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renal Flashcards

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1
Q

causes of AKI

A

pre renal - infection, hypotension, hypercalcaemia, drugs, heart failure, liver failure renal artery occlusion
renal - glomerulonephritis,CKD, nephrotoxics, rhabdomyolysis, myeloma, malignant HTN, autoimmune disease, haemolytic uraemic syndrome
post renal:
obstructive: blocked catheter, BPH, prostate ca, ureter strictures, clot, renal calculi
neuro: MC, cord compression, cauda equina, post-op retention

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2
Q

definition of aki

A

a rise in serum creatinine >25mmol over 48 hours or by 50% in 5 days
or
a reduction in urine output to less than 0.5ml/kg/hour for more than 6 hours

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3
Q

aki stage 1 criteria

A

1.5-2 x rise in creatinine

<0.5ml/kg/hr over 6 hours UO

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4
Q

aki stage 2 criteria

A

2-3 x rise in creatinine

<0.5ml/kg/hr over 12 hours UO

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5
Q

aki stage 3 criteria

A

creatinine over 350
or >3 x rise in creatinine
or anuria or <0.5ml/kg/hr for over 12 hours

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6
Q

4 complications of AKI

A
  1. hyperkalaemia
  2. metabolic acidosis
  3. uraemia
  4. fluid overload
  5. death + multi organ failure
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7
Q

diagnosis of AKI

A
  1. U+E and urine output
  2. history! pre renal: dehydration, hypoperfusion, infection
    renal: rashes, change in meds, weight loss, post-renal:urinary symptoms
  3. examination: BP,HR, temp, abdo, assess fluid status - overloaded or dehydrated?
  4. check meds and stop nephrotoxics
  5. investigate for cause:
    FBC + infection screen
    calcium - raised do myeloma screen
    CK for rhabdomyolysis
    VBG for metabolic acidosis
    CXR to look for fluid overload - fluid restrict
    urinalysis (+?immunology screen)
    USS KUB
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8
Q

ABCDE of AKI

A 
assess meds
boost bp
calculate fluid balance
dip urine
exclude obstruction
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9
Q

management of hyperkalameia

A

protect the heart: IV calcium gluconate 30ml 10%
10 units actrapid in 10% dextrose over 15 mins
can give salbutamol

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10
Q

raised calcium in AKI

A

do myeloma screen!

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11
Q

when is dialysis indicated in AKI

A

aki stage 3

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12
Q

when to call the med reg for AKI

A 
aki stage 3
hyperkalaemia
resistant oedema
renal transplant patient
underluing CKD stage 4/5
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13
Q

symptoms of uraemia

A 
nausea
itching
vomiting
fatigue
anorexia
muscle cramps
confusion
increased thirst
visual disturbance
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14
Q

drugs to stop in aki

A

nephrotoxics: acei, arb, gentamicin
renally excreted drugs: metformin, LMWH in stage 2+3
drugs that accumulate: opioids, digoxin, lithium
stop diuretics in dehydration
continue diuretics in fluid overload

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15
Q

CKD staging

A 
1 egfr >90
2 60-90
3a 45-59
3b 30-44
4 15-29
5 <15 (established renal failure - dialysis)
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16
Q

name 7 findings on blood results in CKD

A 
low egfr
high creatinine
high urea
low vit D 
high phosphate
low calcium
low Hb
high K+
metabolic acidosis
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17
Q

name 6 complications of CKD

A 
hypertension
fluid accumulation
osteoporosis
vitamin d deficient
anaemia
metabolic acidosis
hyperkalaemia
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18
Q

indications for dialysis

A

stage 5 ckd

or aki with uraemia symptoms, unresponsive to tx

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19
Q

what are the 2 types of dialysis and how do they work

A

peritoneal dialysis: catheter inserted into peritoneal space and dextrose fluid inserted into peritoneum and peritoneum acts as a filter either continuously or over night

haemodialysis - either with av fistula or with tunnelled catheter in subclavian or jugular veing +into right atrium

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20
Q

name 3 complications of peritoneal dialysis

A

weight gain from absorbing dextrose
bacterial peritonitis
peritoneal sclerosis
functional failure over time

