Renal Medicine

What three things must be present for nephrotic syndrome?

Proteinuria
Hypoalbuminemia
Oedema

Why does oedema occur in nephrotic syndrome?

There is sodium retention in the extracellular compartments and molecular changes in the capillary barrier

What are the causes of nephrotic syndrome? (9)

Glomerulonephritis
Focal segmental glomerulosclerosis
Membranous glomerulonephritis
Meningiocapillary glomerulonephritis
Proliferative glomerulonephritis
Diabetes mellitus
Systemic lupus erythematosus
Drugs
Allergies

How do you manage nephrotic syndrome (8)

Treat the cause
Restrict salt intake
Diuretics
ACE inhibitors if chronic
Treat infections quickly
Flu and pneumococcal vaccines
Prophylactic heparin
Treat hypertension

What are the complications of nephrotic syndrome? (3)

Increased risk of infections
Thromboembolism
Hyperlipidaemia

What are the investigations for nephrotic syndrome? (6)

Cholesterol levels
Renal biopsy
U&Es
Blood pressure
Fluid balance
Weight

What are the clinical features of renal vein thrombosis? (6)

Asymptomatic
Loin pain
Haematuria
Palpable kidney
Sudden deterioration in renal function
Pulmonary embolism

What are the risk factors for renal vein thrombosis? (4)

Hypercoagulable state
Membranous nephropathy
Renal vein carcinoma
Thrombophilia

What investigations should be done in renal vein thrombosis? (4)

Doppler ultrasound
CT
MRI
Renal angiography

What is the management for renal vein thrombosis?

Anticoagulate with warfarin

What is acute renal failure?

Significant deterioration in renal function that occurs over hours to days. There will be increased plasma urea and creatinine

What are the common causes of acute renal failure? (6)

Acute tubular necrosis
Pre-renal failure
Severe illness
Sepsis
Trauma
Surgery

What are the pre-renal causes of acute renal failure? (7)

Hypovolaemia
Sepsis
Congestive cardiac failure
Liver cirrhosis
Renal artery stenosis
NSAIDs
ACE inhibitors

What are the intrinsic causes of acute renal failure? (16)

Ischaemia
Aminoglycosides
Amphotericin B
Tetracyclines
Radiological contrast agents
Uric acid crystals
Haemoglobinuria
Myeloma
Vasculitis
Malignant hypertension
Cholesterol emboli
Haemolytic uraemic syndrome
Thrombocytopenic purpura
Glomerulonephritis
Interstitial nephritis
Hepatorenal syndrome

What are the post renal causes of acute renal failure?

Obstruction

What bloods should be done in acute renal failure? (12)

U&Es
FBCs
Clotting
Creatine kinase
ESR
CRP
ABG
Cultures
Hepatitis serology if dialysis is needed
Immunoglobulins
Complement levels
Autoantibodies

What other investigations should be done in acute renal failure? (5)

Urine dipstick
Urine MC&S
Chest x-ray
ECG
Renal ultrasound

What are the indications for acute dialysis? (5)

Refractory pulmonary oedema
Persistent hyperkalaemia
Severe metabolic acidosis
Uraemic encephalopathy
Uraemic pericarditis

What is the management for acute renal failure? (5)

Treat shock if present
Urgent ultrasound
Stop any nephrotoxic drugs
Stop metformin if creatinine is above 150mmol/l
Find and treat any exacerbating factors

How do you monitor acute renal failure? (5)

Basic observations
Fluid balance
Weight chart
Adjust doses of renally excreted drugs
Maintain calorie intake

At what stage does chronic renal failure typically present?

Stage 4 when GFR is below 30

How do you manage chronic renal failure? (7)

Refer to renal medicine
Treat any reversible causes
Treat the symptoms
Restrict dietary sodium
Moderate protein
Give bicarbonate
Vitamin D and calcium supplements

What are the common causes of chronic renal failure? (10)

Glomerulonephritis
Diabetes mellitus
Renovascular disease
Hypertension
Pyelonephritis
Polycystic disease
Prostatic hypertrophy
Interstitial nephritis
Analgesic neuropathy
Nephrolithiasis

What are the rarer causes of chronic renal failure? (13)

Myeloma
Amyloidosis
Systemic lupus erythematosus
Scleroderma
Vasculitis
Haemolytic uraemic syndrome
Nephrocalcinosis
Gout
Renal tumour
Cystinosis
Oxalosis
Alport's syndrome
Fabry's disease

