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Phase 3B > Nephrology 1 > Flashcards

Nephrology 1 Flashcards

1
Q

What is acute kidney injury?

A

The abrupt loss of kidney function

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2
Q

What can result from acute kidney injury?

A

The retention of urea and other nitrogenous waste products

The dysregulation of extracellular volume and electrolytes

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3
Q

What is the usual pathophysiology of AKI?

A

Acute tubular necrosis (ischaemia, from sepsis or shock, or nephrotoxins - aminoglycosides or myoglobin)
Muddy brown casts of epithelial cells

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4
Q

What staging systems are used for AKI in children and adults?

A

Adults: KDIGO
Children: pRIFLE

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5
Q

How is AKI monitored?

A

Rise in creatinine
Drop in urinary output
Falling eGFR

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6
Q

Name five pre-renal causes of AKI.

A

Volume depletion: severe v+d, haemorrhage
Oedematous states: cardiac failure
Hypotension: sepsis, cardiogenic shock
Renal hypoperfusion: ACEIs or ARBs, AAA, renal artery stenosis

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7
Q

Name three renal causes of AKI.

A

Glomerular disease: glomerulonephritis, HUS
Vasculitis
Ischaemic tubular injury

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8
Q

Name three post renal causes of AKI.

A

Renal calculus
Blood clot
Pelvic malignancy

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9
Q

Give three risk factors for AKI.

A

CKD
Nephrotoxic drugs
Previous history of AKI

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10
Q

Name five nephrotoxic drugs.

A 
Diuretics
ACEIs
Metformin
NSAIDs
Aminoglycosides
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11
Q

How does AKI typically present?

A 
Oliguria/anuria
Rise in serum creatinine
Nausea and vomiting
Dehydration
Confusion
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12
Q

What are the signs of AKI?

A

Hypertension
Dehydration
Raised JVP and oedema

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13
Q

Define AKI

A

Rise in serum creatinine of 26umol/L in 48 hours
Drop in urine output to 0.5ml/kg/hr (for 6 hours in adults and 8 hours in children)
Children - fall in eGFR of 25% or more in the preceding 7 days

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14
Q

What urinalysis investigations are required in AKI?

A

Dipstick for blood, nitrates, leukocytes, glucose, protein
Osmolality
Myoglobinuria

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15
Q

What blood tests are required in AKI?

A 
FBC and film
U&Es
Coagulation studies for DIC and sepsis
CK
Immunoglobulins or ANAs
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16
Q

When is ultrasound indicated in AKI?

A

When obstruction is suspected or no cause identified.

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17
Q

What is the management of electrolytes and fluid balance in AKI?

A

0.9% saline
Restrict oral potassium/sodium and avoid K supplements
Correct electrolyte imbalances

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18
Q

What are the indications of renal replacement therapy in AKI?

A

When any of the following are not responding to medical management:

  • severe refractory hyperkalaemia (>7mmol/L)
  • metabolic acidosis
  • fluid overload
  • symptoms of uraemia (pericarditis too)
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19
Q

Define chronic kidney disease.

A

Presence of kidney damage (albuminuria) or decreased kidney function (GFR<60ml/min/1.73m2) for 3 months or longer

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20
Q

Sustained decrease in GFR of 25% or more and a change in GFR category within 12 months is called what?

A

Accelerated progression of CKD

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21
Q

Define kidney failure.

A

GFR<15ml/min/1.73m2
OR
Need for RRT

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22
Q

Give three causes of CKD.

A

Hypertension or diabetes
Infective, obstructive, and reflux nephropathies
Glomerulonephritis

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23
Q

Give five risk factors for CKD.

A 
CVD
Diabetes, hypertension, smoking
Afro-Caribbean descent
FH
Proteinuria
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24
Q

How is kidney function assessed?

A

GFR

Albumin-creatinine ratio

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25
Q

CKD is usually asymptomatic and discovered routinely. What are the symptoms of severe CKD?

A 
Anorexia, nausea, fatigue
Weakness and muscle cramps
Oedema ---> dyspnoea
Nocturia and polyuria
Insomnia
Headaches
Sexual dysfunction
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26
Q

What are the four Ps, signs of CKD?

A

Pigment: Increased skin pigmentation/ excoriation
Pallor
Pleural effusions/peripheral oedema
Postural hypotension/ hypertension

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27
Q

What is the typical biochemistry results of a patient with CKD?

