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MBBS - Year 3 > Urology - Renal Failure > Flashcards

Urology - Renal Failure Flashcards

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1
Q

define AKI

A

Rapid decline GFR
- Nitrogenous and non-nitrogenous waste products
- Electrolyte (K+)
- Acid-base
- Fluid balance
purley based on blood tests - creatinine

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2
Q

what do you look at in AKI

A

level of creatinine

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3
Q

what is the classification of AKI

A

Serum Cr ≥ 26.5 micromol/l in 48 hrs

Serum Cr ≥ 1.5 (base) within last 7 days

Urine Output < 0.5ml/kg/hr for 6 hrs

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4
Q

what is a stage 1 AKI

A
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5
Q

what is stage 2 and 3 AKI

A
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6
Q

what are the 3 causes of AKI

A

pre-renal, intrinsic, post-renal

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7
Q

which of the causes is most common

A

pre-renal
anything that inpaires blood flow to kidney
dehydration, sepsis, heart failure

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8
Q

You are the FY1 on call and are asked to see a 52 year-old gentlemen in A&E by your registrar; apparently sent in by his GP generally unwell.
52 yrs old
BG: Obesity (BMI>40), Hypertension,Ischaemic Heart Disease,Leg ulcers
PC: Unwell,recent diarrhoea and vomiting,not eating and drinking.
SH: Lives with wife, increasing difficulty with ADL.
Drugs: Lisinopril and Naproxen
Generally Unwell.Temp 40 deg C
CVS: P110/min, BP 74/30, JVP not visible, dry mucus membranes, HS I+II
Resp: RR 24, Sats 94% on 21% FiO2, Chest clear
Abdomen: difficult to examine as sitting, grossly non-tender, BS+ ve
WBC 24
Neut 19
Hb 10.1
Plt 469
Cr 823
Ur 39
K 6.6
CRP 275
What is the cause, give possible diagnosis

A

pre-renal
Hypovolemia, SepsisShock, Nephrotoxic drugs, Renovascular disease, Left ventricular dysfunction
STAGE 3 kidney injury

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9
Q

what 3 factors are considered for eGFR

A

Cardiac output (pump)

Effective Circulatory volume (blood)

Peripheral Vascular Resistance (BP)

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10
Q

what are the 3 protective mechanisms for renal autoregulation

A

Myogenic Reflex

Tubuloglomerular feedback

Renin-Angiotensin system

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11
Q

what happens if arterial pressure decreases

A
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12
Q

who is at high risk of pre renal AKI

A

Elderly
Arteriosclerosis (HTN, DM)
Pre-existing renal disease
Underlying cardiovascular disease
ARB/ACEI/NSAID/Anti-hypertensives/Diuretics

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13
Q

how do NSAIDS, ACEi/ARB cause kdney injury

A

act on autoregulators

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14
Q

what is the management of AKI in dehydrated and septic patient

A

IV access and Bloods (CRP and cultures)
ABG/VBG
ECG
Wound swabs
Urine dip and I/O monitoring
CXR

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15
Q

what are some of the ECG signs seen for hyperkalaemia

A
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16
Q

how would you assess fluid balance

A

Peripherally:
Pulse, CR > secs
Warm/vasodilated/hyperdynamic
Weak/thready/cool

Centrally:
JVP
BP (postural)

Skin turgor/ Mucus membranes

Ausc chest

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17
Q

You’re the FY1 on call and are asked to see a patient in A&E.81 year old gentlemen, GP has sent in as generally “off legs”. A&E have kindly done some bloods for you
Hb 12.0g/dl
WBC 11
Plt 200
Na 130
K 5.8
Ur 40
Cr 1550
81 yr male
BG: Hypertension, Ischaemic Heart Disease, BPH – TURP 1997
PC: Generally unwell, hesitancy, abdominal pain
SX: Independent, Smoker, no ETOH
Drug: Ramipril, Bisoprolol, Furosemide, Aspirin, Simvaststain, Tamsulosin
T 36.1
CVS: P 110 bpm, BP 182/90, JVP 1cm, skin turgor normal, HS I+II
Resp: RR 16, Sats 98% RA, Chest clear
Abdomen: large abdominal mass with suprapubic dullness. DRE: craggy enlarged prostate
What is the cause of AKI

