Renal Investigations and Management Flashcards
Pre-renal AKI management
Assess for hydration:
Clinical observations (BP, HR, UO)
JVP, cap refill, oedema
Pulmonary oedema
Fluid challenge for hypocolaemia:
Crystalloid or colloid
Bolus of fluid, reassess and repeat as necessary
If >1L and no improvement seek help
Renal AKI investigations
U&Es FBC and coagulation screen (clotting? anaemia?) Urinalysis (haemoproteinuria) USS (obstruction? size?) Immunology (ANA, ANCA, GBM) Protein electrophoresis and BJP
Further management of AKI
Fluid resuscitate (if still not achieving adequate BP then inotropes/vasopressors)
Treat underlying cause (e.g. antibiotics for sepsis)
Stop nephrotoxics
Dialysis if remains anuric and uraemia
Post renal AKI investigations
USS
CT
Post-renal AKI
Relieve obstruction:
Catheter
Nephrostomy
Refer to urology if ureteric stenting is required
Hyperkalaemia management
Cardiac monitor and IV access
10mls 10% calcium gluconate (2-3 mins)
Insulin with 50mls 50% dextrose
Salbutamol nebs
Calcium resonium (prevents absorption, not in acute setting)
Urgent indications for haemodialysis
Hyperkalaemia (>7 or >6.5 unresponsive to medial therapy)
Severe acidosis (pH<7.15)
Fluid overload
Urea >40 or pericardial rub/effusion
Target blood pressures for CKD
140/90
130/90 if ACR of 70 or more or diabetes
Lipid lowering therapy in CKD
Atorvastatin 20mg
CV risk modification in CKD
Lifestyle advice
Control of hypertension
Other prophylaxis (lipid lowering therapy, consider aspirin for secondary prevention)
Managing mineral and bone disease in CKD - lifestyle advice
Dietary advice (phosphate restriction) Also consider need for salt, potassium, fluid and other dietary restrictions Correct metabolic acidosis
Managing mineral and bone disease in CKD - medications
Alfacalcidol (active vit D) Phosphate binders (calcium based [adcal/phoslo/osvaren], aluminium [alucaps], non-calcium based [lanthanum, sevelamer]) Calcimimetic (calcinet)
Renal anaemia investigation
Exclude other causes of anaemia:
B12 and folate deficiency
Check ferritin and iron stores
Consider haematological causes
Renal anaemia management
Oral iron
IV iron
EPO injection if no iron or haematinic deficiencies (ESA therapy)
Mild anaemia is okay
Vascular access for dialysis steps (in order of efficacy)
Tunnelled venous catheter
Arteriovenous graft
Fistula
Can also get HeRO grafts
Starting haemodialysis management
Gradual build up (prevents disequilibrium syndrome from too-rapid correction of uraemic toxin levels)
Starting PD management
Training (3-6 weeks)
Build up fill volume size
Regular clinic and nurse follow up
Glomerulonephritis (GN) blood tests
FBC U&E LFT CRP Immunoglobulins Electrophoresis Complement Autoantibodies
Glomerulonephritis investigations
Urinalysis (haemo/proteinuria)
Urine microscopy (RBC [dysmorphic], RBC and granular casts, lipiduria)
Urine protein/creatinine ratio/24 hours urine
Kidney biopsy
Nephritic syndrome findings
Acute renal failure Oliguria Oedema/fluid retention Hypertension Active urinary sediment (RBCs, RBC and granular casts)
Nephrotic syndrome findings
Proteinuria >3g/day Hypoalbuminaemia Oedema Hypercholesterolaemia Usually normal renal function
Histological GN investigations
Light microscopy
Immunofluorescence
Electron microscopy
Histological GN classification
Proliferative or non-proliferative
Focal/diffuse (< or >50% of glomeruli affected)
Global/segmental (all or part of glomerulus affected)
Crescenteric (epithelial extracapillary proliferation)
Non-immunosuppressive management of GN
Anti-hypertensives (<120/75 if proteinuria) ACEI/ARBs Diuretics Statins Maybe anticoagulants
Immunosuppressive management of GN
Drugs (corticosteroids, azathioprine, alkylating agents [cyclophosphamide/chlorambucil], calcineurin inhibitors, mycophenolate mofetil [MMF])
Plasmapheresis
Antibodies (IV immunoglobulin, monoclonal antibodies)
Nephrotic syndrome management
Fluid/salt restriction Diuretics ACEI/ARBs Maybe anticoagulation IV albumin (only if volume deplete) Immunosuppression (induce remission - partial=<3g, complete=<300mg/day)
Minimal change nephropathy renal biopsy investigation
EM (foot process fusion)
Minimal change nephropathy management
Oral steroids
2nd line cyclophosphamide
Focal segmental glomerulosclerosis renal biopsy investigation
Light microscopy (as name suggests) IF (minimal Ig/complement deposition)
FSGS management
Prolonged steroids (remission in 60%)
Membranous nephropathy renal biopsy findings
Subepithelial immune complex deposition in the basement membrane
Membranous nephropathy management
Steroids
Alkylating agents (cyclophosphamide)
B cell monoclonal antibody
IgA nephropathy renal biopsy findings
Light microscopy (mesangial cell proliferation and expansion) IF (IgA deposits in mesangium)
IgA nephropathy management
BP control
ACEI/ARB
Fish oil
Rapidly progressive glomerulonephritis management
Prompt with strong immunosuppression:
Steroids
Cytotoxics (cyclophosphamide/mycophenolate/azathioprine)
Plasmapheresis
Kidney transplant assessment
Immunology Virology Assess cardiorespiratory risk Assess peripheral vessels/bladder function/mental state Assess co-morbidities
Contraindications to kidney transplant
Malignancy (inc solid tumour in last 2-5 years) Active HCV/HIV Untreated TB Severe IHD Severe airways disease Active vasculitis Severe PVD (unusable vessels) Hostile bladder
How do you desensitise a kidney recipient?
