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Pocket MSRA - Book 1 > Nephrology > Flashcards

Nephrology Flashcards

1
Q

What is an AKI?

A

Potentially reversible acute decline in kidney function, measured by creatinine and urine output

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2
Q

What are the KDIGO criteria for stage 1 AKI?

A

Cr increase >26 w/i 48hrs OR Cr increase >1.5-2x baseline
Urine output <0.5ml/kg/hr for 6 consecutive hours

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3
Q

What are the KDIGO criteria for stage 2 AKI?

A

Cr increase >2-3x baseline
Urine output <0.5ml/kg/hr for 12 consecutive hours

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4
Q

What are the KDIGO criteria for stage 3 AKI?

A

Cr increase >3x baseline OR Cr increase >354 OR requiring RTT
Urine output <0.3ml/kg/hr for 24hrs OR anuric >12hrs

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5
Q

How does AKI present?

A

Uraemia
Acidosis
Hyperkalaemia
Fluid overload
Anuric

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6
Q

What risk factors are there for AKI?

A

Old patients
Volume depletion
Cardiac failure
Nephrotoxic medications
Iodine contrast
Systemic illness

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7
Q

What are the three types of AKI?

A

Pre-renal (66%)
Renal (20%)
Post-renal

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8
Q

How can the causes of a pre-renal AKI be classified?

A

Volume depletion
Systemic vasodilation
Intrarenal vasoconstriction
Fluid redistribution

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9
Q

What is the main sequelae of un-treated pre-renal AKI?

A

Acute tubular necrosis

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10
Q

How can the causes of a renal AKI be classified?

A

Glomerular
Interstitial disease
Tubular disease
Vascular disease

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11
Q

What are the glomerular causes of a renal AKI?

A

GPA/SLE
Anti-GBM
Post-strep

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12
Q

What are the tubular causes of a renal AKI?

A

Nephrotoxics - NSAIDs, PPIs, cephalosporins, penicillins
EBV/CMV/HIV
Sarcoid
Allergic

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13
Q

What are the vascular causes of a renal AKI?

A

RV thrombosis
Scleroderma
Atheroembolic disease
Shock
HUS
TTP
Vasculitis

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14
Q

How can the causes of a post-renal AKI be classified?

A

Intrarenal
Bilateral tract
Urethral obstruction
Others - TB, post-op, neuropathy

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15
Q

What are the intrarenal causes of a post-renal AKI?

A

Light chain precipitation
Urate sludge
Tumour lysis

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16
Q

What are the bilateral tract causes of a post-renal AKI?

A

Stones
Retroperitoneal fibrosis
Papillary necrosis

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17
Q

What are the urethral obstruction causes of a post-renal AKI?

A

Post valve
Retroperitoneal fibrosis
BPH
Prostate ca
Urethral strictures

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18
Q

How should AKI be investigated?

A

Pre-renal - BP, volume status
Renal - urine dip
Post-renal - USS + bladder scan

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19
Q

What are the options for imaging the kidneys?

A

USS - 1st choice
CTKUB - no contrast, pick up stones
CTU - contrast, not-effective if eGFR low

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20
Q

How can a pre-renal AKI be distinguished from ATN?

A

Pre-renal - lower urinary Na and Urea, higher urine osmolality
ATN - higher urinary Na, urinary/plasma osmolality equal, urinary casts

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21
Q

How should an AKI be managed?

A

A-E
Stop DAMN (diuretics, ACEi/ARB, metformin, NSAIDs)
Treat reversible cause
Monitor UO (catheter)
Dialysis

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22
Q

When should dialysis be considered in AKI?

A

AEIOU
Acidosis (pH <7.2)
Electrolytes (refractory K+ >6.5)
Intoxication (poisoning e.g. Aspirin)
Oedema (pulmonary)
Uraemia (encephalopathy, pericarditis)

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23
Q

What is nephrotic syndrome?

A

Heavy proteinuria causing hypoalbuminaemia and oedema

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24
Q

How does nephrotic syndrome present?

A

Polyuria
Polydipsia
Frothy urine
Oliguria/anuria
SOB/fatigue (pulmonary oedema)

