Renal Medicine Flashcards
(366 cards)
1
Q
How do you tell the difference between AKI and dehydration on bloods?
A
AKI - creatinine will be much higher than urea
Dehydration - urea will be much higher than creatinine
2
Q
How do you tell the difference between AKI and CKD?
A
CKD patients will have bilateral small kidneys except those with:
- ADPKD
- Early diabetic nephropathy
- Amyloidosis
- HIV nephropathy
3
Q
What is a common cause of fragility fractures?
A
CKD induced secondary hyperparathyroidism
4
Q
What is a common cause of drug-induced AKI?
A
Acute interstitial nephritis
5
Q
What drugs cause acute interstitial nephritis?
A
- Antibiotics including penicillin, rifampicin
- NSAIDs
- Allopurinol
- Furosemide
6
Q
Causes of acute interstitial nephritis?
A
drugs; systemic disease eg. SLE, scaroidosis, Sjogrens; infection eg. Hanta virus, staphlococci
7
Q
What does histology show for acute interstitial nephritis?
A
marked interstitial oedema and interstitial infiltrate in connective tissue between renal tubules
8
Q
Acute interstital nephritis Ix?
A
sterile pyuria and white cell casts
9
Q
How are diabetic patients screened for diabetic nephropathy?
A
albumin:creatinine ratio (ACR) in early morning specimens
10
Q
What are the ECG changes of hypokalaemia?
A
U waves
T wave flattening
ST segment changes
11
Q
What is the most common cause of nephrotic syndrome with malignancy?
A
Membranous nephropathy
12
Q
What would biopsy show for someone with membranous nephropathy?
A
subepithelial immune complex deposits
13
Q
What drugs should be withheld with AKi?
A
- Diuretics
- Aminoglycosides (gentamicin) and ACE/ARB
- Metformin
- NSAIDs
DAMN AKI
14
Q
What drug is most commonly used to decrease phosphate levels?
A
Sevelamer - a non calcium based binder which binds to dietary phosphate and prevents it being absorbed
15
Q
How can stages 1 and 2 of CKD be diagnosed?
A
GFR range PLUS if kidney tests must be abnormal
16
Q
What are causes of focal segmental gomerulosclerosis?
A
idiopathic
secondary to other renal pathology e.g. IgA nephropathy, reflux nephropathy
HIV
heroin
Alport’s syndrome
sickle-cell
17
Q
What is the risk of using 0.9% NaCl fluid therpay in patients who need large volumes?
A
Hyperchloremic metabolic acidosis
18
Q
What can alcohol bingeing lead to?
A
ADH suppression in the posterior pituitary leading to polyuria as well as hypernatremia
19
Q
What is the classic triad for HUS?
A
- AKI
- Haemolytic anaemia
- Thrombocytopenia
20
Q
What organism typically causes HUS?
A
E coli
21
Q
What medication should be used as an alternative to spironolactone for patients with gynaecomastia?
A
Eplerenone
22
Q
How does membranous glomerulonephritis present on histology?
A
basement membrane thickening on light microscopy
subepithelial spikes on sliver stain
positive immunohistochemistry for PLA2
23
Q
What is hyperacute transplant rejection?
A
Rejection within minutes to hours
24
Q
What is the cause of hyper acute transplant rejection?
A
pre-existing antibodies against ABO or HLA antigens
25
What type of hypersensitivity reaction of hyper acute transplant rejection?
Type 2
26
Why does rhabdomyolysis cause renal failure?
Tubular cell necrosis
27
What is the prognosis for HSP?
Full renal recovery
28
What is the diuretic of choice in ascites?
Spironolactone
29
When is a renal biopsy indicated for those with minimal change disease?
If the response to steroids is poor
30
What HLA subtype is the most important for transplants?
HLA-DR
31
What are the side effects of EPO?
- Accelerated hypertension
- Bone aches
- Flu like symptoms
- Skin rash
32
What medication can be used for recurrence of hyperkalaemia?
Calcium resonium
33
How does acute tubular necrosis respond to fluid challenge?
Poorly
34
What is prerenal uraemia?
Where the kidneys hold onto sodium to preserve volume
35
Prerenal uraemia vs ATN?
- Prerenal responds well to fluid challenge
- Urine osmlaitity will be raised
- Urine sodium will be low
36
Why should metformin be stopped in AKI?
Due to increased risk of toxicity
37
How does anti-GBM disease present?
- Haemoptysis
- AKI/proteinuria/haematuria
38
What is the most common cause of refractory HTN?
Renal artery stenosis secondary to atherosclerosis
39
eGFR is an inaccurate in which patients?
Those with extreme muscle mass
40
What investigation is needed for patients with AKI of unknown aetiology?
US
41
Patients with HSP require what to monitor for renal involvement?
BP and urinalysis
42
Patient presents with grey/brown tinge to the skin along with history of CKD?
Urea build up within the blood
43
Management of lupus nephritis?
Cyclophosphamide and methylprednisolone
44
What are the indications for acute haemodyialysis?
AEIOU
Acidosis
Electrolyte disturbance e.g. hyperkalaemia
Intoxication i.e. drug overdose
Oedema
Uraemia symptoms e.g encephalopathy
45
What is causes of sterile pyuria (white cells in urine with negative culture)
- Renal TB
- Partially treated UTI
- Drugs including NSAIDs, Abx
- Urinary tract stones
- Papillary necrosis
46
Schisotchtes on blood film?
Microangiopathic haemolytic anaemia -> HUS
47
Epithelial crescents in the glomeruli?
Rapidly progressing glomerulonephritis
48
What investigation should be done with all patients with AKI of unknown aetiology?
Renal US within 24 hours
49
Management of low urine output post surgery?
Fluid challenge - give bolus of NaCl
50
How should severe hyperkalaemia be managed?
Urgent discussion with nephrology/critical care
51
Pulmonary oedema with AKI needs what?
Haemodialysis
52
Cause of normal anion gap metabolic acidosis
Renal tubular acidosis
53
Causes of CKD
DM, Hypertension , glomerulonephritis, renovascular disease,
pyelonephritis, polycystic kidney disease, obstructive uropathy.
