Case 12: Abdominal distention and weight gain Flashcards
(241 cards)
1
Q
what does ACTH stand for
A
adrenocorticotropic hormone
2
Q
What does PRL stand for?
A
Prolactin
3
Q
what does ADH stand for
A
antidiuretic hormone
4
Q
hormones produced by the posterior pituitary
A
oxytocin
ADH
5
Q
hormones produced by the anterior pituitary
A
TSH
GH
ACTH
FSH/LH
PRL
endorphines
6
Q
what is the target organ of oxytocin
A
uterine muscles of mammary glands
7
Q
what is the target organ of ADH
A
kidney tubules
8
Q
what is the target organ of TSH
A
thyroid
9
Q
what is the target organ of GH
A
entire body
10
Q
what is the target organ of ACTH
A
adrenal cortex
11
Q
what is the target organ of FSH/LH
A
testes and ovaries
12
Q
what is the target organ of prolactin
A
mammary glands
13
Q
what is the target organ of endorphins
A
pain receptors in the brain
14
Q
what structure which is immediately anterior to the pituitary gland produces the characteristic symptoms in those who have a large pituitary tumour
A
the optic chasm
15
Q
why does the optic chiasm show that there is a large pituitary tumour
A
it is compressed with large pituitary tumours
this is associated with bitemporal hemianopia (associated with enlarging pituitary lesion)
16
Q
what is the other name for the adrenal glands
A
suprarenal glands
17
Q
what artery supplies the adrenal glands
A
suprarenal
18
Q
what are the 3 suprarenal arteries and where do they arise from
A
superior- inferior phrenic
middle- AA
inferior- renal
19
Q
what vein drains the suprarenal glands
A
left and right suprarenal veins
20
Q
where does the left suprarenal vein drain into?
A
left renal vein
21
Q
where does the right suprarenal vein drain into
A
IVC
22
Q
3 most commonest causes of end stage renal disease in western countries
A
diabetes
hypertension
glomerular disease
23
Q
the glomerulus structure from blood side to urine side consists of
A
endothelial cells
glomerular basement membrane
epithelial cells (podocytes)
24
Q
what is the glomerulus
A
tightly packed loop of capillaries
25
what supplies the glomerulus
afferent arteriole
26
what drains the glomerulus
efferent arterioles
27
the bowmanns capsule is an extension of what
the Proximal tubule
28
what surrounds the glomerulus
bowmanns capsule
29
what cells play a role in regulating eGFR
mesangial cells (in the centre of the glomerulus)
30
role of the mesangial cells
have contractile properties similar to vascular smooth muscle
31
what type of kidney disease is polycystic kidney disease
autosomal dominat
32
what genes are effected in the polycystic kidney disease
autosomal dominant
33
what genes are affected in polycystic kidney disease
PDK1 (mostly)
PDK2
34
what happens in polycystic kidney disease
small cysts lined by tubular epithelium develop from infancy or childhood and develop and enlarge slowly or irregularly
the surrounding normal kidney tissue is compressed and gradually damaged
35
is the PDK1 or PDK2 mutation worse
end stage kidney disease occurs in 50% of those with PDK1 and has an average onset of 52 years
minority of those with PDK2 get end stage kidney disease and average onset is 69 years
36
what % of patients on renal replacement therapy have polycystic kidney disease
5-10%
37
what can be the result of podocyte injury
focal segmental glomerulosclerosis (FSGS)
minimal change disease
membranous nephropathy
(all categorised as nephrotic syndrome)
38
pathogenesis of FSGS and minimal change disease
remains unknown
circulating factors may increase glomerular permeability and cause injury to podocytes
39
pathogenesis of membranous nephropathy
antibodies attack podocyte surface antigen (phospholipase A2 receptor 1) with complement dependant podocyte injury
40
what type of syndrome is IgA nephropathy categorised as
nephritic syndrome
41
what cells are mainly targeted with IgA nephropathy rather than podocytes
mesangial cells
42
what decreases when albumin is lost in the urine?
