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Finals > Renal > Flashcards

Renal Flashcards

1
Q

how to measure AKI

A

serum creatinine (need to adjust for muscle bulk)

  • Rise in creatinine > 25 micromol/L in 48 hours
  • Rise in creatinine > 50% in 7 days
  • Urine output< 0.5 ml/kg/hour over at least 6 hours
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2
Q

RF for developing AKI

A
  • > 65yrs
  • sepsis
  • CKD
  • Heart failure
  • diabetes
  • liver disease
  • reduced fluid intake
  • medications (NSAID, gentamicin, diuretics, ACEi)
  • radiocontrast agents
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3
Q

causes of renal impairment

A

Pre-renal- MC
- dehydration
- sepsis or blood loss
- heart failure

Renal
- acute tubular necrosis MC
- glomerulonephritis
- acute interstitial nephritis
- HUS
- rhabdomyolysis

Post-renal
- kidney stones
- tumour
- urethral stricture
- BPH
- neurogenic bladder

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4
Q

acute tubular necrosis

A
  • necrosis of epithelial cells in renal tubules
  • MC intrinsic cause of AKI
  • due to ischaemia or nephrotoxins
  • muddy brown casts
  • recovery 1-3 weeks
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5
Q

acute interstitial nephritis

A
  • inflammation of interstitium
  • caused by immune reaction assoc with NSAIDs, abx, infections, autoimmune conditions
  • rash, fever, flank pain, eosinophilia
  • treat cause + steroids
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6
Q

Mx of AKI

A

A-F
A- anaemia (give erythropoieitin)
B- bones (phosphate and calcium)
C- clearance (creatinine)
D- drugs (withhold ACEi and NSAIDs)
E- electrolytes (potassium and phosphate)
F- fluid balance (BP 130/80)

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7
Q

effect of ACEi in AKI

A

will drop BP and renal perfusion

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8
Q

complications of AKI

A
  • fluid overload, heart failure, pulmonary oedema
  • hyperkalaemia
  • metabolic acidosis
  • uraemia
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9
Q

stages of AKI

A
  1. 1.5-2x creatinine rise from base and <0.5ml/kg/hr urine >6hr
  2. 2-3x Cr rise + <0.5ml >12hr
  3. > 3x Cr rise + <0.3ml >24hr
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10
Q

how to manage hydropnephrosis

A

nephrostomy

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11
Q

nephrotic syndrome

A

BM of glomerulus becomes highly permeable
- proteinuria (frothy urine)
- hypoalbuminaemia
- oedema

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12
Q

causes of nephrotic syndrome

A
  • Minimal change disease (MC)
  • Membranous nephropathy
  • focal segmental glomerulosclerosis
  • diabetes, HSP, SLE, HIV
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13
Q

complications of nephrotic syndrome

A
  • DVT: increased risk of thromboembolism related to loss of antithrombin III and plasminogen in the urine
  • ACS and stroke due to hyperlipidaemia
  • CKD
  • increased risk of infection due to urinary immunoglobulin loss
  • hypocalcaemia (vitamin D and binding protein lost in urine)
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14
Q

Minimal change disease

A
  • idiopathic
  • 2-5 y/o child
  • Mx steroids
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15
Q

nephritic syndrome

A

PHAROH
- Proteinuria
- Haematuria
- Azootemia
- Red cell casts
- Oliguria
- Hypertension

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16
Q

Causes of nephritic syndrome

A
  • Acute postinfectious (post-strep) glomerulonpehritis
  • IgA nephropathy (berger disease)
  • Rapidly progressive GN
  • Hereditary nephritis
  • thin BM disease
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17
Q

IgA nephropathy

A
  • MC cause of primary GN
  • 20y/o with haematuria
  • unknown cause
  • IgA deposits
  • rule of thirds for recovery, CKD and progressive CKD
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18
Q

