Renal Flashcards
Type 1 Renal Tubular Acidosis
Cant secrete H+
Hypo k+
Renal Stones
Rheumatoid, SLE
Type 2 renal Tubular Acidosis
Reduced HCO3 reabsorption
Hypo K+
Causes Osteomalacia
Fanconi, Wilsons, Carbonic Anhydrase Inhibitors use
Type 3 Renal Tubular Acidosis
Rare due to Carbonic Anhydrase deficiency
Hypo K+
Type 4 Renal Tubular Acidosis
Hyper K+
Due to reduced Aldosterone
When can grade 1 and 2 CKD be diagnosed?
Only if signs and symptoms of CKD are present like altered U+Es.
What NSAID isn’t stopped during an AKI?
Aspirin at a cardio protective dose.
What are some signs of a prerenal injury?
Increased Serum Urea : Creatine ratio
Urea Plasma : Urea Urine is > 10:1
Urine Osmolarity >500
Low Urine Na+
Muddy brown casts within urine can indicate what?
Acute Tubular Necrosis
Causes of enlarged kidneys on USS
Polycystic kidney disease
Diabetic Nephropathy
Amyloidosis
Chronic HIV associated Nephropathy
What is the effect of CKD of kidney size?
Usually shrunken
Before a diagnosis of Renal Anaemia and EPO can be started what must be done?
Iron Studies and treatment of low iron
What is the commonest form of renal stones?
Calcium Oxalate - Radiopaque
Hypercalciuria
List some radiopaque renal stones and the common causes
Calcium Phosphate - Tubular Acidosis
Struvite Stones - Urease producing bacteria
What is the commonest Radiolucent renal stones?
Uric Acid stones
Xanthine stones
Struvite Stones
Magnesium Ammonia and Phosphate - Radiopaque
Staghorn Calculi
Urease producing bacteria
What bacteria are linked to struvite stones?
Proteus…
Ureaplasma
Signs of Acute Tubular Necrosis
> 40mmol of urinary Na+
<350 Urine osmolarity
Brown Casts
Poor response to fluid challenge
Risk Factors for Contrast Nephrotoxicity
> 70
Renal disease
Dehydration
Nephrotoxic drugs
How is the risk of contrast nephrotoxicity decreased?
12 hours pre and post operation give
IV 0.9% saline 1ml/kg/hour
What medication should be withheld post contrast and for how long?
Metformin for at least 48 hours until risk of AKI is decreased
Describe presentation, investigation results and management of Membranous Nephropathy.
Commonest nephropathy in adults
Linked to malignancy, hepatitis, Anti PLa2r antibodies
Thickened basement membrane and sub epithelial spikes on biopsy
ACEi + Statin + Corticosteroid + Cyclophosphamide + Anticoagulation if high risk
What is the screening test used in Adult Polycystic Kidney Disease
USS
What is the commonest type of APKD
Type 1
Chromosome 16
Early renal failure
What is the diagnostic criteria for APKD
USS
Two cysts uni or bilateral if <30
two cysts bilaterally 30-50
Four cysts bilaterally >50 years
What is the management of APKD?
Tolvaptan
Biochemistry in Multiple Myeloma
Increased Calcium
Normal or raised ALP
Normal Phosphate
Is ALP is raised think metastatic disease
First line investigation in renal colic
Non Contrast CT - KUB
How does CKD cause bone disease?
Increased Phosphate - drags calcium out of bones
Decreased Vitamin D - reduces calcium levels - 2 hyperparathyroidism
How do you manage CKD related bone disease?
Bisphosphonates - reduce bone turn over Reducing dietary phosphate is first line Phosphate binders Vit D Parathyroidectomy
If a stone is below 5mm what is the management?
Symptomatic - diclofenac and supportive
Passes within 4 weeks usually
Renal Stone over 2 cm
Lithotripsy
Renal Stone >2cm but pregnant
Ureteroscopy
Complex renal calculi + Staghorn
Percutaneous Nephrolithotomy
A patient presents with an infection secondary to a ureteric calculi obstruction. What is the management ?
Surgical decompression
Nephrostomy Tubeplacement
Ureteric Catheters
Ureteric Stent
General advice to reduce renal stones
Increase fluid
Reduce animal proteins
Thiazides
Reduce salt
What can help reduce the frequency of oxalate stones?
Cholestyramine
What can help reduce the frequency of uric acid stones?
Allopurinol
What is indicative of an AKI due to dehydration?
Urea and Creatinine have both increased but urea has increased by more.
In a young child presenting with an abdominal mass what must be considered?
Wilms Nephroblastoma
Sterile Pyuria + white cell casts + eosinophilia indicates what?
Acute Interstitial nephritis
Rash and a fever is common
Hypertension and mild renal impairment
How is Nephrogenic diabetes insipidus managed?
Thiazide + low salt diet
Acute Interstitial Nephritis causes
Penicillin NSAIDs Allopurinol
SLE Sjogrens Staphylococci infection
Signs of dehydration onFBC and U+Es
increased haematocrit haemoglobin urea and creatinine
Urea> Creatinine
What is the fastest rate K+ can be infused at?
10mmol / hour unless in an ICU with intensive cardiac monitoring
What should be done immediately if there is new onset hyperkalameia in a patient?
