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Nephrology: Nephritic, Nephrotic, UTI, Renal Function

Ellie Britt Year 4 Medicine English 72 cards

Cards in this deck (72)

  1. 1Glomerulus structure and charge Epithelial pouch invaginated by capillary tuft
     Semi-permeable filter
     Endothelium
     Basement membrane
     Epithelium
     Mesangial cells are specialised smooth muscle cells that support the glomerulus and regulate blood flow and GFR
     GBM is –vely charged → retention of anionic proteins such as albumin which are small enough to pass.
  2. 2% cardiac output that kidneys receive % blood volume filtered?25%
    (1200ml/min)
    20% of blood volume is filtered (~250ml/min)
  3. 3Na reabsorption purpose and trigger Main factor determining extracellular volume
    ↓BP and ↓NaCl @ macula densa (DCT) → renin release → aldosterone release → more Na/K pumps.
  4. 4Water reabsorption triggerDetermines ECF osmolality
    ↑osmolality or ↓BP → ADH release
  5. 5Nephron physiology: PCTReabsorption of filtrate
     70% of total Na+ reabsorption
     Reabsorption of amino acids, glucose, cations
     Bicarbonate reabsorbed using carbonic anhydrase
  6. 6Thick Ascending Limb physiologyCreation of osmolality gradient
     20% of Na reabsorption
     Na/K/2Cl triple symporter
  7. 7DCT physiologypH and Ca reabsorption
     5% of Na reabsorption
     Apical NaCl co-transporter
     Ca2+ reabsorption under control of PTH
  8. 8Medullary and cortical collecting duct physiologyMedullary CD: pH and K regulation
     Na reabsorption coupled to K or H excretion
     Basolateral aldosterone-sensitive Na/K pump
    Cortical CD: Regulation of water reabsorption
     Water reabsorption controlled by aquaporin-2 channels
  9. 9Endocrine function of the kidney Secretion of renin by juxtaglomerular apparatus
     EPO synthesis
     1α-hydroxylation of vitamin D (controlled by PTH)
  10. 10Loop diuretics - examples - MOA - effect - use - SEfursemide, bumetanide
     MOA: inhibit Na/K/2Cl symporter in thick ascending limb
     Effect: massive NaCl excretion, Ca and K excretion
     Use: Rx of oedema – CCF, nephrotic syndrome, hypercalcaemia
     SE: hypokalaemic met alkalosis, ototoxic, Hypovolaemia
  11. 11Thiazide diuretics - example - MOA - effect - use - SEbendroflumethazide
     MOA: inhibit NaCl co-transporter in DCT
     Effect: moderate NaCl excretion, ↑ Ca reabsorption
     Use: HTN, ↓ renal stones, mild oedema
     SE: ↓K, hyperglycaemia, ↑ urate (CI in gout)
  12. 12K-sparing diuretics - examples - MOA - effect - use - SEspironolactone, amiloride
    MOA
     Spiro: aldosterone antagonist
     Amiloride: blocks DCT/CD luminal Na channel
    --> Effect: ↑ Na excretion, ↓K and H excretion
     Use: used c¯ loop or thiazide diuretics to control K loss, spiro has long-term benefits in aldosteronsim (LF, HF)
     SE: ↑K, anti-androgenic (e.g. gynaecomastia)
  13. 13Osmotic diuretic - example - MOA - effect - use - SEmannitol
     MOA: freely filtered and poorly reabsorbed
     Effect: ↓ brain volume and ↓ ICP
     Use: glaucoma, ↑ICP, rhabdomyolysis
     SE: ↓Na, pulmonary oedema, n/v
  14. 14causes of haematuria (renal and extra-renal)Renal
     Congenital: PCK
     Trauma
     Infection: pyelonephritis
     Neoplasm
     Immune: GN, TIN
    Extra-renal
     Trauma: stones, catheter
     Infection: cystitis, prostatitis, urethritis
     Neoplasm: bladder, prostate
     Bleeding diathesis
     Drugs: NSAIDs, frusemide, cipro, cephalosporins
  15. 15false positive for haematuriamyoglobin, porphyria
  16. 16proteinuria values 30mg/dL = 1+
     300mg/dL = 3+
    PCR < 20mg/mM is normal, >300 = nephrotic
  17. 17causes of proteinuriaCommonest
     DM
     Minimal change
     Membranous
     Amyloidosis
     SLE
    Other
     HTN (inc. PET)
     ATN, TIN, UTI
     Fever, orthostatic
  18. 18false negative proteinuriaBence Jones protein
  19. 19Microalbuminuria - what - causes Albumin 30-300mg/24h
     Causes: DM, ↑BP, minimal change GN
  20. 20cellular urinary casts RBC: glomerular haematuria
     WBC: interstitial nephritis or pyelonephritis
     Tubular: ATN
  21. 21urine findings in: - glomerular disease - tubular - pre-renal - CRFGlomerular : Haematuria, proteinuria, red cells / casts
    Tubular: White cell casts, small protein, leukocyturia
    Pre-renal: Nothing
    CRF: Depends on cause
  22. 22What is creatinine? How is it filtered? Why raised? Creatinine is synthesised during muscle turnover.
