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Y3 Medicine > 14 - Renal Medicine > Flashcards

14 - Renal Medicine Flashcards

1
Q

What are the different ways that renal disease can present?

A

1. Asymptomatic: non visible haematuria, asymptomatic proteinuria, abnormal eGFR, HTN, electrolyte abnormalities

2. Renal tract symptoms: urinary symptoms, loin pain, visible haematuria, nephrotic syndrome, symptomatic CKD

3. Systemic disorder with renal involvement: DM, sickle cell, SLE, infection, malignancy, pregnancy, drugs

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2
Q

How do you take a renal history?

A
  • If being dialysed ask them what mode, what access and when they were last dialysed
  • Important to ask if NSAIDs being taken OTC
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3
Q

How do you perform a renal examination on a patient?

A

https: //www.youtube.com/watch?v=PPhwQgsebKY
- General inspection
- Hands
- Arms
- Face
- Chest
- Abdomen
- Legs and Sacrum
- Further tests

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4
Q

What are some of the different modes of renal replacement therapy?

A

- APD (Automated peritoneal dialysis via peritoneal catheter)

- CAPD (Continuous ambulatory peritoneal dialysis)

- Assisted PD (Can perform at home with help of district nurses)

- UHD (Unit based haemodialysis)

- HHM (Home haemodialysis)

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5
Q

What are the different ways of access for dialysis? (both peritoneal and haemodialysis)

A
  • PD catheter
  • AV fistula
  • Tunelled (Perm-Cath)
  • Non-Tunelled (Vas-Cath)
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6
Q

What are some signs on examination of advanced renal disease?

A
  • Brown nails
  • Yellow brown uraemic skin
  • Uraemic frost from sweat on skin
  • Hyperreflexia
  • Pericardial rub
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7
Q

What are some different renal function tests?

A

Bloods: FBC, U+Es, bone profile, CRP, HbA1c

Urine: dipstick, protein-creatinine ratio, albumin-creatinine ratio, urine culture

Imaging: US KUB

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8
Q

How does a metabolic alkalosis show on a VBG and what are some causes of this?

A

- GI losses: vomiting and diarrhoea

- Renal losses: primary hyperaldosteronisms, diuretics

- Intracellular shift: hypokalaemia

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9
Q

How does a metabolic acidosis show on VBG and how can you work out the cause?

A

Anion Gap!!!!

Na - (Cl + HCO3)

Normal is 8-12

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10
Q

What is the cause of the derangment of this patients blood gas?

A
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11
Q

What are some of the symptoms of hypernatraemia and what is the number one cause of this electrolyte abnormality?

A

Thirst, irritability, weakness, confusion, seizures, hyperreflexia, spasticity, coma

Usually due to dehydration which causes cellular dehydration and vascular shear stress so bleeding and thrombosis

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12
Q

What are some causes of hypovolemic, euvolemic and hypervolemic hypernatraemia?

A

Hypovolemic: vomiting, diarrhoea, diuretics, osmotic diuresis

Euvolemic: diabetes insipidus, hypodipsia, inadequate water intake, heatstroke

Hypervolemic: hypertonic dialysis, sodium bicarbonate administration, hypertonic saline administration, hyperaldosteronism, Cushing’s

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13
Q

What are some causes of central and nephrogenic diabetes insipidus?

A

Central (impaired release of ADH)

  • Trauma
  • Tumours
  • Cerebral sarcoid/TB
  • Infection e.g meningitis
  • Cerebral vasculitis e.g SLE

Nephrogenic: (resistance to ADH)

  • Congenital
  • Drugs (lithium, amphotericin)
  • Hypokalaemia
  • Hypercalcaemia
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14
Q

How is hypernatraemia managed?

A

Free water

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15
Q

What are some of the symptoms of hyponatraemia?

A
  • Headache
  • Decreased perception
  • Confusion
  • Seizures
  • Gait disturbance
  • Reversible ataxia
  • Nausea
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16
Q

What is pseudohyponatraemia?

A
  • Sodium <135 but with a normal serum osmolality

- Due to either high lipids, myeloma, hyperglycaemia, uraemia

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17
Q

What are some causes of hypovolemic, euvolemic and hypervolemic hyponatraemia?

