Nephrological system Flashcards
What is the definition of CKD?
What is ESRD?
What is the classification of CKD by GFR and albuminuria?
Compare the features of acute kidney injury vs chronic kidney disease?
- Clinical
- Biochemical
- Radiological
What are common causes of CKD?
- DM nephropathy (45%)
- Hypertension/ Renal artery stenosis (RAS) (27%)
- Glomerulonephritis (10%)
- Interstitial disease (5%)
- Polycystic kidney disease (2%)
What are prerenal, renal and post renal causes of chronic kidney disease?
What are general SS for CKD
What SS related to uremiea?
What history taking done for CKD?
- Medical
- Drug
- Family
What Ix done for chronic kidney disease and why?
- CBC with DC: normochromic normocytic anemia: decreased EPO secretion (decreased renal function + anemia of chronic disease)
- Lipid profile: hypertriglyceridemia due to increased synthessi of lipoproteins in liver due to hypoalbuminemia
- Electrolyte profile and serum Ca2+ and PO4- level:
HypoNa: inability to excrete free water in patients with advanced renal failure leads to water retention and development of hypoNa
HyperK: due to metabolic acidosis
Develops in patients who is oliguric or has additional problems e.g. increased tissue breakdown, reduced aldosterone secretion or responsiveness. Impaired cellular uptake of K+ due to diminished Na+K+ ATPase pump also contributes to hyperK
HypoCa: hyperP leading to hypoCa. Decreased synthesis of calcitriol in kidneys –> muscle cramps, tetany
Hyperphosphatemia: decreased renal excretion of PO4 - ABG: metabolic acidosis and increased anion gap. Excretion of acid and regeneration of HCO3- is impaired in low GFR
Increased H+ production in lactic acid or ketoacids in sepsis and trauma
Decreased HCO3- due to loss from diarrhea or renal tubular acidosis - Serum PTH level: increased PTH level due to secondary hyperparathyroidism (decreased Ca due to decreased calcitriol production from kidneys)
- RFT: increased urea/BUN and creatinine level, decreased GFR
- Urinanalysis: microalbuminuria, proteinuria >3.5g/day
- Renal biopsy: indicated if creatinine is markedly elevated or worsened over course of days
- Autoimmune markers: ANA/anti-dsDNA/C3/4/ANCA/anti-GBM –> membranous nephropathy (adults) (nephrotic pattern)
- LFT: hepatorenal syndrome, increased ALP level
- HBV and HCV serology: urgent HBsAg if haemodialysis is anticipated
- Serum/urine protein electrophoresis with immunofixation (suspicious of light chain nephropathy)
- Serum free light chain assays
What imaging done for kidney disease and what is expected results?
KUB
USG renal
* Evaluate for polycystic kidney disease and obstruction
* Radiological features of CKD
o Small kidneys due to dysplasia, scarring or shrunken in CKD
o Large kidneys in polycystic kidney disease or amyloidosis (infiltration)
o ↑ Renal parenchymal echogenicity
What is the general treatment for chronic kidney disease?
What are the management of common complications of chronic kidne ydisease?
In chronic kidney disease what mineral is most concerned that will affect bones
What is the management?
What are the cardiovascular complications of chronic kidney disease
How are they managed?
Chronic renal failure
* Presence of renal disease for at least 6 years
* Presence of uremic complexion
* Biochemical parameters of hypocalcemia and phosphate retention
* USG evidence of bilateral small and coarsened kidneys
* Absence of notable causes of acute renal failure
o UTI
o Urinary tract obstruction
o Nephrotoxic drug consumption
Another possibility is acute-on-chronic renal failure secondary to accelerated hypertension
How would you assess renal function in this patient?
What accounts for cafe au lait appearance in chronic kidney diseae?
Coexistence of anemia and retention of β-melanocyte-stimulating hormone
Pigment deposition (urochromogens)
What are the indications for emergency dialysis?
- Respi: Acute pulmonary edema
- CVS: Uremic pericarditis or cardiac tamponade
- CNS: Uremic encephalopathy
- Endo: Severe metabolic acidosis
- Endo: Hyperkalemia
How to classify the causes of acute kidney injury?
