Clinical Flashcards
1
Q
5 affects uraemia can have on the body
A
pericarditis encephalopathy neuropathy asterixis gastritis
2
Q
consequences renal dysfunction has: (8)
A
nephrotic oedema hyperK+ uraemia metabolic acidosis drug toxicity anaemia renal bone disease
3
Q
definition of hbp
A
> 140/90
4
Q
accelerated hbp has a dbp of
A
> 120
5
Q
normal amount for a 24hr urine protein collection
A
<150mg
6
Q
stage 1 CKD by GFR
A
> =90ml/min/1.73m^2 AND EVIDENCE OF KIDNEY DAMAGE
7
Q
stage 2 CKD by GFR
A
60-89ml/min/1.73m^2 AND EVIDENCE OF KIDNEY DAMAGE
8
Q
stage 3 CKD by GFR
A
30-59ml/min/1.73m^2
9
Q
stage 4 CKD by GFR
A
15-29ml/min/1.73m^2
10
Q
stage 5 CKD by GFR
A
<15ml/min/1.73m^2
OR
on dialysis
11
Q
proteinuria >3g/24hr hypoalbuminaemia oedema hypercholesteraemia normal renal function usually =
A
nephrotic syndrome
12
Q
AKI oliguria hbp active urinary sediment some proteinuria =
A
nephritic syndrome
13
Q
CKD defintion =
A
chronic reduced GFR +/ evidence of kidney damage
14
Q
used to calculate eGFR =
A
serum creatinine
MDRD4 equation
15
Q
eGFR is accurate if __
A
<60 GFR
16
Q
if muscle mass is low then eGFR ___ GFR
A
overestimates
17
Q
control of bp and proteinaemia in CKD
A
ACEI/ARB
sprionolactone
18
Q
in CKD must check ++_ when anaemic
Rx =
target Hb =
A
folate + vit B12 + Fe
IV Fe / Epo - uses up Fe stores so need topped up too
10.5-12.5g/dl
19
Q
treatment for renal bone disease
A
alfacalcidol (hydroxylated vit D)
decrease phosphate intake
phosphate binders - calcium carbonate/acetate , sevelamer
20
Q
bone disease in CKD is caused by
A
decreased vit D hydroxylation => decreased Ca2+ abs => 2ndry hyper PT = high calcium and phosphate => vascular and valvular calcification
21
Q
start educating ptnt on dialysis when GFR =
A
20 - or before if rapidly progressing
22
Q
best form of vascular access for haemodialysis =
takes __ to mature
A
arteriovenous fistula
6wks
23
Q
refer to vascular surgeon for AV fistula when GFR =
A
15
24
Q
can use peritoneal dialysis catheter ___ after insertion
A
1-2wks
25
can be put on kidney transplant list when within __ of dialysis
6months
26
conservative management of ESRF (often chosen by elderly/comorbidities)
Epo and sympt control
27
confounders of serum creatinine levels =
```
muscle mass (increases Cr)
age
sex
ethnicity
protein diet
```
28
if it is essential to get an accurate measurement of GFR then ___ is the reference standard
^51Cr-EDTA clearance
29
2 ways to quantify proteinuria
24hr urine collection
| spot sample PCR
30
4 types of proteinuria
overflow
tubular
secreted
glomerular
31
1st expression of diabetic nephropathy
microalbuminuria
32
microalbuminuria is undetectable on __
dipstick
33
to assess tubular function compare __ to __
urine osmolarity to serum osmolarity
normal if very different
abnormal if similar
34
Abx that can be used to treat asympt bacteriuria in 1st/2nd trimester =
nitrofurantoin
35
Abx that can be used to treat asympt bacteriuria in 3rd trimester
trimethoprim
36
treatment of pyelonephritis in 6th month of pregnancy
co-amoxiclav
37
bladder wall components inside -> out
```
lamina propria (epithelium, CT with nerves and vessels)
detrusor muscle (inner longitudinal, circular, outer longitudinal)
```
38
__ in brain controls micturition
Pons
39
complications of bladder outflow obstruction = (9)
```
overflow incontinence
stones
haematuria
recurrent UTI
retention
diverticulae/saccules in bladder
trabeculation
atonic bladder
hydronephrosis
```
40
treatment of bladder outflow obstruction
IV fluids for renal function
| catheterise to relieve
41
Rx options for BPH
alpha blocker
finasteride
TURP/laser
42
mutations implicated in ADPKD
| protein they encode
PKD1 gene on chromosome 16
PKD2 gene on chromosome 4
make polycystin 1 +2
43
PKD1/2 for ADPKD develop ESRD earlier
PKD1
44
pathological features of ADPKD
massive cyst enlarged kidneys
epithelial lined cysts arise from small no of renal tubules
benign adenomas in 25% of kidneys
45
renal features of ADPKD
```
decreased urine concentrating ability
chronic pain
hbp - early age
haematuria
cyst infection
renal failure
```
46
