renal disease Flashcards

Question

causes of white urine

Answer 1

pyuria, phosphate crystals, chyluria

Answer 2

haemoglobinuria , alkaptonuria

Answer 3

glomerular problem/damage (usually) | Can be a benign variant (Orthostatic proteinuria)

Answer 4

urine dipstick tells you that it is present need to quantitate spot urine Protein:creatinine ratio (PCR) or albumin:creatinine ration (ACR) ?? normal up to 30 - low level protein excretion

Answer 5

A rapid decline in renal function over hours or days with: Accumulation of (nitrogenous) waste products Potentially life threatening metabolic consequences With or without reduction in urine output.

Answer 6

Serum creatinine rise by greater than 26 umol/L within 48 hrs OR Serum creatinine rise 1.5 x from the reference value which is known or presumed to have occurred within one week OR Urine output is less than 0.5ml/kg/hr for 6 consecutive hours

Answer 7

lowest creatinine | value recorded within 3 months of the event

Answer 8

1 - Serum creatinine rise by greater than 26 umol/L within 48 hrs, Urine output is less than 0.5ml/kg/hr for 6 consecutive hours 2 - SCr increase >=2-2.9 fold from baseline, <0.5mL/Kg/h for 12hr 3 - SCr increase >=3 fold from baseline, or >=354umol/L or initiated on RRT, Urine output is less than 0.5ml/kg/hr for 24 consecutive hours or anuria for 12hr

Answer 9

no - can be critical associated with significant increase in mortality from other conditions

Answer 10

normal - increased risk - damage - reduced GFR - kidney failure - death o Want to recognise people at increased risk – flag to minimise risk they progress down route o Route reversible in most pts but not always

Answer 11

occurs most commonly in patients who are at risk, who either are acutely ill or have had major surgery allows simple preventative measures, eg ensuring adequate hydration, consideration of drugs, regular blood tests

Answer 12

Age >75 years • Pre-existing CKD (eGFR <60 mL/kg/1.73 m2) • Previous episode of AKI • Debility and dementia • Heart failure • Liver disease • Diabetes mellitus • Hypotension (Mean arterial pressure <65mmHg, systolic BP <90mmHg) • Sepsis • Hypovolaemia • Nephrotoxins, eg gentamicin, NSAIDs, iodinated contrast • Continued antihypertensives in setting of hypotension, eg ACE inhibitors, loop diuretics

Answer 13

pre-renal - blood flow into the kidney, all about volume - check BP, JVP and vol intrinsic renal post-renal - obstruction to outflow, need US

Answer 14

o 20% pre-renal – low bp, vol depletion o 13% obstruction o 45% intrinsic – acute tubular necrosis – multiple insult- sepsis, low bp, drugs = damage to kidney – tubules fallen apart, but reversible just need to get everything else right – vol and stop nephrotoxic agents

Answer 15

Hypovolaemia low cardiac output Hypotension Renal artery thrombosis

Answer 16

``` Acute tubular necrosis Glomerulonephritis Vasculitis Nephrotoxins, contrast, rhabdomyolysis Interstitial nephritis HUS/TTP Malignant hypertension Myeloma ```

Answer 17

``` Ureteric obstruction Urethral obstruction Blocked urinary catheter Bladder tumour ```

Answer 18

AKI - potentially reversible CKD - impaired kidney function, usually progressive, and potentially resulting in end stage kidney disease (ESKD) over months to years, often multifactorial. Not reversible

Answer 19

is it acute/chronic if acute - what is the cause? Is it treatable? if chronic - can you identify cause, can progression be slowed, control and treat complications, plan for ESKD (dialysis, transplant, conservative care)

Answer 20

Commonly non-specific symptoms • Symptoms of uraemia (nausea, vomiting, anorexia) • Features of the underlying disease • Decreased urine output • Systemic features (rash, myalgia, arthralgia, headaches) • Abnormal biochemistry (rise in serum urea and creat) • Acidosis, hyperkalaemia, salt and water retention

Answer 21

Duration • Systemic features • Past history, especially vascular, childhood renal disease, UTI’s, diabetes, hypertension • Family history, inc early death & strokes • Drugs, inc herbals, over-the-counter medications (not “drugs” esp analgesics), recreational drugs - – ketamine causes kidney problem

Answer 22

``` For any features indicating cause • For features of systemic disease • Bladder? Palpable kidneys? • For complications • Volume status of patient • URINE analysis, microscopy ```

Answer 23

glomerular disease -Red cells, red cell casts, proteinuria (often heavy) tubular disease - minimal blood, small protein, granular or white cell casts - – nothing going down the tubule so no blood leaking from glomerulus – no blood in urine pre-renal causes - no blood or protein. no casts

Answer 24

``` ATN ⧫ Functional - low BP and low flow ⧫ Myeloma ⧫ ATIN - inflammation in kidney caused by drugs ⧫ Athero-embolic ⧫ Rhabdomyolysis ```

Answer 25

``` ⧫ Systemic vasculitis ⧫ Acute GN ⧫ Lupus Nephritis ⧫ Anti-GBM disease (Goodpasture’s disease) ```

Answer 26

``` previous renal func ABG for hypoxia and acidosis Ca, phos US - see obstruction and size of kidneys CXR - for fluid overload, chest infection assessment of volume status urinalysis ```

