Disease Summary - Urinary

Presentation of urinary tract infections

* dysuria (pain on micturition)
* frequency
* smelly urine
* cloudy or dark urine
* unwell, failure to thrive in the very young
* incontinence, off their feet in the very old

Investigations for urinary tract infections

mid-stream specimen of urine (MSSU)

Causative micro-organisms of UTIs

* mostly bacteria, especially E.coli
* viral infection rare

Complications of UTIs

* urethritis
* cystitis
* ureteritis
* acute pyelonephritis
* sepsis / septic shock

What MSSU culture result is indicative of infection?

10⁵

Risk factors for UTIs

* sex
* pregnancy
* kidney stones
* urinary catheters

Management of UTIs

* analgesia
* short course of antibiotics

What is glomerulonephritis?

conditions that cause inflammation of or around the glomerulus and nephron

What is interstitial nephritis?

inflammation of the space between cells and tubules (the interstitial) within the kidney

What is glomerulosclerosis?

the pathological process of scarring of the tissue in the glomerulus

What are most types of glomerulonephritis treated with?

* immunosuppression e.g. steroids
* blood pressure control by blocking the renin-angiotensin system (ACE inhibitors or angiotensin-II receptor blockers)

Presentation of nephrotic syndrome

* oedema
* frothy urine (proteinuria)

Management of nephrotic syndrome

* treat oedema
* salt and fluid restrictions
* loop diuretics
* hypertension
* Renin-Angiotensin-Aldosterone-blockade
* reduce risk of thrombosis
* heparin
* warfarin
* treat dyslipidemia
* statins

Complications of nephrotic syndrome

* thrombosis
* hypertension
* high cholesterol

What is the most common cause of nephrotic syndrome in children?

minimal change disease

Management of minimal change disease

* prednisolone - 1mg/kg for up to 16 weeks
* initial relapse treated with further steroid course

What is the most common cause of nephrotic syndrome in adults?

focal segmental glomerulosclerosis

What is the most common cause of primary glomerulonephritis?

IgA nephropathy

What does histology of IgA nephropathy (Berger’s Disease) show?

IgA deposits and glomerular mesangial proliferation

What is the most common type of glomerulonephritis?

membranous glomerulonephritis

What does histology of membranous glomerulonephritis show?

IgG and complement deposits on the basement membrane

What can membranous glomerulonephritis be secondary to?

* malignancy
* rheumatoid disorders
* drugs e.g. NSAIDs

Presentation of post streptococcal glomerulonephritis (diffuse proliferation glomerulonephritis)

* 1-3 weeks after a streptococcal infection
* nephritic syndrome
* under 30 years of age

Treatment of post-streptococcal glomerulonephritis

* antibiotics for infection?
* loop diuretics for oedema - frusemide
* anti-hypertensive - vasodilator drugs

What are the 4 common presentations of glomerulonephritis?

* haematuria
* heavy proteinuria
* slowly increasing proteinuria
* acute renal failure

What is classed as upper urinary tract?

* kidneys
* ureters

What is classed as lower urinary tract?

* bladder
* bladder outflow tract

Commonest causes of acute pancreatitis

* gallstones
* ethanol i.e. alcohol
* trauma
* steroids
* mumps
* autoimmune diseases
* scorpion bites
* hypercalcaemia / hyperlipidaemia
* ERCP
* drugs

(GET SMASHED)

Presentation of renal disease

* pain
* pyrexia
* haematuria
* proteinuria
* pyuria
* mass on palpation
* renal failure

What is the definition of proteinuria?

urinary protein excretion > 150mg/day

What is the definition of microscopic haematuria?

