Renal Flashcards
2 interventions for immediate management of hyperkalaemia?
- IV calcium gluconate/chloride
- IV insulin and dextrose
Which of the following might be indications for urgent dialysis?
Potassium 7.8 on intial bloods
Serum bicarbonate 8 on initial bloods
Creatine Kinase 20000
Creatinine 967 umol/l
Urine output 5mls/hour after 4 hours of immediate treatment
Urine output 5mls/hour for first 4 hours of admission
Pulmonary oedema after 4 hours of immediate treatments
Potassium 7.8 4 hours after insulin/dextrose
UO 5mls/hour after 4h of immediate treatment
Pulm oedema after 4h of immed treatments
Potassium 7.8 4h after insulin/dextrose
What is the most important intervention in slowing the decline in kidney function in patients with CKD?
Tight control of BP
How does hypotension cause AKI?
Acute tubular injury/necrosis
What forms the first line of filtration in the glomerulus?
What forms the second line of filtration?
Podocytes
Basement membrane
What absorption/secretion occurs in the proximal convoluted tubules?
Majority of electrolytes (Na, K, Mg, Ca, glucose) reabsorbed here
Active secretion of urea, drugs, toxins, creatinine
How does the counter-current multiplier system of the loop of Henle work?
Na/K ATPase actively pumps Na ions from ascending loop, creates hyperosmolar area so causes reabsorption of water down the osmotic gradient from the descending loop
Which cells detect changes in Na concentration in the glomerulus? What do these cells regulate?
Macula densa cells
Release of renin by the juxtaglomerular cells
ADH released from ?? stimulates what change to occur in the collecting ducts of the kidneys?
Posterior pituitary gland
Aquaporin channgels insert into collecting ducts, allows water to move into interstitial spaces, causing more concentrated urine.
Name 4 actions of angiotensin II
Direct arteriole vasoconstriction
Sympathetic activation
Aldosterone secretion by adrenal cortex– sodium reabsorption and potassium secretion
ADH release, increases water reabsorption
Give the 3 possible criteria for diagnosing an AKI
1) Rise in serum creatinine of 26micromol/L or more in the last 48h
2) Rise in >=50% rise in serum creatinine known/presumed to have occurred in past 7d/ 1.5x rise from baseline
3) Urine output <0.5ml/kg/hr for >6 hours (>8 in kids)
Give 3 pre-renal, renal and post-renal causes of AKI
Pre- sepsis, haemorrhage, renal artery stenosis, hypovolaemia, heart failure, nephrotoxics
Renal- ATN (ischaemia, nephrotoxic meds), glomerulonephritis, vasculitis, acute interstitial nephritis
Post- obstructive causes e.g. tumours, BPE, clots, calculi, strictures.
Give 5 investigations to do in a patient with AKI
- Medication review
- Urinalysis
- Bloods: FBC, U&Es, LFTs, glucose, coag screen, vasculitis screen
- ECG
- Renal US
- Relevant radiology e.g. ECHO, CXR, CTKUB
What investigation can tell you whether AKI is likely pre-renal vs ATN cause?
Fractional excretion of sodium (FEna)
<1% likely pre-renal cause. Because kidneys act to concentrate urine and retain sodium, so urinary sodium low.
>2% likely ATN. Kidneys can’t concentrate urine and retain sodium so urinary sodium is high
Outline the management plan for pts with AKI
Fluid balance, daily weight, may need catheterisation
Encourage oral fluids, may need IV
Review meds and stop nephrotoxics
Identify and treat cause
Supportive therapy e.g. O2, blood transfusion if anaemic
Urgent urology referral if severe obstruction
Monitor renal function
What is the mnemonic for when to refer for renal replacement therapy in AKI?
POPAC Pulm oedema Oedema (gen) Potassium (hyperkalaemia) Acidosis Comps of uraemia (pericarditis, encephalopathy)
A patient presents to A&E due to vomiting, muscle pain, and brown coloured urine. The Dr suspects rhabdomyolsis.
Give 3 causes.
What electrolyte abnormalities would you find?
What serum abnormality helps diagnosis?
What is treatment?
Long lies, crush injuries, compartment syndrome, seizures, ecstasy, statins (esp with clarithromycin).
HyperK+, hypocalcaemia, hyperphosphataemia
CK signif elevated
Aggressive fluids, correct electrolyte abnormalities.
What is the definition of CKD?
Kidney damage for 3+ months, secondary to structural or functional disorders/disease, with eGFR <60 on 2 separate occasions.
The KDIGO guidelines also include the degree of ? in their stratification of CKD?
Albuminuria
Which 2 pops at greater risk of CKD?
Afro-Caribbean and Asian
What are 2 common causes of CKD?
What are 2 other causes?
HTN, diabetes
renovascular disease, GN, SLE, PKD, ITN
Give 3 symptoms that might be seen in severe CKD?
Oedema, pruritus, polyuria, fatigue, muscle weakness
What is considered a normal ACR?
<30 mg/g
Give 2 indications for getting a renal US in a pt with CKD?
Symptoms of obstruction
FH of PKD
Accelerated progression of disease
Visible or persistent microscopic haematuria
What lifestyle advice would you give for CKD?
