Renal Flashcards
1
Q
what are the nice criteria for AKI?
A
Rise in creatinine of ≥ 25 micromol/L in 48 hours
Rise in creatinine of ≥ 50% in 7 days
Urine output of < 0.5ml/kg/hour for > 6 hours
2
Q
what are the risk factors for AKI?
A
- CKD
- HF
- DM
- Liver disease
- > 65
- cognitive impairment
- nephrotoxic meds - NSAID, ACEi
- contrast during CT scans
3
Q
what are the causes of renal impairment?
A
- pre renal
- renal
- post renal
4
Q
what are the pre renal causes of AKI?
A
inadequate blood supply to kidneys -
dehydration
hypotension
HF
5
Q
what are the renal causes of AKI?
A
reduced filtration of blood -
ATN
interstitial nephritis
glomerulonephritis
6
Q
what are the post renal causes of AKI?
A
obstruction of outflow of urine…backpressure and reduced kidney function -
kidney stones
masses in abdomen and pelvis
ureter or urethral strictures
BPH or prostate cancer
7
Q
how do we investigate AKI?
A
urinalysis:
bloods, protein - acute nephritis/infection
leucocytes, nitrites - infection
glcuose - diabetes
8
Q
how is post renal aki diagnosed?
A
USS of KUB - obstruction
9
Q
how is AKI managed?
A
- fluid resus - pre renal
- stop nephrotoxic drugs - renal
- relieve obstruction, ie catheter - post renal
if severe - renal specialist +/- dialysis
10
Q
what are the complications of AKI?
A
Hyperkalaemia
Fluid overload, heart failure and pulmonary oedema
Metabolic acidosis
Uraemia (high urea) can lead to encephalopathy or pericarditis
11
Q
define CKD
A
chronic reduction in kidney function
12
Q
what are the causes of CKD?
A
- DM
- HTN
- age
- glomerulonephritis
- PCKD
- medications - NSAIDS, PPI, lithium
13
Q
what are the risk fx for CKD?
A
Older age
Hypertension
Diabetes
Smoking
Use of medications that affect the kidneys
14
Q
what are the signs and sx of CKD?
A
Pruritus (itching)
Loss of appetite
Nausea
Oedema
Muscle cramps
Peripheral neuropathy
Pallor
Hypertension
15
Q
which investigations are required for CKD?
A
UandE’s - eGFR , two tests 3 months apart to diagnose CKD
urine albumin:creatinine ratio - >3mg/mmol
urine dipstick - 1+ blood (malignancy)
renal USS
16
Q
what are the stages of CKD?
A
G score - eGFR
G1 = eGFR >90
G2 = eGFR 60-89
G3a = eGFR 45-59
G3b = eGFR 30-44
G4 = eGFR 15-29
G5 = eGFR <15 (known as “end-stage renal failure”)
A score - albumin:creatinine ratio
A1 = < 3mg/mmol
A2 = 3 – 30mg/mmol
A3 = > 30mg/mmol
17
Q
what stage does a patient need to HAVE CKD?
A
not have if A1 + G1 or G2
require either eGFR<60 or proteinuria
18
Q
what are the complications of CKD?
A
Anaemia
Renal bone disease
Cardiovascular disease
Peripheral neuropathy
Dialysis related problems
19
Q
what are the guidlines for referring to a specialist with CKD?
A
eGFR < 30
ACR ≥ 70 mg/mmol
Accelerated progression defined as a decrease in eGFR of 15 or 25% or 15 ml/min in 1 year
Uncontrolled hypertension despite ≥ 4 antihypertensives
20
Q
how is CKD managed?
A
Slowing the progression of the disease-
Optimise diabetic control
Optimise hypertensive control
Treat glomerulonephritis
Reducing the risk of complications-
Exercise, stop smoking
Special dietary advice about phosphate, sodium, potassium and water intake
Offer atorvastatin 20mg for primary prevention of cardiovascular disease
Treating complications-
Oral sodium bicarbonate to treat metabolic acidosis
Iron supplementation and erythropoietin to treat anaemia
Vitamin D to treat renal bone disease
Dialysis in end stage renal failure
Renal transplant in end stage renal failure
21
Q
what is the first line drug in treating HTN for CKD?
