Renal Learning Points CSV Flashcards
(125 cards)
1
Q
Renal differences in the neonate (6)
A
(1) nephron number multiplies until 36/40 (increased risk hypertension in preterm)
(2) decreased GFR in preterm
(3) oliguria then polyuria (K wasting in polyuric phase)
(4) ADH increases at birth and can be very high in HIE
(5) renal wasting of bicarb - can be acidotic
(6) renal wasting Calcium
2
Q
what are nephropathies have low C3
A
5 S’s: 1. post Strep, 2. MeSangioProliferative/Membranous GN, 3. SLE, 4 Septic (SBE, HBV, HCV) 5. Shunt nephritis
3
Q
Normal complement nephropathies
A
4 A’s and H: 1. Alport 2. Anti-GBM (Goodpastures) 3. IgA, 4. ANCA associated (Wegeners) & HSP
4
Q
When will children with HSP develop nephritis by?
A
by 6-8 weeks but need to be monitored for 6 months
5
Q
renal biopsy indications
A
nephritic/nephrotic at presentation,
persistently impaired/deteriorating renal function,
C3 low at 3 months
6
Q
IgA nephropathy characteristics
A
Not inherited
gross haematuria with illness, recurrent,
flank pain,
persistent microscopic haematuria
benign in childhood but HTN in adult - treat with ACEi
7
Q
Alport syndrome characteristics
A
hearing loss (age 10),
EYE abnormalities (macular flecks)
recurrent gross haematuria post viral ilness persistent microscopic haematuria,
ESRD late teens
8
Q
With nephropathies are rapidly progressive?
A
crescents >50% glomeruli ANCA associated (pauciimmune) Anti-GBM (Goodpastures - pulm-renal syndrome) SLE (systemic symptoms) Membranoproliferative (low complement) HSP (IgA)
9
Q
Definition nephrotic syndrome & most common cause
A
Oedema,
Proteinuria (uPCR >200, 3+ protein),
Low Alb <25 .
Most common cause = minimal change disease
10
Q
what explains oedema in minimal change disease
A
reduced oncotic pressure and increased sodium reabsorption
11
Q
Complications of nephrotic syndrome
A
hypothyroidism, rickets, thrombosis, short stature, anaemia
12
Q
best way to calculate GFR in clinical setting
A
plasma disappearance of radio-isotope
**inulin gold standard but only in research setting
13
Q
when does GFR reach adult values
A
age 2
14
Q
Triad of HUS
A
Thrombocytopenia,
Haemolytic anaemia,
Acute kidney injury
15
Q
Typical HUS - causes
A
diarrhoea related - E.Coli 0157:H7 - verotoxin/shiga toxin
Shigella – shiga toxin
16
Q
HUS Atypical causes
A
Pneumococcal
*Complement (C3, CD46, factor B, H inhibitors) , *ADAMTS13,
Cobalamin deficiency
*lead to activation of alternative complement
17
Q
what does ADAMTS13 do
A
acts to cleave vWF multimers and prevent thrombus formation
18
Q
Long term sequelae HUS
A
“Microangiopathy” diabetes,
Hypertension,
Proteinuria
CKD
19
Q
What is the most predictive risk factor for long term sequelae in HUS
A
duration anuria >10 days,
prolonged dialysis >7 days
20
Q
Duration follow-up of HUS? ** need to know
A
at least 5 years as long term sequelae can occur up to 5 years post apparent recovery
21
Q
Clues to chronic glomerular causes to CKD
A
Oligouria,
Haematuria/proteinuria,
Hypertension
22
Q
Clues to tubular disease for CKD
A
Polyuria, Polydipsia
Sodium loss,
Enuresis
23
Q
Progression of CKD can be slowed by?
A
Control HTN,
Control proteinuria,
Treatment anaemia,
Treatment hyperlipidaemia
24
Q
Complications CKD
A
- Growth failure
- Osteopenia
- Anaemia,
- Acidosis (impairs GH release),
- Water and electrolyte imbalance,
- Delayed puberty,
- Social and cognitive.
25
What are the bacteria in bacterial peritonitis in a child with PD? Antibiotics?
