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Renal Presentation

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Renal Presentation

  1. 1. Nephrology George Collins and Oscar Swift
  2. 2. Objectives At the end of this session you will be able to: - approach an OSCE scenario relating to nephrology - list the basic anatomy and physiology of the kidney - understand the basic problems, investigation and treatments that renal patients undergo - describe the causes, investigations and treatments for AKI - describe the main features of CKD - have an improved understanding of how to tackle SBAs in nephrology
  3. 3. Not Covered • Nephritic syndrome • Pyelonephritis and Upper UTIs • Lower UTIs • Nephrolithiasis • Prostatitis and prostatism • Polycystic kidney disease • Renal and bladder neoplasms • Renal drugs (eg. diuretics)
  4. 4. Stop us if you have any questions!
  5. 5. The Kidneys • 25% of cardiac output • Two sites of vascular resistance • Glomerulus has little resistance • There are three layers to filtration…
  6. 6. The Glomerular Filtration Barrier • What are the three layers?
  7. 7. The Glomerular Filtration Barrier • Endothelial cells (stops blood cells) • GBM (-ve) • Podocytes
  8. 8. The Nephron • Efferent arterioles continue as vasa recta • Albumin in efferent arterioles driving water reabsorption • Blood flow to distal nephron is low to maintain hypertonicity of loop of Henle (ATN)
  9. 9. The Nephron • Changes in afferent and efferent vascular tone alters hydrostatic pressure and GFR • Avoid NSAIDs (prostaglandins dilate afferent arterioles – avoid in renal failure) • NSAIDs effectively cause a mild renal artery stenosis • Avoid ACE-Is in renal artery stenosis (AGII increases GFR by constricting efferent arteriole)
  10. 10. Any questions?
  11. 11. Renal Transport • Most substances are controlled by reabsorption • Unregulated control proximally • Fine control distally • Some secreted actively Eg. penicillin
  12. 12. Glucose • Glucose transport • Diabetes • Osmotic diuresis • Polydipsia
  13. 13. Sodium • All sodium filtered in Bowman’s capsule • 65% immediately reabsorbed • 25% in ascending LOH • 10% in DCT/CD depending on fluid status
  14. 14. Phosphate • Dietary excess • Kidneys excrete much of it • Renal failure leads to accumulation • Oral phosphate binders reduce intestinal absorption
  15. 15. Potassium • 98% is intracellular • High intake like phosphate • Internal potassium homeostasis • External potassium homeostasis • Renal failure • What is calcium resonium? Insulin? furosemide? Salbutamol?
  16. 16. Any questions?
  17. 17. What are the functions of our kidneys? • To produce urine ?
  18. 18. • Removal of waste products and reabsorption of useful products (eg. glucose, amino acids, etc.) • Regulation of fluid and electrolyte balance • Controls BP (renin) • Maintain acid-base balance (regeneration of bicarbonate, excretion of H+) • Stimulates bone marrow (EPO; anaemia of CKD) • Regulates vitamin D, calcium and phosphate homeostasis (renal osteodystrophy) What are the functions of our kidneys?
  19. 19. What can go wrong in renal disease?
  20. 20. What can go wrong in renal disease? • Uraemia (accumulation of waste products – may need dialysis) • Hyper-/ Hypo- volaemia • Hypertension • Hyperkalaemia (insulin, dextrose, etc.) • Metabolic acidosis (oral bicarbonate) • Normochromic normocytic anaemia* • Vitamin D deficiency and hypocalcaemia* • Hyperphosphataemia* • Renal-bone disease* (osteodystrophy) • * = more likely to occur in chronic kidney disease
  21. 21. What else can go wrong in renal disease? • IMPORTANT! When the glomerulus is involved…. • Hyperlipidaemia (check lipids) • Loss of anti-thrombin III (check clotting) • Loss of complement (beware of infection)
  22. 22. Any questions?
  23. 23. OSCE station • You are a GP trainee. A 21 year old male medical student has developed puffy eyes and ankle oedema after a viral infection he had last week. Please perform a urine dipstick and arrange any appropriate investigations.
  24. 24. What investigations are useful in renal disease?