54
Signs of CKD on examination
purpura, bruising, brown discolouration of
nails, evidence of excoriation, peripheral oedema, hypertension,
pericardial rub, evidence o f pleural effusions, proximal myopathy,evidence of preparation for renal replacement therapy
55
How does haemodialysis work?
Blood and dialysis fluid flow either side of a semipermeable
membrane, molecules diffuse down their concentration gradients, plasma biochemistry changes to become more like the dialysis fluid.
56
What is the management of renal stones?
<5mm - wait and watch if asymptomatic
5mm - 10mm - Shockwave lithotripsy
10mm-20mm - Lithrotripsy / Ureteroscopy
>20mm - percutaneous nephrolithotomy
57
What is the management of ureteric stones?
If <10mm - shockwave lithotripsy +/- alpha blockers
If >10mm - Ureteroscopy
58
Which chromosome is affected in ADPKD?
16
59
Full house immunoflueoresence pattern on renal biopsy?
Lupus nephritis
60
How would Goodpastures present on biopsy?
Crescent formation and linear deposition of IgG antibodies across the glomerular basement membrane (anti-GBM antibodies)
61
What are C/I to renal biopsy?
- HTN
- CKD wit small kidneys
- Abnormal coagulation studies
62
Dietary advice for nephrotic syndrome
Restrict salt intake, normal protein intake
63
AKI + Haemoptysis + Lung changes?
Think Goodpastures
64
What are causes of rhabdomyolysis?
- Prolonged immobilisation
- Crush injuries
- Seizures
- Post surgery
- Medications such as statins
65
Period of hypotension followed by renal impairment with urinary casts
Acute tubular necrosis
66
How to calculate anion gap?
(sodium + potassium) - (bicarbonate + chloride)
Normal = 8-14
67
What are causes of normal anion gap metabolic acidosis?
- Diarrhoea
- Renal tubular acidosis
- Addisons
68
What are causes of raised anion gap metabolic acidosis?
- Shock
- DKA/Alcohol
- Acid poisoning e.g salicylates
69
How to work out pre, renal and post renal cause of AKI?
Urea / (creatinine(umol)/1000
Pre renal - >100
Renal/Normal - 40 - 100
Post renal - <40
70
What is in indication for chronic kidney disease over acute?
Hypocalcaemia
71
Acute interstitial nephritis vs acute tubular necrosis?
AIN is an inflammatory process so white cells will be in the urine whereas ATN is not therefore no white cells in urine
72
Tubulointerstitial nephritis with ueveitis?
usually young females; fever, weight loss and painful red eyes; urinalysis= +ve leukocytes and protein
73
Diarrhoea causes what?
Hypokalaemia metabolic acidosis
74
Eosinophilic casts are an indication of what?
Acute interstitial nephritis
75
What does proteinuria indicate in the context of AKI?
Intrinsic renal AKI cause
76
Anyone with severe hyperkalaemia / ECG changes for hyperkalaemia?
IV 10mls of 10% Calcium Gluconate
Insulin/Dextrose
77
What must be assessed in someone with bilateral calculi?
Renal function
78
HIV nephropathy causes what?
Focal segmental glomerulosclerosis -> causes nephrotic syndrome
79
Rapidly progressing glomerulonephritis is associated with what?
Goodpasture's
GPA
80
What can invalidate an EGR?
Eating red meat
81
AKI values
Creatinine
Stage 1 - 1.5-1.9x baseline / Increased by 26 umol+ in 48hrs / urine output <0.5mls/kg >6 hours
Stage 2 - 2 - 2.9x baseline / urine output <0.5mls/kg >12 hours
Stage 3 - 3x baseline / urine output <0.3mls/kg >24 hours
82
What are the 4 variables in the MDRD equation to work out estimated EGFR in patients with CKD?
Creatinine
Age
Gender
Ethnicity
83
Addisons causes what?
Hyperkalaemic metabolic acidosis
84
Patients with CKD and ACR >30 should be started on what?
ACE + Statin
85
Hereditary haemochromatosis can cause what?
Cranial diabetes insipidus
86
fever + rash + renal dysfunction
Acute interstitial nephritis
87
Urine osmolality >500 + urine sodium < 20
Pre renal uraemia
88
Urine osmolality < 350 + urine sodium > 40
Acute tubular necrosis
89
Brown granular casts are a sign of what?
Acute tubular necrosis
90
What is the most common viral infection in solid organ transplant patients?
CMV
91
What is the treatment for acute clot retention in urethra?
Continuous bladder irrigation via a 3 way urethral catheter
92
What is a drug cause of nephrogenic diabetes insipidus?
Lithium - desensitizes the kidneys ability to respond to ADH in the collecting ducts
93
Granulomatosis with polyangiitis is associated with what?
Rapidly progressing glomerulonephritis
94
Young female patient with AKI after starting ACE?
Fibromuscular dysplasia
95
What is the daily maintenance fluids requirement?
25-30ml/kg/day
96
Haemodialysis can cause what?
A falsely low HbA1c
97
What is monitoring for ACE inhibitors?
Increase in creatinine up to 30% is acceptable
If K+ > 6 - stop ACE and switch to alternative
98
Why do you get kidney stones in PKD?
Cysts block collecting ducts leading to urinary stasis and stone formation
99
What part of nephron does RCC affect?
PCT
100
What are risk factors for RCC?
- Smoking
- Male
- Increasing age
- HTN
- FH
- Obesity
101
Symptoms of chronic renal failure?
- Anaemia
- Fatigue
- Vomiting
- Bone pain
- SOB
- Fluid overload
102
Complications of haemodialysis?
- Hypotension
- Thrombosis
- Infection
- Blockage
103
Complication of peritoneal dialysis?
- Peritonitis
- Obesity
- Hernias
- Loss of membrane function
104
Where does sodium reabsorption take place?
PCT
105
Anti-GBM has antibody against which type of collagen?
Type 4
106
What kind of reaction is IgA nephropathy?
