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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 
    • ​IV 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

– 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 

• Prolonged illness (2-3 weeks duration)

• Fever (above 38.3C) on several occasions

• 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

– Pathological criteria

– Clinical criteria

 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

 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 ?

  • not 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 

– Long history (weeks to months) “PUO”

– Malaise, fever, night sweats, weight loss

– Immunological and embolic phenomena

22

Tx for uncomplicated malaria

  • First line - ARTEMETHER-LUMEFANTRINE (riamet) 
    • ​4 tabs BD for 3 days, take with fatty food, >95% cure in p.falciparum, p.vivax good efficacy 
  • second-line - atovaquone-proguanil (Malarone) 
    • ​4 tabs daily for 3 days, slower parasite clearance than riamet 
    • treatment failure reported 
    • can also be used for prophylaxis 
  • Third line
    • ​quinine + doxy/clinda for 7 days 
      • ​mefloquine 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 
    • ​fever or recent hx of acute fever 
    • hemorrhagic manifestations
    • low platelet count - less than 100,000 
    • objective evidence of leaky capillaries 
      • ​elevated 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 

31

What is the mechanism of action of calcimimetics (Cinacalcet)? 

Cinacalcet directly lowers parathyroid hormone levels by increasing the sensitivity of the calcium sensing receptors to activation by extracellular calcium, resulting in the inhibition of PTH secretion 

32

Treatment for viridans strep SBE ? 

2-4 weeks IV benzylpenicillin IV 4hrly + 2 weeks IV gent (low dose) 

or 

ceftriaxone 2g IV for 4 weeks (outpt course)

or

benzylpenicillin as a single agent for 4 weeks 

33

What is classic dengue fever? 

  • 1st phase  - abrupt onset of fevers 39-40 for 2-3 days, severe back pain, HA, retro-orbital pain, arthralgias, maculopaplular rash, metallic taste 
  • 2nd phase - D-3-6, A/N/V/D, lymphadenopathy 
  • 3rd phase - defervescence for 1-2days 
  • 4th phase - fever recrudescence, morbilliform rash, skin desquamation
  • 5th phase: cnvalescence with prolonged lethargy 

34

What is tolvaptan 

vasopressin V2 receptor antagonist that inhibit cyst growth and decline of renal function - however only 2-3 % less increase in renal volumes - ? not widely used yet 

used in PCKD 

- suppression of vasopressin release reduces second messenger systems - cAMP identified as promoters of kidney-cyst cell proliferation and luminal fluid secretion 

 

35

what is membranous GN 

- Deposition of IgG and C3 along the GBM

- IgG4 most commonly associated idiopathic membranous nephropathy

- most commonly idiopathic - commonest cause of nephrotic syn in adults 

- malignancy responsible for 5-10percent of cases - solid tumour such as cancer of lung or colon 

- SLE - 10-20% of cases of lupus nephritis have a MN picture 

-Spontaneous remission of proteinuria occurs in 5 to 20 percent of cases

• Partial remission (

• incidence of end‐stage renal disease ~14 percent at 5 year

36

HIV 

retrovirus of the lentiviridae family 

human HIV-1 is genetically similar to chimp isolates 

HIV 2 rare in aus, less virulent 

cellular target of HIV - CD4 T cells - predominant target in all tissues 

37

What are the non-immunosuppresive therapies for nephrotic syndrome? 

used most often in cases of FSGS and membranous nephropathy - response to immuosup tx slow or partial 

issues to address - proteinuria, oedema, HTN, dyslipidaemia, thrombotic risk 

- proteinuria - target BP 125/75, proteinuria > 1g/day - use ACEI or ARB, aldo antag- spiro

- diuretics - loop, thiazides (greater anti-hypertensive effect than diuretic) 

- statins 

- pro-thrombotic - decreased levels of anti-thrombin III - urinary losses , anticoag when alb less than 20, 

38

What steps should you take to prevent contrast induced AKI 

- pre-hydration - N/Saline (IV) 

