Nephro Flashcards
Causes of Acute interstitial nephritis
- drugs: the most common cause, particularly antibiotics
penicillin
rifampicin
NSAIDs
allopurinol
furosemide
- systemic disease: SLE, sarcoidosis, and Sjögren’s syndrome
- infection: Hanta virus , staphylococci
Features of Acute interstitial nephritis
fever, rash, arthralgia
eosinophilia
mild renal impairment
hypertension
Investigations of acute interstitial nephritis
sterile pyuria
white cell casts
Tubulointerstitial nephritis with uveitis(TINU) usually occurs in ……?
young females.
Criteria to diagnose AkI
- rise in serum creatinine of >= 26 micromol/litre within 48 hours
- 50% or greater rise in serum creatinine known or presumed to have occurred within the past 7 days
- urine output < 0.5 ml/kg/hourfor > 6 hours in adults and more than
Stage 1 of AKI
- urine output to<0.5mL/kg/hour for≥ 6 hours
Or
2. Increase in creatinine to1.5-1.9times baseline
Or
- Increase in creatinine by ≥26.5 µmol/L
Stage 2 of AKI
- urine output to<0.5mL/kg/hour for≥12 hours
Or
- Increase in creatinine to2.0 to 2.9times baseline
Stage 3 of AKi
- urine output <0.3mL/kg/hour for≥24 hours
Or
- Increase in creatinine to≥ 3.0times baseline
Or
- Increase in creatinine to ≥353.6 µmol/L
ADPKD type 1 vs ADPKD type 2
Which Chromosome ….?
Type 1 : Chromosome 16
Type 2: Chromosome 4
Ultrasound diagnostic criteria of ADPKD (in patients with positive family history)
- Age < 30 years ; 2 cysts uni/ bilateral
- Age 30 - 59 years ; 2 cysts in each kidneys
- Age > 60 ; 4 cysts in each kidneys
Management of ADPKD
tolvaptan(vasopressin receptor 2 antagonist) may be an option. For select patients
Extra-renal manifestations of ADPKD
- Liver cysts 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
Causes of a raised anion gap metabolic acidosis
lactate: shock, hypoxia
ketones: diabetic ketoacidosis, alcohol
urate: renal failure
acid poisoning: salicylates, methanol
5-oxoproline: chronic paracetamol use
Causes of a normal anion gap or hyperchloraemic metabolic acidosis
gastrointestinal bicarbonate loss:diarrhoea, ureterosigmoidostomy, fistula
renal tubular acidosis
drugs: e.g. acetazolamide
ammonium chloride injection
Addison’s disease
ARPKD is due to a defect in a gene located on chromosome ….. which encodes ………
Chromosome 6
encodes fibrocystin
Autosomal recessive polycystic kidney disease (ARPKD) on biopsy
Renal biopsy typically shows multiple cylindrical lesions at right angles to the cortical surface.
The time taken for an arteriovenous fistula to develop is …….?
6 to 8 weeks.
Calciphylaxis presents with ……?
painful necrotic skin lesions.
The risk of developing calciphylaxis is linked with
hypercalcaemia,
hyperphophataemia and
hyperparathyroidism.
Treatment of calciphylaxis
reducing calcium and phosphate levels, controlling hyperparathyroidism and avoiding contributing drugs such as warfarin and calcium containing compounds.
What is the most common presenting feature of Retroperitoneal fibrosis?
Lower back/flank pain
Retroperitoneal fibrosis is associated with (4)
Riedel’s thyroiditis
previous radiotherapy
sarcoidosis
inflammatory abdominal aortic aneurysm
drugs: methysergide
Indications for plasma exchange
Guillain-Barre syndrome
myasthenia gravis
Goodpasture’s syndrome
ANCA positive vasculitis if rapidly progressive renal failure or pulmonary haemorrhage
TTP/HUS
cryoglobulinaemia
hyperviscosity syndrome e.g. secondary to myeloma
Complications of plasma exchange
hypocalcaemia: due to the presence of citrate used as an anticoagulant for the extracorporeal system
metabolic alkalosis
removal of systemic medications
coagulation factor depletion
immunoglobulin depletion
Contrast media nephrotoxicity may be defined as a …….%….. increase in creatinine occurring……..days after administration.
