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Paeds Exam Cram > Renal > Flashcards

Renal Flashcards

1
Q

Proximal convoluted tubule absorption

A
  • Almost complete absorption of important substances
  • Absorption H2O 60%, HCO3 90%, Na, Cl, K, amino acids, glucose, nutrients
  • PTH acts to increase PO4 excretion
  • 65% glomerular filtrate absorbed, not concentrated
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2
Q

Loop of Henle absorption

A
  • Reabsorbs H2O 30%, Na, Cl
  • Concentrates urine
  • PTH acts to increase Ca reabsorption
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3
Q

Distal convoluted tubule absorption

A
  • Reabsorbs H2O, HCO3, Na, Cl
  • Secretes K, H
  • Regulates pH and dilutes urine
  • Aldosterone acts on Na channel to resorb H2O and Na to maintain intravascular volume
  • Fine tuning electrolytes
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4
Q

Collecting duct absorption

A
  • Derived from ureteric bud
  • Final Na, Cl, Urea, J2O reabsorption
  • ADH - creates aquaporins that insert in to membrane to allow for water permeability
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5
Q

Renin Angiotensin System

A

Renin (kidney) -> Angiotensinogen (liver) -> Angiotensin I (lung) -> Angiotensin II (ACE)

  • > Aldosterone (adrenal)
    • > arteries -> vasoconstriction -> increase BP
    • > Na + H2O retention (kidney) -> increase BP
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6
Q

Renin

A

Aims to increase BP

  • Released in response to LOW Na and LOW intravascular volume, LOW BP
  • Suppressed by ADH, Angiotensin II, High Na, High K
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7
Q

Aldosterone

A

Aims to increase BP

  • Acts on ENAC Na Channel in distal tubule to resorb H2O + Na to maintain intravascular volume. Secretes K + H
  • Stimulated by Angiotensin II, High K, Low Na
  • Inhibited by ANP, high Na

Low Aldosterone: LOW BP, LOW Na, High K, acidosis, weight loss e.g. CAH

High Aldosterone: HIGH BP, low K, alkalosis

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8
Q

ADH

A
  • Triggered by: LOW BP, pain, nausea, pregnancy
  • Inhibited by: caffeine, alcohol
  • Acts on collecting duct - inserts aquaporins to allow for water to be reabsorbed
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9
Q

ANP

A
  • Triggered by HIGH BP in response to arterial stretch
  • Dilates afferent, constricts efferent arterioles
  • Inhibits aldosterone and renin secretion
  • Inhibits ADH action on kidney
  • Inhibits NaCl reabsorption in collecting duct
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10
Q

Afferent and efferent arterioles

A

Afferent arteriole dilation + efferent arteriole constriction = increased GFR

Efferent arteriole constriction + efferent arteriole constriction = reduced GFR

  • Afferent Arteriole Dilatation: Low BP, prostaglandin, Dopamine (low dose), ANP, NO
  • Efferent Arteriole Constriction: Angiotensin II (low dose)
  • Afferent Arteriole Constriction: High BP, exercise, shock, angiotensin II (high dose), noradrenaline, endothelin, ADH
  • Efferent Arteriole Dilatation: Angiotensin II blockade

HYPOVOLAEMIA = increased renin, increased aldosterone, increased Na reabsorption
LOW NA = low ANP, high aldosterone, high angiotensin II

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11
Q

Renal tubular acidosis

A

Consider if normal anion gap metabolic acidosis

AG = Na - (Cl+HCO3), high Cl)

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12
Q

Type 1 - Distal RTA

A
  • Can’t excrete H
  • Normal anion gap metabolic acidosis
  • Normal Na, LOW K, High urine Ca, urine pH >5.8
  • Nephrocalcinosis, bone disease, rickets
  • Presents <1yo with FTT, parent has renal stone disease
  • Can have SNHL
  • Associated with Marfans, Elhers Danlos, Wilsons, VUR
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13
Q

