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Renal SB > Kidney Disease > Flashcards

Kidney Disease Flashcards

1
Q

how can kidney disease present

A 
Asymptomatic
Loin Pain / Urinary Symptoms
Haematuria
Proteinuria - urine appears frothy
Hypertension
Acute Kidney Injury
Chronic Kidney Disease
Nephrotic Syndrome
Nephritic Syndrome
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2
Q

function of the kidney

A 
excretion of nitrogenous waste (urea)
fluid balance			
electrolyte balance		
acid-base balance			
vitamin d metabolism / phosphate excretion
production of erytropoietin		
drug excretion			
barrier to loss of proteins
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3
Q

what can errors in fluid balance cause

A

oedema

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4
Q

what does a failure in excretion of nitrogenous waste (urea) cause

A

Uraemia
(pericarditis/ encepalopathy/ neuropathy/ asterixis/ gastritis)
late stage kidney disease
pleural rub heard - emergency dialysis needed

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5
Q

what can errors in electrolyte balance cause

A

Hyperkalaemia & arrythmia

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6
Q

what can errors in acid-base balance cause

A

Metabolic Acidosis & Kussmaul’s Respiration

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7
Q

what can errors in vitamin d metabolism / phosphate excretion balance cause

A

Renal Bone Disease & Vascular Calcification

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8
Q

what can errors in production of erytropoietin cause

A

anaemia

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9
Q

what can errors in barrier to loss of proteins cause

A

Proteinuria & Nephrotic Syndrome

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10
Q

PC - asymptomatic but why could they still be picked up

A

dipstix microscopic haematuria &/or proteinuria
reduced estimated GFR on biochemical screen
raised BP
incidental findings on abdominal imaging
screening because of family history

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11
Q

PC - systemic

A

related to disease
eg: diabetes mellitus, connective tissue disorder, vascular disease

related to loss of kidney function
e.g.: uraemic, fluid retention, anaemia, bone pain

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12
Q

PC - local/renal

A

eg loin/abdo pain, macroscopic haematuria, UTI

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13
Q

systemic enquiry Q’s

A
  • appetite & weight loss
  • nausea & vomiting
  • dyspepsia
  • dyspnoea
  • urinary symptoms eg frequency, urgency, hesitancy, polyuria & nocturia
  • joint pains & arthralgia
  • skin rashes
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14
Q

PMH

A

kidney disease, DM, vascular disease, surgery, TB, rheumatological

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15
Q

FH

A

renal disease, hypertension

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16
Q

SH

A

smoking, alcohol, occupation, carers

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17
Q

Drugs

A

ACE-I, ARB, diuretics (thiazide, loop, potassium sparing)
NSAIDS - very harmful to kidneys (decrease GFR)
Antibiotics: gentamicin (nephrotoxic), trimethoprim, penicillins
Proton pump inhibitors

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18
Q

what is accelerated hypertension

A 
a medical emergency
diastolic BP >120 mmHg
papilloedema seen
end-organ decompensation 
eg: encephalopathy, fits, cardiac failure, acute renal failure
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19
Q

when is leukonychia seen

A

(white patches on nails)

associated with acute illness and profound hypoalbuminemia

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20
Q

when is gouty Tophus seen

A

kidney disease

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21
Q

non blanching skin rash, very red

A

Could be:
Vasculitic Skin Rash
» Acute Glomerulonephritis

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22
Q

Henoch-Schonlein Purpura - HSP

A

form of vasculitis - IgA mediated

seen on extensor surface of skin and buttock

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23
Q

what are the classifications of urine protein

A

24 hour urine collection (normal 3 G/Day)

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24
Q

sign of hyperkalaemia on ECG

A

Tall Tented T waves

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25
Q

what is definition of acute kidney injury

A

Decline in GFR over hours / days / weeks

- with or without oliguria (

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26
Q

what is the triad of nephrotic syndrome

A

Proteinuria > 3 g/day
(mostly albumin, also globulins)
Hypoalbuminaemia
Oedema - esp peri-orbital oedema but not pulmonary oedema

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27
Q

what is often associated with nephrotic syndromes

A

Hypercholesterolaemia

Can have normal renal function

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28
Q

what happens in Nephritic syndrome

A 
1-Acute Kidney Injury
2-Oliguria
3-causes Oedema/ Fluid retention
4-leads to Hypertension
5-Active urinary sediment
- RBC’s, RBC & Granular Casts, proteinuria
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29
Q

definition of CKD

A

Reduced GFR and/or evidence of kidney damage

Must be chronic (!) – CKD can’t be diagnosed from one measurement

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30
Q

how is GFR assessed

A

Estimation by creatinine clearance

Can be estimated from serum creatinine, age, sex and race

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31
Q

what is creatinine and how can this influence GFR

A

product of muscle breakdown; muscular people produce more creatinine giving inaccurate result

