Renal

Question 1

KDIGO Stage 1 AKI

Answer 1

Serum creatinine >1.5x baseline or urine output <0.5ml/kg/hr for >6h

Question 2

KDIGO Stage 2 AKI

Answer 2

Serum creatinine >2x baseline or urine output <0.5ml/kg/hr for >12h

Question 3

KDIGO Stage 3 AKI

Answer 3

Serum creatinine >3x baseline or urine output <0.3ml/kg/hr for >24h or anuria >12hrs

Question 4

AKI: pre-renal causes

Answer 4

hypovolaemia (e.g. haemorrhage, D&V)
hypotension (e.g. HFrEF, hepatorenal syndrome, sepsis)
drugs

Question 5

AKI: nephrotoxic drugs

Answer 5

NSAIDs
iodinated contrast media
aminoglycosides
ACE inhibitors
angiotensin receptor blockers
diuretics

Question 6

AKI: features of nephrotic syndrome

Answer 6

Proteinuria
Hypoalbuminaemia
Oedema

Question 7

AKI: features of nephritic syndrome

Answer 7

Haematuria (+/- red cell casts)
Proteinuria
Hypertension
Oliguria

Question 8

AKI: features of tubulointerstitial disease

Answer 8

Polyuria or oliguria
Typically absence of ‘active urine’ (occasional mild proteinuria)

Question 9

minimal change disease: causes

Answer 9

primary

secondary:
- infection (HIV, CMV)
- malignancy (thymoma, Hodgkin’s Lymphoma)
- drugs (NSAIDs, lithium, rifampicin)
- other (SCD)

Question 10

membranous nephropathy: causes

Answer 10

primary (autoimmune)

secondary:
- autoimmune (SLE)
- infection (Hep B, malaria)
- malignancy
- drugs (gold)

Question 11

membranoproliferative disease: causes

Answer 11

primary:
“C3 nephropathy”

secondary:
- autoimmune (SLE)
- infection (endocarditis)
- chronic thrombotic microangiopathy
- malignancy (monoclonal gammopathy)

Question 12

AKI: causes of nephrotic syndrome

Answer 12

children => minimal change disease
adults => membranous nephropathy

small print: FSGS, membranoproliferative disease

Question 13

AKI: causes of nephritic syndrome

Answer 13

IgA nephropathy (common, associated with DM, occurs WITH streptococcal URTI)

Post-streptococcal glomerulonephritis

Anti-GBM disease
ANCA vasculitis
Immune complex-mediated glomerulonephritis

Question 14

AKI: causes of tubulointerstitial disease

Answer 14

acute tubular necrosis
acute interstitial nephritis
multiple melanoma
tumour lysis syndrome

Question 15

acute tubular necrosis: features

Answer 15

Tubulointerstitial pattern of AKI (polyuria or oliguria without ‘active urine’)

High urinary sodium and low urine osmolality due to failure of kidneys to concentrate urine

Question 16

acute tubular necrosis: causes

Answer 16

prolonged pre-renal AKI or ischaemia
rhabdomyolysis
haemoglobinuria (e.g. malaria, haemolysis, transfusion reaction)
nephrotoxins (concurrent use of ACEi/ARB with iodinated contrast media or gentamicin)

Question 17

acute interstitial nephritis: features

Answer 17

“allergic-type picture”
urinary WCC, eosinophilia, IgE
reduced eGFR

Question 18

acute interstitial nephritis: causes

Answer 18

drugs (antibiotics, chemotherapy)

Question 19

AKI: post-renal causes

Answer 19

calculi
prostatic hyperplasia
metastatic cancer
retroperitoneal fibrosis (rare)

Question 20

AKI: management of pre-renal disease

Answer 20

Fluid resuscitation
Manage underlying cause

Question 21

AKI: management of post-renal disease

Answer 21

USS KUB
Stent / stone retrieval
Monitor for post-obstructive diuresis

Question 22

AKI: management of nephrotic syndrome

Answer 22

Remove precipitant drugs
Symptomatic relief - salt restriction and loop diuretics
Anticoagulate (DVT risk!)

