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General Medicine > Renal > Flashcards

Renal Flashcards

1
Q

Describe polycystic kidney disease.

A

Autosomal dominant

Unilateral or bilateral renal mass(es)

~10% have asymptomatic intracranial aneurysm (therefore screen patients with FHx and ask about subarachnoid haemorrhage symptoms)

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2
Q

What is hepatorenal syndrome?

A

Rapid deterioration in kidney function in individuals with cirrhosis or fulminant liver failure i.e. kidney failure following liver failure due to reduced perfusion

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3
Q

What are the differentials for unilateral renal masses?

A

PRIMARY:

  • cancer (paeds = Wilm’s tumour)
  • haematoma
  • renal abscess (liquefactive necrosis in setting of acute pyelonephritis)
  • xanthogranulomatosis
  • pyelonephritis
  • hydronephrosis
  • renal cyst
  • PCKD (usually bilateral)
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4
Q

What are the differentials for bilateral renal masses?

A
  • renal metastases
  • lymphoproliferative disease
  • renal infarcts
  • primary cancer
  • renal abscesses
  • leukaemia
  • adult PCKD
  • hydronephrosis
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5
Q

What are the investigations in hepatorenal syndrome?

A

BEDSIDE:

  • urine dip. = ?infection, proteinuria, ACR
  • mental status

BLOODS:

  • FBC = ?infection, ?anaemia, ?spontaneous bacterial peritonitis, bilirubin, albumin, clotting, hep. B & C, antibodies
  • LFTs = monitoring
  • U&Es = monitoring
  • clotting
  • complement
  • alpha-fetoprotein = ?hepatocellular carcinoma

IMAGING:
- liver US

FUNCTIONAL:

  • ascitic drain and tap = transudative or exudative
  • OGD = ?varices
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6
Q

What is acute kidney injury?

A

Decrease in renal function which occurs over weeks or months

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7
Q

What are some of the pre-renal causes of acute kidney injury?

A

Systemic:

  • shock
  • dehydration
  • burns
  • crush injury

Local:

  • thrombus
  • atheroma
  • stenosis
  • trauma
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8
Q

What are some of the intrinsic causes of acute kidney injury?

A

Acute tubular necrosis/septic/toxic renal failure (severe acute ischaemia, nephrotoxins)

Interstitial disease (NSAIDs, aminoglycosides, ACE inhibitors, infection)

Glomerular disease:
PRIMARY: IgA nephropathy, minimal change glomerulonephritis, membranous glomerulonephritis, post-infectious glomerulonephritis, focal segmental glomerulosclerosis
SYSTEMIC: vasculitides, SLE, Goodpasture’s, RA, IBD, drugs, neoplastic

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9
Q

Give some examples of small vessel vasculitides.

A 
Behcet's 
Henoch-Schonlein purpura 
Microscopic polyangitis 
Granulomatosis with polyangitis 
Cryglobulinaemia
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10
Q

Give some examples of medium vessel vasculitides.

A

Buerger’s disease
Cutaneous vasculitis
Kawasaki disease
Polyarteritis nodosa

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11
Q

Give some examples of large vessel vasculitides.

A

Polymyalgia rheumatica
Takayasu’s arteritis
Temporal arteritis

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12
Q

What is the management of renal calculi?

A

US: ?hydronephrosis due to obstruction –> nephrostomy

?CT: ?hydropnephosis, location of calculus

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13
Q

Outline the staging of chronic kidney disease.

A

Stage GFR
1. >90 Kidney damage with normal or increased GFR
2. 60-89 Kidney damage with mild decrease in GFR
3A. 45-59 Mild/moderate fall in GFR (but asymptomatic)
3B. 30-44 Moderate fall in GFR and symptomatic
4. 15-29 Severe fall in GFR
5. <15 or on RRT Established renal failure

Use suffix p to denote presence of proteinuria
Stage 1 and 2 need other evidence of kidney damage e.g. urinalysis, USS

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14
Q

How is chronic kidney disease staged according to albumin:creatinine?

A

Stage ACR
A1. <3 Normal
A2. 3-30 Moderate increase
A3. >30 Severely increased

note: albumin makes up 70% of total protein in urine, creatinine is a measure of proteinuria

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15
Q

Outline the screening criteria for CKD.

