Nephrology Flashcards by Lewis Liversedge

Causes of RAISED anion gap metabolic acidosis:

'LUKA'
Lactate: Shock, hypoxia 
Ketones: DKA, alcohol 
Urate: Renal failure
Acid poisoning: salicylates, methanol

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Metabolic acidosis with NORMAL anion gap:

'BRAAD"
Bicarbonate loss (diarrhoea, fistula) 
Renal tubular acidosis
Ammonium chloride injection
Addison's disease
Drugs (acetazolamide)

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Vomiting/aspiration 
Diuretics
Hypokalaemia 
Primary hyperaldosteronism 
Cushing's syndrome 
Congenital adrenal hyperplasia

Cause which biochemical imbalance?:

Metabolic alkalosis

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Acute interstitial nephritis:

Drug causes:

ANTIBIOTICS -> Penicillin, rifampicin, NSAIDs, Allopurinol, furosemide

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Acute intersitital nephritis presentation

AKI w/ fever, rash, arthralgia with eosinophilia and mild renal impairment:

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Feature of CKD less likely to be seen in AKI?

Hypocalcaemia

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Bilateral small kidneys:

CKD

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Oligruria output:

Less than 0.5 ml/kg/hour

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AKI criteria:

Rise in SERUM CREATININE of 26mmol/l within 48 hours

50% or greater rise in serum creatinine in the last 7 days

Fall in urine output to <0.5 ml/kg/hour in 6 hours

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What test should all pts. with suspected AKI have:

Urinalysis

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Drugs to stop in AKI:

the DAAMN drugs

Diuretics
ACEis/ARBS
Aminoglycosides
Metformin (Maybe) - doesn’t contribute to toxicity itself but may worsen AKI
NSAIDS (except asprin at cardioprotective dose)

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Hyperkalaemia tx:

Calcium cluconate (stabilise cardiac membrane)
Insuline/dextrose infusion
Nebulised salbutamol
Calcium resonium, loop diuretics, dialysis (to remove)

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Indications for dialaysis in AKI/hyperkalaemia

Tx. not working resulting in

Pulmonary oedema, acidosis, uraemia or refractory hyperkalaemia

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What do the kidneys attempt to do to preserve volume in PRE-renal AKI -

Keep sodium

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KDIGO criteria for staging AKI

Stage 1: 1.5-2 times baseline increase in CREATININE
Urine output reduced to <0.5mL/kg/hour > 6 hours

Stage 2: 2 to 3 times CREATININE
Urine output reduced to <0.5mL/kg/hour > 12 hours

Stage 3: Greater than 3 times CREATININE or to 353.6 umol/L
Urine output reduced to <0.3mL/kg/hour > 24 hours

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Mx. ADPKD

Select patients: Tolvaptan (vasopressin receptor 2 antagonist)

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Hypertension with recurrent UTIs, haematuria

ADPKD

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Cardiovascular features of ADPKD

Mitral valve prolapse
Mitral/tricuspid incompetence
Aortic root dilation

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Alport’s inheritance:

Type of collagen affected:

X-linked dominant

Type IV

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Bilateral sensorineural deafness plus microscopic haematuria and renal failure:

Alport’s disease

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Diagnostic test for Alport’s

Renal biopsy and genetic testing

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Congo red staining: apple-green birefringence

Amyloidosis

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Anti-GBM disease mx:

Plasma exchange (plasmapharesis)
Steroids
cyclophosphamide

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CKD anaemia classification

Usually a normocytic normochromic anaemia

due to reduced EPO levels

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CKD: calcium and phosphate levels:

Low calcium high phosphate

CKD stages

1) GFR >90 w/ other abnormal kidney tests 2) GFR 60-90 w/ other abnormal kidney tests 3a) 45-60 3b) 30-45 4) 15-29 - severe functional impairment 5) <15

First line antihypertensive in pts. w/ CKD What effect on eGFR/Cr is acceptable

ACEIs eGFR reduction of 25% or rise in Cr of 30% deemed acceptable

First line antihypertensive in pts. w/ CKD What effect on eGFR/Cr is acceptable

ACEIs eGFR reduction of 25% or rise in Cr of 30% deemed acceptable

CKD: Mineral bone disease management

Aim is to to reduce phosphate and parathyroid hormones 1st line: REDUCE intake of dietary phosphate. Phosphate binders Vit D: alfacalcidol May require parathyroidectomy

ACR of 30 mg/mmol is equivalent to: PCR -> Urinary protein excretion

50 | 0.5 g/day

ACR indicating clinically significant proteinuria?

3 mg/mmol

ACR indicating clinically significant proteinuria?

