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Renal Flashcards

1
Q

Define acute kidney injury

A

Drop in kidney function

Rise in serum creatinine

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2
Q

List the NICE criteria for AKI

A

Rise in Cr of >25micromol/L in 48hrs

Rise in Cr of >50% in 7 days

Urine output <0.5ml/Kg/hr for >6hrs

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3
Q

List some risk factors for AKI

A 
Chronic kidney disease
Heart failure
Diabetes
Liver disease
Older age 
Cognitive impairment 
Nephrotoxic medication - NSAIDs and ACEi 
Contrast medium
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4
Q

What causes an AKI

A

Pre-renal

  • Dehydration
  • Hypotension
  • Heart failure

Renal

  • Glomerulonephritis
  • Interstitial nephritis
  • Acute tubular necrosis

Post-renal

  • Stones
  • Urethral or ureter strictures
  • Enlarged prostate or prostate cancer
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5
Q

What investigations would you do for AKI

A

Urinalysis - protein and blood (acute nephritis or infection), leucocytes (infection), glucose (DM)
USS - obstruction

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6
Q

Describe the management of an AKI

A

Prevention - stop nephrotoxic drugs, ensure adequate fluids

Fluid rehydration - IV fluid sin pre-renal
Stop nephrotoxic medications - NSAID, ACEi
Relieve obstruction

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7
Q

List some complications of AKI

A

Hyperkalaemia
Fluid overload, heart failure, pulmonary oedema
Metabolic acidosis
Uraemia - encephalopathy or pericarditis

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8
Q

List some causes of chronic kidney disease

A 
DM
HTN
Age related DM
Polycystic kidney disease
Medication - NSAID, lithium and PPIs
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9
Q

List some risk factors of CKD

A 
Old 
HTN
Smoking
DM
Nephrotoxic meds
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10
Q

Describe the presentation of CKD

A 
Pruitis 
Asymptomatic
HTN
Oedema
Loss of appetite
Nausea
Peripheral neuropathy 
Pallor
Muscle cramps
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11
Q

What investigations would you do for CKD

A

Estimated glomerular filtration rate (eGFR) - 2 tests 3 months apart

Proteinuria - urine albumin:creatinine ratio (ACR), a result >3mg/mmol is significant

Haematuria - urine dipstick

Renal ultrasound - accelerated CKD, FH of polycystic kidney disease or evidence of obstruction

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12
Q

How is CKD scored?

A 
G score - based on eGFR
G1 >90 
G2 60-89 
G3a 45-59 
G3b 30-44
G4 15-29 
Gr <15

A score - albumin:creatinine ratio
A1 <3
A2 3-30
A3 >30

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13
Q

What is needed for a diagnosis of CKD

A

eGFR <60 and Proteinuria

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14
Q

List the complications of CKD

A 
Anaemia 
Renal bone disease
Cardiovascular disease
Peripheral neuropathy 
Dialysis related problems
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15
Q

How is CKD treated

A

Atorvastatin 20mg - primary prevention CVD

Oral sodium bicarbonate - metabolic acidosis

Iron supplementation and erythropoietin - anaemia

ACEi in HTN

Vit D (alfacalcidol and calcitriol), low phosphate diet and bisphosphonates - bone disease

Dialysis and transplant in end stage renal failure

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16
Q

Describe how CKD causes anaemia

A

Kidney cells normally produce erythropeotin which stimulates production of new RBC
In CKD, reduced EPO meansd reduced RBC

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17
Q

List the features and X-ray changes of CKD renal bone disease

A

Osteoporosis
Osteosclerosis - both ends of vertebrae are brighter white
Osteomalacia - centre of vertebrae are less white (rugger jersey sign)

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18
Q

Describe how renal bone disease occurs in CKD

A

High serum phosphate due to reduced excretion, this stimulates hyperparathyroidism as the parathyroid glands sense this and low calcium and secrete parathyroid hormone to increase osteoclast activity leading to more absorption of the calcium from the bone

Active Vitamin D is essential for calcium absorption and metabolism of Vit D is done by the kidneys

Osteomacia - increased turnover of bones without adequate calcium

Osteosclerosis - osteoblasts respond by increasing their activity to match the osteoclasts by creating new tissue in bone

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19
Q

What blood test shows a pre-renal AKI

A

Increased Ur:Cr ratio

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20
Q

List the eGFR variables in the Modification of diet in renal disease equation

A

Creatinine
Age
Gender
Ethnicity

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21
Q

List some indications for dialysis

A 
Acidosis 
Electrolyte disturbance - severe and unresponsive hyperkalaemia
Intoxication 
Oedema
Uraemia - seizures and reduced GCS
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22
Q

