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Renal Flashcards

1
Q

What is the pathogenesis of diabetic nephropathy?

A

Increased glomerular capillary pressure

Non-enzymatic glycosylation of the BM

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2
Q

What is seen on histology of diabetic nephropathy

A

BM thickening
Kimmelstiel-Wilson nodules (nodular glomerulosclerosis)
Hyaline arteriosclerosis

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3
Q

What genetic predisposition may lead to diabetic nephropathy?

A

ACE gene polymorphisms

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4
Q

What are the stages of diabetic nephropathy?

A
  1. Hyperfiltration
  2. Silent (GFR remains elevated)
  3. Microalbuminaemia 30-300mg/day, dipstick -ve
  4. Overt nephropathy: albumin>300mg/d, dipstick +ve, HTN usually present
  5. ESRF
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5
Q

What type of renal stone does proteus mirabilis predispose to?

A

Struvite

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6
Q

Why is there a small rise in creatinine following ACEI introduction?

A

Reduced filtration pressure

Greater rise - underlying renovascular disease

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7
Q

What has the best sensitivity for detecting proteinuria in CKD?

A

Albumin:creatinine ratio

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8
Q

How is proteinuria diagnosed in CKD?

A

First pass morning ACR sample

3-70mg/mmol - repeat
>70 - confirmed

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9
Q

What are the indications to refer to nephrologist in CKD?

A

Urinary ACR>70 unless known to be caused by diabetes
Urinary ACR >30 + haematuria
Urinary ACR 3-29, persistent haematuria, declining eGFR

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10
Q

What causes bone disease in CKD?

A

Low vitamin D
As hydroxylation normally occurs in the kidneys
High phosphate due to decreased excretion

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11
Q

What are the clinical manifestations of renal bone disease?

A

Osteitis fibrosa cystica
Osteomalacia
Osteoporosis

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12
Q

What is the most common histological pattern of lupus nephritis?

A

Diffuse proliferative glomerulonephritis (also the most severe pain)

Other - rapidly progressive GN

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13
Q

What are the histological features of lupus nephritis?

A

Wire loop appearance (endothelial and mesangial proliferation)
Thickened capillary wall secondary to immune complex deposits

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14
Q

What is Henoch-Schonlein purpura?

A

IA mediated small vessel vasculitis

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15
Q

What are the symptoms of HSP?

A

Palpable purpuric rash with localised oedema over buttocks and extensor surfaces of arms and legs
Abdominal pain
Polyarthritis
Features of IgA nephropathy - haematuria and renal failure

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16
Q

What percentage of HSP patients relapse?

A

1/3

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17
Q

What is the triad of haemolytic uraemic syndrome?

A

AKI
Microangiopathic anaemia
Thrombocytopenia

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18
Q

What are the causes of HUS?

A

Verotoxigenic/enterohaemorrhagic e.coli
Also shigella
Primary - atypical (not related to diarrhoea) = complement dysregulation

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19
Q

What is the treatment of HUS?

A 
Supportive
Fluids
Dialysis
Blood transfusion
Atypical - plasma exchange
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20
Q

What is Goodpasture’s disease?

A

Small vessel vasculitis associated with pulmonary haemorrhage and rapidly progressive glomerulonephritis

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21
Q

What is the cause of Goodpasture’s syndrome?

A

Anti-GBM antibodies against type 4 collagen

Associated with HLA DR2

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22
Q

How is Goodpasture’s syndrome diagnosed?

A

Linear IgG deposits on GBM on renal biopsy

Increased TLCO

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23
Q

What is the management of Goodpasture’s syndrome and a common complication

A

Plasmaphresis
Complication - hypocalcaemia

Also steroids, CYC

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24
Q

What are 8 indications for plasma exchange?