- minimise contrast volume 

- use non-ionic contrast which is low or iso-osmolar 

- discontinue nephrotoxins (ACEI or ARB) 

- NAC  (variable effect, also results in minor lowering of Creatinine) - 1200mg BD shown benefit compared to low dose 

- ? Statins - ongoing trials 

- periprocedural haemofiltration - no benefit 

39

pathophysiology of AKI 

  • reduction in kidney perfusion --> ATP depletion in renal tubular epithelial cells - causes cell death (apoptosis / necrosis) 
  • prox tubular cells are susceptible - high metabolic rate 2* to ion transport, limited capacity for anaerobic glycolysis 
  • endothelial injury with microvascular congestion, hypoerfusion particularly in the S3 segment of nephron - outer stripe of medulla 
  • SEPSIS - cytokines and bacterial factors - binds TLR4 on tubular cells and causes cell damage through oxidative stress 
  • microvascular changes - hypo-perfusion in peritubular capillaries - generation of reactive oxygen and nitrogen species 

40

what is first line for gonorrohea 

- Ceftriaxone!!! + azithromycin and doxy to cover for chlyamdia 

- established fluoroquinolone resistance 

41

Diagnosis of Malaria - The great imitator!!

  • FBE - haemoyltic anaemia, WCC normal/low, no eosinophilia, thrombocytopenia common 
  • Thick and thin blood smear 
  • antigen capture tests - rapid dx 15-20mins 
  • ICT 

42

What is the treatment for uncomplicated TV endocarditis/IVDU? 

2 weeks of IV fluclox and gent has been used 

43

What is the anti-relapse therapy for malaria? 

  • Primaquine 
    • ​eliminates liver forms of P vivax and ovale 
    • need G6PD screen 
    • total dose of primaquine received is important 
    • no other alternatives 

44

Clinical approach to ARF 

- Pre renal: hypovolemia, hypotension, CCF, aortic dissection 

- Renal - ATN, tubular injury - ischaemic, toxic - drugs causing acute tubulo-interstitial nephritis, infetions, acute GN - pauci-immune, anti-gbm 

- Post renal - obstruction - staghorn calculi, retroperitoneal fibrosis. 

45

What was the SAFE study? What did it show? 

- was an RCT of 7000 patients 

compared albumin as resus fluid vs N/Saline 

- Showed NO overall benefit in mortality or need for RRT 

fluids containing synthetic colloid - HES - found to be associated with increased need for renal replacement therapy - and increased mortality  

46

FSGS 

Focal – involving some of the glomeruli

Segmental – involving a portion of the affected glomerulus

Electron microscopic findings same as MCD-  Effacement of podocyte foot processes

pathogenesis - injury to the podocyte via an immune mechanism - associated with progressive renal insufficiency in 25-50% of cases

Tx - immunosupp tx for primary FSGS, no role for secondary forms 

- glucocorticoids, cyclosporin - in conj for resistant cases, 

47

Glomerulonephritis classes 

Proteinuric -nephrotic - minimal change, FSGS and membranous 

Haematuric - nephritic - IgA nephropathy, SLE, Pauci-immune GN, anti GBM, post step 

Both - membrano-proliferative GN  - mesangio capillary GN 

48

What is the treatment for enterococcal IE and side effects? 

4-6 weeks of IV benzylpenicillin or amoxil/AMP + Gentamicin (4-6weeks) 

combination of AMP with ceftriaxone may be effective 

for enterococci resistant to AMP - use Vanc + Gent 

SE: ototoxicity and renal failure 

if E.faecalis - then replace gent with ceftriaxone - therefore Amp + Cef 

49

What is carbapenem resistance and where? 

- frequently due to carbapenemase - hydrolyse all B-lactams incl carbapenems 

- esp ppl from india, asia and hospitals in america 

MUST know - New Delhi metallo- beta lactamase - does not occur in isolation, co-transmission of other resistance elements 

50

What is the diagnosis of dengue fever? 

