Renal Flashcards
Causes of hypernatraemia? (4)
How may this present in an infant?
Rx?
Dehydration (e.g. D&V, high fever)
Osmotic diuresis (e.g. DKA)
Diabetes insipidus
Excessive saline infusion
In an infant: jittery, increased muscle tone, hyperreflexia, sunken fontanelles, drowsiness, eventually coma
Rx: Oral rehydration solution 1st line
Slow infusion IV 0.9% NaCl if cannot tolerate oral (D&V), sepsis/shock suspected, or if oral not working
Drugs to stop in AKI as they will cause worsening? (3)
DAAAMN
Diuretics
ACEI/Aminoglycoside/ARB
Metformin
NSAIDs
Drugs that may have to be stopped in AKI as they will build up?
Metformin
Digoxin
Lithium
Is aspirin safe in AKI?
At cardioprotective dose 75mg
Is paracetamol safe in AKI?
Yes
Is warfarin safe in AKI?
Yes
Are statins safe in AKI?
Yes
Is clopidogrel safe in AKI?
Yes
Are B Blockers safe in AKI?
Yes
Diagnosis of AKI?
4 symptoms, 3 bloods
Symptoms:
- oliguria
- oedema
- arrhythmias (from K/acid build up)
- features of uraemia (pericarditis, encephalopathy)
Bloods:
- rise in serum creatinine by 26 mol/l in 48 hours
- rise in serum creatinine by 50% in 7 days
- fall in urine output less than 0.5 ml/kg/hr for 6 hours
What usually increases during an AKI?
Things that the kidney normally excretes
- K
- Creatinine
- Urea
Also usually acidosis
SE of EPO therapy?
Why might someone not respond?
- Accelerated hypertension (encephalopathy and seizures)
- Bone ache
- Flu-like symptoms
- Pure red cell aplasia
- Iron deficiency due to increased erythropoiesis
Non-responsive:
- iron deficiency
- inadequate dose
- infection
- hyperparathyroid bone disease
Alport’s Syndrome:
- inheritance?
- presentation?
- diagnosis?
- why might a transplant fail in an alport’s pt?
X-linked dominant
In childhood:
- microscopic haematuria
- progressive renal failure
- bilateral sensorineural deafness
- Lenticonus: lens protrudes into anterior chamber (needs glasses)
- Retinitis pigmentosa
Diagnosis:
- genetic testing
- renal biopsy: EM - longitudinal splitting of lamina dense of GBM, causing ‘basket-weave’ appearance
Fail: due to anti-GBM antibodies against normal GBM
Minimal change disease:
- presentation? (1)
- renal biopsy? (2)
- Management?
- Nephrotic syndrome (normotension)
Biopsy:
- LM: normal glomeruli
- EM: fusion of podocytes, effacement of foot processes
Rx:
- Oral pred + urgent referral
- Cyclophosphamide if resistant
Why can nephrotic syndrome cause blood clots?
What must happen?
How can it cause infection?
How can it cause hypocalcaemia?
Clots:
- ATIII and plasminogen lost to urine
- Can cause DVT and renal vein thrombosis
- LMWH
Infection: Ig lost to urine
Hypocalcaemia: VitD and binding protein lost in urine
ADPKD:
- presentation? (4)
- extra-real manifestations? (4)
As a young adult:
- hypertension
- abdo pain
- CKD
- loin mass
- haematuria
Extra-renal:
- liver cysts (most common) - hepatomegaly
- berry aneurysm
- mitral/tricuspid incompetence
- pancreatinc/splenic cysts
IgA nephropathy vs post-strep glomerulonephritis?
IgA:
- 1-2 days after URTI
- haematuria
- caused by IgA
Post-strep:
- 1-2 weeks after URTI
- Proteinuria
- haematuria
- low complement count
- caused by IgG, IgM and C3 deposition in glomeruli
Caused by GAS
Renal biopsy of post-strep?
- Acute, diffuse, proliferative glomerulonephritis
- Endothelial proliferation with neurtophils
- EM: subaopithelial ‘humps’ caused by lumpy immune complex deposition
- IF: granular or ‘starry sky’ appearance
How to tell intrinsic AKI from pre/post renal?
