Renal Flashcards
(47 cards)
1
Q
Adrenal cortex mnemonic?
A
GFR-ACD
- Zona Glomerulosa (outside) - mineralocorticoids (mainly Aldosterone)
- Zona Fasciculata (middle): glucocorticoids, mainly Cortisol
- Zona Reticularis (on inside): androgens, mainly Dehydroepiandrosterone (DHEA)
2
Q
Summary of RAAS?
A
-
Renin
- Released by JGA cells in kidney in response to reduced renal perfusion, low sodium
- Hydrolyses angiotensin to form angiotensin I
- Stimulated by - low BP/low renal perfusion, hyponatraemia, sympathetic nerve stimulation, catecholamines, erect posture
- Reduced by - B-blockers, NSAIDs
-
Angiotensin
- ACE (lung) converts angiotensin I to angiotensin II
- Vasoconstriction –> increased BP
- Stimulates thirst and stimulates aldosterone/ADH release
-
Aldosterone
- Released by zona glomerulosa in response to raised angiotensin II, K+ and ACTH levels
- Causes retention of Na+ in exchange for K+/H+ in distal tubule
3
Q
Urinalysis patterns?
A
4
Q
Calcium metabolism?
A
5
Q
Renal bone disease summary? And clinical manifestations?
A
- Osteitis fibrosa cystica
- AKA hyperparathyroid bone disease
- Adynamic
- Reduction in cellular activity (both osteoblasts and osteoclasts) in bone
- May be due to over treatment with vitamin D
- Osteomalacia
- Due to low vitamin D
- Osteosclerosis
- Osteoporosis
6
Q
Management of Renal Anaemia?
A
- Correction of iron with IV if needed
- Ferritin should be > 200 ng/mL before starting EPO
- EPO is used to target Hb 10-12 (>11 or hematocrit >33%) reach the target within 4 months
- Corrected Hb of > 13.5 is associated with HTN crisis
- Hb < 10.5 increased risk of seizures.
7
Q
Side effects of EPO?
A
- HTN and HTN crisis, potentially encephalopathy and seizures (BP increased in 25% of patients)
- EPO induced seizures occurs after 90 days fro starting the treatment
- Bone aches
- Flu-like symptoms
- Skin rashes, urticaria
- Pure red cell aplasia* (due to antibodies against erythropoietin)
- Raised packed cell volume (PCV) = HCT –> increased risk of thrombosis (e.g. Fistula)
- Iron deficiency 2nd to increased erythropoiesis
8
Q
Reasons why people fail to respond to EPO?
A
- Iron deficiency
- Inadequate dose
- Concurrent infection/inflammation
- Hyperparathyroid bone disease
- Aluminum toxicity
9
Q
What mediates hyperacute graft rejection?
A
IgG
10
Q
Graft survival stats?
A
Cadaveric
- 1 year = 90%
- 10 years = 60%
Living donor
- 1 year = 95%
- 10 years = 70%
11
Q
Post-op problems for renal transplant?
A
Up to 4 months post-op (can cause graft dysfunction)
- Acute rejection: risk is great in 1st 2 weeks occurs in 30-50% of cases
- Ciclosporin toxicity
- ATN of graft
- Vascular thrombosis
- Urine leakage
- UTI
12
Q
Management of acute (<6 months) graft failure?
Causes of chronic graft failure (>6 months)?
A
Acute
- Steroids
- If resistant use monoclonal antibodies
Chronic
- Chronic allograft nephrotherapy
- Ureteric obstruction
- Recurrence of original renal disease
13
Q
Autosomal dominant polycystic kidney disease - types, diagnostic criteria?
A
Types
Loci = PKD1 and PKD2 - code for polycystin-1 and 2 respectively
Investigation/Criteria
Abdominal ultrasound
- Recommended after 20 years of age (risk of false -ve)
- <30 yrs - 2 cysts, unilateral or bilateral
- 30-59 yrs - 2 cysts in both kidneys
- >60 yrs - 4 cysts in both kidneys
Management
- Analgeisa
- Abx for UTIs
- HTN control
- Transplantation for ESRF
14
Q
Conditions associated with ADPKD?
A
- Colonic diverticula
- Mitral valve prolapse
15
Q
Autosomal recessive PKD?
A
- Much less common than ADPKD
- Chromosome 6
- Dx - usually on prenatal USS or early infancy with abdo masses and renal failure
- ESRF in childhood
- Liver involvement
16
Q
Nephrotic syndrome causes?
