Medicine Finals > Nephrology > Flashcards

Nephrology Flashcards

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1
Q

Presentation: patient presenting with diarrhoea illness alongside reduced urine output - most likely cause?

A

Haemolytic uraemic syndrome caused by Shiga toxin (either due to E.coli or Shigella)

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2
Q

Presentation: headache in a patient with Autosomal Dominant Polycystic kidney disease?

A

Ruptured berry aneurysm (SAH)

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3
Q

What are the two features of AKI?

A

Raised creatinine

Reduced urine output

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4
Q

How is AKI staged?

A

AKI 1 -creatinine raised to 1.5-1.9x baseline, urine output <0.5ml/kg/hr for 6 hours

AKI 2 - creatinine raised to 2-2.9x baseline, urine output <0.5ml/kg/hr for 12 hours

AKI 3 - creatinine raised to over 3x baseline, urine output <0.3ml/kg/hr for 24 hours

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5
Q

What are pre-renal causes of AKI?

A

Pre-renal AKI = due to lack of perfusion to the kidneys

Dehydration

Hypotension

Renal artery stenosis

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6
Q

What are causes of renal AKI?

A

Acute tubular necrosis

Acute interstitial nephritis

Glomerulonephritis

Rhabdomyolysis

Tumour lysis syndrome

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7
Q

What are causes of post-renal AKI?

A

Renal calculi

Stricture

Prostate enlargement

Mass

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8
Q

How can you determine the cause of AKI from urine results?

A

Pre-renal = low urine sodium (high urine osmolality)

Renal = high urine sodium (low urine osmolality)

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9
Q

What drugs are directly nephrotoxic?

A

NSAIDs

Gentamicin

ACEi/ARBs

Diuretics

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10
Q

Which drugs are not directly nephrotoxic but are renally excreted and should be stopped in AKI?

A

Lithium

Metformin

Digoxin

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11
Q

What is acute tubular necrosis and what are the main causes?

A

Damage/necrosis of the renal tubules (renal cause of AKI)

Mainly due to

  1. Ischaemia (due to sepsis/dehydration)
  2. Toxins - contrast dye, NSAIDs, Gentamicin
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12
Q

What is seen on urinalysis in acute tubular necrosis?

A

Muddy brown casts

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13
Q

How is acute tubular necrosis managed?

A

Stop any nephrotoxic drugs

IV fluids

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14
Q

How can you prevent acute tubular necrosis due to contrast media in patients at risk? Who is at risk?

A

At risk = known renal impairment, age >70, dehydration, cardiac failure, use of nephrotoxic drugs

Prevention = IV 0.9% NaCl 1ml/kg/hr for 12 hours pre and post contrast

Nephrotoxic drugs should be stopped for 48 hours prior to procedure

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15
Q

How does acute interstitial nephritis present?

A

AKI and Hypertension

As well as - rash, fever, raised eosinophils

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16
Q

What can cause acute interstitial nephritis?

A

NSAIDs

Penicillin antibiotics

Rifampicin

Ciprofloxacin

PPIs

Allopurinol

Furosemide

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17
Q

How is acute interstitial nephritis managed?

A

Stop offending drug

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18
Q

What is Rhabdomyolysis?

A

Breakdown of muscle which releases breakdown products into the blood

Myoglobin (nephrotoxic)

Potassium

Phosphate

Creatinine kinase (markedly elevated)

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19
Q

What is the most immediately dangerous breakdown product in Rhabdomyolysis?

A

Potassium - hyperkalaemia can cause cardiac arrhythmias and cardiac arrest

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20
Q

Why does Rhabdomyolysis cause an AKI?

A

Releases myoglobin into blood

Myoglobin is nephrotoxic

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21
Q

What are causes of Rhabdomyolysis?

A

Prolonged immobility (e.g. elderly patient falls and spends time on the floor before being found)

Extremely rigorous exercise

Crush injuries

Seizures

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22
Q

How does Rhabdomyolysis present?