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21
Q

name 4 complications of an AV fistula

A

aneurysm
infection
thrombosis
steel syndrome

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22
Q

how long does an AV fistula take to be ready to use

A

4 months

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23
Q

what 3 drugs are given post renal transplant

A

tacrolimus
mycophenolate
prednisolone
plus immunosuppression

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24
Q

where is renal transplant placed and which vessels are they anastamosed to

A

iliac fossa

internal iliac vessels

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25
characteristics of nephritic syndrome
low urinary protein <3g micro or macroscopic haematuria oliguria (reduced urine output) oedema
26
characteristics of nephrotic syndrome
high proteinuria >3g low albumin peripheral oedema!! high cholesterol
27
management of igA nephropathy
acei and steroids
28
what is henoch schonlein purpura
``` systemic variant of IgA nephropathy where IgA deposits in kidneys, skin, GI tract and joints causing... nephritic glomerulonephritis intermittent polyarthritis GI bleeding non blanching petechial rash on legs ```
29
presentation of henoch schonlein purpura
glomerulonephritis = haematuria, oedema, reduced urine output intermittent joint pains non blanching petechial rash
30
presentation of henoch schonlein purpura
glomerulonephritis = haematuria, oedema, reduced urine output intermittent joint pains non blanching petechial rash abdo pain/ anaemia (GI bleeding)
31
how do you diagnose HSP
positive IgA and C3 in skin IgA deposits on renal biopsy usually just a clinical diagnosis
32
how do you manage HSP
Ace inhibitors and steroids
33
causes of nephritic syndrome
IgA nephropathy HSP post strep glomerulonephritis goodpastures disease
34
presentation of post strep glomerulonephritis
2 weeks after sore throat or skin infection with a group a beta haemolytic strep strep deposits in glomerulus = inflammation = nephritis mg = supportive and abx if active infection
35
presentation of goodpastures disease
antibodies against type 4 collagen found in alveoli and glomerular membrane means you get a nephritis and aki and also pulmonary haemorrhage so pt might present with haematuria, low urine output, high blood pressure, sob haemoptysis
36
how do you manage goodpastures disease
renal: often need dialysis at presentation due to severe reduction in egfr, plasma exchange, steroids and cyclophosphamide pulm: o2
37
name the causes of nephrotic syndrome
primary renal: minimal change disease (kids) focal segmental glomerulosclerosis (adults) membranous nephropathy systemic: diabetic nephropathy, SLE, myeloma, amyloidosis, pre eclampsia
38
pathophysiology of nephrotic syndrome
damaged or abnormal podocytes = larger membrane gaps = protein leakage
39
management of nephrotic syndrome
1. reduce oedema!! fluid and salt restriction, po/iv furosemide, daily weights with aim of 0.5-1kg weight loss daily, 2. treat underlying cause: 3. lower proteinurea with acei/arb 4. VTE prophylaxis 5. give pneumococcal vaccine bc increased infection risk due to immunoglobulins lost in urine
40
why should you only lower weight loss (fluid) by 0.5-1kg per day in nephrotic syndrome
because a rapid decrease in extravascular volume could cause AKI
41
how do you determine the cause of nephrotic syndrome
renal biopsy
42
how do you treat minimal change disease
po prednisolone to induce remission at 1mg/kg for 4-16 weeks | if has a relapse give immunosuppression with cyclophosphamide
43
how do you manage focal segmental glomerulosclerosis
reduce bp | steroids
44
how does lupus nephritis present
lupus plus nephrotic sydrome get autoantibodies deposited in kidneys tests: ANA, anti-dsDNA, C3 and C4
45
how do you manage diabetic nephropathy
aim Hba1c <53 reduce BP and give acei renal protection statins annual albumin:creatinine ratio screen
46
how is lupus nephritis managed
high dose pred | cyclophosphamide / rituximab
47
pathophysiology behind myeloma glomerulonephritis
light chains deposit in renal tubules causing obstruction and damage to glomerulus
48
pathophysiology behind myeloma glomerulonephritis
light chains deposit in renal tubules causing obstruction and damage to glomerulus causes proteinuria and hypercalcaemia
49
what is haemolytic uraemic syndrome
haemolysis of red cells in the small vessels causes an AKI, glomerulonephritis with proteinuria or haematuria, and low platelets
50
what are the 3 pillars of haemolytic uraemic syndrome
microangiographic haemolytic anaemia aki with haematuria/proteinuria low platelets
51