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
47
US of ADPKD findings =
multiple bilateral cysts
| renal enlargement
48
scan at __ if FH of ADPKD
30yo
49
in kids a ___ in high risk ptnts is enough for a ADPKD diagnosis
single cyst
50
___ are rare in kids with ADPKD but renal signs are the same as in adults
cerebral aneurysms
51
on US ___ suggest ARPKD rather than ADPKD
congenital hepatic fibrosis
52
Rx for ADPKD
```
hbp control
hydrate
decrease proteinuria
tolvaptan - decreases cyst vol and progression
dialysis and transplant if failure
```
53
genetic mutation in ARPKD
PKDH1 gene on chromosome 6
54
ARPKD cysts arise from
collecting ducts
55
X linked disorder of type 4 collagen that affects kidneys =
Alport's syndrome / hereditary nephritis
56
gene in Alport's syndrome
COL4A5
57
presentation of Alport's syndrome
```
haematuria
proteinuria
sensorineural deafness
anterior lenticonus
leiomyomatosis of oesophagus/genitals
```
58
haematuria + deafness =
| test you should order =
Alport's syndrome
| renal biopsy
59
thickened GBM and lamina propria splitting is seen in renal biopsy of
Alport's syndrome
60
alpha-galactosidase A deficiency - an Xlinked lysosomal storage disease =
Anderson-Fabrys disease
61
Fabrys affects _+_+_+_
liver, kidneys, lungs and erythrocytes
62
features of Fabrys disease =
```
renal failure
angiokeratomas (dark red to blue telangiectasia in umbilical region)
cardiomyopathy
valve disease
stroke
acroparaesthesia
pyschiatric
```
63
diagnosis of Fabrys is by
alphaGAL activity in plasma/leukocyte
skin biopsy
renal biopsy - concentric lamellar inclusions in lysosomes
64
treatment of Fabrys
fabrysyme (enzyme replacement of alpha-galactosidase A)
65
auto dom condition with cysts in corticomedullary junction/medulla => abnormal tubules and fibrosis = normal/small kidneys =
Medullary cystic kidney
66
diagnose medullary cystic kidney by __+__
on average presents age ___
treatment =
FH and CT
28yo
renal transplant
67
medullary sponge kidney = dilation of ___
| cysts have ___ and these are seen on ___
collecting ducts
calculi
excretion urography
68
Rx for a ptnt with CKD and proteinuria/ DM with microalbuminuria
ACEI/ARB
69
post micturition dribbling in BPH is due to
pooling in bulbar urethra
70
can be an indicator for prostate volume
PSA
71
if high PSA and BPH then these ptnts gain the most from ___ treatment
5 alpha reductase inhibitors
| finasteride and dutsasteride
72
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
73
Ix for incontinence =
3 day bladder diary
dipstick
bladder scan
74
Rx for stress incontinence in F
wt loss
| pelvic floor 3 month trial
75
Rx for urge incontinence F
6 wk bladder retrain
antimusc if ineffective - oxybutynin / darifenacin/solifenacin/tolterodine/trospium chloride
intravaginal oestrogen if atrophy
76
antimuscarinics eg. oxybutynin are contraindicated in
acute closed angle glaucoma
77
treatment of post micturition dribbling in M
urethral milking and pelvic floor exercises
78
treatment of post prostatectomy incontinence in M
pelvic floor exercises
| may => Sx/urethral bulking agents
79
Rx of stress/urge incontinence in M
bladder retrain and pelvic floor
oxybutynin
alpha blocker (alfuzosin) +/ finasteride
80
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
81
features more suggestive of AKI rather than CKD =
unwell ptnt + >=1 of:
50% rise in Cr over hrs/days
decreased eGFR by > 25%
oliguria
82
to diagnose CKD need at least ___ eGFRs over __
3
| 90days
83
target bp for CKD =
| if have proteinuria as well =
<130/90
| <120/80
84
```
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
85
causes of pre renal AKI
```
haemorrhage
hypovolaemia, severe diarrhoea
severe sepsis
lbp
MI
NSAIDs
```
86
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
87
screening for CKD involves __+__
serum creatinine and urinalysis
88
contraindications for a renal biopsy
```
moderate-severe thrombocytopaenia
coagulation defects
small kidneys
hbp
untreated UTI
relative = 1 kidney
```
89
glomerulonephritis definition =
immune mediated disease affecting glomeruli with 2ndry tubulointerstitial damage
