Renal 7.5 Flashcards
(290 cards)
1
Q
Options of renal replacement therapy
A
Tx: living/deceased; always has better outcomes than any dialysis, and more effective when pre-emptive
Haemodialysis
Haemofilltration
Haemodiafiltration (in a Rx centre more effective than HD in a Rx centre)
PD - continuous ambulatory, & automated PD
2
Q
Indications for considering starting RRT?
A
- Sx of uraemia on ADLs
- biochemical measures
- uncontrollable fluid overload
- eGFR 5-7 if no Sx
3
Q
When to start assessment for RRT/conservative Rx?
A
At least 1yr before therapy e.g. Tx/HD is likely to be needed, inc for those with a failing Tx
4
Q
What are AV fistulas?
A
= Direct connections between arteries & veins, may occur pathologically but gene formed surgically to allow access for HD - now regarded as preferred method of access due to lower rates of complications
5
Q
What are the potential complications of AV fistulas?
A
- infection
- thrombosis
- stenosis
- steal syndrome
6
Q
How to calculate anion gap?
A
(Na + K) - (HCO3 + Cl)
normal 8-14
7
Q
Causes of a normal anion gap or hyperchloraemic metabolic acidosis?
A
- GI bicarbonate loss: diarrhoea, fistula, ureterosigmoidostomy
- renal tubular acidosis
- drugs e.g. Acetazolamide
- Ammonium chloride injection
- Addison’s disease
8
Q
Causes of a raised anion gap metabolic acidosis?
A
- lactate: shock, hypoxia, burns, metformin (type B)
- ketones: DKA, etoh
- urate: renal failure
- acid poisoning: salicylates, methanol
9
Q
What is Alport’s syndrome? what is the inheritance?
A
X-linked dominant
- defect in the gene which codes for type IV collagen -> abnormal glomerular-basement membrane
- more severe in males (females rarely develop renal failure)
10
Q
Pt with Alport’s syndrome has a renal Tx that starts to fail - what is the cause?
A
presence of anti-GBM antibodies, leading to a Goodpasture’s syndrome like picture
11
Q
When does Alport's syndrome present? what are the features? renal ear eye
A
- microscopic haematuria
- progressive renal failure
- BL SNHL
- lenticonus: protrusion of the lens surface into the anterior chamber
- retinitis pigmentosa
12
Q
What is on renal biopsy in Alport’s syndrome?
A
Splitting of lamina densa on electron microscopy
13
Q
What is amyloidosis?
A
Extracellular deposition of an insoluble fibrillar protein amyloid
- accumulation of amyloid fibrils leads to tissue/organ dysfunction
14
Q
What are the component of amyloid?
A
- many different precursor proteins
- fibrillar component, insoluble amyloid
- non-fibrillary components inc: amyloid-P (derived from acute phase protein serum amyloid P), apolipoprotein E & heparan sulphate proteoglycans
15
Q
How to classify amyloidosis?
A
systemic vs localised
- further characterised by precursor protein e.g. AL in myeloma - A amyloid, L Light chain Ig fragments
16
Q
3 ways to Dx amyloidosis?
A
- Congo red staining of tissue: apple-green birefringence
- SAP: serum amyloid precursor scan
- Biopsy of rectal tissue
17
Q
What are the 3 main types of amyloidosis?
A
- AL amyloid (Light chain Ig fragment)
- AA amyloid (precursor serum amyloid A protein, acute phase reactant)
- Beta-2 microglobulin amyloidosis (precursor protein, part of the major histocompatibility complex)
18
Q
AL amyloid
- what are the causes?
- what are the features?
A
- myeloma, MGUS, Waldenstom’s
- cardiac & neuro involvement, macroglossia, periorbital eccymoses
19
Q
AA amyloid
- when is it seen?
- what are the features?
A
- chronic infection/inflammation eg TB, RA, bronchiectasis
- fenal involvement is most common feature
20
Q
Beta-2 microglobulin amyloidosis (precursor that is a part of the MHC) - what is it associated with?
A
pts on renal dialysis
21
Q
ARPKD: what is the genetic defect?
A
- defect in gene on chr 6 which encodes fibrocystin (protein important for normal renal tubular development)
22
Q
How to Dx ARPKD?
What are the features?
A
- prenatal US or in early inference with abdo masses & renal failure
- newborns may have features consistent with Potter’s syndrome 2ry to oligohydramnios
- ESRF develops in childhood
- pts also typically have liver involvement e.g. portal & interlobular fibrosis
23
Q
What is on renal biopsy in ARPKD?
A
multiple cylindrical lesions at right angles to the cortical surface
24
Q
What is the genetics of ADPKD type 1?
A
PKD1 loci, which codes for polycystin-1
chr 16
85% of cases, presents with renal failure earlier
25
What is the genetics of ADPKD type 2?
PKD2 loci, which codes for polycystin-2
*chr 4*
15% of cases
26
What is the screening Ix for relatives of ADPKD?
Abdo US/S
27
ADPKD: what is the Ultrasound Dx criteria (in pts with +ve FHx)?
Age<30: 2 cysts UL/BL
Age 30-59: 2 cysts in both kidneys
Age>50: 4 cysts in both kidneys
28
What are the features of ADPKD?
- hypertension
- recurrent UTIs
- abdo pain
- haematuria
- renal stones
- CKD
29
What are the extra-renal manifestations of ADPKD?
- liver cysts 70%
- berry aneurysms 8%
- CVS: MVP, mitral/tricuspid incompetence, aortic root dilation, aortic dissection
- cysts in other organs: pancreas, spleen (v rarely thyroid, oesophagus, ovary)
30
Prerenal causes of AKI?
think ischaemia
- hypovolaemia 2ry to diarrhoea/vomiting etc
- renal artery stenosis
31
Intrinsic causes of AKI?
think damage to glomeruli, renal tubules or interstitium, immune-mediated or dye to toxins/drugs/contrast
- glomerulonephritis
- acute tubular necrosis
- acute interstitial nephritis
- rhabdomyolysis
- tumour lysis syndrome
32
Postrenal causes of AKI?
think obstructive uropathy e.g. UL ureteric stone/BL hydronephrosis 2ry to acute urinary retention caused by BPH
- stone in ureter/bladder
- BPH
- external compression of ureter
33
RFs for AKI?
- age>65
- Hx of AKI
- CKD
- other organ failure.chronic disease e.g. heart failure, liver disease, diabetes
- nephrotoxics inc contrast within past wk
- emergency surgery
- intraperitoneal surgery
- oliguria of urine output <0.5ml/kg/h
- neuro or cognitive impairment or disability that may mean limited access to fluids due to reliance on someone else
34
Sx & signs of AKI?
- reduced urine output
- fluid overload eg peripheral, pulmonary
- rise in K, urea, Cr, change in acid-base balance which can lead to
- arrhythmias
- uraemic complications eg pericarditis, encephalopathy
35
Criteria for Dx of AKI?
