Renal Medicine Flashcards
Renal Hx
- Seven Sx
Renal Hx Sx
- Dyspnoea
- Leg swelling
- LUTS
- Flank pain
- N&V
- ENT
- Constitutional
Dialysis
- Five modes
Dialysis Modes
- APD (automated)
- CAPD (continuous ambulatory)
- Assisted PD
- UHD (Unit-based haemodialysis)
- HHM (?)
Renal FHx
- Five questions
Renal FHx
- Renal disease
- Cardiac disease
- Diabetes
- HTN
- Genetic conditions
Renal Ex
- Three face signs
Renal Ex; face:
- Aneamia (of CKD)
- Rash (SLE)
- Swelling (HD-> SVCO)
Renal Ex
- Neck Sx
Renal Ex Neck
- JVP
- Tunneled/HD line
- Scars
Haematinics
- Three examples
Haematinics
- Iron
- B12
- Folate
Anion gap
- Calculation
- Normal range
Anion gap
- Na - (Cl + HCO3)
- 8-12
High anion gap
- Four causes
High anion gap
- Lactic acidosis
- Ketoacidosis
- Toxins (ethylene glycol, methanol, isoniazid, salicylate)
- Renal failure
Normal anion gap acidosis
- Three causes
Normal anion gap acidosis
- GI losses of bicarb
- Renal losses of bicarb
- Toxins (ammonium chloride, acetazolamide)
Hypernatraemia
Four hypovolaemic causes (dehydration)
Hypovolaemic hypernatraemia (dehydration)
- Renal loss
- Loop diuretics
- Osmotic eg NG tube - Non-renal loss
- Sweating/burns
- Diarrhoea/fistula
Hypernatraemia
Four euvolaemic causes
Euvolaemic hypernatraemia
- Renal loss
- DI/Hypodipsia - Non-renal
- Insensible
- Respiratory
Hypernatramia
Four Hypervolaemic causes
Hypervolaemic hypernatraemia
Non-renal
1. NaCl Tablets
Renal
- Hyperaldosteronism
- Cushing’s
- Dialysis
Diabetes insipidus
- Four causes
DI causes
1. Trauma
2. Tumours
3. Cerebral sarcoid/TB
4. Cerebral inflammation
infection/vasculitis
Hyponatraemia
Four hypovolaemic causes
Hypovolaemic hyponatraemia
- Renal
- Thiazides
- Addison’s - Non-renal
- D+V
- Sweating/burns
Hypovolaemic hyponatraemia
- Mx
Hypovolaemic hyponatraemia Mx
- Fluids (0.9% saline)
Euvolaemic hyponatraemia
- Four causes
Euvolaemic hyponatraemia causes
- Hypothyroidism
- Primary poydipsia
- Adrenal insufficiency
- SIADH
Pseudo-hyponatraemia
(Hypervolaemic)
- Four causes
Pseudo-hyponatramia
(hypervolaemic)
- Hyperglycaemia
- High lipids
- Uraemia
- Myeloma
Hypervolaemic hyponatraemia
- Three causes
Hypervolaemic hyponatraemia causes
- CCF
- Nephrotic syndrome
- Liver cirrhosis
Hypervolaemic hyponatraemia
- Treatment
- Risk of treatment
Hypervolaemic hyponatraemia
- Fluid restrict (+ furosemide)
- Risk of CPM/OM
- Central pontine myelinosis
- Osmotic myelinosis
Acute hyponatraemia
- Mx
Acute hyponatraemia Mx
- 3% hypertonic saline IV boluses
- +/- Furosemide
Chronic hyponatraemia
- Mx
Chronic hyponatraemia
- If seizures - hypertonic saline boluses
- Symptomatic, non-seizing
- Isotonic saline + Furosemide - Asymptomatic
- Water restriction
- Stop drug causes
- Restore volume
Hyperkalaemia
- Five causes
Hyperkalaemia causes
- CKD (with K rich diet eg. dried fruit, potatoes)
- Drugs
- Hyperaldosteronism
- Rhabdomyolysis, tumour lysis, haemolysis
- Artifact hyperkalemia
- Haemolysis, leucocytosis, thrombocytosis
Hyperkalaemia
- Six drug causes
Hyperkalaemia drug causes
- Spironolactone/Amilioride
- ACEi/ARB
- NSAIDs
- Betablockers/Digoxin
- Heparin/LMWH
- Trimethoprim
Hypo-renin-aemic hypoaldosteronism
- Class of acidosis
- Presentation
- RFs
Hyporeninaemic hypoaldosteronism
- Type IV RTA
- Presents with:
- Hypochloraemic acidosis
- Hyperkalaemia - RFs
- Increased age
- Reduced eGFR
- DM, acute G.nephritis, TI.nephritis, sickle, NSAIDs
Renal tubular acidosis (RTA)
- Four types
RTA
Type 1: Distal (dRTA)
- Failure of H+ secretion into lumen
