Renal Medicine Flashcards
(93 cards)
1
Q
What is the clinical diagnosis needed for an AKI?
A
> 6hrs oliguria
Increase in creatinine by 25 from baseline
Increase in creatinine x1.5 from baseline
2
Q
What is the difference between acute tubular necrosis and acute interstitial nephritis?
A
Acute tubular necrosis - ischaemia, either caused by renal injury or direct toxicity, there are granuloma casts
Acute interstitial nephritis - damage to the glomerulonephrons usually by penicillins, NSAIDs, rifampicin or allopurinol. There are white cell casts present, patients present with arthralgia or sterile pyuria
3
Q
How do you manage haemolytic uraemic syndrome?
A
Fluids Blood transfusion Dialysis Plasma exchange Eculizumab
4
Q
What is a common cause of IgA nephropathy?
A
This is when IgA mesangial depositation resulting in haematuria and proteinuria. It is believed to be caused by autoimmune factors resulting in higher IgA levels.
This is NOT the same thing as post-streptococcal glomerulonephritis
5
Q
What are the three features of nephrotic syndrome?
A
Proteinuria
Hypoalbuminaemia
Oedema
6
Q
Give some causes of nephrotic syndrome?
A
Minimal change disease
Focal Segment Glomerulosclerosis
Membranous nephropathy
7
Q
Give some causes of nephrogenic DI?
A
Genetics
Hypercalcaemia, Hypokalaemia
Lithium
Pyelonephritis
8
Q
What is reabsorbed in the proximal tubules?
A
Sodium (sodium, potassium pumps)
Glucose and amino acids (secondary active transport with sodium)
Bicarbonate
9
Q
What is reabsorbed in the collecting duct?
A
Sodium (Potassium and H+ excreted through co-transporters)
Water is reabsorbed through aquaporin channels
10
Q
What effect does hypotension have on the glomerular capillaries?
A
Low BP Decreased GFR Decreased pressure Afferent capillaries CONSTRICT Efferent capillaries DILATE
11
Q
How much is renal blood flow of normal cardiac output?
A
20%
12
Q
What diuretics may result in low K+?
A
Loop diuretics
Thiazide diuretics
13
Q
What cells in the kidney control renin release?
A
Macula densa cells int he juxtaglomerula apparatus detects low sodium causing renin release.
Renin is an enzyme that breaks down ngiotensinogen to Angiotensin I.
14
Q
What risk does long-term corticosteroids hold?
A
Thin skin Increased appetite, weight gain Bone thinning GI symptoms Immunosuppression Impaired glucose regulation
15
Q
What steroids have a predominantly glucocorticoid affect?
A
Prednisolone, Dexamethason
16
Q
What steroids are primarily mineralocorticoid?
A
Fludrocortisone
Hydrocortisone
17
Q
What part of the kidneys do each diuretic type act on? (3)
A
Loop diuretics - Loope of Henle
Thiazine - Distal convoluted tubule
Potassium sparing - aldosterone agonist
18
Q
What are some side effects of thiazide diuretics?
A
Low potassium, sodium, magnesium Metabolic acidosis High uric acid levels Dehydration Rarer - thrombocytopaenia, agranulocytosis, pancreatitis
19
Q
What are the stages of CKD?
A
1 - kidney damage with eGFR >90 2 - kidney damage with mildly lower GFR 60-90 3 - moderate decrease - 30-60 4 - severe decrease - 15-30 5 - kidney failure - <15
20
Q
Give 5 causes of CKD?
A
hypertension diabetes glomerulonephritis, IgA nephropathy renal artery stenosis obstruction
21
Q
What are some clinical features in severe CKD?
A
malaise, anorexia Noctura, polyuria Itching N+V Uraemic symptoms
22
Q
How do you monitor the progression of kidney disease?
A
Blood pressure
Creatinine
Proteinuria
23
Q
What are the DAMN drugs?
A
Diuretics
ACE-i
Metformin
NSAIDs
24
Q
How can you manage proteinuria?
