1
Q
What is an acute kidney injury?
A
-An abrupt loss of kidney function (within 48 hours) resulting in the retention of urea and other waste products = dysregulation of extracellular volume and electrolytes
2
Q
What are the 3 criteria that defines AKI?
A
- Increase in serum creatinine of >26.4μmol/L above baseline
- Increase in serum creatinine of >50%
- Oliguira <0.5mL/kg/hr for >6hr
3
Q
Who are high risk patients for AKI?
A
- CKD
- Diabetics
- Diffuse atherosclerotic disease
- CCF
- Multiple myeloma
- Elderly
4
Q
How can the causes of AKI be classified?
A
- Pre-renal
- Renal
- Post renal
5
Q
What are the pre renal causes of AKI?
A
- Volume depletion ie bleeding, D+V, burns
- Oedematous states ie Cardiac failure, cirrhosis, neprhotic syndrome
- Hyptension ie sepsis, shock
- CV
- Medications ie NSAID, COX-2, ACEi, ARB
6
Q
What are the renal causes of AKI?
A
- Glomoerular disease ie glomerulonephritis, thrombosis
- Tubular injury ie prolonged ischaemia, nephrotoxins
- Acute interstitial nephritis ie drugs, infection, autoimmune disease
- Vascular disease ie Polyarteritis nodosa, vasculitis, renal artery stenosis
- Eclampsia
7
Q
What are the post renal causes of AKI?
A
- Prostatic hypertrophy
- Calculus
- Blood clot
- Urethral stricture
- Tumour
- Pelvic malignancy
- Radiation fibrosis
8
Q
What are the drugs known to cause AKI?
A
- NSAIDS
- gentamycin
- antifungals
- antivirals
- radio-iodine contrast
9
Q
Who is most commonly affected by AKI?
A
-Elderly
10
Q
What are risk factors for AKI?
A
- Age >65
- CKD with eGFR <60
- Past history of AKI
- CO-existing illness eg cardiac failure, liver disease, diabetes
- Neuroimpairment
- Hypovolaemia
- Symptoms of urological obstruction
- Sepsis
- Use of contrast
- Nephrotoxic Medications
- Perioperative period
11
Q
How does AKI present?
A
-Decreasing urine volume and rise in serum creatinine
12
Q
What are symptoms of an AKI?
A
- Decrease in urine output ie oliguria, anuria
- Nausea and vomiting
- Dehydration
- Confusion
13
Q
What are signs of AKI?
A
- Hypertension
- Large painless bladder
- Fluid overload: ^JVP, pulmonary and peripheral oedema
- Postural hypotension and dehydration
- Pallor, rash, bruising
14
Q
What investigations are required for an AKI?
A
- Urinalysis and urine microscopy
- Creatinine blood test along with other normals
- Blood film
- Immunology ie bence jones protein, ANCA, complement
- US (if obstruction suspected)
- Other radiology for systemic disease
- BIOPSY
15
Q
How does CKD differ from AKI?
A
CKD:
- long duration of symptoms
- nocturia
- absence of illness
- anaemia
- hyperphosphatemia
- reduced renal size
16
Q
How is AKI managed?
A
-Supportive treatment: >treat underlying cause >stop nephrotoxic drugs >monitor fluid and electrolytes >treat acute complications ie K+^, acidosis, pulmonary oedema, bleeding
17
Q
What are the indications for dialysis (renal replacement therapy)
A
- Hyperkalaemia
- Pulmonary oedema refractory to medical management
- Severe metabolic acidaemia due to kidney failure
- Progressive renal failure (^creatinine)
- Uraemic complications ie pericarditis, altered mental state)
- Fluid overload
- Renal transplant
- CKD 4 or 5
18
Q
What is the management bundle for AKI?
A
- Haemodynamic restoration (fluids and inotropes)
- Treatment of K+
- Input/output charting and frequent obs
- Urinalysis
- Stop nephrotoxins, drugs with haemodynamic effect, reduce doses of renally excreted drugs
19
Q
What is CKD?
A
-Abnormal kidney function ie eGFR <60ml/min/1.73m^2 for longer than 3 months
or
-Kidney damage
20
Q
What is are risk factors for CKD?
