Flashcards in Nephrology Deck (102):
What are the eGFR ranges for each stage of CKD?
Stage 3a= 45-59
Stage 3b= 30-45
Stage 4 = 15-29
Stage 5 = <15
Name 3 causes of CKD
Name 3 risk factors for the development of CKD
Long-term use of NSAIDs
Being of south Asian or african origin
Untreated urinary obstruction
What factor determines the glomerular capillary pressure?
The difference in pressure between the afferent and efferent arterioles
What substance regulates the pressure of the efferent glomerular arteriole?
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
Name 5 symptoms of severe CKD
Nausea and vomiting
Fatigue and weakness
Nocturia and polyuria
Name 3 signs of CKD
Structural kidney disease
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
What investigations should be done if CKD is present?
USS of kidneys
What are the ACR ranges for classifying CKD?
A1 = <3 = normal
A2 = 3-30 = moderate increase
A3 = >30 = severe increase
How should CKD be managed?
Refer to nephrology if appropriate
Monitor progression with eGFR and ACR
Monitor FBC and bone profile
Assess and manage cardiovascular risk. Prescribe all patients a statin and give aspirin as secondary prevention
Influenza and pneumococcal vaccination
When should a person with CKD be referred to nephrology?
Stage 4 and above
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
What lifestyle advice should be given to patients with CKD?
Avoid over the counter NSAIDS
What is the target blood pressure for someone with CKD?
120-139/<90 if ACR>30
120-129/<80 if ACR>70
Name 3 complications of CKD
Renal bone disease
Name 3 factors which influence the decision of when to start dialysis
Risks to the patient
What supportive pharmacological treatment is required for someone with end-stage renal disease?
Name an advantage of haemodialysis
Good long-term survival
Can be done overnight
Can be done at home
Dose can be individualised
Name 5 possible complications of haemodialysis
Nausea and vomiting
What are the 4 main types of peritoneal dialysis
What are three absolute contraindications for peritoneal dialysis?
Stoma in place
Known peritoneal sclerosis
Name 3 relative contraindications for peritoneal dialysis
Severe respiratory disease
Previous multiple operations
Lack of manual dexterity
What is an advantage of peritoneal dialysis?
Gentler electrolyte control
Name 3 complications of peritoneal dialysis
Name 3 contraindications for renal transplantation
Uncontrolled ischaemic heart disease
Extensive peripheral vascular disease
Name 4 types of donor
Living emotionally related
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
Name 3 pre-renal causes of AKI
Severe vomiting and diarrhoea
Renal artery stenosis
Name 3 renal causes of AKI
Acute tubular necrosis
Name 3 post-renal causes of AKI
Name 5 risk factors for the development of AKI
Being aged 65 and over
Exposure to iodinated contrasts
Cognitive or neurological impairment
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
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
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
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
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
Pulmonary oedema, not responding to treatment.
How should an insulin pen be stored after opening?
At room temperature, for no more than 30 days
How should insulin be administered?
Either IV or SC into outer thigh or abdomen
What are the main types of insulin?
Rapid, short, intermediate and long acting, and insulin mixes
Name two examples of a rapid acting insulin
Name two examples of a short acting insulin
Name two examples of an intermediate acting insulin?
Name two examples of a mixed insulin?
Name to examples of a long acting insulin
Humalin R 500
What is the onset, peak and duration of action of a rapid acting insulin?
Onset = 5-15mins
Peak = 30-60mins
Duration = 3-4hours
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
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
What is the mixture in a mixed insulin?
An intermediate + a rapid or short acting insulin
How often is a mixed insulin usually given?
Twice a day
How often is Humulin R 500 given?
TDS, with meals
Name 3 indications for administering IV insulin
Hyperglycaemic hyperosmolar state
Patients after a cardiovascular event
Type 1s who are:
NBM surgical patients missing >1 meal
Metabolically unwell and not eating and drinking
Name 3 risks of IV insulin
Rebound hyperglycaemia if stopped inappropriately
What is the target capillary blood glucose for a patient on IV insulin?
4-12 is acceptable
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
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
What drugs can cause hypercalcaemia?
How is hypercalcaemia managed?
Rehydration with saline
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
How is the anion gap calculated?
(conc of Na and K)-(conc of Cl- and HCO3)
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
Give three causes of metabolic acidosis with a normal anion gap
GI loss of bicarb eg diarrhoea, fistula, uterosigmoidostomy
Renal tubular acidosis
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
Give three causes of metabolic alkalosis
Congenital adrenal hyperplasia
Give three causes of respiratory acidosis
Life threatening asthma
Brain stem lesion
Give three causes of respiratory alkalosis
Give three renal causes of haematuria
Polycystic kidney disease
Give 5 extra-renal causes of haematuria
Bladder, prostate or urethra neoplasia
Increased bleeding tendency
Give 3 causes of painless haematuria
Thin BM disease
Give 5 causes of proteinuria
Minimal change GN
Give a cause of microalbuminuria
Minimal change glomerulonephritis
How should an uncomplicated UTI be managed?
Trimethoprim or nitrofurantoin for 3-6 days
How should an upper UTI be managed?
Cefuroxime or ciprofloxacin
How should UTIs in men be managed?
Two weeks on a quinolone eg levofloxacin and low threshold for referring to urology
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
Renal USS and biopsy
What is the typical presentation of IgA nephropathy?
Few days after an URTI
Usually in a young male
How is IgA nephropathy managed?
What are the blood pressure targets in glomerulonephritis?
<130/80 ir <125/75 if proteinuria
How does glomerulonephritis present?
Usually as nephritic syndrome or nephrotic
Which renal disease is associated with haemoptysis?
What is henoch-schonlein purpura?
A palpable purpuric rash and localised oedema due to IgA mediated vasculitis
What is nephrotic syndrome?
A triad of proteinuria, oedema and hypoalbuminaemia
Give three causes of nephrotic syndrome
Give two complications of nephrotic syndrome
Increased susceptibility to infection
What is the pathological change in minimal change glomerulonephritis?
Fusion of podocytes in basement membrane increasing permeability to albumin and transferrin only
How is minimal change glomerulonephritis managed?
Steroids +/- cyclophosphomide
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
Steroids to induce remission and cyclophosphamide/ciclosporin if declining function
What is the pathological change in membranous glomerulonephritis?
Thickening of basement membrane and IgG subendothelial deposits
What immunoglobulin is associated with focal segmental glomerulosclerosis?
IgM and C3
Give three complications of AKI
How does chronic transplant rejection cause disease?
Mainly vascular changes causing organ ischaemia and local cell changes
What is the leading cause of death in people with successful renal transplants?
Atheromatous vascular disease
What is renovascular disease?
Stenosis of the renal artery or one of its branches causing hypertension
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
What is the most common case of haemolytic uraemic syndrome?
What are the features of thrombotic thrombocytopenic purpura?
Fluctuating CNS signs
Microangiopathic haemolytic anaemia
What drugs can cause thrombotic thrombocytopenic purpura?
How does renal artery stenosis appear on ultrasound?
Affected kidney will be smaller
How can diabetic nephropathy be monitored for?
Early morning ACR every 6 months
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
How is osmolality calculated?