Week 4 - D - Presentation of kidney disease

Question 1

Why does kidney failure lead to hypertension?

Answer 1

This is due to the kidneys being unable to excrete urine and this therefore leads to a buld up in pressure and the blood pressure rises

Question 2

What are urinary casts a really specific sign of?

Answer 2

These are a very specific sign that the haematuria/pyuria is originiating in the kidneys

Question 3

If on urinalysis, there is proteinuria and haematuria, where do you think the problem has arisen?

Answer 3

In the kidneys (glomeruli)

Question 4

Why can the kidneys causes secondary hyperparathyrodisim?

Answer 4

This is because the kidneys hydroxylate 25hydroxy vit D(calcidiol) to 1,25dihydroxyvitD (cacitriol) If the kidneys are not working, this can stop this and the vitamin D is required for calcium reabsorption in the gut The parathyroid hormone will sense the decreased calcium and therefore promote the excretion of more PTH Secondary parathyroid - means low calcium and high PTH

Question 5

What is a major disease that can account for loss of kidney fnction?

Answer 5

Diabetes - can cause astheroscelrosis of the arteries decreasing perfusion and can increase glomeruloscelrosis causing the glomeruli to function less also

Question 6

In relation to loss of renal fucntion, what can patients often complain of?

Answer 6

Tiredness, fluid retention, bone pain anaemia

Question 7

Why is there bone pain associated with a loss of renal function? Why is there anaemia (renal anaemia) associated with a loss of renal function?

Answer 7

Bone pain - due to the decreased calcium absorption, PTH resorbs more bone to make up calcium levels and this causes weak bone Renal anaemia - kidneys produce erythropoeitin, this is a hormone which stimulates the formation of red blood cells in the bone marrow - loss of renal function stops this being produced

Question 8

What are the urinary questions asked in a systemic enquiry for renal?

Answer 8

Ask about, pain or burning when peeing, any loin pain or masses, any problems with emptying bladder ie flow of stream problems, polyuri, oligouria , nocturia

Question 9

In taking a renal history, it is important to know past medical history What types of imaging can be damaging to the kdiney?

Answer 9

CT and MRI imaging CT contrast (iodinated) causes contrast induced nephropathy MRI contrast (gadolinium) causes nephrogenic systemic sclerosis

Question 10

Asking about drugs is also important What drugs are nephrotoxic? STOP NEPHROTXINS IN AKI & CKD

Answer 10

Aminoglycosides - gentamicin Penicillins Analgesics - NSAIDs PPIs, loops and ACE inhibitors

Question 11

What drug used to treat UTIs can be nephrotoxic to the kidneys?

Answer 11

Sulfonamides such as sulfamethoxazole (given in the community to treat complicated UTIs)

Question 12

Why are NSAIDs contraindicated in renal impairment?

Answer 12

They inhibit the COX1&2 therefore preventing the formation of prostoglandins which dilate the afferent arteriole This therefore causes vasconstriction leading to decreased GFR

Question 13

What is hypertension known as?

Answer 13

A blood pressure greater than 140/90 - Most patinets with CKD have HBP

Question 14

When is high blood pressure a medical emergency? What are symptoms?

Answer 14

This is accelerated/malignant hypertension - systolic over 180 and diastolic over 120 Causes blurred vision, headaches, can be nauseas and vomiting

Question 15

Acclerated hypertension can cause swelling of the optic disc What does the fundus of the eye look like in accelerated hypertension?

Answer 15

Swollen optic Loss of disc margins Flame haemorrhages Cotton wool patches Can have the silver/copper wiring of the vessels

Question 16

How can renal failure end up causing gout tophi?

Answer 16

There will be a decreased uric acid excretion from the kidneys This will lead to a build up of uric acid which is converted to monosodium urate crystals which are small and sharp and can inflame the joint A build up of these crystals is known as gout tophi

Question 17

What does this child have?

Answer 17

Child has Henoch Schnolein Purpura

Question 18

What type of glomerulonephritis is HSP associated with? How does HSP present?

Answer 18

Associated with IgA nephropathy Healthy child experiences palpable purpuric rash on the buttocks and extremities 2weeks post upper rep tract infection Also has abdominal pain, sore joints and haematuria

Question 19

How is HSP treated?

