renal medicine Flashcards
1
Q
usual first line option for independent patients for renal replacement is??
A
peritoneal dialysis
2
Q
usual first line option for patients with Chron’s disease for renal replacement is?
A
haemodialysis
the insertion of a peritoneal dialysis catheter dangerous as well as the infusion and drainage of fluid.
3
Q
CKD: only diagnose stages 1&2 if???
A
supporting evidence to accompany eGFR
4
Q
for egfr The most commonly used formula is the Modification of Diet in Renal Disease (MDRD) equation, which uses the following variables:? (CAGE)
A
serum creatinine
age
gender
ethnicity
5
Q
CKD1:
A
gfr>90
6
Q
CKD2:
A
gfr 60-90
7
Q
CKD3a:
A
gfr45-59
8
Q
CKD3b:
A
gfr 30-44
9
Q
CKD4:
A
15-29
10
Q
CKD 5:
A
<15
11
Q
most common cause of peritonitis secondary to peritoneal dialysis????
A
staph epidermis
coag negative staph
12
Q
post strep glomerulonephritis occurs??
A
1-2 weeks after URTI
13
Q
IgA nephropathy occurs?
A
1-2 days after URTI
aka berger’s
14
Q
post-strep glomerulonephritis pathology?
A
delayed antibody-mediated disease following infection of the pharynx or skin causing nephritic syndrome.
15
Q
what is Alport’s syndrome characterised by?
A
haematuria, sensory hearing loss and ocular disturbances
16
Q
which drugs should be stopped in AKI?
A
NSAIDs, aminoglycosides, ACE inhibitors, angiotensin II receptor antagonists [ARBs] and diuretics) within the past week, digoxin (levels)
17
Q
screening test for PKD?
A
USS abdo
18
Q
how is PKD transmitted?
A
Autosomal dominant
19
Q
ADPKD1 which chromosome?
A
16
85% cases
20
Q
ADPKD2 which chromosome?
A
4
15% cases
21
Q
Hyperacute transplant rejection is suspected.
Which of the following is the best treatment for this patient?
A
removal of graft
22
Q
nephrotic syndrome - what is a recognised cx? why?
A
high risk of VTE disease (eg renal vein thrombosis)
Loss of antithrombin-III, proteins C and S and an associated rise in fibrinogen levels
23
Q
Increased risk of VTE in patients with nephrotic syndrome - mx?
A
LMWH
24
Q
triad of nephrotic syndrome?
A
- Proteinuria (> 3g/24hr) causing
- Hypoalbuminaemia (< 30g/L) and
- Oedema
25
Addison's disease/adrenal insufficiency can cause which metabolic abnormality?
hyperkalaemic metabolic acidosis
26
HSP features:
palpable purpuric rash (with localized oedema) over buttocks and extensor surfaces of arms and legs
abdominal pain
polyarthritis
features of IgA nephropathy may occur e.g. haematuria, renal failure
27
ADPKD is associated with????
berry aneurysms - SAH
28
commonest extra-renal manifestation of ADPKD?
liver cysts - 70%
| could present as hepatomegaly
29
metabolic acidosis with normal anion gap?
```
addison's
GI losses (diarrhoea)
renal tubular acidosis
```
30
low thyroxine but normal free thyroxine levels in which disease?
nephrotic syndrome
31
can aspirin be continued in aki?
yes at cardio-protective dose
32
what ix indicates that kidney disease is chronic and not acute?
hypocalcaemia
33
81-year-old woman is due to have a contrast-enhanced CT scan to investigate suspected lung cancer. She suffers from chronic kidney disease, due to a history of hypertension.Her most recent eGFR is 50ml/min/1.73m2. Due to the increased risk of contrast-induced acute kidney injury in this patient, which of the following would be most appropriate?
offer Iv fluid infusion before and after contrast
34
NICE guidelines suggest referring to a nephrologist from primary care if eGFR ????
falls to below 30 or progressively by >15 a year
35
In a patient with suspected anaemia of chronic disease secondary to CKD, what should be checked and which tx started?
check iron studies FIRST!!!
start epo
patients who are IDA don't respond to EPO
36
Hyaline casts may be seen in the urine of patients ????
taking loop diuretics like furosemide
37
DKA: what ABG finding and what anion gap?
metabolic acidosis and raised anion gap
38
causes of rapidly progressing glomerulonephritis?
goodpastures
wegners
SLE, microscopic polyarteritis
39
what expecting on renal biopsy from canca positive (PR3)?
cresentic glomerulonephritis
40
When prescribing fluids, the potassium requirement per day is?
