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Year 2 Revision > Renal Investigations and Management > Flashcards

Renal Investigations and Management Flashcards

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1
Q

Pre-renal AKI management

A

Assess for hydration:
Clinical observations (BP, HR, UO)
JVP, cap refill, oedema
Pulmonary oedema

Fluid challenge for hypocolaemia:
Crystalloid or colloid
Bolus of fluid, reassess and repeat as necessary
If >1L and no improvement seek help

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2
Q

Renal AKI investigations

A 
U&Es
FBC and coagulation screen (clotting? anaemia?)
Urinalysis (haemoproteinuria)
USS (obstruction? size?)
Immunology (ANA, ANCA, GBM)
Protein electrophoresis and BJP
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3
Q

Further management of AKI

A

Fluid resuscitate (if still not achieving adequate BP then inotropes/vasopressors)
Treat underlying cause (e.g. antibiotics for sepsis)
Stop nephrotoxics
Dialysis if remains anuric and uraemia

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4
Q

Post renal AKI investigations

A

USS

CT

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5
Q

Post-renal AKI

A

Relieve obstruction:
Catheter
Nephrostomy
Refer to urology if ureteric stenting is required

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6
Q

Hyperkalaemia management

A

Cardiac monitor and IV access
10mls 10% calcium gluconate (2-3 mins)
Insulin with 50mls 50% dextrose
Salbutamol nebs

Calcium resonium (prevents absorption, not in acute setting)

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7
Q

Urgent indications for haemodialysis

A

Hyperkalaemia (>7 or >6.5 unresponsive to medial therapy)
Severe acidosis (pH<7.15)
Fluid overload
Urea >40 or pericardial rub/effusion

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8
Q

Target blood pressures for CKD

A

140/90

130/90 if ACR of 70 or more or diabetes

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9
Q

Lipid lowering therapy in CKD

A

Atorvastatin 20mg

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10
Q

CV risk modification in CKD

A

Lifestyle advice
Control of hypertension
Other prophylaxis (lipid lowering therapy, consider aspirin for secondary prevention)

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11
Q

Managing mineral and bone disease in CKD - lifestyle advice

A 
Dietary advice (phosphate restriction)
Also consider need for salt, potassium, fluid and other dietary restrictions
Correct metabolic acidosis
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12
Q

Managing mineral and bone disease in CKD - medications

A 
Alfacalcidol (active vit D)
Phosphate binders (calcium based [adcal/phoslo/osvaren], aluminium [alucaps], non-calcium based [lanthanum, sevelamer])
Calcimimetic (calcinet)
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13
Q

Renal anaemia investigation

A

Exclude other causes of anaemia:
B12 and folate deficiency
Check ferritin and iron stores
Consider haematological causes

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14
Q

Renal anaemia management

A

Oral iron
IV iron
EPO injection if no iron or haematinic deficiencies (ESA therapy)

Mild anaemia is okay

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15
Q

Vascular access for dialysis steps (in order of efficacy)

A

Tunnelled venous catheter
Arteriovenous graft
Fistula

Can also get HeRO grafts

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16
Q

Starting haemodialysis management

A

Gradual build up (prevents disequilibrium syndrome from too-rapid correction of uraemic toxin levels)

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17
Q

Starting PD management

A

Training (3-6 weeks)
Build up fill volume size
Regular clinic and nurse follow up

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18
Q

Glomerulonephritis (GN) blood tests

A 
FBC
U&amp;E
LFT
CRP
Immunoglobulins
Electrophoresis
Complement
Autoantibodies
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19
Q

Glomerulonephritis investigations

A

Urinalysis (haemo/proteinuria)
Urine microscopy (RBC [dysmorphic], RBC and granular casts, lipiduria)
Urine protein/creatinine ratio/24 hours urine
Kidney biopsy

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20
Q

Nephritic syndrome findings

A 
Acute renal failure
Oliguria
Oedema/fluid retention
Hypertension
Active urinary sediment (RBCs, RBC and granular casts)
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21
Q