A
ACE-i
ARB
Lifestyle
Weight loss
25
What should be offered to all patients with CKD?
A statin, unless contraindicated
26
What complications can occur in CKD?
Renal bone disease
Oedema
Heart disease
27
When do you offer haemodialysis?
eDFR 14-10
28
Give some causes of metabolic acidosis that cause a high or low anion gap?
High - lactate (sepsis, shock, hypoxia), DKA, alcohol, urate (renal failure)
Normal - GI bicarb loss (diarrhoea, fistula), drugs, Addison's
29
What is membranous glomerulonephritis?
A cause of nephrotic syndrome, autoimmune association - SLE
Low total thyroxine levels may be seen
Puffy and swollen eyes
Fluid retention
30
What cancer are you at increased risk at post-renal transplant?
Melanoma and skin malignancy - SCC
31
What is HUS?
Haemolytic Uraemic Syndrome
Intravascular haemolysis with fragmentation that causes endothelial damage resulting in abdominal pain, blood diarrhoea and an AKI
32
What often causes HUS?
e.coli
Others include HIV, pneumococcal, SLE
33
What is the triad often seen in HUS?
AKI
Thrombocytopaenia
Microangiopathic haemolytic anaemia
34
How is HUS treated?
Supportive - fluids, blood transfusion and dialysis if required
Plasma exchange - in severe cases (not associated with diarrhoea)
Eculizumab
35
What is acute interstitial nephritis?
Drug-induced AKI
Caused by penicillin, rifampicin, NSAIDs, allopurinol, furosemide, SLE, sarcoidosis
Causes fever, rash, arthralgia, eosinophilia, mild renal impairment, HTN, sterile pyuria and WCC
36
What are risk factors for an AKI?
CKD
Dehydration
Age
Diabetes
37
What is seen on an ABG of someone with DKA?
Metabolic acidosis with a high anion gap
| Hx may include high capillary blood glucose, tachy, dry mucous membranes, reduced skin turgor, fruity smell to breath
38
How much glucose is required per day in fluid therapy?
50-100g/day irrespective of weight
39
Urea that is proportionally higher than creatinine rise may indicate?
GI bleed
| Dehydration
40
What is HSP?
Henoch-Schonlein Purpura
IgA mediated small vessel vasculitis
Seen in children following infection
Palpable purpuric rash, localed oedema, abdominal pain, polyarthritis, haematuria/renal failure
41
What is the most common viral infection in solid organ transplant recipients?
Cytomegalovirus
Treat with Ganciclovir
42
What does a raised anion gap suggest?
Increased production or reduced excretion of... lactic acid, urate, ketones or drugs/toxins (salicylates)
43
What are some non-kidney associations of ADPKD?
```
Mitral valve prolapse
Hepatomegaly (liver cysts)
Diverticulosis
Intracranial aneurysms
Ovarian cysts
```
44
How do you treat minimal change disease?
Prednisolone
45
What foods should be avoided in dialysis?
Tomatoes, bananas, coffee, chocolate, mushrooms and rhubarb - high potassium
Dairy, yoghurt, milk - phosphate
46
Give 3 complications of haemodialysis
Access problems - blocked catheter, fistula inflammation
Hypotension, nausea, headaches
Infection
47
What are the two types of peritoneal dialysis?
Continuous ambulatory peritoneal dialysis - manual drain of 2-3L of fluid, needs doing 3-4x a day
Automated peritoneal dialysis - machine overnight for 7hrs
48
Give an advantage and disadvantage of haemodialysis
Better for those who live alone and need help managing
Better if previous abdominal surgery
Logistics of hospital visits 3 times a week
49
Give an advantage of peritoneal dialysis
Better in severe HF
| Useful for younger patients with work who want control of their care
50
What is the biggest cause of death in dialysis patients?
Ischaemic heart disease
| Mortality is very poor
51
What is glomerulonephritis?
A parenchymal group of kidney diseases that involve inflammation of the glomerulus - usually immune mediated
52
What is the classic triad in acute nephritis syndrome?
