Nephrology Flashcards
Within ADPKD, what are the two different types, which chromosomes cause the mutations and when do they usually reach ESRF?
PKD1 (85%) - Chr16, ESRF by 50s
PKD2 (15%) - Chr4, ESRF by 70s
T1 = most common (1st), Chr (1)6, reaches ESRF 1st
In patients with a positive FH, what is the USS criteria for diagnosing PKD?
two cysts, unilateral or bilateral, if aged < 30 years
two cysts in both kidneys if aged 30-59 years
four cysts in both kidneys if aged > 60 years
What are the main symptoms of PKD and what complications may occur in the kidney?
Abdo pain +/- haematuria
Cyst infection
Renal calculi
Increased BP
Progressive kidney failure
What are the extra-renal manifestations of PKD?
Liver cysts -> hepatomegaly
Intra-cranial aneurysm -> SAH
Cysts: pancreas, ovaries, testes, liver
Mitral valve prolapse (systolic apical murmur) and diverticular disease
- essentially all cystic/out-pouching structures
Management of PKD?
HIGH BP SHOULD BE TREATED AGGRESSIVELY (aim <130/80mmHg)
Strict criteria, but some patients may be offered tolvaptan (vasopressin receptor 2 antagonist) to slow cyst development
No other regular treatment
Treat infections + monitor U&Es
To help pain -> cyst removal/nephrectomy
Increased water intake, decreased sodium intake and avoid caffeine may also help
If a patient develops a SAH with a history of PKD, what might you offer their family members?
Magnetic resonance angiography screening may be done in 1st degree relatives of those with SAH + ADPKD
Which Ab is idiopathic membranous glomerulonephritis related to?
Anti-phospholipase A2 antibodies
What are the three defining features of nephrotic syndrome? + extra finding
Proteinuria (>3g/24hrs)
Hypoalbuminaemia (<30g/L)
Oedema
- also severe hyperlipidaemia
What are the three primary causes of nephrotic syndrome?
Minimal change disease
Membranous nephropathy
Focal segmental glomerulosclerosis
What can cause secondary nephrotic syndrome?
infections: hepatitis B, malaria, syphilis
malignancy (in 5-20%): prostate, lung, lymphoma, leukaemia
drugs: gold, penicillamine, NSAIDs
autoimmune diseases: systemic lupus erythematosus (class V disease), thyroiditis, rheumatoid
What is minimal change disease, causes, how is it Ix and Tx?
fusion of foot processes, more common in children
Can see loss of foot processes on electron microscopy (light microscopy normal)
80% idiopathic, but can be caused by:
drugs: NSAIDs, rifampicin
Hodgkin’s lymphoma, thymoma
infectious mononucleosis
Tx = steroids Prognosis = 1/3 one episode, 1/3 infreq relapses 1/3 freq relapses (stop before adulthood)
What is membranous nephropathy, how is it Ix and Tx?
thickened glomerular BM, more common in adults, usually idiopathic – may be assoc with AI disease e.g. SLE
Tx = ACEi, immunosuppression (steroids + another agent) if severe/progressive
Prognosis = , 1/3 remission, 1/3 remain proteinuric, 1/3 renal failure
What is the pathophysiology of nephrotic syndrome?
Injury to the podocytes appears to be the main cause – usually they wrap around the glomerular capillaries and maintain the filtration barrier, preventing large protein molecules from getting through. Damage can cause a large protein loss.
What are good prognostic indicated of membranous nephropathy?
Female
Young age
Asymptomatic proteinuria at the time of presentation
What is focal segmental glomerulosclerosis, how is it Tx?
Segments of glomeruli develop sclerosis, 50% will get better, 50% develop ESRF, Tx = steroids
What is the presentation of nephritic syndrome?
Haematuria (micro/macro), HTN, drop in GFR
Also - fluid retention + oedema, and proteinuria
Causes of nephritic syndrome?
