Renal Flashcards
1
Q
In CKD what replaces the normal glomeruli and tubules?
A
Fibrosis
2
Q
What is the prevalence of CKD in adults?
A
3 to 7 percent
3
Q
Which races are prone to CKD?
A
Blacks and Asians (2-3x)
4
Q
What is the biggest cause of CKD in the UK?
A
Diabetes
5
Q
What is the second biggest cause of CKD in the UK?
A
Glomerular nephritis
6
Q
What is the third biggest cause of CKD?
A
Hypertension
7
Q
What the common causes of CKD?
A
DM GN HTN Pyelonephritis Vascular disease
8
Q
In which age group is CKD most common?
A
The elderly
9
Q
Describe the natural history of CKD?
A
Hyperfiltration > microalbuminuria > macroalbuminura > nephrotic syndrome and proteinuria > CKD
10
Q
What mode of inheritance is polycystic kidney disease?
A
Autosomal dominant
11
Q
Explain the genetics behind polycystic kidney disease?
A
Single mutation of either one of two interacting genes
12
Q
In polycystic kidney disease, is the patient predisposed to CKD?
A
Yes
13
Q
What complications may arise in polycystic kidney disease?
A
Subarachnoid haemorrhage
14
Q
Where are cysts found in polycystic kidney disease?
A
Liver
Kidneys
Ovaries
15
Q
How is polycystic kidney disease diagnosed?
A
USS
16
Q
How is polycystic kidney disease managed?
A
Treat hypertension
Deal with complications such as infected cysts
Tolvaptan slows progression
Transplant
17
Q
When is a patient with polycystic kidneys likely to reach CKD stage 5?
A
Middle age
18
Q
What other considerations, outside of treatment, must be made in CKD?
A
Screen family
Organise a pre emptive transplant
19
Q
What is a normal GFR?
A
100ml/min
20
Q
What can naturally influence GFR?
A
Age, sex, race and muscle mass
21
Q
Which stages of CKD are normal and do not require treatment?
A
1 and 2
22
Q
What is CKD stage 1?
A
eGFR
23
Q
What is CKD stage 2?
A
eGFR 60-90 with a kidney problem
24
Q
What is CKD stage 3?
A
eGFR 30-60
25
What is CKD stage 4?
eGFR 15-30
26
What is CKD stage 5?
eGFR less than 12
27
What is the most common reason for mortality in stages 3 and 4?
Another cause
28
What is the PCR?
The ratio of protein to creatine in the urine - divided by 100 gives the rough 24h urine protein
29
When is PCR inaccurate?
Extremes of muscle mass
30
Which value of PCR is significant?
over 100
31
What PCR will put you in the nephrotic range?
over 250
32
What stage of CKD needs urgent renal replacement therapy?
5
33
What are the primary targets in CKD treatment?
Reducing BP
| Reducing proteinuria
34
In CKD which drugs are used to lower protein and adjust BP?
ACE-I e.g. ramipril
35
What factors must be considered when managing CKD?
```
BP
Reducing proteinuria
Diabetic control
Cholesterol
Prophylactic aspirin
Healthy living
```
36
Why may anaemia be present in CKD?
Lack of EPO production
37
Why is calcium often high with osteoporosis in CKD?
Kidneys cannot activate vitamin D so PTH is elevated to release calcium from bones
38
Why else might PTH be high in CKD?
High phosphate as not lost in urine can cause PTH to rise
39
How is metabolic acidosis treated in CKD?
Bicarbonate tablets
40
What is a major side effect of bicarbonate tablets?
Raised BP
41
What stages of CKD should be referred onto nephrology?
4 and 5
42
Define an AKI?
Acute, usually reversible decline in kidney function
43
How is AKI defined?
Pre renal
Intrinsic renal
Post renal
44
What may cause pre renal AKI?
Hypovolaemia
| Renal artery stenosis
45
What is the UK prevalence of AKI?
38000/year
46
What is the mortality rate of those with AKI?
15.2 percent
47
What is a stage 1 AKI?
Creatinine over 250mmol or 150-200 percent from baseline
48
What is a stage 2 AKI?
200-300 percent rise in creatinine from baseline
49
What is a stage 3 AKI?
Over 300 percent rise in creatinine from baseline or creatinine over 350mmol
OR
Creatinine over 45 on RRT
50
What is a stage 3 AKI if on RRT?
