Clinical Flashcards
5 affects uraemia can have on the body
pericarditis encephalopathy neuropathy asterixis gastritis
consequences renal dysfunction has: (8)
nephrotic oedema hyperK+ uraemia metabolic acidosis drug toxicity anaemia renal bone disease
definition of hbp
> 140/90
accelerated hbp has a dbp of
> 120
normal amount for a 24hr urine protein collection
<150mg
stage 1 CKD by GFR
> =90ml/min/1.73m^2 AND EVIDENCE OF KIDNEY DAMAGE
stage 2 CKD by GFR
60-89ml/min/1.73m^2 AND EVIDENCE OF KIDNEY DAMAGE
stage 3 CKD by GFR
30-59ml/min/1.73m^2
stage 4 CKD by GFR
15-29ml/min/1.73m^2
stage 5 CKD by GFR
<15ml/min/1.73m^2
OR
on dialysis
proteinuria >3g/24hr hypoalbuminaemia oedema hypercholesteraemia normal renal function usually =
nephrotic syndrome
AKI oliguria hbp active urinary sediment some proteinuria =
nephritic syndrome
CKD defintion =
chronic reduced GFR +/ evidence of kidney damage
used to calculate eGFR =
serum creatinine
MDRD4 equation
eGFR is accurate if __
<60 GFR
if muscle mass is low then eGFR ___ GFR
overestimates
control of bp and proteinaemia in CKD
ACEI/ARB
sprionolactone
in CKD must check ++_ when anaemic
Rx =
target Hb =
folate + vit B12 + Fe
IV Fe / Epo - uses up Fe stores so need topped up too
10.5-12.5g/dl
treatment for renal bone disease
alfacalcidol (hydroxylated vit D)
decrease phosphate intake
phosphate binders - calcium carbonate/acetate , sevelamer
bone disease in CKD is caused by
decreased vit D hydroxylation => decreased Ca2+ abs => 2ndry hyper PT = high calcium and phosphate => vascular and valvular calcification
start educating ptnt on dialysis when GFR =
20 - or before if rapidly progressing
best form of vascular access for haemodialysis =
takes __ to mature
arteriovenous fistula
6wks
refer to vascular surgeon for AV fistula when GFR =
15
can use peritoneal dialysis catheter ___ after insertion
1-2wks
can be put on kidney transplant list when within __ of dialysis
6months
conservative management of ESRF (often chosen by elderly/comorbidities)
Epo and sympt control
confounders of serum creatinine levels =
muscle mass (increases Cr) age sex ethnicity protein diet
if it is essential to get an accurate measurement of GFR then ___ is the reference standard
^51Cr-EDTA clearance
2 ways to quantify proteinuria
24hr urine collection
spot sample PCR
4 types of proteinuria
overflow
tubular
secreted
glomerular
1st expression of diabetic nephropathy
microalbuminuria
microalbuminuria is undetectable on __
dipstick
to assess tubular function compare __ to __
urine osmolarity to serum osmolarity
normal if very different
abnormal if similar
Abx that can be used to treat asympt bacteriuria in 1st/2nd trimester =
nitrofurantoin
Abx that can be used to treat asympt bacteriuria in 3rd trimester
trimethoprim
treatment of pyelonephritis in 6th month of pregnancy
co-amoxiclav
bladder wall components inside -> out
lamina propria (epithelium, CT with nerves and vessels) detrusor muscle (inner longitudinal, circular, outer longitudinal)
__ in brain controls micturition
Pons
complications of bladder outflow obstruction = (9)
overflow incontinence stones haematuria recurrent UTI retention diverticulae/saccules in bladder trabeculation atonic bladder hydronephrosis
treatment of bladder outflow obstruction
IV fluids for renal function
catheterise to relieve
Rx options for BPH
alpha blocker
finasteride
TURP/laser
mutations implicated in ADPKD
protein they encode
PKD1 gene on chromosome 16
PKD2 gene on chromosome 4
make polycystin 1 +2
PKD1/2 for ADPKD develop ESRD earlier
PKD1
pathological features of ADPKD
massive cyst enlarged kidneys
epithelial lined cysts arise from small no of renal tubules
benign adenomas in 25% of kidneys
renal features of ADPKD
decreased urine concentrating ability chronic pain hbp - early age haematuria cyst infection renal failure
extra renal features of ADPKD
Berry aneurysms and subarachnoid haemorrhages
hepatic cysts (10y after renal ones, no function loss)
mitral/aortic valve prolapse
diverticular disease
herniae
US of ADPKD findings =
multiple bilateral cysts
renal enlargement
scan at __ if FH of ADPKD
30yo
