Nephrology Flashcards
What do muscles release when they are dying
Myoglobin
Potassium
Creatine Kinase
Elderly man with frequent falls presents with complaints of tea coloured urine and AKI
CK found to be very high
Dx?
Rhambdomyolysis
Features of rhabdomyolysis
Hematuria- reddish brown or tea coloured urine
=false positive no RBC on dipstick, red because of myoglobin
Hypotension
AKI
Very high CK
Uncommon side effect of statins
Rhabdomyolysis
How does myoglobin cause an AKI
How do you manage it ?
It is nephrotoxic
Rehydration with IV fluid - essential!
ECG of patient with rhambdomyolysis shows tall tent t waves and wide qrs
Next step of management ?
Hyperkalemia
IV calcium gluconate or calcium chloride
Protect the heart!
Initial investigation + management of rhabdomyolysis
To confirm dx?
ECG
IV fluids
Dx - CPK level - it indicates muscle necrosis
Hematuria + hemoptysis + impaired RFTs
Initial investigation?
Most accurate investigation?
Goodpasture syndrome
Initial - Anti- glomerular basement membrane antibodies
Most accurate - lung or kidney biopsy = crescenteric glomerulonephritis
What is Goodpasture syndrome?
Acute rapidly progressive glomerulonephritis +
Pulmonary alveolar hemorrhage
CXR of Goodpasture will show
Patchy interstitial infiltration ( intrapulmonary bleeding)
Hemoptysis + hematuria
+ cannot hear (SNHL)
Diagnosis?
Alport syndrome
X linked
Jaundice + hemoptysis
Diagnosis?
Jaundice - due to the liver being affected
Alpha-antitrypsin deficiency
Antibody in eosinophilia Granulomatosis with polyangiitis
Churg Strauss
P - ANCA
Features of Granulomatosis with polyangiitis
Antibody present?
Wegener Granulomatosis
URT problems - sinusitis/ nasal septum perforation/ epistaxis
+ hematuria
C-ANCA
Hematuria + diarrhoea
With AKI
Diagnosis?
HUS
Pale skin + itching, worse after hot bath + peripheral oedema and increased skin pigmentation
Dx?
Chronic renal failure
Itching - due to uraemia seen in late stage renal failure
Pallor due to anemia (decreased erythropoietin)
Features of liver failure
Ascites
Jaundice
Bleeding
Red skin*/flushed + itching, worse after hot bath + gout + high hb + burning sensation in fingers and toes
Dx?
Polycythemia rubra Vera
Polycythemia rubra Vera vs chronic renal failure
PRV - flushed skin vs pallor in CRF, high hb vs anemia in CRF
Itching worse after hot bath + linear tracks/burrows
Dx?
Scabies
IV fluid allowed in sepsis
RL or NS 0.5% NaCl
= don’t cause dilutional hyponatremia
Commonest renal cause of AKI
Acute tubular necrosis
Massive hemorrhage + hypotensive shock + high creatinine
Dx?
Acute tubular necrosis
= low perfusion to kidneys due to prolonged ischemia
Drug intake + rash fever + hematuria
Dx?
Interstitial nephritis
Where does 25-alpha hydroxylation occur?
Liver
Where does 1-alpha hydroxylation occur?
Kidney
Converts 25-hydroxy vitamin D to active form = 1,25 dihyroxyvitamin D
What causes vitamin D deficiency in renal failure?
Reduced 1-alpha hydroxylase in kidneys
Repeated UTI + hypertension
Possible dx?
Repeated UTI - renal scarring - Chronic pyelonephritis - hypertension
Loin/back pain + UTI
Dx?
Acute pyelonephritis
Repeated UTI + sudden loin/back pain + fever + rigors
Urine = nitrites , leukocyte esterase +ve
Dx?
Acute pyelonephritis
**chronic has NO active infection
Risk factors of pyelonephritis
pregnancy
stones
VUR
DM
Treatment of lower UTI
Trimethoprim , nitrofurantoin
Treatment of upper UTI
Cipro
Co amoxiclav
Investigations of pyelonephritis
Urinalysis
Urine c&s - before you start antibiotics
Adults , older children - mid stream
Young Children - clean catch / catheter/ suprapubic aspirate
When should antibiotics be started in acute pyelonephritis
Start empirical ABx immediately
Most common causing organism of UTI
E.Coli = gram negative
Management of pyelonephritis Men Women - pregnant and non pregnant Indwelling catheters Children
Admission - often Antibiotics = Men, non pregnant women and patients with indwelling Caths === cipro 500 mg bid 7 days === co-amoxiclav 625 mg tid for 14 days
Children
= 1. Co amoxiclav
=2. Cefixime
Pregnant women - cefalexin -500mg bid 10- 14 days PO (if not admitted)
Small kidneys + HTN
Possible Dx?