Post-streptococcal GN

A
  • <30y/o
  • 1-3 weeks after strep infection
  • make full recovery
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19
Q

rapidly progressive GN

A
  • acute severe illness
  • respond well to treatment
  • glomerular crescents on histology
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20
Q

anti-GBM
p-ANCA
c-ANCA

A

anti-GBM= goodpasture
p-ANCA= microscopic polyangiitis
c-ANCA= granulomatosis with polyangiitis

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21
Q

Mx of glomerulonephritis

A
  • Diagnosis- renal biopsy
  • supportive care
  • immunosuppression (steroids)
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22
Q

causes of CKD

A
  • diabetes
  • hypertension
  • Meds (NSAIDs, lithium)
  • Glomerulonephritis
  • PCKD
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23
Q

Presentation of CKD

A
  • fatigue
  • pallor
  • foamy urine
  • nausea
  • loss of appetite
  • pruritus
  • oedema
  • hypertension
  • peripheral neuropathy
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24
Q

Ix for CKD

A
  • eGFR
  • urine albumin: creatinine
  • urine dipstick
  • renal USS
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25
Q

stages of CKD

A

GFR
1. kidney damage with normal GFR >90
2. GFR 60-89
3a. moderate 45-59
3b. moderate 30-44
4. severe 15-29
5. ESRF <15 or dialysis

A:C
A1 <3
A1 3-30
A3 >30

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26
Q

complications of CKD

A
  • anaemia
  • renal bone disease
  • CVD
  • peripheral neuropathy
  • ESKD
  • dialysis related complication
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27
Q

Mx of CKD

A
  • optimise diabetes and hypertension
  • avoid nephrotoxic drugs
  • treat glomerulonephritis
  • BP < 130/80
  • ACEi and SGLT2 slow progression
  • atorvastatin for CVD prevention
  • erythropoietin/iron
  • vit D, low phosphate diet and phosphate binders
  • dialysis and transplant
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28
Q

Renal bone disease

A
  • high serum phosphate, low vit D activity + low serum Calcium
  • kidneys activate vit D and increasing calcium
  • low calcium and high phosphate = more PTH–> secondary hyperPTH
  • –>increase osteoclast activity and calcium bone absorption
  • –> osteomalacia, osteosclerosis
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29
Q

indications for short term dialysis

A

AEIOU
- acidosis
- electrolyte imbalance (hyperkalaemia)
- intoxication
- Oedema
- Uraemia sx (seizures and reduced GCS)

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30
Q

indication for long term dialysis

A

ESRF

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31
Q

haemodialysis

A
  • 4hrs a day 3x a week
  • need anticoagulation with citrate or heparin to prevent blood clotting in machine
  • can use tunnelled cuffed catheter in subclavian/jugular or AV fistula
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32
Q

complications of AV fistula

A
  • anaeurysm
  • thrombosis
  • infection
  • stenosis
  • high output heart failure
  • STEAL syndrome: ischaemia of part of limb
33
Q

signs in a fistula

A
  • palpable thrill
  • machinery murmur on auscultation
34
Q

peritoneal dialysis

A
  • uses peritoneal membrane
  • can do it at home
  • Tenckhoff catheter
35
Q

complications of peritoneal dialysis

A
  • bacterial peritonitis
  • peritoneal sclerosis
  • ultrafiltration failure
  • weight gain
  • psychosocial implications
36
Q

years added from renal transplant compared to dialysis

A

10 yrs

37
Q

donor matching for renal transplant

A

HLA type on Chr6

38
Q

Where and how is kidney transplant done

A
  • donor kidney BVs anastomosed with pelvic vessels (external iliac vessels).
  • ureter of donor kidney anastomosed with bladder
  • donor anterior in abdo in iliac fossa
  • hockey stick (Rutherford Morrison) scar
39
Q

post transplant care

A
  • 2x doses Basiliximab to prevent acute rejection

lifelong immunosuppression
- tacrolimus
- mycophenolate
- ciclosporin
- azathioprine
- prednisolone

