Passmed Renal Mushkies Flashcards
(190 cards)
1
Q
What predisposes to increased thrombosis in nephrotic syndrome?
A
- Loss of antithrombin III, Protein C & S
2. Rise in fibrinogen levels
2
Q
What Abxs require therapeutic monitoring in pts with renal failure?
A
Vancomycin and gentamicin
3
Q
What are 4 drugs to avoid in renal failure?
A
- Abx e.g. tetracyclines, nitrofurantoin
- NSAIDs
- Lithium
- Metformin
4
Q
What are some drugs that are likely to accumulate in CKD and thus need dose adjustment?
A
A MAD FOS
- Most Abx
- Methotrexate
- Atenolol
- Digoxin
- Furosemide
- Opioids
- Sulphonylureas
5
Q
What is the management for acute clot retention?
A
Bladder irrigation via a 3-way urethral catheter
6
Q
How can you classify haematuria?
A
Visible vs. non-visible haematuria
7
Q
How can you classify causes of non-visible haematuria?
A
- Transient
2. Persistent
8
Q
What are the transient causes of non-visible haematuria?
A
- UTI
- Menstruation
- Vigorous exercise
- Sexual intercourse
9
Q
What are the permanent causes of non-visible haematuria?
A
- Infection = prostatitis, urethritis
- Inflammation = IgA nephropathy, thin basement membrane disease
- Malignancy = bladder, renal, prostate
- BPH
- Stones
10
Q
What are some spurious causes of haematuria?
A
- Foods = beetroot, rhubarb
2. Drugs = rifampicin, doxorubicin
11
Q
What is the definition for persistent non-visible haematuria?
A
Blood being present in 2 out of 3 samples tested 2-3 weeks apart
12
Q
What are 4 features of HSP?
A
- Rash over buttocks and extensor surfaces
- Abdo pain
- Polyarthritis
- Features of IgA nephropathy e.g. haematuria, renal failure
13
Q
What are stag-horn calculi typically composed of?
A
Struvite = Ammonium Magnesium Phosphate
14
Q
What typically causes staghorn calculi?
A
Alkaline urine due to e.g. Proteus Mirabilis and Ureaplasma urealyticum
15
Q
When is a triple phosphate stone defined as a staghorn calculus?
A
Whe nit involves the renal pelvis and extends into at least 2 calyces
16
Q
How can one manage lupus nephritis?
A
- Treat HTN
- Corticosteroids if clinical evidence of disease
- Immunosuppressants e.g. azathioprine/cyclophosphamide
17
Q
How can you differentiate between ATN or prerenal uraemia?
A
In prerenal uraemia the kidneys hold onto sodium to preserve volume
18
Q
What is dialysis disequilibrium syndrome?
A
A rare complication usually affecting those who have recently started renal replacement therapy, causes cerebral oedema, but the exact mechanism is unclear. Therefore, this is a diagnosis of exclusion
19
Q
What are the 3 different types of renal replacement therapy?
A
- Haemodialysis
- Peritoneal dialysis
- Renal transplant
20
Q
What kind of things are taken into account by pt and the healthcare team when deciding which RRT to have?
A
- Predicted QoL
- Predicted life expectancy
- Pt preference
- Co-existing medical conditions
21
Q
What are the 2 types of peritoneal dialysis?
A
- Continuous ambulatory peritoneal dialysis (CAPD)
2. Automated peritoneal dialysis (APD)
22
Q
What is the average lifespan of a donated kidney?
A
10-12 yrs from deceased donors, 12-15 yrs from living donors
23
Q
What is the average life expectancy of a pt with renal failure that does not receive renal replacement therapy?
A
6 months
24
Q
How can you classify causes of metabolic acidosis?
A
Normal or raised anion gap
25
What are the causes of a normal anion gap metabolic acidosis?
1. GI loss e.g. diarrhoea
2. Renal tubular acidosis
3. Drugs e.g. acetazolamide
4. Ammonium chloride injection
5. Addison's disease
26
What are the causes of a raised anion gap metabolic acidosis?
1. Lactate = shock, hypoxia
2. Ketones = DKA, alcohol
3. Urate = renal failure
4. Acid poisoning = salicylates, methanols
27
What are some causes of metabolic alkalosis?