A
ACEi
offered to all -
Diabetes plus ACR > 3mg/mmol
Hypertension plus ACR > 30mg/mmol
All patients with ACR > 70mg/mmol
22
Q
what is the target for blood pressure in pts with HTN?
A
<140/90 or <130/80 if ACR >70
23
Q
what is a complication shared by treatment and as a consequence of CKD?
A
hyperkalamia from CKD and ACEi
24
Q
why is anaemia is caused by CKD and how can it be treated?
A
damage kidney cells can not produce EPO - reduced production of RBC’s
treated with exogenous EPO and IV/oral iron (blood transfusions should be limited as they sensitise the immmune system so transplated organs more likely to be rejected)
25
what are the features of renal bone disease and how dot they appear on x ray of the spine?
osteomalacia - softening of bone - less white in centre
osteoporosis - brittle bones
osteosclerosis - denser white at booth ends
...'rugger jersey' spine - stripes
26
why does CKD cause mineral bone disease?
reduced phosphate excretion
low active vit D as kidney usually metabolises to active form
active vit D is required for calcium absorption from intestines and kidneys and regulates bone turnover
due to reduced serum calcium and high serum phosphate - secondary hyperparathyroidism - this increases osteoclast activity leading to absoption of calcium from bone
Osteomalacia occurs due to increased turnover of bones without adequate calcium supply.
Osteosclerosis occurs when the osteoblasts respond by increasing their activity to match the osteoclasts by creating new tissue in the bone, however due to the low calcium level this new tissue is not properly mineralised.
Osteoporosis can exist alongside the renal bone disease due to other risk factors such as age and use of steroids.
27
how is mineral bone disease managed?
- active forms of vit D - calcitriol
- low phosphate diet
- bisphosphonates to treat osteoporosis
28
acute tubular necrosis
urine is very pale even if dehydrated
29
acei
decreases tubular pressure as decreases BP, so less protein in urine but lower eGFR....helps CKD long term but also potentiates it
30
what is the biggest consequence of dialysis?
cardiovascular event
31
when is dialysis considered?
end stage renal failure
any acute indications which continue long term
32
what are the indications for acute dialysis?
A – Acidosis (severe and not responding to treatment)
E – Electrolyte abnormalities (severe and unresponsive hyperkalaemia)
I – Intoxication (overdose of certain medications)
O – Oedema (severe and unresponsive pulmonary oedema)
U – Uraemia symptoms such as seizures or reduced consciousness
33
what are the three main options for dialysis when required long term?
continous ambulatory peritoneal dialysis
automated peritoneal dialysis
haemodialysis
34
how does peritoneal dialysis work?
uses peritoneal membrane as filtration membrane and a dextrose solution is added to the peritoneal cavity. Ultrafiltration occurs from the blood across the membrane and into the solution...the solution is then replaced - so waste products that have been filtered are taken away
- tenckhoff catheter - plastic tube used to insert solution into peritoneal cavity
if continious - eg: 2L changed 4 times a day
or automated - overnight, replaces fluid overnight
35
what are the complications of peritoneal dialysis?
- bacterial peritonitis - due to glucose solution
- peritoneal sclerosis - thickening and scarring of membrane
- ultrafiltration failure - absorbs the dextrose in the filtration solution so gradient less
- weight gain - absorb carbs from dextrose
- psychosocial
36
what is a typical regime for haemodialysis?
4 hours 3 days a week
37
what are the access options for haemodialysis?
tunnelled cuffed catheter (right side below clavicle) - tube into subclavian or jugular vein with a tip that sits in SVA or RA
two lumens - one where blood exits and one where enters
ring called dacron cuff that surrounds catheter - promotes healing and adhesion of tissue to cuff so catheter is more permanent and provided barrier to infection...infection and bloods clots are main complications
AV fistula - artificial connection between artery to a vein, bypasses capillary system and allows blood to flow under high pressure.you create the fistula during surgery and requires 4 weeks-months without use,permanent large easy access blood vessels with high flow - radio cephalic, brachio-cephakic, brachio-basilic
38
how do you examine an AV fistula?
Skin integrity
Aneurysms
Palpable thrill (a fine vibration felt over the anastomosis)
Stereotypical “machinery murmur” on auscultation
39
what are the complications of AV fistula?
