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MRCP Part 1 > Nephrology > Flashcards

Nephrology Flashcards

1
Q

DIDMOAD for Wolfram Syndrome

Causes of Central and Nephrogenic DI

A

DI
Diabetes Mellitus
Optical Atrophy
Deafness

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2
Q

How to conduct a Fluid Deprivation Test and Interpret it

Whats the treatment for Central and Nephrogenic DI and why

Investigations and Management

A

Central
Infection (Meningitis)
Infiltrative (Sarcoidosis)
Trauma
Wolfram Syndrome (DIDOAD)
Histiocytosis X and Sarcoidosis
Vascular (Sickle Cell Crisis)
BINGE DRINKING (inhibit Posterior Pituitary)
Congenital nephrogenic DI (AVPR2 gene) - Mutation in Aquaporin Channel

Nephrogenic
CKD
Post Obstructive Uropathy
Intrinsic Kidney Disease - (Casts . Hematuria)
HyperCal , HypoK
DM

Fluid Depriviation Test (2 micorgram IM)
MRI Head + Posterior Pituitary Function
Serum ACE
bHCG (Pineal Germinomas

Stop Offending Drugs
Desmopressin (Central) and Thiazide / NSAIDs (Nephrogenic)

Thiazide Diuretics –> inhibit Prostaglandin Synthesis which cause Volume Contraction and reduce EGFR so less urine goes to Distal Tubule and more solutes are absorbed in the Proximal hence concentrating Urine

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3
Q

Which Diuretic Acts where ?

A

Acetazolamide - Proximal - Carbonic Anhydrase Inhibitor
Loop Diuretic - Ascending Loop of Henle by Na/K/2Cl symporter
Thiazide - Distal Na/Cl Symporter
Spironolactone - Cortical Cells in Collecting Duct Na/K ATPase

Amiloride - blocks the epithelial sodium channel in the distal convoluted tubule

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4
Q

Explain Plasma Aldosterone / Renin Ratio combinations

Liddle / Bartter (Asociation ?) / RAS / Primary Hyperaldosteronism / Gitelman (association?)

HYPERtension with Hypokalemia differentials

NORMOtension with Hypokalemia differentials

A

-BOTH high ? > renal artery stenosis with HYPERTENSION but if NORMOTENSIVE then it Bartter Syndrome

-both low ? > liddle’s syndrome (Liddle’s syndrome = L = LOW for both )

-high aldosterone and renin is low : primary hyperaldosteronism

Primary Hyperaldosteronism > overproduction of aldosterone > excessive sodium and water reabsorption in the kidneys > negative feedback onto renin > reduced Angiotensin I and II > attempts to suppress aldosterone but due to primary hyperaldosteroninsm, keeps secreting inappropriate amounts of aldosterone

Liddle - Gain of function of sodium channel in the DCT (Gitleman is Loss of Function here —> Hypomagnesemia) > excessive sodium reabsorbed, regardless of renin/aldosterone > causes negative feedback suppression of renin and aldosterone > low for both.

Bratters > impaired Na/K/2Cl in thick ascending loop > low sodium low water low bp > stimulates renin > stimulates aldosterone > high renin high aldosterone

Bartter – > Hypercalciuria (Due to Paracellular Transport of Mg and Ca blocked due to a lack of positive charge from K+ being kicked out)–> Nephrolithiasis

Hypertension with hypoKALEMIA :

Better spot a cushy little con

Better = 11 beta hydroxysteroid dehydrogenase deficiency
Cushy= cushing syndrome
Little = Liddle’s
Con = Conn’s
——————————-
Normotension and hypokalaemia:

Bartering gits can die vomiting

Bartering= Bartter’s
Gits= Gittleman’s
Die= Diuretics
Vomiting= Vomiting

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5
Q

Kidney Stone Management

A

Renal stones

watchful waiting if < 5mm and asymptomatic

5-10mm shockwave lithotripsy

10-20 mm shockwave lithotripsy OR ureteroscopy

> 20 mm percutaneous nephrolithotomy

Uretic stones

< 10mm shockwave lithotripsy +/- alpha blockers
10-20 mm ureteroscopy

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6
Q

Stone Prevention for Calcium Oxalate Stones and Uric Acid Stones

A

Oxalate stones
cholestyramine
pyridoxine

Uric acid stones
allopurinol
urinary alkalinization e.g. oral bicarbonate

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7
Q

ADPKD management

A

ACEi / ARB for HTN
Cyst Hemorrage - Nephrectomy
Cyst Infection - Ciprofloaxacin
Symptomatic or >10mm anuerysm - Surgical Intervntion
Tolvaptan - CKD 2/3 & rapidly growing

