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Scientific Basis of Medicine > The Case Of The Injured Kidneys > Flashcards

The Case Of The Injured Kidneys Flashcards

1
Q

Intravenous Contrast Media - Used in … (3)

A
  • Contrast enhanced plain films –IVU
  • CT scanning
  • Angiography / interventional procedures
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2
Q

Intravenous Contrast Media - What is it, what does it do and how is it given?

A
  • Iodinated hydrocarbon ring
  • Iodine atomic number 53
  • Increases absorption of x-rays
  • Injected intravenously
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3
Q

Side effects of iodinated contrast (5)

A
  • Warmth / Flushing
  • Headache
  • Nausea
  • Itching / rash
  • Metallic taste
  • These do NOT indicate allergy to contrast
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4
Q

Reactions to contrast (Allergy)

A
  • Urticaria
  • Bronchospasm
  • Laryngeal oedema
  • Hypotension
  • Generalised anaphylaxis
    • Incidence of severe reactions: 0.04%
    • Incidence of major anaphylaxis: 0.004%
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5
Q

Reactions to contrast (Allergy)

  • Incidence of severe reactions: …%
  • Incidence of major anaphylaxis: …%
A
  • Urticaria
  • Bronchospasm
  • Laryngeal oedema
  • Hypotension
  • Generalised anaphylaxis
    • Incidence of severe reactions: 0.04%
    • Incidence of major anaphylaxis: 0.004%
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6
Q

Patients at risk of contrast reaction

A
  • Previous contrast reaction
  • Asthma (6 times increase risk of reaction)
    • NOT shellfish allergy or topical Iodine reaction
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7
Q

Contrast reaction - what do we give?

A
  • Oxygen and IV fluids,
  • Anti-hystamine – chlorphenamine 10mg
  • Hydrocortisone – 200mg
  • Adrenaline(IM) – 1:1000 (500mcg initially)
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8
Q

RCR recommendations - contrast

A
  • Doctor available whenever IV contrast is injected
  • If risk factors – decision to inject contrast is taken by radiologist only.
  • Patient never left alone in first 5 mins after injection
  • Facilities / drugs for treating reaction readily available
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9
Q

Contrast-Mediated Nephrotoxicity

  • Nephrotoxicity:
    • defined as …% increase in serum creatinine 48-72hrs following contrast injection
    • A leading cause of hospital acquired …, with increased in-hospital/1yr mortality
  • Direct cytotoxic effect on proximal renal tubules (and exacerbate renal vasoconstriction)
A
  • Nephrotoxicity:
  • defined as 25% increase in serum creatinine 48-72hrs following contrast injection
  • A leading cause of hospital acquired AKI, with increased in-hospital/1yr mortality
  • Direct cytotoxic effect on proximal renal tubules (and exacerbate renal vasoconstriction)
  • Risk of Nephrotoxicity if:
  • renal impairment (raised creatinine)
  • Diabetes
  • Metformin therapy
  • Caution if dehydration, high dose of contrast, CCF
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10
Q

Risk of Nephrotoxicity if:

  • …. impairment (raised …)
  • D…
  • … therapy
  • Caution if …, … dose of contrast, CCF
A

Risk of Nephrotoxicity if:

  • renal impairment (raised creatinine)
  • Diabetes
  • Metformin therapy
  • Caution if dehydration, high dose of contrast, CCF
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11
Q

Preventing contrast induced AKI

  • Stop …. (48hrs post contrast injection)
  • Pre- and post-hydration (oral/IV) – intra-vascular volume expansion maintains renal perfusion
  • Use of contrast is on a risk Vs benefits basis
    • e.g. Trauma or cancer imaging.
  • …. mandated if:
    • History of renal disease or DM
    • …. dose of CM than average
    • If using IA route that will directly expose the kidneys to a larger/more concentrated dose
A
  • Stop Metformin (48hrs post contrast injection)
  • Pre- and post-hydration (oral/IV) – intra-vascular volume expansion maintains renal perfusion
  • Use of contrast is on a risk Vs benefits basis
    • e.g. Trauma or cancer imaging.
  • eGFR mandated if:
    • History of renal disease or DM
    • Larger dose of CM than average
    • If using IA route that will directly expose the kidneys to a larger/more concentrated dose
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12
Q