plasma oncotic pressure (causes swelling)
43
what would you want to know about a patients abdominal distension
how long
is it intermittent or constant
is it related to eating
is it lessened by belching or passing gas
associated with vomiting, loss of appetite, weight loss/gain, change in bowels, SOB, leg swelling
44
what should you ask about for CCF
how many pillows do they sleep on
do you get breathless if you slip off pillows- orthopnea
any history of cardiac issues/angina
do they wake up gasping for air at night
45
what should you ask about for chronic liver disease
how much alcohol
any skin bruising
any skin discolouration
any skin itching
46
what should you ask about for nephrotic syndrome
any ankle/leg swelling
47
what should you ask about for hypothyroidism
skin dryness
hair loss
sensitivity to cold
tiredness
constipation
low mood
48
what should you ask about for metabolic syndrome
excessive thirst
passing lots of urine
49
what should you ask about for cushings syndrome
any skin bruising
changes at the back of the neck
redness in the face
markings on the skin
50
what is cushings syndrome
chronic glucorticoid (cortisol) excess, with loss of circadian rhythm of release
51
signs and symptoms of cushings syndrome
BG SOFAS
B- increased BP
G- increased glucose
S- skin bruising, purple abdominal striae (stretch marks), acne, hyperpigmentation (due to increased ACTH), poor wound healing
O- osteoporosis, achilles tendon rupture, proximal myopathy
F- fat face (moon face), central obesity, buffalo hump, wasted legs
A- affect, altered mood, lethargy, psychosis
S-sex, irregular menstruation, hirsutism (excess hair around mouth and chin), erectile dysfunction, gynaecomastia
52
how to diagnose cushings syndrome
dexamethasone suppression test
24hr urine cortisol
53
causes of cushings
iatrogenic (excess steroid use)
basophilic pituitary adenoma (cushings disease)- usually onset of 25-50
ectopic ACTH syndrome- small cell lung cancer, pancreatic or thyme carcinoid tumour
adrenal adenoma
adrenal adenocarcinoma
54
what is the criteria for metabolic syndrome
high glucose
abdomail obesity
high BP
low levels of HDL cholesterol
hypertriglyceridaemia
55
what is normal BMI
18.5-24.9
56
what is overweight BMI
25-29.9
57
what is obesity I BMI
30-34.9
58
what is obesity II BMI
35-39.9
59
what is obesity III BMI
40+
60
what BMI is considered a risk for black African and Carribean and Asian people
23 is increased risk
27.5 is high risk
61
what is orlistat
pancreatic lipase inhibitor
used for obesity
reduces fat absorption
62
what is liraglutide (saxenda)
GLP-1 analogue (agonist)
used for weight management and T2D
63
when would you offer surgery for obesity
if BMI over 40
or
if BMI 35-40 with other significant weight related disease
if all non-surgical options have been attempted
has been or is willing to receive tier 3 weight management services
fit for anaesthesia and surgery
person commits to need for long-term follow-up
64
how does the dexamethasone suppression test work
dexamethasone is an exogenous steroid which supresses the pituitary through negative feedback
it binds to glucorticoid receptors in the pituitary inhibiting ACTH release by the pituitary
65
what are the results of the dexamethasone test normally and what is pathological
normal= reduction in cortisol with low-dose
cushings= no reduction in cortisol output with low dose, but reduction with high-dose
adrenal tumour or ectopic ACTH= no reduction in steroid production after low or high dose
66
what is cyclical cushings
very rare
characterised by alternating excess or normal endogenous cortisol secretion
has variable clinical features
67
what do to if you suspect cyclical cushings
repeat follow up testing is required
urinary cortisol or late-night salivary cortisol are preferred for screening
68
when do you do dexamethasone test
overnight
69
what are the 2 classifications of cushings syndrome
ACTH dependent
ACTH independent
70
is ACTH dependant or independent more common
dependent
71
ACTH dependant causes of cushings syndrome
pituitary adenoma (cushings disease)= 65-70%
ectopic ACTH= 5-10% (bronchial carcinoid is most common)
unknown source of ACTH= less than 1%
72
ACTH independant causes of cushings syndrome
adrenal adenoma= 10=18%
adrenal carcinoma= 6-8%
adrenal hyperplasia
73
what would you do next if you thought someone has cushings and has a raised cortisol despite dexamethasone suppression test
measure ACTH
74
what are the consequences of removing the anterior pituitary and how can we solve this
hormones produced by the anterior pituitary need to be replaced:
TSH- give thyroxine
GH- some might get GH therapy
ACTH- hydrocortisone therapy
FSH/LH- testosterone or oestrogen/progesterone therapy
some might need desmopressin (synthetic ADH) where ADH secretion is affected because of damage to the posterior pituitary or hypothalamus causing diabetes insipidus
75
what hormones do not need to be replaced when removing the anterior pituitary
prolactin
ADH, endorphins, oxytocin don't need to be replaced as they are stored by the pituitary not produced
76
what size is considered a pituitary microadenoma
<1cm
77
what size is considered pituitary macroadenoma?
