Renal Medicine Flashcards
1
Q
What are the 3 major categories of AKI?
A
Pre-Renal:
- Lower vascular volume due to haemorrhage, D and V…
- Decreased CO ( HF, MI,…)
- Systemic vasodilation due to sepsis/drugs.
- Renal vasoconstriction due to NSAID’s, ACEi/ARBs or hepatorenal syndrome.
Renal:
- Acute tubular necrosis
- Glomerulonephritis
- Infection
Post-Renal:
- Obstruction by malignancy, stones, strictures…
- Extrinsic compression of the tubes from malignancy, prostatic hypertrophy…
2
Q
Recognition of AKI
A
- Creatinine levels and urine output to be monitored so the injury can be staged.
- Watch for confusion and drowsiness
- General nausea, emesis and diarrhoea.
3
Q
Investigations for AKI
A
- Urine dipstick to check for proteinuria or haematuria which overall checks for intrinsic renal disease.
- Ultrasound unless cause is obvious. This checks for CKD ( if kidneys are small), and if kidneys are asymmetrical this will check for renal vascular disease.
- Check for intrinsic renal disease with immunoglobulin, autoantibodies etc…
- Check liver function
- Check platelet count, low may indicate haemolysis therefore you need a blood film.
4
Q
Management and support for AKI-
A
- Discontinue any nephrotoxic drugs
- Ensure volume status is normal and consider urinary catheter to monitor urine output.
- Adjust any current drug medications to the level of kidney function
- Treat underlying cause of the AKI and consider sending to ICU if condition is not helped or is deteriorating
5
Q
What is CKD and what are the common causes?
A
- CKD is abnormal kidney structure or function present for over 3 months with implications on health.
- Presents with a lowering GFR and albuminuria, (higher levels indicate a higher amount of kidney damage).
- Most common causes are glomerulonephritis, high blood pressure and renovascular disease.
- Lower GFR increases the risk of mortality, especially relating to the heart, kidney and it increases the chance of AKI.
6
Q
Recognition of CKD
A
- Check whether patients eGFR has been adjusted to the correct values for ethnicity etc..
- Check past medical history focusing in on previous urological problems. Lower UTI’s especially.
- Check for major risk factors; high blood pressure, diabetes, ischaemic heart disease…
- Family history
- Drug history, especially looking at when drugs where started.
- Systems review to rule out malignancy. Ask, when was the last tie you felt well?
7
Q
Symptoms of CKD
A
- Typically symptoms only start when the GFR is below 30
- Can present with peripheral oedema
- Nausea and vomiting
- Weight loss and fatigue
- Change in mental state
8
Q
Complications of CKD
A
- Hypertension
- CVD
- Bone disease and hyperparathyroidism as kidney can’t activate vitamin D therefore less calcium is absorbed so more bone needs to be broken down in order to replenish the stores.
- Anaemia of Chronic Disease as the kidney isn’t producing as much erythropoietin
9
Q
Monitoring and Referral for CKD
A
- Monitor the albuminuria and the eGFR at least annually, more frequently if the patient is higher risk, (high BP, diabetes, etc…)
- Refer to nephrology when the GFR drops below 30 ( stage 4), stage 5 when the GFR drops below 15, then classed as kidney failure. Also refer if there’s a sudden drop in GFR by more than 25% or if there’s significant proteinuria with haematuria.
10
Q
Treatment of CKD
A
- Treat to SLOW disease progression. Primarily done by the control of blood pressure below 140/90 or 130/80 if diabetic or high albumin to creatinine ratio. Done with ACEi or ARBs. Also control hyperglycaemia, and make lifestyle changes such as more exercise, stop smoking and reducing salt intake
- Treat RENAL complications. Major ones are anaemia, ( check Hb, iron and EPO levels and supplement where necessary). Consider bicarbonate supplement if acidotic. Reduce fluid and salt intake to control oedema, give diuretics if becomes more severe. Phosphate may become high as less activated Vit D therefore can cause bone disease and vascular calcification therefore give calcium free phosphate binders and control dietary intake.
- Treat for CARDIO complications as CKD increases CVD risk due to higher BP, oxidative stress… Give aspirin as an antiplatelet and 20mg of Atorvastatin.
11
Q
How to plan for Renal Replacement Therapy
A
- Should start in CKD patients when the risk of renal failure is 10-20% within the year.
- Patients should be listed for a deceased organ donation 6 months before the anticipated start of RRT
12
Q
Cause of Diabetic Nephropathy
A
- Hyperglycaemia increases RAAS activation, growth factors, and increases oxidative stress.
- All of these factors increase glomerular capillary pressure causing podocyte damage therefore epithelial dysfunction.
- This results in albuminuria.
- Overtime scarring occurs ( glomerulosclerosis), causing overall lower renal function. This process is quickened with higher blood pressure.
13
Q
Investigation for Diabetic Nephropathy
A
- Urine dipstick checking for albuminuria. Starts with microalbuminuria ranging from 3-30mg of albumin. Can still regress at this stage.
14
Q
Management of Diabetic Nephropathy- Su
A
- Tight control of diabetes to prevent progression of albuminuria and any other microvascular progression.
- Control of blood pressure to control albuminuria
- Salt restriction to less 2g of sodium a day.
- Statins to reduce cardiovascular risk. These can be continued if patient on dialysis but shouldn’t be started at this point.
15
Q
What is Nephrotic Syndrome
A
- Type of glomerulonephritis
- Classified by a triad of Oedema, Hypoalbuminemia, and proteinuria ( less than 3g in a day).
- Caused either by primary inflammation, ( minimal change disease, membranous nephropathy…) or secondary to DM, lupus nephritis, myeloma…