Stop smoking, healthy balanced diet, lower potassium phosphate and salt intake. Regular exercise.
What is the management of CKD?
BP control - ACE inhibitors 1st line
Manage CVD RFs - statins, antiplatelets
Manage anaemia - EPO stimulating agents, correct iron deficiency
Manage oedema - furosemide
Check for renal bone disease - adcal, bisphosphonates
How and when should you screen for renal bone disease?
Measure calcium, phosphate, vit D, PTH if eGFR <30
What is target BP in CKD?
What if ACR >70mg/mmol?
<140/90
or <130/90 if ACR >70mg/mmol
Nephrotic syndrome is characterised by what 4 features?
1) Proteinuria >3g/24hrs
2) Hypoalbuminaemia <25g/L
3) Oedema
4) Hyperlipidaemia
Give 3 causes of nephrotic syndrome?
Which is the commonest cause in children?
Which is commonest cause in adults?
Minimal change nephropathy - commonest cause in kids
FSGS
Membranous nephropathy - commonest cause in adults
How is minimal change nephropathy treated?
When is renal biopsy indicated?
What is seen on microscopy?
Prednisolone
Biopsy indicated if no response to steroids
Normal light microscopy, but podocyte fusion on electron microscopy
3 RFs for FSGS?
Biopsy may indicate what?
Treatment?
Afro-Caribbean populations, HIV, drug abuse (heroin)
IgM deposition
Steroids (or immunosuppressants if unresponsive to steroids)
Vast majority of membranous nephropathy cases are idiopathic. What are 3 possible 2ndary causes?
What stain is used on histology and what is the characteristic finding?
Treatment of membranous nephropathy?
Malignancy (lung, colon), penicillamine, gold, AI diseases
Silver staining, shows basement membrane spike and dome pattern enveloping IgG deposits
Steroids, immunosuppressives
What is the prognosis of memranous nephropathy?
Rule of 1/3rds: 1/3 undergo spont remission; 1/3rd respond to treatment; 1/3rd progress to end-stage dis
3 characteristic features of nephritic syndrome?
- Haematuria
- Hypertension
- Assoc proteinuria with oedema (periorbital, pulmonary)
A patient presents with asymptomatic microscopic haematuria following a routine dipstick pre-operation. When asked, they say that their mother had inflammation of the kidneys but they can’t remember what it is called. What is the likely underlying condition and how is it inherited?
What is the management?
Thin basement membrane disease
AD
Excellent prognosis, reassure patient
A 23 year old female is referred to renal due to having visible frank haematuria 3 days after a URTI. Urinalysis showed proteinuria and albuminuria and haematuria.
What is the likely diagnosis?
What investigation and finding is needed confirm the diagnosis?
IgA nephropathy - most common cause of glomerulonephritis worldwide
Renal biopsy with mesangial deposition of IgA
What is the management of IgA nephropathy?
Prognosis?
No specific, steroids may help.
25% progress to end-stage
A patient presents with haematuria and proteinuria 2 weeks following a throat infection.
What type of nephritic syndrome is this?
What 2 characteristic features on blood tests?
Management?
Post-strep glomerulonephritis
Raised anti-streptolysin O titre, decreased C3 level
Supportive
What are Type I, type II and Type III rapidly progressive glomerulonephritis?
Type I = goodpasture
Type II = immune complex mediated
Type III = Pauci immune
What Abs are present in Goodpastures?
2 presenting clinical features that suggest Goodpastures?
What is diagnosis based on?
Treatment
Anti GBM antibodies to type IV collagen
Haemoptysis and haematuria
Linear IgG deposits (remember, IgG puts the G in Goodpasture)
Plasmapheresis, steroids and immunosuppression
Type III RPGN e.g. Pauci immune is associated with what other condition?
Vasculitis e.g. Granulomatosis with polyangiitis
Give 4 features of granulomatosis with polyangiitis?
Mnemonic to remember organ involvement?
ELK = ENT, Lungs, Kidney
cANCA positive RPGN
saddle shaped nose deformity, epistaxis, sinusitis, otitis
Conjuctivitis, episcleritis
Haemoptysis
What medications might be used in the treatment of granulomatosis with polyangiitis?
Methotrexate - asymp, or no organ damage
Cyclophosphamide - symp severe disease. Alt- rituximab
Steroids given as adjuvant theapy
If in remission, switch to methotrexate/azathioprine
2 examples of mixed nephrotic and nephritic glomerulonephritis?
Membranoproliferative (mesangiocapillary glomerulonephritis) - assoc with SLE, cryoglobulinaemia
Alport syndrome - X linked dominant
What is the gold standard investigation for renal vascular disease?
Angiography
Majority of renal vascular disease caused by ?
2 other possible causes?
Atherosclerotic disease
Renal artery stenosis, embolism, renal vein thrombosis, fibromuscular dysplasia
Beads on a string appearance on angiography suggests?
Fibromuscular dysplasia
Consider in young female pts who develop AKI after starting ACE inhibitor
3 features of renal vascular disease?
