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Year 5/6 > Medicine: Renal > Flashcards

Medicine: Renal Flashcards

1
Q

The A-F of what the kidney does

A 
Acidosis
Anaemia
Bones
Clearance
Drugs
Electrolytes
Fluids
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2
Q

What are the consequences of kidney failure based off it’s functions?

A 
Acidotic
Anaemic
HypoCa
High PTH
Uraemia
HyperK
Hypervolaemia
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3
Q

Nephrotic Syndrome

A

Proteinuria
Low Albumin
Oedema
Dyslipidaemia

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4
Q

Nephritic Syndrome

A

Haematuria
HTN
AKI

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5
Q

Which hyperparathyroidism do you get?

A

Secondary: dec Ca + inc Pi

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6
Q

What is the clearance rate of the kidneys?

A

100mL/min = 144L/day

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7
Q

How do you measure clearance?

A

Urea - made by liver in response to nitrogen clearance

Creatinine - made by muscle in response to turnover

We use CKD-EPI and Cockcroft Gault calcs to find the eGFR from the creatinine

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8
Q

If you see someone w a high creatinine and you’re not sure why, what can you do?

A

Check for diabetes and HTN -> failing this see a nephrologist

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9
Q

Hx + Exam

A

Hx: CKD Sx? DM? IHD? SLE? Childhood UTIs? Stones? Drug Hx? FHx? Travel Hx?

Exam: BP, urinalysis, bloods, imaging, biopsy

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10
Q

What are causes of false pos haematuria?

A

Myoglobin + Beetroot

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11
Q

How do you quantify proteinuria?

A

Protein:Creatinine Ratio has now surpassed the 24h urine collection

Significant >100mg/mmol (1g/day)

Nephrotic >300mg/mmol (3g/day)

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12
Q

What can be seen in urine microscopy?

A

Crystals: ca oxalate, struvite, urate

Casts: red (GN), white (PN), muddy (ATN)

+ RBCs, WBCs, Bacteria

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13
Q

What are the indications for kidney biopsy? (3)

A

Unexplained injury w normal size

Histology likely to influence tx or offer prognostic info

Info concerning activity and potential reversibility of a prev identified lesion would be useful

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14
Q

What are the causes of an AKI?

A

Pre-Renal: red blood flow ?sepsis ?shock

Intrinsic: nephrotic + nephritic ?IgA ?lupus

Obstruction: urological ?stones ?malignancy ?prostate

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15
Q

What is a crescent a sign off?

A

V aggressive nephritis

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16
Q

Obs to assess fluid balance

A

Overload: raised JVP, pulm oedema, sacral/peripheral oedema

Deplete: dry mucous membranes, red skin turgor, sunken eyes, inc CRT, tachycardic, hypotensive

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17
Q

CKD Stage v GFR

A

1: >90
2: 60-89
3a: 45-59
3b: 30-44
4: 15-29
5: <15

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18
Q

What are the target BP for CKD pts?

A

If no proteinuria <130/80

If w proteinuria <125/75

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19
Q

When do you start getting sx of renal disease? And what are those sx?

A

Stage 5

Sx: pericardial effusion, N+V, weakness, lethargy, confusion

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20
Q

Mx of CKD

A

Slow Progress: ACEi/ARB, glycaemic control, lifestyle

Tx Comps: bicarbonate, iron, EPO, vit D sups if deficient or analogue if inc PTH, dietary restriction of 3P’s (potassium, phosphate, protein)

ESRF: dialysis w CVD risk measures + transplantation

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21
Q

What are the general functions of each part of the nephron?

A

PCT - electrolytes

Ascending Limb - fluid concentration

DCT - fine tuning both

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22
Q

What/Where/Why does the kidney secrete?

A

EPO, interstitial fibroblasts, dec oxygen delivery

1α-hydroxylase, PCT, low plasma calcium

Renin, juxtaglomerular cells, low blood pressure

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23
Q

What condition should you NOT use ACEi in?

A

Renal Artery Stenosis

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24
Q

How has synthetic EPO revolutionised renal care?

