1
Q
What is CKD?
A
Impairment in renal function lasting > 3 months - GFR < 60mL/min/1.73m2
2
Q
Describe the stages of CKD:
A
3
Q
What are the causes of CKD?
DIP A CHUG
A
DIP A CHUG
-Diabetes (most common)
-Idiopathic
-Pyelonephritis
-Atherosclerosis
- Congenital (e.g. polycystic kidneys)
- HTN
- Urinary tract obstruction (e.g.BPH,calculus disease – but these causes are usually reversible)
-Glomerulonephritis (commonly IgA nephropathy)
4
Q
With CKD patients what are the symptoms you may ask about?
A
- Symptoms (usually when urea > 40mmol/L)
o Nocturia, or polyuria or oliguria
o loss of appetite, nausea, vomiting
o fatigue, weakness
oParesthesia/tetany (hypocalcemia)
o Often asymptomatic if came on slowly
5
Q
What complications may you ask about with CKD?
A
- Sx of Complications
o SOB, Palpitations
o Dyspnea and ankle swelling (fluid overload).
o Bone pain (renal bone disease)
o Pruritis and photosensitivity
o Gout
o Dialysis patients–access problems, infection, pericarditis, peritonitis - Pallor (anaemia)
o Confusion, depression, carpel tunnel, restless legs, peripheral neuropathy (Uraemic)
6
Q
What are common aetiologies for CKD?
A
VITAMIN CDE (Surgical sieve)
o Glomerulonephritis– hx of pro, haem, sore throat, immunosuppressive rx
o Recurrent UTI’s
o Polycystic kidney disease.
o Reflux nephropathy–childhood
renal infections, cystoscopy, operations
o Connective tissue–especially SLE
and scleroderma
7
Q
What are the potential precipitants to trigger a CKD acute presentation?
A
o NSAIDS, radiocontrast ACEi
o Infection, dehydration, anaemia
8
Q
What previous investigations might you be interested in for a CKD patient?
A
- Urinanalysis
- Renal biopsy
9
Q
What previous managements for CKD might you be interested in?
A
o Dietary (saltandwater, protein restriction)
o Medications
ACEi
Erythropoietin
Steroids/ immunosuppressant
o Dialysis (Type, Hz)
o Operations–renal tract, parathyroidectomy
o Transplant work up
10
Q
What broad investigations might you do for CKD?
A
- Bloods
- Urine
- Imaging
- Other
11
Q
What bloods might you do for a patient with CKD?
A
- Glomerular function
o eGFR,creatinineclearance,plasma creatinine/urea level - Tubular function
o Electrolytes,phosphate,uricacid,
calcium, albumin - FBC
o Normocytic, normochromic anaemia
o Platelet abnormalities - Iron studies
- Parathyroid hormone
- Underlying disease
o ANA, HepB surface antigen, HepC, immunoelectrophoresis,
12
Q
What urine investigations might you do for CKD?
A
- Dipstick
- Cultures and sensitivities
- 24hr urine for ACR
13
Q
What imaging might you do for a patient with CKD?
A
- Renal ultrasound
o Renal size, symmetry, obstruction o Kidneys in CKD will be small(<
8cm)
unless
Early diabetic nephropathy.
Polycystic kidneys
Obstructive uropathy
Infiltrative diseases - CT scan
o Be wary of contrast - Cystoscopy
- Renal artery Doppler or CT renal angio
14
Q
What other investigations might you do for a patient with CKD?
A
- Micturating cystogram
- Renal biopsy
o <8cm–mainly scar tissue– irreversible
o >8cm-may still have some cortex– some reversibility - Nerve conduction studies
- Arterial Doppler studies
15
Q
What are the complications of CKD?
MS CAN BEG
A
MS CAN BEG
Metabolic abnormalities
Skin disease
CV disease
Anaemia
Nervous system
Bone disease
Endocrine
GI complications
16
Q
What are the anaemia, bone disease complications of CKD?
A
Anaemia
- erythropoietin deficiency
Bone Disease
- ‘renal osteodystrophy’
combination of
hyperparathyroid bone disease, osteomalacia,
osteoporosis, osteosclerosis
17
Q
What are the skin disease complications of CKD?
A
- pruritis, due to retention of nitrogenous waste products, +/- inadequate dialysis
- dry skin + eczematous lesions over AV fistula
- porphyria cutanea tarda (PCT) is a blistering, photosensitive rash
- Nephrogenic systemic fibrosis – a systemic
fibrosing disorder with predominant skin
involvement 2° to gadolinium contrast
18
Q
What are the GI complications of CKD?
