1
Q
What is the cause of a kidney tubercle?
A
Chronic inflammation
2
Q
What are the 3 causes of kidney inflammation?
A
- Infection
- Acute Inflammation
- Immunological
3
Q
What are the 2 causes of kidney stones?
A
- Genetic
- Metabolic
4
Q
What is Potter Syndrome?
A
Bilateral renal agenesis
5
Q
Describe glomerular disease?
A
- Immunologically mediated
- HLA (human leukocytes antigen) association
6
Q
Give example of primary glomerular disease?
A
Glomerulonephritis (plural= Glomerulonephritides)
7
Q
Give 2 examples of secondary glomerular disease?
A
- Vascular
- Autoimmune ie. amyloid, SLE, diabetes
8
Q
Describe Type II Hypersensitivity kidney disease?
A
- Anti-GBM antibodies
- Complement fixation
- Diffuse Damage
- Fibrin leakage
- Proliferated parietal endothelial cells
- Focal disruption of BM
- Focal loss of foot processes
- Increase mesangial cells
- Cresent formation
9
Q
What is Type II hypersensitivity, autoimmune kidney disease called?
A
Goodpasture syndrome
10
Q
What are the clinical effects of Goodpastures syndrome/Type II Hypersensitivity?
A
- Fast
- Haematuria in early stages
- Some proteinuria
- Fibrin in urine
- Stop passing urine
- Lung involvement
11
Q
What are the causes of Goodpastures syndrome?
A
- Vasculitis ANCA
- SLE
- Organic solvents
12
Q
Describe Type III Hypersensitivity kidney disease?
A
- Immune complexes
- Size determines where deposition occurs
- Gets stuck & forms granular deposits, causes proliferation of endothelial & mesangial cells
13
Q
Describe Proliferative Glomerulonephritis?
A
- Type III hypersensitivity
- Immune complexes
- Increased mesangial cells
- Proliferated endothelial cells
14
Q
What are the clinical effects of Type III hypersensitivity/Proliferative Glomerulonephritis?
A
- Fast/slow
- Haematuria
- More/less urine
- Little proteinuria
- Pain due to swelling
15
Q
What are the causes of Type III hypersensitivity/Proliferative Glomerulonephritis?
A
- Postinfectious (strep.)
- Vasculitis ANCA
- SLE
16
Q
Describe the characteristics of Membranous Glomerulonephritis?
A
- Small immune complexes on the capillary walls
- Males>females
- 15% over 70yrs have cancer
- Hepatitis B
- Idiopathic
- Penicillamine
- SLE
17
Q
Describe Mesangiocapillary GN 1&2?
A
- Focal loss of foot processes
- Immune complexes
- Proliferated endothelial cells
- Increased mesangial cells
18
Q
What is the causes of minimal lesion GN?
A
- Type IV hypersensitivity
- Hodgkin lymphoma
- Remission with measles
19
Q
Who is typically effected with minimal lesion glomerulonephritis?
A
Children
20
Q
How do you treat minimal lesion glomerulonephritis?
A
Steroids
21
Q
What is a characteristic of minimal lesion glomerulonephritis?
A
- Marked proteinuria
- Present with nephrotic syndrome.
22
Q
Describe focal & segmental glomerulosclerosis?
A
- Differential minimal change
- Primary/secondary
- No Immune complexes
- Loads of Proteinuria
23
Q
What are the 3 diseases associated with nephrotic syndrome?
A
- Minimal change glomerulonephritis
- Focal & Segmental Glomerulosclerosis
- Membranous glomerulonephritis
24
Q
What does glomerular damage cause?
A
- Increase permeability of glomerular capillaries to protein
- Proteinuria
- Hypoproteinemia
- Oedema/ Hyperlipidemia
25
What are the 2 diseases associated with Nephritic syndrome?
1. Proliferative glomerulonephritis
| 2. Mesangiocapillary glomerulonephritis
26
What are the clinical signs/symptoms associated with nephritic syndrome?
- Haematuria
- Inflammatory
- Loin pain
- Less proteinuria
- Oliguria
27
What are 2 other causes of proteinuria?
1. Diabetes
| 2. Amyloidosis
28
What are the 3 common vascular diseases affecting the kidney?
- Hypertension
- Vasculitis
- Mesangial IgA disease
29
What causes tubulointerstitial disease?
- Drug hypersensitivity
- Acute tubular necrosis
- Ascending infection
- SLE
- Ischaemia
30
Describe potential causes of Haematuria?
- UTI, inflammation, vascular dilatation & blood cells leaking out of damaged vessels
- Trauma
- Macroscopic gross cancer, Bladder cancer.
- Kidney neoplasm, stone, bladder infection, tumour
31
Describe potential causes of acute renal failure?
