Renal and Urological Conditions

Renal and urological conditions are frequently tested in the AKT. You need to know CKD staging and management, UTI treatment, prostate assessment, and when to investigate haematuria.

Chronic kidney disease is staged by eGFR and albuminuria. Stage 1: eGFR above 90 with evidence of kidney damage. Stage 2: eGFR 60-89. Stage 3a: 45-59. Stage 3b: 30-44. Stage 4: 15-29. Stage 5: below 15. Albuminuria categories: A1 (ACR below 3), A2 (3-30), A3 (above 30). Management includes blood pressure control (target below 140/90, or 130/80 if ACR above 70), ACE inhibitor or ARB if ACR above 30 or if diabetic with ACR above 3, SGLT2 inhibitor if CKD with ACR above 22.6 (or type 2 diabetes with any CKD), statin for cardiovascular risk reduction, and avoiding nephrotoxic drugs (NSAIDs, aminoglycosides). Refer to nephrology if eGFR below 30, ACR above 70, sustained eGFR decline of more than 25% in 12 months, or uncontrolled hypertension despite 4 agents.

UTI management: uncomplicated lower UTI in women is treated empirically without culture. First-line: nitrofurantoin 100mg modified release twice daily for 3 days (avoid if eGFR below 45). Second-line: trimethoprim 200mg twice daily for 3 days. Men with UTI, pregnant women, catheterised patients, and recurrent UTI always require urine culture. UTI in pregnancy requires treatment (nitrofurantoin or cefalexin, avoid trimethoprim in first trimester). Recurrent UTI (3 or more per year): self-start antibiotics, postcoital prophylaxis, or continuous low-dose prophylaxis.

Prostate assessment: PSA testing requires informed consent and discussion of benefits and limitations. Factors that raise PSA include BPH, prostatitis, UTI, recent ejaculation, and digital rectal examination. Refer via 2WW if PSA is above the age-specific reference range or if there is a hard, irregular prostate on DRE. BPH management: watchful waiting for mild symptoms, alpha-blockers (tamsulosin) for moderate symptoms, 5-alpha reductase inhibitors (finasteride) if prostate is enlarged.

Haematuria: visible haematuria in anyone over 45 requires 2WW urology referral (suspected bladder cancer). Non-visible haematuria with proteinuria suggests renal disease (refer nephrology). Non-visible haematuria without proteinuria in over-60s requires 2WW referral for urology assessment.

Renal stones present with acute colicky loin pain radiating to the groin. Non-contrast CT KUB is the gold standard investigation. Management of acute renal colic includes NSAIDs (diclofenac) as first-line analgesia. Stones less than 5mm usually pass spontaneously. Medical expulsive therapy with tamsulosin may help stones 5-10mm. Refer urgently if signs of infection with obstruction (pyonephrosis), bilateral obstruction, or single functioning kidney.