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Finals > Renal > Flashcards

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
Q

List some complications of peritoneal dialysis

A

Bacterial peritonitis

Peritoneal sclerosis

Ultrafiltration failure - absorb the dextrose instead

Weight gain

Psychosocial effects

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26
Q

Describe haemodilayisis

A

Blood filtered by machine 4hrs a day for 3 days a week

Good access - tunnelled cuffed catheter or arteriovenous fistula

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27
Q

Describe tunnelled cuffed catheter

A

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

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28
Q

What are the complications of a tunnelled cuffed catheter

A

Infection

Blood clots

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29
Q

Describe an AV fistula

A

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)

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30
Q

What do you look for when examining AV fistula

A

Skin integrity
Aneurysms
Palpable thrill - fine vibration felt over anastomosis
Machinery murmur on auscultation

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31
Q

List some AV fistula complications

A 
Aneurysms
Infection 
Thrombosis
Stenosis
STEAL syndrome 
High output HF
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32
Q

Describe STEAL syndrome

A

Inadequate blood flow to the limb distal to the AV fistula - steals blood from distal limb - causes distal ischaemia

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33
Q

Describe High output HF in terms of AV fistula

A

Blood is flowing quickly through the fistula - rapid flow of blood to heart increasing pre-load and leading to hypertrophy and HF

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34
Q

What must you never take blood from

A

AV fistula

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35
Q

What type of scar is seen in renal transplant?

A

Hockey stick

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36
Q

How are patient and donor kidneys matched

A

HLA - A, B and C on chromosome 6

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37
Q

How are kidneys transplanted

A

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

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38
Q

Describe the usual immunosuppressant regime post renal transplant

A

Tacrolimus
Mycophenolate
Prednisolone

Possibly cyclosporine, sirolimus and azathioprine

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39
Q

List the complications relating to renal transplant

A

Transplant rejection
Transplant failure
Electrolyte imbalances

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40
Q

List the complications related to the immunosuppressants used in renal transplant

A 
Ischaemic heart disease
T2DM
Infection 
Unusual infections  - PCP, CMV, PJP, TB 
Non-Hodgkin lymphoma 
Skin cancer
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41
Q

What is nephritic syndrome

A

Group of symptoms suggesting

inflammation of the kidney

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42
Q

What features occur in nephritic syndrome

A

Haematuria - micro/macroscopic
Oliguria
Proteinuria <3g/24hrs
Fluid retention

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43
Q

What are the features of nephrotic syndrome

A

Peripheral oedema
Proteinuria >3g/24hr - frothy urine
Serum albumin <25g/L
Hypercholesterolaemia - predisposing to thrombosis, HTN
Sometimes low total thyroxine may be seen

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44
Q

What is nephrotic syndrome

A

A way of saying there is some kidney disease but not specifying the cause

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45
Q

What is glomerulonephritis

A

Umbrella term applied to conditions that cause inflammation of or around the glomerulus and nephron

46
Q

How are most types of glomerulonephritis treated?

A

Immunosuppression

Blood pressure control by blocking the RAAS - ACEi or ARBs

47
Q

What is the most common cause of nephrotic syndrome in children

A

Minimal change disease

48
Q

What is the most common cause of nephrotic syndrome in adults

A

Focal segmental glomerulosclerosis

49
Q

Describe IgA nephropathy (Berger’s disease)

A

Most common cause of primary glomerulonephritis

Peak age = 20s

Histology shows IgA deposits and glomerular mesangial proliferation

Macroscopic haematuria following URTI

50
Q

Describe membranous glomerulonephritis

A

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
Q

Describe post streptococcal glomerulonephritis

A

Patients <30yo
Present 1-3 weeks after streptococcal infection (tonsillitis, impetigo)
Nephritic syndrome
Full recovery

52
Q

Describe Goodpasture’s syndrome

A

Anti-GBM antibodies attack glomerulus and pulmonary basement membranes - anti-GBM antibodies

Glomerulonephritis and pulmonary haemorrhage - AKI and haemoptysis

53
Q

Describe granulomatosis with polyangiitis (Wegener’s syndrome)

A

Vasculitis associated with ANCA antibodies

Wheeze, sinusitis and saddle shaped nose

54
Q

Describe rapidly progressive glomerulonephritis

A

Often presents secondary to Goodpasture syndrome

Presents with very acute illness with sick patients but responds well to treatment

55
Q

What might significant renal impairment after starting an ACE i suggest

A

Bilateral renal artery stenosis

or fibromuscular dysplasia in young female patient

56
Q

What does rhabdomyolysis cause in the kidneys

A

Acute tubular necrosis

57
Q

What picture does acute interstitial nephritis cause

A

Allergic type - raised urinary WCC, IgE and eosinophils alongside renal impairment

58
Q

What is the difference between type 1 and type 2 hepatorenal syndrome

A

Fast onset in Type 1

Slow onset in type 2 `

59
Q

What antibodies is membranous glomerulonephritis associated with

A

PLA2R

60
Q

What can be found in the urine in acute tubular necrosis

A

Granular, muddy brown urinary casts

61
Q

Describe diabetic nephropathy

A

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
Q

Describe the screening for diabetic nephropathy

A

Albumin:creatinine ratio - early morning specimen

U&Es

63
Q

Describe the management of diabetic nephropathy

A

ACEi

Optimise blood sugar levels

64
Q

What is interstitial nephritis and what are the two types

A

Inflammation of the interstitium - space between the cells and tubules

Acute interstitial nephritis

Chronic tubulointerstitial nephritis

65
Q

Describe acute interstitial nephritis and its management

A

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
Q

What is chronic tubulointerstitial nephritis

A

Chronic inflammation of the tubules and interstitium - CKD

Autoimmune, infectious, iatrogenic and granulomatous disease causes

Management - reverse underlying cause and steroids

67
Q

Describe acute tubular necrosis

A

Death of the epithelial cells of the renal tubules

Most common cause of AKI

68
Q

Describe the prognosis of acute tubular necrosis

A

7-12 days to recover as epithelial cells are able to regenerate

69
Q

What causes acute tubular necrosisi

A 
Toxins 
Ischaemia 
Shock 
Dehydration 
Sepsis 
Radiology contrast dye
Gentamicin 
NSAIDs
70
Q