Protein present in intrinsic
How to tell primary from secondary hyperaldosteronism?
Pt with refractory hypertension, low K and high Na (since high aldosterone)
Look at renin activity. If renal artery stenosis then low afferent blood flow will stimulate renon release and cause they hyperaldosteronism
3 things renal artery stenosis can cause?
Renal artery stenosis due to atherosclerosis is most common cause of renal vascular disease (90%), what is next most common cause?
- hypertension
- CKD
- flash pulmonary oedema
Fibromuscular dysplasia
50 y/o patient with progressive weakness, and dyspnoea, hepatomegaly, reduced renal function, T2DM, COPD, no FHx?
Diagnosis?
Amyloidosis
Rectal biopsy - congo red staining shows apple-green birefringence
What should you think of in young woman who develops AKI in response to ACEI?
What is seen on renal USS?
What is seen on duplex scan?
What is next Ix?
Fibromuscular dysplasia
USS: normal kidneys and urinary system
Duplex: stenotic arteries
MR angiography: ‘string of beads’ appearance
HSP:
- what is it?
- features? (4)
- treatment?
- IgA small-vessel vasculitis after URTI - degree of overlap with IgA nephropathy
- palpable purpuricrash with localised oedema over buttocks, extensors and legs
- abdo pain
- polyarthritis
- features of IgA nephropathy (haematuria, renal failure)
Rx: supportive. Good prognosis
If someone with CKD and low GFR needs contrast scan?
Offer Iv hydration before and after contrast infusion
Why is lupus nephritis different from other nephritic syndromes?
There are 6 different types of lupus nephritis - what is the most common?
What is seen on renal biopsy with this?
All patients with lupus nephritis will have proteinuria
Diffuse proliferative glomerulonephritis
endothelial and mesangial proliferation, ‘wire-loop’ appearance
EM: sub endothelial immune complex deposits
IF: granular appearance
Management of rhabdomyolysis causing myoglobinaemia?
What dangerous electrolyte disturbance may occur with this, and may appear before AKI?
Among other causes, e.g. prolonged collapse, seizure, ecstasy etc, what 2 common drugs may interact to cause this?
Lots of IV fluids to maintain good urine output, urinary alkalisation sometimes used
Hyperkalaemia
Statins with clarithromycin - don’t prescribe together
4 causes of transient non-visible haematuria?
5 causes of persistent non-visible haematuria?
2 causes of spurious red/orange urine where blood not present on dipstick?
- UTI
- menstruation
- vigorous exercise (settles after 3 days)
- sex
- cancer (kidney, renal, prostate)
- stones
- BPH
- prostatitis/urethritis (e.g. chlamydia)
- renal e.g. IgA nephropathy
Food: beetroot, rhubarb
Drugs: rifampicin, doxorubicin
Define persistent non-visible haematuria?
What else should be tested? (3)
Non-visible haematuria present on 2/3 samples tested 2-3 weeks apart
Renal function
ACR or PCR
BP
Who gets urgent cancer referral for haematuria?
Age 45+ AND:
- visible haematuria without UTI
- visible haematuroa that persists past UTI
Age 60+ AND:
- unexplained non-visible haematuria with dysuria/raised WBC on bloods
Who gets non-urgent cancer referral for haematuria?
Age 60+ AND:
- recurrent/persistent UTI
Acute interstitial nephritis:
- what is it?
- causes?
- features?
- Ix?
allergic-type reaction involving kidneys, causing interstitial oedema and infiltrates in the connective tissue between renal tubules - accounts for 25% of all drug-induced AKI
Most commonly drugs, usually antibiotics (penicillin, rifampicin) - also NSAIDs, allopurinol, furosemide
Features:
- fever, rash, arthralgia
- Eosinophilia
- mild renal impairment
- hypertension
Ix:
- sterile pyuria (WCC on dipstick but no culture)
- white cell casts
How long for fistulas to develop for dialysis?
3 complications?
