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Flashcards in Urinary and Electrolytes Deck (84):
1

Example, Action and SE of loop diurectics

Furosemide
Inhibit Na/K/2Cl symporter in the tick ascending limb of the LoH
SE - hypokalaemic, hyponatramiea, low mg, met alkalosis, ototoxic, Hypovolaemia/ low BP, nausea

2

Example, Action, SE and CI of thiazide diurectics

Bendroflumethazide
Inhibit NaCl co-transporter in DCT

SE: ↓K,Na,Mg, hyperglycaemia, ↑ urate, postural hypotension, ↑ calcium, impotence

CI - addisons, ↓K, ↑ calcium, gout

3

Example, Action, SE and CI of K-Sparing Diuretics

Spironolactone - aldosterone antagonist
Amiloride - blocks DCT/CD luminal Na channel
 SE: ↑K, anti-androgenic (e.g. gynaecomastia, impotence, menstrual irregularities), ↓Na, lethargy, headache, confusion, hepatotoxic

4

Example, Action, SE and CI of Osmotic Diuretics

mannitol - freely filtered and poorly reabsorbed
 Effect: ↓ brain volume and ↓ ICP
 SE: ↓Na, pulmonary oedema, n/v

5

Causes of haematuria

Hereditary - PKD
Antibiotics - cipro/ cephalosporin
Embolism/ infarct
Malignancy - renal, bladder, prostate
AI - GN, TIN
Trauma - renal/extrarenal - stone/catheter
Urethritis/ prostitis
Renal stone
Infection
Anticoagulants - NSAIDs

6

Causes of proteinuria

Common
- DM
- mimimal change
- amyloidosis
-SLE

Other
- HTN/ UTI/ Fever/ ATN/ TIN

7

what is eGFR modified for

sex, age, race

8

Causes of renal disease/ AKI

Pre-renal
- shock/ hypovolaemia
- renal vascular - RAS, NSAIDs, ACEi, thrombosis, hepatorenal syndrome

Renal
- GN
- ATN - ischaemia (shock) or nephrotoxins

Post-renal - SNIPIN
- Stone
- Neoplasm
- Inflammation (stricture)
- Prostatic hypertophy
- Infection - TB/ Sarcoid
- Neuro - post op/ neuropathy

9

Presentation of renal failure

UP-NAKAD
- Uraemia
- Protein loss and Na retention
poly/oli/an- uria, polydipsia, SOB; oedema, HTN, ↑ JVP
- Acidosis
SOB -+/- kussmaul, confused
- hyperKalaemia - palpitations, chest pain, weakness
- Anaemia - SOB, lethagy, faint, tiniitus, pallor, ↑HTR, Flow murmur
- vitamin D deficiency - bone pain/ # +/- osteomalacia

10

Symptoms and signs of uraemia

Symptoms
Pruritus
n/v, anorexia, wt. loss
Lethargy
Confusion
Restless legs
Metallic taste
Paraesthesia: neuropathy
Bleeding
Chest pain: serositis
Hiccoughs

Signs
Pale, sallow skin
Striae
Pericardial or plueral rub Fits
Coma

11

Presentation of UTI

Pyelonephritis
 Fever, rigors
 Loin pain and tenderness
 Vomiting
 Oliguria if ARF

Cystitis
 Frequency and urgency
 Polyuria
 Haematuria
 Dysuria
 Suprapubic tenderness
 Foul smelling urine

Prostatitis
 Flu-like symptoms
 Low backache
 Dysuria
 Tender swollen prostate on PR

12

Risk Factors for UTIs

 Female
 Sex
 Pregnancy
 Menopause
 DM
 Abnormal tract: stone, obstruction, catheter,
malformation

13

UTI - causative organisms

 E. coli
 Staphylococcus saprophyticus
 Proteus (alkaline urine → struvite renal stones)
 Klebsiella

14

Management of UTIs

Drink plenty, urinate often

Cystitis
 Trimethoprim/ Nitrofurantoin for 3d (F) and 7d (M)

Pyelonephritis
 Cefotaxime 1g IV BD for 10d

Prostatitis
 Ciproflxacin 4 weeks

15

Causes of glomerulonephritis

 Idiopathic
 Immune: SLE, Goodpastures, vasculitis
 Infection: HBV, HCV, Strep, HIV
 Drugs: penicillamine, gold
 Amyloid