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8
Q

Which HLA shows high risk of rejection of transplant

A

HLA DR > B > A

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9
Q

Risk Factors for secondary FSGS

and

Light Microscopy and Electron Microscopy findings

A

HIV
PVB19 via Hemolytic Anemia’s - Sickle Cell or B Thalassemia
Heroin (THE ADDICT)
SLE
Charcot Marie Tooth Disease - Congential

Focal Segmental Sclerosis + Hyalinosis in Light
Podocyte Effacement in Electron

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10
Q

Risk Factors for Secondary Minimal Change Disease

A

Recent Infection / Vaccination
Hodgkin Lymphoma
NSAIDs / Rifampicin
Infectious Mononucleosis

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11
Q

Risk Factors for Membranous Nephropathy

Light and Electron Microscopy Findings

A

Syphillis / SLE (Type 5)
HBV / HCV
Malaria
Schistosomiasis
NON Hodgkin
Cancer
Gold

Light - Thick GBM
Electron - SubEPITHELIUM Spike and Dome pattern due to immune complex deposition

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12
Q

FSGS Selective or Non selective proteinuria ?

A

Non Selective
Only MCD is SELECTIVE

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13
Q

What antibody is associated with Membranous Nephropathy ?

A

Anti PLAR2 (Spike and Dome Subepithelial on Electron)

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14
Q

Prognostic Factors for MGN ?

A

Female Good for MGN

Male Poor for IgA

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15
Q

ADPKD Type 1 and Type 2 Chromosome and Genes ?

A

ADPKD T1 (Chromosome 16) PKD1 Gene - Severe but 85% common

ADPKD T2 (Chromosome 4)
PKD 2 Gene - Less Severe but 15%

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16
Q

Prognostic Markers for IgA

A

markers of good prognosis: frank haematuria

markers of poor prognosis: male gender,
proteinuria (especially > 2 g/day),
hypertension,
smoking,
hyperlipidaemia,
ACE genotype DD

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17
Q

Non Seminoma Types

A

non seminomas (Peak 25)

Cu—choriocarcinomas
Y yolk sac
T teratomassS
E embryonal

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18
Q

Factors that increase risk of Pulmonary Hemorrhage ?

A

smoking
lower respiratory tract infection
pulmonary oedema
inhalation of hydrocarbons
young males

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19
Q

Nephrogenic DI causing Drugs

A

DR. FLAG

D - Demeclocycline
R - Rifampicin
F - Foscarnet
L - Lithium
A - Amphotericin B
G - Glibenclamide

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20
Q

Side effects of Erythropoietin

A

Side effects of Erythropoietin

A- accelerated HTN
B- Bone aches
C-Cellular Aplasia of RBCs
D- Deficiency of Iron
E- Exaggerated Skin symptoms ( Rashes , Urticaria)
F- Fistula Thrombosis due to Raised PCV, Flu like symptoms

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21
Q

Which Kidney Stones are Radio-opaque and which are radio-lucent

A

all the ones that are OOOOOpaque contain an o (phosphate (incl stag horn), oxalate)

all the ones that are radiolucent don’t (urate and xanthine) - just have to remember that cystine are semi-opaque (the c looks like half an o)

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22
Q

High Anion and Normal Anion Gap Causes ?

A

Methanol
Uremia
DKA

Paraldehyde
Iron, Isoniazid
Lactic Acidosis
Ethyl Glycol
Salicylate

Carbon Monoxide
Aminoglycosides
Theophylline

Normal Anion Gap MA

FUSEDCARS

Fistula (biliary, pancreatic), Ureterogastric conduit, Saline administration, Endocrine (Addison disease, hyper-PTH), Diarrhea,

Carbonic anhydrase inhibitor,
Ammonium chloride,
Renal tubular acidosis, Spironolactone

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23
Q

What is the diagnostic investigation for Recurrent UTI in Peads ?

