Renal

Question 1

If taking a history from someone with known CKD, what symptoms should you enquire about? (6)

Answer 1

1. Breathlessness
2. Weight loss
3. Fatigue
4. Swollen ankles
5. Change in urinary frequency
6. Pruritis

Question 2

What are the causes of AKI?

Answer 2

Pre-renal - sepsis, dehydration
Renal - progression of pre-renal with acute tubular necrosis, glomerulonephritis, nephrotoxic drugs
Post-renal - obstruction

Question 3

According to NICE, how is AKI defined?

Answer 3

Rise in creatinine from baseline of >50% in 7 days
OR
Rise by 26mmol
OR
Oliguria <0.5ml/kg/hour

Question 4

What are the common nephrotoxic drugs? (4)

Answer 4

1. NSAIDs
2. ACE inhibitors
3. Diuretics
4. Aminoglycosides

Question 5

Which drugs do you want to stop if someone has an AKI? (DAMN)

Answer 5

1. Diuretics
2. ACE inhibitors/ARBs
3. Metformin
4. NSAIDs

Question 6

What are the indications for dialysis in AKI? (AEIOU)

Answer 6

Acidosis pH <7.1
Electrolytes - hyperkalaemia
Intoxications - lithium 
Overloaded with fluid
Uraemic symptoms e.g. encephalopathy

Question 7

What is CKD?

Answer 7

A chronic irreversible deterioration in renal function

Question 8

What are the causes of CKD - using the mnemonic HIDDEN?

Answer 8

H - hypertension
I - infection
D - diabetes
D - drugs
E - exotica e.g. SLE and other vasculitis
N - nephritis, especially glomerulonephritis

Question 9

What are the indications for dialysis in CKD?

Answer 9

1. Progressive decline in renal function e.g. end stage with eGFR <15ml/min
2. Symptomatic ureamia despite conservative treatment
3. Volume overload despite fluid restriction and diuretics
4. Other indications e.g. pericarditis, bone disease, hyperkalaemia despite treatment

Question 10

What is the best method of access for renal replacement therapy?

Answer 10

An AV fistula

Question 11

What is a fistula?

Answer 11

An abnormal connection between two epithelial surfaces

Question 12

How long does it take for an AV fistula to form and be used for dialysis?

Answer 12

6 weeks

Question 13

Which arteries/veins are commonly used for AV fistula?

Answer 13

Radial artery to cephalic vein
OR
Ulnar artery to basilic vein
(or a brachiocephalic fistula at elbow)

Question 14

What is steal syndrome?

Answer 14

This is when an AV fistula leads to distal tissue ischaemia

Question 15

What are the complications of a fistula? (4)

Answer 15

1. Infection
2. Stenosis
3. Thrombosis
4. Bleeding

Question 16

How is the artery connected to the vein in an AV fistula?

Answer 16

Usually a side-to-end anastamosis with ligation of the distal vein

Question 17

What are the alternatives to an AV fistula?

Answer 17

Continuous ambulatory peritoneal dialysis

Question 18

How is continuous ambulatory peritoneal dialysis done, what are the positives/negatives?

Answer 18

Tenckhoff catheter in the abdomen

Positives: Less expensive than haemodialysis and more convenient, with a relatively easy to teach technique

Negatives: many have to stop due to peritonitis and fibrosis may reduce permeability of the peritoneal membrane

Question 19

How will peritoneal dialysis peritonitis present?

Answer 19

Abdominal pain +/- fever - normally exit site infection will mean taking swabs and/or blood cultures.
There may be a cloudy effluent - patients are often told to look and save the first cloud bag for culture.

Question 20

What are the gram positive organisms known to cause peritoneal dialysis peritonitis, and how are they treated?

Answer 20

Staph or strep or MRSA - treated with intrapertioneal vancomycin

Question 21

If the organism to cause peritoneal dialysis peritonitis is gram negative or pseudomonas, what is the treatment?

Answer 21

IV ciprofloxacin

Question 22

What are the symptoms associated with CKD? (5)

Answer 22

1. Low energy (renal anaemia, solute retention (cerebral depressant), psychosocial e.g. loss of employment)
2. Breathless - anaemia, fluid overload, heart failure
3. Itching - hyperphosphataemia
4. Bone pain or gout - high uric acid levels
5. Tingling or numb peripheries - peripheral neuropathy

Question 23

The mnemonic BIG BEAN is used for the features of CKD, what are they?

Answer 23

B - breathlessness
I - itching
G - gout
B - bone pain
E - energy levels low
A - anaemia/ankle swelling
N - neuropathy

Question 24

What are the bone diseases associated with CKD?