1mmol/kg/day
41
nice recommends how much fluids per day?
20-30ml/kg/day of water
42
nice recommends how much glucose per day to stop starvation ketosis?
50-100g/day
43
who shouldn't have hartmann's ??
patients with hyperkalaemia
| it contains potassium
44
problem with increased saline: sfx?
risk of hyperchloraemic metabolic acidosis
45
63-year-old man attends for a GP appointment and states that he has had two episodes of visible blood in his urine. One episode occurred last week and the other this morning. There was not any pain. He denies any lower urinary tract symptoms. A urinalysis shows +++ blood and is negative for all other markers. What investigation should be requested?
cystoscopy
46
13-year-old girl presents to her GP with her father as she is concerned about recently gaining weight. She feels that her hands and feet have got 'fatter' in the last few weeks and she has had to buy larger shoes as her old ones no longer fit. She also says that her face looks rounder and puffier than it used to. A routine review of symptoms reveals no other problems except when passing urine, she has noticed her urine looks very frothy. dx?
nephrotic syndrome
| minimal change disease
47
mx of minimal change nephropathy?
PO pred and urgent outpt referral to paeds
48
what is second line tx in minimal change disease?
when pred not working (do renal biopsy)
| use cyclophosphamide
49
Sterile pyuria and white cell casts in the setting of rash and fever should raise the suspicion of ??
acute interstitial nephritis
50
common cause of acute interstitial nephritis?
abx therapy
51
what typically presents with haemoptysis and haematuria?
goodpastures syndrome
52
path: goodpastures?
(anti-GBM disease) is a rare type of small-vessel vasculitis associated with both pulmonary haemorrhage and rapidly progressive glomerulonephritis. It is caused by anti-glomerular basement membrane (anti-GBM) antibodies against type IV collagen. Goodpasture's syndrome is more common in men (sex ratio 2:1) and has a bimodal age distribution (peaks in 20-30 and 60-70 age bracket). It is associated with HLA DR2.
53
pre-renal causes of AKI?
(main 2, and FIRST mnemonic)
ix: high serum urea:creatinine ratio
```
sepsis, dehydration (hypoperfusion)
Failures - HF, RF
Infection
RBC haemorrhage
Stenosis
Thrombosis
```
54
renal causes of AKI?
nephotoxics mainly
| acute tubular necrosis
55
sx of hypokalaemia:
```
Asymptomatic
Weakness
Leg cramps
Respiratory issues
Paralysis
Arrythmias
```
56
causes of hypokalaemia:
Drugs: diuretics, laxatives, steroids, abx
GI losses
Renal failure
57
post-renal causes of AKI:
retention
obstruction
(stones)
58
what is an effective form of analgesia for renal stones?
rectal diclofenac
59
A 12-year-old boy presents in acute renal failure. Last week he had a bad episode of bloody diarrhoea but this has now passed. A diagnosis of haemolytic-uraemic syndrome is made.
mx?
ivi and supportive tx including dialysis as necessary
also blood transfusions
abx if concurrent infection
consider plasma exchange if no diarrhoea present
60
HUS cause:
classically Shiga toxin-producing Escherichia coli (STEC) 0157:H7 ('verotoxigenic', 'enterohaemorrhagic'). This is the most common cause in children, accounting for over 90% of cases
61
NICE recognise any of the following criteria to diagnose AKI in adults:
↑ creatinine > 26µmol/L in 48 hours
↑ creatinine > 50% in 7 days
↓ urine output < 0.5ml/kg/hr for more than 6 hours
62
A 5-year-old boy is seen in the paediatric assessment unit. His parents are worried about a purpuric, non-blanching rash that has appeared on his arms and legs. He also complains of abdominal pain and joint pain in his knees. Whilst he is on the ward, you notice that his urine looks red. He appears unwell and is crying.
wcc and esr up. dx?
