Renal 9.5 Flashcards
(85 cards)
1
Q
HIV can lead to what cause of nephrotic syndrome?
A
FSGS
2
Q
Nephrotic syndrome that presents in young adults that has a high occurrence rate in renal Tx?
A
FSGS
3
Q
Causes of FSGS?
A
idiopathic 2ry to other renal pathology e.g. IgA nephropathy, reflux HIV heroin Alport's sickle-cell
4
Q
Chronic analgesia use causes what type of kidney disease?
A
Tubulo-interstitial nephritis & papillary necrosis
- sloughing of papillae can result un urinary tract obstruction ->AoCKI
- can have a salt-losing nephropathy
- eg clubbed calyces & ring signs on IV urogram
5
Q
Papillary necrosis
- causes?
- features?
A
- chronic analgesia
- sickle cell
- TB
- acute pyelonephritis
- DM
- fever, loin pain, haematuria
- IV urogram: ‘cup & spill’ papillary necrosis with renal scarring
6
Q
Diabetic nephropathy
- Ix?
- Rx?
A
- urinary ACR annually - early morning specimen
- if ACR >2.5 then microalbuminuria
- restrict dietary protein, tight glycaemic control, aim BP <130/80, control dyslipidaemia
- ACE-I is reno-protective (a decrease in eGFR up to 25% or a rise in Cr up to 30% is acceptable)
7
Q
Causes of UL hydronephrosis?
PACT
A
Pelvic-ureteric obstruction (congenital/acquired)
Aberrant renal vessels
Calculi
Tumours of renal pelvis
8
Q
Causes of BL hydronephrosis?
SUPER
A
Stenosis of urethra Urethral valve Prostatic enlargement Extensive bladder tumour Retroperitoneal fibrosis
9
Q
Ix of hydronephrosis:
1st line?
to assess position of obstruction?
to allow Rx?
A
- 1st US KUB
- IV urogram assesses position of obstruction
- anterograde/retrograde Pyelography allows Rx
- CT if suspected renal colic
10
Q
Rx of hydronephrosis?
if acute
if chronic
A
- remove obstruction & drain urine
- acute upper: nephrostomy
- chronic upper: ureteric stent or pyeloplasty
11
Q
2 types of peritoneal dialysis?
A
CAPD: continuous ambulatory PD - each exchange lasts 30-40mins, each dwell time lasts 4-8h
APD: automated PD - dialysis machine fills & drains abdomen while pt is sleeping, performing 3-5 exchanges over 8-10h each night
12
Q
Renal Tx - where are the renal donor vessels connected to?
A
Connected to external iliac vessels
13
Q
Complications of peritoneal dialysis?
A
- peritonitis, sclerosing peritonitis
- catheter infection/blockage
- constipation, fluid retention
- hernias, back pain
- malnutrition, hyperglycaemia
14
Q
Complications of haemodialysis?
A
- site infection/stenosis
- endocarditis
- hypotension, cardiac arrhythmia, air embolus
- anaphylaxis reaction to sterilising agents
- disequilibration syndrome
15
Q
Complications of renal Tx?
A
- opportunistic infection, BM suppression, malignancy esp lymphoma/skin cancer
- DVT/PE
- urinary tract obstruction
- CVD
- recurrence in graft
- graft rejection
16
Q
Average life expectance of a pt with renal failure that doesn’t receive RRT is 6months.
What are the Sx not being adequately managed with RRT ?
A
- SOB, fatigue
- insomnia, anxiety, depression
- weakness, poor apposite, swelling, weight gain/loss
- nausea, abdo cramps, muscle cramps, headaches, cognitive impairment
- sexual dysfunction
17
Q
HLA = MHC in humans on chr 6
- what are the class 1 & 2 Ag?
- what is the important when matching for a renal Tx?
A
class 1 = A, B, C class 2 = DP, DQ, DR
DR > B > A
18
Q
Post-op problems in renal Tx?
A
ATN of graft
vascular thrombosis
urine leakage
UTI
19
Q
Hyperacute rejection of renal Tx?