Aneurysm
Infection
Thrombosis
Stenosis
STEAL syndrome
High output heart failure
40
define STEAL syndrome
inadequate blood supply to limb distal to AV fistula, the blood is diverted away from where it is supposed to supply and flows to venous system causing distal ischaemia
41
define high output heart failure
where AV fistula blood is flowing v quickly from arterial to venou system through fistula...rapid return of blood to heart..increasing pre load in heart causing hypertrophy and HF
42
never....from a fistula
NEVER TAKE BLOOD
43
what is the examination of the renal system?
- tunnel cuffed catheter scar - right side, below clavicle
- hockey stick scar on abdomen - renal transplant
- peritoneal dialysis scars
- fistula on arms
- palpable implanted kidney in RIF or LIF
44
how are donors matched for kidney transplants?
based on HLA type A, B, C on chromosome 6...do not have to match and would be immunocompromised to desensitise them to donor HLA if a living donor
45
how does a kidney transplant work?
- patient's kidneys left
- donor's kidney blood vessels are anastomosed with patient's pelvic vessels...external iliac
- donor's ureter is anastomosed with patient's bladder
-donor kidney in anterior of abdomen, palpated in ILIAC area
46
which drugs are used to immunosuppress the patient?
Tacrolimus - IL 2 inhibition
Mycophenolate mofetil
Prednisolone - not for a long term
47
what are the complications of a renal transplant?
Transplant rejection (hyperacute, acute and chronic)
Transplant failure
Electrolyte imbalances
48
what are the complications relating to immunosuppressants?
Ischaemic heart disease
Type 2 diabetes (steroids)
Infections are more likely and more severe
Unusual infections can occur (PCP, CMV, PJP and TB)
Non-Hodgkin lymphoma
Skin cancer (particularly squamous cell carcinoma)
49
what are the criteria for nephritic syndrome?
Haematuria- microscopic (not visible) or macroscopic (visible).
Oliguria - reduced urine
Proteinuria - there is less than 3g / 24 hours. Any more and it starts being classified as nephrotic syndrome.
Fluid retention
50
what is the criteria for nephrotic syndrome?
Peripheral oedema
Proteinuria more than 3g / 24 hours
Serum albumin less than 25g / L
Hypercholesterolaemia
51
define glomerulonephritis
conditions that cause inflammation of or around the glomerulus and nephron
52
define interstitial nephritis
inflammation of the space between cells and tubules (the interstitium) within the kidney:
acute interstitial nephritis and chronic tubulointerstitial nephritis.
53
define glomerulosclerosis
scarring of the tissue in the glomerulus. It is not a diagnosis in itself and is more a term used to describe the damage and scarring done by other diagnoses
- can be caused by any type of glomerulonephritis or obstructive uropathy (blockage of urine outflow), and by a specific disease called focal segmental glomerulosclerosis.
54
what are the specific types of glomerulonephritis?
Minimal change disease
Focal segmental glomerulosclerosis
Membranous glomerulonephritis
IgA nephropathy (AKA mesangioproliferative glomerulonephritis or Berger’s disease)
Post streptococcal glomerulonephritis (AKA diffuse proliferative glomerulonephritis)
Mesangiocapillary glomerulonephritis
Rapidly progressive glomerulonephritis
Goodpasture Syndrome
55
how are most types of glomerulonephritis treated?
Immunosuppression (e.g. steroids)
Blood pressure control by blocking the renin-angiotensin system (i.e. ACE inhibitors or angiotensin-II receptor blockers)
56
how might nephrotic syndrome look on examination?
oedema
frothy urine from proteinuria
57
what does nephrotic syndrome predipose a patient to?
thrombosis, hypertension and high cholesterol.
58
what is the most common cause of nephrotic syndrome in children?
minimal change disease
- treated with steroids
59
what is the most common cause of nephrotic syndrome in adults?
focal segmented glomerulosclerosis
60
what is the aetiology of primary glomerulonephritis?
IgA nephropathy (berger's disease)
- 20's
- IgA deposits and mesangial proliferation
61
what is the aetiology of membranous glomerulonephritis?
