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Phase 3b > Renal Medicine > Flashcards

Renal Medicine Flashcards

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1
Q

5 functions of the kidney

A

Acid-base control (pumps out H+, reabsorbs bicarb)

Regulates blood/fluid volume

Waste, toxin and drug excretion

Produces erythropoietin (stimulating red cell production)

Vitamin D metabolism (Vit D to 1-Hydroxyvit D)

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2
Q

How do we measure kidney function?

A

Creatinine:

Albumin:creatinine ration (mg/mmol)

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3
Q

CKD staging

A

1: >90 (+evidence kidney damage)
2: 60-89 (+evidence kidney damage)
3a: 45-59
3b: 30-44
4: 15-29
5: <15

Takes into account albuminuria (<3, 3-30, >30)

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4
Q

How does renal failure lead to anaemia?

A

Reduced erythropoietin production

Reduced hepcidin clearance (waste product from liver which impairs iron absorption by duodenum)

Therefore give iron supplements (IV as duodenum absorption reduced)

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5
Q

Nephrotic syndrome proteinuria threshold

A

> 3g protein excreted per 24 hours

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6
Q

CKD timescale

A

> 3 months

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7
Q

Which patients should be started on ARB/ACE-i?

What should their BP target be?

A

Diabetic and ACR >3mg/mmol

Hypertensive and ACR >30mg/mmol

ACR >70mg/mmol

Target of 130/80

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8
Q

Management of acute hyperkalaemia?

A

Calcium gluconate 10ml 10% (protects myocardium)

Followed by salbutamol, insulin and dextrose to drive potassium into cells

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9
Q

Role of vitamin D

A

Increases calcium absorption
Increases renal tubular reabsorption
Increases osteoclast activity (releasing calcium from bone)

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10
Q

Stages of vitamin D activation

A

Cholecalciferol to calcidiol by liver

Calcidiol to calcitriol by kidneys

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11
Q

What acid-base changes might occur in CKD?

A

H+ ion retention leading to acidosis - treated with sodium bicarbonate

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12
Q

Possible complications of CKD

A

Anaemia
Fluid overload
Mineral and bone disorders
Hyperkalaemia

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13
Q

What type of anaemia would you see in CKD and how would you manage?

A

Normochromic normocytic

Erythropietin-stimulating agents e.g. epoetin alfa

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14
Q

Indications for dialysis in AKI

A

Refracatory hyperkalaemia
Refractory pulmonary oedema
Severe metabolic acidosis (<7.1)
Severe uraemia (>60mmol/L or CXR)

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15
Q

Complications of AKI

A

Hyperkalaemia
Fluid overload
Metabolic acidosis
Uraemic complications (pericarditis and encephalopathy)

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16
Q

Rhabdomyolysis signs and symptoms

A

Muscle pain
Dark brown urine (myoglobinuria)
Raised CK levels

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17
Q

Nephrotoxic drugs

A 
ACE-i/ARBs
NSAIDs
penicillin 
Diuretics 
Furosemide 
Rifampicin 
Cephalasporins
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18
Q

Clinical definition of oliguria?

A

<0.5mls/kg/hr (35mls/hr in a 70kg patient)

If this persists >6hrs then is defined as AKI

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19
Q

How do NSAIDs adversely affect renal function?

A

Inhibition of COX1/2 leading to inhibition of prostaglandin synthesis. This causes constriction of afferent arterioles and reduced renal perfusion

Promotes natriuresis (sodium excretion in urine)

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20
Q

How is Stage 1 AKI diagnosed?

A

Serum creatinine (increase by >26umol/L in 48 hours or >1.5-1.9 in 7 days)

Urine output (<0.5mls/kg/hr over 6 hours)

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21
Q

Pre-renal causes of AKI and what can they lead to?

A

Cardiac output (cardiac failure)

Arteriolar changes (nephrotoxic drugs e.g. ACE-i or NSAIDs)

Systemic vasodilation (septic shock)

Reduced circulating volume (hypovolaemia)

This can lead to intrinsic damage due to prolonged ischaemia of renal parenchyma and development of acute tubular necrosis (ATN)

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22
Q

Intrinsic causes of AKI

A

Vascular:
Large vessel: atherosclerotic disease, thromboembolic disease, dissection, renal artery stenosis/thrombosis

Small vessel: vasculitides, malignant HTN, microangiopathic haemolytic anaemia (e.g. DIC), thromboembolic disease

Glomerular: primary or secondary. Can cause nephritic/nephrotic syndrome

Tubulointerstitial: acute tubular necrosis (ATN); acute interstitial nephritis (secondary to medication)

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23
Q

Post-renal causes of AKI

A

Obstructive uropathy (urolithiasis, malignancies, strictures and bladder neck obstruction)