A
- due to pre-existing Ab againts donor HLA type 1 Ag (type II hypersens)
- mins-hours
- rare due to HLA matching
20
Q
Acute graft failure of renal Tx?
A
- due to mismatched HLA (cell-mediated by cytotoxic T cells)
- or CMV infection
- within 6months
- may be reversible with steroids & immunosuppressants
21
Q
causes of chronic graft failure with renal Tx?
A
- Ab & cell-mediated mechanisms cause fibrosis to Tx kidney (chronic allograft nephropathy)
- recurrence of original disease: MCGN > IgA > FSGS
22
Q
Which diseases tend to recur in kidney Tx graft?
A
MCGN > IgA > FSGS
23
Q
Rhabdomyolysis
- causes?
- features?
- Rx?
A
- seizure, collapse, coma
- ecstasy
- crush injury
- McArdle’s syndrome
- drugs: statins esp if co-Px with clarithromycin
- AKI with disproportionately raised Cr
- high CK
- myoglobinuria
- low Ca2+ (myoglobin binds Ca2+)
- high phosphate (released from myocytes_
- high K (may develop before renal failure)
- metabolic acidosis
- IV fluids, maintain good urine output
- sometimes urinary alkalinisation
24
Q
Tests for determining a patient’s iron status and thus response to treatment in CKD?
A
- %hypochromic red cells (analysis within 6h) - >6% indicates iron deficiency
- reticulocyte Hb <29 is Dx of IDA
- combo of transferrin sat <20% & ferritin <100
(keep ferritin <800, change iron dose if >500)
25
When does anaemia in CKD become apparent?
Causes?
What does it predispose to?
Rx?
- eGFR <35
- predisposes to LV hypertrophy -> 3X inc risk in mortality
- reduced EPO biggest factor
- reduced erythropoiesis due to toxic effects of uraemia on BM
- reduced iron absorption
- anorexia/nausea due to uraemia
- reduced red cell survival esp in HD
- blood loss due to capillary fragility & poor platelet function
- stress ulceration -> chronic blood loss
- target Hb 10-12
- determine & optimise iron status before starting an ESA: erythropoiesis-stimulating agent (many will require IV iron)
- EPO/Darbepoetin should be used in those who are likely to benefit in terms of QoL & physical function
26
Alport's syndrome = inherited X-linked dominant defect in gene shich codes for type IV collagen -> abnormal GBM
- more severe in males (ESRF)
- usually presents in childhood
- features?
renal: microscopic haematuria, progressive renal failure
eye: retinitis pigments, lenticonus: protrusion of lens surface into anterior chamber
ear: BL SNHL
renal Bx: SPLITTING of lamina densa seen on EM
27
Alport's syndrome pt receives a renal Tx. It startsto fail. What is the Dx?
Goodpasture's syndrome due to presence of anti-GBM Ab
| - immune response to the type IV collagen in the Tx kidneys
28
ADPKD features?
| extra-renal manifestations?
- HTN
- rec UTIs, renal stones, abdo pain, haematuria
- CKD
- liver cysts 70%
- berry aneurysms 8% can rupture -> SAH
- CVS: MVP, mitral/tricuspid incompetence, aortic root dilation, aortic dissection
- other cysts: pancreas spleen
29
Potential complications of AV fistulas?
infection
thrombosis
stenosis
steal syndrome
30
Prevention of stones due to hypercalciuria e.g. calcium phosphate?
Thiazide
| high fluid intake, low animal protein, low salt diet
31
Drug useful in prevention of calcium oxalate stones?
Potassium citrate
Cholestyramine
Pyridoxine
32
Drug useful in prevention of uric acid stones?
Allopurinol
| oral bicarb
33
Dx Ix for renal stone?
Non-contrast CT KUB within 14h
| - immediate if fever, solitary kidney or when Dx uncertain - to exclude other Dx
34
Rx for ureteric obstruction 2ry to a stone, WITH infection?
Emergency decompressive surgery
- nephrostomy tube
- ureteric catheter insertion
- ureteric stent
35
Shockwave lithotripsy for renal stone
- risk?
- when is it used?
