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ESA 3- Urinary System > Acute Kidney Injury and Glomerular Disease > Flashcards

Acute Kidney Injury and Glomerular Disease Flashcards

1
Q

What is oliguria?

A

Less than 500ml of urine per day, or less than 20ml/hour

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2
Q

What is anuria?

A

Less than 100ml of urine per day

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3
Q

What does anuria indicate?

A

Blockage of urine flow

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4
Q

What are the types of acute renal injury (AKI)?

A
  • Pre-renal disease
  • Post-renal failure
  • Intrinsic renal failure
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5
Q

What happens in pre-renal disease?

A

Decreased perfusion

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6
Q

What happens in post-renal failure?

A

Obstruction

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7
Q

What happens in intrinsic renal failure?

A

Damage to kidney

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8
Q

What can cause pre-renal disease?

A
  • Volume depletion
  • Heart failure
  • Cirrhosis
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9
Q

What are the types of intrinsic renal failure?

A
  • Renal artery occlusion
  • Renal parenchymal
  • Renal vein occlusion
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10
Q

What can cause renal parenchymal failure?

A
  • Intrarenal vascular
  • Glomerulonephritis
  • Ischaemic ATN
  • Toxic ATN
  • Interstitial disease
  • Intrarenal obstruction
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11
Q

What can cause post-renal failure?

A

Urinary tract obstruction

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12
Q

What happens unless the cause of pre-renal AKI is recognised and treated promptly?

A

Acute tubular necrosis (ATN) will develop

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13
Q

What can cause reduced renal perfusion?

A
  • Reduced effective ECF volume
  • Impaired renal autoregulation
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14
Q

What can cause a reduced effective ECF volume?

A
  • Hypovolaemia
  • Systemic vasodilation
  • Cardiac failure
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15
Q

What can cause hypovolaemia?

A
  • Blood loss
  • Fluid loss
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16
Q

What can cause systemic vasodilation?

A
  • Sepsis
  • Cirrhosis
  • Anaphylaxis
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17
Q

What can cause cardiac failure?

A
  • LV dysfunction
  • Valve disease
  • Tamponade
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18
Q

What does renal autoregulation do?

A

Maintains a normal perfusion over a range of systemic BP

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19
Q

What can cause impaired renal autoregulation?

A
  • Preglomerular vasoconstriction
  • Postglomerular vasodilation
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20
Q

What can cause preglomerular vasoconstriction?

A
  • Sepsis
  • Hypercalcaemia
  • Hepatorenal syndrome
  • Drugs
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21
Q

What drugs can cause preglomerular vasoconstriction?

A

NSAIDS

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22
Q

What can cause postglomerular vasodilation?

A
  • ACE inhibitors
  • Angiotensin II Antagonists
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23
Q

What does post-renal AKI indicate?

A

An obstruction to urine flow after the urine has left the tubule

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24
Q

What % of AKIs are accounted for by pre-renal AKI?

A

10%

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25
Q

Where can an obstruction to urine flow occur?

A
  • Ureters (bilateral)
  • Bladder
  • Urethra
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26
Q

How can obstructions to urine flow be classified?

A
  • Within the lumen
  • Within the wall
  • Pressure from outside
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27
Q

What can cause urine obstruction within the lumen?

A
  • Calculi
  • Clot
  • Papillary necrosis
  • Tumour
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28
Q

What tumours can cause urine obstruction within the lumen?

A
  • Renal pelvis
  • Ureter
  • Bladder
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29
Q

Where in the lumen can stones cause obstruction of urine?

A
  • Both renal pelves/ureters (unless only one functioning kidney)
  • Neck of bladder
  • Urethra
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30
Q

What size urinary stones do not usually pass through lumen?

A

>10mm

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31
Q

What symptoms are common with urinary stones stuck within the lumen?

A
  • Pain
  • Haematuria
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32
Q

What can cause obstruction to urine flow within the wall?

