Renal

Question 1

AKI =

Answer 1

A sudden decrease in renal function over hours to days

Question 2

Pre-renal causes of an AKI

Answer 2

Hypovolemia - haemmorhage, D&V, burns, diuretic use
Renal hypoperfusion- Renal artery stenosis, occlusion, AAA, hepatorenal syndrome, sepsis, cardiogenic shock
Drugs affecting autoregulation - ACEi/ARK inhibit efferent constriction and NSAID inhibit afferent vasodilation

Question 3

Renal causes of an AKI

Answer 3

Glomerulonephritis
Ischaemic injury - acute tubular necrosis (ATN)
Acute interstitial nephritis
Immune mediated injury (SLE, ANCA vasculitis)
Nephrotoxic injury - rhabdo, contrast media, chemo agents, DAMN drugs (Diuretics, ACEi, metformin, NSAIDs)
Multiple myeloma - large proteins get stuck in tubule

Question 4

Post-renal causes of AKI

Answer 4

Obstruction in..
Kidneys- Retroperitoneal fibrosis, blood clots, RP adenopathy
Ureter - Renal stones, tumour, blood clots
Bladdder - BPH, prostate ca
Urethra - Tumour, stricture

Question 5

If patient has bilateral renal artery stenosis which drug shouldn’t you start them on?

Answer 5

ACE inhibitors

can lead to Acute tubular necrosis (AKI)

Check EGFR as it can drop

Question 6

Who is at increased risk of an AKI?

Answer 6

if you have..

• CKD
• Heart failure, liver disease, diabetes mellitus
• History of AKIs
• Use of drugs with nephrotoxic potential (e.g. NSAIDs, aminoglycosides, ACEi ARBs and diuretics)
• Recent iodine contrast use
• Age >65 years

Question 7

Signs and symptoms of an AKI

Answer 7

Oliguria (reduced urine output)
Fluid overload - increased JVP, pulmonary/peripheral oedema
Electrolyte imbalance (rise in K+, urea, creatinine) - Arrhythmias, uraemia, pericarditis, encephalopathy
Confusion
Lethargy
Hypertension
Abdo/flank pain

Question 8

AKI definition criteria

AKIN, KDIGO, pRIFLE

Answer 8

A rise in serum creatinine of 26 mmol/litre or greater within 48h
a ≥50% rise in serum creatinine within the past 7 days
A fall in urine output to less than 0.5 ml/kg/hour for more than 6 hours

Question 9

Which drugs should be stopped during AKI as they may worsen renal function

Answer 9

• NSAIDs
• Aminoglycosides
• ACE inhibitors
• ARB
• Diuretics

Question 10

Patients can be put on _______ if experiencing fluid overload from AKI

Answer 10

Loop diuretic

Question 11

Treatment of hyperkalaemia

Answer 11

IV calcium gluconate

Insulin/dextrose IV infusion

Question 12

Alport’s syndrome

Answer 12

X-linked dominant pattern
Presents in childhood

Defect in type IV collagen gene leading to abnormal glomerular basement membrane

Alport pts with transplant -> can experience rejection and present with Goodpasture’s syndrome

Question 13

Bilaterally shrunken kidneys seen with..

Answer 13

Glomerulonephritis and hypertension

Question 14

Enlarged kidneys are seen with..

Answer 14

Autosomal dominant polycystic kidney disease
Diabetic nephropathy
Amyloidosis
HIV associated nephropathy

Question 15

Renal transplant patients are at increased risk of developing what type of cancer?

