Renal Flashcards
How do thiazide diuretics work
Block the sodium chloride renal symporter
Another name for necrotising glomerulonephritisi
Eosinophilic granulomatosis with polyangitis
Pathology IgA nephropathy
IgA deposits build up in the kidneys, causing inflammation and damage in the kidneys
Triggers glomerular inflammation and scarring
Most common cause of GN
IgA nephropathy
Presentation IgA nephropathy
Haematuria
URTI
Gastroenteritis
Acute or chronic renal failure may develop
HTN (rare)
Oedema (rare)
Diagnosis of IgA nephropathy
Renal biopsy; Focal or diffuse mesangial proliferation as well as extracellular matrix expansion
Immunofluorescent tests; diffuse mesangial IgA deposition
Treatment of IgA neprhopathy
ACEI if HTN/Proteinuria present
Steriods
What is assosiated with poorer prognosis in IgA neprhopathy
HTN
Granulomastosis with polyangitis (GPA) affects what sized vessels
small to medium
What does GPA most commonly affect
Kidneys
Lungs
Symptoms of GPA
Cough
Haemoptysis
Haematuria
Proteinuria
Nasal obstruction
Epistaxis
Rhinitis
Saddle nose deformity
Subglottic stenosis
Fever
Weight loss
Myalgia
Skin involvement
Eye involvement
GI Sx
Neurological Sx
Diagnosis of GPA
c-ANCAs
Biopsy showing necrotising granulomas and vasculitis
Treatment of GPA
Steriods
Cyclophosphamide
Features of nephrotic syndrome
Massive proteinuria >3/5g/day
Oedema
Hypoalbuminuria
Increased tendency for hyperlipidaemia, thrombosis and infection
Features of nephritic syndrome
Haematuria
Oliguria
Oedema
Proteinuria < 3.5g/day
HTN
Uraemic symptoms
Uraemic symptoms
Anorexia
Puritius
Lethargy
Nausea
What is the way to determine protein excretion
early morning albumin creatinine ACR ratio
Feautres of type 1 mesangiocapillary glomerulonephritis (MCGN)
Tramline appearance on biopsy
Haematuria
Proteinuria
Nephrotic syndrome
Frank kidney disease
Reduced plasma levels of C3, C4
Can be assosiated with Hep B / C
Features of type 2 mesangiocapillary glomerulonephritis (MCGN)
Can occur idiopathically or after measles infection
Cells stain positive for C3
Partial lipodystrophy
Urine findings of FSGS
Protein
Hyaline
Broad, waxy casts
Renal biopsy findings of crescentric GN
Extensive crescents
Features of eosinophilic granulomatosis with polyangitis
Asthma
Blood eosinophilia >10%
Vasculitic neuropathy
Pulmonary infiltrates
Sinus disease
Extravasculareosoinophils on biopsy findings
WHat is goodpasture syndrome
An autoimmune disease where antibodies are produced against the glomerular basement membrane and the alveolar basement membrane
Goodpastures involves
GN
Pulomonary renal syndrome
Pulmonary invovlement more common when environmental triggers
- smoking
- inhalation of cocaine
- respiratory ifnection
- exposure to hydrocarbons
Assosiations of goodpastures
HLA-DR15
HLA-DRB1
Presentation of goodpastures
Haematuria
Frothy urine/proteinuria
Decreased UO
Peripheral oedema
Haemoptysis
Dyspnoea
What differentiates goodpastures from other diseases that cause both pulmonary and renal invovlement
anti-GBM antibodies
Treatment of goodpastures
Plasma exchange
Prednisolone
Cyclophosphamide
ESR in goodpastures
Normal
Renal biopsy in goodpastures
Crescenteric glomerulonephritis
Linear deposition of complement (C3) and IgG along the basement membrane
Features of HIV assosiated nephropathy
Focal segemental glomeruloneprhtisi with a collapsed glomerular tuft
Microcystic tubular dilatation
Treatment of minimal change disease with frequent relapses
High dose steriods
Cyclophosphamide
What do recurrent UTIs, including in childhood, may indicate ?
Chronic reflux nephropathy
What may chronic reflux nephropathy lead to?
