Clinical (Week 4) Flashcards
(274 cards)
1
Q
What is a hamartoma?
A
A tumour with the correct constituencies of the organ it’s from but in wrong distribution
2
Q
What is the most common renal pelvis tumour?
A
Transitional cell carcinoma
3
Q
What is the most common renal parenchymal tumour?
A
Renal cell carcinoma
4
Q
What is the most common renal embryonic tumour?
A
Nephroblastoma (Wilm’s Tumour)
5
Q
What sort of CT is useful in diagnosing a urological malignancy?
A
Triple phased contrast enhanced
6
Q
What is the most common benign asymptomatic renal lesion?
A
Renal cyst (70%)
7
Q
How do we investigate renal cysts and why can we use this modality?
A
USS (it is fluid-filled)
8
Q
When would we biopsy an angiolypoma?
A
If fat-sparse:
- Risk of bled
9
Q
What feature of vessels in an angiolypoma make it prone to bleeds?
A
They are fragile
10
Q
How can we measure lesion density on a CT of angiolypomas?
A
Hounsfield
11
Q
What is Wunderlich’s Syndrome?
A
Collapse due to retroperitoneal bleed in an angiolypoma
12
Q
How does an oncocytoma appear on CT?
A
Central scar:
- Stellate due to central necrosis
- > No angiogenesis therefore benign
13
Q
What is the only way to definitively diagnose an oncocytoma and why is a biopsy not totally useful?
A
Nephrectomy
Biopsy has a high false negative rate
14
Q
What is the classic triad of symptoms in a renal cell carcinoma?
A
Loin pain (40%) Renal masses (25%) Frank haematuria (60%)
15
Q
Which of the following is not a paraneoplastic effect of renal cell carcinoma:
- Weight loss
- Hyperthyroidism
- Anaemia
- Hypertension
- Hypercalcaemia (As it produces parathyroid-like hormone)
A
Hyperthyroidism
16
Q
What is the M:F ratio for the incidence of a renal cell carcinoma?
A
2:1
17
Q
What is the peak incidence age for renal cell carcinoma?
A
65-75 years
18
Q
What type of cancer of a renal cell carcinoma and where is it found?
A
Adenocarcinoma
The PCT
19
Q
How do renal cell cancers appear histologically?
A
Clear cells
Papillary subtypes
20
Q
If there are bilateral or multifocal renal cell carcinomas, what condition should you suspect and what implications does this have?
A
Von Hippel-Lindau:
- Implications for surgery
21
Q
What is the first line investigation for renal cell carcinoma, and what is the best investigation?
A
1st line - USS
Gold standard:
- Triple phase contrast CT
22
Q
What is the downside to using biopsy in the diagnosis of renal cell carcinomas?
A
High false negative rate
23
Q
What staging system is used for renal cell carcinomas?
A
Robson
24
Q
True or false; Direct perinephric fat invasion is rare in renal cell carcinomas?
A
True
25
How do renal cell carcinomas tend to spread?
Lymphatics
| Via IVC
26
Where do renal cell carcinomas commonly spread?
Lungs ('Cannon ball' metastases)
Liver
Bone
Brain
27
What is the standard treatment for a renal cell carcinoma? What does the treatment involve?
Radical nephrectomy (preferably laparoscopically):
- Whole kidney within Gerota's fascia
- Perinephric fat removed
28
When is the standard treatment for a renal cell carcinoma most often carried out?
Within a month of diagnosis
29
When would the adrenal gland be removed in the treatment of renal cell carcinoma and why is it not routinely removed?
If it is involved
| Reduces the risk of adrenal insufficiency (Addison's syndrome)
30
How is a partial nephrectomy carried out? What implications does this have on the operation?
Under cold ischaemic:
| - Must be done in 20-30 minutes
31
What is the benefit to a partial nephrectomy?
It is nephron sparing:
- Maintains renal function
- Increases QoL and life expectancy
32
What surgical approaches can be taken in a partial nephrectomy?
