Renal

Question 1

Type 1 and 2 hepatorenal syndromes and Hx associations

Answer 1

Type I is acute and rapid decline over couple of weeks if that, poor prognosis. Follows acute event like upper GI bleed.

Type II is a slower gradual decline in renal function, often associated with refractory ascites.

Question 2

Mx of hepatorenal syndromes

Answer 2

Vasopressin analogies like terlipressin, cause vasoconstriction to the splanchnic circulation.

Question 3

Presentation of salicylate (aspirin) poisoning

Answer 3

Nausea, vom, headache, tinnitus

Question 4

What overdose does naloxone treat?

Answer 4

Opioid overdose

Question 5

Blood gas pattern for aspirin poisoning + mx

Answer 5

Initially hyperventilate and get respiratory alk- charcoal.
After 24 hours if severe, develop metabolic acidosis with raised anion gap- IV sodium bicarb.
Minor OD- supportive mx

Question 6

Side effect of lithium on kidneys

Answer 6

Nephrogenic D.Insipidus (insensitivity to ADH). Develop polyuria, polydipsia and high-normal Na.

Question 7

What is an acceptable fall in GFR and rise in creatinine in CKD patients being treated with ACE i’s?

Answer 7

Decrease in GFR up to 25%
Rise in creatinine up to 30%
These changes can be expected due to the drugs causing a small decrease in filtration pressure.

Question 8

Pathology and complications of CKD

Answer 8

1) Low Vit.D- hydroxylation step occurs in kidneys usually. So get low Ca due to low vit.D and raised phosphate.
2) Raised phosphate- kidneys usually excrete phosphate. The raised phosphate drags Ca from bones = osteomalacia.
3) Secondary hyperparathyroidism (low Ca, Vit D and raised phosphate)

Question 9

Mx of mineral bone disease in CKD

Answer 9

Aim: reduce PTH and phosphate
Reduced dietary intake of PO4 = first line
Phosphate binders.
Vit D (calcitriol, alfacalcidol)

Question 10

How do you diagnose CKD?

Answer 10

Stages 1-2: GFR + supporting evidence (albuminuria on A:Cr, imaging or histological abnormalities)

Stages 3-5: GFR alone = sufficient.

Question 11

What syndrome does minimal change glomerulonephritis cause?

Answer 11

Nephrotic syndrome

Question 12

Cause and mx of minimal change disease

Answer 12

Majority = idiopathic.
Mx = pred (renal biopsy if unresponsive)

Question 13

Why does anaemia occur in CKD?

Answer 13

Reduced EPO level, toxic effects of uraemia on bone marrow caused reduced erythropoeisis.
Reduced absorption of iron.

Question 14

Type of anaemia and mx in CKD

Answer 14

Normocytic, normochromic anaemia. Usually occurs when GFR < 30.

Mx: iron studies then EPO if likely to benefit.

Question 15

Complication of anaemia in CKD

Answer 15

LVH

Question 16

Tx and mechanisms for hyperkalaemia

Answer 16

Initially IV calcium gluconate: stabilises cardiac membrane
Insulin/dextrose infusion: ST shifts K from extracellular to intracellular compartment.
Calcium resonium: excretion of K. Most effective as enema.

Question 17

How does nephrotic syndrome predispose to thromboses?

Answer 17

Loss of antithrombin-III, proteins C and S.

Associated rise in fibrinogen.

Question 18

Triad of nephrotic syndrome

Answer 18

Proteinuria
Hypoalbuminia
Oedema

Question 19

When should you not give Haartmann’s?

Answer 19

Any patient with hyperkalaemia

E.g. in the context of AKI

Question 20

Fluid resus

Answer 20

500ml bolus of crystalloid over 15 mins.

Question 21

What is the risk of using large volumes of 0.9% saline?

Answer 21

Hyperchloraemic metabolic acidosis

Question 22

What do you need to consider when prescribing fluids in heart failure?

Answer 22

Too much fluid will precipitate pulmonary oedema.

Question 23

How do you calculate anion gap?

Answer 23

Na - (Cl + HCO3).
Normal = 10-18
High anion gap occurs if excessive H accumulation or impaired H excretion.

Question 24

Why does raised anion gap occur?

Answer 24

Anything that raises lactate, ketones, urea (renal failure). Salicylate poisoning.

Question 25

2 causes of Diabetes Insipidus

Answer 25

1) Cranial DI: deficiency of ADH

2) Nephrogenic DI: insensitivity to ADH

Question 26

Mx for 2 types of DI

Answer 26

Cranial: synthetic vasopressin = desmopressin.
Renal: Chlorothiazide- thiazide diuretic causes more sodium to be released into the urine. Breaks polydipsia poyluria cycle.

Question 27

When does haemolytic uraemic syndrome usually occur?

Answer 27

Following exposure to toxin. E.g. after infective diarrhoea like GE.

Question 28

Features of HUS in investigations

Answer 28

Normocytic anaemia, thrombocytopenia and AKI following diarrhoeal illness.

Inv: FBC, Us and Es, stool culture (usually E.coli)

Question 29

Presentation of HUS with mx

Answer 29

Fatigue, pale, petechiae.

Supportive mx.

Question 30

Triad for Alport’s syndrome

Answer 30

Sensorineural hearing loss
Renal failure
Ocular abnormalities

Suspect in children.

Question 31

Signs of overload

Answer 31

Crackles
Ascites
Tachpynoea
Oliguria

Question 32

Typical presentation of IgA nephropathy

Answer 32

Macroscopic haematuria only, in young boys 1-2 DAYS after an URTI.

Question 33

Typical presentation of post-streptococcal glomerulonephritis

Answer 33

Haematuria, proteinuria and low complement 1-2 WEEKS after an URTI.
Haematuria can occur but proteinuria is the main sx.

Question 34

A patient with CKD develops a raised A:Cr. What drug should be started?

Answer 34

ACE-inhibitor

Question 35

Renal US findings for CKD

Answer 35

bilateral shrunken kidneys

Question 36

Renal US findings for chronic diabetic nephropathy

Answer 36

normal/large kidneys

Question 37

How do you calculate routine IV maintenance fluids for kids/young people?

Answer 37

Holliday-segal formula
First 10kg = 100ml per kg
Second 10kg = 50ml per kg
Subsequent kg = 20ml per kg

Above equation is sufficient if no underlying disease, otherwise more accurate calculation required.

Question 38

Most common viral infection following solid organ transplant + mx

Answer 38

CMV

Ganciclovir

Question 39

Post op problems following renal transplant

Answer 39

ATN
Vascular thrombosis
Urine leakage
UTI

Question 40

What’s the recommended K requirement when prescribing fluids?

Answer 40

1mmol/kg/day