>1cm
78
when would you call it cushings disease
when it results from a pituitary adenoma causing excess ACTH release
79
what gland releases cortisol
adrenal gland
80
what is the negative feedback loop for cortisol production
the hypothalamus releases CRH
this acts on the pituitary to release ACTH (ACTH has -ve feedback on hypothalamus)
this acts on the adrenal gland to produce cortisol (cortisol has -ve feedback on the pituitary)
81
in which area of the adrenal cortex is cortisol produced
zona fasiculata
82
when do cortisol levels peak
in the morning (when we need to get up)
83
when do cortisol levels drop
at night (when we need to sleep)
84
what processes to cortisol stimulate
gluconeogenesis
lipolysis
proteolysis
85
what affects does increased cortisol have on the body
vasoconstriction (increases sensitivity to A and NA)
decreased immune response (low T-lymphocytes and prostaglandins)
decreases mood and memory
86
the effects of cushings syndrome on the body
cortisol levels are constantly higher than normal leading to:
severe muscle bone and skin breakdown
elevated glucose levels meaning high insulin levels, this targets adipocytes in the centre of the body and activates lipoprotein lipase which helps adipocytes accumulate- results in central obesity
hypertension due to amplified sensitivity to N and NA
87
why does cushings cause sexual dysfunction
excess cortisol inhibits GnRH via negative feedback to the hypothalamus
this affects ovarian and testicular function, as this decreases FSH and LH from pituitary
88
what is the most common exogenous cause of cushings syndrome
steroid use
89
what is the most common endogenous cause of cushings syndrome
benign pituitary adenoma (known as Cushings disease)
90
for what type of cushings can metyrapone be used
for ACTH independant cushings
91
how does metyrapone work
t inhibits hydroxylation in the adrenal cortex which decreases cortisol release (and to a lesser extent aldosterone)
this increases ACTH release from the pituitary, increasing the release of cortisol precursors (whilst inhibiting the enzymes requires to turn these into cortisol)
92
what are the consequences of having a bilateral adrenalectomy
body no longer produces glucorticoids (cortisol) or mineralocorticoids (aldosterone)
(therefore you need replacement therapy for them both)
93
when would someone who has has a bilateral adrenalectomy need to double their dose of glucorticoids
medical illness
physical/mental stress
trauma (including surgical procedure)
94
what is taken to replace cortisol
hydrocortisone
95
what is taken to replace aldosterone
fludrocortisone
96
what is primary adrenal insufficiency caused by
due to adrenocortical disease (doesn't respond to ACTH)
97
what is secondary adrenal insufficiency
due to pituitary dysfunction (lack of ACTH, therefore adrenal glands not being stimulated)
98
what is tertiary adrenal insufficiency caused by
due to hypothalamus dysfunction (lack of CRH)
99
what is the survival rate of cushings syndrome if left untreated
50 percent after five years
100
what percent of cushings is cushings disease
70 percent
101
are more men or women affected by cushings disease
women 3:1
102
most common age of onset of cushings disease
25-45
103
which electrolyte disturbance may be seen in cushings
hypokalaemia
104
are symptoms of cushings more easy to see in men or women typically
women (harder to detect cushings in men)
105
in what other conditions would you see raised urinary cortisol
obesity
PCOS
depression
106
what is the first screening tool used for cushings
salivary cortisol test
107
what levels of ACTH would you see in ACTH dependant cushings
normal or raised
108