≥3 red blood cells per high power field

Presentation of chronic renal failure

* Asymptomatic (found on blood and urine testing)
* Tiredness
* Anaemia
* Oedema
* High blood pressure
* Bone pain due to renal bone disease
* Pruritus (in advanced renal failure)
* Nausea/vomiting (in advanced renal failure)
* Dyspnoea (in advanced renal failure)
* Pericarditis (in advanced renal failure)
* Neuropathy (in advanced renal failure)
* Coma (untreated advanced renal failure)

Presentation of ureteric diseases

* pain
* pyrexia
* haematuria
* palpable mass
* renal failure

Presentation of bladder disease

* pain
* pyrexia
* haematuria
* lower urinary tract symptoms (LUTS)
* recurrent UTIs
* chronic urinary retention
* urinary leak from vagina
* pneumaturia

Lower urinary tract symptoms (LUTS)

* storage LUTS
* frequency
* nocturia
* urgency
* urge incontinence
* voiding LUTS
* poor flow
* intermittency
* incomplete emptying
* terminal dribbling
* hesitancy

Presentation of bladder outflow tract diseases

* pain
* pyrexia
* haematuria
* lower urinary tract symptoms (LUTS)
* recurrent UTIs
* acute urinary retention
* chronic urinary retention

What is acute urinary retention defined as?

painful inability to void with a palpable and percussible bladder

What is chronic urinary retention defined as?

painless, palpable and permissible bladder after voiding

Complications of chronic urinary retention

* UTI
* post-decompression haematuria
* pathological diuresis
* electrolyte abnormalities
* persistent renal dysfunction

Complications of UTIs

* infection - sepsis, perinephric abscess
* renal failure
* bladder malignancy
* acute urinary retention
* frank haematuria
* bladder or renal stones

How is stage 1 chronic kidney disease defined?

* kidney damage / normal or high GFR
* GFR >90 ml/min/1.74m²

How is stage 2 chronic kidney disease defined?

* kidney damage / mild reduction in GFR
* GFR 60-89 ml/min/1.73m²

How is stage 3a chronic kidney disease defined?

* moderately impaired
* GFR 45-59 ml/min/1.73m²

How is stage 3b chronic kidney disease defined?

* moderately impaired
* GFR 30-44 ml/min/1.73m²

How is stage 4 chronic kidney disease defined?

* severely impaired
* GFR 15-29 ml/min/m²

How is stage 5 chronic kidney disease defined?

* advanced or on dialysis
* GFR

How is kidney filtering function assessed?

* urinalysis
* protein quantification

What is chronic kidney disease (CKD) defined as?

the presence of kidney damage (abnormal blood, urine or x-ray findings) or GFR

Management of acidosis

bicarbonate

Management of anaemia

* (erythropoietin) EPO
* iron

Management of bone disease

* diet
* phosphate binders

Management of fluid overload

* salt and fluid restriction
* diuretics

Causes of chronic kidney disease (CKD)

* diabetes
* glomerulonephritis
* hypertension
* kidney infections
* polycystic kidney disease
* high cholesterol

Presentation of chronic kidney disease

* tiredness
* swollen ankles, feet or hands
* shortness of breath
* nausea
* haematuria
* weight loss / poor appetite
* nocturia
* erectile dysfunction in men

Investigations for chronic kidney disease

* bloods - U&Es, FBC
* urine dip for blood and protein
* renal biopsy
* radiology - ultrasound

Management of chronic kidney disease

* manage blood pressure - ACE inhibitors, beta blockers
* manage proteinuria - ACE inhibitors, ARBs
* manage cholesterol - statins
* treat underlying cause
* dialysis
* kidney transplant

Complications of chronic kidney disease

* acidosis
* anaemia
* bone disease
* dialysis
* electrolytes
* fluid overload
* gout
* hypertension

Risk factors for chronic kidney disease

* heart disease
* obesity
* family history of CKD
* past damage to kidneys
* old age

Management of focal necrotising glomerulonephritis

* high dose steroids
* cyclophosphamide
* plasma exchange

What is the definition of acute kidney injury?