Open
| Robotic laparoscopy
33
What is the main risk of a partial nephrectomy?
Pseudoaneurysm due to healing vessels
34
Apart from nephrectomies, what two other treatment options are available for renal cell carcinoma?
Radiofrequency ablation
| Cryoablation
35
How do we measure the performance status in metastatic renal cell carcinoma?
ECOG
36
What type of drug is Sunitinib? How does it work?
Tyrosine Kinase inhibitor:
- VEG-F and PDG-F inhibition
- Reduces neovascularisation
37
What benefit does using Sunitinib in the treatment of renal cell carcinoma have?
26 vs 20 month progression-free survival
38
What are the five year survival rates of Stage 1-4 renal cell carcinomas?
Stage 1 -> 75%
Stage 2 -> 50%
Stage 3 -> 35%
Stage 4 -> 5%
39
What are Balanitis Xerotica Obliterans and Leukoplakia?
Pre-malignant cutaneous penile cancers
40
What is Balanitis Xerotica Obliterans a form of?
Lichen sclerosus et atrophicus (Lichen sclerosus)
41
How does Balanitis Xerotica Obliterans present?
White patches
Fissuring -> Pain
Bleeding
Scarring
42
Where does Balanitis Xerotica Obliterans occur?
Prepuce
Glans
Urethral extension
43
What is the potential for malignant transformation in Balanitis Xerotica Obliterans?
Low
44
What can predispose to Balanitis Xerotica Obliterans?
Poor hygiene
45
What is Erythroplasia of Queryat?
Squamous cell carcinoma in situ on the:
- Glans
- Prepuce
- Shaft
46
How does Erythroplasia of Queryat appear?
Red, velvety patches
47
What is the name of a squamous cell carcinoma in situ on the rest of the genitalia (ie not Glans, Prepuce or shaft)?
Bowen's Disease
48
What is it important to differentiate a Squamous cell carcinoma in situ from?
Zoon's Balanitis
49
When would we circumcise a Squamous cell carcinoma in situ?
If present on the prepuce alone
50
How else can we treat a Squamous cell carcinoma in situ?
Topical 5-fluorouracil
51
Red, raised area on the penis with a foul smelling, fungating mass and phimosis is the typical presentation in what?
Penile carcinoma
52
How do we diagnose a penile carcinoma?
```
USS
Biopsy (if invasive)
CT -> For distal LNs
MRI
Bone scam
```
53
What is the incidence rate and peak age for penile carcinoma?
1.5 per 100,000 men
| 80 years old
54
What infection is penile carcinoma linked to?
HPV 16
55
What type of cancer is a penile carcinoma?
Squamous cell carcinoma
56
If there is inguinal node invasion of a penile carcinoma, how do we approach the treatment?
1. Assess prognosis
2. Radionucleotide Sentinel Node Biopsy
3. Inguinal lymphadenectomy
57
What chemotherapy agents are used in the treatment of penile cancer?
5-Fluorouracil
| Cis-platin
58
What is the most common germ cell testicular tumour?
Seminoma
59
What are some examples of non-seminomatous germ cell tumours?
Teratoma
Embryonal
Yolk sac
Choriocarcinoma
60
What does ITGCN stand for in terms of germ cell testicular tumours?
Intra-tubular germ cell neoplasia
61
How does a testicular tumour typically present?
Painless, insensitive testicular swelling
62
How many testicular tumours are due to metastases and where do they usually come from? How do they present?
10%:
- Neck LNs
- Dyspnoea
63
What is the best investigation for testicular tumours?
USS (95% sensitivity and specificity)
64
When would CXR and CT be used in investigation testicular tumours?
Staging
| Abdominal and thorax metastases
65
In what germ cell testicular cancer is α-feto protein never raised?
Pure seminoma
66
In what germ cell testicular cancers is hCG raised?
5-10% of pure seminomas
| 60% of teratomas
67
What can LDH be used to indicate in germ cell testicular cancers?
Tumour burden
68
What are testicular tumour markers usually used to gauge?
