Phase 4 Question Knowledge > Renal > Flashcards

Renal Flashcards

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1
Q

AKI

A
  • acute reversible reduction in renal function
  • GFR declines -> failure to maintain fluid, electrolyte, acid-base homeostasis
  • reduced UO, fluid overload, rise in K, urea, creat
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2
Q

AKI Dx criteria

A
  • Rise in creatinine >25umol/L in 48hrs
  • Rise in creatinine >50% in 7d
  • UO less than 0.5ml/kg/hr over >6hrs
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3
Q

AKI stages

A

Look up diagram

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4
Q

AKI causes

A

Pre-renal
- low volume - D+V, burns, haemorrhage….
- decreased CO - MI, cardiogenic shock, HF
- vasodilation - sepsis, drugs
- renal hypoperfusion - NSAIDs, ACEi, ARB…
- flow obstruction - ischaemia, atherosclerosis, RAS

Renal
- ATN, glomerulonephritis, AIN, infection, sarcoidosis, HUS, rhabdo, NSAIDs, ACEi, gent, contrast, methotrexate, vasculitis

Post-renal
- stone, malignancy, stricture, clot
- pelvic malignancy, BPH
- neurogenic bladder

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5
Q

AKI Px

A
  • asym
  • reduced UO
  • pulm / peripheral oedema
  • arrhythmias
  • uraemia - pericarditis / encephalopathy
  • sx of cause
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6
Q

AKI Ix

A
  • U/E
  • urine dip
  • fluid balance
  • renal USS

All patients should get urinalysis

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7
Q

AKI Mx

A
  • tx cause
  • IV fluids
  • stop worsening meds
  • adjust renally-excreted meds
  • tx electrolytes
  • dialysis
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8
Q

Acute tubular necrosis (ATN)

A
  • death of renal tubular epithelial cells
  • ischaemic - hypoperfusion - shock, sepsis
  • nephrotoxins - eg gentamicin, radiocontrast, rhabdo (myoglobin)

Px
- AKI
- muddy brown casts in urine

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9
Q

Acute interstitial nephritis (AIN)

A
  • Acute inflammation of renal tubule-interstitium

Cause
- meds
- systemic disease, eg SLE, sarcoidosis
- infection

Px
- fever, rash, arthralgia
- eosinophilia
- mild renal impairment, HTN

Ix
- urine - sterile pyuria, white cell casts

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10
Q

Tubulointerstitial nephritis with uveitis (TINU)

A
  • usually young females

Px
- fever, wt loss, painful red eyes

Ix
- urinalysis - leucocytes + protein

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11
Q

CKD

A

Chronic kidney function reduction - permanent + progressive

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12
Q

CKD causes

A
  • diabetic nephropathy
  • HTN
  • Meds - NSAIDs, lithium
  • glomerulonephritis
  • PKD
  • chronic pyelonephritis
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13
Q

CKD Dx criteria

A

> 3mo of either:
- eGFR <60
- urine albumin:creatinine ratio (ACR) >3mg/mmol

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14
Q

CKD classification by eGFR

A

1 - >90
2 - 60-89
3a - 45-59
3b - 30-44
4 - 15-29
5 - <15

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15
Q

CKD Px

A
  • asym
  • fatigue
  • pallor
  • foamy urine - proteinuria
  • nausea
  • anorexia
  • pruritis - uraemia
  • oedema
  • polyuria
  • HTN
  • N+V
  • peripheral neuropathy - vit/mineral imbalance
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16
Q

CKD Ix

A
  • ECG - K
  • Bloods - U/E, phosph, Ca, FBC
  • urine albumin:creatinine ratio (ACR)
  • urine dip + MC+S
  • renal USS
  • BP, HbA1c, lipids
  • Kidney Failure Risk Equation
  • Kidney biopsy
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17
Q

CKD Mx

A
  • tx cause
  • ACEi / ARB
  • SGLT-2 inhibitor - dapagliflozin
  • exercise, wt loss, stop smoking
  • atorvastatin
  • ESRF - dialysis, renal transplant
  • review meds
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18
Q

