Renal Flashcards
Myeloma kidney types/causes
SEVERITY OF RENAL DYSFUNCTION CORRELATES WITH PATIENT SURVIVAL
Myeloma cast nephropathy (tubular)
Amyloidosis (glomerular)
Monoclonal immunoglobulin deposition disease (glomerular)
Also plasma cell infiltration (interstitial)
Renal failure also from hypercalcaemia, hyperuricaemia, drugs
Isolated tubular dysfunction often in light chain disease-proximal mostly- giving RTA and maybe acquired Fanconi syndrome
Also interstitial nephritis (interstitial)
Why would you do an abdominal fat pad aspirate?
If you are thinking AL Amyloidosis
- nephrotic range proteinuria
- peripheral sensorimotor neuropathy
- autonomic neuropathy
- carpal tunnel
- peri orbital purpura
- diarrhoea and malabsorption
- macroglossia
- heart failure
Type of renal dysfunction associated with pamindronate
Focal segmental glomerulosclerosis
4 induction drugs
Steroids
Cyclophosphamide
MMF
rituximab- refractory
Side effects cyclophosphamide
Gonadal toxicity Major infection HZV bladder toxicity Malignancy Bone marrow suppression
Mechanism of probenecid increasing plasma concentration of drugs like penicillin and oseltamivir
Inhibits organic anion excretion in proximal tubule
Mechanism of increased creatinine in trimethoprim and cimetidine
Atp dependent transporter called P glycoprotein on brush border membranes secretes lots of drugs as well as creatinine and neurotransmitters. No change in actual gfr, the creatinine is just not being secreted
Abx choice in infected cyst in PCKD
Good pathogen cover AND good cyst penetrance
Cipro
Differentiate between ruptured cyst which has mild fever, some flank pain but usually no white cell count
Rasburicase mechanism in tumour lysis
Breaks down Uric acid and minimises xanthine accumulation
FSGS - what do you see in the urine.
Microscopic haematuria, hypertension, kidney insufficiency
IgA nephropathy - secondary causes include
Chronic liver disease
Coeliac
HIV
IBD
Effects of anaemia in Ckd
LVH
REDUCED QOL
cv complications
Causes of distal RTA
Autoimmune disorders
Lithium or amphotericin
Hypercalciuria
Hyperglobulinaemia
Also see nephrocalcinosis and urine PH over 6 in type 1
Gitleman syndrome
Looks like thiazide effect on kidney Autosomal recessive Hypokalaemic metabolic alkalosis BP low Low mg Inactivating mutation in sodium chloride cotransporter in DCT
Cyclosporine A toxicity renal mech
Constrict adherent and efferent arterioles
Hypertension with high levels
HUS class effect
Chronic toxicity irreversible
Path changes- arteriolar hyalinosis, glomerulosclerosis, interstitial fibrosis, “striped fibrosis” TGF beta and Ang II mediated
Also risk hyperkalaemia, hyperuricaemia, metabolic acidosis, low mg, low phosphate
Name some interstitial nephritis drugs
NSAIDs - even after months exposure. Due to leukotriene increase. Can cause minimal change picture
Aminoglycosides- saturable tubular uptake so single large doses therefore better
Lithium
Amphotericin
Gentamicin
Antivirals- use entecavir over indinavir in HAART if CKD 3 or above. Causes ATN also, low phosphate, low my, increase creatinine, glycosuria
Ppi
Fanconi syndrome
Disease of proximal renal tubules.
Loss glucose, amino acids, Uric acid, phosphate, bicarb in urine
Type 2 RTA
LOSS PHOSPHATE leads to Ricketts
Clinical features polyuria, polydipsia, acidosis, growth failure, low K, high Cl
Inherited- cystinosis, Wilsons, glycogen storage diseases
Acquired- tenofovir, lead poisoning, expired tetracycline, mm or MGUS
Cisplatin and toxicity mech
Renal tubular toxin from free radical formation And CKs
Mg wasting
HUS
Time frame interstitial nephritis and PPI
Usually three months
Sometimes up to nine months
Penicillamine renal side effect
Membranous
Renal effect with VEGF inhibitors…. What is it?