Type 3
107
What can be given for calcium stones due to hypercalcicuria?
- Potassium citrate
- Thiazide diuretics (increase distal tubular reabsorption)
108
Most common cause of death in patients with CKD on harm-dialysis?
IHD
109
What is a complication UTI?
UTI in the presence of an abnormal urinary tract
110
What is the pathophysiology of IgA nephropathy?
IgA immune complex deposit in the mesangial cells
111
haemoptysis + haematuria
Think Good pastures
112
Sickness, headache, vomiting and drowsiness after haemodialysis?
Disequilibrium syndrome caused by rapid changes in plasma osmolality and cerebral oedema
113
Causes of raised CK?
- Burns
- Myositis
- Seizures
- Influenza
- Duchennes muscular dystrophy
114
What gene is responsible for PKD?
PKD1
115
What are complications of PKD?
- Renal failure
- HTN
- Renal calculi
- Cyst infection
- Hepatic cysts
116
What is screening of ADKPD for relatives?
Abdo US scan for first degree relatives
117
subepithelial 'humps' on electron microscopy
Post strep glomerulonephritis
118
A high urea can indicate what gastro pathology?
Upper GI bleed
119
What is a classic sign of renal artery stenosis?
- Worsening renal function after starting an ACE
- Refractory HTN
120
Which UTI medication can cause rise in creatinine?
Trimethoprim
121
What is a good marker prognosis in IgA nephropathy?
Macroscopic haematuria
122
Muddy brown casts
ATN
123
rash, eosinophilia and acute renal impairment
AIN
124
Most common component of renal stones?
Calcium oxalate
125
What is the most common cause of AKI?
Pre-renal causes
126
Management of acute upper urinary tract obstruction
Nephrostomy
127
fever, arthralgia, rash and eosinophilia in a setting of decreased renal function; HTN
Acute interstitial nephritis
128
When can a diagnosis of CKD be made?
When EGFR <60 on 2 tests which are 3 months apart
129
UTI + haematuria?
Must send MSU
130
Trimethoprim can cause a falsely low what?
eGFR
131
thickened glomerular basement membrane with IgG and C3 subepithelial deposits
Membranous nephropathy
132
Treatment of HTN in someone with IgA nephropathy?
ACE inhibitors
133
Headache and tremor can be signs of what?
Calcineurin inhibitors (tacrolimus) toxicity
134
Why are patients with nephrotic syndrome susceptible to clots?
Loss of antithrombin III and plasminogen via the kidneys
135
Periureteric fat stranding on CT KUB can indicate what?
Spontaneously passed calculus
136
Stag horn calculi are made of what?
Struvite (magnesium ammonium phosphate)
137
What is a vitamin D supplement which is used in end stage renal disease?
Alfacalcidol -> does not require activation in the kidneys
138
anti-MPO antibodies are indicative of what?
Microscopic polyangiitis
139
What are the types of renal tubular acidosis?
1 - inability to generate acid urine causing hypokalaemia (causes include RA, Sjogrens, SLE)
2 - decreased bicarb resorption causing hypokalaemia (causes include Wilsons)
4 - reduced aldosterone causing hyperkalaemia (causes include diabetes)
140
Crescent formation on biopsy with rapid decrease in EGFR?
Membranoproliferative glomerulonephritis
141
When is acute vs chronic rejection following transplant?
Acute - within first 6 months
Chronic - >6 months
142
Gold standard imaging for suspected renal cancer?
CT Abdo with contrast
143
Abx for UTI in egfr <45
Trimethoprim
144
What is the most common complication of haemodialysis?
Dialysis-induced hypotension
145
Worsening renal function with dark brown urine
ATN
146
Gentamicin can cause what?
ATN
147
What is calcitriol?
Active form of Vit D
148
What is AKI?
spectrum of injury to kidneys that can result from a number of causes that may co-exist
149
AKI is characterised by a sudden decline in.....
renal excretory function over hrs or days that can result in failure to maintain fluid, electrolyte and acid-base balance
150
What is diagnosis of AKI and its staging based on?
Acute changes in serum creatinine and/or a reduction in urine output (oliguria)
151
what is the word for a reduction in urine output?
oliguria
152
Causes of AKI?
pre-renal
intra-renal
post-renal
153
Pre-renal causes of AKI?
Due to reduced perfusion of the kidneys and/or hypotension
154
Intra-renal (intrinsic) causes of AKI?
Due to structural damage to the kidney
155
Post-renal causes of AKI?
Due to acute urinary tract obstruction
156
What people are at risk of AKI?
- >65yrs
- Hx of AKI/urological obstruction
- Hx CKD, HF, liver disease or DM
- if reliant on others for fluid intake
- pts with sepsis, hypovolaemia, hypotension, dehydration, reduced fluid intake, oliguria
- specific drugs
157
What are Cx of AKI? (depend on AKI severity and duration)
hyperkalaemia, metabolic acidosis, fluid overload, uraemia, CKD
158
When should AKI be suspected?
acute illness with D&V; acute illness with AKI RFs; illness & CKD/urological disease; AKI warning test result based on creatinine change.
159
CP of AKI?
N, V, D or suspected dehydration, reduced urine output or changes to urine colour, confusion, fatigue, drowsiness
160
When can a diagnosis of AKI be made?
if one of the following:
1) A rise in serum creatinine of 26 micromol/L or greater within 48 hours
2) A 50% or greater rise in serum creatinine known or presumed to have occurred within the past 7 days
3) A fall in urine output to less than 0.5 mL/kg/hour for more than 6 hours.
161
A diagnosis of AKI can be made if there is a rise in serum creatinine of ... within 48hrs
26 micromol/L or greater
162
A diagnosis of AKI can be made if there is a ....% or greater rise in serum creatinine in past 7d
50% +
163
A diagnosis of AKI can be made if there is a fall in urine output to less than.... for more than 6hrs?
0.5mL/kg/hr
164
How to assess a person with AKI?
- fluid intake, UO, meds
- volume status and signs of urological obstruction
- renal function & serum potassium.