HSP
likeliest px - full recoverey
63
what is required in the investigation of all patients presenting with an AKI of unknown aetiology?
renal uss
64
A 25-year-old man is injured in a road traffic accident. His right tibia is fractured and is managed by fasciotomies and application of an external fixator. Over the next 48 hours his serum creatinine rises and urine is sent for microscopy, muddy brown casts are identified. What is the most likely underlying diagnosis?
acute tubular necrosis
| caused by compartment syndrome (tibial fracture + fasciotomies) which may produce myoglobinuria
65
32M -> to his GP swelling of his feet and hands and feeling lethargic. Pitting oedema in both his upper and lower limbs and he appears to have peri-orbital oedema. His abdomen is distended and shifting dullness is present and there are coarse crackles audible on auscultation of both lung bases. Urine dip shows +++protein, ph6. dx?
focal segmental glomerulosclerosis
| nephrotic
66
30-F -> GP with a sudden unexplained swelling of her feet, ankles and hands. She also reports a 3 day history of increasing passing urine frequency and says that her urine is appearing foamy. She has had mild breathlessness for 5 years now. PMH: ischaemic heart disease, systemic lupus erythematosus and type 2 diabetes. A pregnancy test is positive and she tells you that she is roughly 8 weeks pregnant. Her blood pressure is 140/80 mmHg, her HbA1c measured 2 months ago was 42mmol/mol (6.0%) and a urine dipstick performed today tests positive for protein. dx?
lupus nephritis
pre-eclapmpsia cannot present before 20/40
67
fluids in paeds - maintenance calculations:
100mL/24 hours for every kilogram from 0-10 kg
50 mL/24 hours for every kilo from 11-20
20 mL per every kilo there after
68
raised urinary WCC, IgE, and eosinophils, alongside impaired renal function ->
acute interstitial nephritis
69
low Na - 129, K - 6.0, urea 26, creatinine 262 - dx?
pre-renal aki
70
ATN or prerenal uraemia? In prerenal uraemia think??
kidneys holding onto Na to maintain volume
71
low urine sodium, as does the urine:plasma osmolality >500 and urea ratio points towards?
points towards prerenal acute kidney injury
72
33-M -> AMU - severe sudden-onset headache associated with vomiting and neck stiffness. He has a history of recurrent migraine, ckd4, autosomal-dominant polycystic kidney disease and early-onset hypertension. obs, bloods are currently stable. He has a CT Head: Hyper-attenuated areas surrounding the circle of Willis and interpeduncular fossa. No skull fracture or parenchymal haemorrhage. Ventricles are normal-sized and there is no midline shift. dx?
SAH - berry aneurysm with ADPKD
73
effect of ca gluconate on serum K levels:
no effect - only stabalises myocardium
74
commonest nephrotic syndrome in adults:
membranous nephropathy
| frequently associated with malignancy
75
renal biopsy. The biopsy will show a thickened basement membrane on light microscopy and sub-epithelial spikes on silver staining. PLA2???
membranous nephropathy
76
mx membranous nephropathy:
conservative Ace-I to reduce protein loss
statin
anticoagulation
77
renal biopsy in this condition would show focal and segmental sclerosis on light microscopy and foot process effacement under electron microscopy. dx?
FSG
78
A 45-year-old man with a history of alcoholic liver disease presents with abdominal distension. Examination reveals tense ascites which is drained. What is the appropriate type of diuretic to help prevent reaccumulation of ascites?
aldosterone antagonist - spironolactone
79
tachycardia, fatigue, pallor and an aortic flow murmur while awaiting renal transplant - what is causing the fatigue?
anaemia
80
A 92-M -> ED following a fall the previous night. He was on the floor until this morning as he was unable to get up until his carer came in and found him. The patient seems confused and weak. You measure his creatinine kinase and find it to be 14,000 units/L. mx?
IV normal saline (rather than hartmann's as electrolyte abnormalities)
rhabdomyolisis (also caused by statins)
81
Microscopic haematuria can be a normal finding in?
women menstruating
82
red cell casts?
nephritic syndrome
83
bland urinary sediment:
prerenal uraemia
84
31-M-> ED with severe stabbing left-sided abdominal pain. CT confirms renal colic secondary to numerous bilateral calculi. Which ix should be followed up urgently?
U+E - renal function vital in bilateral obstruction
85
You receive a call from the Biochemistry Lab. A blood sample you have taken from a patient is reported to have a potassium level of 6.4mmol/L. What is your first step?
ecg baby
86
Nephrotic syndrome is associated with a hypercoagulable state why?
due to loss of antithrombin III via the kidneys
| risk of DVT
87
What is the most likely outcome following the diagnosis of minimal change nephropathy in a 10-year-old male?
full recovery but with future recurrent episode
1/3 no future relapses
1/3 infrequent episodes
1/3 frequent eps before adulthood
88
Patient with CKD taking calcium-based binders can have problems such as (2)?
hypercalcaemia and vascular calcification
| these meds are used to treat high phosphate
89
All diabetic patients require annual screening for nephropathy - how is it ix?
early morning sample of albumin : creatinine ratio
90
77-year-old woman on your ward has chronic kidney disease. hyperhposphataemia, high PTH. how should we correct her vit d deficiency?
