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Renal Flashcards

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1
Q

how to measure AKI

A

serum creatinine (need to adjust for muscle bulk)

  • Rise in creatinine > 25 micromol/L in 48 hours
  • Rise in creatinine > 50% in 7 days
  • Urine output< 0.5 ml/kg/hour over at least 6 hours
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2
Q

RF for developing AKI

A
  • > 65yrs
  • sepsis
  • CKD
  • Heart failure
  • diabetes
  • liver disease
  • reduced fluid intake
  • medications (NSAID, gentamicin, diuretics, ACEi)
  • radiocontrast agents
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3
Q

causes of renal impairment

A

Pre-renal- MC
- dehydration
- sepsis or blood loss
- heart failure

Renal
- acute tubular necrosis MC
- glomerulonephritis
- acute interstitial nephritis
- HUS
- rhabdomyolysis

Post-renal
- kidney stones
- tumour
- urethral stricture
- BPH
- neurogenic bladder

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4
Q

acute tubular necrosis

A
  • necrosis of epithelial cells in renal tubules
  • MC intrinsic cause of AKI
  • due to ischaemia or nephrotoxins
  • muddy brown casts
  • recovery 1-3 weeks
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5
Q

acute interstitial nephritis

A
  • inflammation of interstitium
  • caused by immune reaction assoc with NSAIDs, abx, infections, autoimmune conditions
  • rash, fever, flank pain, eosinophilia
  • treat cause + steroids
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6
Q

Mx of AKI

A

A-F
A- anaemia (give erythropoieitin)
B- bones (phosphate and calcium)
C- clearance (creatinine)
D- drugs (withhold ACEi and NSAIDs)
E- electrolytes (potassium and phosphate)
F- fluid balance (BP 130/80)

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7
Q

effect of ACEi in AKI

A

will drop BP and renal perfusion

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8
Q

complications of AKI

A
  • fluid overload, heart failure, pulmonary oedema
  • hyperkalaemia
  • metabolic acidosis
  • uraemia
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9
Q

stages of AKI

A
  1. 1.5-2x creatinine rise from base and <0.5ml/kg/hr urine >6hr
  2. 2-3x Cr rise + <0.5ml >12hr
  3. > 3x Cr rise + <0.3ml >24hr
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10
Q

how to manage hydropnephrosis

A

nephrostomy

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11
Q

nephrotic syndrome

A

BM of glomerulus becomes highly permeable
- proteinuria (frothy urine)
- hypoalbuminaemia
- oedema

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12
Q

causes of nephrotic syndrome

A
  • Minimal change disease (MC)
  • Membranous nephropathy
  • focal segmental glomerulosclerosis
  • diabetes, HSP, SLE, HIV
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13
Q

complications of nephrotic syndrome

A
  • DVT: increased risk of thromboembolism related to loss of antithrombin III and plasminogen in the urine
  • ACS and stroke due to hyperlipidaemia
  • CKD
  • increased risk of infection due to urinary immunoglobulin loss
  • hypocalcaemia (vitamin D and binding protein lost in urine)
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14
Q

Minimal change disease

A
  • idiopathic
  • 2-5 y/o child
  • Mx steroids. 2nd line cyclosporin
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15
Q

nephritic syndrome

A

PHAROH
- Proteinuria
- Haematuria
- Azootemia
- Red cell casts
- Oliguria
- Hypertension

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16
Q

Causes of nephritic syndrome

A
  • Acute postinfectious (post-strep) glomerulonpehritis
  • IgA nephropathy (berger disease)
  • Rapidly progressive GN
  • Hereditary nephritis
  • thin BM disease
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17
Q

IgA nephropathy

A
  • MC cause of primary GN
  • 20y/o with haematuria
  • unknown cause
  • IgA deposits
  • rule of thirds for recovery, CKD and progressive CKD
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18
Q

Post-streptococcal GN

A
  • <30y/o
  • 1-3 weeks after strep infection
  • make full recovery
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19
Q

rapidly progressive GN

A
  • acute severe illness
  • respond well to treatment
  • glomerular crescents on histology
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20
Q

anti-GBM
p-ANCA
c-ANCA

A

anti-GBM= goodpasture
p-ANCA= microscopic polyangiitis
c-ANCA= granulomatosis with polyangiitis

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21
Q

Mx of glomerulonephritis

A
  • Diagnosis- renal biopsy
  • supportive care
  • immunosuppression (steroids)
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22
Q

causes of CKD

A
  • diabetes
  • hypertension
  • Meds (NSAIDs, lithium)
  • Glomerulonephritis
  • PCKD
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23
Q

Presentation of CKD

A
  • fatigue
  • pallor
  • foamy urine
  • nausea
  • loss of appetite
  • pruritus
  • oedema
  • hypertension
  • peripheral neuropathy
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24
Q

