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Year 2 - Renal > Week 4 > Flashcards

Week 4 Flashcards

1
Q

How does the nephrotic syndrome cause oedema?

A

Disorder in glomerular filtration results in protein (mainly albumin) appearing in urine, causing proteinuria

Loss of protein = decreased oncotic pressure = increased formation of interstitial fluid which causes oedema

Increased fluid in the interstitium also = less blood volume and cardiac output = activation of RAAS = retention of Na+ and H2O = oedema

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2
Q

How does congestive heart failure cause oedema?

A

Reduced cardiac output = renal hypoperfusion = activation of RAAS

RAAS activation results in expansion of blood volume = increased pressure in vessels, plus reduced osmotic pressure = pulmonary and peripheral oedema

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3
Q

How does hepatic cirrhosis with ascites cause oedema?

A

Increased pressure in the hepatic portal vein + decreased production of albumin = loss of fluid into peritoneal cavity and ascites

RAAS activated in response to decreased circulating volume

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4
Q

What is secreted and reabsorped at the proximal convoluted tubule?

How permeable is this segment of the nephron to water?

A

Secreted

  • glucose
  • ions
  • H2O
  • amino acids

Reabsorbed

  • urea

Highly permeable to water

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5
Q

What is secreted at the descending limb of the Loop of Henle?

How does this affect osmolarity inside the nephron?

How permeable is this segment of the nephron to water?

A

Water is secreted but NaCl is retained

This causes the osmolarity inside the tubule to rise

This segment is highly permeable to water

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6
Q

What is secreted at the ascending limb of the Loop of Henle?

How does this affect the osmolarity within the tubule?

How permeable is this segment of the nephron to water?

A

NaCl is secreted, but water is retained

This causes the osmolarity within the tubule to fall

This segment is completely impermeable to water

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7
Q

What is reabsorbed at the distal convoluted tubule?

How permeable is this segment of the nephron to water?

A

H2O

Ca2+

Na+

Cl-

This segment is variably permeable to water

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8
Q

What is secreted at the collecting duct?

How permeable is this segment of the nephron to water?

A

H2O

Ca2+

Na+

Cl-

This segment is variably permeable to water

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9
Q

What diuretics target the proximal convoluted tubule?

What specifically do they target here?

A

Carbonic anhydrase inhibitors e.g. acetazolamide

Target the Na+/H+ exchanger

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10
Q

What diuretics target the Loop of Henle?

What specifically do they target here?

A

Loop diuretics e.g. furosemide and bumetanide

Target the Na+/K+/Cl- triple co-transporter

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11
Q

What diuretics target the distal convoluted tubule?

What specifically do they target here?

A

Carbonic anhydrase inhibitors e.g. acetazolamide

Also Thiazide diuretics e.g. chlorothiazide, indapamide

Carbonic anhydrase inhibitors target Na+/H+ exchange

Thiazides target the Na+/Cl- co-transporter

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12
Q

What diuretics target the collecting tubule?

What specifically do they target here?

What is the benefit of this particular group of diuretics?

A

Potassium-sparing diuretics target the collecting tubule e.g. spironolactone, eplerenone, amiloride and triamterene

Potassium-sparing diuretics target Na+/K+ exchange. By blocking Na+ reabsorption here, these drugs inadvertantly block K+ secretion, thus avoiding hypokalaemia

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13
Q

Why does even a small inhibition of reuptake of NaCl in the kidneys have a significant increase in Na+ excretion?

A

Because the vast majority of NaCl and H2O that passes into the filtrate via the glomerulus is reabsorbed

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14
Q

The site of action of many diuretic drugs is the apical/basolateral membrane of the tubule

A

Apical membrane

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15
Q

What transport system is used in to move acidic drugs into the renal tubule?

Give some examples of diuretics that operate via this system

A

Organic Anion Transporters (OATS)

Diuretics using these tranporters include thiazides and loop diuretics

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16
Q

What transport system is used in to move basic drugs into the renal tubule?

Give some examples of diuretics that operate via this system

A

Organic Cation Transporters (OCTs)

Diuretics using these tranporters include triamterene and amiloride (both potassium-sparing diuretics)

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17
Q

Name some Loop Diuretics

What do they target?

