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Renal Flashcards

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1
Q

What stimulates Na reabsorption?

A

Na reabsorption increases extracellular volume

decreased BP and decreased NaCl @ macula densa -> renin release -> aldosterone release -> more Na/K pumps

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2
Q

what increases water reabsorption?

A

increased osmolality or decreased BP

-> ADH release

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3
Q

endocrine function of the kidney?

A

secretion of renin by juxtaglomerular apparatus

EPO synthesis

1α-hydroxylation of vitamin D (controlled by PTH)

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4
Q

carbonic anhydrase inhibitors?

MOA

A

inhibit carbonic anhydrase in PCT

  • > ↓ HCO3 reabsorption → small ↑ Na loss
    e. g. acetozalamide
    use: glaucoma

SE: drowsiness, renal stones, metabolic acidosis

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5
Q

Loop diuretics MOA?

A

e.g. furosemide, bumetanide

MOA: inhibit Na/K/2Cl symporter in thick ascending limb

Effect: massive NaCl excretion, Ca and K excretion

Use: Tx of oedema – CCF, nephrotic syndrome, hypercalcaemia

SE: hypokalaemic met alkalosis, ototoxic, Hypovolaemia

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6
Q

e.g. of loop diuretics?

A

furosemide

bumetanide

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7
Q

e.g of carbonic anhydrase inhibtors?

A

acetazolamide

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8
Q

thiazide diuretics MOA?

A

e.g. bendroflumethiazide

MOA: inhibit NaCl co-transporter in DCT

Effect: moderate NaCl excretion, ↑ Ca reabsorption

Use: HTN, ↓ renal stones, mild oedema

SE: ↓K, hyperglycaemia, ↑ urate (CI in gout)

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9
Q

e.g. of thiazide diuretics?

A

bendroflumethiazine

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10
Q

K-sparing diuretics?

A

e.g. spironolactone - aldosterone antagonist

amiloride- blocks DCT/CD luminal Na channel

Effect: ↑ Na excretion, ↓K and H excretion

Use: used w loop or thiazide diuretics to control K loss, spiro has long-term benefits in aldosteronism (LF, HF)

SE: ↑K, anti-androgenic (e.g. gynaecomastia)

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11
Q

e.g. of k sparing diuretics?

A

spironolactone

amiloride

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12
Q

osmotic diuretics moa?

A

e.g. mannitol

MOA: freely filtered and poorly reabsorbed

Effect: ↓ brain volume and ↓ ICP

Use: glaucoma, ↑ICP , rhabdomyolysis

SE: ↓Na, pulmonary oedema, n/v

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13
Q

false +ve haematuria?

A

myoglobin, porphyria

menstrual blood

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14
Q

causes of proteinuria?

A

commonest:

DM

minimal change disease

membranous nephropathy

amyloidosis

SLE

other: HTN, UTI, ATN

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15
Q

definition of nephrotic syndrome?

A

proteinuria > 300mg/dL

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16
Q

what is a protein in the urine that wont be picked up on urine dipstick?

A

Bence-Jones proteins

(immunoglobulin light chain)

-> electrophoresis of urine

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17
Q

White cell casts in urine?

A

pyelonephritis

interstitial nephritis

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18
Q

what factors influence creatinine measurement?

A

creatinine synthesised during muscle turnover

increased muscle -> increased creatinine

age, sex, race

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19
Q

what influences urea measurement?

A

urea is produced from ammonia by liver

increases w protein meal (e.g. supplements, upper GI bleed)

decreases w hepatic impairment

decreased urine flow -> increased urea reabsorption (e.g. in dehydration)

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20
Q

raised Ur and Cr vs isolated raised Urea?

A

isolated raised urea = hypoperfusion/ dehydration -> decreased renal flow

increased urea and creatinine = decreased filtration ie. renal failure

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21
Q

causes of renal AKI?

A

glomerulonephritis

e.g. minimal change, membranous, post strep, IgA, rapidly progressive

acute tubular nephritis

interstitial disease

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22
Q

causes of post renal AKI?

A

obstruction

e.g. in renal pelvis, ureters, bladder or urethra

Stone

Inflammation: stricture

Neoplasm

Prostatic hypertrophy

Infection: TB, schisto

Neuro: post op, neuropathy

posterior urethral valves

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23
Q

causes of pre renal AKI?

A

shock

renal artery stenosis:

RAS

toxins: NSAIDS, ACEi

Thrombosis

Hepatorenal syndrome

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24
Q

presentation of renal failure?

