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Phase 4 - Katherine > Renal > Flashcards

Renal Flashcards

1
Q

About how much is GFR

A

120 ml/min/1.73m2

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2
Q

What is creatinine?

A

Chemical waste product from muscle metabolism

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3
Q

What can cause a misleadign creatinine level ?

A

Extreme muscle mass e.g. cachexia/body builder = misleading

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4
Q

Why is creatinine clearance > GfR

A

Secreted as well as filtered

[Therefore inhibitors of secretion will make Cr rise and function look worse e.g. trimethoprim]

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5
Q

3 hormones in Na excretion and therefore volume control

A

Aldosterone (adrenal) -> decreased excretion

Angiotensin II -> decreased excretion

ANP - released by heart in response to high pressure -> increases excretion

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6
Q

In kidney which hormone dilates afferent arteriole? constricts?

A

Prostaglandin

Angiotensin II
[angi is a bit constrictive - the bitch]

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7
Q

Name 2 SEs od ACEi

A

May impair renal function: decrease GFR (avoid NSAIDs), hyperkalaemia (avoid K+ spare diuretics)

Postural hypotension

Bradykinin mediated dry cough

Fatigue

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8
Q

Name an ARB and 2 SEs

A

Losartan

Renal impairment
Postural hypotension
Hyperkalaemia

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9
Q

Name 1 med causing hypo K and 1 causing hyper K

A

Hypokalaemia meds
Loop diuretics, thiazide diuretics

Hyperkalaemia meds
Spironolactone, amiloride, ACEI, ARB

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10
Q

Key transporter in loop of henle

A

NKCC2:
Na K Cl Cotransporter (energy dependent)

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11
Q

Where do ADH and aldosterone take effect on?

A

Distal convoluted tubule and collecting duct

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12
Q

Barter’s syndrome .. same as?

When?
2 features

A

Effect of loop diuretics

Children

Metabolic alkalosis
Low Mg
High urinary Ca

[C’s - Children, [loop=Circle], high Ca]

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13
Q

Gitelmans syndrom same as?
age?
2 features?

A

same effect as Thiazide diuretic (Distal convoluted tubule)

Late childhood

Mg decreased, urine calcium normal/low,

Metabolic alkalosis

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14
Q

What does renal tubular acidosis result in?

A

Hyperchloraemic metabolic acidosis
+ hypobicarbonataemia + decreased arterial pH

+ normal anion gap

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15
Q

2 Most common cause of renal tubular acidosis

A

fanconi syndrome

drug induced

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16
Q

What happens in fanconi syndrome

A

Generalised dysfunction of renal proximal tubule ->
urinary loss of bicarb, [glucose, aa, phosphate, peptides, organic acids. ]

Leads to salt wasting and volume depletion

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17
Q

Name 2 Rfs for RTA

A

Childhood, urinary tract obstruction, DM, [stones, adrenal insufficiency]

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18
Q

Name 3 ways RTA could present?

A

Growth retardation/failure to thrive (children)

Muscle weakness (Fanconi)

Hypoglycaemia after fructose

Rickets (Fanconi and Type 2 proximal have persistent phosphate loss)

Kussmaul breathing if severe

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19
Q

2 key findings from Ix in RTA? name another one

A

Low serum bicarbonate

serum anion gap normal (12-18)

[high serum chloride, variable potassium, arterial pH low, ]

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20
Q

Mx of RTA

if Hyperkalaemia + mineralocorticoid deficiency?

A

Sodium alkali

Fludrocortisone + dietary restriction of potassium

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21
Q

Mx of Hyperkalaemia + mineralocorticoid deficiency
in RTA

A

Fludrocortisone + dietary restriction of potassium

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22
Q

Name 2 comps of RTA

A

volume depetion (due to loss of Na)