Haematuria
Proteinuria
Oedema
53
What is IgA nephropathy and what do you see on biopsy?
Autoimmune nephrophathy
Biopsy: mesangial proliferation, IgA and C3 deposits on immunofluorescence
Cause of glomerulonephritis, occurs post URTI, causes haematuria
54
What is HSP?
Henoch-Schonlein Purpura
Systemic vasculitic variant of IgA nephropathy
Presents with abdominal pain, GI bleeding, nephritis, purpuric rash on extensor surfaces
55
What is Goodpasture's Disease and what other organ can it affect?
Anti-glomerular basement membrane, autoantibodies to type IV collagen
Haematuria, nephritic syndrome, AKI
Can affect the lungs
Treat with plasma exchange
56
What is the difference between nephrotic and nephritic syndrome?
Nephritis - haematuria, proteinuria, oedema
| Nephrotic - low albumin, proteinuria, oedema
57
By what increase in creatinine defines an AKI?
```
>50% increase
or
>26.4 from baseline
or
oliguria
```
58
How are the causes of an AKI divided up and give 3 causes for each.
Pre-renal - dehydration, burns, infection, hamorrhaging (to do with volume), renal artery stenosis
Renal - glomerulonephritis, acute tubular necrosis, nephrotic syndrome, nephrotoxic drugs (damage to kidneys)
Post-renal - obstructive causes, renal stones, tumours, BPH
59
How might an AKI result in complications?
```
Hyperkalaemia
Metabolic acidosis
Pulmonary oedema
Hypernatraemia
Hypocalcaemia
```
60
What actions should be taken to manage an AKI?
Stop ACE-i, diuretics, metformin, anti-hypertensives, NSAIDs
Optimise fluid balance
Monitor
Dialysis
61
What is rhabdomyolysis and what are risk factors for it?
It is inflammation and breakdown of skeletal muscles resulting in chemical release.
Occurs after prolonged falls, crush injuries, post-ischaemia, drugs and statins
62
What are clinical features and symptoms of rhabdomyolysis?
```
Malaise
Dark coloured urine
Muscle swelling, pain and weakness
Hyperkalaemia
AKI
```
63
Give the name of 5 nephrotoxic drugs that should be stopped in an AKI
```
NSAIDs
Gentamicin
ACE-i
Metformin
Acyclovir
Diclofenac
LMWH
```
64
What is transluminal angioplasty used in the treatment of?
Renal vascular disease
65
What is HUS?
Haemolytic uraemic syndrome - microangiopathy, intravascular haemolysis with endothelial fragmentation
Presents with AKI, abdo pain, blood diarrhoea, usually post-e.coli infection
Treat with plasma exchange or dialysis
66
What is TTP?
Thrombotic Thrombocytopenic Purpura
Fragmental and endothelial damage resulting in platelet aggregation
Ix: low platelets, anaemia, fragmental RBC
Treat with plasma exchange and steroids
Monoclonal antibodies - eculizumab
67
What are clinical features of polycystic kidney disease (autosomal dominant)?
Renal enlargement
Cysts on USS (black spaces)
Increased BP
Abdominal pain, haematuria
68
What are associations of Horseshoe kidneys?
Gout, hypomagnesia, abnormal LFTs, abnormal genital tract development
69
What is Alport syndrome and it's main association?
A problem with T4 collagen production
| Glomerular basement membrane problems, sensorineural deafness, eye abnormalities
70
Give 3 diseases that have systemic renal manifestations.
Amyloidosis
Multiple myeloma
Diabetes
71
What happens when the kidneys stop working (AKI)?
```
Reduced urine output
Fluid overload
Raised in potassium, urea and creatinine
(potassium - arrythmias)
(uraemia - pericarditis, encephalopathy)
```
72
Mixed symptoms of weakness, dyspnoea, hepatomegaly and worsening renal function may indicate?
Amyloidosis
Typically diagnosed between 50-65
High levels of proteinuria
73
What would a desmopressin test result look like for cranial DI?