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24
Q

Clinical features of pre-renal AKI

A

Evidence of dehydration/hypovolaemia:
Dry mucus membranes, reduced CRT, reduced urine output, low BP, reduced skin turgor, dizziness and thirst

Hypervolaemia (due to cardiac failure):
Pulmonary/peripheral oedema, orthopnoea, paroxysmal nocturnal dyspnoea, dyspnoea, raised JVP, ascites

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25
Acute tubular necrosis clinical features
Brown muddy casts in urine (tubular cells) | AKI features
26
Clinical features of tubulointerstitial disease
Arthralgia Rashes Fever Eosinophilia
27
Clinical assessment of patient with AKI
``` Fluid assessment (urine output) Urine osmolality and electrolytes MSU Urine dipstick ECG ``` Bloods: FBC, U&Es, bone profile, blood gas Complement, vasculitis screen (ANCA, ANA), clotting, CK, blood film, Ig ULTRASOUND, CXR, renal doppler, MRA
28
When would you discuss an AKI patient with a nephrologist?
<30 GFR, or decrease by >15 in a year ACR >70mg/mmol Rare or genetic cause of CKD Renal artery stenosis Persistent HTN despite 4 anti-hypertensives Diagnosis that may require specialist intervention (e.g. glomerulonephritis, systemic vasculitis)
29
Management of AKI
Regular assessment and monitoring of urine output (catheter), weight, creatinine levels compared with baseline Hypovolaemia: IV fluids Hypervolaemia: fluid restriction/diuretics Hyperkalaemia: 10ml calcium gluconate 10%, 10 units ACTRAPID insulin in 20% dextrose, 2.5mg salbutamol Acidosis: sodium bicarbonate RRT: if refractory pulmonary oedema/hyperkalaemia, severe uraemia (leading to encephalopathy or pericarditis), metabolic acidosis
30
RENAL DRS 26
``` Record baseline creatinine and regular U%Es Obstruction excluded (USS) Urinalysis +/- MSU Nephrotoxic drugs stopped Dry (IV fluids) or wet (furosemide) Urinary output monitoring Prescription review 26 (>26umol/L serum creatinine in 48 hours for diagnosis) ```
31
Triad of nephrotic syndrome (+ other features)
1. Hypoalbuminaemia 2. Proteinuria (>3.5g per day) 3. Oedema (low oncotic pressure) + coagulopathy, sepsis, hyperlipidaemia, hypocalcaemia
32
Rapidly progressive glomerulonephritis features
Thrombosis and rupture of capillaries leading to glomerular crescent formation in >50% of glomeruli 50% reduction in GFR over 3 months
33
Primary and secondary causes of nephrotic syndrome
Caused by structural changes in the glomeruli Primary: Minimal Change Disease (commonest in children), membranous GN (commonest in adults), focal segmental glomerulosclerosis (common in adults) Secondary: SLE, diabetes mellitus, amyloidosis
34
Causes of nephritic syndrome?
Proliferative: IgA nephropathy, membrano-proliferative GN, post-strep GN Proliferative with crescents (rapidly progressing): anti-GBM, Wegener's, microscopic polyangitis
35
Treatment for minimal change disease
Glucocorticoids | Immunosuppressants (cyclophosphamide) if not responding
36
Minimal change disease clinical features
Fusion of podocyte foot processes Nephrotic syndrome Normotensive Highly selective proteinuria PUFFY FACE
37
Causes of minimal change disease
Idiopathic (majority) Drugs: NSAIDs or rifampicin Hodgkin's lymphoma, thymoma infectious mononeucleosis
38
Causes of membranous glomerulonephritis
Thickened basement membrane Idiopathic: anti-phospholipase A2 antibodies Infections: hepatitis B, malaria, syphilis Malignancy: lung cancer, leukemia Drugs: penicillamine, NSAIDs SLE, thyroiditis, rheumatoid
39
Management of membranous glomerulonephritis
ACE-i/ARBs to reduce proteinuria Immunosuppression (corticosteroid + cyclophosphamide) Anti-coagulation if high risk 1/3 spontaneous remission 1/3 ongoing proteinuria 1/3 ESRF
40
Nephritic syndrome clinical presentation
Haematuria Mild proteinuria HTN Oliguria
41
What is nephritic urinary sediment?
Urinary red cell casts Leucocytes Dysmorphic red cells Sub-nephrotic proteinuria (>3.5g/day)
42
Most common cause of glomerulonephritis worldwide?
IgA nephropathy
43
What conditions are associated with IgA nephropathy and how might a patient present?
Alcoholic cirrhosis, coeliac disease/dermatitis herpetiformis, Henoch-Schonlein Purpura Presentation: young male following URTI, recurrent episodes of frank haematuria
44
Difference between IgA nephropathy and post-strep glomerulonephritis?
IgA is 1-2 days after URTI, post-strep 1-2 weeks IgA young males with frank haematuria Post-strep presents with proteinuria with haematuria less common
