renal Flashcards
Which medications should be stopped in AKI as they may worsen renal function
NSAIDs
Aminoglycosides
ACEi
ARB
Diuretics
what is the key diagnostic sign of rhabdomyolysis
elevated CK levels
what are the features of rhabdomyolysis ?
AKI
Raised CK
myoglobinuria : reddish / dark brown urine
elevated phosphate
metabolic acidosis
hypocalcaemia
hyperkalaemia
what is the management of rhabdomyolysis
IV fluids
what causes rhabdomyolysis
seizure
collapse/com
crush injury
ecstasy
statins ( esp. with clarithromycin)
how to distinguish between IgA nephropathy and post streptococcal glomerulonephritis ?
IgA nephropathy : macroscopic haematuria within a day or two of developing an URTI in young males
Post streptococcal glomerulonephritis : onset of nephritis is generally 1-3 weeks after initial infection - also presents with proteinuria
how do you screen a patient for diabetic nephropathy ?
albumin : creatine ratio in early morning specimen
what is the screening test for adult polycystic kidney disease
renal ultrasound scan
what features are seen in Alport’s syndrome
Microscopic haematuria
Renal failure
bilateral sensorineural deafness
ocular abnormalities
All ports affected
eyes
ears
urine
or
cant see
cant pee
cant hear a buzzing bee
what cancer are patients who have had an organ transplantation most at risk of ?
skin cancer = squamous cell carcinoma
most common cause of glomerulonephritis
IgA nephropathy
how do you distinguish between HSP and ITP
polyarthralgia : presents in HSP
absent in ITP
what is the common pattern of presentation of HSP ?
It usually present in children following an infection.
Features : IgA mediated
palpable purpuric rash with oedema on buttocks and extensor surfaces of arms and legs
abdominal pain
polyarthritis
( haematuria, renal failure)
what type of hyperparathyroidism does CKD cause ? how does it present ?
secondary hyperparathyroidism
low calcium
high phosphate
low vitamin D
Most common cause of AKI
Acute tubular necrosis
what is acute interstitial nephritis ? what are its triggers ? how does it present ?
Acute inflammation of renal tubulo-interstitium, usually due to medications.
Triggered by :
PRIDE
Penicillin
Ramipril
Ibuprofen and other NSAID’s
Diuretics
Extras : SLE, Sarcoidosis, Sjogren’s
Presentation
fever, rash, arthralgia
eosinophilia
mild renal impairment
how does IgA nephropathy present on biopsy ?
Mesangial hyper cellularity
Positive immunofluorescence for IgA and C3
What are the features of Goodpasture’s disease?
-pulmonary haemorrhage
-rapidly progressive glomerulonephritis leading to rapid onset SKI
nephritis –> proteinuria + haematuria
what type of deposits are seen in Goodpasture’s syndrome
IgG deposits
how would you distinguish IgA nephropathy and Minimal change disease ?
Minimal change disease : most common cause of nephrotic syndrome presenting with proteinuria and NO HAEMATURIA
whereas IgA nephropathy presents with HAEMATURIA
raised ureA : creatinine ratio represents what cause for AKI
prerenal such as dehydration
what causes anaemia in CKD patients
reduced erythropoietin levels
how do you manage anaemia in CKD
ferrous sulphate
erythropoiesis stimulating agents
____________are the preferred method of access for haemodialysis
Arteriovenous fistulas
what conditions caused a raised anion gap ?
lactate : shock, sepsis, hypoxia
Ketones : DKA, alcohol
what is the screening test for ADPKD ?
abdominal ultrasound
what medication can be used to slow down the progression of cyst development in ADPKD?
Tolvaptan
In the management of hyperkalaemia give drugs used for the following :
- stabilisation of cardiac membrane
2.short term shift in potassium from extracellular to intracellular - removal of potassium from the body
- Calcium gluconate
- insulin / dextrose, nebulised salbutamol
- calcium resonium
how should HSP be monitored ?
Blood pressure and urine analysis
what is the management of minimal change disease ?
oral corticosteroids
cyclophosphamide
what conditions constitute nephrotic syndrome ?