* increase in serum creatinine:
* by ≥26.5 µmol/l within 48 hours **or**
* to ≥1.5 times baseline within 7 days **or**
* urine volume

Definition of stage 1 AKI

serum creatinine:

* 1.5 - 1.9 times baseline **or**
* ≥36.5 µmol/l increase

urine output:

*

Definition of stage 2 AKI

serum creatinine:

* 2.0 - 2.9 times baseline

urine output:

*

Definition of stage 3 AKI

serum creatinine:

* 3.0 times baseline **or**
* increase to ≥354 µmol/l **or**
* initiation of renal replacement therapy

urine output:

*

What is anuria?

failure of kidneys to produce urine

Immediately dangerous complications of acute kidney injury

* acidosis
* electrolyte imbalance
* intoxication TOXINS
* overload
* uraemic complications

AEIOU

Causes of acute kidney injury

Pre-Renal:

* cardiac failure
* haemorrhage
* sepsis
* vomiting and diarrhoea

Post-Renal:

* tumours
* prostate disease
* stones

Intrinsic:

* glomerulonephritis
* vasculitis
* radiocontrast
* myeloma
* rhabdomyolysis
* drugs - NSAIDs, gentamicin

Risk factors for acute kidney injury

* age >75 years
* previous AKI
* heart failure
* liver disease
* chronic kidney disease
* diabetes mellitus
* vascular disease
* cognitive impairement

What is acute kidney injury ‘STOP’ prevention

* **S**epsis - if suspected screen and treat
* **T**oxins - avoid
* **O**ptimise BP and volume status
* **P**revent harm

Management of sepsis

Three tests:

* blood lactate level
* blood cultures
* urine output

Three treatments:

* oxygen to maintain oxygen saturations 94-98%
* empirical broad spectrum antibiotics
* IV fluids

Medicines to stop on sick days

* ACE inhibitors
* ARBs
* NSAIDs
* diuretics
* metformin

What are the medicine sick day rules?

when you are unwell with:

* vomiting or diarrhoea
* fever, sweats, shaking

then stop taking certain medications

Investigations for acute kidney injury

* creatinine levels
* U&Es, FBC, LFTs, clotting factor
* blood gas
* assess volume stasis
* imaging - ultrasound

How to manage hypovolaemia in acute kidney injury

* give boluses of fluid as per intravenous fluid prescription guidelines
* continue to reassess until volume replete
* then treat as per euvolaemia

How to manage euvolaemia in acute kidney injury

* give only maintenance fluid
* fluid can be given oral or IV depending on patient intake and clinical condition
* ensure you have daily fluid balance targets

How to manage hypervolaemia in acute kidney injury

if fluid overloaded and also oliguric, the patient will need a senior review

Indications for renal referral in acute kidney injury

* persistent oliguria or ongoing deterioration
* persistent hyperkalaemia
* persistent pulmonary oedema
* severe metabolic acidosis
* suspicion of intrinsic renal disease
* AKI with low platelets
* AKI stage 3

What should be checked at AKI review?

BUMP

* Bloods:
* consider daily bloods
* consider more frequent review for hyperkalaemia
* Ultrasound:
* consider renal ultrasound
* Medicines:
* ensure appropriate dose adjustment of drugs
* Plan for fluid maintenance
* review fluid balance and adjust fluid prescription based on volume status
* continuation of fluid balance chart
* daily weights

What should be done at AKI follow-up?

RRT

* Record
* document the AKI happened, why and how bad, what investigations showed
* this will help avoidance of further episodes
* Repeat Bloods
* check that renal function has returned to patient’s baseline - plan when and who to repeat
* if renal function has not returned to patient’s baseline, may need review for other diagnosis
* Treatment and Medicines Review
* ensure that medicines are now optimised or there is a plan in place to optimise
* does the patient need to restart diuretics, antihypertensives or other medications - when?
* who needs to assess and when?

What ECG changes can be seen in hyperkalaemia?

