Kidney disease and blood pressure Flashcards
(108 cards)
1
Q
How will glomerular disease present?
A
Hypertension Incidental microscopic haematuria Incidental proteinuria Nephrotic syndrome Progressive renal impairment AKI
2
Q
What is nephrotic syndrome?
A
Heavy proteinuria > 3.5g a day
Hypoalbuminaemia
Oedema
Hyperlipidaemia
3
Q
Most common cause of GD in children?
A
Minimal change disease
4
Q
Why is it called minimal change disease?
A
Under the microscope the kidney tissue looks normal
5
Q
What is renal bruits?
A
Stenosis
6
Q
Blood investigations in glomerulonephritis?
A
U+E FBC CRP C3/4 Abs (IgA) RF Anti-NA, anti-dsDNA, ANCA
7
Q
What are the primary glomerular causes of microscopic haematuria?
A
IgA nephropathy Alports Thin BM disease Post-infectious GN Membranoproliferative GN
8
Q
What are the secondary glomerular causes of microscopic haematuria?
A
Henoch Scorlein Purpura (IgA vasculitis) SLE Haemolytic uraemic syndrome (HUS) ANCA associated vasculitis Sickle nephropathy
9
Q
Presentation of ANCA associated vasculitis
A
Rapid decline in renal function
Rapidly progressing glomerulonephritis
10
Q
Differentials between Henoch Scorlein Purpura and IgA nephropathy?
A
HSP affects small blood vessels in kidney, skin and gut
HSP is associated with a leucocystoclasic vasculitic rash
Extra-renal symptoms
11
Q
Biopsy of IgA nephropathy findings?
A
Mesangial proliferation with IgA deposition
12
Q
Primary causes of nephrotic syndrome:
A
Membranous nephropathy
FSGS
MCGN
Minimal change disease
13
Q
Secondary causes of nephrotic syndrome:
A
Diabetic nephropathy SLE Amyloidosis Malignancy Drugs
14
Q
Complications of nephrotic syndrome:
A
Protein malnutrition Hypovolaemia AKI VTE - risk if albumin <20-25(DVT, PE, Renal vein thrombosis) Infections
15
Q
Pregnancy associated nephrotic syndrome?
A
Pre-eclampsia
16
Q
Which nephrotic syndromes respond well to steroids?
A
Minimal change disease
Focal segmental glomerulosclerosis
17
Q
Management of nephrotic syndrome:
A
Diuretics ACE Anticoagulants Statins Renal biopsy
18
Q
What is a paraneoplastic nephrotic syndrome of Hodgkin’s syndrome?
A
Minimal change disease
19
Q
How will minimal change disease present?
A
Sudden onset oedema
(Periorbital in children)
(Peripheral in adults)
20
Q
Drug causes of minimal change disease?
A
NSAIDs Lithium Pellicinamine Pamidronate Sulfazolizine Immunisations
21
Q
MCD associated with?
A
SLE
T1DM
APKD
HIV nephropathy
22
Q
What sets focal segmental glomerulosclerosis (FSGS) apart from other causes of nephrotic syndrome?
A
It is a lesion not a disease
23
Q
Biopsy of FSGS?
A
Areas of mesangial collapse and sclerosis
24
Q
Secondary causes of FSGS:
A
HIV Reflux nephropathy Massive obesity Scarring from previous insult (e.g. IgA, SLE, vasculitis) Heroin
25
Symptoms of FSGS:
Proteinuria
Hypoalbuminaemia
High cholesterol
VTE risk
26
Most common cause of primary nephrotic syndrome in adults?
Membranous nephropathy
27
Pathology of membranous nephropathy
Glomerular BM thickening
| Immune deposits in the glomerular BM
28
Idiopathic membranous nephropathy Ab?
Anti-PLA2
29
Secondary membranous nephropathy causes?
```
Hep B
Thyroiditis
Carcinomas
Penicillamine
Captopril
NSAIDs
```
30
Mesangiocapillary glomerulonephritis (MCGN) pathology?
Immune complex deposition
| Complement dysregulation
31
Cryoglobulinaemia pathology?
Circulating complexes that precipitate out in the cold
Associated with rash - livedo reticularis
Arthralgia
Myalgia
32
Biopsy of cryoglobulinaemia findings?
MCGN
33
Pulmonary renal syndromes:
Anti-GBM disease
ANCA vasculitis
Lupus with pulmonary haemorrhage
34
What does GPA stand for in the context of ANCA +ve vasculitis?
Granulomatosis with polyangitis
35
ANCA +ve vasculitis biopsy findings?
Crescent formation
| Rapidly progressing GN
36
ANCA stands for?
Anti-neutrophil cytoplasmic antibody
37
Presentation of ANCA +ve vasculitis?
Pulmonary haemorrhage with AKI
38
Symptoms of ANCA +ve vasculitis?
