Renal Flashcards
1
Q
Genetics of Alport’s syndrome?
A
X linked dominant
- defect in gene which codes for type IV collagen -> abnormal glomerular BM
- more severe disease in males
2
Q
Cause (most common) of Alport’s patient with failing renal transplant?
A
Presence of anti-GBM antibodies leading to Goodpasture’s syndrome-like picture
3
Q
Features of Alport’s syndrome?
A
- microscopic haematuria
- progressive renal failure
- bilateral sensorineural deafness
- lenticonus: protrusion of the lens surface into the anterior chamber
- retinitis pigmentosa
4
Q
Renal biopsy features of Alport’s syndrome?
A
splitting of lamina densa seen on electron microscopy
5
Q
Diagnosis of Alport’s syndrome?
A
- molecular genetic testing.
- renal biopsy: electron microscopy showing characteristic finding of longitudinal splitting of lamina dense of the glomerular BM, resulting in a “basket-weave” appearance
6
Q
Management of cranial DI?
A
tx underlying cause. desmopressin
7
Q
Management of nephrogenic DI?
A
thiazides , low salt/protein diet
8
Q
what systemic conditions cause cranial DI?
A
- histiocytosis X
- DIDMOAD is the association of cranial Diabetes Insipidus, Diabetes Mellitus, Optic Atrophy and Deafness (also known as Wolfram’s syndrome)
- haemochromatosis
9
Q
what antibodies are assoc with primary membranous nephropathy?
A
anti-phospholipase A2 receptor antibodies
10
Q
common causes of secondary membranous nephropathy?
A
- malignancies: solid tumours (lung/ colon etc)
- infections: hep B/C, HiB, malaria, syphilis, schistosomiasis
- autoimmune diseases: SLE, sarcoid, IBD
- drugs: NSAIDs, captopril, gold, penicillamine, lithium, clopidogrel
11
Q
Causes of renal artery stenosis?
A
90%: atherosclerosis
10%: fibromuscular dysplasia (‘string of beads’ appearance of renal arteries)
12
Q
Features of fibromuscular dysplasia??
A
- HTN
- CKD/ AKI secondary to ACEi initiation
- flash pulmonary oedema
13
Q
Causes of rapidly progressive GN?
A
aka crescentic glomerulonephritis
- Goodpastures, ANCA positive vasculitis
14
Q
Common causes of polyuria?
A
diuretics, caffeine & alcohol
diabetes mellitus
lithium
heart failure
15
Q
What antibody could be used in treatment of haemolytic uraemic syndrome?
A
Eculizumab (C5 inhibitor monoclonal antibody)
16
Q
MOA of tolvaptan?
A
vasopressin receptor 2 antagonist
- reduces water absorption and increases water loss without sodium loss
17
Q
CKD: if albumin: creatinine ratio is between 3-70mg/mmol, what to do?
A
repeat sample with a subsequent early morning sample.
- > 3 is considered clinically important proteinuria
18
Q
CKD: if albumin: creatinine ratio is >70mg/mmol, what to do?
A
refer to nephrologist
19
Q
Management of proteinuria in CKD?
A
1st line: ACEi (ARB)
20
Q
features of rhabdomyolysis?
A
- AKI with disproportionately raised Cr
- High CK
- Myoglobinuria
- HypoCa (Myoglobin binds calcium)
- High phosphate (released from mycocytes)
- HyperK
- met acidosis
21
Q
Fractional urea excretion in urine in pre-renal uraemia vs ATN?
A
pre-renal: <35% fractional urea excretion
acute tubular necrosis: >35%
**fractional urea excretion = (urine urea /blood urea ) / (urine creatinine/plasma creatinine) x 100
22
Q
Reason for hyper acute organ rejection?
A
presence of pre formed antibody e.g. HLA mismatch/ ABO incompatibility
tx: removal of graft, if left in situ -> abscess
23
Q
Reason for acute organ rejection? usually during first 6 months
A
usually T cell mediated
- tissue infiltrates and vascular lesions
tx: medical management
24
Q
Main reason for chronic organ rejection? occurs after first 6 months
A
vascular changes predominate
25
Most common and severe from of glomerulonephritis secondary to SLE?
Class IV: Diffuse proliferative GN
26
what are stag horn calculi composed of?
struvite (ammonium, magnesium phosphate, triple phosphate)
27
What bacteria predispose to stag horn calculi?
ammonia producing bacteria.
| e.g. ureaplasma urealyticum, proteus infections
28
what stones are radio-lucent?
urate stones, xanthine stones
*cystine stones are semi-opaque, with a ground glass appearance.