A
  • diabetes
  • hypertension
  • CVD: IHD, chronic heart failure, PVD, cerebral vascular disease
  • structural renal tract disease
  • renal calculi
  • prostatic hypertrophy
  • multisystem disease with potential for renal involvement e.g. SLE
  • FHx of stage 5 CKD or hereditary kidney disease
  • opportunistic detection of haematuria or proteinuria
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16
Q

What are the factors in calculating eGFR?

A

Serum creatinine

Age

?female

?Black

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17
Q

Define chronic kidney failure.

A

Progressive and irreversible loss of renal function over a period of months or years

Renal tissue replaced by extracellular matrix in response to tissue damage

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18
Q

How can the risk of CKD be reduced?

A
  • patient education
  • relevant medications: ACE inhibitors/Angiotensin II blockers indicated in diabetes when ACR>3 or established CKD with hypertension and ACR>30
  • lifestyle advice
  • treat hypertension: threshold for treatment is 140/90, target BP is 120-139/<90 (if ACR>70 then target BP is 120-129/<80)
  • assess CVD risk: treat hyperlipidaemia, aspirin if indicated
  • influenza/pneumococcal vaccination
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19
Q

What are the risk factors for renal replacement therapy?

A

Diabetes - 25% (~5% incidence in total UK population)

21% unknown

12% glomerulonephritis

7% chronic pyelonephritis

7% hypertension

7% adult polycystic kidney disease

6% renovascular

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20
Q

Outline the factors of pre-dialysis planning.

A

Dialysis: home or unit (QoL, survival time)

Access:

  • AV fistula = creates large vein which can have a wide bore cannula inserted
  • AV graft
  • (un)tunnelled cuffed catheter
  • implantable titanium port
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21
Q

What are the advantages of dialysis?

A
  • large evidence base, long-term survivors
  • dose can be varied or individualised
  • available
  • may be done at home/overnight
  • daily treatment possible
  • can have up to 4 days off from treatment
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22
Q

What are the disadvantages of dialysis?

A
  • 30% experience intra- and post-dialysis symptoms
  • intermittent treatment leads to large shifts in fluid balance and biochemical changes
  • diet may be sodium/potassium/phosphate/protein/water restricted
  • patient may require transport to haemodialysis centres
  • vascular access may be difficult/limiting
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23
Q

What are some of the complications of dialysis?

A
  • CVD: effects on LV, haemodynamic instability, vascular/valvular calcification
  • sepsis: catheter-related blood infection (1-2/1000 days)
  • degenerative: dialysis-related amyloidosis (gradual accumulation of beta-2 microglobulin in blood, as it cannot cross filter)
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24
Q

What are the contraindications of peritoneal dialysis?

A

ABSOLUTE:

  • GI/urinary stoma
  • known peritoneal sclerosis
  • diaphragmatic fluid leak

RELATIVE:

  • hernia
  • severe back pain
  • nephrotic syndrome
  • lack of manual dexterity
  • severe organomegaly
  • multiple operations
  • severe respiratory disease
  • ascites
  • morbid obesity
  • body image
  • cognitive problems
  • unsuitable home environment
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25
Q

What are the advantages of peritoneal dialysis?

A
  • easy to learn with visual/manual disability
  • independence (home-based therapy)
  • mobility (patient can travel more easily)
  • continuous therapy allows more gentle control of uraemia/fluid balance
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26
Q

What are the disadvantages of peritoneal dialysis?

A
  • limited technique survival (50% at 3yrs)
  • infections may be life-threatening
  • weight gain and metabolic problems (glucose in dialysate)
  • daily therapy time-consuming
  • long-term rise of sclerosing peritonitis
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27
Q

What are the complications of peritoneal dialysis?

A

Peritonitis (1/18-24months)

Fluid leaks

Encapsulating peritoneal sclerosis

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28
Q

What are the causes of treatment failure in peritoneal dialysis?

A

40%-47% peritonitis

15%-19% loss of peritoneal function

9%-15% catheter malfunction

4%-15% patient preference

<2% malnutrition

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29
Q

When is renal transplantation offered?

A

All patients with progressive renal impairment/end-stage renal failure

25% of patients on haemodialysis on list

30
Q

What are the contraindications for renal transplant?