- rise in Cr of >25 within 48h
- 50%+ rise in Cr within 7 days
- fall in urine output to <0.5ml/kg/h for >6hours
36
What drugs should be stopped in AKI as it may worsen renal function?
```
NSAIDs
aminoglycosides
ACE-I
A2RBs
diuretics
```
37
What drugs may have to be stopped in AKI as there is increased risk of toxicity (but don't usually worsen AKI itself)
metformin
lithium
digoxin
38
What Ix to consider when you suspect AKI?
- bloods (U&Es)
- urinalysis
- ecg (hyperkalaemic change/arrhythmias)
- renal US with 24h if at risk/obstructive cause is suspect - +/- urology r/v
39
Rx of hyperkalaemia to stabilise the cardiac membrane?
IV calcium gluconate
40
Rx of hyperkalaemia for a short-term shift in K from extra to intracellular fluid compartment?
- combined insulin/dextrose infusion
| - nebulised salbutamol
41
Rx of hyperkalaemia to remove K from the body?
Calcium resonium - oral/enema
loop diuretics
dialysis
42
In AKI NICE guidelines - when to refer to a nephrologist?
- renal Tx
- ITU pt with unknown cause of AKI
- vasculitis/glomerulonephritis/tubulointerstitial nephritis/myeloma
- AKI with no known cause
- inadequate response to Rx
- complications of AKI
- stage 3 AKI
- CKD stage 4/5
- any indication for renal replacement therapy e.g. refractory hyperkalaemia, metabolic acidosis, uraemic complications, refractory fluid overload
43
```
Prerenal Uraemia - kidneys hold onto sodium to preserve volume - what happens to:
urine sodium?
fractional Na excretion?
fractional urea excretion?
urine:plasma osmolality?
urine:plasma urea?
specific gravity?
urine?
response to fluid challenge?
```
```
urine sodium <20
fractional Na excretion <1%
fractional urea excretion <35%
urine:plasma osmolality >1.5
urine:plasma urea >10.1
specific gravity >1020
urine: bland sediment
response to fluid challenge - Yes
```
44
```
Acute tubular necrosis - what happens to:
urine sodium?
fractional Na excretion?
fractional urea excretion?
urine:plasma osmolality?
urine:plasma urea?
specific gravity?
urine?
response to fluid challenge?
```
```
urine sodium >30
fractional Na excretion >1%
fractional urea excretion >35%
urine:plasma osmolality <1.1
urine:plasma urea <8.1
specific gravity <1010
urine: brown granular casts
response to fluid challenge - No
```
45
BPH - what are the RFs?
| what are the typical LUTS?
- ethnicity black >white >Asian
- age; 50% of 50y.o. men will have evidence of BPH, 30% will have Sx; 80% of 80y.o. men have evidence of BPH
- obstructive voiding Sx - weak/poor flow, straining, hesitancy, terminal dribbling, incomplete emptying
- storage irritative Sx - urgency, frequency, urgency incontinence, nocturia
- post-micturition Sx - dribbling
- complications - UTI, retention, obstructive uropathy
46
Rx options for BPH?
- watchful waiting
- medications: alpha-1 blockers, 5 alpha-reductase inhibitors
- surgery: TURP
47
How do alpha-1 blockers work in BPH?
what are examples?
what are the adverse effects?
- decrease smooth muscle tone (prostate & bladder)
- 1st line, improve Sx in 70% men
- tamsulosin, alfuzosin
- dry mouth, dizziness, depression, postural hypotension
48
How do 5 alpha-reductase inhibitors work in BPH?
how long does it take?
what are the adverse effects?
- e.g. finasteride
- block conversion of testosterone to DHT, which is known to induce BPH
- causes a reduction in rotate volume (unlike alpha blockers) and hence may slow disease progression
- may take 6months to improve Sx
- decreases PSA conc by unto 50%, erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia
49
RFs for transitional cell carcinoma of the bladder?
- smoking
- aniline dyes eg 2-naphthylamine, benzidine
- rubber manufacture
- cyclophosphamide
50
RFs for squamous cell carcinoma of the bladder?
- schistosomiasis
- BCG Rx
- smoking
51
What is Cystinuria?
| what is the genetic defect?
- autosomal recessive disorder characterised by recurrent renal stones formation
- defect in the membrane transport of cystine, ornithine, lysine & arginine (COLA)
- chr 2: SLC3A1 gene
- chr 19: SLC7A9 gene
52
Dx of Cystinuria?
cyanide-nitroprusside test
53
Features of cystinuria?
- recurrent renal stones
| - classically yellow & crystalline, appearing semi-opaque on X-ray
54
Rx of cystinuria?
- hydration
- D-penicillamine
- urinary alkalinisation
55
What is diabetes insipidus?
- ADH deficiency or insensitivity
56
Causes of cranial diabetes insipidus?
- idiopathic
- posy-head injury
- pituitary surgery
- craniopharyngiomas
- histiocytosis X
- DIDMOAD: ass of cranial DI, DM, Optic Atrophy & Deafness = Wolframs syndrome
57
Causes of nephrogenic diabetes insipidus?
- genetic: vasopressin/ADH receptor (commoner) gene mutation, aquaporin 2 channel gene mutation
- electrolytes: hypercalcaemia, hypokalaemia
- drugs: demeclocycline, lithium
- tubulo-interstitial disease: obstruction, sickle-cell, pyelonephritis
58
Features of diabetes insipidus?
- polyuria, polydipsia
59
Ix of diabetes insipidus:
plasma & urine osmolality?
test?
- water deprivation test
- plasma osmolality high
- urine osmolality low (>700 excludes DI)
60
tubulo-interstitial disease causes of nephrogenic DI?
- obstruction
- sickle cell
- pyelonephritis
61
electrolyte causes of nephrogenic DI?
- hypercalcaemia
| - hypokalaemia
62
drug causes of nephrogenic DI?
- lithium
| - demeclocycline
63
What is stage 1 of T1 diabetic nephropathy?
- hyperfiltration: increase in GFR
| - may be reversible
64
What is stage 2 of T1 diabetic nephropathy?
- (silent/latent phase)
- most pts don't develop microalbuminuria for 10yrs
- GFR remains elevated
65
What is stage 3 of T1 diabetic nephropathy?
- incipient nephropathy
| - microalbuminuria (albumin excretion of 30-300mg/day, dipstick negative)
66
What is stage 4 of T1 diabetic nephropathy?
- overt nephropathy
- persistent proteinuria (albumin excretion >300mg/day, dipstick positive)
- histology shows diffuse glomerulosclerosis & focal glomerulosclerosis (Kimmelstiel-Wilson nodules)
67
What is stage 5 of T1 diabetic nephropathy?
- ESRF, typically GFR<10
| - RRT needed
68
What is epididymo-orchitis?
cause?
most important DDx?
Infection of the epididymis +/- testes, resulting in pain & swelling
- most commonly caused by local spread of infections from genital tract e.g. Chlamydia, gonorrhoea, Or the bladder
- ?Testicular torsion***
69
Features of epididymo-orchitis?
