Week 14 - Renal Flashcards
Define AKI?
Rapid decline in kidney excretory function over hours or days, recognised by a rise in serum ureas and creatinine.
What is causes Muddy brown casts in urinalysis?
Acute tubular necrosis
Define oliguria.
Urine output of <1ml/kg/hr in infants or <1ml/kg/hr in children or <400-500ml in 24hours in adults
List some drugs that are nephrotoxic.
NSAIDS, ACEi, gentamicin
What staging system do you use in AKI?
KDIGO
What is acute tubular necrosis?
Damage and necrosis of the epithelial cells of the renal tubules. Always due to undwrperfusion or direct toxicity
Give some toxins causing ATN.
Endogenous - myoglobin, haemoglobin, Ig, calcium, urate
Exogenous - Contrast, lithium, ACEi, NSAIDs, gentamicin
Define chronic kidney disease.
Kidney damage or GFR <60ml/min/1.73m2 for >/= 3 months. E.g. due to diabetic nephropathy, rebovascular disease. GN
What is the classification of CKD?
Stage 1: >/= 90 ml/min/1.73m2 - normal or increased with other evidence of kidney damage
Stage 2: 60-89ml/min - slightly reduced with other evidence of kidney damage
Stage 3 (a and b) - 30-59 - moderate decreased
Stage 4: 15-29 - severe decrease
Stage 5: <15 - established kidney failure
How may anaemia come about in CKD?
Damaged kidney not producing EPO When eGFR<30 Trigger - <100g/L Hb Target 100-120 Give Darbepoietin alfa
What are some complications of CKD?
Renal bone disease - Renal osteodystropy
CVD
Anaemia
Peripheral neuropathy
What are some secondary causes of GN?
Myeloma, CLL ALD, IBD, coeliac HIV, malaria, hepatitis, antibiotics TB, lung cancer RA, lupus NSAIDs, bisphosphonates
What tests are in a GN screen?
ANCA, ANA/dsDNA, anti-GMB, Anti-PLA2R, complement, Ig, RF, hep B, C, HIV
What might IgA nephropathy be associated with?
Synpharyngitis (upper RTI) or secondary to coeliac disease, cirrhosis, Henoch-schonlein purpura
What does IgA nephropathy look like on histology?
Glomerular mesangial proliferation and IgA depositions
What is the most common GM?
Membranous - presents with nephrotic syndrome
Secondary to malignancy, drug.
Anti-phospholipase A2 receptor
What does membranous Gn look like on histology?
IgG (immune complex) and complement depositions on GBM
What GN is commonest in children?
Minimal change disease I
T cell cytokine mediated against glomerular epithelial cells.
What does minimal change disease I look like on histology?
Fusion foot processes
What may cause crescentic GN/rapidly progressive GN
ANCE vasculitis, lupus nephritis, good pasture’s syndrome (anti-GBM), HSP nephritis
What are some indications for RRT?
AEIOU
Acidosis (severe and unresponsive)
Electrolyte imbalance (severe and unresponsive hyperkalaemia)
Intoxication (overdose)
Oedema (severe and unresponsive pulmonary oedema)
Ureamia (seizures, reduced consciousness)
Signs of uraemia.
Itch, anorexia, restless legs, vomiting, weight loss, metallic taste - lemon yellow tinge
How does haemodialysis work?
- removal of solutes - diffusion
- removal of excess fluid - hydrostatic filtration
Arterio-venous fistula
4 hours X3
What are some complications of haemodialysis?
Crash ‘acute hypotension’, air embolism, blood loss, hypokalaemia, cramps, fatigue, access problems
Describe the process of Exchange in peritoneal dialysis.
Diffusion and osmotic filtration
Dialysis solution high in glucose. It absorbs waste and extra fluid from inside your body.
CAPD - continuous ambulatory PD
APD - Automated PD
What are some complications of peritoneal dialysis?
Hernia, worsening of control of diabetes, peritonitis, hypoaluminaemia
What drugs might you use in immunosuppressive therapy in transplant?
Basiliximab - IL-2 receptor
Tacrolimus - calcineurin inhibitor
Mycophenolate mofetil - inhibits proliferation of T and B cells
± steroids - cyclosporin, azathioprine
What are the 5 R’s in fluid management?
Resuscitate - to restore circulation Routine management Replace Redistribute Reassess
What are the clinical signs of hypovolaemia (shock)?
Hypotension SBP <100 Tachycardia >90 Peripherally cool Capillary refilll time > 2s NEWS >5
How would you investigate Testicular cancer?
Seminoma
Scrotal US
Tumour markers - alpha-fetoprotein, Beta hCG, lactate dehydrogenase
Which HPV is penile cancer associated with?
16, 18, 21
What are some risk factors for bladder cancer?
Chronic inflammation - Stones, Schistosomiasis
Cyclophosphamide, pioglitazone
Hydrocarbon exposure - hair dyes, industrial paints
Smoking ***
What is a key presentation of bladder cancer?
Painless Haematuria
Need a cystoscopy and biopsy
Transition cell carcinoma 90%
What are the Tx options for bladder cancer?
