Renal Flashcards
Pre-renal causes of AKI
Hypovolaemia
Low BP
Renal artery stenosis
Intrinsic causes of AKI
Acute tubular necrosis
Nephrotoxic meds
Glomerulonephritis
Interstitial nephritis
Post-renal causes of AKI
BPH
Bladder cancer
Calculi
Any cause of obstruction
What are the three phases of AKI
Oliguric/anuric phase
Polyuric/maintenance phase
Recovery phase
Complications of AKI
Hyperkalaemia Pulmonary oedema/fluid overload Metabolic acidosis Uraemic encephalopathy/pericarditis Low Ca, high PO4
ECG changes in hyperkalaemia
Small/absent P waves
Prolonged PR interval
Peaked T waves
Slurring into ST
Which treatments of hyperkalaemia increase K excretion
IV NaCl
Diuretics
Which treatments of hyperkalaemia move K into cells
Beta-agonists
Bicarbonate
IV insulin
What happens to BUN:Creatinine ratio in pre-renal AKI Vs intrinsic AKI
- In pre-renal AKI as normal all Cr is excreted, tubules are still working and reabsorbing urea so serum urea is higher. So BUN:Cr >20:1
- In intrinsic AKI as normal all Cr is excreted, tubules aren’t working though so more urea being excreted than normal so less serum urea compared to pre-reanl. So BUN:Cr <20:1 (closer to 1)
What happens to urine Na and osmolality in pre-renal AKI
Decreased renal blood flow but tubules still working. RAAS activated causing Na and H2O retention. Concentrated urine - high osmolality >500 but looking at just urine Na concentration this is low <20 because Na is being reabsorbed by the still-functioning tubules
What happens to urine Na and osmolality in intrinsic AKI
Tubules damaged so can’t function and cant reabsorb Na. So Na and H2O lost in urine - dilute urine with a high Na concentration. Low urine osmolality <350, high urinary Na concentration >40
Management of AKI
Treat underlying cause
Stop nephrotoxic drugs
Monitor pH, fluid balance and electrolytes
Involve renal team
How long does disease need to be present to classify as chronic kidney disease
3 months
Causes of CKD
HTN DM Renal artery stenosis Glomerulonephritis Reflux nephropathy Pyelonephritis PCKD
Clinical features of CKD
Polyuria Oedema Anaemia Low Ca, High PO4 Metabolic acidosis Hyperkalaemia Uraemia Mineral and bone disorder
Three main types of renal replacement therapy
Dialysis
Haemofiltration
Transplant
How long does it take before a fistula can be used for dialysis
4 weeks
When would you use haemofiltration rather than dialysis
When a patient is really haemodynamically unstable
What’s the difference between haemodialysis and haemofiltration
Dialysis uses a diffusion gradient whereas filtration uses a hydrostatic pressure gradient
Possible complications of an AV fistula
Thrombosis Stenosis Steal syndrome Infection Heart failure
Haemodialysis is performed roughly how often and for how long each time?
Three times a week
4 hours
What are the two types of peritoneal dialysis
Continuous ambulatory PD (4-6 exchanges/day) Assisted PD (fill in morning, exchange overnight)
6 features of nephrotic syndrome
Proteinuria Increased risk of infection Oedema Hypoalbuminuria Hyperlipidaemia Hypercoagulable state
2 most common causes of nephrotic syndrome in adults
FSGS (black population) Membranous nephropathy (white population)
Most common cause of nephrotic syndrome in children
Minimal change disease
Secondary causes of nephrotic syndrome
SLE Hep B Hep C HIV DM Malignancy
4 primary causes of nephrotic syndrome
Minimal change disease
FSGS
Membranous nephropathy
Membranoproliferative glomerulonephritis
Management of nephrotic syndrome
Low Na and protein diet Fluid restriction Loop diuretics ACEi/ARB VTE prophylaxis Statins Renal biopsy
8 features of nephritic syndrome
Haematuria Hypertension Oliguria Uraemia RBC casts Sterile pyuria Mild proteinuria Mild oedema
5 causes of nephritic syndrome
IgA nephropathy Post-strep glomerulonephritis Rapidly progressive glomerulonephritis (Anti-GBM, GPA, MPA, EGPA_ Membranoproliferative glomerulonephritis HSP
Management of nephritic syndrome
Low Na diet
Fluid restriction
ACEi/ARB
Consider immunosuppression
cANCA positive vasculitis
Granulomatosis with polyangitis (Wegeners)
pANCA positive vasculitis
Microscopic polyangitis
Eosinophilic granulomatosis with polyangitis (Churg-Straus)
Presentation of HSP
Purpuric rash on extensor surfaces of legs
Polyarthritis
Abdo pain (GI bleed)
Nephritis
Which 3 diseases only present as rapidly progressive glomerulonephritis
Goodpasteurs
Granulomatosis with polyangitis (Wegeners)
Microscopic polyangitis
What are the 3 classification types of rapidly progressive glomerulonephritis
Type 1 - linear immunofluorescence
Type 2 - granular immunofluorescence
Type 3 - negative immunofluorescence
Type 1 RPGN cause
Goodpasteurs
Type 2 RPGN causes
Post-strep GN
SLE
IgA nephropathy
HSP
Type 3 RPGN causes
