CSIM renal medicine Flashcards by Matthew Douglas

what role do the kidneys have in metabolism?

excrete metabolites in urine

metabolise vit. D and some proteins

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what is nephrotic syndrome and what are the clinical signs

loss of protein through the kidenys

protein urea >3.5g / day
oedem
hypoalbuminaemia
hyperlipidaemia

the 3.5 is arbitrary - it just needs to be enough to make you hypoalbuminaemic

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what is nephritic syndrome?

inflammation of the kidneys leading to:

haematurea
protein urea
hypertension
oligourea

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what will the creatinine be like in nephrotic syndrome?

normal

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what will the urine look like in nephrotic syndrome?

frothy due to the protein

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in suspected renal disease how should the BP be assessed?

lying and standing

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causes of AKI

PRE: Secondary to sepsis, low BP, nephrotoxins etc
INTRINSIC: nephritis ( inflammation)
POST- obstruction

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what are the symptoms of advanced kidney disease

Tiredness (anaemic) 
swollen ankles, feet or hands (due to water retention)
shortness of breath
nausea
blood in the urine

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symptoms of acute glomerular nephritis

AKI ->
Oedema, hypertension
Smoky or coca- cola coloured urine
Hypertension, reduced urine volumes 
Systemic symptoms- rash,  haemoptysis

could be asymptomatic

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where does the creatinine in the urine come from?

mostly freely filtered through glomerular

some secreted in proximal tubules

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what information is used to get eGFR?

creatinine
sex
ethnicity (black or other)
age

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why dont we measure the actual GFR anymore?

requires 24hr urine collection

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what kind of kidney injury does proteinurea indicate?

Marker of intrinsic renal disease

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2 ways of quantifying proteinurea and whats the difference?

albumin : creatinine for small protein urea

protein : creatinine for large protein urea

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what is a hyaline cast? and what is it dependent on

glycoprotein formed in the renal tubules

seen in small quantities in normal adults

dependent on urine flow and pH

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what can light microscopy of a MSU tell you

red cell casts : diagnostic of glomerular disease
white cell casts : inflammation or infection
organisms and white cells during a urinary infection
tubular debris : in acute tubular necrosis

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which scan will most kidney patients get?

USS

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what does a chronically damaged kidney look like on USS?

shrunken

less well demarcated regions

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what do the inflammatory cells in the kidney look like?

crescent moons

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in monitoring urine output, when should you catheterise?

only if they cant collect urine themsleves

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how small does a molecule have to be to filter through the glomerulus?

<30A

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why kidney damage in trauma ?

large release of protein is neprotoxic

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how many red cells is normal in the urine?

1-2 per micro litre

conveniently this is also the cut off for what dipstix can detect

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causes of haematuria that aren’t related to glomerular disease?

renal malignancy
renal stone disease
bladder tumours

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which protein does the kidney produce and why?

Tamm-Horsfall thought to protect against infection

what is normal protein in urine?

<150mg / day this is NOT detectable on dipstix

what does the amount of protein urea tell you about where the pathology is?

>1 g / day = glomerular disease | <1 g / day = somewhere after the glomerular e.g. tubules, upper/ lower UTI, stones

benign causes of proteinurea

exercise | orthostatic

two non-renal conditions that cause protein urea?

fever | HF

effect of low albumin on lipoprotein level?

increases | liver is trying to make more proteins which includes cholesterol etc

effect of nephrotic syndrome on clotting?

pro-thrombotic due to loss of anti-thrombin protein

why at risk of infection in nephrotic syndrome?

loose immunoglobulins

why do you need to include creatinine when measuring urine protein?

to account for hydration status

5 things that effect serum creatinine?

production: liver function muscle mass muscle metabolism diet (if very malnurished) RENAL DISEASE

the better you filter, the ____ your serum creatinine will be

LOWER

two people with the same serum creatinine, one with large muscle mass the other with small muscle mass. which has the lower GFR?

small muscle mass the large guy/girl has more creatinine due to large amount of muscle

3 main causes of nephrotic syndrome?

glomerulonephritis DM amyloidosis

3 main primary disease of nephrotic syndrome

minimal change membranous focal segmental glomerulosclerosis

what kind of glomerulonephritis is associated with malignancy?

membranous

how to manage persistent low levels of proteinurea?

if all else normal monitor but no need to intervene

how can AKI be distinguished from CKD?

previous bloods repeate creatinine 6 hrs later USS Hx

how is post-renal AKI diagnosed?

USS: gross dilation downstream of kidneys due to obstruction

main causes of post renal AKI?

stones older patients: prostate cancer

define azotaemia

appropriate response to reduced renal perfusion: increased nitrogen

causes of pre renal azotaemia?

``` decreased cardiac output decreased effective circulating volume: hypovolaemia (reduced fluid intake etc) volume redistribution bleeding renal vascular disease drugs ```

definition of AKI we were told to use?

increase in serum creatinine of >0.3mg/dl in 48hrs

which drugs can cause pre renal azotaemia?

NSAIDS ACE i cyclosporin (immunosuppressant)

two types of tubulo-interstital disease?

acute tubular necrosis | acute allergic interstitial necrosis

what two things can cause ATN?

toxins e.g. aminoglycosides, radio contrast | ischaemia due to hypo perfusion

which drugs commonly cause an acute allergic interstitial necrosis?

