Renal Flashcards
1
Q
What is the definition of oliguria
A
<0.5ml/kg/hr
2
Q
How do you collect an MSU?
A
The aim is to collect urine from the bladder
Hold open labia/ retract foreskin
Pee into toilet then divert stream into sterile bottle
Do NOT touch the sample or bottle neck
Hand in ASAP
3
Q
Action and SE or furesomide
A
Inhibit the K/ Na/ 2Cl transporter in the ascending loop of Henle resulting in massive NaCl excretion
Hypokalaemia is main side effect
4
Q
Mechanism and SE of thiazides
A
Inhibit Na/Cl transporter in distal tubule
They also increase reabsorption of Ca
Low Na and K
Increased lipid and uric acid levels - CI in gout
5
Q
Thiazides are CI in gout
A
Thiazides are CI in gout
6
Q
Mechanism and SE of spironolactone
A
Aldosterone antagonist in collecting duct
Hyperkalaemia and gynaecomastia
7
Q
What do urinary RBC casts prove?
A
Haematuria is glomerular in origin e.g. vasculitis, glomerulonephritis
8
Q
What is the significance of tubular cast cells?
A
They occur only in acute tubular necrosis
9
Q
Bacterial diagnosis of UTI
A
Growth of >10^5 organisms/ ml of fresh MSU
10
Q
Presentation of prostatitis
A
Fever, back pain, possibly urinary symptoms + swollen or tender prostate on PR
Treat with analgesia and ciprofloxacin for 28 days
11
Q
Uncomplicated UTI treatment
A
Female = nitrifurantoin for 3 days Males = 5 days
12
Q
UTI in pregnancy
A
Nitrofurantoin for 7 days if trimester 1or 2
Trimethoprim for 7 days if trimester 3
13
Q
Presentation of nephritic syndrome
A
Haematuria + proteinuria + RBC casts + high BP and progressive renal failure
14
Q
Target BP for patients with glomerulonephritis
A
130/80
125/ 75 if proteinuria >1g/day
15
Q
What is the commonest glomerulonephritis in the UK
A
IgA nephropathy
Typically a young male who presents with micro/macroscopic haematuria after a URTI.
IgA is elevated and deposited in mesangial cells causing inflammation
Role for immunosuppression with steroids/ cyclophosphamide
16
Q
Anti-glomerular basement membrane
A
Goodpastures disease
Kidney biopsy will show crescenteric GN
Lungs are also involved resulting in pulmonary haemorrhage
Treatment = plasma exchange + steroids
17
Q
Renal disease + lung symptoms
A
Goodpastures
Cresenteric GN caused by anti-glomerular basement membrane antibodies
18
Q
Post strep throat is the commonest cause of a proliferative GN
A
It typically causes nephritic syndrome
19
Q
What is the treatment for a patient with IgA nephropathy and rapidly deteriorating renal function?
A
Cyclophosphamide
20
Q
HSP =
A
Purpuric rash + IgA nephropathy + polyarthritis
21
Q
How does rapidly progressing GN presenting
A
Acute renal failure
Treat with high dose steroids, cyclophoshamide and plasma exchange (to remove existing antibodies)
22
Q
Triad of nephrotic syndrome
A
Proteinuria (>3g/ 24 hours)
Hypoalbuminaemia (<25g/L)
Oedema
23
Q
Periorbital oedema is relatively specific for renal disease e.g. nephrotic
A
Periorbital oedema is relatively specific for renal disease e.g. nephritic
24
Q
What is the key diagnostic test for a patient with GN?
A
Kidney biopsy
25
What is the commonest cause of nephrotic syndrome in children?
Minimal change GN
Associated with Hodgkins
‘Fusion of podocytes’
Steroid are effective but relapse likely >need cyclophosphamide
26
Investigation shows fusion of podocytes?
Minimal change GN
27
What is the commonest cause of nephrotic syndrome in ADULTS?
Membranous nephropathy - associated with malignancy and drugs e.g. gold
Thickened GBM with IgG and C3 deposits
Risk of renal vein thrombosis
28
‘Tramline’ appearance of double basement membrane
Mesangiocapillary GN
| RARE, presents with nephrotic syndrome
29
Focal segmental glomerulosclerosis can be primary or secondary to IgA nephropathy, sickle cell or HIV
Focal sclerosis on biopsy
30
General management points of GN
```
Reduce Na intake
Moderate fluid intake
Diuretics
ACEI - very important
Manage HT
Be aware that nephrotic syndrome (especially membranous nephropathy) is a hypercoagulable state > renal vein thrombosis is a problem
```
31
What is the effect of PTH?