Type 2 - Proximal RTA

A
  • Reduced HCO3 resorption
  • Metabolic acidosis
  • Low Na, LOW K, LOW PO4, glycosuria, urine pH <5.8
  • Polyuria, growth failure, anorexia, vomiting
  • Associated with Fanconi syndrome
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14
Q

Type 4 - Collecting duct

A
  • Aldosterone deficiency/insensitivity
  • Metabolic acidosis
  • Low Na, HIGH K, high H, urine pH <5.8
  • e.g. post obstructive diuresis (UTI, obstructive uropathy), CAH
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15
Q

Nephritic syndrome

A

Haematuria, hypertension, AKI, oliguria, oedema

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16
Q

Nephritic syndrome - low complement

A

Post Strep GN

  • 4-12 yo, 10-14 days post group A beta haemolytic strep, 3-6 weeks post skin infection
  • Tea coloured urine, RBC acts, ASOT pos
  • Low C3/4 normalises by 6/52 biopsy if persists (think SLE or membranoproliferative if continues

SLE

  • ANA pos most, dsDNA pos most
  • C3/C4 low - C3 normalises with treatment C3 marker of disease activity
  • Biopsy all the IG
  • Rx steroids, immunosuppression

Membranoproliferative GN

  • C3/C4 persistently low
  • Biopsy widened basement membrane due to infiltrates

Shunt nephritis

  • Staph aureus
  • Fevere, arthralgia, hepatosplenomegaly, lethargy, nephritis
  • Low C3/C4
  • Rx antibiotics
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17
Q

Nephritis syndrome - normal complement

A

IgA nephropathy

  • At time of throat infection
  • Most common cause of macroscopic haematuria
  • Associated with autoimmune (SLE, coeliac, IBD)
  • IgA can be normal, normal C3
  • Biopsy - IgA deposits in glomeulus
  • Rx: steroids

Alports

  • X linked (mild in females)
  • Type IV collagen (glomerular basement membrane(
  • Macroscopic haematuria, SNHL, cataracts, anterior lenticonus
  • Biopsy - splitting of basement membrane
HSP
Anti GBM (Good pastures)
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18
Q

Nephrotic syndrome

A

Proteinuria, hypoalbuminaemia, oedema

Congenital

  • Finnish type** no NPHS1 (nephrin)
  • Non-Finnish type no NPHS2 (podicin)
  • Asscoiated with Denys Drash

Minimal change**

  • Preschool age
  • No macroscopic haematuria
  • Light microscopy normal, electron micro fused podocyte foot processes
  • 20% steroid resistant

Membranoproliferative/mesangiocapillary

  • > 10 yo
  • Macroscopic haematuria
  • Consider if thought to be PSGN but C3 doesn’t resolve
  • 20% steroid resistant

Focal Segmental Glomerulosclerosis

  • > 6yo
  • Tea coloured urine
  • RBC casts
  • Glycosuria
  • Focal sclerotic lesions on biopsy
  • IgM C3 positive on stain
  • ESRF
  • 80% steroid resistant

Membranous nephropathy

  • Older children
  • Biopsy - thick capillary walls, IgG deposits
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19
Q

Mixed/GN

A

Rapidly progressive GN

  • Rapid decline in renal function
  • Heavy proteinuria, hypertension, ongoing low complement
  • Crescent cells on biopsy
  • Rx: steroids, cyclophosphamide
  • ESRF in weeks (end point of many Dx)

Steroid resistance - 10% mutations in NPHS2 (podicin)

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20
Q

Nephronophthisis

A 
Commonest genetic form of renal failure
Ciliopathy
NPHP genee
Growth failure, pale
Progress to renal failure
Benign urine micro
Sodium bicarb
Transplant cures
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21
Q

Renal angiomyolipomata

A

TS
Usually bilateral
Can cause fatal spontaneous bleeding
Grows and encroaches on renal tissue –> ESRF

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22
Q

Fanconi syndrome

A 
Type 2 RTA proximal
FTT, polyuria
LOW PO4, HCO3, Na, K, amino acids
Glycosuria
Supplement PO4, HCO3, K, calcitriol
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23
Q

