31. Renal 2 Flashcards
What is CKD?
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
What are the three branches of CKD causes?
Pre-renal
Renal
Post-renal
What are the pre-renal causes of CKD?
Blood supply issues -
CHF
Cirrhosis
Diabetes
What are the renal causes of CKD?
Vascular - HTN, renal artery stenosis
Glomerular disease - nephritic and nephrotic disease
Tubulointerstitial disease
Nephrotoxins e.g. NSAIDs
What are the post-renal causes of CKD?
Prostatic disease
Repeated pyelonephritis
Repeated stones
Signs and symptoms of CKD?
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)
Investigations in CKD?
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
How to manage CKD?
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
What can the compression of cysts in polycystic kidney disease cause?
Blood vessels - hypoperfusion - activation of RAAS causing HTN
Collecting ducts - urine stasis - kidney stones
How might polycystic kidney disease present?
Hypertension Flank pain Haematuria Palpable kidneys Headache
Typically FHx, may have cerebrovascular event
Investigations for polycystic kidney disease?
Bedside - urinalysis, urine culture, BP
Bloods - U&Es, lipid profile
Imagining - Renal USS, abdo CT or MRI
How would we manage polycystic kidney disease?
Conservative - lifestyle
Medical - tolvaptan (if rapidly progressing), ARB or ACEi
Interventional - CT guided cyst aspiration, nephrectomy (uni/bi), renal transplant
What are some complications of renal artery stenosis?
Reduced perfusion causes ischaemic nephropathy
Activation of RAAS causes renovascular HTN
How does renal artery stenosis present?
Severe, progressive, hard to control HTN, sometimes causing end-organ damage.
Onset before 30 = fibromuscular dysplasia
Two main causes of renal artery stenosis?
Renal artery atherosclerosis
Muscular fibrodysplasia
Investigations for renal artery stenosis?
Bedside - urinalysis
Bloods - U&Es, aldosterone to renin ratio < 20 excl. primary aldosteronism
Imaging - duplex USS (measures flow velocity), MRI/CT angiography
Management for renal artery stenosis?
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
What are the two main differentials of renal cell carcinomas?
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
How does renal cell carcinomas present?
SILENT CANCER
Flank pain
Palpable mass
Haematuria
Varicocele on left side
Paraneoplastic syndrome so EPO - polycythaemia Renin - HTN PTHrP - hypercalcaemia ACTH - cushings
Investigations for renal cell carcinomas?
Bloods - anaemia, calcium, WCC, ALP (mets)
Imaging - CT, MRI for staging, CXR for mets
Lymph node biopsy (staging)
Treatment for renal cell carcinomas?
Conservative - active surveillance if low grade (stage1/2) or unfit for surgery
Immunotherapy (tyrosine kinase) if stage 4
Surgical resection - first line
Uncomplicated UTI first line treatment?
Nitrofurantoin
Trimethoprim
(both 3 days)
2nd - pivmecillinam, fosfomycin
Complicated UTI first line treatment?
Nitrofurantoin
Trimethoprim
(both 7 days men)
Cefalexin oral preg women or cefuroxime IV
