Block 9 - Renal Flashcards
What is the diagnostic criteria for Chronic Kidney Disease?
Chronic Kidney Disease (CKD) is diagnosed as:
- an estimated or measured glomerular filtration rate (GFR) <60mL/min/1.73m2 that is present for ≥3 months with or without evidence of kidney damage; or
- evidence of kidney damage with or without decreased GFR that is present for ≥3 months as evidenced by the following, irrespective of the underlying cause:
- albuminuria
- haematuria after exclusion of urological causes
- structural abnormalities (e.g. on kidney imaging tests)
- pathological abnormalities (e.g. renal biopsy)
Why are we worried about CKD?
- Epidemiology?
Which questions should be asked when enquiring about a history of CKD?
CKD - HISTORY
Patients with chronic kidney disease stages 1-3 (glomerular filtration rate [GFR] >30mL/min) are generally asymptomatic; they do not experience clinically evident disturbances in water or electrolyte balance or endocrine/metabolic derangements. Generally, these disturbances become clinically manifest with chronic kidney disease stages 4-5 (GFR <30mL/min)
Questions should be directing towards common symptoms of CKD:
- GIT: nausea, vomiting, diarrhoea, anorexia
- Endocrine: Amenorrhea, male impotence, infertility
- Cardiovascular feature: Ischemic Heart Disease (IHD), heart failure, hypertension, uremic pericarditis (usually painless) and peripheral vascular disease (PVD)
Both reduced eGFR and significant albuminuria are independent risk factors for cardiovascular disease (CVD).
- Recent studies have confirmed that even early CKD constitutes a significant risk factor for cardiovascular events and death.
- For people with CKD, the risk of dying from cardiovascular events is up to 20 times greater than requiring dialysis or transplantation.
11 questions to ask a patient on dialysis?
11 Steps when using an Ophthalmoscope?
Urinalysis Protocol?
Collection of Urine Samples protocol?
What is Fibromyalgia?
- Pathology & causes?
- Signs & Symptoms?
- Diagnostic Criteria?
- Treatment?
What causes fibromyalgia?
How is fibromyalgia diagnosed?
When is fibromyalgia easy to miss?
What is the initial approach to treatment for fibromyalgia?
Genitourinary History Protocol? (8)
Genitourinary History Protocol
1. Introduction
2. Presenting Symptoms
3. Past Medical History
4. Treatment/Medications
5. Allergies
6. Social History
7. Family History
8. Systems review - Repro/Genito, GIT, CVS?
What are 13 common Genitourinary complaints?
Genitourinary History Protocol - Presenting Complaints
1. Change in appearance of urine
2. Swelling/Fluid Retention
3. Symptoms of Diabetes
4. Symptoms of Chronic Kidney Disease
5. Bladder outlet obstruction
6. Incontinence
7. Infective symptoms
8. Renal/ ureteric colic
9. Neoplasia
10. STI symptoms
11. Sexual history
12. Female - reproductive: menses, fertility, contraception
13. Male - erectile dysfunction
Genitourinary History - What questions should you ask about a patient presenting with changes in appearance of urine? (9)
- Differentials?
- 16 questions to ask the patient with suspected renal disease?
Change in appearance of urine
1. Colour?
2. Haematuria- timing (start of stream, throughout)?
3. Frank blood/ clots?
4. Painful or painless?
5. Hx trauma?
6. Anticoagulants/ bleeding disorder?
7. Prior strep infection (sore throat/ skin infection)?
8. Drugs that change urine colour e.g. Rifampicin, large quantities beetroot, haemoglobinura/ myoglobinuria → red.
9. Foamy, brown/cola colour may be nephritic syndrome or kidney failure
Genitourinary History - What questions should you ask about a patient presenting with Swelling/fluid retention? (3)
Swelling/Fluid Retention:
1. Timing?
2. Onset?
3. Treatment?
Haematuria - What favours:
- UTI?
- Renal calculi?
- Source that is not glomerular?
- Blood not in the urine?
- IgA nephropathy?
- Trauma?
- Bleeding disorder?
6 findings on history that suggest polycystic kidney disease?
Genitourinary History - What questions should you ask about a patient presenting with Urinary Symptoms of Diabetes? (3)
Urinary Symptoms of Diabetes:
1. Polyuria
2. Nocturia
3. Polyphagia
Genitourinary History - What questions should you ask about a patient presenting with Symptoms of Chronic Kidney Disease? (12)
- Classification of CDK by GFR?
Symptoms of Chronic Kidney Disease
1. Oliguria
2. Nocturia
3. Polyuria
4. Anorexia
5. Vomiting
6. Metallic taste
7. Fatigue
8. Hiccups
9. Insomnia
10. Itch
11. Bruising
12. Oedema
Define:
- Anuria?
