Renal

Question 1

What medication is indicated in CKD?

Answer 1

ACEi due to following mechanism:

ACE inhibition -> decreased ATII -> efferent arteriole dilation and fall in intraglomerular capillary pressure -> decreased filtration of protein -> decreased proteinuria

*Particularly useful in patients who also have diabetes and hypertension

Question 2

What is acute interstitial nephritis?

Answer 2

Marked interstitial oedema and interstitial infiltrate in the connective tissue between renal tubules

Causes:
* Drugs (most common cause, particularly antibiotics): penicillin, rifampicin, NSAIDs, allopurinol, furosemide
* Systemic disease: SLE, sarcoidosis, and Sjögren’s syndrome
* Infection: Hanta virus , staphylococci

Features:
* fever, rash, arthralgia
* eosinophilia
* mild renal impairment
* hypertension

Question 3

What is the typical presentation of IgA nephropathy?

Answer 3

Nephritic syndrome, usually presenting a couple of days following an upper respiratory tract infection

Question 4

What is the typical presentation of post-streptococcal glomerulonephritis?

Answer 4

Oliguria, visible haematuria, proteinuria and hypertension two weeks following a febrile illness.

Typically this happens 7-14 days following a group A beta-hemolytic Streptococcus infection, usually described as a sore throat.

Question 5

What is done to screen for diabetic nephropathy?

Answer 5

Urinary albumin:creatinine ratio (ACR)
Should be an early morning specimen
ACR > 2.5 = microalbuminuria

Question 6

What is the management of diabetic nephropathy?

Answer 6

• Dietary protein restriction
• Tight glycaemic control
• BP control: aim for < 130/80 mmHg
• ACE inhibitor or angiotensin-II receptor antagonist - should be started if urinary ACR of 3 mg/mmol or more (do not do dual therapy)
• Control dyslipidaemia e.g. Statins

Question 7

What is the unit volume per unit weight per day of recommended maintenance fluid volume?

Answer 7

25-30 ml/kg/day of water

Question 8

How should you treat anaemia in CKD?

Answer 8

Correct iron deficiency before starting erythropoiesis-stimulating agents

Question 9

What is the criteria for diagnosing an AKI?

Answer 9

• Rise in creatinine of 26µmol/L or more in 48 hours OR
• > = 50% rise in creatinine over 7 days OR
• Fall in urine output to < 0.5ml/kg/hour for more than 6 hours in adults (8 hours in children) OR
• > = 25% fall in eGFR in children / young adults in 7 days.

Question 10

What ECG change can uraemia cause?

Answer 10

Widespread PR depression and ST elevation - pericarditis is a manifestation of uraemia

Question 11

What features suggest CKD over AKI?

Answer 11

Hypocalcaemia (due to lack of vitamin D) is seen in CKD

Most patients with CKD have bilateral small kidneys, with exceptions of:
* autosomal dominant polycystic kidney disease
* diabetic nephropathy (early stages)
* amyloidosis
* HIV-associated nephropathy

Question 12

What are the side effects of lithium?

Answer 12

LITHIUM

Leucocytosis
Insipidus (nephrogenic)
Tremor
Hypothyroidism
Increase Urine
Mothers (teratogenic)

Others: GI upset, weight gain, T-wave inversion, eyebrow hair loss

Question 13

What electrolyte imbalance does renal tubular acidosis cause?

Answer 13

Hyperchloraemic, normal anion gap metabolic acidosis

Question 14

Deficiency in what protein causes a hypercoagulable state in nephrotic syndrome?

Answer 14

Antithrombin III

Question 15

In which condition do you see muddy brown casts?

Answer 15

Acute tubular necrosis which is commonly caused by ischaemia or toxins

Question 16

What are features of anti-GBM disease?

Answer 16

Previously known as Goodpasture’s syndrome (autoimmune condition against type IV collagen)

• pulmonary haemorrhage
• rapidly progressive glomerulonephritis - proteinuria + haematuria

*Type IV collagen is found in both the lungs and kidneys

Question 17

What is the most common extra-renal manifestation of ADPKD?

Answer 17

Liver cysts (70%) may cause hepatomegaly

*Berry aneurysms (only 8%) - can cause SAH

Question 18

What urine sample results would you expect in acute tubular necrosis?

Answer 18

Raised urinary sodium with low urine osmolality - inability to retain sodium or concentrate urine

Raised fractional sodium excretion

Brown muddy granular casts

Question 19

What is the diagnostic criteria for AKI?

Answer 19

• Rise in creatinine of 26µmol/L or more in 48 hours OR
• > = 50% rise in creatinine over 7 days OR
• Fall in urine output to < 0.5ml/kg/hour for more than 6 hours in adults (8 hours in children) OR
• > = 25% fall in eGFR in children / young adults in 7 days.

Question 20

In HSP, what is monitored to detect progressive renal involvement post-discharge?

Answer 20

Blood pressure
Urinalysis