Renal Flashcards
Phases to ATN
Oligouric
Polyuric
Recovery phase
Causes of ATN
Ichaemia from no perfusion
Toxins
- rhabdo
- aminoglycosides
- contrast
- lead
What does haematuria at the end of micturition suggest
A distal cause
What is preferred investigation for proteinuria in CKD
Albumin creatinine ratio
When treat proteinuria with an ACEi
Over 3 with DM
Over 30 with coexistent HTN
Over 70 regardless
What medications can be used to manage patients with proteinuria
ACEi
SGLT-2 inhibitors
Which drugs have to stop in AKI
Diuretics
ACEi
ARB
NSAIDS
Aminoglycosides
What dose aspirin is acceptable to stay on in an AKI
75mg
RFs for AKI
DM
The failures- liver, heart
Drugs- ACEi- ARB, diuretics
Contrast agents
What counts as oligouria
<0.5ml/kg/hour for 6 hours
What do if no identifiable cause for AKI
Involve renal
Do USS
Investigations for AKI
All patients should have U&Es monitored and urine dip done
If no identifiable cause do an USS
What drugs can be used to remove potassium from body
Calcium resonium
Loop diuretics
Which drugs can be used too shift potassium intracellularly
Combined dextrose and insulin
Nebulised salbutamol
Management of hyperkalaemia
First to protect the cardiac membrane
- IV calcium gluconate
Short term intracellular shift
- dextrose/insulin
- nebulised salbutamol
Removal of potassium from body
- calcium resonium
- loop diuretics
- dialysis
Indications for dialysis in AKI
Refractory hyperkalaemia
Pulmonary oedema
Acidosis
Uraemia with complications- pericarditis, encephalopathy
Which complications of uraemia indicate dialysis
Pericarditis
Encephalopathy
Investigations for anti-GBM
Anti-GBM antibodies
Renal biopsy- linear IgG depostion on BM
Increased transfer factor in lungs
Presentation of goodpastures
Pulmonary haemorrhage
Rapidly progressive glomerulonpehritis
Management of CKD anaemia
Options include iron, EPO agents like darbepoetin or EPO and haemodialysis
Presentation of acute interstitial nephritis
Fever
Rash
Arthralgia
Renal problems
MCS of acute interstitial nephritis
Sterile pyuria
White cell casts
Most likely cause of peritonitis on peritoneal dialysis
Staph epidermis
How manage hyperphosphataemia in CKD
Initially reduce dietary phosphate
Second line- phosphate binders
What is classification of CKD
1- >90 with signs of kidney damage
2- 60-90 with signs of kidney damage
3a- 45-59
3b- 30-44
4- 15-29
5- 15> eGFR
What investigation do if notice underlying pituitary lesion on MRI
Pituitary blood profile looking for panhypopituitarism
AKI creatinine criteria
Stage 1- 1.5-1.9x baseline or rise in creatinine by over 26
Stage 2- 2.0-2.9x baseline
Stage 3- >3x baseline
When refer an AKI to nephrology
Had renal transplant
Unknown cause of AKI
No response to treatment
Stage 3 AKI
If have stage 4 CKD and above
How differentiate ATN from pre renal cause of AKI
Pre renal
- Urine sodium low
- Urine osmolality high
ATN
- urine osmolality low
- urine sodium high
What happens to urinary sodium and osmolality in ATN
Osmolality low and urine sodium high due to kidney not being able to concentrate urine or retain sodium
What is screening test for autosomal PCKD in family members
Abdo USS not genetic testing
What can be used in management of autosomal PCKD
Tolvaptan- use when eGFR starts to drop
Causes of RAS
90% atherosclerosis
10% fibrous dysplasia
Tetrad of HSP symptoms
Purpura
Arthritis
Abdo pain
Renal disease
What use to monitor HSP
Blood pressure and urinalysis
Most likely cause of microscopic haematuria in women
Menstruation
What renal disease does HIV cause
FSGS
What is first thing need to do if patient with CKD develops anaemia
Ceck iron status if this normal then can start darbapoeitin
If not give IV iron
Causes of rhabdomyolysis
seizure