Most common type of glomerulonephritis
bimodal peak in age in the 20s and 60s
“IgG and complement deposits on the basement membrane”
usually idiopathic
Can be secondary to malignancy, rheumatoid disorders and drugs (e.g. NSAIDS)
62
define post strep glomerulonephritis
<30
1-3 weeks after a streptococcal infection (e.g. tonsillitis or impetigo)
They develop a nephritic syndrome
There is usually a full recovery
63
what is goodpasture's syndrome and how might a patient present?
antibodies attack glomerulus and pulmonary basement membranes....glomerulonephritis and pulmonary haemorrhage
- AKI + haemopytsis
64
what is a differential for goodpasture's syndrome?
granulomatosis with polyangiitis (AKA Wegener’s granulomatosis)
type of vasculitis associated with anti-neutrophil cytoplasmic antibodies (ANCA). Patients with Wegener’s granulomatosis may also have a wheeze, sinusitis and a saddle-shaped nose.
65
histology shows cresenteric glomerulonephritis, what is the diagnosis?
rapidly progressive glomerulonephritis
- very acutely unwell
- often secondary to goodpastures
66
what is the most common cause of CKD in Uk?
diabetic nephropathy- chronic high levels of glucose passing through glomerulus causes glomerulosclerosis
67
how should patients with diabetes be managed with regards to kidney damage?
regular screening for diabetic neuropathy - albumin:creatinine ratio and UE
68
how is diabetic nepropathy managed?
glucose levels and blood pressure
69
what is acute interstitial nephritis caused by?
hypersensitivity reaction to drugs (nsaids, abx) or infection
70
how can patients with acute interstitial nephritis present?
AKI
hypertension
rash
fever
eosinophilia
71
how is acute interstitial nephritis managed?
treat underlying cause
steroids
72
how does chronic tubointerstital nephritis present?
CKD
73
what are the causes of chronic tubointerstitial nephritis?
autoimmune, infectious, iatrogenic and granulomatous disease...treat underlting cause + steroids
74
what is the most common cause of AKI?
ATN
75
define ATN
damage and death (necrosis) of the epithelial cells of the renal tubules
76
is ATN reversible?
epithelial cells have the ability to regenerate making acute tubular necrosis reversible. It usually takes 7-21 days to recover
77
what are the causes of ATN?
hypoperfusion - Shock, Sepsis, Dehydration
direct damage - Radiology contrast dye, Gentamycin, NSAIDs
...managed the same as AKI
78
what is found on urinalysis of ATN?
muddy brown casts on histology
79
what is the aetiology of renal tubular acidosis?
metabolic acidosis due to pathology in the tubules of the kidney. The tubules are responsible for balancing the hydrogen and bicarbonate ions between the blood and urine and maintaining a normal pH
80
what is type 1 renal tubular acidosis caused by?
pathology in DCT...so unable to excrete H ions
Genetic -both autosomal dominant and recessive forms.
Systemic lupus erythematosus
Sjogren’s syndrome
Primary biliary cirrhosis
Hyperthyroidism
Sickle cell anaemia
Marfan’s syndrome
81
how does type 1 renal tubular acidosis present?
Failure to thrive in children
Hyperventilation to compensate for the metabolic acidosis
Chronic kidney disease
Bone disease (osteomalacia)
82
what are the biochemical results of type 1 renal tubular acidosis?
hypokalaemia
metabolic acidosis
urinary pH of 6
83
how is type 1 renal tubular acidosis treated?
bicarbonate
84
what is the cause of type 2 renal tubular acidosis?
PCT - can not reabsorb HCO3- from urine into blood so excess in urine
usually caused by falconi's syndrome
85
what are the biochemical results of type 2...acidosis?
Hypokalaemia
Metabolic acidosis
High urinary pH (above 6)
...also treated with HCO3-
86
what is type 3 renal..acidosis?
combination of type 1 and type 2 with pathology in the proximal and distal tubule. This is rare and unlikely to appear in your exams or clinical practice.
87
what is type 4 renal tubular acidosis caused by?
reduced aldosterone - due to adrenal insuffiency, ACEi and sprinolactone or lupus, DM, HIV
88
what is the biochemical results of type 4...acidosis?
Hyperkalaemia
High chloride
Metabolic acidosis
Low urinary pH
89
how is type 4 renal tubular acidosis treated?
fludrocortisone
sodium bicarbonate and tx of hyperkalaemia
90
define haemolytic uraemic syndrome
thrombosis in small blood vessels throughout the body - usually triggered by shiga toxin
91
what is the triad of haemolytic uraemic syndrome?