Creatinine over 45
51
Which artery enters the kidney?
Afferent renal artery
52
Which artery exits the kidney?
Efferent renal artery
53
What is the normal glomerular filtration pressure?
10mmHg
54
What factors normally maintain renal perfusion?
RAAS
| Sympathetic nervous system
55
What may cause a pre renal AKI?
Loss of blood
Loss of plasma
Loss of salt and water
56
Which conditions can cause reduced kidney perfusion in the absence of hypovolemia?
Cardiac nephrotic syndrome (nephrotic syndrome with CCF)
| 3rd Spacing - loss of intravascular volume to other parts of the body
57
Which type of AKI can be seen on a urine dip?
intrinsic
58
What are the signs of pre renal AKI?
Not visible JVP due to volume depletion
| Orthostatic hypotension
59
When would pre renal AKI have a raised JVP?
Cardiac nephrotic syndrome or in co existing CCF
60
What are the first line investigation in AKI?
Urine dip
Urine sodium
Blood test shows raised creatinine
61
How is pre renal AKI treated?
Volume replacement ( or improve cardiac function in CCF)
62
What treatments are contraindicated in pre renal AKI?
Catheter
| Diuretics
63
Does GN normally present as an AKI?
No, usually CKD
64
Which syndrome may cause intrinsic AKI?
Nephrotic syndrome
65
What musculoskeletal signs are seen in intrinsic AKI?
Myalgia
Bone pain
Joint pain
66
Which signs are often seen on examination with intrinsic AKI?
Depleted fluid status
Rash
Uveitis
Hearing loss or neurodeficit
67
What is the gold standard test for intrinsic AKI?
Renal biopsy
68
Which drugs are most likely to cause intrinsic AKI?
Antibiotics
69
Which tests should be done in intrinsic AKI?
```
Urine culture and microscopy
GN Screen
PCR
Electrophoresis
Blood film
Creatinine
```
70
Which diseases affect the kidney interstitium?
Tubular interstitial nephritis
| Acute tubular necrosis
71
Which drugs can cause tubular interstitial nephritis?
NSAIDs and antibiotics
72
Which white blood cells are present in acute tubular necrosis?
Eosinophils
73
What is seen on microscopy with acute tubular necrosis?
Protein casts
74
What is a complication of acute tubular necrosis due to protein casts?
Cast nephropathy due to obstructive casts
75
Which form of AKI can lead to acute tubular necrosis?
Pre renal AKI
76
Which drug can cause direct acute tubular necrosis?
Gentamycin
77
Which condition can cause acute tubular necrosis?
Rhabdomyolysis
78
How is acute tubular necrosis managed?
Self resolving
79
If acute tubular necrosis does not resolve, what is the complication?
Cortical necrosis
80
How is interstitial nephritis treated?
Stop offending medication
| Start steroids
81
What SHOULD NOT be done when treating intrinsic AKI?
Catheter
82
How is intrinsic AKI initially treated?
IV fluids and diuretics
83
How can obstruction be classified in post renal AKI?
Outside
Within lumen
Within wall
84
Which type of AKI presents with pain?
Post renal
85
Which urine symptoms may be present in post renal AKI?
Anuria
| Haematuria
86
What may be present on examination with post renal AKI?
Palpable bladder due to retention
87
Which lab investigations must be done in post renal AKI?
Urine and bloods
88
What imaging must be done on post renal AKI?
USS and CT
89
What signs are seen on a CT with post renal AKI?
Mickey Mouse sign
| Grossly dilated renal pelvis
90
What is the initial management of a post renal AKI?
Catheter
91
After a catheter, what is the next step in the management of a post renal AKI?
anterograde or retrograde drainage
92
What complication can lead to ECG in AKI?
Hyperkalemia
93
What are the complications of AKI?
Hyperkalemia
Metabolic acidosis
Pulmonary oedema
94
Is hyperkalemia a medical emergency?
Yes
95
How is hyperkalemia treated?
IV calcium
Insulin and dextrose
IV salbutamol
Dialysis
96
Why does pulmonary oedema occur in AKI?
Salt and water retention
97
How is pulmonary oedema treated?
High dose IV diuretics
Dialysis
Vasodilation
Venesection (maybe)
98
What is complication of AKI resolution?
Diuresis
99
When might diuresis occur after AKI?
After acute tubular necrosis or obstruction
100
How is diuresis monitored?