A

post renal obstruction

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18
Q

what are intrinsic and extrinsic causes of post renal obstruction

A

Intrinsic
Intraluminal (stone, blood clot, papillary necrosis)
Intramural (bladder tumour, urethral stricture)

Extrinsic
Prostate
Pelvic
RPF - retro peritoneal fibrosis

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19
Q

how would you manage an obstruction

A

Urinary catheter (SPC)
Polyuric phase – careful input/output monitoring, IVF
USS renal tract
Treat underlying infection
Check PSA/DRE (prostate)

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20
Q

what are the 4 intrinsic renal disease

A

acute tubular necrosis
acute glomerulonephritis
acute tubular interstitial nephritis
acute vascular issues

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21
Q

what causes Acute tubular necrosis

A

Ischaemia
Any cause of renal hypoperfusion (hypovolaemia, hypotension)
End of spectrum

Toxins
Endogenous
- Myoglobin – rhabdomyolysis
- Haemoglobin –massive haemolysis
- Myeloma – light chains
- Uric acid – tumour lysis syndrome –
Key mechanisms: direct toxicity and obstruction

Exogenous
Contrast
Antibiotics: aminoglycosides, Amphotericin B
Chemotherpeutic agents (cisplatin)

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22
Q

what is wrong

A

Acute interstitial nephritis
Normal tubule bottom centre
Amount of inflammatory cells – purple nucleus is WBC – lots in interstitial compartment

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23
Q

what 3 things make up glomerulonephritis

A

nephrotic syndrome
nephritic syndrome
asymptomatic urinary abormalities

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24
Q

what are key features of nephrotic syndrome

A

Proteinuria >3.5g/day
Hypoalbuminaemia
Oedema (periorbital)
Hyperlipidaemia
Lipiduria