Renal osteodystrophy

A

HIGH PO4, HIGH PTH
LOW Vit D (1,25OH), LOW Ca

Monitor PTH
Tx: calcium carbonate (PO4 binder), Vit D if PTH stays high

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24
Q

Tubular interstitial nephritis

A

Drugs (NSAIDS, penicillin), infection
Fever, arthralgia, rash, macroscopic haematuria
Casts in urine

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25
Q

Pulmonary renal syndrome

A

ANCA associated vasculitis most common

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26
Q

Wegners

A

Granulomas
cANCA (ear/nose/throat vasculitis, sinusitis, granulomatous lung vasculitis, Staph. Crescenteric pauci immune GN no deposition of Ab)
Microscopic polyangitis pANCA

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27
Q

HSP

A

Ig A mediated
URTI prior, rash, arthritis, abdominal pain, haematuria, proteinuria, hypertension
Complications - renal, intussusception, CNS vasculitis
Steroids (reduced Sx not complications)

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28
Q

HUS

A

Typical E coli 0157:h& shigatoxin
Atypical pneumococcal, complement
Haemolytic anemia, thrombocytopaenia, AKI, fragmentation on film
High LDH, low haptoglobin, DAT neg in typical

29
Q

Bartter syndrome

A 
Autosomal recessive
LOH gene
Collecting duct - same response as LOOP diuretic - frusemide
Polyuria, polydipsia, nephrocalcinosis
Metabolic alkalosis
LOW Na, LOW K, LOW Cl, HIGH urine Ca
Replace salt/IVF
30
Q

Gitelman syndrome

A

Autosomal recessive
Same as thiazide diuretic e.g. hydrochlorothiazide
Nocturia, joint pain
LOW K, LOW H, LOW Mg, normal Ca, LOW urine Ca
High serum glucose, high uric acid
Rx: KCL supps

31
Q

Prune Belly

A

Abdominal wall defect, undescended testes, infertility, VSD, malrotation

32
Q

Denys Drash

A

WT1

Congenital nephrotic syndrome, Wilm’s thymus, sex disorder (hermaphroditism)

33
Q

Bardel-Beidl

A

Obesity, hypogonadism, polydactyly, developmental delay, renal cysts

34
Q

Multi cystic dysplastic

A

Large peripheral cysts no renal parenchyma (other kidney should hypertrophy if normal)
MAG3 won’t take up tracer
Involut4es then disappears
Long term follow up risk Wilms in remaining kidney

35
Q

ARPKD

A

Both kidneys enlarged, multiple cysts in cortex and medulla
Associated hepatic fibrosis/hepatic cysts
Need to check siblings
50% CKD by 20yo

36
Q

Potter syndrome

A

Severe version ARPKD significant oligohydramnios - pulmonary hypoplasia, DDH etc

37
Q

ADPKD

A

Common
Bilateral enlarged kidneys
>2 cysts
Can have in liver, pancreas, spleen, ovaries
Associated with berry aneurysms
Hypertension monitors disease progr4ession

38
Q

Stones

A

Usually have high urine Ca
Fluids
Low salt diet and Potassium citrate protective
Calcium oxalate sontes - most common
Struvite stones - associated with proteus UTI/underlying anatomical problems
Consider if FTT recurrent urosepsis
Uric acid stones - not seen on XR

39
Q

Renal cysts and diabet4es

A

AD HNF1B
Renal cysts
MODY

40
Q

Horseshoe kidney

A

Associated with VACTERL, trisomy, GDM

41
Q

Ectopic ureter

A

Think if constant wetting day and night

42
Q

Duplex kidney

A

Risk of obstruction where ureters overlap

43
Q

PUJ obstruction

A

Most common
Bilateral 40%
MAG3
Tx: pyeloplasty, antibiotic prophylaxis

44
Q

VUR reflux

A

Complications: hypertension, recurrent UTI, reflux nephropathy
Dx: MAG3
Grade 1-3 prophylactic Abs, Grade 4-5