45
Management of IgA nephropathy
ACE-i; Steroids/immunosuppressants Up to 50% will have ESRF and need RRT
46
Alport syndrome presentation
``` Childhood Progressive renal failure Microscopic haematuria Sensorineural deafness Ocular pathologies (lenticonus - protrusion of lens into anterior chamber) ``` Diagnosed by genetic testing (X-linked) and renal biopsy
47
What antibodies are found in 30% of cases of anti-GBM?
ANCA (associated with better response to treatment)
48
Anti-GBM management
Plasmapheresis (removes antibodies) Corticosteroids Cyclophosphamide
49
Complicated UTIs
``` Male Pregnant Diabetic Immunological abnormalities Catheter Structural abnormalities ```
50
Gram stain for E. coli
Gram negative bacillus
51
Organisms other than E. coli that might cause UTIs
Staph saprophyticus Klebsiella pneumoniae Proteus
52
What is urosepsis?
2 or more signs of systemic inflammatory response syndrome: Temp: >38 or <36 HR: >90 RR: >20 WCC: >12 or <4 + suspected urinary source of infection
53
What would you expect to see on urinalysis for a UTI?
Nitrites (90% +ve) | Leucocytes (50% +ve)
54
Bacteriuria definition
>10^5 colony forming units/ml
55
Which UTI bacteria are associated with poorer outcomes and require broad spectrum ABx?
Extended spectrum beta lactamase producing E. coli Use carbapenems
56
Which bacteria are more likely to lead haematogenous spread of UTI?
Staph aureus Candida Mycobacterium TB
57
What signs might you see with a UTI
``` Suprapubic tenderness Fever Rigors Costovertebral tenderness Flank pain Confusion ```
58
UTI diagnosis
In young, non-pregnant females usually clinical symptoms is enough, but you could also do a urine dip ``` Urine dip (leucocytes and nitrites) Urine microscopy, culture and sensitivity ``` FBC, U&Es, CRP USS, CT (non-contrast) - abscesses, calculi, haemorrhages, obstruction
59
Management of uncomplicated UTI
Nitrofurantoin/trimethoprim BD 3 days female, 7-10 days male Uncomplicated pyelonephritis: don't admit, treat with fluoroquinoline e.g. ciprofloxacin 12-hourly for 14 days
60
Management of complicated UTI
Oral fluoroquinoline (e.g. ciprofloxacin) IV co-amoxiclav if urosepsis or severe pyelonephritis
61
Which Ig protects mucosal surfaces, and what does that include?
IgA Intestines, resp tracts, oral mucosa, urothilium
62
Who should you avoid trimethoprim in, and what adverse effects are there?
Pregnant women (or anyone with folate deficiency) - give nitrofurantoin instead Nausea, vomiting, diarrhoea, rash, pruritis
63
How does rhabdomyolysis lead to AKI?
Causes myoglobinuria Myoglobin causes tubular cell necrosis - ATN
64
When prescribing routine maintenance fluid, what is the normal requirement for chlorine, potassium and sodium?
1 mmol/kg/day
65
What symptoms might come with Henoch-Schonlein Purpura?
Abdominal pain Palpable rash Arthritis Usually children
66
Pulmonary haemorrhage (chest pain/cough/haemoptysis) followed rapidly by haematuria - what is the disease and why does it present like this?
Goodpasture's syndrome (anti-GBM) Anti-GBM antibodies affect Type IV collagen found in lungs and kidneys leading to glomerulonephritis
67
Risk factors and management of Goodpasture's syndrome?
Smoking, LRTI, pulmonary oedema, hydrocarbon inhalation, young age (20-30) Mx: renal biopsy (IgG deposits along basement membrane), raised transfer factor secondary to pulmonary haemorrhage Plasma exchange (plasmapheresis), steroids, cyclophosphamide
68
What do you use to prevent contrast-induced nephrotoxicity? When does it occur?
IV sodium chloride 0.9% 1ml/kg/hour for 12 hours pre- and post-procedure Occurse 3-5 days post-procedure
69
What antibodies would you see in Granulomatosis with polyangitis (Wegener's)?
ANCA Inflammation of blood vessels around the body
70
Crystalloid vs colloid
Crystalloid: smaller molecules, immediate reuscitation, can cause oedema Colloid: larger molecules, more expensive, quicker volume expansion in intravascular space but can cause allergic reactions, clotting disorders and kidney failure
71
Treatment of Henoch-Schonlein?
Analgesia for arthralgia Supportive therapy for nephropathy Usually good recover, 1/3 have relapse
72
What is Alport syndrome caused by
X-linked genetic defect in the gene which codes for type IV collagen (glomerular basement membrane)
73
What can a failed renal transplant in an Alport patient lead to?