A
  • Congential
  • Ureteric stricture
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33
Q

What are the congential cuases of urine flow obstruction within the wall?

A
  • Pelviureteric neuromuscular dysfunction
  • Megaureter
  • Neurogenic bladder
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34
Q

Does obstruction to urine flow caused by something within the wall usually cause chronic or acute kidney injury?

A

Chronic

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35
Q

What can cause obstruction to urine flow due to pressure from outside?

A
  • Prostatic hypertrophy
  • Malignancy
  • Aortic aneurysm
  • Diverticulitis
  • Accidental ligation of ureter (during surgery
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36
Q

What % of AKIs do instrinsic AKIs account for?

A

30%

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37
Q

What are intrinsic AKIs?

A

Direct injury to kidney

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38
Q

What are the causes of intrinsic AKIs?

A
  • Acute tubular necrosis (ATN)
  • Glomerular and arteriolar disease
  • Acute tubule-interstitial nephritis
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39
Q

What are the causes of acute tubular necrosis?

A
  • Severe acute ischaemia
  • Toxic acute tubular necrosis
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40
Q

What are the causes of severe acute tubular ischaemia?

A

Pre-renal causes

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41
Q

What happens if the fall in renal perfusion is not treated promptly in severe acute ischaemia?

A

Tubular necrosis results

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42
Q

What happens in acute tubular necrosis?

A

Nephrotoxins damage epithelail cells lining the tubules, and cause cell death and shedding into lumen

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43
Q

Are nephrotoxins endogenous or exogenous?

A

Can be either

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44
Q

When is acute tubular necrosis much more likely?

A

If there is reduced perfusion and a nephrotoxin

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45
Q

How is acute tubular necrosis identified?

A
  • Muddy brown casts (idk wat this is)
  • Fractional excretion of Na > 3%
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46
Q

Give 3 endogenous nephrotoxins

A
  • Myoglobin
  • Urate
  • Bilirubin
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47
Q

Give 4 exogenous nephrotoxins

A
  • Endotoxin
  • X-ray contrast
  • Drugs
  • Other poisions
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48
Q

What other poisons can act as nephrotoxins?

A
  • Weedkillers
  • Antifreeze
    *
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49
Q

What drugs can act as nephrotoxins?

A
  • ACE inhibitors
  • Aminoglycosides
  • NSAIDs
  • Gentamicin
  • Angiotensin receptor blockers
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50
Q

Why can NSAIDs act as nephrotoxins?

A
  • Prostaglandins normally cause vasodilation of afferent arterioles in renal autoregulation
  • NSAIDs inhibit prostaglandin production (inhibit COX enzyme)
  • Unopposed vasoconstriction of afferent arteriole -> reduced glomerular perfusion pressure -> AKI
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51
Q

How is fractional excretion calculated?

A
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52
Q

What glomerular and arteriolar disease can cause intrinsic AKI?

A

Acute glomerulonephritis

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53
Q

What is acute glomerulonephritis?

A

Immune disease affecting the glomerulus

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54
Q

What are the types of acute glomerulonephritis?

A
  • Primary
  • Secondary
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55
Q

What does primary acute glomerulonephritis affect?

A

Only the kidneys

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56
Q

What happens in secondary acute glomerulonephritis?

A

Kidneys are involved as part of systemic process

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57
Q

What conditions are associated with acute glomerulonephritis?

A
  • SLE
  • Vasculitis
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58
Q

What is acute tubulo-interstitial nephritis?

A

Inflammation of kidney intersticium

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59
Q

What are the causes of acute tubulo-interstitial nephritis?

A
  • Infection
  • Toxin induced
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60
Q

What infection can cause acute tubulo-interstitial nephritis?

A

Acute pyelonephritis

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61
Q

What is acute pyelonephritis?

A

Ascending bacterial infection

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62
Q

What can cause toxin induced acute tubulo-interstitial nephritis?

A

Drugs

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63
Q

When is an AKI pre-renal?