Active removal of blood group or donor specific antigen:
Plasma exchange
B-cell antibody (rituximab)
Immunosuppression during transplant operation
Prednisolone IV
Maintenance treatment after transplant operation
Prednisolone, tacrolimus, MMF
Prednisolone, ciclosporin, azathioprine
Anti-rejection treatments
Pulsed IV methyprednisolone Anti-thymocyte globulin IV Ig Plasma exchange Rituximab, bortezimab, eculizumab Immunosuppression intensification
Infection prophylaxis after transplant
Prophylaxis for PJP for first 3 months
Investigation for CMV disease after transplant
IgM and PCR
CMV disease management
Propylactic PO valganciclovir in higher risk patients
IV ganciclovir if evidence of infection
BK virus nephropathy management
No effective anti-viral therapy
Treat by reducing immunotherapy
Monitor blood viral load by PCR
Management of post-transplant lymphoproliferative disease (lymphoma, usually related to EBV infection)
Reduce immunosuppression
Chemotherapy
No role for antivirals
ADPKD investigations
USS (cysts, renal enlargement)
CT/MRI (when unclear on USS)
Genetic: linkage analysis, mutation analysis
ADPKD management
Rigorous control of hypertension
Hydration
Proteinuria reduction
Cyst haemorrhage and infection management
Tolvaptan (reduces cyst volume and progression)
Renal failure: dialysis, transplant
What findings would suggest ARPKD?
Children
Fibrotic liver cysts
Cysts appearing from collecting duct system
Alports syndrome investigation
Haematuria and hearing loss
Renal biopsy - variable thickness GBM
Alports management
No specific treatment
Standard aggressive treatment of BP and proteinuria
Dialysis/transplantation
Anderson Fabry’s disease investigations
PLasma/leukocyte alpha-galactosidase
Renal bipsy (shows concentric lamellar inclusions within lysosomes)
Skin biopsy
Anderson Fabrys disease management
Enzyme replacement (fabryzyme) Management of complications
Medullary cystic kidney investigation
Family history
CT
Medullary cystic kidney management
Renal transplant
Medullary sponge kidney investigation
Excretion urography (to demarcate calculi)
What are urinary casts formed from?
Precipitation of Tamm-Horsfall mucoprotein
What are the 4 types of urinary cast and what do they mean?
Hyaline (usually benign)
Red cell (always pathological, nephritic syndrome)
Leucocyte (infection/inflammation)
Granular (chronic disease)
Myeloma investigations
Bloods (serum protein electrophoresis, serum free light chains) Urine bence jones protein Bone marrow biopsy Skeletal survey Renal biopsy
Myeloma management
Stop nephrotoxics Manage hypercalcaemia Chemotherapy Stem cell transplant Plasma exchange (to remove light chains) Supportive - dialysis
Amyloidosis renal investigation
Urinalysis and uPCR Blood tests (renal function, inflammatory markers, protein electrophoresis, SFLC) Renal biopsy (congo red staining, apple green under polarised light)
SAP scan shows extent of disease
AA amyloidosis management
Treat underlying condition
Refer to UCL national amyloidosis centre
AL amyloidosis management
Immunosuppression (steroids, chemo, stem cell transplant)
Refer to UCL national amyloidosis centre
AAV affecting kidney investgiation
Urinalysis (blood and protein)
Bloods (inflammatory markers, AKI, anaemia)
Immunology (ANCA, MPO, PR3)
Renal biopsy
AAV affecting kidney management
Immunosuppresion (steroids, cyclophosphamide, rituximab)
Plasma exchange
Supportive (dialysis, ventilation)
What is the name of the classification of lupus nephritis?
ISN classification
Describe the ISN classification of lupus nephritis
Class I: minimal mesangial Class II: mesangial proliferative Class III: focal proliferative Class IV: diffuse proliferative Class V: membranous Class VI: advanced sclerosing
Lupus nephritis management
Progressive immunosuppression increase as classes increase
UTI investigation
Mid stream specimen of urine
Cut offs for specific bacteriuria
> 10^5= significant, probably UTI
10^4= contaminated maybe, need to repeat
<10^3= not significant
For women of child bearing age
Management of abacterial cysitis/urethral syndrome
Alkalinising the urine
Asymptomatic bacteriuria in pregnancy management
Antibiotics
Female lower UTI management
Nitrofurantoin or trimethoprim (3 days)
Uncatheterised male UTI management
Nitrofurantoin or trimethoprim (7 days)
Complicated UTI or pylonephritis (GP) management
Co-amoxiclav or co-trimoxazole (14 days)
Complicated UTI or pyelonephritis (hospital) management
Amoxicillin and gentamicin IV (3 days)
Co-trim and gent if pen allergic
Co-trim step down