Preventing contrast induced AKI

  • Stop Metformin (… post contrast injection)
  • Pre- and post-hydration (oral/IV) – intra-vascular volume expansion maintains renal …
  • Use of contrast is on a risk Vs benefits basis
    • e.g. Trauma or cancer imaging.
  • eGFR mandated if:
    • History of renal disease or ….
    • Larger dose of CM than average
    • If using IA route that will directly expose the kidneys to a larger/more … dose
A
  • Stop Metformin (48hrs post contrast injection)
  • Pre- and post-hydration (oral/IV) – intra-vascular volume expansion maintains renal perfusion
  • Use of contrast is on a risk Vs benefits basis
    • e.g. Trauma or cancer imaging.
  • eGFR mandated if:
    • History of renal disease or DM
    • Larger dose of CM than average
    • If using IA route that will directly expose the kidneys to a larger/more concentrated dose
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13
Q

Imaging in AKI

  • Exclude …. – i.e. is obstruction the cause of the AKI
  • s…
  • …: TCC, prostate, gynae
  • 1st Investigation – renal …
A
  • Exclude hydronephrosis – i.e. is obstruction the cause of the AKI
  • Stones
  • Tumour: TCC, prostate, gynae
  • 1st Investigation – renal U/S
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14
Q

CT Imaging- Kidneys

  • Left image shows - Right … – normal size kidneys (preserved …. thickness)
  • Right image shows - Left …. –
A
  • Right hydronephrosis – normal size kidneys (preserved cortical thickness)
  • Left hydronephrosis – 5mm stone dependent in renal pelvis ? Further stone in ureter?
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15
Q

Nephrostomy Insertion

A
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16
Q

Renal sepsis:

  • ….:
    • U/S is usually normal in acute ….
    • CT often normal. May be oedema, debris, gas or perinephric stranding
A
  • Pyelonephritis:
    • U/S is usually normal in acute pyelonephritis
    • CT often normal. May be oedema, debris, gas or perinephric stranding
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17
Q

Peri-nephric abscess

  • Left - Large … within the perinephric fat posterior to the kidney
  • Right - … from …. obstruction. Perinephric abscess extening into … muscle
  • Both of these abscesses can be drained under…guidance (exactly the same technie as the nephrostomy)
A
  • Left - Large abscess within the perinephric fat posterior to the kidney
  • Right - Pyelonephritis from stone obstruction. Perinephric abscess extening into psoas muscle
  • Both of these abscesses can be drained under U/S guidance (exactly the same technie as the nephrostomy.
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18
Q

Reminder of key functions - Kidneys

  • Fill in the blanks
A
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19
Q

Reminder of key functions - Kidneys

  • Fill in the blanks
A
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20
Q

What is kidney failure?

  • Loss of … …
    • –Irreversible, slow, progressive….CKD
      • Urine output …
    • –Potentially reversible, rapid onset…AKI
      • Oliguria (low urine output)
      • Anuria (no urine output)
  • Degrees of failure
    • Stages 1-… in CKD
    • Stages 1-… in AKI
A
  • Loss of functioning nephrons
      • –Irreversible, slow, progressive….CKD
        * Urine output preserved
        • –Potentially reversible, rapid onset…AKI
          • Oliguria (low urine output)
          • Anuria (no urine output)
  • Degrees of failure
    • Stages 1-5 in CKD
    • Stages 1-3 in AKI
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21
Q

What is kidney failure?