- Tumour
- Shock: dehydrated, hypovalaemic
- Kidneys dont get enough circulation, metabolic shut down.
32
Describe potential causes of proteinuria?
- Hypertension
- Diabetes
- Leaky porous membrane to protein
- Amyloid or other primary glomerular disease
- Bladder/kidney infection
33
What is Vesicoureteric reflux?
- Reflux from bladder to ureter
| - Increased risk of infection
34
What is Renal Artery Stenosis?
- Congenital where artery doesn't develop
- Effected kidney is ischaemic so produces more renin which raises BP.
- Normal kidney exposed to much higher BP than normal, so suffering affects of hypertension
35
What are the 2 genetic causes of kidney disease?
1. Familial Mediterranean fever
| 2. Alport's syndrome
36
What is the Mesangial cell?
Central part of renal glomerulus between capillaries, mesangial cells are phagocytic & separated from capillary lumina by endothelial cells
37
What are the clinical effects of Membranous glomerulonephritis?
- Fast
- More urine initially & as renal failure occurs less
- Lots of proteinuria
- Oedema
- No pain due to no active inflammation
38
What are the clinical signs/symptoms of Nephrotic syndrome?
- Proteinuria
- Oedema
- Hyperlipidaemia
- Fall in plasma proteins
- Unlike nephritic, is slower, non-inflammatory.
39
What is the main difference between Nephrotic and Nephritic syndromes?
- NEPHROTIC syndrome involves the loss of a lot of PROTEIN
| - NEPHRITIC syndrome involves the loss of a lot of BLOOD
40
What buffers the pH in the body?
- Proteins
- Haemoglobin
- Carbonic acid/bicarbonate
41
Where is the acid/base excreted?
- Lungs
| - Kidneys
42
Which 3 scenarios result in acid-base balance disturbances?
1. Problem with ventilation
2. Problem with renal function
3. Overwhelming acid/base load the body can't handle
43
What are the normal pH levels?
7.35-7.45
44
What are the normal pO2 levels?
12-13 kPa
45
What are the normal pCO2 levels?
4.5-5.6 kPa
46
What are the normal bicarbonate levels?
22-26 mmol/l
47
How is standard bicarbonate calculated?
From actual bicarbonate but assuming 37oC & paCO2 of 5.3kPa
48
What does standard bicarbonate reflect?
Metabolic component of acid-base balance
49
What are the 4 steps to approach assessment of Arterial Blood Gases (ABG's)?
- Step 1: assess pO & oxygenation
- Step 2: assess pH
- Step 3: determine the primary problem
- Step 4: is compensation occuring?
50
What is the PaO2/FiO2 ratio or P/F ratio of a healthy individual?
>50
51
What is the PaO2/FiO2 ratio or P/F ratio of someone with acute lung injury?
<40
52
What is the PaO2/FiO2 ratio or P/F ratio of someone with ARDs?
<26.7
53
What does ARDS stand for?
Acute respiratory distress syndrome
54
1. If pH and pCO are changing in
the SAME direction the primary problem is _______?
2. If pH & pCO2 are changing in DIFFERENT directions the primary problem is _______?
1. Metabolic
| 2. Respiratory
55
What is compensation?
Altering in function of respiratory or renal system to change the secondary variable in an attempt to minimise an acid-base imbalance
56
1. If pCO2 & bicarbonate are moving in the SAME direction _______ is likely to be occuring?
2. If they are moving in DIFFERENT directions suspect __________?
1. Compensation
| 2. Mixed Disorder
57
How is anion gap calculated?
Sum of routinely measured cations in venous blood minus routinely measured anions
([Na+] + [K+]) - ([Cl-] + [HCO3-])
58
What does an increase anion gap signal?
Presence of metabolic acidosis
59
What is a normal anion gap?
16
60
How can an overwhelming acid load occur?
- Bodies own production
- Ingestion (exogenous source of aspirin or ethanol)
- Failure of excretion by kidneys
61
When does the body produce acid increasing anion gap?
- Whole body hypoperfusion: shock (cariogenic, septic, hypovolaemic)
- Part of body hypoperfusion: femoral artery embolism
62
What will hypoperfusion cause?
Increased anaerobic metabolism with subsequent increased production of lactic acid = LACTIC ACIDOSIS
63
In health what metabolises lactate?
Liver, process needs oxygen
64
What are 3 other causes of lactic acidosis?
1. Severe acute hypoxia
2. Severe convulsions (respiratory arrest)
3. Strenuous exercise (dehydration)
65
What does the addition of lactic acid do to ionogram?
- Increases the anion gap due to lactic acid being one of the unmeasured anions
- Bicarbonate falls
- Cl- & Na+ remain
66
Body produces acid when insulin _____ & glucagon _____?