Difficult to treat HTN
Investigation for chronic reflux nephropathy
Excretion urography testing
Blood and urinary findings of acute tubular necrosis
Na > 40
Urinary osmolality <350
Causes of acute tubular necrosis
Hypotension
Nephrotoxins
Renal hypoperfusion
Pathophysiology of ATN
Ischaemia
Results in injury of tubular cells, most prominently in the straight position of the proximal tubules and the thick ascending loop of Henle
Cell death results in cast formation
Casts and debris obstruct tubules in multiple nephrons further reducing renal function due to reduced filtration
Ischaemia also reduces the production of vasodilators (NO and prostacyclin) causing vasoconstriction and hypoperfusion
Treatment of AVN
Supportive
Genetics of ADPKD
Mutation in PKD1 gene (85%)
(abscence of functioning of polycystin)
Others defect in PKD2
What antibodies are seen in sjrogrens syndrome
Ro and La autoantibodies
Investigation of renal artery stenosis
Magnetic resonance angiography
What can happen if you have an untreated UTI in patients with diabetes
Renal papillary necrosis, which results in linear breaks at the papillary base, and ureteric obstruction may reults if the papillae have sloguhed off
Features of alport syndrome
Chronic renal failure
- gross haematuria
- proteinuria
- peripheral oedema
Sensorineural hearing loss
Lenticonus
Fatigue
SOB
HTN
INHERITED
- FH of microscopic haematuria in a first degree relative
Features of allergic interstitial nephritis
Eosinophillia
Haematuria
Pyuria
Diffuse maculopapular rash
Fever
Can occur 2 weeks after causative drug
Treatment of allergic interstitial nephritis
Discontinue causative agent
IVF
What is adynamic bone disease and what is it caused by
Can be caused by overtreatment with alfacalcidol
Most prevalent in diabetic patients and those on peritoneal dialysis
Assosiated with increased risk of hip fractures
Tendency towards hypercalcaemia as the bone loses its capacity to buffer serum calcium
Histology of adynamic bone disease
Reduction in both bone formation and resorption
Thin osteoid seams
Little active mineralisation
Few osteoclasts
Calcium, phosphate and PTH levels in osteoporosis
Normal
What is osteitits fibrosa cystica assosiated with
Hyperparathyroidism
What points towards nephrotic syndroem
Low albumin
Abnormal cholesterol
Increased urinary albumin excretion
What is the most common cause of nephrotic syndrome in the older age group
Membranous nephropathy
What symptom needs to be present for a diagnosis of nephrtitc syndrome
Haematuria
What is buergers disease
Accelerated thrombosis of medium and small vessles
Predominately in the lower limbs
Presents with rapidly worsening claudication in heavy smokers
What would make you think of a cholesterol embolism
Recent arterial instrumentation
Marked eosinophilia
Increasing creatinine
WHen would CMV reactivation after transplabntation from a previously infected donor occur and treatment
4-6 weeks after surgery
Minor infection - valaciclovir or valganciclovir
Severe infection - ganciclovir
WHat are bartter and Gitelam syndromes
Renal tubular salt wasting disorders in which the kidneys cannot reabsorb chloride in the thick ascending limb of the loop of Henle, or the distal convoluted tubule, depending on the mutation
Time frame of acute graft rejection
First 4 weeks
Time frame of delayed graft reaction
> 3 months
Most common causes of acute interstitial nephritis
NSAIDs
Penicillin
Sulfa containing drugs
What is the most common cause of acute interstitial nephritis (in broad terms)
Immunologically induced hypersensitivity reaction to an antigen, usually a drug or infectious agent
What would cast nephropathy indicate
Myeloma
What does IgA nephropathy have a close relationship to
URTIs
Pathology of type I RTA
