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AKT > renal > Flashcards

renal Flashcards

1
Q

eGFR is based on serum Cr, age, gender and ethnicity. What 3 things may affect the result?

A

Pregnancy
Muscle mass
Eating red meat 12 hours before

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2
Q

NICE guidelines suggest referring to a nephrologist from primary care if within 1 year, the eGFR falls by…

A

Sustained decrease in eGFR by >15 or >25%
Or falls below <30

Within 1 year

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3
Q

Pruritis can occur in chronic kidney disease secondary to…

A

uraemia

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4
Q

Referral to nephrology from primary care if the urinary albumin:creatinine ratio (ACR) is what level

A

> 70mg/mmol
or >30mg/mmol with haematuria

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5
Q

eGFR is worked out by which 4 variables

A

Serum Cr
Age
Gender
Ethnicity

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6
Q

CKD stages + ranges

A

CKD 1 = >90
CKD 2 = 60-90
CKD 3 = 30-45 (3a = 45-60, 3b = 30-45)
CKD 4 = 15-30
CKD 5 = <15 or ESRF

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7
Q

In a patient with ACR > 30, and high blood pressure or CKD, what is the first line anti-hypertensive medication

A

ACE inhibitor

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8
Q

Patients with hypertension have different treatment guidelines depending on ACR level. What is the cut-off ACR for these guidelines?

A

ACR <30 - treat as usual HTN guidelines
ACR >30 - start on ACE inhibitor

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9
Q

ACE inhibitors are useful in chronic kidney disease when ACR >30 - what is their mechanism of action

A

Reduces proteinuria
Reduces filtration pressure by causing efferent dilation (therefore can increase Cr, decrease eGFR)

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10
Q

What is an acceptable decrease in eGFR or rise in Cr for ACE inhibitors in HTN for CKD patients (ACR >30)

A

eGFR of up to 25% decrease
Cr of up to 30% increase

any higher suggests renal artery stenosis

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11
Q

What loop diuretic is useful as an anti-hypertensive in patients with CKD?

A

Furosemide

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12
Q

Furosemide is useful as anti-HTN in CKD patients particularly when eGFR falls to below…

A

<45
Also lowers K+

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13
Q

In non-diabetics if ACR >/= 70
what is the antihypertensive that should be started regardless of BP

A

Start ACE inhibitor/ARBs
AND refer to nephrology

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14
Q

In Type 2 Diabetics if ACR > 3
what is the anti-hypertensive

A

Start ACE inhibitors/ARBs
Make sure it is titrated to max dose
And then offer SGLT-2 inhibitor (-gliflozin) if ACR >70 (consider if ACR 3-30)

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15
Q

Type 1 diabetes, and ACR >3
what anti-hypertensive should be started

A

ACE inhibitors/ARBs

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16
Q

For all patients with CKD what statin should be started

A

atorvastatin 20mg if no cardiovascular Hx

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17
Q

ACR to PCT to urinary protein excretion (g/24 hours) equivalent values:
ACR 30
ACR 70

A

ACR 30 = PCR 50 = 0.5g/24hrs urinary protein excretion

ACR 70 = PCR 100 = 1g/24hrs urinary protein excretion

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18
Q

ACR sample should be what kind of urine sample

A

First-pass morning
Spot sample

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19
Q

If the initial ACR is between 3-70, how should this be confirmed

A

Subsequent early morning sample
If initial ACR >70, repeat sample does not need to be repeated

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20
Q

NICE guidelines regard a confirmed ACR of what as clinically important proteinuria

A

ACR >3

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21
Q

Other than ACE inhibitors, what other medication may be useful for patients who have proteinuric CKD (with or without diabetes)

A

SGLT-2 inhibitors
e.g. dapagliflozin, empagliflozin

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22
Q

SGLT2 inhibitors can be used for proteinuric CKD patients. What is their mechanism of action

A

Block reabsorption of glucose at the proximal tubule
Increase glycosuria
Reduces sodium reabsorption
Reduces intravascular volume, BP, and intraglomerular pressure

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23
Q

In order to diagnose CKD, you need eGFR below what and over what timeframe

A

eGFR <60 on at least 2 occasions separated by at least 90 days

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24
Q

If the initial ACR test is between 3-70, what should be done in terms of repeat samples/referral?

