MRCP - Part 2 > Renal > Flashcards

Renal Flashcards

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1
Q

ED mx?

A

Trial of sildenafil regardless of cause of ED

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2
Q

Medication to reduce rate of CKD progression in ADPKD?

A

Tolbaptan - Vasopressin 2 antagonist

Needs U+E and LFT monitoring

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3
Q

What staining to assess for amyloidosis?

A

Congo red staining

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4
Q

What is renal papillary necrosis?

A

Renal papillary necrosis describes the coagulative necrosis of the renal papillae due to a variety of causes

eg NSAID use or sickle cell anaemia

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5
Q

How can renal papillary necrosis present?

A

With loin pain and visible haematuria

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6
Q

biopsy has revealed increased mesangial matrix and increased mesangial cellularity in the glomerulus

Suggests what dx?

A

Membranoproliferative glomerulonephritis

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7
Q

linear IgG deposition along the glomerular basement membrane with crescentic glomerulonephritis on renal biopsy

What is the dx and mx?

A

Dx: Anti-GBM disease (Goodpastures)

Mx: Steroids, cyclophosphamide + PLEX

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8
Q

1st line ix for testicular mass?

A

USS testes

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9
Q

Most important dx test for post-strep glomerulonephritis?

A

Anti streptolysin titre

Also check C3 levels which can be low

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10
Q

In a patient with hypercalciuria and renal stones - how to reduce calcium excretion + stone formation?

A

Thiazide diuretics

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11
Q

RFs for testicular ca?

A

infertility (increases risk by a factor of 3)
cryptorchidism - question may hint at prev orchidopexy to treat this
family history
Klinefelter’s syndrome
mumps orchitis

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12
Q

When should diabetics be started on ACEi or ARB?

A

If they have urinary ACR 3 or more

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13
Q

Why can pencillamine use in RA cause RUQ?

A

Pencilliamine can cause membranous glomerulonephritis -> nephrotic syndrome -> portal vein thrombosis

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14
Q

Mx of anaemia in CKD?

A

Correct IDA before considering EPO

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15
Q

What can renal issue can be caused by HIV infection?

A

HIV infection can lead to nephrotic syndrome secondary to focal segmental glomerulosclerosis

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16
Q

What cause of nephrotic syndrome is strongly associated with malignancy? What does it look like?

A

Membranous glomerulonephritis - spike and dome appearance (basement membrane is thickened with subepithelial electron dense deposits)

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17
Q

Renal transplant followed by reduced urinary OP +

urgent renal biopsy of the transplanted kidney demonstrates significant lymphocytic, in particular, mononuclear cell infiltration with no clonal populations, EBV antigen negative and no light chains

What is the dx? What is the tx?

A

Dx: post-transplant lymphoproliferative disorder -> clonal populations of T or B cells in significant lymphoid disruption of renal architecture, EBV antigen present in many cells with significant immunoglobulin light chain expression

Tx: Pulse of IV Steroids followed by maintenance immunosuppression, refractory cases may need cytotoxic chemo

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18
Q

Rash + Eosinophilia + Recent abx administration in nephritic syndrome - dx?

A

Dx: Acute interstitial nephritis

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19
Q

Young woman presenting with AKI and visual disturbance - dx? how else does it present?

A

Dx: TINU (tubulointerstitial nephritis with uveitis)

It typically occurs in young women and presents with fevers, weight loss and uveitis.

Urinalysis shows pyuria and proteinuria.

Acute kidney injury is caused by tubulointerstitial nephritis and usually responds well to steroids.

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20
Q

Why do you get hyperphosphatamia in CKD?

A

Due to reduced phosphate excretion in CKD

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21
Q

Mx of CKD-mineral bone disease

A

1st correct hyperphosphataemia:
1. Dietary restriction
2. Phosphate binder if not working calcium binder or sevelamer if hypercalcaemic

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22
Q

Lithium causes what type of DI?

A

Nephrogenic DI

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23
Q

How can you remember the most common causes of nephrotic syndrome?

A

MMF

Minimal change disease
Membranous nephropathy
Focal segmental glomerulosclerosis

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24
Q

Target for anaemia in CKD?