A

uraemia

protein loss and Na+ retention

acidosis

hyperK

Anaemia

Vit D deficiency

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25
how may uraemia present in a pt? signs and symptoms
symptoms: pruritus anorexia, n/v, weight loss lethargy confusion paraesthesia: neuropathy pericarditis signs: pale, sallow skin fits coma uraemic flap confusion
26
how may protein loss and Na+ retention present in patients? signs and symptoms
symptoms: polyuria, polydipsia oliguria, anuria breathlessness signs: oedema raised JVP HTN
27
how may acidosis present in a pt? signs and symptoms
signs: Kussmaul respiration symptoms: breathlessness confusion
28
how may hyperK present in a pt? signs and symptoms
signs: peaked T waves flattened P waves broad QRS prolonged PR interval sine wave pattern -\> VF symptoms: palpitations chest pain weakness
29
how may anaemia present in a pt? signs and symptoms
signs: conjunctival pallor pallor tachycardia flow murmurs (ESM @ apex) symptoms: breathlessness lethargy faintness tinnitus
30
how may Vit D deficiency present in pts? signs and symptoms
signs: osteomalacia - looser's zones (pseudofractures) - cupped metaphyses symptoms: bone pain fractures
31
definition of UTI?
symptomatic w +ve culture or dipstick
32
what is urethral syndrome?
symptomatic of UTI but no bacteriuria
33
uncomplicated vs complicated UTI?
uncomplicated: normal GU tract and fn complicated: abnormal GU tract, outflow obsturction, decreased renal fn, impaired host defence, virulent organism
34
presentation of pyelonephritis?
fever, rigors loin pain and tenderness vomiting oliguria if AKI UTI symptoms
35
presentation of cystitis?
freq and urgency haematuria dysuria polyuria suprapubic tenderness foul smelling urine
36
presentation of prostatitis?
flu-like symptoms low backache dysuria tender swollen prostate on PR
37
what may cause a sterile pyuria?
pus in urine, but no bacteria cultured TB treated UTI appendicitis calculi Tubulointerstitial nephritis PCKD chemical cystitis e.g. cyclophosphamide
38
risk factors of UTI?
female sex pregnancy menopause DM abnormal tract: stone, obstruction, catheter, malformation
39
most common organism responsible for UTI?
e coli in women - 2nd most common staphylococcus saprophyticus
40
ix of UTI?
urine dipstick - +ve leucocytes and nitrites send MSU for MCS Bloods: FBC, WCC, Blood cultures (if systemic signs), U+E US: recurrence, children, pyelonephritis
41
mx of UTI?
analgesia drink plenty, urinate often ABx: usually trimethoprim, nitrofurantoin 50mg QDS for 3 days
42
mx of pyelonephritis?
cefotaxime 1g IV BD for 10 d
43
prevention of UTIs?
drink more, urinate often abx prophylaxis
44
what is glomerulonephritis?
group of disorders resulting from glomerular damage can -\> proteinuria + haematuria can -\> AKI or End stage renal failure
45
causes of glomerulonephritis?
idiopathic immune: Goodpastures, SLE, Vasculitis infection: Strep, HBV, HCV, HIV Amyloid Drugs: penicillamine, gold
46
ix of glomerulonephritis?
Bloods: FBC, U+E, ESR Complements (C3 and C4) -\> may be low in SLE Abs: ANA, ANCA, dsDNA, GBM serum protein electrophoresis and IgA infection: ASOT titre urine: dip, spot PCR, MCS, Bence-Jones protein Imaging: CXR: infiltrates (goodpastures, wegeners) renal US +/- biopsy
47
general mx of glomerulonephritis?
refer to nephrologist tx HTN aggressively (less than 130/80) ACEi/ ARB
48
causes of asymptomatic haematuria?
IgA nephropathy Thin Basement membrane Alport's
49
what is IgA nephropathy?
aka Berger's disease commonest GN in developed world young male w episodic macroscopic haematuria 24-48h after URTI Raised IgA can -\> nephritic syndrome
50
ix of IgA nephropathy?
biopsy: IgA deposition in mesangium
51
mx of IgA nephropathy?
steroids or cyclophosphamide if renal fn impaired HTN mx: ACEi/ ARBs (IgA nephropathy often causes high BP) no cure: some ppl experience complete remission, some progress -\> RF
52
what is thin basement membrane disease?
autosomal dominant commonest cause of asymptomatic haematuria persistent, asymptomatic microscopic haematuria V small risk of end stage renal failure
53
what is Alport's syndrome?
85% X-linked affects type IV collagen -\> basement membranes in kidney, inner ear and eye are affected Haematuria, proteinuria -\> progressive renal failure Sensorineural deafness (bilat) lens dislocation and cataracts retinal 'flecks' females: haematuria only
54
what is nephritic syndrome?
haematuria + red cell casts proteinuria -\> oedema (esp periorbital) HTN oliguria and progressive renal impairment
55
causes of nephritic syndrome?
1. Post-streptococcal 2. Crescentic/ Rapidly progressive GN
56
features of post strep GN?
young child develops malaise and nephritic syndrome w smoky urine 1-2 wks after sore throat or skin infection raised ASOT titre low C3
57
ix of Post strep GN?
ASOT titre: high Biopsy of kidney: IgG and C3 deposition at BM
58
mx of post strep GN?
supportive 95% children recover fully minority develop rapidly progressive GN
59
what is rapidly progressive GN?
