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Focused 2 > Renal > Flashcards

Renal Flashcards

1
Q

What type of anaemia is seen in chronic kidney disease?

A

normocytic anaemia

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2
Q

What is the management for most blunt renal injuries and when does this differ?

A

most managed conservatively and result in haematuria; usually heals on its own

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3
Q

What are the more serious forms of blunt renal injury?

A

laceration - high velocity injuries, blood/urine may leak into surrounding tissue
if torn from blood vessel attachments - likely to bleed profusely - can be fatal

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4
Q

If a serious blunt kidney injury is suspected how can this be investigated?

A

contrast CT

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5
Q

What is the most common type of bladder injury and how does this occur?

A

extraperitoneal bladder rupture - occurs due to pelvic fractures or penetrating trauma

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6
Q

What proportion of patients with pelvic fracture suffer from genituourinary injuryes, and what should be done as a result?

A

25% - inspect urinary meatures for blood before inserting urinary catheter

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7
Q

How can most cases of extraperitoneal bladder leak from bladder injury be managed?

A

maximal bladder drainage with urethral or suprapubic catheter for 7-10 days (then TWOC)

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8
Q

Is surgery often required for extraperitoneal bladder leak after trauma/pelvic fractures?

A

no - majority heal within 3 weeks but if surgery done for other indications can be repaired surgically at the same time

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9
Q

What are 2 types of urethral injuries?

A
  1. posterior - membranous + prostatic urethra - usually major blunt trauma (RTA, falls, pelvic fractures)
  2. anterior - distal to membranous urethra - blunt trauma to perineum (straddle injuries), may be delayed presentation - stricture
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10
Q

What type of trauma can cause posterior urethral injuries?

A

major blunt trauma e.g. RTA and falls, associated with pelvic fracture

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11
Q

What type of trauma causes anterior urethral injuries?

A

blunt trauma to perineum e.g. straddle injuries, may have delayed presentation e.g. strictures many years later

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12
Q

How do urethral injuries present?

A

perineal bruising, blood at external urethral meatus
PR exam - abnormally high riding prostate/ inability to palpate

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13
Q

What is the management of urethral injury?

A

don’t perform urinary catheterisation; refer to urology; some perform retrograde urethrogram / some prefer suprapubic catheteristion, then imaging

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14
Q

On which chromosome do the majority of patients with ADPKD have an abnormality?

A

chromosome 16

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15
Q

In addition to kidneys what are 3 other organs where cysts are seen in ADPKD?

A
  1. liver (75% patients >60y)
  2. pancreas
  3. spleen
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16
Q

What factors can influence hepatic cysts in ADPKD?

A

affected by female steroid hormones; massive cysts occur almost exclusively in women

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17
Q

What are 4 non-cystic manifestations of ADPKD?

A
  1. mitral valve prolapse
  2. intracranial berry aneurysms (40% of cases)
  3. colonic diverticula
  4. renal cell carcinoma
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18
Q

What are 7 presenting features in ADPKD?

A
  1. haematuria (cyst rupture)
  2. flank pain
  3. hypertension
  4. stroke (SAH)
  5. renal failure
  6. palpable masses
  7. increased incidence UTIs
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19
Q

What may be seen on urinalysis in ADPKD?

A

microalbuminuria in 1/3 (heavy proteinuria rare), haematuria

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20
Q

Why may Hb be raised in ADPKD?

A

polycystic kidneys can produce excess EPO and raise Hb

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21
Q

What size kidney cysts can US detect?

A

from 1-1.5cm diameter

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22
Q

What imaging can detect smaller cysts in ADPKD?

A

CT, MRI

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23
Q

What is the treatment of ADPKD?

A
  • usually supportive
  • tolvaptan (vasopressin receptor 2 antagonist) in select patients
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24
Q

What are the diagnostic criteria for stage 1 AKI?

A
  • increase in creatinine to 1.5-1.9x baseline OR
  • increase in creatinine by >26.5 µmol/L OR
  • reduction in UO to <0.5ml/kg/hr for ≥ 6 hours
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25
Q

What are the diagnostic criteria for AKI stage 2?

A
  • increase in creatinine to 2.0-2.9x baseline OR
  • reduction in UO to <0.5ml/kg/hr for** ≥12 hours**
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26
Q

What are 4 criteria for stage 3 AKI?

A
  1. increase in creatinine to ≥ 3.0x baseline
  2. increase in creatinine to >353.5µmol/L
  3. Reduction in urine output to <0.3 mL/kg/hour for ≥24 hours
  4. initiation of kidney replacement therapy
  5. inpatients <18 years, decrease in eGFR to <35 mL/min/1.73 m2
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27
Q

What is the median age of presentation of Wilms’ nephroblastoma?