- urine dip: underlying cause and renal disease
- U&Es= Na, K, urea, creatinine
165
When to urgently admit someone to hospital or same day referral with AKI?
if AKI stage 3, severe cause or Cx or no identifiable cause
166
Mx of AKI
TUC: advise fluid balance, temporarily stop/reduce specific meds; monitor serum creatinine regularly
167
What follow up should be done for a pt with AKI?
- referral to nephrology if CKD
- monitor renal function regularly= development or progression of CKD
- review need for specific meds
168
What can cause a false positive result in creatinine in pt with suspected AKI?
recently treated with trimethoprim or recently been pregnant
169
AKI: urine dip with negaitive urinalysis?
indicates pre-renal or drug cause
170
AKI what to analyse on urine dip?
blood, protein, leucocytes, nitrites and glucose
171
AKI: urine dip with +ve protien and blood?
may suggest glomerular disease if no evidence of UTI or trauma due to catherisation
172
AKI: urine dip showing increased white cells?
non-specific but typically infection (common) or interstitial nephritis
173
Examples of pre-renal causes of AKI?
- hypovolaemia 2 to D/V
- renal artery stenosis
174
Examples of intrinsic causes of AKI?
- drugs
- glomerulonephritis
- acute tubular necrosis (ATN)
acute interstitial nephritis (AIN), respectively
- rhabdomyolysis
- tumour lysis syndrome
175
Examples of post-renal causes of AKI?
- kidney stone in ureter or bladder
- BPH
- external compression of the ureter
176
When is renal replacement therapy eg. haemodialysis used for AKI?
When not responding to Mx of Cx eg. hyperkalaemia, pulmonary oedema, acidosis or uraemia (eg. pericarditis, encephalopathy)
177
What do the kidneys do in prerenal uraemia?
hold on to sodium to preserve volume
178
What is autosomal dominant polycystic kidney disease (ADPKD)?
Inherited cause of kidney disease, 2 types: PKD1 and PKD2.
179
PKD1 codes for what? Chromosome?
Codes for polycystin-1
Chromosome 16.
180
PKD2 codes for what? Chromosome?
Polycystin-2.
Chromosome 4.
181
ADPKD 1 vs ADPKD 2?
T1 more common and presents with renal failure earlier.
182
Screening Ix for relatives for ADPKD?
Abdo USS
183
USS diagnostic criteria (in pts with +ve family history for ADPKD)?
- two cysts, unilateral or bilateral, if aged < 30 years
- two cysts in both kidneys if aged 30-59 years
- four cysts in both kidneys if aged > 60 years
184
Mx for ADPKD?
Tolvaptan to slow progression of cyst development and renal insufficiency
185
When is tolvaptan used in ADPKD?
- they have chronic kidney disease stage 2 or 3 at the start of treatment
- there is evidence of rapidly progressing disease and
- the company provides it with the discount agreed in the patient access scheme.
186
Tolvaptan drug classification?
vasopressin receptor 2 antagonist
187
Definition of CKD?
Abnormalities in kidney structure or function (or both) present for >3m with associated health implications.
188
CKD should be diagnosed in people with what present for min 3m?
- GFR <60 mL/min/1.73 m2 on at least two occasions separated by a period of at least 90 days (with or without markers of kidney damage).
- Markers of kidney damage such as urinary albumin:creatinine ratio (ACR) >3 mg/mmol, urine sediment abnormalities, electrolyte and other abnormalities due to tubular disorders, abnormalities detected by histology, structural abnormalities detected by imaging, and a history of kidney transplantation.
189
CKD should be diagnosed in people if the GFR is less than... on at least 2 occasions separated by a period of at least 90 days (with or without markers of kidney damage)
<60mL/min/1.73m2
190
CKD should be diagnosed in people with markers of kidney damage present for min of 3m. What are some markers of kidney damage?
- urinary albumin:creatinine ratio (AR) >3mg/mmol
- urine sediment abnorm
- electrolyte & other abnorm due to tubular disorders
- abnorm histology
- structural abnorm detected. by imaging
- Hx of kidney transplant
191
CKD is classified using what?
eGFR and ACR
192
Causes and RFs for CKD and its progression?
HTN, DM, CVD, AKI, nephrotoxic drugs, obstructive uropathy
193
Cx of CKD (increases with disease progression)
AKI, HTN, CVD, renal anaemia, renal mineral and bone disorder, end-stage renal disease (ESRD), mortality
194
CKD should be suspected in people with what?
- RFs
- CP
- incidental finding of raised serum creatinine and/or eGFR of <60 or other markers of kidney damage
195
Inital Ix if CKD is suspected?
- serum creatinine and eGFR
- early morning measure ACR
- urine dip ?haematuria
- BMI, BP, HbA1c, lip profile for ?cvd RFs
- renal tract USS if indicated
196
CKD: indications for renal tract USS?
FHx polycystic kidney disease, suspected urinary tract stones or obstruction
197
If CKD is confirmed, what monitoring for disease progression should be done?
- eGFR and urine ACR
- FBC: exclude renal anaemia
- serum Ca, K, Vit D, PTH : exclude renal metabolic and bone disorders
(depends of severity of CKD)
198
When should you refer to nephrology in pts with CKD?
- 5yr risk needing renal replacement therapy >5%
- accelerated progression
- ACR 70 or more unless have DM
- ACR 30 or more + persistent haematuria (after excluding UTI)
- uncontrolled HTN
- rare or genetic cause
- suspected renal artery stenosis
- suspected Cx of CKD
199
How to measure ACR?
early morning urine sample
200
Mx in primary care for CKD
- manage RFs
- offer ARB
- offer atorvastatatin 20mg and antiplatelet
- consider SGLT-2 inhibitor eg. dapagliflozin (give to everyone with DM)
201
Patients with CKD must be immunised with what vaccines?
Influenza and pneumococcal disease
202
CP of CKD
- Lethergy, itch, breathlessness, cramps (worse at night), sleep disturbance, bone pain, poor appetitie, weight loss, N&V, taste disturbance (end stage).
