38. Causes ARF – Pre-renal - Decreased perfusion of kidneys • shock/hypovolaemia • (usually reversible but may progress to ATN) – Renal • ATN(85%) • GN/interstitial disease – Post renal - Obstruction of urine flow • Intra-lumen – stone • In the wall – stricture/tumour • Compressing wall – prostate/tumour/AAA • Remember blocked catheter if catherised
  39. 39. Acute tubular necrosis - ATN • Tubular cells have a very high oxygen requirement. • If deprived of oxygen they die • Take 7-21 days to regenerate • If insult is prolonged the damage may be irreversible • Oliguria – polyuria - normal
  40. 40. Uraemia • (a term loosely applied to describe the symptoms that accompany renal failure, presumably due to build up of toxic products) • Anorexia, nausea, vomiting • Pruritis, hiccups • Encephalopathy, fits, coma • Pulmonary oedema, hyperkalaemia, acidosis
  41. 41. Approach to ARF • Rule out or treat hypovolaemia • Insert catheter (rules out obstruction and allows close monitoring of fluid balance) • Urine dip • Bloods (U&Es, FBC, ABG, ECG, CRP (+/-ANA, anti GBM, ANCA)) • USS urinary tract • Early nephrological advice • Treat complication – e.g. hyperkalaemia, adjust drug doses e.g. gentamicin
  42. 42. Dialysis in ARF • 4 main indications – Hyperkalaemia not responding to medical treatment – Pulmonary oedema not responding to medical treatment – Severe acidosis – Complications of uraemia – pericarditis or encephalopathy
  43. 43. Chronic Renal Failure • Substantial and irreversible deterioration of renal function, classically develops over a period of years • Commonest causes – DM – HTN – Glomerulonephritis – ADPKD
  44. 44. Chronic renal failure - Problems • Fluid retention • Anaemia (Burr cell) • Metabolic bone disease – (low Ca, high phosphate) – • • • • Hyperparathyroidism (2 and 3rd), osteomalacia, osteoporosis Infection Hypertension, increased CVS risk Pericarditis (uraemic) Acidosis, hyperkalemia
  45. 45. Approach to CRF • Identify cause • Prevent further progression if possible • Once creatinine hits 300 there is usually progressive deterioration regardless of the cause
  46. 46. Dialysis in CRF • This should be started when patient has advanced renal failure, but before they develop complications • Usually creatinine around 600-800 • Usually haemodialysis 4 hours 3x a week
  47. 47. Dialysis • 2 main types • Intermittent haemodialysis – AV fistula – Better filtration • Continuous peritoneal dialysis – ‘Tenckhoff’ catheter – Better kids (growth) and elderly (less haemodynamic fluctuations) • (Haemofiltration – ITU, continuous)
  48. 48. Transplant • Refer to transplant team early • Transplant nurse, transplant coordinator etc • Needs ABO and HLA compatibility • 90%1 year graft survival • 50% 10 year graft survival • Best with living related donor
  49. 49. Transplant drugs • • • • • Steriods Azathioprine Ciclosporin Tacrolimus/Sirolimus Mycophenolate
  50. 50. Complication of transplant • Graft failure – Acute – usually preventable with immunosuppressant's – Chronic – Slow decline in function – irreversible • Infection • Malignancy – skin (SCC), lymphoma • Side effects of drugs – e.g. gum hypertrophy with ciclosporin
  51. 51. Diseases which can reoccur in a graft • • • • IgA Nephropathy Goodpastures Focal Segmental Glomerulosclerosis Metabolic diseases (DM)
  52. 52. Rare Renal
  53. 53. Goodpastures • Autoantibodies against type IV collagen in lung and kidney basement membrane (anti – GBM) – Haemoptysis – Haematuira • Immunosuppression and plasma exchange (recurs in transplant)
  54. 54. Wegners • A vasculitis with granulomas • Get sinusitis, nose bleeds, nasal deformities, arthritis, cavitating lung lesions, haemoptysis and renal failure • Circulating C-ANCA against PR3
  55. 55. SLE and Scleroderma • Kidneys often involved • No renal involvement in drug induced SLE • SLE renal involvement graded I-V, V being nephrotic syndrome due to membranous GN • Scleroderma can get renal crisis – ACEi and dialysis can be lifesaving
  56. 56. DM • Diabetics often have kidney damage • It is a microvascular complication – (due to ischemia, glycosilation) • Get Kimmelstiel-Wilson nodules in kidneys • Microalbuminuria (30-300) is one of the first signs – is screened for • ACEi is renoprotective
  57. 57. Tumour Lysis Syndrome • When cells die they release contents into blood • When large number of cells die all at once, often in cancer on starting treatment urate levels begin to cause issues • Urate causes ARF • Oncologists often start allopurinol (or Rasburicase) prior to chemotherapy
  58. 58. ADPKD • Autosomal dominant polycystic renal disease • PKD1 (chromo 16) PKD2 (chromo 4) • Multiple cysts in kidneys cause: – – – – – Enlargement Pain Haematuria Renal failure At risk of SAH • Screen with USS
  59. 59. Multiple Myeloma • ARF is common in myeloma – Immunoglobulins can block tubules – get ‘fractured casts with giant cell reaction’ – At risk of infection – High calcium damages kidney
  60. 60. Renal Tubular Acidosis • Rare cause of metabolic acidosis due to renal issues • “If patient is acidotic and urine is not the suspect”
  61. 61. RTA • Type I – Don’t get rid of H+ in distal tubule – Assoc stones and hypokalaemia • Type II – Leak bicarbonate – No stones, usually assoc fanconi’s syndrome • Type IV – Get Hyperkalaemia – Usually in diabetics with mild renal failure
