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what are mesangial cells?
specialised smooth muscle cells that support the glomerulus and regulate blood flow and GFR
how is the GBM charged?
negatively
what is the anion gap ?
difference between total cations and total anions
what charge are cations and anions?
cations = + anions = -
can negatively charged particles such as albumin pass through the GBM?
no
what substance does baroreceptors control the release of ?
ADH
what are the specialised cells in the afferent arteriole called?
juxtaglomerular cells
where is the most Na reabsorbed in the nephron?
PCT
what ion channel is present in the ascending limb ?
Na/K/2Cl triple symporter
what is Ca reabsorption under the control of?
PTH
what is Na reabsorption under the control of?
aldosterone
where in the nephron does pH and K regulation occur?
medullary collecting duct
what channels does water pass through in the cortical collecting duct?
aquaporin 2- channel
what paraneoplastic effects can renal cancers have?
EPO - polycythaemia
Renin - HTN
ACTH - cushings
PTHrP - hypercalcaemia
give an example of carbonic anhydrase inhibitor that is used for glaucoma ?
acetazolamide
what affect does carbonic anhydrase inhibitors have on the kidneys ?
decreases bicarbonate reabsorption
give an example of a loop diuretic?
furosemide
what is the mechanism of action of thiazide diuretics ?
inhibit NaCl in DCT
what is the mechanism of action of loop diuretics ?
inhibit Na/K/2Cl symporter in thick ascending limb
what is the mechanism of action of K sparing diuretics ?
Spiro: aldosterone antagonist
Amiloride: blocks DCT/CD luminal Na channel
what is a side effect of carbonic anhydrase inhibitors ?
drowsiness
renal stones
metabolic acidosis
what is a side effect of thiazide diuretic ?
hypokalaemia
hyperglycaemia
increased urate
what condition is contra indicated with thiazide diuretics ?
gout
what two molecules can give a false positive for haematuria ?
myoglobin, porphyria
what molecule can give a false positive for proteinuria ?
bence jones proteins
what are causes of proteinuria?
DM minimal change membranous GN amyloidosis SLE HTN UTI
when is creatinine synthesised?
during muscle turn over
what is urea produced form and in what cycle?
produced form ammonia by liver in ornithine cycle
what would an isolated increased urea suggest?
hypo perfusion
dehydration
state some post renal causes of renal disease ?
Stone Neoplasm Inflammation: stricture Prostatic hypertrophy Posterior urethral valves Infection: TB, schisto Neuro: post-op, neuropathy
state some uraemia symptoms ?
pruritus weight loss lethargy confusion metallic taste paraesthesia restless legs chest pain
state some symtpoms of Na retention ?
polyuria, polydipsia, breathlessness
state some signs of fluid overload ?
oedema
increased JVP
HTN
what breathing is seen in acidosis ?
kussmauls breathing
what are some symptoms of hyperkalaemia ?
palpitations
chest pain
weakness
what sign is seen on X-rays with osteomalacia ?
looser zones
what is Urethral Syndrome?
symptomatic but no bacteriuria
what are the different types of urolithiasis ?
calcium oxalate
triple phosphate
urate
what antibiotic is used for pyelonephritis ?
Cefotaxime
what investigations should be done for GN?
Basic: FBC, U+E, ESR
Complement (C3 and C4)
Abs: ANA, dsDNA, ANCA, GBM
Serum protein electrophoresis and Ig
Infection: ASOT, HBC and HCV serology
Dipstick: proteinuria ± haematuria
Spot PCR
MCS
Bence-Jones protein
what are the causes of GN?
Idiopathic Immune: SLE, Goodpastures, vasculitis Infection: HBV, HCV, Strep, HIV Drugs: penicillamine, gold Amyloid
what would be seen on IgA nephropathy biopsy ?
IgA deposition in mesangium
what is the treatment for IgA nephropathy?
steroids
what are some complications of nephrotic syndrome ?
infection - from reduced Ig, complement activity
VTE
hyperlipidaemia
will nephrotic syndrome have an increased or decreased JVP?
decreased
- fluid deplete
what is the treatment for proliferative GN?
supportive
what is the treatment for crescentic GN?
plasmapheresis and immunosuppression
state some systemic diseases that can cause nephrotic syndrome?
GM - glomerulosclerosis
SLE - membraneous
amyloidosis
what is the treatment for minimal change GN?
steroids
what does the biopsy of minimal change should?
normal light micro, fusion of podocytes on EM
what does the biopsy of membraneous nephropathy should?
subepithelial immune complex deposits
what immunoglobulin is deposited in FSGS?
IgM
what causes acute interstitial nephritis ?
Immune-mediated hypersensitivity ̄c either drugs or other Ag acting as haptans
what is the commonest cause of acute interstitial nephritis ?
drug hypersensitivity
what drugs can cause of hypersensitivity and acute interstitial nephritis?
NSAIDs
Abx: Cephs, penicillins, rifampicin, sulphonamide Diuretics: frusemide, thiazides
Allopurinol
Cimetidine
what immune disorders can cause acute interstitial nephritis
SLE, Sjogrens
what is the presentation of acute interstitial nephritis ?
Fever, arthralgia, rashes
AKI → olig/anuria
Uveitis
what does urinalysis show for acute interstitial nephritis ?
haematuria, proteinuria, sterile pyuria
what immunoglobulin will be increased with acute interstitial nephritis ?
IgE
what is the treatment for acute interstitial nephritis ?