- Polyuria, nocturia.
- Cachexia, cognitive impairment.
- dehydratation/hypovolaemia
- dyspnoea
- frothy urine
- flank mass (cysts/ ?ca)
- pallor (renal anaemia)
- palpable distended bladder
- ammonia-like smell of breath (end stage)
- peripheral oedema
203
CKD: what may frothy urine suggest?
Proteinuria
204
CKD: what may palpable distended bladder suggest?
obstructive uropathy
205
CKD: what may peripheral oedema be due to?
renal sodium retention, hypoalbuminaemia or HF
206
Unexplained chronic renal impairment is an indicator for what condition?
HIV
207
What is associated with increased risk of adverse outcomes in CKD?
Increased ACR or
Decreased GFR or
Increased ACR and Decreased GFR in combination
208
Nephrotoxic drugs?
NSAIDs
PPI
ACE in
ARB
bisphosphonates
diuretics
lithim
methotrexate
aminoglycosides
ciclosporin
209
Type of anaemia most common in patients with GFR <35?
Reduced erythripoietin levels- normochromic normocytic anaemia
210
Causes of anaemia in renal failure?
- reduced erythopoietin levels
- reduced absorption of iron
- reduced erythropoiesis due to toxic effects of uraemia on bone marrow
- anorexia/nause due to uraemia
- reduced cell survival (esp in haemodialysis)
- blood loss due to capillary fragility and poor platelet function
- stress ulceration leading to chronic blood loss
211
Anaemia in CKD predisposes to the development of what?
L ventricular hypertrophy
212
CKS is associated with a decrease in production of what?
Erythropoietin- hormone produced by kidneys that stimulates erythropoiesis in bone marrow. So less RBC production.
213
2 reasons why there can be reduced iron absorption in CKD?
- hepcidin levels increased due to inflamm and reduced renal clearance, leads to decreased iron absorption from gut
- metabolic acidosis (common in CKD) can ihibit converson of ferric iron to absorbable form ferrous iron in duodenum
214
Target Hb in pt with CKD?
100-120
215
What should be done prior to administration of erythropoiesis-stimulating agents (ESA)?
Determination and optimisation of iron status
216
What patients with CKD should be offered oral ion?
Pts not on ESAs or haemodialysis. If Hb levels not reached withinin 3m, switch to IV iron
217
What patients with CKD generally require IV iron?
Pts on ESAs or haemodialysis
218
When should ESAs be used in pts with CKD?
Eg. erythropoietin and darbepoetin. In those who are 'likely to benefit in terms of QOL and physical function'
219
Basic problems in CKD that can lead to bone disease?
- low vit D
- high phosphate
- low Ca
- secondary hyperparathyroidism (low Ca, high phos, low vit D)
220
why do you get low vit D in CKD?
1-alpha hydroxylation normally occurs in kidneys
221
Clinical manifestations of bone disease in CKD?
- osteitis fibrosa cystica (hyperparathyroid bone disease)
- adynamic
- osteomalacia
- osteosclerosis
- osteoporosis
222
What is adynamic in CKD?
Reduction in cellular activity (both osteoblasts and clasts) in bone. May be due to over treatment with vit D.
223
Common causes of CKD?
diabetic nephropathy; chronic glomerulonephritis; chronic pyelonephritis; HTN; adult PKD
224
CKD: what does the Modificaation of Diet in Renal Disease (MDRD) equation used to help estimate eGFR uses what variables?
serum creatinine, age, gender, ethnicity
225
What factors may affect eGFR?
pregnancy; muscle mass (amputees, body-builders); eating red meat 12hr prior to sample taken
226
CKD stages?
Stage 1) eGFR >90ml/min
2) 60-90
3a) 45-59
3b) 30-44
4) 15-29
5) <15
227
What does CKD stage 5 mean?
Established kidney failure- dialysis/kidney transplant may be needed
228
Main features of CKD if symptomatic (late-stage disease)
oedema (ankle swelling, weight gain), polyuria, lethargy, pruritus, anorexia (weight loss), insomnia, N&V, HTN
229
Why may pts with CKD get pruritus?
secondary to uraemia
230
What level of decrease in eGFR or rise in creatinine is acceptable in pts with CKD taking ACE inhibitors for HTN?
decrease in eGFR up to 25% or rise in creatinine up to 30% (any rise should prompt monitoring)
231
Why is a small fall in glomerular filtration pressure (GFR) and rise in creatine be expected when taking ACE inhibitors in CKD?
these drugs tend to reduce filtration pressure
232
What is a useful anti-hypertensive in pts with CKD (as well as ACE inh), particularly if GFR <45?
Furosemide. Added benefit of lowering serum potassium but if pt at risk of dehydration eg. gastroenteritis then consider temp stop.
233
Why can pts with CKD get high phosphate?
kidneys normally excrete phosphatew
234
Why can pts get osteomalacia in CKD?
high phosphate levels 'drags' calcium from bones
235
Why can pts have low calcium in CKD?
due to lack of vit D, high phosphate
236
Why can pts get secondary hyperparathyroidism in CKD?
due to low Ca, high phosphate and low vit D
237
Aim of bone disease Mx in CKD?
reduce phosphate and parathyroid hormone levels
238
Mx of bone disease in CKD?
1st- reduce dietary intake of phosphate
- phosphate binders
- vit D eg. alfacalcidol, calcitriol
- parathyroidectomy may be needed in some cases
239
How do phosphate binders eg. sevelamer work in bone disease management in CKD?
- non-calcium based binder
- binds to dietary phosphate and prevents its absorption
- also can reduce uric acid levels and improve lipid profiles
240
What is an important marker for CKD and esp diabetic nephropathy?
Proteinuria
241
What do you use in patients with proteinuria?
albumin:creatinine ratio (ACR) ?CKD
242
How to take an albumin:creatinine ratio?
first-pass morning urine specimen
243
What if ACR is 3-70mg/mmol?
Confirm by a subsequent early morning sample. If 70+ then don't need a repeat sample.
