Nephrology

Question 1

NICE diagnostic criteria AKI

Answer 1

1. Rise in creatinine >25um/L in 48 hours
2. Rise in creatinine >50% from baseline in 7 days
3. Urine output <0.5ml/kg/hr for >6 hours

Question 2

Nephrotoxic drugs

Answer 2

GOD SAD MAN
Gentamicin / Opiates / Diuretics / Sulfonylureas / ACEi & ARBs / DOACs / Metformin / Aldosterone antagonists / NSAIDs

Question 3

Pre-renal causes of AKI

Answer 3

Pre-renal = hypoperfusion
1. True hypoperfusion = GI losses, dehydration, burns, haemorrhage
2. Relative hypoperfusion = NSAIDs + ACEi

Question 4

Renal causes of AKI

Answer 4

Glomerulonephritis
Acute tubular necrosis
Acute interstitial nephritis
Vascular causes e.g HUS or malignant HTN

Question 5

Post-renal causes of AKI

Answer 5

Bilateral pelvic-ureteric obstruction
Bilateral ureteric obstruction
Bladder outflow obstruction
Urethral obstruction

Question 6

Complications of AKI

Answer 6

Hyperkalemia
Hyperphosphatemia
Uremia
Fluid overload
Metabolic acidosis

Question 7

Classification of CKD

Answer 7

Stage 1 = Kidney damage + GFR > 90
Stage 2 = Kidney damage + GFR 60-89
Stage 3 = GFR 45 - 59
Stage 3b = GFR 30 - 44
Stage 4 = GFR 15 - 29
Stage 5 (ESRF) = GFR <15

Question 8

Which medication can cause rhabdomyolysis

Answer 8

Statins

Question 9

Staging of AKI

Answer 9

Stage 1 = Creatinine rise of >26 in 48hours or 1.5-1.99 x increase from baseline in 7 days
Stage 2 = Creatinine rise of 2 - 2.9 x baseline in 7 days
Stage 3 = Creatinine rise 3x of baseline in 7 days or >350 within 48 hours

Question 10

Indications for dialysis

Answer 10

“AEIOU”
Acidosis
Electrolyte derangement resistant to treatment
Intoxication
Pulmonary Oedema
Uremia

Question 11

What should be prescribed to diabetics with a A:CR of >3

Answer 11

ACE inhibitor

Question 12

Symptoms of uremia

Answer 12

Pruritus
Loss of appetite
Metallic taste in mouth
N&V
Neuropathy
Encephalopathy

Question 13

Management of CKD

Answer 13

Optimise risk factors - HTN/diabetes etc
Treat any glomerulonephritis
Reduce CVD risk = Atorvostatin 20mg
Reduce complications risk - Low K+ and phosphate diet, maintain healthy weight, stop smoking etc

Question 14

Complications of CKD

Answer 14

Hypertension
Anemia
Renal bone disease
Hyperkalemia

Question 15

Management of CKD induced anemia

Answer 15

EPO

Question 16

Side effects of EPO

Answer 16

Bone aches
Flu like symptoms
Skin rashes
Hypertension
Iron deficiency anemia

Question 17

Treatment of renal bone disease

Answer 17

Active Vitamin D (calitrol)
Oral calcium supplementation
Bisphosphonates

Question 18

Xray findings in renal bone disease

Answer 18

Rugger jersey spine (osteosclerosis at edges of vertebrae with osteomalacia in the center)

Question 19

Management of hyperkalemia

Answer 19

IV Insulin + Dextrose infusion
Calcium gluconate - to stabilise cardiac membrane
Nebulised salbutamol
IV fluids
Calcium resonium - removal of K+ from the body

Consider sodium bicarb if acidotic or Dialysis if severe

Question 20

Acute renal transplant failure

Answer 20

Presents <6 months after transplant with Proteinuria + Raised leucocytes + Rising creatinine

Question 21

Acute interstitial nephritis

Answer 21

Inflammation of the interstitium
Sx = AKI + Hypertension + Hypersensitivity reaction e.g fever, arthralgia, eosinophilia.
Cause = penecillins / NSAIDs usually

Management = Steroids

Question 22

Acute tubular necrosis

Answer 22

acute necrosis of the epithlium in the renal tubules leading to an AKI. Classically resulting from ischemia or toxins.