29
extra renal manifestations of PCKD?
- liver cysts (70% - the commonest extra-renal manifestation): may cause hepatomegaly
- berry aneurysms (8%): -> subarachnoid haemorrhage
- CVS: mitral valve prolapse, mitral/tricuspid incompetence, aortic root dilation, aortic dissection
- cysts in other organs: pancreas, spleen; very rarely: thyroid, oesophagus, ovary
30
Triad of features in haemolytic uraemic syndrome?
AKI, MAHA, Thrombocytopenia
31
Causes of transient or spurious non-visible haematuria?
urinary tract infection
menstruation
vigorous exercise (this normally settles after around 3 days)
sexual intercourse
32
most common histological sybtype or renal cell cancer?
clear cell (75-85%)
33
Paraneoplastic hepatic dysfunction syndrome?
seen in renal cell carcinoma
- aka Stauffer syndrome
- presents as cholestasis/ hepatosplenomegaly
- secondary to increased IL-6
34
management of renal cell carcinoma?
- partial/ total nephrectomy
- IFN-alpha, IL-2 can reduce tumour size
- tyrosine kinase inhibitors! e.g. sorafenib, sunitinib
35
causes of nephrogenic DI?
- genetic: more common- defective ADH receptor, less common- defective aquaporin 2 channel
- electrolytes: hypercalcaemia, hypokalaemia
- lithium: desensitizes the kidney's ability to respond to ADH in the collecting ducts
- demeclocycline
- tubulo-interstitial disease: obstruction, sickle-cell, pyelonephritis
36
Genetics of ADPKD type 1 vs ADPKD type 2?
type 1 : chr 16
| type 2: chr 4
37
what antibodies are used in immunosuppression post renal transplant?
selective inhibitors of IL-2 receptor: daclizumab, basilximib
38
commonest cause of glomerulonephritis worldwide?
IgA nephropathy aka Berger's disease
39
Assoc conditions of IgA nephropathy?
alcoholic cirrhosis,
coeliac disease,
henoch-schonlein purpura
40
Mx of IgA nephropathy?
steroids/ immunosuppressants
41
Poor prognostic markers of IgA nephropathy?
```
male,
proteinuria (esp >2g/day),
HTN, hyperlipidaemia
smoking,
ACE genotype DD
```
42
Good prognostic markers of IgA nephropathy?
frank haematuria
43
histology of renal biopsy in IgA nephropathy?
mesangial hypercellularity, positive immunofluorescence for IgA & C3
44
renal biopsy findings in Goodpasture's syndrome?
Linear IgG deposits along the basement membrane
45
Mx of Minimal change glomerulonephritis?
majority 80% are steroid-responsive.
| 2nd line- cyclophosphamide
46
reasons why patients may fail to respond to erythropoietin therapy?
- iron deficiency
- inadequate dose
- concurrent infection/inflammation
- hyperparathyroid bone disease
- aluminium toxicity
47
How long may finasteride take to work for BPH?
6 months
48
SE of erythropoietin injections?
- accelerated hypertension potentially leading to encephalopathy and seizures (blood pressure increases in 25% of patients)
- bone aches
- flu-like symptoms
- skin rashes, urticaria
- pure red cell aplasia* (antibodies against EPO)
- raised PCV increases risk of thrombosis (e.g. Fistula)
- iron deficiency 2nd to increased erythropoiesis
49
Ix of renal vascular disease/ renal artery stenosis?
MR angio
50
Management of renal artery stenosis?
balloon angioplasty
51
most common cause of peritonitis secondary to peritoneal dialysis?
Coagulase negative staph e.g. staph epidermidis
52
Complications of nephrotic syndrome?
- increased risk of clots (loss of antithrombin III and plasminogen in the urine)
- hyperlipidaemia
- CKD
- increased risk of infection due to immunoglobulin loss in urine
- hypocalcaemia (vitamin D and binding protein lost in urine)
53
Causes of type 1 membranoproliferative glomerulonephritis?
- 90% of cases are type 1
| causes: cryoglobulinaemia, Hep C
54
electron microscopy showing: subendothelial and mesangium immune deposits of electron-dense material resulting in a 'tram-track' appearance
type I membranoproliferative glomerulonephritis
55
Causes of type 2 membranoproliferative disease?
partial lipodystrophy (classically patients have loss of subcut tissue from their face), factor H deficiency
56
pathophysiology of type 2 membranoproliferative disease?