A
- Decreased gastric emptying
o GORD and peptic ulceration
o acute pancreatitis
o constipation - increased serum amylase 2° to decreased renal excretion
19
Q
What are the metabolic abnormalities of CKD?
A
**Waste build up: **
o Urate retention
- Uraemia
Medications:
- Don’t use NSAIDS
- Insulin
o Catabolized and excreted by kidneys
o Requirements in DM patients as disease
o End organ resistance in advanced CKD resulting in mild imparied glucose tolerance
**Abnormal lipid handling: **
o Impaired TG clearance
o Hypercholesterolemia
Electrolyte
- High K- cos not excreted- leads to acidosis
20
Q
What are the endocrine abnormalities in CKD?
A
- Prolactin
- LH
- Growth factors
- Testosterone
- Thyroid hormones
21
Q
What are the nervous system abnormalities in CKD?
A
- Central nervous system
o Reduced seizure threshold
o ‘dialysis dementia’
o Psychiatric
- Autonomic nervous system
o Overactive sympathetic nervous system
HTN
- Peripheral Nervous System
o CarpelTunnel
o Restless leg syndrome
- Peripheral polyneuropathy
o Rare if adequately dialyzed
o Common in DM
22
Q
What are the cardiovascular disease complications of CKD?
A
- Increased risk factors
o HTN, DM, Dyslipidaemia, smoking
o Systolic dysfx due to myocardial fibrosis, abnormal myocyte functioning, calcium overload
o Coronary artery calcification due to raised (calcium x phosphate) product - Pericarditis
o Uraemic pericarditis (insufficient
dialysis)
o Dialysis pericarditis (sufficient dialysis) - HF- fluid overload cos can’t excrete salt and so h20
23
Q
Give the broad approach to treating CKD:
A
- Treat reversible causes of deterioration
- Lifestyle modificaitons
- CVD risk factors
- Address anaemia
- Address renal bone disease
- Address restless leg syndrome
- Address odema
- Dialysis/RRT
24
Q
What are the treatable reversible causes of CKD deterioration? (HUCHDD)
A
- Hyperperfusion i.e ACEi (esp in DM)
- UTI/Obstruction
- Cardiac failure
- Hypothyroidism
- Drug use
- Dehydration
25
What are the lifestyle factors you can address in CKD treatment?
- Smoking cessation
- Physical acitivity
- Diet
-> Salt and water
-> Reduced fats
26
What are the CVD risk factors you can address in CKD?
- Monitor and control BP
o Target BP140/85
o In diabetic kidney disease, treat
with ACEi or ARB even if BP is normal
- Monitor and control lipids
o Treat with statins regardless of lipids.
- Aspirin (Low dose)
27
How do you address anaemia in CKD?
- Erythropoietin if CKD ≤ 3 and HB < 100
- Exclude iron deficiency before commencing
- Correct iron deficiency first
- Aim Hb 110 – 120 – any more induces
hyperviscosity and risk of stroke
28
How do you treat renal bone disease in CKD?
- Treat if elevated PTH
- Restrict dietary phosphate
o Milk, cheese, eggs - Phosphate binders i.e Calcitab
o Monitor by looking at phosphate
- Calcitriol
o Increases calcium.
o Monitor effect by looking at PTH
29
How do you address restless legs and oedema in CKD?
Restless Legs
- clonazepam or gabapentin
Oedema
- high dose loop diuretics
30
What are the indications for dialysis/RRT?
AFUCKED acronym
AFUCKED
- Indications
o A–acute renal failure
o F–fluid overload despite mx
o U–uraemic symptoms despite mx
o C – creatinine > 1000
o K– hyperkalaemia despite mx
o E – electrolyte ab n despite charcoal
o D– drugs e.g. dabigatran
31
What are the pros and cons of peritoneal dialysis?
o Positives-CVsafe,largevolumes, freedom of diet and fluid, preferable for DM, daily, at home
o Negatives–peritonitis,exitsite infections, protein loss, hernias and obesity and contraindications, does not control uraemia
32
What are the pros and cons of heamodialysis?
o Positives–takes 18 hours per week, no protein loss, large volumes
o Negatives
–circulatory access problems,
- heparin increasing risk of bleeding,
- increased CV instability,
- anaemia,
- osteodystrophy,
- dialysis dementia,
- patient less involved,
- dietary compliance needed.
33
What are the RRT complications?