Answer 15

Lymphoma
Skin cancer (Squamous)

Due to the immunosuppressive effects of the medication given to prevent transplant rejection

Question 16

Acute Interstitial nephritis (AIN) usually presents after

Answer 16

An infection (staphylococci or Hanta virus)
Use of nephrotoxic drugs (penicillin, rifampicin, NSAIDs, allopurinol, furosemide)

Question 17

Nephrotic syndrome

Answer 17

Proteinuria
Hypoalbuminaemia
Oedema

Question 18

Nephritic syndrome

Answer 18

Haematuria
Hypertension

(Some proteinuria and oliguria)

Question 19

Renal cell carcinoma

Answer 19

Classical triad: haematuria, loin pain, abdominal mass
Pyrexia of unknown origin
Left varicocele (due to occlusion of left testicular vein)
Endocrine effects: may secrete EPO(polycythaemia), PTH (hypercalcaemia), renin, ACTH
25% have metastases at presentation

Question 20

How to differentiate between IgA nephropathy and Post-strep glomerulonephritis

Answer 20

IgA nephropathy presents 1-2 DAYS after an URTI whilst Post-streptococcal glomerulonephritis occurs 1-2 after an URTI

Both typically present as nephritic syndrome (hypertension and haematuria)

Question 21

Causes of hypokalaemia

Drugs, GI, renal, endocrine

Answer 21

POTASSIUM LOSS
Drugs: thiazides, loop diuretics, laxatives, glucocorticoids, antibiotics
GI losses: diarrhoea, vomiting, ileostomy
Renal causes: dialysis
Endocrine disorders: hyperaldosteronism, Cushing’s syndrome

DECREASED POTASSIUM INTAKE
MAGNESIUM DEPLETION (

Question 22

Haemolytic uraemic syndrome TRIAD

Answer 22

Acute renal failure
Microangiopathic haemolytic anaemia (fragmented RBCs)
Thrombocytopenia

HUS generally seen in children

Question 23

Acute interstitial nephritis (AIN) symptoms

Answer 23

Urticarial rash
Fever
Arthralgia
Eosinophilia (urine shows high WCC and eosinophils)
Mild renal impairment
Hypertension

Question 24

Henoch Schonlein Purpura (HSP)

Answer 24

An IgA mediated small vessel vasculitis (overlap with IgA nephropathy)

Usually seen in children following an infection

Palpable purpuric rash (with localized oedema) over buttocks and extensor surfaces of arms and legs
Abdo pain
Polyarthritis
Features of IgA nephropathy e.g. haematuria, renal failure

Question 25

Young female patients who develop AKI after the initiation of an ACE inhibitor think:

Answer 25

Fibromuscular dysplasia In an older patient think atherosclerosis of renal arteries

Question 26

Fibromuscular dysplasia

Answer 26

Proliferation of cells in the walls of the arteries causing the vessels to bulge or narrow String of beads appearance on MR angiography

Question 27

What is dialysis disequilibrium syndrome?

Answer 27

Neurologic symptoms of varying severity that affect dialysis patients, particularly when they are first started on hemodialysis Caused by cerebral oedema

Question 28

How do you screen for adult polycystic kidney disease

Answer 28

Abdo US (to look for cysts)

Question 29

Best way to differentiate prerenal AKI (such as hypovolemia) or from renal AKI (acute tubular necrosis)

Answer 29

Measure urinary sodium In Pre-renal it will be LOW (↑ sodium reabsorption from kidneys to try and restore circulating volume hence low urinary sodium) In renal it will be HIGH (kidney tubules lose ability to retain sodium and concentrate the urine hence high urinary sodium)

Question 30

Which pathogen is associated with post-strep GN?

Answer 30

Streptococcus pyogenes

Question 31

Rhabdomyolysis can occur from which 2 drugs?

Answer 31

Erythromycin and simvastatin (as they inhibit CYP450)

Question 32

What do you see in urine of patient with diabetic nephropathy?

Answer 32

Eosinophilic casts

Question 33

What pathogen is the most common cause of peritonitis?

Answer 33

1) Staphylococcus epidermidis | 2) Staph aureus

Question 34

Which factors might affect eGFR?

