Corrections - Renal 2 Flashcards by Esme Cosham

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

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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

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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

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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

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What cardiovascular effects are associated with nephrotic syndrome? (3)

1) Thrombosis

2) HTN

3) High cholesterol

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What type of glomerulonephritis is associated with histology findings of IgA deposits and mesangial proliferation? (1)

IgA nephropathy (Berger’s)

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What is the main presenting symptom of nephrotic syndrome? (1)

Oedema

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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

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What non-specific urine dipstick findings are seen in acute nephritis? (2)

Haematuria

Mild proteinuria

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What features characterise nephrotic syndrome? (4)

1) Proteinuria (>3g/24 hours)
2) Low serum albumin
3) Peripheral oedema
4) Hypercholesterolaemia

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What happens to phosphate, vitamin D and calcium in renal bone disease? (3)

Low vit D
Low calcium
Raised phosphate

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What defines “accelerated progression” of CKD?

Sustained decline in eGFR within one year of either 25% or 15 ml/min

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What urine output over what timeframe would meet the criteria for acute kidney injury? (2)

<0.5ml/kg/hour over at least 6 hours

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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

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What terms describe the RBCs in anaemia caused by CKD?

Normocytic normochromic

Caused by low EPO

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What common classes of medications can cause hyperkalaemia? (4)

ACEi
Aldosterone antagonists
ARBs
NSAIDs

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What is the characteristic spinal x-ray finding in renal bone disease? (1)

Rugger jersey spine

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What type of incision is used in a kidney transplant? (1)

Hockey stick incision

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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

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What rise in creatinine over what timeframe would meet the criteria for acute kidney injury? (4)

Rise of >50% over 7 days

Rise >25 micromol/L in 48 hours

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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

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What are the two options for longer-term vascular access for haemodialysis? (2)

1) Tunnelled cuffed catheter e.g. Hickman line

2) AV fistula

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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

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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+.

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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