- shock waves can cause solid organ injury
- fragmentation of larger stones can cause obstruction
- uncomfortable for pt
- stone burden <2cm
36
retrograde Ureteroscopy for renal stone
| - when is it used?
- retrograde through ureter into renal pelvis
- indicated when lithotripsy C/I e.g. pregnancy or complex stone disease
- usually stent left in situ 4wks post-procedure
- i.e. stone burden <2cm
37
Percutaneous nephrolithotomy for renal stone Rx
- how?
- when is it used?
- access to renal collecting system, then intra-corporeal lithotripsy/stone fragmentation & stone fragments removed
- complex renal stones or stag horn
38
Rfs for contrast media toxicity?
| Definition?
25% increase in Cr occurring within 3 days of intravascular administration of contrast media
- known renal impairment esp diabetic nephropathy
- age >70
- dehydration
- cardiac failure
- nephrotoxics eg NSAIDs
- prevention: IV 0.9% NaCl at 1 mL/kg/h for 12h pre- & post- procedure
39
Renal Stones formed from triple Mg, ammonium & phos
- Urease-producing bacteria (therefore ass with chronic infections) e.g. proteus, klebsiella, mycoplasma
- pH >7.2 alkaline conditions, the crystals can precipitate
- Slightly radio-opaque
Struvite
pH >7.2
hypercalcamia is a RF
F>M
40
85% of renal stones
- hypercalciuria major RF, also hyperoxaluria & hypocitraturia
- radio-opaque stones
Calcium oxalate
41
10% of renal stones that may occur in RTA 1
- high urinary pH increases supersaturation of urine
- radio-opaque
Calcium phosphate
42
1% of renal stones inherited recessive disorder of transmembrane cystine transport
- decreased cystine absorption from bowel & renal tubule
- multiple stones may form
- relatively radio dense (contain sulfur)
Cystine
43
5-10% of renal stones that may precipitate when urinary pH low
- can be caused by diseases of extensive tissue breakdown e.g. malignancy - product of purine metabolism
- more common in children with inborn errors of metabolism
- radiolucent
Uric acid
44
Urinary pH in helping determine renal stone type
Urine pH 5-7 - falls post-prandially as purine metabolism produces uric acid - then alkaline tide
```
pH 5.5 acid - uric acid
pH >5.5 in normal/alkaline calcium phosphate
pH 6 variable calcium oxalate
pH 6.5 normal cystine
pH >7.2 alkaline struvate
```
45
Retroperitoneal fibrosis
- commonest PC?
- associations?
- lower back/flank pain
- also fever & LL oedema
- Riedel's thyroiditus
- previous RT
- sarcoid
- inflammatory AAA
- drugs e.g. methysergide, bromocriptine
46
Absolute C/I to being an LRD kidney donor?
- uncontrolled BP/on 3 anti-hypertensives (nephrectomy can exacerbate HTN)
- active cancer
- chronic infection
- over proteinuria
- BL renal artery atherosclerosis
- sickle cell disease
47
ADPKD type 1 85%
- which chr
- difference with ADPKD type 2
chr 16
presents with renal failure earlier
(type 2 chr 4)
48
US Abdo Dx criteria on screening family for ADPKD?
- 2 cysts UL/BL age <30
- 2cysts in both aged 30-59
- 4 cysts in both aged >60
49
Rx of ADPKD?
TOLVAPTAN can slow progression of cyst development & renal insufficiency if:
- CKD stage 2/3 at the start
- evidence of rapidly progressing disease
- discount for pt
50
Renal involvement in HIV?
- Rx or virus itself
- PIs eg INDINAVIR can precipitate intratubular crystal obstruction - ie crystalise in urine and cause renal stones - microscopy shows needle-shaped crystals
51
HIVAN: HIV ass nephropathy
- 5 features?
- Rx?
- raised Ur & Cr
- massive proteinuria -> nephrotic
- normal/large kidneys
- FSGS with focal/global capillary collapse on renal Bx
- normotension
Antiretrovirals can alter course of disease
52
Pt with HIV: a collapsing FSGS and presents with nephrotic syndrome
HIVAN
53
Pt with HIV presents with nephritic syndrome
HIV-associated immune complex kidney disease (HIVICK)
54
HIV on Rx: develops acute tubular necrosis / Falcon syndrome - cause?
