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MBBS - Year 3 > Urology - Renal Failure > Flashcards

Urology - Renal Failure Flashcards

1
Q

define AKI

A

Rapid decline GFR
- Nitrogenous and non-nitrogenous waste products
- Electrolyte (K+)
- Acid-base
- Fluid balance
purley based on blood tests - creatinine

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2
Q

what do you look at in AKI

A

level of creatinine

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3
Q

what is the classification of AKI

A

Serum Cr ≥ 26.5 micromol/l in 48 hrs

Serum Cr ≥ 1.5 (base) within last 7 days

Urine Output < 0.5ml/kg/hr for 6 hrs

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4
Q

what is a stage 1 AKI

A
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5
Q

what is stage 2 and 3 AKI

A
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6
Q

what are the 3 causes of AKI

A

pre-renal, intrinsic, post-renal

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7
Q

which of the causes is most common

A

pre-renal
anything that inpaires blood flow to kidney
dehydration, sepsis, heart failure

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8
Q

You are the FY1 on call and are asked to see a 52 year-old gentlemen in A&E by your registrar; apparently sent in by his GP generally unwell.
52 yrs old
BG: Obesity (BMI>40), Hypertension,Ischaemic Heart Disease,Leg ulcers
PC: Unwell,recent diarrhoea and vomiting,not eating and drinking.
SH: Lives with wife, increasing difficulty with ADL.
Drugs: Lisinopril and Naproxen
Generally Unwell.Temp 40 deg C
CVS: P110/min, BP 74/30, JVP not visible, dry mucus membranes, HS I+II
Resp: RR 24, Sats 94% on 21% FiO2, Chest clear
Abdomen: difficult to examine as sitting, grossly non-tender, BS+ ve
WBC 24
Neut 19
Hb 10.1
Plt 469
Cr 823
Ur 39
K 6.6
CRP 275
What is the cause, give possible diagnosis

A

pre-renal
Hypovolemia, SepsisShock, Nephrotoxic drugs, Renovascular disease, Left ventricular dysfunction
STAGE 3 kidney injury

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9
Q

what 3 factors are considered for eGFR

A

Cardiac output (pump)

Effective Circulatory volume (blood)

Peripheral Vascular Resistance (BP)

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10
Q

what are the 3 protective mechanisms for renal autoregulation

A

Myogenic Reflex

Tubuloglomerular feedback

Renin-Angiotensin system

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11
Q

what happens if arterial pressure decreases

A
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12
Q

who is at high risk of pre renal AKI

A

Elderly
Arteriosclerosis (HTN, DM)
Pre-existing renal disease
Underlying cardiovascular disease
ARB/ACEI/NSAID/Anti-hypertensives/Diuretics

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13
Q

how do NSAIDS, ACEi/ARB cause kdney injury

A

act on autoregulators

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14
Q

what is the management of AKI in dehydrated and septic patient

A

IV access and Bloods (CRP and cultures)
ABG/VBG
ECG
Wound swabs
Urine dip and I/O monitoring
CXR

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15
Q

what are some of the ECG signs seen for hyperkalaemia

A
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16
Q

how would you assess fluid balance

A

Peripherally:
Pulse, CR > secs
Warm/vasodilated/hyperdynamic
Weak/thready/cool

Centrally:
JVP
BP (postural)

Skin turgor/ Mucus membranes

Ausc chest

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17
Q

You’re the FY1 on call and are asked to see a patient in A&E.81 year old gentlemen, GP has sent in as generally “off legs”. A&E have kindly done some bloods for you
Hb 12.0g/dl
WBC 11
Plt 200
Na 130
K 5.8
Ur 40
Cr 1550
81 yr male
BG: Hypertension, Ischaemic Heart Disease, BPH – TURP 1997
PC: Generally unwell, hesitancy, abdominal pain
SX: Independent, Smoker, no ETOH
Drug: Ramipril, Bisoprolol, Furosemide, Aspirin, Simvaststain, Tamsulosin
T 36.1
CVS: P 110 bpm, BP 182/90, JVP 1cm, skin turgor normal, HS I+II
Resp: RR 16, Sats 98% RA, Chest clear
Abdomen: large abdominal mass with suprapubic dullness. DRE: craggy enlarged prostate
What is the cause of AKI

A

post renal obstruction

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18
Q

what are intrinsic and extrinsic causes of post renal obstruction

A

Intrinsic
Intraluminal (stone, blood clot, papillary necrosis)
Intramural (bladder tumour, urethral stricture)

Extrinsic
Prostate
Pelvic
RPF - retro peritoneal fibrosis

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19
Q

how would you manage an obstruction

A

Urinary catheter (SPC)
Polyuric phase – careful input/output monitoring, IVF
USS renal tract
Treat underlying infection
Check PSA/DRE (prostate)