A

Hypovolemic: diuretics (thiazides), osmotic diuresis, Addison’s disease due to mineralcorticoid deficiency, diarrhoea

Euvolemic: Hypothyroidism, Glucocorticoid deficiency, SIADH

Hypervolemic: CCF, nephrotic syndrome, liver cirrhosis, renal failure

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18
Q

What are some investigations you should do when a patient has hyponatraemia?

A

- Plasma osmolality: rule out pseudohyponatraemia

- K+ and Mg2+: hypoK and hypoMg can potentiate ADH release

- Urine Na: if <20 then non-renal salt losses, if >40 then SIADH

- TSH and 9am Cortisol

- Calcium, Albumin, Glucose, LFTs

- CT head if suspect SIADH

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19
Q

How do you diagnose SIADH?

A
  • Hyponatraemia with low serum osmolality
  • Urine osmolality >100 with urine Na>20
  • Euvolemia
  • Not on diuretics

PROCESS OF ELIMINATION: normal renal, thyroid and adrenal function

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20
Q

What are some causes of SIADH?

A
  • Malignancy
  • Meningitis
  • Subarachnoid haemorraghe
  • Drugs e.g SSRIs, morphine, amitriptylline
  • Hypothyroidism
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21
Q

What is the management for SIADH?

A

- Fluid restrict: <800mls day

- Furosemide

- Demelocycline or Tolvaptan to induce ADH release (can reverse too far to DI)

  • PO NaCl
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22
Q

What is the management of hypovolemic and hypervolemic hyponatraemia?

A

Hypovolaemic: (renal or GI losses of Na) IV fluids 0.9% NaCl at 1-3ml/kg/hr and add K+ if needed

Hypervolaemic: (increased water lowering Na) fluid restrict and consider furosemide

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23
Q

Why should you not correct hyponatraemia rapdily?

A

Risk of central pontine myelinolysis, correct by <12 mmol/day

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24
Q

How should acute and chronic hyponatraemia be managed?

A

Acute and Symptomatic (<48hours)

  • 3% HYPERTONIC SALINE BOLUSES +/- Furosemide)

Chronic and Symptomatic (>48 hours)

  • If seizures hypertonic saline boluses
  • Otherwise isotonic saline and furosemide