in kids a ___ in high risk ptnts is enough for a ADPKD diagnosis
single cyst
___ are rare in kids with ADPKD but renal signs are the same as in adults
cerebral aneurysms
on US ___ suggest ARPKD rather than ADPKD
congenital hepatic fibrosis
Rx for ADPKD
hbp control hydrate decrease proteinuria tolvaptan - decreases cyst vol and progression dialysis and transplant if failure
genetic mutation in ARPKD
PKDH1 gene on chromosome 6
ARPKD cysts arise from
collecting ducts
X linked disorder of type 4 collagen that affects kidneys =
Alport’s syndrome / hereditary nephritis
gene in Alport’s syndrome
COL4A5
presentation of Alport’s syndrome
haematuria proteinuria sensorineural deafness anterior lenticonus leiomyomatosis of oesophagus/genitals
haematuria + deafness =
test you should order =
Alport’s syndrome
renal biopsy
thickened GBM and lamina propria splitting is seen in renal biopsy of
Alport’s syndrome
alpha-galactosidase A deficiency - an Xlinked lysosomal storage disease =
Anderson-Fabrys disease
Fabrys affects +++
liver, kidneys, lungs and erythrocytes
features of Fabrys disease =
renal failure angiokeratomas (dark red to blue telangiectasia in umbilical region) cardiomyopathy valve disease stroke acroparaesthesia pyschiatric
diagnosis of Fabrys is by
alphaGAL activity in plasma/leukocyte
skin biopsy
renal biopsy - concentric lamellar inclusions in lysosomes
treatment of Fabrys
fabrysyme (enzyme replacement of alpha-galactosidase A)
auto dom condition with cysts in corticomedullary junction/medulla => abnormal tubules and fibrosis = normal/small kidneys =
Medullary cystic kidney
diagnose medullary cystic kidney by __+__
on average presents age ___
treatment =
FH and CT
28yo
renal transplant
medullary sponge kidney = dilation of ___
cysts have ___ and these are seen on ___
collecting ducts
calculi
excretion urography
Rx for a ptnt with CKD and proteinuria/ DM with microalbuminuria
ACEI/ARB
post micturition dribbling in BPH is due to
pooling in bulbar urethra
can be an indicator for prostate volume
PSA
if high PSA and BPH then these ptnts gain the most from ___ treatment
5 alpha reductase inhibitors
finasteride and dutsasteride
Ix for BPH that indicates those with a non diminished peak flow that are more likely to have an overactive bladder and so don’t need Sx
uroflowmetry
Ix for incontinence =
3 day bladder diary
dipstick
bladder scan
Rx for stress incontinence in F
wt loss
pelvic floor 3 month trial
Rx for urge incontinence F
6 wk bladder retrain
antimusc if ineffective - oxybutynin / darifenacin/solifenacin/tolterodine/trospium chloride
intravaginal oestrogen if atrophy
antimuscarinics eg. oxybutynin are contraindicated in
acute closed angle glaucoma
treatment of post micturition dribbling in M
urethral milking and pelvic floor exercises
treatment of post prostatectomy incontinence in M
pelvic floor exercises
may => Sx/urethral bulking agents
Rx of stress/urge incontinence in M
bladder retrain and pelvic floor
oxybutynin
alpha blocker (alfuzosin) +/ finasteride
patients at high risk of CKD who are screened =
DM
hbp
CVD
structural renal tract disease
multisystem disease with potential renal involvement
FH of hereditary kidney disease/ stage 5 CKD
on long term NSAIDS
features more suggestive of AKI rather than CKD =
unwell ptnt + >=1 of:
50% rise in Cr over hrs/days
decreased eGFR by > 25%
oliguria
to diagnose CKD need at least ___ eGFRs over __
3
90days
target bp for CKD =
if have proteinuria as well =
<130/90
<120/80
stop ACEI if potassium \_\_\_ initial fall (but not >\_\_% = \_\_\_) in GFR is good as it suggests \_\_
> 6mmol
25% - renal artery stenosis
preferential relaxation of efferent glomerular vessels
causes of pre renal AKI
haemorrhage hypovolaemia, severe diarrhoea severe sepsis lbp MI NSAIDs
treatment of hyperK+
calcium gluconate 10% 10ml IV
10U actrapid insulin + 50ml glucose 50% IV
2,5mg nebulised salbutamol
will need haemodialysis as these effects on serum K+ are temporary
screening for CKD involves __+__
serum creatinine and urinalysis
contraindications for a renal biopsy
moderate-severe thrombocytopaenia coagulation defects small kidneys hbp untreated UTI relative = 1 kidney
