Kidneys

Question 1

What is glomerulonephritis

Answer 1

Glomerular inflammation, generally caused by immunological mediated injury to the glomeruli
Pathogenic mechanism: deposition of circulating or in situ formation of immune complexes or deposition of antiglomerular basement membrane antibodies

Question 2

What are the symptoms of glomerulonephritis

Answer 2

hypertension, incidental finding of microscopic haematuria, incidental finding of proteinuria, nephrotic syndrome (protein in the urine), progressive renal impairment, acute kidney injury

Question 3

What are non glomerular causes of microscopic haematuria

Answer 3

bladder tumours, renal stones, renal tumours, BPH, UTI, renal injury

Question 4

What are glomerular causes of microscopic haematuria

Answer 4

IgA nephropathy, Alports (genetic condition affecting the basement membrane), thin basement membrane disease, post infectious GN, membranoproliferative PN

Question 5

What is IgA nephropathy

Answer 5

Glomerular deposition of IgA causing inflammation due to abnormalities in IgA
Variable clinical presentation: microscopic haematuria, hypertension, slow progressive renal impairment, rapidly progressive renal impairment, nephrotic range proteinuria

Question 6

What are the tests and management of IgA nephropathy

Answer 6

Lab tests: raised serum IgA, renal biopsy shows mesangial proliferation with IgA deposition
Management: control of BP

Question 7

What is Henoch Schonelin Purpura

Answer 7

most often self-limiting, but some may progress to ESKD
Inflammation of the small blood vessels, esp in kidney, skin and gut
Most common in young children
IgA deposition in the kidney in a similar pattern to IgA nephropathy
Associated with leucocytoclasic vasculitic rash

Question 8

What is nephrotic syndrome

Answer 8

Heavy proteinuria >3.5g
Hypalbuminaemia
Oedema: periorbital in children, peripheral in adults
Hyperlipidaemia (decrease in oncotic pressure stimulates hepatic lipoprotein synthesis resulting in a high cholesterol)

Question 9

What are the primary causes of nephrotic syndrome

Answer 9

membranous nephropathy, FSGS, MCGN, minimal change disease

Question 10

What are the secondary causes of nephrotic syndrome

Answer 10

diabetic nephropathy, SLE, amyloidosis, malignancy, drugs

Question 11

What is minimal change disease

Answer 11

the most common cause of nephrotic syndrome in children.

Question 12

What are the signs of minimal change disease

Answer 12

Proteinuria (abnormal excretion of proteins, mainly albumin, into the urine), oedema (swelling of soft tissues as a consequence of water retention), and hypoalbuminaemia (low serum albumin). Normal light microscopy

Question 13

What are the causes of minimal change disease

Answer 13

Idiopathic esp. in children
NSAIDS
Lithium, pecillicinamine, pamidronate, sulfazalizine, immunisations
Paraneoplastic (Hodgkin’s lymphoma)
Infections (syphilis, TB, mycoplasma, Hep C)
Allergy

Question 14

What is Focal segmental glomerulosclerosis

Answer 14

is the most common cause of nephrotic syndrome in adults. It is characterized by the appearance of tissue scarring in the glomeruli. The term focal is used as some of the glomeruli have scars, while others appear intact; the term segmental refers to the fact that only part of the glomerulus suffers the damage

Question 15

What are the signs of symptoms of FSGS

Answer 15

In children and some adults, FSGS presents as a nephrotic syndrome, which is characterized by edema (associated with weight gain), hypoalbuminemia (low serum albumin, a protein in the blood), hyperlipidemia and hypertension (high blood pressure). In adults, it may also present as kidney failure and proteinuria, without a full-blown nephrotic syndrome.

Question 16

What is the management for nephrotic syndrome

Answer 16

Diuretics
ACE
Anticoagulation (increase risk of VTE if albumin is less than 25 in membranous, less than 20 in other causes)
Statin for high cholesterol
Renal biopsy - children minimal change disease common, so steroids given before biopsy

Question 17

What is membranous glomerulonephritis

Answer 17

Slowly progressive disease of the kidney affecting mostly people between ages of 30 and 50 years, usually Caucasian.

Question 18

What is GPA

Answer 18

a long-term systemic disorder that involves both granulomatosis and polyangiitis.