Post-strep infection
IgA nephropathy
Rapidly progressive GN
Membranoproliferative GN
Goodpastures disease
What is post infectious (post-strep) GN?
Post-infection with Group A B-haemolytic streptococcus (pyogenes)
• Causes inflammation in the glomeruli + defective filtration, causing blood to leak through
• Typically occurs in children
ASSOCIATED WITH LOW COMPLEMENT
- Occurs 1-2 weeks after throat/skin infection
- Tx = supportive, potentially Tx oedema with furosemide, >95% recover renal function
What is IgA nephropathy?
- Commonest GN in HICs in adults - typical: young man with haematuria that recovers rapidly after attacks
- Usually present with macroscopic haematuria, may present 1-2 days after a viral infection
- Renal biopsy – IgA deposits seen in the matrix
- Tx – BP control with ACEi, immunosuppression may slow the decline of renal function
- 20% of adults develop ESRF over 20 years
What is rapidly progressive GN?
- The most aggressive GN
- Different causes – all have crescents (fibrin thickening) in the glomeruli seen on biopsy
- Examples: Goodpasture’s, granulomatosis with polyangiitis, microscopic polyangiitis
What is Goodpasture’s disease?
• Also known as anti-glomerular BM disease
• Caused by auto-Abs to T4 collagen (an essential component of the GBM)
o Features
–> pulmonary haemorrhage
–> rapidly progressive glomerulonephritis (rapid AKI)
• Tx – plasma exchange, steroids +/- cyclophosphamide, if started early full recovery is possible
What are some common causes of polyuria?
diuretics, caffeine & alcohol
diabetes mellitus
lithium
heart failure
What is the mechanism by which alcohol intake causes polyuria?
Alcohol acts to inhibit ADH. This causes reduce aquaporin insertion in the collecting tubules
What is diabetes insipidus?
Either a deficiency of ADH (cranial) or an insensitivity to ADH (nephrogenic)
Causes of cranial diabetes insipidus?
- Idiopathic
- Trauma – post-head injury
- Pituitary surgery
- Craniopharyngiomas
• Histiocytosis X
Causes of nephrogenic diabetes insipidus?
- Genetics (AVPR2)
- Electrolytes (high Ca, low K)
- Drugs (demeclocycline (abx), lithium)
- Tubulo-interstitial disease – obstruction, sickle-cell, pyelonephritis
What is Wolfram’s syndrome?
DIDMOAD - the association of cranial Diabetes Insipidus, Diabetes Mellitus, Optic Atrophy and Deafness
Presentation of DI?
Polyuria + polydipsia
Investigations of DI?
High plasma osmolality, low urine osmolality (urine osmolality >700 excludes DI)
Water deprivation test: give desmopression after period of no water
If nephrogenic - no change
If crania - osmolality will fall
MRI head if cranial suspected
Management of DI?
Nephrogenic - thiazides, low Na/protein diet
Cranial - desmopressin
How to calculate the anion gap? Normal range?
(Na + K) - (Cl + HCO3)
normal range = 8-14 mmol/L
What are the causes of a raised anion gap?
CO, CN
Alcoholic ketoacidosis and starvation ketoacidosis
Toluene
Metformin, Methanol
Uremia
DKA
Phenformin, paraladehyde
Iron, Isoniazid
Lactic acidosis
Ethylene glycol (antifreeze)
Salicylates
What is Alport’s syndrome?
a genetic condition that causes abnormalities in T4 collagen -> characterized by kidney disease, hearing loss, and eye abnormalities
What is the inheritance pattern of Alport’s?
X-linked dominant
In which gender is Alport’s worse?
Males
What is the genetic abnormality on Alport’s syndrome?
D/t defect in gene coding for T4 collagen = abnormal glomerular BM
THINK Alport, in?
- Renal failure
- Bilateral sensorineural hearing loss
- Ocular abnormalities
- microscopic haematuria almost universal
- lenticonus: protrusion of the lens surface into the anterior chamber
- retinitis pigmentosa
Usually presents in childhood
Investigations in Alport’s syndrome?
