Renal

Question 1

Lupus Nephritis

Answer 1

• Females»_space; Males
• Asian, African, Hispanic
• Glomerula Haematuria
• Positive Serology, C3 C4 etc
• Dx - renal biopsy

Question 2

Lupus Nephritis Classes

Answer 2

1. Minimal Mesangial - monitored, no Rx
2. Mesangial Proliferative - Monitored, no Rx
3. Focal Lupus Nephritis 50% of Glomerulus
4. Pure Membranous
5. Advanced Sclerosing LN >90 of glomeruli sclerosed - prep for dialysis
   - Active vs chronic
   - Features - cellular, immune complexes on both sides of the glomerulus
   - Staining for IgG, C1q
   - Poor prognosis in ethnicity, failure to respond, raising Cr

Question 3

Treatment of Lupus Nephritis

Answer 3

Induction

• Steroids - high dose pulses (methyl pred)
• Cyclophosphamide - IV less toxic monthly pulses, infertility
• myocophenaliate
• Retuximab

Question 4

Peritoneal Dialysis

Answer 4

hj

Question 5

Indications for PD catheter removal

Answer 5

• relapsing or refractory peritonitis,
• refractory catheter infection
• fungal or mycobacterial peritonitis
• peritonitis associated with intra-abdominal pathology

Question 6

Polymicrobial peritonitis in PD

Answer 6

• Peritonitis due to multiple enteric organisms or mixed gram-negative/gram-positive organisms
• Concern of intra-abdominal condition such as ischemic bowel or diverticular disease
  # Mx
• Broadspectrum Abs
• Imaging/laproscoptic Ix
• Surgical opinion
• Removal of catheter

Question 7

Noninfectious complications of peritoneal dialysis

Answer 7

# Outflow failure
- usually constipation
# Pericatheter leak
- Leaking around catheter - e.g. weak muscles or increased activity
# Abdominal wall herniation
# Catheter-cuff excursion
# Intestinal perforation

Question 8

Nephrotic range Proteinuria

Answer 8

> 3g/day

Question 9

Nephrotic syndrome

Answer 9

• proteinuria
• hypoalbuminemia
• oedema

Question 10

Trimethoprim in CKD

Answer 10

• Inhibition of Na uptake in distal tubule
• Leading to higher Na excretion.
• Causes the tubular cells to retain K and can cause hyperkalaemia

Question 11

Phenytoin in Renal Disease

Answer 11

• 90% bound to Albumin
• 10% Free
• Hypoalbunaemia - Increase free concentrate of phenytoin

Question 12

Management of end stage renal failure

Answer 12

• Delay Haemodialysis as long as possible (HD -> rapid decline in eGFR
• Every 1ml/min of GFR protects from death
• Avoid nephrotxins
• PD as initial modality
• RAAS blockage
• Avoid Hypovolaemia
• Prevent PD peritonitis

Question 13

Most common stage of CKD in Australia

Answer 13

• Stage 3

Question 14

Non-Traditional Risk CVD risk factors

Answer 14

• albuminuria and eGFR - Independent Risk factors

Question 15

Treatment of contrast Nephropathy

Answer 15

1. Minimise contrast tests
2. Use nonionic low-osmolal agents
3. Prehydration with Sodium Bicarbonate (better than N.Saline)
4. acetylcysteine (NAC) - no evidence
   5.

Question 16

Symptoms suggestive of cryoglobulinemia include

Answer 16

• purpuric rash
• arthralgia
• Raynaud’s phenomenon.

In patients already diagnosed with chronic HCV infection, serum cryoglobulins should be measured.

Question 17

Kidney transplant - Graft regection

Answer 17

Mediated by T Lymphocytes

Tissue destruction occurs due to direct T cell-mediated lysis of graft cells, T cell activation of accessory cells, alloantibody production, and/or complement activation.

Question 18

Infections post renal transplant

Answer 18

# Early (1-6 months)
- Cytomegalovirus *****
- Pneumocystis carinii (septic)
- Legionella
- Listeria
- Hepatitis B
- Hepatitis C
# Late (>6 months)
- BK virus (polyoma) ***** (note renal impairment)
- Aspergillus
- Nocardia
- Herpes zoster
- Hepatitis B
- Hepatitis C

Pneumocystis jiroveci also occurs between 1-6 months post transplant. Patients appear more septic

Question 19

IgA nephropathy

Answer 19

• called Berger’s disease or mesangioproliferative glomerulonephritis
• commonest cause of glomerulonephritis worldwide
• pathogenesis unknown
• histology: mesangial hypercellularity, positive immunofluorescence for IgA & C3 differentiating between IgA nephropathy and post-streptococcal glomerulonephritis

Presentations
- young male, recurrent episodes of macroscopic haematuria
- typically associated with mucosal infections e.g., URTI
- nephrotic range proteinuria is rare
- renal failure
Associated conditions
- alcoholic cirrhosis
- coeliac disease/dermatitis herpetiformis
Management
- steroids/immunosuppressants not be shown to be useful
Prognosis
- 25% of patients develop ESRF
- markers of good prognosis: frank haematuria
- markers of poor prognosis: male gender, proteinuria (especially > 2 g/day), hypertension, smoking, hyperlipidaemia, ACE genotype DD

Question 20

Post Strep GN

Answer 20

• post-streptococcal glomerulonephritis is associated with low complement levels
• main symptom in post-streptococcal glomerulonephritis is proteinuria (although haematuria can occur)
• there is typically an interval between URTI and the onset of renal problems in post-streptococcal glomerulonephritis

Question 21

Target Hb in renal failure

Answer 21

Target Hb in renal failure - 120-130 g/dl.