- UL testicular pain & swelling
- urethral discharge may be present, but urethritis is often aSx
- factors suggesting testicular torsion inc pts<20yrs, severe pain & acute onset
70
Rx of epididymo-orchitis?
- IM Ceftriaxone 500mg stat + Doxycycline 100mg BD PO for 10-14days if organism unknown
- further Ix after Rx to exclude any underlying structural abnormalities
71
What is erythropoietin?
| what are the main uses?
- haematopoietic growth factor that stimulates the production of erythrocytes
- Rx anaemia ass with CKD or cytotoxic therapy
72
Why may pts fail to respond to EPO therapy?
- iron deficiency
- inadequate dose
- concurrent infection/inflammation
- hyperparathyroid bone disease
- aluminium toxicity
73
Side-effects of EPO?
- accelerated hypertension, potentially leading to encephalopathy & seizures (BP increases in 25%)
- bone aches
- flu-like Sx
- skin rashes, urticaria
- pure red cell aplasia due to Abs against EPO (risk reduced with darbepoetin)
- raised PCV increases risk of thromboses e.g. of fistula
- iron deficiency 2ry to increased erythropoiesis
74
What is Fanconi syndrome?
| What are the features?
Generalised disorder of renal tubular transport in the proximal convoluted tubule, resulting in:
- type 2 proximal renal tubular acidosis
- polyuria
- aminoaciduria
- glycosuria
- phosphaturia
- osteomalacia
- lots of urine with AA, sugar & phosphate
75
Causes of Fanconi syndrome?
- cystinosis (commonest cause in children)
- Sjogren's syndrome
- multiple myeloma
- nephrotic syndrome
- Wilson's disease
76
What are the maintenance fluid requirements for adults?
- 25-30ml/kg/day water
- 1mmol/kg/day of K, Na, Cl
- 50-100g/day of glucose to limit starvation ketosis
77
How many mmol of Na & Cl in 0.9% NaCl?
Na 154
| Cl 154
78
How many mmol of Na & Cl in 0.18% saline with 4% glucose?
Na 30
Cl 30
glucose 40g
79
How much Na, Cl, K HCO3 in Hartmanns?
Na 131
Cl 111
K 5
HCO3 29
80
What type of renal impairment does focal segmental glomerulosclerosis lead to?
what happens with renal Tx?
NEPHROTIC syndrome
- CKD
- generally presents in young adults
- has a high recurrence rate in renal Tx
81
Causes of focal segmental glomerulosclerosis?
- idiopathic
- 2ry to other renal pathology e.g. IgA nephropathy, reflux nephropathy
- HIV
- heroin
- Alport's syndrome
- sickle cell
82
What variables does th MDRD equation use to calculate eGFR?
What factors may affect the result?
- serum Cr
- age
- gender
- ethnicity
- pregnancy
- muscle mass
- eating red meat within 12h prior
83
CKD stages?
1. GFR>90 with sign of kidney damage on other tests
2. 60-90 with sign of kidney damage on other tests
3a. 45-59
3b. 30-44
4. 15-29 (severe reduction)
5. <15, established kidney failure - RRT may be needed
84
Common causes of CKD?
- HTN
- diabetic nephropathy
- chronic glomerulonephritis
- chronic pyelonephritis
- ADPKD
85
What type of anaemia is seen in CKD?
| What does it predispose pts to - increasing mortality 3x in renal pts?
- normochromic, normocytic - becomes apparent when GFR <35
- mainly due to reduced EPO
- **LV hypertrophy**
86
Causes of anaemia in renal failure?
- reduced EPO levels (most significant)
- reduced erythropoiesis due to toxic effects of uraemia on bone marrow
- reduced iron absorption
- anorexia/nausea due to uraemia
- reduced red cell survival (esp in haemodialysis)
- blood loss due to capillary fragility & poor platelet function
- stress ulceration leading to chronic blood loss
87
Rx of anaemia in CKD?
| - what is target Hb?
- target Hb 10-12
- optimise iron status before starting ESAs: erythropoiesis-stimulating agents - many pts esp on HD need IV iron
- ESAs eg EPO & darbepoetin should be used in those who are likely to benefit in terms of QoL & physical function
88
How is proteinuria identified in CKD?
ACR: albumin:creatinine ratio (more sensitive than PCR)
| - proteinuria is an esp important marker of CKD for diabetic nephropathy
89
How is an ACR albumin:creatinine ration sample collected?
- spot sample (avoids 24h collection)
- 1st pass morning
- if initial ACR is 3-70, this should be confirmed by a subsequent early morning sample
- if initial ACR>70, repeat sample not needed
90
What level of urine ACR: albumin creatinine ratio is clinical significant for proteinuria?
3mg/mmol +
91
When to refer to a nephrologist with regards to urine ACR?
- urine ACR 70+ (unless known to be diabetes & appropriately treated)
- urine ACR 30+ with persistent haematuria, after excluding UTI
- consider referral to nephrologist if urine ACR 3029 with persistent haematuria and other RFs e.g. declining eGFR or CVD
92
1st line anti-hypertensive in proteinuria renal disease?
ACE-I
- tend to reduce filtration pressure and a small fall in GFR & rise in Cr can be expected
- decrease in eGFR upto 25% or rise in Cr upto 30% is acceptable
- if more than this, may suggest underlying renovascular disease
93
Furosemide for hypertension in CKD?
- useful if GFR<45
- also lowers potassium
- high doses usually required
- may need withholding during periods of risk of dehydration
94
What basic problems lead to bone disease in CKD?
- low vitamin D (1-alpha hydroxylation normally occurs in the kidneys)
- high phosphate
- low calcium: due to lack of vitamin D, high phosphate
- 2ry hyperparathyroidism: due to low calcium, high phosphate, low it D
95
What clinical manifestations of bone disease occur in CKD?
- osteitis fibrosa cystica = hyperparathyroid bone disease
- osteosclerosis
- osteoporosis
- osteomalacia = low vit D
- adynamic = reduction in cellular activity (both blasts & clasts) - may be due to over Rx with it D
96
What are the aims of bone disease Rx in CKD?
| what are the options?
- reduce high phosphate
- reduce PTH level
- phosphate binders
- vitamin D i.e. alfacalcidol (doesn't require activation in kidneys)
97
what are the phosphate binders used in CKD?
| what is the main problem with them?
- calcium-based binders
| - vascular calcification
98
Causes of transient or spurious non-visible haematuria?
- UTI
- menses
- vigorous exercise
- sex
99
Causes of persistent non-visible haematuria?
- cancer: bladder, kidney, prostate
- stones
- BPH
- prostatitis
- urethritis eg Chlamydia
- renal causes: IgA nephropathy, thin basement membrane disease
100
Spurious causes of ?haematuria of red/orange urine where blood isn't present on dipstick?
- foods: beetroot, rhubarb
| - drug: rifampicin, doxorubicin
101
When to do an urgent 2WW referral for haematuria?
