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1

What role does dopamine have on AKI 

NONE 

- 3 systematic reviews - concluded no benefit in treating or preventing AKI 

- potential harm - incl MI, arrhythmias and reduced intestinal blood flow 

e.g Fenoldopam - BAD 

2

Treatment of severe malaria 

  • mortality 15-25% - jaundice, severe anaemia, ARDS¬†
  • IV artesunate - treatment of choice for severe malaria!!!¬†
  • resistance has emerged in SE asia - single point propeller region mutation - chromosome 13¬†
  • Severe malaria¬†
    • ‚ÄčIV artesunate 2.4mg/kg bolus IV then daily (S/e cerebellar ataxia)¬†
    • switch to oral artemether-lumefantrine to complete 3 days¬†
    • if not available, then do IV quinine instead of atesunate¬†

3

Prophylaxis of malaria 

Mefloquine - effective against both vivax and falciparum - resistance in thailand, cambodia - start 2 wks before travel, 4 weeks after reutrn, SE - GI , cardiac, neuro - psychotic episodes, safe in 2nd and 3rd trimester of pregnancy 

Doxycycline - 1 day before and 4 weeks on return - contraindicated in pregnancy - SE - photosensistivity, GIT upset, OCP ineffective 

Malarone - expensive, start one 1 day before, continue one week after 

insufficient data on pregnancy 

4

what is medullary sponge kidney and cystic kidney 

Medullary sponge kidney - common, malformation of terminal collectiing ductos - microscopic and macro medullary cysts - generally bilateral

- benign, but associated with nephrolithiasis and UTIs 

- majority causes sporadic then inherited 

 

Medullary cystic kidney - misnomer - majority do not have renal cysts evident on imaging - predom a tubulo-interstitial disorder - progress to ESRD 

5

define acute infective endocarditis and likely organisms 

Short history (days) of fevers, rigors, unwell,

hypotension, embolic lesions, heart failure

‚Äď Aggressive organism eg Staphylococcus aureus

6

what is NGAL? - Neutrophil Gelatinase Associated liocalin? 

- originally found bound to gelatinase from human neutrophils 

- expression upregulated following ischaemia in renal prox epithelial cells 

- INCREASE in NGAL in blood probably from other organs 

- INCREASE in NGAL in urine from renal tubular cells - predicts development of AKI early and sustained AKI. 

7

Define PUO 

‚ÄĘ Prolonged illness (2-3 weeks duration)

‚ÄĘ Fever (above 38.3C) on several occasions

‚ÄĘ No diagnosis after intelligent investigations

8

What is dengue fever? 

- spread

- incubation? 

- serotypes? 

- flaviviruses - spread by mosquitoes 

- 4 serotyes - 1 to 4, incubation 3-10 days 

- four clinical syndromes - undifferentiated fever, classic fever, dengue hemorrhagic fever, dengue shock syndrome (DSS severe form) 

9

what is autosomal dominant polycystic kidney disease

- inherited disease 

irreversible decline in kidney fn, most common cause of genetic cause of CKD - 5% sporadic, 75% fmhx

accnts for 5% of pts with ESRD on dialysis 

PKD1 - chromosome 16 - polycystin 1 - more RAPID deterioration, more cysts and ESRD at age 54 

PKD2 - chromosome 4 - protein polycystin 2 - more indolent decline renal fn, median age ESRD 74 

10

What is the duke criteria 

 Duke Criteria (Durack) 1994

‚Äď Pathological criteria

‚Äď Clinical criteria

ÔĀģ 2 major - microbiology - typical bugs in two bottles, persistantly positive BC with unusual organism, endocardial involvement - echo criteria and new murmur or positive serology for C.burnetti

ÔĀģ 1 major and three minor¬†

- 5 minor, fever over 38, vascular phenomena, immunological (osler, roth, glomnephritis), heart cond or IVDU, suggestiev microbio 

11

Nephrotoxic agents that can contribute to AKI 

- radiocontrast 

- aminogylcosides

- cisplatin 

- ACEI, ARBs 

- NSAIDs 

- Tacrolimus, cyclosporin 

12

What antibiotics to use when resistance - carbapenems, aminoglycosides, colistinm tigecycline, fosomycin? 

- Carbapenems - use only if low level Resistance - double therapy 

- aminoglycosides - use only if not Resistance (amikacin> gent)

- colistin - nephrotoxicity - complicated dosing 

- tigecycline - inappropriate for bacteraemia - large Vd, increased mortality - does not cover pseudomonas 

- fosomycin - strongest data only for UTI/prostate  

13

Haematuric renal disorders - general classification 

  • proliferation of resident glomerular cells
    • mesangial¬†
    • epithelial
    • endothelial¬†
  • influx of systemic inflamm cells

14

minimal change disease ?