collapse/coma (e.g. elderly patient collapses at home, found 8 hours later)
ecstasy
crush injury
statins (especially if co-prescribed with clarithromycin)
Management of rhabdomyolysis
IV fluids
Urinary alkalisation
Histology of kidney shows positive IgA and C3
IgA nephropathy
Best way to differentiate between AKI and CKD
Renal USS will show small bilateral kidneys in CKD
How to differentiate between CKD and AKI on blood results
In CKD will only see hypocalcaemia as is a chronic change
What are causes of CKD with large kidneys
ADPCKD
Early diabetic nephropathy
Amyloid
HIV associated nephropathy
Causes of acute interstitial nephritis
penicillin
rifampicin
NSAIDs
allopurinol
furosemide
Infections
Systemic autoimmune conditions
Management of minimal change glomerulonephritis
Prednisolone
How manage bone disease in CKD
First line- reduce dietary phosphate
Second line- phosphate binders, Vit D
Side effects of phosphate binders
Hypercalcaemia
What factors affect eGFR
Eating red meat within 12 hours
Pregnancy
Muscle mass
Which people is eGFR measurements affected by
Amputee and bodybuilders due to their muscle mass
Pregnant women
Hyperacute vs acute vs chronic kidney graft failure
Hyperacute- minutes to hours
Acute- within 6 months
Chronic- over 6 months
Pathology of hyperacute kidney graft failure
Pre formed antibodies to HLA or ABO
Management of hyperacute kidney graft failure
No treatment possible, need to remove kidney
Management of acute kidney graft failure
Steroids and other immunosuppressants
What is most common cause of glomerulonephritis in adults
Membranous glomerulonephritis
Subepithelial deposits causing BM thickening on renal biopsy
Membranous glomerulonephritis
Causes of membranous glomerulonephritis
Anti phospholipase A2 antibodies
Malignancy
Hep B, malaria
Drugs- penicillamine, gold, NSAIDs
How does membranous glomerulonephritis tend to present
Nephrotic syndrome with lots of proteinuria
What drug should all CKD patients be started on
Statinsdue to CVD risk
Patient with cancer develops glomerulonephritis
Membranous glomerulonephritis
What is preferred method of access for haemodialysis
AV fistula
What drug can cause hyaline casts on urine MCS
Loop diuretics
Most common extra renal complication of ADPCKD
Liver cysts
Most likely cause of painless haematuria in elderly person
Bladder cancer
What causes RAS in a young healthy person
Fibrous dysplasia
Which medications would you consider stopping in an AKI due to their increased toxicity
Metformin
Lithium
Digoxin
Differentiating between type 1 and type 2 hepatorenal syndrome
Type 1- rapid onset (within 2 weeks)
Type 2- prolonged onset (above 2 weeks)
What typically precipitates hepatorenal syndrome
Variceal bleeds or refractory ascites
Causes of rapidly progressive glomerulonephritis
Wegners
SLE
Goodpastures
What characterises histology of rapidly progressive glomerulonephritis
Formation of epithelial crescents
What use to manage hepatorenal syndrome first line
Terlipressin
What is most likely cause of death in CKD
IHD
When assessing eGFR, what factors go into equation
CAGE
Creatinine
Age
Gender
Ethnicity
What presents with tea coloured urine
Rhabdomyolysis
Presentation of alport syndrome
Bilateral sensorineural hearing loss
Haematuria
Progressive renal failure
Pathophysiology of alports syndrome
X-linked autosomal dominant condition where defect in type IV collagen leads to abnormal glomerular basement membrane
How long does it take for an AV fistula to develop properly
2 months
What is main cause of CKD bone disease
High phosphate drags calcium out of bones
What is renal dialysis disequillibrium syndrome
When start dialysis can get imbalance in fluid and electrolyres causing cerebral oedema. Typically early in presentation
What causes sudden onset confusion and lethargy in someone who just started dialysis