1. Vomiting
2. Diuretics
3. Hypokalaemia
4. Cushings
5. CAH
6. Primary hyperaldosteronism
28
What are some causes of a respiratory acidosis?
1. COPD
2. Resp condition e.g. asthma decompensation
3. Drugs e.g. benzodiazepines, opiate overdose
29
What are some causes of a respiratory alkalosis?
1. Anxiety
2. PE
3. CNS e.g. stroke
4. Altitude
5. Pregnancy
6. Salicylate poisoning
30
What is a common for a rise in urea that is proportionally higher than the rise in creatinine?
Dehydration
31
What are 5 intrinsic causes of renal failure?
1. Glomerulonephritis
2. ATN
3. AIN
4. Rhabdyomyolysis
5. Tumour lysis syndrome
32
How does one diagnose AKI?
1. a rise in serum creatinine of 26 micromol/litre or greater within 48 hours
2. a 50% or greater rise in serum creatinine known or presumed to have occurred within the past 7 days
3. a fall in urine output to less than 0.5 ml/kg/hour for more than 6 hours in adults and more than
33
What 5 drugs should be stopped in AKI as it may worsen renal function?
1. NSAIDs
2. Aminoglycosides
3. ACE inhibitors
4. Ang II receptor antagonists
5. Diuretics
34
What are 3 drugs that may have to be stoppefd in AKI as increased risk of toxicity but doesnt usually worsen the AKI itself?
1. Metformin
2. Lithium
3. Digoxin
35
What is the potassium requirement per day?
1 mmol/kg/day
36
What is the sodium requirement per day?
1 mmol/kg/day
37
What is the chloride requirement per day?
1 mmol/kg/day
38
How much Na and Cl is in normal saline?
154mmol
39
How much Na and Cl is in Hartmann's? How much K and HCO3 is in Hartmann's?
```
Na = 131
Cl = 111
K = 5
HCO3 = 29
```
40
Why shouldnt you use Hartmanns in pts with hyperkalaemia?
It contains potassium
41
What are some complications of giving erythropoietin?
1. Accelerated HTN --> encephalopathy and seizures
2. Bone ache
3. Flu-like symptoms
4. Skin rashes, urticaria
5. Pure red cell aplasia (due to Abs against EPO)
6. Thrombosis
7. Iron deficiency 2nd to increased erythropoiesis
42
What is the most common viral infection in solid organ transplant recipients?
CMV
43
How can you classify graft failure in renal transplant?
1. Hyperacute rejection (mins to hrs)
2. Acute graft failure (<6m)
3. Chronic graft failure (>6m)
44
What causes hyperacute rejection of renal transplants?
Due to pre-existent Abs against donor HLA antigens (Type II Hypersensitivity reaction), and is rarely seen due to HLA matching
45
What causes acute graft failure?
Usually due to mismatched HLA, and is cell-mediated (cytotoxic T cells). Can also be caused by CMV infection. may be reversible with steroids and immunosuppressants
46
What causes chronic graft failure?
1. Both antibody and cell mediated mechanisms causes fibrosis to the transplanted kidney
2. Recurrence of original renal disease (MCGN > IgA > FSGS)
47
What are the causes of minimal change disease?
1. Idiopathic (majority)
2. Drugs = NSAIDs, rifampicin
3. Hodgkins lymphoma, thymoma
4. Infectious mononucleosis
48
What is the prognosis for minimal change disease?
1/3rd one episode
1/3rd infrequent relapses
1/3rd frequent relapses
49
What are 2 risk factors for urate stones?
1. Gout
| 2. Ileostomy (loss of bicarb and fluid results in acidic urine, causing precipitation of uric acid)
50
What are 2 drugs that promote calcium stones?
Loop diuretics and steroids
51
What are 2 pertinent manifestations of uraemia?
Encephalopathy and pericarditis
52
What is the management of renal stones?
1. Conservatively = pass spontaneously
| 2. Surgical = ESWL, percutaneous nephrolithotomy, ureteroscopy, open surgery
53
How do you manage calculi <5mm?
Expectant
54
How do you manage calculi <2cm?
ESWL
55
How do you manage calculi <2cm in pregnant women?