Effectiveness of therapy
69
What approach is taken in orchidectomies? Why is this approach taken?
Inguinal:
- Prevents damage to surrounding layers
- Reduces local recurrance
- > Due to clamping of cessels
70
What is the incidence of testicular tumours and what age is the peak incidence?
5 per 100,000 men
| 20-35 years
71
What is the increase in incidence of testicular tumours if there are undescended testes?
30 times risk
72
What are the three types of teratomas?
Differentiated
Intermediate
Undifferentiated
73
In trophoblastic teratomas, what percentage have a raised hCG?
100%
74
What fraction of residual masses have the following characteristics:
- Only fibrous tissue
- Mature (benign) teratoma
- Residual tumour
Only fibrous tissue - A third
Mature (benign) teratoma - A third
Residual tumour - A third
75
Which of the following does not result from uraemia:
- Pericarditis
- Encephalopathy
- Bronchitis
- Neuropathy
- Asterixis
- Gastritis
Bronchitis
76
What effect does kidney disease have on Vitamin D? What does this result in?
Cannot be converted into the active form (Calcitriol)
Results in:
- Bone disease
- Vascular calcification
77
What effect will kidney failure have on phosphate levels?
Phosphate will not be filtered into the filtrate as well so hyperphosphataemia will result
78
Why does renal failure result in anaemia?
Reduced production of erythropoietin
79
Why can dyspepsia happen in renal failure?
Increased risk of peptic ulcers
80
In renal failure there are a number of urinary tract features, what are they?
Frequency
| Urgency Polyuria
81
How do NSAIDs affect the kidneys?
Reduced eGFR
82
What antibiotics can affect the kidneys?
Gentamicin -> Toxic
Trimethoprim -> Fluid retention
Penicillins
83
What happens to JVP in renal failure?
It is increased
84
What is accelerated hypertension classed as?
Diastolic BP >120mmHg
85
What is leukonychia a sign of?
Hypoalbuminaemia
86
Gouty tophi are seen in what kind of kidney disease?
CKD
87
Vasculitis skin rash and systemic vasculitis are signs of what renal disease?
Acute glomerulonephritis
88
What type of vasculitis is HSP?
IgA
89
What is the usual specific gravity of urine and what does this indicate?
1.01-1.02
| [Urine]
90
What can cause urine to appear red?
Haemoglobin
RBC
Free Hb
Myoglobin
91
Alkaline urine is seen in what?
UTI
92
If RBCs appear isomorphic in urine microscopy, what does this indicate?
It is a lower urinary tract cause
93
If RBCs appear dysmorphic in urine microscopy, what does this indicate?
They are from the glomerulus (been forced out so become misshapen)
94
What is a normal result of a 24hr urine collection for protein?
95
What is a normal protein:creatinine ratio?
96
What is classed as asymptomatic low grade proteinuria?
A protein:creatinine ratio of 0.5-1g/day (100mg/mmol)
97
What is classed as heavy proteinuria?
A protein:creatinine ratio of 1-3g/day (~300mg/mmol)
98
How is nephrotic syndrome classed in terms of protein:creatinine ratio?
>3g/day
99
Increased urine protein can indicate what?
Increased risk of dialysis need in the future
100
What causes urinary casts to form? Where is this secreted from?
Precipitation of Tamm-Horsfall mucoprotein:
| - Renal tubule cells
101
What causes pronounced formation of urinary casts? What precipitates this?
Protein denaturation:
- Reduced urine flow
- Low pH
102
Hyaline casts in the urinary are usually benign; true or false?
True
103
What do RBC urinary casts indicate?
Nephritic syndrome
104
What do leukocyte urinary casts indicate?
Infection
| Inflammation
105
What do granular urinary casts indicate?
CKD
106
What chemicals can show up as crystals on urine microscopy? Which is the most common?
Calcium oxalate (most common)
Urate
Phosphate
Cysteine
107
Hypertension shows ECG changes indicative of what?
LVH and strain
108
What is Stage 1 CKD in terms of description and GFR?