Ix for CKD

A
  • eGFR
  • urine albumin: creatinine
  • urine dipstick
  • renal USS
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25
stages of CKD
GFR 1. kidney damage with normal GFR >90 2. GFR 60-89 3a. moderate 45-59 3b. moderate 30-44 4. severe 15-29 5. ESRF <15 or dialysis A:C A1 <3 A1 3-30 A3 >30
26
complications of CKD
- anaemia - renal bone disease - CVD - peripheral neuropathy - ESKD - dialysis related complication
27
Mx of CKD
- optimise diabetes and hypertension - avoid nephrotoxic drugs - treat glomerulonephritis - BP < 130/80 - ACEi and SGLT2 slow progression - atorvastatin for CVD prevention - erythropoietin/iron - vit D, low phosphate diet and phosphate binders - dialysis and transplant
28
before giving erythropoietin in CKD what do you need to correct
iron oral if not corrected after 3 months give IV
29
Renal bone disease
- high serum phosphate, low vit D activity + low serum Calcium - kidneys activate vit D and increasing calcium - low calcium and high phosphate = more PTH--> secondary hyperPTH - -->increase osteoclast activity and calcium bone absorption - --> osteomalacia, osteosclerosis
30
indications for short term dialysis
AEIOU - acidosis - electrolyte imbalance (hyperkalaemia) - intoxication - Oedema - Uraemia sx (seizures and reduced GCS)
31
indication for long term dialysis
ESRF
32
haemodialysis
- 4hrs a day 3x a week - need anticoagulation with citrate or heparin to prevent blood clotting in machine - can use tunnelled cuffed catheter in subclavian/jugular or AV fistula
33
complications of AV fistula
- anaeurysm - thrombosis - infection - stenosis - high output heart failure - STEAL syndrome: ischaemia of part of limb
34
signs in a fistula
- palpable thrill - machinery murmur on auscultation
35
peritoneal dialysis
- uses peritoneal membrane - can do it at home - Tenckhoff catheter
36
complications of peritoneal dialysis
- bacterial peritonitis - peritoneal sclerosis - ultrafiltration failure - weight gain - psychosocial implications
37
years added from renal transplant compared to dialysis
10 yrs
38
donor matching for renal transplant
HLA type on Chr6
39
Where and how is kidney transplant done
- donor kidney BVs anastomosed with pelvic vessels (external iliac vessels). - ureter of donor kidney anastomosed with bladder - donor anterior in abdo in iliac fossa - hockey stick (Rutherford Morrison) scar
40
post transplant care
- 2x doses Basiliximab to prevent acute rejection lifelong immunosuppression - tacrolimus - mycophenolate - ciclosporin - azathioprine - prednisolone
41
side effects of immunosuppressants
- seborrhoeic warts and skin cancer - tacrolimus = tremor - cyclosporin = gum hypertrophy - steroids = cushing's syndrome
42
complications of renal transplant
- rejection (HA, A, Chronic) - transplant failure - electrolyte imbalance
43
Causes of hyperacute rejection (minutes-hours)
- pre-existing antibodies against HLA or ABO antigens
44
Causes of acute rejection (<6months)
- mismatched HLA - Cell-mediated (cytotoxic T cells) - CMV
45
Causes of chronic rejection (>6 months)
- antibody and cell-mediated mechanisms cause fibrosis to the transplanted kidney - recurrence of original renal disease
46
complications of transplant related to immunosuppressants
- IHD - T2DM - infections - Non hodgkin lymphoma - skin cancer (SCC)
47
infections secondary to immunosuppressant meds
- Pneumocystitis jiroveci pneumonia (PCP) - CMV - TB
48
what is glomerulonephritis
inflammation of glomeruli in kidney
49
What is renal tubular acidosis
metabolic acidosis due to pathology of tubules
50
types of renal tubular acidosis
T1: distal tubule cannot excrete H+. high urine pH and low serum K+. most severe T2: proximal tubule cannot reabsorb bicarbonate. High pH and low K+. Milder T4: low aldosterone or impaired aldosterone function. low pH, high K+. MC. T3: RARE
51
Causes of type 1 renal tubular acidosis
- Genetic - SLE - Sjögren’s syndrome - Primary biliary cholangitis - Hyperthyroidism - Sickle cell anaemia - Marfan’s syndrome
52
Presentation of T1 renal tubular acidosis
- failure to thrive - recurrent UTI - rickets/osteomalacia - muscle weakness - arrhythmia due to low k+
53
causes of type 2 renal tubular acidosis
- inherited - MM - Fanconi's syndrome
54
Mx of renal tubular acidosis
bicarbonate oral KCL 3-3.5 or IV KCL <3
55
What is Haemolytic uraemic syndrome
- thrombosis in small BVs - triggered by E.coli 0157 or Shigella - children post gastroenteritis