Molecular genetic testing
Renal biopsy, electron microscopy - longitudinal splitting of the lamina densa of the glomerular BM -> ‘basket-weave’ appearance
In DI, what are the two genetic causes that result in a nephrogenic picture?
the more common form affects the vasopression (ADH) receptor
Less common form results from a mutation in the gene that encodes the aquaporin 2 channel
How much Na, K, water and glucose do you need/day?
Sodium - 1mmol/kg
Potassium - 1mmol/kg
Water - 30ml/Kg
Glucose - 50-100g
Which immunoglobulins are responsible for hyperacute graft rejection?
IgG (d/t pre-existing Abs against HLA/ABO)
Example of a T2 hypersensitivity reaction
when HLA matching for a renal transplant, what is the relative importance of the HLA antigens?
DR > B > A
Name of few post-op problems after kidney transplant?
ATN of graft
vascular thrombosis
urine leakage
UTI
What occurs in/causes acute graft rejection (<6 months)?
usually due to mismatched HLA. Cell-mediated (cytotoxic T cells)
usually asymptomatic and is picked up by a rising creatinine, pyuria and proteinuria
other causes include CMV infection (Tx ganciclovir)
may be reversible with steroids and immunosuppressants
What occurs in/causes chronic graft rejection (>6 months)?
both antibody and cell-mediated mechanisms cause fibrosis to the transplanted kidney (chronic allograft nephropathy)
Or recurrence of original renal disease (MCGN > IgA > FSGS)
What are the 3 most common sites for stones to obstruct in the urinary system?
Pelvi-uteric junction
Pelvic brim
Vesico-ureteric junction
What is the firstline scan in suspected renal calculi for all patients?
CT KUB
Below which size of renal stones is an expectant approach usually adopted?
<5mm
How would you manage a pregnant women with a renal stone >5mm?
Ureteroscopy (uses laser to break up the stone) - in most cases a stent is left in situ for 4/52 after the procedure
How would you manage a healthy patient with a renal stone >5mm?
Shockwave lithotripsy
In who would you perform percutaneous nephrolithotomy?
Patients with complex renal calculi and staghorn calculi
How to treat calcium stones?
High fluid intake **Low protein**, low salt thiazides diuretics (increase distal tubular calcium excretion) Interestingly, changing Ca dietary intake is not effective
How to treat oxalate stones?
cholestyramine/pyridoxine (vit B6)
-> both reduce urinary oxalate secretion
How to treat uric acid stones?
Allopurinol/oral bicarbonate
Lifestyle management of BPH?
Avoid caffeine/alcohol/relax when voiding/void twice in a row to aid emptying/train bladder by holding on to increase the time between voiding
Medication to manage of BPH?
Alpha-blockers are 1st line (decrease SM tone)
5alpha-reductase inhibitors (finasteride) can be added
Surgical management of BPH?
- TURP – risk to sexual function, 20% need redoing within 10 years
o Comp: TURP syndrome - Transurethral incision of the prostate (TUIP) – less destruction than TURP, relieves pressure on the urethra
- Retropubic prostatectomy – open operation if prostate very large
- Transurethral laser-induced prostatectomy (TULIP) – may be as good as TURP
What is TURP syndrome?
It occurs as a consequence of the absorption of the fluids used to irrigate the bladder during the operation into the prostatic venous sinuses.
What is TURP syndrome?
It occurs as a consequence of the absorption of the fluids used to irrigate the bladder during the operation into the prostatic venous sinuses.
Most common ethnicities effected by BPH?
black > white > Asian
What is the mechanism of action of alpha-1 antagonists?
decrease smooth muscle tone (prostate and bladder)
What are the side effects of alpha-1 antagonist?
dizziness, postural hypotension, dry mouth, depression
What is the mechanism of action of 5 alpha-reductase inhibitors?
block the conversion of testosterone to dihydrotestosterone (DHT), which is known to induce BPH - causes a reduction in prostate volume and hence may slow disease progression
What are the side effects of 5 alpha-reductase inhibitors?
erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia
What is contrast induced nephrotoxicity?