Nephrotic syndrome findings

A 
Proteinuria >3g/day
Hypoalbuminaemia
Oedema
Hypercholesterolaemia
Usually normal renal function
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22
Q

Histological GN investigations

A

Light microscopy
Immunofluorescence
Electron microscopy

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23
Q

Histological GN classification

A

Proliferative or non-proliferative
Focal/diffuse (< or >50% of glomeruli affected)
Global/segmental (all or part of glomerulus affected)
Crescenteric (epithelial extracapillary proliferation)

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24
Q

Non-immunosuppressive management of GN

A 
Anti-hypertensives (<120/75 if proteinuria)
ACEI/ARBs
Diuretics
Statins
Maybe anticoagulants
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25
Immunosuppressive management of GN
Drugs (corticosteroids, azathioprine, alkylating agents [cyclophosphamide/chlorambucil], calcineurin inhibitors, mycophenolate mofetil [MMF]) Plasmapheresis Antibodies (IV immunoglobulin, monoclonal antibodies)
26
Nephrotic syndrome management
``` Fluid/salt restriction Diuretics ACEI/ARBs Maybe anticoagulation IV albumin (only if volume deplete) Immunosuppression (induce remission - partial=<3g, complete=<300mg/day) ```
27
Minimal change nephropathy renal biopsy investigation
EM (foot process fusion)
28
Minimal change nephropathy management
Oral steroids | 2nd line cyclophosphamide
29
Focal segmental glomerulosclerosis renal biopsy investigation
``` Light microscopy (as name suggests) IF (minimal Ig/complement deposition) ```
30
FSGS management
Prolonged steroids (remission in 60%)
31
Membranous nephropathy renal biopsy findings
Subepithelial immune complex deposition in the basement membrane
32
Membranous nephropathy management
Steroids Alkylating agents (cyclophosphamide) B cell monoclonal antibody
33
IgA nephropathy renal biopsy findings
``` Light microscopy (mesangial cell proliferation and expansion) IF (IgA deposits in mesangium) ```
34
IgA nephropathy management
BP control ACEI/ARB Fish oil
35
Rapidly progressive glomerulonephritis management
Prompt with strong immunosuppression: Steroids Cytotoxics (cyclophosphamide/mycophenolate/azathioprine) Plasmapheresis
36
Kidney transplant assessment
``` Immunology Virology Assess cardiorespiratory risk Assess peripheral vessels/bladder function/mental state Assess co-morbidities ```
37
Contraindications to kidney transplant
``` Malignancy (inc solid tumour in last 2-5 years) Active HCV/HIV Untreated TB Severe IHD Severe airways disease Active vasculitis Severe PVD (unusable vessels) Hostile bladder ```
38
How do you desensitise a kidney recipient?
Active removal of blood group or donor specific antigen: Plasma exchange B-cell antibody (rituximab)
39
Immunosuppression during transplant operation
Prednisolone IV
40
Maintenance treatment after transplant operation
Prednisolone, tacrolimus, MMF | Prednisolone, ciclosporin, azathioprine
41
Anti-rejection treatments
``` Pulsed IV methyprednisolone Anti-thymocyte globulin IV Ig Plasma exchange Rituximab, bortezimab, eculizumab Immunosuppression intensification ```
42
Infection prophylaxis after transplant
Prophylaxis for PJP for first 3 months
43
Investigation for CMV disease after transplant
IgM and PCR
44
CMV disease management
Propylactic PO valganciclovir in higher risk patients | IV ganciclovir if evidence of infection
45
BK virus nephropathy management
No effective anti-viral therapy Treat by reducing immunotherapy Monitor blood viral load by PCR
46
Management of post-transplant lymphoproliferative disease (lymphoma, usually related to EBV infection)
Reduce immunosuppression Chemotherapy No role for antivirals
47
ADPKD investigations