This type of diuretic acts rapidly/slowly

A

Furosemide, Bumetanide

Target the Na+/K+/Cl- triple co-transporter by binding to the Cl- site

Rapid onset following IV administration

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18
Q

What other benefit do loop diuretics confer when used to treat pulmonary oedema caused by heart failure?

A

Have an additional indirect venodilator action

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19
Q

What are some of the clinical indications for using loop diuretics?

A

To reduce salt and water overload in…

  • Acute pulmonary oedema
  • CKD
  • Hepatic cirrhosis with ascites
  • Chronic heart failure
  • Nephrotic syndrome

To increase urine volume in acute kidney failure

To treat hypertension

To treat acute hypercalcaemia

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20
Q

What are some of the potential side effects of loop diuretics?

A

Hypokalaemia

Metabolic acidosis

Hypovolaemia and hypertension (especially in the elderly)

Depletion of Ca2+ and Mg2+

Hyperuricaemia = gout

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21
Q

What do thiazide diuretics target?

Give some examples of this class of drug

A

They target the Na+/Cl- co-transporter on the apical membrane in the distal convoluted tubule

Bendroflumethiazide

Indapamide

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22
Q

What is the main adverse effect associated with thiazide diuretics?

A

Hypokalaemia

They do this by inhibiting the Na+/Cl- carrier via binding to the Cl- site, which results in an increased Na+ load being delivered to the distal tubule, and which in turn causes a loss of K+

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23
Q

What addititonal effect do thiazide diuretics have, and how does this affect their use?

A

As well as a moderate diuretic effect, thiazides also have an indirect vasodilator action

This is what makes them useful in the treatment of hypertension, and why they are used in combination with other antihypertensive agents to manage blood pressure

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24
Q

Where do thiazide diuretics enter the nephron?

A

They enter in the proximal convoluted tubule because they are protein-bound and cannot pass through at the glomerulus

This also means that their absorption into the tubule is dependent upon the GFR - if GFR is low, less of the drug will be taken up into the tubule

