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What is kidney failure?

It is the reduction in glomerular filtration rate.


Describe the case of Mrs AB?

50yo woman, 10 days of vomiting, unwed, diarrhoea, past history, diabetes for 15years and hypertension.


What do you want to know when someone comes in?

1. History - often make up 80%. These are symptoms. In terms of Mrs AB, has she been peeing, does she pass urine at night, breathless, vomited up any blood, past history i.e. diabetes, what medicine she is on and familial issues.
2. Examination - signs.


Describe Mrs AB's history?

1. No fever.
2. Reduced urine output.
3. No symptoms infection.
4. No pain.
5. No shortness of breath.


From the history is there anything that you can tell about the type of kidney disease (Mrs AB)?

No you cannot tell whether it is acute or chronic. Leaning towards acute history, but cannot tell.


Describe the examination of Mrs AB?

1. Afebrile.
2. Looks unwell.
3. BP 90/60.
4. Dry skin.
5. Chest clear.
6. JVP = 0cm.


What does it mean when the JVP is below 1-2cm?

the JVP is lower than the sternal notch, therefore it indicates less fluid volume. Volume depleted (also indicated by low BP). This means you are leaning more towards acute kidney injury.


What other blood tests might help you tell whether it is acute or chronic?

Lab tests aren't that helpful, however, haemoglobin is a very helpful blood test.


Why is the Hb a helpful test?

The kidneys produce erythropoietin which stimulates RBC production. And anaemia is common in patients with kidney failure, this is because there is a decrease in RBC production. However, in acute kidney damage anaemia will not show up in the blood tests because RBC have a 120 day life span, and acute damage does not last that long. Whereas in chronic kidney damage, anaemia will appear (decrease in RBC) because the damage has occurred longer than RBC cycles.


What was Mrs AB Hb test results?

Hb in a normal range. This indicates that she has acute renal failure.


Describe acute renal failure?

It is the acute deterioration of kidney function over a short period of time. It is usually reversible and is often associated with other illnesses.


Describe acute pre-renal failure?

This type of acute renal failure is due to decreased perfusion of kidneys. There is generally a low BP. There is also the following symptoms:
1. Bleeding.
2. Sepsis.
3. Dehydration.
4. Heart failure.
Some pre-renal cases progress to intrinsic renal damage - ATN.


Describe acute renal failure?

This is mainly ATN (acute tubular necrosis). Most of these are from pre-renal acute injury that wasn't treated early enough:
-Rhabdomyolysis - acute muscle breakdown, the toxins from broken muscle cause kidney failure.


What are the other causes of intrinsic renal failure?

RPGN = rapidly progressive glomerulonephritis. You get this when you have acute kidney injury and acute renal kidney failure from inflammation of the glomeruli. There are crescents on the glomeruli biopsy. Red blood cells leak into the urine: acres in SLE, vasculitis and post streptococcal GN.


What is the best test for post-renal acute kidney injury?

Renal ultrasound.


Describe Mrs BC case?

68yo woman, 10 days of vomiting, unwell, past history, diabetes for 15 years and hypertension. She has a BP of 180/90, chest is clear and no pericardial rub. However there were signs of fluid overload. Her eGFR is 6ml/min. She has chronic kidney disease.


What are the signs and symptoms for fluid overload (hypervolemia)?

1. Edema (swelling) - particularly at the feet and ankles.
2. Difficulty breathing while lying down - orthopnoea.
3. Crackles on auscultation.
4. High blood pressure.
5. Irritated cough.
6. Jugular vein distension.
7. Shortness of breath (dyspnea).
8. Strong, rapid pulse.


What are the signs of chronic kidney disease?

1. Malnutrition - if you can't eat because you feel nauseated you will get malnourished.
2. Fluid overload - high BP, oedema (swelling), and pulmonary oedema.
3. Rash - uraemia toxins will build up in the skin and will create rash, there is often itchiness as well.
4. Pericardial rub - this is when there is fluid in the pericardial space (crunching sound).


What blood tests will help you to tell that it is acute or chronic?

All of the blood tests are the same in both acute and chronic.


What other tests might be helpful to confirm the diagnosis?

1. Kidney size - small in CKD. Normal size is 10cm, if you have 6cm then it is too small.
2. Presence of obstruction.

Do an ultrasound.


What is the most likely cause of CKD?

1. Diabetes.
2. Hypertension.
3. Glomerular disease.


What is the best treatment to prevent deterioration in CKD?

Treating BP.


What is the best way to treat BP?

ACE inhibitors. If you block angiotensin 2 from forming, you decrease vasoconstriction and you decrease sodium and water being reabsorbed.