Stop offending drug
Prednisolone
what will CT show for analgesic nephropathy?
CT w/o contrast (papillary calcifications)
what is chronic TIN (tubulo-interstitial nephropathy)
fibrosis and tubular loss
what causes chronic TIN?
Reflux and chronic pyelonephritis DM
SCD or trait
what can cause nephrocalcinosis ?
Malignancy ↑PTH Myeloma Sarcoidosis Vit D intoxification RTA
state three endogenous nephrotoxins ?
Haemoglobin, myoglobin
Urate
Ig: e.g. light chains in myeloma
what medication is nephrotoxic?
NSAIDs
Antimicrobials: AVASTA Aminoglycosides Vancomycin Aciclovir Sulphonamides Tetracycline Amphotericin ACEi
Immunosuppressants Ciclosporin
Tacrolimus
Contrast media
Anaesthetics: enflurane
what increases in the blood with rhabdomyolysis ?
K+, PO4, urate
Myoglobin, CK
what causes rhabdomyolysis ?
Ischaemia: embolism, surgery
Trauma: immobilisation, crush, burns, seizures,
compartment syndrome
Toxins: statins, fibrates, ecstasy, neuroleptics
what colour is the urine with rhabdomyolysis ?
red/brown
what is present in the urine with rhabdomyolysis ?
Hb but not RBCs
what is the treatment of rhabdomyolysis
Rx hyperkalaemia
IV rehydration: 300ml/h
what blood tests should be done for CKD?
↓Hb, U+E, ESR, glucose, ↓Ca/↑PO4, ↑ALP, ↑PTH
Immune: ANA, dsDNA, ANCA, GBM, C3, C4, Ig, Hep
Film: burr cells
what is found in the urine with myeloma?
BJP (Bence jones proteins)
what are some complications of CKD?
Cardiovascular disease Renal osteodystrophy Fluid (oedema) HTN Electrolyte disturbances: K, H Anaemia Leg restlessness Sensory neuropathy
what condition is Rugger Jersey spine seen?
osteosclerosis
what is a bone complication of CKD?
renal osteodystrophy
what is the mechanism of renal osteodystrophy?
↓ 1-hydroxylase → ↓ vit D activation → ↓ Ca → ↑ PTH
Phosphate retention → ↓ Ca and ↑ PTH (directly)
↑ PTH → activation of osteoclasts ± osteoblasts
Also acidosis → bone resorption (phosphate lost to excrete H ion in kidneys)
what life style changes can be made for CKD?
Exercise
Healthy wt.
Stop smoking
Na, fluid and PO4 restriction
what is HTN treated with in DM kidney disease?
ACEi
ARB
what four medications can be given to help with renal bone disease ?
Phosphate binders: sevelamer, calcichew
Vit D analogues: alfacalcidol (1 OH-Vit D3)
Ca supplements
Cinacalcet: Ca mimetic
what can be given for restless legs with CKD?
clonazepam
what could cause rising Cr in transplant patient ?
Rejection
Obstruction
ATN
Drug toxicity
state the pathology of DM renal disease which results in HTN?
Hyperglycaemia → renal hyperperfusion → hypertrophy and ↑ renal size
Hypertrophy and metabolic defects inc. ROS production → glomerulosclerosis and nephron loss
Nephron loss → RAS activation → HTN
how is a diagnosis of amyloid kidney disease?
large kidneys in US
biopsy
what renal disease does sarcoidosis result in ?
TIN
↑Ca
what renal disease does myeloma result in ?
ATN - damage from light chains
what is the treatment of myeloma renal disease?
Ensure fluid intake of 3L/d to prevent further impairment
what renal disease does NSAIDs result in ?
ATN
SLE renal disease proteinuria should be treated with?
ACEI
SLE renal disease aggressive GN should be treated with?
immunosuppression
what rheumatological condition can have renal crisis as a complication?
diffuse systemic sclerosis
- other complications include small bowel bacteria overgrowth, pulmonary fibrosis
what is a renal crisis?
malignant HTN + ARF
what is the treatment for renal crisis?
ACEi
what is the gold standard investigation for renovascular disease?
renal angiography
what is the treatment for renovascular disease?
angiography and stenting
what organism causes HUS?
E. coli O157:H7: verotoxin
what does HUS stand for ?
Haemolytic Uraemic Syndrome
what cells are seen on blood film for HUS?
Schistocytes
does HUS have normal clotting ?
yes
what is the treatment for HUS?
Usually resolves spontaneously
Dialysis or plasma exchange may be needed
what condition has Genetic or acquired deficiency of ADAMTS13?
Thrombotic Thrombocytopenia Purpura (TTP)
what is the treatment for Thrombotic Thrombocytopenia Purpura (TTP)?
Plasmapheresis, immunosuppression, splenectomy
what are the features of thrombotic thrombocytopenia purpura?
Fever CNS signs: confusion, seizures MAHA Thrombocytopenia Renal failure
what does MAHA stand for?
microangiopathic hemolytic anemia
what is Fanconi Syndrome?
Disturbance of PCT function → generalised impaired reabsorption
what are the features of Fanconi syndrome ?
Polyuria (osmotic diuresis)
Hypophosphataemic rickets (Vit D resistant) Acidosis, ↓K
what is Bartter’s Syndrome?
Blockage of NaCl reabsorption in loop of Henle (as if taking frusemide)
Congenital salt wasting
what is Gitelman Syndrome?
Blockage of NaCl reabsorption in DCT (as if taking thiazides)
Congenital salt wasting