A

3 years

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28
Q

What are 4 associations of Wilms tumour?

A
  1. Beckwith-Wiedemann syndrome
  2. WAGR syndrome: aniridia, genitourinary malformations, mental retardation
  3. hemihypertrophy
  4. 1/3 associated with loss of function mutation in WT1 gene on chromosome 11
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29
Q

What is the commonest presenting features of Wilms nephroblastoma?

A

abdominal mass

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30
Q

What is a common site of metastases for Wilms nephroblastoma?

A

lung (mets found in 20% of patients)

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31
Q

What is the management of suspected Wilms tumour in primary care?

A

refer for paediatric review within 48h

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32
Q

What are the management options for Wilms’ nephroblastoma?

A

nephrectomy, chemotherapy, radiotherapy if advanced disease

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33
Q

What is the prognosis of Wilms tumour?

A

good - 80% cure rate

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34
Q

What is the advice regarding creatinine / renal function monitoring and ACE inhibitors?

A
  • U+Es should be checked before treatment initiated + after increasing dose
  • rise in serum creatinine up to 30% from baseline + K+ up to 5.5 mmol/L is acceptable
35
Q

What is the triad that defines nephrotic syndrome?

A
  • proteinuria (>1g/m2 /24h)
  • hypoalbuminaemia (<25g/L)
  • oedema
36
Q

What causes the majority of cases of nephrotic syndrome in children?

A

Minimal change disease

37
Q

What is the management of minimal change disease?

A

High dose steroids (90% of cases responsive)

38
Q

What age is the peak incidence of minimal change disease?

39
Q

In addition to the 3 cardinal features of minimal change disease, what are 3 additional associated features?

A
  1. Hyperlipidaemia
  2. Hypercoagulable state (loss of antithrombin III)
  3. Infection (loss of immunoglobulins)
40
Q

What is the commonest formula used to provide an accurate estimate of renal function with eGFR?

A

Modification fo Diet in Renal Disease (MDRD)

41
Q

What are 4 variables that the MDRD uses to work out eGFR?

A
  1. age
  2. gender
  3. ethnicity
  4. serum creatinine
42
Q

What are 3 factors that may falsely affect the result of the eGFR from MDRD?

A
  1. pregnancy
  2. muscle mass (e.g. amputees, body builders)
  3. eating red meat 12 hours prior to the sample being taken
43
Q

What are the 5 stages of CKD as per GFR range?

A
  1. > 90, with some sign of damage on other tests (other U+Es, proteinuria)
  2. 60-90
    3a. 45-59
    3b. 30-44
    4 . 15-29
    5 . <15
44
Q

What is the definition of contrast media nephrotoxicity?

A

25% increase in creatinine occurring within 3 days of IV administration of contrast media

45
Q

How long after contrast administration does nephropathy occur?

46
Q

What treatment is given to prevent contrast-induced nephropathy?

A
  • IV 0.9% saline 1ml/kg/hour for 12hours pre and post procedure
  • if high-risk - withhold metformin for minimum 48h

also evidence for isotonic sodium bicarbonate

47
Q

What electrolyte abnormalities are seen with rhabdomyolysis?

A
  • hypocalcaemia - myoglobin binds calcium
  • hyperphosphataemia - released from myocytes
  • hyperkalaemia

metabolic acidosis

48
Q

What is the treatment of rhabdomyolysis?

A

IV fluids to maintain good urine output; urinary alkalinisation sometimes used

49
Q

What are 3 indications for treatment with tolvaptan in ADPKD?

A
  1. chronic kidney disease stage 2 or 3
  2. rapidly progressing disease
  3. company provides it with the discount agreed in the aptient access scheme
50
Q

3

What are the 3 sets of US diagnostic criteria in ADPKD?

A
  1. 2 cysts unilateral or bilateral if < 30 y
  2. 2 cysts in both kidneys if 30 - 59 y
  3. 4 cysts in both kidneys if > 60 y
51
Q

What are 2 drug causes of minimal change disease?

A
  1. NSAIDs
  2. rifampicin
52
Q

What are 3 non-drug causes of minimal change disease?

A
  1. Hodgkins lymphoma
  2. thymoma
  3. infectious mononucleosis
53
Q

What is blood pressure like in minimal change disease?

A

normotension

54
Q

What are the key features of the proteinuria of minimal change disease?

A

only intermediate-sized proteins such as albumin and transferrin leak through the glomerulus

55
Q

What is seen on renal biopsy in minimal change disease?

A
  • normal glomeruli on light microscopy;
  • electron microscopy shows fusion of podocytes and effacement of foot processes
56
Q

What is the next step in steroid-resistant cases of minimal change disease?

A

cyclophosphamide

57
Q

What is an examples of an INITIAL (not maintenance) regime of immunosuppression after renal transplant?