  • Loss of functioning nephrons
    • –Irreversible, slow, progressive……..
      • Urine output preserved
    • –Potentially reversible, rapid onset…….
      • … (low urine output)
      • …. (no urine output)
  • Degrees of failure
    • Stages 1-5 in ….
    • Stages 1-3 in ….
A
  • Loss of functioning nephrons
    • –Irreversible, slow, progressive….CKD
    • Urine output preserved
      • –Potentially reversible, rapid onset…AKI
    • Oliguria (low urine output)
    • Anuria (no urine output)
  • Degrees of failure
    • Stages 1-5 in CKD
    • Stages 1-3 in AKI
22
Q

Degrees of failure - Kidneys

A
23
Q

What can go wrong? - Kidney tubules

A
24
Q

What can go wrong? - Kidney Glomeruli

A
25
Q

What can go wrong? - Kidney Blood Vessels

A
26
Q

What can go wrong? - Kidney Interstitium

A
27
Q

Effects of diabetes on the glomerulus

A
28
Q

Pathogenesis of diabetic kidney disease

  1. Podocyte damage leading to …
  2. High glucose environment—
    - > reactive oxygen species->vascular endothelial cell damage
  3. Tubulo-interstital and glomerular …
A
  1. Podocyte damage leading to albuminuria
  2. High glucose environment—
    - > reactive oxygen species-àvascular endothelial cell damage
  3. Tubulo-interstital and glomerular fibrosis
29
Q

Who gets diabetic kidney disease?

A
30
Q

Tubules

A
31
Q

What is ATN?

A

Acute tubular necrosis (ATN) is a kidney disorder involving damage to the tubule cells of the kidneys, which can lead to acute kidney failure.

32
Q

Types of injury in ATN - Ischaemic (8)

A
  • Diarrhoea, vomiting
  • Bleeding
  • Dehydration
  • Burns
  • Renal losses via diuretics or osmotic diuresis
  • Third fluid sequestration (e.g nephrotic syndrome)
  • Oedematous states such as heart failure and cirrhosis cause reduced kidney perfusion.
  • Coagulopathy, such as disseminated intravascular coagulation
33
Q

Types of injury in ATN - Toxic (9)

A
  • Aminoglycosides
  • Amphotericin B
  • Acyclovir
  • Cisplatin
  • Cidofovir
  • Uric acid (gout)
  • Light chain accumulation (myeloma)
  • Myoglobin (rhabdomyolysis)
  • Ethylene glycol
34
Q

Types of injury in ATN - Sepsis (3)

A
  • Systemic hypoperfusion
  • Endotoxins leading to vasoconstriction
  • Inflammatory cytokines-àROS-àinjury
35
Q

AKI: What works?
Goals of therapy are to prevent AKI or need for RRT

  • Effective……….. Once AKI is present
    • … (…% saline)
    • Prevent …
    • Avoid …
    • Treat …
    • Specific treatment (mostly …)
A
  • Effective……….. Once AKI is present
    • Hydration (0.9% saline)
    • Prevent hypotension
    • Avoid nephrotoxins
    • Treat obstruction
    • Specific treatment (mostly immunosuppression)
36
Q

The … compartment is affected in all the forms of renal disease.

A

The tubulointerstitial compartment is affected in all the forms of renal disease.

37
Q

AKI - drug causes

A
  • Gentamicin
  • Vancomycin
  • NSAIDS
  • Ethlyene glycol
38
Q

AKI - UTI causes

A
  • Leptospirosis
  • CMV
39
Q

Renal Blood Vessels

A
40
Q

Renal vascular disease

A
41
Q

Final common pathway

A
42
Q

Treatments in CKD

  • Each condition might have specific treatment.
    • e.g. Diabetes-good … control
    • e.g. ….-iv fluids including iv bicarbonate
  • …/… (like ramipril)
  • … inhibitors (like dapagliflozin)
A
  • Each condition might have specific treatment.
    • e.g. Diabetes-good glycaemic control
    • e.g. Rhabdomyolysis-iv fluids including iv bicarbonate
  • ACEi/ARB (like ramipril)
  • SGLT2 inhibitors (like dapagliflozin)
43
Q

Renal replacement therapy comprises either …. or ….