glomerulonephritis definition =
immune mediated disease affecting glomeruli with 2ndry tubulointerstitial damage
glomerular barrier repels ___ charged molecules
-vely
damage to endothelial / mesangial cells => __ lesion = + released, __ attracted and ___
proliferative
Ang2 (hbp), chemokines
inflammatiory cells
vasculitis
damage to podocytes => ___ > ___ lesion
atrophy
non-proliferative
In GN haematuria is usually __/__
asympt microscopic/painless macroscopic
heavy proteinuria =
1-3g/day
microalbuminuria =
30-300mg albumin/day
asympt proteinuria =
<1g/day
nephritic syndrome is caused by a __ process on ___ cells =>
proliferative endothelial AKI oliguria oedema hbp active urinary sediment - RBCs and RBC+granular casts
complications of nephrotic syndrome
infections (lose opsonising Igs) renal vein thrombosis PE volume depletion vit D deficiency subclinical hypothyroid
non IS Rx used for GN
ACEI/ARB, diuretics, statins, anticoag possibly, omega 3/ fish oils
IS drugs used for GN
steroids
azathioprine
alkylating agents - cyclophosphamide/chlorambucil
calcineurin inhibitors - cyclosporin/tacrolimus
mycophenolate mofetil (MMF)
IS last line for GN
plasmaphoresis
IV Ig
monoclonal T/B cell Igs
Rx of nephrotic syndrome =
fluid and salt restrict diuretics ACEI/ARB maybe anticoag IV albumin - if other ineffective and vol deplete IS
complete remission =
partial remission =
of nephrotic disease
<300mg/day
<3g/day proteinuria
commonest cause of nephrotic syndrome in kids =
minimal change GN
foot process fusion in electron microscopy but nothing on other imagings =
minimal change GN
Rx for minimal change GN =
steroids (94% remission)
2nd line - cyclophosphamide / CSA
commonest cause of nephrotic syndrome in adults =
focal segmental GN
2ndry causes of FSGN
obesity
HIV
heroin
reflux nephropathy
parietal epithelial cells migrate to help podocytes => sclerosis =
FSGN
2ndry causes of membranous GN =
hep B / parasites
SLE
carcinoma/lymphoma
gold/penicillamine
subepithelial immune complex deposition in spike and dome in GBM which is thickened
membranous GN
Rx for membrnaous GN
steroid/ alkylating agents / B cell monoclonal Ig
Ig implicated in >70% of membranous GN
anti PLA2r Ig
commonest GN in world =
IgA GN
asympt microhaematuria +/- non-nephrotic range proteinuria - macrohaematuria after URTI/GI infection =
IgA GN
GN ass with HSP
IgA
results of renal biopsy on IgA GN
mesangial proliferation and expansion on light microscopy
IgA deposits in mesangium on immunofluorescence
Rx for IgA GN
fish oils, bp, ACEI/ARB
crescent formation = __ in capillary wall and GBM => __ into Bowman’s capsule => __ formation and + deposited => ___ proliferate
holes coagulation factors fibrin monocytes and lymphocytes parietal epithelial cells proliferate
Goodpastures attacks ___
type IV collagen
nodular glomerulosclerosis aka
is a feature of
Kimmelstiel Wilson lesions
nodular glomerulosclerosis
renal lesions that complicated DM =
widespread ischaemic atrophy 2ndry to atheroma of renal arteries
arteriolar hyalinosis and lumenal narrowing
thickening of capillary BM
diffuse glomerulosclerosis
Kimmelstiel Wilson lesions
severe acute pyleonephritis with renal papillary necrosis
BPH mainly involves which lobes of the prostate
lateral and median
Prostate cancer mainly involves which lobes of the prostate
posterior
microscopic features of BPH
glandulocystic
fibromuscular
hyperplasia
mesangial matrix expansion aka
seen in __
diffuse glomerulosclerosis
DM kidney disease
apple green birefringence on congo red =
amyloid
seminoma tens to spread lymphatically to __
para-aortic lymph nodes
hbp medication if have renal artery stenosis
CCB - amlodipine
dont give ____ in bilateral renal artery stenosis
WHY?
ACEI/ARB
dilates efferent which is needed to maintain glomeruli P and so GFR drops drastically.
investigation for renal artery stenosis
MR angiogram with gadolinium contrast
Factors to reduce the risk of AKI after contrast exposure
hydrate
use as little as possible
use LMW contrast
do you biopsy a typical presentation of diabetes nephropathy?
no
treatment for diabetic nephropathy?
