Renal Flashcards
What are the five functions of the kidney?
- volume management 2. vitamin D physiology 3. EPO production 4. waste excretion and metabolism 5. acid-base balance
what does dialysis manage to do?
volume management waste excretion and metabolism acid-base balance
describe the RAAS?
insert picture
what is nephrotic syndrome?
presence of proteinuria causing hypo albumin and peripheral oedema
what is the most common cause of nephrotic syndrome in children?
Minimal change disease
What is the most common cause of nephrotic syndrome in young adults?
focal segmental glomerulosclerosis (and minimal change disease)
what is the most common cause of nephrotic syndrome in older adults?
Membranous neuropathy and systemic diseases such as diabetes
what are the causes of nephrotic syndrome?
minimal change disease focal segmental glomerulosclerosis membranous nephropathy diabetic nephropathy amyloidosis/SLE
what is minimal change disease?
There is Podocyte effacement causing proteins to leak
what is the management of minimal change disease?
corticosteroids if it is then steroid resistance you must do a renal biopsy
what is focal segmental glomerulosclerosis?
scar tissue forming on some but not all of the glomeruli can be primary or secondary
what are the causes of secondary focal segmental glomerulosclerosis?
HIV obesity reflux nephropathy
what is the management of focal segmental glomerul0 sclerosis?
biopsies
- required to differentiate between idiopathic and secondary causes which informs management
corticosteroids
and reducing intra-glomeruli pressure with RAAS blockade (ACEi or ARB)
what is membranous nephropathy?
basement membrane thickening with IgG deposition through capillary walls causing a spike and dome appearance on electron imaging
what are the causes of membranous nephropathy?
usually idiopathic but can be due to: hepatitis B autoimmune diseases like lupus drug reactions (NSAIDs and penicillinamine)
what is the management of membranous nephropathy?
symptomatic relief with diuretics and our AAAS blockade plus reducing risk of clots with blood thinners or anticoagulants if there is a high risk of kidney disease developing in the next five years use of high-dose corticosteroids and immunosuppressants
how do you assess the risk of chronic kidney disease in membranous nephropathy/any disease really?
assess proteinuria and blood creatinine the amount which they rise in six months
what is diabetic nephropathy?
occurs in both type I and type II diabetes with basement membrane dysfunction and thickening, glomerulosclerosis
how often does diabetic nephropathy cause nephrotic syndrome?
rarely does it progress to proteinuria significant to be defined nephrotic syndrome usually classed as microalbuminea
how do you manage diabetic nephropathy?
diabetic control ACE inhibitors or/and ARB in serious cases dialysis and transplant may be needed
how does amyloidosis cause nephropathy?
Ig light chains from amyloid fibres are deposited within the kidney associated with chronic inflammatory disease (AL or AA chains)
what is the management of amyloidosis/ amyloidosis nephropathy?
treat amyloidosis with anti-plasma cell chemotherapy
what questions should you ascertain in a history of nephrotic syndrome?
looking at differentials of: diabetes malignancy SLE HIV be drug history connective tissue disorders amyloidosis - insert picture
what investigations should you perform in nephrotic syndrome?
urine dipstick spot urine protein to creatinine ratio EGFR FPC lipid profile (+)serum albumin(-) then look for differentials: serum-free light chains and urine electrophoresis (amyloidosis) HIV hepatitis syphilis screen ANA (SLE) renal biopsy if corticosteroid resistant
when are renal biopsy is contraindicated?
Avoided in general if possible but contraindicated in children
what is the management of nephrotic syndrome?
Corticosteroids in general - may also need ARB/ACE I diuretics
why does nephrotic syndrome lead to thromboembolic disease?
As well as albumin being lost clotting inhibitors are also lost
why does nephrotic syndrome caused pleural effusions?
Decrease in argument causes oedema and in the lungs this is a pleural effusion
why does an nephrotic syndrome cause hypercholesterolaemia?
there is decreased albumin force to bind to
what happens to sodium in nephrotic syndrome?
hyponatraemia due to excess bodily fluids (oedema)
what is nephrotic syndrome?
Proteinuria and haematuria
what are the common causes of nephritic syndrome?
IgA neophropathy, glomeruli nephritis including post infectious haemolytic uraemic syndrome henloch schonlein purpura, goodpasteures, SLE
what is the presentation of nephritic syndrome?
