Nephrology Flashcards
Sx of ADPKD? What is the most common extra renal presentation?
HTN, recurrent UTIs, Haematuria, Renal stones, Renal impairment, Liver cysts, Berry aneurysms
Liver cysts are the most common extra renal presentation - suspect if hepatomegaly
How do we diagnose early CKD? How do we interpret this test?
Using albumin: creatinine ratio
ACR >70 or ACR >30 with HTN give ACEis to manage the proteinuria - this is common in diabetic nephropathy
How do we calculate maintenance fluids in children?
1st 10kg = 100ml/kg
2nd 10kg = 50ml/kg
subsequent kg = 20ml/kg
What is seen in nephrotic syndrome?
Oedema, Low serum albumin (less than 30g/L) and protein in the urine (>3g/24hrs)
There should be no blood in the urine!
What is the most common cause of nephrotic syndrome in adults and children respectively? How do you manage?
Children = minimal change disease. Mx = high dose steroids, ACEis and immunosuppressants alongside renal biopsy if steroids resistant.
Adults = Focal segmental glomerulosclerosis and Membranous glomerulonephropathy. Mx = steroids +/- immunosuppression
How fast can you give potassium?
At a max rate of 10mmol/hr via a peripheral line
Can be given up to 20mmol/hr but only if there is cardiac monitoring
Which metabolic abnormality is often seen in adrenal insufficiency?
Hyperkalaemic metabolic acidosis
Aldosterone normally excretes both K+ and H+
What type of anaemia is associated with CKD? How do we investigate and treat this?
Normocytic anaemia due to low EPO production
All other haematinic tests will be normal. If ferritin is low this implies iron deficiency which must be corrected first!
Mx = Darbepoetin alpha injections
Describe post-streptococcal glomerulonephritis?
Seen in children
Haematuria, proteinuria, oedema, HTN and oliguria
Seen 1-3 weeks following URTI or 3-6 weeks following skin infection e.g. impetigo
Classify CKD
Stage 1 = eGFR >90, must be other signs of kidney damage
Stage 2 = eGFR 60-90, must be other signs of kidney damage
Stage 3a = 45-59
Stage 3b = 30-44
Stage 4 = 15-29
Stage 5 <15, consider dialysis and transplant
True or false, nephrotic syndrome decreases the risk of VTE and decreases free thyroxine levels?
FALSE
It increases the risk of VTE - prescribe dalteparin
It also decreases the total thyroxine levels but does not affect free thyroxine
What is an important complication of secondary hyperparathyroidism? How should you mange this?
Mineral bone disease - low calcium, high phosphate and high PTH
1st line = reduce dietary phosphate
2nd line = phosphate binders e.g. calcium acetate
What drug should you start all patients with CKD on?
A statin
What is seen in hyperkalaemia on ECG?
tall tented T waves, loss of P waves, broad QRS and sinusoidal wave pattern
What is the most common and most important viral infection seen in solid organ transplant patients?
Cytomegalovirus
What should you do if K+ is raised but <6.5
ECG!
What has happened if a transplant is rejected in <48 hours?
Hyperacute transplant rejection
This is secondary to pre-existing antibodies against ABO or HLA antigens. Requires urgent return to theatre to remove the organ
What should you suspect in a patient with a recent history of haematuria who is now in urinary retention. How should you manage this?
A clot causing a bladder outlet obstruction
Mx = bladder irrigation via a 3 way urethral catheter
Describe stage 1 AKI?
Urine output <0.5ml/kg/hr for >= 6 hours
Rise in creatinine by >26 umol/L in 48 hrs or increase of 1.5-1.9 times the baseline
Describe stage 2 AKI
Urine output <0.5ml/kg/hr for >= 12 hours
Rise in creatinine by 2.0-2.9 times the baseline
Describe stage 3 AKI
Urine output <0.3ml/kg/hr for >= 24 hours
Rise in creatinine by >3 times baseline or to >=353.6umol/L
Describe stage 3 AKI in those who are under 18 or are initiating kidney replacement therapy?
eGFR <35
How does calcium resonium work? How can you give it?
