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ALS > Nephrology > Flashcards

Nephrology Flashcards

1
Q

Acute Interstitial Nephritis

A

Causes 25% of drug induced AKI.

Causes - penicillin, rifampicin, NSAIDs, allopurinol, furosemide, SLE, sarcoid, Hanta virus, staph

= fever, rash, arthralgia, renal impairment, HTN

Inv - eosinophilia, sterile pyuria, WC casts

TIN with Uveitis
= young females, fever, weight loss, painful red eyes
Inv - leukocytes and protein

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2
Q

Acute Tubular Necrosis

A

Most common cause of AKI, reversable in early stages

Causes
Ischaemic - shock, sepsis
Nephrotoxins - aminoglycosidess, myoglobin (rhabdomyolisis), radiocontrast, lead

= oligouric phase, polyuric, recovery

Inv. - urea, creatinine, K, muddy brown casts

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3
Q

Acute Tubular Necrosis vs Pre-renal Uraemia

A

-Poor reabsorption of Na and water in ATN but low osmolarity as a lot more water relative to Na
-In pre-renal uraemia, the kidneys hold on to Na to preserve volume

Urine sodium - pre-renal (v), ATN (^)
Urine osmolarity - pre-renal (^), ATN (v)
Fluid challenge - pre-renal (good), ATN (poor)
Urea:creat - pre-renal (^), ATN (normal)

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4
Q

ADPKD

A

Type 1 - 85%, Chr 16, earlier renal failure
Type 2 - 15%, Chr 4

= HTN, recurrent UTI, abdo pain, renal stones, haematuria, CKD, liver cysts, berry aneurysms

Screening using abdo US = two cysts <30yrs, two cysts bilaterally <60yrs, four cysts bilaterally 60+

-> Tolvaptan (vasopressin 2 antagonist, slows progression)

Slightly increased risk of RCC

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5
Q

ARPKD

A

Less common, Chr 6 (fibrocystin)

= (infancy) abdo mass, renal failure, Potter’s syndrome 2nd to oligohydramnios, liver fibrosis

Diagnosed on prenatal US, biopsy (lesions at right angle to cortical surface)

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6
Q

Alport’s

A

X linked dominant, more severe in males

Defect in T4 collagen = abnormal GBM

= (childhood) microscopic haematuria, renal failure, bilateral SN deaf, lenticonus (lens protudes into ant. chamber), retinitinis pigmentosa

Inv - biopsy (splitting of lamina densa, basket weave), genetic testing

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7
Q

Amyloidosis

A

Extracellular deposition of amyloid

Inv. - congo red staining gives apple green birefringence, serum amyloid precursor scan, biopsy (skin, rectum, abdo)

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8
Q

Goodpasture’s (anti-GBM)

A

Anti-GBM Ab against T4 collagen, small vessel vasculitis

RF - 2M:F, peak in 20s and 60s

= pulmonary haemorrhage, rapidly progressive GN (protein and blood)

Inv - biopsy (IgG deposits along GBM), raised transfer factor

-> plasma exchange, steroids, cyclophosphamide

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9
Q

AV Fistula

A

Direct connection between artery and vein, 6-8wks to develop

Preferred access for haemodialysis

Comp - infection, thrombosis, stenosis, steal syndrome

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10
Q

Diabetetes Insipidus

A

Cranial (v ADH secretion by pit)
Causes - idio, head injury, pit surgery, sarcoid, haemochromatosis, craniopharyngioma, DIDMOAD

Nephrogenic (insensitivity to ADH)
Causes - lithium, ^Ca, v K, genetic (aquaporin)

= polyuria, polydipsia, high plasma osmolarity vs low urine osmolarity, water deprivation test

-> desmopressin for cranial, thiazides and low salt for nephro

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11
Q

EPO

A

Hematopoietic growth factor, for production of RBCs

Used in CKD, chemotherapy

SE: accelerated HTN (encephalopathy, seizures), bone aches, flu-like, rash, pure red cell aplasia (Ab against EPO), thrombosis (^PCV), iron def

If not responding to EPO, think iron def

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12
Q

Renal Artery Stenosis

A

2nd to atherosclerosis, 10% fibromuscular dysplasia (^^F)

Link - takayasus arteritis

= HTN, flash pulmonary oedema, AKI after ACEi

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13
Q

Focal Segmental Glomerulosclerosis

A

Nephrotic, young adults

Causes - idio, HIV, heroin, Alport’s, sickle cell, 2nd to IgA nephropathy

Inv - biopsy (FS sclerosis, effacement of feet)

-> steroids +/- IS

*high recurrence after renal transplant

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14
Q

Haemolytic Uraemic Syndrome

A

Thrombosis in small blood vessels leads to thrombocytopenia and haemolysis

Causes - Shiga toxin-producing E.coli 0157, pneumococcal, HIV

= kids, AKI, microangiopathic hemolytic anemia and thrombocytopenia

Inv - FBC, U&Es, blood film (schistocytes, helmet cells), negative coombs, stool culture

