Corrections - Renal 2 Flashcards
Mutations in which two genes can cause autosomal dominant polycystic kidney disease, and what chromosomes are they found on? (4)
1) PKD1 gene on chromosome 16
2) PKD 2 gene on chromosome 4
What conditions involving pathology inside the kidneys may cause acute kidney injury? (5)
1) Acute intersitial nephritis
2) Glomerulonephritis
3) Acute tubular necrosis
4) HUS
5) Rhabdomyolysis
In a patient with a kidney transplant, what immunosuppressant medication gives the side effect of a tremor? (1)
What about gum hypertrophy? (1)
What about central obesity, proximal limb muscle wasting, an upper back fat pad and abdominal striae? (1)
1) Tacrolimus
2) Ciclosporin
3) Corticosteroids
What are the A stages of chronic kidney disease? (3)
A1: ACR <3 mg/mmol
A2: ACR 3-30 mg/mmol
A3: ACR >30 mg/mmol
What cardiovascular effects are associated with nephrotic syndrome? (3)
1) Thrombosis
2) HTN
3) High cholesterol
What type of glomerulonephritis is associated with histology findings of IgA deposits and mesangial proliferation? (1)
IgA nephropathy (Berger’s)
What is the main presenting symptom of nephrotic syndrome? (1)
Oedema
What conditions may obstruct the outflow of urine, causing acute kidney injury? (5)
1) BPH
2) Tumours e.g. bladder, prostate
3) Kidney stones
4) Neurogenic bladder
5) Strictures of ureters or urethra
What non-specific urine dipstick findings are seen in acute nephritis? (2)
Haematuria
Mild proteinuria
What features characterise nephrotic syndrome? (4)
1) Proteinuria (>3g/24 hours)
2) Low serum albumin
3) Peripheral oedema
4) Hypercholesterolaemia
What happens to phosphate, vitamin D and calcium in renal bone disease? (3)
Low vit D
Low calcium
Raised phosphate
What defines “accelerated progression” of CKD?
Sustained decline in eGFR within one year of either 25% or 15 ml/min
What urine output over what timeframe would meet the criteria for acute kidney injury? (2)
<0.5ml/kg/hour over at least 6 hours
What ECG changes are seen with severe hyperkalaemia? (4)
1) Tall tented T waves
2) Flatted or absent P waves
3) Prolonged PR interval
4) Broad QRS complexes
What terms describe the RBCs in anaemia caused by CKD?
Normocytic normochromic
Caused by low EPO
What common classes of medications can cause hyperkalaemia? (4)
ACEi
Aldosterone antagonists
ARBs
NSAIDs
What is the characteristic spinal x-ray finding in renal bone disease? (1)
Rugger jersey spine
What type of incision is used in a kidney transplant? (1)
Hockey stick incision
What conditions can lead to short-term hypoperfusion of the kidneys, reducing the filtration of blood and causing acute kidney injury? (3)
1) Dehydration
2) Shock e.g. sepsis, acute blood loss
3) HF
What rise in creatinine over what timeframe would meet the criteria for acute kidney injury? (4)
Rise of >50% over 7 days
or
Rise >25 micromol/L in 48 hours
What active steps are taken in managing a pre-renal acute kidney injury? (3)
1) IV fluids
2) Withhold medications that may worsen condition e.g. NSAIDs, ACEi
3) Withhold/adjust medications that may accumulate e.g. metformin, opiates
What are the two options for longer-term vascular access for haemodialysis? (2)
1) Tunnelled cuffed catheter e.g. Hickman line
2) AV fistula
What condition involves acute inflammation of the interstitium of the kidney caused by an immune reaction to medications, infections or inflammatory diseases? (1)
What notable finding on a full blood count may be seen? (1)
Acute interstitial nephritis
Eosinophilia
What is the basic pathophysiology of type 2 renal tubular acidosis? (1)
What will happen to the urine pH? (1)
What will happen to the serum potassium? (1)
The proximal tubule cannot reabsorb bicarb from the urine to the blood, with excessive bicarb excreted in the urine.
High urinary pH.
Low serum K+.
