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Renal Flashcards

1
Q

What are the causes of CKD?

A 
Diabetes 
HTN
renal artery stenosis
SLE
glomerular diseases 
PCKD
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2
Q

How do the kidneys appear in CKD? When is that not the case?

A

bilaterally small

This is not the case in diabetics

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3
Q

What are the signs and symptoms of CKD?

A

polyuria (eventually progress to oliguria)
ankle oedema
itching
insomnia

anaemia: fatigue, SOB
bone disease: bone pain, fragility fractures
neuro: seizures
uraemia: N&V, cramps, anorexia

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4
Q

What are the stages of CKD?

A

1: >90 + need proteinuria or symptoms
2: 60-90 + need proteinuria or symptoms
3: 30-60
4: 15-30
5: <15 +will have uraemic symptoms

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5
Q

What blood results would you expect to see in CKD?

A 
normocytic normochromic anaemia
raised creatinine and urea
raised potassium
low eGFR
low calcium, high phosphate, high PTH
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6
Q

What is the management of CKD?

A

control risk factors i.e. good diabetes and HTN control
avoid nephrotoxic drugs
loop diuretics for oedema
eventually renal replacement therapy

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7
Q

How would you identify CKD patients with proteinuria?

A

albumin-creatinine ratio

This is a first pass morning urine sample

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8
Q

How is proteinuria in CKD managed? At what point for varying groups of CKD patients would you initiate this treatment?

A

ACE-I
if diabetic then ACR >3
if HTN then ACR >30
if no comorbidities then ACR >70

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9
Q

What can give a false +ve albumin-creatinine ratio?

A

UTI

recent exercise

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10
Q

Anaemia in CKD is what type of anaemia? At what eGFR would you expect the patient to start becoming anaemic?

A

normocytic normochromic

eGFR <35

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11
Q

Why does anaemia occur in CKD?

A
  • reduced EPO production
  • poor iron absorption
  • reduced intake due to anorexia seen with uraemia
  • reduced erythropoiesis as uraemia is toxic to marrow
  • increased RBC destruction due to HD
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12
Q

How is anaemia in CKD managed?

A

first optimise iron with IV iron infusion
then give EPO

(EPO will be useless if low iron)

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13
Q

How is HTN in CKD managed?

A

ACE-I (reduce filtration pressure so reduce workload)

furosemide to balance the potassium

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14
Q

What is the pathophysiology of CKD bone disease?

A
  1. reduced vit D (kidney unable to hydroxylate) and increased phosphate (kidney unable to actively excrete)
  2. reduced Ca
  3. raised PTH and osteomalacia
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15
Q

How is CKD related bone disease managed?

A

bisphosphonates if osteomalacia
Vitamin D
phosphate binders (Sevelamer is a non-calcium containing one that is used to stop calcium associated vessel calcification)

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16
Q

What are the hallmarks of an AKI?

A

uraemia - enough to cause symptoms

oliguria - <0.5ml/kg/hr

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17
Q

What are the causes of AKI?

A

PRE-RENAL:
hypovolaemia/shock
renal artery stenosis

RENAL:
nephrotoxic drugs
IV contrast
rhabdomyolysis
tumour lysis syndrome
vasculitis 
glomerulonephritis
POST-RENAL:
Stones 
BPH
strictures
tumours
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18
Q

Why is creatinine not a good marker for AKI in elderly?

A

they have a low muscle mass and so a low creatinine doesn’t necessarily mean their kidneys are not struggling

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19
Q

What blood results would you expect in AKI?

A

raised creatinine and urea

raised K

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20
Q

How (on bloods) do you differentiate between an acute and a chronic drop in kidney function?

A

the calcium

it only goes low in chronic disease

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21
Q

Compare the urea and creatinine in an AKI vs dehydration

A

AKI: +++creatinine
dehydration: +++urea

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22
Q

What would urine microscopy show in AKI?

A

pre-renal: hyaline casts
renal: muddy brown casts
post renal: red cell casts

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23
Q

Compare the urine sodium levels in pre-renal vs renal AKI. Why does this happen?