Lab findings - early neutropenia with subsequent lymphocytosis, mildly raised ALT and AST 

severe disease-  low platelet count - less than 100,000

elevated transaminases 3-5 of ULN 

Dx - serology - 4 fold rise in antibody titre over 2 weeks 

flavivirus PCI, NS1 antigen 

Mx - symptomatic, supportive 

51

What is MERS CoV

- middle eastern respiratory syndrome coronovirus 

- pt presents with pneumonia and ARDS 

- human to human transmission possible 

- consider in travelllers from middle east in the last 14 days 

- mortality rate 55% 

52

Treatment of AKI 

  • Treat/remove causes/ exacerbating factors 
  • fluids, renal perfusion- resus 
  • mx of hyper K and acidosis 
  • RRT as required - fluid overload, azotemia 
  • stress ulcer prophylaxis 
  • modify med dosing 

53

What is the sensitivity and specificity of echo for IE? 

TTE - sensitivity less than 60%, specificty 98%

TOE - sens very high, spec very high 

        - neg predictive value 99-100% in NVE, Pos PV 90% 

        - PVE 86-94%, 88-100% 

54

What abx would you use for culture negative endocarditis? 

Ceftriaxone 3-4 weeks + gent for 2 weeks - active against bartonella/strep/HACEK

for Bartonella endocarditis - switch to IV doxy or azithromycin + ? gent 

Q fever endocarditis - doxy + plaquenil (12-18months) + RIF 

55

Cause of host genetic resistance to HIV

delta 32 mutation in CCR5 - found in 10% caucasians - heterozygous 

associated with slower HIV disease progression 

 

56

Biomarkers of AKI - Are they sensitive? 

NO - do not become abnormal until GFR reduced by 50%

- begin to change late after injury occurs 

confounding - muscle mass, age, sex, nutrition, meds (steroids) 

57

Causes of PUO

1. infections - SBE usually viridans, TB, intra-abdominal abscess, HIV related infection

2. connective tissue diseases - PMR, Giant cell arteritis, vasculitis (PAN), SLE, thyroiditis

3. Malignancy - lymphoma, necrotic mets, Renal cell cancer 

4. other - drug fever, factitious 

Remember role of PET scan 

58

What is the treatment of Staph IE? 

4-6 weeks IV fluclox - 2g 4hrly

MRSE or MRSE - vancomycin 4-6 weeks - Rifampicin + Fusidic acid in prosthetic valve endocarditis 

**TG - states if vanc resistance or intermediate - then use daptomycin or linezolid*** 

59

Hepato renal syndrome 

- occurs in severe liver dysfunction - progressive oliguria with very low urinary sodium (

- sepsis, hypovolemia due to diuretics/paracentesis 

- splanchnic circulation dilatation, intra-renal arteriolar constrction 

- POOR prognosis 

Prevention - IV albumin reduces AKI after paracentesis, vasoconstriction with terlipressin (improves short term survival and renal fn) 

60

Who to treat with Membranous GN 

• Those with heavy proteinuria- Less likely to spontaneously remit

• Those with renal dysfunction - Disease more likely to progress

Cyclophosphamide and steroid based regimens 1st line immunosppressive therapy

2nd line - cyclosporine - provided preserved GFR, rituximab

61

What is the nerve supply of the bladder - emptying and filling? 

emptying - S2-4 parasympathetic innervation via pelvic nerves mediated by M2 & M3 receptors 

filling - sympathetic T11-L2 innervation via hypogastric nerve mediated by B3 receptors 

Urethra - closure is via external sphincter S2-4 pudental N - somatic originating in onuf's nucleus 

closure - male bladder neck - alpha1A adrenergic 

opening NOS/NO 

62

What stimulates the bladder empyting 

- sensory bladder afferents - complex suburothelial sensory network 

- myelinated Adelta fibres - 30% - mechanoreceptors mediating sense of fullness via spinobulbospinal pathway via pontine micturition centre - PMC 

 

- unmyelinated C fibres - 70% - normally silent, high mechanical threshold, activated by noxious stimuli eg. infection

after spinal dysfuntion - drive spinal segmental reflex pathway

63

what causes ARF in terms of acute GN 

  • pauci immune - anca associated vasculitis 
  • linear IgG - anti- gbm 
  • immune complex deposition - SLE, IgAN, PIGN, MPGN

64

what in polycystic kidney disease genetics is associated with worse disease? 

