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ICSM Year 6 + edits > Medicine - Renal > Flashcards

Medicine - Renal Flashcards

1
Q

What are the 2 main types of dialysis?

A

Haemodialysis

Peritoneal dialysis

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2
Q

What is required for haemodialysis?

A
  • Dialysis machine (patient’s blood is pumped OUTSIDE the body and through this machine)
  • Vascular access is required via an AV fistula (longterm), or a temporary CVC
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3
Q

What happens inside a haemodialysis machine (broadly)?

A

Blood flows through tiny semi-permeable tubes surrounded by a dialysis solution (dialysate)
Filtration occurs via osmosis and diffusion - dialysis fluid contains solutes at a similar level to the level they would be in a healthy patient’s blood
Can add bicarbonate (to combat acidosis), EPO and drugs if needed
Heparin always added

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4
Q

How often should haemodialysis be performed?

A

4 hour treatment 3 times per week

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5
Q

What are the 3 main possible complications of dialysis

A
  • Blood infection (more common in peritoneal dialysis)
  • Thrombosis
  • Internal bleeding (due to added heparin)
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6
Q

What is peritoneal dialysis?

A

Dialysis fluid is introduced into the patient’s abdominal cavity for several hours, and the peritoneum serves as the natural filter
Can be done automatically at night during sleep

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7
Q

Recall some pros of peritoneal dilaysis

A
  • Offers more flexibility (can be done overnight)
  • Is better tolerated by patients
  • Less expensive
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8
Q

What is a tesio line?

A
  • Tunneled dual lumen central line
  • Used as a ‘bridge’ before an AV fistula can be put in
  • One lumen enters the right atrium, the other
    sits outside the RA in the vena cava
  • Both lumens exit the body (with a central line, only 1 lumen enters the skin)
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9
Q

Why is a normal vein unsuitable for haemodialysis, and why is an AV fistula used?

A

Normal vein would easily collapse/ thrombose with recurrent venepuncture
Vein in an AV fistula hypertrophies in response to turbulent flow of blood from artery and so can withstand repeated venepuncture

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10
Q

Recall some contra-indications to renal biopsy in acute renal failure

A
  • Obvious pre or post renal cause (these are contra-indications)
  • Significant coagulopathy
  • Infection at the site
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11
Q

What group of diseases is the most common cause of nephritic syndrome?

A

Proliferative glomerulonephritis

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12
Q

Recall 5 causes of the nephrotic syndrome

A 
Amyloidosis 
Diabetes
Focal segmental glomerulosclerosis 
Membranous glomerulonephritis 
Minimal change disease
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13
Q

What are the most common causes of AKI?

A

Remember STOP:

  • Sepsis/dehydration / heart failure (decrease blood supply)
  • Toxins (NSAIDs, nephrotoxic drugs),
  • Obstruction in the urinary tract (back pressure
  • Parenchymal kidney disease (gnpehritis, inephritis, ATN) - decrease filtration of blood

pre renal, renal & post renal

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14
Q

What are the most common causes of CKD?

A

Diabetic nephropathy

Other causes: HTN, age, gnpehritis, PKD, Nsaids, PPis, lithium

Hypertensive nephropathy

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15
Q

What are the primary functions of the kidney?

A

Balance:

  • Water
  • Electrolyte
  • Acid-base

Endocrine:

  • erythropoietin
  • vit D activation
  • renin-angiotensin system
  • BP control

Excretion:

  • Waste
  • Metabolites
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16
Q

What symptoms might you expect from someone with CKD?

A

Fluid overload (pedal oedema, pleural effusion, ascites, tiredness)

Anaemia (SOB, tiredness, LoC, headcaches)

Hyperkalaemia (palpitations, cardiac arrest, asymptomatic)

Uremia (pruritis, confusion, pericarditis, encephalopathy)

Acidosis (nausea, vomiting,
tiredness)

Increased drug action (e.g. opioid side effects)

Reduced urine output

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17
Q

What diet should be followed in patients with very low creatinine clearance?