What are the indications for long term dialysis

A

End stage renal failure

Any of the acute indications continuing long term

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23
Q

Name the different types of dialysis

A

Continuous ambulatory peritoneal dialysis

Automated peritoneal dialysis

Haemodialysis

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24
Q

Describe peritoneal dialysis

A

Peritoneal membrane as the filtration membrane
Dialysis solution containing dextrose is added to the peritoneal cavity
Ultrafiltation occurs across the membrane in to the dialyisis solution, the solution is then taken away
Tenckhoff catheter - plastic tube into peritoneal acity - insert and remove the fluid

Continuous ambulatory - dilayisis solution is in the peritoneum at all times

Automated dialysis - peritoneal dialysis at night, machine continuously replaces fluid in abdomen overnight to optimise ultrafilttayion - takes 8-10hrs

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25
List some complications of peritoneal dialysis
Bacterial peritonitis Peritoneal sclerosis Ultrafiltration failure - absorb the dextrose instead Weight gain Psychosocial effects
26
Describe haemodilayisis
Blood filtered by machine 4hrs a day for 3 days a week Good access - tunnelled cuffed catheter or arteriovenous fistula
27
Describe tunnelled cuffed catheter
Tube inserted into the subclavian or jugular vein with a tip that sits in the superior vena cava or right atrium 2 lumens - blood exits (red) and blood enters (blue) Dacron cuff - surrounds catheter - promotes healing and adhesion of tissue to the cuff making ti permanent and providing a barrier to infection
28
What are the complications of a tunnelled cuffed catheter
Infection | Blood clots
29
Describe an AV fistula
Artificial connection between an artery and a vein Bypass the capillary system and allows blood to flow under high pressure from the artery directly into the vein Permanent easy access blood vessel with high pressure arterial blood flow Surgical operation and 4week to 4 month maturation period without use Formed between artery and vein in patients forearm (radio-cephalic, brachiocephalic, brachiobasilic)
30
What do you look for when examining AV fistula
Skin integrity Aneurysms Palpable thrill - fine vibration felt over anastomosis Machinery murmur on auscultation
31
List some AV fistula complications
``` Aneurysms Infection Thrombosis Stenosis STEAL syndrome High output HF ```
32
Describe STEAL syndrome
Inadequate blood flow to the limb distal to the AV fistula - steals blood from distal limb - causes distal ischaemia
33
Describe High output HF in terms of AV fistula
Blood is flowing quickly through the fistula - rapid flow of blood to heart increasing pre-load and leading to hypertrophy and HF
34
What must you never take blood from
AV fistula
35
What type of scar is seen in renal transplant?
Hockey stick
36
How are patient and donor kidneys matched
HLA - A, B and C on chromosome 6
37
How are kidneys transplanted
Patients own kidneys are left in situ Donor vessels are connected with external iliac vessels Donor ureter is anastomosed directly with the patients bladder Donor kidney is placed anterior in the abdomen and can be palpated in the iliac fossa area
38
Describe the usual immunosuppressant regime post renal transplant
Tacrolimus Mycophenolate Prednisolone Possibly cyclosporine, sirolimus and azathioprine
39
List the complications relating to renal transplant
Transplant rejection Transplant failure Electrolyte imbalances
40
List the complications related to the immunosuppressants used in renal transplant
``` Ischaemic heart disease T2DM Infection Unusual infections - PCP, CMV, PJP, TB Non-Hodgkin lymphoma Skin cancer ```
41
What is nephritic syndrome
Group of symptoms suggesting | inflammation of the kidney
42
What features occur in nephritic syndrome
Haematuria - micro/macroscopic Oliguria Proteinuria <3g/24hrs Fluid retention
43
What are the features of nephrotic syndrome
Peripheral oedema Proteinuria >3g/24hr - frothy urine Serum albumin <25g/L Hypercholesterolaemia - predisposing to thrombosis, HTN Sometimes low total thyroxine may be seen
44
What is nephrotic syndrome
A way of saying there is some kidney disease but not specifying the cause
45
What is glomerulonephritis
Umbrella term applied to conditions that cause inflammation of or around the glomerulus and nephron
46
How are most types of glomerulonephritis treated?
Immunosuppression | Blood pressure control by blocking the RAAS - ACEi or ARBs
47
What is the most common cause of nephrotic syndrome in children
Minimal change disease
48
