Renal Medicine
Creatinine clearance:
• Measure eGFR with CKD-EPI formua
• Claculate CrCl using and estimtes the eGFR using Cockcroft gault equation (Better
for drug dosing, because old)
o MDRD (good for severe kidney disease)
Rmb that urine tonicity is NOT just sodium but also potassium and
multiply by 2!
Proteinuria: >0.15g/d
Catheter balloons should only be filled with water and not saline
because there is a possibility that the salt may crystallize and result in
inability for balloon to deflate or could lead to the crystals damaging the
urethral mucosa
In cases of transverse process fractures, always look out for kidney injury or lumbar
arterial/venous bleeds due to the mechanism of action involved
eGFR 45 is cut off to give contrast (Now is known as contrast associated nephropathy)
Sometimes can drop cut off to eGFR 30 if tst absolutely needs contrast
Bladder trabeculation, detected by a cystoscope, is the secondary result of a chronic bladder
outlet obstruction and is known to be caused by morphological and histological changes due
to hypertrophy and hyperplasia of the bladder muscle and the infiltration of the connective
tissue.
m-TOR inhibitors: sirolimus, everolimus
• Indicated for renal transplant
• Everolimus has better immunosuppresion effects and lower infection rates, but higher
rejection rates after ceasing and proteinuria effects
Calcineurin inhibitor: tacrolimus, pimecrolimus
Devascularised kidney due to injury etc will NOT be routinely removed as it is
a retroperitoneal structure that is islanded off UNLESS:
• Collecting system damaged
• Infection
• Ileus
• Retroperitoneal hemorrhage
• Cases of devascularition due to avulsion or renal artery dissection will
not be removed
Male genital examination
• Look
o Retract foreskin to expose mucosal surface
o Urethral discharge
o Scrotum (while standing): edema, lie of testes, skin changes
o Hernial orifices
• Feel
o Palpate testes (symmetrical, maldescended, arrested, hydogonadism,
retractile, ascending, atrophy, ectopic)
o Epididymis, vas deferencs, spermatic cord
• Move
o If mass present: determine lump characteristics
• Special
o Transilluminate
o Cremasteric reflex
,Glomerular bleeding:
1. Red cell casts
2. Proteinuria
3. Dysmorphic RBC: schistocytes
4. Acanthocytes
5. Lack of clots
6. Smoky brown (coke) urine
Terminology
Nephritic syndrome: inflammatory process, causing hematuria and RBC casts in urine,
proteinuria hypertension and impaired function, azotemia, raised JVP, edema and
proteinuria but less than nephrotic syndrome
• Signs of nephritic syndrome (PHAROH)
o Proteinuria (<3.5g/d) +/- mild edema
o Hypertension with mild edema
o Azotemia
o RBC casts: cola/smoky/rosea urine (dysmorphic RBC: active urinary
sediments)
o Oliguria: Loss of renal function
o Hematuria
Nephrotic syndrome: proteinuria, oedema (periorbital, facial), hypoalbuminaemia,
hyperlipidimia, thombophilia (protein C and S deficiency) frothy urine, JVP not raised
• Signs of nephrotic syndrome: NAPHROTIC
o Na+ decrease (hyponatremia)
o Albumin decrease (<35g/L)
o Proteinuria >3.5g/day (usually 3g/day clinically)
o Hyperlipidemia
o Renal vein thrombosis
o Orbital edema
o Thromboembolism
o Infection (loss of Immunoglobulin in urine): SBP, celulitis, sepsis
o Hypercoaguable state: due to loss of coagulant inhibitor (antithrombin
3 and protein S) factors
o Intravascular volume collapse and shock
o Hypothyroidism: Lose albumin and TBG
o Non proliferatve and fatty casts (inactive urinary sediments)
Typical features Nephrotic Nephritic
Onset Insidious Abrupt
Oedema ++++ ++
BP Normal ↑
JVP Normal ↑
Proteinuria ++++ ++
Haematuria +++
Red cell cast - Present
Serum albumin Low Normal
,Hematuria DDx:
Cancers
UTI
Renal colic
GN
Note that reflux nephropathy means the backward flow of urine back into the kidney,
while obstructive uropathy is the obstruction and hence hydronephrosis.