- persistent activation of alternative complement pathway
- low circulating levels of C3
- C3b nephritic factor found in 70%
57
electron microscopy showing: intramembranous immune complex deposits with 'dense deposits'
type 2 membranoproliferative glomerulonephritis aka 'dense deposit disease'
58
causes of type 3 membranoproliferative glomerulonephritis?
hep B and C
59
Management of membranoproliferative glomerulonephritis?
steroids
60
Which HLA matching is most important for renal transplant?
HLA DR >B > A
61
Wilms tumour associations?
- Beckwith-Wiedemann syndrome
- part of WAGR syndrome with Aniridia, Genitourinary malformations, mental Retardation
- hemihypertrophy
- around 1/3 of cases are associated with a loss-of-function mutation in the WT1 gene on chromosome 11
62
Ix for vesicoureteric reflux?
micturating cystourethrogram
- after this, DMSA scan to look for renal scarring
63
endocrine effects of renal cell carcinoma?
erythropoietin, parathyroid hormone (HyperCa), renin, ACTH
64
How to calculate anion gap?
Na+ + K+ - (Bicarb + Cl-)
*normal anion gap is 8-14 mmol/L
65
How to calculate anion gap?
Na+ + K+ - (Bicarb + Cl-)
66
Causes of normal anion gap or hyperchloraemic metabolic acidosis?
- GI bicarbonate loss: diarrhoea, ureterosigmoidostomy, fistula
- renal tubular acidosis
- drugs: e.g. acetazolamide
- ammonium chloride injection
- Addison's disease
67
Causes of high anion gap metabolic acidosis?
- lactate: shock, hypoxia
- ketones: diabetic ketoacidosis, alcohol
- urate: renal failure
- acid poisoning: salicylates, methanol
- 5-oxoproline: chronic paracetamol use
68
Which of the following types of renal stones are said to have a semi-opaque appearance on x-ray?
cystine stones
69
Management of oxalate stones?
- cholestyramine - reduces urinary oxalate secretion
| - pyridoxine: same
70
Management of uric acid stones?
allopurinol
| urinary arlkalinization e.g. oral bicarb
71
What is seen in stage 1 diabetic nephropathy?
hyperfiltration: increase in GFR
| - may be reversible
72
What is seen in stage 2 diabetic nephropathy?
silent or latent phase
- GFR remains elevated
- most do not develop microalbuminuria for 10 years
73
What is seen in stage 3 diabetic nephropathy?
microalbuminuria
| albumin excretion 30-300mg/day
74
What is seen in stage 4 diabetic nephropathy?
persistent proteinuria (dipstick +)
HTN
Histology shows diffuse and focal glomerulosclerosis (Kimmelstiel-Wilson nodules)
75
What is seen in stage 5 diabetic nephropathy?
end stage renal disease, GFR typically <10 mL/min
| renal replacement therapy needed
76
Causes of acute interstitial nephritis?
- drugs: the most common cause, particularly antibiotics
penicillin, rifampicin, NSAIDs, allopurinol, furosemide
- systemic disease: SLE, sarcoidosis, and Sjögren's syndrome
- infection: Hanta virus , staphylococci
77
Features of acute interstitial nephritis?
- fever, rash, arthralgia
- eosinophilia
- mild renal impairment
- hypertension
78
Investigations of acute interstitial nephritis?
sterile pyuria, white cell casts
79
High B-HCG + testicular lump?
seminoma
80
Early features of TCA overdose?
anticholinergic symptoms: dry mouth, dilated pupils, agitation, sinus tachy, blurred vision
81
Features of severe TCA overdose?
arrhythmias, seizures, met acidosis, coma
82
ECG changes assoc w TCA overdose?
sinus tachy,
QRS widening,
QT prolongation
83
Management of TCA overdose?
1st line for hypotension or arrhythmias: IV bicarb
- IV lipid emulsion increasingly used to bind free drug and reduce toxicity
84
Dialysis in TCA overdose?
DIALYSIS INEFFECTIVE
85
Adverse effects of finasteride?
impotence
decreased libido
ejaculation disorders
gynaecomastia and breast tenderness
- also causes decreased levels of PSA
86
features of ethylene glycol toxicity?
- confusion, slurred speech
- High anion gap met acidosis
- AKI
87
Management of ethylene glycol toxicity?