most aggressive GN which can -\> end stage renal failure in days 3 types 1. Anti-GBM (goodpastures) 2. Immune complex deposition e.g. SLE, post strep, Bergers (45%) 3. Pauci immune (50%) - e.g. Wegeners, Churg-strauss, microscopic polyangiitis
60
what is Goodpastures syndrome?
Anti-GBM Ab to Type IV collagen -\> haematuria and haemoptysis CXR shows infiltrates -\> TYPE 1 Rapidly progressive GN
61
mx of goodpastures disease?
plasmapheresis and immunosuppression
62
What could cause Type 2 rapidly progressive GN?
complication of any immune complex deposition e.g. Berger's, post strep, infective endocarditis, SLE
63
what is Pauci immune Type 3 Rapidly progressive GN?
may be due to cANCA +ve: Wegener's or pANCA +ve: microscopic polyangiitis, Churg-Strauss
64
what is nephrotic syndrome defined by?
proteinuria: PCR \> 300mg/dL hypoalbuminaemia: \<35g/L Oedema: periorbital, genital, ascites, peripheral (JVP not raised - intravascularly depleted)
65
complications of nephrotic syndrome?
Infection: low Ig, low complement activity VTE: up to 40% Hyperlipidaemia: high cholesterol and triglycerides
66
ix of nephrotic syndrome?
Bloods: FBC, U+E, ESR Complements (C3/4), lipid levels Urine dip, MCS, Spot PCR Imaging: Renal US +/- biopsy - all adults should get biopsied - steroids 1st in children: mostly minimal change
67
most common cause of nephrotic syndrome in children?
minimal change disease
68
causes of nephrotic syndrome?
primary: minimal change disease membranous nephropathy Focal segmental glomerulosclerosis Membranoproliferative/ mesangiocapillary GN secondary: DM: glomerulosclerosis Amyloidosis SLE: membranous
69
what is minimal change GN?
commonest cause of nephrotic syndrome in children assoc w URTI oedema - periorbital, genital could present w AKI and High BP
70
biopsy of kidney showing normal BM on light microscopy, fusion of podocytes
Minimal change disease
71
mx of minimal change glomerulonephritis?
1st line: corticosteroids 2nd: cyclosporine symptomatic mx: salt and fluid restriction to control swelling in adults with high BP: ACEi reduce risk of thrombosis, infection, hyperlipidaemia 1% -\> ESRF
72
what is membranous nephropathy?
20-30% of adult nephrotic syndrome (common) assoc w Ca: lung, colon, breast autoimmune: SLE, thyroid disease infections: HBV drugs: penicillamine, gold biopsy shows: subepithelial immune complex deposits
73
mx of membranous nephropathy?
immunosuppression if renal function declines prognosis: 40% spontaneous remission
74
what is focal segmental glomerulosclerosis?
commoner in Afro carribeans Biopsy shows: focal scarring of the glomerulus, IgM + C3 deposition in the sclerotic segment idiopathic or secondary: chronic pyelonephritis, vesicourethral reflux, berger's, Sickle cell, HIV
75
mx of focal segmental glomerulosclerosis?
steroids or cyclosporin/ cyclophosphamide 30-50% -\> ESRF (may recur in transplants)
76
What is membranoproliferative GN?
deposits in kidney glomerular mesangium and BM thickening, activating complement and damaging the glomeruli may -\> nephrotic or nephritic syndrome assoc w HBV, HCV, endocarditis 50% -\> ESRF
77
mx of nephrotic syndrome?
monitor U+E, BP, fluid balance, weight treat underlying cause symptomatic tx: - oedema: fluid and salt restrict + furosemide proteinuria - ACEi/ ARB decrease proteinuria high lipids: statin VTE: tinzaparin tx HTN
78
definition of AKI?
significant decline in renal function over hrs or days manifesting as an abrupt and sustained increase in serum urea and creatinine
79
most common cause of AKI?
pre renal due to shock, hypovolaemia or renovascular compromise (e.g. NSAIDS, ACEi)
80
what drugs may cause AKI?
contrast dye gentamicin Hb from rhabdomyolysis
81
causes of chronic renal failure?
diabetes HTN
82
clinical assessment of AKI?
acute or chronic? 1. Assess fluid status - JVP, postural hypotension, tachycardia, poor skin turgor, dry mucous membranes, decreased UO 2. GU tract obstruction? - suprapubic discomfort (urinary retention?) palpable bladder enlarged prostate catheter blocked? complete anuria? 3. Rare cause? - proteinuria + haematuria vasculitis: rash, arthralgia, nosebleed
83
ix of AKI?
Bloods: FBC, U+E, LFT, Glucose, Clotting, ESR, Ca ABG: hypoxia (oedema), acidosis, K+ GN screen: if cause unclear Urine: Dip, MCS, PCR, osmolality ECG: hyperK CXR: pulmonary oedema Renal US (hydronephrosis)
84
classification of AKI?
RIFLE classification 3 grades and 2 outcomes Risk: UO \< 0.5ml/kg/h for 6h Injury: UO \< 0.5 ml/kg/h for 12h Failure: UO \< 0.3ml/kg/h for 24h or anuria for 12h Loss: persistent acute renal failure = loss of renal fn \> 4 wks End stage renal disease: complete loss of renal fn \> 3 mo
85
Mx of AKI?
identify cause and treat e.g post/ prerenal cause urgent renal US tx exacerbating factors e.g. sepsis give PPIs stop nephrotoxins: NSAIDs, ACEi, gent, vanc stop metformin if Cr\>150mM tx complications e.g. hyperK, pulmonary oedema Monitor: catheterise and monitor UO, consider CVP fluid balance and daily weights
86
what is impt to monitor in pt w AKI?
catheterise - Urine Output Consider CVP Fluid balance and daily weights
87
mx of HyperK?