A

MCUG for Reflux Uropathy and DMSA later for Renal Scarring

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24
Q

Fibromuscular Dysplasia

A

Female
Flash Pulmonary Edema
AKI after ACE
Uncontrollable HTN

ACEI in CKD - a decrease in eGFR of up to 25% or a rise in creatinine of up to 30% is acceptable

ACEI for HTN - a decrease in eGFR of up to 15% or a rise in creatinine of up to 20% is acceptable - if more than that - HOLD drug and suspect Renovascular dx

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25
Glomerulonephritis with complement Levels
PIMpS Post Streptococcal GN Infective endocarditis (Subacute) Mp – Membranoproliferative GN S – SLE Renal
26
Electrolyte Abnormality in Plasma exchange
Hypocalcemia
27
Voiding Symptoms / Overactive Bladder / Nocturia management in Men >50
Pelvic Floor exercises If moderate or severe risk then Alpha blocker If Prostomegaly + High Risk of Progression then 5-alpha reductase inhibitor If Prostomegaly + Moderate to High voiding symptoms then 5-alpha reductase inhibitor + Alpha Blocker Mixed Voiding and Storage Symptoms not responding to Alpha Blocker then add Antimuscarinic Overactive Bladder Bladder Training Antimuscarinic
28
How long does Finasteride take to be effective for BPH
Upto 6 months
29
BPH treatment ?
Watchful Waiting IPSS >/= 8 (Mild to Moderate) start Alpha blockers If Prostomegaly + High Risk of Progression then 5-alpha reductase inhibitor (might reduce PSA level by 50%) If Prostomegaly + Moderate to High voiding symptoms then 5-alpha reductase inhibitor + Alpha Blocker Mixed Voiding and Storage Symptoms not responding to Alpha Blocker then Antimuscarinic Surgery (TURP)
30
BPH investigations
urinary frequency-volume chart (3 days at least) International Prostate Symptom Score (IPSS) Score 20-35: severely symptomatic Score 8-19: moderately symptomatic Score 0-7: mildly symptomatic
31
Equations for eGFR estimates
**CrCL Cockroft used : 1- Gender 2- Age 3- Weight 4- Serum Creatinine ** MDRD + CKD-EPI used: 1- Gender 2- Age 3- Race 4- Serum Creatinine **MDRD with 6 variable : 1- Gender 2- Age 3- Race 4- Serum Creatinine 5- BUN 6- Albumin
32
Renal Artery Stenosis Gold Standard Investigation
MR Angiography but sequence will be Renal doppler ultrasound CT angiograph of renal arteries MR angiography - non-invasive gold standard Invasive renal angiography - invasive gold standard
33
Urgent Dialysis Indication
Indications for dialysis: AEIOU A – Acidosis – metabolic acidosis E – Electrolytes – refractory hyperkalemia or rapidly rising potassium levels I – Ingested substances * O – Overload – volume overload refractory to diuresis U – Uremia – elevated urea with signs or symptoms of uremia (pericarditis, neuropathy, or uremic encephalopathy) *Use Mnemonic SLIME salicylates lithium isopropanol methanol ethylene glyco
34
Factors associated with Retroperitoneal Fibrosis
Riedel's thyroiditis previous radiotherapy sarcoidosis inflammatory abdominal aortic aneurysm drugs: methysergide
35
Normal anion Gap ?
8-14
36
Urea to Creatnine Ratio elevated in Pre-Renal but Normal in ATN why ?
Given that urea absorption is largely modulated in the proximal tubules, it is not affected by diuretics acting more distally.
37
DPGN associated with Lupus AND ????
PSGN
38
Calciphylaxis
Calciphylaxis lesion are intensely painful, purpuric patches with an area of black necrotic tissue that may form bullae, ulcerate, and leave a hard, firm eschar
39
214 emily
40
Minimal Change Disease not responding to Prednisolone then ?
Cyclophosphamide
41
Nephrogenic DI mutations less and most common cause ?
the more common --> vasopression (ADH) receptor the less common form --> mutation in the gene that encodes the aquaporin 2 channel
42
Tolvaptan antagonizes V1 V2 or V3 ?
Tolvaptan is a vasopressin receptor 2 antagonist
43
What cancer is associated with Post Organ Transplant ?
Squamous Cell Carcinoma
44