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25
What are some of the adverse effects of thiazide diuretics?
Hypokalaemia Metabolic alkalosis Hyperuricaemia - may predispose to development of gout Male sexual dysfunction Impaired glucose tolerance
26
How do thiazides relate to stone formation?
They can be used in the treatment of renal stone disease as they reduce urinary excretion of Ca2+ This does however make patients more susceptible to developing gout
27
ADH acts to (increase/decrease) the number of aquaporins in the cell membrane
**increases** the number of aquaporins at the cell membrane
28
Name some proliferative types of glomerulonephritis
IgA Nephropathy Post-infectious GN Membranoproliferative Rapidly Progressive GN
29
Name some non-proliferative types of glomerulonephritis
Membranous Minimal Change Disease Focal Segmental Glomerulosclerosis
30
Carbonic anhydrase inhibitors are largely no longer in use as diuretic agents, but are still used in certain circumstances - what are these?
Used to treat **glaucoma** by lowering intraocular pressure Used as a prophylaxis for **altitiude sickness** Used to treat some forms of **infantile epilepsy**
31
What is the term used for inflammation of the bladder (either due to infection or other cause)?
Cystitis
32
What is a "complicated UTI"?
A UTI becomes complicated in the event of systemic symptoms or urinary tract abnormality/obstruction e.g. stones
33
What are some of the risk factors for developing a UTI?
Female * Shorter, wider urethra * Proximity of urethra to anus * Increased risk with sexual activity and pregnancy Catheterised patients Abnormalities of the urinary tract
34
What are the two routes of infection that could potentially result in a UTI? Which is more common?
Ascending infection from the bladder (more common) Haematogenous spread (uncommon)
35
What is the best way to test urine for bacteria?
**Culture** Urine dipsticks might tell you an infection is present but aren't useful for determining causative organism
36
Gram negative bacteria causing UTIs are (rods/cocci) These organisms are all (aerobic/anaerobic) and can be further classified based on their ability to \_\_\_\_\_ Name the organisms that can potentially cause a UTI (9)
**G****ram negative rods** These organisms are all **aerobic** and can be further classified based on their ability to **ferment lactose** Lactose fermenters * E coli * Klebsiella * Enterobacter * Serratia * Citrobacter Lactose non-fermenters * Oxidase-positive * Pseudomonas aeruginosa * Oxidase negative * Morganella * Proteus * Providencia
37
What feature of E. coli results in them causing a fever in patients?
E. coli posseses an **endotoxin in its LPS layer**
38
What is Pseudomonas aeruginosa particularly associated with, and what is the treatment?
P. aeruginosa is associated with **catheters and instrumentation**, and it tends to be resistant to most oral antibiotics except **Ciprofloxacin**
39
What gram positive organisms can cause UTIs?
**Enterococcus** * E. faecalis - more common and less resistant of the two * E. faecium **Staphylococcus** * S. sasphrophyticus * S. aureus (uncommon)
40
UTIs - signs and symptoms
Dysuria (pain on passing urine) Frequency Nocturia Haematuria (not typically but can occur) Fever Loin pain Rigors
41
How is a urine sample best collected?
First urine passed is most likely contaminated and will present with bacteria that are not the causative organism of infection Best approach is collecting **midstream urine**
42
If taking a urine sample and using a universal sterile container, within what time frame must it get to the laboratory? If likely to take longer, what else can be used to contain the specimen? How long can it be stored here?
If being kept in a universal sterile container (white cap), a urine sample must make it to the lab **within 2 hours** Alternatively, a **Boricon container** can be used which contains boric acid that will prevent bacteria from multiplying. This can be used to store specimens for **around 24 hours**
43
Urine dipstick isn't great for identifying infection in patients. What does it pick up that _might_ indicate infection?
**Leucocyte esterase** - indicates WBCs in the blood **Nitrites** - indicates the presence of certain bacteria in the urine (mainly **coliforms**) Protein and blood (not for the diagnosis of infection)
44
What scoring criteria is used to determine if a patient has a UTI based on their culture?
**Kass's Criteria** \>105 organisms/ml = significant bacteria, UTI likely NB - this is referring to pure growth of a single organism, this amount of organisms made up of multiple species is likely not significant
45
In a woman presenting with an uncomplicated lower UTI, how long a course of antibiotics should she be put on?
3 days
46
What is the best treatment in a patient presenting with likely abacterial cystitis/urethral syndrome? What causes this condition?
In this case, the patient will have symptoms of a UTI and pus cells will be present in the urine, but not to a signficant degree **Alkanising the urine** may be of benefit as it provides symptomatic relief This presentation may be the early phase of a UTI, may be due to "honeymoon cystitis" or may be due to urethritis caused by gonorrhoeal/chlamydial infection
47
If a patient presents with bacteria in the urine but is asymptomatic (i.e. asymptomatic bacteriuria), how are they best managed?
Antibiotic treatment is often **not required**, especially in the elderly and the condition may recur if an antibiotic is given The exception to this is in **pregnant women** - treat **all** bacteriuria!
48