Blood pressure
Pulse
Assess fluid status using daily weights
101
How is diuresis treated?
IV fluids
102
What is the diagnostic criteria for nephrotic syndrome?
Proteinuria >3g/day
| Hypoalbuminaemia
103
Which medications can cause nephrotic syndrome?
NSAIDs
| Herbal medications
104
Which non specific symptoms may be seen in nephrotic syndrome?
Frothy urine
Low BP
Oedema
105
What would show on urine dip with nephrotic syndrome?
Protein (+/- blood)
106
When does PCR underestimate protein in the urine?
In muscular people
107
When does PCR overestimate protein in the urine?
In frail people with little muscle
108
What is PCR 15-30?
Trace
109
What is PCR 30-100?
1+
110
What is PCR 100-300?
2+
111
What does PCR 300-1000 indicate?
3+
112
What does PCR over 1000 indicate?
4+
113
When might PCR results be a false positive for nephrotic syndrome?
When albumin is not the greatest protein component in urine e.g. in multiple myeloma
114
Which fluid compartment expands with nephrotic syndrome?
Interstitial fluid
115
What complications can arise from oedema?
Pleural effusion
| Ascites
116
Why does pulmonary oedema occur in nephrotic syndrome?
It leads to congestive cardiac failure
117
Why does oedema occur in nephrotic syndrome?
Primary sodium retention (overfill hypothesis)
118
Why does primary sodium retention occur in nephrotic syndrome?
Increase in the sodium/potassium pump activity
119
What can further increase water retention in oedema?
ANP
120
What is the underfill hypothesis?
Low serum albumin so low colloid oncotic pressure activates RAAS that causes salt and water retention
121
In which type of nephrotic syndrome is oedema due to the undersell hypothesis?
Sudden onset
122
What are the first line investigations in nephrotic syndrome?
Urine - PCR, microscopy, and dipstick
FBC, clotting, Us and Es +/- nephritic screen
USS KUB
123
What is the gold standard test to confirm nephrotic syndrome?
Renal biopsy
124
What conditions can cause nephrotic syndrome?
Minimal change disease
FSGS
Membranous nephropathy
Amyloidosis
125
In which group of patients with nephrotic syndrome, is a biopsy not recommended?
Young children
126
What is seen on light microscopy with minimal change disease?
Nothing
127
What is seen on electron microscopy with minimal change disease?
Fusion of podocytes
128
What is the main cause of minimal change disease?
Primary/idiopathic
129
What are secondary causes of minimal change disease?
Drugs
Cancer
Infection
Allergy
130
In which age group is minimal change disease most prevalent?
Children under 5
131
What affect does minimal change disease have on blood pressure?
Normal or low
132
What effect is there on renal function in minimal change disease?
None - unless in pre renal AKI
133
Is there microscopic haematuria in minimal change disease?
No - but possible in adults
134
What are the classifications of FSGS?
Primary idiopathic and secondary
135
How is secondary FSGS identified?
Histological lesion
136
In primary FSGS what symptoms are present?
Nephrotic syndrome
Microscopic haematuria
Hypertension
Renal impairment
137
What is the most common cause of secondary FSGS?
Hypertension
138
Is nephrotic syndrome present in secondary FSGS?
No
139
Which underlying conditions can cause secondary FSGS?
Hypertension
HIV
Obesity
140
Which drugs can cause secondary FSGS?
Heroin
| Pamidronate
141
Which part of the glomerulus is affected in FSGS?
Segmental part
142
Why does sclerosis occur in FSGS?
Excess collagen deposition due to damage
143
When is membranous nephropathy the most common cause of nephrotic syndrome?
In non diabetic adults
144
What are the risk factors for membranous nephropathy?
Older
Male
White
145
What is seen on histology with minimal change disease?
Thickened capillary loops
| Sub endothelial immunoglobulin deposition
146
Which medical conditions can cause secondary membranous nephropathy?
SLE
Malignancy
Infection
Sarcoidosis
147
Which drugs can cause membranous nephropathy?
Penicillamine
Gold
Anti TNF
148
Which infections can cause membranous nepthropathy?
Hepatitis B and C
HIV
Malaria
Syphillis
149
When can amyloidosis cause membranous nephropathy?
In minimal change disease
150
What is a major cause of membranous nephropathy in infants?
Congenital
151
What is the treatment for oedema?