Question 19

WHat is ANCA

Answer 19

anti neutrophil cytoplasmic antibodies and these have been shown to be pathogenic

Question 20

What is anti GBM disease

Answer 20

Auto antibodies to the glomerular basement membrane causing an RPGN (rapidly progressing glomerular nephritis) with crescent formation
Previously known as goodpastures syndrome
Associated with anti-GBM antibodies and alveolar basement membrane antibodies
An cause absolute anuria with pulmonary haemorrhage
Very short time period
Can die from pulmonary embolism

Question 21

What does haemturia on urine dipstick indicate

Answer 21

malignancy, renal stone, prostatitis, trauma, menstruation, active inflammation in the glomerulus for any reason, rhabdomyolysis

Question 22

What does proteinuria on urine dipstick indicate

Answer 22

diabetes, hypertension, obesity, UTI, GN, APKD, myeloma and amyloidosis, SLE

Question 23

What does gravity indicate on urine dipstick

Answer 23

Gravity: if high glucose in diabetes or dehydration. If low can suggest GN or diabetes insipidus

Question 24

What is the ideal GFR

Answer 24

A GFR below 60 for 3 months or more or a GFR above 60 with kidney damage indicates chronic kidney disease

Question 25

What are pre renal causes of renal disease

Answer 25

due to problems with arterial supply and venous drainage Single blood supply and drainage, therefore susceptible to : Hypovolaemia, heart failure, vasodilation, arterial dissection Susceptible renal artery stenosis: Atherosclerosis and fibromuscular dysplasia

Question 26

What are instrinsic causes of renal disease

Answer 26

due to problems within the renal interstitium/tubules

Question 27

What are post renal causes of renal disease

Answer 27

due to problems with outflow tract of the kidney

Question 28

Where is renal biopsy performed

Answer 28

usually left kidney, main complication is bleeding, day case. Samples for light, immune, EM

Question 29

What are indicators for renal biopsy

Answer 29

Progressive or unexplained renal impairment regardless of urine sediment. Nephrotic and diffuse nephritic syndrome. Significant proteinuria with normal blood pressure

Question 30

What are the effects of prostaglandins in kidneys

Answer 30

Cause vasodilatation of afferent arteriole -> increased GFR

Question 31

What are the effects of NSIADS in kidneys

Answer 31

Vasoconstriction of afferent -> decreased GFR

Question 32

What are the effects of ACE inhibitors in kidneys

Answer 32

Vasodilatation of efferent -> decreased GFR

Question 33

What are the effects of angiotensin II in kidneys

Answer 33

Vasoconstriction of efferent -> increased GFR

Question 34

Describe glomerular pathology

Answer 34

Severe injury leads to rupture and thrombosis in the Bowman's capsule i.e. crescent formation. Clinical pattern is usually a loss of function and heavy proteinuria If insidious, then proteinuria may be the only feature

Question 35

What are the PCT an DCT susceptible to

Answer 35

Susceptible to precipitation of solute and luminal obstruction: light chain disease, uric acid, myoglobin (rhabdomyolysis)

Question 36

What causes acute tubular necrosis

Answer 36

hypoperfusion, tubular toxins (aminoglycosides, cisplatin, ethylene glycol, IV contrast)

Question 37

What is the interstitium susceptible to

Answer 37

Drugs - antibiotics like penicillin, NSIADs, herbal medicine, proton pump inhibitors that reduce acid secretion Infections - pyelonephritis, viral (e.g. CMV, HIV), fungal/parasitic Autoimmune - SLE, Sjogren (affects parts of the body that produce fluids like tears and saliva), sarcoid Alloimmune (transplant rejection)

Question 38

What is chronic interstitial nephritis

Answer 38

insidious in onset. Less inflammation, more scarring. Important to establish cause. Steroids unhelpful Less capacity for recovery

Question 39

What is the outflow tract susceptible to

Answer 39

single draining pathway Susceptible to obstruction: Ureteric: stones, retroperitoneal fibrosis (stops peristalsis), gyane malignancy Bladder flow: stones, bladder cancer, prostatic (BPH/cancer) Urethral: stones, urethral stricture

Question 40

What is hydronehprosis

Answer 40

swelling of a kidney due to a build-up of urine. Happens when urine cannot drain out from the kidney to the bladder.