25% increase in creatinine occurring within 3 days of the intravascular administration of contrast media
RFs for contrast induced nephrotoxicity?
known renal impairment (especially diabetic nephropathy)
age > 70 years
dehydration
cardiac failure
the use of nephrotoxic drugs such as NSAIDs
How to prevent contrast induced nephrotoxicity?
IV 0.9% sodium chloride at a rate of 1 mL/kg/hour for 12 hours pre- and post- procedure
Which medication should be held prior to giving contrast and why?
metformin - withhold for a minimum of 48 hours/until the renal function has been shown to be normal. This is due to the risk of lactic acidosis.
Pre-renal causes of AKI?
Pre-renal (40-70%) – due to renal hypoperfusion (FIRST)
- Failure – heart/liver
- Infection/sepsis or Iatrogenic (drugs)
- Red cell haemorrhage
- Stenosis (RAS) or Sick (GI losses)
- Thrombosis
In AKI, what does the presence of protein indicate?
Presence of protein in urine effectively rules out a pre- or post-renal cause
What are the renal causes of AKI?
- Tubular (acute tubular necrosis, radiological contract, myoglobinuria in rhabdomyolysis)
- Glomerular (autoimmune such as SLE, HSP, drugs, infection)
- Interstitial (acute interstitial nephritis caused by drugs – NSAIDs/abx, infiltration with tumour/infection)
- Vascular (vasculitis, malignant BP)
What are the post-renal causes of AKI?
Luminal (clots, stones, sloughed papillae)
Mural (tumour, strictures)
Extrinsic compression (tumour, retroperitoneal fibrosis)
What will you see on microscopy in acute tubular necrosis?
Muddy brown urine casts
What is cystinuria?
Cystinuria is an AR disorder characterised by the formation of recurrent renal stones.
Due to a defect in the membrane transport of cystine, ornithine, lysine, arginine (COLA)
What tests can identify cystinuria?
cyanide-nitroprusside test - turns reddish if presence of excess amino acids
Management of cystinuria?
hydration
D-penicillamine
urinary alkalinisation
Management of cystinuria?
hydration
D-penicillamine
urinary alkalinisation
What is cystinosis?
an AR condition causing defective cystine storage and therefore cystine builds up in the cell -> fanconi syndrome -> ESRD
Causes of renal papillary necrosis?
POSTCARDS: pyelonephritis, obstruction of the urogenital tract, sickle cell disease, tuberculosis, cirrhosis of the liver, analgesia/alcohol abuse, renal vein thrombosis, diabetes mellitus, and systemic vasculitis
What are the symptoms of renal papillary necrosis?
fever, loin pain, haematuria
IVU - papillary necrosis with renal scarring - ‘cup & spill’
What is the preferred method of access for haemodialysis?
AV fistula
How long does it take for an AV fistula to develop?
6-8 weeks
What are stag-horn calculi made of?
Struvite
What are the features of prostatitis?
UTIs, retention, pain, haematospermia, swollen prostate on DRE
What is the management of acute prostatitis?
Analgesia
Levofloxacin for 28 days
Management of chronic prostatitis?
Non-bacterial has no response to abx, Anti-inflammatories, alpha-blockers and prostatic massage have a place
What is the most common cell type in prostate cancer?
Adenocarcinoma
Treatment options for prostate cancer?
Radical prostatectomy
Radical radiotherapy
Hormone (androgen) therapy
Active surveillance
What are the types of hormone therapy for prostate cancer?
GnRH agonists (Goserelin) or antagonists – first stimulate, then inhibit pituitary gonadotrophs -\> Risk: tumour ‘flare’ initially
Usually take for 3yrs, once stopped PSA will rise slightly but usually settle around 1 or 2
Which drug might you prescribe alongside GnRH agonists in the treatment of prostate cancer?