10ml 10% Calcium Gluconate - to stabilise myocardium w cardiac monitoring 100ml 20% glucose with 10 u Insulin (Actrapid) salbumatol 5mg nebulizer calcium resonium 15g PO may need haemofiltration
88
Mx of Pulmonary Oedema?
sit up and give O2 Morphine 2.5mg IV (+ metoclopramide 10mg IV) Frusemide 40-80mg IV GTN spray +/- isosorbide mononitrate iv infusion (unless SBP \<100) if no response consider: CPAP Haemodialysis
89
Indications for Acute Dialysis?
AEIOU Acidosis: severe metabolic acidosis (pH \<7.2) Electrolytes: Persistent HyperK (\>7) Intoxicants: Poisons e.g. aspirin Oedema: Refractory pulm oedema Uraemia: Symptomatic e.g. encephalopathy, pericarditis
90
Tx of Bleeding due to AKI?
increased urea impairs haemostasis Give FFP + platelets as needed transfuse to maintain Hb \<10
91
commonest causes of post renal AKI?
stone catheter malignancy
92
commonest cause of AKI renal?
ATN TIN GN
93
Mx of Acute Renal failure A to E approach?
Resus assess fluid status A: decreased GCS may need airway mx B: pulmonary oedema- sit up, high flow O2 C: assess fluid status (JVP, postural BP, HR, mucous membranes, skin turgot, CRT) Urine output Tx lifethreatening complications e.g. HyperK, pulmonary oedema Tx shock or dehydration: fluid bolus 500 ml over 15 min monitoring: cardiac, urine, CVP, fluid balance Post renal causes: catheter in situ, prostate, bladder Hx and Ix tx sepsis: blood cultures and empirical abx call urologists if obstructed despite catheter care w nephrotoxic drugs e.g. gentamicin
94
evidence of acute vs chronic renal failure?
previous blood results duration of symptoms co morbidities
95
What is tubulointerstitial nephritis?
immune mediated hypersensitivity w either drugs or other antigens e. g. NSAIDs, Abx, diuretics infections: staph, strep
96
Causes of tubulointerstitial nephritis?
Drug hypersensitivity in 70%: NSAIDS abx: cephs, penicillins, rifampicin, sulphonamide Diuretics: furosemide, thiazide allopurinol cimetidine infections: staph, strep Immune: SLE, Sjogrens
97
presentation of tubulointerstitial nephritis?
fever, arthralgia, rashes AKI -\> olig/ anuria uveitis
98
ix of tubulointersitial nephritis?
raised IgE: eosinophilia urine dip: haematuria, proteinuria, sterile pyuria
99
mx of tubulointerstitial nephritis?
stop offending drug prednisolone
100
what is chronic tubulointerstitial nephritis?
fibrosis and tubular loss commonly caused by: reflux and chronic pylenonephritis DM SCD
101
what is nephrocalcinosis?
diffuse renal parenchymal calcification progressive renal impairment causes: Malignancy high PTH Myeloma Sarcoid Vit D intoxication
102
what is acute urate crystal nephropathy?
AKI due to urate precipitation usually after chemo-induced cell lysis Mx: hydration, urinary alkalinsation
103
What is analgesic nephropathy?
prolonged heavy ingestion of compound analgesics often a hx of chronic pain sterile pyuria +/- mild proteinuria slowly progressive chronic renal failure sloughed papilla can -\> obstruction and renal colic Ix: CT w/o contrast (papillary calcifications) tx: stop analgesics
104
E.g.s of endogenous nephrotoxins
either directly toxic -\> ATN of cause hypersensitivity -\> TIN Haemoglobin, myoglobin Urate Ig e.g. light chains in myeloma
105
E.g.s of exogenous nephrotoxins?
either directly toxic -\> ATN or cause hypersensitivity -\> TIN NSAIDs Abx: AVASTA Aminoglycosides e.g. Gentamicin, Kanamycin Vancomycin Aciclovir Sulphonamides Tetracycline Amphotericin ACEi Immunosuppressants: Ciclosporin, Tacrolimus Contrast media Anaesthetics: enflurane
106
what antimicrobials are nephrotoxin?
AVASTA Aminoglycosides e.g gent, kanamycin Vancomycin Aciclovir Sulphonamides Tetracycline Amphotericin
107
pathogenesis of rhabdomyolysis?
skeletal muscle breakdown -\> release of - K+, PO4, urate - myoglobin, creatinine kinase - \> AKI
108
causes of rhabdomyolysis?
ischaemia: embolism, surgery trauma: immobilisation, crush, burns, seizures, compartment syndrome Toxins: Statins, fibrates, ecstacy, neuroleptics
109
features of rhabdomyolysis?
muscle pain, swelling red/ brown urine AKI occurs 10-12 h later
110
ix of rhabdomyolysis?
urine dip: +ve Hb, -ve RBCs bloods: raised CK, K, PO4, urate
111
mx of rhabdomyolysis?
tx hyperK IV fluids CVP monitoring if oliguric IV NaHCO3 may be used to alkalinize urine and stabilise a less toxic form of myoglobin
112
Classification of chronic renal failure?
Stage 1: GFR \>90 2: 60-89 3a: 45-59 3b: 30-44 4: 16-29 5: \<15
113
what stage of CKD do you start getting symptomatic?
stage 4 stage 5 = End stage renal failure, need for Renal replacement therapy
114
Causes of chronic renal failure?
Common: Diabetes mellitus HTN other: Glomerulonephritis PCKD Drugs: e.g. analgesic nephropathy Pyelonephritis: usually 2º to VUR SLE Myeloma + Amyloidosis
115
Hx in chronic renal failure?
Past UTI HTN, DM FH DH Symptoms
116
Bloods in chronic renal failure?
low Hb (low EPO) U+E, ESR, glucose low Ca/ high phosphate high Alk Phos high PTH Immune screen Film: burr cells
117
Urine Ix in chronic renal failure?
Urine dip, MCS, PCR, bence jones proteins
118
imaging of chronic renal failure?
