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Nephrology 1 Flashcards

1
Q

What is acute kidney injury?

A

The abrupt loss of kidney function

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2
Q

What can result from acute kidney injury?

A

The retention of urea and other nitrogenous waste products

The dysregulation of extracellular volume and electrolytes

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3
Q

What is the usual pathophysiology of AKI?

A

Acute tubular necrosis (ischaemia, from sepsis or shock, or nephrotoxins - aminoglycosides or myoglobin)
Muddy brown casts of epithelial cells

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4
Q

What staging systems are used for AKI in children and adults?

A

Adults: KDIGO
Children: pRIFLE

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5
Q

How is AKI monitored?

A

Rise in creatinine
Drop in urinary output
Falling eGFR

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6
Q

Name five pre-renal causes of AKI.

A

Volume depletion: severe v+d, haemorrhage
Oedematous states: cardiac failure
Hypotension: sepsis, cardiogenic shock
Renal hypoperfusion: ACEIs or ARBs, AAA, renal artery stenosis

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7
Q

Name three renal causes of AKI.

A

Glomerular disease: glomerulonephritis, HUS
Vasculitis
Ischaemic tubular injury

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8
Q

Name three post renal causes of AKI.

A

Renal calculus
Blood clot
Pelvic malignancy

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9
Q

Give three risk factors for AKI.

A

CKD
Nephrotoxic drugs
Previous history of AKI

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10
Q

Name five nephrotoxic drugs.

A 
Diuretics
ACEIs
Metformin
NSAIDs
Aminoglycosides
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11
Q

How does AKI typically present?

A 
Oliguria/anuria
Rise in serum creatinine
Nausea and vomiting
Dehydration
Confusion
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12
Q

What are the signs of AKI?

A

Hypertension
Dehydration
Raised JVP and oedema

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13
Q

Define AKI

A

Rise in serum creatinine of 26umol/L in 48 hours
Drop in urine output to 0.5ml/kg/hr (for 6 hours in adults and 8 hours in children)
Children - fall in eGFR of 25% or more in the preceding 7 days

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14
Q

What urinalysis investigations are required in AKI?

A

Dipstick for blood, nitrates, leukocytes, glucose, protein
Osmolality
Myoglobinuria

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15
Q

What blood tests are required in AKI?

A 
FBC and film
U&Es
Coagulation studies for DIC and sepsis
CK
Immunoglobulins or ANAs
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16
Q

When is ultrasound indicated in AKI?

A

When obstruction is suspected or no cause identified.

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17
Q

What is the management of electrolytes and fluid balance in AKI?

A

0.9% saline
Restrict oral potassium/sodium and avoid K supplements
Correct electrolyte imbalances

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18
Q

What are the indications of renal replacement therapy in AKI?

A

When any of the following are not responding to medical management:

  • severe refractory hyperkalaemia (>7mmol/L)
  • metabolic acidosis
  • fluid overload
  • symptoms of uraemia (pericarditis too)
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19
Q

Define chronic kidney disease.

A

Presence of kidney damage (albuminuria) or decreased kidney function (GFR<60ml/min/1.73m2) for 3 months or longer

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20
Q

Sustained decrease in GFR of 25% or more and a change in GFR category within 12 months is called what?

A

Accelerated progression of CKD

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21
Q

Define kidney failure.

A

GFR<15ml/min/1.73m2
OR
Need for RRT

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22
Q

Give three causes of CKD.

A

Hypertension or diabetes
Infective, obstructive, and reflux nephropathies
Glomerulonephritis

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23
Q

Give five risk factors for CKD.

A 
CVD
Diabetes, hypertension, smoking
Afro-Caribbean descent
FH
Proteinuria
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24
Q

How is kidney function assessed?