Age 45+ with:
- unexplained persistent visible haematuria after ruling out or treating a UTI
Age 60+ with:
- unexplained non-visible haematuria with dysuria/raised WCC
102
When to do a non-urgent referral for haematuria?
Age 60+ with:
| - recurrent/persistent unexplained UTI
103
What is Henoch-Schonlein purpora?
IgA-mediated small vessel vasculitis
- overlap with IgA nephropathy
- usually seen in children after an infection
104
What are the features of HSP?
- palpable purpuric rash over buttocks & extensors with localised oedema
- abdo pain
- polyarthritis
- features of IgA nephropathy may occur e.g. haematuria, renal failure
105
Rx of HSP?
- analgesia for arthralgia
- Rx of nephropathy is generally supportive
- self-limiting (esp in children without renal involvement) so there's good prognosis
- 1/3 relapse
106
Renal involvement in HIV - what drugs can precipitate intratubular crystal obstruction?
protease inhibitors eg Indinavir
107
HIVAN = HIV ass nephropathy
- what alters the course of the disease
- what are the 5 key features?
* **Antiretroviral therapy
1. normotension
2. elevated urea & creatinine
3. massive proteinuria
4. normal/large kidneys
5. FSGS with focal/global capillary collapse on renal biopsy
108
What is the triad in haemolytic uraemia syndrome?
1. acute renal failure
2. thrombocytopenia
3. MAHA
109
What are the causes of HUS?
- post-dysentery classically E. coli
- tumours
- pregnancy
- ciclosporin, the pill
- SLE
- HIV
110
Ix in HUS?
- anaemia, thrombocytopenia, fragmented blood film
- U&E AKI
- stool culture
111
Rx in HUS?
- supportive: fluids, blood transfusion, dialysis if required
- plasma exchange in specific severe cases
112
Which diseases typically present with nephritic syndrome i.e. haematuria & hypertension?
- Rapidly progressive GN = crescenteric glomerulonephritis
| - IgA nephropathy aka mesangioproliferative GN, Berger's disease
113
Rapid onset nephritic syndrome (haematuria & HTN), often presenting as AKI - what is the cause?
Rapidly progressive glomerulonephritis = crescenteric GN
114
Causes of rapidly progressive GN aka crescenteric GN?
- Goodpasture's
| - ANCA +ve vasculitis
115
Glomerulonephritides which typically present with nephrotic syndrome (proteinuria, oedema)?
- Minimal change disease (child)
- Membranous glomerulonephritis (adult)
- Focal segmental glomerulosclerosis (young adult)
- Membranoproliferative
116
A child presents with nephrotic syndrome - what is the most likely disease?
Causes?
Minimal change disease
- Hodgkin's, NSAIDs
- good response to steroids
117
Nephrotic syndrome (proteinuria, oedema) +/- CKD caused by infections/rheumatoid drugs/malignancy - what is the most likely disease?
Membranous glomerulonephritis
| - 1/3 resolve, 1/3 respond to cytotoxics, 1/3 develop CKD
118
Nephrotic syndrome (proteinuria, oedema) +/- CKD, which may be idiopathic or 2ry to HIV, heroin - what is the most likely disease?
FSGS: focal segmental glomerulosclerosis
- young adults
- high recurrence rate in renal Tx
119
What diseases lead to a mixed nephritic/nephrotic presentation?
- Diffuse proliferative GN
| - Membranoproliferative GN (mesangiocapillary)
120
What is the most common form of renal disease in SLE?
| How does it present?
- Diffuse proliferative GN
- presents as nephritic syndrome/AKI (mixed picture)
- classically post-strep GN in child
121
Causes of type 1 membranoproliferative GN (mesangiocapillary)?
Presentation?
- mixed nephritic/nephrotic presentation
| - cryogobulinaemia, hepatitis C
122
Causes of type 2 membranoproliferative GN (mesangiocapillary)?
Presentation?
- mixed nephritic/nephrotic presentation
| - partial lipodystrophy
123
4 disorders ass with glomerulonephritis & low complement levels?
- post-Strep GN
- Subacute bacterial endocarditis
- Sle
- meSangiocapillary GN
124
Rx of predominately voiding LUTS in men?
- cons: pelvic floor muscle training, bladder training, prudent fluid intake, containment products
- if mod/severe Sx -> ALPHA-BLOCKER
- if enlarged prostate and at high risk of progression -> 5-ALPHA REDUCTASE inhibitor
- if enlarged prostate & mod/severe Sx -> BOTH
- if mixed Sx of voiding & storage not responding to an alpha-blocker, than a ANTIMUSCARINIC(anticholinergic) can be ADDed
125
Rx of predominately overactive bladder in men?
- cons: moderating fluid intake
- bladder training can be offered
- if Sx persist -> ANTIMUSCARINIC eg OXYBUTYNIN IR, TOLTERODINE IR, DARIFENACIN OD
- MIRABEGRON can be considered if 1st line drugs fail
126
Rx of predominately nocturia in men?
- moderate fluid intake at night
- furosemide 40mg late afternoon can be considered
- desmopressin may be helpful
127
What is the commonest cause of GN worldwide?
IgA nephropathy = Berger's disease = mesangioproliferative GN
128
What is the cause of IgA nephropathy?
- mesangial deposition of IgA immune complexes
129
What is seen on histology of IgA nephropathy?
- mesangial hypercellularity, +ve immunofluorescence for IgA & C3
130
How does IgA nephropathy present?
- young male, rec visible haematuria
- typically ass with mucosal infections e.g. URTI
- nephrotic range proteinuria rare, renal failure unusual
131
Conditions ass with IgA nephropathy?
- alcoholic cirrhosis
- coeliac disease, dermatitis herpetiformis
- HSP
132
IgA nephropathy:
- how many develop ESRF?
- what is a marker of good prognosis?
- what are markers of bad prognosis?
- 25% develop ESRF
- frank haematuria is good
```
X male
X proteinuria esp >2g/day
X hypertension
X smoking
X hyperlipidaemia
X ACE genotype DD
```
133
What is the cause of post-strep GN?
| when does it occur?
- immune complex deposition (IgG, IgM, C3) in the glomeruli
- young children most commonly affected
- 7-14days after a group A beta-haemolytic strep infection
134
Features of post-strep GN?
- headache, malaise
- haematuria, proteinuria
- hypertension
- LOW C3
- raised ASO titre
- good prognosis
135
Features on renal biopsy in post-strep GN?
- acute diffuse proliferative GN
- endothelial proliferation with neutrophils
- EM: subepithelial humps caused by lumpy immune complex deposits
- immunofluorescence: granular/starry sky appearance
136
What is rapidly progressive GN?
Rapid loss of renal function ass with the formation of epithelial crescents in the glomeruli
137
What are the causes of rapidly progressive GN?
- Goodpasture's syndrome
- Wegener's granulomatosis
- SLE
- microscopic polyarteritis
138
Features of rapidly progressive GN?
- nephritic syndrome: haematuria with red cell casts, proteinuria, hypertension, oliguria
- features specific to underlying cause
139
How does minimal change disease present?