Question 22

Is there a benefit of renal artery stenting

N Engl J Med 2014; 370:13-22 - CORAL Study

Answer 22

renal-artery stenting is futile

Question 23

Clinical features of lupus nephritis

Answer 23

1) Acute renal impairment
2) Microscopic hematuria
3) Proteinuria
4) Nephrotic syndrome
5) Lupus serology (DsDNA, C3,C4)

Not Nephritic Syndome

Question 24

Nephritic Syndome

Answer 24

1) Haematuria
2) Proteinuraia
3) HTN
Conditions
- SLE
- IGA GN
- Post Strep GN
- Henoch–Schönlein purpura
- Rapidly progressing GN

Question 25

Nephrotic Syndrome

Answer 25

1) Proteinuria (Large >3.5g/day) 2) Hypoalbumaemia (<2.5 3) Oedema

Question 26

Stages of Lupus nephritis

Answer 26

stage I: Minimal mesangial lupus nephritis(LN) stage II: Mesangial proliferative LN stage III: Focal LN <50% gloms involved. stage IV: Diffuse LN >50% gloms involved. stage V: Pure membranous LN stage VI: Advanced sclerosing LN >90% gloms involved.

Question 27

Lupus nephritis is associated with the following histological features:

Answer 27

``` – subendothelial immune deposits/wire loops – hypercellularity – leukocyte infiltration – fibrinoid necrosis – hyaline thrombi – crescents in severe LN ``` not machrophage infaltration

Question 28

Treatment of Lupus Nephritis

Answer 28

``` 1) Induction agents for lupus nephritis: – Prednisone – cyclophosphamide – Mycophenolate mofetil(MMF) – Rituximab (refractory cases) 2) Maintenance Treatment: – MMF or Azathioprine to continue for at least 2 years post remission. ```

Question 29

Cyclophosphamide toxicity

Answer 29

1) Infertility secondary to gonadal toxicity 2) Malignancy 3) Bladder toxicity 4) Myelosuppression 5) Herpes zoster 6) Major infection

Question 30

MMF causes the following side effects

Answer 30

``` GI upset which is a dose response side effect Leukopenia Thrombocytopenia Anemia Infection Malignancy ```

Question 31

Rapidly Progressive GN

Answer 31

``` # Induction: - cyclophosphamide and IV methylprednisone # Maintenance therapy: - Azathioprine - For severe cases: - Plasma exchange # Other agents: - Methotrexate-induction and maintenance - Rituximab - Bactrim - IVIG ``` Cyclosporin not used

Question 32

Macroalbuminuria in diabetic nephropathy in men

Answer 32

In men: - urine ACR of >25mg/mmol and AER of >300mg/24hrs. In women: - urine ACR of >35mg/mmol and AER of >300mg/24hrs.

Question 33

Indications for use of ACEi to slow progression of microalbuminuria N Engl J Med. 2004 Nov 4;351(19):1941-51

Answer 33

- Hypertension Note in normal blood pressure ARBs - no benefit

Question 34

Effect of ACE & ARB in normotensive T1 & T2DM N Engl J Med. 2009 Jul 2;361(1):40-51

Answer 34

- protective against rentinopathy not microalbuminurea/nephropathy

Question 35

Goodpastures syndrome

Answer 35

- IgG deposits on renal biopsy - anti-GBM antibodies - HLA DR2 - Pulmonary haemorrhage & Rapidly progressive GN Management - plasma exchange (plasmapheresis) - steroids - cyclophosphamide

Question 36

Minimal change glomerulonephritis

Answer 36

1st - prednisolone | 2nd ACEi

Question 37

Thrombotic thrombocytopenic purpura (TTP)

Answer 37

The combination of: - neurological features - renal failure - pyrexia - thrombocytopaenia

Question 38

Primary biliary cirrhosis

Answer 38

the M rule - IgM - anti-Mitochondrial antibodies, M2 subtype - Middle aged females look for raised LFTs (DDx from Sjogren's syndrome)

Question 39

Herpes simplex encephalitis

Answer 39

Features - fever, headache, psychiatric symptoms, seizures, vomiting - focal features e.g. aphasia - peripheral lesions (e.g. cold sores) have no relation to - presence of HSV encephalitis Pathophysiology - HSV-1 responsible for 95% of cases in adults typically affects temporal and inferior frontal lobes Investigation - CSF: lymphocytosis, elevated protein - PCR for HSV - CT: medial temporal and inferior frontal changes (e.g. petechial haemorrhages) - normal in one-third of patients - MRI is better - EEG pattern: lateralised periodic discharges at 2 Hz Treatment - intravenous aciclovir

Question 40

Reactive arthritis

Answer 40

- one of the HLA-B27 associated seronegative spondyloarthropathies Management - symptomatic: analgesia, NSAIDS, intra-articular steroids - sulfasalazine and methotrexate are sometimes used for persistent disease - symptoms rarely last more than 12 months

Question 41

Haemolytic uraemic syndrome

Answer 41

- classically caused by E coli 0157:H7 | - AKI

Question 42

Primary hyperaldosteronism

Answer 42

Features - hypertension - hypokalaemia (e.g. muscle weakness) alkalosis ``` Investigations - high serum aldosterone - low serum renin - high-resolution CT abdomen adrenal vein sampling ``` Management adrenal adenoma: surgery bilateral adrenocortical hyperplasia: aldosterone antagonist e.g. spironolactone