Alfacalcidol is used as a vitamin D supplement in end-stage renal disease because it does not require activation in the kidneys
91
Hyperacute rejection (minutes to hours) caused by?
pre-existing Abs vs HLA and ABO antigens
92
68-F receiving haemodialysis for ESRF. Soon after completing dialysis she complained of a headache and becomes increasingly drowsy. Lung fields are clear to auscultation and electrolytes are normal. What complication of haemodialysis should be considered here?
dialysis disequilibrium syndrome
93
65F->ED sepsis and is also found to have an acute kidney injury. Most likely finding on her arterial blood gas?
metabolic acidosis with a raised anion gap.
94
metabolic acidosis with raised anion gap:
lactate - shock, sepsis, hypoxia
ketones - dka, alcohol
urate - renal failure
acid poisoning - salicylates, methanol
95
Polyuria, polydipsia and a high-normal sodium in a psych patient. which drug?
lithium causing nephrogenic DI
96
hyperkalaemia ecg?
peaked T waves in anterior leads and bradycardia
97
normal anion gap =
8-14
98
how to differentiate between acute interstitial nephritis and acute tubular necrosis in AKI?
acute interstitial nephritis = raised WCC on urine dip
99
what is NOW the preferred method of haemodialysis?
AV fistulae
| takes 6-8/52 to form
100
indications for dialysis in context of AKI?
new confusion - uraemia (encephalopathy/pericarditis)
| not responding to tx for cx
101
differentiating AKI from dehydration?
in dehydration, rise in urea is proportionally higher than the rise in creatinine
102
Primary and secondary aldosteronism can be differentiated by looking at the renin levels.>>
if renin high then 2ndary cause more likely eg renal artery stenosis
103
what is the treatment for acute clot retention? (e.g. in retention and known bladder ca)
3 way catheter irrigation
then when this done needs a flex cystoscopy once obstruction relieved
104
Normocytic anaemia, thrombocytopaenia and AKI following diarrhoeal illness -
consider HUS
| also low haptoglobins, and fragmented RBCs
105
Urine osmolality post-water deprivation 235
Urine osmolality post-desmopressin 240
dx and cause?
nephrogenic DI
| lithium
106
all patients with CKD and a raised albumin:creatinine ratio (urine) should be given?
ACE-I (ramipril)
107
spiro causing gynaecomastia should be switched to ?
eplerenone
108
VBG in excess vomiting?
alkalosis
| hypochoraemia, hypokalaemia
109
55M progressive weakness and dyspnoea. Massive hepatomegaly is detected and on further investigation, his renal function is reduced with heavy proteinuria however his liver function tests appear to be normal. He is a type 2 diabetic and was just this year diagnosed with chronic obstructive pulmonary disease (COPD). There is no ongoing family history of any conditions. dx?
amyloidosis
110
what type of AKI does contrast media cause?
renal
acute tubular necrosis
lose sodium in urine (in pre-renal they conserve na)
111
if microscopic haematuria in male - mx?
if <40 - nephrology referral
| if >40 urology referral
112
Patients who have received an organ transplant are at risk of ?
skin cancer (squamous cell ca ) due to increased use of immunosuppressants
113
CKD on haemodialysis - most likely cause of death is ?
ischaemic heart disease
114
EPO sfx?
```
pure red cell aplasia
encephalopathy
flu like sx
HTN
bone ache
skin rash
```
115
which type of AKI has proteinuria?
intrinsic AKI
| eg gentamycin
116
effect of calcium resonium?
removes K from the body
117
what is a hereditary cause of cranial DI?
```
hereditary haemochromatosis (AR)
ix - ferritin levels
```
118
A 53-year-old man is on the intensive care unit following an emergency abdominal aortic aneurysm repair. He develops abdominal pain and diarrhoea and is profoundly unwell. His abdomen has no features of peritonism. Which of the following arterial blood gas pictures is most likely to be present?
metabolic acidosis secondary to mesenteric infarct - high lactate
119
A 60-year-old man presents with visible haematuria for the past three weeks. He has an ache in the left loin but examination is unremarkable other than a left varicocele. He also notes to feeling intermittently hot and sweaty. dx?
renal cell carcinoma
also POUO
120
classical triad: haematuria, loin pain, abdominal mass =
renal cell carcinoma
121
A 21-year-old female complains of dysuria for the past week, despite just completing a three day course of trimethoprim. Urine dipstick is positive for blood + and leucocytes +. A MSSU shows no organism. dx?
chlamydia
122
A 68-year-old man presents with visible haematuria for the past two weeks. There is no history of pain. MSSU confirms haematuria but fails to show any organism. dx?
transitional cell carcinoma of the bladder
123
painless visible haematuria - think?