A

Myalgia

Oedema

Fatigue

Confusion

Tea coloured (red brown) urine

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23
Q

What investigations should be done in suspected Rhabdomyolysis?

A

Creatine kinase will be markedly elevated

Myoglobinurea

U+Es - look for AKI

ECG - look for cardiac arrhythmia caused by hyperkalaemia (widened flattened P wave, tall tented T waves, broad QRS complex)

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24
Q

How is Rhabdomyolysis treated?

A

Mainstay = IV fluids - 0.9% sodium chloride

Treat hyperkalaemia - insulin + glucose, calcium gluconate (stabilisation of cardiac membranes), potassium

Can give IV Bicarbonate to neutralise the acidity of urine

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25
What ECG changes are seen in hyperkalaemia?
Tall tented T waves Flattened P waves Broad QRS complex
26
What level of potassium warrants urgent treatment?
>6.5 Or >6 with ECG changes (check ECG first if in between 6 and 6.5)
27
What warrants dialysis in hyperkalaemia?
If severe hyperkalaemia associated with AKI | Non-responsive to treatment
28
What is the difference between nephritic syndrome and nephrotic syndrome?
Nephritic syndrome: haematuria, oliguria, Proteinuria, fluid retention Nephrotic syndrome: peripheral oedema, massive Proteinuria, low albumin <25, hypercholesterolaemia
29
What is the main complication of nephrotic syndrome? What are other complications?
Increased risk of VTE due to loss of Antithrombin III AKI, CKD, end stage renal disease
30
What is the most common cause of nephrotic syndrome in children? What is seen on renal biopsy? How is it managed?
Minimal change disease Renal biopsy shows fusion of podocytes and effacement of foot processes (on electron microscopy only - light microscopy is normal) Treated with oral prednisolone
31
What might you want to let someone know who has had minimal change disease?
Majority of people have at least one more episode
32
What is the most common cause of nephrotic syndrome in adults?
Membranous glomerulonephritis
33
What is the difference between IgA Nephropathy and post-strep glomerulonephritis?
IgA nephropathy - usually within 1-2 of infection, mainly macroscopic haematuria (but can also be proteinuria) Post-strep glomerulonephritis - 1-2 weeks post-infection, can be both haematuria + proteinuria, low complement C3 levels Anti-streptolysin O
34
How does membranous glomerulonephitis present and how is it seen on renal biopsy?
Nephrotic syndrome Renal biopsy - thickened basement membrane, igG and complement deposits on basement membrane --> "Spike and dome appearance"
35
Which antigen is associated with membranous glomerulonephritis?
PLA2
36
How is membranous glomerulonephritis treated?
ACEi/ARB
37
What is rapidly progressive glomerulonephritis?
Presents with very acute illness - rapid loss of renal function Histology - epithelial crescents Often secondary to Anti-GBM (Goodpasture’s) or GPA Granulomatosis with Polyangiitis (Wegener’s)
38
What is Anti-GBM disease (Goodpasture’s)? How does it present?
A rare type of small vessel vasculitis Pulmonary haemorrhage (presents with Haemoptysis) Rapidly progressive glomerulonephritis (Proteinuria, haematuria)
39
What is seen on renal biopsy in anti-GBM disease?
Linear IgG deposits on basement membrane Epithelial crescents (Same as what is seen in rapidly progressive glomerulonephritis)
40
How can you differentiate between Anti-GBM and GPA?
Anti-GBM = Haemoptysis, rapidly progressive glomerulonephritis, Anti-GBM antibodies GPA = glomerulonephritis, Haemoptysis, epistaxis, sinusitis, saddle shaped nose deformity, associated with cANCA
41
What is Henoch Schonlein Purpura? How is it managed?
