Renal

Question 1

List common causes of acute kidney injury

Answer 1

Prerenal – hypovolemia, decreased CO, impaired renal autoregulation (NSAIDs, ACEi/ARB, cyclosporine)
Intrinsic – acute glomerulonephritis, vasculitis, malignant hypertension
Postrenal – bladder outlet obstruction, bilateral pelviureteric obstruction

Question 2

List investigations to do for suspected AKI

Answer 2

Urine dipstick
Daily FBC, U&Es, LFTs, bone profile, CRP
Urine PCR, urine MC+S, USS KUB

Question 3

Describe the management of an AKI

Answer 3

Discontinue nephrotoxic agents
Ensure volume status & perfusion pressure – IV fluids/diuretics, aim for euvolemia
Monitor urine output & daily bloods
Avoid hyperglycaemia
Treat underlying cause
Refer to specialist for consideration of RRT & consider ICU admission

Question 4

List presenting symptoms of nephrotic syndrome

Answer 4

Oedema
Albumin <30
Urine PCR > 350 (more than 3.5 grams of protein in 24 hours)

Question 5

Describe the management of glomerulonephritis

Answer 5

MDT approach depending on underlying diagnosis
ACEi/ARB for proteinuria
Control BP
Salt and water restriction if fluid overload
Diuretics for fluid overload
Consider therapeutic LMWH, if hypoalbuminaemic
Statins
Immunosuppressive therapy – specific to the cause
Invasive therapy

Question 6

Describe the treatment for diabetic nephropathy

Answer 6

Intensive DM control
BP < 130/80, use ACEi/ARB
Sodium restriction <2g/day
Statins to reduce CV risk

Question 7

Describe the management of chronic kidney disease

Answer 7

Treat underlying disease
Reduce CVS risk – statin, BP control, control diabetes, weight loss, exercise, stop smoking
Reduce progression of CKD – reduce proteinuria: ACEi/ARB
Prevent/treat complications of CKD – low phosphate/low K+ diet, phosphate binders, IV iron/folate/vit B12 replacement
Plan for future – RRT, home care team input, transplant

Question 8

List complications of CKD

Answer 8

Anaemia of chronic kidney disease
Mineral & bone disease
Secondary & tertiary hyperparathyroidism
CVS disease
Electrolyte disturbances, fluid overload, metabolic acidosis, uraemic pericarditis, uraemic encephalopathy

Question 9

Describe the pathophysiology of mineral bone disease in CKD

Answer 9

Impaired renal function -> less activation of vitamin D -> impaired mineralisation of bone
Stimulation of parathyroid glands caused by:
1) Decreased PO4 excretion, leading to increased plasma PO4
2) Decreased Ca2+ absorption, leading to decreased plasma Ca2+
Increased PTH & impaired mineralisation of bone -> increased bone resorption

Question 10

Describe the pathophysiology of anaemia of chronic disease in CKD

Answer 10

Many factors contribute:
1) Decreased production of EPO from the pericytes
2) Blood loss
3) Absolute iron deficiency
4) Shortened RBC survival
Management: correct any underlying deficiencies, IV iron may be better tolerated than PO, aim for Hb 100-120

Question 11

List complications of all long-term dialysis

Answer 11

CVS disease and sepsis
-peritonitis (from peritoneal dialysis) and staph aureus line infection (haemodialysis)
Amyloidosis – accumulation and polymerisation of B2-microglobulin
-molecule is normally excreted by the kidneys but is not removed by dialysis membranes -> deposition results in carpal tunnel syndrome & joint pains, particularly the shoulder
Renal bone disease