Type Characteristvs Eg
Focal <50% of glomeruli involed FSGS
Diffuse >50% of glomeruli involved Diffuse proliferative GN
Proliferative Hypercellular glomeruli Mesangial proliferative
Membranous Thickening of basement Membranous nephropathy
membrane
1st degree glomerular dx Involves glomeruli only Minimal change disease
2nd degree glomerular dx Involves glomeruli and other SLE, diabetic, nephropathy,
organs vasculitis
Nephrotic syndrome
Primary Secondary
MCD Diabetes
FSGS Lupus
MN Amyloid
MPGN
Nephritic syndrome (all can lead to RPGN)
• IgA nephropathy
• Vasculitis
• Anti-GBM
• Lupus
• PSGN
Diabetic nephropathy: kimmelsteil-wilson syndrome (nodules), nodular sclerosis, nephrotic
syndrome, GBM thickening and mesangial expansion
Minimal change: children, effacement of podocyte foot (electron microscopy), associated
with NSAIDs, hodgkin and leukemia and facial oedema
Focal Segmental Glomerular Sclerosis: segmental solidification and scarring of glomerular
tuft (caused by HIV)
• ACEi and renal transplant
Membranous nephropathy: thickened BM and spikes on silver linings, caused by
melanoma/Hep B/Lupus/RA (1/3 remits, 1/3 progress, 1/3 remains same) and bowel
cancer association
Diabetic nephropathy: kimmelsteil-wilson syndrome (nodules), nodular sclerosis, nephrotic
syndrome, GBM thickening and mesangial expansion
Membranoproliferative: GBM tram track appearance, capillary membrane thickening (mixture)
• Type 1: Immune complex (SLE, RA, Hep B/C, IVDU, HIV, MM) often due to
cryogloulinemic disease
• Type 2: Complement activation (cleavage of C3 complexes)
• Type 3: Mixed picture
IgA; synpharyngitis (URTI same time as GN), children (young asian male) with coke coloured
urine, usually self-limiting
• Associated with celiac and CLD
Post Streptococcal GN: 2-4 weeks after infection, tea coloured urine, postivie anti-streptolysin
titre (ASOT), anti-strep DNA
RPGN:
• Type 1: Goodpasture (IgG anti GBM, with haemoptysis, +ve p-ANCA)
• Type 2: Immune complex (45%-SLE, IgA, Strep)
• Type 3: Wegener’s (PR3, C-ANCA, sinusitis/epistaxis), Microscopic polyangiitis (p-
ANCA/MPO, pauci immune, haemoptysis, neurological symptom), Churg strauss
(peripheral IgE and p-ANCA/MPO, allergic/asthma): Questions usually have
ESR/CRP as clue
, Types of casts:
• RBC: GN, ischemia, malignant HTN, vasculitis
• WBC: pyelonephritis, tubulointerstitial inflammation, transplant rejection
• Fatty: nephrotic
• Pigmented granular/muddy brown: ATN
• Hyaline: normal, tamm-horsfall protein form the basis of casts (produced in the thick
ascending limb of loop of henle)
• Waxy cast: advanced renal disease/CRF (long term)
• No casts: bladder cancer, kidney stones, acute cystitis
Types of urology procedure:
• Cystoplasty means a refashioning of bladder
o Ileocystoplasty: Using part of ileum to make bladder
o Colocystoplasty: Using part of large bowel or colon as blader
o Carcocystoplasty: Using the caecum as bladder
o Gastrocystoplasty: Using part of stomach as bladder
• “Clam” cystoplasty: bladder opened in 2 halves joined at bottom end (bladder neck).
The piece of bowel used is opened along one side so that it is like a rectangular pieve
that is still attached to its arteries and can be anastomosed onto the upper half of
bladder
• Substitution cystoplasty: damaged or diseased bladder is removed leaving behind
Bladder neck and contain sphincter muscle and control passage of urine. Completely
new bladder is then formed from a part of bowerl which has been prepared as before
and the cup like strucure is attached to form new bladder
• Ileal conduit: using a section of ileum and using it to drain urine into the stoma bag.
• Indiana pouch: surgically created urinary diversion using parts of the ileum and
cecum and the ileocaecal valve prevents bacteria from coming into the small intestine
again. One end will be the stoma bag
• Ileal neobladder: uses part of the ileum to form part of the new bladder especially with
augmentation or calm cystoplasty
• Nephrostomy: a needle that enters the renal pelvis percutaneously and removes the
fluid left in the renal pelvis. (If left in place, should be replaced every 6 months)
• Bacillus calmette Guerin (BCG) vaccine can help to reduce cancer growth and
recurrence
• CT KUB: CT of kidneys, ureters, bladder
• CT IVP: CT intravenous pyelogram
• RGP: retrograde pyelogram
• PCNL: percutaneous nephrolithotomy
• ESWL: extracorporeal shockwave lithotripsy
• Cystolitholapaxy: break up stone into small pieces and removing them
• Nephrectomy: removal of kidney
• Ureteronephrectomy: removal of kidney and ureter
• Stenting: using a JJ stent or double J stent or pigtail stent to allow the stent to be put
in place and prevent is from moving. Removed in 2-4 weeks.
o Always insert guidewire with black bended part first (less trauma due to less
rigidity)
Creatinine clearance:
• Measure eGFR with CKD-EPI formua
• Claculate CrCl using and estimtes the eGFR using Cockcroft gault equation (Better
for drug dosing, because old)
o MDRD (good for severe kidney disease)
Rmb that urine tonicity is NOT just sodium but also potassium and
multiply by 2!