Treat if WBC >50 and symptomatic or WBC >100
Bacteria = staph epi, staph aureus
Antibiotics = Cefazolin, ceftazidime OR vancomycin & ciprofloxacin
26
Causes of PD peritonitis
1. Intraluminal (touch contamination),
2. Periluminal (tunnel infections),
3. Intestinal translocation
4. Systemic,
5 Ascending (rare)
27
Benefits transplant over dialysis
1. Mortality,
2. CVD,
3. Growth,
4. Neurodevelopment,
5. QOL
28
Absolute contraindications to renal transplant
1. active malignancy,
2. severe neurological dysfunction,
3. terminal illness / multiorgan failure,
4. psychiatric illness impairing consent
29
6 causes of allograft dysfunction
1. Dehydration,
2. Medication
3. Infection,
4. Obstruction
5. Rejection (biopsy)
6. Perfusion problem
30
Hypertension Treatment post renal transplant
Ca channel blockers (early),
Diuretics (if hypervolaemic)
ACEi once 2-3 months post t/p
31
Tacrolimus SE
```
nephrotoxicity,
HTN,
hepatic dysfunction,
glucose intolerance,
hyperkalaemia, hypomagnesaemia,
alopecia
```
32
Tacrolimus mechanism of action
calcineurin inhibitor > inhibits nuclear activation
33
Cyclosporin SE
neprotoxicity, HTN, gigival hyperplasia, hirsutism, hyperuricaemia, hypercholestoraemia
34
Pulmonary renal syndrome causes
```
[Pneumonic AA STD] -
Anti-GBM,
ANCA,
SLE,
Thrombotic disease (antiphospholipid, TTP, HSP),
Drugs
```
35
RIFLE criteria
```
For renal insult -
Risk dysfunction (Crx1.5),
Injury (Crx2),
Failure (Crx3),
Loss (>4weeks),
ESKD (>3months)
```
36
Causes hypochloraemic metabolic acidosis
```
pyloric stenosis,
prolonged vomiting,
diuretics,
Bartter,
CF,
Choride diarrhoea
```
37
RTA type 1
```
DISTAL, can’t excrete acid,
hypercalciuria (stones),
urine is alkaline (ph >5.5)
loin pain
Low K
CAUSES: obstructive uropathy, marfan, wilsons, drugs (amphotericin)
```
38
RTA type 2
PROXIMAL, can’t resorb bicarb, hypercalcaemia / low calcium in urine
acidic urine (pH <5.5)
Low K
CAUSES: cystinosis, fanconi
39
Fanconi
```
ALL of proximal tubule
short child no growth and vomiting.
Renal >GI losses
occurs at time that transitions from breast milk to cows milk ~6 months age
- hypophosphataemic ricketts
- amino acid uria, glycosuria,
- normal glucose in plasma
```
40
RTA type 4
normal urine anion gap,
hyper aldosteronism
High K, Low Na
CAUSES: CAH, tacro, NSAIDS, tubular aldosterone def
41
Bartter Syndrome
```
Na/K/2Cl Channel defect in LOH -
hypochloraemic hypokalaemic metabolic alkalosis
Hypercalciruia, hyperchloride uria
Prone to hypernatraemic dehydration
Manage with NSAIDS > slow GFR
```
42
Gitelman syndrome
NaCl defect in distal tubule
hyPOcalciuria
present later in childhood with cramps - LOW Mg
43
metabolic alkalosis with volume contraction (normal/low BP)
```
ABCD -
Anorexic (vomiting/laxatives),
Bartter,
CF,
Diuretics.
```
44
metabolic alkalosis with volume expansion (high BP)
Anything that activates RAAS:
- Aldosteronism,
- Renal artery stenosis,
- Renin producing tumour,
- Adrenal carcinoma,
45
what level are the kidneys? Which kidney is larger? How much size discrepancy is normal?
Level T12-L3,
Left larger than Right,
10% difference in size is normal.
46
What percentage of cardiac output reaches kidneys?
20-30%
47
what part of the LOH is high permeable to water?
(thin Loop of Henle) highly permeable to water;
48
Glomerular basement membrane structure
Capillary > endothelium > Basement membrane > podocyte
49
3 Factors affecting filtration through basement membrane
(1) Size <3nm
(2) charge negative (repels albumin),
(3) protein binding
50
When does GFR reach adult levels?
2 years of age
51
3 activators of renin-angiotensin system
Sympathetic nervous system;
hypotension / low RBF,
Oedema
52
6 suppressors of renin-angiotensin
```
Angiotensin 2;
ADH;
Hypernatraemia/Hyperkalaemia;
NSAIDs;
Betablockers;
ACEi
```
53
Renin-angiotensin system
renin (kidneys) converts angiotensinogen (liver) to angiotensin 1 which is then converted to angiotensin 2 (via ACE from lungs).
54
6 Actions angiotensin 2
(1) systemic vasoconstriction
(2) Thirst
(3) ADH release
(4) Aldosterone release
(5) constriction efferent >afferent arterioles
(6) Proximal tubule sodium absorption
55
what undergoes sodium co-transport in the proximal tubule?