What is the main cause?
Other causes?
- nephrotic syndrome, 75% of children, 25% of adults
- majority idiopathic
- NSAIDs, rifampicin
- Hodgkin's lymphoma, thymoma
- EBV
140
Pathophysiology of minimal change disease?
- T cell & cytokine mediated damage to the glomerular basement membrane -> pollination loss
- resultant reduction of electrostatic charge -> increased glomerular permeability to serum albumin
141
Features of minimal change disease?
- nephrotic syndrome
- normotension
- highly selective proteinuria (only intermediate-sized proteins e.g. albumin & transferrin leak though glomerulus)
- renal biopsy: EM shows fusion of podocytes
142
Renal biopsy: EM shows fusion of podocytes
| - what is the Dx?
Minimal change disease
143
Rx of minimal change disease?
| Prognosis?
- majority 80% respond to steroids
- if steroid-resitsnat, consider cyclophosphamide
- 1/3 1 episode, 1/3 infrequent relapses, 1/3 frequent relapses which stop before adulthood
144
What is the commonest type of glomerulonephritis in adults?
Membranous GN
| - 3rd most common cause of ESRF
145
How does membranous GN usually present?
- nephrotic syndrome
| - or proteinuria
146
What is shown on renal biopsy in membranous GN?
- EM: basement membrane is thickened with sub epithelial electron dense deposits
- creating a spike & dome appearance
147
Renal biopsy: - EM: basement membrane is thickened with sub epithelial electron dense deposits, creating a spike & dome appearance
What is the Dx?
Membranous GN
148
Causes of Membranous GN?
- idiopathic
- infection: HBV, malaria, syphilis
- malignancy: lung ca, lymphoma, leukaemia
- drugs: gold, penicillamine, NSAIDs
- autoimmune: SLE class V, thyroiditis, rheumatoid
149
What are good prognostic features in membranous GN?
- female
- young age at presentation
- aSx proteinuria of a modest degree at time of presentation
- 1/3 spontaneous remission
- 1/3 remain proteinuria
- 1/3 develop ESRF
150
Rx of membranous GN?
- immunosuppression: STEROID + OTHER eg Chlorambucil
- control BP: ACE-I shown to reduce proteinuria
- consider anticoagulation
151
What is nephrotic syndrome?
1. proteinuria >3g/24h causing
2. hypoalbuminaemia <30
3. oedema
152
What predisposes to thrombosis in nephrotic syndrome?
What happens to thyroxine levels?
- loss of anti-thrombin III, proteins C & S, and ass rise in fibrinogen levels predispose to thrombosis
- loss of thyroxine-binding globulin lowers the Total (not free) thyroxine levels
153
What are the main causes of nephrotic syndrome?
- 1ry GN 80%
- systemic disease
- drugs
- others: congenital, neoplastic (carcinoma, lymphoma, leukaemia, myeloma), infection (endocarditis, HBV, malaria)
154
Drug causes of nephrotic syndrome?
- gold (sodium aurothiomalate)
| - penicillamine
155
systemic disease causes (20%) of nephrotic syndrome?
- diabetes
- SLE
- amyloid
156
1ry GN causes of nephrotic syndrome?
- minimal change disease
- membranous GN
- FSGS
- membranoproliferative GN
157
How does membranoproliferative GN present? what is the prognosis?
- nephrotic syndrome, haematuria or proteinuria
- aka mesangiocapillary GN
- poor prognosis
158
Type 1 membranoproliferative GN - causes?
| - pathology?
- 90% of cases
- cryoglobulinaemia, hepatitis C
- sub endothelial immune deposits of electron dense material resulting in tram-track appearance
159
Sub endothelial immune deposits of electron dense material resulting in tram-track appearance - what is the Dx?
Type 1 membranoproliferative GN
160
What is type 2 membranoproliferative GN?
| causes?
- dense deposit disease
- reduced serum complement
- C3b nephritic factor (Ab) found in 70%
- partial lipodystrophy (loss of SC tissue from face), factor H deficiency
161
Causes of type 3 membranoproliferative GN?
HBV, HCV
162
Rx of membranoproliferative GN?
Steroids may help
163
'Dense deposit disease'
- presents as nephrotic syndrome, haematuria or proteinuria
- causes: partial lipodystrophy (patients classically have a loss of subcutaneous tissue from their face), factor H deficiency
- reduced serum complement
- C3b nephritic factor (Ab) in 70%
What is the Dx?
Type 2 membranoproliferative GN
164
- presents as nephrotic syndrome, haematuria or proteinuria
- subendothelial immune deposits of electron dense material resulting in a 'tram-track' appearance
- causes: cryoglobulinaemia, hepatitis C
What is the Dx?
Type 1 membranoproliferative GN
165
What are the complications of nephrotic syndrome?
- increased risk of infection (urinary Ig loss)
- increased risk of thromboembolism (loss of anithromb III & plasminogen in urine) -> renal vein thrombosis -> sudden deterioration in renal function
- hyperlipidaemia
- hypocalcaemia (vit D & binding protein lost in urine)
- acute renal failure
166
What is contrast media nephrotoxicity?
| How to prevent?
25% increase in Cr occurring within 3 days of IV contrast media
- 12h IV saline pre & post-procedure
167
RFs for contrast media nephrotoxicity?
- known renal impairment, esp diabetic nephropathy
- age >70
- dehydration
- cardiac failure
- use of nephrotoxic e.g. NSAIDs
168
Causes of papillary necrosis?
- chronic analgesia use
- sickle cell disease
- TB
- acute pyelonephrtis
- diabetes mellitus
169
Features of papillary necrosis?
- fever, loin pain, haematuria
| - IVU - papillary necrosis with renal scarring 'cup & spill'
170
What does CAPD: continuous ambulatory peritoneal dialysis involve?
4 2litre exchanges/day
171
Complications of peritoneal dialysis?
- peritonitis - commonest cause = coag-negative staph eg staph epidermidis. can also be staph aureus
- sclerosing peritonitis
172
Indications for plasma exchange/plasmapheresis?
- Guillain-Barre syndrome
- myasthenia gravis
- Goodpasture's syndrome
- ANCA +ve vasculitis eg GPA, Churg-Strauss
- TTP/HUS
- cryogobulinaemia
- hyperviscosity syndrome eg 2ry to myeloma
173
NICE guidelines when to refer for PSA/prostate cancer?
men aged 50-69 with PSA >3 and/or abnormal DRE, after UTI Rx or ruled out
174
What factors cause raised PSA levels?
- prostate ca
- BPH
- prostatitis & UTI
- ejaculation in prev 48h
- vigorous exercise in prev 48h
- urinary retention
- instrumentation of urinary tract
175
Sensitivity & specificity of PSA?
- 20% men with prostate cancer have a normal PSA
| - 33% of men with PSA 4-10 have prostate ca, if PSA 10-20 this is 60%
176
Localised prostate cancer T1/T2 - what are the Rx options?