Proteinuria: >0.15g/d
Catheter balloons should only be filled with water and not saline
because there is a possibility that the salt may crystallize and result in
inability for balloon to deflate or could lead to the crystals damaging the
urethral mucosa
In cases of transverse process fractures, always look out for kidney injury or lumbar
arterial/venous bleeds due to the mechanism of action involved
eGFR 45 is cut off to give contrast (Now is known as contrast associated nephropathy)
Sometimes can drop cut off to eGFR 30 if tst absolutely needs contrast
Bladder trabeculation, detected by a cystoscope, is the secondary result of a chronic bladder
outlet obstruction and is known to be caused by morphological and histological changes due
to hypertrophy and hyperplasia of the bladder muscle and the infiltration of the connective
tissue.
m-TOR inhibitors: sirolimus, everolimus
• Indicated for renal transplant
• Everolimus has better immunosuppresion effects and lower infection rates, but higher
rejection rates after ceasing and proteinuria effects
Calcineurin inhibitor: tacrolimus, pimecrolimus
Devascularised kidney due to injury etc will NOT be routinely removed as it is
a retroperitoneal structure that is islanded off UNLESS:
• Collecting system damaged
• Infection
• Ileus
• Retroperitoneal hemorrhage
• Cases of devascularition due to avulsion or renal artery dissection will
not be removed
Male genital examination
• Look
o Retract foreskin to expose mucosal surface
o Urethral discharge
o Scrotum (while standing): edema, lie of testes, skin changes
o Hernial orifices
• Feel
o Palpate testes (symmetrical, maldescended, arrested, hydogonadism,
retractile, ascending, atrophy, ectopic)
o Epididymis, vas deferencs, spermatic cord
• Move
o If mass present: determine lump characteristics
• Special
o Transilluminate
o Cremasteric reflex
,Glomerular bleeding:
1. Red cell casts
2. Proteinuria
3. Dysmorphic RBC: schistocytes
4. Acanthocytes
5. Lack of clots
6. Smoky brown (coke) urine
Terminology
Nephritic syndrome: inflammatory process, causing hematuria and RBC casts in urine,
proteinuria hypertension and impaired function, azotemia, raised JVP, edema and
proteinuria but less than nephrotic syndrome
• Signs of nephritic syndrome (PHAROH)
o Proteinuria (<3.5g/d) +/- mild edema
o Hypertension with mild edema
o Azotemia
o RBC casts: cola/smoky/rosea urine (dysmorphic RBC: active urinary
sediments)
o Oliguria: Loss of renal function
o Hematuria
Nephrotic syndrome: proteinuria, oedema (periorbital, facial), hypoalbuminaemia,
hyperlipidimia, thombophilia (protein C and S deficiency) frothy urine, JVP not raised
• Signs of nephrotic syndrome: NAPHROTIC
o Na+ decrease (hyponatremia)
o Albumin decrease (<35g/L)
o Proteinuria >3.5g/day (usually 3g/day clinically)
o Hyperlipidemia
o Renal vein thrombosis
o Orbital edema
o Thromboembolism
o Infection (loss of Immunoglobulin in urine): SBP, celulitis, sepsis
o Hypercoaguable state: due to loss of coagulant inhibitor (antithrombin
3 and protein S) factors
o Intravascular volume collapse and shock
o Hypothyroidism: Lose albumin and TBG
o Non proliferatve and fatty casts (inactive urinary sediments)
Typical features Nephrotic Nephritic
Onset Insidious Abrupt
Oedema ++++ ++
BP Normal ↑
JVP Normal ↑
Proteinuria ++++ ++
Haematuria +++
Red cell cast - Present
Serum albumin Low Normal
,Hematuria DDx:
Cancers
UTI
Renal colic
GN
Note that reflux nephropathy means the backward flow of urine back into the kidney,
while obstructive uropathy is the obstruction and hence hydronephrosis.