25% increase in creatinine occurring2 -5 days after administration.
5 Risk factors of Contrast media nephrotoxicity
known renal impairment (especially diabetic nephropathy)
age > 70 years
dehydration
cardiac failure
the use of nephrotoxic drugs such as NSAIDs
Prevention of Contrast media nephrotoxicity
Iv 0.9% sodium chlorideat a rate of 1 mL/kg/hour for 12 hours pre- and post- procedure
Patients who are high-risk for contrast-induced nephropathy should have metformin withheld for …………..
metformin withheld for a minimum of 48 hours and until the renal function has been shown to be normal.
Spironolactone is analdosterone antagonist which acts in ……
the cortical collecting duct.
Causes of lactic acidosis type A
sepsis, shock, hypoxia, burns
Causes of lactic acidosis type B
metformin
the Modification of Diet in Renal Disease (MDRD) equation, which uses thefollowing 4 variables:
serum creatinine
age
gender
ethnicity
3 Factors which may affect s. Creat
pregnancy
muscle mass (e.g. amputees, body-builders)
eating red meat12 hours prior to the sample being taken
Amyloidosis: types
- AL AMYLOIDOSIS
- AA AMYLOIDOSIS
- Beta 2 microglobulin AMYLOIDOSIS
Causes of AL amyloidosis
myeloma, Waldenstrom’s, MGUS
Causes of AA amyloid
chronic infection/inflammation
e.g. TB, bronchiectasis, rheumatoid arthritis
Beta-2 microglobulin amyloidosis is associated with
patients on renal dialysis
4 Risk factors for urothelial (transitional cell) carcinoma of the bladder include:
- Smoking
- Exposure to aniline dyes
- Rubber manufacture
- Cyclophosphamide
2 Risk factors for squamous cell carcinoma of the bladder include:
Schistosomiasis
Smoking
What is the investigation of choice of Renal vascular disease?
MR angiography
Management of Wilms’ nephroblastoma
nephrectomy
chemotherapy
radiotherapy if advanced disease
Renal cell cancer is associated with (3)
von Hippel-Lindau syndrome
tuberous sclerosis
autosomal dominant polycystic kidney disease
Features of which condition?
haematuria
loin pain
abdominal mass
paraneoplastic hepatic dysfunction syndrome
Stauffer syndrome typically presents ascholestasis/hepatosplenomegaly
Renal cell cancer
Which type of renal stones is radio lucent
Urate stones
Xanthine stones
stag-horn calculi are composed of…
struvite (ammonium magnesium phosphate, triple phosphate).
Renal stones: risk factors
dehydration
hypercalciuria, hyperparathyroidism, hypercalcaemia
cystinuria
high dietary oxalate
renal tubular acidosis
medullary sponge kidney, polycystic kidney disease
beryllium or cadmium exposure
2 Risk factors for urate stones
gout
ileostomy: loss of bicarbonate and fluid results in acidic urine, causing the precipitation of uric acid
4 drugs that promote calcium stones
steroids,
acetazolamide,
loop diuretics,
theophylline
- SALT
alpha blockers recommend in renal stones
for distal ureteric stones < 10 mm in size
ultrasound should be used in renal stones for ……
pregnant women and children
Which drugs can be used to prevent Oxalate stones?
cholestyramine reduces urinary oxalate secretion
pyridoxine reduces urinary oxalate secretion
In Pre renal uremia
- Urine sodium
- Urine osmolality
- Fractional Na excretion
- Fractional Urea excretion
- Serum Urea: creatinine ratio
- Urine:plasma urea
- Urine:plasma osmolality
- Specific gravity
- Urine sodium : < 20
- Urine osmolality >500
- Fractional Na excretion < 1 %
- Fractional Urea excretion < 35%
- Serum Urea: creatinine ratio : raised
- Urine:plasma urea > 10:1
- Urine:plasma osmolality > 1.5
- Specific gravity > 1020
In ATN
- Urine sodium :
- Urine osmolality
- Fractional Na excretion
- Fractional Urea excretion
- Serum Urea: creatinine ratio
- Urine:plasma urea
- Urine:plasma osmolality
- Specific gravity
- Urine sodium : > 40
- Urine osmolality < 350
- Fractional Na excretion > 1 %
- Fractional Urea excretion > 35 %
- Serum Urea: creatinine ratio : normal
- Urine:plasma urea < 8:1
- Urine:plasma osmolality < 1.1
- Specific gravity < 1010
fractional sodium excretion =
*fractional sodium excretion = (urine sodium/plasma sodium) / (urine creatinine/plasma creatinine) x 100
fractional urea excretion =
fractional urea excretion = (urine urea /blood urea ) / (urine creatinine/plasma creatinine) x 100
corticomedullary scarring with atrophy of tubules
Seen in …?