Haemolytic anaemia
Acute kidney injury
Low platelet count (thrombocytopenia)
92
where is shiga toxin produced from?
e.coli 0157
shigella
- use of abx and anti motility meds such as loperamide increases risk
93
how does a pt with e.coli present in contrast to later when they develop HUS?
gastroenteritis - bloody diarrhoea
then 5 days later -
Reduced urine output
Haematuria or dark brown urine
Abdominal pain
Lethargy and irritability (anaemia)
Confusion (uraemia)
Hypertension (renal failure)
Bruising (low platelets)
94
how is HUS managed?
medical emergency -
Antihypertensives
Blood transfusions
Dialysis
95
define rhabdomyolysis
skeletal muscle breaks down and releases breakdown products into the blood..myocytes undergo apoptosis
Myoglobin (causing myoglobinurea)
Potassium
Phosphate
Creatine kinase
96
what are the consequences of the breakdown products of rhabdomyolysis being released?
potassium - hyperkalaemia - cardiac arrhythmias
myoglobin - toxic to kidney - AKI
97
what are the causes of rhabdomylosis?
Prolonged immobility, particularly frail patients that fall and spend time on the floor before being found
Extremely rigorous exercise beyond the person’s fitness level (e.g. ultramaraton, triathalon, crossfit competition)
Crush injuries
Seizures
98
what are the signs and sx of rhabdomyolsis?
Muscle aches and pain
Oedema
Fatigue
Confusion (particularly in elderly frail patients)
Red-brown urine
99
which investigations are used for rhabdo?
CK - very elevated - typically to thousands until 12 hours then remains elevated for 1-3 days and then starts reducing
urine dipstick - myglobin causes blood to be positive
UE - AKI and hyperkalaemia
ECG - hyperkalaemia
100
how is rhabdomyolysis managed?
IV fluids
IV sodium bicarb to make urine more alkaline reducing toxicity of myoglobin on kidneys
IV mannitol - increase GFR and reduce oedema
treat complications - hyperkalaemia
101
what are the causes of hyperkalaemia?
Acute kidney injury
Chronic kidney disease
Rhabdomyolysis
Adrenal insufficiency
Tumour lysis syndrome
Medications - Aldosterone antagonists (spironolactone and eplerenone)
ACE inhibitors
Angiotensin II receptor blockers
NSAIDs
Potassium supplements
102
what may result in a falsely elevated potassium?
haemolysis
103
what are the ECG changes of hyperkalaemia?
Tall peaked T waves
Flattening or absence of P waves
Broad QRS complexes
104
when is hyperkalaemia concerning?
Patients with a potassium ≤ 6 mmol/L with otherwise stable renal function don’t need urgent treatment and may just require a change in diet and medications (i.e. stopping their spironolactone or ACE inhibitor).
Patients with a potassium ≥ 6 mmol/L and ECG changes need urgent treatment.
Patients with a potassium ≥ 6.5 mmol/L regardless of the ECG need urgent treatment.
105
how is hyperkalaemia managed?
insulin and dextrose infusion and IV calcium gluconate
other options-
nebulised salbutamol
IV fluids
oral calcium resonium
sodium bicarb
dialysis
106
define polycystic kidney disease
genetic
multiple fluid filled cysts
may also develop hepatic cysts and cerebral aneurysms
107
how is polycystic kidney disease found on examination?
palpable enlarged kidneys
108
what is the genetic inheritance of polycystic kidney disease?
auto dom or auto rec
109
what are the auto dom associated genes?
PKD-1: chromosome 16 (85% of cases)
PKD-2: chromosome 4 (15% of cases)
110
what are the extra renal manifestations of aut dom polycystic kidney disease?
Cerebral aneurysms
Hepatic, splenic, pancreatic, ovarian and prostatic cysts
Cardiac valve disease (mitral regurgitation)
Colonic diverticula
Aortic root dilatation
111
what are the complications of polycystic kidney disease auto dom?
Chronic loin pain
Hypertension
Cardiovascular disease
Gross haematuria can occur with cyst rupture
Renal stones
End-stage renal failure
112
which gene is associated with polycystic kidney disease aut rec?
gene on chromosome 6
113
how does aut rec polycystic kidney disease often present?
in pregnancy with oligohydramnios as the fetus does not produce enough urine...causing resp failure after birth due to underdevelopment of lungs
- underdeveloped ear cartilage, low set ears and a flat nasal bridge. They usually have end-stage renal failure
114
how is polycystic kidney disease managed?