Depend on life expectancy & pt choice
- conservative active monitoring & watchful waiting
- radical prostatectomy
- RT: external beam & brachytherapy
177
Localised advanced prostate cancer (T3/T4) - what are the Rx options?
- hormonal Rx
- radical prostatectomy
- RT: external beam & brachytherapy
178
Metastatic prostate cancer disease - what are the Rx options?
- hormonal Rx
| - orchidectomy
179
What are the hormonal Rx options for prostate cancer?
- Synthetic GnRH agonists eg Goserelin/Zoladex
| - Anti-androgen eg cyproterone acetate - prevents DHT binding from intracytoplasmic protein complexes
180
What cover is needed with Goserelin/Zoladex in prostate ca?
| What is the MoA?
Synthetic GnRH agonist
| - cover initially with anti-androgen to prevent rise in testosterone
181
What is renal papillary necrosis?
| What are the features?
- coagulative necrosis of the renal papillae
- visible haematuria
- loin pain
- haematuria
182
Causes of renal papillary necrosis?
- severe acute pyelonephritis
- diabetic nephropathy
- obstructive nephropathy
- analgesic nephropathy (classically phenacetin)
- sickle cell anaemia
183
How should SLE pts be monitored for renal complications?
| What is a severe renal manifestation of SLE?
- urinalysis at regular intervals to rule out proteinuria
| - lupus nephritis - can result in ESRF
184
What is the WHO classification for SLE renal disease?
```
I normal kidney
II mesangial GN
III focal & segmental proliferative GN
IV diffuse proliferative GN
V diffuse membranous GN
VI sclerosing GN
```
185
What is the most common & severe form of renal disease in SLE?
class IV diffuse proliferative GN
186
What is shown on renal biopsy in class IV diffuse proliferative GN in SLE?
- glomeruli shows endothelial & mesangial proliferation, with a wire-loop appearance
- if severe, capillary wall may be thickened 2ry to immune complex deposition
- EM shows endothelial immune complex deposits
- immunofluorescent shows granular appearance
187
Renal biopsy EM: subendothelial immune complex deposition
Immunofluorescence: granular appearance
glomeruli: endothelial & mesangial proliferation, 'wire-loop' appearance
What is the Dx?
SLE class IV diffuse proliferative GN
188
Rx of renal complications in SLE?
- treat HTN
- corticosteroids if clinical evidence of disease
- immunosuppressant eg azathioprine (if pregnant)/cyclophosphamide
189
What is the MoA of spironolactone?
| Adverse effects?
- aldosterone antagonist
- acts in the cortical collecting duct
- hyperkalaemia
- gynaecomastia
190
Indications for spironolactone?
- ascites (large doses used) - pts with cirrhosis develop a 2ry hyperaldosteronism
- HTN step 4
- heart failure (reduces all cause mortality when NYHA III & IV and already on an ACE-I)
- nephrotic syndrome
- Conns syndrome
191
Commonest scrotal lump, separate from body of testicle, found posterior to it?
Dx?
Rx?
Epididymal cyst
US scrotum
supportive but surgical removal or sclerotherapy may be attempted for larger/Sx cysts
192
Conditions ass with epididymal cysts?
- polycystic kidney disease
- CF
- von Hippel-Lindau syndrome
193
What is a hydrocele?
| Features?
- accumulation of fluid within the tunica vaginalis
- soft non-tender swelling of the hemi-scrotum, usually anterior & below the testicle
- swelling confined to the scrotum, you can get above it on exam
- transilluminates
- testis may be difficult to palpate if hydrocele is large
194
What is a communicating hydrocele?
- caused by patency of the processes vaginalis allowing peritoneal fluid to drain down int the scrotum
- common in newborn males
- usually resolve within first few months of life
195
What is a non-communicating hydrocele?
- caused by XS fluid production within the tunica vaginalis
196
When may hydroceles develop 2ry to something else?
- epididymo-orchitis
- testicular torsion
- testicular tumours
197
Rx of hydroceles?
- infantile: repair if they don't resolve by age 1-2yrs
| - adults: conservative depending on presentation, US to rule out underlying tumour
198
What is a varicocele?
what is the significance?
what are the features?
when may it present as a different disease?
Abnormal enlargement of the testicular veins
- usually aSx but ass with Infertility
- >80% are on the LEFT side, feel like a bag of worms
- renal cell carcinoma may present as a left varicocele due to occlusion of the left testicular vein
199
Dx of varicocele?
| Rx?
- US with Doppler studies
- usually conservative
- surgery may be required if troubled by pain
200
Features of rhabdomyolysis?
- acute renal failure with disproportionately raised creatinine
- elevated CK
- myoglobinuria
- hypocalcaemia (myoglobin binds to calcium)
- elevated phosphate (released from myocytes)
201
Causes of rhabdomyolysis?
- collapse, seizure, coma
- ecstasy
- crush injury
- MsArdle's syndrome
- drug: statins
202
Rx of rhabdomyolysis?
- IV fluids to maintain good urine output
| - urinary alkalinisation sometimes used
203
Presentation of retroperitoneal fibrosis?
- lower back/flank pain is commonest
| - fever & LL oedema can be seen
204
Lower back/flank pain + fever + LL oedema - Dx?
Retroperitoneal fibrosis
205
Associations of retroperitoneal fibrosis?
- Riedel's thyroiditis
- Previous RT
- sarcoid
- inflammatory AAA
- drugs: methysergide
206
Commonest cause of renal vascular disease?
RFs?
How does it present?
- atherosclerosis >95%
- smoking, HTN -> atheroma etc
- may present as HTN, chronic renal failure or 'flash' pulmonary oedema
207
What to consider in younger pts with renal vascular disease?
FMD: fibromuscular dysplasia
| - more common in young women
208
Characteristic angiography in fibromuscular dysplasia?
| Rx?
- string of beads
| - balloon angioplasty
209
Ix of choice in renal vascular disease?
MR angiography
| renal angio may still have role in planning surgery
210
RFs for urate renal stones?
- gout
| - ileostomy: loss of HCO3 & fluid -> acidic urine -> uric acid precipitation
211
RFs for renal stones?
- dehydration
- hypercalciuria, hyperparathyroidism, hypercalcaemia
- cystinuria
- high dietary oxalate
- renal tubular acidosis
- medullary sponge kidney, polycystic kidney disease
- beryllium or cadmium exposure
212
Drug causes of calcium renal stones?
- loop diuretics
- steroids
- acetazolamide
- theophylline
(thiazides can prevent calcium stones (increase distal tubular calcium resorption))
213
Opaque renal stones on xray?
- calcium oxalate 40%
- mixed calcium oxalate/phosphate 25%
- triple phosphate 10%
- calcium phosphate 10%
214
Radiolucent renal stones on xray?
- urate stones 5-10%
| - xanthine stones <1%
215
Semi-opaque, ground-glass appearance of renal stones on X-ray?
Cystine stones 1%
216
What are stag horn calculi?
What are they made of?
When do they develop?
What predisposes to their formation?
