Renal Flashcards

Question

What is Goodpastures disease?

Answer 1

Goodpastures disease is is also known as Anti glomerular basement membrane (GBM) disease. It involves the development of autoantibodies against type IV collagen. It generally results in a nephritic syndrome and generally affects young males. Type four collagen is also found in the lungs and heamoptysis may also be a feature.

Answer 2

Hyperkaleamia, volume overload, metabolic acidosis

Answer 3

PreRenal causes: hypovoleamia, sepsis, CCF, cirrhosis, renal artery stenosis, NSAIDS, or ACE inhibitors ( these interfere with renal artery blood flow). Intrinsic causes: acute tubular necrosis ( damage to the renal cells caused by ischeamia or nephrotoxins) caused by chemo, drugs, rhabdomyolysis, radiological constrasts or myeloma. Other: vasculitis, malignant hypertension urinary tract obstruction.

Answer 4

Oligouria, nausea and vomiting, Orthoptera, hypotension. Pulmonary oedema, dizziness.

Answer 5

Furosemide (LAsix) is a loop diuretic. It acts on the thick ascending loop of Henle. It blocks the Na/K/2Cl channels. Frusemide causes NaCl excretion and some calcium excretion. It causes dieresis 4 hours after it is given. Furosemide is used to treat oedema in heart failure, ascities, and acute pulmonary oedema.

Answer 6

Loop diuretics cause a hypokaleamoc metabolic alkalosis.

Answer 7

Loop diuretics cause a hypokaleamoc metabolic alkalosis.

Answer 8

Loop diuretics cause a hypokaleamoc metabolic alkalosis.

Answer 9

Around 60% though estimates greatly differ. The most is calcium phosphate, then calcium oxalate, then struvite, then Cystic acid and Uric acid

Answer 10

Renal colic flank pain radiating to the ipsilateral thigh, nausea and vomiting, rarely heamaturia, possible fever and urinary frequency or urgency. Confirm with an abdominal pelvic X-ray or a helical ct scan

Answer 11

UTI, kidney stone, pyelonephritis, recent urethral instrumentation, prostate cancer, kidney cancer. Alports syndrome, BPH

Answer 12

Malignant hypertension. Essential hypertension, preeclampsia

Answer 13

Diabetic nephropathy, glomerularnephritis, chronic interstitial nephritis, poly cystic kidneys, or renal vascular disease

Answer 14

Renal vascular disease is renal artery stenosis, or stenosis of one of its branches. The most common causes are atheroma or muscular dysplasia

Answer 15

Ace inhibitors or ARBs, NSAIDs, and a diuretic

Answer 16

The hypoperfused kidney responds by increasing levels of renin and angiotensin II

Answer 17

Hypertension, possible history of cardiovascular disease or fibromuscular dysplasia, abdominal Brits, flash pulmonary oedema

Answer 18

Haemolytic ureamic syndrome is a clinical syndrome that comprises of progressive renal failure associated with microangiopathic (Coombes negative, nonimmune) haemolytic aneamia and thrombocytopenia. It is the most common cause of acute renal failure in children. HUS may or may not be associated with shigalike toxin. Whilst it also occurs in adults and can be triggered by many causes, it most commonly occurs in children after an episode of acute diarrhoea.