- Released in response to low Ca
- increases osteoclasts activity to release calcium and phosphate
- increased calcium and decreased phosphate reabsorption from kidneys
- increases active vit D production
- high calcium, low phosphate results
32
What are the symptoms of hyperparathyroidism?
- due to increased calcium e.g. stones, bones, polyuria, polydipsia etc
- due to bone damage e.g. fracture
- HT = always check BP
Patients who are young, or symptomatic need a excision of the adenoma
33
Treatment option for patient with primary hyperparathyroidismn in which excision is unsuitable?
Also for patients with secondary hyperparathyroidism e.g. in renal failure
Cinacelet
| It increases the sensitivity of parathyroid cells to Ca
34
Blood result for patient with secondary hyperparathyroidism?
High PTH
Low Ca
Caused by chronic renal failure or poor vit D intake
Treat with cinacelet
35
Tertiary hyperparathyroidism follows chronic secondary hyperparathyroidism
It results in high Ca with inappropriately high PTH
36
Features of MEN 1
Pituitary tumour
Pancreatic tumours
Parathyroid tumours
Associated with MEN 1 gene
Remember the 3P’s
37
Features of MEN 2a
The TAP features
Thyroid medullary carcinoma
Adrenal phaeochromocytoma
Parathyroid hyperplasia
Ret proto-oncogene is involved
38
Features of MEN 2b
The TAM one
Thyroid medullary carcinoma
Adrenal phaeochromocytoma
Marfinoid appearance
Related to ret oncogene
39
Which hormone stimulates the release of ACTH from the anterior pituitary?
Corticotrophin releasing hormone from the hypothalamus
40
Name the 3 classes of steroids release by the adrenal cortex
1) Glucocorticoids - e.g. cortisol involved CHO and lipid metabolism
2) Mineralocorticoids e.g aldosterone involved in Na and Water balance
3) Androgens e.g. tesotosterone
41
Cushing’s syndrome can be caused in ACTH dependant causes e.g.
- Cushing’s disease = adrenal hyperplasia from a ACTH secreting pituitary tumour
- Ectopic ACTH production e.g. small cell lung cancer
Can also be from ACTH independent causes e.g.
Iatrogenic - high dose steroids
Adrenal adenoma/ cancer
42
2 steps in diagnosing Cushing’s disease
1 - identify raised cortisol level
2 - find the cause (1st line is overnight dexamethasonen suppression test)
In a normal person, cortisol should reduce to <50nmol/L
In Cushing’s disease a high dose dexamethasone may be enough to suppress cortisol - this is not the case in ectopic ACTH production
43
Investigation for lady with suspected Addison’s disease?
Low Na, high K and low glucose due to low mineralocorticoid and cortisol level
Remember this is adrenal insufficiency with the potential for life threatening hypovolaemia to occur
Short synacthen test
- Primary Addison’s e.g. autoimmune destruction
- TB
- adrenal mets
- sepsis
- adrenal haemorrhage
All are potentials
44
High ACTH can lead to pigmentation. This helps distinguish primary (hyperpigmentation) and secondary (no -pigmentation) adrenal insufficiency
Long term steroid therapy is commonest secondary cause
45
Management of hyperaldosteronism?
Conn’s = surgically remove the singular adenoma and use spironolactone for BP and K control for 4 weeks pre-op
Bilateral adrenal enlargement = spironolactone or eplerenone (no gynaecomastia)
46
What is the classic triad of phaeochromocytoma?
Episodic headache
Sweating
Tachycardia
47
Management of phaeochromocytoma?
Diagnosed with 3 x 24hr urinary catecholamines
Surgical removal of the catecholamine producing tumour
Use ALPHA blocker first (phenoxybenzamine BEFORE beta blocker!
48
Refractory HT and low K
Exclude:
1) Renal artery stenosis
2) Conn’s disease
49
Differtial diagnosis of hirsutism?
Excess androgen secretion has several causes:
1) Ovarian secretion e.g. PCOS or ovarian cancer
2) Adrenal secretion e.g. Cushing’s or carcinoma
3) Drugs e.g. steroids
50
Definition of acute renal failure
Significant reduction in renal function resulting in an increase in serum creatinine and urea
51
What are the 3 main complications of acute renal failure e.g. that people die of?
1) Volume overload
2) Hyperkalaemia
3) metabolic acidosis
Urine output is so important - measure continuously
52
What is acute tubular necrosis?