A 
Low phosphate
(eg. avoid chocolate, shellfish, nuts)

Low potassium (avoiding chocolate, bananas etc)

Fluid restricted (avoiding alcohol, avoid too much tea/coffee)

Low salt (avoiding processed foods)

Can take phosphate binders if diet restriction alone doesn’t succeed

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18
Q

Recall a mnemonic that can be used to remember the most common indications for emergency dialysis

A

A – acidosis
E – electrolyte imbalance (K+ of 6.5+ and refractory to
medical management)
I – intoxication (certain drugs require dialysis to
clear the blood)
O – overload of fluid (refractory to diuretic treatment)
U – uraemic encephalopathy & pericarditis

BLAST mnemonic for drugs that can be dialysed out - 
Barbiturates
Lithium
Alcohol
Salicylates
Theophylline
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19
Q

What can be used as an alternative to calcium gluconate in hyperkalaemia as a cardioprotective infusion?

A

Calcium chloride

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20
Q

How might a chest x ray appear in Goodpasture’s syndrome?

A

Bilateral widespread airspace opacities

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21
Q

Which diagnosis classically has the symptoms of haematuria and haemoptysis in a young person?

A

Goodpasture’s

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22
Q

What is the likelihood of complete recovery of kidney function following an AKI if there is no pre-existing CKD?

A

80%

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23
Q

Recall 3 ECG changes in hyperkalaemia

A

Tented T waves
Widening QRS complex
Small p waves

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24
Q

What is the most common cause of nephrotic syndrome in adults?

A

Membranous glomerulonephritis

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25
Q

What are the components of the annual review for patients with type 2 diabetes?

A 
Retinopathy screening
Foot assessment for both sensation and doppler testing of vascular supply
Albumin:creatinie ratio
U+E
Serum cholesterol
HBa1c 
Review of any glucose monitoring
Weight assessment
Smoking status assessment
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26
Q

What are the indications for dialysis?

A 
Refractory hyperkalaemia 
Refractory fluid overload 
Metabolic acidosis 
Uraemia symptoms 
CKD stage 5
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27
Q

What will the urinary sodium be in pre-renal vs intrinsic renal ARF?

A

Pre-renal: urinary sodium low

Intrinsic renal: urinary sodium high

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28
Q

Recall the symptoms of HUS vs TTP

A

HUS: MAHA, thrombocytopaenia, AKI

TTP: MAHA, thrombocytopaenia, AKI, neurological impairment and fever

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29
Q

Recall some key nephrotoxic drugs that should be stopped in AKI

A 
stop the DAMN drugs 
Diuretics 
ACEi and ARBs 
Metformin 
NSAIDs
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30
Q

At what GFR would you do a routine nephrology referral?

A

Either at GFR <30 or a reduction in GFR over 12 months of >25% >15mL/min/1.73m^2

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31
Q

How can CKD be managed by diet?

A
  1. Reduce dietary phosphate, sodium, potassium, fluids
  2. Sevelamar (phosphate binder) - reduces uric acid and lipid levels
  3. Vitamin D
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32
Q

Recall 4 features of adult polycystic kidney disease

A

Liver cysts
Berry aneurysms
Mitral valve prolapse
Renal failure signs

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33
Q

What is the medical management of adult polycystic kidney disease?

A

Tolvaptan

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34
Q

Does IgA nephropathy cause nephrotic or nephritic syndrome?

A

Nephritic (rarely nephrotic)

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35
Q

Recall some signs and symptoms of IgA nephropathy

A

Purpuric rash (100%)
Arthralgia (60-80%)
Abdominal pain (60%)
Glomerulonephritis (20-60%)

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36
Q

How should IgA nephropathy be managed?

A

Most cases will resolve spontaneously in 4w
Joint pain –> NSAIDs

Scrotal involvement/severe oedema/ severe abdominal pain –> oral prednisolone

Renal involvement –> IV corticosteroids

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37
Q

What type of cancer is left varicocele most associated with?

A

Renal cell carcinoma

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38
Q

What is the most common form of renal tumour?

A

Clear cell carcinoma

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39
Q

Which urological cancer is most associated with painless haematuria?

A

Transistional cell carcinoma

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40
Q

In patients with CKD, what should be done before any scan that uses contrast?

A

Give IV saline –> volume expansion –> reduced chance of cast nephropathy

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41
Q

What are the variables in the Modification of Diet in Renal Disease equation, that affect eGFR?

A 
CAGE: 
Creatinine 
Age 
Gender 
Ethnicity
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42
Q

What medication should be started in patients with CKD who have an ACR of >30?

A

ACE inhibitor

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43
Q

How long does it take for an AV fistula to develop

A

6-8 weeks

44
Q

How does the size of kidneys differ in chronic diabetic nephropathy vs ckd of another cause?