A
- Increasing age
- Diabetes
- CVD
- Proteinuria
- AKI
- Hypertension
- Smoking
- African, afro-carribean or asian ethnicity
- Chronic use of NSAIDs
- Untreated outflow obstruction
21
Q
Classification of CKD?
A
- Stage 1: normal - eGFR >90 ml/minute/1.73 m2 with other evidence of chronic kidney damage (see below).
- Stage 2: mild impairment - eGFR 60-89 ml/minute/1.73 m2 with other evidence of chronic kidney damage.
- Stage 3a: moderate impairment - eGFR 45-59 ml/minute/1.73 m2.
- Stage 3b: moderate impairment - eGFR 30-44 ml/minute/1.73 m2.
- Stage 4: severe impairment - eGFR 15-29 ml/minute/1.73 m2.
- Stage 5: established renal failure (ERF) - eGFR less than 15 ml/minute/1.73 m2 or on dialysis.
22
Q
What persistent findings may indicate CKD?
A
- Persistent microalbuminuria
- Persistent proteinuria
- Persistent haematuria
- Structural abnormalities ie PCKD
- Biopsy proven glomerulonephritis
23
Q
How does CKD present?
A
- Usually incidentally on a routine blood or urine test
- Long/progressive disease
24
Q
What are the symptoms of severe CKD?
A
Anorexia Nausea Vomiting Fatigue Pruritus Peripheral oedema Dyspnoea Insomnia Muscle cramps Pulmonary oedema Nocturia Headache Sexual dysfunction Very severe Hiccups Pericarditis Coma Seizures
25
What are risk factors that require screening for CKD?
-AKI
-CVD
>ischaemic heart disease, chronic HF, PAD, Cerebral vascular disease
-Structural renal tract disease, prostatic hypertrophy
-Multisystem disease ie SLE
-FHX of CKD
26
Investigations of CKD?
-eGFR
-Biochemistry: k+^, bicarb low, phosphate high
-Haematology: anaemia
-Serology: >autoantibodies: ANA, c-ANCA, p-ANCA, anti-GBM
>Hepatitis
>HIV
-Urinalysis
-Imaging: renal US
-Retrograde pyelogram
-Renal radionuclide scan
-CT (Renal artery stenosis)
-Biopsy
27
Management of CKD?
- Explanation and education
- Medication review
- Monitoring of eGFR
- Immunise against influenza and pneumococcus
- CVD prevention and blood pressure control
- Advice for nutrition and physical exercise
- Manage and monitor bone and mineral disorders and treat with vit d supplementation if required
- Treat hyperphosphataemia with calcium acetate
- Renal replacement therapy if required
28
When should a patient with CKD be referred?
- GFR <30ml/minute/1.73m2 - with or without diabetes
- ACR >70mg/mmol - unless already known to be caused by DM and being treated
- ACR >30mg/mmol with haematuria
- Sustained decrease in GFR of 25%+ within 12 months
- Hypertension poorly controlled despite >4 drugs
- Known or suspected rate or genetic causes of CKD
- Suspected renal artery stenosis
29
What are some potential complication of CKD?
- Anaemia
- Coagulopathy
- Hypertension
- Calcium phosphate loading: cardiovascular disease, arthropathy, soft tissue calcification
- Renal osteodystrophy: disorders of calcium, phosphorus and bone
- Bone changes of secondary hyperparathyroidism
- Neurological: uraemic encephalopathy, neuropathy
- Dialysis amyloid: bone pain, arthropathym carpal tunnel syndrome
- Fluid overload: pulmonary oedema, hypertension
- Malnutrition: increased mortality and morbidity, poor wound healing, infections
- Glucose intolerance due to peripheral insulin resistance
30
What is hyperkalaemia?
-Plasma potassium >5.5mmol/L
31
What are the different severities of potassium and when do the blood tests need to be repeated?
```
-Mild: .5-5.9
>recheck in a week
-Moderate: 6.0-6.4
>recheck next week
-Severe: >6.5
>requires urgent investigation
```
32
Mechanisms of action causing hyperkalaemia:
- Renal causes: decreased excretion of drugs
- Increased circulation of potassium
- A shift from intracellular to the extracellular space
- Pseudohyperkalaemia
33
When is the greatest risk to experience hyper/hypokalaemia?