Acute kidney injury is classified into prereneal, renal and post renal causes, what are they?
What are the lab Ix for acute kidney injury?
How to interpret urinanalysis results of acute kidney injury?
- Proteinuria + haematuria + dysmorphic RBC + RBC casts
- Heavy proteinuria + NO haematuria
- Granular of epithelial cell casts + renal tubular epithelial cells
- Pyuria
How to interpret plasma urea to creatinine ratio/plasma BUN to creatinine ratio? (increased and decreased ratio causes)
GFR
Urine albumin to creatinine ratio (ACR)/urine albumin level
What are SS of acute kidney injury?
What biochemical tests and results in acute kidney injury?
- CBC with DC
- Electrolyte profile and serum Ca2+ and Po43-
HypoNa (inability to excrete free water in patients with advanced renal failure leads to water retention and hypoNa)
HyperK: occurs due to presence of metabolic acidosis
HypoCa: decreased synthesis of calcitriol (vit D) in kidneys –> muscle cramps, tetany, perioral paresthesia and carpopedal spasm
HyperP: decreased renal excretion of PO43- - ABG: metabolic acidosis adn increased anion gap. Excretion of acid and regeneration of HCO3- is impaired in low GFR. Increased H+ in lactic acid or ketoacids in sepsis and trauma
- RFT: increasewd urea/BUN and creatinine level
- Urinanalysis: albuminuria, 24 hour urine and MSU for microscopy and culture with sensitivity testing
- Renal biopsy
- Autoimmune markers: ANA/anti-dsDNA/C3/C4/ANCA/anti GBM
- LFT: hepatorenal syndrome
- HBV and HCV serology: urgent HBsAg if haemodialysis is anticipated
- Serum/urine protein electrophoresis with immunofixation
- Serum free light chain assays
What is general approach to manage acute kidney injury?
What are the indication of renal replacement therapy in acute kidney injury?
- A = Acidosis: Refractory metabolic acidosis with HCO3- < 10 mmol/L
- E = Electrolyte disturbance: Uncontrolled hyperkalemia > 6 mmol/L
- I = Intoxication: Alcohol/ NSAIDs/ acetaminophen/ metformin
- O = Oedema: Refractory fluid overload/ Uncontrolled pulmonary edema
o Uncontrolled pulmonary edema related to renovascular hypertension (chronic hypertension and Na+ and H2O retention due to RAAS activation) - U = Uremia: Uremic pericarditis/ Uremic encephalopathy/ Intractable uremic symptoms
How to manage complications of acute kidney injury?
Volume depletion
Volume overload
Electrolye and acid base disturbances
How to classify glomerulonephritis?
What are the causes of glomerulonephritis (proliferative (nephritic) and non proliferative (nephrotic))?
Primary and secondary causes
What is the structures in a glomerulus?
What is general features of IgA nephropathy?
Clinical course?
Dx?
Treatment?
Etiology?
Morphology?
Primary nephritic syndrome (disease process isolated to kidneys)
What is general features of membranoproliferative glomerulonephritis (MPGN)?
Clinical course?
Dx?
Treatment?
Etiology?
Morphology?
Secondary nephritic syndrome (renal disease as a component of systemic disorder)
What is general features of post streptococcal glomerulonephritis (PSGN)?
Clinical course?
Dx?
Treatment?
Etiology?
Morphology?
Secondary nephritic syndrome
What is general features of lupus nephritis?
Clinical course?
Dx?
Treatment?
Etiology?
Morphology?
What is general features of minimal change disease
Clinical course?
Dx?
Treatment?
Etiology?
Morphology?
Primary nephrotic syndrome
What is general features of focal segmental glomerulosclerosis (FSGN)?
Clinical course?
Dx?
Treatment?
Etiology?
Morphology?
Primary nephrotic syndrome (non proliferative)
What is general features of membranous nephropathy?
Clinical course?
Dx?
Treatment?
Etiology?
Morphology?
Primary nephrotic syndrome (non proliferative)
What is the clinical manifestation of nephritic syndrome?
- present in nephritic but uncommon in nephrotic syndrome