1. Decreases
2. Increases
(leading to ketoacidosis)
67
What are the 3 different types of ketoacidosis?
1. Uncontrolled diabetes mellitus (severe, life-threatening)
2. Alcoholic ketoacidosis
3. Starvation ketoacidosis
68
What are the different accidental/deliberate exogenous acid load ingestions causing an increase anion gap?
- Methanol (industrial solvent, windscreen wash)
| - Ethylene glycol (anti freeze)
69
What are the 2 renal causes of metabolic acidosis?
1. Renal failure both acute & chronic (increase anion gap)
2. Renal tubular acidosis (normal gap)
70
What are the 2 possible causes of normal anion gap metabolic acidosis?
1. Diarrhoea
| 2. Renal tubular acidosis
71
What 3 processes increase due to diarrhoea?
1. Gut below pylorus secretes bicarbonate into gut lumen
2. For every bicarb ion into gut, H+ ion enters ECF
3. Volume depletion, so renin/angiotensin/aldosterone axis stimulated retaining Cl-
72
What does metabolic acidosis with normal anion gap look like on ionogram?
- Bicarb decreases
- Cl- increases
- Unmeasured anions & Na+ remain
73
What 3 other cases can show normal anion gap with metabolic acidosis?
1. Laxative abuse
2. Ileostomy
3. Colostomy
74
What is the compensation for metabolic problems?
1. RESPIRATORY
2. Slow metabolic (renal) correction- secrete more acid (& make new bicarb), plasma H+ decreases (pH rises) & plasma bicarb rises to normal
75
Compensation for metabolic problems can only occur if what 2 things are true?
1. Metabolic acidaemia is of non-renal origin
| 2. Kidneys are functioning effectively
76
What happens to the pCO2 to compensate for a metabolic acidosis?
- pCO2 must fall
| - Minute volume must increase upto ~30l/min but difficult to maintain
77
What is Kussmaul respiration?
Laboured deep, rapid pattern of breathing which is limited by tiredness
78
Why is Metabolic alkalosis (alkalaemia) the least common of acid-base disturbances?
Because kidneys are very good at excreting excess bicarbonate
79
What are the processes which have to happen during metabolic alkalosis (alkalaemia)?
1. Initiating process
| 2. Maintaining process
80
Describe the most common initiating process?
- Loss of H+ from gut (above pylorus), from kidney (furosemide & thiazide)
- Gain of exogenous alkali less common (massive blood transfusion)
81
Describe the 2 types of maintenance of the alkalosis?
- Chloride depletion group
| - Potassium depletion group
82
What happens to bicarbonate when chloride is low in renal tubular fluid?
Bicarbonate must be reabsorbed to maintain electrical neutrality
83
What are the 2 only anions present in appreciable quantities in ECF?
1. Chloride
| 2. Bicarbonate
84
What happens to pCO2 to compensate for metabolic alkalosis?
- pCO2 must increase
| - Minute volume must fall
85
What causes abnormal electrolytes?
- Primary disease state
- Secondary consequence of multitude of diseases
- Iatrogenic problems are very common
86
What is Iatrogenic?
Disease produced secondary to the treatment of the patient
87
How much [Na] & [K] are in ECF?
```
[Na]= 140mmol/L
[K]= 5mmol/L
```
88
How much [Na] & [K] are in ICF?
```
[Na]= 10mmol/L
[K]= 150mmol/L
```
89
What are the 2 major compartments in extracellular fluid?
- Plasma
| - Interstitial
90
What will happen when you decrease the volume of ECF by 4L?
Raise the concentration of any solute
91
What happens when you increase the excretion of a solute?
Decrease the solute concentration
92
What causes loss of isotonic solutions?
- Haemorrhage
| - Fistula fluid
93
What happens when you loose 2L of isotonic fluid?
- Loss is from ECF
- No change in [Na]
- No fluid redistribution
94
What causes loss of hypotonic solutions?
Dehydration
95
What happens when you loose 3L of hypotonic fluid?
- Greater loss from ICF than ECF
- Small increase in [Na]
- Fluid redistribution between ECF & ICF
96
What causes gain of isotonic fluid?
Saline drip
97
What happens when you gain 2L of isotonic fluid?
- Gain is to ECF
- No change in [Na]
- No fluid redistribution
98
What causes gain of hypotonic solution?
- Water
| - Dextrose
99
What happens when you gain 3L of hypotonic fluid?
- Greater gain to ICF than ECF
- Small decrease in [Na]
- Fluid redistribution between ECF & ICF
100
What are the 3 physiological compensatory mechanisms?
