Renal Flashcards
What is the classic triad of symptoms for renal cell carcinoma?
Haematuria
Flank pain
Palpable mass
What are risk factors for renal cell carcinoma?
Smoking, obesity, age
End-stage renal disease
Tuberous sclerosis, von Hippel Lindau syndrome
What is the most common histology of renal cell carcinoma?
Clear cell carcinoma
What are paraneoplastic syndromes associated with renal cell carcinoma?
Hypercalcaemia
Polycythaemia
Hypertension
Varicocele in men
What is the classic radiological feature of renal cell carcinoma metastasis?
Cannonball mets in the lungs
What is the gold standard test for renal cell carcinoma?
Contrast-enhanced CT
What are the complications of renal transplant?
Rejection Failure of transplant Electrolyte imbalance Recurrence of disease Ureter blockage/leakage of anastomosis Infection + effect of immunosuppressant medication
What are the complications of immunosuppressant therapy post-transplant?
Infection IHD T2DM Non-Hodgkin Lymphoma Skin cancer
What are pre-renal causes of AKI?
Hypovolemia - blood loss / dehydration
Hypotension - heart failure, shock
Sepsis
Renal artery obstruction / stenosis
What are renal causes of AKI?
Nephrotoxic medication
Glomerulonephritis
Interstitial nephritis
Acute tubular necrosis
What are post-renal causes of AKI?
Renal/ ureteric calculi Ureteric stricture / blockage Tumour compression / internal tumours Enlarged prostate VUJ dysfunction
How would you approach a patient with suspected AKI?
A-E assessment
Full set of obs
Prescription review
Bloods: FBC, U&E, CRP, LFT, Cultures if septic
Urinalysis: dip for blood, protein, infection
MSU -> MC+S to look for casts, cells and organisms
USS urinary tract -> CTKUB
What are the complications of AKI?
Hyperkalaemia Hyper-uraemia -> encephalopathy, pericarditis Fluid overload -> pulmonary oedema Metabolic acidosis Interstitial damage
What are the causes of CKD?
Diabetes Hypertension Long term use of nephrotoxic medication PKD, Glomerulonephritis Childhood renal disease
Medication: NSAIDs and lithium most commonly
What are the symptoms of CKD?
Often asymptomatic Fluid overload + oedema Nausea, Pruritus, loss of appetite Pallor Hypertension
What investigations can be done for CKD?
- A-E + full set of obs
- Bloods: FBC, U&E, CRP, bone profile, LFT, HbA1c
- Urine: albumin: creatinine ratio, blood (A:Cr >3 = significant)
- Renal USS
For diagnosis, need eGFR <60 or proteinuria
How is CKD managed?
- Fluid restriction
- Sodium restriction
- Glycaemic control
SGLT2 inhibitor eg. dapagliflozin should be given - BP control: ACE-I -> diltiazem
- Atorvastatin
- RRT
- Dialysis
Treat complications
What are the complications of CKD?
- Renal anaemia
- Secondary hyperparathyroidism
- Metabolic acidosis
- Hyperkalaemia
- CVD
- Pulmonary Oedema
What is the treatment for renal anaemia?
- Treat any iron deficiency
- If Hb very low, transfuse (but avoid regular transfusion due to risk of sensitisation)
- Erythropoietin
What are the features of renal bone disease?
Osteomalacia, osteoporosis, osteosclerosis
What is the pathophysiology of secondary hyperparathyroidism?
Reduced phosphate excretion, increased serum levels
Reduced activation of vitamin D by the kidneys -> reduced calcium absorption from gut
In response to low calcium and high phosphate, increased PTH release
PTH stimulates osteoclast activity to resorb bone
What is the management for secondary hyperparathyroidism?
Low phosphate diet Activated vitamin D supplementation: alfacalcidol, calcitriol Bisphosphonates for bone protection Calcium carbonate Phosphate binder e.g. calcium acetate
What are the indications for dialysis?
AEIOU
A: Acidosis- severe, refractory metabolic acidosis
E: Electrolyte abnormality: Severe, refractory hyprekalaemia
I: Intoxication- ingestion of certain toxins
O: Oedema - severe, treatment resistant pulmonary oedema
U: Uraemia- High urea causing encephalopathy or pericarditis
End stage renal failure with anuria
What are the two most common types of AV fistula?
Radiocephalic
Brachiocephalic
How long before an AV fistula is mature and ready to use?
4w-4m
What are the complications of AV fistulae?
Infection Aneurysm formation Thrombosis Stenosis STEAL syndrome: ischaemia to distal limb
What is nephrotic syndrome?
Group of symptoms characterised by:
significant proteinuria, oedema and low serum albumin
You also get high cholesterol production to compensate for the loss in albumin
What are important complications of nephrotic syndrome?
High cholesterol
Loss of antithrombin III - increased risk of clotting
Loss of immunoglobulins- increased risk of infection
Hypertension
Fluid overload -> heart strain
What is nephritic syndrome?
Characterised by group of symptoms:
haematuria, low grade proteinuria, oliguria
Hypertension and oedema also occur as a result of fluid retention
What are common causes of nephrotic syndrome?
Minimal change disease FSGS Membranous nephropathy Diabetic nephropathy Severe membranoproliferazive GN
What are common causes of nephritic syndrome?