Nephrocalcinosis - due to bone buffering of acidosis

Osteoperosis - due to bone buffering of acidosis

Grow retardation - acidosis -> muscle catabolism

Renal rickets - in fanconi

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23
Q

2 Causes of end stage renal failure

A

Glomerulonephritis
Pyelonephritis
Diabetes
PKD

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24
Q

Usual cause and bugs for pyelonephritis

A

Escherichia coli, UPEC
[diabetes/HIV/malignancy/transplant - think candida/klebsiella]

ascending from lower urinary tract or spread hematogenously to kidney

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25
Q

Name 3 RFs for severe pyelonephritis

A

Extremes of age

anatomical abnormality

foreign body

Immunocmpromised

obstruction

pregnant

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26
Q

Cause of pyelonephritis only found in men

A

prostatitis and BPH cause urethral blockage -> bacteriuria -> pyelonephritis

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27
Q

Triad of presentation in pyelonephritis

A

Loin pain

Fever - may not be the case if patient is on steroids or anti-inflammatory

Renal tenderness/costovertebral angle

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28
Q

Name 3 Ix in pyelonephritis

A

Imaging
*Renal USS:
*Contrast CT

Urine dip:

Urinalysis (microscopy) WBC

Gram stain:

Urine culture:

FBC: leukocytosis

ESR/CRP raised

Blood culture (systemic infection SEPSIS)

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29
Q

Seen on gram stain in pyelonephritis

A

G -ve rods (e.coli, klebsiella, proteus)

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30
Q

Mx of mild.mod pyelonephritis ?

Severe/comp/pregnant?

A

Ciprofloxacin PO BD

Severe:
Admit to hospital
IV ceftriaxone / cipro/gent
IV fluids
IV paracetamol
Catheterisation if compromised

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31
Q

Name 2 comps of pyelo

A

Renal failure, abscess formation, parenchymal renal scarring, recurrent UTIs

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32
Q

2 main types of renal cell carcinoma

A

80% clear cell/adeno renal carcinoma

15% papillary tumour

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33
Q

3 RCC RFs

A

smoking, obesity and hypertension

Occupational exposure to some chemicals such as asbestos, cadmium, lead, chlorinated solvents, petrochemicals

VHL

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34
Q

Usual pres of RCC

A

asymptomatic and diagnosed incidentally
3 key are:

abdo mass + haematuria + loin pain

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35
Q

Which genetic cause increases risk of RCC

A

Von hippel lindau

AD

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36
Q

Principles of Ix in RCC…Name 3?

A

Check kidney function
Check for structure
Check for metastasis

=

Percutaneous renal biopsy

*FBC - polycythaemia (EPO)

LDH - raised is poor prognosis

Corrected calcium - >2.5 mmol/l poor prognosis

LFT - raised AST/ALT = metastatic disease

*Cr - elevated with reduced clearance

Urinalysis - haematuria and/or proteinuria

*Abdominal/pelvis USS - cyst, mass, mets

*CT abdo/pelvis - lymphadenopathy, mass, bone mets inc contralateral kidney

MRI - for local invasion etc

CXR - cannonball metastasis, bone scan, MRI brain/spine

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37
Q

Main comp of RCC? Name 1 other

A

Paraneoplastic syndrome (30% of patients) - anaemia

[Hypercalcaemia, SIADH]

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38
Q

Mx of RCC?

A

Surgical
= partial / laparoscopic nephrectomy

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39
Q

What could you use in late stage RCC

A

tyrosine kinase inhibitor = first line e.g. SUNITINIB

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40
Q

Childhood renal tumour

A

Wilm’s tumour -> nephroblastoma

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41
Q

What is AKI

A

An acute decline in *GFR from baseline/increase in creatinine with or without oliguria

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42
Q

Name 4 causes of AKI

A

Pre-renal (50%)
Azotaemia
Renovascular disease

Intrarenal 30%
Acute tubular necrosis (mainly due to sepsis = most common)
*Rapidly progressive glomerulonephritis
*Interstitial nephritis
Vascular disease

Post renal 20%
Mechanical obstruction to urinary tract
Retroperitoneal fibrosis, lymphoma, tumour, prostate hyperplasia, renal calculi, urinary retention, pyelonephritis

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43
Q

What is azotaemia> features?

A

high nitrogen compounds e.g. Ur, Cr) due to reduced perfusion

hypovolaemia, haemorrhage, sepsis

44
Q

Which pt can you not give NSAIDS? why?