Goodpasture syndrome presentation (pulmonary haemorrhage and haematuria caused by anti-GBM antibodies)
74
Potassium-sparing diuretics
Spironolactone | Eplerenone
75
NICE guidelines for IV fluid resus
IV sodium chloride 0.9% 500mls over 15 mins
76
SLE with proteinuria
Lupus nephritis
77
What is the risk with using metformin in renal failure?
Build up of metformin as it is usually cleared by the kidneys Can lead to lactic acidosis
78
Use of aspirin in renal failure?
Has to be reduced to low dose (75mg per day)
79
Features of autosomal dominant polycystic kidney disease
``` HTN Abdominal pain and early satiety Recurrent UTIs Renal stones Haematuria CKD Liver cysts, berry aneyrsysm, pancreatic cysts, CV (mitral valve prolapse, aortic dissection, valve incompetence) ```
80
Cause of diabetes insipidus and what might you see on biochemistry results?
Lack of ADH production from posterior pituitary (cranial) or reduced sensitivity of kidneys to ADH (nephrogenic) High/borderline plasma osmolarity (making patients thirsty to reduce osmolarity) Inappropriately low urine osmolarity
81
How is DI diagnosed
Water deprivation test - leads to rise in plasma osmolarity and continued production of low urine osmolarity In cranial DI, exogenous vasopressin will counteract this In nephrogenic DI, exogenous vasopressin has no effect
82
What drugs remove potassium from the body?
Loop diuretics Calcium resonium Dialysis
83
What conditions lead to bilaterally enlarged kidneys?
Diabetic nephropathy HIV-induced nephropathy Amyloidosis Autosomal-dominant polycystic kidney disease
84
Most common cause of viral infection following organ transplant, and what is the treatment?
Cytomegalovirus | Ganciclovir
85
Best way of distinguishing pre-renal uraemia from ATN?
Pre-renal: <20mmol/L urinary sodium | ATN: >40mmol/L
86
Maintenance fluid calculation for non-neonates
100ml/kg/day for first 10kg 50ml/kg/day for every kg from 10-20kg 20ml/kg/day for all weight after
87
Features of renal cell carcinoma
Triad: haematuria, loin pain, abdo mass Pyrexia Left varicocele (due to occlusion of left testicular vein) Can secrete EPO (polycythaemia), PTH (hypercalcaemia), renin, ACTH
88
Chlamydia features
Majority asymptomatic Urinary leucocytes and blood Dysuria, cervicitis (discharge and bleeding) Men: discharge and dysuria
89
Causes of haematuria
``` Persistent, non-visible: Cancer (bladder, renal, prostate) Prostatitis Cervicitis Stones Renal - IgA nephropathy, thin basement membrane ``` ``` Sudden onset: Menstruation Sexual intercourse UTI Vigorous exercise ``` Spurious: Rifampicin, doxorubicin Beetroot
90
Indications for urgent referral
>45 AND unexplained visible haematuria in absence of UTI or after successful treatment of UTI >60 AND unexplained nonvisible haematuria with either dysuria or raised WCC
91
Indications for non-urgent referral
>=60 with persistent UTIs no referral needed if normotensive, normal renal function and no proteinuria
92
Test to assess diabetic nephropathy in a patient
Early morning ACR
93
Causes of haemolytic uraemic syndrome
E.coli HIV Pneumococcus Cancer
94
Diagnosis and management of HUS
FBC (thrombocytopaenia, anaemia), U&E (AKI), stool culture Management: Fluids, blood transfusion and dialysis if severe, eculizumab
95
Stage 2 AKI
2-2.9 baseline creatinine
96
Most common causes of acute interstitial nephritis
Drugs: rifampicin, penicillin, NSAIDs, allopurinol, furosemide SLE Sarcoidosis Staph
97
Features of acute interstitial nephritis
Arthralgia Rash Fever Eosinophilia Mild renal impairment Hypertension
98
Diagnosis of acute interstitial nephritis
Sterile pyuria | White cell casts
99
Features of tubulointerstitial nephritis with uveitis
Young women Painful red eye Weight loss Fever Urinalysis: leucocytes and protein
100
Indication for MRI in renal failure
Renal artery occlusion
101
Indication for abdo X-ray in renal failure
Renal stones
102
Maintenance fluid calculation for adults
25-30ml/kg/day 1mmol/kg/day of electrolyte 50-100g/day glucose
103
Recommended fluid challenge for patients with no signs of heart failure
500ml 0.9% saline STAT
104
Rhabdomyolysis treatment
IV saline to perfuse kidneys
105
Treatment for nephrogenic DI
Chlorothiazide (promotes sodium release into the urine)
106
EPO side effects
``` Flu-like symptoms HTN leading to encephalopathy Bone aches Skin rashes Pure red cell aplasia Increased risk of thrombosis ```
107
What abx can cause AKI
Gentamicin

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