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20
Q

what are the 4 intrinsic renal disease

A

acute tubular necrosis
acute glomerulonephritis
acute tubular interstitial nephritis
acute vascular issues

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21
Q

what causes Acute tubular necrosis

A

Ischaemia
Any cause of renal hypoperfusion (hypovolaemia, hypotension)
End of spectrum

Toxins
Endogenous
- Myoglobin – rhabdomyolysis
- Haemoglobin –massive haemolysis
- Myeloma – light chains
- Uric acid – tumour lysis syndrome –
Key mechanisms: direct toxicity and obstruction

Exogenous
Contrast
Antibiotics: aminoglycosides, Amphotericin B
Chemotherpeutic agents (cisplatin)

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22
Q

what is wrong

A

Acute interstitial nephritis
Normal tubule bottom centre
Amount of inflammatory cells – purple nucleus is WBC – lots in interstitial compartment

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23
Q

what 3 things make up glomerulonephritis

A

nephrotic syndrome
nephritic syndrome
asymptomatic urinary abormalities

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24
Q

what are key features of nephrotic syndrome

A

Proteinuria >3.5g/day
Hypoalbuminaemia
Oedema (periorbital)
Hyperlipidaemia
Lipiduria

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25
Q

what are some causes of nephrotic syndrome

A

Minimal Change
Membranous
Mesangiocapillary
Diabetes
FSGS
Amyloidosis
HIV
Lupus

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26
Q

what are key features of nephritic syndrome

A

Haematuria (dysmorphic)
Proteinuria (<3g/day)
Oedema
Oligouria
Hypertension

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27
Q

what are some causes of nephritic syndrome

A

IgA and HSP
Small vessel vasculitis (WG, MPA)
Anti-GBM
Post infectious
Mesangiocapillary
Lupus

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28
Q

what blood tests would you perform for AKI

A

Haematology (FBC, ESR)

Biochemistry (U&E, CK, CRP, LFT)

Immunology (
ANA – autoimmune
dsDNA – systemic lupus
ANCA – systemic vasculitis
Anti-GBM – Goodpastures
ASO titres, Anti-Dnase B titres – post-strep
Complement
Myeloma screen (SPE, SFLC, BJP)

Virology (hep B, C, HIV)

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29
Q

what are some urgent indications for dialysis

A

Hyperkalaemia – resistant

Pulmonary Oedema – resistant

Uraemic – encephalopathy, pericarditis

Acidosis

Drug overdose

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30
Q

what does a normal urine dip imply as a diagnosis

A

pre-renal, ATN and post renal

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31
Q

what does haematuria and proteinuria urine dip imply as a diagnosis

A

Acute GN
Vasculitis
Thrombotic Microangiopathy

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32
Q

What does WBC and casts urine dip imply as a diagnosis

A

Acute TIN
Obstruction
Pyelonephritis

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33
Q

what are 3 conditions that require immunosuppression

A

Glomerulonephritis
Tubulointerstital nephritis
graft rejection

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34
Q

Name different causes of glomerulonephritis and their treatment

A

Minimal change disease - Normally steroid-responsive
FSGS - Variable steroid response
Membranous nephropathy - Limited response to immunosuppression
IgA nephropathy - Poor response to immunosuppression
Diabetic nephropathy - Adverse effect of steroids
Goodpasture’s Disease - ?Plasma exchange + immunosuppression
Systemic vasculitis - Often responds to immunosuppression

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35
Q

what is the treatment for interstitial nephritis

A

steroids

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36
Q

common drugs which cause interstitial nephritis

A

NSAIDS, furosemide/bumetanide, PPIs (lanzoprazole)

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37
Q

when is hyperacute transplant rejection

A

immediate
Can cause graft loss within minutes to hoursDue to pre-formed anti-donor antibodies in recipient
Avoided by pre-operative cross-match
Untreatable

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38
Q

at what GFR do you need dialysis

A

10-12

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39
Q

how much more does dialysis give

A

5-10

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40
Q

what are some small molecules immunosuppressive drugs

A
41
Q

what are some immunosuppressive drugs - antibodies (polyclonal and monoclonal)

A

Polyclonal“IVIg” (pooled immunoglobulin)Anti-lymphocyte globulin (ALG)Anti-thymocyte globulin (ATG)

MonoclonalAnti-CD3 – OKT3Anti-CD25 (IL-2 receptor) – basiliximab, daclizumabAnti-CD52 – alemtuzumab (Campath)Anti-CD20 – rituximab

42
Q

how are T cells activated and what drugs inhibit what aspects of T cell activation