Renal dialysis disequillibrium syndrome where get cerebral oedema due to imbalances in electrolytes and fluid balance
When refer to nephrologist based off eGFR
If drops below 30
Drops by over 15 a year
What is urinary sodium in ATN vs dehydration
ATN = above 45
Dehydrated= below 20
What is lenticonus
Cone shaped lens seen in alports syndrome
Differentiating stage of AKI by urine output
Stage 1- less than 0.5ml/kg/hr for 6 hours
Stage 2- less than 0.5ml/kg/hr for 12 hours
Stage 3- less than 0.3ml/kg/hr for 24 hours
Management of HUS
Purely supportive in hospital depending on severity of renal impairment
HTN and bilateral masses
PCKD
Management of lupus nephritis
Steroids with mycophenolate or cyclophosphamide
How interpret microscopic haematuria on patient on warfarin
Should be investigated as normal due to similair incidence of micrsocopic haematuria seen compared to general population
What shows splitting of lamina in GBM or basket weave appearance
Alport syndrome
How does renal disease increase risk of thrombosis
Loss of antithrombin III
What drug give hyperphosphataemia in CKD
Sevelamer
Side effects of darbapoeitin
Skin rash
Aches
Flu like illness
Which vitamin D give CKD patients vs general population
CKD- Alfacidiol which is active 1,25- hydroxy vitamin D
Osteomalacia- 25- hydroxy vitamin D
What decreases in blood due to nephrotic syndrome
Antithrombin III, Protein S and C
IgG
Thyroxine binding globulin
What happens to TFTs during nephrotic syndrome
Lowers thyroxine binding globulin levels which affects total thyroxine but not free thyroxine
Primary kidney diseases causing nephrotic syndrome
Minimal change
Membranous glomerulonpehritis
FSGS
Causes of AA amyloidosis in developing countries
Chronic infections- Tb, osteomyelitis
Management of acute tubulointerstitial nephritis
Avoid trigger
Steroids can be used
Which medications are renal protective in CKD
ACEi as reduces perfusion of kidney
SGLT2i as reduces fibrosis of kidney
If ACEi started as renoprotective agent, what is acceptable change in GFR and creatinine
GFR drop of up to 25%
Creatinine rise of 30%
When start ACEi, what will be effect on kidney function
GFR will drop marginally and creatinine will rise as perfusion reduced
Causes of rhabdo
Intense exercise
Seizures
Ecstasy
Statins
Collapse
What are the two main short term complications from dialysis
hypoglycaemia
transient hypotension
2 options for long term haemodialysis
AV fistula
Tunnelled cuffed catheter into subclavian vein
Complications of AV fistula
Aneurysm
Infection
Thrombosis
Stenosis
STEAL syndrome
High-output heart failure
Main 2 complications of tunnelled cuffed catheter dialysis
Infection
Clots
When does CKD require long term dialysis
Stage 5
CKD potential symptoms
Fatigue
Pallor
Foamy urine
Nausea
Loss of appetite
Pruritus
Oedema
Hypertension
Peripheral neuropathy
When give SGLT2i for kidney disease
DM and ACR over 30
General CKD manamement
Atorvastatin 20mg
ACEi and SGLT2i if meet criteria
Dialysis if stage 5
Treat complications
- bone disease
- phosphate
- anaemia
- acidosis
What gets released in rhabdo
K+
CK
Myoglobin- this which is nephrotoxic
What will give false positive haematuria on dipstick
Myoglobin
Complications of rhabdo
DIC
Compartment syndrome
AKI
Complications of PCKD
SAH
Liver cysts
Mitra valve prolapse
HTN
Infected cysts
Complications of nephrotic syndrome
Thrombosis
High cholesterol
Immunodeficiency
Management of membranous glomerulonephritis
Start ARB or ACEi
Steroids and cyclophosphamide
HSP management
Paracetamol
Steroids if nephrotic syndrome, severe abdo pain or testicular involvement
What is c anca
Proteinase 3
What is p anca
Myeloperoxidase
When medically treat hyperkalaemia
Above 6.5
ECG changes
