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RACP > Renal > Flashcards

Renal Flashcards

1
Q

Lupus Nephritis

A
  • Females&raquo_space; Males
  • Asian, African, Hispanic
  • Glomerula Haematuria
  • Positive Serology, C3 C4 etc
  • Dx - renal biopsy
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2
Q

Lupus Nephritis Classes

A
  1. Minimal Mesangial - monitored, no Rx
  2. Mesangial Proliferative - Monitored, no Rx
  3. Focal Lupus Nephritis 50% of Glomerulus
  4. Pure Membranous
  5. Advanced Sclerosing LN >90 of glomeruli sclerosed - prep for dialysis
    - Active vs chronic
    - Features - cellular, immune complexes on both sides of the glomerulus
    - Staining for IgG, C1q
    - Poor prognosis in ethnicity, failure to respond, raising Cr
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3
Q

Treatment of Lupus Nephritis

A

Induction

  • Steroids - high dose pulses (methyl pred)
  • Cyclophosphamide - IV less toxic monthly pulses, infertility
  • myocophenaliate
  • Retuximab
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4
Q

Peritoneal Dialysis

A

hj

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5
Q

Indications for PD catheter removal

A
  • relapsing or refractory peritonitis,
  • refractory catheter infection
  • fungal or mycobacterial peritonitis
  • peritonitis associated with intra-abdominal pathology
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6
Q

Polymicrobial peritonitis in PD

A
  • Peritonitis due to multiple enteric organisms or mixed gram-negative/gram-positive organisms
  • Concern of intra-abdominal condition such as ischemic bowel or diverticular disease
    # Mx
  • Broadspectrum Abs
  • Imaging/laproscoptic Ix
  • Surgical opinion
  • Removal of catheter
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7
Q

Noninfectious complications of peritoneal dialysis

A 
# Outflow failure
- usually constipation
# Pericatheter leak
- Leaking around catheter - e.g. weak muscles or increased activity
# Abdominal wall herniation
# Catheter-cuff excursion
# Intestinal perforation
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8
Q

Nephrotic range Proteinuria

A

> 3g/day

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9
Q

Nephrotic syndrome

A
  • proteinuria
  • hypoalbuminemia
  • oedema
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10
Q

Trimethoprim in CKD

A
  • Inhibition of Na uptake in distal tubule
  • Leading to higher Na excretion.
  • Causes the tubular cells to retain K and can cause hyperkalaemia
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11
Q

Phenytoin in Renal Disease

A
  • 90% bound to Albumin
  • 10% Free
  • Hypoalbunaemia - Increase free concentrate of phenytoin
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12
Q

Management of end stage renal failure

A
  • Delay Haemodialysis as long as possible (HD -> rapid decline in eGFR
  • Every 1ml/min of GFR protects from death
  • Avoid nephrotxins
  • PD as initial modality
  • RAAS blockage
  • Avoid Hypovolaemia
  • Prevent PD peritonitis
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13
Q

Most common stage of CKD in Australia

A
  • Stage 3
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14
Q

Non-Traditional Risk CVD risk factors

A
  • albuminuria and eGFR - Independent Risk factors
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15
Q

Treatment of contrast Nephropathy

A
  1. Minimise contrast tests
  2. Use nonionic low-osmolal agents
  3. Prehydration with Sodium Bicarbonate (better than N.Saline)
  4. acetylcysteine (NAC) - no evidence
    5.
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16
Q

Symptoms suggestive of cryoglobulinemia include

A
  • purpuric rash
  • arthralgia
  • Raynaud’s phenomenon.

In patients already diagnosed with chronic HCV infection, serum cryoglobulins should be measured.

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17
Q

Kidney transplant - Graft regection

A

Mediated by T Lymphocytes

Tissue destruction occurs due to direct T cell-mediated lysis of graft cells, T cell activation of accessory cells, alloantibody production, and/or complement activation.

18
Q

Infections post renal transplant

A 
# Early (1-6 months)
- Cytomegalovirus *****
- Pneumocystis carinii (septic)
- Legionella
- Listeria
- Hepatitis B
- Hepatitis C
# Late (>6 months)
- BK virus (polyoma) ***** (note renal impairment)
- Aspergillus
- Nocardia
- Herpes zoster
- Hepatitis B
- Hepatitis C

Pneumocystis jiroveci also occurs between 1-6 months post transplant. Patients appear more septic

19
Q

IgA nephropathy

A
  • called Berger’s disease or mesangioproliferative glomerulonephritis
  • commonest cause of glomerulonephritis worldwide
  • pathogenesis unknown
  • histology: mesangial hypercellularity, positive immunofluorescence for IgA & C3 differentiating between IgA nephropathy and post-streptococcal glomerulonephritis

Presentations
- young male, recurrent episodes of macroscopic haematuria
- typically associated with mucosal infections e.g., URTI
- nephrotic range proteinuria is rare
- renal failure
Associated conditions
- alcoholic cirrhosis
- coeliac disease/dermatitis herpetiformis
Management
- steroids/immunosuppressants not be shown to be useful
Prognosis
- 25% of patients develop ESRF
- markers of good prognosis: frank haematuria
- markers of poor prognosis: male gender, proteinuria (especially > 2 g/day), hypertension, smoking, hyperlipidaemia, ACE genotype DD

20
Q

Post Strep GN

A
  • post-streptococcal glomerulonephritis is associated with low complement levels
  • main symptom in post-streptococcal glomerulonephritis is proteinuria (although haematuria can occur)
  • there is typically an interval between URTI and the onset of renal problems in post-streptococcal glomerulonephritis
21
Q

Target Hb in renal failure

A

Target Hb in renal failure - 120-130 g/dl.