CXR: pulmonary oedema, cardiomegaly AXR: calcification from stones Renal US: usually small, may be large - polycystic, amyloid Bone Xrays: renal osteodystrophy CT KUB: e.g. cortical scarring from pyelonephritis renal biopsy: if cause unclear and size normal
119
complications of Chronic renal failure?
CRF HEALS Cardiovascular disease Renal osteodystrophy Fluid (oedema) HTN Electrolyte disturbances: K, H, phosphate Anaemia Leg restlessness Sensory neuropathy
120
features of renal osteodystrophy?
2/3º hyperPTH -\> osteitis fibrosa cystica subperiosteal bone resorption acral osteolysis: short stubby fingers pepperpot skull
121
mechanism of renal osteodystrophy?
decreased 1a-hydroxylase -\> decreased Vit D activation -\> low Ca -\> high PTH Phosphate retention also -\> high PTH - \> activation of osteoclasts - \> increased bone resorption
122
general mx of chronic kidney failure?
tx reversible causes stop nephrotoxic drugs lifestyle: exercise, healthy weight, stop smoking Na, fluid and phosphate restriction CV risk: statins (irrespective of lipids), low dose aspirin, tx DM HTN: target \<140/90 (\<130/80 if DM) -\> ACEi/ARB Oedema: furosemide Bone disease: Alfacalcidol, phosphate binders, ca supplements Anaemia: EPO Restless Legs: Clonazepam
123
mx of anaemia due to CKD?
exclude IDA and ACD EPO to raise Hb to 11
124
mx of bone disease due to CKD?
Phosphate binders: Calcichew Vit D analogues: Alfacalcidol (1-OH Vit D3) Ca supplements \*\*rare: cincalcet: ca mimetic
125
mx of HTN in CKD?
in DM: always give ACEi/ARB if not, give if \>140/90
126
Mx of CV risk due to CKD?
statins -irrespective of lipids low dose aspirin
127
contraindications for renal transplant?
active infection untreated malignancy severe heart failure
128
assessment prior to Renal transplant?
ABO and HLA matching CVD? Virology status: CMV, HCV, HBV, HIV, VZV, EBV TB
129
types of grafts for renal transplant?
cadaveric: brainstem death w CV support Live donor: HLA matched, optimal surgical timing, improved graft survival
130
Immunosuppression pre-renal transplant?
Induction drugs e.g. alemtuzumab Anti-CD52
131
immunosuppression post op renal transplant?
prednisolone short term tacrolimus/ ciclosporin long term
132
complications of renal transplant?
post op: bleeding, graft thrombosis, infection, urinary leaks rejection ciclosporin/ tacrolimus nephrotoxicity immunosuppression: increased risk of infection & malignancy Cardiovasc disease: HTN, atherosclerosis
133
what type of infections are immunosuppressed ppl at risk of?
opportunistic fungi
134
differential of rising creatinine in transplant pt?
rejection obstruction ATN drug toxicity
135
pathology of diabetic nephrology?
conglomerate of lesions occuring concurrently hyperglycaemia -\> renal hyperperfusion -\> hypertrophy and increased renal size hypertrophy and metabolic defects include reactive oxygen species production -\> glomerulosclerosis and nephron loss nephron loss -\> RAS activation -\> HTN
136
features of diabetic nephropathy?
microalbuminuria (30-300mg/d) \*strong independent RF for CV disease progresses to proteinuria (\>300mg/d) diabetic retinopathy usually coexists and HTN is common
137
screening in DM for nephropathy?
T2DMs should be screened for microalbuminuria every 6 months
138
Mx of diabetic nephropathy?
Good glycaemic control delays onset and progression BP target 130/80 start ACEi/ARB even if normotensive stop smoking
139
features of amyloidosis?
renal involvement caused by AL / AA Amyloid proteinuria nephrotic syndrome progressive renal failure
140
diagnosis of amyloidosis causing renal impairment?
large kidneys on US biopsy
141
How could malignancy affect kidneys?
direct: renal infiltration: leukaemia, lymphoma obstruction: pelvic tumour mets nephrotoxicity: toxic chemo, analgesics, tumour lysis syndrome
142
how may sarcoidosis affect kidneys?
raised Ca and tubulointerstitial nephritis
143
pathology of multiple myeloma?
excess production of monoclonal abs +/- light chains (detected in most as urinary BJP) light chains block tubules and have direct toxic effects -\> ATN -\> AL Amyloidosis myeloma also assoc w raised Ca
144
mx of multiple myeloma causing renal failure?
ensure fluid intake of 3L/ d to prevent further impairment dialysis may be required in acute renal failure
145
how may Rheumatoid arthritis lead to kidney problems??
NSAIDs -\> ATN Penicillamine and gold -\> membranous GN AA Amyloidosis occurs in 15%
146
how may SLE affect kidneys?
involves glomerulus in 40-60% -\> ARF/CRF proteinuria and raised BP common may -\> Type 2 rapidly progressive GN
147
tx of SLE kidney disease?
proteinuria: ACEi aggressive GN: immunosuppression
148
diffuse systemic sclerosis and kidneys?
renal crisis: malignant HTN + ARF - \> commonest cause of death tx: ACEi if high BP/ renal crisis
149
HTN and kidney disease?
HTN can be both cause and effect of renal damage renal diseases are commonest cause of secondary HTN - \> activation of RAS - \> retention of Na and water due to decreased excretion
150
cause of renovascular disease? activation of RAS System