A

Repeat another ACR early morning sample
If >30 and haemturia - refer
If >70 - refer

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25
Q

If the initial ACR test result is >70, what should be done in terms of repeat samples/referral?

A

Repeat sample does not need to be done
Refer to nephrology!

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26
Q

When should ACR urine sample be done

A

Early morning sample

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27
Q

minimal change disease (usually presents as a nephrotic syndrome) is usually idiopathic in most causes. in 10-20% causes can be found including what three things?

A
  1. drugs - NSAIDs, rifampicin
  2. Hodgkin’s lymphoma, thymoma
  3. infectious mononucleosis
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28
Q

Minimal change disease renal biopsy usually shows what

A

Normal glomeruli on light microscopy
Electron microscopy shows fusion of podocytes, effacement of foot processes

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29
Q

Nephrotic syndrome triad

A

Oedema
Proteinuria
Hypoalbuminaemia

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30
Q

Nephritic syndrome triad

A

Hypertension
Haematuria
Oliguria

31
Q

Treatment of minimal change disease

A

Oral corticosteroids - 80% are steroid-responsive
Cyclophosmide for steroid-resistant cases

32
Q

Prognosis of minimal change disease

A

1/3 have one episode
1/3 have infrequent relapses
1/3 have frequent relapses that stop before adulthood

33
Q

painless, visible haematuria indicates what cancer

A

Transitional cell carcinoma of the bladder

n.b. renal cell carcinoma typically has mass + abdo pain!

34
Q

what 2 drugs can cause red/orange urine (where blood is not present)

A

rifampicin
doxorubicin

35
Q

persistent haematuria is defined as

A

blood on 2 out of 3 samples at least 2-3 weeks apart

36
Q

urgent 2 week referral criteria for haematuria (young - goes to renal, older - goes to urology)

A

> 45 years and:
- unexplained visible haematuria without UTI; or
- visible haematuria that persists/recurs after UTI treatment

> 60 years and:
- unexplained non-visible haematuria and either dysuria/high WCC on bloods

NON-URGENT REFERRAL: >60 years with persistent/resistant UTI

37
Q

what is a useful medication to lower uric acid and phosphate levels

A

sevelamer

38
Q

what is the mechanism of action of Sevelamer

A

Non-calcium based phosphate binder
Prevents absorption by binding to dietary phosphate
Reduces uric acid

39
Q

1-alpha hydroxylation usually occurs where and what does it do

A

In the kidneys
produces active vitamin D

40
Q

chronic kidney disease leads to lower 1-alpha hydroxylation occurring. what does this do to vitamin D and phosphate levels?

A

Low vitamin D
High phosphate

41
Q

High phosphate levels due to chronic kidney disease has what effect on the bones

A

osteomalacia

42
Q

What parathyroid issue results from chronic kidney disease

A

Secondary hyperparathyroidism

Low vitamin D
Low calcium
High phosphate

43
Q

management of mineral bone disease (high phosphate, low vit D, low calcium, osteomalacia) in chronic kidney disease patients

A
  1. Low phosphate diet
  2. Phosphate binders - calcium based binders; or non-calcium based binders e.g. sevelamer, binds to dietary phosphate and prevents absorption. Reduces phosphate and uric acid)
  3. Vitamin D: alfacalcidol, calcitriol
  4. Parathyroidectomy
44
Q

Calcium based phosphate binders have what 2 side effects

A

Hypercalcaemia
Vascular calcification

45
Q

Referral to nephrologist if:

A

ACR >70
ACR >30 and haematuria
eGFR drop >25% or >15 in 12 months or <30 overall
CKD stage 5

46
Q

in a patient with eGFR <60, the next step is to

A

send early morning sample urine for ACR
and dipstick urine for haematuria

47
Q

Henoch schonlein purpura is also known as

A

IgA vasculitis

small vessel vasculitis

48
Q

Palpable purpura
Arthralgia/arthritis
Abdominal pain
Renal involvement
Follows URTI

Common in children

What is the diagnosis?