IgA mediated small vessel vasculitis Usually seen in children following an URTI Palpable purpuric rash on the buttocks and limbs Abdominal pain Polyarthritis Features of IgA nephropaty - haematuria, Proteinuria Management is supportive
42
What are complications of chronic kidney disease?
Anaemia (normocytic) - due to decreased erythropoietin production Bone disease - kidney does not convert vitamin D to active form (decreased calcium absorption), and stops excreting phosphate Low calcium and high phosphate leads to increased PTH production (secondary hyperparathyroidism) Increased PTH causes bone disease - osteomalacia Hypertension
43
How is anaemia in CKD treated?
Erythropoietin Treat iron deficiency prior to giving erythropoietin
44
How is renal bone disease treated?
Reduced dietary phosphate Active forms of vit D Phosphate binder e.g. Sevelamar/Calcium acetate/Calcium carbonate Bisphosphonates
45
What Spinal X-ray changes can be seen in chronic kidney disease?
Spinal x-ray = sclerosis of both ends of vertebra (denser white) Osteomalacia in centre of vertebra (less white)
46
How is hypertension in chronic kidney disease treated?
ACE inhibitors Monitor serum potassium - CKD with ACEi can cause hyperkalaemia A decrease in eGFR of up to 25% and an increase in creatinine of 30% after starting ACEi = acceptable
47
How is CKD staged?
1 - >90 (plus evidence of renal disease - Proteinuria, albumin:creatinine ratio >30) 2 - 60-89 3a - 45-59 3b - 30-44 4 - 15-29 5 - <15
48
What is the most common cause of CKD in the UK? What are other causes?
Diabetic nephropathy Hypertension PKD Glomerulonephritis Pyelonephritis
49
How is diabetic nephropathy diagnosed?
Monitor early morning albumin:creatinine ratio If abnormal - conduct 1st pass urine for Proteinuria
50
How are kidneys seen on X-ray in CKD?
Small and scarred In diabetic nephropathy- can be large
51
What is the string of beads sign?
Seen in fibromuscular dysplasia String of beads appearance to renal artery on angiogram Fibromuscular dysplasia = cause of renal artery stenosis
52
What are the two types of ADPKD?
PKD1 - chromosome 4 PKD2 - chromosome 16
53
What is the diagnostic criteria for Polycystic kidney disease?
Age below 30 - two cysts (can be in one kidney or two) Age 30-60 - two cysts in both kidneys Age over 60 - four cysts in both kidneys
54
How does Polycystic kidney disease present?
Abdominal pain Early satiety Hypertension CKD Hepatomegaly Diverticulitis Ovarian cysts
55
How is Polycystic kidney disease managed?
Tolvaptan Only needed if patient has reached CKD 2/3
56
What are extra-renal manifestations of Polycystic kidney disease?
Liver cysts (Hepatomegaly) Berry aneurysms (can present as SAH if rupture)
57
How is Polycystic kidney disease screened for in family members?
Abdominal ultrasound
58
What is haemolytic uraemic syndrome?
Triad of AKI, Haemolytic anaemia and low platelets Haemolytic anaemia will cause raised bilirubin due to breakdown Firstly a diarrhoea illness Then around 5 days later - reduced urine output, abdominal pain, confusion, oedema, hypertension, bruising, vomiting Treatment is supportive
59
What is the most common type of renal cell carcinoma?
Adenocarcinoma (Clear cell)
60
What is the classic triad of symptoms seen in renal cell carcinoma?
Haematuria Flank pain Palpable mass
61
What is the 2WW criteria for suspected renal cancer?
>45 plus visible unexplained haematuria
62
What is the most common place for renal cell carcinoma to metastasise?
Lung (seen as cannonball metastases)
63
What are causes of metabolic alkalosis?
Vomiting Diuretics Hypokalaemia Primary hyperaldosteronism Cushing’s
64
What are causes of metabolic acidosis? (raised anion gap vs. normal anion gap)
Raised anion gap = sepsis, shock, DKA, alcohol, aspirin, methanol Normal anion gap = diarrhoea, renal tubular acidosis, Addison’s
65
How is the anion gap calculated? What is a normal anion gap?