what does low ACTH with cushings suggest
a primary adrenal cause
109
which 2 clinical features suggest adrenal insufficiency
hypotension
hyponatraemia (low Na+)
if you see this treat for adrenal crisis straight away rather than awaiting bloods to see if serum cortisol and ACTH is low
110
how to treat an adrenal crisis
high dose hydrocortisone
intravenous saline
111
what does euvolemic mean
having the normal volume of blood in the body
112
what is Addisons disease
inadequate secretion of the adrenal hormones (such as aldosterone and cortisol)
113
what type of adrenal insufficiency is Addisons disease
primary adrenal insufficiency
114
what are the 3 areas of the adrenal cortex
zona glomerulosa
zona fasiculata
zona reticularis
115
what does the zona glomerulosa produce
mineralocorticoids (aldosterone)
116
what does the zona fasiculata produce
glucocorticoids (cortisol)
117
what does the zona reticularis produce
sex hormones
androgen precursors (DHEA)
118
what is the most common cause of primary adrenal insufficiency in developed countries
autoimmune
119
what is the most common cause of primary adrenal insufficiency in developing countries
tuberculosis (infection spreads from the lungs to the adrenal glands, destroying the adrenal cortex)
120
symptoms of adrenal insufficiency usually present when what % of the adrenal cortex has even destroyed
90%
121
what is the result of the zona glomerulosa being destroyed
hyperkalaemia
hyponatraemia
hypovolaemia
acidosis
122
symptoms of zona glomerulosa being destroyed
cravings for salty food
nausea
vomiting
fatigue
dizziness
123
what is the result of the zona fasiculata being destroyed
low blood glucose in times of stress
124
symptoms of zona fasiculata being destroyed
weakness
tiredness
disorientation
hyperpigmentation especially at joints (due to negative feedback increasing the work of the pituitary)
125
what is the result of the zona reticularis being destroyed
men are not affected as the testes are a big source of testosterone
women can experience loss of pubic and armpit hair and decreased sex drive
126
what can trigger an addisonian crisis
injury
surgery
infection
there is a sudden need for aldosterone and cortisol
127
presentation of addisonian crisis
pain in back, abdomen and legs
vomiting and diarrhoea leading to dehydration
low BP leading to loss of consciousness
128
is addisonian crisis dangerous
yes can be fatal if left untreated
129
which syndrome can trigger an addisonian crisis
waterhouse friderichsen syndrome
130
how does waterhouse friderichsen syndrome cause an addisonian crisis
sudden increase in BP causes blood vessels in the adenal cortex to rupture
this fills the adrenal glands with blood causing tissue ischemia and adrenal gland failure
131
how to diagnose Addisons
ACTH stimulation test
Synacthen test (same thing as above)
132
how does the ACTH stimulation test work
synthetic ACTH is given
the cortisol and aldosterone produced is then measured
133
treatment for Addisons disease
lifetime replacement of cortisol, aldosterone and androgens (hydrocortisone, fludrocortisone)
stopping can lead to addisonian crisis
134
when would you do a cortisol 9am
to look for adrenal causes of symptoms
135
why do you do haematinics for tiredness
to rule out iron, B12 and folate deficiency
136
what the tests for non-specific symptoms of tiredness
bone profile- to rule out hypercalcaemia
haematinics
LFTs- to rule out chronic liver dysfunction
137
typical presentation of Addisons disease
hyperpigmentation (bronze)
hypoglycaemia
changes in distribution of body hair
postural hypotension
GI disturbances
weight loss
weakness
extreme fatigue
138
what pathology is related to the zona glomerulosa