CKD Cx

A
  • anaemia
  • CKD mineral and bone disorder (CKD-MBD)
  • metabolic acidosis - oral sodium bicarb
  • CV disease
  • uraemia - lethargy, itch, anorexia, confusion, pericarditis
  • peripheral neuropathy
  • ESRF
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19
Q

Anaemia in CKD

A
  • lack of EPO production -> fewer RBCs
  • normocytic, normochromic

Mx
- oral / IV iron
- EPO

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20
Q

CKD-MBD

A
  • high serum phosph, low vit D, low serum Ca
  • kidneys secrete less phosphate, vit D not activated by kidneys (Ca not reabsorbed by kidneys, nor absorbed by gut), PTH secreted due to low Ca, increased bone turnover, osteosclerosis

Ix
- spinal XR - rugger jersey spine

Mx
- low phosph diet
- phosph binders - Ca based / can use sevelamer
- active vit D - calcitriol
- Ca in diet
- bisphosphonates for osteoporosis

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21
Q

Haemodialysis

A
  • regular filtration of blood through dialysis machine
  • blood access via AV fistula / tunnelled cuffed catheter
  • anticoagulate with citrate / heparin
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22
Q

Indications for short-term dialysis

A

A - acidosis - severe, not responding to tx
E - electrolyte abnormalities - eg tx-resistant hyperkalaemia
I - intoxication - OD
O - oedema - severe, unresponsive pulmonary oedema
U - uraemia sx - seizures, coma

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23
Q

Peritoneal dialysis

A
  • filtration in pt’s abdo - inject dialysis solution into abdo cavity, draws waste products from blood, then drain
  • continuous ambulatory / automatic (at night)

Cx
- peritonitis - add vanc / teic + ceftazidime to dialysis fluid

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24
Q

Renal transplant

A
  • donor kidney matched based on HLA type A,B,C
  • take life-long immunosuppression

Rejection
- Hyperacute (mins-hrs) - T2 hypersensitivity - pre-existing ABs - widespread thrombosis of graft vessels - take graft out
- Acute graft failure (<6mo) - cytotoxic T cells, reversible with steroids, immunosuppressants
- Chronic graft failure (>6mo) - AB / cell mediated