A

Extensive PVD

Mental incapacity

Active viral hepatitis

AIDS with opportunistic infections

Cancer

Active infection

Uncontrolled IHD

31
Q

What are some of the medications given to renal transplant recipients?

A 
Steroids 
Azathioprine 
Cyclosporin A/tacrolimus 
Rapamycin 
Mycophenolate mofetil 
Antibodies
32
Q

What are the advantages of renal transplant?

A
  • freedom from dialysis
  • can restore normal renal function
  • cheap
33
Q

What are the disadvantages of renal transplant?

A 
Requires lifelong immunosuppresive drugs 
Operative morbidity/mortality 
Not suitable for all 
Limited supply of organs 
Still left with progressive CKD
34
Q

What are the complications of renal transplant?

A

SURGICAL:

  • ureteric obstruction
  • lymphocoele
  • urine leaks
  • graft thrombosis
  • renal artery stenosis
  • wound infection
  • bleeding

NON-SURGICAL:

  • rejection
  • drug nephrotoxicity
  • reoccurence of primary renal disease

LONG-TERM:

  • diabetes
  • chronic rejection
  • malignancy
  • infection
35
Q

What are the sources for donor kidneys?

A

Cadavers (donation after brain death)

Non-heart beating donor (donation after cardiac death)

Living related donor

Living emotionally related donor

Living unrelated donor

36
Q

Outline withdrawal of dialysis.

A

2nd commonest cause of death (~15%)

Predictors: age, diabetes, White, co-morbidities, poor QoL

37
Q

What are some of the causes of chronic renal failure?

A
  • hypertension
  • vascular
  • diabetes
  • autoimmune: glomerulonephritis, SLE
  • myeloma, neoplasms
  • infection: pyelonephritis
  • genetic: Alport’s, PCKD
  • idiopathic
  • obstruction/reflux
  • hypercalcaemia
38
Q

What are the investigations indicated in chronic renal failure?

A

Bloods:

  • autoantibody screen
  • complement
  • Ig
  • CRP

Imaging:

  • US: size, ?hydronephrosis
  • CT
  • MRI
  • MR renal angiography

Renal biopsy: if kidneys are normal size and cause of CKD is not obvious

39
Q

What are some of the complications of chronic renal failure?

A
  • anaemia: reduced EPO production, resistance to EPO, reduced RBC survival, blood loss, LV hypertrophy
  • renal osteodystrophy: osteitis fibrosa cystica, vascular calcificatiom, periarticular calcification, (sub)cutaneous calcification
  • secondary hyperparathyroidism: bone pain, fractures, hypocalcaemia, hyperphosphataemia
  • coagulopathy
  • hypertension: LV hypertrophy, heart failure, stroke, CVD
  • neurological: uraemic encephalopathy, peripheral neuropathy, restless legs syndrome, sleep disorders, cognitive impairment
  • dialysis-related amyloidoses: bone pain, arthropathy, carpal tumnel syndrome
  • fluid overload: pulmonary oedema, hypertension
  • malnutrition: infections, poor wound healing
  • glucose intolerance
40
Q

Outline the management of complications of chronic renal failure.

A
  • treat underlying disease: diabetes, hypertension
  • modulation of maladaptive response: antihypertensives, protein restriction
  • fluid balance: restriction of fluid intake in oliguria, diuretics in severe volume overload, dietary restriction of sodium and protein
  • hyperkalaemia: dialysis, restrict potassium intake, prevent GI haemorrhage, acidosis or tissue necrosis
  • chronic metabolic acidosis: oral HCO3- supplements
  • malnutrition: folic acid and vitamin B supplements, ?NG tube feeding
  • coagulopathy: oral antiplatelets/anticoagulants
  • bone: bisphosphonates if GFR>30, vitamin D supplements, dietary phosphate restriction or phosphate binders
41
Q

What are the characteristics of glomerulopathies?

A

Primarily immunologically mediated injury to glomeruli, although renal interstitial damage is a regular accompaniment

Kidneys are involve symmetrically

Secondary mechanisms of glomerular injury result following an initial immune insult such as fibrin deposition, platelet aggregation, neutrophil infiltration, and free radical-induced damage

Renal lesions may be part of a generalised disease e.g. SLE

42
Q

What are the signs and symptoms of nephrotic syndrome?