Damage to renal tubular cells due to ischaemia or nephrotixins
E.g. drugs, radiology contrast, rhabdomyolysis or myeloma
53
In pre-renal failure, the urine is concentrate and sodium is reabsorbed by working tubular cells:
Urine Na will be low and urine osmolarity high
In ascute tubular necrosis this does not happen so urine sodium is high and urine osmolality is low
54
Management of acute renal failure
1) History, Examination and investigations - especially U&E and urinalysis
2) Identify and stop any nephrotixic drugs
3) Treat any reversible causes e.g. fluids for hypovolaemia
4) Insert catheter - daily fluid balance
5) Correct any underlying cause e.g. antibiotics
55
What are the indications for dialysis in patients with acute renal failure?
1) Hyperkalaemia (>7)
2) Severe Metabolic acidosis (pH <7.2)
3) Refractory pulmonary oedema
4) Uraemic encephalopathy
56
What are the classifications for different degrees of chronic renal failure?
```
1 = GFR>90
2 = 60 -89
3a = 45-59
3b = 30-44
4 =15-29
5 = <15
```
57
Define end stage renal failure
GFR< 15 or need for dialysis
58
Causes of chronic renal failure?
```
DM
HT
GN
Polycystic kidney disease
Myeloma
```
59
Symptoms of uraemia/ renal failure
Pallor, yellow skin, pigmentation, easy bruising etc
60
What is the main cause of death in patients with chronic renal disease?
Cardiovascular disease
61
List some nephrotoxic drugs!
```
ACEI
Digoxin
Trimethoprim
Gentamicin
Ethambutol (TB drug)
Lithium
Tetracycline
```
62
Target BP in patients with CKD
140/85
| 130/80 diabetic - all people with DM and kidney disease should be on an ACEI, regardless of BP
63
Indications for renal biopsy
Unexplained acute renal failure
Nephritic syndrome
Systemic disease e.g. SLE
(Remember that biopsy is useless in chronic disease as kidneys are often small, shrunken and will bleed - A LOT)
64
What are the complications of heamodialysis?
1) Disequilibrium syndrome e.g. nausea, vomiting, headache and confusion/ seizure due to rapid changes in plasma osmolality
2) Fistula problems e.g. thrombosis, infection, stenosis etc
3) Time consuming and expensive
65
What are the complications of peritoneal dialysis?
1) Peritonitis
2) Loss of membrane effectiveness
3) Tenchkoff catheter problem e.g. infection
66
What are the complications of renal replacement therapy?
Cardiovascular disease
Platelet dysfunction —> bleeding tendency
Anaemia
Renal bone disease
67
Complications of kidney transplant?
1) Acute graft rejection - rising urea, fever and flank pain
2) Chronic graft rejection
3) Infection - immunocompromised due to drugs
4) Malignancy - immunocompromised due to drugs
5) Hypertension - unknown
68
Balkan nephropathy
Common cause of progressive renal impairment along the river Danube
Causes anaemia, glycosuria, skin pigmentation of hands and soles
69
Urate nephropathy
- acute crystal nephropathy
- most common in lymphoma and other chemo patients
- renal tubules fail due to precipitation of urate crystals
- plasma urate very high and bright renal parenchyma on US
- bifringent crystals on microscopy
- prevent with fluids, allopurinol before chemo and sodium bicarbonate to alkalize urine
70
How to prevent radiocontrast nephropathy?
1) Identify high risk patients e.g. DM, poor renal function
2) Stop nephrotoxic drugs pre procedure e.g. metformin
3) Prehydrate with saline
4) Consider IV acetylcysteine/ sodium bicarbonate to alkalize and protect kidneys
71
How does rhabdomyolysis cause renal failure?
1) Release of muscle breakdown components e.g. myoglobin, K, phosphate, urea and creatinine
2) myoglobin is filtered by the glomeruli and precipitates —> blocked renal tubules
3) beware brown pee!
72
What is the ‘gold standard’ investigation for a suspected renovascular disease?
Remember renovascular disease is essentially renal artery stenosis due to atherosclerosis, post-renal transplant or a giant cell arteritis
Renal angiography
| (Done after US (uneven kidney size) and CT/ MRI
73
HUS leads to intravascular haemolysis and red cell fragmentation —> thrombocytopenia and ARF .
90% are due to 0157. What will the blood film show?
Fragmented RBC (shistocytes)
74
What are the 6 features of thrombotic thrombocytopenia purpura? TTP
1) Fever
2) Fluctuating CNS signs e.g. seizures
3) Haemolytic anaemia (microangipathic)
4) Haematuria/ proteinuria
5) Low platelets
6) Renal failure
This is a medical emergency precipitated by some drugs e.g. clopidogrel
Consider in anyone with unexplained anaemia and thrombocytopenia
Treat with plasma exchange +/- steroids, immunoglobulin or splenectomy
75
What is renal tubular acidosis (RTA)?