* peaked T waves
* tall tented T waves
* P wave widens and flattens
* PR segment lengthens
* P waves eventually disappear

Management of hyperkalaemia

* stabilise (myocardium) - calcium gluconate
* shift (K⁺ intracellularly) - sulbutamol, insulin-dextrose
* remove - diuresis, dialysos, anion exchange resins

Presentation of acute kidney injury

* nausea / vomiting
* diarrhoea
* dehydration
* peeing less than usual
* confusion drowsiness

Management of acute kidney injury

* increase water and fluid intake if dehydrated
* antibiotics if have an infection
* stop certain medicines - NSAIDs, PPIs, statins
* urinary catheter

Investigations for benign diseases of the prostate

* MSSU
* flow rate study
* post-void bladder residual USS
* bloods - PSA, urea, creatinine
* renal tract USS if renal failure or bladder suspected
* flexible cystoscopy if haematuria
* urodynamic studies in selected cases

Complications of transurethral resection of prostate (TURP)

* bleeding
* infection
* retrograde ejaculation
* stress urinary incontinence
* prostatic regrowth causing recurrent haematuria
* bladder outflow obstruction

Presentation of benign prostatic hyperplasia (BPH)

* hesitancy
* frequency
* incomplete emptying

Investigations for benign prostatic hyperplasia (BPH)

* urine test - glucose
* abdominal and genital examination
* rectal examination
* bloods - PSA

Management of benign prostatic hyperplasia (BPH)

* reduced alcohol, caffein and fizzy drink intake
* limit intake of artificial sweeteners
* exercise regularly
* medication
* alpha-blockers
* anticholinergics
* 5-alpha reductase inhibitors
* diuretics
* desmopressins

Complications of benign prostatic hyperplasia

* UTI
* acute urinary retention

Management of uncomplicated benign prostatic obstruction (BPO)

* watchful waiting
* medical therapy
* alpha blockers
* 5 alpha reductase inhibitors (finasteride or dutasteride)
* combination
* surgical intervention
* TURP (prostate size

Management of bladder outflow obstruction (BOO)

* medical therapy
* surgery
* long term catheterisation
* clean intermittent self-catheterisation

Complications of bladder outflow obstruction (BOO)

* progression of LUTS
* acute urinary retention
* chronic urinary retention
* urinary incontinence (overflow)
* UTI
* bladder stone
* renal failure

Causes of obstruction at the pelvic-ureteric junction

Intrinsic

* PUJ obstruction (physiological)
* stone
* ureteric tumour
* blood clot
* fungal ball

Extrinsic

* PUJ obstruction (crossing vessel)
* lymph nodes
* abdominal mass

Causes of obstruction at the ureter

Intrinsic

* stone
* ureteric tumour
* scar
* blood clot
* fungal ball

Extrinsic

* lymph nodes
* iatrogenic
* abdominal / pelvic mass

Causes of obstruction at the vesico-ureteric junction

Intrinsic

* stone
* bladder tumour
* ureteric tumour

Extrinsic

* cervical tumour
* prostate cancer

Prevention of upper tract obstruction

* pain
* frank / microscopic haematuria
* symptoms of complications
* palpable mass

Complications of upper urinary tract obstruction

* infection and sepsis
* renal failure

Presentation of lower urinary tract obstruction?

* lower urinary tract symptoms
* acute / chronic urinary retention
* recurrent UTIs and sepsis
* frank haematuria
* formation of bladder stones
* renal failure

In retention, when should you catheterise?

immediately

What is tenesmus?

the feeling that you need to pass stools, even though your bowels are already empty

Risk factors for prostate cancer

* age
* race / ethnicity
* African or Afro-Caribbean men have higher risk
* White men have moderate risk
* East Asian men have lowest risk
* geography
* family history
* first degree relative (2x risk)
* HPC1, BRCA1 + 2 (5x)
* Lynch syndrome (HNPCC) (2-5x)
* obesity
* diet