6-8 weeks
- infection
- thrombosis (bruit)
- stenosis (limb pain, ischaemia)
What is the most common cause of nephrotic syndrome in adults?
What is seen on biopsy?
Causes?
Membranous glomerulonephritis
- LM: thickened basement membrane
- EM/silver staining: ‘spike and dome appearance’ due to sub epithelial deposits
Causes:
- anti-phospholipase A2 Ig
- hepB, malaria
- malignancy (prostate, lung, blood)
- autoimmune diseases
Management of membranous glomerulonephritis?
All its receive ACEI/ARB
Immunosuppression
Anticoagulation for high risk pts
Stages of CKD?
Definition of CKD?
1 - GFR >90 2 - GFR 60-90 3a - GFR 45-59 3b - GFR 30-44 2 - GFR 15-29 1 - GFR <15 - RRT if uraemia present
Reduced GFR and evidence of kidney damage for at least 3 months. Evidence:
proteinuria, haematuria, abnormal U&E, abnormal imaging. More proteinuria = more damage
6 things that can cause CKD
Diabetes - commonest Glomerulonephritis - 2nd Hypertension Chronic pyelonephritis Renovascular disease PKD Idiopathic - small, scarred kidneys unknown cause
At what GFR do symptoms usually become apparent for CKD?
Mild symptoms
Mod?
Sev?
GFR <20 - due to altered conc of electrolytes and urea
Mild - nocturia (unable to concentrate urine)
Mod - non-specific: fatigue, weakness, loss of appetite, nausea, abdominal cramps, gout, bad taste in mouth
Sev - Restless leg, yellow/brown tinge in skin, paraesthesia/cramps, encephalopathy, pericarditis,, itch, halitosis, seizures, uraemia frost
General management of CKD?
Slow progression with ACEI/ARB +/- Spironolactone
Aim for BP <130/80 to reduce proteinuria
Optimise glycaemia
Counsel on RRT once GFR <15
Anaemia of CKD - what type normally?
Management?
Normochromic normocytic (due to decreased EPO) - can also have malabsorption of Fe/B12/folate, decreased cel survival (dialysis), concurrent GI blood loss etc
Target Hb 10.5-12.5
Optimise Fe status - many require IV Fe
EPO injections weekly
How does renal bone disease occur?
What are the manifestations?
Management?
- high phosphate ‘drags’ Ca from bones –> osteomalacia
- Low vitD (no activation in kidney) causing low Ca –> secondary hyperparathyroidism
Manifest:
- osteoporosis
- osteomalacia
- osteitis fibrosa cystica (due to unchecked hyperparathyroidism)
- osteosclerosis
Rx:
- reduce dietary phosphate
- phosphate binders (calcium carbonate, sevelamer)
- VitD (calcitriol)
- parathyroidectomy in some cases
- Alendronic acid to prevent osteomalacia/osteoporosis
Calcium based phosphate binders risk hypercalcaemia and vascular calcification, so sevelamer may be better option
3 options of RRT?
Haemodialysis:
- most common, usually 3-4 sessions a week
- AV fistula
Peritoneal dialysis:
- filtration in patient’s abdo
- CAPD or APD (overnight)
Renal transplant
Life expectancy of renal transplant?
Anti-rejection meds?
What type of matching is best?
Risks of immunosuppression? (3)
10-12 years
ciclosporin/tacrolimus + MMF
Steroids in acute rejection
HLA most important (DR>A>B surface antigens)
CVD, renal failure, SCC of skin
3 types of transplant rejection?
Hyperacute - mins-hours - type II hypersensitivity from pre-existing Ig to HLA (rare - immediate removal)
Acute (<6 months) - HLA mismatching - Tc cell mediated - can be reversed with steroids
Chronic (>6 months) - chronic allograft nephropathy (renal fibrosis)
Peritoneal dialysis, fever, cloudy dialysis?
How does PD work?
Staph epidermidis
Inject high dextrose solution into abdominal cavity which draws out waste products from blood, drained after several hours dwell time and exchanged for new dialysis solution (so risk of hyperglycaemia as well)
What is seen on biopsy of diabetic nephropathy?