What is found in the urine of someone with acute tubular necrosis

A

Muddy brown casts - pathognomonic

Renal tubular epithelial cells in the urine

71
Q

How is acute tubular necrosis treated

A

Supportive management
IV fluid
Stop nephrotoxic medications
Treat complications

72
Q

Describe type 1 renal tubular acidosis

A

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
Q

How do you treat type 1 renal tubular acidosis

A

Oral bicarbonate

74
Q

Describe type 4 renal tubular acidosis

A 
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
Q

How is type 4 renal tubular acidosis managed

A

Fludrocortisone

Sodium bicarbonate and treatment of hyperkalaemia

76
Q

What is type 2 renal tubular acidosis associated with

A

Osteomalacia

Hypokalaemia

77
Q

List the triad of haemolytic uraemic syndrome

A

Haemolytic anaemia
Low platelets
AKI

78
Q

What is the usual trigger for HUS

A

Shiga toxin

79
Q

What is haemolytic uraemic syndrome

A

Thrombosis in small blood vessels

80
Q

Which bacteria produce the shiga toxin

A

Ecoli 0157

Salmonella

81
Q

What may increase the risk of HUS

A

Use of antibiotics and anti-motility medications - loperamide

82
Q

Describe the presentation of haemolytic uraemic syndrome

A

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
Q

How is HUS managed

A

Supportive care with antihypertensives, blood transfusions and dialysis

84
Q

What is the prognosis of HUS

A

70-80% make full recovery
10% mortality
Self limiting

85
Q

What is seen on blood film in HUS

A

Fragmented red blood cells

86
Q

What is rhabdomyolysis

A

Skeletal muscle tissue breaks down and releases myoglobin, potassium, phosphate and creatine kinase

87
Q

What can rhabdomyolysis cause

A

Hyperkalaemia - arrhythmia

Myoglobin - AKI

88
Q

What are the causes of rhabdomyolysis

A

Prolonged immobility
Extremely rigorous exercise
Crush injury
Seizures

89
Q

List the signs and symptoms of rhabdomyolysis

A 
Muscle aches and pains
Oedema
Fatigue
Confusion 
Red-brown urine
90
Q

List the investigations for rhabdomyolysis

A

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
Q

Describe the management of rhabdomyolysis

A

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
Q

List some conditions which cause hyperkalaemia

A 
AKI
CKD
Rhabdomyolysis 
Adrenal insufficiency 
Tumour lysis syndrome
Blood samples may haemolyse on way to lab giving false hyperkalaemia
93
Q

Which medications cause hyperkalaemia

A

Aldosterone antagonists - spironolactone and eplerenone

ACEi/ARB

NSAIDs

K+ supplements

94
Q

Give the ECG signs of hyperkalaemia

A

Tall tented T waves
Flattening or abscence of the P waves
Broad QRS complexes

95
Q

How is hyperkalaemia managed

A

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
Q

How does Insulin and dextrose cause a lowering of potassium

A

Drives carbohydrates into the cells and takes potassium with it

97
Q

What is polycycstic kidney disease

A

Multiple fluid filled cysts

Reduced kidney fuction

98
Q

What are the two types of polycystic kidney disease

A

Autosomal dominant (most common) - PKD-1 Chromosome 16

Autosomal recessive - PKD2 chromosome 4

99
Q

List some extra-renal manifestations of polycystic kidney disease

A

Cerebral aneurysms
Hepatic, splenic, pancreatic, ovarian and prostatic cysts

Cardiac valve disease - MR

Colonic diverticulum

Aortic valve dilation

100
Q

Describe the complications of polycystic kidney disease

A 
Chronic loin pain 
Hypertension 
CVD
Gross haematuria
Renal stones 
End stage renal failure
101
Q

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

A

Tolvaptan - vasopressin receptor antagonist

102
Q

List some causes of nephritic syndrome

A

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
Q

List some causes of nephrotic syndrome

A

Minimal change disease (most common in children)
Focal segmental glomerulosclerosis (most common in adults)
Membranous glomerulonephritis

104
Q

What is seen on histology in membranous glomerulonephritis

A

Thickened membrane

Sub epithelial spikes

105
Q

What is seen on histology in IgA nephropathy

A

Mesangial proliferation and complement deposition

106
Q

What is seen on histology in rapidly progressive glomerulonephritis

A

Cresenteric glomerulonephritis

107
Q

What is seen on histology in goodpastures

A

IgG on basement membrane

108
Q

Describe the presentation of acute interstitial nephritis

A

High eosinophils - allergic picture

High WCC in urine

109
Q

Why might renal function worsen following initiation of ACEi or ARBs

A

Bilateral renal artery stenosis

110
Q

List the features of nephritic syndrome

A

Proteinuria <3g/L
Haematuria
Fluid retention
Oliguria

111
Q

List the features of nephrotic syndrome

A

Proteinuria >3g/L
Hypoalbuminemia
Peripheral oedema
Hypercholesterolaemia

Finals (18 decks)

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