Joint pains
Rash
Upper respiratory tract symptoms
Nose bleeds
39
Nephritic syndrome associated diseases:
Post-streptococcal glomerulonephritis (post URTI)
IgA nephropathy
Crescentic, rapid GN - Goodpastures, vasculitis
Membranoproliferative GN
HSP
Rhabdomyolysis (myoglobin)
40
Pathology of Goodpastures syndrome?
Anti-glomerular BM Abs (crescent formation and rapid GN)
| Anti-alveolar BM Abs (pulmonary haemorrhage)
41
Goodpastures presentation?
Pulmonary haemorrhage and AKI
42
Presentation of rhabdomyolysis?
Coca-cola coloured urine
43
What is rheumatoid factor?
Anti-bodies to the Fc portion of IgG (usually IgM)
44
Cancer test in glomerular disease?
Myeloma screen - Igs, electrophoresis and urine Bence-Jones proteins
45
Life-threatening complications of glomerular disease?
Hyperkalaemia
| Fluid overload
46
Treatment for hyperkalaemia?
| Need to normalise bicarbonate
Calcium gluconate (prevents arrhythmias)
Then dextrose
Then insulin
47
When are ACE inhibitors contraindicated?
```
Renal failure
Pregnancy/breastfeeding
Renal artery stenosis
Aortic stenosis (hypotension)
High dose diuretic therapy (>80mg furosemide)
Hereditary idiopathic angio-oedema
```
48
Why are ACE inhibitors contraindicated in renal failure?
They lower the glomerular filtration pressure and thus GFR
49
How do ACE inhibitors reduce the glomerular filtration pressure?
Vasodilate the efferent artery (angio II normally constricts it)
50
Side-effects of ACE inhibitors?
Cough
Hyperkalaemia
Angio-oedema (year after starting)
First dose hypotension (especially in those on diuretics)
51
Step 1 treatment for hypertension?
ACE inhibitor or CCB
52
Step 2 treatment for hypertension?
ACE + CCB or ACE + Diuretic
53
Step 3 treatment for hypertension?
ACE + CCB + Diuretic
54
Step 4 treatment for hypertension and K is < or equal to 4.5?
Add spironolactone
55
Step 4 treatment for hypertension and K is > 4.5?
Add alpha- or beta-blocker
56
Which diuretics are potassium sparing and where do they operate?
Thiazides
| Distal convoluted tubule blocking the NaCl symporter
57
Which diuretics are used for reducing fluid overload in heart failure?
Loop diuretics
58
Common side effects of thiazide diuretics:
```
Dehydration
Postural hypotension
Hyponatraemia, hypokalaemia, hypercalcaemia
Gout
Impaired glucose tolerance
Impotence
```
59
Rare side effects of thiazide diuretics:
Thrombocytopaenia
Agranulocytosis
Photosensitivity rash
Pancreatitis
60
Indications for loop diuretics?
```
Heart failure
Resistant hypertension (particularly in patients with renal impairment)
```
61
Adverse effects of loop diuretics?
Hypotension
Hyponatraemia, hypokalaemia, hypomagnesaemia
Hypochloraemic alkalosis
Ototoxicity
Hypocalcaemia
Renal impairment (from dehydration + direct toxic effect)
Hyperglycaemia (less common than with thiazides)
Gout
62
Dietary advice for a patient with chronic kidney disease
Low protein
Low potassium
Low phosphate
Low sodium
63
Kidney cancer in children?
Wilms' tumour (abdominal pain and painless haematuria)
64
Cause fo oxalate nephropathy?
Vitamin C overdose
65
MACHINE mnemonic for causes of hyperkalaemia:
```
M - Medications: ACE, NSAIDs
A - Acidosis: metabolic and respiratory
C - Cellular destruction: burns, traumatic injury
H - Hypoaldosteronism, haemolysis
I - Intake (excessive)
N - Nephrons (renal failure)
E - Excretion (impaired)
```
66
Hyperkalaemic ECG changes:
Tall tented t waves
Small p waves
Widened QRS leading to sinusoidal pattern and asystole
67
Why is metabolic acidosis associated with hyperkalaemia?
H and K ions compete for eachother for sodium ions across cell membranes and in the distal tubule
68
Drug causes of hyperkalaemia:
```
Potassium sparing diuretics
ACE inhibitors
Angiotensin 2 receptor blockers
Spironolactone
Ciclosporin
Heparin
Beta blockers (can interfere with K transport into cells and can cause hyperkalaemia in renal failure patients - treat with salbutamol)
```
69
Disease causes of hyperkalaemia:
Addison's disease
Rhabdomyolysis
Massive blood transfusion
70
Drug causes of hypokalaemia:
```
Beta agonists (temporary)
Calcium resonium (temporary)
Thiazide diuretics
Loop diuretics
Acetazolamide
```
71
Which type hypersensitivity is Goodpastures syndrome?
Type 2
72
Does oliguria in acute tubular necrosis respond to IV fluids?
