Nephro: Clinical Syndromes in Nephrology Flashcards
how do you analyse urine
urine dipstick
what is haematuria?
> 2 red cells/hpf in unspun urine
classification of haematuria
- microscopic/macroscopic
- persistent/transient
- glomerular/non-glomerular
- kidney/urinary tract
causes of glomerular haematuria
IgA nephropathy, thin basement membrane disease, Alport’s disease, other glomerulonephritis
causes of nonglomerular haematuria
tumours, cysts, calculi, pyelonephritis, papillary necrosis, renal vein thrombosis
causes of urinary tract bleeding
cystitis, prostate, tumours, stricture, schistosoma haematobium
most frequent causes of haematuria
- inflammation/infection of the urinary tract or prostate
- urinary calculi
- malignant neoplasms
- glomerular disorders
risk factors for malignancy
- people older than 40yo
- smoking
- pelvic irradiation
- cyclophosphamide treatment
- analgesic abuse
- occupational exposures
- history of gross haematuria
when are glomerular disorders more likely?
- proteinuria >0.5g/24hrs
- dysmorphic erythrocytes present and RBCs cast on phase contrast microscopy
- HTN
- renal impairment
what do pyuria or dysuria entail?
UTI
what do RTIs entail?
postinfectious glomerulonephritis, IgA nephropathy
why is family history important?
polycystic kidney disease, hereditary nephritides
what does back pain entail?
urethral obstruction
why is exercise or injury important in a nephro history
could rule out haematuria caused post-exercise or post-traumatic
what do micturition disorders in older men entail
prostatic obstruction
what does a history of bleeding from multiple sources?
coagulation disorders
investigations for haematuria
- urinalysis
- urine microscopy
- urine culture
- CBC
- U&E
- clotting screen
- PSA
- nephritic screen
- imaging (CT mainly)
- cystoscopy
- urine cytology
- renal biopsy (glomerular haematuria)
why is proteinuria important?
- marker for intrinsic renal disease
- prognostic factor for progession of renal insufficiency
- risk factor for CV mortality
- treatment target in CKD
normal value for proteinuria
<150mg/day
value for microalbuminuria
30-300mg/day
ACR >2.0mg/mmol
classification for pathophysiology of proteinuria
- glomerular
- tubular
- overflow (light chains in multiple myeloma)
- secretory (bladder tumour, prostatitis, blood)
classification of proteinuria (using values)
- mild <1g/day
- significant 1-3.5g/day
nephrotic >3.5g/day
the higher the value, the more likely is to be caused by glomerular disease
what causes leucocyturia
infection (neutrophilia)
tubular intersititial necrosis
causes of sterile pyuria
treated UTI, chlamydia, calculi, prostatitis, bladder tumour, papillary necrosis, TIN, TB
which mix of values has the worst prognosis (of protein and blood in urine)
nephrotic proteinuria and haematuria
criteria for nephrotic syndrome
proteinuria of >3.5g/1.73m2/24h hypoalbuminaemia oedema hyperlipidaemia lipiduria hypercoagulability
pathophysiology of nephrotic syndrome
primary insult = increased glomerular permeability; causing plasma protein leakage into urine
hypoalbuminaemia is the cause of the main clinical features
causes of nephrotic syndrome
- membranous glomerulopathy
- focal segmental glomerulosclerosis
- minimal change glomerulopathy
- miscellaneous proliferative GN
- membranoproliferative GN
- diabetes
- amyloidosis
- other disease
treatment of nephrotic syndrome
- salt and water restriction
- diuretic therapy
- hypertension treat
- anti-proteinuric drugs
- immunosuppressive therapy
definition of nephritic syndrome
glomerular inflammation causing:
- decrease in GFR
- moderate proteinuria
- oedema
- hypertension
- haematuria (red cell casts)
causes of acute nephritis
- IgA A and HSP
- lupus nephritis
- postinfectious GN
- Anti-GBM disease
- ANCA positive small vessel vasculitis and idiopathic pauci-immune GN
- idiopathic crescentic GN
- mesangiocapillary GN
investigations for nephritis
- urine dipstick
- 24h proteinuria variable U&E&C, LFTs
- acute phase markers
- full nephritic screen
- US kidneys
- renal biopsy
immunological findings in poststrep GN
- reduction in CH50 and C3 complement activity
- serial ASO titre measurements
rapidly progressive GN
- decrease in GFR in days/weeks
- acute uraemic or nephritic syndrome with quick renal insufficiency, risk renal failure
extrarenal symptoms of rapidly progressive GN
pulmonary, skin, ORL, CNS
definition of acute renal failure
rapid decrease in GFR (hours/days) due to urea, creatinine retention as well as electrolyte disorders, acid-base disorders, fluid homeostasis disorder
is oligouria present in ARF?
