Nephrology 2 Flashcards
What are the subtypes of nephritis?
Glomerulonephritis
Interstitial nephritis/tubulo-interstitial nephritis
How does nephritis present?
Nephrotic syndrome Nephritic syndrome AKI CKD Renal pain and dysuria
What are the clinical features of nephritic syndrome?
Haematuria and proteinuria
Oliguria
Oedema
Uraemic symptoms
What symptoms suggest elevated levels of urea?
Anorexia
Pruritus
Lethargy
Nausea
What are some causes of nephritis?
Post Group A strep infection
EBV/Hep B infection
SLE/HSP
How is suspected nephritis managed?
Urine dipstick for protein and blood
Refer to secondary care
What is nephrotic syndrome?
A type of glomerulopathy where there is immunologically mediated injury to glomeruli
What are the 3 cardinal signs of nephrotic syndrome?
Large proteinuria (>3.5g/day)
Oedema
Hypoalbuminaemia (serum albumin <30g/L)
How do the signs of nephrotic syndrome come about?
Increased permeability of serum protein through the damaged basement membrane of the renal glomerulus
What are some other problems in nephrotic syndrome?
Dyslipidaemia
Coagulation/fibrinolysis abnormalities
Immunological disorders
What percentage of nephrotic patients progress to end stage renal failure?
25%
What is the most common cause of nephrotic syndrome in adults?
Focal segmental glomerulosclerosis
Name three secondary causes of nephrotic syndrome.
Diabetic nephropathy
SLE
Multiple myeloma
How does hyperlipidaemia occur in nephrotic syndrome?
In response to hypoalbuminaemia, the liver commences a compensatory mechanism, synthesizing proteins
Describe the oedema of nephrotic syndrome.
Children - facial/periorbital then spreads to whole body
Adults - starts with peripheral and spreads to whole body
Genital
Other than oedema, what are the other symptoms of nephrotic syndrome?
Frothy urine
Hypercoagulability
Fatigue etc
Xanthomata
How is nephrotic syndrome diagnosed?
Urine dipstick for haematuria and proteinuria, quantify using early morning urinary PCR or ACR
Renal biopsy and USS
eGFR
FBC and biochemistry
How is nephrotic syndrome managed?
Sodium and fluid restriction
High dose diuretics
PO prednisolone 6 months
What is the treatment of relapsed nephrotic syndrome?
Cyclophosphamide/ciclosporin
What are the different glomerulonephritides?
Minimal change Focal segmental glomerulosclerosis Membranous nephropathy Membranoproliferative glomerulonephritis Rapidly progressive glomerulonephritis
What is the cause of minimal change disease?
Idiopathic/infection/neoplasm
Loss of podocytes and fusion of foot processes
When is the peak incidence of minimal change disease?
2-3 years males
How do most glomerulonephritides present?
Nephrotic syndrome
What is the treatment of minimal change disease?
High dose prednisolone
What is the name of infection within the renal pelvis/parenchyma?
Pyelonephritis
What are the risk factors for chronic pyelonephritis (from repeated attacks of acute pyelonephritis)?
Vesicoureteric reflux
Diabetes
Structural renal tract anomalies
Which organisms cause pyelonephritis?
The same as for lower UTI: E.coli, klebsiella, proteus, enterococcus.
What are risk factors for acute pyelonephritis and cystitis?
Female Children and elderly Abnormalities of the renal tract Calculi Immunocompromised Incomplete bladder emptying
How does pyelonephritis present?
Loin/suprapubic/back pain Fever and rigors V+D, malaise, anorexia LUTS Tenderness without guarding
Name some LUTS.
Frequency
Hesitancy
Dysuria
Gross haematuria
What is found on urinalysis in pyelonephritis?
Urine cloudy with offensive smell
Dipstick positive for blood, protein, leukocyte esterase, nitrite
Pyuria in MCS
What are other investigations in pyelonephritis?
Raised CRP and WCC
+ve cultures
USS in men, children, and recurrent cases
Which antibiotic is recommended for pyelonephritis?
Ciprofloxacin or co-amoxiclav
If culture confirms sensitivity then trimethoprim.
Which bacteria are sensitive to trimethoprim?
E.coli Proteus Klebsiella Enterococcus HIB Strep.pneumoniae
What are three complications of pyelonephritis?