1. Thirst
2. ADH
3. Renin/Angiotensin system
101
What are the 3 therapeutic compensatory mechanisms?
1. Intravenous therapy
2. Diuretics
3. Dialysis
102
Describe ADH?
- Produced by median eminence & release increases when osmolality rises
- Decreases renal water loss
- Increases thirst
103
What are the simple tests to ascertain ADH status?
- Measure plasma & urine osmolality. Urine > plasma suggests ADH active
or
- Measure plasma & urine urea. Urine >> plasma suggests water retention
104
What activates the Renin-angiotensin system?
Reduced intra-vascular volume (IVV)
- Na depletion
- Haemorrhage
105
What does the Renin-angiotensin system cause?
Renal Na retention
106
What is the simple test to ascertain Renin-angiotensin status?
- Measure plasma & urine Na
| - If urine <10mmol/L suggests renin-angiotensin active
107
What happens when you replace the loss of 2L of isotonic fluid with isotonic fluid?
- No change in [Na]
| - No fluid redistribution
108
What happens when you replace the loss of 2L of isotonic fluid with hypotonic fluid?
- Fall in [Na]
| - Fluid redistribution
109
What happens when you replace the loss of 3L of hypotonic fluid with isotonic fluid?
- [Na] slightly increased
| - No fluid redistribution
110
What happens when you replace the loss of 3L of hypotonic fluid with hypotonic fluid?
- [Na] restored
| - Fluid redistribution
111
What is urea?
| Where is it filtered?
- Breakdown product of protein metabolism
| - Filtered at glomerulus
112
In dehydration what is 1st to show change?
Urea
113
What are often parallel to each other during fluid correction?
Sodium & Urea concentrations
114
When is urea elevated?
- CCF
- Shock
- MI
- Severe burns
115
What is Creatinine?
| Where is it filtered?
- Breakdown product of protein & muscle
| - Freely filtered at glomerulus
116
What happens to urea & creatinine in loss of renal function?
- Decrease in filtered volume
- Increase in plasma concentration
- Markers of renal dysfunction
117
What is the best overall measure of kidney function?
Glomerular filtration rate
118
What is Glomerular Filtration rate (GFR)?
Volume of fluid passing through glomerulus, in a given time period
119
What is glomerular filtration rate influenced by?
- Renal perfusion pressure
- Renal vascular resistance
- Glomerular damage
- Post-glomerular resistance
120
What is eGFR?
- "e" = estimated
- Aid "staging" of kidney disease
- Based on creatinine
121
Describe Hyponatraemia?
- Too little Na in ECF
- Excess water in ECF
- (pseudo hyponatraemia due to increase protein/lipid)
122
Describe Hypernatraemia?
- Too little water in ECF
| - Too much Na in ECF
123
Describe dehydration?
- Water deficiency
| - Fluid (Na & water) depletion
124
What 2 things can cause Hyponatraemia?
- Diuretics
| - Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
125
What 3 things can cause Hypernatraemia?
- Decreased water intake
- Osmotic diuresis
- Aldosterone
126
What 4 things are necessary to take into account when understanding electrolyte problems?
- Steady state conditions
- Patient's clinical state
- Effects of the compensatory mechanisms
- Drugs & infusions
127
What is the normal range of potassium?
3.6-5.0mmol/L
128
What can cause potassium values of <3.0 or >6.0?
- Cardiac conduction defects
| - Abnormal neuromuscular excitability
129
What is total body potassium determined by?
Total cell mass
| small proportion of total K+ in plasma
130
What is the potassium intake?
60-200mmol/day
131
What is the relationship of potassium to hydrogen ions?
- K+ & H+ exchange across cell membrane
| - Both bind to negatively charged proteins (Hb)
132
What happens to potassium during acidosis?
Moves OUT of cells --> hyperkalaemia
133
What happens to potassium during alkalosis?
Moves INTO cells --> hypokalaemia
134
What are the 2 Renal causes of hyperkalaemia?
- Acute renal failure
| - Chronic renal failure
135
What are the 2 Mineralocorticoid dysfunction causes of hyperkalaemia?
- Adrenocortical failure
| - Mineralocorticoid resistance ie. sprinonlactone
136
What is the cell death cause of hyperkalaemia?
Cytotoxic therapy
137
What is the treatment for hyperkalaemia?
- Correct acidosis
- Stop unnecessary supplements/intake
- Glucose & insulin drives potassium into cells
- Ion exchange resins: GIT potassium binding
- Dialysis: short & long-term
138
What are the 3 increased urine losses causing potassium depletion?
- Diuretics/osmotic diuresis
- Tubular dysfunction
- Mineralocorticoid excess
139
What are the 3 GIT losses causing potassium depletion?