-> supportive (fluids, blood, dialysis)
NO Abx

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15
Q

HSP

A

IgA mediated small vessel vasculitis, self-limiting, overlaps with IgA nephropathy

= child post-infection, palpable purpuric rash, over bum/ extensors, local swelling, abdo pain, polyarthritis

Inv - monitor BP and urinalysis

-> analgesia, supportive

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16
Q

IgA Nephropathy

A

Bergers disease

Commonest cause of GN in world

= young man, macroscopic blood 1-2d after URTI, no proteinuria

-> ACEi if persistent proteinuria

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17
Q

Membranoproliferative GN

A

Also called mesangiocapillary

Type 1 - 90%, linked to Hep C, biopsy (immune deposits, tram-track)

Type 2 - dense deposit disease, low C3, C3b nephritic factor, biopsy (dense deposits)

Type 3 - linked to hep B and C

-> steroids

18
Q

Membranous GN

A

Commonest GN in adults, 3rd most common cause of ESRF

Causes - idio (APL Ab), cancer (prostate, lung, lymph), penicillamine, NSAIDs, AI, hep B, malaria, syphilis

Inv - biopsy (spike and dome EM)

-> all get ACEi/ ARB, if severe give steroids + cyclophosphamide

1/3 spont remit, 1/3 remain proteinuric, 1/3 ESRF

19
Q

Minimal Change Disease

A

Most common GN in kids (75%)

Causes - ^^idio, NSAIDs, rifampicin, Hodgkin’s, thymoma, glandular fever

= nephrotic, normal BP, selective proteinuria (mid-size, albumin/ transferrin)

Inv - normal LM, fusion of podocytes/ foot effacement EM

-> PO steroids

1/3 have one episode, 1/3 infrequently relapse, 1/3 frequent

20
Q

Nephrotic Syndrome

A

Proteinuria - >3g / 24hr
Low albumin - <30
Oedema

  • Loss of AT-3 and protein C = thrombosis
  • Loss of thryoxine binding globulin = v total but not free thyroxine levels
  • ^hepatic lipogenesis due to falling oncotic pressure = high cholesterol
21
Q

Contrast Nephrotoxicity

A

25% inc in creatinine within 2-5d of contrast

RF - known renal issues, >70yrs, dehydration, HF, NSAIDs

Prevention - IV 0.9% NaCl at 1ml/kg/hr for 12 hours before and after

If at high risk, stop metformin for 48hrs before and until renal function is normal

22
Q

Post Strep GN

A

7-14 days after group A hemolytic strep - pyogenes

Immune complex deposition in glomerulus causing acute diffuse proliferative GN

= young children, headache, malaise, haematuria, oedema (proteinuria), oliguria, HTN

Inv - v C3, ^ASO, biopsy (subepithelial humps EM, granular/ starry sky IF)

23
Q

Rapidly progressive GN

A

Rapid loss of renal function associated with epithelial crescents in glomeruli

Causes - Goodpasture’s, Wegener’s, SLE, microscopic polyarteritis

= nephritic syndrome (blood, protein, oliguria, HTN)

24
Q

Renal papillary necrosis

A

Causes -
Severe acute pyelo
Diabetic nephropathy
Obstructive nephropathy
Analgesic nephropathy (NSAIDs)
Sickle cell anaemia

= macro haematuria, loin pain, proteinuria

25
Q

Graft rejection

A

HLA system is the major histocompatibility complex in humans, Chr 6

Most important HLA is DR then B then A

Post-op complications - ATN of graft, vascular thrombosis, urine leak, UTI

Hyperacute (min-hrs)
Pre-existing Ab against ABO or HLA, T2HS, widespread thrombosis
-> Need to remove

Acute (<6months)
HLA mismatch, cell-mediated
= no symptoms, ^creat, pyuria, proteinuria
-> steroid/ IS

Chronic (>6m)
Ab and cell-mediated, fibrosis

Post-transplant IS- monitor BP, glucose, lipids, renal function, risk of SCC and BCC

26
Q

Rhabdomyolysis

A

Skeletal muscle breaks down, releases breakdown products into blood (myoglobin, potassium, phosphate and CK)

RF - fall, seizure, marathon runner, statins (w/ clarithro), crush

= AKI (^^creat), 5x normal CK, myoglobinuria (dark, dip +blood), v Ca (binds myoglobin), ^K, ^phosphate, met acidosis

-> IV fluids, urinary alkalinization

27
Q

Dipstick +blood

A

Transient
UTI, period, vig. exercise, sex

Persistent
Cancer, stones, BPH, prostatitis, urethritis (chlamydia), kidney problems

Red but not +blood = beetroot, rifampicin, doxorubicin

28
Q

Stauffer Syndrome

A

Paraneoplastic disorder, 5% of RCC

? ^IL6-> hepatic dysfunction (cholestasis, hepatosplenomegaly)

