Renal Flashcards
Define Nephrotic Syndrome:
Criteria is:
*Proteinuria >3.5g/ 24hours
- Hypoalbuminemia <30g
- Oedema
[Must have all these!!]
additional features are:
- hypogammaglobulinemia
- Hypercoagulable
- hyperlipidaemia
List some things that can effect creatinine levels:
Muscle mass
Concentration of plasma
- dehydration
Secretion of creatinine ~15% secreted
Diet
- high protein may increase it slightly
What things can effect urea levels?
G.I bleeds
Dehydration
Liver failure
- low urea
Increased tissue breakdown
- steroids
What does eGFR take into account?
Plasma creatinine
Age
Gender
Race
expressed as GFR expressed as ml/min 1.73m2
MDRD - the method used.
How much can kidney function drop by before the creatinine level rises?
50%
What does eGFR not take into account?
Acute injury to kidneys.
this is because muscle mass takes time to build up levels.
What are the stages of CKD?
Stage 1:
>90, with other abnormality
Stage 2:
60-89, with another abnormality
Stage 3:
30-59
Stage 4:
15-29
Stage 5:
<15
If a person has glomerulonephritis, will both kidneys be affected?
Yes.
but maybe not all of the kidney will be affected.
What is needed to make a diagnosis of glomerulonephritis?
Biopsy
What tests are done during biopsy?
Light microscopy
- glomerular and tubular structure
Immunofluorescence
- looking for IgG
Electron Microscopy
- deposits on membrane
What will be seen with Rapid Progressing Glomerulonephritis?
Crescent formation of the glomeruli membrane
List the stages that occur leading to glomerulonephritis, and the possible therapeutic strategies that can be done:
- Insult
- infection
- antibody - Injury
- Block Ab - Response to Injury
- Steroids
- cytotoxics - Outcome
- dialysis
- transplantation
What is the most common primary nephritis?
How does it present?
IgA nephropathy
- minor urinary abnormalities
- Hypertension
Renal impairment
Can be rapidly progressing
What is IgA nephropathy?
Mesangial disease - proliferation leading to failure of the kidney.
there is deposits of IgA with complement activation.
often presents with Strep infection - Synpharyngitic infection.
its also associated with:
- liver disease
- coeliac disease
What is Membranous Glomerulonephritis?
Disease of adults - specifically caucasians.
Most common cause of nephrotic syndrome
Associated with:
- lung cancer
- prostate cancer
Due to [Anti- phospholipase A2 Receptor] located on the podocytes.
Immune complex deposition within the deposts.
Variable nature:
- third spontaneous remission
- Third progress to ESRF
- third progress to persistent proteinuria
Treatment:
Primary:
- control blood pressure
- immunotherapy - steroids, cyclophosphamide, cyclosporin
Secondary
- treat underlying condition
What is minimal Change disease?
Commonest cause of nephrotic syndrome in children
- so common unlikely to biopsy because likely to be this.
Disorder of the podocytes. - where you get fusion of the podocytes.
T - cell mediated disease
Associated with:
- Hodgkin’s
Associated with:
- URTI
Relapsing disease
Treatment:
- steroids
Crescentic Disease:
Rapidly Progressive Glomerulonephritis
- group of conditions that cause crescents on kidney biopsy
ANCA Vasculitis - MPO Lupus Good Pastures disease - anti GBM Infection Associated Henoch -Schonlein Purpura
What nodules are seen with diabetic nephropathy?
Kimmelstiel wilson nodules
Why are angiograms and contrast CTs not done in renal disease?
Due to the contrast agents which can contraindicate in renal disease.
Where does the hypoxia first occur in renal system in renal stenosis?
Cortex - most metabolically active part
What are the two ways you can lose albumin?
Renal
Bowels
What is the diagnostic tests for Amyloidosis:
Congo Stain
- Apple green bifridgence
What is the treatment for lupus?
Steroids
Cyclophosphamide
Rituximab
Whats the gold standard for assessing renal scars?