- Vomiting
- Diarrhoea/laxatives
- Fistulae
140
What are the 2 hypokalaemia without depletion causes for potassium depletion?
- Alkalosis
| - Insulin/glucose therapy
141
What are the effects of chronic potassium depletion in ICF?
- Lethargy, muscle weakness, heart arrhythmias
- Polyuria, alkalosis (increase renal HCO3 production)
- Vascular
- Gut
142
What is the treatment of potassium depletion?
- Prevention: adequate supplementation
| - Replacement of deficit: oral (48mmol/day + diet), IV (<20mmol/L)
143
How do diuretics work?
Direct action on cells of the nephron to alter ionic pumps or indirectly to modify content of filtrate
144
What do diuretics cause an increase in?
Excretion of Na+ & water from body
145
What do diuretics cause a decrease in?
Net absorption of Na+ & Cl- ions from filtrate to cause natriuresis
146
Where are the 3 main sites of action of diuretics therapeutically?
1. Thick ascending loop of Henle
2. Early distal convoluted tubule
3. Collecting tubules & ducts
147
What are the most powerful diuretics?
Loop diuretics (furosemide)
148
Where do the loop diuretics work?
Act on thick ascending limb of loop of Henle
149
What does loop diuretics inhibit?
- Na+/K+/2Cl- carrier in luminal membrane
| - Thereby inhibit transport of NaCl out of tubule into interstitial tissue
150
What does loop diuretics increase?
Delivery of Na+ to distal tubule causing loss of H+ and K+
151
What may loop diuretics produce?
Metabolic alkalosis
152
What are the 4 indications that you would use loop diuretics in?
1. Pulmonary oedema due to LVF
2. Chronic heart failure
3. Resistant hypertension
4. Oedema
153
How are loop diuretics helpful in cardiac failure?
Reduce pre-load & contribute to venodilation, which helps after load
154
What are the 4 potential side effects of loop diuretics?
- Hypokalaemia
- Hypotension
- Urinary retention (if enlarged prostate)
- Gout
155
Where do thiazide diuretics act?
Distal tubule
156
What are the 2 main examples of thiazide diuretics?
- Bendroflumethiazide
| - Indapamide
157
How do thiazide diuretics work?
- Decrease reabsorption of Na+ & Cl- by binding to the Na+/Cl- co-transport system
- Inhibit co-transporter's action
158
What is the additional extra renal actions thiazide diuretics possess?
Produce vasodilatation
159
What are the 4 indications that you would use thiazide diuretics in?
- Hypertension
- Mild heart failure
- Severe resistant oedema
- Nephrogenic diabetes insipidus
160
What are the potential side-effects of thiazide diuretics?
- Increase cholesterol, glucose, uric acid, calcium
- Decrease potassium, sodium, magnesium, BP
- Metabolic acidosis
161
Where do potassium sparing diuretics act?
Collecting tubules
162
What are weak diuretics?
Potassium sparing diuretics
163
What are the 2 main examples of potassium sparing diuretics?
- Amiloride
| - Spironolactone
164
How do Amiloride & Trimterene potassium sparing diuretics work?
Blocking sodium channels controlled by aldosterone's protein mediator
165
How do Spironolactone & Eplerenone potassium sparing diuretics work?
Antagonists at aldosterone receptor
166
When would you use Potassium sparing diuretics?
Alongside K+ losing diuretics (loop or thiazide) to prevent K+ loss, esp if this loss could be hazardous
167
What are the 3 indications that you would use Spironolactone?
- Heart failure
- Conn's (primary hyperaldosteronism)
- Secondary hyperaldosteronism
168
What are the 3 potential side-effects of K+ sparing diuretics?
- Hyperkalaemia
- GI upset
- Metabolic acidosis
169
Give 1 example of an osmotic diuretic?
Mannitol
170
What are the indications for when you would use Mannitol?
Cerebral oedema + raised intra-ocular pressure
171
Give 1 example of diuretic combination?
Co-amilofruse
| amiloride + furosemide
172
What are the 2 indications for when you would use co-amilofruse?
- Oedema
| - Issues with medication compliance (1 pill rather than 2)
173
Give 1 example of carbonic anhydrase inhibitor?
Acetazolamide
174
What are the 2 indications for when you would use Acetazolamide?
- Mountain sickness
| - Glaucoma (v weak diuretic)
175
What does ABC stand for when talking about diuretics?
A- Furosemide
B- Bendroflumethiazide
C- Spironolactone
176
What does SIADH stand for?
Syndrome of inappropriate ADH secretion
177
Describe SIADH?
Inappropraite ADH secretion from posterior pituitary or from ectopic source despite low serum osmolality
178
What is SIADH associated with?