Secondary HTN, resistant to medical therapy
Flash pulmonary oedema
Decrease in renal function with RFs or ACE inhibitor/ARB treatment
A child presents with bloody diarrhoea and abdominal pain, which during their stay in hospital progresses to thrombocytopenia, jaundice and renal failure.
What is the diagnosis?
What was the causitive organism of the bloody diarrhoea?
Haemolytic uraemic syndrome
E. coli 0157:H7 strain
Briefly outline the pathogenesis of HUS
E coli 0157:H7 produces Shiga-like toxins - damages endothelial cells in microvasculature - causes platelet activation and intravascular thrombosis - erythrocyte fragmentation and haemolysis - this plus glomerular microvasculature thrombosis causes renal impairement.
Management of HUS?
Mostly conservative and it spontaneously resolves.
Some may need dialysis and plasma exchange
How is asymptomatic bacteriuria managed in pregnancy?
Urine sent for culture and treated with nitrofurantoin for 7 days
3 causative organisms of pyelonephritis?
E coli, proteus, klebsiella
Classic triad of pyelonephritis?
Fevers/rigors
Loin pain
Costovertebral angle tenderness
(+/- N/V)
Pts with a history of ? are more likely to develop chronic pyelonephritis?
Vesicoureteric reflux
What is the first line Ix for pyelonephritis?
If needing to confirm diagnosis, what is used?
US
CT
Management of pyelonephritis?
Analgesia, fluids, antiemetics
Ciprofloxacin or co-amox for 7 days
What symptom do pts often complain of that would make you think prostatitis?
Pain on ejaculation
How is bacterial prostatitis diagnosed?
What is management of bacterial prostatitis?
Blood and urine culture
14 days Ciprofloxacin or Levofloxacin. Paracetamol/ibuprofen, fluids. Usual course of prostatitis is several weeks. May need admission if severe or can’t take PO Abx
How are genetic abnormalities in ADPKD classified?
Which is the commonest type and which chromosome is affected?
PKD 1 - most common, Ch 16
PKD 2 and PKD 3
4 renal features of ADPKD?
4 extra renal features?
Loin pain
HTN
Kidney enlargement
Haematuria, stones, infection
Berry aneurysms Hepatic cysts - hepatomegaly Diverticulosis Ovarian cysts Mitral valve disease
4 investigations for ADPKD and what they’d show?
Urinalysis -haematuria
FBC - polycythemia 2ndry to increased EPO
US - shows cystic kidneys
May used CT
What Ix is used to screen relatives of a patient with ADPKD?
US kidneys
Outline the management of ADPKD
- No contact sports, reduce salt intake
- Treat HTN with ACE inhibitor (target 130/80)
- Manage infections e.g. UTI
- NSAIDs/cyst removal for pain
- Likely need transplant or dialysis as disease progresses
Is ARPKD more likely to present in childhood or adulthood?
Infancy/childhood
In ARPKD, what other organ is commonly affected?
Liver e.g. fibrosis
What is the chemical name of struvite?
Magnesium ammonium phosphate
First line Ix for kidney stones?
Non-contrast CT KUB
Is ESWL safe to use in pregnancy to treat kidney stones?
No - should be offered uteroscopy
All 3 types of renal tubular acidosis are associated with what abnormality seen on an ABG?
Hyperchloraemic metabolic acidosis with normal anion gap
What are the 3 different types of renal tubular acidosis?
Type 1 = distal
Type 2 = proximal
Type 4 = hyperkalaemic
1 cause and 1 complication of:
Type 1 renal tubular acidosis?
Type 2
Type 3
1 - causes include idiopathic, Marfans, SLE, sjogrens, RA. Comps - renal stones
2 - Fanconi, Wilsons, idiopathic. Comps = osteomalacia
4 - lowered aldosterone (Addison’s, diabetes, ACE inhibitors). Comps of hyperK e.g. cardiac arrhythmias
What are the 2 types of renal dialysis?
How often are the sessions for each?
Haemodialysis - 3 times a week, 4 hours at a time
Peritoneal dialysis - more flexible e.g. can do continuous ambulatory peritoneal dialysis for 4 20 min episodes distributed throughout the day.
What is the catheter called that is used in peritoneal dialysis?
Tenckhoff
Give 3 complications of each type of dialysis
Haemo - site infections, thrombosis, aneurysm formation, anaphylaxis, muscle cramps
Peritoneal - peritonitis (s. epidermis), blockage of catheter, leaking of catheter, development of hernias
Most patients on dialysis are more likely to die from what?
Cardiovascular disease
Acute graft failure is typically caused by what two mechanisms?
T cell mediated or CMV related
What would you expect to find in the urine in acute interstitial nephritis?
What is a common cause of interstitial nephritis?
It’s an allergic picture, so raised urinary WCC, IgE and eosinophils
Commonly caused by meds e.g. penicillin abx
What is seen on renal biopsy in RPGN?
Crescenteric glomerulonephritis
Triad of a boy with sensorineural hearing loss, renal failure and ocular probs makes you suspect what condition?
Alport syndrome
A child with abdo pain, arthritis, haematuria and purpuric rash on limbs/buttocks is suggestive of?
Henoch-Schonlein Purpura