A
  • massive proteinuria (>3.5g/day)
  • hypoalbuminaemia
  • oedema: peri-orbital, face, arms
  • lipiduria
  • hyperlipidaemia
  • frothy urine
  • ascites
  • normal JVP
43
Q

What are the causes of nephrotic syndrome?

A

All types of glomerulonephritis

Systemic vasculitides

Amyloidoses

Drugs

Allergies

44
Q

What are the general and diagnostic investigations in nephrotic syndrome?

A

GENERAL

  • 24hr urine protein >3-5g/day
  • serum albumin >30g/l
  • serum urea and creatinine
  • creatinine clearance
  • CXR for ?pulmonary oedema

DIAGNOSTIC

  • throat swab
  • antistreptolysin O titre
  • ANCA
  • anti-GBM antibody
  • cryoglobulins
  • renal biopsy (contraindicated in young children with selective protein leak, long-standing diabetes, or drug-induced disease)
45
Q

What is the general and specific management of nephrotic syndrome?

A

GENERAL

  • sodium restriction
  • thiazide diuretics
  • ACE inhibitor

SPECIFIC e.g. minimal change glomerulonephritis –> high dose steroids and cyclophosphamide

46
Q

What are the complications of nephrotic syndrome?

A
  • DVT (req. long-term prophylactic anticoagulation)
  • sepsis (give pneumococcal vaccines)
  • oliguric renal failure
  • lipid abnormalities
47
Q

What are the primary and secondary types of nephrotic syndrome?

A 
PRIMARY 
Bland urine sediments
- minimal change nephropathy 
- focal segmental glomerulosclerosis 
- membranous glomerulopathy

Active urine sediments

  • membranoproliferative glomerulonephritis
  • IgM nephropathy

SECONDARY
Bland urine sediments
- amyloidosis
- diabetic nephropathy

Active urine sediments

  • lupus glomerulonephritis
  • cryoglobulinaemic renal disease
  • Henoch-Schönlein purpura
48
Q

What are the features of minimal change nephropathy?

A

Electron microscopy = fusion of podocytes (non-specific; seen in other conditions associated with proteinuria)

  • most common in children
  • does not lead to CKD
  • high dose corticosteroids indicated
49
Q

What are the features of focal segmental glomerulosclerosis?

A

Massive proteinuria, haematuria, hypertension, and renal impairment

Circulating permeability factor increases membrane permeability in isolated glomeruli

Segmental glomerulosclerosis seen –> global sclerosis

Focal tubular atrophy and interstitial fibrosis also present

Rx = prednisolone, ciclosporin, cyclophosphamide, azathioprine, etc.

50
Q

What are the features of membranous glomerulopathy?

A

Asymptomatic proteinuria or frank nephrotic syndrome

May also have microscopic haematuria/hypertension/renal impairment

~40% develop CKD

75% primary (idiopathic), secondary (drugs, autoimmune, infection, neoplasia)

Immunofluorescence = uniform granular capillary wall deposits of IgG and complement C3 –> deposits encircled by basement membrane on silver staining (“spiky” appearance) –> uniform thickening of capillary basement membrane on light microscopy

Rx = cyclophosphamide, ciclosporin, rituximab, mycophenolate

51
Q

What are the features of amyloidosis?

A

Eosinophilic deposits (insoluble protein fibrils)

Light chains (AL amyloid) or secondary amyloid A (AA)

Renal biopsy required

Rx = reduce treatment of amyloidogenic protein, treat underlying inflammation

52
Q

What are the features of diabetic nephropathy?

A

Initial enlargement of kidneys –> glomerular hyperfiltration

Early histological changes: glomerular basement membrane thickening and mesangial expansion, progressive depletion of podocytes (due to apoptosis or detachment and resulting podocyturia)

Later changes: nodular glomerulosclerosis

Rx = lifestyle, ACE inhibitors/Angiotensin II blockers

53
Q

What are the features if membranoproliferative glomerulonephritis?

A

Mesangial cell proliferation

Most develop end-stage kidney disease eventually

No treatment required when idiopathic and normal renal function

Rx = prednisolone trial (children), aspirin or dipyramidamole (adults)

54
Q

What are the features of IgM nephropathy?

A

Increased mesangial cellularity of glomeruli with associated granular immune deposits (IgM and complement) in mesangial regions

Rx = cyclophosphamide, prednisolone

55
Q

What are the features of lupus glomerulonephritis?