What effect does chronically high blood sugar have on the renal tubules? (1)
What is the key finding on urinalysis when this occurs? (1)
Glomerulosclerosis
Proteinuria
What is the main medical treatment for type 1 and type 2 renal tubular acidosis? (1)
Oral bicarb
What are the G stages of chronic kidney disease? (6)
Stage 1: eGFR >90 + signs of kidney disease e.g. proteinuria
Stage 2: eGFR 60-89 + signs of kidney disease e.g. proteinuria
Stage 3a: eGFR 45-59
Stage 3b: eGFR 30-44
Stage 4: eGFR 15-29
Stage 5: eGFR <15
What blood vessels are a transplanted kidney usually anastomosed with? (1)
External iliac vessels
What is the basic pathophysiology of type 1 renal tubular acidosis? (1)
What will happen to the urine pH? (1)
What will happen to the serum potassium? (1)
Distal tubule cannot excrete H+ ions
High urinary pH
What is the most common cause of nephrotic syndrome in children? (1)
Minimal change disease
What are the key causes of haematuria? (4)
1) Infection
2) Malignancy e.g bladder cancer
3) Kidney stones
4) Glomerulonephritis
What blood test is used in the diagnosis of rhabdomyolysis? (1)
Creatine kinase
What features characterise nephritic syndrome? (4)
1) Haematuria
2) Oliguria
3) Proteinuria (but <3g/24h)
4) Fluid retention
What is the name for when there is inadequate blood flow to the limb distal to an AV fistula? (1)
STEAL syndrome
What notable chemicals are released into the blood with muscle cell apoptosis in rhabdomyolysis? (4)
Potassium
CK
Phosphate
Myoglobin
What causes acute kidney injury and muddy brown casts on urinalysis? (1)
What cells are damaged in this condition? (1)
Acute tubular necrosis
Epithelial cells of renal tubules
What type of glomerulonephritis is associated with histology findings of IgG and complement deposits on the basement membrane? (1)
Membranous nephropathy
What medications are used to help slow the progression of chronic kidney disease? (3)
ACEi
Finerenone
SGLT-2 inhibitors
What breakdown product of muscle cells is particularly toxic to the kidneys in patients with rhabdomyolysis? (1)
Myoglobin
What unusual pathogens may cause infection in a transplant patient taking immunosuppressants? (3)
1) PCP
2) TB
3) CMV
What are the two long-term options for dialysis? (2)
1) Haemodialysis
2) Peritoneal dialysis
What is the primary medical treatment for rhabdomyolysis? (1)
IV fluids
What treatment can slow the development of cysts and the progression of renal failure in autosomal dominant polycystic kidney disease? (1)
Tolvaptan
What is the name of the plastic tube inserted into the peritoneal cavity for peritoneal dialysis? (1)
Tenckhoff catheter
What type of glomerulonephritis is associated with histology findings of glomerular crescents? (1)
Rapidly progressive glomerulonephritis (or crescentic glomerulonephritis)
What type of glomerulonephritis involves anti-GBM (glomerular basement membrane) antibodies attacking the glomerulus and pulmonary basement membranes? (1)
Goodpasture’s syndrome (or anti-glomerular basement membrane disease)
What duration of reduced kidney function is required to diagnose chronic kidney disease? (1)
Sustained over at least 3 months
What are the two types of peritoneal dialysis? (2)
1) Continuous ambulatory peritoneal dialysis (CAPD)
2) Automated dialysis
When are ACE inhibitors offered to patients with chronic kidney disease plus diabetes? (1)
What about CKD plus hypertension? (1)
What about patients with CKD but not diabetes or hypertension? (1)
1) ACR >3
2) ACR >30
3) ACR >70
What is the name for the complication of an A-V fistula where the rapid flow of blood from the arterial to the venous system increases the preload and affects the heart function? (1)
High output HF
How do kidneys appear in the early stages of diabetic nephropathy?
Enlarged
Most patients with CKD have bilateral small kidneys.
What are 4 exceptions to this?