Minimal change disease => steroids

Question 23

AKI: management of nephritic syndrome

Answer 23

Assess for dialysis and/or respiratory support
Immunosuppression (steroids, azathioprine, cyclophosphamide)
Acute pulmonary haemorrhage => PLEX

Question 24

AKI: management of tubulointerstitial disease

Answer 24

Remove precipitant drugs
Treat underlying cause
Supportive treatment

Question 25

CKD Stage 1

Answer 25

eGFR > 90 plus signs of renal disease (haematuria, proteinuria, deranged electrolytes, structural anomaly)

Question 26

CKD Stage 2

Answer 26

eGFR 60-90 plus signs of renal disease (haematuria, proteinuria, deranged electrolytes, structural anomaly)

Question 27

CKD Stage 3a

Answer 27

eGFR 45-60

Question 28

CKD Stage 3b

Answer 28

eGFR 30-45

Question 29

CKD Stage 4

Answer 29

eGFR 15-30

Question 30

CKD Stage 5

Answer 30

eGFR <15

Question 31

CKD Stage A1

Answer 31

Albumen:creatinine ratio <3mg/mmol (normal)

Question 32

CKD Stage A2

Answer 32

Albumen:creatinine ratio 3-30mg/mmol (microalbuminaemia)

Question 33

CKD Stage A3

Answer 33

Albumen:creatinine ratio >30mg/mmol (macroalbuminaemia)

Question 34

CKD: causes

Answer 34

Hypertension Diabetes Small print: inherited disease (ADPKD), renovascular disease, recurrent AKI, HF, immunodeficiency

Question 35

CKD: management

Answer 35

Optimize risk factors (blood pressure, glycaemic control, vascular risk factors) ACE inhibitor or angiotensin receptor blocker first-line antihypertensive, consider amoldipine or doxazocin in low eGFR. Furosemide for symptomatic relief of fluid overload and hyperkalaemia. Empaglifozin (an SGLT2 inhibitor) slows progression in eGFR >45 Dialysis, transplant

Question 36

CKD: sick day rules

Answer 36

Stop antihypertensives (ACE inhibitor, ARB) and diuretics (furosemide) in dehydration

Question 37

CKD: thresholds for dialysis

Answer 37

eGFR <7%: prepare for dialysis eGFR <5%: dialysis

Question 38

CKD: complications

Answer 38

HTN Fluid overload Renal anaemia Hyperkalaemia Secondary hyperparathyroidism (raised PTH and Pi, calcium normal until end-stage where calcium falls) Uraemia (pericarditis and encephalopathy) Acidosis

Question 39

Type 1 RTA: features

Answer 39

Hyperchloraemic metabolic acidosis (normal anion gap) Hypokalaemia and hypercalciuria Nephrocalcinosis and renal stones

Question 40

Type 2 RTA: features

Answer 40

Hyperchloraemic metabolic acidosis (normal anion gap) Hypokalaemia, osteomalacia

Question 41

Type 4 RTA: features

Answer 41

Hyperchloraemic metabolic acidosis (normal anion gap) Hyperkalaemia

Question 42

Type 1 RTA: causes

Answer 42

Idiopathic Rheumatoid arthritis SLE Sjogren's syndrome => impaired H+ excretion in distal tubule

Question 43

Type 2 RTA: causes

Answer 43

Idiopathic Fanconi Syndrome Wilson's Disease Cystinosis Tetracyclines CA inhibitors => impaired HCO3- reabsorption in proximal tubule

Question 44

Type 4 RTA: causes

Answer 44

hypoaldosteronism diabetes

Question 45

ADPKD: features

Answer 45

multiple renal cysts (number and bilaterality required for diagnosis depends on age) pancreatic or hepatic cysts mitral valve prolapse aortic regurgitation berry aneurysm

Question 46

ADPKD: management

Answer 46

tolvaptan (vasopressin receptor 2 antagonist)