A

Renal replacement therapy comprises either transplantation or dialysis

44
Q

Renal Function: responsible for … (4)

A
  • Excretion of waste
  • Maintenance of extracellular fluid(ECF) volume and composition
  • Hormone synthesis(erythropoeitin, vitamin D, Renin/Aldo)
  • Also contribute to gluconeogenesis
45
Q

Kidneys receiving …% of cardiac output

A
46
Q
  • Kidneys receiving 25% of cardiac output
  • Blood → glomerular capillary tuft → glomerular filtrate
  • Glomerular filtrate is ultrafiltrate of …
  • Glomerular filtrate has similar composition to … except …
  • Total filtration rate of the kidneys depends on … pressure, osmotic pressure and integrity of … membrane
A
  • Kidneys receiving 25% of cardiac output
  • Blood → glomerular capillary tuft → glomerular filtrate
  • Glomerular filtrate is ultrafiltrate of plasma
  • Glomerular filtrate has similar composition to plasma except protein
  • Total filtration rate of the kidneys depends on hydrostatic pressure, osmotic pressure and integrity of basement membrane
47
Q
  • Normal Glomerular filtration rate (GFR) is approximately … ml/min ˷ 170L/24h much of it is reabsorbed in proximal convoluted tubules(PCT)
  • Estimated GFR (eGFR) is used in clinical practice
A
  • Normal Glomerular filtration rate (GFR) is approximately 120 ml/min ˷ 170L/24h much of it is reabsorbed in proximal convoluted tubules(PCT)
  • Estimated GFR (eGFR) is used in clinical practice
48
Q

Biochemical investigation of kidney function
Creatinine

A

Creatinine origin

49
Q

Biochemical investigation of kidney function
Creatinine - limitations (5)

A
  • Creatinine starts to rise only when there is a significant decline in glomerular filtration (~50% glomeruli lost)
  • Serum levels can increase with ingestion of large amounts of meat
  • Patient with fluid overload has a lower serum creatinine due to dilution of blood
  • Malnutrition and inactivity decreases muscle mass, thus decrease serum creatinine
  • Sensitivity of serum creatinine in mild to moderate renal impairment is poor.
50
Q

GFR vs serum creatinine
Levey et al Ann Int Med 1999

A
51
Q 
_Biochemical investigation of kidney function
Creatinine Clearance (Ccr) - GFR_
  • To assess GFR(clearance test) : measuring the urinary excretion of a substance that is completely …, not secreted, reabsorbed or metabolised
    • Inulin, iohexol– meet the criteria but not suitable in routine clinical use, rarely used as rarely required to accurately measure GFR (kidney donor assessment)
  • -The most widely used clearance test is Ccr, (Cr is secreted by renal tubules but negligible when GFR is normal)
  • Cr Clearance = U x V/P (ml/min)
  • U= Urinary Cr concentration -µmol/L
  • V= Urine flow rate -ml/min
  • P= Plasma Cr concentration - µmol/L
A
  • To assess GFR(clearance test) : measuring the urinary excretion of a substance that is completely filtered, not secreted, reabsorbed or metabolised
    • Inulin, iohexol– meet the criteria but not suitable in routine clinical use, rarely used as rarely required to accurately measure GFR (kidney donor assessment)
  • -The most widely used clearance test is Ccr, (Cr is secreted by renal tubules but negligible when GFR is normal)
  • Cr Clearance = U x V/P (ml/min)
  • U= Urinary Cr concentration -µmol/L
  • V= Urine flow rate -ml/min
  • P= Plasma Cr concentration - µmol/L
52
Q
A

Scientific Basis of Medicine (35 decks)

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