General Renal, AKI and CKD

Question 1

Recurrent frank haematuria 1-2 days after an upper respiratory infection

Answer 1

IgA nephropathy

Question 2

Nephritic syndrome (haematuria, fall in GFR, hypertension) 1-3 weeks after an infection

Answer 2

Post-infective glomerulonephritis

Typically post-streptococcal

Question 3

Skin or joint involvement

Answer 3

Suggests secondary to underlying condition eg. SLE or vasculitis

Question 4

Obesity and renal problems

Answer 4

Associated with focal segmental glomerulosclerosis

Question 5

Anti-glomerular basement membrane antibody

Answer 5

Goodpastures disease

Question 6

Anti-neutrophil cytoplasmic antibodies - ANCA

Answer 6

Systemic vasculitis

Check for specificity against MPO (myeloperoxidase) or protease 3 (PR3)

Question 7

Antinuclear antibodies with specificity for ds DNA

Low complement levels

Answer 7

SLE

Question 8

Abnormal lung function tests with renal problems

Answer 8

Can be Goodpastures syndrome - blood in alveoli absorbs CO used to measure gas transfer - therefore raises gas transfer coefficient

Question 9

Other signs of drug-induced acute interstitial nephritis

Answer 9

Maculopapular rash, fever or eosinophilia

Question 10

Symptoms/signs of acute interstitial nephritis

Answer 10

May be loin pain from stretching of renal capsule

Mild proteinuria, microscopic haematuria, white blood cells casts and eosinophils in urine

Question 11

Ultrasound in acute interstitial nephritis

Answer 11

Slightly enlarged kidneys

Question 12

Tubular/interstitial causes of acute kidney injury

Answer 12

Drugs (NSAIDs, aminoglycoside antibiotics, ACEi or ARB, PPIs)
Radiological contrast
Rhabdomylosis - myoglobin
Haemolysis - haemoglobin
Systemic/renal infection - infiltration
Gout- excess urate production - urate crystals precipitate in tubules
Tumour lysis syndrome following chemo

Question 13

Signs of chronic kidney injury

Answer 13

Small kidneys

Question 14

When to refer kidney injury to nephrologist

Answer 14

Hyperkalaemia in oligoanuric patient,
Hyperkalaemia or fluid overload not reponsive to medical treatment
Urea >40
Suspected glomerulonephritis (blood or protein on urinalysis)

Question 15

Signs of glomerular disease on urine dip

Answer 15

Protein or blood

Question 16

Presence of Bence Jones proteins in urine

Answer 16

Myeloma

Question 17

General management of AKI

Answer 17

Aim for euvolaemia

Stop nephrotoxic drugs (NSAIDs, ACEi, gentamicin, amphotericin, metformin if creatinine >150)

Question 18

Management of pre-renal AKI

Answer 18

Correct volume depletion
Treat sepsis
If shock - consider ITU

Question 19

Management of post-renal AKI

Answer 19

Catheterise
CT of renal tract if needs be
Urology referral if obstruction

Question 20

Management of intrinsic renal AKI

Answer 20

Refer to nephrology if glomerulonephritis or tubulointerstitial disease suspected

Question 21

Management of uraemia in AKI

Answer 21

May need dialysis if severe or complications eg. encephalopathy, pericarditis

Question 22

Management of acidaemia in AKI

Answer 22

Sodium bicarbonate PO or IV

Question 23

Management of hyperkalaemia in AKI

Answer 23

Give calcium gluconate (cardioprotective)
Give insulin and glucose - get K+ into cells
Salbutamol same affect as insulin/glucose but more needed and tachycardia is a risk
If acidotic - give sodium bicarbonate

Question 24

Definition of Chronic Kidney Disease

Answer 24

Impaired renal function >3 months based on abnormal structure or function
or GFR 3 months without evidence of kidney damage

Question 25

Classification of CKD

Answer 25

Done according to GFR

Question 26

Stage 1 CKD

Answer 26

>90ml/min - therefore normal but with evidence of renal damage eg. proteinuria or haematuria