A
-
Glomerulonephritis (80%)
- Minimal change GN (75% children)
- Membranous GN
- Focal segemnental glomerulosclerosis
-
Systemic disease
- Amyloid
- SLE
-
Drugs
- Gold (sodium aurththiomalate), penicillamine
-
Others
- Congenital
- Neoplasia - carcinoma, lymphoma, leukaemia, myeloma
- Infection - bacterial endocarditis, hep B, malaria
- Renal vein thrombosis
17
Q
Complications of nephrotic syndrome
A
- Infection due to urinary immunoglobulin loss
- Thromboembolism related to loss of antithrombin III and plasminogen in the urine
- Hyperlipidemia
- Hypocalcemia (vitamin D and binding protein lost in urine)
- Acute renal failure could be due to thrombotic renal veins - loin pain and haematuria.
18
Q
Types of glomerulonephritis?
A
-
Membranous GN (Commonest type)
- Proteinuria/nephrotic syndrome/CRF
- Cause - infections, rheumatoid drugs, malignancy, SLE
- Biopsy - sub-epithelial immune complex deposition (IgG, C3)
- 1/3 resolve, 1/3 respond to cytotoxics, 1/3 develop CRF
-
IgA Nephropathy (Commonest worlwide cause of GN)
- Young adult with painless haematuria after UTI
- Associated with HSP, coeliac, dermatitis herpetiformis
- Mesangial hypercellularity, +ve immunofluoresence for IgA and C3
- Good prognosis - frank haematuria
- Poor prognosis - male, proteinuria, HTN, smoking, high lipids
-
Diffuse Proliferative GN
- Post-streptococcal glomerulonephritis in a child
- Nephritic syndrome/ARF
- Most common form of renal disease in SLE
-
Minimal Change Disease
- Child with nephrotic syndrome
- Causes - Hodgkin’s, NSAIDs
- Good response to steroids, next line cyclophosphamide
- Biopsy - podocyte fusion
- Rule of 1/3
-
Focal Segmental GN
- Idiopathic, or 2ndry to HIV/Heroin, Alport’s, Sickle cell
- Proteinuria/nephrotic syndrome/CRF
-
Rapidly Progressive GN (Crescenteric GN)
- Rapid onset –> ARF
- Causes - Goodpasture’s, ANCA +ve vasculitis (Wegener’s)
-
Mesangiocapillary GN (Membranoproliferative)
- Nephrotic syndrome, haematuria, proteinuria
- Poor prognosis
- Type 1 - cryoglobulinaemia, hepatitis C –> low C4
- Type 2 - partial lipodystrophy –> low C3
19
Q
A
20
Q
Alport’s sydnrome?
A
- X-linked dominant
- Defect in gene coding for type IV collagen –> abnormal GBM
- More severe in males
Presentation
- Childhood
- Microscopic haematuria
- Progressive renal failure
- Bilateral senorineural deafness
- Lenticonus - protrusion of lens into anterior chamber
- Retinitis pigmentosa
21
Q
Alport’s with failing renal transplant?
A
- Caused by anti-GBM antibodies
- Leads to Goodpasture’s syndrome picture
22
Q
Risk factors for renal stones? Urate stones? Drug causes?
A
Risk Factors
- Dehydration
- Hypercalciuria, hyperparathyroidism, hypercalcemia
- Cystinuria NOT CYSTINOSIS
- High dietary oxalate
- Renal tubular acidosis
- Medullary sponge kidney, polycystic kidney disease
- Beryllium or cadmium exposure
Urate stones
- Gout
- Ileostomy - loss of bicarb and fluid results in acidic urine –> uric acid
Drug Causes
- Loop diuretics, steroids, acetazolamide, theophylline –> calcium stones
- Thiazides can prevent calcium stones (distal tubular calcium resorption)
23
Q
A
Types of Renal Stones?
24
Q
Stag horn calculi?
A
- Involve the renal pelvis and extend into at least 2 calyces.
- Develop in alkaline urine and are composed of struvite (ammonium magnesium phosphate, triple phosphate).
- Ureaplasma urealyticum and Proteus infections predispose to their formation
25
Albumin creatinine ratio?
**_ACR_**
* Early morning specimen
* \>2.5 = microalbuminaemia
* All diabetic patients should be screened annually
26
Management of diabetic nephropathy?