- Oliguria?
- Nocturia?
- Polyuria?
- Anuria (defined as failure to pass more than 50 mL urine daily)
- Oliguria (less than 400 mL urine daily)
- Nocturia (the need to get up during the night to pass urine), or
- Polyuria (the passing of abnormally large volumes of urine).
Genitourinary History - What questions should you ask about a patient presenting with Symptoms of Bladder outlet obstruction? (8)
Bladder outlet obstruction
1. Decrease in stream?
2. Hesitancy?
3. Dribbling
4. Urine retention?
5. Double voiding (pis-en-deux)?
6. Incomplete bladder emptying?
7. Stranguary?
8. Nocturia?
Genitourinary History - What questions should you ask about a patient presenting with Urinary Incontinence? (9)
- 5 Causes of established urinary incontinence?
**Urinary Incontinence **
1. Onset?
2. Timing?
3. Aggravating factors?
4. Treatment?
5. Stress?
6. Urge?
7. Detrusor inactivity
8. Overflow?
9. Obstructed labour?
Genitourinary History - What questions should you ask about a patient presenting with Urinary infective symptoms? (10)
- 7 Risk factors for UTI?
Infective symptoms
1. Dysuria?
2. Frequency?
3. Urgency?
4. Malodourous urine?
5. Cloudy urine?
6. Fever
7. Loin/back pain?
8. Haematuria?
9. Vomiting?
10. Confusion?
Genitourinary History - What questions should you ask about a patient presenting with Renal/ureteric colic (renal calculi)? (6)
Renal/ ureteric colic – (Renal calculi)
1. Onset?
2. Timing?
3. Aggravating factors?
4. Loin-to-groin pain?
5. Nausea/ vomiting?
6. Haematuria
Genitourinary History - What questions should you ask about a patient presenting with suspected renal/bladder neoplasia? (6)
Neoplasia
1. Fever
2. Apetite
2. Weight loss
3. Night sweats
4. Painless haematuria
5. Abdominal mass - e.g. Wilm’s tumour in children
Genitourinary History - What questions should you ask about a patient presenting with suspected STI? (4)
STI- symptoms
1. Urethral/vaginal discharge?
2. Dysuria?
3. Rash?
4. Lesions?
Genitourinary History - What questions should you ask a patient about their menstrual and sexual history?
Genitourinary History - What questions should you ask a patient about their past medical history? (10)
Genitourinary History - Past Medical History
1. General – medical/surgical, active/inactive
2. History of kidney infections?
3. Glomerulonephritis?
4. Renal calculi?
5. Hypertension?
6. Diabetes?
7. Renal surgery?
8. Autoimmune conditions such as SLE, scleroderma?
9. Renal biopsy?
10. Known CKD?
Genitourinary History - What questions should you ask a patient about their medications/treatments? (5)
Genitourinary History - Medications/Treatments
1. All current medications, in particular nephrotoxic drugs such as:
2. Aminoglycosides?
3. NSAIDs?
4. ACEI?
5. Diuretics?
Genitourinary History - What questions should you ask a patient about their Social History? (6)
Genitourinary History - What questions should you ask a patient about their Family History? (6)
Genitourinary History - Family History
1. General?
2. Polycystic kidney disease?
3. Diabetes?
4. Hypertension?
5. Deafness (Alport’s)?
6. CKD?
What are the 6 major renal syndromes? Definition? Example?
CAUSES OF ACUTE KIDNEY INJURY
- Prerenal?
- Renal?
- Postrenal?
Chronic Kidney Disease Examination Protocol? (14)
Chronic Kidney Disease Examination Protocol
1. Introduction
2. Exposure and positioning
3. General Inspection
4. Weight
5. BP
6. Fundoscopy
7. Hands and Arms
8. Face
9. Neck
10. Chest
11. Abdomen
12. Back
13. Legs
14. Urinalysis
Chronic Kidney Disease Examination Protocol - Introduction, Exposure & Positioning?
Chronic Kidney Disease Examination Protocol - Introduction, Exposure & Positioning
“Hi, my name is Kitty and i’m a second year medical student from the University of Notre Dame. I’ve been asked to come and examine you for any problems with your kidneys if thats ok?
Chronic Kidney Disease Examination Protocol - What are you looking for on General Inspection? (6)
Chronic Kidney Disease Examination Protocol - General Inspection
1. Well, unwell.
2. Any obvious tubes, ports.
3. Sallow complexion - Skin colour may be slate grey to bronze due to iron deposition in dialysis patients that have received blood transfusions (becoming less common with exogenous Erythropoetin)?