- PKD1 gene on chromosome 16, encodes protein polycystin 1 

more rapid deterioration in renal function 

increased number of cysts 

cysts at an earlier age - cf PKD-2 

median age of ESRD at age 54 compared to 74 for PKD-2 on chromosone 4 

65

What are the sonographic criteria for the diagnosis of ADPKD in individuals with a family hx of PCKD 

(remember no dx criteria in those with no family hx) 

15-29 - 3 or more cysts - unilateral or bilateral 

30-39 - 3 or more cysts unilateral or bilateral

40-59 - 2 or more cysts in each kidney 

greater than 60 - 4+ cysts in each kidney 

 

66

What are the extra-renal manifestations of ADPCKD

- polycystic liver disease 

- intracranial aneurysms - in 6% of pts with neg fmx, 16% with fmx 

- thoracic aortic, cervico-cephalic dissections, coronary artery aneuysms

- valvular heart disease - mitral valve prolapse and aortic incompetence 

67

Prognosis of FSGS is related to ? 

• Prognosis dependent upon

  • Severity of proteinuria
  • Degree of renal dysfunction
  • Degree of background renal damage on renal biopsy
  • Response to therapy

68

What is the primary tx for FSGS 

Glucocorticoids cornerstone of therapy

• Cyclosporin (in conjunction with glucocorticoids) in

resistant cases

- Provided renal function is preserved

• Other agents – less studied

• Cyclophosphamide

• Tacrolimus

• Mycophenolate

• Sirolimus

• Rituximab

69

what is the first line treatment for membranous GN

1) cyclophosphamide and steroid based regiments 1st line immunosuppresive therapy 

alt immunosuppresive therapies 

- cyclosporine 2nd line - provided preserved eGFR 

rituximab

70

what is the auto-antibody found in serum of patients with idiopathic membranous nephropathy? 

M-Type Phospholipase A2 receptor as Target antigen in idiopathic membranous nephropathy 

- apparently (anti-phospholipase A2 receptor antibodies)  correlate with clinical status in idiopathic membranous nephropathy

71

what calcium channel blockers possess anti-proteinuric properties? 

the non-dihydropiridine calcium channel blockers 

- verapamil 

- diltiazem 

needed to reach target blood pressure of 125/75 for  nephrotic syndromes 

72

why do u have a pro-thrombotic state in nephrotic syndrome 

- decreased levels of anti-thrombin III due to urinary losses 

- increased platelet activation 

- presence of high molecular weight fibrinogen moieties in the circulation 

- additional possiblilty is that immune mediated injury in the glomerulus results in increased procoagulant activity sufficient to have a systemic effect 

10-40% of cases have deep vein or renal vein thrombosis 

73

What are the light microscopic findings for Mesangial prolif GN / mesangio-capillary GN 

Common to all causes

• Mesangial hypercellularity

• Endocapillary proliferation

• Duplication of the glomerular basement membrane

(producing double contours)

74

what causes seconday MPGN ? 

- usually in association with chronic infections - predominantly hep C 

75

what is the pathophysiology of MPGN

immune complex mediated 

- deposition of immune complexes in the glomeruli resulting from persistent antigenaemia 

- development of antigen-antibody complexes - chronic infectons (hep c) 

Complement mediated MPGN 

- commencing and involving regulation of C3 , loss of complement regulation

independent of antigen/antibody stimulation 

76

What is the potential treatment of complement mediated MPGN 

poor quality of evidence available 

- can use immunosuppressive therapy 

plasma infusion

OR 

non specific inhibition of complement cascade - Eculizumab - anti C5 monoclonal antibody - inhibition of C5 activation 

77

What suggests chronicity of renal disease? 