A

When the kidneys are underperfused

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64
Q

What can cause the kidneys to be underperfused?

A
  • Shock
  • Severe vascular disease
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65
Q

What types of shock can cause the kidneys to be underperfused?

A
  • Hypovolaemic
  • Septic
  • Cardiac
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66
Q

What can cause the kidneys to be underperfused in severe vascular disease?

A

Emboli

67
Q

When is an AKI renal?

A
  • When nephrotoxins are implicated
  • Parenchymal disease
  • Multisystem disease
68
Q

When are nephrotoxins implicated?

A
  • Drugs
  • Sepsis
  • Myoglobin
69
Q

What multisystem disease can cause renal AKI?

A

UTI

70
Q

When is an AKI post-renal?

A

When there is a renal tract obstruction

71
Q

What is investigated in pre-renal AKI?

A

Cardiac failure

72
Q

How can cardiac failure cause AKI?

A

Overloading kidney

73
Q

What will be found on investigation with AKI caused by cardiac failure?

A
  • Gallop rhythm
  • Raised BP
  • Raised JVP
  • Pulmonary oedema
  • Peripheral oedema
74
Q

What are the features of pulmonary oedema on investigation?

A
  • Basal crackles
  • Dyspnoea
75
Q

Where is peripheral oedema found in cardiac failure causing AKI?

A
  • Sacral
  • Ankle
76
Q

What will be found on investigation with sepsis causing renal AKI?

A
  • Pyrexia and rigors
  • Vasodilation
  • Warm peripheries
  • Bounding pulse
  • Rapid capillary fill
  • Hypotension
77
Q

What will be found on investigation with urinary tract obstruction causing post-renal AKI?

A
  • Anuria
  • Single functioning kidney
  • History of renal stones, prostatism, or previous pelvic/abdominal surgery
  • Palpable bladder
  • Pelvic/abdominal masses
  • Enlarged prostate (DRE)
78
Q

What methods are used to investigate patients with AKI?

A
  • Serum biochemistry
  • ECG
  • Urine testing
  • Soluble immunological tests
  • Imaging
  • Histology
79
Q

What will be found on serum biochemistry with AKI?

A
  • Increased urea
  • Increased creatinine
  • Hyperkalaemia
  • Hyponatraemia
  • Hypocalcaemia
  • Hyperphophataemia
80
Q

What causes ECG changes in AKI?

A

Hyperkalaemia

81
Q

What will be seen on ECG with hyperkalaemia?

A
  • Tall T waves
  • Small/absent P waves
  • Increase in PR interval
  • Wide QRS complex
  • ‘Sine wave’ pattern
  • Asystole
82
Q

What urine testing is conducted when investigating AKI?

A
  • Dipstick testing
  • Microscopy
83
Q

What is being looked for with dipstick testing for AKI?

A
  • Blood
  • Protein
  • Leucocytes
84
Q

Is proteinuria present with pre-renal AKI?

A

No

85
Q

Is haematuria seen with pre-renal AKI?

A

No

86
Q

Is proteinuria seen with ATN?

A

No

87
Q

Is haematuria seen with ATN?

A

No

88
Q

Is proteinuria seen with glomerulonephritis?

A

Yes, lots

89
Q

Is haematuria seen with glomerulonephritis?

A

Yes, lots

90
Q

What will be seen on microscopy with pre-renal AKI?

A

Hyaline cast

91
Q

What is hyaline cast?

A

Aggregations of protein seen in concentrated urine

92
Q

Is hyaline cast normal?

A

Yes

93
Q

What will be seen on microscopy with acute tubular necrosis?

A

Muddy brown cast

94
Q

What will be seen on microscopy with rapidly progressing glomerulonephritis?

A

Red blood cell cast

95
Q

What is detected by soluble immunological tests with AKI?

A

Circulating antibodies

96
Q

What ciculating antibodies may be found with AKI?

