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What are the different stages of chronic renal failure?

Must have >3 months of abnormal structure or evidence of damage plus:

Stage 1 GFR > 90 (only have CKD if evidence of kidney damage)

Stage 2 GFR 60 - 89 (have CKD even if no other signs)

Stage 3a GFR 45 - 59
Stage 3b GFR 30 - 44 (symptoms usually start)

Stage 4 GFR 15 - 29

Stage 5 GRF <15 (end stage renal failure)

1

What are the common causes of chronic renal failure?

Hypertension and Diabetes
Glomerulonephritis
Renovascular disease
Pyelonephritis
PKD
BPH
Intersitial nephritis
Analgesic nephropathy
Renal stones

2

What are the 7 functions of the kidney?

1. Regulation of H2O and electrolyte balance
2. Excretion of metabolic waste
3. Excretion of bioactive substances that affect body function
4. Regulation of arterial BP
5. Regulation of RBC production
6. Regulation of Vit D production
7. Gluconeogenesis

3

What are the complications of CKD?

ANAEMIA
Eyrthropoietin deficiency
Haematinic deficiency

BONE DISEASE - renal osteodystrophy
Phosphate retention very early on, PTH increases and calcium can be high or low.

SKIN DISEASE
puritis is common due to build up of nitrogenous waste products

GI
decreased gastric emptying, increased reflux osephagitis, peptic ulcers, acute pancreatitis

METABOLIC ABNORMALITIES
gout, insulin resistance, impaired lipid metabolism

ENDOCRINE ABNORMALITIES
Hyperprolactinaemia, increased LH, decreased testosterone, impaired growth in children, abnormal thyroid function

NERVOUS SYSTEM
severe uraemia causes decreased cerebral function and decreases seizure threshold
impaired baroreceptor sensitvity, impaired vagal function
polyneuropathy

CARDIOVASCULAR
16 fold increased of CVD

4

How should BP be controlled in patients with CKD?

Target BP <130/80 if diabetic
In diabetic kidney disease treat with ACEi even if normal BP

5

How can urinary tract infections be classified?

Lower tract - urethritis, cystitis or prostatitis
Upper tract - pyelonephritis

and then:
uncomplicated - normal renal tract and function
complicated - abnormal renal or GU tract, voiding difficulty or outflow obstruction, decrease in renal function, impaired host defences or virulent organisms

Recurrent UTI = a further infection with a new organism
Relapse = further infection with the same organism

6

What organisms cause UTIs?

E.coli (most common)
Staph saprophyticus, proteus mirabilis
Enterococcus faecalis, klebsiella, enterobacter, pseudomonas, candida

7

What are the symptoms of the different types of UTI?

Pyelonephritis: high fever, rigors, vomiting, loin pain and tenderness, oliguria

Cystitis: frequency, dysuria, urgency, strangury, haematuria suprapubic pain

Prostatitis: flu like symptoms, lower back ache, few urinary symptoms, swollen or tender prostate,

8

What are the causes of sterile pyuria (WBC in urine but no organisms grown on culture)

Treated UTI
Inadequately treated UTI
Appendicitis
Calculi
Bladder tumour
Papillary necrosis (DM or analgesia excess)
Tubulointerstitial nephritis
PKD
Chemical cystitis

9

What is the triad of nephrotic syndrome?

Oedema with:
Proteinuria >3g/24hrs

Hypoalbuminaemia <30g/L

Hypercholesterolaemia

10

What are the complications of nephrotic syndrome?

Increased susceptibility to infection - loss of immunoglobulins in the urine

Thromboembolism - hyper-coagulable state

11

What are the causes of nephrotic syndrome?

Minimal change glomerulonephritis
commonest cause in children
? t lymphocyte mediated
steroids can initiate remission

Membraneous nephropathy
common in adults
unknown cause
biopsy shows thickened GBM with IgG and C3 subepithelial deposits
treat with steroids if renal function is deteriorating
associated with malignancy, drugs, autoimmune (SLE, RA etc), and infections (HBV, syphilis, leprosy)

Focal segmental glomerulosclerosis
may be primary or secondary (due to vesicouretric reflux, IgA nephropathy, Alports syndrome, vasculitis, sickle cell, heroine)
responds to steroids
>30% develop ESRF

Others:
Diabetes
SLE
HIV
Myeloma
Amyloidosis

13

What is the general treatment of nephrotic syndrome?