- involve renal pelvis, extending into >1 calyces
- struvite (ammonium magnesium phosphate, triple phosphate)
- they develop in alkaline urine
- ureaplasma urealyticum & proteus infections
217
Initial Rx of renal colic?
- NSAID for analgesia eg Diclofenac
- IM for rapid relief of pain, for those who require admission
- (alpha-blockers may help in pts amenable to conservative Rx, with greatest benefit in those with larger stones)
218
Initial Ix when suspecting renal stones?
- urine dip + culture
- FBC/CRP ?infection
- U&Es ?renal function
- calcium/urate ?underlying cause
- clotting ?for percutaneous intervention
- blood mcs if febrile etc
219
Imaging in renal stones - what should be performed in all?
CT-KUB within 14h of admission
- 97% sens ureteric stone, 95% spec
(US much lower sens)
220
Imaging in renal stones - if a pt has a fever, just 1 kidney, or there is uncertainty re: Dx, what should be done?
Immediate CT-KUB
| - exclude other causes e.g. ruptures AAA
221
Rx of renal stone <5mm?
| What if severe?
- usually will pass spontaneously within 4wks of Sxonset
| - lithotripsy & nephroithotomy if severe
222
When might urgent Rx be indicated with a renal stone <5mm?
- ureteric obsrtuction
- renal developmental abnormality e.g. horseshoe kidney
- renal Tx
223
Renal stone + ureteric obstruction + infection - what are the Rx options?
Surgical emergency -> Decompression:
- nephrostomy tube placement
- ureteric catheter insertion
- ureteric stent placement
224
What are the options for Rx of renal stone disease when not an emergency but e.g. >5mm?
- extra-corporeal shock wave lithotripsy
- percutanoeus nephrolithotomy
- ureteroscopy
- open surgery remains an option in selected
225
Sx renal stone <2cm in aggregate - Rx of choice?
Lithotripsy
226
Sx renal stone <2cm in aggregate in a pregnant female - Rx of choice?
Ureteroscopy
227
Complex renal stones or stag horn stones - Rx of choice?
Percutanoeus nephrolithotomy
228
What does ureteroscopy involve in renal stone Rx?
When is it indicated?
What happens to the stent?
- ureteroscopy passed retrograde through ureter into renal pelvis
- indicated where lithotripsy is C/I e.g. pregnancy, or in complex stone disease
- stent left in situ for 4wks after procedure
229
What does shockwave lithotripsy involve in renal stone Rx?
| What are the risks/disadvantages?
- shock wave generated externally to pt -> internal cavitation bubbles & mechanical stress lead to stone fragmentation
- solid organ injury from the shock waves
- ureteric obstruction from larger stones fragmenting
- uncomfortable procedure, analgesia required after
230
What does percutaneous nephrolithotomy involve in renal stone Rx?
- access gained to renal collecting system
- intra-corporeal lithotripsy or stone fragmentation performed
- stone fragments removed
231
How to help prevent calcium renal stones?
(prevent hypercalciuria)
- high fluid intake
- low animal protein, low salt diet
- thiazide diuretics
232
How to help prevent oxalate renal stones?
- cholestyramine
- pyridoxine
(they reduce urinary oxalate secretion)
233
How to help prevent uric acid renal stones?
- allopurinol
| - urinary alkalinisation eg oral bicarbonate
234
Where does renal cell carcinoma arise from?
- proximal renal tubular epithelium
- 85% of 1ry renal neoplasms
- = hypernephroma
235
Associations of RCC?
- middle-aged men
- smoking
- tuberous sclerosis, von Hippel-Lindau syndrome
236
Features of RCC
classic triad?
other?
- haematuria, loin pain, abdominal mass
- fever unknown origin
- left varicocele (due to occlusion of left testicular vein)
- endocrine: may secrete EPO (polycythaemia), PTH (hypercalcaemia), renin, ACTH
- 25% have mets at presentation
237
Rx of RCC:
confined disease?
what may help reduce tumour size or help treat pts with metastases?
- partial/total nephrectomy depending on tumour size
- alpha-IFN & IL-2
- receptor TK inhibitors eg Sorafenib, Sunitinib, have been shown to have superior efficacy to IFN-alpha
238
```
Where is the HLA system (human MHC) coded?
what are the class 1 Ag?
what are the class 2 Ag?
```
- chr 6
- 1: A B C
- 2: DP DQ DR
239
What is the relative importance when HLA matching for a renal Tx?
- DR > B > A
240
What are post-op renal Tx problems?
- acute tubular necrosis of the graft
- vascular thrombosis
- urine leakage
- UTI
241
When and why does hyperacute rejection of the graft occur with renal Tx?
- within mins- hours
- due to pre-existent Abs against donor HLA type 1 Ag (type II hypersensitivity reaction)
- rarely seen due to HLA matching
242
When & why does acute graft failure occur with renal Tx?
- within 6months
- due to mismatched HLA - cell-mediated (cytotoxic T cells)
- other causes inc CMV infection
- may be reversible with steroids & immunosuppressants
243
Causes of chronic graft failure with renal Tx?
- both Ab & cell-mediated mechanisms cause fibrosis to the Tx kidney = chronic allograft nephorpathy
- or recurrence of the original disease: MCGN >IgA > FSGS
244
Example initial regime for immunosuppression after renal Tx?
tacrolimus/ciclosporin + mAb
245
Example maintenance regime for immunosuppression after Renal Tx?
tacrolimus/ciclosporin + MMF/Sirolimus
246
Post-renal Tx - what should be added to immunosuppressant regime if there is >1 acute rejection episode?
Add steroids (if the episodes are steroid responsive)
247
MoA of ciclosporin?
- calcineurin inhibitor (phosphatase involved in T cell activation)
248
MoA of Tacrolimus?
What is the benefit of Tac over ciclosporin?
Disadvantage?
- calcineurin inhibitor
- lower incidence of acute rejection
- less HTN & hyperlipidaemia
- but high incidence of impaired glucose tolerance & diabetes
249
MoA of MMF: mycophenolate mofetil?
| Side-effects?
- blocks purine synthesis by IMPDH inhibition
- therefore inhibits proliferation of B & T cells
- GI & bone marrow suppression
250
MoA of Sirolimus/Rapamycin?
| Side-effect?
- blocks IL-2 which blocks T cell proliferation
| - hyperlipidaemia
251
monoclonal antibodies which may be used in immunosuppressant regime for renal Tx?
- selective inhibitors of IL-2 receptor
- daclizumab
- basilximab
252
Pts on long-term immunosuppression for organ Tx require regular monitoring for what complications?
1. CVD - tacrolimus & cyclosporin can cause HTN & hyperglycaemia, Tac can also cause hyperlipidaemia - therefore monitor for accelerated CVD
2. Renal failure - nephrotoxic effects of tacrolimus & ciclosporin/graft rejection/recurrence of original disease in Tx kidney
3. Malignancy - minimise sun exposure etc, reduce risk of SCC & BCC of skin
253
Proteinuria, haematuria, oedema, HTN in a pt with SLE - what is the Dx?