A
  • Anti-nucleur antibodies
  • Anti-neutrophil cytoplasmic antibody
  • Anti-glomerular basement membrane antibodies
97
Q

In what condition would anti-nucleur antibody be found circulating?

A

SLE

98
Q

In what condition would anti-neutrophil cytoplasmic antibody be found circulating?

A

Systemic vasculitis

99
Q

In what condition would anti-glomerular basement membrane antibodies be found circulating?

A

Goodpasture’s disease

100
Q

What imaging is conducted when investigating AKI?

A
  • Ultrasound
  • CXR
101
Q

What is being looked for on ultrasound with AKI?

A
  • Renal size
  • Hydronephrosis
  • Presence of obstruction
102
Q

What is being looked for on CXR with AKI?

A

Pulmonary oedema

103
Q

What is required for histology when investigating AKI?

A

Biopsy

104
Q

When is a biopsy obtained in AKI?

A
  • When pre-renal and post-renal AKI have been ruled out
  • A confident diagnosis of ATN cannot be made
  • Systemic inflammatory symptoms or signs are present
105
Q

Here come dat boi

A

O shit waddup

106
Q

What is treatment of AKI dictated by?

A

Its cause

107
Q

What is the treatment for pre-renal failure?

A

Volume correction

108
Q

How is hypovolaemia treated?

A

Fluid administration

109
Q

How is heart failure treated?

A

Diuretic

110
Q

How is post-renal failure treated?

A

Urological intervention to re-establish urine flow

111
Q

How is acute tubular necrosis treated?

A

Treament is supportive, maintaing good kidney perfusion and avoiding nephrotoxins

112
Q

When is dialysis initiated in AKI?

A

If the kidneys can no longer adequately excrete salt, water, and potassium

113
Q

How is asymptomatic glomerular disease detected?

A

Incidentally, by dipstick analysis

114
Q

When may asymptomatic glomerular disease be detected incidentally?

A

At a health check or life insurance medical

115
Q

How can asymptomatic glomerular disease be detected in dipstick analysis?

A

Microscopy haematuria, proteinuria, or both

116
Q

What is sometimes detected at the same time as asymtomatic glomerular disease?

A

Hypertension

117
Q

What is the first investigation carried out following urine dipstick in asymptomatic glomerular disease?

A

Cystoscopy

118
Q

Is a renal biopsy mandatory in asymptomatic glomerular disease?

A

No

119
Q

What can cause microscopic haemtauria?

A
  • Renal stones/tumours
  • Arteriovenous malformations
  • Glomerular disease
120
Q

What is considered to be non-nephrotic proteinuria?

A

<3.5g/24hrs protein in urine

121
Q

Can microscopic proteinuria be associated with conditions other than glomerulonephritis?

A

Yes

122
Q

Who is the cutest g pig in the world?

A

Gypsy

123
Q

What is often true of episodic macroscopic haematuria associated with glomerular disease?

A

It is often brown or smoky in colour, rather than red

124
Q

Are clots found in macroscopic haematuria?

A

Very unusual

125
Q

What does episodic macroscopic haematuria with glomerular disese need to be distinguished from?

A

Other causes of red or brown urine

126
Q

Other than haematuria, what are the other causes of red or brown urine?

A
  • Haemoglobin uria
  • Myoglobinuria
  • Consumption of food dyes
127
Q

Is macroscopic haematuria painful or painless?

A

Usually painless

128
Q

What is the commnest glomerular cause of macroscopic haematuria?

A

IgA nephropathy

129
Q

What does macroscopic haematuria require?

A

Urological workup

130
Q

What is nephrotic syndrome?

A

A non-specific disorder, where the kidneys are damaged, leaking large amount of protein into urine

131
Q

What are the classical triad of findings in nephrotic syndrome?

A
  • Proteinuria (>3.5g/24hrs)
  • Hypoalbuminaemia
  • Oedema
132
Q

What is variably present in nephrotic syndrome?