- Decreased sodium
- Increased urine osmolality
- Euvolaemia
179
What is SIADH caused by (4)?
1. Neurological- tumour, trauma, infection, GBS, MS, SLE
2. Pulmonary- lung small cell cancer, mesothelioma, pneumonia
3. Malignancy- stomach, pancreas
4. Drugs- thiazide & loop diuretics, SSRIs & PPIs
180
Describe the presentation of SIADH?
- Nausea
- Vomiting
- Cramps/tremors
- Depressed mood, irritability, personality change, memory issues, hallucinations
- Seizures
- Coma
181
What is Erythropoietin (EPO)?
Hormone produced by kidney (peritubular interstitial cells) that promotes RBC formation in bone marrow, process driven by anoxia
182
What happens when someones kidneys do not work?
Kidneys produce less EPO & person becomes anaemic
183
Describe the uses of Erythropoietin drug?
- Artificial version of hormone which can boost body to make RBC's
- 1/2 people on dialysis
- Some of the drugs are also called ESA (erythropoeisis stimulating agent)
184
What are the 3 naturally occurring Cortical hormones (adrenal hormones)
1. Glucocorticoids ie. cortisol
2. Mineralocorticoids ie. aldosterone
3. Androgens
185
What are the 2 naturally occurring Medullary hormones (catecholamines)?
1. Adrenaline
| 2. Noradrenaline
186
What are the 3 different synthetic glucocorticoids?
1. Topical steroids ie. beclomethasone
2. Inhaled steroids ie. budesonide
3. Oral or parenteral steroids ie. hydrocortisone, prednisolone, dexamethasone
187
What is the 1 example of synthetic mineralocorticoids?
Fludrocortisone
188
When would you use topical steroids?
Inflammatory skin conditions ie. eczema, psoriasis
189
When would you use inhaled steroids?
Asthma
190
When would you use oral steroids?
- IBD
- Asthma
- Acute transplant rejection
- Congenital adrenal hyperplasia
- Cerebral oedema
- Acute hypersensitivity
- Anaphylaxis
191
What are the potential side effects of synthetic glucocorticoids?
- Topical treatment can thin the skin
- Adrenal suppression/atrophy
- Psychiatric effects
- Diabetes
- Osteoporosis
- Cushing's syndrome
- Growth restriction
- Peptic ulceration
- Increased susceptibility to infections
192
What can synthetic glucocorticoids lead to?
Suppressive action on hypothalamic-pituitary-adrenal axis
193
What are the 2 indications for when you would use Fludrocortisone (mineralocorticoid)?
- Replacement in adrenocortical insufficiency
| - Addison's
194
What are the 3 potential side effects of Fludrocortisone (mineralocorticoid)?
- Hypertension
- Sodium & water retention
- Potassium & Calcium loss
195
How much of the Scottish population have at least 1 LTC (long-term chronic condition)?
~2million, 40%
196
What are the 6 quality dimensions?
1. Patient centred
2. Safe
3. Effective
4. Efficient
5. Equitable
6. Timely
197
What does HEAT stand for?
Health, efficiency, access & treatment targets
198
What are the 5 HEAT targets for LTC (2009-2010)?
1. T6- reduce long term conditions admissions/bed days
2. T7- improve quality of health care experience
3. T8- increase complex care at home
4. T10- reduce rate of attendance at A&E
5. T12- reduce 65+ emergency bed days
199
What are the 4 different levels to individualised stepped care, an organisational perspective?
Level 0- Inequalities targeted high risk primary prevention
Level 1- self management
Level 2- Poorly controlled single condition
Level 3- Complex co-morbidity
200
Describe Level 1: Self management?
Collaboratively helping individuals & their carers to develop the knowledge, skills & confidence to care for themselves & their condition effectively
201
Describe Level 2: Disease-specific care management?
Providing people with complex single need/multiple conditions with responsive, specialist services using multi-disciplinary teams & disease-specific protocols & pathways such as National Service Frameworks & Quality & Outcomes Framework
202
Describe Level 3: Intensive care/case management?
- Requires identification of very high intensity users of unplanned secondary care.
- Care patients is managed using case management approach, to anticipate, coordinate & join up health & social care
203
What is self-management?
- Concept where the person takes ownership & is central
- Process of becoming empowered to manage life with LTC
- Required individuals & health professionals working in partnership
204
What 3 things is self management concerned with?
- Problem solving
- Decisions making
- Confidence
205
What are the 5 principles of self-management?
1. Be accountable to me & value my experience
2. I am the leading partner in management of my health
3. I am a whole person & this is for my whole life
4. Self management does not mean managing my LTC alone
5. Clear information helps me make decisions that are right for me
206
What are the 3 roles of self-management programmes?