name 2 causes of haemolytic uraemic syndrome
e.coli infection | pregnancy
52
how do you manage haemolytic uraemic syndrome
supportive plasma exchange manage AKI never give antibiotics as makes it worse
53
how does haemolytic uraemic syndrome present
anaemia symptoms | aki symptoms
54
how do you diagnose haemolytic uraemic syndrome
fbc: Hb<100, low platelets, may be raised WCC u+e: AKI blood film: schistocytes (fragmented cells from haemolysis) do stool culture and PCR looking for evidence of shiga toxin producing e.coli
55
how does thrombotic thrombocytopenic purpura present
``` fever microemboli in cerebral circulation = fluctuating neuro signs headache palsy AKI from emboli in renal tract low platelets haemolytic anaemia ```
56
how do you manage TTP
haematological emergency so contact on call reg plasma exchange / infusion steroids and rituximab for relapses
57
name causes of TTP
pregnancy post viral SLE drugs eg ciclosporin, COCP, anti virals
58
what organism is associated with haemolytic uraemic syndrome
shiga toxin producing e.coli triggers an autoimmune response = HUS
59
how is TTP different to HUS
both have aki, low platelets due to clumping and clotting, and a haemolytic anaemia but TTP has additional fever with fluctuating neuro signs due to emboli in cerebral circulation obstructing and then passing so may have headaches and palsys
60
how does aldosterone work in the kidney
causes net reabsorption of sodium and excretion of potassium
61
hypokalaemia metabolic acidosis high urinary pH what is the cause
either type 1 or type 2 renal tubular acidosis | both genetic so generally present in younger kids
62
what causes type 1 renal tubular acidosis and what do you find on investigation
genetic problem with H+ ATPase pump or H/K ATPase caused by: SLE, sjorens, lithium, hyperthyroid, primary billiary sclerosis inv: high urinary pH (bc not excreting acid) hypokalaemia, metabolic acidosis
63
what causes type 2 renal tubular acidosis and what is found on investigation
genetic problem in proximal tubules meaning bicarb is unable to be re absorbed so high amounts of bicarb is excreted so cant neutralise H+ so get metabolic acidosis, hypokalaemia and high urinary pH
64
what causes type 4 renal tubular acidosis and what would you find on investigation
caused by low aldosterone (ie adrenal insufficiency (addisons), spironolactone, SLE, diabetes aldosterone normally causes reabsorption of water and sodium and excretion of potassium and hydrogen ions so if aldosterone is low then potassium and hydrogen ions will be reabsorbed and sodium and water excreted so therefore would get a hyperkalaemic metabolic acidosis, dehydration and a low (acidotic) urinary pH due to reduced ammonia production
65
how do you manage type 4 renal tubular acidosis
fludrocortisone - to boost BP sodium bicarb to correct acidosis manage hyperkalaemia!!
66
name 2 complications of UTI in pregnancy
preterm delivery | intrauterine growth restriction
67
what is the first line management of pyelonephritis in pregnancy
cefalexin
68
which antibiotics are first line in pyelonephritis
co-amox TDS for 7 days or ciprofloxacin BD 7 days
69
cp of pyelonephritis
``` fever rigors back pain dysuris or recent cystitis vomiting white cell casts in urine ```
70
what is the cause of pyelonephritis
ascending infection with e.coli
71
what investigation should you do in pyelonephritis and when should you do it
MSU culture and sensitivity, do before giving abx
72
what makes a UTI 'complicated'
``` recurring pregnant being male non responsive to tx atypical organism on culture persistent haematuria ```
73
difference in management of UTI in men and women
women 3 days | men 7 days
74
causes of hydronephrosis
vesicoureteric reflux urethral strictures renal calculi any form of obstruction eg bph
75
what is vesicoureteric reflux and who is it more common in
more common in kids | when there is a structural abnormality that causes backflow of urine from the bladder to the kidneys
76
complications of vesicoureteric reflux
recurrent uti pyelonephritis hydronephrosis renal scarring --> HTN
77
how do you diagnose vesicoureteric reflux
micturiating cystourethrogram | DMSA scan to look for renal scarring
78
how do you investigate recurrent UTI
USS renal tract to look for abnormalities
79
how does prostatitis present
``` pain in rectum, pelvis, perineum, scrotum, penis, lower back fever nausea and vomiting dysuria, frequency, anuria swollen tender prostate on PR ```
80
how do you manage prostatitis
4 week course of po ciprofloxacin (better than trimethoprim or nitro bc penetrates seminal fluid better)

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