Renal replacement therapy
BIPCAM
BIPCAM
o B–bone disease
o I-infection
o P–protein/caloric malnutrition
o C–CVD; MI, CVA (HTN,Ca/Pdysreg)
o A–amyloid, CTS, arthralgia, #
o M–malignancy
34
Whats the definition of glomerulonephritis?
Group of disorder where damage to the glomerulus causes a leak of protein (nephrotic) +/- blood (nephritic) into the urine.
35
What is nephrotic syndrome? What is the physiological consequence and compensation? What are the common causes?
Nephrotic syndrome = inflammation damages glomerulus, proteins leak, high protein in urine (proteinuria), low protein in blood (hypoalbuminaemia), severe oedema (due to reduced oncotic pressure AND Na+ retention), and hyperlipidaemia (liver releases triglycerides to maintain osmotic pressure).
**Causes include **
- minimal change disease (most common cause in children),
- membranous nephropathy,
- focal segmental glomerulosclerosis,
- and diabetes.
36
What is nephritic syndrome?
Nephritic syndrome = inflammation damages glomerulus so much that blood freely filters through causing proteinuria AND haematuria, this causes decreased kidney perfusion and thus oliguria, and subsequent hypertension.
Causes include IgA nephropathy, rapidly progressive GN, SLE, and Goodpasture’s.
37
What is the hx you would look for in a nephrotic syndrome?
- Frothy urine (proteinuria)
-Oedema (hypoalbuminaemia)
-Severe hyperlipidaemia may also be present (cholesterol and TG’s), as liver releases TG’s to maintain oncotic pressure
38
What is the hx you would look for in nephritic syndrome?
- Haematuria
- Proteinuria (small)
- Hypertension (less filtering)
- Oliguria
- Oedema from high pressure
39
What are the primary causes of nephrotic syndrome and what systemic disease is it associated with?
- Minimal change disease
- Membranous
- Focal segmental glomerulosclerosis
Systemic:
- Db
- Myeloma
40
Nephritic syndrome is primarily caused by: and associated with what systemic conditions?
- IgA nepropathy
- Proliferative:
-> Post Strep A
-> Mesangial
-> Cresentic
- Rapidly progressing GN
- Thin basement membrane
Systemic:
- SLE
- Goodpastures
- Myeloma
41
Is IgA exclusively nephrotic or nephritic?
Can be either
42
What investigations might you perform for glomerulonephritis?
-Urinalysis (Protein, RBC’s)
-Albumin creatinine ratio (ACR) – more accurate than dipstick, allows for dilute/concentrated urine
-eGFR and Creatinine
-Blood (FBC, U+E, LFT, ESR/CRP)
-Autoantibodies (ANA, ANCA, anti-dsDNA, anti- GBM)
-Renal USS +/- biopsy
43
What is the management for glomerulonephritis; Nephrotic and nephritic syndrome
- Refer to a nephrologist
- Depends on the actual diagnosis, but in
general:
- Nephrotic syndrome = Treat underlying
cause, salt restrict, diuretics for oedema, ACEi to reduce proteinuria, monitor BP and treat if high
- Nephritic syndrome = Treat underlying
cause, treat HTN, ACEi, steroids/immunosuppression if autoimmune cause
44
What is the definition of BPH?
Benign enlargement of prostate which impacts flow of urine through prostatic urethra.
45
What might you find on examination of a patient with BPH?
DRE – smooth, enlarged, symmetrical Distended bladder if in retention
46
What investigations might you do for a patient with BPH?
Blood
- PSA
- Cr,U&E MSU
International prostate symptom score
(IPSS)
Imaging
- abdominal USS: Large residual volume, hydronephrosis
- transrectal USS Voiding Studies
- to suggest if stricture/obstruction picture
Biopsy – trans-rectal biopsy (Gleason score) – to rule out malignancy if high suspicion
47
What is the treatment/management of BPH?
Lifestyle
- Avoid caffeine/alcohol (reduces
urgency/nocturia)
- physio; relaxation w voids, distraction methods to control urgency, bladder retraining
Medications (IPSS 8-10)
o a-blockers; Doxazosin, Tamsulosin
o 5a-reducatase Inhibitors; Finasteride
Surgery: (IPSS >20)
- TURP <100g
- Open retro-pubic prostatectomy (if large)
48
What is the action of Alpha blockers and SE? in the context of BPH?
o a-blockers; Doxazosin,Tamsulosin
----- Smooth muscle relaxation
----- 50-70%respond
----- SE:drowsy,dizzy,dry
mouth, hypotension,
ejaculation issues
49
What is the MoA of 5a reductase inhibitors and SE?
blocks conversion DHT to T
prevents haematuria,
minimal effects on size
Takes 6months to work
Excreted in semen- Condoms!
