Dizziness | Vertigo
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Transcript Dizziness | Vertigo
CES: Genitourinary System
Tom Heaps
Consultant Acute Physician
Outline
Basic anatomy
Functional physiology
Symptoms
Examination
Nephrolithiasis
Obstruction
BREAK
Acute Kidney Injury (AKI)
Basic anatomy
Kidneys
Ureters
Bladder
Urethra
Functional anatomy
Outer cortex
Inner medulla
Nephron
Calyces
Renal Pelvis
Ureter
Nephron: the functional unit of the kidney
Glomerular filtration
Net filtration pressure at the glomerulus
= blood hydrostatic pressure – colloid oncotic pressure – capsular hydrostatic pressure
= 55mmHg – 30mmHg – 15mmHg
= 10mmHg
Large surface area and porous membrane
glomerular filtration rate (GFR) of 125 mL/min in normal health
fluid volume of ~180L/day enters glomerular capsule
GFR is regulated by the body depending on circulating volume and [Na+]
Filtration
Vasoconstriction
mediated by
angiotensin II
Vasodilatation
mediated by
prostaglandins
Glomerular
hydrostatic
pressure and
filtration
NSAIDs reduce
prostaglandin
synthesis
ACE-inhibitors reduce
production of
angiotensin II from
angiotensin I by ACE
Role of the kidneys
Production and excretion of urine
Removal of waste e.g. creatinine, urea, uric acid
Maintenance of homeostasis
Regulation of ECF volume and composition:
Control of ion balance and pH
Control blood volume / blood pressure
Control osmolality (excretion / resorption of Na+)
Production of hormones / vitamins
Renin and erythropoietin (EPO)
Vitamin D3
GU Symptoms 1
Too much urine
DM, DI, hypercalcaemia, postobstruction
Not enough / no urine
Dehydration , AKI, obstruction
Going too often
Infection, stones, detrusor
instability
Urgency
Having to go quickly!
Infection, detrusor instability
Dysuria
Painful / burning micturition
Infection
Nocturia
Going >2x per night
Outflow obstruction, infection,
stones, detrusor instability,
causes of polyuria
Hesitancy
Difficulty starting
Outflow obstruction
Terminal Dribbling
Weak stream
Outflow obstruction
Incontinence
Loss of control
Urge, stress, neurological
problems, dementia
Polyuria
Oliguria / Anuria
Frequency
GU Symptoms 2
Infection, stones, tumours,
trauma, glomerulonephritis,
coagulopathy / anticoagulants
Haematuria
Microscopic or Macroscopic
Renal Angle Pain
Renal: pyelonephritis,
Non-renal: cholecystitis,
abscess, stones (renal colic), hepatitis, pancreatitis, splenic
hydronephrosis, cysts,
infarction, gynaecological,
tumours, infarction
shingles, basal pneumonia, MSK
Pain along the urethra +/discharge
Infection / urethritis, STI, stone,
foreign body, tumour
Orchalgia
Testicular pain
Epididymo-orchitis, tumour,
trauma, torsion
Prostatitis
Perineal pain, dysuria,
obstructive symptoms,
tenderness on DRE
Urogenital infection or
instrumentation
Urethralgia
Additional GU History
Hypertension, diabetes
Family and congenital history
Drug History
Sexual and travel history
Systems review
GU Examination
Full systems examination focusing on abdomen
Inspection
GU Examination
Full systems examination focusing on abdomen
Inspection
Palpation
Percussion
Auscultation
Costovertebral angle between lower border of 12th rib and
lateral border of erector spinae
Pain / tenderness, Murphy’s punch +ve
Kidneys usually not palpable unless hydronephrosis,
tumour, cystic disease
Palpate specifically for bladder distension in the elderly
GU Examination
Full systems examination focusing on abdomen
Inspection
Palpation
Percussion
Auscultation
Perineum / Scrotum / Testicles
Vagina / Penis
Digital rectal examination (DRE)
Prostatic enlargement and / or tenderness
Constipation
Masses
Nephrolithiasis (urinary tract stones)
>80% are calcium stones, majority of these are calcium oxalate
Usually asymptomatic until they pass into ureter
Pain (may be excruciating) and nausea
Waxing and waning (renal / ureteric colic)
Abdomen / flank testicle / penis / labia (‘loin to groin’)
Haematuria, frequency, urgency, dysuria, strangury
Non-contrast CT urogram is Ix of choice (sensitivity 88%, specificity 100%)
USS if radiation an issue (sensitivity 57%)
Plain AXR no longer has a role (if CT available)
Conservative Rx with hydration, NSAIDs / opioids, tamsulosin / nifedipine
Urgent urological referral if AKI, sepsis, stone >10mm
Urinary retention / obstruction
Acute vs. chronic, unilateral vs bilateral
Kidney / ureter – stones, TCC, extrinsic tumour, retroperitoneal fibrosis
Bladder – stones, tumour, blood clots, neurological, drugs, constipation
Urethra – prostate cancer, BPH, stricture, stone
Pain (may be absent in chronic retention and dementia)
Oligo-anuria and AKI, haematuria, hypertension,
DRE is mandatory, bladder scan then USS abdomen / pelvis
IV fluids, urinary catheter, fluid balance, -blockers and antispasmodics
Treat precipitant (pain, infection, constipation, drugs etc.)