- 1st Line: fomepizole (inhibitor of alc dehydrogenase)
- ethanol: works by competing with ethylene glycol for the enzyme alc dehydrogenase, limits formation of toxic metabolites.
- haemodialysis has a role in refractory cases
88
what antibiotics inhibit protein synthesis?
- 50S subunit: macrolides, chloramphenicol, clindamycin, linezolid, streptogrammins
- 30S subunit: aminoglycosides, tetracyclines
89
what antibiotics inhibit DNA synthesis?
quinolone e.g. ciprofloxacin
90
what antibiotics inhibit RNA synthesis?
rifampicin
91
What is cetuximab?
epidermal growth factor R antagonist
| - used in metastatic colorectal ca + H&N ca
92
what is alemtuzumab?
anti-CD52, used in CLL
93
What is abciximab?
glycoprotein IIb/IIIa receptor antagonist
- used in patients undergoing PCI
94
What is OKT3?
anti-CD3, used to prevent organ rejection
95
Features of methanol poisoning?
- similar to alcohol (intoxication, nausea)
- visual problems (e.g. blindness)
- due to accumulation of formic acid
96
Management of methanol poisoning?
- fomepizole (competitive inhibitor of alcohol dehydrogenase) or ethanol
- haemodialysis
- cofactor therapy with folinic acid to reduce ophthalmological complications
97
Which clotting factors does LMWH act on vs unfractionated heparin?
LMWH: increases ATIII effect on fXa
Unfractionated heparin: activates ATIII, inhibits thrombin, fXa, IXa, XIa, XIIa.
98
Adverse effects of heparins?
bleeding,
thrombocytopenia (Heparin induced thrombocytopenia),
osteoporosis (increase risk of #)
hyperK
99
features of heparin-induced thrombocytopenia (HIT)?
- antibodies form against complexes of platelet factor 4 and heparin
- develops 5-10 days after tx
- prothrombotic condition
- 50% reduction in platelets
- skin allergy
100
Management of nocturia symptoms in overactive bladder?
- moderate fluid intake at night
- furosemide 40mg in late afternoon may be considered
- desmopressin may be helpful
101
Management of overactive bladder?
- offer bladder retraining exercises
- 1st line: antimuscarinics e.g. oxybutynin, tolterodine, darifenacin
- 2nd line: mirabegron
102
what constitutes AKI?
- Cr rise of >26 in 48h
- Cr rise of >50% within last 7 days
- Fall in UO <0.5mL/kg/h for >6h
103
1st line mx of acute epididymo-orchitis?
IM ceftriaxone 500mg + Oral doxy for 2 wks
104
Complications of plasma exchange?
- hypocalcaemia
- metabolic alkalosis
- removal of systemic medications
- coagulation factor depletion
- Ig depletion
105
Management of haemolytic uraemia syndrome?
- supportive e.g. fluids/ bloods
- if severe and not associated with diarrhoea: plasma exchange
- + eculizumab (C5 inhibitor monoclonal antibody)
106
How to stage CKD?
stage 1: eGFR >90, with some sign of kidney damage (if all tests are normal, NO CKD)
stage 2: 60-90, + some sign of kidney damage
stage 3a: 45-49
stage 3b: 30 -44
stage 4: 15-29
stage 5: <15mL/min
107
How does alcohol lead to polyuria?
alcohol bingeing can lead to ADH suppression in the posterior pituitary gland -> leading to polyuria
108
Causes of AL Amyloidosis?
- most common
- L for Ig Light chains
- Myeloma, Waldenstroms, MGUS
109
Features of AL amyloidosis?
nephrotic syndrome, cardia/ neuro involvement, macroglossia, periorbital eccymoses
110
Causes of AA Amyloidosis?
A for precursor serum amyloid A protein
- seen in chronic infection/ inflammation
- TB, bronchiectasis, rheumatoid arthritis
111
Features of AA Amyloidosis?
renal involvement most common feature
112
Causes of Beta-2 microglobulin amyloidosis?
assoc w patients on renal dialysis
- precursor = beta-2 microglobulin, part of the MHC
113
Tolvaptan use in PCKD?
- used to slow progression of disease in some patients
- V2R antagonist - > reduces cell proliferation, cyst formation and fluid excretion --> reduces kidney growth and protects renal fn
114
normal glomeruli on light microscopy,
+
electron microscopy shows fusion of podocytes and effacement of foot processes
Minimal change disease
115
Features of minimal change disease?
nephrotic syndrome, normotension, Highly selective proteinuria (increased glomerular permeability to serum albumin)
116
Causes of minimal change disease?
majority: idiopathic (80-90%)
other causes:
drugs- NSAIDs, rifampicin
Hodgkins lymphoma, thymoma
Infectious mono
117
Biopsy findings of HIV associated nephropathy?