Evidence suggesting chronicity:

1. Normocytic anaemia

2. ↑phosphate, ↓calcium, ↑PTH, osteodystrophy

3. Small, echogenic kidneys

78

What are the aims of Hb and iron in CRF 

treat if hb less than 100 - aim for 100-120 

egfr less than 60 for pbs funding 

functional iron deficiency with EPO therapy - aim Tsat 20-50%, ferritin 300-500

need to give enough iron as relative functional iron deficiency 

79

what are the targets for ca, phos, pth in CRF pts

Targets: CARI guidelines

Parameter Target

PO4 0.8–1.60 mmol/L

Ca 2.1–2.4 mmol/L

[Ca x PO4]

iPTH 2–3 times the upper normal limit

80

what are the agents to help treat renal bone disease? 

* Control PO4 with phosphate binders

- Ca Carbonate (Calsup), Sevelamer (Renagel), Lanthanum (Fosrenol)

* Use Calcitriol (Vit D3) to titrate up Ca2+

- Measure PTH 2-3 monthly

- PTHectomy if autonomous

- i.e. High PTH & Ca, whilst off all Ca/Vit D agents.

*  Calcimimetics eg. Cinacalcit (Sensipar)

- Parathryroid sensitised to respond to lower ca levels.

- Improve survival surrogotes PTH, Ca, PO4, [CaxPO4]

- BUT – ‘Evolve’ trialno survival benefitPBS de-listing 8/15

81

what are the classess of lupus nephritis 

 I Minimal mesangial LN

normal light microscopy

 II Mesangial Proliferative LN

 III Focal LN

 IV Diffuse LN

>50% of glomeruli involved

 V Pure Membranous LN

 VI Advanced Sclerosing LN

≥ 90% of glomeruli

 

82

what are some of the features seen on proliferative lupus nephritis histology 

 • Subendothelial immune deposits

/wire loops

 • Hypercellularity

 • Leukocyte infiltration

 • Fibrinoid necrosis /hyaline thrombi

 • IF- deposits of IgG,C1q,C3,IgA,IgM

83

what are the agents used for induction of lupus nephritis? 

  • steroids 
    • IV methylpred x 3 pulses or pred 1mg/kg/day then wean 
  • cyclophosphamide 
    • improves renal remission rate, less risk of doubling Cr /ESRF 
    • either IV cyclo monthly for 3-6 months then MMF or Aza 
    • IV route less toxic than oral (cumulative dose accumulation  - infertility )
  • mycophenolate 
    • 1-3g/day in 2 divided doses
  • Rituximab

84

what is the major SE of cyclophosphamide treatment?

- gonadal toxicity 

major infection

herpes zoster 

bladder toxicity 

malignancy 

bone marrow suppression 

cumulative dose of 14g - haemorrhagic cystitis 

85

how does mycophenolate work and major toxicities - relating to lupus nephritis 

  • Inhibitor of inosine monophosphate dehydrogenase
  • Inhibits purine synthesis
  • Anti-proliferative effects on lymphocytes
  • myco is as effective as cyclophos at inducing remission
  • less major infection and minimizes gonadal toxicity 
  • SE
    • ​gastrointestinal upset
    • pancyotpaenia
    • infection
    • malignancy - skin - NEEDS YEARLY SURVEILLANCE 

86

what agents are used for maintenance treatment in lupus nephritis 

  • myco, aza at least as effective as cyclo with less toxicity 
  • maintanence treatment for at least 2 yrs 
  • ? lifelong if relapse 
  • myco superior in maintaining renal response post induction and preventing relapse 

87

what is rituximab and what role does it have in lupus nephritis?

  • murine/human monoclonal antibody 
  • anti-CD 20, b cell depletion 
  • no benefit over standard treatment in LUNAR trial 
  • however possible role in severe refractory or relapsing disease 

88

what is pauci-immune RPGN, ANCA + vasculitis ? 

  •  Autoantibodies reacting with myeloperoxidase(MPO) or proteinase 3 (PR3)

  • Characteristic cytoplasmic (c-ANCA) or perinuclear (p-ANCA) IF staining on ethanol fixed neutrophils.