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25
what are some causes of nephrotic syndrome
Minimal Change Membranous Mesangiocapillary Diabetes FSGS Amyloidosis HIV Lupus
26
what are key features of nephritic syndrome
Haematuria (dysmorphic) Proteinuria (<3g/day) Oedema Oligouria Hypertension
27
what are some causes of nephritic syndrome
IgA and HSP Small vessel vasculitis (WG, MPA) Anti-GBM Post infectious Mesangiocapillary Lupus
28
what blood tests would you perform for AKI
Haematology (FBC, ESR) Biochemistry (U&E, CK, CRP, LFT) Immunology ( ANA – autoimmune dsDNA – systemic lupus ANCA – systemic vasculitis Anti-GBM – Goodpastures ASO titres, Anti-Dnase B titres – post-strep Complement Myeloma screen (SPE, SFLC, BJP) Virology (hep B, C, HIV)
29
what are some urgent indications for dialysis
Hyperkalaemia – resistant Pulmonary Oedema – resistant Uraemic – encephalopathy, pericarditis Acidosis Drug overdose
30
what does a normal urine dip imply as a diagnosis
pre-renal, ATN and post renal
31
what does haematuria and proteinuria urine dip imply as a diagnosis
Acute GN Vasculitis Thrombotic Microangiopathy
32
What does WBC and casts urine dip imply as a diagnosis
Acute TIN Obstruction Pyelonephritis
33
what are 3 conditions that require immunosuppression
Glomerulonephritis Tubulointerstital nephritis graft rejection
34
Name different causes of glomerulonephritis and their treatment
Minimal change disease - Normally steroid-responsive FSGS - Variable steroid response Membranous nephropathy - Limited response to immunosuppression IgA nephropathy - Poor response to immunosuppression Diabetic nephropathy - Adverse effect of steroids Goodpasture’s Disease - ?Plasma exchange + immunosuppression Systemic vasculitis - Often responds to immunosuppression
35
what is the treatment for interstitial nephritis
steroids
36
common drugs which cause interstitial nephritis
NSAIDS, furosemide/bumetanide, PPIs (lanzoprazole)
37
when is hyperacute transplant rejection
immediate Can cause graft loss within minutes to hours Due to pre-formed anti-donor antibodies in recipient Avoided by pre-operative cross-match Untreatable
38
at what GFR do you need dialysis
10-12
39
how much more does dialysis give
5-10
40
what are some small molecules immunosuppressive drugs
41
what are some immunosuppressive drugs - antibodies (polyclonal and monoclonal)
Polyclonal “IVIg” (pooled immunoglobulin) Anti-lymphocyte globulin (ALG) Anti-thymocyte globulin (ATG) Monoclonal Anti-CD3 – OKT3 Anti-CD25 (IL-2 receptor) – basiliximab, daclizumab Anti-CD52 – alemtuzumab (Campath) Anti-CD20 – rituximab
42
how are T cells activated and what drugs inhibit what aspects of T cell activation
43
how does prostate cancer present
insidental finding - rarely have many symptoms
44
where does prostate cancer spread
bones mainly
45
how do you diagnosie prostate cancer
PSA, rectal examination MRI - biopsy can miss the cancer biopsy ISUP - prostate cancer are graded
46
from what grade do you want to treat protate cancer
Gleason 4 and up. below this and the cancer is rarely an issue - aged 80+
47
how do you stage prostate cancer
Bone scan (PSA >20ng/ml) CT (very high PSA or high grade disease on Bx) PET-CT (choline, PSMA) WB-MRI
48
what is the diagnosis if you see an osteoblastic lesion on an x-ray
its prostate cancer until proven otherwise
49
what are the top 4 primary metastisis to bone
breast, prostate, lung, kidney
50
how do bone mets present
pain cauda equina compression
51
what is the treatment for prostate cancer
Active surveillance - GG1, PSA <10 - Life expectancy Radiotherapy Prostatectomy Hormone therapy (anti androgens)
52
58 yr male patient, smoker On and off blood in urine for one month Physical examination unremarkable Haematology- mild anaemia You are the junior doctor assessing him. How would you investigate?
bloods and blood films - macrocytic anaemia ultrasound the kidney
53
58 yr male patient, smoker On and off blood in urine for one month Physical examination unremarkable Haematology- mild anaemia How would you investigate ?
ultrasound
54
what are malignant renal tumors
55
what are benign renal tumors
Angiomyolipoma Oncocytoma
56
what is the most common location of TCC
bladder
57
how do you investigate haematuria
USS urinary tract cystoscopy
58
where do you look for ureter cancer
IVU CT urogram ureteroscopy
59
how do you stage a bladder cancer
MRI
60
what imaging do you do for testicular tumors
ultrasound
61
where would you find the sentinal node in testicular cancer
it skips the pelvis and you see in upper abdomen by the aorta
62
what is chronic kidney disease
A reduction in kidney function, characterised by a reduction in GFR, which is not reversible and may be progressive
63
what is normal gfr (in mL/min/m2)
120mL/min/1.73m2
64
what are the 2 GCA stages of CKD
glomerular and albuminuria stage
65
what 2 things considerable increase the risk of having CKD
albuminuria and impaired glomerular filtration
66
what are some markers of kidney disease
GFR <60 ml/min/1.73m2 Albuminuria / Haematuria Electrolyte abnormalities due to tubular disorders Structural / histological abnormalities (e.g. on imaging, biopsy) Kidney transplantation
67
how is CKD definitlvely diagnosed - what tests and results would you see
2 Samples 90+ days apart eGFR calculated from Creatinine levels (more accurate than Creatinine alone) Haematuria detected best on dipstick Albuminuria detected best on alb:creat ratio Structural disease detected best on US
68
what are the 3 equations which are used to estimate eGFR