Kidney damage with normal or increased GFR
| GFR >90
109
What is Stage 2 CKD in terms of description and GFR?
Kidney damage with mildly reduced GFR
| GFR 60-89
110
What is Stage 3 CKD in terms of description and GFR?
Moderatley reduced GFR:
| - GFR 30-59
111
What is Stage 4 CKD in terms of description and GFR?
Severely reduced GFR:
| GFR 15-29
112
What is Stage 5 CKD in terms of description and GFR?
Kidney failure:
| - GFR
113
What is kidney damage in terms of CKD 1 and 2?
Evidence of disease:
- Haematuria
- Proteinuria
114
What is oliguria classified as?
115
What features need to be present for a patient to have an AKI?
Reduction in GFR over hours/days/weeks
+/- Oliguria
With normal/impaired baseline renal function
116
Proteinuria (>3g/day) (mostly albumin), Hypoalbuminaemia, Oedema (limb and periorbital), Hypercholesterolaemia and often normal GFR are signs of what?
Nephrotic syndrome
117
AKI, Oliguria, Oedema, Hypertension and Active urinary sediment (RBCs, RBC and granular casts and proteinuria) are signs of what?
Nephritic syndrome
118
Can CKD be diagnosed from one eGFR calculation?
No
119
How is GFR measure directly and why is it not routinely used?
Nuclear medicine:
- Time consuming
- Expensive
120
How do we usually calculate an eGFR?
Creatinine clearance
121
Why does creatinine clearance overestimate GFR?
Creatinine is secreted into the tubules
122
What is serum creatinine a product of?
Muscle breakdown
123
For white and asian males, what is the calculation for eGFR if creatinine is in mg/dL?
186 x Creatinine^-1.154 x Age^-0.203
124
For white and asian males, what is the calculation for eGFR if creatinine is in μmol/L?
32788 x Creatinine^-1.154 x Age^-0.203
125
What correction factors are applied to the eGFR calculation for:
1. Women
2. Black people
1. Multiply whole equation by 0.742
| 2. Multiply whole equation by 1.212
126
When is eGFR mostly accurate?
If GFR
127
If a patient has a low muscle mass, what effect does this have on eGFR?
It is overestimated
128
If a patient has a high muscle mass, what effect does this have on eGFR?
It is underestimated
129
When is eGFR valid?
If [Creatinine]p is stable
130
What percentage of patients are in Stage 1 or 2 CKD?
7%
131
What is Stage 3a of CKD?
GFR 45-59ml/min
132
What is Stage 3b of CKD?
GFR 30-44ml/min
133
What percentage of patients are in Stage 3 CKD?
5%
134
What percentage of patients are in Stage 4 CKD?
0.2%
135
What percentage of patients are in Stage 5 CKD?
0.1%
136
What are some common causes of CKD?
```
DM
Hypertension
Vascular disease
Chronic glomerulonephritis
Reflux nephropathy
Polycystic kidney disease
```
137
When do symptoms of CKD tend to appear?
When GFR
138
Which of the following is not a typical non-specific sign of CKD:
- Tiredness
- Poor appetite
- Itch
- Weight loss
- Sleep disturbance
Weight loss
139
Impaired urine concentrating in CKD can cause what?
Nocturia
140
What medications can be used to both reduce proteinuria and control BP?
ACEi
| ARBs
141
What are some cautions when using ACEi/ARB/Spironolactone in CKD?
Modest decline in GFR at first
| Hyperkalaemia
142
How can CVS risk be reduced in CKD?
Control BP and proteinuria
Stop smoking
Statins
143
Apart from erythropoietin, what else should we check as a cause of anaemia in CKD?
Vitamin B12
| Folate
144
What is the initial treatment for anaemia in CKD?
IV iron
145
If after the first line treatment for anaemia in CKD the patient is still anaemic, what do we do?
Epo. injection (weekly/fortnightly)
146
What is the target Hb in a CKD patient?