Chronic and Asymptomatic

  • Water restriction
  • Stop offending drug
  • If dehydrated give water
  • If fluid overloaded give water restriction, furosemide and Na
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25
What drugs can cause hyperkalaemia?
- ACEi/ARBs - Spironolactone - Amiloride - NSAIDs - Heparin - Trimethoprim - Betablockers
26
What are some causes of hyperkalaemia?
- CKD/AKI - Drugs (ACEi, spironolactone, NSAIDs, etc) - Hypoaldosteronism - Addison's disease - Rhabdomyolysis - Metabolic acidosis e.g DKA - Hyperkalaemic periodic paralysis
27
What are some causes of artifact hyperkalaemia?
- Haemolysis - Raised WCC - Raised platelets
28
What can hyperkalaemia do to the pH of the blood?
Metabolic acidosis
29
When is a patient having Type IV RTA (renal tubular acidosis) and what are some common causes of this?
Due to issue with distal tubule not being able to respond to aldosterone ***- Hyperkalemia*** ***- Hypochloraemic metabolic acidosis*** ***- HTN*** **Causes:** hyporeinaemic hypoaldosteronism, diabetic nephropathy, hypertension, NSAIDs, lupus nephritis
30
How is hyperkalaemia due to type 4 RTA treated?
- Low K diet - Fluid restrict - Loop diuretic if overloaded
31
What are some ECG changes with hyperkalaemia?
- Tented T's - Prolonged QRS - Slurring ST segment - Loss of p waves - Sine then asytole
32
What is the first investigation you should do when a patient has hyperkalaemia on their blood results?
- VBG to check correct - ECG to look for changes
33
How is hyperkalaemia with ECG changes treated?
**_Stabilise myocardium to prevent arrhythmias_**: 10mls of 10% Calcium Gluconate over 5-10 minutes **_Shift potassium back into extracellular space:_** IV fast acting insulin with glucose or Salbutamol neb **_Eliminate potassium from body:_** Calcium resonium **_Dialysis:_** if treatment resistant
34
What are some of the symptoms of hypokalaemia?
- Fatigue - Constipation - Proximal muscle weakness - Poor glucose control - Cardiac arrhythmias
35
What are some of the causes of hypokalaemia?
- Poor intake - Gut losses e.g vomiting, NG losses, ileostomy - Drugs e.g alpha blockers, beta agonists, insullin, theophylline - Refeeding syndrome - Conn's syndrome (Primary hyperaldosteronism) - Cushing's syndrome - Diuretics - Hypomagnesiumaemia
36
What are some ECG changes with hypokalaemia?
- Small T waves - U wave after T - Increased PR interval HypoK is \<3.5 but do not see ECG changed until moderately low \<2.5-2.9
37
How is hypokalaemia managed?
- Replace Mg - Oral K replacement - IV replacement in 0.9% NaCl NOT dextrose
38
What are the different options for renal replacement therapy?
- Haemodialysis - Peritoneal Dialysis - Transplantation (best survival and quality of life) - Conservative Management
39
When is long term dialysis started?
When needed to manage the symptoms of renal failure. eGFR usually \<10-15. Used as a bridge to transplantation - Inability to control fluid status e.g pulmonary oedema - Inability to control VP - Acid-base or electrolyte abnormalities - Cognitive impairment
40
How does peritoneal dialysis work to filter the blood?
- **Peritoneal membrane** acts as dialysis membrane - **Catheter** inserted **into peritoneal cavity** and **dialysate fluid** is infused. This **fluid has a high osmotic gradient due to addition of glucose,** which pulls water from the patient into the fluid - **Solutes (urea, creatinine, electrolytes) move from blood across peritoneal membrane** into dialysate fluid - Continuous process with i**ntermittent drainage and refilling of peritoneal cavity**
41
What are the different types of peritoneal dialysis?
**- Automated PD:** Automatic cycler machine at night over 10hours with 10-12L exchanged. Leaves daytime free **- Continuous Ambulatory PD:** 4-5 dialysis exchanges a day at regular intervals of 2L. **- Assisted Automated PD**: healthcare assistants visit the patient's home to set up machine for night
42
What are the advantages of peritoneal dialysis?
- Increase QOL as home based - Good if patient still got some residual renal function - Regime individualised to patient rather than HD clinics - Lower risk of HepC - No anticoagulation needed
43
What are the disadvantages of peritoneal dialysis?
**- Patient needs to learn technique** - Unsuitable if patient has stoma or previous GI surgery **- Risk of peritonitis** **- Hernia** - Hydrothorax - Leaks - Catheter site infection - Loss of membrane function over time
44
How does haemodialysis work to filter the blood long term?
**Blood pumped from patient** into machine where it is **passed over a semi-permeable membrane** containing **dialysis fluid flowing in the opposite direction** **Solutes diffuse across down concentration gradient**. **Excess fluid** diffuses down **hydrostatic gradient** (not osmotic like PD) **Access usually via AV fistula** due to risk of infection with central venous dialysis catheters
45