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25
What are the potential complications of nephrotic syndrome?
Infection Hypercoagulability (VTE) Hypocalcaemia
26
What is the management of nephrotic syndrome?
Na/fluid restrict Diuretics LMWH Trial steroids - if no response --> biopsy
27
What are the histopathological classifications of 1o nephrotic syndrome?
Minimal change Membranous nephropathy Focal segmental glomerulosclerosis (FSGS)
28
What are the risk factors for minimal change nephrotic syndrome?
Hodgkin's lymphoma NSAIDs Common in children Prev. episodes (2/3 recur)
29
What is the treatment for minimal change nephrotic syndrome?
Steroids (80% respond) --> cyclophosphamide if resistant
30
What is the outcome for minimal change nephrotic syndrome?
1/3 1x episode 1/3 infrequent recurrence 1/3 frequent recurrence
31
What is the treatment for membranous nephrotic syndrome?
Combination steroid + cyclophosphamide
32
What are the 2o causes of nephrotic syndrome?
Infection (bacterial, parasitic) Immune/inflammatory (SLE, RA) Metabolic (DM) Malignant Drugs (NSAIDs, penicillamine, heroin etc.) Toxins Pregnany Transplant rejection
33
What is the treatment for FSGS?
Combination steroid + cyclophosphamide Often causes ESRF
34
What are the 5 stages of diabetic nephropathy?
1 - Hyperfiltration (increase eGFR) 2 - Silent stage (early histological change) 3 - Incipient nephropathy/microalbuminuria (30-300mg/24hr) 4 - Overt nephropathy/persistent proteinuria. eGFR decline/HTN 5 - ESRF
35
What are the presenting features of nephritic syndrome?
Haematuria Reduced eGFR Oliguria Uraeia Fluid retention HTN --> headache, LVH
36
What are the causes of nephritic syndrome?
Post infection w/ Group A Strep (proliferative) Infections (bacterial, viral, parasitic) Immune/inflammatory (RA, SLE)
37
What is IgA Nephropathy?
Most common form of idiopathic glomerulonephritis leading to CKD
38
What are the risk factors for IgA Nephropahty?
Commonly occurs post URTI Coeliac disease Young patients Male
39
What is Haemolytic Uraemic Syndrome?
Most common cause of AKI in paeds Triad of -thrombocytopenia -AKI -microangiopathic haemolytic anaemia (Coomb's negative)
40
What are the risk factors for HUS?
Post e.coli infection (0157:H7) Tumours Pregnancy Ciclosporin SLE HIB
41
How should HUS be managed?
Supportive therapy only No need for a/b
42
What is tubulointerstitial nephritis?
Inflammation of renal interstitium
43
What are the causes of tubulointerstitial nephritis?
Drugs (nephrotoxics, abx - Pen, Rifampicin) Infections (staph, strep, CMV/EBV) Immune Chronic TIN fibrosis 2o reflux/DM
44
How does tubulointerstitial nephritis present?
Polyuria Nocturia Polydipsia Glycosuria Urticaria Fever Arthralgia
45
How is tubulointerstitial nephritis treated?
Stop offending drugs Fluids Prednisolone
46
What is renal tubular acidosis?
Acidaemia 2o failure of kidneys to form acidic urine
47
What are the two types of renal tubular acidosis?
Distal -most common -unable to excrete H+ Proximal -unable to resorb HCO3-
48
What are the risk factors for distal RTA?
1o Marfan's SLE Sjogren's
49
What are the risk factors for proximal RTA?
Sjogren's Myeloma Nephrotic syndrome Wilson's disease
50
How does RTA present?
Polyuria Acidotic Arrhythmias (K+) Renal calculi Muscle weakness
51
What is polycystic kidney disease?
Most common inherited cause of renal disease
52
What is the inheritance pattern of PKD?
Autosomal dominant High/complete penetrance
53
What are the two types of PKD?
Type 1 - Chromosome 16 (80%) Type 2 - Chromosome 4
54
How dose PKD present?
Typically w/ complications Loin pain Palpable kidneys Gross haematuria (following trauma) UTI Stones ESRF - 70% by 70y/o
55
What are the extrarenal manifestations of PKD?
HTN Infertility Liver cysts Mitral valve prolapse/aortic root dilation --> aortic dissection Berry aneurysm --> SAH
56
How is PKD diagnosed?
Imaging - USS/CT If <30 - FHx +ve and 2 cysts If 30-59 - 2 cysts both kidneys If >60 - 4 cysts both kidneys
57
What is the management of PKD?
Counselling/risk factor modification MRA screen for berry aneurysm STatin/Aspirin Laparoscopic cyst removal ESRF (50%)
58
What is CKD?
Abnormal kidney function/structure Diagnosis based on reduced function/evidence kidney damage
59
What are the stages of CKD?
1 - eGFR >90 (but proteinuria) 2 - eGFR 60-90 (but proteinuria) 3 - eGFR 30-59 4 - eGFR 15-29 5 - eGFR <15
60
How is CKD diagnosed?
eGFR measurements + proteinuria 2 values at 3/12
61
How is CKD managed?
Slow progression (BUPA) -blood pressure control -underlying illness control -protein intake -avoid obstruction/dehydration/infection/nephrotoxics
