Renal teaching with Jess

Question 1

What is creatine broken down from?

Answer 1

Creatine phosphate from muscle - broken down into creatinine, excreted unchanged in the kidney

Question 2

What affects the rate at which urea is reabsorbed?

Answer 2

More reabsorbed if flow is slow

Question 3

What goes up in dehydration? Why?

Answer 3

Urea high in dehydration -> low volume so slower flow, so more reabsorbed

Question 4

Creatinine clearance equation

Answer 4

Cockcroft-Gault equation

Question 5

Why else might urea be elevated?

Answer 5

High protein meal
GI bleed
Drugs - steroids, tetracyclines, sodium valproate
Dehydration

Question 6

What is AKI

Answer 6

Acute decline in renal function defined by increases in creatinine and urea

Question 7

What is oliguria

Answer 7

Less tahn 400ml / day

Question 8

What is oliguria

Answer 8

Peeing less than 400ml / day

Question 9

What is anuria

Answer 9

Peeing less than 50ml/day

Question 10

Causes of AKI

Answer 10

Prerenal (2/3) - anything that reduces renal perfusion pressures
Post renal

Question 11

Causes of prerenal AKI

Answer 11

Loss of blood e.g. haemorrhage, dehydration, burns, severe gut loss (D&V)

Third spacing - peritonitis, pancreatitis (may look overloaded but intravascularly deplete)

Cardiogenic shock - MI, acute valve lesion (chorda tympani lesion), cardiac tamponade, acute HF

Loss of systemic vascular resistance (causing vasodilation) - anaphylaxis, sepsis, anti-HTN drugs

Hepatorenal syndrome - AKI in context of fulminant liver failure

Renal vasoconstriction - renal artery stenosis, ACEi, ARBs

Question 12

What are the intrinsic renal causes of AKI?

Answer 12

only 1/5 are true intrinsic in origin, most are from

Prerenal acute tubular necrosis

Question 13

?

Answer 13

ACEi/ARB

Question 14

Drugs causing AKI to tubular

Answer 14

?

Question 15

Drugs causing AKI to institiium?

Answer 15

?

Question 16

Drugs that are not nephrotoxic but excreted renally must be stopped. Give some examples

Answer 16

Metformin
if GFR less than 30

Lithium
Digoxin

Question 17

Post renal causes of AKI

Answer 17

Obstructive nephropathy,

Bilateral obstruction:

ie..e 
stones
schistosomiasis induced strictures
SCA
Clots
renal TB
Bilateral paillary necrosis

External urethral compresssion 
pelvic malignancy 
BPH 
Retroperitoneal fibroids
posterior uretral valve (congenital valve in boys - blocks outflow at level of bladder) 
Constipation

Question 18

When do you get uremic symptoms?

Answer 18

If eGFR lower than 15

Question 19

Uremic symptoms

Answer 19

Anorexia
NV
Pruritis
Cofusion
Drowsiness
Uremic uncephalopathy
Uremic serositis - pericarditis, pleural effusion, ascites 
metalic taste
platelet dysfunction & coagulation (platelet disrupted by urea)

Question 20

What do you do to examine a patient with AKI?

Answer 20

Reduced skin turgor
reduced mucous membranes
Reduced cap refill 
High HR 
BP 
JVP

Question 21

Signs of SIRS

Answer 21

Systemic immune response syndrome (SIRS)

Question 22

Signs of reduced ECF

Answer 22

?

Question 23

Signs of expanded intravasculaly circulating volume

Answer 23

?

Question 24

Signs of expanded interstitial compartment

Answer 24

?

Question 25

Signs of systemic disease

Answer 25

?

Question 26

Signs of obstruction

Answer 26

Bladder distention (if the extra fluid is Suprapubic discomfort DRE - abnormal prostate

Question 27

?

Answer 27

Normally you give IV

Question 28

Investigations

Answer 28

Basic obs ECG - hyperkalemia (tall tented q waves, short pr interval) Urine dip - blood might point towards intrinsic cause Bloods: VBG for potassium levels and acidosis (and to work out whether it's AKI or on background of CKD), lactate, FBC, U and E, LFT, high phosphate in CKD hence do bone profile Renal ultrasound within 24hrs to check for pathology/obstruction Avoid contrast - CT KUB can be used as doesn't have contrast Renal biopsy if pre and post renal causes excluded

Question 29

Management

Answer 29

ABCDE and treat adverse features like high news, pulmonary oedema, high potassium over 6 with ECG changes ??????????

Question 30

When to initiate renal replacement therapy

Answer 30

?

Question 31

AKI vs CKD

Answer 31

CKD - elevation in urea/creatinine from

Question 32

?

Answer 32

?

Question 33

Nephrotic vs nephritic syndromes

Answer 33

Glomerulonephritis can present with a spectrum of signs ranging from proteinuriea (nephrosis) to haematuria (nephritic)

Question 34

Nephritic syndrome triad

Answer 34

Haematuria HTN Moderate to severe renal impairment Red cells on dip

Question 35

Causes of nephritic syndrome

Answer 35

``` IgA nephropathy - sore throat POst streptococcal HSP (igA with systemic component e.g. GI bleeds) Anti- good pastures Rapidly progressive GN Alport's syndrome - congential ```

Question 36

Nephrotic syndrome

Answer 36

Leakage of proteins through glomerular membrane, as opposed to blodo leakage

Question 37

Triad for nephrotic syndrome

Answer 37

Hypoalbuminemia Proteinuria Oedema - periorbital, sacral, ankle, genital, ascites

Question 38

?

Answer 38

Total higher than 3.5g/24hrs

Question 39

Causes of nephrotic syndrome

Answer 39

Minimal change disease - only seen on electron microscopy Membranous nephropathy, due to infections, rheum/ Focal segmental glomeruloscleorosis Mesagniocapillary