Does it cause nephritic/nephrotic syndrome?
What should be checked annually?
3 main management points in diabetic nephropathy?
Nodular glomerulosclerosis - kimmelstein-wilson lesions
Nephrotic syndrome
Urinary albumin:creatinine ratio
- Tight glycaemic control
- BP <130/80 (ACEI)
- Statin
What is microalbuminuria?
What is clinical proteinuria?
ACR 2.5-30
Lose 0.15g protein each day in urine
Dipstick will be negative
Regard >2.5 as clinically significant proteinuria. If ACR >70 start ACEI regardless of BP
ACR >30 - will show up as + on dipstick (loss of 0.45g protein per day)
Presentation of chronic pyelonephritis?
What does it cause to the kidney?
Most common cause?
Other causes?
Can be vague - hypertension/CKD, maybe hydronephrosis
Asymmetrical scarring, fibrosis and contraction of the kidney
Vesicoureteric reflux causing reflux nephropathy (name of chronic pyelonephritis due to reflux)
Others: recurrent acute infection, chronic obstruction, xantho-granulomatous abscess
Presentation of vesicoureteric reflux?
Ix?
- May be hydronephrosis in antenatal scan
- Recurrent childhood UTI
- Reflux nephropathy
(renal scarring may increase renin release causing hypertension) - Normally diagnosed with micturating cystourethrogram
- DMSA scan can look for renal scarring
Causes of ischaemic nephropathy?
Essential hypertension Renovascular disease (atherosclerosis 90%, FMD 10%)
Features of renal artery stenosis? (6)
Ix?
Medical Rx?
Surgical Rx?
Hypertension AKI (due to ACEI initiation) Flash pul oed CKD Renal bruit Discrepency in size of kidneys on USS as usually unilateral
Renal US –> Duplex US –> CT angiography
Med: Statin, ACEI (contraindicated in bilateral renal artery stenosis), anti-platelet (same as atherosclerotic disease)
Surgical: angioplasty +/- stent
In GN, what leads to haematuria?
What leads to proteinuria?
Haematuria - due to endothelial/mesangial damage (proliferative)
Proteinuria - due to podocyte damage (non-proliferative - atrophy)
What 3 things cause nephritic syndrome (haematuria, hypertension)?
Rapidly progressive GN
IgA nephropathy
Alport syndrome
What 5 things cause nephrotic syndrome (proteinuria, oedema)?
Minimal change Membranous GN Focal segmental glomerulosclerosis Amyloidosis Diabetic nephropathy
What 3 things can cause a mixed picture of nephritic/nephrotic syndrome?
Diffuse proliferative GN
Membranoproliferative GN
Post-streptococcal GN
Biopsy for IgA nephropathy?
Rx?
LM: mesangial cell proliferation (nephritic)
IF: IgA and C3 deposition
Rx: BP control (ACEI/ARB) and fish oil
(steroids/immunosuppression NOT useful)
Biopsy of minimal change?
LM: normal
EM: podocyte fusion and foot process effacement
Rx: steroids, cyclophosphamide if steroid resistant
Focal segmental glomerulosclerosis:
- typical Hx?
- assoc?
- biopsy?
- Rx?
young adult with nephrotic syndrome and CKD
HIV, reflux nephropathy, heroin, sickle cell
LM: focal/segmental sclerosis + hyalinosis
EM: effacement of foot process
IF: minimal Ig/complement deposition
Rx: steroids +/- immunosuppression - 60% steroid sensitive, 50% progress to ESRF
Membranous nephropathy:
- typical Hx?
- Assoc?
- biopsy?
- Rx?
- Rule of 1/3?
Adult with proteinuria and nephrotic syndrome
Primary - anti-phospholipid A2 Ig (PLA2R)
Secondary - cancer, infection, systemic disease
EM: thick BM, sub-epithelial deposits causing spike and dome appearance
Rx: ACEI, steroids + cyclophosphamide +/- B-cell monoclonal AB
1/3 resolve spontaneously
1/3 respond to Rx
1/3 –> ESRF
Rapidly progressive GN:
- Typical presentation?
