Flashcards in General renal Deck (67):
Indications for acute dialysis?
2. Hyperkalemia refractory to medication
3. Severe fluid balance issues
4. Acid base disturbances (acidaemia)- look at the bicarb level`
What sort of inheritance pattern is polycystic kidney disease?
what are we worried about in End stage renal disease?
urinary retention, hyperkalemia, calcium/PTH issues
why might a person with long term bipolar disorder present with renal failure?
renal failure secondary to lithium toxicity.
what are the signs of uremia?
Change in mental status
why do we get hyperparathyroidism in renal failure?
During renal failure, vitamin D-3 levels are reduced secondary to decreased production in renal tissue, as well as hyperphosphatemia, which leads to decreased calcium absorption from the GI tract and results in low serum calcium levels. Hypocalcemia stimulates the parathyroid gland to excrete PTH, a process termed secondary hyperparathyroidism.
Hyperphosphatemia occurs as excretion of phosphate decreases with progressive renal failure. Hyperphosphatemia stimulates parathyroid gland hypertrophy and stimulates increased production and secretion of PTH.
what do you think when you see cANCA test next to a renal patient's name
Causes of AKI to exclude
S= sepsis and hypoperfusion
P= parenchymal destruction
Acute renal injury- what are the 3 main subtypes?
prerenal, intrarenal, post renal.
what are some causes of pre-renal failure?
hypotension and interrupted blood flow to the kidney
what are some causes of intra- renal failure?
Direct damage to the kidneys by inflammation, toxins, drugs (aminoglycosides, PPI, contrast reaction), infection or prolonged reduced blood supply causing failure of cellular function
what are some causes of post renal failure?
obstruction to urine flow- commonly due to enlarged prostate, kidney stones, bladder tumor and or injury
what defines anuria and oliguria?
anuria= less than 100mls of urine output per 24 hrs; oliguria= less than 400mls of urine output per 24 hrs
What is the equation for corrected calcium?
(0.02 (40- alb) ) + ca2+)
What is the number one reason why a child is on dialysis?
Congenital dysplastic kidneys
What are the two most common reasons why adults get renal failure?
Hypertensive nephropathy and diabetes
indications for renal biopsy?
acute kidney injury without explanation, CKD with normal kidneys, nephrotic syndrome
what is the simple difference between nephrotic and nephritic syndrome?
Nephrotic syndrome involves the loss of a lot of protein, whereas Nephritic syndrome involves the loss of a lot of blood. Since Nephrotic loses a lot of protein--> peripheral oedema. O for oedema
what are some primary causes of nephrotic syndrome?
Minimal change Glomerulonephritis
Focal Segmental Glomerulosclerosis
what are some primary causes of nephritic syndrome?
Post streptococcal Glomerulonephritis – appears weeks after URTI
IgA Nephropathy – appears within a day or two after URTI
+ good pastures, Wegners granulomatosis
why do we see hyperkalemia in renal disease?
Failure of potassium excretion from the kidney tubules
what sort of anemia do you get in renal disease?
normocytic, normochromic due to reduced EPO
what sort of investigations would you do for a patient with acute renal failure symptoms?
urine analysis, immunology, biochemistry, FBE and radiology like renal U/s and biopsy
what are you looking for in your urine analysis, biochemistry and FBE tests for someone with acute renal injury symptoms?
Urinalysis- Blood or Protein – renal inflammation
Microscopy for red cells casts – diagnostic of glomerulonephritis
Biochemistry- Urea, Creatinine, Electrolytes
Haematology- FBE, Coagulation studies – DIC in association with sepsis
what are you looking for in your immunology tests to investigate AKI?
Antinuclear Antibody (ANA) – +ve in SLE & other autoimmune disorders
cANCA – Wegener’s Granulomatosis
pANCA – Microscopic Polyangitis
anti-GBM – Goodpastures disease
anti-sterptolysin O – Post streptococcal infection
what organisms usually cause UTIs?
Ecoli and staphyloccocal saphrophyticus
what are some symptoms of UTIs?
Frequency – cystitis, pyelonephritis
Dysuria – cystitis, pyelonephritis, prostatitis
Flank Pain – pyelonephritis
Fever – pyelonephritis, prostatitis
Visible blood in urine – prostatitis
what are some SIGNS of UTIs?
Offensive smelling urine
Macroscopic haematuria – prostatitis
Abdominal tenderness – cystitis
Swollen bladder – cystitis, pyelonephritis
Fever – pyelonephritis, prostatitis
Confusion – cystitis in the elderly
what sort of ix would you do for UTI?
Urine dipstick, MSU, FBE, U and E, inflammatory markers,
define acute renal failure
A sudden, marked but almost always potentially reversible reduction in renal function.
• 6 hrs of oliguria
• Or, 1.5 x increase from baseline creatinine
what causes renal stones? what are the risk factors?
Calculi formation is likely due to two mechanisms. The first is where stone forming substances such as calcium or uric acid supersaturates the urine beginning crystal formation. The other mechanism depends on stone forming substances depositing on the renal medullary interstitium forming a Randall's plaque and eventually erode into the papillary urothelium creating a calculus.