* Dietary protein restriction
* Tight glycemic control
* BP control: aim for \< 130/80 mmHg
* Benefits independent of blood pressure control have been demonstrated for ACE inhibitors and angiotensin II receptor blockers - these may be used alone or in combination
* Control dyslipidemia e.g. Statins
27
CKD stages?
* 1 - \>90
* 2 - 60-90
* 3a - 45-49
* 3b - 30-44
* 4 - 15-29
* 5 - \<15
28
Causes of transient and persistent microscopic haematuria?
**_Transient_**
* Urinary tract infection
* Menstruation
* Vigorous exercise
* Sexual intercourse
**_Persistent_**
* Cancer (bladder, renal, prostate)
* Stones
* Benign prostatic hyperplasia, Prostatitis.
* Urethritis e.g. Chlamydia
* Renal causes: IgA nephropathy, thin basement membrane disease
29
Fanconi syndrome features and causes?
Generalized disorder of renal tubular transport resulting in:
* Type 2 RTA
* Aminoaciduria
* Glycosuria
* Phosphaturia
**_Causes_**
* Cystinosis (most common cause in children)
* Sjogren's syndrome
* Multiple myeloma
* Nephrotic syndrome
* Wilson's disease
30
RTA Types?
31
Causes of RTA 4?
* Aldosterone deficiency (hypoaldosteronism): Primary vs. hyporeninemic
* Aldosterone resistance:
* Drugs: Amiloride, Spironolactone, Trimethoprim, Pentamidine
* Pseudohypoaldosteronism
* DM
32
Cause of RTA 3?
Juvenile RTA
Carbonic anhydrase II deficiency
Rarely discussed
33
Differences between ATN and Prerenal Uraemia? (Causes of ARF)
Prerenal uraemia = kidneys hold onto sodium to preserve volume
34
Papillary Necrosis - causes and features?
**_Causes_**
* Chronic analgesia use
* Sickle cell disease
* TB
* Acute pyelonephritis
* Diabetes Mellitus
**_Features_**
* Fever, loin pain, haematuria
* On urogram/pyelogram - papillary necrosis with renal scarring ('cup and spill')
35
RCC - location? Associations? Features? Management?
**_Location_**
* Most commonly proximal renal tubular epithelium
**_Associations_**
* Middle aged men
* Smoking
* Von-hippel-lindau syndrome
* Tuberous slcerosis
**_Features_**
* Classically - haematuria, loin pain, abdominal mass
* Pyrexia of unknown origin
* Left varicocele (occlusion of left testicular vein)
* Endocrine effects - secretion EPO (polycythaemia), PTH (hypercalcaemia), renin, ACTH
**_Management_**
* Radical nephrectomy
* a-interferon and IL-2 can reduce tumour size and treat mets
* Tyrosine kinase inhibitors (nibs)
36
Key features of HIV-associated nephropathy (HIVAN)?
1. Massive proteinuria
2. Normal or large kidneys
3. FSGN with focal or global capillary collapse on renal biopsy
4. Elevated urea and creatinine
5. Normotension
37
Renal Vascular DIsease - presentation, Ix, Mx?
**_Presentation_**
* HTN, CKD, flash pulmonar oedema
* U+Es worse on ACE
**_Ix_**
* MR angiography/CT angiography
**_Mx_**
* Balloon angioplasty
* Hypokalaemia and metabolic alkalosis due to compensatory hyperaldosteronism
38
Renal complications of SLE - WHO classification? Management?
**_Classification_**
* Class I: normal kidney
* Class II: mesangial glomerulonephritis
* Class III: focal (and segmental) proliferative glomerulonephritis
* Class IV: diffuse proliferative glomerulonephritis
* Class V: diffuse membranous glomerulonephritis
* Class VI: sclerosing glomerulonephritis
**_Management_**
* Treat HTN
* Steroids
* Immunosuppressants - azathioprine/cyclophosphamide
39
Goodpasture's - cause? Features? Investigations? Management?
**_Cause_**
* Type II hypersensitvity reaction
* Anti GBM antibodies against type IV collagen
* Goodpasture antigen - found in kidney and lungs
**_Features_**
* Bimodal distribution, HLA DR2
* Pulmonary haemorrhage, rapidly progressive glomerulonephritis
* Factors increasing likelihood of pulmonary haemorrhage - young male, smoking, LRTI, pulmonary oedema
**_Investigations_**
* Renal biopsy - linear IgG deposits along basement membrane
* Increased TCLO
* Lung biopsy - accumulation of hemosidren laden macrophages within alveoli
**_Management_**
* Plasma exchange
* Steroids
* Cyclophosphamide
40
Haemolytic uraemic syndrome: triad? causes? Ix? Mx?