Bilateral artery stenosis or
Chronic pyelonephritis
What medications are contraindicated in bilateral artery stenosis?
ACEi
Normal cause of mild proteinuria
Excercise
+1
Proteinuria (mild) + healthy individual
Next step?
Repeat test
If still high protein:creatinine ratio
What is nephrotic syndrome
What is the peak incidence in children?
Proteinuria >3g/24hr
Hypoalbuminemia <30g/L
Oedema
2-5 years old
Majority of cases of nephrotic syndrome in children are due to ?
Minimal change glomerulonephritis
- microscopic hematuria seen in 10%
- good prognosis = 90% respond to steroids (high dose)
Features of minimal change disease?
Definitive dx test?
Nephrotic syndrome
Normal tension
Selective proteinuria
Dx - renal biopsy - electron microscopy shows fusion of podocytes
What causes hyperlipidemia and hypercoagulable state in nephrotic syndrome
Loss of anti thrombin III
What causes liability to infections in nephrotic syndrome
Loss of immunoglobulins
Most common cause of AKI
Metabolic imbalances seen
Pre-renal causes - dehydration “hypovolemia”
HyperK, raised serum urea and creatinine
AKI - decreased eGFR - unable to excrete the above
What can be done to reduce the risk of contrast induced nephropathy ?
Drink plenty fluids
IV NS .9% NaCl pre and post procedure esp in high risk pts
What medication needs to be stopped before any contrast study?
Metformin
=nephron - harmful
HTN + CKD
GFR > 30
ACR >30
What meds should be given?
ACEi - prils or. ARBs - sartans
They slow progression of CKD
ACEi = preferred
Situations ACEi and ARBs can be used in renal impairment
ACR = urinary albumin:creatinine
>=70
>= 30 if there is HTN
>= 3 if there is DM
Most common nephrotic syndrome in adults
Caucasian or unspecified ethnicity - membranous
African/black/Hispanic = focal segmental GN
** for plab - adult >40 = membranous
Causes &
Prognosis of membranous glomerulonephritis
Cause - mainly idiopathic
Infections rheumatoid drugs, malignancy
Prognosis-
30% remission , 30% partial remission, 30% progress to ESRD
Types of glomerulonephritis
2- nephrotic nephritic
Nephritic - rapidly progressive - Goodpasture, igA
IgA- mesangioproliferative
Goodpasture - crescenteric
Causes of minimal change disease
Idiopathic mainly
Hodgkin
NSAIDs
Causes of focal segmental glomerulosclerosis
Idiopathic / 2ry to HIV or heroin
Anemia + hypocalcemia + small kidneys (<9mm) on US
What do you suspect?
What is the reason for the hypocalcemia
CKD
HypoCa = decreased 1-alphahydroxylase
What causes a dynamic bone disease?
=Reduced bone turnover - causes msk pain and immobility
It is due to 1,25 dihydrocycholecalciferol over-replacement
There will be hypoca + inappropriately normal PTH
Hematuria + HTN + loin/flank pain
Suspect?
What is an important association
ADPKD
Intracranial aneurysm
How is the dx of ADPKD made?
Ultrasound
What is haemolytic uremic syndrome? (HUS)
Features, organism
Haemolytic anemia
Uraemia - low urea and creatinine
thrombocytopenia(acute renal failure)
*E.Coli
Diarrhoea (bloody) + renal failure + anemia
Treatment HUS
IV fluids +/- blood transfusion
Dialysis if required
ABX NEVER GIVEN
HUS triad + fever + neurological manifestations
Dx?
thrombotic thrombocytopenic purpura
IgA(bergers ) vs post strept glomerulonephritis
Organism
Treatment
IgA - 1-2 days after URTI with hematuria and usually young males
PSGN _ 1-2 weeks, proteinuria +decreased complement C3
Rena; biopsy shows humps on electron microscopy
O— group A beta- hemolytic streptococci usually strept pyogenes
Tx - supportive mainly (resolves spontaneously)
Causes of small kidneys
Chronic glomerulonephritis
Chronic pyelonephritis
Hypertensive renal disease
Bilateral renal artery stenosis
Causes of large kidneys
ADPKD
Obstructive Uropathy
Reflux nephropathy
Indications of haemodialysis (5)
Persistently high K >6.5 (refractory hyperk) Severe metabolic acidosis Fluid overload with anuria Uremic pericarditis , pulm oedema Uremic encephalopathy
Treatment of reflux nephropathy
Low dose trimethoprim daily
If fails or there is parenchymal damage - surgery
What 4 meds should be stopped if patient presents with diarrhoea/vomiting and there is risk of dehydration/AKI?
DAMN Drugs Diuretics ACEi and ARBs Metformin NSAIDs
Pt with ESRD + MSK pain + hypocalcemia + low vit D+ high PTH
Dx?
2ry hyperparathyroidism or vitamin D deficiency