After water deprivation - 240mOsmol/kg
After desmopressin - 850 mOsmol/kg
High sodium
74
What are some causes of cranial DI?
Post-head injury, pituitary surgery/tumour (craniopharyngiomas)
Haemochromatosis (raised RBCs)
75
What are some causes of nephrogenic DI?
Genetic
Hypercalaemia, hypokaelaemia
Lithium
Pyelonephritis, tubulo-interstitial disease
76
What do fused podocytes on light microscopy indicate and what symptoms might this patient present with?
```
Minimal change disease
Children
Scrotal swelling, leg swelling, eye swelling
Fatigue, frothy urine
Cough
```
77
What is your first line management in cranial and nephrogenic diabetes insipidus?
Cranial - desmopressin
| Nephrogenic - thiazide diuretic, chlorothiazinde, low salt/protein diet
78
What do muddy brown casts on urine microscopy indicate?
Acute tubular necrosis
79
```
What is the difference between the following kidney diseases?
Acute interstitial nephritis
Acute tubular necrosis
Glomerulonephritis
IgA nephropathy
Thin basement membrane
```
Acute interstitial nephritis - drug toxicity, NSAIDs, rifampicin, allopurinol, penicillin, furosemide
Acute tubular necrosis - muddy brown casts, myoglobinuria, worsening renal function
Glomerulonephritis
IgA nephropathy
Thin basement membrane - autosomal dominant, persistant microscopic haematuria, no worsening of renal function
80
What is acute interstitial nephritis?
Acute kidney injury caused by drugs (penicillin, NSAIDs, rifampicin, allopurinol, furosemide), SLE, sarcoidosis, Hanta virus, staphyclocci
There is marked intersitial oedema on histology with intersitial infiltrate in the connective tissue between renal tubules
Features: fever,r ash, arthralgia, eosiophilia, mild renal impairment, HTN
Ix: sterile pyuria, white cell casts
81
Give the name of two alpha blockers and explain their mechanism of action.
Tamsulosin
Alfuzasin
Sympathetic fibre innervation, muscle relaxation
82
What are finasteride and dutasteride?
5-alpha reductase inhibitors
83
What is the classic three symptoms of pyelonephritis and how is it treated?
Loin pain
Fever
Dysuria
Co-amoxiclav or IV cefuroxime if bad
84
Give 8 side effects of PO steroids.
Osteoporosis, central obesity, impaired glucose tolerance, fatigue, fluid retention, headache,
85
What structures arise from the ectoderm?
```
CNS
Brain
Peripheral nerves
Melanocytes
Nails
Sweat glands
Sebaceous glands
Hair
Tooth
Breast
```
86
What structures arise from the mesoderm?
```
Muscle
Bone
Cartilage
Dermis
Connective tissue
Kidneys
Ovary
Testis
Heart
Blood cells
Spleen
```
87
What structures arise from the endoderm?
```
Stomach
Intestine
Liver
Pancreas
Bladder
Epithelial lining of bladder and urethra
Thyroid
Tonsils
Parathyroids
```
88
What is your first line management of high phosphate?
Reduce dietary intake of phosphate
Bisphosphates
Vitamin D: alfacalcidol, calcitriol
May require parathyroidectomy
89
What are your investigations for a renal vein thrombosis?
Doppler ultrasound
90
What are some complications of nephrotic syndrome and post-strep glomerulonephritis?
Renal vein thrombosis
Sepsis
Hyperlipidaemia
91
Why is there a delay in infection before presentation with nephrotic syndrome?
Time requires for immunocomplexes to form, attach to basement membrane and cause resulting damage to basement membrane
92
What cause would you suspect in a child with swollen eyes and frothy urine post-sore throat?
Post-streptococcus proliferative glomerulonephritis
Lancefield group A beta-haem strep
Strep pyogenes
(cause infections of throat, ear and skin)
93
What are some potential causes of a low urine output post-surgery?
- dehydration
- blocked catheter
- retention
Give fluids and see if patient responds, if they don't then consider haemorrhage
