Renal Flashcards
How much is GFR?
120 ml/min/1.73m2
What is creatinine?
Chemical waste product of muscle metabolism
Misleading creatinine level?
Cachexia
Bodybuilder
Why is creatinine clearance > GFR?
Secreted as well as filtered
3 hormones in Na excretion (and therefore volume control)
Aldosterone –> decrease excretion
Angiotensin II –> decrease excretion
ANP –> increase excretion (released by the heart in response to high BP)
Which hormone dilates afferent arteriole in kidney?
Constricts?
Prostaglandin dilates
Angiotensin II constricts
2 SEs of ACEi
Impaired renal function Hyperkalaemia Post hypo Dry cough (bradykinin) Fatigue
2 SEs of ARB
Renal impairment
Post hypo
Hyperkalaemia
Medications causing hypokalaemia?
Loop diuretics
Thiazides
Medications causing hyperkalaemia?
Spironolactone
Amiloride
ACEi
ARB
Transporter in LoH?
NKCC2
Na K Cl Cotransporter
Where do ADH and aldosterone take effect?
DCT and CD
Barter’s syndrome?
Effect of..?
When?
Features?
Effect of loop diuretics
In childhood
Metabolic alkalosis, low Mg, High urinary Ca
Gitelman’s syndrome?
Effect of..?
When?
Features?
Same as thiazide (DCT)
Late childhood
Metabolic alkalosis, Mg decreased, urine Ca norm/low
Renal Tubular Acidosis causes what ABG?
Hypercholoraemic metabolic acidosis + hypobicarbonate + decreased arterial pH
Normal anion gap
Causes of renal tubular acidosis?
Drug induced
Fanconi syndrome
What is fanconi syndrome?
Generalised dysfunction of renal proximal tubule
–> urinary loss of bicarb, glucose, AA, phosphate, peptides
SALT WASTING AND VOLUME DEPLETION
2 RFs for renal tubular acidosis?
Childhood Urinary tract obstruction DM Stones Adrenal insufficiency
Pres of RTA?
Growth retardation FTT Muscle weakness (Fanconi) Hypoglycaemia Rickets Kussmaul breathing in severe
Mx of RTA?
If hyperkalaemia + mineralocorticoid deficiency?
Sodium alkali
Dietary restriction of K
Fludrocortisone
Comps of RTA?
Volume depletion Nephrocalcinosis Osteoporosis Growth retardation Rickets
Causes of end stage renal failure?
DM HTN Glomerulonephritis Pyelonephritis PKD
Cause of pyelonephritis?
E. coli (ascending from LUTI)
UPEC
OR spread hematogenously to kidney (DM, HIV, malignancy, transplant)
3 RFs for severe pyehlonephritis?
Extremes of age Anatomical abnorm Foreign body Immunocomp Obstruction Pregnancy
Pyelonephritis cause in men
prostate causing urethral blockage
Triad in pyelonephritis presentation
Fever
Loin pain
Renal tenderness
Ix in pyelonephritis
Urine dip, urinalysis, gram stain, culture
FBC, ESR/CRP, Blood cultures
Imaging [USS/CT w contrast]
Gram stain in pyelonephritis?
Gram negative rods (e.coli, klebsiella, proteus)
Mx of pyelonephritis:
- mild
- severe
- ciprofloxacin PO BD
2. Admit IV fluids IV pcm IV ceftriaxone/cipro/gent \+/- catheter
2 comps of pyelo
renal failure, abscess, renal scarring, recurrent UTIs
2 types of RCC
80% clear cell
15% papillary
RFs for RCC
smoking, obesity, HTN
Occupational exposure [asbestos, lead, chlorine}
Genetics: VHL
Pres of RCC
Asympto
Triad [abdo mass, haematuria, loin pain]
Genetics cause increases risk of RCC?
