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A2 ME3031 URINARY > W6 Case Studies > Flashcards

W6 Case Studies Flashcards

1
Q

Define AKI

A

decline in renal excretory function over hours or days that can result in failure to maintain fluid, electrolyte and acid-base homeostasis

Parameters:
(1)Creatinine rise of 26 micromol or more within 48 hours
/ Creatinine rise of 50 - 99% from baseline within 7 days

(2) 100-199%) creatinine /7d or urine output <0.5mL/ 12hr+
(3) 200% creat. increase withi 7 days

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2
Q

Define Oliguria

A

Oligura - reduced urine output < 400mls/24hours

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3
Q

What drugs to cease in AKI

A

BISOPROLOL
RAMIPRIL
FUROI
IBUPROFEN

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4
Q

Pre-Renal Causes of AKI

A

Volume depletion
⇩CO
⇩renovasc. blood flow
⇩peripheral vasc resistance

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5
Q

Intrinsic Causes of AKI

A

Acute interstitial nephritis
Vasculitis
Acute Glomerulonephritis

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6
Q

Post-renal Causes of AKI

A

Obstruction

Spinal cord disease/injury

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7
Q

Drug effects on the glomerulus

A

1) Prostaglandins dilate afferent to maintain glomerular perfusion. NSAIDs BLOCK this = constriction. = ⇩perfusion
2) Ang. II constricts efferents if renal perfusion is low so BLOCK ANG. II lead to fall in GFR d/t NSAID

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8
Q

Suitable drugs in AKI

A
  • paracetamol

- weak opiod = codeine phosphate or tramadol

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9
Q

normal range of K+

A

blood potassium level is 3.6 to 5.2 millimoles per liter (mmol/L).

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10
Q

Hyperkalaemia features on ECG

A

tall tented t waves
shortened QT interval
and ST-segment depression

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11
Q

principles of hyperkalaemia management

A

PROTECT HEART = calcium salts (calcium chloride / calcium gluconate) if 6-6.4mmol/L of K+

SHIFT K INTO CELLS = salbutamol; insulin and dextrose
(6-6.4mmol of K+)

REMOVE K FROM BODY = calcium resonium,
(initial milkd 5.5-5.9) or DIALYSIS

MONITOR K AND GLC

PREVENT REOCCURRENCE

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12
Q

You are on night shift and called to the ward to see Mrs C because she is feeling breathless and desaturated.

NEWS = 8
RR 24/min
Sats 96% (4 litres)
HR 105bpm
BP 170/98 mmHg
Temp 37.5°C
Alert
Urine output < 30mls/hour
Mrs C had been admitted with acute kidney injury and has been receiving IV fluids.

What do you do?

A

ABCDE

Fluid assessment

Review output - Is she catheterised? Is the catheter working? Any urine in bladder?

ABG

ECG

Chest x-ray

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13
Q

Complications of AKI

A

Pulmonary oedema picture, fluid retention, JVP, crackles

(1)
> stop fluids, furosi, monitor output, urgent ultrasound to exclude obstruction
> review soon 1hr

(2)
> dialysis

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14
Q

Indications for acute renal replacement therapy.

A

Persistent hyperkalaemia resistant to medical therapy

Symptoms or complications of uraemia

Refractory fluid overload and pulmonary oedema

Severe metabolic acidosis

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15
Q

Significance of cyclical MicroHaemut. with periods

A

Suggestive of endometriosis

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16
Q

Significant travel history for MH

A

Areas endemic with Schistosoma haematobium or TB

17
Q

52 male attends GP for right flank pain
No history of UTIs
History of obesity and T2DM
Stopped smoking a year ago
No family history of renal problems
Apyrexial, BP 150/92mmHg
Prostatic examination, digital rectal examination: some prostatic enlargement, smooth and no tenderness or nodularity
Urinalysis: blood ++ only
Urine protein creatinine ratio is 18mg/mmol (<20mg/mmol)
Urine microsocopy: no evidence of dysmorphic RBCs

Cause of MH? Next steps?

A

Non-glomerular source

CT urogram

18
Q

36 male offshore Oil and Gas worker was found to have non-visible haematuria on 2 consecutive urine samples
He has no significant past medical history
He reports having episodes of sore throat in the past and on one occasion having frank blood in the urine (when he was 16)
No family history of kidney disease
Blood pressure has been elevated recently at 158/100mmHg

What are next investigations?

A

Urine protein creatinine ratio

U&Es

ANA / ANCA / C3-C4 / immunoglobulins

19
Q

Indications for renal biopsy

A

Haematuria (in the absence of infections or urological abnormalities) often in the presence of other markers of kidney injury e.g. significant proteinuria, hypertension, rising creatinine or immunological markers

Proteinuria of more than 1 g/day

Unexplained renal impairment

To investigate renal involvement in systemic diseases

20
Q

A previously fit and healthy 52-year old man presents with bilateral lower limb oedema (acute onset), fatigue and frothy urine. He is a non-smoker and drinks c. 21 units alcohol/week. He works as an accountant. Urine dip shows 4+ protein.

and apt investigations

A

Nephrotic Syndrome, typical picture

> urine p:c / albumin:creatinine + 24hr

> bloods albumin

> definitive: biopsy for light microscopy/ immunifluorescence / electron microscopy

21
Q

features that characterise nephrotic syndrome?

A

Proteinuria (> 3.5g/24hours)
Hypoalbuminaemia (< 30g/L)
Peripheral oedema

+Hyperlipidaemia and thrombosis (usually VTE) are also frequently seen.

22
Q

Primary and 2º Causes of Nephrotic Syndrome

A

Minimal Change Disease
Focal Segmental Glomerulosclerosis
Membranous Nephropathy

2º
Diabetic Nephropathy
Systemic Lupus Erythematosis (SLE)
Amyloidosis

23
Q

Typical picture of nephritic syndrome

A

presence of AKI, increased BP and an active urine sediment of red cells/red cell casts

24
Q

Tests for nephritic syndrome

A

ANCA esp with rapid progressive glomerulonephritis with AKI

25
Q

Key marker in membranous nephropathy

A

Anti-PLA2R, correlation with disease activity thus good monitoring tool.

Receptor expressed on podocytes.

26
Q

Complication of membranous nephropathy

A

Hypercoagulability/thrombosis (due to urinary loss of anticoagulant proteins such as antithrombin II and plasminogen, as well as an increase in clotting factors). Also, immobility and abnormal endothelial function contribute.

Infection e.g. Beta-haemolytic streptococcal cellulitis and pneumococcal peritonitis

AKI

Progressive CKD

27
Q

Mgmt approach to idiopathic membranous nephropathy

A

conservative unless symptomatic or 8g+ proteinuria
> BP control, ACEi, diuretics, statins

High risk of complications
> imm. suppr. Rx

28
Q

Hallmarks of Minimal Change Disease

A

Oedema: periorbital + peripheral
Wt gain

Often childhood

> steroid trial without biopsy in children

A2 ME3031 URINARY (14 decks)

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