90
glomerular barrier repels ___ charged molecules
-vely
91
damage to endothelial / mesangial cells => __ lesion = _+_ released, __ attracted and ___
proliferative
Ang2 (hbp), chemokines
inflammatiory cells
vasculitis
92
damage to podocytes => ___ > ___ lesion
atrophy
| non-proliferative
93
In GN haematuria is usually __/__
asympt microscopic/painless macroscopic
94
heavy proteinuria =
1-3g/day
95
microalbuminuria =
30-300mg albumin/day
96
asympt proteinuria =
<1g/day
97
nephritic syndrome is caused by a __ process on ___ cells =>
```
proliferative
endothelial
AKI
oliguria
oedema
hbp
active urinary sediment - RBCs and RBC+granular casts
```
98
complications of nephrotic syndrome
```
infections (lose opsonising Igs)
renal vein thrombosis
PE
volume depletion
vit D deficiency
subclinical hypothyroid
```
99
non IS Rx used for GN
ACEI/ARB, diuretics, statins, anticoag possibly, omega 3/ fish oils
100
IS drugs used for GN
steroids
azathioprine
alkylating agents - cyclophosphamide/chlorambucil
calcineurin inhibitors - cyclosporin/tacrolimus
mycophenolate mofetil (MMF)
101
IS last line for GN
plasmaphoresis
IV Ig
monoclonal T/B cell Igs
102
Rx of nephrotic syndrome =
```
fluid and salt restrict
diuretics
ACEI/ARB
maybe anticoag
IV albumin - if other ineffective and vol deplete
IS
```
103
complete remission =
partial remission =
of nephrotic disease
<300mg/day
| <3g/day proteinuria
104
commonest cause of nephrotic syndrome in kids =
minimal change GN
105
foot process fusion in electron microscopy but nothing on other imagings =
minimal change GN
106
Rx for minimal change GN =
steroids (94% remission)
| 2nd line - cyclophosphamide / CSA
107
commonest cause of nephrotic syndrome in adults =
focal segmental GN
108
2ndry causes of FSGN
obesity
HIV
heroin
reflux nephropathy
109
parietal epithelial cells migrate to help podocytes => sclerosis =
FSGN
110
2ndry causes of membranous GN =
hep B / parasites
SLE
carcinoma/lymphoma
gold/penicillamine
111
subepithelial immune complex deposition in spike and dome in GBM which is thickened
membranous GN
112
Rx for membrnaous GN
steroid/ alkylating agents / B cell monoclonal Ig
113
Ig implicated in >70% of membranous GN
anti PLA2r Ig
114
commonest GN in world =
IgA GN
115
asympt microhaematuria +/- non-nephrotic range proteinuria - macrohaematuria after URTI/GI infection =
IgA GN
116
GN ass with HSP
IgA
117
results of renal biopsy on IgA GN
mesangial proliferation and expansion on light microscopy
| IgA deposits in mesangium on immunofluorescence
118
Rx for IgA GN
fish oils, bp, ACEI/ARB
119
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
```
120
Goodpastures attacks ___
type IV collagen
121
nodular glomerulosclerosis aka
| is a feature of
Kimmelstiel Wilson lesions
| nodular glomerulosclerosis
122
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
123
BPH mainly involves which lobes of the prostate
lateral and median
124
Prostate cancer mainly involves which lobes of the prostate
posterior
125
microscopic features of BPH
glandulocystic
fibromuscular
hyperplasia
126
mesangial matrix expansion aka
| seen in __
diffuse glomerulosclerosis
| DM kidney disease
127
apple green birefringence on congo red =
amyloid
128
seminoma tens to spread lymphatically to __
para-aortic lymph nodes
129
hbp medication if have renal artery stenosis
CCB - amlodipine
130
dont give ____ in bilateral renal artery stenosis
| WHY?
ACEI/ARB
| dilates efferent which is needed to maintain glomeruli P and so GFR drops drastically.
131
investigation for renal artery stenosis
MR angiogram with gadolinium contrast
132
Factors to reduce the risk of AKI after contrast exposure
hydrate
use as little as possible
use LMW contrast
133
do you biopsy a typical presentation of diabetes nephropathy?
no
134
treatment for diabetic nephropathy?
ACEI
135
features of pre diabetic nephropathy
GFR increases 25-50% (hyperfiltration)
| renal hypertrophy
136
what causes the increased GFR in pre diabetic nephropathy
haemodynamic changes - constricted efferent => afferent dilates by vasoactive mediators => hyperfiltration.