Answer 19

``` Prodromal gastroenteritis Acute renal failure Anuria Lethargy or seizures Hypertension Oedema Pallor ```

Answer 20

Urinalysis, GFR and creatinine, FBC ( measuring RBCs and platelets), EUC, BP, PT and APTT (normal, peripheral blood smear ( schistocytes), adamst13 (levels are normal in HUS and low in TTP)

Answer 21

Thiazides diuretics act on the distal convuluted tubule on the NaCl channels. It causes the excretion of NaCl, but not of calcium. Hence it is used to prevent the formation of calcium renal stones, as well as a diuretic to reduce blood pressure and sometime to reduce oedema

Answer 22

TTP is a rare blood disorder that is characterised by clotting in the small blood vessels of the body resulting in a low platelet count. The full blown condition of this disease consists of microangiopathic haemolytic aneamia, thrombocytopenia purpura, renal disease, neurological abnormalities, and fever.

Answer 23

Two types of potassium sparing diuretics that act as aldosterone antagonists are eplerenone and spironalactone. Two potassium sparing diuretics that act by blocking the sodium channels in the collecting ducts are amiloride and triamterrine.

Answer 24

Aldosterone increases sodium conservation, water conservation, and increases blood pressure. It also causes the dumping of potassium

Answer 25

Potassium spring diuretics increase sodium excretion and decrease K and H excretion. They are used to control the K+wasting caused by long term diuretics

Answer 26

Pituitary surgery, craniopharyngioma, pituitary stalk lesions, traumatic head injury, autoimmune disorders and use of lithium.

Answer 27

Increased thirst, polyuria of dilute hypotonic urine ( normally no hypernateamia as polydipsia adequately replaces fluids)

Answer 28

Diabetes insipidus is a metabolic disorder characterised by an inability to concentrate urine resulting in hypotonic dulite polyuria. It is either caused by a default in the production of vasopressin ( anti diuretic hormone) which is produced by the hypothalamus and secreted by the kidneys. It may also be due to resistance to ADH on the renal collecting ducts.

Answer 29

Respiratory alkalosis

Answer 30

Metabolic alkalosis

Answer 31

Metabolic acidosis

Answer 32

Respiratory acidosis

Answer 33

Renin is released from smooth muscle cells in the walls if the afferent and efferent artierioles at the point where they make contact with the early distal tubule ( macula densa). To form the juxtoglomerular apparatus. Renin release is stimulated by reduced perfusion pressure in the afferent arteriole, increased sympathetic nerve activity, decreased sodium chloride conc in the distal tubular fluid.

Answer 34

Renin is produced by the kidneys in response to signs of hypovoleamia, it acts on angiotensinogen (made in the liver) producing angiotensin 1. Angiotensin1 is cleaved by ACE becoming angiotensin 2 , largely in the pulmonary capillary bed. Angiotensin 2 has multiple actions, including stimulation of the proximal tubular sodium reabsoption, release of aldosterone from the zone glomerulus of the adrenal cortex, and vasoconstriction of small artierioles.

Answer 35

Examinine the patient for signs of hypovoleamia or hypervoleamia, check daily weight change. Review the fluid balance chart checking total volumes in and out on previous day ( should be approx 400mL positive due to insensible fluid losses), correlate chart figures with weight change and clinical volume status to estimate net fluid balance. Assess ongoing pathology: check losses from GI tract and surgical drains, estimate increased insensible losses eg in fever and internal sequestration. Check plasma and EUC. Plasma Na is a marker of fluid balance, K is a marker of extra cellular K balance. HCO3 is a clue for acid base disorder, urea and creatinine monitor renal function.

Answer 36

Impaired renal function from primary renal disease, primary hyper aldosteronism ( eg Conns syndrome), secondary hyper aldosteronism from congestive cardiac failure, cirrhosis of the liver, nephrotic syndrome, malnutrition, renal artery stenosis.

Answer 37

Hyponatreamia is a plasma Na <135 mmol/L. It is a common electrolyte abnormality often detected asymptomatically, but also associated with anorexia, nausea, vomiting, confusion, lethargy, seizures, and coma.the patient experiences more symptoms when they have not had time to adjust eg. Acute changes.

Answer 38

Renal Na losses, diuretic therapy (especially thiazides), adrenocortical failure, gastrointestinal sodium losses, Vomiting, diarrhoea, skin Na losses, burns

Answer 39

Primary polydipsia, excessive electrolyte free water infusion, SIADH, hypothyroidism.

Answer 40

Tumours ( eg lung or colon cancer) CNS disorders: stroke, trauma, infection, psychosis. Pulmonary disorders: pneumonia, tuberculosis, obstructive lung disease Drugs: anticonvulsants( carbemezapine), psychotropics (haloperidol), antidepressants (amitryptine, fluoxetine), cytotoxics (cyclophosphamide, vincristine) hypoglycaemics, opiates, idiopathic.

Answer 41

Typical presentation of Crohn's disease includes abdo pain (may be cramps, relieved with defection), non bloody or intermittently bloody diarrhoea, perianal lesions (skin tags, fistulae, abscesses, scarring, or sinuses). It may commonly present with bowel obstruction, fever, fatigue, abdo tenderness,

Answer 42

Hypovoleamia and urinary tract obstruction.

Answer 43

Enlist specialist help. Whilst waiting, make sure that recent U&E and urine microscopy results that are on hand. Identify and treat the pre renal and post renal causes (obstruction and hypovoleamia). Order an urgent ultrasound scan. You must check for a palpable bladder, but its absence does not rule out obstructive causes. Stop any nephrotic drugs. (NSAIDs, ACEi, gentamicin, vancomycin, amphotericin, stop metformin if creatinine is >150 mmol/L). Check for sis of vasculitis ( nose bleed, heamaturia, rash, ESR/CRP) if there is sis of vasculitis then test for autoantibodies. Monitor pulse, BP, urine output, and CVP hourly (insert a urinary catheter). Correct any volume depletion with IV fluid. Take blood cultures if patient is septic. Remove any possible sources of sepsis when no longer required (eg cannula, catheter). Recheck for any nephrotoxic drugs, adjust doses for any really e created drugs. Aim for normal calorie intake. If oral intake is poor, consider giving TPN.

Answer 44

- hyperkalemia/ECG changes: IV calcium is cardio protective, IV insulin and glucose to lower potassium (check capillary glucose approx 30mins after). Consider calcium resonium to bind K in the gut. Heamodialysis or heamofiltration required if anuric. - Pulmonary oedema: sit up and give high flow oxygen by face mask. Use a venous vasodilator (eg morphine), give fruso die IV over 1 hour, if no response urgent heamodialysis or heamofiltration is needed. Consider CPAP. - Bleeding: impaired haemostasis due to increased urea may be compounded by the precipitating cause. Give PPIs or a H2 antagonist. In the case of an active bleed give fresh frozen plasma or platelets as needed. Blood transfusion to maintain Hb >10g/dL and heamotocrit >30%., desmopressin to increase factor VIII activity.

Answer 45

Indications for acute dialysis include refractory pulmonary oedema, persistent hyperkalemia ( K>7mmol/L), severe metabolic acidosis, (pH<7 or base excess <10), ureamic encephalopathy, ureamic pericarditis (pericardial rub).

Answer 46