Podocyte damage- see thickened BM with podocyte effacement
Need to monitor for proteinuria
Eg bevacizumab
Hydralazine renal side effect
Drug induced lupus
Trimethoprim effect on potassium
Increase- even in normal renal function
Risk of gadolinium in renal failure
Contraindicated if GFR less than 30 due to risk of nephrogenic systemic fibrosis. Dialyse soon after if possible. 2-75 days from exposure, median 25. Most cases with gadodiamide- less risk with gadobenate
minimal change disease drug and secondary causes
Drug: NSAIDs and bisphosphonates
malignancy: usually primary haematological - resolution with control of malignancy
Tests in RPGN
Anca ANA and dsDNA Complement IgA Phospholipase A2 receptor ab HCV HBV anti GBM ab Anti DNase B, ASOT Cryoglobulins
High anion gap METABOLIC ACIDOSIS
GOLD MARK
glycols- propylene and glycolene
Oxolene- paracetamol in malnourished ladies chronic
L- lactate- infusion metabolism phenobarbotone or lorazepam when solute propylene glycol
d lactate- short gut syndrome
Methanol
Aspirin
Renal failure
Ketoacidosis
Normal anion gap MA
8-13
Loss bicarb- diarrhoea, CA Inhibitors, type 2 RTA, pancreatic ileostomy, pancreatic or biliary or intestinal fistula
Exogenous admin HCl or ammonium chloride
Decreased renal acid excretion- type 1 and 4 RTA, renal failure.
Hyperkalaemia
Recovery fromDKA
Urine anion gap use
Differentiate between renal and gut causes of hyperchloraemic MA
GUT uag will be neGUTive
Renal distal accidification problem will be positive
Normal is zero or neg
This is because AG estimates loss of Cl as marker of ammonium in urine. If renal problem cannot do this so positive gap
Distal RTA
Autoimmune HyperPT, vit D toxicity Thyroid disorders Hypergammaglobulinaemia Amphotericin, lithium, ifosfamide, PPI, NSAIDs Chronic hep Obstructive uropathy Sickle cell Renal Tx
Type 2 RTA
Often assoc Fanconi MM contrast agents Adenovir, tenofovir Aminoglycosides Rhabdo Heavy metals Amyloid Interstitial nephritis
Causes type 4 RTA
Acquired: decreased renin from diabetic nephropathy, NSAIDs, interstitial nephritis
Acquired: normal renin reduced aldosterone in ACE ARB heparin
Acquired: decreased response aldosterone in K sparing diuretics, trimethoprim, tac, pentamidine, tubulointerstitial disease- sickle cell, SLE, amyloid, DM
Warfarin in AF and esrf?
High rates GI bleeding in these patients.
Retrospective cohort in Circulation 2014 Jan- suggested higher rate haemorrhagic stroke and other bleeds, need RCT
Consider formation vascular access when…
Patient likely to live more than one year and gfr less than 20
Benefits of PD over HD
Preserve RRF cheaper Less inflammation Less infection Independence and employment Even volume and BP control Increase in early graft function post Tx Reduce EPO/ iron Preserve vascular access
FIVE MAIN EFFECTS OF RENAL BONE DISEASE
Bone Anaemia Fluid Electrolytes Waste retention
Degree of RAS needed to induce Renal ischaemia and activate RAAS
Over 75 percent
Three drugs most well known for drug induced lupus
Hydralazine
Procainamide
Isoniazid
… Arthralgia and arthralgia, pericarditis and pleuritic, ANTI HISTONE AB IN 95%
Why do you give amiloride in nephrogenic diabetes insipidus caused by lithium
Directly blocks ENaC and decrease tubular uptake of lithium leading to reduced long term damage
Differential metabolic acidosis plus resp alkalosis combined
Liver disease
Sepsis
Salicylate toxicity
Indications for dialysis
Uraemic symptoms
Acidosis refractory to medical therapy
Fluid overload refractory
Electrolyte disturbance not easily managed with medications
Progressive deterioration in nutritional status refractory to dietary intervention
Also: refractory bp control and cognitive impairment
How is urine pH important in urine infection suspicion
If over 7 suggest urease splitting organism like proteus or pseudomonas
Also highly alkaline urine can cause false positive dipstick
ABO incompatibility- is it a contraindication to transplantation
No - do just as well!
Benefits of transplantation
improved long term survival comp dialysis- if fit for it
QOL- independence from dialysis and fluid restriction, work, feel better
Cheaper after 1st year
Complications of ADPCKD
UTI risk- GIVE CIPRO
Renal cyst rupture –>pain or haematuria
Hypertension and proteinuria and compl of CKD
ESKD- 50s for PCK-1 and 70s for PCK-2
Thoracic aortic dissection, cervico-cephalic, coronary artery aneurysms
MV prolapse and AI
IC aneurysms- screen with MRA if family history, neuro sx, or high risk like pilot.
What is the most significant cause of renal anaemia?
reduced EPO synthesis