Cockroft-Gault Calculated Creatinine Clearance (140-age) x (1.23 if male/1.04 if female) x weight / serum creatinine MDRD eGFR formula 32788 x serum creatinine-1.153 x age-0.203 x 0.742 if female x 1.21 if black CKD-EPI formula 141 x min(creatinine/k,1)a x max(creatinine/k,1)-1.209 x 0.993age x 1.018 if female x 1.159 if black If female, k=0.7, a=-0.329; if male k=0.9, a=0.411
69
what are the 2 main causes of chronic kidney disease
diabetes - 20-40% hypertension - 10-25%
70
what are some other less common causes of chronic kidney disease
Renovascular disease Reflux disease Obstructive uropathy Autosomal dominant polycystic kidney disease Glomerulonephritis Unknown- idiopathic
71
how would you manage CKD stage IIIb and IV
Ongoing risk factor management Non-glomerular functions start to be relevant Iron-erythropoietin balance Calcium-phosphate balance Tubular function can start to decline Low potassium diet, oral bicarbonate Most common with diabetic nephropathy due to a Type IV renal tubular acidosis.
72
what are some complications of CKD
Anaemia of CKD Mineral Bone Disorder of CKD Salt & Water, Acid-Base disorders ‘Uraemia’ Disease-specific complications
73
how would you manage CKD managment for stage V
Preparation for renal replacement Low Clearance Clinic for discussion of options Definitive dialysis access in good time Listing for pre-emptive transplantation / planned living donation if appropriate Close monitoring of progression Little margin of error Can start to get problems with salt & water May need fluid ration
74
what are the 3 renal replacement therapies
Haemodyalyisis peritoneal dialysis transplantation
75
Identify most important or frequent ADR of specified drug. Patient given iv morphine stat after hip replacement. What important ADR to monitor? Sweating Itching Constipation Respiratory rate/ depression Lethargy
Respiratory Depression
76
Identify most likely cause of specified ADR. 82 year old lady, history of hypertension. 3 months of ankle swelling. Treated with diuretics – no improvement. What is most likely cause? Aspirin Amlodipine Alendronate acid Bendroflumethiazide Bisoprolol
amlodipine
77
Patient with hypertension and heart failure. Routine bloods K+ 5.9 mmol. (3.5 – 5.1 mmol). Select two drugs most likely to interact to cause this: Aspirin Bendroflumethiazide Bisoprolol Digoxin Isosorbide Mononitrate Ramipril Spironolactone
ramipril and spironalactone
78
Patient with hypertension and heart failure. Pulse rate: 48 beats per minute. Select two drugs most likely to interact to cause this: Aspirin Bendroflumethiazide Bisoprolol Digoxin Isosorbide Mononitrate Ramipril Spironolactone
bisoprolol and digoxin
79
what drugs have poor kinetics (narrow range of safety)
Gentamicin, vancomycin Theophylline Phenytoin
80
what drugs affect the liver
Anticonvulsants Anti-TB drugs
81
what drugs affect the kidney
Aminoglycosides Diuretics & other drugs for heart failure
82
how do calcium blockers cause interactions
Calcium blockers →relax smooth muscle → vasodilatation → headache, flushing, oedema
83
what are the 4 adverse drug reactions that need to be memorised
Bisphosphonate – osteonecrosis of the jaw Metformin – lactic acidosis Carbimazole, clozapine – marrow suppression **Statins - myositis
84
what mechanisms help to show possible ADRs
Block A-V node conduction – bradycardia Arterial dilatation – hypotension CNS drugs – sedation Antiplatelets /Anticoagulants – haemorrhage Drugs acting on aldosterone and kidney – potassium and other electrolyte abnormalities
85
how do you predict issues of Treatment of atrial fibrillation – rate control with beta-blocker
86
what are the main ADRs for salbutamol
87
patient presents with tremor or tachycardia after using inhaler what is the most likely drug
salbutamol
88
why do some drugs interact (3)
89
what are bradycardia with the same drug interactions
90
alchohol GTN and alcohol are both vasodilators increased risk of hypotension and fainting especially when GTN used within 1 hour of alcohol
91
what are target sights of trimethoprim and methotrexate
92
what are important enzyme interaction inducers
Drugs for epilepsy – carbamazepine Antibiotics – drugs for TB Alcohol
93
what are important enzyme inhibitors
Antibiotics – clarithromycin, ciprofloxacin Xanthine oxidase inhibitor - allopurinol
94
what is a type A ADR
dose dependent, predictable beta-blocker causes bradycardia because of action on beta-receptors in cardiac conduction
95
what is a type B ADR
not dose dependent, cannot be predicted pharmacologically Anaphylaxis to penicllin
96
what 2 ways are you able to limit the classification
No account of duration e.g. steroid osteoporosis – cumulative dose and length of therapy are relevant What about susceptibility – poorly mobile elderly women more likely to have steroid osteoporosis
97
76 year old recent acute coronary syndrome. TSH 12.6. Please prescribe thyroxine. (you can use BNF)
25mcg OD
98
83 year old with severe acute gout. Started on Naproxen 250 mg bd. What management options to prevent complications from Naproxen?
use lower dose restrict time of treatment 5-10 days assess susceptibility
99
30 year newly diagnosed thyrotoxicosis. Start carbimazole. What is the most important communication item?
“Patient should be asked to report symptoms and signs suggestive of infection, especially sore throat. A white blood cell count should be performed if there is any clinical evidence of infection.”

MBBS - Year 3 (13 decks)

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