TCC bladder
124
A 57-year-old man presents with left sided abdominal pain radiating to his scrotum. The pain is severe and not controlled by a combination of paracetamol and ibuprofen. Urine dipstick shows: blood++, protein+, leucocytes++, nitrites negative. Clinical examination is unremarkable. dx?
renal stones
125
tx hypokalaemia:
mild-mod (2.5-3.4) - oral K
severe <2.4 - IVI + KCl (do not exceed 20mmol K/h)
20 if cardiac monitor, 10 without
126
aspirin od: sx?
salicylic acid -> salicylate toxidrome
Mild cases- nausea and vomiting. Progress to pyrexia, tachypnoea, tachycardia and tinnitus with more severe overdoses.
ABG - mixed respiratory alkalosis and metabolic acidosis. A raised anion gap
127
dry eyes, dry mouth, urinary retention, flushing and tachycardia. ABG should not show a raised anion gap
amitryptiline OD
128
Persistent pyuria and negative urine culture is seen in?
renal TB
129
tx nephrogenic DI?
thiazide diuretics and low salt/protein diet
130
big clue is the fused podocytes on electron microscopy which points to non-proliferative glomerulonephritis, in particular -
minimal change disease
131
high plasma osmolality, low urine osmolality =
DI
132
most common and important viral infection in solid organ transplant recipients?
CMV
133
26M ED polyuria and excessive thirst. PMH depression - SSRI. Dishevelled appearance, pressured speech, flight of ideas and boundless energy. A collateral history from the patient's sister reveals that he has not slept for 3 days, he has been binge drinking more than 20 units of alcohol at a time, and he has been taking MDMA (Ecstasy). He appears hypovolemic. He is apyretic, has normal tone and reflexes, and no evidence of clonus or tremor. high urine and serum osmolality. Hypernatraemia. cause of hypernatraemia?
binging alcohol -> polyuria due to ADH suppression of PPG
134
A 29-year-old man has his renal function checked. The eGFR is calculated to be 54 ml/min. Which one of the following factors is most likely to explain this unexpectedly low result?
body building
135
even if suspect IDA with CKD - what must you do in elderly person?
colonoscopy la
136
High phosphate levels in CKD 'drags' calcium from the bones, resulting in?
osteomalacia
137
in young female patients who develop AKI after the initiation of an ACE inhibitor, consider?
fibromuscular dysplasia
| string of beads appearance
138
CKD induced ??? hyperparathyroidism should be considered in CKD patients with fragility #
2ndary
139
aki with high urine sodium ->?
acute tubular necrosis
140
unexplained haematuria with no UTI ->
2ww referral
141
Chronic diabetic nephropathy will have on USS?
| chronic kidney disease will have on USS?
bilateral enlarged kidneys (also chr HIV)
| bilateral shrunken
142
which ssri causes siadh?
fluoxetine
143
AKI stages 1-3?
1 - Creat 1.5-1.9x, <0.5ml/kg/h for 6hrs
2 - Creat 2-2.9x, " for 12h
3 - creat >3x/>354, anuria 12h or <0.3 for 24h
144
A 41-year-old woman is discharged from hospital following a diagnosis of community-acquired pneumonia, to be managed at home on amoxicillin. A day later she returns to the emergency department with a low-grade fever, widespread erythematous rash and pain throughout her joints and lower back, with her initial bloods showing a significantly elevated creatinine. dx, urine findings?
acute interstitial nephritis
allergic
raised urinary WCC, IgE, and eosinophils, alongside impaired renal function
145
both a pre-renal AKI (due to hypovolaemia) and renal AKI (due to acute tubular necrosis). To determine which has occurred, one can use the urinary sodium level;
hypovolaemia (pre-renal AKI), the kidneys retain sodium in an attempt to increase the circulating volume, resulting in urine with sodium levels <20 mmol/L. Alternatively, in acute tubular necrosis (renal AKI), the blood loss and resulting decreased perfusion causes ischaemia of the tubules and the kidneys are unable to retain sodium, resulting in urine sodium levels >40 mmol/L.
146
Post-contrast peak effect on creatinine occurs between ?
48-72h