- Biopsy?
- Rx?
- AKI, nephritic syndrome with features of underlying condition (SLE, ANCA, Goodpasture’s)
- treatable cause of AKI +/- granular casts
Biopsy: crescentic glomeruli
Rx: Immunosuppression (steroids, cyclophosphamide, azathioprine) +/- plasmapheresis +/- temporary RRT
Membranoproliferative GN:
- Typical Hx?
- Biopsy?
- Rx?
Nephritic and nephrotic syndrome –> poor prognosis
Depends on subtype:
- Type 1 - ‘tram track’ appearance on EM (most common)
- Type 2 - intramembranous immune complex deposition with dense deposits
Rx: Steroids may help
Post-strep GN:
- typical Hx?
- Biopsy?
- Rx?
Kid with GABHS infection (usually pyogenes) 7-14 days prior
Haematuria, proteinuria, hypertension, LOW C3, headache, malaise
Biopsy:
- EM - sub epithelial humps by lumpy immune deposits
- IF - granular/starry sky appearance (neutrophilic)
Rx: supportive - good prognosis
Goodpastures:
- typical Hx?
- Ig?
- Renal biopsy?
- Other thing in blood?
- Rx?
Pulmonary haemorrhage and rapidly progressive GN
Anti-GMB Ig against type IV collagen
Biopsy: linear IgG deposits along basement membrane
Raised transfer-factor
Rx: steroids/cyclophosphamide +/- plasmapheresis
Rx for lupus nephritis?
Azathioprine/MMF (organ involvement)
Hydroxychloroquine (arthritis)
IV steroids/cyclophosphamide if flare
ANCA diseases?
Other, similar disease?
Rx?
cANCA (anti-PR3) - Wegener’s (GPA) - ENT/resp involvement, saddle nose
pANCA (anti-MPO) - microscopic polyangitis - no granuloma
Eosiniphilic GPA (eosinophilia + late-onset asthma)
Rx: Immunosuppression, plasma exchange, dialysis, supportive care
Primary AL amyloid vs Secondary AA?
AL light chain - age of diagnosis 50-60 - heart, kidneys, bowels, skin, nerves
AA (systemic inflammatory IBD/RA etc) - liver, spleen, kidneys, adrenals
How to tell AKI from longstanding CKD in patient who newly presents?
Renal US - bilateral small kidneys <9cm suggests longstanding CKD
Exceptions - ADPKD, diabetic nephropathy, amyloid - kidneys may enlarge/stay normal size
In which case: high phosphate, low calcium, high PTH
Only true way to tell is previous blood tests
What drug can help with symptoms ADPKD?
If someone wants screening?
ARPKD?
Tolvaptan
Renal US (better than genetic)
Polycystic kidneys may be felt/seen at birth - ESRF in childhood
Anderson-Fabry:
- genetics?
- Hx?
- Rx?
X-linked - a-galactosidase metabolism error
renal failure, cardiac myopathy, neuropsychiatric, angiokeratomas
Fabryzyme
Medullary cystic kidney:
- inheritance?
- what does it cause?
- age of renal transplant?
AD
renal tubular necrosis
small kidneys
cysts
(seen on ct)
28
Medullary sponge kidney:
- genetics?
- what does it cause?
- prognosis?
sporadic mutation
Cystic dilation of collecting ducts (bunch of grapes)
Asymptomatic/incidental finding - increased risk of calculi
Good prognosis - rarely progresses to ESRF
What is Fanconi syndrome?
Causes?
Typical Hx?
Inadequate reabsorption occurring in PCT
Causes: Wilson’s, cystinosis, myeloma, Sjrogen’s
(cystinosis most common in kids - AR disorder)
failure of growth, osteomalacia, renal tubular acidosis, polyuria, glycosuria, phosphaturia
Grading of AKI?