SE: impotence, decr libido
50
How can UTIs be broadly categorized?
Presence or growth of bacteria in urine Lower UTI = urethritis, cystitis, prostatitis Upper UTI = pyelonephritis
Uncomplicated = normal renal tract and function
Complicated = abnormal renal tract, voiding difficulty/obstruction, reduced renal function, impaired host defences, virulent organisms eg staph aureus
51
What are the risk factors for UTIs?
- Females
- Sex
- pregnancy
- Menopause
- Immunosuppression
- Diabetes
- Urinary obstruction
- Renal stones
- Urinary catheters
- Malformation
52
What are the common organisms of UTIs?
Usually E. Coli
Occasionally Proteus mirabilis, Staph Aureus or Klebsiella pneumonia.
53
What are the symptoms of UTI? based on location
- Pyelonephritis = fevers, rigors, vomiting, loin pain, flank tenderness, oliguria (if AKI)
- Cystitis = frequency, dysuria, urgency, haematuria, suprapubic pain
- Prostatitis = flu-like symptoms, backache, enlarged prostate on PR, few urinary symptoms
54
What might you find in examination of a patient with suspected UTI?
Abdo/loin tenderness, foul smelling urine, distended bladder if obstruction
55
What are the investigations for a UTI?
- Dipstick urine (look for nitrites, leukocytes, bacteria)
- MSU: for culture and sensitivities
- Bloods: FBC, U+E, CRP, blood culture if
systemically unwell (urosepsis), PSA
- Imaging: in children and med, failure to respond
to treatment, recurrent UTIs or pyelonephritis consider USS and referral to urology
56
What are the causes of sterile pyuria?
- Treated UTI within 2 weeks
- Inadequately treated UTI
- Appendicitis
- Calculi
- Prostatitis
- Bladder tumour
- Polycystic kidneys
57
How do you prevent UTI?
- Drink lots of water
- Antibiotic prophylaxis
- Self-treatment with single dose of abx when
symptoms start
- Cranberry juice (but need to drink lots!)
- No evidence for post-coital voiding
58
Whats in the management of UTI in a non-pregnant woman?
o Treat empirically for E.coli
o Trimethoprim or nitrofurantoin
o If no response do urine culture
o Consider other diagnoses if vaginal itch
or discharge
o If upper UTI take urine culture and treat
with co-axomiclav
o If asymptomatic DO NOT TREAT (very
common)
Drink lots of fluids and urinate often.
59
How do you manage a UTI in a pregnant woman?
o Common
o Get expert help
o Any bacteriuria (asymptomatic or
symptomatic) should be treated (risk of
prematurity and pyelonephritis)
o Repeat dipstick and culture at each
antenatal visit
60
How are UTIS managed in Men?
o Uncommon
o Often results from anatomical or
functional anomaly
o Consider referral to urologist o 2 weeks levofloxacin
61
Differentiate the different types of recurrent UTI
Relapse→further infection with same organism Reinfection→further infection with different organism
62
What are the causes of recurrent UTI?
- Abnormal Renal/GU tract e.g. stones, posterior valves
- Voiding difficulty/outflow obstruction e.g. BPH - Impaired renal function e.g. DM
- Impaired host defences e.g. DM,
immunosuppression
- Poor hygiene/wiping technique - Post-menopausal
- Rest home/hospital
- Diabetes
- Kidney or bladder stones
- Having a catheter
- Previous urinary tract surgery
- Sexual activity
- Having an infected or enlarged prostate
- Congenital abnormality of the urinary tract
63
What are the investigations for recurrent UTI?
- Renal tract USS
- PR
- Renal function test
64
What are the treatment options for recurrent UTI?
- Eradication/manage cause
- Culture and sensitivity to rationalise antibiotics
- Oestrogen cream for post-menopausal females
65
What are the risk factors for prostate cancer?
Age
FHx
66
What are the investigations for suspected prostate cancer?
DRE; Enlarged, craggy, asym, nodular (PSA +ive = 30-40% chance)
Bloods:
- FBC: Low Hb, ALP rise (Mets), Pancytopenia
- PSA >4 abnormal
- Cr
MSU:
- Presence of blood -> Cytoscopy, CT
Imaging:
- TRUS (Needle guided biopsy) (LA and Abx cover)
- CT staging
- Nuclear bone scan (mets)
Biopsy:
- TUBP
67
Whats the relevance of PSA test in prostate cancer?