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25
Glomerulonephritis
- inflammation of glomeruli
26
Nephritic syndrome
- inflammation of kidneys - haematuria, oliguria, proteinuria <3g/24hrs, fluid retention/oedema
27
Nephrotic syndrome
- damage to podocytes, GBM highly permeable to protein - proteinuria >3g/24hrs, low albumin <25g/L, peripheral oedema - leads to - thrombosis, HTN, high cholesterol, CKD, infection risk, hypocalcaemia Rise in fibrinogen can lead to thrombosis Loss of thyroxine-binding globulin lowers the total, but not free, thyroixine levels
28
Nephritic syndrome causes
- IgA nephropathy - post-strep - anti-GBM - ANCA-associated vasculitis - Rapidly progressive glomerulonephritis (RPGN) - Lupus nephritis
29
Nephrotic syndrome causes
- minimal change disease - Focal segmental glomerulosclerosis (FSGS) - membranous nephropathy - Membranoproliferative glomerulonephritis - HSP - diabetic nephropathy - scarring from high BMs - infection - HIV - Systemic lupus erythematosus
30
IgA nephropathy / Berger's disease
- deposition of IgA immune complexes -> inflammation Px - pt in 20s, URTI a couple of days ago - macroscopic haematuria - coca cola urine Ix - U/E - urine dip, MC+S - renal USS / CT / ?biopsy Mx - isolated - no tx - persistent proteinuria - ACEi - falling eGFR - corticosteroids
31
Post-strep glomerulonephritis
- 1-3wks after GAS (b haemolytic - often S pyogenes of tonsils) - immune complexes, ABs, complement get stuck in glomeruli -> inflammation Px - tonsillitis - headache, malaise - brown urine - oedema - decreased UO - HTN Ix - FBC, U/E - ASO - anti-streptolysin O titre - for strep infection - throat swabs, urinalysis, ?renal biopsy Mx - penicillin for throat - worsening renal function - anti-HTN, diuretics
32
Anti-GBM disease / Goodpastures
- small vessel vasculitis - ABs attack glomerulus + pulm basement membranes Px - rapid onset AKI, proteinuria, haematuria - URTI sx first - SOB, raised RR, crackles, cough, fatigue - haemoptysis Ix - renal biopsy - anti-GBM ABs in blood Mx - intubation, ventilation, haemodialysis - plasma exchange - immunosuppression - steroids / cyclophosphamide
33
ANCA-associated vasculitis
- small-vessel vasculitis Ix - p-ANCA / MPO antibodies - microscopic polyangiitis - c-ANCA / PR3 antibodies - granulomatosis with polyangiitis Mx - immunosuppression, steroids
34
Rapidly progressive glomerulonephritis (RPGN)
- rapid loss in kidney function - associated with Goodpasture, SLE, microscopic polyangiitis Px - haematuria, proteinuria, HTN, oliguria Ix - biopsy - glomerular crescent formation
35
Lupus nephritis
- SLE that can lead to ESRF, glomerulonephritis + sclerosis Mx - tx HTN - glucocorticoids + immunosuppression
36
Minimal change disease
- most common cause nephrotic syndrome in children - no specific cause, no change in biopsy Mx - steroids
37
Focal segmental glomerulosclerosis (FSGS)
- a common cause of nephrotic syndrome in adults, also causes CKD Causes - idiopathic, renal pathology, HIV, heroin, Alport's, sickle cell Ix - renal biopsy - sclerosis, effacement of foot processes Mx - steroids +/- immunosuppression
38
Membranous nephropathy
- most common cause nephrotic syndrome in adults - Immune complexes (IgG, complement) deposit in GBM -> thickening, proteinuria - idiopathic, malignancy, SLE, drugs, RA, infections Ix - renal biopsy Mx - ACEi/ARB - immunosuppression + corticosteroid
39
Membranoproliferative glomerulonephritis / mesangiocapillary glomerulonephritis (MCGN)
- <30yo, immune complex deposits + mesangial proliferation Px - nephrotic sx, haematuria, proteinuria Mx - poor prognosis - steroids may help
40
HIV - nephrotic syndrome
either from infection / tx itself 5 features - Massive proteinuria -> nephrotic syndrome - Normal / large kidneys - FSGS, capillary collapse on renal biopsy - Elevated urea, creatinine - Normotension
41
Renal tubular acidosis (RTA)
metabolic acidosis due to pathology in kidney tubules
42
Type 1 RTA
- distal tubule cannot excrete H+ Causes - SLE, genetic, Sjogren, PBC, hyperthyroid, sickle cell, Marfan's Px - failure to thrive (children) - recurrent UTIs - rickets / osteomalacia - muscle weakness - arrhythmias (low K) Mx - oral bicarb
43
Type 2 RTA