Pathological hallmark: focal segmental glomerulosclerosis (FSGS) with a collapsed glomerular tuft, with evidence of numerous tubuloreticular structures on electron microscopy
118
Key features of HIV-associated nephropathy?
- Massive proteinuria -> nephrotic syndrome
- large kidneys may be seen
- focal segmental glomerulosclerosis with focal/ global capillary collapse on renal biopsy
- high Ur, Cr
- normotension
119
Features of scleroderma renal crisis?
- presence of RNA polymerase antibodies
- severe hyper-reninaemic HTN
- Mild MAHA
- obliterative vasculopathy, 'Onion skin lesions'
120
Treatment of choice in scleroderma renal crisis?
ACEi
- to reduce BP, and improves kidney function
121
Cause of primary/ atypical haemolytic uraemic syndrome?
complement dysregulation
122
what to co-prescribe when starting goserelin (gonadorelin analogues)?
anti-androgen tx such as cyproterone acetate
- due to risk of tumour flare during initiation of goserelin
- this phenomenon is secondary to initial stimulation of LH release by pituitary gland -> raised testosterone levels
123
Renal biopsy showing:
- electron microscopy: subepithelial 'humps' caused by lumpy immune complex deposits
- immunofluorescence: granular or 'starry sky' appearance
post streptococcal glomerulonephritis
124
most common cause of nephrotic syndrome in adults?
focal segmental glomerulosclerosis or Membranous glomerulopathy
125
renal biopsy
- > focal and segmental sclerosis and hyalinosis on light microscopy
- > effacement of foot processes on electron microscopy
focal segmental glomerulosclerosis
126
Renal biopsy showing:
- electron microscopy: the basement membrane is thickened with subepithelial electron dense deposits. This creates a 'spike and dome' appearance
Membranous glomerulonephritis
127
Autoantibodies in idiopathic membranous glomerulonephritis?
Anti-phospholipase A2 antibodies
128
typical presentation of membranous glomerulonephritis?
nephrotic syndrome
| - renal biopsy: spike and dome appearance
129
Causes of membranous glomerulonephritis?
- idiopathic: due to anti-phospholipase A2 antibodies
- infections: hepatitis B, malaria, syphilis
- malignancy (in 5-20%): prostate, lung, lymphoma, leukaemia
- drugs: gold, penicillamine, NSAIDs
- autoimmune diseases: systemic lupus erythematosus (class V disease), thyroiditis, rheumatoid
130
What type of SLE renal disease leads to membranous glomerulonephritis/ proteinuria?
class V
131
Good prognostic features of Membranous glomerulonephritis?
female, young age at presentation, asymptomatic proteinuria
132
Management of membranous glomerulonephritis?
ACEi/ ARB
- improves prognosis, reduces proteinuria
+ immunosuppression if severe/ progressive disease: steroids + cyclophosphamide
anticoagulation for high risk patients
133
when does contrast-induced nephropathy normally present after contrast administration?
2-5 days
134
causes of focal segmental glomerulosclerosis?
- idiopathic
- secondary to other renal pathology e.g. IgA nephropathy, reflux nephropathy
- HIV
- heroin
- Alport's syndrome
- sickle-cell
135
Retroperitoneal fibrosis associated with?
- Riedel's thyroiditis
- previous radiotherapy
- sarcoidosis
- inflammatory abdominal aortic aneurysm
- drugs: methysergide
136
renal biopsy shows:
- electron microscopy: characteristic finding is of the longitudinal splitting of the lamina densa of the glomerular basement membrane, resulting in a 'basket-weave' appearance
Alports syndrome
| - X linked dominant
137
how long does it take for an AV fistula to fully mature?
6-8 wks
138
features of cystinuria?
- auto recessive
- recurrent renal stones
- stones classically yellow, crystalline, semi-opaque on XR
139
Diagnosis of cystinuria?
cyanide-nitroprusside test
140
Mx of cystinuria?
- hydration
- D-penicillamine
- urinary alkalinization
141
risk factors for urate stones?
- gout
| - ileostomy: loss of bicarbonate and fluid results in acidic urine, causing the precipitation of uric acid
142
drug causes of renal stones?
drugs that promote calcium stones: loop diuretics, steroids, acetazolamide, theophylline
143
risk factors of renal stones?