``` Stage 1 GFR >90 Stage 2 GFR >60 Stage 3a GFR >45 Stage 3b GFR >30 Stage 4 GFR >15 Stage 5 GFR <15 Stage 1 and 2 must be accompanied by other symptoms suggesting renal damage such as proteinuria, heamaturia, or other evidence of renal disease. ```

Answer 47

End stage renal failure is defined as stage 5 renal failure (GFR<15), or need for renal replacement therapy (dialysis or transplant).

Answer 48

Fatigue, weakness, metallic taste in mouth, anorexia, vomiting, pruritis, restless legs, bone pain, impotence/infertility. Symptoms are common when urea is >40mmol/L. Such as dyspnoea or fluid overload.

Answer 49

High risk groups should be screened for chronic renal failure: DM, HTN, age>60, recurrent UTIs, urinary obstruction, or a systemic illness that affects the kidneys (eg SLE), cardiovascular disease (IHD, CCF, peripheral vascular disease, or cerebral vascular disease and cerebral vascular disease), structural renal tract disease, renal stones, BPH, family history of stage 5 CRF or inherited renal disease.

Answer 50

Yellow skin, brown nails, excoriation, hypertension, pallor, bruising. Increased BP, cardiomegaly, pericardial rub, pleural effusion. Pulmonary or peripheral oedema, proximal myopathy. If untreated may also present with arrhythmias, encephalopathy, seizures, and coma.

Answer 51

Tubulointerstitual nephritis is inflammation of the renal interstitium. It may be acute or chronic. Acute tubulointerstitual nephritis is mediated by an immune reaction to medications, infections and other causes. It may present with renal impairment, HTN, or ARF. May also have systemic symptoms such as fever, rash, arthralgia, with eosinophilia, uveitis, and increased IgE.

Answer 52

Minimal change nephropathy is the most common cause of nephrotic syndrome in young adults/children. Most cases are idiopathic, but in 10% there is a cause (Drugs, Hodgekin's lymphoma, thymoma, mononucleosis).T cells and cytokines attack the glomerular basement membrane, reducing the electrostatic charge, increasing permeability to albumin Presentions with neprotic syndrome and normal blood pressure. Manage with steroids. Prognosis is good..

Answer 53

Chronic tubulointerstitual nephritis is chronic inflammation of the renal interstitium. It results from many disorders, leading to extensive fibrosis and tubular loss on renal biopsy. Patients present with chronic renal failure. Causes include chronic pyelonephritis often with reflux nephropathy, sickle cell disease, lead or cadmium intoxication.