(Sodium+potassium) - (bicarbonate+chloride) Normal anion gap = 8-14
66
What is Alport’s syndrome?
X-linked recessive condition Microscopic haematuria Progressive renal failure Bilateral sensorineural deafness Protrusion of lens surface Retinitis pigmentosa
67
Presentation: renal failure + deafness +/- vision problems?
Alports syndrome
68
What is seen on renal biopsy in Alport’s syndrome?
Longitudinal splitting of the lamina densa Basket-weave appearance
69
What is the NICE criteria for AKI?
Rise in creatinine of ≥ 25 micromol/L in 48 hours Rise in creatinine of ≥ 50% in 7 days Urine output of < 0.5ml/kg/hour for > 6 hours
70
What is renal tubular acidosis? What is the normal function of the renal tubules?
Metabolic acidosis due to a pathology of the renal tubules Renal tubules maintain hydrogen and bicarbonate ion balance to maintain normal pH
71
What is type 1 and type 2 renal tubular acidosis? What lab results are seen?
Type 1 = distal tubule fails to excrete hydrogen ions Type 2 = proximal tubule fails to reabsorb bicarbonate ions Lab results = HYPOkalaema, metabolic acidosis, low urinary pH
72
What are causes of type 1 renal tubular acidosis?
Genetic SLE Sjorgen's syndrome Hyperthyroidism Sickle cell anaemia Marfan's
73
How does type 1 renal tubular acidosis present?
In children - failure to thrive Hyperventilation (compensation for metabolic acidosis) CKD Osteomalacia
74
What is the treatment for type 1 and type 2 renal tubular acidosis?
Oral bicarbonate Hypokalaemia does not need to be treated - oral bicarbonate will fix it
75
Which type of renal tubular acidosis is associated with Fanconi syndrome?
Type 2 renal tubular acidosis
76
What is the most common type of renal tubular acidosis?
Type 4
77
What is type 4 renal tubular acidosis? What are causes/?
Reduced aldosterone which leads to reduced ammonium excretion by the proximal tubule Due to... Adrenal insufficiency ACEi Spironolactone SLE HIV
78
What lab results are seen in type 4 renal tubular acidosis?
HYPERkalaemia Metabolic acidosis High chloride Low urinary pH
79
How is type 4 renal tubular acidosis managed?
Fludrocortisone Oral bicarbonate Hyperkalaemia management
80
What tests do you want to do in ?Rhabdomyolysis
Blood tests- FBC, U+E, Myoglobin, CK ECG - due to potential raised potassium
81
What is seen on urinalysis in acute interstitial nephritis?
Sterile pyuria White cell casts
82
What is sterile pyuria and what are causes?
Raised white cells in urine but Negative urine culture Renal tuberculosis Partially treated UTI Acute interstitial nephritis Urinary tract stones
83
How can you differentiate heart failure from nephrotic syndrome?
Both will have oedema Nephrotic syndrome will have massive proteinuria Heart failure will have little/no proteinuria
84
What are indications for acute dialysis?
AEIOU Acidosis (severe metabolic acidosis with pH of less than 7.20) Electrolyte imbalance (persistent hyperkalaemia with ECG changes) Intoxication (poisoning) Oedema (refractory pulmonary oedema not responding to medication) Uraemia (symptomatic uraemia - encephalopathy or pericarditis)
85
Which autoantibodies are raised in Anti-GBM disease?
Type IV Collagen autoantibodies
86
What are physical signs of haemolytic uraemic syndrome?
Jaundice (due to haemolysis) Bruising(due to low platelets) Abdominal tenderness
87
Who is at risk of AKI?
Chronic kidney disease Diabetes with chronic kidney disease Heart failure Renal transplant Aged 75 or over Hypovolaemia (dehydration) Contrast agent
88
What autoantibodies are raised in post-strep glomerulonephritis?
Anti-streptolysin O antibodies
89
What is seen on electron microscopy in IgA Nephropathy?
IgA deposition in the mesangium
90
What is seen on electron microscopy in Post-strep Glomerulonephritis?
IgG and C3 sub epithelial deposition
