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Integrated Med > Renal > Flashcards

Renal Flashcards

1
Q

Incidence of AKI

A

10-20% hospital admissions
20-30% cardiac surgery patients.
50% ICU admissions

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2
Q

KDIGO stage 1 (AKI)

A

Serum Cr: 1.5-1.9 x baseline or >26.5 umol/L within 48h
Urine output: <0.5ml/kg/h for 6-12h

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3
Q

KDIGO stage 1 (AKI)

A

Serum Cr: 1.5-1.9 x baseline or >26.5 umol/L within 48h
Urine output: <0.5ml/kg/h for 6-12h

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4
Q

KDIGO stage 2 (AKI)

A

Serum Cr: 2-2.9 x baseline
Urine output: <0.5ml/kg/h for >12h

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5
Q

KDIGO stage 3 (AKI)

A

Serum Cr: >3 x baseline or > 353 umol or requiring renal replacement therapy
Urine output: <0.3ml/kg/h for >24h or anuric for >12h

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6
Q

Causes of pre renal AKI

A

Volume depletion: blood loss / dehydration / burns
Reduced BP: shock / medications
Reduced vascular perfusion: renal artery stenosis
Renal vasoconstriction: ACEi / NSAIDs

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7
Q

Urine dip and osmolality of pre renal AKI

A

No blood / no protein
Osmolality: can retain Na to concentrate urine = urine osm high, urine Na low

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8
Q

General symptoms of AKI

A

Oliguria / anuria
Abdo pain
Dizziness / headache
Nausea / vomiting

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9
Q

Symptoms of pre renal AKI

A

Signs of dehydration
Signs of shock

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10
Q

Management of AKI

A
  1. ABCDE
  2. Stop nephrotoxic drugs
  3. Assess and manage fluid status
  4. Assess and manage electrolyte imbalances
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11
Q

Management of pre renal AKI

A

Volume replacement (IV fluids) if volume depletion

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12
Q

Management of intra renal AKI

A

Consider fluid restriction and loop diuretic if overloaded

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13
Q

Management of post renal AKI

A

Consider urine drainage / catheter
Refer to urology

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14
Q

Risk factors for AKI

A

Underlying conditions: CKD, heart failure, liver disease, DM, cognitive impairment
Acute conditions: sepsis, cardiac surgery
Medications: ACEi, NSAIDs, PPIs, gentamicin, ciprofloxacin, allopurinol, penicillins, lithium, contrast medium
Dehydration: elderly, NBM

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15
Q

Complications of AKI

A

Hyperkalaemia
Fluid overload
Pulmonary oedema
Metabolic acidosis
Uraemia

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16
Q

Indications for dialysis

A

Life threatening, refractory AKI with complications

Severe hyperkalaemia / acidaemia / uraemia

Refractory pulmonary oedema

Toxins / drugs

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17
Q

Symptoms of severe hyperkalaemia

A

Chest pain
Palpitations
Dizziness

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18
Q

Management of severe hyperkalaemia

A
  1. 10ml 10% calcium gluconate = stabilise myocardium
  2. IV insulin +25g glucose = drive potassium into cells
  3. Salbutamol nebs = drive potassium into cells
  4. 1.4% sodium bicarbonate = correct acidosis
  5. Treat cause
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19
Q

Define chronic kidney disease

A

Progressive and irreversible deterioration of renal function >3m

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20
Q

Signs and symptoms of chronic kidney disease

A

Anaemia
Bone disease
Hyperkalaemia
Fluid overload
Early uraemia
Late uraemia
Metabolic acidosis

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21
Q

Classification system used for CKD needing RRT

A

Persistent albuminuria:
A1= <3mg/mmol
A2 = 3-30mg/mmol
A3= >30mg/mmol

GFR:
G1= >90
G5 = <15

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22
Q

How does diabetes reduce GFR

A

Glycation of efferent arteriole = increased pressure and sclerosis

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23
Q

How does diabetes reduce GFR

A

Glycation of efferent arteriole = increased pressure and sclerosis

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24
Q

How does HTN reduce GFR

A

Thickened walls of afferent arteriole = hypoperfusion

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25
Q

How does chronic glomerulonephritis cause reduced GFR

A

Inflammation and damage to vessels

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26
Q

How does chronic pyelonephritis cause reduced GFR

A

Urinary reflux or recurrent infection

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27
Q

How does obstructive uropahty cause reduced GFR

A

Back up of pressure = hydronephrosis and damage
-> neurogenic bladder, BPH, malignancy, stones