  • ‚Äčnot associated with progressive renal insufficiency¬†
  • based upon histopath¬†
  • renal biopsy normal on light micro¬†
  • electron micro - reveals effacement flattening of podocyte foot processes¬†
  • disruption of integrity of protein barrier - resulting in heavy proteinuria¬†
  • 90% of cases of nephrotic syn in child less than 10, 10-15% of adult cases of nephrotic syn
  • other causes - malignancy (haem) or drugs (NSAIDs and cox2, bisphosphonates)¬†

15

Tx for PCKD 

- vasopressin receptor antagonist - Tolvaptan 

other novel tx 

- mTOR - rapamycin - no difference 

Mx - HTN, haematuria, UTIs, calculi

extra renal - liver disease, vascular (aneurysms, valvular heart disease 

16

Rhabo summary

- leakage of muscle cell contents into circulation 

- myoglobin - filtered by glomerulus, enters tubular epi cells - causes toxicity through vasocons (intra renal , direct tub toxicity thru oxidative damage and tubular obstruction in distal tubules 

- precipitation of myoglobin within tubules when interacts with TAMM- HORSFALL protein, favoured by acidic urine 

-risk of AKI low when CK less than 15-20k 

- hypocal can occur due to calcium entering damaged muscle, rise in potassium 

Tx - FLUIDS, some evidence for iv sodium bicarb, minimal evi for mannitol 

17

Most common causes of AKI

1. SEPSIS 

major surgery, cardiogenic shock, hypovolemia, medications

hepatorenal syndrome, trauma, cardiopul bypass, rhabdo, obstructive uropathy 

18

acquisition of which gene makes staph aureus methicillin resistant 

SCC MEC - staph casette chromosome mec 

most common is MEC A 

19

what is cystic renal disease? 

- acquired cystic disease of kidney 

multiple bilateral renal cysts 

different from ADPCKD - no fam hx, small to normal sized kidneys and smooth contour 

associated with renal cell cancer - no screening in AUS 

20

What is chikungunya

- alphavirus

- spread by aegypti and albopictus mosquitos 

- same mosquitos that spread dengue fever 

- India, malaysia, carribbean 

- incubation 2-4 days - range 1-14 days 

- Sx FEVERS, arthralgias, rash and myalgia 

- Dx - serology and alphavirus PCR 

- 72-97% get symptomatic disease - arthritis can be debilitating - bent posture

21

Define sub acute endocarditis 

‚Äď Long history (weeks to months) ‚ÄúPUO‚ÄĚ

‚Äď Malaise, fever, night sweats, weight loss

‚Äď Immunological and embolic phenomena

22

Tx for uncomplicated malaria

  • First line - ARTEMETHER-LUMEFANTRINE (riamet)¬†
    • ‚Äč4 tabs BD for 3 days, take with fatty food, >95% cure in p.falciparum, p.vivax good efficacy¬†
  • second-line - atovaquone-proguanil (Malarone)¬†
    • ‚Äč4 tabs daily for 3 days, slower parasite clearance than riamet¬†
    • treatment failure reported¬†
    • can also be used for prophylaxis¬†
  • Third line
    • ‚Äčquinine + doxy/clinda for 7 days¬†
      • ‚Äčmefloquine to be dropped

23

What are the common complications of endocarditis? 

  • CCF from valvular dysfunction¬†
  • Embolisation - risk drops after first week of abx therapy - increase if >1cm ant MV vege or S. aureus¬†
  • Periannular extension of infection - needs valve replacement, may cause AV block (node)¬†
  • Splenic abscess¬†
  • Mycotic aneurysms - can occur early or late¬†

24

What is P.falciparum

  • plasmodia that infects humans¬†
  • almost all death/severe disease¬†
  • no dormant liver stage, no late relapses¬†
  • medical emergency - almost always chloroquine resistant¬†

25

Simple renal cysts significance? 

- Generally increase in size over time 

- do not impact renal fn 

no further follow up required 

further f.u with CT contrast IF - septated cyst, calcifciation or cluster of cysts potentially masking solid lesion 

26

What is proteinuri nephrotic disorders ? 

nephrotic range proteinuria > 3.5g day 

hypoalbuminaemia

peripheral oedema - associated with hyperlipidaemia 

thrombotic disease more frequently observed 

disturbance of podocyte functn or endothelial/gbm/podocyte interface

27

What is dengue haemorrhagic fever? 

  • more common after repeated infections and in children described in first time travellers¬†
  • 4 necessary criteria for DHF¬†
    • ‚Äčfever or recent hx of acute fever¬†
    • hemorrhagic manifestations
    • low platelet count - less than 100,000¬†
    • objective evidence of leaky capillaries¬†
      • ‚Äčelevated hematocrit 20% or more over baseline¬†
      • low albumin¬†
      • pleural or other effusions¬†

28

What is cystatin C? 

  • biomarker of AKI¬†
  • endogenous cysteine proteinase inhibitor¬†
  • produced at a constant rate by all nucleated cells - released into plasma¬†
  • 99% filtered by glomeruli - no tubular secretion or reabosorption into plasma¬†
  • after filtration --> completely absorbed in to prox tubular cells¬†
  • hence NONE in urine¬†
  • SO PLASMA cystatin C is good marker of GFR and Urine cystatin C is a good marker of tubular injury¬†

29

What are the common organisms for Subacute endocarditis - top being most likely? 

1. Viridans strep - mutans, mitis, bovis 

2. Enterococcus 

3. HACEK group - 5% - haemophilus, acinomycetamcomitans 

Others - culture neg - rare 7%, Q fever, Bartonella, coag neg staph

30

Indications for surgical treatment of IE? 

Valve replacement indications

- heart failure

- paravalvular extension

- uncontrolled infection/difficult organism

- recurrent embolic events despite appropriate Ab - mobile vegetations above 10mm