Haematuria oedema less than nephrotic reduced urine output/oliguria hypertension
what would urinealysis show for nephritic syndrome?
haematuria +++ proteinuria++ red-cell casts
what do red cell casts indicates in nephrotic syndrome?
Form in their frown and indicate the glomerular disease
what is IgA nephropathy?
a buildup of IgA in the kidneys
how do you manage IgA nephropathy?
ACE I or ARB + low sodium diet and water restrictions
How do you diagnose IgA nephropathy?
kidney biopsy and serum IgA (+)
what is glomerulonephritis?
An umbrella term encompassing minimal change disease FS GS IgA nephropathy post infectious SLE and vascular to causes
what is post-streptococcal glomerular nephritis?
Inflammation of the glomerulus after skin or throat infection
how do you diagnose post strap glomeruli nephritis?
skin or throat swab (positive) antibiotics to manage infection fluid and electrolyte balance if severe and very symptomatic diuretics and corticosteroids
what is haemolytic uraemic syndrome?
A group of syndromes characterised by low red blood cells and acute kidney failure
who does haemolytic uraemic syndrome are most affect?
children
What is a presentation of haemolytic uraemic syndrome?
Bloody diarrhoea fever vomiting and weakness progressing to kidney injury
what is a common trigger for haemolytic uraemic syndrome?
post infectious of E. coli
what is the management of haemolytic uraemic syndrome?
dialysis steroids blood transfusions and plasmapheresis
how do you diagnose haemolytic uraemic syndrome?
full blood count and blood smear (haemolytic anaemia and thrombocytopenia) EGFR urea and creatinine stool cultures (positive)
what is Henloch schonlen purpura?
a vasculitis IgA with a characteristic triad of 1.maculopapular rash 2. arthralgia 3. abdominal pain
what does the image below show?
the maculopapular, urticarial, rashassociated with HSP - insert image
what is the rash distribution of HSP?
Extensor surfaces and symmetrical, purpuric but blanching
what are consequences of HSP?
Intussusception chronic kidney disease
how does HSP cause chronic kidney disease?
There is IgA deposition and ischaemia
what is the management of HSP?
corticosteroids and one year follow-up
how do you diagnose HSP?
Symptomatic triad evidence of nephritic syndrome biopsy showing IGA deposition
when is kidney biopsy indicated in children?
unresponsive to corticosteroids or evidence of kidney decline and high blood pressure
how do you investigate nephritic syndrome?
Find underlying cause with urea (+) and creatinine (+) ESR potassium(+) igA (+ in IgA neph) ANA (lupus also complement c3 and 4) , dipstick measure BP
how do you manage nephritic syndrome?
supportive therapy: low sodium diet and water restrictions treating underlying cause if more severe add a CEI or ARB diuretics and a very severe renal replacement therapy
What is goodpasteures syndrome?
also antibodies to Alpha three chain of IV collagen causing pulmonary renal syndrome
why does Godpasteures syndrome cause pulmonary renal syndrome?
IV Collagen is primarily found in the basement membrane of the glomeruli and the alveoli thus its destruction will cause pulmonary renal syndrome
what are symptoms of Goospatures syndrome?
reduced urine output spontaneous haemoptysis oedema haematuria and accompanying symptoms of shortness of breath fever and nausea
what HLA protein is Goodpastueres associated with?
HLA DRB-1 or DR-4
what investigations would be diagnostic for Goodpasteures syndrome?
anti-GBM (+ve) biopsy renal showing IgG deposition chest x-ray showing pulmonary infiltrates
what is the management of Goodpasteures syndrome?
immunosuppression with oral corticosteroids and plasmapheresis
what is Wagner’s granulomatosis?
systemic vasculitis typically involving the small and medium vessels of the lower and upper respiratory tract which also affects the glomerulus (causing glomerulonephritis)
what does Wagner’s granulomatosis cause nephrotic or syndrome
nephritic
what is most important to remember about Px of Wagners granulomatosis?
has both respiratory and renal involvement particularly aware of with patients with nosebleeds , Haemoptysis, sob cough … symptoms of upper respiratory tract or lower respiratory tract disorders with also nephrotic syndrome
what is diagnostic for Wagner’s granulomatosis?
