Week 4 (2) Flashcards
What is the definition of CKD?
Reduced GFR and/or evidence of kidney damage - has to be more measurements
Do muscular people produce more creatinine?
Yes
When can eGFR over estimate?
If muscle mass is low - only valid if serum creatinine is stable
What stages of kidney disease are based purely on GFR?
3-5
What does CKD increase risk of?
Cardiovascuklar disease
What increases the progression of CKD?
Proteinuria
What can diabetes, hypertension, vascular disease, chronic glomerulonephritis, reflux nephropathy and PCK all cuse?
CKD
When do symtpoms of CKD due to reduced GFR occur?
Less than 20 GFR
Name some non-soecific symptoms of CKD?
- Tiredness
- Poor appetite
- Itch
- Sleep disturbance
How is proteinuria reduced in CKD?
- Control BP
- ACEI and ARB
- Spironolactone
How is CVS disease risk reduced in CKD?
- Srtop smoking
- Statins
- BP and proteinuria
What are complications of CKD?
Anaemia - erythropoietin produiction declines
Where is vitamin D hydroxylated?
In the kidney
In CKD, impaired Vitamin d hydroxylation leads to reduced calcium absorptin - leading to?
Secondary hyperparathyroidism
In CKD what causes high phosphate and high calcium?
Vascular calcification
How is bone disease mkanaged in CKD?
Alfacalcidol - hydroxylated vit D so doesnt need kidneys
Phosphate
wHEN IS dialysis recommended?
Wjen GFR about 20
What does a rising creatinine mean for mortality with AKI?
Increases
What is AKI defined as?
An abrupt reduction in kidne function defined as
- Absolute increase in serum creatinine by >26.4
- OR increase in creatinine by >50%
- Or a reduction in urine output
What can hypovolaemia (haemorrhage, burns), hypotension (shock, sepsis) and renal hypoperfusion (NSAIDS, COX, ACEI, ARB, hepatorenal syndrome) all cause?
AKI - pre renal causes
What is reversible volume depletion leading to oliguria and increased creatinine?
Pre-renal AKI
What do ACI do to GFR?
Small fall in it
How much cardiac output do the kidneys recieve?
20%
What does untreated pre renal AKI lead to?
Acute tubular necrosis
Give two common causes of acute tubular necrosis?
Dehydration, sepsis, rhabdomyolysis and drug toxicity
What do you give in fluid challenge for hypovolaemia in treatment of pre renal AKI?
Crystalloid 0.9% NaCl
Name a vascular cause of renal AKI?
GPA
Name a glomerular cause of AKI?
Glomerulonephritis
Name three causes of interstitial nephritis leading to AKI?
- Drugs
- Infection TB
- Systemic Sarcoid
Name 4 causes of tubular injury which lead to AKI?
- Ischaemia - prolonged renal hypoperfusion
- Drugs - gentamicin
- Contrast
- Rhabdomyolysis
What does fluid overload, PO, uraemia including itch, pericarditis and oliguria all suggest?
AKI
What are two urgent indications for renal biopsy?
- Suspected rapidly progressive GN
2. Positive immunology and AKI
What is renal biopsy contraindicated in?
Hydronephrosis
Name some life threatening complications of AKI?
- Hyperkalaemia
- Fluid overload PO
- Sever eacidosis
- Uraemic pericardial effusion
- Severe uraemia
What do stones, cancers, stricutres and extrinsic pressure all potentially cause?
Post renal AKI
How do you treat hydronephrosis causing post renal AKI?
Nephrostomy
What are some ECG hyperkalaemia changes?
Tented T waves, flattened p waves, prolonged PR interval, depressed ST segment
How is hyperkalaemia initially treated?
Protect myocardium - 10mls 10% calcium gluconate (2-3 mins)
Insulin (actrapid) with 50mls 50% dextrose (30 mins)
Salbutamol nebs (90mins)
How is hyperkalaemia treated not in the acute setting?
Prevent absorption from GI tract - calcium resonium
What part of the kidney are the glomeruli part of?
Renal parenchyma
Is acute GN treatable?