Tolvaptan (a vasopressin receptor antagonist) can slow the development of cysts and the progression of renal failure in autosomal dominant polycystic kidney disease
115
how are the complications of PCKD managed?
Antihypertensives for hypertension.
Analgesia for renal colic related to stones or cysts.
Antibiotics for infection. Drainage of infected cysts may be required.
Dialysis for end-stage renal failure.
Renal transplant for end-stage renal failure.
116
how else can PCKD be managed?
Genetic counselling
Avoid contact sports due to the risk of cyst rupture
Avoid anti-inflammatory medications and anticoagulants
Regular ultrasound to monitor the cysts
Regular bloods to monitor renal function
Regular blood pressure to monitor for hypertension
MR angiogram can be used to diagnose intracranial aneurysms in symptomatic patients or those with a family history
117
which fluids should be used in AKI (majority)?
high risk of hyperkalaemia - so not Hartmann's as has K, use NaCl instead
118
define cirrhotic AKI
cirrhosis causes portal hypertension resultingin splanchnic arterial vasodilation, reducing arterial blood volume causing AKI and encephalopathy
119
how must mycophenolate moeftil be given
come off if acutely unwell and double prednisolone
120
why might a patient have hypercalcaemia?
immobilisation
mineral bone disease from CKD
121
how often is haemodialysis performed
3 times a week for 4 hours
122
in what forms can haemodialysis access be given?
central line or AV fistula or graft
123
how is PD different?
at home
risk of peritonitis
given through catheter
124
When is alfacalcidol used?
Suppresses PTH, lowering serum calcium so not activating osteoclast activity…used in osteoporosis and vit d deficiency
125
What is a proteus infection?
Usually UTI causing pyelonephritis
In young boys, elderly and structural abnormalities
126
Which hypertension must be removed in fluid overload?
Amlodipine - blocks calcium ion channels resulting in vasodilation and fluid exudate
127
What is used if a dialysis catheter is occluded?
Urokinase infusion
128
What can cyclosporin not be used with?
Anti fungals- fluconazole
129
What electrolyte abnormalities are common in CKD?
Hyperkalaemia - kidneys excrete potassium, met acidosis,
Dysnatriaemia - depending of fluid overload or depleted
130
What is important ro measure in every patient on a renal ward?
JVP!
From sterna angle - straight line up..should be less than 3cm
Otherwise +1, +2, +3 - fluid overload
131
Classification of CKD - severity heat map
See
132
In what circumstances is ACR very important?
Diabetes
133
What is the prognosis of ESRD?
Majority of CKD 1-3 do not progress ro ESRF
Risk of CV death is higher than risk of progression
134
What are the complications of CKD and how are they treated?
Sodium retention - sodium restriction
Volume overload - diuretics, fluid restriction
Hyperkalaemia - dietary restrictions, avoid NSAIDS
Metabolic acidosis - sodium bicarbonate
High phosphate - phosphate binders
Low serum calcium -pans calcitriol - calcimimetrics
Anaemia - EPO, iron
135
Why should you avoid blood transfusions in CKD?
Iron overload
Exposure of HLA antigens
136
what are the sx of uraemia?
N+V
anorexia
weight loss
fatigue
pericarditis
sei\ures
137
what is a type of living donation?
paired and pooled living kidney donation
138
what are the contraindications of kidney transplant?
cardiac/resp
cancer
chronic infection - hep B, C
life expectancy < 5 yrs
139
what are the early and late complications of kindey transplant?
early - bleeding, thrombosis, infection, ureteric, lymphocele
rejection
renal artery stensois
late - rejection, lympho-prolierative disorder (EBV), CMV disease, BK nephropathy, PCP, hypertension, DM
LATER - chronic antibody mediated rejection, recurrent UTI, CV disease, swuamous cell carcinoma
140
what is the optimal way to transplant?
pre emptive, liver donor
141
What are the causes of metabolic acidosis which have a normal anion gap?
Hyperchoraemia
Renal tubular acidosis
Addison’s
Diarrhoea
142
What are the causes of metabolic acidosis which have a raised anion gap?
DKA, salicylate overdose, lactic acidosis, methanol poisoning
143
What are the biochemical results of renal tubular acidosis?