- Alkaline urine and hypokalaemia
Type 2: Proximal (pRTA)
- Failure of tubular bicarb reabsorption
Type 3: Combined P&D
- Rare
Type 4: Absolute hypoaldosteronism/aldosterone insensitivity
- Physiological reduction in ammonium excretion 2º to low K+
Hyperkalaemia
- ECG Changes
Hyperkalaemia ECG
- Tented T
- Long QRS
- Slurred ST
- Loss of P
- Asystole
Hyperkalaemia
- Five management steps
Hyperkalaemia Tx
- Calcium gluconate 10mls 10%
- ActRapid 10 units
IV dextrose 50 mls 50% - NaHCO3
- Salbutamol
- Calcium Resonium
Hypokalaemia
- Six causes
Hypokalaemia causes
- Pseudohypokalaemia
- Acute leukaemia - Extra-renal losses
- Intake, D/V/Stoma - Redistribution
- DTs, Beta agonist, insulin, caffeine - Refeeding syndrome, exercise
- Conn’s/Cushing’s
- Renal loss
- Diuretics, RTA, liquorice
Hypokalaemia
- ECG
Hypokalaemia ECG
- Small T
- U wave
- Increased PR interval
Hypokalaemia
- Three steps to management
Hypokalaemia Mx
- Mg replacement
- Oral K replacement
- IV K replacement in saline (no dextrose)
Stage 2 AKI
- Creatinine
- Urine output
Stage 2 AKI
- 2-2.9 x baseline Creatinine
- 12 hours oliguria (<0.5)
AKI
- Three intrinsic causes
AKI Intrinsic Causes
- Glomerular (GN)
- Tubules and interstitium
- Ischaemia
- Sepsis
- Nephrotoxins - Vascular
- Vasculitis
- Malignant HTN
- TTP-HUS
Malignant hypertension
- Categories
- Causes/definitions
Malignant hypertension
(Accelerated hypertension)
- Classed as
- Urgency
- Emergency 180/120 - Renal disease
Intracranial pressure
Malignant hypertension
- Treatment
Malignant hypertension
Tx
- Labetalol
- Nicardipine/nitroprusside
- Fenoldopam
HUS
- Triad of symptoms
- Common causes
Haemolytic uraemic syndrome
- Microangiopathic h. anaemia
- Thrombocytopenia
- AKI
- Diarrhoea-associated
- Shiga toxin E.c. - Shigella, strep pn.
TTP
- Classic pentad
- Pathology
- Causes
TTP
Classic Pentad (Fat RN):
F ever
A naemia (haemolytic)
T hrombocytopenia
R enal failure
N eurological changes
- Pathology (ADAMTS)
- Von Willebrand factor cleaving enzyme deficiency
- Von W multimers
- Aggregation, microthrombi, and thrombocytpoenia - Causes
- Idiopathic
- Congenital
- HIV
- Pregnancy
- Drug
- Pancreas
- Covid
AKI
- Ix
AKI Ix
Bedside
- Urine dip
- Protein/blood - Urine MSC
Bloods
- FBC, LFT, CRP
- U&E, Serology
- Haemolysis screen/film
Imaging
1. USS KUB
AKI
- Mx
AKI Mx
- Ix and DDx
- STOP nephrotoxic
- Fluid balance
- Glycaemic control
- RRT/ICU
RRT
- Five Indications/Substances
RRT - Indications
- Intoxication
- Urea
- Pericarditis
- Encephalopathy - Potassium
- Refractory - Acid
- Refractory metabolic - Fluid
- Refractory overload
Nephrotic syndrome
- Triad of symptoms
Nephrotic syndrome triad
- Oedema
- Albumin <30
- PCR>350
Nephrotic syndrome
- Four Complications
Nephrotic syndrome complications
Protein losses
- Infection
- VTE
Function
- CKD
- HTN
Nephrotic syndrome
- Four Causes
Nephrotic syndromes
- Minimal change
- FSGS
- Membranous nephropathy
- Membranoproliferative glomerulonephritis
Nephritic syndrome
- Four Presentations
Nephritic presentation
- AKI
- Haematuria (V/NV)
- HTN
- Proteinuria
Nephritic syndromes
- Six examples
Five nephritic syndromes
- Post-infectious GN
- Weeks after group A strep - IgA nephropathy
- Idiopathic and episodic - Small vessel vasculitis (ANCA)
- Goodpastures and Alport’s
- Thin basement
- Lupus
Nephritis treatments
- Post-infectious GN
- IgA nephropathy
Nephritis treatments
- Post-infectious GN (3-12 yo)
- ACEi/ARB (self-limiting)
- RRT (ESRF)
- IgA Nephropathy (10-30yo)
- ACEi/ARB