atherosclerosis in 80% fibromuscular dysplasia thromboembolism external mass compression
151
features of renovascular disease?
refractory HTN worsening renal function after ACEi/ARB flash pulmonary oedema (no LV impairment on echo)
152
gold standard ix of renovascular disease?
renal angiography
153
ix of renovascular disease?
US + doppler: small kidney + low flow renal angio: gold std
154
mx of renovascular disease?
tx medical CV risk factors angioplasty and stenting
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what is haemolytic uraemic syndrome?
E coli O157:H7 verotoxin -\> endothelial dysfunction young children eating undercooked meat bloody diarrhoea and abdo pain precedes: - MAHA - thrombocytopenia - renal failure
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ix findings of HUS?
schistocytes, low platelets low Hb normal clotting
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what is Thrombotic Thrombocytopenic Purpura?
genetic or acquired deficiency of ADAMTS13 -\> giant vWF multimers (ie. antibodies inhibiting ADAMTS13) blood clots form in small blood vessels throughout body -\> kidney, heart and brain dysfunction + low Pl, low Hb adult females pentad: fever CNS signs: confusion MAHA thrombocytopenia renal failure
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what is the Pentad found in thrombotic thrombocytopenic purpura?
fever cns signs: confusion, seizures MAHA thrombocytopenia renal failure
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mx of haemolytic uraemic syndrome?
usually resolves spontaneously may need dialysis or plasma exchange
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mx of thrombotic thrombocytopenic purpura?
plasmapheresis immunosuppression e.g. corticosteroids, rituximab splenectomy pl transfusions generally not recommended
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what is Polycystic Kidney Disease?
most commonly autosomal dominant defect in PKD1 gene on Chr 16 (80%) or PKD2 gene on chr4 cystic changes are bilat
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clinical presentation of PCKD?
bilateral upper quadrant masses (cystic enlargement of the kidneys) dull loin pain frank haematuria (from rupture of a cyst into the renal pelvis) infected cyst hypertension and eventually chronic renal failure (in 10% of cases) Anuerysms: Berry -\> SAH UTIs/ Stones 20 % cystic livers + possibly, pancreas and spleen
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pathology of autosomal dom PCKD?
PKD1 gene on chr 16 affected -\> polycystin 1 affected large cysts arise from all parts of nephron -\> progressive decline in renal fn 70% ESRF by 70 yrs
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causes of minimal change disease?
majority: idiopathic 10-20% cause is found: - drugs: NSAIDs, rifampicin - Hodgkin's lymphoma, thymoma - infectious mono
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Pathophysiology of minimal change disease?
T cell and cytokine mediated damage to the glomerular BM -\> polyanion loss reduction of electrostatic charge of BM -\> increased glomerulat permeability to serum albumin
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what does electron microscopy show for kidney biopsy of minimal change disease?
fusion of podocytes
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what drugs should be stopped in AKI due to increased risk of toxicity (but does not usually worsen AKI itself)
Metformin (increased risk of lactic acidosis) Lithium Digoxin
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what does calcium resonium do in the acute stage of hyperK?
removes K from the body
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why does VTE occur in nephrotic syndrome?
loss of antithrombin III, proteins C and S and an associated rise in fibrinogen levels predispose to thrombosis
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mx of acute graft failure?
may be reversed by steroids and immunosuppression
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what drugs should be stopped in AKI as may worsen renal function?
NSAIDs (afferent constriction) Aminoglycosides ACEi (efferent dilatation) Angiotensin II receptor blockers Diuretics (intravasc depletion)
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Risk factors for AKI?
Chronic Kidney disease other organ failure e.g. heart/liver chronic disease- diabetes hx of AKI use of drugs w nephrotoxic potential use of iodinated ocntrast agents within past wk age 65 or over
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Features of PCKD in kidneys?
large bilateral masses flank pain infected cyst Haemorrhage into cyst -\> haematuria stones High BP
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features of PCKD extra renally?
Berry aneurysms: SAH cysts in liver (70%)/ pancreas cardiovascular system: mitral valve prolapse, mitral/tricuspid incompetence, aortic root dilation, aortic dissection
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mx of PCKD?