A

aim for 100-120 g/l

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25
Prescribing what abx alongside statins can cause rhabdomyolysis?
Clarithromycin alongside statins
26
Hep C infection + purpuric rash leads to which renal issue? What to check?
Here cyroglobulinaemia causes membranoproliferative glomerulonephritis Important to check serum cryoglobulins
27
Focal segmental glomerulosclerosis (FSGS) Renal biopsy findings?
focal and segmental sclerosis and hyalinosis on light microscopy effacement of foot processes on electron microscopy
28
Mx of FSGS?
Steroids +- immunosupression
29
Causes of FSGS?
idiopathic secondary to other renal pathology e.g. IgA nephropathy, reflux nephropathy HIV Heroin Alports Sickle cell
30
HIV pt on HAART (highly active ART) presents with intermittent left flank pain radiating to his groin Likely dx? What can you see on urine microscopy?
Indinavir-induced nephrolithiasis Indinavir can crystallise in the urine and cause renal stones. Urine microscopy shows needle-shaped crystals.
31
What levels should ferritin and transferrin saturation be when IDA is treated?
Ferritin >100 Transferrin sats >20
32
Normocytic anaemia, thrombocytopaenia and AKI following diarrhoeal illness Dx?
HUS
33
What treatment should be provided in atypical HUS?
Atypical HUS - Normal ADAMTS enzyme activity Mx = PLEX + Eculizumab (a C5 inhibitor monoclonal antibody)
34
What are the features of Alports syndrome?
Microscopic haematuria, progressive renal failure, bilateral sensorinerual hearing loss, retinitis pigmentosa + lens protrusion (lenticonus) Typical question may see a patient failing renal transplant due to presence of anti-GBM antibodies
35
Asitic tap findings in PD peritonitis? Mx?
Asitic tap - >100 WCC + >50% polymorphs Mx = Intraperitoneal vanc + oral cipro - coag -ve staph most common cause
36
What is time frame for chronic renal graft failure?
>6 months
37
What are the symptoms of acute graft failure (renal)?
worsening graft function in association with pyuria and proteinuria within 6 months of transplant
38
A renal biopsy was performed, which showed diffuse thickening of the glomerular basement membrane. Dx? What does silver stain show?
Dx = Membranous nephropathy Silver stain showed 'spikes' on the surface of the capillary loops.
39
What is important to check with membranous nephropathy?
Screen for malignancy - prostate, lung, lymphoma, luekaemia
40
Ix findings in DI (osmolalities)?
High plasma osmolality Low urine osmolality
41
Mx of DI?
Cranial - Low dose desmopressin Nephrogenic - thiazides, amiloride and low protein+salt diet
42
What renal issue does anti-GBM disease cause? What is seen on renal biopsy?
rapidly progressive glomerulonephritis (RPGN) Renal biopsy: linear IgG deposits along the basement membrane
43
How to distinguish between ATN and hepatorenal syndrome based on urine microscopy?
Both show granular casts ATN also shows renal epithelial cells
44
Renal biopsy findings in amyloidosis?
Nodular glomerulosclerosis with amorphous hyaline deposits in the glomeruli
45
What is congo red stain used for?
Amyloid -> You would see Apple-green birefringence
46
Recurrent urinary tract infections, tender prostate on examination, and elevated PSA Suggestive dx? mx?
Suggests chronic bacterial prostatitis Mx = 4w of cipro
47
Bowel resection and UC are RFs for what type of renal stone?
Calcium oxalate
48
Can Alports cause hearing loss and cysts?
Hearing loss - YES Cysts - NO
49
What is pre-renal azotaemia? mx?
Accumulation of nitrogenous waste products (urea + creatinine) due to intrinsic renal function Mx = IV hydration w saline 0.9%
50
Vasculitic process that involves the lungs, nasal mucosa and kidneys Dx? Antibody? Type of glomerulonephritis?
Granulomatosis w polyangiitis -> Rapidly progressive glomerulonephritis cANCA NB: Goodpastures also presents w rapidly progressive GN
51
Causes of Rapidly Progressive GN?
Goodpastures Granulomatosis with polyangiitis (Wegners) SLE Microscopic polyarteritis
52
When to refer an AKI to nephrologist?
Renal tranplant ITU patient with unknown cause of AKI Vasculitis/ glomerulonephritis/ tubulointerstitial nephritis/ myeloma AKI with no known cause Inadequate response to treatment Complications of AKI Stage 3 AKI (see guideline for details) CKD stage 4 or 5 Qualify for renal replacement hyperkalaemia / metabolic acidosis/ complications of uraemia/ fluid overload (pulmonary oedema)
53
PKD which chromosome is mutation on?
PKD-1 more severe disease in younger age = Chromosome 16 PKD-2 less severe later age of onset = Chromosome 4