Hyperchloraemia
Low bicarbonate
144
What is associated with ADPKD?
Berry aneurysm (sudden onset headache…can lead to subarachnoid haemorrhage)
Cysts I’m kidney, liver, ovaries and spleen
145
Over how many hours is an AKI defined?
<0.5 mL/kg/hr over 6 hrs
146
Define amyloidosis, how it presents?
50-65 yr olds
Presents as breathlessness and weakness
Loss of renal function and Proteinuria
Hepatosplenomegaly
147
How should a patients with a raised ACR (>3mg/mmol) and DM be managed?
Commence acei
148
How does nephrotic syndrome predispose a patient to VTE?
Loss of antithrombin 111
149
What is the indication for haemodialysis in a patient with AKI?
If they have pulmonary oedema
150
What are some side effects of EPO?
Bone aches
Flu like sx
Skin rash
151
How is ATN diagnosed?
Nephrotoxic causes
Urine osmolality <350 mOsm/kg
High sodium
152
What is a cause of cranial diabetes insipidus?
Sx of CDI - high serum osmolality, low urine osmolality , retuns to normal with desmopressin
Urinary sx
Hereditary haemochromatosis -lethargy and arthralgia…causing CDI
153
How does acute graft failure present and when does it occur?
Usually asx h(different from ATN of graft)
Pyuria
Proteinuria
Rising creatinine
6 months post transplant
154
What can cause deranged liver function tests?
TPN
155
When should patients with CKD be started on ACEi?
ACR >30mg/mmol
156
What drug has shown to reduce the rate of CKD progression in ADPKD?
Tolvaptan - vasopressin receptor 2 antagonist
157
What is the first indicator of diabetic nephropathy?
Microalbuminuria
158
What drug is used to treat hyperphosphataemia in CKD with mineral bone disease?
Sevelamer
159
How can acute interstitial nephritis present?
Allergic type - raised WCC, IgE and eosinophils
Impaired renal function
160
What can be used ro differentiate ATN from AIN causing AKI?
Urine dip -
If protein - not pre or post renal
If no nitrites - no infection
AIN has high white cell count in urine wheras ATN doesn’t
161
How can diabetic neuropathy be distinguished from other causes of CKD?
Large/normal sized on USS
Most patients with CKD have bilateral small kidneys
162
What does a raises serum urea:creatinine ratio indicate?
Pre renal cause
163
What drug can cause rhabdomyolysis?
Statin
164
What drug must be stopped in AKI?
ARB - valsartan
165
What is the most likely causative organism of peritonitis secondary to peritoneal dialysis?
Staph epidermidis
166
How can renal artery stenosis be differentiated from other causes of refractory hypertension?
High renin
167
What is the treatment of a hyper acute transplant rejection?
Remove immediately
168
Define henoch-schonlein purpura
IgA autoimmune mediated Vasculitis
Abdo pain
Arthritis
Haematuria
Pupuric rash over buttocks amd extensor surfaces
169
How does ATN present?
Poor response to fluids
170
what are the causes of hyponatraemia?
diuretics
PPI
anti-epileptics
malignancy
head trauma
.....
Hypovolaemia Euvolaemia Hypervolaemia
Urine [Na+] <20mmol Vomiting or Diarrhoea Acute fluid overload Congestive Cardiac Failure or Liver Cirrhosis*
Urine [Na+] >20mmol Diuretics SIADH Acute Tubular Necrosis
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how do you investiagte hyponatraemia?
the first step when investigating hyponatraemia should be to measure serum osmolality, to see whether it is hypo-osmotic, iso-osmotic or hyper-osmotic. However, in clinical practice, most cases* of hyponatraemia encountered will be hypo-osmotic hyponatraemia, whereby there is either sodium depletion or water excess (or both
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how do you manage hyponatraemia?
careful fluid balance. Start close fluid monitoring, catheterising if necessary; this is particularly important during the intraoperative and post-operative period.
Intravenous fluids (such as 0.9% sodium chloride) are generally advised over enteral hydration for the hyponatraemic patient, as they will provide a greater control to the serum electrolyte levels. Monitor renal function and electrolyte levels regularly, as potential derangement may occur during any fluid redistribution during your management.
If the cause is unknown or evidence of prolonged and marked hyponatraemia, urine osmolality and sodium concentration should be measured to inform additional diagnosis.