>3 mg/mmol

Which psych drug can desensitize the kidneys ability to response to ADH resulting nephrogenic diabetes insipidus:

LITHIUM

Management of nephrogenic diabetes insipidus:

Thiazides with low salt/protein diet

Mx. Central (cranial) DI

Desmopressin

What screening should diabetics receive for nephropathy

ACR - early mornign specimen

What screening should diabetics receive for nephropathy

ACR - early morning specimen

Side effects of EPO

Accelerated hypertension bone aches Flu-like symptoms Pure red cell aplasia

Which condition may initiation of ACEis actually result in a worsening renal function?

Fibromuscular dysplasia - due to renal artery stenosis

Maintenance fluids:

25-30 ml/kg/day WATER 1 mmol/kg/day potassium, sodium and chloride 50-100g/day of glucose

Hartmann's should not be used in patients with which electrolyte disturbance:

Hyperkalaemia

Nephrotic syndrome caused by: | HIV, Heroin, Alport's, sickle-cell and can follow on from other renal pathologies

Focal segmental glomerulosclerosis

Mx. FSGS

Steroids +/- immunosuppression

Haematuria: what two other investigations should be done as standard:

Albumin:creatinine ratio (ACR) and blood pressure

Haematuria: for urgent referral:

> 45 yrs w/ VISIBLE haematuria w/out UTI or haematuria that persists after UTI resolution >60 years w/ non-visible haematuria and either dysuria or raised WCC

HSP rash: | Mx.

Extensor surfaces of arms and legs and over the buttocks Supportive for arthralgia supportive for nephropathy

Hypokalamia features: | ECG features:

Muscle weakness, hypotonia. Hypokalaemia -> digoxin toxicity ECG - U waves, small or absent T waves, prolonged PR, ST depression

Differentiating between IgA Nephropathy and Post-strep nephropathy:

1) PSGN = LOW complement 2) PSGN = mostly PROTEINURIA, IgA = Commonest cause of HAEMATURIA 3) longer interval between URTI and nephro symptoms in PSGN (7-14 days)

IgA nephropathy tx. :

if isolated haematuria - supportive If persistent proteinuria -> ACEi If active disease and failure of ACEi -> STEROIDS

Minimal change disease on renal biopsy electron microscopy:

Fusion of podocytes and effacement of foot processes

Nephrotic syndrome triad:

Proteinuria (3g/24hr) Hypoalbuminaemia (<30g/L) Oedema

Nephritic syndromes:

Rapidly progressive GN Alport's IgA nephropathy

Nephrotic syndromes:

``` Minimal change disease Membranous GN FSGS Amyloidosis Diabetic nephropathy ```

Nephrotoxicity due to contrast media tx.:

0.9% Nacl 1ml/kg/hour for 12 hours PRE and POST procedure Metformin should be withheld if high risk. (Lactic acidosis)

Peritoneal dialysis peritonitis m/c organism:

Staph EPIDERMIDIS

Post-streptococcal GN renal biopsy features:

Subepithelial 'humps' caused by lumpy immune complexes | immunofluorescence shows : Granular/starry sky appearance

Rapidly progressive GN what appears in glomeruli?

Epithelial CRESCENTS

Causes of RPGN

Goodpasture's syndrome Wegener's SLE, MPA

Most common cause of renal artery stenosis

Atherosclerosis (90%)

Features RAS -

Flash pulmonary oedema CKD Hypertension.

Renal papillary necrosis can result from:

severe acute pyelonephritis diabetic nephropathy obstructive nephropathy

``` Renal transplant: Hyperacute rejection Time: Type of hypersensitivity: Due to: Salvageable: ```

Minutes to hours Type 2 Pre-existing antibodies against ABO or HLA No, must be removed

Renal transplant: Acute graft failure Time: Findings: Due to: Salvageable?:

<6 months asymptomatic picked up by rising Cr, pyuria and proteinuria Mismatched HLA May be reversible with steroids and immunosuppressants

Renal transplant: Chronic graft failure Time: Due to:

>6 months both antibody and cell-mediated mechanisms cause fibrosis

Renal transplant: immunosuppression - systemic monitoring:

CV disease - Tacrolimus and ciclosporin can cause hypertension and hyperglycaemia Renal failure - due to nephrotoxic effects of tacrolimus Malignancy - squamous cell carcinomas and BCC

Rhabdomyolysis mx.

IV fluids to maintain good urine output | Urinary alkalinization

What is sterile pyuria:

Increased WCC in urine without organism

Causes of sterile pyuria:

Partially treated UTI Urethritis - chlamydia Renal TB, stones, cancer

Urine - hyaline casts -

Seen in normal urine, after exercise, during fever or with loop diuretics

ATN urine

Brown casts

Red cell casts in urine:

Nephritic syndrome

What is seen in urine in prerenal uraemia

Bland urinary sediment

Membranous nephropathy treatment:

ACEi Steroids Consider anticoagulation, statin

Renal stones on X-ray which are radiolucent:

Urate and Xanthine stones

Renal stones on X-ray which are semi-opaque

Cysteine stones