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32
Q

what can cause an inaccurate eGFR

A

Over-estimates GFR if muscle mass is low
Under-estimates if muscle mass high
Only valid if serum creatinine is stable

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33
Q

what are the stages of CKD

A

Stage 1 – GFR >90ml/min, with evidence of kidney damage

Stage 2 – GFR 60-90ml/min, with evidence of kidney damage

Stage 3 – GFR 30-60ml/min
(3A – 45-60ml/min; 3B – 30-44ml/min)

Stage 4 – GFR 15-30ml/min

Stage 5 – GFR

34
Q

what does CKD increase risk of

A

increases CV risk

35
Q

who is likely to increase in stages of CKD

A

Patients with proteinuria more likely to progress; More proteinuria – faster progression

Younger patients have longer to progress – more likely to reach stage 5

36
Q

what are common causes of CKD

A 
Diabetes - commonest cause
Hypertension
Vascular disease
Chronic glomerulonephritis
Reflux nephropathy
Polycystic kidneys
Cause not known
37
Q

when do symptoms of CKD appear

A

Symptoms due to reduced GFR don’t occur until late – GFR

38
Q

Sx of CKD

A

Non-specific – tiredness, poor appetite, itch, sleep disturbance

Impaired urinary concentrating ability – symptoms may occur earlier - nocturia

39
Q

Mx of CKD

A

Reduce cardiovascular risk
Identify and treat complications of CKD
Prepare for renal replacement therapy

40
Q

how can the progression of CKD be slowed down

A

Reduce Proteinuria + Control blood pressure
ACE-inhibitors and ARB reduce BP and proteinuria
Spironolactone

Stop smoking
Good glycaemic in DM
Statins

41
Q

what can happen when you start a patient on an ACE-i and is a worrying side effect and how is it managed

A

initial fall in GFR

hyperkalaemia - patient given blood test 7-10 days after starting ACE-i to check for hyperkalaemia

42
Q

complications of CKD

A

Anaemia

Bone disease&raquo_space; Secondary Hyperparathyroidism

43
Q

how is anaemia caused in CKD

A

Production of Erythropoietin produced by the kidneys declines

44
Q

Tx of anaemia of CKD

A

1st line - IV iron

2nd line - Erythropoietin given subcutaneously

45
Q

why are the bone problems in CKD

A

Vitamin D hydroxylated in the kidney - Impaired in CKD

Leads to reduced calcium absorption, leading to secondary hyperparathyroidism

46
Q

biochemistry results in CKD

A

In advanced CKD, serum phosphate rises – also increases PTH secretion

47
Q

how is normal serum calcium maintained in secondary hyperparathyroidism

A

at the expense of the bones

48
Q

how can secondary hyperparathyroidism progress

A

1 -Hyperplasia of all glands
2 -One gland may become autonomous – PTH secretion not suppressed by calcium
3 - tertiary hyperparathyroidism

49
Q

what can tertiary hyperparathyroidism lead to

A

hypercalcaemia

50
Q

what does high phosphate and high calcium indicate

A

vascular calcification

|&raquo_space; stiff blood vessels + heart valves stiff

51
Q

Tx of bone disease in CKD

A

Alfacalcidol – hydroxylated vitamin D – doesn’t need activation by kidneys

Phosphate – advice from dietician on intake

52
Q

Tx for end-stage renal failure

A
  • Haemodialysis
  • Peritoneal dialysis
  • Transplantation
  • Conservative management
53
Q

when is dialysis considered

A

when GFR about 20ml/min (earlier if progressing fast)

54
Q

what needs to be done in haemodialysis

A 
plan vascular access
Arteriovenous fistula (AVF) is best from of access

AVF needs 6 weeks to mature after formation

55
Q

what needs to be done in peritoneal dialysis

A

Operation needed to insert catheter

Catheter can be used after 1-2 weeks

56
Q

when is a patient referred to a vascular surgeon to create a AVF for haemodialysis

A

when GFR about 15ml/min

57
Q

when can patients go onto the transplant list

A

Patients can be listed for cadaveric transplantation when within 6 months of dialysis

Patient also needs to be fit enough

58
Q

when is conservative management considered

A

in the elderly with multiple co-morbidities

symptom control/palliative care

59
Q

definition of Acute kidney injury

A

An abrupt (26.4µmol/l
OR increase in creatinine by >50%
OR a reduction in UO

60
Q

pre-renal cause of AKI

A

Hypovolaemia
e.g. Haemorrhage, Volume depletion (e.g. D&V, burns)

Hypotension
e.g. Cardiogenic shock

Renal Hypoperfusion
e.g. NSAIDs / COX-2, ACEi / ARBs

61
Q

what is oliguria

A

very little urine output

62
Q

is pre-renal AKI volume depletion reversible?