1. Do not conflict with existing programmes or treatment
2. Designed to enhance regular treatment & condition-specific education
3. Teach patients skills to co-ordinate all the things needed to manage health & keep active
207
What are the treatment of choice for people with persistent pain?
Pain management programmes based on cognitive behaviour principles
208
What is self-efficacy (Bandura)?
The belief in ones capabilities to organise & execute the course of action required to manage prospective situations
209
What 4 things does self-efficacy influence?
1. Choices we make
2. Effort we put in
3. How long we persist when we have obstacles in our way
4. How we feel
210
What do people with low/high self-efficacy tend to do?
- LOW self-efficacy toward task are more likely to AVOID it
| - HIGH self-efficacy toward task are more likely to ATTEMPT it
211
What 5 things is self-efficacy based on?
1. Past performance
2. Vicarious experiences
3. Verbal experiences
4. Physiological cues
5. NOT a stable trait
212
What does EPP stand for?
Expert Patient Programme
213
What is EPP?
6 weekly Self-management programme for people living with a long-term (chronic) condition
214
The aim of EPP is to support people by what 3 things?
1. Increase their confidence
2. Improve their quality of life
3. Helping them manage their condition more effectively
215
What 6 topics does the initial EPP course cover?
1. Dealing with pain & extreme tiredness
2. Coping with feelings of depression
3. Relaxation techniques & exercises
4. Healthy eating
5. Communicating with family, friends and healthcare professionals
6. Planning for the future
216
What does KPMP stand for?
Kingdom Chronic Pain Self-Management Programme
217
What is the KPMP?
- 10 weekly sessions
- 2-2.30hrs
- Delivered by multidisciplinary team in primary/secondary care
- Education & guided practice on pain, healthy function, problem-solving, relaxation
- Cognitive behavioural principles
218
What does the KPMP aim to improve?
Physical, psychological, emotional & social dimensions of quality of life of people with chronic pain
219
What are the 10 contents of KPMP?
1. Introduction to Pain Management
2. Understanding Chronic Pain
3. Setting Goals & Pacing Your Activities
4. Positive responses to Pain
5. Getting Fitter & Being More Active
6. Managing Your Medicines & Managing Sleep Problems
7. Everyday Activities
8. Relationships & Assertiveness
9. Managing Stress & Problem Solving
10. Flare-ups & Maintenance
220
What are 2 good examples of programmes with help to achieve effective management of chronic conditions in the UK?
1. The Expert Patients Programme (NHS England)
| 2. ALLIANCE (Scotland)
221
What is the meaning of equality?
Sameness
222
What is the meaning of inequality?
Unequal
223
What is the meaning of equity?
Fairness
224
What is the meaning of inequity?
Unfair or Unjust
225
What does the inverse care law state?
Availability of good medical care tends to vary inversely with the need for it in the population served
226
What 3 things can measure health inequalities?
- Measuring Health need
- Measuring access to healthcare
- Measuring quality of healthcare
227
What does Aristotle's theory of distributive justice definite horizontal equity as?
Equity between people with the same health care needs
228
What does Aristotle's theory of distributive justice definite vertical equity as?
Those with unequal needs should receive different or unequal healthcare
229
Describe "felt" need?
Individual perceptions of variations from normal health
230
Describe "expressed" need?
Individual seeks help to overcome variation from normal health (demand)
231
Describe "normative" need?
Professional defines interventions appropriate for the expressed need
232
Describe "comparative" need?
Comparisons between needs for severity, size, range of interventions, cost
233
What are examples of causes of Calculi?
- Hypercalcaemia ie. sarcoid, renal tubular acidosis, hyperPTHism
- Gout
- Obstruction ie. vesico-ureteric reflux
- Genetic
- Dehydration
234
What makes up a calculi?
- Calcium 25%
- Uric acid 20+% (can't see on plain x-ray)
- Infection
- Cystine 1%
235
Describe the characteristics of bladder disease?
- Inflammation
- Infection
- Calculi
- Neoplasia
236
What are the 2 common urinary tract neoplasms/tumours?
1. Bladder- urothelial (transitional cell) carcinoma
| 2. Renal- 4/5 are clear cell carcinoma (ccRCC)
237
What are the 4 uncommon urinary tract neoplasms/tumours?
1. Renal carcinomas other than clear cell including transitional cell
2. Renal nephroblastoma (Wilm's Tumour)
3. Ureter transitional cell carcinoma
4. Renal/bladder sarcoma
238
Describe Wilm's tumour?
- Children
- WT1 tumour suppressor gene
- Histology resembles immature or embryonal blastema
- Younger patients have better prognosis
- Surgery, radio, chemo leads to 90% survival
239
Describe Renal Cell Carcinoma?