  25. 25. • BP • U+E • Urinalysis and M,C and S (casts, etc.) • Urine dipstick • ABG • FBC • BM • Serum calcium, phosphate, PTH • Serum lipids • Clotting (INR) • Infection screen – CRP, urine and blood cultures, hepatitis screen • Imaging (renal biopsy, MRI, angiography, US) What investigations are useful in renal disease?
  26. 26. What medications are useful in renal disease?
  27. 27. • Anti-hypertensives • K+ lowering agents and cardiac protection if required • Sodium bicarbonate? • EPO • Vitamin D analogues • Phosphate binders • Statins • Heparin • Broad spectrum Abx • Vaccinations? • Oral steroids (NS) • Fluids (? albumin infusion) • Diuretics (for oedema) What medications are useful in renal disease?
  28. 28. Any questions?
  29. 29. What are the three categories of causes of acute kidney injury?
  30. 30. • Pre-renal (80% of AKI) • Intrinsic (renal) • Post-renal • …best test to differentiate? What are the three categories of causes of acute kidney injury?
  31. 31. What are some causes of pre-renal AKI?
  32. 32. Pre-renal • Poor perfusion to the kidney – Haemorrhage – Dehydration (poor intake, vomiting, diarrhoea) – Sepsis (septic shock) – Cardiogenic shock (CCF) – Burns – 3rd space losses – Clamping during surgery – Renal artery stenosis (atherosclerosis, fibromuscular dysplasia) – Drugs (NSAIDs, ACE-Is) • Progresses to ischaemia and ATN (as vasa recta are poorly perfused)
  33. 33. Intrinsic (renal) causes of AKI?
  34. 34. Intrinsic • ATN + Interstitial nephritis = tubulointerstitial • Glomerulonephritis = glomerular
  35. 35. Post-renal causes of AKI?
  36. 36. Post-renal • Bladder outlet obstruction – Prostate enlargement (BPH, malignancy, prostatitis) – Pelvic tumours – Urethral stricture – permanent catheter – Other bladder dysfunction • Ureteric obstruction – Tumours (retroperitoneal malignancy) – Stones – Papillary necrosis – Surgical ties (eg. gynae surgery)
  37. 37. Any questions?
  38. 38. What are some key investigations for each? • PRE-RENAL …? – U+Es: high urea to creatinine ratio (exclude other causes of raised urea eg. GI bleed, rhabdomyolysis) – Urine chemistry: Na+ <20mmol/l – Low fractional excretion of Na+ (<1%) – High urine osmolality (>350 mosm) • INTRINSIC – U+Es: low urea to creatinine ratio – Urine chemistry: Na+ >20mmol/l – Low urine osmolality (<350 mosm) – CELL CASTS • POST RENAL – Ultrasound
  39. 39. What are some key investigations for each? • PRE-RENAL (hypovolemic state) – U+Es: high urea to creatinine ratio (exclude other causes of raised urea eg. GI bleed, rhabdomyolysis) – Urine chemistry: Na+ <20mmol/l – Low fractional excretion of Na+ (<1%) – High urine osmolality (>350 mosm) • INTRINSIC …? – U+Es: low urea to creatinine ratio – Urine chemistry: Na+ >20mmol/l – Low urine osmolality (<350 mosm) – CELL CASTS • POST RENAL – Ultrasound
  40. 40. What are some key investigations to differentiate between … • PRE-RENAL – U+Es: high urea to creatinine ratio (exclude other causes of raised urea eg. GI bleed, rhabdomyolysis) – Urine chemistry: Na+ <20mmol/l – Low fractional excretion of Na+ (<1%) – High urine osmolality (>350 mosm) • INTRINSIC – U+Es: low urea to creatinine ratio – Urine chemistry: Na+ >20mmol/l – Low urine osmolality (<350 mosm) – CELL CASTS • POST RENAL …? – Ultrasound
  41. 41. • PRE-RENAL – U+Es: high urea to creatinine ratio (exclude other causes of raised urea eg. GI bleed, rhabdomyolysis). Why? – Urine chemistry: Na+ <20mmol/l – Low fractional excretion of Na+ (<1%) – High urine osmolality (>350 mosm) • INTRINSIC – U+Es: low urea to creatinine ratio – Urine chemistry: Na+ >20mmol/l – Low urine osmolality (<350 mosm) – CELL CASTS • POST RENAL – Ultrasound What are some key investigations for each?