4. Hiccupping - Ominous sign of advanced uraemia
5. Shortness of breath – fluid overload
6. Hyperventilation - metabolic acidosis
Chronic Kidney Disease Examination Protocol - Weight? (3)
Chronic Kidney Disease Examination Protocol - Weight
1. “Dry” or target weight?
2. Usual weight to assess fluid balance?
3. Trends important BMI also as obesity is a modifiable risk factor for CKD.
Chronic Kidney Disease Examination Protocol - BP?
Chronic Kidney Disease Examination Protocol - BP
* Accurate measure of blood pressure.
* If AV fistula present DO NOT take BP from that arm
Chronic Kidney Disease Examination Protocol - Fundoscopy? (2)
Diabetic retinopathy - microaneurysms, intraretinal hemorrhage, exudates, cotton-wool spots, macular edema, macular ischemia, neovascularization, vitreous hemorrhage, and traction retinal detachment.
Hypertensive - Funduscopic examination shows arteriolar constriction, arteriovenous nicking, vascular wall changes, flame-shaped hemorrhages, cotton-wool spots, yellow hard exudates, and optic disk edema.
Chronic Kidney Disease Examination Protocol - Hands and Arms? (6)
Chronic Kidney Disease Examination Protocol - Hands and Arms
1. Nails – Mees lines
2. Bruising
3. Skin pigmentation
4. Scratch marks and excoriation due to uraemic pruritis (itch)
5. Uraemic frost (white powder present on skin)
6. AV fistula - thrill and bruit present?
Chronic Kidney Disease Examination Protocol - Face? (7)
Chronic Kidney Disease Examination Protocol - Face
1. Eyes – anaemia (conjunctival pallor)
2. Jaundice (rare) – haemolysis secondary to retention of nitrogenous wastes.
3. Band Keratopathy = calcium deposition beneath the corneal epithelium due to excessive replacement of Calcium or hyperparathyroidism
4. Mouth – Uraemic fetor = ammonia smell
5. Mouth ulcers
6. Oral thrush
7. Hearing aids may be consistent with Alports syndrome
Chronic Kidney Disease Examination Protocol - Neck? (4)
Chronic Kidney Disease Examination Protocol - Neck
1. Jugular Venous Pressure – assess fluid balance.
2. Scars from or presence of Vascular access catheters (Vascath) for haemodialysis
3. Surgical Scars from parathyroidectomy for treatment of tertiary hyperparathyroidism
4. Carotid artery bruits suggest atherosclerotic disease
Chronic Kidney Disease Examination Protocol - Chest? (5)
Chronic Kidney Disease Examination Protocol - Chest
Signs of Congestive Cardiac Failure and Pulmonary Oedema:
1. Displaced apex beat
2. Bibasal fine crackles
3. Lung bases dull to percussion
4. Increased respiratory rate and work of breathing
5. Pericarditis – pericardial rub, signs of tamponade
Chronic Kidney Disease Examination Protocol - Abdomen? (4)
Chronic Kidney Disease Examination Protocol - Abdomen
As for GIT examination with particular attention to the following
1. Inspect (4) – for nephrectomy scar, Tenckhoff catheter or scars from peritoneal access, ascites, renal transplant scars
2. Palpate (3) – renal masses, transplanted kidneys palpable in LIF or RIF, AAA, renal tenderness or loin pain, Ballot kidneys
3. Percuss (2) – ascites, enlarged bladder
4. Auscultate (1) – renal bruit – above umbilicus 2cm lateral to midline
Chronic Kidney Disease Examination Protocol - Back? (2)
Chronic Kidney Disease Examination Protocol - Back
1. Renal angle tenderness (Murphys punch or balloting)
2. Sacral oedema
Chronic Kidney Disease Examination Protocol - Legs? (7)
Chronic Kidney Disease Examination Protocol - Legs
1. Pitting Oedema
2. Purpura
3. Pigmentation
4. Scratch marks
5. Bruising
6. Signs of peripheral Vascular disease
7. Gouty tophi (uric acid retention can → Gout)
How should you finish the CKD Exam protocol?
Urinalysis
17 Causes of Chronic Kidney Disease?
4 Clinical features suggesting that renal failure is chronic rather than acute?
Causes of Bilateral/Unilateral palpable kidneys?
Causes of urine colour change?
- Very pale/colourless?
- Yellow/orange?
- Brown?
- Pink?
- Red?
- Green?
- Black?
- White/milky?
Causes of proteinuria?
Causes of Glycosuria? (3)
Causes of Ketonuria? (2)
5 CAUSES OF SYNDROME OF INAPPROPRIATE ANTIDIURETIC HORMONE (SIADH)?