general: Increase water intake, decrease Na/ caffeine Monitor BP and U+E Genetic counselling MRA screen for Berry Aneurysms Medical: Tx HTN aggressively (\<130/80) ACEi best. Tx infections Surgical: pain may be helped by laparoscopic cyst removal/ nephrectomy ESRF in 70% by 70 yrs -\> dialysis or transplant
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what is autosomal recessive PCKD?
presents in infancy development of kidneys and liver is abnormal - \> underdeveloped lungs - \> High BP, CKD - \> problems w liver
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Differentials for renal enlargement?
PHONOS polycystic kidneys: PCKD (AD/AR), tuberous sclerosis Hypertrophy 2º to contralat renal agenesis Obstruction (hydronephrosis) Neoplasia: RCC, myeloma Occlusion: renal vein thrombosis Systemic: early DM, Amyloid
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what is Tuberous Sclerosis?
Autosomal dominant condition w hamartomas in skin, brain, eye, kidney Skin: Nasolabial adenoma sebaceum, ash leaf macules, peri ungual fibromas Neuro: low IQ, epilepsy Renal: Cysts, angiomyolipomas
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How is Tuberous sclerosis inherited?
Auto dom
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what is a medullary sponge kidney?
multiple cystic dilatations in the collecting ducts in the medulla typically presents in 20-30s often asymptomatic, but predisposes to - Hypercalciuria + stones - recurrent UTIs and pyelonephritis - haematuria renal fn is usually normal
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what is renal tubular acidosis?
impaired acid excretion -\> hyperCl met acidosis both -\> RAS activation -\> K+ wasting and hypokalaemia
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features of Fanconi Syndrome?
Disturbance of PCT function -\> generalised impaired reabsorption of aas, K+, HCO3, Phosphate, glucose features of: - polyuria (osmotic diuresis) - hypophosphataemic rickets (Vit D resistant) - Acidosis, low K
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types of renal tubular acidosis?
-\> hyperCl met acidosis Type 1: Distal collecting tubule Type 2: Proximal collecting tubule
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Features of Type 1 renal tubular acidosis?
inability to excrete H+ even when acidotic causes: hereditary - Marfans, Ehlers Danlos AI: sjogrens, SLE, thyroiditis Drugs features of rickets/ osteomalacia (bone buffering) renal stones and UTIs nephrocalcinosis -\> ESRF
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diagnosis of renal tubular acidosis (type 1 vs 2)?
I: failure to acidify urine (pH\> 5.5) despite acid load 2: urine will acidify w acid load (pH \<5.5)
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features of type 2 renal tubular acidosis?
defect in proximal collecting tubule - defect in HCO3 reabsorption tubules can reabsorb some HCO3 so can acidify urine in systemic acidosis when HCO3 is low
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what are the hereditary hypoK tubulopathies?
Bartter's Syndrome: HYPOK and met alkalosis Gitelman Syndrome: HypoK and met alkalosis + hypocalciuria both normal BP
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3 main causes of nephrotic syndrome?
minimal change: more common in kids membranous focal segmental: more common in adults
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causes of focal segmental glomerulosclerosis?
causes nephrotic syndrome Causes: idiopathic secondary to other renal pathology e.g. IgA nephropathy, reflux nephropathy HIV heroin Alport's syndrome sickle-cell
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when to urgently refer someone to urology?
Aged \>= 45 years AND: unexplained visible haematuria without urinary tract infection, or visible haematuria that persists or recurs after successful treatment of urinary tract infection Aged \>= 60 years AND have unexplained nonvisible haematuria and either dysuria or a raised white cell count on a blood test
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what are the six classes of SLE glomerulonephritis?
WHO classification ## Footnote class I: normal kidney class II: mesangial glomerulonephritis class III: focal (and segmental) proliferative glomerulonephritis class IV: diffuse proliferative glomerulonephritis class V: diffuse membranous glomerulonephritis class VI: sclerosing glomerulonephritis Class IV most common and severe
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prevention of nephrotoxicity due to contrast media?
IV 0.9% NaCl pre and post procedure
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mx of high PTH in CKD?
Alfacalcidol
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when starting pts with CKD on ACEi, what fall in glomerular filtration pressure (GFR) and rise in creatinine is acceptable?
decrease in eGFR of up to 25% or a rise in creatinine of up to 30% is acceptable although any rise should prompt careful monitoring and exclusion of other causes (e.g. NSAIDs). A rise greater than this may indicate underlying renovascular disease.