137
features of incipient diabetic nephropathy
microalbuminuria, hbp, GFR stable at 100
mesangial expansion (glucose acts as GF)
GBM thickens
arteriolar hyalinosis
138
features of overt diabetic nephropathy
```
decreased GFR
proteinuria
nephrotic syndrome
Kimmelstiel-Wilson nodules
tubulointerstitial fibrosis
```
139
be wary of ____ dialysis in diabetic nephropathy as it contains ___
peritoneal
| dextrose
140
Ischaemic nephropathy causes a drop in GFR because
renal blood flow drops below the level of autoreg compensation
141
causes of ischaemic nephropathy
renal artery stenosis
| fibromuscular dysplasia
142
presentation of renal artery stenosis
```
hbp
AKI after start ACEI
CKD in elderly vasculopaths
flash pulm oedema
abdo bruit
one kidney small and scarred
```
143
imaging for renal artery stenosis
US (kidney size)
| MR angriography
144
in fibromuscular dysplasia see ___ on angriography
| age and gender
beading
| 15-50yo F
145
treatment of fibromuscular dysplasia
stent renal artery
146
fanconi syndrome =
| may be caused by
inadequate reabsorption in prox tubule
| myeloma
147
gold standard treatment for myeloma
stem cell transplant
148
Ix for vasculitis causing nephropathy
urinalysis
bloods
Igs
renal biopsy
149
Rx for vasculitis nephropathy
steroid and cyclophosphamide (if sig renal involvement)
plasma exchange
supportive = dialysis and ventilate
150
Rx for SLE nephropathy
all on HCQ
| steroids + maybe cyclophosphamide/MMF/azathioprine
151
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
152
KDIGO stage 1 AKI =
urine output <0.5ml/kg/hr for >6hrs
| serum Cr increase >26micromol/l or >=1-5-1.9xreferenceCr
153
KDIGO stage 2 AKI =
urine output <0.5ml/kg/hr for >12hrs
| serum Cr increase >=2-2.9xreferenceCr
154
KDIGO stage 3 AKI =
urine output <0.3ml/kg/hr for >24hrs/anuric for >12hrs
| serum Cr increase >3xreferenceCr/ >354 / need RRT
155
untreated pre-renal AKI can lead to
ATN
156
Rx for pre-renal AKI
assess hydration
hypovol = fluid resus - if >1000ml = seek help
dont use dextrose as dont stay intravascular
157
Renal causes of AKI
vasculitis, renovascular disease
GN
interstitial nephritis - NSAID, PPI, Abx, infection
tubular injury - ischaemia, gentamicin, contrast, rhabdomyolysis
158
Ix for renal causes of AKI
```
urinalysis
look at drug chart
FBC
U+E
US
Bence Jones (everyone >50yo)
```
159
urgent indications for dialysis
```
>7/6.5 unresponsive hyperK+
<7.15pH severe acidosis
severe uraemia >40
uraemic pericardial effusion
fluid overload - pulmonary oedema
```
160
Treatment of post renal causes of AKI
catheter/nephrostomy
161
hyperK+ =
| life threatening =
>5.5
| >6.5
162
ECG signs of hyperK+
peaked Ts > flattened P, prolonged PR, depressed ST > atrial standstill, prolonged QRS, increased T peaking > sine wave
163
Rx of hyperK+
10ml 10% calcium gluconate
actrapid insulin 10units + 50ml 50% dextrose
nebulised salbutamol
later for chronic = calcium resonium
164
if suspect pyelonephritis/ gynae path mimicking renal colic imaging =
US
165
if pregnant and have renal colic Ix =
US/MRI
166
gold standard Ix for renal colic
CT - lots of radiation so must have high clinical suspicion
| non-contrast "stone-search" = definitive for calculi
167
to distinguish calculi from phleboliths Ix =
Contrast CT
168
Ix for >50yo with macroscopic haematuria
CTU + cystoscopy
| may then do uteroscopy if want to confirm / ablate ca that is unfit for nephrouterectomy
169
Ix for <50yo with macroscopic haematuria
US
cytoscopy
only CTU is both are normal and haematuria persists
170
If CTU is contraindicated in a ptnt with macroscopic haematuria the Ix =
MR urography
| eg. contrast allergy, renal impairment, pregnancy
171
Ix for renal masses
CT - size and stage ca
MR - with contrast for preg
US - for simple cysts
172
Ix for pre renal failure
MR angiography
173
Ix for renal causes of renal failure
US biopsy
174
Ix for post-renal causes of renal failure
US (exclude obstruction) CT for definitive cause
175
Ix for scrotum =
US
176
varicocele =
dilaed scrotal venous plexus
Usually the left side
>2mm diameter tortuous veins on US
177
`Renal trauma Ix =
CT
178
bladder trauma Ix =
cystography/ CT cystography
179
if long term urethral stricture suspected Ix =
urethrography
