Y5 renal prep for CBD with helen and passmed Flashcards
what is hepatic encephalopathy and what drugs can cause this
Hepatic encephalopathy (HE) is a liver dysfunction that occurs when the liver is unable to process toxins and ammonia properly, causing them to build up in the blood and travel to the brain.
sedatives, analgesics, opiates, benzodiazepines, antidepressants, and antipsychotic agents
most common cause of CKD
DM
other causes of CKD
chronic glomerulonephritis
chronic pyelonephritis
hypertension
adult polycystic kidney disease
what is a good early sign of CKD
high urinary albumin:creatinine (ACR) ratio, usually over 3mg/mmol. ACR
sx of ckd
H2 ONOUR
Hypertension – low GFR leads to excessive reabsorption of Na+, increasing ABP
Hypocalcaemia – due to less renal production of 1,25-DHCC and hyperphosphataemia
Oliguria – low urine output, leading to hyperkalaemia with a metabolic acidosis
Normocytic anemia – damage to kidney leads to decreased erythropoietin
Oedema – due to loss of ultrafiltration which leads to fluid overload in the body
Uremia – renal failure leads to a buildup of urea in the blood causing nausea, anorexia,
encephalopathy, pericarditis, and pruritus
Renal osteodystrophy – a form of metabolic bone disease characterised by bone
mineralisation deficiency, associated with secondary hyperparathyroidism
preffered way to deliver calcium resonium
rectally
orally - 2nd
in the management of hyperkalaemia
causes of haematuria
trauma
infection - TB
malignancy - penile, renal, ureter,
TCC - growns from inside out causing blockage and hydronephrosis - TCC from calcyx all the way down the ureters to bladder wall
glomerulonephritis
stones
BPH
renal vein thrombosis due to RCC
coagulopathy
drugs
exercise
endometriosis
catherterisation
radiotherapy
4 things differentiating between IgA nephropathy and
post-streptococcal glomerulonephritis is associated with low complement levels
main symptom in post-streptococcal glomerulonephritis is proteinuria (although haematuria can occur)
there is typically an interval between URTI and the onset of renal problems in post-streptococcal glomerulonephritis
IgA is associated with HSP, alcoholic cirrhosis, coeliac disease
what nephropathy is associated with malignancy
membranous nephropathy
wnating to do a fluid challenge differeence in heart failure
500ml stat without
250ml stat if with
how does calcium resonium remove potassium from body
Calcium polystyrene sulfonate removes potassium from the body by exchanging it within the gut for calcium.
Normal anion gap ( = hyperchloraemic metabolic acidosis)
gastrointestinal bicarbonate loss:
prolonged diarrhoea: may also result in hypokalaemia
ureterosigmoidostomy
fistula
renal tubular acidosis
drugs: e.g. acetazolamide
ammonium chloride injection
Addison’s disease
Raised anion gap
lactate:
shock
sepsis
hypoxia
ketones:
diabetic ketoacidosis
alcohol
urate: renal failure
acid poisoning: salicylates, methanol
high Na and high serum osmolality and low uirne osmoality that only returns to normal with desmopressin is a diagnosis of cranial DI what is a possible cause of this in a patient who has lethargy, arthralgia and skips generations as autosomal recessive
hereditary haemochromatosis
what medication may need to be stopped in aki but does not usually worsen it
metformin - as increases toxicity - in the form of lactic toxicity
If a patient has a urine output of < 0.5ml/kg/hr postoperatively the first step
consider a fluid challenge, if there are no contraindications or signs of haemorrhage etc
IV crystalloid
Anaemia in CKD
correct iron deficiency before starting erythropoiesis-stimulating agents
AV fistula takes how long to develop
6-8 weeks
why does ATN have a poor response to fluid
Hypotension with compensatory tachycardia is a classic sign seen with AKI due to haemorrhage.
A fluid challenge was done with this patient to identify the cause of the oliguria. In cases of pre-renal uraemia, the fluid challenge would have caused an increase in urine output.
However, in this case, there is tubular cell injury due to the blood loss during the surgery. This cell injury has led to the production of red cell casts which produced brown urine.
most common cause of ATN
haemorrhage
Calcium acetate is a calcium-based binder used to treat
hyperphosphataemia
Patients with chronic kidney disease (CKD) may suffer from hyperphosphataemia since the kidneys are unable to excrete excess phosphate. Calcium-based binders are used to reduce phosphate levels in patients with CKD. Symptoms of hypercalcaemia include ‘bones, stones, groans and psychic moans’.
preferred choice for venous thromboembolism (VTE) prophylaxis
low molecular weight heparin (LMWH)
what is ascits and why doe sit occur
Ascites is a condition that occurs when fluid builds up in the abdomen, usually due to high blood pressure in the liver’s veins (portal hypertension).
how does spironolactone help with ascites
it decreases Na reabsorption and potassium excretion in the distal tubule.
As a result promotes a sodium diuresis, but maintains body potassium levels.