A

Chronic diabetic nephropathy = large/normal kidneys

CKD = small kidneys

45
Q

Nice criteria for a AKI

A

cr rise > 25 in 48 hrs
50% in 7 days
urine output < 0.5 for more than 6 hrs

46
Q

Main Rf for AKI

A

Age
Cardiac
Liver
CKD
Age
Drugs e.g. NSAIDS / ACEi
contrast medium

47
Q

Glucose in urine

A

Diabetes

48
Q

Mx of AKI

A

fluid - pre renal
stop nephrotoxic meds
relieve obstruction

49
Q

Complications of AKI

A

Hyperkalaemia
Fluid overload
metabolic acidosis
uraemia - encephalopathy

50
Q

Main Ix for CKD

A

eGFR - two test 3 months apart
proteinuria
haematuria
renal USS

51
Q

eGFR staging

A

90
60-89
45-59
30-44 (3b)
15-29
15 - end stage renal failure

52
Q

Main complications of CKD

A

anaemia
renal bone disease
cvd
peripheral neruopathy
dialysis

53
Q

Specialist referral ckd

A

30 egfr
70 ACR
decrease of egfr of 15 / 25 % in 1 yr
uncontrolled htn on 4 hypertensives

54
Q

Treat complications of CKD

A

sodium bicarbonate for metabolic acidosis
iron and erythropoietin anaemia
vit d for bone disease
dialysis for end stage renal failure
renal transplant

55
Q

Why should blood transfusions be limited with treating ckd over erythopoietin?

A

Allosensitation - transplant organs more likely to be rejected

iv iron in dialysis

56
Q

Main complications of periotoneal dialysis

A

bacterial periotonities - glucose infusion = growth area
peritoneal sclerosis - thickening and scarring
ultrafilrtation failure - absorb dextrose in solution - reduce gradient
weight gain as absorb carbs in dextrose
psychosocial - sleep with machine

57
Q

Types of haemodialysis and complications

A

Tunnelled cuffed catheter - tube through vein sits at svc, dacron cuff for healing of tissue to cuff making more permanet and avoid bacteria - infection and blood clots

AV fistula - connection between artery and vein - surgical op 4 week to 4 month before use
skin integrity, aneurysms, palpable thrill, machinery murmu
- infection, thrombosis, stenosis, steal syndrome, high output heart failure

58
Q

steal syndrome

A

inadequate flow to distal limb from av fistula - distal ischaemia

59
Q

high output heart failure

A

quick flow artery to vein, rapid return blood to heart - increase pre load- hypertrophy of heart muscle

60
Q

Features of renal transplant

A

HLA matching
life long immunosuppression e.g. tacrolimus
rejection, failure and electoryle imbalance

immuno comp - IHD, t2dm, infeection, pcp, cmv, pjp, non hodgkin, skin cancer SCC

61
Q

Features of nephritic syndrome

A

haematuria
oliguria - reduced urine output
proteinuria <3g tho
fluid retention

62
Q

Features of nephrotic syndrome

A

peripheral oedema
proteinuria >3g
serum albumin less than 25g
hypercholesterolaemia
increase clotting

MCD = child, focal segmental glomeruloscelrosis = adults

63
Q

Interstitial nephritis

A

inflammation space between cells and tubules of intersititum of kidneys - acute and chronic

Acute - AKI and HTN, hypersensitivity - drugs / infection - rash, fever, eosinophilia - cause and steroids

Chronic CKD, autoimmune, infetion etc - cause and steroids

64
Q

Causes of glomerulosclerosis

A

glomerulonephritis
obstructive uropathy
focal segmental glomerulosclerosis

65
Q

Glomerulopehritis treatments

A

steroids
blood pressure control

66
Q

IgA nephropathy

A

common primary glomerulonephritis
20s
IgA deposits and glomerular mesangial proliferation

67
Q

Membranous glomerulonephritis

A

most common overall
20s 60s
IgG and complement deposits on basement membrance
idiopathic
secondary to malignany, rheumatoid and drugs

68
Q

Diffuse proliferative glomerulonephritis (post strep)