DMSA
What is MAG3 cystogram used?
Used for
Vesicoureteral Reflux
Outline the grades of Vesicoureteral Reflux:
Grade 1:
- urine just makes it half way up ureter
Grade 2:
- Urine into the pelvis
Grade 3:
- dilatation of the pelvis
Grade 4:
- Torturous process of ureters and dilation
Grade 5:
- Massively tortuous and dilated.
When can
Vesicoureteral Reflux be picked up?
In utero
After infection
Whats the management for Vesicoureteral reflux:
Prophylaxis antibiotics
Surgery:
- STING procedure
- circumcision
What is another common obstruction that can occur in children which involves faulty valves, and how does it present and how is it managed?
Posterior Urethral Valve
Presentation:
- Antenatal Hydronephrosis
- UTI
- Poor Urinary Syndrome
Management:
- Valve resection
- antibiotic prophylaxis
- CKD care
Outcome:
- Chronic renal failure
Whats the most common cause of hydronephrosis in children?
Pelvi - Ureteric Junction Obstruction
Managed with:
- Pyeloplasty
What is the most common congenital kidney disease?
Adult polycystic kidney disease
- Autosomal dominant condition
Caused by:
- PKD1 - Chromosome 16
- PKD1 - Chromosome 4
kidneys increases massively.
Diagnosed:
- Ultrasound
2 cysts need bilaterally in 15-30 years old.
Outcome:
50% risk of ESKD by 50 years
Cyst accidents - rupturing.
Management:
- supportive
- treat complications
- Dialysis
- Dialysis
- Tolvaptan - reduces cyst formation
- since its V2 antagonist they pass lots of water
Name an inherited kidney disease that effects the collagen 4:
Alport’s syndrome
x-linked disease
Collagen 4 abnormalities
Symptoms:
- renal
- deafness
Name an inherited kidney disease which effects storage defects;
Fabry’s disease
Angiokeratoma - associated skin pathology.
Alpha Gal A defect
In someone with Minimal change disease what investigations would you carry out?
Urinalysis
- high protein ++++
- urine/ creatinine ratio
Serum albumin level
Coagulative factors
- often antithrombin is released
GFR
Serology
- ANA
- ANCA
- Anti GBM
Renal ultrasound
- not just checking for blockages
- assessing kidney size
- checking there is two kidneys
Chest - xray
- pulmonary oedema
- signs of hodgkins
List some negative aspects of using eGFR:
Non- linear relationship but is expecnitional to kidney function.
- only starts to rise after 50% loss of kidney function
Overestimates kidney function in people with low muscle
Under estimates kidney function in people with large muscle mass
it is not useful for acute kidney failure
- there could be 0GFR and the creatinine would be normal until sufficient levels build up
It is inaccurate above eGFR >60. due to the studies it was conducted in
It is inaccurate in children - due to studies of people it was studied and developed in.
What is some complication that can occur in people who are treated for glomerulonephritic conditions?
Infections - due to the high use of immunosupressants
namely - peritoneal infections in nephrotic patients.
*due to the movement of fluids
What complications can occur in nephrotic syndromes?
Clots - due to lack of anti-thrombin III
- painful legs
Pulmonary Oedema - due to lack of Albumin to maintain oncotic pressure
Infections - Hypoglobulinemia
In chronic kidney disease, why would you stop Thiazide diuretics?
Side effect is hyperuricaemia - thus in someone already prone to having high urea this could be dangerous
Outwith direct analysis of the kidney, what other tests would you do to investigate someone with nephritic syndrome?
Chest - x- ray - checking for pulmonary edema
Sepsis check - these patients are hypoalbuminemic and predisposed to pneumococcal infections
Coagulation tests - loss of antithrombin III leaves these people predisposed to clots
Lipid tests - the liver secretes a high amount of lipids
List some symptoms of AKI:
Oliguria
Oedema build up - around eyes and feet
Tachypnea
Confusion
Nausea
Chest pain
List some medications associated with causing AKI:
Diuretics - dehydration
ACE and NSAIDs
- dysregulated autoregulation of the kidney
Gentamicin
- Acute tubular necrosis
Opiates
- blockage of the ureters
**usually it is a compensation or in the setting of damage kidneys already
What is the Investigations in AKI:
Past medical history is absolutely key, to establish anything that may suggest hypovolemia or sorts.