16

Complications of renal biopsy and when you should stop meds before

- mild back pain
- visible haematuria
- bleeding
- need for transfusion

- have bed rest 4h

Stop aspirin 1 week and INR <1.2, LMWH stop 24h before

17

Features of IgA nephropathy and Mx

 Young male
- episodic macroscopic haematuria occurring a few days after URTI.
 Rapid recovery between attacks
 ↑IgA
 Can occasionally → nephritic syndrome

Biopsy - IgA deposition in mesangium

Mx: Steroids or cyclophosphamide if ↓renal function

18

Features of thin BM disease

AD
 Persistent, asymptomatic microscopic haematuria
 V. small risk of ESRF

19

Features of Alport's syndrome

 Haematuria, proteinuria → progressive renal failure
 Sensorineural deafness
 Lens dislocation and cataracts
 Retinal “flecks”
 Females: haematuria only

20

Nephritic v Nephrotic syndrome

Nephritic
 Haematuria (macro / micro) + red cell casts
 Proteinuria → oedema (esp. periorbital)
 Hypertension
 Oliguria and progressive renal impairment

Nephrotic
 Proteinuria: PCR >3.5g/24h
 Hypoalbuminaemia: <35g/L (Muehrcke's nails)
 Oedema: periorbital, genital, ascites, peripheral
- Often intravascularly depleted = ↓ JVP (cf. CCF)

21

Features and Rx of post-streptococcal GN

Young child develops malaise and nephritic syndrome - smoky urine 1-2wks after sore throat or skin infection.
 ↑ASOT (anti-strep Ab titre)
 ↓C3
 ↑ anti-DNAase
Biopsy: IgG and C3 deposition
Rx: Supportive

22

Features of RPGN/ Cresenteric

Type 1: Anti-GBM (Goodpasture’s)
 Ab to NC domain of collagen 4
 Haematuria and haemoptysis
 CXR shows infiltrates
 Rx: Plasmapheresis and immunosuppression

Type 2: Immune Complex Deposition – 45%
e.g SLE

Type 3: Pauci Immune – 50%
cANCA: Wegener’s
pANCA: microscopic polyangiitis, Churg-Strauss

23

Complications of nephrotic syndrome

Infection: ↓ Ig, ↓ complement activity
VTE: up to 40%
Hyperlipidaemia: ↑ cholesterol and triglycerides

24

Causes of nephrotic syndrome

- Systemic - DM, SLE, amyloidosis

1) Minimal change GN - children
 Assoc. URTI
 Biopsy: normal light micro, fusion of podocytes on EM
 Rx: steroids

2) Membranous Nephropathy
 20-30% of adult
 Assoc: Ca: lung, colon, breast; AI: SLE, thyroid disease; HBV; Penicillamine, gold
 Biopsy: subepithelial immune complex deposits
 Rx: immunosuppression if GFR ↓
 40% spontaneous remission

3) FSGS
 Idiopathic or Secondary e.g. HIV
 Biopsy: focal scarring, IgM deposition
 Rx: steroids or cyclophosphamide/ciclosporin
 Prog: 30-50% → ESRF

4) Membranoproliferative GN
 Rare → nephrotic (60%) or nephritic (30%) syndrome
 Asooc. HBV, HCV, endocarditis
 Prog: 50% → ESRF

25

Mx of Nephrotic syndrome

Monitor U+E, BP , fluid balance, wt.
 Treat underlying cause
 Symptomatic / Complication Rx:
 Oedema: salt and fluid restrict + frusemide
 Proteinuria: ACEi / ARA ↓ proteinuria
 ↑ Lipids: Statin
 VTE: LMWH (as ↑ CF)
 Rx HTN
 pneumococcal and varicella vaccines

26

Definition of AKI

Significant decline in renal function over hrs or days manifesting as an abrupt and sustained ↑ in Se U and Cr

27

Presentation of AKI

 Acidosis
 Hyperkalaemia
 Fluid overload
 Oedema, inc. pulmonary
 ↑BP(or↓)
 S3 gallop
 ↑ JVP

