Nephrology

Question 1

Which drugs may worsen an AKI?

Answer 1

NSAIDs (except if aspirin at cardiac dose e.g. 75mg od)
Aminoglycosides
ACE inhibitors
Angiotensin II receptor antagonists
Diuretics

D- diuretics
A- ACEi
A- ARBS
M- Metformin
N- NSAIDS

Question 2

Which drugs should be stopped in an AKI as they may build up to toxic levels?

Answer 2

• Metformin
• Lithium
• Digoxin

Question 3

What are the indications for dialysis?

Answer 3

Acidosis (severe metabolic acidosis ph<7.2)
Electrocyte imbalance (resistant hyperkaleaemia)
Intoxication (drug overdose, poisoning)
Oedema (refractory pulmonary oedema, fluid overload)
Uraemia (systemic uraemia - encephalopathy / pericarditis)

Question 4

What is seen on light microscopy of a biopsy of a kidney with minimal change disease?

Answer 4

normal glomeruli on light microscopy

Question 5

What is seen on electron microscopy of a biopsy of a kidney with minimal change disease?

Answer 5

electron microscopy shows fusion of podocytes and effacement of foot processes

Question 6

What is first and second line for minimal change disease?

Answer 6

oral corticosteroids: majority of cases (80%) are steroid-responsive
cyclophosphamide is the next step for steroid-resistant cases

Question 7

How can a urine dip help to identify the cause of an AKI?

Answer 7

Protein = renal AKI such as acute tubular necrosis, interstitial nephritis, glomerulonephritis

Question 8

How would acute tubular necrosis differ from interstitial nephritis on a urine dip?

Answer 8

Both are causes of a renal AKI, so would show protein
Acute interstitial nephritis is an inflammatory process so there is a higher white cell content in the urine, while acute tubular necrosis is not so the urine has no cellular component.

Question 9

How long does acute graft failure take to develop?

Answer 9

6 months

Question 10

What are the signs of acute graft failure?

Answer 10

Pyuria
Proteinuria
Rising creatinine

Question 11

How are suspected graft failures investigated?

Answer 11

Tissue biopsy

Question 12

How are acute graft failures managed?

Answer 12

IV steroids and T cell depletion

Question 13

When do you do a CT before an LP? Why?

Answer 13

Focal neurology
Presence of papillodema
Continuous or uncontrolled seizures GCS<12
Signs of raised ICP
Can cause herniation!

Question 14

When not to LP?

Answer 14

Coagulopathy
Signs of infection at injection site
More in PC lecture

Question 15

What is the most common cause of peritonitis in peritoneal dialysis?

Answer 15

Coagulase negative staphylococci - S. epidermidis

Question 16

What are the signs of peritonitis?

Answer 16

Diffuse tenderness, rebound tenderness, guarding, cloudy dialysis fluid

Question 17

What is hyperacute graft rejection?

Answer 17

Rejection within minutes to hours

Question 18

What causes hyperacute graft rejection?

Answer 18

Pre-existing antibodies against ABO or HLA antigens - type II sensitivity

Question 19

What is the pathophysiology of type II graft rejection?

Answer 19

Autoimmune attack on graft –> widespread thrombosis of graft vessels –> ischaemia –> necrosis

Question 20

How is a hyperacute graft rejection managed?

Answer 20

No cute - graft must be removed

Question 21

What is acute graft failure?

Answer 21

Failure <6m

Question 22

What causes acute graft failure?

Answer 22

Mismatched HLA causing a T-cell mediated attack on the graft

Question 23

How is acute graft failure diagnosed?

Answer 23

Usually asymptomatic, so identified with rising creatinine, pyuria and proteinuria

Question 24

How is acute graft failure managed?

Answer 24

Steroids and immunosuppressants

Question 25

What is chronic graft failure?

Answer 25

Failure >6m

Question 26

What causes chronic graft failure?

Answer 26

Antibody (B cell) and cell-mediated (T cell) mechanisms cause fibrosis to the transplanted kidney Recurrence of original disease

Question 27

How is minimal change disease managed?

Answer 27

First line - steroid therapy 2nd line - cyclophosphamide

Question 28

Is a biopsy needed for minimal change disease?

Answer 28

No - if a child presents with nephrotic syndrome, it is almost always minimal change, which is highly responsive to steroids, so you can just treat right away

Question 29

How does HSP present?

Answer 29

abdominal pain, arthritis, haematuria and a purpuric rash over the buttocks and extensor surfaces of arms and legs

Question 30

How is HSP managed?

Answer 30

- analgesia for arthralgia - treatment of nephropathy is generally supportive. There is inconsistent evidence for the use of steroids and immunosuppressants

Question 31

What test should be done in an AKI to identify whether there is a renal cause?

Answer 31

Urine dip - proteinuria and haematuria might point to glomerular disease

Question 32

When should ACEi be prescribed in CKD?

Answer 32

Diabetic mellitus and ACR >3mg/mmol HTN and ACR of 30mg/mmol ACR >70, regardless of comorbidities