= sudden RUQ pain, nausea, jaundice and deranged LFTs

29
Q

Drugs to Stop in AKI

A

Diuretics
ACEi/ ARB
Metformin (risk of toxicity)
NSAIDs - keep aspirin 75mg
Lithium (risk of toxicity)
Aminoglycosides
Digoxin (rick of toxicity)

30
Q

RRT Indications

A

A - Acidosis
E - Electrolytes (^K)
I - Intoxicants (lithium, salicylate)
O - Overload
U - Uraemia (pericarditis, encephalopathy)

31
Q

Renal Tubular Acidosis

A

^Cl metabolic acidosis due to renal tubular pathology (normal anion gap)

Type 1
Causes - RA, SLE, Sjogren’s, NSAIDs
Distal tubule unable to excrete H+, loss of K
= hyperventilation, FTT, renal stones
-> treat with bicarbonate

Type 2
Causes - Fanconisyndrome, Wilson, acetazolamide
Prox tubule can’t reabosorb bicarb, loss of K
= osteomalacia

Type 3
Mixed, extremely rare

Type 4 (most common)
Causes - hypoaldosteronism, DM
Reduced proximal ammonium excretion, ^K
-> fludrocortisone and bicarbonate

32
Q

Causes of AKI

A

Prerenal (most common)
Inadequate blood supply to kidneys
- hypovolemia, renal artery stenosis

Renal
Intrinsic damage (only one with proteinuria)
- GN, AIN, ATN, rhabdomyolysis, tumour lysis
- gentamicin if prev. treatment for UTI

Post-renal
Back pressure reduces function of the kidney
- renal/ ureteric stone, BPH, external compression of ureter

33
Q

Common causes of CKD

A

DM
HTN
Age
PCKD
Meds - NSAIDs, PPI
Glomerulonephritis
Chronic pyelonephritis

34
Q

Anaemia of CKD

A

Causes - v EPO production, v iron absorption

Normocytic normochromic anaemia, usually when GFR<35

-> check iron status, EPO

35
Q

Renal Bone Disease

A

In CKD there is;
High phosphate - can’t excrete it
Low Active Vit D - can’t activate it
Low calcium – lack of vit D and high phosphate
Secondary PTH - due to all 3 above, ^osteoclast

Osteomalacia: vit D def, increased bone turnover without enough calcium
Osteosclerosis: compensatory osteoblast^ but not mineralised properly

Rugger jersey spinal XR (sclerosis of ends of vertebral body, malacia in centre)

-> v phosphate in diet, phosphate binders (SE: ^Ca, vascular calcification), vit D (alfacalcidol), parathyroidectomy

36
Q

Common Nephrotic syndromes

A

Minimal change
Membranous
Focal segmental GS
Diabetic
Amyloid

37
Q

Common nephritic

A

Rapidly progressive GN
IgA nephropathy
Alport

Overlap - Diffuse proliferative, membranoproliferative and post strep

38
Q

Extra renal manifestations of PKD

A

Cerebral aneurysms
Hepatic, splenic, pancreatic, ovarian cysts
MR
Colonic diverticula
Aortic root dilatation, dissection
Abdominal wall hernia

39
Q

AKI Staging

A

Diagnose if
^creat by 26+ in 48hrs OR ^creat by 50%+ in 7 days OR urine output <0.5ml/kg/hour for >6hrs

Staging
1 - creatinine increase ≥ 1.5-1.9 x baseline OR urine <0.5ml/kg/hr for 6 hours

2 - creatinine ≥ 2-2.9 x baseline OR
urine <0.5ml/kg/hr for 12 hours

3 - creatinine ≥ 3 x baseline OR
creatinine increase to ≥ 354 OR
urine <0.3ml/kg/hr for 24hrs OR
RRT

40
Q

CKD - classification

A

1) eGFR >90 (must be other evidence of damage e.g., U&Es/ proteinuria)
2) 60-90 + other evidence
3a) <60
3b) <45
4) <30
5) <15 (failure - need dialysis or transplant)

eGFR based on serum creatinine, age, sex, ethnicity
- effected by pregnancy, muscle, red meat

41
Q

CKD - Extras

A

HTN
-> ACEi (investigate if GFR reduces >25% or creatinine rises >30%), furosemide

Proteinuria
Albumin: creatinine, first pass morning
-> refer 70+ or 30 + haematuria, ACEi and SGLT2 inh

Most CKD patients have bilaterally small kidneys (excl. early DM, PCKD, amyloid)

42
Q

Diabetic Nephropathy

A

Annual albumin: creatinine (early morning)

-> ACEi if 3+, v protein, control glucose, statins

BP drugs if >135/85 (or 130/80 in T1 w/ albuminuria)
- aim for 140/90

ALS (22 decks)

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