Renal Flashcards
What are parts of the fluid status examination?
General inspection - oedema, SOB, pallor, anything around the bed
Look in patient notes for fluid chart
Hands - oedema, temperature, radial pulse, capillary refill time
Arms - check BP, Lying and Standing BP, Assess skin turgidity ( pinch skin and see how quick it is to rebound)
Face - mucous membranes, eyes for pallor and sunken
Neck - Check JVP
Abdomen - ascites , shifting dullness
What should you ensure when checking for AKI?
Even if Creatinine is normal look at urine output , use whichever one is higher to stage
What drugs should be withheld in AKI?
Contrast
ACEi
NSAIDs
Diuretics
B-Blokcers
What is shown on ECG in hypokalaemia?
PR Prolongation
Widespread ST depression
T wave flattening
U waves
QT prolongation
Due to AKI due to vomit , what fluid prescription should be given? ( estimated 500ml fluid loss)? He is an 80kg male and has hypokalaemia
Needs 2400ml
Needs 50-100g glucose
Needs 80mmol of Na, Cl and K ( extra K due to hypokalaemia )
1L NaCl 0.9% + 40mmol KCL
1L Dextrose 5% + 40mmol KCl
1L Dextrose 5% + 20mmol KCl
When is renal replacement therapy indicated in AKI?
A - Acidosis
E - Electrolyte abnormalities ( severe and unresponsive hyperkalaemia)
I - Intoxication ( overdose of certai medications such as lithium or metformin)
O - Oedema ( Severe and unresponsive pulmonary oedema )
U - Uraemia symptoms ( Seizures or reduced consciousness)
A 12 year old visits the walk in centre with visible haematuria, what questions would be useful in the history?
Onset
Pain
LUTS
Period History
Systems Review ( Fevers/ infections)
Anemia symptoms
Medications
PHMx
FHx of kidney problems
If she had a sore throat/infection a few weeks ago what would the top differential be?
Post-streptococcal glomerulonephritis?
What is the management for post-streptococcal glomerulonephritis?
Usually self limiting
Can be ACEi/ARBs for proetinuria and HTN
Low sodium diet
What are the differences between Nephrotic Syndrome and Nephritic Syndrome?
Nephrotic - Insiduous onset, Oedema, Proteinuria, Hypoalbuminaemia, Low serum Albumin
Nephritic - Abrupt onset, Haematuria, Hypertension, Raised JVP, Can have proetinuria, Red Blood Cell Casts in urine
If a patient presents with frothy urine what test would you do?
BP
Urine Dipstick
Albumin levels
HbA1C
Clotting
Lipid levels
FBC
Why do patients with low serum Albumin present with oedema?
As protein is lost in the urine, reduced colloid oncotic pressure which causes fluid to leave vessels into the interstitium
Why do patients with CKD present with low clotting factors?
Clotting factors are a type of protein that are lost in the urine
Why do patients with CKD present with anemia?
EPO Insufficiency due to poor synthetic function of the kidneys
Why might a patient with CKD present with back pain?
Rugger-Jersey Spine ( Renal Osteodystrophy ) -> Appears opaque/sclerosis on xray (excess osteoid )
Kidneys produce Calcitriol , reduced production leads to hyperparathyroidism which causes decreased absorption of dietary calcium which causes increased serum Ca2+
What are the signs of hypercalcaemia?
Moans - depression, confusion
Bones - osteolysis, fractures
Stones - renal stones
Abdo groans - Anorexia, N+V, Constipation, Pancreatitis
Lethargy
Hyporeflexia
Muscle weakness
What are signs of hypocalcaemia?
Tetany/muscle cramps
Peri-oral numbness
Peripheral paresthesia
Irritability
Seizure/collapse
Chvostek sign
Trosseau sign
Prolonged QT Interval
Hypotension
What are fundoscopy findings in Diabetic Retinopathy?
Cotten wool spots
Blot haemorrhage
Hard exudates
Neovascularisation
What should diabetics be started on if there HbA1c is above 58mmol/L?
Lifestyle advice - Weight loss, Smoking cessation, Diet
Dual therapy - Metformin + SGLT2 Inhibitor
What medication has can cause a decrease in Creatinine clearance?
Trimethoprim
It competitively inhibits the mechanism for tubular secretion of creatinine
What imaging investigation is important to in AKI to rule our obstructive causes?