10.5-12.5g/dL
147
What does CKD initially cause in regards to Vit. D and calcium metabolism?
Reduced calcium absorption
| Secondary hyperparathyroidism
148
What effect does advanced CKD have on Phosphate and what happens due to this?
Increased serum phosphate -> Increased PTH secretion
149
What effect do increased phosphate and calcium have on the cardiovascular system?
```
Vascular calcification (Become stiff)
(Can also affect heart valves)
```
150
How can we treat bone disease in CKD?
Alfacalcidol (Hydroxylated/Activated Vit D)
Phosphate binders:
- Reduced gut absorption
- eg. Calcium carbonation/acetate + Sevelamer
151
When is dialysis considered?
If GFR
152
How long does an arteriovenous fistula take to form?
6 weeks
153
How long do you have to wait before the catheter can be used in peritoneal dialysis?
1-2 weks
154
How soon can patients be registered for cadaveric kidney transplant?
Within 6 months of dialysis beginning
155
What is the definition of AKI?
Abrupt (26.4μmol/L
- OR rise in Cr by 50%
- OR a decline in urine output
156
What are the 3 criteria that can be used to diagnose Stage 1 AKI (KDIGO staging)?
```
Serum creatinine criteria:
- Increase >26μmol/L
- OR Increase >1.5-1.9 x Reference Cr
Urine output criteria:
- 6 consecutive hours
```
157
What are the 2 criteria that can be used to diagnose Stage 2 AKI (KDIGO staging)?
Serum creatinine criteria:
- Increase >2-2.9 x Reference Cr
Urine output criteria:
- 12 consecutive hours
158
What are the 5 criteria that can be used to diagnose Stage 3 AKI (KDIGO staging)?
```
Serum creatinine criteria::
- Increase >3 x Reference Cr
- OR Increase to >354μmol/L
- OR need for renal replacement therapy
Urine output criteria:
- 24 consecutive hours
- OR Anuric for 12 hours
```
159
What can all the pre-renal causes of AKI be classified as?
Functional causes
160
The following three conditions all cause pre-renal AKI; how can they come about?
- Hypovolaemia
- Hypotension
- Renal hypoperfusion
```
Hypovolaemia:
- Haemorrhage
- D&V/Burns
Hypotension:
- Cardiogenic shock
- Distributive shock (Sepsis/Anaphylaxis)
Renal hypoperfusion:
- NSAIDs/COX-2
- ACEi/ARBs
- Hepatorenal syndrome
```
161
What is pre-renal AKI essentially?
Reversible volume depletion leading to:
- Oliguria
- Increased serum creatinine
162
What is oliguria defined as?
163
What effect do ACE inhibitors have on the efferent arterioles and what does this cause? How does renal perfusion affect this?
Efferent arteriole vasodilation -> Reduced filtration pressure:
- If mildly decreased perfusion -> Mildly reduced GFR
- If hugely decreased perfusion -> Huge GFR drop
164
Put the following steps of the pathophysiology of Pre-renal AKI in order:
- Reduced effective intravascular volume
- Sodium and water retention
- Oliguria
- Volume depletion/Sepsis
- Increased levels of ADH and Aldosterone
- AKI
1. Volume depletion/Sepsis
2. Reduced effective intravascular volume
3. Increased levels of ADH and Aldosterone
4. Sodium and water retention
5. Oliguria
6. AKI
165
How much of the cardiac output do the kidneys receive?
20%
166
What is the commonest presentation of AKI and what causes it?
Acute Tubular Necrosis
| Due to untreated pre-renal AKI
167
What are the common causes of Acute Tubular Necrosis?
Sepsis
| Severe dehydration
168
What are some less common causes of Acute Tubular Necrosis?
Rhabdomyolysis
| Drug toxicity
169
What type of AKI is acute tubular necrosis?
Renal
170
What feature is pathognomonic of Acute Tubular Necrosis?
Muddy brown casts in the urine
171
In acute tubular necrosis, what is the fractional sodium excretion?
Above 2-3%
172
In pre-renal AKI, what is the fractional sodium excretion?