28

Examples of nephrotoxins

- ACEI
- Aminoglycosides, Vancomycin, Aciclovir, Sulphonamides, Tetracyclines
- NSAIDs
- Lithium,
- Hb
- Bilirubin
- Ig in Myeloma
- Contrast
- Ciclosporin and Tacrolimus
- Urate

29

Things to observe in clinical assessment of suspected kidney disease

1. Acute or chronic?
 Hx of comorbidity: DM, HTN
 Long duration of symptoms
 Previously abnormal bloods

2. Volume depleted?
 Postural hypotension
 ↓ JVP
 ↑ pulse
 Poor skin turgor, dry mucus membranes

3. GU tract obstruction?
 Suprapubic discomfort
 Palpable bladder
 Enlarged prostate
 Catheter
 Complete anuria (rare in ARF)

4. Rare cause?
 proteinuria ± haematuria
 Vasculitis: rash, arthralgia, nosebleed

30

Stages of AKI

Stage 1 -
↑Cr x1.5 ↓GFR >25%
<0.5ml/kg/h x 6h
Stage 2 -
↑Cr x 2 ↓GFR >50%
<0.5ml/kg/h x 12h
Stage 3 -
↑Cr x 3 ↓GFR >75%
<0.3ml/kg/h x 24h, or anuria x12h

31

Management of AKI

General
 Identify and Rx pre-renal or post-renal causes
 Urgent US
 Rx exacerbating factors: e.g. sepsis
 Give PPIs
 Stop nephrotoxins: NSAIDs, ACEi, gent, vanc  Stop metformin if Cr > 150mM

Monitor
 Catheterise and monitor UO
 Consider CVP
 Fluid balance
 Wt.

Treat hyperkalaemia, pulmonary oedema and bleeding (FFP. transfuse)

32

Indications for Acute Dialysis

AEIOU
A"- acidosis;
"E"- electrolyte disarray ( K+, Na+, Ca++);
"I" - intoxicants (methanol ethylene glycol, Li, ASA);
"O"- intractable fluid overload;
"U"- uremic symptoms (nausea, seizure, pericarditis, bleeding)

33

Pathogenesis and clinical presentation of Rhabdomyolysis

 Skeletal muscle breakdown → release of K+, PO4, urate, Myoglobin, CK
 ↑K and AKI

 Muscle pain, swelling
 Red/brown urine
 AKI occurs 10-12h later

34

Causes of Rhabdomyolysis

 Ischaemia: embolism, surgery
 Trauma: immobilisation, crush, burns, seizures,
compartment syndrome
 Toxins: statins, fibrates, ecstasy, neuroleptics

35

Ix and Rx of rhabdomyolysis

Ix
 Dipstick: +ve Hb, -ve RBCs
 Blood: ↑CK, ↑K, ↑PO4, ↑urat

Rx
 Rx hyperkalaemia
 IV rehydration: 300ml/h
 CVP monitoring if oliguric
 IV NaHCO3 may be used to alkalinize urine and stabilise
a less toxic form of myoglobin.

36

Features and classification of Chronic renal failure

Progressive and irreversible loss of the excretory and hormone functions of the kidney ≥3mo
Stage 1&2 require other evidence of kidney damage

Stage GFR
1 >90
2 60-89
3a 45-59
3b 30-44
4 16-29
5 <15

37

Causes of CKD

 DM
 HTN

Other
 RAS
 GN
 Polycystic disease
 SLE
 Myeloma and amyloidosis

38

Ix for CKD

Blood
 ↓Hb, U+E, ESR, glucose, ↓Ca/↑PO4, ↑ALP, ↑PTH
 Immune: ANA, dsDNA, ANCA, GBM, C3, C4, Ig, Hep
 Film: burr cells

Urine: dip, MCS, PCR, BJP

Imaging
 CXR: cardiomegaly, pleural/pericardial effusion, oedema
 AXR: calcification from stones
 Renal US - Usually small (<9cm); large: polycystic, amyloid
 Bone X-rays: renal osteodystrophy (pseudo#)
 CT KUB: e.g. cortical scarring from pyelonephritis

Renal biopsy: if cause unclear and size normal

39

Complications of CKD

CRF HEALS
 Cardiovascular disease
 Renal osteodystrophy
 Fluid (oedema)