Hyperacute rejection (minutes to hours) due to pre-existing antibodies against ABO or HLA antigens an. example of a type II hypersensitivity reaction leads to widespread thrombosis of graft vessels → ischaemia and necrosis of the transplanted organ no treatment is possible and the graft must be removed Acute graft failure (< 6 months) usually due to mismatched HLA. Cell-mediated (cytotoxic T cells) usually asymptomatic and is picked up by a rising creatinine, pyuria and proteinuria other causes include cytomegalovirus infection may be reversible with steroids and immunosuppressants Causes of chronic graft failure (> 6 months) both antibody and cell-mediated mechanisms cause fibrosis to the transplanted kidney (chronic allograft nephropathy) recurrence of original renal disease (MCGN > IgA > FSGS)
45
You review a 42-year-old woman six weeks following a renal transplant for focal segmental glomerulosclerosis. Following the procedure she was discharged on a combination of tacrolimus, mycophenolate, and prednisolone. She has now presented with a five day history of feeling generally unwell with anorexia, fatigue and arthralgia. On examination her sclera are jaundiced and she has widespread lymphadenopathy with hepatomegaly. What is the most likely diagnosis? HIV/CMV/HCV/HBV/EBV
CMV is the most
46
Glomerulonephritis that is most characteristically associated with partial lipodystrophy?
Membranoproliferative glomerulonephritis (mesangiocapillary) type 1 (Classical Pathway activated) : cryoglobulinaemia, hepatitis C, CLL, Lymphoma type 2 (Alternative Pathway Activated) : partial lipodystrophy, Factor H Deficiency C4 Low in type I, normal in type 2 C3 Low in Type 2
47
Type 1 Membranoproliferative GN vs Type 2 Membranoproliferative GN on Microscopy
Type 1 and 2 on Light Microscopy (PAS Stain) - 1. Thickened GBM  2. Mesangial proliferation & interposition  3. Mesangial hypercellularity  Type 1 MPGN Electron Microscopy - 1. Immune complex deposits in subendothelial and mesangium  2. Tram Track Appearance Type 2 MPGN Electron Microscopy - 1. Complement deposits in GBM 2. Tram Track Appearance
48
Type 1 MPGN vs Type 2 MPGN treatments
Primary (idiopathic):  1. Oral cyclophosphamide 2. Oral mycophenolate mofetil (MMF) and/or Pred add on Secondary MPGN:  1. Treat the cause ACEi/ARB Statins Wafarin
49
Target for Anti GBM in Goodpasture's Disease
NC1 domain of alpha 3 chain of Type IV collagen
50
Excess NaCl infusion causes what metabolic picture ?
Hyperchloremic metabolic acidosis 1. Excess Na+ and Cl- 2. If ongoing Diahorrea - Loss of HCO3- 3. Excess Cl- force HCO3- into cells and limit HCO3- available for pH buffer
51
Iatrogenic Causes of Renal/Uretic Stones
1. Calcium Stones = SALAD CT S - Steroids A - Antacids L - Loop diuretics A - Acetozolamide D - Vit D C - Vit C T - Theophylline/ Aminophylline 2. Uric acid stones Salicylate Thiazides 3. Precipitate into stones: SIT S - Sulfadiazine I - Indinavir T - Triamterene
52
What type of Catheter to use when there is an URGENT need to Dialyse and no time for an AV fistula to mature ?
Tunneled or Non Tunneled Venous Catheters
53
Pathologies associated with IgA Nephropathy
HSP (IgA vasculitis)  SLE  Coeliac disease  alcoholic liver disease
54
Prostate Cancer Management
Localized (T1/T2) - 1. Watchful Waiting 2. radical prostatectomy - Erectile Dysfunction 3. radiotherapy: external beam and brachytherapy - Proctitis & Malignancy Localised Advanced (T3/T4) 1. Hormonal 2. Same as above 3. Same as above Hormonal 0. GnRH agonist - Goreselin - paradoxical overstimulation but often cyproterone acetate 3 days before till 3 weeks after to avoid tumour flare GnRH antagonist 1. bicalutamide - Non-steroidal anti-androgen 2. cyproterone acetate- Steroidal Anti androgen 3. abiraterone - Androgen Synthesis inhibitor - when androgen deprivation therapy has failed and before Chemotherapy with docetaxel 4. Bilateral Orchidectomy
55
Tumour Markers for Seminomas and Non Seminomas
Seminoma --> bHCG Non Seminoma (embryonal, yolk sac, teratoma and choriocarcinoma) ---> AFP and/or bHCG Teratomas in Twenties and Seminomas in Serties
56
Renal Papillary Necrosis Associations
chronic analgesia use sickle cell disease TB acute pyelonephritis diabetes mellitus IVU - Papillary Necrosis and 'Cup and Spill'
57
Casts and Cause of AKI
Hyaline Cast = Pre-renal Granular = ATN Muddy Brown Renal Tubular Cells Sterile Pyuria = AIN White Cell Casts Eosinophilia Dysmorphic Cells = Glomerulonephritis RBC Casts
58
Causes of Intra Renal AKI