IgA nephropathy Post-streptococcal GN Membranoproliferative GN Goodpasture syndrome Alport syndrome Small vessel vasculitis: GPA, EGPA, MPA, HSP RPGN
What is the most common cause of nephrotic syndrome in children?
Minimal change disease
What is the diagnostic test for minimal change disease?
Renal biopsy and electron microscopy - loss of podocyte foot processes
How is minimal change disease managed?
Tapering course of prednisolone over 4-16w
What is the most common cause of nephrotic syndrome in adults?
Focal segmental glomerulosclerosis
What is seen on biopsy in FSGS?
Focal areas of glomerular scarring
How is FSGS managed?
ACE-I / ARB + other BP control
Steroids
Plasma exchange in recurrent disease
What is seen on biopsy in membranous nephropathy?
IgG and complement deposits in the glomerular basement membrane
How is membranous nephropathy managed?
ACE-I / ARB and BP control
Immunosuppressants in severe disease
What are the general symptoms of nephrotic syndrome?
Oedema, breathlessness, frothy urine, increased clotting, fatigue
What investigations should be done in suspected nephrotic syndrome?
Bloods: FBC, U+E, LFT (low albumin), clotting, lipids
Urine dip: proteinuria
MSU: A:Cr ratio
Renal USS and biopsy -> microscopy
What is the general management in nephrotic syndrome?
Fluid and salt restriction, daily weights
Loop diuretics + thiazide if insufficient response
ACE-I/ARB and BP control
Glycaemic control
Statin
VTE prophylaxis
Steroids/immunosuppressants in more severe disease
What are the classic symptoms of IgA nephropathy?
Microscopic haematuria with episode of macroscopic following: respiratory/GI infection, strenuous exercise
Discernable from post-strep as occurs DURING/days after infection rather than weeks
How is IgA nephropathy diagnosed?
Elevated serum IgA
Low serum C3
Mesangial proliferation
IgA deposits in the mesangium
Which vasculitis has identical findings on renal biopsy to IgA nephropathy?
HSP
- discernible by systemic symptoms in HSP
How is IgA nephropathy treated?
ACE-I / ARB
Steroids if persisting >6m
What is the characteristic presentation of post-strep GN?
Macroscopic haematuria presenting weeks post strep infection - most commonly throat or skin infection
-> 1-2 w post pharyngitis/tonsilitis
-> 3-4w post skin infection
Caused by group A B-haemolytic strep
Also present with oedema, HTN
What is the hypersensitivity type of post-strep GN?
Type 3
What is found on investigation in post-strep GN?
- Low serum C3
- Anti-strep antibodies
- Complement and IgG deposits in GBM and mesangium
How is post-strep GN managed?
Supportive treatment- fluid restrict, diuretics, ACE-I
Antibiotics if any remaining infection
What is goodpasture’s syndrome?
Anti-GBM syndrome- antibodies against type 4 collagen
Causes haemoptysis and nephritic syndrome
How is goodpasture’s syndrome diagnosed?
Symptoms of haemoptysis + haematuria
Presence of anti-GBM/type 4 collagen antibodies in circulation and in the mesangium on renal biopsy
Pulmonary infiltrates on CXR
Iron deficiency anaemia
Usually presents with RPGN
How is goodpasture’s syndrome managed?
- Plasma exchange
- Steroids + cyclophosphamide
+ other nephritic syndrome managements
What is Alport’s syndrome?
X-linked condition: most commonly dominant but can be recessive
Mutation in gene encoding type 4 collagen
Leads to sensorineural hearing loss, loss of vision, haematuria and oedema
Often leads to end-stage renal disease
No specific treatment
Which small vessel vasculitis most commonly cause nephritic syndrome?
GPA and EGPA
GPA: nasal crusting/nasopharyngeal involvement + haemoptysis + haematuria + Purpura
C-ANCA
EGPA: brittle asthma/eosinophilia + haematuria + purpura
P-ANCA
What is rapidly progressing GN?
Rapid decline in renal function due to any form of nephritic syndrome
Can case ESRD within a matter of weeks-months
Characterised by cresents on renal biopsy
Usually requires plasma exchange and immunosuppression
How does nephritic syndrome most commonly present?
Haematuria, proteinuria, hypertension, oedema and oliguria
Proteinuria is far less prominent than in nephrotic syndrome
How would you investigate somebody presenting with nephritic syndrome?
Bloods: FBC, U&E, LFT, CRP
Immunoglobulins, complement, ANCA + antibody screen
Urine dip: haematuria, protein
MSU: A:CR ratio, granular casts in some
Renal USS + biopsyWhat is the generic management of nephritic syndrome?
ACE-I and BP control
Low sodium diet and fluid restriction
Diuretics if severe oedema
Sometimes immunosuppression/plasma exchange
In what condition would you expect waxy urinary casts?
Advanced CKD
In what condition would you expect RBC casts in the urine?
Nephritic syndrome / glomerulonephritis
In which conditions would you expect epithelial cell casts in the urine?
Glomerulonephritis
Nephrotic syndrome
In which condition would you expect WBC casts in the urine?
Pyelonephritis
In which condition would you expect granular/muddy brown casts in the urine?
Acute tubular necrosis
In which condition would you expect fatty casts in the urine?
Nephrotic syndrome