What is the most common cause of nephrotic syndrome in adults
Focal segmental glomerulosclerosis
49
Describe IgA nephropathy (Berger's disease)
Most common cause of primary glomerulonephritis Peak age = 20s Histology shows IgA deposits and glomerular mesangial proliferation Macroscopic haematuria following URTI
50
Describe membranous glomerulonephritis
Most common cause of glomerulonephritis overall Bimodal peak in age - 20s and 60s Histology shows IgG and complement deposits on the basement membrane Majority are idiopathic (70%) Can be secondary to malignancy, RA, drugs (NSAIDs)
51
Describe post streptococcal glomerulonephritis
Patients <30yo Present 1-3 weeks after streptococcal infection (tonsillitis, impetigo) Nephritic syndrome Full recovery
52
Describe Goodpasture's syndrome
Anti-GBM antibodies attack glomerulus and pulmonary basement membranes - anti-GBM antibodies Glomerulonephritis and pulmonary haemorrhage - AKI and haemoptysis
53
Describe granulomatosis with polyangiitis (Wegener's syndrome)
Vasculitis associated with ANCA antibodies Wheeze, sinusitis and saddle shaped nose
54
Describe rapidly progressive glomerulonephritis
Often presents secondary to Goodpasture syndrome Presents with very acute illness with sick patients but responds well to treatment
55
What might significant renal impairment after starting an ACE i suggest
Bilateral renal artery stenosis or fibromuscular dysplasia in young female patient
56
What does rhabdomyolysis cause in the kidneys
Acute tubular necrosis
57
What picture does acute interstitial nephritis cause
Allergic type - raised urinary WCC, IgE and eosinophils alongside renal impairment
58
What is the difference between type 1 and type 2 hepatorenal syndrome
Fast onset in Type 1 | Slow onset in type 2 `
59
What antibodies is membranous glomerulonephritis associated with
PLA2R
60
What can be found in the urine in acute tubular necrosis
Granular, muddy brown urinary casts
61
Describe diabetic nephropathy
Chronic exposure to high levels of glucose lead to damage and scarring of the glomerulus - glomerulosclerosis Proteinuria is a key feature - damage allows protein to be filtered from the blood to the urine
62
Describe the screening for diabetic nephropathy
Albumin:creatinine ratio - early morning specimen U&Es
63
Describe the management of diabetic nephropathy
ACEi | Optimise blood sugar levels
64
What is interstitial nephritis and what are the two types
Inflammation of the interstitium - space between the cells and tubules Acute interstitial nephritis Chronic tubulointerstitial nephritis
65
Describe acute interstitial nephritis and its management
AKI and HTN - rash - eosinophilia - fever Acute inflammation of the tubules and interstitium - hypersensitivity reaction to - drugs and infection Reverse the underlying cause and steroids may help
66
What is chronic tubulointerstitial nephritis
Chronic inflammation of the tubules and interstitium - CKD Autoimmune, infectious, iatrogenic and granulomatous disease causes Management - reverse underlying cause and steroids
67
Describe acute tubular necrosis
Death of the epithelial cells of the renal tubules Most common cause of AKI
68
Describe the prognosis of acute tubular necrosis
7-12 days to recover as epithelial cells are able to regenerate
69
What causes acute tubular necrosisi
``` Toxins Ischaemia Shock Dehydration Sepsis Radiology contrast dye Gentamicin NSAIDs ```
70
What is found in the urine of someone with acute tubular necrosis
Muddy brown casts - pathognomonic Renal tubular epithelial cells in the urine
71
How is acute tubular necrosis treated
Supportive management IV fluid Stop nephrotoxic medications Treat complications
72
Describe type 1 renal tubular acidosis
Pathology in the distal tubule - unable to excrete hydrogen ions ``` Hyperventilation - compensate for metabolic acidosis Hypokalaemia CKD Bone disease Failure to thrive Urinary pH high ```
73
How do you treat type 1 renal tubular acidosis
Oral bicarbonate
74
Describe type 4 renal tubular acidosis
``` Reduced aldosterone Most common cause of renal tubualr acidosis Adrenal insufficiency Medications such as ACEi and spirnolactone or systemic conditions - SLE, DM, HIV Hyperkalaemia High chloride Metabolic acidosis Low urinary pH ```
75
How is type 4 renal tubular acidosis managed
Fludrocortisone | Sodium bicarbonate and treatment of hyperkalaemia
76
What is type 2 renal tubular acidosis associated with
Osteomalacia | Hypokalaemia
77
List the triad of haemolytic uraemic syndrome
Haemolytic anaemia Low platelets AKI
78
What is the usual trigger for HUS
Shiga toxin
79
What is haemolytic uraemic syndrome