A

Before we were reliant on transfusions which inc risk of HIV/Hep C + sensitise for future transplants

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25
Q

Why do we get acidotic?

A

Production of ammonia +/or dec production or loss of bicarbonate

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26
Q

Which ion tends to be elevated in acidosis?

A

Potassium

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27
Q

OsmolaLity vs OsmolaRity

A

If they don’t equal there’s an osmolar gap

OsmolaLity: measured ie 275-295 mOsmol/kg

OsmolaRity: calculated ie 2(Na+K) + Urea + Glucose

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28
Q

Mx of HyperK

A

Recognise it’s a medical emerg >5.5mM so A-E approach

You want a baseline ECG, cardiac monitor, senior support STAT

You give 10mL 10% IV calcium gluconate, 50mL 50% dextrose w 10U insulin infusion, consider dialysis

Liaise w ICU + then once stable ix possible causes: drug chart, U+Es, short synacthen test

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29
Q

What is the long term mx for hyperK?

A

Tbc

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30
Q

Workup for an AKI

A

Tbc

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31
Q

What are the important considerations when starting a drug?

A

?Nephrotoxic
?Renally Excreted
?Correct Dose

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32
Q

Who can support you if you’re unsure about a drug?

A

Check BNF + liaise w pharmacist, senior nurse, reg

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33
Q

What is the best stain for overall assessment of glomerular structure?

A

Periodic Acid Schiff: stains mesangial matrix and basement membranes

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34
Q

What is the definition of oliguria?

A

<0.5mL/kg/hr

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35
Q

What are the secondary causes of nephrotic syndrome?

A 
DM
SLE
Amyloid
Myeloma
PET
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36
Q

What does the histology show in nephrotic syndrome caused by DM?

A
  1. Diffuse glomerular basement membrane thickening
  2. Kimmelstiel Wilson Nodules
  3. Advanced Glomerulosclerosis
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37
Q

What are the most common causes of AKI?

A

STOP: sepsis/dehydration, toxins, obstruction, parenchymal kidney disease - blood cultures, hydration status, review drug chat and OTC hx, US, if all neg discuss biopsy w renal

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38
Q

What are the most common causes of CKD?

A
  1. Diabetic
  2. IgA
  3. Reno-Vascular
  4. Glomerulonephritides
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39
Q

What are the endocrine functions of the kidneys?

A

Erythropoietin
1α-OHase
Renin

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40
Q

Sx of CKD

A 
Acidotic - Nausea + Vomiting
Anaemic - Pale, SOB, Tired
HypoCa - Spasms + Numb
Uraemic - Jaundice + Pruritis
HyperK - Palps + Cardiac Arrest
Oedema - Pulm, Pedal, Ascites
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41
Q

What are the indications for emergency dialysis?

A

Work through all the vowels: acidosis (pH<7.1), electrolyte imbalance (K+>6.5), intoxication, overload refractory to diuretics, uraemic pericarditis or encephalopathy

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42
Q

What dietary recommendations should you advise in a pt attending low clearance clinics?

A

Low PO4/K/NaCl + Fluid Restrict

43
Q

What reduces the incidence of contrast nephropathy in CKD pts due to receive IV contrast?

A
  1. Volume expansion w 0.9% sodium chloride infusion at 1mL/kg
  2. Oral acetylcysteine although trial data is lacking
44
Q

What would you expect the CK to be in rhabdomyolysis?

45
Q

IgA Nephropathy vs Post-Strep Glomerulonephritis

A

Timing: IgA nephropathy develops days after URTI vs weeks for PSGN which is also a/w low complement

46
Q

HyperPTH: 2° vs 3°

A

2°: Dec Ca + Inc PO4

3°: Inc Ca + Dec PO4

47
Q

HyperK ECG

A

1 - Absent P waves, peaked T waves, tachycardia

2 - Wide QRS complexes

3 - Ventricular arrhythmias

48
Q

HypoK ECG

A

Prolonged PR, depressed ST, small flattened T waves, prominent U waves

49
Q

WPW

A

The AV node is bypassed by an aberrant conducting pathway and characterised by a short PR interval and a delta wave

50
Q

What is delta wave?