Type Characteristvs Eg
Focal <50% of glomeruli involed FSGS
Diffuse >50% of glomeruli involved Diffuse proliferative GN
Proliferative Hypercellular glomeruli Mesangial proliferative
Membranous Thickening of basement Membranous nephropathy
membrane
1st degree glomerular dx Involves glomeruli only Minimal change disease
2nd degree glomerular dx Involves glomeruli and other SLE, diabetic, nephropathy,
organs vasculitis
Nephrotic syndrome
Primary Secondary
MCD Diabetes
FSGS Lupus
MN Amyloid
MPGN
Nephritic syndrome (all can lead to RPGN)
• IgA nephropathy
• Vasculitis
• Anti-GBM
• Lupus
• PSGN
Diabetic nephropathy: kimmelsteil-wilson syndrome (nodules), nodular sclerosis, nephrotic
syndrome, GBM thickening and mesangial expansion
Minimal change: children, effacement of podocyte foot (electron microscopy), associated
with NSAIDs, hodgkin and leukemia and facial oedema
Focal Segmental Glomerular Sclerosis: segmental solidification and scarring of glomerular
tuft (caused by HIV)
• ACEi and renal transplant
Membranous nephropathy: thickened BM and spikes on silver linings, caused by
melanoma/Hep B/Lupus/RA (1/3 remits, 1/3 progress, 1/3 remains same) and bowel
cancer association
Diabetic nephropathy: kimmelsteil-wilson syndrome (nodules), nodular sclerosis, nephrotic
syndrome, GBM thickening and mesangial expansion
Membranoproliferative: GBM tram track appearance, capillary membrane thickening (mixture)
• Type 1: Immune complex (SLE, RA, Hep B/C, IVDU, HIV, MM) often due to
cryogloulinemic disease
• Type 2: Complement activation (cleavage of C3 complexes)
• Type 3: Mixed picture
IgA; synpharyngitis (URTI same time as GN), children (young asian male) with coke coloured
urine, usually self-limiting
• Associated with celiac and CLD
Post Streptococcal GN: 2-4 weeks after infection, tea coloured urine, postivie anti-streptolysin
titre (ASOT), anti-strep DNA
RPGN:
• Type 1: Goodpasture (IgG anti GBM, with haemoptysis, +ve p-ANCA)
• Type 2: Immune complex (45%-SLE, IgA, Strep)
• Type 3: Wegener’s (PR3, C-ANCA, sinusitis/epistaxis), Microscopic polyangiitis (p-
ANCA/MPO, pauci immune, haemoptysis, neurological symptom), Churg strauss
(peripheral IgE and p-ANCA/MPO, allergic/asthma): Questions usually have
ESR/CRP as clue
, Types of casts:
• RBC: GN, ischemia, malignant HTN, vasculitis
• WBC: pyelonephritis, tubulointerstitial inflammation, transplant rejection
• Fatty: nephrotic
• Pigmented granular/muddy brown: ATN
• Hyaline: normal, tamm-horsfall protein form the basis of casts (produced in the thick
ascending limb of loop of henle)
• Waxy cast: advanced renal disease/CRF (long term)
• No casts: bladder cancer, kidney stones, acute cystitis
Types of urology procedure:
• Cystoplasty means a refashioning of bladder
o Ileocystoplasty: Using part of ileum to make bladder
o Colocystoplasty: Using part of large bowel or colon as blader
o Carcocystoplasty: Using the caecum as bladder
o Gastrocystoplasty: Using part of stomach as bladder
• “Clam” cystoplasty: bladder opened in 2 halves joined at bottom end (bladder neck).
The piece of bowel used is opened along one side so that it is like a rectangular pieve
that is still attached to its arteries and can be anastomosed onto the upper half of
bladder
• Substitution cystoplasty: damaged or diseased bladder is removed leaving behind
Bladder neck and contain sphincter muscle and control passage of urine. Completely
new bladder is then formed from a part of bowerl which has been prepared as before
and the cup like strucure is attached to form new bladder
• Ileal conduit: using a section of ileum and using it to drain urine into the stoma bag.
• Indiana pouch: surgically created urinary diversion using parts of the ileum and
cecum and the ileocaecal valve prevents bacteria from coming into the small intestine
again. One end will be the stoma bag
• Ileal neobladder: uses part of the ileum to form part of the new bladder especially with
augmentation or calm cystoplasty
• Nephrostomy: a needle that enters the renal pelvis percutaneously and removes the
fluid left in the renal pelvis. (If left in place, should be replaced every 6 months)
• Bacillus calmette Guerin (BCG) vaccine can help to reduce cancer growth and
recurrence
• CT KUB: CT of kidneys, ureters, bladder
• CT IVP: CT intravenous pyelogram
• RGP: retrograde pyelogram
• PCNL: percutaneous nephrolithotomy
• ESWL: extracorporeal shockwave lithotripsy
• Cystolitholapaxy: break up stone into small pieces and removing them
• Nephrectomy: removal of kidney
• Ureteronephrectomy: removal of kidney and ureter
• Stenting: using a JJ stent or double J stent or pigtail stent to allow the stent to be put
in place and prevent is from moving. Removed in 2-4 weeks.
o Always insert guidewire with black bended part first (less trauma due to less
rigidity)