Small vessel vasculitis
- Types
- Presentations
Small vessel vasculitis
- Immunosupression therapy
- GPA (granulomatosis with polyangitis)
- Nasal ulcers/polyps
- Haemoptysis - MPA (microscopic polyangitis)
- Mild resp symptoms - Churg-Strauss (Eosinophillic granulomatosis with PA)
- Asthma, rhinitis
- Purpura, peripheral neuropathy
Nephritis
- Presentations and treatments
- Goodpastures
- Alports
Nephritis
- Goodpastures
1. Pulmonary infiltrates on CXR - IgG along basement membrane (Type 4 HS)
2. Plasma exchange and immunosupression - Alports
- Haematuria
- Sensorineural hearing loss
- GBM irregularity - Supportive treatment
RRT
CKD
- KDIGO
KDIGO - CKD
- Kidney disease, improving global outcomes
- G1-G5 for staging
A1-3 for ACR categories (<3, 3-30, >30)
CKD
- Causes
CKD Causes
- DM
- HTN
- GN
- RVS disease
- PCKD
- Uropathology
- Pyelonephritis
CKD
- Management
CKD Mx
- DM, HTN, Infx
- Tolvaptan
(vasopressin antagonist) - Preventative statin
- ACEi/ARB
- Supplementation
- Haematinics
- EPO
- Vit D
Diabetic nephropathy
- Mx
DM nephropathy Mx
- ACEi/ARB
- BP control
- CVS risk
HTN nephropathy
- Ix
HTN nephropathy Ix
- Metanephrines
- Aldosterone:renin ratio
- Cortisol and dexamethasone supression
- TSH
- MRAngio
PCKD
- Mx
PCKD Mx
- BP
- CKD Mx
- Tolvaptan
- Genetic counselling/testing
Anaemia of CKD
- Mx
Anaemia of CK Mx
- Haematinic measurement
- Replace IV iron and haematinics
- Discussing starting ESA (erythropoiesis stimulating agents)
- Aim for Hb 100-120
CKD
- MBD pathophysiology
Mineral bone disease
- Increased fibroblast GF-23
- Increased ALP and PTH
- Increased phosphate
decreased Ca - Decreased 1,25-Vit D
CKD
- MBD Suspicion
Mineral Bone Disease Suspicion
- Mineral Abnormalities:
- Ca/PO4
- ALP
- PTH, D metabolism - Calcification
- Soft tissue/vasculature - Bone abnormalities
- Turnover/metabolism
- Volume/linear growth/strenght
Mineral bone disease
- Turnover abnormalities
MBD Abnormalities
- Low Turnover
- Adynamic bone disease
- Osteomalacia - High Turnover
- Osteitis Fibrosa
Effects on Calcium
- Vitamin D
- FGF23
- PTH
Effects on Calcium
- Vitamin D
- Increases gut absorption - FGF23
- Increases bone resorption - PTH
- Increases Calcitriol production
Vitamin D3
- Metabolism and effects
Vitamin D3 Metabolism
- 7-Dehydrocholestrol
- Converted by UVB radiation - Vitamin D3
- Cholecalciferol - Calcidiol
- Produced in liver - Calcitriol
- Produced in kidney
- works in gut
CKD MBD
- Mx Aims
Mineral Bone Disease Mx
- Reduce renal bone disease
- Reduce CVS morbidity
- Calcium overload
- High PTH and high phosphate
RRT
- Nine forms
RRT
- A-PD
- 8-10 hours at night - CAPD
- Regular througout day and night - AAPD
- Assistants help with APD - HHD
- Home HD for frequent use - NHD
- Nocturnal long HD - CCRT
- Continuous RRT in acute setting (ITU/HDU) - Related donor
- Unrelated donor
- Paired/chain/altruistic - Deceased donor
- 60%
Kidney transplant
- 3 Induction Dx
Kidney Transplant Induction
- Methylprednisolone
- Basiliximab+thymoglobulin
- Alentuzumab/rituximab
Kidney transplant
- 5 Maintenance drugs
Kidney transplant maintenance
- Prednisolone
- CNIIs
- Tacrolimus
- Cyclosporine
- Voclosporine - Antimetabolites
- Mycophenolate
- Azathioprine - Rapamycin inhibitors
- Sirolimus - T-cell regulation
- Belatecept + belimumab
Kidney transplant
- Long term care
Kidney transplant L-T Care
- Bloods
- GFR
- CNI
- Protein
- Ca, phosphate, PTH
- Lipids, glucose - Vaccination and Infx screen
- CVS, MBD monitoring
- Malignancy monitoring
- SC - Contraception