-At the extreme ends of age
34
What are the renal causes of hyperkalaemia?
- AKI
- CKD
- Hyperkalaemic renal tubular acidosis
- Mineralocorticoid deficiency
- Medicines that interfere with RAAS
35
What drugs can cause hyperkalaemia?
- ACEi
- ARBs
- NSAIDs
- Heparin
- Ciclosporin
- Tacrolimus
- Pentamidine
- Co-trimaxazole
- Herbal remedies
36
What are the exogenous causes of increased potassium?
- Potassium supplementation
| - Increased food consumption of soft fruit, veg, chocolate, coffee
37
What are the endogenous causes of increased potassium?
- tumour lysis syndrome
- rhabdomyloysis
- trauma
- burns
- crush syndrome
38
What causes pseudohyperkalaemia?
- Prolonged tourniquet time
- Difficulty collecting sample
- Clenched fist
- Test tube haemolysis
- Use of wrong haemolysis
- Excessive cooling of specimen
- Length of storage of specimen
- Marked leukocytosis and thrombocytosis
39
How does hyperkalaemia present?
- Non-specific: weakness and fatigue
- Muscular paralysis or SOB, chest pain, palpitations
- Bradycardia
- Tachypnoea from resp weakness
- Flaccid paralysis
- Depressed tendon reflexes
40
What investigations are required for hyperkalaemia?
- 24hr urine volume and electrolytes
- FBC
- Capillary blood glucose
- ABG
41
What are the ECG findings of hyperkalaemia?
- Tall tented T waves (in all chest leads)
- Reduced/loss of P wave
- Widening of QRS
42
When are cardiac conduction disturbances most likely when caused by hyperkalaemia?
-When there is a rapid rise of potassium
43
How is hyperkalaemia managed?
- Calcium gluconate 10% - 10mls - over 1-2 minutes
| - Insulin immediate release and dextrose 10%
44
What is hypokalaemia?
<3.5 mmol/L
45
What are the severities of hypokalaemia?
- Mild: 3.1-3.5mmol/L
- Moderate: 2.5-3.0mmol/L
- Severe: <2.5mmol/L
46
What are most cases of hypokalaemia caused by?
-Diuretic consumption or loss of GI fluids through vomiting, chronic diarrhoea or laxative abuse.
47
What are the causes of hypokalaemia?
- Increased loss
- Transcellular shift
- Decreased intake of potassium
- Misc
48
What causes increased potassium loss via the kidney?
- Thiazide/loop diuretics
- Renal tubular acidosis
- Hypomagnesaemia
- Hyperaldosteronism
- Tubulointerstitial renal disease
- Excess liquorice ingestion
- Activation of RAAS system
49
What causes increased potassium loss via the GI tract?
- Diarrhoea
- Vomiting
- Intestinal fistulae
- Villous adenoma
- Pyloric stenosis
- Laxative abuse
- Bowel prep
50
What causes increased potassium loss via the skin?
- Burns
- Erythroderma
- Increased sweating
- Increased loss in sweat ie CF
51
What are the transcellular shift causes of hypokalaemia?
- Alkalosis
- Insulin and glucose administration
- Calcium channel blockers
- Hypothermia
52
What are the causes of decreased potassium intake?
- Inadequate potassium replacement on IV fluids whilst NBM
- Total parenteral nutrition
- Malnutrition
- Anorexia nervosa
53
How does hypokalaemia present?
- Generally asymptomatic
- General fatigue
- Generalised weakness
- Muscle pain
- Constipation
- Incidental findings
54
How does severe hypokalaemia present?
-Severe muscle paralysis
| >lower extremities moving upwards
55
What bloods are needed for hypokalaemia?
```
-Bloods:
>U&E, Bicarb, glucose, chloride, Mg
-ECG:
>Flat t waves, St depression, U waves, Ventricular arrhythmias
-Urine test
>urinary K+, NA+, osmolality
```
56
What is the management for hypokalaemia?