1) autosomal dominant
2) polycystic kidney disease
diabetic nephropathy (early stages)
3) amyloidosis
4) HIV-associated nephropathy
Does hypocalcaemia suggest CKD or AKI?
CKD (due to lack of vit D)
What is acute interstitial nephritis (AIN)?
An acute inflammation of the reno-tubular interstitium typically mediated by a hypersensitivity reaction to medications.
How do patients with AIN present?
- subacute deterioration in renal function
- joint pain
- hypersensitivity features e.g. fever and rash
- raised WCC in urine
What is the most common cause of AIN?
Drugs
What drugs can cause AIN? (5)
1) penicillin
2) rifampicin
3) NSAIDs
4) allopurinol
5) furosemide
What is Henoch-Schonlein purpura (HSP)?
An IgA mediated small vessel vasculitis.
What condition is there a degree of overlap with in HSP?
IgA nephropathy (Berger’s disease)
HSP is usually seen in children following what?
An infection e.g. URTI
What are 2 key features of uraemia that indicate the need for dialysis?
1) pericarditis
2) encephalopathy
Histology findings in membranous glomerulonephritis? (3)
1) basement membrane thickening on light microscopy
2) subepithelial spikes on sliver stain
3) positive immunohistochemistry for PLA2
What is the commonest type of glomerulonephritis in adults?
Membranous glomerulonephritis
How does membranous glomerulonephritis typically present?
Nephrotic syndrome or proteinuria
What Abs can be present in membranous glomerulonephritis?
Anti-phospholipase A2 antibodies
How is anaemia in CKD managed?
Correct iron deficiency BEFORE starting erythropoiesis-stimulating agents.
What type of kidney problem causes an ‘allergic’ type picture consisting usually of raised urinary WCC and eosinophils, alongside impaired renal function?
AIN
What is Alport syndrome?
A defect in the gene coding for type IV collagen results in abnormal glomerular-basement membrane.
How is Alport’s syndrome inherited?
X-linked dominant
The disease is more severe in males with females rarely developing renal failure.
How does Alport syndrome present?
Usually presents in childhood:
1) microscopic haematuria
2) bilateral sensorineural hearing loss
3) progressive renal failure
4) ocular abnormalities (child normally will wear glasses)
Does acute tubular necrosis respond well to fluid challenge?
No - as cause is intrinsic
What metabolic disturbance is seen in salicylate poisoning?
Initial hyperventilation causes respiratory alkalosis.
This then progresses to a raised anion gap metabolic acidosis.
Management of salicylate poisoning?
IV sodium bicarbonate (alkalinisation)
2ww referral for haematuria?
Aged >= 45 years AND:
1) unexplained visible haematuria without UTI, or
2) visible haematuria that persists or recurs after successful treatment of UTI
Presentation of anti-glomerular basement membrane disease (Goodpasture’s)?
1) pulmonary haemorrhage
2) rapidly progressive glomerulonephritis - typically results in rapid onset AKI:
- nephritis –> proteinuria + haematuria
What does a renal biopsy show in anti-GBM disease?
Linear IgG deposits along the basement membrane
What urine osmolality indicates pre-renal disease?
> 500 mOsm/kg
What urine osmolality indicates ATN?
<350 mOsm/kg
What are the main class of Abx that should be stopped in AKI?
Aminoglycosides e.g. gentamicin
3 principles of treatment of hyperkalaemia
1) Stabilisation of the cardiac membrane –> IV calcium gluconate
2) Short-term shift in potassium from extracellular to intracellular fluid:
- insulin/dextrose infusion
- nebulised salbutamol
3) Removal of potassium from the body:
- calcium resonium
- loop diuretics
- dialysis
What is the most common cause of nephrotic syndrome in children?
Minimal change disease
1st line management of minimal change disease?
Prednisolone
At what gestational age can pre-eclampsia occur?
From 20 weeks onwards
In general, what eGFR indicates the need to start haemodialysis in patients with CKD?
eGFR <15
What pathological mechanism is seen in Goodpasture’s?
Systemic autoimmune condition with autoantibodies generated against Type IV collage (which is enriched in the lung and glomerular basement membrane).
Note - Goodpasture’s is a systemic version or anti-GBM disease (which only results in renal symptoms).
