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Flashcards in Nephrology Deck (102):
1

What are the eGFR ranges for each stage of CKD?

Stage 1=>90
Stage 2=60-89
Stage 3a= 45-59
Stage 3b= 30-45
Stage 4 = 15-29
Stage 5 = <15

2

Name 3 causes of CKD

Diabetes
Hypertension
AKI
Glomerulonephritis

3

Name 3 risk factors for the development of CKD

Family history
Previous AKI
Smoking
Cardiovascular disease
Hypertension
Diabetes
Long-term use of NSAIDs
Being of south Asian or african origin
Untreated urinary obstruction

4

What factor determines the glomerular capillary pressure?

The difference in pressure between the afferent and efferent arterioles

5

What substance regulates the pressure of the efferent glomerular arteriole?

Angiotensin 2

6

How does prolonged hypertension lead to CKD?

Prolonged hypertension means prolonged increase in angiotensin 2, which causes constriction of the fferent arteriole
This increases the glomerular pressure, initially maintaining or increasing the eGFR
Eventually, there is basement membrane damage and sclerosis, leading to proteinuria

7

Name 5 symptoms of severe CKD

Pruritis
Anorexia
Nausea and vomiting
Hiccups
Fatigue and weakness
Peripheral oedema
Dyspnoea
Muscle cramps
Insomnia
Nocturia and polyuria
Sexual dysfunction

8

Name 3 signs of CKD

Reduced GFR
SUstained microalbuminuria
Sustained haematuria
Sustained proteinuria
Structural kidney disease
Chronic glomerulonephritis

9

How is CKD tested for?

Measure serum creatinine to calculate eGFR
Early morning urine sample to calculate Albumin:creatinine ratio
Urine dipstick for haematuria
Repeat GFR in 2 weeks if abnormal
Repeat GFR and ACR in 3 months

10

What investigations should be done if CKD is present?

Blood glucose
U&Es
Bone profile
PTH
Lipid profile
USS of kidneys

11

What are the ACR ranges for classifying CKD?

A1 = <3 = normal
A2 = 3-30 = moderate increase
A3 = >30 = severe increase

12

How should CKD be managed?

Patient education
Medication review
Refer to nephrology if appropriate
Monitor progression with eGFR and ACR
Monitor FBC and bone profile
Lifestyle advice
Treat hypertension
Treat diabetes
Assess and manage cardiovascular risk. Prescribe all patients a statin and give aspirin as secondary prevention
Influenza and pneumococcal vaccination

13

When should a person with CKD be referred to nephrology?

Stage 4 and above
ACR >70mmol
ACR >30 + persistent haematuria
Uncontrolled hypertension despite treatment with 4 drugs
Significant decline in eGFR (15ml or 25%+stage change) in 12 months
Suspicion or confirmation of rare or genetic cause
Suspected renal artery stenosis
Complications such as anaemia or bone disease

14

What lifestyle advice should be given to patients with CKD?

Stop smoking
Exercise
Lose weight
Avoid over the counter NSAIDS

15

What is the target blood pressure for someone with CKD?

120-139/<90 if ACR>30
120-129/<80 if ACR>70

16

Name 3 complications of CKD

Requiring RRT
Renal anaemia
Renal bone disease
Cardiovascular disease
Lipid abnormalities
Neuropathy
Malnutrition

17

Name 3 factors which influence the decision of when to start dialysis

Patient's symptoms
Biochemical disturbances
Comorbidity
Risks to the patient
Resources available

18

What supportive pharmacological treatment is required for someone with end-stage renal disease?

Erythropoeitin
Vitamin D
Anti-pruritics
Anti-emetics
Dietary control

19

Name an advantage of haemodialysis

Good long-term survival
Can be done overnight
Can be done at home
Dose can be individualised

20

Name 5 possible complications of haemodialysis

Line infection
Endocarditis
Thrombosis
Line stenosis
Hypotension
LV hypertrophy
Arrhythmias
Air embolism
Nausea and vomiting
Headaches
Thrombocytopenia
Depression

21

What are the 4 main types of peritoneal dialysis

Continuous ambulatory
Assisted
Automated
Tidal

22

What are three absolute contraindications for peritoneal dialysis?