A

GFR

Albumin-creatinine ratio

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25
CKD is usually asymptomatic and discovered routinely. What are the symptoms of severe CKD?
``` Anorexia, nausea, fatigue Weakness and muscle cramps Oedema ---> dyspnoea Nocturia and polyuria Insomnia Headaches Sexual dysfunction ```
26
What are the four Ps, signs of CKD?
Pigment: Increased skin pigmentation/ excoriation Pallor Pleural effusions/peripheral oedema Postural hypotension/ hypertension
27
What is the typical biochemistry results of a patient with CKD?
``` Plasma glucose: high Serum sodium: low Serum potassium: high Serum bicarb: low Serum albumin: low Serum phosphate: high ```
28
Rise in which substances suggests CKD-related bone disease?
ALP | PTH
29
What sort of anaemia do CKD patients have?
Normochromic normocytic anaemia
30
What urine investigations are performed for CKD?
Urinalysis Spot urine collection for total protein:creatinine ratio ACR Culture
31
What typical interventions are used in CKD patients for the following problems? 1) Primary prevention of CVD 2) Hypertension 3) Obesity 4) Prevention of osteoporosis 5) Secondary hyperparathyroidism (from hypocalcaemia)
1) Atorvastatin 20mg and apixaban 2) ACEI and restrict sodium to <2.4g/day 3) 30-35kcal/IBW/day 4) Bisphosphonates 5) Vitamin D supplementation (hypocalcaemia results from low activated form of vitamin D)
32
What is diabetes insipidus?
Deficiency of ADH (central DI) or insensitivity to its action (nephrogenic DI)
33
Define diabetes insipidus.
>3 litres/24 hours of low osmolality urine
34
Give three causes of central and nephrogenic DI.
Central: cerebral tumour, cerebral bleed, hypothalamic-pituitary surgery, haemochromatosis Nephrogenic: renal disease, hyperkalaemia, sickle cell anaemia
35
How does DI present in adults?
Polyuria and nocturia Extreme polydipsia - ice water Dehydration - v+d Grossly enlarged bladder
36
How does DI present in children?
Irritability, FTT, protracted crying, fever, anorexia
37
How is DI diagnosed?
Simultaneous plasma (high) and urine (low) osmolality 24 hour urine collection Fluid deprivation test
38
What happens in a patient with DI in a fluid deprivation test?
Plasma osmolality rises, urine osmolality remains dilute
39
What is the treatment of cranial DI?
Desmopressin | tablets, intranasal spray, injection
40
What is the treatment of nephrogenic DI?
Hydrochlorothiazide
41
What is the pathophysiology of diabetic nephropathy?
Excess reactive oxygen species damages glomeruli and increased blood glucose damages and thickens the glomerular basement membrane
42
What are some risk factors for diabetic nephropathy?
Poorly controlled blood glucose levels Type 1 diabetes Smoking and hypertension
43
What are the symptoms of diabetic nephropathy?
``` Tiredness Headaches Nausea Vomiting Itchy skin Peripheral oedema ```
44
How is diabetic nephropathy diagnosed?
Urine albumin >300mg/24hour | Early morning ACR annually
45
What are renal calculi composed of?
Men - calcium oxalate and calcium phosphate | Women - mixed infective stones (magnesium ammonium phosphate with calcium)
46
What are the risk factors for renal calculi?
``` Dehydration Hypercalcaemia Hypercalcuria Hyperoxaluria Hyperuricaemia Infection/cystinuria Polycystic kidneys Indwelling catheters ```
47
Where is calcium reabsorbed in the kidney?
Proximal tubule | Parathyroid hormone
48
What are Randall's plaques?
Calcium oxalate precipitates form in the BM of LoH, which accumulate in the renal papillae. Pre-calculus.
49
How do renal stones present?
``` Asymptomatic Renal colic Haematuria Dysuria/anuria Rigors and fever ```
50
What is renal colic?
Sudden severe pain, radiates from flank to iliac fossa or scrotum. There may be vomiting. Usually constant Tenderness
51
How is haematuria classified?
Visible or non visible | Symptomatic or non-symptomatic
52
Define significant haematuria.
