Renal Revision - countdowntofinalsdotnet.files.wordpress.com · Renal Revision Ersong Shang [email protected] . AKI 56 y.o. female was admitted to hospital after 48hrs of D+V.

Renal Revision

Ersong Shang

[email protected]

AKI 56 y.o. female was admitted to hospital after 48hrs of D+V. Her most recent obs are RR 12, HR 110, BP 80/40, she tells you she can’t remember the last time she passed urine. Her bloods on admission are as follows. What would be your immediate fluid management? A. 5% Dextrose STAT B. 0.9% NaCl + 40mmol KCl STAT C. Hartman’s STAT D. 0.9% NaCl over 4hrs E. Hartman’s over 4hrs

Na 148 K 2.9 Ur 19 Cr 200

AKI 86 year old male was admitted to hospital after being found collapsed at home. His initial obs are RR 12, HR 110, BP 80/40. His initial bloods are as follows.

What would be your resuscitation fluid of choice?

A. Hartman’s

B. 1.24% NaHCO3

C. 0.9% NaCl

D. 0.18% NaCl+4% Dextrose

E. 5% Dextrose

Na 148 K 6.8 Ur 19 Cr 200 CK 2000

AKI • Pre-renal - volume depletion, renovascular

• Renal – glomerulus, tubular, interstitium, vascular

• Post-renal – urinary outflow obstruction, vesicoureteric reflux

KDIGO definition and grading of AKI

Fluids • 0.9% NaCl – 154mmol Na+, 154mmol Cl-

• Hartman’s – 131mmol Na+, 5mmol K+, 2mmol Ca2+, 29mmol Lac-, 111mmol Cl-

• 5% Dextrose – 5g of Dextrose in 100ml (50g in 1L)

• 2g MgSO4 – 8mmol Mg2+

• 10ml 10% CaCl2 – 6.8mmol Ca2+

• 10ml 10% Ca2+ gluconate – 2.25mmol Ca2+

CKD • 80 y.o. male with eGFR of 35mL/min/1.73 m2.

What stage CKD does he have?

A. 1

B. 2

C. 3a

D. 3b

E. 4

CKD • 65 y.o. Female with newly diagnosed T2DM.

HbA1c 8%, BP 140/80. Urine dipstick showed trace protein, repeat urine biochemistry showed 50mg/day protein loss. What medication would you like to start to improve her renal outcome?

A. Aspirin

B. ARB

C. Simvastatin

D. Clopidogrel

E. ACE I

CKD

Microalbuminuria – 30-300mg/day Nephrotic - >3.5g/day

UTI

• 67 y.o. female patient presents to GP and describes dysuria and frequency, urine dip is +ve for leucocytes and nitrites. What is your empirical treatment?

A. Vancomycin

B. Trimethoprim

C. Ciprofloxacin

D. Tazocin

E. Gentamicin

Drugs and kidney

• 27 y.o. female inpatient describes dysuria and frequency, urine dip is +ve for leucocytes and nitrites. She is started on a 3 day course of trimethoprim empirically. On day 2 her routine bloods show her creatinine increased from 67 to 95. What is your next course of action?

A. IV fluids

B. Stop trimethoprim

C. Nothing

D. Dialysis

E. Transplant

Drugs and kidney • Isolated/disproportionate rise in Ur – pre-renal AKI, large protein

meal/UGIB

• Isolated/disproportionate rise in Cr – trimethoprim, cimetidine

• Loop diuretics (furosemide) - ↓Na ↓K ↓Ca

• Thiazide (bendroflumethiazide) - ↓Na ↓K ↑Ca

• NSAIDs – increases afferent arteriolar tone, therefore decreases glomerular perfusion pressure, Na and water retention, analgesia nephropathy (Chronic TIN, papilla necrosis and sloughing)

• ACE I, ARB (ramipril, losartan) – decrease efferent arteriolar tone, therefore decrease glomerular perfusion pressure

• Spironolactone – anti-androgen (gynaecomastia)

• Amiloride – loss of salt taste

• K sparing diuretics (ACE I/ARB, mineralocorticoid antagonists, ENaC blockers) – hyperkalaemia