A
43
Q

how does prostate cancer present

A

insidental finding - rarely have many symptoms

44
Q

where does prostate cancer spread

A

bones mainly

45
Q

how do you diagnosie prostate cancer

A

PSA,
rectal examination
MRI - biopsy can miss the cancer
biopsy
ISUP - prostate cancer are graded

46
Q

from what grade do you want to treat protate cancer

A

Gleason 4 and up.
below this and the cancer is rarely an issue - aged 80+

47
Q

how do you stage prostate cancer

A

Bone scan (PSA >20ng/ml)
CT (very high PSA or high grade disease on Bx)
PET-CT (choline, PSMA)
WB-MRI

48
Q

what is the diagnosis if you see an osteoblastic lesion on an x-ray

A

its prostate cancer until proven otherwise

49
Q

what are the top 4 primary metastisis to bone

A

breast, prostate, lung, kidney

50
Q

how do bone mets present

A

pain
cauda equina compression

51
Q

what is the treatment for prostate cancer

A

Active surveillance
- GG1, PSA <10
- Life expectancy
Radiotherapy
Prostatectomy
Hormone therapy (anti androgens)

52
Q

58 yr male patient, smoker
On and off blood in urine for one month
Physical examination unremarkable
Haematology- mild anaemia

You are the junior doctor assessing him. How would you investigate?

A

bloods and blood films - macrocytic anaemia
ultrasound the kidney

53
Q

58 yr male patient, smoker
On and off blood in urine for one month
Physical examination unremarkable
Haematology- mild anaemia

How would you investigate ?

A

ultrasound

54
Q

what are malignant renal tumors

A
55
Q

what are benign renal tumors

A

Angiomyolipoma
Oncocytoma

56
Q

what is the most common location of TCC

A

bladder

57
Q

how do you investigate haematuria

A

USS urinary tract
cystoscopy

58
Q

where do you look for ureter cancer

A

IVU
CT urogram
ureteroscopy

59
Q

how do you stage a bladder cancer

A

MRI

60
Q

what imaging do you do for testicular tumors

A

ultrasound

61
Q

where would you find the sentinal node in testicular cancer

A

it skips the pelvis and you see in upper abdomen by the aorta

62
Q

what is chronic kidney disease

A

A reduction in kidney function, characterised by a reduction in GFR, which is not reversible and may be progressive

63
Q

what is normal gfr (in mL/min/m2)

A

120mL/min/1.73m2

64
Q

what are the 2 GCA stages of CKD

A

glomerular and albuminuria stage

65
Q

what 2 things considerable increase the risk of having CKD

A

albuminuria and impaired glomerular filtration

66
Q

what are some markers of kidney disease

A

GFR <60 ml/min/1.73m2
Albuminuria / Haematuria
Electrolyte abnormalities due to tubular disorders
Structural / histological abnormalities (e.g. on imaging, biopsy)
Kidney transplantation

67
Q

how is CKD definitlvely diagnosed - what tests and results would you see

A

2 Samples 90+ days apart
eGFR calculated from Creatinine levels (more accurate than Creatinine alone)
Haematuria detected best on dipstick
Albuminuria detected best on alb:creat ratio
Structural disease detected best on US

68
Q

what are the 3 equations which are used to estimate eGFR

A

Cockroft-Gault Calculated Creatinine Clearance
(140-age) x (1.23 if male/1.04 if female) x weight / serum creatinine

MDRD eGFR formula
32788 x serum creatinine-1.153 x age-0.203 x 0.742 if female x 1.21 if black

CKD-EPI formula
141 x min(creatinine/k,1)a x max(creatinine/k,1)-1.209 x 0.993age x 1.018 if female x 1.159 if black
If female, k=0.7, a=-0.329; if male k=0.9, a=0.411

69
Q

what are the 2 main causes of chronic kidney disease

A

diabetes - 20-40%
hypertension - 10-25%

70
Q

what are some other less common causes of chronic kidney disease

A

Renovascular disease
Reflux disease
Obstructive uropathy
Autosomal dominant polycystic kidney disease
Glomerulonephritis
Unknown- idiopathic

71
Q

how would you manage CKD stage IIIb and IV

A

Ongoing risk factor management
Non-glomerular functions start to be relevant
Iron-erythropoietin balance
Calcium-phosphate balance
Tubular function can start to decline
Low potassium diet, oral bicarbonate
Most common with diabetic nephropathy due to a Type IV renal tubular acidosis.

