MM renal tutorial Flashcards
1
Q
What is AKI
A
Decreased renal function
2
Q
How is AKI measured?
A
Serum creatinine or urine output
3
Q
How can you differentiate AKI from chronic kidney disease?
A
It occurs over days or hours
4
Q
How many stages of AKI are there?
A
3
5
Q
How should you measure creatinine?
A
Compare it to a patients baseline- younger patients will have different levels to older
6
Q
What will AKI progress to?
A
Chronic kidney disease
7
Q
What are the causes of AKI?
A
Pre renal
Renal
Post renal
8
Q
What are pre renal causes of AKI? Why do they cause AKI?
A
All of them cause hypoperfusion of the kidneys:
Hypovolemia
Renal artery stenosis
Hypotension eg sepsis, heart failure, NSAIDs
9
Q
What are post renal causes of AKI?
A
They can be internal eg renal calculi, urethral, stricture or external eg pelvic, malignancy and BPTT
10
Q
What are renal causes of AKI?
A
Glomerular= glomerulonephritis, haemalytic, uraemic syndrom
Vascular= vasculitis
Tubular= acute tubular necrosis, multiple myeloma
Interstitial disease= acute interstitial nephritis
11
Q
What is the most common cause of renal AKI?
A
Acute tubular necrosis
12
Q
What is acute tubular necrosis?
A
Death of the epithelial cells that line the tubules in the kidney
13
Q
How does AKI present?
A
Different symptoms depending on the cause but they may have symptoms of: Malaise Anorexia Vomiting Pruritis Drowsiness Oligouria Coma
14
Q
What should you always ask if you suspect AKI?
A
Ask about medication (have they been started on any nephrotoxic drugs recently?)
Have they had any recent burns or surgery (can cause hypovolemia)
15
Q
What is the usual cause of hypervolemia?
A
Iatrogenic
16
Q
What are the complications of AKI and how do you remember them?
A
Remember them by thinking about the function of the kidneys and what would go wrong if these functions weren’t carried out. Use the pneumonic A WET BED:
A- maintaining ACID balance (if this isn’t done there will accumulation of acid)
W- maintaining WATER balance (if this isn’t done there is usually hypovolemia but can be hypervolemia too)
E- maintaining ELECTROLYTE balance (if this isn’t done you get hyperkalemia and high phosphates)
T- toxin removal (if this isn’t done you get uremia)
B- maintain BLOOD pressure (if this isn’t done you get hypertension because the kidney secretes renin)
17
Q
What are complications of AKI?
A
Excess acid Hyper or hypovolemia Hyperkalemia High phosphates Uraemia
Progression to CKD
18
Q
What investigations should you do if you suspect AKI?
A
Bloods= U+Es, LFTs, FBC (if you suspect an autoimmune cause you could test for those specific antibodies too)
Urinalysis
ECG
CXR
USS (if you think AKI is obstructive/ unsure of the cause)
Renal biopsy
19
Q
How will hyperkalemia show up on an ECG
?
A
High T waves
20
Q
How do you treat AKI?
A
Depending on the cause
21
Q
How do you treat AKI that has arisen from nephrotoxic drugs?
A
Stop the drug treatment
22
Q
How do you treat pre renal AKI?
A
Manage volume depletion
23
Q
How do you treat renal AKI?
A
Refer to a specialist, likely do a renal biopsy
24
Q
How do you treat post renal AKI?
A
Catheter, urological intervention
25
What should you monitor when treating someone with AKI?
```
Urea and electrolytes
ABG
Potassium levels
Blood pressure
Urea levels
```
26
What happens if you can't control hyperkalemia or pulmonary oedema in an AKI pateint?
Use renal replacement therapy
27
What is given to treat hyperkalemia in AKI?
Calcium
IV dextrose and insulin
Salbutamol
28
Why is calcium given to treat hyperkalemia in AKI?
To prevent risk of cardiac arrythmia
29
Why is IV dextrose and insulin given to treat hyperkalemia in AKI?
To drive potassium into cells
30
Why is salbutamol given to treat hyperkalemia in AKI?
To increase the effects of the IV potassium and insulin
31
How would a metabolic acidosis from AKI be treated?
IV sodium bicarbonate
32
How is pulmonary oedema treated?