Answer 24

1. Osteoporosis
2. Hyperparathyroidism
3. Osteomalacia
4. Osteosclerosis

Question 25

Why does CKD lead to bone disease?

Answer 25

Renal damage --> reduced activation of vitamin D and phosphate retention --> reduced calcium absorption from the gut --> hypocalcaemia --> increased PTH --> activation of osteoclasts and osteoblasts --> subperiosteal bone resoprtion, pepperpot skull, increased bone matrix, sclerotic 'rugger jersey spine'

Question 26

What is seen on renal bone disease? (4)

Answer 26

1. Often asymptomatic 2. Low back pain/vertebral crush fractures 3. Brachydactyly (short stubby fingers) 4. Osteolysis of terminal phalangeal tuft (acronecrosis)

Question 27

What is the name of the catheter used in ambulatory dialysis?

Answer 27

Tenckhoff catheter

Question 28

How does the tenckhoff cathter work?

Answer 28

The peritoneum is used as a semi-permeable membrane - it involves instilling 3 litres of fluid, four times a day, with half hour exchanges. Water is removed via an osmotic gradient by including some bags of hypertonic fluid - with a high glucose or polymer concentration

Question 29

What is the main cause of nephrotic syndrome in children and what is the first line treatment?

Answer 29

Minimal change disease - it is almost always steroid-responsive

Question 30

What are the causes of nephrotic syndrome in adults?

Answer 30

1. Glomerulosclerosis - especially seen in diabetes 2. Membranous glomerulonephritis - usually idiopathic but can be caused by: - malignancy - infections e.g. malaria, hep B - Lupus - drugs e.g. penicillamine and gold 3. Amyloidosis

Question 31

What is the treatment for nephrotic syndrome? (5)

Answer 31

1. Treat oedema with diuretics and salt restriction 2. Minimal change - steroids +/- cyclophosphamide 3. ACE inhibitors to reduce protein excretion - by lowering glomerular filtration pressure 4. Anticoagulation 5. Statins

Question 32

What happens in the kidneys in nephrotic syndrome?

Answer 32

All the causes e.g. minimal change disease and glomerulonephritis cause the basement membrane pores to increase in size and number. This leads to loss of proteins as they leak through and you get frothy urine, oedema, thrombotic tendency (due to loss of antithrombin, increase in lipid synthesis and high platelet count)

Question 33

What are the signs acute nephritic syndrome - abnormal HOST response?

Answer 33

H - hypertension O - oliguria S - smoking brown haematuria with red cell casts T - trace of oedema

Question 34

What are the causes of acute nephritic syndrome? (3)

Answer 34

1. Post streptococcal 2. IgA nephropathy (commonest glomerulonephritis) 3. Vasculitis e.g. lupus

Question 35

What investigations are done for nephritic syndrome? (3)

Answer 35

1. Throat swab 2. ASO titre 3. 24 hour urinary protein

Question 36

What is the treatment for nephritic syndrome?

Answer 36

1. Penicillin if streptococci present 2. Salt restriction 3. Anti-hypertensive medication

Question 37

How can glomerulonephritis be classified?

Answer 37

Proliferative vs. non-proliferative

Question 38

What are the non-proliferative glomerulonephritis conditions and what do they generally cause?

Answer 38

Non-proliferative = nephrotic syndrome - minimal change disease - membranous - focal segmental sclerosis

Question 39

What are the proliferative glomerulonephritis conditons?

Answer 39

1. IgA 2. Mesangial 3. Crescentic (PAN?) 4. Diffuse proliferative

Question 40

The proliferative glomerulonephritis can cause what conditions? (3)

Answer 40

1. Acute nephritic syndrome 2. Recurrent haematuria 3. AKI

Question 41

What are the causes of raised urea? (6)

Answer 41

1. Renal failure 2. Dehydration 3. Heart failure 4. Diuretic use 5. High protein diets (breakdown product of protein) 6. Upper GI bleed

Question 42

What can cause low urea levels? (2)

Answer 42

1. Liver disease | 2. Over-hydration

Question 43

Why are creatinine levels alone a poor marker of renal function?

Answer 43

Creatinine is a breakdown product of creatine - from skeletal muscle, and plasma levels vary hugely according to muscle mass. Elderly people with CKD will have high levels but so will young athletes. Because creatinine is excreted by the kidneys, levels do rise in renal failure, but they do so relatively late in the course of progressive renal disease, so they are a poor marker.

Question 44

What does creatinine clearance refer to?

Answer 44

Clearance means the amount of blood that could be completely cleared of a substance in a minute. If a substance is filtered at the glomerulus and neither secreted nor absorbed at the renal tubules, its clearance will be a good measure of glomerular filtration rate (GFR). Creatinine clearance is used as a measure of glomerular filtration rate.