244
What value for ACR is regarded as clinically important proeinuria?
3mg/mmol or more
245
NICE recommends referral to nephrologist for proteinuria if what?
- ACR 70 or more unless known to be caused by diabetes
- ACR 30 or more with persistent haematuria after excluding UTI
- ACR 3-29 with persistent haematuria + RFs e. decreasing eGFR or CVD
246
Persistent haematuria?
2/3 dip show 1+ or more of blood
247
Mx for proteinuria in CKD?
- ACE inhibitors (if HTN and ACR >30 or if ACR >70 regardless of BP)
- could consider SGLT-2 inhibitors
248
Why may SGLT-2 inhibitors be beneficial for proteinuria in CKD?
act by blocking reabsorption of glucose in proximal tubule- -> lowers renal glucose threshold -> glycosuria.
by blocking the cotransporter, also reduce Na reabsorption -> natruresis reduced intravascular volume and BP and increased delivery of Na to macula densa -> normalises tubuloglomerular feedback and reduces intraglomerular pressure.
249
Nephrotic syndrome?
When basement membrane in glomerulus becomes highly permeable to protein, allowing proteins to leak from blood into urine.
250
What age is nephrotic syndrome most common?
2-5yrs
251
What does nephrotic syndrome present with?
frothy urine, generalised oedema and pallor
252
Nephrotic syndrome triad?
- proteinuria (>3+ on dip) causing
- hypoalbuminaemia (<30g/L) and
- oedema
253
Other features of nephrotic syndrome?
- deranged lipid profile, high cholesterol, triglycerides and low density lipoproteins
- HTN
- hyper-coagulability
254
Causes of nephrotic syndrome?
- minimal change disease (90% in children <10yrs)
- secondary to intrinsic kidney disease
- secondary to underlying systemic illness: Henoch schonlein purpura (HSP), diabetes, HIV, hepatitis, malaria
255
Nephrotic syndrome can occur secondary to intrinsic kidney disease, give 3 examples
- minimal change disease
- focal segmental glomerulosclerosis
- membranoproliferative glomerulonephritis
256
2-5yr old child with oedema, proteinuria and low albumin?
Minimal change disease causing nephrotic syndrome
257
Mx of nephrotic syndrome?
- high dose steroids eg. pred
- low salt diet
- diuretics for oedema
- albumin infusions if severe hypoal
- Abx prophylaxis in severe cases
258
How long are high dose steroids given for nephrotic syndrome?
4w then gradually weaned over next 8w. 80% will relapse at some point and need more.
259
In nephrotic syndrome what Mx can be used in steroid resistant children?
ACE inhibitors and immunosuppressants eg. cyclosporine
260
Cx of nephrotic syndrome?
Hypovolaemia, thrombosis, infection, acute or chronic renal failure, relapse.
261
Minimal change disease?
Nearly always presents as nephrotic syndrome. Most common cause of nephrotic syndrome (90% of children under 10yrs).
262
Causes of minimal change disease?
- most idiopathic
- drugs eg. NSAIDs, rifampicin
- hodgkin's lymphoma, thymoma
- infectious mononucleosis
eg. NSAIDs -> minimal change disease -> nephrotic syndrome
263
Pathophysiology of minimal change disease?
T-cell and cytokine-mediated damage to glomerular BM -> polyanion loss -> reduction of electrostatic charge -> increased glomerular permeability to serum albumin
264
Features of minimal change disease?
- nephrotic syndrome
- normotension
- highly selective proteinuria
265
Why do you get highly selective proteinuria in minimal change disease?
only intermediate-sized proteins such as albumin and transferrin leak through the glomerulus
266
Minimal change disease: features on renal biopsy?
- normal glomeruli on light microscopy
- electron microscopy shows fusion of podocytes and effacement of foot processes
267
Mx of minimal change disease?
Oral corticosteroids (80%) steroid responsive.
- steroid-resistant: cyclophosphamide
268
Is relapse common in minimal change disease?
1/3 have just one episode
1/3 have infrequent relapses
1/3 have frequent relapses which stop before adulthood
269
Nephritic syndrome?
Nephritis +
- Haematuria
- Oliguria
- Proteinuria (but <3g per 24hrs)
- Fluid retention
270
Nephritis?
Inflammation in kidenys
271
Glomerulonephritis?
Inflammation of glomeruli. Describes the pathology that occurs in various diseases rather than being a disease.
272
What does the glomerulus do?
First part of the nephron. Filters fluid out of the capillaries and into renal tubule.
273
Mx for glomerulonephritis?
- diagnosis: renal biopsy for histology
- Mx: suportive care (HTN Mx, dialysis if severe) and immunosuppression eg. corticosteroids
274
Most common cause of primary glomerulonephritis?
IgA nephropathy (Berger's disease)
275
Pt in 20s with haematuria; histology shows IgA deposits and mesangial proliferation.
IgA nephropathy causing glomerulonephritis.
276
What do mesangial cells do?
found in centre of glomerulus and help support capillaries + other functions
277
Membranous nephropathy?
Deposits of immune complexes in glomerular basement membrane, causing thickening and malfunctioning of the membrane and proteinuria.
278
What does histology show in membranous nephropathy?
IgG and complement deposits on basement membrane
279
Membranous nephropathy is a key cause of what in adults?
Nephrotic syndrome
280
What are the causes of membranous nephropathy?
- Majority idiopathy
- 2 to malginancy, SLE, or drugs eg. NSAIDs
eg. malignancy -> membranous nephropathy -> nephrotic syndrome
281
Membranioproliferative glomerulonephritis (or mesangiocapillary glom...)?
typically pts <30yrs, involves immune complex deposits and mesangial proliferation
282
Post-streptococcal glomerulonephritis?
pts <30yrs; presents 1-3w after strep infection (eg. tonsillitis or impetigo); pts usually make full recovery
283
Rapidly progressive glomerulonephritis (or cresentic glom...)?
Acute severe illness but tends to respond well to treatment. Histology= glomerular crescents.
284
Goodpasture syndrome (anti-glomerular base membrane (anti-GBM) disease) causes what?