173
How can we assess hydration?
```
BP
HR
Urine output
JVP
Capillary refill
Oedema
```
174
What solution must we not give as a fluid challenge for hypovolaemia?
5% dextrose
175
When should we seek help in treating hypovolaemia?
If no change after >1L given
176
What is the underlying pathology behind renal AKI?
Inflammation or damage to cells
177
Renal AKI is typically split by the structures affected, what is it divided into?
Vascular
Glomerular
Interstitial
Tubular
178
What are vascular causes of renal AKI?
Vasculitis
| Renovascular disease
179
What are some causes of interstitial nephritis?
Drugs
TB
Sarcoidosis
180
What can cause a tubular injury?
Ischaemia (Prolonged hypeperfusion [pre-renal AKI])
Gentamicin
Contrast
Rhabdomyolysis
181
Uraemia will have what signs in renal AKI?
Itch
| Pericarditis
182
What history features may suggest renal disease?
```
Sore throat
Rash
Joint pains
D&V
Haempotysis
```
183
What electrolytes on U+Es are markers of renal function?
Na+
K+
Urea
Creatinine
184
If, on FBC, there are low platelets, what might be causing the renal AKI?
Haemolytic Uraemic Syndrome
| Thrombotic Thrombocytopaenic Purpura
185
Abnormal clotting can suggest what in renal disease?
Disseminated Intravascular Coagulation
| Sepsis
186
When is anaemia seen in renal disease?
If CKD
| If due to myeloma
187
Haematoproteinuria suggests what?
Active glomerulonephritis
188
Anti-GBM antibodies
Goodpasture's
189
How can we test for myeloma and in what age group would we routinely do these investigations?
Protein electrophoresis
Bence Jones Protein
In everyone >50 years old
190
What are urgent indications for a renal biopsy?
Rapidly progressive glomerulonephritis
| Positive immunology and AKI
191
How can we be sure that performing a renal biopsy will be safe?
Normal clotting (No Warfarin/Aspirin)
Normotensive
No hydronephrosis
192
If fluid resuscitation doesn't work in the treatment of AKI, what might we deliver?
Inotropes
| Vasopressors
193
When is dialysis commenced in AKI?
```
If anuric and uraemic (>40)
Hyperkalaemia:
- >7
- OR >6.5 and unresponsive to therapy
Severe acidosis (pH
```
194
What is severe acidosis defined as?
pH
195
What is severe uraemia defined as?
>40mmol/L
196
What is the general pathophysiology of post-renal AKI?
1. Urine flow obstruction
2. Hydropnephrosis
3. Loss of concentrating ability
197
How is post-renal AKI treated?
Catheter
Nephrostomy
Ureteric stenting
198
What is hyperkalaemia defined as?
>5.0mmol/L
199
What is life-threatening hyperkalaemia defined as?
>6.5mmol/L
200
At a serum potassium level of 6-7mmol/L, what ECG changes will be seen?
Tented T waves
201
At a serum potassium level of 7-8mmol/L, what ECG changes will be seen?
Flattened P waves
Increased PR interval (>0.12-0.20 seconds)
Depressed ST segment
Tented T waves
202
At a serum potassium level of 8-9mmol/L, what ECG changes will be seen?
```
Atrial standstill (absent P waves)
Prolonged QRS (>0.06-0.10 seconds)
Further tenting of T waves
```
203
At a serum potassium level of >9mmol/L, what ECG changes will be seen?
Sine-wave pattern
204
How do we protect the myocardium in hyperkalaemia?
10ml of 10% Calcium Gluconate over 2-3 minutes
| OR 5ml 10% Calcium Chloride
205
Can the myocardial protection treatment in hyperkalaemia be repeated?
Yes (up to 40ml of calcium gluconate)
206
How long does the protective effect over the myocardium last?
207
How does insulin move K+ back into the cells?
1. Binds to its cellular receptor
2. Increases Na-K-ATPase activity
3. K+ taken up into cells
208
How do we administer insulin in hyperkalaemia?