Answer 54

Balkkan Nephropathy is a chronic tubulointerstitual disease associated with a high frequency of urothelial atypia occasionally culminating in tumours of the renal pelvis and urethra. It occurs in people living along the Danube River.

Answer 55

Analgesic nephropathy is associated with the prolonged heavy ingestion of analgesics (particularly NSAIDs, paracetamol, and penacetin). The ingestion of analgesics leads to interstitial nephritis and papillary necrosis. There is often a history of chronic pain. In analgesic nephropathy there is a slow progression to chronic renal failure. Proteinuria or sterile pyuria.

Answer 56

Sterile pyuria is the finding of elevated white cells in a urine sample in which no infection is found. It is found in UTIs and renal disease.

Answer 57

Urate Nephropathy can be either acute crystal nephropathy or chronic crystal nephropathy. In acute crystal nephropathy there is acute oliguric or anuric renal failure due to uric acid precipitation in the tubules. It is most often due to the overproduction of uric acid in patients with lymphoma, leukaemia, or a myeloproliferative disease. The renal parenchyma appears bright on Ultrasound. There are also cases of chronic urate nephropathy.

Answer 58

Hypercalceamia is caused by nephrogenic diabetes insipidus, renal calculi, and nephrocalcinosis (diffuse renal parenchymal calcification, often asymptomatic, causing progressive renal impairment).

Answer 59

Rhabdomyolysis results from skeletal muscle breakdown, with release of its contents into circulation (myoglobin, K, PO4, urate, and creatinine kinase). Comlications include hyperkalaemia and acute renal failure. ARf is cuased by the myoglobulin being filtered through the glomeruli and obstructing the renal tubules. Causes can be divided into: Post Ischeamic (embolism, clamp on artery during surgery), Trauma(prolonged immobilisation, burns, crash injury, excessive exercise, uncontrolled seizures), Drugs and Toxins (statins, fibrates, EtOH, ectasy, heroin, neuroleptic malignant syndrome), Infections, and inherited muscle disorders.

Answer 60

Clinical features of rhabdomyolysis include muscle swelling, pain, tenderness, and red-brown urine (myoglobinuria). Plasma shows increased creatine kinase, and MI must be excluded as a cause. Associated with compartment syndrome, hyperkalaemia, and DIC.

Answer 61

Diabetic nephropathy, glomerulonephritis, chronic interstitial nephritis, polycystic kidney disease or renovascular disease.

Answer 62

Treat the underlying cause (eg. acute renal failure) and stop any exacerbating drugs (eg. ACE Inhibitors). - Stabilise the cardiac membrane (IV Calcium Gluconate) - Short term shift from extracellular to intracellular Potassium (combined insulin/dextrose infusion, nebulised salbutamol) - Remove Potassium from the body (Calcium Resonium, loop diuretics, dialysis).

Answer 63

Renal Vascular disease is stenosis of the renal artery or one of its branches. It is most commonly caused by atherosclerosis in older patients, or fibromuscular dysplasia in younger patients. Clinically, there is hypertension that is resistant to treatment, worsening renal function after ACE inhibitors in bilateral renal artery stenosis, 'flash' pulmonary oedema, sudden onset LV hypertrophy on echo. Abdo and carotid femoral bruits, and weak leg pulses may be found. Ix: Ultrasound, CT MR, renal angiography.

Answer 64

Renal tubular acidosis is metabolic acidosis due to impaired acid secretion by the kidney.

Answer 65

Type 1 Renal Tubular Acidosis is distal. It is due to an inability to excrete hydrogen ions and generate acidic urine in the distal tubule, even in states of metabolic acidosis. Causes include idiopathic, genetic (Marfan's, Ehlers-Danlos), Autoimmune (SLE, Sjorgrens, Autoimmune hepatitis), Nephrocalcinosis, Tubulointerstitual disease, or drugs.

Answer 66

Type Two renal tubular acodisis occurs proximally and is due to 'bicarbonate leak'. It is a defect in the bicarbonate reabsorption in the proximal tubule resulting in excess bicarbonate in the urine. Causes of type two renal tubular acidosis include Idiopathic, Fanconi's syndrome, Tubulointerstitual disease (myeloma, interstitial nephritis), and drugs.