Positive ANCA and renal biopsy showing segmental cruising glomeruli nephritis with immune complex depositions
what is the management of Wagner’s granulomatosis?
immunosuppressants (corticosteroids) plasmapheresis
what is renal colic?
and acute severe flank pain radiating to the groin
what are symptoms of renal calculi?
renal colic nausea and vomiting due to pain urinary frequency/urgency haematuria
what are risk factors for renal calculi?
high protein intake high salt intake previous stone dehydration white male obesity
what investigation is diagnostic for renal calculi?
None contrast CT ultrasound scan can be performed if pregnant
what is an important differential in renal calculi?
ectopic pregnancy in females so do a urine pregnancy test
what is the management of a renal calculi where the stone is not visible?
conservative management with analgesia And antiemetics (+NSAIDS)
what is the management of a stone less than 10 mm?
medical expulsion therapy with tamsulosin
what is the management of a stone greater than 10 mm??
ESWL also do this if there is veiled medical expulsion therapy however if the stone is greater than 50 mm than do percutaneous urteroscopy
why is an FB C useful in stones?
Can show evidence of infection which can indicate antibiotics
what is cystitis?
Infection of the bladder
wall usually causes UTIs?
E. coli
what can complicated UTIs be caused by?
Steph aureus P aerginosa or enterococci
what are symptoms of pyleo nephritis?
Back/flank pain costo vertebral angle tenderness fever
what are the general symptoms of a UTI?
Dysuria frequency haematuria urgency suprapubic pain
if a man presents with symptoms of a UTI what should you also investigate?
prostate enlargement so do DRE +/- PSA
what antibiotics are used for UTI?
nitrofurantoin or trimethoprim
what antibiotics are used for complicated UTI?
Cephalexin or fluoroquinolone in males
how does the management of UTI for males stiffer than the management for females which are not pregnant?
Two minutes seven days for males (also for pregnant individuals) in complicated/older men you can prescribe for 14 days
What is the most common type of bladder cancer?
Transitional cell carcinoma
apart from transitional cell carcinoma what are the other types of bladder cancer?
square miss cell carcinoma Adeno carcinoma
what is the public health significance of bladder cancer?
It’s the 10th most common cancer in the UK
what occupational risk factor is significant in bladder cancer
exposure to dies rather leather textiles and paints – aromatic amines are carcinogenic
apart from occupational risks what other risk factors are associated with bladder cancer?
male smoking genetic conditions such as HNPCC schistosomiasis chronic cystitis long-term catheterisation or intermittent self catheterisation
what is the presentation of bladder cancer?
chemo Tory – painless (usually visible) urgency recurrent UTI suprapubic pain suprapubic pelvic mass may be felt
what investigations are required for anyone presenting with haematuria?
a scan such as ultrasound or CT and cystoscopy of the bladder
what is diagnostic for bladder cancer?
Imaging showing mass urine cytology and cystoscopy (you should still perform a full set of bloods)
where does bladder cancer usually originate from ?
renal power and climbable cortex
describe the stages of bladder cancer?
see image below
in what type of cancer is renal cancer?
renal cell carcinoma - adenocarcinoma
apart from renal cell carcinoma what other types of real cancer are there?
transitional cell carcinoma
what is the commonest type of renal cancer in children?
Wilms tumour A.k.a. Nephroblastoma
what is the typical presentation of a Wilms’ tumour?
Asymptomatic mass unilateral in the abdomen
what are the typical symptoms of renal cancer in adults?
Massive haematuria
loin pain
hypertension
possibly a left-sided variocele
NB less than 10% of patients present with the classic triad most cancers are identified incidentally
what is paraneoplastic syndrome of renal cancer?
Results from polycythaemia due to the paraneoplastic EPO production (causing erythrocytosis)
how is calcium affected in renal cancer?
Hypercalcaemia can occur due to the elevation/production of parathyroid hormone related hormone
why does anaemia occur in renal cancer?
Haematuria may cause anaemia, chronic disease can cause anaemia
what is rhabdomyolysis?
can be the end result of any disease process which causes damage to the myocyte cell membrane of skeletal muscle causing myocyte-lysis
what are some causes of rhabdomyolysis?
physical exertion (inc. seizures or severe agitation) electrolyte disturbances (hypokalaemia hypocalcaemia hypophosphataemia hypo or hyponatraemia) muscle hypoxaemia (even from long immobilisation) metabolic disorders (hyperaldosteronism DKA hypothyroidism) direct muscular damage biological agents (including bacteria or viruses) genetic defects drugs and toxins (statins alcohol diuretics cocaine methadone heroin alkaloids antipsychotics)
what is the presentation of rhabdomyolysis?