A

under 30
1 to 3 weeks post strep
nephritic yndrome
receover

69
Q

Good pastures syndrome

A

anti-gbm
Gn + pulmonary haemarry attack basement membrance
AKI + haemoptysis

70
Q

Rapidly progressive glomerulonephritis

A

crescentic GN
very acute with sick
secondary to good pastures

71
Q

Featres of diabetic nephropathy

A

high levels of glucose cause scarring
proteinuira feature due to damage
ACR and U&Es
blood pressure and sugar optimising

72
Q

Acute tubular necrosis

A

death of epithelial cells of renal tubules - most common AKI - ischaemia / toxins - reversible 7-21 day recovery

Ish - shock, sepsis, dehydration
Toxin - radio contrast dye, gentamicin, nsaids, lithium, heroin

urinalysis - muddy brown casts

Mx - AKI - supportive fluids, cause, stop drugs, and treat complications

73
Q

Renal tubular acidosis

A

metabolic acidosis in the tubules of the kidney
4 types
type 1 - distal tubule unable to excrete hydrogen ions e.g genetic, SLE< sjogren, PBC, HT, sickle, marfans
- failure to thrive, hyperventilation to compensate, ckd, bone disease
- hypokalaemia, met acid, high urinary ph
- oral bicarbonate

type 2 - proximal tubule, unable to reabsorb bicarbonate, excess in urine
- fanconis, jews, bone marrow failure, acute myeloid, cafe au lait
- hypokalaemai, met acid and high urinary ph
- same as above

type 3 - both

type 4 - reduced aldosterone - hyperkalaemic renal tubular acidosis, suppress ammonia, acid urine most common
- adrenal insufficinecy- ACE / spironolactone - SLE / diabetes / HIV
- hyperkalaemia, high chloride, meta acidosis, low urinary pH
- fludrocortisone and bicarbonate

74
Q

Haemolytic uraemic syndrome

A

thrombosis in small blood vessels - shiga toxin
Haemo anaemia, AKI, Low platelet count
e coli 0157
gastroenteririts - then 5 days after, brusing + kidney symptoms
Emergency - supportive anti HTN, blood transfusions and dialysis

75
Q

features of rhabdomyolysis

A

overuse / underuse muscle breakdown
myocyte death 0 myoglobin, potassium, phosphate, CK released
myoglobin toxic to kidney - AKI, acccumulate products more in the blood

red brown urine

ECG for hyperkalaemia but CK main test

Iv fluids encourage filtration
sodium bicarbonate / mannitol increase gfr and reduce oedema

76
Q

Features of hyperkalaemia

A

arrhythmias and ventricular fibrillation
aki/ckd/rhadb/adrenal insuff.tumour lysis
drugs - spiro/ace/AII/nsaids/potassium
always repeat sample
tall t waves, flattened p waves and broad qrs complex
insulin dextrose and calcium gluconate
drive postasium into cels , stabilise cardiac muscle
neb salbutamol - potassium into cells
resonium- out of gut and into stool potassium - good for milder

77
Q

Polycystic kidney disease features

A

cysts in kidney
associated with hepatic cysts and cerebral aneurysms
USS and genetic testing
AD
- PKD1 most common
- mit regrug, colonic diverticula, aortic root dilatation
- loin pain, HTN, CVD, haematuria with cyst rupture, renal stones, end stage renal failure
AR
- oligohydramnios
- underdeveloped lungs - not adults

Mx
- tolvaptan - vasopressin receptor antagonist - slow cysts and progression of renal failure
- supportive
- avoid contact sport, drugs regular monitoring

78
Q

When someone has a AKI what should be done?

Renal DRs26

A
79
Q

If no identifiable cause of AKI is found what should be done

A

renal USS within 24 hrs of assessment

80
Q

Drugs safe to continue on AKI

A
  • Paracetamol
  • Warfarin
  • Statins
  • Aspirin (at a cardioprotective dose of 75mg od)
  • Clopidogrel
  • Beta-blockers
81
Q

Drugs that should be stopped with AKI

A
  • NSAIDs (except if aspirin at cardiac dose e.g. 75mg od)
  • Aminoglycosides
  • ACE inhibitors
  • Angiotensin II receptor antagonists
  • Diuretics
82
Q

Drugs that may need to be stopped with AKI

A
  • Metformin
  • Lithium
  • Digoxin
83
Q

Levels of hyperkalaemia

A

mild: 5.5 - 5.9 mmol/L
moderate: 6.0 - 6.4 mmol/L
severe: ≥ 6.5 mmol/L

84
Q

Why are rectal calcium resonium enemas more useful for removing potassium than oral