Chronic pyelonephritis is
Risk factors of Chronic pyelonephritis
vesicoureteral reflux in children
obstruction e.g.recurrent renal stones
Red cell casts present in: 4 conditions
- Acute glomerulonephritis
- Renal vasculitis
- Accelerated hypertension and
- Interstitial nephritis.
Alport’S SYNDROME is due to a defect in the gene which codes for ……
type IV (4) collagen resulting in an abnormal glomerular-basement membrane
Alport’S SYNDROME is more severe in …….
Males
In Alport’S SYNDROME, deafness occurs……
Before the onset of renal failure
90% of Alport’s syndrome develop renal failure by the age of….
40 years
Alport’s patient with a failing renal transplant. This may be caused by the presence of …..
anti-GBM antibodies leading to a Goodpasture’s syndrome like picture.
5 features of Alport’S SYNDROME
- Microscopic haematuria.
2) Progressive renal failure.
3) Bilateral sensorineural deafness.
- Ocular abnormalities: Lenticonus, corneal ulceration, cataract, retinitis pigmentosa
- Renal biopsy: splitting of lamina densa seen on electron microscopy, light microscopy may be unremarkable.
A definitive diagnosis of Acute interstitial nephritis is established by
Renal biopsy which usually shows interstial oedema with a heavy infiltrate of inflammatory cells and variable tubular necrosis
Mechanism of acute interstitial nephritis
delayed T-cell hypersensitivity or cytotoxic T-cell reaction.
5 Causes of Papillary necrosis
- Chronic analgesia use
- Sickle cell disease
- TB
- Acute pyelonephritis
- DM
Retroperitoneal fibrosis is associated with ( 5)
- Riedel’s thyroiditis
- Previous radiotherapy
- Sarcoidosis
- Inflammatory abdominal aortic aneurysm
- Drugs: methysergide
In plasma exchange most conditions 5% albumin is the plasma substitute of choice, except for …………….. we should use FFP.
TTP
10 Causes of Sterile pyuria
- Partially treated UTI
- STD
- Acute GN
- Tubular interstitial diseases
- Renal stones
- Cancer
- Adult polycystic kidney disease
- Analgesic nephropathy
- Appendicitis
- Renal TB
1) Renal failure 2) Eosinophilia 3) Purpura 4) Livedo reticularis 5) Low C3. 6) ↑ESR. 7) Urine proteinuria.
Features of which condition?
Cholesterol embolisation
PD fluid WCC of greater than…… is diagnostic of PD peritonitis
100/mm3
In PD peritonitis, which is the most common organism?
coagulase negative Staphylococcus (CoNS)
Staphylococcus epidermidisis the most common cause.
Staphylococcus aureusis another common cause
Treatment of PD peritonitis i
- vancomycin (or teicoplanin) + ceftazidime added to dialysis fluidOR
- vancomycin added to dialysis fluid + ciprofloxacin by mouth
- aminoglycosides are sometimes used to cover the Gram negative organisms instead of ceftazidime
basket-weave’ appearance in biopsy
Can be seen in ?