A

in pre-renal your kidney holds on to sodium in an attempt to increase intravascular volume therefore urine sodium is low

in renal the urine sodium is high

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24
Q

Compare the urine osmolality in pre-renal vs renal AKI

A

pre-renal: concentrated (trying to hold on to water)

renal: dilute

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25
Compare the serum urea:creatinine ratio in pre-renal vs renal AKI
pre-renal: raised i.e. proportionally serum urea is high | renal: normal
26
What is the appearance of the urine in pre-renal vs renal AKI?
pre-renal: normal | renal: brown granular casts
27
When would someone be considered for renal replacement therapy?
Raised urea + symptoms or uraemia Raised potassium Metabolic acidosis Pulmonary oedema
28
What are the complications of AKI?
Pulmonary oedema Metabolic acidosis Arrhythmias resulting from hyperkalaemia uraemic symptoms e.g. seizures
29
What else could cause a raised urea?
GI bleed high protein diet increased protein catabolism i.e. fever, stress, steroids
30
What is fibromuscular dysplasia?
Stenosis and aneurysm of medium sized arteries
31
How would fibromuscular dysplasia present?
Young females Slow onset CKD or HTN or they may present acutely following ACE-I initiation Flash pulmonary oedema
32
What would an MR angiogram of fibromuscular dysplasia show?
String on beads i.e. they artery is stenosed but with aneurysms
33
Compare the presentation and urine dip results of HSP, IgA nephropathy and post-strep glomerulonephritis
HSP: young males with haematuria + purpuric rash over buttocks and extensors + joint pain IgA nephropathy: young males, 1/2 days post strep infection with visible haematuria post-strep: 1-2 weeks post strep infection, malaise, proteinuria (oedema) and visible haematuria, HTN
34
What is Alport syndrome? How does it present on biopsy?
x-linked collagen defect leading to an abnormal glomerular basement membrane There is splitting of the lamina densa of the GBM
35
What are the signs and symptoms of alport syndrome?
renal failure microscopic haematuria bilateral sensorineural deafness retinitis pigmentosa
36
What is Goodpastures?
vasculitis | There are anti-glomerular basement membrane antibodies
37
How does Goodpastures present?
glomerulonephritis (rapid onset AKI, proteinuria and haematuria) pulmonary haemorrhage
38
What is the management of Goodpastures?
steroids and plasma exchange
39
What are the hallmark features of nephrotic syndromes?
proteinuria hypoalbuminaemia oedema frothy urea
40
How does the oedema in nephrotic syndrome compare to HF?
it is worse in the morning in nephrotic syndrome
41
What are the causes of minimal change glomerulonephritis?
Hodgkins Infectious mononucleosis NSAIDs
42
How is minimal change glomerulonephritis managed?
1. steroids | 2. cyclophosphamide
43
What is an ADR of cyclophosphamide?
haemorrhagic cystitis
44
What are some risk factors/associations with focal segmental glomerulonephritis?
Obesity HIV Heroin
45
What are the causes of membranous glomerulonephritis?
Malignancy (prostate, lung, haematological) Hepatitis, malaria, syphilis SLE Penicillamine given in Wilson's disease
46
Compare the pathophysiology (briefly) of the 3 types of nephrotic syndrome
minimal change: podocyte damage focal segmental: fibrosis or glomerular tufts membranous: thickened BM and sub epithelial deposits giving "spike and dome appearance"
47
What are some complications of nephrotic syndrome?
Infections: lost immunoglobulins in urine Thrombosis: lost protein C and S and antithrombin in urine Anaemia Hypocalcaemia Reduced total T4
48
How is nephrotic syndrome managed (aside from steroids/immunosuppression)
Heparin (due to being pro-thrombotic) ACE-i Fluid and salt control
49
How is membranous glomerulonephritis managed?
ACE-I to reduce proteinuria | Steroids or cyclophosphamide
50