Yes
Name a size and charge selective barrier?
Glomerular capillary wall
In GN - what does disruption of the barrier lead to?
Haematuria and/or proteinuria
What kind of lesion does damage to endothelial or mesangial cells lead to?
Proliferative lesion and red cells in urine
What does damage to podocytes lead to and what comes in the urine?
Non-proliferative lesion and protein in the urine
Name three things to look for on urinalysis for GN?
RBC (dysmorphic), RBC and granular casts, lipiduria
What type of process is nephritic syndrome indicative of?
Proliferative process
What does nephritic syndrome involve?
- Acute renal failure
- Oliguria
- Oedema
- Hypertension
- Active urinary sediment - RBC, granular casts
What is nephrotic syndrome indicative of?
Non-proliferative process
Name some complications of nephrotic syndrome?
- Infections
- Renal vein thrombosis
- Pulmonary emboli
- Volume depletion (aggtressive use of diuretics)
- Vit D deficiency and subclinical hypothyroidism
When looking at histology to classify GM - what four things are looked at?
- Proliferative or non-proliferative
- Focal/diffuse (greater than 50% glomeruli affected)
- Global/segmental
- Crescentic (RPGN in vasculitis)
What is the target for hypertension when treating GN?
Less than 130/80
Other than anti-hypertensives how else is GN treated?
ACEI, diuretics and statins, fish oil
What is a treatment for GN involving TPE-therapeutic plasma exchange
Plasmapharesis
What immunosuppressive drugs can treat GN?
- Corticosteroids
- Azathioprine
- Alkylating agents (cyclophosphamide)
- Calcineurin inhibitors (cyclosporin and tacrolimus)
- Mycophenolate Mofetil MMF
What is the general management for nephrotic patients?
- Fluid restriction
- Salt restriction
- Diuretics
- ACEI/ARBS
- IV ablumin (if volume deplete)
What is the commonest cause of nephrotic syndrome in children?
Minimal change nephropathy
What is found on EM in minimal change nephropathy?
Foot process fusion on EM
Do you get complete remission with oral steroids in minimal change nephropathy?
Yes 94% do
What is the commonest cause of nephrotic sybndrome in adults?
fsgs - Focal Segmental Glomerulosclerosis
What can cause secondary FSGS?
HIV/heroin use/obesity/reflux nephropathy
What is seen on renal biopsy in FSGS?
LM with minimal Ig
IF with complement deposition
What is the prognosis for FSGS?
50% progress to end stage renal failure after 10 years
What is the second commonest cause of nephrotic syndrome in adults?
Membranous nephropathy
What are some important secondary causes of membranous nephropathy?
Infections - hep B and parasites
CTDs - lupus
Malignancy - carcinomas/lymphoma
Drugs - penicillamine/gold
What does renal biopsy show on membranous nephropathy?
Subepithelial immune complex deposition in the basement membrane
Thickened basement membrane - silver stain
What three things can treat membranous nephropathy?
- Steroids
- Alkylating agents
- B cell monoclonal Ab
What antibody is present in 70% of primary membranous nephropathy?
Anti PLA2r
What is the commonest nephropathy in the world?
IgA nephropathy
What type of haematuria preseents after a resp/GI infection in IgA nephropathy?
Macroscopic
What nephropathy is associated with HSP?
IgA nephropathy
What is seen on renal biopsy in IgA nephropathy?
LM - mesangial cell proliferation and expansion
IF - IgA deposits in mesangium
How is IgA nephropathy treated?
BP control
ACEI/ARB
Fish oil
What active urinary sediment is seen in RPGN?
RBCs, RBC and granular casts
What is seen on biopsy in RPGN?
Glomerular crescents
What two ANCA-positives cause RPGN?
Wegener’s granulomatosis
Microscopic polyangitis
What three ANCA negatives cause RPGN?
- Goodpastures
- HSP
- SLE
Give three drug treatments for RPGN?
Steroids (IV methylprednisolone)
Cytotoxics (cyclophosphamide)
Monoclonal antibodies against CD20 b cells (rituximab)