It removes potassium from the body. Can be given orally or via an enema (this is the best way)
What is seen on renal biopsy in minimal change disease?
Podocyte fusion and effacement of the podocyte foot processes
What is Sevelamer?
A non-calcium based phosphate binder
How can you confirm the diagnosis of a recent strep infection in ?Post-Streptococcal Glomerulonephritis?
Raised anti-streptolysin O titres
What antibodies are seen in Glomerulonephritis?
Anti-Glomerular basement membrane antibodies
How do we correct vitamin D deficiency in CKD?
Alfacalcidol
How can we reduce the rate of CKD progression in ADPKD?
Tolvaptan
What are the S/Es of EPO therapy?
HTN leading to encephalopathy and seizures
Bone aches
Flu like symptoms
Skin rashes/urticaria
Pure red cell aplasia
Thrombosis
Iron deficiency
How can nephrotic syndrome precipitate a hypercoagulable state?
Antithrombin III is lost via the kidneys
Describe Haemolytic Uremic Syndrome?
Typically seen in children post E.coli infection (diarrhoea with or without blood)
Sx = AKI, thrombocytopenia and normocytic anaemia with fragmented RBCs
Mx = supportive
What symptoms can be seen in patients with a negative fluid balance?
Tachycardia, hypotension, oliguria, sunken eyes and reduced skin turgor
What is IgA nepropathy?
A nephritic syndrome which occurs after URTI
What is membranous glomerulonephritis?
A nephrotic syndrome which can be caused by SLE
What is the classic triad seen in renal cell carcinoma?
Flank pain, flank mass and haematuria
What is the NICE criteria to diagnose AKI of any stage?
Rise in creatinine >26umol/L in 48 hours
Rise in creatinine >50% in 7 days
Drop in urine output <0.5ml/kg/hr for >6hours
True or false, amyloidosis can cause hepatosplenomegaly?
True
Name 3 factors which can affect eGFR reading?
Pregnancy, extremes of muscle mass and eating red meat 12 hours before the test
What is the Alubumin:Creatinine ratio cut off for starting diabetics on an ACEi or ARB?
ACR >= 3, measured from a morning specimine
Which drug can you start in patients who have experienced gynaecomastia on spiro?
Eplerenone
How long do arteriovenous fistulas take to develop after being surgically formed?
6-8 weeks
When should you offer haemodialysis to patients with AKI?
When they have complications which are not responding to normal medical treatment e.g. pulmonary oedema, acidosis or uraemia (e.g. pericarditis or encephalopathy)
How is LDH affected in nephrotic syndrome?
It is raised
What may cause transient non-visible haematuria?
UTI, menstruation, vigorous exercise or sexual intercourse
How can we reduce the risk of contrast induced nephropathy?
Give 09% saline pre and post procedure
What is the prognosis in minimal change disease?
1/3 have no relapses, 1/3 have infrequent relapses, 1/3 have frequent relapses which resolve before adulthood
Describe Granulomatosis with Polyangiitis (Wegner’s)
Sx = saddle shaped nose, crusty nasal secretions, sinusitis, nose bleeds, hearing loss, cough, haemoptysis and nephritic syndrome
Ix = cANCA and crescenteric glomerulonephritis
Which conditions is pANCA seen in?
Microscopic polyangiitis and Churg-Strauss Syndrome
Describe Churg-Strauss Syndrome?
Sx = severe asthma presenting in late teenage years/early adulthood, lung, skin and kidney issues
Ix = raised eosinophil levels
Describe Microscopic Polyangiitis?
Renal failure, SOB and haemoptysis
How can we differentiate AKI from CKD?
Small kidneys on USS point to CKD.