Acute vs Chronic
- e-alert changes
FBC:
- signs of anaemia
- Hypocalcaemia
- these are suggestive of long standing renal failure
U&Es
- specifically K+ levels - lack of excretion of K+ can lead to hyperkalemia
Urine output
Urine analysis
Osmolality of blood and urine
ABGs
- looking for acidosis - which can be common due to lack of filtration and excretion of H+
Underlying diagnosis
- ANCAs
- ANAs
- IgA
- volume stasis
Ultrasound
- establish post renal causes
ECG
- for hyperkalemia
What is your management of AKI?
ABCS
Pre-renal:
- fluid - hartmann’s or saline
Remove causes
- sepsis treat
- drug causes - remove drugs
Remove obstructions
- *treat hyperkalemia
- this is what is likely to kill
Dialysis if not improving
- refractory hyperkalemia
- Refractory pulmonary oedema
What features would you expect to see that suggest hyperkalemia and how would this be treated:
Tall T waves
Flattening of P waves
Prolongation of P- R interval
Broad QRS
- late component
Treatment:
- Calcium resonium
(stops absorption in the G.I)
- Insulin - actarapid
+/- - Glucose
- Calcium gluconate
(protects Membrane, less likely to be activated by K+
Treat Acidosis
- bicarbonate
(patients are likely to become acidotic in AKI due to failure of H+ secretion and HCO3- reabsorption - acidosis increases K+ build up)
Dialysis
- if needed
What drugs are associated with tubular necrosis and should be stopped immediately in AKI?
Gentamicin
NSAIDs
ACE
Contrast
Poisons
**note some of these cause necrosis through dysregulation of blood flow and some cause it through direct toxicity
What biochemical marker will be elevated in Rhabdomyolysis?
Serum Creatinine
What side effect may Sulphonylureas or Insulin therapy have in CKD?
Kidneys play a role in insulin metabolism - therefore drugs increasing their level the person more predisposed to developing hypoglycemia
Name some common causes of CKD:
Vascular:
- HTN
- Renal sclerosis
- Diabetes
Congenital:
- Polycystic kidney disease
- Congenital Obstructive Uropathy
Glomerular disease:
- Lupus
- Amyloidosis
- Wegner’s
Tubulointerstitial disease:
- drug toxicity
- TB
Urinary Tract obstruction
- Calculus disease
- Prostatic disease
List some symptoms of CKD and why are these?
Symptoms usually refer to the build up of toxic metabolites:
- malaise
- Loss of appetite
- nocturia (due to impaired ability to concentrate urine)
- itching
- nausea
- restless legs
Advance stages:
- Pericardial rub (urea irates the pericardium)
- Encephalopathy
What is the management of CKD:
Control of Blood pressure
Diabetic control
Overview some common lab abnormalities seen in CKD:
Hyperkalemia
- lack of excretion and acidosis
Hypocalamia
- no Vit D activation and Increased Phosphate
Anemia
- No EPO drive
CKD can cause bone destruction due to secondary hyperparathyroidism, what is this referred to as?
Renal Osteodystrophy
What drug can be used as a synthetic EPO?
Darbepoetin Alfa
What may cause a false positive for haematuria in the setting of AKI?
Rhabdomyolysis
it is myoglobin from muscle break down that is found in the urine and is nephrotoxic.
Why is albumin lost during nephrotic disease?
There is loss of the negatively charged basement membrane
What is a drug that can elevate the creatinine and how does it do this?
Trimethoprim
blocks excretion of creatine in DCT
In pre renal AKI, what would you expect the urine osmolality to be?
HIgh - the kidneys will be concentrating the urine as much as possible