What are the different types of HD?
**- Unit based** **- Home based:** training offered so can do more frequently - **Nocturnal** **- CRRT**: used in ITU/HDU
46
What are the advantages of haemodialysis?
- More efficient form of dialysis - Unit based so support from staff
47
What are the disadvantages of haemodialysis?
- Risk of bleeding due to heparin - Infection - Hypotension - Anaemia - AVF steal syndrome - SVCO from central lines - Time consuming
48
How does haemofiltration work and when is it used?
- Used in critical care patient's BP is too low for haemodialysis - Waste is replaced with volume of clean fluid before (pre-dilution) or after (post dilution) the membrane
49
What are some complications of renal replacement therapy in general?
**- Cardiovascular disease:** raised BP, Ca/PO4 dysregulation, vascular stiffness **- Protein-calorie malnutrition** **- Renal bone disease** **- Infection** **- Amyloid accumulation:** carpal tunnel syndrome, arthralgia
50
Sometimes when a patient is in ESRF the decision is made to not carry out RTT and just have conservative management. Which patients does this occur in?
Decision after discussion with patient and family about risks and benefits. **- Age \>80** **- WHO performance of 3 or more** If the characteristics above then RRT is likely to have no survival benefit
51
What are the principles of conservative management in ESRF?
- Symptom control to enhance QoL - Respect patients preferred place of care - Advanced care plan - Support system for patients and family as end of life
52
What are the advantages and disadvantages of a renal transplant for ESRF?
**_Advantages_** - Near normal lifestyle - Better mortality/morbidity **_Disadvantages:_** - Lifelong medication - Risk of rejection - Risk of malignancies over time - Risk of infection and immunosuppression - Long waiting times - Need to fufill certain criteria
53
What is the biggest cause of death in dialysis patients?
IHD!
54
What are some contraindications for kidney transplantation?
**- Active infection or malignancy** - Severe heart or lung disease - Reversible renal disease **- Uncontrolled substance abuse** - Non-adherance to treatment **- Short life expectancy**
55
What are the different types of renal graft?
**_Deceased Donor:_** - Long waiting list - Survival of kidney and patient lower than living **_Living Related Donors_** - Best possible transplant option as higher compatibility as time to HLA march - Only takes few months **_Living Unrelated Donor:_** - Also a best option **- 4 types:** live-donor paired exchange, live-donor/deceased-donor exchange, live-donor chain, altruistic donation
56
How is hyper acute rejection of a renal graft avoided?
**Induction** of immunosuppression at moment of transplant **_Drugs used:_** ***- Methylprednisolone*** plus one of below - Basiliximab - Thymoglobulin - Alentuzumab - Rituximab
57
How is long term rejection of a renal graft avoided?
Maintenance of immunosuppression therapy **Steroids**: prednisolone or prednisone **Calcineurin Inhibitors**: tacrolimus, cyclosporin **Antimetabolites:** mycophenolate, azathioprin **T cell regulation**: belatacept, belimumab
58
What is the long term care a patient needs following a renal transplant?
- For first 6 months review every few times a month - **Monitor GFR, CNI levels, proteinuria, Ca, PO4, PTH, lipids and glucose** **- Screen for infections** **- Vaccinations** (not live or attentuared) - Check for CVD and bone mineral disease **- Annual skin checks** for skin cancer **- Contraception for first year** then counsel about pregnancy
59
What are the biggest causes of mortality following a renal transplant?
- CVD - Malignancy - Infections
60
What are some complications of a renal transplant?
**Surgical (first month):** bleeding, thrombosis, infection, hernia **Rejection:** acute or chronic, treat with high dose steroids and increased immunosuppression **Infection:** increased risk of infection **Malignancy:** increased risk of skin, gynaecological and PTLD cancers **CVD**
61
What infections are common following a renal transplant?
**\<4 weeks:** nosocomial or from donor **1-12 months:** activation of latent infections or opportunistic infections e.g CMV and Pneumocystitis Jirovecci **After 12 months**: community acquired
62
What endocrine disorder can occur after a renal transplant?
**New onset diabetes after transplant (NODAT)** Look at personal risk factors, medications and new gluconeogenic kidney
63
What malignancies should you screen for after a renal transplant?
- Skin - Cervix - Prostate - Renal and urothelial - Liver - Colorectal - Lymphoproliferative disorder (especially if have EBV)
64
What are some simultaneous transplants that can occur with a kidney transplant?