Oxygen
IV diamorphine
IV GTN
Frusemide
33
Why is IV diamorphine given to treat pulmonary oedema in AKI?
It relieves anxiety and breathlessness
34
What is the main investigation for chronic kidney disease?
Serum electrolytes, urea and creatinine
35
What is CKD?
```
Kidney damage (manifesting as proteinuria or hematuria)
GFR <60 mL/min
For 3 months (longer than AKI)
```
36
How many stages are there of CKD and how are they catagorised?
5
| they are based on GFR
37
What is stage 1 of CKD?
Kidney damage with normal GFR
38
What are causes of CKD?
Glomerular= glomerulonephritis, diabetes, SLE
Vascular= hypertension, heart failure
Tubular/interstitial= interstitial nephritis, pyelonephritis, medication
Obstruction= kidney stones, BPH, multiple myeloma
Medication use= NSAIDs
Congenital= PCKD, alport syndrome
39
What are the 2 biggest causes of CKD?
Diabetes
| Hypertension
40
How does CKD present?
It is cause specific, general symptoms of renal deterioration:
```
Pruritis
Nausea and vomitting
Anorexia
Oedema
Polyuria/ oligouria
Shortness of breath (due to fluid)
Bruising
```
41
What investigations should you do if you suspect CKD?
Bloods (creatinine is used to estimate GFR, check glucose to check for underlying diabetes, FBC, LFTs, calcium and phosphate)
Urinalysis (hematuria/proteinuria/ tubular cells)
CXR (to check for fluid overload)
Renal biopsy
Renal ultrasound is not usually done but can be
42
What is are the best initial investigations for renal patients?
Serum electrolytes, urea, creatinine (you want to check their GFR and this is the way to do it)
43
What is glomerulonephritis?
The inflammation of the glomeruli
44
What does glomerulonephritis lead to?
Nephritic or nephrotic syndrome
45
What are the 2 main symptoms of glomerulonephritis?
Haematuria
| Proteinuria
46
What is the main symptom of nephritic syndrome?
Haematuria
47
How might patients describe haematuria?
Coca-cola coloured urine/ dark urine/ brown urine
48
What is the main symptom of nephrotic syndrome? Whats a good way to remember it?
Proteinuria
| Remember nephrOtic syndrome= prOteinuria whereas as nephritic is more haematuria
49
Is oedema more associated with nephrotic or nephritic syndrome?
Nephrotic
50
What are the symptoms of nephritic syndrome?
Haematuria
Oligouria
Hypertension
Oedema
51
What are the symptoms of nephrotic syndrome?
```
Proteinuria (severe, PCR> 300mg/mol)
Hypoalbuminaemia
Oedema
Hyperlipidaemia
Intravascular volume depletion
```
52
What symptom of glomerulonephritis is IgA nephropathy more associated with?
Haematuria
53
What renal conditions cause haematuria?
```
IgA nephropathy
Post-strep glomerulonephritis
Small vessel vasculitis
Anti-GBM disease
SLE
```
54
What renal conditions cause proteinuria?
```
Minimal change nephropathy
FSGS
Membranous nephropathy
Amyloid
Diabetic nephropathy
SLE
```
55
What will urine casts look like in nephrotic vs nephritic syndrome?
```
Nephritic= RBC casts and cola/smoky urine
Nephrotic= fatty casts
```
56
What will proteinuria levels be like in nephrotic vs nephritic syndrome?
```
Nephrotic= higher (>3.5g/day)
Nephritic= lower (<3.5g/day)
```
57
Why do you get fatty casts in nephritic syndrome?
Due to hyperlipidaemia
58
How does haematuria vary between nephritic vs nephrotic syndrome?
```
Nephrotic= may or may not be present
Nephritic= will be present
```
59
How do clinical features vary between nephrotic and nephritic syndrome?
```
Nephrotic= generalised oedema (periorbital) and hypertension
Nephritic= less oedema more hypertension
```
60
What are the main signs of nephritic syndrome?
```
Haematuria (coca cola coloured urine)
Proteinuria
Oligouria
Uraemia
Hypertension
Oedema
RBC casts in urine
Sterile pyuria (pus in urine)
```
61
What are the 4 main causes of nephritic syndrome? Which is most common?