Actrapid:
| - 10-15IU in 50ml of 50% Dextrose over 30mins
209
How long does insulins affect last for in the treatment of hyperkalaemia?
2-4hrs
210
How regularly can insulin therapy be used in hyperkalaemia?
Every 4 hours
211
How regularly must we check blood glucose after insulin therapy (for hyperkalaemia) and what do we do in it drops?
Every 6 hours
| Infuse 10% glucose if glucose drops
212
How else can we move K+ back into cells?
Nebulised salbutamol for 90 minutes
213
What does calcium resonium do?
Reduces gut absorption of K+
214
If a 25 year old IVDU is found collapsed at home and his renal function has deteriorated, what is the most likely cause?
Rhabdomyolysis
215
Which of the following does not cause hyperkalaemia:
- Spironolactone
- Ramipril
- Amiloride
- Furosemide
- Atenolol
Furosemide
216
What is the second most common cause of Stag 5 CKD (after DM)?
Chronic glomerulonephritis
217
What is glomerulonephritis?
Immune mediated disease affecting the glomeruli with secondary tubulointerstitial damage
218
How does humoral glomerulonephritis arise?
Intrinsic or Planted Ag results in the deposition of circulating immune complexes
219
What causes a proliferative glomerulonephritis and what is the main presenting feature?
Damage to endothelial/mesangial cells
| Haematuria (+/- proteinuria)
220
What causes a non-proliferative glomerulonephritis and what is the main presenting feature?
Damage to podocytes
| Proteinuria (NO haematuria)
221
What would you expect to see on urine microscopy of a patient with glomerulonephritis?
Dysmorphic RBCs
RBC + granular casts
Lipiduria
222
What is microalbuminaemia defined as?
30-300mg Albumin/day
223
What kind of glomerulonephritis can present as an AKI?
Rapidly Progressive Glomerulonephritis (RPGN)
224
Nephritic syndrome is indicative of what kind of process; proliferative or non-proliferative?
Proliferative
225
Nephrotic syndrome is indicative of what kind of process; proliferative or non-proliferative?
Non-proliferative
226
How can nephrotic syndrome result in more infections?
Loss of opsonising antibodies
227
Which of the following is not a complication of nephrotic syndrome:
- Renal vein thrombosis
- Pulmonary embolism
- Volume depletion
- Vitamin D deficiency
- Hyperthyroidism
Hyperthyrodisim (actually causes subclinical hypothyroidism
228
What are the majority of cases of GN?
Idiopathic/Primary
229
What is secondary GN associated with?
```
Infections/Drugs
Malignancy
Systemic disease:
- ANCa associated vasculitis
- SLE
- Goodpasture's
- HSP
```
230
What type of ANCA is PR3 and what is it seen in (mainly)?
c-ANCA
| GPA
231
What type of ANCA is MPO and what is it seen in (mainly)?
p-ANCA
| Microscopic polyangiitis and EGPA
232
What do proliferative and non-proliferative GN refer to?
Absence or presence of mesangial cell proliferation
233
What is cresenteric GN?
Presence of crescents:
- Epithelial cell extracapillary proliferation
eg. RPGN in vasculitis
234
What are the target BPs in GN?
235
What sort of supplements might have a benefit in GN?
Omega-3 fatty acids
| Fish oil
236
What corticosteroids are used in GN?
PO prednisolone
| IV methylprednisolone
237
What alkylating agents are used in GN?
Cyclophosphamide
| Chlorambucil
238
What calcineurin inhibitors are used in GN?
```
Cyclosporin A (CSA)
Tacrolimus
```
239
What two other drugs are used in GN (ie. Not steroids/alkylating agents/calcineurin inhibitors)?
```
Azathioprine
Mycophenalate Mofetil (MMF)
```
240
What other non-drug immunosuppression can be used in the treatment of GN?