Bicalutamide
What are the initial and maintenance immunosuppressive regimes in kidney transplant?
initial: ciclosporin/tacrolimus with a monoclonal antibody
maintenance: ciclosporin/tacrolimus with MMF or sirolimus
add steroids if more than one steroid responsive acute rejection episode
What should you monitor for in patients taking immunosuppressive therapy for renal transplant?
CVS disease
Renal failure - drugs have nephrotoxic effects
Malignancy - immunosuppression can make more at risk, e.g. skin cancers
What are the complications of nephrotic syndrome?
HIT
Hyperlipidaemia (increased risk of CVS disease/strokes), infection, thromboembolism
What causes the increased chance of thrombosis in nephrotic syndrome?
Loss of antithrombin-III (+ proteins C and S) and an associated rise in fibrinogen levels predispose to thrombosis
Marker of good prognosis in IgA nephropathy?
Frank haematuria
Which UTI bacteria predisposes to which type of stone formation?
Proteus mirabilis infection predisposes to struvite kidney stones
What causes acute interstitial nephritis?
Accounts for 25% of drug induced AKI
- penicillin, rifampicin, NSAIDs, allopurinol, furosemide
Also systemic disease (SLE) and infections
Symptoms of acute interstitial nephritis?
Causes an ‘allergy’-type reaction
Features: fever, rash, arthralgia
Mild renal impairment
Investigations for acute interstitial nephritis?
Sterile pyuria
Urine: eosinophils + white cell casts
When might you give someone erythropoietin?
Tx of anaemia associated with CKD + associated with cytotoxic therapy
SEs of erythropoietin?
Accelerated HTN potentially leading to encephalopathy + seizures
Bone aches
Flu-like symptoms
Urticaria
Pure red cell aplasia (d/t Abs against erythropoietin)
Secondary iron deficiency (iron needed for RBC, may not be enough if more are created quickly)
Indications for plasma exchange?
Guillain-Barre syndrome
myasthenia gravis
Goodpasture’s syndrome
ANCA positive vasculitis
TTP/HUS
cryoglobulinaemia
hyperviscosity syndrome e.g. secondary to myeloma
How long might it take for Finasteride to take effect?
Finasteride treatment of BPH may take 6 months before results are seen
What is AL amyloidosis and what can it cause?
Most common type
Associated with a clumping of abnormal light chain fragments
Due to myeloma, Waldenstrom’s, MGUS
features include: nephrotic syndrome, cardiac and neurological involvement, macroglossia, periorbital eccymoses
What is AA amyloidosis and what does it usually occur with it?
associated with the deposition of amyloid AA fibrils
Usually occurs with chronic infection/inflammatory disease e.g. TB, RA, osteomyelitis or Crohn’s
Also occurs in Hodgkin’s/non-Hodgkin’s lymphoma
renal involvement most common feature
Investigations in amyloidosis?
Tissue biopsy - amyloid fibrils stain with Congo red and show apple-green birefringence in polarised light
What percentage of children who present with UTIs suffer from VUR?
30%
What is the best investigation for VUR?
micturating cystourethrogram
Grading of VUR?
I - Reflux into the ureter only, no dilatation
II - Reflux into the renal pelvis on micturition, no dilatation
III - Mild/moderate dilatation of the ureter, renal pelvis and calyces
IV - Dilation of the renal pelvis and calyces with moderate ureteral tortuosity
V - Gross dilatation of the ureter, pelvis and calyces with ureteral tortuosity
What is the triad of symptoms in HUS?
AKI
Microangiopathic haemolytic anaemia
Thrombocytopaenia
What is the most common cause of HUS?
Classically Shiga toxin-producing E. coli (STEC) 0157:H7 – accounts for >90%
How do you manage HUS?
Supportive - fluids, blood transfusion/dialysis if required
No role for antibiotics
Eculizumab/plasma exchange may have a role
What percentage change in creatinine and eGFR would be acceptable when starting an ACEi?
