Approach to renal disease, Lab assessment, renal biopsy Flashcards

1
Q

What are the major lab investigations to be done

A
Evaluate Glomerular function,
   - GFR, eGFR calculation, Creatinine clearance
   - Serum Cystatin C levels
Evaluate Tubular function,
   - Concentrating ability
   - FENa
Analyze Urine.
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2
Q

What is the normal GFR for different age groups.

A
20-30 years: 120 ml/min
30-50 years: 100 ml/min
60 years: 90
70 years: 80
80 years: 70
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3
Q

Formulas for calculating GFR

A

Cockroft-Gault:
Creatinine clearance
= (140-age) x weight / 0.814 x serumCr
Multiply the result by 0.85 for women, and 1 for men

MDRD formula or CKD-EPI formulas: online calculators accounting for gender, ethnicity, creatinine, BUN, and albumin.

GFR = Creatinine clearance + Urea clearance / 2

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4
Q

Fractional sodium excretion,
what is it used for
what is the calculation

A

FeNa% = (UrineNa x PlasmaCre) / (PlasmaNa x Urine Cr) x100%

It is the percentage of the sodium filtered by the kidney that is excreted in the urine.
Used to estimate the level of tubular Na-resorption, and thereby distinguish between Pre-Renal AKI and Intra-Renal AKI

Prerenal failure FeNa stays normal at less than 1%
In Acute Tubular Necrosis, FeNa is above 2%

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5
Q

normal values for fractional sodium excretion

A

Healthy person: FeNa <1%

Hypovolemic person with normal kidney function:
less than 0.1%, and less than 30mMol Na excretion per day.

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6
Q

How to measure renal urine concentrating ability

A

1) Measure urine specific gravity in the morning before any drinks.

normal values
Osmolarity > 800mOsm
Sp.Grav. > 1022

2) Perform Water deprivation test over 18-24 hours.
Osmolarity should increase above 600 mOsm,
Less than this, or any increase in serum osmlarity (beyond 295-300mOsm normal) means there is impaired concentrating ability.
Stop test immediately if body weight decreases by more than 3% - severe dehydration.

If there is impaired concentration, determine if it is Central or Nephrogenic problem

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7
Q

How to distinguish between central and peripheral Diabetes Insipidus

A

Administer 5 IU (international units) of Vasopression/ADH
or 40 ug nasal spray Adiuretin (nasal desmopressin/ADH analog)

If urine osmlality increases, then it is central DI, if there is not, then it is nephrogenic.

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8
Q

Test to measure renal acid secreting capacity, and what is it used for

A

Used to diagnose distal renal tubular acidosis

Acid loading with 0.1 g/Kg of ammonium-chloride

Take urine pH measurement every 2 hours for 6 hours.

Urine pH should drop < 5.3
Plasma HCO3- should drop < 18mM

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9
Q

What are the different colors of urine, what do they indicate

A

Orange: Rifampicin

Red: Macroscopic hematuria, hemoglobin or myoglobin. Phenytoin, beets.

Brown: Bilirubin, Chloroquine, Nitrofurantoin

Green: Methylene blue, Amitryptiline, Propofol

Darker urine when standing than laying down: Porphyria.

White- Chyluria

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10
Q

What does cloudy urine indicate

A

Pyuria - pus or bacteria

Chyluria - lymph and fats (chylomicrons)

Hematuria

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11
Q

What can very odorous urine indicate

A

UTI

Ketonuria

Metabolic disorders - maple syrup urine disease

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12
Q

Normal urine specific gravity range

A

1001-1046 g/L

pH 5-6.5

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13
Q

What does the urine dipstick test check

A
pH
Hemoglobin
Protein
Nitrite
Leukocytes
Glucose
Ketones
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14
Q

What tests are used to detect microalbuminuria

A

Morning urine - with a sensitive dipstick, or calculating albumin creatinine ratio ACR

24 hour collected urine: Albumin excretion rate in mg/24 hours, above 30mg/24 hrs.
Upper end for microalbuminura is 300mg/24 hours

Test must be repeated 3 times. 2 out of 3 positive tests confirms microalbuinuria

False positives: UTIs, Fever, Heart Failure, Strenuous exercise, Uncontrolled Diabetes, and NSAID abuse.