 HTN
 Electrolyte disturbances: K, H
 Anaemia
 Leg restlessness
 Sensory neuropathy

40

Features of renal osteodystrophy

 Osteoporosis: ↓ bone density
 Osteomalacia: ↓ mineralisation of osteoid
 2°/3° HPT → osteitis fibrosa cystica
- Subperiosteal bone resorption
- Acral osteolysis: short stubby fingers
- Pepperpot skull
 May get spinal osteosclerosis → Rugger Jersey spine
- Sclerotic vertebral end-plate with lucent centre

41

Mechanism of renal osteodystrophy

 ↓ 1α-hydroxylase → ↓ vit D activation → ↓ Ca → ↑ PTH
 Phosphate retention → ↓ Ca and ↑ PTH (directly)
 ↑ PTH → activation of osteoclasts ± osteoblasts
 Also acidosis → bone resorption

42

Mx of CKD

General
 Rx reversible causes
 Stop nephrotoxic drugs
Lifestyle
 Exercise  Healthy wt  Stop smoking  Na, fluid and PO4 restriction
CV Risk
 Statins (irrespective of lipids)
 Low-dose aspirin  RxDM
Hypertension
 Target <140/90 (<130/80 if DM - ACEi)
Oedema --> Frusemide
Bone Disease --> calcichew (P binder)
 Vit D analogues: alfacalcidol (1 OH-Vit D3)
 Ca supplements
 Cinacalcet: Ca mimetic
Anaemia
 EPO to raise Hb to 11g/dL (higher = thrombosis risk)

Restless Legs -->Clonazepam

43

Positives and negatives of renal transplant

+ve
- restores near normal renal function
- cheaper than dialysis
- allows mobility and rehab
- improved survival
- good long-term results
- better QoL

Ive
- not all suitable- limited donor supply
- still left with progressive CKD
- operation morbidity
- life-long immunosuppression - malignancy and infection risk

44

Complications of renal transplants

Post-op
 Bleeding  Graft thrombosis
 Infection  Urinary leaks

Hyperacute rejection (minutes)
 ABO incompatibility
 Thrombosis and SIRS

Acute Rejection (<6mo)
 ↑ing Cr (± fever and graft pain)
 Cell-mediated response
 Responsive to immunosuppression

Chronic Rejection (>6mo)
 Interstitial fibrosis + tubular atrophy
 Gradual ↑ in Cr and proteinuria
 Not responsive to immunosuppression

↓ Immune Function
 ↑ risk of infection: opportunists, fungi, warts
 ↑ risk of malignancy: BCC, SCC, lymphoma (EBV)

Cardiovascular Disease
 Hypertension and atherosclerosis

45

Drugs CI in renal failure

Many People Like to Nap Naked
Metformin
Potassium-sparing diuretics
Lithium
Tetracyclins
Nitrofurantoin
NSAIDs

46

Drugs that accumulate in renal failure

Aminoglycosides, penicillins, cephalosporins
LMWH
Digoxin
Atenolol
Methotrexate
Sulphonylureas
Opiods

47

Causes of renovascular disease

 Atherosclerosis in 80%
 Fibromuscular dysplasia
 Thromboembolism
 External mass compression

48

Features of RAS

 Refractory hypertension
 Worsening renal function after ACEi/ARB
 Flash pulmonary oedema (no LV impairment on echo)

--> Renal angiography: gold standard

49

Features of Haemolytic Uraemic Syndrome

 E. coli O157:H7: verotoxin → endothelial dysfunction
Features
 Young children eating undercooked meat (burgers
Bloody diarrhoea and abdominal pain precedes:
- MAHA
- Thrombocytopenia
- Renal failure)

50

Features of thrombotic thrombocytopenia purpura

 Fever
 CNS signs: confusion, seizures
 MAHA
 Thrombocytopenia
 Renal failure

51

Presentation of PKD

MISSHAPES
 Mass: abdo mass and flank pain
 Infected cyst
 Stones
 sBP↑
 Haematuria or haemorrhage into cyst
 Aneurysms: berry → SAH
 Polyuria + nocturia
 Extra-renal cysts: liver
 Systolic murmur: mitral valve prolapse

52

Common type of renal stones

Calcium oxalate

53

Ix and Mx of renal stones

Ix - Spiral non-contrast CT-KUB
Rx - Extracorporeal Shockwave Lithotripsy

54

Features, +ve and -ve of haemodialysis

Blood is passed over a semi-permeable membrane against
dialysis fluid flowing in the opposite direction, diffusion of small solutes occurs down the concentration gradient.