conns syndrome
139
what pathology is related to the zona fasiculata
cushings syndrome
140
what pathology is related to the zone reticularis
congenital adrenal hyperplasia
141
what does the adrenal medulla produce
adrenaline and noradrenaline
142
what pathology is related to the medulla of the adrenal gland
phaeochromocytoma
143
mechanism of action of metyraprone
it is a glucorticoid synthesis inhibitor
inhibits 11-beta-hydroxylase
this inhibits the formation of cortisol from deoxycortisol
also inhibits the formation of corticosterone from deoxycorticosterone
144
treatment for addisonian crisis
IV hydrocortisone
IV 0.9% sodium chloride
145
when is glucorticoid and mineralocorticoid therapy taken to mimic normal circadian rhythm
hydrocortisone 10mg on waking, 12pm and 4pm
fludrocortisone 100 microgram per day
146
which gastrointestinal diseases can cause cough
gastro-oesophageal reflux
laryngo-pharyngeal reflux
147
what would suggest viral illness with a cough
fever
sore throat
coryzal symptoms- these are the hallmark of upper respiratory tract symptoms including nasal stuffiness, runny nose, sneezing, sore throat
148
what would suggest TB with a cough
recent foreign in travel
TB contacts
night sweats
149
what would suggest asthma with a cough
history of eczema or hay fever
cough keeps them awake at night
associated breathlessness
wheeze
triggers such as perfumes
150
what would suggest pneumonia with a cough
fever
coloured sputum
breathlessness
151
what would suggest COPD with a cough
cough worse first thing in the morning
productive cough
smoker
152
what would suggest bronchiectasis with a cough
history of copious sputum (large amounts of clear sputum)
153
what would suggest lung cancer with a cough
haemoptysis
weight loss
smoker
154
what would suggest post nasal drip with a cough
can feel a tickle at the back of their throat before they cough
nasal stuffiness/blocked nose
runny nose
155
what would suggest gastro oesophageal reflux/laryngo pharyngeal reflux with a cough
cough worse after eating
heart burn
156
what is a specific side effect of ACE inhibitors
dry cough
157
why do ACE inhibitors cause dry cough
they increase bradykinin
usually occurs 1 week to 6 months after starting treatment
build-up of bradykinin irritates the airways causing inflammation and coughing
158
which drugs can be given instead of an ACE inhibitor if the patient has experienced the dry cough side effect
angiotensin receptor blockers:
candesartan
irbesartan
losartan
valsartan
159
hypervolemic causes of hyponatraemia
heart failure
cirrhosis
chronic kidney disease
nephrotic syndrome
160
euvolemic causes of hyponatraemia
glucorticoid deficiency
hypothyroidism
SIADH (syndrome of inappropriate ADH secretion)- could be due to SCLC
mass lesions
inflammatory disease
degenerative demyelinating disorders
carcinoma of lung, prostate, larynx or pancreas
leukaemia
atypical pneumonia
COPD
AIDS related complex
drug induced
161
hypovolemic causes of hyponatraemia
diuretic therapy
mineralocorticoid deficiency
third space loses
burns
pancreatitis
bowel obstruction
muscle trauma
salt wasting neuropathy
vomting and diarrhoea
cerebral salt wasting syndrome
sweat losses
162
what tests to do if someone is euvolemic but has hyponatraemia
plasma osmolarity
cortisol
thyroid function
urinary sodium and osmolarity
163
when should a cough be investigated via chest X-Ray
if over 4 weeks
164
what are sodium levels like if plasma osmolarity is increased
Na levels are increased
165
increased sodium makes you feel what
triggers hypothalamus
makes you feel thirsty
166
increased sodium prompts the release of what
ADH (vasopressin)
167
what does ADH do?