Question 41

Where does creatinine come from

Answer 41

Nonenzymatic hydrolysis of creation released from skeletal muscle

Question 42

Where does urea come from

Answer 42

Hepatic breakdown of protein: endogenous or exogenous

Question 43

What is the renal handing of urea

Answer 43

Completely filtered, significant tubular reabsorption

Question 44

What is the renal handling of creatinine

Answer 44

Completely filtered, some tubular secretion (up to 20% of clearance)

Question 45

What are the stages and testing of CKD

Answer 45

1: normal GFR with other evidence of chronic kidney damage. Test every year 2: GFR 60-89 with other evidence of chronic kdieny damage. Test every year 3: 30-59. 6 months. Split into 3A and 3B. 4: 15-29. 3 months 5: under 15. See every 3 months

Question 46

What are Vander's 7 renal functions

Answer 46

Regulation of water and electrolyte balance Excretion of metabolic waste Excretion of bioactive substances that affect body function Regulation of arterial blood pressure Regulation of rbc production Regulation of vitamin D production Gluconeogenesis

Question 47

How is prostatic disease managed

Answer 47

Alpha blocker

Question 48

How are blood pressure and volume managed in kidney disease

Answer 48

assess fluid status (weight, JVP and oedema), correct volume then BP (i.e. if overloaded start with diuretic), use ACEI or A2B in almost all cases for BP control (relaxes kidneys by reducing proteinuria), targets (130/80 probably consensus in CKD)

Question 49

Where is erthyropoetin synthesised

Answer 49

Synthesised by interstitial fibroblasts in the kidney Stimulated by low oxygen tension HIF1alpha protein degraded in normoxia HIF complex stimulates transcription of epo genes Epo binds to receptors on erythroid precursors

Question 50

How is anaemia managed in kidney disease

Answer 50

Check Hb and ferritin regularly Check B12 over 187 and folate over 3.1 Iron stores need to be super-normal - Tsats over 30% (18-71) and ferritin over 500 (22-275) Use epo (often earlier in diabetic) as an injection Target Hb 100-115g/l

Question 51

How does kidney affect PTH

Answer 51

Renal diseases results in high PTH, which would normally would increase tubular excretion of phosphate but due to kidney disease it can't. Calciphylaxis: result of high calcium and phosphate. Very pain and high mortality.

Question 52

What does FGF23 drive

Answer 52

Kidney's ability to activate vit D and get rid of phosphate

Question 53

What is calciphylaxis

Answer 53

result of high calcium and phosphate. Very pain and high mortality.

Question 54

What is normal range for phosphate

Answer 54

0.9 to 1.4 mmol/l

Question 55

What is normal range for calcium

Answer 55

2.15-2.55 mmol/l

Question 56

How to maintain mineral bone density in CKD

Answer 56

If px not on dialysis and with raised PTH treat vit D deficiency (250OH <50) If px not on dialysis reserve vit D analogues to those with severe progressive rise in PTH In px on dialysis aim to keep PTH 2-9x upper limit normal (20-600ng/l)

Question 57

What are the indicates for dialysis

Answer 57

Hyperkalaemia resistant to medical treatment Pulmonary oedema/fluid overload resistant to diuretics Symptoms of uraemia (above 35/40)- poor appetite, vomiting, weight loss, lethargy and fatigue, itching. Symptoms arises insidiously. Acidosis

Question 58

What is haemodialysis

Answer 58

hospital, satellite unit (nurse led) or home (daily). Taking blood from px body, putting it thought filter that acts as the kidney. In hospital, will need 4-5 hours of treatment 3 days a week. Gives equivalent eGFR to 15-20%

Question 59

What is the water requirement for haemo

Answer 59

Water requirement: dialysate flow rate 500-600 ml/min. 30,000ml/hr *4=120 000ml (120 litres per session.

Question 60

What is an AV fistula

Answer 60

``` Arteriovenous fistula (swings vein around into artery): native artery and vein. Radiocephalic, brachiocephalic, brachiobasilic. Matures in 4-8 weeks. 2 needles usual. Do not stick cannula above fistula. Complications: clotting. Stenoses. Thrombosis ```

Question 61

What are the complications of haemo

Answer 61

hypotension (if rate of removal is quicker, then there is less fluid in the blood compartment), septicaemia (plastic in body, also line may site in the left atrium), bleeding (uraemia affects platelet function + heparin), clotting of fistula, dialyser reaction, air embolus

Question 62

What is peritoneal dialysis

Answer 62

Peritoneal: home based - CAPD or APD Benefits: done by px at home. No need to attend hospital. Requirements: physical as px has to lift 2kg bags. Storage space. Hygiene. Some residual kidney function.