72
Q

what are some complications of CKD

A

Anaemia of CKD
Mineral Bone Disorder of CKD
Salt & Water, Acid-Base disorders
‘Uraemia’
Disease-specific complications

73
Q

how would you manage CKD managment for stage V

A

Preparation for renal replacement
Low Clearance Clinic for discussion of options
Definitive dialysis access in good time
Listing for pre-emptive transplantation / planned living donation if appropriate
Close monitoring of progression
Little margin of error
Can start to get problems with salt & water
May need fluid ration

74
Q

what are the 3 renal replacement therapies

A

Haemodyalyisis
peritoneal dialysis
transplantation

75
Q

Identify most important or frequent ADR of specified drug.
Patient given iv morphine stat after hip replacement. What important ADR to monitor?
Sweating
Itching
Constipation
Respiratory rate/ depression
Lethargy

A

Respiratory Depression

76
Q

Identify most likely cause of specified ADR.
82 year old lady, history of hypertension. 3 months of ankle swelling. Treated with diuretics – no improvement. What is most likely cause?
Aspirin
Amlodipine
Alendronate acid
Bendroflumethiazide
Bisoprolol

A

amlodipine

77
Q

Patient with hypertension and heart failure. Routine bloods K+ 5.9 mmol. (3.5 – 5.1 mmol).
Select two drugs most likely to interact to cause this:
Aspirin
Bendroflumethiazide
Bisoprolol
Digoxin
Isosorbide Mononitrate
Ramipril
Spironolactone

A

ramipril and spironalactone

78
Q

Patient with hypertension and heart failure. Pulse rate: 48 beats per minute.
Select two drugs most likely to interact to cause this:
Aspirin
Bendroflumethiazide
Bisoprolol
Digoxin
Isosorbide Mononitrate
Ramipril
Spironolactone

A

bisoprolol and digoxin

79
Q

what drugs have poor kinetics (narrow range of safety)

A

Gentamicin, vancomycin
Theophylline
Phenytoin

80
Q

what drugs affect the liver

A

Anticonvulsants
Anti-TB drugs

81
Q

what drugs affect the kidney

A

Aminoglycosides
Diuretics & other drugs for heart failure

82
Q

how do calcium blockers cause interactions

A

Calcium blockers →relax smooth muscle → vasodilatation → headache, flushing, oedema

83
Q

what are the 4 adverse drug reactions that need to be memorised

A

Bisphosphonate – osteonecrosis of the jaw
Metformin – lactic acidosis
Carbimazole, clozapine – marrow suppression
**Statins - myositis

84
Q

what mechanisms help to show possible ADRs

A

Block A-V node conduction – bradycardia

Arterial dilatation – hypotension

CNS drugs – sedation

Antiplatelets /Anticoagulants – haemorrhage

Drugs acting on aldosterone and kidney – potassium and other electrolyte abnormalities

85
Q

how do you predict issues of Treatment of atrial fibrillation – rate control with beta-blocker

A
86
Q

what are the main ADRs for salbutamol

A
87
Q

patient presents with tremor or tachycardia after using inhaler what is the most likely drug

A

salbutamol

88
Q

why do some drugs interact (3)

A
89
Q

what are bradycardia with the same drug interactions

A
90
Q
A

alchohol
GTN and alcohol are both vasodilators
increased risk of hypotension and fainting
especially when GTN used within 1 hour of alcohol

91
Q

what are target sights of trimethoprim and methotrexate

A
92
Q

what are important enzyme interaction inducers

A

Drugs for epilepsy – carbamazepine
Antibiotics – drugs for TB
Alcohol

93
Q

what are important enzyme inhibitors

A

Antibiotics – clarithromycin, ciprofloxacin
Xanthine oxidase inhibitor - allopurinol

94
Q

what is a type A ADR

A

dose dependent, predictable

beta-blocker causes bradycardia because of action on beta-receptors in cardiac conduction

95
Q

what is a type B ADR

A

not dose dependent, cannot be predicted pharmacologically

Anaphylaxis to penicllin

96
Q

what 2 ways are you able to limit the classification

A

No account of duration e.g. steroid osteoporosis – cumulative dose and length of therapy are relevant

What about susceptibility – poorly mobile elderly women more likely to have steroid osteoporosis

97
Q

76 year old recent acute coronary syndrome. TSH 12.6. Please prescribe thyroxine. (you can use BNF)

A

25mcg OD

98
Q

83 year old with severe acute gout. Started on Naproxen 250 mg bd. What management options to prevent complications from Naproxen?

A

use lower dose
restrict time of treatment 5-10 days
assess susceptibility

99
Q

30 year newly diagnosed thyrotoxicosis. Start carbimazole. What is the most important communication item?

A

“Patient should be asked to report symptoms and signs suggestive of infection, especially sore throat.
A white blood cell count should be performed if there is any clinical evidence of infection.”

MBBS - Year 3 (13 decks)

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