40
Q

side effects of immunosuppressants

A
  • seborrhoeic warts and skin cancer
  • tacrolimus = tremor
  • cyclosporin = gum hypertrophy
  • steroids = cushing’s syndrome
41
Q

complications of renal transplant

A
  • rejection (HA, A, Chronic)
  • transplant failure
  • electrolyte imbalance
42
Q

Causes of hyperacute rejection (minutes-hours)

A
  • pre-existing antibodies against HLA or ABO antigens
43
Q

Causes of acute rejection (<6months)

A
  • mismatched HLA
  • Cell-mediated (cytotoxic T cells)
  • CMV
44
Q

Causes of chronic rejection (>6 months)

A
  • antibody and cell-mediated mechanisms cause fibrosis to the transplanted kidney
  • recurrence of original renal disease
45
Q

complications of transplant related to immunosuppressants

A
  • IHD
  • T2DM
  • infections
  • Non hodgkin lymphoma
  • skin cancer (SCC)
46
Q

infections secondary to immunosuppressant meds

A
  • Pneumocystitis jiroveci pneumonia (PCP)
  • CMV
  • TB
47
Q

what is glomerulonephritis

A

inflammation of glomeruli in kidney

48
Q

What is renal tubular acidosis

A

metabolic acidosis due to pathology of tubules

49
Q

types of renal tubular acidosis

A

T1: distal tubule cannot excrete H+. high urine pH and low serum K+. most severe
T2: proximal tubule cannot reabsorb bicarbonate. High pH and low K+. Milder
T4: low aldosterone or impaired aldosterone function. low pH, high K+. MC.
T3: RARE

50
Q

Causes of type 1 renal tubular acidosis

A
  • Genetic
  • SLE
  • Sjögren’s syndrome
  • Primary biliary cholangitis
  • Hyperthyroidism
  • Sickle cell anaemia
  • Marfan’s syndrome
51
Q

Presentation of T1 renal tubular acidosis

A
  • failure to thrive
  • recurrent UTI
  • rickets/osteomalacia
  • muscle weakness
  • arrhythmia due to low k+
52
Q

causes of type 2 renal tubular acidosis

A
  • inherited
  • MM
  • Fanconi’s syndrome
53
Q

Mx of renal tubular acidosis

A

bicarbonate
oral KCL 3-3.5 or IV KCL <3

54
Q

What is Haemolytic uraemic syndrome

A
  • thrombosis in small BVs
  • triggered by E.coli 0157 or Shigella
  • children post gastroenteritis
55
Q

triad of HUS

A
  • microangiopathic haemolytic anaemia (RBC destruction)
  • AKI
  • thrombocytopenia
56
Q

presentation of HUS

A
  • bloody diarrhoea
  • renal failure
  • fever, abdo pain
57
Q

Mx of HUS

A
  • Supportive (Fluids, blood transfusion and dialysis if required)
  • plasma exchange
  • eculizumab
58
Q

what is rhabdomyolysis

A

SM breaking down releasing:
- myoglobin
- potassium
- phosphate
- CK

59
Q

causes of rhabdomyolysis

A
  • prolonged immobility
  • rigorous exercise
  • crush injury
  • seizure
  • statins
60
Q

Sx of rhabdomyolysis

A
  • muscle pain, weakness and swelling
  • reduced urine
  • red/brown urine
  • fatigue and confusion
  • N&V
61
Q

Mx of rhabdomyolysis

A

IV fluids mainstay
+ Iv sodium bicarbonate and mannitol if necessary

62
Q

types of hyperkalaemia

A

normal 3.5-5.3
mild: 5.4-6
moderate 6-6.5
severe >6.5

63
Q

causes of hyperkalaemia

A
  • AKI
  • CKD
  • rhabdomyolysis
  • adrenal insufficiency
  • tumour lysis syndrome
  • aldosterone antagonists (spironolactone)
  • ACEi
  • AIIRB
  • NSAID
64
Q