     Freely filtered and small proportion secreted by PCT
     ↑ muscle → ↑ creatinine: age, sex, race
     Plasma Cr doesn’t ↑ above normal until 50% ↓ in GFR
  23. 23urea - what - increased/decreased when? - reabsorption Produced from ammonia by liver in ornithine cycle
     ↑ c¯ protein meal (e.g. upper GI bleed, supplements)
     ↓ c¯ hepatic impairment
     10-70% is reabsorbed: depends on urine flow.
     ↓ flow → ↑ urea reabsorption (e.g. in dehydration)
  24. 24Isolated ↑ urea vs. ↑ U and ↑ CrIsolated ↑ urea = ↓ flow (i.e. hypoperfusion / dehydration)
    ↑ U and ↑ Cr = ↓ filtration (i.e. renal failure)
  25. 25Creatine clearance Vol of blood that can be cleared of a substance in 1min
     CrC roughly approximates GFR as it is freely filtered and only a small proportion secreted (~10%)
     Requires urine concentration from 24h collection
     Can use radiolabelled EDTA: very rarely done
  26. 26Modification of Diet in Renal Disease (MDRD) equation - what - problemsfor eGFR
     Serum Cr, sex, age, race
     Obviates need for urine collection
    problems: doesn't work in AKI/dialysis/children, only validated in black or caucasian people, limited in eGFR >60
  27. 27pre-renal causes of renal disease Shock
     Renal Vascular
    - RAS
    - Toxins: NSAIDs, ACEi
    - Thrombosis
    - Hepatorenal syn.
  28. 28renal causes of renal disease Glomerulonephritis
     Acute Tubular Necrosis
     Interstitial disease
  29. 29post-renal causes of renal diseaseSNIPPIN
     Stone
     Neoplasm
     Inflammation: stricture
     Prostatic hypertrophy
     Posterior urethral valves
     Infection: TB, schisto
     Neuro: post-op, neuropathy
  30. 30features of renal failure- uraemia (eGFR <15)
    - protein loss and NA retention
    - acidosis
    - hyperkalaemia
    - anaemia
    - vit D deficiency
  31. 31uraemia signs and symptomsPruritus
    n/v, anorexia, wt. loss
    Lethargy, Confusion
    Restless legs
    Metallic taste
    Paraesthesia: neuropathy
    Bleeding
    Chest pain: serositis
    signs: Pale, sallow skin
    Striae; Pericardial or plueral rub; Fits; Coma
  32. 32symptoms of protein loss and Na retentionSymptoms
    Polyuria, polydipsia
    Oliguria, anuria
    Breathlessness
    Signs
    Oedema
    ↑ JVP
    HTN (or ↓BP)
  33. 33acidosis symptoms and signssymptoms
    - breathlessness
    - confusion
    signs
    - Kussmaul breathing
  34. 34hyperkalaemia symptoms and signssymptoms
    - palpitations
    - chest pain
    - weakness
    signs
    - ECG: peaked T waves, flattened P waves, ↑ PR interval, Widened QRS
    Sine-wave pattern → VF
  35. 35anaemia symptoms and signssymptoms
    - breathlessness
    - lethargy and syncope
    - tinnitus
    signs
    - pallor
    - tachycardia
    - flow murmurs (ESM at apex)
  36. 36vit D deficiency symptoms and signssymptoms
    - bone pain
    - fractures
    signs
    - osteomalacia --> Looser's zones (pseudo#s) and cupped metaphyses
  37. 37definitions: - bacteriuria - UTI - urethral syndrome Bacteriuria: bacteria in urine, symptomatic or asympto
     UTI: symptomatic c¯ +ve culture or dipstick
     Urethral Syndrome: symptomatic but no bacteriuria
  38. 38classification of UTI - uncomplicated - complicated - recurrent - relapse Uncomplicated: normal GU tract and function