Stoma in place
Diaphragmatic leak
Known peritoneal sclerosis

23

Name 3 relative contraindications for peritoneal dialysis

Morbid obesity
Ascites
Severe organomegaly
Severe respiratory disease
Previous multiple operations
Hernias
Lack of manual dexterity
Cognitive impairment

24

What is an advantage of peritoneal dialysis?

Allows independence
Improved mobility
Gentler electrolyte control

25

Name 3 complications of peritoneal dialysis

Sclerosing peritonitis
Peritonitis
Weight gain
Fluid leaks
Malnutrition

26

Name 3 contraindications for renal transplantation

Malignancy
Ongoing infection
Viral hepatitis
Mental incapacity
Uncontrolled ischaemic heart disease
Extensive peripheral vascular disease

27

Name 4 types of donor

Cadaver
Living related
Living emotionally related
Living unrelated

28

Define AKI

A rapidly rising concentration of nitrogenous wastes in the blood, due to renal impairment. There is an inability to maintain fluid, electrolyte and acid-base homeostasis

29

Name 3 pre-renal causes of AKI

Sepsis
Heart failure
Haemorrhage
Burns
Severe vomiting and diarrhoea
Cirrhosis
Nephrotic syndrome
Cardiogenic shock
Anaphylaxis
Arrhythmias
NSAIDs
AAA
Renal artery stenosis

30

Name 3 renal causes of AKI

Glomerulonephritis
Thrombosis
Acute tubular necrosis
Interstitial nephritis
Vasculitis
Eclampsia

31

Name 3 post-renal causes of AKI

Renal calculus
Urethral stricture
Blood clot
Retroperitoneal fibrosis
Prostatic hypertrophy
Pelvic mass

32

Name 5 risk factors for the development of AKI

Being aged 65 and over
Having CKD
Previous AKI
Urological obstruction
Nephrotoxic drugs
Peri-operative patient
Heart failure
Liver disease
Diabetes
Exposure to iodinated contrasts
Cognitive or neurological impairment
Sepsis
Hypovolaemia

33

What is the criteria for stage 1 AKI?

Rise in serum creatinine by at least 26 micromol or 1.5-2x baseline
or urine output <0.5ml/kg/hour for at least 6 hours

34

What is the criteria for stage 2 AKI?

Serum creatinine of 2-3 x baseline or urine output of <0.5ml/kg/hour for at least 12 hours

35

What is the criteria for stage 3 AKI?

Serum creatinine at least 3 x baseline or urine output <0.3ml/kg/hour for 24 hours or anuria for 12 hours

36

What are the general principles of managing AKI?

Identify and treat the underlying cause. Remove any nephrotoxic drugs, treat any infection or fluid overload. Relieve any obstruction and contact nephrology if cause is unclear

37

When might a case of AKI require renal replacement therapy?

pH <7.2, not responding to bicarbonate
Potassium >6.5, not responding to treatment
On top of CKD stage 4 or 5
Uraemic complications
Pulmonary oedema, not responding to treatment.

38

How should an insulin pen be stored after opening?

At room temperature, for no more than 30 days

39

How should insulin be administered?

Either IV or SC into outer thigh or abdomen

40

What are the main types of insulin?

Rapid, short, intermediate and long acting, and insulin mixes

41

Name two examples of a rapid acting insulin

Novorapid
Humalog

42

Name two examples of a short acting insulin

Actrapid
Humulin S

43

Name two examples of an intermediate acting insulin?

Insulutard
Humulin I

44

Name two examples of a mixed insulin?

Humalog mix
Insuman comb

45

Name to examples of a long acting insulin

Humalin R 500
Degludec

46

What is the onset, peak and duration of action of a rapid acting insulin?

Onset = 5-15mins
Peak = 30-60mins
Duration = 3-4hours

47

What is the onset, peak and duration of action of a short acting insulin?

Onset = 30-60mins
Peak = 2-3 hours
Duration = 6-8 hours

48

What is the onset, peak and duration of action of an intermediate acting insulin?