**_Triad_**
* Acute renal failure
* Migroangiopathic haemolytic anaemia
* Thrombocytopenia
**_Causes_**
* Post-dysentery - E coli 0157:H7
* Tumours, pregnancy, cyclosporine, COCP, SLE, HIV
**_Ix_**
* FBC - anaemia, thrombocytopenia, fragmented blood film
* U+E - renal failure
* Stool culture
**_Mx_**
* Supportive management
* No abx
* Plasma exchange in severe cases with no diarrhoea
41
Phenylketonuria?
**_General_**
* Autosomal recessive
* Defect in phenylalanine hydroxylase - converts phenylalanine to tyrosine --\> high levels of phenylalanine --\> LD and seizures
* Chromosome 12
**_Features_**
* Developmental delay
* Fair hair, blue eyes
* LD, seizures, eczema
* Musty odour to urine and sweat
**_Diagnosis_**
* Guthrie test
* Hyperphenylalaninaemia
* Phenylpyruvic acid in urine
**_Mx_**
* Dietary restrictions in pregnancy. Poor evidence to suggest strict diet prevents LD.
42
Cystinuria?
**_General_**
* Autosomal recessive
* Formation of recurrent renal stones
* Defect in membrane transport of COLA (cystine, ornithine, lysine, arginine)
**_Features_**
* Recurrent renal stones - yellow and crystaline - semi-opaque on X ray
**_Dx_**
* Cyanide-nitroprusside test
**_Mx_**
* Hydration
* D-penicillamine
* Urinary alkalinization
43
Homocystinuria?
**_General_**
* Autosomal recessive
* Deficiency of cystathione b-synthase --\> accumulation of homocysteine
**_Features_**
* Fine, fair hair
* MSK - similar to Marfan's - arachnodactyly
* Neuro - LD, seizures
* Ocular - downwards discolouration of lens (opposite to Marfan's)
* Increased risk of arterial/venous thrombosis (not coronary)
* Malar flush, levido reticularis
**_Dx_**
* Cyanide nitroprusside test
**_Mx_**
* B6 supplements
44
Alkaptonuria?
**_General_**
* Autosomal recessive
* Phenylalanine and tyrosine metabolism disorder
* Defect in homogentisate 1,2-dioxygenase. Buildup of tyrosine byproduct (alkapton) accumulates, excreted in urine in large amounts --\> cartilage damage, valvular issues, kidney stones
* Common in Slovakia and Dominican republic
**_Features_**
* Pigmented sclera, darkened skin in sun-exposed areas and around sweat glands
* Low back pain, hip/shoulder pain --\> joint replacement
* Calcification of and regurg in aortic and mitral valves --\> replacement or CHD
* Ear wax exposed to air turns black or red after several hours
**_Tx_**
* Nitisinone - suppressed homogentisic acid production
45
Adverse effects of BPH treatment?
**_Alpha Blockers_**
* Dizziness, postural hypotension
* Dry mouth
* Depression
**_5 alpha-Reductase Inhibitors_**
(Block conversion of testosterone to DHT)
* Erectile dysfunction
* Reduced libido, ejaculation problems
* Gynaecomastia
46
Prostate Ca Mx?
**_Localised Disease (T1/T2)_**
* If life expectancy \<10 years - watchful waiting
* If life expectancy \>10 years - radical prostatectomy and radical radiotherapy
**_Locally Advanced Disease (T3/T4)_**
* Beyond prostatic capsule or involving bladder neck or rectum
* Radiotherapy
**_Disseminated Disease_**
* Synthetic GnRH agonist (Goserelin AKA Zoladex)
* Provides negative feedback to anterior pituitary
* Cover with anti-androgen to prevent rise in testosterone
* Anti-androgen (Cyporterone acetate)
* Prevents DHT binding from intracytoplasmic protein complexes
* Orchidectomy
47
Risk factors for bladder Ca?
* Smoking
* Occupational - aniline dyes used in printing/textiles/rubber industry
* Aromatic amines
* Radiation treatment to pelvis
* Schistosomiasis (S.hematobium infection)
* Mutations (17p13.1 --\> p53)
* Cyclophosphamide