Diffuse proliferative GN on renal Bx
254
'Basket weave' appearance on EM of renal Bx - what is the Dx?
Alport syndrome = mutation in type IV collagen
| - eye problems, SNHL, GN
255
Pt had an MI a month ago, is a smoker, started on aspirin, statin, ace-i, beta-blocker, admitted with breathlessness. Acute pulmonary oedema on CXR. Normal ecg & ECHO shows good LV function. What is the Dx?
Renal artery stenosis
| -> do MR angiography
256
Electrolyte causes of nephrogenic DI?
- hypercalcaemia
| - hypokalaemia
257
```
Non-idiopathic causes of membranous glomerulonephritis?
infective
malignant
drugs
autoimmune
```
- malaria, syphilis, HBV
- lung cancer, lymphoma, leukaemia
- gold, penicillamine, NSAIDs
- SLE class V, thyroiditis, rheumatoid
258
What type of GN does cryglobulinaemia cause?
| What Rx might be indicated?
- type 1 membranoproliferative/mesangiocapillary GN
| - plasma exchange
259
Woman with Hx of membranous GN 2ry to SLE is admitted to hospital
- prev stable renal function has deteriorated rapidly
- left flank tenderness
- ESR 50
- blood ++ & protein +++ in urine dip
What is the likely cause of sudden deterioration in renal function?
RENAL VEIN THROMBOSIS
| - nephrotic syndrome predisposes to thrombosis, esp of renal veins, which can be bilateral
260
Most common glomerulonephropathy linked tor renal vein thrombosis?
- membranous GN
261
What sort of metabolic acidosis does renal tubular acidosis cause?
Normal anion gap
| - hyperchloraemic metabolic acidosis
262
What is type 1 (distal) renal tubular acidosis?
| Complications?
- inability to generate acid urine (secrete H+) in distal tubule
- caused HYPOkalaemia
- nephrocalcinosis & renal stones
263
Causes of type 1 distal RTA?
- idiopathic
- RA, SLE, Sjogren's
- amphotericin B toxicity
- analgesic nephropathy
264
What is type 2 (proximal) RTA?
| what is a complication?
- decreased HCO3- reabsorption in proximal tubule
- causes HYPOkalaemia
- OSteomalacia
265
Causes of type 2 proximal RTA?
- idiopathic
- Wilson's disease
- cystinosis
- as part of Fanconi syndrome
- carbonic anhydrase inhibitors, outdated tetracyclines
266
What is type 4 RTA?
- HYPERkalaemia
| - reduction in aldosterone leads in turn to a reduction in proximal tubular ammonium excretion
267
Causes of type 4 RTA?
- hypoaldosteronism
| - diabetes
268
What type of renal impairment down gentamicin cause?
intrinsic renal AKI
| - therefore proteinuria on urine dip
269
What type of GN is characteristically ass with partial lipodystrophy?
Mesangiocapillary = membranoproliferative type 2 GN
270
What type of GN is ass with Wegener's & Goodpasture's?
Rapidly progressive
271
What is most likely finding on renal biopsy in HSP?
mesangial hypercellularity (IgA deposition)
272
Child presents with anaemia, low platelets, protein & blood in urine. No Hx of diarrhoea
- Dx?
- Rx?
HUS
- supportive
- plasma exchange
273
What is on renal biopsy in Wegener's?
rapidly progressive GN
| = CRESCENTERIC GN
274
32y.o. man presents with LL oedema, feeling lethargic with pitting LL oedema & periorbital oedema + ascites & coarse crackles in lung bases
Urin dip: protein +++, negative for blood urine nitrites glucose
What is most likely underlying pathology?
FSGS: focal segmental glomerulosclerosis
- nephrotic syndrome
- generally presents in young adults
275
EM of renal biopsy: the basement membraneis thickened with subepithelial electron dense deposits - a 'spike and dome' appearance
What is the Dx?
What is the Ab most ass with this condition?
Membranous GN
| - anti-phospholipase A2 is ass with idiopathic membranous GN
276
What Ab is ass with idiopathic membranous GN?
anti-phospholipase A2
277
What is Goodpasture's syndrome?
| What HLA is it ass with?
- pulmonary haemorrhage then rapidly progressive GN
- caused by anti-GBM antibodies against type IV collage
- more common in men 2:1, with bimodal age distribution of 20-30 & 60-70
- HLA-DR
278
Factors which increase likelihood of pulmonary haemorrhage in Goodpasture's syndrome?
- smoking
- LRTI
- pulmonary oedema
- inhalation of hydrocarbons
- young males
279
Ix in Goodpasture's syndrome inc renal Bx?
- linear IgG deposits along basement membrane
| - raised transfer factor
280
Rx of Goodpasture's syndrome?
- plasma exchange (plasmapheresis)
- steroids
- cyclophosphamide
281
Podocyte fusion on renal biopsy - what is the Dx?
Minimal change GN
| occ FSGS
282
What is a known iatrogenic complication of using 0.9% NaCl in large volumes?
hyperchloraemic metabolic acidosis
283
MoA of Abiraterone acetate, used in prostate ca?
- selective androgen synthesis inhibitor, blocks cytochrome p450 17-alpha-hydroxylase
- blocks androgen production in testes & adrenal glands & in prostatic tumour tissue
- given orally with prednisolone
- has survival benefit in men with castrate refractory prostate ca who are yet to receive chemo
- indicated in metastatic castration-resistant (hormone-relapsed) prostate ca who are aSx or mildly Sx after failure of androgen deprivation Rx in whom chemo is not yet clinically indicated
- and in metastatic castration resistant prostate ca when disease has progressed on/after docetaxel-based chemo regimen
284
What is useful in the prevention of oxalate renal stones?
cholestyramine
| pyridoxine
285
```
Pt has HTN refractory to ACE-I & calcium channel blocker at 170/100
K 2.9
aldosterone 600 (high)
renin 6.8 (high)
What is the Dx?
```
BL renal artery stenosis
| 1ry hyperaldosteronism is ass with LOW renin due to negative feedback
286
What type of GN do malignancies cause when ass with nephrotic syndrome?
membranous GN
- paraneoplastic
- HLA-DR3
(lymphomas - minimal change)
287
middle-aged man with nephrotic syndrome & HTN with renal biopsy showing: thickened capillary walls, & sub endothelial deposits
- what is the Dx?
- what is most likely to be beneficial to reduce proteinuria?
Membranous GN
- ACE-I
- (steroids may help in combo with something else)
288
ACR of 30 is approx equivalent to a PCR of?
| And ACR 70?
```
30 = 50 (0.5g protein/24h)
70 = 100 (1g protein/24h)
```
289
What Ig is involved in hyper acute graft rejection?
IgG
290
What is thin basement membrane disease?
- inherited disorder of type IV collagen causing thinning of the basement membrane
- may affect 5% of people, 30% of them report FHx of haematuria
- Dx on Hx of persistent haematuria, normal kidney function, FHx of haematuria without kidney failure
- benign, biopsy rarely indicated