Pyonephrosis
Perinephric/renal abscess
Sepsis
Which types of E.coli are associated with pyelonephritis, and cystitis?
Pyelonephritis - type p fimbriae (PapG adhesin)
Cystitis - type 1 fimbriae (FimH adhesin)
When is a UTI a relapse, and a reinfection?
Relapse: same organism, within 7 days
Reinfection: same or different organisms, after 14 days
How is UTI diagnosed?
Nitrites and leukocyte esterase on dipstick
MCS - leukocytes
How is UTI treated?
Trimethoprim or nitrofurantoin
3d women, 7d men
From where does renal cell carcinoma arise?
Proximal tubule epithelium
What is the most common type of RCC?
Clear cell
Where does RCC spread?
Adrenal glands, liver, spleen, colon, pancreas
Most common site of metastases - lungs, cannon ball secondaries
What are the risk factors for RCC?
Smoking and obesity
Renal disease
Von Hippel Lindau syndrome (AD inheritance, multiple tumours developed)
What is the classic triad of RCC?
Haematuria
Loin pain
Loin mass
But often asymptomatic
How may a left sided varicocele develop in RCC?
If the tumour has invaded the left renal vein, the left testicular vein is obstructed.
Why might hypertension occur in RCC?
Tumour secretes renin
30% RCC patients have paraneoplastic symptoms such as…
Neuromyopathy Anaemia Polycythaemia Amyloidosis Hypercalcaemia
What is the best investigation initially for RCC?
Abdominal CT with contrast
What is the gold standard treatment of RCC?
Laparoscopic partial nephrectomy
What is the gold standard treatment of metastatic RCC?
Tumour nephrectomy with IFN-alpha chemotherapy
What is the syndrome of inappropriate ADH secretion?
Excess release of ADH from posterior pituitary or ectopic source
Why is ADH released normally?
In response to hyperosmolality.
What is the function of ADH?
Increases the amount of water reabsorbed in the kidney
Constricts arterioles, which increases peripheral vascular resistance and arterial blood pressure
What is the pathophysiology of SIADH?
Patient drinks water, plasma osmolality decreases, but ADH continues to be released, leading to a hypo-osmolar state
Which tumours may secrete ADH?
GI
Lung small cell
GU
Lymphoma
Which conditions may increase ADH secretion?
CNS infection, mass, or bleed
Hydrocephalus
MS
Pneumonia or asthma
Which drugs may increase ADH secretion?
Diuretics
SSRIs
PPIs
ACEIs
How does SIADH present?
Stems from water retention and hyponatraemia:
- Confusion, coma, seizures
- Nausea
- Muscle weakness and ataxia
- Cheyne Stokes respiration
How is SIADH diagnosed?
Serum hypoosmolality<275mOsm/kg (low)
Urine osmolality>100mOsm/kg and sodium>30mmol/L (high)
What should be excluded in SIADH investigations?
Hypothyroidism
Addison’s disease
Which formula should be used to calculate electrolyte free water clearance?
Furst formula
What are the principles of management of SIADH?
Fluid restriction in most cases
Increase sodium levels
What drug can be used for SIADH?
Tolvoptan or demeclocycline
What are the symptoms of IgA nephropathy?
Recurrent episodes of macroscopic haematuria, 1-2 days after URTI
How does IgA nephropathy differ from post-strep glomerulonephritis?
Post-strep occurs weeks after URTI
What is the treatment of ascites in patients with chronic liver disease?
Aldosterone antagonists - spironalactone
How do you calculate anion gap?
(Na + K) - (Cl + HCO3)
What is the normal range for anion gap?
8-16mEq/L
How can you differ dehydration from AKI?
In dehydration, the urea is proportionally higher than a rise in creatinine
What is the management of acute clot (urinary) retention?
Continuous bladder irrigation via a 3 way urethral catheter
What is the usual first line option of renal replacement therapy?
Peritoneal dialysis
How does autosomal dominant polycystic kidney disease present?
Usually in 3rd to 4th decade
Haematuria/hypertension Polycythaemia Liver cysts Berry aneurysms MV prolapse
How does autosomal recessive polycystic kidney disease present?
In childhood
Haematuria/HTN
Hepatic fibrosis and portal hypertension
Name three chronic metabolic complications of haemodialysis treated end stage renal failure.
Amyloidosis
Secondary or tertiary hyperparathyroidism
Dyslipidaemia