56
triad of HUS
- microangiopathic haemolytic anaemia (RBC destruction) - AKI - thrombocytopenia
57
presentation of HUS
- bloody diarrhoea - renal failure - fever, abdo pain
58
Mx of HUS
- Supportive (Fluids, blood transfusion and dialysis if required) - plasma exchange - eculizumab
59
what is rhabdomyolysis
SM breaking down releasing: - myoglobin - potassium - phosphate - CK
60
causes of rhabdomyolysis
- prolonged immobility - rigorous exercise - crush injury - seizure - statins
61
Sx of rhabdomyolysis
- muscle pain, weakness and swelling - reduced urine - red/brown urine - fatigue and confusion - N&V
62
Mx of rhabdomyolysis
IV fluids mainstay + Iv sodium bicarbonate and mannitol if necessary
63
types of hyperkalaemia
normal 3.5-5.3 mild: 5.4-6 moderate 6-6.5 severe >6.5
64
causes of hyperkalaemia
- AKI - CKD - rhabdomyolysis - adrenal insufficiency - tumour lysis syndrome - aldosterone antagonists (spironolactone) - ACEi - AIIRB - NSAID
65
ECG changes assoc with hyperkalaemia
- tall tented T waves - flat/absent p waves - prolonged PR - broad QRS
66
Mx of hyperkalaemia
Treat pt with severe hyperkalaemia (≥ 6.5 mmol/L) or with ECG changes: - 10ml 10% IV calcium gluconate (stabilist cardiac muscle) - 100ml 20% dextrose and 10units insulin (drive potassium into cells and prevent hypoglycaemia) - nebulised salbutamol useful adjunt - oral calcium resonium - sodium bicaronate - haemodialysis = severe
67
what is polycystic kidney disease
- AD and AR types. AD is more common - PKD1 gene on Chr16 and PKD2 gene on Chr4 affected - 10% of cases of CKD - 2/3rds require renal replacement therapy - Imaging USS can do MRI later
68
Presentation of polycystic kidney disease
MISHAPES - abdo Mass - Infected cysts and increase BP - Stones - Haematuria - Aneurysms (berry) - Polyuria and nocturia - extra renal cysts (ovary, spleen, pancreas, prostate) - systolic murmur (mitral regurg due to mitral valve prolapse)
69
complications of polycystic kidney disease
- Chronic loin/flank pain - Hypertension - Gross haematuria can occur with cyst rupture - Recurrent UTIs - Renal stones - ESRF occurs at roughly 50yr
70
Mx of polycystic kidney disease
- Tolvaptan slows cyst dvlpt in AD - antihypertensive - analgesia - Abx - drainage - dialysis and transplant
71
Causes of hyaline casts on urine MC&S
- normal - after exercise - loop diuretics
72
causes of chronic kidney disease that present with bilaterally enlarged kidneys on ultrasound
- HIV-associated nephropathy - AD polycystic kidney disease - diabetic nephropathy (early stages) - amyloidosis
73
Causes of metabolic acidosis
Normal anion gap - GI bicarbonate loss: diarrhoea, ureterosigmoidostomy, fistula - renal tubular acidosis - drugs: e.g. acetazolamide -ammonium chloride injection - Addison's disease Raised anion gap - lactate: shock, hypoxia - ketones: diabetic ketoacidosis, alcohol - urate: renal failure - acid poisoning: salicylates, methanol
74
cause of metabolic alkalosis
- vomiting / aspiration (e.g. peptic ulcer leading to pyloric stenos, nasogastric suction) - diuretics - liquorice, carbenoxolone - hypokalaemia - primary hyperaldosteronism - Cushing's syndrome - Bartter's syndrome - congenital adrenal hyperplasia
75
causes of respiratory acidosis
- COPD - decompensation in other respiratory conditions e.g. life-threatening asthma / pulmonary oedema - sedative drugs: benzodiazepines, opiate overdose
76
causes of respiratory alkalosis
- hyperventilation - pulmonary embolism - salicylate poisoning - CNS disorders: stroke, subarachnoid haemorrhage, encephalitis - altitude - pregnancy
77
Hypocalcaemia is an indication that kidney disease is chronic or acute?
chronic
78
indication of Alport Syndrome
renal failure, sensorineural hearing loss and ocular abnormalities develop in a child
79
Post renal transplant mx of low urine output, with tachycardia and relative hypotension
fluid challenge, probably just hypovolaemic
80
causes of acute interstitial nephritis
drugs: the most common cause, particularly antibiotics - penicillin - rifampicin - NSAIDs - allopurinol - furosemide systemic disease: SLE, sarcoidosis, and Sjogren's syndrome infection: Hanta virus , staphylococci
81
features of acute interstitial nephritis
- fever, rash, arthralgia - eosinophilia - mild renal impairment - hypertension - Eosinophilic casts in urine
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