Hypoperfusion causes = shock/sepsis/dehydration/haemorrhage
Toxins = Constrast dye / gentamycin / NSAIDs

Invx = muddy brown casts on urinalysis
Low urine osmolality + high urinary sodium
Fully reversible. Poor response to fluid chalanges

Question 23

Apple-green bifringence on congo red staining

Answer 23

Amyloidosis

Question 24

HSP

Answer 24

Small vessel vasculitis - has overlap with berger’s disease (IgA nephropathy)

Question 25

Characteristic rash in HSP

Answer 25

Palpable purpuric rash over buttocks & extensor surfaces of arms and legs

Question 26

Nephritic syndrome

Answer 26

= inflammation of capillary endothelium + GBM Features: Proteinuria Haematuria Azotemia Red cell casts Oliguria Anti-streptolysin O titre Hypertension Sterile pyuria

Question 27

Nephrotic syndrome

Answer 27

= Podocyte damage in the GBM Proteinuria (>3g in 24hours) Hypoalbuminemia Oedema +/- dyslipidemia

Question 28

'Nephrotic-like' Glomerulonephritis'

Answer 28

Minimal change Membranous Focal segmental

Question 29

"Nephritic-like" Glomerulonephritis'

Answer 29

Post-streptococcal Anti-GBM (Goodpastures syndrome) IgA nephropathy (& HSP) Rapidly progressive Small vessel vasculitis (Microscopic polyangitis = pANCA, Granulomatosis with polyangitis = pANCA) + Alpert's syndrome (hearing problems)

Question 30

Mixed nephrotic + nephritic type GN

Answer 30

Membranoproliferative SLE

Question 31

Minimal Change disease

Answer 31

Most common cause of nephrotic syndrome in children. Histology normal LM normal EM = fusion of podocyte foot processes

Question 32

Membranous Glomerulonephritis

Answer 32

3rd most common cause of ESRF Caused by immune deposition in GBM causing damage to podocytes. Invx = Anti-phospholipase A2 antibodies LM = mesangial expansion Immunoflourescnce = IgG and C3 deposition EM = Subepithelial deposits - silver spikes & domes

Question 33

Focal segmental glomerulonephritis

Answer 33

Most common cause of nephrotic syndrome in adults. (typically younger adults) LM = Focal and segmental scarring & hyalinosis EM = GBM thickening *ANA levels may be risen if SLE is present (common cause of FSGN)

Question 34

IgA Nephropathy

Answer 34

Typified by IgA complexes within the mesangium - type 3 hypersensitivty reactions. Occurs 1-3 days after a sore throat. Associated with HSP Biopsy not needed as clinical diagnosis - but immunoflourescence would should IgA deposition

Question 35

Post-streptococcal GN

Answer 35

Occurs 1-3 weeks after a Group A beta-haemolytic streptoccocus infection (usually pyogenes, e.g tonsillitis) Raised ASO titre Low C3 Increased anti-DNAaseB

Question 36

Membranoproliferative GN

Answer 36

Causes proteinuria +/- Haematuria T1 = caused by immune complex depositis. EM shows 'tram-track' appearance T2 = C3b nephritic factor

Question 37

Anti-GBM GN (Goodpasture's syndrome)

Answer 37

Typically presents with AKI + Haemoptysis (pulmonary haemorrhage) Caused by antibodies to T4 Collagen (which is found in glomerular and alveolar basement membranes) Invx; - Linear IgG deposition in GBM - Raised Transfer factor

Question 38

Granulomatosis with Polyangitis (Wegener's)

Answer 38

Features: Sinusitis + Saddle nose deformity + AKI + Haemoptysis + Malaise + Arthralgia Invx = Raised cANCA Biopsy = granulomatous inflammation Management = Steroids + Cyclophosphamide

Question 39

Rapidly progressive GN

Answer 39

A term used to describe a rapid decline in renal function + Epithelial crescents in bowmans capsule. Causes = Goodpastures, Wegeners, Microscopic polyangitis + SLE. Basically the key finding is Epithelial crescents.

Question 40

Microscopic polyangitis

Answer 40

Nephritic GN No granulomatous inflammation seen Raised pANCA (target = myeloperoxidase 3)

Question 41

Alport's syndrome

Answer 41

Usually presents in childhood with Microscopic haemturia (nephritic syndrome) + progressive renal failure + bilateral sensorineural hearing loss + lenticonus Invx = EM shows splitting on lamina densa