acts on the collecting ducts of the kidneys to increase the number of aquaporin channels
this allows for water to be absorbed into the blood (increases BP)
168
is diabetes insipidus common
rare
169
pathophysiology of diabetes insipidus
either too little ADH is produced by the pituitary (cranial diabetes insipidus)
or
the kidney becomes insensitive to ADH and so does not insert aquaporins to reabsorb water from collecting ducts (nephrogenic diabetes insipidus)
170
what are the clinical manifestations of diabetes insipidus
large amounts of dilute urine are produced- polyuria
excessive thirst- polydipsia
nocturia
171
what happens if those with diabetes insipidus are not able to drink water
hypernatraemia
dehydration
172
diagnosis of diabetes insipidus
water restriction test urinalysis
173
what is the normal amount of urine to urinate per day
1-3 litres
174
how much urine do those with diabetes insipidus urinate
19L
175
risk factors for diabetes insipidus
FH
diuretics
low calcium and hyperkalaemia
serious head/brain injury
176
what is SIADH
syndrome of inappropriate antidiuretic hormone
high amounts of ADH are inappropriatly released
this causes the reabsorption of water from the collecting ducts
means high sodium in urine but hyponatraemia in blood
177
diagnosis of SIADH
comparison of urinary and serum sodium
serum osmolarity is low whereas urinary osmolarity is high
178
causes of SIADH
lung diseases- cancer, pneumonia
brain lesions- tumour, head injury and bleed, stroke
drugs- carbamazepine, SSRIs
179
when to suspect psudeohyponatraemia
this is a laboratory error if there are high levels of glucose, lipids, protein or urea
serum osmolarity will be norma
180
symptoms of true hyponatremia
headache
nausea
dizziness
severe can result in coma
181
what status of the patient should you check with hypoatraemia
hydration status
182
signs of dehydrated/hypovolaemic hyponatraemia
cool peripheries
prolonged capillary refil
tachycardia
weak thread pulse
postural hypotension
confusion
dry mucus membranes
reduced skin turgor
183
signs of fluid overloaded/hypervolaemic hyponatraemia
tachycardia
bounding pulse
raised JVP
pulmonary oedema/pleural effusions
ascites
peripheral oedema
184
most common causes of hyperatraemia
only associated with dehydration where the person has been unable to access water:
elderly with dementia
medically induced comas
hot weather (desert)
185
treatment of SIADH
fluid restriction (1.5 litres per day)
hypertonic saline
demeclocycline
186
common causes for abdominal distention
fetus
fluid- ascites
feces- sub-acute intestinal obstruction/constipation
flatus
fat- obesity
distended bladder
abdominal mass- neoplasm, hernia, aortic anyeurysm
organomegaly- kidneys, liver, spleen
187
what is the major complication of hernias
intestinal obstruction/strangulation
188
what 2 conditions can cause peripheral oedema and ascites
nephrotic syndrome
congestive heart failure
189
what conditions cause hepatomegaly
hepatic steatosis
alcoholic liver disease
viral hepatitis
primary biliary cirrhosis
right heart failure
secondary metastatic cancer
primary hepatocellular cancer
190
what conditions cause splenomegaly
glandular fever
portal hypertension
haemolytic anaemia
rheumatoid arthritis (Feltys syndrome)
systemic lupus erythematosus
malaria, kala-azar (leishmaniasis)
brucellosis, tuberculosis, salmonellosis
bacterial endocarditis
191
what causes both hepatomegaly and splenomegaly
leukaemia
lymphoma
myelofibrosis
polycythaemia
192
how do the kidneys descend on inspiration
vertically down
193
what do the kidneys feel like on palpation
smooth and regular in shape (enlarged polycystic kidneys have an irregular shape)
194
what on palpation would suggest you are palpating the spleen
palpable notch on the medial surface
195
what does shifting dullness suggest on examination
ascites
196
causes of ascites
hypoalbuminaemia- nephrotic syndrome
hepatic cirrhosis with portal hypertension
intra-abdominal malignancy with peritoneal spread
constructive pericarditis with right heart failure
197
what on urine dipstick suggests nephrotic syndrome
proteinuria
198
what be seen on urine dip with nephritic syndrome
++ blood
++ protein
199
what be seen on urine dip with UTIs and renal stones
++ blood
++ nitrates
++ leukocytes
200
what be seen on urine dip with nephrotic syndrome
+++ protein
201
what be seen on urine dip with menstrual cycle, anti-platelet therapy and malignancy of the kidney, ureter or bladder
+++ blood
202
what are mild nephritic syndromes usually associated with
inflammatory lesions of the glomeruli on light microscopy (focal glomerulonephritis)
203
what is seen with mild nephritic syndrome in urine
mild proteinuria
204
symptoms of advanced nephritic syndrome
heavy proteinuria
oedema
hypertension
kidney function impairment
205