• Gentamicin, myoglobin, uric acid, oxalate – form crystals, ATN/ATIN

• Gold, penicillamin – membranous GN

• Tetracycline (demeclocycline) – Anti-ADH effect

Drug’s and the Kidney

Thick

Ascending

Loop

Proximal

Tubule

Distal

Convoluted

Tubule

Collecting

Duct

Bowman’s

Capsule

Afferent

Efferent


Thick

Ascending

Loop

Proximal

Tubule

Distal

Convoluted

Tubule

Collecting

Duct

Bowman’s

Capsule

Afferent

Efferent

HCO3-

Amino acid Glucose

Na+

H2O

H2O

Cl- K+

Na+

2Cl-

K+

Na+

Na+ K+

K+ H+

Urea

Counter-current system

generating osmotic gradient in

adrenal medulla

Aquaporins H2O

(50%)

(40%)

(5%)

H2O

H2O PO4

2-

MD/JGA


Thick

Ascending

Loop

Proximal

Tubule

Distal

Convoluted

Tubule

Collecting

Duct

Bowman’s

Capsule

ACE Afferent

Efferent

MD/JGA

HCO3-

Amino acid Glucose

Na+

H2O

H2O

Cl- K+

Na+

2Cl-

K+

Na+

Na+ K+

K+ H+

Aldosterone

Urea



adrenal medulla

Aquaporins H2O

Renin Angiotensin I

Angiotensin II

(50%)

(40%)

(5%)

(2%)

ADH

H2O

Prostaglandins

H2O PO4

2-

Angiotensin II

Prostaglandins


Thick

Ascending

Loop

Proximal

Tubule

Distal

Convoluted

Tubule

Collecting

Duct

Bowman’s

Capsule

NSAIDS

ACE Afferent

Efferent

MD/JGA

HCO3-

Amino acid Glucose

Na+

H2O

H2O

Cl- K+

Na+

2Cl-

K+

Na+

Na+ K+

K+ H+

Thiazides

Loop

Diuretics

Aldosterone

Urea



adrenal medulla

Aquaporins H2O

Renin Angiotensin I

Angiotensin II

(50%)

(40%)

(5%)

(2%)

ADH

AIIRB’s

Spironolactone

H2O

Delmecocycline

Prostaglandins

Vaptans

H2O PO4

2-

ACEi

Angiotensin II

ACEi

Prostaglandins

NSAIDS


Thick

Ascending

Loop

Proximal

Tubule

Distal

Convoluted

Tubule

Collecting

Duct

Bowman’s

Capsule

NSAIDS

Fanconi

Syndrome

ACE Afferent

Efferent

MD/JGA

HCO3-

Amino acid Glucose

Na+

H2O

H2O

Cl- K+

Na+

2Cl-

K+

Na+

Na+ K+

K+ H+

Thiazides

Loop

Diuretics

Aldosterone

Urea



adrenal medulla

Aquaporins H2O

Type 2

RTA

Renin Angiotensin I

Angiotensin II

(50%)

(40%)

(5%)

(2%)

ADH

AIIRB’s

Spironolactone

H2O

Delmecocycline

Prostaglandins

Vaptans

Type 1

RTA

Type 4

RTA

H2O PO4

2-

Angiotensin II

ACEi

Prostaglandins

NSAIDS


Thick

Ascending

Loop

Proximal

Tubule

Distal

Convoluted

Tubule

Collecting

Duct

Bowman’s

Capsule

NSAIDS

Fanconi

Syndrome

ACE Afferent

Efferent

MD/JGA

HCO3-

Amino acid Glucose

Na+

H2O

H2O

Cl- K+

Na+

2Cl-

K+

Na+

Na+ K+

K+ H+

Thiazides

Loop

Diuretics

Aldosterone

Urea



adrenal medulla

Aquaporins H2O

Type 2

RTA

Renin Angiotensin I

Angiotensin II

(50%)

(40%)

(5%)

(2%)

ADH

AIIRB’s

Spironolactone

H2O

Delmecocycline

Prostaglandins

Vaptans

Type 1

RTA

• Idiopathic

• Tubulointerstitial

disease

• TIN

• Amyloid

• Myeloma

• Tetracyclines

• Lead

• Mercury

• Tubulointerstitial disease

• Nephrocalcinosis

• Autoimmune/lithium/amphotericin

Type 4

RTA

• Idiopathic

• Congenital

• Cysteinosis

• Galactosaemia

• Glycogen storage

disease

• Wilson’s disease

• Acquired

• Heavy metal

• Myeloma

• Amyloid

• Out-of-date

tetracycline

H2O PO4

2-

Angiotensin II

ACEi

Prostaglandins

NSAIDS

ADPKD • 45 y.o. female with a family history of APKD is

worried that she may also be affected by the condition. What modality of screening would you offer her?