Granulomatosis with polyangitis (Wegeners)
Eosinophilic granulomatosis with polyangitis (Churg-Strauss)
What does E.coli look like under microscope
Gram negative rod
Symptoms of acute pyelonephritis
Fever, rigors
Nausea, vomiting
Loin pain, costovertebral angle tenderness
Associated symptoms of cystitis
What is meant by ‘complicated UTI’
UTI in the setting of any condition/comorbidity that may predispose a patient to an increased risk of infection or failed treatment
What is classed as ‘recurrent’ UTI
2+ in 6 months or 3+ in 12 months
Differential diagnosis of haematuria
Malignancy Calculi/stones UTI Glomerulonephritis/nephritic syndrome ADPKD Trauma (biopsy) Coagulopathy Renal TB
Which patients with haematuria need cystoscopy and upper tract imaging
If >45 years old with any haematuria
If <45 with macroscopic haematuria and no infection
How do you manage someone <45 with microscopic haematuria
GFR + BP + PCR
Plus cystoscopy if having frequency/urgency and/or non-contrast CT if loin pain
2 types of benign renal tumours
Angiomyolipoma
Oncocytoma
2 types of malignant renal cancer
Renal cell carcinoma
Transitional cell carcinoma (urothelial cancer)
The most common type of renal cell carcinoma
Clear cell carcinoma
What is the classic triad of renal cell carcinoma
Haematuria
Flank pain
Palpable flank mass
What is the classic triad of transitional cell carcinoma
Haematuria
Pain
LUTS
What are the 2 main types of bladder cancer
Transitional cell carcinoma (urothelial cancer)
Squamous cell carcinoma
How does bladder cancer typically present
Painless macroscopic haematuria
Irritative voiding symptoms (dysuria, frequency, urgency)
Suprapubic pain
Suprapubic mass
Management options for bladder cancer that hasn’t invaded the muscle wall (
Transurethral resection of bladder tumour (TURBT)
Intravesical BCG
Management options for bladder cancer that has invaded the muscle wall
Radical cystectomy
Radiotherapy
What is the most common type of renal stone
Calcium oxalate
Symptoms of renal stones
Severe renal colic that radiates down to groin/perineum Costovertebral angle tenderness Haematuria Nausea, vomiting Dysuria, frequency, urgency Passage of material
Gold standard investigation of renal stones
Non-contrast abdo/pelvis CT
Indications for intervention for renal stones
> 1cm
Complicated
Failure to pass spontaneously after 4-6 weeks
BPH develops in which anatomical zone of the prostate
Middle transitional zone
Prostate cancer develops in which anatomical zone of the prostate
Outer peripheral zone
What tool can you use to assess prostate symptoms
International prostate symptom score
Describe the different types of LUTS
Voiding/obstructive - hesitancy, poor stream, intermittent flow, incomplete emptying, post-voiding dribbling, overflow incontinence
Storage - frequency, nocturia, urgency, urgency incontinence
Common causes of voiding LUTS
BPH
Bladder neck stenosis
Urethral stricture
Poor detrusor contractility
Common causes of storage LUTS
UTI
Bladder calculi
Urothelial carcinoma
Overactive bladder
What investigation would you arrange if you suspected prostate cancer
Ultrasound guided prostate biopsy
What score is used to interpret prostate biopsy
Gleason score
Is BPH a risk factor for prostate cancer
No
What is the first line medication for BPH
Alpha blockers - Tamsulosin, Doxazosin
What class of medications are Tamsulosin and Doxazosin
Alpha blockers
What medication can be used to decrease growth of BPH
5-alpha-reductase inhibitors - Finasteride, Dutasteride
Finasteride belongs to which group of medications
5-alpha-reductase inhibitors
Which mediation helps with both BPH symptoms and ED
Tadalafil - Phosphodiesterase 5 inhibitors
How do patients with ADPKD typically present
Flank pain, HTN and progressive renal disease in adulthood
How do patients with ARPKD typically present
Chronic renal failure, hepatomegaly, liver failure, pulmonary hypoplasia in utero/early life
Which two genes cause ADPKS
PKD1 and PKD2
Extra-renal diseases associated with ADPKD
Hepatic/pancreatic/splenic/ovarian/testicular cysts
Cerebral berry aneurysm –> SAH
Mitral valve prolapse
Diverticulosis
Clinical features of testicular torsion
Sudden onset of unilateral pain Nausea/vomiting Swollen, oedematous, tender testicle Abnormal position Negative Prehn sign Absent cremasteric refex
What is Prehn sign
Positive if lifting testicle relives pain (epididymitis)
Negative if it doesn’t (torsion)
Clinical features of epididymitis
Gradual onset of painful swelling
Fever, dysuria, frequency, discharge
Positive Prehn sign
Positive cremasteric reflex
Typical presentation/history of IgA nephropathy
Episodic gross hematuria during or directly after upper respiratory tract (URT), gastrointestinal (GI) infections, or strenuous exercise
