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Phase 4 Question Knowledge > Renal > Flashcards

Renal Flashcards

1
Q

AKI

A
  • acute reversible reduction in renal function
  • GFR declines -> failure to maintain fluid, electrolyte, acid-base homeostasis
  • reduced UO, fluid overload, rise in K, urea, creat
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2
Q

AKI Dx criteria

A
  • Rise in creatinine >25umol/L in 48hrs
  • Rise in creatinine >50% in 7d
  • UO less than 0.5ml/kg/hr over >6hrs
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3
Q

AKI stages

A

Look up diagram

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4
Q

AKI causes

A

Pre-renal
- low volume - D+V, burns, haemorrhage….
- decreased CO - MI, cardiogenic shock, HF
- vasodilation - sepsis, drugs
- renal hypoperfusion - NSAIDs, ACEi, ARB…
- flow obstruction - ischaemia, atherosclerosis, RAS

Renal
- ATN, glomerulonephritis, AIN, infection, sarcoidosis, HUS, rhabdo, NSAIDs, ACEi, gent, contrast, methotrexate, vasculitis

Post-renal
- stone, malignancy, stricture, clot
- pelvic malignancy, BPH
- neurogenic bladder

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5
Q

AKI Px

A
  • asym
  • reduced UO
  • pulm / peripheral oedema
  • arrhythmias
  • uraemia - pericarditis / encephalopathy
  • sx of cause
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6
Q

AKI Ix

A
  • U/E
  • urine dip
  • fluid balance
  • renal USS

All patients should get urinalysis

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7
Q

AKI Mx

A
  • tx cause
  • IV fluids
  • stop worsening meds
  • adjust renally-excreted meds
  • tx electrolytes
  • dialysis
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8
Q

Acute tubular necrosis (ATN)

A
  • death of renal tubular epithelial cells
  • ischaemic - hypoperfusion - shock, sepsis
  • nephrotoxins - eg gentamicin, radiocontrast, rhabdo (myoglobin)

Px
- AKI
- muddy brown casts in urine

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9
Q

Acute interstitial nephritis (AIN)

A
  • Acute inflammation of renal tubule-interstitium

Cause
- meds
- systemic disease, eg SLE, sarcoidosis
- infection

Px
- fever, rash, arthralgia
- eosinophilia
- mild renal impairment, HTN

Ix
- urine - sterile pyuria, white cell casts

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10
Q

Tubulointerstitial nephritis with uveitis (TINU)

A
  • usually young females

Px
- fever, wt loss, painful red eyes

Ix
- urinalysis - leucocytes + protein

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11
Q

CKD

A

Chronic kidney function reduction - permanent + progressive

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12
Q

CKD causes

A
  • diabetic nephropathy
  • HTN
  • Meds - NSAIDs, lithium
  • glomerulonephritis
  • PKD
  • chronic pyelonephritis
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13
Q

CKD Dx criteria

A

> 3mo of either:
- eGFR <60
- urine albumin:creatinine ratio (ACR) >3mg/mmol

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14
Q

CKD classification by eGFR

A

1 - >90
2 - 60-89
3a - 45-59
3b - 30-44
4 - 15-29
5 - <15

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15
Q

CKD Px

A
  • asym
  • fatigue
  • pallor
  • foamy urine - proteinuria
  • nausea
  • anorexia
  • pruritis - uraemia
  • oedema
  • polyuria
  • HTN
  • N+V
  • peripheral neuropathy - vit/mineral imbalance
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16
Q

CKD Ix

A
  • ECG - K
  • Bloods - U/E, phosph, Ca, FBC
  • urine albumin:creatinine ratio (ACR)
  • urine dip + MC+S
  • renal USS
  • BP, HbA1c, lipids
  • Kidney Failure Risk Equation
  • Kidney biopsy
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17
Q

CKD Mx

A
  • tx cause
  • ACEi / ARB
  • SGLT-2 inhibitor - dapagliflozin
  • exercise, wt loss, stop smoking
  • atorvastatin
  • ESRF - dialysis, renal transplant
  • review meds
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18
Q

CKD Cx

A
  • anaemia
  • CKD mineral and bone disorder (CKD-MBD)
  • metabolic acidosis - oral sodium bicarb
  • CV disease
  • uraemia - lethargy, itch, anorexia, confusion, pericarditis
  • peripheral neuropathy
  • ESRF
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19
Q