- Primary care for 2.5-3.0: compare with previous results, ECG, oral potassium replacement. -->40-120mmol/day
- TARGET: 4.5mmol/L
57
What electrolyte needs to managed before others can be corrected?
-Magnesium
58
What is secondary care management for hypokalaemia?
- Oral dose of 20-40mol K+ 2-4 times daily
| - IV KCL via peripheral line
59
What are the complications of hypokalaemia?
- Arrhythmias, sudden cardiac death
- Muscle weakness
- Abnormal renal function
- Iatrogenic hyperkalaemia
- Digoxin toxicity
60
How is calcium regulated within the body?
-Reduction in serum calcium stimulates PTH
>increases bone resorption
>increases renal calcium reabsorption
>stimulates renal conversion of 25-hydroxyvitamin D3 to 1,25 dihydroxyvitamin D3 (increases intestinal calcium absorption)
>negative feedback
61
What should serum calcium be?
2.25-2.5mol/L
62
Why should you use corrected (unbound) calcium?
-Not bound to albumin so free to take part in cellular activities such as neuromuscular contraction, coagulation
63
What is hypercalcaemia?
Calcium >2.5
64
What is the most common cause of hypercalcaemia?
-Primary hyperparathyroidism
| >usually in postmenopausal women
65
Mneumonic for hypercalcaemic presentation?
- STONES
- BONES
- GROANS
- MOANS
66
What symptoms may someone experience if they have hypercalcaemia?
- Polyuria/polydypsia
- Depression
- Cognitive impairment
- Muscle weakness
- Constipation
- Anorexia
- Abdominal pain
- Vomiting
- Dehydration
- Coma
67
What are the PTH mediated causes of hypercalcaemia?
-Primary hyperparathyroidism
68
What are the non-PTH mediated causes of hypercalcaemia?
- Malignancy
- Granulomatous conditions ie sarcoidosis
- Endocrine conditions ie thyrotoxicosis
- Drugs ie thiazide diuretics, vit A and D supplements
69
What are the 4 mechanisms that malignancy causes hypercalcaemia?
- Ectopic production of PTH related peptide by tumour cells
- Osteolytic hypercalcaemia
- Ectopic calcitriol
- Ectopic PTH produced by tumour cells
70
What imaging investigations are required for hypercalcaemia?
- X ray: bony abnormalities
| - US/CT: urogenital tract imaging >stones or calcification
71
What bony abnormalities may be detected by xray in someone with hypercalcaemia?
- Demineralisation
- Bone cyts
- Bony metastases
- Pathological fractures
72
What is the acute management of hypercalcaemia?
- Increase circulating volume with 0.9% saline
- Bisphosphonates
- Glucocorticoids
73
What is the management of asymptomatic hypercalcaemia?
- Conservative treatment with regular bone density monitoring, renal function, serum and urinary calcium levels
- regular mobilisation
74
What is the management of symptomatic hypercalcaemia?
Removal of parathyroid gland if impaired renal function, hypercalciuria, low bone mineral density, severe hypercalcaemia
75
What is hypocalcaemia?
serum calcium <2.1
76
What level of calcium can result in neuromuscular instability symptoms?
-<1.9
77
What are symptoms of hypocalcaemia?
- Parasthesia (around mouth, toes, fingers)
- Tetany
- Carpopedal spasm
- Muscle cramps
78
What are signs of hypocalcaemia?
- Chvosteks sign
- seizures
- prolonged QT interval
- Laryngospasm
79
What does prolonged hypocalcaemia cause?
- Subcapsular cataract
- Papilloedema
- Abnormal teeth
- Ectopic calcification
- Dementia and confusion
80
What are the most common causes of hypocalcaemia?
- Hypoparathyroidism
- Vitamin D deficiency/abnormal metabolism
- CKD
- Hypomagnesaemia
81
How should hypocalcaemia be investigated?
- Recheck blood sample
- Exclude CKD
- Check mg and p04
- Serum PTH and vit D
- ECG
82
How should acute hypocalcaemia be managed?
- Calcium gluconate 10% 10ml IV
| - Monitor and further infusion if necessary
83
How should persistent hypocalcaemia be managed?
