Renal Flashcards
At what vertebral level do the kidneys sit?
T12-L3
what size are the kidneys?
10-12cm
What is the mesangial of the kidney?
In the glomerular capillary loop with contractile properties
- nucleated
What is a secondary glomerular disease?
A systemic disease that involves the glomerulus such as diabetes, lupus or myeloma
What are examples of primary glomerular diseases?
Nephrotic syndrome
Nephritic syndrome
CKD
what is the triad seen in nephrotic syndrome?
Heavy proteinurea (>3,5gm/day)
Hypoalbuminaemia (<30g/L)
Oedema
Other than the main three (Proteinuria, hypoalbumininaemia and oedema) what are other signs of nephrotic syndrome?
frothy urine, hypercoagubility, hypercholesterolaemia
what are the main three illnesses that cause nephrotic syndrome?
Minimal change disease
Membranous nephropathy
focal segmental glomerulosclerosis
What Is seen in minimal change disease inside the kidneys?
podocyte foot process effacement
what is seen inside the kidney in membranous nephropathy?
Inflammation and thickening of the glomerular basement membrane and immune deposits.
what is the onset for nephritic syndrome?
An abrupt onset of days
onset for nephrotic syndrome is longer
what is a classic cause of nephritic syndrome?
Post streptococcal GN
what is seen in nephritic syndrome?
Haematuria, proteinuria, oedema, hypertension
what is rapidly progressive glomerulonephritis?
Similar to nephritis but over weeks and months
what are the three main groups of rapidly progressive glomerulonephritis?
- antiglomerular basement membrane (goodpasture disease) often get pulmonary haemorrhage and poor prognosis
- small vessel ANCA positive vasculitis
- miscellaneous conditions; damage; fibrin in bowmans space
what is the primary site for reabsorption of filtered nutrients?
PCT
in brief what is fanconis syndrome?
inadequate reabsorption in the PCT
what substances can cause acute tubular injury?
gentamicin, heavy metals, mercury, CCL4.
what are non infectious causes of tubulointerstitual nephritis?
Gentamicin, penicillin, allopurinol and sarcoidosis
what are infectious causes of tubulointerstitual nephritis?
pyelonephritis, TB, legionella, CMV
what is the pathology behind acute interstitial nephritis?
- interstitial oedema- infiltration by inflammatory cells (eosinophils and granulomas), tubular injury but a normal glomeruli.
what is the cause of anaemia in CKD?
Low EPO
what happens to calcium levels in CKD?
Fall
Why do PTH Levels rise in CKD?
Low calcium levels
what form of vit D therapy is appropriate in advanced CKD?
1,25 (OH) vit D
what is the most common cause of death in kidney failure patients?
CVS
what happens to acid base balance in patients with CKD?
acidosis due to low bicarbonate levels. normally carbonic anhydrase is used in the PCT to supply bicarbonate
List some complications of CKD?
- anaemia
- mineral bone disease
- CVS issues
- malnutrition
what is the definition of CKD?
A slow process over more than 3 months of inexorable attrition of nephron number and function due to multiple aetiologies frequently leading to end stage renal failure.
what is the process occurring to the nephrons in CKD?
Fibrosis–> nephron sclerosis –> nephron loss –> hyperfunction of remaining nephrons due to TGF B
what complications occurs occur at each stage of CKD?
Stage 2- increased CVS issues
stage 3- increased CVS, bone disease (high PTH)
Stage 4- increased CVS, anaemia, bone disease (low calcium and high phosphate)
stage 5- increased CVS, anaemia, bone disease, pruritus, bleeding, malnutrition
what is the process of red blood cell formation?
pluripotent stem cell –> myeloid progenitor –> normoblast –> reticulocyte –> erythrocyte
Other than being deficient in EPO what are other causes of anaemia in patients with CKD?
- iron deficiency
- hypothyroidism
- active blood loss
- hemoglobinopathies
- haemolysis
- hyperparathyroid
- folic acid deficiency
- vit B12 deficiency
What is the management flow of anaemia in patients with CKD?
- Exclude other causes such as iron deficiency, vit B12 deficiency and blood loss
- EPO 30ug/week
- monitor Hb every 2 weeks
- adjust EPO 25% increase
- if Ferritin below 200 give IV iron
what is the target haemoglobin and ferritin in patients with CKD?
Hb; 10.5-12 (slightly lower than normal target as getting it back to normal has no extra benefits and increased stroke risk)
Ferritin 200-500
In anaemic CKD patients why can you not give oral iron?
hepcadin will prevent it being absorbed
in patients with CKD what leads to increased calcium mobilisation from the bone?
- Low Vit D from the kidneys
- less calcium absorption
- PTH stimulated
- mobilisation of calcium from the bone
In patients with CKD how does PTH affect phosphate levels?
PTH increases phosphate excretion
what is the effect in CKD of phosphate retention?
Causes FGF23 release which is cardio toxic.
what Vitamin D hydroxylation occurs in the kidney?
1 hydroxylation
what are the types of bone disease seen in patients with CKD?
osteitis fibrosa (increased PTH) osteomalacia (defective mineralisation) adynamic bone disease (low bone turnover) osteoporosis (defective bone formation)
what is the cause of adynamic bone disease in patients with CKD?
Over suppression of PTH causing low bone turnover
what are the bone changes seen in children with CKD?
growth retardation
deformities
how do you manage bone disease in patients with CKD?
- if they have low vitamin D start them on Vit D
- give calcium based phosphate binders for high phosphate
- high PTH give 1alpha calcidol
what are the three diagnostic categories for kidney disease?
Pre renal
renal
post renal
for kidney investigations what is the hierarchy of investigation?
- history and exam
- urine tests
- blood tests
- radiology
- renal biopsy
would does cloudy urine indicate?
infection
what drug can be responsible for red/brown urine?
Rifampicin
what do white blood cells and bacteria in the urine suggest?
UTI
what are post renal causes of haematuria?
cancer, trauma and renal stones
what do dysmorphic red blood cells indicate when in the urine?
glomerular nephritis
what does pyelonephritis present with?
- white cell casts in urine
- fever
what do epithelial cell casts suggest?
acute tubular necrosis
when are oxylate crystals seen in the urine?
Anti freeze poisoning
Oxalate nephropathy
when are urate crystals seen In the urine?
Joint aspirations
Gout
what is the normal range for 24 hour urinary protein and what is nephrotic?
normal; <300mg
Nephrotic; >3g
what do bence jones proteins suggest?
myeloma