Answer 67

The proximal tubule is responsible for reabsorption of many solutes, including 50% of filtered sodium, most bicarbonate, and all filtered glucose and amino acids. Fanconi's Syndrome is a disturbance of the proximal tubule function, with defective resorption of amino acids, potassium, phosphate (leading to hypophosphateamic rickets and osteomalacia), glucose (glucosuria), and bicarbonate (type 2 RTA) There is also polyuria and hypokalaemia. Can be idiopathic, inherited, or acquired from tubule damage.

Answer 68

Polycystic kidney disease is an inherited disorder involved PKD1, and PKD2. It presents with renal enlargement with cysts, abdominal pain +/- haematuria, cyst infection, renal calculi, hypertension, and progressive renal failure. May also present with liver cysts and intracranial aneurysms.

Answer 69

Control Hypertension. Target BP is <45mL/min. Manage CVD risk by giving statins and aspirin. Manage severe anaemia by excluding other causes and giving EPO. Treat osteodystrophy if high PTH. Oedema can be treated with frusemide and fluid and sodium restriction. Restless legs can be treated with clonazepam or gabapentin. Bicarbonate supplements may be needed to correct acidosis.

Answer 70

In haemodialysis, blood flows on one side of a semi-permeable membrane while dialysis fluid flows in the opposite direction on the other side. solute transfer occurs by diffusion. Small solutes (eg. urea) diffuse readily, while larger solutes diffuse less readily and are not cleared as effectively. Ultrafiltration is the removal of excess fluid by creating negative transmembrane pressures.

Answer 71

Problems associated with haemodialysis include disequilibriation syndrome (caused by rapid changes in plasma osmolarity and cerebral oedema caused by dialysis). Hypotension, arrhythmias, Time consuming. Access issues surrounding the fistula include thrombosis, stenosis, aneurysm, steal syndrome and ischeamia. Temporary sites may have problems with infection or blockage.

Answer 72

In heamofiltration, blood is filtered across a highly permeable membrane allowing removal of waste products via a process of convection. Compared with diffusion, convection moves larger solutes almost at the same rate as smaller solutes. The ultrafiltrate is replaced with an equal volume of replacement fluid. It is more expensive and takes longer than HD, but there is less heamodynamic instability and so it is used for critically ill patients.

Answer 73

Peritoneal dialysis is simple to perform, requires less complex equipment, and can be completed at home. It is useful in children, the elderly, and those with cardiovascular disease. PD fluid is introduced into the peritoneal cavity via the Tenchkoff catheter and ureamic solutes diffuse into it across the peritoneal membrane. Ultrafiltration is achieved by adding osmotic agents eg. glucose to dialysis fluid.

Answer 74

Peritoneal dialysis is associated with peritonitis (60%staphlococci). there is also exit site infection, catheter malfunction, Loss of membrane function, Obesity (glucose in dialysis fluid), hernias, and back pain.

Answer 75

``` Cardiovascular disease (IHD, cardiac failure, and stroke), anaemia, Protein-Calorie Malnutrition, Platelet dysfunction causing a tendency to bleed, renal osteodystrophy, infection (uraemia causes granulocyte dysfunction). Beta2 macroglobulin amyloidosis is due to amyloid accumulation in long term dialysis patients, causes carpal tunnel, arthralgia, and fractures. Acquired Renal Cysts occur after years of dialysis and may present with haematuria or malignant transformation. Malignancy has also been found to be more common in dialysis patients, but this may be due to the cause. ```

Answer 76

Active infection, severe heart disease, cancer and other severe comorbidity. Previous TB may reactivate so it must be treated. HEP B and C, CMV, HIV, EBV, and varicella zoster may cause severe disease whilst immunocomprimised.

Answer 77

Cadaveric donor, non heart beating donors, living related donor, live unrelated donation.

Answer 78

``` Most regimes involve: 1. Ciclosporin or tacrolimus, and 2. azathioprine or mycophenalate, +/- 3. Prednisolone. Pre-op receives anti-interleukin 2 receptor antibodies (eg. basiliximab) to reduce rates of early rejection. ```

Answer 79

Acute: bleeding, thrombosis, infection, urinary leaks, oligouria, acute rejection. Chronic: Chronic rejection, Infection related to immunosuppression, ciclosporin/tacrolimus toxicity, increased chance of malignancy, atheromatous vascular disease, and hypertension.