maybe
highest risk in ARF
pulmonary oedema, hyperkalaemia
how is acute renal failure classified
RIFLE classification
- risk, injury, failure, loss, end-stage
acute kidney injury classification
based on the creatinine level and the urine output
causes of ARF
- pre-renal
- renal
- post-renal
pre-renal causes of ARF
- hypotension from low GFR
- arterial stenosis
- NSA
- ACEi
intrinsic causes of ARF
- ATN (ischaemic or nephrotoxic)
- vascular
- acute GN
- acute TIN
postrenal causes of ARF
obstruction
risk factors for ARF
- increasing age
- diabetes mellitus
- pre-existing renal disease
- surgery
- volume depletion
- cardiac disease
- cirrhosis
- drugs (NSA, ACEi, ARB)
- myeloma
what are the two main tests in nephro?
- eGFR
- ACR/PCR
what are the main causes of CKD?
HTN and DM
how can renal insufficiency be classified?
- exocrine dysfunction (disbalance in ions and other catabolites)
- endocrine dysfunction (EPO, Vit D metabolism, renin-angiotensin system)
clinical features of uraemic syndrome
- GI (anorexia, nausea, vomiting)
- neurological (central and peripheral - uraemic encephalopathy and polyneuropathy)
- respiratory (pulmonary oedema)
- cardiac (uraemic pericarditis)
- dermatological (pruritis)
- haematological (fatigue from anaemia)
- endocrinolohical (secondary hyperparathyroidism, dysmenorrhea)
in which 3 clinical situations is uraemia present?
- acute renal failure
- chronic renal failure
- dialysis-treated CRF
what happens to toxic compounds in renal failure
they accumulate
what happens to muscle in metabolic acidosis
there is proteolysis, causing a loss of lean body mass
what happens to bone in metabolic acidosis
inhibition of osteoblasts and stimulation of osteoclasts, causing dissolution of the bone matrix and minerals
which hormones decrease in metabolic acidosis?
vitamin D3, thyroxine, growth hormone
which hormones increase in metabolic acidosis?
PTH level, cortisol, insulin resistance
treatment of uraemia
- Na, K, PO3 and protein diet restriction
- HTN control
- NaHCO3 treatment to reduce metabolic acidosis
- anaemia management (erythropoietin)
- secondary hyperparathyroidism
- dialysis and renal transplant
what are pulmonary-renal syndromes?
acute kidney injury associated with pulmonary haemorrhage
clinical features of pulmonary-renal syndromes
cough, anaemia, dyspnoea, haemoptysis, hypoxaemia, alveolar shadowing on CXR, skin rush, sinusitis, arthritis, fever, fatigue
main causes of pulmonary-renal syndromes
ANCA vasculitis, antiGBM nephritis, SLE, Henoch-Schonlein purpura
types of hypertension
primary (kidney suffers itc)
secondary (kidney is the cause)
why do we control HTN from a nephro POV?
control slows the progression of kidney disease
what are the tubular syndromes which have a normal GFR
fanconi syndrome
isolated cases
what happens in Fanconi syndrome
- amino acids, phosphate and glucose, protein, calcium and high amounts of urine are excreted
- Na and K are lost
- bicarbonate defective reabsorption
types of pain in nephro
- loin pain
- ureteric colic
- suprapubic pain
- bladder irritability
characteristics of loin pain
constant dull ache, radiating to the abdomen, genitalia
causes of loin pain
distension of the renal capsule
differential for loin pain
nerve root irritation (T10-T12)
characteristics of ureteric colic
sudden onset, extremely severe, pale, distressed patient
where is ureteric colic localised?
loin, iliac fossa, genitalia, upper thigh
causes of ureteric colic
passage of a calculus, blood clot or necrotic papillae
cause of suprapubic pain
over-distension of the bladder, cystitis, bladder cancer
symptoms associated with bladder irritability
dysuria, frequency, urgency
causes of bladder irritability
over-distension of the bladder, cystitis
obstructive symptoms of bladder outflow obstruction
hesistancy, impaired force of stream, incomplete emptying
storage symptoms of bladder outflow obstruction
frequency, dysuria, urgency
causes of bladder outflow obstruction
structural: prostatic hyperplasia, carcinoma, urethral stricture
functional: bladder neck dyssyngeria, DM, multiple sclerosis, spinal cord lesions, drugs