-Supplementary calcium and vitamin D
84
What is hypernatraemia?
>145mmol/L
85
What are risk factors for hypernatraemia?
```
-Lack of independent access to water
>children
>elderly patients
>altered mental status
>hypothalamic lesions affecting sense of thirst
>critical illness causing AKI
```
86
What are the causes of AKI?
- Dehydration
- Hypotonic fluid loss
- Hypertonic sodium gain
- Intracellular shift of water (rare)
87
What are the causes of dehydration which may result in hypernatraemia?
- Inadequate water intake
- DI
- Thirst impairment ie dementia
88
What are the causes of hypotonic fluid loss?
-Dermal losses ie burns
-GI losses ie diarrhoea and vomiting
-Urinary losses
ie loop diuretics
89
What are the causes of hypertonic sodium gain?
- Iatrogenic ie tube feeding
- Excess salt ingestion
- Hyeraldosteronism
90
How does hypernatraemia present?
- CNS dysfunction ie lethargy, weakness, confusion
| - Dehydration ie dry mouth, oliguria, tachycardia
91
What investigations are required for hypernatraemia?
- U&E
- Plasma gluocse
- Urine and sodium osmolality
- Neuroimaging if required
92
What is the management of hypernatraemia?
- Treat underlying disorder if possible
- Correct dehydration and hypovolaemia
- Monitor progress
93
What are complications of hypernatraemia?
- Cerebral bleeding
- SAH
- Permanent brain damage
- Death
- Cerebral oedema (if overfast correction)
94
How is hyponatraemia classified?
- Acute vs chronic
| - Hypovolaemic vs hypervolaemic vs euvolaemic
95
What are normal sodium levels?
136-142.
Mild hyponatraemia <136
Severe hyponatraemia <120
96
How is sodium controlled?
- Kidneys regulate sodicum excretion and level of fluid in the body via the RAAS system.
- ADH plays a role in regulation
97
Which patient groups are at risk of hyponatraemia?
-Children and the elderly
98
What are the causes of hypovolaemic hyponatraemia?
- D+V
- Addison's disease
- Burns
- Excessive sweating
- Medications: diuretics
99
What are the causes of hypervolaemic hyponatraemia?
- Cardiac failure
- Cirrhosis
- Kidney failure
100
What are the causes of euvolaemic hyponatraemia?
- Neurological ie brain tumour or trauma
- Lung disorders ie lung cancer, pneumonia
- Cancers
- Medications ie SSRIs, PPI, ACEi
- Pain, postoperative, stress, endurance excercise
101
How does mild hyponatraemia present?
- Anorexia
- Headache
- Nausea
- Vomiting
- Lethargy
102
How does moderate hyponatraemia present?
- Personality change
- Muscle cramps
- Weakness
- Confusion
- Ataxia
103
How does severe hyponatraemia present?
- Drowsiness
| - Seizures
104
What are signs of hyponatraemia?
-Neuro signs: Altered consciousness, cognitive impairment, seziures
-Hypovolaemia signs: dry mucous membranes, tachycardia, reduced skin turgor
-Signs of hypervolaemia: pulmonary rales,
JVP^, peripheral oedema
105
What investigatinos are required for hyponatraemia?
- Fluid status
- Serum sodium and potassium
- Urine sodium level
- Serum TSH and free thyroxine level
- Random serum cortisol level
- Imaging
106
What is the acute management for hyponatraemia?
- Hypertonic 3% saline. 150ml over 15 min.
- repeat after 20 mins if no clincial improvement.
- Recheck Na at 6,12,24, 48hrs for over correction.
107
How should hypvolaemic hyponatraemia be treated?
-0.9% saline
108
How should hypervolaemic hyponatraemia be treated?
-Treat underlying cause. ie ccf, renal failure, liver cirrhosis
109
What are the 3 cardinal features of nephrotic syndrome?
- Proteinuria
- Oedema
- Hypoalbuminaemia
110
What is the aetiology of nephrotic syndrome?
-Often unknown
-Vasculitides
>HSP, SLE,
-Infections
-Allergens ie bee sting
111
What are the clinical features of nephrotic syndrome?