Alport’s syndrome
7 Side-effects of erythropoietin
- accelerated hypertension potentially leading to encephalopathy and seizures
- bone aches
- flu-like symptoms
- skin rashes, urticaria
- pure red cell aplasia* (due to antibodies against erythropoietin)
- raised PCV increases risk of thrombosis (e.g. Fistula)
- iron deficiency 2nd to increased erythropoiesis
5 reasons why patients may fail to respond to erythropoietin therapy:
iron deficiency
inadequate dose
concurrent infection/inflammation
hyperparathyroid bone disease
aluminium toxicity
3 Features of Renal papillary necrosis
visible haematuria
loin pain
proteinuria
Primary HUS (‘atypical’) is due to
complement dysregulation
Typical HUS secondary to ( 6 )
- classically Shiga toxin-producing Escherichia coli (STEC) 0157:H7
- Pneumococcal infection
- HIV
- SLE
- Drugs
- Cancer
indications for plasma exchange in HUS
severe cases of HUS not associated with diarrhoea
eculizumab has evidence of greater efficiency than plasma exchange alone in the treatment of …..??
adult atypical HUS
eculizumab is …..
C5 inhibitor monoclonal antibody
Causes of Fanconi syndrome
cystinosis (most common cause in children)
Sjogren’s syndrome
multiple myeloma
nephrotic syndrome
Wilson’s disease
6 Features of Fanconi syndrome
- Type 2 RTA
- Polyuria
- Glycosuria
- Aminoaciduria
- Phosphaturia
- Osteomalacia
Fanconi syndrome describes a
generalised reabsorptive disorder of renal tubular transport in the proximal convoluted tubule
Thin basement membrane disease is An inherited disorder of type …. collagen
type IV collagen
Vesicoureteric reflux (VUR) is normally diagnosed by …….
a micturating cystourethrogram
Cystinuria is due to a defect in the membrane transport of …..?
cystine, ornithine, lysine, arginine (mnemonic = COLA)
chromosome 2: SLC3A1 gene, chromosome 19: SLC7A9
Cystinuria
Diagnosis of cystinuria
cyanide-nitroprusside test
Management of cystinuria
hydration
D-penicillamine
urinary alkalinization
8 Causes of cranial DI
- idiopathic
- post head injury
- pituitary surgery
- craniopharyngiomas
- DIDMOAD
- histiocytosis X
- sarcoidosis
- haemochromatosis
6 Causes of nephrogenic DI
- genetic, mutation in the gene that encodes the aquaporin 2 channel
- hypercalcaemia
- hypokalaemia
- lithium
- demeclocycline
- tubulo-interstitial disease: obstruction, sickle-cell, pyelonephritis
Investigations of DI
high plasma osmolality,
low urine osmolality
a urine osmolality of >700 mOsm/kg excludes diabetes insipidus
water deprivation test
Management of DI
- nephrogenic diabetes insipidus
- thiazides
- low salt/protein diet
- central diabetes insipidus can be treated with desmopressin
Risk factors of Benign prostatic hyperplasia
- Age
- around 50% of 50-year-old men will have evidence of BPH and 30% will have symptoms
- around 80% of 80-year-old men have evidence of BPH
- ethnicity: black > white > Asian
Causes of minimal changes disease
drugs: NSAIDs, rifampicin
Hodgkin’s lymphoma, thymoma
infectious mononucleosis
Management of Minimal changes disease
oral corticosteroids: majority of cases (80%) are steroid-responsive
cyclophosphamide is the next step for steroid-resistant cases
What is the third most common cause of end-stage renal failure (ESRF).
Membranous glomerulonephritis
electron microscopy: the basement membrane is thickened with subepithelial electron dense deposits. This creates a ‘spike and dome’ appearance
Membranous glomerulonephritis
Management of membranous GN
- ACEi/ ARBs
- immunosuppression
combination of corticosteroid + another agent such as cyclophosphamide is often used
many patients spontaneously improve only patient with severe or progressive disease require immunosuppression
3 Good prognostic features of Membranous glomerulonephritis
- female sex,
- young age at presentation and
- asymptomatic proteinuria of a modest degree at the time of presentation.
Causes of FSGS
idiopathic
secondary to other renal pathology e.g. IgA nephropathy, reflux nephropathy
HIV
heroin
Alport’s syndrome
sickle-cell
Focal segmental glomerulosclerosis & renal transplants
Focal segmental glomerulosclerosis is noted for having a high recurrence rate in renal transplants.
renal biopsy
focal and segmental sclerosis and hyalinosis on light microscopy
effacement of foot processes on electron microscopy
FSGS
Treatment of FSGS
steroids +/- immunosuppressants
Types of organ rejection
- Hyperacute: This occurs immediately through presence of pre formed antibody (such as ABO incompatibility).