**- Liver-Kidney:** if ESRF and cirrhosis **- Pancreas-Kidney:** if type 1 diabetes **- Kidney transplant with ESRF**: re transplanted
65
What is the prognosis following a renal transplant?
66
How do you carry out a fluid assessment on a patient?
**- Hands:** temp, cap refill, turgor **- Pulse and blood pressure** **- JVP** **- Face:** eyes sunken and dry mouth **- Chest:** heart sounds, lung bases, resp rate **- Abdomen:** ascites **- Oedema**
67
What is dehydration?
Excessive loss of water from the body so that there is more water lost than being taken in
68
What hormones regulate fluid balance in the body?
ADH Aldosterone ANP
69
What are some signs on examination of CKD?
**- Oedema** **- Uraemic breath** **- Pericardial rub** - Pulmonary oedema - Palpable kidneys - Uraemic yellow skin
70
What are some of the pros and cons of a live renal donor over a deceased renal donor?
**_Pros:_** - Less chance of rejection - Shorter waiting time **_Cons:_** - Patient may not have someone willing to donate - Risks to the donor
71
What are some of the causes of sterile pyuria?
- TB - Recently treated UTI - Appendicitis - Chlamydia - Calculi - Pregnancy - Recent catheter
72
When should you not treat asymptomatic bacteriuria?
- Non-pregnant women - Men - Adults with catheter
73
How do you manage a UTI in the following patients: - Non pregnant women - Pregnant women - Men - Catheterised patients
**Non pregnant women**: *3 days of Nitrofurantoin or Trimethoprim* if three or more symptoms of cystitis and no vaginal discharge. If pyelonephritis use co-amoxiclav **Pregnant women:** Do not use trimethoprim in 1st trimester or nitrofurantoin in 3rd trimester. Risk of preterm deliver and IUGR **Men:** 7 days of Nitrofurantoin or Trimethoprim. If signs of prostatitis give ciprofloxacin for 4 weeks. Send all men with UTI for urological investifation **Cathererised:** Only send MSU if symptomatic as all catheters have bacteria. Change long term catheter before antibiotics
74
How does urinary tract tuberculosis present?
- Dysuria - Frequency - Suprapubic pain - Sterile pyuria - Negative culture
75
How does diabetic nephropathy develop?
1. Hyperglycaemia leads to **hyperfiltration and capillary hypertension** as **RAAS is activated** due to less Na getting to macula densa **2. GBM thickens** **3. Mesangial proliferation** **4. Glomerulosclerosis**
76
How is diabetic nephropathy diagnosed?
- Screening for **microalbuminuria** using albustix annually **- Dipstick for overt proteinuria** **- ACR** ratio in urine by sending off
77
What is the histology of diabetic nephropathy?
- Glomerulosclerosis - Kimmelsteil-Wilson nodules - Thicker GBM
78
How is diabetic nephropathy treated once microalbuminamia has developed?
Need to stop proteinuria developing as this is irreversible: - Strict HbA1c control \<6.5% - Tight blood pressure contol using ACEi/ARB - Statins
79
What diuretics work in each part of the kidney tubule?
80
What are some nephrotoxic drugs?
- NSAIDs - Rifampacin - Valproate - PPIs - Furosemide - Thiazides - ACEi/ARB - Lithium - Gentamicin and Tobramycin
81
How may a patient with ADPKD present?
- Asymptomatic - Abdominal discomfort due to pressure - Haematuria from haemoraghe into cyst - Hypertension - Renal calculi
82
How is ADPKD diagnosed?
- USS - Genetic testing - Screen for an ask about family history of SAH and intracranial aneurysms
83
How is ADPKD managed?
- Water intake 3-4L a day - Control BP with ACEi then thiazide then betablockers - Plan for RRT and future transplantiation - Tolvaptan
84
What are some examples of loop diuretics, what is their action, when are they given and what are some common side effects?
**Furosemide and Bumetanide** - Block **Na/K/Cl transporter** - Fluid overload - HypoNa, HypoK, Diuresis, Dehydration
85
What are some examples of thiazide/thiazide like diuretics, what is their action, when are they given and what are some common side effects?
**Bendroflumethiazide and Indapamide** - Block NaCl channel in DCT - Hypertension and fluid overload - Cause HypoNa and Hypo K and Hyper GLUC
86
What are some examples of K sparing diuretics, what is their action, when are they given and what are some common side effects?
**Amiloride and Spironolactone** Can cause hyperK and gynacoemastia
87
What are some examples of carbonic anhydrase inhibitors what is their action, when are they given and what are some common side effects?
**Acetazolamide** - Used for glaucoma and benign intracranial HTN - Flushing, metabolic acidosis, agranulocytosis
88
What are some of the side effects of steroids and what are some medications you should give alongside steroids?
- Hyperglycaemia - Raised white cells - Cushing's - Osteoporosis - Glaucoma - Muscle wasting - Skin thinning
89
Who is the handsome chap on the other side of this card?

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