- dehydration
- hypercalciuria, hyperparathyroidism, hypercalcaemia
- cystinuria
- high dietary oxalate
- renal tubular acidosis
- medullary sponge kidney, polycystic kidney disease
- beryllium or cadmium exposure
144
causes of papillary necrosis?
- chronic analgesia use
- sickle cell disease
- TB
acute pyelonephritis
diabetes mellitus
145
features of papillary necrosis?
fever, loin pain, haematuria
| IVU - papillary necrosis with renal scarring - 'cup & spill'
146
features of goodpasture's syndrome?
pulmonary haemorrhage,
| rapidly progressive GN: proteinuria + haematuria
147
Factors which increase likelihood of pulmonary haemorrhage in Goodpasture's syndrome?
- smoking
- lower respiratory tract infection
- pulmonary oedema
- inhalation of hydrocarbons
- young males
148
nephrotic syndrome + marked loss of subcutaneous tissue from the face
Type II membranoproliferative GN (mesangiocapillary)
- assoc with partial lipodystrophy
149
Disorders associated with glomerulonephritis and low serum complement levels
- post-streptococcal glomerulonephritis
- subacute bacterial endocarditis
- systemic lupus erythematosus
- mesangiocapillary glomerulonephritis
150
what is calciphylaxis?
- rare complication of ESRF
- deposition of calcium within arterioles -> microvascular occlusion and necrosis of supplied tissue
- most commonly affects skin and presents w painful necrotic skin lesions
151
Features of Fanconi Syndrome?
- generalised reabsorptive disorder of renal tubular transport in the proximal convoluted tubule
- Type 2 (proximal) renal tubular acidosis
- polyuria
- aminoaciduria
- glycosuria
- phosphaturia
- osteomalacia
152
Most common cause of Fanconi syndrome in children?
cystinosis
153
most common cause of death in amyloidosis?
cardiac involvement
154
Eye abnormality in Alport syndrome?
anterior lenticonus
| - characterised by protrusion of the anterior aspect of the lens
155
management of reducing urinary calcium if there is only a marginal calciuria (causing recurrent stones)?
can give potassium citrate
| - urinary citrate forms soluble complexes with calcium ions, and inhibit crystal growth and aggregation
156
Reason why calcium oxalate stones are predisposed in crowns/UC and in bowel resection?
Particularly in ileal resection.
With fat malabsorption, unabsorbed long-chain fatty acids bind calcium in the lumen
> less calcium available to bind oxalate
> higher levels of oxalate to ppt into calcium oxalate stones
157
Relapse rates of Membranoproliferative glomerulonephritis in renal transplant pts?
80-100% in type II
| Lower in type I
158
Relapse rates of IgA nephropathy in renal transplant pts?
60%
159
Relapse rates of focal segmental glomerulonephritis in renal transplant pts?
50%
160
What conditions may reoccur following kidney transplantation
IgA nephropathy
Membranoproliferative GN
Focal segmental glomerulosclerosis
Membranous GN
161
Differentiating between IgA nephropathy and post-streptococcal glomerulonephritis
1. post-streptococcal GN associated with low complement lvls
2. main symptom in post-streptococcal GN is proteinuria
3. there is typically an interval between URTI and the onset of renal problems in post-streptococcal GN
162
Management of focal segmental glomerulonephritis?
Steroids +/- immunosuppressants
163
Management of IgA nephropathy if isolated haematuria, no proteinuria, normal Cr?
no treatment needed, other than follow-up to check renal function
164
Management of IgA nephropathy if there is persistent proteinuria (>500-1000mg/d), normal or slightly reduced eGFR?
ACEi
165
Management of IgA nephropathy if there is active disease (e.g. falling GFR) or failure to respond to ACE inhibitors?
Immunosuppression with corticosteroids
166
Why is calcium low in rhabdomyolysis
Myoglobin binds calcium
167
Why is calcium low in rhabdomyolysis
Myoglobin binds calcium
168
Rhabdoymyolysis electrolyte abnormalities?
HypoCa
HyperPO4
HyperK
169
Viral cause of acute kidney transplant graft failure? (Ie within 6 months)
CMV
170
Features of papillary necrosis?
fever, loin pain, haematuria
IVU - papillary necrosis with renal scarring - 'cup & spill'
171
Causes of papillary necrosis?