What bloods should be done in chronic renal failure? (8)

FBC
ESR
U&Es
Glucose
Calcium
Phosphate
Alkaline phosphatase
Parathyroid hormone

What other investigations should be done in chronic renal failure? (9)

Urine dipstick
Urine MC&S
24 hour urine protein
Urine PCI
Renal ultrasound
DTPA scan
Chest x-ray
Bone x-ray
Renal biopsy

What are the clinical features of chronic renal failure? (19)

Recurrent UTIs
Fatigue
Weakness
Anorexia
Vomiting
Metallic taste in the mouth
Pruritis
Restless legs
Bone pain
Impotence
Dyspnoea
Ankle swelling
Pallor
Jaundice
Brown nails
Purpura
Bruising
Excoriation
Seizures

What are the renal causes of haematuria? (7)

Neoplasia
Glomerulonephritis
Tubulointerstitial nephritis
Poly-cystic kidney disease
Papillary necrosis
Infection such as pyelonephritis
Trauma

What are the extrarenal causes of haematuria? (4)

Calculi
Infection such as cystitis, prostatitis, and urethritis
Neoplasia such as bladder, prostate, and urethra
Trauma

What tests should be done in haematuria? (11)

Urine MC&S
FBC
U&Es
ESR
CRP
Clotting
Abdominal x-ray
KUB
Urine cytology
Proteinuria estimation
Renal ultrasound

How do you manage haematuria? (3)

Refer to urology
Ultrasound
Cystoscopy

What can cause false positives for haematuria? (8)

Haemoglobinuria
Myoglobin
Beetroot
Porphyria
Alkaptonuria
Rifampicin
Phenindione
Phenolphthalein

How do you treat hyperkalaemia?

Treat the cause

What are the causes of hyperkalaemia? (11)

Oliguric renal failure
Potassium sparing diuretics
Rhabdomyolysis
Burns
Metabolic acidosis
Excess potassium therapy
Addison's disease
Massive blood transfusion
ACE inhibitors
Suxamethonium
Artefact

What are the clinical features of hyperkalaemia? (2)

Cardiac arrhythmias
Sudden death

What are the ECG signs of hyperkalaemia? (4)

Tall tented T waves
Small P waves
Wide QRS complex
VF

When should hypertension be treated?

Above 160/100 or above 140/90 if cardiovascular risk factors are present

What causes isolated systolic hypertension?

The stiffening of the large arteries and atherosclerosis

What are the clinical features of primary hypertension? (4)

Asymptomatic
Retinopathy
Features of underlying cause
End organ damage

What is the most common cause of secondary hypertension?

Renal disease

What are the renal causes of secondary hypertension? (7)

Glomerulonephritis
Polyarteritis nodosa
Systemic sclerosis
Chronic pyelonephritis
Polycystic kidneys
Atheromatous
Fibromuscular dysplasia

What are the endocrine causes of secondary hypertension? (5)

Cushing's syndrome
Conn's syndrome
Phaeochromocytoma
Acromegaly
Hyperparathyroidism

What are the causes of secondary hypertension? (8)

Renal disease
Endocrine disease
Coarctation of the aorta
Pregnancy
Steroids
MAOIs
The oral contraceptive pill

What investigations should be done for hypertension? (6)

U&Es
Creatinine
Cholesterol
Glucose
ECG
Urinalysis

What investigations should be done to exclude a secondary cause of hypertension? (5)

Renal ultrasound
Renal arteriography
24 hour urine
Urinary free cortisol, renin, and aldosterone
24 hour ambulatory blood pressure

What is malignant hypertension?

Severe hypertension over 200/130 as well as bilateral retinal haemorrhages and exudates

What are the clinical features of malignant hypertension? (4)

Headache
Visual disturbance
End organ damage
Fibrinoid necrosis

What is the management for malignant hypertension? (3)

Reduce blood pressure slowly
Bed rest
Diuretic

What happens in dehydrated hyponatraemia?