A

Henoch schonlein purpura (IgA vasculitis)

49
Q

Treatment of Henoch schonlein purpura

A
  1. analgesia for arthralgia
  2. generally supportive
    - not much evidence for steroids or immunosuppressants
  3. Monitor BP and urinalysis to detect progressive renal involvement
50
Q

Prognosis of Henoch schonlein purpura

A
  1. Self-limiting, usually resolves especially if no renal involvement
  2. 1/3 patients have relapse
51
Q

Anaemia in CKD4 - what level of Hb do they aim for?

A

10-12g/dl

52
Q

Anaemia in CKD predisposes to the development of what…

A

Left ventricular hypertrophy

associated with 3x increased mortality in renal patients

53
Q

Management of anaemia in CKD patients

A
  1. Target Hb levels 10-12g/dl
  2. Optimise iron levels - give oral iron if not on ESAs or dialysis. If not at target Hb levels by 3 months, switch to IV iron.
  3. Erythropoeisis stimulating agents (ESAs) e.g. erythropoeitin, darbepoetin
54
Q

What 2 drugs are associated with proteinuria

A

Gold
Penicillamine

55
Q

Main cause of nephrotic syndrome

A

Primary glomerulonephritis (80%)
- minimal change
- membranous
- focal segmental
- membranoproliferative

56
Q

Primary glomerulonephritis is the main (80%) cause of nephrotic syndrome. What 3 systemic diseases can also lead to nephrotic syndrome?

A

Diabetes
SLE
Amyloidosis

57
Q

What are the 3 diuretics indicated for ascites

A

Spironolactone
Amiloride
Chortalidone

58
Q

5 indications for spironolactone use

A
  1. Ascites - cirrhosis ascites can develop secondary hyperaldosteronism
  2. Hypertension
  3. Heart failure
  4. Nephrotic syndrome
  5. Conn’s syndrome
59
Q

Two side effects from spironolactone

A

Hyperkalaemia
Gynaecomastia

60
Q

Patients with CKD, HTN and urinary ACR or >70 should aim for what BP

A

<130/80

61
Q

What diuretic can be useful as an anti-hypertensive in CKD patients with eGFR <45?

A

Furosemide

62
Q

What inheritance is polycystic kidney disease

A

autosomal dominants

63
Q

what is the screening investigation for relatives with polycystic kidney disease

A

abdominal ultrasound

64
Q

what is the ultrasound diagnostic criteria for polycystic kidney disease (if patients have positive family history)

A
  • <30 years - two cysts uni or bilateral
  • 30-59 years - two cysts in both kidneys
  • <60 years - four cysts in both kidneys
65
Q

What is the medication treatment of polycystic kidney disease and the 3 criteria to start it

A

Tolvaptan (vasopressin receptor 2 antagonist)
- if CKD 2 or 3
- evidence of rapidly progressing disease
- company discount with patient access scheme

66
Q

What genes/Chr are involved with polycystic kidney disease

A

Type 1 (85%) = PKD1, Chr 16

Type 2 = PKD2, Chr 4

67
Q

Triad of renal cell carcinoma

A

Haematuria
Loin pain
Abdominal mass

68
Q

Endocrine effects of renal cell carcinoma - i.e. what hormones does it secrete

A

Polycthaemia (secretes EPO)
Hypercalcaemia (secretes PTH)
Rein
ACTH

69
Q

diabetes insipidius is caused by which hormone abnormality

A

Cranial DI - decreased secretion of anti-diuretic hormone (ADH)
Nephrogenic DI - insensitivity to ADH

70
Q

What 2 medications can cause nephrogenic DI

A

Lithium
Demeclocycline

71
Q

What two electrolyte disturbances can induce nephrogenic DI

A

Hypokalaemia
Hypercalacaemia

72
Q

What will diabetes insipidus show on:
plasma osmolality
urine osmolality

A

High plasma osm
Low urine osm

73
Q

Management of diabetes insipidus

A

Nephrogenic - thiazides and low salt/protein diet
Central - desmopressin

74
Q

Patients with CKD on haemodialysis - what is the most likely cause of death

A

ischaemic heart disease

AKT (25 decks)

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