Anaemia in CKD

A
  • lack of EPO production -> fewer RBCs
  • normocytic, normochromic

Mx
- oral / IV iron
- EPO

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20
Q

CKD-MBD

A
  • high serum phosph, low vit D, low serum Ca
  • kidneys secrete less phosphate, vit D not activated by kidneys (Ca not reabsorbed by kidneys, nor absorbed by gut), PTH secreted due to low Ca, increased bone turnover, osteosclerosis

Ix
- spinal XR - rugger jersey spine

Mx
- low phosph diet
- phosph binders - Ca based / can use sevelamer
- active vit D - calcitriol
- Ca in diet
- bisphosphonates for osteoporosis

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21
Q

Haemodialysis

A
  • regular filtration of blood through dialysis machine
  • blood access via AV fistula / tunnelled cuffed catheter
  • anticoagulate with citrate / heparin
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22
Q

Indications for short-term dialysis

A

A - acidosis - severe, not responding to tx
E - electrolyte abnormalities - eg tx-resistant hyperkalaemia
I - intoxication - OD
O - oedema - severe, unresponsive pulmonary oedema
U - uraemia sx - seizures, coma

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23
Q

Peritoneal dialysis

A
  • filtration in pt’s abdo - inject dialysis solution into abdo cavity, draws waste products from blood, then drain
  • continuous ambulatory / automatic (at night)

Cx
- peritonitis - add vanc / teic + ceftazidime to dialysis fluid

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24
Q

Renal transplant

A
  • donor kidney matched based on HLA type A,B,C
  • take life-long immunosuppression

Rejection
- Hyperacute (mins-hrs) - T2 hypersensitivity - pre-existing ABs - widespread thrombosis of graft vessels - take graft out
- Acute graft failure (<6mo) - cytotoxic T cells, reversible with steroids, immunosuppressants
- Chronic graft failure (>6mo) - AB / cell mediated

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25
Q

Glomerulonephritis

A
  • inflammation of glomeruli
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26
Q

Nephritic syndrome

A
  • inflammation of kidneys - haematuria, oliguria, proteinuria <3g/24hrs, fluid retention/oedema
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27
Q

Nephrotic syndrome

A
  • damage to podocytes, GBM highly permeable to protein
  • proteinuria >3g/24hrs, low albumin <25g/L, peripheral oedema
  • leads to - thrombosis, HTN, high cholesterol, CKD, infection risk, hypocalcaemia

Rise in fibrinogen can lead to thrombosis

Loss of thyroxine-binding globulin lowers the total, but not free, thyroixine levels

28
Q

Nephritic syndrome causes

A
  • IgA nephropathy
  • post-strep
  • anti-GBM
  • ANCA-associated vasculitis
  • Rapidly progressive glomerulonephritis (RPGN)
  • Lupus nephritis
29
Q

Nephrotic syndrome causes

A
  • minimal change disease
  • Focal segmental glomerulosclerosis (FSGS)
  • membranous nephropathy
  • Membranoproliferative glomerulonephritis
  • HSP
  • diabetic nephropathy - scarring from high BMs
  • infection - HIV
  • Systemic lupus erythematosus
30
Q

IgA nephropathy / Berger’s disease

A
  • deposition of IgA immune complexes -> inflammation

Px
- pt in 20s, URTI a couple of days ago
- macroscopic haematuria - coca cola urine

Ix
- U/E
- urine dip, MC+S
- renal USS / CT / ?biopsy

Mx
- isolated - no tx
- persistent proteinuria - ACEi
- falling eGFR - corticosteroids

31
Q

Post-strep glomerulonephritis

A
  • 1-3wks after GAS (b haemolytic - often S pyogenes of tonsils)
  • immune complexes, ABs, complement get stuck in glomeruli -> inflammation

Px
- tonsillitis
- headache, malaise
- brown urine
- oedema
- decreased UO
- HTN

Ix
- FBC, U/E
- ASO - anti-streptolysin O titre - for strep infection
- throat swabs, urinalysis, ?renal biopsy

Mx
- penicillin for throat
- worsening renal function - anti-HTN, diuretics

32
Q

Anti-GBM disease / Goodpastures

A
  • small vessel vasculitis - ABs attack glomerulus + pulm basement membranes

Px
- rapid onset AKI, proteinuria, haematuria
- URTI sx first
- SOB, raised RR, crackles, cough, fatigue
- haemoptysis