- Periorbital oedema (particularly on waking)
- Scrotal/Vulval oedema, leg and ankle oedema
- Ascites
- Breathlessness (pleural effusion)
112
What investigations are needed to look for nephrotic syndome?
- Urine protein (urine dipstick)
- Urine microscopy and culture
- Blood pressure
- Bloods (FBC, U+E, creatinine, albumin, complement levels - c3+c4 decrease), antistreptolysin O or anti-DNAase B and throat swab
113
What does histology of steroid sensitive nephrotic syndrome look like?
- Light microscopy: normal
- Electron microscopy: fusion of podocytes
* Minimal change disease*
114
What features suggest steroid sensitive nephrotic syndrome?
```
-Age between 1 and 10 years
>Peak between 2+5
-No macroscopic haematuria
-Normal blood pressure
-Normal complement levels
-Normal renal function
```
115
How is nephrotic syndrome managed?
- Oral corticosteroids (prednisolone) > 60mg/m2/day and reduced slowly from week 4.
- Blood pressure monitoring
- Fluid restriction/balance
- Salt restriction
- Prophylactic antibiotics
116
What are complications of nephrotic syndrome?
- Hypovolaemia
- Thrombosis
- Infection
- Hypercholesterolemia
117
Why does hypovolaemia occur as a complication from nephrotic syndrome?
-Peripheral vasoconstriction and urinary sodium retention
118
Why does thrombosis occur as a complication from nephrotic syndrome?
- Hypercoagulable state due to a loss of antithrombin in the urine
- Thrombocytosis can exacerbate steroid therapy
- Increased blood viscosity from raised haematocrit
- Increased synthesis of clotting factors
119
Why might someone develop an infection if they have nephrotic syndrome?
- Immunoglobulins lost in urine
| - Pneumococcus is most common infective bacteria
120
What are the causes of steroid resistant nephrotic syndrome?
- Focal segmental glomerulonephritis
- Mesangiocapillary glomerulonephritis
- Membranous nephropathy
121
How is steroid resistant nephrotic syndrome treated?
- Depends on the underlying cause of nephrotic syndrome
- Azothioprine
- DIuretics
- Salt restrictions
- ACEi
- NSAIDs
122
What are the 5 functions of the kidneys?
- Elimination of waste material
- Regulation of volume and composition of body fluid >BP regulation, electrolytes
- Endocrine functino > production of EPO and renin, activation of vit D
- Autocrine function > production of endothelin, prostaglandins, renal natriuretic peptide
- Acid base balance > regulares bicarbonate and H+ excretion
123
What drugs inhibit secretion of creatinine (and therefore eGFR)?
- Trimethoprim
- Cimetidine (histamine receptor antagonist)
- Ritonavir (treatment for HIV)
124
What is the role of the proximal convoluted tubule?
- Resorbs 70% of Na+.
| - Also absorbs glucose, bicarb and amino acids
125
What hormone acts mainly on PCT?
-Angiotensin II
126
What is the role of the distal convoluted tubule?
-Regulation of sodium re-absorption (therefore water reabsorption)
-Under the control of aldosterone
>also excretes K+ and H+
127
Why does hypokalaemia and alkalosis occur in Conn's syndrome?
-Conn's syndrome = hyperaldosteronism
>Na+ reabsorption and K+ excretion in DCT.
>K+ also pulls H+
=hypokalaemic and alkalosis
128
Why does Addison's disease cause a hyperkalaemic acidosis?
-Addison's disease = adrenal insufficiency
>impaired sodium reabsorption and K+ excretion
>hypotension
129
Which meds can cause hypokalaemia?
- Loop diuretics
| - Thiazide diuretics ie bendroflumethiazide, indapamide
130
Which meds can cause hyperkalaemia?
- spinonalactone
- amiloride
- ARB
- Trimethoprim
131
How do thiazide diuretics work?
-Block the Na+/Cl- channel in the DCT
| >Bendroflumethiazide
132
How do loop diuretics work?
-Block Na+K+Cl- in the loop of Henle
| >Furosemide
133
How do potassium sparing diuretics work?