Plasmapharesis
Antibodies:
- IV Ig
- Monoclonal T or B cell antibodies
241
Which of the following is not used in the general treatment of nephrotic syndrome:
- Fluid and salt restriction
- Statins
- Diuretics
- ACEi/ARBs
- Anticoagulation
- IV albumin
Statins (though anticoagulation use is questionable)
242
What is complete remission of nephrotic syndrome?
243
What is partial remission of nephrotic syndrome?
244
Who is minimal change nephropathy most common in?
Children (77% of cases)
245
On renal biopsy, how does minimal change nephropathy appear?
Normal on:
- Light microscopy
- Immunofluorescence
Foot process fusion (podocyte) on electron microscopy
246
What drug treatment will induce remission in 94% of patients with minimal change nephropathy?
Oral steroids
247
What are the second line drugs for minimal change nephropathy if the first line doesn't work?
```
Cyclophosphamide
Cyclosporin A (CSA)
```
248
True or false; minimal change nephropathy will not cause progressive renal failure?
True
249
What is the possible cause of minimal change nephropathy?
IL-3
250
Who is focal segmental glomerulosclerosis most common in?
Adults (35% of cases)
251
What can causes secondary focal segmental glomerulosclerosis?
HIV
Heroin
Obesity
Reflux nephropathy
252
What does focal segmental glomerulosclerosis appear like on renal biopsy?
Light microscopy:
- Minimal Ig deposition
Immunofluorescence:
- Minimal complement deposition
253
How many cases of focal segmental glomerulosclerosis will be induced into remission by oral steroids?
60%
254
How many cases of focal segmental glomerulosclerosis progress to ESRD and how long does this take?
50% in 10 years
255
What is the aetiology of focal segmental glomerulosclerosis?
Soluble urokinae plasminogen activator receptor (suPAR) in 67%
Increased integrins
Podocytes effacement
256
Who is membranous nephropathy most common in?
Adults:
- 2nd commonest cause of nephrotic syndrome
- 15-30%
257
What infections are secondary causes of V?
Hepatitis
| Prasites
258
What connective tissue disease is linked to membranous nephropathy?
SLE
259
What malignancies are associated with membranous nephropathy?
Carcinomas
| Lymphoma
260
What drugs are associated with membranous nephropathy?
Gold
| Penicillamine
261
How does membranous nephropathy appear on renal biopsy?
Subepithelial immune complex deposition in BM (making it appear thicker)
262
How is membranous nephropathy treated?
Steroids
Alkylating agents
B-cell monoclonal antibodies
263
How many cases of membranous nephropathy progress to ESRD and how long does this take?
30% in 10 years
264
What can precipitate microscopic haematuria in IgA nephropathy?
Respiratory/GI infection
265
Where is IgA nephropathy most common?
Worldwide (most common cause of GN worldwide)
266
What is IgA nephropathy associated with and how would it present?
HSP:
- Arthritis
- Colitis
- Purpura
267
How does IgA nephropathy appear on renal biopsy?
Light microscopy:
- Mesangial cell proliferation and expansion
Immunofluorescence:
- IgA deposits in mesangium
268
How many cases of IgA nephropathy progress to ESRD and how long does this take?
25% in 10 years
269
How is IgA nephropathy treated?
BP control
ACEi/ARB
Fish oil
270
What is present in the urine of Rapidly Progressive Glomerulonephritis patients?
Active sediment:
- RBCs
- RBC + granular casts
271
How does Rapidly Progressive Glomerulonephritis appear on renal biopsy?
Glomerular crescents
272
What are some ANCA-positive causes of Rapidly Progressive Glomerulonephritis?
GPA
| Microscopic polyangiitis
273
What are some ANCA-negative causes of Rapidly Progressive Glomerulonephritis?
Goodpasture's
HSP/IgA
SLE
274
How is Rapidly Progressive Glomerulonephritis treated?
Steroids:
- IV Methylprednisolone/PO Prednisolone
Cytotoxics:
- Cyclophsphamide/MMF/Azathioprine
Rituximab (B-cell CD20 receptor monoclonal antibodies)
Plasmapharesis