- proximal tubule cannot reabsorb bicarb Causes - genetic, multiple myeloma, Fanconi's syndrome Mx - oral bicarb
44
Type 3 RTA
mix of type 1+2
45
Type 4 RTA
- low aldosterone / impaired function - normally reabsorbs Na, secretes K + H+ - K and H+ retained in blood Causes - adrenal insufficiency, diabetic nephropathy, ACEi, spironolactone Mx - tx cause - fludrocortisone - oral bicarb - hyperkalaemia tx
46
HUS
See paeds notes
47
Rhabdomyolysis
- breakdown of skeletal muscle - releases myoglobin, K, phosph, CK Causes - long lie, vigorous exercise, crush injuries, seizures, statins, ecstasy, McArdle syndrome
48
Rhabdo Px
- muscle pain, weakness, swelling - oliguria - myoglobinuria - red/brown urine - fatigue - N+V confusion
49
Rhabdo Ix
- Bloods - CK, U/E, Ca (myoglobin binds to Ca) - urine dip - blood - ECG
50
Rhabdo Mx
- IV fluids - hyperkalaemia mx - IV sodium bicarb - IV mannitol - increase UO, reduce oedema
51
Polycystic kidney disease (PKD)
- genetic condition - multiple cysts develop throughout kidneys - autosomal dominant (more common) / recessive - PKD1 on ch16 (codes for polycystin 1) / PKD2 on ch4 (polycystin 2) - progressive loss of renal function - from mechanical compression, apoptosis, fibrosis
52
ADPKD Px
- HTN - recurrent UTIs - flank pain - haematuria - palpable kidneys - renal impairment - renal stones Extra-renal - liver cysts - hepatomegaly - berry aneurysms - CVS - mitral valve prolapse, valve incompetence, aortic dissection / root dilatation - other cysts - pancreas, spleen - diverticular disease
53
ADPKD Ix
- abdo USS - genetic testing - MR angiography - of head
54
ADPKD Diagnostic criteria (if positive FHx)
- 2 cysts, uni/bilateral, if <30yo - 2 cyst in both kidneys if 30-59yo - 4 cysts in both kidneys if >60yo
55
ADPKD Mx
- tolvaptan - ACEi for HTN - aspiration / surgery for cyst drainage - dialysis - for ESRF - renal transplant - avoid NSAIDs, anticoags, contact sports - genetic counselling
56
ARPKD
- mutation in PKHD1 gene on ch6 - often identified on antenatal scans, with oligohydramnios - dysmorphic features - ESRF before adulthood
57
Alport syndrome
- genetic condition - defect in gene for type 4 collagen -> abnormal GBM - x-linked dominant Px - px in childhood - microscopic haematuria - progressive renal failure - bl sensorineural deafness - retinitis pigmentosa - lenticonus - protrusion of lens surface into anterior chamber Ix - molecular genetic testing - renal biopsy - splitting of lamina densa on electron microscopy
58
Fanconi syndrome
- reabsorptive disorder of renal tubular transport in PCT -> T2 RTA, polyuria, glycosuria.... Causes - cystinosis, Sjogrens, multiple myeloma, nephrotic syndrome, Wilson's
59
Renal artery stenosis (RAS)
- narrowing of one / both renal arteries Causes - atherosclerosis, fibromuscular dysplasia Patho - kidney hypoperfused, RAAS activated, chronic HTN
60
RAS Px
- HTN - CKD - pulm oedema - bruits on auscultation
61
RAS Ix
- Doppler US kidneys - captopril challenge test (not useful) - renal artery arteriogram
62
RAS Mx
- diuretics - anti HTN - surgery - angioplasty +/- stenting - nephrectomy
63
Contrast media nephrotoxicity
- 25% increase in creatinine <3d after IV contrast RFs - renal impairment, >70yo, dehydration, HF, nephrotoxic drugs Mx - 0.9% NaCl 1ml/kg/hr for 12hrs pre/post procedure - sodium bicarb
64
Renal papillary necrosis
- coagulative necrosis of renal papillae Causes - severe acute pyelonephritis, diabetic nephropathy, obstructive nephropathy, NSAIDs, sickle cell anaemia Px - visible haematuria - loin pain - proteinuria Ix - urinalysis, cytology - bloods - CT, contrast... - cystoscopy, ureteroscopy Mx - supportive - tx cause
65
Amyloidosis
- deposition of amyloid fibrils -> tissue/organ dysfunction - can affect kidneys, heart, nerves, gut, vascular - familial variant - autosomal dominant Px - renal disease - massive proteinuria - hepatomegaly - HF - glove + stocking polyneuropathy - GI malabsorption, macroglossia - periorbital purpura - fatigue, wt loss, bruising, SOB, oedema Ix - biopsy - of tissue - congo red staining (apple-green birefringence) - serum amyloid precursor (SAP) scan Mx - optimise nutrition - chemo + pred - tx conditions - familial - liver transplant
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