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Year 2 Clinical > Presentation of Renal Disease > Flashcards

Presentation of Renal Disease Flashcards

1
Q

Presentation of renal disease?

A

Many patient are asymptomatic and it is an incidental finding

Loin pain/urinary symptoms

Haematuria:
• Microscopic
• Painless macroscopic haematuria (typical of IgA nephropathy, looks like coca-cola)

Proteinuria

Hypertension (asymptomatic OR accelerated)

Acute kidney injury (AKI)
Chronic kidney disease (CKD)

Nephrotic syndrome
Nephritic syndrome

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2
Q

Functions of the kidneys and what happens when these fail?

A
  1. Excretion of urea - uraemia
  2. Fluid balance - fluid retention and oedema
  3. Electrolyte balance - hyperkalaemia and arrhythmia
  4. Acid-base balance - metabolic acidosis and Kussmaul’s respiration
  5. Vitamin D metabolism - renal bone disease (rickets/osteomalacia) and vascular claudication
  6. Production of erythropoietin - anaemia
  7. Drug excretion - drug toxicity, e.g: digoxin, gabapentin
  8. Barrier to loss of proteins - proteinuria and nephrotic syndrome
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3
Q

What does uraemia mean?

A 
Raised urea in the blood leading to:
• Pericarditis
• Encephalopathy and asterixis (CO2/liver flap)
• Neuropathy
• Gastritis
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4
Q

Findings that indicate renal disease on examination and Ix in an asymptomatic patient?

A

Raised BP

Dipstix - microscopic haematuria and/or proteinuria

Reduced eGFR

Incidental findings on abdominal imaging, e.g: USS

Screening due to FH

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5
Q

Systemic features of PC in a patient with renal disease?

A

Related to an underlying disease, e.g:
• Diabetes mellitus
• CTD
• Vasculitis

Related to loss of kidney function, e.g:
• Uraemia
• Fluid retention and oedema
• Anaemia
• Bone pain
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6
Q

Local/renal features of PC in a patient with renal disease?

A

Loin pain

Macroscopic haematuria

UTI

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7
Q

Systemic enquiry in renal disease?

A

Reduced appetite and weight loss

N&V and dyspepsia

Dyspnoea

Urinary symptoms, e.g:
• Frequency (unable to create conc. urine)
• Urgency 
• Hesitancy
• Polyuria and nocturia

Arthralgia

Skin rash (palpable, purpuric for vasculitis)

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8
Q

PMH of relevance in renal disease?

A

CKD, DM, vascular disease (if kidneys do not receive enough blood, they can become ischaemic)

Surgery

TB

Rheumatological disease, e.g: RA

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9
Q

FH of relevance in renal disease?

A

Renal disease, e.g: polycystic kidney disease

Hypertension

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10
Q

SH of relevance in renal disease?

A

Smoking, alcohol, occupation (inorganic dyes, etc), carers

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11
Q

DH of relevance in renal disease?

A

ACEIs, ARBs (good in renal disease but contraindicated with renal artery stenosis), diuretics

NSAIDs, antibiotics, PPIs

Radiology contrast

OTC/herbal remedies

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12
Q

Systemic examination signs in renal disease?

A 
Related to disease:
• Pyrexia
• Skin rash
• Heart murmurs
• Consolidation
• ENT symptoms
• Retinopathy (DM and hypertension)
• Neuropathy 
• Arterial bruits, e.g: femoral, are a sign of vascular disease
• Rheumatoid 
Related to loss of kidney function:
• Pallor
• Arrhythmia
• Pericardial rub and lung crepitations
• Raised JVP (fluid retention) and oedema 
• Gout
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13
Q

Local/renal examination signs in renal disease?

A

Tender loins or upper abdomen

Arterial bruits (over the kidneys)

Palpable kidneys (only in gross disease)

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14
Q

BP cut-off in renal disease?

A

Unacceptable if >140/90 mmHg

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15
Q

What is accelerated hypertension?