A

giving NSAIDs to patient with bilateral renal artery stenosis
-> renovascular disease

45
Q

Most common cause of AKI

A

Acute tubular necrosis
[Acute - AKI
FSG - Glomerulonephritis - in the names]

46
Q

Name 3 nephrotoxic drugs

A

CANT DAMAG

Contrast, antibiotics (penicillin/ceph), NSAIDs, Therapeutic index (narrow), diuretics, ACEI, metformin, ARB, gentamicin

47
Q

What is used to measure stage of AKI

A

Creatinine
Urine output

48
Q

3 Ix in AKI - if anuric which is a priority

A

U+E+Cr:
*Elevated creatinine, *high serum potassium (or on *VBG), *metabolic acidosis

Urine dip, MC + S
Infection -> leukocytes/nitrates
Glomerular disease -> blood/protein

FBC
Anaemia (CKD/blood loss), leukocytosis (infx), thrombocytopenia (HUS, TTP)

Imaging *priority if anuric
Renal USS -> obstruction, cysts, mass

*ECG
For *hyperkalaemia - increased PR, widened QRS, peaked T, sine wave

Ratio serum urea:creatinine + other tests of cause

49
Q

AKI mx …
3 basic things?
Raised K ix?
Obstruction Ix?
Severe?

A

Stop nephrotoxic drugs

ABCDE
Including fluid challenge if hypotensive, diuretic if hypertensive

Catheterise for accurate urine output

K
Urgent VBG/ABG + ECG

Obstruction
Urgent USS KUB

Dialysis If uraemic, severe metabolic acidosis, severe hyperkalaemia

50
Q

What is CKD

A

Proteinuria or haematuria (evidence of kidney damage) and/or reduction in GFR to <60ml/min/1.73m2 for more than 3 months

51
Q

2 causes of CKD

A

DM and HTN (+AI disorder, smoking, obesity)

52
Q

Mx of CKD (think of cause)

A

Glycaemic control for diabetic nephropathy and optimisation of BP

53
Q

Stages of CKD

A

GFR

1 >90
2<60
3a <45
3b<30
4<15
5>15

54
Q

Primary prevention CKD ?

Secondary?

A

DM - HbA1c < 7%,
HTN - BP < 140/90,
smoking cessation, BMI < 27

As above +
salt restriction + protein restriction

55
Q

3 parts of the uraemic syndrome presentation (GFR<15)

A

Uraemic tinge (grey/yellow)
Nausea/vomiting
Itch
*Uraemic encephalopathy
*Pericarditis
*Bleeding
For RRT

56
Q

Name 3 comps of CKD

A

anaemia (less epo)

osteodystrophy
(low Ca / vit D)

CV disease

Protein loss

Hyper K

Metabolic acidosis

Pulm oedema

57
Q

3 Ix in CKD

A

Serum creatinine elevated

Urinalysis: haematuria or proteinuria

Urine microalbumin: microalbuminuria

Renal USS: small kidney, obstruction/hydronephrosis, large kidney (infiltration myeloma, amyloidosis)
eGFR < 60

Blood sugar

FBC - anaemia, normochromic normocytic

Osteodystrophy: hypocalcaemia, hyperphosphataemia and hyperparathyroidism, high alkaline phosphatase

Antibodies

58
Q

Mx of CKD
General
Anaemia
Bone disease
Metabolic acidosis
oedema
HyperK

How to restrict uraemia?

A

Treat reversible causes - obstruction / drugs

Glycaemic control

BP/CV risk - ACEI/ARB
[Statin, smoking cessation, weight loss, aspirin]

Educate about RRT at stage 3/4

Treat anaemia
Epoeitin alfa (EPO stimulating agent)

Treat renal bone disease
Dietary modification (based on Ca and PO4 - milk, cheese, eggs) ± calcitriol if low

Treat metabolic acidosis
Oral sodium bicarbonate

Treat oedema
Loop diuretics and restrict sodium

High potassium
Low potassium diet

Low protein diet to restrict uraemia

59
Q

2 main options of Mx at stage 5 CKD

A

RRT:
dialysis / transplant

60
Q

Give 2 indications for RRT in AKI

A

Uraemia (pericarditis, gastritis, encephalopathy)