NICE suggest that a decrease in eGFR of up to 25% or a rise in creatinine of up to 30% is acceptable, although any rise should prompt careful monitoring and exclusion of other causes
If commencing an ACEi causes a more than acceptable rise in creatinine, what would you worry about?
Something causing hypoperfusion to the kidneys e.g. RAS
What is the most common cancer found in the kidney?
Renal cell carcinoma (90%)
What are the RFs for RCC?
Smoking
Tuberous Sclerosis
von Hippel-Lindau syndrome
What percentage of people with RCC have mets at diagnosis?
25%
What is a common site for metatastes from RCC?
Cannon ball mets in chest
How do you measure prognosis in RCC?
Predicted by the Mayo prognostic risk score (SSIGN) – tumour stage, size, grade and necrosis
What is the most common type of cancer in the bladder?
Transitional cell carcinoma
What are the RFs for bladder cancer?
Transitional cell:
Aromatic amines (dyes) Chronic cystitis
Smoking, rubber, cyclophosphamide
Squamous cell:
Schistosomiasis, smoking (more common RFs for squamous cell carcinomas)
Early management of TCC (80% of patients) and 5yr survival?
Diathermy or TURBT
Need regular cystoscopies
5yr survival = 95%
Management options for TCC if some delay in diagnosis?
Radical cystectomy - gold standard
Radiotherapy/chemo - may be palliative
Very late - chronic cauterisation and urinary diversions
What is a Wilms tumour?
Nephroblastoma - childhood tumour primitive renal tubules and mesenchymal cells
Presents with abdo mass and haematuria
What is the most common organism to cause peritonitis in patient with peritoneal dialysis?
Staph epidermidis
Indications for dialysis?
- Refractory pulmonary oedema (Pulm. oedema not responding to dietary Na restriction + diuretics)
- Persistent hyperkalaemia
- Severe metabolic acidosis
- Uraemic symptoms e.g. pericarditis/encephalopathy
- Drugs – BLAST (barbituates, lithium, alcohol, salicylates, theophylline)
When should you refer a renal patient to a nephrologist?
Renal tranplant
ITU patient with unknown cause of AKI
Vasculitis/glomerulonephritis/tubulointerstitial nephritis/myeloma
AKI with no known cause
Inadequate response to treatment
Complications of AKI
Stage 3 AKI (see guideline for details)
CKD stage 4 or 5
Qualify for renal replacement hyperkalaemia/metabolic acidosis/complications of uraemia/fluid overload (pulmonary oedema)
What condition causes haematuria without kidney disease, in a patient with a FH of haematuria?
Thin Basement Membrane Disease
T4 collagen disorder
What is the mechanism of action of Tolvaptan?
A vasopressin receptor 2 antagonist
RF for testicular cancer?
Undescended testis, infertility, FH, mumps
Commonest age for testicular tumour?
15-44yo
Types of testicular tumour?
Seminoma 55%
Non-seminomatous germ cell tumour 33% (previously called teratoma)
Mixed germ cell tumour 12%
Lymphoma
Tumour markers for testicular cancer?
seminomas: hCG elevated in around 20%
non-seminomas: AFP and/or b-hCG elevated in 80-85%
LDH elevated in around 40% of germ cell tumours
First line investigation for testicular cancer?
ultrasound
Management of testicular cancer?
Radical orchidectomy
Radiotherapy and chemotherapy also have a place
5 year survival is >90%
Seminomas have a better prognosis
What is the mechanism of action of loop diuretics?
Blocks Na/K/Cl co-transporter in the thick ascending limb of the loop
What is the mechanism of action of thiazide diuretics?
Inhibit the NaCl transporter in the distal convoluting tubule
What is the mechanism of action of potassium-sparing diuretics?
Two types – aldosterone antagonists (inhibit the sodium retaining action of aldosterone)
Epithelial sodium channel blockers in the collecting ducts
SEs of loop diuretics?