A
  • Hyperlipiaemia
  • Muehrcke’s bands
133
Q

What does nephrotic syndroem require for diagnosis?

A

Renal biopsy

134
Q

How is the biopsy taken when investigating nephrotic syndrome?

A

Using an ultra-sound guided needle

135
Q

Where is the biopsy aimed when investigating nephrotic syndrome?

A

At the bottom of the kidney

136
Q

Why is the biopsy aimed at the bottom of the kidney when investigating nephrotic syndrome?

A

To make sure a piece of cortex is biopsied

137
Q

Why must a piece of cortex be biopsied in nephrotic syndrome?

A

As there are no glomeruli in the medulla, so it would not be useful for diagnosis

138
Q

What are the causes of nephrotic syndrome?

A
  • Minimal change glomerulonephritis
  • Focal segmental glomerulosclerosis
  • Membranous glomerulonephritis
139
Q

What is nephritic syndrome?

A

A collection of signs (syndrome) associated wth disorders affecting the kidneys, especially glomerular disorders, characterised by having small pores in the podocytes of glomerulus large enough to permit proteins and red blood cells

140
Q

What are the features of nephritic syndrome

A
  • Rapid onset
  • Oliguria
  • Hypertension
  • Generalised oedema
  • Haematuria with smoky brown urine
  • Normal serum albumin
  • Variable renal impairment
  • Urine contains blood protein and red blood cell casts
141
Q

Describe the onset of nephrotic syndrome

A

Insidious

142
Q

Describe the onset of nephritic syndrome

A

Abrupt

143
Q

Is there oedema in nephrotic syndrome?

A

Yes, ++++

144
Q

Is the oedema in nephritic syndrome?

A

Yes, ++

145
Q

What happens to BP in nephrotic syndrome?

A

No change

146
Q

What happens to JVP in nephrotic syndrome?

A

Same or decreasd

147
Q

What happens to BP in nephritic syndrome?

A

Increased

148
Q

What happens to JVP in nephritic syndrome?

A

Increased

149
Q

Is there proteinuria in nephrotic syndrome?

A

Yes, ++++

150
Q

Is the proteinuria in nephritic syndrome?

A

Yes, ++

151
Q

Is there haematuria in nephrotic syndrome?

A

May or may not occur

152
Q

Is there haematuria in nephritic syndrome?

A

Yes, +++

153
Q

Are there red cell casts in nephrotic syndrome?

A

No

154
Q

Are there red cell casts in nephritic syndrome?

A

Yes

155
Q

What happens to serum albumin in nephrotic syndrome?

A

Decreased

156
Q

What happens to serum albumin in nephritic syndrome?

A

Same or slightly reduced

157
Q

What does rapidly progressive glomerulonephritis describe?

A

A clinical situation in which glomerular injury is so severe that renal function deteriorates over days

158
Q

How may a patient present with rapidly progressive glomerulonephritis?

A

As a uraemic emergency, with evidence of extrarenal disease

159
Q

What is rapidly progressive glomerulonephritis associated with?

A

Crescenteric glomerulonephritis

160
Q

What is required for diagnosis of rapidly progressive glomerulonephritis?

A

Renal biopsy

161
Q

What is the natural course of many forms of glomerulonephritis?

A

Slowly progressive renal impairment, including;

  • Hypertension
  • Dipstick abnormalities
  • Uraemic syndrome
162
Q

What is chronic renal failure often associated with?

A

Small, smooth, shrunken kidneys

163
Q

What is the problem with biopsies in chronic renal failure?

A
  • They are hazardous
  • Unlikely to produce diagnostic material
164
Q

What are the symptoms of chronic renal failure?

A
  • Tiredness and lethargy
  • Breathlessness
  • Aches and pains
  • Sleep reversal
  • Nocturia
  • Restless legs
  • Itching
  • Chest pains
  • Seizures and comas

ESA 3- Urinary System (13 decks)

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