Glucose, AA, lactate, Cl, Phos
56
Actions Loop of Henle
countercurrent mechanism
thin descending loop = passive movement of water
thick ascending limb = active pump
Fluid changes from isotonic > hypertonic > hypotonic
57
Action aldosterone
increase Na reabsorption
| excretion K and H
58
Actions ANP
triggered by hypertension tries to oppose it
dilates afferent and contracts efferent arterioles > Increased GFR and diuresis
inhibits aldosterone, renin, ADH
59
Actions of PTH on kidney
increase Ca reabsorption and phosphate excretion
60
Actions prostaglandins
dilate afferent arteriole
61
Polyhydramnios associations
Maternal GDM,
GIT obstruction (TOF, atresia),
Increased output (Bartters, congenital Cl and Na diarrhoea),
CNS failed swallowing
62
Raised AFP associated with
neural tube defect,
congenital nephrotic syndrome,
epidermolysis bullosa
63
Radiology tests for renal function
MCU - PUV voiding dysfunction
DMSA (M=Meat) renal scarring,
DTPA (T=tubules) split renal function
MAG3 best for VUR
64
What layers do nephrotic and nephritic syndrome affect?
Nephrotic - podocyte layer and GBM
Nephritic affects ALL layers hence haematuria, proteinuria, hypertension, AKI, oedema
65
Diagnosis and bacteria in spontaneous peritonitis in nephrotic syndrome
strep pneumonia
| Diagnosis = WCC >250, PMN>50, pH <7.35
66
Features congenital nephrotic syndrome
```
AR, NPHS1 gene,
antenatal increase AFP,
low birth weight and large placenta,
heavy proteinuria,
tubular dilatation with microcytic change,
baby can have Potter syndrome
```
OR AR NPHS2 gene (podocin), presents 3-5 years of age with steroid resistant nephrotic syndrome.
67
Most common cause of idiopathic nephrotic syndrome, features and treatment.
```
Minimal change disease,
2-3 years of age,
NORMAL complement,
treatment with steroids 90% respond, ACEi,
2nd line cyclosporine,
also immunisation, penicillin, aspirin
```
68
What is definition of relapse of nephrotic syndrome?
2+ proteinuria for 3 days
69
Features of FSGS
```
Nephrotic syndrome, steroid resistant
>6yoa,
tea coloured urine, proteinuria,
glycosuria,
IgM and C3
```
70
Features masangiocapillary/membranoproliferative GN
Nephrotic syndrome,
Older child
LOW complement
Poor response to steroids
71
Features membranous GN
Nephrotic syndrome
older children,
Associated Hep B, SLE, malignancy
72
Most common causes haemanturia
Post strep GN
| IgA nephropathy
73
Acute glomerular injury pneumonic
HOOHUP - haemanturia, oligouria, oedema, hypertension, uraemia, proteinuria
74
Rapidly progressive GN
ANCA,
Anti-GBM disease (Good pastures), Membranoproliferative GN
HSP
SLE
75
Features thin BM disease
AD but no chronic issues in family
| Excellent prognosis
76
Features Good pastures
Anti GBM,
Older child
pulmonary renal syndrome
77
Features Shunt nephritis
Due to staph aureus most,
Subacute
LOW complement
78
Features Post Strep GN
```
Group A beta haemolytic strep
2 weeks post throat infection
1 month weeks post skin infection,
ASOT + 1 month,
DNAase B + 2 months (more specific)
Resolves 2-3 weeks, 95% fully recover
Penecillin prevents spread to contacts
```
79
Features SLE nephritis
teenagers,
females,
systemic = rash, oral ulcers, photosensitivity, arthritis, anti dsDNA +, renal, anaemia
Treat class 3-5 (3=focal glomerulosclerosis, 4=segmental/global proliferative nephritis, 5=nephrotic syndrome)
steroids>cyclophosphamide>ritixumab
80
Types ANCA associated nephritis
(1) granulomatosis with polyangiitis cANCA
(2) churg strauss eosinophillic pANCA
(3) microscopic polyangitis pANCA
(4) polyarteritis nodosa
(5) takagasu arteritis
81
differences between pre-renal and ATN
urine osmolality higher in pre-renal,
High urine Na in ATN
urine sediment is normal in pre-renal
82
indications for dialysis
```
hyperkalaemia,
fluid overload resistant to frusemide,
acidosis,
urea >40,
prolonged anuria,
multi-system failure
```
83
fractional excretion of sodium
```
low is salt retaining, high if salt wasting
100 x (sodium in urine x creatinine in plasma)/(sodium plasma x creatinine urine)
```
84
features cystinosis
AR, cystine accumulation in lysosomes
hypophosphataemic rickets
growth failure
fanconi syndrome
85
most common renal stones are?
calcium oxalate
86
what factor is most important in managing persons with renal stones?
