Med C CBLs - Renal and Rheum Flashcards
How would you establish a diagnosis of nephrotic syndrome?
Proteinuria > 3.5
Hypoalbuminaemia
KIDNEY BIOPSY NEEDED
Complications of nephrotic syndrome
- Hypercoagulability
- loss of inhibitors of coagulation in urine
- increase synthesis of procoagulatory factors by liver
VTE!
- Oedema
- decrease in oncotic pressure from hypalbuminaemia
- primary renal sodium retention in collecting tubules - Increased risk of infection
- loss of immunoglobulins
- SEPSIS
Causes of nephrotic syndrome
DIRTY MONKEYS FLING MUD, SMEARING ALL
Diabetic nephropathy
Membranous Glomerular nephritis
Focal glomerular sclerosis
Minimal change disease
SLE
Amyloidosis
Features of nephritic syndrome
Presence of haematuria in association with
- hypertension
- oliguria
- fluid retention
may have proteinuria
Haematuria
- caused by autoantibodies or immune complex deposition
Management of a patient with severe nephrotic syndrome?
Treat underlying cause
- Dietary sodium restriction
- loop diuretic (furosemide)
- ACEi
- reduce proteinuria by lowering glomerular capillary filtration pressure - Regular monitor blood pressure and renal function
- Beware prolonged bed rest –> VTE, LMWH?
- Increased susceptibility to infection –> consider pneumococcal infection
- Lipid abnormalities –> statin
- May require some form of immune suppressive treatment
- high dose corticosteroid
If this fails
- ciclosporin or tacrolimus
Or
- cyclophosphamide
Terminology to describe patterns of joint disease:
- Speed of onset: acute, subacute or chronic
- Number of joints involved: monoarticular (one joint), Oligoarticular (2 - 3 joints) , polyarticular ( > 4 joints)
- Type of joints involved
- axial (spine or sacro-iliac joints)
- large joint (knees, ankles, shoulders)
- small joint (MCPJs, PIPJs)
- symmetrical vs asymmetrical - Pattern
- relapsing / remitting
Risk factors for septic arthritis
- age ( > 80)
- joint prosthesis / foreign material
- immunosuppression: medication, HIV infection
- diabetes mellitus
- existing joint disease e.g. (OA, RA)
- causes of transient bacteraemia (e.g. IVDU)
- joint instrumentation e.g. intra-articular infection, arthroscopy
Key differentials for red-hot swollen joint
- Septic arthritis
- Acute crystal arthropathy (gout or pseudogout)
- Pre-patellar bursitis
- Hemarthrosis: history of trauma, bleeding disorders, medication
- Flare of RA
- Reactive arthritis
Key investigations for red, hot and swollen knee joint
- Inflammatory markers: FBC, ESR, CRP
- Renal profile: nephrotoxic, sepsis related AKI, CKD risk factor for crystal arthropathy
- Clotting: deranged clotting –> risk of hemarthrosis
- serum uric acid –> gout?
- plain X-Ray –> chondrocalcinosis? in patients with calcium pyrophosphate deposition
- Joint aspiration before ABx
- Prosthetic joints –> JOINT ASPIRATION BY ORTHO ONLY!
Joint fluid should be examined for:
- Cell count - WBC > 50,000 –> septic arthritis?
- Differential cell count - predominantly neutrophils present in bacterial joint infection
- Gram stain
- Culture
- Polarised light microscopy
Common bugs causing septic arthritis
- most common
- most common in prosthetic joints
- most common in elderly
Most common: gram + staph aureus
Elderly –> E.coli (UTI)
Prosthetic joints –> coagulase negative staphylococci
Neisseria Gonorrhoea
Classification system used for Hip fractures
GARDEN SYSTEM
Type I: Stable fracture with impaction in valgus
Type II: Complete fracture but undisplaced
Type III: Displaced fracture, usually rotated and angulated, but still has boney contact
Type IV: Complete boney disruption
Management of an intracapsular hip fracture
Undisplaced –> Internal fixation or hemiarthroplasty if unfit
Displaced –> replacement arthroplasty (total hip replacement or hemiarthroplasty)
Total hip replacement favoured
- if patients can walk independently out of doors, not cognitively impaired and are medically fit for anaesthesia
Management of extracapsular fracture
Management
- stable intertrochanteric fractures: dynamic hip screw
if reverse oblique, transverse or subtrochanteric fractures: intramedullary device