62
What is the first line drug for BP control in CKD?
ACE inhibitors
63
What are the contraindications for ACEi in CKD?
Fixed renal aa stenosis Pregnancy Oligohydramnios Prev. hypersensitvity/angioedema
64
What are the complications of CKD?
Anaemia Bones - fractures, deformity, 2o hyperparathyroidism CVD Drug-related side effects (reduced excretion) Emotional dysregulation (sexual dysfunction) Fluids (Pulmonary oedema --> IV Furosemide) Growth restriction HTN Immunosuppression Joint problems Killed by kidneys (death) Legs restless (Clonazepam)
65
What are the options for RRT?
Haemodialysis Peritoneal dialysis Renal transplant
66
Describe the structure of haemodialysis
3 treatments/week 3-5hrs/treatment Done at hospital/satellite site Requires AVF
67
Describe the structure of peritoneal dialysis
Ambulatory exchange/exchange episodes t/o day 8hr exchange o/n (8-20L) Requires peritoneal catheter insertion
68
When is peritoneal dialysis considered preferable?
1st 2 years of dialysis (preserves renal function) Haemodynamic instability Poor veins
69
What are the advantages of peritoneal dialysis?
Flexibility No diet restriction/needles
70
What are the negative aspects of haemodialysis?
Fixed schedule Travel to hospitals Permanent access/recurrent needle sticks Diet/fluid restriction Haemodynamic instability AVF creation
71
What are the common problems w/ arterio-venous fistulas?
Formation (takes 6-8/52 to mature) Infection Thrombosis Stenosis Steal syndrome
72
What is steal syndrome?
Distal ischaemia 2o insertion of AVF -blood preferentially flows through AVF
73
What are the potential complications of haemodialysis?
Sepsis Blood loss Infective endocarditis Disequilibration syndrome Bioincompatability (interaction b/w machines and blood)
74
What is Disequilibration syndrome?
Neurological sx post dialysis -confusion -headache -dizziness -coma -convulsions
75
What are the contraindications to peritoneal dialysis?
Major intrabdominal problems (e.g. adhesions) Poor motivation/hygiene Emactiona COPD Stoma in-situ
76
What are the potential complications of peritoneal dialysis?
Hernia Encapsulating peritoneal sclerosis Infection/blockage PD peritonitis
77
What virology needs checking prior to renal transplant?
CMV HCV HBV HIV VZV EBV
78
What is the prognosis post renal transplant?
Best prognosis of RRT 95% survival 1yr, 90% graft survival 15yr graft srvival
79
What are the potential complications of renal transplant?
Bleeding Graft thrombosis Infection Leaks Rejection
80
Describe hyperacute transplant rejection
Minutes-hrs Type II HR (IgG) Causes vessel thrombosis
81
Describe acute transplant rejection
<6/12 Type IV HR (T-cell) Treated w/ steroids/immunosuppression
82
Describe chronic transplant rejection
>6/12 Antibody/cell fibrosis to kidney (chronic allograft nephropathy Recurrence of CKD
83
How should prescribing in CKD change?
Consider reducing maintenance dose (reduced metabolism/excretion) Increase doses of diuretics/renally acting drugs Reduce doses of nephrotoxics
84
What are the causes of Hypokalaemia?
Reduced intake Excessive losses (sweating, GI, endocrine, renal) Transcellular shifts
85
How does Hypokalaemia present?
Cramps Tetany Weakness Palpitations (arrhythmias) Nephrogenic Diabetes insipidus
86
How should Hypokalaemia be managed?
Mild - Sando K+, K+ sparing diuretics Severe - IV K+ Magnesium
87
What are the causes of Hyperkalaemia?
Excess intake (TPN, a/b, idiopathic, blood transfusion) Reduced losses (addisons, ACE-i, spironolactone, AKI) Transcellular shift (acidosis, haemolysos, rhabdomyolsis)
88
How does Hyperkalaemia present?
Palpitations/arrhythmias Cardiac arrest
89
How shoulder Hyperkalaemia be managed?
Stop nephrotoxics Calcium gluconate (10ml 10% IV) Salbutamol nebs 50ml 50% IV Dextrose Actrapid 10 units Calcium resonium - non-invasive, takes days Haemodialysis
90
When should haemodialysis be considered for Hyperkalaemia?
If K+ >7 (esp. if ECG changes) OR refractory
91
How is anion gap calculated?
(Na + K) - (Cl + HCO3)
92
What are the causes of a non-anion gap metabolic acidosis?
GI loss of HCO3- (diarrhoea) Saline infusion (hyperchloraemic metabolic acidosis) Chronic pancreatitis Renal tubular acidosis
93
What are the causes of a high anion-gap metabolic acidosis?
Lactic acidosis Ketoacidosis e.g. DKA Alcohol (methanol toxicity, ketoacidosis) Iron toxicity/Isoniazid Salicylate toxicity Ethanol/ethylene toxicity Renal causes

Pocket MSRA - Book 1 (7 decks)

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