Thrombosis in small blood vessels
80
Which bacteria produce the shiga toxin
Ecoli 0157 | Salmonella
81
What may increase the risk of HUS
Use of antibiotics and anti-motility medications - loperamide
82
Describe the presentation of haemolytic uraemic syndrome
Blood diarrhoea with Ecoli gastroenteritis ``` 5 days later HUS symptoms - Reduced urine output Haematuria or dark brown urine Abdo pain Lethargy and irritability Confusion HTN Bruising ```
83
How is HUS managed
Supportive care with antihypertensives, blood transfusions and dialysis
84
What is the prognosis of HUS
70-80% make full recovery 10% mortality Self limiting
85
What is seen on blood film in HUS
Fragmented red blood cells
86
What is rhabdomyolysis
Skeletal muscle tissue breaks down and releases myoglobin, potassium, phosphate and creatine kinase
87
What can rhabdomyolysis cause
Hyperkalaemia - arrhythmia | Myoglobin - AKI
88
What are the causes of rhabdomyolysis
Prolonged immobility Extremely rigorous exercise Crush injury Seizures
89
List the signs and symptoms of rhabdomyolysis
``` Muscle aches and pains Oedema Fatigue Confusion Red-brown urine ```
90
List the investigations for rhabdomyolysis
Creatine kinase - rises for 12hrs and then remians elevated 1-3 days after before gradually falling Myoglobinuria - red-brown urine and positive blood on dipstick U&Es - Hyperkalaemia ECG - hyperkalaemia
91
Describe the management of rhabdomyolysis
IV fluids IV sodium bicarbonate to make the urine more alkaline, reduce toxicity of myoglobin IV mannitol to increased GFR and reduce oedema, treat hypovolaemia prior to this Treat complications
92
List some conditions which cause hyperkalaemia
``` AKI CKD Rhabdomyolysis Adrenal insufficiency Tumour lysis syndrome Blood samples may haemolyse on way to lab giving false hyperkalaemia ```
93
Which medications cause hyperkalaemia
Aldosterone antagonists - spironolactone and eplerenone ACEi/ARB NSAIDs K+ supplements
94
Give the ECG signs of hyperkalaemia
Tall tented T waves Flattening or abscence of the P waves Broad QRS complexes
95
How is hyperkalaemia managed
Insulin (actrapid 10 Units) Dextrose (50ml of 50% dextrose) Calcium gluconate - stabiliose the cardiac muscle cells and reduces risk of arrytmia Other drugs - nebulised salbutamol, IV fluids, oral calcium resonium, sodium bicarbonate, dialysis
96
How does Insulin and dextrose cause a lowering of potassium
Drives carbohydrates into the cells and takes potassium with it
97
What is polycycstic kidney disease
Multiple fluid filled cysts | Reduced kidney fuction
98
What are the two types of polycystic kidney disease
Autosomal dominant (most common) - PKD-1 Chromosome 16 Autosomal recessive - PKD2 chromosome 4
99
List some extra-renal manifestations of polycystic kidney disease
Cerebral aneurysms Hepatic, splenic, pancreatic, ovarian and prostatic cysts Cardiac valve disease - MR Colonic diverticulum Aortic valve dilation
100
Describe the complications of polycystic kidney disease
``` Chronic loin pain Hypertension CVD Gross haematuria Renal stones End stage renal failure ```
101
What drug can be given in polycystic kidney disease to slow the development of cysts and progression of renal failure in autosomal dominant polycystic kidney disease
Tolvaptan - vasopressin receptor antagonist
102
List some causes of nephritic syndrome
Post-streptococcal glomerulonephritis - weeks after strep infection IgA nephropathy -days after URTI Rapidly progressive glomerulonephritis - Wegener's (haemoptysis, saddle nose and sinusitis), Goodpasture's (renal and haemoptysis, antiGBM), SLE
103
List some causes of nephrotic syndrome
Minimal change disease (most common in children) Focal segmental glomerulosclerosis (most common in adults) Membranous glomerulonephritis
104
What is seen on histology in membranous glomerulonephritis
Thickened membrane | Sub epithelial spikes
105
What is seen on histology in IgA nephropathy
Mesangial proliferation and complement deposition
106
What is seen on histology in rapidly progressive glomerulonephritis
Cresenteric glomerulonephritis
107
What is seen on histology in goodpastures
IgG on basement membrane
108
Describe the presentation of acute interstitial nephritis
High eosinophils - allergic picture | High WCC in urine
109
Why might renal function worsen following initiation of ACEi or ARBs
Bilateral renal artery stenosis
110
List the features of nephritic syndrome
Proteinuria <3g/L Haematuria Fluid retention Oliguria
111
List the features of nephrotic syndrome
Proteinuria >3g/L Hypoalbuminemia Peripheral oedema Hypercholesterolaemia

Finals (18 decks)

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