  • Three major 

    • ​wegner's granulomatosis - 90% ANCA +, 80-90% PR3 
    • microscopic polyangitis - 70% ANCA, most have MPO 
    • renal limited vasculitis - most anca +, 75-80% MPO 

89

what is the induction treatment for pauci immune RPGN

  • cyclophos - 3-6 months, oral vs IV as IV smaller cumulative dose 
  • steroids - iV methylpred pulse than pred in severe disease 
  • in severe disease ANCA + vasculitis - plasma exchange resulted in higher rate of renal recovery 
    • ​esp in severe renal failure, concurrent anti-gbm antibodies and anca pos, pul haemorrhage 

90

what is the maintenance therapy for pauci immune RPGN 

  • aza verus cyclophos 
  • aza for 18months shown to be as effective as cyclo to minimise relapse 
  • aza more effective than mycophenolate at maintaining remission in ANCA associated vasculitis 
  • rituximab - as alternative to cyclo  - no difference in adverse events, as effective 

91

what are the ranges for microalbuminuria? 

 Urine albumin : Creatinine ratio (UACR)

males 2.5-25mg/mmol

females 3.5-35mg/mmol

Albumin excretion rate (AER)

30-300mg/ 24hrs

20-200μ g/min in timed collection

If positive then further 1-2 checks within 3

months

92

what is the definition of macroalbuminuria 

 Urine albumin : Creatinine ratio (UACR)

males >25mg/mmol

females >35mg/mmol

Albumin excretion rate (AER)

>300mg/ 24hrs

>200μ g/min in timed collection

93

What is atherosclerotic RAS and what part of renal aa does it involve

- ARAS part of generalised atherosclerosis 

common in pts with or without HT 

- typically involves the proximal 1/3rd of main renal aa 

men and women age over 55 

ostial/proximal renal aa 

radiologically eccentric or concentric lesions - total occlusion and ischaemic atrophy 

94

what is fibromuscular dysplasia? 

in women aged 30-40 

mid-distal renal artery, bilateral in 60% 

radiologically string of beads 

can affect carotid, visceral and peripheral arteries 

total occlusion and ischaemic atrophy is rare

perimedial fibroplasia can threaten, cause dissection

95

What happens in the proximal tubule and what drug acts here 

60 – 65% sodium reabsorbed

Site of HCO3 - reabsorption

All glucose and amino acids reabsorbed

Site of solute secretion

• anions (urate, ketoacid, penicillins, cephalosporins, radiocontrast media, diuretics)

• cations (cr, cimetidine, Li)

Target carbonic anhydrase inhibitors

• Mild metabolic acidosis

96

what happens in the thick ascending limb 

  • 25-30% of sodium reabsorption
  • concentration of medulla and counter current system 
  • mg and ca transport passive 
  • frusemide decreases mg absorption - less positive lumen 
  • claudin 16 gene encodes for mg transport paracellular pathway 
  • mutations in paracellin 1 gene - hypomagnesemia and nephrocalcinosis

97

What is Bartter's syndrome 

  • autosomal recessive 
  • normotensive 
  • hypokalaemic, metabolic alkalosis 
  • hypercalciuria +/- hypomg 
  • increase in urine prostaglandin E 
  • increase renin and aldo 
  • neonatal presentation
  •  

Affects NKCC - losing sodium, cannot retain hence high renin and aldo to compensate  

98

What is the distal tubule responsible for and what diuretics ? 