low salt diet - increase bone deposition and decreases calcium urine excretion
87
causes hypercalciuria and hypercalcaemia
```
hyperparathyroidism,
vit D excess,
immobilisation,
hypophosphataemia,
williams syndrome
```
88
causes hypercalciuria and normocalcaemia
```
idioapathic,
immobilisation,
medullary sponge kidney,
drugs (frusemide, steroids),
ketogenic diet,
genetic
```
89
what decreases calcium in urine
potassium and citrate
90
features cystinuria
AR
urine hexagonal crystals,
raised COAL (cystine, ornithine,argentine,lysine) in urine,
treat with fluids, low salt, penecillamine, alkalinise the urine
91
rhabdomyolysis features, and treatment
high CK, K, Phos, Ur, LOW Ca.
| Treat with fluids and allopurinol
92
conditions with cysts seen on USS of kidneys
```
multicystic kidney disease (dysplastic)
autosomal dominant kidney disease,
renal cysts associated with diabetic syndromes (MODY 5)
simple cysts
Tuberous sclerosis
```
93
features ADPCKD
PKD1/2,
cannot be excluded until 30 years of age,
cysts in other areas (liver), cerebral aneurysms, disease progression related to HTN.
94
features ARPCKD
PKHD1,
Large kidneys hyper echoic
Potter syndrome (contractures, pulmonary hypoplasia, typical facies),
hepatic Caroli syndrome - intrahepatic bile duct dilatation, fibrosis
95
features nephronophthisis
```
Ciliopathy, tubular disorder
salt wasting > polydipsia, polyuria
Anaemia
Small smooth echogenic kidneys
growth failure
```
96
features bardet biedl
```
obesity, developmental delay
hypogonadism,
polydactyly,
Retinal problems
renal nephronophthisis
can't even eat, can't even see, can't even think, can't even pee
```
97
what immunosuppressives act in the S phase?
Prednisolone, Methotrexate, MMF, Azathioprine, cytarabine, doxorubicin, thioguanine
98
What does Sirolimus act on
mTOR, G1 phase
99
what immunosuppressives are cell cycle indepamdant
cyclophosphamide (alkylating agents)
Cisplatin
etoposide
ifosfamide
100
What monoclonal antibodies act as TNF inhibitors?
Adalimumab,
Ertanecept,
Infliximab
101
What monoclonal antibody acts on B cells?
Rituximab - Anti-CD20
102
Tocilizumab action
anti-IL6
103
Anakinra
Anti-IL1
104
Basilixumab
Anti-CD25 Treg cells
105
Multi-cyctic dysplastic kidney
No function
Contralateral kidney hypertrophy,
Low risk Wilms,
Nephrectomy cures hypertension.
106
Horseshoe kidney associations
```
VACTERL,
Trisomies,
fetal alcohol syndrome,
infant diabetic mother.
Associated renal carcinoma
```
107
Imaging for PUJ obstruction
MAG 3 scan
108
Posterior urethral valves
poor stream, bilateral dilatation
UTI male,
MCUG at diagnosis then DMSA + MCU 3 months.
Don't use Foley catheter!!!
109
Poor prognostic factors obstruction
oligohydramnios
hydronephrosis 100 after decompression
cortical cysts
diurnal incontinence >5yoa
110
Prune belly syndrome features
absence abdominal wall muscles, megaureter/cysts,
Undescended testes
infertility
also other abnormalities
111
antenatal hydronephrosis
APD >15mm = severe
| APD >10mm = mod
112
indications circumcision
balanitis obliterans,
paraphimosis,
recurrent balanitis/UTI,
phimosis failing steroid treatment
113
complications circumcision
UTI, wound infection, stenosis
114
contraindications to circumcision
hypospadia, micropenis, dorsal hood deformity
115
How does pneumococcal cause HUS?
Produces Neuroimidase > T cell attack
Direct Coombs test +
Treat with Abx
116
Pitfalls of GFR
screwed by tubules & more secreted as GFR falls (inaccurate, overestimates function)
creatnine doesn't rise until <50% function
117
actions prostaglandins
dilate afferent arteriole
118
actions caffeine
dilates afferent arteriole
119
actions calcium channel blockers
increase GFR > diuresis
120
what is the strongest markers for chronic kidney disease?
proteinuria
121
Indications for biopsy with Post Strep GN
Cr elevated at 6 weeks
Complement low at 3 weeks
Proteinuria ongoing at 6 weeks
122
How to calculate plasma anion gap
(Na + K) - (Cl + Bicarb)
>14 abnormal
Normal Anion Gap
Addisons
GI losses
RTA
123
Stones and chance of passage
5mm will pass
5-7mm 50% pass
7mm need to be removed
124
what rise in creatnine is considered acceptable in chronic renal failure treated with ACEinhibitors
20-25%
125
in obstructive uropathy what correlates with prognosis
Creatnine at 12 months