Ototoxicity, electrolyte abnormalities, dehydration, met alkalosis, gout
SEs of potassium-sparing diuretics?
met acidosis, anti-androgenic effects (e.g. gynaecomastia, impotence)
What type of vasculitis is HSP?
an IgA mediated small vessel vasculitis
What non-renal factors might affect your eGFR?
pregnancy
muscle mass (e.g. amputees, body-builders)
eating red meat 12 hours prior to the sample being taken
Biopsy findings in Goodpasture’s?
linear IgG deposits along the basement membrane
ECG changes in hyperkalaemia?
peaked or ‘tall-tented’ T waves (occurs first)
loss of P waves
broad QRS complexes
What is the difference between Alport’s and Goodpasture’s syndrome?
Mutations in genes corresponding to the building blocks of type IV collagen cause Alport’s syndrome, whereas autoantibodies against structures that are usually within collagen IV cause Goodpasture’s syndrome
Biopsy findings in Goodpastures?
linear IgG deposits along the basement membrane
Which type of paraneoplastic syndrome can occur in RCC?
paraneoplastic hepatic dysfunction syndrome. Also known as Stauffer syndrome. Typically presents as cholestasis/hepatosplenomegaly. It is thought to be secondary to increased levels of IL-6
What is fibromuscular dysplasia?
a disease that causes one or more arteries in the body to have abnormal cell development in the artery wall. As a result, areas of stenosis, aneurysms, or dissection may occur
What are the two most common causes of renal vascular disease?
1) Renal artery stenosis (90%)
2) Fibromuscular dysplasia (10%)
What are the symptoms of fibromuscular dysplasia?
HTN
CKD or more AKI e.g. secondary to ACE-inhibitor initiation
‘flash’ pulmonary oedema
What would you see on USS in renal vascular disease?
Asymmetric kidneys with the affected side being smaller. Doppler USS would also show disturbance in renal blood flow.
MR angiography - string of bead appearance
What is cryoglobulinaemia?
Cryoglobulinemia is characterized by the presence of cryoglobulins in the blood. Cryoglobulins are abnormal proteins that thicken and clump together at cold temperatures.
When these proteins clump together, they can restrict blood flow to joints, muscles, and organs.
Drugs causing calcium stones?
SALT
S - steroids
A - Acetazolamide
L - Loop diuretics
T - Theophylline
Endocrine effects of RCC?
may secrete erythropoietin (polycythaemia), parathyroid hormone (hypercalcaemia), renin, ACTH
What would happen to Na in pre-renal AKI as opposed to renal AKI?
In pre-renal, kidneys try to hold on to Na to increase the water retention, therefore there will be low URINE Na
What is Fanconi’s syndrome?
Inadequate reabsorption in the proximal convoluting tubules - multiple causes, results in electrolyte abnormalities
At which stage of CKD do you become symptomatic?
stage 4 (GFR 15-30)
Definition of CKD?
impaired renal function for >3 months based on abnormal structure or function, or GFR<60mL/min/1.73m2 with/without evidence of kidney damage
Which antihypertensives should be used in CKD?
ACEi, then furosemide
How should you protect against bone disease in CKD?
i. Restrict high phosphate foods (milk/cheese/egg) + give phosphate binders (calcium carbonate) to decreased gut absorption
ii. Vitamin D analogies (alfacalcidol) and Ca supplements decrease the resorption of calcium from the bone
How to manage the following symptoms in CKD - anaemia, acidosis, oedema, restless legs/cramps?
a. Anaemia – usually d/t reduced erythropoietin levels, check haematocrit and replace iron/B12/folate if necessary -> If still anaemic consider recombinant human erythropoietin
b. Acidosis – Consider sodium bicarbonate supplements for patients with low serum bicarbonate (also may slow progression of CKD)
c. Oedema – high doses of loop diuretics may be needed and restriction on fluid and sodium intake
d. Restless legs/cramps – check ferritin, clonazepam or gabapentin may help. Quinine sulfate can help with cramps
When should you refer to a nephrologist in CKD?