  42. 42. What is the general management for each? • Pre-renal: ? • Intrinsic: ? • Post-renal: ?
  43. 43. What is the general management for each? • Pre-renal: ? • Intrinsic: ? • Post-renal: ?
  44. 44. What is the general management for each? • Pre-renal: ? • Intrinsic: ? • Post-renal: ?
  45. 45. • Pre-renal: treat cause • Intrinsic: depends on cause – SEE NEXT SLIDES • Post-renal: relieve obstruction What is the general management for each?
  46. 46. Acute Tubular Necrosis • Prolonged ischaemia – Hypotension – Prolonged pre-renal failure – Arterial insufficiency/occlusion • Nephrotoxins – Radiological contrast – Drugs (aminoglycosides, amphotericin B) – Pigments (myoglobin, Hb) • Rx: treat underlying cause (ATN reversible)
  47. 47. Tubulointerstitial Nephritis
  48. 48. Tubulointerstitial Nephritis • Drugs – Beta-lactams – Sulphonamides ? – Rifampicin – Allopurinol ? – NSAIDs • Key finding: urinary eosinophils • Rx: stop drug
  49. 49. Tubulointerstitial Nephritis Contd • Deposition disease • Rx: fluid – Haemoglobin-haemolysis – Rhabdomyolysis – Protein –BJP in MM – Hypercalcaemia – Crystals • Oxalate (ethylene glycol/ high Vitamin C) • Urate (tumour lysis syndrome ?)
  50. 50. Tubulointerstitial Nephritis Contd • Infection: pyelonephritis – WBC casts – Bacteruria – Rx: Abx
  51. 51. Glomerulonephritis • Vaculitis – ANA – ANCA – Igs/ complement – RF – Viral serology ? – Cryoglobulins • Post infection – ASOT ? • Anti-GBM ? • Alport’s syndrome ? • Mx: renal biopsy • Rx: Immunosuppression
  52. 52. Any questions?
  53. 53. Chronic Kidney Disease • Decreased GFR • Insidious rise in creatinine and urea • Cf in AKI where there is a sudden rise in creatinine and urea. • CKD is initially without specific symptoms and can only be detected as an increase in serum creatinine or protein in the urine.
  54. 54. What are the causes of chronic kidney disease?
  55. 55. What are the causes of chronic kidney disease? • 75% of cases are due to Hypertension, Diabetes and Glomerulonephritis • Classified according to the part of the renal anatomy that is involved • 1. Vascular - large vessel disease (RAS) and small vessel disease such as ischemic nephropathy, HUS and vasculitis • 2. Glomerular - Primary Glomerular disease IgA nephritis • - Secondary Glomerular disease such as diabetic nephropathy and lupus nephritis • 3. Tubulointerstitial - polycystic kidney disease, drug and toxin- induced • 4. Obstructive – e.g. bilateral kidney stones and diseases of the prostate • Others - pin worms and HIV nephropathy
  56. 56. What are the stages of chronic kidney disease?
  57. 57. • Stage 1 - Slightly diminished function; kidney damage with normal or relatively high GFR (≥90 mL/min/1.73 m2 ). Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine test or imaging studies • Stage 2 Mild reduction in GFR (60-89 mL/min/1.73 m2 ) with kidney damage. Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine test or imaging studies • Stage 3 Moderate reduction in GFR (30-59 mL/min/1.73 m2 ) • Stage 4 Severe reduction in GFR (15-29 mL/min/1.73 m2 ) Preparation for renal replacement therapy • Stage 5 Established kidney failure (GFR <15 mL/min/1.73 m2 , or permanent renal replacement therapy (RRT)
  58. 58. What is dialysis? What are the types?
  59. 59. Dialysis • Two main types – haemo or peritoneal • Hemodialysis uses a machine and an artificial kidney/ filter to remove the toxins and excess fluids. This requires an AV fistula and has to be done 3 times weekly at facility with required machinery. • Peritoneal uses the peritoneum which acts as a natural filter. Requires a 5inch catheter in abdomen. Peritoneal can be done at home or elsewhere, at the time that's best for patient. Dialysate bag needs to be changed several times daily. Much greater risk of infection (peritonitis) that haemodialysis
  60. 60. Any questions?