Anti-GBM antibodies attack glomerulus and pulmonary basement membranes. Causes glomerulonephritis and pulmonary haemorrhage
285
Pt in their 20s or 60s with acute kidney failure and haemoptysis?
Goodpastures
286
Systemic diseases that cause glomerulonephritis?
HSP, vasculitis (microscopic polyangiitis or granulomatosis with polyangiitis) , lupus nephritis
287
Pt with AKI and haemoptysis, consider which conditions based on different antibodies?
Anti-GBM = Goodpastures
p-ANCA (MPO antibodies)= microscopic polyangiitis
c-ANCA (PR3 antibodies)= granulomatosis with polyangiitis
288
Causes of nephritic syndrome?
- IgA nephropathy
- Post-strep glomerulonephritis
- Goodpastures
- Membranoproliferative glomerulonephritis
- HSP. hepatitis, vasculitis, mononucleosis, measles, mumps
- Alport syndrome
289
Deep vein thrombosis?
Formation of thrombus (clot) in deep vein, usually legs, which partially or completely obstructs blood flow
290
Intrinsic RFs for DVT?
history, cancer, >60, overweight, male, HF, thrombophilia, inflam disorders eg. IBD, vasculitis
291
Extrinsic RFs?
- immbolity eg. recent surgery, wheelchair use
- travel
- signif trauma or direct trauma to vein eg. IV catheter
- HRT
- pregnancy and post-partum
- dehydration
292
Cx of DVT?
PE
293
CP DVT
- pain, pallor, paralysis, paraesthesia, pulseless and perishingly cold
- redness, warmth, vein distension, localised pain and swelling in calf, oedema
294
Determine likelihood of DVT?
Well's score
295
Initial Ix for DVT?
- clinical exam: assess leg and thigh swelling (circum 10cm below tibial tuberosity and compare with other leg; if diff >3cm then high prob)
- DVT Wells score
296
Ix for pt likely to have DVT based on Wells score?
- proximal leg vein USS with results available within 4hrs; if can't be done within 4hrs of being requested then:
- D-dimer testing, interim therapeutic anticoag and USS within 24hrs
297
Ix for pt unlikely to have DVT based on Wells score?
- bloods for D-dimer with results within 4hrs
- if +ve then do same Ix if Well's was likely (USS)
- if -ve then alternative diagnosis
- if results not available within 4hrs= interim anticoag whilst waiting
298
DVT Mx?
- Anticoagulants in secondary care
299
What will pts on discharge after having DVT need?
maintenance treatment with oral anticoag for at least 3m
300
When is DVT Wells risk score likely?
2 points or more
301
When is DVT Wells risk score unlikely?
1 point or less
302
Interim therapeutic anticoag for DVT?
DOAC: Apixaban or rivaroxaban
if not suitable then LMWH 5d followed by dabigatran OR LMWH + vit K antagonist 5d
303
What baseline bloods are needed for people starting interim anticoag therapy for DVT? (don't wait on results before starting)
FBC, renal and hepatic function, PT, activated partial thromboplastin time (APTT)
304
Ensure people with an unprovoked DVT are investigated for what?
cancer and thrombophilia
305
Warfarin INR target (eg. for DVT long term Mx)?
2.5, or within 2-3
306
Contraindications to starting maintenance treatment with anticoag for DVT following acute treatment?
Pregnancy or cancer
307
Maintenance Mx for DVT?
Warfarin, apixaban or ravroxaban (if DVT provoked then 3m, if unprovoked then 6m)
308
CP of dehydration
Dry mucous membranes, loss of skin turgor, sunken eyes.
Severe= tachycardia, hypotension, delirium.
309
Fluid resuscitation?
fluid bolus 500ml crystalloid over less than 15 mins (0.9% saline or Hartmann's)
310
Examples of crystalloid fluids?
Saline 0.9%, Hartmann's
311
Examples of colloid fluids?
Albumin, dextran, blood
312
Crystalloid vs colloid fluids?
Crystalloids: small molecules, cheap, immediate fluid resus but may increase oedema.
Colloid= larger molecules, cost more, risk of allergic reactions and kidney failure
313
Electrolyte concs in plasma
Na+ = 135-145
Cl- = 98-105
HCO3- = 22-28
Glucose = N/A
314
Electrolyte conc in 0.9% saline?
Na+ = 154
Cl- = 154
K+ = N/A
HCO3- = N/A
Glucose = N/A
315
Electrolyte concs in 5% glucose?
Na+ = N/A
Cl- = N/A
K+ = N/A
HCO3- = N/A
Glucose = 50g
316
Electrolyte concs of 0.18% saline with 4% glucose
Na+ = 30
Cl- = 30
K+ = N/A
HCO3- = N/A
Glucose = 40g
317
Electrolyte concs of Hartmann's solution?
Na+ = 131
Cl- = 111
K+ = 5
HCO3- = 29
Glucose = N/A
318
What happens if large volumes of 0.9% saline are used?
increased risk of hyperchloraemic metabolic acidosis
319
What pts should Hartmann's be not used in?
Those with hyperkalaemia as contains potassium
320
In nephrotic syndrome, why is pt predisposed to thrombosis?
loss of antithrombin-III, proteins C and S and an associated rise in fibrinogen levels= thrombosis
321
Most common type of renal stone
Calcium oxalate
322
RFs for calcium oxalate renal stones
Hypercalciuria; hyperoxaluria; hyppercitraturia.
323
Other types of renal stones?
cystine, uric acid, calcium phosphate, struvite
324
pH of urine?
Variation throughout day (5-7).
Falls after eating as purine metabolism produces uric acid.
Then becomes more alkaline (alkaline tide)
325
When a stone is not available for analysis, what may be used to help determine which stone was present?
pH of urine
326
Urine acidity with different renal stones?