Answer 19

Is generally self limiting so analgesics and supportive care Can give oral steroids if severe

Question 20

Patient presents with haematuria and heamoptysis What do you think? If they have a rash on their face like a butterfly?

Answer 20

ANCA related or anti-GBM Butterfly rash - malar flush so measure ANA as you are thinking SLE

Question 21

When doing urinalysis, what things are important to look for?

Answer 21

Specific gravity Leucocytes Nitrites Red blood cell pH - usually alkaline if a renal impairent preventing acid excretion Proteinuria

Question 22

What should the pH of the urine be between? Which UTI causing organism does not actually show for the presence of nitrites?

Answer 22

Should be between 4.5-7 Enterococcus doesnt show the presence of nitrites in the urine

Question 23

If there is protein in the urine, this suggests a kindey problem What syndrome can it point towards and what does the protein in the urine level have to be? (how is this measured)

Answer 23

Indicates nephrotic syndrome 24 hour protein collection - greater than 3g/day Protein/creatinine ratio - greater than 300-350mg/mmol

Question 24

What is a normal urine 24 hour protein count? What is a normal urine protein/creatinine ratio?

Answer 24

24hour protein - normal for <150mg PCR normal - less 50mg/mmol

Question 25

Urine microscopy can be carried out to look for any organisms and to look at red cells What are dysmorphic and isomorphic red blood cells on urine microscopy?

Answer 25

B - Dysmorphic -likely to have come through the glomerulus as they are squashed - pathology A - Isomorphic - lower urinary tract bleed

Question 26

If there is a presence of urinary casts on microscopy, this is highly suggestive that the haematuria/pyuria originates where?

Answer 26

Glomerular or tubular origin

Question 27

Urinary casts are formed by precipitation of Tamm-Horsfall mucoprotein which is secreted by renal tubule cells. What are the four types of urinary casts?

Answer 27

Hyaline Leucocyte Red cell Granular

Question 28

For urinary casts, which is usually benign and which is usually associated with nephritic syndrome?

Answer 28

Hyaline casts - usually benign Red cell casts - nephritic syndrome

Question 29

What do leucocyte and granular casts indicated?

Answer 29

C - Leucocyte casts - indicate infection

D - Granular casts - indicate chronic kidney disease, acute tubular necorosis

A - hyaline

B - red cell

Question 30

What type of urinary casts is pathognomonic of acute tubular necrosis?

Answer 30

This would be a muddy brown granular cast

Question 31

What forms the urinary casts in disease states?

Answer 31

Foromed by the precipitation of Tamm Horsfall mucoproteins which is secreted by the tubular cell

Question 32

o Crystals on urine microscopy Looks for the cause of the renal stones What are the types of crystals?

Answer 32

Calcium oxalate Uric acid Phosphate (aka triple phosphate = struvite) Cystein

Question 33

Which urine microscopy crystals are envelope shaped? Which are hexagonal shaped?

Answer 33

A - envelope - calcium oxalate B - uric acid (messy shapes) C - Phopshate D - hexoagnoal shaped - cysteine

Question 34

What are the five stages of chronic kidney disease?

Answer 34

Stage 1 - GFR greater than 90 with evidence of kidney damage Stage 2 - GFR 60-90 with evidence of kidney damage Stage 3 - GFR 30-60 Stage 4 - GFR 15-30 Stage 5 - GFR <15 or on dialysis

Question 35

What is seen as evidence of kidney damage?

Answer 35

Hameturia + proteinuria

Question 36

What is acute kidney injury defined as?

Answer 36

• Rise in serum creatinine >26.4 µmol/l in 48 hours • Or increase in serum creatinine by >50% over 7 days • Or urine output 6 consecutive hours (<400ml urine output/day)

Question 37

Describe the features of nephrotic syndrome?

Answer 37

Proteinuria - greater than 3g/day Hypoalbuminaemia Oedema - swelling affects everywhere Hyperlipidaemia also Frothy urine in a patinet due to the protein

Question 38

What are the feautures of nephritic syndrome?

Answer 38

Oliguria Hypertension Oedema Haematuria + can have a little proteinuria

Question 39

What is seen in the active urinary sediment?

Answer 39

red cell casts

Question 40

If patinet has an abornaml urinalysis, what should you carry out also? (using stehtascope)

Answer 40

Carry out a blood pressure reading to make sure there is no increased or decreased BP