1. Vascular Infarct APLS Scleroderma Crisis Dissection Vasculitis (PAN, Takayasu) 2. Interstitial AIN - NSAIDs, Sulpha Drugs, PPI, Check Point Inhibitors, Abx, Recurrent Pyelonephritis 3. Tubular ATN - Ischemia, Aminoglycosides, Crystalluria (Acyclovir, Cisplatin,MTX, Ciprofloxacin) MM, TLS, Rhabdomyolysis 4. Glomerulus
59
Urology Urgent and Non Urgent Referral Criteria for Hematuria
URGENT Aged >= 45 years AND: unexplained visible haematuria without urinary tract infection, OR visible haematuria that persists or recurs after successful treatment of urinary tract infection Aged >= 60 years AND unexplained nonvisible haematuria and either dysuria or a raised white cell count on a blood test NON URGENT Aged >/=60 years + recurrent or persistent unexplained urinary tract infection
60
How to prevent Contrast Induced Nephropathy ?
1m/kg/hour for 12 hours pre and post contrast Withhold Metformin for 48 hours post procedure
61
Asymptomatic Microscopic Hematuria + Family H/O = ?
Thin Basement Membrane Disease or Benign Familial Hematuria Autosomal Dominant
62
Indications for Plasma Exchange
Guillian's Good MATCH Guillain-Barre syndrome Goodpasture's syndrome Myasthenia gravisĺ⁹lìĺ⁸ ANCA positive vasculitis if rapidly progressive renal failure or pulmonary hemorrhage TTP Cryoglobulinemia Hyperviscosity syndrome e.g. secondary to myeloma/ HUS
63
How does Plasma exchange cause Metabolic Alkalosis ?
Plasma exchange has Citrate Citrate metabolism releases HCO3- Renal Dysfunction and so HCO3- elevated Metabolic Alkalosis
64
Left sided varicocele in malignancy questions What Cancer should come to mind ?
Renal Because left testicular vein drains into the renal vein, whereas the right drains into IVC directly. Any obstuction/mass pressure on left side as in Renal mass can lead to backpressure.
65
Membranous Glomerulonephritis Treament
ACEi
66
Secondary Typical HUS Causes
HIV Pneumococcal Vaccination
67
Treatment of HUS
Atypical HUS give Plasma Exchange Eclizumab (C5 Monoclonal Inhibitor) > Plasma Exhange in ADULTS ATYPICAL HUS
68
Wilms Tumor Associations
Beckwith-Wiedemann syndrome (Macroglossia, Umbilical Hernia. Facial Plexus Nevus and Lateralized Growth) as part of WAGR syndrome with Aniridia, Genitourinary malformations, mental Retardation Hemihypertrophy Loss of Function Mutation in WT1 gene on Chromosome 11
69
Wilms Tumor Mets Commonly where ?
Lung
70
Cystinuria 1) How it causes recurrent renal stones 2) Chromosome and Gene associations 3) Diagnostic Test 4) Treatment
1) Defect in Membrane Transport for Cystine, Ornithine, Lysine and Arginine (COLA) 2) Chromosome 2: SLC3A1 gene, chromosome 19: SLC7A9 3) Cyanide Nitroprusside Test 4) Hydration D-Penicillamine Urine Alkalinization
71
Whats Stauffer Syndrome
Cholestatic Picture in RCC patients
72
Cause of False Negative PSA
Finasteride
73
Type 1 and Type 2 MPGN Electron Microscopy findings ?
Type 1 - subendothelial and mesangium immune deposits of electron-dense material resulting in a 'tram-track' appearance Type 2 - intramembranous immune complex deposits with 'dense deposits'
74
Autosomal Recessive Kidney Disease Mutation ?
Chromosome 6 Fibrocystin Gene Found via Prenatal USS scan
75
Mesangial deposition 
1. IgA nephropathy  2. Class II lupus nephritis  3. Diabetic nephropathy  4. MPGN
76
Subendothelial space 
1. RPGN  2. Class IV lupus nephritis 
77
Subepithelial Space
1. MPGN 2. Class V lupus nephritis  3. PSGN  
78
Glomerular hypercellularity 
1. PSGN 2. Lupus nephritis  3. MPGN
79
Cystinosis 1. Inheritance 2. Pathophysiology Homocystinuria 1. Inheritance 2. Pathophysiology 3. Features 4. Management
Cystinosis - autosomal recessive, mutation on chromosome 17. Accumulation of AA cystine in lysosome -> leads to Francois syndrome Homocystinuria - Autosomal recessive, deficiency of cysta-thionine beta-synthase. Features = tall, long arms, DOWNWARD lens dislocation, learning difficulties, DVT Management = pyridoxine supplements (vitamin B6)
80
Francois Syndrome Features
Bird Like Face Abnormal Teeth Hypotrichosis Congenital Cataract
81
Medications that make Urate Stones ?
Loop Diuretic Steroid Theophylline Acetazolamide
82

MRCP Part 1 (18 decks)

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