A

A slurred upstroke to the R wave

51
Q

How much of each electrolyte does Hartmann’s solution contain per litre?

A

Na+ 131 mmol, K+ 5 mmol, Ca2+ 2 mmol, HCO3- 29 mmol, Cl- 111 mmol

52
Q

Factors that warrant urgent dialysis

A

HyperK resistant to medical tx, uncontrolled met acidosis, pulmonary oedema w oliguria, uraemic encephalopathy

53
Q

HyperCa ECG

54
Q

HypoCa ECG

A

Prolonged QT

55
Q

Brugada Syndrome

A

RBBB w ST elevation in V1-V3

56
Q

How do you calculate the anion gap?

A

(Na+K) - (Cl+HCO3)

57
Q

What is the anion gap normal range?

A

10-18mmol/L

58
Q

What are causes of met acidosis w normal anion gap? (4)

A 
HARD:
Hypoaldosteronism
Acetazolamide
Renal Tubular Acidosis
Diarrhoea
59
Q

What are causes of met acidosis w raised anion gap? (4)

A 
KULT ACEGIFTS:
Ketoacidosis
Uraemia
Lactate
Toxins
Aminoglycosides
Carbon Monoxide
mEthanol
Glycols
Isoniazid
Ferrous
Theophyllines
Salicylates

CAT MUDPILES:
Carbon Monoxide
Aminoglycosides
Theophyllines

Methanol
Uraemia
DKA
Paracetamol
Propylene Glycol
Isoniazid
Iron
Lactate
Ethanol
Ethylene Glycol
Salicylates
60
Q

What are the two types of lactic acidosis?

A

A: sepsis, shock, hypoxia

B: metformin + NO hypo

61
Q

What are causes of met alkalosis? (4)

A

Hyperaldosteronism
Diuretics
HypoK
Vomiting

62
Q

What are biochem problems in CKD?

A

Dec phosphate excretion + 1α hydroxylation

The high phosphate leads to low calcium and thus osteomalacia

The high PO4, low Ca, low vit D leads to 2° hyperPTH

63
Q

What are the mx principles of CKD?

A

Aim to reduce the PO4/PTH and inc the Ca/vit D: dietary, phosphate binders, calcitriol

64
Q

What is 1° + 3° hyperPTH?

A

Both have high Ca and low PO4

1°: parathyroid adenoma a/w MEN syndrome

3°: autonomous PTH secretion post renal transplant

65
Q

What leads to tubular cell apoptosis? (2)

A

Aminoglycosides + Radiological Contrast Media

66
Q

What leads to tubular cell necrosis? (2)

A

Myoglobinuria + Haemolysis

67
Q

How do the different tx for hyperK work?

A

Stabilises the cardiac membrane: 10mL 10% IV calcium gluconate

Shifts K extra-intracellular: 50mL 50% dextrose w 10U insulin infusion or 5mg salbutamol nebs

Removes K from the body: calcium resonium enema>oral, loop diuretics, dialysis

68
Q

What is spironolactone switched to following troublesome gynaecomastia?

A

Eplerenone

69
Q

Give two phosphate binders used in CKD mx

A

Calcium Acetate: calcium based ie sx of hyperCa bones stones groans moans

Sevelamer: non-calcium based ie just sx of GI discomfort

70
Q

How do pts w rhabdomyolysis typically px?

A

Had a fall or prolonged epileptic seizure and found w acute kidney injury on admission

Ddx UTI, dehydration, biliary obstrc, renal cell carcinoma

71
Q

What are the clinical findings if rhabdomyolysis?

A

AKI w disproportionately raised creatinine, elevated CK, myoglobinuria, low Ca, high PO4, high K, met acidosis

72
Q

What is McArdle’s syndrome?

A

Def of muscle phosphorylase needed for glycogen breakdown

73
Q

Why do pts w rhabdomyolysis have low Ca and high PO4?