A 
GBS
Myasthenia gravis
Goodpasture's syndrome
TTP
HUS
Cryoglobulinaemia
ANCA +ve vasculitis if severe
Hyperviscosity syndrome
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25
What are 4 complications of plasmaphresis?
Hypocalcaemia (due to presence of citrate used as anticoagulant for extra-corporeal system which binds to calcium) Metabolic alkalosis Remove of systemic medications Coag factor/Ig depletion
26
What is the inheritance of PKD?
Autosomal dominant T1 - 85% = chromosome 16 which encodes for polycystin 1 T2 - 15% = chromosome 4
27
How is PKD screened for?
Abdominal ultrasound - good pickup rate of type 1 | However if wanting to donate a kidney therefore screening for type 2 needed as well - genetic screening
28
What is the management of PKD?
Manage HTN | Tolvaptan
29
How does tolvaptan work in PKD?
Vasopressin receptor 2 antagonist - binds to V2 receptors in collecting ducts to reduced cell proliferation, cyst formation, fluid excretion
30
What are the extra-renal manifestations of PKD?
Liver cysts Berry aneurysms MV prolapse Aortic root dilation and aortic dissection
31
What is fibromuscular dysplasia?
Non-atherosclerotic non-inflammatory disease of blood vessels that causes abnormal growth in the wall of an artery
32
What are the features of fibromuscular dysplasia?
Hypertension CKD/AKI secondary to ACEI initiation Flash pulm oedema secondary to fluid retention and diastolic ventricular dysfunction
33
What percentage of renal artery stenosis is caused by fibromuscular dysplasia?
10%
34
How is fibromuscular dysplasia diagnosed?
USS - asymmetric kidneys Duplex USS Contrast catheter angiography of the renal artery
35
What hormones do testicular teratomas secrete?
hCH and AFP
36
What scan is used to diagnose reflux nephropathy?
Micturating cystography
37
What scan is used to diagnose renal scarring?
DMSA scan
38
What is the mechanism of action of ciclosporin?
Inhibits calcineurin which is a phosphatase involved in T cell activation
39
What are the side effects of tacrolimus?
Impaired glucose tolerance
40
What is the mechanism of action of MMF?
Blocks purine synthesis by inhibition of IMPDH, therefore inhibits proliferation of B and T cells
41
When does CMV syndrome occur post renal transplant?
Between 1st and 6th month
42
What is the diagnosis and treatment of CMV syndrome?
PCR | Ganaciclovir
43
What is the pathophysiology of hyperacute organ rejection?
Pre-formed antibody such as ABO incompatibility or HLA mismatch
44
What are the features of hyperacute organ rejection?
Kidney becomes mottled, dusky, vessels thrombose following completion of vascular anastamosis. If left in - abscess formation
45
What are the characteristics of acute organ rejection?
Occurs during first 6 months T cell mediated Medical management
46
What are the features of renal artery thrombosis, a complication of renal transplant?
Sudden complete loss of urine output
47
What would suggest a urine leak post renal transplant?
``` Diminished urine output Rising creatinine Fever Abdo pain USS --> perigraft collection, necrosis of ureter tip ```
48
What are the complications of peritoneal dialysis?
Coagulase -ve staph peritonitis (epidermis) | Sclerosing peritonitis
49
What is the diagnosis of renal vascular disaese?
MR angiography
50
What are the biochemical features of renal artery stenosis?
High aldosterone High renin Low K
51
Why is renin low in primary hypoaldsteronism?
Resulting hypertension causes excessive renal perfusion, which results in decreased renin production
52
What are 4 risk factors for Wilm's tumour?
Beckith-Wiedemann syndrome WAGR syndrome Hemihypertrophy Mutation in WT1 gene on chromosome 11
53
What cell does renal cell cancer arise from?
Proximal tubule epithelium
54
What is the most common histological subtype of renal cancer?
Clear cell
55
What are 3 risk factors for renal cell carcinoma?
Smoking VHL Tuberous sclerosis
56
What are the endocrine effects of renal cell carcinoma?
Secretes EPO, PTH, renin, ACTH
57
What is Stauffer syndrome?
Paraneoplastic hepatic dysfunction syndrome seen in renal cell carcinoma Presents as cholestasis/hepatosplenomegaly
58