- Acute: Occurs during the first 6 months and is usually T cell mediated. Usually tissue infiltrates and vascular lesions
- Chronic: Occurs after the first 6 months. Vascular changes predominate.
In Nephrotic syndrome, increased risk of thromboembolism related to loss of
antithrombin III and plasminogen in the urine
What’s the most common cause of Epididymo-orchitis
1. in sexually active younger adults ?
- In adults with a low-risk sexual history ?
- Chlamydia trachomatis and Neisseria gonorrhoeae
- E. Coli
Membranoproliferative glomerulonephritis
Causes of Type 1
Causes of Type 2
Type 3
type 1: cryoglobulinaemia, hepatitis C
type 2: partial lipodystrophy
Type 3: hepatitis B & C
4 Disorders associated with glomerulonephritis and low serum complement levels
- post-streptococcal glomerulonephritis
- subacute bacterial endocarditis
- systemic lupus erythematosus
- mesangiocapillary glomerulonephritis
Post-streptococcal glomerulonephritis typically occurs…………. daysfollowing a …………………..infection
Post-streptococcal glomerulonephritis typically occurs7-14 daysfollowing a group A beta-haemolyticStreptococcusinfection
Post-streptococcal glomerulonephritis is caused by
immune complex (IgG, IgM and C3) deposition in the glomeruli
electron microscopy:subepithelial ‘humps’ caused by lumpy immune complex deposits
immunofluorescence:granular or ‘starry sky’ appearance
post-streptococcal glomerulonephritis
renal biopsy
electron microscopy: subendothelial and mesangium immune deposits of electron-dense material resulting in a ‘tram-track’ appearance
Type 1 MPGN
renal biopsy
electron microscopy: intramembranous immune complex deposits with ‘dense deposits’
Type 2 MPGN
Treatment of MPGN
Steroids
IgA nephropathy is associated with (3)
alcoholic cirrhosis
coeliac disease/dermatitis herpetiformis
Henoch-Schonlein purpura
mesangial hypercellularity, positive immunofluorescence for IgA & C3
IgA nephropathy
Treatment of Ig A nephropathy
if there is active disease (e.g. falling GFR) or failure to respond to ACE inhibitors
immunosuppression with corticosteroids
1 marker of good prognosis of Ig A nephropathy
frank haematuria
6 markers of poor prognosis of IgA nephropathy
- male gender,
- proteinuria (especially > 2 g/day),
- hypertension,
- smoking,
- hyperlipidaemia,
- ACE genotype DD
4 Causes of transient or spurious non-visible haematuria
- UTI
- Menstruation
- Vigorous e exercise
- Sexual intercourse
6 Causes of persistent non-visible haematuria
- cancer (bladder, renal, prostate)
- stones
- benign prostatic hyperplasia
- prostatitis
- urethritis e.g.Chlamydia
- renal causes: IgA nephropathy, thin basement membrane disease
Spurious causes - red/orange urine, where blood is not present on dipstick
foods: beetroot, rhubarb
drugs: rifampicin, doxorubicin
Urgent cancer referral (i.e. within 2 weeks)
- Age >= 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
persistent non-visible haematuria is often defined as
blood being present in 2 out of 3 samples tested 2-3 weeks apart
Causes of RPGN
Goodpasture’s syndrome
Wegener’s granulomatosis
others: SLE, microscopic polyarteritis
Anti-glomerular basement membrane (GBM) disease is associated with
both pulmonary haemorrhage and RPGN
Anti-glomerular basement membrane (GBM) disease is caused by anti-glomerular basement membrane (anti-GBM) antibodies against type ….. collagen
IV
Anti GBM disease is associated with HLA ……
HLA DR2.
renal biopsy: linear IgG deposits along the basement membrane
Anti GBM disease
Treatment of anti GBM disease
plasma exchange (plasmapheresis)
steroids
cyclophosphamide
One of the main complications of anti GBM disease is pulmonary haemorrhage.