Be vigilant for post-obstructive diuresis and decompression haematuria
Other Rx e.g. ureteric stent, nephrostomy
Acute Kidney Injury
Tom Heaps
Consultant Acute Physician
Clinical Case
82-year-old male presenting with confusion and vomiting
PMHX: T2DM, hypertension, heart failure, BPH
DHX: Aspirin, metformin, ramipril, bendroflumethiazide, bisoprolol
RR 24, SpO2 94% (air), T 38.5C, BP 101/50mmHg, HR 119/min
Urine dip: leuc +++, nit +ve, blood +, protein ++
Na+ 144mmol/L
K+ 5.9mmol/L
urea 15.4mmol/L
creatinine 142μmol/L
With reference to this case…
GROUP 1: Is this AKI? What are the definitions of AKI?
GROUP 2: What are the risk factors for AKI? Which apply to this case?
GROUP 3: What are the common causes of AKI? Which apply to this case?
GROUP 4: What are the 6 most important steps in management of AKI?
GROUP 5: What are the complications of AKI and how are they treated?
AKI 1: definitions
calculated GFR is usually more accurate than serum creatinine in estimating
renal function but most definitions of AKI rely on creatinine measurement
KDIGO (Kidney Disease Improving Global Outcomes) definition of AKI:
creatinine rise by ≥ 26µmol/L within 48 hours or;
Stage of AKI
Serum Creatinine (SCr) criteria
Urine output criteria
creatinine rise ≥ 1.5-fold from the reference value* which is known or
presumed increase
to have occurred
within
one 48h
week
≥ 26 μmol/L
within
oror
<0.5 mL/kg/h for >6
1
increase ≥1.5x to 1.9x reference SCr
consecutive hrs
urine output < 0.5mL/kg/h for >6 consecutive hours
2
increaseis≥the
2xlowest
to 2.9x
reference
SCr
<0.5 mL/kg/h
for >12 hrs
*reference
serum creatinine
creatinine
value recorded
within
3m of the event
3
increase ≥3x reference SCr or
increase ≥354 μmol/L or
commenced on renal replacement
therapy (RRT) irrespective of stage
AKI 2; risk factors
CKD (especially if eGFR <60mL/minute)
heart failure
liver disease
diabetes
history of AKI
neurological / cognitive impairment or disability
hypovolaemia
use of drugs with nephrotoxic potential (NSAIDs, ACE-i, diuretics etc.)
use of iodinated contrast agents within the past week
symptoms / history of or conditions predisposing to urological obstruction
sepsis
deteriorating early warning scores (MEWS)
age ≥ 65
AKI 3: causes
Pre-Renal
Renal
Post-Renal (Obstructive)
(75%)
(20%)
(5%)
• hypotension
• hypovolaemia
• redistribution
• decreased cardiac
output
• renal artery stenosis
or thrombosis
• nephrotoxic
medications
• glomerulonephritis
• interstitial nephritis
• vasculitis
• ischaemia
• rhabdomyolysis
• urethral e.g. BPH
• bladder e.g. stones,
blood clots, tumours
• ureteric e.g. stones,
fibrosis, malignancy
• PUJ obstruction
• intra-tubular e.g.
crystals
• renal vein thrombosis
• abdominal
compartment
syndrome
AKI 4: management principles
1.
Treat underlying cause
IV fluids
restore
and
renal
perfusion
(may require(CVVH)
vasopressors)
Haemodialysis
(HD)
vsmaintain
Continuous
Veno-Venous
Haemofiltration
balanced crystalloids e.g. Hartmann’s + / - sodium bicarbonate
2.
Indications for Renal Replacement Therapy (RRT) in AKI
Prevention is better than cure…
55% of AKI is avoidable (including 30% of deaths due to AKI)
Myths
regarding
balanced
severe
refractory
metabolic acidosis
(pH <7.1, HCOcrystalloids…
<12 or BE < -10 )
4. Monitoring
3. Stop
nephrotoxics
and adjust
doses of other medications if necessary
persistent
hyperkalaemia
(K+ >7.0mmol/l)
3
-
refractory pulmonary oedema
strict
fluid
input
/ output
monitoring
‘
you
can’t
give
Hartmann’s
to
patients
with hyperkalaemia because
uraemic complications (urea usually
>45mmol/L)
5.
consider urinary catheter
it contains potassium’
monitor for and treat complications of AKI
‘you can’t give Hartmann’s to patients with lactic acidosis because it
USS urinary tract
contains lactate’
selected cases only
6.
Renal referral + / - RRT
AKI 5: complications
hyperkalaemia (K+ >5.5mmol/L)
other electrolyte abnormalities e.g. hyperphosphataemia, hyponatraemia
metabolic acidosis
IV fluids, IV bicarbonate (especially if hyperkalaemia), RRT
fluid overload / pulmonary oedema
diuretic / GTN (often ineffective), RRT
uraemia: encephalopathy, pericarditis, bleeding
mortality
overall mortality 26% (severity of illness and / or frailty of patient)
16% in Stage 1, 33% in Stage 2, 36% in Stage 3, 58% if RRT required
QUESTIONS?