This can not be used in PKD or early diabetic nephropathy
Describe Fibromuscular dysplasia?
AKI in a young female who has recently started ACEi. HTN and oedema may be seen. The renal arteries have a string of beans appearance
What should you suspect if a patient presents like Fibromuscular dysplasia (sting of bean appearance renal arteries, AKI, HTN and oedema) but is old?
Atherosclerosis of the renal arteries
What is acute graft failure?
Occurs within 6 months of transplant
It is usually asymptomatic and is picked up by an increase in creatinine, pyuria and proteinuria
Mx = steroids and immunosuppressants
What is chronic graft failure?
Graft failure occurring more than 6 months after the transplant
A diabetic patient presents with new onset foamy urine and an ACR >3. What is the diagnosis and how will the kidneys appear?
Proteinuria secondary to early diabetic nephropathy
There will be bilateral kidney enlargement (with chronic diabetic nephropathy they will be small)
How can timescale help you tell between IgA nephropathy and post-streptococcal glomerulonephritis?
IgA nephropathy occurs 1-2 days after URTI where as post-streptococcal glomerulonephritis occurs 1-2 weeks after
What abnormality is seen on ABG/U&Es in DKA?
Raised anion gap metabolic acidosis
Ix of IgA nephropathy?
renal biopsy which will show IgA deposition
How can alcohol binging affect ADH ? What will this cause?
It can cause ADH suppression
Sx = polyuria, hypernatraemia, high serum osmolality and low urine osmolality
How can MDMA affect ADH ? What will this cause?
It can cause SIADH
Sx = low serum osmolality, high urine osmolality and hyponatraemia
How do you manage hypokalaemia?
If 2.5-3.4 give oral K+ replacements. If <2.5 move to an area with cardiac monitoring an give IV K+ replacement at no more than 20mmol/hr
What drug can you consider adding if patients with minimal change disease do not respond to prednisolone?
Cyclophosphamide
What is the first line RRT?
In mobile patients = peritoneal dialysis
If non-mobile or have UC = haemodialysis
Describe Wilm’s Nephroblastoma?
Seen in children under 5. Presents with abdo mass (most common symptom), flank pain and painless haematuria.
Most commonly metastasises to the lungs
Describe Alport’s syndrome?
An X-linked dominant condition associated with microscopic haematuria, bilateral sensorineural deafness, retinitis pigmentosa and progressive renal failure (or failure of a renal transplant)
When should you refer a patient to nephrology because of their eGFR?
If they have an eGFR <30 or worsening by >15 per year
What abnormality can be seen on ABG in type 1 respiratory failure?
Non-compensated respiratory alkalosis
T1RF leads to hyperventilation, this causes a drop in CO2
How can you calculate the urea:creatinine ratio? How is it significant?
Urea / (creatinine/100)
If it is >100 this indicates a pre-renal cause of renal failure (e.g. dehydration)
What should you suspect if there is a low GCS and uraemia?
Encephalopathy
What is Dialysis Disequilibrium Syndrome?
Cerebral oedema leading to decreased consciousness in those who have recently started RRT
Sx and Mx of Salicylate poisoning (e.g. aspirin)?
Metabolic acidosis with a raised anion gap. There may also be some respiratory alkalosis due to the tachypnoea caused by aspirin.
Tinnitus is also present
Mx = IV sodium bicarbonate
Who should you hold metformin before giving contrast? How long should you hold it for?
In those with high risk of contrast nephropathy (if known renal impairment, >70 years, dehydration, HF and nephrotoxic drug use). Hold for 48 hours before contrast is to be given
What variables affect eGFR?
CAGE
Creatinine, Age, Gender and Ethnicity
What does acute transplant rejection often mimic? How do you treat?
Mimics infection - except creatinine will be newly raised
Mx = increase steroid dose
What is the prefered method of access in haemodialysis?
A/V fistula
Mx of benzo OD?
Flumenezil