Pulmonary oedema (fluid retention) unresponsive med Rx

Severe hyperkalaemia (>6.5) unresponsive to med Rx

Severe hypo/hypernatramia

Severe metabolic acidosis (<7.0) unresponsive to bicarb

Severe renal failure (urea > 30)

61
Q

How does haemodialysis work

A

Blood passed over semi-permeable membrane against dialysis fluid (opposite direction)

Blood meets less concentrated solution and small solutes may diffuse along concentration gradient

Blood drawn from AV fistula, heparin constantly infused

62
Q

Name 3 comps of haemodialysis

A

Access: *infection, thrombosis, aneurysm, endocarditis, stenosis

*Hypotension (common), cardiac arrhythmia, air emboli

Nausea, vomiting, headache, cramps

*Anaphylaxis to sterilising agent

*Disequilibration syndrome: restless, tremor, fits, coma

63
Q

How does peritoneal dialysis work?

A

Dialysate infused into peritoneal cavity, uses blood in peritoneal capillaries

Waste collected below (gravity)

Ultrafiltration controlled by altering osmolality to draw water out of blood (e.g. glucose)

64
Q

2 comps of peritoneal dialysis

A

Infection: peritonitis

Catheter problems: infection, blockage, leak

Constipation, fluid retention, hyperglycaemia + wt gain

Hernia

65
Q

Name 2 advantages of transplant over dialysis

A

Survival, QoL, economic, enable pregnancy, reversal of anaemia and renal bone disease

66
Q

2 Technical challenges with transplant

A

Retrieving kidney, storing (cold storage), implanting

67
Q

Long term immunosupressive agents for renal transplant

A

prednisolone,
calcineurin inhibitors (tacrolimus/ciclosporin)
anti-metabolites (azathioprine

68
Q

Name 2 CIs for renal transplant in CKD

A

active infection, uncontrolled IHD, AIDS

69
Q

Name 4 comps with renal transplant

A

Immediate operative: local infx, pain, DVT

Infections due to immunosuppression (viral HSV for 4 weeks then CMV, bact, fungal)

Urinary tract obstruction

Drug toxicity: bone marrow suppression

*Cancer (skin, lymphoma)

*CV disease (main cause of death), hypertension, dyslipidaemia

Rejection

Disease recurrence

70
Q

Name the types of rejection and how long after surgery you’d expect

A

Hyperacute (mins),
rare due to crossmatch

Accelerated (days),
T cell mediated crisis -> fever, swollen kidney, increased Cr -> IV steroids

Acute cellular (weeks),
25% in <3 weeks -> fluid retention, rising BP, rising Cr, high dose IV steroids

Chronic (years),
gradual rise in Cr and proteinuria, resistant HTN -> graft biopsy shows vascular changes, fibrosis and atrophy (non-responsive to immunosuppression)

71
Q

Most common cause of glomerulonephritis

A

Focal segmental glomerulonephritis in nephrotic syndrome

72
Q

Which is proliferative Nephrotic / nepritic?

2 causes of each

A

Nephritic = proliferative [Nephritic is prolific]
IgA nephropathy (1ary)
Postinfectious GN (1ary)
Rapidly progressive GN:
-Vasculitis
-Anti-GBM GN

Nephrotic = non-proliferative
Deposition disease (amyloidosis + light chain dep)
Minimal change disease
Focal and segmental GN
Membranous nephropathy
Membranoproliferative GN

73
Q

Signs of nephrotic

A

Proteinuria (>3.5g/24 hours)
Hypoalbuminaemia (<30g/L)
Peripheral oedema
Hyperlipidaemia

74
Q

Signs of nephritic

A

Oliguria/AKI (renal dysfunction)
HTN
Haematuria: active urinary sediment (red cells and casts)

75
Q

Usual cause of nephrotic in children?
Cause?
Seen on light microscopy / immunoflourescence/ electron microscopy?

A

Minimal change disease
-Idiopathic, NSAIDs or Hodgkin’s lymphoma

Light microscopy - normal glomeruli

Immunofluorescence - no immune complex deposition

Electron microscopy - effacement of podocyte foot processes

76
Q

Minimal change Mx

A

steroids

77
Q

Usual cause of nephrotic in younger adults ? Cause?
seen on light microscopy?