Tenofovir
55
mesangiocapillary glomerulonephritis = membranoproliferative GN
- how does it present?
```
nephrotic
haematuria
or proteinuria
poor prognosis
rx = steroids may help
```
56
Type 1 mesangiocapillary glomerulonephritis = membranoproliferative GN?
90%
- cryoglobulinaemia, hepatitis C
- sub endothelial immune deposits of electron dense material - tram-track
57
Type 2 mesangiocapillary glomerulonephritis = membranoproliferative GN?
dense deposit disease
- reduced complement
- C3b nephritic factor in 70%
- partial lipodystrophy, factor H deficiency
58
Type 3 mesangiocapillary glomerulonephritis = membranoproliferative GN causes?
hepatitis B &C
59
Pre-Renal Uraemia: kidneys hold on to sodium to preserve volume
- what is in the urine?
- bland sediment
- specific gravity >1020
- urine:plasma urea >10:1
urine: plasma osmolality >1.5
- fractional urea excretion <35%
- fractional sodium excretion <1%
- urine sodium <20
60
Acute tubular necrosis
- does it respond to fluid challenge?
- what is in the urine?
- No
- urine sodium >30
- fractional sodium excretion >1%
- fractional urea excretion >35%
- urine:plasma osmolality <1.1
- urine:plasma urea <8.1
- SG <1010
- urine BROWN GRANULAR CASTS
61
Goodpasture's syndrome: pulmonary haemorrhage & rapidly progressive glomerulonephritis
- anti-GBM against type IV collagen
- ass with HLA DR2
- factors increasing likelihood of pulmonary haemorrhage?
- Ix?
- Rx?
- smoking, LRTI, pulmonary oedema, inhalation of hydrocarbons, young males
- real Bx: linear IgG deposits along BM
- raised transfer factor 2ry to pulmonary haemorrhages
- Rx = plasma exchange/plasmapheresis; steroids, cyclophosphamide
62
post-transplant lymphoproliferative disorder
- clonal populations of T/B cells in significant lymphoid disruption of renal architecture
- EBV Ag with Ig light chain expression
63
Declining renal function in myeloma - what stain on renal Bx for an ass complication?
Congo red
| - 2ry amyloid AL
64
AL myloid = 2ry = commonest
- Ig light chain
- causes?
- features?
myeloma, MGUS, Waldenstrom's
| - nephrotic syndrome, cardiac & neuro involvement, macroglossia, periorbital eccymoses
65
AA amyloid = 1ry = serum amyloid A acute phase reactant protein
- cause?
- features?
- chronic infection/inflammation eg TB, RA, bronchiectasis
| - fenal involvement commonest feature
66
Beta-2 microglobulin amyloidosis
| - association?
- pts on renal dialysis
| - precursor protein is beta-2 microglobulin, part of MHC
67
causes of cranial diabetes insipidus?
```
idiopathic, post-head injury
pituitary surgery
craniopharyngiomas
histiocytosis X
DIDMOAD
```
68
Causes of nephrogenic DI?
genetic (ADH receptor)
high Ca, low K
demeclocycline, lithium
tubulo-interstitial disease: obstruction, sickle cell, pyelonephritis
69
Ix of diabetes insipidus?
- high plasma osmolality, low urine osmolality
- urine osmolality >700
- water deprivation test
70
Post-strep GN day7-14 after
- caused by immune complex deposition in glomeruli
- clinical features?
- renal Bx features?
- headache, malaise, haematuria, proteinuria, HTN, low C3, raised ASO titre
71
Ix for renal vascular disease?
| causes?
young: fibromuscular dysplasia - string of beads on angiography - pts respond well to balloon angioplasty
otherwise commonly atherosclerosis - can present as HTN, CKD, flash pulmonary oedema
Ix = MR angiography
(CT angio or renal agio may help plan surgery)
72
Rx of diabetes insipidus?