-Block Na channels in the collecting duct
| >amiloride
134
How does spinoralactone work?
-Aldosterone antagonist
135
What can kidney stones be made of?
- CALCIUM OXALATE
- Uric acid
- Cysteine
- Calcium phosphate
- Struvite
136
Where are the 3 most common sites for kidney stones?
- Pelvoureteric junction
- Pelvic brim
- Uterovesicular junctino
137
What are risk factors for renal stones?
- Dehydration
- High calcium
- Cystinuria
- High dietary oxalate
- Renal tubular acidosis
- Kidney structural acidosis
138
What are risk factors for urate kidney stones?
- Gout
- Hyperuricaemia
- Ileostomy pts
- Myeloproliferative disorders
139
What are the causes of hyperoxaluria?
-Dietary causes: increased rhubarb, tea, spinach
140
Which meds increase risk of developing kidney stones?
```
-Drugs that promote calcium stones;
>loop diuretics
>steroids
>acetozolamide
>theophylline
```
141
What meds prevent calcium stones from forming?
-Thiazide diuretics
142
What are the clinical features of kidney stones?
- Renal colic. Severe intermittent loin pain (loin to groin pain)
- Writhing pain
- Haematuria
- Dysuria
143
Investigations for kidney stones?
- Urine dipstick and CR
- Serum Cr and electrolytes
- FBC/CRP
- Calcium/urate
- MSSU
- Plain KUB XR + CT
144
Management for kidney stones?
-Strong analgesia
-Most stones pass spontaneously
-Medications:
>alpha adrenergic blockers, calcium channel blockers
145
What are the indications for interventions in kidney stones?
- Persistent pain
- Infection above site of obstruction
- Failure of the stone to pass down the ureter
146
How is interventional removal of kidney stones performed?
- Shockwave lithotripsy
- Ureteroscopy
- Percutaneous nephrolithotomy
- Open surgery
147
How are calcium renal stones prevented?
- High fluid intake
- Low animal protein
- Low salt diet
- Thiazide diuretics
148
Why might flash pulmonary oedema occur in AKI?
-Reduced renal perfusion activates RAAS which reduces fluid clearance by the kidneys
=fluid overload
149
How should flash pulmonary oedema in AKI be managed?
- O2
- Diuretics (IV furosemide)
- Nitrates (GTN infusion)
- Opiates
- Haemodialysis if required
150
What is acute tubular necrosis?
- Necrosis of the renal tubular epithelial cells
| - In the early stages, it's reversible
151
What are the causes of acute tubular necrosis?
- Renal ischaemia
| - Toxins
152
What are the features of ATN?
- Raised urea
- Raised Cr
- Raised K+
- Muddy brown casts in the urine
153
What is acute interstitial nephritis?
-Inflammation of any part of the kidney
154
What are the causes of acute interstitial nephritis?
- Idiopathic
- Drugs ie penicillin, rifampicin, NSAIDs, allopurinol
- Infection ie staph
155
What is glomerulonephritis?
- A broad term that refers to a group of parenchymal kidney disease
- Causes: leaky glomeruli, hypertension, deteriorating kidney function
156
Nephritic vs nephrotic syndrome?
-Nephritic: hypertension, inflammation of the glomeruli, oliguria, haematuria (cola coloured) IgA neuropathy
-Nephrotic:
Hypoalbuminaemia, hyperlipidaemia, proteinuria, peripheral oedema
157
What are possible bone disease mainfestations of CKD?
- Osteitis fibrosa cystica (hyperparathyroid bone disease)
- Adynamic (reduction in cellular activity)
- Osteomalacia
- Osteosclerosis
- Osteoporosis
158
Which drugs need dose alterations if a patient has CKD because they accumulate?
- Most abx ie penicillins, cephalopsorins, gent, vanc
- Digoxin
- Atenolol
- Methotrexate
- Sulfonylureas
- Furosemide
- Opioids
159
What is the distribution of body fluid in an average 70kg person?
- Total volume: 42L
- Intracellular volume: 28L
- Extracellular volume: 14L (11L interstitium, 3L plasma)
160
What are physical signs (and symptoms) of hypovolaemia?