Answer 34

Pregnancy Muscle mass (e.g. amputees, body-builders) Eating red meat 12 hours prior to the sample being taken

Question 35

Proteinuria on urinalysis in patient with SLE, think:

Answer 35

Lupus nephritis It's a severe manifestation of systemic lupus erythematosus (SLE) that can result in end-stage renal disease

Question 36

Features of rhabdomyolysis

Answer 36

acute renal failure with disproportionately raised creatinine elevated CK myoglobinuria hypocalcaemia (myoglobin binds calcium) elevated phosphate (released from myocytes)

Question 37

Goodpastures syndrome typically presents with

Answer 37

Haemoptysis and haematuria (preceded by chest symptoms - coughing/chest pain) Rare condition associated with rapidly progressive glomerulonephritis - anti-glomerular basement membrane (anti-GBM) antibodies against type IV collagen

Question 38

Causes of transient or spurious non-visible haematuria

Answer 38

urinary tract infection menstruation vigorous exercise sexual intercourse

Question 39

Causes of persistent non-visible haematuria

Answer 39

``` cancer (bladder, renal, prostate) stones benign prostatic hyperplasia prostatitis urethritis e.g. Chlamydia renal causes: IgA nephropathy, thin basement membrane disease ```

Question 40

Causes of red/orange urine, where blood is not present on dipstick

Answer 40

foods: beetroot, rhubarb drugs: rifampicin, doxorubicin

Question 41

When would you do an urgent 2 week referral for non-visible haematuria?

Answer 41

Aged ≥ 45 years AND: unexplained visible haematuria without UTI or still there even if UTI has been treated Aged ≥ 60 years AND have unexplained nonvisible haematuria AND dysuria or a raised WCC on a blood test

Question 42

Hypercoagulable state is seen in _______ syndrome

Answer 42

Nephrotic This is due to loss of antithrombin III via the kidneys. The most common site of thrombosis is the renal vein but patients are also at risk of deep vein thromboses and pulmonary embolisms

Question 43

Worsening renal function, together with muddy brown casts is indicative of..

Answer 43

Acute tubular necrosis

Question 44

How to differentiate acute tubular necrosis from acute interstitial nephritis

Answer 44

AIN caused by penicillins whilst ATN caused by aminoglycosides (gentamicin) AIN is an inflammatory process so will have HIGH WCC (plus eosinophils) compared to ATN which is not inflammatory

Question 45

With AKI - The presence of protein in urine more likely to indicate pre/intrinsic/post renal cause

Answer 45

Intrinsic renal AKI Protein in the urine can only occur if there is intrinsic damage to the kidney

Question 46

What is the most common cause of HUS

Answer 46

E coli

Question 47

HUS symptoms

Answer 47

Diarrhoea which becomes bloody 1-3 days after its onset Haemolysis, anaemia, thrombocytopenia Raised lactate dehydrogenase, urea and creatinine

Question 48

Autosomal-dominant polycystic kidney disease (AKPKD) extra-renal manifestations

Answer 48

Liver cysts berry aneurysms -> can lead to subarachnoid haemmorhage Valvular disease: mitral valve prolapse, mitral/tricuspid incompetence, aortic root dilation, aortic dissection Cysts in other organs: pancreas, spleen; very rarely: thyroid, oesophagus, ovary

Question 49

Alport syndrome

Answer 49

X-link dominant condition in gene coding for collagen IV resulting in an abnormal glomerular-basement membrane Renal failure, sensorineural hearing loss and ocular abnormalities in child

Question 50

Which abnormalities are seen with CKD that are absent in AKI

Answer 50

Hypocalcaemia Increased levels of PTH (secondary hyperparathyroidism in compensation for hypocalcaemia) Anaemia due to erythropoietin and iron deficiency

Question 51

If urea is disproportionately raised (ie 2x the upper limit) when compared to creatinine could indicate.. If both proportionally raised then consider..

Answer 51

Patient is dehydrated (urea gets more concentrated in the reduced body fluid volume) CKD

Question 52

Signs of dehydration

Answer 52

Dry mucous membranes, loss of skin turgor, sunken eyes, and in severe dehydration tachycardia, hypotension and delirium.