A

potassium is excreted rectally

85
Q

Maintainence fluid levels

A

25-30 ml/kg/day of water and
approximately 1 mmol/kg/day of potassium, sodium and chloride and
approximately 50-100 g/day of glucose to limit starvation ketosis

86
Q

Risk of using large volumes of 0.9% saline

A

hyperchloraemic metabolic acidosis

87
Q

Why should hartmanns not be used in patients with hyperkalaemia

A

contains potassium

88
Q

Causes of hyperchloraemic metabolic acidosis

A

gastrointestinal bicarbonate loss:
prolonged diarrhoea: may also result in hypokalaemia
ureterosigmoidostomy
fistula
renal tubular acidosis
drugs: e.g. acetazolamide
ammonium chloride injection
Addison’s disease

89
Q

Causes of raised anion gap acidosis

A

lactate:
shock
sepsis
hypoxia
ketones:
diabetic ketoacidosis
alcohol
urate: renal failure
acid poisoning: salicylates, methanol

metformin type 2 lactic acidosis

90
Q

Nephrogenic DI treatment

A

thiazides
low salt/protein diet

91
Q

Associated conditions with diabetic nephropathy

A

alcoholic cirrhosis
coeliac disease/dermatitis herpetiformis
Henoch-Schonlein purpura

92
Q

AKI vs CKD

A

CKD - bilateral small kidneys on USS + hypocalcaemia

exception:
autosomal dominant polycystic kidney disease
diabetic nephropathy (early stages)
amyloidosis
HIV-associated nephropathy

93
Q

Extra renal features of PCKD

A

liver cysts (70% - the commonest extra-renal manifestation): may cause hepatomegaly
berry aneurysms (8%): rupture can cause subarachnoid haemorrhage
cardiovascular system: mitral valve prolapse, mitral/tricuspid incompetence, aortic root dilation, aortic dissection
cysts in other organs: pancreas, spleen; very rarely: thyroid, oesophagus, ovary

94
Q

Factors that affect eGFR

A

pregnancy
muscle mass (e.g. amputees, body-builders)
eating red meat 12 hours prior to the sample being taken

95
Q

Anaemia in CKD

A

correct iron levels before starting EPO agents

if target levels not reached after 3 months - start on IV iron

96
Q

How does myoglobin cause renal failure

A

tubular cell necrosis

97
Q

How quick should fluids be given with AKI

A

within 15 minutes avoid potassium based ones like hartmanns

98
Q

What is pre-renal disease?

A

kidneys hold onto sodium to preserve volume, rasied urine osmoliatiy

99
Q

Iron deficiency in elderly

A

endoscopy to rule out sinister causes

100
Q

Urgent referral for haematuria criteria

A

Aged >= 45 years AND:
unexplained visible haematuria without urinary tract infection, or
visible haematuria that persists or recurs after successful treatment of urinary tract infection

Aged >= 60 years AND have unexplained nonvisible haematuria and either dysuria or a raised white cell count on a blood test

101
Q

Non urgent referral for haematuria criteria

A

Aged 60 >= 60 years with recurrent or persistent unexplained urinary tract infection

102
Q

Patients present with acute or subacute deterioration in renal function (suggested in this patient who is passing less urine), joint pain, and hypersensitivity features (fever and rash). Urinalysis will show a raised urine white cell count.

A

Acute interstitial nephritis

103
Q

Rf for contrast based nephrotoxicity

A

known renal impairment (especially diabetic nephropathy)
age > 70 years
dehydration
cardiac failure
the use of nephrotoxic drugs such as NSAIDs

withhold metformin due to risk of lactic acidosis

104
Q

Most common extra manifestation of ADPKD

A

liver cysts

105
Q

Maximum rate of potassium infusion

A

The maximum recommended rate of potassium infusion via a peripheral line is 10 mmol/hour, whereas rates above 20 mmol/hour require cardiac monitoring

106
Q

Management of bone disease with CKD

A

reduce dietary phosphate levels
phosphate binders
vit d
remove parathyroid gland

calcium binder of phosphate - hypercal + vascular calcification

107
Q

Why is nephrotic syndrome associated with a hypercoaguble state?

A

loss of antithrombin III via the kidneys
and plasminogen

dvt

ICSM Year 6 + edits (28 decks)

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