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28
Q

How does Polycystic kidney disease cause reduced GFR

A

Auto dominant form presents in adults
Fluid filled cysts press on nephrons = atrophy
Causes back pain, headaches and haematuria

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29
Q

Risk factors for CKD decline

A

HTN
DM
Smoking
Infection
NSAIDs / ACEis

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30
Q

Management of CKD

A

Risk reduction of CVD

Treat / manage complications : anaemia / bone disease / oedema

Manage medications

Refer to nephrology if GFR <30

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31
Q

What is the difference between haemodialysis and peritoneal dialysis

A

Haemo: blood pumped out of the body through ‘artificial kidney’

Peritoneal: dialysate solution infused into peritoneal cavity (peritoneum acts as filtering membrane )

32
Q

Complications of haemodialysis

A

Site infection
Hypotension
Air embolus
N&V
Endocarditis

33
Q

Complications of peritoneal dialysis

A

Peritonitis
Catheter problems
Hernia
Fluid retention
Weight gain

34
Q

Freq of haemodialysis

A

3x4h sessions each week

35
Q

Freq of peritoneal dialysis

A

Continuous ambulatory = 4x20min each day while active

Automated = overnight 3-5 exchanges over 8-10h

36
Q

Criteria for suitability of kidney transplant

A

Generally fit for GA
At least 5y left to live
No malignancy
No other significant comorbidities
Good vascular supply to legs

37
Q

Describe process of kidney transplant

A

Transplant placed in iliac fossa and anastomoses of vessels made

Usually leave native kidney in place

38
Q

Post kidney transplant treatment

A

Lifelong immunosuppression = tacrolimus or ciclosporin plus azathioprine

6m of steroids to prevent acute rejection eg prednisolone

Aspirin, antihypertensives, PPI, bone protection

39
Q

Immediate complications of kidney transplant

A

Graft thrombosis
Ureteric leak / obstruction
Bleeding
Rejection

40
Q

3-6m post transplant complications of kidney transplant

A

Rejection
HTN
Ileus
Infection (urinary or resp)

41
Q

Long term complications of kidney transplant

A

Cancer
Interstitial fibrosis (secondary to ciclosporin / tacrolimus)
Cardiac disease
Infections

42
Q

Treatment of transplant rejection

A

IV methylprednisolone and increase immunosuppressants

43
Q

Why is nephrotic syndrome

A

Inflammed BM allows passage of proteins into nephron

44
Q

Triad of findings in nephrotic syndrome

A
  1. Heavy proteinuria
  2. Hypoalbunimaemia
  3. Oedema - periorbital, legs, scrotal, vaginal
45
Q

Clinical manifestations in nephrotic syndrome

A

Peripheral and periorbital oedema (loss of albumin)
Pleural effusion (loss of albumin)
Hyperlipidaemia (loss of liporegulatory proteins)
Hypercoagulability
Infections (loss of immunoglobulins)

46
Q

Primary causes of nephrotic syndrome

A
  1. Minimal change disease
  2. Focal segmental glomerulonephritis
  3. Membranous glomerulonephritis
47
Q

Secondary causes of nephrotic syndrome (damage due to underlying disease)

A
  1. Diabetic nephropathy
  2. SLE
  3. Infection : hep B /C, HIV, malaria, syphilis
  4. Drugs: penicillamine, gold, NSAIDs, iron
  5. Amyloidosis
  6. Myeloma
  7. Pre eclampsia
48
Q

Management of nephrotic syndrome

A
  1. Reduce oedema : loop diuretics + fluid and salt reduction
  2. Reduce proteinuria : ACEis / ARBs
  3. Treat underlying cause : corticosteroids indicated in minimal change disease
49
Q