1 - creatinine rise of 26mmol in 48 hrs, or rise of 50% in a week, or oliguria <0.5ml/kg/hr for 6 hours
2 - creatinine 2-2.99x baseline in 7 days OR oliguria <0.5ml/kg/day for 12 hours
3 - creatinine >3x baseline in 7 days OR oliguria <0.3ml/kg/hr for 24 hrs OR anuria for 12 hours
Symptoms of AKI?
Important assessment steps?
early may be asymptomatic
Oliguria, pul/per oed, uraemia (itch, pericarditis, encephalopathy), arrhythmia (hyperkalaemia)
Assess:
- Hx - disease, fluid, drugs, chemo, rheum, cough etc
- examine - euvolaemia, bladder, kidneys, renal bruit
- Ix: dipstick + culture, microscopy (cells, casts), U&E, FBC, LFT, clotting, CK, ESR, CRP. Consider electrophoresis, Ig (ANCA, ANA, GBM)
Image: renal US
4 indications for dialysis in AKI?
Hyperkalaemia >7 resistant to Rx
Severe acidosis ph <7.15
Fluid overload
Urea >40
5 pre-renal causes of AKI?
4 intra?
4 post?
Most common causes?
Pre: Cardiac failure Sepsis Blood loss Dehydration Vascular occlusion
Intra:
GN
Small-vessel vasculitis
Acute tubular necrosis (drugs, toxins, prolonged hypotension, myoglobin)
Interstitial nephritis (drugs, inflammation, infection)
Post: calculi BPH Cancer (prostate, cervix, ureter) Stricture
90% pre-renal and acute tubular necrosis
Causes of hyperkalaemia?
Symptoms:
Risk?
ECG?
AKI, metabolic acidosis, drugs (ACEI, ARB, spironolactone), Addison’s, massive blood transfusion, tumour lysis syndrome)
Non-specific - fatigue, weakness
Can go into VF
ECG: - loss of P waves - Prolonged QRS - tall, tented T waves - ectopics/escapes If severe: sine wave
Rx hyperkalaemia?
ECG + IV access
Protect myocardium - 10ml 10% Ca gluconate
Short-term shift - act rapid 10 units, 50ml 50% dextrose, nebuliser salbutamol
Removal - Ca resonium, loop diuretics, dialysis
Ca resonium enema better than oral
Management of AKI?
Assess volume status
Aim for euvolaemia
STOP nephrotoxic drugs (DAAAMN)
Treat underlying cause:
Pre-renal: fluid challenge
Post: catheter + consider CT KUB
Intra: renal assessment
Remember indications for dialysis:
- urea >40
- K >7 and refractory
- pH <7.15
- fluid overload (pul oed)
Acute tubular necrosis:
- How does it present?
- urine Na content?
- urine osmolality?
- serum urea:creat ratio?
- response to fluid challenge?
AKI + muddy brown casts (pre-renal = normal/’bland’ sediment)
Na content HIGH (low in pre-renal as trying to conserve volume)
Urine osmolality LOW (high in pre-renal as again trying to conserve volume)
Serum urea:creat normal (raised in pre-renal)
Poor response to fluid challenge (good in pre-renal)
Acute tubular necrosis:
- causes?
- reversible?
- nephrotoxic drugs
- rhabdomyolysis
- ethylene glycol poisoning
- ischaemia (prolonged hypoperfusion)
Reversible if detected early and treatment started
(ethylene glycol = anti-freeze. Rx = fomepizole or ethanol
What is renal papillary necrosis?
Triad of symptoms?
Causes?
Coagulative necrosis of renal papillae (base of pyramids)
Haematuria, loin pain, proteinuria
Causes: acute pyelonephritis, diabetic/obstructive nephropathy, NSAIDs, sickle cell
What is renal tubular acidosis?
Normal anion gap metabolic acidosis caused by impaired H+ secretion by the kidney
There are 4 types, 1 and 2 being the most common. They can be inherited or acquired from e.g. SLE, amphotericin, Wilson’s.
Coliforms that can cause UTI? Gm +ve cocci? What is pseudomonas UTI assoc w? What is CPE UTI assoc w? What are staph saphrophyticus, staph aureus and proteus UTI assoc w?