A

NOT INTERCHANGEABLE WITH MALIGNANT HYPERTENSION (which is assoc. with fibrinoid necrosis)

Medical emergency where the diastolic BP is >120 mmHg and these is assoc:
• Papilloedema
• End-organ decompensation

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16
Q

Examples of end-organ decompensation that may occur in acceleration hypertension?

A

Encephalopathy

Fits

Cardiac failure and acute renal failure

17
Q

Other signs of renal failure/disease?

A

Leukonychia (proteinuria can cause hypoalbuminaemia)

Splinter haemorrhages

Vasculitis skin rash (systemic vasculitis OR acute glomerulopnephritis)

Gouty tophi (gout is more common with renal disease)

18
Q

Variable macroscopic appearance of urine?

A

Normal is straw-coloured

Dark, conc. urine indicates dehydration

Red urine (frank haematuria) - indicates lower urinary tract pathology

Coca-cola urine - indicates upper urinary tract pathology

19
Q

Urinalysis values?

A

Specific gravity (urine conc.)

Haematuria (Hb)

Proteinuria

pH - if alkaline, that indicates an acidosis or a UTI

Leukocyte esterase/nitrites - UTI

20
Q

Methods of quantifying urine protein?

A

24 hour urine collecting (impractical now) - normal is <150 mg / 24 hours

Urine protein : creatinine ratio - 50 mg / mmol

21
Q

Different ranges of proteinuria?

A 
Asymptomatic Low Grade (<1 g / day)
Heavy Proteinuria (1-3g / day)
Nephrotic Range (>3g / day)
22
Q

Uses of urine microscopy?

A

Can shows:
• Bacteria
• RBCs

23
Q

Types of RBCs that can be seen on urine microscopy?

A

Isomorphic - normal, doughnut shaped RBCs; presence indicates a lower urinary tract bleed

Dysmorphic - central, white area in the RBC; presence indicates a glomerular bleed

24
Q

Types of urinary casts?

A

Hyaline - usually benign

Red cell - always pathological and usually assoc. with nephritic syndrome

Leukocyte - infection/inflammation

Granular - indicative of chronic disease

25
Q

ECG signs that may be seen with renal disease?

A

If severe hypertension, may have caused left ventricular hypertrophy (tall QRS complexes)

Hyperkalaemia shows peaked (tall, tented) T-waves

26
Q

Stages of CKD according to the GFR?

A

Stage 1 - kidney damage with normal/increased GFR:
• ≥90

Stage 2 - kidney damage with mildly decreased GFR:
• 60-89

Stage 3 - moderately decreased GFR:
• 30-59

Stage 4 - severely decreased GFR:
• 15-29

Stage 5 - kidney failure:
• <15 or dialysis

27
Q

Patterns of CKS?

A

Stable CKD has a stable GFR over a period of time

Progressive CKD shows a progressively decreasing GFR over a period of time

28
Q

Define acute kidney injury?

A

Decline in GFR over hours/days/weeks:
• With or without oliguria (<400ml urine output/day)
• In a patient with normal/impaired baseline renal function

29
Q

Creatinine pattern in AKI?

A

Rises and then decreases (once AKI settle), however it never returns to normal

30
Q

Define AKI on CKD?

A

Patient who has CKD develops AKI

31
Q

Define diagnostic features of nephrotic syndrome?

A

Proteinuria >3g/day (mostly albumin but also other globulins)

Hypoalbuminaemia

Oedema (nephrOtic syndrome) - pitting oedema on ankles, peri-orbital oedema, etc

They also develop hypercholesterolaemia due to reduced carriage; they often have NORMAL renal function (not always)

32
Q

Define diagnostic features of nephritic syndrome?

A 
AKI with:
• Oliguria 
• Oedema/fluid retention
• Hypertension
• Active urinary sediment, e.g: RBCs, RBC and granular casts, proteinuria

Year 2 Clinical (119 decks)

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