```
chronic analgesia use
sickle cell disease
TB
acute pyelonephritis
diabetes mellitus
```
172
Why are patients with nephrotic syndrome in a hypercoagulable state?
loss of antithrombin III and plasminogen in urine
173
Complications of nephrotic syndrome?
- DVT/PE
- renal vein thrombosis (pain + sudden deterioration renal fn)
- increased risk of infection (urine loss of Ig)
- hypoCa (vitamin D and binding protein lost in urine)
- ckd
- hyperlipidaemia (increasing risk of ACS, stroke)
174
Which HIV medication is associated with kidney damage?
Protease inhibitors such as indinavir can precipitate intratubular crystal obstruction
175
What management options for renal cell carcinoma?
If size <7cm, confined disease: partial/ total nephrec
Alpha IFN and IL2 can reduce tumour size and help w mets
receptor tyrosine kinase inhibitors (e.g. sorafenib, sunitinib)
176
Diagnosis of amyloidosis?
biopsy of skin, rectal mucosa, or abdominal fat
- Congo red staining: apple green birefringence
serum amyloid precursor (SAP) scan
177
Failure of renal transplant in Alport’s syndrome?
De novo anti-GBM antibody disease
(In ~5%)
- antibodies against collagen alpha-5(IV) chain
178
virus precipitating post transplant lymphoproliferative disorder?
EBV
179
Ultrasound diagnostic criteria of Autosomal Dominant Polycystic kidney disease (in pts with positive family history)?
1. 2 cysts, unilateral or bilateral, if aged < 30 years
2. 2 cysts in both kidneys if aged 30-59 years
3. 4 cysts in both kidneys if aged > 60 years
180
What management is offered in ADPCKD (auto dom Polycystic kidney disease) to slow disease progression?
tolvaptan (vasopressin receptor 2 antagonist)
if:
> CKD stage 2 or 3 at the start of treatment
> evidence of rapidly progressing disease
181
Most common causes of polyuria? (>1 in 10)
diuretics, caffeine & alcohol
diabetes mellitus
lithium
heart failure
182
infrequent causes of polyuria (1 in 100)?
HyperCa
| Hyperthyroidism
183
Rare causes of polyuria (1 in 1000)?
chronic renal failure
primary polydipsia
hypokalaemia
184
Very rare causes of polyuria (<1 in 10000)?
Diabetes insipidus
185
why is it important to identify fibromuscular dysplasia as an underlying cause of renal artery stenosis?
typically in younger patients
> characteristic 'string of beads' appearance on angiography
-> respond well to balloon angioplasty
186
how to make diagnosis of CKD? how many blood tests needed?
eGFR < 60 ml / min / 1.73 m2 on at least 2 occasions separated by a period of at least 90 days.
+
kidney damage:
e.g. albuminuria, urine sediment abnormalities, electrolyte abnormalities, histological abnormalities, structural abnormalities and a history of kidney transplantation.
187
management of intraperitoneal sepsis?
intraperitoneal vancomycin + ceftazidime
OR IP vancomycin + PO ciprofloxacin
common bugs: staph aureus, psuedomonas, staph epidermidis
188
most common organism causing peritoneal dialysis sepsis?
staph epidermidis
189
Diagnosis of calciphylaxis?
skin biopsy
190
Treatment of calciphylaxis?
- reducing Ca and PO4 levels
- controlling hyperparathyroidism
- avoid contributing drugs such as warfarin and calcium containing compounds
191
Management of cystine renal stone?
Urinary alkalinisation (potassium citrate) + hydration
2nd line: chelating agent D-penicillamine
192
In secondary hyperparathyroidism (2' CKD), at what level of PTH would you begin supplementation with Ca/Vit D?
PTH levels > 2x UL of normal
- supplementation with Ca/Vit D commenced to decrease risk of progression to tertiary disease and decrease complications such as bone resorption/ #/ ectopic calcification
- if replace when PTH lvls too low: risk of adynamic bone disease
193
What is adynamic bone disease?
reduced synthesis of bone matrix due to decreased osteoblast/clast activity > can lead to fragility #s
- most common form of renal osteodystrophy
- pathophys is unclear, but excessive suppression with PTH plays a major role (hence Vit D/ Ca usually supplemented only when PTH lvls >2 UL of normal)
194
why does anti GBM disease occur after renal transplant in Alport's syndrome?