Urinary sodium is above 20mmol/L and water is being lost either through the kidneys or elsewhere

What are the causes of dehydrated hyponatraemia? (13)

Addison's disease
Renal failure
Diuretic excess
Osmolar diuretics
Diarrhoea
Vomiting
Fistulae
Burns
Villous adenoma of rectum
Small bowel obstruction
Trauma
Cystic fibrosis
Heat exposure

What are the causes of non-dehydrated hyponatraemia? (8)

Nephrotic syndrome
Cardiac failure
Liver cirrhosis
Renal failure
Water overload
Severe hypothyroidism
Glucocorticoid insufficiency
SIADH

What are the causes of SIADH? (5)

Malignancy
CNS disorders
Chest disease
Metabolic disease
Drugs

What are the malignancy causes of SIADH? (4)

Small cell lung cancer
Pancreatic cancer
Prostate cancer
Lymphoma

What are the CNS disorders that can cause SIADH? (8)

Meningoencephalitis
Abscess
Stroke
Subarachnoid haemorrhage
Subdural haemorrhage
Head injury
Guillain-Barre syndrome
Vasculitis

What are the chest causes of SIADH? (4)

Tuberculosis
Pneumonia
Abscess
Aspergillosis

What are the metabolic causes of SIADH? (2)

Porphyria
Trauma

What are the drug causes of SIADH? (4)

Opioids
Psychotropics
SSRIs
Cytotoxic's

What is the pathophysiology of bilateral peripheral oedema?

Systemic disease causing increased venous pressure or decreased intravascular oncotic pressure. It is dependent on gravity and so starts in the ankles

What are the causes of bilateral peripheral oedema? (6)

Right heart failure
Low albumin
Venous insufficiency
Vasodilators such as nifedipine
Pelvic mass
Pregnancy

What are the causes of unilateral peripheral oedema? (6)

DVT
Cellulitis
Necrotising fasciitis
Trauma
Arthritis
Baker's cyst

What is oliguria?

Urine output less than 400ml a day

What is anuria?

No urine output

What are the pre-renal causes of oliguria or anuria? (3)

Hypovolaemia
Severe dehydration
Cardiac failure

What are the other causes of oliguria or anuria? (

Kidney failure
Obstruction

What are the clinical features of benign prostatic hypertrophy? (3)

Frequency
Urgency
Voiding difficulty

What investigations should be done in benign prostatic hypertrophy? (7)

MSU
U&Es
Ultrasound
PSA
PR exam
Transrectal ultrasound
Biopsy if necessary

What are the management options for benign prostatic hypertrophy? (8)

Transrectal incision of the prostate
Transurethral incision of the prostate
Retropubic prostatectomy
Transurethral laser
Alpha blockers
5 Alpha reductase inhibitors
Phytotherapy
Wait and see

How does diabetic nephropathy occur?

Hyperglycaemia causes renal hyperperfusion which increases GFR causing hypertrophy and increased renal size. Mesangial hypertrophy and focal glomerulosclerosis occur due to increased glomerular pressure. This causes microalbuminuria that later progresses to proteinuria

What is the management for diabetic nephropathy? (4)

Good glycaemic control
Antihypertensives
Smoking cessation
Combined pancreas and renal transplant

What is myeloma?

Malignant proliferation of B lymphocyte derived cells. Normally different plasma cells produce different immunoglobulins which are polyclonal but in myeloma there is a single clone of plasma cells that produce identical immunoglobulins

What is found in the urine in myeloma?

Bence-Joyce protein

What are the clinical features of myeloma? (8)

Osteolytic bone lesions
Backache
Pathological fractures
Anaemia
Neutropenia
Thrombocytopenia
Recurrent bacterial infections
Renal impairment

What investigations should be done in myeloma? (7)

FBCs
U&Es
Alkaline phosphatase
Serum and urine electrophoresis
Beta-2 microglobin
X-ray of bone pain
CT or MRI

How do you manage myeloma? (4)

Symptom control
Local radiotherapy
Chemotherapy
Autologous stem cell transplants in younger patients

What are the clinical features of anaemia? (13)

Fatigue
Dyspnoea
Faintness
Palpitations
Headache
Tinnitus
Anorexia
Pallor
Tachycardia
Flow murmurs
Cardiac enlargement
Retinal haemorrhages
Heart failure

What are the types of microcytic anaemia? (3)

Iron deficiency anaemia
Thalassaemia
Sideroblastic anaemia

What are the causes of normocytic anaemia? (7)