A

focal segmental glomerulosclerosis
-Idiopathic or secondary to HIV

Light microscopy - segmental areas of mesangial collapse and sclerosis

78
Q

Most common cause of nephrotic in adult / older ?
seen on light microscopy / immunoflorescence?

A

Membranous nephropathy
-Usually idiopathic or secondary to Hep B, gold, penicillamine, NSAIDs

Light microscopy - basement membrane thickening and associated cellular proliferation

Immunofluorescence - granular IgG deposition

79
Q

Name 2 secondary causes of nephrotic syndrome

A

diabetes, amyloidosis, SLE, infection, drugs Eg NSAIDS, Gold, penicillamine

80
Q

Name 2 DDx of nephrotic

A

CCF (increased JVP, pulmonary oedema, oedema)

Liver disease (decreased albumin)

81
Q

Name 3 comps of nephrotic

A

Susceptibility to infection - increased urinary loss of IgG (streptococcal), or secondary to steroids

Hypercoagubility and thromboembolism - renal vein thrombosis (lupus or urinary loss of antithrombin III, altered protein C and S)

Hypercholesterolaemia - increased hepatic lipoprotein synthesis and loss of lipid regulating proteins

Hypocalcaemia - loss of vit D in urine

Hypervolaemia - severe decrease in GFR resulting in oedema

AKI - more likely with acute GN

HTN - impaired GFR and increased reabsorption of salt and water

82
Q

What is nephritic syndrome

A

acute kidney injury with rapid deterioration in function

83
Q

Most common cause of nephritic syndrome - what happens?

A

buerger’s disease

Macroscopic haematuria 24/48 hours post GI/URTI
IgA deposition in mesangial matrix

84
Q

2 causes of nephritic syndrome

A

Buerger’s
Membranoproliferative
Post infection

Rapidly progressive glomerulonephritis
-Goodpasture
-Wegners
-Microscopic polyangitis

85
Q

Glomerulonephritis presents with RFs + haematuria + oedema + HTN + oliguria+
What do these extra Sx indicate?

Anorexia/nauseas -

Weight loss

Fever

Skin rash

Arthralgia

Abdo pain

Haemoptysis

A

Anorexia/nauseas -> vasculitic

Weight loss -> systemic

Fever -> infectious aetiology

Skin rash -> vasculitic

Arthralgia -> vasculitic

Abdo pain -> HSP and post-streptococcal glomerulonephritis

Haemoptysis -> in anti-glomerular basement membrane disease and Wegener’s

86
Q

Name 3 Ix in glomerulonephritis

A

FBC - anaemia -> systemic

U + E + Cr + LFT -> ?hepatitis, advanced disease, albumin

Urinalysis -> haematuria, proteinuria, RBC casts
GFR -> normal or reduced

Lipid profile + glucose

24 hour urine collection

Renal biopsy and light or electron + immunofluorescence micros

Hep B/C/HIV serology

Antibody testing

Electrophoresis

87
Q

In glomerulonephritis what would these things indicate

ESR

Complement - low

RF

ANCA -

Anti GBM antibody

Antistreptolysin O antibody/anti DNase -

Anti DS DNA/ANA

Electrophoresis - raised gamma globulin

A

ESR - vasculitis

Complement - low in immune complex

RF - RA

ANCA - wegners

Anti GBM antibody - anti-GBM disease or Goodpasture’s

Antistreptolysin O antibody/anti DNase - post strep

Anti DS DNA/ANA - SLE

Electrophoresis - raised gamma globulin in lymphoma and amyloidosis

88
Q

Mx of post strep glomerulonephritis

A

IM BenPen

89
Q

Mx of mild glomerulonephritis - (isolated haematuria, normal GFR)

A

antibiotics/ antivirals/ withdraw drug

*limit salt + fluid

90
Q

Mx of mod/severe glomerlonephritis (haematuria, proteinuria and reduced GFR) ?

What if nephrotic?