  62. 62. Fanconi syndrome • Generalised disturbance of renal function • Can be inherited or acquired • A cause of RTA II
  63. 63. Hepatorenal Failure • Renal failure as a consequence of liver failure • Very poor prognosis unless liver sorted out
  64. 64. Amyloid • ‘Extracellular deposition of protein which form B-pleated sheets’ • Tissues/organs become larger and firmer • On microscopy get ‘apple green birefringence in polarized light after staining with congo-red’ • Often due to myeloma (AL) or chronic inlammatory diseases (AA) • Can cause renal failure
  65. 65. Renal artery stenosis • A cause of hypertension • Narrowing in artery to kidney (e.g. athersclerosis, NF) decreases perfusion pressure • That kidney begins to increase blood pressure (renin-angiotensin-aldosterone) • Get asymetrical kidneys on USS • ACEi are contraindicated
  66. 66. UTI
  67. 67. UTI • Mostly E-Coli (70% E-coli) – Can use • • • • Trimethoprium Nitrofurantoin Amoxicillin (Cefalexin a favourite if pregnant) – Three day course if uncomplicated • If developed pyelonephritis – needs i.v antibiotics (renal angle tenderness, rigors) • • • Staph Saprophiticus – UTI only Proteus – staghorn calculi Pseudomonas – long term catheter, green
  68. 68. UTI • Remember STIs as a cause of dysuria • Can get sterile urethritis • Can get asymptomatic Bacteriuria – treat if pregnant • If suspect TB do three EMU • Prostate can be infected perianal pain and tender prostate, difficult to treat, long course of Abx
  69. 69. Pyelonephritis • Infection of the kidney • Usually due to ascending infection • Fever/Rigors • Loin pain • Needs admisison, treat often with gentamicin, cephalosporin or ciprofloxacin
  70. 70. Renal stones (nephrolithiasis) • Pain – loin to groin, can’t get comfortable, rolling around • 95% have haematuria on dipstix • Commonest cause: Calcium oxalate, • Others: triple phosphate (staghorn calculi), uric acid (radio lucent) • Risk factors – dehydration, UTI, hypercalcaemia, high dietary oxalate
  71. 71. Renal stones • Treat: – Diclofenac, esp PR is excellent – May need antiemetic • Check U&Es to ensure no renal failure from obstruction • Do X-ray KUB, IVU or CT KUB • Often pass on their own can do lithrotripsy, esp for renal pelvis • (Don’t forget AAA as a cause of ‘renal colic’)
  72. 72. BPH • Benign prostatic hyperplasia • Protate gets uniformly enlarged – smooth on pr • PSA may be slightly raised • May get symptoms of Bladder outflow obstruction – Hesitancy, poor stream, terminal dribbling, nocturia
  73. 73. BPH • Treatment – Drugs • Tamsulosin – a-blocker relaxes smooth muscle particular in urogenital tract and eases some of the outflow obstruction • Finasteride – 5a blocker, interfers with testosterone conversion to potent DHT, helps provent progression – Surgery • TURP – Transurethral resection of the prostate
  74. 74. Prostate cancer • 2nd commonest malignancy of men • Adenocacinoma that arises in peripheral prostate • PSA tumour marker • Likes metasisizing to bone (sclerotic lesions on x-ray)
  75. 75. Prostate cancer • • • • Craggy prostate on PR Raised PSA (>4ug/l) Do Transrectal ultrasound and biopsy Bone scan/CT/MRI pelvis • Gleason score – two scores 1-5 – Min score 2 max 10 • Treat Prostatectomy/Radiotherapy/Brachytherapy/C hemotherapy (Zolodex)Watch and wait
  76. 76. Torsion • Urological emergency – Testis twists and cuts off blood supply – Will die in hours – Sudden onset of pain – Testis may lie high and transversely – Needs surgery – untwist and if viable do orchidoplexy, if not ochidectomy
  77. 77. Testicular lumps • Can you get above it – ie is it a hernia • Cold, hard, attached to testis – Cancer • Whole testis swollen and tender – Epididymoorchitis • Is it a lumpy ‘bag of worms’ ontop – varicocele • Is it cystic – above testis – epididymal cyst • Is it cystic – surrounds testis - hydrocele
  78. 78. Testicular tumours • Painless hard lump on testis • Germ cell – Teratomas, 20-30s, secrete BHCG and aFP – Seminomas, 30-40s, secrete alk phos • Treat Orchidectomy and chemo – esp cisplatin • Non germ cell – Leydig, sertoli and lymphoma
  79. 79. RCC • Renal cell carcinoma, aka clear cell • Classic triad of – Pain – Haematuria – Renal mass • Assoc smoking and von Hippel Lindau • Can spread via direct extension, blood and lymph. • Have a special ability to grow along vessels renal vein to IVC • Can secrete EPO
  80. 80. TCC • Transitional cell carcinoma • Can arise from Bladder, Ureter or renal pelvis • Assoc smoking and analine dies • Think in anyone >50 with painless haematuria • Can do urine cytology, often do cystoscopy • Schistosomiasis can cause SCC of the bladder
  81. 81. Paeds Urology • Phimosis – narrowing of opening of foreskin • Paraphimosis – swelling of glans due to tight foreskin being retracted and not replaced • Hypospadias – abnormal opening of urethra • Undescended testis – common in prems, try to surgically correct, if intra-abdominal remove due to risk of malignant change • Balanitis – inflammation of the glans
  82. 82. Notes • • • • • Hyaline casts in normal individuals Granular casts in renal damage Dysmorphic RBCs indicate glomerular disease Destruction of capillary loops – vasculitis Tubular atrophy - CRF

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