Spironolactone is particularly helpful in edematous states caused by hyperaldosteronism, which is typical of the edema and ascites caused by cirrhosis
acute inflammation of the reno-tubular interstitium
AIN
why do you need to correct iron deficiency anaemia before giving EPO
need both iron adn EPO before red bloods cells to be made so by replenishing stores of iron you can then give EPO to make more
3 criteria for dx AKI in adults
↑ creatinine > 26µmol/L in 48 hours
↑ creatinine > 50% in 7 days
↓ urine output < 0.5ml/kg/hr for more than 6 hours
why does ATN lead to low urine osmollaity
occurs because the damaged kidney tubules are unable to effectively reabsorb water from the filtrate, leading to the excretion of dilute urine that closely resembles the composition of plasma, meaning the urine osmolality is similar to blood osmolality, rather than being concentrated as it normally would be
Myoglobinuria causes renal failure by
tubular cell necrosis
drug mx of CKD
ACEi or ARB for the proteinuria - ACR over 30
ACR over 70 regardless of BP
SGLT-2i - block reabsorption of glucose in prox tubule lowering the renal glucose threshold - leading to glycosuria
Normocytic anaemia, thrombocytopaenia and AKI following diarrhoeal illness
HUS
primary aldosteronism is dx by aldosterons/renin ratio which should show high aldosterone levels alongside low renin levels (negative feedback due to sodium retention from aldosterone)
what do you see in secondary hyperaldosteronsim
renin and aldosterone levels are high - most likely renal artery stenosis - when ACEi started worsens stenosis drop EGFR
what would a prerenal cause of deterioriating urinary function show on a results
low urinary sodium level
uraemic encephalopathy sx 4
nausea, confusion, and lethargy
first line ix for ADPKD
Abdominal ultrasound
Renal impairment, flank masses, hypertension
Increased risk of VTE in patients with nephrotic syndrome what should you give
LMWH
4 features of HSP
Abdominal pain
Renal failure
Polyarthritis
purpuric rash over buttocks
what can cause a hypercholraemic met acidosis
fluid resus
why are people with nephrotic syndromes at risk of VTE
The patient is in a hypercoagulable state due to loss of antithrombin III and plasminogen via the kidneys
pre-renal diseae most likely caused by dehydration - is there a good response to fluids
yes
hyperkalameia what should you do
ECG
when transfusing large volumes of RBC what electrolyte imabalnce do you need to be aware of and why
This patient has hyperkalemia which is likely to be secondary to the large-volume transfusion of packed red cells. Using larger volumes of packed red cells carries an increased risk of hyperkalemia as more of the red cells are likely to lyse, releasing potassium ions.
expalin how fluid builds up in the body in nephrotic syndrome in minimal change disease
As a result, the oncotic plasma pressure is reduced in the vessels, which generates an imbalance of Starling’s forces across capillary walls, leading to interstitial leakage of fluid and decreased efficient volume. In this boy, fluid can be seen to be pooling in areas such as the lungs (pulmonary oedema - bilateral lower zone crackles), ankles (pedal oedema) and peritoneal cavity (ascites - shifting dullness on abdominal examination), which implies the hypoalbuminaemia seen has caused a reduced plasma oncotic pressure.
3 human factors affecting egFR
pregnancy
muscle mass (e.g. amputees, body-builders)
eating red meat 12 hours prior to the sample being taken
in HUS you get fragmented blood cells due to toxin what happens to serum haptoglobins and platelet count
Serum haptoglobins (which bind haemoglobin) and the platelet count are decreased in haemolytic uraemic syndrome.
hyperkalaemia: P wave flattening and some mild T wave peaking
long QT- hypocalcaemia
both seen in
end stage renal failure
thyroxine level or high in nephrotic syndrome
low
all new pt with ckd what should be put on
ACR over 30 ACEi
statins as well
mescenteric ischaemia ABG findings
metabolic acidosis with a high lactate level
difference between diarrhoea and vomiting on abg findings
Diarrhoea can cause a normal anion gap acidosis
]vomiting causes alkalosis
3 side effects of EPO
Bone aches
flu-like symptoms
skin rashes
Primary and secondary aldosteronism can be differentiated by looking at the renin levels. If renin is high then
secondary cause is more likely, i.e renal artery stenosis
Bilateral adrenal hyperplasia - plasma renin would not be high.
DM causes bilaterally large kidneys
true
two conditoons that are opposites when you look at serum and urine osmolalities
dehydration and psychogenic polydipsia
dehydration high sodium in plasma, increasing osmolaitieis of both
pp - low soidum and lots of fludi from drinking so low osmolaliies in botjh
what happens acutely with asprin overdose
respiratory alkalosis typically comes on following an acute event
common cause of polyuria
diuretics, caffeine & alcohol
diabetes mellitus
lithium
heart failure
what is sevelamer
Sevelamer is a non-calcium based phosphate binder that treats hyperphosphataemia in patients with CKD mineral bone disease
addisons disease causes what on abg
Addison’s disease/adrenal insufficiency can cause hyperkalaemic metabolic acidosis
Nephrotic syndrome is associated with a hypercoagulable state due to loss of antithrombin III via the kidneys
increasing risk of what renally
renal vein thrombosis
Prerenal disease has a good response to fluid challenge. also high urine osmolality. raised urea to creatiine ratio
kindeys hold onto sodium to preserve volume
what is a common cause of prerenal disease
septic shock
Pre-renal AKI, caused by decreased renal blood flow, often due to volume depletion or decreased cardiac output, is likely here due to meningococcal sepsis causing distributive shock. The patient’s improving urea, creatinine, and urine output with IV fluid resuscitation support this diagnosis.
Prolonged diarrhoea may result in a
metabolic acidosis associated with hypokalaemia
how is acute graft failure usually picked up
rising creatinine, pyuria and proteinuria
unexplained visible haematuria without UTI
2ww
Aged >= 45 years AND:
unexplained visible haematuria without urinary tract infection, or
visible haematuria that persists or recurs after successful treatment of urinary tract infection
Aged >= 60 years AND have unexplained nonvisible haematuria and either dysuria or a raised white cell count on a blood test
when would you non urgent referral for ca
Aged 60 >= 60 years with recurrent or persistent unexplained urinary tract infection
SGLT-2 inhibitors are beneficial in proteinuric CKD, regardless of diabetic status
true
What result suggests a chronic, rather than acute, disease course in this patient? electrolyte
ca
low in CKD
treatment for acute clot retention
continus bladder irrigation with 3 way urethral cather