+ve - 4 dialysis free days a week
-ve- Disequilibration syndrome, hypotension, time consuming, access problems (AV fistula: thrombosis, stenosis, infection, blockage), fluid restrictions

55

Peritoneal dialysis features, +ve and -ves.

Uses the peritoneum as a semi-permeable membrane. Catheter is inserted into the peritoneal cavity and fluid infused, allowing solutes to diffuse slowly across. -

+ve – easily learned; allows mobility; CVS stability; less fluid/food restrictions
-ve – frequent exchanged (~ 4 x day); frequent failure; high revenue costs; EPO injection; body image, PD peritonitis, exit site infection, loss of membrane function over time

56

Presentation of hyponatraemia

- n&v, anorexia, malaise, lethargy, headache, confusion irritable
- muscle cramps dn seizures
- coma, death

57

Mx of hyponatraemia

- Rx cause
- replace Na and water slowly (se central potine myelinosis)
0 acute 1mM/h and chronic 10mM/d

- if asymptomatic and chronic - fluid restrict
- symoptomatic/ dehydrated - 0.9% NS
- hypervolaemia - +/- furosemide
- seizure/coma - hypertonic saline

58

Causes of hyponatramia

- hypovolaemia
> renal loss - diuretics, addisons, renal failure, osmotic diuresis
> extra-renal loss - d&v, fistula, SNO, burns

- hypervolaemia
> cardiac/ renal/ liver failure
> nephrotic sun

- Euvolaemia
> increased osmolality urine - SIADH
> decreased osmolality urine - water overload, severe hypothyroidism, gluco-corticoid insufficiency

59

Presentation of hypernatraemia

- thirst
- lethargy
- weakness
- irritable
- conufsion
- fit/coma
- dehydratino

60

Causes of hypernatraemia

- hypovolaemia - d&v, diuretics, osmotic diuresis, sweat, burns
- euvolaemia - reduced fluid intakem DI, fever
- hypervolaemia - ↑ Aldosterone (↑ BP and hypokaelaemia), hypertonic saline

61

Mx of hypernatraemia

- water
- 5% dextrose IV/ 0.9% NS (hypovolaemic)
- reduce na by 12mm/d (too fast - cerebral oedema)

62

SIADH - features, causes and Rx

- ↑ NA and ↑ osmolality of urine, (opp in blood), no oedema

causes
- resp - SCLC, pneumonia, TB
CNS - meningo-encephalitis, head injury, SAH
Hypothyroidism
Cyclophosphamide, SSRI, CBZ, Amitriptyline

Rx - treat cause and fluid restrict
- +/- vaptans

63

Symptoms and causes of Diabetes insipidus

- polyuria, polydipsia, dehydration

Causes
- nephrogenic - inherited, high ca, Li, obstructive uropathy
- cranial - idiopathic, tumour, trauma, haemorrhage, meningoencephalitis

64

Ix and Rx of DI

Ix - ↑ Na, dilute urine
- water deprivation test

Rx - desmopressin if cranial

65

Signs and symptoms of hyperkalaemia

- fast, irregular pulse
- chest pain
- palpitations
- weakness
- light-headedness

66

Treatment of hyperkalaemia

- NON-URGENT - review meds and rx cause
- calcium resonium PO

URGENT
- ECG changes/ >6.5
- SENIOR HELP
- 10mL calcium chloride (10%) IV over 5 min
- 50mL of 50% glucose and 10u actrapid over 5-15 min
- salbutamol 5mg NEB
- +/- haemofiltration
- calcium resonium (+lactulose)

67

Signs and symptoms of hypokalaemia

- muscle weakness
- hypotonia
- hyporeflexia- constipated
- cramps
- tetany
- palpitations
- light-headed