54
ADPKD - 1st line ix?
USS
55
Nephrotic syndrome + Hep B +ve Dx? what complication can people present with
Membranous glomerulonephritis, can lead to renal vein thrombosis in 5%
56
Acute pain + swelling in fistula with functioning dialysis but pain Dx?
Fistula stenosis
57
What are the indications for PLEX in ANCA-associated vasculitis?
Severe active renal disease (serum creatinine above 354 micromol/L or who require dialysis), Pulmonary haemorrhage, Concurrent anti-GBM autoantibody disease.
58
Mx of Lupus nephritis
Treat HTN Initial in class III or IV: Glucocorticoids + Mycophenolate or Cyclophosphamide Following on - Mycophenolate > Azathioprine due to lower risk of end stage renal disease
59
Staging of lupus nephritis?
class I: normal kidney class II: mesangial glomerulonephritis class III: focal (and segmental) proliferative glomerulonephritis class IV: diffuse proliferative glomerulonephritis class V: diffuse membranous glomerulonephritis class VI: sclerosing glomerulonephritis
60
What features of urine make Struvite stones more likely?
Increased urinary ammonia Alkaline urine >7.2
61
Which renal stones are radio-opaque?
Calcium Oxalate Calcium Phosphate Cystiene NB: Struvite is partially radio-opaque
62
Which renal stone is radio-lucent?
Uric acid
63
Causes of raised anion gap metabolic acidosis?
MUD PILES Methanol Uraemia (renal failure) Diabetic ketoacidosis Paracetamol use (chronic) Isoniazid Lactate Ethanol or propylene glycol Salicylates
64
What should be done before renal biopsy? What are the absolute CIs?
Before renal biopsy - Renal USS is needed Absolute CI: - Polycystic kidneys - Obstruction of urinary tract - Hydronephrosis
65
What complication can arise from agressive use of 0.9% saline in DKA mx?
Hypercholeraemic metabolic acidosis
66
HTN in CKD mx?
ACEi - reno protective Furosemide if eGFR <45
67
This young patient has presented with nephrotic syndrome and hypertension on a background of Hepatitis C. Dx? what else can be seen?
Mesangiocapillary glomerulonephritis Can also see sunken cheeks + dimples in skin due to lipodystrophy
68
What can testicular tumours secrete? Which of these can cause hyperthyroidism?
hCG, LDH and/or AFP hCG -> Hyperthyroidism
69
What is dialysis disequilibrium syndrome and when can it present?
Rare complication of haemodialysis - Dialysis disequilibrium syndrome results in cerebral oedema which can present as focal neurological deficits, papilloedema and a decreased level of consciousness More likely in pts w high urea, met acidosis, vyoung/old + CNS disease
70
Mx of dialysis disequilibrium syndrome?
Leads to cerebral oedema so use IV hypertonic saline or mannitol
71
What can cause raised anion gap met acidosis?
lactate: shock, hypoxia ketones: diabetic ketoacidosis, alcohol urate: renal failure acid poisoning: salicylates, methanol 5-oxoproline: chronic paracetamol use
72
Causes of normal anion gap / hypercholeraemic met acidosis?
gastrointestinal bicarbonate loss: diarrhoea, ureterosigmoidostomy, fistula renal tubular acidosis drugs: e.g. acetazolamide ammonium chloride injection Addison's disease
73
When to start dialysis in CKD?
Dialysis should be started in CKD stage 5 if symptomatic or when eGFR drops to 5-7
74
Most useful early diagnositic test in HUS?
Blood film - evidence of haemolysis like schistocytes
75
Recurrent stones in young age possible dx and mx?
Dx = Cystinuria (high cystine urine conc) Mx = Hydration + Alkalinising using K citrate (no point if urinary pH already high) if fails -> D-pencillamine
76
Mx of anti-GBM disease?
Steroids Cyclophosphamide PLEX
77
Features of AV Steal syndrome?
Ischaemia of the hand as a consequence of reversal or reduction or reversal of flow through the arterial segment of the fistula distal to the AV fistula. It may cause pallor and necrosis of the hand
78
The target blood pressure in diabetic nephropathy?
<130/80 mmHg if ACR ≥3.0 mg/mmol; otherwise <140/90 mmHg is appropriate
79
Bloods in t2 RTA?
Distal RTA = low bicarb + raised chloride
80
What can cause fanconi?
Congential or accquired eg MGUS, MM, Sjogrens
81
Younger pt with haematuria - ix?
Renal biopsy
82
Mx of HUS?
Supportive + notify communicable disease control consultant PLEX - as a general rule plasma exchange is reserved for severe cases of HUS not associated with diarrhoea, can also give eculizumab (c5 MaB)
83
Features of Alport and findings on light microscopy?