A. US abdomen

B. Chr 16 mutation screening

C. Chr 4 mutation screening

D. CT abdomen

E. Urine dip

ADPKD • 45 y.o. female with a family history of APKD is

worried that she may also be affected by the condition. You decide to offer her US screening. Which of the following results would highly suggest a diagnosis of APKD?

A. 1 cyst in L kidney, liver cyst also noted

B. 2 cysts in R kidney 3 cysts in L kidney

C. 3 cysts in R kidney, pancreatic cyst also noted

D. 4 cysts in L kidney

E. 1 cyst in R kidney, 2 cysts in L kidney, both liver and pancreatic cysts are noted

ADPKD • Chr 16 PKD1, Chr4 PKD2

• Associated with liver, pancreatic cysts, mitral valve prolapse, cerebral artery aneurysms

• Screened by US – modified Ravine’s Criteria for diagnosis

15-39 – 3 cysts unilateral or bilateral

40-59 - >2 cysts in both kidney

• Patients advised on high fluid, low salt intake, tight control of BP

• Complications include bleed into cysts, recurrent infections, HTN, polycythaemia, ESRF

Post-strep vs IgA • 25 y.o. male presents to his GP with bloody urine. He is

normally fit and well, except for 2 weeks ago when he developed some sore throat. Urine dip showed ++++ blood, + protein with no nitrites or leucocytes. BP was 170/100. He was referred to renal team, and a renal biopsy was taken. Which of the following pathology reports would most likely match his condition?

A. Subendothelial immune complex deposition (‘tram-line’)

B. IgG immune complex deposition

C. IgA deposition

D. Crescentic aggregates in Bowman’s space

E. Kimmelstiel-Wilson nodules

Glomerulonephritis

• Nephrotic - >3.5g/day proteinuria, hypoalbuminuria, oedema (+hypercoagulable, hyperlipidaemia)

• Nephritic – haematuria, minimal proteinuria, hypertensive, rapidly deteriorating renal functions

IgA nephropathy – related to HSP (systemic manifestation of IgA nephropathy), occurs during infections

PSGN – due to immune complex deposition, 1-12 wks post Group A strep (Strep. pyogenes)

Buzzwords • Podocyte effacement – minimal change

• Thickened BM, ‘spikes’ on silver stain – membranous

• MCGN – Subendothelial immune complex deposition (‘tram-line’)

• Diabetes – Kimmelstiel-Wilson nodules

• Amyloidosis – applegreen birefirengence on Congo Red stain

• Lupus nephritis – ‘wire loop capillaries’

• RPGN – crescents

• Anti-GBM – linear immunofluorescent

• ANCA +ve vasculitis – negative immunofluorescent, ‘pauci-immune’

• Immune complex mediated GN – granular immunofluorescent

Alport • 20 y.o. male with a family history of SNHL and progressive

renal failure in adolescence, received a kidney transplant recently. He initially recovered well after the transplant, however has now recently developed hypertension, haematuria and rapidly progressive renal failure. Which of the following antibody would you expect him to have high titres?

A Anti-dsDNA

B C3 nephritic factor

C. Anti-PR3 (C-ANCA)

D. Anti-MPO (P-ANCA)

E. Anti-GBM

Ureteric calculi • 50 y.o. male presents to A+E with severe colicky

pain, radiating from loin to groin. CT KUB was done which showed a ‘0.4 mm calculi at the PUJ, with no evidence of pelvic dilatation’. Blood tests are unremarkable. What is your management plan?

A. Tamsulosin + analgesia B. ESWL C. PCNL D. Percutaneous nephrostomy E. Ureteric stent

Renal Revision - countdowntofinalsdotnet.files.wordpress.com · Renal Revision Ersong Shang [email protected] . AKI 56 y.o. female was admitted to hospital after 48hrs of D+V.

Documents