One episode of VH One episode of s-NVH Persistent a-NVH
53
What are five causes of haematuria?
``` UTI Renal cell/prostate/bladder malignancy Urinary calculi Trauma to kidney etc Vigorous exercise ```
54
What are three differentials of haematuria?
Haemoglobinuria (no red cells on microscopy) Myoglobinuria Beeturia Rifampicin
55
What are the details of the 2 week cancer pathway referral for haematuria?
Px aged over 45: unexplained VH Px aged over 60: Unexplained NVH and dysuria/raised WCC
56
Which patients are at risk of hypernatraemia?
Elderly patients and infants as impaired expression of thirst and independent access to water Patients with altered mental status Critical illness
57
What are the four causes of hypernatraemia?
Pure free water loss (dehydration) Hypotonic fluid loss (dehydration and hypovolaemia) Hypertonic sodium gain Intracellular shift of water (rare)
58
What are the causes of pure free water loss/dehydration?
Inadequate water intake DI Thirst impairment
59
What are the causes of hypotonic fluid loss?
Burns GI losses Urinary losses e.g. loop diuretics or osmotic diuresis
60
What are the causes of hypertonic sodium gain?
Hypertonic saline | Poisoning
61
How does hypernatraemia present?
Hypovolaemia: Dry mouth and abnormal skin turgor Oliguria Tachycardia and postural hypotension CNS: Lethargy, confusion, seizures
62
How is hypernatraemia managed?
Replace free water losses and electrolytes if appropriate
63
What are fluid requirements composed of?
Water deficit | Measured and insensible fluid losses
64
How fast is a chronic (>24 hours) hypernatraemia corrected?
Slower than 0.5mmol/L/hour If not, there is risk of osmotic demyelination and cerebral oedema.
65
How fast is a rapid hypernatraemia corrected?
More rapidly, but ensure sodium does not rise >6mmol/L in 6h, or >10mmol/L in 24h
66
Which fluids are appropriate to give to hypovolaemic and hypervolaemic patients?
Hypovolaemic - 0.9% saline | Hypervolaemic - 5% dextrose and diuretics.
67
Name a complication of hypernatraemia.
Cerebral bleeding
68
What is the most common electrolyte abnormality?
Hyponatraemia
69
Hyponatraemia can be hypovolaemic, euvolaemic, and hypervolaemic. What are the causes of these?
Hypo - V+D, diuretics, renal disease Eu - acute water load, SIADH Hyper - CCF, cirrhosis, nephrotic syndrome, renal failure
70
What are the symptoms of mild, moderate, and severe hyponatraemia?
Mild - anorexia, headache, vomiting Mod - Confusion, ataxia Severe - drowsiness, seizures
71
Coma, fixed dilated pupil, decorticate or decerebrate posturing, and respiratory arrest are signs of what?
Brainstem herniation
72
Pulmonary rales, S3 gallop, increased JVP, ascites, and peripheral oedema, are signs of what?
Hypervolaemia
73
Dry mucus membranes, tachycardia, and decreased skin turgor, are signs of what?
Hypovolaemia
74
What is the main management of hyponatraemia?
Hypertonic saline
75
In treatment of hypovolaemic hyponatraemia, ADH is suppressed as euvolaemia is regained. What is the effect of this?
There is a resulting diuresis. Sodium elevates rapidly --> Desmopressin
76
What is the treatment of hypervolaemic hyponatraemia?
Treat underlying cause e.g. HF, AKI, cirrhosis
77
How are renal calculi diagnosed?
Dipstick: red cells MCS of MSU Bloods for FBC, renal function, and electrolytes NON ENHANCED HELICAL CT SCNANING OF KUB - gold standard
78
How is an acute episode of renal colic managed?
Diclofenac IM Metoclopramide IM Rehydration Monitor passage of stone
79
Name a procedure to remove renal calculi.
Extracorporeal shock wave lithotripsy.
80
Name two complications of renal calculi.
Hydronephrosis Ulceration Infection and sepsis
81
How are further renal calculi prevented from forming?
Increase fluid intake Reduce salt, animal protein, urate, and oxalate intake Normal calcium intake Cranberry juice

Phase 3B (20 decks)

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