Refer to a nephrologist if the eGFR falls below 30 or drops by >5 in a year
How does CKD cause an increase in phosphate, decrease in calcium and drop in vitamins D?
Kidney’s produce vitD -> in CKD vit D levels fall
Kidney’s normally excrete phosphate -> in CKD phosphate levels rise
The low vit D causes low calcium (as vit D is needed to allow Ca absorption)
This causes Ca to be ‘dragged’ out of bone, which causes Osteomalacia and secondary hyperparathyroidism
What is the most common cause of death in patients requiring dialysis and why?
Ischaemic heart disease
Various factors:
- DM + HTN = leading causes for CKD and also contribute to IHD
- chronic volume overload + anaemia = L vent hypertrophy
- myocardial stunning while undergoing dialysis treatment
- multiple other contributing factors
Complications of haemodialysis?
Infection/stenosis at the site
Endocarditis
Hypotension
Cardiac arrhythmias
Disequilibrium syndrome – caused by cerebral oedema
What causes AR PKD?
Due to defect on Chr 6 which encodes for fibrocystin (impt for normal tubular development)
When do you normally diagnosis AR PKD and what additional features do you find?
Diagnosis can be made on prenatal USS/in early infancy with abdo mass/renal failure
ESRF develops in childhood
Patients also typically have liver involvement
What are the causes of sterile pyuria?
- Treated UTI < 2 weeks before
- Inadequately Tx UTI
- Appendicitis, prostatitis, bladder tumour etc
In which group of patients would you treat asymptomatic pyuria?
Pregnant women - at risk of PYELONEPHRITIS, preterm labour, anaemia
Advice to prevent UTIs?
Regular voiding/double voiding
Increased fluids
Pre + post-sexual intercourse voiding
Reduced spermatocides (diaphragm/condoms)
Increased vaginal oestrogens
Antibiotic prophylaxis (continuously or post-coital)
Cranberry juice
What are the possible causes of testicular lumps that are:
Separate and cystic?
Separate and solid?
Testicular and cystic?
Testicular and solid?
Can’t get above it?
Cannot get above it: Inguinoscrotal hernia or hydrocele extending proximally
Separate and cystic: epididymal cyst
Separate and solid: Epididymitis/varicocele
Testicular and cystic: hydrocele
Testicular and solid: tumour, haematocele, granuloma etc
Causes of epididymo-orchitis?
chlamydia, E. coli, mumps, N. gonorrhoea, TB
Symptoms of epididymo-orchitis?
Sudden-onset tender swelling, dysuria, sweats/fever
Treatment of epididymo-orchitis?
warn of possible infertility and symptoms worsening before improving
If <35 (more likely d/t STI) = azithromycin/doxycycline, if gonorrhoea suspected add ceftriaxone
If >35 (more likely d/t UTI) = ciprofloxacin
Also: analgesia, scrotal support, drainage of abscess
What is varicocele?
Dilated veins of pampiniform plexus
What are the symptoms and clinical findings of a varicocele?
Left side more commonly affected
Often visible as distended scrotal blood vessels, feels like ‘a bag of worms’
Patients may complain of dull ache
How do you treat a varicocele?
Associated with sub-fertility, repair via surgery/embolization
RF/causes of ED?
Multiple
Common = smoking, alcohol and diabetes
Common in >50s
What is Buerger’s disease, who is it common in, what do you find on investigation and how is it treated?
- Thrombotic occlusions in the lower limbs (affects large + medium sized vessels)
- © young male smokers
- Proximal pulses present, pedal pulses lost
- Angiography – tortuous corkscrew collateral vessels
- Tx – smoking cessation
What post-void volumes are acceptable and at what age?
Post-void volumes of <50 ml are considered physiological in patients aged < 65 years old.
Post-void volumes of < 100ml are considered physiological in patients aged > 65 years old.
