Renal Flashcards
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 syndrome?
X-linked
Congenital renal failure and bilateral sensorineural deafness
Lenticonus - lens protrudes into anterior chamber
How can nephrotic syndrome cause hypocalcaemia?
VitD lost to urine
How to tell intrinsic AKI from pre/post renal?
How to tell between pre and post?
Proteinuria in intrinsic
Increased urea:creat ratio in pre
How to tell primary from secondary hyperaldosteronism?
Renin will be high in secondary
e.g. due to renal artery stenosis or heart failure causing low GFR
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
Why is lupus nephritis different from other nephritic syndromes?
There are 6 different types of lupus nephritis - what is the most common?
All patients with lupus nephritis will have proteinuria
Diffuse proliferative glomerulonephritis
4 causes of transient non-visible haematuria?
- UTI
- menstruation
- vigorous exercise (settles after 3 days)
- sex
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
Commonest GN in adults?
Management?
Membranous
ACEI/ARB, immunosuppression, anticoagulation
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
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
Management of CKD anaemia?
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
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 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
Focal segmental glomerulosclerosis:
- typical Hx?
- assoc?
young adult with nephrotic syndrome and CKD
HIV, reflux nephropathy, heroin, sickle cell
Membranous nephropathy:
- typical Hx?
- Assoc?
Adult with proteinuria and nephrotic syndrome
Primary - anti-phospholipid A2 Ig (PLA2R)
Secondary - cancer, infection, systemic disease
What is low on blood test of post-strep GN?
Low C3
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
4 indications for dialysis in AKI?
Hyperkalaemia >7 resistant to Rx
Severe acidosis ph <7.15
Fluid overload
Urea >40
ECG hyperkalaemia
- loss of P waves
- Prolonged QRS
- tall, tented T waves
- ectopics/escapes
If severe: sine wave
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
Below which eGFR should patients not be given bisphosphonates?
35
What biochemical disturbance points to chronic rather than acute kidney disease?
Low Ca
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