Alports: genetic disorder of Type IV collagen
- pts may mount immune response to type IV collagen on graft transplant as it is a novel antigen
- > leads to anti-GBM antibodies + RPGN
195
Management of severe atypical Haemolytic uraemic syndrome not assoc w diarrhoea?
plasma exchange may be indicated
+
eculizumab (C5 inhibitor monoclonal Ab)
196
What stones do indinavir give rise to?
pure indinavir stones that are undetectable on plain XR or CT
197
Mx to reduce calcium stones due to hypoercalciuria?
Thiazide diuretics
e. g chlorthalidone
- to increase distal tubular calcium resorption
198
Mx to reduce oxalate stones?
cholestyramine, pyridoxine
| - reduce urinary oxalate secretion
199
Mx to reduce uric acid stones?
Allopurinol
| Urinary alkalinization e.g. bicarbonate
200
Features of tubulointerstitial nephritis with uveitis?
- usually in young females
- fever, weight loss, painful/red eyes
- Urinalysis: Leukocytes + protein +
201
infectious disease that may predispose to minimal change disease?
Infectious mononucleosis
202
Absolute contraindications to renal biopsy?
1. Polycystic kidneys,
2. Urinary tract obstruction or hydronephrosis
3. uncontrolled HTN
4. significant renal malignancy
5. significant bleeding disorders
203
what management should be considered in T1DM pts nearing ESRF?
joint pancreas and kidney transplants
- will need lifelong immunosuppression after this.
- likely needs MDT discussion
204
Criteria for renal referral in AKI?
- renal transplant
- ITU patient with unknown cause AKI
- vasculitis/ glomerulonephritis/ tubulointerstitial nephritis/ myeloma
- stage 3 AKI
- CKD stage 4/5
- need for renal replacement therapy
- AKI with unknown cause/ inadequate response to tx
205
How does plasma exchange increase the risk of post renal biopsy bleed?
depletion of fibrinogen levels + reduction in plt count
| - should monitor fibrinogen daily + replace with FFP if deplete
206
Complications of Plasma exchange?
```
hypocalcaemia - due to presence of citrate used as anticoagulant for the extracorporeal system
metabolic alkalosis
removal of systemic medications
coagulation factor depletion
Immunoglobulin depletion
```
207
How to give EPO agents? (IV vs sc)
Give sc in pre-dialysis patients and IV in patients undergoing HD
208
stones assoc with alkaline urine?
Struvite stones
- formed in the presence of increased urinary ammonia and alkaline urine (>7.2).
- These occur as a result of urease producing bacteria (and are thus associated with chronic infections).
209
Treatment of dialysis disequilibrium syndrome?
Mannitol or hypertonic saline
| - increases plasma osmolarity and reduces cerebral oedema
210
Urine microscopy of Indinavir renal stones?
Needle shaped crystals
211
General issue in Fanconi syndrome?
Disorder of proximal renal tubular function
- impaired re absorption of filtered solutes
- > LOW bicarbonate, K, phosphate, glucose, uric acid and amino acids lost in urine
-> development of type 2 (proximal) renal tubular acidosis (high Cl, low bicarb)
212
Causes of Fanconi syndrome?
```
Cystinosis (most common cause in children)
Sjögren’s syndrome
Multiple myeloma
Nephrotic syndrome
Wilson’s disease
```
213
Absolute contraindications to donating a kidney?
```
active malignancy
chronic infection
overt proteinuria
bilateral renal artery atherosclerosis
sickle cell disease
Uncontrolled hypertension
```
214
Management of class V lupus nephritis (membranous)?
IV methylprednisolone + IV cyclophosphamide
- endorsed by KDIGO (Kidney Disease Improving Global Outcomes) guidelines
215
Contraindications to starting testosterone replacement?
```
Prostate cancer
PSA >4ng/ml
male breast cancer
severe sleep apnoea
severe LUTS due to BPH
```
216
Common causes of bilateral hydronephrosis?
```
SUPER:
Stenosis of the urethra
Urethral valve
Prostatic enlargement
Extensive bladder tumour
Retro-peritoneal fibrosis
```
217
Common causes of unilateral hydronephrosis?
Pelvic-ureteric obstruction (congenital or acquired)
Aberrant renal vessels
Calculi
Tumours of renal pelvis
218
indications for plasma exchange in ANCA-associated vasculitis?
- Severe active renal disease (serum Cr > 354 micromol/L or require dialysis)
- Pulmonary haemorrhage
- Concurrent anti-GBM autoantibody disease.
219
What kind of GN does post strep GN cause?
acute, diffuse proliferative glomerulonephritis
220
Subsequent maintenance therapy in lupus nephritis after inducing remission?
mycophenolate