What key features are seen in Goodpasture’s?
1) Macroscopic haematuria
2) HTN
3) Haemoptysis
What is the gold standard diagnostic investigation in IgA nephropathy?
Renal biopsy
Hyperkalaemia in chronic vs acute kidney injury?
Hyperkalaemia is more common in AKI than CKD.
What triad of features is seen in HUS?
1) Haemolytic anaemia (jaundice)
2) Thrombocytopenia
3) Renal failure (oliguria)
What kidney condition causes renal biopsy findings of epithelial crescents in the glomeruli?
Rapidly progressive glomerulonephritis (cresenteric glomerulonephritis).
What are some causes of transient proteinuria?
- Fever
- Stress
- Exercise
- Seizures
- Hypovolaemia
What are tubular casts on urine microscopy indicative of?
ATN
Which kidney condition causes reduced complement levels?
Post-strep glomerulonephritis –> as antibody-antigen binding and the formation of immune complexes depletes complement components and lowers C3 levels.
What is Rapidly Progressive Glomerulonephritis (RPGN)?
A severe spectrum of conditions characterised by quick and progressive renal function loss due to glomerular injury.
It is characterised by nephritic syndrome linked with rapid and progressive loss of renal function.
What is a notable symptom in RPGN?
Significant oliguria
In about 85% of causes, on what chromosome is the mutated gene located in ADPKD?
Chromosome 16
What is the most likely primary component of kidney stones when patients have a FH of stones?
Cystine
These occur in patients with cystinuria, a hereditary condition.
What is the management of patients with a large, obstructing urinary tract stone that has resulted in hydronephrosis and renal failure?
Urgent cystoscopy with JJ stent insertion (to relieve the obstruction quickly).
When should a newly started ACEi be stopped (in terms of kidney function)?
If the creatinine rises to >30% of the baseline after 2 weeks.
What analgesic is offered 1st line in renal colic?
PR diclofenac
When is metformin suspended in an AKI?
If eGFR <30
What investigation is indicated in renal TB?
3x early morning urine samples
Which type of renal tubular acidosis is due to mineralocorticoid deficiency?
Type 4
What type of shock causes AKI in sepsis?
Distributive shock leading to renal hypoperfusion
What is the management of anti-GBM disease i.e. Goodpasture’s?
High dose steroids, cyclophosphamide and plasmapharesis.
What is the management of rhabdomyolysis?
IV saline
What causes tea-coloured urine in rhabdomyolysis?
Due to the presence of myoglobin in the urine.
What is the most common extra-renal manifestation in ADPKD?
Liver cysts (may cause hepatomegaly)
What is the Mx of HUS following diarrhoea?
Supportive only e.g. fluids and dialysis as required
How can 1ary and 2ary hyperaldosteronism be differentiated?
By looking at the renin levels
If high then a 2ary cause is more likely, i.e renal artery stenosis.
What redication can cause a drop in eGFR in renal artery stenosis?
ACEi
What are the 3 key features of renal artery stenosis?
1) HTN
2) CKD
3) ‘flash pulmonary oedema’
What is given for hydration to reduce the incidence of contrast-induced AKI in patients at increased risk?
0.9% saline at a rate of 1 mL/kg/hour for 12 hours pre and post procedure.
What monitoring is required in HSP?
Patients with HSP are at risk of renal failure.
Require weekly BP and urinalysis monitoring.
Is clopidogrel safe to continue in an AKI?
Yes
What is the 1st line intervention for clots causing bladder outlet obstruction (and then AKI)?
Irrigate the bladder to washout the clots and relieve the obstruction via a 3 way urethral catheter.
What type of kidney injury do NSAIDs cause?
Acute interstitial nephritis
What type of DI can lithium cause?
Nephrogenic –> lithium desensitises the kidney’s ability to respond to ADH in the collecting ducts
Urine output of < 0.5 ml/kg/hr over how long constitutes an AKI?
6 hours
What is the most likely outcome following the diagnosis of minimal change nephropathy in a 10-year-old male?
Full recovery but with a later recurrent episode