Calcium phosphate= Normal- alkaline >5.5
Calcium oxalate= Variable 6
Uric acid= Acid 5.5
Struvate= Alkaline >7.2
Cystine= Normal 6.5
327
Renal/ureteric colic?
acute and severe loin pain caused when urinary stone moves from kidney or obstructs flow of urine
328
CP of renal colic
- severe unilateral abdo pain from loin/flank to groin (labia in women/ groin or testicle in men)
- pain lasts mins-hrs with spasms then after dull ache
- N & V
- haematuria
- dysuria, urinary frequency and straining
- restless
329
Exclude what if ?renal colic
appendicitis and diverticulitis
330
RFs for renal colic
chronic dehydration, FHx, GI conditions eg. Crohn's, medications (eg. protease inhibitors)
331
Cx of renal colic
urinary tract obstruction (hesitancy, intermittent urinary stream) and UTI (fever, sweats)
332
Immediate hospital admission for pt with renal colic if what symptoms?
- in shock/systemic infection eg. fever, sweats
- increased risk of AKI eg. CKD, transplanted kidney or bilateral stones suspected
- dehydrated and can't take oral fluids due to vomiting
- uncertain about diagnosis
333
Ix for suspected renal colic
- urine dip ?haematuria/infection
- urgent low-dose non-contract CT KUB within 24hrs (USS if child or pregnant)
334
Mx for renal colic
- analgesia: NSAIDs or IV paracetamol
-watch and wait, medical expulsive therapy or surgery
335
What does Mx of urinary stones depend on?
size, severity of symptoms, location (renal or ureteric), age
336
Increasing fluid intake, reducing salt intake (rec 2-6g/day), avoiding carbonated drinks, maintaining normal calcium intake all reduce the risk of recurrence of what?
renal/ureteric colic/stones
337
Reduce risk of recurrence of renal/ureteric colic/stones
- lifestyle and dietary advice
- consider potassium citrate if recurrence of stones that are >50% calcium oxalate
- thiazide if recurrence of stones >50% calcium oxalate & hypercalciuria, after restricting Na+ intake to <6g a day
338
When is watchful waiting advised for renal/ureteric stones?
stone <5mm and asymptomatic
339
Medical expulsive therapy for renal/ureteric stones?
with distal ureteric stones <10mm
use of alpha-blocker to facilitate sponstaneous stone passage under observation
340
Surgery for renal/ureteric stones?
within 48hrs or readmission if pain ongoing or stone unlikely to pass
either: shockwave therapy; percutaneous nephrolithotomy, ureteroscopy or open surgery.
341
What metabolic Ix are recommended for people with renal or ureteric stones?
Serum calcium and stone analysis ?cystinuria, uric acid stones and primary hyperparathyroidism
342
Stones what size usually pass spontaneously?
<5mm
343
Drugs that promote calcium stones (RF)?
loop diuretics, steroids, acetazolamide, theophylline
344
How do thiazides prevent calcium stones?
increase distal tubular calcium resorption
345
How do calcium oxalate stones appear on radiograph?
opaque, 40% frequency
346
Commonest cause of glomerulonephritis?
IgA nephropathy (aka Berger's disease)
347
Macroscopic haematuria in young people following an URTI- think?
IgA nephropathy
348
Conditions associated with IgA nephropathy?
alcoholic cirrhosis; coeliac/dermatitis herpetiformis; Henoch-Schonlein purpura
349
IgA nephropathy thought to be caused by what?
mesangial deposition of IgA immune complexes; pathological overlap with HSP
350
Histology of IgA nephropathy
mesangial hypercellularity, positive immunofluorescence for IgA & C3
351
Differentiate between IgA nephropathy and post-streo glomerulonephritis?
- IgA= develops 1-2 days after URTI, macroscopic haematuria, young males
- Post-strep= 1-2w after URTI, main symptom is proteinuria (haematuria can occur); low complement levels
352
IgA nephropathy Mx: isolated haematuria, no/ <500-100mg/day proteinuria and normal eGFR?
no Mx needed, follow-up to check renal function
353
IgA nephropathy Mx: persistent proteinuria >500-1000/day and a normal or slightly reduced eGFR?
inital: ACE inhibitors
354
IgA nephropathy Mx: active disease (falling GFR) or failure to respond to ACE inhibitors?
immunosuppression with corticosteroids
355
Markers of good prognosis in IgA nephropathy?
frank haematuria
356
Markers of poor prognosis in IgA nephropathy?
male, proteinuria (esp >2g/day), HTN, smoking, hyperlipid, ACE genotype DD
357
25% of pts with IgA nephropathy develop what?
ESRF
358
Renal cell cancer (hypernephroma) arises from what?
Proximal renal tubular epithelium
359
Most common histological subtype of renal cell cancer (hypernephroma)?
clear cell (75-85%) tumours
360
RFs for renal cell cancer (hypernephroma)?
middle-aged men; smoking; von Hippel-Lindau syndrome; tuberous sclerosis.
361
Classic triad for renal cell cancer (hypernephroma)?
haematuria, loin pain, abdo mass
362
Other features apart from the triad for renal cell cancer (hyper nephroma)?
- pyrexia of unknown origin
- varicocele (most L sided; caused by tumour compressing veins)
- stauffer syndrome
- 25% have mets at presentation
- endocrine effects
363
Endocrine effects of renal cell cancer?
- may secrete erythropoietin (polycythaemia)
- parathyroid hormone related protein (hypercalcaemia), renin
- ACHT
364
Stauffer syndrome?
paraneoplastic disorder associated with renal cell ca; presents as cholestasis/hepatosplenomegaly; though to be 2 to increased IL-6 levels
365
T1-T4 for renal cell cancer?
T1= ≤ 7 cm and confined to the kidney
T2= > 7 cm and confined to the kidney
T3= extends into major veins or perinephric tissues but not into ipsilateral adrenal gland and not beyond Gerota's fascia
T4= invades beyond Gerota's fascia (incl contiguous extension into the ipsilateral adrenal gland)
366
Mx for renal cell cancer?
- confined disease: partial (T1) or total nephrectomy
- alpha-interferon and interleukin-2= reduce tumour size & mets
- receptor tyrosine kinase inhibitors eg. sorafenib