Minimal change disease
Membranous GN
Focal segmental glomerulosclerosis
Amyloidosis
diabetic nephropathy
proteinuria, oedema
what conditions constitute nephritic syndrome?
rapidly progressive GN
IgA nephropathy
Alport syndrome
GOODPASTURES
haematuria , hypertension
what is the clinical triad of nephrotic syndrome?
Proteinuria ( > 3 g / 24h)
Hypoalbuminaemia
Oedema
name 3 main complications of nephrotic syndrome
HIT
Hyperlipidaemia ( DVT, PE, renal vein thrombosis)
Infection
Thromboembolism
what is the cellular pathology behind rhabdomyolysis ?
Tubular cell necrosis
what is the best way to distinguish between AKI and CKD?
Bilateral small kidneys
what medications are used in the management of CKD and when are they introduced ?
ACEi = used in the management of proteinuria in CKD and are introduced if the albumin creatinine ratio is > 30 mg / mmol
SGLT2 inhibitors = proteinuric CKD
what are the complications of CKD ?
Anaemia : reduced erythropoietin levels
Renal bone disease : secondary hyperparathyroidism
CVD
Peripheral neuropathy
triad of symptoms seen in HUS
thrombocytopenia
AKI
haemolytic anaemia
what causes HUS
shiga toxin producing E.Coli
according to guidelines how do you describe an AKI
rise in serum creatinine of 26 mmol/l or greater within 48 h
50% / greater rise in serum creatinine within past 7 days
fall in urine output to less than 0.5 ml/kg/h for > 6h in adults
Nephrotic syndrome is associated with a hypercoagulable state due to loss of _______________________ via the kidneys
Antithrombin III
what is the management of nephrogenic diabetes insipidus
Thiazides
low salt / protein
what are the most common extra renal manifestations of ADPKD
liver cysts
what are the indications for acute dialysis ?
AEIOU
Acidosis
Electrolytes
Intoxication ( overdose)
Oedema
Uraemia symptoms- nausea, seizure, pericarditis, encephalopathy, high uric acid
what stage requires long term DIALYSIS
end stage kidney disease ( CKD-5)
what is the catheter in peritoneal dialysis known as
Tennckhoff
what are the options available for haemodialysis
tunnelled cuffed catheter
AV fistula
what are the types of AV fistula available??
Radiocephalic
brachiocephalic
brachiobasilic
what are the complications of haemodialysis
aneurysm
infection
thrombosis
stenosis
high output hf
which cancers are caused by immunosuppression
skin - SCC
Non Hodgkin’s lymphoma
which condition is associated with IgA deposits
IgA nephropathy
which condition is associated with IgG and complement deposits on the basement membrane
membranous glomerulonephritis
what condition is associated with tonsillitis
post-streptococcal glomeronephritis
which condition is associated with pulmonary haemorrhage
goodpasture;s
what is the management of minimal change disease ?
first line : oral corticosteroids
steroid resistant : cyclophosphamide
what does minimal change disease show on renal biopsy?
normal glomeruli on light microscopy
electron microscopy = fusion of podocytes and effacement of foot processes
what is the prognosis of minimal change disease
1/3rd - 1 episode
1/3rd - infrequent relapses
1/3rd - frequent relapses before adulthood
what are the non idiopathic causes of minimal change disease?
drugs - NSAID’s rifampicin
Hodgkin’s lymphoma, thymoma
Infectious Mononucleosis
when is a renal biopsy indicated in minimal change disease
poor response to steroids
what is the time period after which a PSA level can be done in the following activities
1) ejaculation or vigorous activity
2) DRE
3) UTI
4)prostate biopsy
1) 48h
2) 1 week
3) 4 weeks
4) 6 weeks
what is the initial management of renal colic ?