Ureteroscopy
56
How do you manage complex renal calculi and staghorn calculi?
Percutaneous nephrolithotomy
57
How can you prevent calcium stones?
1. High fluid intake
2. Low animal protein, low salt diet
3. Thiazide diuretics
58
How can you prevent oxalate stones?
Cholestyramine and pyridoxine both reduce urinary oxalate excretion
59
How can you prevent uric acid stones?
1. Allopurinol
| 2. Urinary alkalinisation e.g. oral bicarbonate
60
What is the mainstay of treatment for rhabdomyolysis?
Rapid IV fluid rehydration
61
What electrolyte changes do you see in rhabdomyolysis?
1. Hypocalcaemia (myoglobin binds to calcium)
2. High phosphate (released from myocytes)
3. Hyperkalaemia
4. Metabolic acidosis
5. AKI with disproportionately raised creatinine
62
What is the triad for renal cancer?
Flank pain, mass and haematuria
63
What is the most common type of renal cancer?
Clear cell
64
What are some associations of renal cell carcinoma?
1. Middle aged men
2. Smokers
3. vHL syndrome
4. Tuberous sclerosis
65
What cancer can cause a left varicocoele?
Renal cell carcinoma due to occlusion of left testicular vein
66
What are 4 hormones that a RCC may secrete?
1. EPO
2. PTH
3. Renin
4. ACTH
67
What diagnosis should you consider in young female pts who develop AKI after the initiation of an ACE inhibitor?
Fibromuscular dysplasia
68
What is the most common cause of renal artery stenosis?
Atherosclerosis
69
What is fibromuscular dysplasia?
Proliferation of cells in the walls of the arteries causing vessels to bulge or narrow. 'String of beads' appearance.
70
Haematuria 1-2 days after an URTI?
IgA Nephropathy
71
Haematuria 1-2 wks after an URTI?
Post-streptococcal glomerulonephritis
72
What is the commonest cause of glomerulonephritis worldwide?
IgA nephropathy
73
What percentage of pts with IgA nephropathy develop ESRF?
25%
74
What are 4 extra-renal features of ADPKD?
1. Hepatomegaly due to hepatic cysts
2. Diverticulosis
3. Ovarian cysts
4. Berry aneurysms
5. Mitral valve prolapse/aortic dissection
75
How might ADPKD present?
1. HTN
2. Recurrent UTIs
3. Abdo pain
4. Renal stones
5. Haematuria
6. CKD
76
What kind of blocker can be given to pts to aid passage of a stone?
Alpha blocker
77
What pain relief should be given in the acute management of renal colic?
IM diclofenac 75mg
78
What might you see on US in pts with chronic HIV-associated nephropathy?
Large/normal sized kidneys, as opposed to pts with CKD who will have bilateral small kidneys
79
What is the management of salicylate poisoning?
IV sodium bicarbonate
80
What is the ABG reading with salicylate poisoning?
Raised anion gap metabolic acidosis
81
What else can you give to an aspirin overdose if it was very recent?
Activated charcoal
82
What is the treatment for benzodiazepine overdose?
Flumazenil
83
How do you calculate anion gap?
(Na + K) - (HCO3 + Cl)
84
What is the normal range for anion gap?
10-18mmol/L
85
How can you classify metabolic acidosis secondary to high lactate levels?
1. Type A = sepsis, shock, hypoxia, burns
| 2. Type B = metformin
86
What is the management for renal bone disease?
1. Conservative = reduced dietary intake of phosphate
2. Medical = phosphate binders, Vit D (alfacalcidol)
3. Surgical = parathyroidectomy
87
What are 3 classes of phosphate binders?
1. Aluminium-based (less common)
2. Calcium-based binders
3. Sevelamer
88
What is Sevelamer?
A non-calcium based binder that binds to dietary phosphate and prevents its absorption
89
What investigation can you do to differentiate between ATN and AIN?
Urine dip
90
What is the management for nephrogenic DI?
1. Thiazide diuretic
| 2. Low salt/protein diet
91
What would cause a young male to have recurrent episodes of macroscopic haematuria?
IgA Nephropathy
92
What are the causes of nephrogenic DI?