Metabolic acidosis due to impaired renal function
Type 1 = distal —> impaired excretion of H+ ions from the distal tubule e.g. Treatment is with sodium bicarbonate but complications are renal calculus
Type 2 = proximal —> impaired reabsorption of bicarbonate ions from the proximal tubule —> excess bicarbonate in urine (Faconi syndrome is a common cause)
76
Associations of AD polycystic kidney disease
1) Liver cysts
2) Intracranial anuerysms —> SAH
3) Mitral valve prolapse
Features of the disease itself = loin pain, haematuria, HT and renal failure
77
Medullary cystic disease
Rare inherited kidney disorder
1) Tubular loss —> polyuria, polydipsia, salty wasting
2) Medullary cysts —> shrunken kidney, ESRF
3) Extra-renal —> retinal changes, skeletal changes etc
78
Alport’s syndrome
1) type 4 collagen disease
2) haematuria, proteinuria and progressive renal failure
3) sensorineural deafness
4) lens defects
79
Indication for fluid resuscitation
Signs of being systemically unwell e.g. NEWS 5 or more
```
Tachycardia
Hypotension
Cold peripheries
Cap refill> 2seconds
Rapid resp rate etc
```
80
Regime for patient needing fluid resuscitation
```
500ml NaCl bolus over <15minutes
Reassess using ABCDE approach
Give repeated 500ml bolus as required
Keep reassessing
In HF patient, consider 250ml bolus after initial 500ml bolus
```
81
What are daily fluid requirements for maintenance?
30ml/kg water
1mmol/L Na, K and Cl
50-100g/day glucose
82
What is the maximum rate of delivery of K?
10mmol/L
| E.g. if you add 40mmol to a bag then you can only give that bag over 4 hours
83
What test should be done at every diabetic review to assess for signs of nephropathy?
Early morning albumin: ratio
| >3 = bad
84
Causes of a metabolic acidosis with a normal and increased anion gap
Anion gap = (Na + K) - (Cl + HCO3)
Gap is increased in the presence of the molecules such as ketones, phosphate etc
Normal anion gap = ABCD (Addisons, bicarbonate loss, chloride retention and rugs such as acetazolamide)
High anion gap = DKA, renal failure, dehydration, salicylic acid etc
85
What is dabigatran?
A direct thrombin inhibitor
86
Mechanism of action of rivaroxiban and apixiban?
Direct factor Xa inhibitors
87
What is the cause of secondary hyperparathyroidism?
Usually due to Vit D deficiency (e.g. renal failure) which prevents calcium being absorbed --> increase in PTH
88
What is the commonest inherited thrombophilia in the UK?
Factor V leiden deficiency
| Factor 5 is a clotting factor, in this disease the clotting factor is inactivated 10 times faster --> bleeding
89
Investigations in a young patient with unprovoked DVT?
```
FBC
CXR
UE, LFT
CT pelvis if initial tests ok --> need to look for underlying malignancy
Anti-phospholipid screen
```
90
List 4 'common' causes of polyuria
1) heart failure
2) Caffeine/ alcohol
3) lithium
4) dm
91
US finding of a patient with diabetic nephropathy
Bilaterally enlarged kidneys (unusual - other types of chronic renal disease e.g. HT etc cause shrunken kidneys)
92
What is the classification of different grades of AKI?
```
1 = creatinine 1.5-1.9 x baseline + <0.5ml/kg/hr for 6 hours
2 = creatinine 2-2.9 x baseline + <0.5ml/kg/hr for 12 hours
3 = creatinine >3 x baseline or >354 + <0.3ml/kg/hr for 24 hours or anuric
```
93
What is the commonest cause of infection in patient with peritoneal dialysis?
Staph epidermidis
94
What is the 60, 40 , 20 rule?
60% of body weight is water
40% is intracellular
20% is extra cellular
95
Cation = +
Anion = -ve
96
Which drug causes blue/green pee?
Amitryptilline
| Propofol
97
Give a cause of hyaline casts?
Diuretics
98
Cause of red cell casts?
Glomerulonephritis/ vasculitis
99
Epithelial cells in urine microscopy?
Acute tubular necrosis/ Glomerulonephritis
100
Nephrotic syndrome?
1) Proteinuria >3.5g/day
2) hypoalbuminaemia
3) oedema
4) Hyperlipidaemia and lipiduria
101
Minimal change = commonest GN in children
Damage to podocytes foot process
Usuallly idiopathic
Associated with Hodgkin’s Lymphoma
102
How does the membrane in membranous GN look?