Pathogenesis of nephritic syndrome

A

Inflammation damages glomerular capillary so RBCs leak into nephron

Inflammation damages podocytes allowing protein to leak into nephron

Inflammation causes reduced GFR leading to oliguria and HTN

50
Q

Triad of findings in nephritic syndrome

A
  1. Haematuria
  2. Oliguria
  3. Proteinuria
51
Q

Clinical manifestation of nephritic syndrome

A

Volume overload / reduced GFR
- oedema
- hypertension -> seizures

52
Q

Clinical manifestation of nephritic syndrome

A

Volume overload / reduced GFR
- oedema
- hypertension -> seizures

53
Q

Causes of nephritic syndrome

A
  1. Autoantigens (goodpastures disease): anti BM antibodies
  2. ANCA-associated
  3. Immune complexes
54
Q

Causes of nephritic syndrome

A
  1. Autoantigens (goodpastures disease): anti BM antibodies
  2. ANCA-associated
  3. Immune complexes
55
Q

Management of nephritic syndrome

A
  1. Goodpastures disease : plasmapheresis, corticosteroids, cyclophosphamide
  2. ANCA-associated vasculitis : induce remission with corticosteroids and cyclophosphamide -> maintain with azathioprine
  3. IgA nephropathy / post strep infection : ACEi/ARB
56
Q

Symptoms of upper UTI (pyelonephritis)

A

Dysuria
Frequency / urgency
Flank / loin pain
High grade fever, N&V
+/- haematuria

57
Q

Symptoms of lower UTI (cystitis)

A

Dysuria
Frequency / urgency
Suprapubic pain
Foul smelling cloudy urine

58
Q

Complications of upper UTI (pyelonephritis)

A

Sepsis
AKI
Perinephric abscess
Renal papillary necrosis

59
Q

Complications of cystitis (lower UTI)

A

Elderly : confusion +/- incontinence
Young: vague, irritable, poor feeding

60
Q

Investigations for UTI

A
  1. Urine dip : leukocytes, nitrites
  2. MSU for MCS: confirm Dx
  3. Bloods: FBC, CRP / ESR, U&Es, culture
  4. USS KUB
61
Q

Management of upper UTI (pyelonephritis)

A
  1. Admit
  2. Analgesia
  3. IV abx (ciprofloxacine or cefuroxime)
62
Q

Management of lower UTI (cystitis)

A
  1. Lifestyle : hydration, personal hygiene
  2. Analgesia : NSAIDs, paracetamol
  3. ABX (men 7d course, women 3d course)
63
Q

Kidney causes of haematuria

A

UTI
Stones
Trauma
Cancer (RCC or TCC)

64
Q

Ureter causes of haematuria

A

Cancer (TCC)
Stones

65
Q

Bladder causes of haematuria

A

UTI
Stones
Trauma
Cancer (TCC)
Iatrogenic (catheter)

66
Q

Bladder causes of haematuria

A

UTI
Stones
Trauma
Cancer (TCC)
Iatrogenic (catheter)

67
Q

Prostate causes of haematuria

A

BPH
Adenocarcinoma

68
Q

Urethral causes of haematuria

A

Cancer
Trauma

69
Q

Investigations for haematuria

A
  1. Hx and exam : remember DRE
  2. Urinalysis : dip and MSU
  3. Bloods: FBC, clotting, U&Es, PSA
  4. Renal USS
  5. Flexible cystoscopy : show bladder / urethral abnormalities
  6. CT KUB : gold standard
70
Q

Mode of action of spironolactone

A

Aldosterone antagonist which acts in the cortical collecting duct

71
Q

Indications for spironolactone use

A

Ascites
HTN
Heart failure
Nephrotic syndrome
Conn’s syndrome

72
Q

Adverse effects of spironolactone

A

Hyperkalaemia
Gynaecomastia

73
Q

Medications that are safe to continue in AKI

A

Paracetamol
Warfarin
Statins
Aspirin
Clopidogrel
Beta blockers

74
Q

When should patients with CKD be given an ACEi

A

If they have an ACR >30

75
Q

Causes of acute interstitial nephritis

A

Penicillin
Rifampicin
NSAID
Allopurinol
Furosemide

76
Q

What is important to do before starting EPO therapy in anaemia secondary to CKD

A

Check ferritin levels
Adequate iron levels is crucial for efficacy of EPO therapy

Integrated Med (6 decks)

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