1. Genetic = ADH receptor mutation, AQP2 mutation
2. Electrolytes = hypercalcaemia, hypokalaemia
3. Drugs = lithium, demeclocycline
4. Tubulo-interstitial disease = obstruction, sickle cell, pyelonephritis
93
What is the management for minimal change disease?
Steroids, and cyclophosphamide if steroid-resistant
94
What is the most common site of thrombosis in nephrotic syndrome?
Renal vein
95
What is the most likely cause of death in pts with CKD on haemodialysis?
IHD
96
What are the most common causes of CKD?
1. DN
2. Chronic glomerulonephritis
3. Chronic pyelonephritis
4. HTN
5. ADPKD
97
What do you see on urine dip with acute interstitial nephritis?
An 'allergic' type picture consisting usually of raised urinary WCC, IgE and eosinophils
98
What are the causes of acute interstitial nephritis?
1. Idiopathic
2. Drugs = penicillin, rifampicin, NSAIDs, allopurinol, furosemide
3. Infection = staphylococcus, hanta virus
99
What is TINU?
Tubulointerstitial nephritis with uveitis, usually occurs in young females
100
When do you start treating a hyperkalaemia?
If K+ > 6.5 mmol/l or if there are ECG changes
101
What is the treatment for hyperkalaemia?
1. Calcium gluconate 10% 10-20ml by slow IV injection titrated to ECG response
2. Give 10 U Actrapid in 50 ml of 50% glucose over 10-15 minutes
3. Consider use of nebulised salbutamol
4. Consider correcting acidosis with sodium bicarbonate infusion
102
What are 4 causes of rapidly progressive glomerulonephritis?
1. Goodpasture's
2. GPA
3. SLE
4. MPA
103
What electrolyte abnormality is likely to happen if 0.9% saline is used for fluid therapy in pts requiring large volumes?
Hyperchloraemic metabolic acidosis
104
What are the NICE requirements for maintenance fluids?
1. 25-30ml/kg/day water
2. 1mmol/kg/day of K + Na + Cl
3. 50-100g/day glucose to limit starvation ketosis
105
What are 4 common post-op problems with kidney transplants?
1. ATN of graft
2. Vascular thrombosis
3. Urine leakage
4. UTI
106
What may peri-ureteric fat on CT KUB indicate?
May indicate recent stone passage if a ureteric calculus is not present
107
What opioid is safer to use in pts with moderate to end stage renal failure?
Oxycodone
108
What test is done for all diabetic patients requiring screening for diabetic nephropathy?
Early morning albumin:creatinine ratio (ACR)
109
What ACR is indicative of microalbuminuria?
ACR > 2.5
110
What is the management of diabetic nephropathy?
1. Conservative = dietary protein restriction, tight glycaemic control, BP < 130/80 mmHg
2. Medical = ACEi, statin
3. Surgical = transplant
111
What is the gold standard investigation for bladder cancer?
Cystoscopy
112
What is the most common cause of AIN?
Drugs account for 75% cases
113
What is the most common cause of nephrotic syndrome in children?
Minimal change disease
114
How can you reduce the risk of having contrast-induced nephropathy?
Volume expansion with IV 0.9% NaCl pre and post procedure
115
How can you define contrast media nephrotoxicity?
25% increase in creatinine occurring within 3 days of IV administration of contrast media
116
What is an example of an immunosuppression regime following a renal transplant?
1. Initial = ciclosporin/tacrolimus with a monoclonal Ab
2. Maintenance = ciclosporine/tacrolimus with MMF/sirolimus
3. Add steroids if more than one steroid responsive acute rejection episode
117
What is the MOA of ciclosporin?
Calcineurin inhibitor
118
What is a s/e of tacrolimus?
1. Impaired glucose tolerance and diabetes
| 2. Hyperlipidaemia
119
What are 2 mABs that can be given after renal transplant?
Daclizumab and Basiliximab
120
What is a cancer that renal pts are at increased risk of?
Squamous cell carcinomas
121
How can you classify glomerulonephritis?
Proliferative vs. Non-proliferative
122
What is a renal mechanism by which cirrhotic pts develop ascites?
They can develop a secondary hyperaldosteronism
123
What GN is associated with SLE?
Membranous
124
What are the thyroxine levels like in nephrotic syndrome and why?