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what are the sx of hyponatraemia?
mostly asx
malaise, headache, and confusion, before progressing to reduced consciousness and seizures
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HLA antigens renal transplant
When HLA matches for a renal transplant the most important HLA antigen is DR, followed by B and then A. Other antigens to consider include C, DP, and DQ but these are not the most important. Although donors who are closely genetically related to the patient have an increased likelihood of being an organ donor match, it may be the case that they are still not a close enough match to donate.
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what is the most common causative organism of peritoneal dialysis related peritonitis?
Coagulase-negative Staphylococcus is the most common cause of peritonitis secondary to peritoneal dialysis - staph epidermiditis
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what drugs must be stopped in AKI?
Diuretics
Aminoglycosides and ACE inhibitors
Metformin
NSAIDs.
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which nephropathy is most likely to be associated with malignancy?
membranous nephropathy
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tolvaptan
Tolvaptan has been shown to reduce the rate of CKD progression in ADPKD (and is approved by NICE)
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HIV infection is a cause of ...
HIV infection is a cause of focal segmental glomerulosclerosis
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acute interstitial nephritis
Acute interstitial nephritis causes an 'allergic' type picture consisting usually of raised urinary WCC, IgE, and eosinophils, alongside impaired renal function
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iga nephropathy investigations
his would show diffuse mesangial IgA deposition and is required to make a definitive diagnosis of IgA nephropathy. This is the most common primary glomerulonephritis in high-income countries. Approximately half of all patients with IgA nephropathy will present with recurrent episodes of frank haematuria following respiratory or gastrointestinal infections, usually occurring 1-2 days after the onset of infection.
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haemolytic uraemic syndrome
Normocytic anaemia, thrombocytopaenia and AKI following diarrhoeal illness - consider HUS
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ADPKD triad
Renal impairment, flank masses, hypertension → ?ADPKD
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renal USS
An ultrasound is required in the investigation of all patients presenting with an AKI of unknown aetiology
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rapidly progressive glomerulosclerosis CAUSES
Goodpasture's syndrome
Wegener's granulomatosis
others: SLE, microscopic polyarteritis
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low vitamin D ckd
Alfacalcidol is used as a vitamin D supplement in end-stage renal disease because it does not require activation in the kidneys
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primary v secondary hyperaldosteronism
Primary and secondary aldosteronism can be differentiated by looking at the renin levels. If renin is high then a secondary cause is more likely, i.e renal artery stenosis.
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HUS
Haemolytic uraemic syndrome - classically caused by E coli 0157:H7
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screening of AKPD
LIVER USS
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glomerulonephritis what is it
Glomerulonephritis can present with any of the following:
Isolated haematuria or proteinuria
Nephrotic syndrome
Nephritic syndrome
Acute renal failure
Chronic renal failure
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causes of normal anion gap in metabolic acidosis
Causes of a normal anion gap metabolic acidosis are ABCD:
Addison's
Bicarb loss
Chloride
Drugs
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causes of normal anion gap in metabolic acidosis
Causes of a normal anion gap metabolic acidosis are ABCD:
Addison's
Bicarb loss - diarrrhoea
Chloride
Drugs
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dehydration
presenting with confusion, which is an unspecific symptom in elderly patients, especially with dementia, and anuria. The blood tests show that the patient has high sodium and urea. The urine test shows normal osmolarity with sodium inferior to 20 mmol/L. This is a hallmark in the diagnosis of prerenal uraemia. One of the most common causes of prerenal uraemia, especially in elderly patients is dehydration.
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if peritonitis from PD
staph epidermdiits
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minimal change disease fx
Her normotension and preceding history of viral illness are also typical features of MCD. 80% of cases will be steroid responsive.
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diabetic patient with > ACR
All diabetic patients with a urinary ACR of 3 mg/mmol or more should be started on an ACE inhibitor or angiotensin-II receptor antagonist
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alports v goodpastures
Alport's patient with a failing renal transplant. This may be caused by the presence of anti-GBM antibodies leading to a Goodpasture's syndrome like picture.
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high urine osmolality and low urine sodium
pre renal AKI
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acute interstitial nephritis
Acute interstitial nephritis causes an 'allergic' type picture consisting usually of raised urinary WCC, IgE, and eosinophils, alongside impaired renal function
200
aki
results in hyperkalaemia