``` NSAIDS bendrofluazide frusomide PPIs penicillin ```

what Ix distinguishes between glomerular disease and tubulo-intertial disease?

urinalysis

what are the features of rapidly progressive GN?

haematuria proteinurea oedema hypertension

examples of RPGN

``` goodpastures syndrome lupus post infective Wegeners microscopic polyangitis ```

all causes of haematurea

``` Urinary tract infection Catheter trauma Infarction Stone Tumour Glomerulonephritis ```

finding of blood and protein in urine should prompt what?

microscopy and culture

how does urine microscopy differentiate between Glomerular versus Tubulo-interstitial causes of AKI?

GN: red cell casts and inflammatory cresents

what are the three types of RPGN?

type I - Anti-glomerular basement membrane antibody disease (Goodpastures syndrome) type II - immune complex lupus nephritis post-infectious type III - pauci immune (pauci as in latin for few) Wegener’s granulomatosis Microscopic polyangiitis

what is the triad for Goodpastures syndrome?

anti- GBM antibodies pulmonary haemorrhage RPGN

what organism is responsible for post infectious RPGN?

group A, ß-haemolytic streptococcus

what does a low compliment tell you about the cause of RPGN?

likely to be post infectious

diagnosis of lupus nephritis?

ANA renal biopsy immunoflourescence shows ‘full house’ immune deposits

what type of RPGN is SLE?

type II - immune complex

what type of RPGN will give systemic symptoms of night sweats, weight loss, fever, lethargy?

type III - pauci immune

pANCA is associated with what type of RPGN?

type III - pauci immune - microscopic polyangitis

what is Wegeners granulomatosis and what auto-antibody is associated with it?

RPGN | cANCA

what auto-antibody is associated with microscopic polyangitis?

pANCA

when would you NOT renal biopsy RPGN?

in type II - immune complex if there is sufficient clinical evidence that it is post-infectious (culture, reduced compliment and clinical picture)

what % of hypertension is secondary?

10%

causes of secondary ht?

``` CRAP C onns C ushings C oarctation of the aorta R enal A cromegaly P haechromocytoma P arathyroidism (HYPER) P ills ```

renal causes of hypertension?

GN renal artery stenosis autosomal dom. polycystic KD pyelonephritis

what is the problem is Conns?

too much aldosterone (produced in the adrenals)

what is the problem in Cushings?

too much cortisol

what is the problem in phaeochromocytoma?

too much catecholamines

below what age do you start thinking ht is secondary?

what is first line imaging if suspecting Conns?

CT adrenals

what is the Ix for phaeochromocytoma?

serum catecholamines and serum metanephrines

where is renin made?

kidney- juxtaglomerular apparatus

what does an ACE i do to the kidneys?

stops all the things angiotensin II would do therefore: vasodilation reduced aldosterone production (reduced Na retention)

what clinical signs make you think ht is due to coarc1tation of the aorta?

scapular vessels absent pulses machinery mummer radio-radial delay

food that can raise BP? other than salt obvs

liquorice

what sign of chronic ht is seen in the eyes?

papiloedema

what effect on the heart does chronic ht have?

LV hypertrophy

how does increased filtration of proteins cause CKD?

nephrotoxc inflammatory process

on USS kindey, what would one normal and one small kidney suggest?

renal artery stenosis

1st line drug for CKD? why?

ACE-i to reduce proteinuria

If you want to increase your dietary protein for gains, what should you do?

Drink the piss of a patient with nephrotic syndrome

which of the following are complications of CKD? ``` Uraemia Hypokalaemia Acidaemia Mineral bone disorder Dehydration Anaemia ```

``` Uraemia - YES Hypokalaemia - NO (HYPERKALAEMIA) Acidaemia - YES Mineral bone disorder - YES Dehydration - NO (FLUID OVERLOAD) Anaemia - YES ```

why anaemia in CKD?

kidneys produce erythropoiten

why hyperkalaemia in CKD?

unable to actively remove K

effect on pH of CKD?

acidaemia - role in acid base regulation

what is the clinical manifestation of high phosphate?

pruitis

what is the tx for low erythropoeitin?

EPO and iron

what is better transplant or dialysis?

transplant cheaper restores all function knock on effect for the rest of the family

what is the hall mark of interstitial nephritis?

white cell cast need a biopsy to SHOW it's that but you can infer it from the lack of another cause

another name for Good pastures syndrome?

anti glomerular basement membrane disease

what do crescent cells tell you?

``` indicate severe aggressive immune damage guide prognosis (10% good 100% BAD) ```

what first Ix in a women with recurrent UTIs?

US renal tract

Mx of recurrent UTIs?

low does prophylactic abx | one off abx after intercourse

4 indications for urgent dialysis?

uraemia severe acidosis high potassium refractory pulmonary oedema

when do you get re cell casts?

when there is significant haematuria i.e. when there is inflammation in the kidney... not when there is just a bit of nephropathy

effect of CKD on iron metabolism?

inefficient metabolism: iron is less readily available for haemoglobin synthesis

calcium in CKD? why?

low | functional vit. D deficiency

PTH in CKD? why

high due to low calcium

what is the target BP in CKD?

130/80

why give drugs to bind phosphate in CKD?

prevent absorption- it will be high :(