A
  • ciclosporin / tacrolimus with a monoclonal antibody
58
Q

What is an example of MAINTENANCE immunosuppression after renal transplant?

A

ciclosporin / tacrolimus with MMF or sirolimus

59
Q

When should steroids be added to the immunosuppressino regmie in renal transplant?

A

if more than 1 steroid responsive acute rejection episode

60
Q

What is the mechanism of action of ciclosporin for immunosuppression?

A

inhibits calcineurin, a phosphotase involved in T cell activation

61
Q

What are 3 advantages of tacrolimus over ciclosporin?

A
  1. lower incidence of acute rejection compared to ciclosporin
  2. less hypertension
  3. hyperlipidaemia
62
Q

What is a disadvantage of tacrolimus compared with ciclosporin?

A

high incidence of impaired glucose tolerance and diabetes

63
Q

What is the mechanism of action of mycophenolate mofetil (MMF)?

A

blocks purine synthesis by inhibition of IMPDH therefore inhibits proliferation of B and T cells

64
Q

What are 2 side effects of mycophenolate mofetil?

A
  1. GI side effects
  2. marrow suppression
65
Q

What is the mechanism of sirolimus?

A

blocks T cell proliferation by blocking the IL-2 receptor

66
Q

What is a side effect of sirolimus?

A

can cause hyperlipidaemia

67
Q

What are the monoclonal antibodies used in renal transplant and what are 2 examples?

A

selective inhibitors of IL-2 receptor
1. daclizumab
2. basiliximab

68
Q

What are 3 key complications of long-term immunosuppression after renal transplant?

A
  1. cardiovascular disease (tacrolimus/ciclosporin cause HTN And hyperlgycaemia)
  2. renal failure
  3. malignancy - greatest risk squamous cell carcinoma of skin (also basal cell, lymphoma, cervical)
69
Q

How does immunosuppression after renal transplant cause renal failure? 3 ways

A
  • nephrotoxic effects of tacrolimus and ciclosporin
  • graft rejection
  • recurrence of original disease in transplanted kidney
70
Q

Which cancer are patients at the greatest risk of developing after renal transplantation?

A

squamous cell carcinoma

71
Q

What dietary advice should be given to patients with CKD?

A
  • low potassium diet
  • low phosphate
  • low sodium
  • low protein
72
Q

What must be present to diagnose CKD stage 1+2?

A

if eGFR >60 then there must be other abnormal U+Es or proteinuria (i.e. evience of kidney damage) to diagnose

73
Q

What distinguishes poststreptococcal glomerulonephritis from IgA nephropathy (Berger’s disease)?

A
  • IgA nephropathy occurs 24-48h after URTI, poststreptococcal occurs 1-3 weeks after streptococcal infections
  • both present as nephritic syndorme with visible haematuria, oliguria and oedema
  • IgA nephropathy treated with steroids, poststreptococcal treated supportively only
74
Q

What distinguishes GPA, EGPA, Goodpasture’s syndrome?

A
  • GPA: upper and lower respiratory tract involvement, pauci-immune glomerulonephritis
  • EGPA: asthma, GI and cardiac involvement, eosinophilia
  • Goodpasture’s: pulmonary haemorrhage, glomerulonephritis but NO URT involvement
75
Q

Which renal disease may anti-streptolysin O titres be seen?

A

poststreptococcal glomerulonephritis

76
Q

What are 8 causes of nephritic syndrome?

A
  1. post-streptococcal glomerulonephritis
  2. IgA nephropathy
  3. GPA
  4. EGPA
  5. Microscopic polyangiitis
  6. Rapidly progressive glomerulonephritis
  7. Alport syndrome
  8. Thin basement mebrane disease
77
Q

What are 2 causes of nephritic-nephrotic syndrome?

A
  1. membranoproliferative glomerulonephritis
  2. diffuse proliferative glomerulonephritis
78
Q

What is the commonest cause of glomerulonephritis in adults?

A

IgA nephropathy

79
Q

What are 5 caues of nephrotic syndrome?

A
  1. minimal change disease
  2. focal semgental glomerulosclerosis
  3. membranous nephropathy
  4. diabetic nephropathy
  5. amyloid light-chain (AL) amyloidosis, light chain deposition disease
80
Q

What is the most common cause of nephroptic syndorme in adults?

A

focal segmental glomerulosclerosis

82
Q

What are the 2 types of ADPKD and what are 3 differences?

A

Type 1 and 2
1. ADPKD1 more common - 85%
2. type 1 chromosome 16, type 2 chromosome 4
3. type 1 presents with renal failure earlier

83
Q

What is the investigation of choice when a bladder injury is suspected?

A

CT cystogram - may show variable path of extravasated contrast material

Focused 2 (27 decks)

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