A

The myoglobin binds to calcium and the myocytes release phosphate

74
Q

Comps of haemodialysis

A

Infection and stenosis at site, endocarditis, arrhythmia, hypotension, air embolus, anaphylaxis, disequilibration syndrome

75
Q

Comps of peritoneal dialysis

A

Infection and blockage of catheter, peritonitis, constipation, fluid retention, hyperglycaemia, hernia, back pain

76
Q

Tx Rhabdo -> AKI

A

Rehydrate w normal saline until the JVP is seen but if still anuric ?dialysis ?US ?catheter

77
Q

What are the indications for dialysis? (4)

A

HyperK >6.1
Acidosis <7.35
Pulmonary Oedema
Uraemic Pericarditis

Too much: potassium, acid, fluid, urea

78
Q

Which drugs are usually safe to continue in AKI? (6)

A

Paracetamol, low dose aspirin, clopidogrel, warfarin, beta blockers, statins

79
Q

Which drugs should be stopped in AKI as may worsen renal function? (5)

A

NSAIDs, ACEi, ARBs, diuretics, aminoglycosides

80
Q

Which drugs may have to be stopped in AKI as inc risk of toxicity? (3)

A

Metformin, lithium, digoxin

81
Q

What is the most common extra-renal manifestation of ADPKD?

A

Liver Cysts

82
Q

What ix excludes diabetes insipidus?

A

Urine osmolality of >700 mOsm/kg

83
Q

Which hereditary condition can cause cranial DI?

A

Haemochromatosis

84
Q

Which psych drug can cause nephrogenic DI?

85
Q

HUS

A

Preceding diarrhoea then the triad of AKI, MAHA and thrombocytopenia

86
Q

TTP

A

Px w neuro signs

87
Q

What is the relative importance of the HLA antigens when matching for a renal transplant?

A

DR > B > A

88
Q

Which infection can cause acute graft failure post kidney transplant?

89
Q

Timeframe of acute + chronic graft failures

90
Q

Why can you get an aortic flow murmur in anaemia?

A

The hyperdynamic circulation causes turbulent flow

91
Q

What do you need to monitor when pts are on long term immunosuppression? (3)

A

CVS, Renals, Malignancy

92
Q

What are the criteria for dx AKI?

A
  1. Riss in Cr of >=26 over 48hrs
  2. Rise in Cr by >=50% over 7d
  3. Fall in UO to <0.5ml/kg/hr for 6hrs adults and 8hrs children
  4. Fall in eGFR by >=25% over 7d
93
Q

Anti-GBM: DISGAPMMSSP

A

A rare type of small-vessel vasculitis a/w both pulm haemorrhage and rapidly progressive glomerulonephritis

Twice as common in males w a bimodal age distribution of 20-30 and 60-70 a/w HLA DR2

The abs are against type IV collagen and linear IgG deposits can be seen along the basement membrane on renal biopsy

Tx w plasmapheresis, steroids, cyclophosphamide

94
Q

At what eGFR do you refer to the nephrologist? (3)

A

Anytime <30, <15 in a year, <25% and change in category

95
Q

What should be checked before starting EPO in CKD pts?

A

Iron Studies

96
Q

When does the anaemia in CKD become apparent?

97
Q

When should other causes of anaemia be considered aside from ACD in CKD?

98
Q

How long do AV fistulae take to develop?

99
Q

What flow rates can AV fistulae stand?

100
Q

McArdle Disease: Inheritance + Deficiency

A

AR + Muscle Phosphorylase

101
Q

Comp of CAPD

A

Peritonitis w staph epidermidis

102
Q

Addison’s Disease Na + K

A

Low Na + High K

103
Q

Def of persistent non-visible haematuria

A

Pos urine dip 2/3 samples tested 2/3 wks apart

104
Q

When do you urgently refer haematuria to urology?

A

> =45 AND unexplained visible w/o UTI

> =60 AND unexplained non-visible w either dysuria or raised WCC

Year 5/6 (20 decks)

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