Why is bacteriuria ALWAYS treated in pregnant women? What antibiotics are used?
All women are screened for bacteriuria at their first antenatal visit If left untreated, 20-30% will develop **pyelonephritis** and it could also cause **intra-uterine growth retardation or premature birth** If in 1st trimester, give **Nitrofurantoin** If in 3rd trimester, give **Trimethoprim** **Cefalaxin** can also be used and is 2nd line treatment
49
Should patients with a catheter and bacteriuria be given antibiotics? Why?
**Only if they have presenting symptoms of infection** Giving antibiotics unnecessarily can result in the catheter becoming colonised with increasingly resistant bacteria
50
Nephrotic syndrome - clinical features
Oedema Hypoalbuminaemia Hyperlipidaemia Proteinuria Patients present with swelling (including the face, which is a good indicator of the condition) and may have other constitutional symptoms e.g. fatigue, lethargy etc.
51
Patient presents with symptoms of nephrotic syndrome and you perform a urinalysis which shows +++ proteinuria and no haematuria. What do you do next?
Quantify the proteinuria using either a **protein:creatinine ratio** on a spot urine sample, or a **24 hour urine collection** and measure the protein Also take a **blood sample** to check renal function (urea, creatinine and electrolytes) and serum albumin
52
What are some of the causes of Nephrotic Syndrome?
**Primary GN** i.e. GN with no obvious underlying cause **Minimal Change Nephropathy** and **Membranous nephropathy** - commonly cause nephrotic syndrome alongside normal renal function and blood pressure Glomerular disease associated with an **underlying disorder** e.g. diabetes, hypertension, SLE, chronic infections etc. **GN associated with drugs** - gold, penacillin, antibiotics, NSAIDs etc.
53
Prior to performing a renal biopsy, what procedures must be done first? What contraindications are being screened for?
**Blood count and coagulation screen** - both moderate/severe thrombocytopaenia and coagulation defects are contraindications to renal biopsy **Renal USS** - to check size, number and position of kidneys
54
What presentations of kidneys on renal USS would prevent you from performing a renal biopsy?
Small kidneys - increased risk of bleeding and likely poor results of biopsy Presence of a single kidney - relative risk increases
55
Minimal Change Nephropathy - management
Steroids - **Prednisolone 40-60 mg/day** PPI to protect against peptic ulceration Prognosis is good and kidney function is not expected to deteriorate.
56
Female with a lower UTI - treatment
**Trimethoprim** or **Nitrofurantoin** orally for 3 days
57
Uncathaterised male with a UTI - treatment
Get cultures! **Trimethoprim** or **Nitrofurantoin** orally for 7 days
58
Complicated UTI or pyelonephritis (GP) - treatment
**Co-amoxiclav** or **Co-trimoxazole** for 14 days
59
Complicated UTI or pyelonephritis (Hospital) - treatment
**Amoxicillin and Gentamicin IV** for 3 days (replace amoxicillin with co-trimoxazole if allergic) Step down as guided by antibiotic sensitivities
60
What are some of the considerations that have to be kept in mind when prescribing Gentamicin?
It must be given in hospital as it is IV administration only **Avoid in pregnancy** Has a **narrow therapeutic index** - risk of toxicity and can cause renal problems and issues with CN VIII (balance and hearing loss) Should be prescribed for **3 days only**, unless advised otherwise
61
If bacteria develop beta lactamase, what antibiotics are no longer effective against them? What antibiotic can be used instead?
Bacteria become resistant to **all cephalosporins** and **almost all penicillins** **Carbapenems** are the only effective treatments against ESBLs (e.g. IV meropenem, IV ertapenem) Other antibiotics may also be useful - nitrofurantoin (oral), pivmecillinam (oral), temovillin (IV)
62
Typically, first line treatments for coliforms and enterococci are gentamicin and amoxicillin, respectively What are the second-line drugs used for these organisms?
Coliforms * Aztreonam * Pivmecillinam * Temocillin * Piperacillin/Tazobactam * Meropenem * Quinolones * Fosfomycin Enterococci * Vancomycin * (chloramphenicol) * Linezolid * (Daptomycin) * (Tigocylcine)
63
How does trimethoprim work? When should it be avoided? What organisms can it be used to treat, and importantly which one does it not treat?
Inhibits **bacterial folic acid synthesis** Generally safe antibiotic, but **should be avoided in the FIRST trimester of pregnancy** Treats most coliforms, Staph aureus including MRSA **but does NOT treat Pseudomonas**
64
Why is nitrofurantoin _only_ used to treat lower UTIs? When should this antibiotic be avoided? What organisms does it cover and, importantly, what organsism does it not cover?
Only useful in uncomplicated lower UTIs as it **only reaches effective concentrations in bladder urine** It's a cheap and narrow spec antibiotic, but **should be avoided in the THIRD trimester of pregnancy** Treats most coliforms, Enterococci, Staph aureus including MRSA but **does not treat Proteus or Pseudomonas**
65
Why is co-amoxiclav more effective against beta-lactamases?
The clavulanic acid **inhibits beta lactamase**
66
How are adverse drug reactions classified (A-F)?
A - augmented pharmacological effects B - bizarre effects C - chronic D - delayed E - end-of-treatment effects F - failure of therapy
67
What combination of drugs make up the "triple whammy" that particularly predispose the kidneys to developing an AKI?
ACE inhibitor/ARB Diuretic NSAID

Year 2 - Renal (6 decks)

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