31. Renal 2

Question 1

What is CKD?

Answer 1

Progressive decrease in kidney function over a minimum of three months

From eGFRs of G1 > 90 to G5 < 15 (end-stage renal disease)

Albumin from A1 < 30 to A3 > 300mg per day

Question 2

What are the three branches of CKD causes?

Answer 2

Pre-renal
Renal
Post-renal

Question 3

What are the pre-renal causes of CKD?

Answer 3

Blood supply issues -
CHF
Cirrhosis
Diabetes

Question 4

What are the renal causes of CKD?

Answer 4

Vascular - HTN, renal artery stenosis
Glomerular disease - nephritic and nephrotic disease
Tubulointerstitial disease
Nephrotoxins e.g. NSAIDs

Question 5

What are the post-renal causes of CKD?

Answer 5

Prostatic disease
Repeated pyelonephritis
Repeated stones

Question 6

Signs and symptoms of CKD?

Answer 6

1) Water regulation - oedema, SOB
2) Waste removal - uraemia, N&V, poor appetite, encephalitis
3. Electrolyte regulation - hyperkalaemia (arrythmias), hypocalcaemia, acidosis (dyspnoea, N&V)
4. Hormone production - ACE, renin (hypertension), low vitamin D, EPO (anaemia)

Question 7

Investigations in CKD?

Answer 7

Bedside - urinalysis (blood, protein, albumin)
Bloods - Cr, eGFR, FBC, ABG, U&Es, PTH
Imaging - renal US (stone, mass, blood flow), AXR, MRI (cancer)
Invasive - kidney biopsy

Question 8

How to manage CKD?

Answer 8

Conservative - weight, nephrotoxins, manage cause, diet changes, smoking cessation
Medical - ARB, ACEi, loop diuretic, statins
Interventional - Reserved for G5 CKD
Haemodialysis
Peritoneal dialysis
Kidney transplant

Question 9

What can the compression of cysts in polycystic kidney disease cause?

Answer 9

Blood vessels - hypoperfusion - activation of RAAS causing HTN
Collecting ducts - urine stasis - kidney stones

Question 10

How might polycystic kidney disease present?

Answer 10

Hypertension
Flank pain
Haematuria
Palpable kidneys
Headache

Typically FHx, may have cerebrovascular event

Question 11

Investigations for polycystic kidney disease?

Answer 11

Bedside - urinalysis, urine culture, BP
Bloods - U&Es, lipid profile
Imagining - Renal USS, abdo CT or MRI

Question 12

How would we manage polycystic kidney disease?

Answer 12

Conservative - lifestyle
Medical - tolvaptan (if rapidly progressing), ARB or ACEi
Interventional - CT guided cyst aspiration, nephrectomy (uni/bi), renal transplant

Question 13

What are some complications of renal artery stenosis?

Answer 13

Reduced perfusion causes ischaemic nephropathy

Activation of RAAS causes renovascular HTN

Question 14

How does renal artery stenosis present?

Answer 14

Severe, progressive, hard to control HTN, sometimes causing end-organ damage.
Onset before 30 = fibromuscular dysplasia

Question 15

Two main causes of renal artery stenosis?

Answer 15

Renal artery atherosclerosis

Muscular fibrodysplasia

Question 16

Investigations for renal artery stenosis?

Answer 16

Bedside - urinalysis
Bloods - U&Es, aldosterone to renin ratio < 20 excl. primary aldosteronism
Imaging - duplex USS (measures flow velocity), MRI/CT angiography

Question 17

Management for renal artery stenosis?

Answer 17

Conservative - lifestyle

Medical - HTN, ARB or ACEi, aspirin and statin for atherosclerosis

Interventional - renal artery stenting, percutaneous renal artery balloon angioplasty if fibromuscular dysplasia, surgical reconstruction

Question 18

What are the two main differentials of renal cell carcinomas?

Answer 18

Sporadic - solitary tumours of upper kidney, older man + RFs (older, obese, smoking, HTN)

Inherited - von hippel lindau disease, AD mutation in VHL tumour suppressor gene, multiple benign tumours and cysts

Question 19

How does renal cell carcinomas present?

Answer 19

SILENT CANCER

Flank pain
Palpable mass
Haematuria
Varicocele on left side

Paraneoplastic syndrome so
EPO - polycythaemia
Renin - HTN
PTHrP - hypercalcaemia
ACTH - cushings

Question 20

Investigations for renal cell carcinomas?

Answer 20

Bloods - anaemia, calcium, WCC, ALP (mets)
Imaging - CT, MRI for staging, CXR for mets
Lymph node biopsy (staging)

Question 21

Treatment for renal cell carcinomas?

Answer 21

Conservative - active surveillance if low grade (stage1/2) or unfit for surgery
Immunotherapy (tyrosine kinase) if stage 4

Surgical resection - first line

Question 22

Uncomplicated UTI first line treatment?

Answer 22

Nitrofurantoin
Trimethoprim
(both 3 days)

2nd - pivmecillinam, fosfomycin

Question 23

Complicated UTI first line treatment?

Answer 23

Nitrofurantoin
Trimethoprim
(both 7 days men)

Cefalexin oral preg women or cefuroxime IV