Question 27

Stage 2 CKD

Answer 27

60-89 Slight decrease with signs of renal damage IF ALL kidney tests are normal at this GFR then there is no CKD

Question 28

Stage 3 CKD

Answer 28

30-59 - with or without signs of renal damage

Question 29

Stage 4 CKD

Answer 29

15-29 with or without

Question 30

Stage 5 CKD

Answer 30

Below 15

Question 31

End stage renal failure

Answer 31

GFR

Question 32

Causes of CKD x5

Answer 32

``` Diabetes- type 2 more than type 1 Glomerulonephritis Unknown Hypertension or renovascular disease Pyelonephritis ```

Question 33

Screening for CKD in which patients

Answer 33

``` AT RISK HTN DM CVD Structural renal disease Recurrent UTIs Multisystem disorders eg. SLE Family history of ESRF ```

Question 34

Hx in CKD - looking for cause

Answer 34

PMHx of risk factors DHx FHx Systems review for systemic disorder or malignancy

Question 35

Hx in CKD - current state

Answer 35

Uraemic symptoms - anorexia, vomiting, restless legs, fatigue, weakness, pruritus, bone pain Women - amenorrhea Men - impotence

Question 36

Examination of CKD

Answer 36

``` Pallor Uraemic tinge - yellow Purpura and excoriations HTN Cardiomegaly ```

Question 37

Signs of bone problems in CKD

Answer 37

Renal bone disease - bone pain, especially in lower back, hips and legs Often associated with proximal myopathy and soft tissue calcification

Question 38

Haemotological complications of CKD

Answer 38

Anaemia - inadequate erythropoietin production Therefore give erythropoietin SC or IV - only works if iron, folate and B12 are normal Bleeding times increased - can give synthetic vasopressin (desmopressin) to transiently reduce bleeding time

Question 39

Vascular complications in CKD

Answer 39

Many have DM Also hypertension - hypervolemia from salt and water retention Or due to excess renin production

Question 40

Skin complication in CKD

Answer 40

Itch - calcium phosphate deposition in skin | Also ureamia- can get uremic frost

Question 41

GIT in CKD

Answer 41

Peptic ulcer no more common in CKD but gastrin elevated - nausea, vomiting, anorexia and heartburn Higher incidence of oesophagitis and angiodysplasia

Question 42

Endo in CKD

Answer 42

Men - loss of libido, impotence and low sperm count | Women - loss of libido, reduced ovulation and infertility

Question 43

Immunological in CKD

Answer 43

Function is impaired in severe CKD and infection common | Uremia suppresses function of immune cells

Question 44

Lipid in CKD

Answer 44

Hyperlipidaemia - higher in patients on peritoneal dialysis than haemolysis

Question 45

Cardiac in CKD

Answer 45

Pericarditis can occur and more likely if urea or phosphate are high Fluid overload and HTN - left ventricular hypertrophy or dilated cardiomyopathy

Question 46

Management of CKD

Answer 46

Restrict dietary potassium, phosphate and sodium and water BP management Treat complications

Question 47

Neuro in CKD

Answer 47

Cramps, restless legs Peripheral neuropathy Myopathy Depression and anxiety

Question 48

Fused podocytes on electron microscopy - proliferative or non-proliferative glomerulonephritis

Answer 48

Non-proliferative

Question 49

Syndrome caused by proliferative and non-proliferative glomerulonephritis

Answer 49

``` Proliferative = nephritic syndrome Non-proliferative = nephrotic syndrome ```

Question 50

What do you see on electron microscopy of rapidly progressive glomerulonephritis

Answer 50

Crescents | eg. goodpastures and systemic vasculitis

Question 51

What do you see on electron microscopy of membranous IgA nephropathy

Answer 51

thickening of glomerular basement membrane

Question 52

How is Alports syndrome inherited?

Answer 52

X-linked dominant usually

Question 53

Most common and important infective agent in transplant of solid organs

Answer 53

CMV