A 
Plasma glucose: high
Serum sodium: low
Serum potassium: high
Serum bicarb: low
Serum albumin: low
Serum phosphate: high
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28
Q

Rise in which substances suggests CKD-related bone disease?

A

ALP

PTH

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29
Q

What sort of anaemia do CKD patients have?

A

Normochromic normocytic anaemia

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30
Q

What urine investigations are performed for CKD?

A

Urinalysis
Spot urine collection for total protein:creatinine ratio
ACR
Culture

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31
Q

What typical interventions are used in CKD patients for the following problems?

1) Primary prevention of CVD
2) Hypertension
3) Obesity
4) Prevention of osteoporosis
5) Secondary hyperparathyroidism (from hypocalcaemia)

A

1) Atorvastatin 20mg and apixaban
2) ACEI and restrict sodium to <2.4g/day
3) 30-35kcal/IBW/day
4) Bisphosphonates
5) Vitamin D supplementation (hypocalcaemia results from low activated form of vitamin D)

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32
Q

What is diabetes insipidus?

A

Deficiency of ADH (central DI) or insensitivity to its action (nephrogenic DI)

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33
Q

Define diabetes insipidus.

A

> 3 litres/24 hours of low osmolality urine

34
Q

Give three causes of central and nephrogenic DI.

A

Central: cerebral tumour, cerebral bleed, hypothalamic-pituitary surgery, haemochromatosis
Nephrogenic: renal disease, hyperkalaemia, sickle cell anaemia

35
Q

How does DI present in adults?

A

Polyuria and nocturia
Extreme polydipsia - ice water
Dehydration - v+d
Grossly enlarged bladder

36
Q

How does DI present in children?

A

Irritability, FTT, protracted crying, fever, anorexia

37
Q

How is DI diagnosed?

A

Simultaneous plasma (high) and urine (low) osmolality
24 hour urine collection
Fluid deprivation test

38
Q

What happens in a patient with DI in a fluid deprivation test?

A

Plasma osmolality rises, urine osmolality remains dilute

39
Q

What is the treatment of cranial DI?

A

Desmopressin

tablets, intranasal spray, injection

40
Q

What is the treatment of nephrogenic DI?

A

Hydrochlorothiazide

41
Q

What is the pathophysiology of diabetic nephropathy?

A

Excess reactive oxygen species damages glomeruli and increased blood glucose damages and thickens the glomerular basement membrane

42
Q

What are some risk factors for diabetic nephropathy?

A

Poorly controlled blood glucose levels
Type 1 diabetes
Smoking and hypertension

43
Q

What are the symptoms of diabetic nephropathy?

A 
Tiredness
Headaches
Nausea
Vomiting
Itchy skin
Peripheral oedema
44
Q

How is diabetic nephropathy diagnosed?

A

Urine albumin >300mg/24hour

Early morning ACR annually

45
Q

What are renal calculi composed of?

A

Men - calcium oxalate and calcium phosphate

Women - mixed infective stones (magnesium ammonium phosphate with calcium)

46
Q

What are the risk factors for renal calculi?

A 
Dehydration
Hypercalcaemia
Hypercalcuria
Hyperoxaluria
Hyperuricaemia
Infection/cystinuria
Polycystic kidneys
Indwelling catheters
47
Q

Where is calcium reabsorbed in the kidney?

A

Proximal tubule

Parathyroid hormone

48
Q

What are Randall’s plaques?

A

Calcium oxalate precipitates form in the BM of LoH, which accumulate in the renal papillae.
Pre-calculus.

49
Q

How do renal stones present?

A 
Asymptomatic
Renal colic
Haematuria
Dysuria/anuria
Rigors and fever
50
Q

What is renal colic?

A

Sudden severe pain, radiates from flank to iliac fossa or scrotum. There may be vomiting.
Usually constant
Tenderness

51
Q

How is haematuria classified?

A

Visible or non visible

Symptomatic or non-symptomatic

52
Q

Define significant haematuria.

A

One episode of VH
One episode of s-NVH
Persistent a-NVH

53
Q

What are five causes of haematuria?

A 
UTI
Renal cell/prostate/bladder malignancy
Urinary calculi
Trauma to kidney etc
Vigorous exercise
54
Q

What are three differentials of haematuria?