Usually just presents with muscular pain but can also have dark urine general malaise muscular tenderness
how do you diagnose rhabdomyolysis?
serum creatine kinase ++++ / urine disptick shows haematuria in 50%
what investigations should you do in a patient with rhabdomyolysis to find out the underlying cause?
TSH – hypothyroidism ESR – inflammatory disease ANA – autoimmune cause swabs+cultures - bacterial and a good history
how do you treat rhabdomyolysis?
Managing the underlying cause hydration therapy and then diuretic therapy unless it’s being caused by diuretics if anuric or unresponsive to hydration therapy give haemodialysis
what is polycystic kidney disease?
An inherited renal cystic disease which can be autosomal dominant (most common) or recessive
what is the typical presentation of polycystic kidney disease?
Hypertension abdominal flank pain recurrent UTI with fever
what are extra renal features of polycystic kidney disease?
Extra renal cysts intracranial aneurysms and elongated and distended arteries aortic root dilatations and aneurysms mitral valve prolapse and abdominal wall hernias polycystic liver disease
what features would you find in a family history of polycystic kidney disease?
History of cerebrovascular events family history of cardiovascular events family history of end-stage renal disease
what is the management of polycystic kidney disease?
Hypertension mainly treated with ACEi, managed underlying renal pain with analgesia and bed rest give prompt UTI antibiotics and consider prophylaxis if haematuria is present which is not caused by UTI drink lots of water and surgical intervention may be required / in end-stage renal disease give transplant and dialysis
what is a common complication of polycystic kidney disease?
Infected renal cysts treated with ciprofloxacin (if that doesn’t work sister drainage if that doesn’t work in a fracture)
what medication should you not give for the management of pain in polycystic kidney disease and why?
NSAIDs because they are nephrotoxic
what is obstructive at uropathy?
Blockage of urinary flow which can occur at any level of the urinary tract affecting one or both kidneys depending on the level of obstruction
what other causes of unilateral obstructive uropathy?
Renal stones iatrogenic from surgery commonly obstetric/gynaecology malignancy causing compression
what causes of obstructive uropathy?
The 4 S's Stones Strictures Swelling (trauma etc) Surrounding structures (cancers BHP and neurogenic)
------------------------------------------------------------------------------- BPH neurogenic bladder renal or ureteric stones bladder tumour urethral stricture prostate cancer
what is the presentation of obstructive uropathy?
Flank pain fever and UTI symptoms L UTS palpable enlarged bladder from inability to urinate and any symptoms of underlying cause
what investigations should you perform in obstructive uropathy?
Renal ultrasound scan CT pyelogram CT abdomen and pelvis
what is hydronephrosis?
swelling of the kidney due to urine backup this can cause a KI in progress to CKD
define AKI stage I?
serum creatinine: 1.5 – 1.9 x baseline or >/0.3 urine output: <0.5 for 6-12h
define AKI stage II?
Serum creatinine: 2 – 2.9 x baseline urine output:< 0.5 for 12h +
defining AKI stage III?
serum creatinine: 3 x baseline decreasing EGFR to <35ml in patiemts <18 urine output:<0.3 for >24h or anuria for 12h
what are pre-renal causes of AKI?
Anything which causes hypoperfusion – hypovolaemia (from haemorrhage ET C) sepsis over diuresis heart failure hepato-renal syndrome
what are renal causes of AKI?
Glomeruli nephritis vascular causes such as HUS blood clots
what are post renal causes of AKI?
Anything causing outflow obstruction – BPH tumours strictures stones UTI urinary retention
what electrolyte disturbances can in acute kidney injury?
Hyperkalaemia so make sure you do an ECG
how do you manage hyperkalaemia?
Ivy glucose and insulin
when would you need to refer acute kidney injury to specialist?
Signs of abstraction kidney infection and sepsis hypovolaemia or an urgent complication
what complications can occur in acute kidney injury?
Pulmonary oedema hyperkalaemia uraemic encephalopathy pericarditis
what is the acute management of acute kidney injury?
Fluid bolus with IV fluids and less as congestive heart failure or pulmonary oedema in which case use loop diuretics
how would you go about finding the cause of acute kidney injury?