91
What is seen on electron microscopy in Membranous nephropathy?
Spike and dome appearance
92
What is seen on electron microscopy in minimal change disease?
Effacement of foot processes | Fusion of podocytes
93
If AKI is associated with proteinuria, what is the most likely cause? (Renal, pre-renal or post-renal)
Renal AKI
94
Urinary sodium - pre renal vs renal AKI
Pre-renal = Low urinary sodium Renal = High urinary sodium
95
Urine osmolality - pre renal vs renal AKI
Pre-renal = high urine osmolality Renal = Low urine osmolality
96
Serum urea:creatinine ratio - pre renal vs renal AKI
Pre-renal = Raised urea:creatinine ratio Renal = Normal urea:creatinine ratio
97
How can you treat steroid resistant nephrotic syndrome?
Tacrolimus/Ciclosporin/Cyclophosphamide
98
What are risks of oral corticosteroids in children?
Poor growth Obesity Osteoporosis DM Behavioural disturbances
99
What are the two main causes of renal artery stenosis?
Atherosclerosis Fibromuscular dysplasia
100
What does worsening renal function after starting an ACEi suggest?
Bilateral renal artery stenosis
101
What is the gold standard diagnostic investigation for renal artery stenosis?
Renal angiography Also renal ultrasound (first line)
102
How is renal artery stenosis managed?
Transluminal angiography +/- stenting
103
What is an acceptable rise in creatinine after starting an ACEi?
<30% rise
104
Which type of renal replacement therapy is used in AKI?
Haemofiltration
105
What are complications of haemodialysis?
``` Site infection Endocarditis Cardiac arrhythmia Air embolus Anaphylactic reaction Amyloidosis Hypertension Disequilibration syndrome (Acute cerebral oedema - headache+drowsy) ```
106
What are complications of peritoneal dialysis?
``` Peritonitis Catheter infection Catheter blockage Constipation Fluid retention Hyperglycaemia Hernia Back pain Malnutrition ```
107
What is the most common organism which causes peritonitis due to peritoneal dialysis?
Staph epidermis
108
What are complications of renal transplant?
``` DVT/PE Opportunistic infection Malignanies - lymphoma/skin cancer Bone marrow suppression Urinary tract obstruction CVD Graft rejection ```
109
What are the different types of renal transplant rejection?
Hyperacute rejection = minutes to hours Due to antibodies Graft must be removed Acute rejection = less than 6 months Mismatched HLA May be reversible with immunosuppressants Chronic graft rejection = more than 6 months Due to fibrosis
110
Which autoantibody is raised in post-strep glomerulonephritis?
Anti streptolysin O
111
What are causes of focal segmental glomerulonephritis?
HIV Heroin Alport's syndrome Sickle cell disease
112
Which valvular abnormality is associated with polycystic kidney disease?
Mitral valve prolapse
113
What is the definitive diagnosis of acute interstitial nephritis?
Kidney biopsy - will show eosinophils, lymphocytes and plasma cells urinalysis will show sterile pyuria
114
What is a risk of giving someone too much sodium chloride?
Hypercholeraemic metabolic acidosis
115
How do you screen for diabetic nephropathy?
Measure albumin:creatinine ratio - microalbumnaemia is the first sign of diabetic nephropathy If abnormal - do a first pass morning urine sample for proteinuria
116
How is diabetic nephropathy managed?
ACEi/ARB
117
When to give calcium gluconate for hyperkalaemia?
>6.5 or ECG changes
118
What factor in U+Es points towards dehydration being a cause of AKI?
Urea proportionately higher than the creatinine Hypernatraemia
119
What is Fanconi syndrome?
Generalised reabsorptive disorder of renal tubular transport in the proximal convoluted tubule resulting in: ``` type 2 (proximal) renal tubular acidosis polyuria aminoaciduria glycosuria phosphaturia osteomalacia ```
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