triad of findings with nephrotic syndrome
heavy proteinuria
hypoalbuminaemia
peripheral oedema
206
what other findings may be seen with nephrotic syndrome
hyperlipidaemia
thrombotic disease
207
difference between nephrotic and nephritic syndrome on urine dip
nephritic syndrome= blood and protein in urine
nephrotic= protein in urine
208
what may back/flank pain suggest
renal cancer
renal stone
acute pyelonephritis
APKD
nephrotic syndrome
nephritic syndrome
209
what may lower limb oedema suggest
nephritic syndrome
nephrotic syndrome
APKD
210
prenreal causes of AKIs
renal stone
acute pyleonephritis
APKD
nephrotic syndrome
211
renal causes of AKIs
nephritic syndrome
nephrotic syndrome
212
postrenal causes of AKIS
renal stones
213
what is the consequence of dehydration on osmolality
it increases osmolality
214
where is ADH produced
hypothalamus (the supra optic nucleus)
215
the issues with diabetes insipidus is in either of which two places
hypothalamus
kidneys
216
treatment of diabetes insipidus
for central and gestational- desmopressin (ADH analogue which acts like ADH)
for nephrogenic- thiazide diuretics to increase the urinary excretion of sodium
217
what is the cause of gestational diabetes insipidus
release of vasopressinase by the placenta
218
what is nephrotic syndrome
there is an issue with podocytes (or basement membrane)of the glomerulus meaning they are not able to keep the protein in
as a result, there is a loss of protein
219
what does protein in the urine look like
frothy
220
what protein is lost the most with nephrotic syndrome
albumin
221
why can you see increased lipids with nephrotic syndrome
the liver compensates with lipids for the loss of albumin
there is increased lipids in urine and blood
222
why can there be thrombosis with nephrotic syndrome
there is loss of antithrombin-III (AT-III) in the urine
this leads to poor anticoagulation
can see thrombosis particularly in the renal veins (can also have DVT and PE)
223
what is nephritic syndrome
there is glomerular inflammation due to complexing forming
WBCs are recruited
this allowed for WBCs, proteins and RBCs to seep through basement membrane and podocytes (they cant usually do this)
224
how is urination affected by nephritic syndrome
oliguria- decreased urination (due to the damaged glomerulus not being able to filter properly)
225
how is BP affected by nephritic syndrome
hypertension
226
3 most common causes of nephrotic syndrome
focal segmental glomerulosclerosis (FSGS)
minimal change disease
membranous nephropathy
227
causes of nephritic syndrome
membranoproliferazive glomerulonephritis (MPGN)
ANCA vasculitis
good pastures disease
crescentic glomerulonephritis
oliguria
228
treatment of crescentic glomerulonephritis
aggressive steroids
229
what is the gold standard for diagnosing nephritic and nephrotic syndrome
renal biopsy (under ultrasound)
230
what type of disease is APKD
autosomal dominant
231
aside from renal, what other abnormalities is APKD associated with
hepatic and cardiovascular
232
pathophysiology of APKD
there is mutation of polycystin (this is responsible for sensing flow in the tubule
disruption results in decreased cytoplasmic calcium which in the principal cells of the collecting duct causes disorientated cell division leading to cyst formation
233
at what age do the presenting symptoms of APKD typically manifest
from the second decade onwards
234
what are some of the presenting symptoms of APKD
loin pain and/or haematuria from haemorrhage into a cyst, cyst infection or urinary tract stone formation
loin/abdominal discomfort as size of kidneys increase
subarachnoid haemorrhage associated with berry aneurysm rupture
complications of hypertension
complications of associated liver cysts (occurs in 50%)
symptoms of uraemia and/or anaemia associated with CKD
235
potential strategy for management of APKD
vasopressin receptor antagonists- they inhibit cAMP in principal cells, reduce cyst growth and slow the progression of renal failure
are used in those with eGFR less than 30 with rapid disease progression
236
what does anti-PLA2R-ab antibody test for
primary membranous nephropathy
237
overall management of nephrotic syndrome
salt restriction
fluid restriction
diuretics
ACE inhibitors/angiotensin receptor blockers
atorvastatin
anticoagulation
238
when do you take orlistat
before each meal
239
when must you stop taking orlistat
if 5% of total body weight has not been lost in the first 12 weeks patient must stop taking orlistat and consider other weight loss options
240
which test allows for discrimination between pituitary and ectopic causes of excess ACTH
inferior petrosal sinus samling
241
what criteria must you meet on ultrasound to diagnose APKD with a positive family history
must be 15-29 years old with 3 or more cysts bilaterally