A

Overt renal disease occurs in 1/3 of SLE patients, of these 25% reach end-stage CKD within 10yrs

Autoantigen driven, T-cell dependent, B-cell mediated autoimmune disorder

56
Q

What are the features of cryoglobulinaemic renal disease?

A

Cryoglobulins are Igs and complement that precipitate reversibly in the cold.

57
Q

What are the features of Henoch-Schönlein purpura?

A

Characteristic skin rash, abdominal colic, joint pain, glomerulonephritis

Focal segmental proliferative glomerulonephritis

Mainly IgA deposits

Steroids ineffective

58
Q

What are the signs and symptoms of acute nephritic syndrome?

A
  • haematuria
  • proteinuria
  • hypertension
  • oedema
  • oliguria
  • uraemia
59
Q

What are the causes of acute nephritic syndrome?

A

Streptococcal throat infection

Otitis media

Systemic vasculitis

Cryoglobulinaemia

60
Q

What are the complications of acute nephritic syndrome?

A

Hypertensive encephalopathy

Pulmonary oedema

Severe uraemia

61
Q

What are the general and diagnostic investigations in acute nephritic syndrome?

A

GENERAL

  • urine microscopy (red cell casts)
  • serum urea and creatinine
  • creatinine clearance
  • 24hr urine protein
  • C3 and C4
  • CXR for ?pulmonary oedema
  • renal imaging (usually normal)

DIAGNOSTIC

  • throat swab
  • antistreptolysin O titre
  • ANCA
  • anti-GBM antibody
  • cryoglobulins
62
Q

What is the management of acute nephritic syndrome?

A
  • daily weight checks
  • fluid balance chart
  • antihypertensives
  • BP monitoring
  • sodium restriction
  • fluid restriction
  • dialysis if required
  • Abx for post-streptococcal infections
63
Q

What are some of the acute nephritic syndromes?

A 
Post-streptococcal glomerulonephritis 
Non-streptococcal post-infectious glomerulonephritis 
Infective endocarditis 
Shunt nephritis 
SLE 
Henoch-Schönlein purpura 
Cryoglobulinaemia
64
Q

What are the features of post-streptococcal glomerulonephritis?

A

Patient (usually a child) suffers streptococcal infection 1-3wks previously

Renal biopsy: diffuse, acute, florid inflammation in the glomerulus with neutrophils and IgG deposition

Small no. develop CKD in later life

65
Q

Give some examples of causes of non-streptococcal post-infectious glomerulonephritis.

A 
Staph 
Pneumococcus 
Legionella 
Syphilis 
Mumps 
Varicella 
Hepatitis B and C 
Echovirus 
Epstein-Barr virus 
Toxoplasmosis 
Malaria 
Schistosomiasis
66
Q

What are some of the different types of rapidly progressive glomerulonephritis?

A

Goodpasture’s syndrome

ANCA-positive vasculitides

67
Q

What are the features of Goodpasture’s syndrome?

A

IgG and C3 deposits with extensive crescent formation

Associated with pulmonary haemorrhages

Rx = plasma exchange (remove circulating antibodies), steroids, cyclophosphamide

68
Q

What are the features of ANCA-positive vasculitides?

A

Includes polyangitis granulomatosis, microscopic polyangitis, Churg-Strauss syndrome

Features focal necrotising lesions of organs e.g. pulmonary haemorrhage, crescenteric glomerulonephritis, purpuric/vasculitis rash

Rx = corticosteroids, cyclophosphamide

69
Q

What are the causes of asymptomatic haematuria/proteinuria?

A

IgA nephropathy

Alport’s syndrome

70
Q

What are the features of IgA nephropathy?

A

Commonest form of glomerulonephritis

Focal segmental proliferative glomerulonephritis with mesangial deposits of IgA

Common in children

Asymptomatic microscopic haematuria OR recurrent haematuria, sometimes following upper resp. tract/GI infection

Can go on to develop end-stage kidney disease

71
Q

What are the features of Alport’s syndrome?

A

Hereditary nephritis with haematuria, proteinuria (<1-2g/day), progressive kidney disease, and high frequency nerve deafness

15% have ocular abnormalities

85% have X-linked mutation

Glomerular sclerosis

Causes 5% of end-stage kidney disease in children

General Medicine (12 decks)

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