Fluid restrict to less than 1l a day
| Diuretics
152
What is the first line diuretic in oedema?
Loop diuretics e.g. furosemide
153
What is the second line diuretic in oedema?
Aldosterone antagonists e.g. spironolactone
| Thiazide like diuretic metolazone
154
How does a thiazide diuretic work?
By inhibiting the sodium/chloride symporter
155
What the complications of oedema?
Infection
Thromboembolism
Renal impairment
Dyslipidaemia
156
Which age group is more prone to infection from oedema?
Children
157
Why does thromboembolism occur more often in oedema?
Decrease ATIII
158
What is the first line treatment to reduce proteinuria?
ACE-I
159
What is the second line treatment to reduce proteinuria?
ARBs (e.g. losartan)
160
How do ACE-I and ARBs reduce proteinuria?
Reduce intraglomerular pressure
161
How should dyslipidaemia be managed?
Statins
162
Which type of kidney condition takes longer to respond to steroids?
FSGS
163
How is idiopathic membranous nephropathy treated?
Steroids + beta calcinin inhibitor (e.g. cyclophosphamide and nitofinab)
164
What would GN show on a urine dip?
Blood +/- protein
165
What amount of protein is seen in the urine in early GN?
1 to 1.5g
166
What does GN show in urine microscopy?
Renal casts
167
What symptoms are present in aggressive GN?
AKI
Oedema
Hypertension
168
What is the first line investigation in GN?
Urine dip
169
What is the second line investigation in GN?
Urine microscopy and culture
170
How may rapidly processing GN appear?
Rapidly rising creatinine
171
What symptoms characterise nephritic syndrome?
Blood in the urine
Hypertension
Mild oedema
172
What on urine microscopy is trademark of GN?
Red cell casts
173
What are protein casts?
Tamm-Horsfall protein matrix formed in the tubles
174
Which conditions can cause immune mediated GN?
```
Small vessel vasculitis
SLE
Anti GBM disease (Goodpastures)
IgA nephropathy
Cryroglobinaemia
```
175
Which antibodies are present in small cell vasculitis?
ANCA
176
What can cause GN post infection?
```
Hep B
Hep C
HIV
Post - strep
Subacute bacterial endocarditis
```
177
Which malignancies cause GN?
Lymphoma
| Multiple myeloma
178
What should be your top differential with blood on urine dip?
UTI (common things are common)
179
Explain the pathogenesis of GN?
Ig mediated > deposition of antibodies (IgA, GBM antibodies, immunocomplexes) > activation of complement > chemokine release > leukocyte recruitment > glomerular inflammation and crescent formation
180
Which chemotactic factor is involved in the pathogenesis of GN?
C5a
181
How is a crescent formed in GN?
Glomerular necrosis and extra cells infiltrating the urinary space
182
Which leukocytes are recruited in GN?
Neutrophils
Macrophages
Lymphocytes
183
What will be seen on Us and Es with GN?
Raised urea and creatinine
| Reduced bicarbonate
184
What is the gold standard test to diagnose GN?
Renal biopsy
185
Why is a nephritic screen not done on every patient with suspected GN?
High cost
186
What on the nephritic screen is checked using immunofluorescence?
ANCA
187
What is the problem with immunofluorescence of ANCA?
Many false positives
188
What types of ANCA may be present?
Cytoplasmic (cANCA)
| Perinuclear (pANCA)
189
Which types of ANCA are used finding ELISA purified antigens?
```
Proteinase 3 (cANCA)
Myeloperoxidase (pANCA)
```
190
Which GN disease is linked to pANCA?
Microscopic polyangitis (small vessel vasculitis)
191
Which GN is linked to cANCA?
Wegeners
192
What can cause false positive ANCA results?
Endocarditis
193
What is the first line treatment for vasculitis?
High dose glucorticoids (pred or hydro)
Cytotoxic agents such as cyclophosphamide (steroid sparing)
Consider plasma exchange to remove ANCA antibodies
194
What is the second line treatment for vasculitis?
Rituximab
195
How does vasculitis typical present in GN?
Microscopic haematuria that may progress to AKI
196
Other than nephritic syndrome, how may ANCA associated vasculitis present?
Pulmonary renal syndrome
197
What are the signs and symptoms of pulmonary renal syndrome?
Haemoptysis due to pulmonary haemorrhage
Pulmonary nodules
GN