- Tachycardia
- Hypotension
- Reduced skin turgor
- Dry mucuous membranes
- Reduced urine output
- Weight reduction
- Thirst
- Dizziness
161
Which co-morbidities make a patient more at risk of hypervolaemia?
- Chronic kidney disease
- Heart failure
- Liver failure
162
What is third spacing?
```
-FLuid collects in parts of the body that it shouldn't collect ie
>pleural effusion
>ascites
>bowel obstruction
>obesity
```
163
When are crystalloid fluids used? What are some examples?
-Used when a patient needs hydrating (able to move into the extravascular space and nourish tissue)
>Hartmann's
>Normal saline
>5% dextrose
164
What are colloid fluids used for? what's an example?
-Used for hypovolaemic patients. (fluid remains in intravascular compartment ->increases blood volume)
-Commonly used in hypovolaemic shock
>Gelofusine
165
What is autosomal dominant polycystic kidney disease?
-Most common cause of inherited kidney disease
-2 types: PKD1 (chromosome 16 defect> presents with renal failure early)
PKD2 (chromosome 4 defect)
166
What is PKD associated with?
- Brain, liver and pancreatic cysts
- Aneurysms
- Diverticulae
- Mitral valve prolapse
167
What is vascular disease is PKD associated with
-Subarachnoid haemorrhage due to berry aneurysms
168
How do kidney cysts present?
- Polyuria and nocturia
- Enlarged kidney on US
- Renal colic (from increased risk of stones)
169
What investigations should be arranged for PKD?
- Family screening
- US
- CT scan
170
What is the management for PKD?
- Nephrectomy
| - Treat complications
171
What is the most common type of kidney cancer?
-Renal cell carcinoma (adenocarcinoma)
172
What are risk factors for renal cell carcinoma?
- Smoking
- Obesity
- Hypertension
- Tuberous sclerosis
- Renal failure and dialysis
- PKD
- Von Hippel Lindau syndrome
- Heavy metal industry
- Middle aged men
173
Where does kidney cancer commonly metastasise to?
- Lungs
| - Bones
174
What is the pathophysiology of renal cell carcinoma?
- Adenocarcinoma or the renal cortex
| - Arises from the proximal convulated tubule epithelium
175
How does renal cell carcinoma present in a classic triad?
- Haematuria
- Loin pain
- Abdominal mass
176
What other symptoms may someone present with if they have renal cell carcinoma?
- Fever of unknown origin
- Left varicocele (occlusion of left testicular vein)
- Endocrine effects: EPO>polycythaemia, PTH>hypercalcaemia, renin, ACTH
- Systemic features: malaise, weight loss
177
What are the paraneoplastic syndromes caused by renal cell carcinoma?
- Hypertension
- Cachexia
- Weight loss
- Amyloidosis
- Elevated ESR
- Anaemia
- Abnormal LFT
- Hypercalcaemia
- Polycythaemia
178
How is renal cell carcinoma investigated?
- USS
- CT
- MRI
- PET scan (for mets)
- Bone scan
179
Treatment for localised kidney cancer?
- Radical nephrectomy
- Partial nephrectomy
- Cyrotherapy
- Alpha interferon and interkeukin 2 (reduce tumour size)
180
What is the most common type of bladder cancer?
-Transitional cell carcinoma
181
What are risk factors for transitional cell carcinoma of the bladder?
- Smoking
- Exposure to aniline dyes in printing and textile injury
- Rubber manufacture
- Pelvic irradiation
182
What are risk factors for squamous cell carcinoma of the bladder?
- Schistosomiasis
- BCG treatment
- Smoking
183
What is the link between schistosomiasis and bladder cancer?
- Schistosomiasis = parasite that cuases chronic inflammation of the urinary tract
- 20 years later malignancy develops
- good prognosis
184
How does bladder cancer present?
- Painless haematuria
- Recurrent UTIs
- Voiding irritability
- LUTs
- Abdo pain
185
Investigations for bladder cancer?
- Urine dipstick
- Flexible cystoscopy (+/- transurethral resection of the bladder tumour)
- CT urogram