No because the damage is within the kidneys rather than there being fluid depletion
73
Wilms' tumour is an example of what?
Nephroblastoma
74
What is the most common form of AKI?
Acute tubular necrosis
75
How can a fall cause AKI?
Rhabdomyolysis from the fall (myoglobin release from damaged muscle) causes ischaemia and acute tubular necrosis in the kidney
76
Diabetic nephropathy histology findings?
Kimmelstiel-Wilson lesions (nodular glomerulosclerosis)
Hyaline arteriosclerosis
BM thickening
77
What is the histological finding in amyloidosis?
Apple green birefringence in polarised light
78
What does the histological finding of apple green birefringent crystals in the kidney suggest?
Amyloidosis
79
When is the histological finding of wire looping of the capillaries in the glomeruli found?
SLE - a diffuse proliferative glomerulonephritis
80
When is the histological finding of presenting found?
Rapidly progressive glomerulonephritis
81
Pathophysiology of diabetic nephropathy?
Increase in the glomerular capillary pressure
| Glycosylation of the basement membrane
82
Associations with renal cell carcinoma?
Middle aged man
Smoking
Tubular sclerosis
Von Hippel-Lindau syndrome
83
Potential endocrine secretions of a renal cell carcinoma?
Erythropoeitin - polycythaemia
Parathyroid hormone - hypercalcaemia
Renin
ACTH
84
Hepatic paraneoplastic syndrome of renal cell carcinoma?
Stauffer syndrome - cholestastis/hepatosplenomegaly
| (thought to be secondary to increased levels of IL-6
85
What is acute kidney injury?
Syndrome arising from a rapid decline in GFR
Serum creatinine > (or equal to) 26.5 umol/L
OR raise of 1.5 fold or over in 7 days AND urine output <0.5ml/kg/h for 6 hours
86
KDIGO stage 1 AKI:
Serum creatinine 1.5-1.9 x baseline
87
KDIGO stage 2 AKI:
Serum creatinine 2.0-2.9 x baseline
88
KDIGO stage 3 AKI:
Serum creatinine 3 x baseline
89
Pre-renal causes of AKI:
Hypovolaemia
Cardiac failure
Hepatorenal syndrome
90
Renal artery causes of AKI:
Renal artery occlusion
| Large/medium vessel vasculitis
91
Small vessel causes of AKI:
Thrombotic microangiopathy
Renal atheroembolism
Small vessel vasculitis
92
Glomerular disease causes of AKI:
```
Anti-GBM disease (Goodpastures)
Lupus nephritis
Post-infective GN
Infective endocarditis
Membranoproliferative GN
Cryoglobulinaemia
IgA nephropathy/HSP
```
93
Causes of acute tubular necrosis (AKI):
```
Amphotecerin
Aminoglycosides
Antiretrovirals
Cisplatin
Acetaminophen
Radiocontrast
Organic solvents
IV immunoglobulin
```
94
Causes of acute interstitial nephritis (AKI):
Drugs
Infection
Systemic disease
95
Intra-tubular obstruction causes of AKI:
Cast nephropathy
Drugs
Crystalluria
96
Post-renal obstruction causes of AKI:
```
Papillary necrosis
Tumours
Retroperitoneal fibrosis
Renal calculi
Urinary retention
```
97
What can AKI cause?
Hyperkalaemia
98
ECG change with serum K 5.5-6.5 mmol/l
Peaked T waves
| Prolonged PR segment
99
ECG change with serum K 6.5-8 mmol/l
Loss of P wave
Prolonged QRS
ST elevation
(ectopic beats and escape rhythms)
100
ECG change with serum K >8 mol/l
Sine wave
Wide QRS
(ventricular fibrillation, asystole, bundle branch blocks, axis deviation, fascicular blocks)
101
What does the kidney have receptor sites for?
ADH
Aldosterone
ANP
PTH
102
What doe the kidney produce?
```
Urine
Erythropoetin
Prostaglandins
Vitamin D
Renin
(also has a role in gluconeogenesis)
```
103
Features of metabolic acidosis?
pH<7.3
Low PaCO2
Normal-high PaO2
Low bicarbonate
104
Symptoms of metabolic acidosis?
Breathless
Tachypnoea
Nausea
Non-specifically unwell
105
Features of uraemia?
```
Waste retention so higher blood levels of:
Sulfate
Urea
Ammonia
Creatinine
Phosphate
```
106
What does uraemia lead to?
Pericarditis
Pleurisy
Encephalopathy, coma, death
107
RRT may be needed for severe complications of AKI such as...
```
Life threatening pulmonary oedema
Severe metabolic acidosis
Severe hyperkalaemia with ECG changes
Uraemia pericarditis
Uraemic encephalopathy
```
108
Bone disease:
High bone turnover due to hyperparathyroidism
OR low bone turnover causing osteoporosis
Vertebral fracture occurs in 21% of harm-dialysis patients