Onset = 1-2 hours
Peak = 4-6 hours
Duration = 4-16 hours

49

What is the mixture in a mixed insulin?

An intermediate + a rapid or short acting insulin

50

How often is a mixed insulin usually given?

Twice a day

51

How often is Humulin R 500 given?

TDS, with meals

52

Name 3 indications for administering IV insulin

Diabetic ketoacidosis
Hyperglycaemic hyperosmolar state
Patients after a cardiovascular event
Type 1s who are:
NBM surgical patients missing >1 meal
Vomiting
Steroid use
Metabolically unwell and not eating and drinking
TPN/enterally fed

53

Name 3 risks of IV insulin

Hyper-hypoglycaemia
Rebound hyperglycaemia if stopped inappropriately
Fluid overload
Hypokalaemia
Hyponatraemia
Line infection

54

What is the target capillary blood glucose for a patient on IV insulin?

6-10mmol
4-12 is acceptable

55

When should a type 1 diabetic on IV insulin be screening for ketones?

If they have had >2 consecutive readings >1 hour apart showing glucose >12mmols

56

How should IV insulin be discontinued?

Once patient is eating and drinking and back on their normal diabetes regime, insulin can be stopped. It's action stops in 5 minutes

57

What drugs can cause hypercalcaemia?

Lithium
Thiazide diuretics
Antacids

58

How is hypercalcaemia managed?

Rehydration with saline
Bisphosphonates

59

How is hypocalcaemia managed?

If mild, then 5mmol/6hrs PO calcium
If severe, 10mls of 10% calcium gluconate IV over 30 mins
If CKD then give alfacalcidol

60

How is the anion gap calculated?

(conc of Na and K)-(conc of Cl- and HCO3)

61

How does the underlying pathology differ between metabolic acidosis with a normal and an increased anion gap?

In a normal anion gap, there is either bicarbonate loss or H+ ingestion, but chloride is retained
In an increased anion gap, there is either and increased production or reduced excretion of organic acids causing a reduction in HCO3- and accumulation of acids and anions

62

Give three causes of metabolic acidosis with a normal anion gap

GI loss of bicarb eg diarrhoea, fistula, uterosigmoidostomy
Renal tubular acidosis
Drugs
Addison's disease

63

Give three causes of metabolic acidosis with a raised anion gap

Increased ketones in DKA and alcohol
Urate in renal failure
Lactic acid increase in tissue ischaemia, shock and infection
Salicyclate
Methanol
Biguanides

64

Give three causes of metabolic alkalosis

Vomiting
Hypokalaemia (diuretics)
Cushing's
Primary hyperaldosteronism
Barter's syndrome
Congenital adrenal hyperplasia

65

Give three causes of respiratory acidosis

COPD
Life threatening asthma
Opiates
Brain stem lesion
Kyphoscoliosis
Chronic bronchitis

66

Give three causes of respiratory alkalosis

Anxiety
Salicyclate poisoning
Stroke
SAH
Meningitis
Altitude
Hyperthermia
Pregnancy
Pulmonary embolism

67

Give three renal causes of haematuria

Trauma
Pyelonephritis
Neoplasia
Glomerulonephritis
Polycystic kidney disease

68

Give 5 extra-renal causes of haematuria

Urethritis
Prostatitis
Cystitis
Calculi
Catheters
Bladder, prostate or urethra neoplasia
Increased bleeding tendency
NSAIDs
Ciprofloxacin
Furosemide

69

Give 3 causes of painless haematuria

GU cancers
Alport syndrome
IgA nephropathy
Thin BM disease

70

Give 5 causes of proteinuria

Fever
After exercise
Orthostatic
Diabetes mellitus
Minimal change GN
Membranous GN
ATN
Amyloidosis
Hypertension
SLE
Interstitial GN
UTI
Pregnancy
heart failure
Multiple myeloma

71

Give a cause of microalbuminuria

Diabetes mellitus
Hypertension
Minimal change glomerulonephritis

72

How should an uncomplicated UTI be managed?

Trimethoprim or nitrofurantoin for 3-6 days

73

How should an upper UTI be managed?