Von Hippel Lindau
AD
Ix in RCC
Check function - U+Es, FBC, Calcium, LFT,
Check structure - USS, CT
Check for mets - CT abdo pelvis, MRI, CXR (?cannonball mets)
Comp of RCC?
paraneoplastic syndrome - anaemia
hypercalcaemia, SIADH
Mx of RCC?
Surgical [partial / laparascopic nephrectomy]
Drug to use in late stage RCC?
Tyrosine kinase inhibitor
eg Sunitinib
Renal tumour in kids?
Wilm’s –> nephroblastoma
What is AKI?
Acute decline in GFR from baseline/increase in creatinine
+/- oliguria
Causes of AKI
Pre renal - azotaemia, renovascular disease
Renal - acute tubular necrosis (mainly due to sepsis); glomerulonephritis, nephritis, vascular
Post-renal - obstruction
What is azotaemia? Features?
High N containing compounds in blood eg Ur, Cr
Hypovolaemia, haemorrhage, sepsis
Who can you not give NSAIDs to?
B/l renal artery stenosis
Most common cause of AKI?
Acute tubular necrosis
Nephrotoxic drugs?
CANT DAMAG
Contrast, abx (penicillin, ceph), NSAIDs, Therapeutic index (narrow), Diuretics, ACEi, Metformin, ARB, Gentamicin
How to measure AKI?
Creatinine
UO
Ix in AKI?
U+Es, FBC, VBG
Urine dip, MC+S
ECG
Imaging
Mx in AKI?
Stop nephrotoxic drugs ABCDE Catheterise If obstruction --> urgent USS KUB, Dialysis if uraemic/severe acidosis/hyperkalaemia
What is CKD?
Proteinuria/haematuria and/or reduction in GFR to <60 for >3months
Causes of CKD?
DM
HTN
Autoimmune
Smoking
Obesity
Mx of CKD?
Glycaemic control
Optimise BP
Stages of CKD?
Based on GFR
1 > 90 2 > 60 3a > 45 3b > 30 4 > 15 5 < 15 / on dialysis
Primary prevention of CKD?
Secondary prevention?
Optimise DM + BP, smoking cessation
Salt + protein restricted diet
How does uraemic syndrome present?
Uraemic tinge (grey/yellow) N+V Itch *encephalopathy *pericarditis *bleeding
URGENT RRT
Comps of CKD
Anaemia Osteodystrophy CV disease Protein lsos HyperK Metabolic acidosis Pulm oedema
Ix in CKD
U+E, FBC
Urinalysis
Renal USS
Bone profile
Mx of CKD
Treat reversible causes Optimise CVS risk factors Education re RRT EPO for anaemia Ca for bones Low protein and potassium diet
Stage 5 CKD mx?
RRT
Dialysis
Transplant
Indications for RRT in AKI?
Uraemia Resistant Pulm oedema Severe hyperK Severe metabolic acidosis Renal failure
Comps of haemodialysis?
Infection, thrombosis, aneurysm, IE, stenosis
Hypotension
N+V, headache, cramps
Anaphylazis
Diseuilibration syndrome
Comps of peritoneal dialysis?
Peritonitis
Problems with catheters
Constipation, fluid retention, hyperglycaemia,
weight gain
hernia
Why transplant > dialysis?
Survival, QoL, economic, enables pregnancy, reverse aneamia + bone disease
LT immunosuppression post transplant?
Prednisolone
Calcineurin inhib [tacrolimus / ciclosporin]
Anti-metabolite [azathioprine]
CIs for renal transplant in CKD?
Active infection
Uncontrolled IHD
AIDS
Comps for renal transplant?
Immediate [Local infection, DVT, pain]
Immunosuppression [infections]
Obstruction
Drugs [bone marrow suppression]
Rejection
Other [cancer, CV disease]
Types of rejection?
What time frame?
Hyperacute (mins) - due to crossmatch
Accelerated (days) - T-cell mediated crisis
Acute cellular (weeks)
Chronic (years)
Causes of glomerulonephritis?
Focal segmental glomerulonephritis in nephrotic syndrome
Causes of nephrotic syndrome?