E coli, proteus, enterobacter
Enterococcus, staph saphrophyticus, staph aureus
Pseudomonas - catheters
Carbapenemase producing enterobacter - travel to India
Staph saph - pregnancy
Staph aureus - bacteraemia - pyelonephritis
Proteus - foul smell (urea breakdown –> ammonia –> alkaline urine) and struvite stones
When should asymptomatic bacteriuria be treated?
Pregnancy
Do not treat in anyone else, esp older folk as it’s very common
Why is urinalysis not routinely performed in older people?
When else is it nor routinely used?
False positives of leukocytes, nitrite (coliform) and protein/blood
Perform urine culture/microscopy if >65 and suspect
Do not use urinalysis for catheterised patients either. Also will commonly get colonisation. In both cases, do not treat unless clinical signs/symptoms. Treat catheter as complicated UTI
Kass criteria for UTI?
Must have symptoms
>10^5 organisms per ml probable UTI
Or <10^5 but significant pyuria
Uncomplicated female UTI?
Trimethoprim or Nitrofurantoin 3 days
Uncomplicated male UTI?
Trimethoprim or Nitrofurantoin 7 days
Complicated UTI/pyelonephritis/urosepsis?
IV amox + gent
Step down PO co-trimoxazole or as per sensitivities
Abacterial cystitis causes?
UTI symptoms with no significant culture or sterile pyuria
Honeymoon cystitis - trauma (shagging)
Urethritis (STI)
Test for STI
Alkalinising urine may help
What is emphysematous pyelonephritis? Assoc and cause? Features? Ix? Rx?
Necrotising infection causing gas accumulation in renal parenchyma - high mortality
Diabetes - E. Coli
Classic pyelonephritis (dysuria, fever/rigors, loin pain, N&V) AKI, rapid sepsis, crepitations in flank/scrotum
Abdo CT most sensitive
Rx: percutaneous drainage and Abx –> nephrectomy
(urgent CT if not responding to standard therapy)
What bacteria causes of bacterial prostatitis?
Symptoms?
PR exam?
Rx?
E coli
Referred pain - perineum, rectum, penis, back
Fever/rigors
Urinary obstruction maybe present
DRE - tender, boggy
Ofloxacin 28 days
Trimethoprim if unsuitable
(quinolone risk tendon rupture, AA dissection, QT, C diff)
Epididymo-orchitis:
- features?
- what is seen on doppler?
- Rx?
unilateral testicular pain and swelling
May be urethral discharge present
Doppler may be needed to rule out torsion
- increased blood flow and present cremasteric reflex
STI suspected - Doxycycline 14 days
STO NOT suspected - Ofloxacin 14 days
Balanitis:
- causes?
- Rx?
Inflammation of the glans
Infective:
- Candiasis (assoc w intercourse) - itch +/- white discharge
- Staph - pain, itch, yellow discharge
(swab may be helpful if unclear)
- anaerobic - foul smelling yellow discharge
Rx: topical clotrimazole (2 weeks), oral Flucloxacillin, or topical/oral metronidazole respectively respectively
Other causes: dermatitis, lichen plans/sclerosus, circinate balanitis etc
Role for circumcision in these
Haemolytic uraemic syndrome:
- Ix?
- What is seen on bloods?
- Management?
HUS = triad of AKI, thrombocytopenia and MAHA following E. Coli O157 infection
FBC - normocytic anaemia, thrombocytopaenia, AKI (high urea and creatinine)
Other Ix:
- stool culture for STEC
- stool PCR for shiva-like toxin
- film - fragmented cells
Rx:
- supportive - fluids, blood transfusion or dialysis if required
- NO ROLE for Abx
Aspirin/salicylate OD:
- symptoms?
- how does it develop over time?
- Rx?
N&V, tinnitus, headache
Initially hyperventilation causing resp alkalosis
Then over about 24 hours causes raised anion gap metabolic acidosis
Rx: IV sodium bicarbonate (alkalinises urine, promotes excretion)
If someone has eGFR 65 but no symptoms is it CKD?
Not CKD
Need symptoms to diagnose stage 1&2
Also one off test means nothing, must be present for 3 months
When should ACEI be stopped in CKD?