ECG
CKD classifications
Stage 1 = >90 plus signs and symptoms Stage 2 = 60 - 90 plus signs and symptoms Stage 3a = 45 - 59 Stage 3b = 30 - 44 Stage 4 = 15 - 30 Stage 5 = <15
Diarrhoea causes what type of metabolic disorder?
metabolic acidosis - loss of HCO3-
Vomiting causes what type of metabolic disorder?
Metabolic alkalosis
Loss of HCl
What is a normal anion gap?
8 - 14 mol
If the albumin creatinine ratio is >30 what medication should be started?
ACEi -only if hypertensive
If the albumin to creatinine ratio is >70 what medication should be started regardless?
ACEi
What medication is always given in CKD
Statins
AKI - 1.5 to 2x creatinine increase
< 0.5ml/kg/hr urine
Stage 1 AKI
AKI - 2.0x - 2.9x creatinine increase
Urine <0.5ml/kg/hr
Stage 2 AKI
AKI - >3x creatinine increase
< 0.3ml/kg/hr
Stage 3
What is the first line dialysis in an independent patient?
Peritonial dialysis
A peritonitis related to peritoneal dialysis is likely to be due to what?
Staph Epidermidis
Signs of a Pre Renal AKI
Good response to a fluid challenge
Low urinary Na
Increased Urea to creatinine ratio
How much fluid should be used a fluid challenge?
500ml NaCl STAT
250ml if signs of Heart Failure
Excessive fluid resus with NaCl can cause what?
Hyperchloraemic metabolic acidosis
What is a common cause of acute tubular necrosis?
Haemorrhage
In an AKI of unknown cause what investigations should be done?
Urinalysis
USS
Struvite stones are made up of what?
Magnesium and Ammonium
Days post URTI
Macroscopic haematuria
IgA nephritis
Weeks post URTI
Proteinuria
Low complement levels
Post Strep Nephropathy
IgA nephritis management
Normal eGFR + no proteinuria = follow up check
Slightly low eGFR + persistent proteinuria = ACEi
Falling eGFR and no response to ACEi = Steroid
What kind of stones may be lined to a patient with Crohns disease?
Calcium Oxalate
List the types of graft rejection and what mediates them
Hyperacute - HLA or ABO
Acute - Mismathed HLA
Chronic - Antibody and T cell mediated
Hyperacute graft rejection
Within minutes to hours post surgery.
Thrombosis ischaemia and infarction of organ
No treatment apart from removal
Acute Graft rejection
Within 6 months of graft insertion
Usually asymptomatic - picked up on monitoring Increased creatinine
Acute T cell is commonest variant
Some are reversible with steroids and immunosuppression
Chronic graft rejection
Over 6 months
Fibrosis of the organ
Let the order of most important HLA antibodies to match
DR > B > A
What is it in nephrotic syndrome that causes hyper coagulability?
Loss of anti thrombin III
What is a cause of a semi opaque kidney stone?
Cystine
Management of Haemolytic Uraemic Syndrome
Supportive - bloods, fluids and dialysis
No role for Abx
Monitor Blood pressure and renal function
Severe haemolytic syndrome with no diarrhoea before hand
Plasma exchange
Eculizumab
Common causes of acute tubular necrosis
NSAIDs
Ischaemia
Contrast agents
Acceptable responce to ACEi initiation
Creatine increased by 30%
eGFR reduced by 25%
When is furosemide indicated for hypertension in CKD
eGFR below 45
Metformin in CKD
Caution if eGFR <45
Stop if eGFR <30
Management of Anti GMB
Plasma exchange
Steroids
Cyclophosphamide
What can help reduce the frequency of calcium stones?
Thiazides
Isograft
Received from a twin
Autograft
Tissue harvested from own body
Allograft
Tissue taken from another person
Sterile pyuria + negative culture
Dysuria
Haematuria
Abdopain
Renal TB
Differentiating a Chronic Kidney Injury from an AKI
CKD = anaemia and low vitamin D alongside normal urinary output
Urinary ACR >3 - what medication should you start?
ACEi / ARB
Brown grey skin N+V Confusion (encephalopathy) Seizures Comas
Urea toxicity
X linked dominant mutation in type IV collagen.
Allports
Bilateral sensorineural hearing loss
Microscopic haematuria and progressive renal failure
Retinitis pigmentosa
An AKI + pulmonary oedema is an indication for what?
Haemodialysis
What DOAC is preferred in CKD?
Apixiban
Formulae for working out an Anion Gap
(Na + K) - (Cl + HCO3) = Anion Gap
Normal anion gap ( if involving K+) = 10-18
- without K+ = 8-14
Management of systemic sclerosis with renal involvement.
ACEi
Kimmelstein Wilson nodules are seen in
Nodular glomerulosclerosis due to diabetes
Left sided flank pain + haematuria during or after a nephrotic syndrome.
Renal vein thrombosis - loss and antithrombin III causes hyper coagulability
Focal segmental Glomerulosclerosis - causes
HIV Idiopathic Heroin Alports Secondary to other renal nephropathy
Focal segmental glomerulosclerosis - presentation
Nephrotic syndrome and CKD in young adults
Management of focal segmental glomerulosclerosis
Steroids + immunosuppression
How does investigation of nephrotic syndrome differ between adults and children?
In adults you do a renal biopsy.
In children it is assumed to be minimal change disease. Biopsy is done if failure to resolve with prednisolone.
Pentameric Antibody
IgM - Waldenstroms
Monomeric antibody
IgG - Multiple Myeloma