Acute blood loss
Anaemia of chronic disease
Bone marrow failure
Renal failure
Hypothyroidism
Haemolysis
Pregnancy

What are the causes of macrocytic anaemia? (10)

B12 deficiency
Folate deficiency
Alcohol excess
Liver disease
Reticulocytosis
Cytotoxic drugs
Myelodysplastic syndromes
Marrow infiltration
Hypothyroidism
Anti-folate drugs

What are the signs of haemolytic anaemia? (5)

Reticulocytosis
Mild macrocytosis
Reduced haptoglobin
Raised bilirubin
Raised urobilinogen

What are the functions of parathyroid hormone? (3)

Increases osteoclast activity to release calcium and phosphate from the bones
Increases calcium reabsorption and decreases phosphate reabsorption in the kidneys
Increases active 1,25-dihydroxyvitaimin D3 production

What is the goal of parathyroid hormone?

To increased calcium in the blood

What are the causes of primary hyperparathyroidism? (3)

Solitary adenoma
Hyperplasia of all glands
Parathyroid carcinoma

What are the clinical features of primary hyperparathyroidism? (13)

Asymptomatic
Increased calcium
Weakness
Tiredness
Depression
Dehydration
Polyuria
Polydipsia
Renal stones
Abdominal pain
Fractures
Osteopenia or osteoporosis
Hypertension

What are the causes of secondary hyperparathyroidism? (3)

Hypocalcaemia
Low vitamin D intake
Chronic renal failure

What will the bloods show in secondary hyperparathyroidism? (2)

Decreased calcium
Increased PTH

What will the bloods show in tertiary hyperparathyroidism? (2)

Raised calcium
Very high PTH

What happens in tertiary hyperparathyroidism?

There is prolonged secondary hyperparathyroidism that causes the gland to act autonomously after hyperplastic or adenomatous change so there is no feedback control

How do you manage hyperparathyroidism? (4)

Surgical excision where appropriate
Increase fluid intake where surgery is not indicated
High calcium and vitamin D intake where surgery is not indicated
Cinacalcet

What is sarcoidosis?

A multisystem granulomatous disease that has an unknown cause

What are the pulmonary manifestations of sarcoidosis? (6)

Hilar lymphadenopathy
Fibrosis
Dry cough
Progressive dyspnoea
Reduced exercise tolerance
Chest pain

What will the bloods show in sarcoidosis? (6)

Raised ESR
Lymphopenia
Raised LFTs
Raised serum ACE
Raised calcium
Raised immunoglobulins

What will be found on urinalysis in sarcoidosis?

Raised 24h calcium

What other investigations should be done in sarcoidosis? (9)

Tuberculin skin test
Chest x-ray
ECG
Lung function tests
Tissue biopsy
Bronchoalveolar lavage
Ultrasound
Bone x-rays
CT or MRI

What are the non-pulmonary manifestations of sarcoidosis? (21)

Lesions
Lymphadenopathy
Hepatomegaly
Splenomegaly
Uveitis
Conjunctivitis
Keratoconjunctivitis sicca
Glaucoma
Terminal phalangeal bone cysts
Enlargement of the lacrimal and parotid glands
Neuropathy
Meningitis
Brainstem and spinal syndromes
Space occupying lesions
Erythema nodosum
Lupus pernio
Subcutaneous nodules
Cardiomyopathy
Arrhythmias
Hypercalcaemia and renal stones
Pituitary dysfunction

How do you manage sarcoidosis? (5)

Some resolve spontaneously
Bed rest
NSAIDs
Steroid therapy
Immunosuppressants

What are the indications for steroid therapy in sarcoidosis? (5)

Parenchymal lung disease
Neurological involvement
Cardiac involvement
Uveitis
Hypercalcaemia

What are the acute signs of sarcoidosis? (2)

Erythema nodosum
Polyarthralgia

What is systemic lupus erythematosus?

A multisystem autoimmune disease where antibodies are produced against a variety of autoantigens. There is secretion of polyclonal B cells of pathogenic autoantibodies which causes the formation of immune complexes that deposit in places such as the kidneys

What are the three main investigations for systemic lupus erythematosus?

Double stranded DNA autoantibody titres
Complement - Low C3 and C4
ESR - Raised

What other investigations should be done in systemic lupus erythematosus? (6)

Blood pressure
Urinalysis for blood and protein
FBC
U&Es
LFTs
CRP