Thiazide diuretic or NSAIDs
- Diuretics act to induce hypovolaemia leading to a subsequent increase in proximal Na & water reabsorption, thereby diminishing the water delivery to the ADH sensitive sites in the collecting tubules, and reducing the urine output.
73
Complications of nephrotic syndrome
- inc risk infection due to urine Ig loss
- inc risk thromboembolism (antithrombin III & plasminogen in urine) - can cause renal vein thrombosis i.e. sudden deterioration in renal function
- hyperlipidaemia
- hypocalcaemia
- acute renal failure
74
Triad of haemolytic uraemia syndrome?
Typical HUS?
atypical/1ry?
acute renal failure
MAHA
thrombocytopenia
Typical:
- E. coli 90%, pneumococcal, HIV, SLE, drugs, cancer
1ry = atypical = due to complement dysregulation
Ix: anaemia, low platelets, fragmented blood film, AKI, do stool culture
Rx = supportive
- plasma exchange if severe and not ass with diarrhoea
- ECULIZUMAB = C5 inhibitor mAb better than plasma exchange in adult ATYPICAL HUS
75
```
Membranous GN = commonest type of GN in adults - usually presents with nephrotic syndrome & proteinuria
Renal Bx?
Causes?
Prognosis?
good prognostic features?
Rx?
```
- EM: thickened basement membrane with sub epithelial electron dense deposits -> Spike & dome appearance
- idiopathic anti-phospholipase A2 Ab
- hep B, malaria, syphilis
- lung ca, lymphoma, leukaemia
- gold, penicillamine, NSAIDs
- SLE class V, thyroiditis, rheumatoid
- 1/3 spontaneous remission, 1/3 remain proteinuric, 1/3 ESRF
- good Px features: female, young, aSx proteinuria
Rx:
- immunosuppressants steroid + other
- control BP
- consider anticoagulation
76
Normal anion gap acidosis causes?
```
GI loss
RTA
acetazolamide
ammonium Cl injection
Addisons
```
77
Causes of polyuria?
common - diuretics, caffeine, ETOH, DM, lithium, heart failure
infrequent - high Ca, hyperthyroid
rare - CKD, 1ry polydipsia, low K
v rare - diabetes insipidus
78
Fanconi syndrome = generalised disorder of renal tubular transport in pct
- what does it lead to?
- what are the causes?
- T2 proximal RTA
- polyuria
- aminoaciduria
- glycosuria
- phosphaturia
- osteomalacia
- cystinosis
- Sjogren's
- myeloma
- nephrotic syndrome
- WIlson's disease
79
Cystinuria = rec stones that present in first decades of life
Dx?
sodium nitroprusside test
| can be +ve with generalised aminoaciduria
80
```
Minimal change disease - nephrotic syndrome
Causes?
Pathphys?
Features?
Rx?
```
- majority idiopathic
- also NSAIDs, rifampicin, Hodgkin's lymphoma, thymoma, infectious mononucleosis
- Tcell & cytokine mediated damage to glomerular BM -> pollination loss -> reduction of electrostatic charge -> increased glomerular permeability to serum albumin
- nephrotic syndrome, normotension, highly selective proteinuria
- EM shows fusion of podocytes on renal Bx
- 80% steroid-responsive
- next step is cyclophosphamide
81
Factors favouring organic cause of erectile dysfunction?
- gradual onset of Sx
- lack of tumescence
- normal libido
82
Factors favouring psychogenic cause of erectile dysfunction?
- sudden onset Sx, decreased libido
- good quality spontaneous/self-timulated erections
- major life event, problems in relationship/change, prev psych problems
- Hx of prem ejaculation
83
RFs for ED?
CVD RFs
ETOH
SSRIs, beta-blockers
84
Ix & Rx for ED?
- CV risk lipids, glucose
- 9-11am free testosterone, if low/borderline then repeat with FSH, LH & PRL
- PDE-5 inhibitor in absence of C/I
- vacuum erection device
85
Testosterone replacement in deficiency?
If elevated PSA, male breast ca, prostate ca, severe sleep apnoea or severe LUTS then cannot have testosterone