  • 5% of total NACL absorption 
  • thiazide action - indapamide 
  • mg and ca reabsorption
    • ​Mg absorption via TRPM6/M7 - this is inhibited by tacrolimus
    • 2-5% of mg absorbed
  • Thiazides
    • ​inhibit Na/CL co-transporter 
    • compete for Cl site 
    • decrease absorption of Na 
    • increase calcium reabsorption - prevention of renal calculi

99

what is gitelman's syndrome

  • Autosomal recessive - disorder of NaCl transporter 
  • Salt wasting
  • Normotensive, metabolic alkalosis, hypokalemia,
  • hypomagnesemia, hypocalciuria (similar thiaside)
  • Increase renin and aldosterone
  • Urine prostaglandin E normal
  • Diagnosed late childhood or adulthood
  • Musculoskeletal presentation

100

what is pseudohypoaldosteronism type 2 

 

  • •Autosomal dominant
  • •Hypertension 2nd /3rd decade
  • •Normal anion gap acidosis
  • •Hyperkalemia
  • •Hypercalciuria
  • •High aldosterone levels
  • •Treatment thiasides
  • •Mirror image to thiaside use

101

what is the action of potassium sparing diuretics 

Amiloride and Triamterene, High dose trimethoprim

  • close sodium channels directly
  • Amiloride used to inhibit Lithium entry into cells

Spironolactone and Eplerenone

  • competitively antagonises aldosterone at receptor level
  • Eplerenone more specific less anti‐testosterone side effects

102

what is liddle syndrome 

  • Autosomal dominant (chromosome 16)
  • Early onset H/T + hypokalemic metabolic alkalosis
  • decreased plasma renin and aldosterone levels
  •  Increased number of Na channels
  • Mutation identified in  or  subunit of Na channel (unable to catabolise Na channel)
  • Presentation similar to apparent minerocorticoid excess (Licorice)
  • Amiloride and Triamterene, not Spironolactone used for treatment as they close the channels 

103

how does aldosterone and ANP act in the cortical connecting tubule 

Fine tuning by renin angiotensin

Electronegative lumen promotes K+ and H+ excretion

Aldosterone increase number of sodium channels

increase Na reabsorption and secretion of K+

ANP binds to basolateral receptor decreases Na

channels

Li enters these cells via Na channels

104

what is anion gap and causes 

 

  • Anion gap Na+ ‐ (Cl‐+ HCO3)
  •  Anion gap 8‐15
  •  Measure of unmeasured anions (albumin ,Phosphate and sulphate)

 Anion gap increased

  • Decrease K+, Ca2+ or Mg2+
  • Increase anions – lactate, ethylene ketones
  • 2* to increased lactate, methanolol, alcohol, rhabdo, renal failure or ketoacidosis

 Anion gap decreased

  • Low albumin (correction .25 x albumin g/L)
  • Multiple myeloma

105

what is the urine anion gap and what does it signify? 

Urine anion gap = [Na+] + [K+] – [Cl‐]

GI causes: “neGUTive” UAG +

• Infusion ++ amounts Na Cl

 Positive anion gap

• Type 1 RTA, Type 4 RTA, renal failure

 Impaired renal acid excretion

Urinary anion gap unreliable

pH > 6.5

U Na

Toluene/lactic/ketoacidosis

106

what is type 1 RTA 

  • Distal defect --->  decreased H+ secretion
  • K+ secreted instead of H+ (hypokalemia)
  • Urine pH > 5.5
  • Hypercalciuria
  • Most acidotic of the three types of RTA
  • Renal Calculi
    • • Hypercalciuria
    • • Hypocitraturia
  • Confirmatory test –Ammonium Cl acidification
  • primary causes
    • ​idiopathic, sporadic, mutation in H+-ATPase and AE1 gene , association nerve deafness
  • secondary causes
    • autoimmune - sle, sjogrens, RA, drugs - PPI, lithium, chronic hep, renal transplant , thyroid disorders 
  •  

107

what is type 2 RTA

Failure of proximal tubular reabsorption of HCO3

Acidosis is milder that in type 1 RTA (HCO3 ‐ 12‐20 mmol/L)

Urine pH varies with serum HCO3 ‐ (pH

Threshold distal reabsorption of HCO3

‐Treatment may require high dose HCO3 ‐ (10‐15 mmol/kg/day)

Often associated with generalised proximal tubule dysfunction

(Fanconi syndrome - generalised prox tube dysfunction)