  61. 61. Single Best Answer Questions • Not necessarily covered in the lecture (classic UCL)
  62. 62. Single Best Answer Questions 1 A patient with chronic kidney disease is least likely to have which of the following metabolic abnormalities? 1 Acidosis 2 Hyperkalaemia 3 Hyperphosphataemia 4 Uraemia 5 Hypoparathyroidism
  63. 63. Single Best Answer Questions 1 A patient with chronic kidney disease is least likely to have which of the following metabolic abnormalities? 1 Acidosis 2 Hyperkalaemia 3 Hyperphosphataemia 4 Uraemia 5 Hypoparathyroidism
  64. 64. Single Best Answer Questions 2 A patient presents with a K+ of 6.7mmol/L. ECG shows peaked T waves and absence of P waves. Which of the following is most appropriate in the initial management of this patient? 1 Furosemide 2 Dietary restriction of K+ and amino acids 3 Insulin and dextrose 4 Calcium chloride and insulin and dextrose 5 Calcium resonium
  65. 65. Single Best Answer Questions 2 A patient presents with a K+ of 6.7mmol/L. ECG shows peaked T waves and absence of P waves. Which of the following is most appropriate in the initial management of this patient? 1 Furosemide 2 Dietary restriction of K+ and amino acids 3 Insulin and dextrose 4 Calcium chloride and insulin and dextrose 5 Calcium resonium
  66. 66. Single Best Answer Questions 3 Which of the following is not routinely considered as part of a renal screen in the investigation of new-onset renal failure? 1 Complement 2 Renal ultrasound 3 Caeruloplasmin and serum copper 4 Anti-neutrophil cytoplasmic antibodies 5 Bence–Jones protein
  67. 67. Single Best Answer Questions 3 Which of the following is not routinely considered as part of a renal screen in the investigation of new-onset renal failure? 1 Complement 2 Renal ultrasound 3 Caeruloplasmin and serum copper 4 Anti-neutrophil cytoplasmic antibodies 5 Bence–Jones protein
  68. 68. Single Best Answer Questions 4 A 15-year-old boy is referred to the renal clinic by his GP with a history of worsening haematuria. His mother has been worried recently that he has been taking illicit drugs as he has been finding it more difficult to cope at school and has been falling behind in his schoolwork. He also seems to be less attentive of late and has become more withdrawn, watching television on his own with the volume up loud. Which of the following conditions fits most closely with the clinical history? 1 Alport’s syndrome 2 Anderson–Fabry disease 3 Goodpasture’s syndrome 4 Wegener’s granulomatosis 5 Von Hippel–Lindau syndrome
  69. 69. Single Best Answer Questions 4 A 15-year-old boy is referred to the renal clinic by his GP with a history of worsening haematuria. His mother has been worried recently that he has been taking illicit drugs as he has been finding it more difficult to cope at school and has been falling behind in his schoolwork. He also seems to be less attentive of late and has become more withdrawn, watching television on his own with the volume up loud. Which of the following conditions fits most closely with the clinical history? 1 Alport’s syndrome 2 Anderson–Fabry disease 3 Goodpasture’s syndrome 4 Wegener’s granulomatosis 5 Von Hippel–Lindau syndrome
  70. 70. Single Best Answer Questions 5 A 30-year-old man presents to hospital complaining that his urine has been very dark recently. He recently has taken a few days off work with a very sore throat and coryzal symptoms. Urine dipstick in hospital returns highly positive for blood and protein. He is admitted for supportive management and is scheduled for a renal biopsy, which shows mesangial proliferation with a positive immunofluorescence pattern. What is the most likely diagnosis? 1 IgA nephropathy 2 Post-streptococcal glomerulonephritis 3 Rapidly progressive glomerulonephritis 4 Membranous glomerulonephritis 5 Henoch-Schoenlein purpura