Risk factors= low fluid intake, frequent UTIs, drugs that cause calcium to precipitate in the urine
what is a phlebolith?
calculus in the renal vein
how does renal artery stenosis lead to hypertension?
When the stenosis occurs slowly, collateral vessels form and supply the kidney. The kidney wrongly senses the reduced flow as low blood pressure (via juxtaglomerular apparatus) and releases large amount of renin, that converts angiotensinogen to angiotensin I. Angiotensin I is then converted to angiotensin II with the help of angiotensin converting enzyme (ACE) in lungs. Angiotensin II is responsible for vaso-constriction and release of aldosterone which causes sodium and water retention, thus resulting in secondary hypertension.
what are the 2 main causes of renal artery stenosis?
atherosclerosis and fibromuscular dysplasia
what are some causes of haematuria (in general)?
Glomerulonephritis, bladder cancer, urothelial tumours, obstruction by stone, UTIs, anti-coagulant therapy, benign prosaic hypertrophy. (also exclude foods that can dye the urine red)
what do you think when you have painless haematuria?
renal cell carcinoma or transitional cell tumours.
what is a paediatric case of renal cancer?
Wilm's tumour- nephroblastoma
what are the two types of Polycystic kidney disease? which age groups get which?
autosomal dominant and autosomal recessive. Autosomal dominant= adult; autosomal recessive = children
what are some complications of Polycystic kidney disease?
Pancreatic and splenic and liver cysts
what do you think if you have uncontrollable HT?
renal artery stenosis
what is the name of the catheter in peritoneal dialysis?
tenchkoff catheter, inserted in the abdomen
what is the name of the catheter in haemodialysis?
vascath inserted into the jugular
how do we treat hydronephrosis?
nephrostomy- drainage of the urine
if you have bilateral ureteric obstruction?
Bilateral ureteric stents
what would you think if a male came in with severe pain in the left scrotum?
Testicular torsion (need to rule out first), strangulated inguinal hernia, infection, trauma
what types of renal calculi are there
1. calcium oxalate
2. uric acid
characteristics of renal colic pain?
-patient holds hand around the flank.
immediate management of renal colic?
• Analgesia- morphine 10 / pethidine 100 if allergic to morphine
• Maxolon 10 (M and M) or stemitil 12.5mg
• Alpha blocker (tamsulosin)
• PR analgesia (endone) upon discharging
Outpatient appt in 1-2 weeks
which patients CANNOT be sent home in the setting of renal colic?
1. Patient who only have an obstructed single kidney (calculus anuria)
2. Signs of sepsis- fever, urosepsis, confusion
3. unmanageable pain
How do we classify the site of the ureteric stones
1. uper third- lumbar
2. middle third- over the sacroiliac joint
3. lower third- below the sacroiliac joint
which renal stones can be dissolved?
uric acid stones, cysteine stones, calcium phosphate and struvite stones (NOT calcium oxalate)
Why do patients get renal stones?
• F/H of stones, gout, renal disease
• Diarrhoea, steatorrhoea
• Medications: vitamin ADC, antacid, thiazide diuretic, calcium, azetazolamide, steroids
• Diet- high in oxalate
• Hyperparathyroidism--> hypercalcemia
• Idiopathic hypercalciuria
• Genetic hyperoxalouria
• Myeloproliferative disorders--> hyperuricaemia
- recurrent UTIs
- personal hx of stones
what do we mean by MET therapy for renal stones?
Medical expulsion therapy=
-Alpha blocker (tamsulosin)- act on alpha receptors in detrusor muscle to help spontaneously expel the stone
-Calcium channel blocker (nifedipine)
Hoping to expel the stone without surgical intervention
describe the surgical method of ureteroscopy to remove renal stones?
A camera is inserted through the urethra to the ureter to find the stone. (scoping the patient)
Laser is used to break down the stone. Patient is under GA and a ureteric stent is then placed in the ureter
what is struvite stones made out of?
magnesium, phosphate, ammonium
what are the treatment options for stones in the ureter?
1. Conservative (observe- watch and wait)
2. Remove stones= MET/surgical
3. Dissolution (esp. uric acid and cysteine stones)
what are the surgical options for removing stones in the ureter
• Extracorporeal Shock Wave Lithotripsy (ESWL)
• Percutaneous nephroliotomy? (stenting) for big stones
• Ureteroscopy for big stones
what does an elevated specific gravity of urine indicate?
what do you want to look for in the urine for pyelonephritis?
what is the top cause of intrarenal acute kidney injury?
acute tubular necrosis
what causes acute tubular necrosis?
hypo perfusion/acute hypotension
how many stages of AKI are there- and what defines these stages?
there are 3 stages of AKI, defined by creatinine level and urine output
what are 3 main assessments for AKI?
1. volume/fluid status
2. urine analysis
3. renal ultrasound
how do we clinically define AKI?
6 hrs of oliguria
Or, 1.5 x increase from baseline creatinine
what are the two main causes of renal artery stenosis?
1. atherosclerosis (majority)
2. fibromuscular dysplasia
what is the gold standard ix for renal artery stenosis?
angiography +/- ultrasound