ACEI
features of pre diabetic nephropathy
GFR increases 25-50% (hyperfiltration)
renal hypertrophy
what causes the increased GFR in pre diabetic nephropathy
haemodynamic changes - constricted efferent => afferent dilates by vasoactive mediators => hyperfiltration.
features of incipient diabetic nephropathy
microalbuminuria, hbp, GFR stable at 100
mesangial expansion (glucose acts as GF)
GBM thickens
arteriolar hyalinosis
features of overt diabetic nephropathy
decreased GFR proteinuria nephrotic syndrome Kimmelstiel-Wilson nodules tubulointerstitial fibrosis
be wary of ____ dialysis in diabetic nephropathy as it contains ___
peritoneal
dextrose
Ischaemic nephropathy causes a drop in GFR because
renal blood flow drops below the level of autoreg compensation
causes of ischaemic nephropathy
renal artery stenosis
fibromuscular dysplasia
presentation of renal artery stenosis
hbp AKI after start ACEI CKD in elderly vasculopaths flash pulm oedema abdo bruit one kidney small and scarred
imaging for renal artery stenosis
US (kidney size)
MR angriography
in fibromuscular dysplasia see ___ on angriography
age and gender
beading
15-50yo F
treatment of fibromuscular dysplasia
stent renal artery
fanconi syndrome =
may be caused by
inadequate reabsorption in prox tubule
myeloma
gold standard treatment for myeloma
stem cell transplant
Ix for vasculitis causing nephropathy
urinalysis
bloods
Igs
renal biopsy
Rx for vasculitis nephropathy
steroid and cyclophosphamide (if sig renal involvement)
plasma exchange
supportive = dialysis and ventilate
Rx for SLE nephropathy
all on HCQ
steroids + maybe cyclophosphamide/MMF/azathioprine
definition of AKI
abrupt (<48hrs) reduction in kidney function => increased serum creatinine by >26.4micromol/l or>50% or reduced urine output.
Only applied after fluid resus and exclusion of obstruction
KDIGO stage 1 AKI =
urine output <0.5ml/kg/hr for >6hrs
serum Cr increase >26micromol/l or >=1-5-1.9xreferenceCr
KDIGO stage 2 AKI =
urine output <0.5ml/kg/hr for >12hrs
serum Cr increase >=2-2.9xreferenceCr
KDIGO stage 3 AKI =
urine output <0.3ml/kg/hr for >24hrs/anuric for >12hrs
serum Cr increase >3xreferenceCr/ >354 / need RRT
untreated pre-renal AKI can lead to
ATN
Rx for pre-renal AKI
assess hydration
hypovol = fluid resus - if >1000ml = seek help
dont use dextrose as dont stay intravascular
Renal causes of AKI
vasculitis, renovascular disease
GN
interstitial nephritis - NSAID, PPI, Abx, infection
tubular injury - ischaemia, gentamicin, contrast, rhabdomyolysis
Ix for renal causes of AKI
urinalysis look at drug chart FBC U+E US Bence Jones (everyone >50yo)
urgent indications for dialysis
>7/6.5 unresponsive hyperK+ <7.15pH severe acidosis severe uraemia >40 uraemic pericardial effusion fluid overload - pulmonary oedema
Treatment of post renal causes of AKI
catheter/nephrostomy
hyperK+ =
life threatening =
> 5.5
>6.5
ECG signs of hyperK+
peaked Ts > flattened P, prolonged PR, depressed ST > atrial standstill, prolonged QRS, increased T peaking > sine wave
Rx of hyperK+
10ml 10% calcium gluconate
actrapid insulin 10units + 50ml 50% dextrose
nebulised salbutamol
later for chronic = calcium resonium
if suspect pyelonephritis/ gynae path mimicking renal colic imaging =
US
if pregnant and have renal colic Ix =
US/MRI
gold standard Ix for renal colic
CT - lots of radiation so must have high clinical suspicion
non-contrast “stone-search” = definitive for calculi
to distinguish calculi from phleboliths Ix =
Contrast CT
Ix for >50yo with macroscopic haematuria
CTU + cystoscopy
may then do uteroscopy if want to confirm / ablate ca that is unfit for nephrouterectomy
Ix for <50yo with macroscopic haematuria
US
cytoscopy
only CTU is both are normal and haematuria persists
If CTU is contraindicated in a ptnt with macroscopic haematuria the Ix =
MR urography
eg. contrast allergy, renal impairment, pregnancy
Ix for renal masses
CT - size and stage ca
MR - with contrast for preg
US - for simple cysts
Ix for pre renal failure
MR angiography
Ix for renal causes of renal failure
US biopsy
Ix for post-renal causes of renal failure
US (exclude obstruction) CT for definitive cause
Ix for scrotum =
US
varicocele =
dilaed scrotal venous plexus
Usually the left side
>2mm diameter tortuous veins on US
`Renal trauma Ix =
CT
bladder trauma Ix =
cystography/ CT cystography
if long term urethral stricture suspected Ix =
urethrography