68

ECG changes in hypokalaemia

- small/inverted T waves
- prominent U waves
- Long PR and QT
- depressed ST

69

Causes and treatment of hypokalaemia

causes - diuretics, v&d,. cushings, steroids, ACTH, Conn,s, pyloric stenosis, alkalosis, purgative abuse

Treatment
- mild - oral K+ supplemenet
- severe - IV K+ (max 20mmol/h) and replace Mg

70

Causes of hyperkalaemia

-rhabdomyolysis
- oliguric renal failure
- burns
-addisons
- K+ sparing diuretics
- massive blood transfusion
- metabolic acidosis
- ACEi
- Excess K+
- artefact (haemolysis)

71

Symptoms of hypocalcaemia

Spasm(trousseaus)
Periorbital paraesthesia
Anxious/irritable
Seizure
Muscle tone ↑ (colic, dysphagia, wheeze)
Orientation impaied
Dermatitis
Impetigo herpetiformis
Chovsteks

72

Causes of hypocalcaemia

- ↑ PO4
CKD; hypoparathyroid; acute rhabdomyolysis; ↓ Mg, Pseudohypoparathyroidism

- ↓PO4
Vit D def, Osteomalacia, (ALP ↑), Acute pancreatitis, over-hydration, resp alkalosis

73

ECG changes and Mx hypocalcaemia

ECG - long QT

mild - Ca - 5mmol/6h PO (CKD - alfacalcidol)
severe - 10mL or 10% calcium gluconate IV over 30 min
- correct alkalosis

74

Symptoms of hypercalcaemia

Bones -pain, pathological #
Stones - renal
Moans - depression, confusion
Thrones - polyuria and dipsia
Groans - abdo pain, vom and constipaton, pancreatitis, PUD

+ HTN and pyrexia

75

Causes of hypercalcaemia

- ↑ albumin - cuffed specimen
- ↑ urea - dehydrated

↓/- albumin
- ↑ PO4
and ALP ↑ - bone met, sarcoid, thyrotoxicosis, Li
Normal ALP - myeloma, raised vit d, sarcoid, ↑ HCO3 ↓PO4 - 1/3 hyperparathyroid

76

ECG and Mx hypercalcaemia

- short QT interval

- Correct dehydration - IV fluids
- Bisphosphonates infuse slowly (SE - flu, myalgia, n,v, low Mg, low Ca, low PO4, bone pain, seizures)
- malignancy - chemo

77

Signs and symptoms of anaemia

Symptoms
- palpitation
- fatigue
- SOB
- faintness
- headache
- tinnitus

Signs
- angular stomatitis
- conjunctival pallor
- tachycardia
- flow murmur
- glossitis
- koilonychia

78

Causes of microcytic anaemia

Thalaessmia
Anaemia of chronic disease
Iron def
Lead poisoning
Sideroblastic

79

Causes of normocytic anaemia

Anaemia of chronic disease
Haemolysis
Acute blood loss
BM failure
Renal failure
Hypothyroidism
Pregnancy

80

Causes of macrocytic anaemia

- B12 and folate def
- Alcohol
- retioculocytosis
- cytotoxics
- BM failure
- Hypothyroidism
- Pregnancy

81

Causes of iron, b12 and folate deficiency

- reduced intake diet, malabsorption (gastretomy/coeliacs (CD - folate and B12)),

- increased utilisation - growth, pregnancy (tapeworm - b12)
- pernicious anaemia (AI against intrinsic factor)
- loss iron- GI bleed, menorrhagia
DRUGS
folate def - trimethoprim, methotrexate, sulphasalazine
B12 def - metformin NO
Iron def - cimetidine, rantidine

82

Causes of anaemia of chronic disease

malignancy
infection - TB
Renal failure
Inflammation - RA, temporal arteritis

83

Drugs that iron reduces absorption of

tetracycline
Quinolones
bisphosphonates
levodopa
levothyroxine

84

Causes and ix of haemolytic anaemia

Inherited - sickle cell, thalassaemia, spherocytosis, G6PD def, PK def

Acquired - AIHA, drug induce, DIC, TTP, physical damage/heart valves, lead, malaria

Ix - ↑ reticulocytes, ↑ unco bilirubin, ↑ LDH, ↑ urinary urobilinogen
- ↓ free haptoglobin (removed RBC intravascularly)