Renal US
What does Acute Interstitial Nephritis happen due to?
Typically results from hypersensitivity reactions to certain medications, which are not mediated by direct toxicity
Or SLE
Which drugs can cause Acute Interstitial Nephrits?
Antibiotics, such as β-lactams, cephalosporins, and fluoroquinolones
Non-steroidal anti-inflammatory drugs (NSAIDs)
Diuretics
Rifampicin
Allopurinol
Proton-pump inhibitors (PPIs)
What is the most common cause of intrinsic AKI?
Acute Tubular Necrosis
What are the causes of Acute Tubular Necrosis?
Ischemic Causes
Nephrotoxic Causes
What are some ischaemic causes of Acute Tubular Necrosis?
Hypotension
Shock ( haemorrhagic, cardiogenic, septic)
Post-MI
Direct vascular injury ( trauma, surgery)
What are the nephrotoxic causes of Acute Tubular Necrosis?
Drugs such as:
Aminoglycoside antibiotics (e.g., gentamicin)
Antifungals (e.g., amphotericin)
Chemotherapy agents (e.g., cisplatin)
Antivirals (e.g., tenofovir)
NSAIDs
Contrast
Myoglobin (as seen in rhabdomyolysis)
Haemoglobin (as seen in haemolysis)
Uric acid (as seen in tumour lysis syndrome)
What are causes of acute urinary retention?
Luminal - kidney stone, blood clot, tumour, UTI
Mural - stricture, NM dysfunction
Extra-mural - abdominal/pelvic masses, retroperitoneal fibrosis
Neurological - CES, MS
Infectious diseases
Anticholinergic medications ( Amitriptyline, Duloxetine, Diphenhydramine, Oxybutynin, Olanzapine)
Post-operative
Constipation
What test would be useful to do in a patient who has not passed urine in a while ?
Bladder scan - assess if catheterization is needed
What organisms can cause Haemolytic Uraemic Syndrome?
E.Coli
Shigella
Streptococcus Pneumoniae
Release the shigella toxin
What is the triad of Haemolytic Uraemic Syndrome?
Microangiopathic haemolytic anaemia (MAHA)
Thrombocytopenia
AKI
Blood clots block the small vessels of the kidneys
What genes are associated with ADPKD?
PKD1 gene on chromosome 16 ( Majority)
PKD2 gene on chromosome 4
Refractory hyperkalaemia, Severe intractable metabolic acidosis
Intractable fluid overload Pulmonary oedema, Presence of uraemic complications such as pericarditis, encephalopathy and seizures
What is the most common cause of CKD?
Diabetic nephropathy
How would you describe the RBCs in anaemia of CKD?
Normocytic
Normochromic
When are ACEi offered to patients with chronic kidney disease?
ACEi prevent proteinuria, so can help with oedema
CKD plus Diabetes - Urine ACR >3
CKD plus HTN - Urine ACR >30
CKD no DM/HTN - Urine ACR >70
A rise in Creatinine over what timeframe would meet the criteria for an AKI?
More than 25micromol/L in 48 hours
More than 50% in 7 days
Creatinine should be excreted, as it is a waste product, so a rise indicates the kidney is not working effectively
What is the most common cancer in immunosuppressed patients ( e.g patients with renal transplant)
Skin cancer
What symptoms does Alport’s Syndrome present with?
Glomerulonephritis ( Nephritic)
Hearing loss
Vision abnormalities
What infections are more likely in immunosuppressed patients?
CMV
TB
Aspergillus
PIP
Viral infections (VZV, HSV, EBV )
Glomerulonephritis post infection causes?
Days after - IgA Nephropathy
1-2 weeks after - Post-Streptococcal GN
What are indicators of bad prognosis in IgA Nephropathy?
Microscopic Haematuria ( presents later in course of disease)
Hypertension
What antibodies will be raised after streptococcal infection, indicative of PSGN ?
Raised Antistreptolysin O Titer (ASOT)
What is the gold standard for diagnosing IgA nephropathy?
Renal biopsy - shows IgA deposition and mesangial proliferation
What are the presenting symptoms of minimal change disease and the treatment?
Frothy urine
Oedema ( Periorbital and ankle)
treated with Steroids
What is the classic presentation of Goodpasture’s?
Haemoptysis
Haematuria
Anti-GBM is present in both lungs and kidneys
What is the gold standard for diagnosis or all nephrotic syndrome?