Confirmatory test fractional excretion of Bicarbonate > 25%

108

What is type 4 RTA 

Aldosterone deficiency or distal tubule resistance to Aldosterone

Decrease in Na+ absorption

Decreased H+ and K+ secretion hyperkalemia and acidosis

Urine pH

Impaired ammonium production

Acquired causes - dec renin 2* to Diabetic nephro, NSAIDs, interstital nephritis, normal renin dec aldo - ACEI arb, heparin, primary adrenal response 

dec response to aldo - meds - spiro, tac, sle, amloid 

treatment - dietary restriction of Na and frusemide 

109

What is Wegner's granulomatosis - GPA 

granulomatous polyangitis

eponymous description of disease entity

small vessel vasculitis affecting respiratory tract vessels – nose to lungs and renal vessels 

110

what is goodpastures disease? 

  • ​anti GBM antibodies cause this disease
  • mainly present with rapidly progressive disease
  • areas of necrosis and crescents
  • antibody – IgG – deposits on the basement membrane
  • always a cresenteric disease
  • combination of haemoptysis, renal failure and linear IgG deposits points to a diagnosis of good pasture’s syndrome.
  • An antibody to alpha 3 component of type IV collagen
  • More common in men
  • Bimodal distribution – peaks in 20-30 and 60-70, associated with HLA DR2
  • Ix – renal biopsy and raised transfer factor secondary to pul haemorrhage
  • Management – plasma exchange, steroids and cyclophosphamide
  • ANCA related nephropathies are associated with crescentic glomerulonephritis 

111

What is the main risk factor for IgAN progression? Note - IGAN is the most common cause of GN leading to ESKD in ANZ

PROTEINURIA!!!!! 

- degree of proteinuria - esp not responding to tx generally the strongest predictor for renal decline in glomerular diseases 

interaction between BP & proteinuria 

- reflects glomerular injury 

BP control still essential - generally more treatable 

- proteinuria and albuminuria is also a predictor of CV events and all cause mortality in CKD 

Tx - ACEI, ARB, fish oil, glucocorticoids and cyclophosphamide

112

what is the treatment of ANCA associated vasculitis than is PR3-ANCA pos, anti-gbm negative

 

so ideal treatment is cyclo IV to reduce cumulative dose, 

can use rituximab as alternative 

plasmapheresis is used short term in achieving dialysis independence in ANCA pos vasculitis presenting as dialysis requiring - serum Cr greater than 500 

- also in pts with pul haemorrhage or co-existing anti-GBM antibody 

but u also need to use cyclophosphamide as induction therapy 

113

what is the first line treatment of membranous nephropathy 

- cyclophosphamide and prednisolone alternating monthly for 6 months 

- remember PLA2R Ab - present in 70% of idiopathic MN and negative in secondary MN 

steroids alone do not work for iMN 

can use for 6 or 12 months 

another target for idiopathic MN is THSD7A 

114

what are the donor requirements for kidney transplant - 

do they need to be ABO compatible 

do they have a higher rate of ESKD compared to the popn 

So 

- transplant donors are generally from a highly selected population - lower risk of ESKD 

- higher risk than healthy non donors - but absolute risk is LOW 

- cannot transplant melanomas - even past hx - as high death rates

ABOI no longer an absolute contraindication in living donor kidney Tx - generally requires antibody removal pre- TX - antibody remoal for low antibody titres 

- kidney exchange program for high titres- to avoid unsuccessful attempt at Ab removal or higher risk of early rejection 

115

what is the main cause of death in dialysis patients 

1 CVD!!!!!

2. withdrawal from dialysis - however now nearly the same as CVD 

3. infection 

4. vascular - stroke, GI bleed, bowel infarction 

first few months - high risk of infections 

 

116

How does calcitriol work and SE 

  • 1,25 OH vitamin D reduces PTH secretion - directly or indirectly via relative hypercalcaemia 
  • increases GI absorption of Calcium and phosphate - unwanted SEs 
  • avoid relative hypercalcaemia, hyperphosphataemia and low PTH - adynamic bone disease - vascular calcification 
  •  

117

when is egfr most accurate - MDRD 

for patients with CRF and egfr 15-45 mls/min

118