NSAIDs such as parenteral diclofenac
IV paracetamol if NSAID’s are c/i
alpha blockers may be considered if the stones are < 10 mm in size
what imaging is performed to diagnose renal colic ?
non contrast CT-KUB - within 24h of admission
ultrasound for pregnant women and children
what is the management of renal colic ?
if stones are < 5 mm and asymptomatic
watchful waiting
5-10 mm - shockwave lithotripsy
10-20 mm- shockwave lithotripsy / ureteroscopy
> 20 mm Percutaneous nephrolithotomy
what is the management of uretic stones
shockwave lithioscopy +/- alpha blockers >
what is the management of renal stones with signs of infection
Urgent renal decompression and IV Antibiotics ( nephrostomy)
when do you need to need to classify CKD stage 1/ 2?
sign of kidney damage
when is renal replacement therapy recommended in the management of an AKI?
when a patient is not responding to medical treatment of complications - hyperkalaemia, pulmonary oedema, acidosis, uraemia
what are the various types of incontinence ?
overactive bladder/ urge incontinence : detrusor overactivity
stress : leaking when coughing or laughing
mixed : both stress and urge
overflow : due to bladder outlet obstruction
functional
what initial investigations are performed in suspected urinary incontinence?
bladder diaries - 3 days
vaginal exam
urine dip and culture
urodynamic studies
what is the stepwise management of urge incontinence
bladder retraining - 6 weeks
bladder stabilizing drugs - antimuscarinics ( oxybutynin, unless frail in which case use mirabegron)
what is the stepwise management of stress incontinence ?
pelvic floor muscle training
duloxetine
retropubic mid urethral tape procedures
why does gynaecomastia occur with testicular tumours
increased oestrogen : androgen ratio
which drugs should be stopped in AKI
DIANA
Diuretics
Iodinated contrast
ACEi/ ARB
NSAIDs
Aminoglycosides
which medications may have to stopped during an AKI
metformin
lithium
digoxin
what is the risk of using large volumes for fluid therapy
hyperchloraemic metabolic acidosis
what medications are used in the management of CKD related bone disease ? what side effects can it present with
reduced dietary intake of phosphate
phosphate binders ( calcium based binders such as calcium acetate)
side effects are hypercalcaemia and vascular calcification
what class of medication is finasteride ? how long does one need to take it before results are seen?
5 alpha reductase inhibitor
6 months
how is anaemia due to CKD investigated and managed
iron studies before ESA
oral iron - if patient not on haemodialysis
switch to IV iron if target Hb not met
when are 5 alpha reductase inhibitors recommended in the management of BPH
significantly enlarged prostate and considered to be at high risk of progression
what are the side effects of 5 alpha reductase inhibitors
erectile dysfunction
reduced libido
ejaculation problems
gynaecomastia
when is a combination of Tamsulosin and finasteride recommended
if a man has bothersome moderate to severe voiding symptoms and prostatic enlargement
what is a sign of acute interstitial nephritis on microscopic examination of the urine ?
eosinophilic casts
when should ACEi be used in CKD
co-existent HTN and CKD if the ACR is > 30 mg/mmol
ACR > 70 mg/ mmol regardless of BP
which actions reduce renal stones
fluid
lemon juice
limit salt
thiazide diuretics
potassium citrate
what medications reduce oxalate stones
cholestyramine
pyridoxine
which medications reduce uric acid stones
allopurinol
urinary alkalisation
what condition does a bladder still palpable after urination point to
retention with urinary overflow
what is the stepwise management of CKD mineral bone disease
reduced dietary intake of phosphate
phosphate binders
vit d
parathyroidectomy
what type of an AKI is a disproportionately high urea associated with
prerenal like dehydration
what is the key investigation in diagnosing early CKD
Albumin: creatinine ratio
how is an ACR collected
1st pass morning urine
3-70 - repeat
>70 - no repeat
what is the mechanism of action of tamsulosin
alpha 1 antagonist
what is TURP syndrome and how does it present ?
rare and life-threatening complication of trans-urethral resection of prostate
caused due to irrigation with large volumes of glycine which is hypo-osmolar.
this causes hyponatraemia, CNS, resp and systemic symptoms
which bacteria is the most common cause of epididymis-orchitis
chlamydia trachomatis - sexual history
E.Coli- no sexual history
how does epididimorchitis present and what is an important differential?