DISTAL RTA
A-intercalated cells in the distal and collecting tubules fail to secrete H and absorb K
Features of type I RTA
Can be assosiated with DI and salt wasting states
Severe metabolic acidosis and hypokalaemia
Urinary tract calculi (2ndry to the severe acidosis)
GFR often unaffected
COMMON
Pathology of type II RTA
PROXIMAL RTA
Proximal tubule cells fail to reabsorb bicarbonate
Features of type II RTA
Potassium normal or low
Metabolic acidosis (less severe)
GFR often unaffected
assosiated with osteomalacia and rickets
RELATIVELY UNCOMMON
Pathology of Type III RTA
Shares features of both type I and II
- impaired proximal bicarbonate resorption and impaired distal acidification
Features of type III RTA
Rare variant
Acidosis
Biochemical abnormalities will depend on whether the distal or proximal tubule is predominant
Pathology of Type 4 RTA
Kidney either resistant to aldosterone or the plasma aldosterone levels are low
Features of type 4 RTA
Hyperkalaemia
CKD usually present
Commonly due to mineralocorticoid deficiency
Management of renal tubular diseases
Correction of electrolyte disturbances and pathological sequalae
Usually oral bicarbonate and potassium replacement therapy
What is liddles syndrome
Pseudohyperaldosteronism - hypokalaemic metabolic alkalosis with HTN and volume overload, despite normal or low aldosterone level
Lung biopsy of goodpastures
Disruption of alveolar septa
Haemosiderin laden macrophages
Assosiations of membranous nephropathy
SLE
Bowel and lung malignancies
Penicillamine therapy
Hep B infection
Plasmodium malariae
Assosiation with HLA DR3
What is common in 40% of patients with nephrotic syndrome
Renal vein thrombosis
Most common causative organism of peritoneal dialysis peritonitis
Staph A or epidermis
Treatment of common cause of peritoneal dialysis peritonitis
Vancomycin
Blood findings of minimal change nephropathy
Normal high density lipoprotein cholesterol levels
Elevated low density lipoprotein cholesterol concentrations
Commonest cause of death in renal dialysis patients
CV disease
Causes of amyloid
Myeloma
Hereditary forms of amyloidosis
Chronic disease e.g. RA
What can renal amyloidosis precipitate
Nephrotic syndrome
Which diuretic causes the greatest retention of lithium
Thiazide diuretics
Inheritance of fabry disease
X linked
Features of fabry disease
Corneal microscopic lipid deposits
Maltese cross lipid globules in urine microscopy
Skin angiokeratomas
Decreased sweating
Leg lymphodema
Peripheral neuropathy
Cardiac conduction defects
Premature CV disease
Pathology of fabry disease
X linked lysosomal storage disorder
Characterised by myelin deposits in the tubular and vascular epithelium, resulting in ischaemic nephropathy
IgA nephropathy vs post strep glomerulonephritis
IGA nephropathy - frank haematuria 24-48 hours following onset of symptoms of resp tract infection. Normotensive, only a trace of proteinuria. Can also be triggered by UTI and gastroenteritis
Post strep glomerulonephritis - following group A strep infections, symptoms begin around 10 days post strep infection and frank haematuria can be seen
Different types of lupus related renal disease
Class I - Minimal mesangial lupus nephritis - normal crt and urinarylysis, minimal or no proteinuria. Mildest and earlier form
Class II - Mesangial proliferative lupus nephritis - microscopic haematuria and proteinuria. BP normal
Class III - Focal lupus nephritis
Class IV - Diffuse lupus nephritis - symptoms of nephrotic syndrome, but burden of renal disease leads to reduction in GFR and raised crt
Class V - Membraneous lupus nephritis - siginificant proteinuria and peripheral oedema. Crt normal. Hamaturia and HTN seen but not essential. May occur in abscence of other symptoms of lupus !!