- Originates in ducts esp PCT
- Commonest type is "clear cell" due to glycogen
- Papillary, chromophobe
- Mostly sporadic
- Smoking & obesity
- Genetics
- Grows along renal vein to IVC
240
What are the 3 types of genetic susceptibilities for Renal Cell Carcinoma?
1. von Hippel-Lindae Syndrome
2. autosomal dominant RCC
3. Hereditary papillary
241
Who is more prone to Renal Cell Carcinoma (RCC) men or women?
Men > Women
242
Describe the clinical presentation of Renal Cell Carcinoma (RCC)?
- Haematuria most common
- Pain
- Metastases
- Paraneoplastic syndromes ie. pyrexia, hormones (EPO)
243
When do "cannonball lesions" occur?
When Renal Cell Carcinoma metastasises to lung
244
What is the % of 5 year survival rate for Renal Cell Carcinoma?
50% but very stage dependant
245
What are the 3 different types of localisation for bladder (urothelial) cancer?
1. Posterior & lateral wall 70%
2. Trigone & bladder neck 20%
3. Dome 10%
246
What is the typical pattern of bladder (urothelial) cancer?
Papillary 80%
247
What is the aetiology of bladder (urothelial) cancer?
- Smoking
| - Industrial ie. aniline dyes
248
What is the presentation of bladder (urothelial) cancer?
- Haematuria
- Dysuria
- Obstruction
- Tend to recur
249
What are the 3 different types of acute/chronic renal failure?
1. Pre-renal
2. Renal
3. Post-renal
250
What are the different "pre-renal" causes of acute renal failure?
- Shock
| - Major trauma
251
What are the different "renal" causes of acute renal failure?
- Some glomerulo-nephritides
- Toxic ie. drugs, Analgesics
- Malignant
- Hypertension
- Vasculitis
252
What is the "post-renal" cause of acute renal failure?
Obstruction
253
What are the features of acute renal failure?
- Potassium high
- Creatinine high
- May be oliguria
- Hypertension
- Lipids in nephrotic syndrome
254
What is the "pre-renal" cause of chronic renal failure?
Atherosclerosis
255
What are the "renal" causes of chronic renal failure?
- Glomerulonephritis
- Diabetes
- Hypertension
- Polycystic
256
What is the "post-renal" cause of chronic renal failure?
Obstruction
257
What are the effects of chronic renal failure?
- Potassium high
- Creatinine high
- May be oliguria
- Hypertension
- Anaemia
- Small kidneys due to scarring
258
Give some examples of intrinsic and extrinsic obstructive uropathy?
- Ureteropelvic stricture
- Transitional cell carcinoma of renal pelvis
- Ureteral stone
- Blood clot
- Pregnancy
- Urothelial carcinoma
- Urethral stricture
259
What is hydronephrosis?
- Distension & dilation of renal pelvis & calyces, usually caused by obstruction of free flow of urine from kidney
- Must be bilateral for Post-renal failure/ unilateral if patient has 1 kidney
260
List some potential causes of bladder outflow obstruction leading to post-renal renal failure?
- Prostate enlargement in men
- Uterine prolapse in women
- Calculi
- Tumours
- Urethral strictures
- Neurological damage
261
What are the different intrinsic causes of obstruction leading to post-renal renal failure?
- Within the wall: intrinsic tumour ie. transitional cell carcinoma
- In the lumen: calculi, blood clot etc
262
What are the clinical features of renal failure?
- Anaemia
- Immunosuppression
- Bone disease
- Neuropathy
- Neoplasia
263
What is Renal Osteodystrophy?
- Bone disease when your kidneys fail to maintain proper levels of calcium and phosphorus in the blood
- It's common in people with kidney disease & affects dialysis patients
264
What is the purpose of renal replacement therapy?
- Electrolytes
- Fluid
- Excretion
- Erythropoietin
265
Describe haemodialysis?
- Blood inflow then goes through semipermeable membrane
- Dialysate return
- Negative pressure
- Dialysate inflow
- Blood return
266
Describe Peritoneal Dialysis?
Dialysate absorbs waste & fluid from blood, using your peritoneum as a filter to clean blood
267
What does continues ambulatory peritoneal dialysis need?
Permanent catheter
268
What are the different potential donors for transplantation?
- Cadaveric
- Live related
- Liver unrelated
269
What 3 risks does immunosuppression during transplantation cause?
- Risk of infection ie. BK virus
- Risk of skin cancer ie. HPV
- Risk of lymphoma
270
What are the 4 different types of transplantation rejection?
- Acute cellular rejection
- Acute antibody mediated rejection
- Acute vascular rejection
- Chronic allograft nephropathy (chronic rejection)
MD3002
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