nephritis causing microscopic haematuria with episodic frank haematuria, high frequency sensorineural deafness and ocular problems which include corneal ulcers and bilateral lenticonus Light microscopy - NAD
84
CKD iron replacement?
Oral for 3m first if not haemodialysed IV iron otherwise
85
AKI Staging?
Stage 1 - 1.5-1.9x baseline OR increase by 26.5 of creatinine and Urine OP <0.5 for 6-12 hours Stage 2 - 2.0-2.9 times baseline OR <0.5ml/kg/hr for =>12 hours Stage 3 - 3.0 times baseline OR increase => 353.6 µmol/L OR initiation of renal replacement therapy OR anuria =>12 hours
86
Next ix if suspecting under / overestimated eGFR (high/low muscle mass)
Serum cystatin-C
87
Urea when to dialyse?
If symptomatic eg seizures
88
In an individual of 15-39 years of age with a family history of ADPKD, a renal ultrasound with a total of three or more cysts is considered to be diagnostic of the disease Mx ?
15-49 years with early ADPKD (eGFR > 90), treatment with an ACE inhibitor with target BP <110/75 can provide cardiovascular benefit and reduce the rate of cyst growth
89
Varicocele why to be worried?
Varicocele can be a sign of malignancy due to compression of the renal vein between the abdominal aorta and the superior mesenteric artery - known as the nutcracker angle NEEDS CTTAP
90
Nephrotic (proteinuria + hypoalbuminuria) + derranged renal func + peripheral neuropathy + untreated ank spond Dx?
Secondary AA amyloid Diagnose w biopsy of skin, rectal mucosa or abdominal fat
91
CKD bone mineral disease mx?
Correct hyperphosphataemia 1st Using diet then binders
92
Aw renal transplant and needs transfusion next step
Transfuse + advise transplant team postponed for at least 3 months, following repeat antibody screening
93
Mx of IgA nephropathy?
no proteinuria, normal GFR: observe proteinuria: ACE inhibitor signifcant fall in GFR/not responding to ACE inhibitor: corticosteroid
94
https://d32xxyeh8kfs8k.cloudfront.net/images_Passmedicine/xrb120b.jpg What does this show?
RCC - heterogeneously enhancing mass at the upper pole of the right kidney
95
CKD when to ix for anaemia?
Hb falls below 110g/L OR they develop symptoms suggestive of anaemia
96
Target Hb in CKD?
100-120 Aim ferritin 500-800
97
CKD At what level of PTH would you begin supplementation with calcium and vitamin D?
2x normal range
98
PLEX and renal biopsy what to be aware of?
Increased risk of bleeding and delayed bleeding due to depletion of fibrinogen
99
When is PLEX used in ANCA +ve vasculitis?
If there is pulmonary haemorrhage
100
Causes of lactic acidosis?
due to tissue hypoxia. Tissue hypoxia occurs due to one of four main mechanisms: 1. Hypoxaemia (e.g. respiratory pathology), 2. Toxic (e.g. carboxyhemoglobinemia, or cyanide poisoning), 3. Perfusional (e.g. shock), or 4. Severe anaemia
101
Absolute CIs for renal transplant donor?
Uncontrolled HTN Active malignancy Chronic infection Overt proteinuria Bilateral renal artery atherosclerosis Sickle cell
102
CKD staging?
1 Greater than 90 ml/min, with some sign of kidney damage on other tests (if all the kidney tests* are normal, there is no CKD) 2 60-90 ml/min with some sign of kidney damage (if kidney tests* are normal, there is no CKD) 3a 45-59 ml/min, a moderate reduction in kidney function 3b 30-44 ml/min, a moderate reduction in kidney function 4 15-29 ml/min, a severe reduction in kidney function 5 Less than 15 ml/min, established kidney failure - dialysis or a kidney transplant may be needed
103
T1DM and nearing end stage CKD / renal failure - next step?
Combined renal + pancreatic transplants
104
Features of post-transplant lymphoproliferaative disoder ? cause?
Weight loss, anaemia + lymphadenopathy Due to EBV
105
Necrotic looking ulcer in renal failure dx? ix?
calciphylaxis -> Biopsy, would have raised PTH can be worsened with Warfarin
106
Raised PSA and low testosterone
DO NOT REPLACE TESTOSTERONE even if deficient Refer to urology
107
Mx of membranous glomerulonephritis?
Can be due to sickle or NSAIDs Mx = BP control w ACEi, Immunsuppression w chlorambucil / oral pred
108
Rapid drop in renal func after starting ACEi / ARB - dx?
Renal artery stenosis
109
CKD and HTN mx?
1st ACEi /ARB 2nd Diuretics, Loop preferred if eGFR <30
110
Mx of focal segmental glomerulosclerosis?
Mx - steroids +- immunosuppression, untreated chance of remission is <10%
111
Focal or diffuse lupus nephritis ix findings + mx?
Nephrotic proteinuria + haematuria + low C3/4 +ve dsDNA Mx = IV methylpred + mycophenolate OR cyclophosphamide
112
MRCP - Part 2
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