What are the hallmark features of nephritic syndrome?
Haematuria and mild proteinuria Hypertension Raised creatinine
51
What would make a UTI "complicated"
``` Male Catheter associated Renal pathology Immunosuppressed Abnormal organism ```
52
How are UTI's managed?
Uncomplicated: 3 days trimethoprim or nitrofurantoin Lower complicated: 7 days of trimethoprim or nitrofurantoin Upper complicated: 14 days ciprofloxacin
53
How are UTI's managed in pregnancy?
Nitrofurantoin until the third trimester | Cefalexin near term
54
What channels and where in the kidney do the various diuretics work on?
Loop: NKCC2 in the loop of henle Thiazide: sodium-chloride cotransporter in early DCT Aldosterone antagonists: eNaC in late DCT and CD
55
What are the side effects of loop diuretics?
``` (hypotension, AKI) Hypokalaemia Hypocalcaemia Gout Ototoxic Glucose intolerance ```
56
What are the side effects of thiazide diuretics?
``` (hypotension, AKI) Hypokalaemia Hypercalcaemia Gout Glucose intolerance pancreatitis thrombocytopenia ```
57
What are the side effects of aldosterone antagonists?
(hypotension, AKI) Hyperkalaemia Gynecomastia
58
How does ADPKD present?
Haematuria Flank pain Recurrent UTI HTN NOT ANAEMIA (EPO production preserved)
59
What are the extra-renal complications of ADPKD?
``` berry aneurysms Liver cysts mitral regurg/prolapse aortic root dilation and dissection Abdominal wall hernias ```
60
What should you consider in persistent sterile pyuria with persistent negative urine cultures?
Renal TB
61
How long does an AV fistula take to mature?
4-8 weeks
62
What are the pros and cons of HD?
+ Not responsible + Get days off + Can be done in emergency through CVC - unsightly fistula - risk of haemorrhage - risk of thrombosis - multiple days in hosptial/week - air embolus - anaphylactoid reaction to dialysis fluid - steal syndrome (cold, crampy extremities)
63
What are the pros and cons of PD?
+ Can do it at home + No needles + Less long term CVS risk as constantly dialysed - risk of peritonitis - obesity (due to ++glucose in dialysis fluid) - pleural effusion - hernias - you're responsible - peritoneal membrane eventually fails
64
What would indicate someone was underdialysed?
insomnia itching fatigue sensory neuropathy and restless legs
65
What are some complications of a renal transplant?
``` Thrombosis Urine leakage UTIs ATN of the graft Side effects of the anti-rejection medications ```
66
Describe a hyperacute renal transplant rejection (timing, reason, management)
Within minutes to hours Due to ABO or HLA incompatibility which causes thrombosis of the graft vessels Need to remove the graft
67
Describe an acute renal transplant rejection (timing, reason, presentation, management)
<6 months HLA mismatch or CMV infection Rise in creatinine, fevers, graft pain High dose methylprednisolone
68
Describe a chronic renal transplant rejection (timing, reason, presentation)
>6 months Recurrence of the underlying pathology or fibrosis Gradual rise in creatinine and protein
69
What are the causes of rhabdomyolysis?
``` Long lie Crush injury Seizure Ecstasy Statins when given with clarithromycin ```
70
How does rhabdomyolysis present? (in terms of blood results and blood gas)
AKI with +++ creatinine Raised K, phosphate Low calcium Metabolic acidosis
71
How is rhabdomyolysis managed?
Fluids | urinary alkalanisation
72
What is acute interstitial nephritis?
A cause of AKI where there is interstitial oedema and infiltrate
73
How does acute interstitial nephritis present?
Fever, malaise and arthralgia rash mild renal impairment eosinophilia
74
What are the causes of acute interstitial nephritis?
Drugs: - penicillin - NSAIDS - allopurinol - furosemide SLE and sarcoid
75
What characteristic urine and blood results are seen in acute interstitial nephritis?
Sterile pyuria White cell casts Eosinophilia

Finals (16 decks)

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