IgA nephropathy= most common
Post strep glomerulonephritis
Rapidly progressive glomerulonephritis
Alport syndrome
62
What is post step glomerulonephritis associated with?
Infection, usually a child, presents weeks after infection
63
How will someone with nephritic syndrome from IgA nephropathy present?
1-2 days after an upper resp tract infection with high IgA
| Also maybe with Hencoh purpura (affects older children more, they'll have a rash, arthritis etc)
64
What is rapidly progressive glomerulonephritis associated with?
Vasculitis
Lupus nephritis
Goodpastures/ anti GBM disease
65
What antibody will be found in someone with vasculitis?
pNCA
66
What is anti GBM disease also known as?
Goodpastures
67
What antibody is found in goodpastures disease?
anti GBM
68
What will you see in a patient with goodpastures that is key to look for in exam qs?
Pulmonary haemorrhage
69
What part of the body will goodpastures affect asides from the kidneys?
Lungs
70
How does one get goodpastures disease?
Genetic
71
What will be the cause of nephritic syndrome if someone has an infection a few days ago vs a few weeks ago?
A few days ago= IgA nephropathy
| A few weeks ago= post strep glomerulonephritis
72
What are the 5 causes of nephrotic syndrome?
```
Minimal change disease
Focal segmental glomerulosclerosis
Membranous nephropathy
Amyloidosis
Diabetic glomerulonephropathy
```
73
What is the pathophysiology of minimal change disease? What major effect does it have?
T cell/cytokine mediated GBM damage, it results in protein easily slipping through the GBM
74
Who is likely to present with nephrotic syndrome caused by minimal change disease?
Children/ young people
75
How long does it take to present with nephrotic syndrome caused by minimal change disease?
A long time- it takes a while to progress
76
What does nephrotic syndrome caused by minimal change disease respond to?
Steroids
77
What is nephrotic syndrome caused by focal segmental glomerulosclerosis associated with?
HIV +ve patients
78
What is nephrotic syndrome caused by membranous nephropathy associated with?
Malignancy
79
Who is likely to present with nephrotic syndrome caused by membranous nephropathy?
An adult with a malignancy
80
What antigen is membranous nephropathy associated with?
PLAR2
81
How is nephrotic syndrome caused by amyloidosis diagnosed? What will you see when you investigate?
Diagnosed by rectal biopsy
| Congo staining will show apple green birefrigence
82
What is the most common cause of nephrotic syndrome?
Diabetic nephropathy
83
How is nephrotic syndrome caused by diabetic nephropathy diagnosed? What will you see when you investigate?
Ultrasound KUB
| Will show large kidneys
84
How is nephrotic syndrome caused by diabetic nephropathy treated?
Ace inhibitors
85
What is Alport syndrome?
A genetic condition that leads to nephritic syndrome
86
Who will commonly present with Alport syndrome? How?
A child, they present with kidney damage and will also have sensorineural hearing loss
87
Why may someone with nephritic syndrome present with polyphonic wheeze as a sign?
They may have oedema in the lungs
88
How does one get polycystic kidney disease?
Inherited- autosomal recessive PKD1 gene on chromosome 16
89
What is polycycstic kidney disease?
Multiple cysts with renal parenchyma
90
What are symptoms of polycystic kidney disease?
Abdominal or loin pain
Symptoms of chronic renal failure (nausea and vomiting, oedema, pruritis)
Heart murmur
91
What heart murmur is observed in polycystic kidney disease? What does it sound like?
Mitral valve prolapse, its a mid systolic click
92
What murmur is a mid systolic click?
Mitral prolapse
Mid systolic= left side of heart
click= valve prolapsing
93
How might someone suddenly die of polycystic kidney disease? Why?
Via subarachnoid haemorrhage
| Small berry aneurysms form in the brain which are at risk of bursting
94
What should you always ask about if you suspect polycystic kidney disease and why?
Family history, its genetic so if someone in their family suddenly died of a subarachnoid haemorrhage it makes it likely they might have PCKD
95
What investigations should you do if you suspect PCKD?
```
Blood pressure
Urine dip
U+Es
Abdo US
CT head
ECG
```
96
What is the gold standard investigation for PCKD?
Abdominal ultrasound
97
What will you expect to see on U+Es in someone with PCKD?
High creatinine and urea
98
What is renal artery stenosis?