unilateral testicular pain and swelling
urethral discharge
important differential is testicular torsion
which organism is likely to cause staghorn calculi
Proteus mirabilis
what medications are used to treat hyperphosphatemia ? give an example
- non calcium based phosphate binder like sevelamer
what is the most common type of kidney stone
calcium oxalate
what is the cause of a staghorn calculus
struvite
what lifestyle factors can inapropriately decrease e gffr
pregnancy
muscle mass
red meat 12h prior
what are the two main causes of acute tubular necrosis
ischaemia : shock and sepsis
nephrotoxins : aminoglycosides, myoglobin, lead, radiocontrast agents
what is the management of hydronephrosis ?
immediate renal decompression via a nephrostomy tube to reduce the risk of permanent renal damage.
how would you distinguish between acute interstitial nephritis and acute tubular necrosis
acute interstitial nephritis : higher white cell count
what acid-base abnormality is renal tubular acidosis associated with ?
Hyperchloremic metabolic acidosis ( normal anion gap)
Type 1 RTA
no H+ secretion in urine
hypokalaemia
autoimmune stuff causes it
type 2 RTA
decreased bicarb reabsorption
hypokalaemia
type 4 RTA
reduction in aldosterone secretion
hyperkalaemia
most common cause of peritonitis secondary to peritoneal dialysis
staph. epidermis
which valvular disorder is ADPKD associated with
mitral prolapse
which drug can cause hyaline casts in urine
furosemide
When prescribing fluids, the potassium requirement per day is
1 mmol/kg/day
which test can be used to test post-streptococcal glomerulonephritis
Anti-streptolysin O titre
how to distinguish primary and secondary aldosteronism
high renin = secondary causes like renal artery stenosis
low renin =primary
most common cause of death in patients on haemodialysis
IHD
management of acute clot retention causing aki
irrigation of bladder followed by flexible cystoscopy
most patients with CKD have bilateral small kidneys. Exceptions to this rule include:
autosomal dominant polycystic kidney disease
diabetic nephropathy (early stages)
amyloidosis
HIV-associated nephropathy
which nephritis is most common with malignancy
membranous nephropathy
Gold standard for bladder cancer diagnosis is
cystoscopy
first line treatment for a patient not on haemodialysis requiring iron replacement
oral ferrous gluconate
side effects of erythropoietin
HTN
Bone ache
flu
rash and urticaria
red cell aplasia - risk reduced with darbepoetin
hyper acute rejection of renal transplant
minutes –> hours
due to pre-existing antibodies against ABO/HLA
type II hypersensitivity
no treatment, remove graft
acute graft failure
due to mismatched HLA
asymptomatic, decreasing kidney function
CMV
manage with steroids and immunosuppressants
chronic graft failure
antibody and cell mediated
fibrosis
action of calcium resonium
removal of potassium from the body
management of diabetic nephropathy
start ACEi or ARB if urinary 3 mg/mmol or more
statins
dietary protein restriction
tight glycaemic control
what is the preferred method for access for haemodialysis ? How long do they take to be functional
AV fistulas
6 to 8 weeks
fibromuscular dysplasia
can lead to renal artery stenosis in young females
HTN
CKD
flash pulmonary oedema
when to refer CKD to nephrologist
ACR > 70
urinary ACR of 30 mg/ mmol or more with persistent haematuria and no UTI
ACR < 30 but declining
renal cell carcinoma
haematuria, loin pain and abdominal mass
left varicocele
Causes of transient or spurious non-visible haematuria
urinary tract infection
menstruation
vigorous exercise (this normally settles after around 3 days)
sexual intercourse
what happens to the sodium in prerenal and renal AKI
Pre-renal : urine osmolality high, urine sodium low
Renal : urine osmolality low, urine sodium high
There are several types of renal replacement therapy available to patients:
haemodialysis
peritoneal dialysis
renal transplant
haemodialysis
most common form of renal replacement therapy through dialysis machine in hospital
patients need AV fistula
peritoneal dialysis
filtration within the abdomen
CAPD
APD
side effects of haemodialysis
site infection, endocarditis, stenosis, hypotension, diseequilibration syndrome
rare but serious complication of haemodialysis
dialysis disequilibrium syndrome
which conditions are associated with cystine stones
inherited metabolic disorder
radiolucent stones
uric acid