Class VI - Advanced sclerosing lupus nephritis - damage to > 90% of glomeruli, leading to slowly progressive renal failure
Light microscopy findings of membranous lupus nephritis
Diffuse thickening of the glomerular capillary wall on light microscopy
Treatment of pagets disease
Zoledronate
What can long term nitrofurantoin treatment result in
Pulmonary fibrosis
Serum electrophoresis in patients with nephrotic syndrome
Increased a1 and a2 globulin fractions
Decreased serum albumin
What kind of stones are always radiopaque and therefore can be seen on X ray
Calcium stones
What is recent urolithiasis in a young adult with negative x ray findings suspicious of
cystinuria (cystine stones)
Test for cystinuria
Positive urine analysis for hexagon shaped crystals on urine analysis
CT
Poorly radioopaque - cannot see on xray
What causes effacement of foot processes seen on electron microscopy
minimal change disease
Kidney biopsy of post strep glomerulonephritis
Granular deposits of IgG, IgM and C3 complement
Thyroxine levels in nephrotic syndrome
Reduced
Due to enhanced urinary excretion of thyroxine binding globulin
Most important function of the proximal convoluted tubule
Sodium reabsorption
IgA nephropathy disease course
Symptoms tend to recur with subsequent RTIs
Long term renal impairement relatively uncommon
Non visible haematuria can be noted between visible episodes
Renal biopsy for lupus nephritis
“Full house” immunology on immunostaining
Mesangial deposition of IgA, IgG, IgM, C3 and C4
Pneumonic for high anion gap metabolic acidosis
CAT MUDPILES
C - Cyanide poisoning
A - aminoglycosides
T - toluene
M - methanol
U - uraemia
D - DKA
P - Paracetomal
I - Isoniazid
L - Lactic acid
E - ethanol
S - salicylates
Causes of normal ion gap metabolic acidosis
Hypercalcaemia
Type I RTAA
Pathology of medullary sponge kidney
Dilatation of the collecting ducts in the papillae with accompanying cystic changes
One or both, or part of one kidney, may be affected
In severe cases the medually area has a sponge like appreance
Cyst formation commonly assosiated with small calculi within the cysts
Diagnosis of meduallry sponge kidney
Excretion urography
Investigation of chronic reflux nephropahty
TC-DMSA scintigraphy - renal scars, as areas of reduced uptake
IV urography - localised scarring as parenchymal loss and clubbed calycyes
What does adult PCKD often present with
Young adult with HTN
Features of meduallry cystic disease
Autosomally inherited
Presents in early adulthood with progressive renal impariment
Smallcysts at the cortico-meduallry junctions with assosiated tubule-interstitation inflammation and scarring
glomeruli unaffected
What is nephrocalcinosis
deposition of calcium in the renal parencyhma
causes of nephrocalcinosis
Hypercalcaemia
Hyperparathyroidism
TB
Presentation of meduallry sponge kidney
Recurrent UTIs
Haematuria on urine dip in the absence of recent infection
Excretion urography - small calculi in papillary zones, increase in radiodensity after contrast medium is injected
Urinary calcium excretion in familial hypocalciuric hypercalcaemia
Low
Most common presentation of familial hypocalcuric hypercalcaemia
Renal stone disease
What mechanism does solute removal occur on haemodiaylsis
Diffusion
What chronic upper respiratory tract changes are seen in granulomatosis with polyangitis
Sinusitis
Otitis
Mastoiditis
Nasal crusting
Epistaxis
Saddle nose deformity
Lung changes in granulomatosis with polyangitis
Multiple nodules
Cavitating lesions
Diffuse alvolar changes
What is the confirmatory test for granulomatosis with polyangitis
c-ANCA
S/E of finasteride and why
Gynaecomastia and breast tenderness
Leads to increased conversion of testosterone to estradiol and androstenediol
S/E of finasteride
Gynaecomastia
Breast tenderness
Impotence
Decreased libido
Decreased ejaculate volume
Depression
Anxiety
What can chemotherapy involving rapid lysis of malignant cells lead to
Release of large amounts of nucleoprotein and increased uric acid production
How many men with BPH have prostatic carcinoma
10-30%
Treatment for rapid symptom relief of BPH
Alpha blockade
What is kawasaki disease and who does it mainly affect
Acute systemic vasculitis
Children < 5 y/o
Fever lasting >5 days
Bilateral conjunctival congestion
Dryness and redness of lips and oral cavity 3 days after onset
Acute cervical lymphadenopathy
Polymorphic rash
Redness and oedema of palms and soles of feet 2-5 days after onset
What is spared in polyarteritis nodosa
Pulmonary circulation
What is characteristic of polyarteritis nodosa
Small aneurysms strung like beads of a rosary
WHat is polyarteritis nodosa assosiated with
Chronic Hep B
Incidence of contrast induced nephropathy in the general population