Radical cystectomy - removal of bladder& uterus/prostate
Mitomycin C - DNA synthesis inhibitor - Chemo
BCG therapy - immunotherapy - cell mediated immune response
urgent Transurethral resection of bladder tumour
How might someone with renal cancer present?
Varicocele, lower limb oedema,
Mass pain and Haematuria - triad
systemic Sx - fever, fatigue, night sweats, weight loss
Paraneoplastic syndrome - (hypercalacaemia - high PTH. polycythaemia - high EPO, hypertension - renin, rearranges LFTs - staffer’s syndrome)
What is prostate cancer?
Adenocarcinoma, usually of peripheral zone
PTEN, TP53, BRCA2
Gleason grading system
What Sx may indicate prostate cancer has metastasised?
Bone pain * - spinal cord compression
or renal failure - obstruction
What is renal clearance? (GFR)
The amount of plasma, cleared of substance per unit time. ml/min
What makes up Nephrotic syndrome?
- Peripheral oedema
- Proteinuria MORE than 3g/24 hours
- Serum albumin LESS than 25g/L
- hypercholesterolaemia
How does hyperglycaemia cause hypertension and renal failure?
Hyperglycaemia - Volume expansion - intraglomerular hypertension - hyper filtration - proteinuria - hypertension and renal failure
What defines bacteriuria?
> 10 ^5 colony forming bacteria
Need to treat in preschoolers and pregnancy as it can progress to pyelonephritis
How would you manage a UTI in pregnancy?
Amoxicillin and cefalexin for 7-10 days
What are some complications of using catheters?
CAUTI, risk of bladder cancer, obstrective-hydronephrosis, chronic renal failure, urinary tract stones
What antibiotics would you use to treat CAUTI?
Not severely ill - Oral levofloxacin
Severely ill - IV amoxicillin, genatmicin, ceftriaxone
How would you manage acute pyelonephritis? (upper UTI)
send urine ± blood culture ± imaging
Co-amoxiclav, ciproflxacin, trimpethoprim
What are the complications of orchitis?
Testicular infarction, abscess formation
How would you manage Fournier’s gangrene?
1st line - surgical debridement
Pip-tazobactam + gentamicin + metronidazole ± clindamycin
How might renal artery stenosis present?
Increased BP
Worsening renal function after ACEi/ARB in bilateral stenosis
Resistant to treatment
‘flash’ pulmonary oedema - sudden onset
What drug can be used to help aid the spontaneous passage of stones?
Tamsulosin (alpha blocker)
What is renal agenesis?
Congenital absence of the renal parenchyma
What is renal hypoplasia?
Reduction in the number of nephrons
Define pyelonephritis.
Inflammation of the kidney due to a bacterial infection
Complication - renal abscess
What are metastatic complications of prostate cancer?
Spinal cord compression
Ureteric obstruction
What type of drug is Tolvaptan and what are indications?
Vasopressin V2 receptor antagonist
APKD
SE- hepatotoxicity, hypernatraemia
What types of polycystins are there?
PKD 1 on chrom 16 - Rapid progression to ESRD
PKD 2 on chrom 4 - Slower progression to ESRD
What is Alports syndrome?
X-linked - Collagen 4 defects (in BM)
Microscopic Haematuria, proetineuria, ESRD
90% on dialysis/transplant by 40
Sensorineural hearing loss in childhood (deafness and eyes affected)
How would you diagnose the X-linked storage disease, Fabry’s?
Its Alpha galactosidase A def
Measure Alpha gal A activity in leukocytes
Renal biopsy - inclusion bodies of Gb3
What are the drugs of choice for hypertension in CKD?
ACEi/ARB
Ramapril, captopril, valsartan, candestartan
What GN is associated with anti-phospholipase A2 receptor antibody?
Membranous (the receptor is on podocytes)
What are some causes of Crescentic / rapidly progressive GN?
ANCA vasculitis Good pastures syndrome (Anti-GBM) Lupus nephritis HSP nephritis Tx with Oral cyclophosphamide
What test is Gold standard for identifying stones?
CT KUB - Non-contrast scan of kidney, ureters and bladder
Diclofenac, an NSAID, is effective management for kidney stones, what does it do?
Reduces GFR, renal pressure and ureteric peristalsis
What important advice would you give to someone prescribing for a patient with renal artery stenosis?
Do not give ACEi or ARB as it worsens renal function in bilateral RA stenosis
What is amyloidosis?
Extracellular deposition of an insoluble protein in an abnormal fibrillar form, resistant to degradation
Amyloid fibrils cause mesangial cell expansion
Acute pyelonephritis is an ascending upper UTI of moderate to severe infection and involving the renal pelvis. What characterises it, what management would you do and what antibiotics would you give?
Enlarged kidney and abscesses on the surface
Send urine ± blood cultures ± imaging
Co-amoxiclav, ciproflxacin, trimethoprim
Uncomplicated 1-2 wks, complicated >/=2wks± radiological/surgical intervention
What is Fournier’s gangrene?
A form of necrotising fasciitis affecting the external genitals.
1st line - surgical debridement