     Complicated: abnormal GU tract, outflow obstruction, ↓ renal function, impaired host defence, virulent organism
     Recurrent: further infection c¯ new organism
     Relapse: further infection c¯ same organism
  39. 39presentation of cystitis Frequency and urgency
     Polyuria
     Haematuria
     Dysuria
     Suprapubic tenderness
     Foul smelling urine
  40. 40presentation of pyelonephritislower UTI symptoms
     Fever, rigors
     Loin pain and tenderness
     Vomiting
     Oliguria if ARF
  41. 41prostatitis presentation Flu-like symptoms
     Low backache
     Dysuria
     Tender swollen prostate on PR
  42. 42causes of sterile pyuria TB
     Treated UTI
     Appendicitis
     Calculi
     TIN
     Polycystic Kidney
     Chemical cystitis (e.g. cyclophosphamide)
  43. 43risk factors for UTI Female
     Sex
     Pregnancy
     Menopause
     DM
     Abnormal tract: stone, obstruction, catheter,
    malformation
  44. 44common organisms in UTI E. coli
     Staphylococcus saprophyticus
     Proteus (alkaline urine → struvite renal stones)
     Klebsiella
  45. 45investigations in UTI Dipstick
     MSU for MCS
     Bloods: FBC, U+E, blood cultures (if systemic signs)
     US: children, men, recurrence, pyelonephritis
  46. 46Rx of cystitisDrink plenty, urinate often
     Rx for 3d in women, 7d for men
     Trimethoprim 200mg BD
     Nitrofurantoin 50mg QDS (not in RF)
    paracetamol
  47. 47Pyelonephritis RxCiprofloxacin 500mg BD for 7d (or co-amox 500/125mg TDS for 14d)
    paracetamol, hydration
  48. 48What is glomerulonephritis? Group of disorders resulting from glomerular damage
     Can → proteinuria ± haematuria
     Can → AKI or ESRF
  49. 49presentation of glomerulonephritis Asymptomatic haematuria
     Nephrotic syndrome
     Nephritic syndrome
  50. 50causes of glomerulonephritis Idiopathic
     Immune: SLE, Goodpastures, vasculitis
     Infection: HBV, HCV, Strep, HIV
     Drugs: penicillamine, gold
     Amyloid
  51. 51Investigations in glomerulonephritisBlood
     Basic: FBC, U+E, ESR
     Complement (C3 and C4)
     Abs: ANA, dsDNA, ANCA, GBM
     Serum protein electrophoresis and Ig
     Infection: ASOT (anti-streptolysin), HBC and HCV serology
    Urine
     Dipstick: proteinuria ± haematuria
     Spot PCR
     MCS
     Bence-Jones protein
    Imaging
     CXR: infiltrates (Goodpasture’s, Wegener’s)
     Renal US ± biopsy
  52. 52causes of asymptomatic haematuria1. IgA Nephropathy
    2. Thin BM
    3. Alport’s
  53. 53IgA Nephropathy - features - diagnosis - Rx - prognosis Commonest GN in developed world
    Features
     Young male c¯ episodic gross haematuria occurring a few days after URTI.
     Rapid recovery between attacks
     ↑IgA
     Can occasionally → nephritic syndrome
    Biopsy: IgA deposition in mesangium
    Rx: Steroids or cyclophosphamide if ↓renal function
    Prognosis: 20% ESRF after 20yrs
  54. 54Thin BM disease - inheritance - features Autosomal dominant
     Commonest cause of asymptomatic haematuria
    Features
     Persistent, asymptomatic microscopic haematuria
     V. small risk of ESRF
  55. 55Alport's sydnrome - what - features85% X-linked inheritance, defect of type IV collagen
    Features
     Haematuria, proteinuria → progressive renal failure
     Sensorineural deafness
     Lens dislocation and cataracts
     Retinal “flecks”
     Females: haematuria only!