What other drug may be useful as an antihypertensive?
- fall in GFR by 25%
- rise in creatinine by 30%
- GFR <15
Furosemide - has added benefit of lowering K - higher doses usually needed in CKD
When to suspect renal vein thrombosis?
Flank pain and haematuria in background of nephrotic syndrome of hyper coagulable state
When to suspect renal TB?
Symptoms of UTI
Sterile pyuria (i.e. leukocytes but no growth on MSSU)
Elevated CRP
No response to trimethoprim
What diuretic should be used for ascites?
Spironolactone
Dip shows +++ protein, ++ leukocytes and trace blood, no nitrites, is it likely IgA nephropaty, interstitial nephritis or UTI?
Interstitial nephritis
IgA nephropathy would cause more than trace blood
UTI would cause nitrites
What electrolyte disturbance may be seen in nephrogenic DI?
Hypokalaemia
Hypernatraemia
Hypercalcaemia
A few weeks post-renal transplant a patient presents feeling generally unwell and fatigued with anorexia and arthralgia. O/E jaundice and hepatomegaly. Widespread lymphadenopathy.
- Cause?
- Rx?
CMV - most common viral infection of solid organs
Rx: Ganciclovir
Why do the first few dialysis sessions need to be short at around 90 mins?
To prevent dysequilibrium syndrome - the toxins which accumulate have osmotic potential, removing them all too quickly can cause oedema, cerebral oedema can lead to confusion, convulsions and death
Differentials and respective Ix when someone presents in AKI with no Hx of note ie no signs of sepsis/hypovolaemia? (7)
Sepsis - blood and urine culture, suptum if expectorating
Obstruction - inflow/outflow? Renal tract imaging
Acute GN - pANCA, cANCA, Complements (C3&C4), CTD screen, anti-GBM, PLA2 (membranous nephropathy)
Tubulointerstitial nephritis - recent doxy/clarith/omeprazole/naproxen?
Myeloma - Serum Ig and protein electrophoresis, urinary BJP
Thrombotic microangiopathy - HUS/TTP? DIC? Haemolysis screen - film, haptoglobins, reticulocyte count, LDH
ESRF - chronic? Check PTH, iron studies, haematinics, kidney size and appearance
HELLP if pregnant?
Nephrotoxic drugs? OTC nephrotoxins (NSAIDs, alcohol, illegal drugs)
Acute renal artery stenosis? USS/CT angio
(difference in size >1.5cm suggestive of potential RAS)
Below which eGFR should patients not be given bisphosphonates?
35
Protective /prophylactic medication given with steroids/cyclophosphamide for GN?
Other than cyclophosphamide what else can be given as immunosuppression?
Adcal D3 (osteoporosis)
Omeprazole (gastritis)
Co-trimoxazole (pneumocystis jirovicii)
usually given for 6 months-3 years
Rituximab
What chronic conditions give enlarged kidneys instead of small ones? (4)
ADPKD
Diabetic nephropathy
HIV-associated nephropathy (IVDU)
Amyloidosis
What biochemical disturbance points to chronic rather than acute kidney disease?
Low Ca (due to low VitD)
Classic presentation of henoch schonlein purpura?
Purpuric rash Haematuria Abdo pain Joint pain Raised WCC and ESR
Plasma and urine osmolality and sodium levels in pre-renal and renal AKI?
How can you tell if it’s post-renal?
Pre-renal:
- try to retain sodium and water, so:
- urine osmolality high, urine Na low
Renal:
- loss of ability to concentrate urine or retain sodium, so:
- urine osmolality low, urine Na high
(most common = ATN due to hypoxia/toxins, rarer causes are acute GN and acute IN)
Post-renal:
Hydronephrosis on renal USS
In what people may eGFR be inappropriately low?
Bodybuilders in extremes of muscle mass
Treatment of hyper acute kidney transplant rejection?
Removal of transplant
How to guess from U&E if AKI is pre-renal or renal?
Pre-renal: raised urea:creatinine ratio
Renal: normal