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most common organism causing peritonitis in peritoneal dialysis?
Staphylococcus epidermidis (staph aureus is another common cause)
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features of rhabdomyolysis?
acute renal failure with disproportionately raised creatinine elevated CK myoglobinuria hypocalcaemia (myoglobin binds calcium) elevated phosphate (released from myocytes)
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mx of rhabdomyolysis?
IV fluids to maintain good urine output urinary alkalinization is sometimes used
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features of Wilms Nephroblastoma?
typically presents in children under 5 years of age, with a median age of 3 years old. abdominal mass (most common presenting feature) flank pain painless haematuria other features: anorexia, fever unilateral in 95% of cases metastases are found in 20% of patients (most commonly lung)
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what is a common immunosuppressant induction regime before transplant?
Campath Alemtuzumab anti-CD52
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regimen for immunosuppression post-transplant?
initial: ciclosporin/tacrolimus with a monoclonal antibody maintenance: ciclosporin/tacrolimus with MMF or sirolimus add steroids if more than one steroid responsive acute rejection episode
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pts undergoing longterm immunosuppression should undergo regular monitoring for?
Cardiovascular disease - tacrolimus and ciclosporin can cause hypertension and hyperglycaemia. Tacrolimus can also cause hyperlipidaemia. Patients must be monitored for accelerated cardiovascular disease. Renal failure - due to nephrotoxic effects of tacrolimus and ciclosporin/graft rejection/recurrence of original disease in transplanted kidney Malignancy - patients should be educated about minimising sun exposure to reduce the risk of squamous cell carcinomas and basal cell carcinomas
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what does haemodialysis involve?
most common form of renal replacement therapy regular filtration of the blood through a dialysis machine in hospital most often 3 x 3-5h / wk, pt needs surgery to create AV fistula for site of haemodialysis
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what is involved in peritoneal dialysis?
RRT where filtration occurs in patient's abdomen Dialysis solution is injected into the abdominal cavity through a permanent catheter The high dextrose concentration of the solution draws waste products from the blood into the abdominal cavity across the peritoneum. After several hours of dwell time, the dialysis solution is then drained, removing the waste products from the body, and exchanged for new dialysis solution.
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what are the different types of peritoneal dialysis?
- Continuous ambulatory peritoneal dialyssi (CAPD): each exchange ~30-40 mins and each dwell time 4-8h. normal activities w dialysis soln inside abdomen - Automated peritoneal dialysis: a dialysis machine fills and drains the abdo while pt is sleeping, 3-5 exchanges over 8-10h per night
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What is involved in Renal transplantation?
receipt of a kidney from either a live or deceased donor donor kidney transplanted into the groin, with the renal vessels connected to the external iliac vessels Following transplantation, the patient must take life-long immunosuppressants to prevent rejection of the new kidney average lifespan of a donor kidney is 10-12 years from deceased donors and 12-15 years from living donors.
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Complications of haemodialysis?
Site infection endocarditis stenosis at site hypotension cardiac arrhythmia air embolus anaphylactic reaction to sterilising agents Disequilibration syndrome
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Complications of peritoneal dialysis?
peritonitis sclerosing peritonitis catheter infection catheter blockage constipation fluid retention hyperglycaemia hernias back pain malnutrition
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Complications of renal transplantation?
DVT/PE immunosuppression: opportunistic infection, malignancies (skin ca, lymphoma), bone marrow suppression recurrence of original disease Urinary tract obstruction CV disease graft rejection
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1st line Renal replacement therapy for independent pts?
Peritoneal dialysis
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contraindications to peritoneal dialysis?
IBD diverticulitis ischaemic bowel abdo abscess
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Causes of cranial DI?
idiopathic post head injury pituitary surgery craniopharyngiomas DIDMOAD is the association of cranial Diabetes Insipidus, Diabetes Mellitus, Optic Atrophy and Deafness (also known as Wolfram's syndrome)

Medicine (16 decks)

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