  56. 56Nephritic syndrome/Acute GN features Haematuria (macro / micro) + red cell casts
     Proteinuria → oedema (esp. periorbital)
     Hypertension
     Oliguria and progressive renal impairment
  57. 57proliferative/post-strep GN - features - biopsy - Rx - prognosisFeatures
     Young child develops malaise and nephritic syndrome c¯ smoky urine 1-2wks after sore throat or skin infection.
     ↑ ASOT
     ↓C3
    Biopsy: IgG and C3 deposition
    Rx: Supportive, loop diuretics/BBs/CCBs/ACEIs
    Prognosis
     95% of children recover fully
     Minority develop RPGN
  58. 58What is a crescentic glomerulonephritis?Most aggressive GN which can → ESRF in days
  59. 59Goodpastures - % RPGN - features - Rx5% RPGN
     Ab to collagen 4 = anti-GBM
     Haematuria and haemoptysis
     CXR shows infiltrates
    Specific Ix: biopsy, anti-GBM Abs
     Rx: Plasmapheresis and immunosuppression (methylpred, cyclophosphoamide, azathioprine)
  60. 60Immune Complex Deposition GN45% RPGN
     Complication of any immune complex deposition
     IgA, post-strep, endocarditis, SLE
  61. 61Wegener'sGranulomatosis with polyangiits
    - upper and lower respiratory tract involvement (saddle nose, haemoptysis)
    - pauci-immune GN
    - c-ANCA
    - biopsy has vasculitis and granulomas
    Rx: methotrexate or MMF to induce remission, or cyclophosphoamide/rituximab/pred
  62. 62Churg StraussEosinophilic granulomatosis with polyangiitis
    - asthma, eosinophilia >10% in peripheral blood, paranasal sinusitis, pulmonary infiltrates, mononeuritis multiplex or polyneuropathy
    Ix:: p-ANCA, biopsy with necrotising granulomas/vasculitis
    Rx: steroids, cyclophosphoamide
  63. 63features of Nephrotic syndrome Proteinuria: PCR >300mg/mM or >3g/24h
     Hypoalbuminaemia: <35g/L
     Oedema: periorbital, genital, ascites, peripheral (Often intravascularly depleted c¯ ↓ JVP)
    hyperlipidaemia
  64. 64complications of nephrotic syndrome Infection: ↓ Ig, ↓ complement activity
     VTE: up to 40%
     Hyperlipidaemia: ↑ cholesterol and triglycerides
  65. 65Nephrotic syndrome and biopsy: children vs adults? All adults
     Steroids 1st c¯ children: mostly minimal change
  66. 66effect of DM on the nephronglomerulosclerosis
  67. 67SLE and the nephronmembranous GN
  68. 68Minimal change GN - who - association - biopsy - Rx Commonest cause of nephrotic syndrome in children
     Assoc.: URTI
     Biopsy: normal light micro, fusion of podocytes on EM
     Rx: steroids
    (Prog: 1% → ESRF)
  69. 69Membranous Nephropathy - who - associations - biopsy - Rx 20-30% of adult nephrotic syndrome
    Associations
     Ca: lung, colon, breast
     AI: SLE, thyroid disease
     Infections: HBV
     Drugs: Penicillamine, gold
     Biopsy: subepithelial immune complex deposits
     Rx: immunosuppression if renal function declines (40% resolve spont.)
  70. 70FSGSFocal Segmental Glomerulosclerosis
     Commoner in Afro-Caribs
     Idiopathic or Secondary: VUR, Berger’s (IgA), SCD, HIV
     Biopsy: focal scarring, IgM deposition
     Rx: steroids or cyclophosphamide/ciclosporin
    (Prog: 30-50% → ESRF)
  71. 71Membranoproliferative/Mesangiocapillary GN Rare
     May → nephrotic (60%) or nephritic (30%) syndrome
     Asooc. c¯ HBV, HCV, endocarditis
     Prog: 50% → ESRF
  72. 72Treatment of nephrotic syndrome Monitor U+E, BP, fluid balance, wt.
     Treat underlying cause
    Symptomatic / Complication Rx:
    - Oedema: salt and fluid restrict + frusemide
    - Proteinuria: ACEi / ARA ↓ proteinuria
    - ↑ Lipids: Statin
    - VTE: Tinzaparin
    - Rx HTN

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Year 4 Medicine Flashcards on Nephrology: Nephritic, Nephrotic, UTI, Renal Function, created by Ellie Britt on 12/12/2018.
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