45
Q

`PUV

A

Dx MCUG

Tx: valve ablation, vesicostomy, transplant

46
Q

Testicular torsion

A

Acute, excruciating, urine NAD

47
Q

Toersion of the appendix testes

A

Gradual, tender upper pole blue dot sign

48
Q

Epidydimo-orchitis

A

Rare pre puberty
Fever, red, swollen, painful
Bactrim
Adolescents - chlamydia, gonorrhoea

49
Q

Nocturnal enuresis

A

5 yo 20%
10yo 5%
Alarm (motivation)
Desmopressin

50
Q

Urinary incontinence

A

Day and night
>5yo
Improve voiding habits
Oxybutinin

51
Q

RBC casts

A

GN

52
Q

Tubular epithelial cells/casts

A

TIN

53
Q

Granular casts (muddy brown)

A

ATN

54
Q

FGF23

A

Marker for bone disease

High in X linked phosphotaemic rickets

55
Q

TTKG

A

Tests the response of distal tubule to aldosterone

56
Q

MCU

A

Reflux**
Valves**
Duplex system

57
Q

DMSA

A

Function
Scarring**
Function of kidney

58
Q

MAG3

A

Function and excretion

PUJ obstruction**

59
Q

Histology

A

Exudate (infiltration by neutrophils) P Strep GN
Normal high micros, fused podocytes on EM - Minimal change disease
Crescent cells - rapidly progressive GN**, ANCA associated, anti-GBM, SLE

60
Q

Fractional excretion

A

Plasma Cr x Urinary Na /
Urinary Cr x Plasma Na

ARF = <1% prerenal >1% renal >4% post renal

61
Q

GFR

A

Urine concentration x

Volume/
Plasma Concentration

Depends on renal blood flow
Adult level by 2yo
Inulin gold standard (can't measure)
51-Cr EDTA most accurate
Cr overestimates GFR (Cr secreted by tubules)
62
Q

Loop diuretics

A

E.g. Frusemide

Inhibits Na/K/Cl cotransporter
SE: low K/Na/Cl/Ca/Mg
LOOP = LOW EVERYTHING
Gout, high BSL, high lipids

63
Q

Thiazide diuretics

A

E.g. Hydrochlorothiazide

Inhibits resorption of NaCl
SE: Low K, Na, Cl
High Ca
Abnormal BSL, lipids
Gout
64
Q

Potassium sparing diuretics

A

E.g. spironolactone

Block aldosterone activity in DCT/CD to stop H2O resorption
Uses: with loops or thiazide to help keep K stable
SE: high K, gynaecomastia

65
Q

Calcineurin inhibitors

A

Cyclosporin
- Hirsutism, gingival hyperplasia, hyperlipidaemia, hypertension, T2DM

Tacrolimus
- *CYP450, hyperglycaemia, T2DM, low Mg, diarrhoea, seizures

66
Q

Anti-proliferative drugs

A

Inhibit nucleotide synthesis

Methotrexate
- BM suppression, hepatic fibrosis, mucositis, interstitial pneumonitis

Mycophenolate
- Severe diarrhoea, leukopenia, pulmonary fibrosis

Azathioprine
- Agranulocytosis, infection, lymphoma 4x risk, hepatotoxicity, pancreatitis

Sirolimus
- Pancytopaenia, mouth ulcers, abnormal LFTs

67
Q

Alkylating agents

A

Impair DNA replication

Cyclophosphamide
- Sterility, hemorrhagic cystitis, BM suppression, leukaemia, alopecia

68
Q

Monoclonal antibodies

A

TNF inhibitors e.g. infliximab, etanercept
- Heart failure, opportunistic infections, lymphoproliferative disease check TB prior

B cell depletes e.g. rituximab
- Hypersensitivity reactions, flu like illness, enterovirus, meningitis, reactivation of Hep B

Interleukin inhibitors e.g. tocilizumab IL6, anakinra IL2

69
Q

Other drugs

A

Cystinuria - penicillamine
Hydroxyurea - pyridoxine
Uric acid stones - allopurinol
Hypercalcuria - thiazide

Paeds Exam Cram (19 decks)

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