USS (cysts, renal enlargement) CT/MRI (when unclear on USS) Genetic: linkage analysis, mutation analysis
48
ADPKD management
Rigorous control of hypertension Hydration Proteinuria reduction Cyst haemorrhage and infection management Tolvaptan (reduces cyst volume and progression) Renal failure: dialysis, transplant
49
What findings would suggest ARPKD?
Children Fibrotic liver cysts Cysts appearing from collecting duct system
50
Alports syndrome investigation
Haematuria and hearing loss | Renal biopsy - variable thickness GBM
51
Alports management
No specific treatment Standard aggressive treatment of BP and proteinuria Dialysis/transplantation
52
Anderson Fabry's disease investigations
PLasma/leukocyte alpha-galactosidase Renal bipsy (shows concentric lamellar inclusions within lysosomes) Skin biopsy
53
Anderson Fabrys disease management
``` Enzyme replacement (fabryzyme) Management of complications ```
54
Medullary cystic kidney investigation
Family history | CT
55
Medullary cystic kidney management
Renal transplant
56
Medullary sponge kidney investigation
Excretion urography (to demarcate calculi)
57
What are urinary casts formed from?
Precipitation of Tamm-Horsfall mucoprotein
58
What are the 4 types of urinary cast and what do they mean?
Hyaline (usually benign) Red cell (always pathological, nephritic syndrome) Leucocyte (infection/inflammation) Granular (chronic disease)
59
Myeloma investigations
``` Bloods (serum protein electrophoresis, serum free light chains) Urine bence jones protein Bone marrow biopsy Skeletal survey Renal biopsy ```
60
Myeloma management
``` Stop nephrotoxics Manage hypercalcaemia Chemotherapy Stem cell transplant Plasma exchange (to remove light chains) Supportive - dialysis ```
61
Amyloidosis renal investigation
``` Urinalysis and uPCR Blood tests (renal function, inflammatory markers, protein electrophoresis, SFLC) Renal biopsy (congo red staining, apple green under polarised light) ``` SAP scan shows extent of disease
62
AA amyloidosis management
Treat underlying condition Refer to UCL national amyloidosis centre
63
AL amyloidosis management
Immunosuppression (steroids, chemo, stem cell transplant) | Refer to UCL national amyloidosis centre
64
AAV affecting kidney investgiation
Urinalysis (blood and protein) Bloods (inflammatory markers, AKI, anaemia) Immunology (ANCA, MPO, PR3) Renal biopsy
65
AAV affecting kidney management
Immunosuppresion (steroids, cyclophosphamide, rituximab) Plasma exchange Supportive (dialysis, ventilation)
66
What is the name of the classification of lupus nephritis?
ISN classification
67
Describe the ISN classification of lupus nephritis
``` Class I: minimal mesangial Class II: mesangial proliferative Class III: focal proliferative Class IV: diffuse proliferative Class V: membranous Class VI: advanced sclerosing ```
68
Lupus nephritis management
Progressive immunosuppression increase as classes increase
69
UTI investigation
Mid stream specimen of urine
70
Cut offs for specific bacteriuria
>10^5= significant, probably UTI 10^4= contaminated maybe, need to repeat <10^3= not significant For women of child bearing age
71
Management of abacterial cysitis/urethral syndrome
Alkalinising the urine
72
Asymptomatic bacteriuria in pregnancy management
Antibiotics
73
Female lower UTI management
Nitrofurantoin or trimethoprim (3 days)
74
Uncatheterised male UTI management
Nitrofurantoin or trimethoprim (7 days)
75
Complicated UTI or pylonephritis (GP) management
Co-amoxiclav or co-trimoxazole (14 days)
76
Complicated UTI or pyelonephritis (hospital) management
Amoxicillin and gentamicin IV (3 days) Co-trim and gent if pen allergic Co-trim step down

Year 2 Revision (45 decks)

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