What is the cause of Stauffer syndrome?
Increased IL-6
59
What is the treatment of renal cell carcinoma?
Partial/total nephrectomy Alpha-IFN and IL-2 Receptor tyrosine kinase inhibitors e.g. sorafenib
60
What are 5 causes of retroperitoneal fibrosis?
``` Riedel's thyroiditis Prev radiotherapy Sarcoid Inflammatory AAA Methysergide ```
61
What are the features of retroperitoneal fibrosis?
Lower back/flank pain Fever Lower limb oedema
62
What are the biochemical features of rhabdomyolysis?
High CK, K, phosphate (release from myocytes) Low Ca (myoglobin binds calcium) Myoglobinuria Metabolic acidosis
63
What are 5 causes of rhabdomyolysis?
``` Seizure Collapse Ecstasy McArdle's syndrome Statins ```
64
On which chromosome is MHC coded for?
6
65
Where does spironalactone act?
Cortical collecting duct
66
What are 5 indications for spironalactone?
``` Ascites Hypertension Heart failure Nephrotic syndrome Conn's syndrome ```
67
What are 2 side effects of spironalactone?
Hyperkalaemia | Gynaecomastia
68
What are 5 causes of metabolic acidosis with normal anion gap?
``` GI bicarb loss Renal tubular acidosis Acetazolamide Ammonium chloride injection Addison's ```
69
What are 5 causes of metabolic acidosis with raised anion gap?
Lactic acidosis (e.g shock, burns, metformin) Ketones (DKA, alcohol) Urate (renal failure) Acid poisoning (salicylates, methanol)
70
How is diabetes insipidus diagnosed?
Water deprivation test | High plasma osmo, low urine osmo
71
Name 5 causes of cranial DI
``` Pituitary surgery Haemochromatosis Head injury Idiopathic DIDMOAD (Wolfram's syndrome) ```
72
What is the cause of nephrogenic DI?
Mutation in AVPR2 receptor Less common - aquaporin 2 channel mutation Other: High Ca, low K, lithium, democlocycline
73
What is the treatment of diabetes insipidus?
Cranial - desmopressin | Nephro - thiazides
74
What is the cause of congenital nephrogenic DI?
V2R gene
75
What are the biochemical features of alcoholic ketoacidosis?
Metabolic acidosis High anion gap Elevated ketones Normal/low glucose
76
What is the treatment of alcoholic ketoacidosis?
Infusion of saline and thiamine
77
What is the mechanism of action of beta lactams?
Inhibit cell wall formation
78
Which antibiotics inhibit protein synthesis?
Aminoglycosides Chloramphenicol Macrolides Tetracyclines
79
Which antibiotics inhibit DNA synthesis?
Quinolones Metronidazole Sulphonamides Trimethoprim
80
What is the mechanism of action of rifampicin?
Inhibits RNA synthesis
81
What are 3 causes of rapidly progressive glomerulonephritis?
SLE GPA Goodpasture's
82
What are 3 causes of nephritic syndrome?
Rapidly progressive glomerulonephritis IgA nephropathy Alport syndrome
83
What is seen on histology in Rapidly progressive GN
Crescents | Goodpasture's - linear IgG deposits
84
What is the treatment of IgA nephropathy?
Monitoring Steroids if persistent proteinuria Steroids 3rd line or falling eGFR
85
How is IgA nephropathy dianosed?
Mesangial hypercellularity | Positive immunofluorescence for IgA and C3
86
How many days/weeks post URTI does IgA nephropathy occur?
1-2 days
87
What are the features of Alport syndrome
BL SN deafness Lenticonus Retinitis pigmentosa Nephritic syndrome --> ESRF
88
What is seen on electron microscopy in Alport syndrome?
Splitting of lamina densa - basket weave appearance
89
Which conditions can present as both nephritic and nephrotic syndrome?
Diffuse proliferative GN | Membranoproliferative GN
90
What are the causes of diffuse proliferative GN?
SLE | 1-2 weeks post strep (B haemolytic strep usually pyogenes)
91
What is seen on histology in diffuse proliferative GN?
Wire looping of capillaries Subepithelial humps Starry sky
92
What are the causes of membranoproliferative GN?
1. Cryoglobulinaemia, hep C | 2. Partial lipdodystrophy, factor H deficiency
93
What factor is seen in lipodystrophy?
C3b nephritic factor
94
What is seen on electron microscopy in membranoproliferative GN?
1. Tram track | 2. Dense deposits
95
What are 5 causes of minimal change disease?
Idiopathic NSAIDs Rifampicin EBV
96
What is the pathophysiology of minimal change disease?
T cell and cytokine mediated damage to GBM --> polyanion loss and increased glomerular permeability to serum albumin