low, 1-6%
Renal assosiations of turners syndrome
Renal artery stenosis
Increased renal cyst formation S
Single horse shoe kidney
HOw to calculate the anion gap
(SODIUM + POTASSIUM) MINUS (BICARB + CHLORIDE)
Normal anion gap
10-16
Bone profile findings of a patient with CKD5
Low calcium
High phosphate
High PTH
High ALP
What does ATN usualy arise following
An acute ischaemic or nephrotoxic event
What is helpful in distingushing between pre kidney disease and ATN
Urine osmolality
- decreased in ATN, reflecting reduced tubal function and filtration rate. Urinary sodium > 40
- osmolality typically high in pre kidney disease in the context of poor UO and high creatinine. Urinary sodium <20
Urine dipstick of ATN
Typically bland
What do myoglobin casts indicate
Rhabdomyolysis
Presentation of goodpastures disease
Rapidly progressive glomerulonephritis
Pulmonary haemorrhage
What is the pathology of hypocalcaemia and secondary hyperparathyroidism in CKD
Diminished activity of renal 1-a-hydroxylase
WHat will be present in 10% of membranous glomerulonephritis
Malignancy
Causes of membranous nephropathy
Malignancy
Drugs (gold, penicillamine)
Autoimmune diseases (SLE)
Infections (hepatitis)
Pathology of acute organ rejection
Mediated via T cell response
Treatment of acute organ rejection
Anti-T cell monoclonal antibodies
Corticosteriods
What is a common cause of renal impairment in a patient with gouty arthritis
Uric acid stones
What is a common complication seen in up to 50% of CKD patients on haemodialysis
Protein-calorie malnutrition
Features of gietleman syndrome
Hypochloraemia
Hypokalaemia
Hypomagnesia
Increased urinary sodium and potassium loss
NO HTN
Due to defects in the thiazide sensitive sodium chloride symporter
Wat is released after tissue destruction/breakdown
Intracellular potassium
Tubular dysfunction / ATN is assosiated with the presence of what within the urine
Casts
What is suggestive of microscopic polyangitis
Neurological decline
Mononeuritis
Glomerulonephritis
Antibody assosiation of microscopic polyangitis
p-ANCA
How much IVF is likely to increase the intravascular volume
200ml
Anion gap in RTA
NORMAL anion gap
What is one way to differentiate between acute from chronic renal impairment and why
Serum parathyroid hormone
(Generally lower in patients with acute renal failure rather than chronic - a rise in PTH is seen an attempt to maintain calcium levels in the normal range over a long time period)
What malignancies are increased the most in patients post renal transplant
Haematological malignancies
What can indicate ATN
Urinary sodium level > 40-50 mmol/l
What is a staghorn calculus composed of
Magnesium ammonium phosphate
What commonly causes failing renal transplant in patients with alport syndrome
Prescence of anti-GBM antibodies leading to a goodpastures syndrome like picture
Which type of stones can you see on x ray
Urate
Xanthine stones
What ACR value is indicative of microalbuminuria
> 2.5
In a patient with newly detected microalbuminuria in a diabetes patient - what should be done next
repeat in 3-6 months before starting treatment
WHat cells do renal cell cancers arise from
Proximal renular tubular epithelium
Is tacrolimus safe in pregnancy
yes
are ACEI safe in pregnancy
no
Key features of alport syndrome
Progressive renal failure
Hearing loss
Where does gentamicin toxicity occur (renal)
Proximal tubule
Which retroperitoneal structure is directly in contact with the anterior surface of the left kidney
Pancreas
Most common cause of peritonitis in patients undergoing peritoneal dialysis
Staph epidermidis
WHich area of the nephron is most responsible for sodium reabsorption
Proximal convoluted tubule and ascending loop of Henle
What common cause of indwelling line infection in patients with haemodialysis
Staph epidermidis and staph A
Pathology of IDA in CKD
increased hepcidin
Complement and SLE
Low C3 level
How to prevent episodes of renal colic caused by hypercalcaemia
Thiazide diuretics e.g. hydrocholorthiazide and bendroflumethaizide
Investigation of minimal change disease
First morning void urinary ACR
Primary site of action of ADH
Cortical collecting duct
Investigation for renal artery stenosis
Magnetic resonance angiography
Investigation for IgA nephropathy
24 hour urinary protein estimation
70% of solutes (Na, K, Bicarb and glucose) are reabsorbed wheere
Proximal tubule
What area of RTA is most common
DISTAL tubule
Osmolalities of pre renal uraemia
raised urine osmolallity
low urine sodium
Urinary sodium of pre renal disease
<20
Urinary sodium of intrinsic renal dysfunction
> 40
Where are the renal arteries found
Transpyloric plane
Level of the first lumbar vertebrae
Where does the aorta pass through the diaphragm
T12