  71. 71. Single Best Answer Questions 5 A 30-year-old man presents to hospital complaining that his urine has been very dark recently. He recently has taken a few days off work with a very sore throat and coryzal symptoms. Urine dipstick in hospital returns highly positive for blood and protein. He is admitted for supportive management and is scheduled for a renal biopsy, which shows mesangial proliferation with a positive immunofluorescence pattern. What is the most likely diagnosis? 1 IgA nephropathy 2 Post-streptococcal glomerulonephritis 3 Rapidly progressive glomerulonephritis 4 Membranous glomerulonephritis 5 Henoch-Schoenlein purpura
  72. 72. Single Best Answer Questions 6 Which one of the following is an indication for renal replacement therapy (RRT) 1 Pericarditis 2 Hyperkalaemia without ECG changes 3 Anaemia 4 Hypocalcaemia 5 Chronic kidney disease stage III
  73. 73. Single Best Answer Questions 6 Which one of the following is an indication for renal replacement therapy (RRT) 1 Pericarditis 2 Hyperkalaemia without ECG changes 3 Anaemia 4 Hypocalcaemia 5 Chronic kidney disease stage III
  74. 74. Single Best Answer Questions 7 Which of the following diseases do antibodies against type IV collagen in the glomerular basement membrane cause? 1 Wegeners granulomatosis 2 Alport’s syndrome 3 Goodpasture’s syndrome 4 Henoch-Schoenlein purpura 5 Scleroderma renal crisis
  75. 75. Single Best Answer Questions 7 Which of the following diseases do antibodies against type IV collagen in the glomerular basement membrane cause? 1 Wegeners granulomatosis 2 Alport’s syndrome 3 Goodpasture’s syndrome 4 Henoch-Schoenlein purpura 5 Scleroderma renal crisis
  76. 76. Single Best Answer Questions 8 A 71 year old male with chronic kidney disease develops an acutely hot, tender MCP joint on her left hand. What is the most likely diagnosis 1 Rheumatoid arthritis 2 Reiter’s syndrome 3 Gout 4 Pseudogout 5 Renal bone osteodystrophy
  77. 77. Single Best Answer Questions 8 A 71 year old male with chronic kidney disease develops an acutely hot, tender MCP joint on her left hand. What is the most likely diagnosis 1 Rheumatoid arthritis 2 Reiter’s syndrome 3 Gout 4 Pseudogout 5 Renal bone osteodystrophy
  78. 78. Single Best Answer Questions 9 Which one of the following causes of chronic kidney disease is most associated with a normal haemoglobin concentration? 1 Goodpasture’s syndrome 2 Hepatitis C 3 Hypertension 4 Polycystic kidney disease 5 Diabetes mellitus
  79. 79. Single Best Answer Questions 9 Which one of the following causes of chronic kidney disease is most associated with a normal haemoglobin concentration? 1 Goodpasture’s syndrome 2 Hepatitis C 3 Hypertension 4 Polycystic kidney disease 5 Diabetes mellitus
  80. 80. Single Best Answer Questions 10 A 35 year old lady with IBS is found to be hypertensive and hypokalaemic following routine bloods for abdominal pain. She takes only food supplements as medication. What is the most likely cause? 1 Cushing’s disease 2 Peppermint 3 11-beta hydroxysteroid dehydrogenase deficiency 4 Liquorice 5 Conn’s syndrome
  81. 81. Single Best Answer Questions 10 A 35 year old lady with IBS is found to be hypertensive and hypokalaemic following routine bloods for abdominal pain. She takes only food supplements as medication. What is the most likely cause? 1 Cushing’s disease 2 Peppermint 3 11-beta hydroxysteroid dehydrogenase deficiency 4 Liquorice 5 Conn’s syndrome
  82. 82. Objectives At the end of this session you will be able to: - approach an OSCE scenario relating to nephrology - list the basic anatomy and physiology of the kidney - understand the basic problems, investigation and treatments that renal patients undergo - describe the causes, investigations and treatments for AKI - describe the main features of CKD - have an improved understanding of how to tackle SBAs in nephrology
  83. 83. Not Covered • Nephritic syndrome • Pyelonephritis and Upper UTIs • Lower UTIs • Nephrolithiasis • Prostatitis and prostatism • Polycystic kidney disease • Renal and bladder neoplasms • Renal drugs (eg. diuretics)
  84. 84. Any questions?
  85. 85. Feedback Forms • Thank you!

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