Renal biopsy
It is worth noting that a renal biopsy is not always required (for example, in young children presenting with minimal change disease) or if there is a high risk of bleeding
What would be the expected histological finding on renal biopsy in PSGN?
Subepithelial humps in the glomeruli
What would be the expected histological finding on renal biopsy in IgA Nephropathy?
IgA and C3 deposits in sub-endothelium of glomerulus
What would be the expected histological finding on renal biopsy in Goodpasture’s?
Linear deposition of antibodies along the glomerular basement membrane
What would be the expected histological finding in Minimal change disease?
Effacement of podocyte foot processes - only seen on electron microscope
What would be the expected histological finding in Rapidly progressive glomerulonephritis?
Epithelial crescents in the glomeruli
When does acute graft rejection take place?
FIrst few months of renal transplant
Pain around site
Fever
Declining renal function
When does Chronic graft rejection take place?
More than 6 months post-transplant
What are some immunosuppressive medications for renal transplant and their side effects?
Tacrolimus - tremor
Ciclosporin - gingival hypertrophy
Mycophenolate mofetil - GI upset
What are the causes of Type 1 renal acidosis?
Autoimmune disorders: Sjögren’s, SLE, rheumatoid arthritis
Drug-induced: analgesic nephropathy, lithium
Nephrocalcinosis
Chronic tubulointerstitial nephritis (TIN)
Renal stone association!!
What are the causes for Type 2 renal tubular acidosis?
Fanconi syndrome
Myeloma
Amyloidosis
Heavy metal toxicity: lead, cadmium
What are some causes of Renal Tubular Acidosis Type 4?
Diabetes
Drugs, e.g., NSAIDs
Obstructive uropathy
Addison’s disease
Chronic TIN
What do the kidneys look like on renal US in CKD?
Bilaterally shrunken - helps differentiate from AKI
What is the best treatment for Hydronephrosis?
If small - Urgent cystoscopy with JJ stent insertion
If >2cm or staghorn - Percutaneous Nephrostomy
What is the treatment for renal stones?
Analgesia - IM/PR Diclofenac
<5mm = Watchful waiting
<2cm = ESWL or Ureteroscopy ( if pregnant or distal/middle ureteric stone)
>2cm or complex e.g Staghorn/Cysteine stones = Percutaneous nephrolithotomy
What can be used to prevent recurrence of renal stones?
Calcium based - Indapamide
Urate - Allopurinol
Keep hydrated
Avoidd lots of Vitamin C or calcium supplements
Reduce salt intake
What organisms can cause bacterial peritonitis due to peritoneal dialysis?
Skin commensals-
Staphylococcus Epidermidis = MOST COMMON
also Staph Aureus
If you started a patient on an ACEi , what rise in Creatinine from baseline should prompt you to stop it?
> 30% in 2 weeks
Could cause an AKI
Why does CKD cause low Vitamin D?
Reduced alpha hydroxylase 1 expression . This means the active form of Vitamin D cannot be made.
What is the likelihood of a sibling being a HLA match?
25%
What is the treatment for Lupus Nephritis
Cyclophosphamide and methylprednisolone
Which type of dialysis is dependent on the patient having some residual renal function?
Peritoneal
Which immunosuppressant drug given for Renal transplant has a long-term side effect of direct nephrotoxicity?
Ciclosporin
What are some uraemic pathologies? ( indications for dialysis in AKI)
Encephalopathy
Pericarditis
What is a commonly forgotten way to stage an stage 3 AKI?
Increase in creatinine to ≥353.6 µmol/L
Even if it is not 3x baseline, this is still a stage 3 AKI
What is the treatment for severe hyperkalemia? (>6.6.5)
Calcium Gluconate
Insulin/Dextrose
What ABG result does diarrhoea cause?
normal anion gap acidosis
What U&E result does vomiting cause?
hypochloremia
hypokalemia
metabolic acidosis
WHat do the kidneys look like in US in Diabetic Nephropathy and CKD?
Chronic diabetic nephropathy will have large/normal sized kidneys on ultrasound whereas most patients with chronic kidney disease have bilateral small kidneys
Why are patients with Nephrotic syndrome in a hypercoagulable state?
Loss of antithrombin III ( destroys clotting factor) and plasminogen
What is a normal ion gap?
10-18 mmol/L
Which test indicated pre-renal AKI?
Raised serum urea:creatinine ratio