See image
what is chronic kidney disease?
Chronic renal failure causing either haematuria and/or proteinuria or a reduction of EGFR to <60 for 3 months +
what is the most common cause of chronic kidney disease?
Diabetes then hypertension
apart from diabetes and hypertension what other things can cause chronic kidney disease?
Polycystic kidney disease obstructive uropathy causes of nephrotic and nephrotic syndrome such as focal segmental glomerulosclerosis membranous neuropathy SLE amylodosis rapidly progressive glomerulonephritis
what is the pathophysiology of chronic kidney disease?
once renal damage has occurred glomerular hypertrophy occurs in order to maintain GFR this increases the intra-glomeruli pressure and inflammatory processes mean that the glimmer glomerular permeability increases and causes the passage of inflammatory substances to their messenger deal matrix causing scarring fibrosis and more information renal injury also causes angiotensin II production which causes an increase in TGF beta causing collagen synthesis and renal scarring
what are symptoms/features of CKD?
fatigue oede,a nausea and vomiting pruiritis anorexia - many symptoms caused by build up of toxins
what are the stages of CKD?
insert picture
when would urine microalbumin be increased in CKD?
diabetes or HTN
what can CKD cause as a complication?
amaemia (decreased EPO) 2ry hyperthyroidism (vD conversion is decreased) acidosis (decreased ammonia and bicarbonate excretion)
how do you manage stage 1-2 CKD?
Treat HTN and any compliations … reduce CVS risks with ACEi or ARB (2ry CCB) and statins - treat anaemia with EPO stimulating agent and /or iron suppliments treat 2ry hyperparathyroidism with calcium acetate +/- ercocaliferol +/- active vitamin D analogue treat metabolic acidosis wuth PO socium bicarb.
how do you treat anaemia in CKD?
EPO stimulating agent and /or iron suppliments
how do you treat 2ry hyperparathyroidism in CKD?
calcium acetate +/- ercocaliferol +/- active vitamin D analogue
how do you treat metabolic acidosis in CKD?
PO biacrbonate
what is the presentation of a UTI in an infant?
High fever over 39° irritability poor feeding suprapubic tenderness and abdominal/flank pain may be present
what are common features of UTI presentation in older children/teens?
Foul-smelling urine dysuria and frequency (tends to be in order children) as well as suprapubic tenderness and abdominal/funk pain
as well as the usual UTI investigations what other investigations should you perform in a ? UTI - in children?
do blood cultures and also Brown neonates/infants younger than 24 months
What should you do as follow-up for UTIs in children once treatment has commenced?
Cultures are performed after 24 hours of initiation of treatment
what should you do in young males presenting with UTIs?
Check genitourinary structures for abnormalities
what is the management of UTI in a patient under six weeks old?
IV antibiotics ampicillin/gentamicin
what is the management of a UTI and patient over six weeks old?
PO cefexime if stable - if unstable Ivy ampicillin/gentamicin - in teens management is the same as with adults
what is nocturnal enuresis?
In voluntary urination whilst asleep after seven years of age
what is the definition of primary nocturnal enuresis?
When the child hasn’t had a period of dryness and has never stopped bedwetting
what is the definition of secondary nocturnal enuresis?
When a child starts bedwetting after period of dryness
how do you diagnose nocturnal enuresis?
Take a voiding diary fluid intake diary check blood pressure check random blood glucose perform bladder ultrasound scan
why should you check blood pressure in patients with nocturnal enuresis?
Hypertension indicates renal pathology
what are the 3 potential mechanisms for nocturnal enuresis?
High nocturnal urine production high nocturnal bladder function sleep and arousal mechanism dysfunction
what is the management of nocturnal enuresis?
Motivational therapy watch and wait bedwetting alarms waterproof mattress and absorbent underwear medical therapy with: amitriptyline or desmopressin
what is the most common cause of chronic kidney disease in children?
Congenital and hereditary causes such as structural malformations glomerulonephropathies hereditary nephropathy is such as AD-PKD
how do you diagnose current kidney disease in children?
Due to the nature of the causes of childhood CKD it is usually detected on faecal ultrasound otherwise : RFT, urinalysis showing + Al + Cr +/- Haematuria ultrasound/CT
what is a presentation of CKD in childhood?