Low thyroxine levels, due to loss of urinary loss of TBG leading to a low total T4 level, but normal free thyroxine levels
125
What is the definition for severe hypokalaemia?
<2.5mmol/L
126
How can you classify the causes of hypokalaemia?
1. Increased potassium loss
2. Trans-cellular shift
3. Decreased potassium intake
4. Magnesim depletion
127
What are the causes of increased potassium loss?
1. Drugs = diuretics, laxatives, glucocorticoids, Abx
2. GI loss = diarrhoea, vomiting, ileostomy
3. Renal loss = dialysis
4. Endo = hyperaldosteronism, Cushing's syndrome
128
What are the trans-cellular shift causes of hypokalaemia?
1. Insulin/glucose
2. Salbutamol
3. Theophylline
4. Metabolic alkalosis
129
What ECG changes are seen in Hypokalaemia?
1. U waves
2. T wave flattening
3. ST segment changes
130
How can you treat mild to moderate hypokalaemia?
Oral potassium provided the pt is not symptomatic and there are no ECG changes
131
How do you manage severe hypokalaemia?
IV replacement
132
What drug toxicity does hypokalaemia predispose pts to?
Digoxin toxicity
133
What will kidneys look like on US with chronic diabetic nephropathy?
Bilateral large/normal sized kidneys, whilst pts with CKD usually have bilateral small kidneys
134
What are 4 conditions in which you may see enlarged kidneys despite having CKD?
1. APCKD
2. DN
3. Amyloidosis
4. HIV-associated nephropathy
135
What is the best way to differentiate between AKI and CKD?
Renal US
136
What is Type I respiratory failure?
Hypoxia without hypercapnia
137
What is Type II respiratory failure?
Hypoxia with hypercapnia
138
What can be given to pts with troublesome gynaecomastia on spironolactone?
Eplerenone
139
What are 5 indications for spironolactone?
1. Ascites
2. HTN
3. HF
4. Nephrotic syndrome
5. Conn's syndrome
140
What is the most common cause of peritonitis secondary to peritoneal dialysis?
CoNS e.g. Staphylococcus epidermidis
141
What are 2 complications of peritoneal dialysis?
1. Peritonitis (S. epidermidis/aureus)
| 2. Sclerosing peritonitis
142
What is the time taken for an AV fistula to develop?
6-8 weeks
143
What are 4 complications of an AV fistula?
1. Infection
2. Thrombosis
3. Stenosis
4. Steal syndrome
144
How might an AV fistula thrombosis present?
Absence of a bruit
145
How might an AV fistula stenosis present?
Acute limb pain
146
What syndrome presents with haemoptysis and haematuria?
Goodpasture's syndrome
147
What is the management of Goodpasture's syndrome?
1. Plasma exchange
2. Steroids
3. Cyclophosphamide
148
What would cause a persistent pyuria with negative urine culture?
Renal TB
149
What are the causes of sterile pyuria?
```
AAABRUPT
APCKD
1. Appendicitis
2. Analgesic nephropathy
3. Bladder/renal cell carcinoma
4. Renal Stones
5. Urethritis e.g. chlamydia
6. Partially treated UTI
TB (renal TB)
```
150
What do you see on EM of post-streptococcal GN?
Subepithelial 'humps'
151
What is a cause of an inappropriately low eGFR?
Large muscle mass secondary to body building
152
What is the most commonly used equation for eGFR?
Modification of Diet in Renal Disease (MDRD) equation
153
What variables does the MDRD take into account?
```
CAGE
Serum creatinine
Age
Gender
Ethnicity
```
154
What are factors which may affect eGFR?
1. Pregnancy
2. Muscle mass (amputees, body builders)
3. Eating red meat 12 hours prior to the sample being taken
155
What are the stages of CKD>
1. >90 ml/min
2. 60-89 ml/min
3a. 45-59 ml/min
3b. 30-44 ml/min
4. 30-45 ml/min
5. <15 ml/min
156
What is a blood marker that suggests that kidney disease is chronic rather than acute?
Hypocalcaemia
157
What is the triad of Alport's syndrome?
1, Renal failure
2. Sensorineural hearing loss
3. Ocular abnormalities
158
What are the causes of HUS?