97
How is minimal change disease diagnosed?
Light microscopy is normal | Electron microscopy - fusion of podocytes, effacement of foot processes
98
What percentage of minimal change patients are responsive to steroids?
80%
99
What is 2nd line treatment of minimal change disease if resistant to steroids?
Cyclophosphamide
100
What are 5 complications of nephrotic syndrome?
``` Arterial and venous thromboses (loss of antithrombin) Hyperlipidaemia Increased infection (loss of Ig) Low calcium (Loss of vit D) CKD ```
101
What are the most common causes of nephrotic syndrome in adults?
Membranous GN - 1/3 | Focal segmental glomerulosclerosis - 1/3
102
What are the causes of secondary membranous GN?
``` Hep B Malaria Syphilis Malignancy Gold Penicillamine NSAIDs SLE RA ```
103
Which antibodies are seen in primary membranous GN?
Anti-phospholipase A2
104
What is seen on histology on membranous GN?
Spike and dome appearance of basement membrane
105
What is the treatment of membranous GN?
ACEI/ARB to reduce proteinuria Watch and wait Steroids
106
What are the causes of focal segmental glomerulosclerosis?
``` Idiopathic IgA nephropathy/reflux Heroin Alport's syndromee Sickle cell ```
107
What is seen on histology of focal segmental glomerulosclerosis?
Focal and segmental glomerulosclerosis Light microscopy - hyalinosis Electron microscopy - effacement of foot processes
108
What is a risk factor for amyloidosis?
Multiple myeloma | Chronic inflammation
109
What is seen on histology for nephrotic syndrome caused by amyloidosis?
Positive stain for Congo-Red, which when combined with polarised light appears apple-green
110
What are 2 causes of intrinsic AKI?
Acute tubular necrosis | Acute interstitial nephritis
111
What is the pathophysiology of acute tubular necrosis?
Hypovolaemia or prolonged renal ischaemia/direct toxicity from nephrotoxins Causes reduced glomerular perfusion and filtration --> renal cell hypoxia --> necrosis of renal tubular epithelium
112
What is seen on urinalysis in acute tubular necrosis?
Granular, muddy brown urinary casts No white cells
113
Name some toxins that can cause acute tubular necrosis.
Aminoglycosides Myoglobin Radiocontrast Lead
114
What are the causes of acute interstitial nephritis?
``` NSAIDs Penicillins PPIs Ciprofloxacin Allopurinol 25% other - SLE, sarcoid, Sjogrens ```
115
What is the triad of acute interstitial nephritis?
Rash Fever Eosinophilia Also - arthralgia and hypertension
116
What is seen on urinalysis in acute interstitial nephritis?
White cell and/or red cell casts
117
What are the 4 types of renal tubular acidosis?
1: distal 2: proximal 3: mixed 4: hyperK
118
What are 4 causes of type 1 renal tubular acidosis?
RA SLE Sjogrens Amphotericin B toxicity
119
Deficiency of carbonic anhydrase leads to which type of renal tubular acidosis?
Type 3 (mixed)
120
Fanconi syndrome is a cause of which type of renal tubular acidosis?
Type 2 (proximal)
121
Name 3 other causes of type 2 RTA.
Idiopathic Wilson's disease Acetazolamide
122
What is the pathophysiology of type 1 and type 2 RTA?
Type 1: inability to secrete H+ in DVT Type 2: decreased HCO3 reabsorption in PCT
123
What are the cases of type 4 RTA?
Hypoaldosteronism eg. Addisons, diabetes, SLE, ACEIs, BB, amyloid
124
What is the pathophysiology of type 4 RTA?
Reducing in aldosterone --> reduction in PCT ammoniuim excretion
125
What blood gas abnormality is seen on types 1, 2, and 3 RTA?
Low K Hyperchloraemic metabolic acidosis (normal anion gap)
126
What blood gas abnormality is seen on type 4 RTA?
High K Hyperchloraemic metabolic acidosis
127
What is the treatment of type 1 and 2 RTA?
Type 1: correct low K before acidosis. Chronic - PO bicarb prevents urinary K loss Type 2: bicarb. 2nd line hydrochlorthiazide and K
128
Fludrocortisone is the treatment of which type of RTA?
Type 4
129
What are the complications of type 1 and 2 RTA?
Renal stones Growth restriction Renal failure
130
Osteopetrosis, cerebral calcification, XS bone growth are complications of which type of RTA?
Type 3

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