Ix
- renal biopsy
- anti-GBM ABs in blood

Mx
- intubation, ventilation, haemodialysis
- plasma exchange
- immunosuppression - steroids / cyclophosphamide

33
Q

ANCA-associated vasculitis

A
  • small-vessel vasculitis

Ix
- p-ANCA / MPO antibodies - microscopic polyangiitis
- c-ANCA / PR3 antibodies - granulomatosis with polyangiitis

Mx
- immunosuppression, steroids

34
Q

Rapidly progressive glomerulonephritis (RPGN)

A
  • rapid loss in kidney function
  • associated with Goodpasture, SLE, microscopic polyangiitis

Px
- haematuria, proteinuria, HTN, oliguria

Ix
- biopsy - glomerular crescent formation

35
Q

Lupus nephritis

A
  • SLE that can lead to ESRF, glomerulonephritis + sclerosis

Mx
- tx HTN
- glucocorticoids + immunosuppression

36
Q

Minimal change disease

A
  • most common cause nephrotic syndrome in children
  • no specific cause, no change in biopsy

Mx
- steroids

37
Q

Focal segmental glomerulosclerosis (FSGS)

A
  • a common cause of nephrotic syndrome in adults, also causes CKD

Causes
- idiopathic, renal pathology, HIV, heroin, Alport’s, sickle cell

Ix
- renal biopsy - sclerosis, effacement of foot processes

Mx
- steroids +/- immunosuppression

38
Q

Membranous nephropathy

A
  • most common cause nephrotic syndrome in adults
  • Immune complexes (IgG, complement) deposit in GBM -> thickening, proteinuria
  • idiopathic, malignancy, SLE, drugs, RA, infections

Ix
- renal biopsy

Mx
- ACEi/ARB
- immunosuppression + corticosteroid

39
Q

Membranoproliferative glomerulonephritis / mesangiocapillary glomerulonephritis (MCGN)

A
  • <30yo, immune complex deposits + mesangial proliferation

Px
- nephrotic sx, haematuria, proteinuria

Mx
- poor prognosis
- steroids may help

40
Q

HIV - nephrotic syndrome

A

either from infection / tx itself

5 features
- Massive proteinuria -> nephrotic syndrome
- Normal / large kidneys
- FSGS, capillary collapse on renal biopsy
- Elevated urea, creatinine
- Normotension

41
Q

Renal tubular acidosis (RTA)

A

metabolic acidosis due to pathology in kidney tubules

42
Q

Type 1 RTA

A
  • distal tubule cannot excrete H+

Causes
- SLE, genetic, Sjogren, PBC, hyperthyroid, sickle cell, Marfan’s

Px
- failure to thrive (children)
- recurrent UTIs
- rickets / osteomalacia
- muscle weakness
- arrhythmias (low K)

Mx
- oral bicarb

43
Q

Type 2 RTA

A
  • proximal tubule cannot reabsorb bicarb

Causes
- genetic, multiple myeloma, Fanconi’s syndrome

Mx
- oral bicarb

44
Q

Type 3 RTA

A

mix of type 1+2

45
Q

Type 4 RTA

A
  • low aldosterone / impaired function - normally reabsorbs Na, secretes K + H+
  • K and H+ retained in blood

Causes
- adrenal insufficiency, diabetic nephropathy, ACEi, spironolactone

Mx
- tx cause
- fludrocortisone
- oral bicarb
- hyperkalaemia tx

46
Q

HUS

A

See paeds notes

47
Q

Rhabdomyolysis

A
  • breakdown of skeletal muscle - releases myoglobin, K, phosph, CK

Causes
- long lie, vigorous exercise, crush injuries, seizures, statins, ecstasy, McArdle syndrome

48
Q

Rhabdo Px

A
  • muscle pain, weakness, swelling
  • oliguria
  • myoglobinuria - red/brown urine
  • fatigue
  • N+V
    confusion
49
Q

Rhabdo Ix

A
  • Bloods - CK, U/E, Ca (myoglobin binds to Ca)
  • urine dip - blood
  • ECG
50
Q

Rhabdo Mx

A
  • IV fluids
  • hyperkalaemia mx
  • IV sodium bicarb
  • IV mannitol - increase UO, reduce oedema
51
Q