Cefuroxime or ciprofloxacin

74

How should UTIs in men be managed?

Two weeks on a quinolone eg levofloxacin and low threshold for referring to urology

75

How should potential glomerulonephritis be managed?

Bloods for the usual + immunoglobulins, complement, autoantibodies, blood culture and hep B and C
Urine for casts and MC+S
Spot PCR or ACR
CXR
Renal USS and biopsy

76

What is the typical presentation of IgA nephropathy?

Few days after an URTI
Episodic haematuria
Usually in a young male

77

How is IgA nephropathy managed?

Steroids
Cyclophosphamide

78

What are the blood pressure targets in glomerulonephritis?

<130/80 ir <125/75 if proteinuria

79

How does glomerulonephritis present?

Usually as nephritic syndrome or nephrotic

80

Which renal disease is associated with haemoptysis?

Anti-GBM

81

What is henoch-schonlein purpura?

A palpable purpuric rash and localised oedema due to IgA mediated vasculitis

82

What is nephrotic syndrome?

A triad of proteinuria, oedema and hypoalbuminaemia

83

Give three causes of nephrotic syndrome

Minimal change
Focal segmental
Membranous glomerulonephritis
Mesangiocapillary glomerulonephritis
Diabetes mellitus
SLE
Amyloidosis

84

Give two complications of nephrotic syndrome

Increased susceptibility to infection
THromboembolism
Hyperlipidaemia

85

What is the pathological change in minimal change glomerulonephritis?

Fusion of podocytes in basement membrane increasing permeability to albumin and transferrin only

86

How is minimal change glomerulonephritis managed?

Steroids +/- cyclophosphomide

87

In general, how are nephrotic conditions managed?

Monitor U&Es, BP and fluid balance
Aim for negative sodium balance and 0.5-1kg weight loss per day
treat underlying cause
Furosemide +/- spironolactone
ACE inhibitors reduce proteinuria
Treat any infection
Statin if persistent hyperlipidaemia
Treat hypertension
Stop smoking
Pneumococcal vaccination
Steroids to induce remission and cyclophosphamide/ciclosporin if declining function

88

What is the pathological change in membranous glomerulonephritis?

Thickening of basement membrane and IgG subendothelial deposits

89

What immunoglobulin is associated with focal segmental glomerulosclerosis?

IgM and C3

90

Give three complications of AKI

Uraemic pericarditis
Hyperkalaemia
Pulmonary oedema
Metabolic acidosis

91

How does chronic transplant rejection cause disease?

Mainly vascular changes causing organ ischaemia and local cell changes

92

What is the leading cause of death in people with successful renal transplants?

Atheromatous vascular disease

93

What is renovascular disease?

Stenosis of the renal artery or one of its branches causing hypertension

94

What are the features of renal artery stenosis?

Treatment resistant hypertension
Significant worsening of renal function on starting an ACE-i or ARB
Flash pulmonary oedema

95

What is the most common case of haemolytic uraemic syndrome?

E coli

96

What are the features of thrombotic thrombocytopenic purpura?

Fever
Fluctuating CNS signs
Low platelets
Microangiopathic haemolytic anaemia
Renal failure
Haematuria/proteinuria

97

What drugs can cause thrombotic thrombocytopenic purpura?

Clopidogrel
Ciclosporin

98

How does renal artery stenosis appear on ultrasound?

Affected kidney will be smaller

99

How can diabetic nephropathy be monitored for?

Early morning ACR every 6 months

100

What are the general stages in the development of diabetic nephropathy?

Glomerulosclerosis and thickening of the basement membrane due to protein glycosylation
Arterial sclerosis and interstitial fibrosis
Initially, hyperfiltration followed by kidney injury, hypertension and declining renal function
Microalbuminuria develops into macroalbuminuria
Presents as nephrotic syndrome
End stage renal failure follows nephrotic syndrome roughly 5 years later

101

How is osmolality calculated?

(2xNa)+glucose+urea

102

What factors make up the Modified Diet in Renal Disease calculation?

Serum creatinine
Age
Gender
Ethnicity