Hypertension anorexia and failure to thrive oedema caused by proteinuria possibly bone deformities and anaemia of chronic disease
how do you manage childhood CKD?
encourage growth ACEi + Diuretics for HTN and calcium carbonate to decrease potassium
how to stimulate growth in children with CKD?
Enteric feeds and caloric supplements controlling protein intake salt and bicarbonate supplements recombinant hGH
what is the presentation of acute kidney injury in children?
anurea (<10ml x 24h) or oliguria (<400ml x 24h)
what all causes of acute kidney injury in paediatrics?
Pretty much the same as adult however obstruction tends to be congenital rather than because of thrombosis or stone
what is the management of acute kidney injury in paediatrics?
treating the underlying cause - if renal AKI Fluid restriction diuretics sodium control high-calorie diet normal protein feeds
when is dialysis indicated for acute kidney injury in paediatrics?
If there is hyperkalaemia hypernatraemia or hypo notary mere or if there is a pulmonary oedema/pulmonary hypertension severe acidosis or multisystem organ failure
what can precipitate acute on chronic kidney injury?
Dehydration or infection
what are the most common congenital abnormalities (renal) in paediatrics?
pelvic ureteric junction obstruction horseshoe kidney renal Genesis and dysplasia renal cysts polycystic kidneys ectopic kidney
describe the pelvic ureteric junction obstruction?
Can be caused by many things but is a narrowing in the yurt as it joins the renal pelvis obstructing flow of urine from the kidney
What are the consequences of pelvic ureteric junction obstruction?
Risk of infections stones renal failure hydronephrosis
what is a horseshoe kidney?
a fusion anomaly of the kidney joined at the isthmus
What are the causes or horseshoe kidney?
Increased risk of kidney stones pyelonephritis from reflux and pelvic ureteric junction obstruction
when would you treat a horseshoe kidney?
If obstruction is present causing symptoms
what is renal agenesis and dysplasia?
The kidney is either absent or underdeveloped
what does renal agenesis cause if it is bilateral?
Oligohydramnios
pulmonary hypoplasia
extremity and facial anomalies – all part of Potter’s syndrome
– which is fatal within minutes to hours of birth or leads to miscarriage
which type of polycystic kidney disease usually affects children?
Autosomal recessive presents in childhood and is much more severe than autosomal dominant leading to renal failure and can involve liver pancreas leads to hypertension intracranial aneurysms and valve abnormalities
what are duplex kidneys?
Duplex kidneys share a single renal unit with more than one collecting symptom they are usually asymptomatic and the patient has normal kidney function
what duplex kidney is more at risk of developing?
vesico-ureteric reflux uterocele and an ectopic ureter
what is vesico ureteric reflux?
urine does not flow out of the bladder properly and instead goes back up the ureter to the kidneys
what are consequences of vesico ureteric reflux?
UTI damage and scarring to the kidney - nephropathy possibly hydronephrosis
what is a uterocele?
balloon forms like an aneurysm in the ureter where it connects to the bladder urine collected in the balloon involving a narrowing causing obstruction
what is the presentation of vesico ureteric refulx?
recurrent and often UTI infections / can have severe UTI symptoms
what investigations should you perform for vesico ureteric reflux?
USS - MAG3 sees dye be taken up by the kidneys through x-ray imaging MCUG bladder is catheterisation filled with special dye patient is asked to pass urine while being scanned this is good for detecting severity of reflux DMS a assesses whether the kidneys have been affected by urinary infections
what is the management of vesico ureteric reflux?
if reflexes mild key is with preventing kidney infections with good fluid intake and regular urination as well as avoiding constipation add profylaxis if needed and symptomatic and severe = surgery
what is congenital nephrotic syndrome?
An inherited disorder characterised by protein in the urine and causing oedema developing shortly after birth
what is a presentation of congenital nephrotic syndrome?
Low birthweight oedema decreased urine output for an appearance of your own poor appetite cough because of pulmonary oedema recurrent UTI malnutrition kidney failure if untreated
one investigation should you perform for congenital nephrotic syndrome?
Hypertension amniotic fluid can be tested for increased alpha-fetoprotein
what is the management of congenital nephrotic syndrome?
Diuretics ACEi NSAIDS prophylaxis/antibiotics sodium restriction dietary supplements fluid restriction to help control oedema in the end is definitively treated through dialysis and transplant it is typically resistant corticosteroids or other immunosuppressant