Polycystic kidney disease (PKD)

A
  • genetic condition - multiple cysts develop throughout kidneys
  • autosomal dominant (more common) / recessive
  • PKD1 on ch16 (codes for polycystin 1) / PKD2 on ch4 (polycystin 2)
  • progressive loss of renal function - from mechanical compression, apoptosis, fibrosis
52
Q

ADPKD Px

A
  • HTN
  • recurrent UTIs
  • flank pain
  • haematuria
  • palpable kidneys
  • renal impairment
  • renal stones

Extra-renal
- liver cysts - hepatomegaly
- berry aneurysms
- CVS - mitral valve prolapse, valve incompetence, aortic dissection / root dilatation
- other cysts - pancreas, spleen
- diverticular disease

53
Q

ADPKD Ix

A
  • abdo USS
  • genetic testing
  • MR angiography - of head
54
Q

ADPKD Diagnostic criteria (if positive FHx)

A
  • 2 cysts, uni/bilateral, if <30yo
  • 2 cyst in both kidneys if 30-59yo
  • 4 cysts in both kidneys if >60yo
55
Q

ADPKD Mx

A
  • tolvaptan
  • ACEi for HTN
  • aspiration / surgery for cyst drainage
  • dialysis - for ESRF
  • renal transplant
  • avoid NSAIDs, anticoags, contact sports
  • genetic counselling
56
Q

ARPKD

A
  • mutation in PKHD1 gene on ch6
  • often identified on antenatal scans, with oligohydramnios
  • dysmorphic features
  • ESRF before adulthood
57
Q

Alport syndrome

A
  • genetic condition - defect in gene for type 4 collagen -> abnormal GBM
  • x-linked dominant

Px
- px in childhood
- microscopic haematuria
- progressive renal failure
- bl sensorineural deafness
- retinitis pigmentosa
- lenticonus - protrusion of lens surface into anterior chamber

Ix
- molecular genetic testing
- renal biopsy - splitting of lamina densa on electron microscopy

58
Q

Fanconi syndrome

A
  • reabsorptive disorder of renal tubular transport in PCT -> T2 RTA, polyuria, glycosuria….

Causes
- cystinosis, Sjogrens, multiple myeloma, nephrotic syndrome, Wilson’s

59
Q

Renal artery stenosis (RAS)

A
  • narrowing of one / both renal arteries

Causes
- atherosclerosis, fibromuscular dysplasia

Patho
- kidney hypoperfused, RAAS activated, chronic HTN

60
Q

RAS Px

A
  • HTN
  • CKD
  • pulm oedema
  • bruits on auscultation
61
Q

RAS Ix

A
  • Doppler US kidneys
  • captopril challenge test (not useful)
  • renal artery arteriogram
62
Q

RAS Mx

A
  • diuretics
  • anti HTN
  • surgery - angioplasty +/- stenting
  • nephrectomy
63
Q

Contrast media nephrotoxicity

A
  • 25% increase in creatinine <3d after IV contrast

RFs
- renal impairment, >70yo, dehydration, HF, nephrotoxic drugs

Mx
- 0.9% NaCl 1ml/kg/hr for 12hrs pre/post procedure
- sodium bicarb

64
Q

Renal papillary necrosis

A
  • coagulative necrosis of renal papillae

Causes
- severe acute pyelonephritis, diabetic nephropathy, obstructive nephropathy, NSAIDs, sickle cell anaemia

Px
- visible haematuria
- loin pain
- proteinuria

Ix
- urinalysis, cytology
- bloods
- CT, contrast…
- cystoscopy, ureteroscopy

Mx
- supportive
- tx cause

65
Q

Amyloidosis

A
  • deposition of amyloid fibrils -> tissue/organ dysfunction
  • can affect kidneys, heart, nerves, gut, vascular
  • familial variant - autosomal dominant

Px
- renal disease - massive proteinuria
- hepatomegaly
- HF
- glove + stocking polyneuropathy
- GI malabsorption, macroglossia
- periorbital purpura
- fatigue, wt loss, bruising, SOB, oedema

Ix
- biopsy - of tissue - congo red staining (apple-green birefringence)
- serum amyloid precursor (SAP) scan

Mx
- optimise nutrition
- chemo + pred
- tx conditions
- familial - liver transplant

Phase 4 Question Knowledge (30 decks)

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