Narrowing of the renal arteries resulting in hypoperfusion
99
What effect would renal artery stenosis have on blood pressure and why?
Stimulates the renin angiotensin system
| Increased angiotensin II causes increased aldosterone which increases blood pressure
100
What might high blood pressure from renal artery stenosis cause?
Kidney failure
101
Who is most likely to have renal artery stenosis and what are the risk factors?
Men over 50
| Normal cardiovascular risk factors eg diabetes, overweight, hyperlipidaemia, hypertension etc
102
Asides from older men who have cardiovascular risk factors what is another cause of renal artery stenosis and who is it common in?
Fibromuscular dysplasia
| Common in women under 45 who have high blood pressure
103
If a women under 45 with hypertension presents with renal artery stenosis, what is the likely cause?
Fibromuscular dysplasia
104
How will someone with renal artery stenosis present?
They may be asymptomatic
Patients who have a history of hypertension
May have symptoms of renal disease eg proteinuria, fluid overload eg pulmonary oedema, abdominal bruits
105
What drugs may someone with renal artery stenosis have recently been started on?
Ace inhibitor
| Angiotensin receptor 2 antagonist
106
What effect will vasconstriction of the afferent arteriole of the Bowman's capsule have on the GFR?
It will reduce it (perfusion into the bowmans capsule is redcued)
107
What effect will vasconstriction of the efferent arteriole of the Bowman's capsule have on the GFR?
It will increase it (makes it harder for blood to leave the bowman's capsule)
108
What effect would an angiotension II receptor blocker or an ace inhibitor have on GFR?
It would stop the efferent arteriole vasoconstricting and would therefore reduce GFR and perfusion of the kidney
109
What drugs should you not give someone with renal artery stenosis and why?
Ace inhibitor or angiotensin II receptor blocker because they reduce renal perfusion by stopped the efferent arteriole constricting, those with renal artery stenosis already have poor perfusion
110
What investigation should you do for renal artery stenosis?
Bloods (U+Es, FBC, aldosterone:renin)
Duplex ultrasound
Conventional angiography
111
What is duplex ultrasound? Give advantages and disadvantages
It measures the velocity of the blood flow in the renal artery so you can see how occluded it is but its not very sensitive so will only pick up occlusion if its more than 50%
112
What is the gold standard/ best investigation for renal artery stenosis? Give its advantages
Conventional angiography
It is more sensitive than MR/CT angiography and doesn't require contrast whereas MR/ CT angiography does. Contrast may be nephrotoxic
113
What will you hear on examination that may make you think the issue could be renal artery stenosis?
Renal bruit
114
What are some risk factors for renal cell carcinoma?
Smoking
Male
Obese
Hypertension
115
What symptoms will someone with renal cell carcinoma present with?
Triad of haematuria, flank pain and flank/abdominal mass
Malignancy symptoms include malaise, appetite loss, weight loss
Shortness of breath
116
Why may someone with renal cell carcinoma get shortness of breath?
They may be anaemic
117
What is the gold standard investigation for renal cell carcinoma?
CT of the abdomen and pelvis
118
What investigations would you do if you suspect renal cell carcinoma?
CT abdomen/ pelvis
Bloods (FBC for anaemia, U+Es for renal function, LDH is a prognostic factor for late stage disease, calcium, LFTs for liver mets, coagulation)
Urinalysis (check for proteinuria or haematuria)
119
Why might someone with renal cell carcinoma get anaemia or low RBC count?
Lack of erythropoietin
120
What are causes of urinary tract calculi
Mostly idiopathic, sometimes due to high calcium or urea
121
What are risk factors for urinary tract caliculi?
Low fluid intake
Structural abnormalities of the ureter
Crystalluria
High protein and salt intake
122
What are the 3 most common sites of impaction/obstruction of the ureter?
Ureteropelvic junction
Crossing of the iliac artery
Uterovesical junction
123
What is crystalluria?
Formation of crystals in the urine
124
How will a patient with urinary tract calculi present?
```
Often asymptomatic
Severe loin to groin pain
Nausea and vomiting
Urinary frequency/ urgency
Haematuria
```
125
How do you tell apart kidney stone pain from peritonitis?
Kidney stone patients will be writhing around in pain
| Peritonitis patients will be lying completely still and will experience severe pain on moving