63
Q

what happens when there is decreased renal perfusion

A

increased renin
increased angiotensin II
» GFR maintained

64
Q

how does a ACEi affect renal perfusion

A

not as much angiotensin II produced so a slight reduced of GFR

65
Q

what can ACEi causes occasionally and how does this happen

A

Acute renal failure

ACE inhibitors reduce Angiotensin II. Angiotension II mediates arteriolar vasoconstriction therefore increasing GFR. ACE I therefore can cause a fall in GFR by causing effferent arteriolar vasodilation.

66
Q

pathophysiology of pre-renal AKI

A 
1 - Volume depletion and/or Sepsis
2 - Decreased Effective Intravascular Volume
3 - Increased ADH & Aldosterone
4 - Oliguria 
5 - AKI
67
Q

what does untreated Pre Renal AKI lead to

A

Acute tubular necrosis

68
Q

what is Acute tubular necrosis

A

decreased renal perfusion

69
Q

Tx for Pre Renal AKI

A

Assess for hydration
- BP, HR, Oedema, Pulmonary oedema

Crystalloid (0.9% NaCl) or Colloid (Gelofusin) - for hypovolaemia

70
Q

Causes of Renal AKI

A

Vascular
- vasculitis, renovascular disease

Glomerular:
- Glomerulonephritis

Interstitial Nephritis:
Drugs, Infection (TB), Systemic (sarcoid)

Tubular Injury:
Ischaemia—prolonged renal hypoperfusion
Drugs (gentamicin)
Rhabdomyolysis

71
Q

Sx of AKI

A
  • Anorexia, weight loss, fatigue, lethargy
  • Nausea & Vomiting
  • Itch
  • Fluid overload e.g. Oedema, SOB
72
Q

Signs of AKI

A

Fluid overload incl HTN, Oedema, Pul oedema, effusions (pleural & pulmonary)
Uraemia incl itch, pericarditis
Oliguria

73
Q

Ix of AKI

A

U&Es
- Marker of renal function (Na, K, Ur, Cr)

FBC
Urinalysis
USS- Obstruction? Size?

Immunology
- ANA (SLE), ANCA (Vasculitis), GBM (Goodpastures)

Protein electrophoresis & BJP
- myeloma? (everyone over 50yrs)

74
Q

what are indications for a renal biopsy

A

Suspected rapidly progressive GN

Positive Immunology & AKI

75
Q

Tx of AKI

A

Establish good perfusion pressure

  • Fluid resuscitate
  • Once fluid resuscitated, if still not achieving an adequate BP  inotropes/vasopressors

Treat underlying cause
- Antibiotics if sepsis

Stop nephrotoxics

Dialysis if remains anuric & uraemia
Can require urgent dialysis

76
Q

what are life threatening complications of AKI

A 
Hyperkalaemia 
Fluid Overload (Pulmonary oedema)
Severe Acidosis (pH 40)
77
Q

what causes post renal AKI

A

AKI due to obstruction of urine flow leading to back pressure (hydronephrosis) and thus loss of concentrating ability

Causes: Stones, Cancers, Strictures, Extrinsic Pressure

78
Q

Tx of post renal AKI

A

Relieve obstruction

  • Catheter
  • Nephrostomy

Refer to urology if ureteric stenting required

79
Q

what is classified as hyperkalaemia

A

Hyperkalaemia = >5.5

Life threatening hyperkalaemia = >6.5

80
Q

how is hyperkalaemia assessed

A

ECG

Muscle Weakness

81
Q

Tx of hyperkalaemia

A
  • 10mls 10% calcium gluconate
  • Insulin (actrapid 10units) with 50mls 50% dextrose (30 mins)
  • Salbutamol Nebs (90 mins)
82
Q

urgent indications for hemodialysis

A

Hyperkalaemia
>7 or >6.5 unresponsive to medical therapy

Severe Acidosis
pH 40, pericardial rub/effusion

Renal SB (15 decks)

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