Monitor renal function
Fluid balance - fluid restrict 1.5l per day
Weigh regularly
Treat underlying cause

14

What are the extra renal manifestations of Autosomal dominant polycystic kidney disease?

Liver cysts
Intracranial aneurysm - SAH
Mitral valve prolapse
Diverticular disease
ingunial hernias
hypertension

15

What are the genes responsible for PKD?

ADPKD1 - encodes for the proteins polycystin (a membrane glycoprotein)
Generally have an earlier onset on hypertension

ADPKD2 - encodes for polycystin 2

16

What is Acute Kidney Injury?

A significant deterioration of renal function over hours or days.
It can be identified by:
Rise in creatinine >26 in 24hrs
50% rise in creatinine over 7days
Fall in urine output to <0.5ml/kg/hr for more than 6hrs

17

What steps need to be undertaken when a patient is identified as having AKI?

1. The cause needs to be found and corrected
Check and correct fluid status - prerenal

Treat any sepsis

Review medications - stop any nephrotoxic drugs (NSAIDs, Gent, ACEi, Vanc, metformin

Urinalysis - if blood or protein found and no other cause of AKI then ?acute nephritis and refer to the renal team

Renal USS - only offer if likely cause is obstructive or no other cause is found

If any signs of vasculitis (nosebleed, haematuria, increased ESR) do autoantibodies

2. Monitoring
OBS
Insert catheter and monitor hourly fluid balance
Take blood cultures if sepsis

3. Treat complications
Check potassium levels and do ECG to monitor for hyperkalaemia - treat with calcium gluconate and insulin/dextrose if present

Monitor for pulmonary oedema

18

What are the indications for haemodialysis in AKI?

Intractable hyperkalaemia
Intractable pulmonary oedema

Ureamia
Acidosis

19

What are the causes of AKI?

PRE RENAL
any thing that will decrease perfusion to the kidney
hypovolaemia
sepsis
renal artery stenosis
NSAIDs, ACEi
Reduced cardiac output

POST RENAL
obstruction - suggested by anuria

RENAL
Acute tubular necrosis
Nephrotoxic drugs
Nephritic syndrome
Contrast
Intersitial nephritis
etc

20

What is rhabdomyolysis?

Severe muscle damage resulting in the release of myoglobin, CK, K, PO4

21

What are the causes of rhabdomyolysis?

Post ischemia - embolism, clamping an artery during surgery
Immbolisation - after fall
Burns, crush injury, excessive exercise, uncontrolled seizures
Drugs - statins, fibrates, alcohol, ectasy, heroine, snake bites, CO, neuroleptic malignant syndrome
Infections - Coxsackie, EBV, influenza
Metabolic - low K and PO4
malignant hyperpyrexia

22

What is glomerulonephritis?

A group of disorders where there is damage to the glomerular filtrating apparatus causing a leak of protein and blood into the urine.

Patients may be asymptomatic or present with haematuria, proteinuria, renal failure or hypertension.

23

Give some examples of glomerulonephritides?

IgA nephropathy:
commonest in developed world
present with macro or microscopic haematuria
young men who have haematuria after viral infections
biopsy shows- mesangial proliferation, with IgA deposits

SLE

Anti-glomerular basement membrane disease
AKA Goodpastures disease
due to developement of antibodies againt type IV collagen
also causes haemoptysis
renal failure may occur very quickly

Proliferative glomerulonephritis
most common post strep
usually present as a nephritic syndrome

Henoch-Schonlein purpura
associated with rash on extensor surfaces, polyarthritis, abdominal pain

24

What is nephritic syndrome?

Haematuria, proteinuria
Hypertension
AKI

Usually due to a glomerulonephritis