Thickened
Immune complexes
SPike and dome pattern
103
List some causes of focal segmental glomerulosclerosis?
Sickle cell
HIV
Heroin abuse
Segmental sclerosis and hyalinosis on histology
104
List some causes of rapidly progressive glomerulonephritis?
Type 1 = ANti-GBM antibodies e.g. goodpasture (linear)
Type 2 = Immune complex e.g. IgA or SLE (granular)
Type 3 = ANCA e.g. Churg Strauss (negative)
All cause formation of crescent shape in glomerulus due to inflammation
105
What are the features of nephritic syndrome?
```
Haematuria
Proteinuria (mild)
Raised BP
Rapid decline in eGFR
Casts
```
(Post-streptococcal, SLE, Goodpastures, ANCA)
106
Remember people with nephrotic syndrome are hypercoagulable so are at increased risk of thrombosis
The high cholesterol may be an important cause of this
107
What are the key features of HUS?
1) Microangiopathic haemolytic anaemia (inappropriate clots act as boulder which break up the RBC)
2) Low platelets (the platelets are used up forming inappropriate clots)
3) Uraemia (due to clots in the kidneys causing renal damage —> proteinuria, haematuria)
Remember TTP is HUS + fever + neuro signs e.g. confusion and seizure - it is caused by lack of an enzyme (ADAMTT) which breaks up clots)
108
Remember that autosomal PKD causes renal failure in utero leading to oligohydramnios
Other complications occur in liver, bile ducts and lungs
109
List some risk factors for renal artery stenosis?
1) Coronary/ carotid artery disease
2) PVD
3) Smoking/ obesity
4) DM
110
Why does renal artery stenosis cause hypertension?
The kidney senses low blood flow and acts as though pressure is low (not as if there is a block) —> activate RAAS to raise BP
111
The macula densa cells detect Na in reabsorbed fluid. If BP is low then less Na will be absorbed —> low BP detected —> release of prostaglandins to encourage juxtaglomerular apparatus to release renin
The macula densa cells detect Na in reabsorbed fluid. If BP is low then less Na will be absorbed —> low BP detected —> release of prostaglandins to encourage juxtaglomerular apparatus to release renin
112
MR angiogram shows a string of beads...
Fibromuscular dysplasia
| An important cause of renal artery stenosis —> hypertension
113
The indications for dialysis in renal failure can be remembered as 4PE
4P:
- pH <7.2
- Potassium >6.5
- Pulmonary oedema
- pericarditis
- Encephalopathy
114
In HT renal disease the afferent artery becomes thickened which reduces blood supply to the kidney —> Ischaemic
In DM kidney disease, glucose sticks to the efferent arteriole which causes it to stiffen and causes pressure to back up into the kidney
—> hyperfiltration
Rates causes of chronic kidney disease:
- SLE
- RA
- PKD
115
In CKD less K and urea are excreted —> build up
The kidney normally helps activate vit D which increases absorption of calcium —> in CKD Ca is low —> bone resorption occurs
EPO levels falls —> low production of blood cells —> normochromic anaemia
116
What is the investigation of choice for reflux nephropathy?
Micturating cystography
117
Eosinophilic casts are suggestive of chronic pyelonephritis
Waxy casts indicate low urine flow e.g. in renal failure
118
As well as causing an acute myositis, steroids can also cause rhabdomyloysis
All NSAIDs should be stopped in an AKI expect for low-dose aspirin which will do not harm
119
Classic ABG in a septic patient?
Metabolic acidosis with raised anion gap (due to production of lactate)
Raised gap = increased production or reduced excretion e.g. renal failure or DKA
120
Lab results of osteoporosis?
DEXA z -2.5
121
Lab results of osteomalacia?
Low Ca
Low phospahte
High Alk Phos
(Remember that osteomalacia in children = rickets)
122
Lab results of Paget’s?
Isolated high alk phos
| ca and phosphate are normal
123
Lab results in myeloma?
Ca high
Phospahte high/ normal
Alk phos normal
Hence jones proteins
124
Lab results in bony mets?
Ca and alk phos high
| Phospahte high/ normal
125
Hyaline casts
Can be normal OR due to diuretic use
126
Anti-streptolysin antibodies?
In a nephritic syndrome, suggests post- strep glomerulonephritis
127
What is the renal cause of flash pulmonary oedema?
Renal artery stenosis
128
Generally, what is the indication to start dialysis in CKD?
GFR <10ml/min or <15ml/min in diabetics