ECG changes assoc with hyperkalaemia

A
  • tall tented T waves
  • flat/absent p waves
  • prolonged PR
  • broad QRS
65
Q

Mx of hyperkalaemia

A

Treat pt with severe hyperkalaemia (≥ 6.5 mmol/L) or with ECG changes:
- 10ml 10% IV calcium gluconate (stabilist cardiac muscle)
- 100ml 20% dextrose and 10units insulin (drive potassium into cells and prevent hypoglycaemia)
- nebulised salbutamol useful adjunt
- oral calcium resonium
- sodium bicaronate
- haemodialysis = severe

66
Q

what is polycystic kidney disease

A
  • AD and AR types. AD is more common
  • PKD1 gene on Chr16 and PKD2 gene on Chr4 affected
  • 10% of cases of CKD
  • 2/3rds require renal replacement therapy
  • Imaging USS can do MRI later
67
Q

Presentation of polycystic kidney disease

A

MISHAPES
- abdo Mass
- Infected cysts and increase BP
- Stones
- Haematuria
- Aneurysms (berry)
- Polyuria and nocturia
- extra renal cysts (ovary, spleen, pancreas, prostate)
- systolic murmur (mitral regurg due to mitral valve prolapse)

68
Q

complications of polycystic kidney disease

A
  • Chronic loin/flank pain
  • Hypertension
  • Gross haematuria can occur with cyst rupture
  • Recurrent UTIs
  • Renal stones
  • ESRF occurs at roughly 50yr
69
Q

Mx of polycystic kidney disease

A
  • Tolvaptan slows cyst dvlpt in AD
  • antihypertensive
  • analgesia
  • Abx
  • drainage
  • dialysis and transplant
70
Q

Causes of hyaline casts on urine MC&S

A
  • normal
  • after exercise
  • loop diuretics
71
Q

causes of chronic kidney disease that present with bilaterally enlarged kidneys on ultrasound

A
  • HIV-associated nephropathy
  • AD polycystic kidney disease
  • diabetic nephropathy (early stages)
  • amyloidosis
72
Q

Causes of metabolic acidosis

A

Normal anion gap
- GI bicarbonate loss: diarrhoea, ureterosigmoidostomy, fistula
- renal tubular acidosis
- drugs: e.g. acetazolamide
-ammonium chloride injection
- Addison’s disease

Raised anion gap
- lactate: shock, hypoxia
- ketones: diabetic ketoacidosis, alcohol
- urate: renal failure
- acid poisoning: salicylates, methanol

73
Q

cause of metabolic alkalosis

A
  • vomiting / aspiration (e.g. peptic ulcer leading to pyloric stenos, nasogastric suction)
  • diuretics
  • liquorice, carbenoxolone
  • hypokalaemia
  • primary hyperaldosteronism
  • Cushing’s syndrome
  • Bartter’s syndrome
  • congenital adrenal hyperplasia
74
Q

causes of respiratory acidosis

A
  • COPD
  • decompensation in other respiratory conditions e.g. life-threatening asthma / pulmonary oedema
  • sedative drugs: benzodiazepines, opiate overdose
75
Q

causes of respiratory alkalosis

A
  • hyperventilation
  • pulmonary embolism
  • salicylate poisoning
  • CNS disorders: stroke, subarachnoid haemorrhage, encephalitis
  • altitude
  • pregnancy
76
Q

Hypocalcaemia is an indication that kidney disease is chronic or acute?

A

chronic

77
Q

indication of Alport Syndrome

A

renal failure, sensorineural hearing loss and ocular abnormalities develop in a child

78
Q

Post renal transplant mx of low urine output, with tachycardia and relative hypotension

A

fluid challenge, probably just hypovolaemic

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