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15
Q

Healthy urinalysis values for:

24 hours albumin excretion

Albumin creatinine ratio

24 hour protein excretion

Protein Creatinine ratio

A

under 30mg albumin/24 hours

under 3 mg/mMol ACR

under 150 mg/24 total protein excretion

uncer 15 protein creatinine ratio.

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16
Q

Microalbuminuria values for

24 hours albumin excretion

Albumin creatinine ratio

24 hour protein excretion

Protein Creatinine ratio

A

30-300 mg/24 hours

3-30 mg/mM ACR

150-450 mg/24hr urinary protein excretion

15-45 mg/mM protein creatinine ratio

17
Q

frank proteinuria values for

24 hours albumin excretion

Albumin creatinine ratio

24 hour protein excretion

Protein Creatinine ratio

A

> 300 mg/24 hrs albumin

> 30 mg/mM ACR

> 450 mg/24hr protein excretion

> 45 mg/mM protein creatinine ratio

18
Q

Screening methods for proteinuria

A

Sulphosalycilic acid precipitation/turbidity test - broader specificity, detects bence jones immunoglobulins as well as albumin.

Urine electrophoresis immunoelectrophoresis, and staining with general stain. Examining peaks for Albumin, alpha-1 alpha-2, beta globulins, and gamma-immunoglobulins.
Screens for Bence-Jones protein and for albuminuria.

Western blot for NGAL - neutrophil gelatinase associated lipcalin.
An early urinary marker of Acute Kidney Injury. Secreted at higher than normal rates by injured tubular cells.

19
Q

What do white blood cells in the urine indicate

A

UTI
Pyelonephritis
Acute interstitial nephritis
Cholesterol embolisation

20
Q

What do tubular cells in the urine indicate

A

Acute tubular necrosis
Acute interstitial nephritis
Allograft rejection

21
Q

What do squamous cells in the urine indicate

A

contaminated sample

22
Q

What do oval fat bodies in the urine indicate

A

Significatn proteinuria

23
Q

What is the value for microscopic hematuria?

A

more than 3 RBCs/high power feild

24
Q

Causes of isomorphic hematuria

A
Extreme exercise/running
Urolithiasis
Infection
Tumor
Trauma
PCKD
Benigh prostate hyperplasia
Endometriosis
Sickle cell anemia and papillary necrosis
Hypercalciuria
Hyperuricosuria
Coagulopathy
25
Q

Causes of dysmorphic hematuria

A

Glomerulonephritis

26
Q

Types of urinary casts

A
Hyaline
Lipid
Tubular cell
RBC
WBC
ATC cast
27
Q

Types of urinary crystals

A

Calcium-oxalate dihydrate or monohydrate

Calcium-carbonate

Struvite

Cystine

Urate

28
Q

What are the radionuclides used for renal scintigraphy

A

Tc-MAG3: Tubular secretion

Tc-DTPA: Glomerular filtration

Tc-DMSA: Tubular retention

29
Q

What are the indications for a renal biopsy

A

Nephrosis or 1-2 g/day proteinuria with decreasing GFR.

Acute nephritis syndrome

Acute kidney failure - after exluding acute tubular necrosis, pre-renal failure, and post-renal failure, and without improvement after 2 weeks.

Renal failure of unknown origin

Transplant kidney dysfunction.

30
Q

What are the main steps to evaluating a patient for renal disease

A

First, like any patient:

1) Take a thorough history, family history, and current complaints
2) Perform a physical exam
3) Simple investigations
- 3) Urine analysis
- 4) Serum analysis
5) Renal function tests
6) Imaging
7) Renal biopsy.

31
Q

How does serum Cystatin C indicate glomerular funciton

A

Freely filtered protein with no resorption

Levels are not affected by gender, age, or muscle mass

Increased indicates lowered GFR and decreased renal function, more sensitvie to mild renal damage than Creatinine.

32
Q

What do lipid casts look like under the microscope and what do they indicate?

A

Formed by the breakdown of lipid-rich epithelial cells, these are hyaline casts with fat globule inclusions, yellowish-tan in color.

If cholesterol or cholesterol esters are present, they are associated with the “Maltese cross” sign under polarized light.

Pathognomonic for high protein nephrosis syndrome.