22
Q

Is there a benefit of renal artery stenting

N Engl J Med 2014; 370:13-22 - CORAL Study

A

renal-artery stenting is futile

23
Q

Clinical features of lupus nephritis

A

1) Acute renal impairment
2) Microscopic hematuria
3) Proteinuria
4) Nephrotic syndrome
5) Lupus serology (DsDNA, C3,C4)

Not Nephritic Syndome

24
Q

Nephritic Syndome

A

1) Haematuria
2) Proteinuraia
3) HTN
Conditions
- SLE
- IGA GN
- Post Strep GN
- Henoch–Schönlein purpura
- Rapidly progressing GN

25
Q

Nephrotic Syndrome

A

1) Proteinuria (Large >3.5g/day)
2) Hypoalbumaemia (<2.5
3) Oedema

26
Q

Stages of Lupus nephritis

A

stage I: Minimal mesangial lupus nephritis(LN)
stage II: Mesangial proliferative LN
stage III: Focal LN <50% gloms involved.
stage IV: Diffuse LN >50% gloms involved.
stage V: Pure membranous LN
stage VI: Advanced sclerosing LN >90% gloms involved.

27
Q

Lupus nephritis is associated with the following histological features:

A 
– subendothelial immune deposits/wire loops
– hypercellularity
– leukocyte infiltration
– fibrinoid necrosis
– hyaline thrombi
– crescents in severe LN

not machrophage infaltration

28
Q

Treatment of Lupus Nephritis

A 
1) Induction agents for lupus nephritis:
– Prednisone
– cyclophosphamide
– Mycophenolate mofetil(MMF)
– Rituximab (refractory cases)
2) Maintenance Treatment:
– MMF or Azathioprine to continue for at least 2 years post remission.
29
Q

Cyclophosphamide toxicity

A

1) Infertility secondary to gonadal toxicity
2) Malignancy
3) Bladder toxicity
4) Myelosuppression
5) Herpes zoster
6) Major infection

30
Q

MMF causes the following side effects

A 
GI upset which is a dose response side effect
Leukopenia
Thrombocytopenia
Anemia
Infection
Malignancy
31
Q

Rapidly Progressive GN

A 
# Induction:
- cyclophosphamide and IV methylprednisone
# Maintenance therapy:
- Azathioprine
- For severe cases:
- Plasma exchange
# Other agents:
- Methotrexate-induction and maintenance
- Rituximab
- Bactrim
- IVIG

Cyclosporin not used

32
Q

Macroalbuminuria in diabetic nephropathy in men

A

In men:
- urine ACR of >25mg/mmol and AER of >300mg/24hrs.
In women:
- urine ACR of >35mg/mmol and AER of >300mg/24hrs.

33
Q

Indications for use of ACEi to slow progression of microalbuminuria
N Engl J Med. 2004 Nov 4;351(19):1941-51

A
  • Hypertension

Note in normal blood pressure ARBs - no benefit

34
Q

Effect of ACE & ARB in normotensive T1 & T2DM

N Engl J Med. 2009 Jul 2;361(1):40-51

A
  • protective against rentinopathy

not microalbuminurea/nephropathy

35
Q

Goodpastures syndrome

A
  • IgG deposits on renal biopsy
  • anti-GBM antibodies
  • HLA DR2
  • Pulmonary haemorrhage & Rapidly progressive GN
    Management
  • plasma exchange (plasmapheresis)
  • steroids
  • cyclophosphamide
36
Q

Minimal change glomerulonephritis

A

1st - prednisolone

2nd ACEi

37
Q

Thrombotic thrombocytopenic purpura (TTP)

A

The combination of:

  • neurological features
  • renal failure
  • pyrexia
  • thrombocytopaenia
38
Q

Primary biliary cirrhosis

A

the M rule
- IgM
- anti-Mitochondrial antibodies, M2 subtype
- Middle aged females
look for raised LFTs (DDx from Sjogren’s syndrome)

39
Q

Herpes simplex encephalitis

A

Features
- fever, headache, psychiatric symptoms, seizures, vomiting
- focal features e.g. aphasia
- peripheral lesions (e.g. cold sores) have no relation to - presence of HSV encephalitis
Pathophysiology
- HSV-1 responsible for 95% of cases in adults
typically affects temporal and inferior frontal lobes
Investigation
- CSF: lymphocytosis, elevated protein
- PCR for HSV
- CT: medial temporal and inferior frontal changes (e.g. petechial haemorrhages) - normal in one-third of patients
- MRI is better
- EEG pattern: lateralised periodic discharges at 2 Hz
Treatment
- intravenous aciclovir

40
Q

Reactive arthritis

A
  • one of the HLA-B27 associated seronegative spondyloarthropathies
    Management
  • symptomatic: analgesia, NSAIDS, intra-articular steroids
  • sulfasalazine and methotrexate are sometimes used for persistent disease
  • symptoms rarely last more than 12 months
41
Q

Haemolytic uraemic syndrome

A
  • classically caused by E coli 0157:H7

- AKI

42
Q

Primary hyperaldosteronism

A

Features
- hypertension
- hypokalaemia (e.g. muscle weakness)
alkalosis

Investigations
- high serum aldosterone
- low serum renin
- high-resolution CT abdomen
adrenal vein sampling

Management
adrenal adenoma: surgery
bilateral adrenocortical hyperplasia: aldosterone antagonist e.g. spironolactone

RACP (15 decks)

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