PSA > 4 is abnormal
-> Normal in 30%
-> PSA rised in BPH, hypercalcaemia, prostatitis, sex
68
Describe prostate cancer grading:
Gleason system:
- No role of cytological features.
- Score /10.
- 2 Most predominant glandular patterns
69
How is prostate cancer staged?
CT staging, LN (urethral), seminal vesicles, bladder, bone lung
70
What are the management options for prostate cancer?
- Watchful waiting. Life expectancy <10y
- Active surveillance: >70y, low risk.
- Surgery
-> Radical prostatectomy (Open vs robotic). SE: Impotency, urinary probs.
- Radiation
-> Radical. Daily 6/52. (Similar outcomes to surgery) SE: Bowel, bladder probs, secondary Ca. NB: Palliative role (Boney mets)
- Brachytherapy
-> Radioactive iodine. For less aggressive cancers.
- Chemo
-> Docetaxel. Survival benefit for those with good performance.
71
What are the androgen deprivation/Hormonal treatment options for prostate cancer?
No change in life expectancy ‘lead time bias’ - Surgical
o Orchidectomy (decrease libido) - Medical
o LHRH agonist
▪ Zoladex, Lucrin (IM)
▪ Cyproterone acetate (PO)
o Cover with anti-androgen (Goserelin) for
2/52 cover flare
o SE: lethargy, hot flush, mood, weight
gain, OP, decreased muscle mass, ED
72
Whats the prognosis for prostate cancer?
T low and PSA up = androgen independent ☹ 10% die at 6 months; 10% live >10yrs
73
Whats the prevalence of breast cancer?
1 in 9, 30% mortality, most common cause of death in woman 35 – 54
74
What are the risk factors for breast cancer?
Overweight, smoking, alcohol, FMHx, personal cancer Hx, early menarche’s (<11), late menopause (>53), late first pregnancy, radiation, prolonged OCP/HRT, Ashkenazi Jewish
75
What are the genes associated with breast cancer?
- Familial 10-15%
- BRCA 1 (80% breast, 40% ovarian)
- BRCA 2
76
What are the screening rules for breast cancer?
- Mammograms 45 – 69 2 yearly basis
- Harmless screen that can detect something able to tx
- Some over screening and overtreating
77
What is the presentation for breast cancer?
- Breast lumps, axillary nodes
- Peau d’orange
- Nipple discharge; bloody, green, yellow
- Paget’s disease of the nipple
- Abnormal resting place, tethering
- Asymmetry
78
What aspects of a breast lump are you interested in?
Position→commonly upper outer quadrant
Size, shape, consistency (hard, irregular, not discrete) Tenderness (none)
Fixation (?Fixed to CW)
Single, multiple
79
How do you investigate breast cancer?
‘Triple Therapy’ for all breast lumps
1) Examination
2) Imaging
o If <35 year old → USS
▪ Sensitivity 82%, specificity 85%
o If >35 years old → USS and mammogram
▪ Compares glandular vs fatty
▪ Sensitivity 86%; specificity 90%
(misses 40% cancer in under 50s)
o MRI (sometimes)
▪ High risk groups→BRCA carrier, mantel RTX
▪ Post Dx work up ?lobular difficult to see on mammogram; extent of disese
3) Biopsy
80
Describe the findings on FNA for breast cancer:
▪ C1→insufficient tissue
▪ C2→benign
▪ C3→atypical (favours benign)
▪ C4→Suspicious of M
▪ C5→malignant or DCIS
o Core
▪ Distinguishes between DCIS vs
M, ductal vs. lobular, receptor status
81
What are the diagnoses for breast cancer:
Carcinoma insitu
o Lobular CIS – increased risk cancer
o Ductal CIS – Pre-malignant
Invasive carcinoma
o Lobular carcinoma 20%
o Ductal carcinoma 80%
o Other
82
What is the staging features of breast cancer
Stages 1-4 (stage 1 = confined to breast, stage 4 = distant mets)
Also use TNM staging
83
What are the management options for breast cancer:
urgery
- DCIS: excise w 10mm margins
- Partial mastectomy + RTx
- Total mastectomy (uni, bi-lateral)
o +/- SNB
o +/- ANC
o +/- recon immed/delayed
Radiation
- All breast conservation cases, some DCIS
Chemotherapy
- Higher risk cases ie high grade
- Neo-/Adjuvant, palliative (diff Rx)
- Combo CMF, anthracycline
Endocrine
- Tamoxifen (ER+)
Monoclonal Ab
- Herceptin (HER-2+)
Long Case
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