Answer 27

``` volume status (for ATN) • Urine microscopy and dipstick • Imaging (U/S) *** Obstruction *** • ANCA, Anti-GBM, SLE immunology (ANA, dsDNA, complements) - if worried about glomerular disease • Creatinine kinase • FBC, clotting • Inflammatory markers • Myeloma screen (protein electrophoresis, urine BJP) - in older pts • May need biopsy ```

Answer 28

``` What is the cause? • What needs treating NOW? • Reverse underlying factors • Treat the cause if possible • Prevent and manage complications ```

Answer 29

``` Potassium (kills) • Pulmonary oedema (kills) • Acidosis • Hypertension • Uraemia (brain, nerves, heart) ```

Answer 30

``` Intravenous calcium • Insulin and dextrose • Nebulised salbutamol • Calcium resonium or newer binding agents eg SZC or patiromer • Dialysis ```

Answer 31

need to consider immunology

Answer 32

CKD if in young person: either congenital o Or childhood reflux nephropathy and UTIs - asymptomatic mostly means dont have to start dialysis straight away

Answer 33

• A “syndrome” for which there is a cause, although often not identified Often first presentation is at end stage • Kidneys may be normal size, but often small

Answer 34

identify cause if possible, treat and prevent complications, slow progression, plan for future ESKD

Answer 35

by GFR: GFR 60-90 and no other evidence- not CKD, if do have other evidence- could be chronic eg on US as albuminuria gets worse = worse outcomes overall = higher death rate and risks of CVS complications

Answer 36

high - increasing by age | most common in elderly with comorbidities

Answer 37

``` Elderly  Hypertension  Diabetes  IHD  Family History CKD  African American  Obesity ```

Answer 38

Diabetes (~30%) • Chronic glomerulonephritis (~30%) • Vascular diseases including hypertension, ischaemic heart disease (~15%) • Autosomal dominant polycystic kidney disease (~10%) •Congenital/reflux/childho0d infections • Genetic risks .. with another insult (eg ApoL1 risk variants in black patients)

Answer 39

Identify cause - important for progression, systemic features, recurrence after transplant …. This might be treatable • Ensure patient understanding • Ensure regular follow-up • Investigate for complications (metabolic, CV, BP, proteinuria)

Answer 40

AKI CVS mortality kidney failure

Answer 41

BP control, ACEi/ARB and reducing proteinuria, SGLTi drugs - slows down eGFR decline (irbesartan reduces incidence of dm nephropathy) minimise other CV risks - smoking encouraging exercise, low salt and low protein, measure BP, take med even when asymptomatic

Answer 42

``` slow progression of renal disease in CKD, reduce deaths, reduce CV morbidity, reduce hospitalisations ```

Answer 43

Encourage/support /activate patients to understand this BP < 125-130/75-80 (usually 3+ drugs), lower BP target if proteinuria ACEi/ARB .. More ACEi/ARB ... Maximal doses • Second and third line agents for BP and proteinuria • Reduce proteinuria as much as possible • CV risks (aspirin, statins, ezetimibe ..) • Stop smoking, encourage exercise, healthy diet, avoid nephrotoxins eg NSAIDs avoid dehydration

Answer 44

calcification of bv = CVS, atheroma = narrowing of vessels | treat calcification by treating the BP

Answer 45

(heavy proteinuria, oedema, hypoalbuminaemia)

Answer 46

Incidental finding to full blown nephrotic syndrome pt concern is swollen legs, painful, limit walking Normal protein < 300 mg/day (U PCR < 30 mg/mmol) • Nephrotic > 3 g/day (Urine PCR > 300 mg/mmol) • Urine Protein:creatinine ratio < 30 “normal” 100 ~ 1 g/day 300 ~ 3 g/day o Albumin creatinine ratio in urine – if >3 seen as abnormal – sign of microalbuminae in dm. could still be normal if not dm

Answer 47

kidney biopsy Quantitate proteinuria (urine protein:creatinine ratio) • Serum albumin and cholesterol • Serum creatinine, U+Es • Glucose, SLE tests, virology - can cause nephrotic syndrome (Hep B,C and HIV), myeloma screen

Answer 48

``` ALWAYS indicated glomerular pathology • Diabetes • Minimal change (glomerular) disease (and FSGS) • Membranous nephropathy • Amyloid • SLE ```

Answer 49

Control oedema – low salt diet, diuretics • ACEi/ARB (reduce proteinuria) • Treat the cause ! (if possible) • Sometimes steroids or immunosuppression • Uncontrolled proteinuria is a major risk for progressive CKD and ultimate ESKD

Answer 50

not gor everyone  Look in bladder if worry had bladder cancer – but only 24yr, unless other RF  Has a kidney problem  If he were 50yr – would defo need cystoscopy

Answer 51

With pain – think urological cause ie stones or cancers (kidneys, ureter, bladder, prostate) • Age > 40 years, must exclude cancer in urinary tract • BUT age < 40 or protein also present, most likely intrinsic microscopic renal (glomerular) cause may need kidney biopsy

Answer 52

Thin glomerular basement membrane disease or variant eg Alport’s syndrome IgA nephropathy

Answer 53

If “surgical” or cancer/stone most likely – start with imaging (US, CT) and cystoscopy If cause within kidney glomerulus most likely – check urine for protein, eGFR, then blood tests for underlying systemic or immune disease, then possibly renal biopsy.

Answer 54

No recovery possible • Need dialysis or a transplant or decide not to do either and treat symptoms (conservative care)