A

Haemoglobinuria (no red cells on microscopy)
Myoglobinuria
Beeturia
Rifampicin

55
Q

What are the details of the 2 week cancer pathway referral for haematuria?

A

Px aged over 45: unexplained VH
Px aged over 60:
Unexplained NVH and dysuria/raised WCC

56
Q

Which patients are at risk of hypernatraemia?

A

Elderly patients and infants as impaired expression of thirst and independent access to water
Patients with altered mental status
Critical illness

57
Q

What are the four causes of hypernatraemia?

A

Pure free water loss (dehydration)
Hypotonic fluid loss (dehydration and hypovolaemia)
Hypertonic sodium gain
Intracellular shift of water (rare)

58
Q

What are the causes of pure free water loss/dehydration?

A

Inadequate water intake
DI
Thirst impairment

59
Q

What are the causes of hypotonic fluid loss?

A

Burns
GI losses
Urinary losses e.g. loop diuretics or osmotic diuresis

60
Q

What are the causes of hypertonic sodium gain?

A

Hypertonic saline

Poisoning

61
Q

How does hypernatraemia present?

A

Hypovolaemia: Dry mouth and abnormal skin turgor
Oliguria
Tachycardia and postural hypotension
CNS: Lethargy, confusion, seizures

62
Q

How is hypernatraemia managed?

A

Replace free water losses and electrolytes if appropriate

63
Q

What are fluid requirements composed of?

A

Water deficit

Measured and insensible fluid losses

64
Q

How fast is a chronic (>24 hours) hypernatraemia corrected?

A

Slower than 0.5mmol/L/hour

If not, there is risk of osmotic demyelination and cerebral oedema.

65
Q

How fast is a rapid hypernatraemia corrected?

A

More rapidly, but ensure sodium does not rise >6mmol/L in 6h, or >10mmol/L in 24h

66
Q

Which fluids are appropriate to give to hypovolaemic and hypervolaemic patients?

A

Hypovolaemic - 0.9% saline

Hypervolaemic - 5% dextrose and diuretics.

67
Q

Name a complication of hypernatraemia.

A

Cerebral bleeding

68
Q

What is the most common electrolyte abnormality?

A

Hyponatraemia

69
Q

Hyponatraemia can be hypovolaemic, euvolaemic, and hypervolaemic. What are the causes of these?

A

Hypo - V+D, diuretics, renal disease
Eu - acute water load, SIADH
Hyper - CCF, cirrhosis, nephrotic syndrome, renal failure

70
Q

What are the symptoms of mild, moderate, and severe hyponatraemia?

A

Mild - anorexia, headache, vomiting
Mod - Confusion, ataxia
Severe - drowsiness, seizures

71
Q

Coma, fixed dilated pupil, decorticate or decerebrate posturing, and respiratory arrest are signs of what?

A

Brainstem herniation

72
Q

Pulmonary rales, S3 gallop, increased JVP, ascites, and peripheral oedema, are signs of what?

A

Hypervolaemia

73
Q

Dry mucus membranes, tachycardia, and decreased skin turgor, are signs of what?

A

Hypovolaemia

74
Q

What is the main management of hyponatraemia?

A

Hypertonic saline

75
Q

In treatment of hypovolaemic hyponatraemia, ADH is suppressed as euvolaemia is regained. What is the effect of this?

A

There is a resulting diuresis.
Sodium elevates rapidly
–> Desmopressin

76
Q

What is the treatment of hypervolaemic hyponatraemia?

A

Treat underlying cause e.g. HF, AKI, cirrhosis

77
Q

How are renal calculi diagnosed?

A

Dipstick: red cells
MCS of MSU
Bloods for FBC, renal function, and electrolytes
NON ENHANCED HELICAL CT SCNANING OF KUB - gold standard

78
Q

How is an acute episode of renal colic managed?

A

Diclofenac IM
Metoclopramide IM
Rehydration
Monitor passage of stone

79
Q

Name a procedure to remove renal calculi.

A

Extracorporeal shock wave lithotripsy.

80
Q

Name two complications of renal calculi.

A

Hydronephrosis
Ulceration
Infection and sepsis

81
Q

How are further renal calculi prevented from forming?

A

Increase fluid intake
Reduce salt, animal protein, urate, and oxalate intake
Normal calcium intake
Cranberry juice

Phase 3B (20 decks)

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