1. E. coli 0157:H7
2. Pneumococcal infection
3. HIV
4. Rare = SLE, cancer, drugs
159
What is the management of HUS?
1. Supportive = fluids
2. Blood transfusion PRN
3. Dialysis PRN
4. Plasma exchange (if severe and there is no diarrhoea)
160
What is a common complication of nephrotic syndrome?
High risk of VTE
161
What is a complication of cyclophosphamide?
Haemorrhagic cystitis
162
What GI symptom can occur as a part of HUS?
Diarrhoea which becomes bloody 1-3 days after its onset
163
What is the main benefit of EPO injections for pts with CKD?
Improved exercise tolerance
164
At what age is amyloidosis typically diagnosed?
50-65 y/o
165
What are the most common presenting features of amyloidosis?
Breathlessness and weakness
166
What are the causes of anaemia in renal failure?
1. Reduced EPO
2. Reduced iron absorption
3. Anorexia/nausea due to uraemia
4. Reduced RBC survival
5. Stress ulceration leading to chronic blood loss
167
How can you classify the causes of polyuria?
1 .Common >1/10
2. Infrequent 1/100
3. Rare 1/1000
4. Very rare 1/10,000
168
What are 4 common causes of polyuria?
1. Diuretics, caffeine and alcohol
2. DM
3. Lithium
4. HF
169
What are 2 infrequent causes of polyuria?
1. Hypercalcaemia
| 2. Hyperthyroidism
170
What are 3 rare causes of polyuria?
1. CKD
2. Primary polydipsia
3. Hypokalaemia
171
What is a very rare cause of polyuria?
Diabetes Insipidus
172
What are haptoglobin levels like in HUS?
Low as they bind haemoglobins
173
What is the normal range for anion gap?
10-18
174
What are the causes of high anion gap metabolic acidosis?
CAT MUDPILES
1. Carbon monoxide, Cyanide, Congenital HF
2. Aminoglycosides
3. Theophylline, Toluene (glue sniffing)
4. Methanol
5. Uraemia
6. DKA, Alcoholic KA, Starvation KA
7. Paracetamol, Paraldeyhyde
8. Iron, Isoniazid, IEM
9. Lactic Acidosis
10. Ethylene glycol
11. Salicylates
175
How can cranial DI be treated?
Desmopressin
176
What else is required in addition to eGFR levels to diagnose CKD Stage 1 or 2?
Supporting evidence from urinalysis or renal US
177
Which NSAID doesnt need to stop in AKI?
Aspirin as long as it is at a cardio-protective dose
178
What are the causes of FSGS?
1. Idiopathic
2. HIV
3. Heroin
4. Alport's syndrome
5. Sickle Cell
6. Secondary to other renal pathology e.g. IgA nephropathy, reflux nephropathy
179
What are the numerical values for the classification of hyperkalaemia?
1. Mild = 5.5-5.9 mmol/l
2. Moderate = 6.0-6.4 mmol/l
3. Severe = 6.5mmol/l
180
What is the US diagnostic criteria for PCKD in pts with a positive FH?
1. 2 cysts, uni/bilateral, <30 y/o
2. 2 cysts, bilateral, 30-59 y/o
3. 4 cysts, bilateral, >60 y/o
181
What drug can be given to some pts with ADPKD to slow the progression of cyst development/
Tolvaptan
182
What are two eyes signs that are associated with Alport's syndrome?
1. Lenticonus = protrusion of lens surface into the anterior chamber
2. Retinitis pigmentosa
183
What is the investigation of choice for reflux nephropathy?
Micturating cystography
184
How many AKI stages are there?
3
185
What are the 3 AKI stages?
1.
186
What are the 2 drugs for treatment of HTN in CKD?
ACE inhibitors and add Furosemide when GFR <45ml/min
187
What are the thresholds of acceptance for change in GFR and creatinine in pts with CKD who are started on an ACE inhibitor?
1. Decrease in eGFR of up to 25%
| 2. Rise in creatinine of up to 30%
188
What investigation is required in all pts presenting with an AKI of unknown origin?
Renal US
189
What percentage of minimal change disease is steroid-responsive?
80%
190
What is given to pts with minimal change disease the is steroid-resistant?
Cyclophosphamide
