Kidney Disease Flashcards by Kerry Hendrie

List classic clinical features of kidney disease

Loin pain
Haematuria
Dysuria
Proteinuria (frothy)
Oligouria
Appetite and weight
Asymptomatic

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The kidney is involved in excretion of urea. What happens if this is impaired?

Uraemia (urea over 40 before manifests)

Can lead to pericarditis, encephalopathy, neuropathy etc.

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The kidney is involved in fluid balance. What happens if this is impaired?

Fluid retention (oedema)

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The kidney is involved in electrolyte balance. What happens if K becomes too high?

Hyperkalaemia can cause arrhythmias

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The kidney is involved in acid-base balance. What is the classic breathing sign of an acidotic patient?

Metabolic acidosis leads to Kussmaul’s respiration

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Which class of drug has to be closely monitored and can potentially cause renal failure?

ACE inhibitors/ARBs

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What are the effects of NSAID on the kidney?

Allergic reaction
Reduce GFR (inhibit prostaglandin production) due to vasoconstriction of afferent arteriole

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Which antibiotics can insult to the kidney?

Gentamicin
Trimethoprim
Penicillins

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What might radiology contrast cause within the kidney?

Contrast nephropathy

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What does specific gravity in urinalysis tell us?

Urine concentration

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Define heavy proteinuria

1-3g of protein in the urine per day

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Define acute kidney injury

Decline in GFR over hours/days/weeks with/without oliguria in a patient with normal or impaired renal function

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How much urine a day is classed as oliguria?

Less than 400ml a day

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Which equation is used to provide estimated GFR (eGFR)

MDRD4 equation

Encompasses serum creatinine, age, sex and race

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eGFR overestimates GFR if high muscle mass. True/False?

False

eGFR overestimates GFR is muscle mass is low, and underestimates GFR if muscle mass is high

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Define stage 1 CKD

Normal GFR (90 or over)
Evidence of kidney damage (proteinuria, haematuria, abnormal US)

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Define stage 2 CKD

GFR 60-89

Evidence of kidney damage (proteinuria, haematuria, abnormal US)

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Define stage 3 CKD

Define stage 3a and 3b

GFR 30-59
A = 45-59
B = 30-44

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Define stage 4 (severe) CKD

GFR 15-29

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Define stage 5 CKD (renal failure)

GFR less than 15 or renal replacement therapy

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Patients with proteinuria are more likely to progress to CKD. True/False?

True

More proteinuria = faster progression

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List common causes of chronic kidney disease

Diabetes (commonest)
Hypertension
Vascular disease
Chronic glomerulonephritis
Reflux nephropathy
Polycystic kidneys

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Symptoms due to reduced GFR don’t occur until late. True/False?

True

GFR less than 20 usually

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List methods of slowing progression of CKD

Reduce proteinuria + control BP - ACE inhibitors, spironolactone
Glycaemic control in diabetes
Smoking cessation

What is the initial danger of ACE inhibitors for kidney disease?

Cause initial fall in GFR which leads to hyperkalaemia | i.e. short term pain, long term gain

How does anaemia arise in CKD?

Erythropoietin production declines in CKD

How is anaemia in CKD rectified?

IV iron | Erythropoietin injection

How does bone disease arise in CKD?

Impaired vitamin D hydroxylation in damaged kidney leading to reduced calcium absorption (secondary followed by tertiary hyperparathyroidism)

How is bone disease in CKD rectified?

``` Alfacalcidol (active vitamin D) Phosphate intake Phosphate binders (calcium carbonate, calcium acrete, sevalema) ```

If initial CKD therapy is unsuccessful, what are the treatment options for renal failure?

``` PREP FOR RENAL REPLACEMENT THERAPY Haemodialysis Peritoneal dialysis Transplant (within 6 months of dialysis) Conservative/palliative management (epo and symptom control) ```

What is the best form of access for dialysis?

Arteriovenous fistula (AVF) - wait 6 weeks to mature

Acute kidney injury is defined using creatinine and urine output. Define acute kidney injury

Increase in creatinine greater than 26.4 micomol//L, or by 50% or reduction in urine output in less than 48 hours

How is acute kidney injury classified due to cause?

Pre-renal (functional) Renal (structural) Post-renal (obstruction)

List pre-renal causes of acute kidney injury

Hypovolaemia (haemorrhage) Hypotension (shock) Hypoperfusion (NSAID, ACEI)

Pre-renal AKI is reversible. True/False?

True

Outline the pathophysiology of AKI due to volume depletion

Decreased effective intravascular volume causes increased ADH and aldosterone release, causing salt and water retention, leading to oliguria and AKI

What is the commonest form of AKI in hospital?

Acute tubular necrosis due to decreased renal perfusion

Outline treatment for AKI

``` Treat cause/factors 0.9% saline +/- inotropes/ vasopressors Antibiotic if sepsis Stop nephrotoxines Dialysis if anuric and uraemia ```

What is the main vascular cause of renal AKI?

Vasculitis

What is the main glomerular cause of renal AKI?

Glomerulonephritis

List tubular causes of AKI

Ischaemia Drugs (e.g. antibiotics - gentamicin, paracetamol) Contrast nephropathy Rhabdomyolysis

Dark urine in AKI may be a sign of what?

Rhabdomyolysis (myoglobin in urine) | Destruction of skeletal muscle

List initial investigations for AKI

``` U+Es FBC, coagulation, CK Urinalysis (haematuria, proteinuria) Ultrasound Antibodies (ANA, ANCA, GBM) ```

What are the indications for renal biopsy?

Rapidly progressive glomerulonephritis +ve antibodies Not improving

List life-threatening complications of AKI

``` Hyperkalaemia (K >5.5) Pulmonary oedema Acidosis (pH <7.15) Uraemic pericardial effusion Severe uraemia (UR > 40) ```

Trimethoprim can cause AKI. True/False?

True

List the main causes of post-renal AKI

Obstruction from stones/cancer Stricture Extrinsic pressure

Outline management of post-renal AKI

Catheter Nephrostomy Refer to urology (ureteric stenting)

How is hyperkalaemia complicating AKI treated acutely?

PROTECT MYOCARDIUM: 10mls 10% Calcium gluconate (Ca chloride second line) MOVE POTASSIUM BACK INTO CELLS: 10 units of insulin and 50mls 50% dextrose

List investigations used in kidney disease

``` GFR Abdominal imaging Blood pressure ECG Urinalysis looking for proteinuria and haematuria --> PCR if positive ```

What is malignant/accelerated hypertension? What are the signs?

Diastolic BP >120 Papilloedema, headache, haematuria End-organ complication (encephalopathy, fits, HF, acute RF)

List late symptoms of CKD

Tiredness Poor appetite Itch Sleep disturbance

What is usually the first early sign of CKD?

Impaired urine concentrating ability - early nocturia

How is AKI staged?

3 stage KDIGO scale

List risk factors for AKI

``` Age HF CKD/ previous AKI Diabetes Liver disease PVD Exposure ```

List interstitial causes of AKI

Drugs Infection (TB) Systemic disease (sarcoid)

List symptoms of AKI

Itch, fatigue Nausea, vomiting Anorexia, weight loss High blood pressure, peripheral oedema

State the main complication to be aware of in post-renal AKI. How is it diagnosed?

Hydronephrosis | US

What is the first line investigation for a patient with suspected hyperkalaemia? What would the results be?

ECG | Tall T waves, reduced P waves, broad QRS