5 Factors that increase the likelihood of this include:
- Smoking
- LRTI
- pulmonary oedema
- inhalation of hydrocarbons
- young males
What is the most common type of lupus nephritis
Class IV (diffuse proliferative glomerulonephritis)
Treatment of lupus nephritis
- treat hypertension
- glucocorticoids with either mycophenolate or cyclophosphamide
glomeruli shows endothelial and mesangial proliferation,’wire-loop’ appearance
electron microscopy shows subendothelial immune complex deposits
granular appearance on immunofluorescence
Class IV lupus nephritis ( DPGN )
Xanthogranulomatous pyelonephritis is a Chronic/subacute infection by organisms such as……………..predispose to ……….
- Proteus mirabilis
- renal stones including staghorn calculi.
5 features of HIV-associated nephropathy
- massive proteinuria resulting innephrotic syndrome
2.normal or large kidneys
- FSGS
- Elevated urea and creatinine
- Normotension
PSA levels may also be raised by ( 6 )
- benign prostatic hyperplasia (BPH)
- prostatitis and urinary tract infection (NICE recommend to postpone the PSA test for at least 1 month after treatment)
- ejaculation (ideally not in the previous 48 hours)
- vigorous exercise (ideally not in the previous 48 hours)
- urinary retention
- instrumentation of the urinary tract
HLA is coded on chromosome ….
chromosome 6.
Post op renal transplant problems
ATN of graft
vascular thrombosis
urine leakage
UTI
when HLA matching for a renal transplant the relative importance of the HLA antigens are as follows
DR> B > A
Stones < ……. mm will usually pass spontaneously.
Stones < 5 mm
percutaneous nephrolithotomy if renal stone > …..
> 20 mm
Hydroceles may develop secondary to:
epididymo-orchitis
testicular torsion
testicular tumours
Epididymal cysts associated with
polycystic kidney disease
cystic fibrosis
von Hippel-Lindau syndrome
seminomas: hCG may be elevated in around …..%
20%
non-seminomas: AFP and/or beta-hCG are elevated in ……%
80-85%
IgGdeposits on renal biopsy
anti-GBM antibodies
Goodpasture’s syndrome ( anti GBM disease)
Patients who have received an organ transplant are at risk of ….. cancer
Skin cancer particularly Squamous cell carcinoma
Which type of complement is likely to be low in lipodystrophy ?
C3
Mechanism of DI due to alcohol
ADH inhibition
Renal biopsy showed basket weave appearance?
Alport’s syndrome
HTN
High aldosterone & renin
Hypokalemia
Features of….?
Bilateral renal artery stenosis
Finasteride treatment of BPH may take….. before results are seen
6 months
5 features of HIV associated nephropathy
FSGS
High urea & creat
Massive proteinuria
Normotension
Normal or large kidneys
5 features of HIV associated nephropathy
FSGS
High urea & creat
Massive proteinuria
Normotension
Normal or large kidneys
Bicalutamise is
Androgen receptor blocker
Causes of large kidneys
- Stage 1 diabetic nephropathy
- Amyloidosis
- Hydronephrosis
- Acromegaly
- Renal vein thrombosis
- APCKD
- HIV nephropathy
Risk factors of Dialysis disequilibrium syndrome
If serum urea ……
> 60 mmol/l
What is the lipid abnormalities most likely to be seen in CKD?
High TG , LDL
Low HDL
What is the percentage of patients with ATN recover renal function to the level where dialysis is not required ?
Approximately 95 % of patients
Lung biopsy findings in anti GBM
Haemosiderin laden macrophages
Risperidone is associated with which urinary dysfunction?
Pollakiuria ( increased daytime urinary frequency )
Ciclosporin & azole can cause
Ciclosporin toxicity
Lithium can cause……, Which type of GN?
Minimal changes disease
Thiazides & lithium
Thiazides cause the greatest retention of lithium
Medullary sponge kidney Complication during pregnancy
High risk of kidney stone formation
What is the most frequent complication and cause of death in acute renal tubular necrosis?
Infection
Gram -ve septicemia