A

ACEI/ARB), + ABX + furosemide + prednisolone

[FAAP]

immunosuppressant e.g. cyclophosphamide

91
Q

Mx of antiGBM glomerulonephritis

A

plasma exchange (remove aB) + IV methylprednisolone + IV cyclophos

92
Q

Mx of immune complex glomerulonephritis

A

IV methylpred

93
Q

Mx of Lupus nephritis

A

IV methylprednisolone + cyclophosphamide

94
Q

you get AD and AR PKD… Name 2 comps

A

HTN, increased CV morbidity, CKD, ruptured intracranial aneurysm, ESRD

95
Q

What is the protein involved in PKD

A

polycystin

96
Q

What is this
Patients often present in the neonatal period with enlarged echogenic kidneys, renal cysts congenital hepatic fibrosis.

A

ARPKD

High mortality - probs gonna die by teens

97
Q

Name 3 sx/signs on presentation of PKD

Name 3 other places that get cysts

A

FHx of PKD/ESRD or stroke

Flank/abdominal discomfort due to enlarging kidneys, haemorrhage or stone formation

Lumbar pain (females)
Haematuria (males)

HTN (at 20-35) **** -> mandatory screening with renal USS

DUFS (infection, UTI)

Palpable kidneys

Headaches (intracranial aneurysm)

Hepatomegaly (liver)

Cystic locations - Liver (80%), pancreas (10%), seminal vesicles (40%), brain (10%)

98
Q

PKD Ix

A

Renal USS

Genetic - PKD1/2

CT abdo pelvis

Relevant further testing
-Urinalysis (protein, bacteria)
-ECG - LVH +
-echo - aortic root dilation
-MR (Magnetic resonance) angiography - screen for aneurysm

99
Q

Family screening in PKD

A

Screen for SAH in 1st degree relatives of those with ADPKD with MR angiography

100
Q

Mx of infection with PKD eg of UTI or of cyst

A

ciprofloxacin

101
Q

PKD How to limit fluid secretion into cysts?
How to target cell proliferation

A

*Target fluid secretion-
Calcium mimetics - cinacalcet
CFTR inhibitors
Metformin

*Target cell proliferation -
Somatostatin

102
Q

Name 4 causes of glomerulonephritis

A

Idiopathic

Infection - eg strep pyogenes

Systemic
-SLE, RA, Wegners, HUS, HSP, Goodpastures

Drugs
-Penicillamine, NSAIDS, ciclosporin

Metabolic
-HTN, diabetes

Other
-Alports, Lung / bowel Ca, amyloidosis

103
Q

Types of RTA

A

1 - distal
-Cant excrete H+ in distal tubules
->Raised urine pH = stones
-low/normal potassium

2-Proximal
-Cant reabsorb bicarb
->low urine pH
-low normal potassium

4 - distal
-in aldosterone deficiency
-HYPERKALAEMIA
-Low urine pH
-High serum bicarb

Faconi

104
Q

liddles syndrome? metabolics

A

opposite effect to potassium sparing diuretics
[liddle different - opposite effect]

Hypertension, hypokalaemia

Metabolic alkalosis

[Acts at ENaC, Autosomal dominant]

105
Q

CKD comps

A

Nervous
Peripheral neuropathy
Restless leg
tiredness / fatigue (urea)

CV
Fluid overload
ACCELERATED ATHEROGENESIS
Pericarditis

GI
altered taste
reduced Ca absorption

Bone
Hyperparathyroidism
-Osteodystrophy

Electrolyte
Hyper K
Acidosis

Blood
reduced EPO - anaemia of chronic disease
Impaired platelet function

106
Q

Mx of CKD groups

A

Conservative
Education
Planning for dialysis
Fluid RESTRICTION
diet - avoid K and PO4

Medical
CV risk factors
EPO
Bicarbonate
cinacalcet to reduce PTH

Interventional
Renal replacement therapy

107
Q

Mnemonic for Ix in renal

[AND FOR EVERY SPECIALITY]

A

[Cant Believe I Look Fresh]

Cultures
-Urinalysis + culture

Bloods
Arterial - ABG
Venous - K, Urea+creatinine, Antibodies, lipids
LFTs

Imaging
CXR, AXR
USS

Scope / biopsy [looking]
Biopsy

Functional (specific)
ECG

Phase 4 - Katherine (26 decks)

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