Deposition (amyloidosis, light chain dep) MCD (kids) Focal + segmental GN (younger adults) Membranous nephropathy (adults) Membranoproliferative GN
NephrOtic depOsit
Causes of nephritic syndrome?
IgA nephropathy Postinfectious GN Rapidly progressing GN Vasculitis Anti-GBM
Nephritic is prolific
Signs of nephrotic syndrome?
Proteinuria (>3.5g/24h)
Hypoalbuminaemia
Peripheral oedema
Hyperlipidaemia
Signs of nephritic syndrome?
Oliguria
HTN
Haematuria
Mx of MCD
Prednisolone
DDx of nephrotic syndrome?
CCF
Liver disease
(both cause oedema)
Comps of nephrotic syndrome?
Infection (urinary loss of IgG)
Hypercoaguability
Hypercholesterolaemia
Hypocalcamia
Most common cause of nephritic syndrome?
What happens?
IgA nephropathy (Buerger’s disease)
Macroscopic haematuria 24-48h post GI/URTI
IgA deposit in mesangial matrix
Causes of rapidly progressive glomerulonephritis?
Goodpastures (anti-GBM)
Wegeners
Microscopic polyangitis
Ix in glomerulonephritis?
FBC, U+Es, LFT
Urinalysis
Renal biopsy
Antibody testing (ANCA, GMB, dsDNA)
Mx of post strep glomerulonephritis?
IM BenPen
Mx of mild glomerulonephritis?
isolated haematuria, normal GFR
Abx / antivirals
Limit salt + fluid
Mx of severe glomerulonephritis?
haematuria, proteinuria, reduced GFR
ACEi + Abx + furosemide +/- prednisolone (if nephrotic syndrome)
Mx of Goodpastures?
Plasma exchange + IV methylprednisolone + IV cyclophosphamide
Mx of immune complex glomerulonephritis?
IV methylprednisolone
Mx of lupus nephritis?
IV methylprednisolone + cyclophosphamide
Comps of PKD?
HTN, CV morbidity, CKD, SAH, ESRD
Protein in PKD?
Polycystin
Which is worse?
ADPKD or ARPKD
ARPKD worse –> if homozygous will die in utero
If heterozygous presents in neonatal period (enlarged kidneys), death by teens
Pres of PKD?
FH of PKD Flank/abdo discomfort + lumbar pain + haematuria HTN Infections Palpable kidneys Hepatomegaly
Where do you get cysts in PKD?
Kidneys Liver Pancreas Seminal vesicles Brain
Ix in PKD?
Renal USS
Geneitc
CT abdo/pelvis
Urinalysis
ECG, Echo, MRI angiography (screen for aneurysm annually)
Family screening in PKD
Screen for SAH in 1st degree relatives
Mx of infection in PKD?
Ciprofloxacin
Mx in PKD:
Limit fluid secretion?
Target cell proliferation?
Calcium mimetics, CFTR inhibitors, Metformin
Somatostatin
Causes of glomerulonephritis
Idiopathic
Infection
Systemic [SLE, RA, Wegners, HUS, HSP, Goodpastures]
Drugs [penicillamine, NSAIDs, cicosporin]
Metabolic [HTN, DM]
Other [amyloidosis]
Comps of CKD
NS [peripheral neuropathy, restless leg, tiredness, fatigue]
CV [fluid overload, pericarditis, atherogenesis]
GI [altered taste, reduced Ca absorp]
Bone [Hyperparathyroidism, osteodystrophy]
Electrolyte [hyperK, acidosi]
Blood [anaemia]
Pain relief in renal colic? (drug, route and dose)
Which class is better?
IM diclofenac 75mg
NSAIDs > opioids
Mx of renal stones
<5mm?
<2cm? If pregnant?
> 2cm/complicated?
<5mm pass spontaneously
<2cm - ESWL
–> if pregnant - ureteroscopy
> 2cm - percutaenous nephrolithotomy
